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Dateline 7.19.10Welcome to VetCom Publications, a bimonthly newsletter available both in print and online. VetCom Publications offers readers case studies, practice tips from a clinical and cost savings perspective as well as educational opportunities. This issue also includes a forum for veterinarian to manufacturer communication and so much more.

News headlines for the past few months have been dominated by the BP oil spill in the Gulf of Mexico. The stories tell a tragic tale of an envi-ronmental catastrophe. Hundreds of bird and marine animals have been affected by the ever growing black liquid into their habitat.

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in THIS ISSUEClinical Diagnostics of Fluid Therapy 4

Case Study: Beagle with a Poor

Appetite and Lethargy 11

Coming to Trade Show Near You 14

Clinical Update of the Callitrichidae Collection of Loro Parque 15

Contributing Author:

Andrew J. Rosenfeld, DVM, ABVP

Clinical Diagnostics of Fluid Therapy

Cocoa Taylor, a 13 year old female spayed 7 pound black DSH cat enters the hospital with a chief compliant of weakness, anorexia and chronic vomiting for the last 2 days. The owner’s report that Cocoa appears thin, less active, and anorexic. She is vomiting 10-12 times per day. Cocoa is strictly an inside cat and has had no change in diet or any exposure to toxins, poison or plants. Cocoa was 11.5 pounds 3 months ago on her last examination.

On physical examination, the veterinarian finds that Cocoa is depressed, dehydrated (10+ %), and thin. Cocoa’s temperature is subnormal at 98.9 degrees Fahrenheit; her heart rate is elevated at 200 beats/min with weak to normal pulses. Medical recommendations include intravenous fluids, complete blood count, chemistry, urinalysis, thyroid level and fecal examination. In-house lab work is finalized, and parameters are within normal limits except for the following changes in the blood work:

Test Finding Normal

HCT 24% (l) 25-35%

Albumin 4.2 (h) 2.5-3.5 mg /dl

Glucose 132 (h) 80-120 mg/dl

Na 135 (h) 139-150 mEq/L

K 3.1 (l) 3.4-4.9 mEq/L

Cl 104 (l) 106-127 mEq/L

BUN >140 (h) 15-34 mg/dl

Creatinine 8.2 (h) 1.0-2.2 mg/dl

TCO2 19 (17-25)

AnGap 12 (8-25)

pH 7.26 (l) (7.35-7.45)

pCO2 35 (34-40)

HCO3 14 (l) (20-40)

BE excess -12 (l) (-5-0)

Urine Specific 1.011 (l) 1.025-1.045Gravity

Intravenous fluid therapy is the

standard of care at all levels

of practice, whether it is used for

dieresis, rehydration, or emergency

therapy. However, the medical

team must develop clinical

diagnostic protocols that evaluate

the effectiveness of therapy

and monitoring for secondary

disease concerns.


Testing was performed using a VetScan i-STAT 1. These normal ranges are for

the VetScan i-STAT 1. The VetScan VS2 and VetScan Classic may have different

reference intervals based on differences in methodologies.

Based on the available medical history, physical exam findings and clinical diagnostic testing, the veterinarian’s primary concern is chronic renal disease. The veterinarian recommends aggressive intravenous fluid therapy, medications, and clinical monitoring. The medical team begins to administer a fluid bolus of 100 cc of Normosol and then starts Cocoa on 25 cc/hr of Normosol with 20 mEq KCL/L. Over the next 12 hours, Cocoa appears weaker, with decreased pulses, with increased respiratory effort. The medical team obtains another blood sample and blood pressure. The team notes:

The team is now faced with a severely life threatened patient with concerns of anemia, hypertension, hypo-glycemic, and hypokalemia. With a thorough clinical diagnostic protocol in place, Cocoa’s secondary concerns could have been identified earlier, discussed with the client and treated before the patient became critical. Test Finding Normal

HCT 11% (l) 35-55%

Albumin 2.9 2.5-3.5 mg /dl

Glucose 61 (l) 80-120 mg/dl

Na 138 (l) 139-150 mEq/L

K 3.0 (l) 3.4-4.9 mEq/L

Cl 105 (l) 106-127 mEq/L

Blood Pressure 240 (h) < 180 mm Hg

TCO2 19 (17-25)

