Veterinary ECC Small Talk

Improving Patient Care (QI) Dec 01, 2017

In this episode I am joined by my friends and colleagues, Stacey Davidson and Ru Clements of VetLed, to discuss the role of Quality Improvement (QI) in improving patient care.

We discuss what QI is and why you should be engaged with it. We also talk about the role of human factors and workplace culture in QI.

A description of many of the terms used in the episode can be found at the website here.

Apologies for the sometimes crackly sound quality on this episode.

VetLed Facebook page

Veterinary Human Factors private Facebook group started by VetLed

Sepsis and the Glycocalyx Sep 15, 2017

This episode is focused on sepsis. I also talk about the relevance of the glycocalyx. And emphasise how much extrapolation there is from human medicine to veterinary practice.

Topics covered include:

Long-standing sepsis definitions and recently suggested updates
History of sepsis management in human medicine; including early-goal directed therapy and Surviving Sepsis Campaign
Recent large scale human trials: ProCESS (USA), ARISE (Australasia), ProMISe (UK)
Key steps for managing the septic veterinary patient
The glycocalyx: what it is, what it does, why it is relevant, implications for practice

Click Here For Your FREE Copy of a Transcript of This Episode

Click Here for Show Notes To find out more about my Small Animal Emergency Medicine App (iOS, Android) click here.

Feline Hypertension Jun 15, 2017

Although feline hypertension may be a rare reason for emergency presentation, it is a condition that most small animal practitioners will have encountered both in routine practice and in critical care patients.

This episode is based on the 2017 ISFM* Consensus Guidelines on the Diagnosis and Management of Hypertension in Cats which were recently published in the Journal of Feline Medicine and Surgery. The episode discusses the following points: [*International Society of Feline Medicine]

Evidence base behind the Guidelines
Secondary versus primary hypertension
Target organ damage
Monitoring and Underdiagnosis
Which cats to monitor blood pressure in
Importance of ensuring blood pressure is measured as accurately as possible with a reproducible technique
White coat hypertension
Defining normal blood pressure
Criteria for therapeutic intervention and appropriate therapeutic targets
What treatment to use
Emergency treatment

The episode is based on:

ISFM Consensus Guidelines on the Diagnosis and Management of Hypertension in Cats. J Fel Med Surg 2017. 19:288–303.

Click Here For Your FREE Copy of a Transcript of This Episode

For show notes for this episode, click here.

Hepatic Encephalopathy in Dogs and Cats Apr 03, 2017

Hepatic encephalopathy is a relatively common condition in dogs and to a lesser extent in cats. It is a disorder that all clinical veterinary staff, and especially those working in Emergency and Critical Care, should be aware of.

This episode is based on a review article and covers the pathogenesis, clinical presentation, diagnosis, and management of hepatic encephalopathy in dogs and cats including comparisons with human medicine.

The episode is based on:

Lidbury JA, Cook AK, Steiner JM. Hepatic encephalopathy in dogs and cats. J Vet Emerg Crit Care 2016. 26 (4):471-487.

Click Here For Your FREE Copy of a Transcript of This Episode

For episode show notes click here.

For my Small Animal Emergency Medicine App on iOS click here. Android version coming out in early-mid 2017.

Activated Charcoal Dec 16, 2016

Activated charcoal is a widely used therapy, especially in dogs, to facilitate gastrointestinal decontamination following toxin ingestion. Points covered in this episode include:

A reminder about what activated charcoal is and how it is meant to work
Comments about the use of activated charcoal as a therapy contrasting human and veterinary medicine
Contraindications and adverse effects
Timing of administration

Click Here For Your FREE Copy of a Transcript of This Episode

Click Here For SHOW NOTES of This Episode

Click Here For Small Animal Emergency Medicine APP

Physiotherapy in the Critical Veterinary Inpatient Sep 29, 2016

On this episode of the podcast I am joined by Kim Sheader (MSCP HCPC ACPAT Cat A, Chair ACPAT, RAMP), Chartered Veterinary and Human Physiotherapist, to discuss physiotherapy for the critical inpatient. Kim is a highly qualified and experienced physiotherapist and currently works with The Ralph Mobile Physiotherapy & Rehabilitation service.

I start by finding out about Kim’s background, training and experience in human and more recently veterinary physiotherapy. We then go on to discuss:

Physiotherapy for the critical patient with prolonged recumbency
Physiotherapy for the dog with moderate-to-severe tetanus
Respiratory physiotherapy, a subject about which Kim is especially passionate

To contact Kim please email her at kim@theralph.vet or message her via The Ralph MPRS website www.theralphphysio.vet.

Dog and Cat Amputees: 'Tripods' Aug 04, 2016

On this episode of the podcast I am joined by Rene Agredano and Jim Nelson of Tripawds, “the world's largest support community for animal amputees”, to discuss how we as veterinary staff can be better prepared to help clients with dogs and cats that are either facing or have had a limb amputation.

