VETgirl Pearls in Feline Emergency Medicine · 2/22/16 3 Pearls%in%Feline%Emergency%Medicine% IntroducKon% • Inducing%emesis%in%cats% • SacralECoccygeal%Epidural%Epidural%For%Pain%Relief%in%Cats%With%

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Pearls in Feline Emergency Medicine

Kenneth J. Drobatz, DVM, MSCE, DACVIM, DACVECC

University of Pennsylvania

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Kenneth J. Drobatz, DVM, MSCE,

DACVIM, DACVECC University of Pennsylvania

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Pearls in Feline Emergency Medicine IntroducKon

•  Inducing emesis in cats •  Sacral-‐Coccygeal Epidural Epidural For Pain Relief in Cats With

Urethral ObstrucKon •  Vertebral Heart Size to DifferenKate Cardiac Related Respiratory

Distress From Non-‐Cardiac Causes •  Does Axillary Temperature Reflect Rectal Temperature in Cats? •  Abdominal Focused Assessment for Trauma (AFAST) •  Cystocentesis or Not in Cats With Urethral ObstrucKon? •  Is Feline species specific PLI Useful in Diagnosing PancreaKKs In Cats

PresenKng To the ER? •  Spontaneous Pneumothorax in Cats •  Feline emergency cases (if Kme allows)

Pearls in Feline Emergency Medicine Format

•  Will be fairly “rapid fire” facts but open to quesKons at the end!

•  Type them in to the quesKon box.

Inducing Emesis in Cats

•  The need to induce emesis in cats is relaKvely rare compared to dogs. –  recent ingesKon of a toxin (last 2-‐3 hours).

•  Not a benign process. – vagally mediated respiratory/cardiac arrest –  rupture of a compromised stomach – esophagiKs – gastric hemorrhage – aspiraKon of vomitus.


•  ContraindicaKons: –  respiratory distress –  bradycardia – mentaKon changes –  seizures –  laryngeal paralysis –  recent abdominal surgery –  already vomited mulKple Kmes –  ingesKon of a causKc material –  ingesKon of sharp foreign bodies.


•  Gastric decontaminaKon can be life-‐saving if done in a Kmely basis.

Inducing Emesis in Cats Apomorphine (dopamine agonist)

Hydrogen Peroxide

Alpha -‐2 agonists Oral Salt

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Effec7veness of dexmedetomidine for emesis induc7on in cats: 43 cases (2009-‐2014)

Thawley and Drobatz, JAVMA (in press)

•  RetrospecKve Study •  43 cats where emesis was induced.

– Hydrogen peroxide (n=3,0% vomited) – Xylazine (n=25, 44% vomited) – Dexmedetomidine (Dex) (n=16, 81% vomited)

•  Cats were 5X more likely to vomit with dex compared to xylazine.

•  The median dose of dex was 7micrograms/kg (range 0.96 to 10 mcg/kg)

Effec7veness of dexmedetomidine for emesis induc7on in cats: 43 cases (2009-‐2014)

Thawley and Drobatz, JAVMA (in press)

•  Dexmedetomidine –  IM: median dose was 7mcg/kg

–  IV: median dose was 3.5 mcg/kg – 100% of cats given IM vomited – 67% of cats given IV vomited

– Median Kme to emesis was 10 minutes

The only noted side effect was sedation but monitor cardiovascular system closely as anecdotally some cats can be affected.

Hyperglycemia can be seen as well due to alpha 2 receptor binding on The Islet cells.

Sacral-‐Coccygeal Epidural Epidural For Pain Relief in Cats With Urethral

Obstruc7on

Sacral-‐Coccygeal Epidural Epidural For Pain Relief in Cats With Urethral Obstruc7on

•  Urethral obstrucKon is one of the most common problems encountered in feline emergency medicine.

•  Many of these cats are extremely painful even aeer relief of obstrucKon and placement of an indwelling urethral catheter.

•  Anecdotally, some very friendly cats can become fracKous and difficult to handle while hospitalized. –  The concern is that these cats are

quite uncomfortable and painful.

Sacral-‐Coccygeal Epidural

•  Pain medicaKon is essenKal for these unhappy cats and most oeen narcoKcs such as methadone (0.1 -‐0.2mg/kg), butorphanol (0.1 – 0.2 mg/kg) and buprenorphine (0.01 – 0.02 mg/kg) are used to help control their pain. –  Some drawbacks include sedaKon, increased temperature and someKmes causing dysphoria.

