Ascites and SVT in a Labrador

RE: Ascites and SVT in a Labrador

Liz Barton — Thu, 31 Jan 2019 14:03:43 GMT

Hi all

Rather late to the party! Lots of head-banging emoji's I see. Always a sign of impassioned debate . Sadly, much of it not relating to the OP. Anthony Todd it would be better to form a tangent regarding your blind tap technique, allow the free flow of opinion on the subject there, and put it to bed (so to speak). Said thread could always be referenced, rather than repeating the debate under different subject topics.

Busy bee interesting case - I've had a very similar SVT which seemed to develop ascites overnight. Acute on chronic heart disease cases can destabilise quite dramatically once they tip over the precipice.

RE: Ascites and SVT in a Labrador

Thomas Johnson — Wed, 30 Jan 2019 08:38:27 GMT

[quote user="Anthony Todd"]I submit again that ultrasound, isn't as reliable as repeated taps only if needed.[/quote]

And I think this is where we will never agree, having done both blind taps and ultrasound guided taps I am much more successful at getting a sample with ultrasound guidance.

[quote user="Anthony Todd"]Some miss liver tumours apparently, which must be easier than 0.2ml or less of fluid.[/quote]

No, I would say it is easier to see even a small volume of free fluid than some small liver tumours.

RE: Ascites and SVT in a Labrador

Busybee — Tue, 29 Jan 2019 19:52:34 GMT

Just to clarify, the fluid was identified as a high protein content modified transudate.

She is not on any diuretics, just pimo, diltiazem and doxy. I haven't had the Holter results yet but I spoke to the owner today and she is doing great so I think they're hoping to manage her medically rather than implant a pacemaker straight away. The plan is to re-holter her in a few weeks.

RE: Ascites and SVT in a Labrador

Anthony Todd — Tue, 29 Jan 2019 19:17:18 GMT

I can only wish they had tried again and again 'cos I can't believe, with the benefit of hindsight, that a drop wasn't available. I submit again that ultrasound, isn't as reliable as repeated taps only if needed.

Some miss liver tumours apparently, which must be easier than 0.2ml or less of fluid.

I just hope people try it in future, guided or not, with or without ultrasound, rather than not having it's diagnostic pointers.

RE: Ascites and SVT in a Labrador

Thomas Johnson — Tue, 29 Jan 2019 18:39:36 GMT

[quote user="Anthony Todd"]

Trying not to prolong this but the whole point of an invasive tap is that, even if you only get a drop, you will get a vital indication, as to whether it is a transudate or exudate which governs, completely, and almost instantly, how you continue with the case.

A drop almost certainly would have been available, absolutely certainly before the exlap!!

[/quote]

Again, no one is arguing that analysis of the fluid wouldn't have given vital information, or that if a tap had been performed immediately before the ex-lap they would have got some fluid to analyse. The issue is that they had already scanned the dog twice and while they had seen some fluid it was too small an amount to aspirate, and if you can't aspirate it with ultrasound guidance you haven't got a hope of getting any with a blind tap (I will admit here to having been lazy in the past with animals I've been convinced have an abdominal effusion and tried a blind tap unsuccessfully but subsequently have got a sample using ultrasound guidance). Would any of us have expected the amount of effusion to have increased that quickly?

RE: Ascites and SVT in a Labrador

Anthony Todd — Tue, 29 Jan 2019 17:40:19 GMT

A drop almost certainly would have been available, absolutely certainly before the exlap!!

Minds far sharper than mine, I assume,and more after those brief references, should support this or refute it rather than tandemising it by spurious digression.

The case in question wholly supports my reasoning even though I have no wish to criticise the handling of the case, as I do not know ALL the circumstances.

RE: Ascites and SVT in a Labrador

Thomas Johnson — Tue, 29 Jan 2019 17:12:22 GMT

[quote user="Anthony Todd"]

OH FHS, I was talking about transudates or modified transudates with low SGs and the difference in SG and cause of exudates; it was you, I think, that tried to confuse things by introducing "modified" transudates.

Start again; transudates are, I suppose, "haemodynamic" whereas exudates are local, usually infections or tumour linked.

[/quote]

As far as I know no one is disagreeing with you that a lot of important information can be gained by examining an abdominal effusion, in-house haematology machines can even give you a cell count so you can quite quickly get additional information to just the SG. However this case is unusual in that when it was scanned there wasn't enough fluid to get a sample to analyse, but by the time it was operated on a larger volume had developed.

RE: Ascites and SVT in a Labrador

Anthony Todd — Tue, 29 Jan 2019 14:28:31 GMT

Start again; transudates are, I suppose, "haemodynamic" whereas exudates are local, usually infections or tumour linked.

