Saturday, July 2, 2011

Unexpected complication

I recently saw a very sad and frustrating case. "Madeline" was a 13 year old mixed breed dog. She came in to see me one weeknight for generalized lethargy and just plain feeling bad. She wasn't energetic, she seemed kind of dazed (to the owner), and she wasn't interested in her favorite treats. This had happened rather drastically - in the span of 1 day. When I first examined her, I cringed inwardly. Her gums were a muddy, pale pink, she had a slightly increased and labored respiration pattern, her heart rate was higher than it should have been, and her pulses didn't feel great. When I palpated her abdomen, I could feel a possible mass near her rib edge, and she seemed a bit distended. My spidey sense was tingling - telling me I was dealing with the all too common hemoabdomen of large breed, older dogs.

I see this condition all the time in big, old dogs - a belly full of blood secondary to a ruptured tumor (usually spleen or liver in origin). Us ER vets develop a 6th sense for sniffing this out. Sure enough, xrays confirmed mild to moderate abdominal fluid and a big nasty tumor on the spleen. Ultrasound showed it to be growing from the spleen, and abdominal tap yielded frank blood. Luckily, Madeline was not suffering a catastrophic, life-ending hemorrhage. She was actually pretty stable, and the bleed seemed to be slow.

Her owner was not ready to commit to surgery, and he wanted to seek a second opinion (understandable, given the gravity of my diagnosis). So, we hospitalized Madeline for the night on IV fluids and monitored her. In the morning, she was slightly more anemic but otherwise stable. She went to her veterinary where I fully expected the owners to decide to euthanize her.

Imagine my surprise to come back and find her back in the hospital post-operatively. The owners had decided to remove the tumor, despite the high likelihood that it was malignant cancer (hemangiosarcoma). The prognosis post-tumor removal is only 6-12 months, depending on adjuvant chemotherapy. Still, the owners wanted to try, so to surgery they went.

I was happy for my patient. Madeline was a sweet, good dog with a waggy tail She would have a few months left with her owners until the tumor metastasized, and those would be good months. Or so I foolishly thought.

Madeline remained stable throughout the day, eating, drinking, and resting quietly. Her PCV stayed stable, indicating no significant post-operative hemorrhage. Then at 7:00pm, as my shift was ending, she suddenly developed diarrhea. She then vomited a large amount of foul-smelling liquid. Shortly afterwards, she began to sway, then she collapsed. Her gums were white, and her BP plummeted. I was flummoxed. The white gums and BP seemed to point to internal hemorrhage. But what of the vomiting and diarrhea? Where did that come from? We tried to stabilize her rapidly, but her condition continued to deteriorate. Abdominal tap yielded frank blood with a PCV very close to the PCV of Madeline's circulating blood. An internal bleed? But why?

I gave the owner a grave, grave prognosis. To my shock, he elected to re-explore Madeline's abdomen and find out why she was suddenly in such dire condition. We prepped her for surgery as fast as we could, but her condition was spiraling out of control. While we prepped the OR, we transfused her a unit of packed red blood cells as rapidly as they would go (over 20 minutes). This is certainly not the norm. Usually blood transfusions are given over 2 to 4 hours. Madeline was dying in front of us, so we didn't care. The blood was cold too, but our options for saving her pre-operatively were running out. We ran with her into surgery, and as we got her on the table, her heart stopped. We pumped her with atropine and epinephrine while breathing for her, and her heart rate came back.

I slapped some sterile towels around her incision, as there was no time for a drape. Ignoring the staples from the previous surgery ( which would have taken 10 minutes to remove), I slashed my way down her midline alongside the first incision. Opening her abdomen, blood came pouring out. We started suctioning madly and that was when I saw it. Madeline's entire GI tract - from stomach to colon - was thrombosed. Her stomach had turned a dark purple and was covered in petechiae and ecchymotic hemorrhage. Her intestines were swollen and red, and throughout her mesenteric fat, all of the vessels were engorged with blood clots. No pulses beat at all in the vessels that supplied her GI tract. I pulled out her pancreas and stared in awe at the completely engorged and thrombosed organ.

Madeline could not be saved. Her entire GI tract was full of clots, blocking blood flow to the organs. This likely happened secondary to the large tumor that was removed from her spleen. Many of those tumors are malignant hemangiosarcomas, and many of these dogs are suffering subclinical disseminated-intravascular coagulation. A post-operative complication of splenectomy can be massive thromboemoblic disease. Sadly, it was not the first dog that I've seen with this complication. She was the second. The first dog I saw developed this a week post-operatively! It's not common, but when it happens, it is massive, incredibly acute (Madeline went from normal to vomiting, diarrhea, and collapse in 30 minutes), and fatal.

I felt terrible for the owner. He had taken Madeline to surgery with the expectation of spending several more months with her. Now, he had to stand by and helplessly watch as she died. He was with her as we prepped her for surgery and transfused her, so at least her last moments conscious were with her owner but still. It was a crushing and unexpected disappointment.


WeldrBrat said...

ER Vet Hospitals are where you gain the most amount of experience through the flood of scenarios that come through. IF only it would numb one's heart enough to get you through. Compassion and consideration for the pet owners losing their loving animals is practiced. But I wonder if pet owners ever consider the fact that they see it once... while you see it over and over, and over again.

John Valenty said...

What a horrible ordeal!