What have I done wrong?!

Re: What have I done wrong?!

Anthony Todd — Sun, 05 Jan 2014 17:19:00 GMT

[quote user="David Mills"]I know this is rather nit-picking but it's a bugbear of mine that we often make leaps to 'best practice' from experimental studies without looking at whether it has an effect on the main outcome in which we are interested.[/quote]

My main bugbear is that you current vets "make leaps to 'best practice", not from experimental studies, but from human medicine where euthanasia is not a legal option, quality of life, therefore cannot, and isn't, a consideration; but where the "main outcome" is inevitably always terminal.

Re: What have I done wrong?!

Tim Charlesworth — Sun, 05 Jan 2014 16:09:35 GMT

[quote user="David Mills"]

[quote user="Tim Charlesworth"]just trying to promote best practice for any future cases that people may have[/quote]

I understand this but question whether it is best practice as there is no evidence in either human of veterinary clinical studies(anecdotes don't interest me) that Hartmanns over saline improves survival. It may normalise electrolyte abnormalities more quickly but so what? This is the road to dogma othwerwise.

Regarding the lactate effects, its a neat idea in theory but in the face of acidosis the lactate concentrations are so low that they make very little difference - after all, Hartmann's is not an alkylating fluid. The reduction in acidaemia in most cases (except, paradoxically, DKA) is due to restoration of circulating volume and adequate renal perfusion. I'm not sure it's correct to say 'significant acidifying effects' as these are often transient, and, as previous, no evidence exists (ther than experimental documentation of some acidification) that this is clinically relevant.

I know this is rather nit-picking but it's a bugbear of mine that we often make leaps to 'best practice' from experimental studies without looking at whether it has an effect on the main outcome in which we are interested.

Most of the above (except the opinion bits) were from recent CPD with David Church from the RVC who has no problem with using K+ spiked NaCl in DKAs.

[/quote]

I'm not going to let myself be drawn into a long debate re the finer points of this, partially because I am not an anaesthetist and partially because my roof seems to be developing a leak . As far as I understand, normal saline is regarded as an acidifying fluid both in terms of solution pH and by fact that it dilutes the endogenous buffer capacity (and although there is not a lot of lactate in Hartmanns it is enough for this not to happen). I agree that there is not a lot of concrete clinical (veterinary) evidence on which to base decisions but in the absence of such, decisions should be based on the best clinical data out there and if this is experimental or (human) clinical then that is the best we have. The other way of looking at this is: If there are theoretical/experimentally proven (even transient) disadvantages to saline but none to Hartmanns, why shouldn't Hartmanns be recommended?

Re: What have I done wrong?!

Mark Hedberg — Sun, 05 Jan 2014 13:19:15 GMT

[quote user="Anthony Dennison"]

As an aside, I think there are cases where sometimes where the owners aren't ready to say goodbye despite the animal not being in a good way. If it is the first time I have met the dog I will try treatment/pain relief before pushing euth. Is this ethically ok?

[/quote]

Depends totally on the patient. If the patient is eating and drinking, and the actual disease or illness is not painful (or can be made not painful), then palliative care can be completely acceptable. The classic example is putting a dog with cancer on steroids, the dog perks up, eats and drinks well, gets a last few weeks of QOL, and the owner has time to make their peace. (Other diseases and examples are of course available.)

Often if the animal is visibly suffering, the owners have fewer issues saying goodbye. Or if they do have issues, explaining that the animal is in fact in pain and suffering often helps persuade them that euth is the right answer.

Re: What have I done wrong?!

Jenny Smith — Sun, 05 Jan 2014 12:49:00 GMT

Did the second dog have any signs of petechiae? I've seen a particulary nasty DKA - going on for several days at home prior to presentation turn into a DIC crisis with dramatic epistaxsis. Could fit with the dark bloody type fluid you mentioned

Sounds like a really crappy weekend run :( I was having a bad time with cases recently and someone very wise said that with every really sick patient that comes in, it is dead without us doing anything. So, by us trying we are making a difference. Anything you save is a bonus, anything that dies as a result of their illness was going to happen anyway.