Some of the references, so dismissed, did explain this. for emphasis this time.

RE: Ascites and SVT in a Labrador

Anthony Dennison — Tue, 29 Jan 2019 10:56:47 GMT

[quote user="Anthony Todd"]

Of course not, that's the whole point!

It would if it was, from the instant SG, an EXUDATE!

[/quote]

Then why keep on banging on about transudates and modified transudates to try and prove your point that a quick abdo tap would have meant starting diuretics earlier?

You've just switched the goal posts again, no proclaiming about exudates. Ever thought about going in to politics?

RE: Ascites and SVT in a Labrador

Anthony Todd — Tue, 29 Jan 2019 09:44:09 GMT

[quote user="Thomas Johnson"]And knowing that the fluid was a transudate (modified or not) wouldn't have allowed you to differentiate between cardiac and abdominal pathology.[/quote]

Of course not, that's the whole point!

It would if it was, from the instant SG, an EXUDATE!

RE: Ascites and SVT in a Labrador

Thomas Johnson — Tue, 29 Jan 2019 08:52:09 GMT

[quote user="Anthony Todd"]I would be surprised if the referee didn't use some diuretic in the treatment of obvious fluid build up, and hoping, as always, to be logically corrected rather than just denigrated for quoting references, or being out of date.[/quote]

This has now been diagnosed as a cardiac case so yes, diuretics are likely to be used. What I was trying to get at was that if the fluid had turned out to be due to abdominal pathology then you wouldn't necessarily use diuretics as they may not help get rid of the fluid. And knowing that the fluid was a transudate (modified or not) wouldn't have allowed you to differentiate between cardiac and abdominal pathology.

RE: Ascites and SVT in a Labrador

Alistair Graham-Evans — Tue, 29 Jan 2019 07:30:29 GMT

What a weird case. Supra-ventricular tachycardia when you saw it and no P waves at referral.

Wonder what the Holter will reveal ?

I would be careful with Diltiazem dosing if systolic dysfunction, possible sick sinus syndrome and a recent episode of ascites of presumed cardiac origin.

Saw a cat recently with sudden ascites and collapse but that resolved in 12 hours and was a presumed allergic reaction.

RE: Ascites and SVT in a Labrador

Anthony Dennison — Tue, 29 Jan 2019 07:16:21 GMT

I've read it. Just talks about what transudate and exudates are, doesn't talk about causes.

Also:

'Cautions - do not use in viscous fluids'

This fluid was pretty viscous, jelly-like was the term used. You've just used a Google search that has contradicted your argument.

RE: Ascites and SVT in a Labrador

Anthony Todd — Mon, 28 Jan 2019 23:15:58 GMT

i will be interested in seeing the treatment the dog gets from the referee for their diagnosed cardiac problem.

I would be surprised if the referee didn't use some diuretic in the treatment of obvious fluid build up, and hoping, as always, to be logically corrected rather than just denigrated for quoting references, or being out of date.

Here's another reference, just a page, so no need to cherry pick, although there is a summary, all of which seems, again, to support what I've been suggesting.

Let's hope someone reads this one before jumping in, but I doubt it.

https://www.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/8275

RE: Ascites and SVT in a Labrador

Thomas Johnson — Mon, 28 Jan 2019 15:27:05 GMT

[quote user="Anthony Todd"]

So what's being done about that massive amount of fluid in the abdomen and/or has it returned?

The diagnosis in principle, [as the SG would show it was a transudate], could have been made earlier after an abdo tap, with or without the help of ultrasound, which was all I was trying to get across.

Treatment with, at least, a diuretic would have started earlier.

[/quote]

I'm not sure I'd call 450ml in a labrador's abdomen massive, I drained 1,100ml from a cat's abdomen last week... And knowing the fluid was a transudate (or modified transudate if it's been present long enough to trigger an inflammatory response) wouldn't have necessarily have been enough information to know whether the cause was cardiac or abdominal pathology so wouldn't have allowed a diuretic to be started earlier.

RE: Ascites and SVT in a Labrador

Anthony Dennison — Mon, 28 Jan 2019 14:54:27 GMT

[quote user="Anthony Todd"]

Why? Here's a cherry pick in full!: [and first in google]

The result is a mild increase in both total protein (3.0-5.0 g/dl) and nucleated cell count (less than 5000/μl). When this occurs, the fluid is known as a modified transudate. Thus, modified transudates are nothing more than transudates which have been present long enough to illicit a mild inflammatory reaction.1 Aug 2009

[not my bold]

[/quote]

You've been advised previously against cherry picking. Just because you know the specific gravity of the effusion doesn't mean you know the cause. I notice you haven't tried to argue with my point about that...

