Emergency treatment with intravenous infusion of methylene blue followed by oral administration in a cat presented with severe recurrent methemoglobinemia

OBJECTIVE

To describe the use of IV infusion followed by oral administration of methylene blue (MB) to successfully treat recurrent methemoglobinemia (MetHb) in a young cat.

CASE SUMMARY

A 6-month-old male Ragdoll cat presented with recurrent episodes of severe MetHb and was successfully managed with IV infusion of MB followed by a course of oral MB. Although the definitive cause of the patient's MetHb remains unknown, the cat made a full recovery following treatment without developing any significant side effects secondary to therapy and at the time of writing not had any further recurrences. Follow-up at 6 months found the patient in good health and without any long-term consequences.

NEW INFORMATION PROVIDED

To the authors' knowledge, this is the first report of a cat presented with severe MetHb quantitatively assessed via co-oximetry and successfully treated with both IV and oral administration of MB.

Evaluation of cardiac troponin I in dogs presenting to the emergency room using a point-of-care assay

We used a point-of-care assay to evaluate cardiac troponin I (cTnI) in clinically normal dogs and a heterogeneous population of dogs presenting to the emergency room (ER) and to determine whether cTnI has prognostic capabilities in an ER population. Fourteen clinically normal dogs and 129 dogs presented to the ER were evaluated. Of the study group, 88 dogs had normal cTnI (< 0.1 ng/mL), 29 had elevated cTnI (0.1 to 1.0 ng/mL), and 12 had high cTnI (> 1.0 ng/mL). Dogs with elevated cTnI had 8 times the odds of mortality compared to dogs with normal cTnI [odds ratio (OR): 8.2, 95% confidence interval (CI): 3.0, 22.3]. Dogs with high cTnI had 17 times higher odds of mortality compared to dogs with normal cTnI (OR: 17.6, 95% CI: 4.4, 70.1). We conclude that cTnI shows promise as a prognostic indicator for dogs presenting to the ER and can be easily evaluated using a point-of-care assay.

Avian respiratory distress: etiology, diagnosis, and treatment

Respiratory distress is usually a life-threatening emergency in any species and this is particularly important in avian species because of their unique anatomy and physiology. In the emergency room, observation of breathing patterns, respiratory sounds, and a brief physical examination are the most important tools for the diagnosis and treatment of respiratory distress in avian patients. These tools will help the clinician localize the lesion. This discussion focuses on the 5 anatomic divisions of the respiratory system and provides clinically important anatomic and physiologic principles and diagnosis and treatment protocols for the common diseases occurring in each part.

Bullet, Bite, and Burn Wounds in Dogs and Cats

Veterinarians are frequently presented with bullet, bite, or burn trauma patients. Injuries can vary from simple minor penetrating skin wounds to major life-threatening soft and hard tissue damage with concurrent complex metabolic ramifications. This article reviews the diagnostic and therapeutic options for each type of injury.

Prognostic value of clinicopathologic variables obtained at admission and effect of antiendotoxin plasma on survival in septic and critically ill foals

This prospective study compared survival rates of critically ill and septic foals receiving 1 of 2 different types of commercial equine plasma and analyzed admission variables as possible predictors of survival. Standardized clinical, hematologic, biochemical, and hemostatic admission data were collected and foals received either conventional commercially available hyperimmune equine plasma or equine plasma specifically rich in antiendotoxin antibodies in a double-blinded, coded fashion. Sepsis was defined as true bacteremia or sepsis score >11. Overall survival rate to discharge was 72% (49/68). Foals that were nonbacteremic and demonstrated a sepsis score of < or = 11 at admission had a 95% (18/19) survival rate. The survival rate to discharge for septic foals was 28/49 (57%), with truly bacteremic foals having a survival rate of 58% (14/24), whereas that for nonbacteremic, septic foals was 56% (14/25). Sensitivity and specificity for sepsis score >11 as a predictor of bacteremia were 74 and 52%, respectively. For the entire study population, a higher survival rate to discharge was documented for those foals receiving hyperimmune plasma rich in antiendotoxin antibodies (P = .012, odds ratio [OR] 6.763, 95% confidence interval [CI]: 1.311, 34.903). Administration of plasma rich in antiendotoxin antibodies also was associated with greater survival in septic foals (P = .019, OR 6.267, 95% CI: 1.186, 33.109). Statistical analyses demonstrated that, among 53 clinical and clinicopathologic admission variables, high sepsis score (P < .001), low measured IgG concentration (P = .01), high fibrinogen concentration (P = .018), low segmented neutrophil count (P = .028), and low total red blood cell numbers (P = .048) were the most significant predictors of overall mortality.

