Entering Clinics VetGirl April 2014 NO PICS .(PLN) Feline infectious peritonitis (FIP) Blood loss

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4/9/14

1

What to expect before entering clinics

Justine A. Lee, DVM, DACVECC, DABT CEO, VetGirl justine@vetgirlontherun.com @VetGirlOnTheRun @drjustinelee

Introduc7on

Jus7ne A. Lee, DVM,

DACVECC, DABT

CEO, VetGirl

Introduc7on

Garret Pach7nger, VMD, DACVECC

COO, VetGirl

Find us on social media

VetGirl

! VetGirl ELITE ($199) = free for veterinary students!

! Call in from Smart Phone!

! Email / contact with ANY ques7ons

! garret@vetgirlontherun.com

! jus7ne@vetgirlontherun.com

Come prepared

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HOW TO GET A GOOD HISTORY

How to take a good history

Introduce yourself then take control 18 second rule

Pet their pet!

Quick, but thorough 15-20 minutes

EMR/UVIS Type as you go Spelling! Professional!

How to take a good history

Presen7ng complaint (PC)

Details Dates, quan77es, vomi7ng vs. regurg, dysuria, hematuria (stream?), 7me of toxin, 7me of going down

Start from the beginning: PMHX The three Ts:

Trauma Toxins Ticks

Is there anything else I can?

Presen7ng it to the Doc Totally different from what the o will tell us

Quick, efficient, organized

Start with: Signalment PC Physical exam findings Problem list Your plan

Rule outs Diagnos7cs

#1 Physical examina7on

Efficient Easily repeatable

Serial exams Inexpensive Fine-tuned Focused/targeted Subjec7ve

Tips: Palpate aler euthanasia Palpate under anesthesia Palpate abnormal

What people forget: Importance of TPR/weight

Always weigh the pa7ent daily

Dont use the carrier (too much variability!)

Note what scale you weighed the pa7ent on (on ICU sheet)

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Weight Example: 30 kg dog, 10% dry

Dehydra7on: 30 kgs X 0.1 X 1000 mls = 3000 mls replacement

I L = 1 kg

You expect this dog to gain to 33 kgs once hydrated!

Take home message: weight SID-QID! THE ICU SHEET

ICU sheets How to cross out an error

Document, document, document! Observa7ons To x-ray, AUS, visi7ng o

Every other line

Black ball point pen

You touch the animal? You write it down.

mcg vs. mg vs g " 1000 mcg to 1 mg

0.75 mls vs 75 mls

Honesty, honesty, honesty!

Examples of documenta7on

Catheter placement

Labeling catheters

Unblocking a cat what was it like?

Subjec7ve does the pa7ent look nauseated?

FAST ultrasound exam

ICU sheets

Save those lines! Need a CBC drawn at 8 am? Flip + lube eyes

Assess your own pa7ent frequently yourself!

Order your drugs efficiently Cost effec7ve Wasteful Recycle/return ziploc bags to pharmacy

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Be efficient

Disconnec7ng dog for AUS take it outside before or aler (unless they need a cysto)

Minimizes # of hep flushes/disconnec7ng " errors Weight?

Save a walk for ICU techs if hes already out

Owners = walk dogs

S7cking dogs/mean cats

Dont get biuen

Formulas to know

No longer shock dose of fluids (60-90 ml/kg): Instead: 1/3 of a shock bolus aliquot (20-30 mls/kg)

Blood transfusion dose: 10-20 mls/kg

DPL dose: 20 ml/kg

3-5 days, 5-7 days, 10-14 days

CLINICOPATHOLOGIC TESTING

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BIG 4 vs. CBC/CHEM/UA

ER = 40% outpa7ent

Would you spend $300 for blood work each 7me your dog vomited?

BIG 4 + EG8 vs. complete blood work

PCV/ N TS (i.e., 25%/7 g/dL) PCV/N TS (i.e., 65%/7 g/dL) N PCV/ TS (i.e., 40%/5 g/dL) N PCV/ TS (i.e., 40%/9 g/dL) PCV/TS (i.e., 66%/8 g/dL) PCV/ TS (i.e., 25%/5 g/dL) Hemolytic anemia Polycythemia vera Protein-losing

enteropathy (PLE)

Multiple myeloma Hemocon- centration Chronic blood loss (Melena)

Aplastic anemia Hyperthyroidism Protein-losing nephropathy (PLN)

Feline infectious peritonitis (FIP) Blood loss (subacute)

Pure red blood cell aplasia Cushings Liver failure (lack of production of

albumin) Chronic globulin stimulation (i.e., dental, skin disease)

Anemia of chronic disease Hemorrhagic Gastroenteritis

(HGE) Acute blood loss (with splenic contraction)

Severe dehydration + anemia (i.e., CRF)

Is the sample hemolyzed? Icteric? # IMHA

EPO-producing tumor (renal) Third spacing Lipemic serum

BIG 4: Dont forget that blood smear!

Checking for the presence of WBC Parvovirus puppies

Checking for the presence of platelets Epistaxis, bruising from ITP 1 plt/HPF = 10,000 15,000 plt

Checking for the presence of spherocytes DDX: IMHA Found in 80% of IMHA pa7ents

Coag Quickies

Prothrombin (PT): extrinsic + common Elevated quickly with Vitamin K roden7cides Vitamin K dependent factors: II, VII, IX, X Half-life of VII: 7 hours

Ac7vated par7al thromboplas7n 7me (PTT): intrinsic + common

Ac7vated clo{ng 7me (ACT): intrinsic + common + platelets

ACT = PTT

Coag quickies:

PT/PTT never affected by thrombocytopenia!