•  Sacral-‐Coccygeal Epidural is a relaKvely new modality being used in cats with urethral obstrucKon.

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Sacral-‐Coccygeal Epidural (Journal of Veterinary Emergency and CriKcal Care 21(1) 2011, pp 50–52)

•  Produces anesthesia to the perineum, penis, urethra, colon, and anus without loss of motor funcKon to the hind limbs.

•  RelaKvely safe but reported complicaKons include infecKon at the injecKon site and the possibility of systemic absorpKon of the drugs that were injected.

•  ContraindicaKons include bleeding disorders, sepsis, skin infecKon at the site of injecKon, shock or sepsis.

Sacral-‐Coccygeal Epidural Equipment

•  Supplies: •  Sterile Gloves •  Surgical Scrub •  1 cc syringe •  25 gauge 1 inch needle

•  Drugs: •  Bupivacaine 0.22mg/kg •  2% Lidocaine 2 mg/kg •  (dose not to exceed •  0.2 ml/kg)

Sacral-‐Coccygeal Epidural

Step by Step

•  Clip and scrub the skin over the sacral/coccygeal area.

•  While an assistant dorsiflexes the tail, using the non-‐dominant hand index finger palpate the fulcrum where the tail dorsiflexes. The sacral/coccygeal space is located just slightly caudal to that. –  The space between the first two

coccygeal vertebrae may also be used. •  Using the dominant hand place a 25

gauge needle into the appropriate space over the midline while using the non-‐dominant index finger maintaining idenKficaKon of the space (30-‐45 degree angle).

Sacral-‐Coccygeal Epidural Step by Step

•  Using the dominant hand place a 25 gauge needle into the appropriate space over the midline while using the non-‐dominant index finger maintaining idenKficaKon of the space (30-‐45 degree angle).

From “Techniques in Large Animal Surgery”

Sacral-‐Coccygeal Epidural Step by Step

•  A palpable “pop” may occur when the interarcuate/ligamentum flavum is penetrated (variable in occurrence). –  further advancement should encounter minimal resistance.

•  A 3 cc syringe (with 0.1 – 0.2 ml/kg of 2% sterile lidocaine) should be aàched to the needle and gently aspirated.

•  The tail and perineal area should be assessed for sensaKon.

•  If sensaKon is sKll present 5 minutes aeer injecKon then failure of proper placement of the lidocaine has likely occurred and a repeat injecKon is warranted.

•  No more than two injecKons should be aèmpted.

Sacral-‐Coccygeal Epidural Checking EffecKveness

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Sacral-‐Coccygeal Epidural Randomized Clinical Trial (n=88 cats)

•  Compared bupivicaine (0.22mg/kg) alone, bupivicaine (0.22mg/kg mixed with morphine (0.1mg/kg), and a sham.

•  Outcome parameters assessed: –  pain scores, Kme to pain medicaKon administraKon rescue and

the amount of propofol used during catheter placement and complicaKons.

•  Results: –  amount of propofol used to maintain adequate sedaKon during

urinary catheter placement was significantly greater in the sham group

–  Kme to rescue pain medicaKon administraKon aeer catheter placement was significantly shorter for the sham group.

Sacral-‐Coccygeal Epidural Randomized Clinical Trial

•  Amount of propofol used to maintain adequate sedaKon during urinary catheter placement was significantly greater in the sham group

•  Time to rescue pain medicaKon administraKon aeer catheter placement was significantly shorter for the sham group.

•  Overall, the technique was easily learned, quick to perform, safe and appears to relieve some degree of pain in these cats.

Sacral-‐Coccygeal epidural appears to be safe, effecKve and easy

to learn and it’s kind of fun!

Severe anemia in feline pa7ents with urethral obstruc7on: 2002-‐2011.

Kari Santoro Beer, DVM Kenneth J. Drobatz, DVM, MSCE, DAVCECC, DACVIM



JVECCS, In Press

•  17 cats with urethral obstrucKon and severe anemia requiring transfusion

•  30 cats with urethral obstrucKon and mild or no anemia were included as controls.