Feline ocular emergencies

Feline ocular emergencies include any ophthalmic condition that has rapidly developed or is the result of trauma to the eye or periocular structures. Common feline emergencies include proptosis, lid lacerations, corneal ulcers, and foreign bodies. Complete ophthalmic examination including procurement of the minimal ophthalmic database (Schirmer tear test, fluorescein stain, and intraocular pressure measurement) should be obtained whenever possible to ensure that the complete and correct diagnosis is made. Concern for the patient's vision and ocular comfort should guide the practioner's diagnostic and therapeutic plan. This article reviews some of the more common feline ocular emergencies, including conditions affecting the orbit and globe, adnexa, conjunctiva, and cornea. Feline uveitis, glaucoma, and lenticular diseases are covered more thoroughly elsewhere in this issue.

Approach to the acute abdomen

Acute abdomen is a common clinical complaint identified in small animal patients. Success results from a proactive approach to management,including rapid stabilization of major body systems, early identification of the inciting problem(s), attention to comorbid conditions, and timely definitive therapy.

Ophthalmic emergencies

Ophthalmic emergencies are common presenting complaints in an emergency room. Most ophthalmic emergencies can be treated and stabilized until an ophthalmologist can be consulted. Most ocular emergencies involve loss of vision, compromised globe integrity, or severe ocular pain. Delay in treating true emergencies may result ina blind eye or loss of an eye. This article discusses the clinical signs,diagnosis, and treatment as well as the prognosis of some of the more common ophthalmic emergencies.

Analgesia and chemical restraint for the emergent patient

This article discusses analgesia and chemical restraint for the emergency patient. As illness or injury affect all organ systems, specific recommendations and considerations of analgesic, anesthetic, and restraining regimens are presented. As animals of all ages, from neonates to geriatric and those that are pregnant or lactating,may require management of their illness or injury, recommendations for these patients are also presented.

Practical considerations in emergency drug therapy

Drug therapy is integral to emergency and critical care medicine but can also be the source of serious medical errors. There are important considerations with regard to drug, route, and interactions that require close attention in critical patients. The continuous development of new therapeutics and new information concerning current therapies requires practitioners to continually review drug therapies. This article addresses general guidelines, routes of administration, dosage calculations, interactions, monitoring recommendations, and resources available to help clinicians improve their drug therapy practices.

Urinary tract emergencies

A review of common emergencies of the urinary system is presented, with a focus on initial stabilization and treatment. Urethral obstruction, uroperitoneum, and acute renal failure are discussed.

Assessment and treatment of central nervous system abnormalities in the emergency patient

Disease of or injury to the central nervous system is a common rea-son for hospital admission on an emergency basis in veterinary medicine. Head injuries, seizures, and diseases that lead to intra-cranial hypertension frequently result in significant alteration of neurologic function. A thorough understanding of the pathophysiologic disturbances that occur during these conditions is para-mount for providing stabilizing emergent care. A detailed approach that focuses on meticulous physical evaluation, provision of timely and optimal stabilizing treatment, and continued monitoring can aid in improving outcomes in animals with signs and symptoms of neurologic disease or injury.

Reproductive emergencies

The emergency clinician is frequently called on to manage problems relating to the female reproductive tract. Because owners sel-dom have the medical knowledge needed to differentiate normal from abnormal reproductive behaviors, they frequently look to the emergency veterinarian for guidance and information during and after parturition. For this reason, it is essential that the veterinarian have a good understanding of the normal reproductive cycle as well as the common emergencies that may occur. This article reviews the events surrounding normal parturition in the dog and cat and the reproductive emergencies seen most commonly in practice.

