URGENT - Propofol CRI dose

RE: URGENT - Propofol CRI dose

Anthony Dennison — Fri, 14 Jul 2017 10:05:20 GMT

Interesting to read all this and the discussion it has started. Update on the case - dog had no further seizures over the next 24 hours so was discharged yesterday.

[quote user="Malcolm Ness"] In young patients with no other neurological signs, the diagnostic yield of MRI is low. The yield of useful information (i.e. something that will let you usefully change your management plan) is lower still.[/quote]

Yes, you are right and I did suspect it was just a refractory epilepsy or the dose wasn't quite high enough, but the dog didn't appear neurologically normal in the interictal period at the start, which is why I was considering an MRI; normally wouldn't even bother. Turned out it was just affected by the higher dose of meds.

Interestingly enough, had a 7 year old boxer present with seizures which then had breakout seizures. He had an MRI - really big mass compressing the one of the lateral ventricles. But that's a different clinical scenario altogether.

RE: URGENT - Propofol CRI dose

David Mills — Fri, 14 Jul 2017 01:16:03 GMT

I do always wonder how many SE dogs specialists actually see... Given there's a particular disposition for fits to happen at night when dogs are relaxed....

RE: URGENT - Propofol CRI dose

mariette asselbergs — Fri, 14 Jul 2017 00:36:07 GMT

And here are my notes of Clare Rusbridge's lecture on Emergency management of seizures at thisyear's VETfestival:

Status epilepticus can be convulsive and non-convulsive. Both life threatening. Non-convulsive suspected if 30 mins after seizure “ends” the patient doesn't wake up. Treat with anaesthetic coma!
Ketamin (NMDA recptor antagonist) very effective
Diazepam short time effect, and decreased effect if already seizuring. Repeating is useless.
Oxygen!
Venous access: bloods. Often hyperglycaemic. If hypo, then suspect insulinoma. Keep sample to check for phenobarb levels.
Metabolic acidosis, if 7.1 then treat with bicarbonate.
Cautious IVF! Risk if increased ICP.
Mannitol or hypersat saline often appropriate
Phenobarb still best but takes 20 mins to work.
Pexion not licensed for status or cluster seizures
Dexdomitor very good, can be given im, but not licensed. They are asleep not unconscious! 0.5mcg/kg with max of 500mcg/kg in dogs, 40mcg/kg in cats. If too bradycardic, then give ¼ dose of atipamazole.
Propofol cri with 6-24mg/kg/hr. But at risk of benzyl alcohol toxicity after 9 hrs max dose. Check for Heinz body anaemia.
Ketamine lowers ICP, is not neurotoxic and very safe (and cheap). 60 mg in 500 ml bag give at 1 ml/kg/hr.
Levatiracetam 10-20mg/kg iv or im. Neuroprotective but do not combine with diazepam! Use only as add on on top of (increased) levels of phenobarb and other s (bromide, pexion)
In cats susp of pemethrin add metoclopromide and wash the cat. Intralipid most effective.
But think in cats also of toxoplasmosis!
In people they use a ketogenic diet and high dose vitamin B.
Gabapentin does not work!
Trick of despair: stimulate the vagal nerve will help (pressure on eyes)
Possible usefulness of dormetor oral gel.
Diazepam rectal variable effect, but intranasal good (but difficult in status).

RE: URGENT - Propofol CRI dose

mariette asselbergs — Thu, 13 Jul 2017 22:29:28 GMT

Collin Driver at this year's VETfestival had two tricks: 1) The use of paediatric oral levatiracetam rectally for cluster/refractory seizures. Much more effective than diazepam which doesn't work once seizures have started.

And 2) for refractory seizures a CRI of medetomidine with or without ketamine but after a loading dose of phenobarbital. (Phenobarbital takes at least 20 minutes to start working) This seems to be very safe and effective and much cheaper than propofol.

I once kept a seizuring St Bernard on a propofol CRI overnight. I kept him just deep enough to stop seizuring, he was very drowsy but conscious, and I did like it, but I remember the cost was something like £500 just for the propofol!!!

I have lately been impressed with the effect of levatiracetam for clusters and status.

Do you guys also always get at least 3 more seizuring patients once you have one in? Lunatic?

Mariette

RE: URGENT - Propofol CRI dose

David Mills — Thu, 13 Jul 2017 00:17:10 GMT

[quote user="Neil Wheadon"]

[quote user="David Mills"]If after 6 hours fitting again, normally buggered. [/quote]

Which fits sagatal doesn't it? It was easy, if they woke up after 6 hours and fitted, PTS. If didn't fit, carry on, that rational worked very well in many cases of mine (I attract fitting dogs)

Neil

[/quote]

There's an obvious joke in there that I won't say, because your wife also on here... And I'm sure she isn't.

