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

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What to expect before entering clinics…

Justine A. Lee, DVM, DACVECC, DABT CEO, VetGirl [email protected] @VetGirlOnTheRun @drjustinelee

Introduc7on

Jus7ne A. Lee, DVM,

DACVECC, DABT

CEO, VetGirl

Introduc7on

Garret Pach7nger, VMD, DACVECC

COO, VetGirl

Find us on social media

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!  Call in from Smart Phone!

!  Email / contact with ANY ques7ons

!  [email protected]

!  [email protected]

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

•  Don’t 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 μg " 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 he’s already out

•  Owners = walk dogs

•  S7cking dogs/mean cats

Don’t 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: Don’t 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 (<50,000), don’t bother

•  Clinical thrombocytopenia –  < 20-‐30,000 platelets

DRUG CALCULATIONS

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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 doesn’t feel right, it’s not.

•  If it’s not clear, it doesn’t 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?


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


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%


10 yo FS Bichon •  Arterial •  pH 7.334 •  PCO2 23.7 mmHg •  PO2 81.3 mmHg •  BE -‐13.3 mmol/L •  HCO3 12.5 •  O2 Sat 94.8%

•  Mixed acid base: Metabolic acidosis and respiratory alkalosis

•  PaCO2 = 35 – [(22-‐HCO3) X 0.7] mmHg = 28

•  Compensa7on for m. acidosis should be a pCO2 of 28. Dog is hyperven7la7ng (not overcompensa7ng!)

•  A-‐a: 81-‐[150-‐23.7(1.2)] = 40

•  Pulmonary parenchymal disease! pH 7.35-‐7.45 BE -‐3 to +3 pCO2 30-‐35 mmHg HCO3 20-‐24 mmHg pO2 80-‐100 mmHg

ASSESSING FLUID NEEDS (HYPOVOLEMIA VS. DEHYRATION) BETTER

For those of you mathema7cally impaired under cor7sol s7mula7on…

•  Shocky dog? •  No calculator? •  Add a “0” to the pound weight

•  77 lb dog presents tachycardiac, shocky, pale, poor pulse quality aler HBC – 77 + 0 = 770 mls!

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Physical assessment of dehydra7on

% dehydration Clinical signs

<5% Not detectable

5-6% Subtle loss of skin elasticity

6-8% Definite delay in return of skin to normal position Slight prolongation of CRT Possibly dry mm

10-12% Tented skin stands in place Definite prolongation in CRT Sunken eyes Dry mm Possible signs of shock

12-15% Definite signs of shock Death imminent

Evalua7ng hydra7on: 10% dry Labrador, 30 kgs

PCV/TS Sp Gr. Weight 55/9 1.029 30 kgs

40/7 1.024 31 kgs

35/5 1.015-‐1.018 33 kgs

Not assessing hydra7on beuer!

•  Sp. gravity 1.015-‐1.018

•  Urine volume

•  Drinking water in the cage

SQ fluids: How much can you give?

•  Dose = “maintenance fluids”

•  30 kg dog X 50 ml/kg/day = 1500 mls

•  1 L SQ once

BEING SCARED TO PENETRATE BODY CAVITIES

[With a 18 g needle and the good thrust of the hand, there is no body cavity you can’t penetrate…]

– House of God, Dr. Shem

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Thoracocentesis •  Supplies:

– 20 cc syringe – 3 way stopcock – 16-‐22 ga. needle or buuerfly catheter

– Extension se{ng – Empty bowl – +/-‐ seda7on

•  Butorphanol: 0.2-‐0.8 mg/kg IM or IV •  Diazepam: 0.1-‐0.25 mg/kg IV

Abdominocentesis

•  Shave a large area •  Alcohol spray

– 2 minute contact 7me, degreaser

•  Scrub •  Gloves?

Loca7on for performing FAST

•  Caudal to the xyphoid •  Cranial to the bladder •  Right gravity-‐dependent •  Lel gravity-‐dependent

Figure courtesy of Boysen SR from IVECCS proceedings 2006.

Your job

•  Know your pa7ent –  Take good care of them! –  Treat the pa7ent the same way

you would if it was your pet.

•  Learn how to do “tedious” procedures –  Keeping pa7ents clean and dry –  Doppler –  Strong work ethic

•  Team work

•  Communicate

•  Read up at home –  5-‐minute guide –  Not Wikipedia

•  Stay hydrated

Baby boomer vs. X vs. Y •  Strong work ethic

–  Put in your 7me and hours

–  Deteriora7on in veterinary medicine

•  You don’t go home un7l the clinician goes home

•  Play nicely

•  Love up your technical staff

•  Only year to learn

•  You can do anything as a veterinarian…

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•  Save lives and experiment –  CSF taps on cats

•  Learn how to prac7ce “street” medicine –  Learning from people you didn’t think you could learn from!

•  Trust your physical exam

•  Learn from your mistakes…

•  Complete your bucket list

@VetGirlOnTheRun

VetGirlOnTheRun

[email protected]

[email protected]

Questions?

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Dr. JusMne Lee •  April 22-‐24, 2014: Russian Veterinary

Conference, Moscow, Russia •  May 1-‐4, 2014: Interna7onal Veterinary

Seminars, New Orleans, LA.

•  May 13, 2014: New Jersey Veterinary Medical Associa7on, NJ.

•  June 19, 2014: Minnesota Veterinary Medical Associa7on, Saint Paul, MN

Dr. Garret PachMnger

•  April 29, 2014: Delaware Veterinary Medical Associa7on, Dover Downs, DE

•  May 8, 2014: Pennsylvania Veterinary Medical Associa7on, Lancaster, Pa

•  August 16-‐18, 2014: Pennsylvania Veterinary Medical Associa7on Keystone Veterinary Conference in Hershey, PA

•  September 5, 2014: Leon Veterinary Conference, Guadalajara, Mexico

•  September 24-‐28, 2014: Southwest Veterinary Symposium, Ft. Worth, Texas

Where is VetGirl going to be? Check out our upcoming 2014 lectures here:

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

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