After some background discussion of the Tripawds resource, we discuss:

Ethical and moral considerations carers may have around amputation
Steps carers can take to prepare for their amputee dog or cat returning home for the first time
Client concerns about when their pet will be normal again, pain management, and the surgical incision

The following links were mentioned in the episode:

Tripawds - Help For Three Legged Dogs And Cats

The Tripawds charitable foundation

Tripawds on YouTube

Tripawds Downloads

The PBS Show that Rene mentions, “Why we love dogs and cats”

The Tripawds blog by an ECC vet: Hank the Tank (backstory for Hank the Tank)

A Journal of Veterinary Emergency and Critical Care Papers Episode Jun 23, 2016

Anaemia in critically ill cats; severe anaemia in blocked tomcats; spinal shock in dogs; haemorrhagic GI disease in veterinary ICUs. In this episode of the podcast I discuss a few papers from the latest issue of the Journal of Veterinary Emergency and Critical Care (JVECC) that especially caught my eye, in particular as they relate to primary care practice and not just referral centres.

The four papers in question are:

Balakrishnan A, Drobatz KJ, Reineke EL. Development of anemia, phlebotomy practices, and blood transfusion requirements in 45 critically ill cats (2009–2011). J Vet Emerg Crit Care 2016. 26(3):406-411.
Beer KS, Drobatz KJ. Severe anemia in cats with urethral obstruction: 17 cases (2002–2011). J Vet Emerg Crit Care 2016. 26(3):393-397.
Full AM, Barnes Heller HL, Mercier M. Prevalence, clinical presentation, prognosis, and outcome of 17 dogs with spinal shock and acute thoracolumbar spinal cord disease. J Vet Emerg Crit Care 2016. 26(3): 412–418.
Swann JW, Maunder CL, Roberts E, et al. Prevalence and risk factors for development of hemorrhagic gastro-intestinal disease in veterinary intensive care units in the United Kingdom. J Vet Emerg Crit Care 2016. 26(3): 419–427.

Remember as always that what I don’t tend to do in these podcasts is to provide an in-depth evidence-based appraisal of the papers I mention. So I continue to encourage you to get in touch for copies of the papers if you do not have access to JVECC and to read and critique the papers yourself. Don’t just take what the abstract says or indeed what I say here at face value!

Click Here For Your FREE Copy of a Transcript of This Episode For SHOW NOTES for this episode click here. And be sure to check out the Veterinary Small Animal Emergency Medicine App.

Antimicrobial Stewardship in Companion Animal Practice Apr 22, 2016

Antimicrobial resistance is said to be one of the greatest challenges currently facing small animal veterinary medicine. How can we become part of the solution rather than part of the problem?

In this episode of the podcast I start by providing a brief refresher of bacteriology and antibacterials before going on to discuss antimicrobial stewardship in an episode that is derived from this review article:

Guardabassi L, Prescott JF. Antimicrobial Stewardship in Small Animal Veterinary Practice: From Theory to Practice. Vet Clin N Am – Sm Anim Prac 2015. 45(2):361–376.

Areas covered include:

Defining the problem
What is antimicrobial stewardship?
Antimicrobial stewardship strategies
Developing and implementing guidelines
General (generic) guidelines for rational antibiotic use
Role of the microbiology laboratory

Click here for SHOW NOTES for this episode.

Click Here For Your FREE Copy of a Transcript of This Episode

And be sure to check out the Veterinary Small Animal Emergency Medicine App.

Emotional Well-being in Veterinary Practice Mar 06, 2016

In this episode of the podcast I am joined by Enid Traisman M.S.W., CT, CFS to discuss issues around emotional well-being in veterinary practice.

Enid is the Director of Pet Loss Support Services at Dove Lewis, a non-profit emergency animal hospital in Portland, Oregon in the USA.

Topics that we discuss in this episode include the following; where appropriate we talk about prevention, recognition and coping strategies:

Pet loss grief
When veterinary staff have to deal with loss of their own companion animals
Compassion fatigue and burnout
Workplace stress and emotional challenges of the veterinary profession

During the episode Enid mentions creating a memorial table at work when a staff member loses a pet. You can find Enid’s overview of the pet memorial table concept and a list of other REALLY USEFUL RESOURCES, both provided by Enid and some others, HERE.

Find contact details for Enid here on the Dove Lewis website.

And don’t forget to check out the Small Animal Emergency Medicine app for iOS devices here. Android version to follow soon!

What's Magnesium Got To Do With It? Feb 05, 2016

In this episode of the podcast I take a look at magnesium and its role in clinical practice, something which many people may not be very familiar with. The episode is based on the following article:

Humphrey S, Kirby R, Rudloff E. Magnesium physiology and clinical therapy in veterinary critical care. J Vet Emerg Crit Care 2015.

