Small Animal Critical Care Medicine

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Small Animal Critical Care Medicine Copyright page Contributors Preface Acknowledgments Dedication Reference Ranges 1 Evaluation and Triage of the Critically Ill Patient Key Points Introduction Triage Systems Initial Patient Triage Primary Survey Respiratory system evaluation Cardiovascular system evaluation Neurologic system evaluation Urinary system evaluation Additional considerations Triage Diagnostics: Vascular Access, Emergency Database, and Focused Ultrasound Secondary Survey Summary References 2 Physical Examination and Daily Assessment of the Critically Ill Patient Key Points Physical Examination Airway and Breathing Circulation Heart rate Mucous membrane color Capillary refill time Venous distention Pulse quality Auscultation Level of Consciousness Temperature Hydration Abdominal Palpation and Gastrointestinal Assessment Monitoring and Laboratory Data Oncotic Pull, Total Protein, and Albumin Glucose Electrolyte and Acid-Base Balance Oxygenation and Ventilation Red Blood Cell and Hemoglobin Concentrations Blood Pressure Coagulation Renal Function and Urine Output Immune Status, Antibiotic Dosage and Selection, and White Blood Cell Count Drug Dosages and Metabolism Nutrition Nursing Care References 3 Cardiopulmonary Resuscitation Key Points Preparedness and Prevention Basic Life Support Circulation: Chest Compressions Airway and Breathing—Ventilation Monitoring Electrocardiography Capnography Advanced Life Support Drug Therapy Vasopressors Parasympatholytics Antiarrhythmic drugs Reversal agents Intravenous fluids Corticosteroids Alkalinizing agents Electrical Defibrillation Open-chest CPR Prognosis References 4 Post–Cardiac Arrest Care Key Points Propagating Sustained Rosc Systemic Response to Ischemia and Reperfusion: Sepsis-Like Syndrome Hemodynamic Optimization Glycemic Control Adrenal Dysfunction Post–Cardiac Arrest Brain Injury Brain Injury Sustained During Ischemia Versus During Reperfusion Controlled Reoxygenation Mild Therapeutic Hypothermia Other Neuroprotective Treatment Strategies Neurologic Assessment and Prognostication Myocardial Dysfunction Persistent Precipitating Pathology References 5 Shock Key Points Clinical Presentation Diagnostics and Monitoring Monitoring Tissue Perfusion and Oxygen Delivery Blood Lactate Levels Cardiac Output Monitoring and Indices of Oxygen Transport Mixed Venous Oxygen Saturation (SvO2) and Central Venous Oxygen Saturation (ScvO2) Treatment References 6 Systemic Inflammatory Response Syndrome Key Points Systemic Inflammation The Consequences of Systemic Inflammation SIRS and Sepsis Potential Markers of Sepsis Treatment of SIRS in Humans SIRS in Small Animals Summary References 7 Multiple Organ Dysfunction Syndrome Key Points Epidemiology Pathophysiology Immune Dysregulation Coagulation Mitochondria Gastrointestinal Tract Specific Organ Dysfunction Lung Cardiac Liver Gastrointestinal Kidneys Central Nervous System Coagulation and the Endothelium Scoring Systems Sequential Organ Failure Assessment (SOFA) Multiple Organ Dysfunction (MOD) Score Logistic Organ Dysfunction System (LODS) Predisposition Infection Response Organ (PIRO) Dysfunction Which Score To Use? Management Cardiovascular Support Ventilatory Strategies Renal Replacement Therapy Nutritional Support and Glucose Control (see Chapters 127 to 130) Corticosteroids Novel Therapeutic Approaches References 8 Hypotension Key Points Normal Determinants of Blood Pressure Potential Causes of Hypotension Reduction in Preload Reduction in Cardiac Function Reduction in Systemic Vascular Resistance Response to Decreases in Blood Pressure Diagnosis of Hypotesion Physical Examination Measurement of Blood Pressure Direct blood pressure monitoring Indirect blood pressure measurement Doppler ultrasonography Oscillometric sphygmomanometry Additional Diagnostics Treatment of Hypotension Fluid Resuscitation Positive Inotropes Vasopressor Agents Summary References 9 Hypertensive Crisis Key Points Pathophysiology Blood Pressure Measurement Target Organ Damage Ocular Neurologic Renal Cardiovascular Patients at Risk for Hypertension Hypertensive Urgency Hypertensive Emergency Treatment Therapeutic Goals Follow-up References 10 Hyperthermia and Fever Key Points Thermoregulation Hyperthermia True Fever Exogenous Pyrogens Endogenous Pyrogens Inadequate Heat Dissipation Heat Stroke Hyperpyrexic Syndrome Exercise-Induced Hyperthermia Pathologic and Pharmacologic Hyperthermia Benefits and Detriments of Fever Benefits Detriments Clinical Approach to the Hyperthermic Patient Nonspecific Therapy for Febrile Patients The Febrile Intensive Care Patient References 11 Interstitial Edema Key Points Microvascular Filtration Lymphatic Drainage Serosal Transudation Antiedema Mechanisms Mechanisms of Edema Formation Venous Hypertension Hypoproteinemia Increased Microvascular Permeability Impaired Lymph Flow Inflammatory Edema Chronic Edemagenic Conditions Conclusion References 12 Patient Suffering in the Intensive Care Unit Key Points Maslow’s Hierarchy of Needs and Primal Alert Signals Impact of Symptom Relief Palliative Measures References 13 Illness Severity Scores in Veterinary Medicine Key Points Applications of Illnes Severity Scores Applications for the Individual Patient Inappropriate Score Use Applications in Triage and Clinician Performance Benchmarking Research Applications Use of Illness Severity Scores in the Management of Confounding Demonstration of Effective or Ineffective Randomization Provision of Objective Context Reduction of Required Sample Sizes Critical Evaluation of Illness Severity Scores Assessment of Model Validity Discrimination and Calibration Model Transferability Veterinary Models: Disease Specific and Disease Independent Features of Model Construction Selection of Predictive Variables Outcome Selection Model-Building Process APPLE Scores Summary References 14 Oxygen Therapy Key Points Arterial Oxygen Content Indications for Oxygen Therapy Methods of Oxygen Administration Humidification Noninvasive Methods Flow-by oxygen Face mask Oxygen hood Oxygen cage Invasive Methods Nasal prongs Nasal and nasopharyngeal oxygen Transtracheal oxygen Hyperbaric Oxygen Complications of Oxygen Therapy Oxygen Toxicity References 15 Hypoxemia Key Points Collection of Blood Samples for In Vitro Measurement Recognition of Hypoxemia PaO2 SpO2 Cyanosis Mechanisms of Hypoxemia Low Inspired Oxygen Hypoventilation Venous Admixture Regions of low ventilation-perfusion (V/Q) ratio Regions of zero V/Q Diffusion impairment Anatomic Shunts Estimating the Magnitude of the Venous Admixture PaCO2 + PaO2 Added Value (“The 120 rule”) Alveolar-Arterial PO2 Gradient PaO2/FiO2 Ratio Venous Admixture (Shunt) Calculation References 16 Hypoventilation Key Points Definitions Control of Breathing Central Neuronal Control of Breathing Central and Peripheral Chemoreceptors Lung Receptors Respiratory Mechanics and Muscular Control Differential Diagnosis Clinical Signs Diagnosis Treatment References 17 Upper Airway Disease Key Points History and Clinical Signs Emergency Stabilization Diagnostics Diseases of the Upper Airway Brachycephalic Airway Syndrome Nasopharyngeal Polyps Nasopharyngeal Stenosis Congenital Choanal Atresia Nasopharyngeal Foreign Bodies and Infection Laryngeal Paralysis Inflammatory Laryngeal Disease Tracheal Collapse Tracheal Stenosis/Stricture Tracheal Foreign Bodies Upper Airway Neoplasia Complications of Upper Airway Obstruction References 18 Brachycephalic Syndrome Key Points Pathophysiology Respiratory Consequences Consequences of Chronic Upper Airway Obstruction Management of Upper Airway Obstructive Crises in BD Gastrointestinal Consequences Systemic Consequences Summary References 19 Tracheal Trauma Key Points Causes Pathophysiology Clinical Signs Differential Diagnosis and Diagnostic Testing Treatment Outcome and Prognosis References 20 Allergic Airway Disease in Dogs and Cats and Feline Bronchopulmonary Disease Key Points Definition of Allergic Airway Disease Human Asthma Pathogenesis of Small Animal Allergic Respiratory Disease Parasitic Allergic Airway Disease Canine Allergic Bronchitis or Eosinophilic Bronchopneumopathy Pulmonary Infiltrates with Eosinophils Feline Bronchopulmonary Disease Pathogenesis Clinical Signs Laboratory Diagnostic Tests Radiology Bronchoscopy Treatment of Allergic Airway Disease and Feline Bronchopulmonary Disease Glucocorticoids Bronchodilators Miscellaneous Drugs and Other Therapies Prognosis References 21 Pulmonary Edema Key Points Pathophysiology Clinical Presentation High-Pressure Edema Cardiogenic edema Fluid therapy Increased-Permeability Edema Mixed-Cause Edema Diagnostic Tests Treatment Oxygen Therapy Medical Therapy Fluid Therapy Prognosis References 22 Pneumonia Key Points Clinical Presentation Initial Evaluation History Physical Examination Diagnostic Testing Pathophysiology Mechanism Causes Treatment Additional Management Considerations Contagion and Zoonosis Monitoring Prognosis and Outcome References 23 Aspiration Pneumonitis and Pneumonia Key Points Definitions Aspiration Pneumonitis Aspiration Pneumonia Aspiration Pneumonitis and Pneumonia Epidemiology Pathophysiology Diagnosis History Physical examination Radiography and computed tomography Tracheal wash Bronchoscopy and bronchoalveolar lavage Complete blood cell count and serum biochemistry Oxygenation status Biomarkers Treatment Airway management Oxygen therapy Mechanical ventilation Antimicrobial therapy Bronchodilators Cardiovascular support Chest physiotherapy Glucocorticoids Prevention References 24 Acute Lung Injury and Acute Respiratory Distress Syndrome Key Points The Human Perspective Criteria for the Diagnosis of ALI/ARDS Pathophysiology Treatment The Canine Perspective Criteria for the Diagnosis of ALI/ARDS Treatment References 25 Pulmonary Contusions and Hemorrhage Key Points Pathophysiology and Pathology Diagnosis Physical Findings Imaging: Radiology, Computed Tomography, and Ultrasound Blood Gas Analysis and Pulse Oximetry Management Initial Approach Oxygen Therapy and