Thursday, January 27, 2011

The weight

So before I tell this story, I would like to temper it with the fact that my whipworm/pseudo-Addisonian patient from this weekend is doing extremely well. Tonight, she ate on her own, and she is walking well and wagging her tail.

A month or so ago, I was confronted with a nightmare ER case. The doors burst open, and my techs wheeled in a 100+ pound Labrador. She'd been spayed earlier that day at her veterinarian's office. She was in heat during the spay, and she was morbidly overweight. The vet that did her surgery was very experienced (30+ years), and when I spoke to him, he expressed no concerns about how the surgery went.

When she came to me, she was lateral, her gums were muddy and pale, her pulses were weak, her heart rate was sky-high, and her abdomen was severely distended. We started standard aggressive shock treatment with IV fluids while I went about ensuring that she was bleeding into her abdomen.

Sure enough, about 3 liters of blood were present in her abdomen. Her clotting times were normal, so this didn't appear to be a clotting disorder. Thus, I was left to decide if she was still actively bleeding, or if I could maybe stabilize her with IV fluids. When it comes to this decision, it is never, ever an easy one. Many patients that are bleeding post-surgically will eventually clot on their own without surgical intervention. Some will not. Thus, deciding who is who can be difficult. The standard approach is to try and stabilize the patient with IV fluids - get the blood pressure up, get improvement in vitals (heart rate, gum color, capillary refill time, and mentation), and try to keep the patient that way. If that cannot be successfully done, then surgery is usually indicated.

The bleeding patient is a trick in and of itself. The first line of stabilizing a bleeding patient is getting fluids into the body to make up for the blood that is being lost. Crystalloids (which are fluids similar to the composition of blood), colloids (synthetic fluids with very high molecular weight that say in the bloodstream better), and blood products such as packed red blood cells and fresh frozen plasma are all choices. Knowing which one to choose in the bleeding patient can be a really, really big challenge.

In this case, my patient needed blood cells. She also needed regular fluids. Unfortunately, we can only keep 1 unit of packed red blood cells around. We set about warming it. While waiting, we started crystalloids. Using the right amount is crucial - too little, your patient doesn't get better, too many, and they start bleeding worse because of a spike in blood pressure. Further, when you give a large amount of fluids into the bloodstream, you're diluting out the blood. Everything in the blood gets diluted out too - including clotting factors. Thus, if you are not careful with your fluids, the patient will develop a clotting problem (called a "dilutional coagulopathy"). Colloids work better for increasing blood pressure, but the one we use (Hetastarch) has been associated with possibly causing bleeding problems at high doses. Not the best choice in a bleeding patient.

In the end, I used all 3 to no avail. Her condition did not improve, indeed she started to deteriorate. Her anemia worsened, and her clotting times were off the chart high (secondary to blood loss and dilution from all the fluids). I had to take her to surgery.

Of course, in surgery, I found no active bleeding - just a grapefruit sized clot sitting on the uterus. Three technicians assisted me. One was scrubbed in, one was monitoring anesthesia, and one was auto-transfusing my patient's blood as I handed it to her. We were shoving it into her as fast as we could. We closed her up after placing extra sutures on all the blood vessels.

After surgery, she continued to bleed into her abdomen (now due to her inability to clot from a combination of massive fluids and losing all of her clotting factors into her belly). We put a giant needle into her abdomen, sucked out the blood, and auto-transfused her as fast as we could. We bolused her plasma, as fast as we could (plasma will supply the body with clotting factors that it needs), and yet, she looked worse and worse.

Finally, I called the owners and told them I thought we weren't catching up. The bill was already at $3500. They made the call to euthanize her.

I feel terrible about this case. To be fair to myself, I was behind the curve well before that dog hit our doors. Yet part of me feels that if I'd managed the IV fluids better, gotten the plasma and packed blood cells in faster, used less crystalloids and Hetastarch, and waited on surgery, maybe I could have pulled her through. I know - woulda, coulda, shoulda. The case made me feel like a big fat failure, even though I know that's not true. It's been weighing on me heavily since it happened, and I think about it at least once a day. Not in a "let's beat yourself up" kinda way, but in a "what could I have done better, or done differently" sort of way. I've talked to numerous colleagues - specialists and non-specialists about this, and while they have made me feel better, I still wish I could go back in time and do some things very differently.