Areas covered include:
Background theory
Measuring magnesium
Magnesium disorders
Treatment

Click Here For Your FREE Copy of a Transcript of This Episode

For SHOW NOTES for this episode see Here.

And don't forget to check out my Small Animal Emergency Medicine App - currently for iPhone and iPad; Android version out soon!

Journal Papers Episode: JVIM 2015 Dec 24, 2015

HORMONAL SEIZURES, IV POTASSIUM SUPPLEMENTATION, ICU SOUND LEVELS, BRAIN TUMOURS AND IMHA!

In this episode of the podcast I discuss some of the papers that were published in the Journal of Veterinary Internal Medicine during 2015. Remember that this journal is now freely available via open online access.

The papers I mention are as follows:

Van Meervenne SAE, Volk HA, Van Ham ML. Association between Estrus and Onset of Seizures in Dogs with Idiopathic Epilepsy. J Vet Int Med 2015. 29(1):251-253.

Hoehne SN, Hopper K, Epstein SE. Accuracy of Potassium Supplementation of Fluids Administered Intravenously. J Vet Int Med 2015. 29(3):834-839.

Fullagar B, Boysen SR, Toy M, et al. Sound Pressure Levels in 2 Veterinary Intensive Care Units. J Vet Int Med 2015. 29(4):1013-1021.

Hu H, Barker A, Harcourt-Brown T, Jeffery N. Systematic Review of Brain Tumor Treatment in Dogs. J Vet Int Med 2015. 29(6):1456-1463.

Goggs R, Dennis SG, Di Bella A, et al. Predicting Outcome in dogs with Primary Immune-Mediated Hemolytic Anemia: Results of a Multicenter Case Registry. J Vet Int Med 2015. 29(6):1603-1610.

...and don't forget my SMALL ANIMAL EMERGENCY MEDICINE APP FOR IPHONE AND IPAD - Android version in development!

Managing Dog Bite Injuries Dec 04, 2015

**Apologies for the less than optimal sound quality of this episode and the non-stereo recording!**

Dog bite injuries are a relatively common problem to be faced with in small animal practice. In this episode of the podcast I am joined by Nicola Kulendra, a European specialist in small animal surgery, to discuss their management. Some of the points we discuss include:

Adhering to standard ECC principles in terms of initial stabilisation and analgesia
The mechanics of dog bites and the ‘tip of the iceberg’ concept
Exploring bite injuries to uncover their true extent; the role of diagnostic imaging
The importance of wound drainage
Bacterial involvement and the use of antimicrobials
The ‘two hit theory’ in cats with moderate-to-severe dog bite injuries
The ‘big dog, little dog’ phenomenon

iPhone/iPad users see HERE for my Small Animal Emergency Medicine app for iOS; Android version is in development.

[This podcast is closely aligned with the MedEdLIFE Research Collaborative’s Quality Checklist for Podcasts.]

Patient Handovers/Rounds Nov 06, 2015

In this episode I am joined by Liz Hughston and Charlotte Rosenthal, both specialist ECC nurses from the USA, to discuss patient handovers/rounds.

We start with a brief introduction to both my guests and then go on to discuss questions such as:

What is the basic purpose of handover?
Separate rounds for nurses and vets, or combined?
Strategies for doing an efficient and effective handover
Keys bits of information to communicate

This is the first episode in this podcast series to feature guests - please let me know what you think!

Twitter: @VetEmCC

Acute liver failure Oct 02, 2015

Dogs and cats with acute liver failure may present as emergencies and be critically ill. In this episode of the podcast I discuss this condition based on a recent review article from the Journal of Veterinary Emergency and Critical Care*.

(*Weingarten MA, Sande AA. Acute liver failure in dogs and cats. J Vet Emerg Crit Care 2015. 25(4):455-473.)

Topics covered include:

Injury versus failure
Causes
Clinical findings
Diagnosis
Treatment including managing complications
Prognosis

Click Here For Your FREE Copy of a Transcript of This Episode

For SHOW NOTES visit the website HERE.

Management of Traumatic Brain Injury (TBI) Aug 29, 2015

Traumatic brain injury (closed head trauma) is relatively common in dogs and especially cats, often following motor vehicle collision. A rational approach to management is essential to try and maximise the chances of a successful outcome.

In this episode of the podcast I discuss traumatic brain injury focusing on key aspects of management and touching on some potentially contentious issues. Areas covered include:

The need to prioritise potentially life-threatening problems that may be extra-cranial
Primary (already happened) versus secondary (aim to minimise) brain injury
Ensuring adequate oxygenation and ventilation
Ensuring adequate cerebral perfusion
Addressing raised intracranial pressure including hypertonic saline vs. mannitol; furosemide?
The importance of analgesia
Steroids?
Relevance of hyperglycaemia?
Prognostication

Click Here For Your FREE Copy of a Transcript of This Episode

For show notes for this episode go to the website HERE.