Ventilation Fluid Therapy Analgesia Antimicrobial Therapy Glucocorticoids Other Therapies Prognosis and Outcome Atraumatic Pulmonary Hemorrhage Diagnostic Evaluation Treatment Prognosis and Outcome References 26 Pulmonary Thromboembolism Key Points Pathophysiology History and Clinical Signs Physical Examination Diagnostic Testing Treatment and Prophylaxis Summary References 27 Chest Wall Disease Key Points Chest Wall Anatomy and Function Diagnosis of Chest Wall Disease Diseases of the Chest Wall Congenital Neoplasia Rib Fractures Trauma Flail chest and intercostal muscle damage Penetrating wounds Nontraumatic rib fractures Cervical Spine Disease Neuromuscular Disease (see Chapter 85) Tick paralysis Acute idiopathic polyradiculoneuritis Botulism Fulminant myasthenia gravis Elapidae snake envenomation References 28 Pleural Space Disease Key Points Pleural Space Clinical Evaluation Pleural Effusion Pure Transudates and Modified Transudates Exudates Feline Infectious Peritonitis Pyothorax Chylothorax Hemothorax Neoplastic Effusions and Pleural Neoplasia Fibrosing Pleuritis Pneumothorax Space-Occupying Lesions Diaphragmatic Hernia References 29 Nonrespiratory Look-Alikes Key Points PH and PCO2 Receptor Activation PO2 Receptor Activation Cortical Modification of Respiration Thermal Receptor Changes Electrolyte Imbalances and Metabolic Disease Peripheral Nervous System Disease Central Nervous System Disease Clinical Evaluation Summary References 30 Basic Mechanical Ventilation Key Points Compliance The Ventilator Breath Ventilator Settings Indications for Mechanical Ventilation Approach to Initiation of Mechanical Ventilation Goals Carbon Dioxide Oxygen Maintenance of Mechanical Ventilation Complications Troubleshooting Prognosis References 31 Advanced Mechanical Ventilation Key Points Ventilator Concepts Respiratory Cycle Equation of Motion Defining the Ventilator Mode Breath Type Control Variable Phase Variables Trigger variable Cycle variable Limit variable Baseline variable Breath Pattern Continuous mandatory ventilation Continuous spontaneous ventilation Intermittent mandatory ventilation Ventilator Mode Respiratory Rate and Inspiratory-to-Expiratory Ratio Positive End-Expiratory Pressure Ventilator Alarms Low Airway Pressure Alarm High Airway Pressure Alarm Low Tidal Volume Alarm High Tidal Volume Alarm Lung-Protective Ventilation Setting Optimal PEEP Recruitment Maneuvers Patient–Ventilator Asynchrony References 32 Jet Ventilation Key Points Physics and Physiology Equipment Indications Disadvantages Monitoring of Gas Exchange during Jet Ventilation Ventilator Settings References 33 Ventilator Waveforms Key Points Waveform Types General Waveforms in Different Ventilation Modes Pressure Waveform Flow Waveform Volume Waveform Pressure-Volume Loops Flow-Volume Loops Patient–Ventilator Dyssynchrony Summary References 34 Care of the Ventilator Patient Key Points Anesthesia Monitoring Airway Management Endotracheal Tube Humidification Airway Suctioning Oral Care Eye Care Urinary Care Gastrointestinal Tract Recumbent Patient Care Apparatus Care References 35 Discontinuing Mechanical Ventilation Key Points When to Wean Anesthetic Considerations Weaning Prediction Weaning a Patient From Mechanical Ventilation Spontaneous Breathing Trials Pressure Support Ventilation Synchronized Intermittent Mandatory Ventilation Tracheostomy and Weaning Monitoring Failure to Wean Extubation Prognosis References 36 Ventilator-Induced Lung Injury Key Points Definitions Introduction Evidence From Experimental Models Stretch Injury Shear Injury Biotrauma Histopathology Pneumothorax Oxygen Toxicity Clinical Relevance Prevention Conventional Mechanical Ventilation Strategies Low tidal volume Positive end-expiratory pressure Limitation of plateau pressure Using the Pressure-Volume Loop to Guide Settings Avoid Patient–Ventilator Asynchrony Other Strategies Advanced Pulmonary Support Techniques References 37 Ventilator-Associated Pneumonia Key Points Pathogenesis Diagnosis Prevention Nonpharmacologic Strategies Pharmacologic Strategies Treatment References 38 Mechanisms of Heart Failure Key Points Neurohormonal Aspects of Heart Failure Renin-Angiotensin-Aldosterone System Sympathetic Nervous System Natriuretic Peptide System Endothelin and Vasopressin Systems Myocardial Remodeling Abnormal Calcium Ion Handling Abnormal Myocardial Energy Production Global Cardiac Function The Frank-Starling Mechanism as a Key to Understanding Heart Failure Diastolic Heart Dysfunction Clinical Staging and Assessment of Heart Failure Clinical Manifestations of Heart Failure Low output versus congestive failure Left-sided versus right-sided heart failure References 39 Cardiogenic Shock Key Points Pathophysiology Clinical Signs and Diagnosis Systolic Dysfunction Failure of Contractility Dilated cardiomyopathy Sepsis Endomyocarditis Myocardial infarction Mechanical Failure Diastolic Failure Cardiac Tamponade Hypertrophic Cardiomyopathy Tachyarrhythmias Bradyarrhythmias References 40 Ventricular Failure and Myocardial Infarction Key Points Basic Terminology Causes of Ventricular (Systolic) Failure Primary Causes Secondary to Other Cardiac Disease Extracardiac Causes Myocardial Infarction Physical Examination Diagnostic Tests Pathophysiology Treatment Supporting Contractility and Maintaining Blood Pressure Relieving Signs of Congestion Suppressing Arrhythmias Treating the Underlying Cause References 41 Feline Cardiomyopathy Key Points Etiopathogenesis Pathophysiology Diastolic Dysfunction Systolic Anterior Motion of the Mitral Valve Feline Arterial Thromboembolism (FATE) Clinical Presentation Patient History and Physical Findings Electrocardiography Radiography Echocardiography Systemic Blood Pressure Bloodborne Cardiac Biomarkers Diagnostic Approach Therapeutic Approach Management of FATE Management of Acutely Decompensated Heart Failure Management of Chronic Heart Failure References 42 Canine Cardiomyopathy Key Points Dilated Cardiomyopathy Physical Examination Thoracic Radiography Electrocardiography Routine Blood Tests Effusion Analysis Echocardiography Acute Treatment of Congestive Heart Failure Long-Term Treatment of Dilated cardiomyopathy Diuretics Angiotensin-Converting Enzyme Inhibitors Digoxin Pimobendan Novel Therapy Diet Supplements Treatment of Arrhythmias Breed Variations with DCM Cocker Spaniels Doberman Pinschers Dalmatians Great Danes and Irish Wolfhounds Portuguese Water Dogs Arrhythmogenic Right Ventricular Cardiomyopathy in Boxers Electrocardiography Treatment of Arrhythmogenic Right Ventricular Cardiomyopathy Hypertrophic Cardiomyopathy in Dogs Pathologic Features Important Differentials for Concentric Hypertrophy of the Left Ventricle Uncommon Myocardial Diseases of Dogs Duchenne Cardiomyopathy Atrioventricular Myopathy Toxic Myocardial Disease References 43 Valvular Heart Disease Key Points Pathology Pathophysiology History and Physical Examination Laboratory Evaluation Electrocardiographic Findings Radiographic Findings Echocardiographic Findings Emergency Management Cardiac Output Tissue Oxygenation Arrhythmia Management and Adjunctive Therapy Monitoring Long-Term Therapy Prognosis Infectious Endocarditis References 44 Myocardial Contusion Key Points Incidence Etiology, Mechanism of Injury, and Pathophysiology Diagnosis Treatment Summary References 45 Pericardial Diseases Key Points Pericardial Effusion Hemorrhagic Pericardial Effusion Hemangiosarcoma Heart base tumors Other neoplasia Idiopathic (benign) pericardial effusion Transudative Pericardial Effusion Exudative Pericardial Effusion Cardiac Tamponade Clinical Presentation Physical Findings with Tamponade Diagnosis Thoracic Radiographs Echocardiography Electrocardiography Central Venous Pressure Clinicopathologic Findings Pericardial Fluid Analysis Management of Cardiac Tamponade Pericardiocentesis Preparation and Positioning Pericardiocentesis Procedure Complications of Pericardiocentesis Ancillary Treatment Idiopathic Pericardial Effusion Neoplastic Pericardial Effusion Infectious Pericarditis Constrictive Pericardial Disease Clinical Features Diagnosis Treatment Congenital Pericardial Disease Clinical Features Diagnosis Treatment References 46 Bradyarrhythmias and Conduction Disturbances Key Points Definition Differential Diagnosis Sinus Bradycardia Sinus Node Dysfunction Atrioventricular Block Atrial Standstill Treatment Medical Treatment Pacemaker Therapy Transcutaneous pacing Temporary transvenous pacing References 47 Supraventricular Tachyarrhythmias Key Points Historical Data Physical Examination Findings Examining the Electrocardiogram Distinguishing Supraventricular from Ventricular Tachyarrhythmias Diagnosing Atrial Versus Atrioventricular Node–Dependent Tachyarrhythmias Treatment of Supraventricular Tachyarrhythmias Emergent Therapy Long-Term Therapy Medical treatment Catheter ablation References 48 Ventricular Tachyarrhythmias Key Points Introduction Electrocardiographic Diagnosis Approach to the Patient with Ventricular Tachycardia Noncardiac Causes of Ventricular Tachycardia Cardiac Causes of Ventricular Tachycardia Antiarrhythmic Treatment Decision to Treat Antiarrhythmic Drugs Lidocaine Procainamide β-Blockers Sotalol Amiodarone Magnesium sulfate Other Treatments Anesthesia Electrical therapies Postintervention Monitoring References 49 Myocarditis Key Points Infectious Myocarditis Viral Myocarditis Protozoal Myocarditis Chagas’ disease Bacterial and Other Causes of Myocarditis Noninfectious Myocarditis Doxorubicin Toxicity Diagnosis Treatment References 50 Sodium Disorders Key Points Distribution of Total Body Water Osmolality and Osmotic Pressure Regulation of Plasma Osmolality Antidiuretic hormone Thirst Prioritization of Osmolality and Effective Circulating Volume Total Body Sodium Content Versus Plasma Sodium Concentration Hypernatremia Etiology Free water deficit Sodium excess Clinical Signs Physiologic Adaptation to Hypernatremia Treatment of the Normovolemic, Hypernatremic Patient Complications of Therapy for Hypernatremia Hyponatremia Etiology Decreased effective circulating volume Hypoadrenocorticism Diuretics