Small Animal Critical Care Medicine

Small Animal Critical Care Medicine
Copyright page
Contributors
Preface
Acknowledgments
Dedication
Reference Ranges
Part I: Key Critical Care Concepts
1 Evaluation and Triage of the Critically Ill Patient
Key Points
Introduction
Triage Systems
Initial Patient Triage
Primary Survey
Respiratory system evaluation
Cardiovascular system evaluation
Neurologic system evaluation
Urinary system evaluation
Additional considerations
Triage Diagnostics: Vascular Access, Emergency Database, and Focused Ultrasound
Secondary Survey
Summary
References
2 Physical Examination and Daily Assessment of the Critically Ill Patient
Key Points
Physical Examination
Airway and Breathing
Circulation
Heart rate
Mucous membrane color
Capillary refill time
Venous distention
Pulse quality
Auscultation
Level of Consciousness
Temperature
Hydration
Abdominal Palpation and Gastrointestinal Assessment
Monitoring and Laboratory Data
Oncotic Pull, Total Protein, and Albumin
Glucose
Electrolyte and Acid-Base Balance
Oxygenation and Ventilation
Red Blood Cell and Hemoglobin Concentrations
Blood Pressure
Coagulation
Renal Function and Urine Output
Immune Status, Antibiotic Dosage and Selection, and White Blood Cell Count
Drug Dosages and Metabolism
Nutrition
Nursing Care
References
3 Cardiopulmonary Resuscitation
Key Points
Preparedness and Prevention
Basic Life Support
Circulation: Chest Compressions
Airway and Breathing—Ventilation
Monitoring
Electrocardiography
Capnography
Advanced Life Support
Drug Therapy
Vasopressors
Parasympatholytics
Antiarrhythmic drugs
Reversal agents
Intravenous fluids
Corticosteroids
Alkalinizing agents
Electrical Defibrillation
Open-chest CPR
Prognosis
References
4 Post–Cardiac Arrest Care
Key Points
Propagating Sustained Rosc
Systemic Response to Ischemia and Reperfusion: Sepsis-Like Syndrome
Hemodynamic Optimization
Glycemic Control
Adrenal Dysfunction
Post–Cardiac Arrest Brain Injury
Brain Injury Sustained During Ischemia Versus During Reperfusion
Controlled Reoxygenation
Mild Therapeutic Hypothermia
Other Neuroprotective Treatment Strategies
Neurologic Assessment and Prognostication
Myocardial Dysfunction
Persistent Precipitating Pathology
References
5 Shock
Key Points
Clinical Presentation
Diagnostics and Monitoring
Monitoring Tissue Perfusion and Oxygen Delivery
Blood Lactate Levels
Cardiac Output Monitoring and Indices of Oxygen Transport
Mixed Venous Oxygen Saturation (SvO2) and Central Venous Oxygen Saturation (ScvO2)
Treatment
References
6 Systemic Inflammatory Response Syndrome
Key Points
Systemic Inflammation
The Consequences of Systemic Inflammation
SIRS and Sepsis
Potential Markers of Sepsis
Treatment of SIRS in Humans
SIRS in Small Animals
Summary
References
7 Multiple Organ Dysfunction Syndrome
Key Points
Epidemiology
Pathophysiology
Immune Dysregulation
Coagulation
Mitochondria
Gastrointestinal Tract
Specific Organ Dysfunction
Lung
Cardiac
Liver
Gastrointestinal
Kidneys
Central Nervous System
Coagulation and the Endothelium
Scoring Systems
Sequential Organ Failure Assessment (SOFA)
Multiple Organ Dysfunction (MOD) Score
Logistic Organ Dysfunction System (LODS)
Predisposition Infection Response Organ (PIRO) Dysfunction
Which Score To Use?
Management
Cardiovascular Support
Ventilatory Strategies
Renal Replacement Therapy
Nutritional Support and Glucose Control (see Chapters 127 to 130)
Corticosteroids
Novel Therapeutic Approaches
References
8 Hypotension
Key Points
Normal Determinants of Blood Pressure
Potential Causes of Hypotension
Reduction in Preload
Reduction in Cardiac Function
Reduction in Systemic Vascular Resistance
Response to Decreases in Blood Pressure
Diagnosis of Hypotesion
Physical Examination
Measurement of Blood Pressure
Direct blood pressure monitoring
Indirect blood pressure measurement
Doppler ultrasonography
Oscillometric sphygmomanometry
Additional Diagnostics
Treatment of Hypotension
Fluid Resuscitation
Positive Inotropes
Vasopressor Agents
Summary
References
9 Hypertensive Crisis
Key Points
Pathophysiology
Blood Pressure Measurement
Target Organ Damage
Ocular
Neurologic
Renal
Cardiovascular
Patients at Risk for Hypertension
Hypertensive Urgency
Hypertensive Emergency
Treatment
Therapeutic Goals
Follow-up
References
10 Hyperthermia and Fever
Key Points
Thermoregulation
Hyperthermia
True Fever
Exogenous Pyrogens
Endogenous Pyrogens
Inadequate Heat Dissipation
Heat Stroke
Hyperpyrexic Syndrome
Exercise-Induced Hyperthermia
Pathologic and Pharmacologic Hyperthermia
Benefits and Detriments of Fever
Benefits
Detriments
Clinical Approach to the Hyperthermic Patient
Nonspecific Therapy for Febrile Patients
The Febrile Intensive Care Patient
References
11 Interstitial Edema
Key Points
Microvascular Filtration
Lymphatic Drainage
Serosal Transudation
Antiedema Mechanisms
Mechanisms of Edema Formation
Venous Hypertension
Hypoproteinemia
Increased Microvascular Permeability
Impaired Lymph Flow
Inflammatory Edema
Chronic Edemagenic Conditions
Conclusion
References
12 Patient Suffering in the Intensive Care Unit
Key Points
Maslow’s Hierarchy of Needs and Primal Alert Signals
Impact of Symptom Relief
Palliative Measures
References
13 Illness Severity Scores in Veterinary Medicine
Key Points
Applications of Illnes Severity Scores
Applications for the Individual Patient
Inappropriate Score Use
Applications in Triage and Clinician Performance Benchmarking
Research Applications
Use of Illness Severity Scores in the Management of Confounding
Demonstration of Effective or Ineffective Randomization
Provision of Objective Context
Reduction of Required Sample Sizes
Critical Evaluation of Illness Severity Scores
Assessment of Model Validity
Discrimination and Calibration
Model Transferability
Veterinary Models: Disease Specific and Disease Independent
Features of Model Construction
Selection of Predictive Variables
Outcome Selection
Model-Building Process
APPLE Scores
Summary
References
Part II: Respiratory Disorders
14 Oxygen Therapy
Key Points
Arterial Oxygen Content
Indications for Oxygen Therapy
Methods of Oxygen Administration
Humidification
Noninvasive Methods
Flow-by oxygen
Face mask
Oxygen hood
Oxygen cage
Invasive Methods
Nasal prongs
Nasal and nasopharyngeal oxygen
Transtracheal oxygen
Hyperbaric Oxygen
Complications of Oxygen Therapy
Oxygen Toxicity
References
15 Hypoxemia
Key Points
Collection of Blood Samples for In Vitro Measurement
Recognition of Hypoxemia
PaO2
SpO2
Cyanosis
Mechanisms of Hypoxemia
Low Inspired Oxygen
Hypoventilation
Venous Admixture
Regions of low ventilation-perfusion (V/Q) ratio
Regions of zero V/Q
Diffusion impairment
Anatomic Shunts
Estimating the Magnitude of the Venous Admixture
PaCO2 + PaO2 Added Value (“The 120 rule”)
Alveolar-Arterial PO2 Gradient
PaO2/FiO2 Ratio
Venous Admixture (Shunt) Calculation
References
16 Hypoventilation
Key Points
Definitions
Control of Breathing
Central Neuronal Control of Breathing
Central and Peripheral Chemoreceptors
Lung Receptors
Respiratory Mechanics and Muscular Control
Differential Diagnosis
Clinical Signs
Diagnosis
Treatment
References
17 Upper Airway Disease
Key Points
History and Clinical Signs
Emergency Stabilization
Diagnostics
Diseases of the Upper Airway
Brachycephalic Airway Syndrome
Nasopharyngeal Polyps
Nasopharyngeal Stenosis
Congenital Choanal Atresia
Nasopharyngeal Foreign Bodies and Infection
Laryngeal Paralysis
Inflammatory Laryngeal Disease
Tracheal Collapse
Tracheal Stenosis/Stricture
Tracheal Foreign Bodies
Upper Airway Neoplasia
Complications of Upper Airway Obstruction
References
18 Brachycephalic Syndrome
Key Points
Pathophysiology
Respiratory Consequences
Consequences of Chronic Upper Airway Obstruction
Management of Upper Airway Obstructive Crises in BD
Gastrointestinal Consequences
Systemic Consequences
Summary
References
19 Tracheal Trauma
Key Points
Causes
Pathophysiology
Clinical Signs
Differential Diagnosis and Diagnostic Testing
Treatment
Outcome and Prognosis
References
20 Allergic Airway Disease in Dogs and Cats and Feline Bronchopulmonary Disease
Key Points
Definition of Allergic Airway Disease
Human Asthma
Pathogenesis of Small Animal Allergic Respiratory Disease
Parasitic Allergic Airway Disease
Canine Allergic Bronchitis or Eosinophilic Bronchopneumopathy
Pulmonary Infiltrates with Eosinophils
Feline Bronchopulmonary Disease
Pathogenesis
Clinical Signs
Laboratory Diagnostic Tests
Radiology
Bronchoscopy
Treatment of Allergic Airway Disease and Feline Bronchopulmonary Disease
Glucocorticoids
Bronchodilators
Miscellaneous Drugs and Other Therapies
Prognosis
References
21 Pulmonary Edema
Key Points
Pathophysiology
Clinical Presentation
High-Pressure Edema
Cardiogenic edema
Fluid therapy
Increased-Permeability Edema
Mixed-Cause Edema
Diagnostic Tests
Treatment
Oxygen Therapy
Medical Therapy
Fluid Therapy
Prognosis
References
22 Pneumonia
Key Points
Clinical Presentation
Initial Evaluation
History
Physical Examination
Diagnostic Testing
Pathophysiology
Mechanism
Causes
Treatment
Additional Management Considerations
Contagion and Zoonosis
Monitoring
Prognosis and Outcome
References
23 Aspiration Pneumonitis and Pneumonia
Key Points
Definitions
Aspiration Pneumonitis
Aspiration Pneumonia
Aspiration Pneumonitis and Pneumonia
Epidemiology
Pathophysiology
Diagnosis
History
Physical examination
Radiography and computed tomography
Tracheal wash
Bronchoscopy and bronchoalveolar lavage
Complete blood cell count and serum biochemistry
Oxygenation status
Biomarkers
Treatment
Airway management
Oxygen therapy
Mechanical ventilation
Antimicrobial therapy
Bronchodilators
Cardiovascular support
Chest physiotherapy
Glucocorticoids
Prevention
References
24 Acute Lung Injury and Acute Respiratory Distress Syndrome
Key Points
The Human Perspective
Criteria for the Diagnosis of ALI/ARDS
Pathophysiology
Treatment
The Canine Perspective
Criteria for the Diagnosis of ALI/ARDS
Treatment
References
25 Pulmonary Contusions and Hemorrhage
Key Points
Pathophysiology and Pathology
Diagnosis
Physical Findings
Imaging: Radiology, Computed Tomography, and Ultrasound
Blood Gas Analysis and Pulse Oximetry
Management
Initial Approach
Oxygen Therapy and Ventilation
Fluid Therapy
Analgesia
Antimicrobial Therapy
Glucocorticoids
Other Therapies
Prognosis and Outcome
Atraumatic Pulmonary Hemorrhage
Diagnostic Evaluation
Treatment
Prognosis and Outcome
References
26 Pulmonary Thromboembolism
Key Points
Pathophysiology
History and Clinical Signs
Physical Examination
Diagnostic Testing
Treatment and Prophylaxis
Summary
References
27 Chest Wall Disease
Key Points
Chest Wall Anatomy and Function
Diagnosis of Chest Wall Disease
Diseases of the Chest Wall
Congenital
Neoplasia
Rib Fractures
Trauma
Flail chest and intercostal muscle damage
Penetrating wounds
Nontraumatic rib fractures
Cervical Spine Disease
