Gastric perforation secondary to incarcerated para-esophageal hiatal hernia in a French bulldog.

A 6-month-old, intact female, French bulldog was presented to the Emergency Department for evaluation of vomiting and diarrhea over the preceding week which had not responded to supportive medical therapy. Imaging studies identified an incarcerated para-esophageal hernia with peritoneal effusion and gas consistent with gastrointestinal perforation. Following stabilization, the dog underwent an exploratory laparotomy which confirmed an incarcerated hiatal hernia and gastric perforation. A gastrectomy was performed to repair the defect, and to prevent recurrence both a herniorrhaphy and esophagopexy were performed. Post-operative care required treatment for septic shock including vasopressor and hydrocortisone infusions and plasma transfusions for colloidal support. The patient was successfully discharged 4 days after surgery. The histopathology results identified spiral bacteria consistent with Helicobacter spp. which was subsequently treated with oral antibiotics and a proton pump inhibitor. The dog has had no further gastrointestinal signs in the 90 days since surgery. Gastric perforation and peritonitis can occur secondary to an incarcerated esophageal hiatal hernia, and if treated promptly can result in a successful outcome. This case demonstrates a novel etiology of gastric perforation which may be associated with brachycephalic breeds.

Une femelle bouledogue français intacte de 6 mois a été présentée au service des urgences pour une évaluation des vomissements et de la diarrhée au cours de la semaine précédente qui n'avaient pas répondu à un traitement médical de soutien. Les études par imagerie ont identifié une hernie para-œsophagienne incarcérée avec un épanchement péritonéal et des gaz compatibles avec une perforation gastro-intestinale. Après stabilisation, la chienne a subi une laparotomie exploratoire qui a confirmé une hernie hiatale incarcérée et une perforation gastrique. Une gastrectomie a été réalisée pour réparer le défaut et pour prévenir les récidives, une herniorraphie et une œsophagopexie ont été réalisées. Les soins postopératoires ont nécessité un traitement pour choc septique comprenant des perfusions de vasopresseurs et d'hydrocortisone et des transfusions de plasma pour le soutien colloïdal. La patiente a obtenu son congé avec succès 4 jours après la chirurgie. Les résultats d'histopathologie ont identifié des bactéries en spirale compatibles avec Helicobacter spp. qui a ensuite été traité avec des antibiotiques oraux et un inhibiteur de la pompe à protons. La chienne n'a plus eu de signes gastro-intestinaux dans les 90 jours qui ont suivi la chirurgie.Une perforation gastrique et une péritonite peuvent survenir à la suite d'une hernie hiatale oesophagienne incarcérée et, si elles sont traitées rapidement, peuvent donner un résultat positif. Ce cas démontre une nouvelle étiologie de perforation gastrique qui peut être associée aux races brachycéphales.(Traduit par Docteur Serge Messier).

Clinical review of high-flow nasal oxygen therapy in human and veterinary patients.

Oxygen therapy is the first-line treatment for hypoxemic acute respiratory failure. In veterinary medicine this has traditionally been provided via mask, low-flow nasal oxygen cannulas, oxygen cages and invasive positive pressure ventilation. Traditional non-invasive modalities are limited by the maximum flow rate and fraction of inspired oxygen (FiO2) that can be delivered, variability in oxygen delivery and patient compliance. The invasive techniques are able to provide higher FiO2 in a more predictable manner but are limited by sedation/anesthesia requirements, potential complications and cost. High-flow nasal oxygen therapy (HFNOT) represents an alternative to conventional oxygen therapy. This modality delivers heated and humidified medical gas at adjustable flow rates, up to 60 L/min, and FiO2, up to 100%, via nasal cannulas. It has been proposed that HFNOT improves pulmonary mechanics and reduces respiratory fatigue via reduction of anatomical dead space, provision of low-level positive end-expiratory pressure (PEEP), provision of constant FiO2 at rates corresponding to patient requirements and through improved patient tolerance. Investigations into the use of HFNOT in veterinary patients have increased in frequency since its clinical use was first reported in dogs with acute respiratory failure in 2016. Current indications in dogs include acute respiratory failure associated with pulmonary parenchymal disease, upper airway obstruction and carbon monoxide intoxication. The use of HFNOT has also been advocated in certain conditions in cats and foals. HFNOT is also being used with increasing frequency in the treatment of a widening range of conditions in humans. Although there remains conflict regarding its use and efficacy in some patient groups, overall these reports indicate that HFNOT decreases breathing frequency and work of breathing and reduces the need for escalation of respiratory support. In addition, they provide insight into potential future veterinary applications. Complications of HFNOT have been rarely reported in humans and animals. These are usually self-limiting and typically result in lower morbidity and mortality than those associated with invasive ventilation techniques.