AnGap 11 (8-25)

pH 7.29 (l) (7.35-7.45)

pCO2 35 (34-40)

HCO3 16 (l) (20-40)

BE excess -9 (l) (-5-0)


CliniCAl DiAgnostiCs of fluiD theRAPy

1. HEMOGRAM EVALUATION: A combination of the following parameters is best for patient monitoring.

a. Packed Cell Volume (PCV): Packed Cell Volume is one of the first tests that should be completed. The PCV should be evaluated for

Diagnostic Monitoring of Fluid Therapy

Proper clinical diagnostic monitoring for patients on intravenous fluids is dependent on the patient’s disease, in-house laboratory equipment available, and response to treatment. Hospitals must develop standard diagnostic care protocols for proper monitoring of ill patients (See table I). These diagnostic protocols should include:

serum color, red blood cell concentration, and buffy coat. With the patient on intra-venous fluids, changes in PCV can suggest response to treatment, fluid dilution, or concerns of progressive anemia.

b. Hemoglobin (HgB): HgB functions by carrying O2 from

the lungs to the tissues and is therefore a vital parameter. It is also very useful, along with blood smear analysis, in diagnosis of anemia (by allowing calculation of the MCHC along with a MCV measurement) as well as monitoring response to therapy. Except for severe



lipemia, HgB is a very consistent value, not affected by human error in preparation or measurement. This value correlates well with PCV (HgB X 3 = PCV) in most cases. As with PCV, changes in HgB values can be suggest response to treatment or concerns of progressive anemia.

c. Blood Film: In the face of potential anemia, the medical team should evaluate the blood film for evidence of red blood cell regeneration. The medical team can perform a qualitative evaluation of the blood film for nucleated red blood cells, polychromasia or intracellular changes that support a regenerative anemia, or a quantitative reticulo-cyte count. A lack of regeneration in a chronically patient can suggest an anemia of chronic disease and prepare the medical team to monitor for life threatening anemia and the possibility of blood transfusion.

2. TOTAL PROTEIN/ALBUMIN: Dehydration, blood loss, and organ disease can effect albumin and thus affect total protein levels. Decreased albumin concentration can develop with severe blood loss, organ disease, massive whole body infection (sepsis), chronic intestinal disease, and metabolic disease. Albumin maintains a positive pressure (Oncotic Pressure) on the fluid component within blood. When albumin levels decrease, this pressure is lost and fluids migrate into surrounding soft tissue. Low albumin levels can make a patient more at risk for fluid overload and pulmonary edema. Patients on long-term intravenous fluids should have total protein and albumin evaluated every 6-24. Patients found to have prolonged hypoalbunemia should be evaluated for colloid replacement (i.e. Hetastarch), Plasma Transfusion or Canine/Feline Specific Albumin.

Increases in Total Protein/Albumin Levels can be utilized to evaluate dehydration level and response to treatment. As observed in the case on the previous page; severely dehydrated anemic patients may present

with a normal packed cell volume but have a significantly elevated albumin. These patients may develop a life-threatening anemia within the first few hours of rehydration. If this trend is observed, the pet should be closely monitored in the initial 2-6 hours of fluid therapy. A possible blood transfusion should be discussed with the owner.

3. BLOOD SUGAR LEVELS should be monitored regularly and always be obtained from all critical care animals on presentation. Patients suffering from sepsis, shock, endo-crine disease (i.e. Hypoadrenocorticism), and certain toxins and poisons can develop life threatening hypoglycemia. The central nervous system and musculoskeletal system require sugar to maintain normal homeostasis; low blood sugar levels (<50mg/dl) can precipitate seizures, generalized weakness, collapse, anorexia, ataxia, abnormal vocalization, coma and death of the patient. Patients suffering from hypoglycemia should have 5% dextrose added to intravenous fluids. Further, patients should have a bolus of 1 cc of 25 % dextrose/ pound body weight every hour. Blood glucose should be checked hourly until a trend of normal blood glucose levels is observed.

4. ELECTROLYTES: Pets with significant gastro-intestinal loss, prolonged anorexia, or patients on long term intravenous fluid therapy (>24 hours) can also have severe aberrations of electrolytes. Physical symptoms of electrolyte derangements can include slow heart rate, pulse deficits, muscle fasiculations (Muscle tremors/shaking), weakness, and anorexia. Electrolyte derangements can be corrected through proper selection of intravenous fluids and the addition of specific electrolyte components to the fluids. Patients should have baseline electrolytes evaluated every 12-24 hours.

