Veterinary Technician’s Daily Reference Guide: Canine and Feline Second Edition
Veterinary Technician’s Daily Referen...
582 downloads
3968 Views
37MB Size
Report
This content was uploaded by our users and we assume good faith they have the permission to share this book. If you own the copyright to this book and it is wrongfully on our website, we offer a simple DMCA procedure to remove your content from our site. Start by pressing the button below!
Report copyright / DMCA form
Veterinary Technician’s Daily Reference Guide: Canine and Feline Second Edition
Veterinary Technician’s Daily Reference Guide: Canine and Feline Second Edition Candyce M. Jack, LVT Sequim, Washington
Patricia M. Watson, LVT Redmond, Washington
Mark S. Donovan, DVM Consulting Editor Seattle, Washington
First Edition first published 2003 Second Edition first published 2008 © 2008, Candyce M. Jack and Patricia M. Watson Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley-Blackwell. Editorial Office 2121 State Avenue, Ames, Iowa 50014-8300, USA For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book, please see our website at www.wiley.com/wiley-blackwell. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Blackwell Publishing, provided that the base fee is paid directly to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payments has been arranged. The fee codes for users of the Transactional Reporting Service are ISBN-13: 978-0-8138-1204-5/2008. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloguing-in-Publication Data Jack, Candyce M. Veterinary technician’s daily reference guide: canine and feline / Candyce M. Jack, Patricia M. Watson; consulting editor, Mark S. Donovan. – 2nd ed. p. ; cm. Rev. ed. of: Veterinary technician’s daily reference guide: canine and feline / Candyce M. Jack, Patricia M. Watson; consulting editor, Mark S. Donovan. C2003. Includes bibliographical references and index. ISBN 978-0-8183-1204-5 (alk, paper) 1. Veterinary medicine–Handbooks, manuals, etc. I. Watson, Patricia M. II. Jack, Candyce M. Veterinary technician’s daily reference guide. III. Title. [DNLM: 1. Veterinary Medicine–methods–Handbooks. 2. Animal Technicians– Handbooks. 3. Cat Diseases–Handbooks. 4. Dog Diseases–Handbooks. SF 748 J12v 2008] SF748.J33 2008 636.089–dc22 2007050954 A catalogue record for this book is available from the U.S. Library of Congress. Set in Berling-Roman by SNP Best-set Typesetter Ltd Printed in Singapore by Markono Print Media Pte Ltd 1 2008
This book is dedicated to all the licensed veterinary technicians who are doing their best for the advancement of the field and devoting themselves to providing the best possible care to their animal patients. A special thanks to our medical editor, Dr. Mark Donovan, for his commitment to our goal and his perseverance to ensure the book presented advanced and accurate information. Patricia Special thanks for family, co-workers, and friends who are consistently supporting me to new levels of learning and opportunity. Each of you and your pets are a part of this book and I am grateful for your constant support. Thanks to my coauthor, whose insight, energy, dedication to the veterinary field, and perseverance has made this second edition a reality. And finally, I dedicate this book in special remembrance of my beloved Einstein (1991–2006), whose teeth are immortalized within the pages of this book. Candyce With heartfelt gratitude, I thank Dede for her patience and friendship, Linda for her continuous support of my endeavors, Megan for teaching me “you can’t push the river,” and, most important, my incredibly supportive family for the sacrifices they have made to allow me to complete this project.
Table of Contents Figure List Preface Acknowledgments Contributors
xvii xxi xxiii xxiii
Section One: Anatomy
3
Chapter 1:
5
Anatomy Anatomy Overall Musculature Skeletal Internal Organs Circulatory System Nervous System Urogenital Eye Ear
6 6 6 7 8 9 10 11 13 13
Section Two: Preventative Care
15
Chapter 2:
Preventative Care and Vaccinations
17
Physical Examinations Preliminary Examination Physical Examination Pediatric Physical Examination Normal Parturition Care and Feeding of Orphaned Puppies and Kittens Geriatric Physical Examination Cardiac Examination Pulmonary Examination Abdominal Examination Otoscopic Examination Regional Lymph Node Examination Neurologic Examination Orthopedic Examination Vaccinations Guidelines to Follow When Vaccinating an Animal
18 19 20 23 26 27 28 30 32 33 33 34 34 36 37 37
Chapter 3:
Canine Transmissible Diseases Coronavirus, Distemper Hepatitis, Infectious Tracheobronchitis Leptospirosis, Lyme Disease Parvovirus, Rabies Canine Vaccination Protocol Feline Transmissible Diseases Feline Calicivirus Feline Infectious Peritonitis Feline Panleukopenia Virus, Feline Immunodeficiency Virus Feline Leukemia Virus, Feline Rhinotracheitis Virus Feline Vaccination Protocol Animal Care Client Education: Home Dental Care Grooming Bathing Nail Trimming Anal Sac Expression Ear Cleaning and Flushing
38 38 39 41 42 44 44 44 46 47
Nutrition
57
General Nutrition Daily Caloric Requirement Worksheet for a Healthy Animal General Life Stage Feeding Guidelines Body Condition Scoring System Disease Nutritional Requirements Obesity Management
58
49 51 51 52 53 53 54 54 55
59 60 62 64 68
Section Three: Diagnostic Skills
69
Chapter 4:
Laboratory
71
Blood Chemistries Blood Collection, Handling, Storage, and Transport Tips
74 74 vii
Blood Collection Tubes Blood Chemistries Bone Marrow Evaluation Bone Marrow Collection, Handling, Storage, and Transport Tips Supplies for Bone Marrow Collection Smear Techniques Evaluation Bone Marrow Evaluation Cell Type Identification Interpretation Cytology Cytology Collection, Handling, Storage, and Transport Tips Collection Techniques FNB Needle and Syringe Selection Smear Techniques Evaluation Cytologic Criteria of Malignancy Figure 4.4: Cytologic Criteria of Malignancy Specific Tumor Cells Interpretation Fecal Cytology Vaginal Cytology Classifying Vaginal Cells Staging the Estrus Cycle Function Tests Hematology Complete Blood Count Hemacytometer Use Calculating a Differential Evaluation RBC Alterations and Morphology WBC Morphology WBC Alterations WBC Left Shift Platelet Morphology Platelet Alterations Coagulation Tests Coagulation Screening Coagulation Tests Blood Transfusions Crossmatching viii
TABLE OF CONTENTS
75 76 83
Blood Typing Immunology and Serology Tests Microbiology Microbiology Collection, Handling, Storage, and Transport Tips Collection Techniques Specimen Storage Most Commonly Used Culture Media Culture Media Inoculation and Incubation Evaluation of Culture Growth Staining Solutions and Procedures Staining Problems Bacteria Identification Fungi Identification Parasitology Fecal Collection, Handling, Storage, and Transport Tips Endoparasite Examination Methods Fecal Flotation Solutions Blood Parasite Examination Methods Ectoparasite Examination Methods Figure 4.35: Relative Size of Parasite Eggs Endoparasites Ectoparasites Urinalysis Urine Collection, Handling, Storage, and Transport Tips Urine Examination/Urinalysis Gross Examination Preparation Chemistry Strip Examination Sediment Examination Reporting of Bacteria and Sperm Sediment Examination Urine Artifacts
83 84 84 85 85 86 88 88 88 88 89 90 91 92 93 94 95 96 97 97 98 98 104 105 108 108 108 108 112 113 114 115 115 115 115 116 119 119
Chapter 5:
120 120 122 122 123 124 125 126 127 127 130 130 133 134 134 134 137 138 139 139 139 145 147 147 147 148 149 149 150 151 151 155
Imaging
157
Radiology Radiographic Equipment Radiographic Exposure and Image Factors Radiographic Technique Chart Example 1: Veterinary X-Ray Technique Guide
159 160 161 161 162
Example 2: Veterinary X-Ray Technique Chart Evaluating Radiograph Technique Exposure Evaluation Density Evaluation Scale of Contrast Evaluation Radiographic Alterations Radiographic Artifacts Radiographic Positioning Directional Terms Positional Terms Soft Tissue Positioning Thorax Abdomen and Pharynx Head Positioning Skull Zygomatic Arch Tympanic Bullae Temporomandibular Joint Nasal Cavities and Sinuses Nasal Cavities and Sinuses (continued) Spine Positioning Cervical Thoracic–Lumbar Sacrum–Caudal Shoulder and Forelimb Positioning Scapula–Shoulder Humerus Elbow Radius/Ulna and Carpus Metacarpus/Phalanges Pelvis and Hindlimb Positioning Pelvis Femur, Stifles, and Tibia/Fibula Tarsus and Metatarsals Radiographic Contrast Studies Types of Contrast Media Fistula Contrast Studies Fistulography Abdominal Contrast Studies Peritoneography Gastrointestinal Tract Contrast Studies Esophagography and Gastrography Upper and Lower Gastrointestinal Study
163 164 164 164 164 166 167 167 168 168 169 169 169 170 170 171 172 172 173 173 174 174 175 175 176 176 176 177 178 178 179 179 180 181 181 182 183 183 183 183 184 184 185
Head Contrast Studies Dacryocystorhinography, Rhinography, and Sialography Spinal and Joint Contrast Studies Myelography and Epidurography Discography and Arthrography Urethra Contrast Studies Urethrography, Canine Urethrography, Feline Vaginal Contrast Studies Vaginography Urinary Tract Contrast Studies Cystography Cystography (continued) Additional Imaging Techniques Computer Tomography and Echocardiography Fluoroscopy Magnetic Resonance Imaging and Nuclear Medicine Ultrasonography Basic Scanning Technique Sites for Ultrasound Scanning
187 187 188 188 189 190 190 191 192 192 193 193 194 195 195 196 196 197 198 198
General Medicine
201
Cardiopulmonary Asthma and Brachycephalic Airway Syndrome Bronchitis and Cardiomyopathy, Hypertrophic Cardiomyopathy, Dilated Cardiomyopathy, Restrictive and Congenital Heart Disease Endocardiosis and Heartworm Disease Congestive Heart Failure Hypertension and Myocarditis Pneumonia and Pleural Effusion Rhinitis/Sinusitis and Tracheal Collapse Dermatology Acne Acral Lick Dermatitis, Atopy, and Flea Allergy Dermatitis Food Hypersensitivity and Otitis Externa Pyoderma
204 204 205 208
Color Plate Chapter 6:
TABLE OF CONTENTS
210 211 214 215 217 219 220 220 222 224 225 ix
Endocrinology and Reproduction Abortion and Diabetes Insipidus Diabetes Mellitus Dystocia and Eclampsia Hyperadrenocorticism and Hyperparathyroidism Hyperthyroidism and Hypoadrenocorticism Hypoparathyroidism, Hypothyroidism, and Mastitis Pregnancy and Pyometra Gastroenterology Anal Sac Disease, Cholangitis, and Cholangiohepatitis Constipation and Megacolon Diarrhea Exocrine Pancreatic Insufficiency and Gastric Dilatation-Volvulus Hepatic Disease/Failure Hepatic Lipidosis and Inflammatory Bowel Disease Megaesophagus Pancreatitis and Peritonitis Protein-Losing Enteropathy and Vomiting Hematology Anemia and Disseminated Intravascular Coagulation Thrombocytopenia and von Willebrand’s Disease Infectious Diseases Brucellosis and Erhlichiosis Rocky Mountain Spotted Fever and Salmon Poisoning Tetanus and Toxoplasmosis Musculoskeletal Arthritis Cruciate Disease and Hip Dysplasia Osteochondrosis and Osteomyelitis Patellar Luxation and Panosteitis Neurology Encephalitis and Epilepsy Intervertebral Disc Disease and Meningitis Myasthenia Gravis and Myelopathy Vestibular Disease and Wobbler Syndrome Oncology Neoplasia Histiocytoma, Mammary Gland Neoplasia, and Mast Cell Tumor Various Neoplasias x
TABLE OF CONTENTS
227 227 228 230 231 233 235 237 238
Ophthalmology Anterior Uveitis and Cataracts Conjunctivitis and Entropion Cilia Disorders and Glaucoma Keratitis and Keratoconjunctivitis Sicca Lens Luxation and Prolapsed Gland of the Third Eyelid Urology Cystic Calculi, Feline Lower Urinary Tract Disease, and Pyelonephritis Renal Failure Urinary Tract Obstruction and Urinary Tract Infection
238 240 241 243 245 246 248 249 251 253 253 254 256 256 258 259 261 261 263 264 266 267 267 269 271 272 273 273 275 277
Chapter 7:
284 284 285 287 288 290 292 292 294 296
Emergency Medicine
299
Emergency Medicine Emergency Supplies Telephone Assessment and Emergency Transportation Recommendations Inducing Vomiting At-Home Triage Primary Survey Hemostasis Cardiopulmonary Cerebrovascular Resuscitation (CPCR) Secondary Survey Shock Cardiovascular Emergencies Environmental Emergencies Gastrointestinal Emergencies Hematologic Emergencies Metabolic and Endocrine Emergencies Neonatal Emergencies Neonatal Resuscitation Post-Cesarean Neurologic Emergencies Ophthalmic Emergencies Renal and Urinary Emergencies Reproductive and Genital Emergencies Respiratory Emergencies Toxicologic Emergencies Toxins Trauma Emergencies
301 301 304 305 306 306 307 308 309 310 312 313 314 315 316 317 317 318 319 320 321 322 323 324 326
Section Four: Patient Care Skills
327
Chapter 8:
Patient Care
329
Patient Monitoring Blood Pressure Blood Pressure Procedure Blood Pressure Results Central Venous Pressure Blood Gas Analysis Blood Gas Analysis Arterial Blood Gas Interpretation Acid-Base Disturbances Electrocardiogram ECG Procedure ECG Leads ECG Interpretation Figure 8.1 Normal Canine Electrocardiogram Heart Rate Calculation Common Rhythm Abnormalities Figure 8.2 Atrial Premature Contraction/Complex Figure 8.3 ST-Segment Elevation Figure 8.4 Ventricular Premature Contraction/ Complex ECG Problems and Artifacts Heat Administration Recumbent Patient Care Drug Administration Injections Intravenous Catheter Placement Peripheral and Jugular Arterial and Intraosseous Monitoring and Maintenance Chemotherapy Administration Toxicity Client Education: Monitoring Chemotherapy Response Insulin Therapy Client Education: Insulin Administration Client Education: Monitoring Insulin Response Client Education: Monitoring for Hypoglycemia Fluid Therapy Hydration Assessment
332 332 332 333 334 335 335 337 337 338 338 339 340 341 342 343 344 344 344 345 346 347 348 348 349 349 350 351 352 352 353 356 357 357 358 359 359 360
Chapter 9:
Calculating Fluid Requirements Routes of Fluid Administration Commonly Used Fluids Fluid Additives Calculating Drip Rates Monitoring Fluid Therapy Blood Transfusions Blood Types Blood Collection Blood Products Blood Administration Blood Transfusion Reactions Oxygen Therapy Oxygen Administration Routes of Oxygen Administration Oxygen Hood and Nasal Catheter Transtracheal Catheter and Tracheostomy
361 362 363 365 365 366 367 368 369 371 373 374 375 375 376 376 377
Pain Management
379
Pain Management Pain Assessment Pain Scales Instructions for Using the CSU Acute Pain Scale Pain Levels Associated With Surgical Procedures, Injuries, and Illness Behaviors Suggesting Pain and Anxiety Nondrug Approach to Decrease Pain and Anxiety Pain Management Drugs Pain Management Techniques Constant Rate Infusions Setting Up a Morphine/Lidocaine/Ketamine Constant Rate Infusion
380 381 381
Chapter 10: Wound Care
382 383 384 386 386 392 392 393
395
Wound Treatment and Bandaging Wound Healing Process Classification of Wounds Factors Affecting the Healing Process Wound Care TABLE OF CONTENTS
396 396 397 398 399 xi
Wound Cleaning Solutions Topical Wound Medications Wound Bandaging Bandage Care Bandaging Basic Bandage Robert Jones Bandage Chest/Abdominal Bandage Distal Limb Splint Casts Ehmer Sling 90–90 Flexion Velpeau Sling Hobbles Chapter 11: Parenteral Nutrition Nutritional Support Tips on Encouraging Oral Nutrition Enteral Nutrition Coax Feeding and Orogastric Tube Nasoesophageal/Nasogastric Tube Esophagostomy Tube Gastrotomy Tube Without Gastropexy Gastrotomy Tube With Gastropexy Jejunostomy Tube Enteral Nutrition Administration Parenteral Nutrition Parenteral Nutrition Parenteral Nutrition Administration Worksheet for Calculating Total Parenteral Nutrition (TPN) Worksheet for Calculating Peripheral or Partial Parenteral Nutrition (PPN)
Chapter 12: Medical Procedures Gastrointestinal Procedures Stomach Tube and Gastric Lavage Gastrointestinal Tube Placement Verification Abdominocentesis and Diagnostic Peritoneal Lavage Enema, Warm Water xii
TABLE OF CONTENTS
401 402 403 404 405 405 406 407 408 408 409 410 410 411 413 414 414 414 414 415 417 418 419 420 421 422 423 424 425 426
427 428 428 429 429 430
Ophthalmic Procedures Schirmer Tear Test, Fluorescein Sodium Stain, and Tonometry Respiratory Procedures Thoracocentesis and Thoracostomy Tube Placement Nebulization, Coupage, and Metered-Dose Inhalers Urogenital Procedures Urine Collection Urine Collection Devices Urinary Catheterization Urinary Catheter Maintenance
430 430 431 431 432 434 434 435 435 436
Section Five: Anesthesia and Anesthetic Procedures
437
Chapter 13: Anesthesia
439
Guidelines for Safe Anesthesia Preanesthetic Preanesthetic Evaluation Case-Based Anesthesia Preanesthetic Drugs Anesthesia Anesthetic Administration Anesthetic Machine Machine Setup Anesthetic Breathing Systems Anesthetic Administration General Anesthesia Induction Endotracheal Intubation Figure 13.1 Endotracheal Intubation Endotracheal Complications Perioperative Patient Care Intermittent Positive-Pressure Ventilation (IPPV) Anesthetic Monitoring Stages of Anesthesia Anesthesia Monitoring Postanesthesia Recovery Postanesthetic Monitoring Local and Regional Anesthesia Ventilation
441 442 442 444 451 451 451 451 451 452 453 453 454 455 456 456 456 458 458 458 460 466 466 467 470 474
General Information Administration Anesthetic Drugs Preanesthetic Drugs Anticholinergic Drugs Atropine and Glycopyrrolate Phenothiazines Acepromazine Maleate Benzodiazepines Diazepam and Midazolam α2-Agonists Xylazine and Medetomidine Opioids Butorphanol and Buprenorphine Fentanyl and Hydromorphone Morphine Sulfate and Oxymorphone HCl Injectable Induction Anesthetics Barbituates Thiobarbituates and Methylated Barbituates Cyclohexamines Ketamine and Tiletamine Propofol Propofol (continued) Etomidate Etomidate (continued) Inhalant Anesthetics Halothane and Isoflurane Sevoflurane Chapter 14: Dentistry Dentistry Anatomy Figure 14.1: Dentition: Canine and Feline Figure 14.2: Cross Section of a Triple-Rooted Tooth Figure 14.3: Skeletal Structure: Canine and Feline Figure 14.4: Cross Section of Facial Structures: Canine and Feline Dental Instruments and Equipment Hand-held Instruments Figure 14.5: Hand-held Non-mechanical Dental Instruments Instrument Maintenance
474 475 477 477 477 478 478 479 480 480 481 482 484 485 486 487 488 488 489 490 491 492 492 493 494 494 495 496 497 499 499 499 500 500 501 501 501 502 502
Sharpening Technique Mechanical Instruments Dental Prophylaxis Dental Cleaning Procedure Dental Charting Figure 14.6: Sample of Patient’s Dental Health Chart Common Dental Disorders Anatomical Disorders Pathologic Disorders Dental Radiology Equipment Technique Chart Radiographic Film Radiographic Techniques Radiographic Positioning Extractions General Extraction Procedures Local Dental Nerve Blocks Chapter 15: Surgery
503 503 504 504 506 509 510 510 511 512 512 512 513 513 514 517 517 518 521
Instrument Packs Preoperative Protocol Surgical Procedures Abdominal Surgery Abdominal Hernia, Anal Sacculectomy, and Colotomy Enterotomy, Gastric-Dilatation Volvulus, and Gastrotomy Intestinal Resection and Anastomosis and Hepatectomy Aural Surgery Aural Hematoma and Lateral Ear Canal Resection Integumentary Surgery Abscess and Laceration Mass Removal and Onychectomy Neurologic Surgery Disc Fenestration, Dorsal Laminectomy, and Hemilaminectomy Ophthalmic Surgery Cataracts, Ectropion, and Entropion Conjunctival Flap and Enucleation TABLE OF CONTENTS
523 524 525 525 526 528 529 530 530 531 532 533 534 535 536 537 538 xiii
Glaucoma and Nictitating Membrane Flap Replacement Prolapse of the Gland of the Third Eyelid and Traumatic Proptosis Orthopedic Surgery Cranial Cruciate Ligament Repair, Femoral Head Ostectomy, and Fracture Repair Patellar Luxation, Total Hip Replacement, and Triple Pelvic Osteotomy Reproductive Tract Surgery Cesarean Section, Orchiectomy, and Ovariohysterectomy Postoperative Care of Neonates and Dam Thoracic Surgery Diaphragmatic Hernia, Laryngeal Paralysis, and Sternotomy Thoracotomy and Tracheal Collapse Urogenital Tract Surgery Cystotomy and Urethrostomy, Perineal Urethrostomy, Scrotal, and Urethrostomy, Prescrotal Suture Techniques Suture Patterns Knot Tying Postoperative Care Protocol Standard Postoperative Care Instructions Preventing Self-Trauma Alternative Surgical Options Endoscopy: Flexible Gastrointestinal and Rigid Laser Surgery Radiation Therapy: Teletherapy, Brachytherapy and Systemic Therapy Temperature Therapy: Hyperthermia and Cryosurgery
538 539 539 540 541 542 542 544 544 545 546 547 547 548 548 548 549 550 550 550 551 551 552 553 554
Section Six: Complementary and Alternative Veterinary Medicine and Pharmacology
555
Chapter 16: Complementary and Alternative Veterinary Medicine
557
Complementary and Alternative Veterinary Medicine (CAVM) Physical Therapy and Rehabilitation Traditional Chinese Medicine
558 558 562
xiv
TABLE OF CONTENTS
Ayurveda and Chiropractic Flower Essences and Homeopathy Laser Therapy Magnetic Field Therapy Western Herbal Medicine Chapter 17: Pharmacology Pharmacology Basic Calculations Drug Cross-Reference Antifungal Drugs Anti-infective Drugs Aminoglycosides, Cephalosporins, and Chloramphenicol Fluoroquinolones, Lincosamides, and Metronidazole Penicillin, Sulfonamides, and Tetracyclines Antiparasitic Drugs Antinematodals Antinematodals (continued) Anticestodals Ectoparasitics Ectoparasitics (continued) Cancer/Chemotherapy Drugs Alkylating Agents Anthracycline Antibiotics Antimetabolites Enzyme, Immunomodulating, Synthetic Hormone, and Vinca Alkaloid Cardiovascular Drugs Antianemics Antiarrhythmics Anticoagulants and Calcium Supplements Contractility Enhancers and Positive Inotropic Agents Diuretics Vasodilators Dermatologic Drugs Antiseborrheics Antipruritics/Antihistamines Gastrointestinal Drugs Antidiarrheals Antiemetics
563 564 565 565 566 567 570 570 571 574 575 575 576 577 578 578 579 579 580 580 581 581 582 583 584 585 585 586 587 588 589 590 591 591 591 592 592 593
Antiulcer Agents Emetics Enzyme, Laxatives, and Lubricants Protectants and Stool Softener Hepatic Drugs Supplements Metabolic Drugs Adrenal Cortex Pancreatic Pancreatic (continued) Parathyroid and Thyroid Musculoskeletal Drugs Anti-inflammatory Drugs Nonsteroidal Anti-inflammatory Drugs Nonsteroidal Anti-inflammatory Drugs (continued) Nonsteroidal Anti-inflammatory Drugs (continued) Protectant, Muscle Relaxer, and Supplement Neurologic Drugs Appetite Stimulator and Cholinergics Autonomic Nervous System: Adrenergic Agents: Alpha Stimulators Central Nervous System: Anticonvulsants Euthanasia Agents and Muscle Relaxers Analgesics Analgesic/Anticonvulsant, NMDA Antagonist, and Narcotic Agonist Analgesic: Opioids Analgesic: Opioids (continued) Behavioral: Antidepressants Ophthalmic Drugs Adrenergic Agonist, Carbonic Anhydrase Inhibitors, and Immunosuppressant Miotics, Mydriatics/Cycloplegics, Topical Anesthetics, and Stains
594 595 596 597 598 598 599 599 600 601 601 602 602 603 604 605 605 606 606 607 607 608 609 610 611 612 613 613 613
Otic Drugs Topical Anti-infectives Renal/Urinary Drugs Acidifers, Adrenergic Agent. and Alkalinizing Agent Alpha-Adrenergic Agent, Antibacterial/Acidifer, Anabolic Steroid, and Cholinergic Enzyme Inhibitor and Tricyclic Antidepressant Reproductive System Drugs Androgens, Estrogens, and Gonadotrpins Oxytocin, Progestins, and Prostaglandin Respiratory Drugs Antitussives Bronchodilators and Mucolytics Stimulants Toxicologic Drugs Chelating Drugs and Synthetic Alcohol Dehydrogenase Inhibitor Appendix
615 615 616 616 617 618 619 619 620 621 621 622 623 624 624 625 625 625 626 626 627 627 628
Metric Units Weights Liquid Measure Length Kilograms to Body Surface Area Temperature Conversion Disinfectants Glossary Abbreviations Bibliography Index
631 647 651 661
614
TABLE OF CONTENTS
xv
Figure List Chapter 1: Anatomy Figure 1.1 Overall Figure 1.2 Regional Lymph Nodes Figure 1.3 Musculature: Lateral View Figure 1.4 Skeletal: Lateral View Figure 1.5 Skeletal: Dorsal View Figure 1.6 Internal Organs: Left Lateral View Figure 1.7 Internal Organs: Right Lateral View Figure 1.8 Internal Organs: Ventral View Figure 1.9 Circulation: Dorsal View of Heart Figure 1.10 Circulation: Internal View of Heart Figure 1.11 Circulation: Heart Valves Figure 1.12 Circulatory: Lateral View Figure 1.13 Nervous System: Lateral View of Brain Figure 1.14 Nervous System: Lateral View Figure 1.15 Urogenital: Ventral View, Female Figure 1.16 Urogenital: Ventral View, Male Figure 1.17 Urogenital: Lateral View, Male Figure 1.18 Eye Figure 1.19 Ear
6 6 6 7 7 8 8 8 9 9 10 10 10 11 11 12 12 13 13
Chapter 3: Nutrition Table 3.2 Body Condition Score
61
Chapter 4: Laboratory Figure 4.4 Cytologic Criteria of Malignancy Figure 4.35 Relative Size of Parasite Eggs
93 139
Chapter 5: Imaging Table 5.4 Scale of Contrast Evaluation Table 5.7 Directional terms
165 168
Chapter 8: Patient Care Figure 8.1 Normal Canine Electrocardiogram Figure 8.2 Atrial Premature Contraction/Complex Figure 8.3 ST-Segment Elevation Figure 8.4 Ventricular Premature Contraction/Complex
341 344 344 344
Chapter 10: Wound Care Box 10.3 Basic Bandage Box 10.4 Robert Jones Bandage Box 10.5 Chest/Abdominal Bandage Box 10.6 Distal Limb Splint Box 10.7 Casts Box 10.8 Ehmer Sling Box 10.9 90–90 Flexion Box 10.10 Velpeau Sling Box 10.11 Hobbles
405 406 407 408 408 409 410 410 411
Chapter 13: Anesthesia Figure 13.1 Endotracheal Intubation
455
Chapter 14: Dentistry Figure 14.1 Dentition: Canine and Feline Figure 14.2 Cross Section of a Triple-Rooted Tooth Figure 14.3 Skeletal Structure: Canine and Feline Figure 14.4 Cross Section of Facial Structures: Canine and Feline Figure 14.5 Hand-held Nonmechanical Dental Instruments Figure 14.6 Sample of a Patient’s Dental Health Chart Table 14.10 Radiographic Positioning
499 500 500 501 502 509 514
Color Plate Anatomy Figure 1.6 Internal Organs: Left Lateral View Figure 1.7 Internal Organs: Right Lateral View Figure 1.8 Internal Organs: Ventral View Figure 1.9 Circulatory: Dorsal View of Heart Figure 1.10 Circulatory: Internal View of Heart Figure 1.12 Circulatory: Lateral View Figure 1.14 Nervous System: Lateral View Bone Marrow Figure 4.1 Canine Bone Marrow Figure 4.2 Canine Bone Marrow Figure 4.3 Maturation Stages of Megakaryocytes Tumor Cytology Figure 4.5 Histiocytoma
CP-1 CP-1 CP-1 CP-1 CP-2 CP-2 CP-2 CP-3 CP-3 CP-3 CP-4 xvii
Figure 4.6 Lymphoma Figure 4.7 Mast Cell Tumor Fecal Cytology Figure 4.8 Clostridium Figure 4.9 Giardia Figure 4.10 Campylobacter Figure 4.11 Spirochetes Figure 4.12 Yeast Hematology Figure 4.13 Canine Blood Smear Figure 4.14 Canine Distemper Figure 4.15 Feline Blood Smear Figure 4.16 Canine Blood Smear Figure 4.17 Feline Blood Smear Figure 4.18 Feline Blood Smear Figure 4.19 Canine Blood Smear Figure 4.20 Canine Blood Smear Figure 4.21 Babesia canis Figure 4.22 Cytauxoon felis Figure 4.23 Neutrophils Figure 4.24 Lymphocytes Figure 4.25 Monocytes Figure 4.26 Canine Blood Smear Figure 4.27 Eosinophils Figure 4.28 Basophils Figure 4.29 Canine Blood Smear Figure 4.30 Feline Blood Smear Figure 4.31 Canine Blood Smear Figure 4.32 Canine Blood Smear Figure 4.33 Blood Smear Ear Cytology Figure 4.34 Malessezia Endoparasites Figure 4.36 Ancylostoma caninum Figure 4.37 Ancylostoma tubaeforme Figure 4.38 Crytosporidium Figure 4.39 Didylidium caninum Figure 4.40 Dirofilaria immitis Figure 4.41 Echinococcus granulosus Figure 4.42 Giardia Figure 4.43 Isospora spp. Figure 4.44 Taenia spp. Figure 4.45 Toxocara canis xviii
FIGURE LIST
CP-4 CP-4 CP-4 CP-5 CP-5 CP-5 CP-5 CP-6 CP-6 CP-6 CP-6 CP-7 CP-7 CP-7 CP-7 CP-8 CP-8 CP-8 CP-8 CP-9 CP-9 CP-9 CP-9 CP-10 CP-10 CP-10 CP-10 CP-11 CP-11 CP-11 CP-11 CP-12 CP-12 CP-12 CP-12 CP-12 CP-12 CP-12 CP-12
Figure 4.46 Figure 4.47 Figure 4.48 Figure 4.49 Ectoparasites Figure 4.50 Figure 4.51 Figure 4.52 Figure 4.53 Figure 4.54 Figure 4.55 Figure 4.56 Figure 4.57 Figure 4.58 Urinalysis Figure 4.59 Figure 4.60 Figure 4.61 Figure 4.62 Figure 4.63 Figure 4.64 Figure 4.65 Figure 4.66 Figure 4.67 Figure 4.68 Figure 4.69 Figure 4.70 Figure 4.71 Figure 4.72 Figure 4.73 Figure 4.74 Figure 4.75 Figure 4.76 Figure 4.77 Figure 4.78 Figure 4.79 Figure 4.80 Figure 4.81 Figure 4.82 Figure 4.83 Figure 4.84 Figure 4.85 Figure 4.86
Toxocara cati Toxoplasma gondii Trichuris vulpis Uncinaria stenocephala
CP-13 CP-13 CP-13 CP-13
Cheyletiella Ctenocephalides canis Demodex canis Dermacentor variabilis Linognathus setosus Otodectes cynotis Rhipicehpalus sanguineus Sarcoptes scabiei canis Trichodectes canis
CP-13 CP-13 CP-13 CP-13 CP-14 CP-14 CP-14 CP-14 CP-15
Bacteria Bacteria Bacteria White Blood Cells White Blood Cells Epithelial Cells Epithelial Cast Fatty Cast Granular Cast Hyaline Cast Red Blood Cell Cast White Blood Cell Cast Waxy Cast Amorphous Phosphate Crystals Amorphous Urate Crystals Amorphous Biurate Crystals Bilirubin Crystals Calcium Carbonate Crystals Calcium Oxalate Dihydrate Crystals Cystine Crystals Leucine Crystals Sulfonamide Crystals Triple Phosphate Crystals Tyrosine Crystals Uric Acid Crystals Renal Epithelial Cells Squamous Epithelial Cells Transitional Epithelial Cells
CP-15 CP-16 CP-16 CP-16 CP-16 CP-17 CP-17 CP-17 CP-17 CP-18 CP-18 CP-18 CP-19 CP-19 CP-19 CP-19 CP-20 CP-20 CP-20 CP-20 CP-20 CP-20 CP-21 CP-21 CP-21 CP-21 CP-21 CP-21
Figure Figure Figure Figure
4.87 4.88 4.89 4.90
Epithelial Cells and Lipid Droplets Capillaria plica Starch Granules Yeast
CP-22 CP-22 CP-22 CP-22
Pain Scales Figure 9.1 CSU Canine Acute Pain Scale Figure 9.2 CSU Feline Acute Pain Scale
CP-23 CP-24
FIGURE LIST
xix
Preface This second edition of Veterinary Technician’s Daily Reference Guide: Canine and Feline continues from the success of the first edition. As our profession continues to grow and demand more of veterinary technicians, this reference guide has done the same. With the obvious inclusion of updated medical information, this second edition contains an expansive amount of more in-depth skill descriptions allowing the technician to reach an even higher level of care. Its purpose is not to present ideas for the first time but rather to refresh or expand the veterinary technician’s current knowledge. This manual provides the link between the formal learning environment and the daily clinical setting. The goals are to increase confidence and technical skill and to allow veterinary technicians to provide clear client education. This book covers all areas of the veterinary technology profession pertinent to canines and felines, from the basics of physical examinations to advanced skills of chemotherapy administration. We are confident that the veterinary technician will find a daily need for this invaluable resource. In the end, it is our goal that this book will facilitate improved care for patients and the owners who rely on experienced veterinary technicians.
SUMMARY OF KEY FEATURES Comprehensive Guide. This book was written as a quick reference guide. Its purpose is to assist an already trained and licensed veterinary technician throughout the work day—providing a refresher for a seldom-taken radio-
graph, for example, or a pharmacology reminder to help answer a client’s question. The veterinary technology student will also find this book useful as a supplement to more in-depth textbooks as they finish training and join the workforce. Unique Chart and Table Format. The format of this book uses charts and tables for the efficient retrieval of pertinent information. As a result, very little prose text has been included. This unique format leads technicians straight to the answers they need to perform a task quickly. Extensive Art Program. The art program, which includes more than 200 illustrations and photographs, will provide visual assistance to the technician performing laboratory tests, dentistry, client education, and much more. The color insert makes the artwork very clear and easy to use. Expansive Indexing. A comprehensive table of contents and references at the beginning and throughout each chapter will ease the movement through this information-rich text. It is our expectation that this book will be of great assistance to the veterinary technician. Use of this book should result in enhanced performance of a veterinary technician’s duties and, therefore, improved care for patients. Candyce Jack, LVT Patricia Watson, LVT
xxi
Acknowledgments We would like to express our heartfelt thanks to all the people who gave support and guidance during the forming of this book. We also appreciate the professional courtesy extended by Phoenix Laboratory, DentaLabels, Wiley-Blackwell, American Society of Anesthesiologists, Dr. Peter Hellyer, Dr. Narda Robinson, Tara Raske, International Veterinary Association of
Pain Management, Greg deBoer, Anne Rains, Dr. David Stansfield, Novartis, Dr. James H. Meinkoth, Oklahoma State University, Gary Averbeck, Dr. Robert K. Ridley, Kansas State University, and Dr. Jay R Georgi, Dr. Daniel Chan, and Mikki Cook, LVT, Hill’s Pet Nutrition, Animal Emergency and Trauma Center.
Contributors Dina Andrews, DVM, PhD, Dip. ACVP Lisa Coyne, LVT Cindy Elston, DVM J. Michael Harter, DVM Joyce Knoll, VMD, PhD, Dip. ACVP Brita Kraabel, DVM Bob Kramer, DVM, Dip. ACVR Veronica Martin, LVT Linda Merrill, LVT, VTS (Small Animal Internal Medicine)
Kathryn Michel, DVM, MS, Dip. ACVN Jeb Mortimer, DVM Richard Panzer, DVM, MS Patrick Richardson, DVM Nancy Shaffran, CVT, VTS (ECC) Stuart Spencer, DVM Cheryl Stockman, MT (ASCP) Laura Tautz-Hair, LVT, VTS (ECC) Sandy Willis, DVM, MVSc, Dip. ACVIM
xxiii
Veterinary Technician’s Daily Reference Guide: Canine and Feline Second Edition
Section
One
Anatomy
Chapter
1
1
Anatomy Anatomy 6 Figure 1.1. Overall 6 Figure 1.2. Regional Lymph Nodes 6 Musculature 6 Figure 1.3. Musculature: Lateral View 6 Skeletal 7 Figure 1.4. Skeletal: Lateral View 7 Figure 1.5. Skeletal: Dorsal View 7 Internal Organs 8 Figure 1.6. Internal Organs: Left Lateral View 8 Figure 1.7. Internal Organs: Right Lateral View 8 Figure 1.8. Internal Organs: Ventral View 8 Circulatory System 9 Figure 1.9. Circulatory: Dorsal View of Heart 9 Figure 1.10. Circulatory: Internal View of Heart 9
Figure 1.11. Circulatory: Heart Valves 10 Figure 1.12. Circulatory: Lateral View 10 Nervous System 10 Figure 1.13. Nervous System: Lateral View of Brain Figure 1.14. Nervous System: Lateral View 11 Urogenital 11 Figure 1.15. Urogenital: Ventral View, Female 11 Figure 1.16. Urogenital: Ventral View, Male 12 Figure 1.17. Urogenital: Lateral View, Male 12 Eye 13 Figure 1.18. Eye 13 Ear 13 Figure 1.19. Ear 13
10
5
1
ANATOMY For a veterinary technician to be able to accurately complete many of his or her daily tasks, a clear understanding of the anatomy of the canine and feline body is needed. The following diagrams show the basic layout of the body systems, highlighting the areas of interest that are most commonly accessed in daily medicine practices ranging from the correctly positioned radiograph to a single-stick venipuncture.
Overall See Skill Box 2.6 Regional Lymph Node Examination, page 34.
Figure 1.2 Regional lymph nodes.
Musculature Sternocephalicus Cleidocervicalis External Trapezius abdominal Latissimus oblique dorsi
Middle gluteal Superficial gluteal Biceps femoris
Deltoids
Cleidobrachialis
Figure 1.1 Overall.
Pectoralis major Triceps
Sartorius Deep Gracilis pectoral Pectoralis minor Semitendinosus
Figure 1.3 Musculature: lateral view.
6
SECTION ONE: ANATOMY
Gastrocnemius
Skeletal
1
See Skill Box 2.8 Orthopedic Examination, page 36. Orbit
Zygomatic arch
Zygomatic arch Atlas Axis Cervical Spinous Iliac Thoracic process Lumbar crest Ilium Ischial tuberosity Greater trochanter
Maxilla
Mandible Spine of scapula Scapula
Wing of atlas
Axis
T1
Sacrum Ischium Costal arch
Ribs Humerus Ulna
Spine of scapula
Scapula
Xyphoid Patella Sternum Fibula Ulna
Radius Carpus Metacarpus
Femur
Atlas
Tibia Tarsus Metatarsus
L1 Phalanges
Figure 1.4 Skeletal: lateral view.
Iliac crest Ilium Greater trochanter of femur
Sacrum
Ischial tuberosity
Figure 1.5 Skeletal: dorsal view.
CHAPTER 1 / ANATOMY
7
1
Internal Organs
Esophagus
See Skill Box 2.4 Abdominal Examination, page 33. See Color Plates 1.6–1.8. CP-1.
Trachea
Lung
Heart Uterine horn Ovary
Ureter Colon
Right kidney
Lungs
Anus
Diaphragm
Liver
Liver
Gall bladder Common bile duct Liver Duodenum Pancreas Transverse colon Ascending colon Cecum
Liver Heart Greater omentum (covering small intestines)
Urinary bladder
Figure 1.6 Internal organs: left lateral view.
Rectum Esophagus Trachea
Lungs
Spleen
Stomach
Liver
Thymus
Ureter
Small intestines Urinary bladder
Figure 1.7 Internal organs: right lateral view.
SECTION ONE: ANATOMY
Spleen Jejunum Ileum
Descending colon
Mesentery
Anal gland
Left kidney
Heart (cardiac notch)
8
Lesser omentum Stomach Greater omentum (cut)
Colon
Figure 1.8 Internal organs: ventral view.
Circulatory System
Left subclavian artery
See Skill Box 2.2 Cardiac Examination, page 30. See Color Plates 1.9, 1.10, and 1.12. CP-1, 2.
1
Aorta Superior vena cava
Left subclavian artery
Superior vena cava
Right auricle
Right atrium
Aortic arch Pulmonary arteries Left atrium
Pulmonary veins
Left auricle
Right atrium
Tricuspid valve Right ventricle
Pulmonary veins Left ventricle
Apex
Inferior vena cava
Coronary artery Right ventricle Apex
Semilunar valves of aorta
Left atrium
Figure 1.9 Circulatory: dorsal view of heart.
Bicuspid valve Left ventricle
Chordae tendineae Ventral papillary muscle
Figure 1.10 Circulatory: internal view of heart.
CHAPTER 1 / ANATOMY
9
1
Figure 1.12 Circulatory: lateral view.
Nervous System See Color Plate 1.14. CP-2.
Epithalamus
Corpus collosum
Figure 1.11 Circulatory: heart valves. Cerebellum
Olfactory bulb Optic chiasm
Spinal cord
Thalamus Medulla oblongata
Hypothalamus
Pituitary
Figure 1.13 Nervous system: lateral view of brain.
10
Urogenital
Vagosympathetic trunk Brachial plexus
Lumbo-sacral plexus
1
See Skill Box 2.4 Abdominal Examination, page 33. See Skill Box 12.10 Urinary Catheterization, page 435.
Vagus Sciatic
Diaphragm
Femoral Radial
Esophagus
Adrenal gland
Tibial
Median Kidney Ulnar
Uterine tube
Figure 1.14 Nervous system: lateral view.
Ovarian ligament
Ovary Colon
Ureter Round ligament
Broad ligament
Uterus: Horn Body
Urinary bladder
Urethra Rectum Vagina
Anal gland
Figure 1.15 Urogenital: ventral view, female.
CHAPTER 1 / ANATOMY
11
Kidneys
1
Colon Diaphragm
Esophagus
Prostate gland
Adrenal gland
Kidney
Urethra Ureter Urinary bladder Spermatic cord Prepuce Ureter
Colon
Ductus deferens Epididymis
Urinary bladder
Testis Prostate gland
Spermatic cord Urethra Rectum
Bulbourethral gland Ductus deferens
Penis Prepuce Glans penis
Epididymis Anal gland
Testis
Figure 1.16 Urogenital: ventral view, male.
12
SECTION ONE: ANATOMY
Os penis
Glans penis
Figure 1.17 Urogenital: lateral view, male.
Eye
Ear Bulbar conjunctiva
Sclera
1
See Skill Box 2.5 Otoscopic Examination, page 33. See Skill Box 2.13 Ear Cleaning and Flushing, page 55.
Posterior chamber Choroid Retina
Pinna Iris Cornea
Vitreous humor Lens Optic disc
Anterior chamber
Third eyelid
Suspensory ligament
Optic nerve
Palpebral conjunctiva Vertical auditory canal
Figure 1.18 Eye.
Semicircular canals Vestibule Cochlea
Oval window
Horizontal auditory canal
Auditory nerve
Round window Tympanic membrane Middle ear cavity Eustachian tube (auditory)
Figure 1.19 Ear.
CHAPTER 1 / ANATOMY
13
Section
Two
Preventative Care Chapter 2: Preventative Care and Vaccinations Chapter 3: Nutrition 57
17
Chapter
2
2
Preventative Care and Vaccinations Physical Examinations 18 Preliminary Examination 19 Physical Examination 20 Pediatric Physical Examination 23 Normal Parturition 26 Care and Feeding of Orphaned Puppies and Kittens 27 Geriatric Physical Examination 28 Cardiac Examination 30 Pulmonary Examination 32 Abdominal Examination 33 Otoscopic Examination 33 Regional Lymph Node Examination 34 Neurologic Examination 34 Orthopedic Examination 36 Vaccinations 37 Guidelines to Follow When Vaccinating an Animal 37 Canine Transmissible Diseases 38 Coronavirus, Distemper 38
Hepatitis, Infectious Tracheobronchitis 39 Leptospirosis, Lyme Disease 41 Parvovirus, Rabies 42 Canine Vaccination Protocol 44 Feline Transmissible Diseases 44 Feline Calicivirus 44 Feline Infectious Peritonitis 46 Feline Panleukopenia Virus, Feline Immunodeficiency Virus 47 Feline Leukemia Virus, Feline Rhinotracheitis Virus 49 Feline Vaccination Protocol 51 Animal Care 51 Client Education: Home Dental Care 52 Grooming 53 Bathing 53 Nail Trimming 54 Anal Sac Expression 54 Ear Cleaning and Flushing 55
17
Key Words and Phrasesa Alopecia Amyloid Axillary Canarypox vector Core Cryptorchidism Desquamative Diathesis ELISA Encephalopathy Epistaxis Fistula Fontanelle Granulomatous Halitosis Hemoagglutination Hyaluronic acid Hyperpathia Intussusception Lymphadenopathy
2
a
Lyophilized Melena Noncore Nystagmus Panniculus Papilloma PCR Petechia Prodromal Proprioception Proteoglycan Rales Rhonchi Stenosis Strabismus T-lymphocytes Tortuous, redundant aorta Vascularity Western blot Whelping
Abbreviations
Additional Resources, page
APTT, activated thromboplastin time BCS, body condition score BUN, blood urea nitrogen CBC, complete blood count CNS, central nervous system CPV, canine parvovirus CSF, cerebrospinal fluid DIC, disseminated intravascular coagulation ELISA, enzyme-linked immunosorbent assay F, Fahrenheit FCV, feline calicivirus FECV, feline enteric coronavirus FeLV, feline leukemia FHV-1, feline viral rhinotracheitis FIP, feline infectious peritonitis FIV, feline immunodeficiency virus FPV, feline panleukopenia GIT, gastrointestinal tract IFA, immunofluorescent assay IgG, immunoglobulin gamma G IgM, immunoglobulin gamma M IN, intranasal O2, oxygen OVH, ovariohysterectomy PCR, polymerase chain reaction PT, prothrombin time RBC, red blood cell RV, rabies vaccine SQ, subcutaneously v, variable
Abdominocentesis, 429 Anesthesia, 439 Blood transfusions, 367 CBC, 105 Cesarean section, 542 Chemistry panel, 74 Coagulation tests, 115 Coupage, 432 Dentistry, 497 Ear cytology, 88 Figure: Ear, 13 Figure: Heart, 9 Figure: Internal organs, 8 Figure: Heart valves, 10 Figure: Lymph nodes, 6 Fluid therapy, 359 General medicine, 201 Heat administration, 346 Injections, 348 Laboratory, 71 Microbiology, 122 Nebulization, 432 Nutritional support, 414 Oxygen therapy, 375 Pharmacology, 567 Physical examination, 18 Physical therapy, 558 Radiology, 159 Surgery, 521 Thoracocentesis, 431 Urinalysis, 147
Key words and terms are defined in the glossary on page 631.
PHYSICAL EXAMINATIONS A well-done physical examination gives the clinician invaluable information in the assessment of an animal’s health. Technicians can assist the veterinarian by understanding the pertinence of each part of the examination and by
18
SECTION TWO: PREVENTATIVE CARE
being able to conduct an examination in an orderly, precise, and timely fashion. Physical examinations are conducted prior to immunizing, before an anesthetic procedure, and in conjunction with any visit to the veterinarian for a specific problem. The following charts will cover methods and specific areas of the physical examination in both pediatric and adult patients.
Vital Signs
History
Table 2.1 / Preliminary Examination Definition/Normal/Abnormal
Equipment and Technique
Chief Complaint
• The current issue for which the owner is bringing the animal to the clinic
• Current history • Current appetite, water intake, urination and defecation behavior, recent temperament, and current medications are noted. Recent activities to which the animal may have been exposed or changes in the home environment are also noted.
Past History
• Previous medical conditions that may exacerbate the current complaint
• Past history • Immunization dates as well as current medical therapies are noted.
Signalment
• Age, breed, sex, and reproductive status
• N/A
General Appearance
• The patient’s overall health
• Visual evaluation of the condition of animal’s coat, skin, and temperament
Heart Rate • Cardiac function
Normal • Canine: 70–180 beats/min • Feline: 110–220 beats/min Abnormal • Canine: <70 and >160 beats/min • Feline: <100 and >200 beats/min
• Direct palpation of chest wall or pulse • Auscultation of the thoracic cavity • See Skill Box 2.2, Cardiac Examination, page 30. • Electrocardiograph • See Chapter 8, Patient Care, page 338. • Doppler pulse monitor
Respiration • Reflects proper oxygenation of the body’s tissues • Ability to eliminate carbon dioxide from the blood
Normal • Canine: 10–30 breaths/min • Feline: 25–40 breaths/min Abnormal • <8 breaths/min
• Auscultation of the thoracic cavity • See Skill Box 2.3, Pulmonary Examination, page 32. • Pulse oximetry • Calculates the O2 saturation of hemoglobin in circulating RBCs • The probe is placed on an easily accessed capillary bed (e.g., tongue, lip fold, nasal septum, pinna, prepuce, vulva, skinfolds, or toe web) • Normal: 99–100% • Abnormal: <97%, 90% is hypoxemia and must be corrected
Pulses • Cardiac function
Normal • Match rate and rhythm of heart rate Abnormal • Weak, bounding, thready, irregular, deficits
• Direct palpation • Direct digital pressure over the left and right femoral artery • Evaluate pulse quality, strength, rate and symmetry.
Mucous Membranes • Blood loss, anemia, and poor perfusion
Normal • Pink Abnormal • Pale: blood loss, anemia or poor perfusion • Cyanotic: shortage of oxygen
• Visual observation • Observed at the gingival, tongue, buccal mucous membranes, conjunctiva of the lower eyelid, mucous membrane lining the prepuce or vulva
Capillary Refill Time • Reflects the perfusion of tissues with blood
Normal • 1–2 seconds Abnormal • >2 seconds
• Direct palpation • Direct digital pressure is applied to the mucous membranes until blanched and then timed for blood (pink color) to return.
Temperature • Circulation
Normal • 100.5–102.5° F Abnormal • <100° and >103° F
• Direct palpation of paws and ears • Rectal thermometer • Temperature probe (e.g., rectal or esophageal)
Weight
Normal/Abnormal • See Table 3.2, Body Condition Scoring System, page 61.
• Recorded in kilograms and pounds • Note BCS and dietary history
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
2
19
Table 2.2 / Physical Examination Area
Head and Neck
2
20
Specific Region
Examination Findings
History
Head (general)
• Symmetry, alopecia, tumors or swellings, rashes, head tilt, and uniformed muscle mass on skull
• Head tilt or shaking? • Seizures?
Eyes (lids, eyeball, conjunctiva, sclera, pupil, cornea, lens) • Visual examination • Ophthalmic examination
• Normal: bright, clear, uniform, responsive • Cysts, conformity, lash growth, third eyelid position and size, symmetry, ocular discharge, nystagmus, positioning within orbit: protruding vs. sunken, color, vascularity, uniformity of pupils, scars, ulcerations, pigmentation, and opacities
• Pain? • Blinking, squinting, rubbing or pawing? • Discharge? (e.g., quantity, consistency, color, uni- or bilateral) • Blindness?
Muzzle • Visual examination
• Symmet, inflammation, swelling, abscessed teeth and pain on opening mouth
• Rubbing or pawing?
Nares • Visual examination
• Symmetry, movement on inspiration (should move laterally) and discharge
• Sneezing or heavy breathing? • Discharge? (e.g., quantity, consistency, color, uni- or bilateral)
Oral Cavity (lips, mucous membranes, teeth, hard and soft palate, tongue, pharynx, tonsils) • Visual examination
• Normal: symmetrical, pink, slightly moist • Halitosis, inflammation, tumors or papillomas, anatomic defects, excessive salivation, crusting, pigment changes, color and capillary refill time, tacky, periodontal status, ulcerations, and foreign bodies • See Chapter 14, Dentistry, page 497.
• Excessive salivation or dripping water after drinking? • Inappetence or difficulty eating? • Changes? (e.g., gingival pigmentation, bark, meow)
Ears • Visual examination • Otoscopic examination
• Normal: clear and dry • Debris, exudate, odor, inflammation, response to sound, and sensitivity to canal massage or palpation • See Skill Box 2.5 Otoscopic Examination, page 33.
• Shaking head or scratching ears? • Discharge? (e.g., quantity, consistency, color, uni- or bilateral) • Hearing loss?
Lymph Nodes (submandibular) • Palpation
• Normal: firm, oval, and freely movable • Symmetry and size • See Skill Box 2.6 Regional Lymph Node Examination, page 34.
• Increase in size?
Salivary Glands (mandibular, parotid) • Palpation
• Normal: irregular, bumpy texture • Symmetry and size (do not confuse with submandibular nodes)
Neck (throat, trachea, larynx, thyroid, thoracic inlet) • Palpation • Auscultation
• Coughing or sounds during examination, deviation or displacement, tumors, swelling, stridor, or jugular pulse waves
SECTION TWO: PREVENTATIVE CARE
• Gagging, retching, difficulty swallowing? • If a cough is noticed, does the cough occur throughout the day? • Travel or exposure to other dogs?
Table 2.2 / Physical Examination (Continued)
Thoracic Cavity
Trunk and Limbs
Area
Specific Region
Examination Findings
History
Trunk (general) • Visual examination • Palpation
• Normal: visible sheen and coat completeness • Body form and weight, symmetry, tumors, alopecia, inflammation, ectoparasites or their residues, crusts, scales, pustules, and hydration status
• Changes? (e.g., pigmentation, odor, hair loss, texture) • Allergen exposure? (e.g., type of bedding, feathers, carpets, indoor plants, tobacco smoke) • Pruritus? (e.g., behavior, frequency) • Scratching, biting, licking? • Did pruritus precede or coincide with lesions? • Bathing or grooming habits? • Changes in diet?
Lymph Nodes (prescapular, axillary, inguinal, popliteal) • Palpation
• Normal: firm, oval, and freely movable (axillary or disc shaped) • Size and consistency • See Skill Box 2.6 Regional Lymph Node Examination, page 34.
• Increase in size? • Limping and/or favoring limb(s)?
Limbs (muscle, bone, joints, paws) • Visual examination • Palpation
• Symmetry, inflammation, tenderness, tumors, range of motion, gait, atrophy, flexion and extension, interdigital, nails/nail bed, and knuckling
• Licking paws?
Lungs • Auscultation • Percussion
• Rate, depth, and pattern of breathing (rales or rhonchi) and lung sounds (absence of lung sounds may indicate pleural effusion, and dull sound may indicate fluid filled or solid lungs) • See Skill Box 2.3 Pulmonary Examination, page 32.
• Fainting? • If cough is present, does it change throughout the day or worsen with exertion? • Recent travel?
Heart • Auscultation
• Dysrhythmias, murmurs, verify femoral and metatarsal pulses coincide with the heart rate (e.g., no pulse deficits) • See Skill Box 2.2 Cardiac Examination, page 30.
• Fainting, collapsing, or exercise intolerance? • Panting? • Coughing? (e.g., description, frequency)
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
21
2
Table 2.2 / Physical Examination (Continued) Area
Perineal
Abdomen
2
22
Specific Region
Examination Findings
History
Kidneys • Palpation
• Normal: oval shaped with indented side, firm, and smooth • Size, shape, contours of surface, symmetry (between left and right kidneys) and pain
• Excessive water consumption or urinating?
Liver • Palpation, lateral recumbency
• Normal: edges are smooth and well defined • Asymmetric or irregular surface? • Extension beyond costal arch may indicate hepatomegaly
Urinary Bladder • Palpation
• Normal: palpable when urine filled, thin wall with flexibility • Size, tone and turgidity
• Urination (e.g., frequency, quantity, behavior, odor) • Foul odor, color change, or blood? • Straining? • Inappropriate urination?
Small Intestines • Palpation
• Normal: not palpable or mildly gas filled • Tumors, foreign bodies, and pain, thickened/firmness on palpation
• Vomiting, diarrhea, or constipation? (e.g., description, quantity, frequency, behavior) • Time since last bowel movement?
Mammary Glands • Visual examination • Palpation
• Normal: fleshy, semifirm, or fatty character • Estrus/diestrus: firmer and enlarged • Tumors, cysts, inflammation, temperature, discharge (suppurative), pain, and firmness
• If intact female, when last whelping occurred? • When was OVH performed?
General • Visual examination
• Tumors, fistulas, exudate and hernias
• Reproductive status?
Vulva • Visual examination
• Normal: lochia • Size, inflammation, and discharge from or between perivulvar folds
• Last heat cycle, mating, or whelping? • Discharge (e.g., quantity, consistency, color, odor)
Penis • Visual examination • Palpation
• Normal: preputial discharge • Tumors, inflammation, and discharge
• Normal urination? • Blood or urine color change? • Discharge (e.g., quantity, consistency, color, odor)
Scrotum • Visual examination • Palpation
• Descended testicles, swelling, and symmetry
• Pain when sitting?
SECTION TWO: PREVENTATIVE CARE
Table 2.3 / Pediatric Physical Examination
This chart is designed to show the specific areas to note on puppies and kittens. A full examination should be conducted following Table 3.3, General Physical Examination. Age
Puppy Normal
Temperament • Visual examination
Birth–6 weeks
• First 2–3 weeks should consist of eating and sleeping. • Nursing should be vigorous and active with a good “suckle reflex.” • Active playtime with mother and littermates from 3 weeks on
Body Weight
Birth–4 weeks
• • • • •
5 weeks–6 months
• Gain 1–2 g/day/lb of adult body weight • Obtained 50% of adult weight
• Gain 10–15 g/day on average
Reached adult weight
• Small breed: 8–12 months • Medium breed: 12– 18 months • Large–giant breed: 18–24 months • By maturity, most canines will ↑ birth weight 40–50×
• 10 months
Coat/Skin • Visual examination • Flea comb
Birth–6 months
• Shiny and complete hair coat
• State of hydration • Completeness of hair cover, condition of foot pads, wounds, bacterial infections, external parasites, or dermatophytosis
Temperature • Rectal thermometer
Birth–1 week
• 96–98° F • Cannot regulate own body temperature for first 3 weeks (puppy) or 1 week (kitten) • Neonates should never be left unattended or warmed on electric heating pads, because their neuromuscular reflexes are not present until 7 days of age.
• Hyper- or hypothermia • Burns
2–4 weeks
• 99–100.5° F
General Appearance
Specific Region/Examination Method
Toy: 100–400 g Medium: 200–300 g Large: 400–500 g Giant: >700 g Birth weight should double in days 10–12
Kitten Normal
• 100 g • Birth weight should double in 14 days.
Evaluation • Constant crying, extreme inactivity, and/or failure to gain weight can be signs of inadequate milk consumption. • Separation from mother and littermates before 6 weeks of age can lead to numerous behavioral problems later in life. • Failure to gain weight is often the first sign of illness. • Body weight should be checked initially, 12 hours after birth, and daily for 2 weeks; then checked weekly.
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
23
2
Table 2.3 / Pediatric Physical Examination (Continued)
Head
2
24
Specific Region/Examination Method
Age
Puppy Normal
Eyes • Visual examination • Penlight • Ophthalmic examination
Birth–6 months
• Eyes open around 5–14 days • Iris is blue gray. • Changes to adult color at approximately 4–6 weeks of age • Adult vision at 5–10 weeks of age • Pupillary light responses may not be evident until 21 days of age. • Strabismus or deviation of eyes at 3–5 months of age
• Discharge, squinting or holding eye(s) closed, rubbing or pawing at eye(s)
Ears • Visual examination • Otoscopic examination
Birth–6 months
• Complete hearing at 4–6 weeks of age • External ear canals open at 6–14 days and are completely open by 17 days. • Canals may be full of desquamative cells and some oil droplets.
• Size and position • Exudate and odor for possible bacterial or yeast infection or mites
Mouth • Penlight • Tongue depressor or cotton swab
Birth–3 months
• Sucking reflex is present at birth and disappears at 3 weeks of age. Deciduous tooth eruption • Incisors: 2–4 weeks • Canines: 3–5 weeks • Premolars: 4–12 weeks
• Hairlip, cleft palate, sucking reflex, occlusion or malfunction of jaw bones (malocclusion)
4–6 months
Permanent tooth eruption • Incisors: 3–5 months • Canines: 4–7 months • Premolars: 4–6 months • Molars: 4–5 months
• Occlusion or malfunction of jaw bones (malocclusion)
Nose • Visual examination
Birth–6 months
• Normal adult appearance
• Obstruction, stenosis, discharge, or abnormal shape, swelling
Skull • Visual examination
Birth–4 weeks
• Normal adult appearance
• Open fontanelle (soft spot on the forehead)
SECTION TWO: PREVENTATIVE CARE
Kitten Normal
Evaluation
Table 2.3 / Pediatric Physical Examination (Continued) Age
Puppy Normal
General Appearance • Visual examination
Birth–6 months
• Symmetrical chest wall
• Wounds and rib fractures • Congenital sternal or spinal abnormalities
Limbs Perineum Genitals
Kitten Normal
Evaluation
Heart • Visual examination • Stethoscope with 2 cm bell and 3 cm diaphragm
Birth–4 weeks
• Heart rate: 220 beats/min • Heart rhythm is a regular sinus rhythm
• Heart rate and pattern • Murmurs (should be noted and veterinarian consulted, as some can be normal/physiologic)
5 weeks–6 months
• Heart rate: 70–180 beats/min
• Heart rate: 110–200 beats/min
Lungs
Birth–4 weeks
• Respiratory rate: 15–35 breaths/min
• Respiratory rate: 25– 35 breaths/min
5 weeks–6 months
• Respiratory rate:10–30 breaths/min
• Respiratory rate: 25– 40 breaths/min
General Appearance • Visual examination
Birth–4 weeks
• Umbilical cord falls off in 2–3 days.
• Umbilical hernia, inflammation, or infection/ulceration
Internal Organs • Palpation
Birth–4 weeks
• Kidneys are palpable in kittens and some puppies. • Normal spleen will sometimes be palpable in an older puppy if foreleg is extended, allowing organs to fall caudally; spleen only palpable if enlarged in kittens. • Liver margins should not extend past the ribs. • Stomach will feel like a large fluid-filled sac if full. • Intestines are soft and freely movable without pain and may be fluid or gas filled. Thickened/ ”ropy” feel may indicate endoparasitism. • Urinary bladder should have resistance to urine outflow.
• Enlarged or abnormally small organs, pain on palpation, masses • Intussusception—a sausage-like mass and very painful
Forelimbs/Hindlimbs • Visual examination • Palpation
Birth–6 months
• Normal adult appearance (breed-influenced)
• Wounds, bruises, or swelling • Deformities or ↑ or ↓ range of motion in joints
Genitalia • Visual • Palpation
Birth–6 months
• Normal adult appearance • Descended testicles by 4–6 weeks of age (diagnose cryptorchid after 16 weeks)
• Cryptorchidism, vaginitis, congenital abnormalities
Anus • Visual • Palpation
Birth–6 months
• Normal adult appearance
• Rectal prolapse, inflammation, or irritation • Defecation/urination on their own usually occurs at 2–3 weeks.
2
Abdomen
Thorax
Specific Region/Examination Method
• Breathing rate and pattern • Asymmetrical or absent lung sounds
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
25
Table 2.4 / Normal Parturition
2
In late term pregnancy (58–63 days), the bitch or queen should be observed for signs of labor. These may include a rectal temperature drop to <100° F, vulvar discharge, and leaking milk. Once labor starts, the female should be left alone but observed occasionally progression and/or signs of complications. Stage
Time
Observations
Complications
I Prelabor
• 6–12 hours, up to 24
• Restless, nesting behavior, getting up and down, nervous, panting, vomiting • Nesting behavior (e.g., arranging bedding, chewing up paper)
• Black, green, or red vaginal discharge
II Active Labor, Whelping III Expulsion of Placenta
• 3–6 hours, up to 24
• Contractions lying on side or standing in a urination stance • Placenta at the vulva, a neonate should be seen within 15 minutes • Mother will chew the placenta to free the neonate, sever the umbilical cord, and lick the neonate for stimulation. • Placenta should be seen within 5–15 minutes. • The next neonate should follow in 1–2 hours.
• 30–60 minutes of strong contractions with no neonate produced • >2 hours between pups (>1 hour between kittens) is an emergency • Mother may not release the neonate and sever the umbilical cord. • Eating multiple placentas may lead to indigestion and diarrhea. • Queen: if stressed may stop and restart labor the next day
Postpartum
• 1–2 months
• Bitch: 8–10 weeks of bloody discharge • Queen: 3 weeks of black or red discharge
• Mastitis (e.g., fever, lethargy, swollen glands), metritis (e.g., foul smelling discharge), retained placenta (e.g., green discharge) • Eclampsia (e.g., tremors, excitation)
26
• 20–60 minutes per neonate
SECTION TWO: PREVENTATIVE CARE
Skill Box 2.1 / Care and Feeding of Orphaned Puppies and Kittens Housing • Use a box with tall sides to avoid escape, such as a cardboard pet carrier. • Line the bottom of the box with towels and place a diaper or pee pad on top for easy cleaning. • The box will need to be cleaned frequently to keep the neonates clean and dry. Temperature • Neonates are unable to maintain their own body heat; they rely on the ambient temperature and littermates. • The environment should be draft free with a ambient temperature gradient measured by a thermometer. • Electric heating pads and heat lamps should not be used due to the risk of overheating and burns. • The ambient temperature should be 85–90° F for the first week, 80° F for weeks 2–4, and 70° F for week 5.
• Warm the formula to a comfortable temperature, place the neonate in a comfortable dorsal position, and hold the bottle up in a position to closely mimic that of the mother. Ensure that the nipple does not contain air and the bottle is tipped up to avoid air ingestion. Neonates have a vigorous suckling response and can overfeed if not monitored. Milk bubbling out of the neonate’s nose may indicate overzealous feeding or a hole in the nipple that is too large. A satisfied neonate is quiet with a slightly enlarged abdomen. Following each feeding, burping may be necessary to expel excess air ingested. • A nipple bottle is most commonly used, but a feeding tube can be ideal in skilled hands for weak or premature neonates See Skill Box 11.3 Nasoesophageal/Nasogastric Tube, page 415. • With all methods of feeding, care should be taken to avoid aspiration pneumonia, a complication seen with forced nursing, squeezing the bottle, improper feeding tube use, and volume overload. Health • Hydration should be monitored in the neonate by mucus membranes, eyes, urine specific gravity, and urine color.
Diet
• A neonate should gain 10% of its birth weight daily.
• Commercial replacement diets (e.g., Esbilac, KMR) are the best choice for diet replacement.
• Crying for >15 minutes is a sign of distress (e.g., hunger, cold, neglected, pain).
• When commercial diets are not available, the following recipe can be used in the interim.
Urination and Defecation
• 1/2 cup whole milk, 1/2 cup water, 1 tsp. salad oil, 1 drop multivitamins, 2 egg yolks, 2 Tums (antacid) crushed
• For the first 3 weeks, the neonate must be stimulated to urinate and defecate after each feeding.
• Blend all ingredients in a blender, keep refrigerated, and use within 48 hours.
• With the neonate held securely in 1 hand (possibly with a towel) over a sink, gently massaging the lower abdomen in a circular motion. The genitals may also be rubbed with a warm, moist cotton ball.
• The above diet provides 1.2 kcal/mL, which is the same as commercial diets. • Neonates are fed 22–26 kcal/100 g body weight for the first 12 weeks of life. The diet should be gradually increased over 2–3 days to the recommended daily amount to avoid overfeeding and diarrhea.
• The genitals should be cleaned and dried to avoid skin irritation. • Urine and feces should be seen at almost every feeding and in the box. • Feces should be soft, but not green or yellow watery. Overfeeding is the most common cause of diarrhea; further dilute the formula by 1/3 for 2 days.
Feeding • The neonate will cry when hungry, but feeding should initially be expected every 2–3 hours.
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
27
2
Table 2.5 / Geriatric Physical Examination
This chart is designed to show the specific areas to note on geriatric animals. A full examination should be conducted, following Skill Box 2.2, General Physical Examination. However, geriatric animals go through additional changes as a result of the natural aging process and a physical is recommended every 6 months. Many of these changes cannot be visualized on a physical examination, but they may be inferred through the general examination and from discussion with the owner. These symptoms may contribute to or initiate more serious medical conditions, thereby making their determination valuable to the clinician.
General Appearance
Specific Region
Head
2
28
Effects
Associated With
Skin
• ↓ Elastin and collagen • ↓ Blood flow to skin • Thinning of skin and coat
• Ineffective barrier to pathogens • May require more maintenance by owner
Toenails
• ↑ Length because of ↓ activity • More fragile, crumble when trimmed
• Difficulty walking • Wounds in foot pads
Musculature
• ↓ Strength • ↓ Tone
• Muscle atrophy and coordination
Eyes
• • • •
• Atrophy of the iris and ciliary muscles • Nuclear sclerosis
Ears
• Hearing loss
• Loss of cochlear hair cells
Nose
• ↓ Sense of smell
• ↓ Function of olfactory nerve endings, which can affect their eating habits
Neck
• Thyroid nodules
• Hyperthyroidism (feline), tumor
SECTION TWO: PREVENTATIVE CARE
Vision loss ↓ Pupillary light response Change in lens opacity Optic lens hardening
Associated With
Brain
• Amyloid deposition • Memory loss • Personality changes
• Cognitive dysfunction disorder • ↓ Glucose tolerance • Cognitive dysfunction disorder
Lungs
• • • • •
• Rarely a cause of concern unless patient needs to undergo an anesthetic procedure
Heart
• ↑ Sternal contact • Tortuous, redundant aorta (feline) • Radiographic changes
Kidney
• • • • •
Liver
• ↓ Protein synthesis • ↓ Metabolic function
• Liver disease
Limbs
Specific Region
Joints/Cartilage
• ↓ Production of chondroitin sulfate, keratin sulfate, and hyaluronic acid • ↓ Proteoglycan content
• Degenerative joint disease
Urethral Sphincter
• ↓ Tone
• Primary urethral sphincter incontinence
Immune System
• ↓ Function
• Chronic disease • ↑ Susceptibility to infections
Blood
• ↓ Ability to respond to RBC demand • Hypertension
• Anemia • Renal or endocrine disease
Internal Organs
Effects
Genitals
Table 2.5 / Geriatric Physical Examination (Continued)
Loss of lung elasticity ↓ Tidal volume ↓ Expiratory reserve Diminished cough reflex ↑ Density on lung radiographs
↓ ↓ ↓ ↓ ↑
Size Glomerular filtration rate Renal blood flow Ability to handle potassium Mineralization of renal pelvis
2
• Rarely a cause of concern
• Kidney disease • PU/PD • No concern known
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
29
Skill Box 2.2 / Cardiac Examination 2
Cardiac Examination Technique Perform auscultation in a quiet room with a calm patient. Place the patient in a standing or sitting position. Avoid listening to recumbent animals, as the change in heart position and configuration leads to errors. The flat diaphragm is used to detect high-frequency sounds (e.g., normal heart and breath sounds, most murmurs), while the bell is used to detect lower-frequency sounds (e.g., 3rd and 4th heart sounds, diastolic murmurs). The entire heart is examined, paying particular attention to the cardiac valves. Begin by placing the diaphragm gently but firmly at the left apex, where the first heart sound is best heard and also the location of the mitral valve. From here, inch the stethoscope to the left base of the heart, which is approximately 2 rib spaces cranial and slightly dorsal. Note the second heart sound and possible aortic and pulmonic stenosis murmurs. Next, palpate the right apex of the heart and move the stethoscope to this region. This is the tricuspid region and possible location of tricuspid regurgitation. Then move to the right base of the heart and observe for subaortic stenosis. Once an abnormality is noted, the surrounding region should be evaluated to find the point of loudest sound. In this process, the entire heart region should be evaluated and a complete examination given. Rate • Canine: 70–180 beats/min • Feline: 110–220 beats/min
Heart Sounds
Heart Valves
Normal
Normal
• First heart sound (S1) • Location: left apex of the heart • Sound: low-frequency sound longer than S2
• Pulmonic • Location: left 2nd–4th intercostal space above the sternal border
• Second heart sound (S2) • Location: base of the heart • Sound: high-frequency sound shorter than S1 • Third heart sound (S3) • Location: apex • Sound: low-intensity sound shortly after S2 • Fourth heart sound (S4) • Location: apex • Sound: low-intensity sound slightly before S1
30
SECTION TWO: PREVENTATIVE CARE
• Aortic • Location: left 3rd–5th intercostal space at mid-thorax • Mitral • Location: left 4th–6th intercostal space just above the sternal border, the apex of the heart • Tricuspid • Location: right 6th–7th intercostal space at mid-thorax, the apex of the heart
Abnormal • Murmurs Characterized by their location (over which valve they are the loudest), intensity (grade 1/6), frequency (harsh, blowing, musical, honking, or grunting), timing (point in the cardiac cycle the murmur is best heard), and quality (character/behavior).
Rhythms
Description of intensity
• Ventricular premature contractions (VPCs)
• • • • •
Grade 1: barely audible and localized Grade 2: soft and localized, but easily auscultated Grade 3: moderate loudness and evident in more than 1 location Grade 4: loud with palpable thrill and radiates Grade 5: very loud with palpable thrill, audible with stethoscope barely touching thorax • Grade 6: very loud with palpable thrill, audible when the stethoscope is removed from the thorax
• Gallop • Often seen during tachycardia when all four heart sounds are clearly heard. The combination of sounds is similar to the sound of a horse galloping. The rhythm is often heard with congenital heart disease, more specifically with hypertrophic cardiomyopathy in cats. • VPCs interrupt the normal sinus rhythm with a beat that is closer to the previous beat than normal followed by a compensatory pause. Patients often also have pulse deficits. • Atrial fibrillation • Rapid, but totally erratic rhythm with a clunking sound and varying intensity of the first and second heart sounds. Patients often have pulse deficits and variable pulse quality. Artifacts • Panting and excessive thoracic pressure in small patients similar to murmurs • Skin twitching similar to extra heart sounds • Friction from chest piece rubbing across fur similar to crackles
Tip: Ventilation artifacts can be discouraged by holding the mouth shut, whistling, or briefly obstructing a nare. Purring may be controlled with a visual distraction (e.g., visualization of water, another animal), blowing short bursts in air in their face, picking up the cat, or gently pressing over the larynx. Tip: When locating heart valves, count the ribs from caudal to cranial. Tip: The pulse and heart beat should be auscultated together and be synchronous. A heart beat without a pulse is a pulse deficit and may indicate an arrhythmia. Note: See Figures 1.9–1.12, Circulation, pages 9–10, and color plates 1.9, 1.10, and 1.12, pages CP-1, 2.
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
31
2
Skill Box 2.3 / Pulmonary Examination 2
Pulmonary Examination Technique • Begin the examination by observing the respiratory effort (quality) and pattern and any signs of respiratory distress (e.g., nostril flare, intercostal rib retraction). After the initial assessment, perform auscultation in a quiet room with a calm patient. Place the patient in a standing or sitting position. Avoid listening to recumbent patients as it leads to errors due to changes in thoracic conformation. Divide the thoracic cavity into quadrants to follow a sequential pattern. As each quadrant is auscultated, it is observed for respiratory rate and breath sounds. Rate • Canine: 10–30 breaths/min • Feline: 25–40 breaths/min Breath Sounds • Should be heard equally on both sides of the thorax. Breath sounds heard outside the location defined below can be indicative of a medical problem. The normal respirations of canines can be heard throughout inspiration and during the first 1/3 of expiration. Only during inspiration can normal lung sounds be heard in a cat. Normal • Bronchial: • Location: center of the chest cavity over caudal trachea and larger bronchi • Sound: intense and harsh sounds, full inspiratory and expiratory phase with a louder inspiratory phase • Bronchovesicular: • Location: surrounding the bronchial region • Sound: intermediate sounds representing a combination of bronchial and vesicular sounds, full inspiratory phase with a short and quieter expiratory phase. • Vesicular: • Location: periphery of thoracic cavity • Sound: softer sound (e.g., wispy, rustling of leaves), inspiratory phase is slightly longer and louder than expiratory phase.
Abnormal • Stertor: • Location: larynx or trachea • Sound: discontinuous low-pitched snoring sound heard mainly on inspiration • Cause: tissue or secretions transiently obstruct airflow (e.g., elongated soft palate) • Stridor: • Location: larynx or thoracic inlet, referred sounds maybe heard throughout the thorax • Sound: intense continuous high pitched wheezes heard on inspiration • Cause: upper airway obstruction • Crackles (rales): • Location: over chest • Sound: discontinuous popping sound heard mainly on inspiration; defined as fine, medium, or coarse • Cause: fluid or exudate accumulation within airways or inflammation and edema in pulmonary tissue • Rhonchi or wheezes: • Location: isolated or variable • Sound: continuous musical sounds, low or high pitched heard at the end of inspiration or beginning of expiration; defined as high pitched or low pitched • Cause: ↓ airway lumen diameter
Tip: Listen to the lung sounds before listening to heart tones because the ear is much less sensitive to softer sounds once it has adjusted to louder sounds.
32
SECTION TWO: PREVENTATIVE CARE
Skill Box 2.4 / Abdominal Examination
Abdominal Examination Technique • Gentleness when palpating an animal is essential as internal structures may be damaged if handled roughly. Structure descriptions can be: doughy (soft tissue that can be impressed with fingertips), firm (normal organ), hard (bones), fluctuant (soft, elastic, and undulates under pressure). Abnormalities noted on palpation are the following: pain, abnormal structures and their size, consistency, and shape, and location. • Large canine • Place the patient in a standing position. Stand on either side or to the rear. Place 1 hand on either side of the abdomen in a flat and relaxed position. Begin at the spine and gently and slowly move ventrally, allowing the abdominal viscera to slip through the fingers. Repeat this process throughout the abdomen moving caudal. • Small canine or feline • Place the patient in a standing position. Stand next to the patient. Cup 1 hand around the abdomen with the thumb on 1 side and the fingers on the other side in a flat and relaxed position. Begin at the spine and gently and slowly move ventrally, allowing the abdominal viscera to slip through the fingers. Repeat this process throughout the abdomen moving caudal.
• Internal structure location • Cranial abdomen • Palpation of the liver, spleen, and the small intestines • Liver is difficult to palpate and extension past the costal arch may indicate hepatomegaly. • Spleen is difficult to palpate and recognition may indicate splenomegaly. • Normal stomach is rarely palpable, but with overeating (doughy or fluid-filled) or gastric distention it may be felt. • Mid-abdomen • Palpation of the small intestines, kidneys, and spleen • Right kidney is more cranial than the left kidney in cats and may be obscured by the ribs. • Mesenteric lymph nodes are difficult to palpate unless enlarged. • Caudal abdomen • Palpation of the colon, uterus, bladder, prostate, and small intestine • Feces can be discerned from a mass by its deformability with fingertip imprints. • Prostate can occasionally be palpated central to the colon and caudal to the bladder.
Note: See Figures 1.6–1.8, Internal Organs, page 8, and Color Plates 1.6–1.8, pages CP-1.
Skill Box 2.5 / Otoscopic Examination
Otoscopic Examination Technique • Examine the good ear first to avoid spread of infection and to decrease resistance to examination of the possibly more painful ear. Begin with an otoscope with the appropriate sized cone for the patient. For ease of examination, the patient should be placed on a table or large canines should be placed in a sitting position. The head should be held in such a manner to avoid crushing the ear canal while directing the
muzzle toward the thoracic inlet. Holding the pinna up and out from the base of the skull will allow straightening of the ear canal. Gently insert the otoscope into the external ear canal and slowly advance while observing the canal. As the cone enters the vertical canal, the pinna is pulled up and over the otoscope while the otoscope handle is rotated to a horizontal position. The tympanic membrane will then be visualized in a normal ear as a white translucent membrane. Any abnormalities such as: inflammation, redness, exudate, foreign objects, mites, or tumors should be noted.
Note: See Figure 1.19, Ear, page 13.
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
33
2
Skill Box 2.6 / Regional Lymph Node Examination 2
Regional Lymph Node Examination Technique • Three pairs of lymph nodes are routinely palpated in a normal animal; submandibular, prescapular, and popliteal. Axillary and inguinal nodes can often only be palpated with enlargement. Peripheral lymph nodes should be palpated simultaneously to evaluate symmetry. Enlarged nodes may be an initial indicator of a problem. Lymph nodes are generally smooth and oval in shape and can be most easily felt by grabbing the skin and allowing it to slip through the fingertips while pulling the hands away. • Submandibular • Location: ventral to the angle of the mandible, cranial to the parotid and submaxillary salivary glands • Size: group of 2 or 3 nodes pea to grape size
• Prescapular (superficial cervical) • Location: in front of the cranial border of the scapula • Size: group of 2 or 3 nodes slightly larger than submandibular nodes • Popliteal • Location: caudal to the stifle • Size: 1 node about the size of a pea; not always palpable in smaller animals • Axillary • Location: caudal and medial to the shoulder joint • Size: 1 or 2 nodes; not palpable in normal animals (0.5–10 mm) • Inguinal • Location: furrow between the abdominal wall and the medial thigh • Size: 2 nodes, not palpable in normal animals (0.5–10 mm)
Note: See Figure 1.2, Regional Lymph Nodes, page 6.
Skill Box 2.7 / Neurologic Examination
Neurologic Examination Technique • The neurologic examination begins as the patient walks into the examination room. Notice should be paid to the patient’s body posture (e.g., head tilt), attitude (e.g., demented, semicomatose, disoriented) and gait (e.g., inability or abnormal walk, dragging limbs, circling), purposeful movement (e.g., attempt to move down limbs), and palpation (e.g., symmetry, worn toenails, ↑ or ↓ muscle tone, masses).
Postural Reactions
Spinal Reflexes
• The patient’s ability to recognize an abnormal position and change its position to bear weight and be able to walk. All levels of the nervous system are evaluated, but lesion localization is not possible.
• Deficits in spinal reflexes alert to a problem along the nerve pathway; receptor, sensory nerve, efferent nerve, and skeletal muscles. Responses seen may be normal, absent, depressed or exaggerated.
• Extensor postural thrust
• Anal sphincter reflex
• While supporting the patient under the thorax, as the hindlimbs touch the floor, monitor for symmetric caudal walking motions. • Hemistanding/hemiwalking • A hindlimb and front limb of the same side are lifted, monitor for lateral walking movements. 34
SECTION TWO: PREVENTATIVE CARE
• Perineal stimulation with a needle or forceps; monitor for contraction of the anal sphincter muscle. • Panniculus reflex • Pin prick stimulus to skin over the back; monitor for twitching of cutaneous trunci muscles on both sides.
Skill Box 2.7 / Neurologic Examination (Continued) • Hopping • While supporting the patient, 3 limbs are lifted and the patient is moved medially and laterally, monitor for initiation and movement of hopping. • Placing • While supporting the patient under the thorax, the thoracic limbs are brought in contact with the edge of a table; immediate placement of the limbs on top of the table is expected. • This is done twice, once with the eyes covered and once with the eyes opened. • Proprioceptive positioning • While supporting the patient, turn the hind foot over onto the dorsal surface and monitor the length of time to turn it back to a normal position, if even able. • Wheelbarrowing • While supporting the patient under the abdomen with the hindlimbs lifted, monitor the length of time to start walking forward and the walking coordination.
Hindlimb Reflexes • Cranial tibial response • Percuss muscle belly; monitor for flexion of the hock. • Crossed extensor reflex • Pinch digits of down limb; monitor for involuntary movement of upper limb. • Gastrocnemius reflex • Percuss Achilles tendon; monitor for extension of the hock. • Patellar reflex • Patient in lateral recumbency and stifle gently supported in a flexed position, percuss patellar tendon; monitor for extension of the stifle. • Sciatic response • Percuss thumb in the sciatic notch; monitor for jerk of the entire limb. • Withdrawal • Patient in lateral recumbency. pinch digits; monitor for flexion of the limb and pain recognition.
Front Limb Reflexes • Extensor carpi radialis response • Percuss the extensor carpi radialis muscle; monitor for extension of the carpus. • Triceps reflex • Patient in lateral recumbency with limb supported, elbow fully extended and leg caudal, percuss the triceps tendon: monitor for slight extension of the elbow. • Withdrawal • Patient in lateral recumbency, pinch digits; monitor for flexion of the limb and pain recognition.
Sensory Evaluation
Cranial Nerves
• Evaluation of deep pain perception • Hyperpathia • Pressure is applied along the thoracic and lumbar regions to the spine and muscles at each vertebra; monitor for a behavioral response to pain • Sensory level • Pin prick stimulus to skin over the back, monitor for behavioral response
• The following cranial nerves (CN) are evaluated with a suspected brain lesion • Optic nerve (CN II): vision, menace response • Oculomotor nerve (CN III): pupillary light response, size and symmetry • Trochlear nerve (CN III, IV, VI): eye movements • Trigeminal nerve (CN V, VII): muscle mass, jaw tone, facial movements, blinking, lip retraction • Vestibulocochlear nerve (CN VIII): hearing • Glossopharyngeal and vagus nerves (CN IX, X, XI): pharyngeal sensation, gag response • Hypoglossal nerve (CN XII): tongue movement and strength CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
35
2
Skill Box 2.8 / Orthopedic Examination 2
Orthopedic Examination Technique • Similar to the neurologic examination, the orthopedic examination begins as the patient enters the examination room. Notice should be paid to the patient’s conformation, stance, sitting, standing, rising and gait. The examination should continue with a hands-on evaluation of the area of concern, including the alternate side. A systematic approach should be used to cover the entire limb, often beginning distally and moving proximal. Alterations in range of motion and rotation should be noted along with any crepitus, clicking, clunking, instability, swelling, muscle atrophy or overdevelopment, and pain. Begin the examination by evaluating the nonaffected joint to assess the patient’s normal response to manipulation and pressure.
Stifle
Pelvis
• Cranial drawer motion
• Barden’s procedure
• Patient in lateral recumbency, 1 hand stabilizes the femur proximal to the stifle. The second hand is placed with the thumb behind the fibular head and the index finger over the tibial crest. With the femur stabilized, the second hand moves the tibia cranial and distal in a plane parallel to the tibial plateau. Monitor for the tibia sliding cranially or caudally in relationship to the femur indicating cruciate ligament rupture or partial tear. • Test should be performed with the stifle joint in extension, 90º flexion, and normal standing position. • Tibial compression test • Limb is held in a standing position, the hock is flexed to tense the gastrocnemius muscle which compresses the femur and tibia together; monitor for forward motion of the tibia in a ruptured cranial cruciate ligament. • Patellar luxation, medial • Limb is held extended with the foot rotated internally, digital pressure is applied medially; monitor for medial displacement indicating luxation. • Patellar luxation, lateral • Limb is held slightly flexed with the foot rotated externally, digital pressure is applied laterally; monitor for lateral displacement indicating luxation.
• Patient in lateral recumbency, grasp the femur with 1 hand. Place the thumb of second hand on the greater trochanter of the femur, while resting the rest of your palm on the pelvis. With gentle pressure, attempt to lift the femur, keeping it parallel to the table. Monitor for subluxation of the femur through the thumb on the greater trochanter indicating hip laxity. • Barlow’s sign • Patient in dorsal recumbency with stifle flexed, the left hand is placed on the right stifle and slowly adducted, monitor for luxation of the femoral head from the acetabulum indicating joint capsule stretching. • Hip luxation • Patient in a standing position, place the thumb in the space caudal to the greater trochanter, externally rotate the femur; monitor for the trochanter to roll over the thumb indicating luxation. • Ortolani maneuver, lateral recumbency • Limb is held in a standing position parallel to the table surface. One hand is placed over the hip joint, the other hand cups the stifle joint to apply pressure pushing the femoral head in a dorsal direction in relation to the acetabulum. Monitor for hip subluxation indicating hip laxity. • Ortolani maneuver, dorsal recumbency • Stifles are positioned parallel to each other and perpendicular to the table. Downward pressure is applied on the stifles to subluxate the hip. Maintain pressure and abduct the stifle. Monitor for hip subluxation indicating hip laxity.
36
SECTION TWO: PREVENTATIVE CARE
VACCINATIONS Young animals receive a small amount of natural immunity from their mother’s milk, exchanged in the form of colostrum, during the first few days of nursing. However, this temporary maternal protection wanes by 6–9 weeks. To continue and enhance this protection, vaccinations are available to protect the animal from contracting various highly contagious diseases. These diseases and their corresponding vaccinations are charted on the following pages. Vaccines in general are meant to be stored in the refrigerator, and need to be shaken well before dispensing. Lyophilized vaccines should be used within 30 minutes of reconstitution. Heat, excessive cold, and light exposure can inactivate the vaccine and make them ineffective.
Guidelines to Follow When Vaccinating an Animal • A complete physical examination and health evaluation are given by a veterinarian before any vaccination.
Adverse reactions: As with the administration of any drug, vaccines can result in adverse reactions. Possible reactions range from sensitivity at the injection site, a small bump or knot at the injection site, slight fever, hives, lethargy, and anaphylactic shock (vomiting, salivation, dyspnea, and incoordination). Precautions should be taken in animals with a history of vaccine reactions. Vaccines should be avoided if possible, but if they must be given the following guidelines should be observed: • A vaccine from a different manufacturer • Premedication with diphenhydramine and prednisolone sodium succinate 30 minutes prior to the vaccination • Hospital observation for the day Clients should be educated to monitor vaccination sites for lump formation and contact their veterinarian if found. Biopsies should be taken following the AAFP guidelines: • Present for 3 months
• Do not vaccinate pregnant animals with a modified live vaccine.
• ≥2 cm in diameter
• Animals with a fever or in debilitated health should not be vaccinated until healthy.
• ↑ Size after 1 month
As a constant effort to increase patient bonding and improve client satisfaction, special steps can be taken to ensure patient and owner comfort. Taking the extra steps to make this a more enjoyable experience will benefit both the patient and staff in future visits. A few tips for making injections a more comfortable procedure include: • Allowing the vaccine to warm to room temperature • Changing needles before injection; use of a 25-gauge needle • Gently squeezing or flicking the injection site to dull the area • Distracting the patient (e.g., treats, sliding the patient across the table or lifting their front legs, twitching a ear or tapping the nose, talking to the patient).
Titers: The discussion of vaccine titers has become very popular in veterinary medicine, and continues to remain controversial. Titers are available from various laboratories for distemper, parvovirus, rabies, and panleukopenia. If a titer is high, it is accepted as providing protection; however a low titer result does not reflect the immunization of an animal. Titers are best used following the puppy vaccine series to ensure proper levels of immunity have been reached. As each animal and its environment are unique, vaccine recommendations will vary accordingly at the discretion of the veterinarian and in accordance with state laws.
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
37
2
Table 2.6 / Canine Transmissible Diseases: Coronavirus, Distemper Distemper
Definition
Contagious viral disease affecting the GIT, resulting in sporadic outbreaks of vomiting and diarrhea. Diarrhea is caused by the virus invading the enterocytes of the villous tips.
An acute to subacute febrile and often fatal, highly contagious viral disease with respiratory, GIT, and central nervous system (CNS) manifestations.
Presenting Clinical Signs
• Most infected dogs are asymptomatic and less signs are exhibited in adult dogs • Anorexia, depression, diarrhea (yellow-green to orange, malodorous) and vomiting
• Mucosal phase: malaise, nasal discharge followed by pneumonia, vomiting, diarrhea and fever • CNS phase: seizures, circling, pacing, ataxia and paresis
Examination Findings
• Dehydration, mild respiratory effects
• Abdominal pustules, anterior uveitis, conjunctivitis, dental enamel hypoplasia, hyperkeratosis of foot pads, KCS, myoclonus, optic neuritis, retinal degeneration and rhinitis
General
• History/clinical signs
• History/clinical signs
Laboratory
• Electron microscope • Fluorescent antibody tests
• CBC: lymphopenia, leukopenia, thrombocytopenia in early disease • Fluorescent antibody test: detection of virus in intact cells (e.g., conjunctival scrapings, buffy coat, urine sediment, CSF, transtracheal wash) • IgM: serum antibodies measured by ELISA • IgG: serial titers on 2 serum samples 2 weeks apart to detect ↑ titers • PCR: virus detection in respiratory secretions, CSF, feces and urine
Imaging
• N/A
• Thoracic: interstitial or alveolar pneumonia
Procedures
• N/A
• N/A
General
• Symptomatic • Supportive • Fluid therapy
• Supportive • Fluid therapy
Medication
• Imodium
• • • •
Antibiotics B vitamin supplementation Anticonvulsant therapy Antiemetics
Nursing Care
• N/A
• • • • •
Humidification of airways; nebulization and coupage Clean discharge from eyes and nose Nutritional support Adequate fluid intake or therapy Isolation to avoid infecting other patients
Diagnosis
Presentation
Coronavirus
Treatment
2
Disease
38
SECTION TWO: PREVENTATIVE CARE
Table 2.6 / Canine Transmissible Diseases: Coronavirus, Distemper (Continued)
Follow-Up
Disease
Coronavirus
Distemper
Patient Care
• N/A
• Monitor dehydration and electrolytes. • Recheck thoracic radiographs if persistent cough.
Prevention/Avoidance
• Vaccinate • Clean up feces: Will be shed in the feces for typically 6–9 days; but can be for many months
• Vaccinate • Avoid infected dogs or wildlife. • Clean up feces: shedding time typically < 2–3 months
Complications
• Persistent diarrhea for 10–12 days • Dehydration and electrolyte imbalances
• Occurrence of CNS signs may appear for up to 2–3 months after clinical signs • Seizures or CNS signs
Prognosis
• Complete recovery expected
• Ranges from subacute to mortality • Mortality rate of 50%
• Optional part of vaccine series • Consider vaccinating high-risk dogs: field trial dogs and kenneled dogs • Transmitted by fecal-oral route
• Unvaccinated puppies 6–12 weeks of age are most at risk. • Transmitted through body secretions, body excretions, and airborne • Easily destroyed by heat and most disinfectants; survives no more than a few days outside the host • Recovered dogs are not carriers. • Incubation period: 1–5 weeks
Notes
2
Table 2.7 / Canine Transmissible Diseases: Hepatitis, Infectious Tracheobronchitis Hepatitis
Infectious Tracheobronchitis
Definition
Viral disease caused by adenovirus type 1. Affects the liver, eyes, and endothelium
Contagious respiratory disease often caused by the bacteria Bordetella bronchiseptica resulting in the harsh, hacking coughing. It can also be caused by the viruses parainfluenza and canine adenovirus 2.
Presenting Clinical Signs
• Coma, depression, diarrhea, disorientation, lethargy, seizures, stupor, vomiting
• Mild form: repetitive dry-sounding hacking cough (referred to as “seal-like”) often followed by gagging and mild serous naso-ocular discharge • Severe form: anorexia, depression, naso-ocular discharge and productive cough
Examination Findings
• Abdominal pain, anterior uveitis, corneal edema, fever, hemorrhagic diathesis, hepatic encephalopathy, hypoglycemia, pale mucous membranes, nonsuppurative encephalitis, tonsillitis-pharyngitis
• Fever
Presentation
Disease
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
39
Table 2.7 / Canine Transmissible Diseases: Hepatitis, Infectious Tracheobronchitis (Continued) Disease
Diagnosis
2
Hepatitis
Infectious Tracheobronchitis
General
• Clinical signs
• Cough easily elicited on palpation of trachea • History of frequenting boarding facilities or off-leash parks
Laboratory
• • • •
• CBC: mild leukopenia, neutrophilic leukocytosis with a left shift • Cultures of nasal swabs, transtracheal or bronchial washings: Bordetella and Mycoplasma • PCR: virus detection
Imaging
• Radiographs, abdominal: hepatomegaly • Ultrasound: hepatomegaly and abdominal effusion
• Abdominal, thoracic: severe form, interstitial density, and alveolar pattern
General
• Symptomatic • Supportive • Fluid therapy +/− potassium and dextrose supplementation
• Supportive
Medication
• Antibiotics for secondary pneumonia or pyelonephritis
• Antibiotics • Bronchodilators • Antitussives
Nursing Care
• Frequent feedings to avoid hypoglycemia • Restricted activity/cage rest
• • • • • •
Patient Care
• Monitor blood chemistries • Monitor dehydration, acid-base balances, body weight, physical assessment, and electrolytes
• Adequate fluid intake • Airway humidification • Strict rest for 14–21 days
Prevention/Avoidance
• Vaccinate • Avoid urine contact: shedding time, 6 months or more
• • • •
Complications
• • • •
• N/A
Prognosis
• Guarded to good • Some with a complete recovery
• Complete recovery expected unless severe disease develops
• Transmitted through oronasal exposure and shed in all secretions during acute infection • Shed for 6–9 months following recovery • Highly resistant to inactivation and disinfection, thus enabling spread by fomites and ectoparasites
• Highly contagious via aerosol spread and fomites • Disinfect with bleach, Nolvasan, or Roccal. • Incubation period: 3–10 days
CBC: neutropenia, lymphopenia and thrombocytopenia Chemistry panel: ↑ AST, ALT and ↓ glucose Bile acids: mild to moderately high Coagulation tests: prolonged PT, APTT, hypofibrinogenemia
Follow-Up
Treatment
Procedures
Notes
40
Hepatic failure or chronic active hepatitis Acute renal failure DIC Glaucoma
SECTION TWO: PREVENTATIVE CARE
Encourage outpatient care for uncomplicated disease. Airway humidification Strict confinement with low stress, and few dogs Nutritional support ↑ Fluid intake Fresh air flow
Vaccinate Prevent fomite spread with bleach diluted 1:32. Isolate infected animals. Shed for up to 3 months, infectious risk is greatly ↓ after recovery of discharge and cough.
Table 2.8 / Canine Transmissible Diseases: Leptospirosis, Lyme Disease Leptospirosis ZOONOTIC
Lyme Disease ZOONOTIC
Definition
Acute and chronic bacterial disease affecting lungs, kidneys, and liver
A multiorgan disease caused by the spirochete Borrelia burgdorferi
Presenting Clinical Signs
• Anorexia, dehydration, depression, myalgia, reluctance to move and vomiting
• Anorexia and lethargy
Examination Findings
• Acute renal or hepatic failure, conjunctivitis, DIC, epistaxis, fever, melena, petechia, poor capillary perfusion, rapid irregular pulse, tachypnea
• Fever, lymphadenopathy, and polyarthritis
General
• Clinical signs
• Joint palpation: lameness, swelling, and pain • History of travel in known tick infested areas
Laboratory
• CBC: leukopenia, thrombocytopenia, and neutrophilia with left shift • Chemistry panel: ↑ BUN, creatinine, AST, ALT, ALP, bilirubin, phosphorus, ↓ chloride, sodium, and potassium • Urinalysis: proteinuria, pyuria, bilirubinuria, and isothenuria • Microscopic agglutination test: + after 1 week, peaking at 3–4 weeks, fourfold rise in titer • Combined IgM-IgG ELISA titers: IgM is + in first week and persists to 2 weeks; IgG is + 2–3 weeks after infection and persists for months
• • • •
Imaging
• N/A
• Radiographs, joints: +/− effusion
Procedures
• N/A
• N/A
General
• Supportive • Fluid therapy • Transfusion therapy
• Supportive
Medication
• Antibiotic: doxycycline, penicillin (leptospiremia)
• Antibiotics: tetracycline, ampicillin, doxycycline, and cephalexin • NSAIDs
Nursing Care
• Restrict activity/cage rest. • Nutritional support
• Encourage outpatient care. • Pain management
Treatment
Diagnosis
Presentation
Disease
IDEXX SNAP 3Dx test IDEXX SNAP 4Dx test IFA and ELISA: ≥1:152 = highly + Synovial fluid analysis: suppurative and +/− Borrelia organisms within WBC
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
41
2
Table 2.8 / Canine Transmissible Diseases: Leptospirosis, Lyme Disease (Continued) Disease
Follow-Up
2
Leptospirosis ZOONOTIC
Lyme Disease ZOONOTIC
Patient Care
• Monitor blood chemistries and urinalysis.
• Restricted activity
Prevention/Avoidance
• Vaccinate in high-risk areas. • • Avoid water sources where animals may have urinated; shedding time, months • to years. • •
Complications
• DIC • Permanent renal and hepatic dysfunction
• CNS disorders • Fatal renal failure • Heart block (rare)
Prognosis
• Most infections are subclinical; those that are acutely severe have a guarded prognosis.
• Recovery expected, but recurrence possible within weeks to months
• Spread in the urine of recovered animals for months to years following infection • Transmitted by food, water, bedding, soil, vegetation, or fomites • Disinfect with povidine-iodine; bleach 1:10 dilution. • Enters through skin or mucous membranes or by ingestion of contaminated water • Onset is a few days to 30 days; typically 3–14 days.
• Transmitted most commonly by the deer tick Ixodes dammini through a tick bite. • Infected animals pose little risk to humans; they are more of a risk in passing ticks to humans.
Notes
Limit access to tick-infested areas. Use tick repellants/insecticides. Periodically check dogs for ticks. Vaccinate in high-risk areas.
Table 2.9 / Canine Transmissible Diseases: Parvovirus, Rabies Parvovirus (CPV)
Rabies ZOONOTIC
Definition
Highly contagious disease causing severe enteritis and affecting the lymphatic system. Typically affects puppies between weaning and 6 months of age.
A virus that can infect almost all warm-blooded animals and is considered untreatable. It infects the nervous system, causing death from paralysis.
Presenting Clinical Signs
• Anorexia, depression, and vomiting • Diarrhea: profuse, liquid, hemorrhagic, and distinct metallic odor • Symptoms may vary in older dogs.
Three phases • Prodromal phase (2–3 days): fever, subtle behavior changes • Furious phase (2–4 days): irritability, restlessness, barking, ataxia, and seizures • Paralytic phase (2–4 days): paralysis, depression, coma, and death from respiratory paralysis
Examination Findings
• Extreme dehydration, fever
• Prodromal phase: slow corneal and palpebral reflexes
Presentation
Disease
42
SECTION TWO: PREVENTATIVE CARE
Table 2.9 / Canine Transmissible Diseases: Parvovirus, Rabies (Continued) Parvovirus (CPV)
Rabies ZOONOTIC
General
• History/clinical signs
• History/clinical signs
Laboratory
• CBC: severe leukopenia and lymphopenia, PCV variable • Chemistry panel: ↑ bilirubin, ALT, AST and ↓ potassium, sodium and chloride • ELISA assay • IDEXX Parvo Antigen SNAP test • Fecal hemagglutination test
• CSF: minimal ↑ protein and leukocytes • Postmortem virus isolation from fresh brain tissue
Imaging
• Radiographs, abdominal: gas and fluid distention in GIT • Often causing a misdiagnosis of GIT obstruction
• N/A
Procedures
• N/A
• N/A
General
• Symptomatic • Supportive • Fluid therapy: aggressive
• Supportive
Medication
• Antibiotics: ampicillin and gentamicin • Antiemetics: metoclopramide or H2 blocker
• N/A
Nursing Care
• Nothing by mouth for 24 hours after vomiting and severe diarrhea • Quarantine protocol
• Strictly inpatient/quarantine • Runs and cages should be locked.
Patient Care
• Dogs should remain isolated for 1 week after complete recovery.
• None
Prevention/Avoidance
• Vaccinate out to 16–18 weeks • Isolate puppies as much as possible until vaccine series has been completed.
• Vaccinate • Strict quarantine for those suspected of having rabies • Euthanize all animals known to have rabies
Complications
• Septicemia • Secondary bacterial pneumonia • Intussusception
• N/A
Prognosis
• Survival of 3–4 days is usually followed by rapid recovery. • Immunity by natural infection is lifelong if the dog survives.
• Almost 100% fatal
• Transmitted by the fecal-oral route, saliva, vomitus, or direct contact • Stable in the environment for months to years • Rottweilers, Doberman Pinschers, Pit Bull Terriers, and Labrador Retrievers seem to be at higher risk. • Disinfect with 1:32 dilution of bleach and water or Parvocide®. • Incubation period 5–10 days
• Transmitted in the saliva • Inactivated by disinfectants • Head should be chilled on wet ice (do not freeze) and sent to a lab for analysis.
Follow-Up
Treatment
Diagnosis
Disease
Notes
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
2
43
Table 2.10 / Canine Vaccination Protocol
The site of vaccine injection varies between clinics, but it is important to have a designated location for each vaccine and to note these locations in each patient’s chart. Vaccines are routinely given subcutaneously, except for the intranasal version of Bordetella. Vaccine
≤16 Weeks of Age
>16 Weeks of Age
Vaccine Classificationa
DHPP • Canine distemper (D) • Canine hepatitis/adenovirus (H) (CAV-2) • Canine parainfluenza (P) • Canine parvovirus (P)
• 1 dose at 6–9 weeks, then repeat every 3–4 weeks until 16 weeks (e.g., 1 dose at 8, 12 and 16 weeks) • 1 dose at 12 months, then every 3 years
• 1 dose initially • 1 dose 12 months after initial, then 1 dose every 3 years
Core Core
Leptospirosis • Canine leptospirosis
• 1 dose: 12 and 16 weeks • Annually dependent on patient’s risks
• 2 doses, 2–4 weeks apart • Annually dependent on patient’s risks
Noncore
Bordetella • Infectious tracheobronchitis
• IN: 1 dose at 3–12 weeks, then 1 dose 2–4 weeks later, then biannually or annually dependent on patient’s risks • SQ: 1 dose at 6–8 weeks, repeat 1 dose 2–4 weeks later, then annually dependent on patient’s risks
• IN: 2 doses, 2–4 weeks apart, then biannually or annually dependent on patient’s risks • SQ: 1 dose, then biannually or annually dependent on patient’s risks
Noncore
Rabies • Rabies virus
• 1 dose at 12–16 weeks • 1 dose every 1–3 years dependent on vaccine type and state requirements
• 1 dose initially • 1 dose every 1–3 years dependent on vaccine and state requirements
Core
Lyme • Lyme borreliosis
• 1 dose at 9–12 weeks, then repeat 2–4 weeks later • Annually, dependent on patient’s risk
• 2 doses, 2–4 weeks apart • Annually, dependent on patient’s risk
Noncore
Noncore Core
Note: Injection site, age at administration, and booster protocol may vary depending on the manufacturer of the vaccination and veterinarian’s discretion. Recommendations by the individual manufacturer should be followed. The frequency may vary depending on the state’s requirements and the veterinarian’s protocol. Note: Possible reactions range from sensitivity at the injection site, a small bump or knot at the injection site, slight fever, hives, and lethargy to anaphylactic shock (vomiting, salivation, dyspnea, and incoordination). a Core vaccines are those recommended to every dog. Noncore vaccines are recommended based on potential risk factors.
Table 2.11 / Feline Transmissible Diseases: Feline Calcivirus Disease
Feline Calicivirus (FCV)
Definition
One of the major causes of feline upper respiratory disease. An acute, highly contagious viral disease causing oral ulceration, pneumonia, and occasionally arthritis.
Presentation
2
44
Presenting Clinical Signs
Anorexia, depression, dyspnea, mild conjunctivitis, mild sneezing, nasal discharge, ulcerated tip of nose
Examination Findings
• +/− Arthralgia, enteritis, facial and limb edema, fever, gingivitis, limping syndrome, interdigital paw ulcers, oral ulcers
SECTION TWO: PREVENTATIVE CARE
Table 2.11 / Feline Transmissible Diseases: Feline Calcivirus (Continued)
Follow-Up
Treatment
Diagnosis
Disease
Feline Calicivirus (FCV)
2
General
• History/clinical signs
Laboratory
• CBC: neutrophilia and lymphopenia • Chemistry panel: ↑ bilirubin, CK • Virus isolation: cell cultures of swabs from oropharynx, lung tissue, nasal cavity, conjunctiva, feces, and blood
Imaging
• Radiographs, thoracic: generalized ↑ density of the lungs
Procedures
• N/A
General
• Self-limiting in 5–7 days • Supportive
Medication
• • • • •
Nursing Care
• Oxygen supplementation if complicated pneumonia • Nutritional support
Patient Care
• • • • •
Prevention/Avoidance
• Vaccinate • Prevent contact with FCV-infected cats. • Virus is shed continuously.
Complications
• Interstitial pneumonia • Secondary bacterial infections
Prognosis
• Excellent unless pneumonia develops • Recovered cats may shed the virus in their saliva for long periods.
Notes
Antibiotics: amoxicillin Antibiotic (ophthalmic) Pain medication Immunostimulants: interferon Corticosteroids
Keep eyes and nose clear of discharge. Support nutrition and fluid intake Airway humidification Provide soft foods if oral ulcers. Irrigate oral lesions with 0.2% chlorhexidine solution.
• Transmission is through direct contact and fomites; virus is shed in oropharyngeal, conjunctival, and nasal secretions, feces, sloughed hair and skin. • Very resistant virus; disinfect with 1:32 dilution of bleach water. • Cats that recover may remain subclinical carriers for months to years. • Cats should be tested for FIV or FeLV to rule out underlying immunodeficiency syndromes. • Occurs with FHV-1 in most cases. • Incubation period is 1–5 days. • Intermittent shedding may take place for 4 months postinfection.
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
45
Table 2.12 / Feline Transmissible Diseases: Feline Infectious Peritonitis
Definition
A systemic viral disease with high mortality. This disease arises from a mutation of a benign virus, feline enteric coronavirus (FEVC) commonly found in the GIT of cats. There are 2 different forms: wet/effusive form and the dry/noneffusive, granulomatous form.
Presenting Clinical Signs
• Ataxia, behavioral changes, depression, diarrhea, failure to grow, inactivity, paresis, poor condition, seizures, urinary incontinence, vomiting, weight loss • Dry Form: dyspnea, exercise intolerance • Wet Form: abdominal distention
Examination Findings
• Fever, icterus, pallor • Dry form: anterior uveitis, chorioretinitis, iritis, irregular pupils, tumors • Wet Form: abdominal or pleural effusion
General
• Clinical signs after other conditions have been ruled out
Laboratory
• • • • • • •
Imaging
• Radiographs, thoracic: effusion • Radiographs, abdominal: effusion, organomegaly, lymphadenopathy, and ileocolic mass
Procedures
• Abdominocentesis or thoracocentesis; straw-colored fluid, viscous, clots, fibrinous, and ↑ protein • Tumor biopsy: granulomatous inflammation
General
• Therapeutic paracentesis • Fluid therapy • Supportive
Medication
• Corticosteroids: prednisone • Immunosuppressive drugs: cyclophosphamide • Immunostimulants: immunoregulin, interferon, acemannan
Nursing Care
• Nutritional support
Diagnosis
Presentation
Feline Infectious Peritonitis (FIP, Feline Coronavirus)
Treatment
2
Disease
46
SECTION TWO: PREVENTATIVE CARE
CBC: leukopenia (early in disease), leukocytosis with neutrophilia, lymphopenia (late in disease), nonregenerative anemia Chemistry panel: ↑ bilirubin, ALP, ALT, globulins and bile acids, BUN, creatinine Urinalysis: ↓ bilirubin and protein Histopathologic examination: biopsy is the only definitive method for FIP diagnosis Immunohistochemistry: most accurate FIP virus detection on biopsied tissue Titers: limited value, highest titers have ↑ likelihood of disease PCR: virus detection
Table 2.12 / Feline Transmissible Diseases: Feline Infectious Peritonitis (Continued)
Follow-Up
Disease
Feline Infectious Peritonitis (FIP, Feline Coronavirus)
Patient Care
• Confine to prevent exposure to other cats
Prevention/Avoidance
• • • •
Complications
• GIT obstruction • Neurologic disease • Pleural effusion
Prognosis
• Almost 100% mortality • Length of disease is a few days to months.
Notes
2
Prevent contact with FIP-positive cats; transmission is rare between cats. Intranasal vaccine; very low efficacy Routine disinfection Control and prevent feline leukemia virus (FeLV) infection.
• Transmitted through oral and respiratory secretions, feces, urine, and fomites, but most commonly through the mutation of FECV to FIP • Survives in the environment for several weeks • Readily inactivated by commonly used disinfectants
Table 2.13 / Feline Transmissible Diseases: Feline Panleukopenia Virus, Feline Immunodeficiency Virus Feline Panleukopenia Virus (FPV, Feline Parvovirus)
Feline Immunodeficiency Virus (FIV)
Definition
An acute, systemic, and enteric viral disease. It has a sudden onset, is highly contagious, and has a high mortality rate.
An immunodeficiency syndrome characterized by chronic and recurrent infection. Gradually selecting and destroying T-lymphocytes. This process makes cats more prone to secondary syndromes. Affected cats can be asymptomatic for >5years.
Presenting Clinical Signs
• Abdominal pain (crouching position and head between front paws), anorexia, depression, diarrhea, persistent vomiting, rough and dull hair coat
Stage 1 • Usually subclinical: fever, neutropenia, and lymphadenopathy Stage 2 • Latent phase: could last for years Stage 3 • Terminal phase: abscesses, anorexia, cachexia, dementia
Examination Findings
• Fever progressing to hypothermia and progressive dehydration
• Conjunctivitis, gingivitis, otitis, periodontitis, pneumonia, rhinitis, skin infections, stomatitis, tachycardia, urinary tract infections
Presentation
Disease
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
47
Table 2.13 / Feline Transmissible Diseases: Feline Panleukopenia Virus, Feline Immunodeficiency Virus (Continued) Disease
Feline Immunodeficiency Virus (FIV)
General
• History/clinical signs
• History/clinical signs of exposure
Laboratory
• CBC: leukopenia • Chemistry panel: ↑ BUN, creatinine, and electrolyte imbalances • Virus isolation: feces • CITE test for canine parvovirus: detects FPV antigen in the acute stage • Serologic testing: rising titers • Chromatographic test strip, feces: + for FPV and CPV
• • • • • •
Imaging
• N/A
• N/A
Procedures
• N/A
• N/A
General
• Supportive • Fluid therapy • Blood transfusions
• Symptomatic • Fluid therapy • Dental care
Medication
• Antibiotics • Antiemetics: metoclopramide
• • • •
Nursing Care
• Nothing by mouth until vomiting and diarrhea subside • Heat support if hypothermic • Monitor hydration, electrolytes, and CBC
• Nutritional support
Patient Care
• Heat support • Nutritional support once eating
• Maintain current vaccines to prevent infection of respiratory disease
Prevention/Avoidance
• Vaccinate. • Prevent contact with infected cats. • Clean up feces: shedding time up to 6 weeks
• • • •
Complications
• • • •
• N/A
Prognosis
• Poor prognosis in terminal phase: ≤1 year survival
• >50% remain asymptomatic within 2 years after diagnosis • Poor prognosis in terminal phase: ≤1 year survival
• Transmitted by fomites and through all body secretions for up to 6 weeks. • Disinfect with 1:32 dilution of bleach water. • Survives months to years in the environment • In utero transmission from infected queen leads to cerebellar hypoplasia in kittens. • Incubation period: <14 days • Recovered cats have lifetime immunity against FPV.
• • • • •
Follow-Up
Treatment
Diagnosis
2
Feline Panleukopenia Virus (FPV, Feline Parvovirus)
Notes
48
Hypothermia and shock DIC Mycotic infection Jaundice
SECTION TWO: PREVENTATIVE CARE
CBC (stage 3): anemia (v), lymphopenia, neutropenia Chemistry panel: ↑ protein and globulins Urinalysis: ↑ protein ELISA: + Western blot: confirms + results of ELISA Culture, plasma, saliva, tears, urine: FeLV isolated and identified
Antibiotics for secondary infection: metronidazole Appetite stimulants: cyproheptadine, diazepam Corticosteroids: prednisone Immune stimulants: interferon, zidovudine, ddC, PMEA, staphylococcal protein A, Propionibacterium acnes, acemannan
Isolate affected cats. Neuter males. Quarantine and test incoming cats. Retest high-risk cats regularly.
Transmitted through bite wounds, in utero, and transfusions Theoretically transmitted through intimate contact or fomites Shed in the saliva Most commonly seen in unneutered roaming males A kitten may test + when <6 months old due to maternal antibodies: retest at 8–12 months after all maternal antibodies are gone.
Table 2.14 / Feline Transmissible Diseases: Feline Leukemia Virus, Feline Rhinotracheitis Virus Feline Leukemia Virus (FeLV)
Feline Rhinotracheitis Virus (FHV-1, Feline Herpesvirus)
Definition
A retrovirus causing immunosuppression and various types of cancer, specifically lymphoma and leukemia. Cats may clear initial infection, but there is no cure for persistent infection, which ultimately leads to death.
One of the major causes of feline upper respiratory disease. A highly contagious viral disease causing rhinitis, conjunctivitis, and ulcerative keratitis.
Presenting Clinical Signs
• Persistent diarrhea and wasting
• Anorexia, cough (rare), depression, excessive lacrimation, hypersalivation, loss of voice, nasocular discharge, photophobia, sneezing
Examination Findings
• Conjunctivitis, fever, gingivitis, keratitis, lymphadenomegaly, periodontitis, rhinitis, skin infections, stomatitis
• Fever, conjunctivitis, herpetic ulcers, rhinitis, ulcerative keratitis
General
• History/clinical signs
• Clinical signs
Laboratory
• CBC: lymphopenia, neutropenia, nonregenerative anemia, thrombocytopenia, and immune-mediated hemolytic anemia • ELISA: virus antigen detection • Bone marrow aspirate or biopsy • IFA test: +
• CBC: transient leukopenia, leukocytosis • Virus isolation: cell cultures of swabs from the pharynx, nasal epithelium, or conjunctiva • IFA: viral detection • Stained conjunctival smears: intranuclear inclusion bodies detection
Imaging
• N/A
• Radiographs, skull: chronic disease shows changes in the nasal cavities and frontal sinuses
Procedures
• N/A
• N/A
General
• Symptomatic
• Supportive • Fluid therapy
Medication
• Antibiotics, esp. with Haemobartonella infection • Immunomodulatory drugs: interferon
• • • • •
Antibiotics: amoxicillin and enrofloxacin Antibiotics (ophthalmic) Antiviral eye medications: Vira-A Immunomodulatory drugs: interferon Lysine
Nursing Care
• Blood transfusions; many may be necessary. Using blood from FeLVvaccinated cats may reduce the level of FeLV antigenemia in some cats.
• • • •
Nutritional support, feeding tube placement Keep eyes and nose clear of discharge. Airway humidification ↑ Environmental temperature; herpesvirus is temperature sensitive
Treatment
Diagnosis
Presentation
Disease
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
2
49
Table 2.14 / Feline Transmissible Diseases: Feline Leukemia Virus, Feline Rhinotracheitis Virus (Continued) Disease
Feline Leukemia Virus (FeLV)
Feline Rhinotracheitis Virus (FHV-1, Feline Herpesvirus)
Patient Care
• Symptomatic • Nutritional support, low stress environment, management of secondary conditions
• Confine indoors to decrease environmentally induced stress.
Prevention/Avoidance
• Vaccinate outdoor cats and those living with a FeLV-positive cat. • Quarantine and test all new cats to the household or local environment. • Prevent contact with FeLV-positive cats.
• Vaccinate. • Prevent contact with FHV-infected cats. • Virus shed intermittently
Complications
• • • • •
• • • •
Prognosis
• >50% of cats die from related diseases in 2–3 years
• Good; 7–10 days
• All FeLV-positive cats must remain indoors to prevent further spread of the disease. • Test each cat prior to first vaccine or if there has been a long period of time without vaccines. • More false-positive cats when using whole blood on the ELISA test • False negatives can be seen in cats infected within the last 1–3 months. • Do not use modified live vaccines. • Transmission is most commonly through cat-to-cat bites, grooming, shared dishes, litter boxes, in utero, or through nursing
• Transmission is through direct contact and fomites. • Very resistant virus; disinfect with 1:32 dilution of bleach water • Readily inactivated by commonly used disinfectants for months to years • Cats should be tested for FIV and FeLV to rule out underlying immunodeficiency syndromes.
Follow-Up
2
Notes
50
SECTION TWO: PREVENTATIVE CARE
Lymphoma Fibrosarcoma Glomerulonephritis Toxoplasmosis Haemobartonellosis
Chronic rhinosinusitis Persistent nasal discharge Herpetic ulcerative keratitis Permanent closure of nasolacrimal duct
Table 2.15 / Feline Vaccination Protocol
The site of vaccine injection varies between clinics, but it is important to have a designated location for each vaccine and to note these locations in each patient’s chart. Feline vaccines vary as to their route of administration: subcutaneously, intranasally/intraocularly, or transdermally. The Vet Jet transdermal vaccination system utilizes an internal spring system, which disperses the vaccine through the dermis into the dendritic cells.
2
Vaccine
≥16 Weeks of Age
>16 Weeks of Age
Injection Sitea
Vaccine Classificationb
FPV • Feline panleukopenia FCV • Feline calicivirus FHV-1 • Feline viral rhinotracheitis
• 1 dose at 6–9 weeks, then repeat every 3– 4 weeks until 16 weeks (e.g., 1 dose at 8, 12, 16 weeks) • 1 dose 12 months after initial, then 1 dose every 1–3 years dependent on manufacturer and hospital policy
• 2 doses, 3–4 weeks apart • 1 dose 12 months after initial, then 1 dose every 1–3 years dependent on manufacturer and hospital policy
• SQ on right lower shoulder • IN/conjunctival sacs, depending on manufacturer
Core
FeLV • Feline leukemia
• ELISA FeLV test for virus detection prior to vaccination • 1 dose at 8 weeks, then 1 dose 3–4 weeks later • Annually dependent on patient’s risk
• Elisa FeLV test for virus detection prior to vaccination • 2 doses; 3–4 weeks apart • Annually dependent on patient’s risk
• Transdermal on the left hind lower thigh area • SQ on the left lower thigh area
Noncore
Rabies • Rabies virus (RV)
• 1 dose at 8–12 weeks dependent on vaccine type • 1 dose every 1–3 years dependent on vaccine type and state requirements • Annually using canary-pox vector rabies vaccine
• 1 dose initially • 1 dose every 1–3 years dependent on vaccine type and state requirements • Annually using canary-pox vector rabies vaccine
• SQ on right hind lower thigh area
Core
FIV • Feline immunodeficiency virus
• 1 dose at 8 weeks, then 2 doses every 2–3 weeks • Annually dependent on patient’s risk
• 3 doses every 2–3 weeks • Annually dependent on patient’s risk
• SQ
Noncore
Core Core
a
Injection site, age of administration, and booster protocol may vary depending on the manufacturer of the vaccination. Recommendations by the individual manufacturer should be followed. The frequency may vary depending on the state’s requirements and the veterinarian’s protocol. Note: Possible reactions range from sensitivity at the injection site, a small bump or knot at the injection site, slight fever, hives, lethargy, to anaphylactic shock (vomiting, salivation, dyspnea, and incoordination) and injection site sarcomas. Any bump found at the injection site should be assessed by a veterinarian. b Core vaccines are those recommended to every dog. Noncore vaccines are recommended based on potential risk factors.
ANIMAL CARE Along with medical care provided by the veterinarian, owners must take an active role in the day-to-day health of their animals. Dental care, grooming, and basic medical procedures can help provide the animal with increased
health and longevity. Besides providing the basic care, it also allows the owners to be more aware of other health problems that might otherwise be missed (e.g., gum inflammation, tumors, pruritus, otitis externa).
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
51
Skill Box 2.9 / Client Education: Home Dental Care 2
Home dental care should be a daily part of each animal’s life. The commitment to time, energy, and resources from the owner will impact the quantity and quality of their animal’s life.
• Brush the visible teeth (opposite side) and then repeat on the other side. Maintenance:
Supplies:
• Brush daily, at a minimum of 3 times a week.
• Toothbrush (e.g., fingerbrush, pet toothbrush, human toothbrush), gauze, washcloth, pantyhose
• Oral examination
• Veterinary toothpaste, beef bouillon, garlic or tuna water Age: • Home dental care should begin at 8–12 weeks of age. Brushing is not critical until the adult teeth erupt, but starting early allows the animal to become accustomed to the procedure during an impressionable period of development. Introduction: • Regardless of age, introduce brushing slowly and gradually, allowing the animal to determine the amount of time at each stage. • As each step is begun, observe for the animal’s reaction and only advance to the next step once the animal is comfortable. • Massage the animal’s muzzle and lips gently. • Introduce your finger dipped in beef bouillon or garlic water (canine) or tuna water (feline) into the buccal pouch under the upper lip and rub the gum line. • Introduce your finger covered with a gauze, washcloth, or pantyhose and rub the gum line and teeth in a circular motion. • Introduce a pet toothbrush or a very soft human toothbrush held at a 45° angle to the tooth surface, brushing in a oval motion. • Introduce the toothbrush with veterinary toothpaste. • As the animal accepts the procedure, brushing of the lingual surfaces can begin. • Place the nonbrushing hand over the muzzle and tilt head backward to open the animal’s mouth.
52
SECTION TWO: PREVENTATIVE CARE
• Gums: redness, swelling, bleeding, pus • Teeth: loss, instability, broken, change in color • Mouth: halitosis, growth Adjuncts to brushing: • Dental diets or treats • Rawhide bones (e.g., Nylabone) • Yearly dental examinations and cleanings, if needed Tips for successful brushing: • Select the same time each day to brush so the animal expects it (routine and repetition). • Brushing in the evening is often preferred as everyone is in a more quiet mood. • Sessions should be short, roughly 2–3 minutes. • Offer praise and reassurance during and following the brushing. Avoid: • Human toothpaste, baking soda, or hydrogen peroxide • Heavy restraint • Brushing aggressively • Brushing if the procedure may cause pain (e.g., recent thorough oral examination, existing CLL, exposed pulp cavities, gingivitis, ulcerations, tooth mobility) • Natural bones, cow hooves, hard nylon toys as they may fracture teeth
Skill Box 2.10 / Grooming
Skill Box 2.11 / Bathing
Grooming is a segment of veterinary care that is limited and typically presents itself as client education. Even though staff may not routinely provide grooming services, clients often have questions regarding the general care of their pets. Brushing, bathing, and toenail trims are the most basic of grooming procedures. There are also certain procedures that may be performed during periods of medical conditions that must be continued routinely to avoid reoccurrence of the problem, such as anal gland expression and ear cleaning and flushing. Brushing should be a routine part of pet care to remove dead fur and dirt and to prevent matting. Besides providing the animal with a shinier and healthier coat and a chance to look and feel for abnormalities, it also allows bonding between the animal and the owner. There are many types of brushes and combs available for specific types of coats; a variety of options can be helpful. Applying a detangler spray before beginning may help with tangled or slightly matted fur. Using a systematic approach, begin at the head and work toward the tail. Use a gentle stroke, as ripping or pulling at the fur is painful and will make brushing a negative experience. For animals with long, thick coats, brush the fur against the natural lay of the fur and then finish with brushing fur down. Following up with a comb may help remove the extra loose fur.
1. Location: a safe place for both owner and animal to stand, a mixture of hot and cold water available, and an area able to withstand water (e.g., shaking wet dog) • Place a towel or mat in the bottom of the tub to supply traction for the animal. • Have a leash hook fastened to the wall so the animal can be secured without having to always have a hand on the animal. 2. Supplies: multiple towels, appropriate shampoo, plastic apron, gloves (depending on type of shampoo) and protective eyewear. 3. Comb, brush, and demat to remove excess fur, which allows better penetration of shampoo as detailed above. 4. Wet down the animal completely, making sure to get water down to the skin. 5. Apply the shampoo and lather the entire animal, including face. 6. Leave shampoo on for the amount of time indicated on the bottle or by the veterinarian. • Use a timer to ensure that the shampoo is on for the correct time: do not guess. 7. Rinse the animal completely, making sure to remove all soapy residue. 8. Dry the animal’s haircoat and ear canals with a combination of shaking (removes 95% of the water) and towels. • Blow in the animal’s ear to get them to shake. • Dry the ear canals, using either cotton balls or a vinegar rinse. Note: Keep the animal in a warm place until completely dry to avoid the animal becoming chilled. 9. Comb and brush out the animal after the bath to remove all the hair that was loosened. Note: Do not use lubricants in the eyes; it may trap the shampoo in the eye instead of protecting the eye. • Do not place an animal in a heater/dryer cage without direct supervision and access to water to prevent overheating and death of the animal. • If drying an animal with a blow dryer, be sure to keep the dryer on the lowest setting and continuously moving to prevent burns to the animals. CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
53
2
2
Skill Box 2.12 / Nail Trimming
Skill Box 2.13 / Anal Sac Expression
Nail trimming is another routine part of pet care. Failing to trim the nails may lead to the nails growing into the pad of the paw, difficulty or inability of the pet to walk, and pain and pad injuries. Most animals are adverse to nail trimming and may need some coaxing. Choosing a time when the pet is tired and comfortable may make the experience more tolerable. When trimming, it is best to hold the trimmer perpendicular (cutting top to bottom) to the nail; when held parallel (cutting side to side), crushing and splintering of the nail may take place. When trimming nails, it is important to avoid cutting the quick, which consists of the blood vessels and nerves that supply the toenail. In dogs, light-colored nails are easy to trim as the blood supply is easily seen and avoided. Dark-colored nails can be difficult to trim and should be done in small cuts. As small cuts are made, the white to pink crescent shape will begin to appear in the middle of the nail. This represents the quick, and continuing to cut will eventually lead to bleeding. Remember to cut all nails including the dewclaws on both front and rear feet. The rear feet nails are typically shorter and require less trimming. In cats, the paw is gently squeezed to expose the nails and then they are trimmed to within 2 mm of the quick.
1. Supplies: gloves, lubricant (e.g., K-Y Jelly), alcohol, absorbent material (e.g., rolled cotton, paper towels, baby wipes), and deodorizer
54
SECTION TWO: PREVENTATIVE CARE
2. Put alcohol-soaked absorbent material into the gloved hand during the expression to catch the expressed material, insert the forefinger into the rectum, and immobilize the sac between the forefinger and the thumb on the outside of the rectum. 3. Gently apply pressure to the sac with thumb and forefinger (located at the 4 and 8 o’clock positions when looking at the anus), milking from the bottom of the sac upward toward the duct opening. 4. Note the amount and character of the material expressed. Normal secretions are a clear to slightly greenish, foul-smelling (similar to dead fish) substance that is a liquid to a paste in consistency. Material that is very thick or purulent or very dark should be brought to the attention of the veterinarian. 5. Clean the perianal area of the animal with alcohol-soaked material or baby wipe and then spray with a deodorizer. • If using powdered gloves, put 2 gloves on the hand doing the expression, then remove 1 glove after each sac is expressed. • If having difficulty expressing a gland, try rolling the skin outward with the finger outside the rectum to better expose the duct. • If having trouble with positioning, switch and use the thumb on the inside and the forefinger on the outside or teach yourself to be ambidextrous and express the right gland with the left hand and vice versa.
Skill Box 2.14 / Ear Cleaning and Flushing Method
Ear Cleaning
Ear Flushing
Equipment
• Cotton ball • Cleaning solution (chlorhexidine, povidone iodine, Oti-clens, Epi-Otic) • Bulb syringe/syringe without the needle • towel
• • • • • •
Cotton ball Cleaning solution (Ceremune) Ear irrigator (filled with warm water) Video scope or endoscope Anesthetized patient 5 Fr red rubber feeding tube (cut to about ½ its length)
Technique
• Verify the patient has an intact tympanic membrane. • Using either a bulb syringe or syringe without the needle, fill the ear canal with cleaning solution. Be careful not to form a seal between the instrument and the ear canal, and do not use a direct stream on the tympanic membrane. • Put a towel or piece of roll cotton at the entrance of the ear canal and begin gently massaging the ear canal from the bottom up. This will work the solution from the bottom of the ear canal to the opening. With a cotton ball, gently wipe out any debris. Do not push cotton ball in the ear any farther than your finger will go easily. • Repeat steps 1 and 2 until the ear canal and solution on the cotton ball come out clean (5–10 times). • To dry the ear canal, use either a flushing solution or suction via an infant feeding tube attached to a syringe.
• • • • •
Take a picture of the ear canal. If cytology has not been done, take a sample of the ear debris. Insert the Ceremune or other ear cleaner, and massage gently for 3–4 minutes. Wipe out any excess at the entry of the ear. Insert the feeding tube onto the ear irrigator nozzle and turn on the machine, verifying that the pressure gauges are registering as prescribed in the manual. Position the video scope or endoscope into the ear, and then insert the feeding tube into the port and watch on the monitor screen to see the tip protrude from the scope. Depress the water button on the trumpet, release, and then depress the suction button and suction out debris and liquid. Repeat several times. Remove the feeding tube if debris is clogging the tip and clean. A reapplication of the ear cleaning solution may be necessary in ears with a lot of debris. Be sure to remove all of the Ceremune. Take a second picture of the clean canal. Insert any medications if needed.
• • • • • •
2
Note: See Figure 1.19, Ear, page 13.
CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS
55
Chapter
3
3
Nutrition General Nutrition 58 Daily Caloric Requirement Worksheet for a Healthy Animal 59 General Life Stage Feeding Guidelines
Body Condition Scoring System 62 Disease Nutritional Requirements 64 Obesity Management 68 60
Key Words and Termsa Aerophagia Alkali Amino acid Antigenic Bioactive amines Bioavailability Cachexia Carbohydrate Daily energy requirement Digestibility Energy Fat Fatty acid Fiber Hydrolyzed protein Kilocalorie a
Life stage Malnutrition Meat byproducts Meat meal Metabolism Micronutrient Mineral Neonate Nitrogenous waste Nutrient Obesity Protein Resting energy requirement Vasoactive amines Vitamin
Abbreviations
Additional References, page
AAFCO, Association of American Feed Control Officials BCS, body condition score BW, body weight CHF, chronic heart failure DER, daily energy requirement EPI, exocrine pancreatic insufficiency FLUTD, feline lower urinary tract disease GIT, gastrointestinal tract kcal, kilocalorie ME, metabolizable energy NPO, nothing by mouth PLE, protein losing enteropathy RBC, red blood cell RER, resting energy requirement
Laboratory, 71 Parenteral nutrition, 422 Pharmacology, 567 Physical examination, 18 Urinalysis, 147
Key words and terms are defined in the glossary on page 631.
57
GENERAL NUTRITION
3
Proper nutrition is as important as physical examinations, vaccinations, and dental care in maintaining a healthy pet. Unfortunately, not much time is usually given to the subject during client education. Obesity remains the biggest nutritional challenge; it is estimated that 24–44% of dogs and cats in the United States are overweight. Understanding how to feed a pet according to its life stage, how to determine their current condition, how to alter their nutrition based on disease changes, and how to get a pet back to its ideal condition are the keys to proper clinical nutrition. The most important component of proper nutrition begins with a high-quality diet formulated to the appropriate life stage of the animal. Poor-quality, unbalanced, commercial diets; homemade diets of single-food items; indiscriminate mixtures of singlefood items; and variable supplements will lead to dietary imbalances. Along with proper nutrition, fresh, clean water must be provided at all times. Owners often look to the veterinary staff for a better understanding of the “right” diet to feed their pet. Many would like a concrete comparison
58
SECTION TWO: PREVENTATIVE CARE
between different foods, but unfortunately this is virtually impossible to do. The information provided in the ingredient list and on the information panel appears at first glance to be consistent between products, but the variables that exist render a comparison unattainable. The most reliable way to evaluate a food is to evaluate the health and appearance of the animal that is eating it. Each animal is an individual and will handle each diet differently. Some basic guidelines to providing a quality diet include feeding diets that have passed the Association of American Feed Control Officials (AAFCO) feeding trials, feeding diets appropriate for the animal’s life stage, and feeding diets containing meat (not including meat byproducts and meat meal). Some indications that a diet change may be indicated for a particular pet are poor body condition, flatulence, borborygmus, ↑ fecal volume and frequency, changes in the expected appearance of the haircoat. Home-prepared diets can be a very valuable option when an approved recipe is followed to guarantee the proper nutrients have been included. Only those recipes formulated by a credentialed veterinary nutritionist should be considered and then not altered.
Skill Box 3.1 / Daily Caloric Requirement Worksheet for a Healthy Animal Many factors affect the energy requirements of animals. Understanding these factors may prevent an animal from becoming obese. Daily caloric requirements are altered by the physiologic state (e.g., adult maintenance, pregnancy, lactation, and growth), activity level, temperament, environmental temperature, and the diet’s digestibility. The calculations below provide a starting point; adjustments will need to be made based on each individual animal. Step 1: Calculate Daily Resting Energy Requirement (RER) RER = 70 × (current body weight in kg)0.75 or, for animals weighing between 2 and 30 kg: RER = (30 × current body weight in kg) + 70 = ______ kcal/day Adjust kcal based on visual and manual examination and the BCS of animal. Tip: To calculate (BW kg)0.75 without a scientific calculator: multiply the weight by itself 3 times, then take the square root twice Step 2: Calculate daily energy requirement (DER) by multiplying the RER by the activity factor. Life Stage
Activity Factor (RER × ______ = DER) Canine
Feline
2.0
1.6–2.0
Gestation Weeks 5–9 Lactation Week 1–2
1.5a
Week 3–5
a
2.0
1.5 1.5–5.0
Growth Weaning to 50% of adult BW
3.0
3.0
51% of adult BW to adult
2.0
2.0
Inactive, neutered
1.6
1.2
Inactive, intact
1.8
1.4
Active/working
2.0–6.0
1.6
Adult
a 25% of the RER should be provided for each pup in addition to the dam’s DER. These calculations do not take into consideration the type of breed and their differences in growth requirements. Adjust kcal based on visual and manual examination of animal.
Step 3: Calculate volume of food required ______ kcal/day/ ______ kcal/cup or can of food = ______ cup/can(s) of food/day Step 4: Calculate amount of each feeding ______ cup/can(s) of food/day/2–3 feedings per day = ______ cup/can(s) of food/feeding
CHAPTER 3 / NUTRITION
59
3
Table 3.1 / General Life Stage Feeding Guidelines
Each stage of an animal’s life presents changes in nutritional needs. The overall goal of nutrition is to obtain an optimum body condition score (see Table 3.2 Body Condition Scoring System, page 61) while providing the correct balance of nutrients, vitamins, and minerals. Age
Diet
Feeding Method
Comments
Birth to Weaning
• Dam/queen’s milk • Commercial replacement diets • Home prepared replacement diets • See Skill Box 2.1 Care and Feeding of Orphaned Puppies and Kittens, page 27. • Energy requirement is 22–26 kcal/100 g • Begin introducing puppy or kitten diet at 3–4 weeks of age as milk will no longer provide adequate calories or nutrients • Weaning begins at 6–8 weeks of age
• Nursing neonates will feed ad lib • See Skill Box 2.1 Care and Feeding of Orphaned Puppies and Kittens, page 27. • Starting solid food • Mix growth food with warm water to moisten and make into a slurry; place food in a shallow dish. • Allow free access 3–4 times a day. • Remove after 20–30 minutes to prevent bacterial overgrowth. • Neonates can be encouraged to eat by placing their feet in the food, smearing food on their lips, or introducing food into their mouths. • Weaning • Complete weaning should not start before 6 weeks of age (preferably 7–8 weeks of age) and not until close human contact has occurred, and typically does not need assistance after solid foods have been started. • The dam/queen should be separated from the neonates the day before weaning. The neonates should be fed, and food should be withheld from the dam/queen. Water is not removed. • The neonates should be reunited with the dam/queen overnight and be allowed to nurse to drain the mammary glands. Food only should be withheld from both the dam/queen and the neonates overnight. • The neonates are removed from the dam/queen the next day
• Body fat stores are only 1–2% at birth, presenting the risk of hypoglycemia, starvation, and hypothermia. • Adequate glycogen reserves do not develop until after first few days of nursing. • All neonates need to receive colostrum in the first 24 hours of life to ensure transfer of passive immunity. • Hypothermia can lead to poor nursing.
Weaning to 12 Months
• Puppy • Highly digestible, high-quality protein • 25–29% protein of ME • Large- and giant-breed dogs • Overfeeding and extra micronutrients (e.g., calcium) during rapid growth phase contribute to obesity and developmental orthopedic disease. • Maintain feeding puppy diet until an adult to avoid ↑ calcium consumption. • Adjust food intake to maintain a BCS of 2/5. • Kitten • 30% protein of ME • Maintain feeding kitten diet until maturity (10–12 months) if obesity is present, then ↓ amount of food fed.
• Puppy • 2–4 measured feedings per day • Large- and giant-breed dogs • Measured feedings 3–4 meals daily • Remaining food after a meal should be discarded and subsequent meals should be reduced in quantity. • Kitten • Free-feed or measured feedings 2–3 times a day • Neutering ↓ energy requirements by 24–33%
• Obesity: developmental orthopedic disease (large breed) • Thin: hypoglycemia (small breed)
Puppy and Kittens
3
60
SECTION TWO: PREVENTATIVE CARE
Adult
Table 3.1 / General Life Stage Feeding Guidelines (Continued) Age
Diet
Feeding Method
Comments
Maintenance
• High-quality adult food • Homemade diets made from approved published recipes
• 2–3 measured feedings per day • See Skill Box 3.1 Daily Caloric requirement Worksheet, page 58.
• Obesity: diabetes, osteoarthritis, skin problems, surgical risk • Thin: hypoglycemia, hypothermia, muscle disorders
3
Pregnancy Canine
• Diet should gradually be changed during the last 3 weeks to a puppy growth diet to provide additional nutrients. • Avoid • Carbohydrate-free meat-type diets should be avoided during gestation and whelping to prevent hypoglycemia and ↑ neonate death.
• During the first 5 weeks, the feeding schedule should not change, and the dam should maintain her normal weight. • Weeks 6–9 • Frequency • Feed smaller, more frequent meals to accommodate the shrinking stomach size • Amount • ↑ 15% each week • By gestation, the dam’s weight should ↑ 15–25%.
• Obesity: ↓ ovulation, ↓ litter size, large neonates, dystocia • Thin: trouble conceiving, ↓ birth weights, ↑ neonate death
Feline
• High-quality diet intended for reproduction/lactation or growth
• Weeks 2–9 • Amount • ↑ Gradually to a total ↑ of 25–50% • By gestation, the queen’s weight should ↑ by about 40%.
• Obesity: large neonates, dystocia • Thin: trouble conceiving, abortion, ↓ birth weights, ↑ neonate death
Lactation Canine
• High-quality puppy growth food • Avoid • Low-calorie diets (e.g., weight-reducing diets)
• Feed free-choice • Daily energy requirements are approximately 3 times that of nonlactating adults. • Lactation peaks at 3–5 weeks postpartum and is maintained until 8 weeks postpartum. • The dam requires approximately 25% of her DER additional for each neonate.
• Obesity/thin: insufficient milk production
Feline
• High-quality diet intended for reproduction/lactation or growth
• Lactation peaks at 3–4 weeks postpartum • The queen requires 2–3 times her DER during lactation. See Skill Box 3.1 Daily Caloric Requirement Worksheet, page 58.
• Obesity/thin: insufficient milk production
Geriatric
• High-quality adult food for healthy animals • Homemade diets made from approved published recipes • Changes in diet (e.g., protein, fat, phosphorous, sodium, fiber, vitamins, minerals) can be made based upon medical conditions.
• 2–3 measured feedings per day • See Skill Box 3.1 Daily Caloric Requirement Worksheet, page 58, on calculating the appropriate amount of food. • The caloric intake may need to be reduced to obtain the desired BCS. • Avoid placing feeding dishes in hard-to-reach places.
• Obesity: diabetes, osteoarthritis, skin problems, surgical risk • Thin: hypoglycemia, hypothermia, muscle disorders
CHAPTER 3 / NUTRITION
61
Table 3.2 / Body Condition Scoring System
The Body Condition Scoring System standardizes the interpretation of the overall physical appearance of the animal. It should be a basic part of every examination and should be noted in the record for future comparison. This technique can be easily and quickly taught to clients as part of weight management at home. The BCS can change by 1 value with a 10% change in body weight. 3
Canine
Body Condition Score 1: Very Thin Ribs: easily visible and felt with no cover Waist: severe waist Tail Base: lumbar vertebrae and pelvic bones are raised with no fat between the skin and bone Side View: severe abdominal tuck Overhead View: accentuated hourglass shape
2: Underweight Ribs: easily felt with minimal fat cover Waist: easily noted Tail Base: bones are raised with minimal fat between the skin and bone Side View: prominent abdominal tuck Overhead View: marked hourglass shape
3: Ideal Ribs: easily felt with slight fat cover Waist: observed behind ribs Tail Base: smooth contour but bones can be felt under a thin layer of fat Side View: abdominal tuck Overhead View: well-proportioned waist
62
SECTION TWO: PREVENTATIVE CARE
Feline
Table 3.2 / Body Condition Scoring System (Continued) Canine
Body Condition Score
Feline
4: Overweight Ribs: difficult to feel with moderate fat cover Waist: poorly discernible Tail Base: some thickening but bones can be felt under a moderate layer of fat Side View: no abdominal tuck Overhead View: back is slightly broadened
3
5: Obese Ribs: difficult to feel under thick fat cover Waist: absent Tail Base: thickened and difficult to feel bones beneath prominent layer of fat Side View: fat hangs from the abdomen Overhead View: markedly broadened and prominent paralumbar fat deposits
CHAPTER 3 / NUTRITION
63
Table 3.3 / Disease Nutritional Requirements
3
Each disease or combination of diseases alters the nutritional requirements of a patient. Each patient should have a complete nutritional evaluation to ensure the type of diet and the feeding method are appropriate. The overall consideration regarding nutrition is to optimize BCS. Often it is more important to maintain a patient eating versus providing the exact nutritional requirements. For example, it is more important for a patient with CHF to consume enough food to prevent cachexia than it is to restrict sodium. It often requires a dedicated owner to cater to the changing desires of the patient along with providing the necessary nutritional requirements. It is beyond the scope of this book to provide specific alterations; please consult dedicated nutritional references and seek the advice of a credentialed veterinary nutritionist for specific nutritional alterations. Disease
Objective
Comments
Anemia
• Support RBC production.
• Nutritional evaluation: minerals (e.g., iron), protein, vitamins (e.g., B) • Iron deficiency is usually due to excessive loss (e.g., hemorrhage, GIT ulcers, and ectoparasitism) versus inadequate intake.
Bone Loss and Fracture Repair
• Ensure diet is properly balanced. • Ensure adequate energy and protein intake.
• Nutritional evaluation: energy, minerals (e.g., calcium, phosphorus), protein • Supplemental calcium must be absorbable and balanced with phosphorous intake.
Cardiac Disease
• • • •
Control or correct cachexia. Maintain BCS. Control sodium retention. Encourage eating.
• Nutritional evaluation: amino acids (e.g., taurine), carnitine, energy, minerals (e.g., chloride, magnesium, phosphorus, potassium, sodium), water • Sodium and chloride restriction is based on the degree of cardiac disease • Additional sources of sodium should be considered (e.g., softened water, treats, table scraps) when determining total sodium intake.
Constipation
• • • •
Normalize GIT motility. ↑ Water consumption ↑ Bulk or ↓ quantity Optimize BCS.
• • • • • • • •
Nutritional evaluation: fiber, water Feed a highly digestible diet. ↑ Fiber ≤5% per week until clinical signs resolve Additional fiber may be achieved through therapeutic veterinary diets or adding ≤10% fiber to regular diet (e.g., pumpkin, high-fiber cereal). Provide small, frequent meals. ↑ Exercise and prevent obesity. Encourage defecation (e.g., frequent walks, clean litter box). Check anus/rectum for causes of poor defecation habits, tenesmus, or dyschezia.
Degenerative Joint Disease
• ↓ Degenerative joint changes • Optimize BCS.
• Nutritional evaluation: fatty acids, vitamins (e.g., E) • ± Chondroprotectives
Dental Disease
• Prevent or correct periodontal disease. • Optimize oral health.
• Nutritional evaluation: carbohydrates, minerals (e.g., calcium, phosphorus), protein, vitamins (e.g., A, B, C, D), water • Food texture and composition may contribute to ↓ plaque accumulation.
Diabetes Mellitus
• Optimize BCS. • Minimize postprandial fluctuations in blood glucose. • Consistent feeding times and caloric intake
• Nutritional evaluation: energy, fat, fatty acids, fiber, minerals, protein, soluble carbohydrates, water • Avoid semimoist foods as they contain simple carbohydrates and may have a hyperglycemic effect. • Provide small, frequent meals and weigh animal frequently. • Changes in exercise and weight may necessitate altering the insulin dose.
64
SECTION TWO: PREVENTATIVE CARE
Table 3.3 / Disease Nutritional Requirements (Continued) Disease
Objective
Comments
Exocrine Pancreatic Insufficiency (EPI)
• Correct malnutrition. • Reduce requirements for digestive enzymes. • ↑ Caloric intake/density • Optimize BCS.
• Nutritional evaluation: fat, fiber, vitamins (e.g., A, D, K, cobalamin, folate) • Avoid high-fiber diets. • Provide small, frequent meals.
Flatulence
• ↓ Intestinal gas production and bacterial fermentation of undigested food • ↓ Aerophagia
• • • •
Food Allergy
• Identification and avoidance of offending foods (protein) and/or food additives • Relieve clinical signs (e.g., otitis, pruritus, dermatitis, erythema, peripheral lymphadenopathy).
• Nutritional evaluation: food additives, protein, vasoactive or biogenic amines • An elimination diet is feed exclusively for 8–12 weeks consisting of 1–2 protein sources the patient has not be exposed to and void of food additives, vasoactive and biogenic amines, and excess protein. • Regardless of diet fed (e.g., commercial or home prepared), it must be nutritionally adequate for the patient’s life stage and condition. • Diet should be continued 2–3 weeks past glucocorticoid administration. • Canned food contains the least amount of additives. • Feeding dishes should be glass, ceramic, or stainless steel. • Outdoor pets should be confined to avoid dietary indiscretions. • Avoid all flavored medications, treats, table scraps, and vitamin supplements. • With the disappearance of clinical signs, begin feeding 1 eliminated food item back daily for 7 days, discontinue if relapse is noted or assume no allergy if no reactions are seen after 7 days.
Hepatic Disease
• Maintain body weight and BCS. • Promote hepatic regeneration. • ↑ Caloric intake/density
• Nutritional evaluation: amino acids (e.g., taurine), energy, fat, fiber, minerals (e.g., iron, potassium, zinc), protein, vitamins (e.g., C, E, K) • Feed a highly digestible diet. • Provide small, frequent meals while slowly ↑ amount fed over a few days.
Hepatic Lipidosis
• Correct anorexia and malnutrition. • ↑ Caloric intake/density
• Nutritional evaluation: carnitine, energy, fat, minerals (e.g., iron, potassium, zinc), protein, vitamins (e.g., C, E, K) • Recovery is directly related to early diagnosis and treatment via enteral or parenteral nutrition.
Hyperadrenocorticism
• Prevent or correct cachexia. • Optimize BCS.
• Nutritional evaluation: fat, fiber, minerals (e.g., chloride, sodium), protein, water • Feed a highly digestible diet.
Hyperthyroidism
• Correct cachexia. • Optimize BCS.
• Nutritional evaluation: energy, fat, minerals (e.g., calcium, chloride, iodine, iron, phosphorus, potassium, selenium, sodium), protein, water • Feed a highly digestible diet. • Poor absorption of many nutrients and ↑ metabolism
Hypoadrenocorticism
• Optimize BCS.
• Nutritional factors to evaluate: energy, minerals (e.g., chloride, potassium, sodium), protein, water • Feed a highly digestible diet.
3 Nutritional evaluation: carbohydrate, fiber, protein, variable per patient Feed a highly digestible diet. Provide small, frequent meals. Discourage gluttony; provide a noncompetitive environment or slow consumption via novel methods. • ↑ Exercise and ↓ stress
CHAPTER 3 / NUTRITION
65
Table 3.3 / Disease Nutritional Requirements (Continued) Disease
Objective
Comments
Hypothyroidism
• Optimize BCS.
• Nutritional evaluation: fat, energy, fiber, trace minerals
Inflammatory Bowel Disease
• ↓ Antigenic stimulation of the GIT • Provide GIT rest and normalize motility. • ↑ Water consumption
• Nutritional evaluation: energy, fat, fatty acids, fiber, minerals (e.g., potassium, zinc), protein, vitamins (e.g., thiamin, vitamin K) • Diets may consist of a highly digestible low-residue GIT diet, ↑ fiber, or an elimination diet (a “sacrificial” novel protein is fed initially while the GIT is healing and then replaced by a second novel protein or hydrolyzed protein diet long term).
Obesity
• ↓ Body weight and optimize BCS • Control caloric intake. • Prevent obesity-related diseases.
• Nutritional evaluation: carbohydrates, energy, fat, fiber, protein • Prevention is easier than treatment of obesity. • See Skill Box 3.2 Obesity Management, page 67.
Oncology
• Prevent or correct cancer cachexia. • ↑ Nutrient intake • Encourage eating.
• Nutritional evaluation: amino acids (e.g., arginine, glutamine, glycine, tyrosine, phenylalanine, methionine, asparagine), fat, fatty acids, carbohydrates, protein, vitamins (e.g., retinoids, vitamins C and E, beta-carotene) • Feed a highly digestible diet. • Nutritional intervention must begin early in disease to prevent cachexia.
Orthopedic Disease, Developmental
• ↓ Nutrition-related disease • Optimize BCS.
• Nutritional evaluation: energy, fat, minerals (e.g., calcium, copper, phosphorus, zinc), vitamins (e.g., A, C, D) • Overfeeding and extra vitamins (e.g., calcium) during rapid growth phase in large- and giant-breed dogs lead to skeletal disease. • Switching growing animals to an adult food should be avoided as nutritional factors may be inappropriately altered (e.g., calcium). • See Table 3.1 General Life Stage Feeding Guidelines, page 58.
Pancreatitis
• ↓ Pancreatic secretions • Provide pancreatic rest. • Optimize BCS.
• • • • •
Nutritional evaluation: fat, protein, water Feed a highly digestible diet. Enteral and/or parenteral feeding may be part of the initial treatment. Traditional low-fat, weight-reducing diets may be too calorie restrictive. Canine: NPO for 3–7 days, begin with small amounts of water, gradually add in a carbohydrate (e.g., rice) and then a protein source of ↑ bioavailability (e.g., cottage cheese, lean meat)
Protein Losing Enteropathy (PLE)
• Correct cachexia. • ↓ Enteric loss of plasma protein
• • • • •
Nutritional evaluation: carbohydrates, fat, fiber, protein Feed a highly digestible diet. Determining the underlying cause of PLE may alter nutrition. Monitor for protein malnutrition. Provide small, frequent meals.
Renal Disease
• Delay progression of renal failure. • ↓ Amount of nitrogenous waste (↓ azotemia) • Prevent malnutrition and optimize BCS. • ↑ Water consumption • Encourage eating.
• Nutritional evaluation: acid load, amino acids (e.g., arginine), energy, fat, fiber, minerals (e.g., chloride, phosphorus, potassium, sodium, protein, vitamins (e.g., A, B, D), water • Feed a highly digestible diet. • Avoid excess dietary protein in moderate to severe renal failure. • Protein recommendations: • Dogs: 2.0–2.2 g/kg/day • Cats: 3.3–3.5 g/kg/day • Monitor and control mineral imbalances (e.g., phosphorus, calcium). • Optimizing BCS is more important than restricting protein. • Sodium restriction should take place gradually over 2–4 weeks.
3
66
SECTION TWO: PREVENTATIVE CARE
Table 3.3 / Disease Nutritional Requirements (Continued) Disease
Objective
Comments
Urolithiasis, Canine– Ammonium Urate
• Maintain alkaline urine (pH of 7.0–7.5). • Dissolution and prevention of uroliths • ↑ Water consumption and subsequent ↓ urine concentration
• Nutritional evaluation: protein, water • Dissolution on average take 4 weeks. • Meat-based diets tend to have ↑ purine; vegetable-based diets may be more suitable.
Calcium Oxalate
• Maintain alkaline urine (pH of 7.1–7.7). • Prevent uroliths. • ↑ Water consumption and subsequent ↓ urine concentration
• Nutritional evaluation: minerals (e.g., calcium, magnesium, sodium), oxalates, protein, vitamins (e.g., B6, C, D), water • Medical regimen dissolution is not possible for calcium oxalate stones, once formed.
Cystine
• Maintain alkaline urine (pH of 7.5). • Dissolution and prevention of uroliths • ↑ Water consumption and subsequent ↓ urine concentration
• Nutritional evaluation: protein, water • Dissolution can be possible with the addition of 2-MPG.
Struvite
• Maintain acidic urine (pH of 6.2–6.4). • Resolve underlying infection. • ↑ Water consumption and subsequent ↓ urine concentration
• Nutritional evaluation: minerals (e.g., magnesium, phosphorus), protein, water • Dissolution on average takes 3.5 months. • Avoid long-term feeding of dissolution diet due to ↓ protein and sodium.
• Maintain alkaline urine (pH of 6.6–6.8). • Prevent uroliths. • ↑ Water consumption and subsequent ↓ urine concentration
• Nutritional evaluation: fat, fiber, minerals (e.g., calcium, magnesium, sodium), oxalates, protein, vitamins (e.g., B6, C, D), water • Medical regimen dissolution is not possible for calcium oxalate stones, once formed.
• Maintain acidic urine (pH of <6.4) • Dissolution and prevention of uroliths • ↑ Water consumption and subsequent ↓ urine concentration
• Nutritional evaluation: fat, minerals (e.g., magnesium, phosphorus, potassium), protein, water • Average dissolution is 35 days after negative radiographs • Avoid feeding dissolution diet to immature, pregnant/lactating, renal failure, CHF, metabolic acidosis, hypertensive or hypokalemic patients • Free choice feeding provides a more desirable stable urinary pH, but may contribute to obesity
• Provide GIT rest to ↑ gastric secretions and normalize motility. • ↑ Water consumption • ↑ Bulk • ↑ Caloric intake/density
• Nutritional evaluation: amino acids (e.g., glutamine), energy, fat, fiber, minerals (e.g., chloride, potassium, sodium), water • NPO for 24–48 hours, offer small amounts of water every 2–3 hours, then begin small amounts of food 6–8 times a day • Gradually reintroduce normal diet after diarrhea is resolved (2–3 normal stools in a row). • Small, frequent meals to prevent gluttony
Urolithiasis, Feline Calcium Oxalate
Struvite
Vomiting/Diarrhea
3
CHAPTER 3 / NUTRITION
67
Skill Box 3.2 / Obesity Management
3
As the rate of obesity among companion animals continues to rise, clients are in the need of obesity management education. Obesity alone can lead to or further contribute to numerous health concerns, such as diabetes, FLUTD, hepatic lipidosis, orthopedic diseases, and skin diseases. Although prevention early on is the key, a weight loss program can be successfully implemented and carried out with appropriate owner compliance. Becoming overweight is as simple as consuming more energy than the body is able to utilize. There are some medical conditions that can contribute to obesity (e.g., hypothyroidism), but the majority of animals are simply eating too much relative to their exercise/activity level. Therefore, decreasing the amount of food consumed or increasing the amount of exercise will lead to weight loss. Obesity management should be implemented when an animal is classified as having a body conditioning score of 4/5 or 5/5. See Table 3.2 Body Condition Scoring System, page 61. The following steps along with owner compliance should provide a happier and healthier pet. Additional information for the owner should include monitoring the amount of treats, the feeding habits of other family members, and the foods of other household pets. • A full examination of the patient along with appropriate diagnostic testing submitted to rule out medical issues (e.g., blood work, urinalysis) • Obtain a complete dietary history including the names and amounts of food fed (e.g., commercial diets, home prepared diets, treats, table scraps), access to additional food sources (e.g., other pet’s food, other family members or neighbors feeding the pet, hunting) • Calculate the current caloric intake and restrict to 60–80% of this amount. If it is not possible to obtain an accurate diet history, calculate the DER for the optimal weight of the patient. See Skill Box 3.1 Daily Caloric Requirement Worksheet, page 58.
68
SECTION TWO: PREVENTATIVE CARE
• Verify the protein content of the food at the recommended calories is adequate for that particular animal (1 g protein/lb body weight/day). Failure to verify protein content may lead to muscle loss along with fat loss. • Set smaller, more reasonable weight loss goals over a specified amount of time. The use of the BCS can help the owner better understand the goal. • Weigh the animal every 2–3 weeks to ensure a weight loss and verify all recommendations are being followed. The goal of weight loss is 1–2% per week; if this number is not obtained, further restrictions in calories should be done. Weight loss >2% a week is thought to be detrimental to the patient’s health. • Treats should be <10% of the total daily calories and must be calculated into the total daily calories. • Start or increase the daily exercise program to ↑ calorie expenditure, ↑ muscle mass, and stimulate metabolism. • The addition of microsomal triglyceride transfer protein inhibitors (e.g., Slentrol) may prove beneficial, as well as modifying feeding amounts and habits. Tips for success: • Feed multiple small meals a day to satisfy the pet. • Provide appropriate snacks (e.g., low- calorie commercial treats, plain popcorn, plain rice cakes). • Enlist all family members to be active participants in the weight loss program. • Keeping pets out of the kitchen during preparation and consumption reduces begging and owner’s impulse to feed.
Section
Three
Diagnostic Skills Chapter 4: Laboratory 71 Chapter 5: Imaging 157 Color Plate Chapter 6: General Medicine 201 Chapter 7: Emergency Medicine 299
Chapter
4
4
Laboratory Blood Chemistries 74 Blood Collection, Handling, Storage, and Transport Tips 74 Blood Collection Tubes 75 Blood Chemistries 76 Bone Marrow Evaluation 83 Bone Marrow Collection, Handling, Storage, and Transport Tips 83 Supplies for Bone Marrow Collection 84 Smear Techniques 84 Evaluation 85 Bone Marrow Evaluation 85 Cell Type Identification 86 Interpretation 88 Cytology 88 Cytology Collection, Handling, Storage, and Transport Tips 88 Collection Techniques 88 FNB Needle and Syringe Selection 89 Smear Techniques 90 Evaluation 91 Cytologic Criteria of Malignancy 92
Figure 4.4: Cytologic Criteria of Malignancy Specific Tumor Cells 94 Interpretation 95 Fecal Cytology 96 Vaginal Cytology 97 Classifying Vaginal Cells 97 Staging the Estrus Cycle 98 Function Tests 98 Hematology 104 Complete Blood Count 105 Hemacytometer Use 108 Calculating a Differential 108 Evaluation 108 RBC Alterations and Morphology 108 WBC Morphology 112 WBC Alterations 113 WBC Left Shift 114 Platelet Morphology 115 Platelet Alterations 115 Coagulation Tests 115 Coagulation Screening 115 Coagulation Tests 116
93
71
Blood Transfusions 119 Crossmatching 119 Blood Typing 120 Immunology and Serology Tests 120 Microbiology 122 Microbiology Collection, Handling, Storage, and Transport Tips 122 4 Collection Techniques 123 Specimen Storage 124 Most Commonly Used Culture Media 125 Culture Media Inoculation and Incubation 126 Evaluation of Culture Growth 127 Staining Solutions and Procedures 127 Staining Problems 130 Bacteria Identification 130 Fungi Identification 133 Parasitology 134 Fecal Collection, Handling, Storage, and Transport Tips 134 Endoparasite Examination Methods 134
72
SECTION THREE: DIAGNOSTIC SKILLS
Fecal Flotation Solutions 137 Blood Parasite Examination Methods Ectoparasite Examination Methods
138
139
Figure 4.35: Relative Size of Parasite Eggs Endoparasites
139
Ectoparasites Urinalysis
139
145
147
Urine Collection, Handling, Storage, and Transport Tips 147 Urine Examination/Urinalysis Gross Examination Preparation
147
148
149
Chemistry Strip Examination 149 Sediment Examination 150 Reporting of Bacteria and Sperm 151 Sediment Examination Urine Artifacts
155
151
Key Words and Phrasesa Agglutination Aggregation Anisocytosis Anisokaryosis Anticoagulants Axonemes Axostyle Basophilic Brownian movement Carbohydrate Cellularity Cestode Colorimetric Cornified Crenation Dermatophyte Encephalopathy Enzyme Epithelial Extracellular Extrinsic Fibrinogen Genal combs Globulin, α Globulin, β Globulin, γ Gluconeogenesis Glycoaminoglycans Glycogenolysis Granularity Hemolyzed Hemostasis Heparinized Hepatoid Hydatid cyst Hypercellular Hyperplasia Hyperthenuric Hypocellular Hypochromic Hypoplasia Hypothenuric Inanimate Intermediate host Intracellular Intrinsic Lipemic a
Abbreviations Lyophilized Lysed Lysosomes Macrocytosis Macrokaryosis Mesenchymal Metabolism Microfilariae Mitotic figures Mordant Mucoprotein Nematode Normocellular Normochromic Nucleoli Oncosphere Oncotic Oocyst Operculum Paratenic host Percutaneous Plasma Pleomorphism Poikilocytosis Polychromatophilic Polycythemia Postprandial Prepatent period Preprandial Proglottid Pronotal Protozoa Pyknotic Rickettsiae Rodenticide Roulleaux Serum Sporangium Sporulated Thrombosis Trematode Trophozoite Urolithiasis Vacuoles
μg, microgram μm, micrometer μmol, micromole AchRs, serum antibody against nicotinic ACT, activated clotting time ACTH, adrenocorticotropic hormone ADH, antidiuretic hormone AIHA, autoimmune hemolytic anemia Alk phos, alkaline phosphatase ALP, alkaline phosphatase ALT, alanine aminotransferase APTT, activate partial thromboplastin time AST, aspartate aminotransferase AT, adrenocortical tumors BA, blood agar BMBT, buccal mucosal bleeding time BTT, light blue top tube BUN, blood urea nitrogen CBC, complete blood count CDV, canine distemper virus Cl, chloride CNS, central nervous system CO2, carbon dioxide cPLI, canine pancreatic lipase immunoreactivity DEA, dog erythrocyte antigen DIC, disseminated intravascular coagulation dL, deciliter DM, diabetes mellitus EDTA, ethylenediaminetetra-acetic acid F, Fahrenheit FDP, fibrin degradation product FeLV, feline leukemia virus FIP, feline infectious peritonitis FIV, feline immunodeficiency virus fL, femtoliter FNA, fine needle aspirate FNB, fine needle biopsy FSP, fibrin split product GIT, gastrointestinal tract GRNTT, green top tube GTT, gray top tube HAC, hyperadrenocorticism HCO3, bicarbonate Hct, hematocrit IFA, immunofluorescence
Additional Resources, page IgE, immunoglobulin gamma E IM, intramuscular IMHA, immune-mediated hemolytic anemia IV, intravenous K, potassium kg, kilogram KPO4, potassium phosphate L, liter LTT, lavender top tube MC, MacConkey agar MCHC, mean corpuscular hemoglobin concentration MCV, mean corpuscular volume mEq, milliequivalent mg, milligram Na, sodium ng, nanogram NMB, new methylene blue NSAIDs, nonsteroidal anti-inflammatory drugs PAP, immunoperoxidase test PCR, polymerase chain reaction PCV, packed cell volume PDH, pituitary-dependent hyperadrenocorticism pg, picogram pH, potential of hydrogen PIVKA, protein induced by vitamin K antagonism pmol, picomole PT, prothrombin time PTH, prothrombin time RBC, red blood cell RTT, red top tube SAP, alkaline phosphatase SGOT, serum glutamic-oxaloacetic transaminase SGPT, serum glutamic pyruvic transaminase SST, serum separator tube T3, triiodothyronine T4, tetraiodothyronine TBT, toenail bleeding time TLI, trypsin-like immunoreactivity TP, total protein TRH, thyroid releasing hormone TSH, thyroid stimulating hormone TT, thrombin time TWBC, total white blood cell count U, unit USG, urine specific gravity WBC, white blood cell
Anesthesia, 439 Canine Transmissible Diseases, 38 Disinfectants, 627 Feline Transmissible Diseases, 44 General Medicine, 201 Injections, 348 Oncology, 273 Pharmacology, 567
4
Key words and terms are defined in the glossary on page 631.
CHAPTER 4 / LABORATORY
73
P
4
roficiency in laboratory skills is one of the most important skills of a veterinary hospital. Each clinic will use their laboratory to different levels, but the proper technique and understanding of each procedure should always be maintained for the most accurate results. The key to learning laboratory skills is to be able to recognize the normal. Having a clear understanding of what is normal allows a person to more quickly identify the abnormal. This chapter covers all aspects to laboratory medicine. Each section begins with the proper way to collect, handle, store and transport laboratory samples, followed by the precise steps needed to perform each task. Variation may exist among some protocols depending on a particular laboratory. Laboratory medicine is a critical part of each diagnosis, and this process often begins with the technician.
BLOOD CHEMISTRIES Blood chemistries evaluate the various blood levels to reach an insight into the different bodily functions. The critical part of blood chemistries is the collection and handling of each sample. For example, allowing a blood sample to remain at room temperature may elevate some chemistries and decrease others, leading to a possible incorrect diagnosis, treatment, and outcome. Extreme care and diligence should be taken with each sample to ensure the most accurate results.
Blood Collection, Handling, Storage, and Transport Tips Collection • Blood samples should be collected from a fasted patient, at least 2 hours postprandial, preferably 4–6 hours. Lipemic samples may lead to hemolysis and therefore ↓ RBC counts. Lipemic and hemolyzed samples can also falsely alter measured serum chemistries. • When feasible, enough blood should be collected to run the tests 3 times; this allows for human error, machine error, and dilution if needed. • Venipuncture site and technique significantly contribute to the quality of the sample. • Always remove the needle to the syringe and the stopper of the tube to let the blood run down the inside of the tube. Sticking a needle
74
SECTION THREE: DIAGNOSTIC SKILLS
through the rubber stopper contributes to further hemolysis, especially with a <25-gauge needle. Ideally, a vacutainer system should be used to ↓ hemolysis and ensure the correct blood/anticoagulant ratio. Handling • Fill the anticoagulant tubes first to minimize clot formation, ending with the plain tubes. • Gently mix any tube containing an interactive ingredient, to avoid hemolysis. • Blood smears should be made immediately, using fresh blood after blood collection and fanned to facilitate quick drying. (See Skill Box 4.5, Smear Techniques, page 84.) • Blood smears made with an excessive amount of blood will force the feathered edge off the end of the slide, therefore pushing the larger cells off. • Allow blood to clot in an upright position to prevent cells from sticking to the rubber stopper and hemolyzing during centrifuging. • Remove serum from contact with the cells within 30–45 minutes, to prevent altered laboratory results. • Each tube should be clearly labeled with the patient’s full name, date, and time of collection. Storage • If a sample will not be evaluated in 4–6 hours, the plasma or serum should be poured off and refrigerated. • Blood smears should be dried completely to avoid the formation of condensation inside the slide container and subsequent damage of cellular morphology. • Blood smears should be made and stored at room temperature; refrigeration may cause condensation therefore damaging the cellular morphology. • Do not freeze whole blood, because this causes hemolysis. • Samples to be frozen should be immediately placed in an ice bath, centrifuged, transferred into a plastic tube, and frozen. Transport • Wrap ice packs or blood tubes with paper towels or newspapers to avoid direct contact and subsequent hemolysis.
Table 4.1 / Blood Collection Tubes Tube
Contents
Uses
General Information
• Glucose determinations
• Prevents RBCs from metabolizing glucose by inhibiting enzymes in the glycolytic pathway to more accurately measure blood glucose concentrations than an SST or RTT (e.g., diabetes mellitus and insulinoma)
Whole Blood (unclotted) or Plasma Samples • Immediately invert tubes 6–10 times to prevent coagulation. Gray top tube (GTT)
• Potassium oxalate and Sodium fluoride
4
Green top tube (GRNTT)
• Lithium heparin
• Lead determinations
• Binds with lead • Not appropriate for cell morphology
Lavender top tube (LTT)
• EDTA
• Hematology smears
• Does not alter cell volume or morphology
Light blue top tube (BTT)
• Buffered sodium citrate
• Coagulation determinations
• Measures clotting time (e.g., von Willebrand’s disease, warfarin poisoning, activated partial thromboplastin time [APTT], prothrombin time [PT]) • Must be a perfect venipuncture stick to avoid activation of coagulation pathways • Tube must be filled to ensure proper dilution of blood with anticoagulant.
Serum Samples • Invert tube to activate clotting, stand upright for 20 minutes, and then centrifuge for 15 minutes to ensure proper separation. Serum separator tube (SST), red/gray swirl top
• Clot activator polymer gel
• Blood chemistries
• Serum is not able to mix with clotted blood once centrifuged. • The clotting activator can interfere with some lab tests (e.g., phenobarbital levels).
Red (RTT)
• Plain
• Blood chemistries, serology, and blood banking
• Serum and clotted blood can resuspend if the tube is tilted. • Serum should be separated after centrifugation to a separate plain container. • Glucose is metabolized at approximately 10% per hour when left in contact with cells.
Tip: To determine the amount of fluid in a sample, evaluate a well-hydrated patient’s packed cell volume (PCV). A PCV of 50% will yield a sample with 50% cells and 50% fluid. Therefore, a 10-mL sample will yield 5 mL fluid.
CHAPTER 4 / LABORATORY
75
Table 4.2 / Blood Chemistries Chemistry
Definition
Normal Range
Associated Conditions
Handling and Special Considerations
Alanine Aminotransferase (ALT, SGPT)
Source • Major: hepatocytes • Minor: cardiac muscle, skeletal muscle, pancreas Role • Amino acid metabolism Notes • Liver specific • There is a correlation between ALT levels and hepatic cell damage, but not liver function. • ↑ ALT often seen 2–3 days after hepatic insult and resolves by 14 days
Canine/Feline • 5–65 U/L
↑ Cholangitis/cholangiohepatitis, congestive heart failure, diabetes mellitus, dilated cardiomyopathy, canine/feline, ehrlichiosis, endocardiosis, exocrine pancreatic insufficiency, feline hypertrophic cardiomyopathy, hepatic disease/ failure, hepatic lipidosis, hyperadrenocorticism, hyperparathyroidism, hypertension, hyperthyroidism, hypoadrenocorticism, pancreatitis, peritonitis, pyometra, Rocky Mountain spotted fever, thrombocytopenia, toxoplasmosis
Handling • Hemolysis and lipemia; ↑ values Storage • Room temperature or refrigerator for 24 hours • 2 days at 68° F • 1 week at 32°–39° F • Do not freeze sample. Notes • Corticosteroids and anticonvulsants; ± ↑ values (canine)
Albumin
Source • Hepatocytes Role • Maintain osmotic pressure by retaining fluid within the vascular compartment. • Binding and transport protein Notes • Edema and effusions = ↓ values • 35–50% of total plasma protein • Best interpreted with globulin levels
Canine • 2.3–4.0 g/dL Feline • 2.6–4.0 g/dL Danger level • 1.0
↑ Rocky Mountain spotted fever ↓ Brucellosis, cholangitis/ cholangiohepatitis, ehrlichiosis, heartworm disease, hepatic disease/ failure, hepatic lipidosis, glomerular disease, hyperglobulinemia, hypertension, inflammatory bowel disease, pleural effusion, protein losing enteropathy, toxoplasmosis
Handling • Extreme hemolysis and lipemia; ↑ values Storage • Keep sample covered to prevent dehydration; ↑ values • 1 week at 68° F • 1 month at 32–39° F Notes • Ampicillin; ± falsely ↑ values
Albumin-to-Globulin Ratio (A : G ratio)
Source • See Albumin and Globulin Role • See Albumin and Globulin Notes • First indicator of protein abnormality • Divide the albumin concentration by the globulin concentration.
Canine • 0.6–1.2 Feline • 0.5–2.0
4
76
SECTION THREE: DIAGNOSTIC SKILLS
Handling • See Albumin and Globulin Storage • See Albumin and Globulin Notes • See Albumin and Globulin
Table 4.2 / Blood Chemistries (Continued) Chemistry
Definition
Normal Range
Associated Conditions
Handling and Special Considerations
Alkaline Phosphatase (Alk phos, ALP, SAP)
Source • Major: liver (adult animals), bone (young animals) • Minor: kidneys, intestines Role • Assist in various chemical reactions Notes • Canines can often handle a 2–4-fold ↑ in value before significant signs of disease. • Interpretation is slightly different between canines and felines because of half-lives and amount of hepatic ALP present.
Canine • 10–84 U/L Feline • 10–70 U/L
↑ Cholangitis/cholangiohepatitis, congestive heart failure, diabetes mellitus, drugs (glucocorticoids, barbituates, etc.), ehrlichiosis, hepatic disease/failure, hepatic lipidosis, hyperadrenocorticism, hyperparathyroidism, hypertension, hyperthyroidism, pancreatitis, pyometra, Rocky Mountain spotted fever, thrombocytopenia, toxoplasmosis
Handling • Do not use EDTA or oxalate coagulants. Storage • At room temperature >24 hours; ↑ values • 8 days at 32°–39° F Notes • N/A
Ammonia
Source • Liver and muscle Role • Byproduct of the breakdown of proteins, amines, amino acids, nucleic acids, and urea Notes • N/A
Canine • 45–120 μg/dL Feline • 30–100 μg/dL Danger level • >1,000 (canine)
↑ Cholangitis/cholangiohepatitis, hepatic disease/failure, hepatic lipidosis
Handling • Heparinized sample preferred • Centrifuge and pour off plasma immediately. Storage • Store on ice and assay within 1 hour. • Freeze immediately and assay within 2 days. Notes • Vein occlusion for an extended period or strenuous exercise; ↑ values • Antibiotics, enemas, lactulose, diphenhydramine, parenteral amino acids, narcotics, diuretics, or blood transfusions may alter laboratory results.
Amylase
Source • Major: pancreas • Minor: liver and small intestines Role • Breakdown of starches and glycogen in sugars Notes • ↑ values are not always indicative of severity of disease nor specific for pancreas
Canine • 300–1,500 units Feline • 500–1,500 units
↑ Pancreatitis, peritonitis, chronic renal failure, toxoplasmosis
Handling • Hemolysis; ↑ values • Lipemia; ↓ values • Do not use EDTA Storage • 7 days at 68° F • 1 month at 32°–39° F Notes • Corticosteroids; ± ↓ values • Saccharogenic method; ± false ↑ values (canine)
CHAPTER 4 / LABORATORY
77
4
Table 4.2 / Blood Chemistries (Continued) Chemistry
Definition
Normal Range
Anion Gap (AG)
Source • N/A Role • To differentiate causes of metabolic acidosis Notes • To calculate: (Na+ − K+) − (Cl− + HCO3−) = AG
Canine • 12–25 Feline • 13–25
Aspartate Aminotransferase (AST, SGOT)
Source • Major: hepatocytes • Minor: cardiac and skeletal muscles, kidneys, pancreas and erythrocytes Role • Amino acid metabolism Notes • Not liver-specific; ↑ values may indicate liver damage, strenuous exercise, IM injections • Tends to parallel ALT values when caused by hepatic disease
Canine • 16–60 U/L Feline • 26–43 U/L
↑ Cholangitis/cholangiohepatitis, congestive heart failure, diabetes mellitus, endocardiosis, feline dilated cardiomyopathy, feline hypertrophic cardiomyopathy, hepatic disease/ failure, hepatic lipidosis, hyperthyroidism, hypoadrenocorticism, peritonitis, toxoplasmosis
Handling • Hemolysis and lipemia; ↑ values Storage • 2 days at 68° F • 2 weeks at 32–39° F Notes • N/A
Bicarbonate (Venous TCO2)
Source • All cells Role • Aids in transport of CO2 from tissues to the lungs • Bicarbonate/carbonic acid buffer system Notes • 95% of total CO2 measured
Canine/Feline • 21–31 mEq/L
↓ Metabolic acidosis, acute renal failure
Handling • Chill in ice water to prevent alteration of acid–base composition. Storage • Do not freeze, as it results in hemolysis. Notes • N/A
Bilirubin
Source • Hemoglobin via liver processing Role • N/A Notes • Byproduct of erythrocyte degradation • Total bilirubin is composed of conjugated and unconjugated bilirubin. • Not liver specific
Canine/Feline • 0.0–0.5 mg/dL
↑ Cholangitis/cholangiohepatitis, hepatic disease/failure, hemobartonellosis, hemolytic anemia, hepatic lipidosis, hyperthyroidism, pancreatitis, peritonitis, toxoplasmosis
Handling • Lipemia; ↑ values Storage • Not stable when stored in the light or at 68° F • 2 weeks at 32–39° F in the dark Notes • Total bilirubin may ↓ by 50%/hr with direct exposure to sunlight or artificial light.
4
78
SECTION THREE: DIAGNOSTIC SKILLS
Associated Conditions
Handling and Special Considerations Handling • Refer to N.a, K., Cl−, and HCO3− Storage • Refer to N.a, K., Cl−, and HCO3− Notes • Drugs used in combination may blunt the gap ↑.
Table 4.2 / Blood Chemistries (Continued) Chemistry
Definition
Normal Range
Associated Conditions
Handling and Special Considerations
Blood Urea Nitrogen (BUN, SUN)
Source • Amino acids via liver processing Role • N/A Notes • Byproduct of amino acid breakdown • 75% of the kidney must be nonfunctional before ↑ values are seen
Canine • 6–29 mg/dL Feline • 10–35 mg/dL
↑ Canine/feline dilated cardiomyopathy, congestive heart failure, cystic calculi, ehrlichiosis, endocardiosis, hepatic disease/failure, hypertension, hyperthyroidism, hypoadrenocorticism, mastitis, pancreatitis, pyelonephritis, renal failure, Rocky Mountain spotted fever ↓ Cholangitis/cholangiohepatitis, hepatic disease/failure, hepatic lipidosis, overhydration, dietary protein restriction
Handling • N/A Storage • 8 hours at 68° F • 10 days at 32–39° F Notes • 18-hour fast is recommended, because high-protein diets can cause ↑ values
Calcium
Source • Bones Role • Maintenance of neuromuscular excitability and tone • Inorganic ion transfer across cell membranes • Blood coagulation Notes • Hemoglobin and bilirubin; ↑ values with colorimetric test methods • Hypoalbuminemia; ↓ values
Canine/Feline • 8.0–12.0 mg/dL Danger level • ≤7.0 mg/dL or ≥16.0 mg/dL
↑ Hyperparathyroidism, hypoadrenocorticism, neoplasia, renal failure ↓ Dystocia, eclampsia, hypoparathyroidism, pancreatitis, protein losing enteropathy, renal failure
Handling • Hemolysis and contact with cork stoppers; ↓ values • Lipema; ↑ values • Citrate, oxalate, or EDTA anticoagulants; ↓ values Storage • 10 days at 68° F or 32–39° F Notes • N/A
Chloride
Source • Extracellular fluid Role • Acid-base balance • Maintenance of water distribution • Osmotic pressure in blood Notes • Hemoglobin and bilirubin; ↑ values with colorimetric test methods • Tends to parallel serum sodium
Canine • 100–115 mEq/L Feline • 117–128 mEq/L
↑ Metabolic acidosis ↓ Canine dilated cardiomyopathy, constipation, aggressive diuretics, severe emesis, Rocky Mountain spotted fever
Handling • Hemolysis and lipemia; ↓ values Storage • Stable if separated from blood cells Notes • Potassium bromide, acetazolamide, ammonium chloride, androgens, cholestyramine, lithium, demeclocycline and amphotericin; ↑ values
CHAPTER 4 / LABORATORY
4
79
Table 4.2 / Blood Chemistries (Continued) Chemistry
Definition
Normal Range
Associated Conditions
Handling and Special Considerations
Cholesterol
Source • Major: hepatocytes • Minor: adrenal cortex, ovaries, testes and intestinal epithelium Role • Steroid hormone production Notes • Helpful in screening for hypothyroidism and Cushing’s disease
Canine 150–275 mg/dL Feline 75–175 mg/dL
↑ Diabetes mellitus, hepatic disease, failure, hyperadrenocorticism, hypertension, hypoadrenocorticism, hypothyroidism, pancreatitis, Rocky Mountain spotted fever ↓ Drugs, exocrine pancreatic insufficiency, hepatic disease/failure, protein losing enteropathy
Handling • Hemolysis, fluoride, and oxalate; ± ↑ values, depending on testing method Storage • Very stable at 68° F if separated from blood cells Notes • Corticosteroids; ± ↑ values
Creatine Kinase (CK)
Source • Cardiac and skeletal muscle and brain tissue Role • Enzyme that cleaves creatine in muscle for energy utilization Notes • Peaks 6–12 hours after muscle injury and returns to normal in 24–48 hours unless damage is ongoing • Very specific, but almost too sensitive • Only large ↑ are clinically significant (≥10,000 U/L) or chronic elevations (≥2,000 U/L) indicating ongoing muscle damage
Canine/Feline • 50–300 U/L
↑ Encephalitis, feline dilated cardiomyopathy, feline hypertrophic cardiomyopathy, hypothyroidism, myasthenia gravis, polymyositis
Handling • Severe hemolysis, icterus, IM injections; ↑ values • EDTA, citrate, fluoride, exposure to sunlight, and delayed analysis; ↓ values Storage • Not stable, do not freeze; analyze as soon as possible Notes • Exercise, recumbency, IM injections; ± ↑ values
Creatinine
Source • Skeletal muscle Role • N/A Notes • Byproduct of creatine degradation • 75% of the kidney must be nonfunctional before ↑ values are seen
Canine • 0.6–1.6 mg/dL Feline • 1.0–2.0 mg/dL
↑ Canine/feline dilated cardiomyopathy, congestive heart failure, drugs, ehrlichiosis, endocardiosis, hypertension, hyperthyroidism, hypoadrenocorticism, severe muscle damage, pancreatitis, pyelonephritis, renal failure, Rocky Mountain spotted fever, toxoplasmosis
Handling • N/A Storage • 1 week at 86–98.6° F Notes • Exercise, active muscle wasting, and meal containing meat; mild ↑ values
Fibrinogen
Source • Hepatocytes Role • Clot formation Notes • No fibrinogen found in serum, because it is removed from the plasma by the clotting process • Used mostly in cattle and horses
Canine • 100–245 mg/dL Feline • 110–370 mg/dL
↑ Cholangitis/cholangiohepatitis, hepatic failure, severe inflammation ↓ DIC, liver failure/end stage
Handling • Heparin; ↓ values Storage • Several days at 68° F • Several weeks at 32–39° F Notes • N/A
4
80
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.2 / Blood Chemistries (Continued) Chemistry
Definition
Normal Range
Associated Conditions
Handling and Special Considerations
Gamma Glutamyltranspeptidase (GGT)
Source • Major: hepatocytes • Minor: kidneys, pancreas, intestines, and muscle cells Role • Enzyme: function unknown Notes • Values typically parallel ↑ in ALP; can be less influenced by secondary nonhepatic conditions or enzymeinducing drugs • Slightly more sensitive and specific for feline hepatic disease than canine
Canine • 2–10 U/L Feline • 1–8 U/L
↑ Anterior uveitis, brucellosis, deep pyoderma, ehrlichiosis, feline immunodeficiency virus, hepatic disease/failure, meningitis, pleural effusion, pyometra
Handling • N/A Storage • 2 days at 68° F • 1 week at 32–39° F Notes • Corticosteroids or anticonvulsant therapy; ± ↑ values
Globulins
Source • α-Globulins: hepatocytes • β-Globulins: hepatocytes • γ-Globulins: plasma cells Role • α- and β-globulins: transport and bind proteins • γ-Globulins: antibody Notes • Total serum globulin concentration = total serum protein concentration − albumin concentration
Canine • 2.7–4.4 g/dL Feline • 2.6–5.1 g/dL
↑ Diabetes mellitus, hepatic failure, hyperadrenocorticism, hypertension, hyperthyroidism, immune mediated disease, neoplasia, pancreatitis, polyconal gammopathies, renal failure, acute ↓ Acute blood loss, heartworm disease, protein losing enteropathy/ nephropathy
Handling • Hemolysis and lipemia; ↑ values Storage • See Albumin and Total Protein Notes • Dehydration; ↑ values • Neonatal animals are 60–80% of adult values; ↓ values
Glucose
Source • Dietary intake and gluconeogenesis or glycogenolysis by the liver Role • Cellular energy Notes • Indicator of carbohydrate metabolism or endocrine function of the pancreas
Canine • 65–130 mg/dL Feline • 70–125 mg/dL Danger level • ≤60 mg/dL
↑ Diabetes mellitus, hypertension, hyperthyroidism, hyperadrenal, hypoparathyroidism, pyelonephritis, renal failure ↓ Dystocia, hepatic failure, failure, hypoadrenocorticism, insulinoma, neoplasia, peritonitis, sepsis
Handling • GTT at 6–10mg/mL of blood as a glucose preservative Storage • Separate from blood cells immediately (<30 minutes) • 8 hours at 68° F • 72 hours at 32–39° F Notes • 16–24-hour fast is recommended, except if hypoglycemia suspected • Glucose levels can drop by 10%/hr if not separated from the blood cells • Stress; ↑ values
CHAPTER 4 / LABORATORY
81
4
Table 4.2 / Blood Chemistries (Continued) Chemistry
Definition
Normal Range
Associated Conditions
Handling and Special Considerations
Inorganic Phosphorus
Source • Bones Role • Energy storage, release, and transfer, carbohydrate metabolism and composition Notes • Inversely related to calcium
Canine • 3.0–7.0 mg/dL Feline • 3.5–6.1 mg/dL
↑ Bone lesions, chronic renal failure, toxins ↓ Emesis/diarrhea, fanconi syndrome, hepatic lipidosis, hyperparathyroidism, hypoadrenocorticism
Handling • Hemolysis and lipemia; ↑ values Storage • Separate from blood cells immediately • 3–4 days at 68° F • 1 week at 32–39° F Notes • Anabolic steroids, furosemide, mannitol, minocycline, and IV KPO4 may alter values
Lipase
Source • Pancreas and gastric mucosa Role • Break down the long-chain fatty acids of lipids Notes • Value is not representative of severity of disease • Tends to parallel serum amylase
Canine • 0–425 units Feline • 0–200 units
↑ Pancreatitis, hyperadrenocorticism, liver disease, renal disease, failure
Handling • Lipemia; ↑ values • Do not use calcium-binding anticoagulants Storage • 1 week at 68° F • 3 weeks at 32–39° F Notes • Corticosteroids; ± ↑ values
Lipids/Triglycerides
Source • Diet; intestinal absorption Role • Fat metabolism • Stimulus of intestinal lymph flow Notes • Animals at an ↑ risk are obese, high dietary intake of fats and genetic predisposition (e.g., Miniature Schnauzer and Himalayan cats
Canine • 50–150 mg/dL Feline • 17–50 mg/dL Danger level • >1,000 mg/dL
↑ Diabetes mellitus, hyperlipidemia, hypothyroidism, pancreatitis, postprandial ↓ Lymphangectasia, protein-losing enteropathy
Handling ↑ Lipemia; ↑ values Storage • N/A Notes • 12-hour fast recommended
Magnesium
Source • Bones Role • Activator of enzyme systems and involved in production and decomposition of acetylcholine Notes • ↑ Bilirubin can cause ↑ values of magnesium
Canine • 1.8–2.4 mg/dL Feline • 2.0–2.5 mg/dL Danger Level • <1.0 or >10.0 mg/dL
↑ Hypoadrenocorticism, renal failure ↓ Metabolic conditions
Handling • Hemolysis and metal containers; ↑ values • Only heparin anticoagulants should be used. Storage • Samples are very stable. Notes • N/A
4
82
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.2 / Blood Chemistries (Continued) Chemistry
Definition
Normal Range
Associated Conditions
Handling and Special Considerations
Potassium
Source • Intracellular fluid Role • Muscular function, respiration, cardiac function, nerve impulse transmission, and carbohydrate metabolism Notes • N/A
Canine • 4.0–5.7 mEq/L Feline • 4.0–5.8 mEq/L Danger level • ≤2.5 or ≥7.5 mEq/L
↑ Diabetes mellitus, hypoadrenocorticism, massive tissue trauma, acute renal failure, urethral obstruction ↓ Canine/feline dilated cardiomyopathy, congestive heart failure, constipation, diabetes mellitus, gastrointestinal losses, hepatic lipidosis, peritonitis, renal failure
Handling • Hemolysis (esp. Akitas) and refrigeration of an nonseparated sample; ↑ value Storage • Do not freeze nonseparated samples. • Stability is not known. Notes • Plasma is the preferred sample.
Sodium
Source • Extracellular fluid Role • Water distribution, body fluid osmotic pressure maintenance, and pH balance Notes • “Pseudohyponatremia” seen in cases of hyperlipidemia or severe hyperproteinemia
Canine • 140–158 mEq/L Feline • 145–160 mEq/L
↑ Dehydration, heat stroke ↓ Canine dilated cardiomyopathy, congestive heart failure, gastrointestinal losses, hypoadrenocorticism, chronic renal failure, Rocky Mountain spotted fever
Handling • Heparin; ↑ value • Hemolysis; ↓ value Storage • Stability is not known. Notes • Diuretic drugs; ↓ value
Total Protein (TP)
Source • See Albumin and Globulins Role • Oncotic blood pressure, transport mechanism, and immunity Notes • Composed of albumin and globulins
Canine • 5.4–7.6 g/dL Feline • 6.0–8.1 g/dL
↑ Dehydration, gammopathy ↓ Acute blood loss, overhydrated
Handling • Severe hemolysis and sample dehydration; ↑ value Storage • Keep sample covered to prevent dehydration. • Stability is not known. Notes • See Albumin and Globulins
BONE MARROW EVALUATION Bone marrow evaluations can be used to diagnose, to stage certain neoplasias, or to monitor conditions and the body’s response to treatments. The collection and preservation of bone marrow samples are critical to producing diagnostic slides. Properly collected and prepared slides are often evaluated in-house for a preliminary diagnosis before receiving a confirmation from a cytopathologist.
Bone Marrow Collection, Handling, Storage, and Transport Tips Collection • Bone marrow samples degenerate rapidly after collection: neutrophils are the first to take on morphologic changes resembling neoplasia. • Samples should be obtained and prepared within 30 minutes of an animal’s death. CHAPTER 4 / LABORATORY
83
4
Skill Box 4.1 / Supplies for Bone Marrow Collection • Surgical preparation materials
• Place bone marrow aspirate immediately into an EDTA lavender top tube if slides cannot be made immediately.
• Sterile surgical supplies (e.g., gloves, drapes)
• Smears must be made within 30 seconds if an EDTA/isotonic solution is not used, to avoid clotting and cell morphology distortion.
• Analgesic/anesthetic drugs
• Allow the slides to air dry. • Samples must be stained as soon as possible to retain accurate morphology.
3
• 16–18 gauge, 1–1 /4-inch bone marrow biopsy needle
4
Handling
• Scalpel blade
• Staining typically requires 2 times the usual stain contact time to reach adequate staining.
• 12 or 20 mL syringe • Clean microscope slides • 10–20 mL syringe with 2–3% EDTA/isotonic fluid solution Tip: Injecting 0.35 mL isotonic solution into a 7-mL EDTA blood collection tube produces 0.42 mL of 2.5% EDTA/isotonic fluid solution.
Skill Box 4.2 / Smear Techniques Technique
Definition/Uses
Procedure
General Information
Smear Without EDTA
• Samples collected using a clean, dry syringe
1. Hold a slide at a 45–70° angle. 2. Drip the marrow sample down the tilted slide, allowing the marrow flecks to adhere to the slide. 3. With the first slide laying flat, place a second slide on top, allow the drop to spread, and gently pull each slide horizontally in opposite directions. 4. Slides are air-dried and then stained.
• Sample must be smeared within 30 seconds of collection.
Smear With EDTA
• Samples collected using an EDTA/ isotonic solution–filled syringe
1. Sample collected into an EDTA/isotonic solution syringe is expelled onto a Petri dish. 2. Tilt the Petri dish to allow the fluid to drain to the bottom and the marrow flecks to remain adhered to the dish. 3. Using a PCV tube, collect a marrow fleck/spicule and gently place it on a glass slide. 4. Place a coverslip at a 45° angle on the slide so that the corner of the coverslip hangs off the slide. 5. Pull the corner of the coverslip to make a smear of the marrow fleck. 6. Slides are air-dried and then stained.
• Sample must be smeared within a few minutes of collection.
Note: Make some slides using no pressure and some using gentle digital pressure placed on the coverslip.
84
SECTION THREE: DIAGNOSTIC SKILLS
1. Prepare a slide with stain.
Storage
2. Scan the slide, using ×4 magnification.
• Slides need to be completely dry before placing in a slide holder.
a. b. c. d.
Transport • Padding should be placed around both sides of the slide holder to prevent breakage (e.g., bubble wrap, padded envelopes). • Do not mail slides with bottles containing formalin, because the fumes may alter the staining capabilities of the slides.
Verify adequate staining. Verify proper slide preparation. Determine the cellularity. Determine the quantity and maturation of megakaryocytes.
3. Examine the slide, using ×10 magnification. a. Cell size b. Cell type
Evaluation
4
4. Examine the slide, using ×40 magnification.
An air-dried slide should quickly be evaluated with new methylene blue to verify the presence of marrow elements (e.g., megakaryocytes) and its diagnostic quality. If the slide is not adequate, further samples should be taken. Once quality slides are available, a stepwise approach should be taken to ensure a thorough evaluation is completed.
a. Chromatin pattern b. Nucleoli 5. Examine the slide, using oil immersion magnification. a. Myeloid:erythroid ratio
Table 4.3 / Bone Marrow Evaluation Definition
Examination
Classification
Cellularity
Proportion of cells compared to fat cells
Low power (×4–10)
Proportion • Normocellular: 30–70% • Hypercellular: >50–70% • Hypocellular: <30–50%
Megakaryocytes
Quantity, maturation, and morphology
Low power (×4–10)
Quantity • Hypoplasia: <3/large fleck • Hyperplasia: >50/large fleck Maturation • Mature: >50%
Erythrocytes
Quantity, proportions, and morphology
Low and high power (×10–100)
Quantity • Rubricyte: 60–70% • Metarubricyte: 30–35% • Prorubricyte: 2% • Rubriblast: <1% Morphology • Karyolysis, pyknosis of immature cells, cytoplasmic or vacuolation, megaloblastic change
CHAPTER 4 / LABORATORY
85
Table 4.3 / Bone Marrow Evaluation (Continued) Examination
Classification
Granulocytes
Quantity, proportions, and morphology
Low and high power (×10–100)
Quantity • Metamyelocyte, band neutrophils, segmented neutrophils: 80% • Myeloblast, promyelocyte, myelocyte: 20% Morphology • Basophilic cytoplasm, vacuolation
Myeloid:Erythroid Ratio
300–500 cells are evaluated in differing areas and classified as either myeloid or erythroid
High power (×100)
• Normal: slightly > 1 : 1
Organisms
Identification
High power (×100)
• Microorganisms: Histoplasma capsulatum, Toxoplasma gondii, Cytauxzoon felis, Erlichia sp. • Parasites: Mycoplasma sp., Babesia sp.
Note: Lymphocytes, plasma cells, monocytes, macrophage, and iron storage can also be evaluated.
Table 4.4 / Cell Type Identification (See Figure 4.1, 4.2, and 4.3, CP-3) Cell Type
Erthyrocytes
4
Definition
86
Appearance
Rubriblast
• • • •
1–2 Blue nucleoli Large, round, dark purple nucleus with smooth edges Fine granular, linear chromatin Distinct blue tint
Prorubricyte
• • • •
Smaller than rubriblasts Round nucleus with smooth edges Coarse and thickened chromatin Reddish tinge
Rubricyte
• • • •
Smaller than prorubricyte Dark clumps of coarse chromatin that begin to disappear Disappearing nucleoli Redder
Metarubricyte
• Larger than a mature RBC • Very dark, pyknotic nucleus • Chromatin and nucleoli are gone
Reticulocyte
• • • •
SECTION THREE: DIAGNOSTIC SKILLS
Large Nonnucleated Basophilic stippling when stained Residual, nonfunctional RNA
Table 4.4 / Cell Type Identification (See Color Plates 4.1, 4.2, and 4.3) (Continued) Cell Type Myeloblast
• • • • •
Large Nongranular, blue–pink cytoplasm Round to oval, red nucleus Chromatin with stippled pattern 1–2 pale blue nucleoli
Progranulocyte/Promyelocyte
• • • •
↑ Cytoplasm with small, pink granules Dark nucleus Chromatin is dark and lacy in pattern ± Nucleoli
Myelocyte
• • • •
Metamyelocyte
• Indented or U-shaped nucleus • Cytoplasm stains light blue • Can be confused with monocytes of peripheral blood
Band
• U-shaped nucleus with smooth edges • ± Chromatin clumps present • Cytoplasm stains light blue
Megakaryoblast
• Not commonly distinguished in bone marrow samples because of size and number present • 2 reddish nuclei • Small amount of basophilic cytoplasm
Promegakaryoblast
• Dividing nuclei • Deep blue cytoplasm • 2–4 Nucleoli
Megakaryocyte
• Extremely large • Abundant, deep blue to pale blue granular cytoplasm • >4 Nucleoli
Granulocyte Platelet
Appearance
4
Oval nucleus Chromatin is dense with a coarse pattern Cytoplasm stains gray–blue Granules take on stain • Eosinophil—red granules • Canine: pleomorphic • Feline: rod-shaped • Basophil—blue granules • Canine: round, red–purple, and few to many • Feline: oval, lavender, and fill cytoplasm • Can be confused with monocytes of peripheral blood
CHAPTER 4 / LABORATORY
87
Interpretation
4
Once a slide has been evaluated, the results are interpreted in conjunction with the results of the complete blood count (CBC). Interpretation may lead to a definitive diagnosis or be just 1 more step in the diagnostic path. Depending on the findings, additional tests may be indicated or an initial treatment plan may be established. Even though the preliminary diagnosis can be made by the veterinarian, it is recommended that these slides be sent to a cytology laboratory for confirmation and staging by a board-certified clinical pathologist/hematologist.
cinoma), the stage of disease, and its prognosis. Although the final diagnosis must lie in the hands of the veterinarian, the technician may make crucial evaluations and interpretations of the slide material, aiding the veterinarian in the diagnosis.
Cytology Collection, Handling, Storage, and Transport Tips Collection • Multiple collection attempts at multiple sites from the lesion should be made to ensure a representative sample. • Adequate pressure must be used with fine-needle aspiration (FNA) to ensure retrieval of cells.
CYTOLOGY Cytology is performed in a clinical setting on a day-to-day basis. A technician well trained in cytology can quickly and easily make preliminary findings. These findings may aid in the distinction in the type of cell (e.g., adenocar-
• Excessive negative syringe pressure or prolonged aspiration often leads to blood contamination and nondiagnostic slides. • Several slides should be made to allow different staining techniques.
Skill Box 4.3 / Collection Techniques Technique
Uses
Procedure
Comments
Imprints
• External lesions or fresh tissue samples from a surgical biopsy or necropsy
1. Blot the lesion or area to be imprinted with a clean, dry gauze. 2. Touch the lesion against a clean glass slide to make an imprint. • Can repeat several times on 1 slide. • Imprint ulcers before and after cleaning.
• Typically collects the fewest number of cells with the greatest amount of contamination
Scrapings
• External lesions or tissues from surgical biopsy or necropsy
1. Clean lesion and blot dry. 2. Hold scalpel perpendicular to lesion. 3. Pull the blade toward oneself several times in a scraping motion. 4. Transfer the material to the middle of a glass slide with the scalpel blade and smear.
• Collects a large number of cells and possibly a large amount of bacterial contamination and inflammation
Swabs
• Fistulous tracts and vaginal collections
1. Moisten a sterile swab with saline. 2. Gently roll the swab against the inside wall of the tract or vagina. 3. Gently roll the swab across a slide to transfer material in a thin smear.
• Only alternative for tract-like lesions • ↑ Cell damage with rough or improper handling
88
SECTION THREE: DIAGNOSTIC SKILLS
Skill Box 4.3 / Collection Techniques (Continued) Technique
Fine Needle Biopsya
Aspirate
a
Nonaspirate
Uses
Procedure
Comments
• Lesions
1. Isolate and firmly hold the tumor. 2. Insert the needle into the tumor and apply strong negative pressure by pulling the plunger 3/4 of the way back and release pressure. 3. Redirect the needle to a different part of the tumor and again apply pressure; continue this several times in different locations. 4. Quickly smear the contents, using 1 of the smear techniques. (See Skill Box 4.5 Smear Techniques, page 90.) • If the tumor is large enough, negative pressure may be maintained while the needle is being redirected.
• Avoids superficial contamination, but with ↑ contamination of tissues surrounding the tumor during aspiration • ↑ Blood contamination with certain types of tumors • Allows for collection from multiple locations within the lesion
1. Isolate and firmly hold the tumor. 2. Insert the needle only into the tumor and rapidly move the needle up and down while maintaining the same track. 3. Remove the needle and attach an air-filled syringe and quickly expel the contents onto a clean glass slide. 4. Smear the contents, using 1 of the smear techniques. (See Skill Box 4.5 Smear Techniques, page 90.)
• Avoids superficial contamination, but with ↑ contamination of tissues surrounding the tumor during aspiration • Enough material collected for only 1 smear, which may reduce diagnostic yield
• Any mass or solid lesion that is of large enough size to isolate • Ultrasound-guided biopsy of deep tissues • Highly vascular lesions
Fine needle biopsy to the center of a mass typically yields necrotic debris and inflammatory cells, peripheral locations may produce the best results. Difficult in small masses ≤10 mm.
Skill Box 4.4 / FNB Needle and Syringe Selection • The softer the tissue being aspirated, the smaller are the gauge of needle and syringe. • Do not use needles larger than 21 gauge, because they produce core biopsies and have a greater likelihood of blood contamination. • 12-mL syringes are a safe bet for all tumors.
