help- hypoglycaemic chihuahua with haemorrhagic enteritis

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Andrew Kent — Fri, 29 Jun 2012 19:52:24 GMT

Except alphatrack 1 has just been replaced by alphatrack 2 which apparently is a lot better and old sticks are being phased out which is a bit of a pain for clients who have bought one!

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Martin Atkinson — Fri, 29 Jun 2012 17:27:44 GMT

+1 for Alphatrak - is anyone really still using anything else?! Phone Abbot before the end of June so you have to be quick but they are doing an offer of buy one get one free.

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Rajat — Fri, 29 Jun 2012 17:19:21 GMT

Forgot to add the most important bit (Duhh!!) - I like using Alpha trak because it is validated for use in dogs and cats: http://www.alphatrakmeter.com/alphatrak2-species-specific.html

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Rajat — Fri, 29 Jun 2012 17:03:22 GMT

Bob We also had Woodleys the important thing with glucometers as everyone knows I'm sure to remember is calibration regularly - our nurses often remember to do this

Have used accucheck too and again variable results

Woodley is attractive because the machine is cheap the sticks are not tho! I've been pretty annoyed with this issue for some time, but my persistence paid off and we recently (year maybe) changed to the alpha trak glucometer across the board seems more consistent and reliable when I compare it to our I-stat and wet chemistry unit blood glucose readings

I reccommend the alpha trak to all my home monitoring DM clients too - can be bought on amazon

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Bob Russell — Fri, 29 Jun 2012 15:14:25 GMT

What are peoples views on hand-held glucometers? We have two Woodleys 'veterinary' ones that consistently fail to agree by a large margin. Cheap to buy but expensive to run and a human Accu-chek which consistently reads about 1 mmol/l lower than our Vetscan.

This is cheap to buy and cheap to run.

What unit do you have? What are other peoples experiences?

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

An On MRCVS — Fri, 29 Jun 2012 13:21:54 GMT

Sorry for the anon - logged in on somebody else's computer

Fascinating case - wish I'd seen it earlier, as my Tourettesian response to any diarrhoeic dog with bradycardia is to shout ADDISON'S! with some excitement, followed by the crushing disappointment of negative electrolyte and/or ACTH stim tests.

However, not to discount in this case: my dim and distant memory recalls the use of dextrose saline for treatment of hyperkalaemia: something about the glucose holding hands with the potassium as it crosses the cell membrane. It's possible that the glucose therapy actually had a pretty direct effect in protecting the heart from all that un-excreted K. And don't we often find that after symptomatic treatment for undifferentiated diarrhoea, these patients will get better for months at a time, until such time as we actually get round to thinking about Addison's and diagnosing them?

Only had one xylitol case, and to be honest it resolved within a very short space of time - was off the drip and home the following morning, but was substantially better almost immediately on the drip and I suspect was over it before midnight. (this of course being anecdotal, there not having been an equally affected twin to use as a control)

Well done Julie - I suspect the privilege of being a sole practitioner may have seemed less attractive in the wee small hours. Hope you have some recourse to time off this weekend.

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Hannah Wynne Richards — Fri, 29 Jun 2012 09:26:35 GMT

Yes You really have cause to congratulate yourself

Wynne

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Rajat — Fri, 29 Jun 2012 09:24:42 GMT

Hi Julie

So glad the little one has improved, you saved her life! nice work!

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

ilanit — Fri, 29 Jun 2012 05:25:26 GMT

Well done. You did a great job!

And thanks for posting an interesting case. I never knew about xylitol toxicity in dogs!

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Julie Innes — Thu, 28 Jun 2012 22:48:00 GMT

Thanks, Martin. I did give her a small shot of dex early on, but she got worse! The good news is, by 5pm her blood glucose was 5.6, and she went home tonight . I called the owner at 10pm, and she says she is doing really well- eating and playing with the other dogs.

