Troubleshooting the diabetic small animal patient

Effective troubleshooting for a diabetic small animal patient starts with the initial diagnosis of diabetes. Preempting trouble with a thorough and complete history, physical examination, laboratory assessment, and extensive and thoughtful client education before discharge, are crucial first steps toward avoiding trouble altogether. As problems arise, careful consideration of the many variables that contribute to effective diabetic control is necessary. As monitoring strategies evolve and treatment options expand, the clinician's ability to accurately assess and adjust the glycemic control in his or her troubled diabetic patient improves. Common causes of trouble in diabetic patients are reviewed and various strategies for the diagnosis and management of these disorders are discussed in this article. Every effort was made to draw from recently published reports of clinical cases. Few diseases will tie together owner, patient, and therapy as intimately as diabetes mellitus, and few problems will be solved without fully considering all potential factors.     

BOOK REVIEWS Emergency case management

Self-Assessment Colour Review of Small Animal Emergency and Critical Care Medicine Edited by Rebecca Kirby Published by Manson Publishing
Ophthalmology for the Veterinary Practitioner By F. C. Stades, M. H. Boevé, M. Wyman and W. Neumann
The Veterinary Formulary (4th edition) Edited by Yolande Bishop Published by the Pharmaceutical Press, London, in association with the British Veterinary Association     

Critical care monitoring considerations for the diabetic patient

Diabetes mellitus (DM) is a common endocrine disease encountered in the emergency and critical care setting. The diabetic Ketoacidotic (DKA) animal represents an extreme of the DM patient with regard to hyperglycemia and acid-base and electrolyte derangements. Prompt diagnosis of DKA in a critical patient and rapid initiation of appropriate therapy are necessary for a positive outcome. The steps of treatment, in order of importance, include initiation of intravenous fluid therapy, insulin therapy, electrolyte replacement, and reversal of the metabolic acidosis. The main goals of therapy--including correction of dehydration, electrolyte abnormalities and acidosis via aggressive fluid therapy with electrolyte supplementation and correction of ketoacidosis and hyperglycemia via initiation of insulin therapy--can be achieved if these steps are followed. Because of the severity of metabolic alterations in the DKA animal, frequent and careful monitoring are paramount because they will allow the clinician to tailor treatment to each case.     

Anesthetic management of the head trauma patient

Objective: To describe the optimal anesthetic management of patients with brain injury, with emphasis on the support of oxygen delivery to the brain, and the effects of anesthetic agents on cerebral perfusion. Data sources: Clinical and experimental studies from both the human and veterinary neuroanesthesia literature. Summary: The management of patients following primary traumatic brain injury (TBI) significantly impacts outcome. Outcome can be improved by strategies that improve oxygen delivery to the brain and prevent cerebral ischemia. Anesthetic agents have widely variable effects on the blood supply to the brain and, therefore, choice of anesthetic agent can influence neurological outcome. Although in the past, anesthetic agents have been selected for their neuroprotective properties, it is increasingly being recognized that the support of cerebral perfusion during anesthesia contributes more significantly to a positive outcome for these patients. Support of cardiorespiratory function is, therefore, highly important when anesthetizing patients with TBI. Conclusion: Choice of anesthetic agent is determined by the extent of brain injury and intracranial pressure (ICP) elevation. Factors that should be considered when anesthetizing head trauma patients include the effects of anesthetic agents on the cardiac and respiratory systems, their effects on cerebral blood flow (CBF), ICP, and possible neuroprotective benefits offered by certain agents.     

Emergency care and managing toxicoses in the exotic animal patient.

The poisoned exotic veterinary patient remains a significant challenge to the clinician. A patient presenting with the history of exposure to a toxin or poison should be considered to have a potentially life-threatening problem. This article details the ABCs of emergency medicine including fluid therapy and discusses the principles of neurologic management. The last part of the article provides the clinician with guidelines for decontamination and critical care management of some of the more common toxicoses in exotic animals.     

Medical and surgical management of the glaucoma patient

Glaucoma usually causes rapid blindness in small animals and should be treated as a true ophthalmic emergency. Current treatment is directed toward decreasing intraocular pressure to protect the optic nerve and preserve vision. These treatment methods include various medical and surgical methods that are often combined for a particular patient. No magic drugs or surgeries exist to permanently control glaucoma; the clinician often has to switch to assorted methods of treatment after the previous treatments fail to control the intraocular pressure. Newer theories on the cause of glaucoma involve various vascular and toxic effects on the optic nerve rather than simple mechanical damage to the nerve from increased ocular pressure. Therefore, treatments designed to protect the optic nerve from biochemical alterations are probably the future of treating this challenging disease.     

Postoperative management of the exotic animal patient.