Handling • The material obtained must be prepared and smeared on a slide immediately to avoid drying, clumping, and clotting. • Do not allow the smear to reach the edges of the slide if possible. • Rapidly dry the slide after smearing by waving in the air or using a blow dryer. • Slides should be marked as to which side is the top by using the patient’s information. • 2–3 air-dried unstained slides and 2–3 air-dried stained slides should be prepared when sending to the laboratory. The stained slides are a precaution for those cells that do not hold up well unstained for extended periods. • Fluid samples should be sent with prepared slides if possible. CHAPTER 4 / LABORATORY
89
4
Skill Box 4.5 / Smear Techniques The most common error in cytology is sample handling by the laboratory technician. An improperly prepared slide may contain ruptured cells or areas too thick to read, or the sample may dry before it is smeared. All of these errors may lead to improper evaluation, but they can be remedied by proper technique and care on the part of the laboratory technician.
4
Technique
Definition/Uses
Procedure
Blood Smear Technique
• Produces a thin layer of fluid material across the slide • Fluid samples
1. Expel the aspirate material onto a glass slide. 2. Place the second glass slide at a 30–40° angle to the first slide in front of the material. 3. Pull the second slide back into the material and then gently, but swiftly, push across to the end of the first slide. • Rest the “smearing” slide against a fingertip to push across allows a gentle and smooth movement. • The end of the smear should have a feathered edge and not run off the edge of the slide.
Squash Preparation
• Produces well-smeared slides • Thicker samples (e.g., bone marrow aspirates)
1. Expel the aspirate material onto a glass slide. 2. Place a second glass slide on top of the material at a right angle. 3. Without applying any downward pressure, quickly and smoothly slide the top slide across the bottom slide to smear the material.
Squash-Modified Preparation
• Produces well-smeared slides with a ↓ tendency for cell rupture • Thicker samples (e.g., bone marrow aspirates)
1. Follow steps 1 and 2 above. 2. Rotate the top slide 45° and then lift up.
Combination Technique
• A combination using the squash preparation and the blood smear technique • Any sample
1. Expel the aspirate material onto a glass slide. 2. Mentally divide the material into 3 sections and do a blood smear technique on one third of the slide and a squash preparation on the opposite third.
Starfish Preparation
• Prevents destruction of fragile cells • Any sample
1. Expel the aspirate material onto a glass slide. 2. Using the tip of the needle, spread the material out into the shape of a starfish.
90
SECTION THREE: DIAGNOSTIC SKILLS
Storage • Slides need to be completely dry before placing in a slide holder. Transport • Padding should be placed around both sides of the slide holder to prevent breakage (e.g., bubble wrap, padded envelopes). • Do not mail slides with bottles containing formalin, because the fumes may alter the staining capabilities of the slides. • Protect the slides from moisture as the sample may become distorted.
Evaluation Once each slide has been properly collected and prepared, it is often evaluated in the clinic for a preliminary diagnosis. The technician is an integral part of this procedure by evaluating the slide and noting any alterations. The DVM then confirms the slide contents and makes a preliminary diagnosis. The slide is sent to a reference laboratory for official diagnosis. 1. Prepare a slide with stain. 2. Scan the entire slide using ×4 magnification. a. Verify adequate staining. b. Check for staining features and artifacts.
c. Check for overall cellularity and localized areas of cellularity. d. Check for crystals, foreign bodies, parasites, and fungal hyphae. 3. Examine the slide, using ×10 magnification. a. Cell size b. Cell type c. Cellularity 4. Examine the slide, using ×40 magnification. a. Chromatin pattern b. Nucleoli
4
5. Examine the slide, using oil immersion magnification. a. Cell inclusions b. Cell organisms c. Mitotic figures Tip: Placing a drop of immersion oil on a prepared slide (excluding a wet mount) covered by a coverslip enhances the clarity of the slide contents. To increase magnification to ×100, another drop of immersion oil can be placed on top of the coverslip and examined. To save the slide for later evaluation, the coverslip can be gently slid off horizontally to avoid damaging the slide’s contents.
CHAPTER 4 / LABORATORY
91
Table 4.5 / Cytologic Criteria of Malignancy
Any slide showing 1 or a combination of the following cellular changes should be carefully reviewed for potential malignancy. A cytology laboratory should be consulted for clarification if needed. Nuclear characteristics have proven to be the most reliable source of determining malignancy. However, all aspects of the cells should be evaluated. Some types of malignant cells do not routinely show any of the following characteristics; therefore, all other aspects of the complete workup should be viewed simultaneously.
4
Cytologic Characteristics
Appearance
Tumor Cell Types
Nuclear
• • • • • •
Anisokaryosis Macrokaryosis Variation in nuclear : cytoplasmic ratio Coarse chromatin pattern that clumps Irregular nuclear pattern Abnormal size, shape, and appearance of nucleoli • Irregular nuclear membrane
Epithelial • Round nucleus with a smooth to slightly coarse chromatin pattern and usually centrally located • 1 or more nucleoli Mesenchymal • Oval nucleus and centrally located Round cell • Centrally or eccentrically located
Cytoplasmic
• Vascuolization • Variable amount of cytoplasm from cell to cell • Basophilia with Wright’s stain • Abnormal cytoplasmic boundaries
Epithelial • ↑ Cytoplasm with secretory products or vacuolated Mesenchymal • Abnormal cytoplasmic boundaries and extensions • Moderate amount Round cell • Well-defined cytoplasmic boundaries • Variable amount, granularity, and vacuolization
Structural
• Anisocytosis • Macrocytosis • Pleomorphism
Epithelial • Large to very large cells • Round to oval to caudate cells, easily exfoliating into sheets, clusters, or clumps Mesenchymal • Small to medium cells • Spindle-shaped cells hard to exfoliate • Individual cells or in disorganized clusters Round cell • Small to medium cells • Round to oval cells; easy to exfoliate individual cells
92
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.5 / Cytologic Criteria of Malignancy (Continued)
4
Figure 4.4 Cytologic criteria of malignancy. Note: Courtesy of Dina A. Andrews, DVM, Ph.D, DipACVP.
CHAPTER 4 / LABORATORY
93
Table 4.6 / Specific Tumor Cells
The following chart gives a general description of common tumor types. Multiple variations can be seen because of location, duration, and malignancy. Each cell should be evaluated in lieu of the rest of the slide and the general findings of the animal. The diagnosis of a particular condition must be made by the veterinarian. Tumor Type
Epithelial Mesenchymal
Basophilic cytoplasm with ± vacuoles with secretory products Variable nuclear size and nuclear : cytoplasm ratio Nuclei often eccentrically displaced to the periphery of the cells Round to oval cells appearing in clusters Variable nucleolar shape and number
Mammary Adenocarcinoma
• • • • •
Perianal Adenoma
• Hepatoid appearing in clumps • Round to oval nuclei with 1–2 nucleoli • Abundant, foamy, and gray to tan cytoplasm with ± granules
Sebaceous Gland Tumor
• • • •
Squamous Cell Carcinoma
• Basophilic cytoplasm to abundant, pale cytoplasm • Large nuclei with clumped chromatin • Variable nuclear : cytoplasm ratio
Lipoma
• Large cells distended with fat or lacy, collapsed cells
Osteosarcoma
• Variably sized nucleus with clumped chromatin • Spindle-shaped • Abundant, foamy basophilic cytoplasm
Soft Tissue Sarcoma
• Anisocytosis or spindle shaped • Dark blue cytoplasm with ± vacuoles and pink granules • Variable number and size of nucleoli
4
94
Appearance
SECTION THREE: DIAGNOSTIC SKILLS
Large cell Nucleus with a slightly coarse chromatin pattern ↑ Nuclear : cytoplasm ratio ± Basophilic and foamy cytoplasm
Table 4.6 / Specific Tumor Cells (continued)
Round Cell Tumor
Tumor Type
Appearance
Histiocytoma • Color Plate 4.5, CP-4
• • • • •
Anisocytosis Poikilocytosis Variable amount of pale blue cytoplasm ↑ Nuclear:cytoplasm ratio Round, oval, or irregularly shaped nuclei with lacy or finely stippled chromatin pattern
Lymphoma • Color Plate 4.6, CP-4
• • • •
Dense nuclear margins with basophilic cytoplasm ↑ Nuclear:cytoplasm ratio Granular chromatin ≥1 Nucleolus
Mast Cell Tumors • Color Plate 4.7, CP-4
• • • •
Anisocytosis Round to oval nuclei, stain palely Fine to coarse, blue-black to reddish-purple granules within cytoplasm Variable nuclear:cytoplasm ratio depending on differentiation and grade
Melanoma
• Green-black to brown granules that are irregular in shape and size in cytoplasm • Poikilocytosis
Plasma Cell Tumor
• • • •
Interpretation Once a slide has been evaluated, the results should confirm an inflammatory and/or neoplastic process. The distinction of inflammation alone often will enable the veterinarian to determine an initial protocol and treatment plan.
4
Oval to round cells with coarse, clumped chromatin 1 small nucleolus ± Basophilic cytoplasm Nonstaining Golgi apparatus eccentrically placed
If the slide is found to have neoplastic cells, they are then reviewed against the criteria of malignancy. A preliminary diagnosis on cell type, associated disease, and malignancy can be made by the veterinarian. Often, the results are sent to a cytology laboratory for confirmation and staging.
CHAPTER 4 / LABORATORY
95
Table 4.7 / Fecal Cytology
Appearance
Clostridium sp. • Color Plate 4.8, CP-4
• • • •
Giardia • Color Plate 4.9, CP-5
Trophozoites • Pear-shaped with a concave ventral surface • Two outlined nuclei resembling eyes along with a nose and mouth, which are axonemes and median bodies • Forward or “falling leaf” motility • Size: 6–10 μm Cysts • Crescent-shaped indentation when collapsing in fecal float solution • Nuclei, cyst wall, and axonemes seen • Size: 11–13 μm
Curved or Spiral Bacteria
Organism
Yeast
4
Fecal cytology is an important diagnostic tool for identifying inflammatory cells and potentially pathogenic organisms of the GIT. It is indicated in diarrheic animals, either acute or chronic. The first step is to assess the presence and quantity of bacteria. One predominant bacteria may indicate it as an pathogenic organism and a bacterial culture should be pursued. Some conditions may have more than 1 predominant bacteria (e.g., malabsorption, maldigestion). The presence of small numbers of epithelial cells may be found in normal animals. However, the presence of neutrophils or eosinophils may be indicative of inflammatory disease (e.g., Salmonella, Campylobacter sp., eosinophilic colitis). Fecal cytology may also reveal protozoal (e.g., Giardia) or fungal (e.g., Histoplasma sp.) organisms. Fecal cytology is set up in 1 of 2 ways: wet prep or dry prep. See Skill Box 4.16 Endoparasite Examination Methods page 134, for further information.
96
Large, gram-positive rods More easily recognized in the sporulated form “Safety pin” appearance, which represents a nonstaining spore within the sporangium (the body of the cell) >5 per ×100 field may indicate overgrowth
Campylobacter • Color Plate 4.10, CP-5
• • • • •
Treponeme and Spirillum Type (true spirochetes) • Color Plate 4.11, CP-5
• Gram-negative • Stiff corkscrew helical rods with tight spirals • Corkscrewing motility
Brachyspira
• Looser, sinusoid, thin spirals • Rapid, nematode-like movement; when attached to shed epithelial cells in large numbers resemble flagella
Trichomonas sp.
• Single nucleus and undulating membrane • Rolling and erratic motility, flexing axostyle visible, jerky movement • Can be confused with Giardia (feline; diarrheic)
Candida-like • Color Plate 4.12, CP-5
• Rarely internal structures; smaller than Giarda cysts
Cyniclomyes (Sarrharomycopsis)
• Large elongated yeast with bipolar inclusions; sometimes see branching
SECTION THREE: DIAGNOSTIC SKILLS
Gram-negative Tiny, curved, gram-negative rods (not tightly spiraled) Two attached together as a “seagull” or “W” shape “Swarm of bees”: rapid and darting motility Size: 1.5–5 μm
Vaginal Cytology Vaginal cytology is used in evaluating an animal’s stage of estrus cycle. Because of the constant changing of cellular structures during the estrus
cycle, the evaluation of vaginal cells should be done every few days and in conjunction with a thorough medical history and examination (e.g., multiple, sequential samples increase accuracy of estrus stage estimation).
Table 4.8 / Classifying Vaginal Cells
Noncornified Squamous Epithelial Cells
Appearance
Parabasal cells
• Small round cells with a small amount of cytoplasm • Round, distinct nuclei • Uniform in size and shape
Intermediate cells
• Large round cells with a large amount of cytoplasm • Round nuclei
Superficial Intermediate cells
• ↑ Cytoplasm that is irregular, folded, and angular • Smaller nuclei, pyknotic
Cornified Squamous Epithelial Cells
Vaginal Cells
4
Superficial cells
• Large cells • ↑ Cytoplasm, folded and angular • Distinct edges As the cell ages • ± Nucleus (nucleated with young cells and anuclear with older/advanced cells) and vacuoles
CHAPTER 4 / LABORATORY
97
Table 4.9 / Staging the Estrus Cycle Estrus Stage
Definition
Cell Appearance
Anestrus
• No physical changes • Does not attract or accept males • Duration: <4.5 months
• Intermediate or parabasal cells • ± Neutrophils • ± Bacteria
Proestrus
• Swollen vulva, bloody vaginal discharge • Attracts, but will not accept males • Duration: 4–13 days
Early • Noncornified squamous epithelial cells • Neutrophils and erythrocytes • ± Bacteria Late • Superficial intermediate cells and cornified epithelial cells • ↓ Neutrophils and ↑ erythrocytes • ± Bacteria
Estrus
• Swollen vulva and pinkish to straw colored discharge • Accepts males • Duration: 4–13 days
Early • 90% Cornified squamous epithelial cells • ± Superficial intermediate cells • ± Erythrocytes • Bacteria Late • ↑ Neutrophils and ↓ erythrocytes • Bacteria
Metestrus/Diestrus
• Vulvar swelling and discharge • Does not attract or accept males • Duration: 2–3 months
Early • Cornified squamous epithelial cells • ↑ Cytologic debris Late • Intermediate and parabasal cells • ± Neutrophils and erythrocytes
4
FUNCTION TESTS Function tests are used to force a system in the body to perform in a specific way (e.g., suppression or stimulation) to provide predictable results. Depending on the results, the information received will help to determine whether the system is functioning correctly. Most of these procedures require
98
SECTION THREE: DIAGNOSTIC SKILLS
a specific protocol of fasting, injections, and blood drawing times; however, individual laboratories should be consulted regarding their specific protocol. As with any laboratory test, collection and handling remain the area of biggest human error as well as the area easiest to monitor and perform correctly.
Table 4.10 / Function Tests Test
Definition/Uses
Normal Range
Protocols
Handling and Special Considerations
Adrenocorticotropic Hormone (ACTH) Endogenous Plasma, Concentration
Distinguishes between pituitarydependent hyperadrenocorticism (PDH) and adrenocortical tumors (ATs) and primary and secondary hypoadrenocorticism
Canine • 2.2–25 pmol/L • <2.2 = AT • 2.2–10 = nondx • >10 = PDH
• Fast for 12 hours. • Collect a blood sample.
Handling/Storage • Lipemia; may interfere with the assay • Sample should be immediately placed in an ice bath, centrifuged, transferred into a plastic tube, and frozen. • Send by overnight air on dry ice to testing laboratory. • Aprotinin can be added to the EDTA tube to inhibit the degradation of ACTH and remove the need to freeze sample. Notes • N/A
Tube: LTT Amount: full tube Use: Hyperadrenocorticism, Hypoadrenocorticism
ACTH Stimulation Test or ACTH Response Test Tube: SST or RTT Amount: 0.5 mL serum or plasma each sample
The adrenal gland will respond to exogenous ACTH stimulation by glucocorticoid release in proportion to the glands’ size and development. This test measures actual cortisol hormone.
Canine Pretest: • 0–10 μg/dL Posttest: • 8–22 μg/dL Feline Pretest: • 0.4–4.0 μg/dL Posttest: • 8–12 μg/dL
• Obtain baseline sample. • Cosyntropin • Canines: 0.25 mg IM and felines 0.125 mg IM cosyntropin. • Draw blood sample 1 hour post for canines and 30 minutes and 1 hour post for felines. • ACTH gel • Give 1 unit/lb of ACTH gel IM. • Draw blood sample 2 hours post for canines and 1 and 2 hours post for felines.
Handling/Storage • Delay in separation of serum/plasma from blood cells and lipemia; ↓ values • Sample should be immediately placed in an ice bath, centrifuged, transferred into a plastic tube, and frozen. Notes • Discontinue prednisone, prednisolone, cortisone, and fludrocortisone 24–48 hours before test.
Evaluates the effect of exogenous ADH on the renal tubular ability to concentrate urine in the face of dehydration or water deprivation
Canine/Feline • ↑ in urine specific gravity (USG)
• Immediately after a water deprivation test; give 0.5 U/ kg vasopressin IM (max of 5 U) • Empty the urinary bladder and measure specific gravity and osmolality at 30, 60, 90, and 120 minutes
Handling/Storage • N/A Notes • Withhold all food and water until the test has been completed.
Use: Hyperadrenocorticism, Hypoadrenocorticism; screening and monitoring therapy
ADH Response Test or Vasopressin Response Test Use: Diabetes insipidus; differentiates between central and nephrogenic diabetes insipidus
CHAPTER 4 / LABORATORY
99
4
Table 4.10 / Function Tests (Continued) Test
Definition/Uses
Normal Range
Protocols
Handling and Special Considerations
Ammonia Tolerance Test (ATT)
Detect abnormal portal blood flow and liver dysfunction
Canine Preammonia: • 44–116 μg/L Postammonia: • 85–227 μg/L Danger level • >1,000 μg/dL
• Fast for 12 hours and give enemas to clear lower bowel • Obtain baseline sample • Give ammonium chloride at 0.1 g/kg (max of 3 g) • Orally dissolved in 20– 50 mL water and given by stomach tube • Rectally as a 5% solution • Orally as a powder in gelatin capsules • Draw heparinized blood samples at 30 to 45 (gelatin capsules) minutes post
Handling/Storage • Centrifuged immediately, pour plasma off and analyze within 1–3 hours or freeze at −68° F Notes • Not recommended for felines • Do not perform if resting ammonia levels are already ↑, because it may cause hepatic encephalopathy. • Oral administration may cause regurgitation. • Vomiting may occur but does not invalidate test. • Venous occlusion, vigorous activity before, and muscle exertion during restraint; ↑ values • 3–10-fold ↑ indicates portosystemic shunts
A dysfunctional hepatobiliary system allows ↑ levels of bile acids to be found systemically. This test is a very sensitive function test of hepatic and biliary abnormalities.
Canine/Feline Fasted: • <5 μmol/L Postprandial: • <25 μmol/L
• Fast for 12 hours. • Obtain a baseline sample. • Feed ≥2 Tbsp of a high-fat diet to a dog and ≥1 Tbsp to a cat. • Collect a blood sample 2 hours post.
Handling/Storage • N/A Notes • Ursodeoxycholic acid; altered values • Hemolysis: ↓ values • Ileum disease and large-volume diarrhea; ↓ values
A direct measurement of pancreatic lipase versus the general measurement of total serum lipase activity
Canine • 1.9–82.8 μg/L
• Fast for 12–18 hours. • Collect a blood sample.
Handling/Storage • Separate serum and send sample on ice with a direct carrier to Texas A&M GI Lab. Notes • N/A
Tube: GRNTT Amount: full tube
4
Use: Hepatic disease and portosystemic shunting
Bile Acids Tube: SST Amount: 0.5 mL serum each Use: Hepatic disease, portosystemic shunting, and cholestatic disorders Canine Pancreatic Lipase Immunoreactivity (cPLI) Tube: SST Amount: 0.5 mL serum Use: Pancreatitis and Pancreatic mass
100
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.10 / Function Tests (Continued) Test
Definition/Uses
Normal Range
Protocols
Handling and Special Considerations
Dexamethasone Suppression Test High-dose
Differentiates pituitary-dependent hyperadrenocorticism (PDH) from adrenocortical tumors (ATs) in canines. The injected dexamethasone is expected to shut off ACTH production through negative feedback, as seen with PDH. This is also a diagnostic screening test for HAC in felines.
Canine PDH: Pretest: • 1.1–8.0 μg/dL Posttest: • 0.1–1.4 μg/dL or ≤50% of pretest level AT: Pretest: • 2.5–10.8 μg/dL Posttest: • 1.4–5.2 μg/dL
• Obtain a baseline sample. • Give 0.01 mg/kg dexamethasone IV. • Collect a blood sample at 4 (optional) and 8 hours post.
Handling/Storage • N/A Notes • N/A
Used to diagnose or confirm HAC
Canine Pretest: • 1.1–8.0 μg/dL Posttest: • 0.1–0.9 μg/dL • (nondx 1.0–1.4 μg/dL) Feline Pretest: • 1–4 mg/mL Posttest: • <1.5 μg/dL
• Obtain a baseline sample. • Give 0.01 mg/kg (canine) and 0.1 mg/kg (feline) dexamethasone sodium phosphate IV. • Collect a blood sample at 4 and 8 hours post.
Handling/Storage • N/A Notes • Keep felines in a stress-free environment during testing.
Folate is absorbed in the jejunum and cobalamin in the ileum. Reflect intestinal absorptive function and the status of the intestinal flora.
Canine Folate • 3.5–11 μg/L Cobalamin • 300–700 ng/L Feline Folate: • 6.5–11.5 μg/L Cobalamin • 290–1,500 ng/L
• Fast for 12 hours. • Collect a blood sample.
Handling/Storage • Folate hemolysis; ↑ value • Avoid prolonged exposure to light and heat. Notes • N/A
Adjunctive test used to diagnose DM and to monitor glycemic control during insulin therapy
Canine • 370 μmol/L Feline • 375 μmol/L
• Obtain a blood sample.
Handling/Storage • N/A Notes • Corticosteroids, progestins, thiazide diuretics, growth hormone, dextrosecontaining fluids and morphine; ↑ value
Tube: SST Amount: 0.5 mL serum each Use: Hyperadrenocorticism
Dexamethasone Suppression Test Low-dose Tube: SST Amount: 0.5 mL serum each Use: Hyperadrenocorticism
Folate and Cobalamin Tube: SST Amount: 1 mL serum Use: Intestinal bacterial overgrowth, malabsorption, exocrine pancreatic insufficiency, inflammatory bowel disease, or intestinal neoplasia Fructosamine Tube: SST or RTT Amount: 0.5 mL serum Use: Diabetes mellitus
4
CHAPTER 4 / LABORATORY
101
Table 4.10 / Function Tests (Continued) Test
Definition/Uses
Normal Range
Protocols
Handling and Special Considerations
Prothrombin Time (PTH, PT)
A vitamin K–dependent coagulation protein (factor) made by the liver. Evaluates extrinsic and common coagulation pathways
Canine • 5–8 sec Feline • 8–11 sec
• Collect a blood sample.
Handling/Storage • Tube must be completely full. • Centrifuge at 3,000 rpm for 10 minutes, remove plasma. • If >24 hours to run test, spin sample, and freeze plasma. Notes • N/A
Identifies an immune response specifically against muscle AchRs.
Canine • <0.6 nmol/L Feline • <0.3 nmol/L
• Collect a blood sample.
Handling/Storage • Separate serum and ship overnight on ice/chilled. Notes • Corticosteroid therapy can lower serum antibody levels.
Evaluates the ability of the thyroid gland to suppress pituitary TSH secretion followed by a drop in T4 secretion.
Canine/Feline • ↓ in serum T4 after 72 hours of oral T3
• Obtain a baseline sample for T4 and T3. • Give 25 μg/cat of T3 orally TID, starting the next morning for 7 doses. • On the morning of the 3rd day, give 25 μg orally of T3 and redraw blood sample within 4 hours for T3 and T4.
Handling/Storage • N/A Notes • Rise in T3 confirms owner’s compliance in giving medication.
Evaluate the resting thyroid hormone concentration, a measurement of the total T4 or T3.
Canine T4: • 1.0–4.0 μg/dL T3: • 0.5–1.8 ng/mL Feline T4: • 1.8–4.5 μg/dL T3: • 0.4–1.6 ng/mL
• Collect a blood sample.
Handling/Storage • N/A Notes • Corticosteroids, illness, estrus, pregnancy, obesity, stress; altered values • T3 is not as accurate in the early stages of disease.
A measurement of thyroid hormone not bound to a protein (unbound) and available for entry into cells
Canine • 0.3–0.5 ng/dL Feline • 0.8–5.2 ng/dL
• Collect a blood sample.
Handling/Storage • N/A Notes • Least likely to be affected by nonthyroidal diseases
Tube: BTT Amount: 1.8 mL whole blood
4
Use: Liver disease and anticoagulant toxicity Serum Antibody Against Nicotinic AchRs Tube: SST Amount: 1 mL serum Use: Myasthenia gravis T3 Suppression Test Tube: RTT Amount: 0.1 mL serum Use: occult Hyperthyroidism
Thyroid Hormone, Basal Serum (T4 and T3) Tube: SST Amount: 1 mL serum Use: Hyperthyroidism, Hypothyroidism
Thyroid Hormone, Free (Free T4 and Free T3) Tube: SST Amount: 0.5 mL serum Use: Hyperthyroidism, Hypothyroidism
102
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.10 / Function Tests (Continued) Test
Definition/Uses
Normal Range
Protocols
Handling and Special Considerations
Thyroid-Releasing Hormone (TRH) Stimulating Test or TRH Response Test
TRH is responsible for the release of thyroid-stimulating hormone (TSH) from the anterior pituitary and the eventual synthesis of thyroid hormone. Evaluates thyroid gland function by the degree of change after the administration of TRH.
Canine • >2 μg/dL post-TRH or ≥0.5 μg/dL above baseline T4 Feline • Little to no ↑
• Obtain baseline sample. • Give 0.1 mg/kg TRH IV. • Collect blood sample 4 and 6 hours post (canine) and 4 hours post (feline).
Handling/Storage • N/A Notes • TRH administration typically causes hypersalivation, tachypnea, and vomiting up to 4 hours post-stimulation.
TSH is responsible for stimulating the synthesis of thyroid hormones in the thyroid gland.
Canine • 0.02–0.5 ng/mL
• Collect a blood sample.
Handling/Storage • N/A Notes • N/A
Test of pancreatic digestive function. A ↓ amount of serum TLI is found when there is a ↓ in the amount of functioning pancreatic cells.
Canine • 5–35 μg/L Feline • 17–49 μg/L
• Fast for 12 hours. • Collect blood sample.
Handling/Storage • Allow to clot at room temperature. • Serum is stored at −68° F. Notes • More sensitive and specific for pancreatitis than amylase/lipase
Although urine creatinine stays relatively constant in an animal with stable kidney function, increased urine cortisol levels are seen with hyperadrenocorticism.
Canine • <1.35 × 10−5
• Obtain urine sample. • Determine cortisol and creatinine concentrations.
Handling/Storage • N/A Notes • Avoid stress while obtaining urine sample. • Obtain at home with a morning sample • False positives are common.
To determine the significance of protein in the urine; not dependent on urine concentration
Canine • <0.3 Feline • <0.6
• Obtain urine sample via cystocentesis. • Determine protein and creatinine concentrations.
Handling/Storage • N/A Notes • Performed on a morning sample
Tube: SST Amount: 0.5 mL serum each Use: Hyperthyroidism (feline), Hypothyroidism (canine) Thyroid-stimulating Hormone Concentration (endogenous TSH) Tube: SST Amount: 0.5 mL serum Use: Hypothyroidism Trypsin-like immunoreactivity (TLI) Tube: SST or RTT Amount: 1 mL serum Use: Exocrine Pancreatic Insufficiency, Pancreatitis Urine Cortisol:Creatinine ratio Amount: 3–4 mL urine Use: Hyperadrenocorticism
Urine Protein:Creatinine Ratio Amount: 1 mL Cystocentesis sample Use: Glomerulonephritis and renal disease
CHAPTER 4 / LABORATORY
103
4
Table 4.10 / Function Tests (Continued) Test
Definition/Uses
Normal Range
Protocols
Handling and Special Considerations
Water-Deprivation Test
To dehydrate the body to the point of signaling ADH release and the subsequent concentration of urine by the kidneys
Canine • 1.045 Feline • 1.075 • A USG of 1.025 is considered an adequate response.
• Stop either test when the animal loses ≥5% of body weight, becomes ill, or USG is >1.025. Gradual • Determine unrestricted daily water intake. • Measure USG and weigh animal. • Reduce water intake by 5% daily (not <66 mL/kg/day). • Measure USG and weigh animal daily. Abrupt • Empty urinary bladder and measure USG and weigh animal. • Withhold food and water until the end of the test. • Every 2–4 hours, empty urinary bladder, measure USG, and weigh animal.
Handling/Storage • N/A Notes • Contraindications: dehydration, renal disease, and azotemia • A modified water-deprivation test is the ADH response test immediately after the standard water-deprivation test. • BUN should be monitored regularly throughout both tests.
Use: Diabetes insipidus
4
HEMATOLOGY Even though many clinics send their blood samples out to reference laboratories for evaluation or use in-house automated machines, knowledge of how to perform a manual complete blood count (CBC) can be very useful in certain situations. For example, during emergency situations, when time is crucial, the technician may be asked to perform an in-house CBC—or when the automated machine is malfunctioning. The results will provide the veterinarian with crucial information regarding the patient’s hematology status (e.g., anemia, infection, and neoplasia). See Under Blood Chemistries for Blood Collection, Handling, Storage, and Transport Tips.
104
SECTION THREE: DIAGNOSTIC SKILLS
A CBC consists of RBC and WBC evaluation, PCV, TP, hemoglobin (Hgb) concentration, differential, platelet estimate, RBC indices, and a reticulocyte count. These tests are all run using a whole blood sample from an anticoagulant tube, such as EDTA. (See Skill Box 4.1, Blood Collection Tubes, page 74.) The assessment of morphology and cell counts must be performed in a monolayer area of the slide. Thicker areas and the feathered edge should be evaluated for large structures, such as: platelet clumps, microfilaria, and mast cells. Cell inclusions are often confused with platelets and stain precipitate; their location (e.g., within the cell, surface of cell) should always be verified by focusing through the cell.
Skill Box 4.6 / Complete Blood Count Procedure
Definition/Uses
Technique
Normals
Associated Conditions
Packed Cell Volume (PCV, hematocrit, Hct)
• Percentage of whole blood that is composed of RBCs
• Fill a capillary tube 2/3–3/4 full with whole blood and plug 1 end with a clay sealant. • Centrifuge and read results as a percentage. • Record the color and transparency of the plasma.
Canine • 37–55% Feline • 24–45% Plasma • Yellow and clear
• ↑ Polycythemia, dehydration, stress, neonates • ↓ Anemia, overhydration, weanlings
4
Total Protein Concentrationa (TP)
• Indicates oxygen transport capacity of the blood
• Break a spun capillary tube above the buffy coat level and put the plasma onto the face of the refractometer.
Canine • 5.4–7.6 g/dL Feline • 6.0–8.1 g/dL
• ↑ Dehydration • ↓ Overhydration
Hemoglobin Concentration (Hgb)
• Indicates how well the blood is transporting oxygen
• Follow manufacturer’s guidelines for machine’s use.
• 1/3 of the PCV
• ↑ (Falsely) lipemia, Heinz bodies • ↓ Hypochromic anemias
RBC Count
• Gives an accurate count of RBCs • Machine counters have shown to be more accurate than manual counting. • The main use of a RBC count is to calculate indices.
1. Prepare the sample (1 : 200 dilution) and hemacytometer (see Skill Box 4.7, page 108) 2. Find the grid at ×4, focus on the center square of the grid and then increase magnification to ×10, count the RBCs in the center square and each of the 4 corners using ×100. 3. Average the totals from grids of both stages and add 4 zeros. 4. Round to the nearest tenth place and put in scientific notation.
Canine • 5.5–8.5 × 106/μL Feline • 5–10 × 106/μL
• ↑ Polycythemia, dehydration • ↓ Anemia, overhydration
WBC Count (TWBC)
Gives an accurate count of total W.BCs
1. Prepare the sample (1 : 20 dilution) and hemacytometer. 2. Count the entire grid on ×10. 3. Average the totals from both grids. 4. (Averaged totals [AT] + 10% of AT) × 100 e.g., Grid #1 = 75 Grid #2 = 85 75 + 85 = 160/2 = 80 80 + 8 × 100 = 8,800 μL
Canine • 6,000–16,000 μL Feline • 5,000–19,000 μL
• ↑ Hemolysis, inflammation, hemorrhage, immune-mediated disease, infection, leukemia, necrosis, neoplasia, toxemia • ↓ Bone marrow disease, radiation, drug administration, retroviruses, myeloproliferative, lymphoproliferative diseases
CHAPTER 4 / LABORATORY
105
Skill Box 4.6 / Complete Blood Count (Continued) Procedure
Definition/Uses
Technique
Normals
Associated Conditions
Differential
• Indicates the number of specific WBCs found circulating in the blood • The TWBC count should roughly equal the differential totals
1. Examine a prepared blood smear using ×100. 2. Count up 100 WBCs (neutrophils [N], bands [B], lymphocytes [L], monocytes [M], eosinophils [E], and basophils) and classify according to type. 3. See Skill Box 4.8 Calculating a Differential, page 108.
Canine • N—3,600–11,500 • B— 0–300 • M—15–1,350 • L—1,000–4,800 • E—100–1,250 Feline • N—2,500–12,500 • B— 0–300 • M—0–850 • L—1,500–7,000 • E—0–1,500
• Variable dependent on type of cell(s) ↑ or ↓
Nucleated RBCs (nRBC) Color Plate 4.13
• Early release of immature RBCs • The corrected value should be calculated when >5 nRBCs are found and then used to calculate the differential.
1. While performing the differential, keep track of any nRBCs 2. Calculate a corrected TWBC count Corrected TWBC count = Observed TWBC count × 100 100 + nRBC
• N/A
• Anemia, lead poisoning, hemangiosarcoma
Platelet Estimate
• Indicates ability for adequate clotting
1. Examine a prepared blood smear using ×100 in which the RBCs are close but not touching, typically near the periphery of the slide. 2. Count 5 different fields and average. 3. Multiply by 15,000 and 18,000 to obtain a range. • When large areas of clumping are seen, assume adequate numbers of platelets.
Canine • 200,000– 500,000 μL Feline • 300,000– 800,000 μL
• ↑ Myeloproliferative disorder, megakaryocytic leukemia • ↓ B12, iron, or folic acid deficiency, drug toxicity, acute hemorrhage, radiation, viruses, uremia, aplastic anemia
4
Reticulocytes Not until a polychromatophilic erythrocyte is stained with Wright’s stain are they termed reticulocytes. These cells are large, anucleated cells containing RNA stained with a supravital stain (e.g., NMB). The RNA appears as blue intracellular granules. In canines, all reticulocytes are accounted for; however, in felines there are 2 types of reticulocytes and they should be counted and reported separately. Felines have aggregate reticulocytes and punctuate reticulocytes. Aggregate reticulocytes resemble canine reticulocytes and have distinct dark clumps of blue granules and would appear as polychromatophilic erythrocytes with Wright’s stain. Punctuate erythrocytes have individual scattered blue granules with no clumping and would appear as macrocytic mature red blood cells with Wright’s stain. When performing a reticulocyte count, only aggregate reticulocytes are counted as they are the best indicator of regenerative anemia. An ↑ in reticulocytes is expected 2–4 days after blood loss or destruction. A count >60,000 cells/μL indicates regenerative anemia and <60,000 cells/μL indicates a nonregenerative response. See Color Plates 4.13 and 4.17.
106
SECTION THREE: DIAGNOSTIC SKILLS
Skill Box 4.6 / Complete Blood Count (Continued) Procedure
Definition/Uses
Technique
Normals
Associated Conditions
Reticulocyte Count
• Immature RBCs • Used to evaluate the bone marrow’s response to anemia • Perform along with a CBC when severe anemia is present. • PCV values: • Canine: ≤30% • Feline: ≤20%
1. Mix together an equal part of whole blood with NMB, and agitate, and let it sit for 10 minutes. 2. Prepare a blood smear. 3. Examine under ×100 by counting 1,000 RBCs while separately keeping track of the number of reticulocytes. 4. Divide the reticulocyte number by 1,000 and convert to a percentage. 5. Calculate the corrected reticulocyte number. Corrected retic. % = Observed retic. % × PCV Normal mean PCV for species
• <1%
• ↑ Regenerative anemias
RBC Indices Mean Corpuscular Volume (MCV)
• Indicates the size or volume of RBCs • Classifies anemias as normocytic, macrocytic, or microcytic
MCV (fl) =
Canine • 60–77 fL Feline • 39–55 fL
• ↑ Reticulocytosis, B12, folic acid deficiency • ↓ Iron deficiency
Mean Corpuscular Hemoglobin (MCH)
• The mean weight of Hgb in a RBC • Used as a lab check • ↑ MCH should see a ↑ MCV • ↓ MCH should see a ↓ MCV
MCH (PG) =
Canine • 19–24 PG Feline • 12–17 PG
• ↑ Hemolysis • ↓ Iron deficiency
Mean Corpuscular Hemoglobin Concentration (MCHC)
• Indicates the average hemoglobin concentration in each RBC • Classifies anemias as hypochromic or normochromic
MCHC (g dL) =
Canine • 32–36 g/dL Feline • 30–36 g/dL
↑ Hemolysis, lipemia, Heinz bodies ↓ Iron deficiency
PCV (%) × 10 RBC count × 106 μL
Hgb (g dL) × 10 RBC count × 106 μL
Hb (g dL) × 100 PCV (%)
4
a Score the capillary tube with the edge of slide just above the buffy coat to allow easy breaking. Using the unbroken end, tap onto the surface of the refractometer or blow air into the tube to expel the plasma.
CHAPTER 4 / LABORATORY
107
Skill Box 4.7 / Hemacytometer Use 1. Prepare the WBC or RBC sample, following manufacturer’s directions. 2. Shake the sample just before use to redistribute the cells. 3. Fill the stylette by squeezing the bottle and expelling any air bubbles. 4
4. Place the hemacytometer on the table, and place the coverslip on top. 5. While stabilizing the hemacytometer, place the stylet in the indented portion and gently squeeze just until the stage is filled • Overfilling of the stage will result in multilevels of RBCs and give falsely ↑ values. 6. Load up the other indented area as previously described.
Skill Box 4.8 / Calculating a Differential 1. Count up 100 WBCs and differentiate their type and record totals as %/μL. e.g., 45 neutrophils = 45%/μL = 0.45/μL 45 lymphocytes = 45%/μL = 0.45/μL 7 monocytes = 7%/μL = 0.07/μL 3 eosinophils = 3%/μL = 0.03/μL 0 basophils = 0 100 WBCs 2. Multiply each WBC type by the previously obtained TWBC count. e.g., TWBC count = 8,650 8,650 × 0.45 = 3893/μL neutrophils 8,650 × 0.45 = 3893/μL lymphocytes 8,650 × 0.07 = 606/μL monocytes 8,650 × 0.03 = 260/μL eosinophils 8,652/μL TWBC 3. The TWBC should roughly equal the TWBC count. e.g., TWBC (8,652) = TWBC count (8,650)
108
SECTION THREE: DIAGNOSTIC SKILLS
Evaluation Once these tests have been performed, the blood is examined and evaluated on the basis of its morphology, inclusions, and presentation. While viewing in a monolayer area of the slide, the abnormality can be graded as the number per oil immersion field or the terms occasional and rare can be used. 1. Prepare a blood smear slide with stain or use the prepared slide from the differential. 2. Scan the slide, using low magnification. a. Platelet aggregation b. RBC rouleaux c. RBC agglutination 3. Examine the slide, using oil immersion magnification. a. RBC morphology i. Size ii. Shape iii. Color iv. Alterations b. WBC morphology i. Toxic changes ii. Nuclear degeneration iii. Cytoplasmic inclusions iv. Alterations c. Platelet i. Distribution ii. Alterations
RBC Alterations and Morphology The normal morphology of a canine RBC is a large, biconcave disc (7.5 μm) of uniform size with central pallor. A normal feline RBC is a slightly smaller biconcave disk (5 μm) with only slight central pallor. When observing the prepared slide for RBC morphology, the cells should be evaluated for alterations in size, shape, color, and inclusions.
Table 4.11 / RBC Alterations and Morphology (See figures in Color Plate 6–11) Alteration
Definition
Appearance
Associated Conditions
Agglutination
• Immunoglobulin related cell bridging
• Irregular, spherical aggregation or clumping of cells
• IMHA, mismatch blood transfusion
Rouleaux
• ↑ Concentration of plasma proteins (e.g., fibrinogen, immunoglobulins) which results in linear aggregations of erythrocytes
• Linear stacks or stack of coins
• Multiple myeloma, lymphoproliferative disorders, inflammatory conditions • Slight amount is a normal findings in canines and felines
Basophilic Stippling • Color Plate 4.13
• Residual RNA
• Very small, dark-blue inclusions on the surface of the RBC
• Anemia or lead poisoning
Distemper • Color Plate 4.14
• Virus antigen or viral inclusion bodies (identification variable)
• Variable sized round, oval, or irregular inclusions • Most often seen in polychromatophilic cells • Faint blue or magenta
• Canine distemper virus
Heinz Bodies • Color Plate 4.17
• Denatured hemoglobin caused by certain chemicals or oxidant drugs • Seen in up to 10% of normal feline RBCs
• Single, light-colored, rounded protrusions within the RBC membrane • Best seen using new methylene blue stain
• Lymphosarcoma, chronic renal failure, hyperthyroidism, diabetes mellitus, and oxidative toxins (e.g., onions, zinc, acetaminophen)
Howell-Jolly Bodies • Color Plate 4.13 • Color Plate 4.15 • Color Plate 4.30
• Basophilic nuclear remnants seen in young RBCs
• Dark blue to black spherical inclusions
• Splenic disorders
Hypochromasia • Color Plate 4.18
• ↓ Hemoglobin concentration • Can be confused with torocytes and immature polychromatophilic erythrocytes
• ↑ Area of central pallor • Doughnut appearance
• Iron deficiency • Often associated with anisocytosis in regenerative anemia
Polychromasia • Color Plate 4.16 • Color Plate 4.17 • Color Plate 4.20
• Immature erythrocytes that have been released early • When polychromatic erythrocytes are stained with a supravital stain (e.g., NMB), they are termed reticulocytes.
• Bluish or gray tint
• Iron deficiency, regenerative anemia
Microcytosis
• ↓ Cell volume
• RBCs smaller than normal
• Iron deficiency
Macrocytosis
• ↑ Cell volume • Immature RBCs, reticulocytes
• RBCs larger than normal
• Regenerative anemia
Arrangement
4
Inclusions
Morphology, Color
Morphology, Size
CHAPTER 4 / LABORATORY
109
Table 4.11 / RBC Alterations and Morphology (Continued) Alteration
Definition
Appearance
Associated Conditions
Anisocytosis • Color Plate 4.30
• Variation in cell volume • Multiple possibilities (e.g., early cell release or increased cell division of RBCs) • The number of cells showing variation and the degree of variation from the largest to the smallest cells should be noted
• Variation in cell size
• Liver disease, spleen disorders, regenerative anemia
Acanthocytes (spur cell) • Color Plate 4.20
• Caused by cholesterol concentration changes in the cell membrane
• Irregularly spiculated
• Severe liver disease, disseminated intravascular coagulation (DIC), hemangiosarcoma, hepatic lipidosis, lymphosarcoma, portosystemic shunts, and renal disease
Blister Cells (prekeratocytes) • Color Plate 4.18
• Fusion of inner cell membranes
• Blister or vacuole on the cell membrane
• Iron deficiency
Crenation
• pH changes associated with slowdrying blood films
• Notched or scalloped cell membrane
• Artifact • Mostly seen in cats
Dacrocytes
• Deformed during maturation process • Can be confused with smeared RBCs during smear preparation
• Tear shaped
• Myelofibrosis
Eccentrocytes (hemi-ghost cells)
• Fusion of opposing oxidized cell membranes
• Shifting of hemoglobin to 1 side, crescent shaped clear area outlined by a thin layer of membrane and lack of central pallor
• Oxidative injury
Echinocytes (burr cells)
• Mechanism unknown, possibly calcium or adenosine triphosphate (ATP) changes in vivo
• Evenly spaced, blunt to sharp projections of uniform shape and size • Scalloped edge
• Renal disease, lymphosarcoma, doxorubicin toxicity, electrolyte depletion, and snake bites
Keratocytes (bite or helmet cells) • Color Plate 4.18
• Blister cells (vacuolated cells) that enlarge and break open on 1 side of cell membrane
• Spiculated cells with 2 or more projections
• DIC, congestive heart failure, hemangiosarcoma, glomerulonephritis, and chronic doxorubicin toxicity
Leptocytes (codocytes, target cells) • Color Plate 4.19
• Characterized by ↑ membrane and ↓ hemoglobin levels
• Folded or resemble a target
• Nonregenerative anemia
4 Morphology, Shape
110
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.11 / RBC Alterations and Morphology (Continued) Alteration
Definition
Appearance
Associated Conditions
Nucleated RBCs (metarubricytes, normoblasts) • Color Plate 4.1 • Color Plate 4.13 • Color Plate 4.16
• Early release of RBCs still maintaining its • Dark purple nucleus in a normal-size nucleus RBC
• Regenerative anemia, splenic dysfunction, severe stress, hyperadrenocorticism, and corticosteroid treatment
Poikilocytosis
• Characteristic of ↑ RBC fragility
• Variation in shape
• Liver, kidney, spleen, and other vessel problems
Schistocyte (fragments, helmet cells) • Color Plate 4.20
• Shearing of the RBC by intravascular trauma
• Irregularly shaped fragments and sharp pointed projections
• DIC, vascular neoplasms, severe burns, and iron deficiency
Spherocyte • Color Plate 4.16
• ↓ Amount of cell membrane caused by partial phagocytosis by macrophages • Very difficult to distinguish in cats
• Small, dark, round RBCs with little or no central pallor
• Autoimmune hemolytic anemia (AIHA), transfusions, parasitic infections, zinc toxicity and snake venom toxicity
Stomatocytes (mouth cells)
• Multiple possibilities (e.g., leakage of sodium and potassium from the cell membrane)
• Cup shaped • Split-like center opening
• Liver disease, inherited disorders (e.g., Alaskan malamutes)
Torocytes
• Often confused with hypochromasia
• Bowl-shaped or “punched-out cell” • Thick outer ring of hemoglobin with a sharply defined central clear area
• Insignificant
Babesia spp. • Color Plate 4.21
• Rare protozoan, tick-transmitted disease of dogs
• Babesiosis (acute intravascular and extravascular • Large, teardrop- or ring-shaped hemolysis with hemoglobinuria) intercellular structures, often seen in pairs • Size: 1.5–3.0 μm
Cytauxzoon felis • Color Plate 4.22
• Rare protozoan, tick-transmitted disease of cats
• Small, irregular rings within RBCs, lymphocytes, or macrophages • Size: 0.5–2.0 μm
• Hemolytic anemia, icterus, depression, and fever
Mycoplasma haemocanis
• Rare rickettsial disease affecting dogs
• Chain of small cocci or rods that stretch across the surface of an RBC • Chains may branch • Size: 0.3–3.0 μm
• Splenectomized or immunocompromised dogs
Mycoplasma haemofelis Color Plate 4.15
• Common rickettsial disease of cats • Parasite is cyclic, and multiple slides may need to be evaluated for a diagnosis. • Parasite rapidly disappears with antibiotic treatment (e.g., tetracyclines).
• Nonrefractile cocci, rod- or ring-like structures on the periphery of RBCs • Stain dark purple • Size: 0.5–1.0 μm
• Immunocompromised cats, feline hemobartonellosis, or feline infectious anemia
4
Parasites
CHAPTER 4 / LABORATORY
111
WBC Morphology The job of WBCs is to defend the body against foreign organisms, conducting their business in the tissues themselves. They are typically nonfunctional in
the circulatory system. WBC morphology is significantly different between each type of cell. The frequency that they appear in the body is the order listed below.
Table 4.12 / WBC Morphology (See figures in Color Plate 6–11)
4
WBC
Definition
Appearance (stained)
Associated Conditions
Neutrophils (Polys, Segs) • Color Plate • Color Plate • Color Plate • Color Plate
• First line of defense against infection • Highly motile and phagocytic • Replaced in the body 2.5 times per day
• Convoluted and segmented nucleus • Clear to light pink cytoplasm with diffuse granules • Coarse and clumped chromatin
• ↑ Fear, exercise, stress, or inflammation • ↓ Severe infections, infectious agents causing decreased bone marrow production, chemical toxicity, and genetic disorders
Bands • Color Plate 4.23
• Immature neutrophils • Hyposegmented nucleus with the constriction being <1/2 the width of the nucleus • Left shift is an ↑ in immature neutrophils
• Nucleus is horseshoe shaped with large round ends
• ↑ Inflammation, bacterial infection, and neoplasia
Lymphocytes • Color Plate 4.24 • Color Plate 4.30
• Immunity and antibody production • Virus and tumor defense
• Large, round, slightly indented, dark nucleus • Round cell with a small amount of blue cytoplasm • Large, pink cytoplasmic granules
• ↑ Fear, excitement, chronic infections, leukemias, and lymphosarcoma • ↓ Corticosteroids, immunodeficiency diseases, loss of lymph, and impaired lymphopoiesis
Monocytes • Color Plate 4.25 • Color Plate 4.26
• Highly phagocytic; digesting particulate and cellular debris • Antiviral and antitumor qualities • Become macrophages once in extravascular space
• Large, elongated, lobulated, or indented nucleus • Bluish-gray cytoplasm • Large cell with lacy appearance caused by vacuoles • Pink dustlike inclusions • Diffuse nuclear chromatin • Blunt, agranular, light blue cytoplasmic pseudopods
• ↑ Corticosteroids, stress, or severe infections and hemorrhages
Eosinophils • Color Plate 4.27 • Color Plate 4.29 • Color Plate 4.30
• Ingest products of antibody/antigen reactions • Replaced once daily
Canine • Clear cytoplasm with small to large, dull orange granules partially filling cell Feline • Pale cytoplasm with small, dull orange granules completely filling cell
• ↑ IgE stimulation, parasitic infections and allergies • ↓ Corticosteroids
Basophils • Color Plate 4.28 • Color Plate 4.29
• Their function is still unclear, but related to immunity • Rarely seen, possibly because of rapid degranulation
Canine • Dark purple granules partially filling cell • Highly segmented nucleus • Gray-blue cytoplasmic vacuoles Feline • Violet cytoplasm with oval, nonstaining granules • Highly segmented nucleus
• ↓ Hyperlipemia, chronic IgE stimulation and allergies
112
4.15 4.23 4.29 4.30
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.13 / WBC Alterations
Neutrophil toxic change refers to morphologic changes due to altered bone marrow production. The neutrophils’ function is not altered, and they function normally. During an inflammatory response, the bone marrow releases neutrophils at an accelerated rate causing morphology changes such as Döhle bodies, cytoplasmic basophilia, and vacuolation. Reported by an index of 1+, 2+, etc. See Color Plates 4.32 and 4.33. Alteration
Definition
Appearance
Associated Conditions
Distemper
• Virus
• Variable sized round, oval, or irregular cytoplasmic and nuclear inclusions • Most often seen in polychromatophilic cells • Faint blue or magenta
• Distemper virus
Döhle Bodies • Color Plate 4.32 • Color Plate 4.33
• Retained rough endoplasmic reticulum • Seen with ↓ time in the marrow for maturation
• Bluish–gray, angular cytoplasmic inclusions • Typically found at the periphery of the cell • Size: 0.5–2.0 μm
• Severe toxemia, inflammation, and infection
Chediak-Higashi Syndrome
• Autosomal recessive inherited disorder • Fusion of preexisting granules • Persians are most commonly affected
• 1–4 large (2.0 μm), fused lightly pink or eosinophilic cytoplasmic lysosomes in neutrophils • Band appearing eosinophils
• Chediak-Higashi syndrome
Cytoplasmic Basophilia • Color Plate 4.32 • Color Plate 4.33
• Persistent ribosomes
• Varying degree of solid to patchy light blue to blue-purple cytoplasm
• Severe toxemia, inflammation, and infection
Cytoplasmic Vacuolation • Color Plate 4.33
• Disruption in bone marrow production, resulting in a loss of granule and membrane integrity
• Foamy, bubble-like, nonstaining circles
• Systemic toxicity
Mucopolysaccharidoses
• Deficiency of lysosomal enzymes needed for the degradation of glycoaminoglycans
• Dark purple or magenta granules in neutrophils • Granules and vacuoles in lymphocytes
• Mucopolysaccharidoses, lysosomal storage disorders
Nuclear Hypersegmentation
• Prolonged circulating life
• ≥5 nuclear lobes
• Aged neutrophils, prolonged storage of blood
Nuclear Hyposegmentation
• Early release of bands and immature neutrophils
• Unsegmented nucleus
• Steroid use, inflammatory response if intense/severe
Pelger-Huët anomaly
• Seen in heterozygotes for Pelger-Huët anomaly
• Hyposegmented mature neutrophils with a coarse chromatin pattern without inflammation present
• Pelger-Huët anomaly
Pyknosis
• Result of improper anticoagulant • Effect on nucleus
• Condensed, lysed or damaged nucleus
• Insignificant
Inclusions
4
Morphology
CHAPTER 4 / LABORATORY
113
Table 4.13 / WBC Alterations (Continued)
4
Alteration
Definition
Appearance
Associated Conditions
Reactive Lymphocyte (Immunocytes) • Color Plate 4.31
• Immune-stimulated T- and B-cells
• Cytoplasm and basophilia and a larger, more convoluted nucleus
• Antigenic stimulation (e.g., canine ehrlichiosis)
Vacuolated Lymphocytes
• Accumulation of storage products (e.g., proteins, carbohydrates, lipids)
• Cytoplasmic vacuoles
• Acquired lysosomal storage disorder, prolonged storage of blood
Cytauxzoon felis
• Rare protozoan, tick-transmitted disease of cats
• Small, irregular rings within RBCs, lymphocytes, or macrophages • Size: 0.5–2.0 μm
• Hemolytic anemia, icterus, depression, and fever
Ehrlichia canis
• Rickettsia, tick-transmitted disease of dogs
• Large granular lymphocytes • ↑ Cytoplasm and cell size • Variable sized pink cytoplasmic granules typically clustered next to the nucleus (difficult to find)
• Ehrlichiosis
Parasites
Table 4.14 / WBC Left Shift
An increased number of circulating immature neutrophils indicates a left shift. Bands are the most common immature neutrophil identified; however, metamyelocytes and myelocytes can also be seen in more severe cases. Appearance Left Shift
• ↑ Immature neutrophils • >300 μL/blood
Regenerative Left Shift
• • • •
Degenerative Left Shift
• Neutropenia or slight neutrophilia • Mature cells < immature cells • Leukopenia
Transitional Left Shift
• Moderate to marked neutrophilia • Mature cells < immature cells
Right Shift
• Nuclear hypersegmentation
Stress Leukogram (Corticosteroid Leukogram)
• • • •
114
SECTION THREE: DIAGNOSTIC SKILLS
Neutrophilia Mature cells > immature cells Lymphopenia Monocytosis
Mature neutrophilia Lymphopenia Eosinopenia +/− Monocytosis
Platelet Morphology
1. Venipuncture should be atraumatic while using the largest vein possible.
Platelets absorb and carry plasma factors needed to form fibrin to facilitate hemostasis. These thrombocytes vary in size and shape and are nonnucleated with pale blue to lavender granules. They are often seen in clumps at the periphery or feathered edge of a prepared slide. See color plates 4.15, 4.17, and 4.30.
2. Drawn blood should come into contact with the tube additive as soon as possible. 3. The following tubes will give invalid results and should not be used: LTT, GRNTT, SST. 4. Spun samples that are hemolyzed or have visible clots should be redrawn.
4
Table 4.15 / Platelet Alterations Alteration
Definition
Appearance
Associated Conditions
Megathrombocytes (Stress platelets, shift platelets, or giant platelets) • Color Plate 4.31
• Seen in felines, contributes to not being able to use an electronic counter
• Larger than an RBC
• Bone marrow disorders, myelo proliferative disorders
Table 4.16 / Coagulation Screening
Specific coagulation tests are chosen based on which factors they are able to evaluate. Coagulation Factor
ACT
APTT
PIVKA
PT
TT
Extrinsic Pathway
Coagulation Tests Hemostasis is the normal arrest of bleeding and abnormalities of this process can be seen as excessive bleeding (hemorrhage) or excessive hemostasis (intravascular thrombosis). The coagulation process is a sequence of events divided into 3 pathways; intrinsic, extrinsic, and common. Each pathway consists of several coagulation factors that contribute to the entire hemostasis process. A deficiency or abnormality in any 1 or combination of factors can alter the entire process leading to a coagulopathy. Coagulation tests are performed in patients exhibiting signs of questionable clotting abilities. They are able to distinguish between a coagulation problem and a patient with damaged or diseased blood vessels. These tests or a combination of tests can aid in a diagnosis (e.g., von Willebrand disease, DIC) or as monitoring to a hereditary condition or current condition. Blood drawn for coagulation tests must be collected and handled following very specific guidelines to obtain proper results. Activation of the clotting pathway will give erroneous results. Some tips to remember are:
III
X
VII
X
X
Intrinsic Pathway VIII
X
X
IX
X
X
XI
X
X
XII
X
X
I (Fibrinogn)
X
X
II (Prothrombin)
X
X
V
X
X
X
X
X
X
Common Pathway X X
X
X X
X
X
CHAPTER 4 / LABORATORY
115
Skill Box 4.9 / Coagulation Tests Test
Definition
Procedure
Normals
Activated Clotting Time (ACT)
• Test of intrinsic clotting mechanism • Less sensitive than APTT • Clot formation may be inhibited by administration of salicylates, NSAIDs, anticoagulants, antibiotics, barbiturates.
1. Warm syringe and tube containing diatomaceous earth to 98° F (37° C).a 2. Inject 2 mL freshly drawn whole blood into tube and invert 5 times to mix. 3. Begin the clock with the injection of blood into the tube and incubate in a warm water bath for 1 minute. 4. Observe at 5-second intervals for the first sign of clotting. • Place the tube back in incubation between each 5-second check.
Canine • 60–120 seconds Feline • 60–75 seconds • May be slightly prolonged with thrombocytopenia
Buccal Mucosal Bleeding Time (BMBT)
• Making a standard wound and noting the time to the cessation of bleeding. • Some NSAIDs, analgesics and sedatives may alter the results. • Evaluates platelet dysfunction and severe von Willebrand disease
1. Make a deep puncture at a site with no hair (e.g., buccal, gingiva, nose). 2. Begin timing when blood appears. 3. Remove the blood with filter paper at 30second intervals. 4. Stop timing when there is no more blood. • Do not touch the skin with the filter paper.
Canine/Feline • 1–5 minutes
Toenail Bleeding Time (TBT)
• Evaluates platelet dysfunction, severe von Willebrand disease, hemorrhagic phase of DIC, and coagulation factor deficiencies
1. Clip a toenail back past the quick to cause bleeding. 2. Keeping the animal undisturbed, monitor for the bleeding to cease.
Canine/Feline • <5 minutes
Platelet Estimate
• Estimation of platelet number
1. Examine a prepared blood smear, using ×100 on a place where the RBCs are close but not touching near the periphery. 2. Examine at least 5 fields to ensure accurate results.
Canine • 8–29/×100 field Feline • 10–29/×100 field
Clot Retraction Test
• Evaluation of platelet number and function and intrinsic and extrinsic pathways.
1. Draw a blood sample into a plain sterile tube and incubate at 37° C. 2. Exam the tube at 60 minutes where a clot should be evident. 3. Examine the tube at 4 hours to find a retracted clot. 4. Examine the tube at 24 hours to find a markedly compact clot.
• 60 minutes: clot evident • 4 hours: clot retracted • 24 hours: clot markedly compact
Quick Assessment Tests
4
116
SECTION THREE: DIAGNOSTIC SKILLS
Skill Box 4.9 / Coagulation Tests (Continued) Test
Definition
Procedure
Normals
• Test of intrinsic clotting mechanism and common coagulation pathways • Measure the time in seconds for fibrin clot formation. • Proper dilution is crucial to the accuracy of this test.
1. Draw a fresh blood sample to fill a BTT. 2. Gently invert sample 6–10 times to activate anticoagulant. 3. Refrigerate if testing is <24 hours or centrifuge sample, pipette off plasma, and freeze in a plastic tube.
Canine • 8–13 seconds Feline • 13–30 seconds
Fibrin Split Product (FSP) or Fibrin Degradation Product (FDP)
• Measures the presence of products that result from the action of plasmin on fibrin and fibrinogen • Proper dilution is crucial to the accuracy of this test. • Aids in DIC diagnosis
1. Draw a fresh blood sample to fill an FDP tube (2 mL). 2. Gently invert sample 6–10 times. • Clot formation should occur shortly after blood draw.
Canine/Feline • <10 mg/mL
Fibrinogen
• Quantitative measure of plasma fibrinogen
1. Draw a fresh blood sample to fill an LTT. 2. Gently invert sample 6–10 times to activate anticoagulant.
Canine • 100–250 mg/dL Feline • 100–350 mg/dL
Protein C Activity Assay
• Measures the percentage of protein C • Aids in the diagnosis of thrombotic disorders and hepatic disease
1. Draw a fresh blood sample, using a needle (vacutainer preferred), into a 2-mL BTT, or use a syringe containing citrate (1 part citrate to 9 parts blood). • Do not use a dry syringe and then transfer blood into a BTT. 2. Centrifuge blood and gently pipette off plasma into a plastic container and freeze.
Canine • 75–135% Feline • 65–120%
Protein Induced by Vitamin K Antagonism/Absence (PIVKA Test)
• Detects any coagulation factor deficiency of extrinsic clotting mechanism and common coagulation pathways
1. Draw a fresh blood sample to fill a BTT. 2. Gently invert sample 6–10 times to activate anticoagulant. 3. Centrifuge sample, pipette off plasma, and freeze in a plastic tube.
Canine • <25 seconds
Prothrombin Time (PT)
• Test of extrinsic clotting mechanism and common coagulation pathways • Measures the time in seconds for fibrin clot formation • Proper dilution is crucial to the accuracy of this test. • Used for vitamin K antagonist poisons
1. Draw a fresh blood sample to fill a BTT. 2. Gently invert sample 6–10 times to activate anticoagulant. 3. Refrigerate if testing is <24 hours or centrifuge sample, pipette off plasma, and freeze in a plastic tube.
Canine • 5–8 seconds Feline • 8–11 seconds
Definitive Tests Activated Partial Thromboplastin Time (APTT)
CHAPTER 4 / LABORATORY
4
117
Skill Box 4.9 / Coagulation Tests (Continued) Test
Definition
Procedure
Normals
Thrombin Time (TT)
• Test abnormalities of the conversion of fibrinogen to fibrin • Measures the amount of time for a fibrin clot formation in citrated plasma after the addition of thrombin • Normal values with rodenticide poisonings
1. Draw a fresh blood sample to fill a BTT. 2. Gently invert sample 6–10 times to activate anticoagulant. 3. Refrigerate if testing is <24 hours or centrifuge sample, pipette off plasma, and freeze in a plastic tube.
Canine/Feline • 10–12 seconds
von Willebrand Factor Assay (vWF)
• Measurement of vWF antigen • Proper dilution is crucial to the accuracy of this test. • Do not test during pregnancy, estrus, lactation.
• Draw sample before beginning therapy (e.g., plasma, cryoprecipitate) or wait 48 hours post therapy. 1. Draw a fresh blood sample, using a vacutainer needle, into a 2-mL BTT, or use a syringe containing citrate (1 part citrate to 9 parts blood). • Do not use a dry syringe and then transfer blood into a BTT. 2. Centrifuge blood and gently pipette off plasma into a plastic container. • Within 30 minutes, the sample should be centrifuged, transferred into a plastic tube, and frozen.
• Variable, dependent on bleeding time and vWF antigen percentage
4
a
118
Place the tube against your body (e.g., armpit or hand) for easy incubation.
SECTION THREE: DIAGNOSTIC SKILLS
Blood Transfusions
Skill Box 4.10 / Crossmatching Crossmatching determines the compatibility between donor and recipient blood by washing erythrocytes and incubating them with plasma. This procedure will identify incompatibilities that are not identified on blood typing since blood typing only identifies the most common types. However, crossmatching will not pick up low titer antibodies or WBC antigens and not identify incompatibilities to DEA 1 blood types unless previous sensitization (e.g., prior transfusion history) has occurred. Crossmatching is not a substitute for blood typing; both procedures must be performed on every patient (especially feline). Crossmatch
Use
Procedure
Results
Major
• Comparing donor erythrocytes to recipient serum • Checking for preformed antibodies in the recipient serum against RBCs from the donor
Positive • Any hemolysis or agglutination voids any chance of transfusions with this donor. • Agglutination appears as grape-like clusters.
Minor
• Comparing recipient erythrocytes to donor serum • Checking for preformed antibodies in the donor serum that could hemolyse recipient RBCs
1. Collect 1 mL of donor blood and 1 mL of recipient blood and place them each in a separate purple top tube (EDTA) or green top tube (heparin). Spin each tube for 10 minutes to separate plasma. Remove and save the plasma from each in clean glass or plastic tubes. 2. Wash the RBCs by taking 0.2 mL of RBCs and diluting in 5 mL of 0.9% saline. Spin this for 1 minute, remove the supernatant, and repeat the procedure 2 more times with the pelleted RBCs. 3. Prepare 3 tubes by labeling them as Major, Minor, and Recipient Control. To each tube, add 2 drops of plasma and 2 drops of blood to each as follows: • Major crossmatch: recipient plasma + donor cells • Minor crossmatch: donor plasma + recipient cells • Recipient control: recipient plasma + recipient cells 4. Let the tubes sit at room temperature for 15–30 minutes and then centrifuge for 15 seconds. 5. Check the supernatant for hemolysis and then gently resuspend the pellet by tapping the tube to check for RBC agglutination. Agglutination or hemolysis of the control indicates immune-mediated disease. 6. If agglutination is not observed, transfer a small amount to a slide and examine for microscopic agglutination.
4
Positive • Severe hemolysis or agglutination voids transfusion with this donor. • If the donated plasma with slight hemolysis or agglutination is to contribute substantially to the recipient’s plasma volume, the plasma should be removed from the whole blood and packed RBCs should be reconstituted with sterile saline.
CHAPTER 4 / LABORATORY
119
Skill Box 4.11 / Blood Typing Procedure
Results
Canine
Follow the manufacturer’s directions • Add the diluent to each well to rehydrate the lyophilized material. Add 1 drop of the controls and purple top blood sample to appropriate wells. Mix each well and then rock the test card. Prop the card up at a 10° angle to allow the blood to fall to the bottom of the well. Note the wells where gross agglutination has occurred.
• If the patient shows gross agglutination in the well marked “Patient Test” and there is no autoagglutination, the patient is DEA 1.1 positive. If no agglutination is visible in the well marked “Patient Test,” the patient is DEA 1.1 negative. • If the patient is very anemic, the pattern of agglutination may be in the form of discrete, small aggregations, each like the head of a large pin, rather than gross agglutination. • Any fine, granular appearance developing after 2 minutes should be disregarded in determining results.
Feline
Follow the manufacturer’s directions • Add the diluent to each well to rehydrate the lyophilized material. Add 1 drop of the controls and purple top blood sample to appropriate wells. Mix each well and then rock the test card. Prop the card up at a 10% angle to allow the blood to fall to the bottom of the well. Note the wells where gross agglutination has occurred.
• If the assay was run correctly, visible agglutination should have occurred in at least 1 of the wells marked “Patient Test.” • If the patient sample shows agglutination in the well marked “Type A,” the cat tested has blood group A. If the patient sample shows agglutination in the well marked “Type B,” the cat tested has blood group B. If the patient sample shows agglutination in both patient wells, the cat tested has blood group AB. • If the patient is very anemic, the pattern of agglutination may be in the form of discrete, small aggregations, each like the head of a large pin, rather than gross agglutination. • Any fine, granular appearance developing after 2 minutes should be disregarded in determining results.
4
IMMUNOLOGY AND SEROLOGY TESTS Table 4.17 / Immunology and Serology Tests
Immunology and serology tests are specialized laboratory tests used to obtain information regarding the functioning status of the immune system and the diagnostic identification of antibodies in the serum, respectively. They can be valuable tools in the diagnostics of infectious diseases and autoimmune diseases when used in conjunction with other diagnostics. Due to the complexity of these tests, reference laboratories are required for their processing. Each laboratory has varying requirements for sample submission and should be referred to for more information. See Blood Chemistries for Blood Collection, Handling, Storage, and Transport Tips, page 74. Test
Technique
Associated Conditions
Coombs’ Test (Direct Antiglobulin Test)
A species-specific Coombs’ reagent is added to the blood. RBCs that are coated with antibodies will cause agglutination with the added reagent.
• Autoimmune hemolytic anemia (AIHA)
Enzyme-Linked Immunosorbent Assay (ELISA)
A tray with antibody coated wells is filled with the sample. If any antigen is present, it will bind with the antibody in the coated wells. A second enzyme-tagged antibody is added and binds to the antibody–antigen complex. A substrate that reacts with the enzyme is then added and results in a color change if antigen is present. The color change is proportional to the amount of antigen in the sample. The antigen may be actual viral/bacterial material (e.g., FeLV) or the host’s antibody vs. the pathogen (e.g., FIV).
• Heartworm, canine parvovirus, FIV, FIP, FeLV, toxoplasmosis, progesterone, atopy, nonregenerative anemia, allergies, and Lyme disease
120
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.17 / Immunology and Serology Tests (Continued) Test
Technique
Associated Conditions
Immunodiffusion
Viral antigen and an antibody are placed into separate wells in agar. They diffuse through the agar and form a visible band of precipitation if any viral antigen is present.
• Viral and fungal pathogens
Immunofluorescence Assay (IFA) Direct IFA
An antibody for a specific virus is tagged with a fluorescent dye and combined with the sample. If the specific virus is present, the antibody will bind and appear fluorescent during microscopic examination.
• Ehrlichiosis and Rocky Mountain spotted fever
Indirect IFA
An antiviral antibody (immunoglobulin) that was produced in an animal (e.g., rabbit) and a fluorescent tagged antirabbit immunoglobulin are combined with a sample. The second antibody combines with the first antibody, which binds to any viral antigen present in the sample. The antibody-antibody-antigen complex will fluoresce during microscopic examination.
• Cryptosporidium, FIV, Giardia, and systemic lupus erythematosus
Immunoperoxidase Test (PAP)
A specific antibody is bound to the cell or tissue sample. The detection of specific antibody can be done through 3 different methods, all consisting of tagging the antibody and eventually generating a colored product.
• CDV, distemper, FeLV, FIP, Neospora, Toxoplasma
Intradermal Tests
Allergenic extracts are injected intradermal and observed for changes. A wheal formation indicates the presence of antibodies and an allergic reaction.
• Allergies; flea allergy
Latex Agglutination
Small, spherical antibody (or antigen)–coated latex particles are suspended in water. The sample is added, and any antibody–antigen complex will undergo agglutination. The water will be milky or contain clumps of latex particles.
• Canine rheumatoid factor, brucellosis, and DIC antigen complexes that form will cause agglutination.
Polymerase Chain Reaction (PCR)
A specific nucleic acid primer reacts with a portion of the genome from the microorganism in question. The combination is amplified to produce many fragments of the DNA sequence. Electrophoresis is then used to detect the combination and to measure its size and migration pattern. • Often used to confirm results of other tests
• Herpesvirus, FeLV, FIV, coronavirus, Bartonella, Ehrlichia, etc.
Radioimmunoassay
An antibody for a specific virus or antigen is tagged with a radioactive element (e.g., iodine) and combined with the sample. A gamma counter is used to identify the antibody–antigen complex.
• Thyroid diseases
Serum Antinuclear Antibody (ANA)
Serum is serially diluted and added to a prepared slide with 10 areas of monolayer cell lines. If antinuclear antibodies are present, they bind to the nucleus and can be detected through immunofluorescence or immunoperoxidase techniques.
• Glomerulonephritis, immune mediated thrombocytopenia, polyarthritis, polymyositis, systemic lupus erythematosus
CHAPTER 4 / LABORATORY
4
121
Table 4.17 / Immunology and Serology Tests (Continued) Test
Technique
Associated Conditions
Serum Rheumatoid Factor
Latex beads are coated with an antigen which will bind to the rheumatoid factor antibody found in serum or synovial fluid of affected animals
• Polyarthritis of erosive/lytic type
Western Blot (Immunoblot)
Antigens are separated by electrophoresis and blotted to nitrocellulose sheets. The sheets are incubated with labeled antibodies and then observed for bound antibodies by using enzymatic or radioactive methods. • Used to confirm ELISA results
• FIV
4
MICROBIOLOGY A small animal laboratory should only be responsible for presumptive identification of bacteria. Further tests for a definitive diagnosis should be sent to a referral laboratory, where they have access to a greater number of techniques and equipment. Skill Box 4.12 outlines basic guidelines for collection of the sample followed through to the preliminary evaluation and interpretation of bacterial growth. Books dedicated to the subject of microbiology should be consulted for further discussion of alternative tests and techniques.
122
SECTION THREE: DIAGNOSTIC SKILLS
Microbiology Collection, Handling, Storage, and Transport Tips Collection • Collect sample aseptically. • Collect an adequate amount of the samples to allow for complete examination. • Samples should be attained before starting antibiotic therapy.
Skill Box 4.12 / Collection Techniques Site
Collection
Abortion
• Entire fetus or multiple specimens from a range of body parts should be obtained as soon as possible after the animal has died.
Abscess/Wound
• Unruptured: sterile syringe with wide-bore needle • Ruptured: swab near the edge of the wound and take scrapings from the inside wall of the abscess.
Anaerobic bacteria
• Sterile syringe with fine-gauge needle • Expel all air out of syringe before obtaining sample.
Blood
• 5–10 mL of blood from at least 2 different sites and immediately placed in separate blood culture bottles. Collect multiple samples throughout the day.
Ear
• Swabs of both ears canals and middle ear if needed
Eye
• Corneal scrapings, swab of the conjunctival sac, or swab of lacrimal secretions
Fecal
• 1 g freshly voided or rectal examination–obtained feces • Clean anus before collection to avoid contamination with anal skin microflora.
Genital
• Swab of vulvar mucosa
Leptospirosis
• 20 mL of midstream urine
Urine
• 5 mL urine via a catheter or cystocentesis
4
Note: See Cytology, Skill Box 4.3, page 88, and Urinalysis, page 150, and Skill Box 12.8, page 434, and Skill Box 12.10, page 435, sections for specimen collection techniques.
Handling • Samples should be handled carefully to avoid human contamination. • Separate multiple samples to avoid cross contamination. • Maintain a clean environment in which the laboratory tests are run. • Wood-shafted and cotton-tipped swabs should not be used with samples suspected of Chlamydia.
Storage • Swabbed samples need to be placed in a transport media if they are not immediately inoculated. • Agar plates must be stored inverted to prevent condensation buildup on the surface of the agar.
• Sample should be clearly marked with patient’s name, number, origin of the sample, time of collection and whether it was refrigerated.
CHAPTER 4 / LABORATORY
123
Table 4.18 / Specimen Storage
4
Test
Specimen
Storage
Acid-Fast Stain
Tissue
• Red top tube
Slides
• Slide holder
Anaerobic Bacteria
Fluid
• Sterile syringe with fine-gauge needle in a rubber stopper secured with tape • Culturette swab
Blood
Blood (5–10 mL)
• Blood culture bottle (commercially prepared)
Chlamydia
Tissue or dacron swab
• Chlamydia transport media
Culture and Sensitivity (bacterial)
Swab
• Culturette swab or Transwab
Fluid
• Red top tube
Tissue
• Enteric transport media or red top tube
Fecal Culture
Feces
• • • •
Fungal culture
Hair, scrapings or swab (yeast only)
• Red top tube • Culturette swab • Transwab
Fluid
• Screw-cap tube
Slides
• Slide holder
Swab
• Culturette swab • Transwab
Fluid or tissue
• Red top tube
Swab
• Culturette swab • Transwab
Fluid
• Red top tube
Tissue
• Enteric transport medium • Red top tube
Plate with growth
• Culture plate
KOH Preparation
Scrapings or clipped hair or nails
• Red top tube
Mycoplasma
Fluid and tissue
• Mycoplasma transport media • Culturette swab • Note: Mycoplasma may adhere to swabs, giving negative results
Sensitivity Only
Plate with growth
• Culture plate
Urine
Fluid
• Culture needs to be set up within 2 hours to avoid overgrowth of insignificant bacteria or refrigerated for no longer than 18–24 hours
Gram Stain
Identification Only
124
SECTION THREE: DIAGNOSTIC SKILLS
Culturette swab Enteric transport media Red top tube Clean, dry container
Transport • Tape the lids and caps of inoculated tubes and plates before shipment.
• Empty the water that has accumulated on the lid to avoid it dropping onto the agar plate and mixing the colonies of bacteria.
• Tissue submitted for fungal cultures should be frozen and marked “Caution” because of its zoonotic potential.
4 Table 4.19 / Most Commonly Used Culture Media
Numerous types of culture media are available; however, most veterinary clinics use only a few. The more extensive cultures are sent to reference laboratories for growth and interpretation.
a
Medium
Preparation
Uses
Interpretations
Blood Agar
• Trypticase soy agar • Sheep’s blood
• Enriched media that supports the growth of most bacteria
• Observe for growth, rate of growth, morphology, and hemolytic patterns: • Gamma: no lysis or color change • Alpha: incomplete lysis of RBCs, greenish halo around the bacterial growth • Beta: lysis of RBCs, clear halo around bacterial growth
Brain–Heart Infusion Broth
• Calf’s brain • Beef’s heart • Dextrose
• Enrichment media to increase the number of organisms
• Subcultures are made onto agar plates after incubation of 24 hours
Dermatophyte Test Medium
• • • •
• Detection of Microsporum canis and Microsporum gypseum
• Observable growth with a simultaneous red color change in 14–21 days
MacConkey Agar
• Crystal violet • Bile acids • pH indicator
• Selects for gram-negative and Enterobacteriaceae • Helps differentiate bacteria
• Pink to red colonies: lactose fermenters • Colorless to light yellow colonies: nonlactose fermenters
Thioglycollate Brotha
• Thioglycollic acid • Yeast extract • Dextrose
• Supports growth of anaerobic and facultative anaerobic bacteria
• Turbid or streaks if turbidity is not disturbed
Sabouraud’s dextrose agar Antibiotic Cycloheximide Phenol red
Thioglycollate broth should not be used as the only source of collection media.
CHAPTER 4 / LABORATORY
125
Skill Box 4.13 / Culture Media Inoculation and Incubation
General Points for Proper Technique • Keep culture plates closed unless inoculating or transferring specimens. • Do not set down the tube cap of medium to avoid contamination. • Flame the neck of the tube before and after transferring specimens. 4
b. Stab only: stab the wire through the agar and then slowly withdraw it along the same stab path. c. Butt and Slant: combine the above 2 methods, starting with the stab method and finishing with the slant method. 4. Remove the wire and reflame.
• When flaming the inoculation loop or wire, place the end closest to the handle in the hottest portion of the flame, the blue portion, and then move toward the loop to prevent splattering.
Broth Inoculation
• When transferring the sample to the agar, use a gentle touch to avoid tearing the surface of the agar.
2. Dip the wire into the specimen to be cultured.
Plate Inoculation 1. Mentally divide the agar plate into 4 quadrants. 2. Flame and cool the inoculation loop.
1. Flame and cool the inoculation loop or wire. 3. Insert the loop or wire into the broth just below the surface and touch the side of the tube. 4. Remove the loop or wire and reflame. Tip: Work with 2 inoculation loops; one can be cooling while the other is in use.
3. Dip the loop into the specimen to be cultured. 4. Streak the specimen in quadrant A.
Incubation of Cultures
5. Repeat steps 2–4 while slightly overlapping the previous quadrant and then moving around to each quadrant. Be sure to only overlap the previous quadrant’s streaks 1–2 times to prevent excessive numbers of bacteria in 1 area. Quadrant D is expected to grow isolated colonies.
• Maintain incubator temperature at 98.6° F and humidity of 70%.
7. Remove the loop and reflame.
Slant Inoculation 1. Flame and cool the inoculation wire. 2. Dip the wire into the specimen to be cultured. 3. Types of slant inoculations: a. Slant only: make a “S” shape across the slant with the tip of the inoculation wire.
126
SECTION THREE: DIAGNOSTIC SKILLS
• Plates should be placed upside down to prevent the accumulation of condensation on the surface of the agar plate. • Tube media screw caps should be left loose during incubation. • Cultures should be incubated for 48 hours and checked after 24 hours. • To ↑ the level of carbon dioxide, place the plates upside down in a glass jar with a candle on top. Light the candle and place a tightly fitting lid on top. Allow the candle to burn itself out, which will decrease the amount of oxygen and increase the amount of carbon dioxide. This does not create an anaerobic environment. • Place a bowl of water in the bottom of the incubator to maintain a high humidity.
Evaluation of Culture Growth
c. Acid-fast stain d. Negative stain
1. Identify the source of the sample.
5. Differentiation tests
2. Growth Significant
Not Significant
• Only 1–2 types of bacterial growth • >3 Types of scant bacterial growth • Circular colonies with clear edges, • Large, irregular, and granular smooth, convex, or rounded colonies and spreading edges • Opaque to gray
• Heavily pigmented
3. Changes to the media a. Hemolytic pattern b. Color change c. Odor 4. Microscopic evaluation
a. Catalase test i. Differentiates between catalase-positive (e.g., staphylococci) and catalase-negative (e.g., streptococci, enterococci) bacteria ii. Positive test: formation of bubbles b. Oxidase test i. Differentiates between oxidase-positive (e.g., Bordatella bronchiseptica, Pseudomonas aeruginosa) and oxidase-negative (e.g., enterobacter species, escherichia species) bacteria ii. Positive test: purple color change c. Indole test i. Differentiates between indole-positive (e.g., Escherichia coli, Proteus vulgaris) and indole-negative (e.g., Streptococcus pyogenes, Salmonella typhimurium) bacteria ii. Positive test: red color on the surface of the tube
a. Simple stain b. Gram stain
Skill Box 4.14 / Staining Solutions and Procedures The first step to identification of microbiology slides is to properly prepare the slide. All staining of slides should be done on an air-dried heat-fixed slide. To heat-fix a slide, make several rapid passes of the slide over a flame source (e.g., matches, lighter, or Bunsen burner). Once the slide has been immersed in staining solution, it should be agitated to allow fresh stain to remain in contact with its surface. Staining Technique
Uses
Preparation
Procedure
Interpretation
Diff-Quik (modified Wright’s stain)
General cytology and demonstration of bacteria
• Fixative: methanol, triarylmethane dye • Eosinophilic: xanthene dye • Basophilic: thiazine dye mixture
1. Dip the prepared slide 5 times slowly in methanol fixative. 2. Repeat above with eosinophilic stain and basophilic stain. 3. Rinse with water. 4. Air dry.
• Clear differentiation of cellular morphology • Staining ranges from pale pink to dark purple.
Giemsa Stain
Detection of spirochetes and rickettsiae
• Fixative: methanol • Giemsa powder • Glycerol
1. Fix the prepared slide in absolute methanol for 3–5 minutes and air dry. 2. Place the slide in diluted stain; 0–30 minutes. 3. Rinse with water and air dry.
• Purplish-blue stained bacteria
Differential Stains
CHAPTER 4 / LABORATORY
127
4
Skill Box 4.14 / Staining Solutions and Procedures (Continued) Staining Technique
Uses
Preparation
Procedure
Interpretation
Gram Stain
Distinguish between gram-positive and gram-negative bacteria based on their cell wall structure
• Primary stain: crystal violet • Mordant: Gram’s iodine • Decolorizer: alcohol • Counterstain: dilute carbol fuchsin or safranin
1. Flood the prepared slide with crystal violet; 30–60 seconds. 2. Rinse with water for 5 seconds. 3. Flood the slide with ram’s iodine; 30–60 seconds. 4. Rinse with water for 5 seconds. 5. Decolorize until the purple color is gone; ∼10 seconds. 6. Rinse with water for 5 seconds. 7. Flood the slide with dilute carbol fuchsin; 30–60 seconds. 8. Rinse with water for 5 seconds. 9. Air dry or blot between towels.
• Purple-stained bacteria are gram-positive. • Red-stained bacteria are gram-negative.
Lactophenol cotton blue
Detection of fungi
• Lactophenol cotton blue
Same as simple stain
• Visualization of hyphae, septae, and structure of spores
Ziehl/Neelson or Acid-Fast Stain
Detection of Mycobacterium spp. and Nocardia
• Carbol fuchsin • Acid alcohol • Methylene blue
1. Flood the prepared slide with carbol fuchsin and heat over a flame until it steams and then let it sit; 5 minutes. 2. Rinse with water. 3. Decolorize with acid alcohol until the red color is gone; 1–2 minutes. 4. Rinse with water. 5. Counterstain with methylene blue; 2 minutes. 6. Rinse with water and dry over low heat.
• Acid-fast bacteria stain red. • Non–acid-fast bacteria stain blue.
Modified Ziehl/ Neelson Stain With Brilliant Green
Detection of Mycobacterium spp. and Nocardia
• Carbol fuchsin • Acid alcohol • Brilliant green
1. Flood the prepared slide with carbol fuchsin; 3 minutes then heat. 2. Rinse with water. 3. Decolorize with acid-alcohol; 3 minutes. 4. Rinse with water. 5. Counterstain with brilliant green; 3 minutes. 6. Rinse and dry.
• Acid-fast bacteria stain red. • Non–acid-fast bacteria stain green.
Modified Ziehl/ Neelson Stain With Methylene Blue
Detection of Brucella, Nocardia, and Chlamydia
• Carbol fuchsin • Acetic acid • 0.5% Methylene blue
1. Flood the prepared slide with dilute carbol fuchsin; 10 minutes. 2. Rinse with water. 3. Decolorize with acetic acid; 20–30 seconds. 4. Rinse with water. 5. Counterstain with methylene blue; 2 minutes. 6. Rinse and dry.
• Brucella and Chlamydia stain bright red and in clumps.
4
128
SECTION THREE: DIAGNOSTIC SKILLS
Skill Box 4.14 / Staining Solutions and Procedures (Continued) Staining Technique
Uses
Preparation
Procedure
Interpretation
Detection of capsules and difficult to stain bacteria (e.g., spirilli)
A negatively charged chromogen stain • India ink • Nigrosin
1. Prepare an air-dried slide. 2. Apply 1–2 drops of stain to prepared slide. 3. Apply coverslip and examine as a wet mount.
• Capsules appear clear and unstained, surrounded by dark particles.
Demonstration of bacteria and general morphology and shape arrangement
A positively charge chromogen stain • Carbol fuschin • Crystal violet • Methylene blue • New methylene blue • Safranin
Technique #1 1. Place 1 drop on the coverslip and apply to prepared slide. 2. Place a paper towel over the coverslip and apply gentle pressure to absorb excess stain. Technique #2 1. Place 1 drop of stain next to the coverslip on a prepared slide and allow the stain to leak under the coverslip. 2. Place a paper towel over the coverslip and apply gentle pressure to absorb excess stain.
Simple Stains Negative Staining
Simple Stain
4 • Visualization of cell shape and arrangement • Reticulocytes, Heinz bodies, urine sediments, and oily preparations (e.g., suspected lipomas using new methylene blue)
Note: Stains should be periodically filtered, using filter paper to remove any precipitate that may have formed. Note: Rinse slides on the reverse side to avoid disturbing the sample. Note: If a slide is overstained with Diff-Quik, place the slide in methanol for several minutes to destain and then restain. If the slide is understained with Diff-Quik, restain the slide with the appropriate stain color.
CHAPTER 4 / LABORATORY
129
Skill Box 4.15 / Staining Problems To avoid staining problems, use fresh clean stains and slides, do not touch the surface of the slide, and immediately stain slides after air-drying. Problem
Solution
Excessive Staining
• • • •
↓ Staining time Rinse adequately between stains and after staining. Prepare a thinner sample on the slide. Allow slide to dry before applying coverslip.
Weak Staining
• • • •
↑ Staining time Change stains. Stain slides sooner after air-drying. Keep the caps tightly placed on the stain containers to prevent evaporation.
Uneven Staining
• • • • •
Use only clean and dry slides. Do not touch the sample area of the slides before or after preparation. Place slides at an angle for drying to prevent liquid from drying onto the slide. Inadequate mixing of stains. Keep the caps tightly placed on the stain containers to prevent contamination and evaporation.
Slide Precipitate
• • • • •
Rinse adequately between stains and after staining (refer to Skill Box 4.14), page 127. Use clean slides. Do not allow stains to dry onto slide while staining. Change or filter stains periodically and regularly. Keep the caps tightly placed on the stain containers to prevent contamination and evaporation.
4
Table 4.20 / Bacteria Identification Organism
General Information
Associated Conditions
Microscopic
Culture
Bordetella bronchiseptica
• Gram-negative
• Upper respiratory infection and pneumonia
• Small rods
• BA: small, circular, dewdrop shape with +/− beta-hemolysis; slow grower • MC: weak growth
Borrelia burgdorferi
• Spirochete
• Lyme disease
• Refer to reference laboratory for identification.
• Refer to reference laboratory for identification
Brucella canis
• Gram-negative
• Infertility, abortion, and diskospondylitis
• Small, red coccobacillus in clumps
• BA: round, smooth, glistening, and translucent
Campylobacter spp. • Color Plate 4.10, CP-5
• Gram-negative • Does not survive outside the host ≥3 hours
• Gastroenteritis, infertility, and abortion
• Tiny, curved, gram-negative rods (not tightly spiraled) • Two attached together as a “seagull” or W shape • “Swarm of bees,” rapid and darting motility
• Refer to reference laboratory for identification.
130
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.20 / Bacteria Identification (Continued) Organism
General Information
Associated Conditions
Microscopic
Culture
Chlamydia
• Resemble gram-negative • Obligate, intracellular parasite
• Conjunctivitis and pneumonia
• Small, red, pleomorphic coccobacilli in clumps
• N/A
Clostridium • Color Plate 4.8, CP-4
• Gram-positive • Obligate anaerobes • Resistant to most disinfectants, requires 20 minutes of boiling or 121º C in an autoclave for 20 minutes
• Gastroenteritis, otitis and tetanus
• Large, spore-forming rods with rounded ends • “Safety pin” appearance with a swollen, clear center and dark staining ends
• BA: 1–3 mm in diameter, round to slightly irregular, raised, granular, transparent with a double zone of hemolysis • MC: no growth
Escherichia coli
• Gram-negative • Facultative anaerobes • Readily killed by disinfectants, sunlight, and desiccation
• Genital tract infection, musculoskeletal infection, pneumonia, enteritis, abscesses, urinary tract infection, and sepsis
• Small, non–spore-forming rods
• BA: large, smooth, gray, mucoid colonies with +/− hemolysis • MC: red growth, lactose fermentation, hemolytic pattern
Fusobacterium
• Gram-negative • Obligate anaerobes
• Pleuritis and abscesses
• Slender, long rods with pointed ends and long beaded filaments
• BA: small, smooth, convex and whitish-yellow in color colonies with a narrow zone of alpha- or beta-hemolysis
Mycobacterium tuberculosis
• Gram-positive
• Pulmonary nodules (dogs) and gastrointestinal problems (cats)
• Small, straight or slightly curved acid-fast rods, singly or in clumps
• Refer to a reference laboratory for identification
Mycoplasma spp.
• Gram-positive • Lack a cell wall; therefore do not stain adequately enough to evaluate • Readily killed by common disinfectants
• Genital tract infection, arthritis, conjunctivitis (cats) and pneumonia
• Small, coccobacillus-like, non– spore-forming, no cell wall and +/− pleomorphic
• Refer to a reference laboratory for identification
Nocardia spp.
• Gram-positive aerobes • Saprophyte in the soil • Partially acid-fast
• Pleuritis and abscesses in multiple tissues
• Branching, filamentous rods or coccobacilli
• BA: irregularly folded, raised, smooth to rough with a dry granular texture; slow grower • MC: no growth
Pasteurella spp.
• Gram-negative • Facultative anaerobes • Readily killed by most common disinfectants
• Conjunctivitis, genital tract infection, upper respiratory infection, pneumonia, pleuritis, abscesses and urinary tract infections
• Small, non–spore-forming coccobacilli or rods
• BA: round, smooth, gray colonies with +/− hemolysis • MC: no growth
Proteus spp.
• Gram-negative • Facultative anaerobes • Readily killed by common disinfectants, sunlight and dessication
• Cystitis, urinary tract infections, diarrhea, wounds and otitis
• Medium-sized non–spore-forming rods
• BA: large, smooth, gray, swarming, mucoid colonies with +/− hemolysis • MC: colorless growth that may spread
CHAPTER 4 / LABORATORY
131
4
Table 4.20 / Bacteria Identification (Continued)
4
Organism
General Information
Associated Conditions
Microscopic
Culture
Pseudomonas spp.
• Gram-negative • Killed by most common disinfectants, ↑ resistance to high dilutions of quaternary ammonium compounds and phenolic compounds
• Conjunctivitis, otitis musculoskeletal infection, abscesses, and urinary tract infections
• Small rods
• BA: 3–5 mm in diameter, irregular, spreading, translucent, bluish-metallic sheen, betahemolysis and grape-like odor • MC: yellow-green pigmented growth with a grape-like odor
Rickettsia
• Resemble gram-negative • Obligate, intracellular parasite • Smallest organism able to reproduce on its own • Can not live outside the host
• Rocky Mountain spotted fever, salmon poisoning disease, Ehrlichia and Hemobartonella
• Small, pleomorphic coccobacilli
• N/A
Salmonella
• Gram-negative • Readily killed by common disinfectants, sunlight, and dessication
• Gastroenteritis, abortion, hepatitis, and septicemia
• Small, non–spore forming rods
• BA: large, smooth, gray, mucoid colonies with +/− hemolysis • MC: colorless growth
Spirochetes • Color Plate 4.11, CP-5
• Gram- negative
• Lyme disease, leptospirosis,
• Stiff corkscrew helical rods with tight spirals • Corkscrewing motility
• N/A
Staphylococcus aureus/intermedius
• Gram-positive • Stable, surviving for months when dried in pus or other body fluids • ↑ Resistance to common disinfectants
• Conjunctivitis, genital tract infection, mastitis, pyoderma, otitis, osteomyelitis, musculoskeletal infection, pneumonia, abscesses and urinary tract infections
• Cocci, often in grape-like clusters, non–spore forming, +/− capsules
• BA: 4 mm in diameter, round, smooth, glistening with a double zone of hemolysis and gold pigmentation • MC: no growth
Streptococcus spp.
• Gram-positive • Facultative anaerobes • Remain living for weeks to months after being expelled from the body • Readily killed by common disinfectants
• Conjunctivitis, genital tract infection, otitis, pneumonia, abscesses, and urinary tract infections
• Cocci, +/− singly or in chains of varying lengths and non–spore forming
• BA: 1 mm in diameter, round, smooth, glistening and resemble dewdrops with beta-hemolysis (Alpha and gamma-hemolysis are typically normal flora) • MC: no growth
Note: BA = blood agar, MC = MacConkey agar.
132
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.21 / Fungi Identification Organism
Associated Conditions
Microscopic
Culture
Aspergillus
• Nasal infections • Common laboratory contaminant
• Preparation: clear cellophane tape with lactophenol blue or scrapings mixed with 10% sodium hydroxide • Identification: short pieces of thick, septate hyphae
• • • •
Blastomyces —Dermatitidis
• Pulmonary nodules, internal ulcers • Abscesses
• Preparation: wet mount with 20% KOH • Identification: large, oval or spherical, thick-walled with a single bud that is connected to the mother cell by a wide base
• Refer to reference laboratory for confirmation by culture.
Candida spp. • Color Plate 4.12
• Mycotic stomatitis (canine) • Enteritis (kittens)
• Preparation: scrapings of lesions made as wet mounts with 20% KOH, India ink, or lactophenol cotton blue • Identification: thin-walled (no capsule) oval budding yeast cells and +/− pseudohyphae
• • • •
Coccidiodes immitis
• Systemic and bone infections
• Preparation: unstained wet mounts • Identification: thick-walled sporangia
• Caution: Because of its zoonotic potential, refer to a reference laboratory for culture.
Cryptococcus —neoformans
• Paranasal and CNS infections
• Preparation: A small amount of discharge is mixed on a slide with water and India ink in a 1 : 2 ratio • Identification: budding yeast-like cells with large capsules
• • • •
Histoplasma capsulatum
• Systemic, pulmonary and gastrointestinal infections • Soil borne
• Preparation: Giemsa or Wright’s method • Identification: small oval cells surrounded by a halo seen intracellularly in monocytic cells
• Caution: Because of its zoonotic potential, refer to a reference laboratory for culture.
Malassezia –pachydermatis • Color Plate 4.34, CP-11
• Chronic otitis externa (canine) • Pyoderma
• Preparation: wet mounts with 10% NaOH • Identification: oval or bottle-shaped, small budding cells
• • • •
Microsporum canis
• Dermatophytosis
• Preparation: place a few pieces of plucked hair, scales, or crust from skin scraping, 20% KOH, and black India ink on a slide, and apply a coverslip with gentle pressure • Gently heat the slide, and let it sit for 10–15 minutes. • Identification: spores and chains of highly refractile arthrospores
• Medium: dermatophyte test medium (DTM, modified Sabouraud dextrose agar) • Additive: Phenol red, pH indicator • Incubation: 2 weeks at room temperature • Identification: flat colony, white surface and silky in center, red color change to agar
Medium: Blood agar or Sabouraud dextrose agar Additive: none Incubation: 48 hours at 77–98.6º F Identification: flat, white, and floccose, then turns green to dark green and powdery
4
Medium: Blood agar or Sabouraud dextrose agar Additive: none Incubation: 2 days at 77–98.6º F Identification: creamy, smooth colonies with yeastlike odor
Medium: Blood agar or Sabouraud dextrose agar Additive: none Incubation: 14 days at 95–98.6º F Identification: wrinkled, whitish granular colonies to mucoid, cream to brown colonies
Medium: Blood agar or Sabouraud dextrose agar Additive: Olive or coconut oil Incubation: 14 days at 77º F in a CO2 incubator Identification: greenish pigmentation
CHAPTER 4 / LABORATORY
133
Handling
PARASITOLOGY Fecal analysis is 1 of the most common laboratory tests run in small animal clinics. The skills required for preparing and reading these tests are minimal and are expected of every technician. Regardless of their simplicity, the result of these tests and subsequent treatment often leads to a full recovery by the patient.
• Samples should be handled carefully to avoid human contamination. • Maintain a clean environment in which to run the laboratory tests. • Maintain clear records as to the procedure performed. Storage • Fecal samples can be stored in whirl pak bags, small plastic sandwich bags, plastic containers, or disposable laboratory gloves turned inside out.
Fecal Collection, Handling, Storage, and Transport Tips 4 Collection
• Samples can be stored indefinitely in 10% formalin (1 part feces to 9 parts formalin), with minor limitations.
• Sample must be as fresh as possible because of rapid development of eggs once passed. • Owner should witness animal defecating to ensure freshness and observe for any straining, fresh blood, or other problems.
• Samples should not be stored by freezing, 70% ethyl alcohol, or 100% methyl alcohol. Transport
• Fresh samples not to be examined in 2 hours should be refrigerated for no longer than 24 hours.
• Sample should be cooled to 39.2º F in the refrigerator and then packed on ice or cold packs for 24–48 hours.
• Submit the amount equal to the size of an adult male’s thumb, at least 10 g.
• Place important papers in a separate plastic bag in case of sample fluid leakage.
• Sample should be clearly marked with patient’s name, number, time of collection, and whether it was refrigerated.
Skill Box 4.16 / Endoparasite Examination Methods Method
Uses
Technique
Comments
Gross Examination
• Consistency • Color • Blood, mucus, or adult parasites
• Visualize the feces or vomitus.
• Reveals conditions (e.g., blood) not seen in other methods
Direct Smear: Wet Prep
• Protozoa (e.g., Giardia) • Parasite burden • Bacteria (e.g., spirochetes, Cryptosporidium, Campylobacter)
1. Place a drop of saline or water with an equal amount of feces on a slide. Thoroughly mix the feces and water and smear to make a thin film over slide. 2. Remove any large pieces of feces and add a coverslip to examine. 3. Examine under ×10 for parasite eggs, ×40 for protozoal organisms, and ×100 for bacteria. • Stain can be added to the side of the coverslip for clearer identification.
• No egg distortion • Not a concentrated technique (small sample size) leading to low numbers • Motility can be a helpful diagnostic aid
134
SECTION THREE: DIAGNOSTIC SKILLS
Skill Box 4.16 / Endoparasite Examination Methods (Continued) Method
Uses
Technique
Comments
Direct Smear: Dry Prep
• Protozoa (e.g., Giardia) • Parasite burden • Bacteria (e.g., spirochetes, Cryptosporidium, Campylobacter)
1. Place a small amount of feces on a slide and thinly spread out using an applicator stick. 2. Heat fix and stain with Diff-Quik. 3. Examine under ×10 for parasite eggs, ×40 for protozoal organisms, and ×100 for bacteria.
• No egg distortion • Not a concentrated technique (small sample size) leading to low numbers • Not able to judge motility of parasites
Standard or Simple: Flotation
• Most parasites • Parasite burden
1. Place 1–2 g feces in a suitable container (e.g., paper cup) and add flotation solution. 2. Mix the contents thoroughly with a tongue depressor and strain through a tea strainer or cheesecloth into a second container. 3. Pour this mixture into a test tube and add more flotation solution until a meniscus is formed. 4. Place a glass coverslip over the meniscus for 10–15 minutes. 5. The coverslip is then removed, placed on a slide, and examined.
• Commercial fecal flotation kits available • Less efficiently recovers eggs than the centrifugal flotation method • Misses larvae that settle because of gravity
Centrifugal Flotation
• Most parasites • Parasite burden
1. Mix 1 tsp feces in a paper cup with enough water or flotation solution to make a semisolid suspension. 2. Place a tea strainer or cheesecloth over a second paper cup, and empty the contents on top of it. 3. Push the liquid through the strainer with the tongue depressor and then discard the solid waste. 4. Pour the strained mixture into a 15 mL centrifuge tube. 5. Fill the tube with flotation solution to form a slight positive meniscus; do not overfill the tube. 6. Place a coverslip on top of the tube. 7. Put the tube in a balanced centrifuge and spin at 1,300 RPM for 5 minutes. 8. Remove the tube and let it stand for 10 minutes. 9. Lift the coverslip directly upward and place on a glass microscope slide.
• More efficiently recovers eggs than the standard flotation method • Requires a centrifuge with a horizontal rotor and the ability to hold 15-mL tubes • Misses larvae that settle because of gravity
Baermann Technique
• Nematode larvae
1. Fill the funnel with warmed water or physiologic saline (86º F) to cover the wire screen. 2. Spread a piece of cheesecloth or gauze square over the wire screen in the funnel. 3. Place 5–15 g feces, soil, or tissue on the cheesecloth and fold any excess cloth over the sample. Make sure that the warm water covers the sample. 4. Leave the sample undisturbed overnight (>8 hours). 5. Place a glass slide under the cut-off pipette and allow 1 drop of the liquid to fall onto the slide. 6. Apply a coverslip and examine. If the slide is negative, repeat several times for assurance.
• Efficient recovery of larvae
4
CHAPTER 4 / LABORATORY
135
Skill Box 4.16 / Endoparasite Examination Methods (Continued) Method
Uses
Technique
Comments
Fecal Culture
• Hookworm larvae • To distinguish between parasites that have similar-appearing eggs and cysts
1. Place feces in a glass jar rinsed with 0.1% sodium carbonate solution or on a piece of filter paper in a Petri dish. 2. Cover the container and place in a dark area for 7–10 days. There should be enough moisture in the container to produce condensation on the sides; if not, add a small amount of water. 3. After 7–10 days, rinse the container with a small amount of water, collect liquid, and centrifuge. 4. Examine the sediment with a microscope.
• Guaranteed identification
Wet Mount/Fecal Culture • InPouchTM
• Tritrichomonas foetus
Following the manufacturer’s instructions: Remove the pouch from the bag and confirm that ∼1 mL of liquid is in the upper chamber. Open the pouch and insert an applicator stick with 0.03 g of fresh feces or a coated swab into the liquid of the upper chamber. Remove the feces by gently rubbing the stick between thumb and forefinger and walls of chamber. Close the pouch and label. Wet Mount Stand the pouch upright for 15 minutes to concentrate T. foetus at the bottom of the pouch. Place the viewing clip horizontally across the pouch and then lay the pouch across the microscope and examine, paying special attention to the edges. Fecal Culture Squeeze all liquid into the lower pouch, close pouch, and incubate for 18–24 hours. Mix the pouch up and down against an edge 3–4 times. Place the viewing clip horizontally across the pouch and then lay the pouch across the microscope and examine.
• The addition of excess fecal material will make the medium too cloudy to view. • If no T. foetus is seen, evaluate daily for 2–4 days and up to every other day for 12 days. • 1–10 organisms is sufficient to result in a presumptive positive test. • Fecal culture is typically more accurate than the wet mount.
4
Note: A dried tapeworm proglottid may be rehydrated by soaking in water or physiologic saline for 1–4 hours. Note: Additional fecal cytology information can be found at Skill Box 4.7 Fecal Cytology, page 95.
136
SECTION THREE: DIAGNOSTIC SKILLS
Skill Box 4.17 / Fecal Flotation Solutions Fecal flotation solutions are used to assist in the discovery of parasitic eggs in fecal material. The solution chosen must have a specific gravity that allows parasite eggs to float and the bulk of fecal material to sink. Because water has a specific gravity just slightly lower than many parasite eggs, sugar or salts are added to increase the solution’s specific gravity and allow the eggs to float. The desired specific gravity is between 1.2 and 1.25 g/mL. Solutions with a specific gravity >1.35 g/mL will allow both debris and parasite eggs to float, making egg identification more difficult. A specific gravity <1.10 will force both debris and parasite eggs to sink, giving no diagnosis. Solutions that are purchased premixed are preferred because of quality control. Solutions mixed in the clinical setting tend to have less quality control and give variable results. Almost all solutions will form crystals on the slide if left sitting. Media
Preparation
Specific Gravity
General Information
Magnesium Sulfate
• Magnesium sulfate: 400 g • Tap water: 1,000 mL
1.20
• Readily available and inexpensive
Sodium Chloride
• Sodium chloride: 400 g • Tap water: 1,000 mL • Stir while adding the sodium chloride to water. Heating is not necessary, but speeds the dissolution.
1.18–1.20
• Readily available and inexpensive • Corrodes expensive laboratory equipment • Severely distorts eggs
Sodium Nitrate
• Sodium nitrate: 400 g • Tap water: 1,000 mL • Stir while adding the sodium nitrate to water. Heating is not necessary, but speeds the dissolution.
1.20
• • • •
Floats the greatest percentage of eggs Can be purchased in a ready-to-mix solution Distorts the eggs after 15 minutes May not be readily available and more expensive
Sugar Solution, Sheather’s Solution
• Granulated sugar: 454 g • Tap water: 355 mL • Dissolve sugar in water by heating on low heat and stirring. Add 2 mL of 37% formaldehyde or phenol crystals to prevent bacterial growth.
1.27–1.33
• • • •
Readily available and inexpensive Does not distort eggs or crystallize Floats an adequate percentage of eggs Best if used with centrifugal flotation technique
Zinc Sulfate
• Zinc sulfate: 371 g • Tap water: 1,000 mL • Stir while adding the zinc sulfate to water. Heating is not necessary, but speeds the dissolution.
1.18
• Best for intestinal protozoa (e.g., Giardia) • Light must be ↓ and focused immediately under the coverslip. • Floats a high percentage of eggs
Note: If a fecal sample is left for more than 1 hour, the eggs may become waterlogged, resulting in distortion or sinking to the bottom.
CHAPTER 4 / LABORATORY
137
4
Skill box 4.18 / Blood Parasite Examination Methods Method
Uses
Technique
General Information
Direct Examination
• Microfilariae
1. Add 1 drop of blood to a slide. 2. Add a coverslip and examine for movement.
• Small sample volume owing to low sensitivity
Thin Blood Smear
• Trypanosomes, protozoans, and rickettsia
1. Place a drop of blood near 1 end with a glass slide laying on a flat surface 2. Place another slide at a 30%–40% angle in front of the blood. 3. Back the slide up until the blood runs along the edge of the second slide. 4. Then gently and steadily push the slide forward and off the first slide, producing a smear with a feathered edge. 5. Air-dry, +/− add stain and examine.
• Small sample volume
Thick Blood Smear
• Microfilariae, protozoa, and rickettsiae
1. Place 3 drops of blood on a slide, spread the drop out with a wooden applicator stick into a 2-cm circle. 2. Air-dry the slide. 3. Place the slide in a slanted position in a container of distilled water. 4. Once the smear losses its red color, remove it, and allow it to air-dry. 5. Place the slide in methyl alcohol for 10 minutes 6. Add Giemsa stain for 30 minutes. 7. Rinse slide and examine.
• Larger sample volume
Buffy Coat
• Microfilariae
1. Fill and centrifuge an Hct tube for 3 minutes. 2. Using a file or glass slide, score the tube just below the buffy coat and snap apart. 3. Tap the tube until the buffy coat drops onto a glass slide. 4. Add a drop of saline and stain, place a coverslip on, and examine.
• Does not allow differentiation of microfilariae species
Modified Knott’s Technique
• Microfilariae
1. Mix 1 mL whole unclotted blood with 9 mL 2% formalin in a test tube. 2. Centrifuge at 1,300–1,500 rpm for 5 minutes. 3. Pour off the supernatant and add 2–3 drops of stain to the sediment. 4. With a pipette, mix the sediment and stain. 5. Place a drop on a glass slide, apply a coverslip, and examine under ×10.
• Allows differentiation of microfilariae species
4
138
SECTION THREE: DIAGNOSTIC SKILLS
Skill Box 4.19 / Ectoparasite Examination Methods Method
Uses
Technique
General Information
Gross Examination
• Lice, mites, ticks, flies, or fleas
1. Visualize the ectoparasite on the animal or by using a flea comb.
• Limited number of parasites visible
Cellophane Tape
• Lice or mites
1. Bend the cellophane tape into a loop with the sticky side out. 2. Press the tape against the animal’s skin. 3. Put 1 drop of water on a slide and lay tape over it and press down. 4. Examine under a microscope.
• Limited number of parasites visible
1. Place a drop of mineral oil on a glass slide. 2. Roll the swab or material collected in the mineral oil to deposit any debris. 3. Place a coverslip on the slide and examine with a microscope, using 4× magnification.
• Most thorough technique for ectoparasite diagnosis
Microscopic Examination
• Most ectoparasites
4
Table 4.22 / Endoparasites (See figures in Color Plate 11–13)
Prevention of human infection from endoparasites involves proper hygiene (e.g., washing hands and properly cooking food), isolation of infected animals, and quarantine of newly acquired animals. Each fecal sample should be thought of as a zoonotic risk and treated appropriately.
Figure 4.35 Relative size of parasite eggs. Note: Adapted from Veterinary Parasitology Reference Manual by William J. Foreyt.
Parasite
Transmission Route
Clinical Signs
Diagnostics
Common Treatments
Ancylostoma caninum ZOONOTIC • Common Name: Southern hookworm • Type: Nematode • Affected Species: Canine • Disinfection: Bleach • Environment: Can live in cool, moist soil for several weeks • Image: Color Plate 4.36
Eggs passed → ingestion, percutaneous, prenatal and transmammary → lungs for development → coughed up and swallowed → small intestines to mature • Prepatent period: 2 weeks
• Anemia, weakness, inappetance, poor growth, dry cough, diarrhea, constipation, and dark tarry stools
• Fecal flotation • Egg: oval or ellipsoid, capsule-shaped, 8–16 cells inside a thin wall • Sample must be <48 hours old because eggs larvate rapidly in the external environment.
• • • • • • • • • • •
Butamisole Dichlorvos Diethycarbamazine/oxibendazole Febantel/praziquantel Fenbendazole Ivermectin Lufenuron + milbemycin Mebendazole Milbemycin oxime Moxidectin Pyrantel CHAPTER 4 / LABORATORY
139
Table 4.22 / Endoparasites (Continued)
4
Parasite
Transmission Route
Clinical Signs
Diagnostics
Common Treatments
Ancylostoma tubaeforme ZOONOTIC • Common Name: Feline hookworm • Type: Nematode • Affected Species: Feline • Disinfection: Bleach • Environment: Can live in cool, moist soil for several weeks • Image: Color Plate 4.37
Eggs passed → ingestion, percutaneous, prenatal and transmammary → lungs for development → coughed up and swallowed → small intestines to mature • Prepatent period: 3–3.5 weeks
• Interdigital dermatitis, pulmonary lesions, anemia and poor hair coat
• Fecal flotation • Egg: oval or ellipsoid, capsule shaped, 8–16 cells inside a thin wall • Sample must be <48 hours old because eggs larvate rapidly in the external envirnoment.
• • • • • •
Dichlorvos Fenbendazole Milbemycin oxime Mebendazole Moxidectin Pyrantel
Cryptosporidium ZOONOTIC • Common Name: N/A • Type: Protozoa • Affected Species: Canine and feline • Disinfection: Heating >131º F for 15–20 minutes, thorough drying, 5% ammonia solution, and formaldehyde • Environment: Resistant for months • Image: Color Plate 4.38
Oocysts passed → ingested by definitive host → develop in the ileum and cecum • Prepatent period: 2–7 days
• Asymptomatic or diarrhea
• Fecal flotation, acid-fast staining, negative staining, ELISA and IFA tests • Oocysts: oval to spherical, thick-walled and sporulated • Note: difficult to distinguish from yeast cells on fecal flotations
• • • •
Clindamycin Tylosin Azithromycin Paromomycin
Dipylidium caninum ZOONOTIC • Common Name: Flea tapeworm • Type: Cestode • Affected Species: Canine and feline • Image: Color Plate 4.39
Proglottids passed and rupture to release thousands of eggs → ingested by intermediate host (flea and biting lice) → development → definitive host ingests the intermediate host → attaches to lining of small intestines to mature • Prepatent period: 4 weeks
• Anal pruritus, chronic enteritis, vomiting, or nervous system disorders
• Fecal flotation or visual examination of feces, perianal area, or bedding • Egg: double-pored, rice or cucumber seed appearance, oblong packets of 20 eggs or less
• Epsiprantel • Febantel/Praziquantel • Praziquantel
Dirofilaria immitis ZOONOTIC • Common Name: Heartworm • Type: Nematode • Affected Species: Canine and feline • Image: Color Plate 4.40
• Intermediate host (mosquito) must carry the larva for 15–17 days with the temperature ≥58º F → intermediate host infects definitive host → larva passes from venous circulation to heart → resides in pulmonary arteries and right ventricle of heart → microfilaria circulate in blood and are picked up by intermediate host (mosquito) • Prepatent period: 24 weeks
• Murmur, lack of stamina, weight loss, chronic cough, obstruction of pulmonary vessels, and congestive heart failure
• Knott’s test, buffy coat examination, direct blood smear, millipore filtration of blood, and various serologic tests for antigen of adult worm • Microfilaria: straight with 1 tapered end and 1 straight end
Adulticides • Caparsolate • Malarsomine • dihydrochloride Microfilariacides • Diethylcarbamazine • Diethycarbamazine/oxibendazole • Dithiazine • Ivermectin • Levamisole • Milbemycin oxime • Moxidectin • Selamectin
140
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.22 / Endoparasites (Continued) Parasite
Transmission Route
Clinical Signs
Diagnostics
Common Treatments
Echinococcus granulosus and multiocularis ZOONOTIC • Common Name: Canine and feline tapeworm, respectively • Type: Cestode • Affected Species: Canine and feline • Image: Color Plate 4.41
Proglottids passed → ingested by intermediate host (e.g., cattle, swine, sheep and rodents) → attaches to liver → definitive host ingests the intermediate host → attaches to lining of small intestines to mature • Prepatent period: 4 weeks
• Diarrhea • Hydatid cyst disease in intermediate host
• Fecal flotation or purging the animal and collecting the clear mucus at the end • Egg: ovoid containing a single oncosphere with 3 pairs of hooks • Note: indistinguishable from Taenia spp. eggs
• Mebendazole • Praziquantel
Filaroides osleri • Common Name: Tracheal worm and canine lungworm • Type: Nematode • Affected Species: Canine
Eggs passed → ingested (passed from dam to pup through grooming or regurgitated meals) → migrate to small intestines and then to lungs to develop → migrate to oral cavity or passed through feces • Prepatent period: 10 weeks
• Coughing and chronic tracheobronchitis with nodule formation in large airways
• Fecal flotation, Baerman technique, and sputum smear • Larva: short, with an Sshaped tail
• Albendazole • Ivermectin
Giardia ZOONOTIC • Common Name: Giardia • Type: Protozoa • Affected Species: Canine and feline • Disinfection: Bleach and quaternary ammonium • Image: Color Plates 4.12 and 4.42
Eggs passed → ingested → migrate to small intestines • Prepatent period: 5–7 days
• Asymptomatic or diarrhea (appearing pale and greasy with a foul odor)
• Fecal flotation, direct fecal smear, and IFA • Active form: pear-shaped with the anatomy resembling a face of crossed eyes, nose, and a mouth
• Furazolidone • Metronidazole
Isospora canis/felis ZOONOTIC • Common Name: Coccidia • Type: Protozoa • Affected Species: Canine and feline • Disinfection: Incineration, steam cleaning, immersion in boiling water and 10% ammonia solution • Prevention: Insect and rodent control and sanitation • Environment: Extremely resistant to environmental conditions • Image: Color Plate 4.43
Eggs passed, usually by mother → ingested, often by puppy or kitten → develop to a trophozoite → migration to intestines • Prepatent period: 1–2 weeks
• Asymptomatic or diarrhea progressing to vomiting, inappetance, and dehydration
• Fecal flotation • Egg: small, oval, and thin-walled • Sporulated: 2 sporocysts per egg • Unsporulated: 1 cell stage inside egg
• • • •
4
Furazolidone Sulfadiazine + trimethoprim Sulfadimethoxine Toltrazuril
CHAPTER 4 / LABORATORY
141
Table 4.22 / Endoparasites (Continued) Parasite
Transmission Route
Clinical Signs
Diagnostics
Common Treatments
Nanophyetus salminocola ZOONOTIC • Common Name: Salmon poisoning fluke • Type: Trematode • Affected Species: Canine
Eggs passed by definitive host (e.g., raccoon) → ingested by intermediate host (snail) → larva passed → ingested by intermediate host (salmon) → salmon ingested by definitive host (e.g., dog) → develop in intestines • Prepatent period: 1 week
• Lymph-adenopathy, depression, vomiting, and hemorrhagic enteritis • Caused by the rickettsial agent (Neorickettsia helminthoica) carried by the fluke
• Fecal flotation or fecal smear • Egg: gold, operculum at 1 end and blunt point at opposite end
Fluke • Praziquantel Rickettsial organism • Chloramphenical • Doxycycline • Oxytetracycline • Tetracycline
Spirocerca lupi • Common Name: Esophageal worm or park worm • Type: Nematode • Affected Species: Canine
Egg passed by definitive host (e.g., dog) → ingested by intermediate host (beetle) → ingested by paratenic host (e. g., lizards, birds, rodents) or definitive host (e.g., dog) → larva penetrate stomach wall and migrate through the arteries to the esophagus → forms a fistula and releases egg in the feces • Prepatent period: 5–6 months
• Dysphagia, regurgitation, vomiting, esophageal neoplasia, hypersalivation, hypertrophic osteopathy
• Fecal flotation (specific gravity >1.036) or fecal smear • Egg: thick walled, ellipsoid embryonated egg
• Disophenol sodium • Ivermectin • Doramectin
Taenia pisiformis • Common Name: Tapeworm • Type: Cestode • Affected Species: Canine • Image: Color Plate 4.44
Proglottids passed → ingested by intermediate host (e.g., rabbit and ruminant) → attaches and develops in peritoneal cavity → definitive host ingests the intermediate host → develops in the small intestines • Prepatent period: 8 weeks
• Enteritis and intestinal obstruction
• Fecal flotation or visual exam of feces, perianal area or bedding • Egg: round and containing a single oncosphere with 3 pairs of hooks • Each proglottid carries many eggs
• • • • •
Epsiprantel Febantel + praziquantel Fenbendazole Mebendazole Praziquantel
Taenia taeniaeformis • Common Name: Feline tapeworm • Type: Cestode • Affected Species: Feline
Proglottids passed → ingested by intermediate host (e.g., rodent) → attaches and develops in the liver → definitive host ingests the intermediate host → develops in the small intestines • Prepatent period: 5–6 weeks
• Diarrhea and intestinal blockage
• Fecal flotation or visual examination of feces, perianal area, or bedding • Egg: ovoid containing a single oncosphere with 3 pairs of hooks • Each proglottid carries many eggs
• • • • •
Epsiprantel Febantel + praziquantel Fenbendazole Mebendazole Praziquantel
4
142
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.22 / Endoparasites (Continued) Parasite
Transmission Route
Clinical Signs
Diagnostics
Common Treatments
Toxascaris leonina ZOONOTIC • Common Name: Ascarid, roundworm • Type: Nematode • Affected Species: Canine and Feline • Disinfection: Bleach • Environment: Eggs can remain infective in the soil for months to years • Image: Color Plate 4.45
Eggs passed → ingested by definitive host or intermediate host (e.g., mice) → definitive host ingests intermediate host → attaches and develops in small intestines • Prepatent period: 8–10 weeks
• Chronic diarrhea, vomiting, constipation, and unthriftiness
• Fecal flotation or visual examination of feces • Egg: spherical to ovoid, unembyronated, light cytoplasm, and a smooth outer shell
• • • • • • •
Dichlorvos Diethylcarbamazine Fenbendazole Milbemycin oxime Mebendazole Piperazine Pyrantel
Toxocara canis ZOONOTIC • Common Name: Ascarid, roundworm • Type: Nematode • Affected Species: Canine • Disinfection: Bleach • Environment: Eggs can remain infective in the soil for months to years • Image: Color Plate 4.45
Eggs passed → ingested via environment or paratenic host → hatch in small intestines and penetrate mucosa → migrate through the liver and heart until the lungs → develop in lungs → coughed up and swallowed → mature in the small intestines for 4–6 weeks • Prepatent period: 4–6 weeks
• Distended abdomen, weakness, unthriftiness, and diarrhea
• Fecal flotation or visual examination of feces or vomitus • Egg: spherical, unembyronated, deeply pigmented center, and a rough, pitted outer shell
• • • • • • • • •
Dichlorvos Diethylcarbamazine Diethycarbamazine/oxibendazole Febantel + Praziquantel Fenbendazole Mebendazole Milbemycin oxime Piperazine Pyrantel
Toxocara cati ZOONOTIC • Common Name: Ascarid, roundworm • Type: Nematode • Affected Species: Feline • Disinfection: Bleach • Environment: Eggs can remain infective in the soil for months to years • Image: Color Plate 4.46
Eggs passed → ingested via environment or paratenic host → hatch in small intestines and penetrate mucosa → migrate through the liver and heart until the lungs → develop in lungs → coughed up and swallowed → mature in the small intestines for 4–6 weeks • Prepatent period: 7–8 weeks
• Stunted growth and damage caused by migrations
• Fecal flotation • Egg: spherical, unembyronated, deeply pigmented center, and a rough, pitted outer shell
• • • • • • • •
Dichlorvos Diethylcarbamazine Fenbendazole Lufenuron Mebendazole Piperazine Pyrantel Selamectin
CHAPTER 4 / LABORATORY
4
143
Table 4.22 / Endoparasites (Continued)
4
Parasite
Transmission Route
Clinical Signs
Diagnostics
Common Treatments
Toxoplasma gondii ZOONOTIC • Common Name: Toxoplasmosis • Type: Protozoa • Affected Species: Feline • Environment: Can live in the soil for months to >1 year • Image: Color Plate 4.47
Oocysts passed → ingested via environment, intermediate host (most warm-blooded vertebrates) or transplacental → migrate to small intestines and extraintestinal dissemination elsewhere via blood and lymph • Prepatent period: 3–10 days for ingestion of cysts and 20–40 days for oocysts
• Asymptomatic or transient diarrhea, anorexia, depression, fever, and clinical signs dependent on site and extent of injury from migration (e. g., CNS, hepatic, pulmonary)
• Fecal flotation, ELISA, or agglutination procedures • Oocysts: oval and unsporulated
• • • •
Clindamycin Pyrimethamine Sulfadiazine + trimethoprim Toltrazuril
Trichuris vulpis • Common Name: Whipworm, fecal jewel • Type: Nematode • Affected Species: Canine • Disinfection: Diluted sodium chloride • Environment: very resistant • Image: Color Plate 4.48
Eggs passed → ingested → penetrate and develop in small intestines → migrate to cecum and develop for 60–80 days • Prepatent period: 9–12 weeks
• Weight loss, intermittent and chronic diarrhea and typhlitis
• Fecal flotation • Egg: thick, brown-yellow symmetrical shell with clear polar plug at each end and unembyronated
• • • • • •
Diethycarbamazine/oxibendazole Febantel + praziquantel Fenbendazole Ivermectin Mebendazole Milbemycin oxime
Uncinaria stenocephala ZOONOTIC • Common Name: Northern canine hookworm • Type: Nematode • Affected Species: Canine and feline • Disinfection: Bleach • Environment: Can live in cool, moist soil for several weeks • Image: Color Plate 4.49
Eggs passed → ingestion, percutaneous, prenatal and transmammary → lungs for development → coughed up and swallowed → small intestines to mature • Prepatent period: 2 weeks
• Weakness, inappetance, poor growth, and diarrhea
• Fecal flotation • Egg: oval or ellipsoid, capsule shaped, 8–16 cells inside a thin wall • Sample must be <48 hours because eggs larvate rapidly in the external environment
• • • • • •
Dichlorvos Fenbendazole Ivermectin Mebendazole Milbemycin oxime Pyrantel
144
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.23 / Ectoparasites (See figures in Color Plate 13–15) Parasite
Transmission Route
Clinical Signs
Diagnostics
Common Treatments
Cheyletiella ZOONOTIC • Common Name: Fur mite of dogs and cats and walking dander • Type: Mite • Affected Species: Canine and feline • Human Risk: Low • Image: Color Plate 4.50
• Ingest: keratin debris and tissue fluid • Location: skin • Transmission: direct contact and contact through inanimate objects • Life Cycle: 18–21 days
• Asymptomatic, mild alopecia, dandruff, and pruritus
• Scrape margins of lesions, flea comb, visual, or cellophane tape • Adult: body shape resembles a shield or acorn, hook-like accessory mouth parts and comb-like structures at the tip of each leg
• Ivermectin • Selamectin
Ctenocephalides canis/felis • Common Name: Flea • Type: Flea • Affected Species: Canine and Feline • Human Risk: Low • Image: Color Plate 4.51
• Ingest: blood • Location: head and base of tail • Transmission: direct contact or through contact with inanimate objects • Life Cycle: 21 days–>1 year
• Flea bite dermatitis, anemia, pruritus, red lesions, hair loss, and ulcers
• Visual and flea comb • Adult: medium brown to mahogany in color, laterally flattened body, 2–8 mm long with pronotal and genal combs • Transmit Dipylidium and Hemobartonella spp.
• • • • • • • •
Cuterebra • Common Name: Rodent botfly, warbles, and wolves • Type: Fly • Affected Species: Canine and feline • Human Risk: Low
• Ingest: N/A • Location: face and neck region, can be found on any furred area • Transmission: contact with rodent burrow or eggs from an adult fly • Life Cycle: 3–4 weeks
• Cutaneous lump with a breathing hole
• Visual Larvae • 2nd Stage: cream to white, toothlike spines and 5– 10 mm long • 3rd Stage: large, coal black, heavily spined, and up to 3 cm long
• Surgical removal of larvae • Note: do not crush larva when removing, because it may cause anaphylaxis • Wound treatment
Demodex canis • Common Name: Follicular mange mite, red mange, or puppy mange • Type: Mites • Affected Species: Canine • Human Risk: None • Image: Color Plate 4.52
• Ingest: unknown • Location: hair follicles and sebaceous glands • Transmission: direct contact from dam to pup; otherwise not contagious between hosts • Life Cycle: 21 days
• Alopecia of muzzle, face, and forelegs; erythema, 2º bacterial pyoderma, and pruritus
• Deep skin scrapings on squeezed skin or biopsy • Adult: cigar-shaped, 8 stubby legs at anterior end of body, and ¼ cm long
• • • •
Dermacentor variabilis/andersoni • Common Name: American dog tick and wood tick • Type: Tick • Affected Species: Canine • Human Risk: High • Image: Color Plate 4.53
• • • • •
• Asymptomatic or vasculitis • Intermediate host for Rocky Mountain spotted fever, tularemia, and other Rickettsia spp.
• Visual • Adults: blue-gray with white markings on shield
• • • • •
Ingest: blood Location: whole body Transmission: contact Life Cycle: 3 months–2 years Tick must be attached for 5–20 hours to transmit disease
4
Fipronil Imidacloprid Lufenuron Methoprene Nitenpyram Pyrethrins/pyrethroids Pyriproxyfen Selamectin
Amitraz 0.025% Ivermectin Milbemycin oxime Multivitamin/fatty acid supplement • Antibiotics • Benzoyl peroxide 5% (gel or shampoo) aids in penetration in the follicles when used with Amitraz Dichlorvos Fipronil Pyrethrins Pyriproxyfen Selamectin
CHAPTER 4 / LABORATORY
145
Table 4.23 / Ectoparasites (Continued)
4
Parasite
Transmission Route
Clinical Signs
Diagnostics
Common Treatments
Linognathus setosus • Common Name: Sucking louse of dogs • Type: Lice • Affected Species: Canine • Human Risk: Low • Environment: Live 7 days off host • Image: Color Plate 4.54
• • • • •
Ingest: blood Location: whole body Transmission: contact Life cycle: 3–4 weeks Definitive host: canine and feline
• Skin irritation, itching, dermatitis, alopecia, anemia, and roughened hair coat
• Visual • Adult: dorsoventrally flattened, red to gray in color, head is more narrow than the widest part of the thorax, and 1st pair of claws smaller than 2nd and 3rd pairs
• Fipronil • Ivermectin • Pyrethrins
Otodectes cynotis • Common Name: Ear mite • Type: Mite • Affected Species: Canine and feline • Human Risk: N/A • Image: Color Plate 4.55
• • • •
Ingest: epidermal debris Location: ear and base of tail Transmission: contact Life Cycle: 18–21 days
• Shaking of head, irritation, otitis media, hematomas, head tilt, circling, and convulsions
• Visual or ear swab • Adult: oval with 8 legs, fused head and thorax, short unjointed pedicle with suckers on the end of some of the legs
• Clean the ear of all crusty debris. • Ivermectin • Milbemycin oxime • Selamectin
Rhipicephalus sanguineus • Common Name: Brown dog tick • Type: Tick • Affected Species: Canine • Image: Color Plate 4.56
• • • •
Ingest: blood Location: whole body Transmission: contact Life Cycle: 6 weeks–1 year
• Anemia • Intermediate host for babesiosis and ehrlichiosis
• Visual • Adult: brown with prominent lateral extensions on head, giving a hexagonal appearance
• • • • •
Dichlorvos Fipronil Pyrethrins Pyriproxyfen Selamectin
Sarcoptes scabiei canis ZOONOTIC • Common Name: Mange mite or scabies • Type: Mite • Affected Species: Canine • Human Risk: low • Image: Color Plate 4.57
• Ingest: interstitial fluid • Location: ears, lateral elbows, and ventral abdomen • Transmission: contact • Life Cycle: 2–3 weeks
• Severe itching, dry and thickened skin, erythema, papular rash, scaling, crusting, and excoriations
• Deep skin scraping • Adults: oval with 8 legs, fused head and thorax, long unjointed pedicel with suckers on the end of some of the legs
• • • • •
Ivermectin Amitraz Benzyl benzoate Lime-sulfur Selamectin
Trichodectes canis • Common Name: Biting louse of dogs • Type: Lice • Affected Species: Canine • Environment: Live 7 days off host • Image: Color Plate 4.58
• • • •
• Itching, rough hair coat, and dermatitis
• Visual • Adult: dorsoventrally flattened, yellow, large rounded head; head is wider than any other part of the body, 2–4 mm
• Pyrethrins
146
SECTION THREE: DIAGNOSTIC SKILLS
Ingest: skin and hair Location: whole body Transmission: contact Life Cycle: 3–4 weeks
URINALYSIS
• Centrifuge the sample at 500–3000 rpm for 3–5 minutes.
Urinalysis is one of the most frequently performed laboratory tests in small animal clinics. Due to the filtering nature of the urologic system, information gained from this test may assist the veterinarian in a final diagnosis. Rarely does the urinalysis alone provide the diagnosis, but when interpreted along with clinical signs, blood chemistries, and other diagnostic tests, a diagnosis can be made. Even though this is a routinely done lab test, special care must be taken to ensure accurate results. Slight changes can make large alterations in the final results. As a technician, performing a complete urinalysis with great skill is a must.
• Gently pour off the supernatant to avoid disrupting the remaining pellet.
Urine Collection, Handling, Storage, and Transport Tips Collection • Collect before the administration of any medication, if possible. • Morning, prepandial samples offer the most accurate specific gravity, pH and cellular components, but allow for the degeneration of casts overnight in the bladder. • Collection containers must be clean, well rinsed, and free of any disinfectant residues.
• Gently mix the pellet to avoid cellular damage. Note: Applying the brake to produce an abrupt stop may resuspend the sediment and alter results. Storage • Samples at room temperature should be examined within 60 minutes. • Samples can be refrigerated for 6–12 hours in a covered container. • Refrigerated samples tend to form crystals. • Samples may be frozen for chemistry tests, but cellular components will be destroyed. Transport • Add 1–2 drops of serum to the sample to preserve cell morphology. • Add 1 drop of 40% formalin to each ounce of urine.
Urine Examination/Urinalysis
• Collect at least 3–5 mL of urine. • See Skill Box 12.8, page 434, and Skill Box 12.10, page 435, for procedural information on urine collection. Handling • Samples should be covered immediately to avoid pH changes and contamination. • Samples with a delay of examination of >1 hour should be refrigerated, delay in examination can lead to changes in all aspects of a urinalysis. • Thoroughly mix a sample before examination.
All urine samples should be evaluated for the following physical properties. Each of the assessments listed below is observed through a visual examination of the sample, except the specific gravity. The specific gravity is obtained with a refractometer, which accurately measures the amount of solids dissolved in a urine sample. The most accurate results are obtained with the supernatant, as it is free of cellular debris that may give false increases. The refractometer should be checked daily to ensure its calibration is set correctly. Using 1 drop of distilled water, the specific gravity reading should be 0.00.
• Slowly warm refrigerated samples up to room temperature before examination and likewise, allow urine to cool down to room temperature after collection.
CHAPTER 4 / LABORATORY
147
4
Table 4.24 / Gross Examination Physical Property
Observation
Definition
Associated Conditions
Color
Yellow
• Any shade of yellow is considered normal. • Variations are often attributable to changes in concentration (e.g., clear with low USG).
• N/A
Red or red/brown
• Cloudy, red urine is hematuria with intact RBCs. • Clear, red urine is hemoglobinuria with free hemoglobin.
• UTI, cystitis, trauma, neoplasia, urolithiasis
Brown
• Contains myoglobin
• Muscle cell lysis
Yellow/brown or yellow/green
• Contains bile pigments
• Liver disease
White
• Contains leukocytes
• UTI, cystitis, heavy crystalluria
Small amount
• Normal when sample is shaken
• N/A
Large amount
• Contains protein
• Kidney disease, fever, excessive exercise
Green
• Contains bile pigments
• Liver disease
Ammonia
• Breakdown of urease
• UTI, cystitis
Sweet, fruity odor
• Contains ketones and/or glucose
• Diabetes mellitus
Canine • 1.015–1.045 Feline • 1.035–1.060
• Normal • Measurement of the density of urine compared with pure water
• N/A
Canine • >1.045 Feline • ≥1.060
• Hyperthenuric • If dehydrated; canine: ≥1.030; feline: ≥1.035 • False ↑: ↑ glucose and protein
• ↑ Water intake or excretion of solutes • Cold urine produces a falsely high USG.
≤1.007
• Hypothenuric
• ↓ Water intake, pyometra, liver disease, kidney disease, diuretics, or diabetes insipidus
Clear
• Normal
• N/A
Cloudy or flocculent
• Contains cellular components
• UTI
Polyuria
• ↑ Urine production; pale with a ↓ USG (≤1.020)
• Nephritis, diabetes mellitus, diabetes insipidus, pyometra, liver disease, and kidney disease
Oliguria
• ↓ Urine production
• ↓ Water intake, fever, shock, heart disease, and dehydration
Pollakiuria
• Frequent urination
• UTI, urolithiasis, and crystalluria
Anuria
• Complete lack of urine output • No urine output in 12 hours
• Urinary obstruction, urinary bladder rupture, and death
4
Foam
Odor
Specific Gravity (USG)
Transparency
Volume
148
SECTION THREE: DIAGNOSTIC SKILLS
Preparation Chemistry strip evaluation provides detection of elements present in a urine sample that may or may not be seen during visual examination or microscopic evaluation. Because chemistry strips provide many false-negative results, both a visual examination and a microscopic examination should always be performed. Chemistry strip bottles should be kept at room temperature and away from intense light, moisture, and heat. Strips can be immersed in a urine
sample for 2–3 seconds to allow saturation of the pads. Extended time may lead to test reagents leaking into the urine sample. A pipette or dropper also may be used to saturate each pad and then turning the strip on its side and tapping to eliminate excess urine. Allowing urine to run down the test strip can allow mixing of the chemical pads altering the results. The results are then read at the time indicated by the manufacturer in consistent artificial light to avoid the fluctuations seen with natural light. The color change can be subjective and also altered by the presence of urine pigments. (e.g., bilirubin, hemoglobin).
Table 4.25 / Chemistry Strip Examination Chemical Property
Observation
Definition
Associated Conditions
Bilirubin
Bilirubinuria
• A byproduct from the breakdown of hemoglobin • Trace amounts found in dogs if USG is ≥1.030, but not common in cats • False negative: exposure to light • Confirmation tests: Ictotest
• Hemolytic anemia, bile duct obstruction, liver disease, fever, and prolonged fasting or starvation
Blooda
Hematuria
• Presence of intact RBCs • After centrifugation, urine will appear clear with a red pellet.
• UTI, cystitis, renal disease, strenuous exercise, trauma, and genital tract contamination
Hemoglobinuria
• Presence of free hemoglobin, typically caused by intravascular hemolysis • After centrifugation, urine will remain tinted red.
• Hemolytic anemia, severe burns, incompatible transfusions, leptospirosis, babesiosis, systemic lupus erythematosus, and metal toxicity
Myoglobinuria
• Presence of myoglobin typically due to muscle damage • Urine is dark brown to black.
• Muscle damage
Glucose
Glucosuria
• Appears if blood glucose threshold is exceeded BG values • Canine: >180 mg/dL • Feline: >300 mg/dL • Not detectable in the urine of normal animals • False negatives: cold urine
• Diabetes mellitus, Cushing’s disease, chronic liver disease, high carbohydrate meal, stress, fear, restraint, administration of IV glucose, and Fanconi’s syndrome
Ketones
Ketonuria
• • • • • •
• Diabetes mellitus, liver disease, persistent fever, high-fat diets, starvation, fasting, and long-term anorexia
Formed from the breakdown of fatty acids Not detectable in the urine of normal animals Produces a sweet, fruity smell False-negative: delayed analysis False-positives: pigmented urine Confirmation tests: Acetest
CHAPTER 4 / LABORATORY
149
4
Table 4.25 / Chemistry Strip Examination (Continued) Chemical Property
Observation
Definition
Associated Conditions
pH
Normal
• Concentration of H+ ions, a measure of the degree of alkalinity or acidity • Canine: 5.2–6.8 • Feline: 6.0–7.0
• N/A
Alkaline
• ↑ Concentration of H+ ions • <7.0 • False-increases: delayed analysis
• Postprandial alkaline tide, plant diets, UTI, metabolic and/or respiratory alkalosis, distal renal tubular acidosis, urine retention, and certain drugs (e.g., bicarbonate, citrate)
Acidic
• ↓ Concentration of H+ ions • >7.0
• Protein diets, metabolic or respiratory acidosis, fever, starvation, excessive muscular activity, chloride depletion, and certain drugs (e.g., DL-methionine, furosemide)
Protein
Proteinuria
• Measurement of albumin and globulins • Only found in trace amounts in normal urine • Always interpret in light of USG and contents of urine sediment • False positives: ↑ USG, ↑ pH, pigmented urine, detergent contamination • Confirmation tests: sulfosalicyclic acid test, microalbuminuria test (e.g., Heska ERD screen)
• Glomerulonephritis, glomerular amyloidosis, multiple myeloma, parturition, estrus, and UTI
Protein : Creatinine Ratio
Normal
• Quantifies level of proteinuria as significant or not • Canine: ≤0.3 • Feline: ≤0.6
• N/A
Increased
• ↑ Urine protein loss • >1
• Chronic interstitial nephritis, glomerulonephritis, and amyloidosis
4
a
To differentiate between hemoglobinuria and myoglobinuria, compare plasma and urine simultaneously. Plasma and urine will both appear red with the presence of hemoglobin, and only urine will appear red to brown with myoglobin.
Sediment Examination A microscopic examination of the urine sediment should be a part of every routine urinalysis. It is used to confirm findings from gross examination and chemistry strip examination. Much additional information can be gained from a microscopic examination that cannot be determined in any other method. Samples collected first thing in the morning or after several hours of water deprivation provide the most diagnostic information. The increased concentration of these samples increases the likelihood of finding formed elements. Each laboratory needs to determine their normals and urine procedures. Commonly, a standard amount of 5 mL urine is centrifuged and poured off, leaving the pellet and approximately 0.3 mL urine in the tube. The remain150
SECTION THREE: DIAGNOSTIC SKILLS
ing urine and pellet are mixed together, and 1 drop is placed on a slide. A coverslip is placed over the drop, and the sample may be read either stained or unstained. When examining an unstained sample, achieving proper light adjustment (e.g., lower stage slightly or partially close diaphragm) of the microscope to view refractile elements is important. The entire slide is examined with low power to look for areas of cell clusters, casts, cellularity; paying attention to the periphery. Casts and crystals are evaluated at low power and reported as #/lpf (low-power field). RBCs, WBCs, and epithelial cells are examined with high power and reported as #/hpf (high-power field). Bacteria and sperm are examined under high power and reported as rare through 4.
Reporting of Bacteria and Sperm Rare—only a few seen after scanning numerous fields 1+: <1/hpf 2+: 1–5/hpf 3+: 6–20/hpf 4+: >20/hpf 4 Table 4.26 / Sediment Examination (See figures in Color Plate 15–22) Bacteria
Bacteria are not normally found in properly collected normal urine samples. Its presence with WBCs often indicates a bacterial infection, whereas the absence of WBCs typically indicates a contaminated sample. A sample properly collected via cystocentesis or catheterization should be sterile and any presence of bacteria is significant (e.g., diabetes mellitus, Cushing’s disease, and glucocorticoid treatment). See color plates 4.59 and 4.61. Note: Normal brownian movement may often be confused with bacteria in unstained sediments. Component
Appearance
Definition
Associated Conditions
Cocci
• Circular bacteria in singles, pairs, or chains • Refract light and have brownian movement • Confirm with gram stain of an air-dried smear of urine; cocci will be gram-positive • Difficult to detect if <100,000 bacteria/mL
• Acid pH: Enterococcus and Streptococcus spp. • Alkaline pH: Staphylococcus spp.
• UTI, cystitis, pyelonephritis, metritis, prostatitis, vaginitis
Bacilli
• Rod-shaped bacteria in singles, pairs, or chains • Refract light and have brownian movement • Difficult to detect if <10,000 bacteria/mL
• Acid pH: E. coli • Alkaline pH: Proteus spp.
• UTI, cystitis, pyelonephritis, metritis, prostatitis, vaginitis
Blood Cells Blood cells are classified by number per high power field (#/hpf). Blood cells are thought to always be significant unless reviewed against other factors affecting the animal. For example, an animal with only a few RBCs and no other abnormalities may have received trauma through a catheterization procedure. WBCs are always thought to be significant, because they typically only appear with some level of an infection, unless contamination of infected genitalia takes place. WBCs do not need to be classified into type; by the time they reach the bladder, they have degenerated to an unrecognizable state. The presence of WBCs should always result in an in-depth look for bacteria. RBCs • Color Plate 4.64 • Color Plate 4.69
• Smooth edges, small, and biconcave • Size: 6–7 μm • Unstained: pale, yellow to orange disks without nuclei • Stained: varying color from light pink to dark red • Crenated: ruffled edges and slightly darker • Lysed: colorless rings of varying size • Dilute urine may show larger, swollen and globular RBCs
• Normal: Voided: 0–8/hpf Catheter: 0–5/hpf Cystocentesis: 0–3/hpf • Atraumatic technique will produce the above numbers, multiple attempts may ↑ the number of RBCs
• Cystitis, neoplasia, calculi, inflammation, necrosis, trauma, bleeding disorder
CHAPTER 4 / LABORATORY
151
Table 4.26 / Sediment Examination (Continued) Component WBCs • Color • Color • Color • Color
Plate Plate Plate Plate
4.60 4.62 4.63 4.64
4
Appearance
Definition
Associated Conditions
• Round with granular appearance (distinct nuclei) • Size: 10–14 μm • WBCs size ↑ in dilute urine and ↓ in concentrated urine • Presence of WBCs should cause careful consideration for the presence of bacteria and culture setup
• Normal: Voided: 0–1/hpf • Neutrophils are the most common type of WBC seen
• Nephritis, pyelonephritis, cystitis, urethritis, ureteritis
Casts Casts, consisting of a mucoprotein matrix, are formed in the lumen of the distal and collecting tubules of the kidneys. Because of this location, they are all cylindrical with parallel sides and rounded to blunted ends. Cast morphology is susceptible to high-speed centrifugation, rough handling, and delayed analysis (degrade when allowed to sit in alkaline urine or for long periods). The presence of ↑ numbers of casts may indicate tubular disease, but the quantity does not suggest the duration or severity of disease. Epithelial • Color Plate 4.65
• Nearly transparent, clear, and highly refractile with renal epithelial cells
• Originate from the Loop of Henle, distal tubule and collecting tubule • Never observed in normal urine
• Nephrotoxicity, acute renal disease, ischemia, pyelonephritis
Fatty • Color Plate 4.66
• Coarsely granular with fat droplets
• Signify degeneration of the renal tubules
• Diabetes mellitus and renal disease
Granular • Color Plate 4.67
• Coarse to finely granular • Orange: bilirubin • Pink to red: hemoglobin or myoglobin
• Composed of particulate matter from renal tubular cell necrosis or degeneration • Hyaline casts containing granules • Normal to see 0–2/hpf
• Acute renal disease
Hyaline • Color Plate 4.68
• • • •
• Composed of pure protein precipitates (mucoprotein matrix) • Normal to see 0–2/hpf
• Fever, mild renal disease, general anesthesia, IV diuresis, strenuous exercise
RBC/WBC • Color Plate 4.69 • Color Plate 4.70
• RBC: • Contains a few to many RBCs • Deep yellow to orange • WBC: • Contains a few to many WBCs • Appearance changes to granular once the cells start to degenerate
• Formed from the aggregation of RBCs and/ or WBCs • Never observed in normal urine
• Intrarenal bleeding or infection, trauma, glomerulonephritis, renal tubulointerstitial inflammation, toxicity
Waxy • Color Plate 4.71
• Highly refractile, homogeneous, and translucent • Blunted ends and cracks
• Final stage of granular cast degeneration • Most stable of all casts
• Chronic renal disease
152
Nearly transparent, clear and highly refractile Rounded ends Stained: light pink to purple May contain a few inclusions
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.26 / Sediment Examination (Continued) Component
Appearance
Definition
Associated Conditions
Crystals Crystalluria may or may not be indicative of a medical condition. Crystals may form because of sample handling (e.g., refrigeration) or through the accumulation of normal urine components. Urine pH, concentration, temperature, and solubility of the components all contributes to the type of crystal formed. Crystals can be reported as occasional, moderate, many or by using a 1–4+ scale. Amorphous Phosphate • Color Plate 4.59 • Color Plate 4.72
• Granular precipitate • Dull brown in color
• Typically seen in neutral or alkaline urine • Seen in normal urine • Easily confused with bacteria
• Liver disease, portosystemic shunts, or breed predisposed (Dalmatian and English Bulldog)
Amorphous Urate • Color Plate 4.73
• Granular precipitate (sodium, potassium, magnesium and calcium salts) • Yellow or yellow-brown in color
• Typically seen in acidic urine • Dissolve in alkaline urine • Easily confused with bacteria
• Liver disease, portosystemic shunts, or breed predisposed (Dalmatian and English Bulldog)
Ammonium Biurate • Color Plate 4.74
• Round with long spicules • Resemble a thorn apple • Yellow to brown in color
• Seen in alkaline, neutral or slightly acidic urine
• Liver disease, portosystemic shunts, urate urolithiasis, or breed predisposed (Dalmatian and English Bulldog)
Bilirubin • Color Plate 4.75
• Fine elongated spicules • Red brown or golden yellow in color
• May be seen in normal urine
• Liver disease or hemolytic anemia
Calcium Carbonate • Color Plate 4.76
• Round with lines radiating out from the center • May resemble short dumbbells
• Typically seen in alkaline urine
• N/A
Calcium Oxalate Dihydrate • Color Plate 4.77
• Colorless, square with refractile lines forming an × across the surface (e.g., envelopes) • Radiopaque with hard, sharp protrusions • +/− Cuboid shape
• Typically seen in neutral or acidic urine • May be seen in normal urine
• Ethylene glycol toxicity, oxalate urolithiasis
Calcium Oxalate Monohydrate
• Small, flat, elongated structures with pointed ends (e.g., spindles)
• Typically seen in neutral or acidic urine
• Ethylene glycol toxicity, oxalate urolithiasis
Cystine • Color Plate 4.78
• Hexagon and flat • May appear as singles or in layers
• Typically seen in acidic urine
• Renal tubular dysfunction
Leucine • Color Plate 4.79
• Yellow or brown, round with concentric striations
• Typically seen in acidic urine • Not well understood
• Acute liver disease or chloroform or phosphorus toxicity
Sulfonamide • Color Plate 4.80
• Clear to brown, eccentrically bound needles in sheaves
• Rarely seen with the newer forms of sulfonamide drugs
• Sulfonamide treatment
Triple Phosphate (Struvite, Magnesium, Ammonium and Phosphate, MAPS) • Color Plate 4.81
• 8-sided prisms with tapered sides and ends • Resemble coffin lids • ↑ Ammonia leads to fern leaf like appearance
• Typically seen in neutral or alkaline urine
• Cystitis or struvite urolithiasis
CHAPTER 4 / LABORATORY
153
4
Table 4.26 / Sediment Examination (Continued)
4
Component
Appearance
Definition
Associated Conditions
Tyrosine • Color Plate 4.82
• Colorless or yellow, very fine needles in sheaves or clusters
• Typically seen in acidic urine • Not well understood
• Acute liver disease or chloroform or phosphorus toxicity
Uric Acid • Color Plate 4.83
• Yellow brown diamond, rosettes, or oval plates with pointed ends
• Typically seen in acidic urine
• Liver disease, portosystemic shunts, or breed predisposed (Dalmatian and English Bulldog)
Epithelial Cells Squamous and transitional epithelial cells are seen commonly in the urine of normal animals. Squamous epithelial cells are the largest of the epithelial cells and are considered not significant. Transitional epithelial cells only prove to be significant with a large increase in number. Renal epithelial cells, however, are typically only seen with renal disease and always thought to be significant. They are the smallest of the epithelial cells and are often confused with WBCs. Renal • Color Plate 4.84
• Round to caudate with a large eccentric nucleus displaced near the bottom • Prominent nucleolus • Often confused with WBCs
• Epithelial cells originating from the renal tubules • Rarely found and usually indicate renal disease
• Renal disease
Squamous • Color Plate 4.85
• Very large, thin, and polygonal • Tend to fold onto themselves and appear singularly or in sheets • Small, round nucleus, placed close to the center • Appears as a fried egg
• Epithelial cells originating from the urethra, bladder, vagina, and prepuce • Often seen and typically not significant
• N/A
Transitional • Color Plate 4.86
• Round to caudate, granular with a small nucleus centrally located • Varying size
• Epithelial cells originating from the prokimal urethra, bladder, ureters, and renal pelvis • Often seen and only significant in large numbers, clumps or sheets
• Cystitis, pyelonephritis, or neoplasia
Miscellaneous Numerous artifacts can be seen in urine because of contamination. The following also can be seen with a disease condition associated with the urinary tract. Hemoglobin
• Orange globules with varying size
• Intravascular hemolysis resulting in free hemoglobin • Often confused with RBCs
• Severe hemolytic diseases or alkaline urine
Lipid Droplets • Color Plate 4.87
• Varying size, round, light green, and highly refractile • Seen in the plane of field just below the coverslip
• Commonly seen in urine associated with no disease condition • Often confused with RBCs
• Diabetes mellitus, obesity, and hypothyroidism
Mucus Threads
• Resemble twisting ribbons
• More commonly seen after catheterization • May be seen in normal animals
• Urethral irritation or genital
154
SECTION THREE: DIAGNOSTIC SKILLS
Table 4.26 / Sediment Examination (Continued) Component
Appearance
Definition
Associated Conditions
Parasites Two urinary tract parasites can be seen in the dog and cat. Fecal contamination may lead to finding an array of parasites in urine, but the following are the only ones that originate from the bladder. Capillaria Plica • Color Plate 4.88
• Clear to yellow with flattened bipolar end plugs and a roughened shell
• Bladder worm of dogs and cats • Travels through the lungs and may cause coughing
• Nonpathogenic
Dioctophyma Renale
• Barrel shaped, bipolar, yellow brown with a pitted shell
• Giant kidney worm of the dog • Largest nematode affecting domestic animals • Ingest the parenchyma of the right kidney, leaving only the capsule • Crayfish and fish are the intermediate host.
• Kidney disease or peritonitis
Urine Artifacts Many substances can contaminate a urine sample. They may arise from improper collection, the environment, or general anatomy. Besides the arti-
4
facts listed below, parasite eggs, fecal material, fungal spores, and fungi also may be seen. Please refer to the respective sections for identification of these items.
Table 4.27 / Urine Artifacts Urine Artifact
Appearance
Definition
Air Bubbles • Color Plate 4.78
• Varying size, round, flat, refractile with a dark border
• Result from the trapping of air during the application of the cover slip
Fungi
• Aseptae or segmented hyphae
• Contaminant • Patients with systemic fungal disease affecting the urinary system (rare)
Hair
• Needle like with tapered edges
• Contaminant from environment or surrounding genitalia
Pollen
• Double budding spores (e.g., Mickey Mouse®)
• Contaminant from environment
Sperm
• Oval head with a whip like tail
• Seen in the urine of intact males or recently mated females
Starch Granules • Color Plate 4.89
• Faceted or scallop edges with indented or dimpled center • Not refractile
• Contaminant from gloves
Yeast • Color Plate 4.90
• Oblong, colorless budding bodies with double refractile walls • Varying size
• Contaminant from environment or surrounding genitalia • Certain species may infect the urinary tract of patients with resistant UTI (rare)
Note: The normal values for this chapter are used with permission from Phoenix Central Laboratory.
CHAPTER 4 / LABORATORY
155
Chapter
5
Imaging Radiology 159 Radiographic Equipment 160 Radiographic Exposure and Image Factors 161 Radiographic Technique Chart 161 Example 1: Veterinary X-Ray Technique Guide 162 Example 2: Veterinary X-Ray Technique Chart 163 Evaluating Radiograph Technique 164 Exposure Evaluation 164 Density Evaluation 164 Scale of Contrast Evaluation 164 Radiographic Alterations 166 Radiographic Artifacts 167 Radiographic Positioning 167 Directional Terms 168 Positional Terms 168 Soft Tissue Positioning 169 Thorax 169 Abdomen and Pharynx 169 Head Positioning 170 Skull 170 Zygomatic Arch 171
Tympanic Bullae 172 Temporomandibular Joint 172 Nasal Cavities and Sinuses 173 Nasal Cavities and Sinuses (continued) Spine Positioning 174 Cervical 174 Thoracic–Lumbar 175 Sacrum–Caudal 175 Shoulder and Forelimb Positioning 176 Scapula–Shoulder 176 Humerus 176 Elbow 177 Radius/Ulna and Carpus 178 Metacarpus/Phalanges 178 Pelvis and Hindlimb Positioning 179 Pelvis 179 Femur, Stifles, and Tibia/Fibula 180 Tarsus and Metatarsals 181 Radiographic Contrast Studies 181 Types of Contrast Media 182 Fistula Contrast Studies 183
5
173
157
c05.indd 157
3/14/2008 11:49:10 AM
Fistulography 183 Abdominal Contrast Studies 183 Peritoneography 183 Gastrointestinal Tract Contrast Studies 184 Esophagography and Gastrography 184 Upper and Lower Gastrointestinal Study 185 Head Contrast Studies 187 Dacryocystorhinography, Rhinography, and Sialography 187 Spinal and Joint Contrast Studies 188 Myelography and Epidurography 188 Discography and Arthrography 189 Urethra Contrast Studies 190 Urethrography, Canine 190
5
158
c05.indd 158
Urethrography, Feline 191 Vaginal Contrast Studies 192 Vaginography 192 Urinary Tract Contrast Studies 193 Cystography 193 Cystography (continued) 194 Additional Imaging Techniques 195 Computer Tomography and Echocardiography 195 Fluoroscopy 196 Magnetic Resonance Imaging and Nuclear Medicine Ultrasonography 197 Basic Scanning Technique 198 Sites for Ultrasound Scanning 198
196
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:10 AM
a
Key Words and Termsa
Abbreviations
Collimate Commissure Computer radiography Contrast Density Dosimeter Hypertonic Manubrium Mucoceles Radiolucent Radiopaque Retrograde Santes’ rule Stranguria Transaxially
C, cranial Cd, caudal CHF, congestive heart failure CMIARF, contrast medium–induced acute renal failure CRT, capillary refill time CSF, cerebral spinal fluid CT, computed tomography D, dorsal Di, distal DR, digital radiography DV, dorsoventral EU, excretory urography FFD, focal film distance GIT, gastrointestinal tract IP, image plate IVP, intravenous pyelography IVU, intravenous urography kVp, kilovoltage peak
Additional Resources, page L, lateral LAT, lateral M, medial mA, milliamperage mA-s, milliamperage per second MHz, megahertz MM, mucous membranes MRI, magnetic resonance imaging OBL, oblique Pa, palmar Pl, plantar Pr, proxmial R, rostral s, seconds SID, source image distance V, ventral VD, ventrodorsal
Anatomy, 3 Anesthesia, 439 Catheter Placement, 349 Fluid Therapy, 359 General Medicine, 201 Injections, 348 Medical Procedures, 427 Monitoring, 332 Stomach Tube Placement, 428 Urinary Catheter Placement, 435
5
Key words and terms are defined in the glossary on page 631
RADIOLOGY Radiographs are an extremely useful diagnostic tool for the veterinarian. However, to be diagnostic, the radiograph must reflect proper measurement and positioning of the patient. Veterinary technicians are a valuable resource in the production of these radiographs. An understanding of the anatomic layout of the species and the manner in which a radiograph is taken is of great assistance to the production of a diagnostic radiograph. This chapter contains the basic information of radiographic equipment, imaging factors, positioning information, and contrast radiography.
Digital radiography (DR) has made its way into the veterinary field. This technology complements the advancements made in computer technology and results in many benefits for the patient, veterinarian, and staff. The advantages to DR include increased time efficiency in processing, storing and retrieving of radiographs, improved contrast resolution allowing soft tissue and bone evaluation in one image, and the ability to use teleradiology. There is also the ability to change the contrast and density of the image to improve diagnostic sensitivity, but this technique can also add artifacts leading to confusion and misdiagnosis. With the expected decrease in the number of retakes due to computer manipulation and the increased efficiency of the DR unit, patient and staff safety should increase.
CHAPTER 5 / IMAGING
c05.indd 159
159
3/14/2008 11:49:10 AM
Table 5.1 / Radiographic Equipment
Radiographic equipment is especially expensive and extreme care should be taken with its use and maintenance. However, the greatest risk with radiography is patient and staff safety. It has been scientifically proven that ionizing radiation causes damage to living cells (e.g., reproductive, growth, gonadal, cancer, metabolically active cells). There is no level of exposure that is nondamaging; therefore, caution should be taken to limit exposure to the lowest level possible. Protective apparel is the first defense against radiation exposure—lead aprons, thyroid shields, and gloves must be worn in all circumstances. The staff should also protect themselves by wearing a dosimeter badge and goggles and by staying as far back from the primary beam and subsequent scatter radiation as possible. Excessive and unnecessary exposure should also be avoided. Equipment
Description
Maintenance
Protective Apparel
• • • •
• Hang aprons vertically or lay flat. • Gloves should be placed on vertical holders or over bottomless soup cans to allow airflow and avoid cracks in the lead lining. • Radiograph all apparel quarterly to assess protectiveness of shield and check for cracks, tears, or other irregularities.
5
Aprons Thyroid shields Gloves Dosimeter
Film-Screen Radiography Processing Tanks
• Develops the film • May be manual or automatic
• Clean routinely, and replenish liquids as needed. • Clean thoroughly every 2–3 months. • Check manufacturer’s guidelines for your specific machine.
Film
• Imprints the image (various types)
• Handle carefully. • Store in a vertical position in a cool, dry, dark place.
Cassettes
• Houses the film and intensifying screens
• Do not drop or allow leaking liquids into the cassette. • Clean the exterior regularly with mild soap and water. • Clean the intensifying screens routinely with a commercial solution, mild soap and water, or dilute ethyl alcohol. • Leave the cassette open and propped in a vertical position to dry. • Store in a vertical position when loaded with film.
Computed Radiography Reader
• Reads the image from the IP
Image Plate (IP)
• Imprints the image
Computer
• Manipulates and permits viewing of the image
• Erase the plates daily. • Clean the plates once a week.
Direct Digital Radiography Selenium Detector Plate
160
c05.indd 160
• Utilizes a direct energy conversion process to capture image
• Offset calibration daily.
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:11 AM
Table 5.2 / Radiographic Exposure and Image Factors Factor
Definition
Application
Contrast
• The difference between the lightest and darkest part of the film, reflecting 2 adjacent radiographic densities
• High kVp (low contrast) for tissue • Low kVp (high contrast) for bone
Density
• The degree of blackness of a film
• To produce a darker film ↑ mA, kVp, or exposure time
Detail
• The clarity of the image on the film
• For better detail: use longer source–image distance (SID), have the patient closer to the film, and use a shorter exposure time.
Distortion
• The alteration of the original image
• For less distortion: use short SID, have the patient closer to the film, and less angulation of the film or patient.
Exposure Time (s)
• Measures the length of time electrons are allowed to flow across the tube
• Longer exposure time = ↑ production of x-rays • mA-s is the product of milliamperage and the exposure time. It indicates the number of x-rays being produced during an exposure. • Using a high mA setting allows for the use of shorter exposure times.
Grid Factor
• The ↑ in exposure to compensate absorption by the grid device
• Used in the formation of a technique chart (part of Santes’ rule)
Kilovoltage peak (kVp)
• Measurement of the electric potential difference between the cathode and anode in the x-ray tube
• Higher kVp = greater penetration power • Controls the quality • Directly proportional to film density and inversely proportional to film contrast
Milliamperage (mA)
• Measurement of the number of electrons that flow across the tube from cathode to anode
• Higher mA = production of more x-rays • Directly proportional to film density
Milliamperage per Second (mA-s)
• The number of x-rays produced per second
• Controls the number and quantity of x-rays produced
Source Image Distance (SID) • Focal spot to film distance (FFD)
• The distance between the focal spot on the target anode and the radiographic film
• ↑ SID = a ↓ in the number of x-rays reaching the film
Radiographic Technique Chart Every clinic with an x-ray machine should have a technique chart that has been assessed by the local radiologist to fit your particular machine. These charts significantly decrease the time involved in the calculation of the machine settings and thereby reduce the time spent on taking each radiograph. The chart also ensures consistency among the personnel using the machine. Factors involved in a technique chart are the species, the anatomic region, the x-ray machine, screen type, and the film type. The basic steps to set up a technique chart are:
1. Choose an animal of respective size to reflect its species (e.g., canine: an animal around 50 pounds; feline: an animal around 9 pounds). 2. Measure the animal laterally around the thickest part of the thorax. Set standard SID as a constant (40). 3. Calculate the kVp requirement using Santes’ rule: (2 × tissue thickness in cm) + SID + grid factor = kVp. • Example: (2 × 15 cm) + 40 + 8 = 78 kVp 4. Determine mA-s requirement based on the following chart: CHAPTER 5 / IMAGING
c05.indd 161
5
161
3/14/2008 11:49:11 AM
Fast/High-Speed Screens
Average Dog
Medium/Par Speed Screens
MA-s
Anatomical Region
mA-s
2.5
Extremity
5.0
5.0
Thorax
7.5
7.5
Abdomen
10.0
10.0
Pelvis
12.5
Average cat: mA-s is recommended at 1.5. 5 5. Determine the mA and exposure time with emphasis on the highest mA possible. Divide mA by mA-s to get exposure time (seconds). 1 Example: 300 divided by 5.0 = –60
6. Take a trial radiograph of the animal, using the calculated factors and assess its quality. Modify the mA-s by 30–50% in the appropriate direction and retake the radiograph. 7. Once a diagnostic radiograph is produced, use these factor numbers to start your chart. This will need to be repeated for the various areas of the body and for each species. See guidelines below for the chart making: For each 1-cm change, add or subtract 2 kVp, up to 80 kVp. For each 1-cm change, add or subtract 3 kVp, from 80–100 kVp. For each 1-cm change, add or subtract 4 kVp, above 100 kVp. 8. Modifications to this method would include: a. Pleural fluid or ascites or obvious organ enlargement (e.g., cardiomegaly) (↑ mA-s 50%) b. Obesity, heavily muscled dogs, or contrast studies (↑ mA-s 50%) c. Excessively thin animals or puppies/kittens (↓ mA-s by 50%) The following charts reflect 2 different styles of a technique chart. It is helpful to have your chart reviewed by a board-certified radiologist.
Example 1: Veterinary X-Ray Technique Chart The following is for use with: QUANTA 3 screens SID is 40″. Grid ratio is 8:1 CRONEX 7 film Kodak LANEX REGULAR Kodak TMG-1 film mA
Time
mA-s
kVp
Skull 3.3
(2 × cm) + 55 kVp
1/60
5
(2 × cm) + 55 kVp
300
1/60
5
(2 × cm) + 50 kVp
300
1/30
10
(2 × cm) + 48 kVp
Small Dogs and Cats
300
Medium and Large Dogs
300
Small Dogs and Cats Medium and Large Dogs
Cervical
Thorax 3.3
(2 × cm) + 43 kVp
1/60
5
(2 × cm) + 43 kVp
300
1/60
5
(2 × cm) + 45 kVp
300
1/30
10
(2 × cm) + 50 kVp
Small Dogs and Cats
300
1/60
5
(2 × cm) + 52 kVp
Medium and Large Dogs
300
1/30
10
(2 × cm) + 52 kVp
Extra-Large Dogs
300
1/30
10
(2 × cm) + 60 kVp
Small Dogs and Cats
300
Medium and Large Dogs
300
Small Dogs and Cats Medium and Large Dogs
Abdomen and Thoracic Spine
Pelvis
Extremities: Femur and Humerus Small Dogs and Cats
300
1/45
Medium and Large Dogs
300
1/30
Small Dogs and Cats
300
1/45
Medium and Large Dogs
300
1/30
6.6 10
(2 × cm) + 45 kVp (2 × cm) + 45 kVp
Extremities: Radius and Ulna
162
c05.indd 162
6.6 10
(2 × cm) + 45 kVp (2 × cm) + 45 kVp
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:11 AM
Example 2: Veterinary X-Ray Technique Chart Bone 300 mA
Chest 300 mA kVp
Abdomen 300 mA kVp
kVp
cm
Time
Table
Grid
Time
Table
Grid
Time
Table
Grid
4
1/30
42
—
1/60
44
—
1/30
—
—
5
“
“
—
“
46
—
“
—
—
6
“
45
—
“
48
—
“
—
—
7
“
“
55
“
50
—
“
—
—
8
“
“
57
“
52
—
1/15
—
51
9
“
46
59
“
54
—
“
—
53
10
“
“
61
“
56
—
“
—
55
11
“
—
63
“
58
—
“
—
57
12
“
—
65
“
60
74
“
—
59
13
“
—
67
“
62
76
“
—
61
14
“
—
69
“
64
78
“
—
63
15
“
—
71
“
66
80
“
—
65
16
“
—
73
“
68
82
“
—
67
17
“
—
75
“
—
85
“
—
69
18
“
—
77
“
—
88
“
—
71
19
“
—
79
“
—
91
“
—
73
20
“
—
81
“
—
95
“
—
75
21
“
—
84
“
—
99
“
—
77
22
“
—
87
“
—
103
“
—
79
23
“
—
90
“
—
103
“
—
82
24
“
—
94
1/30
—
96
“
—
85
25
“
—
96
“
—
100
“
—
88
26
“
—
103
“
—
105
“
—
91
27
“
—
108
“
—
110
“
—
95
5
“ Indicates same value as above; —, not applicable.
CHAPTER 5 / IMAGING
c05.indd 163
163
3/14/2008 11:49:11 AM
Evaluating Radiograph Technique
Density Evaluation
Following a technique chart to take a radiograph is a straightforward process. However, this still may not produce a radiograph with the contrast and density needed for a quality image. There are many factors that affect the quality of the film; besides equipment issues, the mA, kVp, and time have considerable control of image quality. Understanding their relationship along with the difference based on BCS, breed, and disease condition can produce the desired quality of radiograph.
The density of a film is the degree of blackness and is mostly controlled by mA-s. Begin evaluating the density by determining the degree of blackness. The area outside the patient’s body and inside the collimated area should be black. Lighter shades would indicate ↑ density is needed.
Table 5.3 / Exposure Evaluation
5
To determine if an x-ray needs to be adjusted, one must first be able to evaluate the quality of a film. There are some basic guidelines to a properly exposed image, but there is also veterinarian preference. Begin by evaluating the overall appearance (e.g., too light or too dark) of the x-ray. With the xray on a standard viewing box, place your hand under the image. If you are able to see your fingers, yet not the wrinkles and creases the image has the correct exposure. If you are not able to see your fingers, the image is overexposed (too dark) and if you can see your fingers and all wrinkles and creases the image is underexposed (too light). If it is determined that an image is too light or too dark, further evaluations need to take place to determine why. Underexposed (Too Light)
Good Exposure
Overexposed (Too Dark)
Hand Test
• Fingers, wrinkles, and creases visible
• Fingers visible
• Fingers not visible
Thorax
• Visible: surrounding vasculature • Not visible: vasculature over the heart, lung over diaphragm
• Visible: caudal vena cava, descending aorta, bronchi, pulmonary vessels, cardiac silhouette, air-filled lungs • Taken on inspiration • Optimal: high kVp and low mA-s (↑ contrast and ↓ density)
• Lungs are as black as the background.
Abdomen
• Internal organs are washed out and not distinguishable.
• Visible: margins of the internal organs, stomach, diaphragm, small and large intestines, liver, spleen, bladder, ± kidneys, prostate • Taken on expiration • Optimal: low kVp and high mA-s (↑ density and ↑ contrast)
• Internal organs are dark and not distinguishable.
• Clear margins of compact bone with a radiolucent center, physes in young animals (can be open up to 14 months) • Optimal: low kVp and high mA-s (↑ density and ↑ contrast)
• Bone is bright white with no detail.
Bony Structures • Bone is dark with no detail. Eraluating Radiograph Technique Table 5.4 / Scale of Contrast Evaluation
The scale of contrast is the shades of grays or the degree of blacks and whites and is mostly controlled by kVp. A kVp setting that is too high will give a low contrast (e.g., overall gray appearance). A kVp setting that is too low will give a high contrast (e.g., strong blacks and whites). Once a radiograph has been evaluated and it is determined that alterations are needed, the decision needs to be made as to what settings need to be altered. Unfortunately, this is not an exact science and adjustments of one or more settings may be needed. However, there are some general starting points when adjusting the settings. In general, mA-s is altered by 25–50% to make large overall changes and to alter the density (degree of blackness). kVp is altered by 10–15% to make small subtle changes and alter the scale of contrast. Another point, altering the kVp by 10–15% is approximately the same change in exposure as altering the mA-s by 50% (e.g., halving or doubling the mA-s). Therefore, with proper exposure and the need to only change the contrast, the kVp and mA-s must be altered together in the opposite direction (e.g., ↑ kVp and ↓ mA-s). 164
c05.indd 164
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:11 AM
Table 5.4 / Scale of Contrast Evaluation (Continued) Alteration
↑ Density • Film is too dark.
• ↓ mA-s • To ↓ the amount of x-rays and ↓ the blackness
↓ Density • Film is too light.
• ↑ mA-s • To ↑ the amount of x-rays and ↑ the blackness
↑ Contrast • Film has strong blacks and whites.
• ↑ kVp • To ↑ the penetrating power of the x-rays and to lengthen the scale of contrast
↓ Contrast • Film is washed out/gray appearance.
• ↓ kVp • To ↓ the penetrating power of the x-rays and to shorten the scale of contrast
Example
5
Film
Evaluation
165
c05.indd 165
3/14/2008 11:49:11 AM
Table 5.5 / Radiographic Alterations
BCS
With radiology experience, adjustments to the mA-s and kVp can be made prior to the first x-ray taken. There are certain anatomical factors (e.g., body weight, muscle mass, haircoat) that are known to alter the image based on the technique chart. The technique chart is based on an “average” animal and alteration for normal often requires setting adjustments. The most important point to remember is that large changes are made with mA-s (25–50%) and subtle changes are made with kVp (10–15%).
Disease
Breed and Anatomy
5
166
c05.indd 166
Evaluation
Radiograph Effect
Setting Alteration
Comments
BCS 1–2
• ↓ Body fat, muscle wasting
• ↓ mA-s and/or kVp
• ↓ Subject density
BCS 4–5
• ↑ Body fat
• ↑ mA-s and/or kVp
• ↑ Subject density
Achondroplastic dwarf
• Compressed mediastinal area • Short dense legs
• ↑ mA-s and/or kVp
• ↑ Subject density • Be sure legs are pulled out of the view (e.g., tape stirrups).
Barrel-chested
• ↑ Thoracic size
• ↑ mA-s
• ↑ Subject density • Extend cervical region as far forward as possible.
Brachycephalics
• Motion artifact • Trapped air • X-rays not taken on inspiration/expiration
• ↓ mA-s and/or kVp to ↓ density
• Blow in their nose to briefly stop panting.
Deep-chested
• Deep cranial thorax and thin caudal thorax
• ↓ mA-s and/or kVp
• Two views may need to be taken to achieve proper exposure in both regions. • Ensure proper positioning of VD images (e.g., supportive devices) to avoid oblique images.
Giant breeds
• ↑ Overall size
• ↑ mA-s
• ↑ Subject density • Divide the area into 2 sections (e.g., cranial and caudal thorax) to view entire area.
Haircoat
• Excessive amount or mats • Debris and foreign bodies
• ↑ kVp
• ↑ Subject density • Move excessive hair out of view if possible. • Foreign bodies found on the image should be verified they are not within the haircoat.
Muscle
• ↑ Muscle mass
• ↑ mA-s and/or kVp
• ↑ Subject density • Ensure proper positioning of VD images (e.g., supportive devices) to avoid oblique images.
Skin
• ↑ Skin folds
• ↑ mA-s and/or kVp
• ↑ Subject density • Pull skin folds out of view if possible.
Any condition resulting in:
• Ascites/edema
• ↑ mA-s and ± ↓ kVp
• ↑ kVp along with free fluid = ↑ scatter
• Free air
• ↓ mA-s and/or kVp
• ↓ Subject density
• Foreign bodies
• ± mA-s and kVp alterations
• Adjustments are made based on the opacity of the item.
• Soft tissue swelling
• ↑ mA-s and/or kVp
• ↑ Subject density
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:12 AM
Table 5.6 / Radiographic Artifacts Problems Seen on Radiograph
Artifact
Solution
Blurred images
• Motion • Double exposure
• Proper positioning and handling of animal • Double-check cassette tray for foreign objects
Clear areas on the sides of the radiograph
• Film fog • Mislocation of beam to film
• Proper handling of film • Verification that the beam and cassette are aligned
Dark line with mirror image of object
• Film folded on itself
• Proper loading of cassette
Dark semicircle impression
• Finger pressure mark
• Proper handling of film
Dark striations (sea lichen or dotted)
• Static electricity
• Proper handling of film
Gray streaks
• Wet animal fur
• Clean off and dry animal
Lines or objects visualized outside/inside the animal’s body that are unexplainable
• Foreign objects in or on the cassette (hair, paper, etc.)
• Proper cleaning of cassette • Proper handling of film
Hardwood flooring
• Plank floor
• ↓ mA-s
White lines across the film
• Scratches on the film
• Proper handling of film
Radiographic Positioning The most important factor in positioning a patient for radiographs is to have a mental vision of the part of the body to be radiographed and a good understanding of its anatomic placement. A second important factor is to use supports to ensure that the patient is aligned properly and to decrease the operator’s exposure. These supports can include sandbags,
5
nonradiopaque wedges, nonradiopaque “V” troughs, gauze, and tape. Depending on the species, size, and condition of the animal being radiographed, the following positioning guidelines may need to be adjusted accordingly. Understanding directional terminology is critical to the proper positioning of every radiograph. Specific anatomical landmarks are identified in Chapter 1: Anatomy.
CHAPTER 5 / IMAGING
c05.indd 167
167
3/14/2008 11:49:12 AM
Table 5.7 / Directional Terms
5
Directional Term
Definition
Dorsal (D)
• Any given point toward the back
Ventral (V)
• Any given point toward the lower area of the thorax and abdomen, closest to the ground
Cranial (C)
• Any given point toward the head • The area above the carpal and tarsal joints on the limbs toward the head
Caudal (Cd)
• Any given point toward the tail • The area above the carpal and tarsal joints on the limbs toward the tail
Rostral (R)
• Any given point on the head toward the nose
Proximal (Pr)
• Any given point nearest the point of origin or attachment
Distal (Di)
• Any given point farthest away from the point of origin or attachment
Medial (M)
• An area near the midline • The inside aspect of the limbs
Lateral (L, Lat)
• An area situated away form or opposite the midline • The outside aspect of the limbs
Palmar (Pa)
• Caudal portion of the forelimb distal to the carpal joint
Plantar (Pl)
• Caudal portion of the hindlimb distal to the tarsal joint
Positioning Terms The patient is positioned so as the x-ray beam enters and exits based on the positional term. For example: caudocranial allows the x-ray beam to enter in the caudal aspect and exit the cranial aspect of a given anatomical region.
Dorsalventral (DV) Ventrodorsal (VD) Dorsopalmar (DPa) Palmarodorsal (PaD) Dorsoplantar (DPl) Plantarodorsal (PlD)
Additional Examples:
Recumbent: The patient is positioned on their side, left or right.
Caudocranial (CdC) Craniocaudal (CCd)
Oblique (Obl): The patient is placed in a slanted or inclined position so that the x-ray beam will enter the body at an angle.
168
c05.indd 168
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:12 AM
Soft Tissue Positioning Skill Box 5.1 / Soft Tissue Positioning: Thorax Anatomic Area
Thorax
View
Lateral
V/D
D/V
Positioning
• • • •
• Dorsal recumbency • Forelimbs extended cranially • Hindlimbs flexed
• Sternal recumbency • Forelimbs extended caudally and elbows abducted • Head lies low between forelimbs • Rear limbs in crouching position
Left lateral recumbency (heart assessment) Right lateral recumbency (lung assessment) Forelimbs and head extended cranially Rear limbs extended caudally
Measurement
• Widest area of ribcage
• Widest area of ribcage
• Widest area of ribcage
Beam Center
• Caudal border of scapula
• Caudal border of scapula (6th rib)
• Caudal border of scapula (6th rib)
Field of View
• Thoracic inlet to the last rib
• Thoracic inlet to the last rib
• Thoracic inlet to the last rib
Notes
• Taken on peak inspiration • If pneumothorax is suspected, expiratory radiographs also may be required. • May require support (e.g., wedges) to keep sternum inline with the thoracic vertebrae
• Taken on peak inspiration • If pneumothorax is suspected, expiratory radiographs also may be required. • Restraining the animal at the scapula/armpits results in a straighter thorax.
• Taken on peak inspiration • If pneumothorax is suspected, expiratory radiographs also may be required. • Preferred view for cardiac evaluation or for animal in respiratory stress
5
Skill Box 5.2 / Soft Tissue Positioning: Abdomen and Pharynx Anatomic Area
Abdomen
Pharynx
View
Lateral
V/D
Lateral
Positioning
• Right lateral recumbency • Forelimbs extended cranially • Hindlimbs extended caudally
• Dorsal recumbency • Forelimbs extended cranially and parallel
• Lateral recumbency • Forelimbs flexed caudally • Head should be parallel to the table (may require support) and neck extended.
Measurement
• Caudal aspect of the 13th rib or widest area
• Hindlimbs extended caudally and parallel
• Base of the skull
Beam Center
• Caudal aspect of the 13th rib
• Caudal aspect of the 13th rib or widest area
• Just caudal the base of the skull
Field of View
• 2–3 inches cranial to xyphoid process of sternum to the femoral head
• Caudal aspect of the 13th rib
• Lateral canthus to C3
Notes
• Taken on expiratory pause • A left lateral may also be requested. • Two films may be needed with large dogs.
• Taken on expiratory pause • Two films may be needed with large dogs.
CHAPTER 5 / IMAGING
c05.indd 169
169
3/14/2008 11:49:12 AM
Head Positioning Ensuring that the skull is level to the cassette is extremely important in producing a diagnostic radiograph. Supports strategically placed under the muzzle, neck, or cranium will assist.
Skill Box 5.3 / Head Positioning: Skull 5
Anatomic Area
Skull
View
Lateral
D/V
V/D
Cranium—Rostrocaudal
Positioning
• Lateral recumbency • Foam wedge placed under mandible to make muzzle parallel • Nasal septum parallel to cassette • Forelimbs extended caudally
• Sternal recumbency • Head is parallel to the cassette. • Forelimbs are relaxed with carpus flexed and out of the beam.
• Dorsal recumbency • Head is extended on cassette with support under the mid-cervical region to keep proper alignment. • Nose is parallel to cassette. • Skull is level on the cassette. • Forelimbs extended caudally
• Dorsal recumbency • Base of skull is resting on cassette with neck in a flexed position and the chin pulled toward the thorax with tape or gauze. • Forelimbs extended caudally
Measurement
• Highest point of zygomatic arch
• Widest point of cranium
• Lateral canthus of eye
• Frontal sinuses
Beam Center
• Lateral canthus of eye
• Lateral canthus of eye
• Lateral canthus of eye
• Between the eyes
Field of View
• Tip of nose to base of skull
• Tip of nose to base of skull
• Tip of nose to base of skull
• Entire cranium
Notes
• May require heavy sedation or general anesthesia
• May require heavy sedation or general anesthesia
• May require heavy sedation or general anesthesia
• May require heavy sedation or general anesthesia • Monitor for crimping if endotracheal tube is in place.
170
c05.indd 170
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:12 AM
Skill Box 5.4 / Head Positioning: Zygomatic Arch Anatomic Area
Zygomatic Arch
View
Lateral
D/V
Frontal
Lateral Oblique
V/D Open Mouth
Positioning
• Lateral recumbency • Foam wedge placed under mandible • Nasal septum parallel to cassette • Forelimbs extended caudally
• Sternal recumbency • Head is resting on the cassette. • Forelimbs are relaxed with carpus flexed and out of the beam.
• Dorsal recumbency • Head is resting on cassette with neck in a relaxed flexed position. • Nose is slightly off perpendicular to x-ray beam. • Skull is level on the cassette. • Forelimbs extended caudally
• Lateral recumbency • Cranium supported with wedge to achieve the oblique angle of the arch • Nasal septum perpendicular to cassette
• Dorsal recumbency • Head is extended with support under the midcervical region. • Mandible supported open using gauze • Skull is level on the cassette. • Forelimbs extended caudally
Measurement
• Highest point of zygomatic arch
• Highest point of cranium
• Lateral canthus of eye
• Highest point of cranium
• Lateral canthus of eye
Beam Center
• Lateral canthus of eye
• Lateral canthus of eye
• Lateral canthus of eye
• Slight off center from mid-cranium
• At a 45° angle to the maxilla between the upper 3rd and 4th premolars
Field of View
• Tip of nose to base of skull
• Tip of nose to base of skull
• Tip of nose to base of skull
• Tip of nose to base of skull
• Nasal cavities to cranial temporal skull
Notes
• May require heavy sedation or general anesthesia
• May require heavy sedation or general anesthesia
• May require heavy sedation or general anesthesia
• May require heavy sedation or general anesthesia
• Monitor for crimping if endotracheal tube is in place.
CHAPTER 5 / IMAGING
c05.indd 171
5
171
3/14/2008 11:49:12 AM
Skill Box 5.5 / Head Positioning: Tympanic Bullae Anatomic Area
5
Tympanic Bullae
View
D/V
Lateral Oblique
Rostrocaudal: Open Mouth
Positioning
• Sternal recumbency • Head is resting on the cassette. • Forelimbs are relaxed with carpus flexed and out of the beam.
• • • •
• Dorsal recumbency • Nose is perpendicular to cassette with maxilla and mandible supported open. • Base of skull is level on the cassette. • Forelimbs extended caudally
Measurement
• Highest point of cranium
• Level of tympanic bullae
• Level of commissure of lips
Beam Center
• Center of tympanic bullae
• Center of tympanic bullae
• Center of mouth and between commissure of lips
Field of View
• Lateral canthus of eye to base of skull
• Lateral canthus of eye to base of skull
• Entire nasopharyngeal area
Notes
• Superimposition of cranium makes view of bullae less than ideal; however, it permits comparison of left and right bullae in 1 view.
Lateral recumbency Unaffected bullae toward the cassette Skull slightly oblique Forelimbs slightly extended caudally
Skill Box 5.6 / Head Positioning: Temporomandibular Joint Anatomic Area
Temporomandibular Joint
View
D/V
V/D Oblique (Sagittal Oblique)
Positioning
• Sternal recumbency • Head is resting on the cassette. • Forelimbs are relaxed with carpus flexed and out of the beam.
• Lateral recumbency • Cranium rotated 20° toward the cassette (with support under mandible)
Measurement
• Highest point of cranium
• Lateral canthus of eye
Beam Center
• Lateral canthus of eye
• Temporomandibular joint
Field of View
• Base of the nose to the base of the skull
• Medial canthus of eye to base of skull
172
c05.indd 172
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:12 AM
Skill Box 5.7 / Head Positioning: Nasal Cavities and Sinuses Anatomic Area
Nasal Cavities and Sinuses
View
Lateral
D/V
D/V: Occlusal
Positioning
• Lateral recumbency • Foam wedge placed under mandible to keep muzzle parallel to cassette • Nasal septum parallel to cassette • Forelimbs extended caudally
• Sternal recumbency • Head is resting on the cassette. • Forelimbs are relaxed with carpus flexed and out of the beam.
• • • •
Measurement
• Highest point of zygomatic arch
• Highest point of cranium
• Caudal portion of maxilla
Beam Center
• Lateral canthus of eye
• Lateral canthus of eye
• Caudal portion of maxilla
Field of View
• Tip of nose to base of skull
• Tip of nose to commissure of lips
• Tip of nose to orbital bones
Notes
Sternal recumbency Head is resting on the cassette. Film is between maxilla and mandible. Forelimbs are relaxed with carpus flexed and out of the beam.
5
• Best to use “cassette-less” film (e.g., mammography film)
Skill Box 5.8 / Head Positioning: Nasal Cavities and Sinuses (continued) Anatomic Area
Nasal Cavities and Sinuses
View
V/D Open Mouth
Lateral Oblique
Frontal or Rostrocaudal
Positioning
• Dorsal recumbency • Forelimbs extended caudally • Head is extended on cassette with support under the mid-cervical region. • Nose is parallel to cassette with mandible extended caudally with supports. • Maxilla may be taped into position if necessary. • Skull is level on the cassette.
• Lateral recumbency • Head supported with wedge • Nasal septum perpendicular to cassette
• Dorsal recumbency • Forelimbs extended caudally • Head is resting on cassette with neck in a relaxed flexed position and muzzle pointing up at the tube. • Nose is slightly off perpendicular to cassette (10°). • Skull is level on the cassette.
Measurement
• 3rd upper premolar
• Highest point of cranium
• Most caudal aspect of muzzle (nose stop)
Beam Center
• 15° from vertical with the beam angled into the open mouth between the upper 3rd and 4th premolars
• Lateral canthus of eye
• Between the eyes
Field of View
• Tip of nose to pharyngeal area
• Tip of nose to base of skull
• Tip of nose to base of skull
Notes
• Remove or tie endotracheal tube to mandible.
• Same technique could be used to radiograph the foramen magnum. • Remove or tie endotracheal tube to mandible.
CHAPTER 5 / IMAGING
c05.indd 173
173
3/14/2008 11:49:12 AM
Spine Positioning The spine must be kept level as films are taken. A misaligned spine will result in distortion on the radiograph and therefore possibly a nondiagnostic radiograph. Levelness can be accomplished with supports under the mandible, neck, or thorax or between the limbs. A “V” trough or wedges are recom-
5
mended on all ventrodorsal views to stabilize the body of the animal. Always collimate down to exclude the soft tissues. Most of these positions will require some form of sedation or general anesthesia. Abbreviations have been used to conserve space and are as follows: O = occipital, A = atlantal, C = cervical vertebra, T = thoracic vertebra, TL = thoracolumbar vertebra, L = lumbar vertebra, S = sacral vertebra
Skill Box 5.9 / Spine Positioning: Cervical Anatomic Area
Cervical
View
Lateral
V/D
Extended Lateral
Flexed Lateral
Oblique Lateral
Positioning
• Lateral recumbency • Forelimbs retracted caudally • O-A joint is flexed at a 45° angle. • Elevate the mandible to be parallel to table with support. • Gauze may be needed around the mouth to keep head pulled slightly forward.
• Dorsal recumbency • Forelimbs extended caudally alongside the body • Spine parallel to cassette • Support under the neck can minimize distortion caused by a misaligned vertebra.
• Lateral recumbency • Forelimbs extended caudally • Extend the neck dorsally until resistance is met; gauze may be placed around the muzzle • Place support under the mandible and neck to maintain a level spine (especially with longnecked dogs).
• Lateral recumbency • Forelimbs extended caudally • O-A is flexed at a 90° angle. • Elevate the neck if necessary to keep it level with the spine (wedges). • Pull the lower mandible open with gauze to maintain the 90° angle.
• Lateral recumbency • Elevate the mandible to be parallel to table with support (wedges). • Elevate the sternum 20° above vertebral level/plane with support (wedges).
Measurement
• Over C7
• C5–C6
• Thoracic inlet (C7)
• Thoracic inlet (C7)
• Thoracic inlet (C7)
Beam Center
• C4–C5 and vertebral column
• C4–C5 and vertebral column
• C4–C5 and vertebral column
• C4–C5 and vertebral column
• C4–C5 and vertebral column
Field of View
• Caudal skull to T1
• Caudal skull to T1–T2
• Caudal skull to T1–T2
• Caudal skull to T1–T2
• Caudal skull to T1–T2
Notes
• Two films are recommended for large dogs.
• Two films are recommended for large dogs.
174
c05.indd 174
• Be careful not to overflex the neck, as tracheal damage may occur.
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:12 AM
Skill Box 5.10 / Spine Positioning: Thoracic–Lumbar Anatomic Area
Thoracic
Thoracolumbar
Lumbar
View
Lateral
V/D
Lateral
V/D
Lateral
V/D
Positioning
• Lateral recumbency • Forelimbs extended cranially • Hindlimbs extended caudally • Elevate sternum to thoracic vertebrae level to reduce rotational artifact.
• Dorsal recumbency • Forelimbs extended cranially • Hindlimbs in a relaxed position
• Lateral recumbency • Forelimbs slightly extended cranially • Hindlimbs slightly extended caudally
• Dorsal recumbency • Forelimbs extended cranially • Hindlimbs in a relaxed position
• Lateral recumbency • Forelimbs in a relaxed position • Hindlimbs extended caudally with support between them to keep hips parallel to the table
• Dorsal recumbency • Forelimbs extended cranially • Hindlimbs in a relaxed position
Measurement
• 7th–8th rib
• Highest point of the sternum
• TL junction
• TL junction
• Thickest area (L1)
• Thickest area (L1)
Beam Center
• T6–T7
• T6–T7 (caudal border of scapula)
• TL junction
• TL junction
• L4
• L4
Field of View
• C7–L1
• C7–L1
• T8–L5
• T8–L5
• T13–S1
• T13–S1
5
Notes
• May require support under sternum and midlumbar region for proper alignment and prevention of axial rotation artifact (especially in chondrodystrophic dogs with elongated backs)
• May require support under sternum and midlumbar region for prevention of axial rotation artifact
Skill Box 5.11 / Spine Positioning: Sacrum—Caudal Anatomic Area
Sacrum
Caudal
View
Lateral
V/D
Lateral
V/D
Positioning
• Lateral recumbency • Hindlimbs are slightly apart and relaxed with a support between them. • Tail is extended caudally, not supported.
• Dorsal recumbency • Hindlimbs are relaxed in semiflexion.
• Lateral recumbency • Tail is extended caudally and supported as needed to prevent excessive sagging or lateral flexion.
• Dorsal recumbency • Hindlimbs are relaxed in semiflexion. • Tail is extended straight caudally and supported as needed to prevent excessive sagging or lateral flexion.
Measurement
• Trochanters
• Mid-sacrum
• Area of concern
• Area of concern
Beam Center
• Greater femoral trochanter
• At 30° toward pubis
• Area of concern
• Area of concern
Field of View
• Pelvis to proximal caudal vertebral segments
• L6 to proximal caudal vertebra
• Includes area of concern plus several vertebra on either side
• Includes area of concern plus several vertebra on either side CHAPTER 5 / IMAGING
c05.indd 175
175
3/14/2008 11:49:12 AM
Shoulder and Forelimb Positioning Skill Box 5.12 / Shoulder and Forelimb Positioning: Scapula–Shoulder Anatomic Area
Scapula
Shoulder
View
Lateral—With Tension
Lateral—Without Tension
Caudocranial
Lateral
Caudocranial
Positioning
• Lateral recumbency • Affected forelimb is flexed at the elbow 90° and pulled caudally until the humerus is parallel to the spine and radius/ulna are perpendicular to spine. • Unaffected forelimb is extended caudally.
• Lateral recumbency • Affected forelimb extended caudally • Unaffected forelimb extended cranially
• Dorsal recumbency • Forelimbs extended cranially. • Sternum is rotated slightly away from the scapula of interest (just opposite midline).
• Lateral recumbency • Affected forelimb extended cranially • Unaffected forelimb flexed caudodorsally, parallel to the thorax • Head extended cranially
• Dorsal recumbency • Forelimbs extended cranially
Measurement
• Thickest area of shoulder/cranial thorax
• Thickest area of shoulder/cranial thorax
• Thickest area of shoulder
• Over manubrium
• Thickest area of shoulder
Beam Center
• Mid-scapula
• Mid-scapula
• Mid-scapula
• Shoulder joint
• Shoulder joint
Field of View
• Cranial aspect of the shoulder joint to the caudal scapular crest
• Cranial aspect of the shoulder joint to the caudal scapular crest
• Shoulder joint to T6
• Mid-scapula to mid-humerus
• Mid-humerus to mid-scapula
• Used when patient is injured or in pain
• Best method for viewing acromial process of scapular spine
• Ensure that the manubrium and cranial sternebrae do not overlap shoulder joint.
• Be aware of any rotation in the humerus that would result in an oblique view.
5
Notes
Skill Box 5.13 / Shoulder and Forelimb Positioning: Humerus Anatomic Area
Humerus
View
Lateral
Caudocranial
Craniocaudal
Positioning
• • • •
• Dorsal recumbency • Forelimbs are extended cranially. • Affected forelimb is parallel to cassette.
• Dorsal recumbency • Affected forelimb is extended caudally alongside the body but just clear of the thorax.
Measurement
• Thickest area of shoulder
• Thickest area of shoulder
• Thickest area of shoulder
Beam Center
• Mid-humerus
• Mid-humerus
• Mid-humerus
Field of View
• Shoulder joint to elbow joint
• Shoulder joint to elbow joint
• Shoulder joint to elbow joint
176
c05.indd 176
Lateral recumbency Affected forelimb is extended cranioventrally. Unaffected forelimb is extended caudodorsally. Head is extended dorsally.
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:13 AM
Skill Box 5.14 / Shoulder and Forelimb Positioning: Elbow Anatomic Area
Elbow
View
Lateral
Flexed Lateral
Craniocaudal
Positioning
• Lateral recumbency • Affected limb extended slightly cranioventrally with elbow slightly flexed • Unaffected limb extended caudodorsally • Head is extended dorsally
• Lateral recumbency • Affected limb flexed at the elbow joint with carpus pulled toward neck. • Unaffected limb extended caudoventrally • Head is extended dorsally
• Sternal recumbency • Affected limb extended cranially • Unaffected limb acts as a support for the animal’s head. • Head is placed resting over unaffected limb.
Measurement
• Thickest part of elbow joint
• Thickest part of elbow joint during flexion
• Thickest part of elbow joint
Beam Center
• Elbow joint
• Elbow joint
• Elbow joint
Field of View
• Mid-humerus to mid-radius/ulna
• Mid-humerus to mid-radius/ulna
• Mid-humerus to mid-radius/ulna
Notes
5
• Make sure that, when pulling the carpus, the elbow does not rotate. • This view is best for screening for elbow dysplasia (especially lesions of anconeal process of ulna). • A hyperflexed view also may be needed for diagnostic analysis.
CHAPTER 5 / IMAGING
c05.indd 177
177
3/14/2008 11:49:13 AM
Skill Box 5.15 / Shoulder and Forelimb Positioning: Radius/Ulna and Carpus Anatomic Area
5
Radius/Ulna
Carpus
View
Lateral
Craniocaudal
Lateral
Dorsopalmar
Positioning
• Lateral recumbency • Affected limb extended cranially and slightly flexed at the elbow • Unaffected limb extended caudally • Head is extended dorsally away from cassette.
• Sternal recumbency • Affected limb extended cranially • Unaffected limb extended cranially • Head is placed resting over unaffected limb.
• Lateral recumbency • Affected limb extended cranially • Unaffected limb extended ventrally and relaxed • Head is extended dorsally away from cassette.
• Sternal recumbency • Affected limb extended cranially • Unaffected limb extended cranially • Head is placed resting over unaffected limb.
Measurement
• Elbow joint
• Thickest area of elbow joint
• Distal carpus
• Mid-carpus
Beam Center
• Mid-radius/ulna
• Mid-radius/ulna
• Mid-carpus
• Mid-carpus
Field of View
• Distal humerus to mid-metacarpals
• Distal humerus to mid-metacarpals
• Distal radius/ulna to distal metacarpals
• Distal radius/ulna to distal metacarpals
Notes
• Avoid rotation of radius/ulna in cats.
• Support under the elbow may assist in maintaining proper carpal positioning. • Stressed views under sedation or general anesthesia may be needed to show presence of ligament laxity.
• Support under the elbow may assist in maintaining proper carpal positioning. • Oblique view at a 45° angle also may be required.
Skill Box 5.16 / Shoulder and Forelimb Positioning: Metacarpus/Phalanges Anatomic Area
Metacarpus/Phalanges
View
Lateral
Dorsopalmar
Positioning
• • • • •
• • • •
Measurement
• Middle phalanx
• Mid-metacarpal
Beam Center
• Middle phalanges or affected phalanx
• Mid-metacarpal
Field of View
• Distal radius/ulna to distal digits
• Distal radius/ulna to distal digits
Notes
• Support under the elbow may assist in maintaining proper carpal positioning. • Oblique view(s) may be needed in some cases.
• Support under the elbow may assist in maintaining proper carpal positioning. • Oblique view at 45º angle also may be required.
178
c05.indd 178
Lateral recumbency Affected limb extended cranially Affected phalange is isolated with gauze or tape and pulled dorsally. Unaffected limb extended caudally and relaxed Head is extended dorsally away from cassette.
Sternal recumbency Affected limb extended cranially Unaffected limb is extended cranially. Head is placed resting over unaffected limb.
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:13 AM
Pelvis and Hindlimb Positioning
Skill Box 5.17 / Pelvis and Hindlimb Positioning: Pelvis Anatomic Area
Pelvis
View
Lateral
Lateral Oblique
V/D—Frog Leg
V/D—extended
Positioning
• Lateral recumbency • Hindlimbs are extended down ventrally, slightly apart with the affected limb slightly cranial to unaffected limb, separated with a support to avoid spine rotation.
• Lateral recumbency • Affected hindlimb is extended down ventrally and slightly cranially. • Unaffected hindlimb is elevated to a 20º angle dorsally.
• Dorsal recumbency • Hindlimbs should be abducted and flexed at a 45º angle to spine, positioned identically.
• Dorsal recumbency • Pelvis flat on table • Hindlimbs start in a flexed frog leg position. The area just above the hocks are grasped and limbs are rotated medially so stifles come within 1–2 inches of each other, then extended caudally over the pubis region and ending in a full straight extension of the hindlimbs with patella centered over the femurs.
Measurement
• Greater trochanter
• Greater trochanter
• Acetabulum (groin)
• Acetabulum (groin)
Beam Center
• Greater trochanter
• Greater trochanter
• Pubis/acetabulum
• Pubis/acetabulum
Field of View
• Mid-lumbar spine to mid-femurs
• Mid-lumbar spine to mid-femurs
• Mid-lumbar spine to mid-caudal vertebrae
• Mid-lumbar spine to distal stifle
Notes
• Best view for L-S bony changes if cauda equina pain suspected • Requires high mA-s to penetrate large dog’s pelvic bones
• Used if trauma to the pelvis is suspected • Sandbags and V tray will assist in proper positioning.
• Sedation is necessary. • Standard for assessment of hips • Correct positioning will result in parallel femurs; patellae centered between femoral condyles; left and right pelvis should be displayed as a mirror image. • If hip laxity is in question, sometimes the Penn-HIP method is also recommended, which requires special certification of the veterinarian.
CHAPTER 5 / IMAGING
c05.indd 179
5
179
3/14/2008 11:49:13 AM
Skill Box 5.18 / Pelvis and Hindlimb Positioning: Femur, Stifles, and Tibia/Fibula Anatomic Area
Femur
Stifles
Tibia/Fibula
View
Lateral
Craniocaudal
Lateral
Caudocranial
Lateral
Caudocranial
Positioning
• Lateral recumbency • Affected limb joints slightly flexed and relaxed • Unaffected limb extended dorsally or abducted out of the beam
• Dorsal recumbency • Affected limb extended caudally with slight abduction • Unaffected limb is flexed and relaxed • Tail (if long) gently laid under unaffected limb
• Lateral recumbency • Affected limb slightly flexed and relaxed, with support under the hock if necessary to keep knee from rotating • Unaffected limb extended dorsally out of the beam
• Sternal recumbency • Affected limb extended caudally • Unaffected limb is flexed, relaxed, and supported.
• Lateral recumbency • Affected limb slightly flexed and relaxed, with support under tarsus to keep tibia from rotating • Unaffected limb extended cranially
• Sternal recumbency • Affected limb extended caudally • Unaffected limb is flexed, relaxed, and supported.
Measurement
• Mid-femur
• Mid-femur
• Thickest part of stifle
• Thickest part of stifle
• Mid-tibia/fibula
• Mid-tibia/fibula
Beam Center
• Mid-femur
• Mid-femur
• Mid-stifle joint
• Mid-stifle joint
• Mid-tibia/fibula
• Mid-tibia/fibula
Field of View
• Hip joint to proximal tibia/fibula
• Hip joint to proximal tibia/fibula
• Mid-femur to mid-tibia/fibula
• Mid-femur to mid-tibia/fibula
• Stifle joint to distal tarsus joint
• Stifle joint to distal tarsus joint
Notes
• Best view for bony neoplasia of femur
5
180
c05.indd 180
• Depending on size of animal, elevation of the pelvic area will alleviate weight off the stifle.
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:13 AM
Skill Box 5.19 / Pelvis and Hindlimb Positioning: Tarsus and Metatarsals Anatomic Area
Tarsus
Metatarsals
View
Lateral
Plantarodorsal
Dorsoplantar
Lateral
Plantarodorsal
Dorsoplantar
Positioning
• Lateral recumbency • Affected limb slightly flexed and relaxed with support under tarsus • Unaffected limb extended cranially
• Sternal recumbency • Affected limb extended caudally with support under the stifle • Unaffected limb is flexed, relaxed, and supported.
• Sternal recumbency • Affected limb extended cranially with support under the stifle
• Lateral recumbency • Affected limb slightly flexed at stifle and tarsus with support under stifle • Unaffected limb extended cranially
• Sternal recumbency • Affected limb extended caudally with support under the stifle • Unaffected limb is flexed, relaxed, and supported.
• Sternal recumbency • Affected limb extended cranially with support under the stifle and stifle rotated laterally
5
Measurement
• Thickest area of tarsus
• Thickest area of tarsus
• Thickest area of tarsus
• Distal tarsal joint
• Distal tarsal joint
• Distal tarsal joint
Beam Center
• Mid-tarsus
• Mid-tarsus
• Mid-tarsus
• Mid-metatarsals
• Mid-metatarsals
• Mid-metatarsals
Field of View
• Mid-tibia/fibula to mid-metatarsals
• Mid-tibia/fibula to mid-metatarsals
• Mid-tibia/fibula to mid-metatarsals
• Distal tibia/fibula to distal digits
• Distal tibia/fibula to distal digits
• Distal tibia/fibula to distal digits
Radiographic Contrast Studies Contrast studies are done in cases in which the area of concern cannot be viewed diagnostically from the survey radiographs. The contrast provides the veterinarian with a more thorough observation of the affected area. Many of the procedures listed in the following tables are to be performed by a veterinarian only. However, the tables are provided so the technician can be ready for the procedure and efficiently assist the veterinarian throughout the pro-
cedure. Patient preparation is of extreme importance, and the animal should always be clean and dry for these procedures. In some cases, an enema and fasting may be required so that the gastrointestinal tract is clear of food or feces that could superimpose or distort the anatomic images. The technician should be aware of the possible side effects from the contrast medium and be prepared for appropriate emergency procedures. Preparation for these procedures as well as the dosage of the contrast medium should always be reviewed with the veterinarian before the procedure.
