The use of IV lipid emulsion for lipophilic drug toxicities

IV lipid emulsion (ILE) therapy is emerging as a potential antidote for lipophilic drug toxicities in both human and veterinary medicine. ILE has already gained acceptance in human medicine as a treatment of local anesthetic systemic toxicity, but its mechanism of action, safety margins, and standardized dosing information remains undetermined at this time. Experimental and anecdotal use of ILE in the human and veterinary literature, theorized mechanisms of action, current dosing recommendations, potential adverse effects, and indications for use in human and veterinary emergency medicine are reviewed herein.     

Use of intravenous lidocaine to prevent reperfusion injury and subsequent multiple organ dysfunction syndrome

Objective: The objective of this article is to review the human and veterinary literature and provide evidence for the potential beneficial effects of intravenous (IV) lidocaine hydrochloride in preventing post‐ischemic–reperfusion injury, the systemic inflammatory response syndrome (SIRS), and subsequent multiple organ dysfunction syndrome (MODS). Human data synthesis: Lidocaine is a local anesthetic and antiarrhythmic agent that has been used for years in human and veterinary medicine for the treatment of ventricular dysrhythmias associated with blunt cardiac trauma, myocardial ischemia, and cardiac surgery. More recently, the drug has been touted as a scavenger of reactive oxygen species (ROS), and has been used to prevent reperfusion dysrhythmias after treatment of myocardial infarction, cross‐clamping of the aorta, and in trauma medicine. Veterinary data synthesis: Although no clinical experiments with prophylactic intravenous lidocaine exist in veterinary medicine, there is a large body of evidence from experimental animals that support the use of lidocaine as a Na⁺/Ca²⁺ channel blocker, superoxide and hydroxyl radical scavenger, inflammatory modulator, and potent inhibitor of granulocyte functions. Lidocaine is being used in some clinical situations in an attempt to prevent the SIRS in veterinary trauma patients. ^a,b, ^a,b Conclusions: A large body of experimental evidence exists supporting the use of lidocaine as an anti‐oxidant and inflammatory modulator useful in preventing reperfusion injury. With the lack of cost‐effective and safe treatments for reperfusion injury in veterinary and human trauma medicine, the use of IV lidocaine to prevent the ensuing inflammatory response and MODS makes it an attractive addition to existing treatments. Therefore, it is essential that prospective clinical trials involving lidocaine as a treatment for prevention of reperfusion injury be performed in companion animals to demonstrate its safety and efficacy.     

Treatment compliance

The main aim of this article is to identify those factors that affect treatment compliance, the extent to which the owners of patients comply with the treatment regimen, and how to improve compliance. The article is mainly based on reports from the medical literature. Although compliance can be measured in several ways, there is no valid and reliable method. For this reason, several methods should be used. Factors that affect treatment compliance in human medicine are (I) the expected effectiveness of treatment, (II) the severity of the disorder, (III) the risks associated with medicine use, (IV) the duration and dosage of medical therapy, (V) patient motivation, and (VI) the doctor-patient relationship. In the literature, in veterinary medicine treatment compliance is reported to range from 44% to 55%, whereas in human medicine it is reported to range from 5% to 96%. Compliance can be improved if (I) the owner can easily incorporate the treatment regimen in his/her daily life, (II) the treatment regimen does not disrupt the owner's daily routine, (III) the owner is informed about and understands the treatment provided, and (IV) the relationship between veterinarian and owner is good. In conclusion, many questions about treatment compliance in veterinary medicine remain unanswered, and research is needed to answer them.     

Measurement of ionized calcium in canine blood samples collected in prefilled and self-filled heparinized syringes using the i-STAT point-of-care analyzer

