Preface, vii 1 Vascular Access Techniques, 1 2 Nutritional Support and Orogastric Lavage, 69 3 Thoracocentesis and Thoracostomy Tube Placement, 101 4 Oxygen Supplementation and Respiratory Sampling Techniques, 133 5 Urinary Catheter Placement, Urohydropulsion, and Temporary Antepubic Cystostomy Catheter Placement, 171 6 Abdominocentesis and Diagnostic Peritoneal Lavage, 209 7 Pericardiocentesis and Pericardial Drainage Catheter, 233 8 Central Venous Pressure, 243 9 Cardiopulmonary Resuscitation, 253 10 Continuous Rate Infusions, 273 Index, 277 The companion website provides video clips demonstrating procedures from the book for download at www.wiley.com/go/hackett

Antiemetics are commonly prescribed during the treatment of canine parvoviral enteritis. This blinded, randomized prospective study compared the quality of clinical recovery and duration of hospitalization in canine parvoviral dogs receiving either maropitant (1 mg/kg [0.45 mg/lb] IV q 24 hr, n = 11) or ondansetron (0.5 mg/kg [0.23 mg/lb] IV q 8 hr, n = 11). All dogs were treated with IV fluids, cefoxitin, and enteral nutrition. Frequency of vomiting and pain scoring were recorded twice daily. Rescue analgesics and antiemetics were administered as dictated by specific pain and vomiting criteria. Clinical severity scoring, body weight, and caloric intake were monitored daily. When comparing dogs receiving maropitant versus ondansetron, respectively, there were no differences in duration of hospitalization (3.36 ± 0.56 versus 2.73 ± 0.38 days, P = .36), requirement of rescue antiemetic (3/11 versus 5/11 dogs, P = .66), duration of vomiting (5 versus 4 days, P = .65), or days to voluntary food intake (2 versus 1.5 days, P = 1.0). Results of this study suggest that maropitant and ondansetron are equally effective in controlling clinical signs associated with parvoviral enteritis.

BackgroundMorbidity and case fatality from rattlesnake envenomation is regionally specific because of variability in relative toxicity of the species of snake encountered. A previous report of rattlesnake envenomation in New World camelids (NWC) from the western coastal United States documented high case fatality rates and guarded prognosis for survival.Hypothesis/ObjectivesTo describe clinical findings, treatments, and outcome of NWC with prairie rattlesnake (Crotalus viridis viridis) envenomation in the Rocky Mountain region of the United States.AnimalsTwenty-seven NWC admitted to the Colorado State University Veterinary Teaching Hospital for evaluation of acute rattlesnake envenomation between 1992 and 2012.MethodsMedical records of NWC evaluated for rattlesnake envenomation as coded by the attending clinician and identified by a database search were reviewed retrospectively. Month of admission, signalment, area of bite, clinical and clinicopathologic data, treatments, and outcome were recorded.ResultsTwenty-five llamas and 2 alpacas were admitted for envenomation. Llamas were overrepresented compared to hospital caseload. The face was the most common site of envenomation, observed in 96% of recorded cases. Presenting clinical signs included fever, tachypnea, tachycardia, and respiratory distress. Nine animals required a tracheotomy. Median hospitalization time was 3 days and overall survival rate was 69%.Conclusions and Clinical ImportanceCase fatality rate for prairie rattlesnake envenomation in NWC was lower than that reported in the Western coastal region of the United States and similar to that reported for prairie rattlesnake envenomation in horses.