CHAPTER 5 / IMAGING
c05.indd 181
181
3/14/2008 11:49:13 AM
Table 5.8 / Types of Contrast Media
5
Contrast Media
Positive Insoluble Iodine
Classification
• Barium sulfate (micropulverized suspension)
• Ionic (salt preparation)
• Nonionic (low osmolar)
• Gases
Trade Name
• Microtrast, Esophotrast, E-Z Past, Novopaque, Barotrast, Polibar
• Conray and Conray 43, Hypaque, Renografin 76 (IV, intraurethral, fistulas, intraperitoneal) • Gastrografin (oral only)
• Optiray 240, 320, and 350, Isovue (iopamidol), Omnipaque (iohexol), Visipaque (iodixanol) • Given IV, intraurethrally, into fistulas, intraperitoneally
• Carbon dioxide, nitrous oxide, oxygen, and room air
Indications
• Visualization of esophagus, stomach, small and large bowel, bronchography, and rhinography
• Intravascular usage
• Intravascular and myelographic studies
• Visualization of the bladder, peritoneum, pericardium, joints, and brain
Contraindications
• Perforations or ruptures suspected
• Myelography and arthrography • CHF, dehydration, and renal failure
• CHF and renal failure
• Areas not able to tolerate a transient reduction or interruption in blood flow
Side Effects
• Results in granulomas/ lesions if leaks outside GIT • Has excellent mucosalcoating properties, but can mask foreign bodies
• Acute renal failure, transient pulmonary edema, diarrhea, dehydration, and vomiting (bitter tasting to cats; use gastric tube to administer)
• Less frequently noted
• Gases may result in an embolism; possibly fatal if they access the vascular system
Monitoring
• Vomiting and apnea
• Nausea, vomiting, skin erythema, facial swelling, pulmonary edema (respiration), dehydration, hypotension, hypovolemia (pulse, CRT, MM, and temperature)
Notes
• Radiopaque—shows white on radiograph
• Radiopaque—shows white on radiograph • Patient must be well hydrated for any ionic contrast medium.
182
c05.indd 182
Positive Soluble Iodine
Negative
• Radiolucent—show up black on radiograph • May be combined with other contrast media for doublecontrast images
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:13 AM
Fistula Contrast Studies
Abdominal Contrast Studies
Skill Box 5.20 / Fistulography
Skill Box 5.21 / Abdominal Contrast Studies: Peritoneography
Procedure
Fistulography
Procedure
Area of Study
• Fistulous tracts and draining wounds
Peritoneography (Celiography) Positive Contrast
Area of Study Indications
• Nonresponsive draining wound
• Peritoneal cavity (diaphragm, abdominal wall, and serosal surfaces of abdominal viscera)
Contraindications
• None
Indications
• Suspected presence of diaphragmatic hernia
Contrast Media
• Positive, negative or double
Contraindications
• None
Equipment
• Balloon-tip catheter
Contrast Media
• Positive (iodinated)
Patient Preparation
• Sedation • Survey radiographs
Equipment
• ± Catheter/needle
Patient Preparation Technique
1. Place catheter into the sinus or fistula. 2. Inject ionic or nonionic iodinated contrast media to fill the cavity. 3. Leave catheter in place and radiograph.
• Sedation or general anesthesia • Empty patient’s bladder. • Abdominal survey radiographs
Technique
1. Needle or catheter placement into the peritoneal cavity (lateral to midline and caudal to umbilicus) 2. Aspiration test performed (injection into the umbilical fat will invalidate the study) 3. Infusion of nonionic iodinated contrast media and animal rolled carefully 4. Radiograph
Radiographic Views
• R- and L-LAT, VD, DV
Radiographic Views
LAT, VD, ± oblique
5
CHAPTER 5 / IMAGING
c05.indd 183
183
3/14/2008 11:49:13 AM
Gastrointestinal Tract Contrast Studies Skill Box 5.22 / Gastrointestinal Tract Contrast Studies: Esophagography and Gastrography Procedure
5
Esophagography
Gastrography Positive Contrast Study
Negative Contrast Study (Pneumogastrogram)
Double-Contrast Study
Area of Study
• Esophageal location and morphology
• Gastric morphology
• Gastric morphology
• Gastric morphology
Indications
• Vomiting of undigested food, gagging, or dysphagia
• Gastric masses/foreign body, or vomiting
• Gastric masses/foreign body, or vomiting
• Gastric masses/foreign body, or vomiting
Contraindications
• Inability to swallow, bronchoesophageal, rupture/ perforation, or dyspnea
• Parasitic infection
• Presence of ingesta or fluid
• Diabetes mellitus (if glucagon will be used)
Contrast Media
• Barium sulfate or if perforation is suspected iodinated contrast
• Barium sulfate 30–50% • Organic iodide (diatrizoate solution 10%)
• Carbon dioxide, nitrous oxide, or oxygen
• Barium sulfate 30%–50% and a negative contrast gas
Equipment
• Large syringe • Wet towels
• • • •
• Orogastric tube (only if gas is to be used) • Large syringe • 3-way valve • Bite block
• • • • •
Patient Preparation
• Fasting: 12 hours • Survey radiographs • Conscious patient
• Fasting: 12–24 hours • Large bowel evacuation or enema • Survey radiographs • Conscious patient
• Fasting: 12–24 hours • Survey radiographs • Conscious patient
• Fasting: 12–24 hours • Survey radiographs • Conscious patient
Technique
Technique I Mucosal assessment 1. Place patient in lateral recumbency. 2. Administer positive contrast medium into the buccal pouch. 3.Radiograph as the patient swallows. Technique II Stricture 1. Feed varying sizes of barium-filled gelatin capsules, barium-injected marshmallows, or mix with food. 2. Radiograph
1. Administer positive contrast medium (∼4– 8 mL/kg) orally with a syringe or through an orogastric tube. • Radiograph
1. Insert an orogastric tube into the stomach; verify placement. 2. Administer ∼5–8 mL/kg gas (air or carbon dioxide). 3. Remove orogastric tube and hold muzzle closed while radiographing.
1. Insert an orogastric tube into the stomach; verify placement. 2. Administer positive contrast medium (2 mL/kg). 3. Follow with 10–20 mL/kg gas (air or carbon dioxide) to achieve a tympanic stomach. 4. Roll patient to coat stomach and radiograph.
184
c05.indd 184
Orogastric tube Large syringe Wet towels Bite block
Orogastric tube Large syringe Wet towels 3-way valve Bite block
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:13 AM
Skill Box 5.22 / Gastrointestinal Tract Contrast Studies: Esophagography and Gastrography (Continued) Procedure
Esophagography
Gastrography Positive Contrast Study
Negative Contrast Study (Pneumogastrogram)
Double-Contrast Study
Radiographic Views
• R-LAT, R-VD OBL of neck and thorax
• R- and L-LAT, DV, VD
• R- and L-LAT, DV, VD
• R- and L-LAT, DV, VD
Notes
• Monitor for aspiration of contrast. • Fluoroscopy may aid in evaluation of motility and function. • Iodinated contrast materials are bitter tasting and may result in vomiting. They are also hypertonic (if inhaled, could result in pulmonary edema). • General anesthesia is not recommended because of the risk of aspiration after vomiting.
• Monitor for aspiration of contrast. • General anesthesia is not recommended because of inhibition of GI motility and risk of aspiration after vomiting.
• Monitor for aspiration of contrast. • General anesthesia is not recommended because of inhibition of GI motility and risk of aspiration after vomiting.
• Monitor for aspiration of contrast. • Fluoroscopy may aid gastric lesion evaluation. • General anesthesia is not recommended because of inhibition of GI motility and risk of aspiration after vomiting.
5
Note: See Skill Box 12.1 Stomach Tube and Gastric Lavage, page 428.
Skill Box 5.23 / Gastrointestinal Tract Contrast Studies: Upper and Lower Gastrointestinal Study Procedure
Upper Gastrointestinal Study (UGI) Barium
Upper Gastrointestinal Study (UGI) Iodinated Contrast
Lower Gastrointestinal Study (LGI) Double-Contrast Barium Enema
Area of Study
• Small intestine morphology and functionality
• Small intestine morphology and functionality
• Large bowel morphology
Indications
• Vomiting, diarrhea, neoplasias, or obstructions
• Bloody diarrhea
• Large bowel obstruction or bloody diarrhea
Contraindications
• Perforated esophagus or stomach • Lower bowel obstruction
• Dehydrated patient • Hypertonic mediums should not be used in hypovolemic patients (e.g., Gastrografin).
• Rupture/perforation
Contrast Media
• Barium sulfate 30%
• Ionic or nonionic iodinated contrast
• Barium sulfate diluted (10–20%)
CHAPTER 5 / IMAGING
c05.indd 185
185
3/14/2008 11:49:13 AM
Skill Box 5.23 / Gastrointestinal Tract Contrast Studies: Upper and Lower Gastrointestinal Study (Continued)
5
Procedure
Upper Gastrointestinal Study (UGI) Barium
Upper Gastrointestinal Study (UGI) Iodinated Contrast
Lower Gastrointestinal Study (LGI) Double-Contrast Barium Enema
Equipment
• • • •
• • • •
• • • • • • • •
Examination gloves Warmed barium sulfate Enema syringe Lubricant Foley catheter 3-way stopcock Compression paddle Wet towels
Patient Preparation
• Fasting: 24 hours • Tepid saline enema 4–12 hours before • Chemical restraint may be necessary; however, do not use parasympatholytic agents. • Conscious patient • Survey radiographs
• Fasting: 24 hours • Tepid saline enema 4–12 hours before • Chemical restraint may be necessary; however, do not use parasympatholytic agents. • Conscious patient • Survey radiographs
• • • •
Fasting: 24 hours Oral laxative and tepid water (or isotonic saline) enema General anesthesia Survey radiographs
Technique
1. Administer barium (∼4–8 mL/kg) orally with a syringe or through an orogastric tube. 2. Radiograph
1. Administer iodinated contrast (∼4–8 mL/kg) orally with a syringe or through an orogastric tube. 2. Radiograph
1. Place the animal in right lateral recumbency and insert the balloon catheter in the anus and inflate the balloon to completely occlude the anal canal. 2. Slowly infuse the diluted, body temperature barium sulfate mixture into the large bowel and cecum (∼10–15 mL/kg). 3. Clamp catheter and radiograph (add more contrast medium if bowel distention is not sufficient). 4. After these radiographs have been completed: evacuate the barium, place the animal in left lateral recumbency and infuse gas to redistend the colon. 5. Radiograph
Radiographic Views
Minute Exposure • 0 minutes: R- and L-LAT, VD • 5–15 minutes: R-LAT, VD • 30 minutes: R-LAT, VD • ± 45 minutes: R-LAT, VD • ± Q60 minutes: R-LAT, VD • Considered complete when stomach is empty and contrast medium is in the large intestines.
• LAT, VD every 10–30 minutes until the contrast medium is in the large intestine
• Right LAT, VD abdominal after barium infusion and then again after gas infusion
Notes
• Care must be taken on choice of anesthesia/sedation so as not to impede the motility of the GIT.
• Care must be taken on choice of anesthesia/sedation so as not to impede the motility of the GIT.
• If study is for diagnosis of obstruction or intussusception, no fecal evacuation is necessary. • Elevation of the cranial two thirds of the body may assist removal of the contrast media.
Orogastric tube Wet towels Large syringe Bite block
Orogastric tube Wet towels Large syringe Bite block
Note: See Skill Box 12.1 Stomach Tube and Gastric Lavage, page 428.
186
c05.indd 186
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:13 AM
Head Contrast Studies Skill Box 5.24 / Head Contrast Studies: Dacryocystorhinography, Rhinography, and Sialography Procedure
Dacryocystorhinography
Rhinography
Sialography
Area of Study
• Nasolacrimal duct
• Nasal cavity
• Salivary ducts and glands
Indications
• Conjunctivitis, dacryocystitis, or neoplasia
• Suspected obstruction
• Mucoceles, swelling, abscesses, or neoplasias
Contrast Media
• Positive iodinated
• Positive (barium sulfate 20%–30% or iodinated media)
• Positive iodinated
Equipment
• Cannula • 23–27-gauge lacrimal needle • Syringe
• Syringe
• Cannula • Syringe
Patient Preparation
• General anesthesia • Nasal survey radiographs
• General anesthesia • Nasal survey radiographs including lateral and open mouth VD views
• General anesthesia • Skull/neck survey radiographs
Technique
1. Cannulation of the superior or inferior lacrimal puncta 2. Inject iodinated contrast until several drops are seen in the external nares.
1. Infuse positive contrast into the ventral nasal meatus. 2. With the infused side dependent, elevate the nose approximately 15º.
1. Cannulation of the salivary duct 2. Injection of a small amount of iodinated contrast
Radiographic Views
• LAT, DV
• LAT, VD (open mouth)
• LAT, DV
5
CHAPTER 5 / IMAGING
c05.indd 187
187
3/14/2008 11:49:14 AM
Spinal and Joint Contrast Studies Skill Box 5.25 / Spinal and Joint Contrast Studies: Myelography and Epidurography Procedure
Myelography
Epidurography
Area of Study
• Spinal cord
• Epidural space
Indications
• Clinical transverse myelopathies
• Disc protrusion/extrusion, suspected lesion, or tumor
Contraindications
• Disseminated myelopathy, meningopathy, cerebrospinal fluid (CSF) infection
Contrast Media
• Positive nonionic media only (e.g., iopamidol, iohexol)
• Positive nonionic media only (e.g., iopamidol, iohexol)
Equipment
• 20–22-gauge spinal needle in various sizes: 11/2, 21/2, and 31/2
• Spinal needle
Patient Preparation
• General anesthesia • Spinal survey radiographs • Aseptic preparation of appropriate spinal location
• General anesthesia • Spinal survey radiographs • Aseptic preparation of lumbosacral or coccygeal interarcuate space
Technique
1. Aseptic spinal puncture of subarachnoid space at either cisterna magna or an interarcuate space of caudal lumbar spine (L5–L6) 2. Inject nonionic contrast media slowly to fill the subarachnoid space. 3. The needle may be removed or left in place for the radiographs.
1. Place patient in sternal or lateral recumbency. 2. Aseptic placement of spinal needle into the floor of the spinal canal at the lumbosacral or coccygeal interarcuate space 3. Inject nonionic contrast media to fill the space. 4. The needle is removed.
Radiographic Views
• LAT, VD, DV, OBL, extended/flexed LAT
• LAT, flexed LAT, Extended LAT, VD or DV
Notes
• Tilting of the body may be necessary to assist in the coating of the contrast media. • Elevate head during recovery. • Monitor for apnea and seizures.
5
188
c05.indd 188
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:14 AM
Skill Box 5.26 / Spinal and Joint Contrast Studies: Discography and Arthrography Procedure
Discography
Arthrography
Area of Study
• Central portion of intervertebral disc
• Joint evaluation (shoulder and stifle)
Indications
• Hernia or rupture
• Articular defects or joint capsule abnormalities
Contrast Media
• Positive nonionic media only (e.g., iopamidol, iohexol)
• Positive iodinated diluted to veterinarian’s recommendation
Equipment
• • • •
Spinal needle Sterile gloves Slides Culture
• Sterile gloves • 22-gauge needle • Slides
Patient Preparation
• • • • •
Spinal needle Sterile gloves General anesthesia Spinal survey radiographs Aseptic preparation of appropriate disc space
• General anesthesia • Joint survey radiographs • Prepare area around joint of interest.
Technique
1. Place patient in lateral recumbency. 2. Aseptical placement of spinal needle through the interarcurate ligament and spinal canal into the disc of interest 3. Inject nonionic contrast media into the space. 4. Radiograph
Radiographic Views
• Neutral LAT, hyperflexed, LAT, DV or VD
Notes
5
1. Aseptic articular puncture 2. Removal of small amount of joint fluid for analysis 3. Diluted nonionic contrast media is injected, dependent on animal size as per veterinarian’s recommended dosage 4. Needle is removed. 5. Joint is manipulated and radiographed. • Caudocranial LAT OBL • Radiographs should be taken as soon as contrast is injected. • Positive contrast study provides more information. • Double-contrast study is not recommended.
CHAPTER 5 / IMAGING
c05.indd 189
189
3/14/2008 11:49:14 AM
Urethra Contrast Studies Skill Box 5.27 / Urethra Contrast Studies: Urethrography, Canine Procedure
5
Urethrography Canine: Male
Canine: Female
Area of Study
• Urethra location and morphology
• Urethra location and morphology
Indications
• Stranguria, hematuria, dysuria, suspected masses or lesions
• Stranguria, hematuria, dysuria, suspected masses or lesions
Contraindications
• Uncontrolled hematuria
• Uncontrolled hematuria
Contrast Media
• Iodinated contrast medium (1 part iodine to 2 parts water; 10–15% solution)
• Iodinated contrast medium (1 part iodine to 2 parts water; 10–15% solution)
Equipment
• Urinary catheter (Foley, soft polyethylene male catheter) prefilled with contrast media • Large syringe • 3-way stopcock • Sterile saline • Lubricant • Wet towels • Bowl • Lidocaine
• Urinary catheter (Foley, Swan-Ganz, soft polyethylene male catheter) prefilled with contrast media • Large syringe • 3-way stopcock • Sterile saline • Lubricant • Wet towels • Bowl • Radiolucent paddle or wooden spoon
Patient Preparation
• • • •
• • • •
Technique
Retrograde Urethrography 1. Aseptic placement of a urinary catheter to distal urethra 2. ± Infuse 2–5 mL of lidocaine to ↓ urethral spasms. 3. Infuse undiluted contrast (10–20 mL) to fill urethra. 4. Radiograph during administration of the last few mLs of contrast medium. Repeat infusion for additional radiographs. Antegrade Urethrography 1. Aseptic placement of a urinary catheter to distal urethra 2. ± Infuse 2–5 mL of lidocaine to ↓ urethral spasms. 3. Infuse enough undiluted contrast to fill the bladder and induce urination. 4. Radiograph during voiding; gentle pressure may need to be applied to the bladder.
Retrograde Urethrography 1. Aseptic placement of a urinary catheter to distal urethra 2. ± Infuse 2–5 mL of lidocaine to ↓ urethral spasms. 3. Infuse undiluted contrast (5–10 mL) to fill urethra. 4. Radiograph during administration of the last few mLs of contrast medium. Repeat infusion for additional radiographs. Antegrade Urethrography 1. Aseptic placement of a urinary catheter to distal urethra 2. ± Infuse 2–5 mL of lidocaine to ↓ urethral spasms. 3. Infuse enough undiluted contrast to fill the bladder and induce urination. 4. Radiograph during voiding; gentle pressure may need to be applied to the bladder.
Radiographic Views
• LAT (including perineal area) • Repeat infusion for any additional radiographs.
• LAT, VD
Notes
Antegrade • Can be performed after positive contrast cystogram or urethrogram. • Be prepared to catch voided urine.
Fasting: 24 hours Enema 4 hours before Sedation Survey radiographs • Lateral of perineal and penile regions with hindlimbs extended cranially
Fasting: 24 hours Enema 4 hours before Sedation Survey radiographs
Note: See Skill Box 12.10 Urinary Catheterization, page 435.
190
c05.indd 190
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:14 AM
Skill Box 5.28 / Urethra Contrast Studies: Urethrography, Feline Procedure
Urethrography Feline: Male and Female
Area of Study
• Urethra location and morphology
Indications
• Stranguria, hematuria, dysuria, suspected masses or lesions
Contraindications
• Uncontrolled hematuria
Contrast Media
• Iodinated contrast medium (1 part iodine to 2 parts water; 10–15% solution)
Equipment
• • • • • • • •
Urinary catheter (tomcat catheter for males) prefilled with contrast media Large syringe 3-way stopcock Sterile saline Lubricant Wet towels Bowl Lidocaine
Patient Preparation
• • • •
Fasting: 24 hours Enema 4 hours before Sedation Survey radiographs
Technique
Retrograde Urethrography 5. Aseptic placement of a urinary catheter to distal urethra 6. ± Infuse 2–5 mL of lidocaine to ↓ urethral spasms. 7. Infuse undiluted contrast (5–10 mL) to fill urethra. 8. Radiograph during administration of the last few mLs of contrast medium. Repeat infusion for additional radiographs. Antegrade Urethrography 5. Aseptic placement of a urinary catheter to distal urethra 6. ± Infuse 2–5 mL of lidocaine to ↓ urethral spasms. 7. Infuse enough undiluted contrast to fill the bladder and induce urination. 8. Radiograph during voiding; gentle pressure may need to be applied to the bladder.
Radiographic Views
• LAT, ± OBL
5
Note: See Skill Box 12.10 Urinary Catheterization, page 435.
CHAPTER 5 / IMAGING
c05.indd 191
191
3/14/2008 11:49:14 AM
Vaginal Contrast Studies Skill Box 5.29 / Vaginal Contrast Studies: Vaginography Procedure
Vaginography Retrograde Vaginourethrography
5
Area of Study
• Vagina, cervix, and urethra morphology
Indications
• Masses, suspected ectopic ureter
Contraindications Contrast Media
• Iodinated contrast medium (1 part iodine to 2 parts water; 10–15% solution)
Equipment
• • • • • • • •
Urinary catheter (Foley, soft polyethylene male catheter) prefilled with contrast media 2 syringes (20–60 mL) 3-way stopcock Sterile saline Lubricant Wet towels Bowl Suture or Babcock forceps
Patient Preparation
• • • •
Fasting: 24 hours Enema 4 hours before General anesthesia Survey radiographs
Technique
• • • •
Place a urinary catheter into the vulva and cuff inflated just inside the vaginal vault. ± Pursestring suture or a Babcock forceps is used to keep the vulvar lips closed and the Foley catheter in place during the procedure. Infuse with undiluted iodinated contrast media to fill the vagina (e.g., back pressure felt on syringe). Radiograph as the infusion is administered, while the vagina is distended.
Radiographic Views
• LAT of pelvis and caudal abdomen, ± VD
Notes
• Overdistention of the vagina forces the contrast medium up the urethra and into the bladder.
192
c05.indd 192
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:14 AM
Urinary Tract Contrast Studies Preparation of the patient is extremely important in producing good-quality contrast radiographs of the urinary tract. An enema should always be done before the procedure, because fecal compression on the ureters or the dorsal bladder wall can ruin a study. The enema should be a warmed isotonic saline
enema. Hydration should be assessed and stabilized before beginning any of these procedures. The technician should note the special precautions and monitoring needed when doing an IVU/EU/IVP. Although rare, when complications do occur, they can be fatal, and being prepared for the possible emergency situation can make a difference.
Skill Box 5.30 / Urinary Tract Contrast Studies: Cystography Procedure
Cystography
Procedure
Intravenous Urography (IVU), Excretory Urography (EU), Intravenous Pyelography (IVP) Area of Study
• Urinary system: kidneys, ureters, and urinary bladder
Indications
• Pyuria, hematuria, masses, tender abdomen, abnormal renal size, incontinence, trauma, or suspected ectopic ureters
Contraindications
• • • •
Contrast Media
• Iodinated contrast for intravascular injection; warmed
Equipment
• • • • • • •
IV catheter; large bore, short (contrast is viscous) Syringe 22-gauge—1-inch needle Iodinated contrast Compression bandage Fluids ready to use Resuscitation kit (epinephrine, AMBU bag, oxygen ready)
Patient Preparation
• • • • • • •
24-hour fast but have water available Enema (warm, isotonic saline): 4 hours prior Hydration assessed, stabilized, and monitored Urine sample obtained prior to procedure IV catheter Sedation or general anesthesia Abdominal survey radiographs
Cystography
5
Intravenous Urography (IVU), Excretory Urography (EU), Intravenous Pyelography (IVP) Technique
1. Rapid (1–3 minutes) intravenous infusion of a warmed iodinated contrast media (3 mL/kg; 90 mL maximum) 2. Radiograph immediately and follow-up radiographs as listed below
Radiographic Views
Minute Exposure • 0 minutes: VD, LAT • 3–5 minutes: VD, ± LAT, ± VD OBL, ± R-LAT OBL • 10–15 minutes: VD, LAT, ± LAT OBL • 30–120 minutes: VD, LAT, ± LAT OBL
Notes
• Monitor for hypotension, vomiting, arrhythmia, cardiovascular collapse, anaphylaxis, and contrast medium–induced acute renal failure (CMIARF). • Abdominal compression may be used to visualize the renal collecting system and proximal ureters. • Oblique radiographs may be required to visualize the distal ureters. • Do not use soapy enemas. • Contrast media may cause vasodilation and stinging. • Three stages include nephrogram, pyelogram, and cystogram.
Hypovolemia Creatinine >3–3.5 mg/dL Dehydration No compression if abdominal masses or enlarged or cystic kidneys are suspected
Note: See Skill Box 8.9 Intravenous Catheter Placement, Peripheral and Jugular, page 349.
CHAPTER 5 / IMAGING
c05.indd 193
193
3/14/2008 11:49:14 AM
Skill Box 5.31 / Urinary Tract Contrast Studies: Cystography (continued) Procedure
5
Cystography Positive Contrast
Negative Contrast (Pneumocystography)
Double Contrast
Area of Study
• Urinary bladder wall integrity and position
• Urinary bladder
• Urinary bladder mucosal detail
Indications
• Trauma, hematuria, or straining
• Trauma, hematuria, or straining
• Trauma, hematuria, or straining
Contraindications
• Enlarged bladder
• Enlarged bladder
• Enlarged bladder
Contrast Media
• Iodinated contrast (1 part contrast to 3 parts water)
• Gas (carbon dioxide, nitrous oxide, oxygen)
• Negative and positive iodinated contrast media
Equipment
• Urinary catheter (Foley, tomcat, or soft flexible male catheter) • Large syringe • 3-way stopcock • Sterile saline • Lubricant • Wet towels • Bowl • 5–10 mL 2% lidocaine (to ↓ spasms)
• Urinary catheter (Foley, tomcat, or soft flexible male catheter) • Large syringe • 3-way stopcock • Sterile saline • Lubricant • Wet towels • Bowl • 5–10 mL 2% lidocaine (to ↓ spasms)
• Urinary catheter (Foley, tomcat, or soft flexible male catheter) • Large syringe • 3-way stopcock • Sterile saline • Lubricant • Wet towels • Bowl • 5–10 mL 2% lidocaine (to ↓ spasms)
Patient Preparation
• 24-hour fast • Enema (warm, isotonic saline—4 hours before • Urine sample obtained before procedure • Sedation or general anesthesia • Survey radiographs
• 24-hour fast • Enema (warm, isotonic saline—4 hours before • Urine sample obtained before procedure • Sedation or general anesthesia • Survey radiographs
• • • • •
Technique
1. Aseptic placement of a urinary catheter to the bladder neck 2. Empty the bladder and note amount remove to estimate amount of contrast medium to use. 3. Infuse 5–10 mL lidocaine to ↓ bladder spasticity. 4. Infuse positive contrast medium diluted with saline (∼10 mL/kg) into the urinary catheter and monitor the bladder by palpation until distended. 5. Radiograph
1. Aseptic placement of a urinary catheter to the bladder neck 2. Empty the bladder and note amount remove to estimate amount of contrast medium to use. 3. Infuse 5–10 mL lidocaine to ↓ bladder spasticity. 4. Infuse gas (∼10 mL air/kg) into the urinary catheter and monitor the bladder by palpation until distended. 5. Radiograph
1. Aseptic placement of a urinary catheter to the bladder neck 2. Empty the bladder and note amount remove to estimate amount of contrast medium to use. 3. Infuse 5–10 mL lidocaine to ↓ bladder spasticity. 4. Infuse gas (∼10 mL air/kg) into the urinary catheter and monitor the bladder by palpation until distended. 5. Infuse a small amount (canine: 1–3 mL, feline: 1–2 mL) of iodinated contrast into the urinary catheter. 6. Roll animal to coat bladder wall and radiograph.
194
c05.indd 194
24-hour fast Enema (warm, isotonic saline—4 hours before Urine sample obtained before procedure Sedation or general anesthesia Survey radiographs
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:14 AM
Skill Box 5.31 / Urinary Tract Contrast Studies: Cystography (continued) (Continued) Procedure
Cystography Positive Contrast
Negative Contrast (Pneumocystography)
Double Contrast
Radiographic Views
• LAT, VD OBL • If further radiographs are necessary, inject additional contrast media.
• LAT, VD, ± OBL • If further radiographs are necessary, inject additional contrast media.
• LAT, VD OBL
Notes
• Complications may include trauma due to improper catheterization, iatrogenic infection, or chemical cystitis.
• Room air may cause an air embolus; carbon dioxide is recommended. • Complications may include trauma caused by improper catheterization, iatrogenic infection, or air emboli.
• Room air may cause an air embolus; carbon dioxide is recommended. • Complications may include trauma caused by improper catheterization, iatrogenic infection, air emboli, or chemical cystitis.
5
Note: See Skill Box 12.10 Urinary Catheterization, page 435.
Additional Imaging Techniques In addition to radiographs, the following modalities can be used to further assist in the diagnosis of a patient’s medical problem. Survey radiographs should always be evaluated before any of these modalities. Table 5.9 / Computed Tomography and Echocardiography Procedure
Computed Tomography (CT, CAT scan)
Echocardiography
Definition
A cross-sectional image is taken by a rotating image recorder. A set of 3 images is then used by a computer to construct the final image. This technique facilitates easier visualization by avoiding superimposition of surrounding organs. CT is also able to distinguish between gas, fat, fluid, and calcification.
Noninvasive study of the heart and its structures (aorta, ventricles, atria, auricular appendages, and all the cardiac valves), using ultrasonography
Technique
• A thin rotating x-ray beam passes through the patient transaxially, and 3 views of the area of interest are reconstructed by a computer using the transmitted data onto a video screen.
• The ultrasound transducer is placed on a clipped and cleaned area with ultrasound gel. M-mode is used to view the cardiac structures and produce the image. The animal may be in lateral or dorsal recumbency or standing if necessary.
Indications
• Confirmation or further evaluation of radiographic results • Intracranial disease, musculoskeletal, spinal, thoracic, and abdominal disorders
• Visualize internal cardiac structures. • Evaluate cardiac function and size, defects (e.g., valvular lesions, shunts, myocardial abnormalities, masses, effusions, stenotic lesions). • Evaluate respiratory distress or pleural effusion.
Specialized Equipment
• CT unit
• Ultrasound machine, transducers, Doppler (permits detection and analysis of blood cells in transit), ultrasound gel
Precautions
• ↑ Risk of radiation exposure (much larger amounts used in imaging)
• None
Notes
• Two studies are usually required (with and without contrast media).
• May be necessary to clip the fur from right 3rd–6th intercostal and left 4th–7th intercostal CHAPTER 5 / IMAGING
c05.indd 195
195
3/14/2008 11:49:14 AM
Table 5.10 / Fluoroscopy Procedure
Fluoroscopy
Definition
Real-time radiographic viewing of moving anatomic parts, using an x-ray machine and a fluoroscopic screen with an image intensifier
Technique
• X-rays pass through the patient’s body to the image intensifier tube.
Indications
• Used in assessing the motility and function of the pharynx, esophagus, stomach, and bowel • Evaluation of respiratory and cardiac function
Specialized Equipment
• • • • •
Precautions
• ↑ risk of radiation exposure due to high doses of radiation for this procedure
Notes
• Bone appears black and gas appears white on image. • Endoscope and ultrasound being used in place of this technique more frequently
5
Fluoroscopic x-ray tube Image intensifier tube Mirror imaging or television viewing system Radiopaque contrast medium Protective apparel
Table 5.11 / Magnetic Resonance Imaging and Nuclear Medicine Procedure
Magnetic Resonance Imaging (MRI)
Nuclear Medicine (Scintigraphy)
Definition
A cross-sectional view of a patient’s body, using magnetic fields and radio waves
The use of radiopharmaceutical drugs to ascertain the functional status of an organ or body part of a patient
Technique
• A magnet surrounds a patient’s body, and the magnetic field reacts with the hydrogen atoms in the patient’s body, which is then used to reconstruct an image by a computer onto a video screen.
• A radionuclide is administered intravenously to the patient. Travel throughout the area is captured on x-ray film, using a gamma scintillation camera.
Indications
• Confirmation of further evaluation of radiographic results • Soft tissue contrast, brain, and spine
• Specific areas requiring more information on functionality of specific organs for diagnostic assessment (e.g., hyperthyroidism, lameness, and liver dysfunction)
Specialized Equipment
• Magnetic resonance imaging unit • Special room/building for unit • Nonferrous contrast media
• • • • •
Precautions
• Patient and operator must be free of any metallic devices (pacemakers), metallic foreign bodies (bullets, shrapnel, skin staples, etc.), or ferromagnetic implants. • Operator is in a separate area from the patient.
• Requires special handling of animal’s excretion and restricted contact time with patient
Notes
• CT is preferred for bone evaluation.
• Specific drugs are used to analyze various areas.
196
c05.indd 196
Radiopharmaceutical drugs Gamma scintillation camera Radiographic film Protective lab coat Specialized training in handling drug and patient’s excretions
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:14 AM
Ultrasonography The indications for the use of ultrasound are extensive and provide an additional level to diagnostics. This noninvasive, nonpainful technique is used as a complement to radiography to allow evaluation, diagnosis, and staging of many diseases. Ultrasound is the best modality for the evaluation of fluid-
filled and soft tissue organs, most importantly the heart. Doppler ultrasonography is an additional technique used to identify blood flow and velocity and calculate pressure of the heart and uterus. Ultrasound also excels at diagnosing discrete changes not apparent on any other test. Due to the minute complexities of ultrasound findings, it is often necessary to seek the opinion of a board-certified veterinary radiologist, when feasible and/or practical.
Table 5.12 / Ultrasonography
a
Procedure
Ultrasonography
Definition
The production of a computer image based on the emission and return of sound waves from the ultrasound’s transducer into an animal’s body
Technique
• Ultrasound transducing gel is placed on the clipped and cleaned area of interest. A transducer probe is placed on the gel. B-mode is used to view the abdominal structures. Sound waves are emitted through the transducer into the body, the sound waves strike the internal structures, and then send echoes back to the transducer. The received echoes are then reproduced as a gray scale image on the screen.
Indications
• Confirmation or further evaluation of anomalies found on radiographs • Evaluation of specific endocrine disorders (e.g., adrenal and thyroid glands) or injury/disease of: joints, tendons, cardiac, thoracic, renal, hepatic, GIT, abdominal, urogenital, ocular, vascular, pregnancy, soft tissue • Assessment of cardiac function with a Doppler ultrasonography
Specialized Equipment
• Ultrasound machine • Appropriate transducers (e.g., 5-, 7.5-MHz transducers) • Ultrasound gel
Precautions
• Biopsy complications (e.g., hemorrhage, organ laceration) due to lack of direct visualization • Artifacts on examination can lead to misleading information and an incorrect diagnosis or treatment (experience of operator critical).
Notes
• • • • • •
5
Sedation or general anesthesia may be necessary for ultrasound-guided needle aspirations and commonly used for core biopsies. Sedation if necessary for anxious or fractious patients. Sedation and general anesthesia are contraindicated when performing an echocardiogram. Owners should be made aware that a large area of fur may be clipped. Wipe probe clean of gel as soon as possible. Wash transducer probe with cold water (do not immerse) and dry with a soft towel.
Pregnancy confirmation can be done 20 (feline) or 25 (canine) days post breeding, earlier than radiographic dates.
CHAPTER 5 / IMAGING
c05.indd 197
197
3/14/2008 11:49:14 AM
Skill Box 5.32 / Ultrasonography: Basic Scanning Techniquea
5
5. Choose the highest frequency transducer possible for the patient and area under examination. This provides the best resolution but also limits depth of penetration of the sound beam. 6. Set the power setting as low as possible but so that the most distal structure in the field can be seen. 7. Use the time gain compensation control to obtain an image of uniform brightness. 8. Do not press the transducer too hard against the patient as this may cause discomfort. Simply use sufficient pressure to maintain good contact between the skin and the transducer. 9. Scan slowly and thoroughly to ensure complete examination of each structure, scanning organs in at least 2 planes to allow a threedimensional impression to be built up from the cross-sectional images.
1. Prepare the patient: a. GIT scans: withhold food for 12 hours. b. Urinary tract scans: a full bladder is helpful. c. Clip and clean area of interest. d. ± sedation/anesthesia 2. Position the animal in a consistent orientation on the scanning table (this will make learning and consistent orientation of images easier). 3. If right-handed, it is usually easiest to hold the transducer in the right hand and use the left hand to make control panel adjustments. 4. Dim the room lighting to reduce reflections from the screen and enhance visualization of the image.
a
Reprinted from BSAVA Manual of Advanced Veterinary Nursing (1999), page 129; edited by Alasdair Hotston Moore with publisher’s permission.
Skill Box 5.33 / Ultrasonography: Sites for Ultrasound Scanninga Organ
Position of Animal
Area to Clip
Applications
Liver and Gall Bladder
• Dorsal or lateral recumbency or standing (may need to reposition to relocate bowel gas if it interferes)
• Ventral abdomen from xiphisternum to umbiculus, for several centimeters, to either side of midline
Liver: (deep-chested dogs)
• Left lateral recumbency
• Ventral third of last 4 ribs on right. Position transducer in intercostals spaces
• • • • •
Spleen
• Dorsal or right lateral recumbency
• As for liver, but extend farther caudally. Locate head of spleen on left, then follow body and tail.
• Focal lesions (e.g., tumors) • Diffuse lesions (e.g., venous congestion, tumors)
Kidney
• Lateral recumbency with kidney to be examined uppermost (or can use sternal recumbency or standing)
• Slightly beneath sublumbar muscles • L: behind last rib • R: over last 2 intercostal spaces
• Dorsal recumbency
• Ventral abdomen (but flank approach as above is best)
• • • • •
198
c05.indd 198
Focal lesions (e.g., tumors) Diffuse lesions (e.g., cirrhosis) Biliary obstruction Portocaval shunts Venous congestion
Focal lesions (e.g., cysts) Diffuse lesions (e.g., tumors) Hydronephrosis Pyelonephritis Renal calculi
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:14 AM
Skill Box 5.33 / Ultrasonography: Sites for Ultrasound Scanninga (Continued) Organ
Position of Animal
Area to Clip
Applications
Ovary
• Lateral recumbency as for kidney
• As for kidney • Adrenal located cranial pole of kidney
• Polycystic ovaries • Tumors
Adrenal
• Lateral recumbency as for kidney
• As for kidney • Adrenal located cranial pole of kidney
• Hyperplasia (e.g., Cushing’s) • Neoplasia
Bladder
• Dorsal or lateral recumbency or standing
• Ventral midline from umbilicus to pubic brim, or to 1 side of prepuce in male dogs
• Cystic calculi • Tumors • Cystitis
Prostate
• Dorsal or lateral recumbency
• To 1 side of prepuce just in front of pubic brim. Locate bladder, then move caudally.
• Focal lesions (e.g., cysts) • Diffuse lesions (e.g., tumors) • Paraprostatic cysts
Uterus
• Dorsal or lateral recumbency
• Ventral midline from umbilicus to pubis
• • • •
Testicle and Scrotum
• Dorsal or lateral recumbency
• Scrotal testicles rarely require any clipping
• Scrotal hernia • Tumors • Abscesses
Cryptorchid Testicle
• Dorsal or lateral recumbency
• Pubis to umbilicus on appropriate side of midline. Start in front of pubis and work toward bladder and then kidney.
• Location of intra-abdominal testicle
Pancreas
• Dorsal recumbency
• Entire ventral abdomen from xiphistermun to umbilicus
• Pancreatitis • Tumors
Gastrointestinal Tract
• Dorsal recumbency
• Entire ventral abdomen
• Bowel wall thickening • Intussusception • Intestinal tumors
Abdomen
• Dorsal recumbency
• Entire ventral abdomen
• Free fluid • Unidentified masses (e.g., mesenteric tumors)
Heart
• Left and right lateral recumbency • Best to use a table with a hole cut so can scan from beneath; this keeps heart close to chest wall and keeps lung out of the way.
• Ventral third of ribs 4–6. • Transducer placed in intercostal spaces
• • • •
5
Pregnancy diagnosis Fetal distress/death Pyometra Stump granuloma
Pericardial effusion Valvular disease Myocardial disease Congenital defects
CHAPTER 5 / IMAGING
c05.indd 199
199
3/14/2008 11:49:14 AM
Skill Box 5.33 / Ultrasonography: Sites for Ultrasound Scanninga (Continued)
5
Organ
Position of Animal
Area to Clip
Applications
Thorax
• Left and right lateral recumbency
• Over area of interest
• Free fluid • Masses (e.g., thymic lymphoma, chest wall masses) • Diaphragmatic rupture
Eye • Most useful if direct visualization obscured
• Use local anesthetic drops on cornea
• Place transducer directly on cornea (can scan through closed eyelids but image not as good).
• Retinal detachment • Intraocular masses
Orbit
• As for the eye
• As for the eye
• Retrobulbar foreign bodies, abscesses, tumors
a
Reprinted from BSAVA Manual of Advanced Veterinary Nursing (1999), pages 129–130; edited by Alasdair Hotston Moore with publisher’s permission.
200
c05.indd 200
SECTION THREE: DIAGNOSTIC SKILLS
3/14/2008 11:49:15 AM
Uterine horn Ovary
Ureter Colon
Esophagus Right kidney
Lungs
Trachea
Lungs
Spleen
Left kidney
Stomach
Ureter
Anus
Urinary bladder
Liver Heart Greater omentum (covering small intestines)
Liver
Thymus
Colon
Small intestines Urinary bladder
Heart (cardiac notch)
Figure 1.6 Internal organs: left lateral view. Figure 1.7 Internal organs: right lateral view.
Esophagus
Trachea Left subclavian artery
Lung
Heart
Superior vena cava
Aortic arch Pulmonary arteries Left atrium
Pulmonary veins
Diaphragm
Liver
Left auricle
Right atrium
Liver
Gall bladder Common bile duct
Lesser omentum Stomach Greater omentum (cut)
Liver Duodenum Pancreas Transverse colon Ascending colon Cecum
Spleen Jejunum Ileum
Pulmonary veins Left ventricle
Inferior vena cava
Coronary artery Right ventricle Apex
Rectum
Descending colon
Mesentery
Figure 1.9 Circulatory: dorsal view of heart.
Anal gland
Figure 1.8 Internal organs: ventral view.
CP-1
Left subclavian artery Aorta Superior vena cava Right auricle
Right atrium
Tricuspid valve Right ventricle
Figure 1.12 Circulatory: lateral view.
Apex
Semilunar valves of aorta
Left atrium
Vagosympathetic trunk Brachial plexus
Lumbo-sacral plexus
Vagus Sciatic
Bicuspid valve Left ventricle
Chordae tendineae
Femoral Radial
Median Ulnar
Ventral papillary muscle
Figure 1.10 Circulatory: internal view of heart. Figure 1.14 Nervous system: lateral view.
CP-2
Tibial
Figure 4.1 Top: Canine bone marrow aspirate showing erythroid precursors (e.g., round nuclei, coarse chromatin, blue to red cytoplasm). Bottom: The stages of erythrocyte maturation: 1, rubriblast; 2, prorubricyte; 3, rubricyte; 4, metarubricyte; 5, polychromathilic erythrocyte; 6, mature erythrocyte. (From Veterinary Hematology and Clinical Chemistry, page 151, Figure 13.4.)
Figure 4.3 Maturation stages of megakaryocytes. Large arrow, megakaryoblasts; arrowhead, promegakaryocyte; small arrow, mature megakaryocyte. (From Veterinary Hematology and Clinical Chemistry, page 153, Figure 13.8.)
Figure 4.2 Top: Canine bone marrow aspirate showing granulocytic precursors (e.g., irregularly shaped nuclei, fine chromatin pattern, purple cytoplasm). Bottom: The stages of granulocyte maturation: 1, myeloblast; 2, promyelocyte; 3, myelocyte; 4, metamyelocyte; 5, band neutrophil; 6, segmented neutrophil. (From Veterinary Hematology and Clinical Chemistry, page 151, Figure 13.5.)
CP-3
Figure 4.5 Histiocytoma: poikilocytosis, variable amount of blue cytoplasm, ↑ nuclear/cytoplasm ratio, round, oval, or irregularly shaped nuclei with lacy or finely stippled chromatin pattern. (Photograph courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.)
Figure 4.7 Mast cell tumor: anisocytosis, round to oval nuclei, stain palely, fine to coarse, reddish-purple granules within the cytoplasm. (Photograph courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.)
Figure 4.6 Lymphoma: dense nuclear margins, basophilic cytoplasm, granular chromatin, ↑ nuclear/cytoplasm ratio, and ≥ nucleolus. (Photograph courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.)
Figure 4.8 Clostridium: large rods, “safety pin” appearance (non-staining spore within the sporangium). (Photograph courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.)
CP-4
Figure 4.9 Giardia: pear-shaped, concave ventral surface, two outlined nuclei resembling eyes along with a nose and mouth, forward or “falling leaf” motility. (Photograph courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.)
Figure 4.11 Spirochetes: stiff corkscrew helical rods with tight spirals, corkscrewing motility. (Photograph courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.)
Figure 4.10 Campylobacter: tiny, curved rods, two attached together as a “seagull” or “W” shape, “swarm of bees,” rapid and darting motility. (Photograph courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.)
Figure 4.12 Yeast: rarely internal structures; smaller than Giardia. (Photograph courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.)
CP-5
Figure 4.13 Top: canine IMHA blood smear (e.g., regenerative anemia, polychromatophilic erythrocytes, nucleated erythrocytes [arrowheads]) and Howell-Jolly body (arrow). Bottom left: lead poisoning, basophilic stippling (small arrow). Bottom right: arrow, Howell-Jolly body. (From Veterinary Hematology and Clinical Chemistry, page 76, Figure 5.15.)
Figure 4.14 Distemper (arrows): round, oval, or irregular faint blue inclusions. (From Veterinary Hematology and Clinical Chemistry, page 79, Figure 5.23.)
CP-6
Figure 4.15 Feline blood smear showing macrocytic gray-blue polychromatophilic and normal RBCs, neutrophil, platelets, Howell-Jolly body (large arrow), and Hemobartonella felis (small arrows). (Photograph courtesy of Oklahoma State University Clinical Pathology Teaching Files. From Schalm’s Veterinary Hematology, page 1066, Figure 164.3.)
Figure 4.16 Canine blood smear showing polychromatophilic erythrocytes (arrowheads), nucleated RBCs (rubricytes and metarubriytes—thin arrows), and spherocytes (thick arrows). (Photograph courtesy of Oklahoma State University Clinical Pathology Teaching Files. From Schalm’s Veterinary Hematology, page 1058, Figure 163.2.)
Figure 4.17 Feline blood smear showing reticulocytes (aggregate and punctate), platelets, and polychromatic RBCs with Heinz bodies. The Heinz bodies are also seen floating freely in the background. (From Schalm’s Veterinary Hematology, page 115, Figure 19.4.)
Figure 4.19 Canine blood smear: leptocytes (arrows), folded cells (arrowheads). (From Veterinary Hematology and Clinical Chemistry, page 75, Figure 5.12.)
Figure 4.18 Feline blood smear showing iron-deficiency anemia. Blister cells (small arrows) and keratocytes (large arrows) are present. Insert: Canine blood smear showing iron-deficiency. Blister cell (small arrow) and hypochromic erythrocyte (arrowhead). (From Veterinary Hematology and Clinical Chemistry, page 73, Figure 5.5.)
Figure 4.20 Canine blood smear showing anemia from a patient with a ruptured hemangiosarcoma of the spleen. Left: Acanthocytes (arrows) and polychromatophilic cells. Right: Acanthocytes (arrows) and schistocytes (arrowheads). (From Veterinary Hematology and Clinical Chemistry, page 73, Figure 5.6.)
CP-7
Figure 4.21 Paired, teardrop-shaped structures of a dog infected with Babesia canis. (From Schalm’s Veterinary Hematology, page 158, Figure 27.7.)
Figure 4.22 Small, irregular rings found in the RBCs of a cat infected with Cytauxoon felis. (From Schalm’s Veterinary Hematology, page 160, Figure 27.10.)
CP-8
Figure 4.23 Example of the multiple appearances of the segmented neutrophil nucleus. Band neutrophils begin with a horseshoe-shaped nucleus, and as it ages, the nucleus continues to segment. (From Veterinary Hematology and Clinical Chemistry, page 126, Figure 10.2.)
Figure 4.24 Example of the multiple appearances of lymphocytes. Nucleus varies from oval to round. Cell shape varies with indentation (small arrow) by surrounding RBCs. Lymphocyte size is typically smaller than a neutrophil (large arrow). Amount of cytoplasm varies between cells. (From Veterinary Hematology and Clinical Chemistry, page 126, Figure 10.3.)
Figure 4.27 Example of the multiple appearances of eosinophils. Eosinophils are typically larger than neutrophils (arrowheads). C (canine): variable granular size and dissolving granules during staining to appear as cytoplasmic vacuoles. F (feline): barrel of rod-shaped granules that vary in density. (From Veterinary Hematology and Clinical Chemistry, page 128, Figure 10.7.) Figure 4.25 Example of the multiple appearances of monocytes. Nucleus may be round, bean, amoeboid, or horseshoe shape or segmented. Cytoplasm may contain vacuoles. Monocytes are typically larger and have a darker blue-gray cytoplasm compared to a neutrophil (large arrow). (From Veterinary Hematology and Clinical Chemistry, page 127, Figure 10.5.)
Figure 4.26 Canine blood smear with a vacuolated monocyte and RBCs exhibiting distinct central pallor. (Photograph courtesy of Oklahoma State University Clinical Pathology Teaching Files. From Schalm’s Veterinary Hematology, page 1058, Figure 163.1.)
Figure 4.28 Example of the multiple appearances of basophils. Basophils are larger than neutrophils (inset square). C (canine): sparsely granulated. F (feline): large, poorly staining gray granules packed in the cytoplasm. (LA, large animal.) (From Veterinary Hematology and Clinical Chemistry, page 129, Figure 10.8.)
CP-9
Figure 4.29 Canine blood smear showing the segmented nucleus of a neutrophil (arrow), eosinophil (arrowhead) with variable sized particles and vacuoles, and a basophil with dark purple granules and a segmented nucleus. (Photograph courtesy of Oklahoma State University Clinical Pathology Teaching Files. From Schalm’s Veterinary Hematology, page 1061, Figure 163.9.)
Figure 4.30 Feline blood smear showing moderate anisocytosis, Howell-Jolly body (small arrow), segmented neutrophils, lymphocyte, eosinophil, and platelets. (Photograph courtesy of Oklahoma State University Clinical Pathology Teaching Files. From Schalm’s Veterinary Hematology, page 1065, Figure 164.1.)
CP-10
Figure 4.31 Canine blood smear showing a megathrombocyte (arrow), spherocytes, polychromatophilic erythrocytes, neutrophil, and a reactive lymphocyte. (Photograph courtesy of Oklahoma State University Clinical Pathology Teaching Files. From Schalm’s Veterinary Hematology, page 1060, Figure 163.7.)
Figure 4.32 Canine blood smear showing toxic change in a segmented and band neutrophil. Toxic change showing cytoplasmic basophilia and Dühle bodies. (From Schalm’s Veterinary Hematology, page 371, Figure 55.5.)
Figure 4.33 Neutrophils showing toxic change with prominent cytoplasmic basophilia. Döhle Body (small arrow). Upper left inset: normal neutrophil. Lower right inset: toxic neutrophil with fine cytoplasmic vacuolation. (From Veterinary Hematology and Clinical Chemistry, page 137, Figure 12.3.)
Figure 4.36 Ancylostoma caninum. (From Internal Parasites of Dogs and Cats, page 7.)
Figure 4.34 Malassezia: small oval cells surrounded by a halo seen intracellularly in monocytic cells. (Courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.) Figure 4.37 Ancylostoma tubaeforme. (From Internal Parasites of Dogs and Cats, page 7.)
CP-11
Figure 4.38 Crytosporidium. (Courtesy of Gary A. Averbeck.)
Figure 4.40 Dirofilaria immitis. (From Internal Parasites of Dogs and Cats, page 3.)
Figure 4.39 Dipylidium caninum. (From Internal Parasites of Dogs and Cats, page 5.)
CP-12
Figure 4.41 Echinococcus granulosus. (From Internal Parasites of Dogs and Cats, page 5.)
Figure 4.42 Giardia spp. (From Internal Parasites of Dogs and Cats, page 11.)
Figure 4.43 Isospora spp. (From Internal Parasites of Dogs and Cats, page 11.)
Figure 4.44 Taenia spp. (From Internal Parasites of Dogs and Cats, page 6.
Figure 4.45 Toxocara canis (top)/Toxascaris leonina (bottom). (From Internal Parasites of Dogs and Cats, page 9).
Figure 4.50 Cheyletiella. (From External Parasites of Dogs and Cats, page 14.)
Figure 4.46 Toxocara cati. (From Internal Parasites of Dogs and Cats, page 10.)
Figure 4.51 Ctenocephalides canis. (From External Parasites of Dogs and Cats, page 3.)
Figure 4.48 Trichuris vulpis. (From Internal Parasites of Dogs and Cats, page 10.)
Figure 4.52 Demodex canis. (Photograph courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.)
Figure 4.47 Toxoplasma gondii. (From Internal Parasites of Dogs and Cats, page 12.)
Figure 4.49 Uncinaria stenocephala. (From Internal Parasites of Dogs and Cats, page 8.)
Figure 4.53 Dermacentor variabilis. (From External Parasites of Dogs and Cats, page 25.)
CP-13
Figure 4.56 Rhipicephalus sanguineus. (From External Parasites of Dogs and Cats, page 25.)
Figure 4.54 Linognathus setosus. (From External Parasites of Dogs and Cats, page 10.)
Figure 4.57 Sarcoptes scabiei canis. (From External Parasites of Dogs and Cats, page 17.)
Figure 4.55 Otodectes cynotis. (Photograph courtesy of J. Michael Harter, DVM, originally published on Veterinary Information Network.)
CP-14
Figure 4.58 Trichodectes canis. (From External Parasites of Dogs and Cats, page 10.)
Figure 4.59 Bacteria. Top left: rods, unstained; top right: amorphous crystals, unstained: bottom left: cocci, unstained; bottom right: cocci, gram stain. (Photograph courtesy of Joyce S. Knoll, VMD, PhD, DACVP.)
CP-15
Figure 4.60 Bacteria. [Photograph courtesy of Cheryl Stockman, MT (ASCP).]
Figure 4.62 WBCs. [Photograph courtesy of Cheryl Stockman, MT (ASCP).]
Figure 4.61 Bacteria. (From Graff’s Handbook of Routine Urinalysis, page 116, Figure 3-51.) Figure 4.63 WBCs. (From Graff’s Handbook of Routine Urinalysis, page 77, Figure 3-4.)
CP-16
Figure 4.64 Epithelial cells, WBCs, RBCs, and bacteria. (From Graff’s Handbook of Routine Urinalysis, page 134, Figure 4-2.)
Figure 4.66 Fatty cast. [Photograph courtesy of Cheryl Stockman, MT (ASCP).]
Figure 4.65 Epithelial cast. (From Graff’s Handbook of Routine Urinalysis, page 113, Figure 3-47.) Figure 4.67 Granular cast. [Photograph courtesy of Cheryl Stockman, MT (ASCP).]
CP-17
Figure 4.69 RBC cast and RBCs. (From Graff’s Handbook of Routine Urinalysis, page 110, Figure 3-43.)
Figure 4.68 Hyaline cast. [Photograph courtesy of Cheryl Stockman, MT (ASCP).]
Figure 4.70 WBC cast. (From Graff’s Handbook of Routine Urinalysis, page 194, Figure 4-92.)
CP-18
Figure 4.71 Waxy cast. (From Graff’s Handbook of Routine Urinalysis, page 208, Figure 4-112.)
Figure 4.72 Amorphous phosphate crystals. (From Graff’s Handbook of Routine Urinalysis, page 103, Figure 3-36.)
Figure 4.73 Amorphous urate crystals and an air bubble. (From Graff’s Handbook of Routine Urinalysis, page 128, Figure 3-67.)
Figure 4.74 Amorphous biurate crystals and mucous threads. (From Graff’s Handbook of Routine Urinalysis, page 180, Figure 4-71.)
CP-19
Figure 4.75 Bilirubin crystals. (From Graff’s Handbook of Routine Urinalysis, page 170, Figure 4-55.)
Figure 4.78 Cystine crystals and air bubbles. (From Graff’s Handbook of Routine Urinalysis, page 93, Figure 3-23.)
Figure 4.76 Calcium carbonate crystals. (From Graff’s Handbook of Routine Urinalysis, page 104, Figure 3-37.)
Figure 4.79 Leucine crystals. (From Graff’s Handbook of Routine Urinalysis, page 94, Figure 3-24.)
Figure 4.77 Calcium oxalate dihydrate crystals. (From Graff’s Handbook of Routine Urinalysis, page 152, Figure 4-29.)
Figure 4.80 Sulfonamide crystals. (From Graff’s Handbook of Routine Urinalysis, page 163, Figure 4-45.)
CP-20
Figure 4.81 Triple phosphate crystals. (From Graff’s Handbook of Routine Urinalysis, page 170, Figure 4-56.)
Figure 4.84 Renal epithelial cells. (From Graff’s Handbook of Routine Urinalysis, page 139, Figure 4-9.)
Figure 4.82 Tyrosine crystals. (From Graff’s Handbook of Routine Urinalysis, page 165, Figure 4-48.)
Figure 4.85 Squamous epithelial cells. (From Graff’s Handbook of Routine Urinalysis, page 141, Figure 4-12.)
Figure 4.83 Uric acid crystals. (From Graff’s Handbook of Routine Urinalysis, page 144, Figure 4-16.)
Figure 4.86 Transitional epithelial cells. (From Graff’s Handbook of Routine Urinalysis, page 81, Figure 3-8.)
CP-21
Figure 4.87 Epithelial cells and lipid droplets. (From Graff’s Handbook of Routine Urinalysis, page 220, Figure 4-130.)
Figure 4.89 Starch granules. (From Graff’s Handbook of Routine Urinalysis, page 123, Figure 3-59.)
Figure 4.90 Yeast. (From Graff’s Handbook of Routine Urinalysis, page 217, Figure 4-126.)
Figure 4.88 Capillaria plica. (From Internal Parasites of Dogs and Cats, page 14.)
CP-22
CP-23
Figure 9.1 Colorado State University Canine Acute Pain Scale. See Skill Box 9.1, Instructions for Using the CSU Acute Pain Scale. (Courtesy of Peter Hellyer, DVM, MS, DACVA, and Narda Robinson, DO, DVM, Colorado State University.)
CP-24 Figure 9.2 Colorado State University Feline Acute Pain Scale. See Skill Box 9.1, Instructions for Using the CSU Acute Pain Scale. (Courtesy of Peter Hellyer, DVM, MS, DACVA, and Narda Robinson, DO, DVM, Colorado State University.)
Chapter
6
General Medicine Cardiopulmonary 204 Asthma and Brachycephalic Airway Syndrome 204 Bronchitis and Cardiomyopathy, Hypertrophic 205 Cardiomyopathy, Dilated 208 Cardiomyopathy, Restrictive and Congenital Heart Disease 210 Endocardiosis and Heartworm Disease 211 Congestive Heart Failure 214 Hypertension and Myocarditis 215 Pneumonia and Pleural Effusion 217 Rhinitis/Sinusitis and Tracheal Collapse 219 Dermatology 220 Acne 220 Acral Lick Dermatitis, Atopy, and Flea Allergy Dermatitis 222 Food Hypersensitivity and Otitis Externa 224 Pyoderma 225 Endocrinology and Reproduction 227 Abortion and Diabetes Insipidus 227 Diabetes Mellitus 228
6
Dystocia and Eclampsia 230 Hyperadrenocorticism and Hyperparathyroidism 231 Hyperthyroidism and Hypoadrenocorticism 233 Hypoparathyroidism, Hypothyroidism, and Mastitis 235 Pregnancy and Pyometra 237 Gastroenterology 238 Anal Sac Disease, Cholangitis, and Cholangiohepatitis 238 Constipation and Megacolon 240 Diarrhea 241 Exocrine Pancreatic Insufficiency and Gastric Dilatation-Volvulus 243 Hepatic Disease/Failure 245 Hepatic Lipidosis and Inflammatory Bowel Disease 246 Megaesophagus 248 Pancreatitis and Peritonitis 249 Protein-Losing Enteropathy and Vomiting 251 Hematology 253 Anemia and Disseminated Intravascular Coagulation 253 Thrombocytopenia and von Willebrand’s Disease 254 201
Infectious Diseases 256 Brucellosis and Erhlichiosis 256 Rocky Mountain Spotted Fever and Salmon Poisoning Tetanus and Toxoplasmosis 259 Musculoskeletal 261 Arthritis 261 Cruciate Disease and Hip Dysplasia 263 Osteochondrosis and Osteomyelitis 264 Patellar Luxation and Panosteitis 266 Neurology 267 Encephalitis and Epilepsy 267 6 Intervertebral Disc Disease and Meningitis 269 Myasthenia Gravis and Myelopathy 271 Vestibular Disease and Wobbler Syndrome 272 Oncology 273 Neoplasia 273 Key Words and Termsa Adulticidal Alopecia Amyloidosis Ankylosis Aphakic Aqueous flare Arthrodesis Ascites Ataxia Atrial fibrillation Azotemia Bacteremia Biomicroscopy Blepharospasm Borborygmus Bronchiectasis Cachexia Cardiac tamponade Chemosis Comedones Coprophagia
202
258
Histiocytoma, Mammary Gland Neoplasia, and Mast Cell Tumor 275 Various Neoplasias 277 Ophthalmology 284 Anterior Uveitis and Cataracts 284 Conjunctivitis and Entropion 285 Cilia Disorders and Glaucoma 287 Keratitis and Keratoconjunctivitis Sicca 288 Lens Luxation and Prolapsed Gland of the Third Eyelid 290 Urology 292 Cystic Calculi, Feline Lower Urinary Tract Disease, and Pyelonephritis 292 Renal Failure 294 Urinary Tract Obstruction and Urinary Tract Infection 296
Abbreviations Crepitus Cyanosis Dermatophytosis Descemetocele Diskospondylitis Dyschezia Dysphagia Dysphonia Eczema Edema Edematous Encephalopathy Endophthalmitis Epididymitis Epiphoria Epistaxis Erythropoietin Fetid Folliculitis Furunculosis Glomerulonephropathy
SECTION THREE: DIAGNOSTIC SKILLS
μg, microgram μmol, micromole ACE, angiotensin-converting enzyme AChR, acetylcholine receptor ACT, activated clotting time ACTH, adrenocorticotropic hormone ADH, antidiuretic hormone AGID, agar-gel immunodiffusion Alk phos, alkaline phosphatase ALP, alkaline phosphatase ALT, alanine aminotransferase ANA, antinuclear antibody APC, atrial premature contraction/ complex ARF, acute renal failure AST, aspartate aminotransferase BP, blood pressure BUN, blood urea nitrogen CBC, complete blood count CK, creatine kinase CNS, central nervous system
Additional Resources, page cPLI, canine pancreatic lipase immunoreactivity CRF, chronic renal failure CRT, capillary refill time CT, computed tomography DIC, disseminated intravascular coagulation DJD, degenerative joint disease dL, deciliter DNA, deoxyribonucleic acid DOCP, desoxycorticosterone pivalate ECG, electrocardiogram EEG, electroencephalogram ELISA, enzyme-linked immunosorbent assay FBD, feline bronchopulmonary disease FDP, fibrin degradation product FeLV, feline leukemia virus FLUTD, feline lower urinary tract disease
Abdominocentesis, 429 Anatomy, 3 Bandaging, 405 Bathing, 53 Blood chemistries, 74 Blood gas analysis, 335 Blood pressure, 332 Blood transfusion, 367 Cardiac examination, 30 Central venous pressure, 334 Chemotherapy, 352 Chest tube placement, 431 Coagulation profiles, 115 Complete blood count, 104 Coupage, 432 Cytology, 88 Disinfectants, 627 Drug administration, 348 Electrocardiogram, 338 Endoscopy, 551 Enema, 430
Key Words and Termsa Goniometry Halitosis Hematochezia Hematuria Hemoptysis Hepatomegaly Hyperesthesia Hypertrophic Hypotonia Icterus Ileus Impetigo Inertia Intussusception Iridodenesis Isothenuric Jaundice Leukocytosis Leukopenia Lymphadenomegaly Lymphadenopathy Macrocytosis Mastocythemia Megathrombocytosis Melena Menace response Metastasis Microhepatica Morbidity Mortality Mucopurulent Myalgia Myxedema Neovascularization Nocturia Normochromic Normocytic Nystagmus Oocyst Osteopenia a
Abbreviations Palliative Pallor Pancytopenia Panophthalmitis Paresis Periuria Petechiae Phthisis bulbi Pica Pleomorphism Pleuritis Poikilocytosis Pollakiuria Prophylactic Pruritus Psychogenic Puerperal Pulse deficits Pyrexia Retinopathy Sclerosed Seborrheic Steatorrhea Stertor Strabismus Stranguria Stratum corneum Stridor Syncope Synechia Tenesmus Tetany Thrombocytopenia Thromboembolism Trigone Trismus Turgor Uveitis
FNA, fine needle aspirate (aspiration) fPLI, feline pancreatic lipase immunoreactivity FUS, feline urologic syndrome GGT, gamma glutamyl transpeptidase GI, gastrointestinal HAC, hyperadrenocorticism IFA, immunofluorescent assay IgG, immunoglobulin gamma E IgM, immunoglobulin gamma IM, intramsucular IMHA, immune-mediated hemolytic anemia IMT, immune-mediated thrombocytopenia ITP, idiopathic thrombocytopenic purpura IV, intravenous IVDD, intervertebral disc disease K, potassium KBr, potassium bromide KCS, keratoconjunctivitis sicca LA, left atrium LDH, lactate dehydrogenase LRS, lactated Ringer’s solution LV, left ventricular MCHC, mean corpuscular hemoglobin concentration MCV, mean corpuscular volume mg, millgram MRI, magnetic resonance imaging NPH, neutral protamine hagedon NPO, nothing by mouth NS, nonsuppurative NSAIDs, nonsteroidal antiinflammatory drugs
Additional Resources, page OCD, osteochondrosis dessicans OVH, ovariohysterectomy PABA, para-aminobenzoic acid PCR, polymerase chain reaction PCV, packed cell volume PD, polydipsia PDT, photodynamic therapy PE, physical examination pg, picogram pH, potential of hydrogen PPA, phenylpropanolamine PT, prothrombin time PTH, parathyroid hormone PTT, partial thromboplastin time PU, polyuria PZI, protamine zinc insulin RAST, radioallergosorbent test RBC, red blood cell ROM, range of motion S, suppurative SAP, alkaline phosphatase T3, triiodothyronine T4, tetraiodothyronine TLI, trypsin-like immunoreactivity TP, total protein TPLO, tibial plateau leveling osteotomy TSH, thyroid-stimulating hormone UA, urinalysis UTI, urinary tract infection v, variable VD, ventrodorsal VPC, ventricular premature contraction/complex vWF, von Willebrand disease WBC, white blood cell
Fecal analysis, 134 Fluid therapy, 359 Heat administration, 346 Immunology and serology, 120 Injections, 348 Insulin administration, 357 Laboratory, 71 Lymph node examination, 34 Magnetic resonance imaging, 196 Medical procedures, 427 Metered dose inhalers, 431 Microbiology, 122 Nebulization, 432 Nutrition, 57 Obesity management, 67 Orthopedic examination, 36 Otoscopic examination, 33 Oxygen therapy, 375 Pain management, 379 Parenteral nutrition, 413 Pharmacology, 567 Physical examination, 18 Physical therapy, 558 Pulmonary examination, 32 Pulse oximetry, 463 Radiographic contrast studies, 181 Radiology, 159 Recumbent patient care, 347 Surgery, 521 Thoracocentesis, 431 Ultrasonography, 197 Urinalysis, 147 Vital signs, 19 Wound management, 396
Key words and terms are defined in the glossary on page 631.
CHAPTER 6 / GENERAL MEDICINE
203
6
CARDIOPULMONARY Table 6.1 / Cardiopulmonary: Asthma and Brachycephalic Airway Syndrome Brachycephalic Airway Syndrome
Definition
Asthma and bronchitis are secondary to inflammation and airway disorders causing bronchoconstrictive episodes. The distress is often seen on expiration or as coughing fits. The causes may be allergic, bacterial, infection, pulmonary parasites, heartworm disease, or inhaled irritants.
Brachycephalic breeds have a congenital condition of obstructive airways where the soft palate overlaps the tip of the epiglottis. Common contributing causes are stenotic nares and elongated soft palate; secondary everted laryngeal saccules are a sequela.
Presenting Clinical Signs
• Open-mouth breathing, coughing, wheezing, gagging, sneezing (v), dyspnea, vomiting, lethargy, and inappetance
• Coughing, gagging, panting, open mouth breathing, dyspnea, tachypnea, change in voice, and exercise intolerance
Examination Findings
• Tracheal sensitivity, tachypnea, cyanosis, respiratory crackles, and tachy- or bradycardia
• Stertor, stridor, and enlarged tonsils
General
• History/clinical signs
• History/clinical signs • Airway examination
Laboratory
• • • •
• Blood gas analysis
Imaging
• Radiographs, thoracic: pulmonary hyperinflation, aerophagia, flattened diaphragm, peribronchial or interstitial infiltration, atelectasis of middle lung or lung collapse, or pronounced bronchial pattern
• Radiographs, cervical/pharyngeal: thickened and lengthened soft palate, and tracheal stenosis • Radiographs, thoracic: tracheal stenosis or aspiration pneumonia
Procedures
• ECG: heart disease screen • Bronchoscopy: tumors and airway pathology • Cytology, tracheal or bronchial wash: eosinophils, activated macrophages, nonregenerative neutrophils, bacteria, and parasites
• Pulse oximetry • Laryngoscopy/pharyngoscopy: laryngeal and pharyngeal abnormalities • Tracheoscopy: location and severity of stenotic tracheal lesions and pharyngeal abnormalities
General
• Symptomatic • Oxygen therapy
• Surgery: nasal wedge resection, laryngeal sacculectomy, or staphylectomy
Medication
• Anthelmintics: based on diagnosis or clinical signs and geographic location • Antibiotics: chloramphenical, clavamox, trimethoprim-sulfa, tetracycline, or quinolones • Bronchodilators: aminophylline, theophylline, terbutaline, or albuterol • Corticosteroids: prednisolone, dexamethasone • Corticosteroids (inhalers): fluticasone • Cyproheptadine • Leukotriene receptor blocker: zafirlukast • Sympathomimetic: epinephrine, isoproterenol, terbutaline, albuterol
• No specific medications
Nursing Care
• Handle gently to avoid added stress.
• Intensive monitoring postoperative for signs of airway collapse (e.g., vital signs)
Diagnosis
Presentation
Asthma, Bronchitis, and Bronchopulmonary Disease (FBD)
Treatment
6
Disease
204
CBC: neutrophilia, monocytosis (v) and eosinophilia (v) Fecal analysis: parasites (e.g., Paragonimus) Baermann technique: parasites (e.g., Aelurostrongylus) Heartworm tests: antigen and antibody
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.1 / Cardiopulmonary: Asthma and Brachycephalic Airway Syndrome (Continued)
Follow-Up
Disease
Asthma, Bronchitis, and Bronchopulmonary Disease (FBD)
Brachycephalic Airway Syndrome
Patient Care
• Monitor clinical signs.
• Monitor for several days postoperative for signs of aspiration while eating. • Do not encourage exercise and limit exercise in ↑ environmental temperatures.
Prevention/ Avoidance
• Early detection of recurrent infections • Eliminate any contributing environmental factors (e.g., cigarette smoke, air freshners, hair sprays, dirty furnace filters, or certain cat litters).
• Maintain appropriate weight control. • Selective breeding
Complications
• Progression of disease • Bronchiectasis
• Death from hypoxia during or following an anesthetic procedure • Incisional hemorrhage leading to laryngeal occlusion • Hyperthermia
Prognosis
• Guarded • Excellent with determination of environmental allergen
• Fair • Guarded if severely affected
Notes
Client Education
6
• Caution: Endotracheal tubes should be left in place as long as possible following an anesthetic procedure to prevent tracheal occlusion. • Continue medication despite the disappearance of clinical signs. • Lifelong medication and environmental changes may be necessary.
• Dogs should not be exercised extensively or in hot weather.
Table 6.2 / Cardiopulmonary: Bronchitis and Cardiomyopathy, Hypertrophic Disease
Bronchitis (Canine)
Cardiomyopathy, Hypertrophic Feline (Diastolic Dysfunction)
Presentation
Definition
Presenting Clinical Signs
Bronchitis is usually a progressive condition leading to permanent damage. Less frequently it can be acute with reversible damage. The causes include viral, bacterial, mycoplasma, infection, pulmonary parasites, heartworm disease, allergic, inhaled irritants, or foreign bodies.
Hypertrophic cardiomyopathy is a disease that occurs independently of other cardiac diseases. It is characterized by concentric hypertrophy of the ventricular free wall and/or intraventricular septum. This leads to decreased ventricular compliance and ventricular diastolic dysfunction.
• Cachexia, coughing, dyspnea, gagging, open mouth breathing, shortness of breath, tachypnea, wheezing, and exercise intolerance
• Anorexia, collapse, constant crying, coughing, depression, dyspnea, hindlimb paralysis, hypothermia, inactivity, reluctance to move, pain, sudden death, tachypnea
Examination Findings • Arrhythmias, cyanosis, dehydration, pyrexia, murmur, pulmonary crackles, syncope, tachycardia, tracheal sensitivity
• Atrial gallop rhythm, cyanotic nailbeds and pads, femoral pulse weak, hindlimbs cold, muffled heart sounds, pleural effusion, pulmonary edema, systolic murmur, sinus tachycardia
CHAPTER 6 / GENERAL MEDICINE
205
Table 6.2 / Cardiopulmonary: Bronchitis and Cardiomyopathy, Hypertrophic (Continued) Disease
Bronchitis (Canine)
Cardiomyopathy, Hypertrophic
General
• History/clinical signs • Airway examination
• History/clinical signs • Cardiac auscultation
Laboratory
• • • • • • •
Blood gas analysis CBC: neutrophilia or moncytosis, eosinophilia, and ↑ PCV Chemistry panel: ↑ ALT and alk phos Urinalysis: ↑ specific gravity Fecal analysis: parasites Heartworm tests: microfilaria and adult antigen Cytology, transtracheal or bronchial wash: bacterial clusters, eosinophils, macrophages, neutrophils • Bacterial and fungal culture, transtracheal or bronchial wash: isolation and identification
• Chemistry panel: ↑ CK, AST, ALT, and azotemia • Thyroid panel (T4, free T4, T3): ↑ in secondary cases due to primary hyperthyroidism
Imaging
• Radiographs, thoracic: normal in acute disease or ↑ cardiac size (v), ↑ interstitial density, aerophagia, peribronchial infiltrates, lung lobe atelectatic, flattening diaphragm, dilated airways, hyperinflation, or bronchial pattern • Echocardiogram: right heart enlargement and rule out congestive heart failure
• Radiographs, thoracic: ↑ cardiac size, valentine-shaped heart, elongated heart shadow, LA enlargement, pulmonary edema, and pulmonary vein dilation • Echocardiogram: hypertrophy of the intraventricular septum, LV posterior wall, papillary muscles, left atrial enlargement, and hyperdynamic myocardium • MRI: identifying mild disease and assessing response to therapy
Procedures
• Bronchoscopy: sputum sample, tumor, inflammation, foreign bodies, and parasites • ECG: sinus arrhythmia, peaked P waves, and a wandering atrial pacemaker
• ECG: sinus tachycardia, APCs, VPCs, ↑ P wave duration, ↑ R wave amplitudes, ↑ QRS width, atrial fibrillation • Blood pressure: hypotension
General
• Supportive • Oxygen therapy
• • • •
Symptomatic Fluid therapy Oxygen therapy Thoracocentesis
Medication
• Antibiotics: clavamox, trimethoprim-sulfa, cephalothin, enrofloxacin, or quinolones • Antitussives: hydrocodone or butorphanol • Bronchodilators: aminophylline, theophylline, or terbutaline • Corticosteroids: prednisone, dexamethasone • Corticosteroids (inhalers): fluticasone • Sympathomimetic: epinephrine, isoproterenol, terbutaline, albuterol • Tranquilizers
• • • • • • • • •
β-Blockers: propanolol or atenolol ACE inhibitor: enalapril Aspirin Bronchodilator: aminophylline Ca2+ channel blocker: diltiazem Diuretics: furosemide Sedation: acepromazine Vasodilator: nitroglycerin ointment, captopril Warfarin
Nursing Care
• Nebulization • Chest wall coupage
• Heat support • Low stress environment • Restricted activity
Treatment
6
Diagnosis
Feline (Diastolic Dysfunction)
206
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.2 / Cardiopulmonary: Bronchitis and Cardiomyopathy, Hypertrophic (Continued) Disease
Bronchitis (Canine)
Cardiomyopathy, Hypertrophic Feline (Diastolic Dysfunction)
• Weight loss
• • • • •
Prevention/ Avoidance
• Maintain appropriate weight control. • Use a harness instead of a collar. • Eliminate any contributing environmental factors (e.g., cigarette smoke and dirty furnace filters). • Humidifier followed by light exercise to encourage expelling of sputum • Maintain oral health. • Heartworm prevention
• Avoid stressful situations.
Complications
• • • •
• • • • • •
Prognosis
• Good • Poor with irreversible changes from chronic bronchitis
• Fair to good with some forms if diagnosed and treated early • Poor with progressive heart failure
Notes
• Caution: Equipment used (e.g., nebulizer) needs to be thoroughly cleaned to prevent bacteria contamination.
• Caution: Aggressive fluid therapy must be monitored closely for overload and worsening disease • Pain and crying may indicate thromboembolism to posterior aortic branches.
Client Education
• • • •
Follow-Up
Patient Care
Pneumonia Bacterial infection Bronchiectasis Syncope
Observe closely for return of clinical signs Monitor blood values dependent on medical treatment chosen. Repeat echocardiogram after 4–6 months of initiating treatment. Sodium-restricted diet Warfarin use, monitor prothrombin time
6
Cardiac arrhythmias DIC Left heart failure Mitral valve regurgitation Sudden death Thromboembolism
Harnesses should be used in place of collars. Weight loss may improve symptoms. Exercise assists in clearing airways, limit if results in coughing Dental care reduces secondary bacterial infections.
CHAPTER 6 / GENERAL MEDICINE
207
Table 6.3 / Cardiopulmonary: Cardiomyopathy, Dilated Disease Canine
Feline (Systolic Dysfunction)
Dilated cardiomyopathy is a disease of the ventricular muscle. Advanced cases of disease show dilation of all chambers. Causes are typically idiopathic but have been linked in some cases to nutritional deficiencies, viral, protozoan, and immune-mediated mechanisms.
Dilated cardiomyopathy is a disease of the ventricular muscle. Advanced cases of disease show dilation of all chambers. It is most commonly caused by taurine deficiency and is typically reversible. It can also be idiopathic, often the end stage of another disease. This disease leads to CHF or low cardiac output.
Presenting Clinical Signs
• Abdominal distention, anorexia, ascites, cachexia, collapse, coughing, dyspnea, exercise intolerance, syncope, tachypnea
• Anorexia, constant crying, depression, dyspnea, inactivity, pain, posterior paresis, tachypnea, weakness, vomiting
Primary Survey Findings
• ↑ CRT, arrhythmias, atrial fibrillation, crackles, cyanosis, gallop, hepatomegaly, jugular pulse prominent, muffled heart and lung sounds, murmur, pleural effusion, pulmonary edema, pulse deficits, tachycardia, wheezes
• Arrhythmia, ↑ CRT, crackles, femoral pulse weak or absent, hepatomegaly, hypothermia, jugular vein distention or prominent pulse, murmur, ocular fundus abnormalities, pallor, pleural effusion, pulmonary edema, pulse deficits, ↓ skin turgor, soft heart and lung sounds, summation gallop, tachy- or bradycardia, ventricular gallop
General
• History/clinical signs • Cardiac auscultation • Pulmonary auscultation
• History/clinical signs • Cardiac auscultation • Pulmonary auscultation
Laboratory
• Chemistry panel: ↑ BUN, creatinine, ALT and ↓ sodium, chloride, potassium, protein • Plasma taurine and L-carnitine: ↓ • Blood gases: metabolic acidosis
• CBC: leukocytosis, anemia, ↓ PCV: <18% • Chemistry panel: ↑ CK, AST, ALT, BUN, creatinine, glucose and ↓ potassium • Urinalysis: ↑ myoglobin • Plasma taurine: <40 nmoles/L • Pleural effusion analysis: TP <4.9 g/dL and nucleated cell count <2500/mL is supportive of diagnosis
Imaging
• Radiographs, thoracic: ↑ cardiac size, LA, LV, caudal vena cava enlargement, pleural effusion and pulmonary edema • Echocardiogram: chamber enlargement and speed of velocity and flow, reduced myocardial contractility
• Radiographs, thoracic: ↑ cardiac size, rounding of cardiac apex, caudal vena cava and pulmonary veins enlarged, ascites, pleural effusion or pulmonary edema • Echocardiogram: anatomic abnormalities, dilation of LA and LV, ↓ LV contractility, valvular regurgitation, low aortic outflow velocity or LV muscle thinning • Angiocardiography: arterial thrombosis
Procedures
• ECG: atrial fibrillation, arrhythmias, low voltages (v), ↑ QRS duration, tachycardia, VPCs, and LV enlargement
• ECG: arrhythmias, ↑ amplitude and duration of P waves, left atrial or ventricular enlargement patterns, sinus bradycardia (v), atrial fibrillation, VPCs
Diagnosis
Presentation
Definition
6
208
Cardiomyopathy, Dilated
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.3 / Cardiopulmonary: Cardiomyopathy, Dilated (Continued) Disease Canine
Feline (Systolic Dysfunction)
General
• Symptomatic • Thoracocentesis (palliative)
• • • •
Symptomatic Fluid therapy Oxygen therapy Thoracocentesis
Medication
• • • • • • • • • • •
• • • • • • • • •
ACE inhibitor: enalapril, captopril Arterial dilators: hydralazine Aspirin Bronchodilator: aminophylline Diuretics: furosemide Positive inotropes: digoxin, dobutamine, milrinone Sedation: acepromazine Taurine supplementation Vasodilator: nitroglycerin ointment
Treatment Follow-Up
Cardiomyopathy, Dilated
β-Blockers: sotalol ACE inhibitors: enalapril Aldsterone blocker: spironolactone Antiarrythymics: lidocaine, procainamide, mexiletine Bronchodilators: aminophylline Ca2+ channel blockers: diltiazem Diuretics: furosemide Inodilator: pimobendan Positive inotropes: digoxin and dobutamine Taurine or L-carnitine supplementation Vasodilator: nitroglycerin ointment
6
Nursing Care
• Treated as outpatient
• Heat support • Low stress environment • Nutritional support
Patient Care
• Monitor PE, radiographs, ECG, BP, and renal profile at regular intervals • Sodium-restricted diet • Restrict activity and limit exercise
• • • • •
Prevention/ Avoidance
• N/A
• Feed a high-quality diet with adequate taurine supplementation.
Complications
• Sudden death • Hypothyroidism
• Hyperthyroidism • Thromboembolism
Prognosis
• Grave: 6–24 months following diagnosis
• Good with taurine supplementation after survival of first 2 weeks. • Poor for idiopathic causes
• Great Dane, Irish Wolfhound, Saint Bernard, Doberman Pinscher, Springer Spaniel, and Cocker Spaniel
• Caution: Aggressive fluid therapy must be monitored closely for overload and worsening disease. • Pain and crying may indicate thromboembolism to posterior aortic branches. • Burmese, Abyssinian, and Siamese
Notes
Monitor taurine, electrolyte, and renal levels. Monitor blood values dependent on medical treatment chosen. Check thoracic radiographs after 1 week of initiating treatment. Repeat echocardiogram after 3–6 months of initiating treatment. Sodium-restricted diet
CHAPTER 6 / GENERAL MEDICINE
209
Table 6.4 / Cardiopulmonary: Cardiomyopathy, Restrictive and Congenital Heart Disease Cardiomyopathy, Restrictive Feline (Diastolic Dysfunction)
Congenital Heart Disease
Definition
Restrictive cardiomyopathy is a group of myocardial diseases that result in impaired ventricular filling. This impairment is unknown but might be caused by delayed myocardial relaxation or endocardial fibrosis.
Congenital heart disease is the most common heart condition in animals <1 year of age. It is a malformation of the heart or great vessels. The following is a list of congenital heart defects: patent ductus arteriosus, pulmonic stenosis, subaortic stenosis, ventricular septal defect, atrial septal defect, mitral dysplasia, tricuspid dysplasia, and tetralogy of Fallot.
Presenting Clinical Signs
• Cachexia, depression, dyspnea, hypothermia, open mouth breathing, panting, tachypnea, crackles, pain, pleural effusion, posterior paresis or paralysis, pulmonary edema
• Anoxia, dyspnea, exercise intolerance, stunted growth, seizures, syncope, tachypnea, weakness
Examination Findings
• Arrhythmia, ascites, crackles, cyanosis, gallop, jugular pulse distention, murmur, pleural effusion, pulmonary edema
• Abdominal distention, cyanosis, murmur
General
• History/clinical signs • Cardiac auscultation • Pulmonary auscultation
• History/clinical signs • Cardiac auscultation
Laboratory
• Chemistry panel: ↑ CK, AST, ALT, creatinine, potassium, and azotemia • Plasma taurine levels
• CBC: ↑ PCV
Imaging
• Radiographs, thoracic: ↑ cardiac size, valentine-shaped heart, pleural effusion, pulmonary edema, pulmonary vein dilation, atrial and caudal vena cava enlargement • Echocardiogram: dilation of atria, LV or RV, myocardial fibrosis, myocardial hypertrophy in septum or LV, valvular regurgitation, altered or prominent papillary muscles • Angiocardiography: arterial thrombosis
• Radiographs, thoracic: abnormalities in heart size and shape, major vessels and pulmonary vascularity; specific changes may vary with each defect/type • Echocardiogram: anatomic abnormalities, shunting lesion location and severity, and abnormal blood flow
Procedures
• ECG: arrhythmias, sinus tachycardia, atrial premature complexes, atrial fibrillation, ↑ amplitude and duration of P waves, or LA and LV enlargement patterns
• ECG: ± chamber enlargement patterns
General
• • • •
Symptomatic Fluid therapy Oxygen therapy Thoracocentesis/Pericardiocentesis
• Supportive • Symptomatic • Surgery: dependent on defect
Medication
• • • • • • • • •
β-Blockers: propanolol or atenolol ACE inhibitor: enalapril, captopril Antiarrhythmic: lidocaine Aspirin Ca2+ channel blocker: diltiazem Diuretics: furosemide Positive inotropes: digoxin Vasodilator: nitroglycerin ointment Warfarin
• • • • • •
Presentation
Disease
Treatment
Diagnosis
6
210
SECTION THREE: DIAGNOSTIC SKILLS
β-Blockers: atenolol Antiarrhythmic: lidocaine or procainamide Ca2+ channel blocker: diltiazem Diuretics: furosemide Positive inotropes: digoxin Vasodilators: enalapril
Table 6.4 / Cardiopulmonary: Cardiomyopathy, Restrictive and Congenital Heart Disease (Continued)
Follow-Up
Treatment
Disease
Cardiomyopathy, Restrictive Feline (Diastolic Dysfunction)
Congenital Heart Disease
Nursing Care
• • • • • •
• Treated as outpatient until complications with chronic heart failure • Standard postoperative
Patient Care
• Reevaluate patients every 2–4 months. • Sodium-restricted diet
• • • • •
Prevention/ Avoidance
• Avoid stressful situations
• Selective breeding
Complications
• Thromboembolism
• Chronic heart failure • Arrhythmias • Death
Prognosis
• Poor
• Guarded without surgery
Notes
Heat support Low stress environment Restricted activity Reradiograph within 12–24 hours to monitor pleural effusion Monitor electrolytes daily for 3–5 days. Monitor hydration and renal profile.
Monitor for clinical signs. Monitor PCV every 1–3 months. Monitor radiographs and echocardiograms at regular intervals. Restrict activity. Sodium-restricted diet
6
• Caution: Aggressive fluid therapy must be monitored closely for overload and worsening disease. • Pain and crying may indicate thromboembolism to posterior aortic branches.
Table 6.5 / Cardiopulmonary: Endocardiosis and Heartworm Disease Endocardiosis (Chronic Valvular Heart Disease, Chronic Mitral Valve Insufficiency)
Heartworm Disease
Definition
Endocardiosis is the most common cardiovascular disease in dogs. It accounts for >75% of cases of congestive heart failure in dogs. The disease is an alteration in a structure of the mitral valve complex causing malfunction and progressive secondary cardiac changes, ultimately resulting in chronic heart failure.
Heartworm disease is mostly a problem in dogs affecting most of the United States. It is an infection of Dirofilaria immitis transmitted by many species of mosquitoes. The worms reside in the pulmonary arteries and can extend into the right atrium and ventricle.
Presenting Clinical Signs
• Chronic small airway disease, congestion, cough, syncope, tachypnea, wheezing
• Cachexia, cough, dyspnea, hemoptysis, syncope, vomiting (intermittent, feline), wheezes
Examination Findings
• Arrhythmias, cardiac tamponade, chronic small airway disease, crackles, cyanosis, muffled heart sounds, pleural effusion, pulse deficits, systolic murmur, tachycardia
• Abnormal lung sounds, ascites, crackles, gallop, hypertension, murmur, organomegaly, tachycardia
Presentation
Disease
CHAPTER 6 / GENERAL MEDICINE
211
Table 6.5 / Cardiopulmonary: Endocardiosis and Heartworm Disease (Continued) Endocardiosis (Chronic Valvular Heart Disease, Chronic Mitral Valve Insufficiency)
Heartworm Disease
General
• History/clinical signs • Cardiac auscultation • Pulmonary auscultation
• History/clinical signs • Cardiac auscultation
Laboratory
• Chemistry panel: ↑ BUN, creatinine, phosphorus, ALT, AST, alk phos, ↓ albumin • Urinalysis: ↑ protein, albumin, granular cast, WBC, occult blood • Culture, blood: + supportive of diagnosis
• CBC: eosinophilia and basophilia (v) • Chemistry panel: ↑ hepatic enzymes, bile acids and ↓ albumin, globulin, azotemia • Urinalysis: ↑ protein, globulin, albumin, granular casts • ELISA: adult female worm antigens • Direct blood smear, Knott test or millipore filter test: microfilaria • Immunodiagnostic screens: microfilaria antigen • Serology: + dirofilaria
Imaging
• Radiographs, thoracic: ↑ cardiac size, pulmonary interstitial, alveolar congestion, pulmonary edema, alveolar edema, LA and LV enlargement, hilar lymphadenomegaly and anatomic changes in the LA, LV, and mainstem bronchi • Echocardiogram: anatomic changes, pleural and pericardial effusions, presence and severity of atrioventricular valve insufficiency with regurgitation, mitral valve abnormalities
• Radiographs, thoracic: enlarged, truncated or tortuous arteries, R-sided cardiac enlargement, pneumonitis, or localized or generalized interstitial and/or alveolar infiltrates • Echocardiogram: RA, RV, and pulmonary artery enlargement, worm burden and severity of disease
Procedures
• ECG: recognition and identification of arrhythmia and ↑ P wave duration
• ECG: arrhythmia, RV hypertrophy pattern or tall P waves
General
• Supportive • Symptomatic • Oxygen therapy
• Supportive • Platelet count
Medication
• • • • • • • •
• • • •
Nursing Care
• Low stress environment
Treatment
6
Diagnosis
Disease
212
ACE inhibitor: enalapril Adrenergic blocking agent: prazosin Antibiotics: penicillin,gentamicin, enrofloxacin, amoxicillin Arterial dilators: hydralazine Ca2+ channel blocker: diltiazem Diuretics: furosemide Positive inotropes: digoxin Vasodilator: nitroglycerin ointment
SECTION THREE: DIAGNOSTIC SKILLS
Adulticide: thiacetarsamide sodium or melarsamine Aspirin (low-dose) Corticosteroids: prednisone or prednisolone (cats) Larvacide: ivermectin or milbemycin
• Feed patient 1/2 hour prior to injection to observe for anorexia • Monitor for jaundice, fever, depression, dyspnea or other signs of thromboembolism • Close monitoring after administering injection for signs of toxicity (inflammation at injection site, vomiting, anorexia, lethargy, icterus, and ↑ BUN, ALT, or bilirubin
Table 6.5 / Cardiopulmonary: Endocardiosis and Heartworm Disease (Continued)
Follow-Up
Disease
Endocardiosis (Chronic Valvular Heart Disease, Chronic Mitral Valve Insufficiency)
Heartworm Disease
Patient Care
• Monitor BUN and creatinine when using diuretics and ACE inhibitors. • Monitor PE, ECG, and radiography 1 week after initiating therapy. • Monitor blood cultures and echocardiogram following antibiotic therapy. • Monitor cardiomegaly through radiographs every 6–12 months. • Restrict activity. • Sodium-restricted diet
• Monitor for jaundice, fever, depression, dyspnea or other signs of thromboembolism. • Strict confinement for 4–6 weeks • Start larvacide treatment 4 weeks post-adulticidal treatment. • Retest for microfilaria 7 weeks post-adulticidal treatment.
Prevention/ Avoidance
• N/A
• Prophylactic therapy: milbemycin oxide • Heartworm surveillance testing: 6–12 months of initiating preventative and then at regular intervals
Complications
• • • • • • • •
• • • • •
Prognosis
• Dependent of severity of disease
• Good when subclinical or mild disease • Fair with moderate to severe disease • Guarded if untreated or very high worm burden
• Poodle, Yorkshire Terrier, Cavalier King Charles Spaniel, Schnauzer, Cocker Spaniel
• Caution: Very high mortality in felines when thiacetarsamide therapy is used. • Caution: IM injection can cause pain and sterile abscesses with melarsamine. • Each injection is given in a peripheral vein at a different location as distal as possible with thiacetarsamide sodium. • Indwelling catheters are not recommended for administration.
Notes
Atrial fibrillation Death LA rupture Pulmonary and systemic emboli Right-sided heart failure Tachyarrhythmia Tamponade Toxemia
6
DIC Thrombocytopenia Heart failure Acute pulmonary thromboembolism Thiacetarsamide sodium toxicity
CHAPTER 6 / GENERAL MEDICINE
213
Table 6.6 / Cardiopulmonary: Congestive Heart Failure Disease
Congestive Heart Failure Left-Sided
Diagnosis
214
Heart failure is the failure of the left or right side of the heart to adequately pump blood through the body or through the pulmonary circulation respectively. The causes of congestive heart failure may be mechanical failure (valve insufficiency, aortic regurgitation or hypertension), myocardial failure (myocarditis, dilated cardiomyopathy or neoplasia), interference with cardiac filling (severe arrhythmia, hypertrophic cardiomyopathy or tamponade) or increased requirement for cardiac output (anemia, overexercise, pregnancy or hyperthyroidism).
Presenting Clinical Signs
• Cachexia, cough, dyspnea, hemoptysis, limb swelling, syncope, tachypnea, wheezes
• Cachexia, pallor, syncope
Examination Findings
• Arrhythmias, ascites, crackles, cyanosis, ↑ CRT, femoral pulses weak, gallop, murmur, organomegaly, pallor, pulmonary edema, pulse deficit, weak, pounding or irregular
• Arrhythmia, ascites, gallop, jugular vein distention, muffled heart sounds, murmur, organomegaly, pericardial effusion, pleural effusion, subcutaneous edema, system venous congestion
General
• History/clinical signs • Cardiac auscultation
Laboratory
• Chemistry panel: ↑ ALT, AST, alk phos, BUN, creatinine and ↓ sodium, potassium, protein • Heartworm tests: microfilaria and adult antigen
• CBC: eosinophilia (v) • Chemistry panel: ↑ ALT, AST, alk phos, GGT, BUN, creatinine, ↓ sodium, potassium, protein
Imaging
• Radiographs, thoracic: ↑ cardiac size, systemic or pulmonary venous dilation, pulmonary edema, or hilar lymphadenomegaly • Echocardiogram: cause and extent of disease, pericardial or pleural effusion, neoplasia, or heartworm disease
• Radiographs, thoracic: ↑ cardiac size, distended vena cava, pleural effusion and/or ascites, pulmonary edema, enlarged pulmonary arteries
Procedures
• ECG: arrhythmias, wide (and tall if R-sided) P waves, tall and wide QRS complexes and left axis orientation
General
• • • • •
Symptomatic Fluid therapy Oxygen therapy Thoracocentesis/pericardiocentesis/abdominocentesis, as needed Dependent on underlying condition
Medication
• • • • • • • • • • •
β-Blockers: propanolol, atenolol, or metoprolol ACE inhibitors: enalapril or captopril Arterial dilators: hydralazine Ca2+ channel blockers: diltiazem, amlodipine Diuretics: furosemide Inodilator: pimobendan Positive inotropes: digoxin, dobutamine or dopamine Sedation: morphine sulfate, acepromazine maleate Sodium nitroprusside Taurine supplementation Venodilators: nitroglycerin ointment
Nursing Care
Restrict stress: handling only for extremely necessary procedures
Treatment
6
Presentation
Definition
Right-Sided
SECTION THREE: DIAGNOSTIC SKILLS
• • • •
ACE inhibitors: enalapril or captopril Ca2+ channel blocker: amlodipine Diuretics: furosemide Positive inotropes: digoxin
Table 6.6 / Cardiopulmonary: Congestive Heart Failure (Continued) Disease
Congestive Heart Failure
Follow-Up
Left-Sided
Restrict activity and ↓ anxiety Monitor ECG, echocardiogram, serum chemistries and serum digoxin concentrations regularly Monitor resting respiratory rate (normal: <30 breaths/min) Sodium-restricted diet
Patient Care
• • • •
Prevention/ Avoidance
• Minimize stress and exercise.
Complications
• • • • • • •
Prognosis Notes
Right-Sided
Aortic thromboembolism (feline) Arrhythmias Electrolyte imbalances Digoxin toxicity Renal failure Hypertension Muscle wasting
6
• Dependent on underlying disease • Caution: Aggressive fluid therapy must be monitored closely for overload and worsening disease.
Table 6.7 / Cardiopulmonary: Hypertension and Myocarditis Hypertension
Myocarditis
Definition
Hypertension is an increase in pulmonary arterial or systemic blood pressure. It may be either a primary or secondary condition. Systemic hypertension is diagnosed through Doppler, whereas pulmonary arterial hypertension is found through cardiac catheterization.
Myocarditis is an inflammation of the heart muscle. Some causes are: infectious, viral, protozoan, ischemic injury, trauma, or toxicity. Primary infection is rare; typically, it is secondary to another disease process.
Presenting Clinical Signs
• Dependent on underlying condition • Anorexia, ataxia, blindness, circling, diarrhea, dilated pupils, disorientation, dyspnea, exercise intolerance, hemoptysis, hindleg paresis, ocular hemorrhage, PU/PD, seizures, tachypnea, vomiting
• Cough, fever, exercise intolerance, syncope, weakness
Examination Findings
• Abnormal heart and lung sounds, ascites, atrial gallop, crackles, cyanosis, edema, hypoxemia, retinal detachment, systolic murmur
• Arrhythmias, gallop, murmur, VPCs, ventricular tachycardia
Presentation
Disease
CHAPTER 6 / GENERAL MEDICINE
215
Table 6.7 / Cardiopulmonary: Hypertension and Myocarditis (Continued)
Diagnosis
Disease
Hypertension
Myocarditis
General
• History/clinical signs
• History/clinical signs (e.g., parvovirus, Chagas disease) • Cardiac auscultation
Laboratory
• CBC: neutrophilia and lymphopenia (v), thrombocytopenia, leukopenia, and ↑ PCV • Chemistry panel: ↑ phosphorus, ALT, cholesterol, BUN, creatinine, glucose, alk phos and ↓ albumin and electrolyte imbalances • Urinalysis: ↑ protein, blood, glucose and ↓ specific gravity with renal dysfunction
• Chemistry panel: ↑ CK, LDH, AST • Serology, parvovirus, toxoplasmosis, trypanosomiasis: +
Imaging
• Radiographs, thoracic: ↑ cardiac size, ↑ density, pulmonary artery dilation, ascites, neoplasia, bronchial collapse, tracheal narrowing • Radiographs, abdominal: hepatomegaly or abnormal kidneys • Echocardiogram: pulmonary hypertension, right heart dilation • Ultrasound: adrenal enlargement
• Radiographs, thoracic: pulmonary edema, congestion, pleural effusion, ↑ cardiac silhouette or rounded heart shape • Echocardiogram: pericardial effusion, thickened pericardium or mottled and patchy areas on myocardium • Angiogram: specific chamber involvement or pleural effusion
Procedures
• Blood pressure: systemic hypertension • Pulmonary catheterization: pulmonary hypertension (invasive measurement)
• ECG: arrhythmias and enlargement patterns
General
Only for Complicated Disease • Supportive • Fluid therapy • Oxygen therapy
• Supportive • Pericardiocentesis
Medication
• • • • • •
Nursing Care
• Treat as outpatient if possible to ↓ overall stress.
• Restrict activity
Patient Care
• Sodium-restricted diet • Monitor for signs of hypotension. • Monitor blood pressure every 1–2 weeks, then every 1–3 months.
• Sodium-restricted diet • Monitor ECG and auscultation. • Reradiograph
Prevention/ Avoidance
• Maintain proper weight control. • Measure BP in all renal failure patients.
• Vaccinate. • Monitor ECG and echocardiogram with patients using doxorubicin. • Avoid endemic areas (e.g., Gulf Coast).
Follow-Up
Treatment
6
216
α-Adrenergic blocker: prazosin β-Adrenergic blocker: propranolol ACE inhibitor: enalapril Ca2+ channel blocker: diltiazem or amlodipine (cats) Diuretics: furosemide Hydralazine
SECTION THREE: DIAGNOSTIC SKILLS
Dependent on underlying condition • ACE inhibitor: enalapril • Antiarrhythmics: quinidine • Diuretics: furosemide • Positive inotropes: digoxin
Table 6.7 / Cardiopulmonary: Hypertension and Myocarditis (Continued) Hypertension
Myocarditis
Complications
• • • • •
• Cardiomyopathy • Chronic heart failure
Prognosis
• Good if underlying cause can be determined and treated
Follow-Up
Disease
Notes
Renal failure Chronic heart failure Glomerulonephropathy Retinopathy/blindness CNS signs
• Dependent on extent and severity of disease
Canine Abnormal Systemic Values • Systolic: >160 mm Hg • Diastolic: >100 mm Hg Feline Abnormal Systemic Values • Systolic: >160 mm Hg • Diastolic: >120 mm Hg • An average of 3 readings should be done to adequately evaluate a patient’s blood pressure. • Avoid use of PPA. • Maintain low stress before and during the BP measurement.
6
Table 6.8 / Cardiomyopathy: Pneumonia and Pleural Effusion Pneumonia
Pleural Effusion
Definition
Pneumonia is an inflammatory response of the lungs. It is most commonly caused by bacteria but can also be caused by aspiration of ingesta, fungi, allergic, foreign body, viral, neoplasia, lung parasites, or contusions. It has a high rate of mortality and morbidity, especially in hospitalized animals.
Pleural effusion is an accumulation of fluid in the pleural cavity. It may be seen unilateral or bilateral. This is an abnormal process that has many causes, typically indicating a more severe underlying condition.
Presenting Clinical Signs
• Cachexia, dyspnea, mucopurulent nasal discharge, productive cough, tachypnea, wheezes
• Anorexia, depression, dyspnea, exercise intolerance, pallor, pleuritis, open-mouth breathing, preference for sternal recumbency, tachypnea
Examination Findings
• Crackles, cyanosis, dehydration, pyrexia, loud or asymmetric bronchial sounds, tachycardia
• Ascites, cyanosis, pyrexia, muffled heart and lung sounds, tachycardia
General
• History/clinical signs • Pulmonary auscultation
• • • •
Diagnosis
Presentation
Disease
History/clinical signs Cardiac auscultation Pulmonary auscultation Thoracic palpation and percussion
CHAPTER 6 / GENERAL MEDICINE
217
Table 6.8 / Cardiomyopathy: Pneumonia and Pleural Effusion (Continued)
Diagnosis
Disease
Follow-Up
Treatment
6
218
Pneumonia
Pleural Effusion
Laboratory
• CBC: neutrophilic leukocytosis with or without a left shift and monocytosis • Cytology, tracheal wash: ↑ neutrophils and bacteria • Culture, tracheal wash: bacteria isolation and identification
• • • •
Imaging
• Radiographs, thoracic: ↑ lung density, lung consolidation, pulmonary artery enlargement, or interstitial pattern with air bronchograms • Contrast study: swallowing disorders
• Radiographs, thoracic: ↑ cardiac size, tumor, lung lobe torsion, diaphragmatic hernia, widening of mediastinum, rounded lung lobe edges, obscured cardiac borders and diaphragm, ascites, and pleural fissure lines • Contrast study: tumor, diaphragmatic hernia, and cardiac disease
Procedures
• Bronchoscopy: foreign body or neutrophilic inflammation
• ECG: amplitudes all depressed
General
• • • •
• • • • •
Medication
• Antibiotics: dependent on type of bacteria isolated and one with good penetration into lung tissue (e.g., enrofloxacin) • Antifungal: amphotericin, flucytosine, ketaconazole, fluconazole • Bronchodilators: theophylline or terbutaline
• Antibiotics: dependent on type of bacteria isolated • Analgesics: bupivacaine, NSAIDs, morphine, meperidine
Nursing Care
• • • • • •
• Monitor temperature, respiratory rate and effort and pulse • Nutritional support • Chest tube management
Patient Care
• Airway humidification • Mild exercise • Reradiograph in 48–72 hours, then after 2–6 weeks
• Monitor radiographs
Prevention/ Avoidance
• Vaccinate
• N/A
Complications
• Chronic bronchitis • Secondary infection/sepsis
• Death
Prognosis
• Good
• Guarded to poor
Supportive Fluid therapy Oxygen therapy Surgery: lung lobectomy (rare)
Nebulization with bland aerosols Chest wall coupage Tracheal manipulation Restrict activity Alter patient’s position at least every 2 hours Nutritional support
SECTION THREE: DIAGNOSTIC SKILLS
CBC: leukocytosis and anemia Chemistry panel: ↑ globulin and ↓ albumin: <1 g/dL Serology: FeLV, FIP, FIV, or heartworm Fluid analysis: color, clarity, viscosity, specific gravity, TP, and nucleated cell count, neutrophils, macrophages, mesothelial cells, lymphocytes, eosinophils, or neoplastic cells
Symptomatic Fluid therapy Thoracocentesis Chest tube placement Surgery: thoracotomy
Table 6.8 / Cardiomyopathy: Pneumonia and Pleural Effusion (Continued) Disease
Pneumonia
Notes
Pleural Effusion • Classification of fluids: • Colorless to pale yellow: transudate • Yellow to pink: modified transudate or nonseptic exudate • Yellow to red-brown: septic exudate • Milky white: chylous • Red: hemorrhage • Pain medication may be directly injected through the chest tube to give pleural analgesia.
6
Table 6.9 / Cardiopulmonary: Rhinitis/Sinusitis and Tracheal Collapse Rhinitis/Sinusitis
Tracheal Collapse
Definition
Infection of the nasal sinuses is a common veterinary problem. There is acute rhinitis, which is self-limiting, and chronic sinusitis, which may require constant treatment. The causes are bacterial, viral, fungi, foreign body, dental disease, infectious agents, or neoplasia.
A collapsing trachea is a trachea with a range of dynamic variations resulting in collapse somewhere along its length. It may also involve the mainstem bronchi causing them to collapse also. It can be an acquired weakness or congenital defect. It is most commonly seen in older toy breed dogs.
Presenting Clinical Signs
• Cough, gagging, mucopurulent nasal discharge, ocular discharge, open mouth breathing, retching, sneezing
• Cachexia, change in voice, dyspnea, gagging, heat intolerance, intermittent “honking” cough, syncope
Examination Findings
• Bony swelling, pyrexia, lymphadenopathy, oral ulceration, ocular or neurological changes
• Cyanosis, enlarged tonsils, stertor, stridor
General
• History/clinical signs • Nasal examination
• History/clinical signs • Airway examination
Laboratory
• Cytology and culture: bacteria recognition and identification • Fungal culture: isolation and identification
• N/A
Imaging
• Radiographs, skull: ↑ fluid and bony changes (e.g., loss of bone detail and deviated septum)
• Radiographs, thoracic: narrowing or ballooning of tracheal diameter and ↑ R-sided cardiac size • Radiographs, cervical/pharyngeal: narrowing or ballooning of tracheal diameter
Procedures
• Rhinoscopy: foreign body and bony changes • Biopsy: bacteria or fungi
• Bronchoscopy: severity and small airway disease • Fluoroscopy: narrowing of tracheal diameter may be dynamic
General
• • • •
• Symptomatic • Surgery: application of intraluminal or extraluminal prostheses
Treatment
Diagnosis
Presentation
Disease
Supportive Fluid therapy Radiotherapy Surgery: nasal exploratory, rhinotomy, or turbinectomy
CHAPTER 6 / GENERAL MEDICINE
219
Table 6.9 / Cardiopulmonary: Rhinitis/Sinusitis and Tracheal Collapse (Continued) Rhinitis/Sinusitis
Tracheal Collapse
Medication
• Antibiotics: cephalexin, trimethoprim-sulfa, and chloramphenical • Corticosteroids: prednisone • Fungicides: enilconazole, itraconazole, thiabendazole, or ketoconazole
• Antitussives: butorphanol, hydrocodone • Bronchodilators: aminophylline, theophylline, terbutaline, guaifenesin • Corticosteroids: prednisone
Nursing Care
• Airway humidification
• Intensive monitoring during and postoperative for signs of hypoxia
Patient Care
• Monitor for relapse of clinical signs
• Limit activity • Weight loss • Chest harness
Prevention/ Avoidance
• Vaccinate • Maintain good oral hygiene • Prevent exposure to bird feces (aspergillosis and cryptococcosis)
• Maintain proper weight control • Avoid extreme temperature and humidity changes
Complications
• Brain infection • Epistaxis
• Death from hypoxia (rare)
Prognosis
• Fair to good
• Good with uncomplicated surgery • Guarded with symptomatic treatment
• Serous nasal discharge is indicative of acute or allergic disease • Mucopurulent discharge suggests bacterial or fungal infection (infection may be only secondary to underlying neoplasia)
• Obtain both inspiratory and expiratory radiographs: tracheal collapse may be seen at any point during breathing
Notes
DERMATOLOGY Table 6.10 / Dermatology: Acne Disease
Definition
Presentation
6
Follow-Up
Treatment
Disease
220
Presenting Clinical Signs
Acne Canine
Feline
Chronic inflammatory disorder most often seen in short-coated breeds. It is often associated with superficial and deep pyoderma. It is typically found on the chin and lips of young animals.
Feline acne is often associated with the chin and lower lip. They may have a single episode or a continual lifelong problem. Poor grooming is thought to be one cause for this condition.
• Erythematous papules, swelling, exudate and scarring
• Comedones, erythema papules, serous crusts, swelling, and alopecia
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.10 / Dermatology: Acne (Continued)
Follow-Up
Treatment
Diagnosis
Disease
Acne Canine
Feline
General
• Clinical signs
• Clinical signs
Laboratory
• Culture, bacterial: bacteria isolation and identification
• N/A
Imaging
• N/A
• N/A
Procedures
• Biopsy: to confirm diagnosis
• Biopsy: to confirm diagnosis
General
• Symptomatic • Skin treatment
• Symptomatic • Skin treatment
Medication
• Antibiotics: cephalexin, clavamox, clindamycin, erythromycin, cefpodoxime • Antibiotics (topical): mupirocin • Corticosteroids: prednisone or prednisolone • Medicated gels: pyoben • Medicated shampoo: benzoyl peroxide • Retinoids (topical): retin-A gel and tretinoin
• • • •
Nursing Care
• Treated as outpatient
• Treated as outpatient
Patient Care
• Prevent self-trauma: (e.g., rubbing of chin, chewing on bones that ↑ salivation). • Frequent cleaning/shampooing of chin • Warm compresses
• Shampoo 1–2 times weekly and then taper over a 2–3 week period. • Monitor PE and chemistry panel monthly with retinol.
Prevention/ Avoidance
• Maintenance lifelong treatment may be necessary.
• Maintenance lifelong treatment may be necessary. • Avoid the use of plastic feeding dishes.
Complications
• Deep pyoderma
• Deep pyoderma
Prognosis
• Excellent
• Excellent
• English Bulldog, Boxer, Doberman Pinscher, and Great Dane • Discourage owners from expressing the lesions, it can lead to massive inflammation.
• Discourage owners from expressing the lesions, it can lead to massive inflammation.
Notes
Antibiotics: clavamox or enrofloxacin Antibiotics (topical): mupirocin Medicated shampoo: benzoyl peroxide or sulfur–salicylic acid Retinoids (topical): retin-A gel and tretinoin
CHAPTER 6 / GENERAL MEDICINE
6
221
Table 6.11 / Dermatology: Acral Lick Dermatitis, Atopy, and Flea Allergy Dermatitis Disease
Acral Lick Dermatitis (Lick Granuloma, Acral Pruritic Nodule)
Atopy
Flea Allergy Dermatitis (FAD)
Definition
Acral lick dermatitis is an area of a firm, raised, ulcerative, or thickened area that is usually located on the dorsal aspect of the carpus, metacarpus, tarsus, or metatarsus. The area may have a history of trauma, foreign body reaction, neoplasia, allergy, endocrinology, or others. The problem is typically made worse by the constant licking and chewing by the patient.
Animals that have formed allergies to normally innocuous inhaled substances such as pollen, grass, fleas, molds, and mites. This disease is the cause of a majority of dermatologic problems.
The antigens in the saliva of fleas are the cause of a hypersensitivity reaction called flea allergy dermatitis. It is the most common skin disease in most geographical areas, especially during the summer months. Ctenocephalides felis is the type of flea that usually infests both dogs and cats.
Presenting Clinical Signs
• Alopecia, excessive licking, chewing
• Pruritis and skin lesions • Canine: alopecia, edema, face rubbing, foot chewing, hyperpigmentation • Feline: alopecia, dermatitis, and miliary eczema
• Alopecia (tail base, dorsal lumbar region, caudal thighs, groin, abdomen, head and neck), broken hairs, chewing, dry hair, excoriations, hyperpigmentation, licking, pruritis, rolling, rubbing, scaling, scratching • Feline: alopecia (head and neck)
Examination Findings
• Firm, hyperpigmentation, raised, thickened, ulcerative
• Canine: otitis externa, recurrent pyoderma, seborrheic dermatitis • Feline: miliary eczema, eosinophilic granuloma complex
• Erythema, otitis externa, papules • Feline: lymphadenopathy, miliary eczema
General
• History/clinical signs
• History/clinical signs: seasonal
• History/clinical signs • Presence of fleas or flea dirt
Laboratory
• Skin scraping: bacteria, demodex, dermatophytosis • Culture, bacterial: bacteria isolation and identification • Biopsy, skin: neoplasia • Intradermal skin test: atopy
• CBC: eosinophilia (occasional) • Intradermal skin test: most reliable specific test • ELISA and RAST: ↑ values (nonspecific)
• CBC: hypereosinophilia (cats–v) • Intradermal skin test: + (reliable) • Serology: + serum IgE anti-flea antibody titer
Imaging
• Lower limb: neoplasia, radiopaque foreign body, bony proliferation, and some forms of trauma
• N/A
• N/A
Procedures
• Hypoallergenic test diet: food hypersensitivity
Diagnosis
Presentation
6
222
SECTION THREE: DIAGNOSTIC SKILLS
• Flea combing
Table 6.11 / Dermatology: Acral Lick Dermatitis, Atopy, and Flea Allergy Dermatitis (Continued) Acral Lick Dermatitis (Lick Granuloma, Acral Pruritic Nodule)
Atopy
Flea Allergy Dermatitis (FAD)
General
• Symptomatic • Laser ablation
• Symptomatic
• Symptomatic
Medication
• Antihistamines: chlorpheniramine and hydroxyzine HCl • Antibiotics: variable • Psychotropic drugs: clomopramine HCl, amitriptyline or fluoxetine HCl
• Antihistamines: chlorpheniramine, hydroxyzine and diphenhydramine • Corticosteroids: prednisone or methylprednisolone • Cyclosporine • Immunotherapy: SQ injection of increasing doses of offending allergen • Medicated shampoos • Psychotropic agents: amitriptyline, fluoxetine, barbiturates
• Antihistamines: diphenhydramine or chlorpheniramine • Antiparasitic: fipronil • Corticosteroids: triamcinolone • Fatty acid supplements • Insecticide: imidacloprid and selamectin • Insect growth regulator: lufenuron, pyriproxifen, methoprene
Follow-Up
Treatment
Disease
6
Nursing Care
• Treated as outpatient
• Treated as outpatient
• Treated as outpatient
Patient Care
• Monitor close for licking and chewing. • Check CBC, biochemistry, and ECG every 1–2 months for those receiving tricyclic antidepressants.
• Fatty acid supplementation • Frequent bathing to reduce pruritis • Exam patients 2–8 weeks following treatment, then every 3–12 months.
• Flea comb regularly.
Prevention/ Avoidance
• Determine underlying disease when possible.
• Avoid offending allergen.
• Maintain year around flea control: flea comb, monthly oral medication, and/or spot-on medication.
Complications
• Deep pyoderma
• Superficial pyoderma • Flea allergy dermatitis • Surface pyoderma
• Superficial or deep pyoderma • Acute moist dermatitis • Acral lick dermatitis
Prognosis
• Guarded (not life threatening) if no underlying disease is found and psychogenic causes are suspected
• Good if allergen is determined
• Excellent
• Elizabethan collars, foul-tasting medications and sprays, and bandages may be used to prevent licking and chewing. • Additional attention and exercise may help if psychogenic causes are suspected.
• Do not use penicillins or tetracyclines for treatment of superficial pyoderma. • Some type of treatment is usually needed for life. • It may take up to 6–12 months before results from immunotherapy are seen.
• A complete flea control plan includes treating the pet, other pets in-household, and indoor and outdoor environment. • Control may take 4–8 weeks to achieve. • With many new alternatives to flea control, dips, sprays, and flea collars should be the last choice for control. • Extra care should be taken when using insecticides to avoid overdose to animals and humans. • Flea-infested animals should also be checked for Dipylidium caninum.
Notes
CHAPTER 6 / GENERAL MEDICINE
223
Table 6.12 / Dermatology: Food Hypersensitivity and Otitis Externa Food Hypersensitivity
Otitis Externa
Definition
Food hypersensitivities show symptoms induced by food or food additive ingestion in which there are demonstrable or highly suspected immunologic reactions.
Otitis externa is the inflammation of the soft tissue of the external ear canal. Its causes are often multifactorial, signifying a generalized dermatologic problem. It can be either a primary or a secondary disease, making it very frustrating and difficult to treat.
Presenting Clinical Signs
• Alopecia, diarrhea, flatulence, pruritis (feet, ears, face, neck, inguinal or axillary areas, perineum), seizures, vomiting
• Behavioral changes (irritable, aggression), foul odor, head shaking, head tilting, hearing loss, pain, foul odor, scratching, rubbing at ears
Examination Findings
• Erythematous, otitis externa, Malassezia dermatitis, papular rash
• Calcification/thickening of canal, debris, exudate, inflammation, swelling, ulceration
General
• History/clinical signs • Nonseasonal occurrence and partial or incomplete response to corticosteroids
• History/clinical signs • Otoscopic examination
Laboratory
• N/A
• N/A
Imaging
• N/A
• Radiographs, skull: only used in chronic cases to determine patency of ear canal and rule out otitis media
Procedures
• Intradermal skin testing: inconsistent findings • Hypoallergenic test diet or novel elimination diet trial
• Cytology: parasites, cells, bacteria, yeast, and fungi • Culture: bacteria recognition and identification • Intradermal skin tests: + results
General
• Symptomatic
• Symptomatic • Flush and dry ear canals; Tris-EDTA as pretreatment wash
Medication
• If any, dependent on clinical signs
• Antibiotics: cephalexin, trimethoprim-sulfa, enrofloxacin, clindamycin, clavamox, ciprofloxacin, difloxacin, cefpodoxime • Antibiotics (topical): enrofloxacin, tobramycin, silver sulfadiazine • Antifungals: ketoconazole, miconazole • Corticosteroids: prednisone • Ear cleaner • Parasiticides: ivermectin
Nursing Care
• Treated as outpatient
• Treated as outpatient
Patient Care
• Feed the restricted diet exclusively for 10–12 weeks. • Avoid flavored chew toys, bones, treats, vitamins and medications.
• Recheck ears frequently until resolved: do not treat prior to examination for better visibility.
Prevention/ Avoidance
• Restrict the feeding of hypersensitive foods.
• Clean ears regularly. • Thoroughly dry ears after swimming and bathing. • Lateral ear resection surgery
Complications
• Pruritis: by other sources
• Ruptured ear drum • Otitis media • Permanent ear canal changes: stenosis and calcification
Prognosis
• Good if offending food is determined
• Excellent if treated early
Presentation
Disease
Follow-Up
Treatment
Diagnosis
6
224
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.12 / Dermatology: Food Hypersensitivity and Otitis Externa (Continued) Disease
Food Hypersensitivity
Otitis Externa
Notes
• The diet should consist of foods that the animal has not been previously exposed to (e.g., rice, potatoes, lamb) and without additives or preservatives. (See Table 3.2 Disease Nutritional Requirements, page 64.) • If no improvement, review other food sources and other forms of allergens (e.g., fleas and inhalant). • Corticosteroids should only be used with severe pruritis; otherwise, they may alter the results of the hypoallergenic diet test.
• Enough topical medication must be used to coat the entire ear canal for effectiveness, and then its use is tapered once infection is resolved. • Possible reasons for certain exudates: • Dark, dry, and granular: ear mite infection • Moist, yellow, and odiferous: bacterial infection • Brown and waxy: yeast infection • Yellow and waxy-to-oily: keratinization disorders • Use only warmed 0.9% saline to flush an ear canal with a ruptured tympanic membrane. • Plucking hair from within the ear canal may cause irritation and predisposes the animal to otitis externa.
6
Table 6.13 / Dermatology: Pyoderma Disease
Definition
Presentation
Presenting Clinical Signs
Examination Findings
Pyoderma Deep
Superficial (Superficial Bacterial Folliculitis)
Surface (Acute Moist Dermatitis [Hot Spots], Skinfold Dermatitis)
Deep pyoderma extends into the dermis and, in severe cases, into the subcutaneous tissue. This bacterial skin infection has many different forms, two of the most common being folliculitis and furunculosis. It is almost always secondary to another disease process.
The epidermis is the target of a bacterial infection with superficial pyoderma. It can manifest itself in 2 ways: penetrating the stratus corneum (impetigo) or invading the hair follicles (folliculitis).
Self-trauma and deep skinfolds are the most common reasons for surface pyoderma. This is due to a colony of bacteria on the surface of the epidermis only, without invading the stratum corneum or hair follicles. Acute moist dermatitis (hot spots) and skinfold dermatitis are the two distinct forms of surface pyoderma.
• Alopecia, anorexia, depression, peripheral lymphadenopathy, and fever • Pustules: inguinal, ventral abdominal, and axillary areas extending to the whole body • Erythematous, painful, pruritic skin • Exudate and crust formation, drainage tracts, and hemorrhagic bullae
• Dull haircoat, excessive shedding, scales • Impetigo: pustules (inguinal and ventral abdominal area, esp. young animals), patchy alopecia • Folliculitis: pustules (inguinal, ventral abdominal, axillary areas)
• Biting, licking, and rubbing by patient Acute Moist Dermatitis • Alopecia, thin exudate layer, erythema, surrounded by matted hairs and thickened skin with abrasion Skinfold Pyoderma • Inflammation, exudate, fetid, alopecia, and erythema
• Folliculitis: epidermal collarettes (“bull’seye” lesions), erythema, pruritic skin
CHAPTER 6 / GENERAL MEDICINE
225
Table 6.13 / Dermatology: Pyoderma (Continued) Disease
Superficial (Superficial Bacterial Folliculitis)
Surface (Acute Moist Dermatitis [Hot Spots], Skinfold Dermatitis)
General
• History/clinical signs
• History/clinical signs
• History/clinical signs • Self-trauma, environmental irritant, or any pruritic skin
Laboratory
• • • • • • •
• Cytology: neutrophils and bacteria • Skin scrapings: ectoparasites • Culture: bacteria isolation and identification • Skin biopsy: to confirm folliculitis
• Culture: bacteria isolation and identification • Skin biopsy: nonfollicular subcorneal pustules, suppurative inflammation with sepsis • Skin Scraping: cocci in clusters on squamous epithelial cells or budding yeast
Imaging
• N/A
• N/A
• N/A
Procedures
• Skin scraping and biopsy
• Skin scraping and biopsy
• N/A
General
• Symptomatic • Fluid therapy (severe cases)
• Symptomatic
• Symptomatic • Wound management
Medication
• Antibiotics: variable • Medicated shampoos
• Antibiotics: variable • Medicated shampoos: antibacterial
• Antibiotics (oral and/or topical): variable • Corticosteroids (topical): panalog cream and neopredef powder
Nursing Care
• Clip haircoat on long-coated breeds
• Treated as outpatient
• Treated as outpatient
Patient Care
• Bathe twice daily for 1–2 weeks then 1–2 times weekly. • Whirlpool baths • Provide a high-quality diet. • Supplement with essential fatty acids. • Padded bedding to ease pressure point pyoderma
• • • •
• Maintain a clean and dry wound • Prevent self-trauma: restraint, collars, etc.
Prevention/ Avoidance
• Determine the underlying cause. • Bathe regularly with appropriate shampoo.
• Determine the underlying cause. • Bath with appropriate shampoo, especially after swimming.
• Determine the underlying cause. • Clean and dry the skinfolds routinely with astringents.
Complications
• Bacteremia or septicemia • Scarring
• Deep pyoderma • Recurrence
• Superficial or deep pyoderma
Prognosis
• Excellent if underlying cause is determined
• Excellent
• Excellent
• German Shepard
• If persistent pruritis, ectoparasitism or allergy may be present as underlying etiology.
• Cocker Spaniel, Springer Spaniel, Saint Bernard, Irish Setter, Shar pei, Basset Hound, Bulldog, Boston Terrier, and Pug • Corrective surgery may be performed on chronically infected skinfolds.
Diagnosis
Deep
Follow-Up
Treatment
6
Notes
226
Pyoderma
CBC: leukocytosis with a left shift (v) Chemistry panel: ↑ globulin (v) Cytology: neutrophils, macrophages, and bacteria Skin scrapings: ectoparasites Blood culture: bacteria Culture: bacteria recognition and identification Skin biopsy: to confirm folliculitis, perifolliculitis, or furunculosis
SECTION THREE: DIAGNOSTIC SKILLS
Bathe 2–3 times weekly for 2–3 weeks. Prevent self-trauma. Provide a high-quality diet. Supplement with essential fatty acids.
ENDOCRINOLOGY AND REPRODUCTION Table 6.14 / Endocrinology and Reproduction: Abortion and Diabetes Insipidus Abortion
Diabetes Insipidus
Definition
An abortion is the termination of a pregnancy. It may be the result of difficulties with the mother, fetus, or placenta. Exposures to toxins or infections in the dam are well documented.
Diabetes insipidus is a disorder of water metabolism due to a deficiency of antidiuretic hormone (ADH) caused by either a lack of release of ADH or renal tubular insensitivity to ADH.
Presenting Clinical Signs
• Anorexia, depression, lethargy, vomiting, and diarrhea • Early gestation: vaginal discharge, fetid and purulent • Late gestation: restlessness and abdominal contractions
• Blindness, disorientation, incontinence, nocturia, PU/PD, seizures, weight loss
Examination Findings
• Disappearance of previously documented (e.g., palpation, ultrasound, radiogragh) fetuses
• Dehydration
General
• History/clinical signs • Observe for any systemic signs of illness
• Clinical signs
Laboratory
• Bacterial culture: bacteria isolation and identification • RAST or AGID: Brucella canis
• Chemistry panel: ↑ sodium • Urinalysis: ↑ protein (v), ↓ specific gravity: <1.010 • Abrupt or gradual water deprivation test: UA specific gravity of <1.025 μg/dL • ADH response test: failure to concentrate urine after exogenous ADH administration
Imaging
• Radiographs, abdominal: retained fetuses • Ultrasound: uterine pathology and retained fetuses
• Nuclear imaging and CT: identify pituitary or hypothalamic lesion
Procedures
• Necropsy of dead fetuses
General
• Symptomatic • Fluid therapy • Surgery: cesarean section
• Symptomatic
Medication
• Antibiotics: variable • Prostaglandin
• ADH supplement: vasopressin, pitressin tannate
Nursing Care
• Postparturition or postoperative nursing care
• Free access to water
Patient Care
• Physical examination 7–14 after treatment
• Free access to water • Sodium-restricted diet
Prevention/ Avoidance
• OVH
• Avoid circumstances that might markedly increase water loss
Follow-Up
Treatment
Diagnosis
Presentation
Disease
6
CHAPTER 6 / GENERAL MEDICINE
227
Table 6.14 / Endocrinology and Reproduction: Abortion and Diabetes Insipidus (Continued) Abortion
Diabetes Insipidus
Complications
• • • • • • •
• Primary disease
Prognosis
• Excellent if treated early
• Very good prognosis with lack of release of ADH • Guarded prognosis with renal insensitivity to ADH
• In the first trimester, it is very difficult to distinguish between abortion and infertility. • Aborted fetuses or placenta may be infectious; isolate animal from all other dogs, pups, and humans.
• Water deprivation test is contraindicated in dehydrated animals.
Follow-Up
Disease
Notes
6
Death Infertility Peritonitis Pyometra Sepsis Shock Uterine rupture
Table 6.15 / Endocrinology and Reproduction: Diabetes Mellitus Diabetes Mellitus
Definition
A chronic disorder of carbohydrate metabolism, characterized by hyperglycemia and glucosuria and resulting from inadequate production or utilization of insulin Type 1: insulin-dependent (low to absent secretory ability) Type 2: non–insulin-dependent (inadequate or delayed insulin secretion or peripheral tissue insensitivity to insulin)
Diagnosis
Presentation
Disease
228
Presenting Clinical Signs
• PU/PD, polyphagia, and weight loss • Later stages: anorexia, lethargy, oily hair coat, dorsal muscle wasting, depression, and vomiting
Examination Findings
• Hepatomegaly, cataracts (canine), plantigrade stance (feline)
General
• History/clinical signs
Laboratory
• CBC: eosinophilia and lymphocytosis (v), ↑ PCV/TP, mild nonregenerative anemia, Heinz bodies • Chemistry panel: ↑ glucose (>200 mg/dL in dogs: >250 mg/dL in cats), cholesterol, sodium, phosphate, alk phos, ALT, AST, and ↓ potassium and metabolic acidosis
Imaging
• Radiographs, thoracic: microcardia and hypoperfusion of lungs • Ultrasound: pancreatic and liver pathology
Procedures
• Liver biopsy (e.g., jaundiced patients)
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.15 / Endocrinology and Reproduction: Diabetes Mellitus (Continued)
Follow-Up
Treatment
Disease
Diabetes Mellitus
General
• Supportive • Fluid therapy
Medication
• Insulin: PZI, NPH, glargine, Vetsulin, caninsulin • Oral hypoglycemics: glipizide, metformin, troglitazone, acarbose
Nursing Care
• Free access to water • Try to mimic the same feeding schedule used at home. • Low stress environment
Patient Care
• • • •
Maintain a regimented feeding and medication schedule. Monitor for signs of iatrogenic hypoglycemia, PU/PD, appetite, and body weight. Provide consistent amount of exercise every day to prevent fluctuations in insulin requirements. Monitor serial BGs (initially every few weeks and then once regulated, every few months) or monitor serum fructosamine or glycosylated hemoglobin.
Prevention/Avoidance
• Prevent or correct obesity. • Avoid unnecessary use of corticosteroids or megesterol acetate.
Complications
• • • • •
Prognosis
• Cats may recover but may relapse later. • Dogs have permanent disease. • Normal life span is expected with treatment.
Notes
6
Secondary infections Anemia and hemoglobinemia with severe hypophosphatemia Cataracts (canine) Diabetic neuropathy (feline) Seizures or coma
• Meals should coincide with the administration of insulin. • Feed a canned low-carbohydrate and high-protein diet twice daily (esp. feline). • Patients scheduled for surgery: NPO after 12 AM, give 1/2 the normal dose of insulin the morning of surgery, monitor blood glucose levels, and administer R insulin if needed following the surgery maintain the patient on a 5% dextrose IV drip until food intake has resumed. • Keeshond, Puli, Miniature Pinscher, and Cairn Terrier
Note: See Insulin Therapy, Skill Boxes 8.14, 8.15, and 8.16, page 357.
CHAPTER 6 / GENERAL MEDICINE
229
Table 6.16 / Endocrinology and Reproduction: Dystocia and Eclampsia Dystociaa
Eclampsia (Puerperal tetany)
Definition
Dystocia results from abnormalities associated with parturition. They are due to either primary or secondary uterine inertia. Primary uterine inertia is the failure of uterine contractions sufficient to deliver. Secondary uterine inertia is fetal obstruction due to large pups, narrow birth canal, abnormal pup position, etc.
Eclampsia can be a life-threatening condition often seen 1–4 weeks postpartum. It is due to extremely low serum ionized calcium levels.
Clinical Signs
• Abnormal vaginal discharge, active straining for >45 minutes, crying and biting at vulvar area, intermittent weak contractions for >2 hours, presence of fetal membrane in the vulva for >15 minutes, resting phase for >4–6 hours without straining
• Ataxia, convulsions, drooling, muscle tremors, nervousness, pacing, panting, restlessness, salivation, seizures, stiff gait, tachypnea, tremors, whining
Examination Findings
• Vaginal stenosis
• Dilated pupils, ↓ pupillary light response, pyrexia, tachycardia, tetany
General
• History/clinical signs • Prolonged gestation: >72 days from the first mating
• History/clinical signs
Laboratory
• CBC: ↑ PCV/TP and ↓ glucose and calcium
• Chemistry panel: ↓ calcium (≤7 mg/dL) and glucose (rare)
Imaging
• Radiographs, abdominal: fetal death characterized by intrafetal gas patterns, collapsed spinal cord, overlapping of the skull bones or pup in the birth canal • Ultrasound: uterine pathology and fetal distress (↓ heart rate and fetal bowel movements)
• N/A
Procedures
• Vaginal examination
• ECG: prolonged QT interval, bradycardia, tachycardia or VPCs
General
• • • •
• Symptomatic
Medication
• Anesthesia: isoflurane or reversible induction agents • Ecbolic agents: oxytocin, calcium gluconate, ergonovine maleate or dextrose • Tranquilizer: acepromazine
• Calcium supplementation: calcium gluconate • Tranquilizers: diazepam
Nursing Care
• Postparturition or standard postoperative
• Calcium administration often leads to vomiting, which will subside. • Cold water baths and enemas • Hand-raise puppies until crisis is over.
Patient Care
• Postparturition care • Monitor growth and nursing habits of the neonates.
• Monitor calcium levels • Supplement oral calcium throughout lactation
Prevention/ Avoidance
• OVH • Scheduled cesarean section
• Do not supplement with calcium during gestation. • OVH
Presentation
Disease
Follow-Up
Treatment
Diagnosis
6
230
Symptomatic Fluid therapy Manual manipulation via vagina Surgery: emergency cesarean section
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.16 / Endocrinology and Reproduction: Dystocia and Eclampsia (Continued) Dystociaa
Eclampsia (Puerperal tetany)
Complications
• Maternal or fetal death • ↑ risk in future pregnancies • Neonate stuck in birth canal
• Cerebral edema • Death
Prognosis
• Excellent if discovered early
• Good with immediate treatment • Poor with delayed treatment
• Rule out obstructive dystocia before administering ecbolics agents. • Welsh Corgi and brachycephalic breeds tend to have a congenitally small pelvis, and the pups tend to have large heads and shoulders.
• Response to treatment is rapid; therefore, treat if the diagnosis is suspected while lab confirmation is pending. • Probable reoccurrence with subsequent litters
Follow-Up
Disease
Notes
See Table 2.4, Normal Parturition of Canines and Felines and Skill Box 7.4 Neonatal Resuscitation Post-Cesarean, page 317.
6 Table 6.17 / Endocrinology and Reproduction: Hyperadrenocorticism and Hyperparathyroidism Hyperadrenocorticism (HAC, Canine Cushing’s Syndrome)
Hyperparathyroidism
Definition
Hyperadrenocorticism is most commonly found in canines middle to old age. It is caused by the excessive secretion of cortisol by the adrenal glands. The excess glucocorticoid comes from (1) excessive secretion of ACTH from a pituitary microadenoma or (2) an adrenocortical tumor. Excessive administration of corticosteroids can also result in iatrogenic HAC, a separate syndrome.
The disease results from excessive secretion of the parathyroid hormone (PTH). This can be caused by an adenoma, carcinoma, or hyperplasia of the parathyroid gland.
Clinical Signs
• Behavior changes, bilaterally symmetric alopecia, circling, dull haircoat, dyspnea, excessive panting, infertility, pendulous, distended or pot-bellied abdomen, polyphagia, PU/PD, recurrent skin infections, seizures
• Anorexia, ataxia, constipation, depression, facial swelling, lethargy, muscle tremors, PU/PD, seizures, shivering, stiff gait, twitching, vomiting, weakness
Examination Findings
• Muscle and testicular atrophy, thin skin with hyperpigmentation and ↑ fragility (esp. feline)
• Cataracts, tachycardia
General
• History: exogenous glucocorticoid use • Clinical signs
• Clinical signs • Palpation of a parathyroid gland (feline)
Laboratory
• CBC: steroid leukogram and mild erythrocytosis (v) • Chemistry panel: ↑ alk phos, cholesterol, ALT and glucose (v) • Urinalysis: ↑ protein, blood, bacteria, WBCs, cortisol-to-creatinine ratio (>35), and ↓ specific gravity: <1.020 • ACTH stimulation test: to diagnose type, >20 μg/dL with endogenous HAC, blunted or no response iatrogenic HAC • Low dose dexamethasone suppression test: to confirm diagnosis, >1 μg/dL during 8 hour test • High dose dexamethasone suppression test: to differentiate type, <1.5 μg/dL with pituitary dependent HAC and >1.5 μg/dL with adrenocortical neoplasia • Endogenous plasma ACTH concentration: to differentiate type, >40 pg/mL with pituitary dependent HAC and <20 pg/mL with adrenocortical tumors
• • • •
Presentation
Disease
Diagnosis
a
Chemistry panel: ↑ calcium, ALT, alk phos, ↓ phosphorus Urinalysis: ↓ specific gravity Serum ionized calcium: ↑ values Serum PTH concentration: ↑ values
CHAPTER 6 / GENERAL MEDICINE
231
Table 6.17 / Endocrinology and Reproduction: Hyperadrenocorticism and Hyperparathyroidism (Continued) Hyperadrenocorticism (HAC, Canine Cushing’s Syndrome)
Hyperparathyroidism
Imaging
• • • •
• Radiographs, skeletal: generalized osteopenia, ↑ bone resorption (alveolar bone of the jaw) and cyst-like areas in the bone • Ultrasound: visualization of the parathyroid gland, urolithiasis, and renal abnormalities
Procedures
• N/A
• ECG: premature ventricular complexes
General
• Symptomatic • Radiation therapy: pituitary macroadenoma or marcocarcinoma • Surgery: removal of adrenal tumor, removal of pituitary (hypophysectomy)
• Symptomatic • Fluid therapy • Surgery: removal of the parathyroid gland adenoma
Medication
• • • •
• Diuretics: furosemide • Calcitriol (postoperative for transient iatrogenic hypocalcemia)
Nursing Care
• Treated as outpatient
• Standard postoperative
Patient Care
• Monitor for reoccurrence of previous clinical signs • Perform an ACTH response test 5–10 days initiation of medication (except L-deprenyl) then every 3–6 months • Monitor for inappetance, severe decreased water consumption, attitude, activity, vomiting, or diarrhea relating to the medication
• Monitor serum calcium 1–2 times daily for 1 week postoperative • Diet of ↑ phosphorus and ↓ calcium
Prevention/ Avoidance
• N/A
• N/A
Complications
• • • • • • •
• Hypocalcemia (iatrogenic) • Renal failure
Prognosis
• Guarded due to the number of complications associated with this disease
• Excellent with proper treatment • Poor with associated renal disease
• Easy cutaneous bruising (canine), venipuncture should be perform with extra care • Most commonly seen in Poodle, Dachshund, Boston Terrier, and Boxer
• This is the only condition that causes ↓ phosphorous and ↑ calcium, • Keeshond, German Shepard, Norwegian Elkhound, and Siamese cat
Follow-Up
6
Treatment
Diagnosis
Disease
Notes
232
Radiographs, thoracic: mineralization of bronchial walls Radiographs, abdominal: adrenal tumors and hepatomegaly Ultrasound: ↑ liver and adrenal glands CT: visualization of pituitary tumors and possibly pituitary microadenomas (radiographs and ultrasounds can be used, but are not as accurate)
Corticosteroids: prednisone or prednisolone Ketoconazole L-Deprenyl Mitotane, trilostane
Thromboembolism Congestive heart failure Hypertension Recurrence of clinical signs Progression of CNS signs Infection: skin and urinary Diabetes mellitus
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.18 / Endocrinology and Reproduction: Hyperthyroidism and Hypoadrenocorticism Hyperthyroidism (Feline)
Hypoadrenocorticism (Addison’s Disease)
Definition
A multisystemic metabolic disorder most commonly seen in middleaged to old felines. It is caused by an excessive amount of circulating thyroid hormone. The disease causes an increased basal metabolic rate, which in turn causes the disease’s clinical signs.
Hypoadrenocorticism is a disease of the adrenal gland resulting in a deficiency of glucocorticoid and/or mineralcorticoid secretion from the adrenal cortex. The cause is often thought to be idiopathic or sometimes due to infection, hemorrhagic infarctions, metastatic neoplasia, trauma, and amyloidosis. Mostly seen in young to middleaged female dogs.
Clinical Signs
• ↑ Appetite, behavioral changes, diarrhea, dyspnea, excessive shedding and matting, heat intolerance, hyperexcitability, hyperventilation, panting, PU/PD, restlessness, tachypnea, unkept haircoat, vomiting, weakness, weight loss
• Intermittent anorexia, collapse, depression, diarrhea, lethargy, melena, muscle weakness, polyuria, PU/PD, shivering, vomiting, weight loss
Examination Findings
• Arrhythmia, enlargement of 1 or both thyroid glands, gallop, lymphadenopathy, pallor, systolic murmur, tachycardia
• Arrhythmias, dehydration, progressing to bradycardia, shock, weak pulses
General
• History/clinical signs • Palpation of thyroid gland(s)
• History/clinical signs
Laboratory
• CBC: erythrocytosis (v), mature leukocytosis, eosinopenia, monocytosis, ↑ PCV, MCV, Heinz bodies (v) • Chemistry panel: ↑ ALT, AST, alk phos, BUN, creatinine, calcium, glucose, phosphorus, bilirubin, lactate • Basal serum thyroid hormone concentration: >4 μg/dL • Free T4 by equilibrium analysis: ↑ value • T3 suppression test: >1.5 μg/dL • TRH response test: little to no ↑ in serum T4 • TLI: ↓ TSH
• CBC: normocytic, normochromic nonregenerative anemia • Chemistry panel: ↑ ALT, AST, calcium, potassium, creatinine, BUN and ↓ phosphorus, sodium, chloride, cholesterol, glucose • Urinalysis: ↑ ketones, glucose, ↓ specific gravity: <1.030 • ACTH stimulation test, primary hypoadrenocorticism is <1 μg/dL • Plasma concentration of ACTH: primary is >500 pg/mL and secondary is <20 pg/mL • Plasma aldosterone: ↓ value • Sodium : potassium ratio: <27 : 1
Imaging
• Radiographs, thoracic: cardiomegaly, pulmonary edema, valentineshaped heart • Ultrasound, abdominal: underlying renal disease • Echocardiography: atrial and LV dilation, hypercontractility • Thyroid pertechnetate scan: + thyroid radioisotope
• Radiographs, abdominal: cystic or renal calculi, cholecystitis, and pancreatitis
Procedures
• ECG: atrial fibrillation, APCs, VPCs, tachycardia • Blood pressure: hypertension
• ECG: peaking of T waves, prolonged P-R waves until P wave ultimately disappears, QRS complex widens, and R-R intervals become irregular
Diagnosis
Presentation
Disease
CHAPTER 6 / GENERAL MEDICINE
233
6
Table 6.18 / Endocrinology and Reproduction: Hyperthyroidism and Hypoadrenocorticism (Continued)
Treatment
Disease
Follow-Up
6
Hyperthyroidism (Feline)
Hypoadrenocorticism (Addison’s Disease)
General
• Symptomatic • Radioiodine therapy • Surgery: thyroidectomy
• Supportive • Fluid therapy (acute cases)
Medication
• β-Adrenergic blocking drugs • Antiarrythmics: propranolol • Antithyroid: methimazole, carbimazole, ipodate
• Corticosteroids: prednisolone sodium succinate, dexamethasone, prednisone • Mineralcorticoids: DOCP, fludrocortisones, hydrocortisone hemisuccinate, hydrocortisone phosphate • Calcium gluconate • Sodium bicarbonate
Nursing Care
• Treated as outpatient
• Treated as outpatient
Patient Care
• Monitor CBC, BUN, creatinine, and serum T4 every 2–4 weeks during first 3 months of methimazole treatment. • Monitor serum T4 the first week and then every 3–6 months after thyroidectomy. • Monitor T4 the second week and then every 3–6 months after radioiodine therapy.
• Monitor electrolytes weekly until stabilized. • Monitor electrolytes, BUN and creatinine monthly for 3 months, then every 3–12 months.
Prevention/ Avoidance
• N/A
• N/A
Complications
• • • • • •
• PU/PD from medication
Prognosis
• Excellent with treatment • Poor with thyroid carcinoma
• Good to excellent with proper diagnosis and treatment • Poor prognosis with tumors causing the disease
• Clinical signs are expected to completely resolve with proper treatment. • Radioiodine therapy is the best choice of treatment to cure the disease. • Renal disease may become apparent once euthyroidism is established.
• Most commonly seen in female dogs <7 years old. • Glucocorticoids (e.g., prednisolone) need to be ↑ during times of stress such as travel, hospitalization, and surgery. • Great Dane, Rottweiler, Portuguese Water Spaniel, West Highland White Terrier, Wheaten Terrier, and Standard Poodle
Notes
234
Congestive heart failure Dehydration Diarrhea Hypothyroidism (iatrogenic) Renal damage Retinal detachment
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.19 / Endocrinology and Reproduction: Hypoparathyroidism, Hypothyroidism, and Mastitis Hypoparathyroidism
Hypothyroidism (Canine)
Mastitis
Definition
Hypoparathyroidism is a deficiency in the secretion of the parathyroid hormone. This condition is most commonly seen in dogs as naturally occurring and typically following thyroidectomy in cats.
Hypothyroidism is the most commonly diagnosed endocrine disease in the dog. A condition that results from inadequate production and release of T4. Caused by either destruction of the thyroid gland or impaired secretion of TSH by the pituitary gland.
Mastitis is a bacterial infection of one or more of the lactating glands. Seen in the postpartum dam and queen.
Clinical Signs
• Anorexia, ataxia, depression, diarrhea, listlessness, muscle spasms, nervousness, panting, rigid limb extension, seizures, stiff gait, tremors, twitching, vomiting, weight loss
• Abortion, anestrus, cold intolerance, exercise intolerance, infertility, lethargy, mental dullness, muscle weakness, weight gain
• Anorexia, cachexia, depression, lethargy, mammary gland abscess • Neglected, bloated, crying, restless, failure to thrive neonates
Examination Findings
• Cataracts, tachycardia, weak pulses
• Bradycardia, hyperpigmentation, impaired myocardial contractility, myxedema, neuropathies, pyodermas, testicular atrophy • Bilaterally symmetrical nonpruritic alopecia on ventral and lateral trunk, caudal thighs, dorsal tail, dorsal nose and ventral neck
• Dehydration, pyrexia • Mammary gland(s): firm, swollen, warm, painful, purulent or hemorrhagic discharge
General
• Clinical signs
• Clinical signs
• History/clinical signs
Laboratory
• Chemistry panel: ↑ phosphorus and ↓ calcium • Serum PTH concentration: ↓ value
• CBC: mild normocytic, normochromic, nonregenerative anemia • Chemistry panel: ↑ cholesterol, ALT, AST, SAP, CK, ↓ calcium • Basal serum T4 levels: <1.0 μg/dL • Serum TSH concentration: ↑ value • Free T4 by equilibrium analysis: ↓ value
• CBC: leukocytosis with left shift or leukopenia with sepsis and ↑ PCV (v) • Chemistry panel: ↑ TP and BUN • Cytology and culture, milk: neutrophils, macrophages, RBCs, bacteria isolation and identification
Imaging
• N/A
• N/A
• N/A
Procedures
• ECG: prolongation of QT and ST segments, deep wide T waves, and tachyarrhythmias
• N/A
• N/A
General
• Supportive • Fluid therapy
• Symptomatic
• Supportive • Fluid therapy • Surgery: lance, debride, drain placement of infected glands
Medication
• Calcium supplementation: calcium gluconate, calcium lactate, calcium carbonate • Vitamin D supplementation: vitamin D, hytakerol, calcitriol
• Sodium levothyroxine
• Antibiotics: variable, based on milk pH
Treatment
Diagnosis
Presentation
Disease
CHAPTER 6 / GENERAL MEDICINE
235
6
Table 6.19 / Endocrinology and Reproduction: Hypoparathyroidism, Hypothyroidism, and Mastitis (Continued)
6
Follow-Up
Treatment
Disease
Hypoparathyroidism
Hypothyroidism (Canine)
Mastitis
Nursing Care
• Treated as outpatient
• Treated as outpatient
• Hand raise puppies or find a surrogate dam if glands are necrotic and need surgical care. • Alternate cold and warm compress and manually milk glands several times a day
Patient Care
• Check serum calcium weekly for 1 month, monthly for 6 months, then every 2–4 months. • Diet of ↑ calcium and ↓ phosphorus
• Check serum T4 levels after 1 month of therapy, then every 6–12 months.
• Same as above • Monitor the growth and feeding habits of the neonates.
Prevention/ Avoidance
• N/A
• N/A
• Clean environment • Clip toenails of neonates. • Shave hair around mammary glands.
Complications
• Hypercalcemia (iatrogenic) • Renal disease
• Thyrotoxicosis from administration of high does of L-thyroxine
• Abscessed gland • Hand-raising of neonates
Prognosis
• Excellent with close monitoring of calcium levels
• Excellent with proper treatment • Poor if disease is due to a tumor of the thyroid gland
• Good with prompt treatment
• Check albumin level as it is the most common cause for pseudo-hypocalcemia. • Felines with transient hypoparathyroidism postthyroidectomy typically regain normal function by 4–6 months • Toy Poodle, Miniature Schnauzer, German Shepard, Labrador Retreiver, and Scottish Terrier
• Failure of clinical signs to significantly improve within 3 months may be due to an incorrect diagnosis • Improvement should be seen within 1–2 weeks after initiating treatment (e.g., mostly behavior and appetite). • Serum T4 levels should be checked 4–6 hours post administration of L-thyroxine. • Treatment is lifelong. • Golden Retriever, Doberman Pinscher, Irish Setter, Great Dane, Airedale Terrier, Old English Sheepdog, Miniature Schnauzer, Cocker Spaniel, Poodle, and Boxer
• Avoid antibiotics that may be passed in the milk and cause deleterious effects to the neonates.
Notes
236
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.20 / Endocrinology and Reproduction: Pregnancy and Pyometra Disease
Pyometra may be seen in both dogs and cats following estrus or progesterone administration by 1–2 months. It is caused by a hormonal change in the uterus that allows for secondary infections and is seen with either an open cervix or closed cervix.
Clinical Signs
• Enlarged abdomen, mammary gland development and lactation, nesting instinct
• Anorexia, depression, lethargy, depression, diarrhea, vomiting • Open-cervix pyometra: mild systemic signs, PU/PD, vaginal discharge (purulent, blood, mucus) • Closed-cervix pyometra: collapse, more severe systemic signs
Examination Findings
• Documented fetuses (e.g., palpation, ultrasonography, radiogragh)
• Abdominal distention, enlarged uterus, hypothermia, septicemia, shock
General
• History/clinical signs • Abdominal palpation: 25–36 days after breeding (dogs) and 21–28 days after breeding (cats)
• History/clinical signs
Laboratory
• Chemistry panel: ↑ relaxin and progesterone levels
• CBC: neutrophilia with a left shift and mild nonregenerative anemia • Chemistry panel: ↑ globulin, protein, ALT, ALP, azotemia (v) and electrolyte imbalances • Urinalysis: ↑ protein and isothenuric • Cytology and culture: bacteria isolation and identification
Imaging
• Radiographs, abdominal: fetal skeletal calcification ≥42 days of gestation
• Radiographs, abdominal: enlarged or ruptured uterus and peritonitis • Ultrasonography: differentiate pyometra from pregnancy, intraluminal uterine contents, uterine wall thickened
Procedures
• Ultrasound: 16 days of gestation
• Vaginoscopy: determine site of origin of purulent discharge
General
• N/A
• • • •
Medication
• N/A
• Antibiotics: cephalothin, ampicillin or enrofloxacin • Prostaglandin F2α (PGF2α)
Nursing Care
• N/A
• Standard postoperative
Diagnosis Treatment
Pyometra
Pregnancy is the condition of carrying a developing embryo(s) in the uterus. Parturition consists of 3 stages. Stage 1 is characterized by restlessness, anxiety, nesting behavior, and shivering and can last 6– 12 hours. Stage 2 is the actual delivery of the fetus. There are visible contractions and the first fetus should be delivered within 1–2 hours from the onset of stage 2. There may be a resting period for up to 4 hours after the delivery of a fetus. Stage 3 is the expulsion of the placenta typically following the deliver of each fetus.
Definition
Presentation
Pregnancy
Symptomatic Fluid therapy OVH with abdominal lavage Medical management
CHAPTER 6 / GENERAL MEDICINE
237
6
Table 6.20 / Endocrinology and Reproduction: Pregnancy and Pyometra (Continued)
Follow-Up
Disease
6
Pregnancy
Pyometra
Patient Care
• Provide adequate nutrition throughout pregnancy. • Provide a quiet safe place for the dam/queen to deliver. • Monitor parturition to become aware of any complications.
• Reexam medical managed pyometra cases 1 week after initiation of treatment. • Monitor progesterone levels 1 week after discontinuing treatment. • Vaginal discharge may be seen for 4 weeks post treatment.
Prevention/ Avoidance
• OVH • Supervision
• OVH
Complications
• • • •
• • • • •
Prognosis
• Excellent with proper prenatal care
• Good with OVH and no abdominal contamination • Guarded with medical management of closed pyometra
• The length of gestation is 63 days from ovulation but may extend from 56 to 72 days. • A transient temperature drop occurs within 24 hours of the onset of parturition. • A normal fetal heart rate is twice that of the mother.
• Do not perform cystocentesis when pyometra is suspected due to friable uterus and possible contamination of abdomen. • Diluting PGE2α with 1 : 1 sterile saline and walking an animal for 30 minutes after giving the injection may ↓ side effects.
Notes
Dystocia Retained fetuses or placenta Eclampsia Mastitis
Estrus sooner after treatment PGF2α side effects Recurrent pyometra with medical management necessary Sepsis and peritonitis Uterine rupture
GASTROENTEROLOGY Table 6.21 / Gastroenterology: Anal Sac Disease, Cholangitis, and Cholangiohepatitis Anal Sac Disease
Cholangitis and Cholangiohepatitis
Definition
This is the most common disease of the anal area in small animals, especially dogs. It is the impaction, inflammation, infection, abscess, and/or rupture of the anal gland(s).
Cholangitis is inflammation confined to the bile ducts. Cholangiohepatitis is the inflammation of the bile ducts and adjacent hepatocytes. The inflammatory infiltrates are either supprative (S), most commonly seen in younger cats, or nonsuppurative (NS), mostly seen in older cats.
Clinical Signs
• Behavior change, biting, chewing, discomfort in sitting, licking, malodorous, painful defecation, rubbing at perianal area, scooting, tail chasing, tenesmus
• Anorexia, depression, diarrhea, lethargy, vomiting, weight loss
Examination Findings
• Perianal discharge, swollen anal glands
• Abdominal pain, ascites, dehydration, generalized lymphadenopathy (rare), hepatomegaly (v), pyrexia, jaundice
Presentation
Disease
238
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.21 / Gastroenterology: Anal Sac Disease, Cholangitis, and Cholangiohepatitis (Continued) Anal Sac Disease
Cholangitis and Cholangiohepatitis
General
• Clinical signs • Palpation of the anal glands
• History/clinical signs
Laboratory
• Cytology, exudate/secretion: WBCs and bacteria • Culture: bacteria isolation and identification
• CBC: mild nonregenerative anemia and neutrophilia with a left shift • Chemistry panel: ↑ bilirubin, ammonia, ALT, AST, ALP, GGT, globulin, ↓ albumin and BUN • Urinalysis: ↓ bilirubin • Bile acid concentrations: ↑ values • Coagulation profile: prolonged • Biopsy: • S: ↑ neutrophils, intrahepatic • NS: lymphocytic portal infiltrates • Culture, bile: bacteria isolation and identification
Follow-Up
Treatment
Diagnosis
Disease
6
Imaging
• N/A
Procedures
• N/A
General
• Expression of glands • Duct cannulation and irrigation • Surgery: anal sacculectomy
• Supportive • Fluid therapy • Laparotomy to relieve obstruction
Medication
• Antibiotics (systemic): chloramphenicol, penicillin, or aminoglycosides • Antibiotics (topical): panalog
• • • •
Nursing Care
• Treated as outpatient • Standard postoperative if surgery
• Nutritional support • Vitamin supplementation: vitamin E and water-soluble vitamins
Patient Care
• • • •
• Check liver enzymes and bilirubin every 7–14 days initially, then quarterly.
Prevention/ Avoidance
• High-fiber diet • Routine expression
• Control inflammatory bowel disease.
Complications
• Fecal incontinence following anal sacculectomy • Rupture • Septicemia
• • • • •
Prognosis
• Excellent • Guarded to poor with fecal incontinence
• Good with early treatment of suppurative disease • Variable with nonsuppurative
High fiber diet Exercise Express anal glands every 3–14 days until material is normal. Weight control
• Radiographs, abdominal: hepatomegaly and cholelithiasis • Ultrasonography: cholelithiasis, cholecystitis, obstruction, pancreatic abnormalities, and ↑ echogenecity of the liver
Antibiotics: ampicillin, amoxicillin cephalosporins, metronidazole Corticosteroids (NS): prednisolone Ursodeoxycholic acid: actigal Vitamin K1 therapy
Death Diabetes mellitus Hepatic lipidosis Pancreatitis and triad disease Recurrence of nonsuppurative forms
CHAPTER 6 / GENERAL MEDICINE
239
Table 6.21 / Gastroenterology: Anal Sac Disease, Cholangitis, and Cholangiohepatitis (Continued) Disease
Anal Sac Disease
Cholangitis and Cholangiohepatitis
Notes
• Color and consistency of anal gland contents: • Clear or pale yellow-brown: normal • Thick, pasty brown: impaction • Creamy yellow or thin green: infection • Yellow: inflammation • Red-brown exudate: abscessed
• Caution: Drugs used must be selected with care to not further damage the liver through metabolism. • Caution: Corticosteroids should not be used in suppurative forms. • Himalayan, Persian, and Siamese cats
6 Table 6.22 / Gastroenterology: Constipation and Megacolon Constipation and Megacolon
Definition
Constipation is a condition of prolonged fecal transit time, which contributes to increased water absorption leaving a hard, dry fecal mass. These fecal masses can cause irritation and inflammation of the intestinal mucosa and disrupt normal motility.
Treatment
Diagnosis
Presentation
Disease
240
Clinical Signs
• Anorexia, blood, depression, mucus, tenesmus, hard, dry feces, lack of fecal output, unkept haircoat, vomiting, weakness
Examination Findings
• Dehydration, distended and painful abdomen
General
• History/clinical signs • Abdominal palpation: enlarged colon with large fecal mass and a colon full of hypersegmented fecal balls • Digital rectal examination: fecal impaction and possible detection of underlying condition
Laboratory
• CBC: stress leukogram and ↑ PCV/TP • Chemistry panel: ↑ calcium, ↓ chloride and potassium • T4 (feline): ↑ values
Imaging
• Radiographs, abdominal: enlarged colon with large fecal mass, colon full of hypersegmented fecal balls, possible detection of underlying condition (e.g., pelvic fracture, spinal cord abnormalities) • Contrast, barium enema contrast • Ultrasound: obstructive tumors
Procedures
• Colonoscopy: obstructive mass or lesions
General
• • • •
Supportive Fluid therapy Manual evacuation of the colon Surgery: colostomy, colectomy, pelvic osteotomy
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.22 / Gastroenterology: Constipation and Megacolon (Continued) Disease Medication
• Acetylcholinesterase inhibitors: ranitidine, nizatidine, neostigmine • Laxatives: • Bulk-forming: psyllium, pumpkin • Emollient: Colace, DSS • Lubricant: mineral oil, Laxatone, or sterile lubricant jelly • Osmotic: lactulose, milk, or glycerin • Misoprostol • Prokinetic agents: cisapride
Nursing Care
• Encourage to defecate: clean litter pan, multiple walks
Patient Care
• Encourage activity and exercise after postoperative recovery. • Dietary fiber supplements: psyllium, wheat bran, pumpkin • ↑ Exercise
Treatment Follow-Up
Constipation and Megacolon
Prevention/ Avoidance
• Same as above
Complications
• • • •
Prognosis
• Fair with lifelong treatment • Poor with megacolon
Notes
6
Megacolon Obstipation Perforation of colon wall during manual evacuation Peritonitis, diarrhea, or stricture formation post surgery
• Typically seen in the transverse and descending colon • Verify adequate hydration before adding dietary fiber supplements
Table 6.23 / Gastroenterology: Diarrhea Disease
Diarrhea Acute
Presentation
Definition
Chronic
Diarrhea can be acute or chronic (lasting longer than 3–4 weeks) and either small bowel or large bowel. The causes range from dietary indiscretion, toxins, drugs, intestinal parasites, infectious diseases, and systemic or metabolic disturbances.
Clinical Signs
• • • •
Anorexia, lethargy, vomiting Clinical signs of an underlying condition Small bowel diarrhea: watery, voluminous, and fetid Large bowel diarrhea: watery, mucoid, bloody feces with tenesmus and ↑ sense of urgency
Examination Findings
• Abdominal pain, dehydration, ileus, pyrexia
CHAPTER 6 / GENERAL MEDICINE
241
Table 6.23 / Gastroenterology: Diarrhea (Continued) Disease
Diarrhea Acute
General
• History/clinical signs • Abdominal palpation: mass lesions, pain, mesenteric lymphadenopathy, thickened or fluid-distended bowel loops • Digital rectal palpation: masses, strictures, or anal diseases
Laboratory
• • • • • •
Fecal flotation: parasites or bacteria Fecal direct smear: cysts, larvae, and trophozoites Cytology, fecal: bacteria, fungi, protozoan, inflammatory cells Culture, fecal: + T. foetus (feline) ELISA: parvovirus, Giardia, rotavirus Folate and cobalamin: dependent on different conditions and locations of problems • IFA Giardia/Crypotospordium: +
• • • •
Imaging
• Radiographs, abdominal: foreign bodies, obstruction, intussusception, and ileus
• Radiographs, abdominal: obstruction, mass, foreign body, organomegaly • Contrast study: bowel wall thickening or irregularity, tumor, stricture or foreign body • Ultrasonography: bowel wall thickening or irregularity, mass, foreign body, intussusception, ileus, or other disease process
Procedures
• ± Endoscopy: obtain biopsies
• Endoscopy: obtain biopsies
General
• Supportive • Fluid therapy • Surgery: laparotomy to remove obstruction
• Supportive • Fluid therapy • Surgery: laparotomy to remove obstruction or mass or obtain full thickness biopsy
Medication
• • • • •
• Anthelmintics: fenbendazole and metronidazole
Nursing Care
• NPO for at least 24 hours • Provide a clean litter box or frequent walks.
• Provide a clean litter box or frequent walks.
Patient Care
• Recheck fecal analysis following treatment for parasites. • Small, frequent meals • Bland or hypoallergenic diet
• Bland or hypoallergenic diet • Monitor fecal output: consistency, frequency • Monitor body weight
Prevention/ Avoidance
• Yearly fecal analysis
• Yearly fecal analysis
Diagnosis Treatment Follow-Up
6
242
Chronic
Antibiotics Anthelmintics: fendendazole and metronidazole Local protectant: bismuth subsalicylate Motility modifiers: opiates, loperamide, diphenoxylate Probiotics
SECTION THREE: DIAGNOSTIC SKILLS
CBC: eosinophilia, macrocytosis, and anemia Fecal flotation: parasites or bacteria Fecal cytology: infectious agents or inflammatory cells Folate and cobalamin: ↓↑ depending on different conditions
Table 6.23 / Gastroenterology: Diarrhea (Continued)
Follow-Up
Disease
Diarrhea Acute
Chronic
Complications
• Intussusception
• Dehydration • Abdominal effusion with intestinal adenocarcinoma • Inflammatory bowel disease
Prognosis
• Excellent in mild cases and with proper treatment of severe cases • Poor with chronic diarrhea unresponsive to treatment
Notes
• Most acute diarrhea is self-limiting within 3–4 days. • Do not administer bismuth subsalicylate to cats.
6 Table 6.24 / Gastroenterology: Exocrine Pancreatic Insufficiency and Gastric Dilatation-Volvulus Exocrine Pancreatic Insufficiency (EPI)
Gastric Dilatation-Volulusa (GDV, gastric torsion, bloat)
Definition
EPI is the insufficient secretion of digestive enzymes and clinical signs of malabsorption. It occurs with severe progressive loss of acinar tissue from atrophy and is most commonly seen in middle-aged to older dogs.
GDV is the process in which the stomach becomes dilated with gas or fluid and rotates on its central axis. Gastric dilatation can also occur without torsion, but surgery is still indicated as there is an 80% recurrence rate.
Clinical Signs
• Cachexia, coprophagia, diarrhea, dull haircoat, excessive shedding, feces voluminous, flatulence, greasy oily hair around perineum, ↓ muscle mass, pica, ravenous appetite, unthrifty, vomiting, ↑ water intake
• Abdominal distention, belching, collapse, depression, dry heaving (failed attempts to vomit), excessive salivation, respiratory distress, weakness
Examination Findings
• Borborygmus, dehydration
• ↑ Capillary refill time, cool extremities, ↓ femoral pulses, pale mucous membrane, tachycardia, tachypnea, tympanic cranial abdomen
General
• History/clinical signs
• History/clinical signs
Laboratory
• CBC: mild lymphophenia and eosinophilia • Chemistry panel: ↑ ALT and ↓ cholesterol, lipids, polyunsaturated fatty acids • TLI assay: <5 μg/dL (dogs) and <31 μg/dL (feline) • TLI stimulation test: no response • Fecal elastase: <10 μg/gm • Fecal proteolytic activity: ↓ values • Oral bentiromide digestion test: minimal ↑ PABA • Folate: variable depending on different conditions • Cobalamin: ↓ value
• • • • • •
Imaging
• N/A
• Radiographs, abdominal: “double-bubble” with air-filled pylorus
Procedures
• N/A
• Abdominocentesis/cytology: gastric perforation and peritonitis
Diagnosis
Presentation
Disease
CBC: variable PCV/TP Chemistry panel: ↓ potassium Urinalysis: ↑ specific gravity Blood gas analysis: metabolic acidosis Coagulation tests, PT, APTT, FDP: ↑ time Plasma lactate: <6 mmol/L ↑ survival rate
CHAPTER 6 / GENERAL MEDICINE
243
Table 6.24 / Gastroenterology: Exocrine Pancreatic Insufficiency and Gastric Dilatation-Volvulus (Continued) Exocrine Pancreatic Insufficiency (EPI)
Gastric Dilatation-Volulusa (GDV, gastric torsion, bloat)
General
• Symptomatic
• • • • • •
Symptomatic Supportive Fluid therapy Oxygen therapy Decompression with orogastric tube/trocarization/gastric lavage Surgery: exploratory celiotomy with gastropexy
Medication
• • • •
• • • • • •
Alkalinizer: sodium bicarbonate Antiarrthymics: lidocaine, procainamide Antibiotics: cefazolin, cefoxitin, enrofloxacin, metronidazole Anticoagulant: heparin Corticosteroids: dexamethasone phosphate H2-receptor: famotidine, ranitidine
Nursing Care
• Divide daily food intake into 2–3 meals. • Diet should be low in fiber and highly digestible. • Multivitamin, especially fat-soluble vitamins, cobalamin, and tocopherol
• • • •
NPO for 12–24 hours following surgery Fluid therapy Oxygen therapy Monitor: acid-base status, BP, CBC, chemistry panel, CVP, ECG, electrolytes, urine output
Patient Care
• Monitor weight gain and fecal consistency. • Gradually ↓ enzyme replacement as animal returns to normal.
• Gradually return to normal diet.
Prevention/ Avoidance
• N/A
• Feed smaller meals multiple times a day. • Avoid postprandial exercise.
Complications
• Small bowel bacterial overgrowth • Inadequate response to pancreatic enzyme replacement • Small intestine disease
• • • • •
Prognosis
• Good with dietary and enzyme management • Poor when associated with diabetes mellitus
• Guarded to grave • Good, patients recovering 7 days post treatment
• German Shepard, Rough-coated Collie • Cobalamin must be given SQ for absorption
• Large, deep-chested breeds: Irish Setter, Great Dane, Saint Bernard, Rottweiler, Alaskan Malamute, Labrador Retriever, German Shepards (any breed possible)
Treatment
Disease
Follow-Up
6
Notes
a
Antibiotics: tetracyclines, metronidazole, tylosin H2-receptor blocker: cimetidine and ranitidine Pancreatic enzyme replacement added to each meal Vitamin supplements: cobalamin, vitamins E, K1
See Emergency Medicine, Chapter 7, page 314, and Surgery, Chapter 15, page 521.
244
SECTION THREE: DIAGNOSTIC SKILLS
Arrythmias Aspiration pneumonia DIC Gastric ulceration and peritonitis Reperfusion illness/toxicosis
Table 6.25 / Gastroenterology: Hepatic Disease/Failure Hepatic Disease/Failure (Liver Disease)
Definition
“Hepatic failure” results from the sudden loss of >75% of functioning hepatic mass, and “hepatic disease” is the accumulation of inflammatory cells in the liver over an extended period of time with adequate liver function. Causes include infectious agents, drugs, toxins, immunemediated, traumatic injury, thermal injury, and hypoxia.
Clinical Signs
• Anorexia, circling, constipation, dementia, depression, diarrhea, disorientation, hematuria, hypersalivation, lethargy, melena, nausea, PU/PD, seizures, vomiting
Examination Findings
• Abdominal pain, ascites, ataxia, dementia, hemorrhages, hepatomegaly, pyrexia, jaundice, microhepatica, pallor
General
• History/clinical signs • Abdominal palpation: hepatomegaly and hepatodynia
Laboratory
• CBC: normocytic, normochromic nonregenerative anemia, thrombocytopenia and ± nucleated RBCs • Chemistry panel: ↑ ALT, AST, ALP, GGT, total bilirubin, globulin, ammonia, BUN (acute), glucose (chronic), cholesterol and ↓ albumin, BUN (chronic), glucose (acute), and cholesterol • Urinalysis: ↑ bilirubin, urobilinogen, ammonia, bilirubin crystals, ammonium biurate crystals, and ↓ specific gravity • Coagulation profile, ACT, PTT, PT: prolonged • Bile acid concentrations: ↑ values • Fasting bile acid concentrations: >30 μmol/L • Postprandial bile acid concentrations: >30 μmol/L • Blood ammonia concentrations: ↑ values • Ammonia tolerance test: ↑ values
Imaging
• Radiographs, thoracic: metastasis to lung parenchyma • Radiographs, abdominal: ↑ or ↓ in liver size, changes in tissue characteristics and contours • Ultrasonography: masses, abscesses, cysts, obstructions, and lesions
Procedures
• Biopsy: to determine the nature and severity of hepatic disease
General
• • • •
Symptomatic Supportive Fluid therapy Paracentesis with respiratory distress
Medication
• • • • • • • • • • • •
Antibiotics: penicillin, ampicillin, cephalosporins, metronidazole, and aminoglycosides Antioxidants: vitamins E, C, S-adenosyl-L-methionine, milk thistle Azathioprine (use cautiously) Cholchicine Corticosteroids: prednisolone GI protectants: sulcralfate H2-blocker: ranitidine and cimetidine Lactulose Phenobarbital Ursodeoxycholic acid: actigal Vitamin K therapy Zinc
Treatment
Diagnosis
Presentation
Disease
CHAPTER 6 / GENERAL MEDICINE
6
245
Table 6.25 / Gastroenterology: Hepatic Disease/Failure (Continued) Hepatic Disease/Failure (Liver Disease)
Nursing Care
• • • • •
Patient Care
• Monitor CBC and serum biochemistry frequently depending on severity of presenting condition. • Follow–up biopsies at 6 and 12 months • Dietary modifications (e.g., ↓ copper)
Prevention/ Avoidance
• Vaccinate against infectious agents. • Screen susceptible breeds. • Avoid hepatotoxic drugs.
Complications
• • • • • •
Prognosis
• Dependent on the amount of viable liver mass left after treatment • ↑ Prognosis with determination of underlying cause
Notes
Moderate activity restriction Nutritional support Monitor body weight, temperature, pulse, respiration, and mental status. Vigilant monitoring for signs of infection Vitamin and mineral supplements
Death DIC and bleeding diatheses GI ulceration Liver failure and liver encephalopathy Renal disease or failure Sepsis
• Caution: Drugs used must be selected with care to not further damage the liver through metabolism • Caution: Avoid alkalinizing agents (e.g., lactate, sodium bicarbonate) with patients with hepatic encephalopathy • Bedlington Terrier, Doberman Pinscher, Cocker Spaniel, Labrador Retriever, Standard Poodle, Skye Terriers, and West Highland White Terrier
Table 6.26 / Gastroenterology: Hepatic Lipidosis and Inflammatory Bowel Disease Disease
Hepatic Lipidosis (Fatty Liver Disease)
Inflammatory Bowel Disease (IBD)
Definition
Hepatic lipidosis is seen almost exclusively in cats. It is the result of >50% of cells in the liver accumulating excessive trigylcerides. This disease will lead to death if left untreated. This occurs when there is difference in the rates of deposition and metabolism of fat. It often occurs with prolonged anorexia.
IBD is a group of gastrointestinal diseases that infiltrate the mucosa and submucosa with inflammatory cells. It may involve the stomach, small and large intestines, or a combination. Lymphocyticplasmacytic is the most common type of IBD, found in both dogs and cats.
Clinical Signs
• Constipation, depression, diarrhea, lethargy, prolonged anorexia, vomiting, weakness, weight loss
• Diarrhea, flatulence, hematochezia, intermittent vomiting, listless, mucus, poor haircoat, steatorrhea, tenesmus, vomiting, weight loss
Examination Findings
• Dehydration, hepatomegaly, jaundice, muscle wasting, pallor
• Mesenteric lymphadenopathy, thickened bowel loops
Presentation
6
Follow-Up
Treatment
Disease
246
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.26 / Gastroenterology: Hepatic Lipidosis and Inflammatory Bowel Disease (Continued) Hepatic Lipidosis (Fatty Liver Disease)
Inflammatory Bowel Disease (IBD)
General
• History/clinical signs: obesity
• Clinical signs • Canine IBD Analysis Index (CIBDAI)
Laboratory
• CBC: normocytic, normochromic nonregenerative anemia with poikilocytosis (if prolonged) and neutrohilia and lymphopenia (v) • Chemistry panel: ↑ ALP, ALT, AST, GGT, ammonia, bilirubin, ↓ potassium, phosphorous, albumin, BUN, and azotemia (v) • Urinalysis: ↑ lipids and bilirubin • Coagulation profile, ACT, PTT, PT: prolonged • Bile acid concentrations: ↑ values
• CBC: mild, nonregenerative anemia or mild leukocytosis without a left shift (feline) and neutrophilic leukocytosis with a left shift (canine) • Chemistry panel: ↑ T4 (feline), ↓ protein (canine), and albumin (feline) • Fasting serum TLI: to rule out EPI • Cobalamin and folate assays: ↓↑ depending on different conditions • FeLV/FIV: + results
Imaging
• Radiographs, abdominal: hepatomegaly • Ultrasonography: hepatomegaly and hyperechoic liver
• Radiographs, abdominal: survey films to rule out other diseases • Barium contrast study: mucosal abnormalities and thickened bowel loops • Ultrasonography: measure stomach and intestinal wall thickness and rule out other diseases
Procedures
• Biopsy: hepatocellular vacuoles
• Endoscopy: intestinal biopsies
General
• Supportive • Fluid therapy
• Symptomatic • Fluid therapy if vomiting • Surgery: entertomy biopsies
Medication
• • • • •
• 5-Aminosalicyclic drugs: sulfasalazine, olsalazine, and mesalamine • Antibiotics: metronidazole, oxytetracycline, tylosin • Antidiarrheal drugs: loperamide, diphenoxylate • Corticosteroids: prednisone, budesonide • Chemotherapy: chlorambucil • Cyclosporin A • Immunsuppression: azathioprine • Probiotics
Nursing Care
• Aggressive nutritional support via syringe, nasogastric tube, esophagostomy tube or gastrotomy tube • Vitamin supplementation: vitamin B12, vitamin E, thiamine, taurine, arginine, L-carnitine, and L-citrulline
• Nutritional support if severely malnourished • Vitamin supplementation: folic acid, cobalamin, omega-3, vitamin B12, fat-soluble vitamins
Patient Care
• Continuous feeding via tube by owners for 4–6 weeks or for 10 days post vomiting, eating on their own and normal biochemical values • Monitor potassium and phosphorus • Monitor body weight and hydration
• Hypoallergenic dietary management • Periodic evaluations until patient stabilizes
Prevention/ Avoidance
• Prevent anorexia (especially obese felines) • Monitor food intake in obese cats during times of stress or other disease processes
• N/A
Follow-Up
Treatment
Diagnosis
Disease
Antiemetic: metoclopramide Antibiotics: ampicillin, amoxicillin, metronidazole Lactulose Ursodeoxycholic acid: actigal Vitamin K therapy
CHAPTER 6 / GENERAL MEDICINE
247
6
Table 6.26 / Gastroenterology: Hepatic Lipidosis and Inflammatory Bowel Disease (Continued)
Follow-Up
Disease
Hepatic Lipidosis (Fatty Liver Disease)
Inflammatory Bowel Disease (IBD)
Complications
• • • •
• • • • •
Prognosis
• Grave if left untreated • 65% of patients recover with proper treatment
• Good with continuous maintenance of remission and control of relapses • Course of disease tends to be progressive in prone breeds.
• Caution: Avoid dextrose supplementation as it interferes with fat oxidation. • Majority of felines are obese before this disease process starts. • Vitamin K should be given IM at least 12 hours before biopsies. • Biopsy samples typically float when placed in formalin.
• A hypoallergenic protein source refers to one to which the patient has not yet been exposed or a hydrolyzed diet. • The diet should also be void of artificial colorings, flavors, and preservatives. • Feed a novel protein source for 6 weeks while the GIT heals; then switch to another novel protein source. • Basenji, Soft-Coated Wheaton Terrier, and Shar pei
Notes
6
Vomiting Tube dysfunction Hepatic failure Death
Adverse drug reactions Anemia Malnutrition and dehydration Protein losing enteropathy Small intestinal bacterial overgrowth
Table 6.27 / Gastroenterology: Megaesophagus Megaesophagus (Esophageal Hypomotility)
Definition
Megaesophagus is a segmental or diffuse hypomotility and dilation of the esophagus. There are three main causes: congenital, acquired idiopathic or secondary to another condition (e.g., myasthenia gravis, brain stem lesion, tetanus)
Diagnosis
Presentation
Disease
248
Clinical Signs
• Cough, dyspnea, emaciation, generalized muscle weakness or atrophy, halitosis, mucopurulent nasal discharge, regurgitation, salivation, weight loss
Examination Findings
• Pyrexia, neurologic deficits, pulmonary crackles, raspy breath sounds
General
• History/clinical signs • Palpation of dilated esophagus
Laboratory
• CBC: neutrophilia and left shift • Acetycholine receptor antibody titer: screen for myasthenia gravis
Imaging
• Radiographs, thoracic: distention of esophagus with air, fluid or food, aspiration pneumonia • Contrast study: ↓ movement and pooling of fluid
Procedures
• Fluoroscopy: ↓ strength and coordination or peristaltic contractions • Endoscopy: dilated esophagus, foreign body, neoplasia, and esophagitis
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.27 / Gastroenterology: Megaesophagus (Continued)
Follow-Up
Treatment
Disease
Megaesophagus (Esophageal Hypomotility)
General
• Symptomatic • Supportive
Medication
• • • •
Nursing Care
• Nutritional support to ensure passage of food past dilated esophagus • ↑ Caloric density diet
Patient Care
• Offer small, frequent meals with patient in upright position for 10–15 minutes following meal.
Prevention/ Avoidance
• Diligent feeding rituals will increase life span. • Early detection of recurrent pneumonias
Complications
• Weight loss • Aspiration pneumonia
Prognosis
• Fair with diligent supportive care
Notes
Antibiotics for aspiration pneumonia: variable H2-blockers: sulcralfate Metoclopramide Prokinetic agents: cisapride
6
• Feeding small “meatballs” of canned food to a patient in an upright position often ↓ regurgitation.
Table 6.28 / Gastroenterology: Pancreatitis and Peritonitis Pancreatitis
Peritonitis
Definition
Pancreatitis is inflammation of the pancreas that can be either acute or chronic. Chronic pancreatitis is often seen with morphological changes in the pancreas. It can be caused by obesity, ingestion of excessive fat, or multiple other disease processes.
Peritonitis is a life-threatening condition that requires progressive medical management for resolution. Peritonitis is an inflammatory process involving all or part of the peritoneal cavity.
Clinical Signs
• Anorexia, depression, diarrhea, jaundice, panting, praying position, restlessness, tachypnea, trembling, vomiting, weakness
• Diarrhea, praying posture, reluctance to move, tachypnea, tucked up abdomen, vomiting
Examination Findings
• Dehydration, pyrexia, cranial abdominal pain, and mass effect
• Abdominal pain, dehydration, pyrexia, shock, tachycardia
Presentation
Disease
CHAPTER 6 / GENERAL MEDICINE
249
Table 6.28 / Gastroenterology: Pancreatitis and Peritonitis (Continued)
Diagnosis
Disease
Pancreatitis
Peritonitis
General
• History/clinical signs • Abdominal palpation: enlarged and painful pancreas
• History/clinical signs • Abdominal palpation: pain or organomegaly
Laboratory
• CBC: neutrophilia with or without a left shift, leukocytosis, thrombocytopenia, anemia • Chemistry panel: ↑ amylase, lipase, ALP, ALT, bilirubin, BUN, creatinine, cholesterol, lipids, glucose, ↓ albumin, calcium (v) and azotemia (acute type) • Canine pancreatic lipase immunoreactivity (cPLI): ↑ value • Feline pancreatic lipase immunoreactivity (fPLI): ↑ value • TLI: ↑ value
• CBC: neutrophilia with or without a left shift, leukocytosis, and anemia • Chemistry panel: ↑ amylase, lipase, ALT, AST, bilirubin, ↓ protein, glucose, potassium, electrolyte imbalances, and azotemia • Cytology, abdominal: degenerate neutrophils and intracellular bacteria • ± Culture: bacteria isolation and identification
Imaging
• Radiographs, thoracic: pulmonary edema or pleural effusion (rare) • Radiographs, abdominal: displacement of stomach and duodenum,↑ density, ↓ contrast gastric distention, static gas pattern, thickened and corrugated walls of the duodenum • Ultrasonography: irregular enlargement and abscesses of the pancreas, hyper- and hypoechoic changes, peripancreatic fluid accumulation • Contrast CT: identification and management
• Radiographs, abdominal: free fluid or air, ↓ detail, ileus, distention of loops of bowel with fluid or gas • Iodinated contrast studies: GIT to locate perforation • Ultrasonography: free fluid, abscesses, masses and cause of peritonitis
Procedures
• Biopsy: confirmed diagnosis
• Abdominocentesis
General
• • • •
• • • •
Medication
• Analgesics: meperidine HCl and butorphanol • Antibiotics: ampicillin, cephalosporins, trimethoprim-sulfa, and enrofloxacin • Antiemetics: chlorpromazine, dolasetron, ondansentron • Corticosteroids (shock): prednisone • Glucagon • Somatostatin • Vasopression
• Analgesics: variable • Antibiotics: penicillin, cephalosporins or aminoglycosides, ampicillin, enrofloxacin
Nursing Care
• NPO • Potassium supplementation • Complete rest and confinement
• Standard postoperative • Limit activity. • Nutritional support
Patient Care
• After vomiting has stopped for 1–2 days, slowly reintroduce water followed by a gradual reintroduction of a high-carbohydrate diet.
• Check CBC, chemistry profile, and urinalysis every 1–2 days, even in patients who are responding.
Prevention/ Avoidance
• Avoid fatty foods and dietary indiscretion. • Maintain optimum weight control. • Avoid corticosteroid treatment.
• N/A
Follow-Up
Treatment
6
250
Symptomatic Supportive Fluid therapy Surgery: laparotomy
SECTION THREE: DIAGNOSTIC SKILLS
Supportive Fluid therapy Peritoneal lavage Surgery: laparotomy, correct primary etiology, lavage and drain placement
Table 6.28 / Gastroenterology: Pancreatitis and Peritonitis (Continued) Disease
Pancreatitis ↓ Protein and oncotic pressure Peritonitis Renal failure, acute Septic shock Thromboembolic disease Worsening pancreatitis
Peritonitis • Herniation of abdominal contents • Adhesions
• • • • • •
Prognosis
• Fatal without treatment • Poor with complications
• Poor even with adequate treatment
• Patients with recurrent pancreatitis may try a trial period of enzyme therapy.
• Caution: Do not use povidone-iodine solution for lavage as it may be absorbed and produce toxic effects. • Use a contrast medium with minimal abdominal effects in case of leakage (e.g., iohexol).
Follow-Up
Complications
Notes
Table 6.29 / Gastroenterology: Protein-Losing Enteropathy and Vomiting Protein-Losing Enteropathy
Vomiting
Definition
Protein-losing enteropathy is a disease of excessive loss of serum protein into the intestinal tract. It can be a primary GIT disease or the result of a generalized condition such as congestive heart failure, nephrotic syndrome, or metastatic neoplasia.
Vomiting is the forceful, reflex expulsion of gastric or proximal small bowel contents from the oral cavity. Its duration can be acute or chronic (>14 days).
Clinical Signs
• Diarrhea, dyspnea
• Anorexia, depression, hypersalivation, nausea, repeated swallowing, and licking of lips • Others depending of underlying disease
Examination Findings
• Ascites, edema, pleural effusion, thickened bowel loops
• Abdominal distention or pain
General
• History/clinical signs • Abdominal palpation: intestines
• History/clinical signs • Examination of vomitus
Laboratory
• • • • • • • •
Diagnosis
Presentation
Disease
CBC: +/− anemia and +/− lymphopenia Chemistry panel: ↓ albumin, globulin, calcium, and cholesterol Urinalysis: ↑ protein-to-creatinine ratio Fecal examinations: rule out parasites and bacterial overgrowth TLI and folate: results dependent on disease process Cobalamin: ↓ values Serum bile acids: assess hepatic function T4: ↑ values (feline)
• Dependent on underlying condition
CHAPTER 6 / GENERAL MEDICINE
251
6
Table 6.29 / Gastroenterology: Protein-Losing Enteropathy and Vomiting (Continued) Protein-Losing Enteropathy
Vomiting
Imaging
• Radiographs, thoracic: rule out cardiac disease or fungal disease • Radiographs, abdominal: rule out fungal disease, tumors or intestinal obstruction • Contrast: tumor or bowel disease • Ultrasound: abdominal abnormalities or tumors
• • • •
Procedures
• Endoscopy: mucosal visualization and biopsy
• Endoscopy: stomach and proximal duodenum abnormalities
General
• • • •
Symptomatic Supportive Blood or hetastarch transfusions Surgery: laparotomy for diagnostic full-thickness biopsies
• Symptomatic • Fluid therapy • Surgery: exploratory laparotomy
Medication
• • • • •
Antibiotics: metronidazole, tylosin, or sulfasalazine Chemotherapy: chlorambucil Corticosteroids: prednisone Diuretics: furosemide Immunosuppressive: azathioprine, cyclosporin
• Antiemetic: metoclopramide, diphenhydramine, prochlorperazine, and chlorpromazine • Antisecretory: cimetidine, famotidine, rantidine, omeprazole • GI protectants: sulcralfate
Nursing Care
• Treated as outpatient • Standard postoperative
• NPO
Patient Care
• Dietary modifications depending on underlying cause • Recheck body weight and protein concentrations every 7–14 days. • Monitor for reoccurrence of clinical signs.
• After vomiting has stopped for 12 hours, slowly reintroduce water followed by a gradual reintroduction of a single protein and carbohydrate diet. • Wean back to regular diet over 4–5 days.
Prevention/ Avoidance
• Control inflammatory bowel disease
• Avoid dietary indiscretion
Complications
• • • •
• Dehydration • Electrolyte imbalances • Aspiration pneumonia
Prognosis
• Guarded
• Excellent in mild cases and with proper treatment of severe cases
• ↑ Risk of morbidity postoperative due to slow wound healing because of ↓ albumin, serosal patch graft may be necessary
Types of vomiting • Undigested or partially digested food >12–16 hours old: delayed gastric emptying • Projectile vomiting: gastric or upper small bowel obstruction • Praying mantis position: gastrointestinal pain Physical appearance of vomit • Bile: gastroduodenal reflux • Fresh blood: recent bleeding in esophagus or stomach • Digested blood: ulcer disease • Mucus: concurrent irritation of stomach and intestines
Follow-Up
6
Treatment
Diagnosis
Disease
Notes
252
Diarrhea, severe Malnutrition, severe Respiratory difficulty Slow wound healing
SECTION THREE: DIAGNOSTIC SKILLS
Radiographs, thoracic: heartworm disease Radiographs, abdominal: foreign body, pancreatitis, or pyometra Contrast: foreign body Ultrasound: abdominal abnormalities or tumors
HEMATOLOGY Table 6.30 / Hematology: Anemia and Disseminated Intravascular Coagulation Disease
Anemia Nonregenerative
Disseminated intravascular coagulation is a complex condition that is always secondary to another disease process. It is defined as an excessive activation of the clotting mechanism with complete consumption of clotting factors.
Clinical Signs
• Anorexia, collapse, depression, dyspnea, exercise intolerance, melena, tachypnea, weakness
• Clinical signs of underlying disease • Dyspnea, melena, petechiae, spontaneous hemorrhage from orifices
Examination Findings
• Flea infestation, icteric, lymphadenopathy, pallor, petechiae, pyrexia, retinal hemorrhages, soft systolic murmur, splenomegaly, tachycardia
• Pyrexia, subcutaneous hematoma and petechiae, tachycardia
General
• History/clinical signs
• History/clinical signs
Laboratory
• CBC: ↑ MCV, ↓ PCV, MCHC, TP, leukopenia, thrombocytopenia • Urinalysis: ↑ blood, +/− bilirubin • Fecal analysis: hookworms and coccidia • ELISA: FeLV in-house screening • Cytology, bone marrow: erythroid hypoplasia
• CBC: ↑ +/− MCHC, ↓ PCV, +/− MCV, TP, reticulocytosis, neutrophilia, thrombocytosis, nucleated RBCs, basophilic stippling (feline), spherocytes (canine, IMHA) • Chemistry panel: ↑ bilirubin • Fecal analysis: hookworms and coccidian • Corrected reticuloctye %: >1% • Cytology, bone marrow: erythroid hyperplasia • COOMBS test and ANA serology: + results • Slide agglutination test: + results indicate anemia is immune-mediated
• CBC: thrombocytopenia, schistocytes, ↓ platelet count, fibrinogen levels, and presence of fibrin degradation products • Chemistry panel: ↑ BUN • Urinalysis: hematuria • FDP assay: + • Coagulation tests, PT, PTT, ACT: ↑ times • Latex agglutination test: ↑ value
Imaging
• Radiographs, abdominal: splenomegaly
• Radiographs, thoracic: fluid • Radiographs, abdominal: fluid
• N/A
Procedures Treatment
Regenerative
Anemia is a decreased number of necessary RBC and is a primary bone marrow dysfunction. It can be caused by RBC loss, destruction, or depression of production. Anemia is typically broken down in two types: regenerative (loss and destruction) and nonregenerative (depression of production). Regenerative anemia can be immune-mediated, causing the destruction of RBCs and ending in immune-mediated hemolytic anemia (IMHA).
Diagnosis
Presentation
Definition
Disseminated Intravascular Coagulation (DIC)
General
• N/A • • • •
Supportive Blood transfusions Fluid therapy Oxygen therapy
• • • •
Symptomatic Aggressive fluid therapy Blood transfusions Oxygen therapy
CHAPTER 6 / GENERAL MEDICINE
253
6
Table 6.30 / Hematology: Anemia and Disseminated Intravascular Coagulation (Continued)
Treatment
Disease
Disseminated Intravascular Coagulation (DIC)
Nonregenerative
Regenerative
Medication
• Immunosuppression: cyclosporine • Erythropoietin • Ferrous sulfate
• Antibiotics: tetracyclines • Corticosteroids: prednisone, dexamethasone • Immunosuppression: azathioprine, cyclophosphamide, danazol, chlorambucil • Ferrous sulfate
Nursing Care
• • • • •
Patient Care
• Monitor CBC every 3–5 days until normal. • Monitor blood pressure.
• Monitor PCV weekly until normal, then every 2 weeks for 2 months, then monthly. • Monitor CBC monthly during treatment.
• Related to underlying disease
Prevention/ Avoidance
• Neuter cryptorchid males. • Monitor CBCs of patients receiving cancer drugs.
• N/A
• Related to underlying disease
Complications
• • • •
• • • • •
• Related to underlying disease
Prognosis
• Guarded to poor unless underlying disease can be diagnosed and treated • Recovery make take weeks to months.
6
Follow-Up
Anemia
Monitor for adverse reactions to drugs and transfusions. Monitor heart rate, respiratory rate, and temperature. Heat support Restrict activity Nutritional support
Blood transfusion related Erythropoietin related Hemorrhage Sepsis
Notes
Cardiac arrhythmias DIC Embolisms Hypoxia Infections
• • • • • •
Antibiotics Anticoagulant: sodium heparin Corticosteroids (endotoxic shock) Cryoprecipitate Diuretics: mannitol NSAIDs: aspirin
• • • •
Avoid IM injections and neck leads. Strict confinement Feed soft foods. Use peripheral blood vessels from blood draws and catheter placement.
• Poor to good prognosis with appropriate treatment • Guarded to poor prognosis with IMHA
• Grave
• IMHA: Old English Sheepdog, Cocker Spaniel, Poodle, Irish Setter, English Springer Spaniel, and Collie
• Caution: Venipuncture sites can lead to excessive hematomas; place pressure wraps following procedure.
Table 6.31 / Hematology: Thrombocytopenia and von Willebrand’s Disease Disease
Thrombocytopenia, Immune-Mediated (IMT, Idiopathic Thrombocytopenic Purpura, ITP, Autoimmune Thrombocytopenia)
von Willebrand Disease
Definition
Thrombocytopenia is a deficiency of platelets. Primary immunemediated is the destruction of platelets with no identifiable cause. It may occur as a single entity or as a combination of other immune-mediated diseases.
von Willebrand disease is a bleeding disorder caused by a deficiency or dysfunction of the plasma protein (von Willebrand’s factor, vWF) used for normal platelet functions. This is the most common inherited bleeding disorder in dogs.
254
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.31 / Hematology: Thrombocytopenia and von Willebrand’s Disease (Continued) Thrombocytopenia, Immune-Mediated (IMT, Idiopathic Thrombocytopenic Purpura, ITP, Autoimmune Thrombocytopenia)
von Willebrand’s Disease
Clinical Signs
• Anorexia, dyspnea, retinal and mucosal hemorrhages, epistaxis, hematochezia, melena, lethargy, vomiting, weakness
• ↑ Hemorrhage from wounds and surgery sites, spontaneous hemorrhage from mucosal surfaces of oral and nasal cavities, GIT, and genitourinary tract
Examination Findings
• Murmur, pallor, pyrexia, tachycardia
• Internal hemorrhage
General
• History/clinical signs • Patient response to treatment
• History/clinical signs
Laboratory
• CBC: thrombocytopenia <50,000/μL, microthrombocytosis, neutrophilia or neutropenia, schistocytes, autoagglutination, anemia • Chemistry panel: mild ↑ ALT and ALP (v) and ↓ protein • Urinalysis: ↑ Protein and blood (rare) • Platelet count: thrombocytopenia, ↑ shift platelets, immature platelets • Cytology: bone marrow: ↑ megakaryocytes • Serology: erlichiosis, Rocky Mountain spotted fever, dirofilariasis and leptospirosis • ANA titer: + results • Coagulation profiles: ↓ clotting times
• CBC: anemia, neutrophilia and a mild left shift and reticulocytosis after acute bleeding, thrombocytopenia, megathrombocytosis • Chemistry panel: ↑ ALT, AST • Buccal mucosa bleeding time: ↑ time • Toenail bleeding time: ↑ time • vWF antigen assay: ↓ values • Platelet function analyzer: ↑ time • Collagen binding assay • DNA testing: classifies affected and carriers
• Radiographs, thoracic: tumors • Radiographs, abdominal: tumors
• N/A
Diagnosis
Presentation
Disease
Imaging
Treatment
Procedures
• N/A
General
• • • •
Supportive Fluid therapy Blood transfusion Surgery: splenectomy
• • • •
Supportive Fluid therapy Hormonal therapy Blood transfusions
Medication
• Corticosteroids: prednisone, prednisolone, dexamethasone • Immunosuppressant: vincristine, cyclophosphamide, azathioprine, danazol, cyclosporine, leflunomide • H2-blockers: sulcralfate • Human immunoglobulin
• Cryoprecipitate: a concentrated form of vWF and factor VIII • Desmopressin acetate: ↑ vWF and ↓ bleeding time
Nursing Care
• Treated as outpatient • Standard postoperative • Strict confinement
• • • •
Avoid IM injections, neck leads, trauma, etc. Strict confinement Feed soft foods Use peripheral blood vessels from blood draws and catheter placement
CHAPTER 6 / GENERAL MEDICINE
255
6
Table 6.31 / Hematology: Thrombocytopenia and von Willebrand’s Disease (Continued)
Follow-Up
Disease
6
Thrombocytopenia, Immune-Mediated (IMT, Idiopathic Thrombocytopenic Purpura, ITP, Autoimmune Thrombocytopenia)
von Willebrand’s Disease
Patient Care
• Strict confinement until normal platelet counts return • Monitor platelet counts periodically following recovery.
• Monitor for hemorrhages for 48 hours post surgery.
Prevention/ Avoidance
• • • •
• Neuter affected dogs. • Selective breeding based on DNA testing
Complications
• GI ulceration • CNS hemorrhage • Hemorrhagic shock
• Hemorrhage
Prognosis
• Good with corticosteroid treatment
• Depends on the concentration of the von Willebrand’s factor
Avoid unnecessary vaccinations. Minimize stress. Avoid medications that are suspected of having caused initial IMT. OVH for intact females to prevent hormonal imbalances
• Thyroid supplementation evidence exists that it may ↑ vWF concentration and ↓ bleeding tendency. • Hemorrhage is not generally observed until platelet count is <40 000/μL. • Doberman Pinscher, Scottish Terrier, Shetland Sheepdog, Golden Retriever, Pembroke Welsh Corgi, and Standard Poodle
Notes
INFECTIOUS DISEASES Table 6.32 / Infectious Diseases: Brucellosis and Erlichiosis Disease
Presentation
Definition
256
Brucellosis ZOONOTIC
Ehrlichiosis
A disease caused by Brucella canis.This bacterium is transmitted through ingestion or inhalation and can be found in the lymphatic system, genital tract, eye, kidney, and intervertebral discs.
The most common rickettsial disease of dogs caused by Ehrlichia spp. Transmission is most commonly seen through the bite of the brown dog tick, Rhipicephalus sanguineus, or the Lone Star tick, Amblyomma americanum. Mostly found on the Gulf Coast, Eastern Seaboard, midwest, and California.
Clinical Signs
• Abnormal gait, anorexia, ataxia, exercise intolerance, weakness • Male: scrotal swelling or dermatitis, enlarged epididymis, testicular atrophy • Female: abortion, infertility, and vaginal discharge for 1–6 weeks postabortion
• Acute: ataxia, dyspnea, exercise intolerance, oculonasal discharge • Chronic: dyspnea, epistaxis, pallor, spontaneous bleeding, weakness, weight loss
Examination Findings
• Anterior uveitis, ascites, corneal edema, epididymitis, lymphadenopathy, paralysis, paresis, pyrexia, spinal hyperesthesia, splenomegaly
• Acute: lymphadenopathy, organomegaly, pyrexia, vestibular dysfunction • Chronic: arthritis, intermittent limb edema, neurologic signs, organomegaly, pyrexia, uveitis
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.32 / Infectious Diseases: Brucellosis and Erlichiosis (Continued) Disease
Ehrlichiosis
General
• Clinical signs
• History/clinical signs • Ocular examination: retinal detachment and hemorrhage
Laboratory
• Chemistry panel: ↑ globulin and ↓ albumin • Urinalysis: ↑ protein, albumin • RSAT: accurate for negative dogs, detects infected dogs 3–4 weeks after infection • AGID: highly sensitive, detects infected dogs 4–12 weeks after infection • TAT/2ME-TAT: + titers, detects infected dogs 3–4 weeks after infection • Culture: B. canis identification • Cytology, lymph node: nonspecific reactive hyperplasia • Cytology, semen: >80% of sperm are morphologically abnormal, inflammatory cells • Culture, blood, urine, semen, vaginal discharge, aborted fetuses: Brucella isolation and identification
• CBC: acute, thrombocytopenia, anemia (v), leukopenia and chronic, nonregenerative anemia, thrombocytopenia, lymphocytosis, pancytopenia, leukopenia or leukocytosis • Chemistry panel: acute, ↑ globulin, mild ↑ ALT, ALP, BUN, creatinine, ↓ albumin and chronic, ↑ globulin, BUN, creatinine, ↓ albumin • Urinalysis: acute, ↑ protein, specific gravity • IFA: titers >1:10 (2–3 weeks after exposure, titers not available for all species) • PCR, Erlichia test: +, identifying active infections after treatment • ACT: ↑ clotting times • Buffy coat analysis: Erlichia inclusions in WBCs • Cytology, bone marrow: acute, hypercellular, megakaryocytic, chronic, erythroid hyperplasia, ↑ mast cells
Imaging
• Radiography, spine: diskospondylitis, if found then check for Brucellosis
• N/A
Procedures
• N/A
• N/A
General
• Supportive
• Supportive • Blood transfusion • Fluid therapy
Medication
• Antibiotics: minocycline, gentamicin, doxycycline, enrofloxacin, streptomycin
• Anabolics: oxymetholone, nandrolone decanoate, danazol, stanozolol • Antibiotics: tetracycline, doxycycline, chloramphenicol, imidocarb diproprionate • Corticosteroids: prednisone, prednisolone
Nursing Care
• Treated as outpatient.
• Restrict activity.
Patient Care
• Multiple courses of antibiotic treatment • Serologic titers monthly for 3 months, then at 6 months • Restrict activity in working dogs
• Restrict activity. • Platelet count every 3 days until normal • Repeat serologic testing in 9 months; should be undetectable in 12 months.
Prevention/ Avoidance
• Neuter infected animals. • Quarantine and test all new dogs and breeding individuals.
• Tick control and avoidance through sprays and spot-ons • Avoid tick-infested areas.
Complications
• Infertility • Sexual transmission
• N/A
Prognosis
• Early detected ↑ response to therapy • Guarded if late detection
• Excellent • Poor if bone marrow is severely hypoplastic
Diagnosis Treatment Follow-Up
Brucellosis ZOONOTIC
CHAPTER 6 / GENERAL MEDICINE
257
6
Table 6.32 / Infectious Diseases: Brucellosis and Erlichiosis (Continued) Disease Notes
Brucellosis ZOONOTIC • Transmission is following breeding or abortion, or following contact with semen, vaginal discharge, and urine by penetration of oronasal, conjunctival, or genital mucous membranes. • Lasts for 6–64 months • Low risk of human infection with proper hygiene, mild and easily treated
Ehrlichiosis • Transmitted by the brown dog tick and transfusions. • Incubation period is 7–21 days. • German Shepard and Doberman Pinscher
6 Table 6.33 / Infectious Diseases: Rocky Mountain Spotted Fever and Salmon Poisoning Rocky Mountain Spotted Fever ZOONOTIC
Salmon Poisoning
Definition
This is a tick-borne disease caused by Rickettsia rickettsii. It is the most important rickettsial disease in humans. Found on the East Coast, midwest, and Plains region.
A rickettsial disease caused by Neorikettsia helminthoeca and found in the Pacific Northwest. Attacks the tissue of the small intestinal epithelium and associated lymph system.
