Cat with Gallop Sounds

Re: Cat with Gallop Sounds

Rob Loxley — Wed, 14 Nov 2012 13:31:02 GMT

[quote user="Kate Richardson"]

[quote user="robloxley"]Even better the Buster oxygen cages (without the thick mat) can be radiographed through[/quote]

They are useful, but only thing I don't like about them is they can get quite hot inside which exacerbates the dyspnoea.

[/quote]

Indeed, if they're in for some time then ventilation is an issue. However for the initial acute stabilisation and if wanted radiography I like them - though equally ultrasound to confirm a suspected effusion is my first point of call before xrays. Being reasonable well sealed I have on occasion puffed some Ventolin inside to help with acute 'asthma' cats

Re: Cat with Gallop Sounds

Martin Atkinson — Wed, 14 Nov 2012 11:18:34 GMT

[quote user="Kate Richardson"]Another useful tip for hands off diagnostics in a dyspnoeic cat is to sit the cat in a cardboard box, on top of an xray plate and take the xray,[/quote] Its a good tip I may use in future but I would be concerned that a D/V view is not as diagnostic of pleural effusion as a lateral.

Re: Cat with Gallop Sounds

Kate Richardson — Wed, 14 Nov 2012 10:43:23 GMT

No worries Rajat

[quote user="robloxley"]Even better the Buster oxygen cages (without the thick mat) can be radiographed through[/quote]

They are useful, but only thing I don't like about them is they can get quite hot inside which exacerbates the dyspnoea.

Re: Cat with Gallop Sounds

Rajat — Tue, 13 Nov 2012 20:16:57 GMT

[quote user="Kate Richardson"]Hi Rajat, totally agree that thoracocentesis performed as you describe has huge value, and I know not everyone has access to ultrasound but to be fair you did just say in the initial post there was no harm in it without quantifying the risks. Apologies if being pedantic.[/quote]

No you were prob right in posting what you did - lets make up

I love the cat in the box Xray too!

Re: Cat with Gallop Sounds

Rob Loxley — Tue, 13 Nov 2012 13:25:37 GMT

[quote user="Kate Richardson"]Another useful tip for hands off diagnostics in a dyspnoeic cat is to sit the cat in a cardboard box[/quote]

Even better the Buster oxygen cages (without the thick mat) can be radiographed through

Re: Cat with Gallop Sounds

Kate Richardson — Tue, 13 Nov 2012 12:08:55 GMT

Hi Rajat, totally agree that thoracocentesis performed as you describe has huge value, and I know not everyone has access to ultrasound but to be fair you did just say in the initial post there was no harm in it without quantifying the risks. Apologies if being pedantic.

Another useful tip for hands off diagnostics in a dyspnoeic cat is to sit the cat in a cardboard box, on top of an xray plate and take the xray, towel draped over the top of the box if nec. Won't be perfect but good chance diagnostic ie pleural effusion or not. Often these cats sit pretty symmetrically anyway to aid breathing.

Re: Cat with Gallop Sounds

Thomas Johnson — Tue, 13 Nov 2012 11:52:50 GMT

[quote user="Siobhan Westbrook"]

Add in some Tumil-K! (Potassium supplement in oral form).

[/quote]

The trouble with Tumil-K is that the tablets are very big, and unpalatable. I've been using Kaminox, it's a palatable liquid and has B vitamins as well.

Re: Cat with Gallop Sounds

Rajat — Sun, 11 Nov 2012 15:00:56 GMT

[quote user="Kate Richardson"]Other than you stress the cat much more by clipping and prepping it (unless you don't) and it has to sit still or be restrained and the stress causes the cat to decompensate and die. Or you stick the needle in, the cat decides to freak out at that point in time and you lacerate the lung or cause other iatrogenic haemorrhage adding to the problems. Not saying that thoracocentesis is not a useful diagnostic tool, it is, but its not a no risk procedure. And yes, they can still be stressed with ultrasound, but I would argue less so [/quote]

Kate

I always give moderate to severely dyspnoeic cats oxygen and mild sedation first - I never ever ever do anything that stresses them unduly - I was taught well by the master, Dez Hughes. Some dyspnoeic cats die because of our actions or inactions in the golden period...

