LIC - Small Animal Critical Care Medicine

Deborah Silverstein; Kate Hopper

BOOK

LIC - Small Animal Critical Care Medicine

Deborah Silverstein | Kate Hopper

(2014)

Additional Information

Book Details

ISBN: 978-0-323-24352-0
Edition: 2
Language: English
Pages: 1152
Subjects: Medical study & revision guides & reference material
Veterinary medicine
Veterinary medicine: small animals (pets)
Veterinary medicine: infectious diseases & therapeutics

Abstract

Emphasizing evidence-based therapy for critically ill or injured dogs and cats, Small Animal Critical Care Medicine, 2nd Edition puts diagnostic and management strategies for common disorders at your fingertips. It covers critical care medical therapy, monitoring, and prognosis — from triage and stabilization through the entire course of acute medical crisis and intensive care treatment. To make therapeutic decisions easier, clear guidelines address underlying clinical findings, pathophysiology, outpatient follow-up, and long-term care. From lead editors Deborah Silverstein and Kate Hopper, along with a Who’s Who of experts from the veterinary emergency and critical care world, this comprehensive reference helps you provide the highest standard of care for ICU patients.

Over 200 concise chapters are thoroughly updated to cover all of the clinical areas needed for evaluating, diagnosing, managing, and monitoring a critical veterinary patient.
More than 150 recognized experts offer in-depth, authoritative guidance on emergency and critical care clinical situations from a variety of perspectives.
A problem-based approach focuses on clinically relevant details.
Practical, user-friendly format makes reference quick and easy with summary tables, boxes highlighting key points, illustrations, and algorithmic approaches to diagnosis and management.
Hundreds of full-color illustrations depict various emergency procedures such as chest tube placement.
Appendices offer quick access to the most often needed calculations, conversion tables, continuous rate infusion determinations, reference ranges, and more.

All-NEW chapters include Minimally Invasive Diagnostics and Therapy, T-FAST and A-FAST, Systemic Inflammatory Response Syndrome (SIRS), Multiple Organ Dysfunction Syndrome (MODS), Sepsis, Physical Therapy Techniques, ICU Design and Management, and Communication Skills and Grief Counseling.
NEW! Coverage of basic and advanced mechanical ventilation helps you in deliver high-quality care to patients with respiratory failure.
NEW! Coverage of increasingly prevalent problems seen in the Intensive Care Unit includes multidrug-resistant bacterial infections and coagulation disorders.
NEW chapters on fluid therapy and transfusion therapy provide information on how to prevent complications and maximize resources.
UPDATED coagulation section includes chapters on hypercoagulability, platelet function and testing, anticoagulant therapy, and hemostatic drugs.