BACKGROUND: Heparinized syringes are commonly used with point-of-care analyzers (eg, i-STAT) to measure ionized calcium (iCa(2+)); however there is little information about the validity of their use in canine patients. OBJECTIVE: To examine the suitability of prefilled (40 IU heparin/mL) and self-filled (150 IU heparin/mL) heparinized syringes for iCa(2+) measurements using the i-STAT analyzer. METHODS: Forty-seven blood samples were collected from 41 canine patients. Two milliliters of blood were collected into a 2-mL nonanticoagulated (NA) syringe, a commercially available preheparinized (PH) syringe (dry calcium-balanced lithium heparin, 40 IU/mL), and a 2-mL self-filled heparinized (SH) syringe (liquid sodium heparin, 150 IU/mL). iCa(2+) was measured in the sample using the i-STAT analyzer and a wet-reagent analyzer (KoneLab 30i) used as the reference instrument. Data were analyzed using paired t-tests, Pearson correlation coefficient, and Bland-Altman difference plots. RESULTS: There was no significant difference between the results obtained from NA and PH syringes using the i-STAT analyzer, and the correlation was excellent (r =.97). The i-STAT values from the SH syringes (mean, 1.07 mmol/L) were significantly lower (P<.001) than those from the NA syringes (mean, 1.38 mmol/L). iCa(2+) was significantly higher with the i-STAT analyzer than with the KoneLab analyzer for both the PH (mean i-STAT, 1.38 mmol/L vs mean KoneLab, 1.30 mmol/L) and SH (mean i-STAT, 1.07 mmol/L vs mean KoneLab, 1.03 mmol/L) samples. CONCLUSIONS: Blood samples collected in the PH syringes used in this study can be used interchangeably with those collected in NA syringes for measuring iCa(2+) using the i-STAT analyzer. SH syringes with high-concentration heparin products (5000 IU/mL) are unsuitable for measuring iCa(2+) because they cause clinically significant underestimations. Although there was good correlation between the i-STAT and KoneLab analyzers, the results should be interpreted using analyzer-specific reference intervals.     

Aerobic bacterial culture of used intravenous fluid bags intended for use as urine collection reservoirs

Numerous studies have shown a relationship between indwelling urinary catheters and bacterial urinary tract infection. Some veterinary hospitals utilize stored, used intravenous (IV) fluid bags as part of the urine collection system. The authors cultured 95 such bags to see if they were potential sources of bacterial contamination. Forty-two unused IV bags were emptied of their contents for use as controls. Results indicated no aerobic bacterial growth in either group. The authors conclude that properly stored, used IV bags are unlikely sources of aerobic bacterial contamination when used in a urine collection system.     

The use of intravenous lipid emulsion as an antidote in veterinary toxicology

Objective – To review the use of IV lipid emulsion (ILE) for the treatment of toxicities related to fat‐soluble agents; evaluate current human and veterinary literature; and to provide proposed guidelines for the use of this emerging therapy in veterinary medicine and toxicology. Data Sources – Human and veterinary medical literature. Human Data Synthesis – Human data are composed mostly of case reports describing the response to treatment with ILE as variant from mild improvement to complete resolution of clinical signs, which is suspected to be due to the variability of lipid solubility of the drugs. The use of ILE therapy has been advocated as an antidote in cases of local anesthetic and other lipophilic drug toxicoses, particularly in the face of cardiopulmonary arrest and unsuccessful cardiopulmonary cerebral resuscitation. Veterinary Data Synthesis – The use of ILE therapy in veterinary medicine has recently been advocated by animal poison control centers for toxicoses associated with fat‐soluble agents, but there are only few clinical reports documenting successful use of this therapy. Evidence for the use of ILE in both human and veterinary medicine is composed primarily from experimental animal data. Conclusions – The use of ILE appears to be a safe therapy for the poisoned animal patient, but is warranted only with certain toxicoses. Adverse events associated with ILE in veterinary medicine are rare and anecdotal. Standard resuscitation protocols should be exhausted before considering this therapy and the potential side effects should be evaluated before administration of ILE as a potential antidote in cases of lipophilic drug toxicoses. Further research is waranted.     

Treatment of congestive heart failure a neuroendocrine disorder

The understanding of heart failure is no longer based on a supply and demand model of pump failure. Rather, heart failure is seen as a complex pathophysiological process with activation of various neuroendocrine systems. The goals of treatment have changed towards modifying these counterproductive neuroendocrine systems and slowing myocardial maladaptation. Angiotensin converting enzyme inhibitors are the only licensed drugs in veterinary practice that have a direct effect on neurohormones in heart failure. The range of drug options in human medicine is greater and some of these drugs are also increasingly being used in veterinary cardiology practice. This review describes the neuroendocrine systems involved in heart failure and discusses the range of drugs available in human and veterinary medicine. In doing so, it concentrates on the evidence available from good quality randomised trials in both the veterinary field and, where relevant, the human medical field.     