Buccal mucosal bleeding 7me (BMBT) and ACT If thrombocytopenic (

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Basic calcula7ons

% = 0 + mg/ml

Lasix 5% = 50 mg/ml

50% Dextrose = 500 mg/ml

25% Mannitol = ??

When in doubt

If it doesnt feel right, its not.

If its not clear, it doesnt go IV (for the most part). Sucralfate IV AlOH IV Clinicare IV

Ask

Intern director screaming at intern Digoxin dosing

Drug administra7on

Drug in mgs X concentra7on of ml = amount mgs

Dog: 30 kgs, Dose: Pepcid 0.5 mg/kg SID IV

30 kgs X 0.5 mgs/kg = 15 mgs

15 mgs X 1 ml/10 mgs = 15/10 = 1.5 mls

Con7nuous Rate Infusions (CRIs) Calculate fluid rate

Calculate how many hours are in that whole bag of fluids

Calculate dose/hour

Mul7ple the # of hours in the bag by the dose/hour

Convert to mls = how many mls to add into the total bag of fluids

CRI of 5 mcg/kg/minute of Dopamine, 30 kg dog

Fluid rate of 5 mls/hour

250 ml bag of 0.9% saline/5 mls per hour = 50 hours in the bag

5 mcg X 30 kgs X 60 minutes = 9000 mcg/hour 9000 mcg/hour = 9 mgs/hour

50 hours in a bag X 9 mgs/hour = 450 mgs/bag

450 mgs/bag X 1 ml/40 mgs = 11.25 mls/bag

Dextrose CRIs C1 X V1 = C2 X V2

Make a 2.5% dextrose mix to IVF

50% dextrose = 500 mg/ml

(50%)(X ml) = (2.5%)(1000 ml)

(X ml) = 50 ml

Remove 50 mls from a liter bag of fluids and replace it with 50 ml of 50% dextrose

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Seriously, the hardest part of EG? C1 X V1 = C2 X V2

Make a 7% ethanol solu7on with Everclear (check proof - 190 proof, 95% alcohol):

(95%)(X ml) = (7%)(1000 ml)

(X ml) = 74 ml

Remove 74 mls from a liter bag of fluids and replace it with 74 ml of 190 proof vodka

VENOUS BLOOD GASES JUST GUESS METABOLIC ACIDOSIS

KISS: interpre7ng blood gas

1. pH 7.35-7.45 2. BE -3 to +3 3. pCO2 30-35 mmHg 4. HCO3 20-24 mmHg 5. pO2 80-100 mmHg

Tips on acid-base #1 disturbance: metabolic acidosis

pCO2 = acid

HCO3 = buffers acid!

Venous pCO2 vs. arterial pCO2 Difference of 5-10 mmHg pH 7.35-7.45 BE -3 to +3

pCO2 30-35 mmHg HCO3 20-24 mmHg pO2 80-100 mmHg

Steps of blood-gas analysis

1. pH = acidemic vs. alkalemic?

2. BE = truest component of metabolic component

3. pCO2 = evalua7on of respiratory component

4. Hypoxic?

5. A-a gradient A: [760 mmHg X FIO2]

150 [pCO2X 1.2]

6. Compensatory?

pH 7.35-7.45 BE -3 to +3 pCO2 30-35 mmHg HCO3 20-24 mmHg pO2 80-100 mmHg

Expected magnitude of compensa7on to a primary event

Primary Event

Expected compensation

Metabolic Acidosis

Each 1 mEq/L HCO3- PaCO2 by 0.7 mmHg Expected PaCO2 = 35 [(22-HCO3) X 0.7] mmHg

Metabolic Alkalosis

Each 1 mEq/L HCO3- PaCO2 by 0.7 mmHg Expected PaCO2 = 35 + [(22-HCO3) X 0.7] mmHg

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Expected compensation

Respiratory Acidosis Acute Chronic

Each 1 mmHg pCO2 HCO3- by 0.15 mEq/L Expected HC03 = 22 + [(pCO2 35) X 0.15] Each 1 mmHg pCO2 HCO3- by 0.35 mEq/L Expected HC03 = 22 + [(pCO2 35) X 0.35]

Respiratory Alkalosis Acute

Chronic

Each 1 mmHg pCO2 HCO3- by 0.25 mEq/L Expected HC03 = 22 - [(35 - pCO2) X 0.25] Each 1 mmHg pCO2 HCO3- by 0.55 mEq/L Expected HC03 = 22 - [(35 - pCO2) X 0.55]

11 yo FS Dachshund Venous pH 6.940 PCO2 26.2 mmHg PO2 52.2 mmHg BE -27 mmol/L HCO3 5.9 O2 Sat 71.6%

Severe metabolic acidosis with compensatory respiratory alkalosis

PaCO2: 35 [(22-HCO3)X0.7]

Compensatory

pH 7.35-7.45 BE -3 to +3 pCO2 30-35 mmHg HCO3 20-24 mmHg pO2 80-100 mmHg

10 yo FS Bichon PC: Cushings, PTE Room air

Arterial pH 7.334 PCO2 23.7 mmHg PO2 81.3 mmHg BE -13.3 mmol/L HCO3 12.5 O2 Sat 94.8%

pH 7.35-7.45 BE -3 to +3 pCO2 30-35 mmHg HCO3 20-24 mmH