5. BLOOD PRESSURE: Systolic blood pressure >130-140 mm HG (Canine) and 180-200 mm HG (Feline) can occur secondary renal disease,



ConclusionsMedical team must develop standardized protocols to:

• Identify patients with potential underlying life threatening concerns prior to the initiation of therapy

• Monitor these patients closely for progression of symptoms

• Communicate with the client potential concerns and treatment options

• Re-evaluate complete blood counts, chemistry and other modalities (i.e. blood coagulation, gas

acid-base…) in the face of an abrupt change in the patient’s status.

• Treat the patient effectively

hyperthyroidism (Feline), hyperadrenocorticism (Cushing’s disease), heart disease, and primary hypertension. Aggres- sive fluid therapy can cause a severe hypertensive state producing fluid overload, heart failure, retinal lesions, shock and death. Patients with concerns of hypertension must be identified, monitored constantly, and treated with anti-hypertensive medication in con- junction with fluid therapy.

Life-threatening hypotension can be observed in the emergency patient. The hospital team’s ability to restore normal perfusion with intravenous fluids is the key to stabiliza-tion. Systolic blood pressures <60 mm Hg suggest that the patient is unable to adequately perfuse their tissues and organs. Until blood systolic blood pressure is >60 mg Hg, the patient is still unstable and requires emergency fluid boluses (90 mg/kg/hr) until normal blood pressure is observed. Once stabilized, it is important for team members to monitor blood pressure in these trauma patients. If

systolic pressures rebound >130-140 mm HG, traumatized tissue that have already stopped bleeding may begin to hemorrhage again.

6. ACID-BASE ANALYSIS: Acid-base status is an important part of patient monitoring and choice of therapy when available. Electrolyte disturbances, organ dysfunction and metabolic toxins are some of the factors that affect acid-base balance. Maintaining pH within normal parameters is vital to body metabolism (for example Ca metabolism) and the chemical reactions that drive it. Evolution to determine the cause and severity of the acid-base disorder as well as the appropriate therapy speeds recovery and improves prognosis and should be monitored long term as well. This is a straightforward analysis with the proper equipment.

7. RE-EVALUATION OF COMPLETE BLOOD COUNT, CHEMISTRY AND OTHER DIAGNOSTIC MODALITIES:

If faced with a patient that continues to decline in the face of intravenous fluids and medications; re-evaluation of the complete blood count, chemistry, and possibly other diagnostic modalities (i.e. blood gas/coagulation profile…) would be recommended every 24-48 hours or if there is an acute change in the patient’s status. In many cases, patients may develop into life-threatening syndromes (disseminated intravascular coagulopathy) or develop an underlying infection or disease that manifests itself in spite of treatment. Full blood work can change dramatically in 24 hours. Reevaluation of the complete blood count for changes in white blood cells that suggest infection, decreases in red blood cell and platelet number that suggest bleeding, changes in the blood film, or changes in chemistry and organ function may alert the medical team to changes in condition that may alter prognosis and change treatment needs.


ClinicalTest Outcome ActionConcern

PackedCellVolume

Albumin

Canine > 55%Feline > 45%

Canine: 3.1-4.5 mg/dl

Feline: 2.4-4.1 mg/dl

Canine < 35%Feline < 25%

1. Primary Dehydration.2. Should be a marked increase in Albumin/ Total Protein

Hypoalbunemia:1. Bleeding2. Liver Disease3. Kidney Disease (Protein Losing Nephropathy)4. Intestinal Disease (Protein Losing Enteropathy)5. Sepsis

Hyperalbunemia: Dehydration

1. Bleeding2. Immune Mediate Hemolytic Anemia (IMHA)3. Anemia of chronic disease

1. Prepare patient for Aggressive Fluid Therapy - 1.5 x 2 maintenance.2. If concern of shock, begin emergency fluid bolus - 90 cc/kg/hr.3. Recheck PCV every 1-3 hours until PCV approaches normal level.

