Sedation and GI plans for GI patient Flashcards
Investigations are also useful if they highlight consequences which might need specific management?
For example low cobalamin (B12) in dogs and cats with intestinal or pancreatic disease.
Case 1:
A 7 year old MN DSH cat has been seen several times over the last 6 weeks. He has had chronic low grade GI signs which include the following:
Vomiting: approximately 3-4 times a week but becoming more frequent. He brings up some food and bilious fluid.
Altered stool consistency: he doesn’t always use a litter tray but when he does he is passing soft/semi formed pale brown stools with occasional flecks of blood
Appetite: he used to have a good appetite but his appetite is now variable. Some days he seems very keen to eat and other days he won’t eat at all.
General demeanour: perhaps a little quieter and less keen to go outdoors than he used to. He has never been an especially playful cat. He is still affectionate and keen for company. There has been no obvious change in his drinking.
Physical exam:
Weight: 4.3 kg (previous recorded weight 6 weeks ago was 4.9kg)
BCS: 3/9
Temp: 38.5
Pulse/heart rate: 158.
Peripheral pulses good quality
Respiration rate: 16
The only findings on physical examination are that his small intestinal contents feel quite fluid/gassy.
There has been no response to a change in diet (he is now on a low fat, hydrolysed protein diet) or to a 2 week course of metronidazole. If anything his owners feel his problems are progressing.
Think about the problem list and differentials for this cat.
What are the most likely differentials?
- IBD
- GI lymphoma
- Infectious cause
- Chronic FB consequently traumatising the GI tract
- Intestinal parasite (roundworm, hookworm, or protozoal parasites)
- Kidney disease
- Liver disease
- GDV
- Feline Infectious Peritonitis (FIP)
Do the following blood test results help rule in or rule out any of your differentials?
- Although inflammatory cells a high-normal – helps rule out infection, but may be an indication of chronic inflammation
- Cobalamin – this is an indicator of IBD
- Eosinophils are normal which helps to rule out something like parasites
- Slightly raised WBCs aren’t really sufficient to suggest something like FIP
- Everything on biochem is within the reference range suggesting we can rule out problems such as kidney disease
Case 1.
You decide you would like to do abdominal ultrasound and thoracic radiography under sedation.
How would you justify this plan to the cat’s owner?
Ultrasound – Bloods are showing signs of IBD so we would like to visualise the intestinal loops
Thoracic radiographs – we would like to rule out the possibility of a neoplasia causing lung mets.
We have been able to rule out something like parasite infection, but u/s and radiography are the only ways we are going to be able to rule out differentials such as GDV and get a clearer view of what’s going on
Case 1
What specific questions will need to be asked when the cat is admitted for the procedures?
- Last eat? Last drink? Last bowel movement?
- Any changes in clinical history?
- Well in himself?
- Drinking and urinating normally?
- Has he been starved overnight?
- When was his last dose of metronidazole?
- When did he last pass urine or faeces? à The urinary bladder is best visualized if it is full of urine. Therefore, the cat ideally shouldn’t have urinated within three to six hours of the ultrasound procedure
- Has he vomited at all today?
Case 1
How long might this diagnostic imaging take?
- Abdominal ultrasound in cats normally takes between 20-30 minutes
- It could take between 30-60 minutes to take the radiographs, including positioning and assessment of each image
Case 1
What sedation protocol would you like to use and why?
ACP and buprenorphine
I would class this cat as an ASA category III or IV patient
ASA III: Acepromazine + Opioid depending on evaluation of the cardiovascular system or Benzodiazepine + Ketamine
ASA IV: Benzodiazepine + Ketamine or Opioid alone
In cats that have a quiet temperament sedation with an opioid alone (e.g. buprenorphine or morphine / methadone) may be adequate
Case 1.
Which procedure will you do first and why?
- Radiographs – moving the animal too much may change the thoracic layout.
- Wouldn’t want the gel to distort the images
Case 1
How will you monitor your patient?
HR, RR, MM colour, CRT, Pedal pulse, BP monitor, pedal reflex
Case 2:
A 14 year old MN DSH cat is brought in for vaccination. During the consultation the owner mentions that he seems a bit leaner than he used to be and although he asks for food frequently he sometimes shakes his head and walks away after a couple of mouthfuls and rarely finishes a meal completely. He is generally well and quite active although a less successful hunter than he used to be. He is the only pet at home and he has outdoor access though a cat flap but is kept in at night. His owner mentions that he is using a litter tray to pass urine overnight which he didn’t do in the past.