Successful medical management of perinephric abscess and urosepsis following urethral obstruction in a cat.

OBJECTIVE: To describe the clinical presentation and medical management of a cat with perinephric abscessation and urosepsis following urethral obstruction and catheterization. CASE SUMMARY: A 2-year-old intact male domestic shorthaired cat presented to an emergency and referral center for lethargy, vomiting, and hematuria. Severe azotemia and hyperkalemia were observed on a serum biochemistry panel. The patient was diagnosed with urethral obstruction and was treated with urethral catheterization, calcium gluconate, IV fluid therapy, buprenorphine, and prazosin. The patient's azotemia improved, and the hyperkalemia resolved. Urinary catheterization was discontinued. The patient developed pyrexia, worsening azotemia, hypoalbuminemia, hyperbilirubinemia, and dysuria. Urethral catheterization was repeated. Abdominal radiographs showed left renomegaly, and abdominal ultrasound revealed left perinephric fluid. Ultrasound-guided centesis of the perinephric fluid revealed septic inflammation, and the sample was consistent with urine based upon sample creatinine. Fluid from the perinephric abscess and urine from the bladder both grew Pasturella spp. The patient was treated with perinephric catheterization, saline lavage, and a continuous infusion of cefotaxime for 72 h. The patient's azotemia quickly resolved, and the patient was discharged after 6 days of hospitalization. The patient was reported to have made a full recovery. NEW OR UNIQUE INFORMATION PROVIDED: This is the first described case of perinephric abscess and urosepsis following urethral obstruction in a cat and its successful medical management. Perinephric abscess not associated with intrarenal abscess has not previously been identified. Additionally, continuous antimicrobial infusion to treat overwhelming infection and the use of the RapidBac Vet immunoassay for point-of-care detection of urinary tract infection has not been described in cats.

Traumatic Pulmonary Pseudocysts in a Young Dog Following Non-penetrating Blunt Thoracic Trauma.

Traumatic pulmonary pseudocysts following non-penetrating blunt thoracic trauma is a well-described phenomenon in the human literature, while in veterinary medicine, this disease process is rarely reported and poorly described in the current literature available. This case report describes a 1.5-year-old male castrated Labrador retriever with findings of pulmonary cysts following a road traffic accident. The goal of this report is to expound upon the pathophysiology, diagnosis, and treatment of this disease process in the veterinary field.

Hypertriglyceridemia and transient corneal lipidosis in a cat following intravenous lipid therapy for permethrin toxicosis.

An 8-year-old male neutered domestic shorthair cat developed corneal lipidosis and marked hypertriglyceridemia approximately 36 hours after intravenous lipid therapy (IVLT) for the treatment of permethrin toxicosis. The cat's ocular changes resolved approximately 72 hours after IVLT without treatment. This study reports a rare complication of IVLT.

Hypertriglycéridémie et lipidose cornéenne transitoire chez un chat après une lipidothérapie intraveineuse pour une toxicose à la perméthrine. Un chat commun mâle stérilisé âgé de 8 ans a développé une lipidose cornéenne et une hypertriglycéridémie marquée environ 36 heures après une lipidothérapie intraveineuse (LTI) pour le traitement de la toxicose à la perméthrine. Les changements oculaires du chat se sont résorbés sans traitement environ 72 heures près la LTI. Cette étude signale une complication rare de la LTI.(Traduit par Isabelle Vallières).

Evaluation of oxygen administration with a high-flow nasal cannula to clinically normal dogs.

