ALKP raised on pre-anaesthetic blood sampling - what do you do?

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Anthony Todd — Fri, 23 Oct 2015 17:46:46 GMT

[quote user="Luca Poddighe"]Must be trichinella...[/quote]

Thanks; you can't imagine the antagonism that created, much worse than than the rugby World Cup!

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Luca Poddighe — Fri, 23 Oct 2015 16:25:08 GMT

[quote user="Anthony Todd"][forgotten the name][/quote]

Must be trichinella...

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Rob Loxley — Thu, 22 Oct 2015 17:37:01 GMT

[quote user="Neil Wheadon"]I can't prove it's heartworm but strongly suspiscious[/quote]

The idexx inhouse antiodetect tests work out pretty cheap; if I was in a lungworm endemic area I'd be inclined to consider preop testing

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Anthony Todd — Thu, 22 Oct 2015 16:37:16 GMT

[quote user="Robin Grimmer"]No-one is doing bloods on day 1 of a simple diarrhoea. [/quote]

There have been no diagnostic tests performed yet

I will definitely start with a diagnostic blood profile, and eliminating diet.

Seems like it, in this one, but I may have misunderstood,

I'm on the modvets side though! With stats, it might be shown that x% of animals having "a simple D+" may have Y% chance of having something serious or stats may show that it is only 000001%.

Simple survey to see number of "positive" routine bloods ie that turn up something potentially serious, and not necessarily for the GA, but anything.

You may even be able to trim the tests to the really significant ones, er, ALP mightn't be on the list....

We've already had some significant anecdotal evidence posted; more would make the case for routine bloods a sensible, cost effective option ie before it becomes clinically or ownery apparent.

" in a survey of X clinically normal dogs and/or cats Y% showed evidence of a potentially serious condition. This practice advises a blood screen every ..... in dogs and cats over....."

If anyone moans, show 'em the stats and say "but it's up to you".............

The anecdotes so far have opened my eyes.

Trouble is the human papers don't seem to support the idea and I can't find any pet ones.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Robin Grimmer — Thu, 22 Oct 2015 15:48:22 GMT

[quote user="Clive Ansell"]

[quote user="Robin Grimmer"]

The steroids are the cause of the high ALP in this case, so wouldn't be any point investigating it anyway.

[/quote]

The most likely cause, by far, I agree, but other differentials cannot be totally excluded without further investiagtion. Would have liked a BAST at least, inexpensive and minimally invasive.

[/quote]

It would be meaningless while still on the preds. They could be causing iatrogenic cushings and you might well have moderately increased bast results. You'd need ideally to stop the preds and then check alp etc later. But I realise this might not be possible. In this case I wouldn't be concerned about the alp and the preds and would go ahead with the dental. If it was say having a mastectomy, I might be concerned re wound healing.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Robin Grimmer — Thu, 22 Oct 2015 15:40:01 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]Yes - many practices are offering bloods and/or urine tests on healthy animals as part of a preventative health scheme - usually on seniors. [/quote]

Yep, I see that totally, and the posts on this thread have given the argument even more weight.

[quote user="Robin Grimmer"]you often seem quite scathing of them.[/quote]

Yes I am when what is almost certainly a simple condition and solution, like diarrhoea, has bloods on day one which appears to be the only diagnostic aid given weight. [this isn't personal, I emphasise!!!]

[/quote]

No-one is doing bloods on day 1 of a simple diarrhoea. As I've said before, if they're posting on here, it isn't a simple case so they are going to do a work up which will include bloods.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Anthony Todd — Thu, 22 Oct 2015 14:29:48 GMT

[quote user="Clive Ansell"]Arguably, among the most risky pathologies for routine surgeries must be coagulopathies and electrolyte imbalances. Should we therefore be offering routine screening for electrolytes and clotting times?[/quote]

Yes, if you can back up the risks with statistics, 'cos the public will reckon it is just a gouge without them.

