feline hepatic lipidosis - Veterinary Specialty Hospital

IN OUR COMMUNITY
Escondido Humane Society is Participating in the ASPCS $100K Challenge
The Escondido Humane Society (EHS) is the first San Diego County shelter competing in the
ASPCA $100K Challenge, a nationwide competition for animal shelters and their communities
that aims to get more dogs and cats adopted or returned to their owners. EHS is one of 49 shelters
participating nationwide, and the organization that achieves the greatest increase in lives saved from
Aug. 1 to Oct. 31 will receive a $100,000 grant from the ASPCA. For updates, “Like” EHS on Facebook
at www.facebook.com/EscondidoHumaneSociety. To help them meet their goal, please encourage
anyone looking to adopt a new family member to visit this shelter.
10435 Sorrento Valley Rd
Suite 100
San Diego, CA 92121
CONNECTED
YO U R L I N K TO V E T E R I N A R Y S P E C I A LT Y H O S P I TA L | O C T – D E C 2012
Join Us for the iSweat4Pets™ Nature Dog Walk!
Saturday, October 27th from 10am-1pm at the beautiful San Dieguito County Park. This fundraiser for
the FACE Foundation will help raise funds and awareness for pets in need of life-saving veterinary care!
Please support Team VSH by clicking the link on our Facebook page.
TAKE NOTE
CURRENT CLINICAL TRIALS
*NEW* Internal Medicine – Canine IBD and Probiotic VSL#3
We are enrolling dogs with chronic gastrointestinal signs that
are suspected of having idiopathic inflammatory bowel disease
(IBD). Endoscopy will be performed, and if IBD is confirmed, dogs
will be randomized to receive treatment with prednisone and diet,
or prednisone, diet and probiotic VSL#3. This is an 8-week study
requiring two endoscopic procedures. The cost of the probiotic
VSL#3 and the cost of the second endoscopy will be funded.
Contact Dr. Steve Hill at (858) 875-7500 x702
Internal Medicine – Glomerular Disease Study
VSH is participating in a multi-center prospective study
evaluating increased dosing of enalapril in dogs with glomerular
disease. Client incentives include reduced cost of some initial
testing and no cost for scheduled recheck visits and tests.
Contact: Dr. Julie Fischer at (760) 466-0600
Canine Soft Tissue Sarcoma
Trial examining novel biologic therapy for dogs with
MEASUREABLE soft tissue sarcoma.
Eligibility criteria:
• Generally good health
• Potentially resectable, extra-cavitary or
oral tumors, measuring 1-7 cm
Contact: Dr. Brenda Phillips (858) 875-7500x713
Oncology – Dogs Receiving Doxorubicin
We are investigating the benefit of Fortiflora™ nutritional supplement in dogs receiving doxorubicin chemotherapy. Dogs already
receiving doxorubicin are eligible.
Contact: Dr. Andi Flory (760) 466-0600 or (858) 875-7500 x719
For more details about these and other clinical trials, please visit
our website at www.vshsd.com.
WE’RE LISTENING
We continue to enhance the client experience by leveraging
technology. The status of surgery patients is now available online.
Each patient is given a unique number so the owner can check in
for real time updates for pre-op, surgery and recovery. This helps
reassure our clients by keeping them well-informed and they can
share the link with their family veterinarian.
meeting and working with you all!
Las Vegas in October 2012.
FELINE HEPATIC
LIPIDOSIS
PART TWO
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IN THIS ISSUE:
ANESTHESIA IN
BRACHYCEPHALIC BREEDS
CLINICAL TRIALS
UPCOMING EVENTS
SAN DIEGO 10435 Sorrento Valley Rd San Diego, CA 92121 | NORTH COUNTY 2055 Montiel Rd San Marcos, CA 92069 | www.vshsd.com
ANESTHESIA IN
BRACHYCEPHALIC BREEDS
RICHTER SCALE
Hello colleagues, I hope you all had a terrific summer! There have been some exciting
changes at both locations of VSH in the last several months. We have added two new
specialists: Dr. Holly Hamilton (Ophthalmology) and Dr. Tracy Julius (Emergency and
Critical Care). Dr. Hamilton has some big shoes to fill in replacing Dr. Basher, but she is
up to the task. Dr. Hamilton is a very experienced ophthalmologist and is well rounded
in surgical and medical conditions of the eye. She has a special interest in diseases of
the cornea. She looks forward to meeting you and working with your patients! Dr.
