Case Studies In Small Animal

Cardiovascular Medicine

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Case 11

Joey was seen again about 6 weeks after his last clinic visit on a Sunday on the Emergency Service. He came in dehydrated and hypothermic due to low cardiac output. This is a classic case of a dog that is on high dose diuretic therapy undergoing an event that is stressful and/or that results in him becoming anorexic and not drinking while the diuretic administration continues. In Joey's case, he probably became anorexic or partially anorexic for several days prior to admission as he had lost considerable weight. Then he was put outside one night and not taken in again until the next morning (access to water during that time is unknown; overnight temperature at this time of year is in the 50 to 60 degree F range). Owners must always be told to contact a veterinarian if a dog stops eating and especially if it stops drinking or is drinking less or to stop the diuretic therapy if this happens until they can contact a veterinarian. After Joey was admitted he was treated aggressively with intravenous fluids but all it did was cause more ascites. This is a very poor prognostic sign and he was euthanized once it was determined that he was not going to recover. Following is the entire medical record from Joey's final visit.

Presenting Complaints

Not Eating, Low Temp, White Gums

Pertinent History

Joey has historical mitral regurgitation, tricuspid regurgitation, pulmonary hypertension, and rt. heart failure. This is being controlled with furosemide 50mg PO TID, enalapril 5 mg SID PO, and amlodipine 0.625 mg BID PO all of which he is presently on. He did not receive any drugs today and last night he did not receive any amlodipine in the afternoon of 9/19. On Friday 9/18 in the afternoon, Joey was put outside as he was pestering the owners to go out. In the AM he was let back inside but was cold. The owners also noted he was shivering slightly, he had white mucus membranes, and was not eating well. They brought him to a local vet who took his temp which was about 97 F, and an IM shot of an unknown antibiotic was given. Later that day Joey vomited up some clear fluid. Through that day Sat 9/19 Joey had little or no app, vomited once and was somewhat lethargic. He was also noted to sit by his water bowl for up to an hour at a time, drinking some.

Physical Examination

BAR, about 7-8% dehydrated, Temp=100.9 Coat in relatively good condition, not changed since last visit.
EENT- nuclear sclerosis OU, some debris in ear but no offensive odor, some tartar on teeth, all else WNL.
M/S- Cachectic 1/9, no asymmetry noted.
C/V- rate=160 bpm and regular, weak femoral pulses, grade V/VI murmur noted on right and left side corresponding with historical mitral and tricuspid regurgitation.
Resp-rate 40bpm, eupneic.
GI- severe ascites noted, no masses on loops, liver edges smooth and may be slightly enlarged, could not palpate kidneys/spleen well due to splinting and discomfort.
Rectal: no melena or blood. Prostate slightly enlarged but nonpainful.
GU- no masses noted.
LN- WNL
NE- N/C

Problems

1.Hx mitral regurgitation
2.Hx Tricuspid regurgitation
3.Hx ASD
4.Hx right heart failure
5.Dehydration
6.Vomiting
7.Anorexia

Medical/Surgical Procedures

1.Blood Pressure- MAP=85, Systolic=109, Diastolic=69 (these are averages of many
taken ).
2.ICU electrolytes- Na=144, K=4.4, ionized Ca=.94
3.CBC- PCV=38%, WBC= 22800, Neut=90%, Lymph=3%, Fib=200
4.CHEM- Na=152, Cr=1.8, BUN=68, Ph=9.7
5.Catheter placement- cephalic
6.Fluid administration- .9%NaCl qs 20 mEq KCl at 30 mls/hr
7.replaced cephalic IV catheter (9/21)
8.Renal screen
9.Echocardiogram
10.Abdominal Ultrasound
11.Thoracic radiographs
12.renal screen
13.PCV and total solids

Clinical Diagnoses

1.Severe mitral and tricuspid regurgitation
2.Acquired ASD
3.Pulmonary hypertension
4.Gastrointestinal ulceration / hemorrhage
5.Cachexia
6.Low output and congestive heart failure

