Severe fatal HGE cases

RE: Severe fatal HGE cases

Kate Richardson — Sun, 15 Dec 2019 08:42:58 GMT

[quote user="Emily Rainbow"]

Just discussed this for my cert. the steroid induced hyperglycaemia can induce essentially fluid overload as the fluid is drawn into the blood stream increasing pressure on cats with sub clinical cardiac disease.

interesting there is a paper showing PO anti-inflammatory pred is less likely to induce this vs methylpred depo injection.

steroid induced cardiomyopathy should respond well to oxygen, diuretics etc and if no other underlying clinical cardiac disease long term treatment isn’t necessary - just no more depomedrone!

can dig out the references if you want.

[/quote]

Thanks Emily- how common a phenomenon is this though? I’d be interested in the references if you can post them.

RE: Severe fatal HGE cases

Emily Rainbow — Sat, 14 Dec 2019 13:43:46 GMT

interesting there is a paper showing PO anti-inflammatory pred is less likely to induce this vs methylpred depo injection.

steroid induced cardiomyopathy should respond well to oxygen, diuretics etc and if no other underlying clinical cardiac disease long term treatment isn’t necessary - just no more depomedrone!

can dig out the references if you want.

RE: Severe fatal HGE cases

Julie Innes — Mon, 09 Dec 2019 19:15:34 GMT

Thanks all (for some reason my ability to like or thank has disappeared on this thread!) I knew I thought there was a reason!

RE: Severe fatal HGE cases

Sarah Keir — Mon, 09 Dec 2019 16:26:42 GMT

[quote user="Anthony Todd"]

Steroids were,or seemed to me, the best to stop "cardiac coughs" overnight with no problems, intermittent and only when necessary of course.

Almost all steroid problems seem to me to be when continuous dosage, or a "course" is prescribed.

[/quote]

A lot have concurrent airway disease so which is the steroid helping?

RE: Severe fatal HGE cases

Gillian Mostyn — Sun, 08 Dec 2019 21:22:55 GMT

[quote user="Kate Richardson"]Well I wouldn't be.[/quote]

Good to know, thank-you! I was concerned that I'd inadvertantly precipitated it's death.

RE: Severe fatal HGE cases

Kate Richardson — Sun, 08 Dec 2019 20:02:02 GMT

[quote user="Gillian Mostyn"]

[quote user="Kate Richardson"]but I would be hesitant to put all the blame on it and what was the alternative if no other investigations were possible?[/quote]

Absolutely. It may certainly have been unrelated to the jab and the owner wouldn't have had any issues even if it had .. the 'roids were maintaining its QOL. It was just an observation that, had the steroid not been absolutely necessary and the owner queried the cause of their cat's sudden deterioration, I'd have to justify their use. It just made me a little more cautious with them.

[/quote]

Well I wouldn't be. I have one cat on long term pred for IBD with concurrent heart disease ("properly diagnosed") who we are increasing his pred intermittently from 5mg sid to 5mg bid to control the gut disease (I suspect he has progressed to lymphoma but the owners aren't keen to add chlorambucil currently) with no issues so far, so I am sceptical.

RE: Severe fatal HGE cases

Gillian Mostyn — Sun, 08 Dec 2019 19:47:53 GMT

[quote user="Kate Richardson"]but I would be hesitant to put all the blame on it and what was the alternative if no other investigations were possible?[/quote]

RE: Severe fatal HGE cases

Kate Richardson — Sun, 08 Dec 2019 19:08:10 GMT

[quote user="Gillian Mostyn"]

I had an elderly cat in recently. It had a heart murmur that had never been investigated but it was presented for over grooming. It had received a corticosteroid injection periodically for many years, and another was requested - I administered it.

It represented 6 hours later with dyspnoea and pulmonary oedema which rapidly became fatal. I suspect PE.

It has made me far more cautious about a simple short acting dex injection in cats with possible HCM.

[/quote]

That could just as easily be attributed to the stress of a vet visit being the final nail in the coffin for a cat on the verge of heart failure. I'm not saying the corticosteroid didn't add to to this, but I would be hesitant to put all the blame on it and what was the alternative if no other investigations were possible?

RE: Severe fatal HGE cases

Gillian Mostyn — Sun, 08 Dec 2019 19:02:24 GMT

It represented 6 hours later with dyspnoea and pulmonary oedema which rapidly became fatal. I suspect PE.

It has made me far more cautious about a simple short acting dex injection in cats with possible HCM.

RE: Severe fatal HGE cases

Anthony Todd — Sun, 08 Dec 2019 11:32:36 GMT

Steroids were,or seemed to me, the best to stop "cardiac coughs" overnight with no problems, intermittent and only when necessary of course.

Almost all steroid problems seem to me to be when continuous dosage, or a "course" is prescribed.