The irony, and that includes me, is that if you don't look you'll never find.

[Australia stopped the import of Landrace pigs from NZ back in the day when they were worth thousands for breeding because Ruakura, the best diagnostic LA centre in the world!! found some dangerous worm in the diaphragm [forgotten the name]'

Oz started looking and had them everywhere in spades!!

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Clive Ansell — Thu, 22 Oct 2015 14:25:43 GMT

[quote user="Robin Grimmer"]

The steroids are the cause of the high ALP in this case, so wouldn't be any point investigating it anyway.

[/quote]

The most likely cause, by far, I agree, but other differentials cannot be totally excluded without further investiagtion. Would have liked a BAST at least, inexpensive and minimally invasive.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Clive Ansell — Thu, 22 Oct 2015 14:20:07 GMT

[quote user="Neil Wheadon"]Now aside from scaring everyone that maybe we ought to add Haematology to a screen, all we can do is offer something but try to put sensible and rational arguements forward and let the owner decide. Isn't that what we should be doing these days as professionals?[/quote]

Arguably, among the most risky pathologies for routine surgeries must be coagulopathies and electrolyte imbalances. Should we therefore be offering routine screening for electrolytes and clotting times?

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Neil Wheadon — Thu, 22 Oct 2015 14:03:00 GMT

[quote user="Robin Grimmer"]Yes - many practices are offering bloods and/or urine tests on healthy animals as part of a preventative health scheme [/quote]

Here's an unusual and interesting example from this morning.

4 year old Alaskan Malamute for a spay.

Offered pre-anaesthetic bloods and accepted last week.

Eosinophils were 4.15x10/9 (0.06-1.23)

Decided to abort the spay and Advocate as heartworm/blood everywhere/42kg bitch, not great

Today 1 week later

Eosinophils 2.98

I have advised and this has been accepted that 2 Advocate treatments are needed to get a 95% kill, so operation was postponed and will resample before spay.

I can't prove it's heartworm but strongly suspiscious

Now aside from scaring everyone that maybe we ought to add Haematology to a screen, all we can do is offer something but try to put sensible and rational arguements forward and let the owner decide. Isn't that what we should be doing these days as professionals?

Neil

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Anthony Todd — Thu, 22 Oct 2015 14:00:02 GMT

[quote user="Robin Grimmer"]Yes - many practices are offering bloods and/or urine tests on healthy animals as part of a preventative health scheme - usually on seniors. [/quote]

Yep, I see that totally, and the posts on this thread have given the argument even more weight.

[quote user="Robin Grimmer"]you often seem quite scathing of them.[/quote]

If you use the argument I postulated ie bloods should be done on every animal, say annually, because you will discover X% of occult serious conditions earlier than when clinical signs become obvious then I see the point completely.

Humans medicos don't support this idea, from some papers, but I get the feeling that it is on cost grounds mainly, although you wonder whether it is cheaper to give metformin for diabetes for a long time and not pay to amputate a leg later...?

I have had 2 recent GAs without bloods BTW.

Some stats from modern PMS systems should squash the "more money for you vets" brigade because the examples posted certainly surprised me, and with statistical support, the rationale and health benefits for pets becomes a no-brainer and not a revenue stream.!

Would this not be a service to offer with a booster or a dental?

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Robin Grimmer — Thu, 22 Oct 2015 13:56:30 GMT

[quote user="Clive Ansell"]

I've had a similar case this week. pre anaesthetic bloods for a dental in a 10 year old WHWT showed an ALKP of 1669 (23-212), all other parameters normal. Been on preds for years for Westie skin, and owners frequently change dose. The dog has had dental disease since 2011, so given it has taken 4 years to get the thing booked in I put him on IVFT and carried out the procedure. Dog clinically well otherwise and all further investigation declined

[/quote]

The steroids are the cause of the high ALP in this case, so wouldn't be any point investigating it anyway.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Clive Ansell — Thu, 22 Oct 2015 13:52:34 GMT

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Robin Grimmer — Thu, 22 Oct 2015 13:11:27 GMT

[quote user="Anthony Todd"]

[quote user="Neil Wheadon"]I have known 2 cats in the past year have renal dysplasia picked up by blood testing before neutering. That's from asking a lot of questions in about 30 locum practices. So do you test everything?[/quote]

Extrapolating the data it sounds as if there would be a case for bloods on everything, boosters and consults for any reason, say, annually.