Neuromuscular Disease (see Chapter 85)
Tick paralysis
Acute idiopathic polyradiculoneuritis
Botulism
Fulminant myasthenia gravis
Elapidae snake envenomation
References
28 Pleural Space Disease
Key Points
Pleural Space
Clinical Evaluation
Pleural Effusion
Pure Transudates and Modified Transudates
Exudates
Feline Infectious Peritonitis
Pyothorax
Chylothorax
Hemothorax
Neoplastic Effusions and Pleural Neoplasia
Fibrosing Pleuritis
Pneumothorax
Space-Occupying Lesions
Diaphragmatic Hernia
References
29 Nonrespiratory Look-Alikes
Key Points
PH and PCO2 Receptor Activation
PO2 Receptor Activation
Cortical Modification of Respiration
Thermal Receptor Changes
Electrolyte Imbalances and Metabolic Disease
Peripheral Nervous System Disease
Central Nervous System Disease
Clinical Evaluation
Summary
References
Part III: Mechanical Ventilation
30 Basic Mechanical Ventilation
Key Points
Compliance
The Ventilator Breath
Ventilator Settings
Indications for Mechanical Ventilation
Approach to Initiation of Mechanical Ventilation
Goals
Carbon Dioxide
Oxygen
Maintenance of Mechanical Ventilation
Complications
Troubleshooting
Prognosis
References
31 Advanced Mechanical Ventilation
Key Points
Ventilator Concepts
Respiratory Cycle
Equation of Motion
Defining the Ventilator Mode
Breath Type
Control Variable
Phase Variables
Trigger variable
Cycle variable
Limit variable
Baseline variable
Breath Pattern
Continuous mandatory ventilation
Continuous spontaneous ventilation
Intermittent mandatory ventilation
Ventilator Mode
Respiratory Rate and Inspiratory-to-Expiratory Ratio
Positive End-Expiratory Pressure
Ventilator Alarms
Low Airway Pressure Alarm
High Airway Pressure Alarm
Low Tidal Volume Alarm
High Tidal Volume Alarm
Lung-Protective Ventilation
Setting Optimal PEEP
Recruitment Maneuvers
Patient–Ventilator Asynchrony
References
32 Jet Ventilation
Key Points
Physics and Physiology
Equipment
Indications
Disadvantages
Monitoring of Gas Exchange during Jet Ventilation
Ventilator Settings
References
33 Ventilator Waveforms
Key Points
Waveform Types
General
Waveforms in Different Ventilation Modes
Pressure Waveform
Flow Waveform
Volume Waveform
Pressure-Volume Loops
Flow-Volume Loops
Patient–Ventilator Dyssynchrony
Summary
References
34 Care of the Ventilator Patient
Key Points
Anesthesia
Monitoring
Airway Management
Endotracheal Tube
Humidification
Airway Suctioning
Oral Care
Eye Care
Urinary Care
Gastrointestinal Tract
Recumbent Patient Care
Apparatus Care
References
35 Discontinuing Mechanical Ventilation
Key Points
When to Wean
Anesthetic Considerations
Weaning Prediction
Weaning a Patient From Mechanical Ventilation
Spontaneous Breathing Trials
Pressure Support Ventilation
Synchronized Intermittent Mandatory Ventilation
Tracheostomy and Weaning
Monitoring
Failure to Wean
Extubation
Prognosis
References
36 Ventilator-Induced Lung Injury
Key Points
Definitions
Introduction
Evidence From Experimental Models
Stretch Injury
Shear Injury
Biotrauma
Histopathology
Pneumothorax
Oxygen Toxicity
Clinical Relevance
Prevention
Conventional Mechanical Ventilation Strategies
Low tidal volume
Positive end-expiratory pressure
Limitation of plateau pressure
Using the Pressure-Volume Loop to Guide Settings
Avoid Patient–Ventilator Asynchrony
Other Strategies
Advanced Pulmonary Support Techniques
References
37 Ventilator-Associated Pneumonia
Key Points
Pathogenesis
Diagnosis
Prevention
Nonpharmacologic Strategies
Pharmacologic Strategies
Treatment
References
Part IV: Cardiac Disorders
38 Mechanisms of Heart Failure
Key Points
Neurohormonal Aspects of Heart Failure
Renin-Angiotensin-Aldosterone System
Sympathetic Nervous System
Natriuretic Peptide System
Endothelin and Vasopressin Systems
Myocardial Remodeling
Abnormal Calcium Ion Handling
Abnormal Myocardial Energy Production
Global Cardiac Function
The Frank-Starling Mechanism as a Key to Understanding Heart Failure
Diastolic Heart Dysfunction
Clinical Staging and Assessment of Heart Failure
Clinical Manifestations of Heart Failure
Low output versus congestive failure
Left-sided versus right-sided heart failure
References
39 Cardiogenic Shock
Key Points
Pathophysiology
Clinical Signs and Diagnosis
Systolic Dysfunction
Failure of Contractility
Dilated cardiomyopathy
Sepsis
Endomyocarditis
Myocardial infarction
Mechanical Failure
Diastolic Failure
Cardiac Tamponade
Hypertrophic Cardiomyopathy
Tachyarrhythmias
Bradyarrhythmias
References
40 Ventricular Failure and Myocardial Infarction
Key Points
Basic Terminology
Causes of Ventricular (Systolic) Failure
Primary Causes
Secondary to Other Cardiac Disease
Extracardiac Causes
Myocardial Infarction
Physical Examination
Diagnostic Tests
Pathophysiology
Treatment
Supporting Contractility and Maintaining Blood Pressure
Relieving Signs of Congestion
Suppressing Arrhythmias
Treating the Underlying Cause
References
41 Feline Cardiomyopathy
Key Points
Etiopathogenesis
Pathophysiology
Diastolic Dysfunction
Systolic Anterior Motion of the Mitral Valve
Feline Arterial Thromboembolism (FATE)
Clinical Presentation
Patient History and Physical Findings
Electrocardiography
Radiography
Echocardiography
Systemic Blood Pressure
Bloodborne Cardiac Biomarkers
Diagnostic Approach
Therapeutic Approach
Management of FATE
Management of Acutely Decompensated Heart Failure
Management of Chronic Heart Failure
References
42 Canine Cardiomyopathy
Key Points
Dilated Cardiomyopathy
Physical Examination
Thoracic Radiography
Electrocardiography
Routine Blood Tests
Effusion Analysis
Echocardiography
Acute Treatment of Congestive Heart Failure
Long-Term Treatment of Dilated cardiomyopathy
Diuretics
Angiotensin-Converting Enzyme Inhibitors
Digoxin
Pimobendan
Novel Therapy
Diet
Supplements
Treatment of Arrhythmias
Breed Variations with DCM
Cocker Spaniels
Doberman Pinschers
Dalmatians
Great Danes and Irish Wolfhounds
Portuguese Water Dogs
Arrhythmogenic Right Ventricular Cardiomyopathy in Boxers
Electrocardiography
Treatment of Arrhythmogenic Right Ventricular Cardiomyopathy
Hypertrophic Cardiomyopathy in Dogs
Pathologic Features
Important Differentials for Concentric Hypertrophy of the Left Ventricle
Uncommon Myocardial Diseases of Dogs
Duchenne Cardiomyopathy
Atrioventricular Myopathy
Toxic Myocardial Disease
References
43 Valvular Heart Disease
Key Points
Pathology
Pathophysiology
History and Physical Examination
Laboratory Evaluation
Electrocardiographic Findings
Radiographic Findings
Echocardiographic Findings
Emergency Management
Cardiac Output
Tissue Oxygenation
Arrhythmia Management and Adjunctive Therapy
Monitoring
Long-Term Therapy
Prognosis
Infectious Endocarditis
References
44 Myocardial Contusion
Key Points
Incidence
Etiology, Mechanism of Injury, and Pathophysiology
Diagnosis
Treatment
Summary
References
45 Pericardial Diseases
Key Points
Pericardial Effusion
Hemorrhagic Pericardial Effusion
Hemangiosarcoma
Heart base tumors
Other neoplasia
Idiopathic (benign) pericardial effusion
Transudative Pericardial Effusion
Exudative Pericardial Effusion
Cardiac Tamponade
Clinical Presentation
Physical Findings with Tamponade
Diagnosis
Thoracic Radiographs
Echocardiography
Electrocardiography
Central Venous Pressure
Clinicopathologic Findings
Pericardial Fluid Analysis
Management of Cardiac Tamponade
Pericardiocentesis
Preparation and Positioning
Pericardiocentesis Procedure
Complications of Pericardiocentesis
Ancillary Treatment
Idiopathic Pericardial Effusion
Neoplastic Pericardial Effusion
Infectious Pericarditis
Constrictive Pericardial Disease
Clinical Features
Diagnosis
Treatment
Congenital Pericardial Disease
Clinical Features
Diagnosis
Treatment
References
46 Bradyarrhythmias and Conduction Disturbances
Key Points
Definition
Differential Diagnosis
Sinus Bradycardia
Sinus Node Dysfunction
Atrioventricular Block
Atrial Standstill
Treatment
Medical Treatment
Pacemaker Therapy
Transcutaneous pacing
Temporary transvenous pacing
References
47 Supraventricular Tachyarrhythmias
Key Points
Historical Data
Physical Examination Findings
Examining the Electrocardiogram
Distinguishing Supraventricular from Ventricular Tachyarrhythmias
Diagnosing Atrial Versus Atrioventricular Node–Dependent Tachyarrhythmias
Treatment of Supraventricular Tachyarrhythmias
Emergent Therapy
Long-Term Therapy
Medical treatment
Catheter ablation
References
48 Ventricular Tachyarrhythmias
Key Points
Introduction
Electrocardiographic Diagnosis
Approach to the Patient with Ventricular Tachycardia
Noncardiac Causes of Ventricular Tachycardia
Cardiac Causes of Ventricular Tachycardia
Antiarrhythmic Treatment
Decision to Treat
Antiarrhythmic Drugs
Lidocaine
Procainamide
β-Blockers
Sotalol
Amiodarone
Magnesium sulfate
Other Treatments
Anesthesia
Electrical therapies
Postintervention Monitoring
References
49 Myocarditis
Key Points
Infectious Myocarditis
Viral Myocarditis
Protozoal Myocarditis
Chagas’ disease
Bacterial and Other Causes of Myocarditis
Noninfectious Myocarditis
Doxorubicin Toxicity
Diagnosis
Treatment
References
Part V: Electrolyte and Acid-Base Disturbances
50 Sodium Disorders
Key Points
Distribution of Total Body Water
Osmolality and Osmotic Pressure
Regulation of Plasma Osmolality
Antidiuretic hormone
Thirst
Prioritization of Osmolality and Effective Circulating Volume
Total Body Sodium Content Versus Plasma Sodium Concentration
Hypernatremia
Etiology
Free water deficit
Sodium excess
Clinical Signs
Physiologic Adaptation to Hypernatremia
Treatment of the Normovolemic, Hypernatremic Patient
Complications of Therapy for Hypernatremia
Hyponatremia
Etiology
Decreased effective circulating volume
Hypoadrenocorticism
Diuretics
Syndrome of inappropriate antidiuretic hormone secretion
Other causes of hyponatremia
Clinical Signs
Physiologic Adaptation to Hyponatremia
Treatment of the Normovolemic, Hyponatremic Patient
Patients asymptomatic for hyponatremia
Patients symptomatic for hyponatremia
Complications of Therapy for Hyponatremia
Pseudohyponatremia
Volume Expansion in the Hypovolemic, Hyponatremic, or Hypernatremic Patient
References
51 Potassium Disorders
Key Points
Normal Distribution of Potassium in the Body
Hypokalemia
Definition and Causes
Consequences
Management of Hypokalemia
Anticipated Complications
Hyperkalemia
Definition and Causes
Consequences
Pseudohyperkalemia
Treatment of Hyperkalemia
References
52 Calcium Disorders
Key Points
Calcium Homeostasis
Calcium Measurement
Sample Handling Techniques
Ionized Versus Total Calcium
Hypercalcemia
Clinical Signs and Diagnosis
Differential Diagnoses
Treatment of Hypercalcemia
Hypocalcemia
Clinical Signs and Diagnosis
Differential Diagnoses
Treatment
References
53 Magnesium and Phosphate Disorders
Key Points
Magnesium
Hypomagnesemia
Causes
Clinical signs
Diagnosis
Therapy
Hypermagnesemia
Causes
Clinical signs
Diagnosis
Therapy
Phosphate
Hypophosphatemia