Syndrome of inappropriate antidiuretic hormone secretion Other causes of hyponatremia Clinical Signs Physiologic Adaptation to Hyponatremia Treatment of the Normovolemic, Hyponatremic Patient Patients asymptomatic for hyponatremia Patients symptomatic for hyponatremia Complications of Therapy for Hyponatremia Pseudohyponatremia Volume Expansion in the Hypovolemic, Hyponatremic, or Hypernatremic Patient References 51 Potassium Disorders Key Points Normal Distribution of Potassium in the Body Hypokalemia Definition and Causes Consequences Management of Hypokalemia Anticipated Complications Hyperkalemia Definition and Causes Consequences Pseudohyperkalemia Treatment of Hyperkalemia References 52 Calcium Disorders Key Points Calcium Homeostasis Calcium Measurement Sample Handling Techniques Ionized Versus Total Calcium Hypercalcemia Clinical Signs and Diagnosis Differential Diagnoses Treatment of Hypercalcemia Hypocalcemia Clinical Signs and Diagnosis Differential Diagnoses Treatment References 53 Magnesium and Phosphate Disorders Key Points Magnesium Hypomagnesemia Causes Clinical signs Diagnosis Therapy Hypermagnesemia Causes Clinical signs Diagnosis Therapy Phosphate Hypophosphatemia Causes Clinical signs Diagnosis Therapy Hyperphosphatemia Causes Clinical signs Diagnosis Treatment References 54 Traditional Acid-Base Analysis Key Points Sample Collection and Handling Traditional Approach PCO2 Bicarbonate Base Excess Total Carbon Dioxide Anion Gap Compensation Acid-Base Analysis Causes of Acid-Base Abnormalities Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis Bicarbonate Therapy Dose and Administration References 55 Nontraditional Acid-Base Analysis Key Points The Stewart Approach Strong Ion Difference Total Weak Acids (ATOT) Strong Ion Gap Semi-Quantitative Approach Free Water Effect Chloride Effect Albumin Effect Phosphate Effect Lactate Effect Unmeasured Ions (XA) Conclusion Clinical Examples Case 1 Case 2 References 56 Hyperlactatemia Key Points Introduction Biochemistry Physiology Lactate Pharmacokinetics in Health Lactate Pharmacokinetics in Disease Etiology of Hyperlactatemia Type A Hyperlactatemia Increased oxygen demand Decreased oxygen delivery Type B Hyperlactatemia Type B1 Type B2 Type B3 Hyperlactatemia Without Metabolic Acidosis d-Lactate Clinical Use Prognostic Use Diagnostic Use Lactate as a Therapeutic Endpoint References 57 Assessment of Hydration Key Points Introduction Physiologic Definitions Variability in Assessing Hydration Distribution and Control of Total Body Water Measuring Total Body Water Clinical Assessment of Hydration Status Interstitial Volume Changes Intravascular Volume Changes Intracellular Volume Changes Hypotonic Fluid Loss Isotonic Fluid Loss Special Challenges Conclusion References 58 Crystalloids, Colloids, And Hemoglobin-Based Oxygen-Carrying Solutions Key Points Crystalloids Isotonic Fluids Hypotonic Fluids Hypertonic Fluids Acid-Base Effects of Crystalloids Colloids Synthetic Starch Colloids Allogenic Blood Products Human Albumin Hemoglobin-Based Oxygen-Carrying Solutions Conclusion References 59 Daily Intravenous Fluid Therapy Key Points Total Body Water Movement of Fluids Within the Body Isotonic Fluid Loss Hypotonic Fluid Loss Hypertonic Fluid Loss Increased Vascular Permeability Fluid Therapy Plan Fluid Deficit Maintenance Fluid Therapy Ongoing Losses Route of Administration Fluid Type Replacement Fluids Maintenance Fluids Free Water Administration Synthetic Colloids Monitoring Discontinuation of Fluid Therapy References 60 Shock Fluids and Fluid Challenge Key Points Administration of Shock Fluids Resuscitation Endpoints and Monitoring Shock Fluids Isotonic Crystalloids Adverse effects Synthetic Colloids Hetastarch Tetrastarch Pentastarch Adverse effects Hypertonic Solutions Adverse effects Albumin Blood Products Hypotensive Resuscitation Fluid Challenge References 61 Transfusion Therapy Key Points Indications for Transfusion Therapy Red Blood Cell Transfusions Fresh Frozen Plasma Other Blood Products Blood Typing Canine Blood Types Feline Blood Types Blood Crossmatching Blood Donors and Sources Blood Collection Administration of Blood Products Adverse Transfusion Reactions Alternatives References 62 Prevention and Treatment of Transfusion Reactions Key Points Complications of Blood Products Transfusions Monitoring Severe Transfusion Reactions in the Canine Severe Transfusion Reactions in Felines Additional Diagnostics Storage Lesions Leukoreduction Future Directions References 63 Massive Transfusion Key Points Electrolyte Disturbances Hemostatic Defects Hypothermia Metabolic Acidosis Immunosuppression and Wound Healing Acute Lung Injury Other Immunologic Transfusion Reactions Nonimmunologic Transfusion Reactions Recommendations for Management Outcome References 64 Diabetic Ketoacidosis Key Points Pathophysiology Risk Factors Clinical Signs and Physical Examination Findings Clinical Pathology Differential Diagnosis Treatment Outcome References 65 Hyperglycemic Hyperosmolar Syndrome Key Points Pathogenesis Hormonal Alterations Reduction of Glomerular Filtration Rate Influence of Concurrent Disease History and Clinical Signs Physical Examination Diagnostic Criteria Additional Diagnostic Evaluation Treatment Fluids Insulin Electrolytes Treating Concurrent Disease Monitoring Postcrisis Therapy Prognosis References 66 Hypoglycemia Key Points Normal Glucose Homeostasis Clinical Signs and Consequences of Hypoglycemia Diagnosis of Hypoglycemia Causes of Hypoglycemia Excess Insulin or Insulin Analogs Exogenous insulin overdose Insulinoma Paraneoplastic hypoglycemia Toxins and medications Inadequate Glucose Production Hypoglycemia of neonates and toy breed dogs Hepatic disease Hypocortisolism and other counterregulatory hormone deficiencies Excess Glucose Utilization Infection Exercise-induced hypoglycemia Polycythemia and leukocytosis Treatment of Hypoglycemic Crisis References 67 Diabetes Insipidus Key Points Urine Concentration Mechanism Vasopressin Secretion and Sodium Homeostasis Antidiuretic Effects of Vasopressin Central Diabetes Insipidus Nephrogenic Diabetes Insipidus Diagnosing Diabetes Insipidus Modified Water Deprivation Test Problems and risks Causes of misdiagnoses Associated risks Desmopressin Acetate Trial Imaging After a Diagnosis of CDI Treatment of Diabetes Insipidus Emergency Treatment Prognosis References 68 Syndrome Of Inappropriate Antidiuretic Hormone Key Points Causes Clinical Signs Laboratory Findings Diagnostic Imaging Findings Diagnosis Treatment Prognosis References 69 Thyroid Storm Key Points Pathogenesis High Levels of Circulating Thyroid Hormones Rapid, Acute Increases in Circulating Thyroid Hormones Hyperactivity of the Sympathetic Nervous System Increased Cellular Response to Thyroid Hormones Precipitating Events Clinical Signs Diagnosis Laboratory Abnormalities Treatment Reduction in Production or Secretion of New Thyroid Hormones Inhibition of Peripheral Effects of Thyroid Hormone Systemic Support Eradication of the Precipitating Factor Outcome References 70 Hypothyroid Crisis in the Dog Key Points Pathophysiology Risk Factors Clinical Signs and Physical Examination Findings Clinical Pathology Differential Diagnosis Treatment Outcome References 71 Pheochromocytoma Key Points Clinical Signs Diagnosis Treatment Preoperative Treatment Anesthesia and Monitoring Surgical Excision Postoperative Monitoring and Complications Medical Treatment Prognosis References 72 Critical Illness–Related Corticosteroid Insufficiency Key Points Background Suspected Pathophysiology Clinical Manifestations Diagnosis of CIRCI Veterinary Data Treatment of CIRCI Veterinary Data Prognosis References 73 Hypoadrenocorticism Key Points Who is Affected? Etiology Clinical Presentation History Physical Examination Clinicopathologic Findings Electrocardiographic Findings Diagnostic Imaging Diagnosis Treatment Fluid Therapy Initial Hormonal Replacement Supportive Therapies Timeline for Clinical Improvement Associated Disorders Prognosis References 74 Approach to Drug Overdose Key Points Obtaining an Appropriate History Triage When to Decontaminate Activated Charcoal (AC) Multidose Activated Charcoal Contraindications and Complications of Activated Charcoal Administration Cathartics Treatment Fluid Therapy Gastrointestinal Support Neurologic Support Sedatives and Reversal Agents Hepatoprotectants Miscellaneous Intravenous Lipid Emulsion Conclusion References 75 Blood Purification for Intoxications and Drug Overdose Key Points Methods Toxin Overview Considerations Ethylene Glycol Acetaminophen Nonsteroidal Antiinflammatory Drugs Mushrooms Barbiturates Lily Ingestion Summary References 76 Nonsteroidal Antiinflammatory Drugs Key Points COX-1, COX-2, and Prostaglandins Potential Adverse Effects Gastrointestinal Effects Renal Effects Hepatic Effects Coagulation Effects Bone and Cartilage Effects Neurologic Effects Drug Interactions with NSAIDs Toxic Dosage Clinical Signs Diagnosis of NSAID Toxicity Treatment Asymptomatic Patients Symptomatic Patients Prognosis Client Education References 77 Sedative, Muscle Relaxant, and Narcotic Overdose Key Points Sedative Overdose Mechanism of Action Pharmacokinetics Clinical Signs Treatment Muscle Relaxant Overdose Mechanism of Action Pharmacokinetics Clinical Signs Treatment Prognosis Narcotic Overdose Mechanism of Action Pharmacokinetics Clinical Signs Treatment Prognosis References 78 Calcium Channel Blocker and β-Blocker Drug Overdose Key Points Method of Action Calcium Channel Blockers Cardiac effects Vascular effects Pancreatic effects β-Blockers Cardiac effects Pulmonary, pancreatic, gastrointestinal, vascular, and renal effects Pharmacokinetics Calcium Channel Blockers β-Blockers Diagnosis of Overdose Therapy Asymptomatic Patients Decontamination Symptomatic Patients Calcium salts Parasympatholytics and sympathomimetics Vasopressin Glucagon Hyperinsulinemia and euglycemia Intravenous lipid emulsion Mechanical support Supportive Care Conclusion References 79 Serotonin Syndrome Key Points Definition Serotonin and Pathophysiology of Serotonin Syndrome Clinical Signs Toxicity