Clinical Signs
• Abnormal gait, anorexia, ataxia, convulsions, depression, diarrhea, dyspnea, epistaxis, face and limb edema, lethargy, myalgia, weakness
• Diarrhea, hypothermia, naso-ocular discharge, profound weight loss, vomiting
Examination Findings
• Anterior uveitis, arthritis, ascites, conjunctivitis, lymphadenopathy, ocular pain, petechial hemorrhages, pyrexia, scleral injection, tachycardia, vasculitis, vestibular signs
• Conjunctivitis, lymphadenopathy, pyrexia, tachycardia
General
• History/clinical signs • Ticks recently removed from the dog
• History/clinical signs • Recent ingestion of raw salmonoid fish meat
Laboratory
• CBC: eukocytosis with a left shift, +/− toxic neutrophils, monocytosis, mild anemia, thrombocytopenia • Chemistry panel: ↑ ALT, ALP, BUN, creatinine, cholesterol, albumin, ↓ sodium, chloride, protein, metabolic acidosis • Urinalysis: ↑ protein, blood • Micro-IFA: titers >1 : 128 • Direct immunofluorescence with skin biopsies: rickettsial antigens as early as 3–4 days postinfection • ACT: ↑ clotting times
• Urinalysis: ↑ specific gravity • Direct fecal smear: operculated fluke eggs (Nanophyetus salminicola) • Giemsa-stained FNA of lymph nodes: hyperplasia with intracytoplasmic rickettsial bodies in macrophages
Imaging
• N/A
• N/A
Procedures
• N/A
• N/A
Diagnosis
Presentation
Disease
258
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.33 / Infectious Diseases: Rocky Mountain Spotted Fever and Salmon Poisoning (Continued)
Follow-Up
Treatment
Disease
Rocky Mountain Spotted Fever ZOONOTIC
Salmon Poisoning
General
• Supportive • Blood transfusions • Fluid therapy
• Supportive
Medication
• Antibiotics: tetracycline, doxycycline, chloramphenicol, imidocarb diproprionate
• Antibiotics: tetracyclines, chloramphenicol • Anticestodal: praziquantel
Nursing Care
• Restrict activity.
• Restrict activity.
Patient Care
• Monitor platelet count every 3 days until normal. • Micro-IFA titers 2–4 weeks after initial titer: 2–4 fold rise in titer • Restrict activity.
• Monitor temperature, hydration, electrolytes, and acid-base balances.
Prevention/Avoidance
• Tick and rodent control • Using gloves or instruments, check daily for ticks and remove entire tick if found.
• Prevent eating of raw fish (salmonoid type). • Thoroughly cook or freeze fish.
Complications
• N/A
• N/A
Prognosis
• Good if early diagnosis and treatment • Poor if in later stages with CNS disease
• Good with treatment
• Caution: Handling of an infected tick may result in transmission of the disease even without attachment. • Transmitted by the American deer tick, wood tick, Lone Star tick, and transfusions • The tick must be attached for 5–20 hours to infect dogs. • Primary host is rodents and rabbits • Incubation time is 2 days to 2 weeks. • High titers can be seen for 1 year following successful treatment.
• Transmitted through eating raw salmon or related fish carrying encysted forms of the fluke N. salminicola. • Incubation of 5–21 days
Notes
6
Table 6.34 / Infectious Diseases: Tetanus and Toxoplasmosis Disease
Presentation
Definition
Tetanus
Toxoplasmosis ZOONOTIC
Disease caused by Clostridium tetani which is found in the soil and as part of the normal bacterial flora of the intestinal tract of mammals.
This disease, caused by the protozoan parasite, Toxoplasma gondii, can invade and multiply in any cell in the body.
Clinical Signs
• Ataxia, convulsions, disoriented, dyspnea, ears erect, forehead wrinkled, hypersalivation, lips retracted, localized or generalized muscle rigidity, seizures, stiffness, tetanic spasms, trismus, walking difficulty, weakness
• Subclinical most of the time • Anorexia, ataxia, depression, diarrhea, dyspnea, exercise intolerance, lethargy, paralysis, paresis, seizures, stiff gait, tremors, vomiting, weakness, weight loss
Examination Findings
• Altered heart and respiratory rates, hyperventilation, laryngeal spasms, pyrexia, tachycardia
• Abdominal effusion and pain, anterior and posterior uveitis, blindness, icterus, myocarditis, pancreatitis, pneumonia, pyrexia
CHAPTER 6 / GENERAL MEDICINE
259
Table 6.34 / Infectious Diseases: Tetanus and Toxoplasmosis (Continued) Disease
Tetanus • Clinical signs • Recent wound (esp. with high levels of necrosis and anaerobic conditions)
• Clinical signs
Laboratory
• Chemistry panel: ↑ CK (CPK)
• CBC: leukopenia with degenerative left shift or neutrophilic leukocytosis and nonregenerative anemia • Chemistry panel: ↑ bilirubin, bile acids, AST, ALT, ALP, GGT, creatinine, amylase, lipase, ↓ albumin • Urinalysis: ↑ protein and bilirubin • IgM: elevated 2 weeks postinfection, >1 : 256 or >1 : 64 and negative IgG indicates active infection • IgG: elevated 2–4 weeks postinfection, >1 : 512 active infection or 2–4 fold rising titer 2 weeks apart • Antigen serum titers: + 1–4 weeks postinfection
Imaging
• N/A
• Radiographs, abdominal: hepatomegaly, effusion • Radiographs, thoracic: effusion, patchy alveolar and interstitial pulmonary infiltrates
Procedures
• N/A
• ECG: arrhythmia, cardiac irregularity
General
• Supportive • Fluid therapy • Wound management: debridement, H2O2 flushing, cleaning
• Supportive • Fluid therapy
Medication
• Antibiotics: penicillin G or metronidazole • Anticonvulsants/muscle relaxants: diazepam, chlorpromazine, acetylpromazine, phenobarbital, pentobarbital, methocarbamol • Tetanus antitoxin
• Antibiotics: clindamycin, pyrimethamine, trimethoprimsulfonamide • Folic acid, yeast • Ophthalmic drops: 1% prednisone
Nursing Care
• Keep patient in a dark quiet area and do not disturb. • Provide soft bedding and rotate every 4 hours to prevent decubital sores and lung congestion. • Prevent urinary and fecal retention with urinary catheterization and enemas. • Nutritional support: force feeding is not advised because it may cause tetanic state. • Monitor blood pressure and ECG.
• Typically treat as outpatients. • Confine patients with neurologic signs.
Patient Care
• N/A
• Examine 2 and 14 days post initiation of treatment for improvement. • Provide a high-quality diet, biannual physical examinations, annual blood work, vaccines, and prompt attention to illness.
Diagnosis
General
Follow-Up
Treatment
6
260
Toxoplasmosis ZOONOTIC
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.34 / Infectious Diseases: Tetanus and Toxoplasmosis (Continued)
Follow-Up
Disease
Tetanus
Toxoplasmosis ZOONOTIC
Prevention/ Avoidance
• Prevent skin wounds: maintain clean and safe runs and yards. • Give proper wound care management. • Aseptic surgical technique
• Prevent ingestion of raw meat, bones, viscera, or unpasteurized milk. • Prevent free roaming to hunt prey or access to the housing of food-producing animals.
Complications
• N/A
• N/A
Prognosis
• Extremely guarded when severely affected
• Guarded: can be become carriers and relapse clinically if immunocompromised
• Clinical signs show up 5 days to 3 weeks later. • Death is from respiratory dysfunction. • Animals can be pretested for anaphylactic reaction to the antitoxin by giving an intradermal injection first and monitoring for 30 minutes.
• Caution: Disease can be transmitted to an unborn fetus by an infected human mother. • Transmitted by ingesting infected animal tissues, cat feces, and transplacental infection • Excrete eggs 3–10 days after infection for 1–2 weeks: can shed again if stressed. • Oocysts must first sporulate to become infectious. • Oocysts can last in the soil for >1 year.
Notes
6
MUSCULOSKELETAL Table 6.35 / Musculoskeletal: Arthritis Disease
Arthritis Acute
Diagnosis
Presentation
Definition
Degenerative Joint Disease (DJD, Osteoarthritis)
There are two types of clinically diagnosed arthritis: degenerative and acute inflammatory. Acute arthritis is a pathogenic organism within the closed space of a joint and is broken down into 3 types: septic, traumatic, and immune-mediated. DJD is a progressive deterioration, characterized by a loss of hyaline cartilage matrix and death of chondrocytes. There is no cure for DJD; treatment is based on alleviating clinical signs and slowing progression.
Clinical Signs
• Joint swelling, lameness, pain, reluctance to jump or climb stairs, stiff gait
• Abnormal gait, ataxia, exercise intolerance, ↑ lameness following moderate to heavy exercise, stiff upon rising after recumbency, swelling, walking difficulty
Examination Findings
• Crepitus, laxity, pain, ↓ ROM
• Crepitus, edema, laxity, muscle atropy, pain
General
• History/clinical signs • Joint palpation and manipulation
• History/clinical signs • Joint palpation
CHAPTER 6 / GENERAL MEDICINE
261
Table 6.35 / Musculoskeletal: Arthritis (Continued) Disease
Degenerative Joint Disease (DJD, Osteoarthritis)
Laboratory
• • • • • • • • •
• Synovial fluid analysis: ↑ mononuclear cells (e.g., lymphocytes), protein, ↓ viscosity, cell count (compared to septic or inflammatory arthritides) • Mucin clot test: clot poor
Imaging
• Radiograph, affected joint: joint capsular distension, soft tissue thickening, joint effusion and bone lysis
• Radiograph, affected joint: osteophytes, subchondral sclerosis, narrowed joint space, and remodeling of subchondral bone/ epiphyses
Procedures
• Arthrocentesis
• Arthrocentesis
General
• Supportive • Surgery: arthrotomy, reconstructive procedures, arthrodesis
• Supportive • Surgery: resection arthroplasty, joint replacement, arthrodesis
Medication
• Antibiotics: variable • Chondroprotective agents: Adequan, glucosamine with chondroitin sulfate • Corticosteroids: prednisone or triamcinolone • Methyl sulfonyl methane • Misoprostol • NSAIDs: aspirin, carprofen, deracoxib, etodolac, firocoxib, meloxicam, tepoxalin
• • • •
Nursing Care
• Standard postoperative • Treated as outpatient
• Standard postoperative • Treated as outpatient
Patient Care
• Moderate activity, but restricted to a level that minimizes discomfort • Strict confinement with acutely painful episodes • Obesity control • Physical therapy: hot/cold treatment, swimming, ROM exercises and massage
• Weight control • Encourage moderate and consistent exercise (e.g., swimming—low impact)
Prevention/ Avoidance
• Maintain appropriate weight control. • Early recognition to prevent proceeding to secondary condition
• Maintain proper weight control. • Early use of glucosamine with chondroitin sulfate to slow progression
Complications
• Nonambulatory • DJD • Osteomyelitis
• Nonambulatory
Prognosis
• Good with septic form • Fair to guarded with immune-mediated form
• Progressive
Diagnosis
Acute
Follow-Up
Treatment
6
262
Arthritis
CBC: leukocytosis, neutrophilia Urinalysis: ↑ protein ANA test: + results Tick-borne agent serology: + results Synovial fluid analysis: ↑ WBCs and bacteria Biopsy, synovial: neoplasia Cytology, synovial: ↑ WBCs, turbidity, bacteria Culture, synovial: bacteria, yeast, fungi, additional organisms Mucin clot test: clot poor
SECTION THREE: DIAGNOSTIC SKILLS
Chondroprotective agents: glucosamine with chondroitin sulfate Corticosteroids: prednisone or triamcinolone Misoprostol NSAIDs: aspirin, carprofen, deracoxib, etodolac, firocoxib, meloxicam, tepoxalin
Table 6.36 / Musculoskeletal: Cruciate Disease and Hip Dysplasia Cruciate Disease (Cranial Cruciate Rupture)
Hip Dysplasia
Definition
Cruciate disease results in a partial or complete instability of the stifle joint. The tearing of the anterior cruciate ligament can be done acutely or as a degenerative process.
Hip dysplasia is the most common condition of the hip joint and cause of osteoarthritis. Hip dysplasia is a faulty development of the hip joint contributing to joint laxity and subluxation early in life. Joint instability occurs as muscle development and maturation lag behind the rate of skeletal growth.
Clinical Signs
• Abnormal gait, acute or intermittent lameness, ataxia, walking difficulty
• Abnormal gait, ataxia, exercise intolerance, hindlimb lameness
Examination Findings
• Deformed stifle joint, edema, joint effusion, muscle atrophy of hindlimb musculature, swelling
• Barden’s sign, Barlow’s sign, crepitus, joint laxity, muscle atrophy, Ortolani + test, pain, ↓ ROM
General
• History/clinical signs • Joint palpation: + anterior drawer sign
• History/clinical signs • Joint palpation
Laboratory
• Synovial fluid analysis: rule out sepsis and immune-mediated disease
• N/A
Imaging
• Radiograph, stifle joint: joint effusion with capsular distention, periarticular osteophytes, compression of infrapatellar fat pad and calcification of cruciate ligament • MRI: confirmation and severity of disease
• Radiographs, skeletal: joint subluxation of femoral head, flattening of femoral head, shallow acetabulum, periarticular osteophytes, or widening of joint space between femoral head and cranial acetabulum
Procedures
• Arthrocentesis • Arthroscopy: confirmation and severity of disease
• N/A
General
• Symptomatic • Cage rest • Surgery: tibial plateau leveling osteotomy (TPLO), “over-the-top” fascia lata graft, fibular head transposition imbrication procedure, extracapsular reinforcing procedures
• Surgery: triple pelvic osteotomy (TPO), femoral head and neck excision arthroplasty, pectineal myectomy, intertrochanteric osteotomy, or total hip replacement
Medication
• Chondroprotective drugs: Adequan, glucosamine with chondroitin sulfate • Misoprostol • NSAIDs: aspirin, carprofen, deracoxib, etodolac, firocoxib, meloxicam, tepoxalin
• Analgesics: variable • Chondroprotective agents: Adequan or glucosamine with chondroitin sulfate • Corticosteroids: prednisone, triamcinolone (short-term use) • Misoprostol • NSAIDs: aspirin, piroxicam, carprofen, etodolac, phenylbutazone, meclofenamic acid
Nursing Care
• Placement of Robert Jones bandage
• Postoperative radiographs to evaluate surgery • Physical therapy • Restrict activity.
Treatment
Diagnosis
Presentation
Disease
6
CHAPTER 6 / GENERAL MEDICINE
263
Table 6.36 / Musculoskeletal: Cruciate Disease and Hip Dysplasia (Continued)
Follow-Up
Disease
6
Cruciate Disease (Cranial Cruciate Rupture)
Hip Dysplasia
Patient Care
• Cryotherapy • Physical therapy: ROM exercises and massage • Restricted activity: leash only exercise and no use of stairs for 3 months postoperative • Reradiograph at 8 weeks • Full exercise by 6–9 months postoperative • Control obesity
• Restrict activity. • Monitor radiographs to assess degeneration.
Prevention/ Avoidance
• Selective breeding • Maintain proper weight control.
• Selective breeding • Nutritional manipulation for large breed dogs during growth and development • Avoid excessive exercise.
Complications
• Osteoarthritis
• Osteoarthritis • Nonambulatory
Prognosis
• Excellent with surgery
• Good depending on severity of disease
Notes
• Joint is palpated for drawer motion, movement of tibia relative to femur during the tibial compression test, and thickening of joint capsule. • In 30–40% of canines, the opposite cranial cruciate ligament ruptures within 17 months. • Rottweiler and Labrador Retriever
Table 6.37 / Musculoskeletal: Osteochondrosis and Osteomyelitis Osteochondrosis or Osteochondritis Dessicans (OCD)
Osteomyelitis
Definition
Osteochondrosis is a defect in endochondral ossification leading to an excessive retention of cartilage. This defect may occur in any limb joint. Ununited anconeal process and fragmented coronoid process may also be seen along with osteochondrosis or separately. It is often seen in animals between 5–10 months of age.
Osteomyelitis is an infection of the bone and its soft tissue elements and membranes. Infectious organisms often complicate an existing condition leading to an infection that is very difficult, and sometimes impossible, to treat.
Clinical Signs
• Abnormal gait, anorexia, cachexia, forelimb or hindlimb lameness, reluctance to exercise, walking difficulty
• Anorexia, cachexia, depression, exercise intolerance, lameness, lethargy, rising difficulty, weakness
Examination Findings
• Arthritis, crepitus, hyperextension pain, joint effusion, joint pain, muscle atrophy, swelling
• Edema, inflammation, intermittent draining tracts, pain, paralysis, paresis, pyrexia, swelling, tachycardia
General
• History/clinical signs • Joint palpation
• History/clinical signs • Skeletal palpation • Neurologic examination
Diagnosis
Presentation
Disease
264
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.37 / Musculoskeletal: Osteochondrosis and Osteomyelitis (Continued)
Follow-Up
Treatment
Diagnosis
Disease
Osteochondrosis or Osteochondritis Dessicans (OCD)
Osteomyelitis
Laboratory
• Joint tap and fluid analysis: confirms involvement and mononucleated cells
• CBC: neutrophilic leukocytosis • Cytology: toxic neutrophils, phagocytized bacteria or fungal organisms • Culture: bacteria isolation and identification and sensitivity
Imaging
• Radiographs, skeletal: joint abnormalities, bone lengths, arthritis, sclerosis of underlying bone or bone flap/fragments (joint “mice”) • CT/MRI: location and severity of lesion • Arthrogram: identifies cartilage flap or loose cartilage via contrast enhanced joint radiographs after intraarticular injections
• Radiographs, skeletal: soft tissue swelling, bone resorption, sclerosis, bone sequestra, fracture nonunion, cortical thinning, widening of fracture gap, reactive periosteal new bone, foreign bodies, or fungal lesions • Contrast: sinus location and severity, foreign bodies • Radionuclide imaging: detecting osteomyelitis
Procedures
• Arthroscopy: confirming cartilage lesion
• N/A
General
• Symptomatic • Surgery: arthrotomy or arthroscopy
• Symptomatic • Wound management: debridement, drainage and irrigation • Surgery: sequestrectomy, amputation, bone grafts, or biopsy
Medication
• Analgesics • NSAIDs
• Antibiotics: variable
Nursing Care
• Cryotherapy postoperative • Place modified Robert Jones bandage.
• Sterile dressing applied to surgical wounds left to close by 2º intention. • Irrigate daily with sterile saline.
Patient Care
• Cryotherapy for 15–20 minutes 3 times daily for 3–5 days if no bandage placed • Physical therapy: ROM exercises • Restrict activity for 4 weeks, then gradually increase to normal activity over the next 4 weeks. • Reradiograph 4–6 weeks postoperative • Obesity management
• Monitor radiographs for fracture healing.
Prevention/ Avoidance
• Selective breeding • Maintain proper weight control. • Nutritional manipulation for large-breed dogs during growth and development
• Proper wound and fracture management
Complications
• Osteoarthritis • Disuse atrophy
• Recurrence and relapse • Limb deformity or impaired function • Neurologic disease
Prognosis
• Good with early surgical repair (forelimb) • Guarded with stifle or tarsal OC
• Good with acute disease • Poor with chronic disease
• Great Dane, Labrador Retriever, Newfoundland, Rottweiler, Bernese Mountain Dog, English Setter, and Old English Sheepdog
• Saint Bernard, German Shepard, Labrador Retriever, Golden Retriever, and Rottweiler
Notes
CHAPTER 6 / GENERAL MEDICINE
6
265
Table 6.38 / Musculoskeletal: Patella Luxation and Panosteitis Patellar Luxation, Medial
Panosteitis (Enostosis)
Definition
Medial patellar luxation is generally a concern of small breed dogs. It is typically a congenital or developmental malformation of the stifle joint causing the patellar to displace from the femoral trochlea. Luxations are graded on a scale of I–IV, which allows guidance of treatment options.
Panosteitis is a disease of young large-breed dogs that begins in the medullary bone marrow in the region of the nutrient foramen. Its cause is unknown. It gives intermittent lameness of one or multiple limbs. The disease is self-limiting, but its clinical signs will remain for months.
Clinical Signs
• Abnormal gait, ataxia, intermittent lameness of hindlimb, skipping, walking difficulty
• Anorexia, ataxia, cachexia, depression, forelimb and hindlimb lameness, lethargy, shifting leg lameness, walking difficulty
Examination Findings
• Arthritis, pain, stifle joint deformity
• Pain on palpation of diaphysis, pyrexia
General
• History/clinical signs • Patella palpation: laxity
• History/clinical signs • Bone palpation
Laboratory
• N/A
• CBC: eosinophilia (v)
Imaging
• Radiographs, hindlimb: bowing and/or torsion of tibia or femur and shape of femoral trochlea
• Radiograph, skeletal: ↑ density, progressive mottling and radiopacity within the medullary cavity, new bone formation and thickened bone cortices • Scintigrams, bone: bone lesions
Procedures
• N/A
• N/A
General
• Supportive • Symptomatic • Surgical: trochleoplasty, trochlear sulcoplasty, recession sulcoplasty, trochlear chondroplasty, chondroplasty, wedge recession, patelloplasty or tibial tuberosity translocation
• Supportive
Medication
• Analgesics • Chondroprotective agents: Adequan or glucosamine with chondroitin sulfate • Corticosteroids: prednisone (short-term use) • Misoprostol • NSAIDs: aspirin, carprofen, etodolac, piroxicam
• • • •
Nursing Care
• Cryotherapy immediately postoperative then 15–20 minutes daily for 3–5 days if no bandage • Placement of Robert Jones bandage • Physical therapy: ROM exercises and swimming
• Treated as outpatient
Patient Care
• Restricted activity: leash only exercise and no use of stairs for 3 months postoperative • Full exercise by 6–9 months postoperative • Correct obesity
• Restrict activity • Recheck lameness every 2–4 weeks for more serious orthopedic problems
Presentation
Disease
Follow-Up
Treatment
Diagnosis
6
266
SECTION THREE: DIAGNOSTIC SKILLS
Analgesics Corticosteroids: prednisone Misoprostol NSAIDs: aspirin, piroxicam, carprofen, etodolac
Table 6.38 / Musculoskeletal: Patella Luxation and Panosteitis (Continued)
Follow-Up
Disease
Patellar Luxation, Medial
Panosteitis (Enostosis)
Prevention/ Avoidance
• Selective breeding • Maintain proper weight control
• N/A
Complications
• Recurrence following surgery • DJD
• N/A
Prognosis
• Excellent with surgery
• Excellent
• Miniature and Toy Poodle, Yorkshire Terrier, Pomeranian, Pekingese, Chihuahua, and Boston Terrier
• German Shepard, Irish Setter, Saint Bernard, Doberman Pinscher, Airedale, Basset Hound, and Miniature Schnauzer
Notes
6
NEUROLOGY Table 6.39 / Neurology: Encephalitis and Epilepsy Encephalitis
Epilepsy
Definition
Encephalitis is an inflammatory disease of the brain with random progression. The causes of this condition are wide ranging from breed predilections to infectious diseases to viral, protozoan, fungal, and bacterial infections. The clinical signs, diagnosis, and treatment are all dependent on determining the underlying disease.
Epilepsy is a condition of recurring seizures regardless of their cause. Primary epilepsy has no known cause and may be genetic/ hereditary. Secondary epilepsy is acquired through brain injury and/or inflammation.
Clinical Signs
• Dependent on underlying disease • Aggression, ataxia, behavioral changes, circling, depression, head tilt, pacing, paralysis, photophobia, seizures, tremors, vomiting
3 Stages of Seizures • Aura: immediately preceding seizure, restlessness, crying and hiding • Ictus: actual seizure, lasting <2–5 minutes, stiff, muscle spasms, chomps its jaw, salivates profusely, urinates, defecates, vocalizes and paddles with all four paws • Postictus: immediately following seizure – lasting <30 minutes, behavioral changes, weakness, blindness, hungry, thirsty, depressed, pacing, or tired
Examination Findings
• Abnormal heart and respiratory rates, corneal changes, nystagmus, pulmonary abnormalities, pyrexia
• Postictus signs
General
• History/clinical signs • Neurologic examination
• History/clinical signs • Neurologic examination
Laboratory
• • • • •
• N/A
Diagnosis
Presentation
Disease
CBC: leukocytosis and dependent on underlying disease Chemistry panel: ↑ protein, creatine kinase CSF analysis: ↑ WBCs, protein, fungi, bacteria CSF titers: + results Serology: antibody recognition and identification
CHAPTER 6 / GENERAL MEDICINE
267
Table 6.39 / Neurology: Encephalitis and Epilepsy (Continued)
Diagnosis
Disease
Encephalitis
Epilepsy
Imaging
• Radiographs, thoracic: lung abnormalities • Radiographs, skull: sinusitis or rhinitis (cryptococcosis) • CT/MRI: tumor
• • • • •
Procedures
• EEG: diffuse multifocal cerebral involvement • Ophthalmoscopy: retinitis, chorioditis, uveitis, or vasculitis of retinal vessels
• EEG: tumor, inflammation or metabolic disease • Ophthalmoscopy: retinitis, chorioditis, uveitis, or vasculitis of retinal vessels
General
• Symptomatic • Supportive • Radiation therapy
• • • •
Medication
• • • • •
Dependent on underlying disease Antibiotics: enrofloxacin, clavamox Corticosteroids: dexamethasone Fungal: itraconazole or fluconazole Lomustine
Acute (IV/IN) • Anticonvulsants: diazepam, lorazepam, midazolam, phenobarbital, sodium pentobarbital, felbamate, zonisamide • Propofol Chronic (oral) • Anticonvulsant: gabapentin, phenobarbital, felbamate, potassium bromide
Nursing Care
• • • •
Dependent on underlying disease Monitor neurologic functions. Frequent turning to prevent decubital sores and pulmonary edema Cold water, alcohol baths, or ice packs for hyperthermia
• Constant monitoring for seizures, hyperthermia • Cold water, alcohol baths, or ice packs for hyperthermia
Patient Care
• Monitor neurologic functions. • Monitor blood work dependent on underlying disease.
• Avoid swimming. • Monitor CBC, chemistry panel, urinalysis, phenobarbital, bromide, bile acids annually • Maintain a log of all seizure activity and review biannually with veterinarian.
Prevention/ Avoidance
• Tick control • Vaccinations • Proper wound management
• Castrate affected animals. • Maintain antiseizure medication.
Complications
• Dependent on underlying disease • Death
• Phenobarbital complications • Status epilepticus
Prognosis
• Variable: dependent on underlying disease • Many forms are lethal
• Proper treatment gives ↓ seizure frequency
Follow-Up
Treatment
6
268
SECTION THREE: DIAGNOSTIC SKILLS
Radiographs, thoracic: tumors Radiographs, abdominal: tumors Radiographs, skull: hydrocephalus, trauma or tumor CT: tumor, inflammation or granulomas MRI: tumor, inflammation
Symptomatic Oxygen therapy Ocular compression Fluid therapy: do not give lactated Ringer’s in patients receiving potassium bromide
Table 6.39 / Neurology: Encephalitis and Epilepsy (Continued) Disease
Encephalitis
Epilepsy
Notes
• Caution: Chosen drugs must be able to cross the blood-brain barrier. • Determining the underlying cause is critical to the patient’s survival.
• Ocular compression is the gentle compression of the globe into the orbit by digital pressure over the upper lid for 10–60 seconds at 5-minute intervals. • Most seizures occur while sleeping or at rest, often at night or in early morning. • Do not stop medications abruptly as it may cause seizures; slowly reduce over 4–8 weeks (taper gradually). • German Shepard, Irish Setter, Miniature Poodle, Siberian Husky, Beagle, Cocker Spaniel, Labrador Retriever, Keeshond, and Miniature Schnauzer
6
Table 6.40 / Neurology: Intervertebral Disc Disease and Meningitis Intervertebral Disc Disease
Meningitis
Definition
Intervertebral disc disease is an age-related condition affecting an individual disc or discs. This condition may lead to protrusion or extrusion of the disc leading to compression of the spinal cord, nerve roots, or meninges. The process can be either a degenerative or infectious process (diskospondylitis).
Bacterial infection of the meninges is the cause of meningitis. It can be the result of septicemia, local invasion, or bite wounds. Secondary inflammation of the brain or spinal cord may also be seen with meningitis.
Clinical Signs
• Abnormal gait, ataxia, crying when touched, paresis or paralysis of some or all limbs, reluctance to move or jump, stiff or hunched stance/appearance, urinary incontinence, walking difficulty
• Ataxia, cachexia, convulsions, depression, dyspnea
Examination Findings
• Edema, pain, Schiff-Sherrington syndrome
• Ataxia, cervical pain and rigidity, edema, hyperesthesia, nasal, sinus or inner ear infection, mild paresis, pyrexia, tachycardia, tremors
General
• History/clinical signs • Spine palpation
• History/clinical signs • Neurologic examination
Laboratory
• Urinalysis: leukocytes, ↑ protein, bacteria • CSF analysis: inflammatory cells and infectious agents
• • • • •
Diagnosis
Presentation
Disease
CBC: leukocytosis Chemistry panel: ↑ globulin Urinalysis: pyuria, ↑ bacteria Serology tests: + Cytology, skin, eyes, nasal discharge and sputum: bacterial, fungal, protozoan, rickettsial, or viral • CSF analysis: bacteria, neutrophilic pleocytosis, protein
CHAPTER 6 / GENERAL MEDICINE
269
Table 6.40 / Neurology Intervertebral Disc Disease and Meningitis (Continued) Disease
Diagnosis
Imaging
Intervertebral Disc Disease
Meningitis
• Radiographs, spine: narrowed, wedge-shaped disc space, small intervertebral foramen, collapsed articular facets or mineralized disc material in the spinal cord, intervertebral foramen or vertebral endplate lysis or sclerosis • CT/MRI: location and severity of disc lesion, spinal cord edema • Myelography: location and severity of disc lesion
• Radiographs, spine: bony infection • Radiographs, skull: sinus, nasal cavity, or ear infection • MRI/CT: ↓ opacity of cerebral hemisphere, lack of contrast
Procedures
Follow-Up
Treatment
6
General
• • • •
Medication
• Corticosteroids: prednisone, prednisolone or methyl prednisolone succinate
• • • •
Nursing Care
• Careful handling of patients to prevent further trauma: protect the spine during any movement • Nutritional support • Monitor for worsening neurological signs. • Monitor urine output and defecation. • Turn recumbent patients at least every 4 hours and keep well padded.
• Intensive care monitoring • Restricted activity
Patient Care
• Restrict activity. • Physical therapy: ROM exercises, hydrotherapy, start 2 weeks postoperative • Monitor urinalysis in nonambulatory patients. • Use harnesses to keep pressure off cervical discs. • Obesity management
• Monitor for neurologic signs, fever, systemic signs, and leukocytosis.
Prevention/ Avoidance
• Maintain proper weight control. • Avoid strenuous exercise with prone breeds.
• Treat local infections early and thoroughly to prevent spread of infection to the CNS.
Complications
• Recurrence of pain
• Irreversible damage to the brain and spinal cord • DIC
Prognosis
• Excellent with surgery
• Variable dependent on degree of infection and inflammation
Notes
270
• N/A Symptomatic Cage rest for 2 weeks Acupuncture Surgery: laminectomy, hemilaminectomy, durotomy, decompression
• Caution: Corticosteroids should not be used with diskospondylitis. • Caution: Do not use corticosteroids and NSAIDs together due to GIT hemorrhage. • For confinement to work, it must be strict with only leash walks to eliminate. • Beagle, Toy Poodle, Dachshund, Doberman Pinscher, and all chondrodystrophic breeds SECTION THREE: DIAGNOSTIC SKILLS
• Symptomatic • Supportive • Fluid therapy Antibiotics: variable Anticonvulsants: diazepam or phenobarbital Corticosteroids: dexamethasone, prednisolone Diuretics: mannitol (osmotic type)
Table 6.41 / Neurology: Myasthenia Gravis and Myelopathy Myasthenia Gravis
Myelopathy (Degenerative Myelopathy)
Definition
Myasthenia gravis is associated with autoantibodies directed at nicotinic acetylcholine receptors (AChRs). This leads to a loss of AChRs, which impairs neuromuscular transmission and causes muscle weakness and episodic collapsing.
Myelopathy is a degenerative process affecting the myelin and axons of the spinal cords. This slow, progressive problem has no known cause but is limited to the hindlimbs. There is no known treatment; it remains to be only supportive.
Clinical Signs
• Abnormal gait, body trembling, dysphagia, excessive drooling, dysphonia, dyspnea, muscle weakness, paresis/paralysis, regurgitation
• Abnormal gait, ataxia, crossing over of hindlimbs, knuckling, scuffing of hindlimbs, swaying when turning, walking difficulty, weakness, worn toenails
Examination Findings
• Masticatory dysfunction, ventroflexion of head
• Muscle atrophy
General
• History/clinical signs (episodic) • Neurologic examination
• History/clinical signs • Neurologic examination
Laboratory
• • • • •
Chemistry panel: ↑ CK Thyroid and adrenal function tests ANA assay: + result Serum antibodies against nicotinic AChRs: + result Edrophonium chloride challenge test: ↑ muscle strength following injection • Edrophonium response test: + • Electrodiagnostic evaluation: location and severity of disease
• CSF analysis: ↑ protein, WBCs
Imaging
• Radiographs, thoracic: megaesophagus, cranial mediastinal mass, aspiration pneumonia
• Radiographs, thoracic: metastasis and tumors • Radiographs, abdominal: same as above • Radiographs, spine: ossification, spondylosis or narrowed intervertebral disc space • MRI: to rule out IVDD
Procedures
• Fluoroscopy: dysfunction of swallowing
• N/A
General
• • • •
• Supportive
Medication
• Anticholinesterase drugs: pyridostigmine bromide or neostigmine • Corticosteroids: prednisone • Cyclophosphamide
• Aminocaproic acid (v) • N-Acetylcysteine (v) • Vitamin supplements: vitamin C, E
Nursing Care
• Nutritional support
• Treated as outpatient
Patient Care
• Feed animal in an upright position and ensure the animal remains upright for at least 10 minutes after eating. • Feed different consistencies of food to determine which works best. • Radiograph every 4–6 weeks to monitor megaesophagus. • Recheck AChR antibody titers every 6–8 weeks until normal.
• Keep as active as possible to delay onset of nonambulatory state. Nonambulatory • Cart, slings for mobility • Avoid decubital sores • Urinary catheter • Vitamin supplementation
Follow-Up
Treatment
Diagnosis
Presentation
Disease
Supportive Fluid therapy Oxygen therapy Surgery: feeding tube placement or tumor removal
6
CHAPTER 6 / GENERAL MEDICINE
271
Table 6.41 / Neurology: Myasthenia Gravis and Myelopathy (Continued)
Follow-Up
Disease
Myasthenia Gravis
Myelopathy (Degenerative Myelopathy)
Prevention/ Avoidance
• N/A
• N/A
Complications
• Aspirate pneumonia • Third-degree heart block • Respiratory arrest
• Decubital sores • Fecal and urine incontinence
Prognosis
• Good • Guarded with cranial mediastinal mass
• Guarded to poor • Patients eventually lose function of both hindlimbs and front limbs.
• Jack Russell Terrier, Springer Spaniel, Smooth Fox Terrier, Golden Retriever, German Shepard, Labrador Retriever, Dachshund, and Scottish Terrier
• German Shepard, Collie, Labrador Retriever, Chesapeake Bay Retriever, Kerry Blue Terrier, and Pembroke Welsh Corgi
Notes
6
Table 6.42 / Neurology: Vestibular Disease and Wobbler Syndrome Vestibular Disease of Older Dogs, Acute
Wobbler Syndrome (Caudal Cervical Spondylomyelopathy, Cervical Vertebral Instability)
Definition
Vestibular disease is an acute condition affecting geriatric dogs. It is the disturbance of the peripheral vestibular system. Otitis media is a common cause of the disease in younger dogs.
Wobbler syndrome is due to pressure placed on the spinal cord by malformation of bone or spinal ligaments. It leads to instability or chronic disc disease. It is thought that overnutrition and rapid growth may be a contributing factor to this condition.
Clinical Signs
• Anorexia, asymmetrical ataxia, circling, disorientation, falling, head tilt toward the affected side, loss of balance, nausea, nystagmus, rolling, vomiting
• Abnormal gait, ataxia, dragging of toes, knuckling, paraparesis and ambulatory or nonambulatory tetraparesis, rigid flexion of neck, walking difficulty
Examination Findings
• Facial paresis or paralysis, Horner’s syndrome, strabismus
• ↓ Proprioception, pain, supraspinatus atrophy
General
• Clinical signs • Neurologic examination • Otoscopic examination: fluid, ruptured or bulging tympanum
• History/clinical signs
Laboratory
• N/A
• N/A
Imaging
• Radiographs, skull: osseous bullae fluid, sclerosed, osteitis • MRI/CT: tumor, osseous bullae sclerosed
• Radiographs, spine: bony changes, herniation, subluxation or narrowing of intervertebral disc space • Myelogram: site and type of cord compression
Procedures
• BAER: evaluation of cochlear portion of cranial nerve VIII
• CSF analysis: ↑ protein • Thyrotropin stimulation test: minimal to no response
Diagnosis
Presentation
Disease
272
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.42 / Neurology: Vestibular Disease and Wobbler Syndrome (Continued)
Follow-Up
Treatment
Disease
Vestibular Disease of Older Dogs, Acute
Wobbler Syndrome (Caudal Cervical Spondylomyelopathy, Cervical Vertebral Instability)
General
• Supportive • Fluid therapy
• Supportive • Surgery: ventral spondylectomy, dorsal laminectomy, fenestration, stabilization or fusion of involved vertebrae
Medication
• Antibiotics: trimethoprim-sulfa, cephalexin, cefadroxil, enrofloxacin, orbifloxacin • Antiemetics: dimenhydrinate, meclizine • Tranquilizers: diazepam
• Corticosteroids: prednisone, methylprednisone sodium succinate, dexamethasone • Muscle relaxant: methocarbamol, diazepam
Nursing Care
• Treated as outpatient
• • • •
Urinary catheter in nonambulatory patients Avoid decubital sores. Physical therapy of all limbs to prevent ankylosis Restrict activity of ambulatory patients or use a neck brace.
Patient Care
• Restrict activity as needed for disorientation. • Reexam 2–3 days after discharge to verify continued improvement.
• Monitor neurologic functions. • Physical therapy
Prevention/ Avoidance
• Prompt recognition and treatment of ear infections if present
• Limit running and jumping. • Use harness instead of a neck collar.
Complications
• Dehydration • Electrolyte imbalances • Renal insufficiencies
• • • •
Prognosis
• Excellent • Most patients return to normal in 2–3 weeks.
• Good when presented ambulatory • Poor when nonambulatory with tetraparesis
Notes
6
Failure of surgical repair Degenerative changes of surrounding disc spaces Decubital sores Urinary tract infection or urine scalding
• Caution: Flexion and tension stress during radiographs can make clinical signs worse. • Great Dane and Doberman Pinscher
ONCOLOGY Table 6.43 / Oncology: Neoplasia Neoplasia
Definition
Neoplasia is the development of a new and abnormal formation of tissue, as a tumor or growth. It serves no useful function but grows at the expense of the healthy organism.
Presentation
Disease
Clinical Signs
• Presence of a tumor or 2 effects attributable to adjacent organ/tissue injury (e.g., halitosis, swelling, pain) • Anorexia, depression, diarrhea, inappetance, lethargy, vomiting, weight loss
Examination Findings
• Detection of tumor, variable (e.g., lymphadenopathy, organomegaly, hyperemic mucous membranes) and additional disorders
CHAPTER 6 / GENERAL MEDICINE
273
Table 6.43 / Oncology: Neoplasia (Continued) Disease
• History/clinical signs • Physical examination: tumor and lymph node palpation
Laboratory
• • • • • •
CBC: variable (see specific tumor type), anemia: normocytic and normochromic Chemistry panel: variable (see specific tumor type) Urinalysis: variable (see specific tumor type) Fine needle aspirate, core biopsy, or surgical biopsy of tumor or enlarged lymph node(s) Cytology: cells fulfilling the criteria for malignancy Histopathology: clean margins and tumor grade
Imaging
• • • •
Radiographs, thoracic (VD and left and right laterals): tumor identification, metastases, lymphadenopathy, pleural effusion Radiographs, abdominal: tumor identification, metastases, lymphadenopathy, organomegaly Ultrasound: tumor identification, lymphadenopathy, guided biopsy MRI/CT: tumor identification, metastases, lymphadenopathy, tumor margins, tissue of origin
Procedures
• Variable
General
• • • • • •
Symptomatic Fluid therapy Radiation therapy Cryosurgery Photodynamic therapy Surgery: excision with 2–3 cm clean margins
Medication
• • • •
Variable (see specific tumor type) Chemotherapy agents Corticosteroids Analgesics
Nursing Care
• Standard postoperative following surgical excision
Patient Care
• Variable (see specific tumor type) • Monitor specific blood values • Monitor response to treatment, chemotherapy (see Skill Box 8.13, page 356) appetite, elimination, and energy level
Prevention/ Avoidance
• N/A
Complications
• Variable (see specific tumor type)
Prognosis
• Dependent on tumor type, size, location, time of discovery, and completeness of excision
Diagnosis
General
Follow-Up
Treatment
6
274
Neoplasia
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.44 / Oncology: Histiocytoma, Mammary Gland Neoplasia, and Mast Cell Tumor Disease
Histiocytoma (Button Tumor)
Mammary Gland Neoplasia
Mast Cell Tumor
Definition
A histiocytoma is a benign skin tumor often found on the head, ear pinna, and limbs. They are most commonly seen in dogs less than 2 years of age.
Mammary gland neoplasia is very prevalent among female, intact dogs and very rare in male dogs. The tumors show malignancy 50% of the time. If the tumors are malignant, they have usually metastasized by the time of diagnosis.
Mast cell tumors are malignant tumors that arise from mast cells. They are a very unpredictable tumor in their appearance, growth rate, and response to treatment.
• Fast growing, firm, small, dome- or button-shaped mass, fast growing, solitary, nonpainful, ± ulcerated
• Firm nodular mass, ± ulceration • Nipples: red, swollen, and exudate (e.g., tan, red) • Fever
Dogs • Lymphadenopathy, erythema, and edema • Tumor: solitary skin or SQ mass, present for days to months, recent rapid growth Cats • Anorexia and vomiting • Tumor: found in SQ tissue or dermis, papular or nodular, solitary or multiple, hairy or alopecic and/or ulcerated
Presentation
Clinical Signs
Diagnosis
Examination Findings
• Edematous hindlimbs
• Lymphadenopathy, hepatomegaly, intestinal wall thickening, splenomegaly
General
• Clinical signs
• Clinical signs • Mammary gland palpation
• History/clinical signs
Laboratory
• Cytology: pleomorphic round cells, variable sized and shaped nuclei, appearance of hepatocytes, variable amounts of pale blue cytoplasm resembling monocytes, ± lymphocyte, plasma cell, and neutrophil infiltrate
• CBC: anemia and leukocytosis • Cytology: cells with cytoplasmic basophilia, variable nuclear/cytoplasmic ratios and if malignant have typical carcinoma clumps (e.g., acinar)
• CBC: eosinophilia, basophilia (v), anemia and mastocythemia (rare) • Buffy coat smear: mast cells • Cytology: round cells with basophilic cytoplasmic granules not forming sheets or clumps and ± eosinophilic infiltrate • Biopsy: confirmation and severity of disease • Histopathology: confirmation of completeness of excision
Imaging
• N/A
• Radiographs, thoracic: pleural effusion and lung metastases • Radiographs, abdominal: ascites and ↑ size of sublumbar lymph nodes • Ultrasound: ascites and size of sublumbar lymph nodes
• Radiographs, abdominal: ↑ spleen, liver, and lymph nodes • Ultrasound: visceral metastasis
Procedures
• N/A
• N/A
• Lymph node aspirates • Darier’s sign: a tumor that has been manipulated will degranulate causing erythema and wheel formations.
CHAPTER 6 / GENERAL MEDICINE
275
6
Table 6.44 / Oncology: Histiocytoma, Mammary Gland Neoplasia, and Mast Cell Tumor (Continued)
Treatment
Disease
Histiocytoma (Button Tumor)
Mammary Gland Neoplasia
Mast Cell Tumor
General
• Spontaneous regression • Surgery: excision or cryosurgery
• Symptomatic • Surgery: mastectomy
• • • • •
Medication
• N/A
• Chemotherapy: doxorubicin, cyclophosphamide, and mitoxantrone
• Chemotherapy: L-asparaginase, vinblastine, cyclophosphamide, lomustine, and vincristine • Corticosteroids: prednisone • GI protectants: sulcralfate • H1-blockers: diphenhydramine • H2-blockers: cimetidine, ranitidine
Nursing Care
• Standard postoperative
• Standard postoperative
• Standard postoperative
Patient Care
• Monitor its growth and the presence of new tumors.
• Reexam every 2 months for reoccurrence of mammary tumors.
• Monitor CBC and lymph node enlargement before each chemotherapy administration. • Monitor for the presence of new tumors.
Prevention/ Avoidance
• N/A
• Early hysterectomy: ≤2nd heat cycle
• N/A
Complications
• N/A
• • • • • •
• • • •
Prognosis
• Excellent
• Dependent on size, time of detection, and completeness of excision
• Dependent on the area affected, time of detection, and completeness of excision • Metastasis to regional lymph nodes, liver, spleen, and bone marrow
• Boxer, Dachshund, Cocker Spaniel, Great Dane, and Shetland Sheepdog
• Freely movable tumor implies benign, and fixed to body wall or skin implies malignant. • Removal of all 4 glands of the affected chain is recommended.
• Animals with tumors on the extremities tend to live longer than do animals with trunk tumors. • Boxer, Boston Terrier, Bullmastiff, English Setter, and Siamese cats
Follow-Up
6
Notes
276
SECTION THREE: DIAGNOSTIC SKILLS
Anemia Ascites DIC Hypercalcemia Osteoporosis Pleural effusion
Symptomatic Chemotherapy Radiotherapy Cryosurgery (grade I, small, cutaneous) Surgery: aggressive excision and splenectomy
Bleeding Chemotherapy toxicity Hemorrhagic gastroenteritis Radiation reaction
Table 6.45 / Oncology: Various Neoplasias Type of Cancer
Clinical Signs
Diagnosis
Treatment
Follow-Up
Complications
Prognosis
• Dyschezia, tenesmus, PU/PD, pruritis, ulceration, bleeding, weakness, and paresis
• Chemistry panel: ↑ calcium, ↓ phosphorus • PTH/PTHrP: ↑ values • Radiographs, thorax: metastasis (nodules) • Radiographs, abdominal: enlarged lymph nodes, fluid • Ultrasound, abdominal: enlarged lymph nodes, liver or spleen nodules • Biopsy: confirmation
• Chemotherapy: cisplatin (canine), carboplatin, doxorubicin • Calcitonin • Diruetics: furosemide • Fluid therapy • Radiation therapy • Surgery: tumor and lymph node excision/debulking
• Examination, radiographs, ultrasound and blood work every 3 months following surgery
• • • • •
• Poor
CARCINOMA Adenocarcinoma Anal Sac • Mostly seen in geriatric female dogs with a very high rate of metastasis
Fecal incontinence Metastasis Renal failure Reoccurrence Sepsis
6
Nasal • Most tumors begin as unilateral but progress to bilateral
• Epistaxis, epiphora, sneezing, nasal discharge, halitosis, and seizures • Facial deformity: nasal bone swelling
• Radiographs, skull: tumor location, extent • Radiograph, thorax: metastasis (nodules) • MRI/CT or Rhinoscopy: tumor location, extent and effect on surrounding structures and biopsy • Mycotic cultures: fungal rhinitis • Biopsy: confirmation
• Antiemetic: butorphanol • Chemotherapy: cisplatin (canine), cyclophosphamide, piroxicam, vincristine • Radiotherapy • Surgery: tumor excision/debulking
• Survey radiographs, CT or MRI when clinical signs return
• Brain involvement across cribiform plate
• Fair with radiation • Poor with brain involvement
Pancreas • Liver metastasis is very common.
• Ascites, icterus, maldigestion • Palpable abdominal mass, pyrexia
• CBC: mild anemia, neutrophilia • Chemistry panel: ↑ amylase, lipase • Radiograph, abdominal: metastasis, fluid, ascites • Ultrasound, abdominal: tumor, pancreatitis • Biopsy: confirmation
• Palliative • Surgery: tumor excision
• Monitor quality of life
• Diabetes insipidus • Intestinal or biliary obstruction • Pancreatic abscess • Pancreatitis • Peritonitis
• Grave
CHAPTER 6 / GENERAL MEDICINE
277
Table 6.45 / Oncology: Various Neoplasias (Continued) Type of Cancer
Clinical Signs
Diagnosis
Treatment
Follow-Up
Complications
Prognosis
Prostate • Prostrate tumors are always malignant.
• Cachexia, constipation, dyschezia, dyspnea, dysuria, exercise intolerance, rear limb lameness, stranguria, tenesmus • Hematuria, pyrexia
• CBC: inflammatory leukogram • Chemistry panel: ↑ alk phos, azotemia • Urinalysis: pyuria, ↑ blood, malignant epithelial cells • Radiography, thorax: metastasis • Radiograph, abdominal: lesions, prostrate changes, lymphadenopathy • Ultrasound, abdominal: prostate changes (asymmetry) • Contrast cystography: distortion of prostatic urethra
• Analgesics: NSAIDs or opioid drugs • Chemotherapy: cisplatin (canine), carboplatin, doxorubicin • Radiotherapy • Stool softeners • Surgery: prostate excision, castration
• Monitor ability to urinate and defecate. • Monitor pain levels.
• Constipation • Metastasis • Urethral obstruction
• Grave
Salivary Gland
• Dysphagia, pain on opening mouth, swelling of upper neck, ear base, upper lip, maxilla, mucous membrane of lip
• Radiographs, thorax: metastasis • Biopsy: confirmation
• Radiotherapy • Surgery: tumor excision
• Monitor for tumor growth every 3–6 months.
Thyroid • High rate of metastasis • Biopsy and FNA can cause excessive bleeding. • Rare in felines
• Dysphagia, dysphonia, dyspnea, PU/PD, regurgitation • Firm, nonpainful cervical mass, tachycardia • See Canine Hypothyroidism signs
• CBC: nonregenerative anemia • Radiographs, cervical: displacement of normal structures • Ultrasound, thorax: disease extent • CT: disease extent • Radioiodine study: thyroid hormone production • T4, T3, TSH concentrations • Thyroid gland scintigraphy: location
• β-Blockers • Analgesics: butorphanol • Chemotherapy: doxorubicin, cisplatin, carboplatin • Methimazole • Radioactive iodine (feline) • Radiotherapy • Surgery: tumor, gland, lymph node excision • Thyroxin (secondary hypothyroidism)
• Examination tumor site and radiographs every 3 months • Monitor calcium, thyroid concentration levels.
6
278
SECTION THREE: DIAGNOSTIC SKILLS
• Unknown
• • • • • •
Anemia DIC Hypoparathyroidism Hypothyroidism Laryngeal paralysis Respiratory distress
• Dependent on size of tumor and lymph node involvement • Larger fixed tumors have a poor prognosis.
Table 6.45 / Oncology: Various Neoplasias (Continued) Type of Cancer
Clinical Signs
Diagnosis
Treatment
Follow-Up
Complications
Prognosis
Squamous Cell Carcinoma Digit • Often seen in large, black dogs • Arises from subungual epithelium
• Chronic and progressive lameness, swelling, ulceration
• Radiographs, affected foot: lysis of the 3rd phalanx
• Chemotherapy: cisplatin (canine), mitoxantrone, bovine collagen matrix with 5-fluorouracil • Piroxicam • Retinoids • Surgery: wide margin amputation
• Limit sun exposure. • Use sunscreen or tattoo on low pigmented areas of the paws.
• Good
Ear • Areas of low pigmentation and those subjected to solar radiation are more at risk.
• Crusty eczematous lesions on edge of pinna, ulceration
• Biopsy: confirmation
• Bleomycin • Chemotherapy: cisplatin (intralesional injections) • Cryosurgery • Etretinate • Hyperthermia • Photodynamic therapy • Radiotherapy • Surgery: amputation/ pinnectomy ± ablation of ear canal • Vitamin E
• Limit sun exposure. • Use sunscreen or tattoo on low pigmented areas of the ears.
• Good with complete excision
Gingiva
• Bloody oral discharge, dysphagia, excessive salivation, halitosis, loose teeth, and facial deformity • Plaque-like areas that bleed easily
• Radiographs, skull: bone involvement and lysis • Radiographs, thorax: metastasis • CT: bone involvement and lysis • Biopsy: confirmation
• Chemotherapy: cisplatin (canine), mitoxantrone, carboplatin • Cryosurgery • Photodynamic therapy (PDT) • NSAIDs: piroxicam, ± meloxicam • Radiotherapy • Surgery: tumor excision/debulking
• Feed soft foods or by enteral feeding tube.
• Poor due to local invasion (feline) • The more rostral the tumor is located, the better is the prognosis (canine).
CHAPTER 6 / GENERAL MEDICINE
279
6
Table 6.45 / Oncology: Various Neoplasias (Continued) Type of Cancer
Clinical Signs
Diagnosis
Treatment
Follow-Up
Skin • Areas of low pigmentation and those subjected to solar radiation are more at risk. • Malignant tumor of squamous epithelium
• Crusty, pigmentation, ulceration • Facial skin involvement (feline), nail bed involvement (canine)
• Radiographs, extremity: bone involvement • Radiographs, thorax: metastasis • Biopsy: confirmation
• Chemotherapy: cisplatin (canine), carboplatin, mitoxantrone, bovine collagen matrix with 5fluorouracil (canine) • Cryosurgery • Photodynamic therapy • Radiotherapy • Retinoids • Surgery: tumor excision/debulking
• Reexam and radiographs every 3 months for 1 year, then every 6 months for 1 year. • Limit sun exposure. • Use sunscreen or tattoo low pigmented areas of the skin.
• Dysuria, hematuria, pollakiuria, PU/PD, recurrent stranguria, tenesmus, urinary incontinence
• Chemistry panel: azotemia if at trigone • Urinalysis: ↑ blood, malignant epithelial cells • Urine culture: UTI • Radiograph, thorax: metastasis • Double contrast cystography: irregularities or mass lesions • IV pyelography, voiding urethrogram or vaginogram • Ultrasound, abdomen: extent of disease, proximity to trigone
• Chemotherapy: cisplatin (canine), carboplatin, mitoxantrone • NSAIDs: piroxicam, meloxicam • Radiotherapy
• Cystography or ultrasonography every 6–8 weeks • Thoracic radiographs every 2–3 months
• Transplantation of cells during surgery or biopsy • Urinary incontinence, urethral or ureteral obstruction, renal failure
• Grave
• Lameness, nasal discharge • Pain, swelling
• Radiograph, affected limb: lesion • Radiograph, thorax: metastasis • CT scan: extent of disease • Nuclear bone scan: staging of disease • Biopsy: definitive diagnosis
• Chemotherapy: cisplatin (canine), carboplatin, doxorubicin • Radiotherapy • Surgery: tumor excision, amputation
• Thoracic radiographs monthly for 3 months, then every 3 months
• Brain involvement
• Poor to excellent, dependent on tumor grade
6
Complications
Prognosis • Good with superficial lesions • Guarded with nail bed or digit involvement
Transitional Cell Carcinoma Bladder, Urethra • High rate of metastasis • FNA may cause seeding of tumor cells along the needle tract.
SARCOMA Chondrosarcoma Bone • Affects large breed dogs
280
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.45 / Oncology: Various Neoplasias (Continued) Type of Cancer
Clinical Signs
Diagnosis
Treatment
Follow-Up
Complications
Prognosis
Nasal and Paranasal Sinus • Affects large breed dogs
• Epiphoria, halitosis, nasal discharge, seizures, sneezing • Facial deformity, pain
• Radiographs, skull: tumor, fluid, and destruction of caudal turbinates • MRI/CT: integrity of cribiform plate and orbital invasion
• Chemotherapy: doxorubicin • Radiotherapy • Surgery: tumor excision/debulking
• Radiographs and CT/MRI may be repeated when clinical signs return.
• Fair • Poor with brain involvement (cribriform plate destruction)
• Fracture, lameness, pain, swelling
• Radiograph, affected limb: lesion • Radiograph, thorax: metastasis • CT: extent of disease • Biopsy: definitive diagnosis
• Chemotherapy: cisplatin (canine), carboplatin, doxorubicin • Radiotherapy • Surgery: tumor excision, amputation
• Thoracic radiographs monthly for 3 months, then every 3 months
• Guarded
• Bloody oral discharge, dysphagia, excessive salivation, halitosis • Facial deformity, loose teeth
• Radiographs, skull: bone involvement • Biopsy: intraoral
• Chemotherapy: doxorubicin, cisplatin • Cryosurgery • Radiotherapy • Surgery: tumor excision/debulking
• Feed soft foods
• Fair with early detection and aggressive treatment
• Fracture, lameness, pallor, swelling
• CBC: regenerative anemia, nucleated RBCs, poikilocytosis, anisocytosis, thrombocytopenia, leukocytosis, ↓ protein • FDP, PT, and PTT: ↑ values • Fibrinogen: ↓ values • Radiographs, bone: lysis • Radiographs, thorax: metastasis • Ultrasound: metastasis • CT: extent of disease
• Chemotherapy: doxorubicin, cyclophosphamide • Surgery: tumor excision, amputation
• Examination, thoracic radiographs and ultrasound every 3 months for 1 year then every 6 months
Fibrosarcoma Bone • Primarily affect the axial skeleton
Gingiva
6
Hemangiosarcoma Bone
• Pathologic fractures • Rupturing tumors causing hemorrhage
• Unknown
CHAPTER 6 / GENERAL MEDICINE
281
Table 6.45 / Oncology: Various Neoplasias (Continued)
6
Type of Cancer
Clinical Signs
Diagnosis
Treatment
Follow-Up
Complications
Prognosis
Heart • Pulmonary metastasis very common
• Dyspnea, exercise intolerance, syncope, weight loss • Abdominal and pleural effusion, arrhythmia, hepatomegaly, hindlimb paresis, jugular distention, pulse deficits
• CBC: anemia, nucleated RBCs • Chemistry panel: azotemia • Ultrasound, thorax: location of tumor • Biopsy, heart: definitive diagnosis
• Chemotherapy: doxorubicin, vincristine, cyclophosphamide • Pericardial and pleuralcentesis • Surgery: tumor excision/debulking
• Examination, thoracic radiographs and ultrasound monthly
• Centesis, surgery complications
• Guarded to poor
Spleen, Liver • Rapid growth and widespread metastatic vascular neoplasia
• Ataxia, dementia, intermittent collapse, lameness, paresis, seizures, weakness • Enlarged abdomen, pale mucous membranes, peritoneal fluid, tachycardia
• CBC: regenerative anemia, polychromasia, reticulocytosis, nucleated RBCs, anisocytosis, leukocytosis, neutrophilia, thrombocytopenia • Chemistry panel: ↑ liver enzymes • FDP, PT, and PTT: ↑ values • Radiograph, abdomen: tumor detection, fluid • Radiograph, thorax: metastasis • Ultrasound, heart: tumor location and metastasis
• Antihistamines: diphenhydramine • Biological response modifier L-MTP-PE • Blood transfusions • Chemotherapy: cyclophosphamide, doxorubicin, chlorambucil, methotrexate, vincristine • Fluid therapy • Surgery: splenectomy
• Restrict activity • Thoracic and abdominal radiographs and abdominal ultrasound every 3 months
• Sepsis • Skin sloughs • Tumor rupture leading to hemorrhage • Vomiting and diarrhea
• Poor
• CBC: anemia, leukocytosis, and lymphoblastosis • Chemistry panel: ↑ creatinine, BUN, ALT, AST, calcium • Urinalysis: ↑ bilirubin, protein, isothenuria • Serology: + FeLV • Cobalamin and folate: ↓ values • Ultrasound, abdominal • Cytology: bone marrow, tumor, lymph nodes • Histopathology: clean margins and tumor grade
• Chemotherapy: vincristine, cytosine arabinoside, methotrexate, cyclophosphamide, chlorambucil, L-asparaginase, doxorubicin, actinomycin-D • Corticosteroids: prednisone • Surgery
• Examination, CBC and platelet count before each weekly cycle of chemotherapy
• Leukopenia • Sepsis
• Dependent on form
Lymphosarcoma/Lymphoma Feline • Most common sites are alimentary tract, anterior mediastinum, liver, spleen, and kidneys.
282
• Dependent on form (mediastinal, renal, alimentary, solitary or multicentric) • Coughing, open mouth breathing, regurgitation, weight loss • Renal failure signs, thickened intestines
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.45 / Oncology: Various Neoplasias (Continued) Type of Cancer
Clinical Signs
• Canine • Seen most commonly is solid tissues: lymph nodes, bone • marrow and visceral organs • ↑ Risk with exposure to the herbicide: 2,4dichlorophenoxyacetic
Coughing, drooling, dysphagia, dyspnea, exercise intolerance Anterior uveitis, ascites, lymphadenopathy, lymphoid infiltrate, organomegaly
Diagnosis
Treatment
Follow-Up
Complications
Prognosis
• CBC: anemia, lymphocytosis, lymphopenia, neutrophilia, monocytosis, circulating blasts, and thrombocytopenia • Chemistry panel: ↑ ALT, ALP, and calcium • Echo: cardiac contractility • Ultrasound, abdominal • Cytology: bone marrow, tumor, lymph nodes • Histopathology: clean margins and tumor grade • Immunochemical staining of lympocytes
• Chemotherapy: doxorubicin, vincristine, epirubicin, cyclophosphamide, L-asparaginase, methotrexate, chlorambucil • Corticosteroids: prednisone • Fluid therapy • Radiotherapy • Retinoids • Surgery • Thoraco- and abdominocentesis
• Restrict activity of patients with ↓ WBCs or platelet count. • Monitor CBC and platelet count during chemotherapy. • Echo and ECG: cardiotoxicity of doxorubicin
• Alopecia • DIC • Leukopenia and neutropenia • Pancreatitis • Sepsis • Tissue sloughing • Vomiting and diarrhea
• Good
6
Osteosarcoma • Most common bone tumor in dogs, typically affecting the appendicular skeleton of large to giant breeds
• Lameness, pain, swelling • Pathologic long bone fracture
• Radiograph, affected bone: bone lysis, proliferation in the metaphyseal region of long bones, soft tissue swelling • Nuclear bone scans: bony or soft tissue metastatic disease
• Analgesics: butorphanol, piroxicam, fentanyl, morphine sulfate • Biological response modifiers: L-MTP-PE • Chemotherapy: cisplatin (canine), carboplatin, doxorubicin • Radiotherapy • Surgery: amputation
• Restrict activity. • Monitor radiographs every 2–3 months. • Monitor CBC and platelet count 7–10 days after chemotherapy.
• Metastasis (>90% of cases at examination) and hypertrophic osteopathy
• Guarded once metastases is present
Vaccine-Induced Sarcoma • Typically fibrosarcoma, but may be many other types of sarcoma •Most common with FeLV and rabies
• Firm, painless, SQ swelling located at a previous vaccination site
• Radiograph, tumor site: bone lysis or extension of the tumor along other tissue planes • Radiograph, thorax: metastasis check • Contrast CT scan: extent of disease • Biopsy: confirm diagnosis • Histopathology: clean margins and tumor grade
• Chemotherapy: doxorubicin, cyclophosphamide • Radiotherapy • Surgery
• Evaluate monthly for 3 months, then every 3 months. • Monitor CBC and platelet count before each chemotherapy treatment.
• Recurrence, new lesions
• Poor
CHAPTER 6 / GENERAL MEDICINE
283
OPHTHALMOLOGY Table 6.46 / Ophthalmology: Anterior Uveitis and Cataracts Disease
Presentation
Definition
Treatment
Diagnosis
6
284
Anterior Uveitis
Cataracts
Anterior uveitis is inflammation of the iris and ciliary body. Corneal ulceration, trauma, autoimmune, lens-induced, or infections can cause anterior uveitis, but the disease may also be primary.
Cataracts are pathological changes in the eye that lead to opacity. The changes are in the lens protein composition or disruption of lens fiber arrangement. The general causes are hereditary, inflammatory, metabolic, traumatic, nutritional, or toxic.
Clinical Signs
• Blepharospasm, blindness, elevation of nictitating membrane, epiphora, inappetence, lethargy, miosis, photophobia, redness, tearing
• Blindness, visual impairment
Examination Findings
• Aqueous flare, conjunctival hyperemia, hypotony, corneal edema, fibrinous exudate
• Aqueous flare, any opacity in the lens of a dilated eye, synechia
General
• Clinical signs • Ophthalmic examination
• History/clinical signs • Ophthalmic examination
Laboratory
• Chemistry panel: ↑ globulin • Serology: toxoplasmosis, Bartonella, FeLV, FIP, FIV, FHV-1
• Serology: systemic mycoses, rickettsial disease, brucellosis, toxoplasmosis, FeLV, FIV
Imaging
• Radiographs, thoracic: tumors or evidence of fungal disease • Radiographs, abdominal: tumors • Ultrasound, ocular: foreign body and penetrating wounds
• Ultrasound, ocular: retinal detachment
Procedures
• Tonometry: ↓ pressure or ↑ pressure when secondary to glaucoma
• • • •
General
• Symptomatic
• Supportive • Surgery: phacoemulsification, extracapsular extraction, and implantation of an intraocular lens • Laser surgery: capsulotomy
Medication
• Antibiotics: clindamycin • Corticosteroids (systemic): prednisone • Corticosteroids (topical): 1% prednisolone acetate, 0.1% dexamethasone • Mydriatic-cycloplegic: 0.5–1% atropine • NSAIDs: 0.03% flurbiprofen, 1% suprofen, Rimadyl, Deramaxx, meloxicam
• • • •
Nursing Care
• Treated as outpatient
• Treated as outpatient • Standard postoperative (e.g., monitor in flammation) • Pain management
SECTION THREE: DIAGNOSTIC SKILLS
Electroretinogram: degree of retinal atrophy Gonioscopy Biomicroscopy Tonometry: ↓ pressure
Corticosteroids: 1% prednisolone acetate Mydriatics: 1% tropicamide NSAIDs Mydriatic-cycloplegic: atropine
Table 6.46 / Ophthalmology: Anterior Uveitis and Cataracts (Continued)
Follow-Up
Disease
Anterior Uveitis
Cataracts
Patient Care
• Reexam 5–7 days after initiation of treatment then every 2–3 weeks • Monitor intraocular pressure
• Examination frequently for several months postoperative, then every 6 months for life
Prevention/ Avoidance
• N/A
• Prompt treatment of uveitis • Selective breeding • Well-balanced nutrition in hand-fed neonates
Complications
• • • • • •
• • • •
Prognosis
• Dependent on severity of disease upon presentation
• Dependent on stage and location of disease and age of animal
• Caution: Corticosteroids are contraindicated in cases of primary conjunctivitis and corneal ulceration. • It takes 2 months for the blood-aqueous barrier to completely heal after an insult; therefore, continue to treat for 2 months.
• Caution: Differentiate from nuclear sclerosis, which is an increase in the clarity of the nucleus of the lens and is a normal aging process. • Special considerations must be taken with medications and procedures for patients with diabetes mellitus. • Miniature Poodle, American Cocker Spaniel, Miniature Schnauzer, Golden Retriever, Boston Terrier, and Siberian Husky and Persian, Birman, and Himalayan cats
Notes
Blindness Secondary glaucoma Cataracts Endophthalmitis or panophthalmitis Iris atrophy Lens luxation
Anterior uveitis Corneal endothelial damage Glaucoma Retinal detachment
6
Table 6.47 / Ophthalmology: Conjunctivitis and Entropion Disease
Entropion
Conjunctivitis is a general term for inflammation of the ocular mucous membrane that covers the sclera and lines the inner surface of the eyelids. Its causes can be infectious, foreign body, trauma, tear film deficiency, chemical or environmental irritants, immune-mediated, or due to other eye diseases.
Entropion is the inward rolling of the eyelid, causing contact of the eyelashes or eyelid hair with the eye.
Clinical Signs
• Discharge, pain
• Blepharospasms, blindness, epiphora, purulent discharge, visual impairment
Examination Findings
• Chemosis, hyperemia, tissue proliferation
• Conjunctivitis, corneal rupture, corneal ulceration
Definition
Presentation
Conjunctivitis
CHAPTER 6 / GENERAL MEDICINE
285
Table 6.47 / Ophthalmology: Conjunctivitis and Entropion (Continued)
Diagnosis
Disease
• History/clinical signs • Ophthalmic examination
• History/clinical signs • Ophthalmic examination
Laboratory
• Serology: FeLV or FIV • Cytology: inflammation, neoplasia, viral or chlamydial infection • Biopsy: neoplasia or preocular mucin deficiency
• N/A
Imaging
• N/A
• N/A
Procedures
• • • •
General
• Symptomatic • Surgery: keratectomy or removal of foreign body, hairs or mass
• Surgery: correction of anatomic entropion, eyelid eversion suture technique
Medication
• Amino acid: L-lysine (FHV-1) • Antibiotics (systemic): tetracycline, erthyomycin, chloramphenical • Antibiotics (topical): triple antibiotic, oxytetracycline, erythromycin, doxycycline • Antiviral: trifluridine, vidarabine, interferon • Corticosteroids (systemic): megesterol acetate • Corticosteroids (topical): 1% dexamethasone • Lacrimostimulants: hyaluronic acid • NSAIDs
• Antibiotic (topical): triple antibiotic
Nursing Care
• Irrigate the eye with a eyewash solution to remove any exudate. • Clip the hair surrounding the eye. • Apply an Elizabethan collar to prevent self-trauma.
• Treated as outpatient.
Patient Care
• Maintain the eyes clear of exudate. • Examination 5–7 days after initiation of treatment and then as needed
• Do not allow rubbing at eyes/sutures.
Prevention/ Avoidance
• Vaccinate. • Isolate patients with infectious conjunctivitis. • Minimize stress for patients with the herpetic conjunctivitis.
• Selective breeding
Complications
• Corneal sequestration • Symblepharon • Keratoconjunctivitis sicca (KCS)
• Conjunctivitis • Impaired vision
Prognosis
• Excellent with bacterial conjunctivitis • Fair with feline herpesvirus, immune-mediated diseases, or KCS
• Good
• Caution: Corticosteroids are contraindicated in cases of primary conjunctivitis and corneal ulceration.
• Chow, Shar pei, and hunting dogs
Follow-Up
Notes
286
Entropion
General
Treatment
6
Conjunctivitis
Schirmer tear test: ↓ tear production Fluorescein stain: ulceration and nasolacrimal duct patency Culture: bacteria or fungi isolation and identification Tonometry: ↑ pressure
SECTION THREE: DIAGNOSTIC SKILLS
• N/A
Table 6.48 / Ophthalmology: Cilia Disorders and Glaucoma Disease
Presentation Diagnosis Treatment
Glaucoma
Cilia disorders are the abnormal location or positioning of the eyelashes. Trichiasis is cilia arising from normal sites that are directed toward the eye. Distichiasis is the growing of cilia from the meibomian glands and emergence from their ducts. Ectopic cilia are cilia that arise from the meibomian gland and erupt through the palpebral conjunctival surface.
Glaucoma is an increase in intraocular pressure with subsequent damage to the optic nerve. Chronic glaucoma is often caused by retinal and optic nerve degeneration and buphthalmos.
Clinical Signs
• Blepharospasm, discharge, epiphora
• Blepharospasm, blindness, dilated pupil, epiphora, impaired vision, ↑ pupillary light response • Weak to absent menace response
Examination Findings
• Anisocoria, hyperemia, chemosis, pain, pigmentation, tissue proliferation, vascularization
• Buphthalmos, conjunctival hyperemia, corneal edema, luxated lens, retinal degeneration
General
• History/clinical signs • Ophthalmic examination
• History/clinical signs • Ophthalmic examination
Imaging
• N/A
• Radiographs, skull: fungi or neoplastic lesions • Ultrasound, ocular: structural abnormalities
Procedures
• N/A
• Tonometry: ↑ pressure, >25–30 mm Hg (canine) and >31 mm Hg (feline) • Electroretinography: vision loss
General
• Surgery: cryoepilation, electroepilation, tarsoconjunctival resection, facial fold resection, or medial canthal closure
• Supportive • Symptomatic • Surgery: cyclophotocoagulation, gonioimplatation, intraocular prosthesis or enucleation
Medication
• Antibiotics (topical): triple antibiotic
• Adrenergic agents: 0.1% dipivefrin, 0.25–0.5% timolol • Miotics: pilocarpine 2%, demecarium bromide, epinephrine 1%, dipivefrin HCl 0.1%, or timolol maleate 0.5% • Carbonic anhydrase inhibitors: methazolamide, dorzolamide, brinzolamide • Corticosteroids: dexamethasone • Diuretics: 20% mannitol or glycerin • Prostaglandins: latanoprost
Nursing Care
• Treated as outpatient
• Treated as outpatient
Patient Care
• Treat swelling with topical antibiotics, corticosteroids, and/or hypertonic saline.
• Warm, moist compresses twice daily for 5–7 days postoperative • Monitor every 1–2 days for 1 week for improvement. • Treat the other eye prophylactically daily with an autonomic agent.
Definition
Follow-Up
Cilia Disorders (Distichiasis, Trichiasis and Ectopic Cilia)
6
Laboratory
CHAPTER 6 / GENERAL MEDICINE
287
Table 6.48 / Ophthalmology: Cilia Disorders and Glaucoma (Continued)
Follow-Up
Disease
Cilia Disorders (Distichiasis, Trichiasis and Ectopic Cilia)
Glaucoma
Prevention/ Avoidance
• Clip hair on facial folds and around the eyes.
• Yearly ophthalmic examination in predisposed breeds • Examinations 2–3 times a year on unaffected eye when 1 eye already has glaucoma
Complications
• Recurrence • Conjunctivitis • Keratitis
• Blindness • Chronic ocular pain
Prognosis
• Excellent with facial fold resection • Fair to good with hair removal
• Fair with surgery • Poor with medical treatment alone
• Felines do not have cilia, and canines normally only have them on the upper eyelid.
• Normal intraocular pressure is 15–25 mm Hg. • 50% of animals develop glaucoma in the second eye within 8 months of the initial diagnosis. • 40% of dogs will be blind in affected eye within 1 year regardless of treatment. • May take up to 6 weeks for vision to return
Notes
6
Table 6.49 / Ophthalmology: Keratitis and Keratoconjunctivitis Sicca Disease
Presentation
Keratoconjunctivitis Sicca (KCS, Dry Eye Syndrome)
Nonulcerative (Chronic Superficial Keratitis)
Ulcerative (Corneal Ulceration/Erosion)
Keratitis is inflammation of the cornea with possible corneal erosion. It can be caused by trauma, foreign bodies, bacterial infection, irritant, cilia disorders, KCS, feline herpesvirus, or corneal exposure.
Ulceration is the loss of a full-thickness of epithelium with at least some stromal loss. This can be caused by trauma, bacterial infection, pseudomonas, feline herpesvirus, epithelial dystrophy, corneal dryness, neurotrophic keratitis, or complications from other diseases.
KCS is a lack of normal tear production causing drying and inflammation of the cornea and conjunctiva. It is thought to be an immune-mediated disease against the lacrimal gland. It can also be caused by long-term use of sulfonamides.
Clinical Signs
• Blepharospasm, photophobia, prolapsed third eyelid, squinting, rubbing at eyes, serous to mucopurulent discharge, tearing
• Blepharospasm, epiphora, photophobia, rubbing at eyes, serous to mucopurulent discharge
• Blepharospasms, blindness, eye rubbing, mucoid to mucopurulent discharge, periocular crust, photophobia, pruritus
Examination Findings
• Corneal edema, hyperemia, neovascularization, pigmentation
• Aqueous flare, corneal edema, corneal opacity, conjunctival hyperemia, hypotony, miosis, neovascularization, surface depression
• Chemosis, dull, opaque or pigmentation of cornea, hyperemia, superficial vascularization, thickened conjunctiva, ulceration
Definition
288
Keratitis
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.49 / Ophthalmology: Keratitis and Keratoconjunctivitis Sicca (Continued)
Follow-Up
Treatment
Diagnosis
Disease
Keratitis
Keratoconjunctivitis Sicca (KCS, Dry Eye Syndrome)
Nonulcerative (Chronic Superficial Keratitis)
Ulcerative (Corneal Ulceration/Erosion)
General
• History/clinical signs • Ophthalmic examination
• History/clinical signs • Ophthalmic examination
• History/clinical signs • Ophthalmic examination
Laboratory
• Virus isolation: feline herpesvirus
• Virus isolation: feline herpesvirus • Culture: bacteria or fungi isolation and identification
• Cytology: severity of bacterial overgrowth
Imaging
• N/A
• N/A
• N/A
Procedures
• Schirmer tear test: ↓ production • Cytology: recognition and identification of bacteria
• Fluorescein stain: retention of stain • Schirmer tear test: >15 mm/min
• Schirmer tear test: ↓ production, <10 mm/min • Fluorescein stain: retention of stain
General
• Symptomatic • Contact lenses • Plesiotherapy with strontium-90–generated beta-radiation • Surgery: debridement, laceration repair, keratotomy, keratectomy, superficial keratotomy, or conjunctival flap surgery
• Symptomatic • Debridement of ulcer edges • Surgery: conjunctival flap, tissue adhesion, pedicle flap, keratectomy, linear keratotomy, contact lenses and collagen shields
• Symptomatic • Surgery: transposition of the parotid salivary duct
Medication
• 2% Cyclosporine • Antibiotics: chloramphenical, tobramycin, erythromycin, triple antibiotic or gentamicin • Antiviral: trifluridine or idoxuridine • Mydriatic-cycloplegic: atropine • Corticosteroids (topical): 0.1% dexamethasone, 1% prednisolone acetate • Mucolytics: acetylcysteine • NSAIDs: aspirin
• Antibiotics (systemic): variable • Antibiotics (topical): gentamicin, tobramycin and triple antibiotic • Antiprotease agent: acetylcysteine
• Antibiotics (topical): variable • Artificial tears supplementation: hyaluronic acid, hydroxypropyl methycellulose • Immunosuppression: cyclosporine, tacrolimus • Miotics: pilocarpine • Mucolytics: acetylcysteine
Nursing Care
• Treated as outpatient
• With deep ulcer, restrict activity to prevent rupture. • Apply an Elizabethan collar to prevent self-trauma.
• Clean eyes regularly to keep them clear of discharge.
Patient Care
• Exam every 1–2 weeks to monitor progress until resolved.
• Monitor healing process with fluorescein stain every 1–2 days until improvement is seen.
• Monitor Schirmer tear test every 2–4 weeks until normal. • Clean eyes regularly to keep them clear of discharge.
Prevention/ Avoidance
• N/A
• Lubricant ointment administration in brachycephalic (canine) • Continuous treatment with KCS
• N/A
CHAPTER 6 / GENERAL MEDICINE
6
289
Table 6.49 / Ophthalmology: Keratitis and Keratoconjunctivitis Sicca (Continued) Disease
Keratoconjunctivitis Sicca (KCS, Dry Eye Syndrome)
Ulcerative (Corneal Ulceration/Erosion)
Complications
• Blindness • KCS • Keratitis, ulcerative
• • • • • • •
Prognosis
• Dependent on severity of disease may require lifelong treatment
• Fair to good: may take several weeks to heal
• Good with lifelong treatment
• Caution: Corticosteroids are contraindicated in cases of primary conjunctivitis and corneal ulceration.
• Schirmer tear test: at least 15 mm/min of wetting • Acetylcysteine 5% is mixed 1 : 1 with artificial tears for ophthalmic use. • Cocker Spaniel, Bulldog, West Highland Terrier, Lhaso Apso, Miniature Schnauzer, and Shih tzu
Follow-Up
Nonulcerative (Chronic Superficial Keratitis)
Notes
• Keratitis, ulcerative
Descemetocele Chronic ophthalmitis Glaucoma Rupture of globe Endophthalmitis Blindness Phthisis bulbi
Table 6.50 / Ophthalmology: Lens Luxation and Prolapsed Gland of the Third Eyelid Lens Luxation
Prolapsed Gland of the Third Eyelid (Cherry Eye)
Definition
Lens luxation is the actual movement of the lens either anteriorly or posteriorly. It is often caused by glaucoma, uveitis, cataracts, trauma, or primary zonular degeneration.
Cherry eye is caused by a weak attachment to the nictitating membrane gland, allowing it to protrude/prolapse from the leading edge of the third eyelid.
Clinical Signs
• Blepharospasm, epiphora, redness
• Blepharospasms, discharge, epiphora, swelling at medial canthus
Examination Findings
• Aphakic crescent, corneal edema, hyperemia, iridodenesis, pain
• Conjunctivitis, hyperemia
General
• Clinical signs • Ophthalmic examination
• History/clinical signs • Clinical Signs
Laboratory
• N/A
• N/A
Imaging
• Radiographs, thoracic: metastasis from intraocular neoplasia • Ultrasound, ocular: structural abnormalities
• N/A
Procedures
• Wood’s lamp: fluorescence of a clear lens • Tonometry: ↑ values
• N/A
Presentation
Disease
Diagnosis
6
Keratitis
290
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.50 / Ophthalmology: Lens Luxation and Prolapsed Gland of the Third Eyelid (Continued)
Follow-Up
Treatment
Disease
Lens Luxation
Prolapsed Gland of the Third Eyelid (Cherry Eye)
General
• Supportive (posterior luxation) • Surgery (anterior luxation): cyclocryosurgery, evisceration, intrascleral prosthesis or enucleation
• Surgery: repositioning of the nictitating membrane gland and anchoring securely
Medication
• • • •
Mydriatics: 1% tropicamide Miotics: demecarium bromide Carbonic anhydrase inhibitors: dichlorphenamide Corticosteroids (topical): 0.1% dexamethasone, prednisolone acetate • Diuretics: mannitol
• Antibiotics: variable • Corticosteroids (topical): 1% dexamethasone • NSAIDs
Nursing Care
• Treated as outpatient
• Standard postoperative
Patient Care
• Examine within 24 hours and then frequently after that until intraocular pressure stabilizes. • Examine every 3 months.
• Do not allow rubbing at eyes/sutures.
Prevention/Avoidance
• Selective breeding
• Selective breeding
Complications
• • • • • • • •
• Reprolapse of the gland • Infection at surgery site • Corneal ulcer/erosion secondary to suture abrasion
Prognosis
• Good with surgery
• Excellent with surgery
• Caution: Pupil should not be dilated with acute anterior lens luxation. • Poodle, Shar pei, Whippet, Norwegian Elkhound, and terriers
• Cocker Spaniel, Bulldog, Pitbull Terrier, Beagle, Bloodhound, Lhasa Apso, Shih tzu, and Shar pei
Notes
Uveitis Corneal edema Dyscoria Blindness Synechia Glaucoma Retinal detachment Vitreous entrapment in the incision
CHAPTER 6 / GENERAL MEDICINE
6
291
UROLOGY Table 6.51 / Urology: Cystic Calculi, Feline Lower Urinary Tract Disease, and Pyelonephritis Feline Lower Urinary Tract Disease (FLUTD) (Feline Urologic Syndrome, FUS)
Pyelonephritis (Upper Urinary Tract Infection)
Definition
Any macroscopic concretions found within the urinary bladder are called cystic calculi. They can be found anywhere along the urinary tract, but most commonly seen in the urinary bladder.
FLUTD is inflammation of the lower urinary tract including the bladder and urethra. It is typically idiopathic. It can also occur secondary to bacterial infection, crystalluria, or iatrogenic (e.g., urinary catheterization).
Pyelonephritis is inflammation of the renal parenchyma, collecting diverticula, ureters, and its pelves. It is typically used to refer to a kidney infection and is most commonly secondary to bacterial invasion.
Clinical Signs
• Dysuria, hematuria, malodorous, stranguria, pollakiuria
• Anuria, dysuria, hematuria, licking at perineal area, periuria, pollakiuria, polyuria
• Anorexia, arched back, cachexia, depression, dysuria, hematuria, lethargy, malodorous or discolored urine, pollakiuria, PU/PD, stranguria, vomiting
Examination Findings
• Abdominal pain, dehydration
• Thickened, firm contracted bladder wall
• Abdominal and lumbar pain, dehydration, pyrexia, tachycardia
General
• History/clinical signs: recurrent bacterial UTIs • Bladder palpation (v)
• History/clinical signs • Abdominal palpation: bladder • Perineal examination
• History/clinical signs • Abdominal palpation: kidney
Laboratory
• Chemistry panel: ↑ potassium, BUN, creatinine and metabolic acidosis • Urinalysis: ↑ bacteria, crystals, change in pH (depending on type of crystal) • Urine culture: bacteria isolation and identification • Bile acids or ammonia concentration: ↑ with ammonium urate calculi and portosystemic shunts • Stone analysis and bacterial culture: needed for long term treatment
• Urinalysis: pyuria, ↑ blood, bacteria, crystals • Urine culture: bacteria isolation and identification
• CBC: neutrophilic leukocytosis with a left shift (v) and nonregenerative anemia • Chemistry panel: ↑ BUN, creatinine, phosphorus and azotemia • Urinalysis: pyuria, ↑ bacteria, blood, protein, leukocyte casts, crystals, ↓ specific gravity • Urine culture: bacteria isolation and identification • Cytology, renal pelvis: bacteria and neutrophils
Imaging
• Radiographs, abdominal: radiopaque calculi • Contrast: radiolucent calculi and vesicourachal diverticula • Ultrasound, abdominal: calculi
• Radiographs, abdominal: anatomic abnormalities, calculi, urethral plugs, tumors, or urachal diverticula • Contrast: urethral strictures, tumors, radiolucent uroliths, or vesicourachal diverticula • Ultrasound, abdominal: anatomic abnormalities, calculi, tumors, or urachal diverticula
• Radiographs, abdominal: ↓ size of kidneys and contours (v) • Ultrasound, abdominal: dilation of renal pelves and proximal ureter, kidney size, and nephrolithiasis
Procedures
• N/A
• N/A
• Pyelocentesis
Presentation
Cystic Calculi (Urocystoliths)
Diagnosis
6
Disease
292
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.51 / Urology: Cystic Calculi, Feline Lower Urinary Tract Disease, and Pyelonephritis (Continued) Cystic Calculi (Urocystoliths)
Feline Lower Urinary Tract Disease (FLUTD) (Feline Urologic Syndrome, FUS)
Pyelonephritis (Upper Urinary Tract Infection)
General
• • • •
Symptomatic Medical dissolution (struvite only) Urohydropulsion Surgery
• Symptomatic
• Symptomatic • Surgery: nephrotomy • Lithotripsy
Medication
• • • •
Allopurinol (ammonium urate) Antibiotics: variable MPG or D-penicillamine (cystine) Urine alkalinizer: potassium citrate
• • • •
• Antibiotics: variable
Follow-Up
Treatment
Disease
• • • • •
Analgesics: butorphanol, buprenorphine Antibiotics: variable Anticholinergics: propantheline Glycosaminoglycan: glucosamine, pentosan polysulfate sodium Methenamine mandelate Phenoxybenzamine Tranquilizers: diazepam Tricyclic antidepressant: amitriptyline Urine acidifier: DL-methionine, ammonium chloride
6
Nursing Care
• Access to clean litter box or frequent walks • Monitor for anuria.
• Access to clean litter box or frequent walks • Monitor for anuria. • Treated as outpatient
• Access to clean litter box or frequent walks • Treated as outpatient
Patient Care
• Monitor urine pH and specific gravity. • Strict diet restrictions depending on type of calculus • Monitor dissolution monthly by radiographs, urinalysis, urine culture, and ultrasonography. • Monitor radiographs every 3–4 months on patients with surgical removal for reoccurrence.
• Culture urine 1 week after beginning treatment. • ↑ Water consumption by feeding canned food mixed with water, adding potassium or sodium chloride to the food or subcutaneous fluids. • Monitor males for urethral obstruction.
• Culture urine 3–5 days and 1 month after beginning treatment. • Perform a urinalysis and urine culture 7 days and 28 days after completing treatment. • ↑ Water consumption by feeding canned food mixed with water, adding sodium chloride to the food or subcutaneous fluids
Prevention/ Avoidance
• Strict diet restrictions depending on type of calculi • Monitor urine pH.
• • • •
• Correct ectopic ureters. • Encourage water consumption.
Complications
• Reoccurrence • Urethral obstruction • Secondary bacterial UTI
• Urethral obstruction (feline, male) • Recurrence
• • • • •
Prognosis
• Excellent with treatment
• Excellent
• Fair to good: may have irreversible kidney damage
Acidifying or low magnesium diet Avoid stress. Encourage water consumption. Maintain a clean litter box.
Chronic renal failure Reoccurrence Nephrolithiasis Septicemia or septic shock Metastatic infection
CHAPTER 6 / GENERAL MEDICINE
293
Table 6.51 / Urology: Cystic Calculi, Feline Lower Urinary Tract Disease, and Pyelonephritis (Continued) Cystic Calculi (Urocystoliths)
Notes
• Calculi and urine pH • Struvite: alkaline urine • Ammonium urate and silica : neutral to acid urine • Cystine: acid urine • Calcium oxalate: any urine pH
Feline Lower Urinary Tract Disease (FLUTD) (Feline Urologic Syndrome, FUS)
Pyelonephritis (Upper Urinary Tract Infection)
Table 6.52 / Urology: Renal Failure Disease
Presentation
294
Renal Failure Acute (ARF)
Chronic (CRF)
Acute renal failure is the rapid decline in renal function. It is the accumulation of uremic toxins due to filtration failure, dysregulation of fluids, electrolytes, and acid-base balances. Unlike CRF, this condition may be reversible if diagnosed quickly and treated aggressively.
Chronic renal failure is the progressive decline in the function of the kidneys leading to their shutdown over months to years. The damage is irreversible. The causes may be familial, toxins, infections, neoplasia, or infectious disease.
Clinical Signs
• Anorexia, anuria, ataxia, bruising, diarrhea, dyspnea, lethargy, depression, oliguria, polyuria, seizures, tachypnea, vomiting
• Anorexia, blindness, coma, constipation, diarrhea, lethargy, nocturia, PU/PD, seizures, vomiting, dehydration weakness, and exercise intolerance
Examination Findings
• Bradycardia, cardiac abnormalities, dehydration, enlarged painful kidneys, halitosis, hypothermia, nonpalpable urinary bladder, oral ulcerations, pyrexia
• Ascites, dehydration, halitosis, oral ulcerations, small, firm nodular kidneys, subcutaneous edema
General
• History/clinical signs • Abdominal palpation: kidney
• History/clinical signs • Abdominal palpation: kidney
Laboratory
• CBC: leukocytosis with or without a left shift (v), lymphopenia, monocytosis, ↑ PCV and nonregenerative anemia (v) • Chemistry panel: ↑ BUN, creatinine, phosphate, glucose, potassium, alk phos, albumin, lipase, calcium (ARF), ↓ protein, calcium (ethylene glycol) and azotemia • Urinalysis: pyuria, bacteria, crystals, ↑ albumin, glucose, cellular and granular casts, ↓ specific gravity • Protein-to-creatinine ratio: >1 (3–5 severe) • Urine culture: bacteria isolation and identification • Blood gasses: metabolic acidosis • Serology: leptospirosis or ehrlichiosis • Eythlene glycol concentration: + results • Biopsy: confirmation, cause and severity of disease
• CBC: nonregenerative anemia • Chemistry panel: ↑ protein, BUN, creatinine, amylase, lipase, phosphate, ↓ potassium, ± calcium and metabolic acidosis • Urinalysis: ↑ protein (v), ↓ specific gravity • Protein:creatinine ratio: to determine severity of proteinuria and glomerular disease • Culture, urine: bacteria isolation and identification • Biopsy, renal: confirmation, cause and severity of disease
Definition
Diagnosis
6
Disease
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.52 / Urology: Renal Failure (Continued) Disease
Chronic (CRF)
Imaging
• Radiographs, abdominal: renal size and shape, renal uroliths, peritonitis • Contrast: obstruction or structural rupture • Ultrasound, abdominal: renal uroliths and parenchymal and anatomical abnormalities
• Radiographs, abdominal: renal size and shape and renal uroliths • Contrast: obstruction or structural rupture
Procedures
• Endoscopy: gastric ulcers • Blood pressure: hypertension
• Blood pressure: hypertension
General
• • • • • • • •
• • • • • • •
Diagnosis
Acute (ARF)
Symptomatic Supportive Fluid therapy, ± potassium Hemodialysis Peritoneal dialysis Blood transfusions Poison antidotes (e.g., ethylene glycol) Renal transplantation
Medication
• • • • • • • •
Nursing Care
• • • •
Patient Care
• Monitor blood values until normal. • Nutritional support • Renal diet: ↑ omega-3, omega-6, caloric density, fiber, ↓ highquality protein, phosphorus, sodium • Fresh water at all times to increase water consumption • Subcutaneous fluids for diuresis and hydration
Treatment Follow-Up
Renal Failure
Alkalinizer: sodium bicarbonate Anabolics: testosterone, nandrolone, oxymethalone, stanozolol Antibiotics: variable Antiemetics: trimethobenzamide or chlorpromazine Calcium gluconate Diuretics: 20% mannitol, 20% dextrose, furosemide H2-receptor antagonist: cimetidine or rantidine Phosphate binders: aluminum hydroxide, calcium carbonate, calcium acetate, epakitin • Potassium supplement: potassium chloride, potassium gluconate • Vasodilators: dopamine
Symptomatic Supportive Fluid therapy Hemodialysis Peritoneal dialysis Blood transfusions Renal transplantation
6
• • • • • •
ACE inhibitors: enalapril, benazepril, amlodipine Alkalinizer: sodium bicarbonate Androgens: stanozolol, nandrolone decanoate Erythropoietin: rHuEPO H2-receptor antagonist: cimetidine, famotidine, rantidine Phosphate binders: aluminum hydroxide, calcium carbonate, calcium acetate, epakitin • Potassium supplement: potassium chloride, potassium gluconate • Vitamin D: calcitriol
Nutritional support Monitor urine output, 1–3 mL/min initially. Monitor hydration, temperature, and body weight. Monitor PCV and blood values. • Nutritional support • Renal diet: ↑ omega-3, omega-6, caloric density, fiber, ↓ high quality protein, phosphorus, sodium • Fresh water at all times to increase water consumption • Subcutaneous fluids for diuresis and hydration • Monitor weekly initially, then monitor hydration; weight and blood values every 1–4 months depending on severity of CRF
CHAPTER 6 / GENERAL MEDICINE
295
Table 6.52 / Urology: Renal Failure (Continued)
Follow-Up
Disease
Renal Failure Acute (ARF)
Chronic (CRF)
Prevention/ Avoidance
• Anticipate ARF in susceptible animals and conduct preventative fluids and medication. • Avoid use of nephrotoxic drugs. • Restrict exposure to antifreeze. • Maintain adequate blood pressure during anesthesia, especially in prolonged procedures and older animals.
• Anticipate ARF in susceptible animals and conduct preventative fluids and medication. • Avoid use of nephrotoxic drugs. • Maintain adequate blood pressure during anesthesia. • Selective breeding
Complications
• Cardiac arrhythmias, congestive heart failure, pulmonary edema, uremic pneumonitis, or cardiopulmonary arrest • Gastrointestinal bleed • Hypovolemia, sepsis, and death • Seizures or coma
• • • • • • •
Prognosis
• Guarded to poor, but depends on severity and cause of disease
• Guarded to poor long term due to progression of disease
Urine Output • Anuria: ≤0.1 mL/kg/hr • Oliguria: ≤0.25 mL/kg/hr • Nonoliguria: ≥2 mL/kg/hr
• Approximately 75% of the kidney must be nonfunctional before an elevation in serum BUN and creatinine is seen.
6
Notes
Anemia Dehydration and constipation Gastroenteritis Hypertension Uremic stomatitis Urinary tract infection Weight loss
Table 6.53 / Urology: Urinary Tract Obstruction and Urinary Tract Infection Disease
Presentation
Definition
296
Urinary Tract Obstruction
Urinary Tract Infection (Cystitis, Urethrocystitis)
An obstruction restricting the flow of urine along the pathway from the kidneys to the external urethral orifice. The obstruction can be from blood clots, urethral plugs, uroliths, and sloughed tissue fragments.
Urinary tract infection is usually bacteria-induced inflammation of the lower urinary tract including the bladder and urethra. The cause is due to an ascending bacterial infection from the urethral orifice or hematogenous.
Clinical Signs
• Anorexia, crouching, depression, dysuria, hematuria, lethargy, pollakiuria, ↑ size and velocity of urine stream, stranguria, vomiting
• Dysuria, hematuria, malodorous, periuria, pollakiuria, stranguria, urinary incontinence
Examination Findings
• Abdominal pain, bradycardia, dehydration, distended urinary bladder, hypothermia, renomegaly
• Thickened, firm contracted bladder wall
SECTION THREE: DIAGNOSTIC SKILLS
Table 6.53 / Urology: Urinary Tract Obstructin and Urinary Tract Infection (Continued)
Follow-Up
Treatment
Diagnosis
Disease
Urinary Tract Obstruction
Urinary Tract Infection (Cystitis, Urethrocystitis)
General
• History/clinical signs • Abdominal palpation: kidneys and bladder
• History/clinical signs: recent catheterization or urinary tract surgery • Abdominal palpation: kidneys and bladder • Digital rectal examination: prostate in males
Laboratory
• • • •
Imaging
• Radiographs, abdominal: anatomic abnormalities, extended bladder, calculi, urethral plugs, tumors or urachal diverticula • Contrast: urethral strictures, tumors, radiolucent uroliths or vesicourachal diverticula • Ultrasound, abdominal: anatomic abnormalities, extended bladder, calculi, tumors, or urachal diverticula
• Radiographs, abdominal: anatomic abnormalities, calculi, tumors or urachal diverticula • Contrast: radiolucent calculi • Ultrasound, abdominal: anatomic abnormalities, calculi, tumors, or urachal diverticula
Procedures
• Cystoscopy • ECG: bradycardia, atrial standstill
• N/A
General
• • • •
• Symptomatic
Medication
• Antibiotics: variable • Calcium gluconate • Sodium bicarbonate
• Antibiotics: variable
Nursing Care
• Monitor bladder size and urine output.
• Treated as outpatient
Patient Care
• Monitor urine output and hydration status.
• Culture urine 1 week and 1 month after beginning treatment. • Allow frequent access to litter box or outdoors.
Prevention/ Avoidance
• Dependent on cause of obstruction
• Avoid glucocorticoid use or urethral catheterization.
Complications
• • • •
• Pyelonephritis • Cystic calculi • Recurrence
Prognosis
• Good with early detection and correction
CBC: ± stress leukogram Chemistry panel: ↑ phosphorus, potassium, ↓ calcium and azotemia Urinalysis: ↑ blood, protein, crystals Blood gases: metabolic acidosis
Fluid therapy Urohydropulsion Surgery: urethrotomy, urethrostomy Lithotripsy
Reobstruction UTI Urinary bladder rupture Urethral trauma during catheterization
• • • •
Chemistry panel: ↑ BUN, creatinine and azotemia Urinalysis: pyuria, ↑ blood, protein, bacteria, specific gravity Urine culture: bacteria isolation and identification Prostatic fluid analysis: bacteria and neutrophils
• Excellent
CHAPTER 6 / GENERAL MEDICINE
297
6
Table 6.53 / Urology: Urinary Tract Obstructin and Urinary Tract Infection (Continued) Disease
Urinary Tract Obstruction
Urinary Tract Infection (Cystitis, Urethrocystitis)
Notes
• Caution: Due to the patient’s compromised state, chose anesthetics carefully. • Fluid therapy should not be started until obstruction is relieved.
Significant Bacteria Count Canine Cystocentesis: ≥1000 Catheter: ≥10,000 Voided: ≥100,000 Expressed: ≥100,000
6
298
SECTION THREE: DIAGNOSTIC SKILLS
Feline ≥1000 ≥1000 ≥10,000 ≥10,000
Chapter
7
Emergency Medicine Emergency Medicine 301 Emergency Supplies 301 Telephone Assessment and Emergency Transportation Recommendations 304 Inducing Vomiting At-Home 305 Triage 306 Primary Survey 306 Hemostasis 307 Cardiopulmonary Cerebrovascular Resuscitation (CPCR) 308 Secondary Survey 309 Shock 310 Cardiac Emergencies 312 Environmental Emergencies 313
Gastrointestinal Emergencies 314 Hematologic Emergencies 315 Metabolic and Endocrine Emergencies 316 Neonatal Emergencies 317 Neonatal Resuscitation Post-Cesarean 317 Neurologic Emergencies 318 Ophthalmic Emergencies 319 Renal and Urinary Emergencies 320 Reproductive and Genital Emergencies 321 Respiratory Emergencies 322 Toxicologic Emergencies 323 Toxins 324 Trauma Emergencies 326
7
299
Key Words and Termsa Abducted Ambulation Anisocoria Ataxia Azotemia Cathartics Cyanosis Decerebellate posture Decerebrate resposne Dyschezia Dystocia Ecchymoses Edema Epistaxis Flail chest Hematemesis Hematochezia Hemoptysis Hyperemic Hyperesthesia Hyperreflexia Hyperthermia Hypertonia Icterus Incontinence Intraosseus Intussusception
7
a
Isoerythrolysis Lacrimation Lymphadenopathy Melena Mentation Micturition Mydriasis Nystagmus Oliguria Pallor Paradoxical respiration Paraphimosis Philtrum Pollakiuria Polydipsia Polyuria Ptyalism Pulse deficits Purulent Schiff-Sherrington’s posture Scleral injection Septicemia Strabismus Stranguria Triage
Key words and terms are defined in the glossary on page 631.
300
SECTION THREE: DIAGNOSTIC SKILLS
Abbreviations
Additional Resources, page
ACT, activated clotting time ACTH, adrenocorticotropic hormone ANA, antinuclear antibody ASPCA, American Society for the Prevention of Cruelty to Animals BP, blood pressure BUN, blood urea nitrogen Ca2+, Calcium cm H2O, centimeters of water CNS, central nervous system CPCR, cardiopulmonary cerebrovascular resuscitation CRT, capillary refill time CT, computed tomography CVP, central venous pressure DOCP, desoxycorticosterone acetate ECG, electrocardiogram ET, endotracheal tube Fr, French GDV, gastric dilatation volvulus GIT, gastrointestinal tract GV, governing vessel H2O2, hydrogen peroxide HR, heart rate IV, intravenous kg, kilogram mg, milligram mm Hg, milliliters of mercury MM, mucous membranes MRI, magnetic resonance imaging NPO, nothing by mouth NSAIDs, nonsteroidal anti-inflammatory drugs PCV, packed cell volume pH, potential of hydrogen RR, respiratory rate Tb, tablespoon TP, total protein URI, upper respiratory infection UTI, urinary tract infection
Abdominocentesis, 429 Blood culture, 122 Blood gas analysis, 335 Blood pressure, 332 Blood transfusions, 367 Bone marrow evaluation, 83 Cardiopulmonary, 30 Central venous pressure, 334 Cesarean section, 542 Chest drain, 431 Coagulation tests, 115 Coupage, 432 CPCR, 308 Diagnostic peritoneal lavage, 429 Disinfectants, 627 Electrocardiogram, 338 Endoscopy, 551 Enema, 430 Fecal analysis, 134 Fine needle biopsy, 89 Fluid therapy, 359 Fluorescein sodium stain, 430 Gastric lavage, 428 Heat administration, 346 Laboratory, 71 Nebulization, 432
Neurologic examination, 34 Nutritional support, 413 Orthopedic examination, 36 Otoscopic examination, 33 Oxygen therapy, 375 Pain management, 379 Patient monitoring, 332 Pericardiocentesis, 431 Pharmacology, 567 Physical examination, 18 Pulse oximetry, 463 Radiology, 157 Recumbent patient care, 347 Shirmer tear test, 430 Stomach tube, 428 Surgery, 521 Thoracocentesis, 431 Tonometry, 430 Tracheostomy, 377 Ultrasound, 197 Urinalysis, 147 Urinary catheter maintenance, 436 Urinary catheter placement, 435 Urine collection, 434 Ventilator, 474 Vital signs, 19
Emergency Medicine Emergencies typically happen at the most inconvenient times. A well-stocked clinic and a staff trained in handling emergencies will make your team more efficient and each emergency therefore less stressful. Each member of the clinic should have a specific job during emergencies. Understanding the basics of what constitutes an emergency as well as being able to perform stabilizing and monitoring techniques is essential to assisting the veterinarian. This chapter covers the basic supplies, support, and monitoring techniques
necessary to handle an emergency. It also gives a very general coverage of emergencies by body system. All diagnoses and treatment prescriptions can be done only by the veterinarian. These tables are to assist the technician in monitoring the patient. The technician then will be able to alert the veterinarian of abnormalities and to carry out the veterinarian’s treatment therapy where applicable. Please note that this chapter is not meant to be “all inclusive,” and we urge each clinic to have a thorough emergency resource library in the clinic.
Table 7.1 / Emergency Supplies
Before any emergency patient arrives at the hospital, a crash cart should be assembled and diligently maintained to be available to assist the veterinarian and staff. Each clinic will have preferences regarding supplies and should set up their supplies to suit their needs. The items listed are examples of what may be needed and are not meant to be all inclusive. The most important part of the selected emergency supplies is familiarity. Each staff member must know his or her location and understand their use and operation. This knowledge will lead to a smooth recovery attempt.
7
Crash Cart • The items contained in the crash cart are the first items utilized in an emergency. These items should be dedicated to emergencies and are not used for daily purposes. One person should be designated to maintain the crash cart on a regular basis and to alert staff to any changes. Supplies • Stethoscope • IV catheters of various sizes, caps, T-ports, and tape • Syringes and needles (regular, spinal, intraosseus) of various sizes • Blood collection tubes
• Fluid delivery system (IV fluid bags and IV administration tubing) • Clippers and surgical scrub • Masks and gloves • Minor surgical instrument pack (scalpel handle, thumb forceps, needle holders, and 3 hemostats of various sizes)
• Scalpel blades • Suture material of various types • Endotracheal tubes of various sizes, laryngoscope, local anesthetic, ties, cuff syringe, and mouth gags • Urinary catheters for intratracheal injection
Equipment • Defibrillator
• Electrocardiograph
Drugs • • • •
Drug dose chart Atropine Ca2+ chloride or gluconate Dexamethasone sodium phosphate
• • • •
Dextrose Diazepam (if lock box available) Epinephrine Lidocaine 2%
• IV fluids (LRS, dextran 70, hypertonic saline, hetastarch) • Sodium bicarbonate • ± Phenobarbital (if lock box available)
Basic Equipment • These items provide basic support to the patient. These supplies may not necessarily be in the crash cart due to size and multiple hospital uses, but their location is known and easily accessible.
CHAPTER 7 / EMERGENCY MEDICINE
301
Table 7.1 / Emergency Supplies (Continued) Supplies • • • •
Bandaging material Lubricating jelly Thermometer Heat support
• • • •
Blood pressure equipment Blood gas analyzer Pressurized fluid infusion cuff IV fluid warmer
• Oxygen delivery system (ambu bag, line to oxygen source, humidifier) • Pulse oximetry • Nebulizer
Specialized Equipment • These items are advanced equipment used in specific, critical situations. These items may not necessarily be in the crash cart due to size and multiple uses, but their location is known and easily accessible. • Respirator • Suction supplies (suction tubing, jar, pump)
• Tracheostomy pack • Thoracotomy pack
• Pericardiocentesis pack • Abdominocentesis pack
Drugs • This listing of drugs includes most of those used to treat critical patients. These drugs are typically kept in their regular location, the exception to the drugs listed in the crash cart. These drugs are used for treatment and not for immediate life-threatening situations.
7
Cardiac Drugs • Antiarrhythmics • Diltiazem, dexamethasone sodium phosphate, esmolol, lidocaine, procainamide, propranolol, verapamil • Diuretics • Furosemide • Inotropes • Digoxin, dobutamine, dopamine, isoprenaline, isoproterenol
• Vasodilators • Acepromazine, hydralazine, nitroglycerin ointment, nitroglycerin patch, captopril, diltiazem, sodium nitroprusside, amlodipine besylate, enalapril • Sedatives • Morphine, butorphanol, buprenorphine
• Other • Aspirin (antithrombotic therapy) • Ca2+ chloride (ventricular asystole) • Glycopyrrolate • Heparin (antithrombotic therapy) • Potassium chloride (chemical defibrillator)
• Bronchodilators • Cholinergic blockers, antihistamines, beta-2-adrenergic agonists (epinephrine, isoproterenol, albuterol), Methylxanthines (aminophylline)
• Stimulants • Doxapram hydrochloride, naloxone, yohimbine
• Antiulcer • H2-receptor antagonists (cimetidine, famotidine, ranitidine), antacids (magnesium hydroxide), gastromucosal protectants (sucralfate) • Misoprostol • Proton pump inhibitors (omeprazole) • Laxatives • Enemas, milk of magnesias, and glycerin
• Emetics • apomorphine, xylazine, ipecac syrup, hydrogen peroxide • Protectants/adsorbents • Bismuth subsalicylate, kaolin/pectin, activated charcoal
Respiratory Drugs • Antitussives • Butorphanol tartrate, hydrocodone bitartrate, codeine, dextromethorphan, Temaril-P Gastrointestinal Drugs • Antidiarrheals • Narcotic analgesics • Antiemetics • Chlorpromazine, prochlorperazine, anticholinergics, metoclopramide
302
SECTION THREE: DIAGNOSTIC SKILLS
Table 7.1 / Emergency Supplies (Continued) Neurologic Drugs • Antiseizuring • Diazepam, phenobarbital
• Muscle relaxant • Methocarbamol
• Rapid-acting corticosteroids • Methylprednisolone sodium succinate
• Topical anesthetics • Proparacaine hydrochloride, tetracaine
• Stains • Fluorescein strips
• Ca2+ channel blockers • Diltiazem, verapamil • Diuretics • Furosemide, mannitol 20%, glucose
• Urinary alkalizers • Potassium citrate, sodium bicarbonate (oral) • Vasodilators • Hydralazine, dopamine, dobutamine
• R-insulin
• Percorten (DOCP)
• Pralidoxime (against organophosphates) • Fomepizole/Antizol-Vet (against ethylene glycol—dogs only)
• Hemostatic agent • Vitamin K1 • Antihistamine • Diphenhydramine
Ophthalmic Drugs • Reduces Intraocular pressure (IOP) • Carbonic anhydrase inhibitors, timolol maleate, mannitol, glycerol Renal/Urinary Drugs • ACE inhibitors • Captopril, enalapril • Antidiuretics • Vasopressin
7
Reproductive Drugs/Hormones • Oxytocin Toxicologic Drugs—Antidotes • Antidotes • Acetylcysteine (against acetaminophen) • Dimercaprol (against arsenical compounds) • Ethanol (against ethylene glycol)
CHAPTER 7 / EMERGENCY MEDICINE
303
Table 7.2 / Telephone Assessment and Emergency Transportation Recommendations
When a client calls with an emergency situation, asking very specific questions and advising the owner on how to assess the situation, provide initial treatment, and move the animal are very important. Before beginning the assessment, inquire as to whether the owner and the animal are in a safe place. In any traumatic emergent situation, it is advisable to place a muzzle on the animal if no respiratory distress is noted and mucous membranes are pink. Recommendations listed below should be altered if the animal becomes aggressive or the procedure produces additional stress. Always ask the owner what is their expected arrival time. This will allow the staff to make any preparations necessary prior to their arrival. The goal of dealing with an emergency situation is to minimize stress of both the owner and the patient. Questions may need to be asked multiple times to maintain the attention of the upset and distracted owner. Regardless of the nature of the injury, if the owner perceives it as an emergency, it must be handled in that manner. On-Site Questions to the Client
Recommendations
What is the nature of the injury?
Have the owner give a quick assessment of the situation and the extent of the injuries. Based on this information, further questions can be asked.
Traumatic
7
• Hit by car, poisoning, seizures, drowning, fall, lacerations, fractures, and eye injuries • Is your animal awake or unconscious? • Does your animal respond to your commands?
• If the animal is unconscious, it needs to be rapidly assessed for breathing and circulation.
• Is your animal breathing? • Is your animal having trouble breathing?
• Animals in respiratory distress should have limited activity during transport and be allowed to maintain a position of comfort. • Animals not breathing should be given mouth-to-nose resuscitation and chest compressions during transport. Frequently, this will stimulate spontaneous breathing if initially caused by a vasovagal reflex. • See Skill Box 7.3 Cardiopulmonary Cerebrovascular Resuscitation (CPCR), page 308.
• What is the color of your animal’s mucous membranes?
• Compare the mucous membranes to your own—Are they more white, blue, or red? • If white or blue, assess for breathing and circulation. • Palpate the chest for a heartbeat or feel for a jugular pulse.
• Does your animal have external bleeding? • Is it pulsating?
• Apply direct pressure to the site of bleeding and elevate above the heart. • Leashes or ropes can be used as tourniquets placed proximal to the injury with arterial pulsating bleeding.
• Does your animal have a limb in an abnormal position? • Is he limping or not bearing any weight on the limb?
• Support fractures believed to be below the elbow or hock. • Secure the fractured limb with a roll of newspaper, magazine, board, or piece of cardboard with pieces of fabric or duct tape. • If this causes additional stress, gently transport the animal on thick fabric or a board (thin wood or cardboard).
Acute • GDV, poisoning, GIT obstruction, hives, vaccine reaction, respiratory complications • Is your animal having a seizure?
• If diabetic, administer Karo syrup orally. • Transport in a large towel for protection of the owner and animal; only loosely cover the animal during transport to avoid hyperthermia.
• Does your animal have a distended abdomen?
• Avoid pressure on the abdomen. • Do not allow the animal to eat or drink in transport. • If nonambulatory, transport on thick fabric or a board (thin wood or cardboard).
304
SECTION THREE: DIAGNOSTIC SKILLS
Table 7.2 / Telephone Assessment and Emergency Transportation Recommendations (Continued) • Has your animal eaten something poisonous? If so, when?
• Remove the animal from the toxin. • Bring any remaining substance and/or packaging, vomit, or feces. • If no other symptoms are present, call Poison Control Center and possibly induce vomiting (e.g., hydrogen peroxide). • See Skill Box 7.1, page 305 and Chapter 17 Pharmacology, page 593.
• Is your animal vomiting or have diarrhea?
• Bring in samples.
• Is your animal gagging/retching?
• Try to comfort the animal to decrease these symptoms.
• Is your animal choking?
• If possible, observe the inside of the mouth for an obstruction to be removed. • Administer a sharp blow with the palm of your hand between the shoulder blades. • Perform a modified Heimlich procedure—With the animal beside you and head forward, place arms around abdomen with fist just behind the ribs, compress the abdomen 3–5 times with quick inward-up pushes, check the mouth for the foreign body, and repeat 1–2 more times if necessary.
Chronic • UTI, kennel cough, URI
7
• What is your animal’s ability to urinate?
• Avoid pressure on the abdomen.
• Is your animal coughing?
• Once arriving at the clinic, leave your animal in the car while checking in.
• Is your animal in labor?
• Place the delivered neonates in a box with heat support (warm water bottles or heating pad wrapped in a towel). • Gently transport the female as she may be quite uncomfortable.
Skill Box 7.1 / Inducing Vomiting At-Home Inducing vomiting is a very common treatment for a foreign body or toxic ingestions. However, care must be taken before giving this advice or performing the procedure as it can be more dangerous to bring the item back up versus letting the animal digest or pass the item. For example, alkalis, acids, corrosive agents, petroleum products, or hydrocarbons should not be expelled, and animals with preexisting conditions such as epilepsy, cardiovascular disease, debilitated, or recent abdominal surgery or those with a potential for gastric torsion should avoid induced vomiting. One of the best resources for accurate information is the Poison Control Center (800-222-1222) or the ASPCA Poison Control Center (888-426-4435 with a possible consultation fee). Vomiting at-home is best performed using hydrogen peroxide (H2O2) within 2–3 hours postingestion with expectation of getting 40–60% of the stomach contents expelled. Three percent H2O2 produces mild gastric irritation leading to vomiting. Higher strengths or overdosing will lead to severe gastritis, especially in cats. If no vomiting occurs after the second
dose, the animal should be brought in for administration of apomorphine and/or other treatments. H2O2 Dose 1 mL (1 tsp) per lb. to a maximum dose of 45 mL (3 Tb) This dose may be repeated 1 time in 10 minutes. Tips for a Successful At-Home Procedure 1. Verify the H2O2 is a 3% strength. 2. Verify the H2O2 has not expired. 3. Feed a small meal, e.g., 1–2 pieces of bread. 4. Administer the H2O2. a. Mix with equal parts of milk or ice cream (1 Tb. H2O2 + 1 Tb. milk). b. Use a liquid medicine syringe, sports squirt bottle, or turkey baster. 5. Exercise the animal (e.g., playing fetch, quick walk). CHAPTER 7 / EMERGENCY MEDICINE
305
Triage When presented with an animal suffering a life-threatening problem, a successful outcome requires hospital readiness, effective teamwork, practiced triage skills, and a rapid response to primary survey abnormalities. “Triage” is the process of giving priority to those patients with the most critical problems. This begins with the assessment of the 3 major body systems: respiratory, cardiovascular, and neurologic. This quick primary survey will allow the best approach to treatment to be continued during the secondary survey. The primary survey is a brief physical examination. Many details are ascertained simultaneously to obtain the information quicker. Even though obvious injuries can be alarming, the patient must have a stable cardiovas-
cular and respiratory system before other injuries are addressed. Begin the assessment as you approach the animal, evaluating the presenting clinical signs. Next, address any arterial vessel injury. Respirations can then be appreciated with auscultation while also evaluating the heart. If no respirations are heard, oxygen supplementation via ET tube or tracheostomy should be done. The heart should have clear decisive sounds heard from either side and should be evaluated in conjunction with the peripheral pulse. The patient’s capillary refill time, mucous membrane color, and body temperature should also be evaluated. Any alterations should be addressed (e.g., CPCR, drug administration, debrillator, etc.) to stabilize the patient. The central nervous system should also be evaluated through pupillary response and position, reflexes, and presenting clinical signs.
Table 7.3 / Primary Survey
7
Presenting Clinical Signs
Physical Examination
Causes
Immediate Action
• No passage of air • Loud inspiratory or expiratory sounds • Altered breathing patterns • ↑ Respiratory effort, dyspnea • Change in mucous membrane color
• • • • • • • •
Respiratory distress Complete or partial obstruction Upper airway trauma or rupture Pneumothorax Hemothorax Pulmonary contusions Diaphragmatic hernia Flail chest
• Oxygen therapy • Intubate orally or by slash tracheostomy • Remove foreign object manually or by a modified-Heimlich maneuver • CPCR
• Change in mucous membrane color and moisture • Delayed capillary refill time • Pulse presence and intensity • Heart rate and rhythm • Hyper- or hypothermia • Cold extremities • Crackles in lung fields on auscultation
• • • • •
Arterial or venous injury Heart failure Thromboembolism Pleural effusion Pulmonary edema
• • • • •
Respiratory • • • • • •
Panting (feline) Paradoxical respiration Open mouth breathing Coughing ↑ or ↓ Respiratory rates Extended head or neck with abducted elbows • Nasal flare Cardiovascular • • • • •
External hemorrhage Panting Weakness, collapse Abdominal distention Cough, exacerbated with activity or exercise
306
SECTION THREE: DIAGNOSTIC SKILLS
Hemostasis Oxygen therapy CPCR Thoracocentesis/pericardiocentesis ECG monitoring
Table 7.3 / Primary Survey (Continued) Presenting Clinical Signs
Physical Examination
Causes
Immediate Action
• Pupillary response, size, and position • Eye position: strabismus, nystagmus • Motor reflexes • Pain response • Hyperthermia • Hypertonia • Hyperflexia
• • • • • •
• Oxygen therapy • Anticonvulsants
• Changes in conformation, limb angles • Pain response • Bleeding soft tissue wounds
• Trauma
Central Nervous System • • • •
Level of consciousness Head position Seizuring Ambulation • Severe front end rigidity and hindend weakness: Shiff-Sherrington Syndrome • Generalized weakness/paresis
Heat trauma Intoxication Spinal cord injury Seizures Infections; bacterial, parasitic Vestibular syndrome
Body Condition • • • • •
Lacerations Fractures/malalignments Eye injuries Abdominal distention Burns
• Oxygen therapy • Analgesics • Wound care: keep moist with a sterile water soluble lubricant and sterile dressing • Fractures: clip, examined, stabilize
Skill Box 7.2 / Hemostasis Controlling hemorrhage can be a first-line defense against shock, allowing the patient to maintain an adequate volume of blood. Initially, direct digital pressure can be placed to provide hemostasis. This can be direct pressure over the injury (or if an extremity or tail) by encircling the area proximal to the injury and applying pressure. Sterile dressings should always be used to avoid contamination of the wound. Pressure wraps can be placed for hemostasis. If the wrap becomes soaked, another wrap
should be placed on top of the first. Tourniquets should be avoided as they can cause tissue and nerve damage within minutes. With arterial hemorrhage, the artery should be clamped and ligated when possible. If that is not possible, direct pressure should be placed on a pressure point following one of the techniques below dependent on which artery is compromised.
Area of Hemorrhage
Pressure Point
Area of Hemorrhage
Pressure Point
• Maxillary artery
• Deep area adjacent and ventral to the mandible
• Inguinal artery
• Caudal abdomen
• Brachial artery
• Axillary area
• Distal extremity artery
• BP cuff placed proximal to the injury with a pressure of 200 mm Hg
• Femoral artery
• Inguinal and femoral canal region
CHAPTER 7 / EMERGENCY MEDICINE
307
7
Skill Box 7.3 / Cardiopulmonary Cerebrovascular Resuscitation (CPCR) CPCR should ideally be conducted on an adjustable height solid table. Depending on the size of the animal and staff, it may be necessary to provide a stool or perform the procedure on the floor. A surgical grated prep table should not be used for CPCR as it does not provide the counterpressure needed for chest and abdominal compressions. The steps below should be assigned to various team members so that the animal’s resuscitation is conducted as smoothly and thoroughly as possible.
7
A. Airway Alert the emergency team of upcoming arrival of patient. Assess the airway. • Extend the patient’s head and neck and pull tongue forward; remove any debris manually or with suction. • Establish a patent airway with endotracheal intubation or a slash tracheostomy. B. Breathing Assess breathing. • Confirm apnea. • Provide mechanical ventilation via an Ambu bag or anesthetic machine with 100% oxygen at a rate of 150 mL/kg/min. • Initiate with 2 breaths for 2 seconds each. • Reassess for spontaneous respiration. • If none, continue at 12–20 breaths/min (1 breath/3–5 seconds) and attempt acupuncture to stimulate respiration. (Place a 25-gauge needle into the midline just below the nose [philtrum] at acupuncture point governing vessel [GV] 26. Penetrate the skin and subcutaneous tissue from 2 to 4 mm. Rotate the needle up and down at this point to stimulate the site.) • Each breath should have an expiration slightly longer than inspiration and a manometer pressure reading of: • Canine pressure: ≤20 cm H2O • Feline pressure: ≤15 cm H2O C. Circulation Assess circulatory function. • Confirm absence of heart beat and peripheral pulses. • External cardiac compression • Provides ∼30% of normal cardiac output • Check for femoral or carotid artery pulse repeatedly throughout this process. • Animal weighing <7 kg: lay in right lateral recumbency and start compressions with 1 or 2 hands over the 3–5 intercostal space. • Animal weighing >7 kg: lay in right lateral or dorsal recumbency and start compressions with the palm of the hands over the distal 1/3 of the rib cage. • Use enough force to displace the thorax 30%. • Respirations are given with every or every other compression. • Abdominal compressions are given between chest compressions. • One person: 5 compressions, then 1 ventilation. • Two people: 1 compression, then 1 ventilation. • Three people: 1 compression, 1 ventilation, then 1 abdominal compression. • Internal cardiac compression • Provides 60–90% more effective cerebral and coronary perfusion • Preferred method with rib fractures, pleural effusion, pneumothorax, cardiac tamponade, diaphragmatic hernia, flail chest • Initiated after 5 minutes if effective tissue perfusion is not seen 308
SECTION THREE: DIAGNOSTIC SKILLS
Skill Box 7.3 / Cardiopulmonary Cerebrovascular Resuscitation (CPCR) (Continued) • Initiated after 10 minutes is spontaneous rhythm has not returned • Place in left lateral recumbency and a thoracotomy is performed at the 5th–6th intercostal space. • The palm and fingers are used to pump the heart in a rhythmic fashion. D. Drugs (atropine, epinephrine, lidocaine, naloxone, magnesium chloride) E. Evaluation of the patient with a thorough examination ECG F. Fibrillation Control Fluids
Table 7.4 / Secondary Survey
After the primary survey, the patient is classified as stable, potentially unstable, or unstable. Following this determination, resuscitation of vital functions and stabilization of life-threatening problems takes place. Once stable, a thorough past and current medical history, physical examination, and laboratory database are obtained. This is followed by reassessment of the original treatments. Secondary Survey
History and Procedures
Past Medical History
• • • • •
Medical conditions Drug therapies Allergies Vaccination history Previous transfusions
Current Medical History
• • • • • • • • • •
Presenting complaint When animal was last normal Chronology and progression of signs Potential toxin ingestion Physical trauma Signs of collapse, weakness or ↓ ability to exercise Signs of abnormal neurologic behavior Travel history Access to other animals Affinity to eat abnormal things
Physical Examination
• Vital signs • Evaluation of organ systems not involved • See Chapter 2 Physical Examination, page 18.
Stat Lab Database
• • • •
PCV, TP Chemistry panel and electrolytes Complete blood count Urinalysis
CHAPTER 7 / EMERGENCY MEDICINE
309
7
Table 7.5 / Shock
Shock is typically the result of poor oxygen delivery. The goal, regardless of form, is to optimize oxygen delivery. The most effective way to improve oxygen delivery is to ↑ cardiac output by optimizing preload with fluid administration. Cardiogenic Shock
Septic Shock
Definition
Diminished blood volume leading to tissue perfusion failure.
Tissue perfusion failure due to inadequate cardiac output
Circulatory disorder due to bacteria or bacterial endotoxin release
Cause
Hemorrhage, fluid loss (e.g., burns, vomiting, diarrhea, ↑ urine production), poor venous return (e.g., GDV), severe GIT bleed, severe epistaxis, addisonian crisis (e.g., hypotension)
Cardiomyopathy, cardiac tamponade, cardiac arrhythmias, heartworm disease, pulmonary hypertension, pulmonary thromboembolism, pericardial disease, heart failure, valvular disease with decompensation
GIT compromise/rupture, urinary tract infection (UTI), septic peritonitis, pneumonia, bacterial endocarditis, bite wounds, myelosuppression, prostatitis
Presenting Clinical Signs
• Muscle weakness, mental depression
• Muscle weakness or collapse, mental depression, cough, labored breathing
• Extreme weakness, mental depression
Primary Survey Findings
Compensatory stage: bounding pulses, cool extremities, pale or hyperemic mucous membranes, hypertension, delayed CRT, tachycardia, tachypnea Decompensatory stage: hypotension, hypothermia, ↓ mental status, oliguria, pale or muddy mucous membranes, delayed CRT, poor peripheral pulses, tachycardia or bradycardia
Abnormal heart sounds (e.g., gallop, murmur), arrhythymias, cardiac tamponade (tachycardia, weak pulses, hepatomegaly, jugular distention), cool extremities or hypothermia, dyspnea or tachypnea, harsh lung sounds or crackles, pale or cyanotic mucous membranes, prolonged CRT, variable HR and RR, weak femoral pulses and pulse deficits
Compensatory stage: bounding pulses, dyspnea or tachypnea, hyperemic mucous membranes, hypertension, mental depression, pyrexia, rapid CRT (<1 second), tachycardia, weakness Decompensatory stage: cool extremities, GIT bleeding (hematemesis, hematochezia), pale mucous membranes and delayed CRT, peripheral edema, petechiation, poor peripheral pulses, tachycardia or bradycardia, tachypnea
Equipment
• Crash cart • Basic emergency equipment • Specialized emergency equipment
• Crash cart • Basic emergency equipment • Specialized emergency equipment
• Crash cart • Basic emergency equipment • Specialized emergency equipment
Medication
• • • • •
• • • •
• • • • • •
Presentation
Hypovolemic Shock
Preparation
7
Emergent Condition
310
Blood plasma transfusions Positive inotropes Steroid therapy (short-acting) Vasopressor agents IV crystalloids/colloids
SECTION THREE: DIAGNOSTIC SKILLS
Antiarrhythmics Diuretics Positive inotropes Vasodilators
Antibiotics Blood/plasma transfusions Positive inotropes Sodium bicarbonate Steroids Vasopressor agents
Table 7.5 / Shock (Continued) Emergent Condition
Diagnostics / Treatments
Procedures
Patient Care
Monitoring
Hypovolemic Shock
Cardiogenic Shock
Septic Shock
• • • • • •
• • • •
• • • • • •
BP CVP ECG Endoscopy Hemostasis Imaging: • Thoracic radiographs • ± Abdominal radiographs • Ultrasonagraphy • Lab tests: • ACT • Blood gas analysis • Coagulation profile • Stat lab database • Oxygen therapy • Thoraco- or abdominocentesis
• General: general behavior, muscle strength, body temperature • Respiratory: RR and effort, lung sounds, tidal volume, respiratory pattern, SpO2 • Cardiovascular: HR and rhythm, BP, mucous membranes, CRT, ECG, CVP • Renal: urine output • Lab tests: PCV, TP, electrolytes, BUN, creatinine, liver enzymes, blood gas analysis, lactate
• • • •
BP CVP ECG Imaging: • Thoracic radiographs • Echocardiography Lab tests: • Blood gas analysis • Stat lab database Oxygen therapy Pericardiocentesis Pulse oximetry
•
• • • • General: general behavior, muscle strength, body temperature • Respiratory: RR and effort, lung sounds • Cardiovascular: HR and rhythm, BP, mucous membranes, CRT, ECG, CVP, SpO2 • Renal: urine output • Lab tests: PCV, TP, electrolytes, BUN, creatinine, liver enzymes, blood gas analysis
Abdominocentesis, arthrocentesis BP CVP ECG Endoscopy Imaging: • Thoracic radiographs • Echocardiography • Ultrasonagraphy Lab tests: • ACT • Blood cultures • Blood gas analysis • Coagulation profile • Stat lab database Oxygen therapy Surgery Wound care
7
• General: general behavior, muscle strength, body temperature • Respiratory: RR and effort, lung sounds • Cardiovascular: HR and rhythm, BP, mucous membranes, CRT, CVP, ECG, SpO2 • Renal: urine output • Lab tests: PCV, TP, electrolytes, BUN, creatinine, liver enzymes, blood gas analysis
CHAPTER 7 / EMERGENCY MEDICINE
311
Table 7.6 / Cardiovascular Emergencies
Diagnostics / Treatments Patient Care
7
Preparation
Presentation
Emergent Condition
312
• Atrial or ventricular septal defect, cardiac arrest, cardiac arrhythmias, cardiac tear, cardiomyopathy, caval syndrome, congestive heart failure, heartworm disease, hypertension, infective endocarditis, left- and/or right-sided heart failure, patent ductus arteriosus, pleural effusion, pulmonary edema, pulmonic or aortic stenosis, severe ascites, subvalvular aortic stenosis, tetrology of Fallot, thromboembolism, tricuspid dysplasia, valvular, tamponade, or pericardial disease
Presenting Clinical Signs
• Abdominal distention, anxiety, depression, exercise intolerance, head extended ± hemoptysis, lethargy, acute blindness, resistance to restraint/movement, sudden lameness, syncope, weakness/collapse, abdominal respiration, dyspnea ± cough or muffled sounds, open-mouth breathing, tachypnea
Primary Survey Findings
• Abdominal swelling, ascites, cold extremities, mydriasis, weakness, dull heart sounds, harsh lung sounds, delayed CRT, dysrhythmias, jugular vein distention, murmurs, pale or cyanotic mucous membranes, tachycardia with weak or bounding pulses, hepatomegaly, dehydration, hypotension, oliguria
Equipment
• Basic crash cart equipment • Specialized crash cart equipment • Radiography
Medication
• • • •
Procedures
• • • • •
Bilateral thoracocentesis or pericardiocentesis (with ECG monitoring) CVP Pulse oximetry ECG Lab tests: • Stat lab database • Arterial blood gas analysis • Blood culture (pericardial fluid) • Imaging: • Thoracic radiographs • Oxygen therapy and positive pressure ventilation
Monitoring
• General: Body temperature, body weight, pain management, minimal patient handling, calm and quiet environment, support in sternal position to elevate the head and neck to facilitate cerebral blood flow, heat support and warming of extremities • Respiratory: RR and effort, lungs sounds • Cardiovascular: HR and rhythm, pulse rate and quality, femoral pulses (feline), BP, mucous membranes, CRT, ECG, CVP, thoracic radiographs • Renal: Urine output, hydration • Lab tests: Electrolytes, BUN, creatinine, blood gas analysis
SECTION THREE: DIAGNOSTIC SKILLS
β-Blockers Diuretics Sodium influx inhibitors Positive inotropes
• Tranquilization • Vasodilators • Sympathomimetics
Table 7.7 / Environmental Emergencies
Patient Care
Diagnostics / Treatment
Preparation
Presentation
Emergent Condition
• Drowning, electrocution, frostbite, heatstroke, hypothermia
Presenting Clinical Signs
• Ataxia, burns, collapse, diarrhea, epistaxis, hematemesis, hematochezia, hemoptysis, hypersalivation, listlessness, loss of consciousness, muscle tremors, shivering, vomiting, dyspnea, moist cough, panting, seizures
Primary Survey Findings
• Hyper- or hypothermia, hypotension, localized swelling, oral sensitivity, petechiation, tissue necrosis, pulmonary edema, respiratory arrest, cardiac arrthythmias, pale or cyanotic mucous membranes, tachy- or bradycardia, weak or hyperdynamic pulses
Equipment
• Basic crash cart equipment • Radiography
Medication
• • • • • •
Procedures
• ECG • Imaging: • Thoracic radiographs • Lab tests: • Stat lab database • Coagulation profiles • Blood gas analysis • Intubation and positive end-expiratory pressure • Oxygen therapy • Temperature control
Monitoring
• • • • •
Antibiotics Anticonvulsants Bronchodilators Diuretics Gastric protectants Steroids
7
General: Pain management, nutritional support Respiratory: RR and effort Cardiovascular: HR and rhythm, BP, ECG Renal: Urine output Lab tests: Blood gas analysis
CHAPTER 7 / EMERGENCY MEDICINE
313
Table 7.8 / Gastrointestinal Emergencies
Preparation
Presentation
Emergent Condition
Presenting Clinical Signs
• Abdominal distention/pain, anxiety, diarrhea, dyschezia, hematochezia, hypersalivation, lethargy, melena, nonproductive retching, pawing at mouth, polydipsia, restlessness, vomiting (hematemesis)
Primary Survey Findings
• Cyanosis, distended abdominal veins, ecchymoses, halitosis, hyperthermia, periumbilical hemorrhage, petechiation, ↓ femoral pulses, weak or rapid pulse, ↓ CRT, dehydration
Equipment
• • • •
Basic crash cart equipment Endoscopy Radiography Ultrasonography
Medication
• • • • •
Analgesics Antacids Antibiotics Antidiarrheal Antiemetics
Procedures
• Abdominocentesis, ± diagnostic peritoneal lavage • CVP • Lab tests: • Stat lab database • ACT • Coagulation profile • Fecal analysis (direct, flotation, parvovirus test) • Urinalysis • Imaging: • Abdominal radiographs, ± contrast studies • Utrasonograph • Endoscopy (foreign body retrieval) • Laparotomy
Monitoring
• General: Pain management, NPO for hours to days with gradual introduction of a bland diet, turn recumbent patients every 2–4 hours, neck should be kept slightly elevated if concern of regurgitation or aspiration • Respiratory: RR and effort • Cardiovascular: HR and rhythm, pulse rate and strength, BP, mucous membranes, CRT, ECG, CVP • Gastrointestinal: Inappetence, defecation, vomiting • Renal: Urine output, hydration • Lab tests: PCV, TP, electrolytes, BUN, amylase, lipase, blood glucose, albumin, white blood cell count
Patient Care
Diagnostics / Treatment
7
314
• Acute gastritis, acute hepatic failure, acute intussusception, acute pancreatitis, bowel perforation, colitis, constipation, alimentary foreign bodies/obstructions, GDV, hemorrhagic gastroenteritis, parasitic infections, poisons, rectal prolapse, gastroduodenal ulcer disease
SECTION THREE: DIAGNOSTIC SKILLS
• • • • •
Dextrose Gastric protectants Motility modifiers Plasma therapy Sedation
Table 7.9 / Hematologic Emergencies
Patient Care
• Anemia, hemorrhage, immune-mediated thrombocytopenia, coagulopathies
Presenting Clinical Signs
• Anorexia, collapse, epistaxis, exercise intolerance, fleas/ticks, hematochezia, bruising, hematoma, hemoptysis, hemorrhage, lethargy, melena, muscle wasting, pica, syncope, weakness, weight loss, hematuria
Primary Survey Findings
• Ecchymoses, gingival bleeding, hypothermia, icterus, joint pain or swelling, lymphadenopathy, organomegaly, pallor, petechiation, dyspnea, murmurs, tachycardia, weak/thready or pounding pulses
Equipment
• • • •
Basic crash cart equipment Specialized crash cart equipment Radiography Utrasonograph
Medication
• • • • • • • • •
Anticoagulants Antiparasiticidals Blood products Chemotherapy agents Gastric protectants H2-blockers Proton pump inhibitors Steroids Vitamin K
Procedures
• BP • Bone marrow biopsy • Imaging: • Thoracic and abdominal radiographs • Ultrasonography • Lab tests: • Stat lab database • Reticulocyte count • Bone marrow evaluation • Coombs’ test • Coagulation profile • Fecal analysis • Bleeding time tests • ANA titer • von Willebrand test • Oxygen therapy
Monitoring
• • • •
Diagnostics / Treatment
Preparation
Presentation
Emergent Condition
7
General: Body temperature Respiratory: RR and effort, lung sounds Cardiovascular: HR and rhythm, BP, CVP, SpO2 Lab tests: PCV, TP, urinalysis, ACT
CHAPTER 7 / EMERGENCY MEDICINE
315
Table 7.10 / Metabolic and Endocrine Emergencies
Treatment
316
• Diabetes mellitus, diabetic ketoacidosis, hyper- or hypocalcemia, hyper- or hypokalemia, hyper- or hyponatremia, hypoadrenocorticism (Addison’s), hypoglycemia, hypoproteinemia, metabolic acidosis, metabolic alkalosis, thyrotoxicosis
Presenting Clinical Signs
• Anorexia, ataxia, coma, diarrhea, dry and flaky skin, hypersalivation, Kussmaul breathing, lethargy, muscle tremors, panting, plantigrade stance, polydipsia, polyphagia, polyuria, restlessness, seizures, vomiting, weakness, weight loss
Primary Survey Findings
• Blindness, epigastric pain, hyper- or hypothermic, ketotic breath, muscle wasting, severe depression, weight loss, dehydration, hypotension
Equipment
• Basic crash cart equipment • Blood glucose monitor • Electrolyte analyzer (e.g., VetTest, I-stat)
Medication
• • • • • •
Procedures
• Lab tests • Stat lab database • ACTH stimulation test • ECG
Monitoring
• • • • •
Patient Care
7
Preparation
Presentation
Emergent Condition
SECTION THREE: DIAGNOSTIC SKILLS
Antiemetic Anti-inflammatory Bone resorption inhibitors Dextrose Diuretics Fluid therapy (± sodium bicarbonate, dextrose, or electrolytes)
• Insulin therapy (insulin adheres to plastic, flush tubing with 30–50 mL of insulin before beginning treatment) • Mineralocorticoids (e.g., Florinef, Percorten-V) • Supplements • Ca2+ • Phosphorous • Potassium
General: Mental and neurological status, body temperature, body weight, pain management Respiratory: RR and effort, lung sounds Cardiovascular: Pulse, ECG Renal: Urine output Lab tests: PCV, TP, electrolytes, BUN, creatinine, blood glucose, Ca2+, phosphorous, blood gas analysis, urinalysis
Table 7.11 / Neonatal Emergencies
Patient Care
Treatment
Preparation
Presentation
Emergent Condition
• Conjunctivitis, dehydration, severe dermatitis, dysphagia, hypoglycemia, hypothermia, hypoxia, infectious diseases, intussusception, juvenile cellulitis, neonatal isoerythrolysis, heavy parasitic load, septicemia, umbilical infection
Presenting Clinical Signs
• Anorexia, bloating, crying, depression, diarrhea, edematous rectum, facial swelling, fever, lethargy, limp, poor muscle tone, relaxed, tremors, unthriftiness, vomiting, weight loss, seizures
Primary Survey Findings
• Coma, deep pyoderma, GIT paralysis, hypothermia, lymphadenopathy, pale, gray or cyanotic mucous membranes, palpable intussusception, poor bowel sounds, ↓ respirations, tachy- or bradycardia, dehydration
Equipment
• Basic crash cart equipment • Warming cage or unit
Medication
• • • • • •
Antibiotics Blood transfusion Dextrose Respiratory stimulants Steroids Vitamin K
7
Procedures
• Lab tests: • Stat lab database • Blood glucose • Fecal analysis (direct, flotation, parvovirus test) • Bacterial culture samples (whole blood, urine, feces, exudate) • Oxygen therapy
Monitoring
• General: Mentation, body temperature, body weight, heat support (gradual warming over 30–60 minutes), turn every hour, nutritional support • Respiratory: RR and effort, lung sounds • Cardiovascular: HR and rhythm, mucous membranes, CRT • Renal: urine output, hydration • Lab tests: PCV, TP, blood glucose
Skill Box 7.4 / Neonatal Resuscitation Post-Cesarean There are many methods that can be used to stimulate a neonate to begin spontaneous respirations. A delivered neonate should be immediately placed in a dry towel with an assistant. The neonate is dried off by rubbing vigorously with the towel to lessen the chances of hypothermia and to stimulate respirations. The neonate should be examined for any obstructive secretions or fluid obstructing the airway. If spontaneous respirations do not begin, the assistant may employ 1 or more of the following techniques: • While supporting the head and neck to avoid whiplash or concussive injury, swing the neonate in a large downward arc to clear fluid in the chest via centrifugal forces and gravity.
• Place 1–2 drops of doxapram hydrochloride sublingually. • Use the acupuncture point governing vessel (GV) 26. Hold the neonate with its head elevated above its heart and its neck extended, and place a 25-gauge needle into the midline just below the nose (philtrum). Penetrate the skin and subcutaneous tissue 2–4 mm, and stimulate the site by rotating the needle up and down. • Provide artificial respiration by placing a 20-gauge catheter endotracheally or by blowing gently into the nose and mouth (normal, 15–40 breaths/ min).
CHAPTER 7 / EMERGENCY MEDICINE
317
Table 7.12 / Neurologic Emergencies
Preparation
Presentation
Emergent Condition Presenting Clinical Signs
• Aggression, agitation, ataxia, blindness, circling, coma, depression, disorientation, epistaxis, head tilt, head tremors, leaning, loss of balance/coordination, loss of motor ability, mastication, nystagmus, paralysis, paresis, salivation, stupor, vomiting, hyperventilation, seizures
Primary Survey Findings
• ↓ Facial sensation, anisocoria, anorexia, ataxia, Horner’s syndrome, hyperreflexia, hyperthermia, hypertonia, otitis media/ interna, pain, paresis, reflex deficiencies, Cheyne-Stokes respiration, decerebellate rigidity, decerebrate rigidity, SchiffSherrington’s posture
Equipment
• Basic crash cart equipment
Medication
• • • •
Procedures
• BP • Lab tests: • Stat lab database • Blood gas analysis • Lead levels • Serology for infectious diseases • Ear cytology • Myelography, spinal tap, MRI • Otoscopic examination • Oxygen therapy
Monitoring
• General: Mentation, body temperature, pain management, elevate the front end 20–30° to ↑ cerebral venous drainage and avoid pressure on the neck • Respiratory: RR and effort, respiratory pattern, SpO2 • Cardiovascular: HR and rhythm, pulse rate and quality, BP • Neurologic: Pupil size and response, motor activity, deep pain assessment, posture, vision • Lab tests: PCV, TP, blood glucose, blood gas analysis
Patient Care
Treatment
7
318
• Bacterial infections, cancer/tumors, comas, head injuries, metabolic imbalances with secondary CNS changes, parasitic infestations, seizures, spinal cord injuries, toxins, vestibular syndrome
SECTION THREE: DIAGNOSTIC SKILLS
Anticonvulsants Antibiotics Diuretics Steroids
Table 7.13 / Ophthalmic Emergencies • Bite wounds/scratches, chemical burns, corneal laceration/abrasion/perforation/ulcer, descemetocele, severe ectropion, enophthalmos, severe entropion, foreign bodies, glaucoma, hyphema, keratoconjunctivitis sicca, lens luxation, orbital cellulitis, panophthalmitis, proptosed globe, retrobulbar mass, symblepharon, uveitis • Blindness, corneal color change, discharge, pain, pawing or rubbing the eye, photophobia, running into objects, squinting
Primary Survey Findings
• ↑ or ↓ intraocular pressure, absent papillary light reflex, aqueous flare, blepharospasm, bulb protusion, corneal edema, dilated pupil, inability to blink, inability to retract eye, lacrimation, loss of visual acuity, miotic pupil, negative menace response
Equipment
• • • • •
Black light Fluorescein strips Ophthalmoscope Schirmer tear test strips Tonometer
Medication
• • • • • • •
Antiglaucomas Diuretics Miotics Mydriatics Steroids Topical anesthetics Topical antibiotics
Diagnostics / Treatment
Presenting Clinical Signs
Procedures
• Imaging: • Skull radiographs • CT Scan • Lab tests: • Stat lab database • Ophthalmic examination: • Tonometer • Schirmer tear test • Fluorescein stain • Surgery
Patient Care
Preparation
Presentation
Emergent Condition
Monitoring
• General: Elizabethan collar, pain management • Ophthalmic: discharge, worsening of previous clinical signs
7
CHAPTER 7 / EMERGENCY MEDICINE
319
Table 7.14 / Renal and Urinary Emergencies
Preparation
Presentation
Emergent Condition Presenting Clinical Signs
• Anorexia, ataxia, crying, depression, dysuria, lethargy, vomiting, pollakiuria, polydipsia, polyuria, stranguria, seizures
Primary Survey Findings
• Distended and/or painful abdomen, halitosis, hyper- or hypothermia, oral ulcerations, scleral injection, tachypnea, bradycardia, pale mucous membranes, anuria, dehydration, distended bladder, hematuria, large painful firm kidneys, polydipsia, polyuria
Equipment
• • • • •
Basic crash cart equipment Radiology Ultrasonography Urinary catheters; variety of types (rigid, Foley, feeding tubes) and sizes (3.5–14 Fr) Closed urinary collection system
Medication
• • • • • •
Antibiotics Antiemetics Diuretics Metabolic disorder drugs (e.g., Ca2+, dextrose, insulin) Gastric protectants Sodium bicarbonate
Procedures
• • • • •
Monitoring
• • • • •
Patient Care
Treatment
7
320
• Acute or chronic late-stage renal failure, azotemia, bacterial infection, bladder/ureter/urethra ruptures, feline lower urinary tract disease, pyelonephritis, severe cystitis, toxins, urinary obstructions, uroliths
SECTION THREE: DIAGNOSTIC SKILLS
BP CVP Cystocentesis ECG Imaging: • Abdominal radiographs • Ultrasonography • Lab tests: • Stat lab database • Urine culture • Ethylene glycol testing • Leptospirosis titers • Surgery • Urethral catheterization, normograde, retrograde, hydropropulsion General: Elizabethan collar, body weight, pain management, nutritional support Respiratory: RR and effort, lung sounds Cardiovascular: HR and rhythm Renal: Urine output, hydration, pH, specific gravity Lab tests: PCV, TP, electrolytes, BUN, creatinine, Ca2+, phosphorus, blood glucose, blood gas analysis
Table 7.15 / Reproductive and Genital Emergencies
Patient Care
• Male: Acute prostatitis, acute scrotal dermatitis, fractures of the os penis, infectious orchitis, laceration of the penis, paraphimosis, scrotal neoplasia, testicular torsion, • Female: Acute metritis, dystocia, eclampsia, pyometra, septic mastitis, uterine prolapse/torsion/rupture, vaginal prolapse/neoplasia
Presenting Clinical Signs
• Male: Depression, difficulty urinating/defecating, licking genital area, pain, purulent or bloody discharge from the urethra, vomiting, walking difficulties • Female: Depression, pain, panting, restlessness, salivation, vomiting, walking difficulties, licking genital area, unproductive labor/delivery, vaginal discharge
Primary Survey Findings
• Male: Abdominal pain, extended penis, inappetence, unilateral swelling of testicles • Female: Active straining for >60 minutes without delivery of a fetus, anorexia, fever, foul-smelling or purulent vulvar discharge, hot/swollen/painful mammary glands, muscle weakness, time delay between pups/kittens >4–5 hours
Equipment
• • • •
Basic crash cart equipment Specialized crash cart equipment Radiology Ultrasonography
Medication
• • • • •
Antibiotics Analgesics Ecbolic agents Metabolic imbalances (e.g., Ca2+, potassium, insulin, dextrose) NSAIDs
Procedures
• Imaging: • Abdominal radiographs • Ultrasonography • Lab tests: • Stat lab database • Vaginal cytology • Blood gas analysis • Manual manipulation, hyperosmotic topical therapy to shrink tissues • Surgery
Monitoring
• • • •
Treatment
Preparation
Presentation
Emergent Condition
7
General: Mentation, body temperature, Elizabethan collar, pain management Cardiovascular: HR and rhythm Renal: Urine output Lab tests: PCV, TP, electrolytes, BUN, creatinine, liver enzymes
CHAPTER 7 / EMERGENCY MEDICINE
321
Table 7.16 / Respiratory Emergencies • Aspiration pneumonia, brachycephalic occlusive syndrome, bronchitis, cancer, collapsing trachea, diaphragmatic hernia, feline asthma, flail chest, tracheal and bronchial foreign bodies, hemothorax, laryngeal paralysis, lung contusions, lung parenchymal issues, pleural effusion, pneumomediastinum, pneumonia, pneumothorax, pulmonary edema, smoke inhalation, soft tissue swellings, tracheal stenosis
Presenting Clinical Signs
• Abduction of elbows, cough, flared nostrils, head straightened, hemoptysis, lips drawn back, neck extended, preference to stand or lie in sternal recumbency, reluctance to hold mouth closed, subcutaneous emphysema, wheezing, apnea, dyspnea, open mouth breathing
Primary Survey Findings
• Hyperthermia, ↑ respiratory rate and effort, abnormal respiratory sounds (e.g., laryngeal stridor), irregular respiratory pattern, change in mucous membranes color, tachycardia
Equipment
• Basic crash cart equipment • Specialized crash cart equipment
Medication
• • • • • •
Antibiotics Bronchodilators Cough suppressants Diuretics Steroids Tranquilizers
Procedures
• • • •
Airway suctioning Bronchioalveolar lavage Chest tube placement Imaging: • Thoracic radiographs • Tracheoscopy, bronchoscopy for foreign body retrieval Lab tests: • Stat lab database • Blood gas analysis • Heartworm tests • Fecal analysis • Fluid analysis Oxygen and/or ventilator therapy Surgery Thoracocentesis Tracheostomy, nasal catheter, transtracheal catheter Transtracheal wash
Treatment
•
• • • • • Patient Care
7
Preparation
Presentation
Emergent Condition
322
Monitoring
SECTION THREE: DIAGNOSTIC SKILLS
• General: Pain management, minimal patient handling, calm and quiet environment, turn recumbent patients every 2–4 hours, use harnesses instead of collars • Respiratory: RR and effort, lung sounds, nebulization/coupage • Cardiovascular: HR and rhythm, pulse quality and rate, BP, mucous membranes, SpO2 • Renal: Urine output • Lab tests: Blood gas analysis
Table 7.17 / Toxicologic Emergencies
Patient Care
• Bacterial/fungal toxins, food ingredient (e.g., grapes, onions), household compounds/chemicals, household plants, insecticides, herbicides, medication ingestions/overdoses, pesticides, rodenticides, zinc ingestion
Presenting Clinical Signs
• Ataxia, coma, diarrhea, hyperexcitability, hypersalivation, muscle tremors, progressive depression, stupor, vomiting, weakness, dyspnea, seizures, anuria
Primary Survey Findings
• Abdominal pain, facial edema, hyperthermia, mouth odor, cardiac arrhythmias, cyanosis, pallor mucous membranes, urinary incontinence, vomiting
Equipment
• Basic crash cart equipment • Specialized crash cart equipment
Medication
• • • • • • •
Procedures
• • • • • •
Monitoring
• • • • • •
Treatment
Preparation
Presentation
Emergent Condition
Anticonvulsants Antidote (if available and specific toxin identified) Antiemetics Diuretics Emetics Gastrointestinal protectants Muscle relaxants
7
Bathing, rinsing ECG Enemas Emesis Gastric lavage and charcoal administration Imaging: • Radiographs • Lab tests: • Stat lab database • Ethylene glycol testing • Coagulation testing General: Mentation, body temperature Respiratory: RR and effort Cardiovascular: HR and rhythm, pulse rate and quality, CVP Neurologic: Tremors, seizures Renal: Urine output Lab tests: Electrolytes, BUN, creatinine, urinalysis
CHAPTER 7 / EMERGENCY MEDICINE
323
Table 7.18 / Toxins
The goals with poisoning are always the same—prevent further exposure, ↓ absorption, hasten elimination, and provide supportive care. The prognosis for each situation depends on the toxin, quantity, and time delay from initial exposure to toxin.
7
Toxin
Toxic Doses
Clinical Signs
Treatment
Acetaminophen
Canine: 150 mg/kg Feline: 50–60 mg/kg Onset: hours to days
• Brown mucous membranes and blood, depression, facial or paw edema, hepatic necrosis, hypothermia, icterus, vomiting, weakness, cyanosis, dyspnea, tachypnea, keratoconjunctivitis sicca (canine)
• Emesis, gastric lavage, cathartics, oxygen therapy, blood transfusions, diuresis, cimetidine, ascorbic acid • Antidote: 5% N-acetylcysteine (NAC) solution
Amphetamines
1.3 mg/kg Onset: variable
• Agitation, circulatory collapse, coma, hyper- or hypotension, hyperactivity, hypertension, hyperthermia, mydriasis, pallor or hyperemic mucous membranes, ptyalism, restlessness, tremors, tachypnea, cardiac arrhythmias, tachycardia, seizures
• Emesis, gastric lavage, activated charcoal, cathartics, oxygen therapy • Antidote: chlorpromazine
Ethylene glycol
Canine: 4–6 mL/kg Feline: 1.5 mL/kg Onset: 30 minutes–12 hours
• Ataxia, coma, depression, knuckling, lethargy, nystagmus, vomiting, tachypnea, tachycardia, polydipsia, polyuria, seizures
• Blacklight detection, emesis, gastric lavage, supportive care • Antidote: 20% ethanol (feline), 4-methylpyrazole (canine)
Ibuprofen
Canine: 100 mg/kg Feline: 50 mg/kg Onset: 1–4 hours
• Abdominal pain, anorexia, coma, depression, diarrhea, hematemesis, melena, polyuria, stupor, vomiting, seizures
Emesis, gastric lavage, activated charcoal, GIT protectants, diuresis
Metaldehydes • Snail and slug bait
100 mg/kg Onset: 1–4 hours
• Anxiety, ataxia, hyperesthesia, hypersalivation, hyperthermia, incoordination, nystagmus, pulse irregularities, tremors, bradypnea, tachy- or bradycardia, seizures
• Milk, emesis, gastric lavage, activated charcoal • Antidote: none
Organophosphates • Sprays, dusts, dips
Variable Onset: variable
• Colic, diarrhea, hypersalivation, lacrimation, miosis, tremors, vomiting, bronchoconstriction, excessive bronchial secretions, bradycardia, seizures, frequent urination
• Bathing, activated charcoal, cathartics, anticholinergics • Antidote: pralidoxime chloride
Pyrethrins/pyrethroids • Sprays, dips, foggers
Variable Onset: variable
• Anorexia, ataxia, depression, diarrhea, disorientation, hyperactivity, hyperexcitability, hypersalivation, muscle twitching, tremors, vocalization, vomiting, bradycardia, dyspnea, seizures
• Bathing, emesis, gastric lavage, activated charcoal, cathartics, anticholinergics
• Permethrin
Onset: 3–72 hours
• Tremors, seizures
• Bathing (liquid hand soap), methocarbamol, barbiturates, and/or propofol
Insecticides
324
SECTION THREE: DIAGNOSTIC SKILLS
Table 7.18 / Toxins (Continued) Toxin
Toxic Doses
Clinical Signs
Treatment
Lily
Onset: 2 hours
• Anorexia, depression, vomiting, polyuria
• Emesis, activated charcoal, cathartics
Mushrooms
Variable Onset: 6–8 hours
• Abdominal pain, ataxia, coma, defecation, depression, diarrhea, DIC, hallucinations, hyperthermia, lacrimation, nausea, salivation, vomiting, seizures, urination
• Emesis, gastric lavage, activated charcoal, cathartics, bowel irrigation, oxygen therapy, supportive care
Pseudoephedrines
5–6 mg/kg Onset: 15–30 minutes
• Agitation, head bobbing, hyperactivity, hypertension, hyperthermia, mydriasis, panting, tremors, cardiac arrhythmias, tachycardia, seizures
• Emesis, gastric lavage, activated charcoal, GIT protectants, diuresis
Anticoagulant • Warfarin, pindone, bromadiolone, brodifacoum, chlorphacinone, difethialone, diphacinone, coumafuryl, dicoumarol, difenamrol
Variable Onset: 6 hours–2 days
• Anorexia, blindness, depression, ecchymoses, epistaxis, exercise intolerance, frank and petechial hemorrhage, hematemesis, hematochezia, lameness, lethargy, melena, pale mucous membranes, paralysis swollen joints, weakness, cough, dyspnea, hematuria
• Emesis, activated charcoal, cathartics, blood transfusions, oxygen therapy • Vitamin K therapy
Bromethalin
Canine: 4.7 mg/kg Feline: 1.8 mg/kg Onset: immediate–2 weeks
• Anisocoria, CNS depression, excitement, forelimb extensor rigidity, head pressing, hyperesthesia, hyperexcitability, hyperthermia, loss of vocalization, paralysis, paresis, Schiff-Sherrington posture, tremors, weakness, seizures
• Emesis, gastric lavage, activated charcoal, cathartics, bowel irrigation, supportive care, diuretics, steroids, Ginkgo biloba • Antidote: none
Cholecalciferol • Vitamin D3
0.1 mg/kg Onset: 12–36 hours
• Anorexia, constipation, depression, hematemesis, hypertension, lethargy, muscle weakness, petechiation, vomiting, ventricular fibrillation, polydipsia, polyuria, seizures
• Emesis, gastric lavage, activated charcoal, cathartics, diuretics, steroids • Antidote: calcitonin, pamidronate
Snakebite envenomation
Variable Onset: immediate
• Dilated pupils, edema, fang marks, hemorrhages, pain, salivation, swelling, tachycardia
• Supportive care • Antidote: antivenin, trivalent crotalidae, atropine
Spider bite envenomation
Variable Onset: immediate-weeks
• Abdominal rigidity, hypersalivation, hypertension, muscle spasms and rigidity, pain, restlessness, salivation, respiratory distress, bronchorrhea
• Supportive care • Antidote: antivenin, dantrolene sodium, Dapsone
Theobromine • Chocolate
10–15 mg/kg Milk chocolate: 44 mg/oz theobromine Baking chocolate: 390 mg/ oz theobromine Onset: 2–4 hours
• Abdominal pain, agitation, ataxia, bloating, coma, cyanosis, diarrhea, hyper- or hypotension, muscle tremors, vomiting, cardiac arrhythmias, tachycardia, seizures, hematuria, polydipsia, polyuria, urinary incontinence
• Emesis, gastric lavage, activated charcoal, cathartics, supportive care, ECG, urinary catheter • Anticonvulsants and antiarrhythmics
Plants
Rodenticides
CHAPTER 7 / EMERGENCY MEDICINE
7
325
Table 7.19 / Trauma Emergencies
Preparation
Presentation
Emergent Condition Presenting Clinical Signs
• Depression, fractures, lacerations, limping, loss of consciousness, pain, panting, shivering, shock, seizures
Primary Survey Findings
• Burns, hemoptysis, hemorrhage, hyper- or hypothermia, necrosis of lips/tongue, pain, petechiation, dyspnea, irregular lung sounds, patterns and rates, maligned or deformed limbs, pneumomediastinum, pneumothorax, pulmonary edema, subcutaneous emphysema, thoracic or abdominal effusion, tachy- or bradycardia
Equipment
• Basic crash cart equipment • Specialized crash cart equipment
Medication
• • • •
Procedures
• • • • •
Monitoring
• • • • •
Patient Care
Treatment
7
326
• Animal attack, burns, fractures, hit by car, lacerations
SECTION THREE: DIAGNOSTIC SKILLS
Analgesics Antibiotics Blood transfusions Corticosteroids
Abdominal tap/abdominal pressure wrap Bandaging, splinting, and basic wound care ECG Heat support Imaging: • Thoracic and abdominal radiographs • Spinal and skull radiographs • Ultrasonography • Lab tests: • Stat lab database • Blood gas analysis • Oxygen therapy • Surgery General: Mentation, body temperature, pain management, immobilize as needed Respiratory: RR and effort, lung sounds Cardiovascular: HR and rhythm, pulse rate and quality, BP, ECG, CVP, SpO2 Renal: Micturition reflex, urine output Lab tests: PCV, TP, electrolytes, BUN, blood glucose, blood gas analysis, platelet count
Section
Four
Patient Care Skills Chapter 8: Patient Care 329 Chapter 9: Pain Management 379 Chapter 10: Wound Care 395
Chapter 11: Parenteral Nutrition 413 Chapter 12: Medical Procedures 427
Chapter
8
Patient Care Patient Monitoring 332 Blood Pressure 332 Blood Pressure Procedure 332 Blood Pressure Results 333 Central Venous Pressure 334 Blood Gas Analysis 335 Blood Gas Analysis 335 Arterial Blood Gas Interpretation 337 Acid-Base Disturbances 337 Electrocardiogram 338 ECG Procedure 338 ECG Leads 339 ECG Interpretation 340 Figure 8.1 Normal Canine Electrocardiogram 341 Heart Rate Calculation 342 Common Rhythm Abnormalities 343 Figure 8.2 Atrial Premature Contraction/Complex 344 Figure 8.3 ST-Segment Elevation 344 Figure 8.4 Ventricular Premature Contraction/ Complex 344
ECG Problems and Artifacts 345 Heat Administration 346 Recumbent Patient Care 347 Drug Administration 348 Injections 348 Intravenous Catheter Placement 349 Peripheral and Jugular 349 Arterial and Intraosseous 350 Monitoring and Maintenance 351 Chemotherapy 352 Administration 352 Toxicity 353 Client Education: Monitoring Chemotherapy Response 356 Insulin Therapy 357 Client Education: Insulin Administration 357 Client Education: Monitoring Insulin Response 358 Client Education: Monitoring for Hypoglycemia 359 Fluid Therapy 359 Hydration Assessment 360
8
329
Calculating Fluid Requirements 361 Routes of Fluid Administration 362 Commonly Used Fluids 363 Fluid Additives 365 Calculating Drip Rates 365 Monitoring Fluid Therapy 366 Blood Transfusions 367 Blood Types 368 Blood Collection 369
8
330
SECTION FOUR: PATIENT CARE SKILLS
Blood Products 371 Blood Administration 373 Blood Transfusion Reactions 374 Oxygen Therapy 375 Oxygen Administration 375 Routes of Oxygen Administration 376 Oxygen Hood and Nasal Catheter 376 Transtracheal Catheter and Tracheostomy
377
Key Words and Phrasesa Acidotic Alkalosis Alloantibody Amplitude Antiemetics Antipyretics Apex Ataxia Bipolar Cachexia Carbohydrate Chemo-pin Crystalloids Cyanosis Decubital Diastolic Electromechanical dissociation Epistaxis Erythema Extracellular Extravasation F wave Fructosamine Glycosylated Hemolyzed Holter apparatus Humidification Hypercalcemia Hyperglycemia Hyperkalemia Hypernatremia Hyperoncotic Hypochloremia Hypoglycemia Hyponatremia Hyporeflexia Immunogenic Infarction a
Intracellular Ischemia Isoantibody Manometer Metabolic acidosis Metabolic alkalosis Microaggregates Myelosuppressive Myocardium Nadir Neuropathy Neutropenia Normovolemic Oscillometric Osmotic Osteopenia Papilledema Perfusion Perioperative Petechiae Pollakiuria Polydipsia Polyuria Precordial Prophylaxis Pruritis Repolarization Respiratory acidosis Respiratory alkalosis Serous Stranguria Supraventricular Systolic Tetany Thrombocytopenia Turgor Unipolar Urticaria Vagal
Abbreviations APC, atrial premature contraction/complex APTT, activated partial thromboplastin time aVF, augmented voltage foot aVL, augmented voltage left arm aVR, augmented voltage right arm BG, blood glucose BGC, blood glucose curve bpm, beats per minutes BW, body weight C, Celsius CBC, complete blood count CHF, chronic heart failure CO2, carbon dioxide CPCR, cardiopulmonary cerebrovascular resuscitation CPD, citrate phosphate dextrose CPDA-1, citrate phosphate dextrose adenine CRT, capillary refill time CVP, central venous pressure D5W, 5% dextrose in water DEA, dog erythrocyte antigen DIC, disseminated intravascular coagulation DMSO, dimethylsulfoxide ECG, electrocardiogram E-collar, Elizabethan collar ET, endotracheal tube FeLV, feline leukemia virus FFP, fresh frozen plasma FIV, feline immunodeficiency virus FP, frozen plasma Fr, French FUO, fever of unknown origin GFR, glomerular filtration rate H2O, water IM, intramuscular IO, intraosseous IV, intravenous
Additional Resources, page KCl, potassium chloride kg, kilogram L, liter LA, left arm lb, pound LL, left leg LRS, lactated Ringer’s solution mg, milligram dL, deciliter min, minute mL, milliliter NaCl, sodium chloride NSAIDs, nonsteroidal antiinflammatory drugs O2, oxygen PCV, packed cell volume PPV, positive pressure ventilation pRBCs, packed red blood cells PT, prothrombin time PZI, protamine zinc insulin R, right RA, right arm RBC, red blood cell RL, right leg SA, sinoatrial SIRS, systemic inflammatory response syndrome SQ, subcutaneous STD, standard SWB, stored whole blood TP, total protein V, voltage VPC, ventricular premature contraction/complex WBC, white blood cell
Anatomy, 3 Anesthesia, 439 Blood chemistries, 74 Canine transmissible diseases, 38 Cardiology, 204 Feline transmissible diseases, 44 General medicine, 201 Injections, 348 Laboratory, 71 Nebulization, 432 Nutrition, 57 Radiographs, 159 Surgery, 521 Urinalysis, 147
8
Key words and terms are defined in the glossary on page 631.
CHAPTER 8 / PATIENT CARE
331
PATIENT MONITORING Monitoring of a hospitalized patient is one of the crucial responsibilities of a veterinary technician. This section includes some basic monitoring skills;
blood pressure, central venous pressure (CVP), cardiac values (ECG readings), and heat administration. See Skill Box 13.8, page 467, and Chapter 9 Pain Management, page 379, for further monitoring information.
Blood Pressure Skill Box 8.1 / Blood Pressure Procedure Measuring accurate blood pressures on animals is not trivial, and lots of experience and attention to every detail is important:—limb selection, proper cuff size, snug fit of the cuff, position of the animal—is important so that no weight or pressure is on the measurement limb or cuff, the animal is a relaxed and still. Research has shown that if an animal is upset or agitated due to handling or due to the measurement procedure itself, it will take 8–10 minutes after the animal is calmed and relaxed for the animal’s blood pressure to return to normal. Measurements on an agitated animal are not an indication of their normal blood pressure and are usually worthless clinically when diagnosing a hypertensive animal. 8
Method:
Direct Arterial Pressure
Doppler Ultrasound Flow Detectors
Oscillometric
Indications
• Monitoring during anesthesia, CPCR, shock, fluid administration, and any other condition leading to secondary hyper- or hypotension
• Monitoring during anesthesia, CPCR, shock, and any other condition leading to secondary hyper- or hypotension • Detection of flow in distal limbs (e.g., traumatic wounds, saddle thrombi), corneal flow during CPCR • Irregular pulse signals or rates can indicate cardiac arrhythmias.
• Monitoring during anesthesia, CPCR, shock, fluid administration, and any other condition leading to secondary hyper- or hypotension
Contraindications
• Using large vessels in patients with coagulopathies • Upset or agitated patients
• Upset or agitated patients
• Upset or agitated patients
Setup
• Catheter (e.g., arterial, over-the-needle, through-the-needle) • Heparinized saline • Pressure transducer and monitor
• Equipment • Ultrasonic gel
• Equipment (e.g., petMAP)
332
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 8.1 / Blood Pressure Procedure (Continued) Method:
Direct Arterial Pressure
Doppler Ultrasound Flow Detectors
Oscillometric
Procedure
The catheter is placed in an artery (e.g., dorsal pedal, femoral, or auricular) and flushed with 1–1.5 mL of heparinized saline. The catheter is thoroughly secured with tape to avoid dislodging or kinking. The catheter is then labeled to prevent inadvertent intra-arterial injections. The catheter is then connected to the pressure transducer by rigid tubing filled with heparinized saline. Refer to the manufacturer’s guidelines for further setup and monitoring instructions. The method for measuring CVP can also be used if a transducer system is not available.
Place the patient in a comfortable position. Select a cuff that has a width that is approximately 40% of the circumference of the patient’s distal limb or tail. Snugly place the cuff on any place an artery is accessible, typically a limb distal to the elbow or hock or the base of the tail. Place the probe over the artery but distal to the cuff, turn on Doppler, and listen for blood flow. Position probe until a clear flow is heard and tape into place. Inflate the cuff and slowly release the trigger until the first flow sound is heard, this is the systolic pressure. The second sound heard is the diastolic, which often cannot be heard.
Place the patient in a comfortable position. Select a cuff that has a wdith that is approximately 40% of the circumference of the patient’s distal limb or tail. Snugly place the cuff on any place an artery is accessible, typically a limb distal to the elbow or hock or the base of the tail. Connect the cuff to the monitor and turn on. The cuff is inflated until the artery is occluded and then slowly released until the pulse returns. The systolic, diastolic, and mean arterial pressures and heart rate will be displayed.
Complications
• Hemorrhage, thrombosis, infection, and necrosis
• Poor contact between probe and artery
• Poor blood flow, small arteries, movement, shaking, or shivering can lead to inaccurate results.
Tip: Doppler: if the skin is dry, rub in ultrasonic gel first and then apply more when placing the probe over the artery.
Table 8.1 / Blood Pressure Results
The normal and abnormal values for blood pressure measurements are clearly defined in human medicine but have not yet been solidly established in veterinary medicine. The following table shows the ranges currently accepted.
a
Blood Pressure
Normal
Abnormala
Canine
• Systolic: 110–160 mm Hg • Diastolic: 60–100 mm Hg • Mean: 80–120 mm Hg
• Systolic: <80 and >160 mm Hg • Diastolic: >100 mm Hg • Mean: <60 and >120 mm Hg
Feline
• Systolic: 120–170 mm Hg • Diastolic: 70–120 mm Hg • Mean: 80–120 mm Hg
• Systolic: <80 and >160 mm Hg • Diastolic: >120 mm Hg • Mean: <60 mm Hg and >120 mm Hg
Abnormal results do not necessarily warrant therapy.
CHAPTER 8 / PATIENT CARE
333
8
Skill Box 8.2 / Central Venous Pressure The CVP measures the heart’s ability to pump fluids returned to it and also evaluates blood volume compared to blood volume capacity. The pressure within the intrathoracic anterior vena cava is compared to a column of water in a manometer or pressure transducer and oscilloscope. Fluctuations are seen with changes in pressure. An ↑ CVP can indicate a backup of blood due to excessive volume (e.g., fluid overload) leading to ascites, pulmonary edema, pneumothorax, or pneumomediastinum. A ↓ CVP can indicate a ↓ blood volume (e.g., dehydration) leading to hypovolemia. An initial crude estimate of CVP can also be done by evaluating resting jugular distention, then filling and relaxation time with digital occlusion. The jugular vein is clipped and observed: Passive • Observed for tension • Mildly distended: often seen with patients in lateral recumbency • Highly distended: patient standing or in sternal recumbency indicates a ↑ CVP • Flat: indicates ↓ CVP and hypovolemia Active Test • Occluded with digital pressure and observed for filling time and then released and observed for relaxation time • ↓ Filling time: >4 seconds indicates ↓ CVP and hypovolemia • ↓ Relaxation time: >2 seconds indicates right side of the heart may be overloaded as with chronic right-sided heart failure, chronic liver disease, acute heart failure 8
Method
Central Venous Pressure
Indications
• Patients prone to hypertension (e.g., renal or liver failure)
Contraindications
• Burn, abrasion, or pyoderma over site, severe coagulopathy, hypercoagulable, or thrombosis of chosen vein inhibiting jugular catheter placement
Setup
• Surgical site preparation materials • IV jugular catheter • Heparinized saline
Procedure
A jugular catheter is placed and advanced to the cranial vena cava. (See Skill Box 8.9 Intravenous Catheter Placement, Peripheral and Jugular, page 349.) Attach an extension set to the catheter, followed by a 3-way stopcock. Attach the IV fluids to the open line of the stopcock. Attach the manometer to the upright opening of the stopcock. Place the patient in sternal recumbency, and position the manometer at the level of the sternum. Turn off the fluids to the patient and fill the manometer with fluids. Open the extension set and the fluid level will equalize. The level at which the fluids stabilizes is the CVP reading. Repeat twice more for accurate results.
Complications
• Blood clots or occlusions can ↑ values. • If fluids are not running through the catheter, flush with heparinized saline every hour.
334
SECTION FOUR: PATIENT CARE SKILLS
• 3-way stopcock • Bandaging materials • IV fluid set up
Skill Box 8.2 / Central Venous Pressure (Continued) Method
Central Venous Pressure
Results
Normal: <8 cm H2O Abnormal: >12–15 cm H2O • Monitor trends over time, not a single reading. Following a Fluid Bolus • Normovolemic: ↑ of 2–4 cm H2O with a return to baseline in 15 minutes • Hypovolemic: ↑ with a rapid return to baseline • Hypovolemic (severe): small or no ↑
Tip: Jugular catheter placement can be verified by the 2–5 mm fluctuations seen on the manometer with each respiration.
Blood Gas Analysis 8 Skill Box 8.3 / Blood Gas Analysis Blood gas analysis is used to monitor pulmonary function and the metabolic state of the patient through the delicate balance between carbon dioxide (CO2), bicarbonate (HCO3−), hydrogen (H+), and oxygen (O2). With a change in CO2 or HCO3−, alterations are seen in the body’s pH, ultimately affecting its ability to carry out various enzyme activities. The acid-base equation (CO2 + HCO3 ↔ CO2 + H2O) shows how a change in CO2 or HCO3− can alter the pH. The lungs are primarily responsible for regulating CO2 through respiration, while the kidneys regulate HCO3− through resorption and excretion in the proximal tubule. Because CO2 and HCO3− are the main determinates to the acid-base status (pH) of a patient, a change in one factor can affect the other. For example, it is common to see respiratory changes with metabolic disturbances. The body’s ability to compensate for abnormalities can often mask underlying disturbances, making diagnosis and treatment more difficult. Method
Blood Gas Analysis
Indications
• Patients with respiratory disease and/or metabolic disturbances (e.g., toxins, hypoadrenocorticism, diabetes mellitus, chronic renal failure)
Contraindications
• Patients taking potassium bromide
Setup
• • • • •
25-gauge needle with 1 mL syringe Heparin Cork to cap needle or sterile red top tube Ice bath (for temporary storage) Blood gas analyzer
CHAPTER 8 / PATIENT CARE
335
Skill Box 8.3 / Blood Gas Analysis (Continued) Method
Blood Gas Analysis
Procedure
A syringe coated with heparin (1,000 U/mL) is used to obtain a blood sample. A full 1 mL of blood should be obtained to avoid any dilution with heparin. All excess air is expelled from the syringe and the sample is analyzed immediately. If temporary storage is required, the sample can be stored at room temperature for <10–15 minutes or <1–2 hours in an ice-bath once placed in a container with a tight-fitting cap (e.g., cork, rubber stopper, red top tube). Arterial • Femoral or lingual artery (use of other peripheral arteries possible) • Hold off for 3–5 minutes or place temporary pressure wrap to prevent hematoma formation. Venous • Jugular, cephalic, or saphenous vein (use of other peripheral veins possible) • Note: The sample must be protected from air to avoid alterations.
Complications
• Samples stored at room temperature for >20 minutes: ↓ pH • Excessive heparin: ↓ HCO3−
Resultsa
Normal: Arterial pH: 7.35–7.45 PaCO2: 35–42 mm Hg PaO2: 85–105 mm Hg HCO3−: 20–25 mEq/L BE: −4 to +4 Venous pH: 7.35–7.45 PvCO2: 40–50 mm Hg PvO2: 30–42 mm Hg HCO3−: 20–25 mEq/L BE: −4 to +4 Abnormal: • Single or multiple alterations from above • pH: <7.35, acidemia; >7.45, alkalemia
8
a
Slight variations in normal and abnormal results occur throughout literature and instrumentation used. Note: BE: base excess represents the magnitude of acid-base abnormality contributed by metabolic components.
336
SECTION FOUR: PATIENT CARE SKILLS
The results of the blood gas analysis are then evaluated to determine the status of the patient. This can often be a tricky process, but the basic interpretation is shown below as a 5-step process.
Arterial Blood Gas Interpretation 1. Evaluate the PaO2 and determine if the patient is hypoxemic (needs oxygen). 2. Evaluate the pH and determine if the patient is normal, acidotic or alkalotic. 3. Evaluate the PaCO2 and determine if it supports the pH findings. • Yes: condition is primarily respiratory • No: condition is not primarily respiratory
4. Evaluate the HCO3− and determine if it supports the pH findings. • Yes: condition is primarily metabolic • No: condition is not primarily metabolic 5. Evaluate the parameter not responsible for abnormal condition to assess for compensation.
Note: Reprinted with permission from Nancy Shaffran, CVT, VTS (ECC).
Table 8.2 / Acid-Base Disturbances
8
Respiratory Acidosis
Metabolic Acidosis
Respiratory Alkalosis
Metabolic Alkalosis
Cause
• Severe pulmonary disease, airway obstruction, pleural effusion, pneumothorax, flail chest, drug side effects, CNS lesions, cardiac arrest, improper use of mechanical ventilator, diseases of respiratory muscles
• Diarrhea, diabetic ketoacidosis, intoxication (e.g., ethylene glycol), hyperphosphatemia, uremic acidosis, post chronic hypocapnia, renal failure
• Intrathoracic disease, fear, anxiety, septicemia, hypoxia, fever, severe liver failure, CNS disease, heat stroke
• Vomiting, drug administration (e.g., sodium bicarbonate, furosemide), post chronic hypercapnia, severe hypokalemia
Clinical Signs
• Anxiety, lethargy (chronic), coma (acute), ↑ mentation, hypoxia, papilledema
• Hyperventilation, hypotension, ventricular fibrillation, anorexia, vomiting, hyperkalemia
• Neurologic (e.g., seizures, tetany), hypokalemia
• No reliable signs • +/− ↑ Respiratory rate, effort and depth
Blood Gas Analysis
• ↓ pH and ↑ PCO2
• ↓ pH and HCO3−
• ↑ pH and ↓ PCO2
• ↑ pH and HCO3−
Treatment
• Oxygen therapy, ventilation support • Treat underlying condition (e.g., thoracocentesis).
• Drug administration (e.g., sodium bicarbonate)
• Fluid therapy (e.g., 0.9% NaCl−) • Drug administration (e.g., potassium)
• Treat underlying condition.
CHAPTER 8 / PATIENT CARE
337
Electrocardiogram An electrocardiogram (ECG) is a graphic interpretation of the electrical activity of the cardiac muscle. Its use is required for accurate diagnosis of arrhythmias and conduction disorders. An ECG should be a regular part of any systemic disease workup because life-threatening arrhythmias (e.g., ven-
tricular tachycardia, atrial tachycardia) are easily missed on auscultation. Besides physical examination findings indicating an ECG, they are also useful in the preoperative evaluation of geriatrics, in anesthesia monitoring (preoperative, perioperative, and postoperative), and for evaluating the effects of cardiac drugs. This simple procedure provides great diagnostic value and should be routinely used in every veterinary hospital.
Skill Box 8.4 / ECG Procedure
8
Method
Electrocardiogram
Indications
• Cardiac arrhythmias and the status of the myocardium • Tachycardia, bradycardia, extra beats, murmurs, cardiomegaly, and electrolyte disturbances • Exercise intolerance, panting, dyspnea, cyanosis, fainting, seizures, and shock
Contraindications
• If animal is exhibiting severe dyspnea
Setup
• Equipment • Conducting solution (e.g., alcohol, gel) • Staples or wire sutures
Procedure
Using a nonconductive table (e.g., formica or metal covered with a blanket or pad), place the patient in right lateral recumbency or, if critically ill, in any position that does not further increase injury or illness. The limbs should be held parallel to each other and not touching. The forelimbs should be perpendicular to the long axis of the body. If using clips, moisten the areas of attachment with conductive gel, paste, creams, or alcohol. Apply the clips and reapply the conductive agent. • RA/LA: proximal to the olecranon and on the caudal aspect (electrodes may need to be positioned halfway between the olcranon and carpus if cadiac interference is seen) • RL/LL: patellar ligament on the anterior aspect • Cardiac: left intercostal space at costochondral junction, dependent on desired unipolar precordial chest lead Small metal plates covered with conductive gel, paste, or creams can be applied to the pads of the feet, or shave the fur and adhere electrode pads (Holter apparatus) for long-term monitoring. To record the activity of the heart, begin by turning on the machine. Position the stylus in the center of the paper and maintain that position throughout the recording. Turn the sensitivity switch to 1 to allow 1 mV input to move the stylus 1 cm (2 large boxes). (Turn the sensitivity switch to 2 if the tracing is small and unclear or turn it to 1/2 if the tracing is large and extending to the top and bottom of the paper.) Turn the record switch to a paper speed of 50 mm/sec and push the standardization button to record the reference size of 1 mV. Record the desired leads: • Turn the lead selector to 1 and record 2 sets (30 large boxes). • Without turning off machine or changing any other parameters, turn the lead selector to 2 and continue through to aVF and CV6LU (V4). • Turn the lead selector to 2 and record 2–4 feet of lead II rhythm strip at 25 mm/sec. • If precordial chest leads are desired, stop recording and reposition chest lead for each reading. Return the lead selector to STD and push the standardized button. Stop recording and remove clips from the patient. Fold up ECG strip and record the patient’s information (e.g., name, position, excitement level) on the strip.
338
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 8.4 / ECG Procedure (Continued) Method
Electrocardiogram
Complications
• • • •
↑ Stress can exacerbate already critical situations Variations in the body conformation of many dog breeds may alter standard measurements Drug administration (e.g., chemical restraint) may alter recording results If the machine does not have a modern 3-prong plug, attach the ground lead wire to a water pipe or object with a common ground
Tip: When recording an ECG strip, it is best to “drive” with both hands. The left hand is placed on the stylus position knob to help maintain a centered tracing, because they tend to wander during long readings or when switching leads. The right hand is placed on the lead selector switch to change through the various leads smoothly. Tip: ECG activity may continue to appear normal even after all mechanical activity has ceased and the patient has no palpable pulse (e.g., deceased) (electromechanical dissociation). Tip: The teeth of the alligator clips may be bent out, flattened, or filed to improve patient comfort. Tip: Conductive gel, paste, and creams are better at lowering the electrical resistance than alcohol and do not evaporate; however, alcohol-soaked pads may be used between the clip and skin.
Table 8.3 / ECG Leads Lead
Measurement
Movement and Electrode Position
Use
8
Bipolar Standard Leads I
• Measurement between 2 limbs
• R arm (−) → L arm (+. )
II
• R arm (−) → L leg (+. )
III
• L arm (−) → L leg (+. )
• Abnormalities in P-QRST deflections and cardiac arrhythmias • Determining mean electrical axis
Augmented Unipolar Limb Leads aVR aVL
• Measurement from one limb to a point halfway in between the other 2 limbs
• L arm and leg (−) → R arm (+. ) • R arm and L leg (−) → L arm (+. )
• Determining mean electrical axis and heart position • Confirming information gained from other leads
• L arm and R arm (−) → L leg (+. )
aVF Unipolar Precordial Chest Leads CV5RL (rV1) CV6LL (V2) CV6LU (V4) V10
• Measurement from the dorsal and ventral surfaces of the heart • The limb leads form a potential equal to that in the center of the heart, allowing voltage to be measured from the center of the heart to the selected location of the chest lead.
• R and L arm and L leg (−) → 5th R intercostal space near edge of sternum (+. ) • R and L arm and L leg (−) → 6th L intercostal space near edge of sternum (+. )
• R and L ventricular enlargement, myocardial infarction, bundle branch block, and cardiac arrhythmias • Confirming information gained from other leads
• R and L arm and L leg (−) → 6th L intercostal space at costochondral junction (+. ) • R and L arm and L leg (−) → over spinous process of the 7th thoracic vertebra (+. )
CHAPTER 8 / PATIENT CARE
339
Table 8.3 / ECG Leads (Continued) Lead
Measurement
Movement and Electrode Position
Use
Esophageal
• Measurement from limb and base of the heart • The electrocardiograph is run on and compared with lead I.
• L arm → base of heart
• Rhythm monitoring and accurate identification of P waves
Intracardiac
• Measurement is based on the position of the exploring catheter tip placed through a jugular venipuncture and attached to an outside electrode.
• Dependent on the position of the exploring catheter tip within the heart
• Cardiac arrhythmias (accurate identification of P waves), differentiation between ventricular and supraventricular tachycardia, and for pacing the heart
Invasive Leads
Table 8.4 / ECG Interpretation
8
a b
Cycle Segment
Movementa
Image
Measurementb
Action
P wave
• SA node → R atrium → L atrium → AV node
• Positive wave
• Width: 0.04 second (2 boxes) • Height: 0.4 mV (4 boxes)
• Depolarization of the R and L atrium
P-R interval
• SA node → ventricle
• P wave and ending straight line
• Start of the P wave to start of Q wave (R wave if no Q wave) • 0.06–0.13 second (36.5 boxes)
• Time delay to allow filling of ventricles
QRS
• R bundle branch and L bundle branch → apex and ventricular free walls → basal regions of free walls and septum
• Negative wave (Q) followed by a tall positive wave (R) and ended with a short negative wave (S)
• Start of Q wave to the end of the S wave • Width: 0.05–0.06 second (2.5 boxes) • Height: 2.5–3.0 mV (25–30 boxes)
• Depolarization of the ventricles
ST interval
• Basal regions of free walls and septum → apex and ventricular free walls
• Straight line with no deviations
• End of the QRS complex to the start of the T wave • Width: 0.2 mV (2 boxes) • Height: 0.15 mV (1.5 boxes)
• Early phase of ventricular repolarization
T wave
• Apex and ventricular free walls
• Positive wave
• Height: ≤1/4 of the amplitude of the R wave
• Repolarization of the ventricles
Q-T interval
• R bundle branch and L bundle branch → apex and ventricular free walls → basal regions of free walls and septum → apex ventricular free walls
• Negative wave (Q), tall positive wave (R), short negative wave (S) ending with a straight line (ST segment)
• Start of the Q wave to the end of the T wave
• Summation of depolarization and repolarization of the ventricles
Electrical impulse movement through the heart. Measurement taken at a paper speed of 50 mm/sec.
340
SECTION FOUR: PATIENT CARE SKILLS
8
Figure 8.1 Normal canine electrocardiogram. Reprinted with permission from Larry Patrick Tilley: Essentials of Canine and Feline Electrocardiogram Interpretation and Treatment, 3rd ed. Philadelphia, 1992, Lippincott Williams and Wilkins.
CHAPTER 8 / PATIENT CARE
341
Skill Box 8.5 / Heart Rate Calculation ECG Paper and Grid Lines 25 mm/sec Small box = 0.04 second Large box (5 small boxes) = 0.20 second Set (15 large boxes) = 3 seconds Rhythm
50 mm/sec Small box = 0.02 second Large box (5 small boxes) = 0.10 second Set (15 large boxes) = 1.5 seconds
Paper Speed 25 mm/sec
50 mm/sec
• Average Heart Rate
Method 1: the number of complete complexes in 1 set × 20 = bpm
Method 1: the number of complete complexes in 1 set × 40 = bpm
• Instantaneous Heart Rate
Method 2: 1500 / the number of small boxes between 2 QRS complexes = bpm
Method 2: 3,000 / the number of small boxes between 2 QRS complexes = bpm
Method 3: 300 / the number of large boxes between 2 QRS complexes = bpm
Method 3: 600 / the number of large boxes between 2 QRS complexes = bpm
Regular Rhythm
8
Method 4: heart rate calculator used according to provided directions Irregular Rhythm • The fraction of the last cycle should be estimated in tenths
342
The number of cycles in 2 sets × 10 = bpm
SECTION FOUR: PATIENT CARE SKILLS
Method 1: the number of cycles in 2 sets × 20 = bpm Method 2: the number of cycles in 4 sets × 10 = bpm • Greater accuracy with slower rates
Table 8.5 / Common Rhythm Abnormalities Rhythm Pattern
Cause
Image
Associated Conditions
Atrial Fibrillation
• Rapid and disorganized depolarization pattern in the atria • ↓ Cardiac output
• Indistinguishable P waves are replaced by numerous F waves. • QRS complexes may be normal or wide with varying amplitude.
• Atrial enlargement, congenital heart defects, drug reactions, anesthesia, heartworm disease, trauma, or hypertrophic cardiomyopathy
Atrial Premature Contraction/ Complex (APC)
• Premature atrial beats originating outside the SA node
• Premature P wave • QRS complexes are normal unless the P wave is so premature they overlap with varying results. • See Figure 8.2.
• Congenital heart disease, cardiomyopathy, electrolyte imbalances, neoplasia, hyperthyroidism, drug reactions, toxemias, atrial myocarditis, or normal variations in aged animals
Respiratory Sinus Arrhythmias
• Irregular sinus rhythm originating in the SA node • Respiratory rate ↑ during inspiration and ↓ during expiration
• Normal sinus rhythm • ↑ Number of cycles during inspiration and ↓ number of cycles during expiration
• Normal finding (brachycephalic), vagal stimulation, and chronic respiratory diseases
ST-Segment Depression
• Net electrical event of myocardial cell repolarization
• Depression of the ST segment of the QRS complex
• Normal finding, myocardial ischemia (inadequate circulation), hyper- or hypokalemia, cardiac trauma, or acute myocardial infarction
ST-Segment Elevation
• Net electrical event of myocardial cell repolarization
• Elevation of the ST segment of the QRS complex • See Figure 8.3.
• Normal finding, myocardial hypoxia (oxygen deficiency), myocardial infarction, or pericarditis
Ventricular Fibrillation
• Weak and uncoordinated ventricular contractions • ↓ To zero cardiac output
• Completely irregular, chaotic, and deformed reflections of varying width, amplitude, and shape
• Shock, anoxia, trauma, electrolyte imbalances, drug reactions, aortic stenosis, cardiac surgery, electric shock, myocarditis, or hypothermia
Ventricular Premature Contraction/Complex (VPC)
• An impulse originating in the ventricles instead of the SA node
• P wave is dissociated from the QRS complex. • Widened and bizarre QRS complex • See Figure 8.4.
• Cardiomyopathy, congenital defects, GDV, drug reactions, myocarditis, cardiac neoplasia, hyperthyroidism, or chronic valvular disease
CHAPTER 8 / PATIENT CARE
8
343
Figure 8.2 Atrial premature contraction/complex. Reprinted with permission from Larry Patrick Tilley: Essentials of Canine and Feline Electrocardiogram Interpretation and Treatment, 3rd ed. Philadelphia, 1992, Lippincott Williams and Wilkins.
8
Figure 8.3 ST-segment elevation. Reprinted with permission from Larry Patrick Tilley: Essentials of Canine and Feline Electrocardiogram Interpretation and Treatment, 3rd ed. Philadelphia, 1992, Lippincott Williams and Wilkins.
Figure 8.4 Ventricular premature contraction/complex. Reprinted with permission from Larry Patrick Tilley: Essentials of Canine and Feline Electrocardiogram Interpretation and Treatment, 3rd ed. Philadelphia, 1992, Lippincott Williams and Wilkins.
344
SECTION FOUR: PATIENT CARE SKILLS
Table 8.6 / ECG Problems and Artifacts Alteration
Problem
Solution
Baseline not well defined
• Poorly defined baseline
• ↑ the stylus heat and verify whether it is clean • ↓ sensitivity to 1/2 to ↓ the amplitude of the wave
Flat line
• An electrode has fallen off
• Replace electrode that has fallen off: • Lead I works and leads II and III do not—replace L leg • Lead II works and leads I and III do not—replace L arm • Lead III works and leads I and II do not—replace R arm
Negative R wave
• True abnormality • Misplaced electrode
• Verify that the electrodes are placed in the correct position.
QRS complex off the paper
• Excessive amplitude of QRS complex
• ↓ Sensitivity to 1/2 to ↓ the amplitude of the wave
Rapid and irregular vibrations of the baseline
• Muscle tremors • Body movements • Purring
• • • •
Regular sequence of 60 sharp up and down waves
• Electrical interference
• Verify the machine is properly grounded. • Verify the electrode clips are clean, securely attached to skin, and moistened (not saturated) with gel or alcohol. • Verify that the legs are held apart and the clips are not touching each other, and the animal is not touching anything metal (e.g., table). • Verify that the table is not touching electrical cords and is positioned away from electrical wiring. • Verify that the cords are not tangled or coiled up on one another.
Up and down movement of baseline
• Respiratory movements (e.g., panting and coughing)
Verify the patient is in a comfortable position and electrodes are comfortably placed. Place a hand over the chest wall with moderate pressure to ↓ body tremors. Blowing in a cat’s face or gentle manipulation of the larynx to stop purring ↓ Sensitivity to 1/2 to ↓ the amplitude of the wave
• Verify that the patient is in a comfortable position. • Hold the animal’s mouth shut for short periods to obtain each lead.
CHAPTER 8 / PATIENT CARE
345
8
Skill Box 8.6 / Heat Administration Heat support is required for all animals unable to regulate their body temperature at the normal level (100.5–102.5° F). Anesthetized, severely ill, and/or physically compromised patients are unable to regulate their body temperature and routinely require additional methods of heat support. Hypothermia will significantly slow recovery and severe hypothermia can cause arrhythmias and coagulation problems; prevention is better than management. Alternatively, monitoring the patient who is on heat support is also important to ensure that they do not become overheated or incidentally burned. Hospitalized or anesthetized patients are often unable to move away from an external heat source and often have decreased peripheral blood supply, leading to sometimes severe and extensive thermal burns. Shivering increases oxygen demand by up to 400%; additional oxygen should be provided if a patient is cold and shivering. It is better not to have to warm patients in recovery (e.g., keep them warm under anesthesia). Warming devices should be used immediately; otherwise, cooling will continue. Bair huggers, incubators, IV fluid warmers, and circulating warm air blankets are ideal. Warmed IV fluid bags are not recommended as severe and extensive contact burns occur. Proper padding on all surfaces should be instituted to control heat loss to the undersurface. Rectal temperature is not core temperature but allows trends to be assessed and should be measured regularly to ensure a return to normothermia. Esophageal temperature probes may be reflective of core body temperature in anesthetized patients. Basic heat support that does not require additional equipment includes keeping the patient dry, keeping patients away from air vents and air conditioners, maintaining warm room temperatures, and providing insulation materials against surgery tables and cages. Along with providing heat support, it is also important to ensure heat retention. Many quick methods have been devised, such as wrapping the patient with bubble wrap, placing the patient on foam padding, and placing baby socks on the paws. 8
Method
Use
Comments
Circulating Heated Water Blankets
• Preheated circulating controlled warm water vinyl pad is placed under the patient.
• Thermal burns may occur (rare). • Blankets or other protective coverings are placed on top of the pad to prevent inadvertent puncture. • Provide a minimal amount of heat support.
Heated Air Blankets (Bair Huggers)
• Blanket is placed over the patient. • Place a cotton blanket over the blanket or gown for maximum effectiveness.
• Do not use over transdermal medication as ↑ drug delivery and subsequent overdose may occur. • Do not place blankets over the patient’s head as corneal drying may occur. • Use caution when using in surgery to avoid circulating contaminated air; do not turn on until patient is fully prepped and draped.
Heated Bags
• Expired IV fluid bags, rice or oat bags • Wrap the bag in a blanket or towel and place to the side of the patient.
• Not recommended as severe thermal burns often occur • Bags should never be placed on top, underneath, or next to a shaved area of skin. • Remove bag once it has cooled to prevent reverse heat exchange.
Hot Line IV Fluid Warmer
• Fluids are warmed within the administration set using metal warming channels or multilumen circulating warm water.
• Additional methods can be used alone or along with fluid warmers; running the fluid administration set through a bowl of hot water, placing a circulating heated water blanket around the line, coiling the line under the patient’s heat source.
Warm Blankets and Towels
• Blankets and towels warmed by a clothes dryer
• Amount and length of heat are limited.
346
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 8.7 / Recumbent Patient Care Decubital sores (pressure sores), urine and fecal scalding, and lung atelectasis can be the source of further patient complications and can lead to ↑ morbidity and mortality. Recumbent patients with neurologic or orthopedic disease are at the greatest risk of acquiring these complications. Appropriate and observant nursing care should prevent or identify these complications in their early stages. Early identification will minimize the impact they place on the patient. Patients should be lifted and turned as dragging or pulling across the floor can lead to disruption in skin integrity and the beginning of decubital sores. Condition
Cause
Prevention
Treatment
Comments
Decubital Sores
• Excessive pressure, friction, or shearing forces over a bony prominence resulting in local or regional ischemia • Anatomical differences: thin breeds (↓ muscle or fat padding over bones), obese or large and giant breeds (excessive weight and pressure), thick hair coat (trapping of moisture and inability to monitor skin changes) • Underlying disease conditions: paralysis, inability or unwillingness to change position, malnutrition, impaired circulation, metabolic disease, thick hair coat
• Identifying at-risk patients • Monitor daily for early signs (e.g., erythema, edema, tenderness, exudate, alopecia) • Adequate nutritional status • Beds (e.g., hammocks, air or water mattresses) • Bedding (e.g., orthopedic pads, thick blankets) • Keeping the patient’s skin clean and dry • Repositioning every 2–4 hours • Passive exercise and massage to circulation
• Relieve pressure (e.g., “doughnuts,” inflatable rings). • Clip and clean with an antiseptic. • Drug administration (e.g., systemic antibiotics) • Debridement, surgical and wound management (See Chapter 10 Wound Care and Bandaging, page 395.)
• Greater trochanter is the most common site, but additional pressure points of forelimbs and hindlimbs are also seen. • Obtain bacterial swabs prior to cleaning.
Urine and Fecal Scalding
• Exposure to urine or feces for extended periods of time or with compromised skin integrity
• • • •
Clean bedding Grates Beds (e.g., nylon mesh hammock) Protective topical ointments (e.g., petrolatum) applied to the perineal and inguinal areas • Bathing
• Clip and clean with an antiseptic • Drug administration (e.g., silver sulfadine, systemic antibiotics) • Debridement, surgical and wound management (See Chapter 10 Wound Care and Bandaging, page 395.)
• Patients with urinesoaked fur should assumed to have urinesoaked skin. • Can result in severe dermatitis and predispose to decubital ulcers
Lung Atelectasis
• Extended periods of one-sided recumbency
• Repositioning every 2–4 hours
• Reexpansion (e.g., repositioning, removal of air or fluid from pleural space)
• Auscultation reveals localized areas of dullness.
8
CHAPTER 8 / PATIENT CARE
347
DRUG ADMINISTRATION Skill Box 8.8 / Injections Subcutaneous Injection (SQ)
Intramuscular Injection (IM)
Intravenous Injection (IV)
Location
• Typically between the scapulas, but could be anywhere the skin can provide a tent for injection
• Lumbar region, semimembranous, and semitendinosus muscles
• Any accessible vein (e.g., external jugular vein, cephalic vein, saphenous vein, pedal veins, lingual vein during anesthesia)
Volume
• Fluid administration: 50–100 mL in one location depending on the size and species of the animal
• <3 mL per site
• Large volumes can be administered.
Technique
• Gently pull an area of skin up to form a small “tent.” Insert the needle with the bevel side up at a 15° angle through the center of the “tent.” You should feel the needle pop through the skin. Aspirate for blood and then inject the contents intended.
Rear Leg • Place the needle at least a thumb’s width from the femur. Inject the needle in a slightly caudal direction, aspirate for blood and inject the contents of the syringe. • Avoid: sciatic nerve, femoral artery and vein, popliteal lymph node and the femur Lumbar Region • Place your thumb on the wing of the ilium and your middle finger on a vertebra of the spine. Let your index finger fall naturally; where it lands is the location for the injection. Inject the needle straight into the muscle, aspirate for blood, and inject contents of syringe. • Avoid: all nerves and blood vessels
Jugular Vein • Occlude the vein in the jugular furrow at the thoracic inlet with thumb of nonsyringe hand. The head should be slightly rotated toward the injection site for better visibility. The jugular vein typically lies in the cowlick of the fur running from the ramus of the mandible to the thoracic inlet. Insert the needle parallel to the skin in a cranial direction, aspirate for blood, either inject contents of syringe or withdraw blood. • Avoid: the carotid artery Peripheral Vein • Once vein is occluded by either a tourniquet or assistant, lay thumb alongside the vein to stabilize it. Insert the needle parallel to the skin in a cranial direction, aspirate for blood, either inject contents of syringe or withdraw blood. • Avoid: all nerves
Tips
• Changing needles before injection; use of a 25-gauge needle • Gently squeezing or flicking the injection site to dull the area • Distraction (e.g., treats, sliding the patient across the table or lifting their front legs, twitching a ear or tapping the nose, talking to the patient).
• Pinching the injection site before administration desensitizes the area. • Changing to a 25-gauge needle also provides a less painful injection, because the new needle is not dull and is smaller. • Distract the animal while giving the injection.
• Use EMLA on prepared skin to desensitize the animal’s reaction to insertion of the catheter. Place 1 g on shaved area, cover with dressing, and wait a minimum of 1 hour for full effect. • Gentle insertion of the needle typically results in much less of a reaction than thrusting. • Distract the animal while giving the injection.
8
348
SECTION FOUR: PATIENT CARE SKILLS
Intravenous Catheter Placement Catheters are used in veterinary medicine to gain access to the vascular system for administration of medications or fluids as well as to obtain blood
samples. The following section explains the various techniques and their care. Being able to place a catheter quickly is a valuable skill in a technician.
Skill Box 8.9 / Intravenous Catheter Placement: Peripheral and Jugular Method
IV Catheter, Peripheral
IV Catheter, Jugular
Indications
• IV access for fluids, medications, and anesthesia • Central line placement is desired and a jugular vein is not available.
• IV access for fluids, medications, and anesthesia • Patients with poor peripheral veins or circulation, CVP measurement or reliable blood sampling
Contraindications
• Burn, abrasion, or pyoderma over site, thrombosis of chosen vein, and infusion of hyperoncotic solutions (parenteral nutrition)
• Burn, abrasion, or pyoderma over site, severe coagulopathy, hypercoagulable, or thrombosis of chosen vein
Catheter Sites
• Cephalic and saphenous veins • Pedal vein (contraindicated with hypertonic fluids)
• External jugular vein and femoral vein
Setup
• Surgical site preparation materials • 1/2 and 1 inch tape
• • • •
Procedure
Clip a wide area of hair leaving a 2″ border above and below the catheter insertion point. Wash hands and put on gloves. Apply Nolvasan from a yoker bottle and using cotton balls, wipe the skin gently. (Avoid vigorous scrubbing) Follow with an alcohol soaked cotton ball to wipe the area being sure not to introduce bacteria from the outer edges of the clipped site. Follow the above steps using Technicare. As the final prep, apply Technicare, but do not wipe off with alcohol. Change gloves. Perform a cut down if necessary with the tip of a sterile needle. Insert catheter SQ and then penetrate the vessel. Cap the catheter with a T-port and flush with saline and secure with tape. Additional bandaging may be placed in long term catheters, however less is typically more in this case.
• • • •
IV catheter Saline flush T-port 22-gauge needle
Surgical site preparation materials Sterile gauze: 3X3 1 /2 and 1 inch tape IV catheter
• • • •
Saline flush T-port primed with saline 22-gauge needle Lidocaine 2%
8
Set up all required materials. Hold off the jugular vein and carefully clip the area of the insertion site, avoiding clipper burn. (If the animal is in sternal recumbency, the person who is placing the catheter holds off the vein; if the animal is in lateral recumbency, the restrainer holds off the vein.) Wash hands, put on gloves and follow scrub technique for peripheral catheter placement. Change to sterile gloves, tent the skin, place the needle under the skin near the vessel at a 30–45° angle. While maintaining the same catheter angle, palpate the vessel and advance only the tip of the catheter into the vein. A “pop” should be felt. A flashback is not seen in many jugular catheters until aspirated. Thread the catheter the rest of the way into the vein. If there is a needle guard, place the needle in the groove and clamp shut. Be sure the hub of the catheter is locked into the hub of the needle. Remove the stylet and attach the T-port. Aspirate and then flush with 3–6 mL heparinized saline. Place a butterfly tape around the catheter hub and secure the catheter. The needle guard can be used to suture the catheter in place, or a butterfly tape can be applied to provide more stability. Adhere the catheter to the skin with 3 simple interrupted nonabsorbable sutures (one on each side of the catheter and a third as an anchor). Place triple antibiotic ointment over the catheter entry site. Place a drop of glue to the catheter/ needle hub if applicable to the catheter type. Place a second strip of tape in a counterclockwise direction. Apply cast padding loosely around the animal’s neck clockwise and then counter clockwise, keeping the T-port clear. Apply the gauze wrap in the same manner. Flush T-port with heparinized saline, aspirate, and then flush again. Place a layer of elastic tape, testing the tightness by ensuring that 2 fingers can be inserted under the wrap. Place a piece of tape to secure the T-port and write the date of placement on it. Radiographs can be taken to assess proper placement.