Causes
Clinical signs
Diagnosis
Therapy
Hyperphosphatemia
Causes
Clinical signs
Diagnosis
Treatment
References
54 Traditional Acid-Base Analysis
Key Points
Sample Collection and Handling
Traditional Approach
PCO2
Bicarbonate
Base Excess
Total Carbon Dioxide
Anion Gap
Compensation
Acid-Base Analysis
Causes of Acid-Base Abnormalities
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
Metabolic Alkalosis
Bicarbonate Therapy
Dose and Administration
References
55 Nontraditional Acid-Base Analysis
Key Points
The Stewart Approach
Strong Ion Difference
Total Weak Acids (ATOT)
Strong Ion Gap
Semi-Quantitative Approach
Free Water Effect
Chloride Effect
Albumin Effect
Phosphate Effect
Lactate Effect
Unmeasured Ions (XA)
Conclusion
Clinical Examples
Case 1
Case 2
References
56 Hyperlactatemia
Key Points
Introduction
Biochemistry
Physiology
Lactate Pharmacokinetics in Health
Lactate Pharmacokinetics in Disease
Etiology of Hyperlactatemia
Type A Hyperlactatemia
Increased oxygen demand
Decreased oxygen delivery
Type B Hyperlactatemia
Type B1
Type B2
Type B3
Hyperlactatemia Without Metabolic Acidosis
d-Lactate
Clinical Use
Prognostic Use
Diagnostic Use
Lactate as a Therapeutic Endpoint
References
Part VI: Fluid Therapy
57 Assessment of Hydration
Key Points
Introduction
Physiologic Definitions
Variability in Assessing Hydration
Distribution and Control of Total Body Water
Measuring Total Body Water
Clinical Assessment of Hydration Status
Interstitial Volume Changes
Intravascular Volume Changes
Intracellular Volume Changes
Hypotonic Fluid Loss
Isotonic Fluid Loss
Special Challenges
Conclusion
References
58 Crystalloids, Colloids, And Hemoglobin-Based Oxygen-Carrying Solutions
Key Points
Crystalloids
Isotonic Fluids
Hypotonic Fluids
Hypertonic Fluids
Acid-Base Effects of Crystalloids
Colloids
Synthetic Starch Colloids
Allogenic Blood Products
Human Albumin
Hemoglobin-Based Oxygen-Carrying Solutions
Conclusion
References
59 Daily Intravenous Fluid Therapy
Key Points
Total Body Water
Movement of Fluids Within the Body
Isotonic Fluid Loss
Hypotonic Fluid Loss
Hypertonic Fluid Loss
Increased Vascular Permeability
Fluid Therapy Plan
Fluid Deficit
Maintenance Fluid Therapy
Ongoing Losses
Route of Administration
Fluid Type
Replacement Fluids
Maintenance Fluids
Free Water Administration
Synthetic Colloids
Monitoring
Discontinuation of Fluid Therapy
References
60 Shock Fluids and Fluid Challenge
Key Points
Administration of Shock Fluids
Resuscitation Endpoints and Monitoring
Shock Fluids
Isotonic Crystalloids
Adverse effects
Synthetic Colloids
Hetastarch
Tetrastarch
Pentastarch
Adverse effects
Hypertonic Solutions
Adverse effects
Albumin
Blood Products
Hypotensive Resuscitation
Fluid Challenge
References
61 Transfusion Therapy
Key Points
Indications for Transfusion Therapy
Red Blood Cell Transfusions
Fresh Frozen Plasma
Other Blood Products
Blood Typing
Canine Blood Types
Feline Blood Types
Blood Crossmatching
Blood Donors and Sources
Blood Collection
Administration of Blood Products
Adverse Transfusion Reactions
Alternatives
References
62 Prevention and Treatment of Transfusion Reactions
Key Points
Complications of Blood Products Transfusions
Monitoring
Severe Transfusion Reactions in the Canine
Severe Transfusion Reactions in Felines
Additional Diagnostics
Storage Lesions
Leukoreduction
Future Directions
References
63 Massive Transfusion
Key Points
Electrolyte Disturbances
Hemostatic Defects
Hypothermia
Metabolic Acidosis
Immunosuppression and Wound Healing
Acute Lung Injury
Other Immunologic Transfusion Reactions
Nonimmunologic Transfusion Reactions
Recommendations for Management
Outcome
References
Part VII: Endocrine Disorders
64 Diabetic Ketoacidosis
Key Points
Pathophysiology
Risk Factors
Clinical Signs and Physical Examination Findings
Clinical Pathology
Differential Diagnosis
Treatment
Outcome
References
65 Hyperglycemic Hyperosmolar Syndrome
Key Points
Pathogenesis
Hormonal Alterations
Reduction of Glomerular Filtration Rate
Influence of Concurrent Disease
History and Clinical Signs
Physical Examination
Diagnostic Criteria
Additional Diagnostic Evaluation
Treatment
Fluids
Insulin
Electrolytes
Treating Concurrent Disease
Monitoring
Postcrisis Therapy
Prognosis
References
66 Hypoglycemia
Key Points
Normal Glucose Homeostasis
Clinical Signs and Consequences of Hypoglycemia
Diagnosis of Hypoglycemia
Causes of Hypoglycemia
Excess Insulin or Insulin Analogs
Exogenous insulin overdose
Insulinoma
Paraneoplastic hypoglycemia
Toxins and medications
Inadequate Glucose Production
Hypoglycemia of neonates and toy breed dogs
Hepatic disease
Hypocortisolism and other counterregulatory hormone deficiencies
Excess Glucose Utilization
Infection
Exercise-induced hypoglycemia
Polycythemia and leukocytosis
Treatment of Hypoglycemic Crisis
References
67 Diabetes Insipidus
Key Points
Urine Concentration Mechanism
Vasopressin Secretion and Sodium Homeostasis
Antidiuretic Effects of Vasopressin
Central Diabetes Insipidus
Nephrogenic Diabetes Insipidus
Diagnosing Diabetes Insipidus
Modified Water Deprivation Test
Problems and risks
Causes of misdiagnoses
Associated risks
Desmopressin Acetate Trial
Imaging After a Diagnosis of CDI
Treatment of Diabetes Insipidus
Emergency Treatment
Prognosis
References
68 Syndrome Of Inappropriate Antidiuretic Hormone
Key Points
Causes
Clinical Signs
Laboratory Findings
Diagnostic Imaging Findings
Diagnosis
Treatment
Prognosis
References
69 Thyroid Storm
Key Points
Pathogenesis
High Levels of Circulating Thyroid Hormones
Rapid, Acute Increases in Circulating Thyroid Hormones
Hyperactivity of the Sympathetic Nervous System
Increased Cellular Response to Thyroid Hormones
Precipitating Events
Clinical Signs
Diagnosis
Laboratory Abnormalities
Treatment
Reduction in Production or Secretion of New Thyroid Hormones
Inhibition of Peripheral Effects of Thyroid Hormone
Systemic Support
Eradication of the Precipitating Factor
Outcome
References
70 Hypothyroid Crisis in the Dog
Key Points
Pathophysiology
Risk Factors
Clinical Signs and Physical Examination Findings
Clinical Pathology
Differential Diagnosis
Treatment
Outcome
References
71 Pheochromocytoma
Key Points
Clinical Signs
Diagnosis
Treatment
Preoperative Treatment
Anesthesia and Monitoring
Surgical Excision
Postoperative Monitoring and Complications
Medical Treatment
Prognosis
References
72 Critical Illness–Related Corticosteroid Insufficiency
Key Points
Background
Suspected Pathophysiology
Clinical Manifestations
Diagnosis of CIRCI
Veterinary Data
Treatment of CIRCI
Veterinary Data
Prognosis
References
73 Hypoadrenocorticism
Key Points
Who is Affected?
Etiology
Clinical Presentation
History
Physical Examination
Clinicopathologic Findings
Electrocardiographic Findings
Diagnostic Imaging
Diagnosis
Treatment
Fluid Therapy
Initial Hormonal Replacement
Supportive Therapies
Timeline for Clinical Improvement
Associated Disorders
Prognosis
References
Part VIII: Therapeutic Drug Overdose
74 Approach to Drug Overdose
Key Points
Obtaining an Appropriate History
Triage
When to Decontaminate
Activated Charcoal (AC)
Multidose Activated Charcoal
Contraindications and Complications of Activated Charcoal Administration
Cathartics
Treatment
Fluid Therapy
Gastrointestinal Support
Neurologic Support
Sedatives and Reversal Agents
Hepatoprotectants
Miscellaneous
Intravenous Lipid Emulsion
Conclusion
References
75 Blood Purification for Intoxications and Drug Overdose
Key Points
Methods
Toxin Overview
Considerations
Ethylene Glycol
Acetaminophen
Nonsteroidal Antiinflammatory Drugs
Mushrooms
Barbiturates
Lily Ingestion
Summary
References
76 Nonsteroidal Antiinflammatory Drugs
Key Points
COX-1, COX-2, and Prostaglandins
Potential Adverse Effects
Gastrointestinal Effects
Renal Effects
Hepatic Effects
Coagulation Effects
Bone and Cartilage Effects
Neurologic Effects
Drug Interactions with NSAIDs
Toxic Dosage
Clinical Signs
Diagnosis of NSAID Toxicity
Treatment
Asymptomatic Patients
Symptomatic Patients
Prognosis
Client Education
References
77 Sedative, Muscle Relaxant, and Narcotic Overdose
Key Points
Sedative Overdose
Mechanism of Action
Pharmacokinetics
Clinical Signs
Treatment
Muscle Relaxant Overdose
Mechanism of Action
Pharmacokinetics
Clinical Signs
Treatment
Prognosis
Narcotic Overdose
Mechanism of Action
Pharmacokinetics
Clinical Signs
Treatment
Prognosis
References
78 Calcium Channel Blocker and β-Blocker Drug Overdose
Key Points
Method of Action
Calcium Channel Blockers
Cardiac effects
Vascular effects
Pancreatic effects
β-Blockers
Cardiac effects
Pulmonary, pancreatic, gastrointestinal, vascular, and renal effects
Pharmacokinetics
Calcium Channel Blockers
β-Blockers
Diagnosis of Overdose
Therapy
Asymptomatic Patients
Decontamination
Symptomatic Patients
Calcium salts
Parasympatholytics and sympathomimetics
Vasopressin
Glucagon
Hyperinsulinemia and euglycemia
Intravenous lipid emulsion
Mechanical support
Supportive Care
Conclusion
References
79 Serotonin Syndrome
Key Points
Definition
Serotonin and Pathophysiology of Serotonin Syndrome
Clinical Signs
Toxicity
Diagnosis and Treatment
Prognosis
References
Part IX: Neurologic Disorders
80 Deteriorating Mental Status
Key Points
States of Consciousness
Normal
Obtunded
Stupor or Semicoma
Coma
Neuroanatomy
Cerebrum
Reticular Activating System
Etiology of Lesions
Evaluation
Level of Consciousness
Motor Activity
Respiratory Patterns
Pupil Size and Reactivity
Oculocephalic Reflex
Diagnostic Approach
Treatment
References
81 Coma Scales
Key Points
Intracranial Pressure After Head Trauma
Neurologic Assessment
Modified Glasgow Coma Scoring System
Levels of Consciousness
Limb Movements, Posture, and Reflexes
Neuroophthalmologic Examination
Pupils
Eye movements
Coma Scales and Long-Term Functional Outcome
The Future of Coma Scales
References
82 Seizures and Status Epilepticus
Key Points
Definitions
Classification
Pathophysiology
Etiology
Diagnostic Plan
History
Age and Breed
Physical Examination
Neurologic Examination
Minimum Database
Diagnostic Tests for Intracranial Disease
Treatment Plan
Status Epilepticus
Pharmacologic Therapy for Status Epilepticus
Benzodiazepines
Barbiturates
Propofol
Chronic Seizure Disorders
References
83 Spinal Cord Injury
Key Points
Pathophysiology
Localization
Spinal Cord Segments S1-S3
Spinal Cord Segments L4-S1
Spinal Cord Segments T3-L3
Spinal Cord Segments C6-T2
Spinal Cord Segments C1-C5
Spinal Shock
Diagnosis
Treatment
Prognosis
Acknowledgment
References
84 Intracranial Hypertension
Key Points
Physiology of Intracranial Pressure
Intracranial Fluid Dynamics
Cerebrospinal Fluid Flow
Brain Water Movement
Cerebral Blood Flow
Intracranial Pressure
Homeostatic Responses of the Brain
Volume buffering
Autoregulatory mechanisms
Pressure autoregulation
Chemical autoregulation
Partial Pressure of Arterial Carbon Dioxide.