Diagnosis and Treatment Prognosis References 80 Deteriorating Mental Status Key Points States of Consciousness Normal Obtunded Stupor or Semicoma Coma Neuroanatomy Cerebrum Reticular Activating System Etiology of Lesions Evaluation Level of Consciousness Motor Activity Respiratory Patterns Pupil Size and Reactivity Oculocephalic Reflex Diagnostic Approach Treatment References 81 Coma Scales Key Points Intracranial Pressure After Head Trauma Neurologic Assessment Modified Glasgow Coma Scoring System Levels of Consciousness Limb Movements, Posture, and Reflexes Neuroophthalmologic Examination Pupils Eye movements Coma Scales and Long-Term Functional Outcome The Future of Coma Scales References 82 Seizures and Status Epilepticus Key Points Definitions Classification Pathophysiology Etiology Diagnostic Plan History Age and Breed Physical Examination Neurologic Examination Minimum Database Diagnostic Tests for Intracranial Disease Treatment Plan Status Epilepticus Pharmacologic Therapy for Status Epilepticus Benzodiazepines Barbiturates Propofol Chronic Seizure Disorders References 83 Spinal Cord Injury Key Points Pathophysiology Localization Spinal Cord Segments S1-S3 Spinal Cord Segments L4-S1 Spinal Cord Segments T3-L3 Spinal Cord Segments C6-T2 Spinal Cord Segments C1-C5 Spinal Shock Diagnosis Treatment Prognosis Acknowledgment References 84 Intracranial Hypertension Key Points Physiology of Intracranial Pressure Intracranial Fluid Dynamics Cerebrospinal Fluid Flow Brain Water Movement Cerebral Blood Flow Intracranial Pressure Homeostatic Responses of the Brain Volume buffering Autoregulatory mechanisms Pressure autoregulation Chemical autoregulation Partial Pressure of Arterial Carbon Dioxide. Partial Pressure of Arterial Oxygen. Cerebral Metabolic Rate of Oxygen Consumption. Cushing Response Causes of Intracranial Hypertension Clinical Aspects of Intracranial Hypertension Level of Consciousness Brainstem Reflexes Size and reactivity of pupils Resting eye position, eye movements, and oculovestibular reflexes Corneal reflexes Respiration Motor Responses Posture Diagnosis of Intracranial Hypertension Treatment of Intracranial Hypertension General Supportive Care Prevent hypoxia Prevent hypotension Guidelines for Specific Therapy of Intracranial Hypertension Maintain adequate cerebral perfusion pressure Decrease cerebral venous blood volume Control PaCO2 Control PaO2 Reduce cerebral edema with hyperosmolar fluid therapy Mannitol Hypertonic Saline Furosemide Glucocorticoids Other Drugs Cerebral metabolic rate of oxygen consumption Surgical therapy Other considerations Prognosis References 85 Diseases of the Motor Unit Key Points Identifying Neuropathies, Junctionopathies, and Myopathies Clinical Signs Clinicopathologic Testing Electrophysiologic Testing Nerve and Muscle Biopsy Imaging Causes of Acute Neuropathy, Myopathy, or Junctionopathy Acute Neuropathies Neuropathies Associated with Specific Cranial Nerves Trigeminal neuritis Trigeminal nerve sheath tumor Facial nerve paralysis Laryngeal paralysis Traumatic Neuropathies Acute Polyneuropathies Metabolic causes Neoplasia Toxoplasmosis and neosporosis Acute polyradiculoneuritis Aortic thromboembolism Intoxications Myopathies Inflammatory Myopathies Generalized polymyositis Masticatory myositis Noninflammatory generalized myopathies Megaesophagus Junctionopathies Acquired myasthenia gravis Botulism Tick paralysis Snake bites Aminoglycoside intoxication References 86 Tetanus Key Points Etiology Pathogenesis Clinical Presentation Diagnosis Treatment Neutralization of Unbound Toxin Removal of Source of Infection Control of Rigidity and Spasms Supportive Intensive Care Prognosis References 87 Vestibular Disease Key Points Neuroanatomy of the Vestibular System Nerve Pathways to the Extraocular Muscles Neuron 1 Neuron 2 Nerve Pathways to the Spinal Cord Nerve Pathways to the Cerebellum Clinical Signs Specific Signs of Vestibular Dysfunction Head tilt Nystagmus Ataxia Signs That May Be Associated with Vestibular Dysfunction Facial paresis, paralysis, and hemifacial spasm Horner’s syndrome Conscious proprioception deficits Hemiparesis or tetraparesis Circling, leaning, and falling Altered mental state Multiple cranial nerve dysfunction Decerebellate posturing Vomiting Differential Diagnosis of Acute Vestibular Disease Diagnostic Approach to the Animal with Acute Vestibular Disease Minimum Database Otoscopy and Pharyngeal Examination Radiography Myringotomy Brainstem Auditory Evoked Potentials Cerebrospinal Fluid Analysis Advanced Imaging Treatment and Prognosis References 88 Hepatic Encephalopathy Key Points Causes Pathophysiology Clinical Signs Diagnosis Treatment References 89 Nosocomial Infections and Zoonoses Key Points Nosocomial Infections in Dogs and Cats Risk Factors Multiple Antibiotic–Resistant Nosocomial Pathogens Zoonoses Emerging Nosocomial Infections in Dogs and Cats Nosocomial Infection Prevention and Control Conclusion References 90 Febrile Neutropenia Key Points Neutrophil Physiology Neutrophil Function Neutrophil Production Pathophysiology of Neutropenia Increased Utilization Decreased Egress from the Bone Marrow Depletion of granulocyte progenitor cells Infectious diseases Medications, toxicants, and radiation Myelophthisis Cyclic hematopoiesis Ineffective granulopoiesis despite normal to excessive quantities of progenitor cells Immune-Mediated Destruction Clinical Presentation and Diagnostic Tests Treatment and Supportive Care References 91 Sepsis and Septic Shock Key Points Definitions and Clinical Manifestations Pathogenesis of the Septic Systemic Inflammatory Response Microbial Factors Host Response to Bacterial Infection Loss of Homeostatic Mechanisms in Sepsis Loss of vasomotor tone Dysregulation of inflammation and coagulation Endothelial, microcirculatory, and mitochondrial abnormalities Epidemiology Septic Foci, Diseases, and Pathogens Associated with Sepsis Resuscitation and Treatment of Sepsis, Severe Sepsis, and Septic Shock Introduction to the Bundle Concept Bundle Element: Lactate Bundle Element: Samples for Culture (Blood, Tissue, or Fluid Cultures) Bundle Element: Early Source Control and Early Antibiotic Administration (see Chapters 175 to 182) Bundle Element: Treat Hypotension with Fluids and Possibly Vasopressors Assessment of volume status and responsiveness Fluid choice Hypotension despite volume resuscitation (septic shock) Bundle Element: Target Central Venous Pressure and Central Venous Pressure and ScvO2 Conclusion References 92 Mycoplasma, Actinomyces, and Nocardia Key Points Nonhemotropic Mycoplasmas Etiology and Clinical Syndromes Respiratory Infections Urogenital Associated Infections Other Infections Diagnosis Treatment Actinomycosis and Nocardiosis Etiology and Clinical Syndromes Clinical Signs Diagnosis Treatment References 93 Gram-Positive Infections Key Points Gram-Positive Cell Structure and Pathogenicity Streptococcal Infections Enterococcal Infections Staphylococcal Infections Empiric Antibiotic Strategies References 94 Gram-Negative Infections Key Points Gram-Negative Cell Structure and Pathogenicity Identification of Gram-Negative Bacteria of Medical Importance Enterobacteriaceae Nonfermenting Gram-Negative Bacteria Resistance among Gram-Negative Pathogens Therapy for Gram-Negative Infections References 95 Fungal Infections Key Points Blastomycosis Clinical Signs Diagnosis Prognosis Histoplasmosis Clinical Signs Diagnosis Prognosis Coccidioidomycosis Clinical Signs Diagnosis Prognosis Cryptococcosis Clinical Signs Diagnosis Prognosis Treatment Respiratory Supportive Therapy Gastrointestinal Supportive Therapy Ocular Supportive Therapy Other Supportive Therapy References 96 Viral Infections Key Points Canine Distemper Virus Infection Canine Influenza Virus Infection Other Emerging Respiratory Viral Infections of Dogs Feline Panleukopenia Feline Respiratory Viral Disease Feline Infectious Peritonitis References 97 Canine Parvovirus Infection Key Points Evolution of Canine Parvovirus 2 Signalment Pathogenesis Clinical Signs Diagnosis Clinicopathologic Findings Diagnostic Imaging Treatment Fluid Therapy Antibiotics Antiemetics Nutrition Antiviral Drugs Gastric Protectants Controversial Treatments Vaccination Prevention of Transmission Acknowledgement References 98 Infective Endocarditis Key Points Pathophysiology Microbial Adherence and Endothelial Invasion Congestive Heart Failure Immune-Mediated Disease Thromboembolism Incidence, Signalment, and Presenting Complaint Predisposing Factors Etiologic Agents Clinical Abnormalities Clinicopathologic Abnormalities Diagnosis Echocardiography Blood Culture Modified Duke Criteria for Diagnosis of Infective Endocarditis Treatment Prognosis References 99 Urosepsis Key Points Pathogenesis Causes of Urosepsis Pyelonephritis Bladder Rupture Prostatic Infection Pyometra Catheter-Associated Urinary Tract Infection Conclusion References 100 Mastitis Key Points Anatomy: Brief Overview Etiology Clinical Findings Acute Mastitis Chronic or Subclinical Mastitis Diagnosis Differential Diagnoses Treatment References 101 Necrotizing Soft Tissue Infections Key Points Diagnosis Laboratory Findings Imaging Definitive Diagnosis Treatment Antimicrobial Therapy Surgical Debridement Postoperative Care Hyperbaric Oxygen Conclusion References 102 Catheter-Related Bloodstream Infection Key Points Definition Incidence Diagnosis Treatment Prevention References 103 Multidrug-Resistant Infections Key Points Definitions Risk Factors for Multidrug-Resistant Pathogens Escalation Versus De-Escalation Therapy Specific Multidrug-Resistant Pathogens Methicillin-Resistant Staphylococcus Enterococcus Pseudomonas aeruginosa β-Lactamase–Producing Gram-Negative Bacteria References 104 Hypercoagulable States Key Points Mechanisms of Thrombophilia Endothelial Disturbances Increased Procoagulant Elements Decreased Endogenous Anticoagulants Perturbations in Fibrinolysis Diagnostics Common Conditions in Veterinary Medicine Systemic Inflammation Protein-Losing Nephropathy Immune-Mediated Hemolytic Anemia Hypercortisolemia Cardiomyopathies Neoplasia Isolated