Get your FREE one page summary of TBI management

Early Approach to Dyspnoeic Cats, First Do No Harm! Jul 31, 2015

In this episode of the podcast I discuss an approach to the early management of dyspnoeic cats that is predicated on ‘first do no harm’ and thinking risk-benefit at all times. The main take-home messages from the episode are:

Appreciate that dyspnoeic cats can be very vulnerable and easily tipped over the cliff edge.
Even more so than normal, pay acute attention to the risk-benefit assessment at all times.
Understand that each cat is clearly going to be an individual patient with their own set of circumstances and behaviour, but that a hands-off, slow, staged approach is likely to be the least risky and most beneficial in most cases.
Continue to improve your ability and confidence in examining these cases paying attention to trying to anatomically localise the cause of the dyspnoea; this will allow you to make the most sensible decisions in terms of how to help the patient.
Don’t be in a hurry to x-ray dyspnoeic cats until and unless you feel like you have done all you can to make them as stable as possible beforehand.
And, lastly engage more with POCUS, point-of-care ultrasound, if you are not already.

Click Here For Your FREE Copy of a Transcript of This Episode

For SHOW NOTES for this episode click HERE.

Journal papers: PORV in dogs, Lactate in cats, and 'All in a tangle' Jul 09, 2015

In this episode of the podcast I discuss two papers from the Journal of the American Veterinary Medical Association in 2015. The first is on post-operative regurgitation and vomiting (PORV) in dogs and the second is on lactate in cats. To end the podcast I mention a letter-to-the-editor case report from Veterinary Anaesthesia and Analgesia, also in 2015, which describes a complication of oesophagostomy tube placement in a cat with a cuffed endotracheal tube.

For abstracts and references, visit the website HERE.

Click Here For Your FREE Copy of a Transcript of This Episode

A Critical Patient Daily Checklist Jun 26, 2015

Critically ill patients almost by definition have a number of different problems and management considerations. They can be high maintenance requiring intensive care and it is easy to accidentally overlook different aspects of their care; this is especially the case when you are looking after more than one critically ill patient and/or working in an otherwise busy practice environment.

Using some form of checklist on a daily basis is a quick and easy way of being reminded of all the different aspects of the care of critically ill patients and hopefully minimises how often treatment considerations are overlooked and sub-optimal care provided.

In this episode I discuss my version of a daily checklist for critically ill patients including aspects such as monitoring, analgesia, nursing care and non-clinical considerations.

To download a COPY OF THE CHECKLIST for free and a TRANSCRIPT of the episode. visit the website HERE.

You can also get a copy of the checklist by directly going to this link.

Click Here For Your FREE Copy of a Transcript of This Episode

The Shock Index in Veterinary Patients Jun 05, 2015

The shock index is equal to heart rate divided by systolic arterial blood pressure. It has received a fair amount of attention in the human medicine literature being evaluated for example in haemorrhagic hypovolaemic shock, especially post-traumatic, sepsis and obstetric patients, and for correlation for example to length of hospital stay and mortality. There is very little clinical veterinary information on the shock index.

In this episode I discuss what the shock index is, the parameters that are included in the shock index, the potential value of the shock index, some of the human medicine studies, and the following two canine studies:

Porter A, Rozanski E, Sharp C, et al. Evaluation of the shock index in dogs presenting as emergencies. J Vet Emerg Crit Care 2013. 23(5):538–544.

Peterson KL, Hardy BT, Hall K. Assessment of shock index in healthy dogs and dogs in hemorrhagic shock. J Vet Emerg Crit Care 2013. 23(5):545-550.

For show notes for this episode and a full list of all papers that informed or were mentioned in this episode, see HERE.

Click Here For Your FREE Copy of a Transcript of This Episode

Steroids and Shock! May 20, 2015

Whether or not steroids should be used in shock has been an on-going debate for many years. In this episode I discuss some of the literature, in particular relating to the use of steroids in septic shock, and the concept of ‘relative adrenal insufficiency’ – more recently referred to as ‘critical illness-related corticosteroid insufficiency’ (CIRCI).

An episode summary is as follows:

Use of steroids in shock in general is not recommended unless that patient happens to have a steroid-responsive disease as the cause of their shock; this is rare.

‘Low dose’ or ‘physiological’ steroids can be used in patients with septic shock – or other critical illness – that is refractory to fluid resuscitation and exogenous catecholamine use; many veterinary practitioners may not have access to vasopressor/inotropic agents.
A positive response to low dose steroid use suggests the presence of CIRCI
Hydrocortisone is typically suggested; dexamethasone may be less preferable but can still be used

***Much remains to be clarified about this in human and especially veterinary medicine in terms of which patients are the best candidates, when to start steroids, what protocol to use and so on.***

This episode is in part derived from:

Burkitt Creedon JM. Controversies surrounding critical illness-related corticosteroid insufficiency in animals. J Vet Emerg Crit Care 2015. 25(1):107-112.