CHAPTER 8 / PATIENT CARE
349
Skill Box 8.9 / Intravenous Catheter Placement: Peripheral and Jugular (Continued) Method
IV Catheter, Peripheral
IV Catheter, Jugular
Complications
• Phlebitis, nonpatent, and FUO
• Phlebitis, nonpatent, FUO, facial and front limb edema
Removal
• Remove after 72 hours. • Tape is cut with bandage scissors and catheter is slowly pulled out. • A cotton ball and Vet-Wrap bandage is placed for 1–2 hours
• Remove after 72 hours. • Tape is cut with bandage scissors and catheter is slowly pulled out. • A cotton ball and Vet-Wrap bandage is placed for 1–2 hours
Tip: The right external jugular maintains a straighter course and is often preferred for jugular placement.
Skill Box 8.10 / Intravenous Catheter Placement: Arterial and Intraosseous 8
Method
IV Catheter, Arterial
IV Catheter, Intraosseous
Indications
• Blood gas analysis, continuous blood pressure monitoring, blood sampling
• CVP fluid administration
Contraindications
• Drug or fluid administration • Burn, abrasion, or pyoderma over site • Thromboembolic disease, hypercoagulopathy, and ambulatory patients
• Osteopenia or infected tissue over the site
Catheter Sites
• Dorsal pedal, femoral, and auricular arteries
• Greater trochanter of the proximal femur, flat medial aspect of the proximal tibia (in obese animals), and greater tubercle of the humerus
Setup
• • • • • •
• • • • • •
350
Surgical site preparation materials /2- and 1-inch tape IV catheter Saline flush T-port 22-gauge needle
1
SECTION FOUR: PATIENT CARE SKILLS
Surgical site preparation materials Sterile gauze: 3 × 3 inches 1 /2- and 1-inch tape IV catheter Saline flush T-port primed with saline
• • • • • •
22-gauge needle Lidocaine 2% No. 15 or No. 11 scalpel blade 16-gauge bone marrow needle Suture material Triple antibiotic ointment
Skill Box 8.10 / Intravenous Catheter Placement: Arterial and Intraosseous (Continued) Method
IV Catheter, Arterial
IV Catheter, Intraosseous
Procedure
Follow peripheral catheter protocol. Place a gauze square just below the insertion site to help maintain an aseptic area as well as absorb any blood. Using a smooth and steady technique, insert the catheter with bevel side facing up into the artery at a 30–45° angle. A flashback of blood is seen upon entering the artery. Palpate the pulse and then advance the catheter toward the strongest area of pulse; withdraw the needle stylet. Blood should be seen at the hub of the catheter. Cap the catheter with a T-port and flush with saline and secure with tape. Label the catheter as arterial.
Set up all required materials. Clip the greater trochanter and scrub with chlorhexidine soaked gauze, using aseptic technique. Inject a bupivacaine or lidocaine subcutaneously if the animal is responsive (0.1 mL at the catheter insertion site). Place a sterile gauze square just below the insertion site to help maintain an aseptic area as well as absorb any blood. Incise the insertion site with a No. 15 or No. 11 scalpel blade. Using sterile technique and the leg in adduction, place one hand along the side of the femur with the thumb pointing toward the greater trochanter. Pass the catheter through the insertion site, down the medial aspect of the greater trochanter, and into the trochanteric fossa. Push the catheter through the cortex by applying downward pressure and rotating a quarter turn with each rotation. A loss of resistance is felt when the catheter passes through the cortex. The catheter will bounce lightly down the bone. Verify placement by aspirating and observing for bone marrow particulates and by rotating the femur; the catheter and femur should move as one. Remove cap and stylet and attach fluid set. Secure into place by suturing tape attached to the catheter to the skin. Secure in place with bandage material.
Complications
• Venous puncture, phlebitis, nonpatent, and FUO
• Osteomyelitis, fractures, growth plate damage, and displacement
Removal
• Remove after 3–5 days. • Tape is cut with bandage scissors and catheter is slowly pulled out. • A pressure wrap is placed for 10 minutes, followed by a cotton ball and Vet-Wrap bandage for 1–2 hours.
• Remove after 3–5 days. • Tape is cut with bandage scissors and catheter is slowly pulled out.
8
Tip: Use EMLA on prepared skin to desensitize the animal’s reaction to insertion of the catheter. Place 1 g on shaved area, cover with dressing, and wait a minimum of 1 hour for full effect. Tip: Securely attach the tape to the catheter by making a tape butterfly. Leave approximately 1 inch of tape on either side of the catheter and then loop the tape back onto itself such that there is a 1-inch “wing” on either side of the catheter. Use these wings to suture the catheter in or as an additional spot of contact when taping around the circumference of the limb of the patient.
Skill Box 8.11 / Intravenous Catheter Monitoring and Maintenance Patient Care
Equipment Care
• Monitor for signs of fever, lethargy, or changes in vital signs in the animal (which may represent sepsis).
• Swab injection ports on catheter and fluid bags with an antimicrobial solution prior to each injection.
Catheter Care
• Replace T-ports and administration sets every 24 hours or sooner with obvious wear or contamination, especially in critically ill and immunosuppressed patients.
• Flush catheter every 4–6 hours with saline to assess patency and patient response. • Remove bandaging every 24 hours to observe for phlebitis, swelling, redness, pain, hot to the touch and displacement. • Replace catheters every 3–5 days or sooner if warranted. • Replace bandaging every 24 hours, when soiled or wet.
• Observe strict aseptic technique when changing administration sets and fluid bags. Note: In discontinuing fluid therapy, fluids should not be stopped abruptly, especially with patients receiving high flow rates. Slowly weaning the patient off fluids over 24 hours allows the kidneys to adjust and again concentrate urine well, to avoid continuous excessive fluid loss.
CHAPTER 8 / PATIENT CARE
351
Chemotherapy As the number of clinics providing chemotherapy administration increases, it is important for the safety of the person administrating, the owner, and the patient to have the appropriate safety information available. Proper training is essential as these drugs are considered potentially hazardous.
Routes of exposure include absorption, inhalation, and ingestion. Each clinic should have documented preparation, storage, and disposal protocols for the various agents. Chemotherapy administration should take place in a well-ventilated, low-traffic area of the hospital.
Skill Box 8.12 / Chemotherapy: Administration Steps
Preparation
1. Drug Calculation
• Review the patient’s record, and recheck the chemotherapy protocol and drug calculations. • It is best to have a second person confirm the drug calculations. Note: Chemotherapy drugs differ as to their body weight calculations (e.g., kilograms, pounds, or square meters): be sure to verify the correct form. Also, most drugs are based on lean body weight, not actual body weight.
2. Personnel Supplies
Prepare yourself and assistant with safety gear regardless of administration technique: • Latex gloves: high-risk gloves or 2 pairs regular gloves Tip: With 2-pair system, wear 1 pair under the cuff of gown and 1 pair over the cuff of the gown. • Full face shield or protective eyewear • Mask: dust or mist respirator or a mask with a filter
8
Note: Surgical masks do not have a filter and are not sufficient. • Gown: disposable with long sleeves, closed front, and cuffs 3. Administration Supplies
Oral • Chemotherapy agent • Hemostat or pill-gun
4. Drug Preparation
1. 2. 3. 4. 5. 6. 7. 8. 9.
SQ/IM • Alcohol-soaked gauze sponges • Chemo-pin • Drop cloth with plastic backing • Chemotherapy agent • Gauze sponges • Syringe
IV Same as above and along with • Catheter • Clippers • Scrub preparation materials • Tape
Preparation in a well-ventilated area. Remove plastic cover of vial, and wipe the top with an alcohol swab. Insert the chemo-pin into the vial. Attach syringe to the chemo-pin while holding the vial upright. If adding a diluent, add slowly and then mix contents of vial completely, with the Luer-Loc syringe left in place. Turn vial upside down and aspirate drug into syringe slowly to avoid excess air bubbles. Push any excess air back into the syringe before separating from vial. Wrap gauze around the connection between the syringe and vial and gently pull apart. Place a covered needle onto the syringe.
Tip: Do not inject air into the vial; maintaining a negative pressure within the vial reduces the risk of aerosolization. • When not using a chemo-pin, all the above steps are accomplished with a needle attached to the end of a Luer-Lok syringe. • Do not fill a syringe more than 2/3 full, to prevent the plunger from detaching from the syringe. • If an agent is to be administered via a fluid bag, fill the administration set with plain diluent before adding the chemotherapy agent to reduce the risk of contamination when attaching the line to the patient.
352
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 8.12 / Chemotherapy: Administration (Continued) Steps
Preparation
5. Patient Preparation
1. 2. 3. 4.
6. Drug Administration
1. With an alcohol-soaked gauze around the end of the catheter, insert the needle into the catheter and administer the drug at the correct rate but at an even pace to avoid leakage around venipuncture site. 2. Flush the catheter with 3–5 mL nonheparinized 0.9% sodium chloride after administration to avoid irritation to the vein. 3. Monitor for allergic reactions for up to 1 hour after administration of certain drugs (e.g., L-asparginase). 4. Apply a pressure wrap after removing the catheter, and maintain pressure for several minutes. • Place an alcohol-soaked gauze sponge over the injection site whenever inserting or removing the needle or catheter to avoid aerosolization of the drug. • Do not aspirate the drug back into the catheter after administration to avoid dilution and residual drug in the catheter injection port.
7. Disposal
1. Place all items in a zip-lock bag to prevent aerosolization. 2. Dispose of the waste into an appropriate biohazard container. 3. Clean the preparation and administration surfaces thoroughly.
Select vein: peripheral veins are recommended because they provide better visualization of any drug that becomes extravascular. Aseptically clip and prepare the site. Place a catheter: butterfly, over-the-needle, or through-the-needle intracatheter. Ensure patency of the catheter by flushing at least 12 mL nonheparinized 0.9% sodium chloride. • Once a vein has been unsuccessfully punctured, a new vein should be used. If this is not possible, it is recommended that time be allowed for the proper clotting to occur before a proximal site is used. • Heparinized saline should not be used as it may cause the drug to form a precipitate.
8
Tip: Before removing gloves, place capped syringes and any other used products that may aerosolize into your hands, pull gloves off over the materials, and then dispose of them. 8. Post Patient Care
1. Wear double layer of gloves when handling waste from the patient for the first 72 hours. 2. Wipe down cages as using a hose or spray may aerosolize excreted drugs. 3. Closely monitor response to drug (e.g., attitude, appetite, eliminations, and general behavior).
Table 8.7 / Chemotherapy: Toxicity
Chemotherapy is the process of administering drugs to attack actively growing and dividing tumor cells. Unfortunately, these agents are not selective for tumor cells and will also attack other cells (e.g., bone marrow cells, gastrointestinal cells). With the administration of any chemotherapy agent, the patient must be monitored for adverse reactions and toxicities. Toxicities may not appear for several days following administration or until an accumulation of toxic levels have been obtained within the body. Most protocols are generally designed to result in <5% hospitalization rate (e.g., sepsis) for chemotherapy toxicity and <1% direct mortality rate from any particular toxicity.
CHAPTER 8 / PATIENT CARE
353
Table 8.7 / Chemotherapy: Toxicity Treatment
Comments
• Neutropenia • Anemia, thrombocytopenia (rare)
Neutropenia • <1000–2000/μL • ↓ Dose by 10–25% • <1500/μL • ↓ Dose by 10–25% • Drug administration (e.g., trimethoprim-sulfa, fluoroquinolones) • Monitor temperature. Neutropenia and fever • Hospitalization, IV fluids, antibiotics, blood work, blood culture, urinalysis and culture, thoracic radiographs, ± colony-stimulating factors Thrombocytopenia • Delay administration when platelet counts are <50,000–100,000/μL
• CBC and platelet count are required 12–24 hours before all chemotherapy agents known to cause myelosuppresive (e.g., cisplatin, carboplatin, doxorubicin). • Severely neutropenic patients may not be able to show signs of infection or fever. • Nadir is typically seen 5–10 days after administration. • Delay of chemotherapy for 1 week typically allows for bone marrow recovery.
• Arrhythmias • Acute, rare, transient • Cardiomyopathy • Chronic, cumulative
Prevention • Drug administration with iron-chelating cardioprotective agents (e.g., dexrazoxane) • Drug infusion over 15 minutes or a CRI over several hours • ECG monitoring Treatment • Discontinue drug use if rhythm abnormalities are seen. • Drug administration (e.g., antiarrhythmics)
• Mostly seen with canine doxorubicin administration • Limit total cumulative dose to <180 mg/m2 as a guideline for doxorubicin. • Cardiotoxicity is almost always irreversible and fatal.
• Alopecia, delayed hair regrowth, hyperpigmentation, hair color alterations
• No treatment necessary
• Mostly seen in nonshedding breeds (e.g., Poodle, Terriers, Old English Sheepdog). • Regrowth seen soon after discontinuing chemotherapy. • Change in color or textures may be initially seen, but often resolves with time.
• Local tissue necrosis • Secondary to extravasated agent
Prevention • Meticulous catheter placement and monitoring Treatment • Discontinue infusion. • Do not remove needle; withdraw as much of the drug as possible. • Inject 10–20 mL of sterile saline and dexamethasone (1–4 mg) into the area of extravasation. • Vincristine: • Instill 1 mL of hyaluronidase (150 units/mL) for every mL extravasated. • Apply warm packs for 24–48 hours to site. • Doxorubicin: • Instill 10 times the amount of DHM3 or dexrazoxane IV for the amount extravasated and SQ at the site of extravasation. • Apply cold packs for 6–10 hours to site. • Cisplatin • Instill 1 mL of isotonic sodium thiosulfate for every mL extravasated.
• Mostly seen with vincristine, doxorubicin, and cisplatin. • Sloughs typically appear at 7–10 days and should be treated as an open wound. • Bandages and E-collars can be used to avoid additional self-trauma. • ± Use of topical DMSO and infiltrated hydrocortisone (doxorubicin and vincristine) • Warn of potential for limb amputation if severe necrosis.
Cardiac
Hematologic
Complication
Dermatologic
8
354
SECTION FOUR: PATIENT CARE SKILLS
Comments
• Nausea, inappetence, vomiting, diarrhea, enterocolitis
• Symptomatic therapy (e.g., highly palatable food, appetite stimulants, antiemetics, motility modifiers) • Severe: • IV fluids • Nutritional support • Antibiotic therapy • Preemptive antiemetics (e.g., odansetron)
• Mostly mild and self-limiting, except cisplatin, which can be severely emetogenic • Typically occur 5–7 days post administration
Hypersensitivity
Complication
• Urticaria, erythema, restlessness, head shaking, vomiting • Cardiovascular collapse (canine, rare), anaphylaxis • Respiratory distress (feline)
Prevention • Drug administration (e.g., diphenhydramine, dexamethasone) Treatment • Slowing or discontinuing drug infusion in hypersensitive patients • IV fluids • Drug administration (e.g., dexamethasone, epinephrine) preemptively or during symptoms
• Mostly seen with doxorubicin and L-asparaginase administration
• Cerebellar ataxia • Peripheral neuropathy (e.g., constipation, hyporeflexia, weakness, motor dysfunction)
Peripheral neuropathy • Bulk laxatives • Remain within guidelines of dosages (e.g., 5-FU < 20 mg/kg PO)
• Mostly seen with 5-FU (cerebellar ataxia) and vincristine (peripheral neuropathy)
• Nephrotoxicity
• IV fluid diuresis (pre and post) • Monitor serum creatinine and urine specific gravity
• Mostly seen with cisplatin (canine) and doxorubicin (feline) • Avoid use in canines with existing renal insufficiency.
• Hemorrhagic cystitis • Stranguria, pollakiuria, hematuria
Prevention • Altering dosing frequency or drug choice • Administer in the morning to allow more time to empty bladder. • Drug administration (e.g., furosemide) • IV diuresis around time of injection • Provide access to fresh water and frequent trips outside. Treatment • Drug administration (e.g., NSAIDs, DMSO, 1% formalin)
• Mostly seen with canine cyclophosphamide administration • Do not repeat if cystitis occurs. • Mild cases are often self-limiting.
• Acute collapse and shock
• Aggressive fluid therapy • Labwork monitoring
• Rare condition • Extensive treatment for lymphoma or leukemia with rapid tumor breakdown
Acute Tumor Lysis Syndrome
Urologic
Gastrointestinal
Treatment
Neurologic
Table 8.7 / Chemotherapy: Toxicity (Continued)
8
CHAPTER 8 / PATIENT CARE
355
Skill Box 8.13 / Client Education: Monitoring Chemotherapy Response Patients receiving chemotherapy should be closely monitored by their owners to evaluate their response to treatment. Often clients are overly concerned about the health of the animal and therefore should be given guidelines as to when to call the clinic and when to monitor at home. Educating the client can give them the information and tools to make basic care decisions at home. Clinical Signs
8
When to Call Monitor
Call Clinic
Appetite
• Picky, but still eats treats
• Inappetance
Attitude
• Slightly lethargic
• Lethargic and/or reluctant to move
Bowel movements
• Soft stool
• Diarrhea
Temperature
• ≤103° F
• >103° F
Urination
• Normal
• Bloody urine
Vomiting
• Single event
• Frequent and retching
• Wear double-layer gloves when cleaning up urine, feces, or vomitus for 48 hours after receiving chemotherapy and follow proper disposal guidelines. • Maintain a low-stress environment. • Ensure proper scheduling of the next chemotherapy administration and follow-up evaluations and lab work.
356
SECTION FOUR: PATIENT CARE SKILLS
Insulin Therapy Skill Box 8.14 / Client Education: Insulin Administration Not all insulin syringes are alike, which can lead to incorrect dosage of insulin. Insulin syringes are typically found in 100-unit and 30-unit sizes. The 100-unit syringes are numbered in 10s with the smallest lines each measuring 2 units of insulin. The 30-unit syringes are numbered in 5s with the smallest line each measuring 1 unit of insulin. When administering small amounts of insulin it is advisable to use 30 unit syringes so as to ensure accuracy. Care must be taken to verify the type of syringe after purchase and before administration. Variations can also exist in the concentration of insulin; Vetsulin and PZI are U-40 with each 1 mL containing 40 units of insulin, while Glargine and Humulin R and U are U-100, with each 1 mL containing 100 units of insulin. Not being aware of this difference can greatly overdose or underdose a patient. Preparation
Drawing Up the Medication
Administering the Insulin
• See Table 17.30 Metabolic Drugs: Pancreatic, page 600. • Do not shake the vial; gently roll it between the palm of your hands to mix. • Use a new syringe for each injection.
1. Pull back the plunger of the syringe to position the top of the plunger (part closest to the needle) at the desired dose. 2. Insert the needle into the vial, and inject the air to prevent a vacuum in the vial. 3. Slowly pull back on the plunger to the desired amount and withdraw the needle from the vial. 4. Check to make sure there are no bubbles in the syringe; if present, pull back on the plunger, and tap the syringe to move the bubbles to the top. Then push the plunger until all the air is out of the syringe. 5. Verify the correct amount of insulin is within the syringe.
1. Locate an area anywhere from mid neck to the last rib and halfway down on either side, changing with each injection. 2. Place your index finger against the back of the animal and use your thumb and middle finger to pull up skin to form a “tent” under your index finger. 3. Insert the needle, bevel side up, into the skin at a 45° angle. 4. Pull back on the plunger to verify no blood or air fills the syringe; if present, remove needle and try again. 5. Depress the plunger to insert the insulin under the skin. 6. Remove the syringe and immediately recap it. 7. Properly dispose of the syringe and needle.
CHAPTER 8 / PATIENT CARE
357
8
Skill Box 8.15 / Client Education: Monitoring Insulin Response When caring for a diabetic patient, diligent monitoring both at home and along with careful veterinary management must take place to achieve the appropriate patient plan. Along with monitoring for life-threatening hypoglycemia, hyperglycemia must also be monitored to evaluate the patient’s response to insulin and to detect any early complications. With the initiation of insulin therapy, the protocol will vary until the patient has become regulated. To monitor long-term insulin therapy with veterinary management, physical examinations are scheduled every 2–6 months and serum fructosamine or glycosylated hemoglobin concentrations are obtained. The success of the treatment of most diabetic patients lies in the hands of the owner, their attention to detail and keen observations are critical. At home monitoring includes the parameters listed below; all results should be relayed to the veterinarian so adequate dose adjustments can be made.
8
• Monitor • Appetite • Attitude • Body condition • Polydipsia/polyuria • Urine glucose/ketone levels • Initially, monitor daily and then 2–4 times monthly. • Urine glucose should maintain 0–1+. • Consistent high results (>2+) may require ↑ dose and consistently low results (0) may require ↓ dose as directed by veterinarian. • Positive results may be seen with excitement, ↑ carbohydrate intake and corticosteroid administration. • See Tips under Urogenital Procedures for collecting urine samples at home, page 434. • Glucometer • Fasting blood glucose (BG) twice weekly and blood glucose curve monthly or as directed by veterinarian • BGC • Necessary to assess insulin efficacy, peak and duration of effect, and degree of fluctuations • At home monitoring: • Test every 2 hours (every 4 hours with Glargine) starting before the morning insulin and ending after the following morning insulin dose. • Ideal BGC results show the nadir (lowest BG) between 100–150 mg/dL halfway between dosing intervals. • A variety of glucometers are available for home monitoring. • Blood samples are obtained from the capillary bed of the ear margin, foot pads, and (canine only) lip, elbow callus, and base of tail.
358
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 8.16 / Client Education: Monitoring for Hypoglycemia Hypoglycemia is the condition of a low blood glucose level, too low to effectively fuel the body’s blood cells. This is often seen when there is a relative or absolute excess of insulin circulating in the bloodstream caused by; too much insulin administered, missed or delayed meal, eating a smaller than normal meal, vomiting a meal, strenuous exercise, stress and certain medications. With a blood glucose level <60 mg/dL, most animals will exhibit a drunken state and the administration of a carbohydrate source will show a quick recovery. Animals with a blood glucose level <20 mg/dL often lose consciousness and seizures may occur; the administration of a carbohydrate source should be immediately instituted followed by immediate medical attention. Signs to Watch for
Actions to Take
Prevention
• • • • • •
• Give a carbohydrate source orally (e.g., Karo syrup, maple syrup). • Seek veterinary care immediately. • Keep the animal warm.
• Feed the animal the same food and amount at the same times every day. • Do not feed table scraps or any diet other than the agreed-on diabetic diet. • Feed multiple meals each day. • Provide fresh clean water at all times. • Maintain a consistent exercise program. • Do not administer insulin to a patient that is not eating unless directed to do so by the veterinarian.
Depression, lethargy Deviations from normal behavior Drunken state (e.g., stumbling, staggering) Lack of appetite Panting Seizures, comas
8
FLUID THERAPY Fluid administration is necessary when an animal is dehydrated, experiencing shock, losing blood, or having a surgical procedure that may result in excessive blood loss or has a disease that is resulting in depletion of the animal’s normal fluid, electrolyte, or acid-base balances. Dehydration may lead to hypovolemia and hypoperfusion. Fluid requirements are based on an animal’s hydration status, reason for
fluid loss, and physical condition. The veterinarian is responsible for prescribing the appropriate fluid therapy. Obtaining the following assessments will assist the veterinarian in the calculation of fluid requirements for the animal. Distinction between dehydration and perfusion status is an important factor in the veterinarian’s choice of fluid therapy. The following charts are to provide the technician with information to help understand the veterinarian’s fluid therapy plan and to assist in the process of administration.
CHAPTER 8 / PATIENT CARE
359
Skill Box 8.17 / Hydration Assessment
Physical Examination
Assessment of Hydration
Medical History
Laboratory Assessment
8
360
Hydration Significance
Assess Dehydration Status • Skin turgor: assess the amount of time it takes for the skin to return to the animal’s body when gently pulled up and twisted at the back of the neck or along the spine. Use 2 or 3 assessment locations. • Obesity can falsely ↓ turgor, and emaciation can falsely ↑ turgor. • Mucous membranes: assess for dryness of gums and cornea (moist, tacky, dry) • Eye position: assess the degree of eye sinkage into the bony orbit Assess Perfusion Status • Capillary refill time: direct digital pressure is applied to the mucous membranes until blanched and then timed for blood (pink color) to return (normal: <1–2 seconds) • Heart rate and pulse (femoral and metatarsal): assess heart rate, pulse (amplitude and duration) • Canine: 70–180 bpm • Feline: 110–220 bpm • Weight of the animal: Patient’s normal body weight and current weight should be noted. 1 lb. body weight = 1 pint (480 mL) fluid
<5%: normal hydration • No obvious clinical sign • Skin turgor: <2 seconds 6%–8%: mild dehydration • Skin: Inelastic and leathery • Twist: disappears immediately • Skin turgor: >3 seconds • Eyes: duller than normal and sunken • Mucous membranes: tacky to dry 8%–10%: moderate dehydration • Skin: inelastic and leathery • Twist: disappears slowly • Skin turgor: >3 seconds • Eyes: duller than normal and sunken • Mucous membranes: tacky to dry • Heart rate: ↑ 10%–12%: severe dehydration • Skin: no elasticity • Twist: remains indefinitely • Skin turgor: remains indefinitely • Eyes: dry, deeply sunken • Mucous membranes: dry, cyanotic, and possibly cold • CRT: prolonged or absent • Heart rate: ↑ • Pulse: weak 12%–15%: patient is in shock and death is imminent
Packed cell volume • Canine: 37%–55% • Feline: 24%–45%
• Dehydration at >45%
Total protein, serum • Canine: 5.4–7.6 g/dL • Feline: 6.0–8.1 g/dL
• Dehydration at >8.0 g/dL
Urine specific gravity • Canine: >1.035 • Feline: >1.040
• Evaluates kidney function more than hydration status, only reflects dehydration if kidneys are healthy.
CVP • <8 cm H2O • Monitor trends over time, not a single reading
• See Skill Box 8.2 Central Venous Pressure, page 334. • Assesses true venous return to the heart • Low pressure reflects low effective circulating volume.
Serum lactate
• ↑ Serum lactate may indicate poor perfusion.
Patient’s history
Fluid Loss • Amount of vomiting, diarrhea, and salivation • Amount of fluid and food intake
Review of patient’s file
• Previous physical problems (e.g., heart disease, kidney diseases) will influence fluid therapy
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 8.18 / Calculating Fluid Requirements The rates shown below are for those patients without pulmonary, cardiac or severe renal disease and are able to handle total rapid or high fluid rates. Veterinarians will need to prescribe the actual amount, the type of, and the rate of the fluid to be administered. Purpose
Basis of Calculations
Rate
Rehydration
Basic Rehydration Formula • Calculates the fixed rate of replacement fluids to correct the deficit over 4–6 hours
• % dehydrated × body weight (kg) × 1000 mL/kg = mL of fluid replacement Example: Animal weighing 20 kg is dehydrated 6%. Fluid needed for basic rehydration is calculated as: 0.06 × 20 (kg) × 1000 (mL/kg) = 1,200 mL
Maintenance Calculation • Calculates the amount of fluid to replace losses resulting from urination, feces, respiration • Panting and fever will ↑ amount of fluid loss (evaporative loss).
• 40–60 mL/kg/day in a mature animal • Dependent on the cause of the loss and animal’s condition
Ongoing losses • Calculates the amount of fluid loss attributable to excessive vomiting, diarrhea, polyuria, and third spacing of body fluids
• 20 mL vomit = 20 mL fluids
Anesthetic Protocol
• Calculated on expected fluid loss during surgery (e.g., blood)
• Healthy patients, elective procedures: 5 mL/kg/hr • 5–15 mL/kg/hr • Adjustments made based on patient’s status (e.g., blood pressure, perfusion)
Postoperative Protocol
• Calculated to account for rehydration, maintenance, and ongoing losses
• Evaluation rehydration above
Pediatric Protocol
• Calculated to account for the rapid water turnover of neonates as their body weight is 80% water
• 60–180 mL/kg/day
Shock Protocol
• Calculated to establish a circulating blood volume to allow adequate tissue perfusion
• Crystalloids • Canine: 40–90 mL/kg/hr • Feline: 20–60 mL/kg/hr • Colloids • Canine: 15–20 mL/kg, increments of 5 mL/kg over 15 minutes • Feline: 25 mL/kg/day, administered over 30–40 minutes • Rates are adjusted when crystalloids and colloids are given concurrently. • Rates are indicated when the patient has adequate/normal cardiopulmonary function.
CHAPTER 8 / PATIENT CARE
8
361
Table 8.8 / Routes of Fluid Administration Route
Indication
Complications
Notes
Oral
• Minimal fluid loss • Recent anorexia, neonates
• Tracheal intubation and aspiration, vomiting, regurgitation, aerophagia
• Contraindicated: vomiting, diarrhea, dysphagia, or life-threatening situations (e.g., shock) • Administration by bottle, syringe, or enteral feeding tubes
Subcutaneous Dorsal Midline Dorsal Flanks
• Mild to moderate dehydration • Maintenance
• Injection site infection (rare) • Do not use >2.5 % dextrose, as sloughing and abscesses may occur
• Contraindicated: infected or devitalized skin, hypothermia, or severely dehydrated • Warmed to body temperature and allow flow by gravity • Use only isotonic fluids. • Use several sites; no more than 10–20 mL/kg. • Absorption is expected within 6–8 hours. • Technique: See Skill Box 8.8 Injections, page 348.
Intravenous
• Severe dehydration • Condition of animal is severe • Perioperative precaution
• Phlebitis, septicemia, embolism, volume overload
• • • • •
Intraperitoneal
• Mild to moderated dehydration • Large volumes
• Peritonitis and intraabdominal abscess
• Contraindicated: ascites, peritonitis, sepsis, pancreatitis, or expected abdominal surgery • Warmed to body temperature isotonic fluids • Absorption can take up to 20 minutes. • Used to treat severe hyper- or hypothermia • Technique: the caudal abdomen is aseptically prepared. An 18–22 gauge needle is inserted on the ventral midline, caudal to the umbilicus. The syringe is aspirated, if no fluid is seen (e.g., blood) the fluids are attached and administered. If fluid is seen, the needle is removed and repositioned.
Intraosseous
• Small animals (<5 kg), neonates, or animals with poor venous access
• Osteomyelitis, fractures, and growth plate damage
• Flush catheter with heparinized saline every 4–6 hours if fluid therapy is discontinued. • An IV catheter should be placed as soon as a site allows (24–72 hours). • All intravenous medications and fluids can be administered IO. • Technique: See Skill Box 8.10 Intravenous Catheter Placement: Arterial and Intraosseous, page 350.
8
362
SECTION FOUR: PATIENT CARE SKILLS
Contraindicated: anemia Warmed to body temperature Requires rate calculation Requires closer monitoring; especially in cardiac insufficiency cases Flush catheter with heparinized saline every 6–12 hours; replace catheter every 72 hours. • Technique: See Skill Box 8.9 Intravenous Catheter Placement: Peripheral and Jugular, page 349.
Table 8.9 / Commonly Used Fluids
Selecting the type of fluid to administer can be as important as the selected route and rate. In selecting a fluid, it is important to know the electrolyte status of the patient and the underlying disease. From this information, fluids are then chosen based on a composition that best fits the patient’s condition and need. Colloids are most commonly used in shock, severe hypoalbuminemia, sepsis, SIRS, and hypotension, as they replace intravascular fluids. Due to the large-molecular-weight substances, colloids remain in the plasma compartment, leading to volume expansion. Synthetic colloids are chosen when the albumin is >2 g/dL; patients with albumin <2 g/dL require natural colloids (e.g., plasma, pRBCs). Crystalloids are the most commonly used extracellular replacement fluid, due to reduced expense, availability, and rapid rate of correcting volume deficits. Crystalloids contain electrolyte and nonelectrolyte solutes and are able to enter all body fluid compartments. However, only 20–33% remains in the vascular space 30 minutes and 10–20% 1 hour after administration.
Synthetic Colloids
Fluid Type
Indications
Route
Comments
Dextran 70
• Volume expansion • Shock therapy
IV slowly
• Monitor cardiac function. • Allergic responses (rare) • Possible coagulopathies, ↑ BG levels, altered TP and blood crossmatching results • Remains within the vascular space for 4–8 hours
Hetastarch
• Hypoproteinemia • Shock therapy
IV
• • • •
• Volume expansion • Anemia and shock due to tissue hypoxia
IV
Oxyglobin
Allergic responses, mostly cats, and eliminated with slow infusion Possible coagulopathies and ↑ amylase Remains within the vascular space for 12–48 hours ↑ Osmotic and oncotic pressure of blood
8
• Oxygen-carrying capacity for up to 40 hours • Altered serum chemistries and bilirubinuria • Slow infusion and diligent monitoring required to avoid fluid overload in normovolemic patients. • Used within 24 hours after removing the foil packaging • Indicated for dogs only
CHAPTER 8 / PATIENT CARE
363
Table 8.9 / Commonly Used Fluids (Continued)
8
Crystalloids
Fluid Type
364
Indications
Route
Comments
Dextrose 5% in Water (D5W) • Isotonic
• Free water deficits • Calories (179 kcal/L) • Hypernatremia
IV
• High dosages or prolonged use may produce pulmonary edema and dilution of electrolytes • Incompatible with penicillins
Lactated Ringer’s • Isotonic
• • • •
IV, SQ
• Contraindicated: hepatic disease, hypercalcemia, hyperkalemic, hyperlactatemic • Incompatible with cephalothin sodium and chlortetracycline
Normosol-R • Isotonic
• Replacement fluid • Maintenance fluid • Acidotic states
IV, SQ
• Contraindicated: cancer, hypercalcemia, hyperkalemic • May sting when given SQ
Plasma-Lyte A • Isotonic
• • • •
IV, SQ
• Contraindicated: hyperlactatemic, hypercalcemia, hyperkalemic • May sting when given SQ
Ringer’s Solution • Isotonic
• Replacement fluid • Corrects metabolic alkalosis
IV, SQ, IP
• Monitor: electrolyte concentrations and pulmonary function
0.45% Sodium Chloride (NaCl) • Hypotonic
• • • •
IV
• Contraindicated: shock therapy • Used for patients with high risk of fluid retention
0.9% Sodium Chloride (NaCl) • Isotonic
• Replacement fluid • ↑ Plasma volume • Hyponatremia, hypochloremia, hyperkalemia, hypercalcemia • Bathes tissue during surgical procedures • Shock therapy
IV, SQ, IP
• Contraindicated: sodium restricted cases, heart failure, hypertension, metabolic acidosis • Monitor: electrolyte concentrations and pulmonary pressure • Long-term infusion may cause electrolyte imbalances • Incompatible with amphotericin B
7.5% Sodium Chloride (NaCl) • Hypertonic
• Volume expansion • Shock therapy
IV
• Normal hydration required before use • Administered in small boluses (e.g., 3–5 mL/kg) • Monitor: CVP, electrolytes
SECTION FOUR: PATIENT CARE SKILLS
Replacement fluid Maintenance fluid (short term) Acidotic states Shock therapy
Replacement fluid Maintenance fluids Acidotic states Shock therapy
Long term fluid therapy Free water deficits Hypernatremia Sodium restrictions
Table 8.10 / Fluid Additives Additive
Indications
Route
Comments
Calcium Gluconate and Calcium Chloride
• Correction of hypocalcemia • Eclampsia
IV slowly
• Contraindicated: hypercalcemia and ventricular fibrillation • Rate is variable depending on condition and other laboratory values. • Monitor: hypercalcemia, hypotension, cardiac arrhythmias (when given in conjunction with potassium), cardiac arrest and venous irritation • Calcium gluconate compatible with D5W, NaCl, LRS, dextrose/NaCl combinations and dextrose/LRS combinations
Dextrose 50%
• Hypoglycemia • Caloric supplementation
IV
• Contraindicated: hyperglycemia • See Skill Box 17.1 Basic Calculations, page 570.
Potassium Chloride (KCl)
• Prevention or correction of hypokalemia
SQ, IM
• Contraindicated: hyperkalemia, acute renal failure, acute dehydration and severe hemolytic reactions • Rate of infusion is critical: • IV: ≤0.5 mEq/kg/hr, do not exceed 40 mEq/L • SQ: ≤30 mEq/L • Must be diluted • Monitor: hyperkalemia, bradycardia, or arrhythmias • Compatible with all commonly used IV fluids • Acidosis may show falsely ↑ K+ levels and alkalosis falsely ↓ K+ levels. • Protect fluid bag from light.
Sodium Bicarbonate
• Correction of metabolic acidosis • Hypercalcemic and hyperkalemic crises
IV
• • • • •
Vitamin B Complex
• Anorexic patients
SQ, IM, IV
• Necessary for sufficient energy metabolism (e.g., glucose, fat, protein) • Protect fluid bag from light.
Contraindicated: metabolic or respiratory alkalosis, hypochloremia and LRS fluids Caution: congestive heart failure or other edema-causing conditions Rate is variable depending on condition and other laboratory values. Monitor: blood gas measurements and acidosis status Compatible with D5W, NaCl, dextrose/NaCl combinations
Skill Box 8.19 / Calculating Drip Rates 1. Number of mL needed/Time in which the fluid can be administered (in minutes) = mL/min
Example: Need 1200 mL to be given over 5 hours, using a 15 drops/mL administration set:
2. mL/min × drops/mL of the administration set = No. of drops/min
[1200 divided by (5 hours multiplied by 60 min/hr)] multiplied by 15 drops/mL = 60 drops/min or 1 drop/sec
3. No. of drops/min divided by 6 = No. of drops/10 seconds or No. of drops/min divided by 60 = No. of drops/second if the flow rate is high
[1200/300] × 15 = 60 drops/min or 1 drop/sec
CHAPTER 8 / PATIENT CARE
365
8
Table 8.11 / Monitoring Fluid Therapy
8
Physical
Monitoring fluid therapy for the desired effect as well as potential adverse effects is necessary for a successful outcome. No one parameter or value can evaluate fluid therapy; it is a combination of results and trends over time. Along with monitoring the patient for dehydration and overhydration, the equipment (e.g., catheter, administration set, fluid bag, pump) must also be monitored for proper function.
366
Assessment
Dehydration
Normal
Overhydration
Comments
Blood Pressure
• Hypotension
• See Table 8.2, Blood Pressure Results, page 337.
• Hypertension
• See Table 8.1 Blood Pressure Procedure, page 335.
Capillary Refill Time
• ↓ CRT
• 1–2 seconds
• ↑ CRT
• Assesses peripheral perfusion
Heart Rate, Pulse Rate, and Effort
• Tachycardia • Weak pulses
• Canine: 70–180 bpm • Feline: 110–220 bpm
• Tachycardia, gallop • Strong or bounding pulses
• Assesses cardiovascular status and intravascular fluid volume status
Mentation
• Depressed, dull
• Calm, relaxed
• Agitated, restless
Physical Examination
• Sunken eyes
• See Table 2.2 Physical Examination, page 18.
• Serous nasal discharge, ↑ jugular pulses, pitting edema, chemosis, dyspnea
• Performed multiple times a day to evaluate hydration and calculate ongoing losses
Pulmonary Auscultation
• N/A
• Heard equally on both sides • Smooth, quiet sound
• Cough, pulmonary edema, harsh lung sounds, crackles, rales
• See Table 2.3 Pulmonary Examination, page 32.
Respiratory Rate and Effort
• Variable
• Canine: 10–30 breaths/min • Feline: 25–40 breaths/min
• Tachypnea, dyspnea
Skin Turgor
• ↓ Skin turgor
• <2 seconds
• ↑ Skin turgor
• See Table 8.17 Hydration Assessment, page 360.
Urine Output
• <1 mL/kg/hr
• 1–2 mL/kg/hr
• Alteration from normal
• Assesses renal function and perfusion (GFR)
Weight
• ↓ Weight
• Variable
• ↑ Weight
• Monitor weight 3–4 times a day with aggressive fluid administration and daily with maintenance rates. • ↑ Weight may be a sign of developing pulmonary edema or elevated CVP. • An ↑ of 1 kg equals 1 L of fluid. • Body weight ↑ by the % of dehydration indicates a need to change to a maintenance fluid rate from that point forward.
SECTION FOUR: PATIENT CARE SKILLS
Laboratory
Table 8.11 / Monitoring Fluid Therapy (Continued) Assessment
Dehydration
Normal
Overhydration
Comments
Central Venous Pressure
• −2 to +5 cm H2O
• <8 cm H2O
• >10 cm H2O or an ↑ of more than 5 cm H2O within a 24hour period
• Assesses true venous return to the heart • Low pressure reflects low effective circulating volume. • High pressure may reflect fluid overload, rightsided myocardial failure, or restrictive pericarditis.
Electrolytes
• N/A
• See Table 4.2 Blood Chemistries, page 76.
• N/A
• Evaluated to determine the need for replacement therapy
Packed Cell Volume
• ↑ PCV, >50%
• Canine: 37%–55% • Feline: 24%–45%
• ↓ PCV, <20%
• Assesses hydration status and hemodilution effect of rapid crystalloid infusion
Temperature
• Variable
• 100.5–102.5° F
• Hypothermia, shivering
• A rise of 1.8° F may require a 10% ↑ in the maintenance fluid rate.
Total Protein
• >8.0 g/dL
• Canine: 5.4–7.6 g/dL • Feline: 6.0–8.1 g/dL
• <4.0 g/dL
• Assesses the relative serum oncotic pressure • A ↓ in oncotic pressure allows more fluid to flow into the interstitium, causing edema (e.g., pulmonary, SQ).
8
BLOOD TRANSFUSIONS Blood transfusions have become very popular with the wide availability of blood products. National commercial animal blood banks have been established along with many in-hospital donor programs. With this available
treatment option, increased knowledge has been gained, leading to the promotion of blood component therapy. Treating each patient according to their individual needs with specific blood components decreases the possibility of transfusion reactions and allows multiple patients to benefit from each unit of blood.
CHAPTER 8 / PATIENT CARE
367
Table 8.12 / Blood Types
The first step to performing a blood transfusion is the full understanding of blood types for both the canine and feline. Misinformation in this step can lead to serious transfusion reactions and even death. Blood types are distinguished by different genetic markers on the surface of the RBC. These genetic markers are antigenic and to different degrees cause the immune system to react to unmatched transfused blood to form antibodies (alloantibodies or isoantibodies). These antibodies are found in the plasma and can lead to reactions that can cause minor to severe transfusion reactions. Dogs have more than 12 different blood groups and multiple blood types. The genetic markers on the surface of the RBC are known as dog erythrocyte antigens (DEAs). Dogs do not have naturally occurring alloantibodies and are designated as either positive or negative for a specific antigen (e.g., DEA 1.1+ or DEA 1.1−). DEA 1.1+ is found in over 50% of dogs and is currently the most clinically significant in dog transfusion reactions. Transfusing a DEA 1.1− dog (recipient) with DEA 1.1+ blood will allow the recipient to form alloantibodies, leading to immediate reactions or potentially life-threatening reactions on following transfusions. There are also other known and unknown blood types that can lead to transfusion reactions on the first and subsequent transfusions. Cats have only 1 blood group but 3 blood types: A, B, and AB. These blood types, like dogs, are distinguished by specific antigens found on the membranes of the RBCs. All cats have naturally occurring antibodies specifically directed against the antibody they lack (e.g., A or B). Therefore, a transfusion of mismatched blood types will lead to immediate and possibly life-threatening reactions. Even though the overwhelming majority of cats have type A blood, cats with blood type B have the strongest alloantibodies against type A blood and suffer the most severe reactions. Although uncommon, type B blood is most commonly found in certain breeds and concentrated in certain geographical locations.
8
Feline Blood Types
Prevalence
Naturally Occurring Alloantibodies
Mismatched Transfusion Reactions
A
• Most prevalent worldwide • 99.7% of cats
• Weak anti-B antibodies at a low titer
• Administering type B blood: acute hemolytic transfusion reaction (↓ cell life) • Less severe reaction than administering type A blood to a type B patient
B
• 0.3% of all felines • >30%: Devon Rex, British Shorthair, Exotic Shorthair, Turkish Van, Turkish Angora • 15–30%: Abyssinian, Birman, Himalayan, Persian, Somali • Certain geographical areas with DSH
• Strong anti-A antibodies at a high titer
• Administering type A blood: apnea, hypotension, cardiac arrhythmias, collapse, death
AB
• Extremely rare • Abyssinian, Birman, British Shorthair, DSH, Japanese Bobtail, Norwegian Forest, Persian, Scottish Fold, Somali
• Lack antibodies to type A or B blood • Universal recipient
• None based on blood type
368
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 8.20 / Blood Collection To ensure the quality of each unit of blood obtained, a strict collection protocol must be followed. Each donor should only be selected once he or she has fulfilled all the protocol requirements. Once selected, 13–17 mL/kg in dogs and 10–12 mL/kg in cats of blood can be collected monthly. Blood is collected into a closed system, which is also airtight and sterile. The most important step to blood collection is sterility. Sterility must be maintained through every step of the process to avoid nonimmunogenic transfusion reactions. Throughout the process, the donor’s status must be continuously evaluated (e.g., mucous membranes, pulse rate and strength, respiratory rate). Any sign of donor compromise is cause for potential discontinuation. Donor Requirements
Canine
• Easy to handle and neutered • No health concerns or current medications • Current vaccinations • Currently taking heartworm preventative • >50 lb ideal • 1–7 years of age
Testing
Collection Supplies
Procedure
• Complete physical examination • Blood typing • Baseline laboratory work • CBC, biochemical profile, urinalysis, thyroid hormone, fecal examination, von Willebrand’s factor • Infectious disease screening • Dirofilaria immiti, Erhlichia canis, Babesia canis, B. gibsoni, Brucella canis, Bartonella • Additional testing may be necessary depending on the breed and geographical area.
• Blood donor bag and tubing • Venipuncture needle • Anticoagulant • CPDA-1, CPD • Shelf-life of 28–35, 21 days, respectively • 14 mL/100 mL of blood • Sodium citrate • Shelf-life of 48 hours • 1 mL/7–8 mL of blood • Guarded hemostat • Tube sealing • Aluminum sealing clips • Electric sealer • Tubing sealer stripper or household pliers
1. Clamp the tubing behind the needle. 2. Add anticoagulant to the blood donor bag, paying close attention to sterility. 3. Charge the tubing with anticoagulant as the blood must flow through the anticoagulant to the bag. 4. Prepare and perform sterile venipuncture. 5. Place the collection bag as far below the patient as the tubing will allow. 6. Frequently mix the bag and anticoagulant to prevent clotting during collection. 7. Collect the desired amount of blood; then clamp the tubing next to the needle and remove from the donor. 8. Strip the tubing of blood, mix the bag, and allow the tubing to refill with blood. 9. Seal the tubing, cut off excess and remove clamped hemostat.
CHAPTER 8 / PATIENT CARE
369
8
Skill Box 8.20 / Blood Collection (Continued) Donor Requirements • Easy to handle and neutered • No health concerns or current medications • Current vaccinations • >10 lb • 1–7 years of age
Collection Supplies
• Complete physical examination • Blood typing • Baseline laboratory work • CBC, biochemical profile, urinalysis, thyroid hormone, fecal examination • Infectious disease screening • FeLV, FIV, Mycoplasma hemofelis, Bartonella spp. • Additional testing may be necessary depending on the geographical area.
• • • •
370
• • • • •
Feline
8
Testing
SECTION FOUR: PATIENT CARE SKILLS
Blood donor bag and tubing 19-gauge butterfly catheter 3-way stopcock Anticoagulant • CPDA-1, CPD • Shelf-life of 28–35, 21 days, respectively • 1.4 mL/10 mL of blood • Sodium citrate • Shelf-life of 48 hours • 1 mL/7–8 mL of blood Guarded hemostat 12 mL syringe 60 mL syringe Tube sealing • Aluminum sealing clips • Electric sealer Tubing sealer stripper or household pliers
Procedure 1. Assemble the stopcock, donor bag, tubing and syringe. 2. Place the stopcock in the off or closed position. Note: At no time should the stopcock be positioned to allow outside air to enter the tubing, leading to contamination. 3. Add anticoagulant to the injection port of the 60 mL syringe, paying close attention to sterility. 4. Place the stopcock in the open position to charge the butterfly catheter tubing with anticoagulant, as the blood must flow through the anticoagulant to the bag. 5. Remove the hemostat and connect the donor tubing to the catheter tubing. Note: Sedation and IV fluids may be required for feline donors. 6. Prepare and perform sterile venipuncture. 7. Gently and lightly aspirate blood into the syringe. 8. Collect the desired amount of blood, place the stopcock in the closed position, and remove the needle from the donor. 9. Gently invert the syringe several times to mix the anticoagulant with the blood. 10. Transfer the blood from the syringe into the blood donor bag. 11. Strip the tubing of blood, mix the bag, and allow the tubing to refill with blood. 12. Seal the tubing and cut off.
Table 8.13 / Blood Products Blood Product
Contents
Use / Action
Storagea
Preparation / Administration
Whole Blood, Stored (SWB)
• RBCs, WBCs, plasma proteins
• Use • Anemia, hypoproteinemia • Large volume deficits • Action • ↑ Blood volume and oxygencarrying capacity
• Storage: 4° C (39.2° F) • Shelf-life: 48 hours with sodium citrate and 28 days with CPDA-1
• Preparation • A change in color (e.g., purple, brown, green) or texture (e.g., clots) may indicate contamination • ± Warm to <35° C (98.6° F) • Administration • Volume: 6–12 mL/kg (2 mL of whole blood/kg will raise the PCV 1%) • General: 10 mL/kg/hr until desired PCV reached • Rate: initial rate of 0.1–1 mL/min for 30 minutes, with a gradual ↑ to 4–6 mL/ min as the patient allows • Caution: canine CHF: ≤5 mL/kg/day
Packed RBCs (pRBC)
• Most of the supernatant plasma removed • 80% PCV
• Use • Anemia • Animals in fear of fluid overload (e.g., CHF) • ↓ Risk of exposure to plasma antigens • Action: • ↑ Oxygen-carrying capacity
• Separated from unrefrigerated whole blood within 8 hours of collection • Storage: 4° C (39.2° F) • Shelf-life: 35 days with CPDA-1 and 21 days with CPD • Gently mix refrigerated bags twice weekly
• Preparation • A change in color (e.g., purple, brown, green) or texture (e.g., clots) may indicate contamination • ± Warm to <35° C (98.6° F) • Addition of 0.9% sterile saline may be needed to ↓ viscosity of the pRBCs. • Administration • Volume: 6–12 mL/kg • 1 mL of whole blood/3 lb of BW will raise the PCV 1.5% • Rate: initial rate of 0.1–1 mL/min for 30 minutes, with a gradual ↑ to 4–6 mL/ min as the patient allows
• Use • Coagulation factor deficits, DIC, severe liver disease, vitamin K deficiency, pancreatitis, severe parvovirus enteritis • Hypoproteinemia and hypoglobinemia • Prolonged PT/APTT • Control of active bleeding • Preoperative prophylaxis • Action • Full activity of all coagulation factors • Expand extracellular fluid volume.
• Frozen within 8 hours of collection • Storage: −20° C (1° F) • Shelf-life: 1 year, then can be relabeled as FP for an additional 4 years
• Preparation • Plasma bags are brittle and should be warmed in their transport box and then inspected for cracks prior to administration. • Unopened bags can be refrozen with minimal loss of activity. • Warm to <35° C (98.6° F). • Administration • Volume: 6–12 mL/kg • Rate: initial rate of 1–2 mL/min to a maximum rate of 3–6 mL/min, administer within 1–2 hours to allow therapeutic plasma levels to be obtained
Fresh Frozen Plasma (FFP)
• Plasma supernatant • Hemostatic proteins, albumin, globulins, coagulation factors
CHAPTER 8 / PATIENT CARE
371
8
Table 8.13 / Blood Products (Continued) Blood Product
Contents
Use / Action
Storagea
Preparation / Administration
Frozen Plasma (FP)
• Plasma supernatant • Hemostatic proteins, albumin, globulins, coagulation factors (II, VII, IX, X)
• Use • Coagulation factor • Hypoproteinemia and hypoglobinemia • Action • Full activity of coagulation factors II, VII, IX, and X • Low activity of coagulation factors V and VIII
• Frozen >8 hours after collection • Storage: −20° C (1° F) • Shelf-life: 5 years
• Preparation • Plasma bags are brittle and should be warmed in their transport box and then inspected for cracks prior to administration. • Unopened bags can be refrozen with minimal loss of activity. • Warm to <35° C (98.6° F) • Administration • Volume: 10–20 mL/kg • Rate: initial rate of 1–2 mL/min to a maximum rate of 3–6 mL/min, administer within 1–2 hours to allow therapeutic plasma levels to be obtained
Cryoprecipitate
• Heavy, cold-insoluble proteins • 50% yield of factor VIII • von Willebrand’s factor, fibrinogen, fibronectin
• Use • Hemophilia A, von Willebrand disease, fibrinogen deficiency, or dysfunction • Topical hemostatic in surgery • Action • Coagulation factor replacement
• Storage: −20° C (1° F) • Shelf-life: 1 year
• Preparation • Plasma bags are brittle and should be warmed in their transport box and then inspected for cracks prior to administration. • Warm to <35° C (98.6° F) • Thawed product may be refrozen within 2 hours without effect. • Administration • Volume: 1–2 mL/kg • Rate: slow IV bolus over 10–20 minutes
Oxyglobin
• Acellular oxygencarrying replacement fluid • Derived from bovine hemoglobin
• Use • ↑ Intravascular volume • Alleviates the risk of RBC sensitization • ↑ Oxygen-carrying capacity • Action • Carries O2 and CO2 similar to hemoglobin • Expand extracellular fluid volume.
• Storage: room temperature or refrigerated • Shelf-life: 3 years
• Preparation • ± Warm to <35° C (98.6° F) • Administration • Volume: 10–30 mL/kg • Rate: IV to a maximum rate of 10 mL/kg/hr • Used within 24 hours after removing the foil packaging • Indicated for canines only
8
a
Storage referring to blood collected in a closed collection system.
372
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 8.21 / Blood Administration Transfusion Protocol
Patient
Blood
Preparation
• Perform blood typing and a crossmatch before every transfusion. • Catheter • The catheter must be dedicated to transfusion use only. • Technique • Place an IV catheter with strict aseptic technique. • To use an existing catheter, flush the catheter before and after the transfusion with 0.9% sterile saline.
• Inspection • Verify the correct patient and blood type have been selected. • Each bag should be thoroughly inspected prior to administration for changes in the integrity of the bag, changes in blood color, and presence of hemolysis or clots. • Warming • Refrigerated products do not need to warmed unless large volumes are to be given or the patient is hypothermic. • Temperatures > 37° C (98.6° F) may lyse RBCs (↓ oxygen-carrying capacity, inactivate proteins and clotting factors) and accelerate bacterial overgrowth. • Techniques • Place bag at room temperature for 30 minutes. • Place blood bag (and transport box if included) into zip-lock bags (to avoid infusion port contamination and damage to brittle bags) and submerge bags into a container of warm water for 15 minutes or until ≤37° C (98.6° F). • Run the IV tubing through warm water during the transfusion.
Setup
• Place the patient in a clean comfortable cage with white bedding to observe for hemoglobinuria. • Place in an area of the hospital allowing continuous visual monitoring by all staff.
• Filters • A blood administration set with an inline 170- to 270-μm pore, non-Latex filter should be used to remove clots and debris collected during storage. • Filters are functional for 2–4 units of blood or for a maximum use of 4 hours. • No fluids (LRS, D5W, hypotonic saline) or medications should be added to a blood bag except 0.9% sterile saline, to avoid triggering coagulation (e.g., calcium in fluids).
Monitoring • Obtain baseline vital signs before beginning the transfusion (e.g., urine color, PCV, temperature, pulse, RR). • Obtain basic vital signs very 5 minutes for 15–30 minutes. • Continue monitoring every 15 minutes for the duration of the transfusion.
• Routes • IV is the preferred route of transfusions, but intraosseous catheters can be used in patients with difficult venous access with excellent results (e.g., femur, tibia, humerus). • Ratea • The rate is based on the blood product, recipient size, and health status. • The initial slow rate of 0.1–1 mL/min for 30 minutes, with a gradual ↑ to 4–6 mL/min as the patient allows. • Blood may be administered by gravity or through a infusion pump rated to delivery blood products while causing no harm to the cells. • Transfusions should be completed within 4 hours to ↓ bacterial overgrowth.
Administration
a See Skill Box 8-19 Calculating Drip Rates, page 365. Note: Storage of blood samples from the donor and recipient for 1 week post transfusion can be used if the event of an adverse reaction. Note: 10 mL/kg of packed RBCs or 20 mL/kg of whole blood ↑ the PCV by 10% if the donor has a PCV of approximately 40% (Thrall, 2004, p. 200).
CHAPTER 8 / PATIENT CARE
373
8
Table 8.14 / Blood Transfusion Reactions
Transfusion reactions under most circumstances can be avoided with attention to detail. With the proper selection and testing of donors, proper collection of blood and proper handling and care of blood products and IV catheters, the majority of transfusions will take place uneventfully. However, reactions do occur due to factors that cannot be tested for or expected. Reactions can be seen either acutely (within minutes to hours) or delayed (days to years) and are divided into either immunologic or nonimmunologic. Immunologic reactions are caused by an antigen–antibody response between the recipient and the donor blood product. Nonimmunologic reactions are seen with inadequate donor screening, contamination, improper handling or administration techniques, or cytokine activation in the blood product. The most common reaction is volume overload; merely reducing the administration rate can often remedy this situation. Treatments for transfusion reactions are directed toward alleviating clinical signs and basic supportive care. Fluid support, oxygen support, diuretics, antipyretics, steroids, and antihistamines are the most common treatments initiated. Reaction
Cause
Signs
Acute Immunologic • Typically occurs within minutes of initiating transfusion
• RBC
• Intravascular or extravascular hemolysis, fever, anaphylaxis, hypotension, tachy- or bradycardia, cyanosis, apnea, salivation, lacrimation, urination, defecation, emesis, collapse, acute renal failure, shock, death
• Platelets, WBC
• Fever, emesis
• Plasma proteins
• Urticaria, facial edema, erythema, pruritis
• Contamination
• Fever, sepsis, infection, hypotension, hemolysis, vomiting, DIC, renal failure, shock, emesis, diarrhea • Blood products: dark, discoloration of RBCs, clumped cells, hemolysis, air bubbles
• Improper collection
• Hemolysis, emesis, edema, dyspnea
• Volume overload
• Dyspnea, emesis, retching, pulmonary edema, vocalization, tachycardia, coughing, tachypnea, cyanosis
• Microaggregates
• Thrombosis
• Citrate toxicity (hypocalcemia toxicity)
• Tetany, tremors, cardiac arrhythmias, emesis, ECG changes
• RBC
• ↓ PCV, fever, icterus, shortened red cell survival • Neonatal hemolysis
• Platelet
• Thrombocytopenia, petechiae extravascular hemolysis (e.g., hyperbilirubinemia, hemoglobinuria, bilirubinuria)
• Infected donor
• Disease transmission (e.g., FeLV, FIV)
Acute Nonimmunologic
8
Delayed Immunologic • Occurs over days
Delayed Nonimmunologic
Note: Fever is considered to be a >1° C (2° F) increase over the pretransfusion temperature within 1–2 hours.
374
SECTION FOUR: PATIENT CARE SKILLS
OXYGEN THERAPY The objective of oxygen therapy is to provide adequate oxygen to the arterial blood and to remove carbon dioxide. Any acutely ill or injured patient has
a higher demand for oxygen and should be provided supplemental oxygen until stabilized. Monitoring the patient who is receiving supplemental oxygen is crucial. Hyperthermia, increased humidity, and CO2 can be fatal.
Skill Box 8.22 / Oxygen Administration Oxygen administration requires the following equipment: an oxygen source, a humidifier, oxygen tubing, and Christmas tree adapters or syringe case. Humidification The normal function of the respiratory tract is to warm and humidify inspired gases. With oxygen supplementation this process is lost, leaving the patient with cold and dry inspired gases. Providing humidified oxygen can reduce the risk of increased water loss and drying of the lower airway, predisposing the patient to pneumonia. Humidification should be provided for all patients receiving long-term oxygen supplementation or when delivered directly into the nose, ET tube, or trachea. The humidifier should be cleaned and dried after each patient. Oxygen Flow Rates Oxygen is toxic at high concentrations. Maintaining levels of O2 at >60% for longer than 12 hours can pose a problem. Oxygen levels should only be maintained at concentrations of 40% when used for long-term oxygen supplementation. • Flow by: 3–15 L/min • Oxygen hood: 200 mL/kg/min • Nasal catheter: small canines and felines, 50 mL/kg/min; larger canines, 100 mL/kg/min
Oxygen Flow-by Connect the oxygen tube to the gas source and run at 6 L/min. Place the open end of the tube about 6 inches from the patient’s mouth/ nose. Avoid directing the flowing into the nares as this can cause irritation. Mask Connect the oxygen tube to the gas source and run at 6 L/min. Connect an anesthetic mask to the open end of the tube and place over the patient’s mouth and nose. The mask can be kept in place with a muzzle. Be sure the fit is not so tight that CO2 is prevented from escaping. Carrier/Box A method best used with fractious or overly stressed cats. Place a clear plastic bag (e.g., garbage can liner) over the entire carrier or box or tape the openings shut. (A paper flap can be placed over one opening or just left open to allow an exhaust escape.) Connect the oxygen tube to the gas source and run at 6 L/min. Place the open end of the tube inside a hole in the clear bag. This method provides no control of heat or airway; therefore, the patient should be monitored closely. The methods listed below are for longer-term oxygen administration. Each technique has its own advantages and disadvantages.
Immediate and Temporary Approaches to Respiratory Distress The methods listed here are for immediate and temporary use. The patient tolerance is typically high.
CHAPTER 8 / PATIENT CARE
375
8
Routes of Oxygen Administration Skill Box 8.23 / Routes of Oxygen Administration: Oxygen Hood and Nasal Catheter
8
Method
Oxygen Hood
Nasal Catheter
Indications
• Respiratory distress • Hypoxemia
• Respiratory distress • Hypoxemia
Contraindications
• • • •
• • • • •
Setup
• Specialized oxygen hood E-collars or • E-collar • Saran Wrap
Procedure
Saran wrap is taped to the outside of an E-collar to cover 3/4 of the opening. The opening at the top is for CO2, heat, and condensation to escape. The E-collar is placed over the patient’s head and secured with gauze or using the patient’s collar. The oxygen tube is fed in at the neck opening and secured near the front of the E-collar with tape.
Place several drops of topical anesthetic in the nostril to be used. Be sure to elevate head to allow coating of the nasal passage. Measure the tube from the nostril to the medial canthus of the eye and mark. Place several more drops of anesthetic in the nostril. Place a simple interrupted suture at the lateral commissure of the nose and another somewhere between the eyes to on top of the head. Lubricate the tip of the tube with lidocaine gel. Using your thumb, push up on the nose into a pig position, then insert the tube ventrally and medially to the level of the mark on the tube. Using the sutures previously placed; connect with a Chinese finger trap suture. See Skill Box 15.4 Suture Patterns, page 549.
Complications
• Hyperthermia
• Sneezing • ↑ Stress
Removal
• Remove E-collar
• Remove sutures and gently, but swiftly remove the catheter
Airway obstruction Panting Hyperthermia ↑ Stress • Tape • Tie (e.g., gauze, collar) • Oxygen setup
Airway obstruction, nasal or facial trauma ↑ Stress Epistaxis, coagulopathies ↑ Intracranial pressure Brachycephalic breeds
• Red rubber catheter • Small patients: 3.5–5 Fr • Medium canines: 5–8 Fr • Large canines: 8–10 Fr • Topical anesthetic (e.g., proparacaine, lidocaine gel)
• • • • •
Permanent marker Suture, nonabsorbable Needle holders Oxygen setup E-collar
Tip: Selecting a larger red rubber catheter for nasal catheters provides increased patient tolerance. It is speculated that it fills the space, eliminating movement and tickling, and eliminates the higher-pressure hose effect when the O2 is turned on.
376
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 8.24 / Routes of Oxygen Administration: Transtracheal Catheter and Tracheostomy Method
Transtracheal Catheter
Tracheostomy, emergency
Indications
• • • •
• Airway obstruction • Laryngeal or pharyngeal collapse • Long-term PPV
Contraindications
• Tracheal trauma or injury • Airway obstruction distal to catheter placement
• Tracheal trauma or injury • Airway obstruction distal to tracheostomy site
Setup
• • • • • •
• • • • •
Procedure
Patient is placed in dorsal recumbency and the neck is surgically prepped from the ramus of the mandible to the thoracic inlet and dorsally to midline. An incision is made over the larynx and is bluntly dissected down to the trachea. Insert the catheter along a groove director. Once in the trachea, remove the groove director and stylet and direct the catheter to the level of the carina. Secure the catheter to the skin with Chinese finger trap sutures. Loosely apply bandage around the catheter.
Patient is placed in dorsal recumbency and the neck is surgically prepped from the ramus of the mandible to the thoracic inlet and dorsally to midline. An incision is made over the larynx and is bluntly dissected down to the trachea. Two stay sutures are placed around the 4th and 5th tracheal rings and are used to retract the opening. An incision is made between the rings while avoiding cutting more 35% of the circumference of the trachea. The stay sutures are retracted and the tracheostomy tube is inserted. The tube is secured with tape.
Complications
• Tracheal trauma or injury • Tracheitis, SQ emphysema, catheter kink or obstruction, pneumomediastinum, hematoma
• Tracheal trauma or injury
Maintenance
• All contact should be performed aseptically. • Monitor respiratory rate, lung sounds, and all vital signs. • Monitor site for infection, kinking, SQ emphysema, and dislodgment. • Change bandages frequently.
• All contact should be performed aseptically. • Preoxygenate patient before any procedure. • Suction 3–4 times every 30–60 minutes for 3–7 seconds; supplemental oxygen may be needed between suctioning. • Monitor respiratory rate, lung sounds, and all vital signs. • Nebulize and coupage 3–4 times a day. • Tube should be changed daily. • Instill sterile saline (1 mL/10 kg) every 3–4 hours.
Removal
• Remove the tube and allow the wound to heal by second intention.
• Remove the tube and stay sutures and allow the wound to heal by second intention.
Upper airway obstruction Head, facial, or nasal trauma Epistaxis or coagulopathies Patients not tolerant of nasal catheters or those requiring a higher flow rate than tolerated by a nasal catheter
Surgical site preparation materials Sedation or general anesthesia Sterile surgical pack Tracheal catheter or large bore over the needle catheter Oxygen set up Bandaging material
Surgical site preparation materials Sedation or general anesthesia Tracheostomy tube (various sizes) Sterile surgical pack Suture material
CHAPTER 8 / PATIENT CARE
377
8
Chapter
9
Pain Management Pain Management 380 Pain Assessment 381 Pain Scales 381 Instructions for Using the CSU Acute Pain Scale 382 Pain Levels Associated With Surgical Procedures, Injuries, and Illness 383 Behaviors Suggesting Pain and Anxiety 384
Nondrug Approach to Decrease Pain and Anxiety 386 Pain Management Drugs 386 Pain Management Techniques 392 Constant Rate Infusions 392 Setting Up a Morphine/Lidocaine/Ketamine Constant Rate Infusion 393 9
379
Key Words and Phrasesa
Abbreviations
Additional Resources, page
Agonists Allodynia Analgesics Antagonists Extracapsular Hyperalgesia Hyperesthesia Normotensive Normovolemic Receptors Wind-up phenomenon
μg, microgram CNS, central nervous system CRI, constant rate infusion FLK, fentanyl/lidocaine/ketamine GDV, gastric dilation volvulus GI, gastrointestinal HCl, hydrochloride HLK, hydromorphone/lidocaine/ketamine hr, hour IM, intramuscular IV, intravenous kg, kilogram lb, pound LRS, lactated Ringer’s solution mg, milligram min, minute mL, milliliter MLK, morphine/lidocaine/ketamine NRS, numerical rating scale NSAIDs, nonsteroidal anti-inflammatory drugs OVH, ovariohystrectomy PO, by mouth Q24, every 24 SDS, simple descriptive scale SQ, subcutaneous UMPS, University of Melbourne Pain Scale VAS, visual analog scale
Blood chemistries, 74 Fluid therapy, 359 Injections, 348 Kilograms to body surface area, 627 Patient care, 329 Patient monitoring, 332 Pharmacology, 567 Recumbent patient care, 347 Surgery, 521 Vital signs, 19
9 a
Key words and terms are defined in the glossary on page 631.
PAIN MANAGEMENT Animals do not uniformly respond to pain or stress in the same way. Their breed, age, previous experiences, and degree of illness and stress can alter their response to a stimulus. Research shows that a patient’s normal functions return sooner and they recover and heal quicker with pain control. In the past, the hardest part of pain control was trying to decide when the patient was truly in pain. It is now known that preemptive treatment is the best method. Do not wait for the patient to prove he or she is in pain; assume, after a surgical procedure and during illness and injuries, that a patient is experiencing pain. To ensure a patient’s comfort, continual observation and appropriate treatment are needed, especially in the first 12–24 hours. The pain pathway begins with the stimulation of receptors and peripheral nerves through the conversion of a chemical, mechanical, or thermal insult into a nerve impulse. The signal is then conducted through the spinal cord to the 380
SECTION FOUR: PATIENT CARE SKILLS
brain, where it is perceived as pain. The degree of pain is related to the number of receptors in the injured tissue. The skin, periosteum, joint capsule, muscle, tendon, and arterial wall contain the highest density of pain receptors. The peripheral nervous system is the source of the intense sharp pain felt with an injury. This is directly related to the number and location of pain receptors. The central nervous system produces burning, throbbing pain because of the low density of pain receptors found there. The internal organs require a major insult on the organ to produce intense pain. Typically, it is hard to locate diffuse pain in contrast to the easily located intense pain associated with the peripheral nervous system. Pain Management Myths 1. Analgesics mask the physiologic indicators of patient deterioration. Evidence exists in both human and veterinary medicine showing that
this is not the case. In fact, if the patient were treated adequately for pain, any changes in physiologic indicators would indeed be attributable to patient deterioration rather than a pain stress response. 2. Potential for toxicity or adverse reactions is associated with drug administration. With our current level of understanding, there is no longer an overpowering reason to avoid the use of analgesics. Many drug options exist for both canines and felines, with proven guidelines to allow safe administration. 3. Pain is hard to recognize. It is best to think of pain in terms similar to human pain. Treat for this level of pain regardless of whether you think the animal is truly showing signs of pain. Assume that invasive procedures, trauma, and illness result in a need for analgesics. Merely being aware and observing for behavioral signs of pain will make recognition easier. 4. Pain keeps an animal from moving around and injuring itself. Through research, pain makes a patient more agitated and unable to relax and rest. Pacing, changing position, and chewing at the incision are behaviors that indicate pain versus boredom or agitation. Continuous pain can also contribute to poor healing, decreased immune function, and increased inflammation. In cases of excessive
activity, sedation and confinement can be used to control the activity level of the patient. 5. The breed is just “a wimp.” Each animal and human experiences and exhibits pain differently. Some breeds tend to show stronger reactions to pain, therefore having a lower threshold to pain. This additional knowledge can lead to better preemptive pain management in particular breeds.
Pain Assessment The assessment of pain in someone other than yourself is a very difficult task, especially when dealing with another species. There are many ways to assess a patient’s level of pain; however, not one single method provides a complete picture. Observant and thorough patient care is the most important part of pain assessment. It is through this keen awareness and the use of alternate methods that a thorough pain management plan can be formulated. The 4 most common approaches are physiologic responses, the use of preestablished pain scales, expected pain, and the patient’s behavior. Physiologic signs are the least predictable signs when assessing pain, as many of the same physiologic signs can also be seen with fear, anxiety, and excitement. Increased heart rate, increased respiratory rate, hypertension, dilated pupils, and increased serum cortisol and epinephrine are all signs potentially relating to pain.
Table 9.1 / Pain Scales (See figures in Color Plate 23–24)
Pain scales formulated through research and anecdotal hospital situations provide another means of evaluating patients. Each scale has its advantages and disadvantages and should be used with those in mind. Observer training is the key to using these systems appropriately and consistently. Pain Scale
Definition
Simple descriptive scale (SDS)
• Ease of use Utilizes a numbering system based on the observation of the patient to indicate the level of pain, with (0) indicating no pain and (4) indicating extreme pain
Preemptive scoring system Estimate of expected pain based on the procedure to be performed, and the amount of tissue trauma expected rated as none, mild, moderate, or severe Visual analog scale (VAS)
Advantages
• Ease of use
A 100 mm straight line bracketed with “No Pain” • Ease of use and one end and “Worst Pain Possible” at other • Visual indication if pain is improving or end. A vertical line is draw across the line to worsening indicate the patient’s level of pain.
Disadvantages • Observer bias
• Individual patient extent of pain and response to therapy
• Subjective nature of where to stop the line • Uncertainty of what “Worst Possible Pain” indicates, relating to all pain or pain for a specific procedure
CHAPTER 9 / PAIN MANAGEMENT
381
9
Table 9.1 / Pain Scales (Continued) Pain Scale
Definition
Advantages
Disadvantages
Numerical rating scale (NRS)
A set of categories used to evaluate the patient on visual and physiologic observations
• Ease of use • Encourages a thorough patient evaluation
• Similar to SDS • Limited validation
Behavioral and Physiologic Response Scales
9
Colorado State University Acute Pain Scale • See Skill Box 9.1 • See Color Plate 9.1 • See Color Plate 9.2
Evaluation of psychologic and behavioral signs, responses to palpation and body tension
• Limited observer bias • Observations clearly defined
• Limited validation
University of Melbourne Pain Scale (UMPS)
Evaluation of psychologic and behavioral signs
• Increased accuracy • Ability to weigh the importance of different categories
• Limited validation
The Glasgow Composite Pain Tool
Evaluation of specific behavior signs
• Limited observer bias • Observations clearly defined • Avoids variable physiologic responses
• Greater use for musculoskeletal
Skill Box 9.1 / Instructions for Using the CSU Acute Pain Scale Use of the scale employs both an observational period and a hands-on evaluation of the patient. In general, the assessment begins with quiet observation of the patient in its cage at a relatively unobtrusive distance. Afterward, the patient as a whole (wound as well as the entire body) is approached to assess reaction to gentle palpation, indicators of muscle tension and heat, response to interaction, etc. 1. The scale utilizes a generic 0–4 scale with quarter marks as its base along with a color scale as a visual cue for progression along with the 5-point scale. 2. Artists’ realistic renderings of animals at various levels of pain add further visual cues. Additional drawings provide space for recording pain, warmth, and muscle tension; this allows documentation of specific areas of concern in the medical record. A further advantage of these drawings is that the observer is encouraged to assess the overall pain of the patient in addition to focusing on the primary lesion. 3. The scale includes psychologic and behavioral signs of pain as well as palpation responses. Further, the scale uses body tension as an evaluation tool, a parameter not addressed in other scales.
382
SECTION FOUR: PATIENT CARE SKILLS
4. There is a provision for nonassessment in the resting patient. To the authors’ knowledge, this is the only scale that emphasizes the importance of delaying assessment in a sleeping patient while prompting the observer to recognize patients that may be inappropriately obtunded by medication or a more serious health concern. 5. Advantages of this scale include ease of use with minimal interpretation required. Specific descriptors for individual behaviors are provided which decreases interobserver variability. Additionally, a scale is provided for both the dog and the cat. 6. A disadvantage of this scale is a lack of validation by clinical studies comparing it to other scales. Further, its use is largely limited to and is intended for use in acute pain. See Figure 9.1, color plate, Colorado State University Canine Acute Pain Scale. See Figure 9.2, color plate, Colorado State University Feline Acute Pain Scale.
Table 9.2 / Pain Levels Associated With Surgical Procedures, Injuries, and Illnesses
Surgical procedures, illnesses, and injuries are known to cause pain in humans and are thought to do so in animals, also. This chart can be used to preemptively treat animals for expected pain. It will also help to choose the correct drug or combination of drugs to administer when there is an understanding of the level of pain each procedure may produce. Mild to Moderate
Moderate
Moderate to Severe
Severe to Excruciating
Surgical • Aural hematoma Procedure • Castration (young animals) • Chest drains • Dental cleaning • Ear examination and cleaning • Mass removal • OVH (young animals) • Tracheotomy • Urinary catheterization
• • • • • • • •
Anal sacculectomy Castration (older or obese animals) Cystotomy (inflamed) Dental extractions Enucleation Fracture repair (radius, ulna, tibia, fibula) Inguinal hernia repair Laparotomy (short procedure with minimal manipulation and no inflammation) • Mass removal • OVH (older, obese, or pregnant animals)
• • • • • • •
Disc surgery (thoracic, lumbar) Exploratory laparotomy Laminectomy Mandibulectomy Mastectomy Onychectomy Total ear ablation
• • • •
Injury
• Diaphragmatic hernia repair (acute, simple with no organ injury) • Extracapsular cruciate repair • Fracture repair (radius, ulna, tibia, fibula) • Laceration repair (severe) • Soft tissue injury
• • • •
• Fracture repair (pelvis) Corneal abrasion or ulceration • Multiple fracture repair with Fracture repair (femur, humerus) extensive soft tissue injury Frostbite • Neuropathic pain (nerve Intra-articular surgical procedure (large entrapment, cervical intervertebral canines or extensive manipulation) disk herniation, inflammation) Mesenteric, gastric, testicular, or other torsions Rewarming after accidental hypothermia Trauma (orthopedic, extensive soft tissue injury, head injury) Traumatic diaphragmatic hernia repair (organ and extensive tissue injury)
• Abscess lancing • Laceration repair-minor • Removing cutaneous foreign bodies
• • • •
Illness
• Cystitis • Otitis
• Pancreatitis (early or resolving) • Urethral obstruction
• Osteoarthritis, acute polyarthritis • Peritonitis
Disc surgery (cervical) Ear resections Limb amputation Postsurgical pain (with extensive tissue injury or inflammation) • Thoractomy
• Meningitis • Bone cancer (especially after biopsy) • Pathologic fractures • Necrotizing cholecystitis • Necrotizing pancreatitis • Extensive inflammation (peritonitis, fasciitis, cellulitis)
CHAPTER 9 / PAIN MANAGEMENT
383
9
Table 9.3 / Behaviors Suggesting Pain and Anxiety
Each behavior that an animal portrays may have a variety of meanings. Often, a behavior may be indicative of both pain and a normal behavior. When evaluating whether a patient is in pain, look for multiple behaviors to ensure a correct assessment of pain. Research has shown that animals routinely hide their pain when in the presence of observers making this assessment approach even harder. Remember, it is always best to err on the side of pain and administer a pain medication; most likely a patient is always experiencing some level of pain after a surgical procedure or during an illness or injury. The behaviors listed below are marked based on their possible cause. Pain can cause any behavior, but it may not be the only cause or the cause in a particular patient. Evaluating a large number of behaviors will help in determining a patient’s level of pain. Behavior
Pain Poor Apprehension/ Normal General Anxiety Behavior Health
Posture
9
Behavior
Pain Poor Apprehension/ Normal General Anxiety Behavior Health
Vocalization
Hunched up guarding abdomen
X
Screaming
X
X
X
Tensing abdomen and back muscles
X
Whining
X
X
X
X
Splinting of abdomen
X
Crying
X
X
X
X
Reluctance to lie down
X
X
None
X
X
X
Leaning against cage wall
X
X
Barking/growling (Canine)
X
X
X
Sitting or lying in an abnormal position
X
X
Growling/hissing (Feline)
X
X
X
Resting in abnormal position
X
X
General Appearance X
X
Praying position (forequarters on ground, X hindquarters in air)
Not grooming
X
X X
Weak tail wag
X
X
Dull eyes
X
Low carriage of tail
X
X
Ears pulled back
X
Head hangs down
X
X
Penile prolapse
X
X
Stare into space
X
X
Grimacing
X
Non–weight bearing (partial or complete) X
Sleepy
X
Stiff
X
Photophobic
Unwilling to walk
X
Unable to walk
X
Gait Limping
384
SECTION FOUR: PATIENT CARE SKILLS
X
X
X
Ruffled greasy fur
X
X
X X
X X
X
Table 9.3 / Behaviors Suggesting Pain and Anxiety (Continued) Behavior
Pain Poor Apprehension/ Normal General Anxiety Behavior Health
Movement Restless, agitated
Behavior
Pain Poor Apprehension/ Normal General Anxiety Behavior Health
Aggressiveness
X
X
Inability to sleep regardless of obvious exhaustion
X
X
X
Physiologic X
X
X
X
Tachypnea/panting
X
X
X
X
Tachycardia
X
X
X
X
Dilated pupils
X
X
Hypertension
X
X
Increased body temperature
X
X
X
X
X
X
Trembling, shaking
X
X
Thrashing
X
X
No movement when sleeping
X
Lying quietly and not moving for hours and does not dream
X
Increased salivation
Stuporous
X
Appetite/Elimination
X
Recumbent and unaware of surroundings X
X
Inappetance
X
X
Slow to rise
X
X
X
Decreased appetite
X
X
Reluctant to move head (eye movement only)
X
X
X
Picky appetite
X
X
Stretching all 4 legs when abdomen is touched
X
Makes no attempt to move to eliminate
X
Pacing
X
X
Repetitively lying down, getting up, lying X down
X
X
X
X
X
Looking, licking, chewing at painful area X
X
X
9
X
Attitude Bite or attempts to bite caregivers
Hyperesthesia/hyperalgesia
X
Allodynia
X
X
X
CHAPTER 9 / PAIN MANAGEMENT
385
Table 9.3 / Behaviors Suggesting Pain and Anxiety (Continued) Behavior
Pain Poor Apprehension/ Normal General Anxiety Behavior Health
Sitting in back of cage
X
X
X
Hiding under blanket (feline)
X
X
X
Cleaning/licking wound
X
Behavior
Pain Poor Apprehension/ Normal General Anxiety Behavior Health
X
Skill Box 9.2 / Nondrug Approach to Decrease Pain and Anxiety Contact • Visits from owners • Interactions with staff during and in between treatments (e.g., talking, petting, stroking, brushing)
Environment • Provide familiar toys and blankets. • Ensure a quiet location, away from loud animals and human noise. • Keep the cage clean and warm. • Provide hiding places for cats (e.g., carriers, boxes).
Nursing Care • Schedule the least interruptions possible; combine monitoring, medication administration, and cage moving. • Offer multiple opportunities for canines to urinate or defecate. • Keep the patient comfortable (e.g., clean, dry, rotated often; pressure sores clean; moisten dry mouth). • Monitor catheters and bandages for discomfort.
Table 9.4 / Pain Management Drugs
There are multiple classes of drugs used for analgesics; the 2 more commonly used are opioids and NSAIDs. The formation of a pain management plan reviews the effects of the different classes and individual drugs to provide a balanced analgesic plan. The use of multiple drugs often gives an additive or synergistic effect, allowing a decreased dosage of each drug and a more complete relief of pain for the patient. Drug
Opioids
9
Along with the use of analgesics and sedatives, proper nursing care plays a critical role in helping to alleviate pain. Anxiety and stress lower the threshold to pain sensation. The following should be continuously observed in every patient admitted to the hospital.
386
Indications
Buprenorphine HCl • Canine: mild to moderate pain • Partial agonist at μ • Feline: moderate to severe pain receptors • Preoperative sedation, acute and perioperative pain
SECTION FOUR: PATIENT CARE SKILLS
Dose/Route/Duration
Comments
Dose • Canine: 0.01–0.03 mg/kg • Felines: 0.005–0.02 mg/kg • Epidural: 0.03 mg/kg • Sublingual: 0.01–0.02 mg/kg Route • Sublingual (felines only), SQ, IM, IV Duration (affected by dose) • Delayed onset of 45–60 minutes • 6–12 hours
• Very effective in felines • Sublingual application is only acceptable for felines, due to their unique oral pH • Will not usually achieve the same degree of analgesia as morphine, hydromorphone, or fentanyl • Due to its high affinity for the μ receptor, virtually impossible to reverse
Table 9.4 / Pain Management Drugs (Continued)
Opioids
Drug
Indications
Dose/Route/Duration
Comments
Butorphanol Tartrate • Mild to moderate pain • Pure antagonist at • Canine: visceral pain μ receptor and • Feline: skin pain partial agonists at κ receptor
Dose • Canine: 0.2–0.8 mg/kg SQ, IM 0.1–0.4 mg/kg IV • Feline: 0.1–0.4 mg/kg SQ, IM 0.05–0.2 mg/kg IV Route • SQ, IM, IV Duration • Canine: 20 minutes (SQ, IM), 45 minutes (IV) • Feline: 4 hours (SQ, IM), 45–60 minutes (IV)
• Has an anesthetic ceiling effect in which an ↑ amount will not ↓ the pain further • Can be used to partially reverse pure agonist opioids at μ receptors • Will not usually achieve the same degree of analgesia as morphine, hydromorphone, or fentanyl • Can be given PO, but not highly effective for pain
Codeine/ Acetaminophen
• Moderate to severe pain • Chronic pain
Dose • Canine: 1–2 mg/kg codeine Route • PO Duration • 8–12 hours
• Do not use in felines. • Available in 30 or 60 mg codeine and 300 mg acetaminophen (e.g., Tylenol No. 3) • Chronic use: tolerance and constipation may occur
Fentanyl Citrate • Pure agonist at μ receptor
• Moderate to severe pain
Injection Dose • Canine: 10 μg/kg SQ 2–5 μg/kg IV • Feline: 1–2 μg/kg IV • CRI: See Table 9.5, page 392. Route • SQ (canine only), IV Duration • Canine: 40–60 minutes (SQ) • Canine/feline 15–30 minutes (IV) Transdermal patch Dose • Canine/feline: 3–5 μg/kg/hr • <11 lb = 12.5 μg • 11–22 lb = 25 μg • 22–44 lb = 50 μg • 44–66 lb = 75 μg • >66 lb = 100 μg Duration • Delayed onset of 12–24 hours • Canine: minimum of 3 days • Feline: up to 4 days
• Feline hyperthermia is often seen. • May cause auditory sensitization, ↑ body temperature and bradycardia • Cotton in the ears and a quiet environment may alleviate signs of sound sensitivity. • Patch is inadequate when used alone with acute surgical pain or severe traumatic pain. • Patch use with febrile patients or with a heating device can greatly ↑ rates of absorption and should be avoided. • The use of mixed agonist/antagonist opioids will reverse the effects. • Patch placement: • Sites may be the neck, thorax, inguinal area, metatarsal/carpal areas, base of tail of canines and lateral thorax, inguinal area, metatarsal/carpal areas, base of tail of felines • Clip hair over desired area, clean with water, and allow to dry completely. • Apply patch, hold in place with palm of hand for several minutes to allow the patch to adhere, and cover with an adhesive bandage. • Label bandage with patch size, date, and time of placement.
CHAPTER 9 / PAIN MANAGEMENT
387
9
Table 9.4 / Pain Management Drugs (Continued)
Opioids
Drug
9
388
Indications
Dose/Route/Duration
Comments
Hydromorphone • Pure agonist at μ receptor
• Moderate to severe pain
Dose • Canine: 0.1–0.2 mg/kg SQ, IM 0.03–0.1 mg/kg IV • Feline: 0.05–0.1 mg/kg SQ, IM 0.01–0.025 mg/kg IV Route • SQ, IM, IV (slowly) Duration • Delayed onset of 15–30 minutes • 3–4 hours (SQ, IM), 30–45 minutes (IV)
• Feline hyperthermia is often seen. • Less likely to induce vomiting or hypotension than morphine • Constipation with long-term use
Methadone • Agonist at the μ receptor
• Mild to moderate pain
Dose • Canine: 0.5–2.2 mg/kg SQ, IM 0.1–0.5 mg/kg IV • Feline: 0.1–0.5 mg/kg SQ, IM 0.05–0.1 mg/kg IV Route • SQ, IM, IV Duration • 4–6 hours (SQ, IM), 60 minutes (IV)
• May induce less vomiting and sedation than morphine • Less likelihood of developing tolerance
Morphine Sulfate • Pure agonist at μ receptor
• Moderate to severe pain
Dose • Canine: 0.5–4 mg/kg PO 0.5–2.2 mg/kg SQ, IM 0.1–0.5 mg/kg IV slowly • Feline: 0.25–1.0 mg/kg PO 0.1–0.5 mg/kg SQ, IM 0.05–0.1 mg/kg IV slowly • Epidural: 0.1 mg/kg Route • PO, SQ, IM, IV slowly Duration • 3–4 hours (PO), 3–6 hours (SQ, IM), 60 minutes (IV)
• Feline hyperthermia is often seen. • High doses may cause excitement in felines; give lower doses combined with a tranquilizer. • Avoid IV administration in canines that are not normovolemic and normotensive.
Oxymorphone HCl • Pure agonists at μ receptor
• Moderate to severe pain
Dose • Canine: 0.05–0.2 mg/kg • Feline: 0.02–0.1 mg/kg Route • IM, IV Duration • 2–6 hours
• Feline hyperthermia is often seen.
SECTION FOUR: PATIENT CARE SKILLS
Table 9.4 / Pain Management Drugs (Continued) Indications
Dose/Route/Duration
Comments
Tramadol • Synthetic μ receptor opiate agonist
• Moderate to severe chronic pain
Dose • Canine: 2–5 mg/kg • Feline: 2–3 mg/kg Route • PO Duration • 8–12 hours
• Most effective when used in conjunction with an NSAID • Protect from light. • Taper dose at withdrawal.
Medetomidine
• Mild pain • Moderate to severe pain when combined with opioids
Dose • Canine/Feline: 5–10 μg/kg IM, IV Route • IM, IV Duration • 30–90 minutes
• Used with opioids to enhance analgesic effects • Extremely excited and agitated dogs need 15–20 minutes of quiet rest time after drug is given. • Use atropine or glycopyrrolate for the bradycardia. • Placement of cotton balls in the patient’s ears and a quiet environment may alleviate signs of sound sensitivity. • Bottle labeled as μg/m2 for dosing; see Appendix
Xylazine
• Mild pain
Dose • Canine/Feline: 0.05–0.1 mg/kg Route • IM, IV Duration • 30–60 minutes
• • • •
Bupivacaine
• Eliminate all pain
Dose • Canine/Feline: 1–2 mg/kg • Epidural: 0.1–0.75 mg/kg Route • Infiltration, epidural Duration • Delayed onset of 15–20 minutes • 6–8 hours
• Avoid IV administration as cardiac arrest may result. • Toxic dose is 4 mg/kg.
Lidocaine
• Eliminate all pain
Dose • Canine/Feline: 1–2 mg/kg Route • Infiltration, epidural, IV Duration • Onset of 3–10 minutes • 60 minutes
• Felines are very sensitive to the CNS effects—use with caution • Avoid IV administration in felines. • Toxic dose is 10 mg/kg. • CRI: See Table 9.5, page 392.
Local
Alpha–2 Agonists
Opioids
Drug
Sedation may outlast analgesia. Used with opioids to enhance analgesic effects Use atropine or glycopyrrolate for the bradycardia Placement of cotton balls in the patient’s ears and a quiet environment may alleviate signs of sound sensitivity.
CHAPTER 9 / PAIN MANAGEMENT
9
389
Table 9.4 / Pain Management Drugs (Continued)
9
Nonsteroidal Anti-inflammatory
Drug
390
Indications
Dose/Route/Duration
Comments
Carprofen
• Mild to moderate (severe in some cases) • Treatment of inflammation
Dose • Canine: 2.2 mg/kg PO 4.4 mg/kg SQ, IM, IV • Feline: 1.2 mg/kg SQ Route • PO, SQ, IM, IV Duration • Delayed onset of 60 minutes • 12 hours (canine PO), 18–24 hours (canine SQ, IM, IV), 48–72 hours (feline SQ)
• Monitor blood values when using long term. • NSAIDs are not recommended in hypovolemic or dehydrated patients or patients with bleeding disorders or GI or renal disease. • Discontinue if vomiting or diarrhea develops. • Give with food.
Deracoxib
• Mild to moderate (severe in some cases) • Postoperative orthopedic pain • Treatment and pain associated with osteoarthritis
Dose • Canine, postoperatively: 3–4 mg/kg • Canine, osteoarthritis: 1–2 mg/kg Route • PO Duration • 24 hours
• Monitor blood values when using long term. • NSAIDs are not recommended in hypovolemic or dehydrated patients or patients with bleeding disorders or GI or renal disease. • Discontinue if vomiting or diarrhea develops. • Give with food. • Give for up to 7 days postoperatively.
Etodolac
• Mild to moderate (severe in some cases) • Treatment of inflammation associated with osteoarthritis
Dose • Canine: 10–15 mg/kg Route • PO Duration • Onset of 60 minutes • 24 hours
• Monitor blood values when using long term. • NSAIDs are not recommended in hypovolemic or dehydrated patients or patients with bleeding disorders or GI or renal disease. • Discontinue if vomiting or diarrhea develops. • Very difficult to accurately dose canines <5 kg
Firocoxib
• Mild to moderate (severe in some cases) • Treatment of inflammation associated with osteoarthritis
Dose • Canine: 5 mg/kg Route • PO Duration • 18–24 hours
• Monitor blood values when using long term. • NSAIDs are not recommended in hypovolemic or dehydrated patients or patients with bleeding disorders or GI or renal disease. • Discontinue if vomiting or diarrhea develops.
Ketoprofen
• Mild to moderate (severe in some cases) • Treatment of inflammation
Dose • Canine/Feline: 1 mg/kg PO • Canine/Feline 1–2 mg/kg SQ Route • PO, SQ Duration • 18–24 hours
• Monitor blood values when using long term. • NSAIDs are not recommended in hypovolemic or dehydrated patients or patients with bleeding disorders or GI or renal disease. • Discontinue if vomiting or diarrhea develops. • May mask signs and symptoms of infection • Do not use preoperatively as it may cause intraoperative bleeding.
SECTION FOUR: PATIENT CARE SKILLS
Table 9.4 / Pain Management Drugs (Continued)
Adjuvant
Nonsteroidal Anti-inflammatory
Drug
Indications
Dose/Route/Duration
Comments
Meloxicam
• Mild to moderate (severe in some cases) • Treatment of chronic inflammatory disease of the musculoskeletal system • Hip dysplasia or chronic osteoarthritis in Canines
Dose • Canine: 0.2 mg/kg, PO on first day of treatment; then 0.1 mg/kg Q24 hr • Feline: 0.2 mg/kg, PO on first day of treatment; then 0.1 mg/kg Q24 hr for 2–4 days Route • PO Duration • 18–24 hours
• Monitor blood values when using long term. • NSAIDs are not recommended in hypovolemic or dehydrated patients or patients with bleeding disorders or GI or renal disease. • Discontinue if vomiting or diarrhea develops. • Small canines and felines: place drops into animal’s food, not directly into the mouth.
Tepoxalin
• Mild to moderate (severe in some cases) • Treatment and pain associated with osteoarthritis
Dose • Canine: 20 mg/kg on first dose, then 10 mg/ kg PO Q24 hours Route • PO Duration • 18–24 hours
• Monitor blood values when using long term. • NSAIDs are not recommended in hypovolemic or dehydrated patients or patients with bleeding disorders or GI or renal disease. • Discontinue if vomiting or diarrhea develops. • Place the disintegrating tablet in the patient’s mouth and hold shut for 4 seconds to allow it to dissolve.
Amantidine • Antiviral • NMDA antagonist
• Mild to moderate chronic pain
Dose • Canine/feline: 3 mg/kg Route • PO Duration • 24 hours
• Used in conjunction with an opioid or NSAID to prevent or treat wind-up • Effects may not be seen for up to 1 week.
Dose • Canine/feline: 1.25–10 mg/kg Route • PO Duration • 24 hours
• Sedation may be seen. • Taper dose at withdrawal.
Gabapentin • Anticonvulsant
• Mild to moderate pain • Prevents allodynia and hyperalgesia
9
Note: Additional drug information can be found in Chapter 13 Anesthesia, page 439, and Chapter 17 Pharmacology, page 567.
CHAPTER 9 / PAIN MANAGEMENT
391
PAIN MANAGEMENT TECHNIQUES Table 9.5 / Constant Rate Infusions
A constant rate infusion (CRI) is the administration of a drug or combination of drugs delivered IV over an extended period of time. Drugs commonly used for CRIs are fentanyl (F), morphine (M), hydromorphone (H), lidocaine (L), and ketamine (K). The most common CRIs are FLK, MLK, HLK, an opioid alone, or lidocaine alone. Using a combination of 1 or more drugs allows for more complete analgesia with fewer side effects. This same technique is routinely used in anesthesia with superior results. Initially, a loading does is given to rapidly achieve therapeutic levels; then, a maintenance dose is started to maintain those established therapeutic levels. Avoiding the loading dose will greatly delay the amount of time for pain control to be achieved. As with any analgesic plan, pain assessments and monitoring must continue during the CRI and the plan or rate adjusted as needed to control pain. Drug
Indications
Compatible Fluids
Rate
Comments
• Analgesia • ↓ Anesthetic gas requirements
• 5% dextrose
• Loading dose: • Canine: 2–5 μg/kg SQ, IM, IV • Feline: 1–2 μg/kg IV • Maintenance: 5–20 μg/kg/hr
• Protect from light (e.g., syringes, fluid bags) • Monitor for respiratory depression.
Hydromorphone • Analgesia, sedation
• 0.45%, 0.9% saline • 2.5%, 5% dextrose • LRS
• Loading dose (if not previously given): • Protect from light (e.g., syringes, fluid bags). • Stable in fluid bags for 24 hours • Canine: 0.1–0.2 mg/kg SQ, IM • Monitor for respiratory depression. 0.03–0.1 mg/kg IV • Feline: 0.05–0.1 mg/kg SQ, IM 0.01–0.025 mg/kg IV • Maintenance: • Canine: 0.02–0.07 mg/kg/hr • Feline: 0.005 mg/kg/hr
Morphine
• Analgesia • ↓ Anesthetic gas requirements
• 0.45%, 0.9% saline • 2.5%, 5% dextrose • LRS
• Loading dose (if not previously given): • Protect from light (e.g., syringes, fluid bags). • Use low end dose in felines to avoid • Canine: 0.5–2.2 mg/kg SQ, IM dysphoria and excitement. 0.1–0.5 mg/kg IV slowly • Monitor for respiratory depression. • Feline: 0.1–0.5 mg/kg SQ, IM 0.05–0.1 mg/kg IV slowly • Maintenance: • Canine: 0.05–0.2 mg/kg/hr • Feline: 0.025–0.2 mg/kg/hr
Lidocaine
• Analgesia, sedation • Cytoprotective (e.g., GDV, splenectomy) • Prevention of ileus (e.g., enterotomies)
• 0.45%, 0.9% saline • 2.5%, 5% dextrose • LRS
• Loading dose: 2 mg/kg IV • Maintenance: 0.6–3.0 mg/kg/hr (20–50 μg/kg/min)
• Not recommended in cats • Stable in fluid bags for 24 hours • Monitor for toxicity; muscle tremors, seizures, nausea, and vomiting.
Ketamine
• To prevent “wind-up,” an • 0.9% saline amplification of the pain • 5% dextrose response • LRS • Enhanced analgesic effect
• Loading dose: 0.5 mg/kg IV • Maintenance: 0.1–1.2 mg/kg/hr (2 μg/kg/min)
• Never to be used alone • Intended to be added to an opioid
Fentanyl
Opioids
9
Note: Ketamine/morphine/saline bags have been shown to be stable for at least 4 days.
392
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 9.3 / Setting Up a Morphine/Lidocaine/Ketamine Constant Rate Infusion Method
Example
1. Determine the patient’s weight in kg.
10 kg canine
2. Determine the patient’s maintenance fluid rate.
Maintenance fluid rate: see Table 9.5, page 361. 400 mL/day over 24 hours = 16.5 mL/hr
3. Determine the number of hours the CRI will run based on the size of the fluid bag.
250 mL fluid bag/(16.5 mL/hr) = 15 hours
4. Calculate the amount of each drug: a. Morphine (15 mg/mL) b. Lidocaine (20 mg/mL) c. Ketamine (100 mg/mL)
(0.05 mg) (10 kg) (15 hr) = 7.5 mg/(15 mg/mL) = 0.5 mL (0.6 mg) (10 kg) (15 hr) = 90 mg/(20 mg/mL) = 4.5 mL (0.1 mg) (10 kg) (15 hr) = 15 mg/(100 mg/mL) = 0.15 mL
5. Remove as much fluid from the IV fluid bag to equal the amount of drugs to be added.
(0.5 + 4.5 + 0.15) = 5.15 mL
6. Add drugs to IV fluid bag. 7. Label bag with the name of each drug, concentration, amount added, date, time, and patient’s name. Tip: To allow easy adjustment of the fluid rate without the risk of overhydration or dehydration, piggyback the CRI drugs into the main fluid line via another fluid bag or a syringe pump. Tip: CRIs containing an opioid or lidocaine can be protected from light by being wrapped with a dark towel, material, or bandaging material.
9
CHAPTER 9 / PAIN MANAGEMENT
393
Chapter
10
Wound Care Wound Treatment and Bandaging 396 Wound Healing Process 396 Classification of Wounds 397 Factors Affecting the Healing Process 398 Wound Care 399 Wound Cleaning Solutions 401 Topical Wound Medications 402 Wound Bandaging 403 Bandage Care 404
Bandaging 405 Basic Bandage 405 Robert Jones Bandage 406 Chest/Abdominal Bandage 407 Distal Limb Splint 408 Casts 408 Ehmer Sling 409 90–90 Flexion 410 Velpeau Sling 410 Hobbles 411
10
395
Key Words and Termsa Adherent Autolytic Degloving Dehiscence Edematous Epithelialization Exudate Fibroblasts Granulation bed Hydrophilic Lavage Macrophages Necrotic Onychectomy Sequestra Serosanguineous Viscous a
Abbreviations
Additional Resources, page
DL, deciliter EDTA, ethylenediaminetetraacetic acid g, gram LRS, lactated Ringer’s solution mm, millimeter NaCl, sodium chloride SSD, silver sulfadiazine U, units
Commonly used fluids, 363 Disinfectants, 627 Surgery, 521 Ultrasound, 197
Key words and terms are defined in the glossary on page 631.
WOUND TREATMENT AND BANDAGING Inevitably, pets end up with wounds, either self-inflicted or caused by another source. These wounds may be intentional, such as a surgical incision, or an accident. A technician plays a valuable role in the setup, preparation, cleaning, and the actual bandaging of these wounds. An under-
standing of the wound healing process, supplies to use, and the expected final outcome is necessary for proper treatment and care. These items are included in this chapter to facilitate excellent nursing care by the technician.
10 Table 10.1 / Wound Healing Process
The wound healing process is not a stationary process; several phases occur simultaneously with subtle transitions. The rate and quality of the healing are dependent on many factors, such as nutritional status, current medications (e.g., steroids, cytotoxic drugs), infection, and additional treatments (e.g., radiation). Inflammatory 䉴 1. Hemorrhage cleans the wound and begins to provide cells necessary for debridement. 2. Vasconstriction is in first 5–10 minutes, allowing the small vessels to clot. 3. Vasodilation permits the leakage of plasma and protein necessary for clotting. 4. Neutrophils leak out (∼6 hours after initial trauma) to engulf and remove bacteria and necrotic tissue. 5. Monocytes fill the wound (∼12 hours after initial trauma) and participate in tissue formation remodeling. 6. Monocytes become macrophages (∼24–48 hours after initial trauma) and continue to remove bacteria, foreign material, and necrotic tissue.
396
SECTION FOUR: PATIENT CARE SKILLS
Repair 䉴
Wound Contraction 䉴
Maturation
7. Fibroblasts and new capillaries fill the wound, producing granulation tissue (∼3–5 days), which protects the wound from infection and provides a surface for the attachment of epithelial cells to connect the 2 sides of the wounds. 8. New epithelial cells reproduce at wound edge, covering the granulation bed and resulting in a scab.
9. Fibroblasts pull together the wound edges at ∼0.6–0.8 mm/ day (∼5–9 days after initial trauma).
10. Remodeling of fibrous tissue strengthens the scar and reduces the scab (begins ∼4 weeks after initial trauma). 11. Scar may continue to gain strength for years but will always be 15– 20% weaker than surrounding tissue.
Table 10.2 / Classification of Wounds Classification
Characteristics
Tissue Integrity Open
• Lacerations or skin loss
Closed
• Crushing injuries and contusions
Etiologic Force Abrasion
• Loss of epidermis and portions of dermis. Usually attributable to shearing between 2 compressive surfaces or friction from blunt trauma
Avulsion
• Tearing of tissue from its attachment and the creation of skin flaps • Avulsions with extensive skin loss on extremities are degloving injuries. • Forces similar to those causing abrasion but of greater magnitude
Burns
• A partial- or full-thickness skin injury caused by heat or chemicals
Incision
• Created by a sharp object • Wound edges are smooth, and minimal tissue trauma is present in surrounding tissue.
Laceration
• Irregular wound caused by tearing of tissue with variable damage to superficial and underlying tissue
Puncture
• Skin penetration by a missile or sharp object • Superficial damage may be minimal, but damage to deeper structures may be considerable. • Contamination by hair and bacteria with subsequent infection is common.
Degree of Contamination and Duration Class I
• Zero to 6 hours; duration with minimal contamination
Class II
• Six to 12 hours; duration with significant contamination
Class III
• Twelve hours; duration or longer with gross contamination
10
Degree of Contamination Clean wound
• Surgically created under aseptic conditions. No invasion of respiratory, alimentary, or genitourinary tracts or of the oropharyngeal cavities.
Clean contaminated
• Minimal contamination and contamination can be effectively removed. Includes operative wounds involving the respiratory, wound alimentary, and genitourinary tracts.
Contaminated wound • Open traumatic wound with heavy contamination and possibly foreign debris. Includes operative wounds with major breaks in aseptic technique, and incisions in areas of acute nonpurulent inflammation adjacent to inflamed or contaminated skin. Dirty/infected wound • Old traumatic wounds and wounds with clinical infection or perforated viscera Adapted from Steven F. Swaim and Ralph A. Henderson Jr: Small Animal Wound Management, 2nd ed, Chapter II, page 14. Baltimore, 1997, Lippincott Williams and Wilkins.
CHAPTER 10 / WOUND CARE
397
Table 10.3 / Factors Affecting the Healing Process Factor
10
Effect on Healing
Blood Supply
• Blood supply is responsible for the delivery of oxygen and metabolic substrates that promote wound healing. • Dehydration, trauma to the area, tight bandages, or location of the wound may have an effect on this factor. • Certain stages (e.g., epithelialization) of wound healing are oxygen dependent and require optimal blood supply.
Dead Space
• Separation of tissue can result in fluid accumulation (e.g., seromas), producing a hypoxic state impairing cell migration. • Fluid accumulation mechanically inhibits adhesion (e.g., flaps and grafts) to the granulation bed. • Sutures and drains reduce the dead space.
Diseased or Debilitated Patients
• Diseased, debilitated, or stressed organs hinder the healing process. • Delayed wound healing with diabetes, hepatic disease, hyperadrenocorticism, neoplasia, and uremia. • Geriatrics often heal slower, potentially due to concurrent disease or debilitation.
Foreign Material
• Foreign material (e.g., foreign debris or suture material) results in prolonged inflammatory phase of healing and ↑ risk of infection.
Hemostasis
• If bleeding is not stabilized effectively, a seroma or hematoma may form. • Extra fluid in a wound slows down the healing process as the body must reabsorb and breakdown old blood and fluid during the inflammatory phase. • Can predispose wound to sepsis
Infection
• Overgrowth of bacteria prolongs the inflammatory phase and may lead to a systemic infection (sepsis).
Medications
• • • • •
Moisture
• A moist environment allows for optimal healing. • Allows for cell migration and subsequent healing, ↑ rate of epithelialization, and limits infection and penetration of topical medications. • Bandaging helps to keep a wound warm and moist.
Necrotic Tissue
• Dead tissue prolongs the inflammatory phase and predisposes the animal to sepsis.
Nutrition
• Malnutrition and serum albumin <1.5–2.0 g/dL delay wound healing and diminish wound strength. • Vitamin supplementation (e.g., vitamins A and E) and aloe vera can ↑ wound healing.
398
Medications may inhibit connective tissue building and epithelial cell turnover rate. Corticosteroids delay the entire wound healing process and ↑ the risk of infection. Aspirin may affect blood clotting during early phase of wound healing. Anti-inflammatory drugs affect inflammation. Chemotherapeutic drugs and radiation can drastically inhibit wound healing (e.g., postoperative interval 10–14 days desirable between surgery and adjunct antineoplastic treatment).
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 10.1 / Wound Care Care for an open or superficial wound should begin immediately after trauma. The wound should be covered with a clean, dry cloth or bandage to prevent further hemorrhage or contamination. Ideally, wounds should be treated within the first 6–8 hours before bacterial contamination has multiplied and the wound becomes infected. Infected wounds, rather than contaminated wounds, are often covered with a thick, viscous exudate and visually appear dirty. Before any procedure involving wound care, gloves should be worn by those in contact with the wound because bacteria may be translocated to the wounds. Setup • • • •
Chlorhexidine solution Suture material Clippers Sterile water-soluble lubricant
• Wound cleaning fluids • Surgical instruments (e.g., hemostats, needle holder, scissors, thumb forceps) • Gloves
Tip: Scissors dipped in mineral oil can be used so that the hair will stick to the scissors. Step I: Wound Preparation 1. Clean out any large, obvious debris. 2. Protect the wound from further contamination (e.g., water-soluble lubricant [K-Y Jelly], saline-soaked gauze, or temporarily close with sutures, clamps, or staples). 3. Remove the hair from around the wound with scissors or clippers. 4. Prepare the clipped skin as a surgical prep; avoid using alcohol. 5. Remove the wound protectant (e.g., water-soluble lubricant [K-Y Jelly], saline-soaked gauze, or temporarily close with sutures, clamps, or staples). Step II: Wound Cleaning • Lavage the wound to reduce the bacterial count and remove additional contaminants and necrotic debris. Lavage Solutions • Warm, balanced electrolyte solutions (e.g., LRS), sterile saline, or tap water • See Table 8.9 Commonly Used Fluids, page 363. Lavage Method • Intravenous administration set with a 3-way stopcock attached to the syringe and needle. • A 30–35 mL syringe with 18–19 gauge needle. • Use moderate pressure to thoroughly clean the wound, all debris should be removed
10
Step III: Wound Debridement • Autolytic: maintaining a moist environment with hydrophilic, occlusive, or semiocclusive bandaging • Bandage: wet-to-dry and dry-to-dry bandages allowed to adhere to the wound surface and when top layers when removed; not highly recommended due to unselective debridement and damage during the proliferative stage of wound healing • Biosurgical: sterile medicinal maggot therapy to remove necrotic tissue, disinfect, and promote granulation • Enzymatic: agents used to break down necrotic tissue • Surgical: excision of devitalized tissue (e.g., skin, muscle, contaminated fat) and bone sequestra
CHAPTER 10 / WOUND CARE
399
Skill Box 10.1 / Wound Care (Continued) Step IV: Wound Closure Type of closure is dependent on time lapse, degree of contamination, tissue damage, thoroughness of debridement, blood supply, animal’s health, closure without skin tension or dead space, and location of wound. Primary Wound Closure • First intention wound healing, wound is sutured closed • Used when wounds are 6–8 hours old, with minimal tissue damage and minimal contamination or cleaned wounds Contraction and Epithelialization • Second intention wound healing, wound is left to heal open with epithelialization and skin defect contraction over time (days to week) • Used when wounds are ≥5 days old, have significant tissue damage and loss, or are excessively contaminated • Allows gradual debridement and drainage; new skin may not contain hair follicles Delayed Primary Closure • Third intention wound healing, wound is sutured closed after the granulation tissue has formed • Used when wounds are 3–5 days old and are heavily contaminated or infected • Allows controlled debridement and optimal drainage Drain Placement • Used to eliminate dead space and provide drainage of potentially harmful fluids (e.g., blood, pus, serum) • Passive drains (e.g., Penrose drains) allow drainage by gravity and are most commonly used for subcutaneous spaces • Active drains allow drainage with an intermittent or continuous negative pressure that is either open or closed to the environment and are most commonly used for deep wounds and after grafting of skin. • Ascending infection is the most common complication of drains (especially Penrose drains) and should therefore be covered with a sterile dressing; change as needed.
10
Step V: Postoperative Care and Assessment Monitoring • Visual inspection for fluid accumulation, tension, infection, dehiscence, and necrosis • Ultrasound evaluation for fluid accumulation, scar formation, granulation tissue, blood clots, edematous regions, and epidermis Drain Care • Monitor for drainage as tissue fragments, viscous exudate, or fibrin may occlude the tube. • Apply hot compresses to the drainage area 2–3 times daily to improve drainage and to keep passive drainage sites open. • Typically removed in 3–5 days, but may be needed for up to 14 days Suture Care • Keep dry. • Suture removal is 7–14 days; with longer use, suture material will become a foreign material.
400
SECTION FOUR: PATIENT CARE SKILLS
Table 10.4 / Wound Cleaning Solutions Solution
Comments
0.9% NaCl
• Grossly contaminated, burns, lacerations, dermal ulcers and abrasions
• Isotonic solution • No antimicrobial activity
Balanced Electrolyte Solution
• Grossly contaminated, burns, lacerations, dermal ulcers and abrasions
• Ideal isotonic solution that is the least cytotoxic • No antimicrobial activity
Tap Water
• Grossly contaminated and lacerations
• Not an ideal solution, but can be used as an initial treatment to lavage severely contaminated wounds • Hypotonic and can cause cell swelling, leading to destruction and delayed wound healing • No antimicrobial activity
Chlorhexidine • Nolvasan
• Grossly contaminated, burns, lacerations, dermal ulcers, abrasions
• Wide spectrum of antimicrobial activity and residual activity for up to 2 days • Promotes rapid healing with minimal systemic absorption and toxicity even in the presence of blood and organic debris • A 0.05% solution (1 mL chlorhexidine 2% + 39 mL LRS) is recommended as higher concentrations may lead to ↓ wound healing and tissue slough. • Precipitates in LRS and NaCl, causing no detriment to wound care • Complications: resistance in some bacteria, corneal drying and synovial inflammation with joint lavage
Chloroxylenol • Technicare
• All wound care
• Effective against all gram-negative and gram-positive organisms within 30 seconds, antiviral and antifungal • Apply to wound and gently scrub with a gauze sponge for 2 minutes to cleanse and stimulate antimicrobial action and rinse. • Safe and effective for mucous membranes and around ears and eyes • Do not leave in wound bed.
(e.g., LRS, Normosol)
Wound Lavage and Cleaning
Indications
10
Povidone-Iodine • Betadine
• Grossly contaminated
• • • •
Wide spectrum of antimicrobial activity and residual activity for 4–8 hours A 0.1% solution (1 mL povidone-iodine + 99 mL LRS) is recommended. Scrubbing of wounds can damage tissues and ↑ infections. Complications: intensify metabolic acidosis, excessive systemic iodine, inactivated by organic debris and contact hypersensitivities
Tris-EDTA
• Otitis externa, abscess, rhinitis, cystitis
• Formulated by adding Tris-EDTA, sodium hydroxide to a solution (e.g., sterile water, chlorhexidine) and autoclaving or a commercially available formula (e.g., trizEDTA, T8 solution) • Keeps solution slightly basic and allows entry of antibiotics through the cell wall of gram negative bacteria, leaving them more susceptible to destruction.
CHAPTER 10 / WOUND CARE
401
Table 10.5 / Topical Wound Medications
The use of topical medications allows direct contact of the medication with the wound bed. While each topical medication has its benefits, they can also cause deleterious effects (e.g., cytotoxicity, delaying epithelialization), and care should be taken when choosing the medication. Topical medications used on wounds heavily contaminated will not be able to penetrate the deeper tissues; therefore, the wound should be debrided and cleaned prior to use. Antibacterial Hydrophilica Promotes Promotes Comments Granulation Epithelialization
Medication
Indications
Acemannan
• Burns, lacerations, dermal ulcers, abrasions, nonhealing wounds
Aloe Vera
• Burns, fungal infections
X
X
D-Glucose
• Contaminated and X infected wounds
X
Polysaccharide
X
Gentamicin Sulfate • Grafted wounds (preoperative and postoperative)
X
Honey (Raw, Unpasteurized) and Sugar
• Avulsions, bedsores, frostbite
X
Ketanserin
• Impaired circulation, peripheral sites
Nitrofurazone
• Lacerations, dermal ulcers, abrasions
X
Silver Sulfadiazine (SSD)
• Burns, necrotic wounds
X
Triple Antibiotic Ointment
• Lacerations, dermal ulcers, abrasions
X
X
X
• Derived from the aloe vera plant • Used during the early inflammatory stages of healing • Excessive granulation may be seen, which inhibits wound contraction. X
• Counteracts inhibitory effects of SSD • Antibacterial activity against Pseudomonas
X
• Daily bandage change and application necessary • Isotonic solutions are preferred. • Inactivated by purulent exudate
X
X
• Enhances debridement, granulation bed formation, epithelialization, improves wound nutrition, reduces edema and inflammation, and is antibacterial-like • After the wound is clean of exudate (3–4 days), honey or sugar is applied to the nonadherent layer and bandaged as usual. • Change bandage daily until granulation bed established and exudate decreases, then every 1–2 days.
X
• Not for use in deep or infected wounds or immediately following surgery • Twice-daily treatment
10
a
X
• Delays epithelialization
X
Hydrophilic properties help cleanse the wound and reduce wound edema by pulling fluids through the wound into the bandage.
402
SECTION FOUR: PATIENT CARE SKILLS
• Effective against most gram-positive, gram-negative, and fungi • Ointments effective for 3 days and dressing effective for 7 days • Combined with insulin (100 U insulin, 1 oz SSD) for burn treatments • Ability to penetrate eschar and necrotic tissue • • • • •
Bacitracin, neomycin, polymyxin Anaphylactic reactions (feline, rare) Poor activity against Pseudomonas Not very effective on infected wounds Poor absorption by the tissues
Table 10.6 / Wound Bandaging
Wound healing is a process involving many different stages, each requiring a specific environment for optimal results. Bandaging most often can provide the changing environment needed for each stage. Bandaging provides cleanliness, immobility, control of wound environment, elimination of dead space, hemostasis, decreased edema and pain, moisture, and warmth. Bandaging can also increase the acidity of the wound environment, resulting in an increase in oxygen dissociation from hemoglobin, thereby increasing oxygen to the wound, which promotes healing. The patient should be more comfortable after bandage placement. A patient that is very upset with a bandage should be evaluated for incorrect bandage placement, skin irritation, or worsening of the wound. Some keys to successful bandaging are: • Pressure should be applied over and distal to the wound, as proximal pressure will impede blood and lymphatic return with subsequent swelling and edema. • Avoid wrinkles in the bandaging material, as these may become areas of discomfort. • Ensure the area to be bandaged (e.g., surrounding skin, hair, between toes) is dry, as these areas may develop moist dermatitis. • Almost all bandages and splints should be applied with the limb in a normal functional angle, as seen when the animal is at rest in lateral recumbency. Bandage Layer
Purpose
Material Type
Comments
Primary
• Protect the wound and in some cases for debridement
• See below
• Should remain in contact even during movement
• Gauze pads, cling gauze
• Not highly recommended due to unselective debridement and damage during the proliferative stage of wound healing • Dry gauze is placed over wound and bandaged. • Painful to remove, rewetting the gauze with warm saline may facilitate removal • Change: daily
(Contact Layer)
Adherent: promote debridement in the inflammatory stage • Dry/Dry
• Absorbs exudate, necrotic tissue, and foreign material • Debris adheres to the material and is removed with bandage change
• Wet/Dry
• Loosens dried exudate, necrotic tissue, and foreign material by rehydration of wound • Absorbed by the secondary layer
• Gauze pads or cling gauze soaked in saline or 0.05% chlorhexidine
• Not highly recommended due to unselective debridement and damage during the proliferative stage of wound healing • Dry gauze is placed over wound, soaked, and bandaged. • Painful to remove, rewetting the gauze with warm saline may facilitate removal • Disadvantage: bacterial proliferation and strike through • Change: daily
• Film or Skin Sealant
• Provide a barrier to the wound surface from bacteria, water, environmental contaminants (e.g., urine, feces)
• Transparent liquid
• May be used alone or bandaged • Change: every 3–4 days
Nonadherent: promote moisture retention and epithelialization with minimal disruption of granulation bed • Switched from adherent dressing when granulation bed is forming and drainage is serosanguineous, typically 3–5 days • Occlusive
• Used when no exudate is present; in the repair stage
• Hydrocolloid dressing; hydrogel, hydrophilic beads, polyurethane films
• Impermeable to air, which can lead to trapping excessive moisture and subsequent skin damage • Change: 2–7 days, dependent on product
CHAPTER 10 / WOUND CARE
403
10
Table 10.6 / Wound Bandaging (Continued) • Semiocclusive
• Prevents tissue dehydration, but allows fluid absorption
• Telfa pads, gauze coated with petrolatum, polyethylene glycol, petrolatum-based antibiotic ointment, calcium alginate
• Used once epithelialization begins • Change: 1–3 days, dependent on product
• Foam
• To protect the wound from further impacts and trauma • Promote moist wound environment and autolytic debridement
• Polyurethane foam, hydrosorb
• • • •
Secondary Layer (Intermediate Layer)
• To protect the wound from further • Heavy padding: rolled cotton • Enough pressure needs to be applied to avoid spaces between the impacts and trauma and draw away • Moderate padding: cast wound, primary layer, and secondary layer. and store heavy secretions and padding • Excessive pressure impairs blood supply and impairs wound healing exudates • Light padding: stretch bandage (e.g., contraction). • Thickness is determined on the expected amount of drainage to absorb.
Tertiary Layer (Outer Layer)
• To provide consolidation of the secondary layer
• Stretch gauze
Protective Layer
• To protect the bandaging from outside contamination • Apply pressure, conform and immobilize the bandage
• Elastic wrap (Coban, VetWrap) • Can create an occlusive bandage leading to trapped excessive • Adhesive tape moisture and subsequent skin damage
Nonadherent to wound surface, but adhesive to surrounding skin Can be used dry or moistened with saline or medications Used for all types of wounds, cut to fit Change: 1–5 days
• Enough pressure needs to be applied to avoid spaces between the wound, primary layer, secondary layer, and tertiary layer. • Excessive pressure impairs blood supply and impairs wound healing (e.g., contraction). • Splints and supports are incorporated into the tertiary layer.
10
Skill Box 10.2 / Bandage Care 1. Bandage should be checked daily for slippage, wetness, and odor. 2. Wet bandages should be changed immediately to avoid skin and wound damage. 3. Bandage should be kept clean and dry. A plastic bag should be place when outside, but should be removed within a 30-minute period to reduce buildup of moisture. 4. Chewing the bandage should be controlled with an Elizabethan collar, foul-tasting spray, or other measures to avoid causing further damage. 5. Monitoring of the toes for warmth, color, swelling, and foul odor should be done twice daily. 6. Follow instructions of the veterinarian for bandage changes and removal.
404
SECTION FOUR: PATIENT CARE SKILLS
BANDAGING Skill Box 10.3 / Basic Bandage Usage: Bandaging of basic wounds and incisions 1. Place 2 adhesive tape strips on either side of the wound from where you expect the bandage to start to the distal portion of the limb to prevent slippage. Tip: A tongue depressor may be placed at the distal end to temporarily adhere the tape ends and to avoid entangling. Tip: Apply tape laterally when wound is at the distal end of the extremity (e.g., onychectomy, toe amputation). Tip: Small pieces of cotton or gauze can be placed in depressions (e.g., between toes, metatarsal-metacarpal pad) to smooth out bandaging area.
2. Apply primary bandage layer over the wound. 3. Apply secondary bandage layer starting 2/3 up from the expected bottom of the bandage such that the layers overlap one another by 50% and are taut, but not constricting. Place extra padding over the depression areas and be careful not to permit wrinkles. Toes can be covered to inhibit edema (the secondary layer is brought over the toes dorsal to ventral and then reflected back, ventral to dorsal) or can be left exposed to check on temperature of limb, permit drainage of fluids, and permit assessment of the healing environment (wrap the secondary layer obliquely at the distal end to keep the 3rd and 4th digits exposed).
4. Place 1 layer of tertiary bandage layer (as described in Step 3), twist and reflect adhesive strips back over this layer, and finish with final layer of tertiary bandage.
5. Place protective layer of elastic wrap (as described in Step 3). 6. Place adhesive tape around top of bandage, partially adhering to fur and covering the bottom of bandage for reinforcement of the toe area.
Tip: Always end the bandage at the bottom of the area to alleviate pressure.
CHAPTER 10 / WOUND CARE
405
10
Skill Box 10.4 / Robert Jones Bandage Usage: Temporary immobilization of fractures below the stifle or elbow joint before or after surgery by providing rigid stabilization. (Remove after 1 day.) 1. Place 2 adhesive tape strips on either side of the wound from where you expect the bandage to extend to the distal portion of the limb. 2. There is no primary layer unless sutures or wounds are present; then a nonadherent dressing can be placed. 3. While maintaining normal flexion of the limb, wrap thick roll cotton (4–6 inches thick) around the limb from mid femur/mid humerus to toes to constitute the secondary layer.
5. Twist and reflect adhesive strips back over the secondary layer. 6. Place protective layer of elastic wrap as the tertiary layer. 7. Place adhesive tape around the top of the bandage, partially adhering to fur and around the bottom of the bandage for reinforcement.
10 4. Compress with at least 2–3 layers of a conforming gauze (3–4 inches wide) secondary layer. Apply sufficient compression on the conforming gauze throughout application to achieve a smooth, even tension.
Tip: A well-applied Robert Jones bandage should make a dull thudding sound when tapped. Alternative: Modified Robert Jones bandage is placed following the instructions above while using <½ of the cotton padding to place a less bulky bandage. Their use is to reduce postoperative swelling of a limb.
406
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 10.5 / Chest/Abdominal Bandage Usage: To control abdominal bleeding (effective for 1–2 hours and should be removed before 4 hours) and cover and protect wounds, surgical incisions, or drains. 1. Apply primary bandage layer over the wound if necessary.
3. Apply tertiary layer around the torso, then through the legs and over the shoulders in a crisscross fashion (or figure of 8) to prevent slippage. 4. Place protective layer of elastic wrap. 5. Place adhesive tape around the cranial aspect of the bandage, partially adhering to fur.
2. Apply secondary bandage layer, starting mid thorax such that the layers overlap one another by 50% and are taut but not constricting. The bandage should extend to the pelvis. On male dogs, be sure to leave the animal’s prepuce exposed. Care must be taken to ensure that the bandages are not too tight so as to restrict thoracic movement. The amount of secondary layer is determined by the expected amount of drainage.
10
CHAPTER 10 / WOUND CARE
407
Skill Box 10.6 / Distal Limb Splint
Skill Box 10.7 / Casts
Usage: Temporary immobilization or definitive stabilization for distal extremity fractures or luxations.
Usage: for stabilization of simple fractures and immobilization of limbs (typically for 4–5 weeks).
1. Place 2 adhesive tape strips on either side of the wound from where you expect the bandage to extend to the distal portion of the limb. 2. Apply primary bandage layer over the wound or suture line if necessary. 3. While maintaining normal flexion of the limb firmly wrap secondary bandage layer (e.g., cast padding) around the limb to 1 inch above the proximal end of the splint. Apply enough material to cover bony prominences to ensure comfort from pressure sores and abrasions, while limiting material bulk. 4. Apply a conforming gauze tertiary bandage layer, compressing the secondary bandage layer. Place the appropriate-sized splint on the caudal aspect of the limb, ensuring there are no gaps between the tertiary layer and splint. Twist and reflect adhesive strips onto the splint. Continue with a final layer of the tertiary layer.
1. Have a bowl of hot water ready for the cast material and examination gloves ready for the application process. 2. Place 2 adhesive tape strips on either side of the wound or incision line from where you expect the bandage to start to the distal portion of the limb. 3. Apply a stockinette as a primary layer (smooth with wrinkles). 4. Apply secondary bandage layer, starting 2/3 up from the expected bottom of the bandage such that the layers overlap one another by 50% and are taut but not constricting. Pad the prominences on the leg, not the depressions. Toes can be covered to inhibit edema or they can be left exposed to check on temperature of limb, permit drainage of fluids, and permit assessment of the healing environment. 5. The cast material is used as the tertiary layer. Cast materials vary, and manufacturer’s guidelines should be followed. 6. Twist and reflect adhesive strips and stockinette edges back over the top layer of the cast material. 7. Protective tape is applied over the ends of the cast.
10
5. Place protective layer of elastic wrap. 6. Place adhesive tape around top of bandage, partially adhering to fur and covering the bottom of bandage for toe reinforcement.
408
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 10.8 / Ehmer Sling Usage: Immobilization of the hindlimb after reduction of a craniodorsal coxofemoral luxation and prevention of weight bearing after pelvis surgery (change: 5–7 days). 1. Place minimal padding on the metatarsal area using secondary layer material. 2. Using 2-inch adhesive tape, wrap the tape around the medial aspect of the metatarsal, and attach the tape end to the tape roll. Continue medially around the flank and back around the metatarsus. Keep the limb with stifle and hock in maximum flexion for 1–2 passes. 3. On the next pass, go around the flank and twist behind the hock.
4. Pass over the front of the metatarsal area. 5. Repeat Steps 3 and 4 for 3–4 passes.
10
Note: Correct application results in the internal rotation and adduction of the coxofemoral joint. Alternative: Use gauze in place of adhesive tape followed by a final layer of elastic adhesive.
CHAPTER 10 / WOUND CARE
409
Skill Box 10.9 / 90–90 Flexion Usage: After distal femoral fracture surgery in young patients and for prevention of weight bearing after hindlimb surgeries.
2. Bandage the forelimb in same manner, keeping the foot exposed, and pad the depressions of the limb.
1. Stifle and hock are in a 90˚ flexion. No attempt to adduct or internally rotate the coxofemoral joint is made. 2. Place minimal padding on the metatarsal area. 3. Same as for Ehmer sling, Step 2. 4. The tape is passed horizontally around the tibia to hold the layers in place.
10
3. Gently flex the forelimb against the chest wall and attach adhesive tape (2–4 inches wide) around the chest and flexed forelimb, creating a sling.
Skill Box 10.10 / Velpeau Sling Usage: Holds flexed forelimb against the chest; non–weight-bearing sling for the forelimb; reduction of scapulohumeral joint luxation; immobilization of a scapular fracture. 1. Cover the chest wall and shoulder with a lightly padded secondary layer and gauze tertiary layer. 410
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 10.11 / Hobbles Usage: To prevent excessive abduction of the hindlimbs; specifically indicated after reduction of ventral coxofemoral luxation; to relieve excessive tension in the inguinal region; to prevent excessive activity after pelvic fracture repair, or nonsurgical, conservative management of pelvic fractures. 1. Stand the animal with the hindlimbs equal distance to the width of the pelvis. 2. Pass the adhesive tape (which needs to be wide enough to cover half of the metatarsal area) around the 2 limbs. Press the tape together in the area between the 2 limbs.
10
CHAPTER 10 / WOUND CARE
411
Chapter
11
Parenteral Nutrition Nutritional Support 414 Tips on Encouraging Oral Nutrition 414 Enteral Nutrition 414 Coax Feeding and Orogastric Tube 414 Nasoesophageal/Nasogastric Tube 415 Esophagostomy Tube 417 Gastrotomy Tube Without Gastropexy 418 Gastrotomy Tube With Gastropexy 419 Jejunostomy Tube 420
Enteral Nutrition Administration 421 Parenteral Nutrition 422 Parenteral Nutrition 423 Parenteral Nutrition Administration 424 Worksheet for Calculating Total Parenteral Nutrition (TPN) 425 Worksheet for Calculating Peripheral or Partial Parenteral Nutrition (PPN) 426 11
Key Words and Termsa Aborally Amino acid Carbohydrate Celiotomy Cellulitis Dehiscence Epistaxis Fat Hyperosmolar Isosmolar Kilocalorie a
Abbreviations Lipid Malassimilation Minerals Percutaneous Peristomal Perivascular Pneumoperitoneum Protein Refeeding syndrome Thrombocytopathia Vitamins
μ, micro BUN, blood urea nitrogen BW, body weight CRI, constant rate infusion Fr, French g, gram GDV, gastric dilatation volvulus GIT, gastrointestinal tract hr, hour kcal, kilocalorie kg, kilogram
Additional Resources, page lb, pound mL, milliliter mOsm, milliosmoles PCV, packed cell volume PER, partial energy requirement PN, parenteral nutrition PPN, partial or peripheral nutrition PVC, polyvinyl chloride RER, resting energy requirement TPN, total parenteral nutrition
Catheter placement, 349 Constant rate infusions, 392 Drug administration, 348 Fluid therapy, 359 Nutrition, 57 Patient monitoring, 332 Suture techniques, 548
Key words and terms are defined in the glossary on page 631.
413
NUTRITIONAL SUPPORT Many hospitalized patients are at risk of becoming severely malnourished because they lack the desire or ability to eat. In response to injury and illness, the body breaks down protein, depleting the body’s protein stores. Providing protein, carbohydrate, fat, and other nutrients slows the breakdown of lean
body mass and optimizes the patient’s response to therapy. Injuries and illnesses can further increase a patient’s caloric requirement, making nutritional support even more crucial. There are many ways to provide this support, both enterally and parenterally. The following will give basic guidelines for choosing the correct method and administration protocols.
Skill Box 11.1 / Tips on Encouraging Oral Nutrition Hospitalized patients, for many reasons, whether physical or emotional, choose not to eat while in our care. Sometimes, with a small amount of our time and energy, their appetites can be stimulated and their moods improved, leading to an empty dinner plate. This effort can often save the patient from having to endure enteral or parenteral nutritional support. Unless contraindicated by an illness or injury, this approach should always be tried first. Environment
• If possible, move the patient to a quiet area, away from barking dogs and loud noises. • Spray the environment with feline facial pheromones (feline). • Try various shapes and types of bowls; plastic may have a strange smell (feline).
Patient
• Make sure the patient is capable of oral intake. • Hand-feed or pet the animal during feeding. • Make sure the nasal passages are clear of exudate to allow sufficient olfactory senses.
Diet
• • • • • •
Warm the food; stir the food well before feeding to avoid hot spots. Add water to either dry food (to moisten) or to canned food (to make a slurry). Use top dressings such as baby food or canned food. Use foods that have a strong odor or flavor. Offer a variety of foods with differing flavors and textures, both canned and dry. Specific situations may benefit from the administration of short-term appetite stimulants: cyproheptadine, diazepam.
Enteral Nutrition 11
Enteral nutrition is the preferred way of providing nutrition. Providing nutrition to some portion of the gastrointestinal tract allows for the health and integrity of the tract to remain. Prolonged periods of nonuse contribute to
its mucosal barrier failure and systemic bacterial contamination. Patients that are unable or unwilling to eat at least 85% of their RER but are able to digest and absorb nutrients in the small intestines should be provided nutrition by this route. Depending on the patient’s medical condition, there are many options of providing enteral nutrition.
Skill Box 11.2 / Enteral Nutrition: Coax Feeding and Orogastric Tube Method
Coax Feeding
Orogastric Tube
Advantages
• Noninvasive • Ease of procedure • Minimal patient stress
• Ease of procedure • Rapidly deliver high quantities
Disadvantages
• Patient tolerance • Difficult to meet caloric needs • May lead to learned food aversion
• • • •
414
SECTION FOUR: PATIENT CARE SKILLS
Patient tolerance ↑ Restraint and stress on patient Aspiration Repeated intubation; trauma
Skill Box 11.2 / Enteral Nutrition: Coax Feeding and Orogastric Tube (Continued) Indications
• Partial anorexia
• Partial anorexia in neonates
Contraindications
• Patients with difficulty swallowing
• Neonates with disorders of the oral cavity, pharynx, larynx, or esophagus
Setup
• 12-mL curved tipped syringe • High-calorie canned diet, ± blended with water to facilitate passage through the syringe tip
• • • • •
Procedure
Cut the end of the curved tip syringe about ¼–1/3 inch to allow easier passage of food. Insert the syringe between the molar teeth and cheek (canine) or between the canine teeth (feline) of the patient’s mouth positioned toward the back of the mouth. Slowly begin filling the mouth according to the speed of swallowing while allowing breaks to breathe. Feeding should be stopped if patient does not swallow food voluntarily.
Measure the feeding tube from the tip of the nose to the last rib and mark with a permanent marker. Lubricate the end of the tube and position the patient’s head in a slightly flexed position. Begin inserting the tube into the patient’s mouth, allowing them to swallow the tube. Continue to insert tube until the premeasured mark. Confirm proper placement by checking for negative pressure, injecting 3–5 mL of sterile saline into the tube, which will elicit a cough if placed in the airway, or placing 5–10 mL of air into the tube and auscultating for borborygmus at the xyphoid. Administer diet and then remove the tube by bending in half to occlude and pulling in a downward direction to prevent backflow.
Complications
• Aspiration • Vomiting
• Patient biting tube into pieces • Endotracheal placement: kittens do not have a gag reflex, allowing easy endotracheal intubation and aspiration • Vomiting
Removal
3.5–8 Fr feeding tube High-calorie diet that has a texture allowing easy flow through the tube Lubricant Mouth speculum Permanent marker
• Immediately following each procedure • Kink tube and gently, but briskly remove the tube to avoid fluid aspiration
11 Skill Box 11.3 / Enteral Nutrition: Nasoesophageal and Nasogastric Tube Method
Nasoesophageal/Nasogastric Tube
Advantages
• • • • • •
Disadvantages
• Size restriction of tube • Need for a liquid or highly blended diet
Indications
• Any patient experiencing malnutrition and/or anorexia
Easy placement and removal Patient tolerance Placement without general anesthesia Removal of gastric air and fluid from the esophagus and stomach by suction (e.g. post GDV and megaesophagus) Patient can eat and drink around the tube. Tube removal can be performed anytime after placement.
CHAPTER 11 / PARENTERAL NUTRITION
415
Skill Box 11.3 / Enteral Nutrition: Nasoesophageal and Nasogastric Tube (Continued) Contraindications
• Patients undergoing oral, pharyngeal, esophageal, gastric, or biliary tract surgery • Patients with esophageal disorders or reflux, vomiting, regurgitation, megaesophagus, thrombocytopenia/thrombocytopathia, or nasopharyngeal trauma • Patients who are unconscious or recumbent • Patients who are hypothermic or hypotensive
Setup
• • • • • •
Procedure
Place 2 (0.5–1 mL) applications of local anesthetic in the nasal cavity by tilting the head up to encourage coating of the nasal mucosa. Select proper tube size and measure from the nares to the 7th or 8th intercostal space for nasoesophageal placement or the last rib for nasogastric placement and mark with tape. Lubricate the end of the tube with 5% viscous lidocaine and hold the head in a normal functional position; avoiding hyperflexion or hypoflexion of the neck. Gently and briskly insert the tube ventrally and medially. The tube will drop into the oropharynx and stimulate a swallowing reflex. Pass the tube to the desired location. Confirm proper placement by checking for negative pressure, injecting 3–5 mL of sterile saline into the tube, which will elicit a cough if placed in the airway, placing 5–10 mL of air into the tube and auscultating for borborygmus at the xyphoid, and by taking a radiograph. Once proper placement is established, secure the tube. Place the tube directly over the dorsal aspect of the nose and forehead and secure it with Chinese finger trap sutures or by suturing a tape tag directly to the skin. Finally, place an Elizabethan collar.
Complications
• • • • •
Removal
• Tubes can be removed at anytime or be left in place for up to 14 days • Cut sutures and then kink tube and gently, but briskly remove the tube to avoid fluid aspiration
11
Topical anesthetic (proparacaine hydrochloride 5%) Permanent marker 5% viscous lidocaine Sterile saline Needle holders Suture material, nonabsorbable
• • • • • •
Elizabethan collar Surgical site preparation materials ± Light sedation Stethoscope 3–5 mL syringe 5–10 Fr feeding tube
Sphincter incompetence, esophagitis, or esophageal reflux when the tube passes through the cardiac sphincter Distal esophageal trauma due to large-bore tubes, reflux, or excessively heated foods Epistaxis, sinusitis Inadvertent tube removal by vomiting, sneezing, coughing, or pawing Diarrhea due to an all-liquid diet
Tip: Continue to grasp the tube as close to the patient’s nares as possible to provide stability in case of patient sneezing. Tip: Using your thumb, push up on the nose into a pig position, then insert the tube ventrally and medially to the level of the mark on the tube. Tip: Patient discomfort (e.g., pawing, sneezing) can be lessened with the application of more topical anesthetic.
416
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 11.4 / Enteral Nutrition: Esophagostomy Tube Method
Esophagostomy Tube
Advantages
• • • • • • •
Disadvantages
• General anesthesia
Indications
• Anorexic patients with a functional GIT • Patients with disorders of the oral cavity or pharynx (e.g., severe maxillofacial trauma, severe dental disease, neoplasia)
Contraindications
• • • •
Patients Patients Patients Patients
Setup
• • • • • •
Surgical site preparation materials Mouth speculum 8–20 Fr polyvinyl chloride feeding tube Permanent marker Eld feeding tube placement device Bandage material
Procedure
Administer general anesthesia and place the patient in right lateral recumbency. Aseptically prepare the lateral midcervical area from the ramus of the mandible to the thoracic inlet and dorsally and ventrally to midline. Place a mouth speculum and slightly extend the neck. Measure the tube from the point of exit (midcervical region) to the 7th or 8th intercostal space and mark with the permanent marker. Using the Eld feeding tube placement device, make an incision through the cervical musculature and place the tube into the esophagus according to manufacturer’s guidelines. The tube can also be placed by placing the carmalt down the esophagus to the point of insertion and incising over the tips. Place the tube into the tips of the carmalt and withdraw out the mouth. Then, using the carmalt, stylet, or fingers, push the tube down the esophagus until the proximal end of the tube flips rostrally when the tube is in place. Suture the tube to the cervical skin using the Chinese finger trap. An antibiotic ointment is used and a gauze bandage is placed. Radiograph to verify proper placement.
Easy placement and removal Patient tolerance Slurried food can be used. Patient can eat and drink around the tube. Easy tube care for owner Tube removal can be performed anytime after placement. Large-bore tubes
with with with who
an esophageal dysfunction or stricture, esophagitis, megaesophagus, vomiting, regurgitation esophageal foreign body removal or esophageal surgery respiratory disease (e.g., severe cough, pneumonia) are hypothermic or hypotensive • • • • •
No. 10 or No. 15 scalpel blade and handle, needle holders, Mayo scissors, Rochester carmal Suture material, nonabsorbable Sterile, water-soluble lubricant 3 mL syringe General anesthesia
Complications
• Inadvertent tube removal by vomiting, pawing, or chewing the end • Distal esophageal trauma due to large bore tubes, reflux, or excessively heated foods • Cellulitis
Removal
• Immediate or up to several months • To remove, cut the skin sutures and pull. • Exit site does not need further care; the holes will seal in 1–2 days and heal in 7–10 days.
Tip: The tip of the feeding tube can be cut at the distal end just above the holes to allow a larger diameter for the food to exit to prevent clogging. Verify the cut end does not have sharp edges.
CHAPTER 11 / PARENTERAL NUTRITION
417
11
Skill Box 11.5 / Enteral Nutrition: Gastrotomy Tube Without Gastropexy Method
Gastrotomy Tube: Without Gastropexy
Advantages
• Direct visualization of the tube during placement • Placement of large diameter catheters • Can use calorie dense diets
Disadvantages
• Inability to perform gastropexy to ensure seal between stomach wall and body wall • Tube must remain in place for 10–14 days.
Indications
• Anorexic patients with functional GIT distal to stomach • Patients undergoing surgery of oral cavity, larynx, pharynx, or esophagus
Contraindications
• Patients with primary gastric disease: gastritis, gastric ulceration, or gastric neoplasia • Vomiting • Patients who are hypothermic or hypotensive Percutaneous Endoscopic Gastrotomy (PEG) Tube Placement
Surgical Placement
Setup
• • • • • • •
• • • • • • • • •
Procedure
Aseptically prep the left flank caudal to the left costal arch. The endoscope is placed in the stomach and the stomach is inflated. Digital palpation is performed and a small incision is made in the skin. An IV catheter is placed through the body wall into the stomach. The stylet is removed and suture is passed through, which is grabbed by the endoscope and extracted out of the mouth. The feeding tube is attached to the suture and then passed through the mouth into the stomach. The feeding tube is anchored at the skin surface where the incision had been made. The endoscope is reinserted to verify placement. The tube should be clamped and capped.
Complications
• • • •
11
418
14-gauge needle or catheter 20–24 Fr Pezzer’s catheter Endoscope General anesthesia Luer-Slip catheter plug Sterile lubricant Suture material
No. 11 scalpel blade 18–20 Fr Foley catheter 6 mL syringe General surgical pack Large curved forceps Large-bore stiff stomach tube Mouth speculum Surgical site preparation material Suture material
Administer general anesthesia. Aseptically prepare the skin of the left flank. Place a stomach tube or feeding tube placement device from the oral cavity to the stomach. Palpate the tube bulging against the left body wall. Direct it 1–2 cm caudal to last rib. Pass an 18-gauge needle through the abdominal wall and into the lumen of the stomach tube. Thread the needle with suture and direct through to oral cavity. Remove the stomach tube. Thread the end of the suture through the 18-gauge sovereign catheter and tie it to the proximal end of the Pezzer urinary catheter. Pull the suture and the attached catheter back into the stomach cavity, enlarge the exit hole, and pull sovereign catheter out until the mushroom tip of the Pezzer catheter is snugly against the body wall. This will ensure a seal between the stomach wall and body wall. Secure the catheter to the skin with sutures.
Placement trauma (splenic laceration, pneumoperitoneum, and gastric hemorrhage) Vomiting, aspiration pneumonia, gastroesophageal reflux Peritonitis and dehiscence with tube migration Peristomal infection and cellulitis
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 11.5 / Enteral Nutrition: Gastrotomy Tube Without Gastropexy (Continued) Removal
• Can be removed after 14 days • Can be removed after 14 days • Feline: flatten mushroom tip with stylet and pull out with firm • Cut the sutures, deflate the cuff, and gently pull out the tube. traction. • Canine: either deflate the tip and extract or, for larger canines, cut the tube at the body wall and push the tip into the stomach to be passed in the animal’s feces.
Skill Box 11.6 / Enteral Nutrition: Gastrotomy Tube With Gastropexy Method
Gastrotomy Tube: With Gastropexy
Advantages
• • • •
Disadvantages
• General anesthesia • Feeding cannot take place until 24 hours after tube placement.
Indications
• Anorexic patients with functional GIT distal to stomach • Patients undergoing surgery of oral cavity, larynx, pharynx, or esophagus
Contraindications
• Patients with primary gastric disease: gastritis, gastric ulceration, or gastric neoplasia • Patients with disorders causing vomiting • Patients who are hypothermic or hypotensive
Setup
No special equipment Ease of finding the stomach in an anorexic patient Ensures immediate seal between stomach wall and body wall Confirmation of tube placement during procedure
11
Surgical Placement
Laparotomy Placement
• • • • • • • • •
• • • • • • •
Surgical site preparation material Large-bore stiff stomach tube Mouth speculum General surgical pack No. 11 scapel blade 18–20 Fr Foley catheter Suture material Large curved forceps 6 mL syringe
Surgical site preparation material General surgical pack No. 11 scalpel blade 18–20 Fr Foley or Pezzer catheter Suture material Sterile saline 6 mL syringe
CHAPTER 11 / PARENTERAL NUTRITION
419
Skill Box 11.6 / Enteral Nutrition: Gastrotomy Tube With Gastropexy (Continued) Administer general anesthesia. With a midline laparotomy approach, incise into the stomach. Place the Pezzer catheter directly into the stomach and place through the stomach and body wall as above. Fix the stomach wall to the body wall with sutures. Suture the abdomen closed.
Procedure
Administer general anesthesia. Aseptically prepare the skin of the left flank. Place a stomach tube into the stomach and palpate the left flank until the stomach tube can be felt and grasped. The tube should be felt 1–2 cm past the last rib and 3–4 cm ventral to the transverse processes of lumbar vertebrae 2, 3, and 4. While holding the tube, make a 2-cm incision over the end of the tube. Dissect down to the outside of the stomach lumen. Place a purse string suture in the stomach, and then with a scalpel blade, insert the tube. Inflate bulb on Foley catheter, withdraw stomach tube, and tighten purse string. Suture stomach wall to the body wall and place some subcutaneous sutures. Suture tube to abdominal skin.
Complications
• Leakage of gastric contents into the abdominal cavity resulting in peritonitis • Vomiting • Peristomal infection
Removal
• After 14 days or several weeks or months • Cut the sutures, deflate the cuff, and gently pull out the tube. • Exit site does not need further care; the holes will seal in 1–2 days and heal in 7–10 days.
Skill Box 11.7 / Enteral Nutrition: Jejunostomy Tube
11
Method
Jejunostomy
Advantages
• Immediate feeding of a highly digestible, low-bulk diet allowed • Intermittent bolus feeding can be used, but continuous feeding is typically better tolerated.
Disadvantages
• General anesthesia • Performing a celiotomy
Indications
• Patients undergoing oral, pharyngeal, esophageal, gastric, pancreatic, duodenal, or biliary tract surgery where the GIT is functional past the lesion or disease • Patients unable to protect their airway or at risk for pulmonary aspiration • Gastric, intestinal, or pancreatic disease
Contraindications
• Patients with lower GIT disorders or diseases • Patients who are hypothermic or hypotensive
Setup
• • • • • •
420
Surgical site preparation materials 5–8 Fr PVC feeding tube General surgical pack No. 11 scalpel blade Suture material Bandaging material
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 11.7 / Enteral Nutrition: Jejunostomy Tube (Continued) Procedure
Administer general anesthesia. Make a 2–3 mm stab incision through the abdominal wall. Through the celiotomy, select a section of jejunum that can be easily moved to the stab incision in the body wall. Incise into the jejunum; place the distal end of the feeding tube through the incision and pass 25–30 cm of the tube aborally into the jejunum. Suture the exit site of the jejunum and fix to the body wall. Secure the exit portion of the tube to the outside skin. Incorporate the tube into an abdominal bandage.
Complications
• Peritonitis and dehiscence with tube migration • Peritoneal or subcutaneous leakage
Removal
• Can be removed 10–14 days after placement
Skill Box 11.8 / Enteral Nutrition Administration Method
Tube Care
Diet
Calculations
Administration
Syringe
• Rinse syringe with water after administration.
• Calculate the resting energy requirement (see Skill Box 3.1, page 58). • Divide the total daily volume by 3–4 feedings.
• Fill syringe with desired food and place the tip of the syringe in the cheek pouch directed toward the back of the mouth. • Gently depress plunger of syringe and deposit food. • Speed will depend on the rate of swallowing and patient tolerance.
Orogastric Tube
• Rinse tube with water after administration.
• If diet is hyperosmolar (>350 mOsm/kg water) it will need to be diluted with water to make it hypoosmolar • Commercial diets not requiring blenderizing (e.g., CliniCare, Ensure, Jevity, Osmolite HN, Promote, Vital HN, Vivonex HN)
Nasoesophageal/ Nasogastric Tube
• Place a column of water in the tube and cap it at the end of each feeding to prevent intake of air, reflux of esophageal contents, and occlusion of the tube by the diet.
Esophagostomy Tube
• Place a column of water in the tube and cap it at the end of each feeding to prevent intake of air, reflux of contents, and occlusion of the tube by the diet.
Gastrotomy Tube
• Clean the site of tube exit with an antiseptic solution and monitor for movement daily.
• Commercial diets typically requiring blenderizing (e.g., CNM-CV Feline, Iams NRF, Eukanuba Feline Max, Hill’s A/D, Hill’s P/D)
• Once tube is in place (see Skill Box 12.1 Stomach Tube and gastric Lavage, page 428), attach food-filled syringe to the end of the tube. • Begin depressing plunger to administer required amount. • Calculate resting energy requirement (see Skill Box 3.1 Daily Caloric Requirement Worksheet, page 58). • Give 50% volume on day 1, 100% volume on day 2, depending on patient tolerance. • Divide the total daily volume by 3–4 feedings.
• Warm the food to body temperature in a warm water bath, stirring thoroughly to avoid hot spots. • Remove the cap on the tube and draw back on syringe to observe for any food or fluid. Food will only be seen if the tip of the tube is located within the stomach (e.g., nasogastric tube placement). • If more than 0.5 mL/lb are withdrawn, do not feed. • Infuse 5–10 mL water to ensure the tube is patent. • Infuse the allotted food slowly over a few minutes. • Infuse 5–10 mL water to clear tube and recap.
CHAPTER 11 / PARENTERAL NUTRITION
421
11
Skill Box 11.8 / Enteral Nutrition Administration (Continued) Method
Tube Care
Diet
Calculations
Administration
Jejunostomy Tube
See above
• Commercial liquid diets (e.g., Clinicare) • Liquid formulas are required to prevent tube clogging. • Dilution with water is not needed if a isosmolar formula is used.
• Calculate the resting energy requirement (see Skill Box 3.1 Daily Caloric Requirement Worksheet, page 58). • Dilute 1 : 1 on day 1, 1 : 0.5 on day 2, and full strength on day 3. • Give 25–50% volume on day 1 and gradually increase over the next 3–4 days.
• May feed immediately after surgery. • Infuse continuously with an infusion pump, checking regularly for back pressure. • Do not hang bag for more than 24 hours as bacterial growth and contamination may occur.
PARENTERAL NUTRITION
11
Parenteral feeding is nutrition delivered by the intravenous route, another form of assisted feeding that is typically reserved for the most critically ill patients—those with nonfunctioning GITs, unretractable vomiting, or those unable to withstand a surgical procedure for a jejunostomy tube. The natural enteral route of feeding should be the first choice of treatment or consequences such as mucosal atrophy and loss of the barrier function of the GIT are seen. However, parenteral feeding offers an alternative to those patients unable to obtain complete and proper nourishment through enteral feeding. Total parenteral nutrition (TPN) provides the total patient’s daily energy requirement, and partial parenteral nutrition (PPN) is used to supplement enteral feeding providing only a portion (40–70%) of the patient’s total daily energy requirement. Parenteral nutrition (PN) is administered ideally through a dedicated polyurethane or silicone central catheter or lumen of a central catheter. Long
422
SECTION FOUR: PATIENT CARE SKILLS
peripheral catheters (jugular catheters placed peripherally) can be used but have an increased risk of phlebitis due to the high osmolality of the PN solution. With the use of peripheral catheters, the PN solution must be dramatically diluted, requiring larger volumes of fluid to be given, which may be contraindicated in some patients and comes with an increased risk of sepsis. The catheter must be dedicated for the sole purpose of administering the PN solution. Due to its high nutrient content, bacterial sepsis becomes a high risk. Along with a dedicate catheter, strict aseptic technique must be followed. Even though PN can see severe complications, these can be dramatically reduced with attention to aseptic technique in formulating solution, catheter placement, and catheter maintenance. The information in the tables below provides a brief outline of PN; please refer to a textbook dedicated to this topic for further information.
Table 11.1 / Parenteral Nutrition Method
Total Parenteral Nutrition
Partial Parenteral Nutrition
Advantages
• Provides the total patient’s daily energy requirement • Provides an alternative to patient’s unable to obtain enteral support
• Provides a portion of the patient’s daily energy requirement • Provides an alternative to patient’s unable to obtain sufficient enteral support
Disadvantages
• • • • •
24-hour nursing care required Difficulty inserting and maintaining a central venous catheter Difficulty obtaining or preparing PN solutions Complications (e.g., sepsis, thrombosis, refeeding syndrome, ↑ permeability of the GIT) Expense
Indications
• • • • • • •
Nonfunctional GIT Postoperatively for some surgeries Prolonged ileus Severe malassimilation Patients with vomiting or regurgitation Pancreatitis Pulmonary aspiration risk
Contraindications
• Patients of marginal nutritional status • Well-nourished animals undergoing elective surgery or diagnostic procedures • Patients with fluid intolerance
Setup
• See Skill Box 8.9 Intravenous Catheter Placement: Peripheral and Jugular, page 349. • Areas of potential contamination should be kept to a minimum or avoided (e.g., stopcocks, tubing connections, piggybacking)
Procedure
• See Skill Box 8.9 Intravenous Catheter Placement: Peripheral and Jugular, page 349.
Complications
Metabolic • Refeeding syndrome is the rapid movement of ions from the plasma to the intracellular space (e.g., hypophosphatemia, hypokalemia, hypomagnesemia) seen with malnutrition, starvation, and prolonged diuresism possibly leading to muscle weakness, intravascular hemolysis, and cardiac and respiratory failure. • Hyper- or hypoglycemia, hyperlipidemia, hyperammonemia Mechanical • Sepsis of catheter or lines, thrombophlebitis
Removal
• Slow discontinuation essential to prevent a metabolic crises (e.g., hyper- or hypoglycemia)
• • • •
Patients of marginal nutritional status Patients who cannot receive a jugular catheter Patients needing supplemental feeding to enteral feeding Patients benefiting from nutritional support before surgery for gastrotomy or jejunostomy tube • Nondebilitated animals needing IV support for <7 days • Patients with vomiting or regurgitation • Debilitated patients needing full nutritional support • Well-nourished animals undergoing elective surgery or diagnostic procedures
11
• Discontinue PPN after patient consumes >50% of its energy requirement orally. • Slow discontinuation essential to prevent a metabolic crises (e.g., hyper- or hypoglycemia)
CHAPTER 11 / PARENTERAL NUTRITION
423
Table 11.2 / Parenteral Nutrition Administration Patient and Catheter Care
Diet
Calculations
Administration
• Patient • Fluid, electrolyte, and acid-base abnormalities should be corrected before administration. • Check body weight and temperature twice daily. • Daily evaluation of serum electrolytes, glucose, total protein, serum lipids, PCV, BUN, and liver enzymes. • Catheter • Change sterile bandage daily, and observe for any signs of thrombosis, sepsis, or perivascular infusion. • Catheter should be placed in a new vein if there is any question to its patency, sterility, or tissue irritation around site. • If the catheter sepsis is suspected, obtain a blood sample for culture, remove catheter, and submit catheter tip for culture. • Change administration set every 24–48 hours.
• Solutions contain a combination of a protein source, fat source, carbohydrate source, and possibly vitamins, electrolytes, and trace minerals (e.g., zinc, copper, manganese, chromium). • Commercial solutions can be purchased from human hospitals and health care suppliers; however, the contents of these solutions need to be compared to the specific requirements of the patient. • Homemade solutions consisting of amino acid solutions (e.g., 8.5% Travesol Injection with Electrolytes), lipid emulsions (e.g., Intralipid 20%), dextrose (e.g., 50% Dextrose), and vitamin supplements (e.g., vitamins B, A, D, E, K). • Homemade solutions must be made under strict aseptic technique using a laminar flow hood or PN compounding bags; therefore, purchasing already formulated mixtures is more practical for most hospitals. • Homemade TPN solutions should be mixed in an all-in-one container with separate sterile transfer lines for each solution. • Refer to a parenteral reference for the proper technique and calculation of each component.
• Calculate the resting energy requirement based on ideal body weight (see Skill Box 3.1 Daily Caloric Requirement Worksheet, page 58). • Calculate protein, carbohydrate, and fat requirements based on ideal body weight. TPN • Administer 50% the first day and 100% the second day. PPN • Subtract the enteral calories from the RER; then administer the remaining.
Calculation is critical and should be verified. • Unused PN solutions should be kept refrigerated; prepared solutions should be made fresh daily and not shared between patients. • Solutions being administered should not be at room temperature longer than 24 hours. • Place an inline 1.2-μm aireliminating filter in the administration set to avoid embolisms. • Infusion pumps should always be used to avoid bolus administration. • No fluid or drug can be added to the PN solution due to the risk of incompatibility and precipitates. • Using an aseptically prepared and dedicated catheter, slowly begin a 24 hour CRI of PN solution based on the patient’s RER.
11
424
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 11.9 / Worksheet for Calculating Total Parenteral Nutrition (TPN) b. Nonprotein calories
1. Resting energy requirement (RER)
• The calories supplied by protein (4 kcal/g) are subtracted from the total calories needed to get total nonprotein calories needed.
RER = 70 × (current body weight in kg)
0.75
or, for animals weighing between 2 and 30 kg: RER = (30 × current body weight in kg) + 70 = ____ kcal/day Tip: To calculate (BW kg)0.75 without a scientific calculator: multiply the weight by itself 3 times, then take the square root twice. 2. Protein requirements Standard Decreased (hepatic/renal failure) Increased (protein-losing conditions)
Canine 4 g/100 kcal 2 g/100 kcal 6 g/100 kcal
Feline 6 g/100 kcal 3 g/100 kcal 6 g/100 kcal
(RER ÷ 100) × ____ g/100 kcal (protein req) = ____ g protein required/day 3. Volume of nutrient solutions a. 8.5% amino acid solution (0.085 g protein/mL) ____ g protein required/day ÷ 0.085 g/mL = ____ mL/day of amino acids
____ g protein required/day × 4 kcal/g = ____ kcal from protein ____ total kcal required/day − kcal from protein = ____ total nonprotein kcal needed/day c. Nonprotein calories are usually provided as a 50 : 50 mixture of lipid and dextrose. • This ratio may need to be adjusted if the animal is hyperglycemia or hypertriglyceridemia. 20% lipid solution (2 kcal/mL) To supply 50% of nonprotein calories ____ lipid kcal required ÷ 2 kcal/mL = ____ mL of lipid/day 50% dextrose solution (1.7 kcal/mL) To supply 50% of nonprotein calories ____ dextrose kcal required ÷ 1.7 kcal/mL = ____ mL of dextrose/day 4. Total daily requirements ____ mL ____ mL ____ mL ____ mL rate
8.5% amino acid solution 20% lipid solution 50% dextrose solution (use half on first day) total volume of TPN solution ÷ 24 hours = ____ mL/hr infusion 11
• Be sure to adjust the animal’s other intravenous fluids accordingly. • TPN vitamins and trace metals can be added during formulation if indicated. Tip: To calculate (BW kg)0.75 without a scientific calculator: multiply the weight by itself 3 times, then take the square root twice. Note: Reprinted with permission from Daniel Chan, DVM, DACVECC, DACVN, MRCVS.
CHAPTER 11 / PARENTERAL NUTRITION
425
Skill Box 11.10 / Worksheet for Calculating Peripheral or Partial Parenteral Nutrition (PPN) 1. Resting energy requirement (RER) RER = 70 × (current body weight in kg)
0.75
or, for animals weighing between 2 and 30 kg: RER = (30 × current body weight in kg) + 70 = RER = ____ kcal/day Tip: To calculate (BW kg)0.75 without a scientific calculator: multiply the weight by itself 3 times, then take the square root twice 2. Partial energy requirement (PER) To supply 70% of the patient’s RER PER = RER × 0.70 = PER = ____ kcal/day 3. Nutrient requirements Patients 3–10 kg: PER × 0.25 = ____ kcal/day from dextrose PER × 0.25 = ____ kcal from amino acids PER × 0.50 = ____ kcal/day from lipids Patients 10–25 kg: PER × 0.33 = ____ kcal/day from dextrose PER × 0.33 = ____ kcal from amino acids PER × 0.33 = ____ kcal/day from lipids Patients >25 kg: PER × 0.50 = ____ kcal/day from dextrose Note: Reprinted with permission from Daniel Chan, DVM, DACVECC, DACVN, MRCVS.
11
426
SECTION FOUR: PATIENT CARE SKILLS
PER × 0.25 = ____ kcal from amino acids PER × 0.25 = ____ kcal/day from lipids 4. Volume of nutrient solutions 5% dextrose (0.17 kcal/mL) ____ kcal/day from dextrose ÷ 0.17 kcal/mL = ____ mL/day 8.5% amino acids (0.34 kcal/mL) ____ kcal/day from amino acids ÷ 0.34 kcal/mL = ____ mL/day 20% lipid (2 kcal/mL) ____ kcal/day from lipid ÷ 2 kcal/mL = ____ mL/day 5. Total daily requirements ____ mL 5% dextrose ____ mL 8.5% amino acids ____ mL 20% lipid ____ mL total volume of PPN solution ÷ 24 hours = ____ mL/hr infusion rate • This calculation should approximate a patient’s maintenance fluid requirements. Be sure to adjust the animal’s other intravenous fluids according. The volume may be higher than maintenance fluid requirements for very small animals (<3 kg) or in animals with cardiac disease. • TPN vitamins and trace metals can be added during formulation if indicated.
Chapter
12
Medical Procedures Gastrointestinal Procedures 428 Stomach Tube and Gastric Lavage 428 Gastrointestinal Tube Placement Verification 429 Abdominocentesis and Diagnostic Peritoneal Lavage 429 Enema, Warm Water 430 Ophthalmic Procedures 430 Schirmer Tear Test, Fluorescein Sodium Stain, and Tonometry 430
Key Words and Termsa Applanation Caustic Uroabdomen
a
Respiratory Procedures 431 Thoracocentesis and Thoracostomy Tube Placement 431 Nebulization, Coupage, and Metered-Dose Inhalers 432 Urogenital Procedures 434 Urine Collection 434 Urine Collection Devices 435 Urinary Catheterization 435 Urinary Catheter Maintenance 436
Abbreviations
Additional Resources, page
Fr, French GIT, gastrointestinal tract hr, hour IV, intravenous kg, kilogram MDI, metered-dose inhaler mL, milliliter mm Hg, millimeters of Mercury
Anatomy, 3 Patient monitoring, 332 Recumbent patient care, 347 Suture techniques, 548
12
Key words and terms are defined in the glossary on page 631.
427
GASTROINTESTINAL PROCEDURES Skill Box 12.1 / Gastrointestinal Procedures: Stomach Tube and Gastric Lavage Method
Stomach Tube
Gastric Lavage
Indications
• Activated charcoal, barium, or food administration • Toxicity
• Toxicity removal, and dilution
Contraindications
• Patients with disorders of the oral cavity, pharynx, larynx, or esophagus • Vomiting, ileus or gastric obstruction • Ingestion of corrosives, heavy metals, or petroleum distillates
• Patients with disorders of the oral cavity, pharynx, larynx, or esophagus • Ingestion of caustic materials or petroleum distillates
Setup
• • • • • •
• • • • • •
Procedure
Measure the feeding tube from the tip of the nose to the last rib and mark with a permanent marker. Prefill the tube with water to avoid introducing air. Lubricate the end of the tube and position the patient’s head in a slightly flexed position. Begin inserting the tube into the patient’s mouth, allowing the animal to swallow the tube. Continue to insert tube until the premeasured mark. Administer diet.
Administer general anesthesia and place the animal in lateral recumbency. Measure the feeding tube from the tip of the nose to the last rib and mark with a permanent marker. Lubricate the end of the tube and position the patient’s head in a slightly flexed position. Insert the tube to the premarked line. Instill water at 5–10 mL/kg to obtain a slightly distended stomach while monitoring for respiratory distress. Then lower the tube below the patient’s head to remove the water by gravity. Turn patient and continue until all removed fluid is clear.
Complications
• Patient biting tube into pieces • Endotracheal placement: kittens do not have a gag reflex, allowing easy inadvertant endotracheal intubation and aspiration • Aspiration pneumonia • Vomiting
• Aspiration pneumonia • Vomiting
Removal
• Kink tube and gently but briskly remove the tube to avoid fluid aspiration.
• Kink tube and gently but briskly remove the tube to avoid fluid aspiration.
12
428
Stomach tube Lubricant Permanent marker Catheter-tipped syringes Activated charcoal, barium, or prepared food Towels
SECTION FOUR: PATIENT CARE SKILLS
Stomach tube Pump or 60 mL syringes Permanent marker Lubricant Mouth speculum 2 buckets (1 empty and 1 with body temperature water)
Skill Box 12.2 / Gastrointestinal Tube Placement Verification • Attach a syringe and aspirate air—a negative pressure will result with esophagus or stomach tube placement, and aspirated air indicates tracheal placement. • Rapidly inject 6–12 mL of air into the tube while auscultating for borborygmus at the xyphoid.
• Inject 3–5 mL of sterile saline; a cough will be elicited with tracheal tube placement. • Take a radiograph.
Skill Box 12.3 / Gastrointestinal Procedures: Abdominocentesis and Diagnostic Peritoneal Lavage Method
Abdominocentesis
Diagnostic Peritoneal Lavage
Indications
• Acute abdominal pain, fever of unknown origin • Peritonitis, trauma, hemorrhage, uroabdomen, neoplasia, inflammatory conditions
• Negative abdominocentesis • Acute abdominal pain, fever of unknown origin • Peritonitis, trauma, hemorrhage, neoplasia, inflammatory conditions
Contraindications
• Penetrating abdominal wounds
• Penetrating abdominal injury
Setup
• Surgical site preparation materials • 20–22 gauge 1½ inch needle or 18–20 over-theneedle catheters • 3–6 mL syringes • Red and lavender top tubes • Culturettes
• • • • • • • •
Procedure
Place the animal in lateral recumbency or in a standing position. Aseptically prepare a 10-cm square on the ventral abdomen with the umbilicus in the middle. Insert the needle 1–2 cm caudal to the umbilicus on the right side of the midline. Gently twist the needle on insertion to move aside any hollow organs. Needles in all 4 quadrants may need to be placed if fluid pocketing is suspected. Drip or aspirate fluid into the sterile tubes and culturette.
Place the animal in lateral recumbency. Aseptically prepare a 10-cm square on the ventral abdomen with the umbilicus in the middle. Using the scalpel blade, cut ports into the side of the catheter. Insert the needle 1–2 cm caudal to the umbilicus on the right side of the midline. Gently twist the needle on insertion to move aside any hollow organs. Remove the stylet and observe for fluid. If noted, aspirate with the syringe; otherwise, instill 10–20 mL/kg warmed saline over 3–5 minutes. Remove the catheter and walk the patient while massaging the abdomen or gently roll the patient side to side. Return the patient to lateral recumbency and perform a 4-quadrant abdominocentesis to obtain 0.5–1 mL of fluid.
• Stomach or internal organ laceration
• Stomach or internal organ laceration
Complications
Surgical site preparation materials 20–22 gauge 1½ inch needle or 18–20 over-the-needle catheters #10 scalpel blade 3–6 mL syringes Sterile saline, warmed IV fluid administration set Red and lavender top tubes Culturettes
Tip: A second needle may need to be placed 2 cm from the first to facilitate flow. Tip: Redirecting the needle, tapping or applying alternating dorsal and ventral hand pressure may help direct fluid toward the needle.
CHAPTER 12 / MEDICAL PROCEDURES
429
12
Skill Box 12.4 / Gastrointestinal Procedures: Enema, Warm Water Method
Enema, Warm Water
Indications
• Constipation • Elimination of toxic materials in the lower GIT
Contraindications
• Disorders of the lower GIT and rectum • Any human enema product
Setup
• Lubricant (e.g., K-Y Jelly) • Enema bucket and tubing
Procedure
• Animal is placed in lateral or sternal position. Sedation or anesthesia may be needed. The enema bucket is prepared by filling with warm water, mild soap, or a lubricant, and the tube is clamped off. The bucket is hung above the patient to facilitate flow. The tip of the tubing is lubricated and inserted into the rectum. The clamp is released and the tube is moved back and forth while moving cranially until 60–120 mL has been instilled. The tube is reclamped, and manual extraction is attempted by placing one hand with a deep abdominal grasp and the other hand along the spine to trap the feces. Using the spine hand, work the feces through the pelvic canal and extract with the index finger of the abdomen hand.
Complications
• Rectum or lower GIT trauma
OPHTHALMIC PROCEDURES Skill Box 12.5 / Ophthalmic Procedures: Schirmer Tear Test, Fluorescein Sodium Stain, and Tonometry Method
Schirmer Tear Test
Fluorescein Sodium Stain
Tonometry, Applanation
Indications
• Assessment of normal tear production • Discharge, inflammation, corneal disease (e.g., ulceration)
• Epithelial defects (e.g., ulcerations, injury) • Evaluation of nasolacrimal system
• Red or painful eye • Glaucoma
Contraindications
• Anesthetized eye
• Use precollection of conjunctival or corneal epithelial cells • During intraocular surgery
• Multiple lesions/ulcers
Setup
• Tear strips
• Stain strips
• Tonopen, TonoVet • ± Topical anesthetic
12
430
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 12.5 / Ophthalmic Procedures: Schirmer Tear Test, Fluorescein Sodium Stain, and Tonometry (Continued) Procedure
Place the notched end of the tear strip in the palpebral fissure. The eyelids are held closed for exactly 1 minute. The strip is removed and measured and recorded according to the scale on the package. Normal: >15 mm
Before removing the strip from the package, fold it in half lengthwise to form a trough. Remove the strip and place 2–3 drops of sterile saline or eye wash in the trough. Tilt the strip and allow the stain to drip into the patient’s eye. Do not touch the eye to avoid iatrogenic stain retention. Rinse the eye with eye wash onto a cotton ball. Examine the eye with a pen light followed by a Wood’s lamp observing for green stain indicating a break in the epithelium. To evaluate the nasolacrimal system, do not rinse and observe the nares in 5 minutes for canines and up to 10 minutes in felines for appearance of the green stain.
The eye is anesthetized with a topical anesthetic (TonoVet does not require the topical anesthesia). The patient is loosely confined in a sitting or standing position with the head in a normal position perpendicular to the floor/table. The restrainer should be aware not to apply pressure on the jugular veins or thoracic inlet. The instrument is held in any orientation and the tip placed on the central cornea completely perpendicular to the corneal surface. The button is pushed and a reading is displayed. Several readings should be taken to assure consistent measurement. Normal: 15–25 mm Hg
Complications
• None noted
• Iatrogenic stain retention
• None noted
RESPIRATORY PROCEDURES Skill Box 12.6 / Respiratory Procedures: Thoracocentesis and Thoracostomy Tube Placement Method
Thoracocentesis
Thoracostomy Tube Placement (closed chest)
Indications
• Pleural effusion (hemothorax, chylothorax, pyothorax, neoplastic effusion, right-sided cardiac failure) or pneumothorax
• Multiple thoracocentesis required and/or failure to achieve negative pressure • Pleural effusion, pneumothorax
Contraindications
• Coagulopathies • Pleural adhesions
• Coagulopathies • Pleural adhesions
Setup
• • • • • •
Surgical site preparation materials 18–22 gauge needle or butterfly 3-way stopcock 20–60 mL syringe IV extension tubing Surgical blade
• Local anesthetic agents • Collection basin • Red and lavender toped tubes • Culturettes • Oxygen
12
• Surgical site preparation materials • Thoracostomy tube or 12–20 Fr red rubber catheter • Syringe/chest drain valve • Christmas tree adapter • 3-way stopcock
• • • • • •
Minor surgical instrument pack Local anesthetic agents Suture materials Bandaging materials ± Suction Oxygen
CHAPTER 12 / MEDICAL PROCEDURES
431
Skill Box 12.6 / Respiratory Procedures: Thoracocentesis and Thoracostomy Tube Placement (Continued) Procedure
Place the patient in sternal or lateral recumbency. Surgically prep a 4–8 cm square in the center of the right side of the chest at the 7th–9th intercostal space. Place a local block in the awake patient. Insert the needle in the intercostal space avoiding the intercostal arteries on the caudal aspect of each rib. Advance the needle into the pleural space while angling the needle flat against the chest wall with bevel outwards. While moving the needle along the chest wall, position the needle dorsally to obtain air and ventrally to obtain fluid. Aspirate and reserve fluid in sterile tubes via the 3-way stopcock.
Place the patient in lateral recumbency or a position resulting in the least amount of stress. Surgically prepare the entire lateral thorax. Have an assistant pull the skin from the 9th–10th intercostals space cranially until it lies over the 7th–8th intercostals space. Place a local block being sure to include the nearby pleura and intercostal muscles. Making a skin incision over the 9th–10th intercostal space, insert the thoracostomy tube with stylet or use surgical instruments to dissect down to the pleural space. The tube is then directed to the cranioventral thorax. The skin is then released allowing a subcutaneous tunnel to the 7th–8th intercostal space to be made. The tube is sutured in place using subcutaneous and finger -trap sutures. A chest wrap is placed to further secure the tube and prevent contamination. The tube is connected to the Christmas tree adapter, IV extension set, and syringe and evacuation is begun.
Complications
• Trauma or laceration to the lungs and intercostal vessels
• Trauma or laceration to the lungs and intercostal vessels • Worsening pneumothorax
Maintenance
• N/A
• All contact should be performed aseptically. • Frequent or continuous suction • Tube bandage should be changed daily.
Removal
• Remove needle, and observe site for fluid leakage.
• Suction the chest while removing clamp; place a gauze over insert point, then suture or glue together skin edges.
Tip: Place a mark on the tubing to indicate where the bevel of the needle is to allow correct positioning while in the thorax. Tip: After the needle has been inserted through the skin, fill the hub of the needle with sterile saline, as the needle is advanced the saline will be pulled in as the pleural space is entered.
Skill Box 12.7 / Respiratory Procedures: Nebulization, Coupage, and Metered Dose Inhalers 12
Nebulization is an aerosol therapy providing a fine mist of liquid droplets in a carrier gas. Nebulization is indicated to moisten respiratory tissue, loosen secretions, and stimulate coughing. Ideally, the patient uses slow, deep breaths to allow the peripheral airways to be reached; otherwise, treatment will be concentrated in the upper airways. Improvement with subsequent treatments will allow better treatment of lower respiratory system. Treatments are often followed by coupage as a way of breaking up and eliminating respiratory debris through coughing. Metered-dose inhalers are able to deliver high drug concentrations to the lungs while avoiding or minimizing systemic side effects. Method
Nebulization
Coupage
Metered-Dose Inhalers (MDIs)
Indications
• Upper respiratory conditions (e.g., asthma, pneumonia, infectious tracheobronchitis) • Tracheostomy tube care • Administration of medications (e.g., gentocin, aminoglycosides)
• Upper respiratory conditions (e.g., asthma, pneumonia, infectious tracheobronchitis) • Following nebulization
• Upper respiratory conditions (e.g., asthma, pneumonia, chronic bronchitis) • Administration of medications (e.g., Gentocin, aminoglycosides)
432
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 12.7 / Respiratory Procedures: Nebulization, Coupage, and Metered Dose Inhalers (Continued) Contraindications
• Further damage or trauma from coughing
• Thoracic trauma, thrombocytopenia • Further damage or trauma from coughing
• Adverse reactions to medicine
Setup
• Nebulizer machine • Medical cups • Extension adapters
• N/A
• Inhaler with spacer • Facemask • Medication (e.g., glucocorticoids, albuterol, salmeterol, nedocromil)
Procedure
The nebulizer housing is filled with sterile saline (± medications) and prepared according to manufacturer’s instructions. The housing is placed in front of the patient’s mouth and nose, and the animal is allowed to breathe normally. Treatments are typically 10–20 minutes.
Using a cupped hand on one or both sides, repeated thumps are made against the chest wall. Work from back to front and lower to upper areas of the chest. Treatments are typically 4 times a day following nebulization.
The MDI is primed and the inhaler shaken. Place the inhaler over the patient’s face and press the metal canister down firmly and fully. Hold the mask in place for 5–10 seconds or 5 breaths. Wait 30–60 seconds and repeat as needed according to the medication directions.
Complications
• Concentration of treatment in upper airway
• Thoracic trauma
• Patient resistance
• • • •
Extension hoses Elbow adapter 0.9% saline Medication
12
CHAPTER 12 / MEDICAL PROCEDURES
433
UROGENITAL PROCEDURES Skill Box 12.8 / Urine Collection: Voided, Manual Expression, and Cystocentesis Method
Voided
Manual Expression
Cystocentesis
Indications
• Urine collection
• Urine collection • Neurologic impairment
• Urinalysis • Bacterial culture
Contraindications
• Bacterial culture
• Urethral obstruction • Bacterial culture
• Urethral obstruction
Setup
• Collection cup or litter box • Clean syringe
• Collection cup
• • • •
Procedure
Canine: walk on a short leash and catch a voided midstream sample. Feline: place in a cage with a clean, empty litter box.
Place the patient in lateral recumbency and clean the vulva or prepuce. Palpate the caudal abdomen for a bladder. Isolate and trap the bladder between the spine and hand and apply steady, firm pressure until a stream of urine is produced.
Have the animal in a standing position or place the animal in lateral or dorsal recumbency. Palpate the bladder and isolate against the spine. Insert the needle into the bladder in a caudal-dorsal direction at a 45º angle toward the midline. (Male canines: caudal to the umbilicus and to the side of the sheath. Female canines and felines: ventral midline caudal to the umbilicus.) Aspirate the syringe slowly. When finished, stop aspirating and slowly and smoothly remove the needle.
Complications
• Altered results from trace amounts of soaps, disinfectants, bacteria, or any other debris
• Bladder injury or rupture • Introduction of RBCs and protein into the urine sample
• • • •
22–23 gauge needle 6–12 mL syringe Alcohol Sterile red topped tube
Puncture of internal organs Bladder hematoma Urine leakage Shock (rare, but a potential vagal response)
Tip: To help locate the bladder, pour alcohol onto the abdomen of an animal in dorsal recumbency and it will pool in the location of the bladder, or mentally draw an X crossing over the abdomen between the last 2 sets of mammary glands. These techniques are then confirmed by palpation. Tip: Always save ≥1 mL of sterile urine for an unexpected culture.
12
434
SECTION FOUR: PATIENT CARE SKILLS
Skill Box 12.9 / Urine Collection Devices Litter Pan • A clean litter pan or a disposable aluminum cooking pan can be used with one of the following techniques: • • • •
Empty Covered within a plastic bag Nonabsorbent pellets Shredded wax paper
Collection Cups
alter the urine results, leading to a misdiagnosis. Using the most appropriate collection cup is required for proper results. Collection cups can be fixed to a long metal pole (e.g., aluminum rod or coat hanger) to allow access to the urine stream without disturbing the patient. • Sterile red top tube • Sterile urine cup • Cleaned container lined with a plastic bag
• Use of an improper collection cup can give misleading information on the urinalysis. Many detergents and container content residue can
Skill Box 12.10 / Urogenital Procedures: Urinary Catheterization Method
Urinary Catheterization
Indications
• Urine collection and/or quantification • Nonambulatory patient care
Contraindications
• Urethral trauma or injury
Setup
• Surgical site preparation materials • Lubricant (e.g., K-Y Jelly) • Urinary catheter (e.g., red rubber, Foley, infant feeding tube)
• • • •
Procedure
Canine, Female Place the patient in a standing position or in ventral recumbency and clip and clean the external urethral opening. Apply 2 stay sutures if the catheter is to remain in place. Using aseptic technique, apply lubricant to the catheter tip. Flush the vagina with saline or sterilized water injected through a syringe. Place a speculum in the vagina to visualize the urethral opening. The urethral orifice is 3–5 cm cranial to the ventral commissure of the vulva, just cranial to the clitoral fossa. Place the catheter past the clitoral fossa and advance along the ventral floor of the vagina until it enters the urethral fossa. Urine will begin to flow once the catheter has reached the bladder. Connect the catheter to the closed collection system and suture into place with a Chinese finger trap suture pattern. If using a Foley catheter, fill the balloon with the correct amount of sterile water.
Canine, Male Place the animal in lateral recumbency and shave the fur on the tip of the prepuce. Clean the tip of the prepuce and then place 2 stay sutures on either side (if the catheter is to remain). Expose the urethral opening by reflecting the prepuce away from the penis. Clean the tip of the penis while avoiding any contact with the prepuce or surrounding hair. Wearing sterile gloves, measure the catheter from the tip of the penis to the bladder. Lubricate the end of the catheter and insert the catheter into the urethral opening. Apply gentle pressure to advance the catheter past the level of the os penis and the point where the urethra curves around the ischial arch. Urine will begin to flow once the catheter has reached the bladder. Connect the catheter to the closed collection system and suture into place with a Chinese finger trap suture pattern. If using a Foley catheter, fill the balloon with the correct amount of sterile water.
• Urethral obstruction • Neurologic impairment
Vaginal speculum Minor surgical pack Suture material Urine closed collection system
CHAPTER 12 / MEDICAL PROCEDURES
435
12
Skill Box 12.10 / Urogenital Procedures: Urinary Catheterization (Continued) Method
Urinary Catheterization Feline, Female Sedate or anesthetize the patient and place in lateral or sternal recumbency. Clean the vulva and place 2 stay sutures (if catheter is to remain in place). Wearing sterile gloves, measure the catheter from the vulva to the bladder. Advance the catheter into the urethral opening while applying gentle downward pressure on the catheter tip. Gently advance and retract the catheter until entry into the urethra. Urine will begin to flow once the catheter has reached the bladder. Connect the catheter to the closed collection system and suture into place with a Chinese finger trap suture pattern if catheter is to remain in place. Tape catheter to tail while assuring enough catheter for normal movement.
Complications
• Urethral inflammation or injury • Introduction of bacteria into the bladder • Introduction of RBCs, protein, and transitional epithelial cells
Maintenance
• See Skill Box 12.11 Urinary Catheter Maintenance, page 436.
Removal
• Remove sutures and gently and swiftly remove the catheter.
Feline, Male Sedate or anesthetize the patient and place in lateral or dorsal recumbency. Clean the prepuce and place 2 stay sutures (if the catheter is to remain in place). Wearing sterile gloves, measure the catheter from the penis to the bladder. Expose the urethral opening by reflecting the prepuce away from the penis and holding tightly at the base of the penis. Clean the penis and avoid any contact with the prepuce or surrounding hair. Lubricate the tip of the catheter, insert into the urethral opening, and gently advance the catheter in a rotary motion. While advancing the catheter, gently pull the penis and prepuce out to straighten the urethra. Urine will begin to flow once the catheter has reached the bladder. Connect the catheter to the closed collection system and suture into place with a Chinese finger trap suture pattern if catheter is to remain in place. Tape catheter to tail while ensuring enough catheter for normal movement.
Tip: Closed collection system consists of sterile IV tubing and fluid bag connected via a Christmas tree adaptor to the urinary catheter. Tip: Urinary catheters can be placed in the freezer to make them more rigid and to allow easier placement.
12
Skill Box 12.11 / Urinary Catheter Maintenance Patient • Voided urine and dehydration should be monitored to ensure normal micturition (normal: 1–2 mL/kg/hr). • The vulva or prepuce should be cleaned twice daily with an antimicrobial solution and gently dried. Catheter • Gloves should always be worn when working with the catheter and closed collection system. • Catheter patency should be evaluated every 4 hours.
436
SECTION FOUR: PATIENT CARE SKILLS
• Observation of urine flow • Instill 1–2 mL of saline into the catheter and then aspirate. Closed Collection System • Place below the patient to prevent backflow of urine to the patient. • Place on a clean surface (off the floor) to prevent bacterial contamination (e.g., clean towel). • All collection system connections should form a tight seal and be cleaned with a disinfectant if disconnected.
Section
Five
Anesthesia and Anesthetic Procedures Chapter 13: Anesthesia 439 Chapter 14: Dentistry 497 Chapter 15: Surgery 521
Chapter
13
Anesthesia Guidelines for Safe Anesthesia 441 Preanesthetic 442 Preanesthetic Evaluation 442 Case-Based Anesthesia 444 Preanesthetic Drugs 451 Anesthesia 451 Anesthetic Administration 451 Anesthetic Machine 451 Machine Setup 451 Anesthetic Breathing Systems 452 Anesthetic Administration 453 General Anesthesia Induction 453 Endotracheal Intubation 454 Figure 13.1 Endotracheal Intubation 455 Endotracheal Complications 456 Perioperative 456 Patient Care 456 Intermittent Positive-Pressure Ventilation (IPPV) Anesthetic Monitoring 458 Stages of Anesthesia 458 Anesthesia Monitoring 460
458
Postanesthesia 466 Recovery 466 Postanesthetic Monitoring 467 Local and Regional Anesthesia 470 Ventilation 474 General Information 474 Administration 475 Anesthetic Drugs 477 Preanesthetic Drugs 477 Anticholinergic Drugs 477 Atropine and Glycopyrrolate 478 Phenothiazines 478 Acepromazine Maleate 479 Benzodiazepines 480 Diazepam and Midazolam 480 α2-Agonists 481 Xylazine and Medetomidine 482 Opioids 484 Butorphanol and Buprenorphine 485 Fentanyl and Hydromorphone 486 Morphine Sulfate and Oxymorphone HCl
13
487 439
Injectable Induction Anesthetics 488 Barbituates 488 Thiobarbituates and Methylated Barbituates Cyclohexamines 490 Ketamine and Tiletamine 491 Propofol 492 Propofol (continued) 492
13
440
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
489
Etomidate 493 Etomidate (continued) 494 Inhalant Anesthetics 494 Halothane and Isoflurane 495 Sevoflurane 496
Key Words and Termsa Acidotic Apneustic breathing Ataxia Azotemia Barotrauma Cataleptic Catecholamine Cholestasis CO2 absorber Compressed gas Cylinders Cyanosis Dysphoria Ectopic Emetics Endotoxemia Exsanguinate Flowmeter Hypercapnia Hypercarbia Hyperkinesis Hypocapnia Hypocortisolemia Hypotonia Iatrogenic Intercostal a
Interpleural Manometer Metabolic acidosis Miosis Moribund Myoclonus Nonrebreathing system Nystagmus Oliguria Oncotic Paradoxical Perivascular Pop-off valve Rebreathing bag Rebreathing system Receptor Reservoir bag Scavenger hose Stridor Synechiae Thyroid storm Tidal volume Vasovagal Vomition Wind-up
Abbreviations
Additional Resources, page
APTT, activated partial thromboplastin time ASA, American Association of Anesthesiologists BG, blood glucose BP, blood pressure bpm, beats per minutes CNS, central nervous system CRI, constant rate infusions CSF, cerebrospinal fluid CV, cardiovascular ECG, electrocardiogram ET, endotracheal GABA, γ-aminobutyric acid IM, intramuscular IPPV, intermittent positive-pressure ventilation IV, intravenous K+, potassium kg, kilogram lb, pound mg, milligram MM, mucous membranes NMDA, N-methyl-D-aspartic acid PCV, packed cell volume PT, prothrombin time SQ, subcutaneous TP, total protein VPC, ventricular premature contraction/complex
Anatomy, 3 Blood chemistries, 74 Blood gases, 335 Blood pressure, 332 Cardiac examination, 30 Catheter placement, 349 CAVM, 557 Coagulation tests, 115 Complete blood count, 104 Constant rate infusion, 392 Drug administration, 348 Electrocardiography, 338 Fluid therapy, 359 Heat administration, 346 Laboratory, 71 Oxygen therapy, 375 Pain management, 379 Physical examination, 18 Pulmonary examination, 32 Radiology, 157 Surgery, 521 Thoracocentesis, 431 Thoracostomy tube, 431 Ultrasound, 197 Urinalysis, 147 Vital signs, 19
Key words and terms are defined in the glossary on page 631.
GUIDELINES FOR SAFE ANESTHESIA Anesthesia is the powerful ability to provide restraint, loss of consciousness, elimination of pain, and seizure control to our patients. To provide this act safely and effectively, the anesthetist must have a complete understanding of many factors. The patient’s history and current condition must be evaluated, and the anesthetist must have thorough knowledge of the anesthetic equipment, anesthetic drugs, monitoring techniques, recovery protocol, and emergency procedures. It is only through this knowledge that the inherent risks of anesthesia can be lessened and anticipated.
• Hypoventilation • ↓ Tear production Patient Evaluation • Signalment
13
• History • Weight • Vital signs • Physical examination
Potential Problems Associated With All Anesthetic Procedures
• Laboratory workup
• Hypothermia
• Diagnostic tests
• Hypotension
• ASA physical status CHAPTER 13 / ANESTHESIA
441
Patient Preparation
Induction
• Venous access • Providing a calm, relaxed, and pain-free state
• Providing a rapid loss of consciousness without excitation, distress, or struggling potentially resulting in injury
• Optimizing effective circulating blood volume
• Obtaining control of the airway Perioperative
Machine Preparation
• Maintaining normal surgical vital signs
• Leak test
• Maintaining a surgical plane of anesthesia
• Setup
Recovery
Drug Protocol • Emergency drug reference sheet prepared • Choose a anesthetic drug protocol that does not further complicate existing conditions or initiate others
• Allowing a smooth recovery without excitation, distress, or struggling • Maintaining normal vital signs
• Analgesia plan
PREANESTHETIC Table 13.1 / Preanesthetic Evaluation
A complete review of this list should be conducted on each patient prior to the administration of any drugs. These initial assessments will prove valuable in choosing the correct drug protocol and in monitoring the patient during and after the anesthetic procedure. Category
13
Parameters to Evaluate
Signalment
The species, breed, age, and temperament of the patient can have direct implications on the type of drugs used during the anesthetic procedure along with the type of monitoring used.
History
Both recent and past history of anesthetic episodes, medications, meals, and ongoing diseases will affect the anesthetic protocol.
Weight
• A current weight in both kilograms (kg) and pounds (lb)
Vital Signs • See Table 2.1 Preliminary Examination, page 18.
• • • • • •
Physical Examination • See Chapter 2 Physical Examination, page 20.
A complete physical exam must be performed to help acquire a baseline for the patient. This initial exam must be performed prior to the administration of any drugs for accurate results.
442
Temperature Pulse Heart rate Respiration rate Capillary refill time Mucous membrane (MM) color
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.1 / Preanesthetic Evaluation (Continued) Category Laboratory Workup • See Chapter 4, Laboratory, page 201.
Parameters to Evaluate A wide range of protocols exist for preanesthetic laboratory workup. However, all patients should have a PCV/TP performed with a CBC and serum chemistry panel depending on the patient’s presenting condition, history, and results of the PCV/TP. Additional tests may also be necessary. • • • • • •
PCV/TP Serum chemistry panel CBC Electrolytes Urinalysis Coagulation profile • Activated clotting time • PT/APTT assays • Platelet count • Venous or arterial blood gases Additional Diagnostic Testing
Radiography is used to detect and evaluate congenital or acquired cardiopulmonary disease or conditions associated with traumatic injuries; e.g., pulmonary contusions, diaphragmatic hernia, or pneumothorax. Abdominal radiographs can detect and evaluate congenital or acquired organ disease; e.g., hepatic, urinary, or gastrointestinal diseases. Electrocardiography should be performed in patients with suspected or known heart disease, those with recent trauma and possible myocarditis, and patients with electrolyte abnormalities. Ultrasound can be an additional tool used to evaluate the degree of many diseases or traumatic states.
ASA Physical Statusa
The American Society of Anesthesiologists’ (ASA) Physical Status Classification System adapts to small animal medicine with ease. It allows a system to evaluate the patient based on the presence and severity of systemic disease present. I II III IV V
a
Excellent anesthetic risk; patients with no underlying disease, undergoing elective surgeries Good anesthetic risk; mild to moderate disease changes or signs of extreme fear and anxiety Fair anesthetic risk; severe disease changes that limits activity, but is not incapacitating Poor anesthetic risk; severe disease changes that limits activity and are a constant threat to life Critical anesthetic risk; moribund, not expected to survive with or without surgery
Based on ASA Physical Status Classification System of the American Society of Anesthesiologists. A copy of the full text can be obtained from ASA, 520 N. Northwest Highway, Park Ridge, IL 60068-2573.
13
CHAPTER 13 / ANESTHESIA
443
Table 13.2 / Case-Based Anesthesia
Along with the basic preanesthetic evaluation, a patient presenting with a existing health concern should be further evaluated and have a specific anesthetic plan designed for them. Preoperative Examination and Diagnostic Tests
Potential Complications
Recommended Anesthetic Protocols
Anesthetic Alterations
Special Surgical Care and Recovery
• Maintain the endotracheal tube as long as possible in recovery. • Possibly sedate to reduce stress during recovery and allow tube to remain in longer. • Possibly continue oxygen administration until extubation. • Closely monitor respiration for at least an 1 hour following recovery. • Extend neck and tongue to facilitate breathing.
Brachycephalic • English Bulldog, French Bulldog, Pug, Boston Terrier, Boxer, Shar pei, and Pekingese • Evaluate degree of respiratory compromise. • Baseline oxygen saturation (SpO2) reading on room air • Thoracic radiographs
↑ Vagal tone Airway obstruction Bradycardia Cyanosis Difficulty or failure to intubate (e.g., laryngeal collapse, small tracheal lumen size, and difficult visualization) • Dyspnea and apnea
Preanesthetic • Butorphanol and atropine or glycopyrrolate • Meperidine and atropine or glycopyrrolate Induction • Ketamine and diazepam • Propofol and diazepam • Thiopental and diazepam
• Avoid deep sedation. • Preoxygenate for 5–10 minutes. • Rapid IV induction with subsequent intubation • Prepare for a tube size smaller than anticipated. • Prepare for possible tracheostomy tube placement.
• • • •
• No special considerations
• Preoxygenate. • Observe for overhydration. • Pediatric protocol for induction • Avoid anticholinergics, barbituates, α2-agonists, and halothane.
• No special considerations once stabilized
• Preoxygenate. • Avoid α2-agonists and halothane • Propofol may further hypotension • IPPV may contribute to further hypotension; may need to ↑ fluid therapy.
• • • • •
Congenital Heart Disease • Obtain resting heart rate and respiratory rate. • Thoracic radiographs
Bradycardia Ventricular ectopic beats Hypothermia Pulmonary edema
Hypotension/Hypovolemia • Blood pressure
• Cardiac arrest • Circulatory failure • Hemodilution (with IV crystalloids)
13
444
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
• Stabilize with fluids and/or whole blood prior to anesthetic procedure. • Observe for overhydration/ hemodilution; use low-volume IV fluid rate. • Intermittent PCV and TP monitoring
Table 13.2 / Case-Based Anesthesia (Continued) Preoperative Examination and Diagnostic Tests
Potential Complications
Recommended Anesthetic Protocols
Anesthetic Alterations
Special Surgical Care and Recovery
• • • • •
Arrhythmias Bradycardia Hypovolemia Pulmonary edema Tachycardia
Preanesthetic • Oxymorphone (and ± glycopyrrolate • Butorphanol (and ± glycopyrrolate Induction • Etomidate and diazepam • Thiopental and diazepam • Propofol and diazepam • Innovar-Vet
• Preoxygenate. • Avoid drugs producing tachycardia (anticholinergics and cyclohexamines), except with congestive cardiomyopathy, where ↑ heart rate may be beneficial. • Avoid α2-agonists and halothane.
• Observe for overhydration. • Continuous ECG and BP monitoring
• • • • •
Anesthetic drug overdose Delayed recovery Fluid overload Hypoxemia Pulmonary edema
• No special considerations
• Preoxygenate. • Highly protein bound drugs will give an ↑ effect and the dose should be ↓. • Avoid α2-agonists and halothane.
• Anesthesia causes a 3–5% ↓ in PCV • Blood transfusion if PCV is <25–30% • Intermittent monitoring of PCV and TP should be done intraoperative and postoperative • Conservative fluid therapy to avoid pulmonary edema due to reduced vascular oncotic pressure (esp. crystalloids) • Supplemental oxygen postoperative
• No special considerations
• No special considerations
• No special considerations
Impaired Cardiac Function • +/− Cardiac ultrasound • Blood pressure • ECG • PCV/TP • Serum potassium • Thoracic radiographs • Urinalysis
Anemia/Hypoproteinemia • Complete blood evaluation • Urinalysis
Heartworm Disease • Complete blood evaluation • Thoracic radiographs
• ↓ Cardiac output • Cardiac arrhythmias • Pulmonary dysfunction
13
CHAPTER 13 / ANESTHESIA
445
Table 13.2 / Case-Based Anesthesia (Continued) Preoperative Examination and Diagnostic Tests
Potential Complications
Recommended Anesthetic Protocols
Anesthetic Alterations
Special Surgical Care and Recovery
↑ Cardiac output Dyspnea Hypertension Hypotension Neonatal depression from anesthetic agents • Tachycardia • Uterine hemorrhage • Vomiting
Preanesthetic • Oxymorphone and atropine • Butorphanol and atropine Induction • Propofol • Thiopental • Ketamine and diazepam • Etomidate and diazepam
• ↓ Drug dose by 40% and inhalant dose by 25%. • Preoxygenate. • Consider drugs that can be antagonized or are rapidly metabolized. • Avoid pentobarbital because of its close to 100% mortality in neonates. • Avoid phenothiazines, benzodiazepines, cyclohexamines, and α2-agonists. • Morphine epidural will ↓ inhalant dose and allow smoother recovery. • IPPV to compensate for the distended abdomen.
• Surgical preparation should be done in an awake animal in left lateral recumbency to remove pressure from the vena cava. • See Skill Box 7.4 Neonatal Resuscitation Post Cesarean, page 317.
• • • •
Preanesthetic • Butorphanol and atropine (or glycopyrrolate) • Meperidine and atropine (or glycopyrrolate) • Oxymorphone and atropine (or glycopyrrolate) Induction • Thiopental and diazepam • Propofol and diazepam
• Consider drugs that can be antagonized or are rapidly metabolized. • Avoid α2-agonists and cyclohexamines as sole agents with high doses.
• Patient should be stabilized and regulated if possible. • Procedure should be scheduled in early morning after normal administration of insulin. • Possibly ↓ insulin dose by 50% on day of surgery due to fasting. • Intermittent BG monitoring, maintaining at 150–250 mg/dL. • IV fluid administration of 5% dextrose if needed • Maintain IV fluids to counteract diuresis caused by hyperglycemia.
Cesarean, Emergency • PCV and TP • Serum calcium • Thorough history
• • • • •
Endocrine • Diabetes mellitus • Blood glucose • Urinalysis
Delayed recovery Hyperglycemia Hypoglycemia Higher infection risk
13
446
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.2 / Case-Based Anesthesia (Continued) Preoperative Examination and Diagnostic Tests
Potential Complications
Recommended Anesthetic Protocols
Anesthetic Alterations
Special Surgical Care and Recovery
• • • • • •
Airway obstruction Bradycardia Hypoglycemia Hyper- or hypotension Hypoxemia “Thyroid storm” (tachycardia, hypertension, cardiac arrhythmias, hyperthermia, and shock)
Preanesthetic • Oxymorphone Induction • Propofol • Etomidate and diazepam • Thiobarbiturate and diazepam
• Avoid α2-agonists and cyclohexamines. • Avoid phenothiazines and barbituates with complicated disease. • ↑ Oxygen consumption. • Due to the thyroid tumor, intubation may be more difficult, leading to airway obstruction.
• Attempt to regulate T4 level before anesthesia • β-Blockers for severe tachycardia may be necessary. • Continuous ECG and blood pressure monitoring • Intermittent BG monitoring
• • • •
Arrhythmias Hypocortisolemia Hypotension Shock
• No special considerations
• Avoid phenothiazines and etomidate.
• Patient should be stabilized and regulated before an anesthetic procedure. • IV fluid and glucocorticoids administration preoperative, intraoperative, and postoperative to avoid an addisonian crisis
• • • • • •
Bradycardia Delayed recovery Hypotension Hypothermia Respiratory difficulty Hypoventilation
Preanesthetic • Meperidine and atropine • Butorphanol and atropine • Oxymorphone and atropine Induction • Ketamine and diazepam • Etomidate and diazepam • Propofol and diazepam • Thiopental and diazepam
• Consider drugs that can be antagonized or are rapidly metabolized. • Avoid phenothiazines, α2agonists and morphine.
• Heat support • Monitor breathing during surgery (e.g., respirometry, capnography, or reservoir bag).
Hyperthyroidism • +/− Cardiac ultrasound • Complete blood evaluation • ECG • T4 level • Thoracic radiographs
Hypoadrenocorticism • Electrolytes
Hypothyroidism • PCV and TP
13
Gastrointestinal • Gastric dilatation volvulus • Arterial gases • Complete blood evaluation • ECG • Hypovolemic status
• • • • •
Cardiac arrhythmias Septic shock Metabolic acidosis Hypokalemia Peritonitis
Preanesthetic • Oxymorphone and glycopyrrolate Induction • Ketamine and diazepam • Oxymorphone and diazepam • Innovar-Vet
• Stabilize shock before anesthesia • Preoxygenate • Avoid the use of emetics (e.g., morphine, acepromazine, and xylazine). • Avoid nitrous oxide. • IPPV throughout surgery
• Intermittent PCV and TP monitoring • Continuous ECG and BP monitoring intraoperative and postoperative • IV antibiotics
CHAPTER 13 / ANESTHESIA
447
Table 13.2 / Case-Based Anesthesia (Continued) Preoperative Examination and Diagnostic Tests
Potential Complications
Recommended Anesthetic Protocols
Anesthetic Alterations
Special Surgical Care and Recovery
• Hypotension
Preanesthetics • Opioids
• Avoid the use of α2-agonists and halothane.
• Monitor and care for the underlying condition.
• • • • • • •
• No special considerations
• Dose drugs on lean weight to prevent overdosing. • Preoxygenate. • IPPV throughout surgery • Drugs that distribute to the body fat will have longer recovery times (halothane).
• Avoid dorsal recumbency with head positioned down if possible. • Monitor breathing during surgery (e.g., respirometry, capnography or reservoir bag). • Maintain endotracheal tube as long as possible.
Pancreatitis • Complete blood evaluation Obesity • Complete blood evaluation • Estimate lean body weight.
Airway obstruction Delayed recovery Drug overdose Hyperthermia Hypoventilation Hypoxemia Respiratory difficulty
Geriatric • A patient who has reached 75% of its expected life span • Complete blood evaluation • ECG • Thoracic radiographs • Thorough history and medications • Thyroid hormone levels • Urinalysis
• • • •
↓ Organ function Hypotension Hypothermia Hypoventilation
Preanesthetic • Meperidine and atropine • Butorphanol and glycopyrrolate Induction • Thiopental and diazepam • Ketamine and diazepam
• ↓ Drug dose by 30–50%. • Avoid phenothiazines and α2-agonists. • Allow longer time for response to drugs. • Preoxygenate. • Monitor anesthetic level for inhalant overdose.
• Heat support • Monitor fluid rate to ensure adequate hydration and urine production (e.g., enlarging bladder, skin tenting, MM).
• • • • • • • •
Delayed recovery Further hepatic disease Hypogylcemia Hypokalemia Hypotension Hypothermia Pulmonary edema Seizures
Preanesthetic • Meperidine and atropine • Butorphanol and atropine • Oxymorphone and atropine Induction • Propofol • Thiopental • Isoflurane
• Avoid phenothiazines and α2-agonists. • Avoid seizurogenic drugs. • Preoxygenate. • IPPV should be avoided with hypotension.