Global assessment of the emergency patient

The approach to the global assessment of the emergency patient must bean organized, focused, and efficient pursuit of identification all the patient's problems in the order of their importance to survival. The format of the problem-oriented approach serves as a guide. The patient's history and physical examination results serve as the database for global assessment;they are the core of emergency practice.

Assessment and treatment of perfusion abnormalities in the emergency patient

Many patients presented to the emergency veterinarian are suffering from global or local tissue hypoperfusion. Global or systemic hypoperfusion can occur secondary to a reduction in the effective circulating intravascular volume (hypovolemic shock) or reduced ability of the heart to pump blood around the body secondary to reduced cardiac function (cardiogenic shock),obstruction to blood flow (obstructive shock), or maldistribution of the circulating intravascular volume (distributive shock). Initial assessment involving physical examination supplemented by measurement of hemodynamic and metabolic parameters allows the clinician to recognize and treat patients with severe global hypoperfusion. Use of techniques like sublingual capnometry and measurement of central venous oxygen saturation may aid recognition and evaluation of early hypoperfusion. Treatment decisions are made based on an assessment of the severity of the hypoperfusion and its probable underlying cause. Early effective treatment of hypoperfusion is likely to lead to a better outcome for the patient.

Approach to the patient with respiratory distress

Respiratory emergencies are common presentations to emergency clinicians. Appropriate assessment and timely interventions may be crucial in the stabilization of dyspneic patients. The emergency clinician should be fully prepared and equipped to correctly ascertain and treat the most likely cause of respiratory compromise of a patient. Based on history, signalment, clinical presentation, and brief physical examination findings, the clinician should be able to formulate a plan of action to relieve respiratory distress and communicate with the owner about the diagnostic and therapeutic strategies and overall prognosis of the patient. Prompt recognition of the underlying respiratory disease and complete familiarity with emergency diagnostic and therapeutic procedures can lead to the successful management of many emergency respiratory patients.

Anesthetic protocols for common emergencies

Anesthesia, sedation, and pain management should be taken seriously in the emergency patient. Proper knowledge of the drugs available and their pharmacokinetics and pharmacodynamics are necessary to administer anesthesia safely to critical patients. A proactive approach regarding monitoring, titration of anesthetic drugs, and anticipation of life-threatening complications helps in achieving successful anesthetic outcomes.

Pediatric emergencies

The unique anatomic and physiologic characteristics of neonatal and pediatric patients make diagnosis, monitoring, and treatment a challenge. Adult parameters cannot be relied on in these patients, and an awareness of these unique characteristics is essential for any practitioner with a neonatal and pediatric patient base. In addition, many laboratory and pharmacologic data differ dramatically in neonates compared with adults of the same species. Familiarity with these variations is essential in the monitoring and treatment of the neonatal and pediatric illness, such as hypovolemia, shock, and sepsis.

Overdose during chemical restraint in a black rhinoceros (Diceros bicornis)

A juvenile female black rhinoceros (Diceros bicornis) was successfully treated after overdose of drugs used for chemical restraint. Subsequent general anaesthesia for surgical reduction of a recurrent rectal prolapse was uneventful. Over a 25-minute period before transportation to the veterinary hospital, the animal received a total dose of 1.225 mg etorphine, 30 mg acepromazine and 30 mg detomidine. Based on an estimated mass of 200 kg, these corresponded to doses of 6.1 microg kg(-1) etorphine, 150 microg kg(-1) acepromazine, and 150 microg kg(-1) detomidine which constitutes considerable overdose for each drug given separately, notwithstanding the synergy that probably resulted when the three drugs were present concurrently. The estimated body mass may have substantially overestimated the actual body mass and exacerbated overdosage. The animal was recumbent and apnoeic on arrival at the hospital. Heart sounds were auscultated and a weak peripheral pulse was palpated; no pulse deficits were detected, although the heart rate was low. The trachea was intubated, inspired breath was enriched with oxygen and the lungs ventilated manually. Diprenorphine (1.5 mg) was given intravenously and spontaneous breathing resumed 11 minutes later. After induction of general anaesthesia using isoflurane, emergency surgery for correction of rectal prolapse was performed, from which the animal recovered uneventfully. The case highlights some of the practical problems that may be encountered in dealing with dangerous and unfamiliar species.

