Sunday, January 23, 2011

Holy WTH, Batman??

Yowza, what a draining weekend. No surgeries, but plenty of difficult, confusing cases that left me wishing I was smarter, more capable, and perhaps board-certified in emergency and critical care. The "last" case of the day was a humdinger.

I was presented with 6 year old, unspayed female terrier type dog. She'd been perfectly normal that day, no health problems, UTD on her vaccines, and otherwise healthy. The owners let her out into the backyard for about a half hour. The yard is fenced, and there are no chemicals, plants, or anything else the dog could have ingested.

When they found her 30 minutes later, she was unable to walk, she was drooling profusely, and she was covered in a mucoid diarrhea. She was barely responsive and had absolutely no palpable femoral pulses.

By the time she got to me, her temperature was 94.2 degrees, her heart rate was a whopping 20 beats per minute (normal 90-150). Her blood pH was 6.99 (normal 7.35-7.5) - indicating a horrible acidosis that was almost incompatible with life. Her blood glucose was elevated at 400, and she had very high amylase and lipase values (enzymes secreted by many organs in the body including the GI tract, pancreas, and kidneys). Initially, I was concerned about diabetic ketoacidosis, but the more I examined this dog, the more convinced I became that she was suffering anaphylactic shock or (less likely) organophosphate toxicity.

I gave her a dose of atropine to bring her heart rate up, and she responded beautifully. We bolused her fluids, and she responded very well. Blood pressure up, blood glucose came down to normal (105), and her blood pH normalized at 7.36. She began to sit up and take interest her in her surroundings.

She was suffering a syndrome I had never heard of until I went to NAVC this past week. It's called "stress of death" hyperglycemia. In cats, it is very normal for the blood sugar to spike when they are stressed or ill. I have seen cats with a blood glucose of 400 simply due to stress. This is a very unusual response in a dog, however. If you see a hyperglycemia in a critically ill animal that is not diabetic, it is called a "stress of death" hyperglycemia, is secondary to massive catecholamines (epinephrine, norepinephrine, etc), and is an indicator of impending cardiac arrest.

When I saw this hyperglycemia in a patient that I didn't suspect was diabetic, my mind immediately jumped to that - and I started treating aggressively.

She has responded much better than I expected, given the severity of her condition. She has developed "mucosal diarrhea." She is losing the lining of her intestines. Why? The GI tract acts as the shock organ in the dog. When there is hypoxemia, low blood pressure, and other shock factors, the gut bears the brunt of it. Hence, the elevated amylase and lipase.

To further my case, I did a brief abdominal ultrasound (also to rule out a weird pyometra manifestation) and found gallbladder wall edema, a very common marker in anaphylaxis.

Unfortunately, my patient is very, very ill. She went to the brink of death, and we brought her back. I don't know if she will make it though. Her blood pressure is stable, her electrolytes, pH, and blood glucose are normal...but she is mentally damaged to some extent. We'll see how it goes. Keep your fingers crossed for her, she is a very sick girl.


Elizabeth said...

Paws crossed!

Holly said...

Holy Moley! That's one scary episode! Please update us on your patient when you can.

Anonymous said...

Wow, I didn't know that either--"stress of death hyperglycemia". Very puzzling indeed. Keep us posted.