We are proud members of both the Veterinary Emergency and Critical Care Society (VECCS) and the American College of Veterinary Emergency and Critical Care (ACVECC), honored to be serving as elected officers. Our work with both organizations has brought us in direct contact with many brilliant and dedicated members. It is very rewarding to associate with such intelligent, driven, motivated, and fascinating members who care about the advancement of veterinary medicine and animal care. Over the past year, we watched in amazement as members of both organizations came together through the efforts and motivation of Dr. Manuel Boller and Dr. Dan Fletcher to participate in the Reassessment Campaign on Veterinary Resuscitation (RECOVER). More than 80 veterinary professionals worked with advice from a co-chair of the International Liaison Committee on Resuscitation (ILCOR), Dr. Vinay Nadkarni, to critically evaluate the state of resuscitation medicine and its application to clinical veterinary medicine. The results of this collaboration are the basis for this issue of the Journal of the Veterinary Emergency and Critical Care. We are extremely proud of the efforts of the RECOVER team and what was accomplished in such a short time, and sincerely thank the RECOVER group for this timely, informative work. The RECOVER initiative speaks to what can be accomplished through the mutual efforts of our organizations and highlights what can happen when the combined resources of VECCS and ACVECC are focused on a common goal. VECCS and ACVECC have collaborated for years on many great ventures, most notably the outstanding continuing education program presented annually at the International Veterinary Emergency and Critical Care Symposium (IVECCS). One of our shared visions is to encompass emergency medicine and critical issues faced by all species, and seek the best information wherever it can be found. Combine the caseload and experience of the veterinarians, veterinary technicians, hospital administrators, and industry members of VECCS with the specialist expertise of members of ACVECC, and the possibilities of future collaborations are limitless. What will we do next?

Objective To report a correlation between the increased number of medical marijuana licenses and marijuana toxicosis in dogs in a state with legalized marijuana for medical use. Design Retrospective case series from January 1, 2005 to October 1, 2010. Setting Private specialty referral hospital and a university teaching hospital. Animals A total of 125 client-owned dogs presenting for known or suspected marijuana toxicosis with or without a urine drug screening test (UDST). Interventions None. Measurements and Main Results During the study period, 125 dogs were evaluated including 76 dogs with known marijuana exposure or a positive UDST (group 1), 6 dogs with known marijuana ingestion and a negative UDST (group 2), and 43 dogs with known marijuana ingestion that were not tested (group 3). The incidence of marijuana toxicosis presenting to both hospitals increased 4-fold, while the number of people registered for medical marijuana in the state increased 146-fold in the last 5 years. A significant positive correlation was detected between the increase in known/suspected marijuana toxicosis in dogs (groups 13) and the increased number of medical marijuana licenses (correlation R coefficient = 0.959, P = 0.002). Two dogs that ingested butter made with medical grade marijuana in baked products died. Conclusions A significant correlation was found between the number of medical marijuana licenses and marijuana toxicosis cases seen in 2 veterinary hospitals in Colorado. Ingestion of baked goods made with medical grade tetrahydrocannabinol butter resulted in 2 deaths. UDST may be unreliable for the detection of marijuana toxicosis in dogs.

Drug therapy is integral to emergency and critical care medicine but can also be the source of serious medical errors. There are important considerations with regard to drug, route, and interactions that require close attention in critical patients. The continuous development of new therapeutics and new information concerning current therapies requires practitioners to continually review drug therapies. This article addresses general guidelines, routes of administration, dosage calculations, interactions, monitoring recommendations, and resources available to help clinicians improve their drug therapy practices.

This issue of Veterinary Clinics of North America: Small Animal Practice is devoted to a systems-based review of organ dysfunction seen in our most critical patients. With advances in trauma and emergency care, patients surviving previously fatal problems now succumb to the failure of one or more major systems. While devastating, multiple organ failure is really a disease of success. A single patient may suffer altered function in any or all of the systems discussed in this text. My goal in bringing together these experts and articles is to provide a single reference to review causes, diagnosis, management, and prevention of vital organ dysfunction in small animals. I hope this will be a useful reference for small animal practitioners managing these complex cases. After an introduction on the history, epidemiology, and understanding of organ failure, experts discuss individual organ systems. The authors are all practicing specialists who see and manage these cases in their respective practices. I will admit to a personal bias toward the respiratory system.Respiratory failure and inadequate tissue oxygenation are leading causes of the failure of other organ systems.DrCampbell starts off with important insight into the acute respiratory distress syndrome and respiratory failure in the critically ill. While hypotension and inadequate cardiac output as causes of organ failure are discussed in nearly every article, Dr Bulmer’s article on cardiac dysfunction highlights the myocardial changes seen in the septic and systemically ill. The kidney and liver are often the most obvious systems failures we associate with critical illness. Dr Lunn presents the causes andmanagement of acute renal failure and Drs McCord andWebb discuss the manifestations andmanagement of hepatic failure. The role of the gastrointestinal tract in critical illness including the signs and consequences of gastrointestinal failure are also discussed. Moving away from classic organ systems, Dr Martin discusses the important role of the adrenal gland in the body’s response to stress. Her article focuses on the recognition and management of adrenal insufficiency associated with critical illness.