Positron emission tomography: diagnostic imaging on a molecular level

In human medicine positron emission tomography (PET) is a modern diagnostic imaging method. In the present paper we outline the physical principles of PET and give an overview over the main clinic fields where PET is being used, such as neurology, cardiology and oncology. Moreover, we present a current project in veterinary medicine (in collaboration with the Paul Scherrer Institute and the University Hospital Zurich), where a hypoxia tracer is applied to dogs and cats suffering from spontaneous tumors. Finally new developments in the field of PET were discussed.     

Using 20-gauge percutaneous peripheral catheters to reliably collect serial 4-mL blood samples from conscious dogs

Objective To determine the reliability of collecting serial 4-mL blood samples over 13 h using a 20-gauge, cephalic catheter in conscious dogs. Design Prospective, observational study. Animals Twelve (6 males, 6 females) healthy, neutered, lean dogs. Procedure Percutaneous placement of a 20-gauge, 1.1 × 30 mm intravenous over-the-needle catheter into the cephalic vein was performed in each dog on three occasions. Catheter patency was maintained by intermittent flushing with 0.9% saline and 1 IU/mL heparinised saline solutions. Blood samples (4 mL) were obtained at 10 time-points over 13 h, with close monitoring of the dogs and the indwelling catheters. Blood volume, resistance on aspirating blood sample (minimal or marked resistance) and the methods used to improve blood flow were recorded. Results A high proportion (93%) of blood sample collections achieved the required 4-mL volume, and the remaining samples were greater than 1.5 mL. Of the 358 collections via the cephalic catheter, 311 (87%) were obtained with ‘minimal resistance’. The remaining collections had ‘marked resistance’ (n=47) and were associated with a loose catheter in 11% (5/47) and of unknown cause in 89% (42/47). After ‘marked resistance’ had been encountered and the catheter was flushed with saline and heparin solutions, subsequent sampling with ‘minimal resistance’ was frequently possible from the same catheter. Conclusion Use of a percutaneous, 20-gauge intravenous cephalic catheter allowed reliable serial collection of 4-mL blood samples over 13 h in conscious dogs.     

Effect of Manually Preheparinized Syringes on Packed Cell Volume and Total Solids in Blood Samples Collected from American Alligators (Alligator mississippiensis)

The hemodilution effect of manually preheparinized syringes was determined by evaluating the packed cell volume (PCV) and total solids (TS) from blood samples collected from 50 American alligators (Alligator mississippiensis). A volume of 0.2 mL of blood was drawn into 3 syringes of 1 mL: control with no heparin sodium, heparin sodium drawn to 0.1 mL and then expelled, and heparin sodium drawn to 0.2 mL and then expelled. PCV and TS values were determined from each syringe immediately after collection. Mean PCV and TS values were compared between the control and heparin groups using linear mixed modeling. The syringes coated with heparin resulted in a significantly lower mean PCV and TS values when compared with controls, with no significant difference between the heparin groups. This dilution effect was also found to be inconsistent and not accurate from one syringe to another. An adjunct method of obtaining 0.5 mL from already-collected blood samples into 1-mL syringes that were coated with heparin drawn to 0.2 mL and then expelled also showed a significant decrease in PCV and TS values when compared with the control samples, although to a lesser extent. As a result, it cannot be recommended to manually preheparinize syringes when collecting small volume of blood samples from American alligators because significant and unpredictable hemodilution is likely to occur.     