For SHOW NOTES of this episode including a full list of all papers that informed or were mentioned in this episode, see HERE.

Click Here For Your FREE Copy of a Transcript of This Episode

Canine Haemoabdomen - Part 2 May 08, 2015

This is the second of a two-part mini-series on canine haemoabdomen loosely based around the following review article:

Herold LV, Devey J, Kirby R, Rudloff E. Clinical evaluation and management of hemoperitoneum in dogs. J Vet Emerg Crit Care 2008. 18(1):40-53.

If you have not yet listened to Part 1, please do before listening to this episode!

Points discussed in this episode include:

Improving and maintaining oxygen-carrying capacity
Arresting haemorrhage
Autologous transfusion (cell salvage)
Abdominal counterpressure

For SHOW NOTES of this episode click HERE.

Click Here For Your FREE Copy of a Transcript of This Episode

Canine Haemoabdomen - Part 1 Apr 24, 2015

In a recent Facebook survey 80% of 150 respondents mentioned haemoabdomen, especially due to splenic rupture, as a top cause of collapse in dogs. This is the first of a two-part mini-series on canine haemoabdomen loosely based around the following review article:

Herold LV, Devey J, Kirby R, Rudloff E. Clinical evaluation and management of hemoperitoneum in dogs. J Vet Emerg Crit Care 2008. 18(1):40-53.

Points discussed in this episode include:

Causes of canine haemoabdomen
Canine abdominal haemangiosarcoma
Restoring an effective circulating blood volume
Diagnosing haemoabdomen

Further points to be discussed in the second part include maintaining adequate oxygen-carrying capacity, arresting haemorrhage, possible use of abdominal counterpressure etc.

For SHOW NOTES of this episode click HERE.

Click Here For Your FREE Copy of a Transcript of This Episode

Ketamine Apr 10, 2015

Ketamine is a drug with complex pharmacology and a number of potential clinical effects and uses including a dose-dependent central nervous system continuum from analgesia through to sedation, partial dissociation and complete dissociation. In this episode I discuss this drug based around the following points:

How does ketamine work? What does it do?
Continuum of central nervous system effects
Is ketamine contraindicated with raised intracranial pressure?
Ketamine is sympathomimetic
What about ketamine in cats with HCM
“Ketamine head”
Can ketamine be used as a sole agent?
Is ketamine contraindicated with raised intraocular pressure?
Ketamine in caesarean section
Other bits ‘n’ pieces

For SHOW NOTES of this episode see HERE.

Click Here For Your FREE Copy of a Transcript of This Episode

Feline Asthma: 10 Bits of Jibber Jabber Mar 27, 2015

Dyspnoeic cat with wheezes and an expiratory ‘push’ – the classic asthmatic cat, right?! In this episode I discuss this syndrome according to the following points:

What do we call this syndrome?
Who gets feline asthma?
Pathogenesis
Clinical findings
Diagnosis
Thoracic radiography
Treatment – Acute crisis
Treatment – Sub-acute and Chronic
Alternative or novel therapies?
Cyclosporine

Some papers that informed this episode:

Cooper ES, Syring RS, King LG. Pneumothorax in cats with a clinical diagnosis of feline asthma: 5 cases (1999-2000). J Vet Emerg Crit Care 2003. 13(2):95–101.

Liu DT, Silverstein DC. Feline secondary spontaneous pneumothorax: A retrospective study of 16 cases (2000–2012). J Vet Emerg Crit Care 2014. 24(3):316–325.

Nafe LA, Leach SB. Treatment of feline asthma with ciclosporin in a cat with diabetes mellitus and congestive heart failure. J Fel Med Surg 2014. Online. Accepted 6 November 2014.

Reinero CR. Advances in the understanding of pathogenesis, and diagnostics and therapeutics for feline allergic asthma. Vet J 2011. 190(1):28-33.

Trzil JE, Reinero CR. Update on Feline Asthma. Vet Clin Sm Anim 2014. 44:91-105.

Venema C, Patterson C. Feline asthma: What’s new and where might clinical practice be heading? J Fel Med Surg 2010. 12:681-692.

Whitehouse W, Viviano K. Update in Feline Therapeutics: Clinical use of 10 emerging therapies. J Fel Med Surg 2015. 17:220–234.

For SHOW NOTES for this episode see HERE.

Click Here For Your FREE Copy of a Transcript of This Episode

Listeners Questions Episode on Blood Administration Mar 13, 2015

Red Cell Transfusions: To Pump Or Not To Pump?

Although not worldwide just yet, veterinary practices are increasingly able to give red cell transfusions. But how should you do this – with or without an infusion device?

In this episode I address this listener’s question: “What are your thoughts about using IVF pumps to administer blood products? The hospital I work at currently will not use fluid pumps, but instead calculates drops/second because they feel the pumps will cause cell lysis.”