[/quote]

Yes - many practices are offering bloods and/or urine tests on healthy animals as part of a preventative health scheme - usually on seniors. Often the nurses see these. Also presurgery blood tests are routinely offered. I don't understand your opposition to blood tests, you often seem quite scathing of them. If owners want to them run, and are willing to pay for them, what's the problem? If normal then great, puts their minds at rest, if not then you've picked up something early.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Anthony Todd — Thu, 22 Oct 2015 12:39:26 GMT

Extrapolating the data it sounds as if there would be a case for bloods on everything, boosters and consults for any reason, say, annually.

Not being a troll at all, or a smart-a, but if you divide the "ops" into the annual client visits the profession must be missing, what 5-10 times these important conditions?

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Neil Wheadon — Wed, 21 Oct 2015 16:05:00 GMT

[quote user="Robin Grimmer"]Test for Cushings, also do urinalysis as would expect low SG with Cushings and culture if indicated.[/quote]

OK spoke to the owner and we shall do this

SG first then hopefully Cushings test

I'm locumming but returning in 3 weeks so will try to update

Neil

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

bob lehner — Wed, 21 Oct 2015 15:58:14 GMT

I'm sure you will have checked - but has it recently been on any meds ? Lots of things can raise AlkP.

(I remember once getting very excited about a similar case, but had failed to notice a previous prescription for preds).

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Anthony Todd — Wed, 21 Oct 2015 15:53:35 GMT

[quote user="Neil Wheadon"](I saw a run of post dental cats dying of renal failure recently that weren't tested.)[/quote]

Wow, that statement needs amplification. I would say that dying old cats after a dental or a GA were really rare let alone"a run" of them"??

Got to be something else going on.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Robin Grimmer — Wed, 21 Oct 2015 15:30:14 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"] If that isn't an argument for doing bloods (and urine) in outwardly healthy animals then I don't know what is.[/quote]

Yep, touche, but you'd still be in the same boat without the previous normal one or don't you ever diagnose anything without a previous "normal" result?

A raised value is still raised whatever the previous one was.

[/quote]

It wasn't as black and white as that. The previous bloods showed a mild increase in urea, but urine SG was1.045. The urea had gone up slightly this time, but urine SG was now 1.014, a big change in 6 months. Also, it's helpful to show trends. Eg if the urea and creatinine have increased but still may be within the 'normal' range.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Anthony Todd — Wed, 21 Oct 2015 15:22:27 GMT

[quote user="Robin Grimmer"] If that isn't an argument for doing bloods (and urine) in outwardly healthy animals then I don't know what is.[/quote]

Yep, touche, but you'd still be in the same boat without the previous normal one or don't you ever diagnose anything without a previous "normal" result?

A raised value is still raised whatever the previous one was.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Robin Grimmer — Wed, 21 Oct 2015 15:19:20 GMT

[quote user="Neil Wheadon"]

Hot off the E Mail

Now what? (I'm asking because I'm curious)

Results from IDEXX

Test Result Alert Units Reference Range

*Total Protein 64.5 g/L 54.9 - 75.3

*Albumin 32.4 g/L 26.3 - 38.2

*Globulin 32.1 g/L 23.4 - 42.2

*AG Ratio 1.01 0.70 - 1.40

*Urea 5.0 mmol/L 3.1 - 10.1

*ALT (SGPT) 37 C 35.2 U/L 19.8 - 124.0

*Alk. Phosphatase 37 C 1889.0 High U/L <= 130.0

*Gamma GT 37 C 6.7 U/L 2.5 - 10.6

*AST (SGOT) 37 C 25.0 U/L 10.0 - 50.0

*Total Bilirubin 1.0 umol/L 0.1 - 4.2

*Bile Acids (fasting) 0.7 umol/L 0.1 - 5.0

*Bile Acids (post fatty 2.1 umol/L 0.1 - 10.0

meal)

