Georgia Veterinary Technician and Assistant Association
An Association for Technicians and Assistants by Technicians
Case Study: Rocket
A middle-aged miniature schnauzer presented for less than 24 hours duration hematochezia and lethargy and experiences a hypoglycemic crisis resulting in cortical blindness.
‘Rocket,’ a 7 year old, neutered male miniature schnauzer, was presented to the Veterinary Emergency and Referral Center of Pensacola, FL at 2:45am 5/30/10 with a 24-hour history of lethargy, hematochezia, and frank hematemesis. Rocket weighed 22.4 lbs/10.2 kg. His temperature at presentation was 98.5 F, pulse 120 with slightly decreased quality, a respiratory rate of 40 breaths/minute, eupneic, with mucous membranes pink and tacky, capillary refill 3 seconds, decreased borborygmus and with a painful abdomen on palpation. Based on his depression and history of hemorrhagic stools, Rocket was evaluated in the treatment area upon presentation. Permission was given for CBC, comprehensive chemistry panel, canine pancreatic lipase SNAP test, and two-view abdominal x-rays. A 20g over-the-needle IV catheter was placed and the patient received a bolus of 250 ml Plasmalyte-A along with IV famotidine, maropitant citrate SQ, and cefazolin IV.
CBC revealed elevated hematocrit (64.7%, N 37-54%) along with normal WBC and platelet counts. A comprehensive chemistry panel showed elevated ALP, elevated BUN, elevated calcium, elevated phosphorus, elevated creatinine, and decreased blood glucose. Abdominal films showed a generalized hazy appearance with no organomegaly or obstructive pattern detected. Rocket was admitted to the critical care unit at 3:30 am 5/30/10 for further supportive care based on a presumptive diagnosis of pancreatitis +/- hemorrhagic gastroenteritis (HGE). He received a bolus of 10ml 50% dextrose diluted with 15ml normal saline IV and heat support was initiated. After his bolus, he was placed on Plasmalyte-A IV at 50ml/hr.
At 9am 5/30/10 Rocket had a grand mal seizure of 15-30s duration which stopped upon the administration of an additional bolus of 50% dextrose. After the seizure, he was hyperthermic at 103.5 F, tachycardic at 172 bpm with bounding pulses, RR 42/eupneic, mm pink and CRT 3 seconds. In addition, he had urinated and defecated during the seizure—at this time, the stool was liquid, and leaked constantly. His mentation returned to normal after the administration of dextrose--he was able to stand, and while depressed, was interactive. After an attenuated bath he was fitted with a bell collar. His fluids were adjusted to a 5% dextrose solution and a 150 ml fluid bolus was administered. Temperature support was discontinued.
At 10 am Rocket was discovered in his kennel laterally recumbent and obtunded. He was moved from his cage to a treatment table. Testing showed a BG of <10 mg/dL along with a blood lactate of 4.1 mmol/L (N <2.5). His rectal temperature was 101.1 F with bounding pulses, RR 42, mm pink, and CRT 2 seconds. ECG showed NSR and his mean systolic BP (Doppler) was 75 mm Hg. Over the next hour, Rocket received 3 crystalloid boluses of 100-150 ml and repeated dextrose supplementation along with two boluses of Hetastarch (50 ml each over 5 minutes). He also received 125 mg Metronidazole IV over 10 minutes. His temperature dropped to 99.5 degrees and temperature support was initiated with a Bair Hugger.
At this time the clients were updated and a guarded/grave prognosis given. Orders were adjusted to reflect recumbent patient care, ECG and blood pressure monitoring, repeat BG and lactate assays, and continued antibiotic therapy. By early afternoon Rocket’s BG had normalized on a 5% dextrose CRI to 117-135 mg/dL. An 8 french red rubber indwelling urinary catheter was placed to monitor ins/outs. While Rocket continued to be minimally responsive, he did react to painful stimuli (ie, suturing of urinary catheter). Gelid-to-liquid hematochezia persisted. A urinalysis was performed with a catheter sample and found normally concentrated urine (SPG 1.035), cocci TNTC/HPF, 2-3 WBC/HPF, rare transitional and squamous epithelial cells/HPF, waxy casts 3-4/LPF, fat droplets, and 500 mg/dL of glucose. Mannitol was administered IV (0.5 mg/kg IV q6h PRN) for suspected cerebral edema.
By 8-9pm, Rocket was able to lift his head and move his legs. Menace was absent bilaterally. Rocket continued to improve overnight—his BG was maintained in a normal range, his renal values normalized, PLRs returned, his blood pressure remained normal, and no further seizures were noted. His diarrhea began to change character from frank blood to a dark greenish-brown. Heat support and ECG were discontinued.
By noon on day 2 he was eating small amounts of a bland diet hand-fed and drinking small amounts of water from a bowl. His urinary catheter was removed. Injectable medications (metronidazole and cefazolin) were switched to oral form. His IV fluid rate was decreased to 40 ml/hr. Rocket was ambulatory but circling to the left, ataxic, ‘wall-walking,’ and blind. We also suspected him to be deaf, as he showed no response to aural stimulus.
Rocket was discharged to home and his owner’s care on 6/1/10. His cortical blindness and neurologic signs continued to improve and as of six weeks post-discharge, he was living a normal life.
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