SAM Mid-Term Flashcards
What is the most common presentation of a uremic crisis?
Complication or exacerbation of CKD
What are the common findings with CKD?
Dehydration, anorexia, vomiting, weakness, and lethargy
What should you assess if you suspect a uremic crisis related to CKD?
Azotemia, Anemia, and Possible investigation of secondary problems
How would you treat a patient with CKD that is in a uremic crisis?
Correct the dehydration, treat the symptoms, and address comorbidities as needed
This is when the kidneys filter more than normal fluid
Diuresis
When is diuresis appropriate and inappropriate?
- Appropriate = In cases of volume overload
- Inappropriate = In cases of CKD
What does forced diuresis consist of?
Giving fluids and diuretics
What should be corrected aggressively in patients with CKD?
Dehydration
This is the only type of azotemia that resolves with fluid therapy
Pre-renal azotemia (as long as you rehydrate quickly!)
What type of fluids should be used to rehydrate and maintain a CKD patient?
Balanced electrolyte (LRS) for rehydration and Low sodium maintenance fluid
What are some at-home management strategies for CKD?
- Hydration
- Renal diets
- Phosphate binders
- Potassium supplementation
- Blood pressure management
- Anemia management
Regarding hydration in CKD, when voluntary intake is insufficient, what are the two options?
- Intermittent SQ fluid administration or feeding tube placement
What are some pros and cons of SQ fluid administration?
Pros
- can be started immediately
- no procedures needed
Cons
- high salt fluids
- needles
- pets & clients may not tolerate well
- cost of supplies
What are some pros and cons of E-tube placement?
Pros
- Physiologic (can just give water)
- No needs/pain free
- Well tolerated
- May be cheaper in long term
- Can give most PO meds
Cons
- Increased up front costs
- Requires anesthesia
- Tube can be inadvertently removed
- Possible esophageal stricture
What specific type of disease is the leading cause of renal disease in dogs?
Glomerular diseases
What are signs of recurrent LUT issues?
- Hematuria (macroscopic and microscopic)
- Stranguria
- Pollakuria
What are some characteristics of a complicated UTI?
- Presence of anatomic or functional abnormality (urinary or repro tract abnormalities)
- Presence of comorbidities that predispose to persistent infections
- Recurrence
- Intact male dog
- Cats
What are some characteristics of an uncomplicated UTI?
- Sporadic bacterial infection
- Otherwise healthy animal
- Normal urinary tract and fxn
What are some predisposing factors to recurrent LUT signs?
- Degenerative diseases (CKD)
- Anatomical features (obesity, hooded vulva, female)
- Metabolic disorders (diabetes)
- Neoplasia (TCC)
- Inflammatory/infectious/immune (polyps, immunosuppression)
What two structures make up the upper urinary tract?
Kidneys and ureters
What two structures make up the lower urinary tract?
Bladder and urethra
Endotracheal washes are performed in what animals?
Cats and Small dogs
What is the purpose of an endotracheal and transtracheal wash?
Collect airway fluid samples for cytology and culture
When are endotracheal washes contraindicated?
If the patient is not a good anesthetic candidate
Why are transtracheal washes contraindicated in small dogs and cats?
It can cause iatrogenic SQ emphysema and tracheal laceration
What ligament do you palpate and “pop” through during a transtracheal wash?
Cricothyroid ligament
What is in indication for an NE/NG tube?
Short term (< 7 days) enteral nutritional support in critically ill patients
What are contraindications of a NE/NG tube?
Nasal cavity disease, coagulopathy, vomiting
How do you confirm proper placement of an NE/NG and esophagostomy tube?
With radiographs
What are indications for an esophagostomy tube?
Long term enteral nutritional support in anorexic patients or patients with oral disease, trauma, or surgery limiting their ability to eat
Esophagostomy tubes are placed in what animals?
Cats, Small dogs, +/- medium sized dogs
What are contraindications of esophagostomy?
Esophageal disease and coagulopathy
When developing a nutritional plan for feeding patients through a tube, the diet choice is dictated by what 3 things?
Tube size, patient needs, and energy density of diet
What is the typical interval of RER that you start with when feeding tubed patients?
1/3-1/4 RER
What are some indications for a bone marrow aspirate?
- Unexplained thrombocytopenia, non-regenerative anemia, neutropenia, or pancytopenia
- Investigation of atypical cells observed in peripheral blood
- Dx or staging of neoplasia
- Evaluation of iron stores
- Aid in dx of infectious dz
(T/F) There are many contraindications for a bone marrow aspirate
FALSE, there are none
What are the 3 bone marrow sampling sites?