Probably not explaining it properly, but it made sense to me!

Jenny

Re: What have I done wrong?!

Gerry Henry — Sun, 05 Jan 2014 12:35:20 GMT

Do what is right for the animal each and every time Anthony and you won't go far wrong.

Re: What have I done wrong?!

mariette asselbergs — Sun, 05 Jan 2014 11:51:21 GMT

As long as you are confident that your treatment/painrelief will really keep the animal safe from misery.

Mariette

Re: What have I done wrong?!

Anthony Dennison — Sun, 05 Jan 2014 04:25:16 GMT

I called the owner to come and see the dog as she was deteriorating. She crashed soon after but no decision had been made about euthanasia. I wanted to tell the owner I had done everything physically possible to save her precious companion. Yes soft I know, but that's me.

Re: What have I done wrong?!

David Mills — Sat, 04 Jan 2014 13:26:50 GMT

[quote user="Tim Charlesworth"]just trying to promote best practice for any future cases that people may have[/quote]

Most of the above (except the opinion bits) were from recent CPD with David Church from the RVC who has no problem with using K+ spiked NaCl in DKAs.

Re: What have I done wrong?!

Arlo Guthrie — Sat, 04 Jan 2014 11:17:46 GMT

That was how I read it, too.

Re: What have I done wrong?!

Christopher Saul — Sat, 04 Jan 2014 10:35:42 GMT

[quote user="Gerry Henry"]

although I managed to resuscitate one of the dogs (so the owner could be with her for PTS)

You resuscitated a dog so the owner could be present for PTS, deary deary me.

[/quote]

I think, Gerry, he did not resuscitate the dog for the purpose of the owners being able to be present. I interpreted the post as meaning that he resuscitated it with the best of intentions, only for the decision to then be made for PTS.

Re: What have I done wrong?!

Gerry Henry — Fri, 03 Jan 2014 18:35:50 GMT

although I managed to resuscitate one of the dogs (so the owner could be with her for PTS)

You resuscitated a dog so the owner could be present for PTS, deary deary me.

Re: What have I done wrong?!

Anthony Dennison — Fri, 03 Jan 2014 13:51:07 GMT

Thanks everyone for your replies, it helps a lot knowing it definitely was just coincidence! It was 2 patients at the end of quite a weekend - abdominal mass found on ex-lap, 2 aortic thromboembolisms, a nasty cat RTA, a FB and these two.

Luckily I spent this week celebrating in the New Year on Achill Island, so feeling recharged! I would recommend Achill to anyone who wants time out from work to enjoy the great outdoors.

Re: What have I done wrong?!

Tim Charlesworth — Fri, 03 Jan 2014 09:12:09 GMT

[quote user="David Mills"]

[quote user="Tim Charlesworth"]

Sorry to hear about your day. I don't think that there's anything that you could have done that would have altered the eventual outcome but one thing I noticed is that you gave the 2nd dog NaCl. It was likely acidotic (as you mentioned) and so Hartmanns would have been a better fluid choice (even if potassium was raised). This contains lactate that dogs use as a bicarb precursor (to mop up the H+ ions). NaCl is generally considered an "acidifying" fluid. May help you in other cases but I don't think it would have made much difference here.

Tim

[/quote]

I would always use Hartmanns in acidotic patients for the reasons that you state. These cases would ideally have acid/base analyses and I have certainly seen quite a few cases of acidotic hyperkalaemic cases worsen (both clinically and measurably in terms of blood pH) when on saline but which then have responded well to Hartmanns (due to the bicarb effects already described). Equally there is no disadvantage to using Hartmanns whereas saline has been shown to have significant acidifying effects. Again - almost certainly would not have made any difference in this case but just trying to promote best practice for any future cases that people may have..