Section Title	Page	Action	Price
Front cover	cover
Reference Ranges	IFC2
Small Animal Critical Care Medicine	i
Copyright page	ii
Contributors	iii
Preface	xv
Acknowledgments	xv
Dedication	xvi
Table of Contents	xvii
I Key Critical Care Concepts	1
1 Evaluation and Triage of the Critically Ill Patient	1
Key Points	1
Introduction	1
Triage Systems	1
Initial Patient Triage	2
Primary Survey	2
Respiratory system evaluation	2
Cardiovascular system evaluation	2
Neurologic system evaluation	4
Urinary system evaluation	4
Additional considerations	4
Triage Diagnostics: Vascular Access, Emergency Database, and Focused Ultrasound	4
Secondary Survey	5
Summary	5
References	5
2 Physical Examination and Daily Assessment of the Critically Ill Patient	6
Key Points	6
Physical Examination	6
Airway and Breathing	6
Circulation	6
Heart rate	6
Mucous membrane color	7
Capillary refill time	7
Venous distention	7
Pulse quality	7
Auscultation	7
Level of Consciousness	8
Temperature	8
Hydration	8
Abdominal Palpation and Gastrointestinal Assessment	8
Monitoring and Laboratory Data	8
Oncotic Pull, Total Protein, and Albumin	9
Glucose	9
Electrolyte and Acid-Base Balance	9
Oxygenation and Ventilation	9
Red Blood Cell and Hemoglobin Concentrations	9
Blood Pressure	9
Coagulation	9
Renal Function and Urine Output	9
Immune Status, Antibiotic Dosage and Selection, and White Blood Cell Count	10
Drug Dosages and Metabolism	10
Nutrition	10
Nursing Care	10
References	10
3 Cardiopulmonary Resuscitation	11
Key Points	11
Preparedness and Prevention	11
Basic Life Support	11
Circulation: Chest Compressions	11
Airway and Breathing—Ventilation	13
Monitoring	13
Electrocardiography	13
Capnography	13
Advanced Life Support	13
Drug Therapy	13
Vasopressors	14
Parasympatholytics	14
Antiarrhythmic drugs	14
Reversal agents	14
Intravenous fluids	15
Corticosteroids	15
Alkalinizing agents	15
Electrical Defibrillation	15
Open-chest CPR	15
Prognosis	16
References	16
4 Post–Cardiac Arrest Care	17
Key Points	17
Propagating Sustained Rosc	18
Systemic Response to Ischemia and Reperfusion: Sepsis-Like Syndrome	19
Hemodynamic Optimization	20
Glycemic Control	20
Adrenal Dysfunction	20
Post–Cardiac Arrest Brain Injury	20
Brain Injury Sustained During Ischemia Versus During Reperfusion	20
Controlled Reoxygenation	20
Mild Therapeutic Hypothermia	21
Other Neuroprotective Treatment Strategies	21
Neurologic Assessment and Prognostication	22
Myocardial Dysfunction	22
Persistent Precipitating Pathology	22
References	23
5 Shock	26
Key Points	26
Clinical Presentation	26
Diagnostics and Monitoring	27
Monitoring Tissue Perfusion and Oxygen Delivery	27
Blood Lactate Levels	27
Cardiac Output Monitoring and Indices of Oxygen Transport	27
Mixed Venous Oxygen Saturation (SvO2) and Central Venous Oxygen Saturation (ScvO2)	28
Treatment	28
References	30
6 Systemic Inflammatory Response Syndrome	30
Key Points	30
Systemic Inflammation	31
The Consequences of Systemic Inflammation	31
SIRS and Sepsis	31
Potential Markers of Sepsis	31
Treatment of SIRS in Humans	32
SIRS in Small Animals	32
Summary	33
References	33
7 Multiple Organ Dysfunction Syndrome	35
Key Points	35
Epidemiology	35
Pathophysiology	36
Immune Dysregulation	36
Coagulation	36
Mitochondria	37
Gastrointestinal Tract	38
Specific Organ Dysfunction	38
Lung	38
Cardiac	38
Liver	38
Gastrointestinal	39
Kidneys	39
Central Nervous System	39
Coagulation and the Endothelium	39
Scoring Systems	39
Sequential Organ Failure Assessment (SOFA)	40
Multiple Organ Dysfunction (MOD) Score	40
Logistic Organ Dysfunction System (LODS)	41
Predisposition Infection Response Organ (PIRO) Dysfunction	41
Which Score To Use?	41
Management	41
Cardiovascular Support	42
Ventilatory Strategies	42
Renal Replacement Therapy	42
Nutritional Support and Glucose Control (see Chapters 127 to 130)	42
Corticosteroids	42
Novel Therapeutic Approaches	43
References	43
8 Hypotension	46
Key Points	46
Normal Determinants of Blood Pressure	46
Potential Causes of Hypotension	47
Reduction in Preload	47
Reduction in Cardiac Function	47
Reduction in Systemic Vascular Resistance	48
Response to Decreases in Blood Pressure	48
Diagnosis of Hypotesion	48
Physical Examination	49
Measurement of Blood Pressure	49
Direct blood pressure monitoring	49
Indirect blood pressure measurement	49
Doppler ultrasonography	49
Oscillometric sphygmomanometry	49
Additional Diagnostics	49
Treatment of Hypotension	50
Fluid Resuscitation	50
Positive Inotropes	50
Vasopressor Agents	50
Summary	50
References	50
9 Hypertensive Crisis	51
Key Points	51
Pathophysiology	51
Blood Pressure Measurement	51
Target Organ Damage	52
Ocular	52
Neurologic	52
Renal	53
Cardiovascular	53
Patients at Risk for Hypertension	53
Hypertensive Urgency	53
Hypertensive Emergency	53
Treatment	53
Therapeutic Goals	53
Follow-up	54
References	54
10 Hyperthermia and Fever	55
Key Points	55
Thermoregulation	55
Hyperthermia	55
True Fever	55
Exogenous Pyrogens	55
Endogenous Pyrogens	56
Inadequate Heat Dissipation	56
Heat Stroke	56
Hyperpyrexic Syndrome	57
Exercise-Induced Hyperthermia	57
Pathologic and Pharmacologic Hyperthermia	58
Benefits and Detriments of Fever	58
Benefits	58
Detriments	58
Clinical Approach to the Hyperthermic Patient	58
Nonspecific Therapy for Febrile Patients	59
The Febrile Intensive Care Patient	59
References	59
11 Interstitial Edema	60
Key Points	60
Microvascular Filtration	60
Lymphatic Drainage	61
Serosal Transudation	61
Antiedema Mechanisms	61
Mechanisms of Edema Formation	61
Venous Hypertension	62
Hypoproteinemia	62
Increased Microvascular Permeability	62
Impaired Lymph Flow	62
Inflammatory Edema	62
Chronic Edemagenic Conditions	63
Conclusion	63
References	63
12 Patient Suffering in the Intensive Care Unit	64
Key Points	64
Maslow’s Hierarchy of Needs and Primal Alert Signals	64
Impact of Symptom Relief	66
Palliative Measures	66
References	66
13 Illness Severity Scores in Veterinary Medicine	67
Key Points	67
Applications of Illnes Severity Scores	67
Applications for the Individual Patient	67
Inappropriate Score Use	67
Applications in Triage and Clinician Performance Benchmarking	68
Research Applications	69
Use of Illness Severity Scores in the Management of Confounding	69
Demonstration of Effective or Ineffective Randomization	69
Provision of Objective Context	70
Reduction of Required Sample Sizes	70
Critical Evaluation of Illness Severity Scores	70
Assessment of Model Validity	70
Discrimination and Calibration	71
Model Transferability	71
Veterinary Models: Disease Specific and Disease Independent	71
Features of Model Construction	71
Selection of Predictive Variables	71
Outcome Selection	72
Model-Building Process	73
APPLE Scores	73
Summary	73
References	74
II Respiratory Disorders	77
14 Oxygen Therapy	77
Key Points	77
Arterial Oxygen Content	77
Indications for Oxygen Therapy	77
Methods of Oxygen Administration	77
Humidification	77
Noninvasive Methods	77
Flow-by oxygen	77
Face mask	78
Oxygen hood	78
Oxygen cage	78
Invasive Methods	78
Nasal prongs	78
Nasal and nasopharyngeal oxygen	78
Transtracheal oxygen	79
Hyperbaric Oxygen	79
Complications of Oxygen Therapy	80
Oxygen Toxicity	80
References	80
15 Hypoxemia	81
Key Points	81
Collection of Blood Samples for In Vitro Measurement	81
Recognition of Hypoxemia	81
PaO2	81
SpO2	81
Cyanosis	81
Mechanisms of Hypoxemia	82
Low Inspired Oxygen	83
Hypoventilation	83
Venous Admixture	83
Regions of low ventilation-perfusion (V/Q) ratio	83
Regions of zero V/Q	84
Diffusion impairment	84
Anatomic Shunts	84
Estimating the Magnitude of the Venous Admixture	84
PaCO2 + PaO2 Added Value (“The 120 rule”)	85
Alveolar-Arterial PO2 Gradient	85
PaO2/FiO2 Ratio	85
Venous Admixture (Shunt) Calculation	85
References	85
16 Hypoventilation	86
Key Points	86
Definitions	86
Control of Breathing	87
Central Neuronal Control of Breathing	87
Central and Peripheral Chemoreceptors	88
Lung Receptors	88
Respiratory Mechanics and Muscular Control	89
Differential Diagnosis	89
Clinical Signs	89
Diagnosis	89
Treatment	91
References	92
17 Upper Airway Disease	92
Key Points	92
History and Clinical Signs	92
Emergency Stabilization	93
Diagnostics	94
Diseases of the Upper Airway	95
Brachycephalic Airway Syndrome	95
Nasopharyngeal Polyps	95
Nasopharyngeal Stenosis	96
Congenital Choanal Atresia	96
Nasopharyngeal Foreign Bodies and Infection	96
Laryngeal Paralysis	97
Inflammatory Laryngeal Disease	98
Tracheal Collapse	98
Tracheal Stenosis/Stricture	99
Tracheal Foreign Bodies	99
Upper Airway Neoplasia	99
Complications of Upper Airway Obstruction	100
References	100
18 Brachycephalic Syndrome	104
Key Points	104
Pathophysiology	104
Respiratory Consequences	105
Consequences of Chronic Upper Airway Obstruction	105
Management of Upper Airway Obstructive Crises in BD	105
Gastrointestinal Consequences	105
Systemic Consequences	106
Summary	106
References	106
19 Tracheal Trauma	107
Key Points	107
Causes	107
Pathophysiology	107
Clinical Signs	107
Differential Diagnosis and Diagnostic Testing	108
Treatment	108
Outcome and Prognosis	110
References	110
20 Allergic Airway Disease in Dogs and Cats and Feline Bronchopulmonary Disease	111
Key Points	111
Definition of Allergic Airway Disease	111
Human Asthma	111
Pathogenesis of Small Animal Allergic Respiratory Disease	111
Parasitic Allergic Airway Disease	112
Canine Allergic Bronchitis or Eosinophilic Bronchopneumopathy	112
Pulmonary Infiltrates with Eosinophils	113
Feline Bronchopulmonary Disease	113
Pathogenesis	113
Clinical Signs	113
Laboratory Diagnostic Tests	113
Radiology	113
Bronchoscopy	113
Treatment of Allergic Airway Disease and Feline Bronchopulmonary Disease	114
Glucocorticoids	114
Bronchodilators	114
Miscellaneous Drugs and Other Therapies	114
Prognosis	115
References	115
21 Pulmonary Edema	116
Key Points	116
Pathophysiology	116
Clinical Presentation	117
High-Pressure Edema	117
Cardiogenic edema	117
Fluid therapy	117
Increased-Permeability Edema	117
Mixed-Cause Edema	117
Diagnostic Tests	118
Treatment	119
Oxygen Therapy	119
Medical Therapy	119
Fluid Therapy	119
Prognosis	119
References	119
22 Pneumonia	120
Key Points	120
Clinical Presentation	121
Initial Evaluation	121
History	121
Physical Examination	121
Diagnostic Testing	122
Pathophysiology	123
Mechanism	123
Causes	124
Treatment	124
Additional Management Considerations	125
Contagion and Zoonosis	125
Monitoring	126
Prognosis and Outcome	126
References	126
23 Aspiration Pneumonitis and Pneumonia	127
Key Points	127
Definitions	127
Aspiration Pneumonitis	127
Aspiration Pneumonia	127
Aspiration Pneumonitis and Pneumonia	127
Epidemiology	127
Pathophysiology	127
Diagnosis	128
History	128
Physical examination	128
Radiography and computed tomography	128
Tracheal wash	129
Bronchoscopy and bronchoalveolar lavage	129
Complete blood cell count and serum biochemistry	129
Oxygenation status	129
Biomarkers	129
Treatment	129
Airway management	130
Oxygen therapy	130
Mechanical ventilation	130
Antimicrobial therapy	130
Bronchodilators	130
Cardiovascular support	130
Chest physiotherapy	130
Glucocorticoids	131
Prevention	131
References	131
24 Acute Lung Injury and Acute Respiratory Distress Syndrome	133
Key Points	133
The Human Perspective	133
Criteria for the Diagnosis of ALI/ARDS	133
Pathophysiology	134
Treatment	135
The Canine Perspective	135