Papers discussed in this episode are:

McDevitt RI, Ruaux CG, Baltzer WI. Influence of transfusion technique on survival of autologous red blood cells in the dog. J Vet Emerg Crit Care 2011. 21(3) 2011, pp 209–216.

Heikes BW, Ruaux CG. Effect of syringe and aggregate ﬁlter administration on survival of transfused autologous fresh feline red blood cells. J Vet Emerg Crit Care 2014. 24(2):162–167.

For SHOW NOTES of this episode see HERE.

Click Here For Your FREE Copy of a Transcript of This Episode

2015 AAHA/AAFP Pain Management in Dogs and Cats Guidelines Feb 27, 2015

Thankfully (!) pain management continues to gain increasing recognition in clinical veterinary practice. In this episode I look at some of the key points made in the following recently published guidelines focusing on those most relevant to ECC and acute short-term pain management:

Epstein M, Rodan I, Griffenhagen G, et al. AAHA/AAFP Pain Management Guidelines for Dogs and Cats. J Fel Med Surg 2015. 17, 251–272.

The ten points discussed in the episode are:

Pain management must be central to our clinical practice
Pain physiology should be considered when implementing our pain management
The patient’s behaviour is key to pain assessment
Pain scoring tools can be useful
Multimodal (balanced) analgesia is another key strategy in pain management
Opioids are the best analgesics in many emergency patients
Non-steroidal anti-inflammatory drugs (NSAIDs) may be contraindicated in emergency patients
Don’t overlook non-pharmacological measures
DON’T OVERLOOK TLC!
Conflicts of interest

Click Here For Your FREE Copy of a Transcript of This Episode

Canine Hypoadrenocorticism (Addison's Disease): 10 Talking Points Feb 13, 2015

Dogs (and cats) having a crisis as a result of hypoadrenocorticism (Addisonian crisis) can be in a life-threatening state and this represents one of the true small animal emergencies. Stabilisation of these patients starts with appropriately aggressive intravenous fluid therapy as the first priority and treatment for clinically significant hyperkalaemia and hypoglycaemia may also be needed very early on. Intravenous glucocorticoids are typically then required to continue stabilisation. In this episode I discuss ten talking points relating to canine hypoadrenocorticism, namely:

“The Great Pretender”
Likely Genetic Basis
Aldosterone may be low in ‘atypical’ cases
Hypoglycaemia may be severe
Bradycardia is not always present and not just due to hyperkalaemia
ACTH stimulation test provides definitive diagnosis
Single resting plasma cortisol may be useful for screening – but limited role in emergencies?
Intravenous fluid therapy
Client communication and education
Prognosis is good with appropriate management – yey!

Click Here For Your FREE Copy of a Transcript of This Episode

PAPERS that helped inspire some of the content for this episode are:

Baumstark ME, Sieber-Ruckstuhl NS, Mϋller C, et al. Evaluation of Aldosterone Concentrations in Dogs with Hypoadrenocorticism. J Vet Intern Med 2014; 28:154–159. (Open access online)

Boag AM, Catchpole B. A Review of the Genetics of Hypoadrenocorticism. Topics in Companion Animal Medicine 2015 (Accepted manuscript pending publication).

Bovens C, Tennant K, Reeve J, Murphy KF. Basal Serum Cortisol Concentration as a Screening Test for Hypoadrenocorticism in Dogs. J Vet Intern Med 2014; 28:1541–1545. (Open access online)

Lennon EM, Boyle TE, Hutchins RG, et al. Use of basal serum or plasma cortisol concentrations to rule out a diagnosis of hypoadrenocorticism in dogs: 123 cases (2000–2005). J Am Vet Med Assoc 2007; 231:413–416. (Abstract)

Resuscitation Fluids, and Colloids in Hypoproteinaemia Jan 30, 2015

Crystalloids versus colloids for resuscitation is an age old debate! In this episode I present the following paper before going on to talk about the use of colloids in hypoproteinaemia.

Click Here For Your FREE Copy of a Transcript of This Episode

For online presentations and notes on Hypovolaemia and Shock and Parenteral Fluid Therapy visit my online training portal.

Cazzolli D, Prittie J. The crystalloid-colloid debate: Consequences of resuscitation fluid selection in veterinary critical care. J Vet Emerg Crit Care 2015. Early View online 22 January.

ABSTRACT

Objective:

To provide a comprehensive review of the current literature in human and veterinary medicine evaluating the impact of resuscitation fluid choice on patient outcome and adverse effects.

Data Sources:

Prospective and retrospective studies, experimental models, and review articles in both human and veterinary medicine retrieved via PubMed.