If Hypoalbunemia is noted:1. Monitor patient for fluid overload symptoms.2. If Albumin is 2.0–2.5 mg/dl: Use Synthetic Colloid Therapy (E.g. Hetastarch)3. If Albumin <2.0: Plasma or Canine/Feline specific albumin therapy is indicated.

If Hyperalbunemia is noted:1. Continue Aggressive fluid therapy2. Monitor PCV closely (q 1-2 hrs) if there is a concern of chronic anemia

1. Evaluate Purple top tube, wet prep of blood for agglutination (IMHA)2. Evaluate Albumin; low albumin can help support bleeding or chronic disease.3. Evaluate clotting times to help evaluate bleeding concerns.4. Evaluate blood film to check for regenerative response, agglutination, or abnormal cell morphology to help define the cause of the anemia.5. Recheck PCV every 1–3 hours, if PCV is rapidly falling (<12–16%) prepare for blood transfusion.

Table I: Recommended Clinical Diagnostics of Patients on Fluid Therapy

References: Clinical Pathology of the Veterinary Team, Rosenfeld, A & Dial, S. Wiley, Ames Ia, 2010

Textbook of Veterinary Internal Medicine, 6th Edition. Ettinger, S and Feldman, E., Elsevier, Baltimore, 2004.

The 5 minute Veterinary Consult – Canine and Feline, 4th Edition. Tilley, L and Smith, F. Wiley, Ames, Ia, 2008.

Handbook of Small Animal Practice, 5th Edition. Morgan, R. Saunders, Baltimore, 2007.




ClinicalTest Outcome ActionConcern

BloodGlucose

Electrolytes

BloodPressure

< 60 mg/dl

Systolic < 60 mm HG

Systolic > 100-140 mm HG

Sodium (Na) 145-155 mEq/l

Chloride (Cl)112-124 mEq/l

Potassium (K)2.7-5.0 mEq/l

1. Sepsis2. Insulin Overdose3. Juvenile Hypoglycemia4. Hypoadrenocorticism5. Shock6. Toxin/Poison/Medical Overdose7. Hypoadrenocorticism8. Shock9. Toxin/Poison/Medical Overdose

1. Trauma2. Shock3. Endocrine Disease4. Sepsis

1. Renal Disease2. Hyperthyroidism (Feline)3. Cardiac Disease4. Hyperadrenocorticism (Canine)5. Primary Hypertension

1. Anorexia2. Gastrointestinal Loss3. Organ Disease4. Endocrine Disease5. Urinary Obstruction

1. Add 5% dextrose to Intravenous Fluids2. Give 1 cc/pound 25% dextrose3. Monitor Glucose hourly until sustained blood glucose is observed

1. Aggressive Fluid Therapy to make sure systolic pressure > 60 mm HG2. If not responding, add synthetic colloid (i.e. Hetastarch)3. Continuously monitor blood pressure until normalizes.4. If there is a concern about trauma, make sure pressures do not exceed 140 mm HG.

1. Identify Hypertensive Patient2. Treat with Intravenous therapy cautiously3. Use anti-hypertensive medications4. Monitor blood pressure continuously

1. Treat Underlying Disease2. Administered a balanced electrolyte solution3. Administer additional electrolyte therapy (i.e. KCL added to fluids in the hypokalemic patient)4. Monitor electrolytes every 2-12 hours dependent on disease concerns.

Textbook of Medical Physiology, 11th Edition. Guyton, S. Saunders, Baltimore, 2005.

Handbook of Veterinary Procedures and Emergency Treatment, 7th Edition. Bistner, Stephen. Ford, Richard. and Raffe, Mark. WB Saunders, Philadelphia. 2000.

Fluid Therapy in Small Animal Practice , 2nd Edition. DiBartola, Stephen. WB Saunders, Philadelphia. 2000.


Case of the Beagle with a Poor Appetite and LethargyContributing Author:

Dr. Ann DelBorgo-Ladner

Saucier Veterinary

Hospital

Saucier, MS

Bre, a 3.5 year old intact female beagle weighing 24 lbs. was presented at Saucier Veterinary Hospital for a poor energy level and reduced appetite. This was her first visit and records from previous facilities were unavailable. History provided from the owner included lethargy, anorexia and the possibility that Bre might be pregnant. Physical examination revealed white gums, yellow discharge from the eyes, an unhealthy coat, a body condition score of 3 out of 9 and a distended abdomen which all resembled congestive heart failure and abdomnial palpation indicated the possibility of a gravid uterus. Another concern that the owner disclosed was that heartworm prevention was provided inconsistently which in our area, heartworm disease is endemic.