OBJECTIVE To evaluate the safety and efficacy of oxygen administration by use of a high-flow nasal cannula (HFNC) in sedated clinically normal dogs. ANIMALS 6 healthy adult dogs undergoing routine dental prophylaxis. PROCEDURES Dogs were sedated with butorphanol tartrate and dexmedetomidine. An esophageal balloon catheter was inserted into the esophagus, a double-pronged nasal cannula was inserted into the nares, and a catheter was inserted into the dorsal pedal artery. Dogs were positioned in right lateral recumbency. After a 6-minute acclimation period, baseline blood gas values and transpulmonary pressure were measured. Dogs then received supplemental oxygen via conventional oxygen therapy (COT) at a rate of 100 mL/kg/min (COT-100 treatment) and an HFNC at a rate of 20 L/min (HF-20 treatment) and 30 L/min (HF-30 treatment). Arterial blood gas and transpulmonary pressure were measured after a 6-minute acclimation period for each oxygen delivery method. Radiographs were obtained before and after oxygen administration to evaluate gastric distension. RESULTS Median Pao2 was significantly higher for HF-20 (519.9 mm Hg) and HF-30 (538.1 mm Hg) treatments, compared with median Pao2 for the COT-100 treatment (202.9 mm Hg). The Pao2 did not differ significantly between the HF-20 and HF-30 treatments. There was no significant difference in Paco2 or change in transpulmonary pressure between baseline and any oxygen delivery method. CONCLUSIONS AND CLINICAL RELEVANCE In this study, HFNC appeared to be a safe and effective method for oxygen delivery to sedated healthy dogs. Further studies are needed to evaluate use of HFNCs for oxygen administration to hypoxemic patients.

Dexmedetomidine to control signs associated with lisdexamfetamine dimesylate toxidrome in a cat.

A 5-month-old intact female domestic shorthaired cat had mydriasis, agitation, and increased locomotion after ingestion of lisdexamfetamine, 10.3 mg/kg body weight (BW). Despite treatment with IV fluids, IV acepromazine, oral cyproheptadine and intravenous lipid emulsion the patient's clinical signs worsened. Dexmedetomidine administered at 2 µg/kg BW and continued at 0.5 µg/kg BW per hour rapidly controlled the patient's signs. An episode of vomiting and hematuria developed. Follow-up 5 days after discharge revealed that the cat appeared normal.

Dexmédétomidine pour contrôler les signes associés à la toxidrome à la lisdexamfétamine dimesylate chez une chatte. Une chatte domestique intacte âgée de 5 mois présentait de la mydriase, de l'agitation et une locomotion accrue après avoir ingéré de la lisdexamfétamine, 10,3 mg/kg poids corporel (PC). Malgré le traitement à l'aide de solutions intraveineuses, d'acépromazine intraveineuse, de cyproheptadine orale et d'émulsion de lipides intraveineux, les signes cliniques de la patiente s'étaient aggravés. La dexmédétomidine administrée à 2 µg/kg PC et maintenue à 0,5 µg/kg PC l'heure a rapidement contrôlé les symptômes de la patiente. Un épisode de vomissements et d'hématurie s'est développé. Un suivi 5 jours après le congé a révélé que la chatte semblait normale.(Traduit par Isabelle Vallières).

Retrospective evaluation of the effect of high flow oxygen therapy delivered by nasal cannula on PaO2 in dogs with moderate-to-severe hypoxemia.

OBJECTIVE: To describe the effects of high flow oxygen therapy (HFOT) in canine patients failing traditional oxygen therapy (TOT). DESIGN: Retrospective study. SETTING: Private referral practice. ANIMALS: Six client-owned dogs with primary pulmonary hypoxemia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: High flow oxygen was delivered by high flow nasal prongs to dogs assessed clinically to be failing TOTs. HFOT was able to significantly improve PaO2 compared to TOT in severely hypoxemic dogs (median, 133.75 mm Hg; range, 109.2-304.8) versus median 61.85 mm Hg (range, 52.3-71.8; xsP = 0.0412). Flow rates were significantly higher with HFOT compared to TOT (median, 688 mL/kg/min; range, 523-1,667 mL/kg/min) versus median 122 mL/kg/min (range, 80-208; P = 0.0412). Complications included patient discomfort requiring light sedation in 1/6 dogs and persistence of a pneumothorax in 1 dog. Hypoxemia resolved in 4/6 dogs. CONCLUSION: These data suggest HFOT is a viable clinical intervention for dogs with moderate-to-severe hypoxemia assessed to be failing TOT. Further studies are needed to determine if HFOT can be used as an alternative to mechanical ventilation in resource limited settings and to characterize the complications associated with this therapy.