Plans and Progress Notes

1.9/20/98: S/O: See PE and HX for more info. A: Our primary concerns with Joey are his dehydration and azotemia. We wanted to stabilize him and get him to a condition where he would want to eat and drink normally. ICU electrolytes/CBC/CHEM results were basically WNL except for Na=144 (ICU), CR=1.8, BUN=68, PH=9.7, mean blood pressure=85, systolic blood pressure=109, diastolic blood pressure=69. We are planning on letting the cardiologists look at him tomorrow to re-asses his heart condition and drug protocol. We put him on a fluid plan (.9%NaCl
qs 20 mEq KCl 3mls/kg/hr) that would replace his losses but not too much too quickly. We don't want to overload his vascular volume, which could result in the heart not being able to pump the increased volume and ascites and pulmonary edema may result. With this fluid rate we hope to replace his losses as well as resolve some of the pre-renal azotemia. Both of which can be contributing to the decreased app/drinking and overall lethargy. We are continuing with the furosemide at 25 mg TID PO, amlodipine at .625 mg PO BID, but discontinuing the enalapril as it may be contributing to some of his signs. P: To feed him BID continue with his medications till the cardiologists can re-asses his condition and drug protocol, continue his fluids .9% NaCl qs 20 mEq KCl at 30 mls/hr , monitor his TPR rates and quality, record any vomiting and or urination/defecation.
2.9/21/98: S/O Joey is depressed, but rousable and can walk for brief periods of time. Vomited once in a.m. when abdomen was palpated. He is anorexic, even when offered cottage cheese and rice in p.m. In a.m., abdomen quite distended. Still dehydrated and weak. T in AM was 98.7. It increased to 99.4 in the afternoon. RR 36-40, HR 140, mm pink, CRT 1 sec. Rectal exam - formed feces and no melena or hematochezia. prostate not enlarged, slight asymmetry, with right larger than left. Urinated large volume of yellow/clear urine on walk. Renal panel showed: K+ 6.5, Na+ 152, Cl- 112, P 11.1, Creatinine 2.2, BUN 103, Ca2+ 10.5, albumin 2.9. Abdomen tap removed 2 liters of serosanguinous fluid. A: Ascites severe enough to drain off for improved comfort. Due to increased azotemia and persistent dehydration, fluids to be increased. Fluids need to be switched to LRS without K+ due to hyperkalemia and H2 blockers started (suspect GI ulceration due to disproportionate BUN:creatinine ratio). On thoracic radiographs, no pulmonary edema present, but should be monitored. Fluid overload is a problem, but
increased fluids needed to combat azotemia and dehydration. Abdominal ultrasound showed large amount of fluid but no gross lesions other than hepatomegaly and distended hepatic vessels. Abdominal fluid submitted for cytology to rule out any infectious possibility. U/A submitted for culture. Joey will be monitored and re-evaluated regarding prognosis 9/22. P: Continue IV fluids of LRS at 40 ml/hr.
Famotidine IV 4 mg BID. Monitor respiratory rate and temperature. Until temperature improves, keep on heating pad. Walk BID. Feed cottage cheese and rice. No cardiac meds due to increasing dehydration. Replaced IV catheter which was out of vein with 22 gauge catheter and T-port. Abdominal drainage (2 liters.) Record any vomiting, urination, or defecation.
3.9/22/98: S/O: Joey is depressed, mostly laterally recumbent but capable of turning over and walking for very brief periods. Anorexic. Dark, blood flecked feces overnight (melena and hematochezia.) No vomiting. Drank small amount of H2O today (few licks.) Urine yellow and clear. Urine culture from 9/21 negative for growth of microbes. Mucus membranes paler but moist. Abdomen is more distended than last night and moderately painful. CRT 1 sec, HR 140, lungs auscult clear but difficult to hear due to reverberence from murmur. RR is 36-40 still. Body temperature started at 99 this AM, but decreased to 98.6 at 2 PM. On renal panel, Na 156, Cl 156, K 5, TCO2 19, Ca 9.8, P 9.2, Creatinine 2.3, BUN 111, Alb 2.5, and anion gap 2.5. PCV 41%, Ts 5.7. A: Joey is doing worse today than yesterday. He whimpers some and lies laterally recumbent and unresponsive unless a lot of stimulus. His increasing BUN with less rise in creatinine is consistent with GI bleeding, as is evidenced by his bloody stools.
Decreasing albumin is probably due to loss into the abdomen or in the GI tract. Ascites is filling abdomen again. Fluids should be increased to combat poor cardiac output and consider dobutamine. Pale mucus membranes are likely to be due to vasoconstriction, since hematocrit is not consistent with degree of paleness. Gastric protectants should be used to comfort inflamed tract. With worsening condition, owners to be advised on his condition at 6 PM 9/22 during visit. P: Add in sucralfate 250 mg PO in 5 ml H2O as gastric protectant. Continue with Famotidine 4 mg IV BID, and increase LRS to 50
ml/hr IV. Monitoring his respiration, temperature, and turning over are to be continued throughout the day.
4.9/22/98: Joey was euthanized at owner's request 7:30 PM.

Comments

Joey presented on 9/20/98 to the emergency service dehydrated, vomiting, hypothermic, and azotemic with a BUN of 68 and creatinine of 1.8, PCV 38%. He also had a markedly distended abdomen consistent with ascites. He was discontinued from his cardiac medications and started on conservative fluid therapy. He was then evaluated by  the cardiology service. Renal values showed worsening
azotemia (BUN 103 and creatinine of 2.2 as well as elevated potassium 6.5 and phosphorus 11.1. The elevated BUN in respect to creatinine indicated that there was some GI bleeding, although no blood was evident on rectal examination initially although the next day melena and hematochezia were noted. He was started on IV famotidine and his fluid rate increased. Thoracic radiographs showed no evidence of
pulmonary edema and abdominal ultrasound showed no organ lesions, only a large volume of abdominal fluid. The fluid was drained (2 liters) and sent in for cytology (which came back as modified transudate.) Urine was sent in for culture, which came back with no growth. During the night, Joey had bloody stool. On 9/22, Joey's condition had worsened. he was more depressed and over the course of the day his abdomen began to fill up with fluid again. His renal panel came back with better
electrolyte values, potassium 5 and phosphate 9.2, but his BUN was 111 and his creatinine 2.3. His albumin had also dropped form 2.9 on 9/21 to 2.5 on 9/22. PCV remained stable. He did not eat when fed on 9/21 and 9/22. Sucralfate was also started on 9/22. Due to his worsening condition, Joey's owners decided to euthanize him on 9/22 at 7:30 PM. Joey's initial stimulus for anorexia and vomiting was most likely gastrointestinal ulceration. He rapidly spiraled into a state of severe dehydration for which in his already compromised state, he was not able to recover. His cardiac disease was quite advanced and refractory to medication. It is quite unusual for dogs with mitral regurgitation to exhibit signs of low output failure and was yet another indication of severity. He was treated supportively for three days with aggressive fluid therapy, warmth and gastroprotectants with no clinical response and deterioration. The owners elected euthanasia.

 

Mark D. Kittleson, D.V.M., Ph.D. All rights reserved.