•  Conclusions-‐ A history of previous urethral obstrucKon and longer duraKon of clinical signs may be important risk factors for severe anemia. AddiKonally, anemic cats appeared to be more severely affected as evidenced by lower blood pressure, more severe metabolic acidosis, higher BUN and creaKnine, and worse outcome.

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Feline Respiratory Distress

Loud upper airway sounds Yes

Upper Airway disease

Laryngeal paralysis Collapsing trachea Other Thoracic auscultation

Increased lung sounds

Cardiac abnormalities

Consider heart failure

Cardiac sounds normal

Consider pulmonary parenchymal disease

Pneumonia PTE Hemorrhage

Neoplasia NPE ARDS

Decreased lung sounds

Consider pleural space disease

Pneumothorax Pleural Effusion Diaphragmatic Hernia

Vertebral Heart Size in to Differen7ate Cardiac Related

Respiratory Distress From Non-‐Cardiac Causes

•  Verterbral heart size (VHS): more objecKve and precise assessment of radiographically measured cardiac size in dogs and cats.

•  For VHS determinaKon……………………

For VHS determinaKon:

•  The long axis measurement: ventral aspect of the lee mainstem bronchus to the lee ventricular apex. – Measure vertebral segments from the cranial edge of the fourth thoracic vertebrata to the nearest 0.1 vertebrae.

•  Maximal perpendicular short axis is measured in the same manner and is similarly quanKfied beginning at the fourth thoracic vertebra.

•  Sum the two values to give the VHS.

Reference range of 6.9 – 8.1 VHS

Use of the vertebral heart scale for differenKaKon of cardiac and noncardiac causes of respiratory

distress in cats: 67 cases (2002–2003) Meg M. Sleeper, vmd, dacvim; Risa Roland, dvm, dacvim; Kenneth J. Drobatz, dvm, msce, dacvecc, dacvim

•  J Am Vet Med Assoc 2013;242:366–371 •  Sixty seven dyspneic cats were included in this retrospecKve study. –  VHS of > 8.0 vertebrae was the best cut point when screening for heart disease

–  VHS of > 9.3 vertebrae was very specific for the presence of heart disease

–  Between 8.0 and 9.3 vertebrae suggested the cause of dyspnea was equivocal (Echo needed)

–  VHS of ≤ 8.0 vertebrae indicates that underlying heart disease is very unlikely to be causing dyspnea and an echocardiogram is unlikely to be a cost-‐effecKve diagnosKc tool.

Heart failure unlikely Equivocal, need echo Heart failure likely

</= 8.0 VHS 8.0 – 9.3 VHS >9.3 VHS

OR

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Feline Respiratory Distress

Loud upper airway sounds Yes

Upper Airway disease

Laryngeal paralysis Collapsing trachea Other Thoracic auscultation

Increased lung sounds

Cardiac abnormalities

Consider heart failure

Cardiac sounds normal

Consider pulmonary parenchymal disease

Pneumonia PTE Hemorrhage

Neoplasia NPE ARDS

Decreased lung sounds

Consider pleural space disease

Pneumothorax Pleural Effusion Diaphragmatic Hernia

Empirical Therapy Feline Respiratory Distress

•  Supplemental Oxygen

•  Thoracocentesis (if indicated)

•  Furosemide (1 – 2mg/kg IV or IM)

•  Dexamethasone (0.1 mg/kg IV or IM)

•  Terbutaline (0.01 mg/kg IM)

•  AnKbioKcs?

Does Axillary Temperature Reflect Rectal Temperature in Cats?


•  Rectal temperature is the standard measurement used to assess body temperature in animals

•  Axillary temperature has been described and is oeen used as a subsKtute.

•  Studies in people have shown there is a wide variaKon between axillary and rectal temperatures in both adults and neonates.


•  Inaccurate body temperature measurements can lead to inappropriate diagnosKc and treatment decisions that may affect overall paKent care.

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Axillary Temperature in Cats

•  Variables evaluated included signalment, body weight, body condiKon score, physical perfusion parameters (mucous membrane color, capillary refill Kme, pulse quality), mentaKon, heart rate, coat length, coat density, length of hair in the axilla, lesions in the axilla or rectum, and whether diarrhea was present in the history (large or small intesKne), lactate, and blood pressure

Axillary Temperature Study Results Summary

•  A large variaKon in axillary temperature, compared with rectal temperature.