• Heat support • Intermittent PCV, TP, and BG intraoperative monitoring • Blood pressure monitoring • Arterial blood gases in portalcaval shunts monitoring • Caution with intraoperative analgesics due to ↑ liver metabolism • Liver function tests postoperative
Liver/Hepatic Disease • Portal-caval shunt • Coagulation profile • Complete blood evaluation
13
448
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.2 / Case-Based Anesthesia (Continued) Preoperative Examination and Diagnostic Tests
Potential Complications
Recommended Anesthetic Protocols
Anesthetic Alterations
Special Surgical Care and Recovery
Neonatal • A patient under 3 months of age • No special considerations
• • • • • • • •
Bradycardia Hypoglycemia Hypothermia Hypotension Hypovolemia Hypoxemia Inadequate organ function Pulmonary edema
Preanesthetic • Atropine or glycopyrrolate • Neuroleptanalgesics Induction • Ketamine and diazepam • Propofol
• ↓ Drug dose by 30–50%. • Allow longer time for response to drugs. • Neonates have a higher oxygen consumption, yet anesthetic concentrations are the same as for adults. • ↑ Sensitivity to protein-bound anesthetics • Due to immature organ systems, drugs may have a prolonged effect. • Nonrebreathing systems and properly sized ET tubes should be used.
• Heat support • Blood transfusion should be considered after 10% blood loss. • Preoperative fasting of no more than 2–4 hours for those on a diet of solids • Traditional monitoring parameters are unreliable (e.g., eye position).
• • • • • •
Dehydration Delayed recovery Further renal disease Hyperkalemia Hypotension Renal hypoperfusion
Preanesthetic • Butorphanol, atropine or glycopyrrolate • Oxymorphone, atropine or glycopyrrolate Induction • Thiopental and diazepam • Propofol and diazepam • Ketamine and diazepam
• ↓ Doses of injectable drugs (acepromazine, xylazine, diazepam, opioid agents, ketamine, and barbituates). • Azotemic animals have ↑ CNS drug sensitivity. • Acidotic animals have ↑ sensitivity to protein-bound anesthetics.
• Avoid preoperative fasting. • RBC transfusion if PCV is <18% in felines and <20% in canines. • Proper positioning and padding are needed to avoid pressure necrosis. • Blood pressure and arterial gases monitoring • Continuous ECG monitoring if any risk of hyperkalemia (e.g., acute renal failure) • Continue IV fluids postoperative and monitor fluid rate to ensure adequate hydration and urine production (e.g., enlarging bladder, skin tenting, MM).
Renal Disease • Blood pressure • Complete blood evaluation • ECG • Urinalysis
CHAPTER 13 / ANESTHESIA
449
13
Table 13.2 / Case-Based Anesthesia (Continued) Preoperative Examination and Diagnostic Tests
Potential Complications
Recommended Anesthetic Protocols
Anesthetic Alterations
Special Surgical Care and Recovery
Respiratory Disease • Pleural effusion, diaphragmatic hernia, pneumothorax, pulmonary contusions, pneumonia, tracheal collapse, and pulmonary edema • Arterial blood gases • Complete blood evaluation • Complete respiratory examination • ECG • Thoracic radiographs
• Hypoventilation • Hypoxemia • Tachypnea, dyspnea, and/or apnea • Worsening pneumothorax
Preanesthetic • Opioid and atropine Induction • Ketamine and diazepam • Thiopental • Propofol
• Postpone any anesthesia for a few days if possible. • Avoid nitrous oxide. • Preoxygenate. • Mild preanesthetic may be needed to reduce stress. • Rapid induction with injectable anesthetic agents to obtain control of airway. • IPPV, ↓ pressure to reduce the chance of a tension pneumothorax
• Prepare for thoracocentesis and chest tube placement. • Monitor breathing during surgery for worsening pneumothorax (e.g., respirometry, capnography, or reservoir bag). • Supplemental oxygen preoperative and postoperative • Maintain endotracheal tube as long as possible. • Place nasal catheter postoperative to continue oxygen administration.
• Do not use tranquilizers and barbituates (except methohexital).
• Heat support • Proper positioning and padding are needed to avoid pressure necrosis. • Recover in a quiet area to ↓ excitement.
• Postpone any anesthesia for a few days if possible. • ↓ Drug doses. • Avoid phenothiazines, barbituates, and α2-agonists. • Preoxygenate. • IPPV, ↓ pressure to reduce the chance of a tension pneumothorax
• Monitor body temperature. • Continuous ECG monitoring • Intermittent PCV and TP monitoring
Sighthounds • Greyhound, Saluki, Afghan Hound, Whippet, and Russian Wolfhound • No special considerations
• Death
Preanesthetic • Opioid and atropine Induction • Propofol and diazepam • Methohexital and diazepam
Trauma • Hit by car, head trauma, thoracic and abdominal trauma, thermal/burn trauma • • • •
13
ECG Monitor PCV and TP Thoracic radiographs Urine output and concentrating ability
450
• • • • • • •
Cardiac arrhythmias Dyspnea or tachypnea Internal injuries Pneumothorax Seizures (e.g., head trauma) Shock Tachycardia
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Preanesthetic • Opioid • Atropine or glycopyrrolate Induction • Ketamine and diazepam • Propofol and diazepam Maintenance • ↓ Inhalant with supplemental narcotic
Table 13.2 / Case-Based Anesthesia (Continued) Preoperative Examination and Diagnostic Tests
Potential Complications
Recommended Anesthetic Protocols
Anesthetic Alterations
Special Surgical Care and Recovery
• • • •
Preanesthetic • Atropine and Butorphanol Induction • Ketamine and diazepam • Propofol • Thiopental
• ↓ Drug dose. • Avoid α2-agonists.
• Do not administer fluids until after the obstruction has been relieved (unless patient is in shock). • Cystocentesis may be required preoperative to relieve bladder tension. • Careful positioning is needed in animals with urethral obstruction to avoid rupture. • Continuous ECG monitoring if any risk of hyperkalemia (K+ > 7.0).
Urinary Obstruction • Complete blood evaluation • ECG if hyperkalemic • Evaluate hydration, heart rate and rhythm, and CNS depression.
Bradycardia Cardiac arrhythmias Cardiac failure Hyperkalemia
Preanesthetic Drugs
ANESTHESIA
The preanesthetic drug protocol is just one part of the complete anesthetic drug protocol. Before the administration of any medications, an Emergency Drug Reference Sheet should be prepared and all lab work should be completed. The administration of drugs can alter certain lab values (e.g., PCV can be ↓ 30% by the preadministration of acepromazine). All syringes must be clearly labeled with the patient’s name, drug name, and amount. When giving the preanesthetic SQ it is typically given 30–45 minutes before the procedure, or 15–20 minutes when given IM. Some common preanesthetic drug protocols are listed below. Refer to the end of this chapter for more information on individual drugs and dosages.
Anesthetic Administration
Acepromazine and butorphanol
Verify the Following
Acepromazine and opioid Butorphanol Hydromorphone Medetomidine and butorphanol Medetomidine and opioid Midazolam and butorphanol Midazolam and opioid Morphine Oxymorphone
Anesthetic Machine Machine Setup Before the administration of a general anesthetic, the equipment must be checked over to ensure it is in proper working condition. Many anesthetic complications can be avoided by taking this important step.
• Adequate amount of inhalant in the vaporizer and cap is tightly closed 13
• Adequate oxygen supply • Fresh CO2 absorber • Equipment is connected correctly • Oxygen supply tube is connected • Machine is set up for correct breathing system (see Skill Box 13.1 Anesthetic Breathing Systems, page 452.) • Correct sized reservoir bag is attached • Pop-off valve is open • Scavenger tube is connected and evacuation fan is activated CHAPTER 13 / ANESTHESIA
451
• Adequate pressure test • Once the machine is properly connected, close the pop-off valve, occlude the end of tubing leading to the patient, fill the system with oxygen from the O2 flush, and monitor the pressure gauge. • No leaks will maintain a constant pressure. • Leaks in the system will show a dropping pressure.
(a) Test for leak detection with diluted soapy water at the system junctions • The inner tube of a nonrebreathing system can be tested by occluding the patient end of the tubing with the O2 flowing at 1–2 L/min. The float in the flowmeter should fall if no leaks are present.
Skill Box 13.1 / Anesthetic Breathing Systems Rebreathing–Circle System • Patient rebreathes its own exhaled gases minus the carbon dioxide and with the addition of fresh oxygen and anesthetic gases.
13
Types
Indications for Use
Oxygen Flow Rates
Comments
Total Rebreathing/ Closed • Pop-off valve is completely closed.
• Patients >15 lb • Patients must have lungs strong enough to push gases through the machine
• 2–3 mL/lb/min
• Do not use nitrous oxide. • Relatively low gas rates can be used resulting in slow changes in anesthetic depth. • Ventilation is readily observed and controlled by the rebreathing bag. • Minimal heat loss and airway drying • ↑ Resistance to gas flow
Partial Rebreathing/Semiclosed • Pop-off valve is partially open.
• Patients >15 lb
• 3 (BW [kg] × 10) = ? mL/min • 5–20 mL/lb/min
• Much higher gas rates need to be used. • Ventilation can be observed by the rebreathing bag.
Nonrebreathing System • Patient receives fresh oxygen and anesthetic gases with each breath. Types
Indications for Use
Oxygen Flow Rates
Comments
Open • Pop-off valve is completely open.
• Any size patients, typically those <15 lb • Minimal resistance to breathing
• 3 (breaths/min × 10) = ? mL/min • 150–200 mL/kg/min • 0.5–4 L/min
• Much higher gas rates needed to eliminate exhaled gases • Minimal or no rebreathing of expired gases by patient • Minimal resistance to gas flow
452
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Skill Box 13.1 / Anesthetic Breathing Systems (Continued) Rebreathing Bag Size • <15 lb = 1 liter bag • >15 lb and <40 lb = 2 liter bag • >40 lb and <120 lb = 3 liter bag • >120 lb and <300 lb = 5 liter bag
Compressed Gas Cylinders • Green tank = oxygen • Blue tank = nitrous oxide
Anesthetic Administration Table 13.3 / General Anesthesia Induction
The administration of anesthesia allows necessary veterinary procedures to commence without difficulty by immobilizing the patient and eliminating pain. The proper administration of anesthesia ensures the comfort of the patient during administration, during the procedure, and following the procedure. Prior to the induction of any anesthetic, an intravenous catheter should be placed. This allows for titration of the induction agent, emergency intravenous access, and intravenous fluid administration and to avoid the risk of a perivascular injection. Method of Induction
Common Drugs Used
Procedure
Uses
Associated Risks
Patient Contraindications
Oral
• Ketamine
Draw up a single dose of the drug into a syringe and squirt into the patient’s mouth
• Uncooperative animals • Animals where injections are difficult
• Aspiration • Poor administration
• Animals with gastrointestinal disease or injury
Intramuscular
• Ketamine • Ketamine and midazolam • Tiletamine and zolazepam
Draw up a single dose of the drug into a syringe and administer by an IM injection.
• Uncooperative animals • Animals where IV injections are difficult (ie puppies, kittens)
• Delayed recovery • Overdose
• Old and debilitated animals that would benefit from induction to effect (e.g., lower dosing) • Brachycephalics due to no rapid control of airway
Intravenous
• Diazepam and opioid • Etomidate • Ketamine and diazepam • Ketamine and midazolam • Propofol • Thiopental • Tiletamine and zolazepam
Place an IV catheter and administer the drug by one of the following methods: • Bolus ¼ dose, wait 30–45 seconds, then repeat • Bolus over 10–15 seconds • Slow injection over 1–2 minutes • IV fluid drip
• Minor anesthetic procedures • Induction to general anesthesia with inhalant anesthetics • Animals where rapid control of the airway is needed (e.g., laryngeal collapse, Brachycephalic, etc.)
• Perivascular injection • Accumulation of drug with repeated dosing (e.g., delayed recovery)
• Obese animals where locating a vein may not be possible • Fractious animals
CHAPTER 13 / ANESTHESIA
453
13
Table 13.3 / General Anesthesia Induction (Continued) Method of Induction
Common Drugs Used
Procedure
Uses
Associated Risks
Patient Contraindications
Face mask
• Isoflurane • Halothane • Sevoflurane
• With adequate restraint, place an anesthetic mask over the mouth and nose tightly to minimize waste gas and dead space. • Run 100% oxygen at 3 L/min for 5 minutes to allow adjustment to mask then begin anesthetic flow slowly over a few minutes to a level of 3–4%.
• Induction to general anesthesia with inhalant anesthetics via endotracheal tube • Premedicated animals, moribund animals, or tractable dogs
• Vomiting • No airway control • Environmental anesthetic pollution • Can be stressful to some patients
• Brachycephalic dogs • Animals with respiratory or cardiovascular disease • Animals that have not been fasted
Chamber
• Isoflurane • Halothane • Sevoflurane
• Place the animal in a chamber large enough to allow lying down and extension of the neck. • Run oxygen at 3–5 L/min and the anesthetic flow at 4–5%. • Once the animal has lost its righting reflex remove them from the chamber and place an ET tube.
• Induction to general anesthesia with inhalant anesthetics • Premedicated felines and small canines • Intractable, fractious felines
• Inability to adequately monitor • No airway control • Environmental anesthetic pollution
• Brachycephalic dogs • Animals with respiratory or cardiovascular disease • Animals that have not been fasted
Tip: The facemask can be held on by slipping it into a large muzzle or tying with gauze.
Skill Box 13.2 / Endotracheal Intubation Setup • Size
13
1. Palpate the neck of the awake patient and view thoracic radiographs if available. 2. Select the estimated size and then 1 size larger and smaller. 3. Use the largest tube that will fit in the trachea without strain. • Length 1. The length of the tube should extend from the thoracic inlet to no more than 1 inch past the mouth. 2. Tubes need to be cut if they do not fall within these guidelines to avoid dead space and endobronchial intubation.
• Function 1. Fill cuff with air to observe for any leaks. 2. Acquire material (e.g., gauze, IV tubing) to tie tube in once placed. Technique 1. Place small to medium patients in sternal recumbency; larger patients can be placed in lateral recumbency. 2. Open patient’s mouth and gently grasp tongue with a 3 × 3 gauze pad (prevents slipping). 3. Extend tongue for a clear view of the throat area. 4. Tube should have bevel facing up and concave side facing ventrally.
454
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Skill Box 13.2 / Endotracheal Intubation (Continued) 5. Insert tube over the epiglottis between the arytenoid cartilages into the larynx, rotating from 0º to 90º to facilitate passage. 6. Tie tube in place with gauze or tubing to prevent slippage. 7. Inflate cuff to ensure no leakage of gases. • Attach a clean syringe full of air to the tubing of the cuff. Close pop-off valve and place ear next to mouth of patient to listen for escaping air while gently squeezing reservoir bag (the pressure manometer should read <20 cm H2O). Depress plunger of syringe and fill cuff with air just until no air can be heard escaping around tube. Remove syringe and open pop-off valve. Record volume of air used to inflate cuff. To Ensure Proper Use • Verify placement. • Palpate throat region. • 1 hard structure ensures tracheal placement. • 2 hard structures indicate esophageal placement. • Thoracic auscultation • Auscultate the lungs bilaterally during a breath and listen for lung sounds. • Unilateral lung sounds indicate endobronchial intubation. • No lung sounds indicates esophageal intubation. • Capnography • Normal respiratory rate and effort along with a ↓ ETco2 indicate esophageal or bronchial intubation. • Absence of vocalization • Condensation of respiratory gases on the inside of the tube during exhalation • Movement of reservoir bag with each breath • Verify seal. • Check for leaking air. • See above. Tips: • To ↓ friction, place water or a water-based lubricant (e.g., K-Y Jelly) on the tube.
• Feline, with the index finger of the hand holding the tongue, apply pressure to the trachea to elevate the larynx for better visibility of the trachea. • A mouth speculum can be placed to allow 1 person to intubate safely. Esophagus (external/internal) Soft palate
Arytenoid cartilage Trachea Epiglottis
Esophagus Trachea
13
Tongue
• A stylet can be used for small floppy tubes. • A laryngoscope can be used for better visualization of throat. • Feline, application of lidocaine (0.1 mL) to glottis will reduce spasms.
Figure 13.1 Endotracheal intubation.
CHAPTER 13 / ANESTHESIA
455
Table 13.4 / Endotracheal Complications
A common complication of anesthetic administration is the inability of the patient to reach a surgical plane of anesthesia. There are many reasons to account for this situation and are found in the table below. Cause
Clinical Signs
Treatment
Esophageal intubation
• Patient awake • Able to vocalize
• Reintubate • See Skill Box 13.2 Endotracheal Intubation, page 454.
Endobronchial intubation
• Light plane of anesthesia • Exaggerated breathing motions • Cyanosis
• Reintubate with a shorter tube. • Withdraw the tube slightly.
• • • •
• Patient awake • Light plane of anesthesia
• Troubleshoot ET tube and machine.
• Light plane of anesthesia
• Preventative: administer preanthestic drugs and avoid excited handling. • Administer additional induction drugs and/or mask until intubation is possible.
Vaporizer setting set too low Oxygen flow rate too low Empty vaporizer ET tube or anesthetic machine leak
• Excitement
Perioperative The perioperative period includes the procedures leading up to, during and immediately following the procedure. This period of time is the most critical for patient safety and requires diligence and awareness of the anesthetist.
Table 13.5 / Patient Care
Monitoring the vital signs of the anesthetized patient is critical to the success of the procedure. However, monitoring the patient themselves along with the equipment being used is also important to a successful outcome. Below are some areas to pay special attention during before, during and after the procedure. 13
Procedure
Complication
Treatment
• Inducing anesthesia
• Bodily injury when losing consciousness • Stress-induced catecholamine release with subsequent potential for harmful cardiac arrhythmias
• Support all body parts when inducing • Try to avoid Stage II anesthesia level; rapidly induce to Stage III • Reduce stress by premedication when appropriate • Induction environment should be quiet, and technique chosen according to patient sensitivity to stress
Patient Induction
456
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.5 / Patient Care (Continued) Procedure
Complication
Treatment
Body Positioning
• Positioning
• Overextension or hyperflexion of neck and limbs causing permanent neurologic injury • Hyperflexion of the neck may occlude the endotracheal tube
• Assure the patient maintains as normal of a position as possible • Be aware of any restrictions due to orthopedic or neurologic conditions
Hydration
• Fluid administration
• • • • • •
Overhydration Hemodilution ↑ Lung sounds and respiratory rate Dyspnea Chemosis Ocular and nasal discharge
• ↓ Fluid rate • Oxygen administration • Drug administration (e.g., diuretics)
• • • • •
Dehydration Hypovolemia Hypotension Tacky or dry MM Oliguria or anuria
• Bolus fluids • ↑ Fluid rate (and/or colloid or blood administration)
• Intubation
• • • •
Incorrect placement (e.g., esophageal placement) Incorrect size Malfunctioning tube Traumatic placement into glottis (laryngitis)
• See Skill Box 13.2 Endotracheal Intubation, page 454.
• Rolling or turning the patient
• Kinked endotracheal tube resulting in airway obstruction • Tracheal trauma or tear • Removal of the endotracheal tube
• Disconnect tube before moving. • Armored ET tubes (spiral wire embedded in tube wall)
Anesthetic Hoses
• Placement of anesthetic hoses
• Tracheal trauma • Removal of the endotracheal tube • Kinked endotracheal tube
• Correct support of anesthetic hoses to prevent weight placed on the endotracheal tube • Correct position of anesthetic hoses to prevent a kink or bend in the ET tube
Drapes/Instruments
• Placement of drapes and instruments
• Compression of chest cavity of small patients
• Avoid placing heavy drapes and instruments directly on the chest of small patients.
Table
• Tilted table
• Abdominal organs compressing the diaphragm and compromising heart and lung function
• Do not tilt more than 15°. • IPPV
• Restraining devices
• ↓ Peripheral blood circulation
• Avoid tight limb restraints.
Equipment Endotracheal Tube
CHAPTER 13 / ANESTHESIA
13
457
Skill Box 13.3 / Intermittent Positive-Pressure Ventilation (IPPV) • IPPV is the manual compression of the reservoir bag to provide adequate ventilation to the lungs. • Perform every 5 minutes on a anesthetized patient with no complications. • Perform frequently (every 6 seconds to deliver 10 breaths a minute) in place of a mechanical ventilator. • Certain medical conditions may require increased pressure to adequately ventilate the patient. • Conditions such as diaphragmatic hernias, thorax or abdominal tumors, or fluid in the thorax and abdomen. • IPPV may cause ↓ blood pressure due to the pressure placed on the venous return to the heart, the amount of pressure may need to be ↓ if this poses an additional risk to the patient.
• ↑ Fluid rates may compensate for this change and monitor BP. • Smaller (15 cm H2O), more frequent shallow breaths may need to be performed to avoid this complication. • Technique: • Assess depth of anesthesia • If animal is adequately anesthetized, turn down vaporizer before giving a IPPV. • If animal is too lightly anesthetized, leave vaporizer at current setting thereby increasing inhalant agent in alveoli. • Close pop-off valve and gently and consistently squeeze the reservoir bag for ≤1 second to a pressure reading of 15 cm H2O while monitoring the rising chest of the patient; if the chest is not rising sufficiently, increase to no more than 20 cm H2O. • Release bag and open pop-off valve.
Anesthetic Monitoring Table 13.6 / Stages of Anesthesia
There is a variety of sophisticated and complex monitoring devices available to monitor all situations of an anesthetic procedure. As much as these instruments are beneficial in the overall picture, nothing can take the place of an attentive and educated anesthetist. All anesthetists should be able to adequately monitor a patient under anesthesia without the use of any equipment. The equipment should be available as a tool or aid in monitoring the patient, not a substitute for the anesthetist. Stage I
Stage II
Stage III
System Affected
Characteristic Observed
Plane 1 Light Heart rate
Cardiovascular
13
Normal
Increased
90–120 beats/min
Tachycardia Pulse Blood pressure
Normal
Normal
Regular and strong Normal
1 second or less +++
+++
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
2
3 Medium
Dog: 80–120 beats/min Cat: 120–160 beats/min
4 Deep
Decrease
Decrease
Progressive Bradycardia
Hypertension
Capillary refill time Dysrhythmias probability
458
Stage IV
++
Relatively strong
Weakened
Cardiac arrest Weak or imperceptible
Weakened
Increasing hypotension
Shock level
Progressive delay
3 seconds or more
+
++
++++
Table 13.6 / Stages of Anesthesia (Continued) Stage I
Stage II
System Affected
Characteristic Observed
Stage III Plane 1
2
Respiratory
Light
3 Medium
Deep
Irregular or increased
Progressive decrease
Slow irregular
Ceased, may gasp terminally
Respiratory depth
Irregular or increased
Progressive decrease
Slow irregular
Ceased
Cyanosis
Pale to white
Variable-pattern diaphragmatic
Ceased
12–20 breaths/min Dog: 12–16 breaths/min Cat: 20–40 breaths/min Mucous membrane, skin color Respiratory action
Normal May be breath holding ++++
+++
Regular and smooth rhythm
Irregular rate and pattern thoracoabdominal, abdominal
+
Lost
Laryngeal reflex
+ + + + May vocalize
Lost
Intubation possible
No
Yes
Salivation
++++
+++
+
Oropharyngeal reflex
++++
+++
+
Lost
+
Very slight
Vomition probability
+++
Reflux potential
None
Pupils
Constricted
Diminished, absent
Dilated
Corneal reflex
Normal
+++
Lacrimation
Normal
+++
Photomotor reflex
Normal
Constricted
Normal
+++
Eyeball position
Variable
Central
Progressive dilation
+
Possiblenystagmus
Fully dilated Widely dilated Absent
Diminished, absent Sluggish response
+
Minimal or absent response
Absent Unresponsive
Diminished, absent Third eyelid prolapsed
Rotated-medially Normal
++++
Diminishes, lost
Responsive
Palpebral reflex
Nystagmus
Absent
Increases with relaxation
Moderately dilated
Ocular
4
Respiratory rate
Cough Reflex
Gastrointestinal
Stage IV
13
Absent
Absent Centrally fixed
Slight medial–rotation
Possible slight nystagmus
Absent
CHAPTER 13 / ANESTHESIA
459
Table 13.6 / Stages of Anesthesia (Continued) Stage I
Stage II
Stage III
System Affected
Characteristic Observed
Plane 1
2
Musculoskeletal
Light
Nervous
Stage IV
3
4
Medium
Deep
Jaw tone
++++
Decreased, minimal
Lost
Limb muscle tone
++++
Decreased, minimal
Lost
Abdominal muscle tone
++++
Sphincters (anus, bladder)
May void
Pedal reflex
++++
Reaction to surgical stimulus
++
Decreased, minimal
Lost
Progressive relaxation Decreased
Absent
Increased respiratory rate and heart rate Limb movement
Control lost
No response
Absent
Traction reflexes
+ to ++++ = degree present.
Table 13.7 / Anesthesia Monitoring Significance
Values
Equipment and Technique
Complication and Treatment
Normal: • Canine: 70–180 bpm • Feline: 110–220 bpm Abnormal: • Canine: <70 and >160 bpm • Feline: <100 and >200 bpm
• Direct palpation of chest wall or pulse • Auscultation of chest with a stethoscope • See Skill Box 2.2 Cardiac Examination, page 30. • Esophageal stethoscope • Monitors heart rate, rhythm and pulse deficits • A thin tube attached to a stethoscope is placed in the esophagus of the patient until an audible heartbeat is heard. • Allows auscultation even when the patient’s chest is covered during surgery • Electrocardiograph • See below and Skill Box 8.4 ECG Procedure, page 338. • Doppler pulse monitor • See below and Skill Box 8.1 Blood Pressure Procedure, page 332. • Used to monitor heart rate indirectly
Bradycardia • Cause • ↑ Anesthetic depth • ↑ Vagal tone • Treatment • Drug administration of anticholinergics or a β-receptor stimulant (e.g., dopamine, dobutamine) Tachycardia • Cause • Pain • ↓ Anesthetic depth • Preexisting disease • Hypoxemia, hypercapnia, hypovolemia, or hyperthermia • Anesthetic drug side effects • Sympathetic response • Treatment • Evaluate anesthetic depth • Drug administration (e.g., vasodilator or furosemide)
Heart rate
13
Cardiovascular
• ↓ Rate is often seen in an anesthetized animal. • Cardiac function • Acute intraoperative blood loss can trigger compensatory tachycardia.
460
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.7 / Anesthesia Monitoring (Continued) Significance
Values
Equipment and Technique
Complication and Treatment
Normal: Canine • Systolic: 110–160 mm Hg • Diastolic: 60–100 mm Hg • Mean: 80–120 mm Hg Feline • Systolic: 120–170 mm Hg • Diastolic: 70–120 mm Hg • Mean: 80–120 mm Hg Abnormal: Canine • Systolic: <80 and >160 mm Hg • Mean: <60 and >120 mm Hg Feline • Systolic: <80 and >160 mm Hg • Mean: <60 mm Hg and >120 mm Hg
• Strength of peripheral pulse • Direct palpation of femoral, lingual, carotid, or dorsal pedal arteries • Indirect monitoring • Doppler • A cuff with a crystal sensor to measure the systolic blood pressures is placed on the limb of the patient. • See Skill Box 8.1 Blood Pressure Procedure, page 332. • Stethoscope • The same steps are taken as for Doppler use except a stethoscope is used to listen for the returning pulsating artery. • Oscillometric • A cuff with an incorporated device to measure and calculate the systolic, diastolic, and mean blood pressures is placed on the limb of the patient. • See Skill Box 8.1 Blood Pressure Procedure, page 332. • Direct monitoring • Indwelling catheter
Hypotension • Cause • Hypovolemia • ↓ Cardiac output (e.g., bradycardia, tachycardia, arrhythmias, or valvular disease) • Peripheral vasodilation (e.g., sepsis, drugs, hypoxemia, hypercapnia, or hyperthermia) • Anesthetic drug side effects • ↓ Venous return to the heart (e.g., hypovolemia, ↑ intra-abdominal pressure, controlled ventilation, or change on posture) • Treatment • ↓ Anesthetic depth • Rapid fluid administration (e.g., bolus or ↑ rate) • Colloids and RBCs administration • Drug administration of sympathomimetics (e.g., dopamine, dobutamine or ephedrine) Hypertension • Cause • Anesthetic drug side effect • Pain • Hypercarbia or malignant hyperthermia syndrome • Treatment • Evaluate anesthetic depth • Evaluate ventilation • IPPV • Discontinue drugs causing side effects • Drug administration (e.g., dobutamine, dopamine, or sodium bicarbonate) • IV fluid administration adjustment
Normal: 1–2 seconds Abnormal: >2 seconds
• Direct palpation • Direct digital pressure is applied to the MM until blanched and then timed for blood (pink color) to return
↑ CRT / Hypoperfusion • Cause • Hypovolemia, hypothermia, and pain • ↑ Anesthetic depth • Drug side effects (e.g., α2-agonists) • Treatment • Evaluate anesthetic depth. • Correct underlying condition. • See Hypotension above.
Blood Pressurea
Cardiovascular
• The pressure of the blood in a large artery as the product of cardiac output, vascular capacity, and blood volume • Reflects the adequacy of blood circulation throughout the body
Cardiovascular
Capillary Refill Time • Reflects the perfusion of tissues with blood
CHAPTER 13 / ANESTHESIA
13
461
Table 13.7 / Anesthesia Monitoring (Continued) Significance
Values
Equipment and Technique
Complication and Treatment
Normal: <8 cm H20 Abnormal: >12–15 cm H2O • Monitor trends over time, not a single reading
• Indwelling catheter • A long catheter is inserted percutaneously or by cutdown into the anterior vena cava. • The catheter is inserted close to the right atrium of the heart. • The catheter is then connected to a water manometer to obtain a measurement. • The manometer should be positioned at the approximate level of the heart. • See Skill Box 8.2 Central Venous Pressure, page 334.
↑ CVP • Cause: • Hypervolemia, venoconstriction or ↓ cardiac output • Treatment: • ↓ or stop IV fluid administration • Drug therapy (e.g., dobutamine or furosemide) ↓ CVP • Cause: • Hypovolemia, ↑ cardiac output or vasodilation • Treatment: • ↑ IV fluid administration (and/or colloid or blood administration)
Normal: See Table 8.4 ECG Interpretation, page 340. Abnormal: See Table 8.5, Common Rhythm Abnormalities, page 343.
• Electrocardiograph • See Chapter 8 Electrocardiogram, page 338.
Ventricular Premature Contractions • Causes • Preexisting heart disease • Catecholamine release (e.g., ↓ anesthetic depth, hypoxemia, hypercapnia, or hypotension) • Anesthetic drug side effects • See Table 8.5 Common Rhythm Abnormalities, page 343. • Treatment • Evaluate potential anesthetic administration problems • IPPV • Rapid fluid administration • Administration of an antiarrhythmic (e.g., lidocaine, procainamide or propranolol)
Normal: <15% loss Abnormal: >15% loss PCV <20–25% Tip: to calculate normal blood volume: Canine: 88 mL/kg Feline: 56 mL/kg
• Visual observation • Free blood in surgical site, suction bottle, soaked gauze and drapes • 1 soaked 4 × 4 gauze sponge equals approximately 5–6 mL of blood • Tachycardia, hypotension, white MM, and labored breathing
Hypovolemia • Cause • Hemorrhage • Treatment • ↓ or discontinue anesthesia • Rapid IV crystalloid administration • IV hetastarch administration • IV fluid colloid administration • Blood transfusion or synthetic blood equivalent
Cardiovascular
Central Venous Pressure • Allows assessment of blood return to the heart and how well the heart can receive and pump blood
Cardiovascular
Electrocardiograph • To assess the pattern and rhythm of myocardial contractions • Abnormal size, duration, shape, and/or regularity of ECG tracing offers information on electrical impulse conduction and myocardial function. • Identification of arrhythmias
Blood Loss
Cardiovascular
13
462
• • • •
Circulation Blood pressure Cardiac output Peripheral perfusion
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.7 / Anesthesia Monitoring (Continued) Significance
Values
Equipment and Technique
Complication and Treatment
Normal: Canine: 10–30 breaths/min Feline: 25–40 breaths/min Abnormal: <8 breaths/min
• Movement of the reservoir bag or thorax • Direct visualization of the bag or thorax • Auscultation of the thoracic cavity • A normal chest cavity has almost inaudible sounds. • Harsh noises, whistles, squeaks, crackles, or wheezes may indicate narrow or obstructed airways in the presence of fluid or secretions. • See Skill Box 2.3 Pulmonary Examination, page 32. • Pulse oximetry • Calculates the O2 saturation of hemoglobin in circulating RBCs • The probe is placed on an easily accessed capillary bed (e.g., tongue, lip fold, nasal septum, pinna, prepuce, vulva, skinfolds, or toe web). • Normal: 99–100% • Abnormal: <97%, 90% is hypoxemia and must be corrected
Bradypnea • Cause • ↑ Anesthetic depth • Hypocapnia • Edema (e.g., cerebral and spinal) • Treatment • Evaluate anesthetic depth. • IPPV Tachypnea • Cause • ↑ or ↓ Anesthetic depth • Hypercapnia, hypoxemia, hypotension, hyperthermia, airway obstruction, pleural or pulmonary disease • Treatment • IPPV (with anesthetic gas flowing) to correct level of anesthesia • Evaluate anesthetic depth.
Normal: 35–45 mm Hg Abnormal: <35 and >45 mm Hg
• Capnograph • Monitors breathing by measuring exhaled CO2 • A sensor is placed between the breathing circuit and the ET tube • No ETCO2 can be detected with apnea, patient disconnect, esophageal intubation, or airway obstruction.
Hypocapnia • Cause • Hyperventilation • Endobronchial intubation or pulmonary thromboembolism • Treatment • Evaluate anesthetic machine or ventilator settings. • Evaluate tube placement. Hypercapnia • Cause • Hypoventilation • ↑ Anesthetic depth, interference with chest wall expansion, early malignant hyperthermia, or equipment dead space • Treatment • Evaluate anesthetic depth. • Evaluate anesthetic machine. • IPPV or ventilator use
Respiratory Rate
Respiratory
• Reflects proper oxygenation of the body’s tissues • Ability to eliminate carbon dioxide from the blood
End-Tidal CO2
Respiratory
• A measure of carbon dioxide in the blood • Measures adequacy of ventilation
CHAPTER 13 / ANESTHESIA
463
13
Table 13.7 / Anesthesia Monitoring (Continued) Significance
Values
Equipment and Technique
Complication and Treatment
Normal: Arterial pH: 7.35–7.45 PaCO2: 35–42 mm Hg paO2: 85–105 mm Hg BE: −4 to +4 Venous pH: 7.35–7.45 Paco2: 40–50 mm Hg paO2: 30–42 mm Hg BE: −4 to +4 Abnormal: Single or multiple alterations from above
• Blood gas analysis equipment • Arterial blood draw • See Skill Box 8.3 Blood Gas Analysis, page 335. • Follow manufacturer’s directions.
Alkalosis • Cause • Drug effects • Brain damage, thoracic disease or trauma, pulmonary disease, excessive emesis, gastrointestinal obstruction, or obesity • Treatment • Evaluate IV fluid administration. • Drug administration (e.g., potassium chloride) Acidosis • Cause • Anxiety, fear, endotoxemia, or pneumonia • Hypoxemia or heart failure • Treatment • Drug administration (e.g., sodium bicarbonate) • IV fluid administration
Normal: Pink Abnormal: Pale: blood loss, anemia or poor perfusion Cyanotic: shortage of oxygen
• Visual observation • Observed at the gingival, tongue, buccal MM, conjunctiva of the lower eyelid, mucous membrane lining the prepuce or vulva
Cyanosis • Cause • Shock or cardiac arrest • Methemoglobinemia • Hypotension • Apnea • Improper ET tube placement • Treatment • Oxygen administration and IPPV • Discontinue further anesthetics. • Evaluate ET tube position.
Normal: See Table 13.6 Stages of Anesthesia, page 458.
• Alter the level of anesthesia. • Corneal • Touch the cornea with a sterile cotton swab, sterile drop of water, or ophthalmic ointment and observe for blinking and withdrawal of the eye into the orbital fossa. • Ear flick • Gently touch the hairs on the inside of the pinna and observe for movement. • Eye position • Visual observation
Respiratory
Blood Gases • Alterations in acid-base and respiratory function • Venous blood determines metabolic acidosis and alkalosis • Arterial blood determines metabolic and respiratory acidosis and alkalosis
Mucous Membranes
Respiratory
• Blood loss, anemia, and poor perfusion
Reflexes • Assessment of anesthetic depth Respiratory
13
464
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.7 / Anesthesia Monitoring (Continued) Significance
Values
Equipment and Technique
Complication and Treatment
• Muscle tone • Open jaw to observe for jaw tone. • Flex and extend foreleg and observe for resistance. • Observe size of anal orifice for anal tone. • Palpebral • Tap the lateral or medial canthus of the eye to observe for blinking. • Pedal • Pinch or squeeze a digit or pad and observe for resistance. • Pupil size • Visual observation • Pupillary light reflex • Shine a pen light to observe constriction of pupil. • Salivary/lacrimal secretions • Visual observation • Tactile estimate • Surgical stimuli • Visual observation of body movement, lacrimation, salivation, and sweating on foot pads • Swallowing • Observe neck/throat for typical movements. Thermoregulation • Circulation • Hypothermia causes delayed recovery from anesthesia due to slow rate of anesthetic drug metabolism by the liver. • Malignant hyperthermia can be a fatal condition and should be tended to immediately.
Normal: 100.5–102.5° F Abnormal: <100 and >103° F
• Direct palpation of paws and ears • Rectal thermometer • Temperature probe (e.g., rectal or esophageal) • Temperature should be monitored at minimum every 30 minutes.
Hypothermia • Cause • Anesthetic drug side effects • Exposure to cold solutions, cold table surfaces, or open body cavities • Treatment • Warmed IV fluids, hot water circulating heating pads, warm air blanket, insulated hot water bottles, bubble packing, foil wraps, and blankets • See Skill Box 8.6 Heat Administration, page 346. Hyperthermia • Cause • ↑ Metabolic rate due to ↑ muscle activity, ↓ depth of anesthesia, bacteremia or endotoxemia • Insulation due to drapes and obesity • Malignant hyperthermia syndrome • Anesthetic drug side effect
CHAPTER 13 / ANESTHESIA
465
13
Table 13.7 / Anesthesia Monitoring (Continued) Significance
Values
Equipment and Technique
Complication and Treatment • Treatment • Rapid fluid administration • Drug administration (e.g., corticosteroids and sodium bicarbonate) • Alcohol or cold-water baths/compresses • Ice-water enemas or gastric lavage • Administration of antipyretics (e.g., aspirin, aminopyrine, dipyrone or phenylbutazone)
To calculate mean arterial pressure: MAP = Diastolic + 1/3 (Systolic − Diastolic). Tip: Warm air blankets placed over the head of patients can lead to corneal drying and ulceration Tip: Afterdrop—core temperature will continue to drop after cooling techniques have been stopped. Aggressive techniques should be stopped when the core temperature reaches 104º F.
a
POSTANESTHESIA Recovery
13
The postanesthetic period begins as soon as the procedure ends and the anesthetic drugs have been discontinued. Monitoring will be continued until the patient’s vital signs return to normal and the patient is extubated and sternal. Even though an analgesic plan was started in the beginning, it will be continued through the recovery period and through patient discharge. The patient should remain connected to the anesthetic machine with oxygen flowing until the depth of breathing increases and/or for 5–10 minutes following the procedure. This will help to provide oxygen to a depressed respiratory system and allow the exhaled gases to be scavenged and avoid environmental contamination. The urinary bladder should be emptied at the end of surgery and the amount of urine noted. The patient should be monitored for normal urine production postoperatively. A rectal temperature should be taken immediately to set a baseline for postoperative heat support. Temperatures should be taken every 15–30 minutes and maintained between 99 º and 103 ºF. Patients need to be closely monitored for hypothermia along as hyperthermia. Patients with limited mobility, poor circulation and other disease processes can quickly become hyperthermic. Patients must also be monitored for dropping temperatures as their heat source is removed. IV Fluids should be continued postoperative depending on the veterinarians requests. The IV catheter should be flushed with saline if fluids are disconnected and remain in place for a minimum of one hour postoperative. 466
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Patients should be continuously monitored for cardiac and respiratory function and mental status following extubation. A dedicated recovery area in view of numerous nursing staff is recommended for such close observation during this time. Pediatric patients should be offered food within 2–3 hours of recovery to reduce hypoglycemia. Extubation The endotracheal tube should be maintained until the swallowing reflex has returned. Particular breeds and certain disease processes require the endotracheal tube be maintained as long as possible. Keeping the patient in a subdued, quiet area without physical stimulation will help facilitate the ET tube longer. In most patients, as soon as the patient is removed from the anesthetic machine, the cuff should be completely deflated and the tie used to secure the tube should be untied. The tie should also be arranged out the front of the mouth to assure it will not get tangled upon extubation. In some cases the cuff should only be slightly deflated if there is fear that fluids may be resting on the top of the ET tube. Slow removal of the tube with a partial deflated cuff will remove the fluids. The coughing reflex may return well in advance of the swallowing reflex. Complete protection against aspiration may not be assured until several hours after the patient has regained consciousness. Following extubation presents a good point for assessing pain management success and/or the need for additional postoperative analgesics as the patient regains sensation and control of its body. Discharge Instruction The effects of anesthesia can often be seen for 24 hours following the event. Patients should be kept quite for this time and observed closely. Patients are
often unstable and slightly disoriented and normal activities may now become a hazard. Animals can be offered small amounts of water after arriving home, but should be monitored for guzzling. Once the animal has successfully had water without vomiting, it can be offered a small amount (25–50%) of their normal meal, unless otherwise directed by the veterinarian. A full meal can be provided the following day.
The client should leave feeling comfortable about the home care they will be providing and the medical follow up care. This includes suture removal, drain care, analgesic plan, activity plan, E-collar use, medications, and recheck appointments.
Table 13.8 / Postanesthetic Monitoring
Monitoring an animal recovering from anesthesia continues until monitoring parameters return to normal for that particular patient. The monitoring guidelines listed in Table 13.7 Anesthesia monitoring, page 458. continue in the postanesthetic period along with the items listed below. Normal and abnormal values and equipment and techniques can be found in Table 2.1. Preliminary Examination, page 19. and Table 13.7 Anesthesia Monitoring, page 458.
Cardiovascular
System Affected
Vital Signs Monitored
Complication and Potential Cause
Clinical Signs
Treatment
• • • •
• Dysrhythmias • Drug side effect • Pain • Disease condition (e.g., GDV)
• Irregular ECG tracing • Tachycardia • Pulse deficits
• Continuous or intermittent ECG tracing • Drug administration (e.g., antiarrhythmics) • Manage pain
• Pain • Surgical procedure • See Chapter 9 Pain Management, page 379.
• • • • • •
• Circulatory shock • Anaphylactic shock • Drug administration or vaccines • Cardiogenic shock • Heart disease, pulmonary embolus, arrhythmias, hypoxia, and hypercarbia • Hypovolemic shock • Hemorrhage, excessive vasodilation, inadequate fluid administration • Septic shock • Portocaval shunt, intestinal spillage, or gastric volvulus • See Table 7.5 Shock, page 310.
• Tachycardia or bradycardia • Weak or irregular pulses and hypotension • ↑ Capillary refill time • Pale MM • Cold extremities • Oliguria/anuria
Heart rate Capillary refill time Electrocardiograph Pulse
• Tachycardia Tachypnea or hypoxemia • Hypertension Vomiting, regurgitation, or ileus • Prolonged recumbency • Behavior changes •
Evaluate analgesic plan and adjust as needed using pain score/index. Provide heat support. Provide a clean, dry cage in a peaceful, quiet environment. Provide reassuring contact. Provide acupuncture, acupressure, and/or massage as indicated.
• • • •
Check airway and supply oxygen. ↑ IV fluid administration. Blood transfusion Drug administration (e.g., corticosteroids, anesthetic antagonist, dopamine, atropine, or sodium bicarbonate) • Monitor urine output.
CHAPTER 13 / ANESTHESIA
467
13
Table 13.8 / Postanesthetic Monitoring (Continued) Vital Signs Monitored
Complication and Potential Cause
Clinical Signs
Treatment
• • • •
• Airway obstruction • Upper airway swelling due to prolonged head down position, allergic reaction, or pharyngeal surgery • Tongue swelling • Soft palate entrapment • Trauma from intubation • Breed predisposition (e.g., brachycephalics) • Foreign body • Laryngeal paralysis • Collapsing trachea
• Cyanotic • Bradypnea or apnea • Excessive chest wall or abdominal movement • Anxious behavior • Noise during inspiration (e.g., stridor)
• Oxygen therapy • Position head to extend the neck and tongue. • Recover in a dark, quiet room. • Drug administration (e.g., dexamethasone sodium phosphate) • Reinduce/reintubate. • Tracheotomy/tracheostomy
• • • • • •
• • • • •
• Oxygen therapy • Sedation and controlled ventilation • Drug administration (e.g., furosemide and aminophylline)
Respiratory rate Mucous membranes Oropharyngeal reflex Pulmonary auscultation
Anxiety, restlessness Dyspnea, coughing Cyanosis Pulmonary rales Froth in the ET tube or at the nostrils
Ocular
Pulmonary edema ↑ Pulmonary capillary pressure Acute respiratory failure Hypoproteinemia Rapid expansion of collapsed lung Seizures
• Pupils • Palpebral reflex • Eyeball position
• Blindness • Cerebral hypoxia
• Blindness
• Supportive therapy to return the vital signs to normal as quick as possible • Drug administration (e.g., corticosteroids)
Musculoskeletal
Respiratory
System Affected
• Jaw tone • Limb muscle tone • Sphincters (anus and bladder)
• Rigidity • Drug side effect • ↓ Anesthetic depth
• Extended and stiff extremities
• Supportive care
• Flaccid • ↑Anesthetic depth
• Lack of any muscle tone
• Supportive care
13
468
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.8 / Postanesthetic Monitoring (Continued) Vital Signs Monitored
Complication and Potential Cause
Clinical Signs
Treatment
• • • •
• Seizures • Epilepsy • Hypoglycemia, hypoxemia, or thromboembolism • ↑ Intracranial pressure • Drug side effect (e.g., ketamine) • Radiographic contrast media parenteral or intrathecal • Secondary hyperthermia
• Seizure activity • Hyperthermia
• • • •
• Behavior change • Drug administration (e.g., oxymorphone-acepromazine, fentanyl-droperidol, and ketamine) • Hypoglycemia
• • • • • • •
• Manage pain. • Provide postoperative sedation. • Provide dark, quiet place for recovery.
• Pain • See Chapter 9 Pain Management, page 379.
• See above
• See above
• Urine output
• • • • •
Oliguria or anuria Hypoperfusion Renal dysfunction Nephrotoxicity Hypovolemia
• Urine output <0.5 mL/kg/hr in recovery
• Verify patent urethra and check bladder size. • Placement of a urinary catheter • Maintain or administer IV fluids to ↓ temperature. • Drug administration (e.g., furosemide, dopamine, and mannitol)
• Temperature
• • • •
Hypothermia Drug side effect Inadequate heat support Pediatric or geriatric
• Rectal temperature <101 °F • Shivering • Curled up resting position or hiding
• Warmed IV fluids, hot water circulating heating pads, warm air blanket, insulated hot water bottles, bubble packing, foil wraps, and blankets
• • • • • • •
Hyperthermia Pediatrics Diabetes mellitus Excessive heat application ↑ Metabolic rate Drug side effect Malignant hyperthermia syndrome
• • • •
Pedal reflex Reaction to stimulus Behavior Comfort
Thermoregulatory
Urogenital
Nervous
System Affected
Excitement Hyperreflexia Disoriented Depression Restlessness Aggression Listlessness and lethargy
Rectal temperature >103 °F Panting Patient hot to the touch Injected MM or flushed skin
Maintain adequate oxygen levels. Monitor hypoglycemia. Maintain or administer IV fluids. Administer seizure medications (e.g., diazepam or phenobarbital). • Drug administration (e.g., methylprednisolone and mannitol)
• Rapid IV fluid administration • Drug administration (e.g., corticosteroids and sodium bicarbonate) • Alcohol or cold-water baths • Ice-water enemas or gastric lavage • Administration of antipyretics (e.g., aspirin, aminopyrine, dipyrone, or phenylbutazone)
CHAPTER 13 / ANESTHESIA
469
13
Table 13.9 / Local and Regional Anesthesia
The use of local anesthetics is severely underutilized in small animal veterinary medicine. The potential for their use is extensive and can be applied to numerous surgical and nonsurgical procedures. Besides the analgesic effects additional benefits are seen, such as decreased requirements of anesthetics, decreased “wind-up,” quicker return to normal activity, and ↓ chance of establishing chronic pain. The supplies typically needed to place a local anesthetic are gloves, clippers, surgical prep supplies, sterile hypodermic needles (20–25 gauge, 2–3 inches long), sterile syringe, and local anesthetic drug(s). Placement of a local anesthetic requires strict aseptic technique. The area should be clipped and surgically prepared, which can often take place during prep for surgery. Many of the techniques listed below require minimal skill, while others can be mastered with proper instruction. Care must be taken to not instill more than the maximum dose of drug allowed for that particular patient. This table provides a brief description of local anesthetic techniques. Please review a text dedicated to this subject for more complete technique descriptions.
13
Epidural Anesthesia
Brachial plexus block
Types
470
Area and Nerves Blocked
Uses
Drug and Dose
Equipment and Method
Associated Risks
• Block distal to and including the elbow • Radial, ulnar, median, musculocutaneous, and axillary nerves
• Surgery below the elbow
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • 0.5–1.0 mg/kg • 1 mL/4.5 kg
Equipment: • 22 gauge 2–3 inch spinal needle • Sterile syringe Method: • Instill drug into the axillary space at the level of the shoulder joint, parallel to the thoracic wall to a point approximately at the caudal aspect of the shoulder joint. • The syringe is aspirated prior to injection and again any time the needle is adjusted during the injection.
• Avoid insertion into a blood vessel or thoracic cavity. • Failure to obtain complete anesthesia
• Central neuraxial block • Depending on dose, block up to T5
• Animals who are severely depressed, in shock, or need immediate hindquarter surgery • Aged animals, those in high risk, or those where anesthetics agents are contraindicated • To provide analgesia after abdominal surgery or hindquarter surgery
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine • Canine: 1 mL/3.4 kg • Feline: 1 mL/4.5 kg • Bupivacaine • Canine: 1 mL/ 4.5 kg • Feline: 1 mL/7.0 kg
Equipment: • 2–4 inch, 18–22 g, short bevel with stylet spinal needle • 2.5 mL and 5 mL syringe • Thin-walled, 18 gauge, 3 inch needle for a continuous epidural Method: • Animal is placed in sternal recumbency with hind legs froglegged cranially or lateral recumbency with hind legs pulled cranially
• Duration is prolonged 1–1.5 hours with the addition of epinephrine. • Improper placement of the local anesthetic into the intervertebral space • Do not use in patients with septicemia, coagulation defects, or spinal inflammation. • Respiratory depression and paralysis with drug overdose; drug needs to migrate to C5 or C7 for this affect
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.9 / Local and Regional Anesthesia (Continued) Area and Nerves Blocked
Drug and Dose
Equipment and Method
Associated Risks
• Deposit a small amount of SQ 2% lidocaine and then apply a surgical prep to the site. • The bevel of spinal needle should be positioned cranially. Insert the spinal needle between L7 and S1. Push the needle in a slight cranial or caudal angle as needed until a distinct “pop” is felt or resistance is met. • Remove the stylet and observe for blood or CSF and/or inject 1–2 mL of air to ensure correct placement. If SQ crepitus is felt the needle is incorrectly placed; no resistance should be felt. • Inject the drug over 60 seconds to achieve the correct level of anesthesia.
• Hypothermia • Anesthetic in vertebral sinuses: vomiting, tremors, hypotension, convulsions, and paralysis • Malignant hyperthermia for susceptible animals
• Same as Epidural Anesthesia
• Intraoperative and postoperative pain • Critical care patients
Drug (preservative-free): • Morphine (M) • Oxymorphone (O) • Hydromorphone (H) Dose: • M = 0.1 mg/kg • O = 0.05–0.1 mg/kg • H = 0.1 mg/kg Duration: • M = 10–24 hours • O = 10–20 hours • H = 10–24 hours
• Same as Epidural Anesthesia • Can be administered as a continuous rate infusion if epidural catheter is placed.
• • • • •
• Block cranial and caudal to incision or injury site • Intercostal nerves
• Thoracotomy, chest tube placement, rib fractures, pleural drainage
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Intercostal: 0.25–1.0 mL per nerve blocked • Interpleural: • Canine: 1.5 mg/kg • Feline: 0.5 mg/kg
Equipment: • 22–25 gauge needle • Sterile syringe Method (intercostal): • Block the 2 nerves cranial and 2 nerves caudal to the incision site. • Instill the drug at the caudal border of the rib near the level of the intervertebral foramen Method (interpleural): • Instill the drug into the thoracic cavity during a thoracotomy or chest tube • Instill 5–10 mL saline to flush the drug into the interpleural space
• Inadvertent pneumothorax • Bupivacaine may sting when administered through the chest tube. • Contraindicated with an open pericardium and not effective in pyothorax • When using a chest tube, allow the patient to lay with that side down for 15 minutes.
Epidural Analgesia Intercostal and interpleural block
Uses • Rear limb lacerations or fractures, abdominal surgery, perianal surgery, cesarean sections, surgical procedures of the tail, perineum, vulva, vagina, rectum, and bladder, urethrostomies, and obstetrical manipulations
Epidural Anesthesia
Types
Respiratory depression Urine retention Delayed gastrointestinal motility Vomiting Pruritus
CHAPTER 13 / ANESTHESIA
471
13
Table 13.9 / Local and Regional Anesthesia (Continued)
Intravenous regional block, ‘Bier Block’
Intra-articular block
Types
Area and Nerves Blocked
Uses
Drug and Dose
Equipment and Method
Associated Risks
• Variable, dependent on joint • Block tissues surrounding the joint capsule
• Arthroscopy • Joint surgery; stifle, elbow, shoulder
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine: • Canine: 5 mg/kg • Feline: 2.5 mg/kg • Bupivacaine: • Canine: 1.0–2.0 mg/ kg • Feline: 1.0 mg/kg
Equipment: • 22–25 gauge needle • Sterile syringe Method: • With the patient in lateral recumbency and the affected stifle up, flex the stifle and apply digital pressure to the medial side of the straight patellar ligament. • Insert the needle on the opposite side of the straight patellar ligament midway between the patella and the tibial tuberosity and direct it obliquely and distally toward the intercondylar space of the tibia.
• Morphine may also be used in inflamed joints at 0.1–0.3 mg/kg.
• Extremity distal to tourniquet • Nerve endings in peripheral tissues
• Biopsies • Foreign bodies from the paw or other minor surgical procedures of an extremity
Drug: • Lidocaine 2% Dose: • Lidocaine: • Canine: 5 mg/kg • Feline: 2.5 mg/kg
Equipment: • 22 gauge needle, 1 ½ inch Method: • Place an IV catheter in a vein distal to the tourniquet. • Apply a pressure bandage to exsanguinate the limb prior to placing the tourniquet. Remove bandage once the tourniquet is placed. • Inject 2.5–5 mg/kg of 1% lidocaine intravenously. Full effects are seen in 5–10 minutes. • Following the procedure, the tourniquet should be removed slowly over a 5 minute period to prevent overdose of local anesthetic agents. (esp. feline)
• Do not use bupivacaine • Ensure diluted lidocaine is used • Tourniquet left on over 90 min can lead to tourniquet-induced ischemia, 4 hours can lead to reversible shock and over 8 hours can lead to sepsis, endotoxemia, and death • Malignant hyperthermia in susceptible animals
13
472
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.9 / Local and Regional Anesthesia (Continued) Area and Nerves Blocked
Uses
Drug and Dose
Equipment and Method
Associated Risks
• Tissues immediately proximal to target area • Placed between the target area and the spinal cord
• Surgery on an area of tissue served by many nerves • Analgesia involving superficial tissues • Skin biopsies and small skin tumors • Repair of minor lacerations
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine: • Canine: 5 mg/kg • Feline: 2.5 mg/kg • Bupivacaine: • Canine: 1.0–2.0 mg/ kg • Feline: 1.0 mg/kg • Volume of total dose can be diluted with sterile saline up to 50% for greater coverage
Equipment: • 23 or 25 gauge needle • Sterile syringe Method: • Apply a surgical prep to surgery site. • Visualize a line of infiltration that is proximal to the surgery site. Insert the needle along the proposed line of infiltration and aspirate to verify placement is not in a blood vessel. • Inject small amounts of drugs as the needle is gradually withdrawn. The drug will then diffuse through the tissues to reach the target tissues.
• Avoid injecting directly into a nerve as temporary or permanent nerve loss can occur. • Avoid IV injection as CNS or CV effect may occur. • Do not inject into inflamed areas. • Cats are more sensitive to systemic effects of (L); avoid using >1 mL/10 lb.
• Any nerve with direct visualization
• Amputations
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine: • Canine: 5 mg/kg • Feline: 2.5 mg/kg • Bupivacaine: • Canine: 1.0–2.0 mg/ kg • Feline: 1.0 mg/kg
Equipment: • 23 or 25 gauge needle • Sterile syringe Method: • Visualize and directly infiltrate the nerve to be severed (e.g., amputation).
• Do not attempt to inject the nerve; rather bathe the nerve by applying drug to the immediate area.
• Block of the distal radial, median, dorsal and palmar branches of the ulnar nerve
• Onychectomy, digit, tail amputation
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine: • Canine: 5 mg/kg • Feline: 2.5 mg/kg • Bupivacaine: • Canine: 1.0–2.0 mg/ kg • Feline: 1.0 mg/kg
Equipment: • 20 or 22 gauge needle • Sterile syringe Method: • Insert the needle subcutaneously along the lateral aspect of the paw proximal to the carpus. • Slowly withdraw needle while instilling the local anesthetic. • Repeat on the medial side
• Do not attempt to inject the nerve; rather bathe the nerve by applying drug to the immediate area.
Ring block
Nerve Block
Line Block
Types
13
CHAPTER 13 / ANESTHESIA
473
Table 13.9 / Local and Regional Anesthesia (Continued)
Splash block
Types
Area and Nerves Blocked
Uses
Drug and Dose
Equipment and Method
Associated Risks
• Tissues in contact with the drug
• Open surgical incision line • Ear ablation
Drug: • Lidocaine 2% Dose: • Canine: 5 mg/kg • Feline: 2.5 mg/kg
Equipment: • 20 or 22 gauge needle • Sterile syringe Method: • Spray a surgical area with the drug and allow it to remain in contact for 15–20 minutes.
• Fluids (e.g., blood) will negate the effect of this block. • Not as effective as blocking prior to incision
Note: Preservative-free fentanyl, buprenorphine, and morphine are required for epidurals. Note: See Skill Box 14.3 Dental blocks (infraorbital and mandibular), page 518.
VENTILATION Table 13.10 / Ventilation: General Information
One of the key elements to successful anesthesia is providing adequate ventilation to the patient. Without proper maintenance of ventilation, the procedure may lead to hypoxia and brain damage or even death. Even though respiration can be seen by the rising and falling of the chest, this does not always ensure adequate movement of air. Assisted ventilation or controlled ventilation can give peace of mind that the patient is receiving proper oxygen levels throughout the body. Uses
• • • • •
Animals with compromised respiration (e.g., obese or debilitated animals) Thoracic surgery (e.g., diaphragmatic hernia or pneumothorax) Head, chest, or nerve trauma Prolonged anesthetic procedures, >90 minutes Drug overdose
Normal Ventilator Values Tidal volume
• The amount of gas exchanged in one respiratory cycle • 5 mL/lb in awake animals • 7 mL/lb when ventilator in use
Airway pressure
• 15–20 cm H2O in awake animals and when ventilator in use • 20–30 cm H2O when ventilator in use during thoracic surgery
Inspiratory time
• 1 second in awake animals • <1.5 seconds when ventilator in use
Ventilatory rate
• Canine: 8–14 breaths/min • Feline: 10–14 breaths/min
Minute ventilation
• 300–500 mL/lb/min
13
474
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.10 / Ventilation: General Information (Continued) Ventilator controls Volume preset
• Delivers a preset constant volume of gas despite changes in the lungs during anesthesia • Volume is variable and depends on the following; lung compliance, airway resistance, pressure within the thorax, and the number of functioning alveoli. • Can allow for developing high airway pressures and of small leaks that cannot be compensated for, compromising the patient’s tidal volume
Pressure preset
• Delivers a gas at a preset volume during the inspiratory phase • Does not allow a buildup of high pressure and compensates for leaks in the system • Pressure may need to be increased to compensate for volume variability
Time cycled
• Delivers gas at a preset frequency or respiratory rate, inspiratory:expiratory ratio (I : E), or inspiratory flow rate
Associated risks
• • • • • •
Thoracic blood flow impairment, leading to ↓ blood pressure, stroke volume, and cardiac output Hyperventilation, leading to respiratory alkalosis and ↓ cerebral blood flow Barotrauma, leading to pneumothorax, pneumomediastinum, pulmonary hemorrhage, and air embolism Improper setup of ventilator or ventilator malfunction In-circle vaporizers can cause ↑ amounts of vaporized anesthetics; leading to deepened anesthetic states. Ventilator equipment can be a source of microbial contamination for the patient.
Skill Box 13.4 / Ventilation: Administration There are numerous types of ventilators used in veterinary medicine, each with varying complexity of controls. The manufacturer’s guidelines for instructions should be referred to for proper use. Prior to each use, the ventilator function should be verified with a leak check and a general function test. Definition
Uses
Initiating Method
Ending Method
• Any healthy, anesthetized animal
• The pop-off valve is closed and pressure is applied to the reservoir bag to a manometer reading of 10– 15 (feline and canine <22 lb) and 15–20 (canine) cm H2O to inflate the lungs (holding for no more than 1 second) and then slowly released for exhalation. • A breath should be given every 5 minutes throughout the procedure. • Vaporizer setting in an in-circle, nonprecision vaporizer should be turned to zero before giving an IPPV.
• Normal procedure of discontinuing inhalant anesthetics
Manual Assist • Patient’s breathing is assisted by manual compressions of the reservoir bag. • Often referred to as giving a “sigh” or as intermittent positive-pressure ventilation, (IPPV). • See Skill Box 13.3, page 458.
CHAPTER 13 / ANESTHESIA
13
475
Skill Box 13.4 / Ventilation: Administration (Continued) Definition
Uses
Initiating Method
Ending Method
Controlled • Patient’s breathing is controlled by manual compressions of the reservoir bag.
• Animals with compromised respiration (e.g., obese or debilitated animals)
• Reduce vaporizer setting initially and begin bagging (as described above) at a rate of 12–16 breaths/min. If the chest cavity is open, the manometer reading should be ↑ to 20–30 cm H2O. Spontaneous breathing should cease after 3–5 minutes; if it does not, a neuromuscular agent may need to be used. • Once control of respiration has been established, a rate of 8–12 breaths/min should be maintained. • Inspiratory time should be 1–1.5 seconds with an expiratory time of twice as long. • The pop-off valve should be closed during compressions, but should be opened every 2–3 breaths to allow escape of back pressure.
• Discontinue the use of the inhalant anesthetic and nitrous oxide while continuing to ventilate with O2. • Administer the reversal if a neuromuscular agent and/or an opioid were used. • The rate of respiration should be gradually ↓ to 5 breaths/min while the animal is observed for spontaneous breathing. Spontaneous breathing may take several minutes to resume, especially in older or debilitated animals or those undergoing a long anesthetic procedure. • Once spontaneous respiration is seen, the anesthetist should switch to manual, controlled ventilation. The rate can continue to ↓ to 1–4 breaths/min. • Bagging can be stopped altogether when the rate and tidal volume are back to normal.
Assist • Patient initiated ventilation • The initiation of a breath from the patient triggers a preselected tidal volume from the ventilator. • Patient determines frequency of ventilation and minute volume.
• Animals with compromised respiration; e.g., obese or debilitated animals • Animals with prolonged anesthetic procedures
• Refer to the ventilator’s manual for complete instructions. • Connect the ventilator to the patient’s breathing system. • Adjust the controls. • Turn on the ventilator. • Make minor adjustments to the controls based on the patient’s monitored values.
• See above.
Assisted-Controlled • The initiation of a breath from the patient triggers a preselected tidal volume from the ventilator • The anesthetist sets a minimal respiratory rate which the animal may override by initiating spontaneous respiratory efforts at a faster rate.
• See above.
• See above.
• See above.
Mechanical
13
476
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Skill Box 13.4 / Ventilation: Administration (Continued) Definition
Uses
Initiating Method
Ending Method
Controlled • The anesthetist sets the ventilator to control the rate and volume of the animal’s respiratory cycle.
• See above. • Thoracic surgery (e.g., diaphragmatic hernia or pneumothorax) • Head trauma
• See above.
• See above.
ANESTHETIC DRUGS Preanesthetic Drugs Table 13.11 / Anticholinergic Drugs Drug Class
Anticholinergics
Drug (Trade Name)
• Atropine sulfate • Glycopyrrolate (Robinul-V)
Mode of Action
• Works on muscarinic receptors of the parasympathetic nervous system by blocking the action of the neurotransmitter, acetylcholine • Reverses the effects of the parasympathetic nervous system
Physical Effects
• • • •
Uses
• Preanesthetic • Treatment of sinus bradycardia, sinoatrial arrest, incomplete AV block, and bronchconstrictive disease • Antidote of organophosphate poisoning
Monitoring
• Heart rate and rhythm • Mouth/secretions and dryness • Thirst/appetite, urination/defecation compatibility
Notes
• Counters bradycardia that develops from laryngeal or ocular stimulation and other vasovagal stimulation • Glycopyrrolate has a ↓ chance of tachycardia over atropine; as well as a ↓ chance of cardiac arrhythmias, and it suppresses salivation more thoroughly. • Glycopyrrolate does not cross the blood-brain or placental barrier.
↑ Heart rate and cardiac output ↓ Oral, pharyngeal, and respiratory tract secretions and GIT motility Pupil and bronchial dilation Blocks vagal nerve stimulation
13
CHAPTER 13 / ANESTHESIA
477
Table 13.12 / Anticholinergic Drugs: Atropine and Glycopyrrolate Drug Class Drug (Trade Name)
Anticholinergics Atropine
Glycopyrrolate (Robinul-V)
Dose/Route/Duration
Dose: 0.02–0.04 mg/kg Route: SQ, IM, IV Duration: 60–90 minutes
Dose: 0.005–0.01 mg/kg Route: SQ, IM, IV Duration: 2–3 hours for major effects; 7 hours for salivation
Metabolism
Canine: kidney and excreted in the urine Feline: liver
Precautions
• • • • • • •
↑ Risk of cardiac arrhythmias and sinus tachycardia in dogs ↓ Serous portion of salivary secretions, leaving the thicker, ropey mucoid portion, (esp. feline) ↓ Tear production (eyes should be protected with an ophthalmic ointment to prevent corneal drying esp. if using Ketamine) Bronchodilation (↑ dead space) Do not mix with Diazepam Mydriasis (esp. feline, can cause retinal damage if exposed to bright light for an extended period of time due to reduced pupillary light reflex) Urine retention
Contraindications
• • • • •
Amitriptyline administration Congestive heart failure Constipation, ileus, GIT infections Glaucoma (narrow angle) or iris synechiae (adhesions) Tachycardia (canine: >140 bpm; feline: >160 bpm)
Toxicity
• Canine are more susceptible to toxicity than felines • Drowsiness, dry MM, thirst, excitability, dilated pupils, tachycardia, vomiting, seizures, and depression
Table 13.13 / Phenothiazines
13
Drug Class
Phenothiazines
Drug (Trade Name)
• Acepromazine maleate (Promace), acetylpromazine, Promazine (Sparine), and Chlorpromazine (Thorazine)
Mode of Action
• Depresses the reticular activating center of the brain • Inhibits action of dopamine as a neurotransmitter in CNS
Physical Effects
• • • •
478
Calming effect Muscle relaxant ↓ Motor activity ↑ Threshold for responding to external stimuli and analgesic effects of other drugs even though they are not personally noted for producing any analgesic qualities • Antiemetic effect is very obvious at low doses during the anesthetic period, GIT upset, or motion sickness. • Depress respiratory system (dose dependent and an additive effect with hypnotics or narcotics) and potentially hypotensive • Protects against catecholamine-induced arrhythmias
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.13 / Phenothiazines (Continued) Drug Class
Phenothiazines
Uses
• • • • •
Preanesthetic agent Tranquilizer Antiemetic Antispasmodic Antiarrhythmic effects
Monitoring
• • • •
Blood pressure Body temperature Cardiac rate and rhythm Degree of tranquilization
Notes
• • • •
Protect from light Minimal effects on the cardiac system ↓ Seizure potential in myelogram cases More effective when used in combination with an opioid agent
Table 13.14 / Phenothiazines: Acepromazine Maleate Drug Class Drug (Trade Name)
Phenothiazines Acepromazine maleate (Promace)
Dose/Route/Duration
Preanesthetic Dose: Canine: 0.03–0.05 mg/kg (maximum dose of 3 mg) Feline: 0.02–0.1 mg/kg Route: PO, SQ, IM, IV (cautiously) Duration: 4–8 hours
Metabolism
• Liver
Precautions
• Excitement rather than sedation (paradoxical aggression from CNS stimulation) • Peripheral vasodilation (possibly leading to hypothermia or hypotension) • Prolonged recovery in aged animals, portocaval shunts, or ↓ hepatic function
Contraindications
• • • • • •
Toxicity
• Seizures, hypotension, hypothermia, and hypoventilation
Sedative Dose: Canine: 0.025–0.2 mg/kg IV; (maximum dose of 3 mg) 0.1–0.25 mg/kg IM Feline: 0.05–0.1 mg/kg IV (maximum dose of 1 mg) Route: SQ, IM, IV (cautiously) Duration: 4–6 hours
13
Allergy skin testing (prevents the release of histamine therefore reducing allergic reactions) Anemic patient (may ↓ PCV by 30%) Geriatric, neonatal, and compromised liver patients may have an ↑ potency (cut dose by ½ ) Patients with epilepsy, shock, head trauma, or those undergoing procedures such as a myelogram Sight hounds, giant breeds, and possibly Boxers Splenic disease patient (induces enlargement and/or engorgement)
CHAPTER 13 / ANESTHESIA
479
Table 13.15 / Benzodiazepines Drug Class
Benzodiazepines
Drug (Trade Name)
• Diazepam (Valium, Vazepam) • Midazolam HCl (Versed)
Mode of Action
• Releases an inhibitory neurotransmitter in the brain, GABA
Physical Effects
• Antianxiety and calming effect • Skeletal muscle relaxation • Anticonvulsant activity
Uses
• Preanesthetic • Sedative • Anticonvulsant, those undergoing procedures that commonly show seizures postoperatively (cerebrospinal fluid taps or myelograms), or with drugs that lower the seizure threshold (Ketamine, Opioids, and local anesthetics). • Oral Diazepam may be used to curb inappropriate urination in cats • IV Diazepam may be used as an appetite stimulant (feline), however it is transient and dose-dependent
Monitoring
• Level of sedation • Respiratory and cardiac signs
Notes
• • • • • • •
Class IV controlled substance Protect from light Diazepam should not be stored in plastic syringes, bags, or tubing; it is readily absorbed into the plastic Diazepam may increase the effects of Digoxin Minimal adverse effects on the cardiovascular and respiratory systems Oral Diazepam is a controlled drug that is not licensed for use in animals in the United States Benzodiazepines should be given IV slowly to prevent hypotension associated with the propylene glycol carrier (Diazepam) and to ↓ the apnea response
Table 13.16 / Benzodiazepines: Diazepam and Midazolam
13
Drug Class
Benzodiazepines
Drug (Trade Name)
Diazepam (Valium, Vazepam)
Midazolam (Versed)
Dose/Route/Duration Dose: 0.2–0.4 mg/kg (max dose of 10 mg) Route: PO, IV (slowly) Duration: Canine: 3–5 hours Feline: 5 hours
Dose: 0.2–0.4 mg/kg Route: IM, IV (slowly) Duration 1–2 hours
Metabolism
• Liver
480
• Liver and excreted in the urine and feces
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.16 / Benzodiazepines: Diazepam and Midazolam (Continued) Drug Class
Benzodiazepines
Precautions
• Rapid IV administration may cause bradycardia, short-term arrhythmias, hypotension, and apnea. • IM injections are painful with variable absorption. • Best not utilized as a sole anesthetic agent because it does not produce sedation; combine with opiates or ketamine. • May cause significant thrombophlebitis • Crosses placenta • Do not store in plastic syringes or tubing due to absorption.
Contraindications
• Do not mix with atropine, acepromazine, barbituates, or opioids • Has advantage of water-soluble base; can be mixed with other aqueous since they will produce a precipitate. agents/drugs • May cause either sedation or excitement (canine) • May cause behavior modification (feline); irritability or depression
Toxicity
• • • •
Ataxia CNS depressant Confusion, coma, and decreased reflexes Hypotension
• Flumazenil Canine: 0.01 mg/kg IV
• Rapid IV administration may cause bradycardia and respiratory depression • Best not utilized as a sole anesthetic agent because it does not produce sedation; combine with opiates or ketamine • May cause either sedation or excitement (canine) • May cause behavior modification in cats; irritability, dysphoria, agitation, depression and difficult restraint • Use with caution in geriatric or debilitated patients undergoing Isoflurane anesthesia.
• • • •
Ataxia CNS depressant Confusion, coma, and ↓ reflexes Respiratory depression
• Flumazenil Canine: 0.01 mg/kg IV
Table 13.17 / a2-Agonists Drug Class
a2-Agonists
Drug (Trade Name)
• Xylazine (Rompun, AnaSed, Gemini) • Medetomidine (Domitor)
Mode of Action
• Stimulates α2-receptors, causing a decrease in the level of the neurotransmitter norepinephrine released in the brain
Physical Effects
• Calming and sedation • Muscle relaxation • Suppresses salivation, gastric secretions, and gastrointestinal motility; can trigger emesis
Uses
• • • • • • •
13
Preanesthetics Sedation Short anesthetic procedures Chemical restraint Short periods of analgesia Induce vomiting in felines after ingestion of toxins Stimulate appetite in low doses
CHAPTER 13 / ANESTHESIA
481
Table 13.17 / a2-Agonists (Continued) Drug Class
a2-Agonists
Monitoring
• • • •
Body temperature Cardiovascular function Level anesthesia and analgesia Respiratory function
Notes
• • • •
Xylazine has the highest rate of anesthetic complications and death. Medetomidine is more potent than xylazine with less side effects; however, it is not licensed for use in felines in the United States. Atropine is often given in conjunction with xylazine to counteract the vomiting and cardiovascular changes. Affects glucose values after drug administration; suppresses insulin release, causing ↑ plasma glucose concentration and glucosuria, use with caution in non–insulin-dependent diabetics.
Table 13.18 / a2-Agonists: Xylazine and Medetomidine Drug Class Drug (Trade Name)
a2-Agonists Xylazine (Rompun, AnaSed, Gemini)
Medetomidine (Domitor)
Dose/Route/Duration
Dose: 0.2–0.5 mg/lb IV 0.05–1 mg/lb SQ, IM Route: SQ, IM, IV, epidurally, and subarachnoidally Duration: 20–40 minutes
Dose: Canine: 10–40 μg/kg IM 0.001–0.01 mg/kg IV, IM, SQ Feline: 40–80 μg/kg IM 0.001–0.01 mg/kg IV, IM, SQ • If using a premed, dose can be cut by 50% • ↑ Doses do not ↑ sedation, merely prolong duration IM Protocol, “kitty magic” 25 μg/kg medetomidine, 5 mg/kg ketamine, 0.2 mg/kg butorphanol IM Route: SQ, IM, IV, sublingually Duration: 4–6 hours
Metabolism
• Liver and excreted in the urine
• Liver and excreted in the urine
13
482
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.18 / a2-Agonists: Xylazine and Medetomidine (Continued) Drug Class Drug (Trade Name)
a2-Agonists Xylazine (Rompun, AnaSed, Gemini)
Medetomidine (Domitor)
Precautions
• Vomiting (50% of canines and 90% of felines) usually seen within 3–5 minutes, do not induce further anesthesia until after this time period to prevent aspiration • Severe respiratory depression • Hypotension (initial ↑ and then subsequent decrease) • Bradyarrhythmias • Cardiac output possible ↓ of 30–50% • Depresses thermoregulatory mechanism • Can be absorbed through skin abrasions and MM (should be handled carefully)
• Mucous membranes cannot be used as a vital sign for oxygen saturation; they may appear blanched or cyanotic. • Bradycardia, sometimes unresponsive and fatal • Respiratory depression • Depressed thermoregulatory mechanism • ↓ Blood pressure
Contraindications
• Brachycephalic breeds (may cause stridor and dyspnea and depresses the swallowing reflex) • Patients with a history of cardiac or respiratory disease • Highly excited or nervous patients (may produce ataxia, violent reactions, or inadequate response) • Canine prone to gastric dilatation or torsion (may cause abdominal distention) • Animals taking epinephrine
• Patients with history of cardiac disease, respiratory disorders, renal or hepatic disease • Animals in shock, severely debilitated, or stressed due to extreme heat, cold or fatigue • Breeding or pregnant dogs • Highly excited or nervous patients should be calmed before administration and then let sit quietly for 10–15 minutes. • Animals less than 12 weeks old
Toxicity
• • • • •
• • • • • •
Cardiac arrhythmias Hypotension Profound CNS depression Respiratory depression Seizures
• Yohimbine: 0.05 mg/lb IV slowly • Tolazoline: 1–2 mg/lb IV slowly
Bradycardia Hyperglycemia Hypothermia Occasional AV block Respiratory depression Vomiting
• Atipamezole (antisedan): give an equal volume (mL per mL) as medetomidine IM • Dose will be 5× the concentration of medetomidine; ½ the volume may be given IV if 45 minutes has elapsed since administration of medetomidine • May repeat ½ of the IM dose 10–15 minutes after initial.
13
CHAPTER 13 / ANESTHESIA
483
Table 13.19 / Opioids Drug Class
Opioids
Drug (Trade Name)
• • • • • • •
Mode of Action
• Acts on 3 different receptors (μ, κ, and σ) found within the brain. • Each agent affects different receptors or combination of receptors in different ways.
Physical Effects
• • • • • • • • • •
CNS depression or excitement Respiratory depression Gastrointestinal function; nausea, vomiting, hypermotility, and defecation Bradycardia Hypotension Cough suppression, except oxymorphone Miosis in dogs and mydriasis (feline) ↑ Response to noise Excessive salivation Histamine release (morphine)
Uses
• • • •
Preanesthetics Induction agents Analgesia Epidurals
Monitoring
• Respiratory and cardiovascular function • Provide IPPV. • Monitor emetic effects.
Notes
• • • •
Butorphanol (Torbutrol, Torbugesic) Buprenorphine (Buprenex) Fentanyl (Sublimaze) Hydromorphone Meperidine (Demerol) Morphine sulfate Oxymorphone (Numorphan)
Rapid IV administration in canines can cause excitement and histamine release (morphine). Meperidine usually does not cause vomiting and defecation and fentanyl usually does not cause vomiting. Opioids can be combined with local anesthetics to provide spinal analgesia for several hours or in CRI solutions. Store away from light.
13
484
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.20 / Opioids: Butorphanol and Buprenorphine Drug Class
Opioids
Drug (Trade Name)
Butorphanol Tartrate (Torbugesic, Torbutrol) • Pure antagonist at μ receptor and partial agonist at κ receptors
Buprenorphine HCl (Buprenex) • Partial agonist at μ receptors
Dose/Route/Duration
Dose: 0.2–0.4 mg/kg Route: SQ, IM, IV (use lower dose if IV) Duration: Canine: 30–60 minutes Feline: 1–3 hours
Dose: Canine: 0.005–0.02 mg/kg Feline: 0.005–0.03 mg/kg Epidural: 0.03 mg/kg Route: Sublingual, SQ, IM, IV, epidural Duration: (affected by dose) 3–12 hours Delayed onset of 30–60 minutes
Metabolism
• Liver and excreted in the urine
• Liver and excreted in the feces and urine
Precautions
• • • • • • •
Apnea Ataxia and incoordination Excitement, dysphoria Mild bradycardia Mild hypotension Rarely causes anorexia and diarrhea SQ injection absorption can be unpredictable
• Bradycardia • Hypotension • Respiratory depression (caution in patients with cardiopulmonary compromise)
Contraindications
• • • • •
Addison’s disease Geriatric or debilitated animals Hypothyroidism Patients with head trauma or other CNS dysfunction Severe renal and hepatic disease
• • • • •
Toxicity
• • • • •
CNS effects Cardiovascular changes Profound respiratory depression Seizures Diuretic response
• Cardiovascular changes • Profound respiratory depression • ↑ bile duct pressure (caution in cholestasis)
• Naloxone: Canine: 0.04 mg/kg SQ, IM, IV Feline: 0.05–0.1 mg/kg SQ, IM, IV
Addison’s disease Geriatric or debilitated animals Hypothyroidism Patients with head trauma or other CNS dysfunction Severe renal and hepatic disease
• Naloxone: Canine: 0.04 mg/kg SQ, IM, IV Feline: 0.05–0.1 mg/kg SQ, IM, IV
CHAPTER 13 / ANESTHESIA
13
485
Table 13.21 / Opioid Drugs: Fentanyl and Hydromorphone Drug Class
Opioids
Drug (Trade Name)
Fentanyl (Sublimaze) • Pure agonist at μ receptor
Hydromorphone • Pure agonist at μ receptor
Dose/Route/Duration
Dose: Canine: 0.001–0.005 mg/kg IV Feline: 0.001–0.002 mg/kg IV Route: IM, IV (bolus or CRI) Duration: less than 30 minutes (bolus)
Dose: 0.05–0.2 mg/kg Route: SQ, IM, IV (slowly) Duration: 2–4 hours Delayed onset of 15–30 minutes
Metabolism
• Liver and excreted in the urine
• Liver and excreted in the urine
Precautions
• • • • • • • •
Contraindications
Toxicity
• • • • •
↓ GIT motility with resultant constipation Bradycardia Panting Respiratory and CNS depression Vomiting and defecation
• Preexisting respiratory problems • Avoid use in geriatric, very ill, or debilitated animals.
• • • • • •
Addison’s disease Diarrhea caused by a toxic ingestion or GIT obstructions Geriatric or debilitated animals Hypothyroidism Patients with head trauma or other CNS dysfunction Renal and hepatic disease
• • • •
• • • •
Cardiovascular collapse Hypothermia Muscle hypotonia Profound respiratory and CNS depression
↑ Amylase and lipase levels Ataxia Bradycardia Not used in felines commonly Exaggerated response to loud noises Panting Respiratory depression, may persist for several hours Urine retention and constipation
Bradycardia Cardiovascular collapse Profound respiratory and CNS depression Tremors, neck rigidity, and seizures
• Naloxone: Canine: 0.04 mg/kg SQ, IM, IV Feline: 0.05–0.1 mg/kg SQ, IM, IV
13
486
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
• Naloxone: Canine: 0.04 mg/kg SQ, IM, IV Feline: 0.05–0.1 mg/kg SQ, IM, IV
Table 13.22 / Opioid Drugs: Morphine Sulfate and Oxymorphone HCl Drug Class
Opioids
Drug (Trade Name)
Morphine sulfate • Pure agonist at μ receptor
Oxymorphone HCl (Numorphan) • Pure agonist at μ receptor
Dose/Route/Duration
Dose: Canine: 0.5–1.0 mg/kg SQ, IM; 0.2 mg/kg IV Feline: 0.25–0.5 mg/kg SQ, IM Route: SQ, IM, IV (slowly) Duration: 4–6 hours
Dose: Canine: 0.05–0.2 mg/kg IM, IV Feline: 0.025–0.05 mg/kg IM, IV Epidural: 0.05 mg/kg, total volume not to exceed 0.3 mL/kg Route: SQ, IM, IV, epidural Duration: 2–5 hours IV and 8 hours epidural
Metabolism
• Liver and excreted in the urine
• Liver and excreted in the urine
Precautions
• • • • • • • • •
↓ Cough reflex and tidal volume and drying of respiratory secretions ↓ GIT motility/constipation Bradycardia Histamine release with IV administration May cause bladder hypertonia May cause CNS depression, hypothermia, panting, and miosis in dogs May cause stimulatory effects and hyperthermia in cats Respiratory depression Vomiting and defecation after administration
• • • • • • •
↓ Cardiac contractility and GIT motility Ataxia and incoordination in cats with high doses Bradycardia Crosses placenta Excitement, ataxia, and hyperesthesia in cats Panting after initial administration in dogs Respiratory depression
Contraindications
• • • • • • •
Acute uremia due to potential to ↓ urine production Addison’s disease Diarrhea due to toxin ingestion Geriatric or debilitated animals Head traumas or acute abdominal injuries Hypothyroidism Renal and hepatic disease; cholestasis
• • • • • • •
Addison’s disease Diarrhea due to toxin ingestion Geriatric or debilitated animals Head traumas or acute abdominal injuries Hypothyroidism Renal and hepatic disease Respiratory disease or dysfunction
Toxicity
• • • • •
Cardiovascular collapse Hypothermia Muscle hypotonia Profound respiratory and CNS depression CNS excitability and seizures in felines
• • • • •
Cardiovascular collapse Hypothermia Muscle hypotonia Profound respiratory depression Effects may last longer than initial dose of naloxone
• Naloxone: Canine: 0.04 mg/kg SQ, IM, IV Feline: 0.05–0.1 mg/kg SQ, IM, IV
13
• Naloxone: Canine: 0.04 mg/kg SQ, IM, IV Feline: 0.05–0.1 mg/kg SQ, IM, IV
CHAPTER 13 / ANESTHESIA
487
Injectable Induction Anesthetics Table 13.23 / Barbituates Drug Class
Barbituates
Drug (Trade Name)
• • • •
Mode of Action
• Depresses the reticular activating center of the brain, causing a loss of consciousness
Physical Effects
• • • • • • •
↓ GIT motility ↑ Salivary secretions resulting in coughing, hiccuping, sneezing, or laryngospasm. CNS depression Hypotension Poor analgesic and muscle relaxation qualities Predispose to cardiac arrhythmias Respiratory depression, dose and administration related
Uses
• • • •
Sedation Induction agents Sole anesthetic agents Pentobarbital can be used for seizure treatment associated with epilepsy and strychnine poisoning and euthanasia.
Monitoring
• • • •
Body temperature Levels of consciousness Respiratory and cardiovascular signs Seizure control
Notes
• • • • • • •
Premedication with atropine or glycopyrrolate is always recommended with barbiturate administration. Administered to effect; 1/3 given IV over 3–10 seconds, animal observed for 1 minute and then more given if needed The effects of repeated doses are cumulative, except with methohexital. Methohexital is the preferred barbiturate for sight hounds and brachycephalic breeds due to its rapid metabolism. Their effect ends when the drug leaves the brain and is redistributed to the muscle and adipose tissues. Avoid in pregnant animals because it may cause complete inhibition of fetal respiratory movements. All animals should be intubated and oxygen administration provided.
Pentobarbital sodium (Nembutal, Somnotol) Thiopental sodium (Pentothal) Thiamylal sodium (Surital, Bio-tal) Methohexital (Brevital)
13
488
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.24 / Barbiturates: Thiobarbituates and Methylated Barbituates Drug Class
Barbituates
Drug (Trade Name)
Thiobarbituates, ultra-short acting • Thiopental sodium (Pentothal) • Thiamylal sodium (Surital, Bio-tal)
Methylated Barbituates, ultra-short acting • Methohexital (Brevital)
Dose/Route/Duration
Dose: 13–26 mg/kg Thiamylal is slightly more potent than Thiopental Dose based on lean body mass Route: IV Duration: 10–30 minutes
Dose: 5–11 mg/kg Route: IV Duration: 5–10 minutes
Metabolism
• Liver and excreted in the urine
• Liver and excreted in the urine
Precautions
• • • • • •
↓ Doses by 80% in debilitated or sedated animals Air injected into the bottle may give premature precipitation. Anemic patient (may ↓ PCV by 30%) Crosses placenta No muscle relaxation and poor analgesic Perivascular infiltration may cause local necrosis (infuse area with saline to ↓ necrosis and inject with 2% lidocaine to ↓ pain). • Repeated administration is cumulative • Transient apnea, hypotension, and arrhythmias may be seen with rapid induction; esp. in felines.
• • • • • • • •
Apnea and hypotension with rapid induction Crosses placenta No muscle relaxation and poor analgesic Perivascular infiltration may cause local necrosis (infuse area with saline to ↓ necrosis and inject with 2% lidocaine to ↓ pain). Postoperative excitement, a premedication is recommended. Postoperative seizures Recovery may be seen by pronounced involuntary excitement and convulsions Respiratory depression
Contraindications
• Sight hounds • Pregnant animals, almost completely inhibits fetal respiratory movements • Cardiovascular disease, preexisting ventricular arrhythmias, shock, myasthenia gravis, asthma, or ↑ intracranial pressure
• Pregnant animals, almost completely inhibits fetal respiratory movements • Cardiovascular disease, preexisting ventricular arrhythmias, shock, myasthenia gravis, asthma, or ↑ intracranial pressure
Toxicity
• Respiratory and cardiovascular depression • Hypothermia • Hypotension
• Respiratory depression and apnea
13
CHAPTER 13 / ANESTHESIA
489
Table 13.25 / Cyclohexamines Drug Class
Cyclohexamines
Drug (Trade Name)
• Ketamine (Ketaset, Ketalean, Vetalar) • Tiletamine (Telazol)
Mode of Action
• Acts by disruption of the nervous system pathways within the cerebrum and a stimulation of the reticular activating center of the brain • Induce a state of anesthesia and amnesia by over stimulating the CNS or inducing a cataleptic state
Physical Effects
• • • • • • • •
↓ Corneal reflex ↑ Heart rate and blood pressure ↑ Sensitivity to sound, light, and other stimuli, especially with large doses Confusion, agitation, and fear Excessive salivation Hallucinations Normal to ↑ muscle tone and rigidity Respiratory depression at high doses
Uses
• • • • • •
Restraint Unconsciousness Analgesia, somatic pain Inhibits NMDA receptors in CNS (↓ “wind-up” effect) Induction agent Sole anesthetic agent for minor procedures
Monitoring
• • • • •
Body temperature Cardiovascular function Level of anesthesia and analgesia Monitor eyes to prevent drying or injury (lubrication recommended) Respiratory function
Notes
• This agent is a dissociative anesthetic, which produces catalepsy. • Ocular, oral, and swallowing reflexes are only weakened. • The use of a premedication like a tranquilizer, barbiturate, or benzodiazepine is recommended to relieve ↑ muscle tone, ↓ salivation and lacrimation, and produce visceral analgesia. • Its use as an induction agent is enhanced when mixed with diazepam and given IV (esp. in canines).
13
490
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.26 / Cyclohexamines: Ketamine and Tiletamine Drug Class
Cyclohexamines
Drug (Trade Name)
Ketamine (Ketaset, Ketalean, Vetalar, Vetaket)
Tiletamine (Telazol, 1 : 1 combination of zolazepam and tiletamine)
Dose/Route/Duration
Dose: 1 mL/ 20 lb (50/50 mixture with diazepam) IV Feline: 5–10 mg/kg (0.2–0.4 mg/kg midazolam) IM Route: Canine: IV Feline: PO, SQ, IM, IV Duration: 10–30 minutes
Dose: 3–10 mg/kg IM 2–5 mg/kg IV Route: IM, IV Duration: 30 minutes–1 hour
Metabolism
• Liver and excreted in the urine
• Liver and excreted in the urine
Precautions
• Eyes remain open, central and dilated during anesthesia; use an ophthalmic ointment to prevent corneal drying. • May cause personality changes that will spontaneously resolve in a few days or weeks • Pinnal, palpebral, pedal, laryngeal, and pharyngeal reflexes remain when used alone • Produces apneustic breathing; can induce significant respiratory depression at high doses or if given too rapidly IV • Recovery is hyperresponsive with ataxia • Recovery cerebral encephalopathy (rare) • Repeated doses can accumulate in the tissues prolonging recovery and ↑ the chance of convulsions during the recovery period • Respiratory depression • Spastic jerking movements, seizures, muscular tremors, and hypertonicity • Tachycardia, hypertension, hypersalivation, hyperthermia, and nystagmus • Tissue irritation and pain on IM injection
• Animals with renal disease have a prolonged recovery. • Coughing, swallowing, corneal and pedal reflexes remain intact • Eyes remain open, central, and dilated during anesthesia; use an ophthalmic ointment to prevent corneal drying. • Hypertension initially, then hypotension • Hypothermia • Pain on IM injection • Pinnal, palpebral, pedal, laryngeal, and pharyngeal reflexes remain when used alone • Possible muscle rigidity during recovery • Crosses placenta • Prolonged recovery, 1–5 hours • Respiratory depression, producing apneustic breathing or apnea • Spastic jerking movements, seizures, muscular tremors, and hypertonicity • Tachycardia, hypersalivation
Contraindications
• Hyperthyroidism, cardiomyopathy, preexisting cardiac disease, and cardiac arrhythmias • Ingestion of strychnine, metaldehyde, marijuana, and organophosphates • Neurological procedures, (e.g., CSF tap or myelogram) • Eye injury and cranial trauma • Hepatic disease in dogs and renal disease in felines • Epilepsy • Malignant hyperthermia
• Animals with pancreatic disease, severe cardiac disease, and/or pulmonary disease • Cesarean sections
• Profound respiratory depression
• Profound respiratory depression
Toxicity
13
CHAPTER 13 / ANESTHESIA
491
Table 13.27 / Propofol Drug Class
Propofol
Drug (Trade Name)
Propofol (Diprivan, Rapinovet, PropoFlo)
Mode of Action
• Induces depression by enhancing the effects of the inhibitory neurotransmitter GABA and ↓ the brain’s metabolic activity • It is a short-acting hypnotic agent unlike any other anesthetic agent
Physical Effects
• • • • • • •
Uses
• Sedation/short anesthesia (up to 20 minutes) • Induction agent • Animals with preexisting cardiac arrhythmias, mild or moderate cardiac disease, liver or kidney disease
Monitoring
• • • •
Notes
• Protect from light, shake well, and use within 24 hours to prevent iatrogenic sepsis. • Little to no analgesic properties • Short duration due to rapid redistribution from CNS to peripheral tissue
↑ Appetite ↓ Intraocular pressure Antiemetic properties Bradycardia (esp. with opiate preanesthetics) Hyperkinesis during induction (e.g., paddling, myoclonic twitching) Hypotension Respiratory depression and apnea
Level of anesthesia CNS effects Respiratory depression Cardiovascular status
Table 13.28 / Propofol (continued)
13
Drug Class
Propofol
Drug (Trade Name)
Propofol (Diprivan, Rapinovet, PropoFlo)
Dose/Route/Duration
Dose: Induction: 1–6 mg/kg depending on sedation (Give 25% of dose every 30 seconds until intubation possible) Maintenance: 0.6 mg/kg/min Route: IV slowly Duration: 2–5 minutes for each single bolus
Metabolism
• Liver and excreted in the urine
492
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 13.28 / Propofol (continued) (Continued) Drug Class
Propofol
Precautions
• • • • • • • • • •
↑ Appetite ↓ Intraocular pressure Antiemetic properties Bradycardia Crosses placenta Epilepsy Heinz body production in felines Hypotension Minimal analgesic action Respiratory depression and initial apnea
Contraindications
• • • •
Systemic infections Hypoproteinemia Use with caution in animals experiencing shock or stress or that have undergone trauma. ↓ dose by 25% when premedicating with acepromazine or opiates due to exacerbation of bradycardia and hypotension
Toxicity
• Respiratory depression • Cardiovascular depression
Table 13.29 / Etomidate Drug Class
Etomidate
Drug (Trade Name)
Etomidate (Hypnomidate, Radenarcon, Sibul)
Mode of Action
• Not well understood • Causes minimal hemodynamic changes along with minimal effects on the cardiovascular and respiratory systems • ↓ Cerebral blood flow and oxygen consumption, intraocular pressure, and intracranial pressure
Physical Effects
• • • • •
Uses
• Cardiac dysfunction (e.g., dilated cardiomyopathy) • Critically ill patients
Monitoring
• Level of consciousness • Respiration rate and rhythm • Cardiovascular function
Notes
• Protect from light. • Premedication is highly recommended due to side effects. • Give injection in the fluid line to ↓ injection site pain.
Excitement or myoclonus during induction or recovery Eye movements Postoperative retching/vomiting Suppresses adrenocorticol function for 3 hours after administration Hemolysis due to propylene glycol
13
CHAPTER 13 / ANESTHESIA
493
Table 13.30 / Etomidate (continued) Drug Class
Etomidate
Drug (Trade Name)
Etomidate (Hypnomidate, Radenarcon, Sibul)
Dose/Route/Duration
Dose: Canine:0.5–2 mg/kg rapidly IV or 1 mg/kg and diazepam 0.5 mg/kg IV Feline: 0.5–2 mg/kg Route: IV Duration: 3–5 minutes
Metabolism
• Liver and excreted in the urine, bile, and feces
Precautions
• • • • • • • •
Contraindications
• Animals with compromised adrenocorticol function • Pregnant or nursing animals • Epilepsy
↓ Cerebral blood flow and oxygen consumption ↓ Intraocular and intracranial pressure Excitement or myoclonus during induction or recovery Eye movements Hypoproteinemia Postoperative retching/vomiting Suppresses adrenocorticol function for 3 hours after administration When utilizing the propylene glycol preparation, give slowly IV or give with IV fluids to minimize pain on injection and to minimize hemolysis due to the propylene glycol.
Table 13.31 / Inhalant Anesthetics Drug Class
Inhalants
Drug (Trade Name)
• Isoflurane (AErrane, Isoflo, Florane) • Halothane (Fluothane) • Sevofluranee (Sevoflo, Ultane)
Mode of Action
• True mode of action is unknown, the following are 2 possibilities: • Inhibits the breakdown of GABA, an inhibitory neurotransmitter • Causes the membrane to lose its ability to conduct nerve impulses by dissolving in the nerve cell membrane
Physical Effects
• Muscle relaxation
Uses
• General anesthesia
Monitoring
• • • •
Notes
• Store isoflurane and halothane in a tight, light-resistant container.
13
494
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Level of anesthesia Respiratory and ventilatory status Cardiac rate and rhythm Blood pressure
Table 13.32 / Inhalant Anesthetics: Halothane and Isoflurane Drug Class Drug (Trade Name)
Inhalants Halothane (Fluothane)
Isoflurane (AErrane, IsoFlo, Florane)
Attributes
• Produces muscle relaxation and slight analgesia • Fairly rapid induction and recovery • Mask induction takes approximately 10 minutes in a tranquilized animal. • Recovery takes less than 1 hour to achieve sternal recumbency.
• Extremely rapid induction and recovery • Mask and chamber induction • Used for animals with cardiac disease, liver and kidney disease, and neonatal and geriatric animals • Excellent muscle relaxation
Dose
Induction: 3% Maintenance: 0.5–1.5%
Induction: 5% Maintenance: 0.5–2.5%
Metabolism
• Mostly eliminated by the lungs • 12–40% is metabolized by the liver and metabolites are excreted by the kidneys
• 99% eliminated unchanged by the alveoli • 0.17% metabolized by the liver
Precautions
• • • • • • • •
↓ Cardiac output, intestinal tract motility, tone, and peristaltic activity ↑ Cerebral blood flow, vasodilation Hypothermia and hypotension Abdominal muscles are only relaxed at deeper levels of anesthesia. Bradycardia and arrhythmias Hepatotoxicity Malignant hyperthermia Pupils may be constricted at all stages of anesthesia with shallow and rapid respiration. • Respiratory and CNS depression • Sensitizes the heart to catecholamines to give possible arrhythmias (VPCs)
• • • • • • •
Contraindications
• History of malignant hyperthermia or hepatic impairment after previous halothane exposure • Hypovolemic or hypotensive animals • Cardiac arrhythmias (preexisting) • Use with caution in animals with ↑ CSF, head injury, or myasthenia gravis.
• History of malignant hyperthermia • Use with caution in animals with ↑ CSF, head injury, or myasthenia gravis.
↑ Cerebral blood flow ↓ Smooth muscle tone and motility Arrhythmias (VPCs) Crosses placenta GIT effects (e.g., nausea, vomiting, and ileus) Hypothermia Progressive vasodilation and hypotension occurs with deeper levels of anesthesia. • Rapid recovery and no analgesia postoperatively can lead to pain and excitement (e.g., emergence delirium). • Respiratory and CNS depression • Slight ↓ in cardiac output
13
CHAPTER 13 / ANESTHESIA
495
Table 13.33 / Inhalant Anesthetics: Sevoflurane Drug Class Drug (Trade Name)
Inhalants Sevoflurane (Sevoflo, Ultane)
Attributes
• • • •
Dose
Induction: 5–7% Maintenance: 3.3%–4%
Metabolism
• Rapid elimination through the lungs • 3% metabolized by the liver
Precautions
• • • • • • • • • • • •
Contraindications
• History of malignant hyperthermia • ↑ CSF and head injury • Renal compromise/insufficiency
13
496
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Extremely rapid induction and recovery Mask and chamber induction Produces muscle relaxation and analgesia Nonpungent odor
↑ Cerebral blood flow ↑ Concentration may cause rapid hemodynamic changes (e.g., hypotension) Bradycardia Crosses placenta GIT effects (e.g., nausea, vomiting, and ileus) Hypotension, bradycardia, shivering and nausea Hypothermia Myocardial depression Not stable in moist soda lime and may release carbon monoxide Respiratory and CNS depression The safety of this agent has not been evaluated in geriatric, debilitated, breeding, or neonate animals. Vasodilation
Chapter
14
Dentistry Dentistry 499 Anatomy 499 Figure 14.1: Dentition: Canine and Feline 499 Figure 14.2: Cross Section of a Triple-Rooted Tooth 500 Figure 14.3: Skeletal Structure: Canine and Feline 500 Figure 14.4: Cross Section of Facial Structures: Canine and Feline 501 Dental Instruments and Equipment 501 Hand-held Instruments 501 Figure 14.5: Hand-held Non-mechanical Dental Instruments 502 Instrument Maintenance 502 Sharpening Technique 503 Mechanical Instruments 503 Dental Prophylaxis 504 Dental Cleaning Procedure 504
Dental Charting 506 Figure 14.6: Sample of Patient’s Dental Health Chart Common Dental Disorders 510 Anatomical Disorders 510 Pathologic Disorders 511 Dental Radiology 512 Equipment 512 Technique Chart 512 Radiographic Film 513 Radiographic Techniques 513 Radiographic Positioning 514 Extractions 517 General Extraction Procedures 517 Local Dental Nerve Blocks 518
509
14
497
Key Words and Termsa Alveolar Alveolitis Apically Brachygnathism Buccal Calculus Carnassial Cementum Crown Deciduous Dentin Enamel Endotoxins Epulides Extraorally Fluoride Frenulum Furcation Germination Gingiva Glycoproteins Incisal Infraorbital Interdental
a
Intraorally Ipsilateral Lingually Mesially Mucoperiosteum Occlusal Odontoclast Oligodontia Oronasal Palatine Periodontal Planing Plaque Polydontia Prognathism Pulp cavity Stomatitis Subgingivally Sulcus Supernumerary Supragingivally
Key words and terms are defined in the glossary on page 631.
14
498
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Abbreviations
Additional Resources, page
AL, attachment loss CI, calculus index CLE, cervical line erosion CLL, cervical line lesion CNL, cervical neck lesion CTD, cumulative trauma disorders ECG, electrocardiogram EOR, external odontoclastic resorption FE, furcation exposure FxC, fracture closed FxO, fracture open GI, gingival index kg, kilogram kVp, kilovoltage peak L, lesion M, mobility mA-s, milliamperage per second mg, milligram mm, millimeters NV, nonvital ORL, odontoclastic resorbtion lesion P, pocketing PD, probe depth PDI, periodontal disease index PI, plaque index RPC, root plane closed RPO, root plane open Rtr, retained roots V, vital W, worn X, simple extraction (1 root) XS, sectioned extraction (2 or 3 roots) XSS, surgical extraction (gingival retraction)
Anatomy, 3 Anesthesia monitoring, 458 Anesthesia, 439 Blood pressure, 332 Catheter placement, 349 Directional terms, 168 Fluid therapy, 359 Heat administration, 346 Home dental care, 52 Pain management, 379 Patient monitoring, 332 Physical examination, 18 Postanesthetic monitoring, 467 Suture patterns, 548 Vital signs, 19
DENTISTRY Veterinary dental care continues to be an area of neglect as the majority of owners still do not provide essential dental care to their animals. The American Veterinary Dental Society reports that 80% of canines and 70% of felines show signs of oral disease by age 3. As animals are living longer and eating diets that do not challenge plaque formation, the client’s intervention is crucial to maintaining oral health. Along with home dental care, veterinary intervention is often necessary to address existing disease; therefore, an ongoing relationship must exist between the client and the veterinarian to provide optimum oral health. Oral or periodontal disease is the progressive process of inflammation (bacterial infection) of the structures surrounding the tooth. The process begins by the formation of a soft film called plaque on the tooth, which is composed of salivary glycoproteins, bacteria, food particles, WBCs, and sloughed epithelial cells. The accumulated plaque begins to disrupt the tooth structure through the release of bacterial endotoxins and harmful WBC byproducts. Plaque then calcifies with minerals in the saliva to form a hard, thick substance known as tartar or calculus. The continuous formation of tartar can harbor bacteria, which invade below the gumline, causing gingivitis and affecting the integrity of the tooth structure. In the final stages of periodontal disease, the tooth becomes loose due to destruction of the soft tissues surrounding the tooth and erosion of the bony socket. This process not only affects the tooth itself but plays a large role in overall animal health by allowing the accumulated bacteria to enter the bloodstream, affecting all other body systems (e.g., heart, lungs, kidneys). Client education is the key to gaining acceptance to veterinary dentistry. The combination of preventative and therapeutic dental care will positively impact the quantity and quality of life for our veterinary patients.
ANATOMY
Anatomy of the mouth
8
Feline
6
1 – Arytenoid cartilage 2 – Epiglottis 3 – Frenulum (under tongue) 4 – Hard palate 5 – Mandible 6 – Maxilla 7 – Soft palate 8 – Incisors
4 7 1 2
3
5
Deciduous teeth = 26 Permanent teeth = 30 Dental formula: 1 3 2 x (I 3 C 1 P 2 M 3
1 1
)
8
Canine
4
6
7 1
2
3 5
Deciduous teeth = 28 Permanent teeth = 42 Dental formula: 2 x (I 3 C 1 P 4 M 3
1
4
2 3
14 )
Figure 14.1 Dentition: canine and feline. CHAPTER 14 / DENTISTRY
499
Feline Crown Enamel Maxilla
Dentin Pulp chamber
Pre-maxilla
Gingival sulcus Gingiva Mandible
Furcation Maxilla
Canine
Infraorbital foramen Incisivomaxillary canal Alveolar bone
Apex
Apical delta (nutrient supplier)
Figure 14.2 Cross section of a triple-rooted tooth.
Mandible Mandibular canal
Figure 14.3 Skeletal structure: canine and feline.
14
500
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Feline
DENTAL INSTRUMENTS AND EQUIPMENT
Frontal sinus
Table 14.1 / Hand-held Instruments
Nasal conchae Posterior nares
Premaxilla Palatine process of maxilla
Sphenoid sinus Palatine bone Soft palate Hard palate
Canine Frontal sinus Sphenoid sinus
Posterior nares
Nasal conchae
Palatine bone
4th premolar
Instrument
Usage
Curette scalers
• Used beneath the gingiva to remove calculus and to root plane
Dental claw
• Used to remove large amount of calculus supragingivally
Dental elevators
• Used to displace the tooth from its support structures
Dental extraction forceps
• Used to remove tooth from its socket and to clean heavy calculus off teeth
Dental hoe
• Used to remove large amounts of calculus supragingivally
Explorer
• Used to examine the tooth’s surface subgingivally and check tooth mobility
Periodontal probe
• Used to measure the depth of the gingival sulcus in millimeters
Periosteal elevators
• Used to reflect and retract mucoperiosteum
Scaler
• Used on the exposed tooth to remove calculus above the gingiva (not to be used subgingivally)
Soft palate Premaxilla Hard palate
Figure 14.4 Cross section of facial structures: canine and feline.
14
CHAPTER 14 / DENTISTRY
501
Figure 14.5 Hand-held nonmechanical dental instruments.
Table 14.2 / Instrument Maintenance
14
Sharpening Stones
Type/Lubricant Required
Usage
India
• Fine/medium—oil lubricant
• To sharpen extremely dull instruments
Arkansas
• Fine—oil lubricant
• To finish sharpening after a medium coarse stone was used
Ceramic
• Fine/medium—water lubricant or dry
• Same as other 2, but uses water as its lubricant
Conical
• A round Arkansas stone—oil lubricant
• To sharpen curved instruments; can shorten the life of an instrument because it damages the face of the instrument
Tip: Hand-held instruments need to be sharpened on a regular basis with a stone and oilstone oil.
502
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Skill Box 14.1 / Sharpening Technique Flat Stone 1. Place small amount of oil onto the stone and wipe to cover the stone face. 2. Place stone on a flat surface parallel to the floor. 3. Place instrument to be sharpened on the oiled stone with the tip facing the operator and the face of the instrument on the surface of the stone. a. Care should be taken not to damage the surface of the instrument.
Table 14.3 / Mechanical Instruments
Decision on dental equipment should be a clinic-directed process, reviewing many of the types of equipment available, with assessment of who will be using it and what procedures will be performed. Manufacturer’s care and maintenance instructions should be made a part of the clinic’s routine. Equipment: Scalers Ultrasonic: • Converts energy to sound waves, which result in a mechanical vibration of the handpiece. When water passes over the tip, a scouring property known as cavitation is produced. Follow manufacturer’s maintenance guidelines.
4. Move the instrument up and down on the stone, ending with a down stroke. 5. Check for sharpness by visual inspection or by using a plexiglass rod. a. Dull edges look rounded and reflect light b. Sharp edges give off no light reflection. 6. Disinfect instrument after sharpening.
• Magnetostrictive
• Tip vibrates in an elliptical motion; has a working tip on all sides; uses metal stacks
• Piezoelectric
• Tip vibrates in a linear motion; only 1 side of the tip is used against the tooth; uses crystals in handpieces
Sonic:
• Converts air to mechanical vibration. Follow manufacturer’s maintenance guidelines.
Polishers/drilling units
• Two types are available: electric or air driven. Various heads are available. Follow manufacturer’s maintenance guidelines.
Conical Stone 1. Place instrument in hand with tip pointing outward, wrapped around the oiled conical stone. 2. As you rotate the stone slide the stone toward the tip of the instrument. • In either technique, safety glasses are recommended for safety.
Description
14
CHAPTER 14 / DENTISTRY
503
DENTAL PROPHYLAXIS Skill Box 14.2 / Dental Cleaning Procedure
14
Step
Method
Comments
1. Setup Technician: • Face shield or glasses, gloves, surgical mask, smock for dental use only, and surgical cap • Dental equipment and supplies • Adjustable stool
Not applicable
• Proper setup reduces risk of cumulative trauma disorders (CTDs) to technicians. CTDs include carpal tunnel syndrome and any trauma caused by repetitive motions.
Patient: • Appropriate measures to maintain patient’s temperature and towels to cushion patient on grate • Appropriate monitoring equipment • IV catheter/fluids if necessary • Pain management protocol • Anesthesia protocol • Appropriate-size mouth gag • Gauze sponges in back of throat to absorb excess water and debris • Head positioned downward to permit proper drainage
Additional Resources: • Heat administration (see Skill Box 8.6, page 346.) • IV catheter placement (see Skill Box 8.9, page 349.) • Fluid therapy (see Chapter 8, page 359.) • Pain management (see Chapter 9, page 392.) • Anesthetic administration (see Table 13.3, page 451.) • Anesthesia monitoring (see Table 13.7, page 460.)
• Heating pad with proper cover to ↓ chance of burning, warmed towels, warmed fluid bags, or Bair hugger blanket • Doppler or other blood pressure device, pulse oximetry, electrocardiogram (ECG), and/or apnea monitor
2. Oral Examination • Perform a thorough examination of the patient’s mouth, charting all abnormal conditions. The veterinarian should be consulted on any abnormality noted.
• External examination: check for symmetry of the animal’s head and face, halitosis, nasal or ocular discharge or swelling, problems with occlusion, anomalies of lips, mouth, or tongue • Internal examination: chart degree of plaque/calculus, missing teeth and any abnormalities that can be visualized at this time; check lips, oral tissues, and tongue for any abnormalities. • Document mouth condition and, if available, take a “pre” and “post” digital photograph. • Radiograph suspect areas. • If extractions are identified, administer appropriate nerve blocks. (See Skill Box 14.3 Local Dental Nerve Blocks, page 518.)
• Be gentle with any manipulation of the tongue so as not to injure the nerve supply or muscle attachments. • Follow a systematic approach to ensure all teeth are checked, cleaned, and charted. • See Table 14.4 Dental Cleaning, page 504, and 14.9 Radiographic Techniques, page 513.
3. Brush Teeth
• Brush with chlorhexidine toothpaste and irrigate with 0.1–0.2% chlorhexidine solution.
• To get rid of excess bacteria before cleaning
4. Remove Gross Calculus
• Use forceps (calculus or extraction) to remove large accumulations of calculus. Using a modified pen grasp, place the scaler at a 45–90° angle on the tooth such that the tip conforms to the curve of the tooth and the cutting edge of the scaler is beneath the calculus. Use a pull stroke away from the gumline. • This stroke should use the shoulder muscles and not the wrist. • This is to only be used supragingivally.
• To ↓ the overuse of the ultrasonic scaler • Ultrasonic scalers can be used to complete the removal of any remaining calculus.
504
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Skill Box 14.2 / Dental Cleaning Procedure (Continued) Step
Method
Comments
5. Ultrasonic Cleaning
• Using the same grasp as on a scaler, use light brush stroke touches on the tooth. Keep the tip moving to prevent overheating of the tooth and remain no longer than 10–15 seconds on any tooth. • Use only on those teeth with plaque/calculus.
• Cleaning teeth absent of any plaque/ calculus is not recommended because of the damaging effects on the cementum.
6. Subgingival Cleaning and Root Planing
• Preliminary removal of subgingival calculus can be achieved with perioshaped rotosonic, sonic, or subsonic scalers. Use hand curettes at a 45–90° angle with a sharp, firm, pulling stroke. Check removal effectiveness with an explorer. • Root plane, using a curette, on teeth with pocketing of 4–6 mm. Use 10–20 short overlapping strokes (horizontal, vertical and oblique) to achieve a glassy smooth surface. This can be accomplished without surgery in some cases (pocketing of 4–5 mm) and is noted as root plane closed (RPC); in other cases (pocketing of 5–6 mm), the root will need to be exposed by cutting a flap in the gingiva, which is considered surgery and charted as a root plane open (RPO).
• • • •
7. Air Dry Teeth or Use a Plaque Disclosing Solution
• Direct a stream of compressed air to each tooth to inspect for remaining plaque.
• To double check for plaque. • Plaque will show up as white specks.
8. Polish Teeth
• Using plenty of medium to fine paste with a light touch (enough to make the cup flare) and a setting in accordance with the manufacturer’s guidelines, place the prophylaxis cup on the tooth at the gumline and move smoothly downward. Do not let the prophylaxis cup remain on the tooth longer than 5 seconds. • If a coarse paste must be used, be sure to finish with a fine paste.
• A smooth surface deters plaque accumulation. • Polish all surface of the teeth.
9. Irrigation
• Use 0.1–0.2% chlorhexidine solution and flush each tooth.
• Irrigation solution: 15 mL chlorhexidine to 1 gallon of distilled water
10. Tooth Evaluation
• Measure and chart the gingival sulcus for each tooth, tooth mobility, and general gingival health • If extractions are identified, administer appropriate nerve blocks. (See Skill Box 14.3 Local Dental Nerve Blocks, page 518.)
• See Table 14.4 Dental Cleaning, page 506.
11. Adjust Patient to Other Side and Repeat Steps 3–10
• Disconnect endotracheal tube. Turn patient over with legs facing down (do not flip patient over on the back), reconnect the endotracheal tube, and start the dental routine.
12. Extractions
• Check with your state’s policy on technicians performing extractions. • Proper training is extremely important. • See Table 14.11 General Extraction Procedures, page 517.
Used when pocket depths are: Canine: 3–5 mm Feline: 2–4 mm Cementum is beneficial to the reattachment process, and therefore care must be given to not be too aggressive in these techniques.
14 • Extractions are recommended following Step 9, to ensure the least amount of bacteria present.
CHAPTER 14 / DENTISTRY
505
Skill Box 14.2 / Dental Cleaning Procedure (Continued) Step
Method
Comments
13. Fluoride Treatment
• Application of fluoride on the patient’s teeth is being questioned by the veterinary community. If used, apply 1.23% acidulated phosphate fluoride gel to dried teeth and let sit for 4 minutes. Depending on the manufacturer’s guidelines, rinse or wipe thoroughly with absorbent gauze.
• ↓ Tooth sensitivity and rate of plaque formation • Believed to be beneficial on cervical line lesions in cats
14. Barrier Sealant Application
• Apply a barrier sealant to each tooth following the manufacturer’s guidelines.
• Protects from bacterial adherence
15. Clean Up Animal and Continue With Anesthesia Recovery
• Inspect the animal’s mouth for blood and debris or gauze and remove if found. Dry off the animal’s head with a towel or hairdryer.
• Each clinic should set up and follow a cleaning routine for the dental area and equipment.
16. Home care instructions
• Depending on what the dental prophylaxis revealed and the veterinarian’s diagnosis, the owner should be appropriately advised of home care to include next recheck, daily brushing, and food recommendations.
• See Skill Box 2.9 Home Dental Care, page 52.
Table 14.4 / Dental Charting
Below are some of the generally used charting symbols. Your clinic may have adapted their own. There are currently 2 numbering systems used when charting an animal’s teeth: anatomical and triadan systems. Each clinic will have to decide which system best serves their dental services. Area of Concern
Method
Charting Symbol
Description
Plaque/Calculus
• Visual examination
Plaque Index (PI)
PI0 PI1 PI2 PI3
• • • •
Calculus Index (CI)
CI1 CI2 CI3
• Calculus covers 1/2 the crown. • Calculus covers 3/4 of the crown. • Calculus covers all the crown and is found subgingivally.
GI0 GI1
• Normal: gum tissue is shrimp color; sharp gingival margins • Marginal gingivitis: mild inflammation, slight color change, mild alteration of gingival surface, halitosis
14 Gingival Health/Periodontal Disease
• Visual examination and periodontal probe
Gingival Index (GI)
506
No plaque Thin film at gingival margin Moderate amount at gingival margin Heavy accumulation with overlapping into interdental space
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 14.4 / Dental Charting (Continued) Area of Concern
Method
Periodontal Disease Index (PDI)
Charting Symbol
Description
GI2/PDI1 GI3/PDI2 PDI3 PDI4
• Moderate gingivitis: moderate inflammation, tissue is ruby red, plaque and bleeding • Severe gingivitis/early periodontitis: severe inflammation, tissue has red and purple margins, pockets are forming, bleeding and ulceration; <25% alveolar loss • Moderate periodontitis: severe inflammation and edema with deep pus forming pockets, slight tooth mobility and early bone loss around alveolar socket; 25– 50% alveolar loss • Severe periodontitis: tooth mobility and loss of teeth, pus, >50% bone loss and presence of anaerobic gram-negative rods • Normal: 1–4 mm (canine) and 0.5–1 mm (feline) • ↑ Pocketing depths generally require more than a standard prophylaxis and the veterinarian should be consulted.
Gingival Sulcus Pocketing Probe Depth (P, PD)
• Periodontal probe placed in gingival sulcus and walked around the tooth
P or PD + the mm depth (e.g., P2)
Gingival Hyperplasia
• Periodontal probe
+ with the mm of tissue above the gingival line (e.g., +2)
Gingival Recession
• Periodontal probe placed on the free gingival margin
Drawn line on tooth to reflect recession
Lesions (L)
• Periodontal probe
Circled on the chart L1 L2 L3 L4 L5
• • • • •
• If complete attachment is gone, chart as complete attachment loss (AL).
Stage Stage Stage Stage Stage
1: 2: 3: 4: 5:
enamel only affected; pits/fissures on occlusal surfaces enamel and dentin affected; PM and M proximal surface exposed pulp; I&C proximal surface included includes root fracture; I &C incisal surface included unstable tooth
Tooth Mobility
• Periodontal probe • Radiograph
M1 M2 M3
• Slight mobility • Moderate mobility: 1 mm of movement • Marked mobility: >1 mm of movement
Furcation Exposure
• Visual examination • Periodontal probe • Radiograph
FE1 FE2 FE3
• Minimal detection of an entrance • Probe enters furcation, but does not extend through • Probe passes through the furcation
Malpositioned Teeth
• Visual examination • Radiograph
Curved arrow to signify how tooth is positioned.
• Visual examination
Circled on chart
Missing Teeth
14 • Radiograph to see if tooth and/or root exists
CHAPTER 14 / DENTISTRY
507
Table 14.4 / Dental Charting (Continued) Area of Concern
Method
Charting Symbol
Description
Odontoclastic Resorption Lesions (Osteoclastic Resorptive Lesions, Neck Lesions, or Cervical Line Lesions)
• Visual examination • Periodontal probe • Radiograph
ORL or CLE
Graded I–V • I: Enamel only affected; edges can be felt with an explorer, but generally not seen • II: Enamel and dentin affected; lesion seen and felt • III: Pulp penetration • IV: Tooth unstable • V: Crown is gone, root(s) remaining
Retained roots
• Visual examination • Periodontal probe • Radiograph
Rtr
• Tooth crown is missing, but roots are still present
RPC RPO
• Closed root planing • Open root planning
Root Planing Slab Fractures/Fractures
• Visual examination
FxC FxO + “V” or “NV”
• Closed fracture; only through the enamel • Open fracture; damage extends into the pulp cavity/canal • V: vital tooth, pulp chamber bleeds • If awake, animal flinches when tooth is touched • If anesthetized, lower jaw chatters • NV: nonvital tooth, dark pulp chamber
Supernumerary Teeth
• Radiograph
Draw tooth
• Mark on chart where the extra teeth are located and radiograph to see if there are any unerupted teeth.
Worn Tooth
• Visual examination
W
• Brown in the center with no access to the pulp cavity by an explorer
Extractions
• Visual examination
X XS XSS
• Simple extraction (1 root) • Sectioned extraction (2 or 3 roots) • Surgical extraction (requires gingival retraction)
14
508
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Figure 14.6 Sample of a patient’s dental health chart (Triadan Numbering System). Courtesy of DentaLabels (Dentalabs, 19 Norwood Avenue, Kensington, CA 94707; 510-524-6162/800-662-7920).
14
CHAPTER 14 / DENTISTRY
509
COMMON DENTAL DISORDERS While it is the veterinarian’s responsibility to diagnose the following problems, the technician can assist the veterinarian by being aware of the following conditions and their presentation.
Table 14.5 / Anatomical Disorders Disorders
Description
Comments
Anterior Crossbite
• Maxilla is shorter than mandible. • Upper incisors are caudal to the lower incisors.
• Inappropriate wear on teeth
Base Narrow Lower Canine Teeth
• Permanent canine teeth are lingually or mesially displaced.
• Soft or hard tissue damage and possibly formation of oronasal fistula
Brachygnathism
• Maxilla is longer than mandible. • Overshot jaw (parrot mouth)
• Overcrowded mandibular teeth; ↑ chance of periodontal disease
Dental Interlock
• Abnormal eruption of deciduous teeth
• Prevents forward growth of mandible
Fusion
• 2 tooth buds grow together
Gemination
• 1 root with 2 crowns
• Plaque accumulation and periodontal disease
Impacted Upper Canine Teeth
• Teeth are not able to erupt.
• Formation of unapparent oronasal fistula • Common in Miniature Poodle and Shetland Sheepdog
Level Bite
• End-to-end bite of the incisors
Oligodontia
• Less teeth than considered normal
• Cosmetic/show canines • Typically incisors or premolars
Polydontia (Supernumerary)
• More teeth than considered normal
• ↑ Chance of periodontal disease
Posterior Crossbite
• Mandible is wider than maxilla at the premolars.
• Heavy amounts of calculus can develop on the buccal surface of the lower premolars and molars • ↑ Home care is a necessity. • Common in Boxer and long-nosed breeds
Prognathism
• Mandible is longer than maxilla. • Undershot jaw • Associated with anterior crossbite
• Inappropriate wear on teeth and overcrowded or rotated teeth; ↑ chance of periodontal disease • Normal in brachycephalic breeds
Retained Deciduous
• Permanent teeth erupt lingually to deciduous (except upper canines)
• Can cause malocclusion • Periodontal disease • Common in toy breeds and felines
Wry Mouth
• One quadrant develops unevenly from other quadrants.
14
510
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 14.6 / Pathologic Disorders Disorders
Description
Comments
Caries
• Odontoclastic resorption lesions are often mistaken as caries (rare).
• Upper 1st and 2nd molars and lower 1st molar most commonly affected
Contact Ulcers
• Ulcer caused by continual contact of mucosa and teeth
• Requires consistent home care
Enamel Hypoplasia
• Sections of enamel are reduced or missing, typically caused by the animal having had distemper, high fevers, nutritional deficiency, or heavy parasitism as a puppy.
• Client education is needed typically including a brushing and stannous fluoride routine.
Eosinophilic Ulcers
• “Rodent ulcer” is a slowly growing cancer that destroys soft tissues and bones on the lips of felines. Round, well-defined, reddish brown lesions. Occasionally found on tongue and hard palate
• Usually benign
Fractures
• Typically involves the canines, upper 4th premolars and incisors, but can occur with any tooth.
• Chronic exposure to infection • Infraorbital swelling
Gingival Hyperplasia
• Thickening of gingiva due to chronic inflammation; overgrowth of gingival tissue
Inapparent Oronasal Fistula
• Abscess of maxillary canine tooth • Clinical signs: nasal discharge with possible presence of swelling over the root. • A periodontal probe will extend from the palatal aspect of the maxillary canine to the nasal cavity.
• Infection
Nasopharyngeal Polyps
• Polyp attached to a long, thin stalk found in cats.
• Can cause respiratory distress or interfere with swallowing
Odontoclastic Resorption Lesions (ORLs)
• Decay of enamel at the neck of the tooth • Also known as osteoclastic resorptive lesion (ORL), external odontoclastic resorption (EOR), cervical line lesion (CLL), cervical neck lesion (CNL)
• Painful to animal. Radiographs should be taken prior to restoration. • Typically graded I–V
Parulis (Gumboil)
• An inflamed circular area below the mucogingival line
• Caused by the drainage of a fistula
Periodontal disease
• Caused by a lack of daily dental care, which results in excess bacteria in the mouth and causes plaque accumulation, which results in calculus formation
• Can result in the loss of teeth and changes in the animal’s overall systemic health
Stomatitis, Foreign Body, Chemical, Thermal, or Immune Related
• An inflammation of the soft tissue of the oral cavity
• Infection
Tetracycline Staining
• Stains on teeth of young dogs caused by administration of tetracycline to a pregnant dog or young pups
• Cosmetic only
Tumors, Benign Epulides
• Tumor that involves the periodontal ligament and can be bone invasive • Fibromatous: generally smooth, pink, and originating from gingival sulcus, rarely displaces teeth • Ossifying: gingiva covers new bone growth
• Biopsy
14
CHAPTER 14 / DENTISTRY
511
Table 14.6 / Pathologic Disorders (Continued) Disorders
Description
Comments
Malignant Melanoma
• Canine: orally a very aggressive tumor, 2/3 pigmented, ulcerated
• Metastases common • Most common malignant tumor in canines (rare in felines)
Squamous Cell Carcinoma
• Canine: locally invasive; metastases are rare. Typically red, irregularly surfaced, friable, and very vascular • Feline: locally invasive, rapid growing cancer; metastases are rare.
• 2nd most common malignant tumor in canines and also common in felines
Malignant Fibrosarcoma
• Canine: firm, flat, ulcerated, locally invasive • Feline: firm
• Metastases uncommon • 3rd most common malignant tumor in canines. • Typically occurs under the tongue in felines (rare).
Tumors, Malignant
Equipment
DENTAL RADIOLOGY Radiology is an analysis tool used by the veterinarian in the evaluation of the health of an animal’s mouth. Radiographs assist in the evaluation of complete removal of all root remnants after extraction, identifying unerupted and/or impacted teeth, the status of periodontal disease, and/or the progress of a therapeutic program. Radiographs also assist in the diagnosis of fistulas, cysts, tumors, and neoplasms. See Chapter, 5 Imaging, page 157, for an indepth discussion on radiology.
Clinics should invest in a dental x-ray machine if they plan to provide thorough dental diagnostic and therapy to their clients. The clinic’s medical x-ray machine can be used, but the radiograph will not be as diagnostic, and its use is usually more time consuming. Other accessories useful in the taking of dental radiographs are foam wedges, sandbags, syringe cases (1 and 3 mL protective syringe cases cut to various lengths, radiolucent mouth gags), and appropriate safety apparel. Each clinic should assess their particular needs and research the variety of equipment available.
Table 14.7 / Technique Chart
A technique chart will need to be designed for each radiograph unit; however the following chart will provide the initial starting points.
14
Machine Type
Animal Size
mAs
Focal Distance
Time
Digital X-ray
• Preset timer selections based on tooth and species
Dental X-ray
Small canines and felines
40–50 kVp
8–10 mA-s
10–12 inches
1
Medium canines
50–65 kVp
10 mA-s
10–12 inches
1
Large canines
65–75 kVp
10 mA-s
10–12 inches
1
60–64 kVp
100 mA-s
10–12 inches
1
Veterinary X-ray
512
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
kVp
/10–2/10 second /10–2/10 second /10–2/10 second /15–2/10 second
Table 14.8 / Radiographic Film
Stippled side always faces the x-ray beam. Place the raised dot corner with the same orientation. Type of Film
Usage
Sizes (inches)
Periapical
• Small canines and felines
• 0: 7/8 × 13/8 • 1: 15/16 × 19/16 • 2: 11/4 × 15/8
Occlusal
• Medium and large canines • Intraorally or extraorally to show location of cystic lesions, impacted teeth, salivary duct stones, and bone fractures
• 4: 21/4 × 3
Tip: Film developing: • Follow the manufacturer’s guidelines. • Fixer time is typically twice the developing time. • Room temperature will affect the developing time. • Agitation of chemicals is important to remove air bubbles from the liquids. • Film should be left in final water rinse no less than 5 and no more than 60 minutes.
Table 14.9 / Radiographic Techniques Technique
Description
Usage
Parallel
• Place patient in lateral recumbency with affected arch closest to x-ray tube. Position film parallel to the long axis of the tooth, but as close to the tooth as possible. The xray beam is positioned perpendicular (90° angle) to the film and the axis of the tooth.
• Evaluating mandibular premolars, molars, or nasal cavity • Positions where the angle between the film and long axis of structure is <15°.
Bisecting Angle of Maxillary Teeth
• Place patient in dorsal, sternal, or lateral recumbency. Film is placed intraorally. The beam is placed over the root of the tooth of interest and perpendicular to an imaginary bisecting line located between the plane of the tooth axis and the plane of the film.
• Evaluating maxillary premolars and molars, and both maxillary/mandibular canines and incisors • Technique of choice, because it minimizes distortion of the teeth
Tip: A tongue depressor used to help visualize the bisecting angle
14
CHAPTER 14 / DENTISTRY
513
Table 14.10 / Radiographic Positioning Positioninga
Incisor and Canine Teeth
View Rostral Maxillary View
• Patient: sternal recumbency • Film: placed against the canine and premolar tips. • Beam: centered over midline of nose and perpendicular to bisecting line. On small canines and felines, the beam will need to be centered more over the nose.
Rostral Mandibular View
• Patient: dorsal recumbency with pad under maxilla for support • Film: placed against the canine and premolar tips of the maxilla with part of the film extending out of the mouth and the tongue pushed toward the back of mouth, off the film • Beam: directed rostrocaudally, centered over the chin perpendicular to the bisecting line
Rostral Oblique
• Patient: dorsal recumbency • Film: resting on the maxilla • Beam: closer to ventral than rostral with bisecting technique, but move approximately 30° from midline to the side of the canine
Visualization Diagram
Radiograph
No radiograph
No radiograph
14
514
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 14.10 / Radiographic Positioning (Continued)
Premolar and Molar Teeth
View
Positioninga
Caudal Mandibular View • Canine: 4th premolars and molars • Feline: mandibular premolars and molars
• Patient: lateral recumbency • Film: placed between tongue and jaw; parallel to the axis of the tooth roots • Beam: as close as possible and perpendicular to the long axis of the tooth. The beam may need to be moved more ventrally, and a support may be needed to keep the film in place
Rostral Mandibular View • Canine: premolars
• Patient: lateral recumbency • Film: vertical to table in mouth, placed at the crown of near lower canine and base of opposite lower canine • Beam: centered over premolars and bisecting lower canine
Rostral Maxillary View • Canine: canines and premolars
• Patient: lateral recumbency • Film: laid across the palate, extending out near side of face behind the canine • Beam: bisecting angle technique
Visualization Diagram
Radiograph
14
CHAPTER 14 / DENTISTRY
515
Table 14.10 / Radiographic Positioning (Continued) Positioninga
View
• Patient: lateral recumbency • Film: laid across the palate and extending out of side of mouth • Beam: directed at middle of 4th premolar at a 30–45° angle above the tooth
Maxillary View • Feline: premolars and molars
• Patient: lateral or sternal recumbency with mouth propped open • Film: vertically in mouth, resting on the far side lingual teeth; parallel to tooth roots • Beam: modified parallel technique, directed at the base of root in question
Premolar and Molar Teeth
Caudal Maxillary View • Canine: 4th premolar and molars
Visualization Diagram
14
a
See directional terms, Table 5.7, page 168, and Chapter 1 Anatomy, page 3. Note: Drawings used with permission from M. Lynne Kesel: Veterinary Dentistry for the Small Animal Technicians, Ames, IA, Iowa State University Press.
516
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Radiograph
EXTRACTIONS Dependent upon the laws governing technicians in your state, extractions may only be performed by a veterinarian. Table 14.11 indicates the instruments typically used and the general procedure so that the technician will
be better able to assist the veterinarian. If technicians in your state are allowed to perform these procedures, proper training in this area is critical. General extraction complications include fractured socket or jaw, fractured or broken root tips, hemorrhage, endocarditis, secondary infection, oronasal fistula, soft tissue trauma, alveolitis, and gingival laceration.
Table 14.11 / General Extraction Procedures Extraction
Instruments
Procedure
Cautions
Simple: • Involves elevation of the tooth • Incisors, upper 2nd premolar, upper molars, possibly canines
• • • • • • • • • • • •
1. Sever gingival attachment sharply with a No. 15 blade angled at a 45° angle to the long axis of the tooth. 2. Elevate gingiva from tooth, then insert the elevator between the tooth and the alveolar crest/bone to begin loosening the periodontal ligament fibers. Elevator is placed tight to the tooth neck, pointing to the tip of the root and rotated around the tooth. Use short rotating movements to sever periodontal ligament fibers and advance apically. 3. Use twisting motions to add leverage; applied carefully and held for several seconds. 4. Using the extraction forceps, grasp the tooth gently but firmly close to the gumline and twist. If no movement is noted, use the elevators again. Once the tooth is extracted, check for any retained roots. 5. Clean alveoli of necrotic or infected debris with bone curette. 6. Assess for sharpness and, if found, smooth the excess alveolar crest with the dental drill. 7. Radiograph if any retained root tips are suspected. 8. A root tip pick, small elevator, or surgical retrieval techniques may be required to extract a broken root. 9. Lavage extraction site 10. The pocket can be filled with a synthetic material 11. Compress extraction area using gauze 12. Suture if necessary with absorbable suture (chromic gut) with tapered or cutting needle dependent upon on gingival tissue consistency
• Elevation may cause gingival and bone damage. • Root breakage caused by improper use or force (e.g., deciduous or feline teeth) • Suturing of small extraction sites may cause additional trauma; second-intention wound healing may be the best approach.
• • • • •
Absorbable suture (3-0 or 4-0) Consil, Collaplug Curettes Dental elevators Disinfectant solution Excavators Extraction forceps Gauze sponges Needle holder Periosteal elevators Radiographs of tooth Scissors: periodontal and suture Senn retractor Surgical blade (No. 15) with scalpel handle Surgical towels Synthetic packing material Thumb forceps
Sectioned: • Target tooth is cut between the roots to the surface of the bone
• Simple extraction instruments • Dental drill with tapered fissure-type cutting burs or general purpose pear-shaped burs • Root tip picks • Bone implant material
1. 2. 3. 4. 5.
Incise the gingival attachment. Elevate gingiva with a periosteal elevator. Section tooth with drill. Elevate between crown sections, 1 root at a time. Follow simple extraction Steps 2–13.
• Avoid using adjacent teeth for leverage. • Avoid getting air from drill into the bone as it can cause an air embolus in the patient’s system.
Surgical: • Cutting to the bone to extract roots • Upper 4th premolar, canines and a canine’s upper 1st and 2nd premolar
• Simple extraction instruments • Dental drill with tapered fissure-type cutting burs or general purpose pear-shaped burs • Root tip picks • Bone implant material
1. 2. 3. 4. 5.
Incise the gingival attachment. Create a buccal mucoperiosteal flap. Elevate the flap if necessary. Reduce the alveolar crest with cutting bur. Follow sectioned extraction steps 4–5.
• Technique is used when there is no access to the root, danger to the adjacent structures, tooth root fragility, or ankylosis of the bone to the root is present.
Tip: Post extraction care: • Medication: pain management and antibiotic therapy • Feed soft food. • Rinse the extraction site daily. • Schedule a surgical recheck in 2 weeks.
CHAPTER 14 / DENTISTRY
517
14
Skill Box 14.3 / Local Dental Nerve Blocks Use of local dental nerve blocks prior to extractions has been found to decrease the amount and depth of general anesthetic used during the procedure, creates a smoother recovery, and decreases the need for immediate postoperative narcotics for pain management. Dental nerve blocks interrupt the nerve conduction to a specific part of the body. Training on proper placement of these blocks is essential as well as verifying that licensed veterinary technicians are allowed to perform this procedure within the state of residence. It is critical to aspirate prior to injection of the anesthesia to avoid improper injection into the bloodstream. Intravenous injection of the local anesthetic may cause cardiac and/or nervous system toxicosis (total dose should not exceed 2 mg/kg). Neurologic complications of nerve blocks are transient loss of vision, Horner’s syndrome, facial nerve palsy, unilateral deafness, and transient nerve paralysis. Epinephrine may be added for its vasoconstrictive effects. Local anesthetics cause a vasodilation effect, which removes the drug the intended area quicker—with the addition with epinephrine and its vasconstrictive effects, the duration of the local anesthetic is extended. Its use is contraindicated in patients with cardiac arrhythmias, uncontrolled hyperthyroidism, or asthma or if using halothane anesthesia. Bupivacaine has a lag time of 6–12 minutes post injection but provides 4–6 hours of analgesia.
Caudal Infraorbital
Cranial Infraorbital
Types
Area and Nerves Blocked
Drug and Dosea
Injection Site and Methodb
Associated Risks
• Rostral superior alveolar nerve • Maxillary incisors, canines, and soft tissue
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine • 1.0 mg/kg • Bupivacaine • 0.2–0.5 mg/kg Volume per block: • Canine: 0.2–0.4 mL • Feline: 0.1–0.2 mL
Injection Site • Infraorbital foramen • Canine: palpated at the distal root of the maxillary 3rd premolar) • Feline: Typically not palpated; located dorsal to the furcation of the maxillary 3rd premolar) Method • Insert needle into the foramen approximately 1 mm; aspirate 360°; then inject slowly placing digital pressure over the injection entrance and maintaining pressure 30–60 seconds after injecting.
• Feline: needle advancement into the foramen is not recommended due to possible orbital trauma
• Maxillary nerve (middle and caudal superior alveolar nerve) • All maxillary teeth, and soft tissues on the blocked side of the head (ipsilateral)
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine • 1.0 mg/kg • Bupivacaine • 0.2–0.5 mg/kg Volume per block: • Canine: 0.2–0.4 mL • Feline: 0.1–0.2 mL
Injection Site • Infraorbital foramen • Canine: palpated at the distal root of the maxillary 3rd premolar) Method • Canine: Insert needle or Teflon catheter into the foramen; advance approximately 2–3 mm, but no farther than level with the medial canthus. • Feline: This nerve block is not recommended.
14
518
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Skill Box 14.3 / Local Dental Nerve Blocks (Continued) Area and Nerves Blocked
Drug and Dosea
Injection Site and Methodb
• Rostral alveolar nerve • Mandibular incisors, canines, 2nd premolar, lower lip, and soft tissues
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine • 1.0 mg/kg • Bupivacaine • 0.2–0.5 mg/kg Volume per block: • 0.1–0.3
Injection Site • Middle mental foramen • Canine: Caudal to mandibular labial frenulum palpated at the mesial root of the mandibular 2nd premolar • Feline: not easily palpated; at or just caudal to the apex of the mandibular canine tooth Method • Canine: insert needle into just rostral to the frenulum; advance needle into the foramen; aspirate; apply digital pressure at needle insertion site and inject slowly as the needle is gradually withdrawn. • Feline: insert needle at the rostral border of the mandibular labial frenulum at or just caudal to the apex of the mandibular canine tooth; aspirate; apply digital pressure at insertion site and inject slowly.
• Inferior alveolar nerve • All mandibular teeth and associated soft tissue of the ipsilateral hemimandible
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine • 1.0 mg/kg • Bupivacaine • 0.2–0.5 mg/kg Volume per block: • 0.25–0.5 mL if nerve is well palpated from the intraoral approach; more volume is needed when extraoral approach is used
Injection Site • Mandibular foramen • Lingual aspect of mandible above mandibular notch; palpated caudal to the last molar Method • Extraoral: insert 1–1.5 inch 22–25 gauge needle perpendicular to mandible through skin and walk it off ventral mandible; then change angle and advance dorsally to the mandibular foramen; aspirate; inject. • Intraoral: draw a mental line between the last molar and the angular process of the mandible; insert needle just rostral to the midpoint of this line; aspirate; inject.
• Extraoral is difficult to perform; can result in a regional diffusion of anesthetic
• Oral side of hard palate, partial anesthesia of maxillary incisors, canines, and premolars
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine • 1.0 mg/kg • Bupivacaine • 0.2–0.5 mg/kg Volume per block: • 0.1–0.2 mL
Injection Site • Major palatine foramen • Canine: midpoint between mesial root of maxillary 1st molar and the palate midline • Feline: midpoint between palatal root of the maxillary carnassial tooth and the palate midline Method • Insert needle at the midpoint of the 2 points of reference; aspirate; inject.
• Canine: need to supplement with infraorbital nerve block • Can result in a regional diffusion of anesthetic
Palatine
Caudal Mandibular and Mandibular Nerve
Middle Mental
Types
Associated Risks
14
CHAPTER 14 / DENTISTRY
519
Skill Box 14.3 / Local Dental Nerve Blocks (Continued)
Maxillary and Extraoral Approach
Types
Area and Nerves Blocked
Drug and Dosea
Injection Site and Methodb
Associated Risks
• Caudal superior alveolar nerve • Bone, soft tissue, and palatal tissue
Drug: • Lidocaine 2% • Bupivacaine 0.5% Dose: • Lidocaine • 1.0 mg/kg • Bupivacaine • 0.2–0.5 mg/kg Volume per block: • Canine: 0.2–0.4 mL • Feline: 0.1–0.2 mL
Injection Site • Palpate notch at the rostral ventral aspect of the zygomatic arch perpendicular to the last molar’s root. Jaw should be as closed as possible around the endotracheal tube for this approach. Method • Insert needle through skin adjacent to the bone angled perpendicular/medially to the horizontal line of the palate at the caudal root of the last molar; walk the needle along the caudal aspect of the notch until just beyond the level of the last molar’s root tip; aspirate; inject slowly into the pterygopalatine fossa.
• Much more difficult to perform than the intraoral approach discussed for the caudal infraorbital/maxillary nerve above
a
In mg/kg as a total dosage of all blocks cumulative: (bupivacaine 0.5%) (lidocaine 2%). Use tuberculin syringe with 25–27 gauge; 3/4–1 inch needle or via Teflon IV catheter (over-the-needle type). Note: See directional terms: Table 5.7, page 168, and Chapter 1 Anatomy, page 3.
b
14
520
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Chapter
15
Surgery Instrument Packs 523 Preoperative Protocol 524 Surgical Procedures 525 Abdominal Surgery 525 Abdominal Hernia, Anal Sacculectomy, and Colotomy 526 Enterotomy, Gastric-Dilatation Volvulus, and Gastrotomy 528 Intestinal Resection and Anastomosis and Hepatectomy 529 Aural Surgery 530 Aural Hematoma and Lateral Ear Canal Resection Integumentary Surgery 531 Abscess and Laceration 532 Mass Removal and Onychectomy 533 Neurologic Surgery 534 Disc Fenestration, Dorsal Laminectomy, and Hemilaminectomy 535 Ophthalmic Surgery 536 Cataracts, Ectropion, and Entropion 537 Conjunctival Flap and Enucleation 538
530
Glaucoma and Nictitating Membrane Flap Replacement 538 Prolapse of the Gland of the Third Eyelid and Traumatic Proptosis 539 Orthopedic Surgery 539 Cranial Cruciate Ligament Repair, Femoral Head Ostectomy, and Fracture Repair 540 Patellar Luxation, Total Hip Replacement, and Triple Pelvic Osteotomy 541 Reproductive Tract Surgery 542 Cesarean Section, Orchiectomy, and Ovariohysterectomy 542 Postoperative Care of Neonates and Dam 544 Thoracic Surgery 544 Diaphragmatic Hernia, Laryngeal Paralysis, and Sternotomy 545 Thoracotomy and Tracheal Collapse 546 Urogenital Tract Surgery 547 Cystotomy and Urethrostomy, Perineal 547 Urethrostomy, Scrotal, and Urethrostomy, Prescrotal 548
521
15
Suture Techniques 548 Suture Patterns 548 Knot Tying 549 Postoperative Care Protocol 550 Standard Postoperative Care Instructions Preventing Self-Trauma 550
a
15
550
Alternative Surgical Options 551 Endoscopy: Flexible Gastrointestinal and Rigid 551 Laser Surgery 552 Radiation Therapy: Teletherapy, Brachytherapy and Systemic Therapy 553 Temperature Therapy: Hyperthermia and Cryosurgery 554
Key Words and Termsa
Abbreviations
Additional Resources, page
Anastomosis Blepharospasm Dehiscence Devitalized Dyschezia Endophthalmitis Epithelialization Fenestration Hematuria Hemilaminectomy Laminectomy Nucleus pulposus Opacity Palliative Panophthalmitis Photoablation Seroma Signalment Slough Stranguria Sublingually Tenesmus Trocarization Urocystitis
BP, blood pressure CNS, central nervous system CRT, capillary refill time CVP, central venous pressure ECG, electrocardiogram GDV, gastric dilatation-volvulus GIT, gastrointestinal tract gtt, drop IM, intramuscular IPPV, intermittent positive-pressure ventilation IV, intravenous KCS, keratoconjunctivitis sicca kg, kilogram mg, milligram mm, millimeter MM, mucous membranes MRI, magnetic resonance imaging NPO, nothing by mouth OHE, ovariohysterectomy OVH, ovariohysterectomy PCV, packed cell volume SQ, subcutaneous TP, total protein
Anatomy, 3 Anesthesia, 439 Bandaging, 405 Blood gases, 335 Blood pressure, 332 Central venous pressure, 334 Coagulation tests, 115 Complete blood count, 104 Directional terms, 168 Disinfectants, 627 Drug administration, 348 Ear cleaning and flushing, 55 Endoscopy, 551 Fluid therapy, 359 General medicine, 201 Induction to general anesthesia, 453 Laboratory, 71 Laser surgery, 552 Medical procedures, 427
Nerve blocks, 392, 518 Nutrition, 57 Oxygen therapy 375 Pain management, 379 Parenteral nutrition, 413 Patient monitoring, 332 Physical examination, 18 Physical therapy, 558 Postoperative monitoring, 467 Preanesthetic evaluation, 442 Radiology, 157 Recumbent patient care, 347 Stomach tube placement, 428 Ultrasonography, 197 Urinalysis, 147 Urine collection, 434 Wound care, 399
Key words and terms are defined in the glossary on page 631.
Many of the listed surgical procedures may not be performed in the average clinical setting. However, at some point, technicians will be faced with having to explain a particular procedure to a client. These descriptions are not meant as directions on how to perform the procedure, but rather a quick synopsis that will allow the technician to prepare for the procedure, manage patient care, and clearly explain the procedure and aftercare to a client whose pet may be undergoing these procedures. With every surgical procedure, pain management needs to be addressed and handled. See Chapter 9 Pain Management, page 379. 522
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Skill Box 15.1 / Instrument Packs These packs are examples of the instruments included in basic surgical packs. Each clinic will need to organize packs that best fit their surgery type and surgeon. Each surgeon has preferences on individual types of instruments for different surgeries. Each pack may include gauze, laparotomy pads, towels, saline bowl, needles, sutures, and scalpel blades, or they may be prepared separately.
Basic Surgical Packs Abdominal Pack Abdominal forceps Abdominal retractors Balfour abdominal retractor Suction tips General Surgical Pack Grooved director Hemostats Needle holders Retractors Scalpel handle Scissors Spay hook Thumb forceps Tissue forceps Towel clamps
Laceration Pack Hemostats Needle holder Scalpel handle Scissors Thumb forceps Neurology Pack Bone wax Dental spatula Dural hook Rongeurs Duck-bill Lempert Ophthalmic Pack Eyelid forceps Eyelid retractor
Pin cutter Retractors Senn retractor Volkmann retractor Rongeurs Wire-cutting scissors
Hemostats Lacrimal cannulas Needle holders Scalpel handle Scissors Thumb forceps Orthopedic Pack Bone drill Bone chuck and key Bone-cutting forceps Bone-holding forceps Bone rasps and files Gigli handles and wire Mallet Osteotome Orthopedic wire Periosteal elevator
Thoracic pack General surgical pack Instruments with long handles Rib retractors Wilson rib spreader Bone-cutting forceps Right-angle forceps Vessel clamps Bulldog clamp
Specialized Surgical Packs Many instruments may be used only on occasion and should be set aside in separate packs. Instruments weaken with constant scrubbing and autoclaving and should therefore not be subjected to unnecessary sterilization. The instrument type and number included in each of these packs will depend on surgeon preference. Biopsy/trephine pack Curette pack Retractor pack
Hemostat pack Implant set Screw set
Periosteal elevator pack Pin set Suction tips and tubing pack
15
CHAPTER 15 / SURGERY
523
Skill Box 15.2 / Preoperative Protocol Once a surgical procedure has been planned, a set of preoperative guidelines should be followed to ensure the safety of the patient. These guidelines evaluate the patient physically, correct underlying problems if possible and prepare the patient for the actual procedure. They also ensure the client is aware of the steps ahead and are comfortable with their decision. Specific details for a particular surgery are listed in that section. Client Communication • Ensure the client is aware of the procedure, options, risks, postoperative care, and cost. Preanesthetic Evaluation (See Table 13.1, page 442.) • Signalment • History • Weight • Vital signs • Physical examination • Laboratory workup • Additional diagnostic tests • ASA physical status Patient Stabilization • Fluid therapy (See Chapter 8, page 359.) • Correcting acid-base abnormalities • Pain management plan (See Chapter 9 Pain Management, page 379.) • Drug administration (See Chapter 8 Drug Administration, page 348.) • Stabilizing procedures (e.g., oxygen therapy, thoracocentesis, abdominocentesis) (See Chapter 12 Medical Procedures, page 427.) • Nutritional evaluation and administration (See Chapter 3 Nutrition, page 57, and Chapter 11 Parenteral Nutrition, page 413.)
15
Patient Preparation • Have the owners bath the animal prior to surgery if necessary. • Withhold food for 6–12 hours before surgery in adults and 4–6 hours in young animals or those prone to hypoglycemia. • The patient should be allowed to urinate and defecate prior to induction. • Verify the correct patient, surgical procedure, and surgical site. • Induce anesthesia (See Table 13.3 General Anesthesia Induction, page 453.) • Prepare the surgical site. • Clip the intended site with wide margins to allow for drape movement, additional incisions, and drain placement. • Remove excess hair and debris with a vacuum. • Cleanse the site and surrounding hair. • Move the patient into the surgical suite and perform the sterile skin prep. • Begin along the intended incision line and move in a circular pattern moving away from the center. • Be sure to not return to the center as this may translocate bacteria back to the incision line. • Solutions used for cleaning are variable; a standard should be set for each hospital (e.g., povidone-iodine, chlorhexidine, chloroxylenol). • Depending on the product, rinsing with water or alcohol may be necessary. • Pooling of solutions should be prevented or dried prior to draping and surgical incision.
524
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
SURGICAL PROCEDURES Table 15.1 / Abdominal Surgery
Preparation
Procedure
Abdominal Surgery
Instruments
• • • • • • • •
Abdominal pack Electrocautery Gauze sponges/laparotomy pads General surgical pack Retractor pack Saline bowl Saline, warmed Suction tips and tubing pack
Patient
• • • • •
Preanesthetic evaluation Preoperative protocol Empty the urinary bladder Flush prepuce of male dogs with antiseptic solutions See particular surgery
Surgical Technique
• The organ or area to be examined should be exteriorized and packed with saline-moistened gauze sponges. • All tissues must be kept consistently moist with warm saline. • Handling of the internal organs must be done carefully to avoid further damage, but secure enough to not allow leakage of the bowel contents into the surgery site. • Provide clean sterile drapes, towels, gloves, and instruments for abdominal closure. • Patient should be monitored for excessive blood loss, contamination of peritoneal cavity, and an ↑ tendency to vomit with organ manipulation. • See Figures 1.6–1.8, page CP-1, and color plates. • • • • • • • • • • •
Abscess Dehiscence Gastric or intestinal perforation Hemorrhage (e.g., poor hemostasis and inadvertent injury to vascular organs) Ileus Intestinal stricture Pancreatitis Peritonitis/sepsis (e.g., contamination with GIT contents) Pleural effusion Failure of intended surgery Adhesions between visceral surfaces
Patient
• • • • • •
Hyperthermia with prolonged procedures Abdominal pain Fecal incontinence Fever Tenesmus/constipation/dyschezia Vomiting
Complications
Procedural
15
CHAPTER 15 / SURGERY
525
Table 15.1 / Abdominal Surgery (Continued)
Follow-Up
Procedure
Abdominal Surgery
Patient Care
• • • • •
NPO for 12–24 hours Continue analgesia postoperatively. Monitor ability, frequency, appearance of defecation Standard postoperative care Confine and restrict activity until suture/staple removal or as directed by veterinarian.
Client Education
• Postoperative care protocol • Feed a low-fat, bland diet for 2–3 days, then gradually reintroduce regular food
Table 15.2 / Abdominal Surgery: Abdominal Hernia, Anal Sacculectomy, and Colotomy Procedure
Abdominal Hernia
Anal Sacculectomy
Colotomy
Definition
• Repair of a hole in the abdominal wall that is allowing an organ or part of an organ to protrude
• Removal of 1 or both anal sacs and associated anal sac duct
• Incision made into the colon
Indications
• Intestinal obstruction and/or strangulation damage
• Correction of long-term anal sac infection, recurrent impaction, anal fistulas, and neoplasia
• Full-thickness biopsy, obstructions, and perforation
Patient Preparation
• Dorsal recumbency • Prepare 3 inches on either side of the hernia
• Ventral recumbency with rear legs draped over end of table and tail secured cranially • Prepare a 4″ radius around anus • Express anal sacs, evacuate as much of the feces from the colon as possible, and pack rectum with sponges • Closed: ± instill self-hardening gel or resin into sac(s) to be removed
• Empty the intestinal tract to ↓ bacterial count and risk of infection and to ↑ visibility • Feed a low residue diet for 2–3 days and no food for 24 hours prior to surgery • Colon electrolyte solutions, enemas, laxatives, or cathartics 24 hours prior to surgery to cleanse the colon, • Contraindicated with obstructions or perforations • Dorsal recumbency • Prepare entire ventral abdomen
15
526
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.2 / Abdominal Surgery: Abdominal Hernia, Anal Sacculectomy, and Colotomy (Continued) Procedure
Abdominal Hernia
Anal Sacculectomy
Colotomy
Surgical Technique
An incision is made over the hernia and dissected down to the hernia orifice. Any adhesions are removed and the organs and/or viscera are returned to the peritoneal cavity. The edges of the hernial orifice are sharply freshened and sutured closed. Routine closure of the abdomen is performed.
Closed Place hemostat, self-hardening gel/resin, and balloon-tip catheter into the gland to isolate or isolate the hardened sac, an incision is made over the sac. The surrounding tissue is gently dissected away from the sac, and the sac and duct are removed. The area is lavaged with warmed saline, and the remaining tissue is closed in a routine closure. Open The anal sac orifice is visualized and a grooved director is placed into the sac orifice to the most ventral aspect. An incision is made along the grooved director, and the entire sac and duct are dissected out. The area is lavaged with warmed saline, and the remaining tissue is closed in a routine closure. • Remove packed sponges in the rectum.
A caudal midline abdominal incision is made. The affected area is exteriorized and packed with salinemoistened gauze sponges. Stay sutures are placed, and the colonic contents are milked away from the intended incision site. An incision is made into the colon for obstruction repair or to obtain full thickness biopsies and then sutured. Resection and anastomosis may be necessary and performed using a suture or staple technique. The abdomen is flushed with warm saline and the colotomy is covered and tacked with a piece of omentum. Contaminated instruments and gloves are replaced and routine closure of the abdomen is performed.
Notes
• Patient care: vomiting, fever, leukocytosis may indicate peritonitis • Client education: Chronic or small hernias may not require surgical intervention • Expected pain: moderate
• Instruments: • Closed: self-hardening gel or resin and administration equipment • Open: grooved director • Surgery: Careful, atraumatic dissection with minimal muscle damage is essential to preserve nerve and sphincter function. • Patient care: cold pack the surgical site immediately after surgery, antibiotics for 7–10 days postoperative if contamination occurs • Client education: hot pack incision twice daily until suture removal, administer a stool softener for 2–3 weeks • Expected Pain: moderate
• Surgery: Stay sutures may not be necessary, especially if a surgical assistant is present. • Surgery: Ideally, biopsy samples are obtained through endoscopy, ultrasonography, or laparotomy. • Surgery: Stapled anastomosis has a better outcome in healthy tissue compared to sutures. • Patient care: antibiotics during surgery and postoperative if contamination is suspected • Expected pain: moderate to severe
15
CHAPTER 15 / SURGERY
527
Table 15.3 / Abdominal Surgery: Enterotomy, Gastric Dilatation-Volvulus, and Gastrotomy Procedure
Enterotomy
Gastric Dilatation-Volvulus (GDV, gastric torsion, bloat)
Gastrotomy
Definition
• Incision made into the small intestines
• To reposition the stomach and the spleen to their correct location and restore blood circulation • Fix the stomach to the abdominal wall to prevent further torsion.
• Incision made into the stomach
Indications
• Examination for ulcers, strictures, or neoplasia, fullthickness biopsy, obstruction, and feeding tube placement
• A stomach that dilates and twists around its central axis
• Full-thickness biopsy, obstruction, and GDV
Patient Preparation
• Dorsal recumbency • Prepare entire abdomen.
• Orogastric decompression or needle trocarization • Dorsal recumbency • Prepare midsternum to 2–3 inches below the umbilicus.
• Dorsal recumbency • Prepare from bottom third of the sternum to 2–3 inches below the umbilicus.
Surgical Technique
A midline abdominal incision is made. The entire length of intestines are examined, the affected area is then exteriorized and packed with saline-moistened gauze sponges. Stay sutures are placed, and the bowel contents are milked away from the intended incision site. Intestinal forceps or an assistant using a scissors-like grip with the index and middle finger occludes the intestines on either side of the enterotomy. An incision is made into the intestines to obtain biopsy samples or for obstruction removal. Resection and anastomosis are potentially performed based on the viability of the intestines. The abdomen is flushed with warm saline, and the enterotomy is covered and tacked with a piece of omentum. Contaminated instruments and gloves are replaced, and routine closure of the abdomen is performed.
A midline abdominal incision is made. Further orogastric decompression is performed if necessary via an orogastric tube or suction. The stomach is rotated back to its normal position and assessed for necrotic tissue. A partial gastrectomy is performed if necrosis is seen. The spleen is evaluated for rotation and necrosis. A splenectomy is performed if necrosis is seen. Gastroplexy is then performed on the right side of the dog by one of many methods. Contaminated instruments and gloves are replaced and routine closure of the abdomen is performed.
A cranial midline abdominal incision is made. The entire length of the intestines are examined; the stomach is then exteriorized and packed with saline moistened gauze sponges. Stay sutures are placed. The stomach is excised into and suctioned free of liquid contents. The obstruction is removed or biopsy specimens are taken. The stomach is closed in a multilayer fashion, lavaged with warmed saline, and possibly covered with omentum. Contaminated instruments and gloves are replaced, and routine closure of the abdomen is performed.
Notes
• Surgery: Stay sutures may not be necessary, especially if a surgical assistant is present. • Surgery: Enterotomy incisions are usually made in tissue adjacent to the obstruction rather than directly over it for better incision healing. • Surgery: Stapled anastomosis has a better outcome in healthy tissue compared to sutures. • Expected pain: moderate to severe
• Instruments: orogastric tube • Patient care: Monitor electrolytes, blood gases, PCV, TP, urinary output, ECG, and CVP as necessary. • Patient care: Begin feeding a soft, lowfat diet 12–24 hours postoperative and monitor for vomiting. • Client education: Mortality rates reach 45% even in treated animals. • Client education: Feed small meals 3–4 times daily, and avoid exercise after each meal. • Expected pain: moderate to severe
• Surgery: Feeding tubes can be placed at the time of surgery if their use is expected. • Expected pain: moderate
15
528
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.4 / Abdominal Surgery: Intestinal Resection and Anastomosis and Hepatectomy Procedure
Intestinal Resection and Anastomosis
Hepatectomy, partial
Definition
• Removal of a diseased or nonviable section of the intestines with end-to-end bowel reattachment
• Removal of < 80% of the liver
Indications
• A nonfunctioning section of bowel possibly caused by obstruction, neoplasia, intussusception, bowel necrosis, fecal infiltrative bowel disease, or volvulus
• Biopsy, neoplasia, necrosis, abscess, or hemorrhage
Patient Preparation
• Dorsal recumbency • Prepare from the caudal end of the sternum to the pubis.
• Coagulation tests and thrombocyte count • Dorsal recumbency • Prepare entire abdomen and caudal third of sternum
Surgical Technique
Notes
a
A ventral midline abdominal incision is made. The area of the intestines to be resected is exteriorized, packed with saline moistened gauze sponges, and major vessels are ligated. The bowel contents are milked away from the intended site. Intestinal forceps or an assistant using a scissors-like grip with the index and middle finger occlude the intestines on either side of the enterotomy. The diseased portion is removed, and one of many types of suture patterns or staples may be used to allow complete closure of the intestines. Bowel contents are milked back into the anastomosis site to asses for leakage. The entire abdomen is flushed with warmed saline if contamination is suspected. The site of anastomosis is flushed with saline and an antimicrobial solution and then covered with a piece of omentum. Contaminated instruments and gloves are replaced and routine closure of the abdomen is performed. • Patient complication: short bowel syndrome (rare) • Surgery: Stapled anastomosis has a better outcome in healthy tissue compared to sutures. • Expected pain: moderate to severe
A ventral midline abdominal incision is made. Gauze sponges are placed between the liver and diaphragm for better visualization. The liver is examined for biopsy areas or portions to be removed. The associated vessels are securely ligated, and the partial hepatectomy is performed. The area is observed for confirmation of adequate hemostasis, and routine closure of the abdominal wall is performed.
• Patient care: Recovery from anesthesia should be closely monitored because delayed drug metabolism may result after hepatectomy. • Client education: Liver mass is restored to normal in a matter of weeks by compensatory hypertrophy of the remaining tissue.a • Expected pain: severe
From M. Joseph Bojrab: Current Techniques in Small Animal Surgery. Baltimore, Williams and Wilkins, 1998.
15
CHAPTER 15 / SURGERY
529
Table 15.5 / Aural Surgery
Preparation
Procedure
Aural Surgery
Instruments
• • • •
Patient
• Preanesthetic evaluation • Preoperative protocol • See particular surgery.
Complications
• Electrocautery is an important part of ear surgery because of the highly vascular tissue and degree of hemorrhage. • See Figure 1.9 Ear, page 13.
Procedural
• Hematoma formation
Patient
• Head shaking or scratching • Hearing loss
Follow-Up
Surgical Technique
Buttons or Silastic tubing Cartilage scissors Electrocautery Laceration pack or general surgical pack
Patient Care
• • • •
Client Education
• Postoperative care protocol
Bandage of ear against head and wrapped and secured with stockinette and/or tape Standard postoperative care Continue analgesia postoperatively. Confine and restrict activity until suture/staple removal or as directed by veterinarian.
Table 15.6 / Aural Surgery: Aural Hematoma and Lateral Ear Canal Resection
15
Procedure
Aural Hematoma
Lateral Ear Canal Resection
Definition
• Drainage and apposition of the cartilage surfaces of the ear to allow healing and prevent reoccurrence of hematoma
• Removal of the lateral ear wall to allow proper drainage and exposure of the horizontal canal. • Must be performed early in course of chronic otitis externa if success is to be achieved
Indications
• Irritations causing head shaking or scratching at ears
• Chronic infections, trauma, or neoplasia • Anatomic due to breed (e.g., Shar pei)
Patient Preparation
• Lateral recumbency • Clean and treat underlying otitis externa if present. • Place 1–2 cotton balls in ear canal to prevent fluid accumulation in deep canal. • Prepare the entire pinna on both sides.
• Lateral recumbency with head propped up on a towel • Clean the ear canal of all waxy material and debris. • Prepare entire pinna and the external ear canal region (e.g., side of the face).
530
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.6 / Aural Surgery: Aural Hematoma and Lateral Ear Canal Resection (Continued) Procedure
Aural Hematoma
Lateral Ear Canal Resection
Surgical Technique
An incision is made down the long axis of the pinna in an ‘S’ shape. The pinna is probed for and removed of fibrin tags and blood clots and flushed with saline. A mattress pattern or simple interrupted sutures (± incorporating buttons and Silastic tubing) are placed along the surface of the pinna to remove any dead space and allow complete apposition of both sides of the ear cartilage. Place a non-adherent pad over the incision and bandage the ear over the top of the head.
Two incisions are made parallel to the vertical ear canal margins and a transverse incision joining them. The skin and SQ tissue are reflected, and two incisions are made through the cartilage to expose the inside of the vertical canal. The reflected flap of cartilage is trimmed and sutured to the skin to make a drainboard ventrally.
Notes
• Surgery: Laser surgery provides another technique requiring no sutures. • Client education: Strict confinement is necessary to allow pinna to heal properly. • Client education: Even with appropriate treatment, disfiguration (cauliflower appearance) of the pinna may occur. • Expected pain: mild to moderate
• Patient care: hot compress 3–4 times a day for 2–3 days if excessive swelling • Client education: This procedure is not a cure, continuous medical management may still be required, but is made easier. • Client education: Do not use any foreign object (e.g., cotton balls, cotton-tipped applicators) in the shortened ear canal, to avoid damage to the tympanic membrane. • Expected pain: severe to excruciating
Table 15.7 / Integumentary Surgery
Preparation
Procedure Instruments
• Laceration pack or general surgical pack • ± Penrose drain
Patient
• Preanesthetic evaluation • Preoperative protocol • See particular surgery.
Surgical Technique
• See particular surgery.
Procedural
• • • •
Patient
• Fever • Pain or swelling from infection or SQ seroma
Patient Care
• • • • •
Follow-Up
Complications
Integumentary Surgery
Client Education
Dehiscence, skin necrosis, and slough Failure of intended surgery Sepsis Seroma
Monitor for pain or swelling. Monitor appearance of drain material when a Penrose drain is placed. Pain management Standard postoperative care Confine and restrict activity until suture/staple removal or as directed by veterinarian.
15
• Postoperative care protocol
CHAPTER 15 / SURGERY
531
Table 15.8 / Integumentary Surgery: Abscess and Laceration Procedure
Abscess, Superficial
Laceration, Superficial
Definition
• Accumulation of pus, forming an isolated cavity in body tissue because of a pathogen
• A full-thickness disruption through the dermis and exposing the SQ
Indications
• Swelling and painful location that is not draining and is disrupting the normal function of the animal • Sepsis
• To restore skin integrity and allow for reepithelialization by primary intention healing
Patient Preparation
• Positioned to allow access to the affected site • Prepare the site to include the location of swelling with an additional 1–2 inch margin.
• Positioned to allow access to the affected site • Prepare the site to include the location of injury with an additional 1–2 inch margin. • Clipped hair and other debris must not enter the laceration site; fill with sterile lubricant or cover with a moistened gauze sponge.
Surgical Technique
A sharp object is used to make an opening into the abscess or enlarged the tract’s opening. Accumulated pus and fluid is drained and the cavity is lavaged with copious amounts of fluid (e.g., chlorhexidine, diluted hydrogen peroxide, saline) to remove any additional contaminated fluid, bacteria, or debris. Any devitalized tissue is removed, and an additional hole is made for drain placement. The drain is placed through both holes and sutured into place for 3–5 days.
The area is clipped and cleaned, and any foreign material is removed. Devitalized tissue is debrided and the area is lavaged (e.g., chlorhexidine, diluted hydrogen peroxide, saline) to remove any additional contaminated fluid, bacteria, or debris. The dead space is closed via sutures, and a drain may be placed. The skin edges are then apposed and sutured or stapled closed.
Notes
• Surgical: Abscesses should not be opened in sterile operating rooms to avoid contamination. • Patient care: systemic antibiotics postoperatively for ≥1 week • Client education: hot compress 2–3 times daily to keep drain open and draining for 3–5 days • Expected pain: mild to moderate
• Surgery: Fluids used to flush should not contain sugars, as that provides nutrients for the pathogens. • Surgery: Suture line skin tension will delay healing and promote dehiscence. • Patient care: ± bandage and immobilize for ↑ healing and to ↓ swelling • ClienteEducation: E-collars or other measures must be taken to avoid chewing at suture line or any drains placed. • Expected pain: mild to moderate
15
532
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.9 / Integumentary Surgery: Mass Removal and Onychectomy
a
Procedure
Mass Removal
Onychectomy (Declaw)a
Definition
• Removal of a tumor, mass, growth, or cyst
• Removal of the nail and entire third phalanx
Indications
• Obstruction with function, neoplasia, or cosmetic
• Trauma, infection, or neoplasia
Patient Preparation
• Positioned to allow access to the affected site • Prepare the site to include the tumor location with an additional 1–2 inch margin. • Larger margins when neoplasia is suspected or confirmed
• Lateral recumbency • Paws are clipped if long hair is present, washed, and sprayed with an antiseptic.
Surgical Technique
Varying techniques are employed for the varying sizes and shapes of specific tumors Perform excision as atraumatically as possible to avoid spread of tumor cells and protect adjacent tissue. An elliptical incision is made around the tumor through all layers assuring wide enough margins to prevent regrowth. The tumor is dissected out while hemostasis is maintained to prevent tumor cells or other substances (e.g., histamine). The incision site is irrigated, the dead space is closed via sutures, and a drain may be placed. The skin edges are then apposed and sutured closed.
A ring block is performed with opioid analgesics and/or lidocaine/bupivicaine. The blood is milked proximally, and a tourniquet is placed below the elbow. A scalpel, guillotine nail trimmers, electrosurgery or a CO2 laser are used to remove the entire third phalanx. Care is taken to avoid cutting the digital pads. The toes are then left open or closed with suture or tissue glue. A secure bandage is placed to prevent hemorrhage.
Notes
• Surgery: Replace instruments, gloves, and drapes when removing tumors from multiple sites. • Patient care: ± bandage • Client education: E-collars or other measures must be taken to avoid chewing at suture line. • Expected pain: moderate
• Instruments: tourniquet, skin glue, sterile nail trimmers, electrosurgery, or CO2 laser • Surgical complications: The third phalanx must be removed from each toe to avoid additional pain, nail regrowth, infection, “phantom” pain sensation, and/or occasional limping. • Patient complications: patient biting as a substitute for clawing • Expected pain: moderate to severe
The authors strongly believe this procedure should only be done as medical treatment and not as behavioral modification.
15
CHAPTER 15 / SURGERY
533
Table 15.10 / Neurologic Surgery
Preparation
Procedure Instruments
• General surgical pack • Orthopedic pack • Neurology pack
Patient
• • • • • •
Complications
Surgical Technique
Follow-Up
Neurology Surgery
Preanesthetic evaluation Preoperative protocol Patient with spinal instability should be put in braces or secured to a rigid surface to decrease further damage. ± Corticosteroid administration Two venous catheters should be placed to allow rapid fluid and blood administration if hemorrhage were to occur. Patient positioning is determined for each procedure (e.g., linear traction, gentle flexion, extension, rotation) to facilitate visualization, reduce fractures, and/or decompress spinal cord.
• See particular surgery • See Figures 1.4 and 1.5 Skeletal View, page 7.
Procedural
• • • • •
Venous sinus hemorrhage Nerve and/or CNS damage Spinal instability and/or collapse Seroma Infection
Patient
• Decubital sores and urinary tract infections • Joint stiffness and muscle atrophy • Pneumonia and GIT ulceration
Patient Care
• Critical observation for the first 24 hours (e.g., pain management, respiratory depression, GDV, seizures) • Intensive patient care (e.g., frequent rotation, bladder expression, physical therapy, maintaining a clean and dry environment)
Client Education
• Postoperative care protocol • Physical rehabilitation often required daily until healed and full function returns (days to weeks) • Frequent neurologic examination over the first 12 months
15
534
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.11 / Neurologic Surgery: Disc Fenestration, Dorsal Laminectomy, and Hemilaminectomy Procedure
Disc Fenestration
Dorsal Laminectomy
Hemilaminectomy
Definition
• Creation of a window in the ventral annulus to access and remove the nucleus pulposus that is calcified or may become calcified/degenerated
• Removal of dorsal lamina to expose the spinal cord and correct the underlying problem (e.g., removal of disc material or tumor, fracture stabilization)
• Removal of right and/or left lateral lamina to expose the spinal cord and correct the underlying problem (e.g., removal of disc material or tumor, fracture stabilization)
Indications
• Disc rupture, spinal cord compression, nerve root entrapment
• Lesions located in the dorsal or lateral vertebral canal (e.g., disc fragments, fracture segments, tumors)
• Lesions located in the lateral, dorsolateral or ventrolateral vertebral canal (e.g., disc material or tumor, fracture fragment)
Surgical Technique
An incision is made based on the surgical approach (e.g., ventral, lateral, or dorsolateral). Dissection is performed to the annulus fibrosus where a window is made and the nucleus pulposus is removed. Changing the patient’s position may facilitate the removal of the nucleus pulposus. Close the incision routinely.
An incision is made in the dorsal midline along the length of 2 spinous processes. The affected intervertebral body or space is dissected down to and the veterbral canal is entered. After the vertebral canal is entered, a durotomy may or may not be performed to relieve spinal cord swelling. The compressive lesion is removed and irrigated with sterile saline. Wire can be used to close the site with a layer of subcutaneous fat placed over the site to prevent adhesions. Close the remaining area routinely.
An incision is made in the dorsal midline along the length of 2 spinous processes. The affected intervertebral body or space is dissected down to at the lateral aspect and the veterbral canal is entered. After the vertebral canal is entered, a durotomy may or may not be performed to relieve spinal cord swelling. The compressive lesion is removed and irrigated with sterile saline. A layer of subcutaneous fat placed over the site to prevent adhesions and the remaining area closed routinely.
Notes
• Surgery: most commonly performed in conjunction with laminectomy or hemilaminectomy
• Surgery complication: venous sinus, bone hemorrhage, CNS trauma
• Surgery complication: venous sinus, bone hemorrhage, CNS trauma
15
CHAPTER 15 / SURGERY
535
Table 15.12 / Ophthalmic Surgery
Preparation
Procedure Instruments
• • • •
Patient
• • • • •
Surgical Technique
Ophthalmic surgical pack Eyelid speculum Operating microscope or magnification head loupe may be required for certain procedures. Focal light source
Preanesthetic evaluation Preoperative protocol Ventral recumbency with the head propped up on a towel or cushion Place a sterile ophthalmic ointment in the eye to protect from clipped hair and cleaning solutions. Prepare area immediately around eye by clipping, brushing away, or using adhesive tape to clean area; flush conjunctival sac with a diluted saline/antiseptic solution; and gently wash surrounding area with cotton tipped swabs or surgical sponges soaked in a diluted disinfectant. • Avoid using vacuums after clipping, soaps, detergents, and alcohol as they may all cause damage to the delicate eye tissues. • See particular surgery, • See Figure 1.18 Ear, page 13.
Procedural
• • • • •
Patient
• Swelling • Pain and pruritus
Patient Care
• • • • •
Client Education
• Postoperative care protocol
Follow-Up
Complications
Ophthalmic Surgery
Failure of intended surgery Infection Tissue necrosis Keratitis secondary to corneal drying and/or trauma Scar tissue leading to chronic irritation
Continue analgesia postoperatively Standard postoperative care Allow a quiet anesthetic recovery to prevent trauma upon waking Prevention of self-trauma, confine and restrict activity until suture/staple removal or as directed by veterinarian Monitor daily for tearing, mucopurulent discharge, inflammation, blepharospasm
15
536
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.13 / Ophthalmic Surgery: Cataracts, Ectropion, and Entropion Procedure
Cataracts
Ectropion
Entropion (Ventral, Dorsal, Lateral or Medial)
Definition
• Removal of the lens through surgical removal or physical dissolution
• Removal of excess skin to decrease laxity and shorten and strengthen the lower eyelid
• Removal of a section of eyelid skin, depending on the type of entropion
Indications
• Opacity of the lens, which could lead to uveitis, glaucoma, visual deficits, or retinal detachment
• Outward rolling of the eyelid resulting in keratitis, conjunctivitis, and KCS
• Inward rolling of the eyelid resulting in keratitis, corneal ulceration, and pain
Patient Preparation
• See Table 15.12.
• See Table 15.12.
• See Table 15.12.
Surgical Technique
• Phacofragmentation: An ultrasound-driven needle is used to emulsify and remove the affected lens simultaneously and irrigate the eye. • Extracapsular lens extraction: A corneal or corneoscleral incision is made, and the anterior lens capsule is removed. Typically used for very hard lenses. • Intracapsular lens extraction: Removal of the entire lens and capsule. Only used with lens luxation due to ↑ complications. • An intraocular lens is often placed to further ↑ vision.
• Trephination: Remove one or more skin circles using a skin biopsy punch of the lower lid. Suture closed perpendicular to the lid margin. • Wedge resection: Remove a full-thickness triangular wedge of lid near the lateral canthus. Align skin edges and suture closed.
• An elliptical or V-shaped area of skin is removed 1–3 mm below the margin of the lid, depending on the location of the entropion. The area is then sutured closed with a nonabsorbable suture, allowing lid eversion and to remain in a normal anatomic position.
Notes
• Indications: must be distinguished from nuclear sclerosis • Patient care: Inflammation must be controlled for success. • Expected pain: moderate
• Surgical complication: Entropion may result with overcorrection. • Expected pain: moderate
• Surgical: Everting sutures may be used temporarily in young dogs for correction without excision of eyelid. • Client education: Ectropion may be initially present until swelling has decreased; multiple procedures may be needed. • Expected pain: moderate
15
CHAPTER 15 / SURGERY
537
Table 15.14 / Ophthalmic Surgery: Conjunctival Flap and Enucleation Procedure
Conjunctival Flap
Enucleation
Definition
• A conjunctival flap is secured over the site of a deep corneal ulcer to provide protection and a source of blood vessels, antibodies, and serum antiproteases.
• Removal of the eye (e.g., globe, nictitating membrane, eyelid margins)
Indications
• Deep corneal ulcers, trauma, descemetoceles, ruptures, or corneal diseases
• Glaucoma, trauma, neoplasia, endophthalmitis, panophthalmitis, congenital defects, or severe infections
Surgical Technique
• The ulcer is cleaned of any necrotic tissue and corneal epithelium to assure graft adherence. A thin flap is harvested from the bulbar conjunctiva and placed over the ulcer and sutured into place. The harvested site is then suture closed. The flap is trimmed after the ulcer has healed (4–6 weeks) without disturbing the conjunctiva from the former ulcer site.
• Transconjunctival: An incision is made at the lateral canthus, and the eye is stabilized. The eye is dissected through the muscle attachments, optic nerve, and blood vessels and then removed. The tissues are then sutured in a layered fashion. • Transpalpebral: The eyelids are sutured closed, and an elliptical incision is made 5–6 mm from the eyelid margin. See above.
Notes
• Surgery complications: flap failure (e.g., bacterial infection, poor technique, flap necrosis, inadequate ulcer debridement) • Client education: e-collar and activity restriction for 1 week • Expected pain: moderate
• Surgery complications: hemorrhage (e.g., angularis oculi vein is severed), damage to the optic chiasm affecting vision in remaining eye • Expected pain: moderate
Table 15.15 / Ophthalmic Surgery: Glaucoma and Nictitating Membrane Flap Replacement Procedure
Glaucoma
Nictitating Membrane Flap Replacement
Definition
• To ↓ the production and ↑ outflow of aqueous humor and to ↓ ocular pressure • To retain vision and normal intraocular pressure and ↓ pain
• Temporary attachment of the nictitating membrane to the upper palpebra for corneal support
Indications
• ↑ Intraocular pressure
• Deep corneal ulcers, trauma, or corneal diseases as a temporary bandage during healing
Surgical Technique
• Laser cyclophotocoagulation: killing small areas of the ciliary body via a laser • Cyclocryotherapy: freezing the ciliary body in multiple sites (4–8) with liquid nitrogen administered via a cyroprobe • Anterior chamber shunts: implantation of a tube to allow continuous drainage of aqueous fluid
• The nictitans is sutured to the upper eyelid or bulbar conjunctiva, incorporating buttons or Silastic tubing to prevent tissue necrosis from the sutures.
Notes
• Surgery complications: blindness • Client education: Painful, blind eyes will not benefit from the above-mentioned surgeries and should be enucleated. • Expected pain: moderate
• Surgery complications: sutures may pull through with excess tension, eyelid necrosis, corneal irritation • Client education: Suture removal varies between 10 days and 4 weeks. • Expected pain: moderate
15
538
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.16 / Ophthalmic Surgery: Prolapse of the Gland of the Third Eyelid and Traumatic Proptosis Procedure
Prolapse of the Gland of the Third Eyelid (Cherry eye)
Traumatic Proptosis
Definition
• Repositioning of the third eyelid gland and anchoring in a more normal position
• Return of the eye back into the socket and normal position
Indications
• Hypertrophy and prolapse of the third eyelid gland
• Forward displace of the globe with subsequent entrapment of the palpebral margins behind the eye
Patient Preparation
• See Table 15.12.
• See Table 15.12.
Surgical Technique
• Pocket: An incision is made along the margins of the gland into the palpebral conjunctiva. A pocket is formed, and the gland is returned to its normal position. The incision is apposed and then sutured together over the gland. • Pursestring: The third eyelid is exposed and stabilized. A purse string suture is placed over both ends of the gland. The gland is returned to normal position with a cotton-tipped applicator, and the purse string suture is pulled tight and knotted. Recurrence rate of 20–25%.
Temporary sutures are placed in the eyelids allowing retraction. Gently apply pressure to the globe while everting the eyelids to return the globe to the proper position. An incision in the lateral canthus may be necessary to facilitate placement. Suture eyelid closed using stents to avoid pressure necrosis. An area at the medial canthus is left open to allow application of medications.
Notes
• Client education: removal of the gland is no longer recommended due to future risks of KCS; suture abrasion of cornea • Expected pain: moderate
• Patient preparation: Keep the eye moist with sterile saline, viscous lubricating ointment, or antibiotic ointment. • Patient care: cold compresses for 2–3 days, then hot compress to alleviate pain and swelling • Expected pain: moderate to severe
Table 15.17 / Orthopedic Surgery
Patient
Surgical Technique
• • • • •
Orthopedic pack Pin set Screw set Implant set Periosteal elevator set
• Preanesthetic evaluation • Preoperative protocol • Lateral recumbency • See particular surgery • See Figures 1.4 and 1.5 Skeletal View, page 7.
Procedure Complications
Preparation
Instruments
Orthopedic Surgery
Orthopedic Surgery
Procedural
• Failure of intended surgery • Infection (e.g., osteomyelitis) • Malunion or nonunion from inadequate immobilization
Patient
• Gait alterations
Patient Care
• • • • •
Client Education
• Postoperative care protocol
Follow-Up
Procedure
± Bandage Physical therapy Pain management Standard postoperative care Confine and restrict activity until suture/staple removal or as directed by veterinarian.
CHAPTER 15 / SURGERY
539
15
Table 15.18 / Orthopedic Surgery: Cranial Cruciate Ligament Repair, Femoral Head Ostectomy, and Fracture Repair Procedure
Cranial Cruciate Ligament Rupture
Femoral Head Ostectomy (FHO)
Fracture Repair
Definition
• To stabilize the joint by ↓ or eliminating abnormal forces exerted on the stifle joint because of ligament loss, and thereby to prevent further injury and return the leg to normal function
• Removal of the femoral head and part of the neck to form a fibrous false joint
• To provide stability so fracture healing may occur with the least amount of disruption to the natural healing process
Indications
• Progressive lameness and degenerative joint disease
• Small canines and felines with hip dysplasia or hip injury
• Any type of break in a bone, typically a long bone
Patient • Variable, surgeon preference Preparation • Dorsal or lateral recumbency, rotated to allow placement of the stifle flat on the table when flexed • Prep: hip to tarsus
• Lateral recumbency • Prep: dorsal midline to stifle
• Variable: dependent on fracture site
Surgical Technique
• Fibular head transposition: extracapsular technique using cranial advancement of the fibular head to fix the stifle in external rotation • “Over-the-top” fascia strip: intracapsular technique using a strip of fascia passed through the bone tunnels to mimic the cranial cruciate ligament • “Over-the-top” patellar tendon graft: intra-articular technique using a patellar tendon graft to replace the cranial cruciate ligament • Retinacular Imbrication: extracapsular technique using sutures placed both laterally and medially to stabilize the stifle short-term and allow fibrous tissue to form for long term stabilization • Tibial plateau leveling osteotomy (TPLO): repositioning of the tibial plateau through osteotomy to allow surrounding muscles to provide stifle stability • Tibial wedge osteotomy (TWO): similar to the TPLO except the osteotomy is performed more distal on the tibia • Tibial tuberosity advancement (TTA): repositioning of the tibial crest to allow the patellar ligament to be perpendicular to the slope of the tibial plateau relieving the need for the cranial cruciate ligament
A craniolateral incision is made. The • Cerclage wire: wire placed around hip joint is dissected down and the the bone fracture for stabilization, hip is luxated to allow ↑ visibility. often used with other techniques The femoral head and a portion of • Tension band wiring: wire and the neck are removed with a intramedullary pins placed to fix and combination of a drill, mallet, and apply compression to the tension side osteotome or with an oscillating of a fracture to counteract muscle drill. Remove any irregularities of traction at insertion of muscles the cut bone with rongeurs to • Interlocking nail and intramedullary provide a smooth surface. Suture the pin fixation: pins placed down the joint capsule closed over the intramedullary canal of long bones acetabulum and return all tendons and fixed at either end with screws or and muscles to their original cross-locking bolts location and sutured. Routine • Stack-pinning: multiple intramedullary closure of the tissue in layers is pins placed for internal fixation performed. • Bone plate and screw fixation: screws placed through bone plates along fracture site for stabilization
Notes
• Patient preparation: Scrub midhock to ventral midline with the leg suspended by gauze. • Surgery: Technique chosen is most often based on surgeon’s preference; despite choice, a near 90% success rate is typically seen.a • Surgery: Meniscus integrity must be examined in each patient as the majority of CCL ruptures have a meniscal tear. • Client education: A 4–5-month recovery period is often seen, but the patient should follow veterinarian postoperative instructions for optimal recovery. • Client education: physical rehabilitation often required daily until healed and full function returns; restrictions on use vary between procedure choices • Expected pain: moderate to severe
• Client education: Activity is started immediately after surgery for short periods and return to complete activity typically takes 6–12 months. • Client education: physical rehabilitation often required daily until healed and full function returns • Client education: Permanent limp may be present due to shortened leg length. • Expected pain: moderate to severe
15 a
From Theresa W. Fossum: Small Animal Surgery, St. Louis, 2007, Mosby, p. 1260.
540
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
• Patient preparation: ↑ traction on the affected bone • Client education: Physical activity should be restricted until given approval by veterinarian. • Client education: physical rehabilitation often required daily until healed and full function returns • Client education: Some implants require retrieval later, especially with loosening. • Expected pain: moderate to severe
Table 15.19 / Orthopedic Surgery: Patellar Luxation, Total Hip Replacement, and Triple Pelvic Osteotomy Procedure
Patellar Luxation
Total Hip Replacement
Triple Pelvic Osteotomy (TPO)
Definition
• To stabilize the patella in the trochlea and allow movement of the limb without luxation
• Replacement of the femoral head and acetabular cup with artificial prostheses
• Rotation of the acetabulum portion of the pelvis to help prevent degenerative joint disease in hip dysplasia
Indications
• Patella that luxates spontaneously or with palpation
• Canines >9 months old with a disabling condition of the hip • Placed as late in life as possible
• Young dogs (5–18) months with hip dysplasia and no signs of degenerative joint disease
Patient Preparation
• Dorsal or lateral recumbency • Prep: dorsal midline to tarsus
• Lateral recumbency • Prep: dorsal midline to tarsus
• Lateral recumbency • Prep: dorsal midline to tarsus
Surgical Technique
• Trochlear block recession: to deepen the trochlear groove by forming a flap of cartilage, removing underlying bone, and replacing the flap • Trochlear wedge recession: to deepen the trochlear groove by cutting a wedge of cartilage out and replacing it further recessed into the groove • Tibial tuberosity transposition: transplantation of the attachment of the patellar ligament to a more lateral position, using wires for stabilization • Medial fascial release: release of the medial retinaculum to allow the patella to stabilize in the deepened groove
• A craniolateral incision is made. The femoral head and a portion of the neck is removed and replaced with the prosthetic. The location of the original acetabular cup is widened, and the prosthetic acetabular cup is cemented to the medial pelvic wall. The femoral head is then reduced into the acetabular cup, and the joint is closed tightly. Then routine closure of the tissue in layers is performed. • Cementless caps are also used, allowing bone growth into the shell of the cap. Precise preparation of the femoral canal and acetabulum are required for a tight fit. Often chosen for younger animals.
Three incisions are made into the wing of the ilium, pubis, and ischium around the acetabular cup. The acetabulum is then free to be rotated to provide more dorsal coverage of the femoral head. Bone plates, wires, or screws are then placed to secure the acetabulum in its new position. Routine closure of the tissue in layers is then performed.
Notes
• Surgery: Use of more than 1 technique is often required to prevent reluxation. • Patient care: at least 3 weeks of restricted activity • Expected pain: moderate to severe
• Patient preparation: IV antibiotics are started the day before the procedure, and the surgery site is clipped to check for skin infections. • Surgery complications: infection of implants, loosening and weakening of cement, luxation • Client education: physical rehabilitation often required daily until healed and full function returns • Expected pain: moderate to severe
• Complications: infection and loosening of bone plates • Client education: Restrict to leash walks for 6 weeks or until there is radiograph evidence of complete healing. • Client education: physical rehabilitation often required daily until healed and full function returns • Expected pain: moderate to severe
15
CHAPTER 15 / SURGERY
541
Table 15.20 / Reproductive Tract Surgery
Preparation
Procedure
Reproductive Tract Surgery
Instruments
• General surgical pack • Spay hook
Patient
• • • •
Surgical Technique
Preanesthetic evaluation Preoperative protocol Dorsal recumbency Flush prepuce of male dogs with antiseptic solutions
• See particular surgery.
Follow-Up
Complications
• See Figures 1.15–1.17 Urogenital, page 11–12. Procedural
• • • • •
Adhesions of uterine stump, bladder, or scrotal skin Failure to remove all gonadal tissue completely (e.g., ovarian remnant syndrome) Hemorrhage Peritonitis/sepsis Inadvertent damage to vital urinary structures (e.g., ureters)
Patient
• Vomiting • Inappetance
Patient Care
• Standard postoperative care • Confine and restrict activity until suture/staple removal (typically 5–7 days) or as directed by veterinarian.
Client Education
• Postoperative care protocol
Table 15.21 / Reproductive Tract Surgery: Cesarean Section, Orchiectomy, and Ovariohysterectomy Procedure
Cesarean Section (C-section, Hysterotomy)
Orchiectomy (Alter, Neuter, Castration)
Ovariohysterectomy (Spay, OVH, OHE)
Definition
• Removal of all fetuses from the uterus through the abdomen
• The removal of the testes
• The removal of the uterine body, horns and ovaries
Indications
• Dystocia, uterine inertia, prolonged gestation, fetal death, trauma, or toxemia
• Sterilization, reduction of aggressiveness, wandering, and marking behavior, cancer, traumatic injury, infections, and prostate gland problems
• Sterilization, uterine infections, cancer, uterine torsion, congenital abnormalities, ovarian-induced hormone imbalances, elimination of estrus, and extensive injury
15
542
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.21 / Reproductive Tract Surgery: Cesarean Section, Orchiectomy, and Ovariohysterectomy (Continued) Procedure
Cesarean Section (C-section, Hysterotomy)
Orchiectomy (Alter, Neuter, Castration)
Ovariohysterectomy (Spay, OVH, OHE)
Patient Preparation
• Dorsal recumbency • Prepare xiphoid to pubis. • Prepare as much of the surgical site as possible before induction of anesthesia to limit depression of neonates. • Caution: Avoid narcotic premedications that might compromise fetal condition via placental blood flow.
• Verify the patient is a male, has not previously been neutered, and has 2 palpable testicles. Canine • Dorsal recumbency • Prepare the prepuce to the area surrounding and including the scrotum. Feline • Ventral recumbency • Prepare the area surrounding and including the scrotum.
• Verify the patient is a female and has not previously been spayed. • Dorsal recumbency • Manually express the bladder. • Prepare entire ventral abdomen.
Surgical Technique
A ventral midline incision is made, and the horns of the uterus are exteriorized. The incision is packed with moistened gauze or laparotomy pads to avoid abdominal contamination. An incision is made into the uterus, and one by one each fetus is milked down to the incision and gently pulled out. The fetal membranes are removed to allow breathing and the umbilical cord is clamped 2– 3 cm from the abdomen. Once all the fetuses have been removed, the uterine horns are checked for any remaining fetuses or placentas. The uterine incision is closed, moistened with saline, covered with omentum, and returned to the abdominal cavity. Routine closure of the tissue in layers is performed.
Canine • An incision is made just cranial to the scrotum, and 1 testicle is exposed through the fascia. The entire spermatic cord may be ligated to remove the testicle (closed), or the outer tunic may be incised to reveal the spermatic vessels and cord. These structures are then ligated or knotted onto themselves (open). Gentle traction is placed on the scrotum to allow the remaining tunic tissue to retract into the scrotum. The procedure is repeated for the second testicle. Feline • An incision is made into the scrotum over each testicle in a caudoventral position, and the open or closed technique may then be applied.
A ventral midline incision is made, and the left uterine horn is located. The suspensory ligament is stretched or broken, and the ovary is ligated and detached. The right uterine horn is located, and the broad ligament is broken and the ovary is ligated and detached. Then the uterus is ligated at the stump, and the combined uterus and ovaries are removed. Routine closure of the tissue in layers is performed.
Notes
• Surgical: intense monitoring (especially circulatory) once the neonates are delivered to prevent shock in the dam • Surgery: OVH may be performed at the same time. • Patient care: Bloody vaginal discharge is to be expected for 3–7 days, but copious amount of clotted or foul-smelling vaginal discharge should be reported. • Patient care: Avoid postoperative analgesics that will be passed into the milk. • Client education: Once an animal has had a cesarean section, it is more likely to need one with the next litter and multiple cesarean sections cause scarring at the incision line and may complicate surgery. • Expected pain: moderate
• Patient care: Monitor for scrotal hematoma. • Client education: Insemination is still possible for several weeks after neuter. • Client education: Behavioral changes expected after neutering may take several months to show; and no changes may be seen in animals altered later in life. • Expected pain: mild to moderate
• Patient care: Monitor for extreme listlessness, persistent bleeding, urinary incontinence, and skin problems. • Client education: Animals that are altered early (e.g., 6–12 weeks) have an ↑ risk of urinary incontinence, anesthetic complication, and grow taller. Animals altered after first estrus months have an slight ↑ risk of mammary tumors. • Client education: ↓ caloric intake; the activity of a spayed animal ↓ and so should their caloric intake • Expected pain: mild to moderate
CHAPTER 15 / SURGERY
543
15
Skill Box 15.3 / Postoperative Care of Neonates and Dam Neonate Care 1. Remove fetal membranes and verify that the umbilical cord is temporarily clamped 2–3 cm from the abdomen. 2. Assess the condition: whether a heartbeat can be palpated, clear the mouth and nose of fluid and mucus by gentle suction or cotton swabs. 3. Stimulate respiration. • Rub the neonate briskly with a towel. • Grasp the neonate firmly in both hands and gently swing downward from over head to the floor. • Caution: strong force may cause brain damage. • Administer doxapram (1–2 gtt sublingually or 0.1 ml IV in the umbilical vein) or naloxone (0.01 mg/kg IM or IV). • Place an acupuncture needle or a small-gauge needle (<25 g) between the upper lip and the nose to a depth of 2–4 mm while firmly holding the head extended and elevated above the heart. 4. If the above methods do not produce a neonate that is breathing and crying, emergency resuscitation must take place.
5. Once the neonates are stable, ligate and disinfect the umbical cord and place them in a warm, confined location (e.g., incubator, box with towels, or circulating hot water pad). • Caution: Neonates are often small enough to fall between the bars on a cage door. 6. Place them with the dam as soon as possible to nurse. 7. Verify the neonates are free of congenital abnormalities and are nursing appropriately before discharge. Dam Care 1. Mammary glands should be cleaned of surgical preparation solutions, blood, or fetal fluids. 2. Dam should be allowed to recover from anesthesia alone and then returned to her litter once there is no risk of injury to the neonates. 3. Monitor for the first few hours after surgery for relapses into shock due of uterine hemorrhage. 4. Continue to monitor for appropriate behavior signs of the dam, (e.g., grooming and allowing neonates to nursing). 5. Discharge dam and litter once she is able to stand and continues to show appropriate mothering instinct.
Table 15.22 / Thoracic Surgery
Preparation
Procedure Instruments
• • • • • •
Electrocautery General surgical pack Hemostat pack Retractor pack Suction tips and tubing pack Thoracic pack
Patient
• • • • •
Preanesthetic evaluation Preoperative protocol Oxygen support Dorsal or lateral recumbency See particular surgery.
Surgical Technique
• Ventilation support and circulation monitoring required throughout surgery • See Figures 1.6–1.8 Internal Organs, page 8, CP-1 and Figures 1.9–1.12 Circulatory, page 9–10, CP-1, CP-2.
15
544
Thoracic Surgery
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.22 / Thoracic Surgery (Continued) Thoracic Surgery
Procedural
• • • •
Patient
• Pain • Difficulty breathing
Patient Care
• • • • •
Client Education
• Postoperative care protocol
Follow-Up
Complications
Procedure
Hemorrhage (e.g., hemothorax) Pleuritis/sepsis Pneumothorax Ventricular arrhythymias
Monitor radiographs for signs of pleural effusion. Monitor for pain and discomfort. Pain management Standard postoperative care Confine and restrict activity until suture/staple removal or as directed by veterinarian.
Table 15.23 / Thoracic Surgery: Diaphragmatic Hernia, Laryngeal Paralysis, and Sternotomy Procedure
Diaphragmatic Hernia
Laryngeal Paralysis
Sternotomy, Median
Definition
• Variably sized hole in the diaphragm allowing passage of the abdominal contents into the thoracic cavity
• Enlargement of the glottis to alleviate obstruction while avoiding aspiration of food and saliva
• To gain access to the thoracic cavity by splitting the sternum, structures in the dorsal mediastinum (e.g., esophagus and bronchial hilus) will not be accessible
Indications
• Herniation of liver, spleen, GIT, or omentum into the thoracic cavity
• Respiratory distress
• Cardiac and respiratory diseases, neoplasia, correction of cardiovascular defects, and to obtain biopsy specimens
Patient Preparation
• Dorsal recumbency • Prepare bottom half of sternum to 2–3 inches below umbilicus.
• Lateral recumbency • Oxygen support • Prepare lateral neck.
• Dorsal recumbency • Prepare entire thorax.
Surgical Technique
A ventral midline abdominal incision is made. Any herniated structures are examined for extended strangulation/obstructive damage and then placed back into the abdominal cavity. The abdominal cavity contents, lungs, and pleural space are examined for any further damage. The diaphragm is examined for any other tears and then the defect(s) is sutured closed. A chest tube is placed and maintained for 8–12 hours to ensure control of the pleural space. Air can also be aspirated as the last suture is tied, but does not allow pleural space maintenance if needed. Routine closure is performed on the abdominal wall.
Unilateral arytenoid lateralization: Incise into the lateral neck and dissect to the laryngeal area. Place a suture through the arytenoid cartilage and the cricoid cartilage to abduct the arytenoid cartilage laterally to widen. Lavage the site with sterile saline. Routine closure of the tissue in layers is performed.
An incision is made over the midline on the sternum. The sternum is cut with an oscillating saw or sternal splitter. Retractors are placed, and the exploratory is performed. Before closure, a chest tube is placed if necessary. The thoracic wall is sutured closed in many layers. A pleural vacuum is created through the chest tube, and a light bandage is placed over the tube entrance.
CHAPTER 15 / SURGERY
545
15
Table 15.23 / Thoracic Surgery: Diaphragmatic Hernia, Laryngeal Paralysis, and Sternotomy (Continued) Procedure
Diaphragmatic Hernia
Laryngeal Paralysis
Sternotomy, Median
Notes
• Surgery: IPPV is crucial to allow the surgeon to work while avoiding injury to pulmonary tissue. • Surgery complication: reexpansion pulmonary edema or pneumothorax upon repair • Patient care: Monitor pain, heart rate, CRT, MM color, pulse strength and character, respiratory rate, BP, blood gases, and pulse oximetry. • Expected pain: moderate to severe
• Patient preparation: oxygen support and corticosteroid treatment • Expected pain: mild to moderate
• Instruments: oscillating saw or sternal splitter • Patient complication: pneumothorax, Hemothorax, pulmonary edema • Patient care: Monitor pain, heart rate, CRT, MM color, pulse strength and character, respiratory rate, BP, blood gases, and pulse oximetry. • Expected pain: severe to excruciating
Table 15.24 / Thoracic Surgery: Thoracotomy and Tracheal Collapse Procedure
Thoracotomy, Intercostal
Tracheal Collapse
Definition
• To gain access to one third of the left or right side of the thorax and expose selected thoracic organs via an intercostal approach
• Placement of rings to support and alleviate the obstruction of the trachea from surrounding flaccid cartilage
Indications
• Cardiac and respiratory diseases, neoplasia, correction of cardiovascular defects, and to obtain biopsy specimens
• Dyspnea, exercise intolerance, coughing, gagging
Patient Preparation
• Lateral recumbency • Prepare lateral thorax
• Oxygen support • Corticosteroid treatment • Dorsal recumbency
Surgical Technique
The correct intercostal space is chosen based on the location in the thorax desired. An incision is made from the costovertebral junction to the sternum, and then the muscles are dissected through to the thoracic cavity. The anesthetist is warned that the pleural cavity is about to be punctured. Once the cavity is punctured the lungs will collapse and the thoracic organs are accessed. Before closure, a temporary or permanent chest tube is placed if necessary. The thoracic wall is sutured closed in many layers. A pleural vacuum is created through the chest tube and a light bandage is placed over the tube entrance.
An incision is made along the ventral cervical midline. Dissection is done to the cervical trachea. A prosthetic ring is positioned around the circumference of the trachea and 3–5 sutures per ring are placed to secure. An additional 4–5 rings 5–8 mm apart are placed along the trachea. The site is lavaged with sterile saline and the tissue is closed in layers.
Notes
• Patient complication: pneumothorax, hemothorax, pulmonary edema • Patient care: Monitor pain, heart rate, CRT, MM color, pulse strength and character, respiratory rate, BP, blood gases, and pulse oximetry. • Expected pain: severe to excruciating
• Surgery complications: incorrect ring placement, nerve damage, implant infection • Patient complications: edema, laryngeal paralysis, respiratory distress • Client education: Weight control must be done and harnesses used instead of collars.
15
546
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.25 / Urogenital Tract Surgery
Patient
Surgical Technique
• • • • • • • •
Abdominal pack Curettes pack General surgical pack Saline bowl Saline, warmed Suction tips and tubing pack Syringe, 60-mL catheter tip Urethral catheter(s)
• • • •
Preanesthetic evaluation Preoperative protocol Flush prepuce of male dogs with antiseptic solutions See particular surgery.
Procedure Complications
Preparation
Instruments
Urogenital Tract Surgery
Urogenital Tract Surgery
Procedural
• • • •
Patient
• Stranguria • Urine scalding
Patient Care
• • • • •
Client Education
• Postoperative care protocol
Follow-Up
Procedure
• See particular surgery. • See Figures 1.15–1.17 Urogenital, page 11–12.
Urinary incontinence Stricture formation Hemorrhage Urinary tract infection
Hematuria for 12–36 hours up to 5–7 days is normal Remove catheter 1–2 days postoperatively. Monitor ease and amount of urine production. Standard postoperative care Confine and restrict activity until suture/staple removal.
Table 15.26 / Urogenital Tract Surgery: Cystotomy and Urethostomy, Perineal Procedure
Cystotomy
Urethostomy, Perineal
Definition
• An incision made into the urinary bladder.
• The creation of a new urethral orifice
Indications
• Cystic or urethral calculi, neoplasia, urethral reimplantation, and repair of ectopic ureters
• Recurrent cystic calculi, trauma, urethral stricture or tumor • Typically done in male felines
Patient Preparation
• Dorsal recumbency • Place and secure a urinary catheter and empty urinary bladder. • Prepare from umbilicus to ventral abdomen.