The North Carolina State University College of Veterinary Medicine Turtle Rescue Team: a model for a successful wild-reptile clinic

The North Carolina State University College of Veterinary Medicine (NCSU-CVM) Turtle Rescue Team (TRT) is a veterinary student-run organization that treats native, sick and injured, wild chelonians. First-, second-, and third-year students are responsible for case management, consultation coordination, diagnostic testing within the hospital, and placing of recuperating animals with local wildlife rehabilitators. Several clinical research publications have resulted from the opportunity to work with these wild reptiles. Active student participants can also gain a course credit by attending eight hours of lecture/ seminar related to reptile medicine. With regards to outcome assessment, 86% of survey respondents found the program to be valuable or extremely valuable to their veterinary medical education. The logistics of organizing, supporting, and running this service are discussed, and its value as a clinical learning tool is supported by the results of a survey.

Clinical study of cats injured and killed in road traffic accidents in Cambridgeshire

Data were collected on the injuries, treatment and outcome of 128 cats involved in road accidents and seen as first-opinion cases in veterinary practices in Cambridgeshire. Sixteen cats were dead on arrival; the mortality rate for the remaining cats was 16 per cent. Half of the cats were aged between seven months and two years, with more males than females affected. Most cats had moderate injuries; strays had more severe injuries than owned cats. Areas of the body most often injured were the extremities, head and neck, pelvis and thorax. Skeletal injuries were present in 67 cats and neurological signs in 29. Diagnostic procedures and medical treatment were necessary for the majority of cats; surgery was required in 51 cases. Most cats were hospitalised for between two and seven days and some required up to one month of treatment. The cost of treatment was less than 400 pounds sterling for 84 per cent of cats.

Transfusion medicine in veterinary emergency and critical care medicine

Transfusion medicine is a vital part of veterinary emergency and critical care medicine. The goals of this article are to review blood banking and the transfusion principles surrounding care of the critically ill or injured small animal, to highlight the differences in emergency/critical care transfusions compared with standard transfusion medicine, and to discuss traumatic blood loss and sepsis as unique entities in emergency and critical medicine.

Two years' activity of the Veterinary Toxicology Attention Service of Lugo, Spain

The Veterinary Toxicology Attention Service was created at the beginning of 2001 as the first on-line toxicology service for veterinarians and animal owners in Spain. In the present study, data about the general functioning of the Service and the toxicological analysis and consultations performed are summarized. Canine-related cases constituted the main call group and veterinary practitioners represented half of the consultations. Coordination between all veterinary toxicology services in Spain and the rest of the European Union should improve this service.

The use of antigen and vaccine banks in case of emergency vaccination in the European community

The Community control measures for foot-and-mouth disease (FMD) have been reviewed and are currently laid down in Directive 2003/85/EC of 29 September 2003. The Community is free of FMD and infection without practising vaccination. Legal provisions are in place to resort to emergency vaccination where required by the epidemiological situation and reserves of suitable antigens of the FMD virus for express formulation into vaccines have been established.

Extending the foot-and-mouth disease module to the control of other diseases

During the recent devastating epidemics of foot-and-mouth disease (FMD), bluetongue (BT), the highly pathogenic avian influenza (HPAI) and New Castle disease, more than 115 million animals were culled. The mass slaughter of animals raised serious ethical questions. These epidemics showed that the use of emergency vaccination is an essential element in disease control. During the last decade the FMD antigen banks have proved to be effective and this module should be extended. An international vaccine stock should be considered for classical swine fever and HPAI. Agreements with vaccine producers should be made easily available, with instant access to a vaccine reserve for rinderpest, peste des petits ruminants, BT, African horse sickness and Rift valley fever. These vaccines should meet international standards and should allow distinction between vaccinated and infected animals. Information should be gathered proactively on the use of vaccines for lumpy skin disease, sheep and goat pox and contagious bovine pleuropneumonia.