Brain Injury Management of Hypercoagulable Conditions Treatment of the Underlying Condition Recombinant Anticoagulant Therapy Antithrombotic Therapy Inflammatory conditions Protein-losing nephropathy Immune-mediated hemolytic anemia Hypercortisolemia Cardiomyopathies Neoplasia Isolated brain injury Conclusion References 105 Bleeding Disorders Key Points Hemostasis and Fibrinolysis Hemostatic Testing Platelet Enumeration and Estimation Buccal Mucosal Bleeding Time The Prothrombin Time and Activated Partial Thromboplastin Time Fibrin Split Products D-dimers Fibrinogen Concentration Thrombin Time Thromboelastography and Thromboelastometry Etiology Hypocoagulability in the Critically Ill or Injured Patient Dilutional Coagulopathy Hypothermia Acidemia Diagnosis History Physical Examination Hemostatic Testing Principles of Management Plasma and Platelet transfusion Prohemostatic Agents Desmopressin Antifibrinolytics Specific Conditions Thrombocytopenia Thrombopathia Inherited Coagulopathies Vitamin K Deficiency Hepatic Failure Trauma-Induced Coagulopathy Disseminated Intravascular Coagulation Delayed Postoperative Bleeding in Greyhound Dogs References 106 Thrombocytopenia Key Points Causes Thrombocytopenia in the Critically Ill Diagnostic Techniques for Thrombocytopenia Mechanisms of Thrombocytopenia Decreased Production Consumption Sequestration Increased Destruction Therapeutic Approaches to Thrombocytopenia Platelet Transfusions References 107 Platelet Disorders Key Points Inherited Disorders Extrinsic Disorders Intrinsic Disorders Acquired Disorders Drugs von Willebrand’s Disease Uremia Treatment Summary References 108 Anemia Key Points Signalment and History Clinical Signs Laboratory Tests Therapeutic Principles Summary References 109 Methemoglobinemia Key Points Pathophysiology Oxidation in the Erythrocyte Heinz Bodies Specific Causes of Erythrocyte Oxidation Acetaminophen Topical Benzocaine Skunk Musk Nitrites and Nitrates Hydroxycarbamide Methemoglobin Reductase Deficiency Diagnosis Clinical Signs Determining Methemoglobin Presence and Levels Treatment N-Acetylcysteine Methylene Blue Adjunctive Treatments References 110 Acute Hemolytic Disorders Key Points Evaluation of the Patient with Hemolysis Fragmentation Hemolysis Toxicant-Induced Hemolysis Heritable Hemolysis Infection-Related Hemolysis Infection of Red Blood Cells Systemic Infections Immune-Mediated Hemolysis Findings Suggestive of Immune-Mediated Hemolytic Anemia Treatment of Immune-Mediated Hemolytic Anemia Immune suppression Supportive care Prevention of complications Other Causes of Immune-Mediated Hemolytic Anemia References 111 Rodenticides Key Points Anticoagulant Rodenticides Pathophysiology and Clinical Signs Case Management Acute ingestion Coagulopathies Outcome Cholecalciferol Pathophysiology and Clinical Signs Case Management Acute ingestion Hypercalcemia Outcome Bromethalin Pathophysiology and Clinical Signs Case Management Acute ingestion Neurologic complications Outcome Miscellaneous Rodenticides References 112 Acute Abdominal Pain Key Points Diagnostic Evaluation Signalment and History Physical Examination Emergency Clinical Pathology Abdominal Radiographs Abdominal Fluid Analysis Surgical Versus Medical Management References 113 Acute Pancreatitis Key Points Pathophysiology Clinical Presentation Diagnosis Laboratory Assessment Diagnostic Imaging Cytology and Histopathology Additional Diagnostic Evaluation Determining Severity Treatment Resuscitation, Fluid Therapy, and Monitoring Pain Management Nutrition Additional and Supportive Therapy Antibiotic Therapy Surgery Outcome Conclusion References 114 Acute Cholecystitis Key Points Clinical Findings Common Causes of Cholecystitis in Dogs and Cats Infectious Agents Bacteria Parasites Obstruction Gallbladder Mucocele Gallbladder Infarction References 115 Hepatitis and Cholangiohepatitis Key Points Historical Findings Physical Examination Findings Mechanisms of Hepatocellular Injury Causes of Hepatitis and Cholangiohepatitis in Dogs and Cats Idiopathic Causes Feline cholangitis complex Neutrophilic Cholangitis Lymphocytic Cholangitis Canine chronic hepatitis Role of Copper Nonspecific reactive hepatitis Viral Causes Infectious canine hepatitis Feline infectious peritonitis Bacterial Causes Leptospirosis Bartonellosis Septicemia Drugs and Toxins References 116 Hepatic Failure Key Points Pathophysiology Hepatic Encephalopathy Coagulation Disorders Other Clinical Signs Diagnosis Therapy Prognosis Future Therapies References 117 Gastroenteritis Key Points Anatomy and Physiology History and Clinical Signs Causes Infectious Gastroenteritis Viral enteritis Bacterial enteritis Parasitic gastroenteritis Fungal gastroenteritis Hemorrhagic Gastroenteritis Dietary Indiscretion Protein-Losing Enteropathy Extraintestinal Diseases Diagnosis Treatment Conclusion References 118 Motility Disorders Key Points Megaesophagus Etiology and Clinical Signs Diagnosis and Treatment Gastric Emptying Disorders Etiology and Clinical Signs Diagnosis and Treatment Small Intestinal Transit Disorders Etiology and Clinical Signs Diagnosis and Treatment Megacolon Etiology and Clinical Signs Diagnosis and Treatment Prokinetic Drugs for Gastrointestinal Motility Disorders Serotonergic Drugs Cisapride Metoclopramide Ghrelin Mimetics and Motilin Receptor Agonists Acetylcholinesterase Inhibitors References 119 Gastrointestinal Hemorrhage Key Points Etiology History and Physical Examination Diagnostic Tests Tests to Help Detect Presence of Gastrointestinal Hemorrhage Tests to Help Identify Underlying Causes Treatment Medical Management Endoscopy, Interventional Radiology, and Surgery Prognosis References 120 Regurgitation and Vomiting Key Points Differentiation of Vomiting and Regurgitation Regurgitation Definition Clinical Consequences of Regurgitation Differential Diagnoses Diagnostic Approach History Physical examination Clinical pathology Diagnostic imaging Further diagnostic testing General Treatment Guidelines Prognosis Vomiting Definition Physiology of Vomiting Clinical Consequences of Vomiting Differential Diagnoses Diagnostic Approach History Physical examination Clinical pathology Diagnostic imaging General Treatment Guidelines Conclusion References 121 Diarrhea Key Points Pathophysiologic Mechanisms of Diarrhea Iatrogenic Causes of Diarrhea Primary Gastrointestinal Causes of Diarrhea Extragastrointestinal Diseases Causing Diarrhea Diagnostic Evaluation Treatment References 122 Peritonitis Key Points Clinical Signs Diagnostic Tests Treatment Medical Stabilization Surgical Treatment Postoperative Care Prognosis References 123 Gastric Dilatation-Volvulus Key Points Pathogenesis Pathophysiology History and Clinical Signs Physical Examination Diagnosis Treatment Goals Surgical Treatment Postoperative Care Owner Recommendations References 124 Acute Kidney Injury Key Points Etiology Pathophysiology Clinical Presentation History Physical Examination Diagnosis Laboratory Tests Imaging Other Diagnostic Modalities Treatment Fluid Therapy Diuretics Acid-Base and Electrolyte Balance Management of Gastrointestinal Signs Nutritional Support Renal replacement therapy Fluid administration during recovery phase polyuria Specific Treatments Prognosis References 125 Chronic Kidney Disease Key Points Etiology Pathophysiology Clinical Presentation Diagnosis Laboratory Tests Imaging Other Diagnostic Modalities Treatment Fluid Therapy Acid-Base and Electrolyte Balance Management of Gastrointestinal Signs Nutritional Support Management of Anemia Long-Term Management Dietary Therapy Fluid Therapy Additional Considerations Advanced Therapeutic Modalities Prognosis References 126 Pyometra Key Points Incidence Pathogenesis Diagnosis Signalment History and Physical Examination Diagnostic Imaging Laboratory Findings Treatment Stabilizing the Patient Surgical Management Medical Management Uterine Stump Pyometra References 127 Nutritional Assessment Key Points Impacts of Nutritional Support during Critical Illness Screening Systems Used for Nutritional Assessments Body Weight Body Composition Adipose Tissue Body condition score systems Lean Body Mass Muscle condition scoring Diet History Current intake Historical intake Laboratory Data Conclusion References 128 Nutritional Modulation of Critical Illness Key Points Omega-3 Fatty Acids Antioxidants Immune-Modulating Nutrients Arginine Glutamine Nucleotides Probiotics Conclusion References 129 Enteral Nutrition Key Points Determining the Route of Nutritional Support Enteral Versus Parenteral Oral Intake Versus Enteral Feeding Device Enteral Feeding Tubes Nasoesophageal or Nasogastric Tubes Esophagostomy Tube Gastrostomy Tube Jejunal Tubes Determining the Amount to be Fed Selecting the Diet Patient Variables Nonpatient Variables Monitoring Therapy Preventing and Managing Complications Patient-Related Complications Non–Patient-Related Complications References 130 Parenteral Nutrition Key Points Technical Requirements Vascular Access Monitoring and Nursing Care Formulating and Compounding Nutrient Admixtures Nutritional Assessment Prescription Formulation Calculation of Energy Requirements Calculation of Protein Requirements Calculation of Lipid and Carbohydrate Requirements Calculation of Micronutrient Requirements Delivery and Monitoring Preventing and Managing Complications Catheter and Parenteral Nutrition Admixture Complications Metabolic Complications References 131 Perioperative Evaluation of the Critically Ill Patient Key Points Preoperative Patient Evaluation Respiratory Resuscitation Cardiovascular Resuscitation Pain ASA Scoring Global Assessment Laboratory Testing Coagulation Blood Type and Crossmatch Kirby’s Rule of Twenty The Postoperative Period Airway and Breathing Ventilation and Oxygenation Oxygen Delivery Arrhythmias, Decreased Myocardial Contractility, and Hypotension Analgesia Hypothermia Laboratory Parameters Coagulation Acid-Base and Electrolyte Status Patient Cleanliness, Wound and Catheter Care, and Bandaging Patient Immobilization and Physical Therapy Nutrition Summary References 132 Portosystemic Shunt Management Key Points