- Greater tubercle of the humerus
- Trochanteric fossa of the femur
- Iliac crest of the pelvis
What is the purpose of a bone marrow biopsy?
To provide information about bone marrow architecture
What are indications for a thoracocentesis?
- To collect pleural effusion for cytologic and/or microbiologic analysis
- To relieve clinical signs of dyspnea caused by pleural effusion
What is a contraindication for thoracocentesis and abdominocentesis?
Coagulopathy (unless its hemothorax preventing ventilation)
Which intercostal space do you approach for a thoracocentesis?
7th-9th intercostal space
What are indications for an abdominocentesis?
- To collect abdominal effusion for cytologic and/or microbiologic analysis
- To relieve clinical signs of dyspnea or discomfort associated with severe abdominal effusion
What are some indications for arthrocentesis?
- Joint swelling or pain in one or more multiple joints
- Shifting leg lameness
- Fever of unknown origin (polyarthritis)
What are contraindications for arthrocentesis?
- Significant coagulopathy
- Pyoderma overlying arthrocentesis site
What are the common arthrocentesis sites?
- Carpus
- Stifle
- Tarsus
What are some common causes of hypercalcemia?
- Lymphosarcoma
- Anal sac adenocarcinoma
- Other neoplasia
- Renal failure
Name the 3 forms of calcium
- Ionized calcium (free)
- Protein bound calcium (albumin)
- Complexed calcium
Plasma is primarily composed of which type of calcium?
Ionized (50%) followed by protein bound (40%)
What are some effects of calcium on the kidney?
- Induces nephogenic diabetes insipidus
- Increased medullary blood flow
- Renal arteriolar vasoconstriction
- Renal mineralization
Why does PU/PD occur from hypercalcemia?
- Increased water consumption
- Reduced tubular function
- Deficiency or impaired response to ADH
What are clinical signs of hypercalcemia?
- PU/PD
- Anorexia/hyporexia
- Lethargy
- Weakness
- Cardiac arrhythmias
- Seizures/muscle twitching
What are some aggressive therapy options for hypercalcemia?
- IV 0.9% NaCl
- Furosemide
- Biphosphate injection
- AVOID thiazides!
What are some maintenance therapy options for hypercalcemia?
Oral corticosteroids or oral alendronate
Describe diabetes mellitus
- A problem with insulin (lack of production and response)
- Characterized by hypERglycemia
This type of diabetes is the lack of insulin production by beta cells
Type I
This type of diabetes is the resistance to the effects of insulin
Type II
Without insulin (or its substrate - glucose), these are converted into ketone bodies causing ketosis in diabetic patients
Fatty acids
How can you diagnose diabetic ketoacidosis?
Diabetes mellitus + acidemia (that is NOT caused by something else
What is the treatment for diabetic ketoacidosis?
- Reverse the ketoacidosis by giving insulin
- ID and treat the underlying cause
What are two reasons why patients develop DKA?
- Unmanaged or poorly managed diabetes mellitus
- Previously well-managed diabetics that develop a co-morbidity
When do you start insulin therapy in DKA?
Early, ideally within 1-4 hours
What is the goal of insulin therapy in DKA vs DM?
DKA = get rid of the ketones
DM = regulate blood glucose
Which enzymes are associated with hepatocellular injury?
ALT and AST
Which enzymes are associated with cholestasis/enzyme induction?
ALP and GGT
Which values are associated with indicating impaired liver function? Which of these values is exclusively made in the liver?
- Bilirubin, albumin, glucose, cholesterol, and BUN
- Albumin
What is the most sensitive liver function test that is readily available for use in small animals?
Bile acids
What are indications for a bile acids test?
Screening for loss of hepatic function or PSS
The most common cause of abnormal liver enzymes is _______ to non-hepatic disease
secondary
What are common symptoms associated with increased liver enzymes?
- PU/PD
- hyperactivity
- Excessive panting, hair loss
- Vomiting, diarrhea, inappetence
- Cough or difficulty breathing
Name some reasons to investigate further when liver enzymes are increased
- ALT greater than twice normal over several months
- Unexplained liver enzyme elevation persisting over 6-8 weeks
- Non-hepatic causes have been ruled out
How do you diagnose pancreatitis?
- Hx/CS
- Bloodwork
- Imaging
- Cytology/biopsy
- Pancreatic lipase immunoreactivity (PLI)
What bloodwork findings support pancreatitis diagnosis?
- Inflammation
- Liver enzyme elevation
- Hyperbilirubinemia
What does supportive care look like for pancreatitis patients?
- Fluid therapy
- Pain management
- Anti-emetics
What is essential in treating acute pancreatitis?
