Case 11
Joey was seen again about 6 weeks after his last clinic visit on a Sunday on the
Emergency Service. He came in dehydrated and hypothermic due to low cardiac output. This
is a classic case of a dog that is on high dose diuretic therapy undergoing an event that
is stressful and/or that results in him becoming anorexic and not drinking while the
diuretic administration continues. In Joey's case, he probably became anorexic or
partially anorexic for several days prior to admission as he had lost considerable weight.
Then he was put outside one night and not taken in again until the next morning (access to
water during that time is unknown; overnight temperature at this time of year is in the 50
to 60 degree F range). Owners must always be told to contact a veterinarian if a dog stops
eating and especially if it stops drinking or is drinking less or to stop the diuretic
therapy if this happens until they can contact a veterinarian. After Joey was admitted he
was treated aggressively with intravenous fluids but all it did was cause more ascites.
This is a very poor prognostic sign and he was euthanized once it was determined that he
was not going to recover. Following is the entire medical record from Joey's final visit.
Presenting Complaints
Not Eating, Low Temp, White Gums
Pertinent History
Joey has historical mitral regurgitation, tricuspid regurgitation, pulmonary
hypertension, and rt. heart failure. This is being controlled with furosemide 50mg PO TID,
enalapril 5 mg SID PO, and amlodipine 0.625 mg BID PO all of which he is presently on. He
did not receive any drugs today and last night he did not receive any amlodipine in the
afternoon of 9/19. On Friday 9/18 in the afternoon, Joey was put outside as he was
pestering the owners to go out. In the AM he was let back inside but was cold. The owners
also noted he was shivering slightly, he had white mucus membranes, and was not eating
well. They brought him to a local vet who took his temp which was about 97 F, and an IM
shot of an unknown antibiotic was given. Later that day Joey vomited up some clear fluid.
Through that day Sat 9/19 Joey had little or no app, vomited once and was somewhat
lethargic. He was also noted to sit by his water bowl for up to an hour at a time,
drinking some.
Physical Examination
BAR, about 7-8% dehydrated, Temp=100.9 Coat in relatively good
condition, not changed since last visit.
EENT- nuclear sclerosis OU, some debris in ear but no offensive odor, some tartar on
teeth, all else WNL.
M/S- Cachectic 1/9, no asymmetry noted.
C/V- rate=160 bpm and regular, weak femoral pulses, grade V/VI murmur noted on right
and left side corresponding with historical mitral and tricuspid regurgitation.
Resp-rate 40bpm, eupneic.
GI- severe ascites noted, no masses on loops, liver edges smooth and may be slightly
enlarged, could not palpate kidneys/spleen well due to splinting and discomfort.
Rectal: no melena or blood. Prostate slightly enlarged but nonpainful.
GU- no masses noted.
LN- WNL
NE- N/C
Problems
1.Hx mitral regurgitation
2.Hx Tricuspid regurgitation
3.Hx ASD
4.Hx right heart failure
5.Dehydration
6.Vomiting
7.Anorexia
Medical/Surgical Procedures
1.Blood Pressure- MAP=85, Systolic=109, Diastolic=69 (these are averages of many
taken ).
2.ICU electrolytes- Na=144, K=4.4, ionized Ca=.94
3.CBC- PCV=38%, WBC= 22800, Neut=90%, Lymph=3%, Fib=200
4.CHEM- Na=152, Cr=1.8, BUN=68, Ph=9.7
5.Catheter placement- cephalic
6.Fluid administration- .9%NaCl qs 20 mEq KCl at 30 mls/hr
7.replaced cephalic IV catheter (9/21)
8.Renal screen
9.Echocardiogram
10.Abdominal Ultrasound
11.Thoracic radiographs
12.renal screen
13.PCV and total solids
Clinical Diagnoses
1.Severe mitral and tricuspid regurgitation
2.Acquired ASD
3.Pulmonary hypertension
4.Gastrointestinal ulceration / hemorrhage
5.Cachexia
6.Low output and congestive heart failure
Plans and Progress Notes
1.9/20/98: S/O: See PE and HX for more info. A: Our primary concerns with Joey are his
dehydration and azotemia. We wanted to stabilize him and get him to a condition where he
would want to eat and drink normally. ICU electrolytes/CBC/CHEM results were basically WNL
except for Na=144 (ICU), CR=1.8, BUN=68, PH=9.7, mean blood pressure=85, systolic blood
pressure=109, diastolic blood pressure=69. We are planning on letting the cardiologists
look at him tomorrow to re-asses his heart condition and drug protocol. We put him on a
fluid plan (.9%NaCl
qs 20 mEq KCl 3mls/kg/hr) that would replace his losses but not too much too quickly. We
don't want to overload his vascular volume, which could result in the heart not being able
to pump the increased volume and ascites and pulmonary edema may result. With this
fluid rate we hope to replace his losses as well as resolve some of the pre-renal
azotemia. Both of which can be contributing to the decreased app/drinking and overall
lethargy. We are continuing with the furosemide at 25 mg TID PO, amlodipine at .625 mg PO
BID, but discontinuing the enalapril as it may be contributing to some of his signs. P: To
feed him BID continue with his medications till the cardiologists can re-asses his
condition and drug protocol, continue his fluids .9% NaCl qs 20 mEq KCl at 30 mls/hr ,
monitor his TPR rates and quality, record any vomiting and or urination/defecation.
2.9/21/98: S/O Joey is depressed, but rousable and can walk for brief periods of time.
Vomited once in a.m. when abdomen was palpated. He is anorexic, even when offered cottage
cheese and rice in p.m. In a.m., abdomen quite distended. Still dehydrated and weak. T in
AM was 98.7. It increased to 99.4 in the afternoon. RR 36-40, HR 140, mm pink, CRT 1 sec.