The gastrointestinal (GI) tract is one of the shock organs in dogs. GI dysfunction in critically ill veterinary patients manifests in mild problems such as hypomotility, anorexia, and nausea to more serious problems such as intractable vomiting, severe diarrhea, and septicemia. Septicemia is a serious complication of GI dysfunction because intestinal flora gains access to a patient's bloodstream, leading to infections in other organ systems and a systemic inflammatory response. The therapy for GI dysfunction is mainly supportive, treating nausea and dehydration although supporting the ailing GI tract with adequate enteral nutrition and, in some cases, dietary supplements and antibiotics.

Multiple organ failure and multiple organ dysfunction syndrome (MODS) were first recognized as undesirable complications of advancements in emergency and critical care. MODS remains the leading cause of death and resource expenditure in human intensive care units. MODS has been documented in small animal veterinary patients raising similar concerns. The understanding of the pathogenesis of MODS has evolved from uncontrolled infection to uncontrolled inflammation. Management is primarily through supportive care, early and aggressive monitoring of organ function, and intensive care nursing. Tissue hypoxia, microvascular thrombosis, increased vascular permeability, and disrupted cell-cell communication are prominent features of MODS.

OBJECTIVE:To describe the surgical technique and report outcome of dogs undergoing bioprosthesis valve replacement for severe tricuspid regurgitation (TR) secondary to congenital tricuspid valve dysplasia (TVD).ANIMALS, MATERIALS AND METHODS:Twelve client-owned dogs (19-43 kg) with TVD underwent tricuspid valve replacement with a bovine pericardial or porcine aortic bioprosthesis with the aid of cardiopulmonary bypass. Anticoagulation with warfarin was maintained for 3 months after surgery and then discontinued.RESULTS:Ten of 12 (83.3%) dogs survived surgery and were discharged from the hospital. Seven dogs were alive with complete resolution of TR for a median period of 48 months (range 1-66 months) after surgery. Two dogs underwent euthanasia because of bioprosthesis failure due to inflammatory pannus at 10 and 13 months after surgery. Two dogs experienced valve thrombosis that was resolved by tissue plasminogen activator. One dog developed suspected endocarditis after surgery that was resolved with antibiotics. Serious cardiac complications included atrial fibrillation and flutter, right-to-left shunt through an uncorrected patent foramen ovale, complete atrioventricular block, and sudden cardiac arrest. Postoperative atrial fibrillation or flutter did not occur in 7 dogs treated prophylactically with oral amiodarone before surgery.CONCLUSIONS:Curative intermediate-term outcomes are possible in dogs undergoing open tricuspid valve replacement with a bioprosthesis. Prosthesis-related complications include inflammatory pannus, thrombosis, and endocarditis. Postoperative atrial fibrillation or flutter can be reduced or prevented by prophylactic preoperative treatment with amiodarone. Several identified complications are avoidable or can be reduced with increased awareness and experience with these techniques.

OBJECTIVETo describe the clinical presentation and resultant metabolic disturbances following retroperitoneal administration of hyperphosphate enemas in alpaca crias.CASE OR SERIES SUMMARYTwo crias presented to the Colorado State University Veterinary Teaching Hospital after inadvertent transvaginal retroperitoneal hyperphosphate enema administration. The first cria developed an acute onset of neurologic signs, severe hypernatremia, and died soon after presentation. The second cria developed severe hyperphosphatemia, hypocalcemia, and acidemia. The metabolic derangements normalized within 24 hours of intensive treatment with calcium supplementation and IV crystalloid fluid diuresis. The cria was discharged after 1 week in the hospital.NEW OR UNIQUE INFORMATION PROVIDEDThis report provides a description of electrolyte disturbances secondary to inadvertent transvaginal retroperitoneal administration of hyperphosphate enemas in 2 crias and attendant clinical signs of these disturbances. Management of hyperphosphatemia and hypocalcemia in 1 cria via aggressive fluid therapy with calcium supplementation led to a rapid and sustained normalization of phosphorus, calcium, and acid-base balance.