Accidental colchicine poisoning in a dog

A 14-month-old toy poodle-cross was presented, after ingesting the owner's colchicine medication, with severe gastrointestinal disturbances and in shock. Despite aggressive medical management, the patient was euthanized approximately 24 hours after the ingestion. The clinical features, treatment, and necropsy findings of colchicine poisoning are discussed.

Australian contingency plans for emergency animal disease control: the role of antigen/vaccine banks

Vaccination is an important element of contingency plans for many animal diseases. The decision whether or not to use vaccine is complex, and must consider epidemiological, economic and social issues. Vaccines are rarely available in a country for emergency animal diseases unless a low pathogenicity strain of the agent is present or it is localised in carrier hosts. High quality commercial vaccine from overseas is often the preferred source of vaccine in an emergency, although less reliable sources may be used with additional safeguards. Alternatively, master seeds may be imported or developed for production within the country For contingency planning, diseases may be ranked according to the expected role of vaccine in the disease eradication strategy, with diseases for which vaccine is part of the initial response strategy receiving highest priority for action. A range of preparedness options is available, ranging from identifying producers of vaccine, obtaining permits for import and use from regulatory authorities, to establishing vaccine or antigen banks. Countries need to consider their individual situations and develop strategies to address the diseases of significance to them.

A global virtual network for foot-and-mouth disease in case of emergency

The use of emergency vaccination is considered in different contingency national plans as part of a foot-and-mouth disease (FMD) control strategy in countries whether vaccination is practised or not. The development of the inter-governmental and national FMD vaccine and antigen banks and some technical and operational problems that could affect their efficiency are analysed. The possibility of improving and implementing a more rational use of the antigen and vaccine banks through the creation of a Global Virtual Network of Vaccine and Antigen Banks is discussed.

Amphetamine poisoning in a dog: case report, literature review and veterinary medical perspectives

Amphetamine abuse in human beings has increased, resulting in many reports of toxicity and death. In the US over 4 million people have abused amphetamines at least once, thus small animals are exposed to increased accidental poisoning risk. This report describes an acute amphetamine poisoning in a dog due to ingestion of 15 mg/kg fenproporex, leading to typical signs of catecholamines release and effects in different organ systems. Similar clinical and laboratory findings observed in human beings are reviewed and physiopathogenic mechanisms discussed, as well as the therapeutic approaches available in veterinary medicine.

Overingestion of methionine tablets by a dog

Methionine tablets are used as urinary acidifiers for pets and to decrease damage from dog urine to lawns. A 39-kg Labrador Retriever ingested approximately 350 tablets containing 150 mg methionine/tablet and was presented after repeated episodes of vomiting. The only abnormality was posterior ataxia suggestive of spinal cord injury. The animal was treated with i.v. fluids, steroids and gastrointestinal protectants. Approximately 4.5 h after entering the clinic the dog had a single seizure episode lasting 2-3 min which was treated with phenobarbital. Serum ammonia at that time was normal (0.19 mg/dL). The animal did not show further CNS abnormalities and awoke apparently normal. A musty odor to the breath was noticed through the course of the day, possibly due to volatile mercaptans produced from methionine metabolism. The animal made an uneventful recovery and was discharged the next day.

Oncologic emergencies

Cancer can lead to emergencies either due to the primary disease, or as a result of therapy. Appropriate diagnosis and rapid treatment of these conditions can result in survival of the patient. Whether chemotherapy is implemented or not, the clinician may be presented with a patient in need of emergency stabilization. Common occurring emergencies are related to effects of the cancer, ranging from immune dysfunction due to marrow infiltration to brain herniation due to increased intracranial pressure from neoplasia. Often adverse effects secondary to chemotherapy can cause emergency situations such as sepsis. Prompt diagnosis and treatment may result in a favorable outcome. Addressed in this chapter are commonly occurring emergencies and specific stabilizing treatments.