Preoperative Stabilization Medical Management Surgical Options Postoperative Monitoring Postoperative Complications Portal Hypertension Coagulopathy Neurologic Complications Prognosis References 133 Peritoneal Drainage Techniques Key Points Indications for Peritoneal Drainage Septic Peritonitis Chemical Peritonitis Other Indications for Peritoneal Drainage Techniques for Peritoneal Drainage Needle or Catheter Paracentesis Paracentesis with a Fenestrated Catheter per the Mini-Laparotomy Method Paracentesis with a Fenestrated Catheter Using the Seldinger Technique Surgical Placement of Closed Suction Drains Open Peritoneal Drainage Technique Vacuum-Assisted Drainage Complications of Peritoneal Drainage Volume and Albumin Loss Conclusion References 134 Postthoracotomy Management Key Points Immediate Postthoracotomy Assessment Analgesia Postthoracotomy Pain Syndrome in Humans Ventilation Hypoxemia Hypovolemia Complications and Mortality after Thoracotomy Hypothermia Thoracostomy Tube Care Conclusion References 135 Kidney Transplantation Key Points Indications Case Selection Evaluation of the Urinary Tract Cardiovascular Disease Infectious Disease Donor Selection Preoperative Management Immunosuppression for the Feline Renal Transplant Recipient Anesthetic Management Surgery Postoperative Management and Perioperative Complications Long-Term Management and Complications Canine Transplantation Conclusion References 136 Minimally Invasive Procedures Key Points Instrumentation Approaches/Access Scope-Guided Procedures Laparoscopic/thoracoscopic procedures Tracheoscopy/bronchoscopy Esophagoscopy/gastroscopy/duodenoscopy Cystourethroscopy Interventional Radiology Procedures Urethral stenting Ureteral stenting Tracheal stenting Cavity effusions and percutaneous drainage Intravascular foreign body removal Epistaxis Vascular obstructions References 137 Traumatic Brain Injury Key Points Incidence and Prevalence of Head Injury General Approach to the Patient with a Head Injury Pathophysiology Primary Injury Secondary Injury Neurologic Assessment Diagnostic Tests and Monitoring Treatment Extracranial Therapy Intracranial Therapy Hyperosmotic agents Corticosteroids Furosemide Decreasing cerebral blood volume Seizure treatment/prophylaxis Decreasing cerebral metabolic rate Prognosis References 138 Thoracic and Abdominal Trauma Key Points Trauma Categories Blunt Trauma Penetrating Trauma Diagnostics Clinical Laboratory Tests Imaging Fluid Analysis Stabilization Monitoring Antimicrobial Therapy Fluid Therapy/Blood Product Administration External Wound Care Specific Conditions Diaphragmatic Rupture Body Wall Rupture/Abdominal Evisceration Chylothorax/Chylous Ascites Pyothorax Septic Peritonitis Bile Peritonitis Hemothorax/Hemoperitoneum/Hemoretroperitoneum Uroperitoneum/Uroretroperitoneum Prognosis References 139 Wound Management Key Points Wound Healing Principles Wound Classification Phases of Healing Initial Patient Assessment Debridement and Lavage Sugar and Honey Dressing and Bandaging Exposed Bone Wound Closure Drains Negative Pressure Wound Therapy Additional Wound Management Modalities Antimicrobial Therapy Patient Care Complications Prognosis References 140 Thermal Burn Injury Key Points Definitions Patient Assessment and Medical Management Metabolic Derangements Nutrition Patient Comfort Antimicrobial Therapy Burn Wound Management Topical Agents Closure Options and Healing Complications References 141 Pain and Sedation Assessment Key Points Definition of Pain Pain Versus Stress Pain Assessment Behavior Tools Summary References 142 Sedation of the Critically Ill Patient Key Points Patient Evaluation and Management Choice of Agent Opioids Sedatives and Tranquilizers Benzodiazepines (see Chapter 164 for further details) Phenothiazine Tranquilizers α2 Agonists (see Chapter 165 for further details) Other Anesthetic Agents Ketamine Propofol Sedation of Animals with Specific Conditions Cardiovascular Instability Respiratory Disease Conclusion References 143 Anesthesia in The Critically Ill Patient Key Points Stabilization Premedication Induction Thiopental and Propofol Alfaxalone Etomidate Ketamine Opioids Maintenance Inhalants Constant Rate Infusion Neuromuscular Blocking Agents Benzylisoquinolinium agents Monitoring of neuromuscular blocking agents Reversal Agents for neuromuscular blocking agents Monitoring Intraoperative Hypotension Recovery Summary References 144 Analgesia and Constant Rate Infusions Key Points Analgesia Opioids Nonsteroidal Antiinflammatory Drugs α2-Adrenergic Agonists Transdermal Analgesics N-Methyl-D-Aspartate Receptor Antagonists Acepromazine Infiltrative and Local Anesthetics Epidural Analgesics Constant Rate Infusions Morphine-Lidocaine-Ketamine Conclusion References 145 Rehabilitation Therapy in the Critical Care Patient Key Points Musculoskeletal System Range-of-Motion Exercise Passive Range-of-Motion Exercise Active Assisted and Active Range-of-Motion Exercise Therapeutic Exercise and the Importance of Early Mobilization Assisted Standing Walking (Assisted and Unassisted) Neuromuscular Electrical Stimulation and Transcutaneous Electrical Stimulation Neuromuscular electrical stimulation Transcutaneous electrical stimulation Massage Respiratory System Positioning Postural Drainage Percussion (Coupage) and Vibration Summary References 146 Complementary and Alternative Medicine Key Points Acupuncture Massage Therapy Laser Therapy Music Therapy Herbs Aromatherapy Homeopathy and Flower Essences Conclusion References 147 Smoke Inhalation Key Points Pathophysiology Carbon Monoxide Hydrogen Cyanide Thermal Injury Irritant Gases and Superheated Particulate Matter Reduced lung compliance Airway damage and obstruction Bacterial pneumonia Dermal Burn Injury History Physical Examination Clinical Evaluation Arterial Blood Gas Analysis Acid-Base Status Thoracic Radiography Laryngoscopy, Bronchoscopy, and Transtracheal Aspiration Diagnosis Treatment Oxygen Supplementation Cyanide Toxicity Airway Management Sedation Mechanical Ventilation Intravenous Fluid Therapy Additional Therapies Prognosis References 148 Hypothermia Key Points Classification Review of Thermoregulation Physiologic Effects of Hypothermia Cardiovascular and Hemodynamic Effects Respiratory Effects Neuromuscular Effects Acid-Base Effects Coagulation Effects Renal and Metabolic Effects Core Body Temperature Measurement Rewarming Therapy Cardiopulmonary Resuscitation Therapeutic Hypothermia References 149 Heat Stroke Key Points Physiology, Pathogenesis, and Pathophysiology Physical Examination Temperature, Pulse, and Respiratory Rate Cardiovascular System Respiratory System Central Nervous System Renal System Gastrointestinal System Coagulation System Laboratory Evaluation Treatment and Monitoring Cooling Procedures Cardiovascular System Respiratory System Central Nervous System Renal System Coagulation System Gastrointestinal System Prognosis References 150 Electrical and Lightning Injuries Key Points Mechanisms of Electrical Injury Predisposition to Electrical Injury Clinical Findings Secondary Effects of Electrical Injury Treatment of Electrical Injury Prognosis Lightning Injury References 151 Drowning and Submersion Injury Key Points Definitions Incidence and Epidemiology Humans Veterinary Patients Pathophysiology of Injury Pulmonary System Fluids and Electrolytes Neurologic and Cardiovascular Systems Effect of Water Temperature Diagnostic Tests and Monitoring Treatment Outcome References 152 Anaphylaxis Key Points Pathophysiology Differential Diagnosis Clinical Manifestations Treatment Epinephrine Other Vasopressors Antihistamines Glucocorticoids Potential Therapies Fluid Therapy Ancillary Patient Management Prevention References 153 Air Embolism Key Points Gas Embolization Due to Intravenous Access Mishaps Gas Embolization during Laparoscopic Procedures Gas Embolization during Surgery Gas Embolization From Lung Biopsy Gas Embolization during Hyperbaric Therapy Detection of Air Emboli Management of Air Embolism References 154 Ocular Disease In The Intensive Care Unit Key Points Blepharospasm Red Eye Tear Film Abnormalities Absent Palpebral Reflex Corneal Changes Anterior Chamber Abnormalities Pupil Abnormalities Anisocoria Miosis Mydriasis Dyscoria Blindness References 155 Critically Ill Neonatal and Pediatric Patients Key Points Physical Examination Findings Laboratory Values Imaging Intravenous and Intraosseous Catheterization Fluid Requirements Temperature Control Nutrition Monitoring Pharmacology Sepsis Conclusion References 156 Critically Ill Geriatric Patients Key Points Laboratory Values Imaging Fluid Therapy Nutrition Pharmacology Conclusion References 157 Catecholamines Key Points Hypotension Poor Contractility Catecholamine Choices Dopamine Dobutamine Ephedrine Norepinephrine Phenylephrine Vasopressin Angiotensin Epinephrine Isoproterenol Dopexamine Choosing the Right Catecholamine Combination Therapies Vasomotor Tone Catecholamines and Cortisol Other Effects of Catecholamines References 158 Vasopressin Key Points Physiology of Vasopressin Vasopressin Receptors Physiologic Effects of Vasopressin Pharmacology Clinical Uses Cardiopulmonary Resuscitation Vasodilatory Shock Hemorrhagic Shock Central Diabetes Insipidus von Willebrand Disease Gastrointestinal and Pulmonary Disease Adverse Effects Vasopressin Antagonists Conclusion References 159 Antihypertensives Key Points Etiology of Hypertension Proposed Mechanism of Blood Pressure Elevation Antihypertensive Drugs Angiotensin-Converting Enzyme Inhibitors Mechanism of action Indications Adverse effects Angiotensin II Receptor Blockers Mechanism of action Indications Adverse effects Adrenergic Receptor Antagonists Mechanism of action Indications Adverse effects Aldosterone Blockers Mechanism of action and indications Adverse effects Calcium Channel Blockers Mechanism of action Indications Adverse effects Arteriolar Vasodilators Hydralazine Mechanism of action and indications Adverse effects Sodium Nitroprusside Mechanism of action and indications Adverse effects Fenoldopam Mechanism of action Indications Adverse effects Hypertensive