Tracy Julius just joined the Emergency and Critical Care staff. Dr. Julius completed her
ECC residency here at VSH under Dr. Monica Clare’s mentorship. She has broad
interests in critical care, and will help support and grow our emergency caseload, while
also supporting our ICU patients. Both of our criticalists are also now freed up to
spend more time in the ICU since Dr. Amber Hopkins (anesthesiologist) is overseeing
the critical patients in surgery. Our North County location also continues to grow with
the addition of full-time surgeon Dr. Seth Ganz, joining the other newer specialists
(Nicole Roybal, ophthalmologist, and Andi Flory, oncologist).
by AMBER HOPKINS, DVM, CVMA
Treatment:
-
The primary concerns with handling, sedation, and anesthesia in these
patients are stress induced respiratory distress, difficult intubations,
vomiting and aspiration of contents (primarily with laryngeal collapse/
paralysis), and obstruction of airway during the recovery period. The
goals of pre-anesthetic medications in these patients are to provide
enough sedation/anxiolysis to minimize their anxiety, while avoiding
excessive sedation or muscle relaxation which may predispose to them
to airway obstruction; provide pain relief for the surgical procedure;
and minimize their risk of vomiting or regurgitation.
We are grateful to those of you who filled out our recent online survey so we know
what we do well and know what we can improve upon. We are proud to be viewed as
having unsurpassed medical quality. Our specialists, facility, and equipment are
thought of by you as second to none. Though we are ranked high in client experience
and communication, these are the areas we continue to dedicate our focus. Accordingly, we hired Erika Picciolo as our client experience coordinator. She has already
begun to instill a culture of hospitality that is being noted on recent client surveys.
The comments are extremely positive, demonstrating that her efforts are paying off in
this culture shift. The other new position is the addition of Margaret Trinh as our
referral coordinator. She will help make sure communication between you and our specialists is optimized and we are also receiving positive feedback with her in this role.
Well, my sports season has been cut short by a disappointing Padres season. I managed
to get to 66 games, so by that measure it was a success. Too bad I had to come back to
work after many of those games. I really think they would be in the playoffs if they
hadn’t gotten off to such a bad start. Next year the Padres are favored by some to win
the Pennant. Those same pundits are picking the Chargers to win this year’s Super
Bowl. It’s great to be a San Diego sports fan!! (I hope you are not wondering who
these pundits are!)
Until next year….
Keith Richter, DVM
Diplomate ACVIM
Brachycephalic breeds are classified as those breeds which have a
shortened longitudinal axis of the skull. The term brachycephalic
syndrome refers to a combination of anatomic abnormalities which
can predispose these breeds to respiratory problems and include
stenotic nares, elongated soft palate, everted laryngeal saccules, and
narrowed (hypoplastic) trachea. These conditions can contribute to
compromised ventilation and oxygenation in these patients, putting
them at higher anesthetic risk.
Vet Clin Small Anim,
Analgesia for airway surgery may include butorphanol or a pure mu
opioid (such as methadone or hydromorphone) depending on the
extent of surgical intervention. Butorphanol can provide adequate
sedation without any significant respiratory depression, though its
analgesic properties are mild and short lived. Butorphanol would be a
good option in patients presenting for non-invasive anesthetic
procedures or minor surgical procedures. Pure mu opioids will provide
better and longer lasting analgesia but may induce panting or
vomiting. They would be more appropriate for patients presenting for
major or invasive surgeries. Maropitant (Cerenia) may be used in
conjunction with these opioids to minimize the patient’s potential for
vomiting. Acepromazine can provide good supplemental sedation in
very stressed patients and has minimal effects on ventilation. In
patients with laryngeal collapse or laryngeal paralysis, I generally
avoid the use of muscle relaxants, such as benzodiazepines.
Pre-anesthetic oxygen by a loose fitting face mask or high concentration oxygen flow-by is generally recommended prior to induction of
anesthesia, as intubation in these patients can sometimes be difficult.
Pre-oxygenation can help minimize acute desaturation and hypoxemia. A variety of endotracheal tube sizes should always be available
to accommodate the smaller sized trachea in many of these breeds.
Bulldogs in particular have significantly smaller tracheas compared to
non-brachycephalic breeds of the same size. It is wise to have Dopram,
a stylet and tracheostomy set readily available in the event of apnea
and/or airway obstruction. Drugs used for induction of anesthesia
should ideally be those which promote smooth and rapid induction of
anesthesia, no vomiting, and minimal to no decrease in respiratory
ability. Ketamine maintains the patient’s ability to ventilate spontaneously and maintains much of the patient’s airway reflexes which can
be beneficial. Propofol provides a rapid and smooth induction and is
commonly used but one should be careful with amount and rapidity
of administration, as it may also induce apnea. Either would be an
appropriate choice in these patients.
Generally with no other underlying medical conditions, once the
patient is intubated, their intraoperative anesthetic risk is generally
minimal. In overweight dogs, ventilation may be compromised and
mechanical or assisted ventilation necessary.
Like the induction period, recovery is a critical part of anesthesia in
these breeds. Some clinicians choose to administer an anti-inflammatory dose of steroids prior to recovery, especially if there is evidence
or concern for upper airway inflammation which may precipitate
airway obstruction after extubation. Maintaining the patient in
sternal recumbency with their head/neck extended and the endotracheal tube in place as long as possible will help ensure adequate
recovery from anesthetic drugs and best ventilation for the patient.