Human Data Synthesis:

A series of recent, large, randomized controlled trials in critically ill human patients comparing crystalloid versus colloid driven fluid resuscitation algorithms have demonstrated no outcome benefit with the use of natural or synthetic colloids. Synthetic colloidal solutions are associated with an increased incidence of adverse effects including acute kidney injury, need for renal replacement therapy, and coagulopathies. Further, colloidal solutions demonstrate a larger volume of distribution in the setting of critical illness than hypothesized. These findings have created controversy regarding colloid fluid resuscitation in critically ill patients and challenge current resuscitation strategies. A thorough review of the most influential human data is provided.

Veterinary Data Synthesis:

No veterinary clinical outcome data pertaining to fluid resuscitation choice currently exist. Veterinary data from experimental and small clinical trials evaluating the coagulopathic effects of hydroxyethyl starch solutions are described. Data pertaining to the use of natural colloids and albumin products in clinical veterinary patients are reviewed. In addition, data pertaining to the comparative intravascular volume expansion effectiveness of different fluid types in canine patients are reviewed.

Conclusions:

Clinical data from critically ill human patients have failed to demonstrate an outcome advantage associated with colloidal fluid resuscitation and indicate that hydroxyethyl starch solutions may be associated with significant adverse effects, including acute kidney injury, need for renal replacement therapy, coagulopathies, and pathologic tissue uptake. The ability to apply these findings to veterinary patients is unknown; however, similar pathophysiology may apply, and critical re-evaluation of resuscitation strategies is justified.

Clinical Policies and Predictive Transfusion Formulae Jan 16, 2015

Today's episode is split into two sections but has an evidence-based medicine theme throughout. In the first section, prompted by something I recently encountered in human medicine, I discuss clinical policies and guidelines. How can we have confidence in them?

In the second section of this episode I discuss a couple of journal papers looking at the use of predictive transfusion formulae in dogs and cats. Do these formulae accurately predict the increase in PCV after a blood transfusion?

The papers are:

“Accuracy of formulas used to predict post-transfusion packed cell volume rise in anemic dogs” by Short, Diehl, Sheshadri and Serrano, published in the Journal of Veterinary Emergency and Critical Care in August 2012. (Volume 22, Issue 4, pages 428–434, August 2012).

“Assessment of five formulae to predict post-transfusion packed cell volume in cats” by Reed, Espadas, Lalor et al. This is from the Journal of Feline Medicine and Surgery August 2014. (Volume 16, Issue 8, pages 651-656, August 2014).

Click Here For Your FREE Copy of a Transcript of This Episode

Want 15 pages of NOTES ON ANAEMIA for FREE? Click HERE.

Listeners' Questions on Fluid Therapy Jan 02, 2015

There are some well know standard principles of fluid therapy with different approaches to the treatment of hypovolaemia and dehydration. Regardless of the indication, individual patients may have additional problems or considerations that should influence our fluid therapy approach. In this episode I respond to questions sent in by listeners with respect to findings that should influence our fluid therapy approach - pulmonary contusions and heart murmurs. I then go on to discuss the role of and approach to fluid therapy in patients exposed to renally excreted nephrotoxins.

Click Here For Your FREE Copy of the Transcript of this Episode

For online training material on Parenteral Fluid Therapy and Hypovolaemia, Shock and Dehydration, CLICK HERE.

Christmas Hazards for Dogs and Cats Dec 19, 2014

Do you see dogs and cats exposed to poisons around the festive period? Sure you do! There are many potential poisons and other hazards to which dogs and cats are more likely to be exposed during the Christmas period. In this episode I discuss some of them in detail - chocolate, grapes/raisins/currants/sultanas, xylitol - and mention a variety of others to remind you of the high level bits of essential information.

As mentioned in the episode, if you would like a one-page summary of the general approach to tremorgenic neuromuscular toxins (e.g. from mouldy food), please click the link below and follow the instructions:

Click Here For a 1-Page Summary of the General Approach to Tremorgenic Toxins

Nutritional Management of Acute Pancreatitis Dec 05, 2014

This episode focuses on the nutritional management of acute pancreatitis in dogs and cats answering questions such as:

When should we be providing nutrition to dogs and cats with acute pancreatitis?
Should we be using enteral or parenteral nutrition?
Should we be using post-pyloric jejunal feeding or is oral or gastric feeding okay?

The episode is largely based around the following clinical practice review article:

Jensen KB, Chan DL. Nutritional management of acute pancreatitis in dogs and cats. J Vet Emerg Crit Care 2014. 24(3):240-250.

As mentioned in the episode, if you would like a FREE copy of some general notes on acute pancreatitis in dogs and cats that cover more than 'just' the nutritional aspects, please click the link below and follow the instructions:

Get your FREE copy of notes on acute pancreatitis

In the episode I also mention a blog post on syringe feeding which you can find HERE.