Pain management
Name 3 causes of pre-hepatic (AKA hemolysis)
- Immune-mediated
- Toxic
- Post-transfusion
Name some causes of hepatic (AKA liver failure)
- Toxicity
- Hepatitis (infectious)
- Cirrhosis (rare)
- PSS (end-stage)
- Microvascular dysplasia
- Secondary injury (hepatic lipidosis)
- Congenital deficiencies
Name 4 causes of post-hepatic (AKA biliary obstruction)
- Gall bladder mucocele
- Cholelithiasis
- Pancreatitis
- Tumors
What are findings supportive or pre-hepatic, hepatic, and post-hepatic?
Pre-hepatic: MM color, anemic, recent transfusion
Hepatic: liver enzyme elevation, hx of liver dz/injury
Post-hepatic: belly pain, liver enzyme elevation (cholestatic enzymes)
Name some immunosuppressive therapies
- Glucocorticoids (prednisolone, dexamethasone)
- Azathioprine
- Cyclosporine
- Chlorambucil
- Leflunomide
- Mycophenolate mofetil
Name some adjunctive therapies
- Human IVIG
- Vincristine
- Melatonin
- Supportive (blood products and antiplatelet therapy)
What factors into the selection of immunosuppressive therapies?
- Expected course and prognosis of disease
- Concurrent diseases
- Safety and efficacy
- Ease of administration and monitoring (client compliance)
- Cost
What is a first line immunosuppressive therapy?
Glucocorticoids
What immunosuppressive therapy has the following side effects:
- PU/PD, panting, polyphagia
- muscle atrophy and weakness
- iatrogenic hyperadrenocorticism
- vacuolar hepatopathy
- infection, sepsis
- GI ulceration
- hypercoagulability
Glucorticoids
What are the contraindications of glucocorticoids?
- Diabetes mellitus
- infections
- hyperadrenocorticism
- NSAID therapy (washout)
When should you consider other therapies?
- No or poor response
- Excessive side effects
- Long duration of therapy anticipated
- Corticosteroids contraindicated
What is the MOA of azathioprine?
- Inhibits purine synthesis –> disrupts lymphocyte proliferation
- Blocks T-cell activation and promotes T-cell apoptosis
- Decreases antibody synthesis
You should limit the use of the azathioprine in which species?
Cats
What immunosuppressive therapy has the following side effects:
- cytopenias
- hepatotoxicity
- chronic subclinical anemia
- GI signs (mild and self-limiting)
Azathioprine
What is the MOA of cyclosporine?
- Calcineurin inhibitor
- Impairs function of T-cells and blunts immune response
What immunosuppressive therapy has the following side effects:
- Primarily GI
- Hepatotoxicity, nephrotoxicity
- Gingival hyperplasia, hypertrichosis
- Platelet activation
* NOT myelosuppressive *
Cyclosporine
Cyclophosphamide is used for dogs with what condition?
IMHA
What immunosuppressive therapy has the following characteristics:
- alkylating agent antineoplastic
- immunosuppressive properties (targets B cells)
- slow onset of action (2 weeks)
Chlorambucil
What immunosuppressive therapy has the following side effects:
- GI
- myelosuppression
- alopecia, poor hair growth
- neurological signs in cats
Chlorambucil
What is the MOA of leflunomide?
- Inhibits de novo pyrimidine synthesis
- inhibits B and T cells function and proliferation
- suppresses antibody production
What immunosuppressive therapy has the following side effects:
- well tolerated
- GI effects
- myelosuppression
- cutaneous drug reactions
- hepatotoxicity
Leflunomide
What is the MOA of mycophenolate mofetil?
- Reversible inhibitor of inosine monophosphate dehydrogenase
- inhibits de novo purine synthesis
- inhibits lymphocyte proliferation and antibody production
What immunosuppressive therapy has the following side effects:
- GI common (diarrhea, vomiting, poor appetite)
- Myelosuppression
Mycophenolate mofetil
Describe an immunosuppression monitoring response?
- Improvement in clinical signs and clinicopathologic abnormalities
- Initiate prednisone taper by 25% q 2-4 weeks
- Acceptable maintenance dose or discontinue
- Treatment for at least 3 months
- 2nd line drug tapered in a similar manner
If there is a relapse, what is the next step?
Prednisone + second line therapy drug
- Long term therapy (low dose glucocorticoid or second line drug)
This immunosuppressive therapy has been used to treat IMHA and ITP
Human IVIG
What is the MOA of Vincristine?
- Disruption of intracellular microtubles
- Cell cycle specific cytotoxic agent