Pharmacokinetics and efficacy of intravenous and extradural tramadol in dogs

Tramadol is a synthetic opioid agonist used extensively in human and, to a lesser extent, veterinary medicine throughout the world. The clinical efficacy and pharmacokinetic profile of intravenous (IV) and extradural (ED) tramadol (2 mg/kg) and its o-desmethyl metabolite were studied in dogs undergoing tibial plateau levelling osteotomy (TPLO). Intra-operative cardiorespiratory variables were monitored and post-operative pain was assessed using the short form of the Glasgow Composite Pain Scale. A rapid (<5 min) and effective production of o-desmethyl tramadol was recorded. The pharmacokinetic profile was similar for tramadol and its metabolite irrespective of the route of administration. ED tramadol provided sufficient intra- and post-operative analgesia without significant clinical side-effects, but the post-operative analgesia was comparable to that following IV administration and the ED route could therefore not be considered a practical alternative to the IV route.     

Cystatin C: A New Renal Marker and Its Potential Use in Small Animal Medicine

The occurrence of chronic kidney disease is underestimated in both human and veterinary medicine. Glomerular filtration rate (GFR) is considered the gold standard for evaluating kidney function. However, GFR assessment is time‐consuming and labor‐intensive and therefore not routinely used in practice. The commonly used indirect GFR markers, serum creatinine (sCr) and urea, are not sufficiently sensitive or specific to detect early renal dysfunction. Serum cystatin C (sCysC), a proteinase inhibitor, has most of the properties required for an endogenous GFR marker. In human medicine, numerous studies have evaluated its potential use as a GFR marker in several populations. In veterinary medicine, this marker is gaining interest. The measurement is easy, which makes it an interesting parameter for clinical use. This review summarizes current knowledge about cystatin C (CysC) in humans, dogs, and cats, including its history, assays, relationship with GFR, and biological and clinical variations in both human and veterinary medicine.     

Discussion of the Compendium of Veterinary Standard Precautions: preventing zoonotic disease transmission in veterinary personnel

Veterinary practices are unique environments that bring humans into close contact with many different species of animals; therefore, the risk of exposure to infectious pathogens is inherently different in veterinary medicine than in human medicine. In contrast to the risk of exposure to blood in human medicine, infections from zoonotic diseases in veterinary personnel are primarily related to exposure to animal faeces, infected skin, wounds, droplets and puncture wounds. Infection-control measures in veterinary practices are often insufficient to prevent zoonotic disease transmission. The Veterinary Standard Precautions (VSP) Compendium is designed to help prevent transmission of zoonotic pathogens from animal patients to veterinary personnel in private practice.     

The Coombs' test in veterinary medicine: past, present, future

The Coombs' test, also known as the antiglobulin test, is used most frequently in veterinary medicine as an aid in the diagnosis of immune-mediated hemolytic anemia. The test also is used widely in human medicine to screen for red blood cell alloantibodies. Polyspecific reagents for veterinary use typically contain anti-IgG, anti-IgM, and anti-C3. Monospecific reagents also are available. False-positive and false-negative test results can be obtained. Inadequate sensitivity of the standard test in human and veterinary medicine has necessitated development of alternate, more sensitive technologies.     

Derivation of feline vaccine-associated fibrosarcoma cell line and its growth on chick embryo chorioallantoic membrane – a new in vivo model for veterinary oncological studies

Feline vaccine associated fibrosarcomas are the second most common skin tumor in cats. Methods of treatment are: surgery, chemotherapy and radiotherapy. Nevertheless, the usage of cytostatics in feline vaccine associated sarcoma therapy is limited due to their adverse side effects, high toxicity and low biodistribution after i.v. injection. Therefore, much research on new therapeutic drugs is being conducted. In human medicine, the chick embryo chorioallantoic membrane (CAM) model is used as a cheap and easy to perform assay to assess new drug effectiveness in cancer treatment. Various human cell lines have different tumors growth on CAM. In veterinary medicine such model has not been described yet. In the present article derivation of feline vaccine associated fibrosarcoma cell line and its growth on CAM is described. The cell line and the tumor grown were confirmed by histopathological and immunohistochemical examination. As far as we believe, this is the first attempt to create such model, which may be used for further in vivo studies in veterinary oncology.     