BACKGROUND:This study was performed to document the frequency and severity of limb injuries that occur when dogs come in contact with metal landscape edging. A retrospective study from 1997 to 2007 was performed at Colorado State University veterinary teaching hospital. Sixty dogs were admitted to hospital for traumatic limb injuries resulting from metal landscape edging identified by a computerized medical records search.KEY FINDINGS:Most dogs were young, large breed dogs. All 60 dogs suffered traumatic pedal lacerations when contacting metal landscape edging, the majority of which occurred on the forelimbs. Eighty-five percent required surgical repair. All 60 dogs were discharged from the hospital and 30 were available for long-term follow-up. While most dogs healed with a perfect cosmetic outcome, 3 dogs with tendon involvement developed residual digital deformities.SIGNIFICANCE:Dogs are at risk of injury when exposed to metal landscape edging. Severity of pedal injury determines treatment protocol and prognosis for recovery.

Urethral obstruction is a common medical emergency in cats. Frequency of post-obstruction diuresis in cats following resolution of urethral obstruction is unknown. The objective of this study was to document frequency and associated clinical features of post-obstruction diuresis in cats. The records of 32 cats undergoing 33 admissions to the Colorado State University Veterinary Hospital for urethral obstruction were reviewed. Signalment, admission blood values, fluid therapy, and urine output were recorded. Diuresis was defined as urine output greater than 2ml/kg/h. Post-obstructive diuresis occurred in 46% (13/28) of cats within the first 6h of treatment. Occurrence of post-obstructive diuresis was statistically more likely in cats with venous pH<7.35 on admission. Urine production following resolution of urethral obstruction should be monitored so that fluid therapy can be adjusted to the individual patient, as many cats will have a higher fluid requirement secondary to post-obstruction diuresis.

Polyunsaturated fatty acids (PUFAs) have anti-inflammatory effects at low concentrations; however increased dietary consumption may conversely increase susceptibility to oxidation by free radicals. The objective of this study was to determine the effects of PUFAs on selective oxidative injury and inflammatory biomarkers in canine urine and serum. Dogs (n = 54) consumed a diet supplemented with 0.5% conjugated linoleic acid/dry matter, 1.0% conjugated linoleic acid/dry matter, or 200 mg/kg docosahexaenoic acid/eicosapentaenoic acid for 21 days. All dogs exhibited significantly increased plasma PUFA concentrations. All dogs had significant elevations in urinary F(2a) isoprostane concentration, though dogs consuming a diet containing 1.0% conjugated linoleic acid/dry matter had the highest increase (P = .0052). Reduced glutathione concentrations within erythrocytes decreased significantly in all three dietary treatment groups (P = .0108). Treatment with diets containing 1.0% conjugated linoleic acid/dry matter resulted in the greatest increase in oxidant injury. Caution should be exercised when supplementing PUFAs as some types may increase oxidation.

Case Description —A 6-year-old castrated male Llewelyn Setter was evaluated because of an acute onset of myalgia and respiratory distress. Clinical Findings —Physical examination revealed a stiff stilted gait, swollen muscles that appeared to cause signs of pain, panting, and ptyalism. The dog had a decrease in palpebral reflexes bilaterally and a decrease in myotatic reflexes in all 4 limbs. The panniculus reflex was considered normal, and all other cranial nerve reflexes were intact. Serum biochemical analysis revealed markedly high cardiac troponin-I concentration and creatine kinase and aspartate aminotransferase activities. Urinalysis revealed myoglobinuria. Results for thoracic and abdominal radiography, blood pressure measurement, and an ECG were within anticipated limits. Echocardiographic findings were consistent with secondary systolic myocardial failure. Arterial blood gas analysis confirmed hypoxemia and hypoventilation. The dog had negative results when tested for infectious diseases. Examination of skeletal muscle biopsy specimens identified necrotizing myopathy. Treatment and Outcome —Treatment included ventilatory support; IV administration of an electrolyte solution supplemented with potassium chloride; administration of dantrolene; vasopressor administration; parenteral administration of nutrients; use of multimodal analgesics; administration of clindamycin, furosemide, mannitol, and enrofloxacin; and dietary supplementation with L -carnitine and coenzyme Q 10 . Other medical interventions were not required, and the dog made a rapid and complete recovery. Clinical Relevance —Necrotizing myopathy resulting in rhabdomyolysis and myoglobinuria can lead to life-threatening physical and biochemical abnormalities. Making a correct diagnosis is essential, and patients require intensive supportive care. The prognosis can be excellent for recovery, provided there is no secondary organ dysfunction.

