Untitled

Advanced Monitoring and
Procedures for Small Animal

Emergency and Critical Care
Advanced Monitoring and Procedures for Small Animal
Emergency and Critical Care
Second Edition
Edited by
Jamie M. Burkitt Creedon

School of Veterinary Medicine, University of California, Davis
California, USA
Harold Davis
Retired, University of California
Clinical Educational Veterinary Consultant
California, USA
This edition first published 2023
© 2023 John Wiley & Sons, Inc.
Edition History
First edition © 2012 by John Wiley & Sons, Inc.
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Library of Congress Cataloging-in-Publication Data applied for

HB ISBN: 9781119581413
Cover Design: Wiley

Cover Images: © Jamie M. Burkitt Creedon, Harold J. Davis
Set in 9.5/12.5pt STIXTwoText by Straive, Pondicherry, India

v
Contents
List of Contributors xi
Preface to the Second Edition xvii
Acknowledgments xix
About the Companion Website xxi
Section One Fundamental Elements of Emergency and Critical Care Practice 1
1 Triage 3
Harold Davis
2 The Small Animal Emergency Room 13

Martin D. Miller and Sean D. Smarick
3 Intensive Care Unit Design 23

Joris H. Robben and Lindsey Dodd
4 Developing and Using Checklists in Practice 47

Elizabeth B. Davidow and Carmen King
5 Medical Charting 53
Karl E. Jandrey and Sharon Fornes
6 Point-of-Care Ultrasound for Emergency and Critical Care 75

Søren Boysen and Valerie Madden
Section Two Cardiovascular Procedures and Monitoring 81
7 Catheterization of the Venous Compartment 83

Andrea M. Steele and Jessica L. Oram
8 Arterial Puncture and Catheterization 103

Elisa M. Mazzaferro and Nicole van Sant
9 Ultrasound-Guided Vascular Access 117

10 Principles of Electrocardiography 127

vi Contents
11 Electrocardiogram Interpretation 135

Casey J. Kohen
12 Fluid-Filled Hemodynamic Monitoring Systems 153

13 Direct Systemic Arterial Blood Pressure Monitoring 169

Edward Cooper and Stacey Cooper
14 Noninvasive Arterial Blood Pressure Monitoring 181

Christopher L. Norkus and Nicholas L. Rivituso
15 Central Venous Pressure Monitoring 191

Rosalind S. Chow
16 Cardiac Output Monitoring 207

Mack Fudge
17 Point-of-Care Cardiac Ultrasound 225

Valerie Madden and Søren Boysen
18 Pericardiocentesis 241
Simon P. Hagley
19 Monitoring Tissue Perfusion: Clinicopathologic Aids and Advanced Techniques 251

Alexandra Nectoux and Guillaume L. Hoareau
20 Cardiopulmonary Resuscitation 261

Sean D. Smarick
21 Open-Chest Cardiopulmonary Resuscitation 271

Janelle R. Wierenga and Katherine R. Crosse
22 Defibrillation 281
Casey J. Kohen
23 Temporary Cardiac Pacing 291

Anna Grimes and H. Edward Durham, Jr
Section Three Respiratory Procedures and Monitoring 309
24 Oxygen Therapy 311

Kate Farrell
25 Pulse Oximetry and Co-Oximetry 327

Kate Farrell
26 Blood Gas Analysis 339

Sarah Gray
27 Point-of-Care Lung and Pleural Space Ultrasound 347

Contents vii
28 Tracheal Intubation 365

Marc Raffe and Rachel Bassett
29 Temporary Tracheostomy 377

F. A. (Tony) Mann
30 Capnography 389
Linda S. Barter and Alessia Cenani
31 Mechanical Ventilation 399

Kate Hopper and Julie Eveland-Baker
32 Ventilator Waveform Analysis 409

Deborah Silverstein and Justina Gerard
33 Alternative Methods of Augmented Ventilation 427