Criteria for the Diagnosis of ALI/ARDS	135
Treatment	136
References	137
25 Pulmonary Contusions and Hemorrhage	138
Key Points	138
Pathophysiology and Pathology	138
Diagnosis	139
Physical Findings	139
Imaging: Radiology, Computed Tomography, and Ultrasound	139
Blood Gas Analysis and Pulse Oximetry	140
Management	140
Initial Approach	140
Oxygen Therapy and Ventilation	140
Fluid Therapy	141
Analgesia	141
Antimicrobial Therapy	141
Glucocorticoids	141
Other Therapies	141
Prognosis and Outcome	141
Atraumatic Pulmonary Hemorrhage	141
Diagnostic Evaluation	142
Treatment	143
Prognosis and Outcome	143
References	143
26 Pulmonary Thromboembolism	144
Key Points	144
Pathophysiology	145
History and Clinical Signs	145
Physical Examination	145
Diagnostic Testing	145
Treatment and Prophylaxis	146
Summary	147
References	147
27 Chest Wall Disease	148
Key Points	148
Chest Wall Anatomy and Function	148
Diagnosis of Chest Wall Disease	148
Diseases of the Chest Wall	148
Congenital	148
Neoplasia	148
Rib Fractures	148
Trauma	148
Flail chest and intercostal muscle damage	148
Penetrating wounds	149
Nontraumatic rib fractures	149
Cervical Spine Disease	149
Neuromuscular Disease (see Chapter 85)	149
Tick paralysis	149
Acute idiopathic polyradiculoneuritis	149
Botulism	150
Fulminant myasthenia gravis	150
Elapidae snake envenomation	150
References	150
28 Pleural Space Disease	151
Key Points	151
Pleural Space	151
Clinical Evaluation	151
Pleural Effusion	152
Pure Transudates and Modified Transudates	152
Exudates	153
Feline Infectious Peritonitis	153
Pyothorax	153
Chylothorax	153
Hemothorax	154
Neoplastic Effusions and Pleural Neoplasia	154
Fibrosing Pleuritis	154
Pneumothorax	154
Space-Occupying Lesions	155
Diaphragmatic Hernia	155
References	155
29 Nonrespiratory Look-Alikes	157
Key Points	157
PH and PCO2 Receptor Activation	157
PO2 Receptor Activation	158
Cortical Modification of Respiration	158
Thermal Receptor Changes	158
Electrolyte Imbalances and Metabolic Disease	159
Peripheral Nervous System Disease	159
Central Nervous System Disease	159
Clinical Evaluation	160
Summary	160
References	160
III Mechanical Ventilation	161
30 Basic Mechanical Ventilation	161
Key Points	161
Compliance	161
The Ventilator Breath	161
Ventilator Settings	161
Indications for Mechanical Ventilation	162
Approach to Initiation of Mechanical Ventilation	163
Goals	164
Carbon Dioxide	164
Oxygen	164
Maintenance of Mechanical Ventilation	164
Complications	164
Troubleshooting	164
Prognosis	165
References	165
31 Advanced Mechanical Ventilation	166
Key Points	166
Ventilator Concepts	166
Respiratory Cycle	166
Equation of Motion	166
Defining the Ventilator Mode	166
Breath Type	166
Control Variable	167
Phase Variables	167
Trigger variable	168
Cycle variable	168
Limit variable	168
Baseline variable	168
Breath Pattern	168
Continuous mandatory ventilation	168
Continuous spontaneous ventilation	168
Intermittent mandatory ventilation	168
Ventilator Mode	168
Respiratory Rate and Inspiratory-to-Expiratory Ratio	169
Positive End-Expiratory Pressure	169
Ventilator Alarms	169
Low Airway Pressure Alarm	169
High Airway Pressure Alarm	169
Low Tidal Volume Alarm	169
High Tidal Volume Alarm	169
Lung-Protective Ventilation	169
Setting Optimal PEEP	170
Recruitment Maneuvers	170
Patient–Ventilator Asynchrony	171
References	171
32 Jet Ventilation	172
Key Points	172
Physics and Physiology	173
Equipment	173
Indications	173
Disadvantages	174
Monitoring of Gas Exchange during Jet Ventilation	174
Ventilator Settings	174
References	174
33 Ventilator Waveforms	175
Key Points	175
Waveform Types	175
General	175
Waveforms in Different Ventilation Modes	175
Pressure Waveform	177
Flow Waveform	178
Volume Waveform	179
Pressure-Volume Loops	179
Flow-Volume Loops	181
Patient–Ventilator Dyssynchrony	182
Summary	184
References	184
34 Care of the Ventilator Patient	185
Key Points	185
Anesthesia	185
Monitoring	186
Airway Management	187
Endotracheal Tube	187
Humidification	187
Airway Suctioning	187
Oral Care	188
Eye Care	188
Urinary Care	188
Gastrointestinal Tract	188
Recumbent Patient Care	189
Apparatus Care	189
References	189
35 Discontinuing Mechanical Ventilation	190
Key Points	190
When to Wean	191
Anesthetic Considerations	191
Weaning Prediction	191
Weaning a Patient From Mechanical Ventilation	192
Spontaneous Breathing Trials	192
Pressure Support Ventilation	192
Synchronized Intermittent Mandatory Ventilation	192
Tracheostomy and Weaning	192
Monitoring	193
Failure to Wean	193
Extubation	193
Prognosis	193
References	193
36 Ventilator-Induced Lung Injury	194
Key Points	194
Definitions	194
Introduction	194
Evidence From Experimental Models	194
Stretch Injury	195
Shear Injury	195
Biotrauma	195
Histopathology	195
Pneumothorax	195
Oxygen Toxicity	195
Clinical Relevance	195
Prevention	196
Conventional Mechanical Ventilation Strategies	196
Low tidal volume	196
Positive end-expiratory pressure	196
Limitation of plateau pressure	196
Using the Pressure-Volume Loop to Guide Settings	196
Avoid Patient–Ventilator Asynchrony	197
Other Strategies	197
Advanced Pulmonary Support Techniques	197
References	197
37 Ventilator-Associated Pneumonia	199
Key Points	199
Pathogenesis	199
Diagnosis	200
Prevention	201
Nonpharmacologic Strategies	201
Pharmacologic Strategies	201
Treatment	202
References	202
IV Cardiac Disorders	205
38 Mechanisms of Heart Failure	205
Key Points	205
Neurohormonal Aspects of Heart Failure	205
Renin-Angiotensin-Aldosterone System	205
Sympathetic Nervous System	205
Natriuretic Peptide System	206
Endothelin and Vasopressin Systems	206
Myocardial Remodeling	206
Abnormal Calcium Ion Handling	206
Abnormal Myocardial Energy Production	206
Global Cardiac Function	207
The Frank-Starling Mechanism as a Key to Understanding Heart Failure	207
Diastolic Heart Dysfunction	208
Clinical Staging and Assessment of Heart Failure	208
Clinical Manifestations of Heart Failure	209
Low output versus congestive failure	209
Left-sided versus right-sided heart failure	209
References	209
39 Cardiogenic Shock	210
Key Points	210
Pathophysiology	210
Clinical Signs and Diagnosis	210
Systolic Dysfunction	211
Failure of Contractility	211
Dilated cardiomyopathy	211
Sepsis	212
Endomyocarditis	212
Myocardial infarction	212
Mechanical Failure	212
Diastolic Failure	212
Cardiac Tamponade	212
Hypertrophic Cardiomyopathy	212
Tachyarrhythmias	212
Bradyarrhythmias	213
References	213
40 Ventricular Failure and Myocardial Infarction	214
Key Points	214
Basic Terminology	214
Causes of Ventricular (Systolic) Failure	214
Primary Causes	214
Secondary to Other Cardiac Disease	214
Extracardiac Causes	215
Myocardial Infarction	215
Physical Examination	215
Diagnostic Tests	215
Pathophysiology	216
Treatment	216
Supporting Contractility and Maintaining Blood Pressure	216
Relieving Signs of Congestion	217
Suppressing Arrhythmias	217
Treating the Underlying Cause	217
References	217
41 Feline Cardiomyopathy	218
Key Points	218
Etiopathogenesis	218
Pathophysiology	218
Diastolic Dysfunction	218
Systolic Anterior Motion of the Mitral Valve	219
Feline Arterial Thromboembolism (FATE)	219
Clinical Presentation	219
Patient History and Physical Findings	219
Electrocardiography	219
Radiography	220
Echocardiography	220
Systemic Blood Pressure	220
Bloodborne Cardiac Biomarkers	220
Diagnostic Approach	221
Therapeutic Approach	222
Management of FATE	222
Management of Acutely Decompensated Heart Failure	222
Management of Chronic Heart Failure	223
References	223
42 Canine Cardiomyopathy	225
Key Points	225
Dilated Cardiomyopathy	225
Physical Examination	226
Thoracic Radiography	226
Electrocardiography	226
Routine Blood Tests	226
Effusion Analysis	226
Echocardiography	226
Acute Treatment of Congestive Heart Failure	226
Long-Term Treatment of Dilated cardiomyopathy	226
Diuretics	226
Angiotensin-Converting Enzyme Inhibitors	226
Digoxin	227
Pimobendan	227
Novel Therapy	227
Diet	227
Supplements	227
Treatment of Arrhythmias	227
Breed Variations with DCM	227
Cocker Spaniels	227
Doberman Pinschers	228
Dalmatians	228
Great Danes and Irish Wolfhounds	228
Portuguese Water Dogs	228
Arrhythmogenic Right Ventricular Cardiomyopathy in Boxers	228
Electrocardiography	228
Treatment of Arrhythmogenic Right Ventricular Cardiomyopathy	228
Hypertrophic Cardiomyopathy in Dogs	229
Pathologic Features	229
Important Differentials for Concentric Hypertrophy of the Left Ventricle	229
Uncommon Myocardial Diseases of Dogs	229
Duchenne Cardiomyopathy	229
Atrioventricular Myopathy	229
Toxic Myocardial Disease	229
References	229
43 Valvular Heart Disease	230
Key Points	230
Pathology	230
Pathophysiology	231
History and Physical Examination	231
Laboratory Evaluation	231
Electrocardiographic Findings	232
Radiographic Findings	232
Echocardiographic Findings	232
Emergency Management	233
Cardiac Output	233
Tissue Oxygenation	234
Arrhythmia Management and Adjunctive Therapy	234
Monitoring	234
Long-Term Therapy	234
Prognosis	234
Infectious Endocarditis	234
References	235
44 Myocardial Contusion	236
Key Points	236
Incidence	236
Etiology, Mechanism of Injury, and Pathophysiology	236
Diagnosis	237
Treatment	237
Summary	238
References	238
45 Pericardial Diseases	239
Key Points	239
Pericardial Effusion	239
Hemorrhagic Pericardial Effusion	239
Hemangiosarcoma	239
Heart base tumors	239
Other neoplasia	240
Idiopathic (benign) pericardial effusion	240
Transudative Pericardial Effusion	240
Exudative Pericardial Effusion	240
Cardiac Tamponade	240
Clinical Presentation	240
Physical Findings with Tamponade	240
Diagnosis	241
Thoracic Radiographs	241
Echocardiography	241
Electrocardiography	242
Central Venous Pressure	242
Clinicopathologic Findings	242
Pericardial Fluid Analysis	242
Management of Cardiac Tamponade	242
Pericardiocentesis	243
Preparation and Positioning	243
Pericardiocentesis Procedure	243
Complications of Pericardiocentesis	243
Ancillary Treatment	244
Idiopathic Pericardial Effusion	244
Neoplastic Pericardial Effusion	244
Infectious Pericarditis	244
Constrictive Pericardial Disease	244
Clinical Features	244
Diagnosis	244
Treatment	244
Congenital Pericardial Disease	245
Clinical Features	245
Diagnosis	245
Treatment	245
References	245
46 Bradyarrhythmias and Conduction Disturbances	246
Key Points	246
Definition	246
Differential Diagnosis	246
Sinus Bradycardia	246
Sinus Node Dysfunction	247
Atrioventricular Block	247
Atrial Standstill	248
Treatment	248
Medical Treatment	248
Pacemaker Therapy	248
Transcutaneous pacing	248
Temporary transvenous pacing	248
References	249
47 Supraventricular Tachyarrhythmias	250
Key Points	250
Historical Data	250
Physical Examination Findings	250
Examining the Electrocardiogram	250
Distinguishing Supraventricular from Ventricular Tachyarrhythmias	250
Diagnosing Atrial Versus Atrioventricular Node–Dependent Tachyarrhythmias	251
Treatment of Supraventricular Tachyarrhythmias	251
Emergent Therapy	251
Long-Term Therapy	253
Medical treatment	253
Catheter ablation	254
References	254
48 Ventricular Tachyarrhythmias	255
Key Points	255
Introduction	255
Electrocardiographic Diagnosis	256
Approach to the Patient with Ventricular Tachycardia	256
Noncardiac Causes of Ventricular Tachycardia	256
Cardiac Causes of Ventricular Tachycardia	257
Antiarrhythmic Treatment	257