Recombinant human thyrotropin in veterinary medicine: current use and future perspectives

Recombinant human thyrotropin (rhTSH) was developed after bovine thyrotropin (bTSH) was no longer commercially available. It was approved by the Food and Drug Administration (FDA) and the European Medicines Agency (EMEA) as an aid to diagnostic follow-up of differentiated thyroid carcinoma in humans and for thyroid remnant ablation with radioiodine. In addition, rhTSH is used in human medicine to evaluate thyroid reserve capacity and to enhance radioiodine uptake in patients with metastatic thyroid cancer and multinodular goiter. Likewise, rhTSH has been used in veterinary medicine over the last decade. The most important veterinary use of rhTSH is thyroidal functional reserve testing for the diagnosis of canine hypothyroidism. Recent pilot studies performed at Ghent University in Belgium have investigated the use of rhTSH to optimize radioiodine treatment of canine thyroid carcinoma and feline hyperthyroidism. Radioiodine treatment optimization may allow a decreased therapeutic dosage of radioiodine and thus may improve radioprotection. This review outlines the current uses of rhTSH in human and veterinary medicine, emphasizing research performed in dogs and cats, as well as potential future applications.     

Adverse drug interactions of importance in veterinary practice

Multiple drug therapy is often used in veterinary practice; occasionally, inappropriate combinations of drugs may be administered which interact to produce adverse responses. Such interactions may occur in vitro because of physically or chemically incompatible drugs having been mixed before administration or in vivo. A number of important in vitro incompatibilities concerning parenteral drugs are tabulated, consideration having been given both to problems attending the use of intravenous fluids as vehicles for their administration and to incompatibilities between the drugs themselves. Interactions which occur in vivo are also examined; these have been grouped according to the various mechanisms by which they occur.     

Molecular characterization of community‐associated methicillin‐resistant Staphylococcus aureus from pet dogs

Community‐associated methicillin‐resistant Staphylococcus aureus (MRSA) is a serious public health concern and in Australia, one that disproportionately affects Aboriginal people. Paralleling MRSA in human medicine, methicillin‐resistant S. pseudintermedius (MRSP) is an increasingly prevalent pathogen in veterinary medicine. We aimed to characterize the carriage of MRSA and MRSP in dogs and cats from predominantly Aboriginal communities in a very remote region of New South Wales (NSW), Australia. Pets (303 dogs and 80 cats) were recruited from six communities in western NSW. Three swabs were collected from each animal (anterior nares, oropharynx and perineum) and from skin lesions or wounds (if present) and cultured on selective media for methicillin‐resistant staphylococci. Human host‐adapted community‐associated MRSA representing four multilocus sequence types (ST1‐IV, ST5‐IV, ST72‐IV, ST93‐IV) were isolated from eight dogs (prevalence 2.6%, 95% confidence interval 1.3%–5.1%). Two ST5‐IV isolates from a single dog were phenotypically trimethoprim‐resistant, harbouring trimethoprim‐resistant gene dfrG within the SCCmec type IVo mobile genetic element. MRSA was not isolated from any cats and MRSP was not isolated from any dogs or cats. This study estimated a high prevalence of human host‐adapted community‐associated MRSA carriage in dogs despite an absence of MRSP. This suggests MRSA carried by dogs in remote NSW originate from human hosts. The cycle of transmission between people, dogs and common environmental sources warrants further investigation. To our knowledge, this is the first report of trimethoprim‐resistant ST5‐IV in eastern Australia and the first report of trimethoprim‐resistant ST5‐IV from a dog.     

Helium‐oxygen gas‐carrier mixture (heliox): a review of physics and potential applications in veterinary medicine

Background – To review the physics of helium with regard to airway physiology, as well as known human and potential veterinary applications of administration of inhaled helium‐oxygen gas‐carrier mixture (heliox). Data Sources – Human and veterinary studies. Human Data Synthesis – Helium‐oxygen mixtures have been used in human medicine for over 70 years as an adjunct therapy in various upper and lower respiratory disorders. Helium's low density promotes laminar flow through partially obstructed airways, resulting in a decreased work of breathing. Veterinary Data Synthesis – Little to no evidence‐based medicine exists to support or oppose the use of heliox in veterinary species. However, domestic animal species and humans share several common pathophysiologic aspects of various obstructive airway disorders. Thus, veterinary patients may also ultimately and significantly benefit from this novel therapy. Conclusion – Prospective studies are needed in veterinary medicine to determine the utility of heliox in clinical scenarios.