• Ventral recumbency with rear legs draped over end of table and tail secured cranially • Place a purse string suture in the anus. • Place and secure a urinary catheter and empty urinary bladder. • Prepare the entire perineal area, including the base of the tail.
Surgical Technique
A caudal midline abdominal incision is made. The caudal abdomen is examined for additional abnormalities. The bladder is isolated, exteriorized, and packed with saline-moistened gauze sponges, and stay sutures are placed. A ventral cystotomy incision is made into the bladder away from ureters and urethra and between major blood vessels. The bladder is examined for tumors, calculi and a diverticulum. The bladder is flushed by retrograde propulsion via the urinary catheter, and any grit is removed via curettes or suction. The bladder wall is securely closed and distended with saline to check for leakage. Routine closure is performed on the abdominal wall.
An elliptical incision is made around the scrotum, starting halfway between the anus and scrotum. If also neutering, proceed in the normal neuter procedure. The area is dissected down to the urethra, and an incision is made into the dorsal midline of the urethra and enlarged to 3 cm. The urethra mucosa and skin are sutured together to make a single edge around the elliptical incision, leaving a new urethral orifice. The penis is then removed caudal to the urethral incision and sutured. The urinary catheter is removed, and a new one is placed in the new urethral orifice and sutured into place.
• Patient care: Calculi must be sent out for analysis and appropriate medical management started.
• Complications: urethral stricture, rectal prolapse, urocystitis, infection, and fecal and urinary incontinence • Client education: Use shredded paper litter until suture removal.
Notes
CHAPTER 15 / SURGERY
547
15
Table 15.27 / Urogenital Tract Surgery: Urethostomy, Scrotal, and Urethrostomy, Prescrotal Procedure
Urethostomy, Prescrotal
Urethostomy, Scrotal
Definition
• An incision made into the urethra.
• The creation of a new urethral orifice
Indications
• Recurrent cystic calculi, trauma, urethral stricture, or tumor
• Recurrent cystic calculi, trauma, urethral stricture, or tumor
Patient Preparation
• Dorsal recumbency • Prepare from umbilicus to ventral abdomen.
• Dorsal recumbency with rear legs abducted and secured caudally • Place and secure a urinary catheter and empty urinary bladder. • Prepare the prepuce to the area surrounding and including the scrotum.
Surgical Technique
An incision is made from just caudal to the prepuce and cranial to the scrotum. The area is dissected down to the urethra, and the urethra is incised. All calculi are removed, and a catheter is placed in the incision into the proximal urethra to identify further calculi or obstruction. The catheter is also advanced distally to dislodge any calculi in the penile urethra. The urethral incision may be left open to heal by secondary intention or sutured closed.
An elliptical incision is made over the base of the scrotum. If the patient is not neutered, this is done in the normal fashion. The area is dissected down to the urethra and an incision is made into the ventral midline of the urethra and enlarged to 2.5–4 cm. The urethra mucosa and skin are sutured together to make a single edge around the elliptical incision, leaving a new urethral orifice.
Notes
• Complications: urethral stricture • Patient care: monitor renal function, electrolyte concentrations, and hydration status
• Complications: urocystitis and urethral stricture • Patient care: Apply petroleum jelly around incision to ↓ urine scald until ↓ inflammation.
SUTURE TECHNIQUES Suturing provides the hemostasis and tissue support needed for wound healing. As technicians, suturing opportunities may present themselves as closing a surgical incision or necropsy, suturing lacerations, or suturing in
Skill Box 15.4 / Suture Patterns
15
Method
Suture Patterns
Indications
• Traumatic wound closure • Surgical incision closure
Contraindications
• Contaminated wound
Setup
• Suture material • Needle holders
548
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
drains, thoracotomy tubes, or urinary catheters. The decision of the most appropriate type of suture pattern and knotting is important to the success of the suture line.
Skill Box 15.4 / Suture Patterns (Continued) Method
Suture Patterns
Procedure
Simple Interrupted The suture is placed by inserted the needle perpendicular to the plane of the tissue with its ends emerging on opposite sides of the wound an equal distance from the wound edge on each side. The 2 sides of the stitch should be symmetrically placed in terms of depth and width, while maintaining a greater width at the base. A knot is then placed while pulling the skin edges together. • Removal: Lift tags and cut one side of the suture loop and pull the tags to remove the suture. Remove every other suture initially to ensure healing.
Simple Continuous The suture is started by placing a simple interrupted, which is tied, but not cut. A series of simple sutures are placed without interruption while maintaining even spacing and tension. The suture line is tied off by placing a knot using the tail end of the suture and the last loop placed. • Removal: Cut the end suture knot and using thumb forceps, remove the entire suture line.
Continuous Locking The steps are followed according to the simple continuous suture pattern. However, the needle is passed through the loop preceding it as each stitch is placed or the needle passes above the unused suture. • Removal: Cut the end suture knot and, using thumb forceps, remove the entire suture line.
Chinese Finger Trap Place 1–2 stay sutures close to the item (e.g., urinary catheter, thoracostomy tube) to be anchored. Take a long piece of suture material and place through the stay sutures and underneath the anchoring item. Place a square knot on top of the tube and then cross the suture underneath the tube and place another surgeon’s throw over the top of the tube. Continue this pattern 5–10 times and end with a square knot on top of the tube. • Removal: Cut the suture connected to the stay sutures and see Simple Interrupted to remove the stay sutures.
Complications
• Tissue reaction • Wound infection
• Suture line failure and dehiscence
Maintenance
• Keep sutures clean and dry. • Observe daily for red, swelling, and discharge.
• Monitor patient for licking or chewing at suture line, place an E-collar
Tip: All knots should be placed on the same side to avoid getting trapped in clot formation.
Skill Box 15.5 / Knot Tying Square Knot
Surgeon’s Knot
• Place the suture needle (A) on top of the suture end (B), then bring the suture needle (A) under the suture end (B) and pull allowing skin edges to come together. Place the suture end (B) on top of the suture needle end (A), then bring the suture end (B) under the suture needle (A) and pull tight. The second half of the knot is always made in the opposite direction to the first part, to ensure that the knot lies flat. Failure to perform this step opposite to the first results in a granny knot, which is prone to slippage and knot failure.
• Begin with the first step of the square knot, repeat, and then finish with the final step of the square knot. Instrument Tie (Square or Surgeon’s Knot) • For the first throw, the needle end of the suture is wrapped around the tip of the needle holders. The needle holders are then used to grasp the suture end on the opposite side of the suture line. The suture end is pulled through the loop and tightened to allow the edges to come together. The second throw is done in the same manner on the opposite side of the suture line.
CHAPTER 15 / SURGERY
549
15
POSTOPERATIVE CARE PROTOCOL The final success of each surgical procedure often lies in the patient care that follows the procedure. This care begins as the anesthetic gas is turned off and continues with the client at home. Communication is the key through the transition from surgery table to recovery and, finally, when the patient is discharged to the client. Written instructions should be sent home with
the client as often the information is more than can be remembered from one conversation. Clients should be strongly encouraged to call via telephone if any questions or concerns arise. Follow-up telephone calls 1–2 days after a surgical procedure by the staff will also encourage client communication.
Skill Box 15.6 / Standard Postoperative Care Instructions
Skill Box 15.7 / Preventing Self-Trauma
• Medication instructions (e.g., antibiotics, pain) • Rehabilitation and activity instructions (e.g., massage, ROM exercises, confined, leash walks) • Nutrition • Feed only half of the normal food and water the first evening after surgery. • Monitor for vomiting, inappetance, and nausea. • Diet change based on surgical findings (e.g., bladder calculi) • Wound Care • Check incision daily for redness, swelling, discharge, odor, warm to the touch • Prevent licking, chewing, or rubbing at incision line, sutures and staples • Keep the animal and/or bandages dry and clean until suture or bandage removal • Avoid bathing or swimming until suture removal or for 5–7 days with SQ sutures • Follow up • Appointments (e.g., rechecks, suture or drain removal, labwork, radiographs) • Lab results • Phone if any of the following occur • Repeated vomiting • Extreme listlessness • Bleeding or discharge • Loss of appetite for >24 hours • Opened incision lines or unexplained swelling (e.g., seroma)
Rarely will an animal disturb an incision line out of boredom, more often it is due to pain, irritation (e.g., tight sutures, cleaning solutions, clipper burn), infection or rough tissue handling. When an animal begins to bother their incision line (e.g., licking, chewing, rubbing) investigation into why is warranted and possibly implementing the following ideas:
15
550
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
1. Use an Elizabethan collar (e-collar, neck brace, etc.) at all times 2. Apply a bandage (e.g., soft padded bandage, hobbles, or SchroederThomas splint with sheet aluminum) 3. Foul-tasting substance (e.g., bitter apple, atropine, Tabasco, or thumb-sucking preparations) 4. Cover the area with a sock, baby t-shirt, or stockinette 5. Body brace, side bar, or tail-tip protector
ALTERNATIVE SURGICAL OPTIONS Table 15.28 / Endoscopy: Flexible Gastrointestinal and Rigid
Endoscopy has quickly become a popular technique for minimally invasive procedures. Its primary indications are vast and include visualization of the GIT, respiratory tract, peritoneal cavity, pleural cavity, urinary bladder, and joints. The examination of these structures can allow direct visualization of the structure to aid in further diagnosis (e.g., biopsies, brushings, washes) along with performing often curative procedures (e.g., foreign body retrieval, polyp or tumor removal, dilation of strictures, cartilage and bone fragment removal). Due to the delicate nature of this specialized equipment and the potential patient complications with their use, only trained individuals should operate this equipment. Arthroscopy is a specialized endoscopic procedure that has become very common among specialty practices and therefore is widely available. This procedure is performed with the use of a rigid endoscope and is used to evaluate diseases of the shoulder, elbow, hock, hip, and stifle joints of canines (size limitations). Evaluation can lead to a diagnosis and/or treatment. Procedure
Flexible Gastrointestinal Endoscopy
Rigid Endoscopy
Definition
• Flexible endoscopy is used to evaluate the internal surface of hollow structures through a natural opening. Most commonly, it is used for gastroscopy, enteroscopy, rhinoscopy, and bronchoscopy. Flexible endoscopes are a greater financial investment and require more extensive training to use properly when compared to the rigid endoscope.
• As its name suggests, a rigid endoscope is a stiff tube that can not change directions (e.g., turn corners), but with a lens at its tip, it is able to look back upon itself. It is most commonly used for arthroscopy, cystoscopy, laparoscopy, otoscopy, rhinoscopy, thoracoscopy, urethroscopy, and vaginoscopy.
Indications
• Internal evaluation of the GIT, respiratory tract, nasal passages, urinary tract • Biopsies, brushes, washes, foreign body retrieval, polyp or tumor removal, esophageal stricture dilation, feeding tube placement
• Internal evaluation of the GIT, respiratory tract, nasal passages, urinary tract, joints, thoracic and abdominal cavities • Biopsies, foreign body retrieval, polyp or tumor removal, joint cartilage and bone fragment removal, chest tube placement
Equipment
• Endoscope and variety of telescopes • Accessory instruments (e.g., biopsy forceps, cytology brushes, balloon dilating catheters) • Retrieval instruments (e.g., coin-retrieval device, rat’s tooth forcesp, 4-wire basket)
• Endoscope and variety of telescopes • Trocar-cannula unit (e.g., arthroscopy sheath, cystoscopy sheath) • Accessory instruments (e.g., biopsy forceps, aspiration, cautery, CO2 insufflators, motorized shavers, diode lasers)
Technique
Patient should be NPO for 24–36 hours. The patient is anesthetized, placed in left lateral recumbency and a mouth gag is inserted. The scope is advanced into the GIT through the center of the lumen while distending the lumen with air and observing the surrounding structures. At completion, the endoscope is removed while observing for hemorrhage and evacuating any infused air. The patient is then recovered.
Depending on the procedure (e.g., laparoscopy), the patient should be NPO for 12–24 hours. The patient is sedated or anesthetized and the area to be examined is surgically prepped. A cannulae is inserted (e.g., laparoscopic cannulae is inserted into the abdomen) to allow insertion of the endoscope and to avoid repeated trauma to tissues and leakage of insufflated gas. Additional instruments (e.g., light source, drainage needle) are placed to form a triangle based on the endoscope placement. At completion, the instruments are removed, incision sites are sutured closed and the patient is recovered.
Precautions
• Iatrogenic trauma (e.g., perforations, organ laceration) • Hemorrhage (e.g., nasal, liver, kidney biopsies, coagulopathies), respiratory compromise (e.g., gastric distention with air), aspiration pneumonia (e.g., dilated esophagus, gastric distention with food), GDV (e.g., gastric distention with air), esophagitis (e.g., reflux)
Notes
• Biopsies: 1. Samples are immediately removed from the biopsy forceps carefully using a 25 gauge needle. 2. Samples are unfolded and placed with the luminal side up on a tissue cassette sponge. 3. Samples are allowed to adhere to the sponge, but are then promptly put in formalin to avoid drying out. • Extremely important to follow manufacturer’s instructions on handling, setup, cleaning, and maintenance. • Endoscopes are handled by the ocular (eyepiece) and overflexion must always be avoided.
15
CHAPTER 15 / SURGERY
551
Table 15.29 / Laser Surgery
Laser use in veterinary medicine continues to advance and additional new uses explored. Despite its claim of ↓ tissue trauma, pain and healing time; safety must be of extreme importance. Many additional steps must be taken before laser equipment is used in the operating room to assure safety of the patient, surgeon and support staff. Procedure
Laser Surgery (Light Amplification by the Stimulation Emission of Radiation)
Definition
• Laser surgery consists of light interaction (reflected, absorbed, scattered, transmitted) with tissue, causing certain effects.
Indications
• • • • •
Equipment
• Several different lasers (e.g., CO2 laser, Nd:YAG lasers, diode lasers) exist with varying wavelengths, delivery, and application techniques. • Endotracheal tubes approved for laser surgery or, less desirably, a red rubber endotracheal tubes wrapped in metal tape
Technique
• The laser tip is focused toward the tissue to be incised and discharged. • Technique is variable depending on desired outcome (e.g., focused laser location for drilling a hole).
Precautions
Exposure risk: ocular damage, burns, inhalation of viable tumor cells • Protective eyewear should always be worn and patient’s eyes should be shielded. • Proper evacuation of noxious smoke • Use blackened or pitted instruments to absorb stray or reflected light. Combustion/fire • Approved endotracheal tubes to avoid explosion of flowing oxygen • A bucket of water and a CO2 fire extinguisher should be within reach. • Use moistened gauze sponges or drapes around the surgical area. • Evacuate or pack the rectum to control methane gas release. • Avoid use of excess iodine or alcohol during skin preparation. • Appropriate warning signs and window barriers should be available.
Side Effects
• ± ↑ Healing time
Notes
• ↓ Amount of postoperative edema, drainage, and pain • Laser surgery continues to ↑ in its indications as new techniques are discovered and perfected
Surgery requiring precise incision, excision, photoablating, and hemostasis (e.g., perianal fistulas, tongue, pinna) Lithotripsy and angioplasty Soft tissue dental procedures Dermatology surgery (e.g., acral lick granuloma) Ophthalmic surgery (e.g., glaucoma, tumors, retinal detachment)
15
552
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Table 15.30 / Radiation Therapy: Teletherapy, Brachytherapy, and Systemic Therapy
Radiation therapy is meant to supply enough radiation to a specific site to cause abnormal cell death while minimizing the amount of surrounding tissue damage. This form of neoplastic treatment is gaining popularity and access as the equipment becomes more available. Its uses and positive outcomes are endless and showing great promise to the treatment of varying types of tumors. Procedure
Teletherapy (External Beam)
Brachytherapy (Interstitial)
Systemic Therapy
Definition
• Radiation therapy delivered from an external source to a specific tissue/tumor site. The affected cells are damaged and then die when attempting to divide. It is used for localized tumors, not appropriate for systemic disease.
• Radiation therapy delivered from an external source to a radioactive implant placed within the tumor site. The affected cells are damaged and then die when attempting to divide. It is used for localized tumors, not appropriate for systemic disease.
• Systemically injecting radioactive material to target specific tissues/tumor sites.
Indications
• Oral, nasal, rectal, perianal, and anal tumors • Soft-tissue sarcomas, mast cell tumors, osteosarcoma, malignant melanoma, lymphoproliferative disorders, and CNS tumors
Equipment
• Megavoltage machine: superficial and deep-seated tumors • Cobalt-60 • Linear accelerators • Orthovoltage machine: superficial tumors
• Isolation ward • Megavoltage machine: superficial and • Radionuclide (e.g., iodine-131) deep-seated tumors • Cobalt-60 • Linear accelerators • Orthovoltage machine: superficial tumors • Sealed needles or seeds that contain radionuclides that emit gamma and/or beta rays
Technique
The patient is anesthetized and positioned in an exact position based on findings from an MRI. Tattoos or other marking methods may be used to ensure proper positioning. The radiation equipment is placed over the desired location and a treatment for 10–15 minutes is administered.
The patient is anesthetized and positioned in an exact position based on findings from an MRI. Tattoos or other marking methods may be used to ensure proper positioning. The radiation equipment is placed over the radioactive implants and a treatment for 10–15 minutes is administered.
• Hyperthyroidism • Metastatic thyroid carcinoma
Administration of radionuclides orally, IV, or by peritoneal or pleural space injection
Precautions • Human exposure risk
• Human exposure risk
Side Effects
• Dependent on site being treated • Patient becomes radioactive with ± environmental contamination. • Often seen near the end of treatment (e.g., hair loss, skin irritation) or months to years after treatment (e.g., necrosis or fibrosis of normal tissue) • Typically limited to the treatment site
• Dependent on site being treated • Iatrogenic hypothyroidism • Patient becomes radioactive with ± environmental contamination • Sore throat, voice change (rare)
Notes
• A series of treatments, termed fractions, given over 2–5 weeks is often necessary for curative effects or weekly fractions for 2–4 weeks to achieve palliative effects. • Cells, both normal and abnormal, can repair themselves within a few hours of irradiation. • Hypoxic cells are radioresistant—certain drugs ↑ oxygenation, which ↓ radiation effects.
• A series of treatments, termed fractions, given over 2–5 weeks is often necessary for curative effects or weekly fractions for 2–4 weeks to achieve palliative effects.
• Patients must remain inside for 2 weeks once discharged and should receive limited contact, especially children <12 years of age and pregnant women. • Line cat box with plastic and dispose of feces and urine promptly. • Hands should be thoroughly washed after contact with the patient, food dishes, or litter pans.
CHAPTER 15 / SURGERY
553
15
Table 15.31 / Temperature Therapy: Hyperthermia and Cryosurgery
The use of temperature has remained a popular complement or alternative to the treatment of neoplastic conditions. This technique has the ease of local treatment with only a few side effects, even though its scope of use is limited to mostly small tumors. Procedure
Hyperthermia
Cryosurgery
Definition
• Destruction of tissue by ↑ the temperature of the lesion and surrounding tissues to >104° F externally or internally
• Destruction of tissue by ↓ the temperature of the lesion and surrounding tissues to <−4° F
Indications
• Lesions <1 cm in diameter and up to 14 cm deep • Oral and facial sarcomas, squamous cell carcinoma, and hemangiopericytoma
• Lesions <1 cm in diameter • Skin and other external areas • Cataract surgery
Equipment
• Handheld radiofrequency, microwave, or ultrasound device
• Liquid nitrogen units • Nitrous oxide tanks
Technique
• Local anesthesia is injected around the treatment site and a biopsy sample is taken. • Tips are placed on either side of the lesion or, if >0.2 cm deep, inserted down the sides of the lesion and then heated twice.
• The area is shaved and cleaned, local anesthesia is injected, and a biopsy sample is taken. • Blood flow should be restricted to the site to prevent warming and to ↑ freezing. • The lesion is rapidly frozen until it has reached <−4° F, slowly thawed, and then refrozen 1–2 more times.
Precautions
• Exhaust or runoff of liquid nitrogen spray may lead to inadvertent freezing of normal tissue on the animal or surgical team. • Freezing of mast cell tumors may lead to ↑ erythema and sloughing because of local release of histamine and heparin. • Not to be used when there is bone involvement because of its poor freezing ability and subsequent weakening of bone
Side Effects
• Pain after treatment for 1–2 days • Burns • Loss of hair or change in color of skin pigment or fur at treatment site
• • • • •
Notes
• Whole-body hyperthermia is performed at only a few research institutions. • Hyperthermia and radiation therapy are often combined because of their synergistic effects.
• Liquid nitrogen is available in cans with spray nozzles, allowing treatment of larger lesions. • Sedation might be required because of the pain involved in the freezing and the startling hissing noise of the unit. • Cryosurgery has often been replaced by radiation therapy and laser surgery.
15
554
SECTION FIVE: ANESTHESIA AND ANESTHETIC PROCEDURES
Burns Loss of hair or change in color of skin pigment or fur at treatment site Swelling, with resolution within 48 hours Excessive bleeding because of subsequent vasodilation after biopsy and freezing Odor from accumulated exudate and necrotic tissue
Section
Six
Complementary and Alternative Veterinary Medicine and Pharmacology Chapter 16: Complementary and Alternative Veterinary Medicine 557 Chapter 17: Pharmacology 567
Chapter
16
Complementary and Alternative Veterinary Medicine Complementary and Alternative Veterinary Medicine (CAVM) 558 Physical Therapy and Rehabilitation 558 Traditional Chinese Medicine 562 Ayurveda and Chiropractic 563
a
Flower Essences and Homeopathy Laser Therapy 565 Magnetic Field Therapy 565 Western Herbal Medicine 566
564
Key Words and Termsa
Abbreviations
Additional Resources, page
Cryotherapy Fibrosis Goniometry Phytotherapy Prophylaxis Proprioception Proteoglycans Thrombophlebitis
AVMA, American Veterinary Medical Association BCS, body condition score CAVM, complementary and alternative veterinary medicine CHM, Chinese herbal medicine ECG, electrocardiogram gtt, drop oz, ounce PEMF, pulsed electromagnetic field therapy PST, pulsed signal therapy ROM, range of motion TCM, traditional Chinese medicine US, ultrasound
Pain management, 379 Surgery, 521
16
Key words and terms are defined in the glossary on page 631.
557
COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE (CAVM) The desire to provide alternative therapies by both owners and the veterinary profession continues to gain popularity. The use of complementary, alternative or integrative veterinary medicine has been termed complementary and alternative veterinary medicine (CAVM) by the AVMA. This phrase includes a wide variety of therapies such as aromatherapy; Bach flower remedy therapy; energy therapy; low-energy photon therapy; magnetic field therapy; orthomolecular therapy; veterinary acupuncture, acutherapy, and acupressure; veterinary homeopathy; veterinary manual or manipulative therapy (similar to osteopathy, chiropractic, or physical medicine and therapy); veterinary nutraceutical therapy; and veterinary phytotherapy. By integrating traditional Western medical techniques with complementary modalities, the focus remains on the mental, emotional, and physical health of the patient. This section provides a brief survey of various types of CAVM. It is meant to introduce the technician to other options that might complement an existing medical plan or be used as an alternative. The philosophies and techniques should only be performed by properly trained individuals and in some cases only by a licensed veterinarian with additional training and degrees in the particular area.
PHYSICAL THERAPY AND REHABILITATION Physical therapy is often implemented following musculoskeletal and neurological injuries or surgeries to strengthen muscles, increase flexibility and range of motion, and decrease pain. Evaluation of a patient prior to beginning physical therapy will allow a means for measuring the patient’s progress. Routine evaluations to assess stability of any surgical repair, the condition of the tissues involved, and verify progress is being accomplished are a vital part of the rehabilitation protocol. Progress is expected and also provides encouragement to the owner.
Examinations • Physical examination (see Table 2.2 Physical Examination, page 18) • Body condition scoring system (see Table 3.2 Body Condition Scoring System, page 61) • Pain evaluation (see Chapter 9 Pain Management, page 379) • Neurologic examination (see Skill Box 2.7 Neurologic Examination, page 34) • Orthopedic examination (see Skill Box 2.8 Orthopedic Examination, page 36) • Gait analysis • Evaluate the patient during a multitude of gaits (e.g., standing, sitting, walk, trot, running, stairs) and circumstances (e.g., walking toward, walking away, various surfaces, viewed from both sides, weight bearing). • Radiographic examination (see Chapter 5 Imaging, page 157) Measurements • Joint goniometry • Measurements are taken to evaluate a joint’s range of motion using a goniometer. • The joint angle (e.g., hip, stifle, tarsus, shoulder, elbow, carpus) is measured in a standing position, flexion, or extension. • Comparison measurements are taken with opposite joint. • Measurements obtained will vary between breed and BCS. • Muscle girth • Relative measurement taken of the circumference of the proximal and distal forelimb and hindlimb • Comparison measurements are taken with opposite limb. • Measurements obtained will vary between breed, BCS, limb position, and measurement position
16
558
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Skill Box 16.1 / Physical Therapy and Rehabilitation Effect
Technique
Uses
Comments
• Swimming • Underwater treadmill • Gait patterning • Exercises, massage, and stretching can be done before, during, or after water treatment. • Begun after all wounds have completely healed.
• Osteoarthritis, postoperative orthopedic, gait retraining, neurologic deficits, nerve damage, athletic conditioning
• Action: provides resistance while limiting joint impact • Altering buoyancy, resistance, speed, and temperature allows creation of individual and progressive programs. • Swimming more adequately builds forelimbs versus hindlimbs.
• Various carts and slings are available to assist with mobility.
• Weak, painful, or paralyzed patients
• An adjustment period may be necessary for the patient to acclimate to the new device.
• Ice packs, moldable cold packs, or towels soaked with cold water are laid over the affected area for 15–25 minutes. Observe the skin every few minutes for cyanotic changes resulting in frostbite. • Place a wet towel between the cold pack and skin to ↑ conduction and monitor skin color at 10-minute intervals to avoid tissue damage (e.g., frostbite). • Bags with crushed ice provide the greatest deep tissue cooling. • Additional methods: ice massage (rubbing ice over the affected area), cold baths, whirlpools
• Acute injury, postoperative orthopedic swelling and pain, muscle spasms, edema, musculoskeletal trauma (e.g., tendonitis, bursitis, sprains)
• Action: local arteriolar vasoconstriction and ↓ local tissue metabolism • Contraindicated: areas of compromised circulation, ↓ or absent sensation, previous frostbite to that area, cold hypersensitivity
• Orthopedic or neurologic patients • Postoperative, muscle atrophy prevention and/or reformation
• Action: muscle contraction through stimulation from an electrical current • Contraindicated: seizure disorders, thrombophlebitis, pregnant animals, infection • Avoid exposure to eyes, ears, cardiac pacemakers, heart, carotid sinus, areas of malignancy, ↓ sensation, cervical ganglia
Aquatic/Hydrotherapy • ↑ Flexibility, strength, mobility, circulation, endurance, balance, ROM • ↓ Pain
Assisted Mobility Devices • ↑ Mobility, strength, independence Cold Therapy • Cryotherapy • ↑ Arteriolar vasoconstriction • ↓ Bleeding, metabolism, pain, muscle spasm, edema formation
Electrical Stimulation, Neuromuscular • ↑ ROM, muscle strength and tone, wound healing, blood and lymph circulation, delivery of topical drugs (iontophoresis) • ↓ Pain, muscle spasms, edema
• Clip the area and clean with alcohol. Locate the point where the motor nerve enters the muscle and place an electrode and place another at the distal end of the muscle. Using the lowest possible current, move the motor point electrode around until a good contraction is observed. Treatments are typically 15–20 minutes daily or every other day.
16
CHAPTER 16 / COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE
559
Skill Box 16.1 / Physical Therapy and Rehabilitation (Continued) Effect
Technique
Uses
Comments
• Packs (e.g., washcloths, towels) soaked with water as hot as can be tolerated and laid over the affected area for 30–45 minutes on and off cycles, reheating as necessary. Skin should be observed for red, mottled areas or white areas. • Plastic wrap can be placed over the wet towel to trap heat. • Additional methods: warm baths, whirlpools (see Aquatic Therapy)
• Areas of minimal soft tissue (e.g., joints) prior to stretching, pain relief, relaxation • Muscle spasms, tissue tightness, adhesions (↓ scar tension), subacute and chronic traumatic and inflammatory conditions • ↓ Ischemia via vasodilation
• Action: ↑ Blood vessel diameter and ↓ smooth muscle tone • Superficial heat to no more than 3 cm, typically 0–0.5 cm • Contraindicated: fever, acute inflammation, active bleeding, ↓ or absent sensation, neoplasms, active infection, areas of compromised circulation • Typically started 72 hours post surgery or injury (the healing phase after most inflammation is gone)
• In a quiet area, the patient is placed in a comfortable position, and gentle stroking of the affected area is begun. Begin massaging from the distal end moving proximal for approximately 30 minutes. • Effleurage: broad stroking motion applied to the long lines of the muscle fibers moving toward the heart. The hands always remain in contact with the skin; firm pressure is used toward the heart and a lighter pressure is used when moving away from the heart. Affects connective tissue, blood flow, and lymphatic flow and promotes relaxation. • Pétrissage: hands are placed in a “C” shape and superficial and deeper soft tissues are lifted, rolled, and kneaded together. ↑ Blood flow and ↓ muscle stiffness • Cross-friction: a finger or thumb is used at a single point to rub tissue against each other (rotary motion) while moving in a pattern. • Tapotement: tapping or drumming motion of the fingers or hands to stimulate nerve endings or provide a sedative effect
• Orthopedic or neurologic patients • Postoperative, muscle spasms, tissue tightness, adhesions
• Action: ↑ circulation, release scar tissue, balance muscle function and relaxation • Contraindicated: acute inflammatory conditions, infections, unhealed incisions, unstable fractures, absent sensation, bleeding disorders • Avoid: eyes, throat, kidneys, brachial plexus, deep abdomen
Heat Therapy • Hyperthermia • ↑ Vasodilation, oxygenation, ROM, enzyme activity, muscle relaxation • ↓ Pain, joint stiffness
Massage • ↑ Relaxation, circulation, flexibility • ↓ Pain, edema, muscle spasms, fibrosis • Most studies done in humans with extrapolation to small animals
16
560
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Skill Box 16.1 / Physical Therapy and Rehabilitation (Continued) Effect
Technique
Uses
Comments
• Begin with the most proximal joint and move distal. Place a hand above and below the joint to stabilize. Guide the limb through 10 alternating flexions and extensions on each joint while holding for 10–30 seconds. Then cycle the entire limb through small circles advancing to full ROM 10 times. • All stretches should begin pain free and then slowly move beyond while remaining comfortable for the patient. • Perform on each joint separately postoperative and patients with ↓ mobility. • Avoid damage to ligaments and tendon by avoiding hyperflexion of carpus and tarsus. • Perform 3 times daily.
• Orthopedic or neurologic patients • Postoperative (analgesics may be needed 30–60 minutes prior to stretching)
• Action: ↓ Dense connective tissues, enhances venous and lymphatic drainage • Contraindicated: joint instability
• Creative exercises are designed for each patient to provide variety for both patient and owner while ↑ the physical activity of the patient. • Exercise examples: standing, sit to stand, stand to down, balance board, controlled walks, Cavaletti rails, therapy balls, obstacle work, stair climbing, land treadmill, wheelbarrowing, dancing
• Orthopedic or neurologic patients • Postoperative, healing phase
• Action: ↑ physical activity • Contraindicated: dependent on patient’s progress
• Clip an area twice the diameter of the probe head and apply ultrasound gel. Apply the ultrasound head and move in a pattern to cover the entire area. Continuously move the head to avoid thermal burns and observe the patient for discomfort. Each treatment is about 5–10 minutes. Stretching and exercises should be done during or immediately following the treatment for maximum benefit. Treatments are initially daily then ↓ as condition improves.
• Pain, muscle spasm, scar tissue contraction, wound healing (e.g., 2 weeks post, chronic), tendonitis, bursitis
• Action: use of sound waves through tissues to cause certain physiological effects (e.g., deep tissue heating up to 5 cm) • Contraindicated: eyes, testes, neoplasms, bony prominences, metal implants, infected wounds, pregnancy, thrombophlebitis, heart, cardiac pacemaker, neck decompressive spinal surgeries
Stretching (Passive Range of Motion, PROM) • ↑ ROM, scar strength, joint and soft tissue flexibility and mobility, joint nutrition, cartilage regeneration, blood flow • ↓ Adhesions
Therapeutic Exercise • ↑ ROM, muscle mass and strength, endurance, balance, proprioception
Therapeutic Ultrasound • ↑ Stretching, blood flow, ROM, scar stretch, wound healing, enzyme activity, delivery of topical drugs • ↓ Pain, muscle spasm (especially deep soft tissues, >3 cm)
16
CHAPTER 16 / COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE
561
Table 16.1 / CAVM: Traditional Chinese Medicine (TCM)
TCM is used as a complement to Western medicine and as an alternative treatment. TCM encompasses 4 aspects: acupuncture, herbal medicine, therapeutic massage, and nutrition. Acupuncture and Chinese herbal medicine are the most commonly used portions of this medical system. Acupuncture itself can have many different techniques: dry-needle acupuncture, acupressure, aquapuncture, electroacupuncture, sonapuncture, laserpuncture, and implantation. The needles themselves also may be stimulated in different ways: electroacupuncture, moxibustion, and manually. The goal is not always to heal the patient; it can also be used to allow the body to be better able to deal with disease conditions. Animals treated with acupuncture may reach death more peacefully and with less suffering. Procedure
Acupuncture
Chinese Herbal Medicine (CHM, Phytotherapy)
Definition
The adjustment of energy, known as Qi, to provide homeostasis, promote healing, and strengthen the body
A complex combination of selected parts of medicinal plants and other products used to help improve and restore internal organ function and balance energy, Qi
Diagnostics
To discover the Qi imbalance: • Thorough history • Pulse strength and rate • Tongue appearance
To discover the Qi imbalance: • Thorough history • Pulse strength and rate • Tongue appearance
Technique
• Insertion of fine-gauge needles into specific sites along the body to regulate bodily function • The depth of the needle, the type of stimulation applied to the needle, and the duration of the treatment are determined by the condition being treated and constitution of the patient. • ± Moxibustion uses a source of external heat over the acupuncture site or the acupuncture needle itself.
• After the diagnosis of an imbalance (excesses or deficiencies), specific herbs are chosen to restore balance. • Any alteration from normal • Long-term chronic degenerative conditions (e.g., arthritis, liver or kidney failure, and autoimmune problems) • Short-term post illness (e.g., chemotherapy and radiation therapy) • Antiviral • Preventatively to strengthen the body • Drug sensitivity • Vague symptoms with no Western diagnosis
Indications
• Any alteration from normal • Long-term chronic degenerative conditions (e.g., arthritis, liver or kidney failure, autoimmune problems) • Short-term post illness (e.g., chemotherapy and radiation therapy) • Preventatively to strengthen the body
• Any alteration from normal
Specialized Equipment
• Sterile, disposable acupuncture needles • Moxa stick • Acupuncture lasers
• Herbs may cause gastrointestinal disturbances, restlessness, and itchy skin as minor side effects, and severe side effects can be deadly.
Precautions
• Incorrect points may lead to worsening condition (e.g., ↑ tumor growth). • Do not perform acupuncture on fatigued animals; after a heavy meal; in animals that are emotional, pregnant, recently bathed, or soon to be bathed; after injections of certain drugs (e.g., atropine and narcotics); or in animals currently taking corticosteroids.
• Some herb formulas can be used for extended periods with little or no side effects.
Comments
• Considered a medical procedure by the AVMA and should only be performed by a licensed veterinarian with postgraduate training in acupuncture
• Considered a medical procedure by the AVMA and should only be performed by a licensed veterinarian with postgraduate training in CHM.
16
562
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 16.2 / CAVM: Ayurveda and Chiropractic Procedure
Ayurveda
Chiropractic
Definition
The use of diet, massage, herbal supplements, and exercise creates balance among the 3 elements of nature and provides a gradual process of healing. The 3 elements of nature, or doshas (Vata, Pitta, and Kapha), constitute the body types; the 7 dhatus constitute body tissues, and the 7 chakras constitute the energy centers.
Chiropractic is the use of manual spinal manipulations to correct misalignments between the spinal column and nervous system, resulting in disturbance of normal biochemical and neurologic function.
Diagnostics
To determine the physical constitution type and mental status of the patient (Dosha) through: • Thorough history and physical examination • Pulse strength and rate • Gross examination of urine, tongue, skin, and nails
• Thorough history and physical examination of the patient • Static and motion palpation • Gait evaluation
Technique
Prevention Therapy • Prophylaxis therapy: specific combination of diet, lifestyle, herbal medicine, and therapeutic purification exercises to strengthen or weaken specific Doshas to establish balance among all 3 Doshas Disease Therapy • Purification therapy: combination of vomiting, enemas, smoke inhalation, and blood letting • Alleviation therapy: combination of basic foods
• Adjustment: contact is made directly to the specific vertebral segment, and a quick controlled thrust is applied along the plane of motion to a controlled depth, speed, and amplitude. • Manipulation: distributes nonthrust force to multiple segments with slow velocity • Variations of the basic technique and additional advanced techniques may be learned.
Indications
• Any alteration from normal and disease prevention
• Lameness, gait changes, inability to sit for long periods, refusing to jump, head and muscle tilting, and muscle atrophy
Specialized Equipment
• None
• ± Activator—small impacting device used to make indirect adjustments
Precautions
• Disease therapy should only be used on patients strong enough to withstand the intense process.
• Patients should also be evaluated by using other diagnostic aids such as radiography, blood work, and electrocardiogram (ECG). • Incorrect adjustment may lead to severe outcomes (e.g., paralysis).
Comments
• Considered a medical procedure by the AVMA to be performed only by a licensed DVM with postgraduate training in ayurvedic medicine
• Considered a medical procedure by the AVMA and should only be performed by a licensed DVM with postgraduate training in chiropractic care • Chiropractic medicine is meant as a adjunct to other forms of veterinary medicine, not as a replacement.
16
CHAPTER 16 / COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE
563
Table 16.3 / CAVM: Flower Essences and Homeopathy Procedure
Flower Essences
Homeopathy
Definition
Flower essences are used to treat the mental and emotional states of a patient on a level of vibrational healing. By addressing the emotional state (e.g., fear, depression, anxiety, trauma) of the patient, the barrier to physical healing is thought to be removed.
The treatment of clinical signs with incredibly small doses of a certain preparation (e.g., herbal, mineral, and animal products). The chosen preparation may actually cause the clinical sign at pharmaceutical or high doses or if given repeatedly to a healthy animal.
Diagnostics
• Thorough history to evaluate the personality, feelings, and mood of a patient
• Thorough history to evaluate the mental, emotional, and physical state of the patient
Technique
• Single or a combination of essences based on the above findings Dosages • Dilute 2 gtt of each essence (up to 5) into 1 oz of mineral water and give 1–4 times daily. • Full-strength essences dropped onto the tongue, rubbed behind the ears, or dropped onto the lips • Add to drinking water, 15 gtt per gallon
• An appropriate remedy or combination of remedies is chosen. • Pellets or tablets are poured into the back of the animal’s mouth from either a folded piece of paper or a hollowed-out cap of the bottle. • Liquid preparations may be dropped into the animal’s mouth or added to a water bowl.
Indications
• Altered mental and emotional health
• Any alteration from normal and disease prevention
Specialized Equipment
• None
• None
Precautions
• Patients may initially experience a few hours of exaggerated symptoms or development of suppressed symptoms as the healing process begins; however, alterations may be needed to alleviate these symptoms if they do not subside on their own.
• Do not touch the remedy. • Incorrect potencies may have no effect if too low, or aggravate the condition if too high.
Comments
• To avoid the 20% alcohol content, the essences can be applied externally or dropped into hot water to allow the alcohol to evaporate. • There is no documentation or standardized preparations available for veterinary medicine. • If an incorrect remedy is chosen, there are no side effects, but no effect is seen at all. • If no results are seen after a few weeks, reevaluate the combination selected. • The most common remedy used is Rescue Remedy, for the relief of fear, anxiety, and trauma. • Flower essences are meant as a adjunct to other forms of veterinary medicine, not as a replacement.
• Considered a medical procedure by the AVMA and should only be performed by a licensed veterinarian with postgraduate training in homeopathy • Homeopathic remedies should be stored away from sunlight, odors, moisture, and magnetic fields. • It is thought by some that all other forms of vibrational or energy medicine (e.g., acupuncture, flower essences, and certain foods) are contraindicated in combination with homeopathy. • If the incorrect remedy is chosen, there are no side effects, but no effect is seen at all.
16
564
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 16.4 / CAVM: Laser Therapy Procedure
Laser Therapy
Definition
Low-energy photon therapy, soft and cold lasers, uses low levels to stimulate surface tissues (1–3 mm). High-power laser therapy using Class IV lasers provides more power, deeper penetration (>4 inches), and a larger surface treatment area. It is the ability of monochromic light to alter cellular function and enhance healing nondestructively.
Diagnostics
• Physical examination and diagnosis
Technique
• The tip of the laser is placed 0–5 cm from the skin for direct application or a beam is used at a distance of 1–50 cm. • Multiple treatments may be needed, with each lasting 3–10 minutes depending on the size of the animal and the area being treated.
Indications
Wound and ulcer healing, stomatitis, gingivitis, tendonitis, postoperative orthopedic and soft tissue pain, osteoarthritis
Specialized Equipment
• Class III therapeutic lasers • Class IV therapeutic lasers • Protective eyewear
Precautions
• Retinal and thermal burns • Contraindicated: patients currently taking steroids or light-sensitive drugs, over regions of hemorrhage, eyes, pacemakers, heart disease, carcinomas, thyroid gland
Comments
• Many parameters must be altered to achieve the desired treatment (e.g., wavelength, waveform, output power, power density). • Improvement is often seen starting the second week of treatment.
Table 16.5 / CAVM: Magnetic Field Therapy Procedure
Static Magnets
Pulsed Electromagnetic Field Therapy
Definition
A disturbed electrical field may lead to physical and emotional pain. Static or stationary magnets applied directly to the area of concern provide continuous treatment in the form of magnet lines of force permeating the area of injury and stimulating healing. Magnetic fields can stimulate metabolism and enzyme action and ↑ the amount of oxygen available to cells.
Pulsed electromagnetic field therapy (PEMF) is a pulsing current undergoing acceleration while moving through a coil of wire producing a magnetic field. Pulsed signal therapy (PST) is one type of PEMF typically used for the treatment of osteoarthritis with good to excellent results. PST allows reconstruction of the disturbed electrical field, leading to ↑ production of proteoglycans and collagen.
Diagnostics
• Physical examination and diagnosis
• Physical examination and diagnosis
Technique
• Placement of magnets either in the cage (e.g., pad) or secured to the affected area on the animal for minutes, hours, or days
• Coils are placed over the area to be treated for 30–60 minutes, as often as daily.
Indications
• Bone and wound healing, epilepsy, pain relief, slowing the growth rate of cancer and bacterial cells
• Nonunion fractures, acute and chronic injury (e.g., tendon, ligament), osteoarthritis, inflammatory joint disorders, wound healing
Specialized Equipment
• Magnets of different strengths (>50 Gauss) and sizes
• Battery-powered therapy devices consisting of several coils of wire, a control box with varying pulse settings, and a power source
CHAPTER 16 / COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE
565
16
Table 16.5 / CAVM: Magnetic Field Therapy (Continued) Procedure
Static Magnets
Pulsed Electromagnetic Field Therapy
Precautions
• • • •
Comments
• Because there is no current research regarding the use of magnets with animals, testimony makes up the background for their use. • The composition and size of the magnetic affect its strength and intensity. • The size and shape of a magnet are related to the depth of penetration.
Magnet strength and size needed for each animal are highly variable. Magnet therapy should begin with lower strengths and for short periods and then ↑ if well tolerated. Discontinue with worsening conditions (e.g., ↑ seizures and lethargy). Do not use with pacemakers or partial cranial cruciate ruptures.
Table 16.6 / CAVM: Western Herbal Medicine Procedure
Western Herbal Medicine
Definition
• The knowledge of various plants and other natural products is combined to provide healing of physical disease. The 3 most common herbal treatments are symptomatic, detoxification, and tonic. Symptomatic treatments are used to treat the actual condition, similar to western medicine. Detoxification treatments are used to cleanse various organs and body systems. Tonic treatments are the long term use of small amounts of herbs to invigorate, strengthen or protect the body.
Diagnostics
• Thorough history and physical examination
Technique
• Tea infusion: place 2 tsp. of dried herbs in a strainer in a heat-resistant cup. Pour 8 oz of water over strainer, cover, and let sit for 10 minutes. Infusion can be stored for 48 hours in a cool place. • Poultices: fresh or dried herbs are boiled for 5 minutes; herbs are squeezed of excess water and allowed to cool. The cooled herbs are applied to the skin and wrapped with gauze for a few minutes to several hours. • Compressions: cotton gauze is soaked in a herbal extract (e.g., infusion, tincture) and applied to the skin • Capsules, tablets, extracts, bulk herbs: can be given directly to the patient or added to food
Indications
• Any alteration from normal
Specialized Equipment
• None
Precautions
• • • • •
Some herbs are not interchangeable between species (e.g., marigold, nutmeg, cocoa, and mistletoe). No dosages exist for herbs, and it can often be through trial and error that the correct amount is discovered. Healing effects may take longer than with medical drugs because of ↓ concentrations. Monitor for adverse reactions (e.g., gastrointestinal disturbances, restlessness, itchy skin). Verify compatibility of herb(s) with any drug currently being administered, avoid use during chemotherapy.
Comments
• • • •
Often requires large amounts of herbs, frequently over a long period Herbs are relatively safe when compared with medical drugs, but they can still be deadly. Herbs are classified as food supplements and are not subjected to the same research on purity, quality, and usage as are medical drugs. Store dried herbs in a cool, dark place for ≤1 year.
16
566
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Chapter
17
Pharmacology Pharmacology 570 Basic Calculations 570 Drug Cross-Reference 571 Antifungal Drugs 574 Anti-infective Drugs 575 Aminoglycosides, Cephalosporins, and Chloramphenicol 575 Fluoroquinolones, Lincosamides, and Metronidazole 576 Penicillin, Sulfonamides, and Tetracyclines 577 Antiparasitic Drugs 578 Antinematodals 578 Antinematodals (continued) 579 Anticestodals 579 Ectoparasitics 580 Ectoparasitics (continued) 580 Cancer/Chemotherapy Drugs 581 Alkylating Agents 581 Anthracycline Antibiotics 582 Antimetabolites 583 Enzyme, Immunomodulating, Synthetic Hormone, and Vinca Alkaloid 584
Cardiovascular Drugs 585 Antianemics 585 Antiarrhythmics 586 Anticoagulants and Calcium Supplements 587 Contractility Enhancers and Positive Inotropic Agents Diuretics 589 Vasodilators 590 Dermatologic Drugs 591 Antiseborrheics 591 Antipruritics/Antihistamines 591 Gastrointestinal Drugs 592 Antidiarrheals 592 Antiemetics 593 Antiulcer Agents 594 Emetics 595 Enzyme, Laxatives, and Lubricants 596 Protectants and Stool Softener 597 Hepatic Drugs 598 Supplements 598 Metabolic Drugs 599 Adrenal Cortex 599
588
567
17
Pancreatic 600 Pancreatic (continued) 601 Parathyroid and Thyroid 601 Musculoskeletal Drugs 602 Anti-inflammatory Drugs 602 Nonsteroidal Anti-inflammatory Drugs 603 Nonsteroidal Anti-inflammatory Drugs (continued) 604 Nonsteroidal Anti-inflammatory Drugs (continued) 605 Protectant, Muscle Relaxer, and Supplement 605 Neurologic Drugs 606 Appetite Stimulator and Cholinergics 606 Autonomic Nervous System: Adrenergic Agents: Alpha Stimulators 607 Central Nervous System: Anticonvulsants 607 Euthanasia Agents and Muscle Relaxers 608 Analgesics 609 Analgesic/Anticonvulsant, NMDA Antagonist, and Narcotic Agonist 610 Analgesic: Opioids 611 Analgesic: Opioids (continued) 612 Behavioral: Antidepressants 613
17
568
Ophthalmic Drugs 613 Adrenergic Agonist, Carbonic Anhydrase Inhibitors, and Immunosuppressant 613 Miotics, Mydriatics/Cycloplegics, Topical Anesthetics, and Stains 614 Otic Drugs 615 Topical Anti-infectives 615 Renal/Urinary Drugs 616 Acidifers, Adrenergic Agent, and Alkalinizing Agent 616 Alpha-Adrenergic Agent, Antibacterial/Acidifer, Anabolic Steroid, and Cholinergic 617 Enzyme Inhibitor and Tricyclic Antidepressant 618 Reproductive System Drugs 619 Androgens, Estrogens, and Gonadotrpins 619 Oxytocin, Progestins, and Prostaglandin 620 Respiratory Drugs 621 Antitussives 621 Bronchodilators and Mucolytics 622 Stimulants 623 Toxicologic Drugs 624 Chelating Drugs and Synthetic Alcohol Dehydrogenase Inhibitor 624
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Key Words and Termsa Adulticide Agonist Alopecia Antagonist Antipuritic Anuria Aqueous humor Ascites Ataxia Azotemia Bactericidal Bacteriostatic Candidiasis Chemoreceptor trigger zone Cholestasis Cholinergic Concentration COX-2 Dermatophytosis Diuretics Dosage Dose Edrophonium Emetic Ergosterol Erythema Fungicide Fungistatic Hematopoietic Hyperkalemia Hyperkeratotic Hyperphosphatemia Hypochloremia
a
Hypokalemia Hyponatremia Idiosyncratic Intracellular Keratin Keratolytic Keratoplastic Leukopenia Mesothelioma Microfilaria Miosis Mydriasis Myelosuppressive Nephrocalcinosis Neuropathy Oliguria Ototoxicity Perivascular Peroxidase Phospholipase Polycythemia Polydipsia Polyphagia Seborrheic Tachypnea Teratogenic Tetany Thrombocytopenia Trichophytosis Wolff-Parkinson-White syndrome Züllinger-Ellison syndrome
Abbreviations
Additional Resources, page
ACE, angiotensin-converting enzyme BP, blood pressure BW, body weight C, concentration CBC, complete blood count CHF, chronic heart failure CNS, central nervous system COX, cyclooxygenase DDAVP, desmopressin acetate DES, diethylstilbestrol DIC, disseminated intravascular coagulation DNA, deoxyribonucleic acid DOCA, desoxycorticosterone acetate DOCP, desoxycorticosterone pivalate ECG, electrocardiogram FSH, follicle-stimulating hormone G−, gram-negative G+, gram-positive GABA, γ-aminobutyric acid GIT, gastrointestinal tract HCl, hydrogen chloride HPA, hypothalamic-pituitary-adrenal IHSS, idiopathic hypertrophic subaortic stenosis IM, intramuscular IOP, intraocular pressure IV, intravenous KBr, potassium bromide KCS, keratoconjunctivitis sicca L, liter LH, luteinizing hormone LOX, 5-lipoxygenase LRS, lactated Ringer’s solution MAOI, monoamine oxidase inhibitor mg, milligram mL, milliliter NSAID, nonsteroidal anti-inflammatory drug PCV, packed cell volume PD, polydipsia pH, potential of hydrogen PSGAG, polysulfated glycosamino-glycans PU, polyuria PZI, protamine zinc RBC, red blood cell RNA, ribonucleic acid SAMe, S-adenosylmethionine SQ, subcutaneous SSRI, selective serotonin reuptake inhibitor T3, triiodothyronine UTI, urinary tract infection V, volume vWF, von Willebrand’s factor
Chemotherapy administration, 352 Drug administration, 348 Ectoparasites, 145 Endoparasites, 139 Fluid requirement calculations, 361 Fluid therapy, 359 Laboratory, 71 Nutrition, 57 Pain management, 379 Patient care, 329 Radiotherapy, 553 Urinalysis, 147
Key words and terms are defined in the glossary on page 631.
CHAPTER 17 / PHARMACOLOGY
569
17
PHARMACOLOGY Although all drugs are prescribed by the veterinarian, the technician is often the person administering the drugs. An awareness of the purpose of the drug used and its interaction with other drugs is essential for monitoring the patient and answering clients’ questions regarding these drugs. All dosages should be double-checked before administration, as should all other medications the patient is currently using and their inter-
actions. New products are constantly being brought to market, and every technician should be reviewing information for new products that are purchased for use in their clinic. Every clinic should have a current veterinary drug book on site. This chapter is meant only to give pertinent technician information. A veterinary drug book should always be consulted if there are any questions regarding a medication’s side effects or interactions. Unless noted, the medications discussed here are to be kept at room temperature.
Skill Box 17.1 / Basic Calculations Type of Calculation
Equation
Example
Dosage calculation using pure drug form
Dose = (Body weight × Dosage of drug) Concentration of drug
A 5 kg cat requires 2.7 mg/kg dosage of Cestex (12.5 mg/tablet): D = (5 kg × 2.7 mg/kg)/(12.5 mg/tablet) D = (13.5 mg)/(12.5 mg/tablet) D = 1.08 tablet Give the cat 1 tablet Cestex (12.5 mg)
Solutions (denoted by their strength as percentages or ratio) • 5% denotes 5 parts of solute in 100 parts solution • 1 : 5 ratio denotes 1 part of solute in 5 parts of solution
Amount of pure drug needed = (amount of solution needed) × (strength required)
Liquids • Make 125 mL of 4% bleach solution D = 125 mL × (4 mL/100 mL) D = 500 mL/100 mL D = 5 mL of bleach Add 5 mL of bleach to 120 mL of water* Solids • Make 200 mL of 5% dextrose solution using the powdered form of dextrose and LRS: D = 200 mL × (5 grams/100 mL) D = 10 grams Add 10 grams powdered dextrose to 200 mL lactated ringers
Dilution of Stock Solution (changing a concentration of solution)
Desired concentration (C1) = Volume to use (V1) Available concentration (C2) Volume to make (V2) Or noted as: (C1 × V2) = (C2 × V1)
Prepare 600 mL of 5% dextrose solution using 50% stock solution and sterile water. You need to find the volume of the stock to use: (5% = 5 mL/100 mL) V1 = (C1 × V2)/C2 V1 = (5 mL × 600 mL)/50 mL V1 = 3000 mL/50 mL V1 = 60 mL Add 60 mL of the 50% stock solution to 540 mL sterile watera
a When dealing with liquids, always extract an equal volume from the container that you are going to put the solution in (i.e., remove 100 mL saline before adding 100 mL of dextrose solution.)
17
570
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Chart 17.1 / Drug Cross-Reference
Key Abbreviation
Body System
CAN CV D GI H M MS N OP OT R REP RU T
Cancer Cardiovascular Dermatologic Gastrointestinal Hepatic Metabolic Musculoskeletal Neurologic Ophthalmic Otic Respiratory Reproductive Renal/urinary Toxicologic
Drug
Category
Page
Acepromazine
GI: antiemetic N: phenothiazine OP: carbonic anhydrase inhibitor R: mucolytics MS: NSAID CAN: antibiotic GI: protectant Antinematodal R: bronchodilator RU: enzyme inhibitor GI: antiulcer GI: antiulcer N: NMDA antagonist Anti-infective GI: antidiarrheal, antiemetic GI: bronchodilator RU: Tricyclic antidepressant CAR: antiarrhythmic RU: acidifier Anti-infective Anti-infective CAR: contractility enhancer GI: antiulcer CV: antiarrhythmic GI: emetic CV: hypotensive
593
Acetazolamide Acetylcysteine Acetylsalicylic acid Actinomycin-D Activated charcoal Albendazole Albuterol Allopurinol Aluminum carbonate Aluminum hydroxide Amantadine Amikacin Aminopentamide Aminophylline Amitriptyline Amlodipine besylate Ammonium chloride Amoxicillin Ampicillin Amrinone Antacids Anticoagulant Apomorphine Atenolol
613 622 603 582 597 578 622 618 594 594 610 575 592 622 618 586 616 577 577 588 594 587 595 586
Drug
Category
Page
Atropine sulfate
GI: antidiarrheal, antiemetic OP: mydriatic/cycloplegic CAN: antimetabolite N: local anesthetic D: antiseborrheics RU: cholinergic GI: antidiarrheal N: local N: narcotic agonist R: antitussives MS: parathyroid GI: antiulcer CV: calcium supplement CV: calcium supplement CV: vasodilator OP: miotic CAN: alkylating agent MS: NSAID CV: contractility enhancers Anti-infective CAN: alkylating agent Anti-infective
592 614 583 609 591 617 592 609 610 611 601 594 587 587 590 614 581 603 588 575 581 575, 615 590 591 593 617 594 576 593 581 576 613 574 591 621 602 581 613 606
Azathioprine Benzocaine Benzoyl peroxide Bethanechol chloride Bismuth subsalicylate Bupivicaine Buprenorphrine Butorphanol tartrate Calcitroil Calcium carbonate Calcium chloride Calcium gluconate Captopril Carbachol Carboplatin Carprofen Catecholamines Cephalosporins Chlorambucil Chloramphenicol Chlorinated hydrocarbons Chlorpheniramine maleate Chlorpromazine Cholinergic Cimetidine Ciprofloxacin Cisapride Cisplatin Clindamycin Clomipramine HCl Clotrimazole Coal tar Codeine phosphate Corticosteroids Cyclophosphamide Cyclosporine Cyproheptadine Danazol Deracoxib Desmopressin acetate Desoxycorticosterone acetate (DOCA; DOCP) Dexrazoxane Dextromethorphan Diazepam
Ectoparasitic D: antipruritic GI: antiemetic R: antihistamine GI: antiulcer Anti-infective GI: antiemetic CAN: alkylating agent Anti-infective N: behavioral Antifungal D: antiseborrheics R: antitussives MS: anti-inflammatory CAN: alkylating agent OP: immunosuppressant N: appetite stimulant R: bronchospasm manager CAN: synthetic hormone MS: NSAID M: pancreatic M: adrenal cortex T: chelating R: antitussives N: anesthetic, anticonvulsant; appetite stimulant; toxicologic CHAPTER 17 / PHARMACOLOGY
584 603 601 599 624 621 607
571
17
Drug
Category
Page
Drug
Category
Page
Dichlorphenamide Digoxin Dihydrostroptomycin
OP: carbonic anhydrase inhibitor CV: contractility enhancer Anti-infective Antibiotic-aminoglycoside CV: antiarrhythmic T: chelating OT: anti-infective R: antihistamines GI: antidiarrheal CV: positive inotropic
613 588 575
Gabapentin Gentamicin sulfate
N: analgesic OT: anti-infective
586 624 615 591 592 588
GI: stool softener
597
GI: antiemetic CV: contractility enhancer R: stimulant CAN: antibiotic RU: acidifier T: chelating Antiparasitic N: cholinergic CV: vasodilator Anti-infective N: adrenergic CV: contractility enhancer R: bronchodilator OP: adrenergic agonist Anticestodal Anti-infective CV: antianemia MS: NSAID GI: antiulcer Antinematodal N: opioid CV: antianemia Ectoparasitic MS: NSAID D: antifungal M: adrenal cortex MS: anti-infective MS: NSAID OP: stain Anti-infectives CAN: antimetabolite N: behavioral MS: corticosteroid T: synthetic alcohol dehydrogenase inhibitor CV: diuretics
593 588 923 582 616 624 590 606 590 576 607 588 622 613 579 576 585 603 594 578 611 585 580 604 574 599 602 604 614 576 583 613 602 624
Glargine Glipizide Glucosamine Chondroitin Gonadorelin Griseofulvin Heparin Hydralazine Hydrocodone Hyrdocortisone Hydrogen peroxide Hydromorphone Hydroxyzine Imidacloprid Imidazole Insulin Interferon Isoproterenol Ivermectin Kaolin-pectin Ketamine
M: insulin M: insulin MS: supplement REP: gonadotropin Antifungal CV: anticoagulant CV: vasodilators R: antitissuves MS: anti-inflammatory GI: emetic N: opioid D: antihistamine Ectoparasitic Antifungal M: pancreatic CAN: immunomodulating CV: contractility enhancer Antinematodal GI: protectant N: Disassociative anesthetic and NMDA antagonist Antifungal MS: NSAID CAN: enzyme GI: laxative M: thyroid N: anesthetic, numbing agent CV: antiarrhythmic Anti-infective GI: antidiarrheal Ectoparasitic GI: antiulcer and laxative CV: diuretics Anti-infective Antinematodal R: antihistamines N: α2-Agonist REP: progestin REP: progestin Antinematodal MS: NSAID N: opioid RU: antibacterial M: thyroid N: muscle relaxant
610 575, 615 600 600 605 619 574 587 590 621 602 595 611 591 580 574 600 584 588 578 597 610
Diltiazem Dimercaprol Dimethyl sulfoxide Diphenhydramine Diphenoxylate Dobutamine hydrochloride Docusate sodium succinate Dolasetron mesylate Dopamine Doxapram Doxorubicin DL-Methionine D-Penicillamine Ectoparasitics Edrophonium chloride Enalapril Enrofloxacin Ephedrine Epinephrine Epsiprantel Erythromycin Erythropoietin Etodolac Famotidine Fenbendazole Fentanyl citrate Ferrous sulfate Fipronil Firocoxib Flucytosine Fludrocortisone Flumethasone Flunixin meglumine Fluorescein Fluoroquinolones Fluorouracil Fluoxetine Fluticasone propionate Fomepizole Furosemide
17
572
Ketoconazole Ketoprofen L-Asparaginase Lactulose Levothyroxine sodium Lidocaine Lincomycin Loperamide Lufenuron Magnesium hydroxide Mannitol Marbofloxacin Mebendazole Meclizine Medetomidine HCl Medroxyprogesterone Megestrol acetate Melarsomine Meloxicam Meperidine HCl Methenamine Methimazole Methocarbamol
589
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
574 604 584 596 601 586, 609 576 592 580 594 589 576 578 593 609 620 620 578 604 612 617 601 658, 608
Drug
Category
Page
Drug
Category
Page
Methotrexate Methylprednisolone 4-Methylpyrazole
CAN: antimetabolite MS: anti-inflammatory T: synthetic alcohol dehydrogenase inhibitor REP: androgen R: bronchodilators GI: antiemetic CV: antiarrhythmic Anti-infective/antiprotozoal CV: antiarrhythmic REP: androgen Antinematodal GI: antiulcer M: adrenal cortex CAN: antibiotic N: opioid Antinematodal R: stimulant RU: androgen Anti-infective N: cholinergic CV: vasodilators Anti-infective Antifungal GI: antiulcer GI: antiemetic Anti-infective Ectoparasitic N: opioid REP: GI: enzyme
583 602 624 619 622 593 586 576 586 619 578 594 599 582 612 579 623 617 575 606 590 576 574 594 593 576 580 612 620 596
MS: anti-inflammatory CV: antiarrhythmic GI: antiemetic GI: antiemetic GI: antidiarrheal CV: hypotensive OP: anesthetic REP: GI: laxative Antinematodal Ectoparasitic CV: antiarrhythmic GI: antiulcer H: liver supplement D: antiseborrheic Ectoparasitic M: adrenal cortex H: liver supplement R: alkalizing agent CV: antiarrhythmic CV: antiarrhythmic RU: aldosterone antagonist RU: androgen GI: antiulcer Anti-infective D: antiseborrheic GI: emetic MS: NSAID R: bronchodilator REP: androgen
602 586 593 593 592 586 614 620 596 579 580 586 594 598 591 580 599 598 616 586 586 589 517 594 577 591 595 605 622 619
GI: antidiarrheal MS: anti-inflammatory Anti-infective N: anticonvulsant, anesthestic, euthanasia solution N: anticonvulsant RU: α-Adrenergic RU: β-Adrenergic N: cholinergic CV: Inodilator Antinematodal MS: NSAID MS: protectant
592 602 577 607 608 607 617 616 602 588 579 605 605
Prednisolone Procainamide Prochlorperazine Promethazine Propantheline Propranolol Proparacaine Prostaglandins Psyllium Pyrantel Pyrethrins Quinidine Ranitidine S-Adenoylmethionine Salicylic acid Selamectin Selegiline (L-deprenyl) Silymarin Sodium bicarbonate Sodium influx inhibitors Sotalol HCl Spironolactone Stanozolol Sucralfate Sulfonamides Sulfur Syrup of ipecac Tepoxalin Terbutaline Testosterone: (cypionate, enanthate, propionate) Tetracyclines Theophylline Thiabendazole Tobramycin Tramadol HCl Triamcinolone Trilostane Trimethobenzamide Tylosin Vasopressin Vinblastine/vincristine Verapamil hydrochloride Warfarin Xylazine
N: anticonvulsant Anticestodal CV: vasodilator
607 579 590
Anti-infective R: bronchodilator OT: anti-infective Anti-infective N: opioid MS: anti-inflammatory M: adrenal R: antihistamine GI: antidiarrheal M: pancreatic CAN: vinca alkaloid CV: antiarrhythmic CV: anticoagulant GI: emetic N: anesthetic N: stimulant
577 622 615 575 612 602 599 593 592 601 584 586 587 595 482 623
Methyltestosterone Methyxanthines Metoclopramide Metoprolol Metronidazole Mexiletine HCl Mibolerone Milbemycin oxime Misopristol Mitotane Mitoxantrone Morphine sulfate Moxidectin Naloxone Nandrolone deconate Neomycin Neostigmine methylsulfate Nitroglycerin ointment Norfloxacin Nystatin Omeprazole Ondansetron Orbifloxacin Organophosphate Oxymorphone Oxytocin Pancreatic enzyme replacement Paregoric Paramethasone Penicillin Pentobarbital Phenobarbital Phenoxybenzamine Phenylpropanolamine Physostigmine Pimobendan Piperazine Piroxicam Polysulfated glycosaminoglycans Potassium bromide Praziquantel Prazosin
Yohimbine
CHAPTER 17 / PHARMACOLOGY
573
17
ANTIFUNGAL DRUGS Table 17.1 / Antifungal Drugs Drug Class
Antifungals
Drug (Trade Name)
• Clotrimazole (Lotrimin, Mycelex) • Imidazole (Enilconazole)
• Flucytosine
• Griseofulvin (Fulvicin, Grisactin, and Grifulvin)
• Ketoconazole (Nizoral, Ketofen)
• Nystatin (Panalog and Mycostatin)
Action
• Inhibits membrane synthesis
• Interferes with RNA and protein synthesis
• Inhibits mitosis of fungi
• Inhibits ergosterol synthesis in the fungal cell membrane
• Fungistatic and fungicidal
• Mainly execreted unchanged
• Liver
• Liver
Metabolized Indications
• Candida stomatitis, localized dermatophytosis, and canine nasal aspergillosis
• CNS cryptococcosis; candidiasis
• Mycotic infections (trichophytosis and dermatophytosis)
• Systemic mycotic infections (Malassezia canis, candidiasis and dermatophytosis) and superficial skin infections
• Candidiasis and Malassezia canis
Dispensible Forms
• Topical
• Capsule
• Tablet
• Tablet and topical
• Topical
• Renal, hepatic, hematologic disease, bone marrow suppression
• Felines and pregnant animals have ↑ toxicity due to metabolizing difficulties.
• May ↓ testosterone and fertility in stud canines • Hepatic disease or thrombocytopenia
• Hepatocellular disease • Pregnant animals
• Patients taking antisecretory drugs, antacids, anticonvulsants, cyclosporine, and cisapride • Pregnant animals
• Monitor renal, hepatic function, and CBC
• Monitor for toxicity (anorexia, vomiting, diarrhea and lethargy). • Provide a high-fat diet to facilitate absorption.
• Monitor for vomiting, diarrhea, ↓ appetite, and liver dysfunction (jaundice). • Administer with food.
• Monitor for GI upset
• Typically used with other antifungal drugs • ↓ Rate of absorption if given with food
• Phenobarbital ↓ absorption • Reaches high concentrations in skin, hair, and nails • Drug effects are seen ≥6 weeks after initiation. • Vaccinations are not recommended during treatment.
• Potentially teratogenic
• Usually combined with other drugs
Cautions
Contraindications
Patient Care/Client Education
Notes
17
574
• Monitor for local irritation, salivation, sneezing, and weight loss. • Wash hands after applying.
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
ANTI-INFECTIVE DRUGS Antibiotics should typically be given with food, unless specifically stated in
drug insert. The signs of an allergic reaction are shock, skin rash, facial or site swelling, swollen lymph nodes, or fever.
Table 17.2 / Anti-infective Drugs: Aminoglycosides, Cephalosporins, and Chloramphenicol Drug Class
Aminoglycosides
Cephalosporins
Chloramphenicol
Drug (Trade Name)
• • • • •
1st Generation • Cefadroxil, cephalexin, cephradine, cephalothin, cefazolin, cephapirin (Kefsol, Ancef, Zolicef, Cefa-drops, Cefa-tabs, Cefazolin) 2nd Generation • Cefamandole, cefaclor, cefoxitin (Mandol, Ceclor, Mefoxin) 3rd Generation • Cefixime, cefotaxime, cefoperaxone, ceftazidime, moxalactam (Suprax, Claforan, Fortaz) 4th Generation • Cefepime
• Chloramphenicol (Amphicol, Chloramphenicol Ophthalmic Ointment, Vedichol Tablets; Amphicol Capsules; Bemocal)
Action
• Bactericidal
• Bactericidal
• Bacteriostatic
Metabolized
• Kidneys
• Liver
• Liver
Indications
• Broad spectrum (mainly G−); but not against anaerobic bacteria • Genitourinary tract infections • Leptospirosis (Ethamycin)
• • • •
• G− & G+ bacteria, Rickettsia spp. • Respiratory illnesses • Need central nervous system (CNS) penetration
Dispensible Forms
• Injectable
• Tablet, injectable, and oral suspensions
• Tablet, capsule, ointment
Cautions
• Do not mix with penicillin in the same syringe as it renders them ineffective.
• Animals (especially felines) may vomit on an empty stomach
• May cause bone marrow suppression (idiosyncratic) • Felines tend to show more sensitivity to the adverse effects of this drug.
Contraindications
• • • •
• Animals taking bacteriostatic drugs • Allergies to penicillin
• Animals taking bactericidal drugs • Pregnant animals • Impaired liver function (drug is a potent liver enzyme inducer) or myocardial dysfunction
Patient Care/Client Education
• Monitor for respiratory paralysis, cardiovascular depression, vestibular toxicity, deafness, and nephrotoxicity. • Use with fluid therapy to support kidneys.
• Monitor for allergic reactions.
• Monitor for allergic reactions.
Notes
• Administer parenterally or topically because of poor absorption in the GIT. • Accumulates in the inner ear and kidneys • Neostigmine is the reversal agent.
• Execreted by the kidneys
• Do not use for >3 weeks. • Execreted by the kidneys
Amikacin (Amiglyde-V, Amikin) Gentamicin (Gentocin, Garasol, Garacin) Neomycin (Biosol, Mycifradin) Dihydrostreptomycin (Ethamycin) Tobramycin (Nebcin)
Ruptured eardrums (topically) Kidney disease (parenterally) Pregnant or young animals Animals taking furosemide
1st Generation: G+ 2nd/3rd Generation: G−/G+ 4th Generation: G−/G+ Cystitis, respiratory, skeletal and genitourinary, skin and soft tissue infections
CHAPTER 17 / PHARMACOLOGY
575
17
Table 17.3 / Anti-infective Drugs: Fluoroquinolones, Lincosamides, and Metronidazole
17
Drug Class
Fluoroquinolones
Lincosamides
Metronidazole
Drug (Trade Name)
• • • • •
• Clindamycin (Antirobe) • Erythromycin (Erythro-100) • Lincomycin (Lincocin)
• Metronidazole (Flagyl)
Action
• Bactericidal
• Bacteriostatic
• Bacteriostatic • Nonspecific anti-inflammatory for intestines
Metabolized
• Liver
• Liver
• Liver
Indications
• G−/G+ bacteria • Genitourinary tract, respiratory, and external auditory infections • Need for soft tissue penetration
• G+ and anaerobic bacteria • Chronic skin, bone, oral, and bladder infections • Neospora caninum and Babesia canis
• G− anaerobic bacteria and Giardia • Diarrhea
Dispensible Forms
• Tablet and injectable
• Tablet, capsule, solution
• Tablet, powder, and injectable
Cautions
• Concurrent use with NSAIDs may cause seizures.
Contraindications
• Growing animals, because it causes articular/ physeal damage • Pregnant animals
• Animals taking kaolin (lincomycin) • Candidiasis infection • Liver insufficiency or cholestasis
• Pregnant animals
Patient Care/Client Education
• Administer 1–2 hours before feeding • Monitor for vomiting, diarrhea, polydipsia, dehydration, and CNS dysfunction. • Keep animals well hydrated
• Monitor for vomiting and diarrhea.
• Monitor for anorexia, hepatotoxicity, neutropenia, vomiting, diarrhea, and CNS signs.
Notes
• ↓ Dosages with kidney disease • Excreted by kidneys
• Excreted in bile or urine
• Clinical signs of toxicity can manifest 7–12 days after initiating therapy. • Do not crush the pills due to a bitter taste.
576
Ciprofloxacin (Cipro) Enrofloxacin (Baytril) Marbofloxacin (Zeniquin) Norfloxacin (Noroxin) Orbifloxacin (Orbax)
• Toxicity can occur even at recommended doses.
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 17.4 / Anti-infective Drugs: Penicillin, Sulfonamides, and Tetracyclines Drug Class
Penicillin
Sulfonamides
Tetracyclines
Drug (Trade Name)
• Amoxicillin (Amoxi-tabs, Biomox, and Robamox-V) • Ampicillin (Polyflex, Amcill, Omnipen) • Potentiated amoxicillin (Clavamox with clavulinic acid)
Short Acting: • Sulfadiazine (Tribissen, Di-Trim) • Sulfamerazine • Sulfamethazine • Sulfamethoxazole • Intermediate Acting: • Sulfisoxazole • Sulfadimethoxine (Albon)
• • • • •
Action
• Bactericidal
• Bacteriostatic
• Bacteriostatic
Metabolized
• Kidneys
• Liver
• Kidneys
Indications
• G+ bacteria • Respiratory, skin and soft tissue infections
• G−/G+ bacteria and protozoa • Respiratory, urinary tract, meningeal, enteric and soft tissue (sulfadimethoxine) and coccidial (sulfadimethoxine) infections
• G−/G+ bacteria, Rickettsia spp., and Bordetella spp.
Dispensible Forms
• Tablet and injectable
• Tablet and solution
• Tablet, powder, solution, and injectable
Cautions
• Do not mix with aminoglycosides. • Resistance to amoxicillin with Bordetella spp. and some E. coli strains
• Ineffective in the presence of pus • Bone marrow suppression with extended use • Use with caution with kidney and thyroid disease. • Not recommended for use for more than 14 days (feline)
• Dairy products, antidiarrheal agents and antacids will interfere with absorption
Contraindications
• Animals taking bacteriostatic drugs
• Liver disease, blood diseases or sulfonamide sensitivity
• Kidney disease (oxytetracycline and minocycline) • Animals taking bactericidal drugs
Patient Care/Client Education
• Administer 1–2 hours before feeding. • Monitor for allergic reactions (shock, skin rash, facial swelling, swollen lymph nodes, and fever).
• Maintain adequate hydration. • Monitor for pruritis, photosensitivity, alopecia, allergic reactions, and keratoconjunctivitis sicca (KCS) (dogs). • Monitor for anemia (Tribissen).
• Monitor for vomiting, diarrhea, hypotension, and anorexia.
• Excreted in the urine
• Causes yellow discoloration of teeth and bones in young animals during enamel development
Notes
Chlortetracycline (Auroemycin) Doxycycline (Vibramycin) Minocycline (Minocin) Oxytetracline (Terramycin, Liquamycin) Tetracycline (Panmycin Aquadrops, Tetracycline Soluble Powder-324, OxyTet 100 Injectable)
CHAPTER 17 / PHARMACOLOGY
577
17
ANTIPARASITIC DRUGS Table 17.5 / Antiparasitic Drugs: Antinematodals Drug Class
Antinematodals
Drug (Trade Name)
Benzimidazoles • Albendazole (Valbazen) • Fenbendazole (Panacur) • Mebendazole (Telmin)
• Ivermectin (Ivomec and Heartgard)
• Melarsomine (Immiticide)
• Milbemycin oxime (Interceptor, Sentinel)
Action
• Interferes with parasite’s energy metabolism
• Interferes with parasite’s CNS
• Interferes with parasite’s metabolism
• Interferes with parasite’s CNS
Metabolized
• Liver
• Liver
Indications
• Ascarids, Hookworms, Whipworms and T. pisiformis tapeworms
• Heartworm microfilariacide (canine) • Most parasites (excl. Demodex, cestodes, and liver flukes) • Ear mites
• Canine heartworm adulticide
• Hookworms, whipworms, and ascarids • Heartworm preventative
Dispensible Forms
• Tablet, paste, and powder
• Tablet and injectable
• Injectable
• Tablet
Cautions
• Liver toxicity (mebendazole)
• Collies and most herding breeds are very sensitive and may develop toxic signs
• Vessel blockage by dead worms • Wear gloves and wash hands after administering
• Shock-like symptoms in dogs with a high level of microfilaria (rare)
• Puppies <6 weeks
• Class IV heartworm disease • Felines
• Monitor for mydriasis, ataxia, vomiting, diarrhea, hypersalivation, tremors, and depression.
• Monitor for swelling or tenderness at the injection site, coughing, emesis, depression, lethargy, fever, and anorexia.
• Monitor for neurologic signs.
• Passes through the blood–brain barrier • Pretesting for heartworm infection should be done before administering.
• Dimercaprol may be used as an antidote.
• Retroactive action on larval forms recently acquired • Test for preexisitng heartworm infection.
Contraindications Patient Care/Client Education
Notes
17
578
• Monitor for vomiting and diarrhea.
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 17.6 / Antiparasitic Drugs: Antinematodals (continued) Drug Class
Antinematodals
Drug (Trade Name)
• Moxidectin (Pro Heart 6)
• Piperazines (Pipa-Tabs, Sergeant’s Worm Away, Purina liquid wormer)
• Tetrahydropyrimidines • Pyrantel (Strongid-T and Nemex)
Action
• Interferes with parasite’s CNS
• Paralyzes the worms
• Interferes with parasite’s CNS
Metabolized
• Kidneys
Indications
• Heartworm preventative
• Ascarids
• Ascarids, hookworms
Dispensible Forms
• Injectable
• Tablet and solution
• Tablet and solution
Cautions
• Heartworm testing is recommended before initiation of treatment.
• Seizure disorders
• Use with caution in animals with liver dysfunction, dehydration, malnutrition, or anemia.
• Chronic hepatic disease or renal disease
• Organophosphates, diethlycabamazine, or piperazines
• Monitor for tremors, ataxia, seizures, emesis, and weakness.
• Monitor for ↑ respiration, sweating, and incoordination. • Safe in pregnant and lactating animals
• Live worms are passed: appropriate environmental cleanup should be implemented.
• Suspensions: shake well prior to use
Contraindications Patient Care/Client Education
• Monitor for depression, ataxia, GIT upset, and swelling at the site of injection.
Notes
Table 17.7 / Antiparasitic Drugs: Anticestodals Drug Class
Anticestodals
Drug (Trade Name)
• Epsiprantel (Cestex)
• Praziquantel (Droncit)
Action
• Reduces worm’s resistance to host’s digestive system
• Reduces worm’s resistance to host’s digestive system
Metabolized
• Liver
Indications
• Tapeworms except Echinococcus spp.
• Tapeworms and Paragonimus infections in dogs
Dispensible Forms
• Tablet
• Tablet and injectable
Contraindications
• Animals <7 weeks
• Puppies <4 weeks old and kittens <6 weeks old
Patient Care/Client Education
• Monitor for vomiting, diarrhea, anorexia, and lethargy.
• Monitor for vomiting, diarrhea, anorexia, and lethargy.
Notes
• Effective with a single dose
• Effective with a single dose • Eggs are passed in feces; appropriate environmental cleanup should be implemented.
CHAPTER 17 / PHARMACOLOGY
579
17
Table 17.8 / Antiparasitic Drugs: Ectoparasitics Drug Class
Ectoparasitics
Drug (Trade Name)
• Fipronil (Frontline, Frontline– Top Spot)
• Imidacloprid (Advantage)
• Lufenuron (Program)
• Organophosphates (Proban) • Chlorinated hydrocarbons (Paramite Dip) • Carbamates (Sevin)
Action
• Disrupt parasite’s neuro-transmission
• Adulticide
• Protein inhibitor in flea egg that prevents the eggs from hatching or the larvae from developing
• Disrupts parasite’s neuro-transmission
Indications
• Fleas and ticks
• Fleas
• Fleas
• Fleas, lice, and ticks
Dispensible Forms
• Liquid
• Liquid
• Tablet and injectable (feline)
• Liquids and powders
Cautions
• Avoid contact with eyes and mouth. • Wear gloves when administering or wash hands thoroughly.
• Avoid contact with eyes and mouth. • Wear gloves when administering or wash hands thoroughly.
• Does not kill adult fleas
• Do not combine the use of multiple organophosphates • Feline show ↑ sensitivity • Wear gloves when adminstering
Contraindications
• Puppies <10 weeks old • Kittens <12 weeks old
• Puppies <7 weeks old • Kittens <8 weeks old
• Puppies <6 weeks old
• Animals <12 weeks old • Pregnant or nursing animals
Patient Care/Client Education
• Monitor for skin irritation at application site.
• Repeated baths may ↓ effectiveness.
• Administer monthly. • A fatty meal may enhance absorption. • Do not split tablets.
• Monitor for bradycardia, respiratory depression, salivation, muscle tremors, convulsions, paralysis, constricted pupils, vomiting and diarrhea.
Notes
• Effective for 4 weeks for ticks and 3 months for fleas
• Effective for 4 weeks
• Takes 30–60 days to reach full effectiveness because of life cycle disruption.
• Atropine can ↓ toxic effects.
Table 17.9 / Antiparasitic Drugs: Ectoparasitics (continued) Drug Class
Ectoparasitics
Drug (Trade Name)
• Pyrethrins and synthetic pyrethroids (Ovitrol, Sectrol, Kiltix)
• Selamectin (Revolution)
Action
• Stimulates parasite’s CNS
• Adulticide and inhibits eggs from hatching
Indications
• Fleas, ticks, ear mites, and flies
• Fleas, ear mites, heartworm prevention, sarcoptic mange (canine), and nematode treatment (feline)
Dispensible Forms
• Liquid
• Liquid
Cautions
17
• Debilated animals
Contraindications
• Animals <6 weeks
• Animals <6 weeks old
Patient Care/Client Education
• Hypersalivation is common.
• Monitor for alopecia at the site of administration, vomiting, diarrhea, anorexia, lethargy, salivation, tachypnea, and muscle tremors.
Notes
• Some are degraded by ultraviolet light, and some lose effectiveness when in contact with synthetic fibers.
• Collie breeds may be sensitive.
580
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
CANCER/CHEMOTHERAPY DRUGS Table 17.10 / Cancer/Chemotherapy Drugs: Alkylating Agents Drug Class
Alkylating Agents
Drug (Trade Name)
• Carboplatin (Platinol)
• Chlorambucil (Leukeran)
• Cisplatin (Cisplatin, Paraplatin)
• Cyclophosphamide (Cytotoxan, Neosar)
Action
• Interrupts DNA replication
• Inhibits DNA and RNA synthesis and base pairing
• Interrupts DNA replication
• Interrupts DNA replication and inhibits DNA synthesis and base pairing
Metabolized
• Liver
• Liver
Indications
• Adenocarcinomas, squamous cell carcinoma and osteosarcomas
• Lymphocytic leukemia, lymphoma, polycythemia vera, multiple myeloma, ovarian adenocarcinoma, and macroglobulinemia
• Canine osteosarcoma, nasal adenocarcinoma, squamous cell carcinoma, transitional cell carcinoma, thyroid carcinoma, mesothelioma, and testicular and ovarian neoplasia
• Lymphosarcoma, hemangiosarcoma, mammary gland carcinoma, mastocytoma, and mammary adenocarcinoma
Dispensible Forms
• Injectable (IV)
• Tablet
• Injectable
• Tablet and injectable
Cautions
• Requires saline diuresis 4 hours before and 2 hours after treatment • Use with caution in patients with active infections, hearing impairment, or preexisting renal/ hepatic disease.
• Use with caution in patients with bone marrow depression.
• Wear gloves and protective clothing when preparing solution (skin contact may cause local reaction).
• Wear gloves when handling, splitting or crushing tablets; drug is absorbed through skin and toxic to humans. • Use with caution with patients with hepatic/renal dysfunction, leukopenia, thrombocytopenia, immunosuppression, or previous radiotherapy.
Contraindications
• Severe bone marrow suppression or sensitivity to platinum containing compounds
Patient Care/ Client Education
• Monitor for GI upset, bone marrow suppression, ototoxicity, alopecia, neuropathy, nephrotoxicity, and emesis (rarely). • Use with caution in patients with active infections, hearing impairment and preexisting renal/hepatic disease.
• Monitor CBC on a regular basis. • Monitor for leukopenia, thrombocytopenia and anemia, cerebellar toxicity, bone marrow suppression, alopecia, and gastrointestinal toxicity.
• Monitor for vomiting, anemia, bone marrow suppression with bimodal nadir, nephrotoxicity, and rarely neuropathy (ototoxicity).
• CBC should be assessed weekly for first 2 months and then monthly; assess urine output for 48 hours after administering. • Monitor for vomiting, gastrointestinal toxicity, bone marrow depression, hemorrhagic cystitis, and alopecia.
Notes
• May modify killed or live virus vaccines • Store at room temperature, protect from light
• Alopecia is more profound in Poodles and Kerry Blues • Refrigerate
• Less nephrotoxic than carboplatin (diuresis not required) • Store at room temperature or freeze (3 weeks), protect from light.
• Response may take 1–4 weeks. • Only used 4–5 months
• Felines, renal impairment, myelosuppression, and sensitivity to platinumcontaining compounds
CHAPTER 17 / PHARMACOLOGY
581
17
Table 17.11 / Cancer/Chemotherapy Drugs: Anthracycline Antibiotics Drug Class
Anthracycline Antibiotics
Drug (Trade Name)
• Actinomycin D; dactinomycin (Cosmegen)
• Doxorubicin hydrochloride (Adriamycin)
• Mitoxantrone (Novantrone)
Action
• Inhibits DNA, RNA, and protein synthesis
• Disrupts DNA and RNA synthesis
• Disrupts DNA and RNA synthesis
• Liver
• Liver
Metabolized
17
Indications
• Bone and soft tissue sarcomas, lymphoma
• Lymphoma, osteosarcomas, solid neoplasia, and sarcomas (hemangiosarcoma, thyroid carcinoma, mammary adenocarcinoma, and mesothelioma)
• Leukemia, lymphoma, mammary adenocarcinoma, and squamous cell carcinoma
Dispensible Forms
• Injectable (IV)
• Injectable (IV—given slowly over 10-minute period in a free-flowing line)
• Injectable (IV)
Cautions
• Use with caution in animals that have had radiation therapy within the past 3–6 months or bone marrow suppression, infection, obesity, or renal/hepatic impairment. • Wear gloves and eye shield. If skin is contaminated, rinse with running water for 10 minutes, then rinse with buffered phosphate solution. If solution gets into the eyes, wash with water immediately; then irrigate with water or isotonic saline for 10 minutes.
• Wear gloves and eye shield. If skin is contaminated, wash with soap and rinse thoroughly. • Pregnant women should not be handling this drug. • Monitor for immediate hypersensitivity reaction (facial swelling, urticaria, vomiting, arrhythmias, and/or hypotension).
• Do not mix with heparin.
Contraindications
• Viral infection
• Myelosuppression, impaired cardiac function
• Myelosuppression, cardiac dysfunction, infection, or prior cytotoxic treatment
Patient Care/Client Education
• Monitor for GI upset, anorexia, anemia, alopecia, bone marrow suppression, and GI toxicity.
• CBC should be analyzed 10 days after initiation and before each treatment. • Monitor for head shaking, pruritis, erythema, vomiting, diarrhea, weight loss, leukopenia, alopecia, bone marrow suppression, and GI toxicity.
• Monitor for depression, vomiting, diarrhea, anorexia, thrombocytopenia, leukopenia, anemia, and sepsis.
Notes
• Store at room temperature, protect from light
• Refrigerate, protect from light
• Related to doxorubicin
582
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 17.12 / Cancer/Chemotherapy Drugs: Antimetabolites Drug Class
Antimetabolites
Drug (Trade Name)
• Azathioprine (Imuran)
• Fluorouracil (Adrucil)
• Methotrexate
Action
• Suppresses primary and secondary antibody responses and is an anti-inflammatory
• Interferes with DNA synthesis
• Inhibits DNA, RNA, and protein synthesis
Metabolized
• Liver
Indications
• Autoimmune disease
• Canine carcinomas and sarcomas
• Lymphoreticular neoplasms, carcinomas, lymphoma, and leukemia
Dispensible Forms
• Tablet and injectable
• Injectable (IV)
• Tablet and injectable
Cautions
• Use with caution in patients with hepatic dysfunction or currently taking allopurinol.
Contraindications
• Not recommended for treatment in felines or pregnant animals
• Not recommended for usage in felines • Debilitated animals
• Preexisting bone marrow suppression, severe hepatic/renal insufficiency, or hypersensitivity to drug
Patient Care/Client Education
• Pregnant women should not handle this medication. • Wash hands thoroughly after handling. • Monitor leukocytes biweekly for first 8 weeks, then monthly. • Monitor for leukopenia, anemia, thrombocytopenia, pancreatitis, jaundice, skin problems, and poor hair growth.
• Monitor for stomatits, diarrhea, leukopenia, thrombocytopenia, anemia and ataxia.
• Monitor for vomiting, nausea, diarrhea, leukopenia, anemia, thrombocytopenia, renal tubular necrosis, bone marrow suppression, alopecia and gastrointestinal toxicity.
Notes
• Store at room temperature and protected from light.
• Store at room temperature and protect from light. • May be given with Leucovorin to ↑ anticancer effectiveness
• Store at room temperature and protect from light. • May be given with Leucovorin to protect healthy cells
• Wear gloves when splitting or crushing tablets.
CHAPTER 17 / PHARMACOLOGY
583
17
Table 17.13 / Cancer/Chemotherapy Drugs: Enzyme, Immunomodulating, Synthetic Hormone and Vinca Alkaloid Drug Class
Enzyme
Immunomodulator
Synthetic Hormone
Vinca Alkaloid
Drug (Trade Name)
• L-asparaginase (Elspar, Oncaspar, Erwinase)
• Interferon (Interferon α2a, Roferon A)
• Danazol (Danocrine, Cyclomen)
• Vinblastine (Velban) • Vincristine (Oncovin, Vincasar)
Action
• Hydrolyzes asparagines into aspartic acid and ammonia
• Regulation of lymphocytes (immunomodulating) and blocks replication of viral cells (antiviral)
• Suppresses LH and FSH and estrogen synthesis and stabilizes RBCs
• Arrests cancer cell division
• Liver
• Liver
Metabolized
a
17
Indications
• Lymphoma, lymphoblastic leukemia, mast cell tumors, and idiopathic thrombocytopenia
• Feline leukemia
• Canine immunemediated thrombocytopenia and hemolytic anemia associated with prednisolone or predisone
• Lymphoid, hematopoietic neoplasms, feline mammary neoplasms, sarcomas, canine venereal tumors, mast cell tumors, and immune-mediated thrombocytopenia
Dispensible Forms
• Injectable (IV, IM, SQ)
• Solution (gently shake)
• Capsule
• Injectable (IV)
Cautions
• Liver disease, diabetes mellitus, infection, history of urate calculi, preexisting renal, hepatic, hematologic, GI or CNS dysfunction
• Hepatopathy (canine), severe cardiac or renal impairment, and undiagnosed abnormal vaginal bleeding
• Use with caution in patients with liver disease, leukopenia, bacterial infections, or neuromuscular disease. • Can cause severe tissue irritation and necrosis if placed perivascularly. Infiltrate with sodium bicarbonate, dexamethasone, or hyaluronidase
Contraindications
• Do not use with methotrexate unless necessary, and then 48 hours between medications is recommended. • Pancreatitis (current or history of having)
Patient Care/Client Education
• Monitor for hypersensitivity, vomiting, diarrhea, hypotension, pruritis, pancreatitis, pain at injection site, DIC, sensitivity to drug and collapse.
Notes
• Store powder in a cool place <8° C; solution in refrigerator (8 hours) and protect from light
• Bacterial infection, leucopenia (Vinblastine)
• Solution of 3 million IU/mL must be diluted into 1 liter of sterile saline, placed into appropriate aliquots, and frozen.a • Refrigerate; do not freeze diluent.
From Dana Allen: Handbook of Veterinary Drugs.
584
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
• Response time may be 2–3 months.
• Wear gloves. • Monitor for constipation, alopecia, gastrointestinal toxicity, peripheral neuropathy, perivascular slough, and leucopenia.
• May ↓ total serum thyroxine (T4) and ↑ T3 uptake (thyroid-binding globulin is decreased) • Stored in tightly sealed containers at room temperature
• Store in the refrigerator and protect from light.
CARDIOVASCULAR DRUGS
Table 17.14 / Cardiovascular Drugs: Antianemics Drug Class
Antianemics
Drug (Trade Name)
• Erythropoieten (Epogen, Marogen, Procrit)
• Ferrous sulfate (Fer-In-Sol, Slow-Fe)
Action
• Hormone that stimulates production of erythrocytes
• Supplements iron
Indications
• Anemia resulting from renal failure
• Iron-deficiency anemia
Dispensible Forms
• Injectable (SQ); do not shake
• Tablet, syrup, elixir
Cautions
• Use with caution in animals prone to seizures.
• Antacids ↓ absorption of iron
Contraindications
• Hypertension, low iron levels, or pregnant/nursing • Animal currently taking desmopression, androgens, or probenecid
• GIT ulcers, enteritis, colitis, and hemolytic anemia
Patient Care/Client Education
• Monitor for fever, arthralgia, rash at the injection site, and seizures (feline). • Monitor packed cell volume (PCV) while on medication.
• Monitor for GIT upset.
Notes
• Store injectable in the refrigerator. • Can be diluted
Metabolized
CHAPTER 17 / PHARMACOLOGY
585
17
Table 17.15 / Cardiovascular Drugs: Antiarrhythmics Drug Class
17
Antiarrhythmics β-Blockers
Calcium Channel Blockers (Class IV)
Sodium Influx Inhibitors (Class I)
Drug (Trade Name)
• • • •
• Amlodipine besylate (Norvasc) • Diltiazem (Cardizem) • Verapamil hydrochloride
• • • •
Action
• Blocks the sympathetic nervous system receptors (β1) in the heart
• Blocks calcium entry into cells via blockade of slow channel
• Inhibits the movement of sodium ions across damaged cell membranes
Metabolized
• Biotransformed in the liver
• Liver
• Liver
Indications
• Cardiac arrhythmias, hypertension, and hypertrophic cardiomyopathy
• Supraventricular tachycardia, atrial flutter, and atrial fibrillation, hypertrophic cardiomyopathy and hypertension (feline)
• Ventricular arrhythmias and atrial fibrillation
Dispensible Forms
• Tablet, capsule, solution, and injectable
• Tablet and injectable
• Lidocaine: injectable (IV: bolus or slow drip) • Procainamide and quinidine: tablet and injectable • Mexiletine: capsules
Cautions
• Use with caution in diabetic animals as it ↓ insulin secretion, hyperthyroidism, renal insufficiency or bronchoconstriction
• Use with caution with liver and kidney impairment and Wolff-Parkinson-White syndrome.
• Do not use lidocaine with epinephrine IV. • Use of quinidine in combination with digoxin may ↑ digoxin concentrations.
Contraindications
• Chronic heart failure, thromboembolic disease, 2nd- or 3rd-degree heart block, bronchoconstrictive disease, and sinus bradycardia
• Hypotension and digitalis intoxication
• Myasthenia gravis, digitalis intoxication and heart block (quinidine) • 2nd- or 3rd-degree AV block or cardiogenic shock (mexiletine)
Patient Care/Client Education
• Monitor dose effectiveness. • Monitor for bradycardia, hypotension, bronchoconstriction, hypoglycemia, and diarrhea.
• Monitor for hypotension, cardiac depression, bradycardia, AV block, pulmonary edema, fatigue, dizziness, nausea, and anorexia.
• Monitor for sedation, shock, seizures, and vomiting (lidocaine). • Monitor for hypotension, vomiting, diarrhea, anorexia, weakness,blood levels and urine retention (quinidine).
Notes
• Propranolol loses its effectiveness over extended usage period. • Store at room temperature protected from light, heat, and moisture.
• Diltiazem is less potent than verapamil. • Store at room temperature protected from light.
586
Atenolol (Tenormin) Metoprolol (Lopressor) Propranolol (Inderal) Sotalol HCl (Betapace)
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Lidocaine (Xylocaine) Mexiletine HCl (Mexitil) Procainamide (Pronestyl, Procan SR) Quinidine (Duraquin, Cardioquin, Quiniglute)
Table 17.16 / Cardiovascular Drugs: Anticoagulants and Calcium Supplements Drug Class
Anticoagulants
Calcium Supplements
Drug (Trade Name)
• Heparin sodium (Heparin)
• Warfarin (Coumadin)
• Calcium chloride
• Calcium gluconate
Action
• Potentiates anticoagulant effects of antithrombin III
• Interferes with clotting and depletes vitamin K
• ↑ Available calcium
• ↑ Available calcium
Metabolized
• Partially metabolized in the liver
• Liver
Indications
• Thrombosis, DIC, and burn victims
• Thromoembolic disease or hypercoagulable disease
• Cardiac arrest and hypocalcemia
• Hypocalcemia, ventricular asystole, severe bradycardia, hyperkalemic cardiotoxicity, and eclampsia
Dispensible Forms
• Injectable
• Tablet
• Injectable
• Injectable
Cautions
• Animals on drugs that interact with platelet function and/or coagulation factors
• Hemorrhagic disease or scheduled for eye or CNS surgery
• Inject slowly to avoid an extravascular injection causing inflammation, tissue necrosis, and sloughing. • Use with caution with nephrocalcinosis. • ↑ Toxicity risk if used with digitalis
• Inject slowly to avoid an extravascular injection causing inflammation, tissue necrosis, and sloughing. • ↑ Toxicity risk if used with digitalis • Use with caution in patients receiving digitalis, with renal or cardiac insufficiency.
Contraindications
• Animals with coagulation disorders
• Ventricular fibrillation, renal calculi, and hypercalcemia
• Ventricular fibrillation, renal calculi, and hypercalcemia
Patient Care/Client Education
• Monitor for bleeding and thrombocytopenia.
• Monitor for bradycardia, arrhythmias, hypotension, and hypercalcemia.
• Monitor for constipation.
Notes
• Do not use heparin flushes or heparin catheters in animals with coagulation disorders.
• Monitor for pale mucous membranes, weakness, dyspnea, prothrombin times, PCV, and feces for blood.
CHAPTER 17 / PHARMACOLOGY
587
17
Table 17.17 / Cardiovascular Drugs: Contractility Enhancers and Positive Inotropic Agents Drug Class
a
17
Contractility Enhancers
Positive Inotropic Agents
β-Adrenergic
Bipyridine Derivatives
Cardiac Glycosides
Catecholamines
Inodilator
Drug (Trade Name)
• Isoproterenol (Isuprel, Iperenol)
• Amrinone (Inocor)
• Digoxin
• Dobutamine HCl • Dopamine • Epinephrine
• Pimobendan (Vetmedin)
Action
• ↑ AV conduction and ventricular excitability and promotes bronchodilation
• ↑ Cardiac output and ↓ pulmonary capillary pressure
• ↑ Cardiac contractility and ↓ heart rate
• Stimulates myocardium
• Inhibition of phosphodiesterase III and stimulates myocardial contractile proteins to calcium
Metabolized
• Liver
• Kidneys
• Dobutamine and epinephrine: GIT and liver • Dopamine: GIT, kidney, liver and plasma
Indications
• Short-term management of incomplete heart block, sinus bradycardia, and sick sinus syndrome
• CHF and cardiomyopathy
• CHF, atrial fibrillation, and supraventricular tachycardia
• CHF, atrial fibrillation, and supraventricular tachycardia
• Canine CHF, mitral regurgitation, and dilated cardiomyopathy
Dispensible Forms
• Injectable and inhalation
• Injectable
• Tablet, capsules, elixir and injectable
• Injectable
• Capsules
Cautions
• Coronary insufficiency, hyperthyroidism, renal disease, hypertension or diabetes
• Use with caution in animals with liver or kidney dysfunction or aortic stenosis
• Dobermans and feline have ↑ sensitivity • Heart failure; glomerulonephritis, IHSS
• Avoid alkalinizing agents when mixing dobutamine (dilute with 5% dextrose solution, e.g., 250 mg in 1 L 5% dextrose)a
• Uncontrolled cardiac arrhythmias
Contraindications
• Cardiac glycoside intoxication
• Ventricular fibrillation or digitalis intoxication
• IHSS (dobutamine HCl) • Ventricular fibrillation or tachyarrhythmia (dopamine), closed-angle glaucoma • Closed-angle glaucoma, diabetes, hypertension (epinephrine)
• Hypertrophic cardiomyopathies
Patient Care/Client Education
• Monitor for tachycardia, tachyarrhythmias, vomiting, and weakness.
• Monitor for anorexia, vomiting, diarrhea, and arrhythmias.
• Monitor for hypertension or hypotension, arrhythmias, dyspnea, anxiety, excitability, and nausea.
• Monitor heart function (BP, ECG, echo studies). • Feed 1 hour after giving medication.
Notes
• Short-term use • Administered via carefully monitored constant rate of infusion
• Monitor for tachycardia, arrhythmias, hypotension, anorexia, vomiting, and diarrhea.
The 5 Minute Veterinary Consult, Canine and Feline, Second Edition.
588
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
• Administer via carefully monitored constant rate infusion.
Table 17.18 / Cardiovascular Drugs: Diuretics Drug Class
Diuretics
Drug (Trade Name)
• Furosemide (Lasix)
• Mannitol (Osmitrol)
• Spironolactone
Action
• Prevents reabsorption of sodium from the renal tubules
• Draws water into the renal tubules
• Aldosterone antagonist
Indications
• CHF with pulmonary edema (reduces preload) • Oliguria
• Prevention/treatment of oliguria • Acute glaucoma • Management of acute cerebral edema
• CHF, ascites
Dispensible Forms
• Tablet, solution, and injectable (IV, slowly)
• Injectable
• Tablet
Cautions
• Animals receiving angiotensin-converting enzyme (ACE) inhibitors to ↓ risk of azotemia, renal/hepatic disease, or geriatric • May cause ototoxicity (feline)
• Use cautiously when intracranial bleeding is suspected, because it may ↑ bleeding.
• Renal/hepatic disease
Contraindications
• Anuria or progressive kidney disease
• Dehydrated patients, pulmonary edema, or anuria
• Hyperkalemia, anuria, Addison’s disease, renal failure, pregnancy, or patients on ACE inhibitors or potassium supplements
Patient Care/Client Education
• Monitor for leukopenia, hypokalemia, hyponatremia, hypochloremic acidosis, dehydration, vomiting, and diarrhea. • PU/PD is common.
• Monitor fluid and electrolyte balances, urine output, and respiration. • Monitor for nausea, vomiting, and dizziness.
• Monitor electrolytes, kidney values • ↑ absorption when administered with food
Notes
• Prolonged use can lead to low potassium levels.
• Do not add to whole blood.
CHAPTER 17 / PHARMACOLOGY
589
17
Table 17.19 / Cardiovascular Drugs: Vasodilators Drug Class
Vasodilators
Drug (Trade Name)
• Captropril (Capoten) • Enalapril (Enacard and Vasotec)
• Hydralazine (Apresoline)
• Nitroglycerin ointment (Nitrobid and Nitrol)
• Prazosin (Minipress)
Action
• Blocks the formation of angiotensin II
• Direct relaxation of the smooth muscle cells in vessels (stimulates angiotensin II release)
• Results in dilation of venous system and “pools” blood in the peripheral tissues to reduce preload
• Blocks vasoconstriction caused by the sympathetic nervous system (blocks α1-receptors)
• Liver
• Liver
• Liver
Metabolized Indications
• Class II–IV heart failure (mainly canine) and hypertension
• CHF and other cardiovascular disorders characterized by high peripheral vascular resistance
• Heart failure and in cases of pulmonary hypertension
• CHF, dilated cardiomyopathy (canine), systemic hypertension, urethral obstruction and pulmonary hypertension
Dispensible Forms
• Tablet
• Tablet and injectable
• Ointment and transdermal patch
• Tablet and capsule
Cautions
• Antihypertensive effectiveness may be reduced if given with NSAIDs. • Use with caution with diuretics and potassium supplements or with patients with renal disease.
• Severe renal disease or intracerebral bleeding
• Wear gloves when applying ointment. • Head trauma
• Chronic renal failure or hypotension
• Hypotension, coronary heart disease, or hypovolemia
• Severe anemia
• Monitor for tachycardia, hypotension, vomiting, diarrhea, and sodium and water retention. • Incompatible with dextrose
• Monitor for hypotension and a rash at the application site.
Contraindications
17
Patient Care/Client Education
• Give on an empty stomach • Monitor electrolytes and kidney function 3–7 days after initiating therapy and periodically thereafter. • Monitor for hypotension, azotemia, hyperkalemia, vomiting, and diarrhea. • Reduce usage slowly per veterinarian’s instructions.
Notes
• Captopril is considered the better choice for patients with liver disease.
590
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
• Rotate application sites • Intermittent use for optimum effect • 1 inch of ointment is ≈15 mg
• Monitor for hypotension, syncope, vomiting, diarrhea, nausea and constipation. • Baseline thoracic radiographs recommended
DERMATOLOGIC DRUGS Table 17.20 / Dermatologic Drugs: Antiseborrheics Drug Class
Antiseborrheics
Drug (Trade Name)
• Sulfur (SebaLyt Shampoo, Allerseb T Shampoo, Sebbafon)
• Salicylic acid (Allerseb T, Sebbafon)
• Coal tar
• Benzoyl peroxide (OxyDex Shampoo, Ben-A-Derm, Pyoben)
Action
• Loosens horny layer of the epidermis, promotes normalization of keratin development and mildly antibacterial
• Promotes normalization of keratin development
• • • •
• Loosens horny layer of the epidermis and promotes normalization of keratin development
Indications
• Seborrhea, mites, lice, chiggers, fleas, dermatophytosis, pyoderma, pruritis, crusts, and scales
• Seborrhea and hyperkeratotic skin disorders
• Seborrhea and as a degreaser
• Seborrhea oleosa, hot spots, skinfold dermatitis, superficial folliculitis, schnauzer comedo syndrome, tail gland hyperplasia, and stud tail (feline)
Dispensible Forms
• Shampoo
• Shampoo
• Shampoo
• Shampoo
Cautions
• Stains; wear gloves
• Stains; wear gloves
Contraindications
• Felines
Notes
• Not recommended for routine bathing
Keratolytic Keratoplastic Antipruritic Vasoconstrictive
• Not recommended for routine bathing
• Not recommended for routine bathing
Table 17.21 / Dermatologic Drugs: Antipruritics/Antihistamines Drug Class
Antipruritics/Antihistamines
Drug (Trade Name)
• Chlorpheniramine maleate (Chlor-Trimeton) • Diphenhydramine (Benadryl)
• Hydroxyzine (Atarax)
Action
• Blocks the histamine receptor on the smooth muscle surrounding the bronchiole and decreases sinus/nasal secretions with an upper respiratory infection
• Acts at peripheral tissues and centrally in the brain
Metabolized
• GIT and liver
• Liver
Indications
• Pruritis and allergic reactions • Relax skeletal, pharyngeal, and laryngeal muscles
• Pruritis and behavioral disorders (compulsive scratching and self-trauma)
Dispensible Forms
• Tablet, capsule, and syrup (chlorpheniramine maleate) • Shampoos, sprays, capsules, tablets, syrup, or injectable (diphenhydramine)
• Tablet, capsule, solution, and injectable
Cautions
• Glaucoma, urinary retention, CNS disorders, GIT disorders, hyperthyroidism, hypertension, or cardiovascular disease • Pregnant animals and neonates
• Bladder neck obstruction, glaucoma, prostatic hypertrophy
Contraindications
• Pregnant animals • Animals on epinephrine
Patient Care/Client Education
• Monitor for sedation, vomiting, and diarrhea.
Notes
• May counteract heparin/warfarin effects
• Monitor for hypotension, drowsiness, dry mucous membranes, seizures, tremors, urinary retention, ↓ appetite, and diarrhea.
CHAPTER 17 / PHARMACOLOGY
591
17
GASTROINTESTINAL DRUGS Table 17.22 / Gastrointestinal Drugs: Antidiarrheals Drug Class
Antidiarrheals
Drug (Trade Name)
• Antibiotic Tylosin (Tylan, Tylocine, Tylosin tartrate)
Anticholinergics • Atropine • Aminopentamide (Centrine) • Propantheline (Pro-Banthine)
• Bismuth subsalicylate (Pepto-Bismol)
Opiates • Diphenoxylate (Lomotil) • Loperamide (Imodium) • Paregoric
Action
• Binds to ribosome and inhibits synthesis (macrolide antibiotic)
• Modifies intestinal motility by blocking the effect of acetylcholine (reduces peristalsis and GIT secretions)
• Blocks hypersecretion (bismuth coats the intestinal mucosa as a protectant; salicylate inhibits the secretion of fluids) • Mild antibacterial properties
• Modifies intestinal motility by ↑ segmental contractions and reducing peristaltic movements
• GIT and liver
• Liver
• Liver
Metabolized Indications
• Colitis
• Diarrhea and vomiting
• Diarrhea
• Diarrhea
Dispensible Forms
• Tablet and powder
• Tablet, solution, ointment, and injectable • Tablet only (propantheline)
• Tablet and solution (shake well)
• Tablet, capsule, and solution
Cautions
• May ↑ serum digitalis levels
• May ↓ GIT secretions and motility • Hepatic/renal disease, hyperthyroid, esophageal reflux, CHF, pediatric, geriatric
• Use with caution in felines; salicylate is absorbed systemically, • ↓ absorption of tetracyclines; separate doses by at least 2 hours • Bleeding disorders
• Head trauma, acute abdominal issues, hyperthyroidism, Addison’s disease, geriatric, or respiratory issues
Contraindications
17
• Heart insufficiencies, suspected bacterial toxin, glaucoma, asthma, intestinal ileus, gastroparesis, and tachycardia
• Heart insufficiencies, septicemia, or patients on MAOIs • Liver disease, obstructive gastrointestinal disease, glaucoma, diarrhea due to a toxin, and obstructive uropathy (loperamide) • Not recommended for felines
Patient Care/Client Education
• May cause pain at site if injected
• Monitor for sinus tachycardia, dry mouth, dry eye, and urinary hesitancy
• Monitor fluid/electrolyte status
• Monitor for constipation, bloating, and sedation
Notes
• Monitor for diarrhea and anorexia.
• Discontinue if diarrhea is present >72 hours (propantheline).
• Eliminated in the feces, resulting in dark, tarry stools. • May be stored at room temperature, but refrigeration improves palatability
• May cause stool discoloration • Discontinue loperamide if diarrhea is present >48 hours. • Diphenoxylate and paregoric are controlled substances.
592
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 17.23 / Gastrointestinal Drugs: Antiemetics Drug Class
Antiemetics Antihistamines
Motility Modifiers
Phenothiazines
Serotonin Antagonist
Drug (Trade Name)
• Meclizine (Antivert) • Promethazine (Phenergan) • Trimethobenzamide HCl (Tigan-canine)
• Cisapride (Propulsid) • Metoclopramide (Reglan)
• Acepromazine (PromAce and Atravet) • Chlorpromazine (Thorazine) • Prochlorperazine (Compazine and Darbazine)
• Dolasetron mesylate (Anzemet) • Ondansetron (Zofran)
Action
• ↓ Neural impulses from the vestibular cranial nerve to the vomiting center
• Blocks the dopamine receptors at the chemoreceptor trigger zone and directly ↑ gastric emptying
• Blocks receptors at the chemoreceptor trigger zone and the vomiting center of the brain
• Antagonizes 5-HT3 (serotonin3) receptors
Metabolized
• Liver
• Liver
• Partially metabolized in the liver
Indications
• Gastroesophageal reflux, vomiting, motion sickness
• Gastroesophageal reflux, gastric motility disorders, vomiting, and constipation (feline)
• Gastroesophageal reflux and vomiting
• Severe vomiting of chemotherapy patients
Dispensible Forms
• Tablet and capsules
• Tablet, oral, and injectable (metoclopramide) (IV slowly) • Compounding pharmacy (Cisapride)
• Tablet, capsule, suppository, and injectable (IV slowly)
• Tablet and injectable
Cautions
• Produces a sedative effect • Affects allergy testing • Prostatic hypertrophy, severe cardiac failure, bladder neck obstructions, pyeloduodenal obstruction, and glaucoma
• Pregnant animals
• ↓ BP and seizure threshold • Possible vasodilation • Check drug’s interactions with other drugs (chlorpromazine) • Liver failure, cardiac disease, geriatric, or debilitated
• Hypokalemia, hypomagnesia, or animals on antiarrhythmic or diuretic drugs
Contraindications
• Allergy testing
• Animals using atropine • GIT obstruction, perforation, or epilepsy (metoclopramide)
• Tetanus, dehydrated patients, or hypovolemic shock
• Atrioventricular block II-III or prolonged QT, (dolasetron mesylate) • Hepatic dysfunction and Collie breeds (ondansetron)
Patient Care/Client Education
• Monitor for sedation. • Travel sickness: give pill 30–60 minutes prior to travel.
• Monitor for sedation or excitement (feline), dyspnea, convulsions, or diarrhea. • Cisapride is typically given 15 minutes before a meal. • Metoclopramide is typically given 30 minutes before a meal.
• Monitor for hypotension, aggression, seizures, and constipation.
• Monitor heart rhythm.
• Metoclopramide is a direct-acting agonist cholinergic
• Protect from light
Notes
CHAPTER 17 / PHARMACOLOGY
593
17
Table 17.24 / Gastrointestinal Drugs: Antiulcer Agents Drug Class
Antiulcer Agents
Drug (Trade Name)
Antacids, nonsystemic • Aluminum carbonate (Basalgel) • Aluminum hydroxide (Amphojel, Dialume, Maalox, and Mylanta) • Calcium carbonate (Tums and Rolaids) • Magnesium hydroxide (Phillips Milk of Magnesia, Riopan, Carmilax, Magnalax, and Rulax II)
Antacids, systemic • Cimetidine (Tagamet) • Famotidine (Pepcid) • Ranitidine (Zantac)
• Misoprostol (Cytotec)
• Omeprazole (Prilosec, Gastrogard)
• Sucralfate (Carafate)
Action
• ↑ Stomach pH to neutralize stomach acids
• Blocks the histamine receptor of the parietal cell thereby ↓ the acidity of the stomach • Neutralize stomach acids
• Protects the GIT mucosa, and ↓ acid secretion
• Directly blocks/ disables parietal cell proton-pump mechanism, thereby shutting down gastric acid production
• Binds to proteins found in the active ulcers
Metabolized
17
• Partially metabolized in the liver
• Liver
Indications
• Gastritis and ulcers • Hyperphosphatemia caused by renal failure
• Gastritis and ulcers
• Ulcer preventative for patients taking NSAIDs
• Gastrointestinal ulceration and gastrinoma (ZollingerEllison Syndrome)
• Gastric mucosa ulcers
Dispensible Forms
• Tablet, capsule, and solution
• Tablet, solution, and injectable
• Tablet
• Tablet
• Tablet and suspension
Cautions
• May interfere with absorption of other drugs • Use with caution in patients with gastric obstruction
• Cimetidine may interfere with absorption of other drugs • Geriatric or hepatic/renal disease
• Cerebral or coronary disease
• Hepatic/renal disease
• GIT expulsion or estrus
Contraindications
• Kidney disease (magnesium) • Alkalosis
• Monitor feces for blood.
• Pregnant or nursing
• Patients being given acid-dependent drugs
• Animals taking antacids
Patient Care/Client Education
• Monitor phosphate levels. • Monitor for constipation (calcium) and diarrhea (magnesium).
Notes
• Poor palatability
594
• Monitor for constipation. • Administer on an empty stomach.
• Monitor for vomiting, diarrhea, flatulence, and discomfort. • Ranitidine is more potent than cimetidine.
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
• Omeprazole is more potent than cimetidine.
Table 17.25 / Gastrointestinal Drugs: Emetics Drug Class
Emetics
Drug (Trade Name)
• Apomorphine (canine)
• Syrup of Ipecac
• Hydrogen peroxide • Warm salt water • Mustard and water
Action
• Stimulates dopamine receptors in the chemoreceptor trigger zone
• Irritates the GIT to stimulate the vagus nerve
• Irritates the GIT to stimulate the vagus nerve
Metabolized
• Conjugated in the liver
Indications
• Initiate vomiting (e.g., acute toxin ingestion).
• Initiate vomiting (e.g., acute toxin ingestion).
• Initiate vomiting (e.g., acute toxin ingestion).
Dispensible Forms
• Tablet
• Suspension
• Solution
Cautions
• May cause CNS depression and prolonged vomiting • Verify with veterinarian or poison control that the substance should be brought back up (e.g., caustic materials)
• High concentrations can lead to toxic effects on the heart • Verify with veterinarian or poison control that the substance should be brought back up (e.g., caustic materials).
• Avoid contact with patient’s eyes and mucous membranes. • Verify with veterinarian or poison control that the substance should be brought back up (e.g., caustic materials).
Contraindications
• Strychnine poisoning, narcosis, or unconscious patients • Patients with respiratory or CNS depression • Ingestion of sharp object
• Animals recently receiving activated charcoal • Ingestion of sharp object
• Ingestion of sharp object
Patient Care/Client Education
• Monitor for bradycardia, hypotension, respiratory depression, sedation, salivation, and prolonged vomiting. • If the tablet was placed in the conjunctival sac, use an eyewash to remove any remaining tablet after vomiting.
• Do not administer with milk, dairy products, or carbonated beverages.
Notes
• The tablet also may be dissolved in a syringe with saline and injected SQ. • Do not use discolored tablet.
• Do not exchange “extract of ipecac” for “syrup.”
Note: Xylazine is also used as an emetic, see Table 13.17, page 482.
CHAPTER 17 / PHARMACOLOGY
595
17
Table 17.26 / Gastrointestinal Drugs: Enzyme, Laxatives, and Lubricants
17
Drug Class
Enzyme
Laxatives
Lubricants
Drug (Trade Name)
• Pancreatic enzyme replacement; pancrelipase, pancreatin (Pancrezyme, Viokase)
• Lactulose (Chronulac) • Magnesium hydroxide (Milk of Magnesia) • Psyllium (Metamucil)
• Cod liver oil • Mineral oil • White petrolatum (Laxatone, Petromalt)
Action
• Replaces enzymes
• Pulls water into the feces and stimulates colonic/ rectal peristalsis by distension • ↓ Blood ammonia by lowering pH of colon (lactulose)
• Coats the feces for easier passage
Indications
• Pancreatic exocrine insufficiency
• Hairballs, constipation (prevention), and colitis • Hepatic encephalopathy (lactulose)
• Hairballs and constipation
Dispensible Forms
• Tablet and powder
• Tablet, powder, and solution
• Gel, liquid
Cautions
• Wash hands after handling; avoid inhalation.
• Renal insufficiency or cardiac disease
• Long-term usage can decrease absorption of lipid-soluble vitamins (A, D, E, and K) from the bowel.
Contraindications
• Hypersensitivity to pork products
• Felines or small canines with kidney disease • Dehydration, pain, vomiting, CHF, congenital megacolon or fecal impaction
• Vomiting, diarrhea, pain, obstruction, or dysphagia
Patient Care/Client Education
• Mix powder thoroughly with moistened food; tablets are given before feeding. • Monitor for nausea, cramping, diarrhea, and skin and nasal irritation. • Used in conjuction with a bland, easily digestible diet with low levels of fat.
• Monitor for dehydration, cramping, flatulence, and bloating (psyllium and lactulose). • Monitor for hypotension, depression, loss of deep tendon reflexes and weakness (magnesium). • Water should be available to the patient. • May be unpalatable
• May take 6–12 hours to be effective
Notes
• Cimetidine may improve efficacy
• May take 12–24 hours for effectiveness
• Store in a cool place
596
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 17.27 / Gastrointestinal Drugs: Protectants and Stool Softener Drug Class
Protectants
Stool Softener
Drug (Trade Name)
• Activated charcoal (Superchar and Toxiban)
• Kaolin-pectin (Kaopectate)
• Docusate sodium succinate (Colace, Docusate solution, Disposaject) • Docusate calcium (Surfak)
Action
• Adsorbent that binds with enterotoxins
• Coats the intestinal bowel wall
• Reduces surface tension of feces to permit water to penetrate the dry stool
Indications
• Poisoning (acetaminophen, atropine, digitalis, glycosides, phenytoin, mercuric chloride, morphine sulfate, and ethylene glycol)
• Poisoning and diarrhea
• Constipation
Dispensible Forms
• Solution
• Solution
• Tablet, capsule, solution, syrup, and enema
Cautions
• Do not use with syrup of Ipecac, dairy products, or mineral oil because it negates adsorbent qualities of charcoal.
• Do not use 2 hours before or 3 hours after administration of antimicrobial drugs or digoxin.
• Do not use with mineral oil unless separating administration by 2 hours. • Preexisting fluid/electrolyte abnormalities
Contraindications
• Ingestion of cyanide, mineral acids, caustic alkalis, organic solvents, ethanol, lead, iron, and methanol
Patient Care/Client Education
• Monitor for vomiting, diarrhea, and constipation. • Stools often will have altered color.
• Monitor for vomiting, diarrhea, dehydration, and constipation.
• Monitor for dehydration, cramping, nausea, vomiting, diarrhea, and throat irritation.
• Store in airtight containers.
• Store in airtight containers.
Notes
CHAPTER 17 / PHARMACOLOGY
597
17
HEPATIC DRUGS Table 17.28 / Hepatic Drugs: Supplements Drug Class
Supplement
Drug (Trade Name)
• S-Adenosylmethionine (SAMe, Denosyl) • S-Adenosylmethionine + silybin (Denamarin)
• Silymarin • Silymarin + vitamin E + Zinc (Marin)
Action
• Antioxidant; Increases glutathione levels
• Antioxidant; inhibits lipid peroxidase and β-glucoronidase
Indications
• Liver Disease • Oseoarthritis • Acetaminophen toxicity
• Liver disease • Ingestion of hepatotoxic agents
Dispensible Forms
• Tablets
• Tablets
Metabolized
Contraindications
17
• Animal on exogenous estrogens
Patient Care/Client Education
• Monitor liver enzymes. • Give 1 hour before feeding; do not crush pills.
• Product is considered “investigational.”
Notes
• Store at room temperature. • Also is sold with other additives: Denamarin (SAMe + Silybin). • SAMe is formed naturally in the liver from the amino acid methionine.
• Store at room temperature.
598
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
METABOLIC DRUGS Table 17.29 / Metabolic Drugs: Adrenal Cortex Drug Class
Adrenal Cortex
Drug (Trade Name)
• Desoxycorticosterone acetate (DOCA, Percoten acetate) • Desoxycorticosterone pivalate (DOCP and Percorten pivalate)
• Fludrocortisone (Florinef)
• Mitotane (Lysodren)
• Selegiline–l-deprenyl (Anipryl, Eldepryl)
• Trilostane (Vetoryl)
Action
• Replaces aldosterone in the body
• Promotes sodium retention and urinary potassium execretion
• Suppresses adrenal cortex
• Restores brain dopamine
• Adrenal enzyme inhibitor
Metabolized
• Liver
• Liver
Indications
• Hypoadrenocorticism (replacement therapy)
• Hypoadrenocorticism (replacement therapy), and hyperkalemia
• Pituitary-dependent hyperadrenocorticism in dogs and adrenal tumors
• Uncomplicated pituitary-dependent hyperadrenocorticism (canine) • Canine cognitive dysfunction syndrome
• Hyperadrenocorticism
Dispensible Forms
• Injectable (IM)
• Tablet
• Tablet
• Tablet
• Capsule
Cautions
• Pregnant
• If discontinuing medication, taper off dose gradually over a few days.
• Use with caution in patients with liver/ renal disease. • May ↓ insulin requirements in diabetic patients
• If discontinuing therapy, allow 14 days before initiation of a tricyclic antidepressant.
• Renal/hepatic impairment
Contraindications
• CHF, severe renal disease or edema
• Pregnant
• Pregnant
• Animal on Amitraz or phenylpropanolamine (discontinue 2 weeks before starting Anipryl)
Patient Care/Client Education
• Monitor for edema, hypotension, hypokalemia, hypernatremia, and weakness. • Monitor electrolyte status of patients at 14- and 25-day intervals to determine dosing.
• Monitor for edema, hypotension, hypokalemia, PU/PD, and weakness. • Monitor electrolyte status of patients.
• Administer with food to ↑ absorption. • Monitor for vomiting, diarrhea, lethargy, weakness, and anorexia.
• Monitor for vomiting, diarrhea, and listlessness.
Notes
• Do not administer IV.
• Monitor for hyperkalemia.
CHAPTER 17 / PHARMACOLOGY
599
17
Table 17.30 / Metabolic Drugs: Pancreatic Drug Class
Pancreatic
Drug (Trade Name)
Short-acting Insulin • Regular (R)
Intermediate-acting Insulin • NPH • Lente • Vetsulin
Long-acting Insulin • Glargine (Lantus) • Protamine Zinc (PZI) • Ultralente
Oral • Glipizide
Action
• Enhances distribution of glucose to tissues and organs, thereby ↓ blood glucose levels
• Enhances distribution of glucose to tissues and organs, thereby ↓ blood glucose levels
• Restores β cells of pancreas which ↑ insulin production (glargine) • Enhances distribution of glucose to tissues and organs, thereby ↓ blood glucose levels
• Increases production of endogenous insulin
Metabolized
• Kidneys and liver
• Kidneys and liver
• Kidneys and liver
• Kidneys and liver
Indications
• Diabetes ketoacidosis, diabetic coma
• Diabetes mellitus, uncomplicated
• Diabetes mellitus, uncomplicated (feline)
• Type II diabetes
Dispensible Forms
• Injectable (IV, SQ, IM)
• Injectable (SQ)
• Injectable (SQ)
• Tablets
Cautions
• Inaccurate dosing may lead to hypoglycemia • Do not use if solution is discolored.
• Inaccurate dosing may lead to hypoglycemia
• Inaccurate dosing may lead to hypoglycemia
• Fever, vomiting, thyroid/ renal impairment, or unrelated adrenal/pituitary insufficiency
Contraindications
• Hypoglycemia
• Hypoglycemia or ketoacidosis • Allergies to pork products (Vetsulin)
• Hypoglycemia or ketoacidosis
• Severe burns, trauma, infection, or diabetic coma
Patient Care/Client Education
• Feed several small-portion meals throughout the day (3–4). • Monitor for weakness, ataxia, shaking, and seizures (signs of iatrogenic hypoglycemia). • Serum fructosamine levels (every 4–12 months) and serial blood glucose curves (1–2 times a year) are recommended.
• Feed several small-portion meals throughout the day (3–4). • Monitor for weakness, ataxia, shaking, and seizures (signs of iatrogenic hypoglycemia). • Serum fructosamine levels (every 4–12 months) and serial blood glucose curves (1–2 times a year) are recommended.
• Feed 3–4 small-portion meals throughout the day (high protein; low carbohydrates) • Monitor for weakness, ataxia, shaking, and seizures (signs of iatrogenic hypoglycemia). • Serum fructosamine levels (every 4–12 months) and serial blood glucose curves (1–2 times a year) are recommended. • Weekly blood curves for first 4 months (Glargine)
• Weekly examinations; monitor for hyper- or hypoglycemia
Notes
• Refrigerate insulin.
• Refrigerate insulin.
• Refrigerate insulin.
Note: See Chapter 8 Insulin therapy, page 357.
17
600
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 17.31 / Metabolic Drugs: Pancreatic (continued) Drug Class
Pancreatic
Drug (Trade Name)
• Desmopressin acetate (DDAVP)
• Vasopressin (Pitressin)
Action
• Stimulates the release of preformed factor VIII from storage sites
• Stimulates the release of preformed factor VIII from storage sites
Metabolized
• Destroyed in the liver
Indications
• Central diabetes insipidus • von Willebrand’s type I (presurgery)
• Diabetes insipidus
Dispensible Forms
• Injectable (IV, IM) and nasal drops
• Injectable (IV, IM)
Cautions
• Perform a response test in vWF dogs • Buccal mucosal bleeding time test and plasma vWF pre and post administration of DDAVP and presurgery is recommended.
• Use with caution with heart failure or asthma patients.
Contraindications
• Type 2 diabetes or platelet type von Willibrand’s disease
• Cardiorenal disease, hypertension, or epilepsy
Patient Care/Client Education
• Monitor for hypotension, tachycardia, and fluid retention.
• Monitor for nausea, vomiting, and fluid retention.
Notes
• Refrigerate.
• Store at room temperature.
Table 17.32 / Metabolic Drugs: Parathyroid and Thyroid Drug Class
Parathyroid
Thyroid
Drug (Trade Name)
• Calcitriol (Rocaltrol, Calcijex)
• Levothyroxine sodium (l-Thyroxine, Soloxine, Thyro-tabs, Synthroid, Eltroxin)
• Methimazole (Tapazole)
Action
• Increases calcium absorption in the intestines
• Converted to active T3 form
• Prevents the production of normal thyroid hormones
Indications
• Hypocalcemia or secondary hyperparathyroidism with chronic renal failure
• Hypothyroidism (via supplementation), von Willebrand’s disease and platelet dysfunction
• Hyperthyroidism
Dispensible Forms
• Capsule and injectable
• Tablet and powder
• Tablet
Cautions
• Use with caution on animals taking digitalis or calcium carbonate.
• Geriatric patients, diabetes, cardiac disease, or hypoadrenocorticism
• Hematologic abnormalities, autoimmune or liver disease
Contraindications
• Vitamin D toxicity, hypercalcemia, hyperphosphatemia, or malsorption
• Cardiac insufficiency, primary hypertension or thyroid toxicosis
Patient Care/Client Education
• Monitor calcium plasma concentration for hypercalcemia (PU/PD, vomiting, depression, anorexia, trembling, and muscle weakness).
• Monitor serum thyroid levels every 6–12 months • Monitor for tachycardia, panting, abnormal papillary reflexes, nervousness, polyphagia, PU/PD, weight loss, vomiting and diarrhea
• Monitor serum thyroid levels (every 6–12 months), weight, and blood pressure every 3–6 months. • Monitor for anorexia, vomiting, skin eruptions, and lethargy.
Notes
• Protect from light.
• Protect from light. • Blood work should be checked 4–6 hours after last dose (check with your local laboratory facility on special drawing/handling instructions).
• May need to ↑ dosage as thyroid grows • Blood work should be checked 4–6 hours after medication. • May cause bone marrow disease
CHAPTER 17 / PHARMACOLOGY
601
17
MUSCULOSKELETAL DRUGS ANTI-INFLAMMATORY DRUGS Potential Side Effects of Corticosteroids: Most common side effects are polyphagia, PU/PD, panting, weakness, bilateral alopecia, and HPA-axis suppression. Other possible side effects are GIT ulceration, anorexia, diarrhea, melena, hepatopathy, diabetes mellitus, hyperlipidemia, immunosuppres-
sion, ↓ thyroid hormone, protein synthesis, and wound healing. Overuse of glucocorticoids can lead to hyperadrenocorticism. General Notes: Corticosteroids will affect blood values as well as intradermal allergy skin testing; all testing should be performed prior to administration. These medications are not recommended during the healing phase of fractures, in young animals, or in pregnant animals. Caution should be used in animals with CHF, diabetes mellitus. and renal disease.
Table 17.33 / Musculoskeletal Drugs: Anti-inflammatory Drugs Drug Class
17
Anti-inflammatory Drugs Short Acting (<12 hours)
Intermediate Acting (12–36 hours)
Long Acting (>48 hours)
Drug (Trade Name)
• Cortisone acetate • Hydrocortisone • Hydrocortisone sodium succinate (Solu-Cortef) • Fluticasone Propionate
• • • •
Methylprednisolone (Medrol, Depo-Medrol) Prednisone (Deltasone) Prednisolone (Delta-cortef) Prednisolone sodium succinate (Solu-Delta-Cortef) • Triamcinolone (Vetalog, Trimtabs, Aristocort)
• • • •
Action
• Inhibits phospholipase
• Inhibits phospholipase
• Inhibits phospholipase
Indications
• Anti-inflammatory, replacement therapy, shock, asthma (feline), and acute hypoadrenocortical crisis
• Anti-inflammatory, replacement therapy, immunosuppression, shock, and CNS trauma
• Anti-inflammatory, immunosuppression, and CNS inflammation
Dispensible Forms
• Tablet, topical, suspension, and injectable
• Tablet, topical, and injectable
• Tablet, topical, and injectable
Cautions
• See paragraph above.
• See paragraph above.
• May ↓ sperm viability in stud dogs (betamethasone)
Contraindications
• See paragraph above.
• See paragraph above.
• Pregnancy: last trimester
Patient Care/Client Education
• When reducing dosages, taper gradually as • When reducing dosages, taper gradually abrupt cessation from long-term administration as abrupt cessation from long-term may result in Addison’s disease. administration may result in Addison’s • Monitor for PU/PD, polyphagia, panting, disease. lethargy, weakness, and bilateral alopecia. • Monitor for PU/PD, polyphagia, panting, lethargy, weakness, and bilateral alopecia. • Provide lots of fresh water and continuous access to litter box or outdoors. • Provide lots of fresh water and continuous access to litter box or outdoors.
• When reducing dosages, taper gradually as abrupt cessation from long-term administration may result in Addison’s disease. • Monitor for PU/PD, polyphagia, panting, lethargy, weakness, and bilateral alopecia. • Provide lots of fresh water and continuous access to litter box or outdoors.
Notes
• Discard clouded or 3-day-old unused solution.
• Dexamethasone is used in testing for hyperadrenocorticism. • Betamethasone, dexamethasone is 30× more potent than cortisol • Flumethasone is 15× more potent than cortisol.
602
• Prednisone is 4× more potent than cortisol • Methylprednisolone and triamcinolone is 1.25× more potent than prednisone. • Felines typically require higher doses than canines, but usually suffer fewer side effects.
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Betamethasone (Betasone, Betavet soluspan) Dexamethasone (Azium, Azium SP) Flumethasone (Flucort) Paramethasone
Table 17.34 / Musculoskeletal Drugs: Nonsteroidal Anti-inflammatory Drugs Drug Class
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Drug (Trade Name)
• Acetylsalicylic acid (Aspirin)
• Carprofen (Rimadyl)
• Deracoxib (Deramaxx)
• Etodolac (Etogesic)
Action
• Inhibits COX and antithrombotic
• Inhibits COX (predominantly COX-2)
• Inhibits COX (COX-2)
• Inhibits COX (predominantly COX-2)
Metabolized
• Liver
• Liver (biotransformed)
• Liver
Indications
• Pain, inflammation, fever, cardiomyopathy (feline), endotoxic shock • Used in conjunction with postadulticide heartworm treatment
• Pain, inflammation, and fever
• Postoperative pain, osteoarthritis pain, and transitional cell carcinoma of the bladder
• Pain and inflammation
Dispensible Forms
• Tablet
• Tablet
• Tablet
• Tablet
Cautions
• Use cautiously in coagulopathic deficient patients. • Administer no more frequently than every 3 days to felines, due to slow meatbolism and subsequent salicylate intoxication.
• Possible adverse effects on kidney function • Geriatric or pregnant patients
• GIT issues, renal/hepatic disease and hypoproteinemia
• May cause ↓ platelet function and kidney injury
Contraindications
• Pregnancy or bleeding ulcers
• Felines • Animals taking glucocorticoids or with bleeding disorders
• Animals taking other NSAIDs or corticosteroids • Animals with a sensitivity to sulfa drugs • Felines • Canines <4 lb
• Felines
Patient Care/Client Education
• Monitor for ulceration, bleeding, and vomiting • Administer with food
• Monitor for ulceration, bleeding, vomiting, and aggression. • Chemistry profile screening should be done before and during chronic therapy. • Administer with food.
• Chemistry blood profile should be done every 6 months. • Give with food at least 2 hours prior to surgery.
• Monitor for weight loss, vomiting, and diarrhea. • Administer with food. • Chemistry profile screening should be done before and during chronic therapy.
Notes
• Use of the enteric-coated brands is not typically recommended. • 1 gr “baby” aspirin = 65 mg • 1.25 gr “baby” aspirin = 81 mg
• Idiosyncratic acute hepatic toxicity (2–3 weeks after beginning treatment)
• Do not use with corticosteroids.
CHAPTER 17 / PHARMACOLOGY
603
17
Table 17.35 / Musculoskeletal Drugs: Nonsteroidal Anti-inflammatory Drugs (continued) Drug Class
17
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Drug (Trade Name)
• Firocoxib (Previcox)
• Ketoprofen (Ketofen, Orudis)
• Flunixin meglumine (Banamine)
• Meloxicam (Metacam)
Action
• Inhibits COX (predominantly COX-2)
• Inhibits COX catalysis
• Inhibits COX
• Inhibits COX (COX-2 preferential)
Metabolized
• Liver
• Liver
• Liver
• Biotransformed in the liver
Indications
• Canine osteoarthritis
• Pain and inflammation
• Short-term treatment of moderate pain and inflammation • Intestinal endotoxemia (e.g., Parvovirus)
• Osteoarthritis
Dispensible Forms
• Tablet
• Injectable, tablets (Canada)
• Granules, ophthalmic, and injectable
• Suspension or injectable
Cautions
• Dehydrated patient
• GI ulcers, renal or hepatic disease, and breeding animals
• Ulcerogenic effects are potentiated when administered with corticosteroids
• Dehydration, hypovolemic or hypotensive
Contraindications
• Feline
• Known hypersensitivity
Patient Care/Client Education
• Monitor GI upset, liver/ renal values
• May cause ↑ blood glucose, serum bilirubin, or iron • Vomiting, anorexia, or ulcers may occur.
• Monitor for ulceration, bleeding, and vomiting. • Administer with food
• Monitor GIT distress and renal values. • Shake well prior to dispensing. • Use manufacturer’s dispensing syringe. • Place drops onto food.
Notes
• Do not use with corticosteroids.
• Store protected from the light.
• IM injection may cause irritation. • Only used for 3–4 days • More potent analgesic than other NSAIDs • Do not use with corticosteroids.
• Do not use with corticosteroids.
604
• GIT ulceration, impaired hepatic/ cardiac/renal function or pregnancy
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 17.36 / Musculoskeletal Drugs: Nonsteroidal Anti-inflammatory Drugs (continued) Drug Class
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Drug (Trade Name)
• Piroxicam (Feldene)
• Tepoxalin (Zubrin) • Inhibits COX and 5-lipoxygenase (LOX)
Action
• Inhibits COX
Metabolized
• Biotransformed in the liver
Indications
• Degenerative joint disease or neoplastic disease
• Canine osteoarthritis
Dispensible Forms
• Capsule
• Tablet
Cautions
• Renal/cardiac dysfunction, hypertension, coagulopathy disorders or feline
• Hepatic/cardiovascular/renal function or active GI ulcers
Contraindications
• Hemophilia, GIT ulcers or bleeding
Patient Care/Client Education
• Monitor for anorexia, vomiting, and anemia.
• Monitor for GIT upset, CBC, and chemistry panels.
Notes
• Also used in the management of pain from transitional cell carcinoma of the bladder and inducing partial remission of squamous cell carcinoma in canines • Do not use with corticosteroids.
• Do not use with corticosteroids.
Table 17.37 / Musculoskeletal Drugs: Protectant, Muscle Relaxer, and Supplement Drug Class
Protectant
Muscle Relaxer
Supplement
Drug (Trade Name)
• Polysulfated glycosaminoglycans (PSGAG, Adequan IM)
• Methocarbamol (Robaxin, Robaxin-V)
• Glucosamine with chondroitin sulfate (Cosequin)
Action
• Stimulates the synthesis of glycosaminoglycans, inhibits collagen and proteoglycan catabolism, and inhibits neutrophil migration into synovial fluid
• Depresses polysynaptic reflexes
• Stimulates synthesis of synovial fluid and inhibits degradation of articular cartilage
Indications
• Osteoarthritis
• Muscular spasm
Dispensible Forms
• Capsule and injectable
• Tablet and injectable
Cautions
• Pregnant
• Give IV slowly.
Contraindications
• Dogs with bleeding disorders
• Renal disease or pregnant animals
Patient Care/Client Education
• Monitor for allergic reactions.
• Monitor for sedation, vomiting, weakness, and ataxia. • Use may result in dark urine
Notes
• Discard unused portions.
• Glucosamine with ASU (Dasuquin)
• S-Adenosylmethionine (SAMe)
• Degenerative joint disease
• Degenerative joint disease
• Liver disease • Oseoarthritis • Acetaminophen toxicity
• Tablet and capsule
• Tablet
• Tablets
• For canines only
• Results are typically seen by the seventh week. • Protect from light.
• Monitor liver enzymes. • Give 1 hour before feeding; do not crush pills. • Store at room • Store at room temperature, temperature. protected from light.
CHAPTER 17 / PHARMACOLOGY
605
17
NEUROLOGIC DRUGS A listing of anesthetic drugs can be found in Chapter 2 Anesthesiology.
Table 17.38 / Neurologic Drugs: Appetite Stimulator and Cholinergics Drug Class
Appetite Stimulator
Cholinergics
Drug (Trade Name)
• Cyproheptadine HCl (Periactin)
Indirect acting agonists: • Edrophonium chloride (Tensilon) • Neostigmine bromide (Prostigmine) • Physostigmine (Antilirium)
Action
• Competes with histamine for H1-receptor sites
• Inhibits acetylcholine breakdown, thereby prolonging postsynaptic stimulation
Metabolized
• Liver
Indications
• Feline appetite stimulant
• Aid in diagnosing myasthenia gravis and treatment of curare poisoning (edrophonium) • Myasthenia gravis (neostigmine, physostigmine) • Antidote for neuromuscular blockers (neostigmine)
Dispensible Forms
• Tablet and solution
• Tablet, solutions, and injectable
Cautions
• Use with caution on patients with prostatic hypertrophy, angle-closure glaucoma, pyloric or duodenal obstruction, urinary retention, acute asthma, and severe cardiac disease. • May cause aggression or excitability (feline)
• Use with caution with asthma or cardiac arrhythmias.
Contraindications
17
• UTI obstructions or peritonitis (Neostigmine bromide) • Bronchial asthma (Edrophonium)
Patient Care/Client Education
• Monitor for polyphagia, sedation, and CNS depression.
• Monitor for bradycardia, hypotension, heart block, lacrimation, papillary constriction, laryngospasm, nausea, diarrhea, vomiting, ↑ intestinal activity or rupture, and muscle weakness
Notes
• Also used as a bronchospasm manager
• Atropine can be used to counteract effects of neostigmine and physostigmine. • Crosses blood-brain barrier (physostigmine)
606
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 17.39 / Neurologic Drugs: Autonomic Nervous System: Adrenergic Agents: Alpha Stimulators Drug Class
Autonomic Nervous System: Adrenergic Agents: Alpha Stimulators
Drug (Trade Name)
• Ephedrine (Vatronol)
Action
• α-Receptor stimulant
Metabolized
• Liver
Indications
• ↑ Blood pressure, bronchodilator, nasal decongestant, and to control urinary incontinence by ↑ smooth muscle sphincter tone in urethra
Dispensible Forms
• Capsule and injectable
Cautions
• Use caution with patients currently taking sodium bicarbonate or amitriptyline. • Glaucoma, hyperthyroidism, hypertension, or diabetes mellitus
Contraindications
• Severe cardiovascular disease
Patient Care/Client Education • Monitor for tachycardia, hypertension, excitability, and urine retention.
Table 17.40 / Neurologic Drugs: Central Nervous System: Anticonvulsants Drug Class
Central Nervous System: Anticonvulsants
Drug (Trade Name)
• Diazepam (Valium and Valrelease)
• Pentobarbital (Nembutal)
• Phenobarbital (Luminal)
• Potassium Bromide (KBr)
Action
• Potentiates inhibitory actions of GABA
• Potentiates inhibitory actions of GABA
• Potentiates inhibitory actions of GABA
• Stabilized neuronal cell membranes
Metabolized
• Liver
Indications
• Appetite stimulant, behavioral issues, or urethral obstruction • Poisoning (chocolate, nicotine, amphetamine, strychnine or salicylate) • Seizuring animals
• Seizuring animals
• Seizuring animals
• Seizuring animals
Dispensible Forms
• Tablet, solution, rectal gel and injectable
• Injectable
• Tablet, capsule, powder, elixir and injectable
• Solution
Cautions
• Use with caution with hepatic disease. • If given with erythromycin, ketoconazole, or propanolol, excessive sedation may occur.
• Cardiac/respiratory disease
• Cardiac/respiratory disease
• Renal dysfunction
• Liver
CHAPTER 17 / PHARMACOLOGY
607
17
Table 17.40 / Neurologic Drugs: Central Nervous System: Anticonvulsants (Continued) Drug Class
Central Nervous System: Anticonvulsants
Contraindications
• Felines exposed to chlorpyrifos
• Severe liver disease
Patient Care/Client Education
• Monitor for sedation, cardiac or respiratory depression, anxiety, incoordination, agitation, polyphagia, aggression, PU/PD, and lethargy.
• Monitor for respiratory depression.
• Monitor for sedation, cardiac or respiratory depression, and polyphagia. • Monitor serum phenobarbital levels every 6 months (collect just before the next dose).
• Monitor for sedation, cardiac or respiratory depression, dehydration, vomiting, diarrhea, and ataxia. • Monitor serum KBr levels every 6 months.
Notes
• Not recommended for use for more than 2 days as an appetite stimulant • A controlled substance • Seizure control duration of 3–4 hours
• Short-acting barbiturate • A controlled substance • Seizure control duration of 1–3 hours
• Long-acting barbiturate • Phenobarbital causes ↑ metabolism of phenylbutazone, glucocorticoids, estrogens, and methylxanthines, because it is a hepatic enzyme inducer. • If using with chloramphenicol, ↓ the dosage of phenobarbital. • A controlled substance
• Diets with a high chloride content may require a higher dosaging of KBr. (e.g., Hill’s S/D or I/D). • KBr is used with phenobarbital when phenobarbital is not totally effective alone.
Table 17.41 / Neurologic Drugs: Euthanasia Agents and Muscle Relaxers Drug Class
Euthanasia Agents
Muscle Relaxers
Drug (Trade Name)
• Pentobarbital sodium (Sleepaway, Beuthanasia-D, Euthanasia-6, Fatal-Plus)
• Methocarbamol (Robaxin, Robaxin-V)
Action
• Produces unconsciousness and cessation of all vital functions
• Depresses polysynaptic reflexes
Metabolized
• Liver
Indications
• Euthanize
• Muscular spasm
Dispensible Forms
• Solution and powder
• Tablet and injectable
Cautions
• Handle with care and avoid contact with open wounds.
• Give IV slowly.
Contraindications
• Renal disease or pregnant animals
Patient Care/Client Education
• Monitor for sedation, vomiting, weakness, and ataxia.
Notes
17
608
• Pentobarbital sodium products are controlled substances. • Medications must be given as prescribed to be effective.
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
• May darken urine
Table 17.42 / Neurologic Drugs: Analgesics Drug Class
a2-Agonist
Local Anesthetic
Local Anesthetic
Local Anesthetic
Drug (Trade Name)
• Medetomidine HCl (Domitor)
• Benzocaine (Cetacaine)
• Lidocaine
• Bupivicaine HCl (Marcaine, Sensorcaine)
Action
• α2-Adrenoreceptor agonist
• Reversibly blocking nerve conduction
• Blocks generation and conduction of nerve impulses
• Blocks generation and conduction of nerve impulses
Metabolized
• Liver
• Plasma cholinesterases (primary)
• Liver
• Liver
Indications
• Sedation needed for examination and procedures that do not require intubation.
• Gag reflex when intubating
• Wound repair • Arrhythmia
• Surgeries and dental extractions
Dispensible Forms
• Injectable
• Spray
• Injectable
• Injectable
Cautions
• Geriatric patients • Used with propofol monitor for hypoxemia • Used with fentanyl/meperidine/ butorphanol; monitor for increased sedation • Use in agitated canines.
• Spray for only 1 second.
• • • • •
• ↑ CNS or depression • Crosses placenta
Contraindications
• Cardiac, respiratory, liver or kidney disease • Pregancy • Shock • Severely debilitated
• Large areas of denuded tissue
• Cardiac issues • Adams-Stokes syndrome • Do not use IV if product containes epinephrine. • Do not use with ampicillin, cefazolin, methohexital sodium, or phenytoin sodium.
Patient Care/Client Education
Monitor heart rate, respiration, and body temperature. • May cause spontaneous muscle contractions
Notes
• Canines >12 weeks
Liver disease Severe respiratory depression CHF Shock Felines
• Monitor on ECG and watch CNS for signs of toxicity.
• 30 second onset; 30–60 minute duration
• Rapid onset with longer lasting effects than other local anesthetics
Notes: See Table 13.9 Regional and Local Anesthetics, page 470.
CHAPTER 17 / PHARMACOLOGY
609
17
Table 17.43 / Neurologic Drugs: Analgesic/Anticonvulsant, NMDA Antagonist, and Narcotic Agonist Drug Class
Analgesic/Anticonvulsant
NMDA Antagonist
Drug (Trade Name)
• Gabapentin (Neurontin)
• Amantadine (Symmetrel)
• Ketamine
• Buprenorphine (Buprenex)
Action
• Modulates calcium influx
• Inhibits viral replication and believed to release brain dopamine from nerve endings
• Disrupts nervous system pathways; inhibits GABA
• Partial μ agonist
Metabolized
• Kidneys and partially in the liver
• Liver
• Liver
Indications
• Seizuring animals and for chronic pain
• Chronic pain
• Fractious felines, analgesia, induction agent
• Analgesia
Dispensible Forms
• Capsules, tablets, and oral solution
• Tablets, capsule, and oral solution
• Injectable
• Injectable
Cautions
• Renal impairment
• Untreated glaucoma, CHF, renal or hepatic disease
• Hyperthyroidism, cardiomyopathy, cardiac disease
• Crosses placenta • Hypothyroid, severe kidney disease, Addison’s disease, or geriatric • Head trauma
Contraindications
• Hypersensitivity to drug
• Hypersensitivity to drug or rimantadine
• Hypersensitivity to drug • Head trauma
• Do not mix with diazepam.
Patient Care/Client Education
• If used with an oral antacid, give 2 hours apart. • If used for epilepsy, wean off drug.
• Agitation in canines may be noted. • Monitor GIT system.
• Monitor cardiac and respiratory function and body temperature. • Use eye lubricant. • Use minimal handling during recovery.
• Monitor cardiac and respiratory function.
Notes
• Store tablet or capsule at room temperature; liquid in the refrigerator.
• Store at room temperature. • Eliminated via kidneys
Note: See Chapter 9 Pain Management, page 386, 391.
17
610
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Narcotic Agonist
• Protect from light.
Table 17.44 / Neurologic Drugs: Analgesic: Opioids Drug Class
Opioids
Drug (Trade Name)
• Butorphanol (Torbugesic)
• Fentanyl citrate (Duragesic, Sublimaze)
• Hydromorphone
Action
• κ-Agonist and μ antagonist
• μ-Agonist
• μ-Agonist
Metabolized
• Liver
• Liver
• Liver
Indications
• Preanesthetic • Analgesia
• Pain management • Analgesia
• Analgesia • Sedation
Dispensible Forms
• Injectable
• Injectable and patches
• Injectable, tablets, and powder
Cautions
• Hypothyroid, renal/hepatic disease, Addison’s disease, geriatric/debilitated • Head trauma
• Respiratory disease or impairment, geriatric, or debilitated • Usage with other CNS depressants • Possible ↑ absorption in febrile patients
• Hypothyroid, severe kidney issues, geriatric, debilitated, acute GIT issues • Head trauma
Contraindications
• Animals with heartworm • Lower respiratory tract conditions with mucous production
• Preexisting respiratory problems
• Patient taking MAIOs
Patient Care/Client Education
• Monitor respiratory, elimination, and behavior function.
• Use gloves when handling/disposing of patch. • Removal of patch should be scheduled with the clinic. • Monitor for respiratory depression, bradycardia, and rashes at site of application. • A fever will ↑ absorption.
• May cause vomiting and panting • Monitor for CNS depression, bradycardia, and blood pressure changes. • Miosis (canine) • Mydriasis (feline)
Notes
• CII controlled substance • Short–intermediate acting • Possibly less respiratory depression than other μ opioid agonists
• • • •
• • • •
CII controlled substance Short-acting opioid Protect from light Recommended application is 24 hours in advance of surgery (minimum 12 hours) Onset • Canine: 12 hours • Feline: 6 hours • Duration: 72 hours (possibly longer) • Amylase/lipase may be ↑ for 24 hours
CII controlled substance Protect from light Onset: 15–30 minutes Reversal agent: Naloxone
Note: See Chapter 9: Pain Management, page 387, 388.
CHAPTER 17 / PHARMACOLOGY
611
17
TABLE 17. 45 / Neurologic Drugs: Analgesic: Opioids (continued) Drug Class
Opioids
Drug (Trade Name)
• Meperidine HCl (Demerol)
• Morphine sulfate
• Oxymorphone
• Tramadol HCl (Ultram)
Action
• μ-Agonist
• μ-Agonist
• μ-Agonist
• μ-Agonist
Metabolized
• Liver
• Liver
• Liver
• Liver
Indications
• Pain management • Acute pancreatitis
• Preanesthesia and pain management
• Sedation, pain management
• Pain management • Coughing
Dispensible Forms
• Injectable and tablet
• Injectable, tablets, oral solutions, and suppository
• Injectable and suppository
• Tablets
Cautions
• Respiratory or kidney disease, hypothyroid, geriatric • Addison’s disease • Administer IV slowly
• Respiratory or kidney disease, hypothyroid, geriatric • Addison’s disease • Administer IV slowly
• Hypothyroidism, renal insufficiency, respiratory disease • Head trauma
• Seizure prone animals, geriatric, or with renal/hepatic impairment
Contraindications
• Head trauma • Diarrhea from toxic ingestion
• Head trauma • Toxic ingestion induced diarrhea • Do NOT use with diazepam or barbituates.
• Toxic ingestion induced diarrhea
• Hypersensitivity to opioids • Avoid use with SSRIs and MAOIs
Patient Care/Client Education
• Monitor for hypotension.
• Monitor for cardiac, respiratory, BP changes • May defecate or vomit Monitor for • Canine: CNS depression, emesis • Feline: stimulatory effects, emesis
• Monitor for cardiac, respiratory, blood pressure changes
• Avoid brands containing acetaminophen (feline) (Ultracet). • Monitor CNS and GIT for toxicity. • Naloxone is not recommended as a reversal agent.
Notes
• CII controlled substance • Short-acting opioid • Incompatible with many drugs, check prior to administering • Amylase/lipase may be ↑ for 24 hours.
• CII controlled substance • Longer duration than other opioid agonists • Amylase and lipase may be ↑ for 24 hours. • Reversal agent: Naloxone • Protect from bright light • Some drug incompatibilities so check prior to use.
• CII controlled substance • Reversal agent: Naloxone • Protect from light.
• Not a controlled substance • Store at room temperature.
Note: See Chapter 9 Pain Management, page 388, 389.
17
612
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 17.46 / Neurologic Drugs: Behavioral: Antidepressants Drug Class
Tricyclic Antidepressant
Antidepressant
Drug (Trade Name)
• Clomipramine HCl (Clomicalm)
• Fluoxetine HCl (Prozac, Reconcile)
Action
• Blocks neuronal reuptake of serotonin (5-HT) and norepinephrine
• Selective inhibitor of serotonin reuptake
Metabolized
• Liver
• Liver
Indications
• Separation anxiety, obsessive-compulsive disorders, aggression
• Separation anxiety, obsessive-compulsive disorders, aggression
Dispensible Forms
• Tablets
• Capsules, tablets, and oral solution
Cautions
• Seizure prone animals, GIT motility issues, urinary retention, ↑ IOP
• Diabetes mellitus, hepatic disease, seizure-prone animals
Contraindications
• Animals using MAOIs
• Animals using MAOIs
Patient Care/Client Education
• Ingestion of cheese is not recommended. • Liver values should be monitored yearly.
• Monitor temperament and appetite.
Notes
• Store veterinary brands at room temperature.
• Store at room temperature in tight containers.
OPHTHALMIC DRUGS Table 17.47 / Ophthalmic Drugs: Adrenergic Agonist, Carbonic Anhydrase Inhibitors, and Immunosuppressant Drug Class
Adrenergic Agonist
Carbonic Anhydrase Inhibitors
Immunosuppressant
Drug (Trade Name)
• Epinephrine (Adrenalin)
• Acetazolamide (Acetazolam, Diamox) • Dichlorphenamide (Daranide)
• Cyclosporine (Optimmune, Sandimmune)
Action
• Reduces intraocular pressure
• Reduces the production of the aqueous humor at cellular pump level
• Inhibits B- and T-lymphocyte activation
Metabolized
• GIT and liver
• 90% excreted unchanged
• Liver
Indications
• IOP • Diagnose Horner’s syndrome
• Glaucoma
• Chronic KCS
Dispensible Forms
• Injectable
• Tablet, capsules, powder and injectable
• Ointment, capsules, and solution
Cautions
• Potentially toxic effects when used with sympathomimetic agents
• Use with caution in animals sensitive to sulfonamides
• Cimetidine, erythromycin, and ketoconazole ↑ cyclosporine concentration
Contraindications
• Closed-angle glaucoma (mydriasis can exacerbate glaucoma), diabetes, parturition, or hypertension
• Obstructive pulmonary disease, hyponatremia, hypokalemia, hyperchloremic acidosis, liver or renal disease or adrenocorticol insuffiency
• IV injection may cause acute anaphylactoid reactions (canine).
Patient Care/Client Education
• Monitor for local irritation.
• Monitor for hypokalemia, weakness, polyuria, dysuria, • Monitor for vomiting, diarrhea, anorexia, vomiting, IOP, diarrhea, panting, and skin rash. gingival hyperplasia, pyoderma, and • Chronic users should monitor serum potassium papillomatosis. levels.
Notes
• Discard injectable within 24 hours after opening.
• May also be used in management of autoimmune disease, perianal fistulas, and organ/tissue rejection CHAPTER 17 / PHARMACOLOGY
613
17
Table 17.48 / Ophthalmic Drugs: Miotics, Mydriatics/Cycloplegics, Topical Anesthetics, and Stains Drug Class
Miotics
Mydriatics and Cycloplegics
Topical Anesthetics
Stains
Drug (Trade Name)
• Carbachol (Carbacel, Carbamylcholine chloride)
• Atropine sulfate
• Proparacaine hydrochloride (Ophthaine, AK-Taine, Alcaine, Kainair, Ocu-Caine, and Ophthetic)
• Fluorescein strips (Fluorets)
Action
• ↑ Outflow of aqueous humor by miosis
• Dilation of the pupils and paralyzation of the ciliary body muscle
• Desensitizes cornea and conjunctiva
• Adheres to corneal stroma, not intact epithelium
Metabolized
• Liver
Indications
• Reduces intraocular pressure, stimulates tear production, chronic open-angle glaucoma, and closed-angle glaucoma
• Acute inflammatory conditions
• Anesthesize the cornea for examination.
• Diagnose anterior and posterior segments and in the patency of the nasolacrimal system
Dispensible Forms
• Solution and injectable
• Ointment and injectable
• Drops
• Paper strips
• Use cautiously in animals with allergies, cardiac disease, and hyperthyroidism. • Wear gloves when dispensing.
• Fluorescein will stain the patient’s fur.
Cautions
Contraindications
• Cardiac or respiratory disease, GIT obstruction, and aged animals • Pregnant animals
• Glaucoma, KCS, asthma, paralytic ileus, and adhesions between the iris and lens
Patient Care/Client Education
• Monitor for hypotension and bronchoconstriction.
• Monitor for salivation.
Notes
17
614
• Monitor for local irritation. • Store open bottles in the refrigerator. • Discard any discolored solutions. • Not meant for long-term usage
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
OTIC DRUGS Table 17.49 / Otic Drugs: Topical Anti-infectives Drug Class
Topical Anti-infectives
Drug (Trade Name)
• Chloramphenicol with prednisolone, tetracaine, and cerumene (Liquichlor)
• Dimethyl sulfoxide with fluocinolone acetonide (Synotic)
• Gentamicin sulfate with betamethasone valerate and clotrimazole (Gentocin Otic Solution, Otomax)
• Thiabendazole, neomycin, and dexamethasone (Tresaderm)
Action
• Bactericidal, anti-inflammatory, and anesthetic
• Bacteriostatic, fungicidal
• Bactericidal, fungicidal and anti-inflammatory
• Bactericidal and anti-inflammatory
Metabolized
• Liver
Indications
• Acute otitis externa and pyoderma
• Acute/chronic otitis and pruritis
• Otitis (canine) and superficial infected lesions (feline)
• Otitis externa and inflammatory dermatoses
Dispensible Forms
• Solution
• Liquid
• Ointment and solution
• Solution
Cautions
• Wear gloves when administering.
• Wear gloves when administering.
• Remove any debris before administration.
• Remove any debris before administration.
• Pregnant animals • Ocular, renal, or liver disease • Animals <4.5 kg
• Ruptured eardrums • Pregnant animals
• Ruptured eardrums
• Monitor for erythema, pruritis, or pain.
• Monitor for ototoxicity, emesis, PU/PD, diarrhea, erythema, stinging, blistering, peeling edema, pruritis, and urticaria.
• Monitor for tachycardia, ototoxity, erythema, increased thirst, weakness, lethargy, oliguria, vomiting, and diarrhea.
• May result in oyster-like breath • Inactive in purulent exudates
• Monitor for Cushing’s with prolonged usage.
• Store in the refrigerator. • Do not use for more than 1 week.
Contraindications
Patient Care/Client Education
Notes
• Monitor for PU/PD and weight gain.
• Liver
CHAPTER 17 / PHARMACOLOGY
615
17
RENAL/URINARY DRUGS Table 17.50 / Renal/Urinary Drugs: Acidifiers, Adrenergic Agent, and Alkalinizing Agent Drug Class
Acidifiers
Alkalinizing Agent
Drug (Trade Name)
• Ammonium chloride
• DL-methionine (Racemethione, Uroeze, Methio-Tabs)
• Phenylpropanolamine (Proin, Propagest)
• Sodium Bicarbonate (Baking soda)
Action
• Acidifies urine
• Acidifies urine
• ↑ Smooth muscle sphincter tone in urethra
• Alkalizes urine
Indications
• Metabolic acidosis, urinary tract infection, struvite urolithiasis
• Struvite urolithiasis
• Urinary incontinence
• Metabolic acidosis • Hypercalcemic or hyperkalemic
Dispensible Forms
• Tablet and granule
• Tablet, powder, and gel
• Tablet, capsule, and drops
• Injectable and tablets
• Use caution in patients on NSAIDs or animals wearing tick preventive collars (Amitraz).
• Hypocalemia: IV slowly • CHF, hypertensive, oliguria, nephritic syndrome, or volume overload
• Patients currently on Anipryl (L-deprenyl) • Heart disease, hypertension, glaucoma, diabetes mellitus, and hyperthyroid
• Metabolic or respiratory alkalosis, hypocalcemia with the possibility of tetany
Cautions
17
Adrenergic Agent: b Inhibitor
Contraindications
• Severe hepatic disease, renal failure, and pregnant animals
Patient Care/Client Education
• Monitor for nausea and vomiting
Notes
• Poor palatability
616
• Metabolic acidosis, renal/ hepatic function impairment, pancreatic disease, and kittens
• Monitor blood pH, electrolytes, urine pH • May be used in conjunction with DES if it is ineffective alone
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
• Incompatible with many solutions, consult with drug book • Store at room temperature,
Table 17.51 / Renal/Urinary Drugs: Alpha-Adrenergic Agent, Antibacterial/Acidifier, Anabolic Steroid and Cholinergic Drug Class
α-Adrenergic Agent: α-Blocker
Antibacterial/Acidifier
Anabolic Steroid
Cholinergic: Direct Acting Agonists
Drug (Trade Name)
• Phenoxybenzamine (Dibenzyline)
• Methenamine hippurate • Methenamine mandelate
• Nandrolone deconate (Deca-Durabolin) • Stanozolol (WinstrolV)
• Bethanechol chloride (Urecholine and Duvoid)
Action
• Binds with α-receptor on smooth muscles
• Converts to formaldehyde (nonspecific antibacterial) in acidic urine
• Reverses catabolic conditions and stimulates erythropoiesis
• Mimics the action of acetylcholine
Indications
• Vasodilator, urethral obstruction to reduce urethral sphincter tone (cats)
• Recurrent UTI
• Chronic renal failure
• ↑ Contraction of urinary—bladder
Dispensible Forms
• Capsule
• Tablet and suspension
• Tablet and injectable (IM)
• Tablet, solution, and injectable
• May ↑ the effects of anticoagulants
• Administer SQ only (bethanechol)
Cautions Contraindications
• Cardiovascular disease
• Renal disease, hepatic impairment, severe dehydration, or pregnancy
• Cardiac/renal insufficiency, hypercalcemia, neoplastic disease, and pregnant animals
• Obstructive pulmonary disease, bronchial asthma, epilepsy, hyperthyroidism, pregnancy, cystitis, and urethral obstruction • Patient currently being administered neostigmine
Patient Care/Client Education
• Monitor for hypotension, tachycardia, muscle tremors, seizures, ↑ intraocular pressure, nausea, and vomiting.
• Monitor urine pH and for GIT upset.
• Monitor for hepatotoxicity. • Monitor blood glucose.
• Monitor urine output and for arrhythmias, hypotension, and bronchospasm.
CHAPTER 17 / PHARMACOLOGY
617
17
Table 17.52 / Renal/Urinary Drugs: Enzyme Inhibitor and Tricyclic Antidepressant Drug Class
Enzyme Inhibitor
Tricyclic Antidepressant
Drug (Trade Name)
• Allopurinol (Zyloprim, Lopurin)
• Amitriptyline (Elavil)
Action
• Inhibits xanthine oxidase enzyme and blocks the formation of uric acid
• Inhibits uptake of serotonin
Metabolized Indications
• Canine urolithiasis or canine leishmaniasis
• Inappropriate feline urination
Dispensible Forms
• Tablet
• Tablet, injectable, and syrup
Cautions
• Use with caution if animal has renal disease or is using azathioprine.
• ECG screening is recommended before administration • Use with caution in animals with diabetes mellitus or hyperthyroid and renal/hepatic disease.
Contraindications
• Pregnancy
• Cardiac disease, diabetic animals, urinary retention, seizure history (drug ↓ seizure threshold) • Animals on Anipryl (MAOIs) • Pregnant animals
Patient Care/Client Education
• Administer after a meal. • Monitor CBC, renal/liver values, and for skin reactions.
• Monitor for hyperexcitability, vomiting, constipation, arrhymthias, dry mouth, ataxia, and sedation. • Periodic liver enzyme analysis recommended (Liver)
Notes
17
• Liver
618
• Also used for excessive grooming or separation anxiety
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
REPRODUCTIVE SYSTEM DRUGS Table 17.53 / Reproductive System Drugs: Androgens, Estrogens, and Gonadotropins Drug Class
Androgens
Estrogens
Gonadotropins
Drug (Trade Name)
• • • •
• Mibolerone (Cheque drops)
• Gonadorelin (Cystorelin and Factrel)
Action
• Releases free testosterone
• Blocks release of LH
• Stimulates release of LH and FSH
Metabolized
• Liver
• Liver
Indications
• Testosterone replacement therapy
• Prevent estrus and treat pseudocyesis and galactorrhea
• Diagnose reproductive failure, identify intact animals and induce estrus
Dispensible Forms
• Tablet and injectable
• Solution from compounding pharmacy
• Injectable
Cautions
• Use with caution with hepatic, renal, and cardiac disease. • May ↓ blood glucose concentrations
Contraindications
• Prostatic carcinoma or pregnancy
• Cats and Bedlington Terriers • Perianal adenoma, perianal adenocarcinoma, liver and renal disease • Pregnant animals
Patient Care/Client Education
• Monitor for prostatic hyperplasia (canine, male), masculinization (canine, female), and hepatopathy.
• Monitor immature females for premature epiphyseal closure and vaginitis. • Monitor mature females for vulvovaginitis, clitoral hypertrophy, mounting behavior, seizures, and ↑ body odor.
Notes
• Testosterones are administered IM. • Methyltestosterone is administered orally.
Methyltestosterone (Android) Testosterone cypionate (DEPO-Testosterone) Testosterone enanthate (Malogex) Testosterone propionate (Testex)
• Refrigerate.
CHAPTER 17 / PHARMACOLOGY
619
17
Table 17.54 / Reproductive System Drugs: Oxytocin, Progestins, and Prostaglandin
a
17
Drug Class
Oxytocin
Progestins
Prostaglandin
Drug (Trade Name)
• Oxytocin (Pitocin and Syntocinon)
• Megestrol acetate (Ovaban, Megace) • Medroxyprogesterone acetate (Depo-Provera, Provera)
• Prostaglandin F-2α (Lutalyse)
Action
• Stimulates uterine muscle contraction
• Suppresses secretion of FSH and LH
• Contracts the myometrium and relaxes the cervix
Metabolized
• Liver and kidneys
• Liver
Indications
• Induce or continue labor and stimulate milk letdown
• Control estrus cycle, behavior management, dermatologic disorders, and benign prostatic hyperplasia
• Open pyometra and abortion
Dispensible Forms
• Injectable and intranasal solution
• Tablet and injectable
• Injectable
Cautions
• Treat hypoglycemia or hypocalcemia before using.
Contraindications
• Dystocia or closed cervix
• Reproductive problems or mammary tumors • Pregnant animals
Patient Care/Client Education
• Monitor for fetal stress and progression of labor, listlessness, depression, and seizure.
• Monitor for PU/PD, adrenal suppression, diabetes, weight gain, immunosuppression, pyometra, diarrhea, and neoplasia.
• Monitor for tachycardia, vocalization, panting, fever, vomiting, diarrhea, and abdominal discomfort.
Notes
• Refrigerate.
• Inguinal area is recommended site of injection (medroxyprogesterone).
• Walking the animal for 20–40 minutes after administration tends to ↓ side effects
From Dana Allen: Handbook of Veterinary Drugs.
620
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
RESPIRATORY DRUGS Table 17.55 / Respiratory Drugs: Antitussives Drug Class
Antitussives
Drug (Trade Name)
• Codeine phosphate (Methylmorphine)
• Dextromethorphan (Benylin)
• Hydrocodone (Hycodan and Tussigon)
Action
• Suppresses the cough center in the brainstem
• Suppresses the cough center in the brainstem
• Suppresses the cough center in the brainstem
Metabolized
• Liver
Indications
• Nonproductive cough (canine)
• Nonproductive cough (canine)
• Nonproductive cough (canine)
Dispensible Forms
• Tablet, syrup, and solution
• Tablet, syrup, and solution
• Tablet and syrup
Cautions
• Epiletic, hypothyroid, renal insufficiency, cardiac issues, or debilitated patients
• Aged patients, liver and kidney impairment, hypothyroidism,geriatric Addison’s disease, and narrow-angle glaucoma
Contraindications
• Liver disease and GIT dysfunction
• Patients on MAOIs or with diarrhea produced by toxin ingestion
Patient Care/Client Education
• Monitor for sedation and constipation.
Notes
• Monitor for sedation and constipation.
• Monitor for sedation and constipation.
• 15–20 times less potent than butorphanol
• Store at room temperature and protect from light.
CHAPTER 17 / PHARMACOLOGY
621
17
Table 17.56 / Respiratory Drugs: Bronchodilators and Mucolytics Drug Class
17
Bronchodilators
Mucolytics
Drug (Trade Name)
b-Adrenergic Agonists: • Albuterol (Ventolin, Proventil) • Epinephrine (Adrenalin) • Terbutaline (Brethine, Bricanyl)
Methylxanthines: • Aminophylline (Phylloconton) • Theophylline (Theo-Dur, Theolair, Quibron-T/SR, Slo-Bid)
• Acetylcysteine (Mucomyst)
Action
• Stimulates sympathetic nervous system receptors involved in bronchodilation and inhibits histamine release
• Inhibits phosphodiesterase
• ↓ Viscosity of secretions
Metabolized
• Liver
• Liver
• Liver
Indications
• Bronchospasm
• Bronchospasm
• Bronchial nebulizing • Acetaminophen toxicity
Dispensible Forms
• Tablet and solution
• Tablet, caplet, and injectable
• Solution
Cautions
• Do not use terbutaline within 14 days of MAOIs.
• Barbiturates ↑ metabolism (methylxanthines)
• Oral administration can cause nausea or vomiting • Use with caution in patients with asthma.
Contraindications
• Cardiovascular disease, hyperthyroid, and diabetes mellitus • Pregnant animals
• Cardiovascular disease, hyperthyroid, diabetes mellitus, glaucoma, gastric ulcers, liver and kidney disease • Pregnant animals
Patient Care/Client Education
• Monitor for tachycardia, hypertension, muscle tremors, nervousness, fear, depression, vomiting, urine retention, site irritation, and panting.
• Monitor serum levels 29–30 hours (canine) and 40 hours for (feline) after therapy initiation and just before the next dose (theophylline). • Monitor for tachycardia, hypertension, hyperglycemia, muscle tremors, nervousness, fear, depression, vomiting, polyphagia, and panting.
• Monitor for nausea and vomiting.
Notes
• Onset of action is 15–30 minutes; duration ≤8 hours.
• Do not inject air into aminophylline vials to avoid precipitation. • Onset of action is 15–30 minutes; duration ≤8 hours (extended release: ≥12 hours). • Check drug interactions when combining with other drugs.
• Drug has a bad taste.
622
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
Table 17.57 / Respiratory Drugs: Stimulants Drug Class
Stimulants
Drug (Trade Name)
• Doxapram HCl (Dopram)
• Naloxone (Narcan)
• Yohimbine (Yobine, Antagonil)
Action
• Stimulates the respiratory center of the brainstem
• ↑ Cardiac output, ↑ arterial blood pressure, ↓ hemoconcentration, ↓ metabolic acidosis, and helps prevent hypoglycemia
• α2-Adrenergic blocking agent
Metabolized
• Liver
Indications
• Depressed anesthetic respiration and neonate resuscitation
• Narcotic-induced respiratory depression
• Xylazine overdose
Dispensible Forms
• Injectable
• Injectable
• Injectable
Cautions
• Do not mix with alkaline solutions. • Asthma, arrhythmias, or tachycardias
• Cardiac abnormalities
• Renal disease or seizures
Contraindications
• Seizures or head trauma
Patient Care/Client Education
• Monitor for hypertension, arrhythmias, coughing, dyspnea, hyperventilation, laryngospasm, muscle tremors, seizures, vomiting, and diarrhea.
• Monitor for seizures if high dosaging is used.
• Monitor vital signs.
• Reversal agent for butorphanol
• Reversal agent for xylazine
Notes
CHAPTER 17 / PHARMACOLOGY
623
17
TOXICOLOGIC DRUGS Table 17.58 / Toxicologic Drugs: Chelating and Synthetic Alcohol Dehydrogenase Inhibitor Drug Class
Chelating Drugs
Drug (Trade Name)
• Dexrazoxane (Zinecard)
• Dimercaprol (BAL)
• d-Penicillamine (Cuprimine, Depen)
• 4-Methylpyrazole, (Fomepizole, Antizol-Vet)
Action
• Chelates intracellular iron
• Chelates arsenic, lead, mercury and gold
• Chelates cystine, lead, copper and promotes excretion
• Inhibits dehydrogenase enzyme
Metabolized
• Liver
• Liver
• Liver
Indications
• Anthracycline cardiotoxicity • Doxorubicin extravasation injuries
• Arsenic, lead, mercury, or gold poisoning
• Copper or lead toxicity • Hepatitis due to copper • Cystine urolithiasis
• Ethylene glycol toxicity
Dispensible Forms
• Injectable
• Injectable (Deep IM)
• Tablet and capsule
• Injectable (IV)
Cautions
• Use only if an anthracycline antineoplastic agent is used.
• Use with caution in patients who are renal impaired or hypertensive.
• Use with caution in animals in the wound healing stage.
• Hepatic insufficiency
• Pregnant animals • Administer on an empty stomach (1–2 hours before a meal). • Monitor for vomiting.
Contraindications
17
Synthetic Alcohol Dehydrogenase Inhibitor
Patient Care/Client Education
• Wear gloves when handling.
• Monitor for vomiting, tachycardia, tremors, seizures, and coma. • Monitor renal/liver function. • Potentially toxic to kidneys; recommended to keep urine alkaline during therapy
Notes
• Store powder at room temperature; reconstituted solution stable for 6 hours; discard unused portion.
• IM injection is painful. • Can form toxic compounds with iron, selenium, uranium, and cadmium.
624
SECTION SIX: COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE AND PHARMACOLOGY
• Monitor for CNS depression, decrease appetite, weight loss, and sweet breath.
• Not as effective as ethanol in felines Administer within • Canine: 8 hours of ingestion • Feline: 3 hours of ingestion
Appendix Kilograms to Body Surface Area 627 Temperature Conversion 627 Disinfectants 628
Metric Units 625 Weights 625 Liquid Measure 626 Length 626
Metric Units Prefix
Symbol
Power
Base 10
Prefix
Symbol
Power
Base 10
kilo
k
103
1,000
centi
c
10−2
0.01
hecto
h
102
100
milli
m
10−3
0.001
deca
da
unity deci
d
−6
10
micro
μ
10
1
1
nano
n
10−9
0.000000001
10−1
0.1
pico
p
10−12
0.000000000001
10
1
0.000001
Weights Kilogram (kg) 1 kilogram
1 kg
Gram (g) 1,000 g
Milligram (mg)
Microgram (mcg or μg)
1 × 106 mg
1 × 109 μg
Pound (lb) 2.2 lb
Ounce (oz)
Grain (gr)
36 oz
–
0.001 kg
1g
1,000 mg
1 × 10 μg
–
–
15 gr
1 milligram
1 × 10−6 kg
0.001 g
1 mg
1,000 μg
–
–
–
1 microgram
1 × 10−9 kg
1 × 10−6 g
0.001 mg
1 μg
–
–
–
1 pound
0.454 kg
454 g
–
–
1 lb
16 oz
–
1 ounce
0.028 kg
28.4 g
–
–
0.0625 lb
1 oz
–
–
–
1 gram
1 grain
–
0.065 g
65 mg
6
–
1 gr
Note: In cases in which the conversion is not useful, a “–” has been listed.
625
Liquid Measure Liter (L) 1 liter
Milliliter (mL)/Cubic centimeter (cc)
Gallon (gal.)
1L
1,000 mL
0.001 L
1 mL
1 gallon
3.84 L
3,840 mL
1 gal.
1 quart
0.960 L
960 mL
¼ gal.
1 pint
½L
480 mL
1/8
1 cup
¼L
240 mL
1/16
1 milliliter
¼ gal.
Quart (qt) 1 qt
Pint (pt)
Cup (c.)
2 pts.
4 c.
Tablespoon (Tb)
Teaspoon (t)
–
–
34 oz
Dram
–
250 dram
–
–
1/5
4 qts.
8 pts.
16 c.
–
–
128 oz
–
–
1 qt
2 pts.
4 c.
–
–
32 oz
–
250 dram
gal.
½ qt
1 pt
2 c.
32 Tbsp
–
16 oz
–
120 dram
gal.
¼ qt
½ pt
1 c.
16 Tbsp
48 tsp
8 oz
–
60 dram
1 Tbsp
3 tsp
½ oz
180 gtt
4 dram
Tbsp
1 tsp
1/6
oz
60 gtt
1 dram
2 Tbsp
6 tsp
1 oz
360 gtt
8 dram
60 gtt
1 dram
–
–
15 mL
–
–
–
–
1 teaspoon
–
5 mL
–
–
–
–
1 ounce
–
30 mL
–
–
–
–
1 dram
–
4 mL
–
–
–
–
1/3
1 drop
–
–
–
–
–
–
1/3
Tbsp
t
Drop (gtt)
–
–
1 tablespoon
–
Ounce (oz)
–
1 tsp –
12 gtt
1/8
oz
–
1 gtt
¼ dram
–
Length Meter (m) 1 meter
Centimeter (cm)
1m
100 cm
1 centimeter
0.01 m
1 cm
1 millimeter
0.001 m
1 yard
Millimeter (mm)
Feet (ft)
Inch (in)
1.0936 yd
3.2808 ft
39.37 in
10 mm
0.0109 yd
0.03281 ft
0.3937 in
0.1 cm
1 mm
0.0011 yd
0.00328 ft
0.03937 in
0.9144 m
91.44 cm
914.40 mm
1 yd
3 ft
36 in
1 foot
0.3048 m
30.48 cm
304.8 mm
0.333 yd
1 ft
12 in
1 inch
0.0254 m
2.54 cm
25.4 mm
0.0278 yd
0.0833 ft
1 in
626
APPENDIX
1,000 cm
Yard (yd)
Kilograms to Body Surface Area (m2)
Temperature Conversion: Celsius to Fahrenheit (° C × 1.8) + 32 = ° F Fahrenheit to Celsius (° F − 32) × 0.555 = ° C
Common equations used to calculate body surface area: 10.1 × ( weight in grams) 10, 000
2/3
Canine:
Celsius
10 × ( weight in grams) 10, 000
2/3
Feline:
Canine and Feline:
(weight in kilograms)2 / 3 10
Canine
Feline 2
kg
m
2
m
kg
m
0.5
0.06
14
0.58
28
1
0.10
15
0.60
2
0.15
16
3
0.20
4
2
2
2
Fahrenheit
0
32.0
4.0
39.2
25.0
77.0
32.0
89.6
37.0
98.6
38.6
101.5
kg
m
kg
m
39.1
102.5
0.92
0.5
0.063
5.5
0.311
39.4
103
29
0.94
1
0.1
6
0.330
0.63
30
0.96
1.5
0.131
6.5
0.348
17
0.66
35
1.07
2
0.159
7
0.366
0.25
18
0.69
40
1.17
2.5
0.184
7.5
0.383
5
0.29
19
0.71
45
1.26
3
0.208
8
0.400
6
0.33
20
0.74
50
1.36
3.5
0.231
8.5
0.416
7
0.36
21
0.76
55
1.47
4
0.252
9
0.432
8
0.40
22
0.78
60
1.55
4.5
0.273
9.5
0.449
9
0.43
23
0.81
65
1.64
5
0.292
10
0.464
10
0.46
24
0.83
70
1.72
11
0.49
25
0.85
75
1.80
12
0.52
26
0.88
80
1.88
13
0.55
27
0.90
85
1.96
kg
APPENDIX
627
Disinfectants The effectiveness of each product can be assured by verifying the correct organism is listed on the product’s label and by following the manufacturer’s directions on concentration and contact time. Without following the specific directions, the spread of infection cannot be prevented. Agent
Uses
Spectrum of Activitya
Directions for Use
Action
Comment
Alcohol, isopropylb
• Disinfectant
• Bacteria, ± fungi, enveloped virus
• Disinfect: skin should be kept wet for at least 2 minutes
• None, repeated applications are required due to evaporation • Inhibited by organic matter
• No activity against spores of fungi • Only apply to intact skin • 100% alcohol has no disinfecting qualities, 50– 95% concentrations are used • Not effective for cold sterilization
Formaldehyde • Formalin
• Specimen preservation
• Bacteria, bacterial spores, fungi, virus
• Place tissue sample in a widemouth container with a secure lid, assuring a 1 : 10 ratio of tissue to formalin
• Complete fixation by 24 hours
• Can cause respiratory difficulty and eczema with long term exposure
Chlorhexidine • Nolvasan
• Wound cleaning and lavage • Surgical and catheter prep • Cold sterilizationc
• Bacteria, virus, fungi, yeast and mold Bacteria • Proteus, E. Coli, Staphylococci, Pseudomona
• Surgical Prep: scrub site with chlorhexidine scrub alternating with rinse (e.g., chlorhexidine solution) for two 30-second applications • Disinfect: remove all animals and food products, clean area with soap and water, apply, let sit for 10 minutes, wipe dry • See Table 10.4 Wound Cleaning Solutions, page 401.
• 48 hours with a rapid onset • Persistent and residual efficacy • Inactivated by soap
• Nonirritating to skin, avoid contact with eyes and mucous membranes • Not affected by alcohol • Precipitation when mixed with electrolyte solutions does not affect activity
Chlorine Bleach
• Disinfectant
• Bacteria, bacterial spores, fungi, virus Bacteria • Proteus, Pseudomonas Virus • Canine parvovirus
• Disinfect: remove gross material, apply, let sit for 10 minutes, rinse with water
• Ineffective or unstable by organic matter, soap and hard water
• Dilute 1 : 30 with water • Inactivated by light, store in opaque container and change daily
Chloroxylenol • Technicare
• Wound cleaning and lavage • Surgical and catheter prep
• Bacteria
• Surgical Prep: scrub site for 2 minutes, do not rinse • See Table 10.4 Wound Cleaning Solutions, page 401.
• 24 hours (occluded), 6–8 hours (nonoccluded)
• No contraindications for use • Do not wash off
628
APPENDIX
Agent
Uses
Spectrum of Activitya
Directions for Use
Action
Comment
Didecyl dimethyl ammonium chloride • D-256
• Germicidal detergent and deodorizer
• Bacteria, viruses, fungi Bacteria • Pseudomonas, Listeria, Staphylococcus, Streptococcus, pseudorabies, Salmonella, Bordetella, E. coli Virus • Canine Parvovirus, Canine Distemper Virus and pseudorabies
• Disinfect: remove all animals and food products, clean area with soap and water, apply diluted solution (½ oz per 1 gallon water), let sit for 10 minutes, wipe dry, ventilate area
• Inactivated by organic matter, soap and hard water
• Can cause irreversible eye damage, skin burns, inhalant irritant • Wear protective eyewear, clothing and gloves • Prepare fresh solution daily or sooner if visibly dirty
Dimethyl benzyl ammonium chlorides • Parvosol
• Disinfectant cleaner and deodorizer
• Bacteria, viruses, fungi Bacteria • Staphylococcus, Salmonella, Pseudomonas, E. coli Viruses • Canine Parvovirus, Rabies virus
• Disinfect: remove gross material, apply, let sit for 10 minutes, wipe dry
• Still effective in the presence of organic matter
• Wash hands thoroughly after use
Glutaraldehyde • Metricide
• Cold sterilizationc
• Bacteria, bacterial spores, virus, fungi Bacteria • Clostridium, Staphylococcus, Salmonella, Pseudomonas, Mycobacterium Virus • Adenovirus
• Disinfect: storage of instruments in ± diluted solution, rinse thoroughly before use • Clean containers, test efficacy with specific test strip and change solution as needed or every 10– 28 days (depending on type used)
• Slight residual activity • Partly inactivated by organic matter, soap and hard water
• Can cause throat, lung and eye irritation, nosebleeds, hives, headaches and nausea • Wear nitrile or butyl rubber gloves (latex not adequate), goggles and face shield
Iodine/iodophors • Surgical prep, • Povidinewound iodine treatment, joint • Betadine or body cavity lavage
• Bacteria, yeast, fungi, protozoa and virus
• Surgical Prep: scrub site with an iodophor alternating with alcohol for a total contact time of 5 minutes, following with a spray/ paint application of iodine • See Table 10.4 Wound Cleaning Solutions, page 401.
• 4–6 hours when left on the skin • Inactivated by organic matter and alcohol
• Can cause skin irritation or acute contact dermatitis in up to 50% of patients and staff • Iodine toxicity possible, manufacturer’s dilution guidelines should be followed
Quaternary ammonium • Roccal-D
• Effective against bacteria (not against some species of Pseudomonas), fungi, ± enveloped virus Bacteria • Mycoplasma, Streptococcus, Staphylococcus, E. coli, Salmonella, Giardia Virus • Canine Parvovirus, parainfluenza and pseudorabies
• Disinfect: allow treated surfaces to remain moist for at least 10 minutes before wiping or rinsing
• Residual bacteriostat and inhibits bacterial growth on moist surfaces • Inactivated by organic matter, soap and hard water
• Undiluted solution can cause chemical burns • Contains rust corrosion inhibitors
• Disinfectant cleaner and deodorizer
a
Verify spectrum of activity with the manufacturer’s label for specific organisms. Alcohol-based solutions containing another agent (e.g., Iodophors, Chlorhexidine) are becoming available to allow a shorter or one-step surgical prep. c Cold sterilization trays should soak instruments for a minimum of 3 hours for sterilization and 10–30 minutes for disinfection (glutaraldehyde: 10 hours for sterilization and 20 minutes for disinfectant) and all instruments should be rinsed before use. b
APPENDIX
629
Glossary Abduct Aboral Absorber Acetylcholine
Acidosis
Acini Adherent Adrenergic Adulticide Aerophagia Agglutination
Aggregation Agonists Akinesia Alkali Alkalosis Alloantibody Alloantigen Allodynia Alopecia Alveolar
To draw away from the median plane of the body or one of its parts Opposite to, or away from, the mouth Filters out carbon dioxide particles from the patient’s exhaled gases Chemical neurotransmitter substance; thought to play an important role in nerve impulse transmissions Excessive acidity of body fluid due to an accumulation of acids or an excessive loss of bicarbonate Smallest division of a gland; a group of secretory cells surrounding a cavity Attached to, as of two surfaces Nerve fibers that release epinephrine when stimulated Insecticide used to kill adult insects Swallowing of air One type of antigen–antibody reaction in which a solid antigen clumps together with a soluble antibody Clustering or coming together of substances That which works with the action of something else Loss of motor response (movement) caused by paralysis of nerves Substance having marked basic properties Excessive alkalinity of body fluids due to accumulation of alkalies or reduction of acids Antibody produced by an isoantigen Substance found in an individual that causes antibody formation in another individual Condition in which a normal painless stimulus is now perceived as painful Absence or loss of hair Small hollow
Ambulation Amino Acid
Amplitude Amyloid Amyloidosis Analgesia Anastomosis Anechoic Anesthetic Anisocoria Anisocytosis Anisokaryosis Ankylosis Antagonist Anticoagulant Antiemetics Antipruritic Antipyretic Anuria Apex Aphakic Apnea Apneustic breathing
Applanation Aqueous flare Aqueous humor
Ability to walk One of a large group of organic compounds marked by presence of both an amino acid and a carboxyl group Largeness of dimension Resembling starch Metabolic disorder marked by deposition of amyloid in organs and tissue Temporary loss of pain Surgical or pathological connection of two tubular structures To not produce any or only a few echoes Agent that produces loss of feeling or sensation Inequality of the size of the pupils Excessive inequality in the size of cells Unequal size of the cell’s nuceli Immobile joint That which counteracts the action of something else Delaying or preventing blood coagulation Preventing or relieving nausea or vomiting Inhibiting itching Agent that reduces fever Absence of urine formation Pointed extremity of a conical structure Absence of the crystalline lens of the eye Cessation of respiration Breathing in which there is inspiratory hold or pause before ex-halation; often seen in dissociative anesthesia Abnormal flattening especially to the corneal surface Increased turbidity of aqueous humor Thick water substance in the eye to maintain IOP and inflate the globe of the eye 631
Arterial blood gases Arthralgia Arthrodesis Artificial colloid Ascites Ataxia Atelectasis Atrial Fibrillation
Auscultate Autolysis
Axillary Axoneme Axostyle Azotemia Bacteremia Bactericidal Bacteriostatic Barotrauma
Basophilic Bioactive amine Bioavailability
Biot’s respiration
632
GLOSSARY
Gases found in the blood; clinically useful oxygen and carbon dioxide Pain in the joint Surgical immobilization of a joint Intravenous solution containing protein or starch molecules Accumulation of serous fluid in the peritoneal cavity Defective muscular coordination Collapsed or airless condition of the lung Cardiac arrhythmia affecting the atria; disorganized activity in the atria leads to irregular conduction of impulses to the ventricles To examine by listening to the sounds produced within the body Self-dissolution or self-digestion that occurs in tissues or cells by enzymes in the cell’s themselves Pertaining to the area beneath the forelimb; armpit Cytoskeletal structure in the inner core of cilia or flagella providing support Rod in many parasites to aid in movement or supports function Presence of nitrogenous bodies Bacteria in the blood Destroying bacteria Inhibiting bacterial growth Any injury caused by a change in atmospheric pressure between a potentially closed space and the surrounding area Staining readily with a basic (blue) stain Amines capable of producing a biological effect (e.g., catecholamines, benzodiazepines) Rate and extent to which an active drug metabolite enters the general circulation, thereby permitting access to the site of action Sequence of uniformly deep breaths, apnea, and then deep breaths again
Bipolar Blepharospasm Borborygmus Brachygnathism Breathing tubes
Biomicroscopy Blepharospasm Bronchial sounds Bronchiectasis Brownian movement
Buccal Buphthalmos
Cachexia Calculus Candidiasis Carbohydrate
Cardiac tamponade
Carnassial Canarypox vector Catalepsy
Having two poles or processes Twitching of the spasmodic contraction of the orbicularis oculi muscle Rumbling sound produced by the movement of gas through the GIT Abnormal shortness of the lower jaw Corrugated tubing connecting the endotracheal tube of the patient to the anesthetic machine Microscope for viewing the eye Twitch of the eyelid Produced by air movement in the trachea and larger bronchi; louder on expiration Chronic dilatation of the bronchus or bronchi, with a secondary infection Oscillatory movement of particles resulting from chance bombardment of molecules moving at high velocities Pertaining to the cheek or mouth Condition of infantile glaucoma resulting in uniform enlargement of the eye, particularly the cornea State of ill health, malnutrition, and wasting Any abnormal concretion within the animal body Infection of Candida Group of chemical substances, including sugars, glycogen, starches, dextrins and celluloses, that contain only carbon, oxygen and hydrogen Accumulation of fluid in the pericardium resulting in increased pressure on the heart and decreased diastolic filling of the ventricles Last upper premolar and first lower molar, used for shearing in a scissors-like way Vaccines able to produce an immune response without any adjuvant Trance-like state, muscle rigidity, fixity of posture (limbs will remain in whatever position placed in), decreased sensitivity to pain
Cataract Catecholamine
Catelepsy
Cathartics Caudate Caustic Celiotomy Cellularity Cellulitis Cementum Cestode Chelate Chemo-pin Chemoreceptor trigger zone Chemosis Cholestasis Cholinergic Chyle
CO2 absorber Collimate Colobomas
Opacity of the lens of the eye and/or its capsule Chemical compound (e.g., epinephrine, norepinephrine and dopamine) typically used to prepare the body for the fight-or-flight response (e.g., increase in blood pressure, heart rate, blood glucose) State in which there is malleable rigidity of the limbs and the patient is generally unresponsive to aural, visual, or minor painful stimuli Substance to accelerate defecation Possessing a tail Destructive to living tissue Incision into the abdominal cavity Quality of the cell (e.g., component size and shape) Inflammation of connective tissue Calcified surface layer of the tooth root Gastrointestinal flatworm To chemically grasp a toxic substance, making it nonactive Device pushed into a drug vial to prevent overpressurization and aerosolization Area of the brain which stimulates vomiting when certain toxins enter the bloodstream Edema of the conjunctiva around the cornea Failure of bile flow Nerve fibers that release acetylcholine when stimulated Milk-like, alkaline contents of the lacteals and lymphatic vessels of the intestines, consisting of the products of digestion and principally absorbed fats Removes CO2 from anesthetic gases Radiology: to decrease the field of area to be radiographed to reduce x-ray scatter Lesion or defect of the eye, usually a fissure or cleft of the iris, ciliary body, or choroid
Determination of the amount of absorbance of a solution at a particular wavelength of light Colostrum Mammary fluid produced by the animal a few days before and after birthing; containing proteins, calories, antibodies, and lymphocytes Comedones Discolored dried sebum plugging an excretory duct of the skin Commissure Point or line across the midline or dividing space of two structures Compressed gas cylinders Metal cylinder with gas held under pressure to increase capacity of cylinder Computer radiography Cross-sectional set of images Concentration Amount of a given substance mixed with another substance Continuous positive airway Used to manage or prevent alveolar pressure (CPAP) collapse or atelectasis Contrast Difference between the lightest and darkest part of the film, reflecting two adjacent radiographic densities Convex Curved evenly; resembling the segment of a sphere Coprophagia Eating of excrement Core Vaccines recommended for every dog Cornified Changed into horny tissue Coupage Striking the chest to loosen bronchial secretion and thus facilitate chest wall drainage Crenation Notched or scalloped cell membrane Crepitus Having or making a crackling sound Crown Area of the tooth above the gumline, usually covered by enamel Cryotherapy Use of low temperatures for medical therapy Crypt Pit or depression into an epithelial surface Cryptorchidism Failure of one or more testicles to descend normally Crystalloid Isotonic or electrolyte solution typically used as a replacement or maintenance solution Colorimetric
GLOSSARY
633
Central venous pressure
Cyanosis Cyclooxygenase (COX)
Cycloplegic Daily energy requirement Danger level
Dead space, anatomic Dead space, physiologic
Decerebellate posture Decerebrate response Deciduous Decubital Definitive host Degloving
Dehiscence Density Dentin Dermatophyte Descemetocele
Desquamative cells 634
GLOSSARY
Pressure within the superior vena cava; represents the pressure of the blood returning to the right atrium Blue or gray coloring of mucous membranes and skin during hypoxia Enzyme responsible for the formation of prostanoids (e.g., prostaglandins) which play a role in forming inflammation and pain Medication that results in paralysis of the ciliary muscle in the eye Total daily energy requirement of an animal Point at which the level of a specific chemistry in the blood is reaching a critical (dangerous) point Volume of air from the nose and the mouth to the alveoli Anatomic dead space and the volume of air in any nonfunctioning alveoli, and the volume of air in excess of the amount needed to convert oxygen content of capillary blood to that of arterial blood Hindlimbs are flexed while the forelimbs are in extensor rigidity, altered mentation Involuntary extension of the forelimbs in response to external stimuli Tending to fall out or being shed; temporary Bedsores Animal harboring a sexually mature parasite Tearing off of an extensive amount of skin from the underlying tissue, severing its blood supply Rupture of a wound Degree of blackness of a radiograph Calcified tissue laying over the pulp cavity and covered by the enamel of a tooth Fungal parasite of the skin Corneal ulcer extending through the stroma at a great risk of perforation; protrusion of Descemet’s membrane Shedding epidermal cells
Devitalized Diastolic Diatheses Dermatophytosis Digestibility
Diskospondylitis Dissociative anesthesia
Diuretic Dosage Dose Dosimeter Dyschezia Dyscoria Dysphagia Dysphonia Dysphoria Ecchymoses Echogenicity Echoic Ectopic Eczema, miliary
Edema Edematous
To deprive of life Time when the heart relaxes after contraction and fills with blood Constitutional predisposition to certain disease conditions Fungal infection Percentage of the food’s gross nutrient content released following mechanical and chemical digestive processes Infectious process of the intervertebral disk State in which that patient is disconnected from its environment; interruption of information flow from the unconscious to the conscious parts of the brain Increasing the secretion of urine Amount, frequency, and duration of a medication Specific amount of a therapeutic agent to be taken at one time Device to measure the amount of exposed radiation to an individual Painful or difficult bowel movement Abnormal form or shape of the pupil Difficulty eating Difficulty in speaking State of exaggerated feelings of anxiety, restlessness, or sadness Extravasation of blood into the surrounding tissues from ruptured blood vessels Strength or amplitude of returning echoes To produce echoes Abnormal position Acute or chronic cutaneous inflammatory condition with erythema, papules, vesicles, pustules, scales, crusts, or scabs alone or in combination Area of tissue containing an excessive amount of interstitial fluid Area of edema
Edrophonium Electromechanical dissociation ELISA Embryonated Emetic Enamel Encephalopathy Endophthalmitis
Endotoxemia Endotoxin Energy Enucleation Enzyme Epididymitis Epidural anesthesia Epiphora
Epistaxis Epithelialization Epithelium Epulides Ergosterol
Erythema Erythropoietin Evisceration
Reversible acetylcholinesterase inhibitor Heart rhythm observed on an ECG that should produce a pulse, but is not Used for detection of an antibody or an antigen Having an embyro To cause vomiting Hard mineralized material covering the crown of the tooth Disease of the brain Inflammation of the inside of the eye that may or may not be limited to a particular chamber Toxins in the blood Bacterial toxin within a bacterium that is released upon destruction of the bacterium Ability to do work Removal of the eye and all orbital tissues Proteins produced by living cells that catalyze chemical reactions Inflammation of the epididymis Deposition of local anesthesia within the epidural space Abnormal overflow of tears down the cheek caused by excess secretion of tears or obstruction of the lacrimal duct Hemorrhage from the nose Growth of skin over a wound Cells forming the epidermis and the surface layer of the mucous and serous membranes Firm tumors involving the gingival tissue Component of fungal cell membrane required to build and maintain the membrane Diffused redness over the skin due to capillary congestion Hormone stimulating red blood cell production Surgical removal of intraocular contents
Exsanguinate Extracapsular Extracellular Extraorally Extravasation Extrinsic Exudate
F wave Facultative Fat Fatty acid Fenestration Fetid Fiber
Fibrinogen
Fibroblasts Fibrosis Field block
Fistula
Draining or losing of blood; milking the blood away from an area Outside a capsule Outside a cell Outside of the mouth Leakage of fluid in surrounding tissue No forming part of or belonging to a thing Fluid filtered from the circulatory system and accumulating into lesions or areas of inflammation Fibrillating (flutter) waves during contraction of the atria Having the ability to live under certain circumstances Triglyceride that contains three fatty acids attached to glycerol by an ester linkagea Derived from natural fats and classified as either saturated or unsaturated Opening made in a structure Rank or foul in odor Food that is not digestible and passes through the small intestines undigested; consists of cellulose, hemicellulose, gums, and pectin Soluble plasma glycoprotein synthesized by the liver, converted to fibrin during clot formation Any cell or corpuscle from which connective tissue is developed Accumulation of excessive fibrous connective tissue as a repair or reactive response Creation of “walls” of anesthesia encircling the surgical field by means of injection of a local anesthetic Abnormal passage from one cavity to another
a
Michael Hand, Small Animal Clinical Nutrition (Marceline: Walsworth Publishing Company, 2000). GLOSSARY
635
Flail chest
Broken segment of the thoracic wall (rib) that is detached from the rest of the chest wall moving freely with respiration
Floccose
Growth made up of short and densely but irregularly interwoven filaments
Flocculent
Culture containing whitish shreds of mucus
Flowmeter
Controls the rate at which a particular gas is delivered to the patient
Fluoride
Compound of fluorine that makes teeth more resistant to the formation of tooth decay
Globulin, a
Globulin, b
Globulin, g
Glomerulonephropathy Gluconeogenesis
Follicle-stimulating
Promotes growth and maturation of ovarian
hormone (FSH)
follicles in females and spermatogenosis in males
Folliculitis
Inflammation of a hair follicle
Fontanelle
Unossified space of tissue lying between the cranial bones of a fetus; also known as the soft spot
Frenulum
Small fold of tissue used to hold a moveable organ in place (e.g., tongue)
Fructosamine
Compound containing fructose and ammonia or an amine used in a test to evaluate diabetic control
Fungicide
Destroying fungi
Fungistatic
Inhibiting fungal growth
Furcation
Something that is branched (e.g., where the roots divide on a tooth)
Granulation bed
Furunculosis
Condition resulting from boils
Granulomatous
Genal
Pertaining to the cheek
General anesthesia
Controllable and reversible loss of consciousness induced by intoxication of the CNS
Germination
Process where growth develops following a period of dormancy
Gingiva
Gums; the mucous membranes surrounding the teeth
Globulin
Globular protein in plasma insoluble in pure water and soluble in dilute salt solutions
636
GLOSSARY
Glycogenolysis Glycoproteins Glycosaminoglycan (GAGs) Glycosylated Gonadotropin releasing hormone (GnRH) Goniometry Granularity
Halitosis Hematemesis Hematochezia Hematopoietic Hematuria Hemilaminectomy Hemoagglutination Hemolytic
Globular protein in plasma (e.g., alpha-1, alpha-2) used for transport and assists in the formation of other substances; produced by the liver Globular protein in plasma used for transport and assists in the formation of other substances; produced by the liver Immune protein (e.g., antibodies) responsible for immune response; produced by B-lymphocytes Disease of the glomerulus of the kidney Process of making glucose from noncarbohydrate sources (e.g., amino acids, fatty acids) by the liver Body’s process of converting glycogen to glucose Combination of a carbohydrate and a protein Carbohydrate forming an important component of connective tissue Process of forming a glycoprotein Stimulates the release of LH or FSH or the activity similar to the hormones Process of measuring joint movements and angles Measure of the size of the components (e.g., fine, coarse) Combination of new fibroblasts, fibrous tissue and capillaries on a wound Containing a mass of inflamed and often infected granulation tissue Bad breath Blood in the vomitus Blood in the feces Formation of blood Blood in the urine Surgical removal of part of the vertebral lamina Agglutination of red blood cells Breaking down of red blood cells
Hemolyzed Hemoptysis Hemostasis Heparinized Hepatoid Hepatomegaly Holter apparatus
Humidification Hyaluronic acid
Hydatid cyst Hydrolyzed protein
Hydrophilic Hyperalgesia Hypercalcemia Hypercapnia Hypercarbia Hypercellular Hyperechoic Hyperemic Hyperesthesia Hyperglycemia Hyperkalemia Hyperkeratotic Hyperkinesis
Breakdown of red blood cells Expectoration of blood arising from the oral cavity, larynx, trachea, bronchi, or lungs Arrest of bleeding To stop coagulation of blood with the addition of heparin Having the structural form of the liver Enlarged liver Used to record the physiological signals of the heart; performing 24 hour ECG monitoring Providing increased moisture in the air Nonsulfated GAG naturally found in connective, epithelial and neural tissues (e.g., synovial fluid, articular cartilage) Cyst formed in the tissues for development of the larval stage of Echinococcus Protein broken down into smaller components (animo acids) reducing the chance of eliciting an allergic response Capable of hydrogen binding; strong affinity for water Increased sensitivity to pain Excessive amount of calcium in the blood Excessively high level of carbon dioxide in the blood Excessively high level of carbon dioxide in the blood Increased cellular content To produce more echoes than the surrounding tissue Increase blood flow to different tissues in the body Increased sensitivity to sensory stimuli (touch, sight, sound) Excess of sugar in the blood Excessive amount of potassium in the blood Hypertrophy of the corneous layer of the skin Overactive restlessness, uncontrollable activity or muscular movements
Hypernatremia Hyperoncotic Hyperosmolar Hyperpathia Hyperphosphatemia Hyperplasia Hyperreflexia Hyperthenuric Hyperthermia Hypertonia Hypertonic Hypertrophic Hypnosis
Hypocapnia Hypocellular Hypochloremia Hypochromic Hypocortisolemia Hypoechoic Hypoglycemia Hypokalemia Hyponatremia Hypoperfusion
Hypoplasia Hyporeflexia Hypothenuric Hypotonia Hypotonic
Excessive amount of sodium in the blood Increased oncotic pressure Increased osmolarity of the blood Greatly exaggerated pain sensation Excessive amount of phosphate in the blood Proliferation of cells Overactive or responsive reflexes Abnormally concentrated urine Unusually high fever Increase in muscle tone and stiffness Having a higher osmotic pressure than a compared solution; >300 mOsm/L Thickening or enlargement of an organ Artificially induced sleep or a trance resembling sleep from which the patient can be aroused by stimuli Excessively low level of carbon dioxide in the blood Decreased cell content Depleted amount of chloride in the blood Depleted amount of color Depleted amount of cortisol in the blood To produce less echoes than the surrounding tissue Depleted amount of sugar in the blood Depleted amount of potassium in the blood Depleted amount of sodium in the blood Abnormally low amount of tissue blood flow resulting in decreased oxygen and nutrients to the body as well as failure to remove wastes Incomplete or stopped development of an organ Decreased or absent reflexes Abnormally diluted urine Decrease in muscle tone and stiffness Solution having a lower osmotic pressure than a compared solution; <300 mOsm/L GLOSSARY
637
Hypotony Hypovolemia Iatrogenic Icterus Idiopathic
Idiosyncratic Ileus Immunization/vaccination
Immunogenic Impetigo Inanimate Incisal Incontinence Inertia
Infarction
Infraorbital Intercostal Interdental Intermediate host
Intermittent partial pressure ventilation Interpleural Intracellular Intraorally Intraosseus 638
GLOSSARY
Defective muscular tension or tone Abnormally low blood volume Adverse effect or complication caused by or resulting from medical treatment Yellow coloration of the skin and mucous membranes Conditions without clear pathogenesis, or disease without recognizable cause, as of spontaneous origin Individual hypersensitivity Limited or absent intestinal passage; intestinal obstruction Process of administering a vaccine to produce a protective immune response from the host Producing an immune response Skin disease seen with crusted and possibly ruptured pustules Not alive Cutting Inability to retain urine Property of an object to remain at constant velocity unless acted upon by an outside force Area of tissue in an organ or part that undergoes necrosis after cessation of blood supply Situated below the eye socket (orbit) Between the ribs Between the teeth Animal used during the immature stages of the parasite’s life cycle to continue their development Manual method of placing air into a patient’s lungs Within the pleura Within the cell Within the mouth Within the bone
Intrinsic Intussusception Ipsilateral Iridodonesis Ischemia Ischemic
Isoantibody Isoantigen Isoechoic Isoerythrolysis Isosmolar Isothenuric
Isotonic solution Jaundice
Karyo Keratin Keratolytic Keratoplastic Kilocalorie Lacrimation Laminectomy Lavage Left shift Leukocytosis
Originating or due to causes within a body organ or part Invagination; the slipping of one part of the intestines into another part Affecting the same side of the body Tremulousness of iris, seen in an aphakic eye or one with subluxated lens Restriction in blood supply Local and temporary deficiency of blood supply caused by obstruction of circulation to a part Antibody produced by an isoantigen Substance found in an individual that causes antibody formation in another individual To produce similar echoes as the surrounding tissue Lysis of red blood cells by isoantibodies Equal osmolarity as the solution being compared to Condition of urine being of a uniform specific gravity and osmolarity despite fluctuations in fluid uptake Exerting an equivalent osmotic pressure to the compared solution; =300 mOsm/L Yellow coloration of the skin and mucous membranes due to excessive bilirubin in the blood Referring to a cell’s nucleus Fibrous structural proteins of the skin, hair and nails Loosening or shedding of the keratin Promotion of thickening of the keratin layers Unit of measure for heat Secretion of tears Surgical removal of the vertebral lamina Therapeutic washing out of a cavity Increased number of immature neutrophils in the blood Increase in the number of leukocytes
Leukopenia Life stage Lingually Lipemic Lipid Local anesthesia Lochia Luteinizing hormone (LH) Luxation Lymphadenomegaly Lymphadenopathy Lyophilized Lysed Lysosome Macrocytosis Macrokaryosis Macrophages Maintenance solution Malassimilation Malnutrition Manometer Manubrium Mastocythemia Meat byproducts Meat meal Megathrombocytosis b
Decreased number of white blood cells Physiological stages of life Related to the tongue Increased fat in the blood Fat or fat-like substances Injection of an anesthetic agent into the tissues that are to be incised or manipulated Clear, odorless, serosanguineous normal postpartum discharge Stimulates ovulation in females and testosterone in males Displacement of organs or articular surfaces Enlargement of the lymph nodes Disease of the lymph nodes To freeze-dry To cause dissolution or decomposition Intracellular organelles that contain digestive enzymes Enlarged cell size Enlarged red blood cell nucleus Cell found within the tissues, originating as a monocyte Solution that contains less sodium and more potassium than replacement solutions Inability or incomplete ability of the GIT to take up ingested nutrients Improper or insufficient diet Monitors pressure within the breathing system Uppermost segment of the sternum Increased number of mast cells in the blood Nonrendered, clean parts, other than meat, derived from slaughtered animalsb Rendered product from mammalian tissueb Condition of enlarged platelets
Adapted from the AAFCO definition
Melena Menace response
Meniscus Mentation Mesenchymal Mesially Mesothelioma Mesothelium Metabolic acidosis
Metabolic alkalosis
Metabolism Metastasis Microaggregates Microfilariae Microhepatica Micronutrient Micturition Mineral Miosis Mitotic figures Mixed echogenicity Mordant
Black, tarry feces caused by action of intestinal secretions on free blood Rapid eye closure, with or without head withdrawal, in response to a threatening or unexpected image suddenly appearing in the near field vision Concavo-convex lens Mental activity Embyronic connective tissue Toward the midline Malignant cells developed in the mesothelium Protective lining that covers most of the body’s internal organs (e.g., pleura) Condition in which there is an excess of hydrogen ions resulting in a decrease in the body pH Condition in which there is an excess of hydrogen ions resulting in a increase in the body pH Complete set of chemical reactions that occur in living cells Transfer of disease from one organ to another Microscopic clots (e.g., particles, platelets, cells) found in stored blood The embryos of filarial worms (e.g., heartworm) Abnormally small sized liver Essential nutrient; required in only small amounts Act of voiding urine from the body Inorganic homogeneous crystalline chemical element or compound Abnormal contraction of the pupil Chromosomes visible as tangled, darkstaining threads; no nucleus For one structure to produce more than one echogenicity Substance used to set dyes GLOSSARY
639
Morbidity Moribund Mortality Mucoceles Mucoperiosteum Mucoprotein Mucopurulent Myalgia Myasthenia gravis Mydriasis Myelosuppressive Myocardium Myoclonus Myxedema Nadir Narcosis
Necrotic Nematode Neonate Neovascularization Nephrocalcinosis Nephrogram Nerve block
Neurolept analgesia
Neuropathy 640
GLOSSARY
State of being diseased Dying Death rate Enlargement of a hollow organ or sac (e.g., lacrimal sac) Periosteum with a mucous membrane Complex compound containing a protein and a mucopolysaccharide Consisting of pus and mucus Muscle pain Disease characterized by muscle weakness and progressive fatigue Abnormal dilation of the pupil Inhibition of bone marrow production Middle muscular layer of the heart Repetitive, rhythmic twitching or clonic spasm of a muscle or group of muscles Condition resulting from hypofunction of the thyroid gland The lowest point Drug-induced stupor or sedation in which the patient is oblivious to pain, with or without hypnosis Death of tissue Roundworms Newborn up to 6 weeks of age Formation of functional microvascular networks with red blood cell perfusion Diffuse, fine, renal calcification Radiograph showing the opacification of the functional parenchyma of the kidneys Injection of an anesthetic agent close to the major nerves whose conductivity is to be cut off State characterized by lack of apprehension and anxiety (neurolepsis) and loss of pain perception (analgesia) Disease of the nerves
Neutropenia Nictitans Nitrogenous waste NMB (new methylene blue) Nocturia Noncore Nonrebreathing system Normocellular Normochromic Normocyte Nystagmus Obesity Occlusal Odontoclast Oligodontia Oliguria Oncosphere Oncotic pressure
Onychectomy Oocyst Opacity Operculum Oronasal Oscillometric
Decreased number of neutrophils in the blood Third eyelid; nictitating membrane Nitrogen waste eliminated by the kidney Stain used in microbiology Excessive urination at night Vaccines recommended based on potential risk factors Patient receives fresh oxygen and anesthetic gases with each breath Possessing normal cellular qualities and content Possessing normal color Normal sized cell Constant, involuntary, cyclical movement of the eyeball Excessive accumulation and storage of body fat Relating to the closure of an opening; biting surface of the teeth Cell responsible for the absorption of the root of a deciduous tooth Less teeth than considered normal Decreased amount of urine formation Embyronic phase of a tapeworm in which it has hooks Pressure exerted by plasma proteins in the blood and tissue fluid proteins on the capillary walls Removal of the nail and entire third phalanx Encysted form of a fertilized gamete occurring in certain sporozoa Degree to which something is nontransparent Any covering Regarding the nose and mouth Measurement of oscillations caused by the arterial pressure pulse
Osmolality
Osmotic pressure Osteopenia Ototoxicity Oxygen flush Valve Palatine Palliative Pallor Palpate Pancytopenia Panniculus Panophthalmitis Papilloma Papule Paradoxical respiration
Paraphimosis Paratenic host Paresis PEEP (positive endexpiratory pressure) Penn-HIP
Determination of a particle’s ability to attract water based on a relative number of solute particles in 1 kg of the solution Hydrostatic pressure between two solutions separated by a semipermeable membrane Decrease in bone mineral density Adverse effects of the structures or nerves involved in hearing or balance Delivers oxygen to the anesthetic system at 35–75 L/min Regarding the palate of the mouth To relieve or alleviate, not cure Lack of color, paleness To examine the consistency of body areas by touch, using your fingers with light pressure Decreased number of red and white blood cells Dense layer of fatty tissue growth Inflammation of the entire eye Benign epithelial tumor Red elevated area on the skin, solid and circumscribed When the affected side of a pneumothorax bulges out during expiration and caves in during inspiration Trapping of the foreskin behind the glans penis Animal serving as a transport for an immature parasite; no development takes place Partial or incomplete paralysis Respiration method used to hold alveoli open during expiration Additional method to evaluate hip laxity and hip dysplasia when radiographs are inconclusive. The procedure uses the OFA VD view distraction and compression views. A distractor unit is used in one view, and this method requires special training and certification by the veterinarian. Acronym for (University of) Pennsylvania Hip Improvement Program.