A chemistry panel and confirmatory heartworm antigen test was performed using the Canine Wellness Profile including Heartworm.

In addition to the physical examination, we performed a fecal floatation and rapid heartworm test. Results were positive for both hook worms and heartworms. Concerned with her lack of strength and current findings, hospitalization was recommended for fluid therapy and observation but declined. Therefore, Bre was given electrolytes, vitamin K and placed on a de-worming regimen with recheck appointment one week later.

As scheduled, Bre returned for her recheck examination. Her optimistic owner com-municated slight increase in strength and energy. She had gained 2 lbs of body

weight and displayed a minimal increase in strength, but nothing else had changed regarding her physical exam-ination findings. A chemistry panel and confirmatory heartworm antigen test was performed using the Canine Wellness Profile including Heartworm. We chose the Canine Wellness Profile to confirm the heartworm infection with a different methodology in addition to obtaining important health information for further diagnostics and prior to prescribing heartworm treatment. The panel indi-cated a below normal ALT, BUN, GLU and ALB as well as an elevated ALP. The


CBC showed severe elevations in her WBC, NEU and MONO counts as well as a mild normoncytic, normochromic anemia. Rule outs from these tests were hepatopathy (infectious or inflammatory), other infectious/inflammatory conditions (mucometra/pyometra), anemia of chronic disease, leukemoid response and heartworm and hook worm disease, indicating a leukemiod response or severe inflammation.

Radiology results were consistent with pregnancy (6 fetuses identified) of approxi-mately 6 weeks gestation based on fetal development. Additional diagnostics (such as paired bile acid testing and ultrasound) along with hospitalization and aggressive treatment were recommended. However, the owner chose to take Bre home with antibiotic treatment. While she has not been returned for further diagnostics or treatment, the owner called the hospital a week later with questions concerning labor, as Bre was struggling to have her puppies. Since then, check-up calls were placed with no reply.

In cases such as these where a comprehensive chemistry profile and heartworm screen can be performed at a reasonable cost to the client with minimal time required by the staff, the Canine Wellness Profile is a useful addition to our chemistry testing menu and effective alternative for cost sensitive clients. Within our hospital, the CWP is a highly utilized profile as it provides multiple uses for confirmatory heartworm testing, pre-surgical exams, wellness exams, senior visits and health monitoring. Our success at gaining client consent for blood work is contributed to constant face to face client education and communication about the importance of maintaining the health or treating an illness of their close companions. Coupling client education with an affordable exam has resulted in approximately 90% compliance among all clients where such testing was recommended.

CWPChEmisTryrEsulTs

Test Finding

CHW POS

ALP *456.0

ALT *9.0

TBIL 0.2

BUN *5.0

CRE *0.2

TP 6.7

ALB *1.9

GLOB 4.8

GLU *52.0

CA 9.4

PHOS 6.0

CBCrEsulTs

Test Finding

WBC *92.66

LYM 2.24

MON *10.53

NEU *78.26

EOS *1.53

BAS *0.11

RBC *4.29

HGB *9.2

HCT *27.5

MCV 64.2

MCH 21.36

MCHC 33.3

RDWc 16.1

PLT *763.0

*Results out of normal range.

CAse of the BeAgle with A PooR APPetite AnD lethARgy


Date

7/16/10–7/17/10

7/31/10–8/3/10

8/2/10–8/4/10

8/7/10–8/8/10

8/12/10–8/15/10

8/12/10–8/15/10

8/15/10

8/23/10–8/30/10

9/12/10–9/14/10

9/22/10–9/26/10

9/22/10–9/26/10

9/24/10–9/26/10

Conference

Pacific Veterinary Conference

AVMA

AAV

Peter Piper Memorial Conference -Coloosa Vet Society

Southern Veterinary Conference

Keystone VMA

Jacksonville VMA

CVC Central

IVECCS

Northeast Association of Equine Practitioners

Colorado VMA

Southwest Veterinary Symposium

location

San Francisco, CA

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San Diego, CA

Sanibel Island, FL

Trussville, AL

Hershey, PA

Jacksonville, FL

Kansas City, MO

San Antonio, TX

Groton, CT

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Fort Worth, TX

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Clinical Update of the Callitrichidae Collection of Loro Parque

Callitrichidae are New World Monkeys which live in the tropical rainforests of Central and South America. The family includes four genera:

marmosets1. tamarins2. lion tamarins3. spring tamarin4.

