Galina M. Hayes

Severe seizures associated with traumatic brain injury managed by controlled hypothermia, pharmacologic coma, and mechanical ventilation in a dog

OBJECTIVE To describe the management and outcome of a dog presenting with intractable seizures associated with traumatic brain injury. CASE SUMMARY A spayed female Wheaten Terrier was presented to an emergency clinic with neurologic deficits (modified Glasgow coma scale of 10) shortly after a road traffic accident. Seizures were uncontrolled despite aggressive pharmacologic intervention. Controlled hypothermia to achieve a rectal temperature of 33-35 degrees C (91.4-95 degrees F) was initiated as a protective measure to reduce intracranial pressure and cerebral metabolic rate, and to assist with seizure control. Intubation and mechanical ventilation were required to protect the airway and manage hypercapnia associated with hypoventilation. The patient went on to make a full recovery, although behavioral changes were noted by the owners for an 8-week period following injury. NEW OR UNIQUE INFORMATION PROVIDED To the authors knowledge, this is the first instance of therapeutic hypothermia reported in the veterinary literature. A short review of this treatment modality is provided.

Retrospective cohort study on the incidence of acute kidney injury and death following hydroxyethyl starch (HES 10% 250/0.5/5:1) administration in dogs (2007-2010).

Objective To determine the incidence of in-hospital adverse outcomes including acute kidney injury (AKI) and death in a population of dogs admitted to the intensive care unit (ICU) receiving 10% hydroxyethyl starch (HES) [250/0.5/5:1] compared with the general ICU population, while controlling for illness severity. Design Cohort study conducted between January 2007 and March 2010. Setting Veterinary teaching hospital. Animals Consecutive sample of dogs receiving HES (n = 180) were compared with a randomly selected sample of dogs (n = 242) admitted to the ICU over the same period. Interventions None Measurements and Main Results AKI was defined as an at least 2-fold increase in baseline creatinine concentration or new onset of oliguria/anuria persisting for ≥12 hours. The primary outcome was a composite of in-hospital death or AKI. Unadjusted and adjusted analysis controlling for illness severity using the acute patient physiologic and laboratory evaluation (APPLEfast) score and other confounders was performed. HES was administered either as incremental boluses (median dose 8.2 mL/kg/day, interquartile range [IQR] 5.0–11.3 mL/kg/day) or as a continuous rate infusion (CRI; median dose 26mL/kg/day, IQR 24.0–48 mL/kg/day). In unadjusted analysis, HES administration was associated with increased risk of mortality (odds ratio [OR] = 2.33, 95% confidence interval [CI] = 1.51–3.58, P < 0.001) or AKI (OR = 3.87, 95% CI = 1.21–12.37, P = 0.02). In an adjusted analysis after controlling for illness severity, admission type, and concurrent administration of blood products, HES administration remained an independent risk factor for the composite adverse outcome (OR = 1.98, 95% CI = 1.22–3.22, P = 0.005), with a number needed to harm (NNH) = 6 (95% CI = 4–23). Conclusions HES therapy is associated with increased risk of an adverse outcome including death or AKI in dogs. A randomized controlled trial investigating the safety of HES therapy in canine patients is warranted.OBJECTIVE To determine the incidence of in-hospital adverse outcomes including acute kidney injury (AKI) and death in a population of dogs admitted to the intensive care unit (ICU) receiving 10% hydroxyethyl starch (HES) [250/0.5/5:1] compared with the general ICU population, while controlling for illness severity. DESIGN Cohort study conducted between January 2007 and March 2010. SETTING Veterinary teaching hospital. ANIMALS Consecutive sample of dogs receiving HES (n = 180) were compared with a randomly selected sample of dogs (n = 242) admitted to the ICU over the same period. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS AKI was defined as an at least 2-fold increase in baseline creatinine concentration or new onset of oliguria/anuria persisting for ≥12 hours. The primary outcome was a composite of in-hospital death or AKI. Unadjusted and adjusted analysis controlling for illness severity using the acute patient physiologic and laboratory evaluation (APPLEfast ) score and other confounders was performed. HES was administered either as incremental boluses (median dose 8.2 mL/kg/day, interquartile range [IQR] 5.0-11.3 mL/kg/day) or as a continuous rate infusion (CRI; median dose 26mL/kg/day, IQR 24.0-48 mL/kg/day). In unadjusted analysis, HES administration was associated with increased risk of mortality (odds ratio [OR] = 2.33, 95% confidence interval [CI] = 1.51-3.58, P < 0.001) or AKI (OR = 3.87, 95% CI = 1.21-12.37, P = 0.02). In an adjusted analysis after controlling for illness severity, admission type, and concurrent administration of blood products, HES administration remained an independent risk factor for the composite adverse outcome (OR = 1.98, 95% CI = 1.22-3.22, P = 0.005), with a number needed to harm (NNH) = 6 (95% CI = 4-23). CONCLUSIONS HES therapy is associated with increased risk of an adverse outcome including death or AKI in dogs. A randomized controlled trial investigating the safety of HES therapy in canine patients is warranted.