Thoracocentesis is not a no risk - but say you don't have access to US. should you transport the cat to the main clinic after giving frusemide and/or other meds or should you do thoracocentesis first? What of those places that don't have US- should they be radiographing (!!) before draining the chest?

Have seen them being transported or other procedures first before chest tapping- not advisable IMHO - and I agree US stresses them very little - I feel not sedating mildly is often a mistake tho. It saves lives. Not doing a thoracocentesis to delay for imaging where the clinical signs are very suggestive (as outlined above- and its in a paper in JVECCS too) is crazy. And that's what I was trying to put across- of course its not risk free but the risk, if done properly, is very very low. Don't forget the risk of leaving a dyspnoeic cat while transporting for imaging- not one that I'd put my cat thru if I had strong clinical signs of a pleural effusion.

My dyspnoeic cats always get IM torb +/- midaz, and oxygen and HANDS OFF as a first rule for 5 or 10 (or longer if they need it) minutes. Once bit more stable and relaxed, they get an iv cath (while getting blow by O2) and then imaging/chest tap/whatever I think is appropriate first based on the respiratory pattern. Of course, if the US is readily available one is advised to use it - I know I have enough times. Sometimes they localize fluid to one part of the chest. Sometimes you need to see if there's loads on the other side if their mediastinum is im-perforate and so on. Having used US on plenty of occasions in pleural effusion cases I can attest to the diagnostic accuracy of monitoring the respiratory pattern. I was only trying to put across a very useful tool for these cases to detect pleural effusion. If it helps, I would not do a diagnostic tap on a cat not showing paradoxical abdo breathing.

Re: Cat with Gallop Sounds

Kate Richardson — Sun, 11 Nov 2012 10:02:56 GMT

[quote user="Rajat"]And there's no harm in a naegative chest tap.[/quote]

Other than you stress the cat much more by clipping and prepping it (unless you don't) and it has to sit still or be restrained and the stress causes the cat to decompensate and die. Or you stick the needle in, the cat decides to freak out at that point in time and you lacerate the lung or cause other iatrogenic haemorrhage adding to the problems. Not saying that thoracocentesis is not a useful diagnostic tool, it is, but its not a no risk procedure. And yes, they can still be stressed with ultrasound, but I would argue less so

Re: Cat with Gallop Sounds

Rajat — Sun, 11 Nov 2012 07:16:21 GMT

One more thought (now that I caught my flight on time...)

I agree with Kate US is far far easier at dx pleural effusion than rads. But there is a simpler quicker way for those who 1) don't have access to US 2) like to enhance or use their primary diagnostic tools- eyes and stethoscope

Obviously there is the whole ventral dullness (Easier) and percussion (tougher, much tougher for me) with stethoscopes

But the nugget here is that its worth watching the dyspnoea carefully. In cats especially, if there is paradoxical abdominal effort, with the abdomen going in when the chest goes out, there is a very high chance of pleural space disease. In a cat with addiitonal signs consistent with heart dzs, such as gallop rhythms, murmurs, muffled heart sounds, jugular distension etc I would even forego the US and just do a little tap to see if there is fluid. 95% of the time or more there is, and it is the cause of the dyspnoea. And there's no harm in a naegative chest tap.At the worst you just do lung fnab. And if one isn't sure, a US can always be follow up.

Besides, you look like a badass rock-star when you take one look at the cat, tell the owner whats wrong with the cat and then fix it, albeit temporarily

Re: Cat with Gallop Sounds

Kate Richardson — Sat, 10 Nov 2012 18:04:14 GMT

A few thoughts

People have mentioned xrays and thoracocentesis for diagnosis of a pleural effusion, but not many have mentioned ultrasound. Ultrasound is by far and away the best way to diagnose a pleural effusion in a dyspnoeic animal- quick, painless, not noisy, minimal restraint, clipping not often necessary. If you can assess LA size as well even better as is relatively easy once you have a bit of practice looking at normal cats

Gallop sounds always abnormal in cats and would indicate cardiac disease

If you have got a pleural effusion then depending on how much present, the cat will be much happier with it drained and likely less stressed and your diuretic therapy will work better at keeping the fluid away.