Decision to Treat	257
Antiarrhythmic Drugs	257
Lidocaine	257
Procainamide	258
β-Blockers	258
Sotalol	258
Amiodarone	258
Magnesium sulfate	258
Other Treatments	258
Anesthesia	258
Electrical therapies	258
Postintervention Monitoring	258
References	258
49 Myocarditis	259
Key Points	259
Infectious Myocarditis	259
Viral Myocarditis	259
Protozoal Myocarditis	259
Chagas’ disease	259
Bacterial and Other Causes of Myocarditis	260
Noninfectious Myocarditis	260
Doxorubicin Toxicity	260
Diagnosis	260
Treatment	261
References	261
V Electrolyte and Acid-Base Disturbances	263
50 Sodium Disorders	263
Key Points	263
Distribution of Total Body Water	263
Osmolality and Osmotic Pressure	263
Regulation of Plasma Osmolality	263
Antidiuretic hormone	264
Thirst	264
Prioritization of Osmolality and Effective Circulating Volume	264
Total Body Sodium Content Versus Plasma Sodium Concentration	264
Hypernatremia	264
Etiology	264
Free water deficit	264
Sodium excess	265
Clinical Signs	265
Physiologic Adaptation to Hypernatremia	265
Treatment of the Normovolemic, Hypernatremic Patient	265
Complications of Therapy for Hypernatremia	265
Hyponatremia	266
Etiology	266
Decreased effective circulating volume	266
Hypoadrenocorticism	266
Diuretics	266
Syndrome of inappropriate antidiuretic hormone secretion	266
Other causes of hyponatremia	266
Clinical Signs	266
Physiologic Adaptation to Hyponatremia	266
Treatment of the Normovolemic, Hyponatremic Patient	266
Patients asymptomatic for hyponatremia	266
Patients symptomatic for hyponatremia	267
Complications of Therapy for Hyponatremia	267
Pseudohyponatremia	267
Volume Expansion in the Hypovolemic, Hyponatremic, or Hypernatremic Patient	267
References	267
51 Potassium Disorders	269
Key Points	269
Normal Distribution of Potassium in the Body	269
Hypokalemia	269
Definition and Causes	269
Consequences	269
Management of Hypokalemia	270
Anticipated Complications	271
Hyperkalemia	271
Definition and Causes	271
Consequences	272
Pseudohyperkalemia	272
Treatment of Hyperkalemia	272
References	273
52 Calcium Disorders	274
Key Points	274
Calcium Homeostasis	274
Calcium Measurement	274
Sample Handling Techniques	274
Ionized Versus Total Calcium	275
Hypercalcemia	275
Clinical Signs and Diagnosis	275
Differential Diagnoses	276
Treatment of Hypercalcemia	276
Hypocalcemia	278
Clinical Signs and Diagnosis	278
Differential Diagnoses	279
Treatment	279
References	280
53 Magnesium and Phosphate Disorders	281
Key Points	281
Magnesium	281
Hypomagnesemia	281
Causes	281
Clinical signs	282
Diagnosis	283
Therapy	283
Hypermagnesemia	283
Causes	283
Clinical signs	283
Diagnosis	284
Therapy	284
Phosphate	284
Hypophosphatemia	285
Causes	285
Clinical signs	286
Diagnosis	286
Therapy	286
Hyperphosphatemia	286
Causes	287
Clinical signs	287
Diagnosis	287
Treatment	287
References	287
54 Traditional Acid-Base Analysis	289
Key Points	289
Sample Collection and Handling	289
Traditional Approach	289
PCO2	290
Bicarbonate	290
Base Excess	290
Total Carbon Dioxide	290
Anion Gap	290
Compensation	291
Acid-Base Analysis	291
Causes of Acid-Base Abnormalities	292
Respiratory Acidosis	292
Respiratory Alkalosis	292
Metabolic Acidosis	292
Metabolic Alkalosis	293
Bicarbonate Therapy	293
Dose and Administration	294
References	294
55 Nontraditional Acid-Base Analysis	296
Key Points	296
The Stewart Approach	296
Strong Ion Difference	296
Total Weak Acids (ATOT)	297
Strong Ion Gap	297
Semi-Quantitative Approach	297
Free Water Effect	298
Chloride Effect	298
Albumin Effect	298
Phosphate Effect	298
Lactate Effect	298
Unmeasured Ions (XA)	298
Conclusion	298
Clinical Examples	298
Case 1	298
Case 2	299
References	299
56 Hyperlactatemia	300
Key Points	300
Introduction	300
Biochemistry	300
Physiology	301
Lactate Pharmacokinetics in Health	301
Lactate Pharmacokinetics in Disease	301
Etiology of Hyperlactatemia	301
Type A Hyperlactatemia	301
Increased oxygen demand	301
Decreased oxygen delivery	301
Type B Hyperlactatemia	302
Type B1	302
Type B2	302
Type B3	302
Hyperlactatemia Without Metabolic Acidosis	303
d-Lactate	303
Clinical Use	303
Prognostic Use	303
Diagnostic Use	303
Lactate as a Therapeutic Endpoint	303
References	304
VI Fluid Therapy	307
57 Assessment of Hydration	307
Key Points	307
Introduction	307
Physiologic Definitions	307
Variability in Assessing Hydration	307
Distribution and Control of Total Body Water	307
Measuring Total Body Water	308
Clinical Assessment of Hydration Status	308
Interstitial Volume Changes	308
Intravascular Volume Changes	309
Intracellular Volume Changes	309
Hypotonic Fluid Loss	309
Isotonic Fluid Loss	309
Special Challenges	310
Conclusion	310
References	310
58 Crystalloids, Colloids, And Hemoglobin-Based Oxygen-Carrying Solutions	311
Key Points	311
Crystalloids	312
Isotonic Fluids	312
Hypotonic Fluids	312
Hypertonic Fluids	312
Acid-Base Effects of Crystalloids	313
Colloids	313
Synthetic Starch Colloids	313
Allogenic Blood Products	314
Human Albumin	314
Hemoglobin-Based Oxygen-Carrying Solutions	315
Conclusion	315
References	315
59 Daily Intravenous Fluid Therapy	316
Key Points	316
Total Body Water	317
Movement of Fluids Within the Body	317
Isotonic Fluid Loss	317
Hypotonic Fluid Loss	317
Hypertonic Fluid Loss	317
Increased Vascular Permeability	317
Fluid Therapy Plan	318
Fluid Deficit	318
Maintenance Fluid Therapy	318
Ongoing Losses	318
Route of Administration	318
Fluid Type	318
Replacement Fluids	318
Maintenance Fluids	319
Free Water Administration	319
Synthetic Colloids	320
Monitoring	320
Discontinuation of Fluid Therapy	320
References	320
60 Shock Fluids and Fluid Challenge	321
Key Points	321
Administration of Shock Fluids	321
Resuscitation Endpoints and Monitoring	322
Shock Fluids	322
Isotonic Crystalloids	322
Adverse effects	322
Synthetic Colloids	323
Hetastarch	323
Tetrastarch	324
Pentastarch	324
VII Endocrine Disorders	343
64 Diabetic Ketoacidosis	343
Key Points	343
Pathophysiology	343
Risk Factors	343
Clinical Signs and Physical Examination Findings	344
Clinical Pathology	344
Differential Diagnosis	344
Treatment	344
Outcome	346
References	346
65 Hyperglycemic Hyperosmolar Syndrome	347
Key Points	347
Pathogenesis	347
Hormonal Alterations	347
Reduction of Glomerular Filtration Rate	347
Influence of Concurrent Disease	347
History and Clinical Signs	348
Physical Examination	348
Diagnostic Criteria	348
Additional Diagnostic Evaluation	348
Treatment	349
Fluids	349
Insulin	349
Electrolytes	349
Treating Concurrent Disease	350
Monitoring	350
Postcrisis Therapy	350
Prognosis	350
References	351
66 Hypoglycemia	352
Key Points	352
Normal Glucose Homeostasis	352
Clinical Signs and Consequences of Hypoglycemia	352
Diagnosis of Hypoglycemia	353
Causes of Hypoglycemia	353
Excess Insulin or Insulin Analogs	353
Exogenous insulin overdose	353
Insulinoma	353
Paraneoplastic hypoglycemia	354
Toxins and medications	354
Inadequate Glucose Production	354
Hypoglycemia of neonates and toy breed dogs	354
Hepatic disease	354
Hypocortisolism and other counterregulatory hormone deficiencies	355
Excess Glucose Utilization	355
Infection	355
Exercise-induced hypoglycemia	355
Polycythemia and leukocytosis	355
Treatment of Hypoglycemic Crisis	355
References	356
67 Diabetes Insipidus	357
Key Points	357
Urine Concentration Mechanism	357
Vasopressin Secretion and Sodium Homeostasis	357
Antidiuretic Effects of Vasopressin	358
Central Diabetes Insipidus	358
Nephrogenic Diabetes Insipidus	358
Diagnosing Diabetes Insipidus	359
Modified Water Deprivation Test	360
Problems and risks	360
Causes of misdiagnoses	360
Associated risks	360
Desmopressin Acetate Trial	360
Imaging After a Diagnosis of CDI	361
Treatment of Diabetes Insipidus	361
Emergency Treatment	361
Prognosis	361
References	361
68 Syndrome Of Inappropriate Antidiuretic Hormone	362
Key Points	362
Causes	362
Clinical Signs	363
Laboratory Findings	363
Diagnostic Imaging Findings	363
Diagnosis	363
Treatment	363
Prognosis	364
References	364
69 Thyroid Storm	364
Key Points	364
Pathogenesis	365
High Levels of Circulating Thyroid Hormones	365
Rapid, Acute Increases in Circulating Thyroid Hormones	365
Hyperactivity of the Sympathetic Nervous System	365
Increased Cellular Response to Thyroid Hormones	365
Precipitating Events	365
Clinical Signs	365
Diagnosis	365
Laboratory Abnormalities	366
Treatment	366
Reduction in Production or Secretion of New Thyroid Hormones	366
Inhibition of Peripheral Effects of Thyroid Hormone	366
Systemic Support	367
Eradication of the Precipitating Factor	367
Outcome	367
References	367
70 Hypothyroid Crisis in the Dog	368
Key Points	368
Pathophysiology	368
Risk Factors	369
Clinical Signs and Physical Examination Findings	369
Clinical Pathology	369
Differential Diagnosis	370
Treatment	370
Outcome	370
References	370
71 Pheochromocytoma	371
Key Points	371
Clinical Signs	371
Diagnosis	372
Treatment	373
Preoperative Treatment	373
Anesthesia and Monitoring	374
Surgical Excision	374
Postoperative Monitoring and Complications	374
Medical Treatment	374
Prognosis	374
References	375
72 Critical Illness–Related Corticosteroid Insufficiency	376
Key Points	376
Background	376
Suspected Pathophysiology	377
Clinical Manifestations	377
Diagnosis of CIRCI	377
Veterinary Data	377
Treatment of CIRCI	378
Veterinary Data	378
Prognosis	378
References	379
73 Hypoadrenocorticism	380
Key Points	380
Who is Affected?	380
Etiology	380
Clinical Presentation	381
History	381
Physical Examination	381
Clinicopathologic Findings	381
Electrocardiographic Findings	382
Diagnostic Imaging	382
Diagnosis	382
Treatment	382
Fluid Therapy	382
Initial Hormonal Replacement	382
Supportive Therapies	383
Timeline for Clinical Improvement	383
Associated Disorders	383
Prognosis	383
References	383
VIII Therapeutic Drug Overdose	385
74 Approach to Drug Overdose	385
Key Points	385
Obtaining an Appropriate History	385
Triage	385
When to Decontaminate	386
Activated Charcoal (AC)	386
Multidose Activated Charcoal	387
Contraindications and Complications of Activated Charcoal Administration	387
Cathartics	387
Treatment	387
Fluid Therapy	388
Gastrointestinal Support	388
Neurologic Support	388
Sedatives and Reversal Agents	388
Hepatoprotectants	388
Miscellaneous	388
Intravenous Lipid Emulsion	388
Conclusion	389
References	389
75 Blood Purification for Intoxications and Drug Overdose	390
Key Points	390
Methods	390
Toxin Overview	391
Considerations	392
Ethylene Glycol	392
Acetaminophen	392
Nonsteroidal Antiinflammatory Drugs	392
Mushrooms	393
Barbiturates	393
Lily Ingestion	393
Summary	393
References	393
76 Nonsteroidal Antiinflammatory Drugs	395
Key Points	395
COX-1, COX-2, and Prostaglandins	395
Potential Adverse Effects	395
Gastrointestinal Effects	395
Renal Effects	396
Hepatic Effects	396
Coagulation Effects	396
Bone and Cartilage Effects	396
Neurologic Effects	396
Drug Interactions with NSAIDs	396
Toxic Dosage	396
Clinical Signs	397
Diagnosis of NSAID Toxicity	397
Treatment	397
Asymptomatic Patients	397
Symptomatic Patients	397
Prognosis	398
Client Education	398
References	398
77 Sedative, Muscle Relaxant, and Narcotic Overdose	400
Key Points	400
Sedative Overdose	400
Mechanism of Action	400
Pharmacokinetics	400
Clinical Signs	400
Treatment	400
Muscle Relaxant Overdose	400
Mechanism of Action	401
Pharmacokinetics	401
Clinical Signs	401