OBJECTIVE:To investigate a technique of central venous pressure (CVP) measurement using a newly developed catheter in healthy adult horses.DESIGN:Prospective experimental study.SETTING:University research facility.ANIMALS:Twenty healthy adult horses.INTERVENTIONS:An equine central venous catheter was inserted into the jugular vein to a length of approximately 80 cm from the mid-cervical region in an attempt to catheterize the pulmonary artery. Pulmonary arterial catheterization was confirmed by echocardiography. Insertion distance and pressure were measured at this location with a disposable manometer. The catheter was then withdrawn until presence in the right atrium was confirmed by echocardiography. Insertion distance and pressure were also measured at this location. The catheter was then withdrawn in 5 cm increments until exiting the jugular insertion site with pressure measured at each location. All pressure measurements were taken with the manometer zero position at the point of the shoulder.MEASUREMENTS AND MAIN RESULTS:Pulmonary artery catheterization was successful in 16 of 20 horses. Mean pulmonary arterial pressure was 23.8 cm H2O (17.5 mm Hg) (95% confidence interval [CI] 20.9-26.7 cm H2O [15.4-19.6 mm Hg]). Mean right atrial pressure was 8.3 cm H2O (6.1 mm Hg) (95% CI 7.1-9.4 cm H2O [5.2-6.9 mm Hg]). Right atrial pressure was compared with pressures recorded at sequential insertion distances and resulted in a recommendation for catheter insertion of at least 40 cm for CVP measurement in adult horses. Jugular venous pressure measurement was statistically different from CVP measurement.CONCLUSIONS:This catheter measurement technique is well tolerated in normal horses. Routine clinical use of this equine central venous catheter may improve our ability to monitor patients and improve patient care and outcomes of ill horses in hospital.

Hemoglobin-based oxygen carriers (HBOC) have been primarily studied for blood loss treatment. More recently infusions of HBOC in euvolemic subjects have been proposed for a wide variety of potential therapies in which increased tissue oxygenation would be beneficial. However, compared with the exchange transfusion models to study blood loss, less is known about HBOC oxygen delivery and vasoacitvity when it is infused in euvolemic subjects. We hypothesized that HBOC [polymerized bovine hemoglobin (PBvHb)] infusion creating hypervolemia would increase oxygen delivery to tissues during acute global hypoxia. Vascular oxygen content and hemodynamics were determined after euvolemic rats were infused with 3 ml of either lactated Ringer or PBvHb solution (13 g/dl, 1.3 g/kg) during acute hypoxia (FIO 2 = 10%, 4 h) or normoxia (FIO 2 = 21%) exposure. Our data demonstrated that compared with Ringer-infused animals, in hypoxia and normoxia, PBvHb treatment improved oxygen content but raised mean arterial pressure, lowered stroke volume, heart rate, and cardiac index, which resulted in a net reduction in blood flow and oxygen delivery to the tissues. The PBvHb vasoactive effect was similar in magnitude and direction as to the Ringer-infused animals treated with a nitric oxide synthase inhibitor nitro-l-arginine, suggesting the PBvHb effect is mediated via nitric oxide scavenging. We conclude that infusion of PBvHb is not likely to be useful in treating global hypoxia under these conditions.