Diuretics are the main stay of treatment of cardiac failure in cats, but I would also use an ace-inhibitor, possibly pimobendan, low dose aspirin or plavix for their anti-thrombotic effects. But how many different meds I used would depend on the cats amenability to being medicated as I would want to minimise stress, but you could use gel capsules to combine drugs into one dosing if direct pilling is possible.

Re diuretics, I would use frusemide (5-10mg bid/tid initially if oral) and spironolactone (usually 10mg sid) together as I find the combination works better than either drug alone, and the spironolactone has potassium sparing effects which help to counteract the potassium loss you get with frusemide and the combination means you can use a lower frusemide dose. Frusemide will also often cause some azotaemia so some caution needed, but its a case of benefit versus risk in these cases. Hypokalaemia is a serious problem in these cases, they are often hypokalaemic when they present and the frusemide (which you can't avoid using) just knocks it lower and then the cat becomes more inappetant and more hypokalaemic, so institute a potassium supplement immediately in this case as someone esle suggested. If not eating, then I sometimes have to supplement iv using a higher concentration of KCl than I would usually use for the level of hypokalaemia but using a very low fluid rate to avoid overload, whilst continuing my diuretics alongside. Really tricky balancing acts!

Re: Cat with Gallop Sounds

Rajat — Thu, 08 Nov 2012 20:52:40 GMT

I would not use dom-torb period.

That's the one major difference I guess from other posts here

Torb or torb midaz is more than enough to allow drainage.

The reductions in cardiac output with even 2-3ug/kg medetomidine can be dramatic

Not the best to say the least for kitty in CHF !!

Re: Cat with Gallop Sounds

Martin Atkinson — Thu, 08 Nov 2012 17:57:32 GMT

[quote user="Anthony Dennison"]

I was thinking about moving over to prilactone, if I remember from a seminar at uni it also helps decrease remodelling of the heart via aldosterone reduction, which can only be a good thing? I'll look in to Tumil-K too, thanks!

Am I being negligent by not getting the cat in for rads/thoracocentesis ASAP as this is the best treatment?

[/quote] Not sure there is any indication for spironolactone in cats, in its role as an anti-fibrotic that is, and it is too weak a diuretic to use on its own. Potassium supplementation is a good idea though it is virtually impossible to over-supplement a cat that hasn't got CKD due to their regulatory mechanisms. Don't know if you'd be negligent not doing rads if the stress the cat is in is counter-productive, its another risk/benefit analysis so long as you can show the decision was made on sound logic. But if in your heart of hearts you think you should be doing it and you don't honestly think it would be counter-productive then you should, not least you don't want to be worrying about it all weekend. Certainly unless you know there is a pleural effusion then not doing thoracocentesis can't be an issue. How about getting the owner to use some Calmaid and/or Feliway to reduce stress levels before bringing him in. Respiratory rate may not tell you if the cat has a pleural effusion, although double lift breathing might be indicative, it could be still the result of not fully compensated cardiac failure however, if it's resp rate is low 20's then you can probably rest easier over the weekend.

Re: Cat with Gallop Sounds

Anthony Dennison — Thu, 08 Nov 2012 17:42:01 GMT

Thanks everyone for your advice, just read the replies as its been a hectic day (mammary strip, mets everywhere, eurgh).

The main problem with the cat is he gets massively stressed out coming to the vets - talking to the owner on the phone today she says he's like a normal cat at home, eating well and bright. Bring him in to the surgery and it's a different story! Think at the moment it's going to be a conservative treatment, at least for over the weekend. I've asked the owner to measure his resp rate whilst sleeping, if its too high (>30) we'll get him in for thoracocentesis.

Am I being negligent by not getting the cat in for rads/thoracocentesis ASAP as this is the best treatment?

Re: Cat with Gallop Sounds

Siobhan Westbrook — Thu, 08 Nov 2012 13:31:03 GMT

Add in some Tumil-K! (Potassium supplement in oral form). Frusemide lowers K, and if you don't correct for that, or switch to/add in (unlicensed) potassium-sparing diuretic (spironolactone- 'prilactone') then the cat will likely re-present in a week or so wobbly, anorexic and with much increased respiratory effort through weakness rather than through dypsnoea. As the K is already low, this is quite urgent. It tends to decrease anyway with anorexia, and the cattery stay, stress + CHF have prob all combined to reduce this cat's appetite, plus you've added in a drug that reduces potassium. He will be much perkier once his potassium is back in the normal range.

