Management Plans for Vomiting SA

Question 1

Create a problem list

Jordan is a 7 yr-old FN DSH cat, 3.5kg

• an indoor/outdoor cat, living alone
• vaccinated and wormed regularly
• vomited 5 times in the last 48 hours

–active abdominal effort when vomits

–no blood but some bilious fluid brought up

• some weight loss over the last 6 months
• a few recent episodes when she has been reluctant to eat and has vomited food
• no diarrhoea seen (she has access to a litter tray)
• bright and alert in the consulting room
• T = 39.5oC, P = 170bpm and regular, pulse quality good, mucous membranes pink, CRT 1-2 seconds, respiration normal
• severe periodontal disease and gingivitis
• both submandibular lymph nodes are enlarged
• grade 2/6 systolic murmur audible over the sternum
• abdominal palpation unremarkable, no other findings

Answer 1

–vomiting

–occasional loss of appetite

–weight loss?

–periodontal disease/gingivitis

–sub-m LN enlargement

–heart murmur

–vomiting

–occasional loss of appetite

–weight loss?

–periodontal disease/gingivitis

–sub-m LN enlargement

–heart murmur

Question 2

• Outline your approach to this case. What is your advice for Jordan’s owner?
• Vomited 5 times in the last 48 hours

–Active abdominal effort when vomits

–No blood but some bilious fluid brought up

• Some weight loss over the last 6 months
• A few recent episodes when she has been reluctant to eat and has vomited food
• T = 39.5oc (high)
• Severe periodontal disease and gingivitis
• Both submandibular lymph nodes are enlarged
• Grade 2/6 systolic murmur audible over the sternum

Answer 2

–home on symptomatic treatment?

–double check vaccination and worming history?

–screen for primary diseases?

• haematology and biochemistry, urinalysis?
• diagnostic imaging?

–radiography?

–ultrasound?

• total T4?
• FeLV/FIV test?

–recommend dental work once vomiting has resolved?

Question 3

Discuss Jordans radiograph

What you going to do?

Answer 3

Caused gas build up cranially
But build up of faeces
Hair tie seen RHS SI
Not hugely dilated
Yes it has a FB – but we aren’t worried about
Good serosal detail – not worried about perforation

We can leave this. Depends on the owner tho. Could always radiograph at the time of a dental

Question 4

What are the 4 things a FB can do

Answer 4

• Vomit up
• Pass through
• Obstruct
• Could wedge in the gut = toxins release. Could perforate

Question 5

what are the signs of obstruction on radiograph?

Answer 5

Fluid/gas build up

Plus dilation

Question 6

•Based on the physical examination findings, how dehydrated do you think Marcus is?

Marcus: 8 mth old ME Labradoodle, 18kg

• lives with one cat but no other dogs
• vaccinated and wormed regularly
• fed Bakers complete, usually eats well
• vomiting and diarrhoea for 4-5 days (5-6 times/day)

–watery, yellow vomit

–explosive watery yellow/brown diarrhoea

• last ate 4 days ago
• dull and subdued in the consulting room
• T = 39.5˚C, heart & pulse rate = 160bpm, pulse quality reasonable, mucous membranes pink but tacky, CRT 2 seconds, respiratory rate 30
• skin tenting over dorsal neck
• abdominal palpation:

–possible small mass in caudal abdomen?

–gas and fluid filled small intestine

Answer 6

8-10%

Question 7

• You decide to admit Marcus for fluid therapy
• You collect blood and urine samples before starting his intravenous fluids

–what 5 basic individual tests would you be most interested in at this stage?

Answer 7

• urine SG
• electrolytes (especially potassium)
• PCV/TS
• blood smear
• urea and creatinine

Question 8

8-10% dehydrated

18kg marcus

Vomiting and diarrhoea for 4-5 days (5-6 times/day)

What is the fluid deficit?

What are the maintenance requirements?

What are teh on going losses?
Estimate each D+ as 100ml
Estimate each V+ as 50ml

Answer 8

What is the fluid deficit?

• Fluid deficit = % dehydration x body weight (L)
• Fluid deficit = % dehydration x body weight x 1000(mls)
• Fluid deficit = 0.09 x 18 x 1000 = 1620 (mls)

What are the maintenance requirements?

–maintenance calculations:

• 50mls/kg/24 hours = 900 mls/24 hrs
• or approx 2 mls/kg/hour= 36 mls/hr = 964 mls/24hrs
• or (30 x weight) +70 = 610 mls / 24 hrs

What are the on-going losses?

–diarrhoea 5 times/ day = 500ml

–vomit 5 times/ day = 250ml

–total ongoing losses = 500 + 250 = 750ml

Question 9

8-10% dehydrated

18kg marcus

Vomiting and diarrhoea for 4-5 days (5-6 times/day)

Fluid deficiet - 1800ml

Ongoing losses - 750ml

What type of fluid should be given?