Once extubated, the patient should be monitored closely visually and
by pulse oximetry to assure adequate ability to ventilate and appropriate oxygenation. It is important to always have sedation and induction drugs readily available with a laryngoscope, stylet, endotracheal
tubes and 100% oxygen in the event the patient obstructs their
airway upon extubation and needs re-intubation. Being overly
prepared will minimize many of the potential risks associated with
anesthesia in these breeds.
FELINE HEPATIC LIPIDOSIS
RICHTER SCALE
Hello colleagues, I hope you all had a terrific summer! There have been some exciting
changes at both locations of VSH in the last several months. We have added two new
specialists: Dr. Holly Hamilton (Ophthalmology) and Dr. Tracy Julius (Emergency and
Critical Care). Dr. Hamilton has some big shoes to fill in replacing Dr. Basher, but she is
up to the task. Dr. Hamilton is a very experienced ophthalmologist and is well rounded
in surgical and medical conditions of the eye. She has a special interest in diseases of
the cornea. She looks forward to meeting you and working with your patients! Dr.
Tracy Julius just joined the Emergency and Critical Care staff. Dr. Julius completed her
ECC residency here at VSH under Dr. Monica Clare’s mentorship. She has broad
interests in critical care, and will help support and grow our emergency caseload, while
also supporting our ICU patients. Both of our criticalists are also now freed up to
spend more time in the ICU since Dr. Amber Hopkins (anesthesiologist) is overseeing
the critical patients in surgery. Our North County location also continues to grow with
the addition of full-time surgeon Dr. Seth Ganz, joining the other newer specialists
(Nicole Roybal, ophthalmologist, and Andi Flory, oncologist).
We are grateful to those of you who filled out our recent online survey so we know
what we do well and know what we can improve upon. We are proud to be viewed as
having unsurpassed medical quality. Our specialists, facility, and equipment are
thought of by you as second to none. Though we are ranked high in client experience
and communication, these are the areas we continue to dedicate our focus. Accordingly, we hired Erika Picciolo as our client experience coordinator. She has already
begun to instill a culture of hospitality that is being noted on recent client surveys.
The comments are extremely positive, demonstrating that her efforts are paying off in
this culture shift. The other new position is the addition of Margaret Trinh as our
referral coordinator. She will help make sure communication between you and our specialists is optimized and we are also receiving positive feedback with her in this role.
Well, my sports season has been cut short by a disappointing Padres season. I managed
to get to 66 games, so by that measure it was a success. Too bad I had to come back to
work after many of those games. I really think they would be in the playoffs if they
hadn’t gotten off to such a bad start. Next year the Padres are favored by some to win
the Pennant. Those same pundits are picking the Chargers to win this year’s Super
Bowl. It’s great to be a San Diego sports fan!! (I hope you are not wondering who
these pundits are!)
Until next year….
Keith Richter, DVM
Diplomate ACVIM
PART TWO: TREATMENT AND PROGNOSIS
by STEVE HILL, DVM, MS, DACVIM (SAIM)
Treatment:
Treatment of hepatic lipidosis (HL) initially requires correction of
fluid and electrolyte abnormalities, but the cornerstone of therapy
is enteral nutritional support with a focus on meeting protein and
caloric needs via a feeding tube. Complications of HL such as
vomiting, hepatic encephalopathy (HE), or bleeding tendencies must
also be managed. An important component of treatment is also the
diagnosis and concurrent management of any underlying disease
process. Client education and encouragement is important as
significant owner participation is necessary for a successful
outcome of this reversible condition.
It is important that enteral feeding be initiated as early as possible
and that it is sustained until adequate voluntary food intake
resumes. Oral forced feeding and appetite stimulants are generally
inadequate to provide enough calories to reverse HL. Provision of
adequate calories to reverse the progression of HL almost always
requires placement of a feeding tube. An esophagostomy tube is
generally the feeding tube of choice (a video on the technique for
inserting an esophagostomy tube can be found on the Blog section
of our website under VSH Videos). If the patient is not stable to be
anesthetized for an esophagostomy tube in the first 24 hours a
nasogastric feeding tube can be placed (generally with minimal
sedation) and feeding can be initiated with CliniCare (Abbott
Laboratories). Diets that derive the majority of their calories from
protein and fat should be used. Iams Maximum Calorie or Hill’s a/d
are good first choices which can be readily fed through an esophagostomy tube.
Antiemetic and GI prokinetic therapy are administered as needed.
The preferred antiemetic is maropitant citrate (Cerenia, Pfizer)
0.5-1.0 mg/kg SQ or PO SID and the preferred GI prokinetic is
cisapride 3.0 mg/kg/day divided based on the frequency of feeding
(1.0 mg/kg if feeding TID, 0.75 mg/kg if feeding QID, 0.5 mg/kg if
feeding q6h) administered 30 minutes before feeding PO. Increasing evidence suggests that maropitant may also help provide
analgesia for concurrent painful conditions, such as pancreatitis.
Cobalamin (B12) 250 mcg SQ is commonly administered as cats
with HL may be cobalamin deficient, especially if there is underling gastrointestinal disease. Vitamin K1 0.5-1.5 mg/kg q12h SQ is
administered for 2-3 doses prior to invasive procedures to address
potential vitamin K deficiency commonly associated with HL.