Re: Cat with Gallop Sounds

Martin Atkinson — Thu, 08 Nov 2012 13:30:17 GMT

[quote user="David Mills"]I tend now more towards dom/torb; [/quote] I would use this comb as well but went to a recent cardio seminar and ACP/Torb was advocated. I was also under the impression that this is the best combo for getting a half reasonable ECG trace if you can't do one conscious.

[quote user="David Mills"]There is no evidence that ACEis, pimo, ditiazem, beta blockers work better than each other[/quote] There are lot of cats dying from cardiac failure and FATE because of adherence to this doctrin, we as practitioners are not as rigidly bound by EBM as specialists and research workers and sometimes anecdote is our saviour. But as you said David - we've been here before.

Re: Cat with Gallop Sounds

David Mills — Thu, 08 Nov 2012 13:14:45 GMT

It sounds like CHF. Sedate and xray and drain as neccessary - don't worry too much about your protocol but you want the cat still and unstressed - stress will kill cats far more often than your sedative protocol. We seem to alternate between ket/midaz (0.12-0.15ml of each IM) and dom/torb (0.1ml of each). There is some evidence that in cats dom can actually improve cardiac funcion by increasing ventricular filling time; similarly ketamine has been shown to be cardiotoxic and may increase HR which can be disastrous. They may also struggle more under ket/midaz so I tend now more towards dom/torb; in humans one of the first things they give CHF patients is morphine to vasodilate, so an opiate of some description seems sensible.

If you need to drain, spin down a sample and look at the deposit under a microscope - if there are loads of lymphoblasts then you have a diagnosis.

Gallop sounds can come from any feline cardiomyopathy but top two would be RCM and HCM. Arrhythmias are common in cardiomyopathy; this is far more likely to be a primary cardiomyopathy than a primary arrhythmia. Defining type of CM needs echo, and is only important in offering prognosis (RCM carrying the worst).

Echo would be very useful, and quicker, than proBNP in this case to define resp vs cardiac case. If LA is larger than 16.5mm diameter then this is highly likely CHF. If you're not confident with measuring this then proBNP would be the next choice.

Treatment of cat CHF has a very poor evidence base. We've been here before but everything seems to be as good (or as bad) as frusemide alone in terms of survival. There is no evidence that ACEis, pimo, ditiazem, beta blockers work better than each other. Pimo is currently in vogue and there are a number of case series showing it to be safe - there is no evidence it increases survival time. I am somewhat sceptical about putting dyspnoeic cats on loads of tablets with no evidence base. Far more important to get the frusemide down (consider liquid frusol if cat not possible to tablet). Treatment for all CMs is the same.

Re: Cat with Gallop Sounds

Graham Bilbrough — Thu, 08 Nov 2012 13:09:11 GMT

Thank you. Please keep in mind that reducing the stretch/stress with cardiac medication (e.g. frusemide) will reduce the circulating concentration of Nt-proBNP.

Re: Cat with Gallop Sounds

Anthony Dennison — Thu, 08 Nov 2012 09:22:06 GMT

T4 was 19 (IDEXX ref range 10-60 normal)

Re: Cat with Gallop Sounds

Martin Atkinson — Thu, 08 Nov 2012 09:11:34 GMT

ECG, X-rays and T4 and blood pressure essential in a case like this although I appreciate the difficulty of getting a decent ECG trace and BP in an un-cooperative cat but I don't worry too much about mild sedation for X-ray. NT-proBNP a good idea as well, anything over 270 probably indicates cardiac disease, IME over 350 definitely - I think it is a wonderful tool. Pimobendan can be useful but you need a diagnosis of the arrhythmia before anti-arrhythmics. A high proportion of these will be hyperthyroid and will settle with treatment.

Re: Cat with Gallop Sounds

jd2008 — Thu, 08 Nov 2012 09:11:27 GMT

In a bit of a rush so don't have time to reply fully, sorry. But, first thing to do is to check for pleural effusion with radiograph or thoracocentesis. Pre-oxygenate and sedate if required (midazolam, low dose opiate, butorphanol or a combination) Avoid stressing the cat at all costs. Minimal handling, lots of rest periods with oxygen. Will try and add more later!