Partial Pressure of Arterial Oxygen.
Cerebral Metabolic Rate of Oxygen Consumption.
Cushing Response
Causes of Intracranial Hypertension
Clinical Aspects of Intracranial Hypertension
Level of Consciousness
Brainstem Reflexes
Size and reactivity of pupils
Resting eye position, eye movements, and oculovestibular reflexes
Corneal reflexes
Respiration
Motor Responses
Posture
Diagnosis of Intracranial Hypertension
Treatment of Intracranial Hypertension
General Supportive Care
Prevent hypoxia
Prevent hypotension
Guidelines for Specific Therapy of Intracranial Hypertension
Maintain adequate cerebral perfusion pressure
Decrease cerebral venous blood volume
Control PaCO2
Control PaO2
Reduce cerebral edema with hyperosmolar fluid therapy
Mannitol
Hypertonic Saline
Furosemide
Glucocorticoids
Other Drugs
Cerebral metabolic rate of oxygen consumption
Surgical therapy
Other considerations
Prognosis
References
85 Diseases of the Motor Unit
Key Points
Identifying Neuropathies, Junctionopathies, and Myopathies
Clinical Signs
Clinicopathologic Testing
Electrophysiologic Testing
Nerve and Muscle Biopsy
Imaging
Causes of Acute Neuropathy, Myopathy, or Junctionopathy
Acute Neuropathies
Neuropathies Associated with Specific Cranial Nerves
Trigeminal neuritis
Trigeminal nerve sheath tumor
Facial nerve paralysis
Laryngeal paralysis
Traumatic Neuropathies
Acute Polyneuropathies
Metabolic causes
Neoplasia
Toxoplasmosis and neosporosis
Acute polyradiculoneuritis
Aortic thromboembolism
Intoxications
Myopathies
Inflammatory Myopathies
Generalized polymyositis
Masticatory myositis
Noninflammatory generalized myopathies
Megaesophagus
Junctionopathies
Acquired myasthenia gravis
Botulism
Tick paralysis
Snake bites
Aminoglycoside intoxication
References
86 Tetanus
Key Points
Etiology
Pathogenesis
Clinical Presentation
Diagnosis
Treatment
Neutralization of Unbound Toxin
Removal of Source of Infection
Control of Rigidity and Spasms
Supportive Intensive Care
Prognosis
References
87 Vestibular Disease
Key Points
Neuroanatomy of the Vestibular System
Nerve Pathways to the Extraocular Muscles
Neuron 1
Neuron 2
Nerve Pathways to the Spinal Cord
Nerve Pathways to the Cerebellum
Clinical Signs
Specific Signs of Vestibular Dysfunction
Head tilt
Nystagmus
Ataxia
Signs That May Be Associated with Vestibular Dysfunction
Facial paresis, paralysis, and hemifacial spasm
Horner’s syndrome
Conscious proprioception deficits
Hemiparesis or tetraparesis
Circling, leaning, and falling
Altered mental state
Multiple cranial nerve dysfunction
Decerebellate posturing
Vomiting
Differential Diagnosis of Acute Vestibular Disease
Diagnostic Approach to the Animal with Acute Vestibular Disease
Minimum Database
Otoscopy and Pharyngeal Examination
Radiography
Myringotomy
Brainstem Auditory Evoked Potentials
Cerebrospinal Fluid Analysis
Advanced Imaging
Treatment and Prognosis
References
88 Hepatic Encephalopathy
Key Points
Causes
Pathophysiology
Clinical Signs
Diagnosis
Treatment
References
Part X: Infectious Disorders
89 Nosocomial Infections and Zoonoses
Key Points
Nosocomial Infections in Dogs and Cats
Risk Factors
Multiple Antibiotic–Resistant Nosocomial Pathogens
Zoonoses
Emerging Nosocomial Infections in Dogs and Cats
Nosocomial Infection Prevention and Control
Conclusion
References
90 Febrile Neutropenia
Key Points
Neutrophil Physiology
Neutrophil Function
Neutrophil Production
Pathophysiology of Neutropenia
Increased Utilization
Decreased Egress from the Bone Marrow
Depletion of granulocyte progenitor cells
Infectious diseases
Medications, toxicants, and radiation
Myelophthisis
Cyclic hematopoiesis
Ineffective granulopoiesis despite normal to excessive quantities of progenitor cells
Immune-Mediated Destruction
Clinical Presentation and Diagnostic Tests
Treatment and Supportive Care
References
91 Sepsis and Septic Shock
Key Points
Definitions and Clinical Manifestations
Pathogenesis of the Septic Systemic Inflammatory Response
Microbial Factors
Host Response to Bacterial Infection
Loss of Homeostatic Mechanisms in Sepsis
Loss of vasomotor tone
Dysregulation of inflammation and coagulation
Endothelial, microcirculatory, and mitochondrial abnormalities
Epidemiology
Septic Foci, Diseases, and Pathogens Associated with Sepsis
Resuscitation and Treatment of Sepsis, Severe Sepsis, and Septic Shock
Introduction to the Bundle Concept
Bundle Element: Lactate
Bundle Element: Samples for Culture (Blood, Tissue, or Fluid Cultures)
Bundle Element: Early Source Control and Early Antibiotic Administration (see Chapters 175 to 182)
Bundle Element: Treat Hypotension with Fluids and Possibly Vasopressors
Assessment of volume status and responsiveness
Fluid choice
Hypotension despite volume resuscitation (septic shock)
Bundle Element: Target Central Venous Pressure and Central Venous Pressure and ScvO2
Conclusion
References
92 Mycoplasma, Actinomyces, and Nocardia
Key Points
Nonhemotropic Mycoplasmas
Etiology and Clinical Syndromes
Respiratory Infections
Urogenital Associated Infections
Other Infections
Diagnosis
Treatment
Actinomycosis and Nocardiosis
Etiology and Clinical Syndromes
Clinical Signs
Diagnosis
Treatment
References
93 Gram-Positive Infections
Key Points
Gram-Positive Cell Structure and Pathogenicity
Streptococcal Infections
Enterococcal Infections
Staphylococcal Infections
Empiric Antibiotic Strategies
References
94 Gram-Negative Infections
Key Points
Gram-Negative Cell Structure and Pathogenicity
Identification of Gram-Negative Bacteria of Medical Importance
Enterobacteriaceae
Nonfermenting Gram-Negative Bacteria
Resistance among Gram-Negative Pathogens
Therapy for Gram-Negative Infections
References
95 Fungal Infections
Key Points
Blastomycosis
Clinical Signs
Diagnosis
Prognosis
Histoplasmosis
Clinical Signs
Diagnosis
Prognosis
Coccidioidomycosis
Clinical Signs
Diagnosis
Prognosis
Cryptococcosis
Clinical Signs
Diagnosis
Prognosis
Treatment
Respiratory Supportive Therapy
Gastrointestinal Supportive Therapy
Ocular Supportive Therapy
Other Supportive Therapy
References
96 Viral Infections
Key Points
Canine Distemper Virus Infection
Canine Influenza Virus Infection
Other Emerging Respiratory Viral Infections of Dogs
Feline Panleukopenia
Feline Respiratory Viral Disease
Feline Infectious Peritonitis
References
97 Canine Parvovirus Infection
Key Points
Evolution of Canine Parvovirus 2
Signalment
Pathogenesis
Clinical Signs
Diagnosis
Clinicopathologic Findings
Diagnostic Imaging
Treatment
Fluid Therapy
Antibiotics
Antiemetics
Nutrition
Antiviral Drugs
Gastric Protectants
Controversial Treatments
Vaccination
Prevention of Transmission
Acknowledgement
References
98 Infective Endocarditis
Key Points
Pathophysiology
Microbial Adherence and Endothelial Invasion
Congestive Heart Failure
Immune-Mediated Disease
Thromboembolism
Incidence, Signalment, and Presenting Complaint
Predisposing Factors
Etiologic Agents
Clinical Abnormalities
Clinicopathologic Abnormalities
Diagnosis
Echocardiography
Blood Culture
Modified Duke Criteria for Diagnosis of Infective Endocarditis
Treatment
Prognosis
References
99 Urosepsis
Key Points
Pathogenesis
Causes of Urosepsis
Pyelonephritis
Bladder Rupture
Prostatic Infection
Pyometra
Catheter-Associated Urinary Tract Infection
Conclusion
References
100 Mastitis
Key Points
Anatomy: Brief Overview
Etiology
Clinical Findings
Acute Mastitis
Chronic or Subclinical Mastitis
Diagnosis
Differential Diagnoses
Treatment
References
101 Necrotizing Soft Tissue Infections
Key Points
Diagnosis
Laboratory Findings
Imaging
Definitive Diagnosis
Treatment
Antimicrobial Therapy
Surgical Debridement
Postoperative Care
Hyperbaric Oxygen
Conclusion
References
102 Catheter-Related Bloodstream Infection
Key Points
Definition
Incidence
Diagnosis
Treatment
Prevention
References
103 Multidrug-Resistant Infections
Key Points
Definitions
Risk Factors for Multidrug-Resistant Pathogens
Escalation Versus De-Escalation Therapy
Specific Multidrug-Resistant Pathogens
Methicillin-Resistant Staphylococcus
Enterococcus
Pseudomonas aeruginosa
β-Lactamase–Producing Gram-Negative Bacteria
References
Part XI: Hematologic Disorders
104 Hypercoagulable States
Key Points
Mechanisms of Thrombophilia
Endothelial Disturbances
Increased Procoagulant Elements
Decreased Endogenous Anticoagulants
Perturbations in Fibrinolysis
Diagnostics
Common Conditions in Veterinary Medicine
Systemic Inflammation
Protein-Losing Nephropathy
Immune-Mediated Hemolytic Anemia
Hypercortisolemia
Cardiomyopathies
Neoplasia
Isolated Brain Injury
Management of Hypercoagulable Conditions
Treatment of the Underlying Condition
Recombinant Anticoagulant Therapy
Antithrombotic Therapy
Inflammatory conditions
Protein-losing nephropathy
Immune-mediated hemolytic anemia
Hypercortisolemia
Cardiomyopathies
Neoplasia
Isolated brain injury
Conclusion
References
105 Bleeding Disorders
Key Points
Hemostasis and Fibrinolysis
Hemostatic Testing
Platelet Enumeration and Estimation
Buccal Mucosal Bleeding Time
The Prothrombin Time and Activated Partial Thromboplastin Time
Fibrin Split Products
D-dimers
Fibrinogen Concentration
Thrombin Time
Thromboelastography and Thromboelastometry
Etiology
Hypocoagulability in the Critically Ill or Injured Patient
Dilutional Coagulopathy
Hypothermia
Acidemia
Diagnosis
History
Physical Examination
Hemostatic Testing
Principles of Management
Plasma and Platelet transfusion
Prohemostatic Agents
Desmopressin
Antifibrinolytics
Specific Conditions
Thrombocytopenia
Thrombopathia
Inherited Coagulopathies
Vitamin K Deficiency
Hepatic Failure
Trauma-Induced Coagulopathy