Acute kidney injury in severe sepsis: pathophysiology, diagnosis, and treatment recommendations.

OBJECTIVE: To review the unique pathophysiology of sepsis-induced acute kidney injury (AKI) and highlight the relevant aspects of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury that may apply to veterinary patients. DATA SOURCES: Electronic search of MEDLINE database. HUMAN DATA SYNTHESIS: Sepsis-induced AKI is diagnosed in up to 47% of human ICU patients and is seen as a major public health concern associated with increased mortality and increased progression to chronic kidney disease (CKD). Consensus criteria for the definition and classification of AKI has allowed for accurate description of the epidemiology of patients with AKI. AKI develops from a complex relationship between the initial insult and activation of inflammation and coagulation. In contrast to the traditional view, clinical and experimental data dispute the role of renal ischemia-reperfusion in the development of sepsis-induced AKI. Renal tubular dysfunction with activation of the tubuloglomerular feedback mechanism appears to be a crucial contributor to sepsis-induced AKI. Furosemide and n-acetylcysteine (NAC) do not appear to be helpful in the treatment of AKI. Hydroxyethyl starches (HES), dopamine, and supraphysiological concentrations of chloride are harmful in patients with AKI. VETERINARY DATA SYNTHESIS: Community and hospital-acquired AKI is a significant factor affecting survival in critical ill patients. Sepsis-induced AKI occurs in 12% of dogs with abdominal sepsis and is an important contributor to mortality. Early detection of AKI in hospitalized patients currently offers the best opportunity to improve patient outcome. The use of urinary biomarkers to diagnose early AKI should be evaluated in critical care patients. CONCLUSION: Veterinary clinical trials comparing treatment choices with the development of AKI are needed to make evidence-based recommendations for the prevention and treatment of AKI.

The role of antimicrobials in the treatment of sepsis and critical illness-related bacterial infections: examination of the evidence.

OBJECTIVE: To appraise the evidence behind the Surviving Sepsis Campaign Guidelines on antimicrobial therapy in sepsis and evaluate relevant literature in small animal veterinary critical care. DATA SOURCE: Electronic searches using MEDLINE and EMBASE databases. HUMAN DATA SYNTHESIS: Current recommendations are to administer appropriate antimicrobials within 1 hour of a diagnosis of severe sepsis or septic shock. Evidence is supportive of this recommendation in septic shock but the evidence is less compelling in milder forms of critical illness-related infections. It is unclear when the administration of appropriate antimicrobials is most beneficial and when it should be considered essential. Evidence supports shorter courses of antimicrobial therapy for many infections seen in the critical care unit with the biomarkers procalcitonin and C-reactive protein helpful in guiding the duration of therapy. VETERINARY DATA SYNTHESIS: Current evidence is lacking to support the use of early and aggressive use of antimicrobials in all patients with critical illness-related bacterial infections. Two studies failed to demonstrate improved survival in patients with pulmonary or abdominal infections administered appropriate vs inappropriate empirical antimicrobials. One study failed to show an improved survival when dogs with abdominal infections were administered antimicrobials within 1 hour vs 6 hours of diagnosis of infection. Information regarding ideal duration of antimicrobial therapy and use of biomarkers to guide therapy is currently lacking. CONCLUSION: Clinicians should aim to administer early and appropriate antimicrobials; however, the impact this will have on patient outcome remains uncertain. The ability to administer early and appropriate antimicrobials may be considered a measure of the quality of medical practice rather than a prognostic indicator.

Impact of appropriate empirical antimicrobial therapy on outcome of dogs with septic peritonitis.

OBJECTIVE: To determine whether appropriate empirical antimicrobial therapy influenced survival in dogs with septic peritonitis. DESIGN: Retrospective case series (2003-2011). SETTING: University teaching hospital. ANIMALS: Eighty-six dogs with cytological confirmation or positive bacterial culture of abdominal sepsis and subsequent surgical intervention. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Forty-nine of 86 dogs (57%) survived to hospital discharge. Thirty-seven of 86 dogs were classified as having ''abdominal infection,'' 31/86 as ''severe sepsis,'' and the remaining 18/86 as in ''septic shock.'' Mortality was greatest in the ''septic shock'' category (94%). Empirical antimicrobial treatments were appropriate in 41/78 dogs (52.6%). Appropriateness was not associated with treatment outcome overall or when compared between sepsis severity groups. Antimicrobials had been given in the 30 days before admission in 63/86 (73.3%) dogs. Prior therapy with antimicrobials showed no association with outcome (P = 0.512) but was associated with subsequent inappropriate empirical antimicrobial selection (P = 0.031). Recent abdominal surgery was associated with subsequent inappropriate empirical antimicrobial selection (P = 0.021). CONCLUSIONS: In this population, appropriateness of empirical antimicrobial choice was not associated with survival to discharge. Previous antimicrobial administration or abdominal surgery was associated with subsequent inappropriate empirical antimicrobial selection.