Supplementation with micronutrients is warranted based on their
physiologic role in lipid metabolism, in the urea cycle, or as antioxidant. The most commonly prescribed supplements are: L-carnitine
(QuinicarinTM Nutramax Laboratories, Inc.; Carnitor®, Sigma-Tau
Pharmaceuticals, Inc.), taurine each at 250 mg added to the food
q12-24h, and S-adenosylmethionine (SAMe) 90-225 mg/cat PO
q24h (DenosylTM, Nutramax Laboratories, Inc.). Silybin-phosphatidylcholine (milk thistle) in combination with SAMe (DenamarinTM,
Nutramax Laboratories, Inc.) is also available.
Although signs of HE (most notably ptyalism and depressed
mentation) occur in <5% of cats with HL, HE can be a significant
complication requiring therapeutic intervention. Cats with HE are
treated by feeding a diet moderate in protein (Hill’s l/d or k/d) and,
if necessary, by administration of lactulose and/or antibiotics by
mouth or through a feeding tube.
Prognosis:
Cats making a successful clinical recovery from HL demonstrate a
gradual improvement in laboratory abnormalities over time. Total
bilirubin concentration is expected to decrease by ≥50% within
7-10 days, although serum liver enzyme activities often require
more time to improve. Clinically, the two most important factors
affecting the outcome in HL appear to be the presence of a serious
and irreversible concurrent disease (more likely in an older cat) and
how early enteral nutritional support is begun. In the absence of a
fatal concurrent disease, recovery rates of 80% or higher can be
expected if enteral feeding is initiated early in the course of
disease and if feeding is sustained until voluntary food intake
resumes. Tube feeding is usually required for several (3-6) weeks
which requires the client be an active participant in their cat’s
recovery. Once a cat recovers from HL, recurrence is unlikely.
Suggested Reading:
Armstrong PJ, Blanchard G. Hepatic lipidosis in cats.
Vet Clin Small Anim, Philadelphia: Elsevier, 2009;39:599-616.
Center SA, Feline hepatic lipidosis. Vet Clin Small Anim,
Philadelphia: Elsevier, 2005-a;35:225-69.
Introduction and Diagnosis of HL appeared in the previous issue
(Jul-Sept 2012) of Connected.
ANESTHESIA IN
BRACHYCEPHALIC BREEDS
by AMBER HOPKINS, DVM, CVMA
Brachycephalic breeds are classified as those breeds which have a
shortened longitudinal axis of the skull. The term brachycephalic
syndrome refers to a combination of anatomic abnormalities which
can predispose these breeds to respiratory problems and include
stenotic nares, elongated soft palate, everted laryngeal saccules, and
narrowed (hypoplastic) trachea. These conditions can contribute to
compromised ventilation and oxygenation in these patients, putting
them at higher anesthetic risk.
The primary concerns with handling, sedation, and anesthesia in these
patients are stress induced respiratory distress, difficult intubations,
vomiting and aspiration of contents (primarily with laryngeal collapse/
paralysis), and obstruction of airway during the recovery period. The
goals of pre-anesthetic medications in these patients are to provide
enough sedation/anxiolysis to minimize their anxiety, while avoiding
excessive sedation or muscle relaxation which may predispose to them
to airway obstruction; provide pain relief for the surgical procedure;
and minimize their risk of vomiting or regurgitation.
Analgesia for airway surgery may include butorphanol or a pure mu
opioid (such as methadone or hydromorphone) depending on the
extent of surgical intervention. Butorphanol can provide adequate
sedation without any significant respiratory depression, though its
analgesic properties are mild and short lived. Butorphanol would be a
good option in patients presenting for non-invasive anesthetic
procedures or minor surgical procedures. Pure mu opioids will provide
better and longer lasting analgesia but may induce panting or
vomiting. They would be more appropriate for patients presenting for
major or invasive surgeries. Maropitant (Cerenia) may be used in
conjunction with these opioids to minimize the patient’s potential for
vomiting. Acepromazine can provide good supplemental sedation in
very stressed patients and has minimal effects on ventilation. In
patients with laryngeal collapse or laryngeal paralysis, I generally
avoid the use of muscle relaxants, such as benzodiazepines.
Pre-anesthetic oxygen by a loose fitting face mask or high concentration oxygen flow-by is generally recommended prior to induction of
anesthesia, as intubation in these patients can sometimes be difficult.
Pre-oxygenation can help minimize acute desaturation and hypoxemia. A variety of endotracheal tube sizes should always be available
to accommodate the smaller sized trachea in many of these breeds.
Bulldogs in particular have significantly smaller tracheas compared to
non-brachycephalic breeds of the same size. It is wise to have Dopram,
a stylet and tracheostomy set readily available in the event of apnea
and/or airway obstruction. Drugs used for induction of anesthesia
should ideally be those which promote smooth and rapid induction of
anesthesia, no vomiting, and minimal to no decrease in respiratory
ability. Ketamine maintains the patient’s ability to ventilate spontaneously and maintains much of the patient’s airway reflexes which can
be beneficial. Propofol provides a rapid and smooth induction and is
commonly used but one should be careful with amount and rapidity
of administration, as it may also induce apnea. Either would be an
appropriate choice in these patients.