Treatment	401
Prognosis	404
Narcotic Overdose	404
Mechanism of Action	404
Pharmacokinetics	404
Clinical Signs	405
Treatment	405
Prognosis	406
References	406
78 Calcium Channel Blocker and β-Blocker Drug Overdose	407
Key Points	407
Method of Action	408
Calcium Channel Blockers	408
Cardiac effects	408
Vascular effects	408
Pancreatic effects	408
β-Blockers	408
Cardiac effects	409
Pulmonary, pancreatic, gastrointestinal, vascular, and renal effects	409
Pharmacokinetics	409
Calcium Channel Blockers	409
β-Blockers	409
Diagnosis of Overdose	409
Therapy	410
Asymptomatic Patients	410
Decontamination	410
Symptomatic Patients	411
Calcium salts	411
Parasympatholytics and sympathomimetics	411
Vasopressin	412
Glucagon	412
Hyperinsulinemia and euglycemia	412
Intravenous lipid emulsion	413
Mechanical support	413
Supportive Care	413
Conclusion	413
References	413
79 Serotonin Syndrome	414
Key Points	414
Definition	415
Serotonin and Pathophysiology of Serotonin Syndrome	415
Clinical Signs	415
Toxicity	416
Diagnosis and Treatment	416
Prognosis	418
References	418
IX Neurologic Disorders	419
80 Deteriorating Mental Status	419
Key Points	419
States of Consciousness	419
Normal	419
Obtunded	419
Stupor or Semicoma	419
Coma	419
Neuroanatomy	419
Cerebrum	419
Reticular Activating System	419
Etiology of Lesions	419
Evaluation	420
Level of Consciousness	420
Motor Activity	420
Respiratory Patterns	420
Pupil Size and Reactivity	420
Oculocephalic Reflex	421
Diagnostic Approach	421
Treatment	421
References	421
81 Coma Scales	422
Key Points	422
Intracranial Pressure After Head Trauma	422
Neurologic Assessment	422
Modified Glasgow Coma Scoring System	422
Levels of Consciousness	423
Limb Movements, Posture, and Reflexes	423
Neuroophthalmologic Examination	424
Pupils	424
Eye movements	425
Coma Scales and Long-Term Functional Outcome	425
The Future of Coma Scales	425
References	425
82 Seizures and Status Epilepticus	426
Key Points	426
Definitions	426
Classification	426
Pathophysiology	426
Etiology	427
Diagnostic Plan	427
History	427
Age and Breed	427
Physical Examination	427
Neurologic Examination	427
Minimum Database	427
Diagnostic Tests for Intracranial Disease	428
Treatment Plan	429
Status Epilepticus	429
Pharmacologic Therapy for Status Epilepticus	429
Benzodiazepines	429
Barbiturates	430
Propofol	430
Chronic Seizure Disorders	430
References	430
83 Spinal Cord Injury	431
Key Points	431
Pathophysiology	431
Localization	431
Spinal Cord Segments S1-S3	432
Spinal Cord Segments L4-S1	432
Spinal Cord Segments T3-L3	432
Spinal Cord Segments C6-T2	433
Spinal Cord Segments C1-C5	433
Spinal Shock	433
Diagnosis	433
Treatment	434
Prognosis	435
Acknowledgment	435
References	435
84 Intracranial Hypertension	436
Key Points	436
Physiology of Intracranial Pressure	436
Intracranial Fluid Dynamics	436
Cerebrospinal Fluid Flow	437
Brain Water Movement	437
Cerebral Blood Flow	437
Intracranial Pressure	437
Homeostatic Responses of the Brain	437
Volume buffering	437
Autoregulatory mechanisms	437
Pressure autoregulation	437
Chemical autoregulation	437
Partial Pressure of Arterial Carbon Dioxide.	437
Partial Pressure of Arterial Oxygen.	438
Cerebral Metabolic Rate of Oxygen Consumption.	438
Cushing Response	438
Causes of Intracranial Hypertension	438
Clinical Aspects of Intracranial Hypertension	438
Level of Consciousness	438
Brainstem Reflexes	438
Size and reactivity of pupils	438
Resting eye position, eye movements, and oculovestibular reflexes	439
Corneal reflexes	439
Respiration	439
Motor Responses	439
Posture	439
Diagnosis of Intracranial Hypertension	439
Treatment of Intracranial Hypertension	439
General Supportive Care	440
Prevent hypoxia	440
Prevent hypotension	440
Guidelines for Specific Therapy of Intracranial Hypertension	440
Maintain adequate cerebral perfusion pressure	440
Decrease cerebral venous blood volume	440
Control PaCO2	440
Control PaO2	440
Reduce cerebral edema with hyperosmolar fluid therapy	440
Mannitol	440
Hypertonic Saline	441
Furosemide	441
Glucocorticoids	441
Other Drugs	441
Cerebral metabolic rate of oxygen consumption	441
Surgical therapy	441
Other considerations	441
Prognosis	441
References	442
85 Diseases of the Motor Unit	442
Key Points	442
Identifying Neuropathies, Junctionopathies, and Myopathies	442
Clinical Signs	442
Clinicopathologic Testing	443
Electrophysiologic Testing	443
Nerve and Muscle Biopsy	443
Imaging	443
Causes of Acute Neuropathy, Myopathy, or Junctionopathy	443
Acute Neuropathies	443
Neuropathies Associated with Specific Cranial Nerves	443
Trigeminal neuritis	443
Trigeminal nerve sheath tumor	444
Facial nerve paralysis	444
Laryngeal paralysis	444
Traumatic Neuropathies	444
Acute Polyneuropathies	444
Metabolic causes	444
Neoplasia	444
Toxoplasmosis and neosporosis	445
Acute polyradiculoneuritis	445
Aortic thromboembolism	445
Intoxications	445
Myopathies	445
Inflammatory Myopathies	445
Generalized polymyositis	445
Masticatory myositis	445
Noninflammatory generalized myopathies	445
Megaesophagus	445
Junctionopathies	446
Acquired myasthenia gravis	446
Botulism	446
Tick paralysis	447
Snake bites	447
Aminoglycoside intoxication	447
References	447
86 Tetanus	448
Key Points	448
Etiology	448
Pathogenesis	448
Clinical Presentation	448
Diagnosis	449
Treatment	450
Neutralization of Unbound Toxin	450
Removal of Source of Infection	450
Control of Rigidity and Spasms	450
Supportive Intensive Care	451
Prognosis	451
References	452
87 Vestibular Disease	452
Key Points	452
Neuroanatomy of the Vestibular System	453
Nerve Pathways to the Extraocular Muscles	453
Neuron 1	453
Neuron 2	453
Nerve Pathways to the Spinal Cord	453
Nerve Pathways to the Cerebellum	453
Clinical Signs	453
Specific Signs of Vestibular Dysfunction	453
Head tilt	453
Nystagmus	454
Ataxia	454
Signs That May Be Associated with Vestibular Dysfunction	454
Facial paresis, paralysis, and hemifacial spasm	454
Horner’s syndrome	454
Conscious proprioception deficits	454
Hemiparesis or tetraparesis	454
Circling, leaning, and falling	454
Altered mental state	454
Multiple cranial nerve dysfunction	454
Decerebellate posturing	455
Vomiting	455
Differential Diagnosis of Acute Vestibular Disease	455
Diagnostic Approach to the Animal with Acute Vestibular Disease	455
Minimum Database	455
Otoscopy and Pharyngeal Examination	455
Radiography	455
Myringotomy	456
Brainstem Auditory Evoked Potentials	456
Cerebrospinal Fluid Analysis	456
Advanced Imaging	456
Treatment and Prognosis	456
References	458
88 Hepatic Encephalopathy	458
Key Points	458
Causes	459
Pathophysiology	459
Clinical Signs	460
Diagnosis	460
Treatment	460
References	461
X Infectious Disorders	463
89 Nosocomial Infections and Zoonoses	463
Key Points	463
Nosocomial Infections in Dogs and Cats	463
Risk Factors	463
Multiple Antibiotic–Resistant Nosocomial Pathogens	463
Zoonoses	464
Emerging Nosocomial Infections in Dogs and Cats	464
Nosocomial Infection Prevention and Control	465
Conclusion	465
References	465
90 Febrile Neutropenia	466
Key Points	466
Neutrophil Physiology	467
Neutrophil Function	467
Neutrophil Production	467
Pathophysiology of Neutropenia	467
Increased Utilization	468
Decreased Egress from the Bone Marrow	468
Depletion of granulocyte progenitor cells	468
Infectious diseases	468
Medications, toxicants, and radiation	468
Myelophthisis	468
Cyclic hematopoiesis	469
Ineffective granulopoiesis despite normal to excessive quantities of progenitor cells	469
Immune-Mediated Destruction	469
Clinical Presentation and Diagnostic Tests	469
Treatment and Supportive Care	470
References	470
91 Sepsis and Septic Shock	472
Key Points	472
Definitions and Clinical Manifestations	472
Pathogenesis of the Septic Systemic Inflammatory Response	474
Microbial Factors	474
Host Response to Bacterial Infection	474
Loss of Homeostatic Mechanisms in Sepsis	474
Loss of vasomotor tone	474
Dysregulation of inflammation and coagulation	474
Endothelial, microcirculatory, and mitochondrial abnormalities	475
Epidemiology	475
Septic Foci, Diseases, and Pathogens Associated with Sepsis	475
Resuscitation and Treatment of Sepsis, Severe Sepsis, and Septic Shock	476
Introduction to the Bundle Concept	476
Bundle Element: Lactate	476
Bundle Element: Samples for Culture (Blood, Tissue, or Fluid Cultures)	476
Bundle Element: Early Source Control and Early Antibiotic Administration (see Chapters 175 to 182)	476
Bundle Element: Treat Hypotension with Fluids and Possibly Vasopressors	477
Assessment of volume status and responsiveness	477
Fluid choice	477
Hypotension despite volume resuscitation (septic shock)	478
Bundle Element: Target Central Venous Pressure and Central Venous Pressure and ScvO2	478
Conclusion	478
References	478
92 Mycoplasma, Actinomyces, and Nocardia	481
Key Points	481
Nonhemotropic Mycoplasmas	481
Etiology and Clinical Syndromes	481
Respiratory Infections	481
Urogenital Associated Infections	482
Other Infections	482
Diagnosis	482
Treatment	483
Actinomycosis and Nocardiosis	483
Etiology and Clinical Syndromes	483
Clinical Signs	485
Diagnosis	485
Treatment	486
References	486
93 Gram-Positive Infections	488
Key Points	488
Gram-Positive Cell Structure and Pathogenicity	488
Streptococcal Infections	488
Enterococcal Infections	489
Staphylococcal Infections	490
Empiric Antibiotic Strategies	491
References	492
94 Gram-Negative Infections	493
Key Points	493
Gram-Negative Cell Structure and Pathogenicity	493
Identification of Gram-Negative Bacteria of Medical Importance	493
Enterobacteriaceae	493
Nonfermenting Gram-Negative Bacteria	495
Resistance among Gram-Negative Pathogens	496
Therapy for Gram-Negative Infections	496
References	499
95 Fungal Infections	499
Key Points	499
Blastomycosis	500
Clinical Signs	500
Diagnosis	500
Prognosis	500
Histoplasmosis	501
XI Hematologic Disorders	541
104 Hypercoagulable States	541
Key Points	541
Mechanisms of Thrombophilia	541
Endothelial Disturbances	541
Increased Procoagulant Elements	542
Decreased Endogenous Anticoagulants	542
Perturbations in Fibrinolysis	542
Diagnostics	542
Common Conditions in Veterinary Medicine	543
Systemic Inflammation	543
Protein-Losing Nephropathy	544
Immune-Mediated Hemolytic Anemia	545
Hypercortisolemia	545
Cardiomyopathies	545
Neoplasia	545
Isolated Brain Injury	546
Management of Hypercoagulable Conditions	546
Treatment of the Underlying Condition	546
Recombinant Anticoagulant Therapy	546
Antithrombotic Therapy	547
Inflammatory conditions	547
Protein-losing nephropathy	547
Immune-mediated hemolytic anemia	547
Hypercortisolemia	547
Cardiomyopathies	547
Neoplasia	547
Isolated brain injury	548
Conclusion	548
References	548
105 Bleeding Disorders	554
Key Points	554
Hemostasis and Fibrinolysis	554
Hemostatic Testing	555
Platelet Enumeration and Estimation	555
Buccal Mucosal Bleeding Time	556
The Prothrombin Time and Activated Partial Thromboplastin Time	556
Fibrin Split Products	556
D-dimers	556
Fibrinogen Concentration	557
Thrombin Time	557
Thromboelastography and Thromboelastometry	557
Etiology	558
Hypocoagulability in the Critically Ill or Injured Patient	558
Dilutional Coagulopathy	559
Hypothermia	559
Acidemia	559
Diagnosis	559
History	560
Physical Examination	560
Hemostatic Testing	560
Principles of Management	560
Plasma and Platelet transfusion	560