One paragraph from the paper that I read out in the episode and promised to include here was as follows:

“The traditional approach to AP centered on the premise that withholding food would reduce pancreatic autodigestion by decreasing pancreatic stimulation and enzyme release. However, the pathogenesis of pancreatitis more likely involves premature intracellular activation of proteolytic enzymes rather than pancreatic stimulation. Avoidance of feeding as a means to decrease pancreatic stimulation may be unwarranted and could lead to malnutrition and impaired gastrointestinal barrier function. Lack of enteral nutrition results in the loss of normal physiologic intestinal motility, is associated with intestinal villus atrophy, and compromises intestinal mucosal blood flow. If sustained, the lack of enteral nutrition could lead to a compromise of local immunoglobulin and biliary salt production with consequent disruption of normal internal bacterial flora and gastrointestinal barrier function. It also has been demonstrated in experimental rodent models and in people with naturally occurring disease that exocrine pancreatic secretion actually decreases during pancreatitis and that the decrease is more pronounced with increasing severity of inflammation. The practice of withholding food for several days from the time of initiation of therapy may prove detrimental as a period of anorexia often precedes the initial clinical presentation to veterinarians in patients with AP. Implementation of nutritional support may be critical for successful management of patients with AP.”

And the list of summary points from the paper is as follows:

There is increasing evidence supporting the important role of early EN (ideally within 48 h of diagnosing pancreatitis) in positively impacting outcome in patients with AP.
Nutritional support is an integral and key aspect of the successful management of AP.
The use of enteral feeding in veterinary medicine is now considered to be safe, effective, and well-tolerated in severe AP.
Enteral nutrition is less expensive than parenteral feeding and helps to maintain gastrointestinal mucosal function, and therefore is likely to have a beneﬁcial inﬂuence on the disease course.
Use of NG, nasoesophageal, jejunal, and oesophagostomy feeding tubes is effective and safe in dogs and cats and should be used unless speciﬁc contraindications are identiﬁed. There is no evidence at this time to support the superiority of post-pyloric jejunal feeding over oral or gastric feeding.
The optimal enteral diet for patients with AP has not been identiﬁed, but diets commonly used for convalescing dogs and cats can be used.
Avoidance of enteral diets with high fat content does not appear to be necessary in the majority of patients.
Despite the growing evidence that EN can be used effectively in the management of patients with AP, there may still be patients that require some form of PN until sufﬁcient EN can be tolerated.
And of course we have the usual and completely reasonable conclusion that future veterinary studies investigating feeding routes, dietary composition, and optimal timing of nutritional support in AP are warranted.

Fluid Choice in Tomcat Urethral Obstruction (Blocked Cats) Nov 21, 2014

Cats with urethral obstruction ("blocked cats") can present in a state of shock with moderate-to-severe hypoperfusion and should receive adequate fluid resuscitation with bolus therapy as needed using an isotonic crystalloid solution before worrying about relieving the obstruction. Blocked cats may have clinically significant hyperkalaemia and can also be severely acidaemic. With this in mind, does it matter whether we use 0.9% sodium chloride or a more balanced solution such as Hartmann's solution (buffered lactated Ringer's solution, compound sodium lactate), Normosol-R or Plasmalyte 148? This is discussed in detail in this podcast and a paper from the veterinary literature presented.

A summary of the podcast including the reference for the paper discussed can be found on the Veterinary ECC Small Talk website HERE.

If you are interested in taking a presentation and acquiring some course notes describing in detail an approach to the overall management of blocked cats, please visit the website HERE.

Intravenous Lipid Emulsion as an Antidote Nov 07, 2014

Intravenous lipid emulsion (ILE) (e.g. Intralipid 20%) has been used for some time and is being used more and more as an antidote for certain toxins in both human and veterinary medicine. How does it work? What is the evidence base for its use? What poisons should we consider using it for in dogs and cats? These are amongst some of the questions that I discuss in this episode of the podcast.

Listen to this episode to find out more and feel free to share your thoughts on the main website or via social media.

** To get your FREE copy of some notes on intravenous lipid emulsion visit the Veterinary ECC Small Talk website HERE **

I would be very grateful if you could also take the time to rate and/or review these podcasts! Thank you!

Antibiotics in Canine Acute Haemorrhagic Diarrhoea Oct 21, 2014

Canine acute haemorrhagic diarrhoea is a common presentation in small animal veterinary practice and often these patients present as emergencies. Aside from fluid therapy and other medical treatments, antibiotics are often prescribed. But is this appropriate in all cases? Should all dogs with acute haemorrhagic diarrhoea receive antibiotics? Listen to this episode to find out more and feel free to share your thoughts on the main website or via social media.

Show notes for this episode can be found HERE

I would be very grateful if you could also take the time to rate and/or review these podcasts! Thank you!

Introduction Oct 21, 2014

An introduction to the Veterinary ECC Small Talk podcast, bringing the small animal veterinary Emergency and Critical Care (ECC) small talk and jibber jabber!

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