Rank #1: Acute liver failure
Dogs and cats with acute liver failure may present as emergencies and be critically ill. In this episode of the podcast I discuss this condition based on a recent review article from the Journal of Veterinary Emergency and Critical Care*.
(*Weingarten MA, Sande AA. Acute liver failure in dogs and cats. J Vet Emerg Crit Care 2015. 25(4):455-473.)
Topics covered include:
- Injury versus failure
- Clinical findings
- Treatment including managing complications
For SHOW NOTES visit the website HERE.
Oct 02 2015
Rank #2: Ketamine
Ketamine is a drug with complex pharmacology and a number of potential clinical effects and uses including a dose-dependent central nervous system continuum from analgesia through to sedation, partial dissociation and complete dissociation. In this episode I discuss this drug based around the following points:
- How does ketamine work? What does it do?
- Continuum of central nervous system effects
- Is ketamine contraindicated with raised intracranial pressure?
- Ketamine is sympathomimetic
- What about ketamine in cats with HCM
- “Ketamine head”
- Can ketamine be used as a sole agent?
- Is ketamine contraindicated with raised intraocular pressure?
- Ketamine in caesarean section
- Other bits ‘n’ pieces
For SHOW NOTES of this episode see HERE.
Apr 10 2015
Rank #3: Canine Hypoadrenocorticism (Addison's Disease): 10 Talking Points
Dogs (and cats) having a crisis as a result of hypoadrenocorticism (Addisonian crisis) can be in a life-threatening state and this represents one of the true small animal emergencies. Stabilisation of these patients starts with appropriately aggressive intravenous fluid therapy as the first priority and treatment for clinically significant hyperkalaemia and hypoglycaemia may also be needed very early on. Intravenous glucocorticoids are typically then required to continue stabilisation. In this episode I discuss ten talking points relating to canine hypoadrenocorticism, namely:
- “The Great Pretender”
- Likely Genetic Basis
- Aldosterone may be low in ‘atypical’ cases
- Hypoglycaemia may be severe
- Bradycardia is not always present and not just due to hyperkalaemia
- ACTH stimulation test provides definitive diagnosis
- Single resting plasma cortisol may be useful for screening – but limited role in emergencies?
- Intravenous fluid therapy
- Client communication and education
- Prognosis is good with appropriate management – yey!
PAPERS that helped inspire some of the content for this episode are:
Baumstark ME, Sieber-Ruckstuhl NS, Mϋller C, et al. Evaluation of Aldosterone Concentrations in Dogs with Hypoadrenocorticism. J Vet Intern Med 2014; 28:154–159. (Open access online)
Boag AM, Catchpole B. A Review of the Genetics of Hypoadrenocorticism. Topics in Companion Animal Medicine 2015 (Accepted manuscript pending publication).
Bovens C, Tennant K, Reeve J, Murphy KF. Basal Serum Cortisol Concentration as a Screening Test for Hypoadrenocorticism in Dogs. J Vet Intern Med 2014; 28:1541–1545. (Open access online)
Lennon EM, Boyle TE, Hutchins RG, et al. Use of basal serum or plasma cortisol concentrations to rule out a diagnosis of hypoadrenocorticism in dogs: 123 cases (2000–2005). J Am Vet Med Assoc 2007; 231:413–416. (Abstract)
Feb 13 2015
Rank #4: Canine Haemoabdomen - Part 1
In a recent Facebook survey 80% of 150 respondents mentioned haemoabdomen, especially due to splenic rupture, as a top cause of collapse in dogs. This is the first of a two-part mini-series on canine haemoabdomen loosely based around the following review article:
Herold LV, Devey J, Kirby R, Rudloff E. Clinical evaluation and management of hemoperitoneum in dogs. J Vet Emerg Crit Care 2008. 18(1):40-53.
Points discussed in this episode include:
- Causes of canine haemoabdomen
- Canine abdominal haemangiosarcoma
- Restoring an effective circulating blood volume
- Diagnosing haemoabdomen
Further points to be discussed in the second part include maintaining adequate oxygen-carrying capacity, arresting haemorrhage, possible use of abdominal counterpressure etc.
For SHOW NOTES of this episode click HERE.
Apr 24 2015
Rank #5: What's Magnesium Got To Do With It?
In this episode of the podcast I take a look at magnesium and its role in clinical practice, something which many people may not be very familiar with. The episode is based on the following article:
Humphrey S, Kirby R, Rudloff E. Magnesium physiology and clinical therapy in veterinary critical care. J Vet Emerg Crit Care 2015.
- Areas covered include:
- Background theory
- Measuring magnesium
- Magnesium disorders
For SHOW NOTES for this episode see Here.
