I am such an idiot

Re: I am such an idiot

Evelyn Barbour-Hill — Sat, 29 Dec 2012 22:04:25 GMT

[quote user="An On MRCVS"]With regards to the equipment, I think the problem was that we only had dog IV catheters and the gauge was not enough. So the pressure needed to pull on the syringe was really difficult and we didn't have an extension line so it was difficult not to move the needle when pulling on the syringe. [/quote]

I sympathise. As for extension line though, that's easily achieved with a giving set. Cut off the bit with the spike and chamber. If you have the posher giving sets that you can unscrew in the middle, it's even easier. Use a three-way tap at the syringe end and you're all set.

14g iv catheters come in handy for all sorts of things. Emergency decompression of a gastric dilation for instance - stick two or three of them in. Not for draining pus from a cat's chest though - in my hands they always seem to crease across the ribs.

Re: I am such an idiot

David Mills — Sat, 29 Dec 2012 21:30:44 GMT

[quote user="An On MRCVS"]

Oh and we are planning to send a sample of the fluid to the lab on Monday to see if they can give us a diagnosis.

[/quote]

I wouldn't bother with sending fluid to the lab, the diagnostic yield is very, very low - in fact at various CPD events I've never heard a cardiologist say that they've ever got anything useful back from this, largely because the fluid contains no neoplastic cells as the tumours exfoliate very poorly; save the client's money in case it happens again.

Care with relying too much on ECG- not all show electrical alternans (think about 70% do) though you should see R wave depression. Far more sensitive is a quick echo, and very simple. As previosuly, ECGs can be useful to assess placement.

Re equipment, order in some cow/horse catheters, 2In 12/14g - very simple, and cheap to use. The seldinger stuff etc can be very fiddly and hellishly expensive for questionable benefit. You can also use the bigger catheters for ear flushes etc.

Re: I am such an idiot

David Mills — Sat, 29 Dec 2012 21:25:28 GMT

Frusemide primarily causes a decrease in preload (hence its use in CHF) mainly from the venous system. This loss causes a decrease in circulating volume, meaning the haemodynamics in the abdominal circulation favours resorption of the fluid. It would, theoretically, help with PE but it would takes days to have an effect. In the meantime, the lack of preload to the RA/RV in the presence of an effusion makes tamponade far more likely, and it is this that will kill the dog.

Interestingly, IV frusemide may help temporarily as it can cause vasocontriction which would transiently increase preload and improve cardiac function, but its a hell of a risk for questionable benefit.

Re: I am such an idiot

An On MRCVS — Sat, 29 Dec 2012 21:10:42 GMT

Thank you so much. It really helps to know that I'm not the only one to have missed this, and even more so that it has helped someone else to avoid the same mistake.

With regards to the equipment, I think the problem was that we only had dog IV catheters and the gauge was not enough. So the pressure needed to pull on the syringe was really difficult and we didn't have an extension line so it was difficult not to move the needle when pulling on the syringe. We used ultrasound to see where the needle was rather than ECG. It took over an hour to drain all of the fluid, if we'd have had an ECG running the whole time we would have run out of ECG paper. I'm going to make sure we get something with a bigger gauge and an extension line so that we are prepared for the next time it is needed.

Oh and we are planning to send a sample of the fluid to the lab on Monday to see if they can give us a diagnosis.

Thats an interesting point about diuretics being contra-indicated. We didn't give diuretics in this case but that was more because I wasn't sure it would help rather than knowing it was contra-indicated.

It is amazing that this dog coped so well with such a prolonged anaesthetic, it really does make me think that maybe we are too worried about the risks of anaesthetics, for example in the old dogs that need a dental but have a heart murmur.

Re: I am such an idiot

Anthony Todd — Sat, 29 Dec 2012 21:01:48 GMT

[quote user="Mark Holmes"]These dogs are often dependant on the cardiac preload. If you give them diuretics it falls and they get worse.[/quote]

Yes, got that bit but how does this fit when complicated by pericardial effusion and ascites and, what might be, a compromised liver.

The performance of the heart is regulated by the level of myocardial contractility and the cardiac preload and afterload. These factors, previously of interest primarily to basic scientists, are now clinically important for an understanding of both cardiac function and therapeutics.

The above [part] abstract seemed to summarise it for me but, as I said, when you have pericardial effusion and ascites it's a sort of double whammy, affecting both myocardial contractility and afterload, and I wonder whether diuretics wouldn't be the best non-invasive approach initially ,to be followed by an ultrasound and drainage of both when confirmed.

If given I/V frusemide, at a high dose rate, would reduce both the pericardial effusion and the ascites while waiting for the ultrasound to confirm the diagnosis or not.