Disseminated Intravascular Coagulation
Delayed Postoperative Bleeding in Greyhound Dogs
References
106 Thrombocytopenia
Key Points
Causes
Thrombocytopenia in the Critically Ill
Diagnostic Techniques for Thrombocytopenia
Mechanisms of Thrombocytopenia
Decreased Production
Consumption
Sequestration
Increased Destruction
Therapeutic Approaches to Thrombocytopenia
Platelet Transfusions
References
107 Platelet Disorders
Key Points
Inherited Disorders
Extrinsic Disorders
Intrinsic Disorders
Acquired Disorders
Drugs
von Willebrand’s Disease
Uremia
Treatment Summary
References
108 Anemia
Key Points
Signalment and History
Clinical Signs
Laboratory Tests
Therapeutic Principles
Summary
References
109 Methemoglobinemia
Key Points
Pathophysiology
Oxidation in the Erythrocyte
Heinz Bodies
Specific Causes of Erythrocyte Oxidation
Acetaminophen
Topical Benzocaine
Skunk Musk
Nitrites and Nitrates
Hydroxycarbamide
Methemoglobin Reductase Deficiency
Diagnosis
Clinical Signs
Determining Methemoglobin Presence and Levels
Treatment
N-Acetylcysteine
Methylene Blue
Adjunctive Treatments
References
110 Acute Hemolytic Disorders
Key Points
Evaluation of the Patient with Hemolysis
Fragmentation Hemolysis
Toxicant-Induced Hemolysis
Heritable Hemolysis
Infection-Related Hemolysis
Infection of Red Blood Cells
Systemic Infections
Immune-Mediated Hemolysis
Findings Suggestive of Immune-Mediated Hemolytic Anemia
Treatment of Immune-Mediated Hemolytic Anemia
Immune suppression
Supportive care
Prevention of complications
Other Causes of Immune-Mediated Hemolytic Anemia
References
111 Rodenticides
Key Points
Anticoagulant Rodenticides
Pathophysiology and Clinical Signs
Case Management
Acute ingestion
Coagulopathies
Outcome
Cholecalciferol
Pathophysiology and Clinical Signs
Case Management
Acute ingestion
Hypercalcemia
Outcome
Bromethalin
Pathophysiology and Clinical Signs
Case Management
Acute ingestion
Neurologic complications
Outcome
Miscellaneous Rodenticides
References
Part XII: Intraabdominal Disorders
112 Acute Abdominal Pain
Key Points
Diagnostic Evaluation
Signalment and History
Physical Examination
Emergency Clinical Pathology
Abdominal Radiographs
Abdominal Fluid Analysis
Surgical Versus Medical Management
References
113 Acute Pancreatitis
Key Points
Pathophysiology
Clinical Presentation
Diagnosis
Laboratory Assessment
Diagnostic Imaging
Cytology and Histopathology
Additional Diagnostic Evaluation
Determining Severity
Treatment
Resuscitation, Fluid Therapy, and Monitoring
Pain Management
Nutrition
Additional and Supportive Therapy
Antibiotic Therapy
Surgery
Outcome
Conclusion
References
114 Acute Cholecystitis
Key Points
Clinical Findings
Common Causes of Cholecystitis in Dogs and Cats
Infectious Agents
Bacteria
Parasites
Obstruction
Gallbladder Mucocele
Gallbladder Infarction
References
115 Hepatitis and Cholangiohepatitis
Key Points
Historical Findings
Physical Examination Findings
Mechanisms of Hepatocellular Injury
Causes of Hepatitis and Cholangiohepatitis in Dogs and Cats
Idiopathic Causes
Feline cholangitis complex
Neutrophilic Cholangitis
Lymphocytic Cholangitis
Canine chronic hepatitis
Role of Copper
Nonspecific reactive hepatitis
Viral Causes
Infectious canine hepatitis
Feline infectious peritonitis
Bacterial Causes
Leptospirosis
Bartonellosis
Septicemia
Drugs and Toxins
References
116 Hepatic Failure
Key Points
Pathophysiology
Hepatic Encephalopathy
Coagulation Disorders
Other
Clinical Signs
Diagnosis
Therapy
Prognosis
Future Therapies
References
117 Gastroenteritis
Key Points
Anatomy and Physiology
History and Clinical Signs
Causes
Infectious Gastroenteritis
Viral enteritis
Bacterial enteritis
Parasitic gastroenteritis
Fungal gastroenteritis
Hemorrhagic Gastroenteritis
Dietary Indiscretion
Protein-Losing Enteropathy
Extraintestinal Diseases
Diagnosis
Treatment
Conclusion
References
118 Motility Disorders
Key Points
Megaesophagus
Etiology and Clinical Signs
Diagnosis and Treatment
Gastric Emptying Disorders
Etiology and Clinical Signs
Diagnosis and Treatment
Small Intestinal Transit Disorders
Etiology and Clinical Signs
Diagnosis and Treatment
Megacolon
Etiology and Clinical Signs
Diagnosis and Treatment
Prokinetic Drugs for Gastrointestinal Motility Disorders
Serotonergic Drugs
Cisapride
Metoclopramide
Ghrelin Mimetics and Motilin Receptor Agonists
Acetylcholinesterase Inhibitors
References
119 Gastrointestinal Hemorrhage
Key Points
Etiology
History and Physical Examination
Diagnostic Tests
Tests to Help Detect Presence of Gastrointestinal Hemorrhage
Tests to Help Identify Underlying Causes
Treatment
Medical Management
Endoscopy, Interventional Radiology, and Surgery
Prognosis
References
120 Regurgitation and Vomiting
Key Points
Differentiation of Vomiting and Regurgitation
Regurgitation
Definition
Clinical Consequences of Regurgitation
Differential Diagnoses
Diagnostic Approach
History
Physical examination
Clinical pathology
Diagnostic imaging
Further diagnostic testing
General Treatment Guidelines
Prognosis
Vomiting
Definition
Physiology of Vomiting
Clinical Consequences of Vomiting
Differential Diagnoses
Diagnostic Approach
History
Physical examination
Clinical pathology
Diagnostic imaging
General Treatment Guidelines
Conclusion
References
121 Diarrhea
Key Points
Pathophysiologic Mechanisms of Diarrhea
Iatrogenic Causes of Diarrhea
Primary Gastrointestinal Causes of Diarrhea
Extragastrointestinal Diseases Causing Diarrhea
Diagnostic Evaluation
Treatment
References
122 Peritonitis
Key Points
Clinical Signs
Diagnostic Tests
Treatment
Medical Stabilization
Surgical Treatment
Postoperative Care
Prognosis
References
123 Gastric Dilatation-Volvulus
Key Points
Pathogenesis
Pathophysiology
History and Clinical Signs
Physical Examination
Diagnosis
Treatment Goals
Surgical Treatment
Postoperative Care
Owner Recommendations
References
Part XIII: Urogenital Disorders
124 Acute Kidney Injury
Key Points
Etiology
Pathophysiology
Clinical Presentation
History
Physical Examination
Diagnosis
Laboratory Tests
Imaging
Other Diagnostic Modalities
Treatment
Fluid Therapy
Diuretics
Acid-Base and Electrolyte Balance
Management of Gastrointestinal Signs
Nutritional Support
Renal replacement therapy
Fluid administration during recovery phase polyuria
Specific Treatments
Prognosis
References
125 Chronic Kidney Disease
Key Points
Etiology
Pathophysiology
Clinical Presentation
Diagnosis
Laboratory Tests
Imaging
Other Diagnostic Modalities
Treatment
Fluid Therapy
Acid-Base and Electrolyte Balance
Management of Gastrointestinal Signs
Nutritional Support
Management of Anemia
Long-Term Management
Dietary Therapy
Fluid Therapy
Additional Considerations
Advanced Therapeutic Modalities
Prognosis
References
126 Pyometra
Key Points
Incidence
Pathogenesis
Diagnosis
Signalment
History and Physical Examination
Diagnostic Imaging
Laboratory Findings
Treatment
Stabilizing the Patient
Surgical Management
Medical Management
Uterine Stump Pyometra
References
Part XIV: Nutrition
127 Nutritional Assessment
Key Points
Impacts of Nutritional Support during Critical Illness
Screening Systems Used for Nutritional Assessments
Body Weight
Body Composition
Adipose Tissue
Body condition score systems
Lean Body Mass
Muscle condition scoring
Diet History
Current intake
Historical intake
Laboratory Data
Conclusion
References
128 Nutritional Modulation of Critical Illness
Key Points
Omega-3 Fatty Acids
Antioxidants
Immune-Modulating Nutrients
Arginine
Glutamine
Nucleotides
Probiotics
Conclusion
References
129 Enteral Nutrition
Key Points
Determining the Route of Nutritional Support
Enteral Versus Parenteral
Oral Intake Versus Enteral Feeding Device
Enteral Feeding Tubes
Nasoesophageal or Nasogastric Tubes
Esophagostomy Tube
Gastrostomy Tube
Jejunal Tubes
Determining the Amount to be Fed
Selecting the Diet
Patient Variables
Nonpatient Variables
Monitoring Therapy
Preventing and Managing Complications
Patient-Related Complications
Non–Patient-Related Complications
References
130 Parenteral Nutrition
Key Points
Technical Requirements
Vascular Access
Monitoring and Nursing Care
Formulating and Compounding Nutrient Admixtures
Nutritional Assessment
Prescription Formulation
Calculation of Energy Requirements
Calculation of Protein Requirements
Calculation of Lipid and Carbohydrate Requirements
Calculation of Micronutrient Requirements
Delivery and Monitoring
Preventing and Managing Complications
Catheter and Parenteral Nutrition Admixture Complications
Metabolic Complications
References
Part XV: Surgical and Postoperative Conditions
131 Perioperative Evaluation of the Critically Ill Patient
Key Points
Preoperative Patient Evaluation
Respiratory Resuscitation
Cardiovascular Resuscitation
Pain
ASA Scoring
Global Assessment
Laboratory Testing
Coagulation
Blood Type and Crossmatch
Kirby’s Rule of Twenty
The Postoperative Period
Airway and Breathing
Ventilation and Oxygenation
Oxygen Delivery
Arrhythmias, Decreased Myocardial Contractility, and Hypotension
Analgesia
Hypothermia
Laboratory Parameters
Coagulation
Acid-Base and Electrolyte Status
Patient Cleanliness, Wound and Catheter Care, and Bandaging
Patient Immobilization and Physical Therapy
Nutrition
Summary
References
132 Portosystemic Shunt Management
Key Points
Preoperative Stabilization
Medical Management
Surgical Options
Postoperative Monitoring
Postoperative Complications
Portal Hypertension
Coagulopathy
Neurologic Complications
Prognosis
References
133 Peritoneal Drainage Techniques
Key Points
Indications for Peritoneal Drainage
Septic Peritonitis