The entire family callitrichidae is endangered in the wild because of destruction of the rainforests. The Loro Parque facilities house three different species of Callitrichidae: Emperor Tamarin (Saguinus impe rator), Red-handed Tamarin (Saguinus midas)

and White-headed Marmoset (Callithrix geoffroyi).

All three species are organised in the European conservation breeding program (EEP). The idea is to build up a healthy and self-preserving population in the zoos, and the long term target is to return the animals back into the wild to support and/or to rebuild the wild population. Loro Parque takes an active part in the European conservation breeding program and is breeding the animals with good success.

Contributing Authors:

Kirstin Oberhäuser DVMHeiner MüllerSara Capelli DVMLoro Parque and Loro Parque Fundación, Tenerife

The veterinary department also endeavours to discover more clinical information about this species. Abaxis supported the Loro Parque clinic’s efforts to further its scientific studies in the fields of haematology and biochemistry in our callitrichidae.

With the help of Abaxis, who gave us the HM5 haematology machine and the VS2 biochemistry analyzer, we expanded our clinical examination to include a complete blood check which contains haematology


and biochemistry with the mammalian comprehensive profile and the thyroxin and cholesterol values.

The veterinarians, the nurses and the keepers worked together on the clinical examinations of all our twenty animals.These exams included the adspectation of the skin, the oral cavity, the palpation of the abdomen, the auscultation of lung and heart, the weight control and the blood work.

A special comment I would like to make about the thyroxin values in Callitrichidae: the thyroxin level is much higher and much more varied between individual Callitrichidae than in other mammalian.

In conclusion, we verified that all of our Callitrichidae are in excellent health and we also achieved new reference values for this species which will help in the future interpretation of the blood work of this family. We would like to express our gratitude to Abaxis, who made it possible for us to undertake these studies.It is a great help for the Loro Parque clinic to have received both the Abaxis VS2 chemistry analyzer and the HM5 haematology analyzer. We utilize these machines every day in helping us to understand and to preserve our species.


CallitrichidaeThe Callitrichidae (synonym Hapalidae) is one of five families of New World Monkeys. The family includes several genera, including the marmosets, tamarins, and lion tamarins. For a few years, this group of animals was regarded as a subfamily, called the Callitrichinae, of the Family Cebidae.

All callitrichides are arboreal. They are the smallest of the anthropoid (i.e. simian) primates. They eat insects, fruit, and the sap or gum from trees; occasionally they will take small vertebrates. The marmosets rely quite heavily on exudates, with several species (Callithrix jacchus and Cebuella pygmaea) considered obligate exudativores.


TamarinTamarin habitats range from southern Central America (Costa Rica) through middle South America (Amazon basin and north Bolivia, however not in the mountainous parts). Many species typically have mustache-like facial hairs. Their body size ranges from 18 to 30 cm (plus a 25 to 44 cm long tail) and they weigh from 220 to 900 grams. Tamarins differ from marmosets primarily in the fact that the lower canine teeth are clearly longer than the incisors.

Occurrence: Tamarins are inhabitants of tropical rain forests and open forest areas. They are diurnal and arboreal, and run and

Scientific Classification

Kingdom: Animalia

Phylum: Chordata

Class: Mammalia

Order: Primates

Family: Callitrichidae

Genus: Saguinus (Hoffmannsegg, 1807)

jump quickly through the trees. Tamarins live together in groups of up to 40 members consisting of one or more families. More frequently, though, groups are composed of just three to nine members.Food: Tamarins are omnivores, eating fruits and other plant parts as well as spiders, insects, small vertebrates and bird eggs.Gestation is typically 140 days, and births are normally twins. The father primarily cares for the young, bringing them to their mother to nurse. After aproxi-mately one month the young begin to eat solid food, although they aren‘t fully weaned for another two to three months. They reach full maturity in their second year. In captivity, tamarins live to be 18 years old.


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