Careful postoperative management is crucial for the success of any orthopedic surgical repair. The special needs of the exotic animal must be met during the immediate postoperative period and during hospitalization. Many exotic animals require a quiet, stress-free environment and careful attention to housing parameters, such as perching, temperature, and visual security. To provide adequate pain relief in these patients, analgesia should be given before, during, and after surgery. The drugs most often used for pain relief are NSAIDs and opioid analgesics. After surgery, monitor the healing process carefully with regular examinations and radiographs while remaining vigilant for potential problems such as osteomyelitis or nonunion. Physical therapy prevents the development of fracture disease, which includes joint or ligament contracture and bone or muscle mass loss. Because physical therapy affords the patient full use of the affected limb, it is considered a helpful practice in all patients. Physical therapy, however, is critical for free-ranging exotic animals that will be released back into the wild, such as birds of prey.     

Emergency management of open fractures and luxations.

This article discusses the emergency management of open fractures and traumatic joint luxations. The emergency management of open fractures can be challenging. The proper initial evaluation and treatment of open fractures can have a positive impact on their successful outcome. The clinical signs and diagnosis of traumatic joint luxations are reviewed. Emphasis is placed on the management of these injuries in the emergency situation.     

Postoperative management of the large colon volvulus patient.

Horses with large colon volvulus (LCV) often require intensive postoperative medical management. Although early referral and surgical intervention are critical for minimal postoperative complications and a successful outcome, this is often not possible for many reasons. Endotoxemia, extensive mucosal damage with subsequent severe hypoproteinemia, and focal ischemic necrosis are the major causes of postoperative morbidity and mortality.Although fluid therapy, flunixin meglumine, and antimicrobials are still the mainstay of perioperative management, synthetic colloids are being used to maintain plasma oncotic pressure, hyperimmune antiendotoxic plasma and polymixin B are being used for management of endotoxemia, and lidocaine and constant rate infusion of butorphanol can be used for postoperative analgesia. The use of heparin, dimethyl sulfoxide, and corticosteroids for management of LCV are still controversial. Future studies are required to investigate nutritional improvement and methods to manage cases after surgery to prevent recurrence.     

Clinical management of the cancer patient. Taking a biopsy

Good biopsy protocol depends on excellent interaction with diagnostic pathologists. This article reviews the essentials of diagnostic appraisal, specimen preparation, biopsy interpretation, proper reporting, and implementation of biopsy results in case management. The emphasis is on biopsy of malignancy.     

Assessment and management of the severely polytraumatized small animal patient

Objective: To review the current recommendations for the care of the seriously injured polytraumatized small animal patient, including team organization and facility readiness; scene assessment and care; transport; and hospital assessment and care. Data sources: Original research articles, scientific reviews, book chapters, and clinical experience. Human data synthesis: The care of the seriously injured patient is demanding and requires adequate preparation, rapid access to organized resources and equipment, and skilled personnel. Second in urgency only to stabilization of the airway and breathing is shock. In many, surgical intervention to provide improved and continued stability is required. Evidence is provided by data published comparing survival for humans with high injury scores being cared for at level I trauma centers compared with small rural hospitals. Personal experience as a member of an emergency medical team in the care of multiple injured human patients in both level I trauma centers and small hospitals is also used in this review. Veterinary data synthesis: Publications reporting large clinical series of seriously injured dogs and cats are minimal. Experimental animal models of shock caused by blood loss and the study of various organ injuries and their management are numerous. These and 35 years of the author's experience in managing severely injured dogs and cats (estimated to be >750) is also used in this review for generation of guidelines. Conclusions: Guidelines for care of severe multiple injury patients are presented and are recommended to be used in clinical veterinary medical practice to improve outcome.     

Pain management and regional anesthesia for the dental patient

Current standards of care in veterinary medicine dictate an adequate level of pain control for our patients. Effective pain control uses a proactive, multimode approach that starts with preoperative medications, includes the anesthetic protocol selected, and continues into the postoperative period. A basic understanding of the physiology of pain assists in selecting those agents and modalities best suited for individual patients. Analgesic drug selection and local anesthesia are both integral parts of pain control when performing surgery in the oral cavity. Local (regional) anesthesia plays an important part in the pain control of oral surgical patients. Regional anesthetic techniques are used for many common oral procedures, including extractions, periodontal flap surgery, treatment of traumatic injuries of the oral cavity, tumor removal, palatal surgery, periodontal therapy, and root canal therapy. This presentation will cover strategies for analgesia and the techniques and materials used in local/regional anesthesia in the oral cavity. Anatomic landmarks and guidelines for effective regional blocks will be covered.     

Clinical management of the cancer patient. Principles and applications of chemotherapy

Chemotherapy is an important and effective modality of modern cancer treatment. Practitioners are encouraged to become familiar with this branch of medicine because it can be employed in the local practice setting. In the process of providing service for clientele and care for their pets, practicing clinicians will inevitably be confronted with involvement in some aspect of a chemotherapeutic protocol initiated by a veterinary oncologist. With an understanding of the principles of chemotherapy, the toxicities inherent in the use of these compounds, and the judicious handling of these agents, veterinarians will be able to provide a better standard of care for the animals presented to them.     

Preoperative evaluation and management of the emergency surgical small animal patient.

The initial management and stabilization of the emergency surgical patient is challenging. A consistent systematic evaluation of the four major body systems, determination of the underlying cause, and aggressive stabilization before surgery can optimize the outcome.