Acetaminophen toxicosis in a Dalmatian

An 11-year-old, spayed female Dalmatian was presented with suspected acetaminophen toxicosis. The dog was severely depressed. Methemoglobinemia, facial edema, and hemoglobinuria responded to treatment with intravenous fluids, N-acetylcysteine, ascorbic acid, and sodium bicarbonate. There was no clinical evidence of hepatic damage typical of acetaminophen toxicity in the dog.

Triage and approach to the acute abdomen

The presentation of a patient with acute abdominal pain often is both a diagnostic and therapeutic challenge for the veterinary practitioner. Rapid physical examination and assessment of the patient's cardiovascular status are critical to initiating appropriate and often aggressive medical management as diagnostic tests are being performed. A number of diagnostic tests can be performed, including complete blood count, serum biochemistry profile, serum amylase and lipase, abdominal radiographs, abdominal ultrasound, abdominal paracentesis or diagnostic peritoneal lavage, cytology, and fluid analysis. In some cases, surgical exploration may be indicated, depending on each patient's clinical signs and response to therapy. Of the most important aspects of medical management of the patient with acute abdominal pain is to maintain oxygen delivery to tissues and to treat aggressively for pain or discomfort. The initial triage and approach to the patient with acute abdomen are discussed.

Evaluation of the bone injection gun as a method for intraosseous cannula placement for fluid therapy in adult dogs

OBJECTIVE

To evaluate the Bone Injection Gun (BIG) for placement of intraosseous cannulas through impact penetration and compare it with a standard Jamshidi bone marrow needle (JBMN) and to compare fluid delivery dynamics through each device.

STUDY DESIGN

Randomized in vivo study.

ANIMALS

Forty-eight mature dogs.

METHODS

During surgical laboratories, dogs were randomly assigned to 2 groups (n = 24), and intraosseous access in the proximal tibial metaphysis was obtained using a BIG or JBMN. Variables measured during placement included insertion success, time required for placement, and alterations in respiratory rate (RR), heart rate (HR), and systolic blood pressure. After placement, maintenance fluids were administered to 6 dogs from each group, and fluids were administered under pressure to 6 dogs from each group to compare rates of delivery through each device. After euthanasia, the tibiae were harvested to evaluate and compare the morphologic consequences of needle and cannula placement.

RESULTS

Successful placement occurred in 20 (83%) dogs for the BIG and 23 (96%) dogs for the JBMN, which was not significantly different (P =.3475). Time required for placement was significantly less (P =.0024) for the BIG (mean, 22.4 +/- 8.2 seconds) compared with the JBMN (mean, 42.0 +/- 28.1 seconds). Significant increases in RR occurred in both groups and in the HR for the BIG group, but significant differences were not noted between groups. Mean rate of pressurized fluid administration was similar for both groups. Two distinct patterns of cortical bone damage occurred, but the clinical significance of this observation is uncertain.

CONCLUSIONS

The BIG provides more rapid access to the intraosseous space for fluid administration than the JBMN.

CLINICAL RELEVANCE

The BIG is an effective alternative for obtaining rapid access to the intraosseous space for emergency fluid and drug administration.

Respiratory pharmacotherapy in emergency and critical care medicine

Successful pharmacologic management of most respiratory diseases is possible. All moderately to severely affected animals benefit from rest and supplemental oxygen. Careful identification of the underlying cause as well as an understanding of the pathophysiology behind various diseases is essential to successful patient outcome.

Cervical injury following a horse kick to the head in two dogs

Two dogs were presented to North Carolina State University Veterinary Teaching Hospital following blunt trauma to the head delivered by a horse kick. On presentation, both dogs had resolving clinical signs directly related to the head trauma, but both also had compromise to their upper airway as a result of indirect injury to the soft tissues of the neck, visible on plain radiographs. One dog made a full recovery following a period of assisted ventilation. The other dog was euthanized at the request of the owner. These injuries illustrate the importance of evaluating the cervical spine and soft tissues of the neck following blunt trauma to the head.