Her actual owner is home tomorrow, and I'm not sure who her vet is, but I have mentioned that if I was continuing her care I would still be thinking of doing an ACTH stim- we'll see what happens! I still have the xylitol toxicity as a candidate for causing this, and I will be interested to see what her insulin levels were when they come back. Just pleased she has at least stabilized for her owner coming home! And only missing her a little tonight...

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Martin Atkinson — Thu, 28 Jun 2012 16:14:50 GMT

Another for Addisons, IME these are very typical presenting symptoms, electrolytes and ACTH stim test essential, but rapid fluid responsive weakness and collapse is almost diagnostic and just the saline drip can save its life. Dose for Synacthen is 5ug/kg bw so you can use far less than a vial although most texts suggest 1/2 vial for small dogs. But remember some Addisons cases present only with GI signs and a hypoglycaemia and these may only have a glucocorticoid deficiency so you may not get electrolyte abnormalities, although you shouldn't get a low lymphocyte count with these, so you must conduct an ACTH stim test. In cases where you can't do an ACTH stim test immediately I understood that a dose of dexamethasone could save the patient's life but would not interfere with the test. I'm not sure if that is still held true.

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Hannah Wynne Richards — Thu, 28 Jun 2012 16:13:13 GMT

Well done

Wynne

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Julie Innes — Thu, 28 Jun 2012 15:46:57 GMT

Well, you will all be pleased to know that she has been off the drip for 3 hours now and her blood glucose is.....4.6!!

She is very bright, not eating dog food but ate cheese voraciously last night (hence the reason my kids had dog food cold meat on their packed lunch sarnies today!!), and is now very indignant about having anything done to her!

Will test her blood glucose again later, but hoping she might go home tonight (with oral glucose)...

Still no word back re the insulin yet, and her owner gets home early tomorrow, so might still suggest an ACTH test in the near future, just to cover all bases! It would be nice to know what is actually going on with her

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Lorna McHardy — Thu, 28 Jun 2012 10:20:31 GMT

[quote user="Julie Innes"]

Thanks Rajat! As I am a sole vet practitioner, you guys have been a great help!

[/quote]

From where I'm sitting, it looks as though you're doing a spectacularly good job on a nightmare of a case!! My sympathies (in buckets), and I really hope it's a good outcome in the end... and that you have the weekend off

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Rajat — Wed, 27 Jun 2012 23:50:36 GMT

Hi Julie

No worries, I can understand your situation is pretty tough and you're doing all you can for the wee little thing!

I don't know for sure if Xylitol would cause diarrhoea or not I guess it could (like in people), HGE sounded a bit different but hey weird stuff does happen.

[quote user="Julie Innes"]Also not convinced I was getting terribly accurate results with the glucometer/ skin pricks- this morning it said 1.4, but she was bouncing about trying to escape! Hmm[/quote]

Which glucometer are you using? 1.4 is fairly low, tho I have seen 'normal' animals around 2, I think they hide their signs well, I like your idea of monitoring HR too!

There's really no danger of overdoing the glucose. I reckon we think and work better with sleep, and you should get some, so I would be fairly happy with having her mildly hyperglycemic overnight (i.e 8-12 mmol/L) which will cause no issues at all short term..and if it keeps her eating then prevents the vicious cycle of hypoglycemia and anorexia like you mentioned

[quote user="Julie Innes"]I've not done a central line before, but wish I had now at the start![/quote]

Ahh always the way with these. Don't feel too bad, I reckon getting one into a tiny chihuahua would be pretty tricky anyways, but I learnt this way too (by wishing I had one in a critical case where both jugs were knackered thanks to yours truly), and after that experience I have been more proactive with them - tho you can get PICC lines you insert peripherally which go centrally (company is MILA, through DMS suppliers)

A good review on Xylitol toxicity - https://docs.google.com/open?id=0Bx91qiJtLeKwNloxWUQ5VkNER0E

Hi ALT is worrying, I'd prob start SAM-E at this stage to try to help the liver, as I am sure you know already hepatic necrosis is a possibility with Xylitol..

Have a good night

Raj

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Julie Innes — Wed, 27 Jun 2012 23:25:21 GMT

Thanks Rajat! As I am a sole vet practitioner, you guys have been a great help!