Generally with no other underlying medical conditions, once the
patient is intubated, their intraoperative anesthetic risk is generally
minimal. In overweight dogs, ventilation may be compromised and
mechanical or assisted ventilation necessary.
Like the induction period, recovery is a critical part of anesthesia in
these breeds. Some clinicians choose to administer an anti-inflammatory dose of steroids prior to recovery, especially if there is evidence
or concern for upper airway inflammation which may precipitate
airway obstruction after extubation. Maintaining the patient in
sternal recumbency with their head/neck extended and the endotracheal tube in place as long as possible will help ensure adequate
recovery from anesthetic drugs and best ventilation for the patient.
Once extubated, the patient should be monitored closely visually and
by pulse oximetry to assure adequate ability to ventilate and appropriate oxygenation. It is important to always have sedation and induction drugs readily available with a laryngoscope, stylet, endotracheal
tubes and 100% oxygen in the event the patient obstructs their
airway upon extubation and needs re-intubation. Being overly
prepared will minimize many of the potential risks associated with
anesthesia in these breeds.
FELINE HEPATIC LIPIDOSIS
RICHTER SCALE
Hello colleagues, I hope you all had a terrific summer! There have been some exciting
changes at both locations of VSH in the last several months. We have added two new
specialists: Dr. Holly Hamilton (Ophthalmology) and Dr. Tracy Julius (Emergency and
Critical Care). Dr. Hamilton has some big shoes to fill in replacing Dr. Basher, but she is
up to the task. Dr. Hamilton is a very experienced ophthalmologist and is well rounded
in surgical and medical conditions of the eye. She has a special interest in diseases of
the cornea. She looks forward to meeting you and working with your patients! Dr.
Tracy Julius just joined the Emergency and Critical Care staff. Dr. Julius completed her
ECC residency here at VSH under Dr. Monica Clare’s mentorship. She has broad
interests in critical care, and will help support and grow our emergency caseload, while
also supporting our ICU patients. Both of our criticalists are also now freed up to
spend more time in the ICU since Dr. Amber Hopkins (anesthesiologist) is overseeing
the critical patients in surgery. Our North County location also continues to grow with
the addition of full-time surgeon Dr. Seth Ganz, joining the other newer specialists
(Nicole Roybal, ophthalmologist, and Andi Flory, oncologist).
We are grateful to those of you who filled out our recent online survey so we know
what we do well and know what we can improve upon. We are proud to be viewed as
having unsurpassed medical quality. Our specialists, facility, and equipment are
thought of by you as second to none. Though we are ranked high in client experience
and communication, these are the areas we continue to dedicate our focus. Accordingly, we hired Erika Picciolo as our client experience coordinator. She has already
begun to instill a culture of hospitality that is being noted on recent client surveys.
The comments are extremely positive, demonstrating that her efforts are paying off in
this culture shift. The other new position is the addition of Margaret Trinh as our
referral coordinator. She will help make sure communication between you and our specialists is optimized and we are also receiving positive feedback with her in this role.
Well, my sports season has been cut short by a disappointing Padres season. I managed
to get to 66 games, so by that measure it was a success. Too bad I had to come back to
work after many of those games. I really think they would be in the playoffs if they
hadn’t gotten off to such a bad start. Next year the Padres are favored by some to win
the Pennant. Those same pundits are picking the Chargers to win this year’s Super
Bowl. It’s great to be a San Diego sports fan!! (I hope you are not wondering who
these pundits are!)
Until next year….
Keith Richter, DVM
Diplomate ACVIM
PART TWO: TREATMENT AND PROGNOSIS
by STEVE HILL, DVM, MS, DACVIM (SAIM)
Treatment:
Treatment of hepatic lipidosis (HL) initially requires correction of
fluid and electrolyte abnormalities, but the cornerstone of therapy
is enteral nutritional support with a focus on meeting protein and
caloric needs via a feeding tube. Complications of HL such as
vomiting, hepatic encephalopathy (HE), or bleeding tendencies must
also be managed. An important component of treatment is also the
diagnosis and concurrent management of any underlying disease
process. Client education and encouragement is important as
significant owner participation is necessary for a successful
outcome of this reversible condition.
It is important that enteral feeding be initiated as early as possible
and that it is sustained until adequate voluntary food intake
resumes. Oral forced feeding and appetite stimulants are generally
inadequate to provide enough calories to reverse HL. Provision of
adequate calories to reverse the progression of HL almost always
requires placement of a feeding tube. An esophagostomy tube is
generally the feeding tube of choice (a video on the technique for
inserting an esophagostomy tube can be found on the Blog section
of our website under VSH Videos). If the patient is not stable to be
anesthetized for an esophagostomy tube in the first 24 hours a
nasogastric feeding tube can be placed (generally with minimal
sedation) and feeding can be initiated with CliniCare (Abbott
Laboratories). Diets that derive the majority of their calories from
protein and fat should be used. Iams Maximum Calorie or Hill’s a/d
are good first choices which can be readily fed through an esophagostomy tube.