Any tell-tale signs of pericardial effusion? You know, late at night, on your own, ultrasound at the main branch etc. etc.

Re: I am such an idiot

Bibs — Sat, 29 Dec 2012 20:39:12 GMT

I recently went on a heart scanning course and only then did I learn that you should scan the heart of dogs with ascites. It wouldn't have really occured to me before. Apprently a lot of dogs that get referred for investigations into ascites have pericardial effusions, so I guess a lot of people don't know to check for this.

It's hard because we want to do a perfect job but a lot of the time we are on our own, with no-one teaching or supporting us, and trying to do out best with these complicated cases under pressure and learn as we go.

Sounds like things turned out alright in the end.

Thinking back I'm sure there could be at least a couple of cases like this were I have missed a pericardial effusion in the past.

Re: I am such an idiot

Elisabeth Knappett — Sat, 29 Dec 2012 20:26:18 GMT

You are not an idiot - you have taught me something! On call and presented with a very similar situation, weak and wobbly dog with abdominal distension, on tap looks ascitic (vs blood) and liver abnormal appearance, heart rate/rhythm etc all WNL. Remembering what I read on here this morning, I scanned the heart (first time for everything!) and lo and behold, a rather large pericardial effusion. Dog is currently recovering post drainage (through a horse IV catheter - the only thing suitable on site....) and I'm keeping my fingers crossed. So thank you, certainly would have never crossed my mind to scan the heart primarily.

Re: I am such an idiot

Mark Holmes — Sat, 29 Dec 2012 19:44:15 GMT

[quote user="Anthony Todd"]

[quote user="Rajat"]PS These are common causes for RCHF - one thing to remember is diuretics are contra indicated - They will only make the patient worse[/quote]

Sorry, sheer ignorance and/or idiocy here, but why are they contraindicated?

Patronage is expected.

My approach to ascites used to be: take a sample and, while waiting for results, put them on frusemide at least until the results came back. Mind you I suppose none were RCHF 'cos they all improved ,as far as I recall, at least temporarily.

[/quote] These dogs are often dependant on the cardiac preload. If you give them diuretics it falls and they get worse.

Re: I am such an idiot

Anthony Todd — Sat, 29 Dec 2012 18:59:39 GMT

[quote user="Rajat"]PS These are common causes for RCHF - one thing to remember is diuretics are contra indicated - They will only make the patient worse[/quote]

Sorry, sheer ignorance and/or idiocy here, but why are they contraindicated?

Patronage is expected.

Re: I am such an idiot

Evelyn Barbour-Hill — Sat, 29 Dec 2012 18:20:08 GMT

[quote user="An On MRCVS"]

Now I'm kicking myself for not investigating the heart before jumping in to the ex-lap. I can't believe I was so stupid to miss it and I can't stop thinking about it.

[/quote]

Why kicking yourself? Well, because veterinary surgeons are always very hard on themselves! You were sharp enough to do the chest Xray. You came to the right answer albeit in a roundabout sort of way. Presumably both you and your colleague auscultated the heart before heading to the liver. You've nothing to apologise to the owner about very specially. I guess we've all done this sort of thing.

The retrospectoscope is a wonderful instrument. When a similar case crops up in future you will probably be in a position to say to your junior "Hmmm, I think you should investigate the heart first" and impress all your admiring underlings with your diagnostic acumen.

Re: I am such an idiot

Kate Richardson — Sat, 29 Dec 2012 17:58:26 GMT

PS You're not an idiot!

Re: I am such an idiot

Kate Richardson — Sat, 29 Dec 2012 17:57:41 GMT

As per everyone else, don't beat yourself up, hindsight is a wonderful thing. Most importantly you accepted you made a misjudgment and won't make it again- would be much worse if you didn't acknowledge it and were blase about it or made up some BS to tell the owner, so the fact you are so annoyed by it is a mark of a good vet who cares about they do. Your owner will have appreciated your honesty and will respect you for it and the dog has come through ok. Hopefully by now you are feeling better and can chalk it down to experience.

Re: I am such an idiot

Louise6732 — Sat, 29 Dec 2012 15:59:30 GMT

It is easy to beat yourself up about cases (especially if you are a perfectionist like me!)

There is a VERY good chance you will not miss this kind of presentation again. And that is why learning by your mistakes is often the best way, it sticks in your mind for next time!

Louise

Re: I am such an idiot

Mark Holmes — Sat, 29 Dec 2012 14:29:48 GMT

I did this once. Now with more experience I appreciate how uncommon an abdominal modified transudate is in a dog and always think cardiogenic when I see one. In fact I cannot remember one that wasn't either associated with PC effusion or another form of right side failure. As an aside it puts Ga and heart disease into perspective! Profound heart disease and it survived a prolonged ga and exlap.