And don't forget to check out my Small Animal Emergency Medicine App - currently for iPhone and iPad; Android version out soon!
Feb 05 2016
Rank #6: Early Approach to Dyspnoeic Cats, First Do No Harm!
In this episode of the podcast I discuss an approach to the early management of dyspnoeic cats that is predicated on ‘first do no harm’ and thinking risk-benefit at all times. The main take-home messages from the episode are:
- Appreciate that dyspnoeic cats can be very vulnerable and easily tipped over the cliff edge.
- Even more so than normal, pay acute attention to the risk-benefit assessment at all times.
- Understand that each cat is clearly going to be an individual patient with their own set of circumstances and behaviour, but that a hands-off, slow, staged approach is likely to be the least risky and most beneficial in most cases.
- Continue to improve your ability and confidence in examining these cases paying attention to trying to anatomically localise the cause of the dyspnoea; this will allow you to make the most sensible decisions in terms of how to help the patient.
- Don’t be in a hurry to x-ray dyspnoeic cats until and unless you feel like you have done all you can to make them as stable as possible beforehand.
- And, lastly engage more with POCUS, point-of-care ultrasound, if you are not already.
For SHOW NOTES for this episode click HERE.
Jul 31 2015
Rank #7: A Journal of Veterinary Emergency and Critical Care Papers Episode
Anaemia in critically ill cats; severe anaemia in blocked tomcats; spinal shock in dogs; haemorrhagic GI disease in veterinary ICUs. In this episode of the podcast I discuss a few papers from the latest issue of the Journal of Veterinary Emergency and Critical Care (JVECC) that especially caught my eye, in particular as they relate to primary care practice and not just referral centres.
The four papers in question are:
- Balakrishnan A, Drobatz KJ, Reineke EL. Development of anemia, phlebotomy practices, and blood transfusion requirements in 45 critically ill cats (2009–2011). J Vet Emerg Crit Care 2016. 26(3):406-411.
- Beer KS, Drobatz KJ. Severe anemia in cats with urethral obstruction: 17 cases (2002–2011). J Vet Emerg Crit Care 2016. 26(3):393-397.
- Full AM, Barnes Heller HL, Mercier M. Prevalence, clinical presentation, prognosis, and outcome of 17 dogs with spinal shock and acute thoracolumbar spinal cord disease. J Vet Emerg Crit Care 2016. 26(3): 412–418.
- Swann JW, Maunder CL, Roberts E, et al. Prevalence and risk factors for development of hemorrhagic gastro-intestinal disease in veterinary intensive care units in the United Kingdom. J Vet Emerg Crit Care 2016. 26(3): 419–427.
Remember as always that what I don’t tend to do in these podcasts is to provide an in-depth evidence-based appraisal of the papers I mention. So I continue to encourage you to get in touch for copies of the papers if you do not have access to JVECC and to read and critique the papers yourself. Don’t just take what the abstract says or indeed what I say here at face value!
Click Here For Your FREE Copy of a Transcript of This Episode For SHOW NOTES for this episode click here. And be sure to check out the Veterinary Small Animal Emergency Medicine App.
Jun 23 2016
Rank #8: Managing Dog Bite Injuries
**Apologies for the less than optimal sound quality of this episode and the non-stereo recording!**
Dog bite injuries are a relatively common problem to be faced with in small animal practice. In this episode of the podcast I am joined by Nicola Kulendra, a European specialist in small animal surgery, to discuss their management. Some of the points we discuss include:
- Adhering to standard ECC principles in terms of initial stabilisation and analgesia
- The mechanics of dog bites and the ‘tip of the iceberg’ concept
- Exploring bite injuries to uncover their true extent; the role of diagnostic imaging
- The importance of wound drainage
- Bacterial involvement and the use of antimicrobials
- The ‘two hit theory’ in cats with moderate-to-severe dog bite injuries
- The ‘big dog, little dog’ phenomenon
iPhone/iPad users see HERE for my Small Animal Emergency Medicine app for iOS; Android version is in development.
[This podcast is closely aligned with the MedEdLIFE Research Collaborative’s Quality Checklist for Podcasts.]
Dec 04 2015
Rank #9: A Critical Patient Daily Checklist
Critically ill patients almost by definition have a number of different problems and management considerations. They can be high maintenance requiring intensive care and it is easy to accidentally overlook different aspects of their care; this is especially the case when you are looking after more than one critically ill patient and/or working in an otherwise busy practice environment.
Using some form of checklist on a daily basis is a quick and easy way of being reminded of all the different aspects of the care of critically ill patients and hopefully minimises how often treatment considerations are overlooked and sub-optimal care provided.