Antiemetic and GI prokinetic therapy are administered as needed.
The preferred antiemetic is maropitant citrate (Cerenia, Pfizer)
0.5-1.0 mg/kg SQ or PO SID and the preferred GI prokinetic is
cisapride 3.0 mg/kg/day divided based on the frequency of feeding
(1.0 mg/kg if feeding TID, 0.75 mg/kg if feeding QID, 0.5 mg/kg if
feeding q6h) administered 30 minutes before feeding PO. Increasing evidence suggests that maropitant may also help provide
analgesia for concurrent painful conditions, such as pancreatitis.
Cobalamin (B12) 250 mcg SQ is commonly administered as cats
with HL may be cobalamin deficient, especially if there is underling gastrointestinal disease. Vitamin K1 0.5-1.5 mg/kg q12h SQ is
administered for 2-3 doses prior to invasive procedures to address
potential vitamin K deficiency commonly associated with HL.
Supplementation with micronutrients is warranted based on their
physiologic role in lipid metabolism, in the urea cycle, or as antioxidant. The most commonly prescribed supplements are: L-carnitine
(QuinicarinTM Nutramax Laboratories, Inc.; Carnitor®, Sigma-Tau
Pharmaceuticals, Inc.), taurine each at 250 mg added to the food
q12-24h, and S-adenosylmethionine (SAMe) 90-225 mg/cat PO
q24h (DenosylTM, Nutramax Laboratories, Inc.). Silybin-phosphatidylcholine (milk thistle) in combination with SAMe (DenamarinTM,
Nutramax Laboratories, Inc.) is also available.
Although signs of HE (most notably ptyalism and depressed
mentation) occur in <5% of cats with HL, HE can be a significant
complication requiring therapeutic intervention. Cats with HE are
treated by feeding a diet moderate in protein (Hill’s l/d or k/d) and,
if necessary, by administration of lactulose and/or antibiotics by
mouth or through a feeding tube.
Prognosis:
Cats making a successful clinical recovery from HL demonstrate a
gradual improvement in laboratory abnormalities over time. Total
bilirubin concentration is expected to decrease by ≥50% within
7-10 days, although serum liver enzyme activities often require
more time to improve. Clinically, the two most important factors
affecting the outcome in HL appear to be the presence of a serious
and irreversible concurrent disease (more likely in an older cat) and
how early enteral nutritional support is begun. In the absence of a
fatal concurrent disease, recovery rates of 80% or higher can be
expected if enteral feeding is initiated early in the course of
disease and if feeding is sustained until voluntary food intake
resumes. Tube feeding is usually required for several (3-6) weeks
which requires the client be an active participant in their cat’s
recovery. Once a cat recovers from HL, recurrence is unlikely.
Suggested Reading:
Armstrong PJ, Blanchard G. Hepatic lipidosis in cats.
Vet Clin Small Anim, Philadelphia: Elsevier, 2009;39:599-616.
Center SA, Feline hepatic lipidosis. Vet Clin Small Anim,
Philadelphia: Elsevier, 2005-a;35:225-69.
Introduction and Diagnosis of HL appeared in the previous issue
(Jul-Sept 2012) of Connected.
ANESTHESIA IN
BRACHYCEPHALIC BREEDS
by AMBER HOPKINS, DVM, CVMA
Brachycephalic breeds are classified as those breeds which have a
shortened longitudinal axis of the skull. The term brachycephalic
syndrome refers to a combination of anatomic abnormalities which
can predispose these breeds to respiratory problems and include
stenotic nares, elongated soft palate, everted laryngeal saccules, and
narrowed (hypoplastic) trachea. These conditions can contribute to
compromised ventilation and oxygenation in these patients, putting
them at higher anesthetic risk.
The primary concerns with handling, sedation, and anesthesia in these
patients are stress induced respiratory distress, difficult intubations,
vomiting and aspiration of contents (primarily with laryngeal collapse/
paralysis), and obstruction of airway during the recovery period. The
goals of pre-anesthetic medications in these patients are to provide
enough sedation/anxiolysis to minimize their anxiety, while avoiding
excessive sedation or muscle relaxation which may predispose to them
to airway obstruction; provide pain relief for the surgical procedure;
and minimize their risk of vomiting or regurgitation.
Analgesia for airway surgery may include butorphanol or a pure mu
opioid (such as methadone or hydromorphone) depending on the
extent of surgical intervention. Butorphanol can provide adequate
sedation without any significant respiratory depression, though its
analgesic properties are mild and short lived. Butorphanol would be a
good option in patients presenting for non-invasive anesthetic
procedures or minor surgical procedures. Pure mu opioids will provide
better and longer lasting analgesia but may induce panting or
vomiting. They would be more appropriate for patients presenting for
major or invasive surgeries. Maropitant (Cerenia) may be used in
conjunction with these opioids to minimize the patient’s potential for
vomiting. Acepromazine can provide good supplemental sedation in
very stressed patients and has minimal effects on ventilation. In
patients with laryngeal collapse or laryngeal paralysis, I generally
avoid the use of muscle relaxants, such as benzodiazepines.