Prohemostatic Agents	561
Desmopressin	561
Antifibrinolytics	561
Specific Conditions	561
Thrombocytopenia	561
Thrombopathia	561
Inherited Coagulopathies	561
Vitamin K Deficiency	562
Hepatic Failure	562
Trauma-Induced Coagulopathy	562
Disseminated Intravascular Coagulation	563
Delayed Postoperative Bleeding in Greyhound Dogs	563
References	564
106 Thrombocytopenia	567
Key Points	567
Causes	568
Thrombocytopenia in the Critically Ill	568
Diagnostic Techniques for Thrombocytopenia	568
Mechanisms of Thrombocytopenia	569
Decreased Production	569
Consumption	569
Sequestration	569
Increased Destruction	569
Therapeutic Approaches to Thrombocytopenia	569
Platelet Transfusions	570
References	570
107 Platelet Disorders	572
Key Points	572
Inherited Disorders	572
Extrinsic Disorders	572
Intrinsic Disorders	573
Acquired Disorders	573
Drugs	573
von Willebrand’s Disease	574
Uremia	574
Treatment Summary	574
References	574
108 Anemia	575
Key Points	575
Signalment and History	576
Clinical Signs	576
Laboratory Tests	577
Therapeutic Principles	579
Summary	580
References	580
109 Methemoglobinemia	580
Key Points	580
Pathophysiology	580
Oxidation in the Erythrocyte	580
Heinz Bodies	581
Specific Causes of Erythrocyte Oxidation	581
Acetaminophen	582
Topical Benzocaine	582
Skunk Musk	582
Nitrites and Nitrates	582
Hydroxycarbamide	582
Methemoglobin Reductase Deficiency	583
Diagnosis	583
Clinical Signs	583
Determining Methemoglobin Presence and Levels	583
Treatment	583
N-Acetylcysteine	584
Methylene Blue	584
Adjunctive Treatments	584
References	584
110 Acute Hemolytic Disorders	586
Key Points	586
Evaluation of the Patient with Hemolysis	586
Fragmentation Hemolysis	587
Toxicant-Induced Hemolysis	587
Heritable Hemolysis	587
Infection-Related Hemolysis	588
Infection of Red Blood Cells	588
Systemic Infections	588
Immune-Mediated Hemolysis	588
Findings Suggestive of Immune-Mediated Hemolytic Anemia	589
Treatment of Immune-Mediated Hemolytic Anemia	589
Immune suppression	589
Supportive care	589
Prevention of complications	589
Other Causes of Immune-Mediated Hemolytic Anemia	590
References	590
111 Rodenticides	591
Key Points	591
Anticoagulant Rodenticides	592
Pathophysiology and Clinical Signs	592
Case Management	593
Acute ingestion	593
Coagulopathies	593
Outcome	594
Cholecalciferol	594
Pathophysiology and Clinical Signs	594
Case Management	594
Acute ingestion	594
Hypercalcemia	594
XII Intraabdominal Disorders	597
112 Acute Abdominal Pain	597
Key Points	597
Diagnostic Evaluation	597
Signalment and History	597
Physical Examination	597
Emergency Clinical Pathology	598
Abdominal Radiographs	598
Abdominal Fluid Analysis	599
Surgical Versus Medical Management	599
References	600
113 Acute Pancreatitis	601
Key Points	601
Pathophysiology	601
Clinical Presentation	601
Diagnosis	602
Laboratory Assessment	602
Diagnostic Imaging	602
Cytology and Histopathology	602
Additional Diagnostic Evaluation	603
Determining Severity	603
Treatment	603
Resuscitation, Fluid Therapy, and Monitoring	603
Pain Management	604
Nutrition	604
Additional and Supportive Therapy	604
Antibiotic Therapy	604
Surgery	604
Outcome	605
Conclusion	605
References	605
114 Acute Cholecystitis	606
Key Points	606
Clinical Findings	607
Common Causes of Cholecystitis in Dogs and Cats	607
Infectious Agents	607
Bacteria	607
Parasites	607
Obstruction	607
Gallbladder Mucocele	608
Gallbladder Infarction	609
References	609
115 Hepatitis and Cholangiohepatitis	610
Key Points	610
Historical Findings	610
Physical Examination Findings	610
Mechanisms of Hepatocellular Injury	610
Causes of Hepatitis and Cholangiohepatitis in Dogs and Cats	611
Idiopathic Causes	611
Feline cholangitis complex	611
Neutrophilic Cholangitis	611
Lymphocytic Cholangitis	611
Canine chronic hepatitis	612
Role of Copper	612
Nonspecific reactive hepatitis	612
Viral Causes	612
Infectious canine hepatitis	612
Feline infectious peritonitis	613
Bacterial Causes	613
Leptospirosis	613
Bartonellosis	613
Septicemia	613
Drugs and Toxins	613
References	614
116 Hepatic Failure	615
Key Points	615
Pathophysiology	615
Hepatic Encephalopathy	615
Coagulation Disorders	616
Other	617
Clinical Signs	617
Diagnosis	618
Therapy	619
Prognosis	620
Future Therapies	620
References	621
117 Gastroenteritis	622
Key Points	622
Anatomy and Physiology	622
History and Clinical Signs	622
Causes	622
Infectious Gastroenteritis	622
Viral enteritis	623
Bacterial enteritis	623
Parasitic gastroenteritis	623
Fungal gastroenteritis	623
Hemorrhagic Gastroenteritis	623
Dietary Indiscretion	624
Protein-Losing Enteropathy	624
Extraintestinal Diseases	624
Diagnosis	624
Treatment	625
Conclusion	625
References	625
118 Motility Disorders	626
Key Points	626
Megaesophagus	626
Etiology and Clinical Signs	626
XIII Urogenital Disorders	655
124 Acute Kidney Injury	655
Key Points	655
Etiology	655
Pathophysiology	655
Clinical Presentation	657
History	657
Physical Examination	657
Diagnosis	657
Laboratory Tests	657
Imaging	657
Other Diagnostic Modalities	657
Treatment	658
Fluid Therapy	658
Diuretics	658
Acid-Base and Electrolyte Balance	658
Management of Gastrointestinal Signs	659
Nutritional Support	659
Renal replacement therapy	659
Fluid administration during recovery phase polyuria	659
Specific Treatments	660
Prognosis	660
References	660
125 Chronic Kidney Disease	661
Key Points	661
Etiology	661
Pathophysiology	661
Clinical Presentation	662
Diagnosis	662
Laboratory Tests	662
Imaging	663
Other Diagnostic Modalities	663
Treatment	663
Fluid Therapy	663
Acid-Base and Electrolyte Balance	663
Management of Gastrointestinal Signs	664
Nutritional Support	664
Management of Anemia	664
Long-Term Management	665
Dietary Therapy	665
Fluid Therapy	665
Additional Considerations	665
Advanced Therapeutic Modalities	665
Prognosis	665
References	666
126 Pyometra	667
Key Points	667
Incidence	667
Pathogenesis	667
Diagnosis	668
Signalment	668
History and Physical Examination	668
Diagnostic Imaging	668
Laboratory Findings	668
Treatment	669
Stabilizing the Patient	669
Surgical Management	669
Medical Management	669
Uterine Stump Pyometra	670
References	670
XIV Nutrition	673
127 Nutritional Assessment	673
Key Points	673
Impacts of Nutritional Support during Critical Illness	673
Screening Systems Used for Nutritional Assessments	673
Body Weight	674
Body Composition	674
Adipose Tissue	674
Body condition score systems	674
Lean Body Mass	674
Muscle condition scoring	674
Diet History	675
Current intake	675
Historical intake	675
Laboratory Data	675
Conclusion	675
References	675
128 Nutritional Modulation of Critical Illness	676
Key Points	676
Omega-3 Fatty Acids	677
Antioxidants	677
Immune-Modulating Nutrients	678
Arginine	678
Glutamine	678
Nucleotides	679
Probiotics	679
Conclusion	679
References	680
129 Enteral Nutrition	681
Key Points	681
Determining the Route of Nutritional Support	681
Enteral Versus Parenteral	681
Oral Intake Versus Enteral Feeding Device	681
Enteral Feeding Tubes	683
Nasoesophageal or Nasogastric Tubes	683
Esophagostomy Tube	683
Gastrostomy Tube	684
Jejunal Tubes	684
Determining the Amount to be Fed	684
Selecting the Diet	685
Patient Variables	685
Nonpatient Variables	685
Monitoring Therapy	685
Preventing and Managing Complications	685
Patient-Related Complications	685
Non–Patient-Related Complications	685
References	686
130 Parenteral Nutrition	687
Key Points	687
Technical Requirements	687
Vascular Access	687
Monitoring and Nursing Care	687
Formulating and Compounding Nutrient Admixtures	687
Nutritional Assessment	688
Prescription Formulation	688
Calculation of Energy Requirements	688
Calculation of Protein Requirements	688
Calculation of Lipid and Carbohydrate Requirements	689
Calculation of Micronutrient Requirements	689
Delivery and Monitoring	689
Preventing and Managing Complications	689
Catheter and Parenteral Nutrition Admixture Complications	689
Metabolic Complications	690
References	690
XV Surgical and Postoperative Conditions	691
131 Perioperative Evaluation of the Critically Ill Patient	691
Key Points	691
Preoperative Patient Evaluation	691
Respiratory Resuscitation	691
Cardiovascular Resuscitation	691
Pain	691
ASA Scoring	691
Global Assessment	692
Laboratory Testing	692
Coagulation	692
Blood Type and Crossmatch	692
Kirby’s Rule of Twenty	692
The Postoperative Period	692
Airway and Breathing	693
Ventilation and Oxygenation	693
Oxygen Delivery	693
Arrhythmias, Decreased Myocardial Contractility, and Hypotension	693
Analgesia	693
Hypothermia	693
Laboratory Parameters	693
Coagulation	693
Acid-Base and Electrolyte Status	693
Patient Cleanliness, Wound and Catheter Care, and Bandaging	694
Patient Immobilization and Physical Therapy	694
Nutrition	694
Summary	694
References	694
132 Portosystemic Shunt Management	695
Key Points	695
Preoperative Stabilization	695
Medical Management	695
Surgical Options	696
Postoperative Monitoring	696
Postoperative Complications	697
Portal Hypertension	697
Coagulopathy	697
Neurologic Complications	697
Prognosis	697
References	698
133 Peritoneal Drainage Techniques	699
Key Points	699
Indications for Peritoneal Drainage	699
Septic Peritonitis	699
Chemical Peritonitis	699
Other Indications for Peritoneal Drainage	700
Techniques for Peritoneal Drainage	700
Needle or Catheter Paracentesis	700
Paracentesis with a Fenestrated Catheter per the Mini-Laparotomy Method	700
Paracentesis with a Fenestrated Catheter Using the Seldinger Technique	701
Surgical Placement of Closed Suction Drains	701
Open Peritoneal Drainage Technique	701
Vacuum-Assisted Drainage	702
Complications of Peritoneal Drainage	702
Volume and Albumin Loss	702
Conclusion	702
References	702
134 Postthoracotomy Management	703
Key Points	703
Immediate Postthoracotomy Assessment	703
Analgesia	703
Postthoracotomy Pain Syndrome in Humans	705
Ventilation	705
Hypoxemia	705
Hypovolemia	706
Complications and Mortality after Thoracotomy	706
Hypothermia	706
Thoracostomy Tube Care	706
Conclusion	707
References	707
135 Kidney Transplantation	708
Key Points	708
Indications	708
Case Selection	708
Evaluation of the Urinary Tract	709
Cardiovascular Disease	709
Infectious Disease	709
Donor Selection	709
Preoperative Management	710
Immunosuppression for the Feline Renal Transplant Recipient	710
Anesthetic Management	710
Surgery	711
Postoperative Management and Perioperative Complications	711
Long-Term Management and Complications	712
Canine Transplantation	713
Conclusion	714
References	714
136 Minimally Invasive Procedures	715
Key Points	715
Instrumentation	716
Approaches/Access	716
Scope-Guided Procedures	716
Laparoscopic/thoracoscopic procedures	716
Tracheoscopy/bronchoscopy	716
Esophagoscopy/gastroscopy/duodenoscopy	717
Cystourethroscopy	717
Interventional Radiology Procedures	717
Urethral stenting	717
Ureteral stenting	718
Tracheal stenting	718
Cavity effusions and percutaneous drainage	718
Intravascular foreign body removal	719
Epistaxis	719
Vascular obstructions	719
References	720
XVI Trauma	723
137 Traumatic Brain Injury	723
Key Points	723
Incidence and Prevalence of Head Injury	723
General Approach to the Patient with a Head Injury	723
Pathophysiology	723
Primary Injury	723
Secondary Injury	723
Neurologic Assessment	724
Diagnostic Tests and Monitoring	724
Treatment	725
Extracranial Therapy	725