In this episode I discuss my version of a daily checklist for critically ill patients including aspects such as monitoring, analgesia, nursing care and non-clinical considerations.
To download a COPY OF THE CHECKLIST for free and a TRANSCRIPT of the episode. visit the website HERE.
You can also get a copy of the checklist by directly going to this link.
Jun 26 2015
Rank #10: The Shock Index in Veterinary Patients
The shock index is equal to heart rate divided by systolic arterial blood pressure. It has received a fair amount of attention in the human medicine literature being evaluated for example in haemorrhagic hypovolaemic shock, especially post-traumatic, sepsis and obstetric patients, and for correlation for example to length of hospital stay and mortality. There is very little clinical veterinary information on the shock index.
In this episode I discuss what the shock index is, the parameters that are included in the shock index, the potential value of the shock index, some of the human medicine studies, and the following two canine studies:
Porter A, Rozanski E, Sharp C, et al. Evaluation of the shock index in dogs presenting as emergencies. J Vet Emerg Crit Care 2013. 23(5):538–544.
Peterson KL, Hardy BT, Hall K. Assessment of shock index in healthy dogs and dogs in hemorrhagic shock. J Vet Emerg Crit Care 2013. 23(5):545-550.
For show notes for this episode and a full list of all papers that informed or were mentioned in this episode, see HERE.
Jun 05 2015
Rank #11: Intravenous Lipid Emulsion as an Antidote
Intravenous lipid emulsion (ILE) (e.g. Intralipid 20%) has been used for some time and is being used more and more as an antidote for certain toxins in both human and veterinary medicine. How does it work? What is the evidence base for its use? What poisons should we consider using it for in dogs and cats? These are amongst some of the questions that I discuss in this episode of the podcast.
Listen to this episode to find out more and feel free to share your thoughts on the main website or via social media.
** To get your FREE copy of some notes on intravenous lipid emulsion visit the Veterinary ECC Small Talk website HERE **
I would be very grateful if you could also take the time to rate and/or review these podcasts! Thank you!
Nov 07 2014
Rank #12: Fluid Choice in Tomcat Urethral Obstruction (Blocked Cats)
Cats with urethral obstruction ("blocked cats") can present in a state of shock with moderate-to-severe hypoperfusion and should receive adequate fluid resuscitation with bolus therapy as needed using an isotonic crystalloid solution before worrying about relieving the obstruction. Blocked cats may have clinically significant hyperkalaemia and can also be severely acidaemic. With this in mind, does it matter whether we use 0.9% sodium chloride or a more balanced solution such as Hartmann's solution (buffered lactated Ringer's solution, compound sodium lactate), Normosol-R or Plasmalyte 148? This is discussed in detail in this podcast and a paper from the veterinary literature presented.
A summary of the podcast including the reference for the paper discussed can be found on the Veterinary ECC Small Talk website HERE.
If you are interested in taking a presentation and acquiring some course notes describing in detail an approach to the overall management of blocked cats, please visit the website HERE.
Nov 21 2014
Rank #13: Listeners' Questions on Fluid Therapy
There are some well know standard principles of fluid therapy with different approaches to the treatment of hypovolaemia and dehydration. Regardless of the indication, individual patients may have additional problems or considerations that should influence our fluid therapy approach. In this episode I respond to questions sent in by listeners with respect to findings that should influence our fluid therapy approach - pulmonary contusions and heart murmurs. I then go on to discuss the role of and approach to fluid therapy in patients exposed to renally excreted nephrotoxins.
For online training material on Parenteral Fluid Therapy and Hypovolaemia, Shock and Dehydration, CLICK HERE.
Jan 02 2015
Rank #14: Nutritional Management of Acute Pancreatitis
This episode focuses on the nutritional management of acute pancreatitis in dogs and cats answering questions such as:
- When should we be providing nutrition to dogs and cats with acute pancreatitis?
- Should we be using enteral or parenteral nutrition?
- Should we be using post-pyloric jejunal feeding or is oral or gastric feeding okay?
The episode is largely based around the following clinical practice review article:
Jensen KB, Chan DL. Nutritional management of acute pancreatitis in dogs and cats. J Vet Emerg Crit Care 2014. 24(3):240-250.
As mentioned in the episode, if you would like a FREE copy of some general notes on acute pancreatitis in dogs and cats that cover more than 'just' the nutritional aspects, please click the link below and follow the instructions:
In the episode I also mention a blog post on syringe feeding which you can find HERE.