Chemical Peritonitis
Other Indications for Peritoneal Drainage
Techniques for Peritoneal Drainage
Needle or Catheter Paracentesis
Paracentesis with a Fenestrated Catheter per the Mini-Laparotomy Method
Paracentesis with a Fenestrated Catheter Using the Seldinger Technique
Surgical Placement of Closed Suction Drains
Open Peritoneal Drainage Technique
Vacuum-Assisted Drainage
Complications of Peritoneal Drainage
Volume and Albumin Loss
Conclusion
References
134 Postthoracotomy Management
Key Points
Immediate Postthoracotomy Assessment
Analgesia
Postthoracotomy Pain Syndrome in Humans
Ventilation
Hypoxemia
Hypovolemia
Complications and Mortality after Thoracotomy
Hypothermia
Thoracostomy Tube Care
Conclusion
References
135 Kidney Transplantation
Key Points
Indications
Case Selection
Evaluation of the Urinary Tract
Cardiovascular Disease
Infectious Disease
Donor Selection
Preoperative Management
Immunosuppression for the Feline Renal Transplant Recipient
Anesthetic Management
Surgery
Postoperative Management and Perioperative Complications
Long-Term Management and Complications
Canine Transplantation
Conclusion
References
136 Minimally Invasive Procedures
Key Points
Instrumentation
Approaches/Access
Scope-Guided Procedures
Laparoscopic/thoracoscopic procedures
Tracheoscopy/bronchoscopy
Esophagoscopy/gastroscopy/duodenoscopy
Cystourethroscopy
Interventional Radiology Procedures
Urethral stenting
Ureteral stenting
Tracheal stenting
Cavity effusions and percutaneous drainage
Intravascular foreign body removal
Epistaxis
Vascular obstructions
References
Part XVI: Trauma
137 Traumatic Brain Injury
Key Points
Incidence and Prevalence of Head Injury
General Approach to the Patient with a Head Injury
Pathophysiology
Primary Injury
Secondary Injury
Neurologic Assessment
Diagnostic Tests and Monitoring
Treatment
Extracranial Therapy
Intracranial Therapy
Hyperosmotic agents
Corticosteroids
Furosemide
Decreasing cerebral blood volume
Seizure treatment/prophylaxis
Decreasing cerebral metabolic rate
Prognosis
References
138 Thoracic and Abdominal Trauma
Key Points
Trauma Categories
Blunt Trauma
Penetrating Trauma
Diagnostics
Clinical Laboratory Tests
Imaging
Fluid Analysis
Stabilization
Monitoring
Antimicrobial Therapy
Fluid Therapy/Blood Product Administration
External Wound Care
Specific Conditions
Diaphragmatic Rupture
Body Wall Rupture/Abdominal Evisceration
Chylothorax/Chylous Ascites
Pyothorax
Septic Peritonitis
Bile Peritonitis
Hemothorax/Hemoperitoneum/Hemoretroperitoneum
Uroperitoneum/Uroretroperitoneum
Prognosis
References
139 Wound Management
Key Points
Wound Healing Principles
Wound Classification
Phases of Healing
Initial Patient Assessment
Debridement and Lavage
Sugar and Honey
Dressing and Bandaging
Exposed Bone
Wound Closure
Drains
Negative Pressure Wound Therapy
Additional Wound Management Modalities
Antimicrobial Therapy
Patient Care
Complications
Prognosis
References
140 Thermal Burn Injury
Key Points
Definitions
Patient Assessment and Medical Management
Metabolic Derangements
Nutrition
Patient Comfort
Antimicrobial Therapy
Burn Wound Management
Topical Agents
Closure Options and Healing
Complications
References
Part XVII: Anesthesia and Pain Management
141 Pain and Sedation Assessment
Key Points
Definition of Pain
Pain Versus Stress
Pain Assessment
Behavior
Tools
Summary
References
142 Sedation of the Critically Ill Patient
Key Points
Patient Evaluation and Management
Choice of Agent
Opioids
Sedatives and Tranquilizers
Benzodiazepines (see Chapter 164 for further details)
Phenothiazine Tranquilizers
α2 Agonists (see Chapter 165 for further details)
Other Anesthetic Agents
Ketamine
Propofol
Sedation of Animals with Specific Conditions
Cardiovascular Instability
Respiratory Disease
Conclusion
References
143 Anesthesia in The Critically Ill Patient
Key Points
Stabilization
Premedication
Induction
Thiopental and Propofol
Alfaxalone
Etomidate
Ketamine
Opioids
Maintenance
Inhalants
Constant Rate Infusion
Neuromuscular Blocking Agents
Benzylisoquinolinium agents
Monitoring of neuromuscular blocking agents
Reversal Agents for neuromuscular blocking agents
Monitoring
Intraoperative Hypotension
Recovery
Summary
References
144 Analgesia and Constant Rate Infusions
Key Points
Analgesia
Opioids
Nonsteroidal Antiinflammatory Drugs
α2-Adrenergic Agonists
Transdermal Analgesics
N-Methyl-D-Aspartate Receptor Antagonists
Acepromazine
Infiltrative and Local Anesthetics
Epidural Analgesics
Constant Rate Infusions
Morphine-Lidocaine-Ketamine
Conclusion
References
145 Rehabilitation Therapy in the Critical Care Patient
Key Points
Musculoskeletal System
Range-of-Motion Exercise
Passive Range-of-Motion Exercise
Active Assisted and Active Range-of-Motion Exercise
Therapeutic Exercise and the Importance of Early Mobilization
Assisted Standing
Walking (Assisted and Unassisted)
Neuromuscular Electrical Stimulation and Transcutaneous Electrical Stimulation
Neuromuscular electrical stimulation
Transcutaneous electrical stimulation
Massage
Respiratory System
Positioning
Postural Drainage
Percussion (Coupage) and Vibration
Summary
References
146 Complementary and Alternative Medicine
Key Points
Acupuncture
Massage Therapy
Laser Therapy
Music Therapy
Herbs
Aromatherapy
Homeopathy and Flower Essences
Conclusion
References
Part XVIII: Environmental Emergencies
147 Smoke Inhalation
Key Points
Pathophysiology
Carbon Monoxide
Hydrogen Cyanide
Thermal Injury
Irritant Gases and Superheated Particulate Matter
Reduced lung compliance
Airway damage and obstruction
Bacterial pneumonia
Dermal Burn Injury
History
Physical Examination
Clinical Evaluation
Arterial Blood Gas Analysis
Acid-Base Status
Thoracic Radiography
Laryngoscopy, Bronchoscopy, and Transtracheal Aspiration
Diagnosis
Treatment
Oxygen Supplementation
Cyanide Toxicity
Airway Management
Sedation
Mechanical Ventilation
Intravenous Fluid Therapy
Additional Therapies
Prognosis
References
148 Hypothermia
Key Points
Classification
Review of Thermoregulation
Physiologic Effects of Hypothermia
Cardiovascular and Hemodynamic Effects
Respiratory Effects
Neuromuscular Effects
Acid-Base Effects
Coagulation Effects
Renal and Metabolic Effects
Core Body Temperature Measurement
Rewarming
Therapy
Cardiopulmonary Resuscitation
Therapeutic Hypothermia
References
149 Heat Stroke
Key Points
Physiology, Pathogenesis, and Pathophysiology
Physical Examination
Temperature, Pulse, and Respiratory Rate
Cardiovascular System
Respiratory System
Central Nervous System
Renal System
Gastrointestinal System
Coagulation System
Laboratory Evaluation
Treatment and Monitoring
Cooling Procedures
Cardiovascular System
Respiratory System
Central Nervous System
Renal System
Coagulation System
Gastrointestinal System
Prognosis
References
150 Electrical and Lightning Injuries
Key Points
Mechanisms of Electrical Injury
Predisposition to Electrical Injury
Clinical Findings
Secondary Effects of Electrical Injury
Treatment of Electrical Injury
Prognosis
Lightning Injury
References
151 Drowning and Submersion Injury
Key Points
Definitions
Incidence and Epidemiology
Humans
Veterinary Patients
Pathophysiology of Injury
Pulmonary System
Fluids and Electrolytes
Neurologic and Cardiovascular Systems
Effect of Water Temperature
Diagnostic Tests and Monitoring
Treatment
Outcome
References
Part XIX: Miscellaneous Disorders
152 Anaphylaxis
Key Points
Pathophysiology
Differential Diagnosis
Clinical Manifestations
Treatment
Epinephrine
Other Vasopressors
Antihistamines
Glucocorticoids
Potential Therapies
Fluid Therapy
Ancillary Patient Management
Prevention
References
153 Air Embolism
Key Points
Gas Embolization Due to Intravenous Access Mishaps
Gas Embolization during Laparoscopic Procedures
Gas Embolization during Surgery
Gas Embolization From Lung Biopsy
Gas Embolization during Hyperbaric Therapy
Detection of Air Emboli
Management of Air Embolism
References
154 Ocular Disease In The Intensive Care Unit
Key Points
Blepharospasm
Red Eye
Tear Film Abnormalities
Absent Palpebral Reflex
Corneal Changes
Anterior Chamber Abnormalities
Pupil Abnormalities
Anisocoria
Miosis
Mydriasis
Dyscoria
Blindness
References
155 Critically Ill Neonatal and Pediatric Patients
Key Points
Physical Examination Findings
Laboratory Values
Imaging
Intravenous and Intraosseous Catheterization
Fluid Requirements
Temperature Control
Nutrition
Monitoring
Pharmacology
Sepsis
Conclusion
References
156 Critically Ill Geriatric Patients
Key Points
Laboratory Values
Imaging
Fluid Therapy
Nutrition
Pharmacology
Conclusion
References
Part XX: Pharmacology
157 Catecholamines
Key Points
Hypotension
Poor Contractility
Catecholamine Choices
Dopamine
Dobutamine
Ephedrine
Norepinephrine
Phenylephrine
Vasopressin
Angiotensin
Epinephrine
Isoproterenol
Dopexamine
Choosing the Right Catecholamine
Combination Therapies
Vasomotor Tone
Catecholamines and Cortisol
Other Effects of Catecholamines
References
158 Vasopressin
Key Points
Physiology of Vasopressin
Vasopressin Receptors
Physiologic Effects of Vasopressin
Pharmacology
Clinical Uses
Cardiopulmonary Resuscitation
Vasodilatory Shock
Hemorrhagic Shock
Central Diabetes Insipidus
von Willebrand Disease
Gastrointestinal and Pulmonary Disease
Adverse Effects
Vasopressin Antagonists
Conclusion
References
159 Antihypertensives
Key Points
Etiology of Hypertension
Proposed Mechanism of Blood Pressure Elevation
Antihypertensive Drugs
Angiotensin-Converting Enzyme Inhibitors
Mechanism of action
Indications
Adverse effects
Angiotensin II Receptor Blockers
Mechanism of action
Indications