Yep you have to remember my age, despite my wisdom, but sounds sensible.

I think a lot of the pentobarb went off the market after it was discovered the biggest industry for it was export to America for the death penalty about 10years ago.

Interesting aside here

https://www.spectator.co.uk/2017/07/dr-death-and-his-50-suicide-workshops/

RE: URGENT - Propofol CRI dose

Neil Wheadon — Thu, 13 Jul 2017 00:04:27 GMT

[quote user="David Mills"]If after 6 hours fitting again, normally buggered. [/quote]

Which fits sagatal doesn't it? It was easy, if they woke up after 6 hours and fitted, PTS. If didn't fit, carry on, that rational worked very well in many cases of mine (I attract fitting dogs)

Neil

RE: URGENT - Propofol CRI dose

David Mills — Wed, 12 Jul 2017 23:29:37 GMT

Medetomidine in these dogs can work quite well. Jury is out whether its a true anti seizure med but it does stop the shaking and deleterious effects of high temp etc.

Levetiracetam has some low level evidence iv in these dogs, think about 80pc will stop. I find diazepam almost useless so always co admin with phenobarb. Ketamine shows promise in humans and can be cri.

Dont worry about propofol doses, most anecdotal, basically anaesthetise and wake up slowly over 6 hours and buy the poor nurse a bottle of whisky next day.

If after 6 hours fitting again, normally buggered.

Remember a cpd course (Mark Lowry) which said fits are either in the brain or blood getting to the brain. If no systemic disease then bloods are academic. After that about >99% will be idiopathic epilepsy. Makes sense really.

RE: URGENT - Propofol CRI dose

Evelyn Barbour-Hill — Wed, 12 Jul 2017 22:08:08 GMT

[quote user="jamie winstone"]I am convinced the colour of the solution puts most people off when the alternative for a cost conscious client is termination.[/quote]

Use the pink one?

RE: URGENT - Propofol CRI dose

jamie winstone — Wed, 12 Jul 2017 21:54:50 GMT

I have used Pentobarbitone(euthatal) on many occasions in status epilepticus, always diluting it first and then giving enough to achieve total anaesthesia. It has saved many lives and allows both the owner and the vets to take stock when instant irreversible decisions are sometimes made. Often diazepam doses have been given many times first with no improvement.

I am convinced the colour of the solution puts most people off when the alternative for a cost conscious client is termination.

RE: URGENT - Propofol CRI dose

janine redman — Wed, 12 Jul 2017 21:47:53 GMT

Did like saggatal as meant you could sleep for a bit in the days before overnight nurses on duty, syringe drivers and drip pumps!

RE: URGENT - Propofol CRI dose

Eilidh Corr — Wed, 12 Jul 2017 21:39:19 GMT

Sagatal was preferred because you could give it and go to bed

RE: URGENT - Propofol CRI dose

Neil Wheadon — Wed, 12 Jul 2017 21:15:14 GMT

I can concur with Malcolm on this

Anecdotally (I realise this isn't great) I asked a nurse who had worked in a centre that did a lot of these and asked how many lesions had been found in young dogs.

None was the reply

It's an area that I would think twice, neh three times, before suggesting referral for advanced imaging

Neil

RE: URGENT - Propofol CRI dose

Malcolm Ness — Wed, 12 Jul 2017 20:30:36 GMT

Vet J. 2008 Jun;176(3):320-5. Epub 2007 May 11.

Findings on low-field cranial MR images in epileptic dogs that lack interictal neurological deficits.

Smith PM1, Talbot CE, Jeffery ND.

Author information

Abstract

Recurrent seizuring is a common neurological problem in dogs and can present diagnostic difficulties for the attending clinician. Associated interictal neurological deficits strongly suggest brain disease but the frequency of structural abnormalities in patients without such deficits is unknown. In this study the prevalence of clinically significant magnetic resonance imaging (MRI) abnormalities was determined in two groups of interictally normal dogs, those younger than 6 years and those older than 6 years of age. In the former group, only 1/46 dogs (2.2%) had significant MRI abnormalities, whereas in the latter group, 8/30 (26.7%) were abnormal. None of the dogs had an identifiable metabolic cause for the seizures. These findings suggest that the diagnostic yield of advanced neuroimaging techniques in young seizuring dogs without interictal neurological deficits is low, but reaffirms their value in similar older individuals.

RE: URGENT - Propofol CRI dose

Nicola Cole — Wed, 12 Jul 2017 20:28:13 GMT

Sagatal was great! I personally haven't used euthatal but I know of vets who have used it (with signed consent from owner and potential pit falls explained) to good effect.