Her ALT is hi (576, I think) , but ALKP ok, tbil ok. I did wonder if the laxative effect xylitol has on humans could maybe have caused the bowel eruptions we were getting <clutching at straws>!

I've not done a central line before, but wish I had now at the start! Poor wee thing has been stuck to death . Ah well, you live and learn- should have been braver! I'm finding her HR goes down as her blood glucose drops, so I'm monitoring that and trying to stick as little as possible tonight. Also not convinced I was getting terribly accurate results with the glucometer/ skin pricks- this morning it said 1.4, but she was bouncing about trying to escape! Hmm!

I'm also finding each time I increase the drip/ give her a bolus and her blood glucose comes up, that is when she wants to eat! Another question- is there a danger I can overdo the glucose??! She is just so wee, there seems to be more margin for error, IYSWIM?

Hoping that she stabilises tomorrow!! Have to admit, I've become bizarrely attached to the silly wee thing! Was going to say I'd also love a night's sleep, but even if she goes home tomorrow, I know I will be awake fretting....The joys!

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Rajat — Wed, 27 Jun 2012 22:51:32 GMT

[quote user="Julie Innes"]Question- would you still give a whole vial of synacthen to such a tiny dog- I'm a bit worried![/quote]

I'd be happy giving half a vial. Equally I have given full vials to yorkies without problems

I think Xylitol is a possiblity, interestingly, it sends insulin levels sky high soon after ingestion, not sure what it'd do a day or 2 later. If BG still low I suppose insulin will be high and hence confuse the picture. Don't mean to sound like a downer!

If liver values now high it'd support Xylitol ingestion, along with hypophos hypokalemia etc. Alth the haemorrhagic D+ doesn't fit it..Altho I remember reading about prolonged hypoglycemia with it, I cannot now find this reference, and all I have states hypoglycemia and treatment on dextrose CRI for 24 hours ..lets see how she is tomorrow, hope much better!

[quote user="Julie Innes"]Part of me would like to refer (and pass the buck!)....[/quote]

I know how you feel!!

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Julie Innes — Wed, 27 Jun 2012 22:12:59 GMT

[quote user="Sandra Patzner"]

Just had a very quick read through the history etc. Any Hx of access to Xylitol? Am sure that causes plummeting blood glucose that can take a good few days to resolve. (???)

[/quote]

I have asked the owner that, Sandra, and I can't find anything conclusive. She says the dog did manage to scupper some low sugar Angel delight- it seems to have aspartme in it, but not xylitol- would this maybe do the same thing?? Can't find anything definite, but its still on my list. Interested to hear the effects of such could last a few days- I had thought if it was something like this the effect might have worn off by now. I'd be really relieved if it was something like this, as it means it should resolve at some point! I can't keep her on a drip forever

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Sandra Milburn — Wed, 27 Jun 2012 21:50:30 GMT

Just had a very quick read through the history etc. Any Hx of access to Xylitol? Am sure that causes plummeting blood glucose that can take a good few days to resolve. (???)

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Julie Innes — Wed, 27 Jun 2012 21:25:56 GMT

Thanks again, guys. I haven't managed to do an ACTH stim yet, just been trying to get her glucose levels somewhere steady. My worry is she actually got worse after the dex the last time . And her bloods didn't really fit (neutrophilia, renal parameters all AOK) I don't think I would trust any electrolyte reading we would get now either. Question- would you still give a whole vial of synacthen to such a tiny dog- I'm a bit worried!

I'm also stumped because there is absolutely NO previous history of even being remotely off colour. Just the sudden seizure, HGE, progressing to coma!! Incidentally, when she was collapsed, her pupils were really constricted- is that symptomatic of any particular condition? Her eyes were rolling down like she had been anaesthetised but with tiny pupils. Still no evidence of any toxin either. Sigh.

I actually don't believe it should be an insulinoma either, but I don't want to miss anything!