[quote user="Anthony Todd"]

EBVM, I would have thought?

[/quote]

EBVM is appropriate research used in a meaningful way. Not jumping on google to find something that supports your dogma. Yes you might find that your dogma is right with plenty of supporting evidence, but not all the time (and rarely with your search criteria).

I'm starting to feel like Karl Pilkington's choice of superhero...

RE: Ascites and SVT in a Labrador

Anthony Todd — Mon, 28 Jan 2019 10:49:28 GMT

[quote user="Anthony Dennison"]Oh give it a rest.[/quote]

Why? Here's a cherry pick in full!: [and first in google]

[not my bold]

Cytology of effusions (Proceedings) - dvm360.com

veterinarycalendar.dvm360.com/cytology-effusions-proceedings-0

EBVM, I would have thought?

RE: Ascites and SVT in a Labrador

Anthony Dennison — Mon, 28 Jan 2019 10:29:38 GMT

Oh give it a rest. Heart failure would give a modified transudate, not a transudate. Just because you know the SG of a fluid from an abdominal cavity doesn't directly give you the diagnosis - could be multiple causes including liver failure.

Only type of abdominal tap that is 100% diagnostic is when you get blood, and even then it won't tell you which organ is bleeding just that you need to get in there.

RE: Ascites and SVT in a Labrador

Anthony Todd — Mon, 28 Jan 2019 09:45:33 GMT

[quote user="Busybee"]There was a mild to moderate amount of free fluid in the abdomen. [/quote]

So what's being done about that massive amount of fluid in the abdomen and/or has it returned?

Treatment with, at least, a diuretic would have started earlier.

RE: Ascites and SVT in a Labrador

Busybee — Sun, 27 Jan 2019 20:03:07 GMT

Hi all! I'm not going to wade into the 'discussions' above , but I can provide you with the referral report....

At referral, her heart rate was normal with good pulses and a respiratory rate of 40/minute. The rest of the exam was normal.

Echo showed a normal left ventricle with an abnormally positioned papillary muscle. There was evidence of systolic dysfunction and both the left and right atria were mildly enlarged. There was mild mitral and tricuspid regurgitation. The ECG showed a ventricular rhythm without obvious P waves and therefore suspected atrial standstill, persistent sino-atrial block or accelerated idioventricular rhythm.

There was a mild to moderate amount of free fluid in the abdomen.

Suspected diagnosis - atrial myocardial disease with secondary atrial standstill.

She was discharged with a Holter (results pending) and on doxycycline (to treat possible myocarditis), diltiazem and pimobendan and depending on the Holter results, may require a pacemaker.

They haven't ruled out any other concomitant systemic disease.

Hope this helps!

RE: Ascites and SVT in a Labrador

Anthony Todd — Fri, 25 Jan 2019 17:28:42 GMT

[quote user="Anthony Dennison"]confronted with over 450ml....[/quote]

Does anyone really believe that that 450mls of fluid, and with any physiology of any animal or human, ie not a ruptured bladder, for example, could accumulate in that time period of some 4 hours?

I believe the fluid, or most of it, was not picked up on the earlier scan, and this is without criticism of anyone.

I'm happy to be contradicted, hopefully with experimental or other actual evidence.

If [experienced?] operators can pick up or miss liver tumours then it seems possible that fluid can be missed?

This Ultrasound. 2017 May; 25(2): 69–79. suggests I'm wrong though, but no discussion of volumes, mainly small...

This J Ultrason. 2017 Jun; 17(69): 96–100. suggests that you still need to look at the fluid sooner or later anyway?

RE: Ascites and SVT in a Labrador

Anthony Dennison — Fri, 25 Jan 2019 15:42:46 GMT

[quote user="Busybee"]The 1st scan was done around 7pm Saturday evening and there was no free fluid; the second scan was done 9 am Sunday morning and a small amount was seen (a pocket of around 1x2cm next to the spleen); the last scan was done around 1pm and slightly more fluid was seen (around 2x2cm pocket). We went to surgery around 5pm and were confronted with over 450ml....[/quote]

RE: Ascites and SVT in a Labrador

Anthony Todd — Fri, 25 Jan 2019 15:38:57 GMT

[quote user="Anthony Dennison"]Read back in the thread - Busybee mentioned multiple scans where fluid build up was documented. [/quote]

I did read this:

[quote user="Busybee"]Any ideas?? ps. this fluid developed v quickly (ie. no fluid on scan last night, 450ml found at ex-lap this afternoon)[/quote]

and I could only find one ultrasound reference as above.