Jessica Schavone and Elizabeth Rozanski
34 Pleural Space Drainage 431

Amanda Arrowood and Lori S. Waddell
Section Four Urinary and Gastrointestinal Procedures 449
35 Urethral Catheterization 451

36 Peritoneal Dialysis 467

Michael D. Santasieri, Carolyn Tai, and Mary Anna Labato
37 Technical Management of Hemodialysis 481

Karen Poeppel and Cathy Langston
38 Peritoneal Evaluation 499

Laura Osborne and Lindsey Strang
39 Point-of-Care Abdominal Ultrasound 513

40 Specialized Gastrointestinal Techniques 523

Lisa Smart and Joyce Lau
41 Postoperative Peritoneal Drainage Techniques 539

Margo Mehl
Section Five Nutrition 545
42 Nutritional Requirements in Critical Illness 547

Daniel L. Chan
43 Enteral Diets for Critically Ill Patients 555

Sally C. Perea
viii Contents
44 Assisted Enteral Feeding 567

Wan K. A. Tan
45 Parenteral Nutrition 585

Jennifer Larsen
Section Six Analgesia and Anesthesia 599
46 Drug Administration 601

Damion Asselin and Jane Quandt
47 Pain Recognition and Management 617

Chiara Valtolina and Liza Lindeman
48 Systemic Analgesia 631

Sarah Haldane and Angela Chapman
49 Local Anesthesia 651

Christopher L. Norkus
50 Monitoring the Anesthetized Patient 665

Benjamin M. Brainard and Jessica Perlini
51 Nursing Care of the Long-Term Anesthetized Patient 681

Yekaterina Buriko and Bridget M. Lyons
52 Neuromuscular Blockade 691

Manuel Martin-Flores and Karen L. Basher
Section Seven Clinicopathologic Techniques 699
53 Blood Sample Collection and Handling 701

Courtney Waxman and Tami Lind
54 In-House Hematologic Evaluation 717

Karl Jandrey and Andrew Burton
55 In-House Evaluation of Hemostasis 739

April Summers, Jocey Pronko, and Julien Guillaumin
56 Electrolyte Evaluation 747

Louisa J. Rahilly and Katherine Vachon
57 Acid–Base Evaluation 763

Kate Hopper
58 Osmolality and Colloid Osmotic Pressure 771

Elke Rudloff and Angel Rivera
59 Body Fluid Collection and Handling 779

Adesola Odunayo and Eric Hilton
Contents ix
60 Urinalysis in Acutely and Critically Ill Dogs and Cats 787

Lucy Kopecny and Sean Naylor
61 Cytology 797
Rebecca J. Greer
Section Eight Infection Control 807
62 Minimizing Healthcare-Associated Infections 809

Jane E. Sykes
63 Care of Indwelling Device Insertion Sites 819

Helen Philp
64 Antiseptics, Disinfectants, and Sterilization 837

Samantha Jones, Krystle Reagan, and Nicole Saunders
65 Personnel Precautions for Patients with Zoonotic Disease 845

Sarah Fritz and Christopher G. Byers
Section Nine Transfusion Medicine 859
66 Blood Typing and Crossmatching 861

Sarah Musulin and Kenichiro Yagi
67 Blood Transfusion 879

Julien Guillaumin and Kristin Kofron
68 Administration of Other Biological Products 891

Jennifer E. Prittie and Jasmine De Stefano
69 Blood Banking 905

Marie K. Holowaychuk and Kenichiro Yagi
Section Ten Nursing Care of Specific Populations 921
70 Care of the Patient with Intracranial Disease 923

Marie K. Holowaychuk and Charlotte E. Donohoe
71 Care of the Burned Animal 935

Steven Epstein
72 Care of the Environmentally Injured Animal 941

Michael S. Lagutchik, Rufus W. Frederick, and James O. Barclay
73 Blood Glucose Monitoring and Glycemic Control 951