RE: Severe fatal HGE cases

Richard Carter — Fri, 06 Dec 2019 19:18:59 GMT

in cats that are prone to thrombus, cortisone can make this worse and I suppose over long term use, heart muscle will fatigue in dogs with dilative CM.

strange that we are brain washed to believe that steroids will damage the immune response when the medics are currently reconsidering NSAIDs post op for the exact same reasons with the idea that you need inflammation to heal properly and you need activated wbc to find the bugs/ debris and the control of pain as opposed to inflammation is better achieved with other medicines

Having graduated in the parvo days, the dogs that got dex survived, the ones that got finadyne/ banamine (then marketed and sold as the latest 'safest' NSAID) died of renal failure so the idea that haem g/ent as a condition for avoiding cortisone is a myth. Sometimes you just need to keep body and soul together until the patient can get to the next stage of healing/ recovery

RE: Severe fatal HGE cases

Anthony Dennison — Fri, 06 Dec 2019 14:19:48 GMT

[quote user="Julie Innes"]While we are on the subject, does anyone know why I have got it into my head that steroids are contraindicated with heart disease?? (May be another misapprehension of mine, which would be nice!)[/quote]

Because of water retention I think, increased blood volume even more than it has done already increasing preload on the heart.

RE: Severe fatal HGE cases

Julie Innes — Fri, 06 Dec 2019 14:06:30 GMT

No dig taken, Kate! I think maybe this is where the fear comes from- that you will somehow "make them worse!". I actually like steroids most of the time, and am not usually afraid of them. I feel like it seems to go in cycles- steroids are great-- steroids are the work of the devil-- steroids are useful!

While we are on the subject, does anyone know why I have got it into my head that steroids are contraindicated with heart disease?? (May be another misapprehension of mine, which would be nice!)

RE: Severe fatal HGE cases

Anthony Dennison — Fri, 06 Dec 2019 11:59:45 GMT

[quote user="Julie Innes"]I have been wary of giving them for HGE as I guess the rationale is you are expecting possible infectious causes, so suppressing immune system???[/quote]

I had this discussion with one of our vets yesterday. The routine doses of steroids we give are anti-inflammatory rather than immunosuppressive

RE: Severe fatal HGE cases

Kate Richardson — Fri, 06 Dec 2019 11:40:30 GMT

[quote user="Julie Innes"]I have been wary of giving them for HGE as I guess the rationale is you are expecting possible infectious causes, so suppressing immune system???[/quote]

This is maybe where the 'fear' of corticosteroids comes from- there is a huge dose range for corticosteroids from anti-inflammatory to immunosuppressive, and anti-inflammatory dose at the bottom the dose range is not going to cause a complete breakdown of the immune system!

ps This is not a dig at you, Julie!

RE: Severe fatal HGE cases

Utlendigur — Thu, 05 Dec 2019 19:54:49 GMT

I had a cocker spaniel with pancreatitis and immune-mediated thrombocytopenia (discovered on pre-op BMBT and bloods prior to removing his anal gland mass to try to resolve the hypercalcaemia...and don't mention the ears, skin, calcinosis cutis...). The advice from a specialist pretty much "why wouldn't you be using corticosteroids?".

I do also give dex to HGE cases if they aren't responding to fluids etc on the basis of possible anaphylaxis and of not wanting them to die for want of trying it. I didn't know about the gall bladder sign - thanks!

RE: Severe fatal HGE cases

Julie Innes — Thu, 05 Dec 2019 12:12:50 GMT

See, I used to give corticosteroids for pancreatitis years ago, then I'm sure someone told me/ I read/ CPD claimed they were contraindicated, so now I don't! Still give them for triaditis, so I guess I'm contradicting myself..

I have been wary of giving them for HGE as I guess the rationale is you are expecting possible infectious causes, so suppressing immune system??? No idea if one dose of dex would actually do that, though... Having recently read on here about the anaphylaxis thing, however, I would now! Isn't CPD wonderful thing!

RE: Severe fatal HGE cases

Bob Russell — Thu, 05 Dec 2019 11:10:05 GMT

I suspect there is a lack of clarity with benefits versus risk here.

I gave corticosteroids fairly routinely for suspected pancreatitis (and other suspected inflammatory situations). Then, out of the blue came the don't use them in pancreatitis. I have to assume this was from some cpd but appears to be quite widespread in the profession.

It is not really a fear of them but an acceptance that they are contraindicated. Perhaps this is another case of 'cannot give opiates to cats'?

RE: Severe fatal HGE cases

Kate Richardson — Thu, 05 Dec 2019 10:48:32 GMT

At risk of sounding like AT, I do despair sometimes at the attitudes of some vets towards corticosteroids and over emphasis on the negative effects whilst seeming to ignore the benefits. Similar with meloxicam and cats with renal disease (or any old cat). What has happen to benefits versus risks?