•  Although the median rectal to axillary temperature difference (RAG) was acceptable (0.17°), only 65% of cats had an RAG that was considered acceptable (</= 0.5°C).

•  SensiKvity and specificity were 33% and 100% respecKvely in detecKng hyperthermia

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Axillary Temperature Study Results Summary

•  SensiKvity and specificity were 80% and 96% respecKvely in detecKng hypothermia.

•  In other words, results suggest that animals with a high axillary temperature are likely hyperthermic (as determined by a rectal temperature measurement), but an axillary temperature within reference range does not rule out the possibility of hyperthermia.

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Abdominal Focused Assessment for Trauma (AFAST)

•  A rapid, cage-‐side, assessment for free abdominal fluid due to any cause.

•  The primary purpose of AFAST is to detect free fluid within the peritoneal space. –  hence this technique does not require any specific or in depth training in ultrasonography.

•  Free fluid generally appears as anechoic areas (dark areas )that have angular outlines.

Feline Ascites DDX

•  Heart failure •  Chronic liver disease •  PeritoniKs •  Neoplasia •  Chyle •  FIP •  Hemorrhage •  Urine •  Bile

(AFAST)

•  Consists of four views and can be performed in right or lee lateral recumbency or sternal if paKent stability is compromised in these posiKons.

•  The four sites of probe placement are: –  DH (diaphragmaKcohepaKc view) – SR (splenorenal view) – CC (cystocolic view) – HR (hepatorenal view)

Fluid Analysis of Ascites

•  Cytology •  Total Solids •  PCV •  Bilirubin •  Potassium/CreaKnine

•  Lactate/glucose?

Cystocentesis or Not in Cats With Urethral Obstruc7on?

Cystocentesis or Not in Cats With Urethral Obstruc7on?

•  Compromised integrity of a urinary bladder that has become ischemic .

•  Some authors advocate that the risk is minimal: –  Advantages include:

•  immediate relief of bladder pressure •  facilitaKng urinary catheter passage

•  Recently, a study out of University of Minnesota has refuted this concern about bladder rupture.

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J Vet Emerg Crit Care 2015; 25(2): 256–262

•  RetrospecKve study: 47 cats – Thirty five cats had abdominal imaging of some type (radiography, contrast radiography, and/or abdominal ultrasound).

–  InteresKngly, 11/ 20 cats where imaging was done prior to cystocentesis have evidence of free peritoneal fluid.

– Six of 10 cats that had imaging aeer cystocentesis had evidence of free peritoneal fluid.

Cystocentesis Study

•  Forty three cats survived to discharge –  4 cats were euthanized due to reobstrucKon (2 cats), 1 for likely pyelonephriKs, and 1 for oliguric renal failure.

•  The results of this study suggest that decompressive cystocentesis in cats with urethral obstrucKon does not result in clinically significant urinary leakage. –  The effect on ease of urinary catheter placement is sKll not answered.

Procedure for decompressive cystocentesis

•  Equipment needed: 22 gauge/1.5 inch needle aàched serially to an iv extension tube, 3-‐way stopcock and a 20 cc syringe. –  Prior sedaKon/analgesia can be administered based on the clinician’s assessment of the stability of the paKent.

–  Gently immobilize the urinary bladder against the midline of the ventral abdomen.

–  The needle is inserted at an approximately 45-‐degree angle.

–  As much of the urine should be removed as possible while keeping the urinary bladder and needle staKonary.

–  Save some urine for analysis and culture if indicated.

Is Feline species specific PLI Useful in Diagnosing Pancrea77s In Cats Presen7ng To the ER?

•  Diagnosing feline pancreaKKs is very challenging. •  Clinical signs are non-‐specific:

–  anorexia (87%) –  lethargy (81%) –  dehydraKon (54%) –  weight loss (47%) –  vomiKng (46%) –  hypothermia (46%) –  icterus (37%) –  fever (25%) –  abdominal pain (19%) –  diarrhea (12%) –  palpable abdominal mass (11%).

Feline PancreaKKs Diagnosis

•  DiagnosKc opKons: – General clinical pathology (CBC, CS) give assessment of other disease processes but cannot provide a specific diagnosis of pancreaKKs.