Pre-anesthetic oxygen by a loose fitting face mask or high concentration oxygen flow-by is generally recommended prior to induction of
anesthesia, as intubation in these patients can sometimes be difficult.
Pre-oxygenation can help minimize acute desaturation and hypoxemia. A variety of endotracheal tube sizes should always be available
to accommodate the smaller sized trachea in many of these breeds.
Bulldogs in particular have significantly smaller tracheas compared to
non-brachycephalic breeds of the same size. It is wise to have Dopram,
a stylet and tracheostomy set readily available in the event of apnea
and/or airway obstruction. Drugs used for induction of anesthesia
should ideally be those which promote smooth and rapid induction of
anesthesia, no vomiting, and minimal to no decrease in respiratory
ability. Ketamine maintains the patient’s ability to ventilate spontaneously and maintains much of the patient’s airway reflexes which can
be beneficial. Propofol provides a rapid and smooth induction and is
commonly used but one should be careful with amount and rapidity
of administration, as it may also induce apnea. Either would be an
appropriate choice in these patients.
Generally with no other underlying medical conditions, once the
patient is intubated, their intraoperative anesthetic risk is generally
minimal. In overweight dogs, ventilation may be compromised and
mechanical or assisted ventilation necessary.
Like the induction period, recovery is a critical part of anesthesia in
these breeds. Some clinicians choose to administer an anti-inflammatory dose of steroids prior to recovery, especially if there is evidence
or concern for upper airway inflammation which may precipitate
airway obstruction after extubation. Maintaining the patient in
sternal recumbency with their head/neck extended and the endotracheal tube in place as long as possible will help ensure adequate
recovery from anesthetic drugs and best ventilation for the patient.
Once extubated, the patient should be monitored closely visually and
by pulse oximetry to assure adequate ability to ventilate and appropriate oxygenation. It is important to always have sedation and induction drugs readily available with a laryngoscope, stylet, endotracheal
tubes and 100% oxygen in the event the patient obstructs their
airway upon extubation and needs re-intubation. Being overly
prepared will minimize many of the potential risks associated with
anesthesia in these breeds.
IN OUR COMMUNITY
Escondido Humane Society is Participating in the ASPCS $100K Challenge
The Escondido Humane Society (EHS) is the first San Diego County shelter competing in the
ASPCA $100K Challenge, a nationwide competition for animal shelters and their communities
that aims to get more dogs and cats adopted or returned to their owners. EHS is one of 49 shelters
participating nationwide, and the organization that achieves the greatest increase in lives saved from
Aug. 1 to Oct. 31 will receive a $100,000 grant from the ASPCA. For updates, “Like” EHS on Facebook
at www.facebook.com/EscondidoHumaneSociety. To help them meet their goal, please encourage
anyone looking to adopt a new family member to visit this shelter.
CONNECTED
YO U R L I N K TO V E T E R I N A R Y S P E C I A LT Y H O S P I TA L | O C T – D E C 2012
Join Us for the iSweat4Pets™ Nature Dog Walk!
Saturday, October 27th from 10am-1pm at the beautiful San Dieguito County Park. This fundraiser for
the FACE Foundation will help raise funds and awareness for pets in need of life-saving veterinary care!
Please support Team VSH by clicking the link on our Facebook page.
TAKE NOTE
CURRENT CLINICAL TRIALS
*NEW* Internal Medicine – Canine IBD and Probiotic VSL#3
We are enrolling dogs with chronic gastrointestinal signs that
are suspected of having idiopathic inflammatory bowel disease
(IBD). Endoscopy will be performed, and if IBD is confirmed, dogs
will be randomized to receive treatment with prednisone and diet,
or prednisone, diet and probiotic VSL#3. This is an 8-week study
requiring two endoscopic procedures. The cost of the probiotic
VSL#3 and the cost of the second endoscopy will be funded.
Contact Dr. Steve Hill at (858) 875-7500 x702
Internal Medicine – Glomerular Disease Study
VSH is participating in a multi-center prospective study
evaluating increased dosing of enalapril in dogs with glomerular
disease. Client incentives include reduced cost of some initial
testing and no cost for scheduled recheck visits and tests.
Contact: Dr. Julie Fischer at (760) 466-0600
Canine Soft Tissue Sarcoma
Trial examining novel biologic therapy for dogs with
MEASUREABLE soft tissue sarcoma.
Eligibility criteria:
good health
• Potentially resectable, extra-cavitary or
oral tumors, measuring 1-7 cm
Contact: Dr. Brenda Phillips (858) 875-7500x713
Oncology – Dogs Receiving Doxorubicin
We are investigating the benefit of Fortiflora™ nutritional supplement in dogs receiving doxorubicin chemotherapy. Dogs already
receiving doxorubicin are eligible.