Urgency Treatment of Hypertensive Urgency Hypertensive Emergency Treatment of Hypertensive Emergency References 160 Diuretics Key Points Physiology of Diuresis and Antidiuresis Pharmacology Osmotic Diuretics Carbonic Anhydrase Inhibitors Loop Diuretics Thiazide Diuretics Aldosterone Antagonists Other Potassium-Sparing Distal Diuretics Aquaretics Indications for Diuretic Therapy Urinary Diseases Congestive Heart Failure Liver Failure Electrolyte and Mineral Disorders Systemic Hypertension References 161 Gastrointestinal Protectants Key Points Histamine-2 Receptor Antagonists Proton Pump Inhibitors Sucralfate Prostaglandin Analogs Antacids Future Drug Therapy Potential Complications of Increased Gastric pH References 162 Antiemetics and Prokinetics Key Points Antiemetics Neurokinin-1 Receptor Antagonists 5-HT3 Receptor Antagonists Metoclopramide Promazine Derivatives Anticholinergic Agents Other Drugs Peripherally Acting Antiemetics Prokinetic Drugs 5-HT4 Serotonergic Agonists Cholinomimetic Drugs Motilin Receptor Agonists Metoclopramide Misoprostol References 163 Narcotic Agonists and Antagonists Key Points Terminology and History Opium Opiate Opioid Narcotic Structure-Activity Relationship Mechanism of Action Opioid Receptors Physiologic Effects of Opioids Metabolism and Excretion Potency and Effectiveness of Opioids Epidural Opioids Characteristics of Clinically Useful Opioids Morphine Methadone Hydromorphone and Oxymorphone Fentanyl and Remifentanil Butorphanol Nalbuphine Buprenorphine Tramadol Codeine Opioid Antagonists: Naloxone, Nalmefene, Naltrexone Conclusion References 164 Benzodiazepines Key Points Action Diazepam Versus Midazolam Benzodiazepine Effects Benzodiazepines and Cats Indications Sedation Anticonvulsant Therapy Appetite Stimulation Hepatic Encephalopathy References 165 α2 Agonists and Antagonists Key Points α2 Adrenoceptors Effects of α2 Agonists Central Nervous System Cardiovascular System Other Effects Imidazoline Receptors Drugs Clinical Use α2 Antagonists Conclusion References 166 Anticonvulsants Key Points Seizures Phenobarbital Bromide Zonisamide Levetiracetam Benzodiazepines Gabapentin and Pregabalin Felbamate References 167 Antiplatelet Drugs Key Points Platelet Physiology Antiplatelet Drugs Adenosine Diphosphate Receptor Antagonists Thienopyridines Nucleoside analogs Cyclooxygenase Inhibitors Fibrinogen Receptor Antagonists References 168 Anticoagulants Key Points Pathogenesis Indications for Anticoagulant Use Anticoagulants Vitamin K Antagonists Adverse Effects Monitoring Heparins Unfractionated Heparins Low-Molecular-Weight Heparins Heparin Dosage Direct Thrombin Inhibitors Factor Xa Inhibitors Conclusion References 169 Thrombolytic Agents Key Points Specific Thrombolytic Agents Streptokinase Urokinase Tissue Plasminogen Activator Adverse Effects of Thrombolytic Therapy Thrombolytic Therapy in Dogs Streptokinase Urokinase Tissue Plasminogen Activator Thrombolytic Therapy in Cats Streptokinase Urokinase Tissue Plasminogen Activator Conclusion References 170 Hemostatic Drugs Key Points Antifibrinolytic Drugs Indications Contraindications Use of Antifibrinolytic Drugs in Cats ε-Aminocaproic acid Tranexamic Acid Topical Antifibrinolytic Therapy Desmopressin Protamine Conjugated Estrogens Recombinant Factor VIIa Yunnan Paiyao References 171 Antiarrhythmic Agents Key Points Classification Schemes Class I Antiarrhythmic Agents Class Ia Antiarrhythmic Agents Class Ib Antiarrhythmic Agents Class Ic Antiarrhythmic Agents Class II Antiarrhythmic Agents Class III Antiarrhythmic Agents Class IV Antiarrhythmic Agents Other Antiarrhythmic Agents Digoxin Magnesium Sulfate Adenosine Antiarrhythmic Devices and Procedures References 172 Inhaled Medications Key Points Introduction Principles of Aerosol Deposition in the Lungs Delivery Systems Jet Nebulizers Ultrasonic Nebulizers Metered Dose Inhalers Clinical Applications Feline Bronchopulmonary Disease Inhaled bronchodilators Inhaled glucocorticoids Other inhaled medications Canine Infectious Tracheobronchitis and Pneumonia Medications for Use with Bronchoscopy Conclusion References 173 Complications of Chemotherapy Agents Key Points Principles of Chemotherapy Testing for Chemotherapy Drug Sensitivity Chemotherapy Drugs Toxicities and Treatment of Chemotherapy-Related Emergencies Acute Tumor Lysis Syndrome Allergic Reactions Bone Marrow Toxicity Anemia Thrombocytopenia Neutropenia Sepsis Cardiotoxicity Dermatologic Toxicity Extravasation Gastrointestinal Toxicity Cachexia and anorexia Vomiting Diarrhea Neurologic Toxicity Urologic Toxicity References 174 Antitoxins and Antivenoms Key Points Tetanus Antitoxin Tick Antitoxin Botulism Antitoxin Black Widow Spider Antivenom Scorpion Antivenom Snake Antivenom Production of Poisonous Snake Antivenom Pit Viper Antivenom Coral Snake Antivenom References 175 Antimicrobial Use in the Critical Care Patient Key Points Antimicrobial Resistance Advent of Resistance Nosocomial Infections Reducing Microbial Resistance Antimicrobial Selection and Treatment Timely Assessment of Need for and Initiation of Antimicrobial Therapy Identification of the Target and Its Susceptibility Design of the Dosing Regimen Role of the minimum inhibitory concentration in the dosing regimen Site of Infection Host Immune Response Impact of Microbial Factors Adverse Drug Events Antimicrobial Deescalation References 176 β-Lactam Antimicrobials Key Points Mechanism of Action Pharmacology Resistance Production of β-Lactamase Changes in Cell Wall Permeability Selected Penicillins and Cephalosporins Penicillin G Extended-Spectrum Penicillins Antipseudomonal Penicillins First-Generation Cephalosporins Second-Generation Cephalosporins Third-Generation Cephalosporins Carbapenems References 177 Aminoglycosides Key Points Mechanism of Action Spectrum of Activity Indications Pharmacology and Dosing Adverse Effects References 178 Fluoroquinolones Key Points Structure and Physical Properties Mechanism of Action Bacterial Spectrum Pharmacokinetics and Pharmacodynamics Resistance Clinical Uses Administration and Drug Interactions Adverse Effects References 179 Macrolides Key Points Mechanism of Action Pharmacology Resistance Selected Macrolides Erythromycin Azithromycin References 180 Antifungal Therapy Key Points Introduction Classes of Antifungal Drugs Polyene Antibiotics Azole Antifungals Recommendations for Specific Fungal Infections Blastomycosis Histoplasmosis Coccidioidomycosis Cryptococcosis References 181 Miscellaneous Antibiotics Key Points Metronidazole Chloramphenicol Tetracyclines Potentiated Sulfonamides Vancomycin Polymyxins Clindamycin Rifampin Newer Agents Active Against Multidrug-Resistant Gram-Positive Cocci Daptomycin Tigecycline Quinupristin-Dalfopristin Linezolid References 182 Strategies for Treating Infections in Critically Ill Patients Key Points Bacterial Susceptibility How to Proceed with Empirical Treatment Assessing Initial Response To Escalate or De-escalate? What to Do if the Initial Empirical Treatment Fails Penetration to the Site of Infection Diffusion into Tissues Urinary Tract Intracellular Infections Local Factors That Affect Antibiotic Effectiveness Pharmacokinetic-Pharmacodynamic Optimization of Doses Aminoglycosides Fluoroquinolones β-Lactam Antibiotics Other Time-Dependent Drugs References 183 Hemodynamic Monitoring Key Points Continuous Electrocardiogram Monitoring Blood Pressure Monitoring Noninvasive Blood Pressure Monitoring Photoplethysmography Invasive Blood Pressure Monitoring Telemetric Blood Pressure Monitoring Central Venous Pressure Monitoring Pulmonary Artery Pressure Monitoring Mixed Venous and Central Venous Oxygen Saturation Lactate and Base Deficit References 184 Cardiac Output Monitoring Key Points Indications for Cardiac Output Measurement Measurement of Cardiac Output Invasive Methods of Determining Cardiac Output Fick oxygen consumption method Carbon dioxide rebreathing methods Indicator dilution method (including thermodilution) Noninvasive or Minimally Invasive Methods of Determining Cardiac Output Normal Values Potential Causes of Error Disease States and Cardiac Output Measurement Potential Complications References 185 Electrocardiogram Evaluation Key Points Indications Electrocardiographic Principles Technique Electrocardiogram Waveforms Electrocardiogram Interpretation Effects of Disease States on the Electrocardiogram Electrolyte Abnormalities Hyperkalemia Hypokalemia Hypercalcemia Hypocalcemia Magnesium level Hypoxemia Intrathoracic Effusions Pain References 186 Blood Gas and Oximetry Monitoring Key Points Hydrogen Ions Buffers Henderson-Hasselbalch Equation Regulation of pH Blood Gas Analysis: Getting Started Temperature Correction Step-by-Step Acid-Base Analysis Number 1: Evaluate the pH Number 2: Evaluate PCO2 (see also Chapter 16) Number 3: Evaluate the metabolic indices Number 4: Determine if there is one problem or many Anion gap The Stewart approach (see Chapter 55) Strong Ion Difference. Strong Ion Gap. Base Excess Modification. Number 5: Determine how well the patient is oxygenating (see also Chapter 15) Pulse oximetry Number 6: Look at the whole picture Venous Blood Gas Values References 187 Colloid Osmotic Pressure and Osmolality Monitoring Key Points Colloid Osmotic Pressure Starling’s Hypothesis Calculated versus Measured Values Normal Colloid Osmotic Pressure Values Colloid Osmotic Pressure in Critically Ill Patients How Colloid Osmotic Pressure Is Measured Indications for Colloid Osmotic Pressure Measurement Osmolality Definition Determination of Osmolality Osmolal Gap Effective Osmolality Urine Osmolality References 188 Intraabdominal Pressure Monitoring Key Points Definitions and Incidence Risk Factors Pathophysiology Methods of Intraabdominal Pressure Measurement Physiologic Effects of Intraabdominal Hypertension Hemodynamic Effects Renal Effects Pulmonary and Thoracic Effects Central Nervous System Effects Visceral Effects Systemic Effects General Considerations Acknowledgment References 189 AFAST and TFAST in the Intensive Care Unit Key Points Terminology Objective of Focused Assessment with Sonography for