Erica L. Reineke
74 Critical Nursing Care of the Neonate 965

Autumn Davidson and Janice Cain
x Contents
75 Safe Handling and Care of Patients Exposed to Radioactive and Anti-Neoplastic Agents 997

Michael S. Kent and Kristen Sears
76 Handling the Suspected Cruelty Case 1005

Alison Liu
Section Eleven Wellness for the Veterinary Health Care Team 1017
77 Self-Compassion: The Cornerstone of Wellbeing 1019

Deborah A. Stone
Index 1027
xi
List of Contributors
Damion Asselin RVT, VTS (ECC) Andrew G. Burton BVSc (Hons), DACVP
University of Georgia College of Veterinary Medicine, IDEXX Laboratories, North Grafton, MA, USA
Athens, GA, USA
Christopher G. Byers, DVM, DACVECC, DACVIM (SAIM), CVJ
Amanda Arrowood, BS, CVT/VTS (ECC) Teleconsultant, VetCT, Inc., Omaha, NE, USA
Matthew J. Ryan Veterinary Hospital, University of
Pennsylvania, Philadelphia, PA, USA Janice Cain DVM, DACVIM (SAIM)
School of Veterinary Medicine, University of California,
James O. Barclay LATG Davis, CA, USA
Department of Defense Military Working Dog
Veterinary Services, Joint Base San Antonio-Lackland, Alessia Cenani DrMedVet, MS, DACVAA
TX, USA University of California, Davis, CA, USA
Linda S. Barter, MVSc, BSc (Vet), PhD, DACVA Daniel L. Chan, DVM, DACVECC, DECVECC, DACVIM
University of California, Davis, CA, USA (Nutrition), FHEA, MRCVS
Department of Clinical Science and Services, Royal
Karen L. Basher LVT, VTS (Anesthesia and Analgesia) Veterinary College, University of London, North Mymms,
Anesthesia Department, Cornell University Hospital for Hertfordshire, United Kingdom
Animals, Ithaca, NY, USA
Angela Chapman, BSc(Hons), RVN, DipAVN,
Rachel Bassett, AAS, CVT, VTS (Anesthesia & Analgesia) VTS(ECC), MMgt
Animal Emergency and Referral Center of Minnesota, Department of Animal, Plant and Soil Sciences, La Trobe
Oakdale, MN, USA University, Melbourne, Victoria, Australia
Søren Boysen, DVM, DACVECC Rosalind S. Chow, VMD, DACVECC

Faculty of Veterinary Medicine, University of Calgary, Department of Veterinary Clinical Sciences, College
Calgary, Alberta, Canada of Veterinary Medicine, University of Minnesota,
St. Paul, MN, USA
Benjamin M. Brainard, VMD, DACVA, DACVECC
Department of Small Animal Medicine and Surgery, Edward Cooper, VMD, MS, DACVECC
College of Veterinary Medicine, University of Georgia, Department of Veterinary Clinical Sciences, Ohio State
Athens, GA, USA University, Columbus, OH, USA
Yekaterina Buriko, DVM, DACVECC Stacey Cooper, RVT, VTS (ECC)