I'd just love to get her glucose levels stable, and get her off this drip. Her owner comes home Friday morning. Part of me would like to refer (and pass the buck!).... Will keep you posted!

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Rajat — Wed, 27 Jun 2012 20:55:42 GMT

[quote user="Julie Innes"]Have sent blood away for insulin levels. [/quote]

Sorry being sleep deprived and stupid I failed to read this bit!

Utlendigur its a good thought, and a good ddx, stranger things have happened, sods law now that I said its atypical signalment it will come back with sky high insulin levels

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Utlendigur — Wed, 27 Jun 2012 20:27:03 GMT

I think it might have been my fault for mentioning insulinoma earlier. I wasn't intending it as a suggestion in this case (ones I've seen have been 1 border collie, 1 beardie, 1 golden retriever, 2 boxers and all 8yrs plus) - just saying that one of the "side effects" I'd seen with severe hypoglycaemia in a dog with an insulinoma had been sudden D++ associated with collapse. Sorry for confusing the picture.

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Rajat — Wed, 27 Jun 2012 20:18:10 GMT

Hi Julie

Thats a shame, we all were cheering for you and the pup!

So thinking of the options, I assume Na/K ratio is normal? Did you manage to do an ACTH stim today?

Insulinomas are typically found in larger breed middle aged-old dogs so would be atypical in this patient. Even in big dogs these are challenging to find sonographically- millimetre -nodule is 2-3mm across . The gold standard for detection is surgical palpation at exploratory. You can do a fasting Bg/insulin and hi insulin in face of low BG (or even normal insulin with hypoglycemia) is suggestive of it.

Bcause of signalment I'd put insulinoma lower on the list.

I'd feed her ad lib, lots of food pref hi energy like a/d dont worry about overfeeding and keep her on glucose CRI at 5% because she went hypo at 2.5%. BEcause of regular sticks and long term need for BG samples etc I like to put central lines in these little ones, allows fluids and sampling, dunno if thats something you do at yr practice but its really not difficult to do ..

If you want to cover all the bases I would run the insulin glucose ratio with ACTH stim but otherwise I'd do the acth stim first. CSL do insulin levels I think. And personally I would give dexamethasone 0.05-0.1mg/kg IM/IV and monitor BG closely anf it it normalises and is peachy for 24-48 hours it gives you some support of addisons while waiting for yr stim results. Obv would want to make sure no signs re sepsis or any signs of infection prior to 'roids

Best of luck! keep us posted!

Best wishes

Raj

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Julie Innes — Wed, 27 Jun 2012 19:19:52 GMT

Cheers all, but it was a bit short-lived- checked blood glucose 1 hr later and was down to 2.6mmol

Increased drip again, she perked up again, ate more (and was looking for more, but I was frightened to give her too much!) She did well over night (although I am shattered!). Took her back to work today, bl gluc 7.7mmol. We tried slowing the drip again, blood glucose plummeted again

Have sent blood away for insulin levels. She is as bright as a button- trying to get out, wanting to play, eating- as long as she stays on the drip!!! thankfully the D+ seems to have subsided a lot- just little bits (my kitchen smelt lovely last night!!)

So home with me again tonight! Too scared to take her off the drip overnight- when she was presented yesterday I really thought she was going to die, and I soo don't want her to go back there. Surely if it was xylitol poisoning (which I was hoping!) her levels would be steadying out a little by now? I'm still worried about insulinoma. Thought about scanning her, but I am not an expert, and she is smaller than a bloody guinea pig, so not too hopeful of seeing anything! . I'm veering away from addison's as she is responding to glucose alone, but it's still at the back of my mind. Thing is, i think her electrolytes could be misleading atm due to the D+/ fluids etc, and she is now well enough to wriggle plenty when we try to take a spot of blood for the glucometer, so trying to blow as few veins as possible!

Looks like another long night!

Re: help- hypoglycaemic chihuahua with haemorrhagic enteritis

Hannah Wynne Richards — Wed, 27 Jun 2012 09:55:49 GMT

Congratulations and well done

Wynne