Trauma Abdominal Focused Assessment with Sonography for Trauma AFAST Technique Abdominal Fluid Score Technique AFAST for Blunt Abdominal Trauma AFAST for Penetrating Abdominal Trauma AFAST for Determining the Cause of Intraabdominal Injury Thoracic Focused Assessment with Sonography for Trauma TFAST Technique Chest Tube Site Views Pleural line and the bat sign A-lines B-lines Lung curtain Sonographic signs of pneumothorax Absence of glide sign and B-lines Pericardial Chest Site and Subxiphoid Site Views Emergency Lung Ultrasound to Detect Interstitial-Alveolar Lung Injury References 190 Capnography Key Points Nondiverting and Diverting Monitors Technology Physiology Capnogram Interpretation Equipment Patient References 191 Intracranial Pressure Monitoring Key Points Determination of Intracranial Pressure Intracranial Pressure Locations for Monitoring Intracranial Pressure in the Brain Types of Intracranial Pressure Monitoring Devices Intracranial Pressure Monitoring Systems Ventriculostomy catheter with external transducer Transducer-tipped catheters Subarachnoid bolt Fluid-filled catheter Evaluation of Intracranial Pressure Normal Intracranial Pressure Accuracy of Intracranial Pressure Monitoring Systems Complications of Intracranial Pressure Monitoring Indications for Intracranial Pressure Monitoring in Dogs and Cats References 192 Urine Output Key Points Urine Output as a Monitoring Tool Measurement of Urine Output Determinants of Urine Output Glomerular Filtration Rate Tubular Reabsorption of Water and Solutes Impedance to Flow Normal Urine Output Abnormal Urine Output Oliguria Prerenal oliguria Postrenal oliguria Renal oliguria Polyuria Prerenal polyuria Postrenal polyuria Renal polyuria Fluid Balance Case Example References 193 Peripheral Venous Catheterization Key Points Catheter Types Winged or Butterfly Needle Over-the-Needle Catheter Through-the-Needle Catheter Multilumen Catheter Advantages of Peripheral Venous Catheterization Catheter Insertion Site Cephalic Vein Saphenous Vein Pedal Veins Auricular Vein Insertion Technique Percutaneous Placement Facilitative Incision or Relief Hole Venous Cutdown Peripherally Inserted Central Venous Catheters Complications Associated with Catheterization Phlebitis Thrombosis Catheter Embolism Subcutaneous Fluid Infiltration Infection Catheter Maintenance References 194 Intraosseous Catheterization Key Points Historical Perspectives Physiology Indications Contraindications Methods Complications References 195 Central Venous Catheterization Key Points General Concepts Catheter Types Through-the-Needle Catheter Over-the-Needle Catheter Long Single-Lumen Catheter Multilumen Catheter Percutaneous Sheath Catheter Introducer Catheter Insertion Site Saphenous Vein Jugular Vein Catheter Insertion Through-the-Needle Catheter Insertion Seldinger Technique Rewiring of Seldinger Catheters Peel-Off Sheathed Needle Technique Complications and Catheter Maintenance Heparinized Saline References 196 Blood Film Evaluation Key Points Blood Film Preparation Blood Film Evaluation White Blood Cell Responses Red Blood Cell Responses Platelet Responses Leukemia (Myeloid and Lymphoid) References 197 Endotracheal Intubation and Tracheostomy Key Points Endotracheal Intubation Airway Assessment Routine Intubation Dogs Cats Difficult Intubation Preoxygenation Equipment setup Approach Alternative Techniques and Adjuncts Needle cricothyroidotomy Cricothyroidotomy Fiberoptic-assisted intubation Digital palpation Nasal intubation Retrograde intubation Cricoid pressure Placement Verification Complications Tracheostomy Tracheostomy Tube Selection Percutaneous Tracheostomy Surgical Tracheostomy Transverse incision Vertical incision Securing the tracheostomy tube Tracheostomy Tube Management Suctioning Tube Removal Complications Summary References 198 Thoracocentesis Key Points Indications Materials Techniques Needle Insertion Techniques Thoracocentesis using a butterfly needle Thoracocentesis using a hypodermic needle with a saline-filled hub Over-the-Needle Catheter Insertion Technique Thoracocentesis using an over-the-needle intravenous catheter Thoracocentesis using a thoracostomy tube Through-the-Needle Catheter Technique Seldinger Technique Diagnostic Evaluation of the Aspirate Postprocedure Care Complications References 199 Thoracostomy Tube Placement and Drainage Key Points Indications Thoracostomy Tube Placement Materials Anesthesia Techniques Drainage Passive Drainage Techniques Active Drainage Techniques Maintenance and Care Removal Complications References 200 Abdominocentesis and Diagnostic Peritoneal Lavage Key Points Indications Focused Assessment with Sonography for Trauma Technique Preparation of the Patient Closed-Needle Abdominocentesis Open-Needle Abdominocentesis Four-Quadrant Abdominocentesis Alternatives to Abdominocentesis Abdominal Fluid Analysis Analysis of Diagnostic Peritoneal Lavage Samples Conclusion References 201 Arterial Catheterization Key Points Patient Preparation Percutaneous Arterial Catheter Placement Dorsal Pedal Artery Catheterization Femoral Artery Catheterization Auricular Artery Catheterization Radial Artery Catheterization Coccygeal Artery Catheterization Surgical Cutdown for Arterial Catheter Placement Maintenance of the Arterial Catheter Three-Syringe Technique References 202 Pulmonary Artery Catheterization Key Points Types of Catheters and Uses Cardiac Output Pulmonary Capillary Wedge Pressure Right Ventricular End-Diastolic Volume Selective Pulmonary Angiography Additional Measurements Indications Placement Flow-Directed Placement Fluoroscopy Complications Alternatives References 203 Temporary Cardiac Pacing Key Points Indications for Temporary Cardiac Pacing Description of the Temporary Pacemaker Systems Transvenous Pacing System Transcutaneous Pacing System Transesophageal Pacing System Troubleshooting Transvenous Pacing System Transcutaneous Pacing System Transesophageal Pacing System Complications Transvenous Pacing System Transcutaneous Pacing System Transesophageal Pacing System References 204 Cardioversion and Defibrillation Key Points Definitions Mechanism of Cardioversion and Defibrillation Defibrillator-Cardioverter Approach to Defibrillation Indications Preparation Therapy Complications Approach to Synchronized Cardioversion Indications Preparation Therapy Complications References 205 Renal Replacement Therapies Key Points Principles of Dialysis Indications Contraindications Components of Dialysis Catheters for Intermittent Hemodialysis and Continuous Renal Replacement Therapy Catheters for Peritoneal Dialysis Dialysate Dialyzer Anticoagulation Dialysis Prescription Complications and Other Considerations Outcome and Prognosis Summary References 206 Apheresis Key Points Equipment Principles of Apheresis Indications Myasthenia Gravis Immune-Mediated Hemolytic Anemia Future Applications References 207 Cerebrospinal Fluid Sampling Key Points Cerebrospinal Fluid Formation and Functions Indications for Cerebrospinal Fluid Collection and Analysis Contraindications and Risks Cerebrospinal Fluid Collection Techniques Preparation Collection Sites and Techniques Cisternal puncture Positioning Needle insertion Tips for troubleshooting cerebrospinal fluid puncture Precaution. Lumbar puncture Positioning Note. Analysis of Cerebrospinal Fluid Specimen Handling and Examination Physical Characteristics Total Cell Count and Differential Cytologic Analysis Protein Concentration Other Tests Interpretation of Common Findings References 208 Urinary Catheterization Key Points Indications Intermittent Catheterization Indwelling Catheter Risks and Complications Infection Mechanical Difficulties Catheter Types Materials Size Foley Catheters Placement Technique Male Dog Female Dog Male Cat Female Cat Securing the Catheter Closed Collection System Care of an Indwelling Urinary Catheter References 209 Intensive Care Unit Facility Design Key Points The Design Process Location in the Hospital Arrangement and Size Unit Configuration Staff Work Areas Patient Care Areas Patient modules Procedure area and storage Isolation room Ancillary Services Utilities Environmental Aspects Lighting Air Conditioning Acoustic Environment Floor and Wall Surfaces, Ceiling Finishes Furnishings Details and Common Design Elements Infection Prevention and Control Safety and Security Patient- and Owner-Centered Care Ambiance Communication References 210 Management of the Intensive Care Unit* Key Points Intensive Care Unit Personnel: Staff Qualifications and Scheduling Role of the Intensive Care Unit Director Staffing Veterinarians Residents and interns Nursing staff Scheduling Staff/Patient Ratio Management of Intensive Care Unit Staff Communication Delegation of Responsibility Conflict: Causes, Categories, and Resolution Categories of conflict Methods of conflict resolution Conflict prevention Recruitment of Intensive Care Unit Nursing Staff Training intensive care unit nurses Retention of Staff: Handling Stress and Burnout References 211 Client Communication and Grief Counseling Key Points Client Communication The Human-Animal Bond Client Expectations End-of-Life Decisions Compassion Fatigue Support for veterinary staff Communicating with Difficult Clients Stages of Grief Types of Grief Anticipatory Grief Multiple Losses and “Trigger Grief” Grief from Expected Loss Grief from Unexpected Loss Disenfranchised Grief Complicating Factors Financial Considerations Mental Health History Children and Loss Pet Loss and Older Adults Veterinary Resources Support Groups Individual Grief Support Sessions Lectures, Seminars, and Workshops Healing Through Pet Loss Finding Meaning Memorializing a Pet References Appendices Appendix 1 Clinical Calculations Appendix 2 Important Physiologic Formulas Appendix 3 Ideal Gas Laws Appendix 4 Surviving Sepsis Campaign 2012 Bundle Recommendations for Humans Appendix 5 Constant Rate Infusion Calculations Micrograms per Kilogram per Minute Milligrams per Kilogram per Hour (Using 250 ml bag of fluids) Appendix 6 Common Drug Dosages for Constant Rate Infusions Index A B C D E F G H I J K L M N O P Q R S T U V W X Y Z