– Abdominal radiograph findings •  inconsistent •  decreased contrast in the right cranial abdomen •  mass effect in the right cranial abdomen

•  primarily useful for ruling out other diseases

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•  Abdominal ultrasound – commonly used for assessing the presence of pancreaKKs.

– even with the most experienced radiologists this has been shown to have a sensiKvity of only 35% in cats when assessing for all degrees of severity of pancreaKKs.

•  Serum lipase and amylase are also not sensiKve or specific.


•  Serum trypsin like immunoreacKvity (TLI) has a very short half-‐life and also has poor diagnosKc performance in diagnosing feline pancreaKKs.

•  Feline specific test for anKbodies to feline pancreaKc lipase (PLI – pancreaKc lipase acKvity) has shown greater promise

Feline specific TLI

•  interpreted with cauKon because lack of clinically useful gold standard. –  the sensiKvity of fPLI was 79% in one large report. –  In another study cats with acute and/or chronic pancreaKKs (based on histopathology) the sensiKvity was 100% for moderate to severe pancreaKKs. •  In this same study fPLI was 54% for mild pancreaKKs •  Combining all severity categories of pancreaKKs results in an overall sensiKvity of 67%.

Feline specific TLI

•  Specificity of fPLI is reported to be between 67% and 100%.

•  Azotemia has not been shown to effect fPLI.

•  the results may not be clinically useful in a real Kme basis – must be sent to an outside lab. –  snap fPLI test has been developed. –  Rigorous performance evaluaKon has not been done. –  the manufacturer reports a high level agreement with the serum test.

Snap Feline specific TLI

•  SensiKvity of this test is speculated to be quite high making this test a good screening tool for feline pancreaKKs. –  A negaKve test is highly suggesKve that pancreaKKs is not the underlying problem

– A posiKve test requires further accumulaKon of evidence to rule in pancreaKKs.

SNAP® fPL™ Test (feline pancreas-‐specific lipase)

Spontaneous Pneumothorax in Cats

•  RelaKvely rare –  small list of differenKals (generated mostly from single case reports.

•  asthma •  Heartworm •  infecKon •  neoplasia •  pulmonary thromboembolism •  pulmonary abscess •  pneumonia secondary to Aelurostrongylus abstrusus and salmonellosis

•  ruptured bullae secondary to bronchopulmonary dysplasia-‐like changes

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•  Median age was 8 years (range 7 weeks to 17 years)

•  11 males and 5 females

•  The most common clinical signs were respiratory distress, coughing, and sneezing.

•  Harsh lung sounds were auscultated in 7 cats, decreased sounds in 4 cats and wheezes in 2 cats.


•  Primary diagnoses: –  uknown (1) –  asthma (4) –  pulmonary carcinoma with PTE and intersKKal pneumonia (1)

–  chronic intersKKal pneumonia with hisKocytosis (1) –  necrosuppuraKve pneumonia with rhiniKs (1) pneumonia and URI (1)

–  intersKKal pneumonia and carcinoma –  KBr related asthma and Toxoplasmosis(1) –  Emphysematous accessory lung lobe (1).


•  Treatment for the pneumothoraces included observaKon only (5), thoracocentesis (4), and tube thoracostomy (3).

•  Two cats were euthanized and the rest survived to discharge.

•  Four cats returned for another episode of pneumothorax between 3 days 15 months aeer the iniKal episode.

Spontaneous Pneumothorax in Cats Summary/Boòm Line

•  Two major groups – – cats with asthma

– cats with intersKKal lung disease usually related to neoplasia or infecKon of some type.

•  Overall, prognosis for discharge is good.

#CPRwheel

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Check out our 2016 upcoming VETgirl appearances!

Dr. JusKne Lee •  AAHA, March 2016 •  AVMA, July 2016 •  NAVC InsKtute, May 2016

Dr. Garret PachKnger •  AAHA, March 2016 •  NAVC InsKtute May 2016 •  SWVC September 2016

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VETgirl Pearls in Feline Emergency Medicine · 2/22/16 3 Pearls%in%Feline%Emergency%Medicine% IntroducKon% • Inducing%emesis%in%cats% • SacralECoccygeal%Epidural%Epidural%For%Pain%Relief%in%Cats%With%