Evaluation of acute congestive heart failure in dogs and cats: 145 cases (2007-2008).

OBJECTIVE: To characterize the clinical presentation, management, and in-hospital outcomes of dogs and cats diagnosed with acute congestive heart failure (CHF). DESIGN: Retrospective study of animals seen between January 2007 and May 2008. SETTING: Emergency service at a university teaching hospital. ANIMALS: Ninety dogs and 55 cats with CHF. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, including age, clinical signs, clinicopathologic abnormalities, diagnostic testing, and outcome were recorded. Forty-eight of the animals already were receiving cardiac medications at the time of presentation. The most common diseases represented were chronic valvular disease and cardiomyopathies. Cats had significantly lower median body temperature at admission compared with dogs (P<0.001). The most common abnormalities were elevated lactate (64%), elevated BUN (52%), hypochloremia (31%), hyperglycemia (27%), and elevated liver enzymes (26%). Many of these became even more prevalent during hospitalization. One hundred and sixteen animals were discharged from the hospital, for a survival rate of 80%. There was no survival difference between dogs and cats (P=0.39). Dogs that developed hypokalemia during hospital stay (P=0.04) were more likely to survive compared with those without hypokalemia and initial body temperature was lower for those cats that did not survive (P=0.02). Of those that did not survive, the majority were euthanized (n=25), while 4 dogs died. CONCLUSIONS: Dogs and cats presented to the emergency service with CHF had a high survival rate. In cats, initial body temperature was lower for those cats that did not survive. Although clinicopathologic abnormalities were common in both species, only dogs with hypokalemia had improved survival to hospital discharge.

Clinical investigation of a point-of-care blood ammonia analyzer.

BACKGROUND: Hyperammonemia has frequently been implicated in the pathogenesis of hepatic encephalopathy. Blood ammonia determination requires minimal delay between sampling and analysis for accurate results. OBJECTIVES: The aim of this study was to investigate the PocketChem BA, a new point-of-care (POC) blood ammonia analyzer for clinical use by determining machine precision, linearity, repeatability, and accuracy. METHODS: Coefficients of variation were determined by repeated measurement of 2 control solutions. Linearity was investigated by testing serial dilutions of a stock solution. For accuracy, samples from clinical cases were used to compare the results on the PocketChem BA with those obtained using an enzymatic reference method for canine plasma. Canine and feline patients were consecutively enrolled if blood ammonia was assayed and samples could be analyzed shortly after collection. Classification of results (as normal or high, using 100 micromol/L as a cutoff value), Bland-Altman and Deming regression plots, and intraclass correlation coefficients were used to compare the methods. Stability of samples and test strips also was assessed over time. RESULTS: Coefficients of variation were 10.6% and 4.8% for low and high controls, respectively. Concentrations of ammonia in diluted stock solutions correlated positively with mean measured concentrations (Pearson coefficient 0.988, P<.001). Of the 54 samples obtained from 38 dogs and 4 cats, 41 had ammonia concentrations within the readable range. Results from the POC analyzer and the reference method were correlated positively (intraclass coefficient 0.800, 95% confidence interval 0.655-0.888), with the POC analyzer having negative constant and proportional biases. The methods agreed in the classification of 45/54 (83.3%) samples, with 7 false negative results on the POC analyzer. Results of repeated sample and strip analyses at 1 and 24 hours were significantly different (P<.05) from those at 0 hour. CONCLUSIONS: The PocketChem BA has acceptable precision, adequate linearity, and satisfactory agreement with a reference method, but negative constant and proportional biases. The POC analyzer may be suitable for clinical use in patients suspected of having hepatic encephalopathy, using a lower reference limit of 60 mumol/L to decrease false negative results.