Veterinary Hospital of the University of Pennsylvania, Small Animal Emergency and Critical Care,
Philadelphia, PA, USA Veterinary Medical Center, Ohio State University,
Columbus, OH, USA
Jamie M. Burkitt Creedon, DVM, DACVECC
Department of Surgical and Radiological Sciences, Katherine R. Crosse, MA, VetMB, MANZCVS, DipECVS
School of Veterinary Medicine, University of California, School of Veterinary Science, Massey University,
Davis, CA, USA Palmerston North, New Zealand
xii List of Contributors
Elizabeth B. Davidow DVM, DACVECC James Mack Fudge, DVM, MPVM, DACVECC
Timberline Veterinary Emergency and Specialty, Hill Country Animal League, Boerne, TX, USA
Seattle, WA, USA
Justina Gerard, MBA, RRT
Autumn Davidson DVM, MS, DACVIM IngMar Medical, Pittsburgh, PA, USA
Davis, CA 95616, USA Sarah Gray, DVM, DACVECC
Horizon Veterinary Specialists, Ventura, CA, USA
Harold Davis, BA, RVT, VTS (ECC) (Anesth & Analgesia)
Retired, University of California Rebecca J. Greer, DVM, MS, DACVECC
Clinical Educational Veterinary Consultant Veterinary Specialty Services, Manchester, MO, USA
California, USA
Anna Grimes, BS, RVT, VTS (Cardiology)
Jasmine De Stefano
Wilmington, NC, USA
Woodhull Medical and Mental Health Center,
New York, NY, USA
Julien Guillaumin DVM, DACVECC, DECVECC
Emergency and Critical Care Services, Colorado State
Lindsey Dodd, BSc(Hons), VPAC, VTS(ECC), PgCert in HE,
University, Fort Collins, CO, USA
FHEA, RVN
Lumbry Park Veterinary Specialists, Alton,
Hampshire, UK Simon P. Hagley, BVSc, DipACVEC, DipECVECC
Vets Now Manchester Referral Hospital, Whitefield,
Charlotte E. Donohoe RVT, VTS (ECC), CCRP Manchester, United Kingdom
Intensive Care Unit, University of Guelph, Guelph,
Ontario, Canada Sarah Haldane, BVSc, MVSc, MANZCVS, DACVECC
Melbourne, Australia
H. Edward Durham Jr., CVT, RVT, LATG, VTS (Cardiology)
Southwest Florida Veterinary Specialists, Bonita Eric Hilton, BSc, RVT, CVT, VTS(ECC)
Springs, FL, USA Veterinary Medicine Management Group,
Philadelphia, PA, USA
Steven E. Epstein DVM, DACVECC
Department of Surgical and Radiological Sciences, Marie K. Holowaychuk, DVM, DACVECC
School of Veterinary Medicine, University of California, Reviving Veterinary Medicine, Calgary, Canada
Davis, CA, USA
Kate Hopper, BVSc, PhD, DACVECC
Julie Eveland-Baker, RVT, VTS(ECC) Dept of Veterinary Surgical and Radiological Sciences,
William R. Pritchard Veterinary Medical Teaching School of Veterinary Medicine, University of California,
Hospital University of California, Davis, CA, USA Davis, CA, USA
Kate Farrell, DVM, DACVECC Guillaume L. Hoareau DVM, PhD, DACVECC, DECVECC
Department of Surgical and Radiological Sciences, Department of Emergency Medicine, University of Utah
School of Veterinary Medicine, University of California, Health, Salt Lake City, UT, USA
Davis, Davis, CA, USA
Karl E. Jandrey, DVM, MAS, DACVECC
Sharon Fornes, RVT, VTS (Anesthesia) School of Veterinary Medicine, University of California,
VCA Hospitals, California, USA Davis, CA, USA
Rufus W. Frederick LVT Samantha Jones RVT

