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: 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 #3: 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 #4: Emotional Well-being in Veterinary Practice
In this episode of the podcast I am joined by Enid Traisman M.S.W., CT, CFS to discuss issues around emotional well-being in veterinary practice.
Topics that we discuss in this episode include the following; where appropriate we talk about prevention, recognition and coping strategies:
- Pet loss grief
- When veterinary staff have to deal with loss of their own companion animals
- Compassion fatigue and burnout
- Workplace stress and emotional challenges of the veterinary profession
During the episode Enid mentions creating a memorial table at work when a staff member loses a pet. You can find Enid’s overview of the pet memorial table concept and a list of other REALLY USEFUL RESOURCES, both provided by Enid and some others, HERE.
Find contact details for Enid here on the Dove Lewis website.
And don’t forget to check out the Small Animal Emergency Medicine app for iOS devices here. Android version to follow soon!
Mar 06 2016
Rank #5: Dog and Cat Amputees: 'Tripods'
On this episode of the podcast I am joined by Rene Agredano and Jim Nelson of Tripawds, “the world's largest support community for animal amputees”, to discuss how we as veterinary staff can be better prepared to help clients with dogs and cats that are either facing or have had a limb amputation.
After some background discussion of the Tripawds resource, we discuss:
- Ethical and moral considerations carers may have around amputation
- Steps carers can take to prepare for their amputee dog or cat returning home for the first time
- Client concerns about when their pet will be normal again, pain management, and the surgical incision
The following links were mentioned in the episode:
Aug 04 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: 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 #8: Antimicrobial Stewardship in Companion Animal Practice
Antimicrobial resistance is said to be one of the greatest challenges currently facing small animal veterinary medicine. How can we become part of the solution rather than part of the problem?
In this episode of the podcast I start by providing a brief refresher of bacteriology and antibacterials before going on to discuss antimicrobial stewardship in an episode that is derived from this review article:
Guardabassi L, Prescott JF. Antimicrobial Stewardship in Small Animal Veterinary Practice: From Theory to Practice. Vet Clin N Am – Sm Anim Prac 2015. 45(2):361–376.
Areas covered include:
- Defining the problem
- What is antimicrobial stewardship?
- Antimicrobial stewardship strategies
- Developing and implementing guidelines
- General (generic) guidelines for rational antibiotic use
- Role of the microbiology laboratory
Click here for SHOW NOTES for this episode.
And be sure to check out the Veterinary Small Animal Emergency Medicine App.
Apr 22 2016
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: 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 #11: 2015 AAHA/AAFP Pain Management in Dogs and Cats Guidelines
Thankfully (!) pain management continues to gain increasing recognition in clinical veterinary practice. In this episode I look at some of the key points made in the following recently published guidelines focusing on those most relevant to ECC and acute short-term pain management:
Epstein M, Rodan I, Griffenhagen G, et al. AAHA/AAFP Pain Management Guidelines for Dogs and Cats. J Fel Med Surg 2015. 17, 251–272.
The ten points discussed in the episode are:
- Pain management must be central to our clinical practice
- Pain physiology should be considered when implementing our pain management
- The patient’s behaviour is key to pain assessment
- Pain scoring tools can be useful
- Multimodal (balanced) analgesia is another key strategy in pain management
- Opioids are the best analgesics in many emergency patients
- Non-steroidal anti-inflammatory drugs (NSAIDs) may be contraindicated in emergency patients
- Don’t overlook non-pharmacological measures
- DON’T OVERLOOK TLC!
- Conflicts of interest
Feb 27 2015
Rank #12: Physiotherapy in the Critical Veterinary Inpatient
On this episode of the podcast I am joined by Kim Sheader (MSCP HCPC ACPAT Cat A, Chair ACPAT, RAMP), Chartered Veterinary and Human Physiotherapist, to discuss physiotherapy for the critical inpatient. Kim is a highly qualified and experienced physiotherapist and currently works with The Ralph Mobile Physiotherapy & Rehabilitation service.
I start by finding out about Kim’s background, training and experience in human and more recently veterinary physiotherapy. We then go on to discuss:
- Physiotherapy for the critical patient with prolonged recumbency
- Physiotherapy for the dog with moderate-to-severe tetanus
- Respiratory physiotherapy, a subject about which Kim is especially passionate
To contact Kim please email her at email@example.com or message her via The Ralph MPRS website www.theralphphysio.vet.
Sep 29 2016
Rank #13: 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 #14: 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 #15: Steroids and Shock!
Whether or not steroids should be used in shock has been an on-going debate for many years. In this episode I discuss some of the literature, in particular relating to the use of steroids in septic shock, and the concept of ‘relative adrenal insufficiency’ – more recently referred to as ‘critical illness-related corticosteroid insufficiency’ (CIRCI).
An episode summary is as follows:
Use of steroids in shock in general is not recommended unless that patient happens to have a steroid-responsive disease as the cause of their shock; this is rare.
- ‘Low dose’ or ‘physiological’ steroids can be used in patients with septic shock – or other critical illness – that is refractory to fluid resuscitation and exogenous catecholamine use; many veterinary practitioners may not have access to vasopressor/inotropic agents.
- A positive response to low dose steroid use suggests the presence of CIRCI
- Hydrocortisone is typically suggested; dexamethasone may be less preferable but can still be used
***Much remains to be clarified about this in human and especially veterinary medicine in terms of which patients are the best candidates, when to start steroids, what protocol to use and so on.***
This episode is in part derived from:
Burkitt Creedon JM. Controversies surrounding critical illness-related corticosteroid insufficiency in animals. J Vet Emerg Crit Care 2015. 25(1):107-112.
For SHOW NOTES of this episode including a full list of all papers that informed or were mentioned in this episode, see HERE.
May 20 2015