RE: URGENT - Propofol CRI dose

Malcolm Ness — Wed, 12 Jul 2017 20:24:59 GMT

[quote user="Anthony Dennison"]refer for a brain MRI.[/quote]

I would suggest doing a very careful neurological exam and then reading ?? Nick Jeffrey's paper that looked at the diagnostic yield of brain MRI in fitting dogs. In young patients with no other neurological signs, the diagnostic yield of MRI is low. The yield of useful information (i.e. something that will let you usefully change your management plan) is lower still.

RE: URGENT - Propofol CRI dose

vetbl.locum — Wed, 12 Jul 2017 19:24:32 GMT

Several hundreds of pounds!!!

real shame Sagatal was withdrawn

Anyone used Euthatal instead?

Rgds

RE: URGENT - Propofol CRI dose

Thomas Johnson — Wed, 12 Jul 2017 16:50:26 GMT

[quote user="Neil Wheadon"]27 years ago, we used to use Pentobarbitone (you could/can?) get a sterile version. The dogs used to sleep for about 6 hours after which many recovered (meaning didn't start fitting again) [/quote]

Sagatal was the trade name, I think it was withdrawn about 12 or 13 years ago, which was a real shame as it was very useful for status epilepticus.

RE: URGENT - Propofol CRI dose

Neil Wheadon — Wed, 12 Jul 2017 16:41:57 GMT

This is areal Dinovet question but......

27 years ago, we used to use Pentobarbitone (you could/can?) get a sterile version. The dogs used to sleep for about 6 hours after which many recovered (meaning didn't start fitting again)

What's the difference between this and a propofol CRI?

Neil the dinosaur

RE: URGENT - Propofol CRI dose

Anthony Dennison — Wed, 12 Jul 2017 15:02:43 GMT

Thanks for all the information. Dog woke up over the course of an hour, nice and slowly. Couple of very short seizures - over by the time the on call vet could get to her they were over.

Started on levetiracetam this morning and upped the pheno dose. She's a bit wobbly today, not sure if that's because all of the meds or abnormal inter-ictal period, so on seizure watch today, if no further seizures home for monitoring and potentially refer for a brain MRI.

RE: URGENT - Propofol CRI dose

janine redman — Wed, 12 Jul 2017 00:08:14 GMT

We have done a few and the dose depends on how much midazolam and phenobarbital the patient has had. On a couple we have woken them enough to load them with phenobarbital orally when injection form not available and then if they showed signs of seizure get them straight back to sleep. Border collies are sometimes very refractory to phenobarbital and additional drugs sadly.

And if possible DNA profiling to the AHT may help their research into epilepsy.

RE: URGENT - Propofol CRI dose

Busybee — Tue, 11 Jul 2017 21:46:46 GMT

Hi Anthony,

I've resorted to a propofol CRI a few times. I know a couple have been euthanised despite our efforts due to recurrent seizuring, which I believe isn't unusual as by the time you're using propofol, they tend to be quite far gone. But I have recovered a few successfully. Some of these have needed to be under a propofol CRI for 24hours.

From my last CPD, the doses are...

2-4mg/kg (0.2-0.4ml/kg) bolus to effect
Then 6-24mg/kg/hr (0.6-2.4ml/kg/hr) to achieve heavy sedation but so the animal is still self ventilating.

I really like midazolam CRIs too at 0.1-0.3mg/kg/hr.

With any CRI, maintain for 6hrs then taper by 50%

Never tried it in a status situation but apparently Keppra injectable is great!

RE: URGENT - Propofol CRI dose

Anthony Dennison — Tue, 11 Jul 2017 17:35:58 GMT

Thankyou. Dog started to wake a little on 6mg/hr, so we've increased to 8mg/hr (2.5mg/kg/hr) and she's settled on this. Will be waking her up in about an hour - apparently we have injectable levetiracetam somewhere in the building, but I can't find it!

RE: URGENT - Propofol CRI dose

Emily Rainbow — Tue, 11 Jul 2017 17:35:49 GMT

I tend to titrate down slowly and monitor for signs of seizures. Hopefully your pheno would have kicked in by the time you really wean down. Any access to Keppra? Can also be useful.

i tend to find you can wean them off ok, or you can't, or they just don't wake up TBH.

RE: URGENT - Propofol CRI dose

Julie Innes — Tue, 11 Jul 2017 15:23:21 GMT

Sorry, Anthony, I have used it once, but can't remember what dose rate (I think we would have used the BSAVA one). If your dog is nice and stable, that sounds good! Hope it goes well when you wake her up. I think from memory we gradually reduced the dose rate and monitored for any recurrence of seizures. From recollection, though, the dog continued to go into cluster seizures over the next few weeks, and was euthanased as the owners were struggling to cope. Hope yours has a happier outcome!