Department of Defense Military Working Dog Veterinary Lead Technician, Internal Medicine Service
Services, Joint Base San Antonio- Lackland, TX, USA Veterinary Medical Teaching Hospital
University of California, Davis
Sarah Fritz, BA, LVT, RVT Davis, California
List of Contributors xiii
Michael S. Kent, DVM, DACVIM (Onc), DACVR (RO), ECVDI Alison Liu, DVM
(RO-add on) American Society for the Prevention of Cruelty to
Department of Surgical and Radiological Sciences, Animals, New York, NY, USA
Davis, CA, USA Bridget M. Lyons, VMD, DACVECC
Emergency and Critical Care, Cornell University
Carmen King, LVT, VTS (ECC) Veterinary Specialists, Stamford, CT, USA
Montreal, Quebec, Canada
Valerie Madden, DVM, DACVECC
VCA Canada Western Veterinary Specialists and
Kristine Kofron LVT
Emergency Centre, Calgary, Alberta, Canada
Veterinary Teaching Hospital, Colorado State University,
Fort Collins, CO, USA
F. A. (Tony) Mann, DVM, MS, DACVS, DACVECC
Veterinary Health Center, University of Missouri,
Casey J. Kohen, DVM, DACVECC
Columbia, MO, USA
MarQueen Pet Emergency and Specialty Group,
Roseville, CA, USA Manuel Martin-Flores MV, DACVAA
Department of Clinical Sciences, College of Veterinary
Lucy Kopecny, BVSc (Hons), DACVIM (Small Animal Medicine, Cornell University, Ithaca, NY, USA
Internal Medicine)
Small Animal Specialist Hospital, North Ryde, New South Elisa M. Mazzaferro, MS, DVM, PhD, DACVECC
Wales, Australia Cornell University Veterinary Specialists, Stamford, CT, USA
Mary Anna Labato, DVM, ACVIM Margo Mehl, DVM, DACVS