*Cholesterol 6.98 High mmol/L 3.20 - 6.20

*Glucose 6.3 mmol/L 3.6 - 7.0

[/quote]

Test for Cushings, also do urinalysis as would expect low SG with Cushings and culture if indicated. Assuming you can rule out otner causes of high ALP eg non liver causes, drugs then do a scan.Nodular hyperplasia in the liver of older dogs can cause increase in ALP but is a benign lesion.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Anthony Todd — Wed, 21 Oct 2015 15:16:15 GMT

[quote user="Neil Wheadon"] The classic is the blocked cat I saw this morning, if it has a raised creatinine do I not unblock the bladder[/quote]

Of course you do but you don't wait for the [K+] before you start, as a post sometime ago suggested! Doing them a week later would be sensible rather than doing them at the time; you're still going to unblock the cat.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Neil Wheadon — Wed, 21 Oct 2015 15:11:26 GMT

Hot off the E Mail

Now what? (I'm asking because I'm curious)

Results from IDEXX

Test Result Alert Units Reference Range

*Total Protein 64.5 g/L 54.9 - 75.3

*Albumin 32.4 g/L 26.3 - 38.2

*Globulin 32.1 g/L 23.4 - 42.2

*AG Ratio 1.01 0.70 - 1.40

*Urea 5.0 mmol/L 3.1 - 10.1

*ALT (SGPT) 37 C 35.2 U/L 19.8 - 124.0

*Alk. Phosphatase 37 C 1889.0 High U/L <= 130.0

*Gamma GT 37 C 6.7 U/L 2.5 - 10.6

*AST (SGOT) 37 C 25.0 U/L 10.0 - 50.0

*Total Bilirubin 1.0 umol/L 0.1 - 4.2

*Bile Acids (fasting) 0.7 umol/L 0.1 - 5.0

*Bile Acids (post fatty 2.1 umol/L 0.1 - 10.0

meal)

*Cholesterol 6.98 High mmol/L 3.20 - 6.20

*Glucose 6.3 mmol/L 3.6 - 7.0

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Robin Grimmer — Wed, 21 Oct 2015 15:08:12 GMT

Well I've picked up many early kidney cases in older cats in for dentals etc which were showing no signs whatsoever. Recently I picked up an early kidney case in a dog in for a dental, and the dog had had bloods and urine done 6 months previously so I had those to compare it to - brilliant. Now the urine sg was isosthenuric, but the owner wasn't aware of any pupd. Urine culture showed a UTI. So not only have we picked up an early kidney case, but we've found something treatable and potentially reversible. If that isn't an argument for doing bloods (and urine) in outwardly healthy animals then I don't know what is.

RE: ALKP raised on pre-anaesthetic blood sampling - what do you do?

Anthony Todd — Wed, 21 Oct 2015 14:59:14 GMT

[quote user="Anthony Dennison"]Abdominal palpation/scan revealed a closed pyo[/quote]

Sorry, not being mean, but couldn't that have been picked up before the bloody prompt?

[quote user="Anthony Dennison"] And if they're not lying they can be incredibly unobservant.[/quote]

Tell me about the chemist who, when specifically asked how much water the dog was drinking, said "a saucepan full".....

[quote user="Anthony Dennison"] I don't think I'm a poorer vet if I want to do further investigations.[/quote]

Of course not, but I'm talking about animals that are normal, totally eg C/S or castrations.

You talk about "further investigations" and sure, those are the ones where they're obviously needed, but I'm talking about PABs 'cos "we always do them".