Re: What have I done wrong?!

David Mills — Wed, 01 Jan 2014 23:39:26 GMT

[quote user="Tim Charlesworth"]

Tim

[/quote]

Whilst what you say is true theoretically and experimentally, the use of Hartmann's in acidotic patients has not been shown to improve survival, even though it may normalise electrolytes more quickly in some patients. The key thing with DKA is to correct dehydration, potassium, hyperglycaemia and acidosis in that order. Re potassium, there is often a whole body deficit in potassium due to loss in PU resulting in intracellular hypoK requiring, even though K may be elevated in serum, so should always be supplemented. As you say, in this case the dog was knackered anyway, but equally, on the evidence available, I think the choice of fluid was fine in this case and wouldn't worry about it too much.

Re: What have I done wrong?!

Tim Charlesworth — Wed, 01 Jan 2014 21:22:02 GMT

Tim

Re: What have I done wrong?!

Christopher Saul — Tue, 31 Dec 2013 11:57:02 GMT

I've only had a v quick read through on my phone - on the go -but I'd tend to agree with what others have said

the first sounds like congestive heart failure - whilst it is true that IV fluids can precipitate heart failure, this dog was dehydrated and the fluid rate you gave was fairly conservative and not at all excessive. If the dog couldn't take gentle and appropriate fluid therapy for the degree of dehydration then its days were numbered whatever you did

The second I agree sounds like necrotising pancreatitis/DKA - and if I had to take a punt at the cause of death I would go with pulmonary embolism - about which you could have done next to nothing, even if you knew it was happening at the time.

I'm really sorry you had such a crap day, it hurts when you get a bad run like this. You have done nothing wrong, and you are not to blame. No-one could have saved them. Coincidences happen, and it's just awful luck that these two particular cases decided to crash on you during the same morning.

The fact that you are upset means that you care, and that is the most important thing. The day you stop caring is the day you should give up.

Re: What have I done wrong?!

Stephen Courtney — Mon, 30 Dec 2013 21:05:16 GMT

You should agitate for infusion pumps - they are a game changer. but you didn't do anything anyone else wouldn't have done.

You can't save everything, all you can do is your best, and that includes communicating well with the clients. Keep good, contemporaneous records and you will be fine. most clients are nice people and appreciate what you do.

Re: What have I done wrong?!

macflea — Mon, 30 Dec 2013 16:48:38 GMT

all i can say is well done , i probably would have recommended pts for both without doing anything. i am glad you kept good notes , as if there is a large bill i could see a client making a complaint to rcvs trying to wrangle out of paying it if they are not insured , they usually do ,you gave it 100 percent and did everything right , but the more you do for clients the more they will turn on you, accussing you of something so as not to pay. also beware of the client that is too nice cos they come with a sting. all i can say don't worry u are spot on .

Re: What have I done wrong?!

Glen McIntosh — Mon, 30 Dec 2013 09:42:28 GMT

Alternative explanations could include:

Neurogenic pulmonary oedema for the first.

Acute respiratory distress syndrome (ARDS) for the second (this can occur with severe pancreatitis).

Whatever the underlying disease process, I can't see anything that you have done wrong.

Re: What have I done wrong?!

Gillian Mostyn — Mon, 30 Dec 2013 08:06:18 GMT

I was thinking exactly the same - heart failure in 1st, ketoacaidosis/necrotising pancreatitis in 2nd.

Your calculations are fine- as long as amount actually given is the amount you had planned on giving (did you weigh the bags just to double check?) then you have done nothing wrong.

Oh, and a 26kg beagle.......

Re: What have I done wrong?!

Braden Collins — Mon, 30 Dec 2013 07:11:49 GMT

From a quick read through - doesn't sound like fluid overload. First one sounds like heart failure and second I would guess necrotising pancreatitis.

How much fluid had been administered over the time? I find it can be easy to mildly overload without a pump but it would have to be a pretty massive overload to kill animals of this size.