Physical examination:
Weight 4.9kg (weight 1 year ago 5.3kg)
BCS 5/9
Temperature: 39 C
Pulse/heart rate: 220
Respiratory rate: 22
The main findings on physical examination are evidence of gingivitis and gingival hyperplasia with evidence of “neck lesions” (feline odontoclastic resorptive lesions; FORLs) affecting several premolars. The submandibular lymph nodes are firm and prominent. Thoracic auscultation is normal and you cannot palpate a thyroid mass. On abdominal palpation the kidneys are a little irregular but feel normal in size and are not painful. Hydration status appears normal.
Think about the problem list and differentials for this cat?
- Weight loss
- Head shaking
- Urinating overnight now
- Pyrexic
- Tachycardic
- Gingivitis
- Gingival hyperplasia
- FORLs
- Enlarged LNs
- Irregular kidneys shape
Case 2:
A 14 year old MN DSH cat is brought in for vaccination. During the consultation the owner mentions that he seems a bit leaner than he used to be and although he asks for food frequently he sometimes shakes his head and walks away after a couple of mouthfuls and rarely finishes a meal completely. He is generally well and quite active although a less successful hunter than he used to be. He is the only pet at home and he has outdoor access though a cat flap but is kept in at night. His owner mentions that he is using a litter tray to pass urine overnight which he didn’t do in the past.
Physical examination:
Weight 4.9kg (weight 1 year ago 5.3kg)
BCS 5/9
Temperature
39 C
Pulse/heart rate
220
Respiratory rate
22
The main findings on physical examination are evidence of gingivitis and gingival hyperplasia with evidence of “neck lesions” (feline odontoclastic resorptive lesions; FORLs) affecting several premolars. The submandibular lymph nodes are firm and prominent. Thoracic auscultation is normal and you cannot palpate a thyroid mass. On abdominal palpation the kidneys are a little irregular but feel normal in size and are not painful. Hydration status appears normal.
What is the justification for doing blood tests in this case?
- Irregular kidneys
- PU possible PD
- Weight loss
- Gingivitis – check for systemic
- Gingival hyperplasia – want to check as possible neoplastic
- LN raised – although likely to be related to dental.. best to check
Case 2:
How do the following blood and urine test results help you prioritise a plan for this case?
- High WBC
- High neutrophils
- High monocytes
- Low normal lymphocytes
- An explanation of this is a possible stress leukogram, and also gingivitis
- High urea – kidney
- High creatinine – kidney
- USG 1.025 – maybe slightly dilute so would question the concentrating ability
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Case 2:
Are you happy to consider a dental for this cat?
I’m a little reserved due to the kidneys
Case 2:
What will you discuss with his owner?
The issue is, there is a risk of the GA damaging the kidneys further, however not doing a GA and the cat not eating could damage the kidneys further.
The O needs to be aware of this, have informed consent.
Case 2:
Come up with a detailed plan for this cat from the time of admit to the time of discharge assuming his owners consent to him being booked in for a dental assessment and appropriate treatment. Your plan needs to include information about drug protocols, monitoring, anaesthesia and patient care but not the details of the actual dental procedures- this is something to think about in week 12?
- Admit – no food since the evening before, can have water until that morning.
- At the vets – do a full clinical exam, reassess hydration, suggest to the O that kidney U/S maybe beneficial. Place the cat on IV fluids, Hartmanns is grand.
- Fluid rate – maintenance, and during the GA twice maintenance
- Pre med – ASA 3 – ACP and Opiod e.g. methadone or buprenorphine depending on the pain. Acepromazine (ACP) would be a good sedative to use as it has properties that work to the advantage of a cat with chronic renal failure (CRF)
- Anaesthetic – Propofol or alfaxalone
- Drugs – meloxicam and AB probably (amoxi-clav broad spectrum)
- Intubation and maintain on isoflurane.
- Monitor – HR, RR, MM, CRT, Eye position, pedal reflex, jaw done, pulses pulse oximeter and temperature. DON’T FORGET BLOOD PRESSURE! (can then alter fluid therapy if there is an issue with BP)
- Keep this cat warm
- Monitor very closely on recovery
- Offer recovery food when awake
- Keep warm
- Monitor and TPR regularly
- Needs a gradual change onto a renal diet
- https://www.nzvna.org.nz/site/nzvna/files/Quizzes/Best%20practice%20anaesthesia%20for%20an%20elderly%20cat%20with%20.pdf
