Monday, November 17, 2008

crushing defeat...yet again

when i came on the day shift monday, a case was transferred to me that had been hospitalized for the weekend. max was a 1 year old, beautiful boxer. he was absolutely stunningly gorgeous, and he was sweet to boot. he and his sister dog had decided it would be a good idea to raid mom and dad's medicine cabinet. during the raid - an enormous quantity of naproxen and advil was consumed. the toxic dose of naproxen in dogs is VERY low - something like 5 milligrams / kilogram. max had ingested about 50-100 times that amount.

he was treated at his veterinarian with decontamination (induced vomiting, activated charcoal to absorb toxins in the stomach, hospitalization, and monitoring). his sister did well, but he developed SEVERE bleeding in his GI tract. this isn't surprising, since NSAIDs (non-steroidal anti-inflammatory drugs) inhibit the production of prostaglandins in the body. when you have a headache or muscle ache, this is a good thing, because some prostaglandins promote inflammation. unfortunately, there are good prostaglandins, too - and these are also inhibited by NSAIDs. these good PGs help keep the gastric mucosa healthy and the acid level normal. when you inhibit them, the stomach and upper small intestine have problems with the normal coating, and GI ulcers occur. this is why you have to be cautious when taking NSAIDs. too many can lead to stomach and duodenal ulcers. the biggest concern in these severe cases is that the area of ulcerated mucosa will eventually rupture, leading to perforation of the GI and spillage of the intestinal contents into the abdomen (septic abdomen = BAD).

max started to have extremely black stools - full of digested blood from his ulcerated stomach and GI. he was depressed, and he didn't want to eat. we managed him aggressively, but his PCV (packed cell volume) continued to drop, as he lost massive quantities of blood into his intestines. his albumin (a critical protein in the body) also dropped precipitously, because - again - he was losing it in his blood through the ulcers.

we supported him with GI protectants out the wazoo (pepcid, prilosec, carafate) and misoprostol - a medication that is a mimic of prostaglandins made by the body, but his biggest problem was his falling PCV and albumin. i made the decision on wednesday to transfuse him. transfusion won't bring the proteins up much - you need massive quantities of albumin to do that, but it would help his PCV. in total, he received 1 unit of packed red blood cells, 2 units of fresh frozen plasma, and 450mL of whole blood from a donor.

and he bounced back. his appetite and attitude improved, his PCV hovered around 26% (as opposed to 15%), and he started wagging his stump again. i made plans with his owners to send him home on thursday.

and then...from the jaws of victory, defeat was snatched. he spiked a fever of 105. his PCV dropped from 26% to 18% then to 16%. he turned yellow. his liver values went off the chart high - and i mean high (for vet people - his ALT was 6500!!). 24 hours after his transfusions, he was suffering a delayed reaction to the blood products. his body started to destroy all of that blood we had pumped into him. even worse, he went into acute liver failure.

on saturday, i wasn't with him, caring for him as i was supposed to be. his PCV dropped to 12%, and he collapsed and began to have difficulty breathing.

his owners - invested emotionally and financially ($4000!) were crushed, i'm told - as the final decision to euthanize him was made. i spent a week working with this guy, loved him, saw him improve dramatically, and allowed myself to hope that we had been able to undo some of the terrible damage to his GI tract - only to watch him suffer the most severe reaction to a transfusion possible.

chalk it up to another loss for the home team.

addendum: i just noticed that all of my work posts are depressing...i promise that the next story i tell will have a happy ending. problem is - i have to come up with an interesting case that ended well. it's a dilemma - because if it's interesting enough to write about - the outcome probably wasn't good.

1 comment:

Elizabeth said...

You were where you were supposed to be. Had something happened to your Father and you weren't there because you went to work you would never have forgiven yourself..