Wednesday, January 13, 2010

Update on: Here comes mother (see bottom)...

I had my first GDV at the new job (famously known as the mother of all emergencies). It SHOULD have been a breeze. The owners caught it within 15 minutes of the onset of clinical signs (non-productive retching, restlessness, and distended abdomen). It was a Great Dane, so they knew to watch for the signs of a GDV. When I got into the abdomen, the stomach was absolutely healthy and gorgeous - the most lovely pink I've ever seen. No hint of gastric necrosis (death) and no need for any stomach resection. I should have been in and out in about 1 hour, at the most.

Of course, I wasn't. The dog was on prednisone for its skin disease, so she bled and bled and bled and bled (prednisone makes platelets not sticky, just like aspirin, so clots don't readily form). She was 120 pounds, and I had a very hard time decompressing her stomach with the stomach tube. Once it was decompressed, I had a really hard time with the pexy and was not satisfied with the final product at all (tacking it to her body wall so that this wouldn't happen again). Once all that was done, the bleeding in her abdomen just went on and on. I checked everything - liver, mesentery, spleen, kidneys, and couldn't locate a source of bleeding. Everything just oozed. Finally, I lavaged the abdomen with 3 liters of saline, suctioned it out, and closed up the patient. The skin and subcutaneous tissue OOZED AND OOZED. I was terrified she would bleed to death after surgery.

I stared at her obsessively through the night, after my 2.5 hours of surgery. She did well, although her heart rate remained very elevated, despite taking every step to relieve pain, discomfort, and rehydrating her aggressively.

She is back in the ICU tonight for monitoring and continued post-operative care. So far, she is doing very well.

Keep your fingers crossed for her. Being a 9 year old Great Dane is hard enough as it is!

Update: this was originally written in early October. My patient made a full recovery and continues life as a geriatric Great Dane.


Elizabeth said...

I have my fingers crossed for her. Just curious though as to the dose of pred she is taking. How much pred can cause this kind of problem? I have an 75lb Addisonian who takes a very small daily dose of pred ( 1.25mg )along with percorten. I am assuming a small dose should not be a problem, but I know assuming can get me in trouble..

The Homeless Parrot said...

I don't know the answer to that. Aspirin inhibits platelets at a low dose in cats and dogs (0.5mg/kg). I would assume it would be the same with prednisone. This dog is on it every other day for skin issues.

The Homeless Parrot said...

Thus, a low dose could be problematic in the case that your dog ever needs surgery. On the other hand, mine is doing fine. She finally stopped bleeding, apparently!

Elizabeth said...

Glad to hear she stopped bleeding.
Unfortunately my dog cannot stop taking the pred and it is even recommended that the dose be increased to a therapeutic dose from the maintenance dose if he requires surgery..
Just one more reason to insist on an IV during surgery even if it's just for a dental..
I must do some research on this issue.
If you do find out more on this please post it :)

Thanks for this post!

The Homeless Parrot said...

Yes, prednisone is pretty important to the Addisonian dog. And honestly, I probably just overreacted to how much bleeding was going on. GDVs are stressful enough, and it was making it even worse to see her ooze. She was never anemic however, so it looked worse than it was.

As for at what dose this happens with prednisone, I don't know. I posted the question in the clinical pharm board on VIN, since I couldn't find anything with my own research. I'll get back to you!

Elizabeth said...

Thanks Doc you rock! I always like to be prepared.

You may have overreacted to the oozing but better to take it seriously than not too..

The Homeless Parrot said...

So, Elizabeth: the clinical pharmacologist (one weighed in on my question) says that though prednisone has glucocorticoid (steroid) receptors that this observation of increased bleeding tendency has not been borne out in clinical practice. No one knows if it happens at all. He thinks my patient went into "non-overt DIC" - meaning the bloodwork didn't show any changes consistent with DIC (low platelets, elevated clotting times). I'm not sure what to think, but I still have to lean toward the prednisone causing this.