Clinical management of flail chest in dogs and cats: a retrospective study of 24 cases (1989-1999)

Cases of flail chest injury for 24 client-owned companion animals following various traumas were evaluated. Concurrently sustained injuries, initial emergency treatments, and definitive treatment and outcome for regimens that utilize stabilization of the flail segment were compared with cases treated with no stabilization. Flail chest was confirmed in 24 animals: 21 dogs and three cats. There was an even division (12 each) of right and left flail segments. The median number of ribs involved was three (range, two to seven). Flail segment stabilization was performed in nine, and 15 were treated with no stabilization. Statistical analysis using multiple data permutations evaluating all combinations failed to reveal a significant difference in outcome between stabilized and unstabilized cases.

S-adenosyl-L-methionine (SAMe) for the treatment of acetaminophen toxicity in a dog

An 8-month-old, spayed female Shetland sheepdog presented 48 hours after ingesting acetaminophen (1 gm/kg body weight). On presentation, the dog was laterally recumbent and hypovolemic. The dog had brown mucous membranes, severe Heinz-body hemolytic anemia, bleeding tendencies, and a red blood cell (RBC) glutathione (GSH) concentration that was 10% of reference values, despite a regenerative erythroid response. Treatment with s-adenosyl-l-methionine (SAMe) as a GSH donor successfully rescued this dog, despite the animal's late presentation after drug ingestion. A loading dose (40 mg/kg body weight) of a stable SAMe salt per os was followed by a maintenance dose (20 mg/kg body weight) sid for 7 days. Additional therapeutic interventions included an intravenous (i.v.) infusion of one unit of packed RBCs (on admission), i.v. fluid support (3 days), and famotidine (7 days) to reduce gastric acidity. Sequential assessment of RBC GSH concentrations and RBC morphology documented response to antidote administration within 72 hours. This case suggests that SAMe may provide a therapeutic option for treatment of acetaminophen toxicosis in dogs capable of retaining an orally administered antidote and maintaining adequate hepatic function for metabolism of SAMe to its thiol substrates.

Gastroduodenal ulceration in cats: eight cases and a review of the literature

Gastroduodenal ulceration (GU) and blood loss was diagnosed in eight cats and compared with 25 previously reported cases of feline GU. Cats with GU presented in a critical condition. Clinical signs consistent with gastrointestinal bleeding were infrequently identified although anaemia was a common finding. Non-neoplastic causes of feline GU tended to have a shorter clinical course with ulcers confined to the stomach. Conversely, cats with tumour-associated GU usually had a more protracted clinical course, weight loss, and ulcers located in the stomach for gastric tumours and the duodenum for extra-intestinal tumours. In this series, definitive diagnosis was possible for cats with neoplasia (gastric tumours and gastrinoma), however, it was difficult to precisely identify the underlying aetiology in cats with non-neoplastic GU. Prompt stabilisation with a compatible blood transfusion, surgical debridement or resection, antibiotic and antiulcer therapy, and treatment of the underlying disease, if identified, was successful in the majority of cases. The prognosis for cats with appropriately managed GU depended on the underlying aetiology, but even cats with neoplasia could be successfully palliated for prolonged periods.

Metabolic acid-base disorders

Acid-base homeostasis is an important determinant of many physiologic functions. Nowhere is understanding the mechanisms and significance of hydrogen ion (H+) imbalance more important than in critical care management, where patients are threatened with a physiochemical disorder that is often as complex as it is dangerous. Although there may be contentious issues yet unresolved concerning acid-base homeostasis, the incontrovertible fact is that the body at least seems to defend H+ balance as vigorously as it does oxygen transport or perfusion pressure. Equally, there seems to be an important and predictable relation between this balance and other physiochemical variables such as concentrations of other ionic species, carbon dioxide, and plasma proteins. The prudent clinician strives to understand whether or not and how acid-base imbalances are affecting his or her patient and what to do about it.

Systemic inflammatory response syndrome, sepsis, and multiple organ dysfunction

Companion animals with sepsis and multiple organ dysfunction can be the most challenging of all patients to treat. Current research in humans and laboratory models offers some exciting insights into the pathophysiology behind some of our most frustrating clinical challenges. This article applies several current concepts to a clinical case of pancreatitis and secondary sepsis to illustrate some of the cardiovascular, immune, and coagulation abnormalities commonly seen.