One paragraph from the paper that I read out in the episode and promised to include here was as follows:
“The traditional approach to AP centered on the premise that withholding food would reduce pancreatic autodigestion by decreasing pancreatic stimulation and enzyme release. However, the pathogenesis of pancreatitis more likely involves premature intracellular activation of proteolytic enzymes rather than pancreatic stimulation. Avoidance of feeding as a means to decrease pancreatic stimulation may be unwarranted and could lead to malnutrition and impaired gastrointestinal barrier function. Lack of enteral nutrition results in the loss of normal physiologic intestinal motility, is associated with intestinal villus atrophy, and compromises intestinal mucosal blood flow. If sustained, the lack of enteral nutrition could lead to a compromise of local immunoglobulin and biliary salt production with consequent disruption of normal internal bacterial flora and gastrointestinal barrier function. It also has been demonstrated in experimental rodent models and in people with naturally occurring disease that exocrine pancreatic secretion actually decreases during pancreatitis and that the decrease is more pronounced with increasing severity of inflammation. The practice of withholding food for several days from the time of initiation of therapy may prove detrimental as a period of anorexia often precedes the initial clinical presentation to veterinarians in patients with AP. Implementation of nutritional support may be critical for successful management of patients with AP.”
And the list of summary points from the paper is as follows:
- There is increasing evidence supporting the important role of early EN (ideally within 48 h of diagnosing pancreatitis) in positively impacting outcome in patients with AP.
- Nutritional support is an integral and key aspect of the successful management of AP.
- The use of enteral feeding in veterinary medicine is now considered to be safe, effective, and well-tolerated in severe AP.
- Enteral nutrition is less expensive than parenteral feeding and helps to maintain gastrointestinal mucosal function, and therefore is likely to have a beneﬁcial inﬂuence on the disease course.
- Use of NG, nasoesophageal, jejunal, and oesophagostomy feeding tubes is effective and safe in dogs and cats and should be used unless speciﬁc contraindications are identiﬁed. There is no evidence at this time to support the superiority of post-pyloric jejunal feeding over oral or gastric feeding.
- The optimal enteral diet for patients with AP has not been identiﬁed, but diets commonly used for convalescing dogs and cats can be used.
- Avoidance of enteral diets with high fat content does not appear to be necessary in the majority of patients.
- Despite the growing evidence that EN can be used effectively in the management of patients with AP, there may still be patients that require some form of PN until sufﬁcient EN can be tolerated.
- And of course we have the usual and completely reasonable conclusion that future veterinary studies investigating feeding routes, dietary composition, and optimal timing of nutritional support in AP are warranted.
Dec 05 2014
Rank #15: Resuscitation Fluids, and Colloids in Hypoproteinaemia
Crystalloids versus colloids for resuscitation is an age old debate! In this episode I present the following paper before going on to talk about the use of colloids in hypoproteinaemia.
For online presentations and notes on Hypovolaemia and Shock and Parenteral Fluid Therapy visit my online training portal.
Cazzolli D, Prittie J. The crystalloid-colloid debate: Consequences of resuscitation fluid selection in veterinary critical care. J Vet Emerg Crit Care 2015. Early View online 22 January.
To provide a comprehensive review of the current literature in human and veterinary medicine evaluating the impact of resuscitation fluid choice on patient outcome and adverse effects.
Prospective and retrospective studies, experimental models, and review articles in both human and veterinary medicine retrieved via PubMed.
Human Data Synthesis:
A series of recent, large, randomized controlled trials in critically ill human patients comparing crystalloid versus colloid driven fluid resuscitation algorithms have demonstrated no outcome benefit with the use of natural or synthetic colloids. Synthetic colloidal solutions are associated with an increased incidence of adverse effects including acute kidney injury, need for renal replacement therapy, and coagulopathies. Further, colloidal solutions demonstrate a larger volume of distribution in the setting of critical illness than hypothesized. These findings have created controversy regarding colloid fluid resuscitation in critically ill patients and challenge current resuscitation strategies. A thorough review of the most influential human data is provided.
Veterinary Data Synthesis:
No veterinary clinical outcome data pertaining to fluid resuscitation choice currently exist. Veterinary data from experimental and small clinical trials evaluating the coagulopathic effects of hydroxyethyl starch solutions are described. Data pertaining to the use of natural colloids and albumin products in clinical veterinary patients are reviewed. In addition, data pertaining to the comparative intravascular volume expansion effectiveness of different fluid types in canine patients are reviewed.
Clinical data from critically ill human patients have failed to demonstrate an outcome advantage associated with colloidal fluid resuscitation and indicate that hydroxyethyl starch solutions may be associated with significant adverse effects, including acute kidney injury, need for renal replacement therapy, coagulopathies, and pathologic tissue uptake. The ability to apply these findings to veterinary patients is unknown; however, similar pathophysiology may apply, and critical re-evaluation of resuscitation strategies is justified.
Jan 30 2015