A review of local antibiotic implants and applications to veterinary orthopaedic surgery

In the face of increasing incidence of multi-drug resistant implant infections, local antibiotic modalities are receiving increased attention for both infection prophylaxis and treatment. Local antibiotic therapy that achieves very high antibiotic drug concentrations at the site of the implant may represent an avenue for treatment of biofilm-forming bacterial pathogens. Randomized controlled trials in human patients have demonstrated an infection risk reduction when antibiotic-impregnated cement is used for infection prophylaxis in implanted joint prostheses, and when a gentamicin-impregnated collagen sponge is used for infection prophylaxis in midline sternotomy. The other modalities discussed have for the most part yet to be evaluated in randomized controlled trials in veterinary or human patients. In general, the in vivo pharmacokinetics and appropriate dosing profiles for local antibiotic modalities have yet to be elucidated. Toxicity is possible, and attention to the dose applied is warranted.

Refractometric total plasma protein measurement as a cage-side indicator of hypoalbuminemia and hypoproteinemia in hospitalized dogs.

OBJECTIVE To assess the relationship between total plasma protein (TPP) as measured by refractometry and serum hypoalbuminemia and hypoproteinemia in hospitalized dogs. DESIGN Retrospective, observational study conducted over 6-month period between March and August 2008. SETTING University teaching hospital. ANIMALS Four hundred and three hospitalized dogs in an ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS TPP, serum albumin, total protein, glucose, urea, cholesterol was measured from dogs enrolled in study. TPP was evaluated as a predictor for hypoalbuminemia defined both as albumin <25 g/L (<2.5 g/dL) and albumin <20 g/L (<2.0 g/dL), and serum hypoproteinemia, defined as serum total protein <40 g/L (<4.0 g/dL), using logistic regression. Impact of glucose, urea, cholesterol, and total bilirubin on refractometric readings were also assessed. TPP predicted hypoalbuminemia at albumin concentrations of <25 g/L (<2.5 g/dL) and <20 g/L (<2.0 g/dL) (P<0.001). A TPP<60 g/L (<6.0 g/dL) predicted albumin <25 g/L (<2.5 g/dL) with 73% sensitivity and 86% specificity. A TPP<58 g/L (<5.8 g/dL) predicted a serum albumin <20 g/L (<2.0 g/dL) with 70% sensitivity and 80% specificity. For dogs with known risk factors where specificity optimization may be appropriate, refractometer TPP<50 g/L (<5.0 g/dL) and <48 g/L (<4.8 g/dL) predicted hypoalbuminemia at each level with >95% specificity, although sensitivity was poor. Refractometer TPP<58 g/L (<5.8 g/dL) predicted serum total protein of <40 g/L (<40 g/dL) with sensitivity of 82% and specificity of 84%. Hypercholesterolemia and hyperglycemia significantly affected TPP readings; an increase in serum glucose by 10 mmol/L (180 mg/dL) was associated with an average independent increase in refractometer TPP of 2.27 g/L (0.23 g/dL) (P<0.001, 95% confidence interval=1.08-3.47) and an increase in serum cholesterol of 1 mmol/L (38.6 mg/dL) was associated with an average independent increase in refractometer TPP of 1.36 g/L (0.14 g/dL) (P<0.001, 95% confidence interval=1.12-1.59). CONCLUSION Suboptimal sensitivity limits the use of refractometric TPP for prediction of hypoalbuminemia in the context of patient screening; a high proportion of false negatives may result. However, identification of a refractometric TPP<58 g/L is strongly indicative of both serum hypoalbuminemia and hypoproteinemia, with high specificity, and warrants further investigation. Refractometric readings may be falsely increased in patients with hyperglycemia or hypercholesterolemia.