How much fluid should be giveen?

How should the fluid be given?

Over what time period should the fluid be given?

Answer 9

What type of fluid should be given?

• –balanced isotonic crystalloid fluid

•E.g. lactated Ringers solution (Hartmann’s)

–colloids may also be given but this decision is more controversial and they are given at a very different rate

• all the calculations for Marcus are for crystalloids!
• experimentally colloids are shown to increase plasma oncotic pressure and allow the jejunum to maintain normal absorptive capacity

How much fluid should be given?

• 3160 mls in 24 hours
• 130 mls/hour = 7.2 mls/kg/hour

How should the fluid be given?

• intravenously, peripheral vein?
• large bore catheter

Over what time period should the fluid be given?

• –bolus of 10-20mls/kg over 15 minutes +/- repeat if worried about
• hypotension
• absent pulses
• signs of hypovolaemia/shock

–or you can give 30-50% of the deficit in the first 4-6 hours and the remainder over 24 hours

Question 10

• All the practice fluid pumps are in use on other patients
• Calculate the drip rate for Marcus, using a 20 drops/ml giving set

Needs 3160ml

Answer 10

• fluid required:3160ml in 24 hours
• drip factor of giving set: 20 drops/ml
• time period for administration: 24 hours
• = 3160 x 20 drops in 24 hours
• = 3160 x 20 drops/minute

24 x 60

= 44 drops/minute

Question 11

After calculating Marcus’s fluid requirements his blood results are now available:

• His serum potassium is 2.05mmol/l
• What do you do and why?

Answer 11

–hypokalaemia likely to worsen unless potassium is supplemented. This is due to

• poor intake (anorexia)
• significant ongoing GI losses (vomiting, diarrhoea)
• fluid therapy contributing to diuresis (renal loss)
• do not exceed 0.5mmols KCl/kg/hr. This is often quite hard to do unless the serum potassium is very low as it is here
• maximum fluid rate for Marcus with 80 mmols KCl/litre would be 6 mls/kg/hour = 108 mls/hour ie you would need to reduce the fluid rate from the one you calculated if you add potassium at this rate
• potassium should not be added to any fluids that are being given as a bolus

Question 12

What is important when giving potassium supplementation?

Answer 12

–Always add potassium to a new bag of fluids rather than guessing how much is left in a bag that has already been started

–Mix the potassium well as you first add it to the bag of fluids- you will not need to mix it again as it will stay in solution

–Clear labelling of the drip bag to ensure everyone is aware of the concentration of potassium in the bag

–Clear documentation on the kennel sheet regarding the fluid therapy plan such as

• rate and volume to be given
• parameters to monitor

Question 13

As a group briefly discuss and interpret the blood test results

•Do the results alter the prognosis for Marcus?

Answer 13

–raised PCV/TS, urea and creatinine with a concentrated urine all suggest dehydration with pre renal azotaemia

–the blood smear helps make severe and overwhelming inflammation or sepsis less likely

–the hypokalaemia (low potassium) is already being addressed

Prognosis:

–the findings are all likely to be reversible with appropriate fluid therapy and correction of any underlying disease causing vomiting/diarrhoea

–the results do not suggest kidney failure because the urine is concentrated (SG >1.040)

–this will be covered more in the urinary system modules but is an important concept to consider across all the body systems

Question 14

Diagnositic plan for marcus?

Answer 14

•additional blood tests?

–think about individual tests that might help rule disease in or out. At this stage there are not very many - you might want to rule out pancreatitis if you can

•diagnostic imaging?

–in a dog or cat with relatively sudden onset and severe vomiting, you need to consider the possibility of obstruction such as foreign body or intussusception.

–diarrhoea makes obstructive disease less likely but does not rule it out

–radiography and/or ultrasound are worth considering

Question 15

Treatment plan for marcus?

Answer 15

• continue iv fluids with potassium supplementation at a reduced rate (not >6 mls/kg/hr if supplementing K+ at 80mmols/l)
• review fluid requirements at least daily based on

–physical exam/evidence of dehydration

»P & R every 1-4 hours? (quality, rate, any signs of fluid overload?)

»T every 12 hours?

»monitor body weight

–ongoing losses

–PCV/TS monitoring

• anti emetics?
• gastro protectants?

Question 16

Discuss this and what the issues may be

What would you do next?

Answer 16

• No labels, generally of diagnostic quality
• Gassy – radiolucent area
• FB
• Radiolucent Obstruction – gas/filled intestine and dilated
• Opacities can be seen

–They could just be built up because of the obstruction; the obstruction can act as a partial sieve like the sink plug blocker

–Known as a gravel sign

• Could always take another xray as the gut should NOT look the same – if they do then you have a problemo
• Stabilsie – Maybe then get a VD view, go forward to an ex lap?