Re: I am such an idiot

Andrew Kent — Sat, 29 Dec 2012 14:24:23 GMT

Around 50% of the pericardial effusions that we get referred have had an ex-lap so you are not alone in doing this, but right sided heart failure often seems to be overlooked despite the fact it is a very common cause of ascites. PE's should be drained from the right as less chance of damaging the coronary vessels. I either use a Martin Pericardiocentesis catheter set, a Mila seldinger chest drain or a big horse iv catheter. The Mila drain is probably my favourite. I wouldn't be too gloomy about the outcome of your case, certainly a detailed echo would be useful but even without this the nature of the fluid is not predictive of cause. I would monitor for recurrence and keep draining if needed and infrequent it may do better than you think. Andy

Re: I am such an idiot

Rajat — Sat, 29 Dec 2012 14:19:02 GMT

Hi anon

Don't worry we all miss things and dog's recovered from op etc so I wouldn't be too stressed.

Re equipment- I use an IV catheter and advance the catheter off the stylet into the pericardium. Usually 18gauge or larger unless dog <10 kg which is rare.. Then a 3 way tap or a centesis adapter and an extension set for drainage. You can get special Seldinger pericardiocentesis catheter sets from MILA (via DMS medical) or use a jugular catheter in the same fashion- bit more time consuming much more expensive but probably more stable/quicker drainage/less trauma especially if you are doing more than the odd one..

I sometimes use an ECG, not always. I do use US to decide on best spot for entry (tho you don't have to if massive) and for putting in some lidocaine

Pericardial effusions when presenting with collapse/syncope are more likely to be due to a neoplastic cause than those where these clinical signs are absent. Dogs tend to put up with the slower developing effusions better than an acute bleed.

I agree with your reasoning re chronology - as a very general rule, larger effusions tend to accumulate over larger period of time. Acute bleeds tend to be smaller volume over shorter period of time. But this is a flatcoat retriever, so all bets are off in my mind - until proven otherwise I'll be putting a fiver on neoplasia rather than idiopathic!

How about an echo especially looking at this R atrium and auricle? Probably easier to see masses when there is some fluid in there. Also would be worth sending some fresh slides to lab for cytology and fluid for analysis. We may get lucky!

PS These are common causes for RCHF - one thing to remember is diuretics are contra indicated - They will only make the patient worse

Re: I am such an idiot

Michael Woodhouse — Sat, 29 Dec 2012 14:04:05 GMT

[quote user="James Laidlaw"]There's probably a thorough guide to pericardiocentesis in the rcvs guide to procedures in small animal practice.

[/quote]

Do you mean the BSAVA book?

That suggests a Long (5–12.5 cm) wide-bore (14–18 G) over-the-needle catheter approach from the RHS.

Re: I am such an idiot

James Laidlaw — Sat, 29 Dec 2012 13:14:59 GMT

There's probably a thorough guide to pericardiocentesis in the rcvs guide to procedures in small animal practice.

Re: I am such an idiot

Martin Atkinson — Sat, 29 Dec 2012 11:07:42 GMT

Don't worry yourself about it, we all do something like this sometime in our careers, the important thing is to learn from it and not make the same mistake twice. Look on the bright side, the dog didn't suffer, you've got your diagnosis and the owner is understanding. The pericardial effusions I've drained have been done with minimal equipment, prep the dog and attach to the ECG (you should see depressed R waves and electrical alternans) advance a suitable sized needle (21g x 1.5") with a 3 way tap from the left side between ribs 6-7, 2/3rds down and as the tip of the needle hits the pericardium you'll see a blip on the ECG trace, Advance a fraction further and apply suction, drain 20ml or so and see if it clots, if it doesn't you've got pericardial effusion if it does it maybe you're in the heart so pull back a bit. Once you're satisfied you've withdrawn all the effusion the ECG trace should be more normal i.e. taller R waves and no variation in amplitude, re-X-ray to confirm normal heart shape.

Re: I am such an idiot

KMurphy — Sat, 29 Dec 2012 10:57:41 GMT

Hindsight is always 20/20. Maybe you would do things in a different order next time but we only get one go at most cases. Focus on the positives - you've dealt with the effusion, the dog is home with the owner, the owner has realistic expectations. You've got a good liver biopsy - who knows what that will show.

Unless you've mastered time travel, there's nothing you can do differently in this case. Beating yourself up is not going to change anything. Learn from it but don't give it more thought than that.

Try and enjoy what's left of the holidays :)