Adverse effects
Adrenergic Receptor Antagonists
Mechanism of action
Indications
Adverse effects
Aldosterone Blockers
Mechanism of action and indications
Adverse effects
Calcium Channel Blockers
Mechanism of action
Indications
Adverse effects
Arteriolar Vasodilators
Hydralazine
Mechanism of action and indications
Adverse effects
Sodium Nitroprusside
Mechanism of action and indications
Adverse effects
Fenoldopam
Mechanism of action
Indications
Adverse effects
Hypertensive Urgency
Treatment of Hypertensive Urgency
Hypertensive Emergency
Treatment of Hypertensive Emergency
References
160 Diuretics
Key Points
Physiology of Diuresis and Antidiuresis
Pharmacology
Osmotic Diuretics
Carbonic Anhydrase Inhibitors
Loop Diuretics
Thiazide Diuretics
Aldosterone Antagonists
Other Potassium-Sparing Distal Diuretics
Aquaretics
Indications for Diuretic Therapy
Urinary Diseases
Congestive Heart Failure
Liver Failure
Electrolyte and Mineral Disorders
Systemic Hypertension
References
161 Gastrointestinal Protectants
Key Points
Histamine-2 Receptor Antagonists
Proton Pump Inhibitors
Sucralfate
Prostaglandin Analogs
Antacids
Future Drug Therapy
Potential Complications of Increased Gastric pH
References
162 Antiemetics and Prokinetics
Key Points
Antiemetics
Neurokinin-1 Receptor Antagonists
5-HT3 Receptor Antagonists
Metoclopramide
Promazine Derivatives
Anticholinergic Agents
Other Drugs
Peripherally Acting Antiemetics
Prokinetic Drugs
5-HT4 Serotonergic Agonists
Cholinomimetic Drugs
Motilin Receptor Agonists
Metoclopramide
Misoprostol
References
163 Narcotic Agonists and Antagonists
Key Points
Terminology and History
Opium
Opiate
Opioid
Narcotic
Structure-Activity Relationship
Mechanism of Action
Opioid Receptors
Physiologic Effects of Opioids
Metabolism and Excretion
Potency and Effectiveness of Opioids
Epidural Opioids
Characteristics of Clinically Useful Opioids
Morphine
Methadone
Hydromorphone and Oxymorphone
Fentanyl and Remifentanil
Butorphanol
Nalbuphine
Buprenorphine
Tramadol
Codeine
Opioid Antagonists: Naloxone, Nalmefene, Naltrexone
Conclusion
References
164 Benzodiazepines
Key Points
Action
Diazepam Versus Midazolam
Benzodiazepine Effects
Benzodiazepines and Cats
Indications
Sedation
Anticonvulsant Therapy
Appetite Stimulation
Hepatic Encephalopathy
References
165 α2 Agonists and Antagonists
Key Points
α2 Adrenoceptors
Effects of α2 Agonists
Central Nervous System
Cardiovascular System
Other Effects
Imidazoline Receptors
Drugs
Clinical Use
α2 Antagonists
Conclusion
References
166 Anticonvulsants
Key Points
Seizures
Phenobarbital
Bromide
Zonisamide
Levetiracetam
Benzodiazepines
Gabapentin and Pregabalin
Felbamate
References
167 Antiplatelet Drugs
Key Points
Platelet Physiology
Antiplatelet Drugs
Adenosine Diphosphate Receptor Antagonists
Thienopyridines
Nucleoside analogs
Cyclooxygenase Inhibitors
Fibrinogen Receptor Antagonists
References
168 Anticoagulants
Key Points
Pathogenesis
Indications for Anticoagulant Use
Anticoagulants
Vitamin K Antagonists
Adverse Effects
Monitoring
Heparins
Unfractionated Heparins
Low-Molecular-Weight Heparins
Heparin Dosage
Direct Thrombin Inhibitors
Factor Xa Inhibitors
Conclusion
References
169 Thrombolytic Agents
Key Points
Specific Thrombolytic Agents
Streptokinase
Urokinase
Tissue Plasminogen Activator
Adverse Effects of Thrombolytic Therapy
Thrombolytic Therapy in Dogs
Streptokinase
Urokinase
Tissue Plasminogen Activator
Thrombolytic Therapy in Cats
Streptokinase
Urokinase
Tissue Plasminogen Activator
Conclusion
References
170 Hemostatic Drugs
Key Points
Antifibrinolytic Drugs
Indications
Contraindications
Use of Antifibrinolytic Drugs in Cats
ε-Aminocaproic acid
Tranexamic Acid
Topical Antifibrinolytic Therapy
Desmopressin
Protamine
Conjugated Estrogens
Recombinant Factor VIIa
Yunnan Paiyao
References
171 Antiarrhythmic Agents
Key Points
Classification Schemes
Class I Antiarrhythmic Agents
Class Ia Antiarrhythmic Agents
Class Ib Antiarrhythmic Agents
Class Ic Antiarrhythmic Agents
Class II Antiarrhythmic Agents
Class III Antiarrhythmic Agents
Class IV Antiarrhythmic Agents
Other Antiarrhythmic Agents
Digoxin
Magnesium Sulfate
Adenosine
Antiarrhythmic Devices and Procedures
References
172 Inhaled Medications
Key Points
Introduction
Principles of Aerosol Deposition in the Lungs
Delivery Systems
Jet Nebulizers
Ultrasonic Nebulizers
Metered Dose Inhalers
Clinical Applications
Feline Bronchopulmonary Disease
Inhaled bronchodilators
Inhaled glucocorticoids
Other inhaled medications
Canine Infectious Tracheobronchitis and Pneumonia
Medications for Use with Bronchoscopy
Conclusion
References
173 Complications of Chemotherapy Agents
Key Points
Principles of Chemotherapy
Testing for Chemotherapy Drug Sensitivity
Chemotherapy Drugs
Toxicities and Treatment of Chemotherapy-Related Emergencies
Acute Tumor Lysis Syndrome
Allergic Reactions
Bone Marrow Toxicity
Anemia
Thrombocytopenia
Neutropenia
Sepsis
Cardiotoxicity
Dermatologic Toxicity
Extravasation
Gastrointestinal Toxicity
Cachexia and anorexia
Vomiting
Diarrhea
Neurologic Toxicity
Urologic Toxicity
References
174 Antitoxins and Antivenoms
Key Points
Tetanus Antitoxin
Tick Antitoxin
Botulism Antitoxin
Black Widow Spider Antivenom
Scorpion Antivenom
Snake Antivenom
Production of Poisonous Snake Antivenom
Pit Viper Antivenom
Coral Snake Antivenom
References
175 Antimicrobial Use in the Critical Care Patient
Key Points
Antimicrobial Resistance
Advent of Resistance
Nosocomial Infections
Reducing Microbial Resistance
Antimicrobial Selection and Treatment
Timely Assessment of Need for and Initiation of Antimicrobial Therapy
Identification of the Target and Its Susceptibility
Design of the Dosing Regimen
Role of the minimum inhibitory concentration in the dosing regimen
Site of Infection
Host Immune Response
Impact of Microbial Factors
Adverse Drug Events
Antimicrobial Deescalation
References
176 β-Lactam Antimicrobials
Key Points
Mechanism of Action
Pharmacology
Resistance
Production of β-Lactamase
Changes in Cell Wall Permeability
Selected Penicillins and Cephalosporins
Penicillin G
Extended-Spectrum Penicillins
Antipseudomonal Penicillins
First-Generation Cephalosporins
Second-Generation Cephalosporins
Third-Generation Cephalosporins
Carbapenems
References
177 Aminoglycosides
Key Points
Mechanism of Action
Spectrum of Activity
Indications
Pharmacology and Dosing
Adverse Effects
References
178 Fluoroquinolones
Key Points
Structure and Physical Properties
Mechanism of Action
Bacterial Spectrum
Pharmacokinetics and Pharmacodynamics
Resistance
Clinical Uses
Administration and Drug Interactions
Adverse Effects
References
179 Macrolides
Key Points
Mechanism of Action
Pharmacology
Resistance
Selected Macrolides
Erythromycin
Azithromycin
References
180 Antifungal Therapy
Key Points
Introduction
Classes of Antifungal Drugs
Polyene Antibiotics
Azole Antifungals
Recommendations for Specific Fungal Infections
Blastomycosis
Histoplasmosis
Coccidioidomycosis
Cryptococcosis
References
181 Miscellaneous Antibiotics
Key Points
Metronidazole
Chloramphenicol
Tetracyclines
Potentiated Sulfonamides
Vancomycin
Polymyxins
Clindamycin
Rifampin
Newer Agents Active Against Multidrug-Resistant Gram-Positive Cocci
Daptomycin
Tigecycline
Quinupristin-Dalfopristin
Linezolid
References
182 Strategies for Treating Infections in Critically Ill Patients
Key Points
Bacterial Susceptibility
How to Proceed with Empirical Treatment
Assessing Initial Response
To Escalate or De-escalate?
What to Do if the Initial Empirical Treatment Fails
Penetration to the Site of Infection
Diffusion into Tissues
Urinary Tract
Intracellular Infections
Local Factors That Affect Antibiotic Effectiveness
Pharmacokinetic-Pharmacodynamic Optimization of Doses
Aminoglycosides
Fluoroquinolones
β-Lactam Antibiotics
Other Time-Dependent Drugs
References
Part XXI: Monitoring
183 Hemodynamic Monitoring
Key Points
Continuous Electrocardiogram Monitoring
Blood Pressure Monitoring
Noninvasive Blood Pressure Monitoring
Photoplethysmography
Invasive Blood Pressure Monitoring
Telemetric Blood Pressure Monitoring
Central Venous Pressure Monitoring
Pulmonary Artery Pressure Monitoring
Mixed Venous and Central Venous Oxygen Saturation
Lactate and Base Deficit
References
184 Cardiac Output Monitoring
Key Points
Indications for Cardiac Output Measurement
Measurement of Cardiac Output
Invasive Methods of Determining Cardiac Output
Fick oxygen consumption method
Carbon dioxide rebreathing methods
Indicator dilution method (including thermodilution)
Noninvasive or Minimally Invasive Methods of Determining Cardiac Output
Normal Values
Potential Causes of Error
Disease States and Cardiac Output Measurement
Potential Complications
References
185 Electrocardiogram Evaluation
Key Points
Indications
Electrocardiographic Principles
Technique
Electrocardiogram Waveforms
Electrocardiogram Interpretation
Effects of Disease States on the Electrocardiogram
Electrolyte Abnormalities
Hyperkalemia
Hypokalemia
Hypercalcemia
Hypocalcemia
Magnesium level
Hypoxemia
Intrathoracic Effusions
Pain
References
186 Blood Gas and Oximetry Monitoring
Key Points
Hydrogen Ions
Buffers
Henderson-Hasselbalch Equation
Regulation of pH
Blood Gas Analysis: Getting Started
Temperature Correction
Step-by-Step Acid-Base Analysis
Number 1: Evaluate the pH
Number 2: Evaluate PCO2 (see also Chapter 16)
Number 3: Evaluate the metabolic indices
Number 4: Determine if there is one problem or many
Anion gap
The Stewart approach (see Chapter 55)
Strong Ion Difference.
Strong Ion Gap.
Base Excess Modification.