But then ultrasounds never get it wrong... I don't need the modern emoje thingies

Surely "450ml" would have been suspected if the abdomen was percussed, or even use the old Mk1 eyeball, but actually doing things so old-fashioned never seems to be mentioned on vs.org

I emphasise I am not being personally critical, only trying to help in the future, others may have [and probably did] influence the decision-making in this case and I'm sure ultrasound interpretation is a skill.

PS I have given these recurring arguments a lot of thought and I reckon, BITD, dinovets skipped the "diagnosis" or sort of didn't recognise it, and went straight to the treatment unless, as in this case a test, simply obtained influenced the treatment vitally, completely, quickly and cheaply.

[I'd never scrape obvious scabies for instance] NOT A TANGENT!!

RE: Ascites and SVT in a Labrador

Anthony Dennison — Fri, 25 Jan 2019 14:32:57 GMT

[quote user="Anthony Todd"][Lots of references to ultrasound accuracy, and the accuracy even for solid masses, eg liver isn't 100%...][/quote]

We're not talking about solid masses. We're talking about fluid. And ultrasound is very sensitive at detecting fluid. You've done your usual 'I'm losing an argument, quick change the goalposts slightly and Google for a study I can use in my argument'.

[quote user="Anthony Todd"]

[quote user="Anthony Dennison"] Why stab a needle into an animal if you don't have to? [/quote]

Because it will, and can, and did, give you vital info, via even a drop or two!

[/quote]

You didn't read what I put. If there's no fluid (which ultrasound will show), there's no point sticking a needle in.

[quote user="Anthony Todd"]Do you really believe, in this case there really really wasn't any fluid in the abdomen at the time of the ultrasound? I mean not a drop....?[/quote]

THERE WAS FLUID DETECTED ON ULTRASOUND

Read back in the thread - Busybee mentioned multiple scans where fluid build up was documented.

[quote user="Anthony Todd"]But, as I said, now that ultrasound is available, why not use it plus a guided tap.[/quote]

No, you said you would do a blind tap and then use ultrasound. I called you up on it and you didn't answer it, just repeated about what you did BITD.

[quote user="Anthony Todd"]Remember however you find the fluid, you've still got to decide the why it's there![/quote]

One thing we can agree on - and the OP posted on here to try and figure out what the cause could be. Unfortunately the thread has been derailed by me not letting you off another 'I used to do it this way and I won't hear anything otherwise' post.

[quote user="Anthony Todd"]BTW, BITD I, and I'm sure someone told me, used to use a blood urea test strip to decide if suspicious abdominal fluid after, say, a road accident was urine from a ruptured bladder [also in suspiciously blocked cats].[/quote]

Yes, you can do that. We don't have any urea sticks in so we normally just run it through our bloods machine. If urea/creatinine or potassium is higher in the fluid than in blood it's likely a ruptured bladder.

Same as if you check the glucose of abdominal fluid and compare it to blood glucose - if the former is higher it's probably peritonitis.

RE: Ascites and SVT in a Labrador

Anthony Todd — Fri, 25 Jan 2019 14:20:15 GMT

[quote user="Anthony Dennison"]That may have been the case in your day Tony, however with these newfangled ultrasound machines I can get a lot of information without having to stick a needle into an animal. Less pain for the animal, less risk of complications.[/quote]

Ironic, IMHO, that the thread had a "negative" ultrasound and then in 24 hours of fluid, 450ml, in the abdomen, on a negative ex-lap....but I didn't want to press this although the SG might have pointed to CHF which was my guess at the start.

[quote user="Anthony Dennison"] Why stab a needle into an animal if you don't have to? [/quote]

Because it will, and can, and did, give you vital info, via even a drop or two!

[quote user="Anthony Dennison"]If you think you can get fluid from a blind tap when ultrasound hasn't showed any fluid present, I honestly think you're deluded. [/quote]

Do you really believe, in this case there really really wasn't any fluid in the abdomen at the time of the ultrasound? I mean not a drop....?

[Lots of references to ultrasound accuracy, and the accuracy even for solid masses, eg liver isn't 100%...]

But, as I said, now that ultrasound is available, why not use it plus a guided tap.

Remember however you find the fluid, you've still got to decide the why it's there!

BTW, BITD I, and I'm sure someone told me, used to use a blood urea test strip to decide if suspicious abdominal fluid after, say, a road accident was urine from a ruptured bladder [also in suspiciously blocked cats].

The positives saved the day occasionally and sometimes the patient.