RE: Severe fatal HGE cases

Bob Russell — Thu, 05 Dec 2019 09:52:51 GMT

Thank you!

I was aware of the first reference which supports the use of corticosteroids.

So generally there appears to be logic and benefit from using corticosteroids rather than it being a no! no!

I would like to know where the idea that they are contraindicated came from. My recollection is that it was believed to increase the risk of precipitating necrotising pancreatitis but I cannot recall where this came from.

Sadly I think I have been doing my patients a bit of a disservice by avoiding a shot of dex!

RE: Severe fatal HGE cases

Roland Bulkyn-Rackowe — Wed, 04 Dec 2019 16:43:10 GMT

Slightly randomly plucked:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555660/

https://www.ncbi.nlm.nih.gov/pubmed/6462952

https://www.ncbi.nlm.nih.gov/pubmed/7091513

I'm sure I had been told by a colleague to avoid steroids and I have been averse to using them. For some patients they seem to be the magic bullet and not to be avoided.

RE: Severe fatal HGE cases

Bob Russell — Tue, 03 Dec 2019 10:53:21 GMT

I am not sure where the no steroids for pancreatitis came from.

It was standard treatment when I qualified and became an apparent no,no some time back.

Most feel a lot better very quickly after a shot of dex and I cannot think of one that did not survive. I am not sure what papers are out there on the subject but I do discuss the fact that many are against it as a treatment option with the owner.

Seems fairly standard treatment in humans!

RE: Severe fatal HGE cases

Glen McIntosh — Tue, 03 Dec 2019 09:09:36 GMT

[quote user="David Mills"]

HGE is a common symptom of so many disease processes I think it's difficult to generalise.

[/quote]

This is true.

But I think a proportion of the really sick ones are anaphylaxis, and it is important to recognise these as they can easily be confused with other syndromes and while they seem to respond really well to appropriate treatment, but are potentially fatal if treated inappropriately.

These cases are not that common (I have been seeing 3 or 4 a year) but had one a couple of nights ago, as it happens. 9 yo dog with a history of Cushings disease being treated with mitotane and had previously had possible concerns about iatrogenic addisons. Dog sitting on couch at 11pm with owners. Suddenly cried out, seemed to lose consciousness, fell off the sofa, then vomited a couple of times. Seemed to get a bit better over the next 30 mins or so, then started passing bloody diarrhoea.

By the time it got to us it was in lateral recumbency, grey mm, hr 200, SBP 60, lactate 8. Dog was borderline anaemic but has been documented long term anaemia, and its hct was 6% points higher than a few weeks previously.

Ultrasound showed a very large liver mass - so I was initially thinking I was dealing with an acute bleed. Did a bit more scanning and saw that there was no free abdominal fluid at all, and an extremely obvious gall bladder halo sign, no pericardial effusion and not much else of interest.

So treated it with multiple fluid boluses, Dex, some antihistamines and some FFP (clotting times also significantly prolonged) and it did very well.

Was this anaphylaxis? I think so, but I don’t know why it occurred. No insect sting etc noted by the owner. It wasn’t a bleed. It wasnt iatrogenic Addison's (cortisol > 256, slight high Na and lowish K). I suspect the liver mass was an incidental finding.

The concern is that these suspected anaphylaxis cases can look like an acute abdominal bleed, and unlike the case described above often times there is some blood in the abdomen as well, but if you take these cases to surgery looking to stop a bleed you won’t find one, and worse still it could end up being fatal to the animal if they are coagulopathic, which they often are.

The main point is if you see a gall bladder halo sign in an acutely collapsed animal, and you have ruled out other causes of gall badder halo sign such as pericardial effusion etc, then you might want to consider anaphylaxis, and think twice before taking it to surgery, even if has so blood in the abdomen.

RE: Severe fatal HGE cases

janine redman — Mon, 02 Dec 2019 23:37:18 GMT

I always used to use steroids but this was severely frowned upon by younger vets within the practice so I tend not to now. What is the justification for steroids in the HGE cases where addisons is not suspected ?

RE: Severe fatal HGE cases

David Mills — Mon, 02 Dec 2019 19:19:22 GMT

HGE is a common symptom of so many disease processes I think it's difficult to generalise. I think the anaphylaxis things is interesting but the papers linked previously had a rather simplistic but evangelical air about them based on very little evidence as far as I could see.

I suspect the really sick ones are a flavour of acute or peracute pancreatitis, I think I picked up on the obvious correlation of HGE with pancreatitis on here (anatomical vicinity). All our HGE and pancreatitis cases get dex and we haven't had one not survive til discharge for a long time AFAIK. Of course, we might just be seeing milder cases. It's probably more useful to divide them into those that are bright, or brighten considerably after a few hours fluids, and those that don't. Having said that I remember those that were bright then keeled over, stumped as to what happens with these but must be some overwhelming septicaemia or thrombus I suspect.