Intracranial Therapy	725
Hyperosmotic agents	725
Corticosteroids	725
Furosemide	726
Decreasing cerebral blood volume	726
Seizure treatment/prophylaxis	726
Decreasing cerebral metabolic rate	726
Prognosis	727
References	727
138 Thoracic and Abdominal Trauma	728
Key Points	728
Trauma Categories	728
Blunt Trauma	728
Penetrating Trauma	728
Diagnostics	729
Clinical Laboratory Tests	729
Imaging	729
Fluid Analysis	729
Stabilization	730
Monitoring	730
Antimicrobial Therapy	730
Fluid Therapy/Blood Product Administration	730
External Wound Care	730
Specific Conditions	730
Diaphragmatic Rupture	730
Body Wall Rupture/Abdominal Evisceration	731
Chylothorax/Chylous Ascites	731
Pyothorax	731
Septic Peritonitis	731
Bile Peritonitis	731
Hemothorax/Hemoperitoneum/Hemoretroperitoneum	731
Uroperitoneum/Uroretroperitoneum	732
Prognosis	732
References	732
139 Wound Management	734
Key Points	734
Wound Healing Principles	734
Wound Classification	734
Phases of Healing	734
Initial Patient Assessment	735
Debridement and Lavage	735
Sugar and Honey	736
Dressing and Bandaging	736
Exposed Bone	738
Wound Closure	738
Drains	738
Negative Pressure Wound Therapy	738
Additional Wound Management Modalities	739
Antimicrobial Therapy	740
Patient Care	741
Complications	741
Prognosis	742
References	742
140 Thermal Burn Injury	743
Key Points	743
Definitions	743
Patient Assessment and Medical Management	744
Metabolic Derangements	745
Nutrition	745
Patient Comfort	745
Antimicrobial Therapy	745
Burn Wound Management	745
Topical Agents	746
Closure Options and Healing	746
Complications	746
References	747
XVII Anesthesia and Pain Management	749
141 Pain and Sedation Assessment	749
Key Points	749
Definition of Pain	749
Pain Versus Stress	750
Pain Assessment	750
Behavior	750
Tools	751
Summary	753
References	753
142 Sedation of the Critically Ill Patient	754
Key Points	754
Patient Evaluation and Management	754
Choice of Agent	754
Opioids	754
Sedatives and Tranquilizers	755
Benzodiazepines (see Chapter 164 for further details)	755
Phenothiazine Tranquilizers	756
α2 Agonists (see Chapter 165 for further details)	756
Other Anesthetic Agents	756
Ketamine	756
Propofol	757
Sedation of Animals with Specific Conditions	757
Cardiovascular Instability	757
Respiratory Disease	757
Conclusion	758
References	758
143 Anesthesia in The Critically Ill Patient	759
Key Points	759
Stabilization	759
Premedication	760
Induction	760
Thiopental and Propofol	761
Alfaxalone	762
Etomidate	762
Ketamine	762
Opioids	762
Maintenance	763
Inhalants	763
Constant Rate Infusion	763
Neuromuscular Blocking Agents	763
Benzylisoquinolinium agents	763
Monitoring of neuromuscular blocking agents	764
Reversal Agents for neuromuscular blocking agents	764
Monitoring	764
Intraoperative Hypotension	764
Recovery	765
Summary	765
References	765
144 Analgesia and Constant Rate Infusions	766
Key Points	766
Analgesia	766
Opioids	768
Nonsteroidal Antiinflammatory Drugs	769
α2-Adrenergic Agonists	769
Transdermal Analgesics	769
N-Methyl-D-Aspartate Receptor Antagonists	770
Acepromazine	770
Infiltrative and Local Anesthetics	770
Epidural Analgesics	770
Constant Rate Infusions	771
Morphine-Lidocaine-Ketamine	772
Conclusion	772
References	772
145 Rehabilitation Therapy in the Critical Care Patient	773
Key Points	773
Musculoskeletal System	774
Range-of-Motion Exercise	774
Passive Range-of-Motion Exercise	774
Active Assisted and Active Range-of-Motion Exercise	774
Therapeutic Exercise and the Importance of Early Mobilization	774
Assisted Standing	775
Walking (Assisted and Unassisted)	775
Neuromuscular Electrical Stimulation and Transcutaneous Electrical Stimulation	775
Neuromuscular electrical stimulation	775
Transcutaneous electrical stimulation	775
Massage	775
Respiratory System	776
Positioning	776
Postural Drainage	776
Percussion (Coupage) and Vibration	776
Summary	777
References	777
146 Complementary and Alternative Medicine	777
Key Points	777
Acupuncture	778
Massage Therapy	779
Laser Therapy	779
Music Therapy	780
Herbs	780
Aromatherapy	781
Homeopathy and Flower Essences	781
Conclusion	781
References	781
XVIII Environmental Emergencies	785
147 Smoke Inhalation	785
Key Points	785
Pathophysiology	785
Carbon Monoxide	785
Hydrogen Cyanide	785
Thermal Injury	785
Irritant Gases and Superheated Particulate Matter	785
Reduced lung compliance	785
Airway damage and obstruction	786
Bacterial pneumonia	786
Dermal Burn Injury	786
History	786
Physical Examination	786
Clinical Evaluation	786
Arterial Blood Gas Analysis	786
Acid-Base Status	786
Thoracic Radiography	786
Laryngoscopy, Bronchoscopy, and Transtracheal Aspiration	787
Diagnosis	787
Treatment	787
Oxygen Supplementation	787
Cyanide Toxicity	787
Airway Management	787
Sedation	787
Mechanical Ventilation	787
Intravenous Fluid Therapy	787
Additional Therapies	788
Prognosis	788
References	788
148 Hypothermia	789
Key Points	789
Classification	789
Review of Thermoregulation	789
Physiologic Effects of Hypothermia	790
Cardiovascular and Hemodynamic Effects	790
Respiratory Effects	790
Neuromuscular Effects	791
Acid-Base Effects	791
Coagulation Effects	791
Renal and Metabolic Effects	791
Core Body Temperature Measurement	792
Rewarming	792
Therapy	793
Cardiopulmonary Resuscitation	794
Therapeutic Hypothermia	794
References	794
149 Heat Stroke	795
Key Points	795
Physiology, Pathogenesis, and Pathophysiology	796
Physical Examination	796
Temperature, Pulse, and Respiratory Rate	796
Cardiovascular System	796
Respiratory System	797
Central Nervous System	797
Renal System	797
Gastrointestinal System	797
Coagulation System	797
Laboratory Evaluation	797
Treatment and Monitoring	797
Cooling Procedures	797
Cardiovascular System	798
Respiratory System	798
Central Nervous System	798
Renal System	798
Coagulation System	798
Gastrointestinal System	798
Prognosis	799
References	799
150 Electrical and Lightning Injuries	799
Key Points	799
Mechanisms of Electrical Injury	799
Predisposition to Electrical Injury	800
Clinical Findings	800
Secondary Effects of Electrical Injury	801
Treatment of Electrical Injury	801
Prognosis	802
Lightning Injury	802
References	802
151 Drowning and Submersion Injury	803
Key Points	803
Definitions	803
Incidence and Epidemiology	804
Humans	804
Veterinary Patients	804
Pathophysiology of Injury	804
Pulmonary System	804
Fluids and Electrolytes	804
Neurologic and Cardiovascular Systems	804
Effect of Water Temperature	804
Diagnostic Tests and Monitoring	805
Treatment	805
Outcome	805
References	806
XIX Miscellaneous Disorders	807
152 Anaphylaxis	807
Key Points	807
Pathophysiology	807
Differential Diagnosis	808
Clinical Manifestations	808
Treatment	809
Epinephrine	809
Other Vasopressors	810
Antihistamines	810
Glucocorticoids	810
Potential Therapies	810
Fluid Therapy	810
Ancillary Patient Management	810
Prevention	810
References	811
153 Air Embolism	811
Key Points	811
Gas Embolization Due to Intravenous Access Mishaps	812
Gas Embolization during Laparoscopic Procedures	812
Gas Embolization during Surgery	813
Gas Embolization From Lung Biopsy	813
Gas Embolization during Hyperbaric Therapy	813
Detection of Air Emboli	813
Management of Air Embolism	814
References	814
154 Ocular Disease In The Intensive Care Unit	815
Key Points	815
Blepharospasm	815
Red Eye	815
Tear Film Abnormalities	815
Absent Palpebral Reflex	816
Corneal Changes	817
Anterior Chamber Abnormalities	817
Pupil Abnormalities	818
Anisocoria	818
Miosis	818
Mydriasis	818
Dyscoria	819
Blindness	819
References	819
155 Critically Ill Neonatal and Pediatric Patients	820
Key Points	820
Physical Examination Findings	820
Laboratory Values	821
Imaging	821
Intravenous and Intraosseous Catheterization	821
Fluid Requirements	821
Temperature Control	822
Nutrition	822
Monitoring	823
Pharmacology	823
Sepsis	823
Conclusion	824
References	824
156 Critically Ill Geriatric Patients	825
Key Points	825
Laboratory Values	825
Imaging	826
Fluid Therapy	826
Nutrition	827
Pharmacology	827
Conclusion	828
References	828
XX Pharmacology	829
157 Catecholamines	829
Key Points	829
Hypotension	829
Poor Contractility	829
Catecholamine Choices	830
Dopamine	830
Dobutamine	830
Ephedrine	830
Norepinephrine	831
Phenylephrine	831
Vasopressin	831
Angiotensin	831
Epinephrine	831
Isoproterenol	831
Dopexamine	831
Choosing the Right Catecholamine	832
Combination Therapies	832
Vasomotor Tone	832
Catecholamines and Cortisol	833
Other Effects of Catecholamines	833
References	833
158 Vasopressin	835
Key Points	835
Physiology of Vasopressin	836
Vasopressin Receptors	836
Physiologic Effects of Vasopressin	837
Pharmacology	837
Clinical Uses	837
Cardiopulmonary Resuscitation	837
Vasodilatory Shock	838
Hemorrhagic Shock	838
Central Diabetes Insipidus	839
von Willebrand Disease	839
Gastrointestinal and Pulmonary Disease	839
Adverse Effects	839
Vasopressin Antagonists	839
Conclusion	839
References	839
159 Antihypertensives	840
Key Points	840
Etiology of Hypertension	841
Proposed Mechanism of Blood Pressure Elevation	841
Antihypertensive Drugs	841
Angiotensin-Converting Enzyme Inhibitors	841
Mechanism of action	841
Indications	841
Adverse effects	841
Angiotensin II Receptor Blockers	843
XXI Monitoring	957
183 Hemodynamic Monitoring	957
Key Points	957
Continuous Electrocardiogram Monitoring	957
Blood Pressure Monitoring	957
Noninvasive Blood Pressure Monitoring	957
Photoplethysmography	958
Invasive Blood Pressure Monitoring	958
Telemetric Blood Pressure Monitoring	959
Central Venous Pressure Monitoring	959
Pulmonary Artery Pressure Monitoring	960
Mixed Venous and Central Venous Oxygen Saturation	961
Lactate and Base Deficit	961
References	961
184 Cardiac Output Monitoring	962
Key Points	962
Indications for Cardiac Output Measurement	963
Measurement of Cardiac Output	963
Invasive Methods of Determining Cardiac Output	963
Fick oxygen consumption method	963
Carbon dioxide rebreathing methods	964
Indicator dilution method (including thermodilution)	964
Noninvasive or Minimally Invasive Methods of Determining Cardiac Output	965
Normal Values	965
Potential Causes of Error	965
Disease States and Cardiac Output Measurement	966
Potential Complications	966
References	966
185 Electrocardiogram Evaluation	967
Key Points	967
Indications	967
Electrocardiographic Principles	967
Technique	968
Electrocardiogram Waveforms	968
Electrocardiogram Interpretation	968
Effects of Disease States on the Electrocardiogram	969
Electrolyte Abnormalities	969
Hyperkalemia	969
Hypokalemia	969
Hypercalcemia	969
Hypocalcemia	969
Magnesium level	970
Hypoxemia	970
Intrathoracic Effusions	970
Pain	970
References	970
186 Blood Gas and Oximetry Monitoring	970
Key Points	970
Hydrogen Ions	970
Buffers	971
Henderson-Hasselbalch Equation	971
Regulation of pH	971
Blood Gas Analysis: Getting Started	971
Temperature Correction	971
Step-by-Step Acid-Base Analysis	972
Number 1: Evaluate the pH	972
Number 2: Evaluate PCO2 (see also Chapter 16)	972
Number 3: Evaluate the metabolic indices	972
Number 4: Determine if there is one problem or many	973
Anion gap	973
The Stewart approach (see Chapter 55)	974
Strong Ion Difference.	974
Strong Ion Gap.	974
Base Excess Modification.	974
Number 5: Determine how well the patient is oxygenating (see also Chapter 15)	974
Pulse oximetry	976
Number 6: Look at the whole picture	976