Contact: Dr. Andi Flory (760) 466-0600 or (858) 875-7500 x719
For more details about these and other clinical trials, please visit
our website at www.vshsd.com.
WE’RE LISTENING
We continue to enhance the client experience by leveraging
technology. The status of surgery patients is now available online.
Each patient is given a unique number so the owner can check in
for real time updates for pre-op, surgery and recovery. This helps
reassure our clients by keeping them well-informed and they can
share the link with their family veterinarian.
FELINE HEPATIC
LIPIDOSIS
PART TWO
• Generally
LIKE US ON FACEBOOK TO KEEP
UP WITH THE LATEST VSH NEWS
AND HAPPENINGS!
www.facebook.com/VeterinarySpecialtyHospital
IN THIS ISSUE:
ANESTHESIA IN
BRACHYCEPHALIC BREEDS
CLINICAL TRIALS
UPCOMING EVENTS
SAN DIEGO 10435 Sorrento Valley Rd San Diego, CA 92121 | NORTH COUNTY 2055 Montiel Rd San Marcos, CA 92069 | www.vshsd.com
10435 Sorrento Valley Rd
Suite 100
San Diego, CA 92121
ANNOUNCEMENTS
TAKE NOTE
*NEW*
Contact Dr. Steve Hill at (858) 875-7500 x702
Internal Medicine – Glomerular Disease Study
Contact: Dr. Julie Fischer at (760) 466-0600
Canine Soft Tissue Sarcoma
MEASUREABLE soft tissue sarcoma.
Eligibility criteria:
good health
• Potentially resectable, extra-cavitary or
oral tumors, measuring 1-7 cm
• Generally
We welcome Holly Hamilton, DVM, MS, DACVO as the newest
member of our Ophthalmology Department. She will be working
exclusively in Sorrento Valley on Monday through Thursday. She joins
us from Veterinary Medical and Surgery Group - Orange County. Dr.
Hamilton received her DVM from the University of Wisconsin in 1989
followed by a year in a small animal private practice. She completed
a one-year small animal internship at Washington State University,
then completed an ophthalmology residency and Master’s degree at
Auburn University in 1991. In 1995 she accepted a faculty position
in ophthalmology at Louisiana State University. She has been in
ophthalmology private specialty practice since 1999 in both
Colorado and California. Dr. Hamilton is well rounded in all aspects
of ophthalmology, including medical and surgical problems. She has
a special interest in diseases of the cornea. She has published several
articles and book chapters in ophthalmology, and looks forward to
meeting and working with you all!
Dr. Andi Flory was elected president of the Veterinary Cooperative
Oncology Group (VCOG), a group of the international organization
Veterinary Cancer Society (VCS). VCOG serves to standardize aspects
of veterinary clinical oncology practice via creation of consensus
documents, and also implements multi-center prospective clinical
trials and provides access to companion species patient databases. Dr.
Flory’s presidency will commence at the annual meeting of VCS in
Las Vegas in October 2012.
SAVE THE DATE
May 19, 2013 – VSH Annual Symposium
8:00 am - 4:30 pm at the University of San Diego
Multiple Educational Tracks: Veterinarians, Technicians,
Managers, plus Workshops!
Registration information and more details to come.
A Special Program for Front Office Staff
and Those Who Work with the Public
San Diego and North County Facilities + Webinar
October 11, 2012
6:15-8:00 pm
Effective Communication: The Key to Dealing with Difficult People
Stacey McKibbin, Certified Business Coach, Action COACH
Temecula CE Dinner and Lecture
Ponte Family Estate & Winery
October 23, 2012
6:30 - 9:00 pm
•Updates
in Veterinary CPR
Tracy Julius, DVM
Radiology
Seth Ganz, DVM, DACVS
•Orthopedic
Fall CE Dinner Program
November 15, 2012
Details TBA
Dr. Mauricio Dujowich held 5 hours of lectures in August at the XIII
International Baja California Veterinary Medical Association
Conference. Topics included surgery of the liver, spleen, pancreas,
kidney, septic abdomens, and intestinal foreign bodies. At the end of
October he will be lecturing for 4 hours at the Eastern European
Veterinary Medical Association conference in Belgrade, Serbia.
Roundtable Discussion & Dinner
San Diego Facility
December 13, 2012
6:30 - 8:00 pm
Adrenal Tumors – a Multi-Specialty Approach
Dr. Andrew Loar is officially settled in as the Clinical Director/
Consulting Cytologist for STAT Veterinary Lab. Back in San Diego
after 12 years in New York, he is eager to re-connect with members
of the Southern California community, and meet new ones. Please
contact Andy at 858.875-7550 or andy.loar@vshsd.com.
For more information on Continuing Education events,
please visit vshsd.com/Veterinarians or contact Ann Ong
at (858) 875-7544 or ann.ong@vshsd.com.
| www.vshsd.com