Objective: Compare cardiac index (CI) and oxygen delivery index (DO2I) in conscious, critically ill dogs to control dogs; evaluate the association of CI and DO2I with outcome.Design: Prospective non-randomized clinical study.Setting: Veterinary teaching hospital.Animals: Eighteen client-owned dogs with systemic inflammatory response syndrome (SIRS) and 8 healthy control dogs.Measurements and Main Results: CI of dogs with SIRS was measured using lithium dilution at times 0, 4, 8, 16, and 24 hours. Data collected included physical exam, arterial blood gas (ABG) and hemoximetry. CI of control dogs was measured 3 times with 1 measurement of ABG. Mean CI +/- SE in SIRS patients was 3.32 +/- 0.95 L/min/m(2); lower than controls at 4.18 +/- 0.22 L/min/m(2) (P < 0.001). Mean DO2I +/- SE in SIRS patients was 412.91 +/- 156.67 mL O-2/min/m(2); lower than controls at 785.24 +/- 45.99 mL O-2/min/m(2) (P < 0.001). There was no difference in CI (P=0.49) or DO2I (P=0.51) for dogs that survived to discharge versus those that did not. There was no difference in mean CI (P=0.97) or DO2I (P=0.50) of survivors versus non-survivors for 28-day survival. Survivors had lower blood glucose (P=0.03) and serum lactate concentrations (P=0.04) than non-survivors.Conclusions: CI and DO2I in conscious dogs with SIRS were lower than control dogs, which differs from theories that dogs with SIRS are in a high cardiac output state. CI and DO2I were not significantly different between survivors and non-survivors. Similar to previous studies, lactate and glucose concentrations of survivors were lower than non-survivors.

It is estimated that there are over 5 million homeless animals in the United States. While the veterinary profession continues to evolve in advanced specialty disciplines, animal shelters in every community lack resources for basic care. Concurrently, veterinary students, interns, and residents have less opportunity for practical primary and secondary veterinary care experiences in tertiary-care institutions that focus on specialty training. The two main goals of this project were (1) to provide practical medical and animal-welfare experiences to veterinary students, interns, and residents, under faculty supervision, and (2) to care for animals with medical problems beyond a typical shelter's technical capabilities and budget. Over a two-year period, 22 animals from one humane society were treated at Colorado State University Veterinary Medical Center. Initial funding for medical expenses was provided by PetSmart Charities. All 22 animals were successfully treated and subsequently adopted. The results suggest that collaboration between a tertiary-care facility and a humane shelter can be used successfully to teach advanced procedures and to save homeless animals. The project demonstrated that linking a veterinary teaching hospital's resources to a humane shelter's needs did not financially affect either institution. It is hoped that such a program might be used as a model and be perpetuated in other communities.

OBJECTIVE:To determine the frequency of canine and feline emergency visits with respect to the lunar cycle.DESIGN:Retrospective case series.ANIMALS:11,940 dogs and cats evaluated on an emergency basis during an 11-year period.PROCEDURES:Date of emergency visit, signalment, and chief complaint were retrieved from a medical records database. Emergency type was categorized as animal bite, cardiac arrest, epilepsy, ophthalmic, gastric dilatation-volvulus, trauma, multiple diseases, neoplasia, or toxicosis. The corresponding lunar phase was calculated and recorded as new moon, waxing crescent, first quarter, waxing gibbous, full moon, waning gibbous, last quarter, or waning crescent. The effect of lunar phase on the frequency of emergency visits was evaluated by calculating relative risk.RESULTS:Of 11,940 cases, 9,407 were canine and 2,533 were feline. Relative risk calculations identified a significant increase in emergencies for dogs and cats on fuller moon days (waxing gibbous to waning gibbous), compared with all other days.CONCLUSIONS AND CLINICAL RELEVANCE:Results suggested that more emergency room visits occurred on fuller moon days for dogs and cats. It is unlikely that an attending clinician would notice the fractional increase in visits (0.59 and 0.13 more canine and feline visits, respectively) observed in this study at a facility with a low caseload. If the study is repeated at a facility with a robust emergency caseload, these results may lead to reorganization of staffing on fuller moon dates. A prospective study evaluating these findings under conditions of high caseload is necessary to determine the clinical relevance.