Intra-Articular Pharmacokinetics of a Gentamicin Impregnated Collagen Sponge in the Canine Stifle: An Experimental Study

OBJECTIVE To investigate local and systemic pharmacokinetics of gentamicin after intra-articular implantation of a gentamicin impregnated collagen sponge (GICS) in the inflamed canine joint. STUDY DESIGN Descriptive repeated measures experimental study. ANIMALS Dogs (n = 9). METHODS Stifle joint inflammation was caused by urate injection. Twenty-four hours later a GICS (gentamicin dose, 6 mg/kg) was arthroscopically implanted. Synovial fluid and plasma gentamicin concentrations were measured for 14 days after implantation, and pharmacokinetic parameters modeled using statistical moment analyses. RESULTS Intra-articular gentamicin concentrations fell to sub-MIC for Staphylococcus sp. (4 µg/mL) by 22.4 hours (95% CI: 18.6-26.2) after sponge implantation. Cmax synovial was 2397 µg/mL (95%CI: 1161-3634 µg/mL) at 1.2 hours (95%CI: 0.5-1.8 hours). Plasma gentamicin concentrations achieved levels of Cmax plasma  = 8.0 µg/mL (95%CI: 6.1-10.0 µg/mL) at 1.5 hours (95%CI: 0.8-2.1) after GICS placement and fell below target trough of 2.0 µg/mL by 5.6 hours (95%CI: 4.7-6.5 hours) after GICS placement. CONCLUSIONS Intra-articular gentamicin concentration after GICS placement at an IV-equivalent dose reached high levels and declined rapidly. The maximum plasma levels attained were ∼1/3 of the recommended sub-toxic target for people after parenteral gentamicin administration.

Oral thermal injury associated with puncture of a salbutamol metered-dose inhaler in a dog.

Objective To describe the clinical features, diagnostic work-up, treatment, and outcome of a dog with oral thermal injury secondary to chewing on a salbutamol metered-dose inhaler (MDI). Case Summary A Boxer dog was presented after chewing on a salbutamol MDI. The dog was anxious, tachycardic and had moderate hypokalemia. The dog was treated with potassium supplementation and discharged after 24-hour hospitalization. Five hours after the discharge, the dog represented for dysphagia, anorexia, cervical pain, and a left-sided head tilt. Oral examination revealed edematous and erythematous swelling of the soft palate causing airway compromise; histopathology demonstrated vascular necrosis and infarction. The dog was treated with supportive care including the placement of a tracheostomy tube. The dog recovered fully and was discharged 8 days after initial presentation. New or Unique Information Provided Salbutamol toxicity has been documented previously in dogs but oral thermal injury associated with a salbutamol MDI has not been reported in dogs. Although a rare complication, dogs who have been exposed to MDIs should have a thorough oral exam and be monitored closely for signs of respiratory compromise.OBJECTIVE To describe the clinical features, diagnostic work-up, treatment, and outcome of a dog with oral thermal injury secondary to chewing on a salbutamol metered-dose inhaler (MDI). CASE SUMMARY A Boxer dog was presented after chewing on a salbutamol MDI. The dog was anxious, tachycardic and had moderate hypokalemia. The dog was treated with potassium supplementation and discharged after 24-hour hospitalization. Five hours after the discharge, the dog represented for dysphagia, anorexia, cervical pain, and a left-sided head tilt. Oral examination revealed edematous and erythematous swelling of the soft palate causing airway compromise; histopathology demonstrated vascular necrosis and infarction. The dog was treated with supportive care including the placement of a tracheostomy tube. The dog recovered fully and was discharged 8 days after initial presentation. NEW OR UNIQUE INFORMATION PROVIDED Salbutamol toxicity has been documented previously in dogs but oral thermal injury associated with a salbutamol MDI has not been reported in dogs. Although a rare complication, dogs who have been exposed to MDIs should have a thorough oral exam and be monitored closely for signs of respiratory compromise.