Venous Blood Gas Values	976
References	976
187 Colloid Osmotic Pressure and Osmolality Monitoring	978
Key Points	978
Colloid Osmotic Pressure	978
Starling’s Hypothesis	978
Calculated versus Measured Values	978
Normal Colloid Osmotic Pressure Values	979
Colloid Osmotic Pressure in Critically Ill Patients	979
How Colloid Osmotic Pressure Is Measured	979
Indications for Colloid Osmotic Pressure Measurement	979
Osmolality	980
Definition	980
Determination of Osmolality	980
Osmolal Gap	980
Effective Osmolality	980
Urine Osmolality	981
References	981
188 Intraabdominal Pressure Monitoring	982
Key Points	982
Definitions and Incidence	982
Risk Factors	982
Pathophysiology	983
Methods of Intraabdominal Pressure Measurement	983
Physiologic Effects of Intraabdominal Hypertension	984
Hemodynamic Effects	984
Renal Effects	984
Pulmonary and Thoracic Effects	984
Central Nervous System Effects	985
Visceral Effects	985
Systemic Effects	985
General Considerations	985
Acknowledgment	986
References	986
189 AFAST and TFAST in the Intensive Care Unit	988
Key Points	988
Terminology	988
Objective of Focused Assessment with Sonography for Trauma	988
Abdominal Focused Assessment with Sonography for Trauma	988
AFAST Technique	989
Abdominal Fluid Score Technique	990
AFAST for Blunt Abdominal Trauma	990
AFAST for Penetrating Abdominal Trauma	991
AFAST for Determining the Cause of Intraabdominal Injury	991
Thoracic Focused Assessment with Sonography for Trauma	991
TFAST Technique	991
Chest Tube Site Views	992
Pleural line and the bat sign	992
A-lines	992
B-lines	992
Lung curtain	993
Sonographic signs of pneumothorax	993
Absence of glide sign and B-lines	993
Pericardial Chest Site and Subxiphoid Site Views	993
Emergency Lung Ultrasound to Detect Interstitial-Alveolar Lung Injury	993
References	993
190 Capnography	994
Key Points	994
Nondiverting and Diverting Monitors	995
Technology	995
Physiology	995
Capnogram Interpretation	996
Equipment	996
Patient	996
References	997
191 Intracranial Pressure Monitoring	998
Key Points	998
Determination of Intracranial Pressure	998
Intracranial Pressure	998
Locations for Monitoring Intracranial Pressure in the Brain	998
Types of Intracranial Pressure Monitoring Devices	999
Intracranial Pressure Monitoring Systems	999
Ventriculostomy catheter with external transducer	999
Transducer-tipped catheters	999
Subarachnoid bolt	1000
Fluid-filled catheter	1000
Evaluation of Intracranial Pressure	1000
Normal Intracranial Pressure	1000
Accuracy of Intracranial Pressure Monitoring Systems	1000
Complications of Intracranial Pressure Monitoring	1001
Indications for Intracranial Pressure Monitoring in Dogs and Cats	1001
References	1001
192 Urine Output	1001
Key Points	1001
Urine Output as a Monitoring Tool	1001
Measurement of Urine Output	1002
Determinants of Urine Output	1002
Glomerular Filtration Rate	1002
Tubular Reabsorption of Water and Solutes	1002
Impedance to Flow	1002
Normal Urine Output	1002
Abnormal Urine Output	1003
Oliguria	1003
Prerenal oliguria	1003
Postrenal oliguria	1003
Renal oliguria	1003
Polyuria	1003
Prerenal polyuria	1003
Postrenal polyuria	1003
Renal polyuria	1003
Fluid Balance	1004
Case Example	1004
References	1004
XXII Procedures	1005
193 Peripheral Venous Catheterization	1005
Key Points	1005
Catheter Types	1005
Winged or Butterfly Needle	1005
Over-the-Needle Catheter	1005
Through-the-Needle Catheter	1005
Multilumen Catheter	1005
Advantages of Peripheral Venous Catheterization	1006
Catheter Insertion Site	1006
Cephalic Vein	1006
Saphenous Vein	1006
Pedal Veins	1006
Auricular Vein	1006
Insertion Technique	1006
Percutaneous Placement	1006
Facilitative Incision or Relief Hole	1007
Venous Cutdown	1007
Peripherally Inserted Central Venous Catheters	1007
Complications Associated with Catheterization	1007
Phlebitis	1007
Thrombosis	1008
Catheter Embolism	1008
Subcutaneous Fluid Infiltration	1008
Infection	1008
Catheter Maintenance	1008
References	1008
194 Intraosseous Catheterization	1009
Key Points	1009
Historical Perspectives	1009
Physiology	1010
Indications	1010
Contraindications	1010
Methods	1010
Complications	1012
References	1012
195 Central Venous Catheterization	1013
Key Points	1013
General Concepts	1014
Catheter Types	1014
Through-the-Needle Catheter	1014
Over-the-Needle Catheter	1014
Long Single-Lumen Catheter	1014
Multilumen Catheter	1014
Percutaneous Sheath Catheter Introducer	1014
Catheter Insertion Site	1014
Saphenous Vein	1015
Jugular Vein	1015
Catheter Insertion	1015
Through-the-Needle Catheter Insertion	1015
Seldinger Technique	1015
Rewiring of Seldinger Catheters	1016
Peel-Off Sheathed Needle Technique	1017
Complications and Catheter Maintenance	1017
Heparinized Saline	1017
References	1017
196 Blood Film Evaluation	1018
Key Points	1018
Blood Film Preparation	1018
Blood Film Evaluation	1018
White Blood Cell Responses	1019
Red Blood Cell Responses	1020
Platelet Responses	1022
Leukemia (Myeloid and Lymphoid)	1023
References	1023
197 Endotracheal Intubation and Tracheostomy	1024
Key Points	1024
Endotracheal Intubation	1024
Airway Assessment	1024
Routine Intubation	1024
Dogs	1024
Cats	1024
Difficult Intubation	1024
Preoxygenation	1024
Equipment setup	1025
Approach	1025
Alternative Techniques and Adjuncts	1025
Needle cricothyroidotomy	1025
Cricothyroidotomy	1025
Fiberoptic-assisted intubation	1025
Digital palpation	1025
Nasal intubation	1025
Retrograde intubation	1025
Cricoid pressure	1025
Placement Verification	1025
Complications	1025
Tracheostomy	1026
Tracheostomy Tube Selection	1026
Percutaneous Tracheostomy	1026
Surgical Tracheostomy	1026
Transverse incision	1026
Vertical incision	1026
Securing the tracheostomy tube	1027
Tracheostomy Tube Management	1027
Suctioning	1027
Tube Removal	1027
Complications	1028
Summary	1028
References	1028
198 Thoracocentesis	1029
Key Points	1029
Indications	1029
Materials	1029
Techniques	1030
Needle Insertion Techniques	1030
Thoracocentesis using a butterfly needle	1030
Thoracocentesis using a hypodermic needle with a saline-filled hub	1030
Over-the-Needle Catheter Insertion Technique	1031
Thoracocentesis using an over-the-needle intravenous catheter	1031
Thoracocentesis using a thoracostomy tube	1031
Through-the-Needle Catheter Technique	1031
Seldinger Technique	1031
Diagnostic Evaluation of the Aspirate	1031
Postprocedure Care	1031
Complications	1031
References	1031
199 Thoracostomy Tube Placement and Drainage	1032
Key Points	1032
Indications	1032
Thoracostomy Tube Placement	1032
Materials	1032
Anesthesia	1033
Techniques	1033
Drainage	1034
Passive Drainage Techniques	1034
Active Drainage Techniques	1034
Maintenance and Care	1035
Removal	1035
Complications	1035
References	1035
200 Abdominocentesis and Diagnostic Peritoneal Lavage	1036
Key Points	1036
Indications	1036
Focused Assessment with Sonography for Trauma	1037
Technique	1037
Preparation of the Patient	1037
Closed-Needle Abdominocentesis	1037
Open-Needle Abdominocentesis	1037
Four-Quadrant Abdominocentesis	1037
Alternatives to Abdominocentesis	1037
Abdominal Fluid Analysis	1038
Analysis of Diagnostic Peritoneal Lavage Samples	1039
Conclusion	1039
References	1039
201 Arterial Catheterization	1040
Key Points	1040
Patient Preparation	1040
Percutaneous Arterial Catheter Placement	1040
Dorsal Pedal Artery Catheterization	1040
Femoral Artery Catheterization	1041
Auricular Artery Catheterization	1041
Radial Artery Catheterization	1042
Coccygeal Artery Catheterization	1042
Surgical Cutdown for Arterial Catheter Placement	1042
Maintenance of the Arterial Catheter	1042
Three-Syringe Technique	1043
References	1043
202 Pulmonary Artery Catheterization	1043
Key Points	1043
Types of Catheters and Uses	1043
Cardiac Output	1045
Pulmonary Capillary Wedge Pressure	1045
Right Ventricular End-Diastolic Volume	1045
Selective Pulmonary Angiography	1045
Additional Measurements	1045
Indications	1045
Placement	1046
Flow-Directed Placement	1046
Fluoroscopy	1047
Complications	1047
Alternatives	1047
References	1048
203 Temporary Cardiac Pacing	1049
Key Points	1049
Indications for Temporary Cardiac Pacing	1050
Description of the Temporary Pacemaker Systems	1050
Transvenous Pacing System	1050
Transcutaneous Pacing System	1051
Transesophageal Pacing System	1052
Troubleshooting	1052
XXIII ICU Design and Management	1073
209 Intensive Care Unit Facility Design	1073
Key Points	1073
The Design Process	1073
Location in the Hospital	1073
Arrangement and Size	1074
Unit Configuration	1074
Staff Work Areas	1074
Patient Care Areas	1074
Patient modules	1074
Procedure area and storage	1075
Isolation room	1076
Ancillary Services	1076
Utilities	1077
Environmental Aspects	1077
Lighting	1077
Air Conditioning	1077
Acoustic Environment	1077
Floor and Wall Surfaces, Ceiling Finishes	1077
Furnishings	1078
Details and Common Design Elements	1078
Infection Prevention and Control	1078
Safety and Security	1079
Patient- and Owner-Centered Care	1079
Ambiance	1079
Communication	1080
References	1080
210 Management of the Intensive Care Unit*	1081
Key Points	1081
Intensive Care Unit Personnel: Staff Qualifications and Scheduling	1081
Role of the Intensive Care Unit Director	1082
Staffing	1082
Veterinarians	1082
Residents and interns	1082
Nursing staff	1082
Scheduling	1082
Staff/Patient Ratio	1083
Management of Intensive Care Unit Staff	1083
Communication	1083
Delegation of Responsibility	1083
Conflict: Causes, Categories, and Resolution	1083
Categories of conflict	1083
Methods of conflict resolution	1084
Conflict prevention	1084
Recruitment of Intensive Care Unit Nursing Staff	1084
Training intensive care unit nurses	1084
Retention of Staff: Handling Stress and Burnout	1084
References	1085
211 Client Communication and Grief Counseling	1085
Key Points	1085
Client Communication	1085
The Human-Animal Bond	1085
Client Expectations	1086
End-of-Life Decisions	1086
Compassion Fatigue	1086
Support for veterinary staff	1086
Communicating with Difficult Clients	1086
Stages of Grief	1086
Types of Grief	1086
Anticipatory Grief	1086
Multiple Losses and “Trigger Grief”	1087
Grief from Expected Loss	1087
Grief from Unexpected Loss	1087
Disenfranchised Grief	1087
Complicating Factors	1087
Financial Considerations	1087
Mental Health History	1087
Children and Loss	1087
Pet Loss and Older Adults	1088
Veterinary Resources	1088
Support Groups	1088
Individual Grief Support Sessions	1088
Lectures, Seminars, and Workshops	1088
Healing Through Pet Loss	1088
Finding Meaning	1088
Memorializing a Pet	1088
References	1089
Appendices	1091
Appendix 1 Clinical Calculations	1091
Appendix 2 Important Physiologic Formulas	1092
Appendix 3 Ideal Gas Laws	1093
Appendix 4 Surviving Sepsis Campaign 2012 Bundle Recommendations for Humans	1093
Appendix 5 Constant Rate Infusion Calculations	1093
Micrograms per Kilogram per Minute	1093
Milligrams per Kilogram per Hour (Using 250 ml bag of fluids)	1093
Appendix 6 Common Drug Dosages for Constant Rate Infusions	1094
Index	1097
A	1097
B	1100
C	1102
D	1106
E	1107
F	1108
G	1109
H	1110
I	1113
J	1115
K	1115
L	1115
M	1116
N	1118
O	1119
P	1120
Q	1123
R	1123
S	1124
T	1126
U	1128
V	1129
W	1130
X	1130
Y	1130
Z	1130
Conversion Tables	IBC5

LIC - Small Animal Critical Care Medicine

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