Percutaneous Perfusion Periodontal Perioperative Peristomal Periuria Perivascular Peroxidase Petechiae Philtrum Phospholipase Photoablation Phthisis bulbi Phytotherapy Pica Planing Plaque Plasma Pleomorphic Pleomorphism Pleuritis Pneumoperitoneum Poikilocytosis Pollakiuria Polychromatophilic Polycythemia Polydipsia Polydontia
Internal access obtained through needlepuncture of the skin To cause to flow or spread Area around the tooth Period around surgery; including immediately before, during and immediately after Around the mouth Urination in inappropriate locations Area around a vessel Group of enzymes often used to catalyze a reaction Small, purplish hemorrhagic spots on the skin or mucous membranes Vertical groove in the upper lip Enzyme that converts phospholipids into fatty acids Removal or excision with the use of light (e.g., laser) Shrunken, nonfunctional eye Use of plants and plant extracts as medicine Abnormal craving and eating of nonedible substances (e.g., ashes, clay, crayon) Scraping away of plaque and calculus from the surface of the tooth root Sticky, colorless bacterial film on the teeth Yellow-colored liquid component of blood Having many shapes Cells changing form under certain conditions to cells of another type Inflammation of the pleura Accumulation of air or gas in the peritoneal cavity Variations of shape Abnormally frequent passage of urine Cell able to take on multiple stains Excess of RBCs Excessive thirst More teeth than considered normal GLOSSARY
641
Polyphagia Polyuria Pop-off valve
Postprandial Postprandial alkaline tide
Prepatent period
Preprandial Pressure relief valve (Pop-off valve)
Prodromal Proglottid Prognathism Pronotal Prophylactic Proprioception Protein
Proteoglycan Protozoa Pruritus Psychogenic Ptyalism Puerperal 642
GLOSSARY
Excessive eating Excessive urination Allows the release of excess pressure from the anesthetic system; the volume of gas in excess of the animal’s minute consumption is vented from the system After a meal ↑ Secretion of alkaline ions by the kidney after a meal to compensate for acid ions secreted in the stomach to aid digestion, resulting in alkaline urine Period between the time of introduction of parasitic organisms into the body and their appearance in the blood or tissues until they reach reproductive maturity Before a meal Allows the release of excess pressure from the anesthetic system; the volume of gas in excess of the animal’s minute consumption is vented from the system Initial stage of a disease; early symptoms Segment of a tapeworm; containing both male and female reproductive organs Mandible is longer than maxilla Before or in front of the dorsal area Preventative treatment Sense of the relative position of neighboring parts of the body Organic compounds composed of carbon, hydrogen, oxygen and nitrogen; providing the amino acids necessary for the growth and repair of animal tissue Combination of a protein and a GAG One celled unicellular microbes with membrane bound nuclei Severe itching Originating in the mind Excessive salivation Concerning postpartum
Pulp cavity
Pulse deficits Purulent Pyelogram Pyknotic Pyrexia Radiolucent Radiopaque Radiopharmaceutical drug Rales
Rebreathing bag Rebreathing system
Receptor
Redundant Refeeding syndrome
Regional anesthesia
Regulator
Replacement solution
Central cavity of the tooth containing blood vessels and nerves entering from the root canal Difference between heart beats and pulsations at the periphery Creating or containing pus Radiograph showing the opacification of pelvic recesses, renal pelves, and ureters Thickness Above normal temperature Greater transparency; permeable to radiation Greater opacity; impermeable to radiation Compound mixed with a radionuclide Abnormal thoracic sounds caused by a secretion from or a thickening of bronchial walls; “crackling sounds” Used as a reservoir of gases in the anesthetic system to ventilate the patient as necessary Patient rebreathes its own exhaled gases minus the carbon dioxide and with the addition of fresh oxygen and anesthetic gases Protein (e.g., on cell membrane, in cytoplasm or nucleus) that binds to a specific molecule to produce a specific cellular response More than necessary; an overflow Rapid movement of ions from the plasma to the intracellular space (e.g., hypophosphatemia, hypokalemia, hypomagnesemia) seen with malnutrition, starvation and prolonged diuresis possibly leading to muscle weakness, intravascular hemolysis, cardiac and respiratory failure Producing the loss of sensation in a portion of the body by interrupting sensory nerve conduction from that region of the body Reduce the variable pressure of the gas within the cylinder to a constant pressure of approximately 50 psi Solutions that are typically more similar to extracellular fluid
Repolarization
Reservoir bag
Respiratory acidosis
Respiratory alkalosis
Resting energy requirement Retinopathy Retrograde Rhonchi
Riskettsiae Rodenticide Rouleaux
Santes’ rule
Scavenger hose
Scavenger system Schiff-Sherrington posture
Scleral injection
Return of membrane potential after depolarization; movement of positively charge potassium ions of the cell Used as a reservoir of gases in the anesthetic system to ventilate the patient as necessary Condition in which there is a deficit of hydrogen ions resulting in a decrease in the body pH Condition in which there is a deficit of hydrogen ions resulting in an increase in the body pH Total resting energy requirement of an animal Disease of the retina Moving backward Abnormal sounds of the thorax typically indicating an airway obstruction; “musical sounds” Gram-negative, nonmotile, non–sporeforming, highly pleomorphic bacteria Agent used to kill rodents ↑ Concentration of plasma proteins (e.g., fibrinogen, immunoglobulins) which results in linear aggregations of erythrocytes Used to calculate the kVp of a radiographic technique chart; (2 X tissue thickness in cm) + SID + Grid Factor = kVp Tubing attached to the anesthetic pop-off valve collecting waste gas and depositing it outside the building Removes waste gas to an outside environment or filtering system Hindlimbs are relaxed while the forelimbs are in extensor rigidity, normal level of consciousness Dilated blood vessels leading to the appearance of redness on the surface of the eye
Sclerosed Seborrheic Second-gas effect Sedation
Septate Septicemia Sequestra Seroma Serosanguineous Serous Serum Signalment Slough Specific gravity Sporangia Sporangium Sporulated Steatorrhea Stenosis Stertor Stomatitis Strabismus Stranguria Stratum corneum Stridor
Hardened Disease of the sebaceous glands; abnormally increased secretion Uptake of one gas is sped up by the uptake of another Mild depression of the CNS during which the patient is awake, calm, and sometimes drowsy Having a dividing wall Bacterial infection of the blood Piece of a dead bone that has separated from healthy bone Pocket of serum resembling a tumor Containing both blood and serum Resembling serum; pale yellow, transparent and benign Serous fluid; any clear bodily fluid Detailed description of a patient; age, breed, sex and reproductive status Dead matter or necrosed tissue separated from living tissue Weight of a substance compared with an equal volume of water Supporting stalk for a spore sac of certain fungi Sac containing and producing spores Production of spores Increased fat in feces Constriction or narrowing of a passage or orifice Snoring or laborious breathing caused by obstruction of air passages in the head Inflammation of the mouth Inability to properly align the eyes with one another Difficult and painful urination Outermost layer of the epidermis Harsh sound during respiration, high pitched GLOSSARY
643
Subgingivally Sublingually Sulcus Supernatant Supernumerary Suppurative Supragingivally Supraventricular Symblepharon Syncope Synechia Synechiae Systolic Tachypnea Tenesmus
Teratogenic Tetany
Thrombocytopathia Thrombocytopenia Thromboembolism Thrombophlebitis Thrombosis Thrombus
and resembling the blowing of wind, caused by obstruction of air passages; wheezing sound made on inspiration typically indicating a laryngeal obstruction Beneath the gingiva Beneath the tongue Furrow, groove, crevice or slight depression Clear liquid remaining at the top after a precipitate settles More teeth than considered normal Producing or associated with generation of pus Above or on top of the gingiva Above or on top of the ventricles Adhesions between conjunctiva of lens and eyeball Transient loss of consciousness caused by inadequate blood flow to the brain Adhesions of iris to lens and cornea Adhesion; often the iris to the lens and cornea Contraction of the heart Increased respirations Spasmodic contraction of anal or vesical sphincter with pain and persistent desire to empty bowel or bladder, with involuntary ineffectual straining efforts Causing developmental malformations Nervous affection characterized by intermittent tonic spasms that are usually paroxysmal and involve extremities Insufficient function of platelets Abnormally decreased number of platelets Obstruction of a blood vessel by an embolus Inflammation of a vein due to a thrombus Formation of a thrombus inside a blood vessel Blood clot that obstructs a blood vessel or a cavity of the heart
Thyroid storm
Tidal volume T-lymphocytes Tonicity Topical anesthesia
Tortuous Toxic change
Tranquilization Transducer Trematode Triage Trichophytosis Trigone
Trismus Trocarization Trophozoite Turgor Unidirectional valves
Unipolar 644
GLOSSARY
High blood levels of thyroid hormones causing acutely increased metabolism characterized by tachycardia, hypertension, cardiac dysrhythmias, hyperthermia, and shock Amount of air breathed in and out during normal respiration White blood cell with a central role in cellmediated immunity State of normal tension Application of a local anesthetic agent to the surface of the skin or mucous membranes Having many twists and turns Prominent purplish cytoplasmic granules, cytoplasmic vacuolation, cytoplasmic basophilia, or Döhle bodies of a cell State of relaxation and calmness without drowsiness Probe that sends and receives the sound wave signal of an ultrasound machine Fluke, parasitic flatworm Determining priority of care based on severity on injuries Superficial fungal infection Triangular area of the urinary bladder comprised of the two ureter openings and the urethral opening Tonic contraction of the muscles of mastication Insertion of a large-bore needle to relieve distension Sporozoan nourished by its host during its growth stage Resistance of skin to be changed from its normal position on the body Prevent exhaled gas from being rebreathed before it passes through the absorbent cannister in an anesthetic system Having only one pole
Uremic
Uroabdomen Urocystitis Urolithiasis Urine specific gravity (USG) Urticaria Uveitis Vaccine Vacuoles Vagal Vaporizer Vascularity Vasoactive amine Vasovagal Ventricular premature contraction/complex (VPC)
Toxic condition associated with renal insufficiency produced by the retention in the blood of nitrogenous substances normally excreted by the kidneys Accumulation of urine in the abdomen Inflammation of the urinary bladder Urinary calculi Clinically relates to the concentration of the urine Eruption of itchy wheals (hives) Inflammation of the interior of the eye Biologic product that stimulates the immune system to produce antibodies Small air or fluid filled space in the tissues of an organism; cytoplasm of a cell Relating or involving the vagus nerve Delivers specified concentrations of anesthetic gas to the patient Area composed of blood vessels Amine acting on blood vessels: alters permeability or cause vasodilation Effects of the vagus nerve on the blood vessels Impulse originating in the ventricles instead of the SA node
Vesicular sounds
Viscous Vitamin
Volvulus Vomition Western blot Whelping Wind-up phenomenon
Wolff-Parkinson-White syndrome Xerostomia Zöllinger-Ellison syndrome
Sounds produced by the small bronchi, bronchioles, and alveoli; typically louder on inspiration; sounds like “rustling leaves” Degree of thickness or resistance to flow of a fluid Organic substance required for normal growth, development and metabolism of the body Twisting of the bowel on itself, causing obstruction Act of vomiting Method used to detect a specific protein through gel electrophoresis To give birth Causes untreated pain to become worse; nerve fibers transmitting a painful impulses to the brain become “trained” to deliver pain signals Syndrome of preexcitation of the ventricles of the heart Dryness of the mouth Increased levels of the hormone gastrin resulting in increased production of gastric HCl
GLOSSARY
645
Abbreviations μ, micro μg, microgram μm, micrometer μmol, micromole AAFCO, Association of American Feed Control Officials ACE, angiotensin-converting enzyme AChR, acetylcholine receptor AchRs, serum antibody against nicotinic ACT, activated clotting time ACTH, adrenocorticotropic hormone ADH, antidiuretic hormone AGID, agar-gel immunodiffusion AIHA, autoimmune hemolytic anemia AL, attachment loss Alk phos, alkaline phosphatase ALP, alkaline phosphatase ALT, alanine aminotransferase ANA, antinuclear antibody APC, atrial premature contraction/complex APTT, activate partial thromboplastin time ARF, acute renal failure ASA, American Association of Anesthesiologists ASPCA, American Society for the Prevention of Cruelty to Animals AST, aspartate aminotransferase AT, adrenocortical tumors aVF, augmented voltage foot aVL, augmented voltage left arm AVMA, American Veterinary Medical Association aVR, augmented voltage right arm BA, blood agar BCS, body condition score BG, blood glucose BGC, blood glucose curve BMBT, buccal mucosal bleeding time BP, blood pressure bpm, beats per minutes BTT, light blue top tube BUN, blood urea nitrogen BW, body weight
C, Celsius C, concentration C, cranial Ca+, calcium CAVM, complementary and alternative veterinary medicine CBC, complete blood count Cd, caudal CDV, canine distemper virus CHF, congestive heart failure CHM, Chinese Herbal Medicine CI, calculus index CK, creatine kinase Cl, chloride CLE, cervical line erosion CLL, cervical line lesion cm H2O, centimeters of water CMIARF, contrast medium induced acute renal failure CNL, cervical neck lesion CNS, central nervous system CO2, carbon dioxide COX, cyclooxgenase CPCR, cardiopulmonary cerebrovascular resuscitation CPD, citrate phosphate dextrose CPDA-1, citrate phosphate dextrose adenine cPLI, canine pancreatic lipase immunoreactivity CPV, canine parvovirus CRF, chronic renal failure CRI, constant rate infusions CRT, capillary refill time CSF, cerebral spinal fluid CT, computerized tomography CTD, cumulative trauma disorders CV, cardiovascular CVP, central venous pressure D, dorsal D5W, 5% dextrose in water DDAVP, desmopressin acetate DEA, dog erythrocyte antigen DER, daily energy requirement 647
DES, diethylstilbestrol Di, distal DIC, disseminated intravascular coagulation DJD, degenerative joint disease dL, deciliter DM, diabetes mellitus DMSO, dimethyl sulfoxide DNA, deoxyribonucleic acid DOCA, desoxycorticosterone acetate DOCP, desoxycorticosterone pivalate DR, digital radiography DV, dorsoventral ECG, electrocardiogram E-collar, Elizabethan collar EDTA, Ethylenediaminetetra-acetic acid EEG, electroencephalogram ELISA, enzyme linked immunoassay EOR, external odontoclastic resorption EPI, exocrine pancreatic insufficiency ET, endotracheal tube EU, excretory urography F, Fahrenheit FBD, feline bronchopulmonary disease FCV, feline calicivirus FDP, fibrin degradation product FE, furcation exposure FECV, feline enteric coronavirus FeLV, feline leukemia FFD, focal film distance FFP, fresh frozen plasma FHV-1, feline viral rhinotracheitis FIP, feline infectious peritonitis FIV, feline immunodeficiency virus fL, femtoliter FLK, fentanyl, lidocaine, ketamine FLUTD, feline lower urinary tract disease FNA, fine needle aspirate FNB, fine needle biopsy FP, frozen plasma fPLI, feline pancreatic lipase immunoreactivity FPV, feline panleukopenia Fr, french FSH, follicular stimulating hormone 648
ABBREVIATIONS
FSP, fibrin split product FUO, fever of unknown origin FUS, feline urologic syndrome FxC, facture closed FxO, fracture open g, gram G−, gram-negative G+, gram-positive GABA, γ-aminobutyric acid GDV, gastric dilation volvulus GFR, glomerular filtration rate GGT, gamma glutamyl transpeptidase GI, gastrointestinal GI, gingival index GIT, gastrointestinal tract GRNTT, green top tube gtt, drop GTT, gray top tube GV, governing vessel H2O, water H2O2, hydrogen peroxide HAC, hyperadrenocorticism HCl, hydrochloride HCO3, bicarbonate Hct, hematocrit HLK, hydromorphone, lidocaine, ketamine HPA, hypothalamic-pituitary-adrenal HR, heart rate hr, hour IFA, immunofluorescent assay IgE, immunoglobulin gamma E IgG, immunoglobulin gamma G IHSS, idiopathic hypertrophic subaortic stenosis IM, intramuscular IMHA, immune-mediated hemolytic anemia IMT, immune mediated thrombocytopenia IN, intranasal IO, intraosseus IOP, intraocular pressure IP, image plate IPPV, intermittent positive pressure ventilation ITP, idiopathic thrombocytopenic purpura IV, intravenous
IVDD, intervertebral disk disease IVP, intravenous pyelography IVU, intravenous urography K+, potassium KBr, potassium bromide Kcal, kilocalorie KCl, potassium chloride KCS, keratoconjunctivitis sicca Kg, kilogram KPO4, potassium phosphate kVp, kilovoltage peak L, lateral L, lesion L, liter LA, left arm LA, left atrium LAT, lateral lb, pound LDH, lactate dehydrogenase LH, luteinizing hormone LL, left leg LOX, 5-Lipoxygenase LRS, lactated ringers solution LTT, lavender top tube LV, left ventricular M, medial M, mobility mA, milliamperage MAOI, monoamine oxidase inhibitors mAs, milliamperage per second MC, MacConkey agar MCHC, mean corpuscular hemoglobin concentration MCV, mean corpuscular volume MDI, metered dose inhalers ME, metabolizable energy mEq, milliequivalent mg, milligram MHz, megahertz min, minute mL, milliliter MLK, morphine, lidocaine, ketamine mm Hg, milliliters of mercury mm, millimeter
MM, mucous membranes mOsm, milliosmoles MRI, magnetic resonance imaging Na, sodium NaCl, sodium chloride ng, nanogram NMB, new methylene blue NMDA, N-methyl-D-aspartic acid NPH, neutral protamine hagedon NRS, numerical rating scale NS, nonsuppurative NSAIDs, nonsteroidal anti-inflammatory drugs NV, nonvital O2, oxygen OBL, oblique OCD, osteochondrosis dessicans OHE, ovariohysterectomy ORL, odontoclastic resorbtion lesion OVH, ovariohystrectomy oz, ounce P, pocketing Pa, palmar PABA, para-aminobenzoic acid PAP, immunoperoxidase test PCR, polymerase chain reaction PCV, packed cell volume PD, polydipsia PD, probe depth PDH, pituitary-dependent hyperadrenocorticism PDI, periodontal disease index PDT, photodynamic therapy PE, physical examination PEMF, pulsed electromagnetic field therapy PER, partial energy requirement pg, picogram pH, potential of hydrogen PI, plaque index PIVKA, protein induced by vitamin K antagonism Pl, plantar PLE, protein losing enteropathy pmol, picomole PN, parenteral nutrition PO, by mouth ABBREVIATIONS
649
PPA, phenylpropanolamine PPN, partial or peripheral nutrition PPV, positive pressure ventilation Pr, proxmial pRBCs, packed red blood cells PSGAG, polysulfated glycosaminoglycans PST, pulsed signal therapy PT, prothrombin time PTH, parathyroid hormone PTH, prothrombin time PTT, partial thromboplastin time PU, polyuria PVC, polyvinyl chloride PZI, protamine zinc insulin Q24, every 24 R, right R, rostral RA, right arm RAST, radioallergosorbent test RBC, red blood cell RER, resting energy requirement RL, right leg RNA, ribonucleic acid ROM, range of motion RPC, root plane closed RPO, root plane open RR, respiratory rate Rtr, retained roots RTT, red top tube RV, rabies vaccine s, seconds S, suppurative SA, sinoatrial SAMe, S-adenosylmethionine SAP, alkaline phosphatase SDS, simple descriptive scale SGOT, serum glutamic-oxaloacetic transaminase SGPT, serum glutamic pyruvic transaminase SID, source image distance SIRS, systemic inflammatory response syndrome
650
ABBREVIATIONS
SQ, subcutaneous SSD, silver sulfadiazine SSRI, selective serotonin reuptake inhibitor SST, serum separator tube STD-standard SWB, stored whole blood T3, triiodothyronine T4, tetraiodothyronine Tb, tablespoon TBT, toenail bleeding time TCM, traditional Chinese medicine TLI, trypsin-like immunoreactivity TP, total protein TPLO, tibial plateau leveling osteotomy TPN, total parenteral nutrition TRH, thyroid releasing hormone TSH, thyroid stimulating hormone TT, thrombin time Twbc, total white blood cell count U, unit UA, urinalysis UMPS, University of Melbourne Pain Scale URI, upper respiratory infection US, ultrasound USG, urine specific gravity UTI, urinary tract infection v, variable V, ventral V, vital V, voltage V, volume VAS, visual analog scale VD, ventrodorsal VPC, ventricular premature contraction/complex vWF, von Willebrand disease W, worn WBC, white blood cell X, simple extraction (1 root) XS, sectioned extraction (2 or 3 roots) XSS, surgical extraction (gingival retraction)
Bibliography
AAFP. AAFP Feline Vaccine Advisory Panel Report. JAVMA. 2006:229:1414. Abbott Laboratories Insert for Dextrose and Sodium Chloride Injection, USP, 1989. Abrams K. Cataracts (online). Available: http://users.ids.net/peteyes/cataract.htm, 1996. Abrams K. Glaucoma (online). Available: http://users.ids.net/peteyes/glaucoma.htm, 1996. Accuvet. Advantages of Laser Surgery (online). Available: http://petlasers.com/site/ content/avl_laservet.asp, 2000. Ackerman L. In-Clinic Diagnostic Testing, Paper presented at Tufts Animal Expo 2002, Boston, MA, 2002. Alleman AR. White Cell Responses in Disease I, Paper presented at Western Veterinary Conference 2003, Las Vegas, NV, 2003. Allen DG, Pringle JK, Smith DA, et al. Handbook of Veterinary Drugs (2nd ed.). Philadelphia, PA: Lippincott, Williams and Wilkins, 1998. American Association of Feline Practitioners/Academy of Feline Medicine. Panel report on feline senior health care. Compendium on Continuing Education for the Practicing Veterinarian 1999;21:531–539. Anderson WD, Anderson BG. Atlas of Canine Anatomy. Philadelphia, PA: Lea & Febiger, 1994. Andrews DA. Cytologic Features of Neoplastic Disease, Paper presented at Western Veterinary Conference 2002, Las Vegas, NV, 2002. Bach E. Bach Flower Essences for the Family. London: Wigmore Publications Ltd., 1996. Baldwin K. Step-by-step placing an intraosseous catheter in the canine trochanteric fossa. Veterinary Technician, 1999;20:656–659. Baldwin K. Fluid Therapy for the companion Animal, Paper presented by Atlantic Coast Veterinary Conference 2001, Atlantic City, NJ, 2001. Barbe P. Addison’s Disease (Hypoadrenocorticism) (online). http://www.miragesamoyeds.com/Addison.htm, 2000. Barger AM, Grindem CB. Analyzing the results of a complete blood cell count. Veterinary Medicine 2000;95:535–545. Bartels KE. Laser Basics, Paper presented at Western Veterinary Conference 2002, Las Vegas, NV, 2002. Bartels K. Surgical Laser Basics, The NAVTA Journal, Fall 2005:29–34. Bartelt S. The Art of Tonometry, Veterinary Technician, January 2004: 24–26. Battaglia AM. Small Animal Emergency and Critical Care, A Manual for the Veterinary Technician. Philadelphia, PA: Saunders, 2001. Battaglia-Lawrence A. Shock: Recognition, treatment and monitoring. Veterinary Technician, 1997;18:167–178. Battaglia-Lawrence A. Step-by-step placing a peripheral intravenous catheter. Veterinary Technician, 1998;19:86–88.
Baxter Inserts for Dextrose Injection, USP, Lactated Ringer’s Injection, USP, and Sodium Chloride Injection, USP. Beckman B, Legendre L. Regional Nerve Blocks for Oral Surgery in Companion Animals, www.cvmbs.colostate.edu/ivapm/professionals/members/drug_protocols/ Regional NerveBlocksfor Oral Surgery.pdf. Beckman B. Anatomical Landmarks for Nerve Blocks for Oral Surgery, http://www. veterinary dentistry.net/nerveblocks.htm. Berg M. A complete Prophylaxis for the Periodontal Patient, The NAVTA Journal, Winter 2005:53–58. Berg M. Educating Clients About Preventative Dentistry. Veterinary Technician, February 2005:102–111. Bergerson WO. Golden opportunities: technical, economic, and professional aspects of urinalysis. Veterinary Technician 1998;19:574–583. Bergman PJ. Chemotherapy Preparation, Administration & Disposal, Paper presented at ABVP 2004, New Orleans, LA 2004. Bergman PJ. Side Effects of Chemotherapy: What You Should Know, Paper presented at ACVIM 2003, Charlotte, NC, 2003. Biller D. Understanding Contrast Studies, Paper presented at Atlantic Coast Veterinary Conference 2002, Atlantic City, NJ, 2002. Birchard SJ, Sherding RG. Saunders Manual of Small Animal Practice. Philadelphia, PA: WB Saunders Company, 1994. Bistner SJ, Ford R, Raffe M. Kirk and Bistner’s Handbook of Veterinary Procedures and Emergency Treatment, 7th ed. Philadelphia, PA: WB Saunders Company, 2000. Blagburn, B.L. Ectoparasites in 2003, Paper presented at Western Veterinary Conference 2003, Las Vegas, NV, 2003. Bolette DP. Worming their way in: identifying cestodes, trematodes, and acanthocephala. Veterinary Technician 1998;19:510–517. Bolton G. Handbook of Canine Electrocardiography. Philadelphia, PA: WB Saunders Company, 1975. Boon JA. Manual of Veterinary Echocardiography, Philadelphia, PA: Lippincott, Williams & Wilkins, 1998. Borjab JM, Ellison GW, Slocum B. Current Techniques in Small Animal Surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 1998. Boyd B. Internet Vets (online) http://www.internetvets.com, 1999–2000. Brearley MJ. Radiotherapy: When Should I Refer? British Small Animal Veterinary Congress 2006, www.vin.com/Members/Proceedings/Proceedings.plx?CIDbsava2006. Brewer WG. Preventing and Treating Chemotherapy Toxicity, Paper presented at Western Veterinary Conference 2003, Las Vegas, NV, 2003. Brock N. Veterinary Anesthesia Update, Guidelines and Protocols for Small Animal Anesthesia Vol. 1, Veterinary Anesthesia Northwest.
651
Brock N. Veterinary Anesthesia Update, Guidelines and Protocols for Small Animal Anesthesia, Vol. 2. Veterinary Anesthesia Northwest. 2000. Brooks W. Pet Health Care Library: Radiotherapy (online). Available: http://www.vin. com/members/searchdb/misc/m05000.htm, Mar Vista Animal Medical Center, 2001. Brooks WC. Pet Health Care Library: What is a Cataract? (online). Available: http://www.vin.com/members/searchdb/misc/m05000/m01291.htm, Veterinary Information Network, 2000. Bruyette D. Senior Wellness Programs, Paper presented at Atlantic Coast Veterinary Conference 2002, Atlantic City, NJ, 2002. Burkholder WJ. Age-related changes to nutritional requirements and digestive function in adult dogs and cats. JAVMA 1999;215:625–629. Burris P. It’s the little things . . . Cryptosporidium. Veterinary Technician 2000;21: 192–201. Byard V. Case Study: Dentistry, The NAVTA Journal, Winter 2005:32–34. Cappuccino JG, Sherman N. Microbiology, A Laboratory Manual, 4th Ed. Menlo Park, CA: The Benjamin/Cummings Publishing Company, Inc., 1996. Carmichael DT. Dental Corner: How to perform a nonsurgical extraction, Veterinary Medicine, http://www.vetmedpub.com/vetmed/content/printContentPopup.jsp? id=160621, May 2005. Carmichael DT. Dental Corner: Using intraoral regional anesthetic nerve blocks. Veterinary Medicine, http://www.vetmedpub.com/vetmed/content/ printContentPopUp.jsp?id=128730. Sept. 2004. Carroll GL. Pain Management in the Orthopedic Patient, Paper presented at Western Veterinary Conference 2004, Las Vegas, NV, 2004. Cartee RE and contributors. Practical Veterinary Ultrasound, Philadelphia, PA: Williams & Wilkins, 1995. Carter GR, Chengappa MM, Roberts AW. Essentials of Veterinary Microbiology, 5th Ed. Baltimore, MD: Williams and Wilkins, 1995. Chandler ML, Guilford WG, Payne-James J. Use of peripheral parenteral nutritional support in dogs and cats. JAVMA 2000;216:669–673. Chew DJ, DiBartola SP. Interpretation of Canine and Feline Urinalysis. Wilmington, DE: The Gloyd Group, Inc., 1998. Christopher MM. Evaluation of Bone Marrow, Paper presented at WSAVA World Congress Proceedings 2004, Rhodes, Greece, 2004. Clare M, Hopper K. Mechanical Ventilation: Ventilator Indications, Goals, and Prognosis. Compendium, 2005,27(3):195. Clare M, Hopper K. Mechanical Ventilation: Ventilator Settings, Patient Management, and Nursing Care. Compendium, 2005;27(4):269. Colmery I, Ben H. Diagnosing Dental Disease Film Vs. Digital Radiography, Veterinary Technician, February 2005:114–119. Cook CS, Mughannam AJ, Szymanski CM. Cataract Surgery: The Current State of the Art (online). Available: http://www.veterinaryvision.com/dvm_forum/dvmcataracts/htm, Veterinary Vision, 1998. Cook CS, Mughannam AJ, Szymanski CM. Glaucoma (online). Available: http:// www.veterinaryvision.com/dvm_forum/dvm-glaucoma/htm, Veterinary Vision, 1998.
652
BIBLIOGRAPHY
Cordell D, Duke A, Mack JD, et al. Delivering Compassionate Care: A Roundtable Discussion Part II. Good Medicine is Only the Beginning. Veterinary Technician 2000;21:284–288. Cornell C. Nursing Management of the Heart Failure Patient, Paper presented ACVIM 2003, Charlotte, NC, 2003. Cornick-Seahorn J, Marks SL. Emergency! Treating Patients in Shock. Veterinary Technician., 1998;19:355–369. Corwin RM, Nahm J. Veterinary Parasitology (online). Available: www.parasitology. org, University of Missouri-Columbia, 1997. Côté E. Clinical Veterinary Advisor, Dogs and Cats, St. Louis MO: Mosby, 2007. Cowell RL, Tyler RD, Meinkoth JH. Diagnostic Cytology and Hematology of the Dog and Cat, 2nd Ed. St. Louis, Mosby-Year Book, Inc., 1999. Crawford P, Connor K. A breath of a chance: Pleural effusions in small animals. Part I. Veterinary Technician 2000;21:455–461. Crowe DT Jr, Devey J. Peel-away long venous catheter technique minimizes placement steps. DVM Newsmagazine 2000:15–35. Crowe DT. Airway Access Technique- The Surgical Parachutes, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Crowe DT. On the Cutting Edge of Emergency and Critical Care, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Crowe DT. Procedures Involving Emergency Care of Fractures/Wounds, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Crowe DT Jr, Dennis T, Devey J. Oxygen, Oxygen, Oxygen: the Wonder Drug, The NAVTA Journal, Fall 2004:45–47. Crump K. Integrated Medicine: A Discussion of Flower Essence Therapy, Paper presented at the 2002 SAVMA Symposium, Fort Collins, CO, 2002. Davenport DJ. Complications of Enteral Feeding: How to Recognize and Avoid Them, ACVIM 2003, www.vin.com/Members/Proceedings/Proceedings.plx?CID= ACVIM2003. Davis H. Cardiopulmonary Resuscitation: An Overview, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Davis H. Triage in the Emergency Room, Paper presented at Atlantic Coast Veterinary Conference 20061 Atlantic City, NJ, 2001. Day MJ. Immunodiagnostic Tests for Autoimmune Disease, Paper presented at Western Veterinary Conference 2003, Las Vegas, NV, 2003. Dentistry: Take A Closer Look, DVM: In Focus, September 2006. DeStefano CJ. Applied Kinesiology in Anima Practice, Paper presented at the 2002 SAVMA Symposium, Fort Collins, CO, 2002. Devey J. Coagulation Monitoring: Survival for the Critical Patient, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Douglas SW, Williamson HD. Principles of Veterinary Radiography, 2nd Ed. London, England: Bailliere Tindall, 1972. Drobatz K. Approach to the Emergency Patient, Paper presented at ACVIM 2003. Charlotte, NC, 2003. Dunning D. Rehabilitation of Fracture Patients (VET-372), Paper presented at the Western Veterinary Conference 2004, Las Vegas, NV, 2004.
Dunning D. Rehabilitation of Neurological Patients (VET-371), Paper presented at the Western Veterinary Conference 2004, Las Vegas, NV, 2004. Dunning D. Rehabilitation of Postoperative Joint Surgery Patients (VET-370), Paper presented at the Western Veterinary Conference 2004, Las Vegas, NV, 2004. Dunning D. Rehabilitation of Postoperative Patients (T-13), Paper presented at the Western Veterinary Conference 2004, Las Vegas, NV, 2004. Dunning D. Rehabilitation of the Osteoarthritic Patient (VET-369), Paper presented at the Western Veterinary Conference 2004, Las Vegas, NV, 2004. Dunning D. Therapeutic Exercise and Weight Management in the Obese Orthopedic Patient (VET-373), Paper presented at the Western Veterinary Conference 2004, Las Vegas, NV, 2004. Dyson D, Gaynor JS, Grimm KA., et al. Managing Medical, Surgical, Chronic, and Traumatic Pain, Pfizer Inc, The Gloyd Group Inc., Wilmington, DE, 2004. Eigner DR. CFA Health Committee Feline Vaccine Guidelines (online). Available: www.cfainc.org/health/vaccination-guidelines.html, 1998. Emily P, Penman S. Handbook of Small Animal Dentistry. Oxford: Pergamon Press, 1990. Ettinger SJ, Feldman EC. Textbook of Veterinary Internal Medicine, 4th Ed. Philadelphia, PA: WB Saunders, 1995. Ettinger SJ, Feldman EC. Textbook of Veterinary Internal Medicine, 5th Ed. Philadelphia, PA: WB Saunders, 2000. Evans HE, Christensen GC. Miller’s Anatomy of the Dog, Philadelphia, PA: WB Saunders Company, 1979. Evans HE, deLahunta A. Miller’s Guide to the Dissection of the Dog. Philadelphia, PA: WB Saunders Company, 1971. Fascetti AJ. Obesity Management in Dogs and Cats, Paper presented at Western Veterinary Conference 2004, Las Vegas, NV, 2004. Feldman EC, Nelson RW. Canine and Feline Endocrinology and Reproduction, 2nd Ed. Philadelphia, PA: WB Saunders, 1996. Feldman BF, Zinkl JG, Jain NC. Schalm’s Veterinary Hematology, 5th Ed. Philadelphia, PA: Lippincott, Williams and Wilkins, 2000. Feline Leukemia Virus. Veterinary Technician, 1997;18:680–682. Fenner WR. Quick Reference of Veterinary Medicine. Philadelphia, PA: Lippincott Williams & Wilkins, 2000. Firth AM, Haldane SL. Development of a scale to evaluate postoperative pain in dogs. JAVMA 1999;214:651–659. Ford RB. Vaccines and Vaccinations: Change is in the Wind, The NAVTA Journal, Spring 2005:31–35. Foreyt WJ. Veterinary Parasitology Reference Manual. Pullman: Washington State University, 1994. Fortney WD. Neonatal Clinical Findings: Is it Normal or a Problem, Paper presented at the Western Veterinary Conference 2004, Las Vegas, NV, 2004. Fortney WD. The Care & Feeding of Orphan Puppies & Kittens, Paper presented at the Atlantic Coast Veterinary Conference 2006, Halifax, Nova Scotia, 2006. Fortney WD. “Painless” Vaccinations: How to Minimize Yipping, Paper presented at Western Veterinary Conference 2004, Las Vegas, NV, 2004.
Fortney WD. Triage and Diagnosis for Sick Neonates, Paper presented at Western Veterinary Conference 2004. Las Vegas, NV, 2004. Fossum TW. Proceedings from Veterinary Post Graduate Institute Seminar on SoftTissue Surgery. Texas A & M, 1997. Fossum TW. Small Animal Surgery, 3rd Ed. St. Louis, MO: Mosby Elsevier, 2007. Foster R, Smith M, Nash H. Vaccination Recommendations for Dogs, www. peteducation.com/article_print.cfm?articleid=950. Frost P. The Veterinary Clinics of North America—Dentistry Vol 16, no. 5. Philadelphia, PA: WB Saunders Company, 1986. Gaynor JS. Is postoperative pain management important in dogs and cats? Veterinary Medicine 1999;94:254–257. Gelens H. Intraosseous Fluid Therapy, Paper presented at Western Veterinary Conference 2003. Las Vegas, NV, 2003. Gilbert SG. Pictorial Anatomy of the Cat, 9th Ed. Seattle, WA: University of Washington Press, 1991. Glaze K. Treating a broken heart: Congenital heart disease—Part I. Veterinary Technician 1998;19:169–179. Glaze K. Treating a broken heart: Congenital heart disease—Part II. Veterinary Technician 1998;19:339–347. Glaze M. Management of Deep Corneal Ulcers, Paper presented at Atlantic Coast Veterinary Conference 2002, Atlantic City, NJ, 2002. Goodwin C. Canine cilia disorders. Veterinary Technician 1998;19:115–124. Gourley IM, Vasseur PB. General Small Animal Surgery, Philadelphia, PA: J. B. Lippincott Company, 1985. Graff SL. A Handbook of Routine Urinalysis. Philadelphia, PA: J.B. Lippincott Company, 1983. Greene CE. Infectious Disease of the Dog and Cat, 2nd Philadelphia, PA: WB Saunders, 1998. Greene CE. Infectious Disease of the Dog and Cat, 3rd Philadelphia, PA: WB Saunders, 2007. Greiner EC, McIntosh A. Comparison of the efficacy of three fecal flotation media. Veterinary Technician 1997;18:283–287. Griffith D, Limehouse J. Holistic Medicine (online). Available: http://www.vin. com/members/searchdb/rounds/lc970706.htm, Veterinary Information Network, 1997. Griffith D. Herbal Medicine (online). Available: http://www.vin.com/members/ searchdb/rounds/lc990523.htm, Veterinary Information Network, 1999. Hackett TB. Feline Fluid Therapy-Crystalloids, Colloids and Fluid Planning, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Hackett TB, Mazzaferro EM. Veterinary Emergency and Critical Care Procedures, Blackwell Publishing, Ames, Iowa, 2006 Hackett TB, Mazzaferro EM. Veterinary Emergency & Critical Care Procedures, Ames, IA: Blackwell Publishing, 2006. Hale FA. Understanding Veterinary Dentistry. Veterinary Information Network. http://www.vin.com/Members/Proceedings/Proceedings.plx?CID=HALE2004& PID=14961&O=VIN June 2007. BIBLIOGRAPHY
653
Hamilton S. Therapeutic Exercises for the Canine Patient, The NAVTA Journal, Fall 2003:43–47. Hancock R, Rashmir-Raven A. Principles and techniques of the Robert-Jones bandage. Veterinary Technician 2000;21:463–465. Hand MS, Thatcher CD, Remillard RL, Roudebush P. Small Animal Clinical Nutrition, 4th Ed. Marceline, MO: Walsworth Publishing Company, 2000. Hanks J, Spodnick G. Wound Healing in the Veterinary Rehabilitation Patient, Veterinary Clinics Small Animal Practice, 2005;35:1453–1471. Hanson B. Common Mistakes in Fluid Therapy, Paper presented at ACVIM 2003, Charlotte, NC, 2003. Harari J. Surgical Complications and Wound Healing in the Small Animal Practice. Philadelphia, PA: WB Saunders Company, 1993. Harvey CE, Emily PP. Small Animal Dentistry. St. Louis: Mosby, 1993. Harvey CE. The Veterinary Clinics of North America—Feline Dentistry, Vol 22. Philadelphia, PA: WB Saunders Company, 1992. Harvey JW. Erythrocyte Morphology in Disease, Paper presented at Western Veterinary Conference 2006, Las Vegas, NV, 2006. Hawkins BJ. Down in the Mouth: Examining the Feline Oral Cavity, Veterinary Technician, 1997; Vol. 18:671–678. Hawkins J. Waltham Applied Dentistry. Veterinary Learning Systems Co., Inc., 1993. HealthyPet. AAHA Dental Care Guidelines (online). Available: http://www. healthypet.com/library_view.aspx?ID=142 HealthyPet. Brushing Your Pet’s Teeth (online). Available: http://www.healthypet. com/library_view.aspx?ID=135&sid=1 Heath D. Lifeline to recovery: Intravenous catheterization techniques. Veterinary Technician, 1998;19:614. Heath D. Step-by-step placing an over-the-needle catheter in the cephalic vein. Veterinary Technician, 1998;19:617. Heins AL. A new approach to treatment of periodontal disease. Veterinary Technician 1997;18:372–378. Hellyer PW. Pain Assessment and Multimodal Analgesic therapy in Dogs and Cats, Paper presented at ABVP 2006, San Antonio, TX. Hendrix CM. Diagnostic Veterinary Parasitology. St. Louis: Mosby-Year Book, Inc., 1998. Hickman A. Parenteral Nutrition. Paper presented at Spring Conference, Kansas State University (Spring 1997). Hoffman KA. Magnetic Resonance Imaging as a Localization Tool, Veterinary Technician, December 2006:744–748. Holloway C, Buffington T. A clinical problem: obesity and related health risks. Veterinary Technician 2000;21:281–283. Holloway C, Buffington T. Basic guidelines for dogs and cats. Veterinary Technician 1999;20:499–505. Holmstrom SE, Frost P, Gammon RL. Veterinary Dental Techniques for the Small Animal Practitioner. Philadelphia, PA: WB Saunders Company, 1998. Holmstrom SE. Veterinary Dentistry for the Technician & Office Staff. Philadelphia, PA: WB Saunders Company, 2000.
654
BIBLIOGRAPHY
Hoskins JD. Pediatric Health Care and Management, The Veterinary Clinics of North America Small Animal Practice 1999;29: 837–852. Hoskins JD. Veterinary Pediatrics: Dogs and Cats from Birth to Six Months. Philadelphia, PA: WB Saunders, 1995. Hoskins JD. Pediatric Critical Care, Paper presented at Western Veterinary Conference 2004. Las Vegas, NV, 2004. Hoskins JD. Small Animal Pediatric Medicine, Paper presented at the Tufts Animal Expo 2002, Boston, MA, 2002. Hughes D. Cardiovascular Assessment and Haemodynamic Monitoring, Paper presented at ECVIM-CA/ESVIM Congress, Munich, Germany, 2002. Hughes D. Triage and Major Body System Evaluation, World Small Animal Veterinary Association, www.vin.com/proceedings.plx?CID=WSAVA2005&PID. IGI-EVCSO Pharmaceuticals (online) http://www.evscopharm.com (no dates noted). Ikram M, Hill E. Microbiology for Veterinary Technicians. St. Louis, MO: Mosby-Year Book, Inc., 1991. Introduction to Sonography (online). Available: http://www.webvet.cornell.edu/ cvm/imaging/notes_US.html. Ivens VR, Mark DL, Levine ND. Principal Parasites of Domestic Animals in the United States, Biological and Diagnostic Information. Urbana, IL: University of Illinois, 1981. Jensen MM, Wright DN, Robison RA. Microbiology for the Health Sciences. 4th Ed. Upper Saddle River: Prentice Hall, 1997. Jewett L. Test Directory. Phoenix Central Laboratory, Everett, WA 98024 Updated in April 2000. Joseph D. Step-by-step placement of jugular catheters in small animals. Veterinary Technician 2000;21:587–590. Kazacos KR. Diagnostic Methods for Internal Parasites, Paper presented at Western Veterinary Conference 2002, Las Vegas, NV, 2002. Kealy JK. Diagnostic Radiology of the Dog and Cat. Philadelphia, PA: WB Saunders Company, 1979. Kennedy MA. Diagnostic Methods for Feline Viral Pathogens, Paper presented at ACVIM 2003, Charlotte, NC, 2003. Kerwin SC. Introduction to Arthroscopy, Paper presented at Western Veterinary Conference 2004, Las Vegas, NV, 2004. Kesel ML. Veterinary Dentistry for the Small Animal Technician. Ames, IA: Iowa State University Press, 2000. King L, Hammond R. Manual of Canine and Feline Emergency and Critical Care. Shurdington, Cheltenham: British Small Animal Veterinary Association, 1999. King L, Hammond R. Manual of Canine and Feline Emergency and Critical Care, Chapter 2: Fluid Therapy. Dez Hughes, British Small Animal Veterinary Association, 1999. King LG. Fluid Therapy for Critically Ill Cats I, Western Veterinary Conference 2004. Las Vegas, NV, 2004 King LM. Fluid Therapy for Critically Ill Cats II, Paper presented at Western Veterinary Conference 2004, las Vegas, NC, 2004.
Kirk RW. Kirk’s Current Veterinary Therapy X. Philadelphia, PA: WB Saunders, 1989. Kirk RW. Kirk’s Current Veterinary Therapy XI. Philadelphia, PA: WB Saunders, 1992. Kirk RW. Kirk’s Current Veterinary Therapy XII. Philadelphia, PA: WB Saunders, 1995. Klamarias L. The Intraosseous Infusion, World Small Animal Veterinary Association World Congress Proceedings, 2004, www.vin.com/Members/Proceedings/ Proceedings.plx?CID=WSAVA2004&PID. Kleine LJ, Warren FG. Small Animal Radiology. St. Louis, MO: The C.V. Mosby Co., 1983. Knoll J, Stockman C. The Complete Urinalysis: Interpretation of Sediment Abnormalities, VSPN Continuing Education, October, 2006. LaFlamme D. Sweet success: Managing diabetes mellitus. Veterinary Technician 2001;22:24–25. Laflamme DP, Kealy RD, Schmidt DA. Estimation of body fat by conditioning score. J Vet Intern Med 1994;154:59–65. Lappin MR. Feline toxolasmosis. Veterinary Technician 1997;18:298–299. Lappin MR. Use of Rectal Cytology in Diagnosis of Feline Diarrhea, Paper presented at Western Veterinary Conference 2006, Las Vegas, NV, 2006. Lavin LM. Radiography in Veterinary Technology. Philadelphia, PA: WB Saunders Company, 1994. Lavin LM. The imaging chain: Links to high-quality radiography. Veterinary Technician, 2001;22:230–241. Leib MS. Introduction to Gastrointestinal Endoscopy, Paper presented at Western Veterinary Conference 2006, Las Vegas, NV, 2006. Lemke KA, Dawson SD. Local and regional anesthesia. The Veterinary Clinics of North America Small Animal Practice 2000;30:839–857. Levine D, Mills D, Marcellin-Little D, Taylor R. November 2005, Rehabilitation and Physical Therapy, Veterinary Clinics of North America Small Animal Practice, November 2005. Lichtenberger M. Noninvasive Cardiac Output Monitoring, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Little S. CFA Health Committee Establishing Vaccination Protocols for Catteries (online). Available: www.cfainc.org/health/vaccination-protocol-catteries.html. Looney AL. Acupunture and Physical Therapy Analgesic Modalities, Paper presented at the Tufts Animal Expo 2002, Boston, MA, 2002. Love L, Harvey R. Arterial Blood Pressure Measurement: Physiology, Tools, and Techniques, Compendium, June 2006:450–460. Lumb WV, Jones EW. Lumb & Jones’ Veterinary Anesthesia. Philadelphia, PA: Lippincott Williams & Wilkins, 1996. Macintire DK. Pediatric intensive care. The Veterinary Clinics of North America Small Animal Practice 1999;29:971–988. Macintire DK. Metabolic Derangements in Critical Patients, Paper presented by ACVIM 2003. Charlotte, NC, 2004. Macintire DK. Pediatric Emergencies, Paper presented by Western Veterinary Conference 2002. Las Vegas, NV, 2002.
Macintire DK. Reproductive Emergencies I: Dystocia, Acute Metritis, Eclampsia, Paper presented by Western Veterinary Conference 2004. Las Vegas, NV, 2004. Macintire DK. Reproductive Emergencies II: Mastitis, Pyometra, Prolapses, and Mismatching, Paper presented by Western Veterinary Conference 2004. Las Vegas, NV, 2004. MacWilliams P. Profiling the Urinary System I, Paper presented at Western Veterinary Conference 2003, Las Vegas, NV, 2003. MacWilliams P. Profiling the Urinary System II, Paper presented at Western Veterinary Conference 2003, Las Vegas, NV, 2003. Madsen LM. Perioperative Pain Management, Veterinary Technician May 2005: 359–367. Maloney C. Fluid Therapy in Small Animals, Veterinary Technician Vol. 24, No 7 (July 2003):462–471. Mama K. New options for managing chronic pain in small animals. Veterinary Medicine 1999;94:352–357. Mama KR, Steffey EP. Use of Opioids in Anesthesia Practice, 27 WSAVA Congress, www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2002&PID Marsden SP. Alternative Approaches to Cancer: Treatments, Paper presented at the Western Veterinary Conference 2002, Las Vegas, NV, 2002. Marsden SP. An Integrated Approach to Holistic Physical Medicine, Paper presented at the Western Veterinary Conference 2002, Las Vegas, NV, 2002. Marsden SP. Theory and Practice of Chinese Physical Therapies, Paper presented at the Western Veterinary Conference 2002, Las Vegas, NV, 2002. MarVista Animal Medical Center (online) http://www.marvistavet.com/html/ pharmacy_center.html, 1997–2002. Mathews KA. Pain assessment and general approach to management. The Veterinary Clinics of North America Small Animal Practice 2000;30:729–755. Mathews KA. Pain Management for the Critically Ill I & II, Paper presented at Western Veterinary Conference 2004, Las Vegas, NV, 2004. Matteson V. Block that pain, local anesthesia in dogs and cats. Veterinary Technician 2000;21:332–339. Mauldin G. Practical Clinical Nutrition. Paper presented at a lecture at Buffalo Academy, 2000. Mazzaferro EM. Arterial Catheterization, International Veterinary Emergency and Critical Care Symposium 2004, www.vin.com/Member/Proceedings/Proceedings. plx?CID=IVECCS2004 Mazzaferro EM. Fluid Therapy: The Critical Balance Between Life and Death, NAVC Clinician’s Brief, November 2006:73–75. McClure RC, Dallman MJ, Garrett PD. Cat Anatomy, Philadelphia, PA: Lea & Febiger, 1973. McCormick TS. The Essentials of Microbiology. Piscataway, NJ: Research and Education Association, 1995. McCurnin DM. Clinical Textbook for Veterinary Technicians, 4th Ed. Philadelphia, PA: WB Saunders Company, 1994. McCurnin DM. Clinical Textbook for Veterinary Technicians. Philadelphia, PA: WB Saunders Company, 1994. BIBLIOGRAPHY
655
McCurnin DM, Bassert JM. Clinical Textbook for Veterinary Technicians, 5th Ed. Philadelphia, PA: WB Saunders Company, 2002. McCurnin DM, Bassert JM. Clinical Textbook for Veterinary Technicians, 6th Ed. Philadelphia, PA: WB Saunders Company, 2006. McEntee MC. Radiation Therapy Today: Options and Applications, Paper presented at Atlantic Coast Veterinary Conference 20061 Atlantic City, NJ, 2001. McKelvey D, Hollingshead KW. Small Animal Anesthesia. St. Louis, MO: Mosby-Year Book, Inc., 1994. McMichael M, Dhupa N. Pediatric critical care medicine: Physiologic considerations. Compendium, 2000;22:206. Meadows I, Gwaltney-Brant S. The 10 Most Common Toxicoses in Dogs. Veterinary Medicine. 2006:92:142–148. Measurement of central venous pressure. Small Animal Diagnostic and Therapeutic Techniques (online). Available: www.vetmed.wsu.edu/courses_samDX/cvp.htm, 2002. Meleo K. Radiation Therapy: Machines, Fractions, and Doses (online). Available: http://www.vin.com/members/searchdb/rounds/lc000319.htm, Veterinary Information Network, 2000. Meleo KA. Clinical Radiation Therapy, Paper Presented at Western Veterinary Conference 2003, Las Vegas, NV, 2003. Merck Veterinary Manual (online) Available: http://www.merckvetmanual.com, Whitehouse Station, NJ, 2006. Merola V, Dunayer E. The 10 Most Common Toxicoses in Cats. Veterinary Medicine. 2006:95:339–342. Michel KE. Designing an Effective Weight Reduction Program, Paper presented at Atlantic Coast Veterinary Conference 2002, Atlantic City. NJ, 2002. Michel KE. Weight Reduction in Cats—Great Frustrations in Feline Nutrition, Paper presented at WASVA World Congress Proceedings, 2001, Vancouver, BC, 2001. Mihatov L. So what is Giardia anyway? Veterinary Technician 2000;21:188– 190. Mills D. Introduction to Small Animal Physical Rehabilitation Presented at the Atlantic Coast Veterinary Conference 2002, Atlantic City, NJ, 2002. Mills D. Therapeutic and Aquatic Exercises©, Paper presented at the Atlantic Coast Veterinary Conference 2002, Atlantic City, NJ, 2002. Mills D. Therapeutic Ultrasound and Neuromuscular Electrical Stimulation©, Paper presented at the Atlantic Coast Veterinary Conference 2002, Atlantic City, NJ, 2002. Moore AH. BSAVA Manual of Advanced of Veterinary Nursing. Quedgeley, Gloucester: Woodrow House, 1999. Moore AH. Manual of Advanced Veterinary Nursing, British Small Animal Veterinary Association, England, 2004. Morse H, Webb JL. Acid-Base Balance, An Overview. Veterinary Clinical Pathology Clerkship Program. http://www.vet.uga.edu/vpp/clerk/morse/index.php. Muir W III, Hubbell JAE. Handbook of Veterinary Anesthesia. St. Louis: Mosby-Year Book, Inc., 1995.
656
BIBLIOGRAPHY
Muir WW III, Hubbell JAE. Handbook of Veterinary Anesthesia, 2nd Ed. St. Louis, MO: Mosby, 1995. Mullane PA. Practical neonatal care: Tube feeding. Veterinary Technician 1998; 19:532–535. Newer Drugs for Neuropathic Pain, Drug Effectiveness Review Project, www.ohsu. edu/drugeffectiveness/reports/documtents/KQS_Final_12-07-06.pdf. Novartis Canada, (online) http://www.ah.ca.novartis.com/product/index.html, 2001. Novartis. A Multimodal Approach to Treating Osteoarthritis, Symposium Proceedings, 2006. Novotny B. Nutritional assessment. Hill’s HealthCare Connection 1996;95:139– 149. O’Brien TR. Radiographic Diagnosis of Abdominal Disorders in the Dog and Cat. Davis, CA: Covell Park Veterinary Company, 1981. Ogilvie GK, Moore AS. Managing the Veterinary Cancer Patient. Trenton, NJ: Veterinary Learning Systems Co., Inc., 1995. Olsen JL, Ablon L, Giangrasso A. Medical Dosage Calculations, 6th Ed. Menlo Park, CA: Addison-Wesley Nursing, 1995. Ortega TM, Marcella F. Harb-Hause. Managing PEG Tubes and Feeding Tubes, maxshouse.com/managing_peg_tubes_and_feeding_t.htm. Osborne CA, Stevens JB. Handbook of Canine and Feline Urinalysis. St. Louis, MO: Ralston Purina Company, 1981. Osborne CA, Stevens JB. Urinalysis: A Clinical Guide to Compassionate Patient Care. Trenton, NJ: Veterinary Learning Systems Co., Inc., 1999. Osborne JN, Sharp NJH. Putting wobblers back on track—Part II. Veterinary Technician 1998;19:519–527. Otoscopy in Veterinary Practice, (online). Available: http://www.ksvea.com/small_ otoscopy.html. Owens JM, Biery DN. Radiographic Interpretation for the Small Animal Clinician, 2nd Ed. Philadelphia: Lippincott Williams & Wilkins, 1999. Owens JM. Radiographic Interpretation for the Small Animal Clinician, Ralston Purina, 1982. Pascoe PJ. Perioperative pain management. The Veterinary Clinics of North America Small Animal Practice 2000;30:917–932. Pastor J. Applications of the Blood Smear in Emergency Medicine, Paper presented at WSAVA World Congress 2002, Granada, Spain, 2002. Paul MA, et al. 2006 AAHA Canine Vaccine Guidelines (online). Available: http:// www.aahanet.org/PublicDocuments/VaccineGuidelines06Revised.pdf, American Animal Hospital Association, 2006. Peak RM. Regional and Local Dental Nerve Blocks for cats and Dogs, Paper presented at Atlantic Coast Veterinary Conference 2006, Atlantic City, NJ, 2006. Pfizer Inserts for Bordetella Bronchiseptica Vaccine. Pitcairn RH, Pitcairn SH. Dr. Pitcarin’s Complete Guide to Natural Health for Dogs and Cats. Emmaus, NJ: Rodale Press, Inc, 1995. Placement of a jugular catheter. Small Animal Diagnostic and Therapeutic Techniques (online). Available: www.vetmed.wsu.edu/courses_samDX/jugcath.htm.
Plumb DC. Veterinary Drug Handbook, 3rd Ed. Ames, IA: Iowa State University Press, 1999. Plumb DC. Plumb’s Veterinary Drug Handbook 5th Edition, Blackwell Publishing, 2005. Plumlee KH. Treatment of Insecticide Poisoning, Paper presented at Western Veterinary Conference 2004. Las Vegas, NV, 2004. Plunkett SJ. Emergency Procedures for the Small Animal Veterinarian, Philadelphia, PA: WB Saunders Company, 1993. Plunkett SJ. Emergency Procedures for the Small Animal Veterinarian, 2nd Ed. Spain: WB Saunders, 2000. Poppenga RH. Zootoxins, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Poundstone M. Emergency medicine: CPR techniques. Veterinary Technician 1992; 13:357–362. Pratt PW. Lab Procedures for Veterinary Technicians, 3rd Ed. St. Louis, MO: Mosby, 1997. Pratt PW. Laboratory Procedures for Veterinary Technicians. St. Louis, MO: MosbyYear Book, Inc., 1997. Pressler B, Rishniw M, Wolf A. The Low-Down on Canine Leptospirosis (online). Available: http://www.vin.com/Members/Proceedings/Proceedings. plx?CID=medfaq&PID=pr11568&O=VIN, Veterinary Information Network, 2005. Prince J. Endoscopy (online) http://www.peteducation.com/vet_proc/endoscoopy. htm, 1997–2001. Quandt JE, Lee JA, Powell LL. Analgesia in Critically Ill Patients. Compendium Vol 27(6) (June 2005):433–445. Randall A. The (hook)worms crawl in: Ancylostoma infection in humans. Veterinary Technician 1999;20:189–197. Rebar AH. Handbook of Veterinary Cytology. St. Louis, MO: Ralston Purina Company, 1980. Rebar AH, MacWilliams PS, Feldman BF, Metzger FL, Pollack RV, Roche J. A Guide to Hematology. Jackson, WY: Teton NewMedia, 2002. Reding J. Bordetelia bronchiseptica: Is your cattery at risk? (online). http://www. fanciers.com/other-faqs/bordetalla.html, 1996. Remillard, Rebecca L, Armstrong PJ, Deborah J. Davenport. Enteral-Assisted Feeding, maxshouse.com/Enteral-Assisted_Feeding.htm. Richards JR, et al. Caring for the senior cat, American Association of Feline Practitioners/Academy of Feline Medicine Update Vol 3. Veterinary Technician 1999;20:438–441. Richards JR, et al. Caring for the senior cat, American Association of Feline Practitioners/Academy of Feline Medicine Update Vol 2. Veterinary Technician 1999;20:368–372. Riel D. Bone Marrow Aspirates and Arthrocentesis, Paper presented at ACVIM 2002, Dallas, TX, 2002. Rieser TM. Logical Fluid Therapy, Paper presented at Western Veterinary Conference 2003. Las Vegas, NV, 2003.
Rieser TM. Emergency Management of Heart Failure, Paper presented at Western Veterinary Conference 2003. Las Vegas, NV, 2003. Rivera A. Clinical Importance of Triage & Vital Signs, Paper presented at ACVIM 2003. Charlotte, NC, 2003. Rivera MJ. A pointed approach: The fundamentals of veterinary acupuncture. Veterinary Technician 2000;21:32–40. Rivera MJ. Homeopathy: Like cures like. Veterinary Technician 2000;21:681–684. Rivera MJ, Rivera PL. Veterinary chiropractic. Veterinary Technician 2000;21: 301–304. Rochette J. Local Anesthetic Nerve Blocks and Oral Analgesia, Paper presented at WSAVA World Congress Proceedings 2001, Vancouver, BC, 2001. Root C. Contrast radiography for veterinary technologists. 1985 Annual Veterinary Technology Convention. Rosenfeld AJ. The True Nature of Triage: Concepts of Emergency Evaluation, Paper presented at the Atlantic Coast Veterinary Conference 2002, Atlantic City NJ, 2002. Royer N. Step by step, performing cystocentesis. Veterinary Technician 1997; 18:298–299. Rozanski E. The CRASH Cart, Paper presented at Tufts Animal Expo 2002, Boston, MA 2002. Ruben D. Transfusion Medicine. Blood Products, Blood-Typing and Preliminary Testing. Veterinary Technician, 2004;25:484–492. Rudloff E. Clinical Signs of Respiratory Distress, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Rudloff E. Emergency Transport and Survey, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Rudloff E. The Rule of 20 in the ICU, Paper presented at Western Veterinary Conference 2002. Las Vegas, NV, 2002. Sandman KM, Harari J. Canine cranial cruciate ligament repair techniques: Is one best? Veterinary Medicine 2001;96:850–855. Schebitz H, Wilkens H. Atlas of Radiographic Anatomy of the Dog and Cat, 3rd Ed. Philadelphia, PA: WB Saunders Co., 1978. Schoen A. Companion Animal Chiropractic and Physical Manipulative Therapies, Paper presented at the WSAVA World Congress Proceedings, 2001, Vancouver, BC, 2001. Schoen AM, Wynn SG. Complementary and Alternative Veterinary Medicine. St. Louis, MO: Mosby, 1998. Schoenherr WD. Management of Feline Obesity, Paper presented at Western Veterinary Conference 2004, Las Vegas, NV, 2004. Scott DW, Miller WH, Griffin CE. Muller and Kirk’s Small Animal Dermatology. Ithaca, NY: WB Saunders, 2000. Secrest S. Basic Principles of Ultrasonography, Veterinary Technician, December 2006:756–763. Severin GA. Severin’s Veterinary Ophthalmology Notes, 3rd Ed. Fort Collins, CO: Veterinary Ophthalmology Notes, 1996. Shaffran N. Blood gas analysis. Veterinary Technician 1998;19:95–103.
BIBLIOGRAPHY
657
Shaffran N. Pain in critically ill small animals: Ethical aspects. Veterinary Technician 1998;19:349–353. Sharp S. Dental Radiography, Veterinary Technician, February 2005:92–99. Shipp AD, Fahrenkrug P. Practitioners’ Guide to Veterinary Dentistry, 1st Ed. Glendale, CA: Griffin Printing, Inc., 1992. Sink AA, Feldman BF. Laboratory Urinalysis and Hematology for the Small Animal Practitioner. Jackson, WY. Teton NewMedia, 2004. Sirios M, Anthony E. Fluid Therapy, What, Why, and How, Paper presented by Atlantic Coast Veterinary Conference 2002, Atlantic City, NJ, 2002. Sirois M, Anthony A. In-House Coagulation Testing, Paper presented at Atlantic Coast Veterinary Conference 2002, Atlantic City. NJ, 2002. Sirios M, Anthony E. Hematology, Paper presented by Atlantic Coast Veterinary Conference 2002, Atlantic City, NJ, 2002. Skarda RT. Anesthesia case of the month. JAVMA, 1999;214:37–39. Slatter D. Fundamentals of Veterinary Ophthalmology, 2nd Ed. Philadelphia, PA: WB Saunders Company, 1990. Slatter D. Textbook of Small Animal Surgery, 2nd Ed, Vol. 2.. Philadelphia, PA: WB Saunders, 1993. Slatter DH. Textbook of Small Animal Surgery, Vol 1., Philadelphia, PA: WB Saunders Company, 1985. Sobel DS. In Introduction to Rigid Operative Endoscopy, Paper presented at British Small Animal Veterinary Congress 2006, Birmingham, England, 2006. Spellane-Newman M. Laser surgery: The cutting edge. Veterinary Technician 2001; 22:412–416. Spreng D. How To Prepare Emergencies, Paper presented at WSAVA World Congress 2002, Granada, Spain, 2002. Stafford D. The great mimic: Canine Addison’s disease. Veterinary Technician 1999;20:490–497. Stafford C. Enhanced Radiographic Studies, Veterinary Technician, June 2004: 384–397. Stearns ED. Computed Radiography in Perspective, The NAVTA Journal, Summer 2004:53–58. Stedman TL. Stedman’s Concise Medical Dictionary, 3rd Ed. Baltimore, MD: Williams & Wilkins, 1997. Steele AM. Under Pressure: ABP, CVP, What are the Numbers Really Telling Us?, Paper presented at IVECCS 2006, San Antonio, TX. Steenkamp G. Malignant Oral Tumors. VetPath. http://www.vetpath.co.za/small_ 2_non-odontogenic-malignant-oral-tumors-in-dogs-and-cats, modified June 25, 2004. Stein D. Natural Healing for Dogs & Cats. Freedom, IA: The Crossing Press, 1993. Strombeck DR. Home-Prepared Dog & Cat Diets: The Healthful Alternative. Ames, IA: Iowa State University Press, 1999. Surgeon TW. Pain Management, Paper presented at Western Veterinary Conference 2004, Las Vegas, NV, 2004. Swaim SF, Henderson RA Jr. Small Animal Wound Management, 2nd Ed. Philadelphia, PA: Williams & Wilkins, 1997.
658
BIBLIOGRAPHY
Swartz H. Implementing a Sustainable Dental Program. Product Forum & Market News. 2005. Sweethaven Publishing Services. Dental Instrument Setups. www.free-ed.net/ sweethaven/MedTech/Dental/DentSetups/lessonMain.asp?iNum=, 2005. Tabers CW. Taber’s Cyclopedic Medical Dictionary. Philadelphia, PA: F. A. Davis Company, 1989. Tams TR. Diarrhea Caused by Giardia and Clostridium Perfringens Enterotoxicosis, Paper presented at Atlantic Coast Veterinary Conference 2001, Atlantic City, NJ, 2001. Taylor R. Developing Protocols for Physical Therapy, Paper presented at the WSAVA World Congress Proceedings 2001, Vancouver, BC, 2001. Taylor R. Physical Therapy in Veterinary Medicine, Paper presented at the WSAVA World Congress Proceedings 2001, Vancouver, BC, 2001. Techniques in Practice, Focus: Dentistry, Veterinary Technician, Vol. 27, No. 10(A), 2006. Terry B. Arterial Catheter Placement, Veterinary Technician, July 2005:439–441. The 2006 American Association of Feline Practitioners Feline Vaccine Advisory Panel Report, JAVMA, Vol. 229, No. 9, November 1, 2006. Thompson NM. Injection-Site Sarcomas in Cats, Veterinary Technician, February 2005: 140–144. Thompson RCA. Gastrointestinal Parasites of Dogs and Cats: Current Issues, Paper presented at Bayer Zoonosis Symposium 2003, Chicago, IL, 2003. Thrall DE. Textbook of Veterinary Diagnostic Radiology. Philadelphia, PA: WB Saunders, 1986. Thrall MA. Veterinary Hematology and Clinical Chemistry. Baltimore, MD: Blackwell Publishing, 2004. Ticer JW. Radiographic Technique in Veterinary Practice. Philadelphia, PA: WB Saunders, 1984. Tighe MM, Brown M. Mosby’s Comprehensive Review for Veterinary Technicians, Baltimore, MD: Mosby, 1998. Tilghman M. Chiropractic Theory, Paper presented at the Atlantic Coast Veterinary Conference 2002, Atlantic City NJ, 2002. Tilley LP. Essentials of Canine and Feline Electrocardiography Interpretation and Treatment, 3rd Ed. Philadelphia, PA: Lippincott Williams and Wilkins, 1992. Tilley LP, Smith FWK Jr. The 5-Minute Veterinary Consult, Canine and Feline, 2nd Ed. Philadelphia, PA: Lippincott, Williams and Wilkins, 2000. Tilley LP, Smith FWK Jr. The 5-Minute Veterinary Consult, Canine and Feline, 3rd Ed. Philadelphia, PA: Lippincott, Williams and Wilkins, 2000. Tracy DL. Mosby’s Fundamentals of Veterinary Technology Small Animal Surgical Nursing. St. Louis, MO: Mosby, 1994. Tranquilli WJ, Grimm KA. Pain Management Alternatives for Common Surgeries, Paper presented at Managing Pain Symposium 2003, Orlando, FL. Tranquilli WJ, Grimm KA, Lamont LA. Pain Management for the Small Animal Practitioner. Jackson, WY: Teton NewMedia, 2004. Tvedten H. Urine Sediment Examination, Paper presented at Western Veterinary Conference 2004, Las Vegas, NV, 2004.
Ummel C, Zody K. Sparkle Technique and other Bright Ideas in Radiographic Imaging VSPN Continuing Education, July, 2006. Veterinary Partner. Dental Home Care (online). Available: http://www. veterianrypartner.com/Content.plx?P=PRINT&A=640. Veterinary Partner. Orphan Puppy & Kitten Care (online). Available: http://www. veterianrypartner.com/Content.plx?P=PRINT&A=576. Vigano F, Galilei VG. Fluid Therapy: Choosing the Right Fluid, Paper presented at ECVIM-CA/ESVIM Congress, Munich, Germany, 2002. Volhard W, Brown K. The Holistic Guide for a Healthy Dog. New York: Howell Book House, 1995. Waddell LS. Evaluation and Interpretation of Blood Gases, Paper presented at Western Veterinary Conference 2004, Las Vegas, NV, 2004. Wagner AE. Is butorphanol analgesic in dogs and cats? Veterinary Medicine 1999;94:346–351. Wanamaker BP, Pettes CL. Applied Pharmacology for the Veterinary Technician. Philadelphia, PA: WB Saunders, 1996. Washington State University. Small Animal Diagnostic & Therapeutic Techniques, Placement of a Jugular, http://courses.vetmed.wsu.edu/templates. Washington State University. Small Animal Diagnostic and Therapeutic Techniques, College of Veterinary Medicine, http://courses.vetmed.wsu.edu/templates/printb. aspx . Whatmough C, Lamb CR. Computed Tomography: Principles and Applications, Compendium, November 2006:789–798. Williams JF, Zajac A. Diagnosis of Gastrointestinal Parasitism in Dogs and Cats. St. Louis, MO: Ralston Purina Company, 1980. Williams LT, Bagley RS. Pot-bellied dogs? Diagnosing and managing canine hyperadrenocorticism. Veterinary Technician 1998;19:47–56. Williard MD. GI Endoscopy, Paper presented at British Small Animal Veterinary Congress 2006, Birmingham, England, 2006. Wilson S. Feeding tube care. Internal Medicine and Endoscopy, Photocopy. Wingfield SG, Wingfield WE. Triage in trauma: Nursing implications and initial assessment. Veterinary Technician, 1997;18:183–190.
Wingfield WE, Bowen RA. Enteral Feeding Calculations (online). Available: http:/ www.cvmbs.colostate.edu/clinsci/wing/enteral.html, Colorado State University, 1998. Wingfield WE. Enteral Nutritional Support in Critically Ill Dogs and Cats: Making the Right Decisions. Colorado State University, Fort Collins, 1998. Wingfield WE. Fluid and electrolyte Therapy (online). Available: http:/www.cvmbs. colostate.edu/clinsci/wing/fluids/fluids.htm, Colorado State University, 1998. Wischnitzer S. Atlas and Dissection Guide for Comparative Anatomy, 5th Ed. New York: W.H. Freeman and Company, 1993. Wohl JS. Applications of Fluid Therapy in the Critical Patient, Paper presented at ACVIM 2003, Charlotte, NC, 2003. Wortinger A. Learning and teaching from pet food labels. Veterinary Technician 1999;19:586–590. Wortinger A. Managing inflammatory bowel disease. Veterinary Technician 1998;19:689–695. Wortinger A. Nutritional support for hospitalized pets. Veterinary Technician 1999;20:316–323. Wortinger A. Nutrition for Veterinary Technicians and Nurses, Ames, IA: Blackwell Publishing, 2007. Wynn SG. Herb Doses for Small Animal Patients (online). Available: http://www. vin.com/members/searchdb/misc/m05000/m00923.htm, Veterinary Information Network, 2000. Young JF. Advancement in Imaging: Digital Radiography—PACS & DICOM. NAVC Clinician’s Brief , October 2005:44–45. Zigler M. Glaucoma of the Veterinary Patient (online). Available: http://www. eyevet.ca, Eyevet Consulting Services, 2001. Zigler M. Prolapsed Gland of the Third Eyelid (online). Available: http://www. eyevet.ca, Eyevet Consulting Services, 2001. Zsombor-Murray E, Freeman LM. Peripheral parenteral nutrition. Compendium on Continuing Education for the Practicing Veterinarian 1999;21:512–523.
BIBLIOGRAPHY
659
Index
Page numbers in italics denote figures. Abdomen bandaging, 407, 407 contrast studies, 183 peritonitis, 249–251 physical examination, 22 palpation, 22, 33 pediatric, 25 technique, 33 radiographic positioning, 169 surgery, 525–529 anal sacculectomy, 526–527 colotomy, 526–527 complications, 525 enterotomy, 528 gastric dilatation-volvulus (GDV), 528 gastrotomy, 528 hepatectomy, partial, 529 hernia, 526–527 intestinal resection and anastomosis, 529 overview, 525–526 ultrasonography, 199 Abdominocentesis, 429 Abortion, 123, 227–228 Abscess microbiology sample collection, 123 superficial, 532 Acanthocytes (spur cell), 110, CP–7 ACE inhibitors, 303 Acemannan, 402 Acepromazine maleate, 479, 593 Acetaminophen, 324, 387 Acetazolamide, 613 Acetylcysteine, 303, 622 Acetylsalicylic acid, 603 Acid-base disturbances, 337 Acid-fast stain, 124, 128 Acidifiers, urinary, 616 Acidosis, 337, 464
Acne canine, 220–221 feline, 220–221 Acral lick dermatitis, 222–223 ACTH. See Adrenocorticotropic hormone ACTH stimulation test, 99 Actinomycin D, 582 Activated charcoal, 597 Activated clotting time (ACT), 116 Activated partial thromboplastin time (APTT), 117 Acupuncture, 317, 544, 562 Acute moist dermatitis, 225–226 Acute tumor lysis syndrome, 355 Addison’s disease, 233–234 Adenocarcinoma anal sac, 277 nasal, 277 pancreatic, 277 prostatic, 277 salivary gland, 277 thyroid, 277 Adenovirus, canine, 39–40, 44 Adequan. See Polysulfated glycosaminoglycans ADH (antidiuretic hormone), 227 ADH response test for, 99 Adrenal glands hyperadrenocorticism, 231–232 hypoadrenocorticism, 233–234 ultrasonography, 199 Adrenergic agents, 607, 613, 616, 617 Adrenocorticotropic hormone (ACTH) endogenous plasma, concentration, 99 stimulation test, 99 Adriamycin. See Doxorubicin Adrucil. See Fluorouracil Advantage. See Imidacloprid Aerrane. See Isoflurane
AG (anion gap), 78 Agglutination, RBC, 109 Air bubbles, in urine, 155, CP–20 Alanine aminotransferase (ALT, SGPT), 76 Albendazole, 578 Albon. See Sulfonamides Albumin, 76 Albumin-to-globulin ratio (A : G ratio), 76 Albuterol, 622 Alcohol, 628 Alcohol dehydrogenase inhibitor, 624 Alkaline phosphatase (ALP, SAP), 77 Alkalinizing agent, 616 Alkalosis, 337, 464 Alkylating agents, 581 Allergy atopy, 222–223 flea allergy dermatitis (FAD), 222–223 food hypersensitivity, 224–225 intradermal tests, 121 Allopurinol, 618 Aloe vera, 402 ALP (alkaline phosphatase), 77 Alpha-2 agonists, 481–483, 609 medetomidine, 389, 482–483 xylazine, 389, 482–483 ALT (alanine aminotransferase), 76 Alternative medicine. See Complementary and Alternative Veterinary Medicine Aluminum carbonate, 594 Aluminum hydroxide, 594 Amantadine, 391, 610 Amblyomma americanum, 256 Amcill. See Ampicillin American Society of Anesthesiologists (ASA) Physical Status Classification System, 443 Amikacin, 575 Aminoglycosides, 575
661
Aminopentamide, 592 Aminophylline, 622 Amitriptyline, 618 Amlodipine besylate, 586 Ammonia, 77 Ammonia tolerance test (ATT), 100 Ammonium biurate crystals, 153, CP–19 Ammonium chloride, 616 Ammonium urate urolithiasis, 66 Amoxicillin, 577 Amphetamines, 324 Ampicillin, 577 with clavulanic acid, 577 Amrinone, 588 Amylase, 77 ANA (antinuclear antibody), 121 Anabolic steroid, 617 Anaerobic bacteria microbiology sample collection, 123 microbiology specimen storage, 124 Anal sac adenocarcinoma, 277 Anal sac disease, 238–240 Anal sac expression, 54 Anal sacculectomy, 526–527 Anal sphincter reflex, 34 Analgesics, 380–381, 471, 609, 610, 611–612 AnaSed. See Xylazine Anastomosis, intestinal, 529 Anatomy, 6–13 circulatory, 9, 10, CP–1, CP–2 dental, 499–500 dentition, 499 disorders, 510 facial structures, 501 skeletal structure, 500 tooth, 500 ear, 13 eye, 13 heart, 9, 10, CP–1, CP–2 internal organs, 8, CP–1 lymph nodes, 6 musculature, 6 nervous system, 10, 11, CP–2 overall, 6 skeletal, 7 skull, 500 urogenital, 11, 12
662
INDEX
Ancylostoma caninum, 139, 139, CP–11 Ancylostoma tabaeforme, 140, CP–11 Androgens, 619 Anemia anesthesia considerations, 445 antianemics, 585 iron-deficiency, CP–7 nonregenerative, 253–254 nutritional requirements, 63 regenerative, 253–254, CP–6 Anesthesia, 439–496 administration anesthetic machine, 451–452 breathing systems, 452–453 general anesthesia induction, 453–454 ventilation, 475–477 case-based brachycephalic breeds, 444 cardiovascular disease anemia/hypoproteinemia, 445 cardiac function impairment, 445 congenital heart disease, 444 heartworm disease, 445 hypotension/hypovolemia, 444 cesarean, emergency, 446 endocrine disorders, 446–447 diabetes mellitus, 446 hyperthyroidism, 447 hypoadrenocorticism, 447 hypothyroidism, 447 gastrointestinal disease, 447–448 gastric dilatation volvulus, 447 pancreatis, 448 geriatrics, 448 hepatic disease, 448 neonates, 449 obesity, 448 renal disease, 449 respiratory disease, 450 sighthounds, 450 trauma, 450 urinary obstruction, 451 drugs inhalant, 494–496 halothane, 495 isoflurane, 495 sevoflurane, 496
injectable induction anesthetics barbiturates, 488–489 cyclohexamines, 490–491 etomidate, 493–494 propofol, 492–493 preanesthetic, 451, 477–487 α2-agonists, 481–483 anticholinergics, 477–478 benzodiazepines, 480–481 opioids, 484–487 phenothiazines, 478–479 endotracheal intubation, 454–456, 455 evaluation, preanesthetic, 442–443 guidelines for safe, 441–442 induction, 453–454 local and regional, 470–474, 609 brachial plexus block, 470 dental nerve blocks, 518–520 epidural analgesia, 471 epidural anesthesia, 470–471 intercostal and interpleural block, 471 intra-articular block, 472 intravenous regional block (Bier Block), 472 line block, 473 nerve block, 473 ring block, 473 splash block, 474 monitoring, 458–469 blood gases, 464 cardiovascular system, 460–462 blood loss, 462 blood pressure, 461 capillary refill time, 461 central venous pressure, 462 electrocardiograph, 462 heart rate, 460 mucous membranes, 464 postanesthesia, 466–469 reflexes, 464–465 respiratory system, 463 stages of anesthesia, 458–460 thermoregulation, 465–466 nerve blocks, dental, 518–520 caudal infraorbital, 518 caudal mandibular and mandibular nerve, 519 cranial infraorbital, 518 maxillary, 520
middle mental, 519 palatine, 519 patient care, 456–457 postanesthesia, 466–469 stages of, 458–460 topical ophthalmic, 614 ventilation administration, 475–477 manual, 475–476 mechanical, 476–477 general information, 474–475 intermittent positive-pressure (IPPV), 458 Anesthetic machine, 451–452 Anestrus, cytology, 98 Anion gap (AG), 78 Anipryl. See Selegiline-l-deprenyl Anisocytosis, 110, CP–4, CP–10 Antacids, 594 Antagonil. See Yohimbine Anterior cruciate ligament. See Cranial cruciate ligament rupture Anterior uveitis, 284–285 Anthracycline antibiotics, 582 Anti-infective drugs, 575–577 aminoglycosides, 575 cephalosporins, 575 chloramphenicol, 575 fluoroquinolones, 576 lincosamides, 576 metronidazole, 576 penicillin, 577 sulfonamides, 577 tetracyclines, 577 Anti-inflammatory drugs, 602–605 corticosteroids, 602 nonsteroidal (NSAIDs), 603–605 Antianemics, 585 Antiarrhythmics, 302, 586 Antibiotics. See Anti-infective drugs Anticestodals, 579 Anticholinergics, 477–478, 592 atropine, 478 glycopyrrolate, 478 Anticoagulants, 587 rodenticides, 325 Anticonvulsants, 607–608, 610 Antidepressants, 613
Antidiarrheals, 302, 592 Antidiuretic hormone (ADH), 227 Antidiuretics, 303 Antidotes, 303 Antiemetics, 302, 593 Antifungal drugs, 574 Antihistamines, 591, 593 Antilirium. See Physostigmine Antimetabolites, 583 Antinematodals, 578–579 Antinuclear antibody (ANA), 121 Antiparasitic drugs, 578–580 anticestodals, 579 antinematodals, 578–579 ectoparasitics, 580 Antipruritics, 591 Antirobe. See Clindamycin Antiseborrheics, 591 Antiseizure drugs, 303 Antitussives, 302, 621 Antiulcer agents, 594 Antivert. See Meclizine Antizol-Vet. See Methylpyrazole Anuria, 148 Anus, physical examination, 25 Anzemet. See Dolasetron mesylate APC (atrial premature contraction complex), 343, 344 Apomorphine, 595 Appetite behavior suggesting pain and anxiety, 385 stimulator, 606 Apresoline. See Hydralazine APTT (activated partial thromboplastin time), 117 Aquatic therapy, 559 Aristocort. See Triamcinolone Arrhythmia, 31, 343, 344 antiarrhythmics, 302, 586 Arterial intravenous catheter, 350–351 Arthritis acute, 261–262 degenerative joint disease (DJD), 261–262 Arthrography, 189 Artifacts radiographic, 167 urine, 155
ASA (American Society of Anesthesiologists) Physical Status Classification System, 443 Aspartate aminotransferase (AST, SGOT), 78 ASPCA Poison Control Center, 305 Aspergillus, 133 Aspirate, for fine needle biopsy, 89 Aspirin. See Acetylsalicylic acid Assisted mobility device, 559 AST (aspartate aminotransferase), 78 Asthma, feline, 204–205 Atarax. See Hydroxyzine Atelectasis, lung, 347 Atenolol, 586 Atopy, 222–223 Atravet. See Acepromazine Atrial fibrillation, 31, 343 Atrial premature contraction complex (APC), 343, 344 Atropine, 478, 592, 614 ATT (ammonia tolerance test), 100 Attitude, suggesting pain and anxiety, 385 Aural surgery, 530–531 hematoma, 530–531 lateral ear canal resection, 530–531 overview, 530 Auroemycin. See Chlortetracycline Auscultation heart, 21, 30–31 lungs, 21, 32, 366 monitoring fluid therapy, 366 Autoimmune disease myasthenia gravis, 102, 271–272 thrombocytopenia, 254–256 Axillary lymph node, 34 Ayurveda, 563 Azathioprine, 582 Azium. See Dexamethasone Babesia spp., 111, CP–8 Bacteria. See also Microbiology; specific species identification, 130–132 in urine sediment, 151, CP–15, CP–16 Baermann technique, 135 BAL. See Dimercaprol Banamine. See Flunixin meglumine Band, 87, 112, CP–3, CP–8 INDEX
663
Bandaging, 403–411 adherent, 403 basic bandage, 405, 405 care of, 404 casts, 408 chest/abdominal, 407, 407 distal limb splint, 408, 408 Ehmer sling, 409, 409 hobbles, 411, 411 layers, 403–404 90–90 flexion, 410, 410 nonadherent, 403–404 Robert Jones, 406, 406 Velpeau sling, 410, 410 Barbiturates methylated, 489 overview, 488 thiobarbiturates, 489 Barden’s procedure, 36 Barium contrast media, 182, 185–186 Barium enema, 185–186 Barlow’s sign, 36 Barrier sealant, 506 Base excess (BE), 336 Basophilia, WBC, 113, CP–10, CP–11 Basophilic stippling, 109, CP–6 Basophils, 112, CP–9, CP–10 Bathing, 53 Baytril. See Enrofloxacin BE (base excess), 336 Benadryl. See Diphenhydramine Benylin. See Dextromethorphan Benzimidazoles, 578 Benzocaine, 609 Benzodiazepines, 480–481 diazepam, 480–481 midazolam, 480–481 Benzoyl peroxide, 591 Beta-adrenergics, 588, 622 Beta-blockers, 586 Betadine, 629 Betamethasone, 602, 615 Betapace. See Sotalol Betasone. See Betamethasone Bethanechol chloride, 617 Bicarbonate (HCO3−), 78, 335–336 Bier Block, 472
664
INDEX
Bile acids, 100 Bile ducts, inflammation of, 238–240 Bilirubin, 78, 149 Bilirubin crystals, 153, CP–20 Bilirubinuria, 149 Bio-tal. See Thiamylal sodium Biomox. See Amoxicillin Biopsy, fine needle, 89 Biosol. See Neomycin Bipyridine derivatives, 588 Bismuth subsalicylate, 592 Bladder, urinary contrast study, 193–195 cystic calculi, 292–294 cystitis, 296–298 cystotomy, 547 palpation, 22 transitional cell carcinoma, 280 ultrasonography, 199 Blastomyces dermatitidis, 133 Bleach, 628 Bleeding time, 116 Blister cells (prekeratocytes), 110, CP–7 Bloat, 243–244, 528 Blood collection, 74 collection tubes, 75 evaluation of geriatric patient, 29 handling, 74 microbiology sample collection, 123 microbiology specimen storage, 124 parasite examination methods, 138 smear, 74, 90, 138 storage, 74 transport, 74 urine, 149, 151 Blood agar, 125 Blood chemistry alanine aminotransferase (ALT, SGPT), 76 albumin, 76 albumin-to-globulin ratio (A:G ratio), 76 alkaline phosphatase (ALP, SAP), 77 ammonia, 77 amylase, 77 anion gap (AG), 78 aspartate aminotransferase (AST, SGOT), 78 bicarbonate (HCO3−), 78
bilirubin, 78 blood collection, handling, storage, and transport, 74 blood collection tube, 75 blood urea nitrogen (BUN, SUN), 79 calcium, 79 chloride, 79 cholesterol, 80 creatine kinase (CK), 80 creatinine, 80 fibrinogen, 80 gamma glutamyltranspeptidase (GGT), 81 globulins, 81 glucose, 81 lipase, 82 lipids/triglycerides, 82 magnesium, 82 phosphorus, inorganic, 82 potassium, 83 sodium, 83 total protein (TP), 83 Blood collection tube, 75 Blood gas analysis, 335–337 acid-base disturbances, 337 anesthesia monitoring, 464 interpretation, 337 Blood loss, monitoring during anesthesia, 462 Blood parasite examination methods, 138 Blood pressure anesthesia considerations, 444 anesthesia monitoring, 461 central venous pressure (CVP), 334–335, 367, 462 Doppler ultrasound flow detector, 332–333 monitoring fluid therapy, 366 normal values, 333 oscillometric, 332–333 procedure, 332–333 results, 333 Blood transfusions, 119–120, 367–374 administration protocol, 373 blood collection, 369–370 blood products, 371–372 cryoprecipitate, 372 fresh frozen plasma (FFP), 371 frozen plasma (FP), 372 oxyglobin, 372
packed RBCs (pRBC), 371 whole blood stored (SWB), 371 blood types, 368 transfusion reactions, 374 Blood types, 120, 368 Blood urea nitrogen (BUN, SUN), 79 BMBT (buccal mucosal bleeding time), 116 Body condition emergency survey, 307 scoring system, 61–62, 61–62 Body surface area, 627 Bone. See also Skeletal system chondrosarcoma, 280 fibrosarcoma, 281 fracture repair, 63, 540 hemangiosarcoma, 281 osteosarcoma, 283 Bone loss, nutritional requirements for repair, 63 Bone marrow, 83–88 cell type identification, 86–87, CP–3 collection, 83, 84 evaluation, 83, 85–86 handling, 84 interpretation, 88 smear techniques, 84 storage, 85 transport, 85 Bordetella bronchiseptica, 39–40, 44, 130 Borrelia burgdorferi, 41–42, 44, 130 Brachial plexus block, 470 Brachycephalic breeds airway syndrome, 204–205 anesthesia considerations, 444 Brachygnathism, 510 Brachyspira, 96 Brachytherapy, 553 Bradycardia, 460 Bradypnea, 463 Brain anatomy, 10 evaluation of geriatric patient, 29 Brain-heart infusion broth, 125 Breath sounds, 32 Breathing systems, anesthetic, 452–453 Brethine. See Terbutaline Brevital. See Methohexital Bricanyl. See Terbutaline
Bromethalin, 325 Bronchitis canine, 205–207 feline, 204–205 Bronchodilators, 622 Bronchopulmonary disease, feline, 204–205 Brownian movement, 151 Brucella canis, 130, 256 Brucellosis, 256–258 Brushing hair coat, 53 teeth, 52 Buccal mucosal bleeding time (BMBT), 116 Buffy coat, 138 BUN (blood urea nitrogen), 79 Bupivacaine, 389, 470–473, 518–520, 609 Buprenex. See Buprenorphine Buprenorphine, 386, 485, 610 Burr cells, 110 Butorphanol tartrate, 387, 485, 611 Button tumor, 275–276 C-section (cesarean section), 446, 542–543 Calcijex. See Calcitriol Calcitriol, 601 Calcium, 79 Calcium carbonate, 594 Calcium carbonate crystals, 153, CP–20 Calcium channel blockers, 586 Calcium chloride, 365, 587 Calcium gluconate, 365, 587 Calcium oxalate urolithiasis, 66 dihydrate crystals, 153, CP–20 monohydrate crystals, 153 Calcium supplements, 587 Calculations, 570 Calculus charting, 506 formation of, 499 removal, 504 Calicivirus, feline, 44–45, 51 Caloric requirement worksheet, daily, 58 Campylobacter, 96, 130, CP–5 Cancer. See also Oncology chemotherapy drugs, 581–584 alkylating agents, 581 anthracycline antibiotics, 582
antimetabolites, 583 danazol, 584 interferon, 584 L-asparaginase, 584 vinca alkaloid, 584 cytology criteria of malignancy, 92–93 tumor cell types, 94–95, CP–4 oral, 512 Candida, 96, 133 Canine pancreatic lipase immunoreactivity (cPLI), 100 Capillaria plica, 155, CP–22 Capillary refill time (CRT) anesthesia monitoring, 461 evaluation of, 19 monitoring fluid therapy, 366 Capnograph, 463 Capoten. See Captopril Captopril, 303, 590 Carafate. See Sucralfate Carbachol, 614 Carbamates, 580 Carbon dioxide, 335–336 end-tidal CO2, 463 Carbonic anhydrase inhibitors, 303, 613 Carboplatin, 581 Carcinoma adenocarcinoma anal sac, 277 nasal, 277 pancreatic, 277 prostatic, 277 salivary gland, 277 thyroid, 277 squamous cell digit, 279 ear, 279 gingiva, 279 skin, 280 transitional cell, 280 Cardiac disease, nutritional requirements, 63 Cardiac examination, 30–31 heart sounds, 30–31 rhythms, 31 valves, 30 Cardiac glycosides, 588 INDEX
665
Cardiogenic shock, 310–311 Cardiomyopathy dilated, 208–209 hypertrophic, 205–207 restrictive feline, 210–211 Cardiopulmonary cerebrovascular resuscitation (CPCR), 308–309 Cardiopulmonary disease, 204–220 asthma, bronchitis, and bronchopulmonary disease (feline), 204–205 brachycephalic airway syndrome, 204–205 bronchitis (canine), 205–207 cardiomyopathy, dilated canine, 208–209 feline, 208–209 cardiomyopathy, hypertrophic, 205–207 cardiomyopathy, restrictive feline, 210–211 congenital heart disease, 210–211 congestive heart failure, 214–215 endocardiosis, 211–213 heartworm disease, 211–213 hypertension, 215–217 myocarditis, 215–217 pleural effusion, 217–219 pneumonia, 217–219 rhinitis/sinusitis, 219–220 tracheal collapse, 219–220 Cardioquin. See Quinidine Cardiovascular drugs, 585–590 antianemics, 585 antiarrhythmics, 586 anticoagulants, 587 calcium supplements, 587 contractility enhancers, 588 diuretics, 589 positive inotropic agents, 588 vasodilators, 590 Cardiovascular emergency, 312 Cardiovascular system anesthesia considerations anemia/hypoproteinemia, 445 cardiac function impairment, 445 congenital heart disease, 444 heartworm disease, 445 hypotension/hypovolemia, 444 anesthesia effect on, 458 emergency survey, 306
666
INDEX
monitoring during anesthesia, 460–462 blood loss, 462 blood pressure, 461 capillary refill time, 461 central venous pressure, 462 electrocardiograph, 462 heart rate, 460 postanesthetic monitoring, 467 toxicity, chemotherapy, 354 Cardizem, See Diltiazem Caries, 511 Carprofen, 390, 603 Carpus, radiographic positioning, 178 Castration, 542–543 Casts, urine, 152, CP–17–CP–19 Casts (bandaging), 408 Catalase test, 127 Cataracts, 284–285, 537 Catecholamines, 588 Catheter intravenous, 349–351 nasal, 376 for parenteral nutrition (PPN), 422, 424 transtracheal, 377 urinary, 435–436 Caudal infraorbital nerve block, 518 Caudal mandibular and mandibular nerve block, 519 CBC. See Complete blood count Celiography, 183 Cellophane tape, for ectoparasite examination, 139 Central nervous system, emergency survey of, 307 Central venous pressure (CVP), 334–335, 367, 462 Centrifugal flotation, 135 Centrine. See Aminopentamide Cephalosporins, 575 Cervical line lesions, 508 Cervical vertebral instability, 272–273 Cesarean section (C-section), 446, 542–543 Cestex. See Epsiprantel Cetacaine. See Benzocaine Chamber, anesthesia induction, 454 Charcoal, activated, 597 Chediak-Higashi syndrome, 113 Chelating drugs, 624 Chemistry. See Blood chemistry Chemotherapy, 352–356 administration, 352–353
client education, 356 drugs, 581–584 alkylating agents, 581 anthracycline antibiotics, 582 antimetabolites, 583 danazol, 584 interferon, 584 L-asparaginase, 584 vinca alkaloid, 584 monitoring response, 356 toxicity, 353–355 Cheque drops. See Mibolerone Cherry eye, 290–291, 539 Chest/abdominal bandage, 407, 407 Cheyletiella, 145, CP–13 Chinese herbal medicine (CHM), 562 Chiropractic, 563 Chlamydia identification of, 131 microbiology specimen storage, 124 Chlorambucil, 581 Chloramphenicol, 575, 615 Chlorhexidine, 401, 504, 505, 628 Chloride, 79 Chlorinated hydrocarbons, 580 Chlorine, 628 Chloroxylenol, 401, 628 Chlorpheniramine maleate, 591 Chlorpromazine, 593 Chlortetracycline, 577 CHM (Chinese herbal medicine), 562 Chocolate, 325 Cholangiohepatitis, 238–240 Cholangitis, 238–240 Cholecalciferol, 325 Cholesterol, 80 Cholinergics, 606, 617 Chondrosarcoma, 280–281 Chronulac. See Lactulose Cilia disorders, 287–288 Cimetidine, 594 Ciprofloxacin, 576 Circulatory system, anatomy, 9, 10, CP–1, CP–2 Cisapride, 593 Cisplatin, 354, 581 CK (creatine kinase), 80 Clavulanic acid, 577
Claw, dental, 501 Clindamycin, 576 Clomicalm. See Clomipramine Clomipramine, 613 Clostridium C. tetani, 259–261 identification of, 131, CP–4 Clot retraction test, 116 Clotrimazole, 574, 615 Coagulation definitive activated partial thromboplastin time (APTT), 117 fibrin split product (FSP), 117 fibrinogen, 117 protein C activity assay, 117 protein induced by vitamin K antagonism (PIVKA) test, 117 prothrombin time (PT), 117 thrombin time (TT), 118 von Willebrand’s factor (vWF) assay, 118 drawing blood for, 115 factors evaluated by, 115 quick assessment activated clothing time (ACT), 116 buccal mucosal bleeding time (BMBT), 116 clot retraction test, 116 platelet estimate, 116 toenail bleeding time (TBT), 116 Coal tar, 591 Coat evaluating, 23 grooming, 53 Cobalamin, 101 Coccidia, 141 Coccidioides immitis, 133 Cod liver oil, 596 Codeine, 387, 621 Codocytes, 110, CP–7 Cold therapy, 559 Colloid, 363 Colorado State University Acute Pain Scale, 382 Colotomy, 526–527 Compazine. See Prochlorperazine Complementary and alternative veterinary medicine (CAVM), 557–566 acupuncture, 562
ayurveda, 563 chiropractic, 563 flower essences, 564 herbal medicine, Chinese, 562 herbal medicine, western, 566 homeopathy, 564 laser therapy, 565 magnetic field therapy, 565–566 physical therapy and rehabilitation, 558–561 traditional Chinese medicine (TCM), 562 Complete blood count (CBC), 105 differential, 106, 108 evaluation, 108 hemacytometer use, 108 hemoglobin concentration (Hgb), 105 mean corpuscular hemoglobin concentration (MCHC), 107 mean corpuscular hemoglobin (MCH), 107 mean corpuscular volume (MCV), 107 nucleated RBCs (nRBCs), 106 packed cell volume (PCV), 105 platelet estimate, 106 RBC count, 105 reticulocyte count, 106, 107 total protein concentration (TP), 105 WBC count, 105 Computed tomography (CT, CAT scan), 195 Congenital heart disease, 210–211, 444 Congestive heart failure, 214–215 Conjunctival flap, 538 Conjunctivitis, 285–286 Constant rate infusions, 392–393 Constipation, 63, 240–241 Contamination, wound, 397 Contractility enhancers, 588 Coombs’ test (direct antiglobulin test), 120 Corneal reflex, 464 Cornified squamous epithelial cells, 97 Coronavirus canine, 38–39 feline, 46–47 Corticosteroid leukogram, 114 Corticosteroids as anti-inflammatory drugs, 602 side effects, 602 Cortisone acetate, 602 Cosequin. See Glucosamine with chondroitin sulfate
Cosmegen. See Dactinomycin Coughing reflex, 466 Coumadin. See Warfarin Coupage, 432–433 CPCR (cardiopulmonary cerebrovascular resuscitation), 308–309 CPLI (canine pancreatic lipase immunoreactivity), 100 Crackles (rales), 32 Cranial cruciate ligament rupture, 263–264, 540 Cranial drawer motion test, 36 Cranial infraorbital nerve block, 518 Cranial nerves, evaluation of, 35 Cranial tibial response, 35 Crash cart, 301 Creatine kinase (CK), 80 Creatinine, 80 Crenation, RBC, 110 Cross-friction massage, 560 Crossbite, 510 Crossed extensor reflex, 35 Crossmatching, 119 CRT. See Capillary refill time Cruciate disease, 263–264 Cryoprecipitate, 372 Cryosurgery, 554 Cryotherapy, 559 Cryptococcus neoformans, 133 Cryptosporidium, 140, CP–12 Crystalloid, 363, 364 Crystals, 153–154, CP–19–CP21 CT (computed tomography), 195 Ctenocephalides spp., 145, CP–13 Culture and sensitivity, 124 Culture media, 125–126 inoculation and incubation, 126 types, 125 Cuprimine. See d-penicillamine Cushing’s syndrome, 231–232 Cuterebra, 145 CVP (central venous pressure), 334–335, 367, 462 Cyanosis, 464 Cyclohexamines ketamine, 491 overview, 490 tiletamine, 491 Cyclomen. See Danazol INDEX
667
Cyclophosphamide, 581 Cycloplegics, 614 Cyclosporine, 613 Cyniclomyes (Sarrharomycopsis), 96 Cyproheptadine, 606 Cystic calculi, 292–294 Cystine crystals, 66, 153, CP–20 Cystitis, 296–298 Cystocentesis, 434 Cystography, 193–195 Cystorelin. See Gonadorelin Cystotomy, 547 Cytauxzoon felis, 111, 114, CP–8 Cytology, 88–98 collection, 88–89 estrous cycle, staging, 98 evaluation, 91 fecal, 96, CP–4, CP–5 handling, 89 interpretations, 95 malignancy criteria, 92–93 smear techniques, 90 storage, 91 transport, 91 tumor cell types epithelial, 94 mesenchymal, 94 round cell, 95, CP–4 vaginal, 97 Cytotec. See Misoprostol Cytotoxan. See Cyclophosphamide D-256, 628 D-glucose polysaccharide, 402 D-penicillamine, 624 Dacrocytes, 110 Dacryocystorhinography, 187 Dactinomycin, 582 Danazol, 584 Danocrine. See Danazol Daranide. See Dichlorphenamide Darbazine. See Prochlorperazine Dasuquin. See Glucosamine with ASU DDAVP. See Desmopressin acetate DEAs (dog erythrocyte antigens), 368 Deca-Durabolin. See Nandrolone deconate Deciduous teeth, retained, 510
668
INDEX
Declaw, 533 Decubital sores, 347 Defecation, stimulation in neonates, 27 Degenerative joint disease (DJD), 63, 261–262 Delta-cortef. See Prednisolone Deltasone. See Prednisone Demerol. See Meperidine HCl Demodex canis, 145, CP–13 Denosyl. See S-adenosylmethionine (SAMe) Dentistry, 497–520 anatomy dentition, 499 facial structures, 501 skeletal structure, 500 tooth, 500 charting, 506–508, 509 cleaning procedure, 504–506 disorders anatomical, 510 pathologic, 511–512 home dental care, 52 instruments hand-held, 501, 502 maintenance, 502 mechanical, 503 sharpening, 502, 503 nerve blocks, dental, 518–520 caudal infraorbital, 518 caudal mandibular and mandibular nerve, 519 cranial infraorbital, 518 maxillary, 520 middle mental, 519 palatine, 519 nutritional requirements in dental disease, 63 overview, 499 radiography, 512–516 equipment, 512 positioning caudal mandibular view, 515, 515 caudal maxillary view, 516, 516 maxillary view, 516, 516 rostral mandibular view, 514, 514, 515, 515 rostral maxillary view, 514, 514, 515, 515 rostral oblique, 514 radiographic film, 513 technique chart, 512 techniques, 513
Dentition, 499 Depen. See d-penicillamine Depo-Medrol. See Methylprednisolone Depo-Provera. See Medroxyprogesterone acetate Deracoxib, 390, 603 Deramaxx. See Deracoxib Dermacentor spp., 145, CP–13 Dermatology, 220–226 acne canine, 220–221 feline, 220–221 acral lick dermatitis, 222–223 atopy, 222–223 drugs, 591 flea allergy dermatitis, 222–223 food hypersensitivity, 222–223, 224–225 otitis externa, 224–225 pyoderma, 225–226 deep, 225–226 superficial, 225–226 surface, 225–226 toxicity, chemotherapy, 354 Dermatophyte test medium, 125 Desmopressin acetate, 601 Desoxycorticosterone acetate (DOCA), 599 Desoxycorticosterone pivalate (DOCP), 599 Dexamethasone, 602, 615 Dexamethasone suppression test high-dose, 101 low-dose, 101 Dexrazoxane, 624 Dextran 70, 363 Dextromethorphan, 621 Dextrose 5% in water (D5W), 364 50% solution, 365 Di-Trim. See Sulfonamides Diabetes insipidus, 227–228 ADH response test for, 99 water-deprivation test, 104 Diabetes mellitus, 228–229 anesthesia considerations, 446 fructosamine test, 101 insulin, 357–359, 600 administration, 357 monitoring for hypoglycemia, 359 monitoring response, 358
nutritional requirements, 63 Diamox. See Acetazolamide Diaphragmatic hernia, 545–546 Diarrhea acute, 241–243 antidiarrheals, 592 chronic, 241–243 nutritional requirements, 66 Diazepam, 303, 480–481, 607–608 Dibenzyline. See Phenoxybenzamine DIC (disseminated intravascular coagulation), 253–254 Dichlorphenamide, 613 Didecyl dimethyl ammonium chloride, 628 Diestrus, cytology, 98 Diet, 58. See also Nutrition Diff-Quik, 127 Differential, white blood cell count, 106, 108 Differential stain, 127–128 Digit, squamous cell carcinoma, 279 Digoxin, 588 Dihydrostreptomycin, 575 Dilated cardiomyopathy, 208–209 Diltiazem, 586 Dimercaprol, 303, 624 Dimethyl benzyl ammonium chloride, 629 Dimethyl sulfoxide, 615 Dioctophyma renale, 155 Diphenhydramine, 591 Diphenoxylate, 592 Diprivan. See Propofol Dipylidium caninum, 139, 140, CP–12 Direct IFA, 121 Dirofilaria immitis, 140, 211, CP–12 Disc fenestration, 535 Discography, 189 Disease. See also specific diseases canine transmissible, 38–43 feline transmissible, 44–50 nutritional requirements, 63–66 Disinfectants, 627–629 Diskospondylitis, 269 Disseminated intravascular coagulation (DIC), 253–254 Distal limb splint, 408, 408 Distemper, canine, 38–39, 44, 109, 113, CP–6 Distichiasis, 287–288
Diuretics, 302, 589 DJD (degenerative joint disease), 63, 261–262 Dobutamine, 588 DOCA (desoxycorticosterone acetate), 599 DOCP (desoxycorticosterone pivalate), 599 Docusate calcium, 597 Docusate sodium succinate, 597 Dog erythrocyte antigens (DEAs), 368 Döhle body, 113, CP–10, CP–11 Dolasetron mesylate, 593 Domitor. See Medetomidine Dopamine, 588 Dopram. See Doxapram Dorsal laminectomy, 535 Doxapram hydrochloride, 317, 544, 623 Doxorubicin, 354, 582 Doxycycline, 577 Drip rate, calculating, 365 Droncit. See Praziquantel Drug administration chemotherapy, 352–356 administration, 352–353 client education, 356 monitoring response, 356 toxicity, 353–355 injections, 348 insulin, 357–359 administration, 357 monitoring for hypoglycemia, 359 monitoring response, 358 intravenous catheter placement, 349–351 arterial, 350–351 intraosseous, 350–351 jugular, 349–350 monitoring and maintenance, 351 peripheral, 349–350 Drugs. See Pharmacology; specific drugs Dry eye syndrome, 288–290 Duragesic. See Fentanyl Duraquin. See Quinidine Duvoid. See Bethanechol chloride Dystocia, 230–231 Ear anatomy, 13 cleaning, 55 flushing, 55
microbiology sample collection, 123 otitis externa, 224–225 physical examination, 20, 28, 33 squamous cell carcinoma, 279 surgery, 530–531 hematoma, 530–531 lateral ear canal resection, 530–531 overview, 530 Ear flick reflex, 464 Eccentrocytes (hemi-ghost cells), 110 ECG. See Electrocardiogram Echinococcus granulosus, 141, CP–12 Echinocytes (burr cells), 110 Echocardiography, 195 Eclampsia, 230–231 Ectoparasitics, 580 Ectopic cilia, 287–288 Ectropion, 537 Edrophonium chloride, 606 Effleurage, 560 Ehmer sling, 409, 409 Ehrlichia canis, 114 Ehrlichiosis, 256–258 Elavil. See Amitriptyline Elbow, radiographic positioning, 177 Eldepryl. See Selegiline-l-deprenyl Electrical stimulation, neuromuscular, 559 Electrocardiogram (ECG) anesthesia monitoring, 462 heart rate calculation, 342 interpretation, 340 leads, 339–340 normal canine, 341 problems and artifacts, 345 procedure, 338–339 rhythm abnormalities, 343, 344 Electrolyte solution, balanced, 401 Electrolytes, monitoring fluid therapy, 367 Elevators, dental, 501 ELISA (enzyme-linked immunosorbent assay), 120 Elspar. See L-asparaginase Emergency, 299–326 cardiopulmonary cerebrovascular resuscitation (CPCR), 308–309 cardiovascular, 312 drugs, 301, 302–303 antidotes, 303 INDEX
669
Emergency (continued) cardiac, 302 gastrointestinal, 302 neurologic, 303 ophthalmic, 303 renal/urinary, 303 reproductive/endocrine, 303 respiratory, 302 endocrine, 316 environmental, 313 gastrointestinal, 314 genital, 321 hematologic, 315 hemostasis, 307 metabolic, 316 neonatal, 317 neurologic, 318 ophthalmic, 319 renal, 320 reproductive, 321 respiratory, 322 shock, 310–311 supplies, 301–303 telephone assessment, 304–305 toxicologic, 323–325 transportation recommendations, 304–305 trauma, 326 triage primary survey, 306–307 secondary survey, 309 urinary, 320 vomiting, inducing at-home, 305 Emetics, 305, 595 Enacard. See Enalapril Enalapril, 303, 590 Enamel hypoplasia, 511 Encephalitis, 267–269 Endocardiosis, 211–213 Endocrine disorders, 227–236. See also specific disorders anesthesia considerations, 446–447 diabetes insipidus, 227–228 diabetes mellitus, 228–229, 446 emergencies, 316 hyperadrenocorticism, 231–232 hyperparathyroidism, 231–232 hyperthyroidism, 233–234, 447
670
INDEX
hypoadrenocorticism, 233–234, 447 hypoparathyroidism, 235–236 hypothyroidism, 235–236, 447 Endoscopy, 551 Endotracheal intubation complications, 456, 457 extubation, 466 procedure, 454–455, 455 Enema barium, 185–186 warm water, 430 Enilconazole, See Imidazole Enostosis, 266–267 Enrofloxacin, 576 Enteral nutrition, 414–422 administration, 421–422 calculations, 421–422 coax feeding, 414–415 esophagostomy tube, 417, 421 gastrotomy tube, 421 with gastropexy, 419–420 without gastropexy, 418–419 jejunostomy tube, 420–421, 422 nasoesophageal/nasogastric tube, 415–416, 421 orogastric tube, 414–415, 421 tube care, 421 Enterotomy, 528 Entropion, 285–286, 537 Enucleation, 538 Environmental emergency, 313 Enzyme-linked immunosorbent assay (ELISA), 120 Eosinophilic ulcers, 511 Eosinophils, 112, CP–9, CP–10 Ephedrine, 607 EPI (exocrine pancreatic insufficiency), 64, 103, 243–244 Epidural analgesia, 471 anesthesia, 470–471 Epidurography, 188 Epilepsy, 267–269 Epinephrine, 518, 588, 613, 622 Epithelial cast, 152, CP–17 Epithelial cells, in urine sediment, 154, CP–21, CP–22
Epithelial tumor criteria of malignancy, 92 cytology, 94 Epogen. See Erythropoietin Epsiprantel, 579 Epulides, 511 Equipment dental instruments hand-held, 501, 502 maintenance, 502 mechanical, 503 sharpening, 502, 503 oxygen administration, 375 radiography, 160 surgical packs, 523 Erwinase. See L-asparaginase Erythrocyte. See Red blood cell (RBC) Erythromycin, 576 Erythropoietin, 585 Escherichia coli, 131 Esophageal hypomotility, 248–249 Esophageal worm, 142 Esophagography, 184–185 Esophagostomy tube, 417 Estrogens, 619 Estrus, cytology, 98 Estrus cycle, staging, 98 Ethamycin. See Dihydrostreptomycin Ethanol, 303 Ethylene glycol, 324 Etodolac, 390, 603 Etogesic. See Etodolac Etomidate, 493–494 Euthanasia agents, 608 Examination. See Physical examination Excretory urography, 193 Exercise, therapeutic, 561 Exocrine pancreatic insufficiency (EPI), 64, 103, 243–244 Explorer, dental, 501 Extensor carpi radialis response, 35 Extensor postural thrust, 34 Extubation, endotracheal tube, 466 Eye. See also Ophthalmology anatomy, 13 anesthesia effect on, 459 microbiology sample collection, 123
ophthalmic surgery, 536–539 cataracts, 537 conjunctival flap, 538 ectropion, 537 entropion, 537 enucleation, 538 glaucoma, 538 nictitating membrane flap replacement, 538 overview, 536 prolapse of the gland of the third eyelid, 539 proptosis, traumatic, 539 physical examination, 20, 24, 28 ultrasonography, 200 Eyelids ectropion, 537 entropion, 537 Face mask, anesthesia, 454 Facial structures, anatomy of, 501 Factrel. See Gonadorelin FAD (flea allergy dermatitis), 222–223 Famotidine, 594 Fatty cast, 152, CP–17 Fatty liver disease, 246–248 FCV (feline calicivirus), 44–45, 51 FDP (fibrin degradation product), 117 Fecal collection, handling, storage, and transport tips for parasitology, 134 culture, 124, 136 cytology, 96, CP–4, CP–5 microbiology sample collection, 123 Fecal flotation solutions, 137 Feeding. See also Nutrition enteral nutrition, 414–422 general life stage feeding guidelines, 59–60 orphaned puppies and kittens, 27 parenteral nutrition, 422–426 Feldene. See Piroxicam Feline calicivirus (FCV), 44–45, 51 Feline coronavirus, 46–47 Feline herpesvirus, 49–50, 51 Feline immunodeficiency virus (FIV), 47–48, 51 Feline infectious peritonitis (FIP), 46–47 Feline leukemia virus (FeLV), 49–50, 51 Feline lower urinary tract disease (FLUTD), 292–294 Feline panleukopenia virus (FPV), 47–48, 51
Feline parvovirus, 47–48, 51 Feline rhinotracheitis virus, 49–50, 51 Feline urologic syndrome (FUS), 292–294 FeLV (feline leukemia virus), 49–50, 51 Femoral head ostectomy (FHO), 540 Femur, radiographic positioning, 180 Fenbendazole, 578 Fenestration, disc, 535 Fentanyl, 387, 392, 486, 611 Fer-In-Sol. See Ferrous sulfate Ferrous sulfate, 585 FFP (fresh frozen plasma), 371 FHO (femoral head ostectomy), 540 Fibrin degradation product (FDP), 117 Fibrin split product (FSP), 117 Fibrinogen, 80, 117 Fibrosarcoma, 281, 512 Fibula, radiographic positioning, 180 Fibular head transposition, 540 Filaroides osleri, 141 Film, radiographic, 513 Fine needle biopsy, 89 FIP (feline infectious peritonitis), 46–47 Fipronil, 580 Firocoxib, 390, 604 Fistulography, 183 FIV (feline immunodeficiency virus), 47–48, 51 Flagyl. See Metronidazole Flatulence, nutritional requirements, 64 Flea, 145, CP–13 Flea allergy dermatitis (FAD), 222–223 Florane. See Isoflurane Florinef. See Fludrocortisone Flotation, fecal, 135 Flower essences, 564 Flucort. See Flumethasone Flucytosine, 574 Fludrocortisone, 599 Fluid therapy, 359–367 colloids, 363 crystalloids, 363, 364 drip rate, calculating, 365 fluid additives, 365 hydration assessment, 360 monitoring, 366–367 requirements, calculating fluid, 361 routes of administration, 362
Flumethasone, 602 Flunixin meglumine, 604 Fluocinolone acetonide, 615 Fluorescein, 430–431, 614 Fluoride treatment, 506 Fluoroquinolones, 576 Fluoroscopy, 196 Fluorouracil, 582 Fluothane. See Halothane Fluoxetine, 613 FLUTD (feline lower urinary tract disease), 292–294 Fluticasone propionate, 602 Folate, 101 Folliculitis, superficial bacterial, 225–226 Fomepizole. See Methylpyrazole Food. See Feeding; Nutrition Food hypersensitivity/allergy, 64, 224–225 Forceps, dental extraction, 501 Forelimb, radiographic positioning of, 176–178 carpus, 178 elbow, 177 humerus, 176 metacarpus/phalanges, 178 radius/ulna, 178 Formaldehyde, 628 FPV (feline panleukopenia virus), 47–48, 51 Fracture repair of bone, 63, 540 tooth, 508, 511 Fresh frozen plasma (FFP), 371 Front limb reflexes, 35 Frontline. See Fipronil Frozen plasma, 372 Fructosamine, 101 FSP (fibrin split product), 117 Fulvicin. See Griseofulvin Function tests, 98–104 ACTH stimulation test, 99 ADH response test, 99 adrenocorticotropic hormone (ACTH), 99 ammonia tolerance test (ATT), 100 bile acids, 100 canine pancreatic lipase immunoreactivity (cPLI), 100 cobalamin, 101 dexamethasone suppression test, high dose, 101 dexamethasone suppression test, low-dose, 101 INDEX
671
Function tests (continued) folate, 101 fructosamine, 101 nicotinic AchRs, serum antibody against, 102 prothrombin time (PT), 102 T3 suppression test, 102 thyroid hormone, basal serum, 102 thyroid hormone, free, 102 thyroid-releasing hormone (TRH) stimulating test, 103 thyroid-stimulating hormone concentration (endogenous TSH), 103 trypsin-like immunoreactivity (TLI), 103 urine cortisol:creatinine ratio, 103 urine protein:creatinine ratio, 103 water deprivation test, 104 Fungi antifungal drugs, 574 culture, 124 identification, 133 microbiology specimen storage, 124 in urine, 155 Furcation exposure, 507 Furosemide, 589 FUS (feline urologic syndrome), 292–294 Fusobacterium, 131 Gabapentin, 391, 610 Gait, behavior suggesting pain and anxiety, 384 Gall bladder, ultrasonography, 198 Gallop rhythm, 31 Gamma glutamyltranspeptidase (GGT), 81 Garacin. See Gentamicin Garasol. See Gentamicin Gastric dilatation volvulus (GDV), 243–244, 447, 528 Gastric lavage, 428 Gastric torsion, 243–244, 528 Gastrocnemius reflex, 35 Gastroenterology, 238–252. See also Gastrointestinal system anal sac disease, 238–240 cholangitis and cholangiohepatitis, 238–240 constipation and megacolon, 240–241 diarrhea, 241–243 exocrine pancreatic insufficiency (EPI), 243–244 gastric dilatation-volvulus (GDV), 243–244
672
INDEX
hepatic disease/failure, 245–246 hepatic lipidosis, 246–248 inflammatory bowel disease (IBD), 246–248 megaesophagus, 248–249 pancreatitis, 249–251 peritonitis, 249–251 protein-losing enteropathy, 251–252 vomiting, 251–252 Gastrogard. See Omeprazole Gastrography, 184–185 Gastrointestinal system, 238–252 anesthesia considerations, 447–448 effect of anesthesia on, 459 gastric dilatation volvulus, 447 pancreatis, 448 contrast studies, 184–186 esophagography, 184–185 gastrography, 184–185 lower GI, 185–186 upper GI, 185–186 diseases constipation, 240–241 diarrhea, 241–243 exocrine pancreatic insufficiency (EPI), 243–244 gastric dilatation-volvulus (GDV), 243–244 inflammatory bowel disease (IBD), 246–248 protein-losing enteropathy, 251–252 vomiting, 251–252 drugs, 592–597 antidiarrheals, 592 antiemetics, 593 antiulcer agents, 594 emetics, 595 laxatives, 596 lubricants, 596 pancreatic enzyme replacement, 596 protectants, 597 stool softener, 597 emergencies, 314 endoscopy, 551 medical procedures abdominocentesis, 429 enema, warm water, 430 gastric lavage, 428 peritoneal lavage, diagnostic, 429 stomach tube, 428
verification of gastrointestinal tube placement, 429 surgery, 525–529 colotomy, 526–527 enterotomy, 528 gastric dilatation-volvulus (GDV), 528 gastrotomy, 528 hepatectomy, partial, 529 intestinal resection and anastomosis, 529 toxicity, chemotherapy, 355 ultrasonography, 199 Gastrointestinal tube placement, verification of, 429 Gastropexy, gastrotomy tube placement with, 419–420 Gastrotomy, 528 Gastrotomy tube with gastropexy, 419–420 without gastropexy, 418–419 GDV (gastric dilatation volvulus), 243–244, 447, 528 Gemini. See Xylazine Genital system anatomy, 11, 12 emergencies, 321 microbiology sample collection, 123 physical examination, 25, 29 postanesthetic monitoring, 469 ultrasonography, 199 vaginal contrast studies, 192 Gentamicin, 402, 575, 615 Geriatric patients anesthesia considerations, 448 feeding guidelines, 60 physical examination, 28–29 blood, 29 general appearance, 28 genitals, 29 head, 28 immune system, 29 internal organs, 29 limbs, 29 GGT (gamma glutamyltranspeptidase), 81 Giardia, 96, 141, CP–5, CP–12 Giemsa stain, 127 Gingiva fibrosarcoma, 281 hyperplasia, 507, 511
recession, 507 squamous cell carcinoma, 279 sulcus pocketing, 507 Gingival index, 506 Glasgow Composite Pain Tool, 382 Glaucoma, 287–288, 538 Globulins, 81 Glomerulonephritis, 103 Glossopharyngeal nerve, evaluation of, 35 Glucometer, 358 Glucosamine with ASU, 605 Glucosamine with chondroitin sulfate, 605 Glucose, 81 Glucosuria, 149 Glutaraldehyde, 629 Glycerol, 303 Glycopyrrolate, 478 Gonadorelin, 619 Gonadotropins, 619 Gram stain, 124, 128 Granular cast, 152, CP–17 Granulocytes in bone marrow evaluation, 86 cell type identification, 87, CP–3 Griseofulvin, 574 Grooming, 53 Hair, in urine, 155 Hair coat evaluating, 23 grooming, 53 Halothane, 495 Hct (hematocrit), 105 Head contrast studies dacryocystorhinography, 187 rhinography, 187 sialography, 187 physical examination, 20, 24, 28 radiographic positioning, 170–173 nasal cavities and sinuses, 173 skull, 170 temporomandibular joint, 172 tympanic bullae, 172 zygomatic arch, 171 Heart. See also Heart disease anatomy, 9, 10, CP–1, CP–2
echocardiography, 195 electrocardiogram (ECG), 338–345, 341, 344 physical examination, 30–31 general, 21 geriatric, 29 heart sounds, 30–31 pediatric, 24 rhythms, 31 valves, 30 sounds, 30–31 toxicity, chemotherapy, 354 ultrasonography, 199 Heart disease. See also Cardiopulmonary disease anesthesia considerations, 444–445 arrhythmias, 343, 344 cardiomyopathy, dilated canine, 208–209 feline, 208–209 cardiomyopathy, hypertrophic, 205–207 cardiomyopathy, restrictive feline, 210–211 congenital heart disease, 210–211, 444 congestive heart failure, 214–215 endocardiosis, 211–213 heartworm disease, 211–213, 445 hemangiosarcoma, 282 myocarditis, 215–217 Heart rate anesthesia monitoring, 460 calculating from electrocardiogram (ECG), 342 monitoring fluid therapy, 366 normal values, 19, 30 Heart valves, 9, 10 endocardiosis, 211–213 evaluation, 30 Heartgard. See Ivermectin Heartworm disease, 140, 211–213, 445 Heat support, 346 Heat therapy, 560 Heinz body, 109, CP–7 Helmet cells, 110, 111, CP–7 Hemacytometer, 108 Hemangiosarcoma, 281–282 Hematocrit (Hct), 105 Hematology, 104–120 blood transfusions, 119–120 blood typing, 120 crossmatching, 119
coagulation tests, 115–118 definitive test, 117–118 factors evaluated by, 115 for quick assessment, 116 complete blood count, 105 differential, 106, 108 evaluation, 108 hemacytometer use, 108 hemoglobin concentration (Hgb), 105 mean corpuscular hemoglobin concentration (MCHC), 107 mean corpuscular hemoglobin (MCH), 107 mean corpuscular volume (MCV), 107 nucleated RBCs (nRBCs), 106 packed cell volume (PCV), 105 platelet estimate, 106 RBC count, 105 reticulocyte count, 106, 107 total protein concentration (TP), 105 WBC count, 105 disorders anemia nonregenerative, 253–254 regenerative, 253–254 disseminated intravascular coagulation (DIC), 253–254 thrombocytopenia, 254–256 von Willebrand’s disease, 254–256 emergencies, 315 platelet morphology, 115 RBC morphology, 108–111 arrangement, 109 color, 109 inclusions, 109 parasites, 111 shape, 110–111 size, 109–110 toxicity, chemotherapy, 354 WBC morphology, 112 cell types, appearance of, 112 inclusions, 113 left shift, 114 parasites, 114 Hematoma, aural, 530–531 Hematuria, 149 Hemi-ghost cells, 110 Hemilaminectomy, 535 INDEX
673
Hemistanding/hemiwalking, 34 Hemoglobin, in urine sediment, 154 Hemoglobin concentration (Hgb), 105 Hemoglobinuria, 149 Hemorrhage, controlling, 307 Hemostasis, 307 Heparin, 587 Hepatectomy, partial, 529 Hepatic disease, 245–246 anesthesia considerations, 448 cholangiohepatitis, 238–240 function tests, 100, 102 hemangiosarcoma, 282 hepatitis, canine, 39–40, 44 lipidosis, 64, 246–248 nutritional requirements, 64 Hepatic drugs, 598 Herbal medicine Chinese, 562 western, 566 Hernia abdominal, 526–527 diaphragmatic, 545–546 Herpesvirus, feline, 49–50, 51 Hetastarch, 363 Hgb (hemoglobin concentration), 105 Hindlimb reflexes, 35 Hindlimbs, radiographic positioning of, 180–181 femur, 180 metatarsals, 181 stifle, 180 tarsus, 181 tibia/fibula, 180 Hip dysplasia, 263–264 Hip luxation, 36 Histiocytoma, 95, 275–276, CP–4 Histoplasma capsulatum, 133 History, 19 Hobbles, 411, 411 Hoe, dental, 501 Homeopathy, 564 Honey, 402 Hookworm, 139, 140, 144 Hopping, 35 Hot spots, 225–226 Housing, orphaned puppies and kittens, 27 Howell-Jolly body, 109, CP–6, CP–10
674
INDEX
Humerus, radiographic positioning, 176 Hyaline cast, 152, CP–18 Hycodan. See Hydrocodone Hydralazine, 590 Hydration assessment, 360 Hydrocodone, 621 Hydrocortisone, 602 Hydrocortisone sodium succinate, 602 Hydrogen peroxide, 305, 595 Hydromorphone, 388, 392, 471, 486, 611 Hydrotherapy, 559 Hydroxyzine, 591 Hyperadrenocorticism, 64, 99, 101, 231–232 Hypercapnia, 463 Hyperparathyroidism, 231–232 Hypersensitivity chemotherapy toxicity, 355 food, 224–225 Hypertension, 215–217, 461 Hyperthermia, 465, 554, 560 Hyperthyroidism, 102, 103, 233–234 anesthesia considerations, 447 nutritional requirements, 64 Hypertrophic cardiomyopathy, 205–207 Hypnomidate. See Etomidate Hypoadrenocorticism, 99, 233–234 anesthesia considerations, 447 nutritional requirements, 64 Hypocapnia, 463 Hypochromasia, 109, CP–7 Hypoglossal nerve, evaluation of, 35 Hypoglycemia, 359 Hypoparathyroidism, 235–236 Hypoperfusion, 461 Hypoproteinemia, anesthesia considerations, 445 Hypotension, 444, 461 Hypothermia, 346, 465 Hypothyroidism, 102, 103, 235–236 anesthesia considerations, 447 nutritional requirements, 65 Hypovolemia, 444, 462 Hypovolemia shock, 310–311 Hysterotomy, 542–543 IBD (inflammatory bowel disease), 65, 246–248 Ibuprofen, 324
Idiopathic thrombocytopenic purpura (ITP), 254–256 IFA (immunofluorescence assay), 121 Illness, pain levels associated with, 383 Imaging, 157–200. See also specific modalities computed tomography (CT), 195 echocardiography, 195 fluoroscopy, 196 magnetic resonance imaging (MRI), 196 nuclear medicine (scintigraphy), 196 radiology, 159–195 ultrasonography, 197–200 Imidacloprid, 580 Imidazole, 574 Immiticide. See Melarsomine Immune-mediated thrombocytopenia (IMT), 254–256 Immune system, evaluation of geriatric patient, 29 Immunization. See Vaccination Immunoblot, 122 Immunocytes, 114, CP–10 Immunodiffusion, 121 Immunofluorescence assay (IFA), 121 Immunology tests, 120–122 antinuclear antibody (ANA), 121 Coombs’, 120 enzyme-linked immunosorbent assay (ELISA), 120 immunodiffusion, 121 immunofluorescence assay (IFA), 121 immunoperoxidase test, 121 intradermal, 121 latex agglutination, 121 polymerase chain reaction (PCR), 121 radioimmunoassay, 121 rheumatoid factor, 122 western blot (immunoblot), 122 Immunoperoxidase test, 121 Immunosuppressant, 613 Imodium. See Loperamide Imprint, 88 IMT (immune-mediated thrombocytopenia), 254–256 Imuran. See Azathioprine Inclusions RBCs, 109, CP–6, CP–7, CP–10 WBC, 113, CP–10, CP–11 Inderal. See Propranolol
Indirect IFA, 121 Indole test, 127 Induction, general anesthesia, 453–454 Infectious disease, 256–261. See also specific diseases brucellosis, 256–258 ehrlichiosis, 256–258 Rocky Mountain spotted fever, 258–259 salmon poisoning, 258–259 tetanus, 259–261 toxoplasmosis, 259–261 Inflammatory bowel disease (IBD), 65, 246–248 Inguinal lymph node, 34 Inhalant anesthetics, 494–496 halothane, 495 isoflurane, 495 sevoflurane, 496 Injectable induction anesthetics barbiturates, 488–489 cyclohexamines, 490–491 etomidate, 493–494 propofol, 492–493 Injections, 348 Injury, pain levels associated with, 383 Inocor. See Amrinone Inodilator, 588 Inotropic agents, 302, 588 Insecticides, 324 Instruments dental hand-held, 501, 502 maintenance, 502 mechanical, 503 sharpening, 502, 503 surgical packs, 523 Insulin, 357–359, 600 administration, 357 monitoring for hypoglycemia, 359 monitoring response, 358 Integumentary system, surgery of, 531–533 abscess, superficial, 532 laceration, superficial, 532 mass removal, 533 onychectomy, 533 overview, 531 Interceptor. See Milbemycin oxime Intercostal and interpleural block, 471 Interferon, 584
Intermediate cells, in vaginal cytology, 97 Intermittent positive-pressure ventilation (IPPV), 458 Internal organs anatomy, 8, CP–1 physical examination, 25, 33 Intervertebral disc, contrast study, 189 Intervertebral disc disease, 269–270 Intestinal resection and anastomosis, 529 Intra-articular block, 472 Intradermal tests, 121 Intramuscular anesthesia induction, 453 Intramuscular injection (IM), 348 Intraosseous catheter, 350–351 Intraosseous fluid administration, 362 Intraperitoneal fluid administration, 362 Intravenous anesthesia induction, 453 Intravenous catheter, 349–351 arterial, 350–351 intraosseous, 350–351 jugular, 349–350 monitoring and maintenance, 351 peripheral, 349–350 Intravenous fluid administration, 362 Intravenous injection (IV), 348 Intravenous pyelography (IVP), 193 Intravenous regional block, 472 Intravenous urography (IVU), 193 Intubation, endotracheal, 454–456, 455, 457 Iodine contrast media, 182, 185–186 Iodine/iodophors, 629 Ipecac, syrup of, 595 Iperenol. See Isoproterenol IPPV (intermittent positive-pressure ventilation), 458 Iron-deficiency anemia, CP–7 Irrigation, during dentistry, 505 IsoFlo. See Isoflurane Isoflurane, 495 Isopropyl alcohol, 628 Isoproterenol, 588 Isospora spp., 139, 141, CP–12 Isuprel. See Isoproterenol ITP (idiopathic thrombocytopenic purpura), 254–256 Ivermectin, 578 IVP (intravenous pyelography), 193 IVU (intravenous urography), 193
Jejunostomy tube, 420–421 Joints arthritis acute, 261–262 degenerative joint disease (DJD), 261–262 contrast study (arthrography), 189 evaluation of geriatric patient, 29 goniometry, 558 hip dysplasia, 263–264 osteochondrosis, 264–265 Jugular catheter, 349–350 Kaolin-pectin, 597 Kennel cough. See Tracheobronchitis, infectious Keratitis nonulcerative, 288–290 ulcerative, 288–290 Keratoconjunctivitis sicca (KCS), 288–290 Keratocytes (bite or helmet cells), 110, CP–7 Ketalean. See Ketamine Ketamine, 392, 393, 491, 610 Ketanserin, 402 Ketaset. See Ketamine Ketoconazole, 574 Ketofen. See Ketoconazole; Ketoprofen Ketonuria, 149 Ketoprofen, 390, 604 Kidney contrast study, 193 evaluation of geriatric patient, 29 function tests, 103 palpation, 22 pyelonephritis, 292–294 renal failure acute (ARF), 294–296 chronic (CRF), 294–296 toxicity, chemotherapy, 355 ultrasonography, 198 Kiltix. See Pyrethrins and pyrethroids Kittens. See Pediatric patients Knot typing, 549 KOH preparation, 124 L-asparaginase, 584 Labor, 26 Laboratory medicine, 74–155 blood chemistries, 74–83 INDEX
675
Laboratory medicine (continued) bone marrow evaluation, 83–88 cytology, 88–98 function tests, 98–104 hematology, 104–120 immunology and serology, 120–122 microbiology, 122–133 parasitology, 134–146 preanesthetic evaluation, 443 urinalysis, 147–155 Laceration, superficial, 532 Lactated Ringer’s, 364 Lactation, feeding guidelines in, 60 Lactophenol cotton blue, 128 Lactulose, 596 Laminectomy, dorsal, 535 Laryngeal paralysis, 545–546 Laser surgery, 552 Laser therapy, 565 Lasix. See Furosemide Lateral ear canal resection, 530–531 Latex agglutination, 121 Lavage gastric, 428 peritoneal, diagnostic, 429 Laxatives, 596 Laxatone. See Petrolatum, white Left shift, WBC, 114 Length, measurement of, 626 Lens extraction, 537 luxation, 290–291 Leptocytes (codocytes, target cells), 110, CP–7 Leptospirosis canine, 41–42, 44 microbiology sample collection, 123 Leucine crystals, 153, CP–20 Leukeran. See Chlorambucil Levothyroxine sodium, 601 Lice, 146, CP–14, CP–15 Lick granuloma, 222–223 Lidocaine, 389, 392, 393, 470–474, 518–520, 586, 609 Lily, 325 Limbs bandaging, 405–406, 408–411 physical examination, 21, 25, 29
676
INDEX
radiographic positioning forelimb, 176–178 hindlimbs, 180–181 Lincomycin, 576 Lincosamides, 576 Line block, 473 Linognathus setosus, 146, CP–14 Lipemia, 74 Lipid droplets, in urine sediment, 154, CP–22 Lipids/triglycerides, 82 Lipoma, cytology of, 94 Liquamycin. See Oxytetracycline Liquid measure, 626 Liver evaluation of geriatric patient, 29 hepatectomy, partial, 529 palpation, 22 ultrasonography, 198 Liver disease, 245–246 anesthesia considerations, 448 cholangiohepatitis, 238–240 function tests, 100, 102 hemangiosarcoma, 282 hepatic lipidosis, 64, 246–248 nutritional requirements, 64 Lomotil. See Diphenoxylate Loperamide, 592 Lopressor. See Metoprolol Lopurin. See Allopurinol Lotrimin. See Clotrimazole Lower gastrointestinal study, 185–186 Lubricants, 596 Lufenuron, 580 Luminal. See Phenobarbital Lungs, physical examination of auscultation, 366 general examination, 21, 32 geriatric, 29 pediatric, 24 Lungworm, canine, 141 Lutalyse. See Prostaglandin F-2α Lyme disease, 41–42, 44 Lymph nodes anatomy of regional, 6 physical examination, 20, 21, 34 Lymphocytes, 112, CP–8, CP–10 reactive, 114, CP–10
vacuolated, 114 Lymphoma canine, 283 cytology, 95, CP–4 feline, 282 Lymphosarcoma, 282, 283 Lysodren. See Mitotane MacConkey agar, 125 Macrocytosis, 109 Magnesium, 82 Magnesium, ammonium and phosphate (MAPS) crystals, 153 Magnesium hydroxide, 594, 596 Magnesium sulfate, 137 Magnetic field therapy, 565–566 Magnetic resonance imaging (MRI), 196 Malassezia pachydermatis, identification of, 133, CP–11 Malignancy, cytologic criteria of, 92–93 Malignant melanoma, 512 Mammary adenocarcinoma, cytology, 94 Mammary glands mastitis, 235–236 neoplasia, 275–276 palpation, 22 Mange, 145–146 Mannitol, 303, 589 MAPS (magnesium, ammonium and phosphate) crystals, 153 Marbofloxacin, 576 Marcaine. See Bupivacaine Marogen. See Erythropoietin Marrow. See Bone marrow Mass removal, 533 Massage, 560 Mast cell tumor, 95, 275–276, CP–4 Mastitis, 235–236 Maxillary nerve block, 520 Mean corpuscular hemoglobin concentration (MCHC), 107 Mean corpuscular hemoglobin (MCH), 107 Mean corpuscular volume (MCV), 107 Mebendazole, 578 Meclizine, 593 Medetomidine, 389, 482–483, 609 Medrol. See Methylprednisolone
Medroxyprogesterone acetate, 620 Megace. See Megestrol acetate Megacolon, 240–241 Megakaryoblast, 87, CP–3 Megakaryocytes in bone marrow evaluation, 85 identification of, 87 maturation stages, CP–3 Megaesophagus, 248–249 Megestrol acetate, 620 Melanoma, 95, 512 Melarsomine, 578 Meloxicam, 391, 604 Meningitis, 269–270 Meperidine HCl, 612 Mesenchymal tumor criteria of malignancy, 92 cytology, 94 Metabolic acidosis, 337 Metabolic alkalosis, 337 Metabolic drugs, 599–601 Metabolic emergency, 316 Metacam. See Meloxicam Metacarpus, radiographic positioning, 178 Metaldehydes, 324 Metamyelocyte, 87, CP–3 Metarubricyte, 86, 111, CP–3, CP–6 Metatarsals, radiographic positioning, 181 Metered-dose inhalers (MDIs), 432–433 Metestrus, cytology, 98 Methadone, 388 Methenamine, 617 Methimazole, 601 Methionine, 616 Methocarbamol, 605, 608 Methohexital, 489 Methotrexate, 582 Methylmorphine. See Codeine Methylprednisolone, 602 Methylpyrazole, 624 Methyltestosterone, 619 Methylxanthines, 622 Metoclopramide, 593 Metoprolol, 586 Metric units, 625 Metricide, 629 Metronidazole, 576
Mexiletine, 586 Mibolerone, 619 Microbiology, 122–133 bacteria identification, 130–132 culture media, 125–126 inoculation and incubation, 126 types, 125 evaluation of growth, 127 fungi identification, 130–132 sample collection, 122–123 handling, 123 storage, 123–124 transport, 125 staining, 127–130 differential stains, 127–128 acid-fast, 128 Diff-Quik, 127 Giemsa stain, 127 Gram stain, 128 lactophenol cotton blue, 128 Ziehl/Neelson, 128 Ziehl/Neelson with brilliant green, 128 Ziehl/Neelson with methylene blue, 128 negative stain, 129 problems, 130 simple stain, 129 Microcytosis, 109 Microsporum canis, 133 Midazolam, 480–481 Middle mental nerve block, 519 Milbemycin oxime, 578 Mineral oil, 596 Minipress. See Prazosin Minocycline, 577 Miotics, 614 Misoprostol, 594 Mites, 145–146, CP–13, CP–14 Mitotane, 599 Mitoxantrone, 582 Mitral valve insufficiency, 211–213 Modified Knott’s technique, 138 Monocytes, 112, CP–9 Morphine, 388, 392, 393, 471, 487, 612 Motility modifiers, 593 Mouth. See Oral cavity Mouth cells (stomatocytes), 111
Movement, behavior suggesting pain and anxiety, 385 Moxidectin, 579 MRI (magnetic resonance imaging), 196 Mucolytics, 622 Mucomyst. See Acetylcysteine Mucopolysaccharidoses, 113 Mucous membranes anesthesia monitoring, 464 evaluation of, 19 Mucus threads, in urine sediment, 154 Murmurs, 30, 31 Muscle girth measurement, 558 Muscle relaxant, 605, 608 Musculature anatomy, 6 physical examination, 28 Musculoskeletal system anesthesia effect on, 460 disorders, 261–267 arthritis, acute, 261–262 cruciate disease, 263–264 degenerative joint disease (DJD), 261–262 hip dysplasia, 263–264 osteochondrosis, 264–265 osteomyelitis, 264–265 panosteitis, 266–267 patellar luxation, medial, 266–267 drugs, 602–605 antiinflammatory drugs, 602–605 corticosteroids, 602 muscle relaxer, 605 nonsteroidal antiinflammatory drugs (NSAIDs), 603–605 protectant, 605 supplements, 605 postanesthetic monitoring, 468 Mushrooms, 325 Muzzle, physical examination, 20 Myasthenia gravis, 102, 271–272 Mycelex. See Clotrimazole Mycifradin. See Neomycin Mycobacterium tuberculosis, 131 Mycoplasma spp. identification of, 131 M. haemocanis, 111 M. haemofelis, 111, CP–6 INDEX
677
Mycoplasma spp. (continued) microbiology specimen storage, 124 Mycostatin. See Nystatin Mydriatics, 614 Myeloblast, 87, CP–3 Myelocyte, 87, CP–3 Myelography, 188 Myeloid:erythroid ratio, in bone marrow evaluation, 86 Myelopathy, 271–272 Myocarditis, 215–217 Myoglobinuria, 149 Nail trimming, 54 Naloxone, 544, 623 Nandrolone deconate, 617 Nanophyetus salminocola, 139, 142 Narcan. See Naloxone Narcotic agonist, 610 Nasal catheter, 376 Nasal cavity adenocarcinoma, 277 chondrosarcoma, 281 contrast study, 187 physical examination, 20, 24, 28 radiographic positioning, 173 Nasoesophageal/nasogastric tube, 415–416 Nasolacrimal duct, contrast study, 187 Nasopharyngeal polyps, 511 Nebcin. See Tobramycin Nebulization, 432–433 Neck, physical examination, 20, 28 Neck lesions, 508 Negative staining, 129 Nembutal. See Pentobarbital Nemex. See Pyrantel Neomycin, 575, 615 Neonatal patients anesthesia considerations, 449 care and feeding of orphaned puppies and kittens, 27 emergencies, 317 postoperative care of, 544 resuscitation post-cesarean, 317 Neoplasia, 273–274. See also Oncology Neorikettsia helminthoeca, 258–259 Neosar. See Cyclophosphamide
678
INDEX
Neostigmine bromide, 606 Nerve blocks, 473, 518–520 caudal infraorbital, 518 caudal mandibular and mandibular nerve, 519 cranial infraorbital, 518 maxillary, 520 middle mental, 519 palatine, 519 Nervous system anatomy, 10, 11, CP–2 anesthesia effect on, 460 postanesthetic monitoring, 469 Neurology carcinoma transitional cell, 280 disorders, 267–273 encephalitis, 267–269 epilepsy, 267–269 intervertebral disc disease, 269–270 meningitis, 269–270 myasthenia gravis, 271–272 myelopathy, 271–272 vestibular disease, 272–273 wobbler syndrome, 272–273 drugs, 606–613 adrenergic agents, 607 analgesic/anticonvulsant, 610 analgesics, 609 anticonvulsants, 607–608 antidepressants, 613 appetite stimulator, 606 cholinergics, 606 euthanasia agents, 608 muscle relaxants, 608 narcotic agonist, 610 NMDA antagonist, 610 opioids, 611–612 emergencies, 318 neurological examination, 34–35 cranial nerves, 35 front limb reflexes, 35 hindlimb reflexes, 35 postural reactions, 34–35 sensory evaluation, 35 spinal reflexes, 34 sarcoma chondrosarcoma, 280–281
fibrosarcoma, 281 hemangiosarcoma, 281–282 lymphosarcoma/lymphoma, 282–283 osteosarcoma, 283 vaccine-induced, 283 surgery disc fenestration, 535 dorsal laminectomy, 535 hemilaminectomy, 535 overview, 534 toxicity, chemotherapy, 355 Neuromuscular system, electrical stimulation of, 559 Neurontin. See Gabapentin Neuter, 542–543 Neutrophils, 112, CP–6, CP–8, CP–10 bands, 87, 112, CP–3, CP–8 segmented, CP–3, CP–8 toxic change, 113, CP–10, CP–11 Nicotinic AchRs, serum antibody against, 102 Nictitating membrane flap replacement, 538 90–90 flexion bandage, 410, 410 Nitrofurazone, 402 Nitroglycerin, 590 Nizoral. See Ketoconazole NMDA antagonist, 610 Nocardia spp., 131 Nolvasan, 628 Nonsteroidal anti-inflammatory drugs (NSAIDs), 603–605 carprofen, 390 deracoxib, 390 etodolac, 390 firocoxib, 390 ketoprofen, 390 meloxicam, 391 tepoxalin, 391 Norfloxacin, 576 Normoblasts, 111 Normosol-R, 364 Noroxin. See Norfloxacin Norvasc. See Amlodipine besylate Novantrone. See Mitoxantrone NRBC (nucleated red blood cell), 106, 111, CP–6 NSAIDs. See Nonsteroidal anti-inflammatory drugs Nuclear medicine, 196 Nucleated red blood cell (nRBC), 106, 111, CP–6 Numorphan. See Oxymorphone
Nutrition, 58–67 body condition score, 61–62, 61–62 daily caloric requirement worksheet, 58 disease nutritional requirements, 63–66 feeding guidelines, 59–60 obesity management, 67 orphaned puppies and kittens, 27 Nutritional support enteral, 414–422 administration, 421–422 calculations, 421–422 coax feeding, 414–415 esophagostomy tube, 417, 421 gastrotomy tube, 421 with gastropexy, 419–420 without gastropexy, 418–419 jejunostomy tube, 420–421, 422 nasoesophageal/nasogastric tube, 415–416, 421 orogastric tube, 414–415, 421 tube care, 421 oral, tips on encouraging, 414 parenteral, 422–426 administration, 424 formulas and calculations, 424, 425, 426 partial parenteral nutrition (PPN), 422–423, 426 patient and catheter care, 424 total parenteral nutrition (TPN), 422–423, 425 Nystatin, 574 Obesity anesthesia considerations, 448 body condition scoring, 62 nutritional requirements, 65 prevalence of, 58 OCD (osteochondritis desiccans), 264–265 Oculomotor nerve, evaluation of, 35 Odontoclastic resorption lesions (ORLs), 508, 511 OHE, 542–543 Oligodontia, 510 Oliguria, 148 Omeprazole, 594 Omnipen. See Ampicillin Oncaspar. See L-asparaginase Oncology, 273–283 cancer/chemotherapy drugs, 581–584 carcinoma adenocarcinoma
anal sac, 277 nasal, 277 pancreatic, 277 prostatic, 277 salivary gland, 277 thyroid, 277 squamous cell digit, 279 ear, 279 gingiva, 279 skin, 280 chemotherapy, 352–356 administration, 352–353 client education, 356 monitoring response, 356 toxicity, 353–355 histiocytoma, 275–276 mammary gland neoplasia, 275–276 mast cell tumor, 275–276 nutritional requirements, 65 oral tumors benign epulides, 511 malignant fibrosarcoma, 512 malignant melanoma, 512 squamous cell carcinoma, 512 overview, 273–274 Oncovin. See Vincristine Ondansetron, 593 Onychectomy, 533 Ophthalmology disorders, 284–291 anterior uveitis, 284–285 cataracts, 284–285 cilia disorders, 287–288 conjunctivitis, 285–286 entropion, 285–286 glaucoma, 287–288 keratitis nonulcerative, 288–290 ulcerative, 288–290 keratoconjunctivitis sicca (KCS), 288–290 lens luxation, 290–291 prolapsed gland of the third eyelid, 290–291 drugs, 613–614 emergencies, 319 medical procedures fluorescein sodium stain, 430–431
Schirmer teat test, 430–431 tonometry, 430–431 physical examination, 20, 24 postanesthetic monitoring, 468 surgery, 536–539 cataracts, 537 conjunctival flap, 538 ectropion, 537 entropion, 537 enucleation, 538 glaucoma, 538 nictitating membrane flap replacement, 538 overview, 536 prolapse of the gland of the third eyelid, 539 proptosis, traumatic, 539 Opiates, 592 Opioids, 611–612 buprenorphine, 386, 485 butorphanol tartrate, 387, 485 codeine (with acetaminophen), 387 constant rate infusion, 392–393 fentanyl citrate, 387, 392, 486 hydromorphone, 388, 392, 486 methadone, 388 morphine sulfate, 388, 392, 393, 487 overview, 484 oxymorphone, 388, 487 tramadol, 389 Optic nerve, evaluation of, 35 Optimmune. See Cyclosporine Oral cavity, physical examination, 20, 24 Oral fluid administration, 362 Oral nutrition, tips on encouraging, 414 Orbax. See Orbifloxacin Orbifloxacin, 576 Orbit, ultrasonography, 200 Orchiectomy, 542–543 Organophosphates, 324, 580 ORLs (odontoclastic resorption lesions), 508, 511 Orogastric tube, 41415 Oronasal fistula, 511 Orphans, care and feeding of, 27 Orthopedics disease, nutritional requirements in, 65 examination, 36 surgery, 539–541 cranial cruciate ligament rupture, 540 INDEX
679
Orthopedics (continued) femoral head ostectomy (FHO), 540 fracture repair, 540 patellar luxation, 541 preparation, complications, and follow-up, 539 total hip replacement, 541 triple pelvic osteotomy (TPO), 541 Ortolani maneuver, 36 Orudis. See Ketoprofen Osmitrol. See Mannitol Osteoarthritis, 261–262 Osteochondritis desiccans (OCD), 264–265 Osteochondrosis, 264–265 Osteoclastic resorptive lesions, 508 Osteomyelitis, 264–265 Osteosarcoma, 94, 283 Otic drugs, 615 Otitis externa, 224–225 Otodectes cynotis, 146, CP–14 Otoscopic examination, 20, 24, 33 Ovaban. See Megestrol acetate Ovariohysterectomy, 542–543 Ovary, ultrasonography, 199 OVH, 542–543 Ovitrol. See Pyrethrins and pyrethroids Oxidase test, 127 Oxygen, blood gas analysis, 335–336 Oxygen administration carrier/box, 375 equipment, 375 flow-by, 375 flow rates, 375 humidification, 375 mask, 375 nasal catheter, 376 oxygen hood, 376 tracheostomy, 377 transtracheal catheter, 377 Oxygen hood, 376 Oxyglobin, 363, 372 Oxymorphone, 388, 471, 487, 612 Oxytetracycline, 577 Oxytocin, 303, 620 P-R interval, 340 P wave, 340 Packed cell volume (PCV), 105, 367
680
INDEX
Packed RBCs (pRBC), 371 Pain, evaluation of deep pain perception, 35 Pain management, 379–393 drugs, 386–393 adjuvant amantadine, 391 gabapentin, 391 alpha-2 agonists medetomidine, 389 xylazine, 389 local bupivacaine, 389 lidocaine, 389, 392, 393 nonsteroidal anti-inflammatory drugs (NSAIDs) carprofen, 390 deracoxib, 390 etodolac, 390 firocoxib, 390 ketoprofen, 390 meloxicam, 391 tepoxalin, 391 opioids buprenorphine, 386 butorphanol tartrate, 387 codeine (with acetaminophen), 387 constant rate infusion, 392–393 fentanyl citrate, 387, 392 hydromorphone, 388, 392 methadone, 388 morphine sulfate, 388, 392, 393 oxymorphone, 388 tramadol, 389 myths, 380–381 nondrug approach, 386 pain assessment behaviors suggesting pain and anxiety, 384–386 appetite/elimination, 385 attitude, 385–386 gait, 384 general appearance, 384 movement, 385 physiologic, 385 posture, 384 vocalization, 384 illness, 383 injury, 383
pain scales, 381–382 surgical procedures, 383 Pain scale, 381–382 canine acute, CP–23 feline acute, CP–24 Palatine nerve block, 519 Palpation, 20, 21, 22, 25, 33, 34 Palpebral reflex, 465 Panacur. See Fenbendazole Panalog. See Nystatin Pancreas adenocarcinoma, 277 function tests, 100, 103 ultrasonography, 199 Pancreatic enzyme replacement, 596 Pancreatitis, 249–251 anesthesia considerations, 448 function tests, 100, 103 nutritional requirements, 65 Panmycin. See Tetracycline Panniculus reflex, 34 Panosteitis, 266–267 Parabasal cells, in vaginal cytology, 97 Parainfluenza, canine, 39, 44 Paralysis, laryngeal, 545–546 Paramethasone, 602 Paramite dip. See Chlorinated hydrocarbons Paraplatin. See Cisplatin Parasitology, 134–146 blood parasites, 111, 114, 138, CP–6, CP–8 ectoparasites Cheyletiella, 145, CP–13 Ctenocephalides spp., 145, CP–13 Cuterebra, 145 Demodex canis, 145, CP–13 Dermacentor spp., 145, CP–13 examination methods, 139 Linognathus setosus, 146, CP–14 Otodectes cynotis, 146, CP–14 Rhipicephalus sanguineus, 146, CP–14 Sarcoptes scabiei canis, 146, CP–14 Trichodectes canis, 146, CP–15 endoparasites Ancylostoma caninum, 139, 139, CP–11 Ancylostoma tabaeforme, 140, CP–11 Cryptosporidium, 140, CP–12 Dipylidium caninum, 139, 140, CP–12
Dirofilaria immitis, 140, CP–12 Echinococcus granulosus, 141, CP–12 eggs, relative sizes of, 139 examination methods, 134–136 Baermann technique, 135 centrifugal flotation, 135 direct smear: dry prep, 135 direct smear: wet prep, 134 fecal culture, 136 flotation, 135 gross examination, 134 Filaroides osleri, 141 Giardia, 141, CP–12 Isospora spp., 139, 141, CP–12 Nanophyetus salminocola, 139, 142 Spirocerca lupi, 142 Taenia pisiformis, 142 Taenia taeniaeformis, 142 Toxascaris leonina, 139, 143, CP–12 Toxocara canis, 139, 143, CP–12 Toxocara cati, 139, 143, CP–12 Toxoplasma gondii, 139, 144, CP–13 Trichuris vulpis, 139, 144, CP–13 Uncinaria stenocephala, 139, 144, CP–13 fecal collection, handling, storage, and transport, 134 fecal flotation solutions, 137 RBC, 111, CP–6, CP–8 in urine sediment, 155, CP–22 WBC, 114 Parathyroid gland hyperparathyroidism, 231–232 hypoparathyroidism, 235–236 Parathyroid hormone (PTH), 231–232 Paregoric, 592 Parenteral nutrition, 422–426 administration, 424 formulas and calculations, 424, 425, 426 partial parenteral nutrition (PPN), 422–423, 426 patient and catheter care, 424 total parenteral nutrition (TPN), 422–423, 425 Park worm, 142 Partial parenteral nutrition (PPN), 422–423, 426 Parturition, 26 Parulis (gumboil), 511 Parvosol, 629
Parvovirus canine, 42–43, 44 feline, 47–48, 51 Passive range of motion (PROM), 561 Pasteurella spp., 131 Patellar luxation, 36, 266–267, 541 Patellar reflex, 35 Patient care, 329–377 blood transfusions, 367–374 administration protocol, 373 blood collection, 369–370 blood products, 371–372 blood types, 368 transfusion reactions, 374 drug administration, 348–359 chemotherapy, 352–356 administration, 352–353 client education, 356 monitoring response, 356 toxicity, 353–355 injections, 348 insulin, 357–359 administration, 357 monitoring for hypoglycemia, 359 monitoring response, 358 intravenous catheter placement, 349–351 arterial, 350–351 intraosseous, 350–351 jugular, 349–350 monitoring and maintenance, 351 peripheral, 349–350 fluid therapy, 359–367 colloids, 363 crystalloids, 363, 364 drip rate, calculating, 365 fluid additives, 365 hydration assessment, 360 monitoring, 366–367 requirements, calculating fluid, 361 routes of administration, 362 oxygen therapy, 375–377 patient monitoring, 332–347 blood gas analysis, 335–337 acid-base disturbances, 337 interpretation, 337 blood pressure central venous pressure, 334–335
procedure, 332–333 results, 333 electrocardiogram (ECG) heart rate calculation, 342 interpretation, 340 leads, 339–340 normal canine, 341 problems and artifacts, 345 procedure, 338–339 rhythm abnormalities, 343, 344 heat administration, 346 recumbent patient care, 347 PCR (polymerase chain reaction), 121 PCV (packed cell volume), 105, 367 Pedal reflex, 465 Pediatric patients feeding guidelines, 59 orphaned puppies and kittens, care of, 27 physical examination, 23–26 abdomen, 25 general appearance, 23 head, 24 limbs, 25 perineum and genitals, 25 thorax, 24 PEG (percutaneous endoscopic gastrotomy) tube placement, 418–419 Pelger-Huët anomaly, 113 Pelvis evaluation of, 36 radiographic positioning, 179 PEMF (pulsed electromagnetic field therapy), 565–566 Penicillin, 577 Penis, physical examination, 22 Pentobarbital, 607–608 Pentothal. See Thiopental sodium Pepcid. See Famotidine Pepto-Bismol. See Bismuth subsalicylate Percoten acetate. See Desoxycorticosterone acetate Percoten pivalate. See Desoxycorticosterone pivalate Percutaneous endoscopic gastrotomy (PEG) tube placement, 418–419 Periactin. See Cyproheptadine Perianal adenoma, cytology, 94 Perineal region, physical examination, 22 Perineum, physical examination, 25 INDEX
681
Periodontal disease, 499, 507, 511 Periodontal probe, 501 Periosteal elevators, 501 Peripheral intravenous catheter, 349–350 Peripheral nervous system, 380 Peritoneal lavage, diagnostic, 429 Peritoneography, 183 Peritonitis, 249–251 Permethrin, 324 Pétrissage, 560 Petrolatum, white, 596 Petromalt. See Petrolatum, white PH blood, 335–336 urine, 150 Phacofragmentation, 537 Phalanges, radiographic positioning, 178 Pharmacology, 567–624. See also specific drugs anesthetic drugs, 477–496 inhalant, 494–496 injectable induction, 488–494 preanesthetics, 477–487 anti-infective drugs, 575–577 anti-inflammatory drugs, 602–605 antifungal drugs, 574 antiparasitic drugs, 578–580 calculations, 570 cancer/chemotherapy drugs, 581–584 cardiovascular drugs, 585–590 dermatologic drugs, 591 drug cross-reference table, 571–573 emergency drugs, 301, 302–303 gastrointestinal drugs, 592–597 hepatic drugs, 598 metabolic drugs, 599–601 musculoskeletal drugs, 602–605 neurologic drugs, 606–613 ophthalmic drugs, 613–614 otic drugs, 615 pain management drugs, 386–393 renal/urinary drugs, 616–618 reproductive system drugs, 619–620 respiratory drugs, 621–623 topical wound medications, 402 toxicologic drugs, 624 Pharynx, radiographic positioning, 169 Phenergan. See Promethazine
682
INDEX
Phenobarbital, 303, 607–608 Phenothiazines, 478–479, 479, 593 Phenoxybenzamine, 617 Phenylpropanolamine, 616 Phosphate crystals, 153, CP–19 Phosphorus, inorganic, 82 Photon therapy, 565 Phylloconton. See Aminophylline Physical examination, 18–36 abdominal, 22, 33 cardiac, 30–31 general examination, 19–22 abdomen, 22 head and neck, 20 history, 19 perineal, 22 thoracic cavity, 21 trunk and limbs, 21 vital signs, 19 geriatric, 28–29 blood, 29 general appearance, 28 genitals, 29 head, 28 immune system, 29 internal organs, 29 limbs, 29 monitoring fluid therapy, 366 neurological, 34–35 cranial nerves, 35 front limb reflexes, 35 hindlimb reflexes, 35 postural reactions, 34–35 sensory evaluation, 35 spinal reflexes, 34 oral during dental prophylaxis, 504 orthopedic, 36 otoscopic, 33 pediatric, 23–26 abdomen, 25 general appearance, 23 head, 24 limbs, 25 perineum and genitals, 25 thorax, 24 preanesthetic evaluation, 442 preliminary examination, 19
pulmonary, 32 regional lymph node, 34 Physical therapy and rehabilitation aquatic/hydrotherapy, 559 assisted mobility devices, 559 cold therapy, 559 electrical stimulation, neuromuscular, 559 examinations, 558 exercise, therapeutic, 561 heat therapy, 560 massage, 560 measurements, 558 stretching, 561 ultrasound, therapeutic, 561 Physostigmine, 606 Phytotherapy, 562 Pimobendan, 588 Piperazines, 579 Piroxicam, 605 Pitocin. See Oxytocin Pitressin. See Vasopressin Placenta, expulsion of, 26 Placing, 35 Plants, toxic, 325 Plaque charting, 506 composition of, 499 Plaque disclosing solution, 505 Plasma cell tumor, cytology, 95 Plasma-Lyte A, 364 Platelets cell type identification, 87, CP–3 estimate, 106, 116 megathrombocyte, 115, CP–10 morphology, 115, CP–6, CP–7, CP–10 thrombocytopenia, 254–256 Platinol. See Carboplatin PLE (protein-losing enteropathy), 65, 251–252 Pleural effusion, 217–219 Pneumocystography, 194–195 Pneumogastrogram, 184–185 Pneumonia, 217–219 Poikilocytosis, 111, CP–4 Poison Control Center, 305 Polishers, dental, 503 Polishing teeth, 505 Pollakiuria, 148
Pollen, in urine, 155 Polychromasia, 109, CP–6, CP–7 Polydontia, 510 Polyflex. See Ampicillin Polymerase chain reaction (PCR), 121 Polysulfated glycosaminoglycans, 605 Polyuria, 148 Popliteal lymph node, 34 Portal-caval shunt, anesthesia considerations, 448 Positive inotropic agents, 588 Postural reactions, 34–35 Posture, behavior suggesting pain and anxiety, 384 Potassium, 83 Potassium bromide, 607–608 Potassium chloride, 365 Povidone iodine, 401, 629 PPN (partial parenteral nutrition), 422–423, 426 Praziquantel, 579 Prazosin, 590 PRBC (packed RBCs), 371 Preanesthetic drugs, 451, 477–487 Precapsular lymph node, 34 Prednisolone, 602, 615 Prednisolone sodium succinate, 602 Prednisone, 602 Pregnancy, 237–238 abortion, 227–228 dystocia, 230–231 feeding guidelines, 60 labor and parturition, 26 Prekeratocytes, 110, CP–7 Pressure sores, 347 Previcox. See Firocoxib Prilosec. See Omeprazole Pro-Banthine. See Propantheline Pro Heart 6. See Moxidectin Proban. See Organophosphates Procainamide, 586 Procan SR. See Procainamide Prochlorperazine, 593 Procrit. See Erythropoietin Proestrus, cytology, 98 Progestins, 620 Prognathism, 510 Program. See Lufenuron
Progranulocyte, 87 Proin. See Phenylpropanolamine Prolapsed gland of the third eyelid, 290–291 PROM (passive range of motion), 561 Promace. See Acepromazine; Acepromazine maleate Promegakaryoblast, 87 Promegakaryocyte, CP–3 Promethazine, 593 Promyelocyte, 87, CP–3 Pronestyl. See Procainamide Propagest. See Phenylpropanolamine Propantheline, 592 Proparacaine, 614 PropoFlo. See Propofol Propofol, 492–493 Propranolol, 586 Proprioceptive positioning, 35 Proptosis, traumatic, 539 Propulsid. See Cisapride Prorubricyte, 86, CP–3 Prostaglandin F-2α, 620 Prostate gland adenocarcinoma, 278 ultrasonography, 199 Prostigmine. See Neostigmine bromide Protectants, 597 Protein, urine, 150 Protein C activity assay, 117 Protein induced by vitamin K antagonism/absence (PIVKA test), 117 Protein-losing enteropathy (PLE), 65, 251–252 Protein:creatinine ratio, urine, 150 Proteinuria, 150 Proteus spp., 131 Prothrombin time (PT), 102, 117 Proventil. See Albuterol Provera. See Medroxyprogesterone acetate Prozac, Fluoxetine Pseudoephedrines, 325 Pseudomonas spp., 132 PSGAG. See Polysulfated glycosaminoglycans Psyllium, 596 PT (prothrombin time), 102 PTH (parathyroid hormone), 231–232 Puerperal tetany, 230–231 Pulmonary examination, 32
Pulse evaluation of, 19 rate, monitoring fluid therapy, 366 Pulse oximetry, 19 Pulsed electromagnetic field therapy (PEMF), 565–566 Pupillary light reflex, 465 Puppies. See Pediatric patients Pyelonephritis, 292–294 Pyknosis, 113 Pyoderma, 225–226 deep, 225–226 superficial, 225–226 surface, 225–226 Pyometra, 237–238 Pyrantel, 579 Pyrethrins and pyrethroids, 324, 580 Q-T interval, 340 QRS, 340 Quaternary ammonium disinfectant, 629 Quinidine, 586 Rabies disease, 42–43 vaccine, 44, 51 Radenarcon. See Etomidate Radiation therapy brachytherapy, 553 systemic therapy, 553 teletherapy, 553 Radiography, 159–195 alterations of technique, 166 artifacts, 167 contrast studies, 181–195 abdominal, 183 fistulography, 183 gastrointestinal, 184–186 esophagography, 184–185 gastrography, 184–185 lower GI, 185–186 upper GI, 185–186 head dacryocystorhinography, 187 rhinography, 187 sialography, 187 joint (arthrography), 189 INDEX
683
Radiography (continued) media types, 182 patient preparation, 181 spinal discography, 189 epidurography, 188 myelography, 188 urethrography, 190–191 canine, 190 feline, 191 urinary tract, 193–195 cystography, 193–195 excretory urography (EU), 193 intravenous pyelography (IVP), 193 intravenous urography (IVU), 193 vaginal, 192 dental, 512–516 equipment, 512 positioning caudal mandibular view, 515, 515 caudal maxillary view, 516, 516 maxillary view, 516, 516 rostral mandibular view, 514, 514, 515, 515 rostral maxillary view, 514, 514, 515, 515 rostral oblique, 514 radiographic film, 513 technique chart, 512 techniques, 513 digital, 159 equipment, 160 exposure and image factors, 161 exposure evaluation, 164 positioning, 167–181 directional terms, 168 forelimb, 176–178 carpus, 178 elbow, 177 humerus, 176 metacarpus/phalanges, 178 radius/ulna, 178 head, 170–173 nasal cavities and sinuses, 173 skull, 170 temporomandibular joint, 172 tympanic bullae, 172 zygomatic arch, 171 hindlimbs, 180–181
684
INDEX
femur, 180 metatarsals, 181 stifle, 180 tarsus, 181 tibia/fibula, 180 pelvis, 179 positional terms, 168 scapula, 176 shoulder, 176 soft tissue, 169 spine, 174–175 caudal, 175 cervical, 174 lumbar, 175 sacrum, 175 thoracic, 175 thoracolumbar, 175 scale of contrast evaluation, 164–165, 165 technique charts, 161–163 Radioimmunoassay, 121 Radius, radiographic positioning, 178 Rales, 32 Ranitidine, 594 Rapinovet. See Propofol RBC. See Red blood cell RBC cast, 152, CP–18 Rebreathing systems, 452 Reconcile, See Fluoxetine Rectal thermometer, 23 Recumbent patient care, 347 Red blood cell (RBC) arrangement agglutination, 109 Rouleaux formation, 109 in bone marrow evaluation, 85 cast, 152, CP–18 cell type identification, 86, CP–3 color hypochromasia, 109, CP–7 polychromasia, 109, CP–6, CP–7 count, 105 inclusions basophilic stippling, 109, CP–6 distemper, 109, CP–6 Heinz bodies, 109, CP–7 Howell-Jolly bodies, 109, CP–6, CP–10 indices, 107
nucleated (nRBC), 111, CP–6 parasites Babesia spp., 111, CP–8 Cytauxzoon felis, 111, CP–8 Mycoplasma haemocanis, 111 Mycoplasma haemofelis, 111, CP–6 polychromophilic, CP–3 shape acanthocyte (spur cell), 110, CP–7 blister cell (prekeratocyte), 110, CP–7 crenation, 110 dacrocyte, 110 eccentrocyte (hemi-ghost cell), 110 echinocyte (burr cell), 110 keratocyte (bite or helmet cell), 110, CP–7 leptocyte (codocyte, target cell), 110, CP–7 nucleated RBCs, 111 poikilocyte, 111 schistocyte, 111, CP–7 spherocyte, 111, CP–6 stomatocyte (mouth cell), 111 torocyte, 111 size anisocytosis, 110, CP–10 macrocytosis, 109 microcytosis, 109 normal, 108 in urine sediment, 151, CP–17, CP–18 Reflexes. See also specific reflexes anesthesia monitoring, 464–465 front limb, 35 hindlimb, 35 spinal, 34 Reglan. See Metoclopramide Rehabilitation. See Physical therapy and rehabilitation Renal epithelial cells, 154, CP–21 Renal system contrast study, 193 disease anesthesia considerations, 449 nutritional requirements, 65 pyelonephritis, 292–294 renal failure acute (ARF), 294–296 chronic (CRF), 294–296 drugs, 616–618
emergencies, 320 evaluation of geriatric patient, 29 function tests, 103 palpation, 22 toxicity, chemotherapy, 355 ultrasonography, 198 Reproductive system disorders abortion, 227–228 dystocia, 230–231 eclampsia (puerperal tetany), 230–231 mastitis, 235–236 pyometra, 237–238 drugs, 619–620 emergencies, 321 surgery, 542–544 cesarean section, 542–543 orchiectomy, 542–543 ovariohysterectomy, 542–543 overview, 542 postoperative care of neonates and dam, 544 RER (resting energy requirement), 425, 426 Respiratory acidosis, 337 Respiratory alkalosis, 337 Respiratory rate anesthesia monitoring, 463 monitoring fluid therapy, 366 normal values, 19, 32 Respiratory sinus arrhythmias, 343 Respiratory system anesthesia effect on, 459 anesthesia monitoring, 463 disease, 204–220 anesthesia considerations, 450 asthma, bronchitis, and bronchopulmonary disease (feline), 204–205 brachycephalic airway syndrome, 204–205 bronchitis (canine), 205–207 pleural effusion, 217–219 pneumonia, 217–219 rhinitis/sinusitis, 219–220 tracheal collapse, 219–220 drugs, 621–623 emergency, 322 emergency survey, 306 medical procedures coupage, 432–433
metered-dose inhalers (MDIs), 432–433 nebulization, 432–433 thoracocentesis, 430–431 thoracostomy tube placement, 430–431 postanesthetic monitoring, 468 Resting energy requirement (RER), 425, 426 Restrictive feline cardiomyopathy, 210–211 Resuscitation cardiopulmonary cerebrovascular (CPCR), 308–309 neonatal post-cesarean, 317 Reticulocyte, 86 count, 106, 107 types, 106, CP–7 Revolution. See Selamectin Rheumatoid factor, 122 Rhinitis, 219–220 Rhinography, 187 Rhipicephalus sanguineus, 146, 256, CP–14 Rhonchi, 32 Rhythms, heart, 31 Rickettsia, 132, 258 Rimadyl. See Carprofen Ring block, 473 Robamox-V. See Amoxicillin Robaxin. See Methocarbamol Robert Jones bandage, 406, 406 Robinul-V. See Glycopyrrolate Rocaltrol. See Calcitriol Roccal-D. See Quaternary ammonium disinfectant Rocky Mountain spotted fever, 258–259 Rodenticides, 325 Roferon. See Interferon Rompun. See Xylazine Root planing, 505, 508 Rouleaux formation, 109 Round cell tumor criteria of malignancy, 92 cytology, 95 Roundworm, 143 Rubriblast, 86, CP–3 Rubricyte, 86, CP–3, CP–6 S-adenosylmethionine (SAMe), 598, 605 S-T interval, 340 S-T segment depression, 343 S-T segment elevation, 343, 344
Salicylic acid, 591 Salivary glands adenocarcinoma, 278 contrast study, 187 physical examination, 20 Salmon poisoning, 258–259 Salmon poisoning fluke, 142 Salmonella, 132 Sandimmune. See Cyclosporine SAP (alkaline phosphatase), 77 Sarcoma chondrosarcoma, 280–281 cytology, 94 fibrosarcoma, 281 hemangiosarcoma, 281–282 lymphosarcoma/lymphoma, 282–283 osteosarcoma, 283 vaccine-induced, 283 Sarcoptes scabiei canis, 146, CP–14 Scalding, urine and fecal, 347 Scale of contrast evaluation, 164–165 Scaler hand-held, 501 mechanical, 503 Scapula, radiographic positioning, 176 Schirmer tear test, 430–431 Schistocyte (helmet cells), 111, CP–7 Sciatic response, 35 Scintigraphy, 196 Scraping, 88 Scrotum physical examination, 22 ultrasonography, 199 Sealant, dental, 506 Sebaceous gland tumor, cytology of, 94 Sectrol. See Pyrethrins and pyrethroids Selamectin, 580 Selegiline-l-deprenyl, 599 Self-trauma, preventing, 550 Sensorcaine. See Bupivacaine Sentinel. See Milbemycin oxime Septic shock, 310–311 Serology tests, 120–122 Serotonin antagonist, 593 Sevin. See Carbamates Sevoflo. See Sevoflurane Sevoflurane, 496 INDEX
685
SGOT (aspartate aminotransferase), 78 SGPT (alanine aminotransferase), 76 Sharpening stones, 502–503 Sheather’s solution, 137 Shock cardiogenic, 310–311 hypovolemic, 310–311 septic, 310–311 Shoulder, radiographic positioning, 176 Sialography, 187 Sibul. See Etomidate Sighthounds, anesthesia considerations for, 450 Silver sulfadiazine, 402 Silymarin, 598 Simple stain, 129 Sinus rhythm, 343 Sinuses chondrosarcoma, 281 radiographic positioning, 173 Sinusitis, 219–220 Skeletal system anatomy, 7 musculoskeletal disorders, 261–267 musculoskeletal drugs, 602–605 Skin abscess, superficial, 532 laceration, superficial, 532 mass removal, 533 monitoring fluid therapy, 366 physical examination, 23, 28 squamous cell carcinoma, 280 turgor, 366 Skinfold dermatitis, 225–226 Skull anatomy, 500 physical examination, 24 radiographic positioning, 170 Slow-Fe. See Ferrous sulfate Small intestine, palpation of, 22 Smear blood, 74, 90, 138 bone marrow, 84 cytology, 90 fecal for parasitology, 134–135 Snakebite envenomation, 325 Sodium, 83 Sodium bicarbonate, 365, 616
686
INDEX
Sodium chloride fecal flotation solution, 137 fluid therapy, 364 wound cleaning solution, 401 Sodium influx inhibitors, 586 Sodium nitrate, 137 Soft tissue radiographic positioning, 169 sarcoma, 94 Solu-Cortef. See Hydrocortisone sodium succinate Solu-Delta-Cortef. See Prednisolone sodium succinate Sotalol, 586 Spay, 542–543 Specific gravity, urine (USG), 148 Sperm, in urine, 155 Spherocyte, 111, CP–6 Spider bite envenomation, 325 Spinal reflexes, evaluation, 34 Spine contrast studies discography, 189 epidurography, 188 myelography, 188 radiographic positioning, 174–175 caudal, 175 cervical, 174 lumbar, 175 sacrum, 175 thoracic, 175 thoracolumbar, 175 Spirocerca lupi, 142 Spirochaetes, 96, 132, CP–5 Spironolactone, 589 Splash block, 474 Spleen hemangiosarcoma, 282 ultrasonography, 198 Spondylomyelopathy, caudal cervical, 272–273 Spur cell, 110, CP–7 Squamous cell carcinoma cytology, 94 digit, 279 ear, 279 gingiva, 279 oral, 512 skin, 280
Squamous epithelial cells, 154, CP–21 Square knot, 549 Squash preparation, 90 Stains acid-fast, 124, 128 Diff-Quik, 127 differential, 127–128 Giemsa, 127 Gram, 124, 128 lactophenol cotton blue, 128 negative, 129 ophthalmic, 430–431, 614 problems, 130 simple, 129 Wright’s, modified, 127 Ziehl/Neelson, 128 Ziehl/Neelson with brilliant green, 128 Ziehl/Neelson with methylene blue, 128 Stanozolol, 617 Staphylococcus aureus/intermedius, 132 Starch granules, in urine, 155, CP–22 Starfish preparation, 90 Stenosis, 30 Sternotomy, median, 545–546 Stertor, 32 Stethoscope. See Auscultation Stifle evaluation of, 36 radiographic positioning, 180 Stomach tube, 428 Stomatitis, 511 Stomatocytes (mouth cells), 111 Stool softener, 597 Streptococcus spp., 132 Stress leukogram, 114 Stretching, 561 Stridor, 32 Strongid-T. See Pyrantel Struvite crystals, 66, 153 Subcutaneous fluid administration, 362 Subcutaneous injection, 348 Sublimaze. See Fentanyl Submandibular lymph node, 34 Sucralfate, 594 Sugar solution, 137 Sulfonamide crystals, 153, CP–20 Sulfonamides, 577
Sulfur, 591 SUN (blood urea nitrogen), 79 Superchar. See Charcoal, activated Superficial bacterial folliculitis, 225–226 Superficial cells, in vaginal cytology, 97 Superficial intermediate cells, in vaginal cytology, 97 Supernumerary teeth, 508, 510 Surgeon’s knot, 549 Surgery, 521–554 abdominal, 525–529 anal sacculectomy, 526–527 colotomy, 526–527 complications, 525 enterotomy, 528 gastric dilatation-volvulus (GDV), 528 gastrotomy, 528 hepatectomy, partial, 529 hernia, 526–527 intestinal resection and anastomosis, 529 overview, 525–526 aural, 530–531 hematoma, 530–531 lateral ear canal resection, 530–531 overview, 530 cryosurgery, 554 endoscopic, 551 instrument packs, 523 integumentary, 531–533 abscess, superficial, 532 laceration, superficial, 532 mass removal, 533 onychectomy, 533 overview, 531 knot typing, 549 laser, 552 neurology disc fenestration, 535 dorsal laminectomy, 535 hemilaminectomy, 535 overview, 534 ophthalmic, 536–539 cataracts, 537 conjunctival flap, 538 ectropion, 537 entropion, 537 enucleation, 538 glaucoma, 538
nictitating membrane flap replacement, 538 overview, 536 prolapse of the gland of the third eyelid, 539 proptosis, traumatic, 539 orthopedic, 539–541 cranial cruciate ligament rupture, 540 femoral head ostectomy (FHO), 540 fracture repair, 540 patellar luxation, 541 preparation, complications, and follow-up, 539 total hip replacement, 541 triple pelvic osteotomy (TPO), 541 pain levels, 383 postoperative care protocol, 550 preoperative protocol, 524 reproductive tract, 542–544 cesarean section, 542–543 orchiectomy, 542–543 ovariohysterectomy, 542–543 overview, 542 postoperative care of neonates and dam, 544 self-trauma, preventing, 550 suture patterns, 548–549 thoracic, 544–546 diaphragmatic hernia, 545–546 laryngeal paralysis, 545–546 overview, 544 sternotomy, median, 545–546 thoracotomy, intercostal, 546 tracheal collapse, 546 urogenital tract, 547–548 cystotomy, 547 overview, 547 urethrostomy perineal, 547 prescrotal, 548 scrotal, 548 Surital. See Thiamylal sodium Suture patterns, 548–549 Swab, for cytology, 88 Symmetrel. See Amantadine Syntocinon. See Oxytocin Syrup of ipecac, 595 T3 suppression test, 102 T wave, 340 Tachycardia, 460
Tachypnea, 463 Taenia spp., 139, CP–12 T. pisiformis, 142 T. taeniaeformis, 142 Tagamet. See Cimetidine Tapazole. See Methimazole Tapeworm, 140, 141, 142 Tapotement, 560 Target cells, 110, CP–7 Tarsus, radiographic positioning, 181 TBT (toenail bleeding time), 116 TCM (traditional Chinese medicine), 562 Technicare, 628 Telephone emergency assessment, 304–305 Teletherapy, 553 Telmin. See Mebendazole Temperament, assessment of, 23 Temperature, body anesthesia monitoring, 465–466 evaluation of, 19, 23 heat support, 346 hypothermia, 346 monitoring fluid therapy, 367 pediatric patients, 27 postanesthetic monitoring, 469 Temperature therapy, 554 cold therapy (cryotherapy), 559 heat therapy (hyperthermia), 560 Temperature, conversion of values, 627 Temporomandibular joint, radiographic positioning, 172 Tenormin. See Atenolol Tensilon. See Edrophonium chloride Tepoxalin, 391, 605 Terbutaline, 622 Terramycin. See Oxytetracycline Testicle, ultrasonography of, 199 Testosterone, 619 Tetanus, 259–261 Tetracaine, 615 Tetracycline, 511, 577 Tetrahydropyrimidines, 579 Theobromine, 325 Theophylline, 622 Thermoregulation anesthesia monitoring, 465–466 postanesthetic monitoring, 469 INDEX
687
Thiabendazole, 615 Thiamylal sodium, 489 Thioglycollate broth, 125 Thiopental sodium, 489 Third eyelid, prolapsed gland of, 290–291, 539 Thoracic cavity, physical examination of, 21, 24 Thoracocentesis, 430–431 Thoracostomy tube placement, 430–431 Thoracotomy, intercostal, 546 Thorax physical examination, 21, 24 radiographic positioning, 169 surgery, 544–546 diaphragmatic hernia, 545–546 laryngeal paralysis, 545–546 overview, 544 sternotomy, median, 545–546 thoracotomy, intercostal, 546 tracheal collapse, 546 ultrasonography, 200 Thorazine. See Chlorpromazine Thrombin time (TT), 118 Thrombocytopenia, 254–256 Thyroid gland adenocarcinoma, 278 hyperthyroidism, 233–234 hypothyroidism, 235–236 Thyroid hormone basal serum, 102 free, 102 Thyroid-releasing hormone (TRH) stimulating test, 103 Thyroid-stimulating hormone (TSH) concentration, 103 Tibia, radiographic positioning, 180 Tibial compression test, 36 Tibial plateau leveling osteotomy (TPLO), 540 Tibial tuberosity advancement (TTA), 540 Tibial wedge osteotomy (TWO), 540 Tick, 145–146, 256, CP–13, CP–14 Tigan-canine. See Trimethobenzamide Timolol maleate, 303 Titer, vaccine, 37 TLI (trypsin-like immunoreactivity), 103 Tobramycin, 575 Toenail bleeding time (TBT), 116
688
INDEX
Toenails physical examination, 28 trimming, 54 Tonometry, 430–431 Tooth anatomical disorders, 510 anatomy, 500 brushing, 504 cleaning procedure, 504–506 dental charting, 506–508, 509 evaluation of, 505 extraction, 505, 517–520 charting, 508 general procedures, 517 nerve blocks for, 518–520 fluoride treatment, 506 fractures, 508, 511 home dental care, 52 lesions, 507, 508, 511 malpositioned, 507 missing, 507 mobility, 507 polishing, 505 radiology, 512–516 retained deciduous, 510 sealant application, 506 supernumerary, 508, 510 Torbugesic. See Butorphanol; Butorphanol tartrate Torbutrol. See Butorphanol tartrate Torocytes, 111 Total hip replacement, 541 Total parenteral nutrition (TPN), 422–423, 425 Total protein, 83, 105, 367 Tourniquets, 307 Toxascaris leonina, 139, 143, CP–12 Toxiban. See Charcoal, activated Toxicology chemotherapy, 353–355 drugs, 324, 624 emergencies, 323–325 insecticides, 324 plants, 325 rodenticides, 325 Toxocara canis, 139, 143, CP–12 Toxocara cati, 139, 143, CP–13 Toxoplasma gondii, 139, 144, 259–261, CP–13 Toxoplasmosis, 259–261
TPLO (tibial plateau leveling osteotomy), 540 TPN (total parenteral nutrition), 422–423, 425 Tracheal collapse, 219–220, 546 Tracheal worm, 141 Tracheobronchitis, infectious, 39–40, 44 Tracheostomy, 377 Traditional Chinese medicine (TCM), 562 Tramadol, 389, 612 Transfusion, blood, 119–120 Transfusion reaction, 374 Transitional cell carcinoma, 280 Transitional epithelial cells, 154, CP–21 Transportation, emergency recommendations, 304–305 Transtracheal catheter, 377 Trauma anesthesia considerations, 450 emergency, 326 Treponeme, 96 TRH (thyroid-releasing hormone) stimulating test, 103 Triage, 306–307 Triamcinolone, 602 Tribissen. See Sulfonamides Triceps reflex, 35 Trichiasis, 287–288 Trichodectes canis, 146, CP–15 Trichomonas sp., 96 Trichuris vulpis, 139, 144, CP–13 Tricyclic antidepressant, 613, 618 Trigeminal nerve, evaluation of, 35 Triglycerides, 82 Trilostane, 599 Trimethobenzamide, 593 Trimtabs. See Triamcinolone Triple antibiotic ointment, 402 Triple pelvic osteotomy (TPO), 541 Triple phosphate crystals, 153, CP–21 Tris-EDTA, 401 Tritrichomonas foetus, 136 Trochlear nerve, evaluation of, 35 Trunk, physical examination of, 21 Trypsin-like immunoreactivity (TLI), 103 TSH (thyroid-stimulating hormone) concentration, 103 TT (thrombin time), 118 TTA (tibial tuberosity advancement), 540
Tumors, oral, 511–512 Tussigon. See Hydrocodone TWO (tibial wedge osteotomy), 540 Tylosin, 592 Tympanic bullae, radiographic positioning, 172 Tyrosine crystals, 154, CP–21 Ulcer antiulcer agents, 594 corneal, 288–290 eosinophilic, 511 oral, 511 Ulna, radiographic positioning, 178 Ultane. See Sevoflurane Ultram. See Tramadol Ultrasonic cleaning, 505 Ultrasonography, 197–200 basic scanning technique, 198 Doppler, 197, 332–333 overview, 197 sites for scanning, 198–200 therapeutic, 561 Uncinaria stenocephala, 139, 144, CP–13 University of Melbourne Pain Scale (UMPS), 382 Upper gastrointestinal study, 185–186 Urate crystals, 153, CP–19 Urecholine. See Bethanechol chloride Urethrostomy prescrotal, 548 scrotal, 548 Urethra contrast studies, 190–191 transitional cell carcinoma, 280 Urethral sphincter, evaluation of geriatric patient, 29 Urethrocystitis, 296–298 Urethrostomy, perineal, 547 Uric acid crystals, 154, CP–21 Urinalysis, 147–155 artifacts, 155 chemistry strip examination, 149–150 bilirubin, 149 blood, 149 glucose, 149 ketones, 149 pH, 150 preparation for, 149
protein, 150 protein:creatinine ratio, 150 gross examination color, 148 foam, 148 odor, 148 specific gravity, 148 transparency, 148 volume, 148 sample collection, 147 catheterization, 435–436 collection cups, 435 cystocentesis, 434 litter pan, 435 manual expression, 434 void, 434 handling, storage, and transport, 147 sediment examination, 150–155 artifacts, 154, CP–22 bacteria, 151, CP–15, CP–16 casts, 152, CP–17–CP–19 crystals, 153–154, CP–19–CP–21 epithelial cells, 154, CP–21, CP–22 overview, 150 parasites, 155, CP–22 red blood cells (RBCs), 151, CP–17, CP–18 reporting of bacteria and sperm, 151 white blood cells (WBCs), 152, CP–16, CP–17 Urinary bladder contrast study, 193–195 cystic calculi, 292–294 cystitis, 296–298 cystotomy, 547 palpation, 22 transitional cell carcinoma, 280 ultrasonography, 199 Urinary system anatomy, 11, 12 contrast studies, 193–195 cystography, 193–195 excretory urography (EU), 193 intravenous pyelography (IVP), 193 intravenous urography (IVU), 193 disorders cystic calculi, 292–294
feline lower urinary tract disease (FLUTD), 292–294 pyelonephritis, 292–294 renal failure acute (ARF), 294–296 chronic (CRF), 294–296 urinary tract infection, 296–298 urinary tract obstruction, 296–298, 451 drugs, 616–618 emergencies, 320 postanesthetic monitoring, 469 renal/urinary drugs, 616–618 surgery, 547–548 cystotomy, 547 overview, 547 urethrostomy perineal, 547 prescrotal, 548 scrotal, 548 toxicity, chemotherapy, 355 transitional cell carcinoma, 280 ultrasonography, 198, 199 Urinary tract infection (UTI), 296–298 upper (pyelonephritis), 292–294 Urinary tract obstruction, 296–298, 451 Urination, stimulation in neonates, 27 Urine microbiology sample collection, 123 microbiology specimen storage, 124 urinalysis, 147–155 Urine cortisol:creatinine ratio, 103 Urine protein:creatinine ratio, 103 Urine specific gravity (USG), 148 Urocystoliths, 292–294 Urogenital system. See Genital system; Urinary system Urolithiasis ammonium urate, 66 calcium oxalate, 66 cystine, 66 nutritional requirements, 66 struvite, 66 USG (urine specific gravity), 148 Uterine inertia, 230 Uterus pyometra, 237–238 ultrasonography, 199 INDEX
689
Vaccination adverse reactions, 37 canine transmissible diseases, 38–43 vaccination protocol, 44 feline transmissible diseases, 44–50 vaccination protocol, 51 guidelines, 37 titers, 37 Vaccine-induced sarcoma, 283 Vacuolation, WBC, 113, CP–11 Vaginal cytology cell classification, 97 estrus cycle staging, 98 Vaginography, 192 Vaginourethrography, retrograde, 192 Vagus nerve, evaluation of, 35 Valbazen. See Albendazole Valium. See Diazepam Valrelease. See Diazepam Valvular heart disease, 211–213 Vasodilators, 590 Vasopressin, 303, 601 Vasopressin response test, 99 Vasotec. See Enalapril Vatronol. See Ephedrine Vazepam. See Diazepam Velban. See Vinblastine Velpeau sling, 410, 410 Ventilation administration, 475–477 manual, 475–476 mechanical, 476–477 intermittent positive-pressure ventilation (IPPV), 458 Ventolin. See Albuterol Ventricular fibrillation, 343 Ventricular premature contraction (VPC), 31, 343, 344, 462 Versed. See Midazolam Vestibular disease of older dogs, 272–273 Vestibulocochlear nerve, evaluation of, 35 Vetaket. See Ketamine Vetalar. See Ketamine Vetalog. See Triamcinolone Vetmedin. See Pimobendan
690
INDEX
Vetoryl. See Trilostane Vibramycin. See Doxycycline Vinblastine, 584 Vinca alkaloid, 584 Vincasar. See Vincristine Vincristine, 354, 584 Viokase. See Pancreatic enzyme replacement Vital signs physical examination, 19 preanesthetic evaluation, 442 Vitamin B complex, 365 Vitamin D3, 325 Vocalization behavior, suggesting pain and anxiety, 384 Vomiting, 251–252 inducing at-home, 305 nutritional requirements, 66 Von Willebrand’s disease, 254–256 Von Willebrand’s factor (vWF) assay, 118 VPC (ventricular premature contraction), 343, 344, 462 Vulva, physical examination, 22 Warfarin, 587 Water-deprivation test, 104 Waxy cast, 152, CP–19 WBC. See White blood cell WBC cast, 152, CP–18 Weight body condition score, 61–62, 61–62 monitoring fluid therapy, 366 obesity management, 67 pediatric patient, 23 Weights, 625 Western blot, 122 Wheelbarrowing, 35 Wheezes, 32 Whelping, 26 Whipworm, 144 White blood cell (WBC) alterations inclusions, 113, CP–10, CP11 morphology, 113–114, CP–10, CP11 parasites, 114 cast, 152, CP–18 count differential, 106, 108
total, 105 left shift, 114 types bands, 112, CP–8 basophils, 112, CP–9, CP–10 eosinophils, 112, CP–9, CP–10 lymphocytes, 112, CP–8, CP–10 monocytes, 112, CP–9 neutrophils, 112, CP–6, CP–8, CP–10 in urine sediment, 152, CP–16, CP–17 Whole blood, stored, 371 Winstrol V. See Stanozolol Withdrawal reflex, 35 Wobbler syndrome, 272–273 Wounds bandaging, 403–411 90–90 flexion, 410, 410 adherent, 403 basic bandage, 405, 405 care of, 404 casts, 408 chest/abdominal, 407, 407 distal limb splint, 408, 408 Ehmer sling, 409, 409 hobbles, 411, 411 layers, 403–404 nonadherent, 403–404 Robert Jones, 406, 406 Velpeau sling, 410, 410 care of, 399–400 classification, 397 cleaning solutions, 401 healing process factors affecting, 398 phases, 396 medications, topical, 402 microbiology sample collection, 123 Wright’s stain, modified, 127 Wry mouth, 510 X-ray. See Radiography Xylazine, 389, 482–483 Xylocaine. See Lidocaine Yeast fecal cytology, 96, CP–5 in urine, 155, CP–22
Yobine. See Yohimbine Yohimbine, 623 Zantac. See Ranitidine Zeniquin. See Marbofloxacin Ziehl/Neelson stain, 128 with brilliant green, 128 with methylene blue, 128 Zinc sulfate, 137 Zinecard. See Dexrazoxane Zofran. See Ondansetron Zolazepam, 491 Zoonosis canine transmissible disease
leptospirosis, 41–42 Lyme disease, 41–42 rabies, 42–43 ectoparasites Cheyletiella, 145, CP–13 Sarcoptes scabiei canis, 146, CP–14 endoparasites Ancylostoma caninum, 139, 139, CP–11 Ancylostoma tabaeforme, 140, CP–11 Cryptosporidium, 140, CP–12 Dipylidium caninum, 139, 140, CP–12 Dirofilaria immitis, 140, CP–12 Echinococcus granulosus, 141, CP–12 Giardia, 141, CP–12
Isospora spp., 139, 141, CP–12 Nanophyetus salminocola, 139, 142 Toxascaris leonina, 139, 143, CP–12 Toxocara canis, 139, 143, CP–12 Toxocara cati, 139, 143, CP–13 Toxoplasma gondii, 139, 144, CP–13 Uncinaria stenocephala, 139, 144, CP–13 infectious diseases brucellosis, 256–258 Rocky Mountain spotted fever, 258–259 toxoplasmosis, 259–261 Zubrin. See Tepoxalin Zygomatic arch, radiographic positioning, 171 Zyloprim. See Allopurinol
INDEX
691