Number 5: Determine how well the patient is oxygenating (see also Chapter 15)
Pulse oximetry
Number 6: Look at the whole picture
Venous Blood Gas Values
References
187 Colloid Osmotic Pressure and Osmolality Monitoring
Key Points
Colloid Osmotic Pressure
Starling’s Hypothesis
Calculated versus Measured Values
Normal Colloid Osmotic Pressure Values
Colloid Osmotic Pressure in Critically Ill Patients
How Colloid Osmotic Pressure Is Measured
Indications for Colloid Osmotic Pressure Measurement
Osmolality
Definition
Determination of Osmolality
Osmolal Gap
Effective Osmolality
Urine Osmolality
References
188 Intraabdominal Pressure Monitoring
Key Points
Definitions and Incidence
Risk Factors
Pathophysiology
Methods of Intraabdominal Pressure Measurement
Physiologic Effects of Intraabdominal Hypertension
Hemodynamic Effects
Renal Effects
Pulmonary and Thoracic Effects
Central Nervous System Effects
Visceral Effects
Systemic Effects
General Considerations
Acknowledgment
References
189 AFAST and TFAST in the Intensive Care Unit
Key Points
Terminology
Objective of Focused Assessment with Sonography for Trauma
Abdominal Focused Assessment with Sonography for Trauma
AFAST Technique
Abdominal Fluid Score Technique
AFAST for Blunt Abdominal Trauma
AFAST for Penetrating Abdominal Trauma
AFAST for Determining the Cause of Intraabdominal Injury
Thoracic Focused Assessment with Sonography for Trauma
TFAST Technique
Chest Tube Site Views
Pleural line and the bat sign
A-lines
B-lines
Lung curtain
Sonographic signs of pneumothorax
Absence of glide sign and B-lines
Pericardial Chest Site and Subxiphoid Site Views
Emergency Lung Ultrasound to Detect Interstitial-Alveolar Lung Injury
References
190 Capnography
Key Points
Nondiverting and Diverting Monitors
Technology
Physiology
Capnogram Interpretation
Equipment
Patient
References
191 Intracranial Pressure Monitoring
Key Points
Determination of Intracranial Pressure
Intracranial Pressure
Locations for Monitoring Intracranial Pressure in the Brain
Types of Intracranial Pressure Monitoring Devices
Intracranial Pressure Monitoring Systems
Ventriculostomy catheter with external transducer
Transducer-tipped catheters
Subarachnoid bolt
Fluid-filled catheter
Evaluation of Intracranial Pressure
Normal Intracranial Pressure
Accuracy of Intracranial Pressure Monitoring Systems
Complications of Intracranial Pressure Monitoring
Indications for Intracranial Pressure Monitoring in Dogs and Cats
References
192 Urine Output
Key Points
Urine Output as a Monitoring Tool
Measurement of Urine Output
Determinants of Urine Output
Glomerular Filtration Rate
Tubular Reabsorption of Water and Solutes
Impedance to Flow
Normal Urine Output
Abnormal Urine Output
Oliguria
Prerenal oliguria
Postrenal oliguria
Renal oliguria
Polyuria
Prerenal polyuria
Postrenal polyuria
Renal polyuria
Fluid Balance
Case Example
References
Part XXII: Procedures
193 Peripheral Venous Catheterization
Key Points
Catheter Types
Winged or Butterfly Needle
Over-the-Needle Catheter
Through-the-Needle Catheter
Multilumen Catheter
Advantages of Peripheral Venous Catheterization
Catheter Insertion Site
Cephalic Vein
Saphenous Vein
Pedal Veins
Auricular Vein
Insertion Technique
Percutaneous Placement
Facilitative Incision or Relief Hole
Venous Cutdown
Peripherally Inserted Central Venous Catheters
Complications Associated with Catheterization
Phlebitis
Thrombosis
Catheter Embolism
Subcutaneous Fluid Infiltration
Infection
Catheter Maintenance
References
194 Intraosseous Catheterization
Key Points
Historical Perspectives
Physiology
Indications
Contraindications
Methods
Complications
References
195 Central Venous Catheterization
Key Points
General Concepts
Catheter Types
Through-the-Needle Catheter
Over-the-Needle Catheter
Long Single-Lumen Catheter
Multilumen Catheter
Percutaneous Sheath Catheter Introducer
Catheter Insertion Site
Saphenous Vein
Jugular Vein
Catheter Insertion
Through-the-Needle Catheter Insertion
Seldinger Technique
Rewiring of Seldinger Catheters
Peel-Off Sheathed Needle Technique
Complications and Catheter Maintenance
Heparinized Saline
References
196 Blood Film Evaluation
Key Points
Blood Film Preparation
Blood Film Evaluation
White Blood Cell Responses
Red Blood Cell Responses
Platelet Responses
Leukemia (Myeloid and Lymphoid)
References
197 Endotracheal Intubation and Tracheostomy
Key Points
Endotracheal Intubation
Airway Assessment
Routine Intubation
Dogs
Cats
Difficult Intubation
Preoxygenation
Equipment setup
Approach
Alternative Techniques and Adjuncts
Needle cricothyroidotomy
Cricothyroidotomy
Fiberoptic-assisted intubation
Digital palpation
Nasal intubation
Retrograde intubation
Cricoid pressure
Placement Verification
Complications
Tracheostomy
Tracheostomy Tube Selection
Percutaneous Tracheostomy
Surgical Tracheostomy
Transverse incision
Vertical incision
Securing the tracheostomy tube
Tracheostomy Tube Management
Suctioning
Tube Removal
Complications
Summary
References
198 Thoracocentesis
Key Points
Indications
Materials
Techniques
Needle Insertion Techniques
Thoracocentesis using a butterfly needle
Thoracocentesis using a hypodermic needle with a saline-filled hub
Over-the-Needle Catheter Insertion Technique
Thoracocentesis using an over-the-needle intravenous catheter
Thoracocentesis using a thoracostomy tube
Through-the-Needle Catheter Technique
Seldinger Technique
Diagnostic Evaluation of the Aspirate
Postprocedure Care
Complications
References
199 Thoracostomy Tube Placement and Drainage
Key Points
Indications
Thoracostomy Tube Placement
Materials
Anesthesia
Techniques
Drainage
Passive Drainage Techniques
Active Drainage Techniques
Maintenance and Care
Removal
Complications
References
200 Abdominocentesis and Diagnostic Peritoneal Lavage
Key Points
Indications
Focused Assessment with Sonography for Trauma
Technique
Preparation of the Patient
Closed-Needle Abdominocentesis
Open-Needle Abdominocentesis
Four-Quadrant Abdominocentesis
Alternatives to Abdominocentesis
Abdominal Fluid Analysis
Analysis of Diagnostic Peritoneal Lavage Samples
Conclusion
References
201 Arterial Catheterization
Key Points
Patient Preparation
Percutaneous Arterial Catheter Placement
Dorsal Pedal Artery Catheterization
Femoral Artery Catheterization
Auricular Artery Catheterization
Radial Artery Catheterization
Coccygeal Artery Catheterization
Surgical Cutdown for Arterial Catheter Placement
Maintenance of the Arterial Catheter
Three-Syringe Technique
References
202 Pulmonary Artery Catheterization
Key Points
Types of Catheters and Uses
Cardiac Output
Pulmonary Capillary Wedge Pressure
Right Ventricular End-Diastolic Volume
Selective Pulmonary Angiography
Additional Measurements
Indications
Placement
Flow-Directed Placement
Fluoroscopy
Complications
Alternatives
References
203 Temporary Cardiac Pacing
Key Points
Indications for Temporary Cardiac Pacing
Description of the Temporary Pacemaker Systems
Transvenous Pacing System
Transcutaneous Pacing System
Transesophageal Pacing System
Troubleshooting
Transvenous Pacing System
Transcutaneous Pacing System
Transesophageal Pacing System
Complications
Transvenous Pacing System
Transcutaneous Pacing System
Transesophageal Pacing System
References
204 Cardioversion and Defibrillation
Key Points
Definitions
Mechanism of Cardioversion and Defibrillation
Defibrillator-Cardioverter
Approach to Defibrillation
Indications
Preparation
Therapy
Complications
Approach to Synchronized Cardioversion
Indications
Preparation
Therapy
Complications
References
205 Renal Replacement Therapies
Key Points
Principles of Dialysis
Indications
Contraindications
Components of Dialysis
Catheters for Intermittent Hemodialysis and Continuous Renal Replacement Therapy
Catheters for Peritoneal Dialysis
Dialysate
Dialyzer
Anticoagulation
Dialysis Prescription
Complications and Other Considerations
Outcome and Prognosis
Summary
References
206 Apheresis
Key Points
Equipment
Principles of Apheresis
Indications
Myasthenia Gravis
Immune-Mediated Hemolytic Anemia
Future Applications
References
207 Cerebrospinal Fluid Sampling
Key Points
Cerebrospinal Fluid Formation and Functions
Indications for Cerebrospinal Fluid Collection and Analysis
Contraindications and Risks
Cerebrospinal Fluid Collection Techniques
Preparation
Collection Sites and Techniques
Cisternal puncture
Positioning
Needle insertion
Tips for troubleshooting cerebrospinal fluid puncture
Precaution.
Lumbar puncture
Positioning
Note.
Analysis of Cerebrospinal Fluid
Specimen Handling and Examination
Physical Characteristics
Total Cell Count and Differential
Cytologic Analysis
Protein Concentration
Other Tests
Interpretation of Common Findings
References
208 Urinary Catheterization
Key Points
Indications
Intermittent Catheterization
Indwelling Catheter
Risks and Complications
Infection
Mechanical Difficulties
Catheter Types
Materials
Size
Foley Catheters
Placement Technique
Male Dog
Female Dog
Male Cat
Female Cat
Securing the Catheter
Closed Collection System
Care of an Indwelling Urinary Catheter
References
Part XXIII: ICU Design and Management
209 Intensive Care Unit Facility Design
Key Points
The Design Process
Location in the Hospital
Arrangement and Size
Unit Configuration
Staff Work Areas
Patient Care Areas
Patient modules
Procedure area and storage
Isolation room
Ancillary Services
Utilities
Environmental Aspects
Lighting
Air Conditioning
Acoustic Environment
Floor and Wall Surfaces, Ceiling Finishes
Furnishings
Details and Common Design Elements
Infection Prevention and Control
Safety and Security
Patient- and Owner-Centered Care
Ambiance
Communication
References
210 Management of the Intensive Care Unit*
Key Points
Intensive Care Unit Personnel: Staff Qualifications and Scheduling
Role of the Intensive Care Unit Director
Staffing
Veterinarians
Residents and interns
Nursing staff
Scheduling
Staff/Patient Ratio
Management of Intensive Care Unit Staff
Communication
Delegation of Responsibility
Conflict: Causes, Categories, and Resolution
Categories of conflict
Methods of conflict resolution
Conflict prevention
Recruitment of Intensive Care Unit Nursing Staff
Training intensive care unit nurses
Retention of Staff: Handling Stress and Burnout
References
211 Client Communication and Grief Counseling
Key Points
Client Communication
The Human-Animal Bond
Client Expectations
End-of-Life Decisions
Compassion Fatigue
Support for veterinary staff
Communicating with Difficult Clients
Stages of Grief
Types of Grief
Anticipatory Grief
Multiple Losses and “Trigger Grief”
Grief from Expected Loss
Grief from Unexpected Loss
Disenfranchised Grief
Complicating Factors
Financial Considerations
Mental Health History
Children and Loss
Pet Loss and Older Adults
Veterinary Resources
Support Groups
Individual Grief Support Sessions
Lectures, Seminars, and Workshops
Healing Through Pet Loss
Finding Meaning
Memorializing a Pet
References
Appendices
Appendix 1 Clinical Calculations
Appendix 2 Important Physiologic Formulas
Appendix 3 Ideal Gas Laws
Appendix 4 Surviving Sepsis Campaign 2012 Bundle Recommendations for Humans
Appendix 5 Constant Rate Infusion Calculations
Micrograms per Kilogram per Minute
Milligrams per Kilogram per Hour (Using 250 ml bag of fluids)
Appendix 6 Common Drug Dosages for Constant Rate Infusions
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z