KateA said...

Sounds like the dog was one foot in the ground prior to surgery....morbidly obese and in heat? That is some bad mojo. That is the kind of dog that should have waited for surgery until out of the very least, it should have been punted directly to you for aftercare.

Something that might help in these cases is yunan baiyo (sp? not always spelled the same depending on the source). Given every 4 hours or so, it helps coagulation. I would have been tempted to use hypertonic saline and plasma/packed RBC while waiting on a donor animal. So very hard to walk the line of enough BP, but not too much.

Sounds like you guys did a bang up job with a case that was built to spill.

Main thing for the average reader/comsumer to take away? Spay now or pay later....spaying at a relatively young age, while the animal does not have masses of greasy fat in the abd (so much harder to get all of the little bleeders and make it more likely that ligatures will slip) and to *not* spay during heat are both important.

The Homeless Parrot said...

Yunan Baiyo sounds like an SG idea...did she get that from NC State? She didn't mention it last time I talked to her about a hemoabdomen, but I can only assume its her. BP isn't into that stuff...

I've been reading on VIN about aminocaproic acid (and some side stuff about formalin in horses).

Elizabeth said...

Looks like you were cleaning up from a vet that should have refused to spay until the dog was out of heat at the very least considering weight of the dog as well.

I am very glad the pseudo Addison's dog is doing well. Feel good abou tthat!

Anonymous said...

I'm with Elizabeth. I know I'd be feeling the same as you though. Tough case.

Anonymous said...

Considering the fact that the patient was likely ASA level V and that you did absolutely everything the way you should, you definitely shouldn't feel bad. I agree that the choice to spay may not have been the best.

Holly said...

you said you spoke to the original vet. Did he indicate .why. he chose to spay a higher risk candidate during a heat cycle? That seems a bit odd to me, but I'm not a vet.

This sounded like a finger in a dam kind of situation.

I'm sorry you lost her, but LOOK at what you did for the other dog!

KateA said...

I got the YB from Dr. Crowe and Katie Linderman (from VIN). Worked fairly well in my hands. Valproic acid is something that SG brought that back from IVECCS. They are using on battle fields in place of blood.

Outrider said...

When you say the clot was sitting on the uterus, I assume you mean the uterine stump, since this was a spay.

Re: YB, Amicar and formalin - I've used all three in racetrack practice for EIPH. Amicar works decently when combined with Lasix, but again, that's pre-race for EIPH in an otherwise healthy horse.

I've found formalin and YB to be worthless for EIPH, though the trainers like the latter because it doesn't test, and they buy it themselves. There's a lot of voodoo medicine at the racetrack.

Dunno when used for this purpose.

Do you ever use hypertonic saline on these cases? I seem to remember reading an article in the last year or two on that subject (Veterinary Medicine?).

WeldrBrat said...

The saddest fact that led to this scenario has absolutely nothing to do with you.

Had this girl been spayed as soon as possible during " Puppy Stage " - nobody would have been hitting any panic buttons - including (from all accounts shown) her owners.

You were not trained to suffer from "out-of-your-hands and after-the-fact" scenarios. Most of your training pertains to Preventative medicine. There is only so much you can do when animal owners don't meet you halfway from the beginning, Hon. You did the very best you could.

The Homeless Parrot said...

Outrider: I do use hypertonic saline, but there are some downsides that made me want to stay away from it too. This dog really needed massive volumes of blood products - packed red cells and plasma. We just don't have access to that much blood. We had our 1 unit of pRBCs and plasma - and that accounted for $1000 of the bill...

The Homeless Parrot said...

Weldr: Thank you :)

Outrider said...

>>I do use hypertonic saline, but there are some downsides that made me want to stay away from it too. This dog really needed massive volumes of blood products - packed red cells and plasma. We just don't have access to that much blood.>>

Just curious. I use HS only for shocky patients when I can follow up by replacing volume, rapidly. I've never used it for the situation you described because in ambulatory equine practice, we don't see many acute abdominal bleeds of this magnitude.