Rectal exam - formed feces and no melena or hematochezia. prostate not enlarged, slight
asymmetry, with right larger than left. Urinated large volume of yellow/clear urine on
walk. Renal panel showed: K+ 6.5, Na+ 152, Cl- 112, P 11.1, Creatinine 2.2, BUN 103, Ca2+
10.5, albumin 2.9. Abdomen tap removed 2 liters of serosanguinous fluid. A: Ascites severe
enough to drain off for improved comfort. Due to increased azotemia and persistent
dehydration, fluids to be increased. Fluids need to be switched to LRS without K+ due to
hyperkalemia and H2 blockers started (suspect GI ulceration due to disproportionate
BUN:creatinine ratio). On thoracic radiographs, no pulmonary edema present, but should be
monitored. Fluid overload is a problem, but
increased fluids needed to combat azotemia and dehydration. Abdominal ultrasound showed
large amount of fluid but no gross lesions other than hepatomegaly and distended hepatic
vessels. Abdominal fluid submitted for cytology to rule out any infectious possibility.
U/A submitted for culture. Joey will be monitored and re-evaluated regarding prognosis
9/22. P: Continue IV fluids of LRS at 40 ml/hr.
Famotidine IV 4 mg BID. Monitor respiratory rate and temperature. Until temperature
improves, keep on heating pad. Walk BID. Feed cottage cheese and rice. No cardiac meds due
to increasing dehydration. Replaced IV catheter which was out of vein with 22 gauge
catheter and T-port. Abdominal drainage (2 liters.) Record any vomiting, urination, or
defecation.
3.9/22/98: S/O: Joey is depressed, mostly laterally recumbent but capable of turning over
and walking for very brief periods. Anorexic. Dark, blood flecked feces overnight (melena
and hematochezia.) No vomiting. Drank small amount of H2O today (few licks.) Urine yellow
and clear. Urine culture from 9/21 negative for growth of microbes. Mucus membranes paler
but moist. Abdomen is more distended than last night and moderately painful. CRT 1 sec, HR
140, lungs auscult clear but difficult to hear due to reverberence from murmur. RR is
36-40 still. Body temperature started at 99 this AM, but decreased to 98.6 at 2 PM. On
renal panel, Na 156, Cl 156, K 5, TCO2 19, Ca 9.8, P 9.2, Creatinine 2.3, BUN 111, Alb
2.5, and anion gap 2.5. PCV 41%, Ts 5.7. A: Joey is doing worse today than yesterday. He
whimpers some and lies laterally recumbent and unresponsive unless a lot of stimulus. His
increasing BUN with less rise in creatinine is consistent with GI bleeding, as is
evidenced by his bloody stools.
Decreasing albumin is probably due to loss into the abdomen or in the GI tract. Ascites is
filling abdomen again. Fluids should be increased to combat poor cardiac output and
consider dobutamine. Pale mucus membranes are likely to be due to vasoconstriction, since
hematocrit is not consistent with degree of paleness. Gastric protectants should be used
to comfort inflamed tract. With worsening condition, owners to be advised on his condition
at 6 PM 9/22 during visit. P: Add in sucralfate 250 mg PO in 5 ml H2O as gastric
protectant. Continue with Famotidine 4 mg IV BID, and increase LRS to 50
ml/hr IV. Monitoring his respiration, temperature, and turning over are to be continued
throughout the day.
4.9/22/98: Joey was euthanized at owner's request 7:30 PM.
Comments
Joey presented on 9/20/98 to the emergency service dehydrated, vomiting, hypothermic,
and azotemic with a BUN of 68 and creatinine of 1.8, PCV 38%. He also had a markedly
distended abdomen consistent with ascites. He was discontinued from his cardiac
medications and started on conservative fluid therapy. He was then evaluated by the
cardiology service. Renal values showed worsening
azotemia (BUN 103 and creatinine of 2.2 as well as elevated potassium 6.5 and phosphorus
11.1. The elevated BUN in respect to creatinine indicated that there was some GI bleeding,
although no blood was evident on rectal examination initially although the next day melena
and hematochezia were noted. He was started on IV famotidine and his fluid rate increased.
Thoracic radiographs showed no evidence of
pulmonary edema and abdominal ultrasound showed no organ lesions, only a large volume of
abdominal fluid. The fluid was drained (2 liters) and sent in for cytology (which came
back as modified transudate.) Urine was sent in for culture, which came back with no
growth. During the night, Joey had bloody stool. On 9/22, Joey's condition had worsened.
he was more depressed and over the course of the day his abdomen began to fill up with
fluid again. His renal panel came back with better
electrolyte values, potassium 5 and phosphate 9.2, but his BUN was 111 and his creatinine
2.3. His albumin had also dropped form 2.9 on 9/21 to 2.5 on 9/22. PCV remained stable. He
did not eat when fed on 9/21 and 9/22. Sucralfate was also started on 9/22. Due to his
worsening condition, Joey's owners decided to euthanize him on 9/22 at 7:30 PM. Joey's
initial stimulus for anorexia and vomiting was most likely gastrointestinal ulceration. He
rapidly spiraled into a state of severe dehydration for which in his already compromised
state, he was not able to recover. His cardiac disease was quite
advanced and refractory to medication. It is quite unusual for dogs with mitral
regurgitation to exhibit signs of low output failure and was yet another indication of
severity. He was treated supportively for three days with aggressive fluid therapy, warmth
and gastroprotectants with no clinical response and deterioration. The owners elected
euthanasia.