Tufts University, Cummings School of Veterinary San Francisco Animal Medical Center,
Medicine, 200 Westboro Road, North Grafton, MA San Francisco, CA, USA
01536, USA
Martin D. Miller
Michael S. Lagutchik, DVM, MS, DACVECC Lower Burrell, PA, USA
Department of Defense Military Working Dog Veterinary
Services, Joint Base San Antonio-Lackland Air Force Sarah Musulin, DVM, DACVECC
Base, TX, USA North Carolina State University, Raleigh, NC, USA
Sean Naylor
Cathy Langston, DVM, DACVIM
Hemodialysis and Blood Purification Unit, Veterinary
Ohio State University Veterinary Clinical Sciences,
Medical Teaching Hospital, University of California,
Columbus, OH, USA
Davis, CA, USA
Jennifer A. Larsen, DVM, MS, PhD Alexandra Nectoux, DVM, MSc, DECVECC
Department of Molecular Biosciences, School of Veterinary SIAMU, VetAgro Sup Campus vétérinaire de Lyon, Marcy
Medicine, University of California, Davis, CA, USA l’Etoile, France
Joyce Lau Jie Ying BS, VTS (ECC) Christopher L. Norkus, DVM, DACVAA, CVPP, DACVECC
The Animal Hospital at Murdoch University, Bloomfield, Connecticut, USA
Murdoch, WA, Australia
Adesola Odunayo DVM, MS, DACVECC
Tami Lind RVT, VTS (ECC) Department of Small Animal and Clinical Sciences,
College of Veterinary Medicine, Purdue University, West College of Veterinary Medicine, University of Florida,
Lafayette, IN, USA Gainesville, FL, USA
Liza Lindeman – van der Mei RVT, VTS (ECC) Jessica L. Oram RVT
Department of Clinical Sciences, Utrecht University, the Ontario Veterinary College, Health Sciences Centre,
Netherlands Guelph, Ontario, Canada
xiv List of Contributors
Laura Osborne, BVSc (Hon I), DACVECC Joris H. Robben. PhD, DECVIM, CA
Western Veterinary Specialist and Emergency Centre, Section of Emergency and Intensive Care Medicine,
Calgary, Alberta, Canada Department of Clinical Sciences, Utrecht University,
Utrecht, Netherlands
Sally C. Perea, DVM, MS, DACVIM (Nutrition)
Royal Canin PHNC, Lewisburg, OH, USA Elizabeth Rozanski, DVM, DACVECC, DACVIM (SA-IM)
Cummings School of Veterinary Medicine, Tufts
Jessica Perlini RVT, VTS (Anesth and Analgesia) University, North Grafton, MA, USA
Veterinary Teaching Hospital, University of Georgia,
Athens, GA, USA Elke Rudloff, DVM, DACVECC, cVMA
BluePearl Pet Hospice, Milwaukee, WI, USA
Helen S. Philp, BVMS, DACVECC
Veterinary Medical Teaching Hospital, University of Michael D. Santasieri BS, CVT, LVT, FFCP
California, Davis, CA, USA Cummings School of Veterinary Medicine, Tufts
University, North Grafton, MA, USA
Karen Poeppel, BS, LVT
Schwarzman Animal Medical Center, New York, NY, USA Nicole Saunders
American Animal Hospital, Randolph, NJ, USA
Jennifer E. Prittie, DVM, DACVIM, DACVECC
Department of Emergency and Critical Care, Jessica J. Schavone, BS, LVT, VTS (ECC)
AMC Schwartzman Animal Medical Center, Department of Clinical Sciences, Cummings School
New York, NY, USA of Veterinary Medicine, Tufts University, North
Grafton, MA, USA
Jocelyn Pronko BS, CVT, VTS (ECC)
Veterinary Teaching Hospital, Colorado State University Kristen Sears, RVT
for Critical Care Services, Drake Fort Collins, CO, USA School of Veterinary Medicine, University of California,
Davis, CA, USA
Jane Quandt, DVM, MS, DACVA, DACVECC
University of Georgia College of Veterinary Medicine, Deborah Silverstein, DVM, DACVECC
Athens, GA, USA Department of Clinical Sciences and Advanced
Medicine, University of Pennsylvania,
Marc R. Raffe, DVM, MS, DACVAA, DACVECC, eMBA Philadelphia, PA, USA
Veterinary Anesthesia and Critical Care Associates LLC,
St. Paul, MN, USA Sean D. Smarick, VMD, DACVECC
North Huntingdon, PA, USA
Louisa J. Rahilly, DVM, DACVECC
Cape Cod Veterinary Specialists, Buzzards Bay and Cape Lisa Smart, BVSc (Hons), PhD, DACVECC
Dennis, MA, USA Small Animal Specialist Hospital, Tuggerah, NSW,
Australia
Krystle Reagan, DVM, PhD, DACVIM (SAIM)
Veterinary Medical Teaching Hospital, University of Andrea M. Steele MSc, RVT, VTS (ECC)
California, Davis, CA, USA Ontario Veterinary College, Health Sciences Centre,
Guelph, Ontario, Canada
Erica L. Reineke, VMD, DACVECC
Advanced Medicine, School of Veterinary Medicine, Deborah A. Stone, MBA, PhD, CVPM
University of Pennsylvania, Philadelphia, PA, USA Ausitn, TX, USA
Angel Rivera, CVT, VTS (ECC) Lindsey Strang, RVT, VTS (ECC)
Milwaukee, WI, USA Cardiology Service, VCA Western Veterinary Specialist
and ER Centre, Calgary, Alberta, Canada
Nicholas Rivituso, CVT, VTS (ECC)
Steel Center for Career and Technical Education, Jefferson April Summers, DVM, PhD, DACVECC
Hills, PA, USA Blue Pearl Pet Hospital, Maitland, FL, USA
List of Contributors xv
Jane E. Sykes, BVSc(Hons), PhD, MBA, DipACVIM (SAIM) Nicole Van Sant LVT, VTS (ECC)
Department of Medicine and Epidemiology, University of Cornell University Veterinary Specialists, Stamford, CT, USA
California, Davis, CA, USA
Lori S. Waddell, DVM, DACVECC
Wan Khoon Avalene Tan, BVSc, DAVECC Matthew J. Ryan Veterinary Hospital, University of
Veterinary Teaching Hospital, School of Veterinary Pennsylvania, Philadelphia, PA, USA
Science, Massey University, Palmerston North, Department of Clinical Sciences and Advanced Medicine,
New Zealand Matthew J. Ryan Veterinary Hospital,
University of Pennsylvania, Philadelphia, PA, USA
Carolyn Tai CVT, VTS (ECC) (SAIM)
Tufts University, Cummings School of Veterinary Courtney Waxman CVT, RVT, VTS (ECC)
Medicine, North Grafton, MA, USA Veterinary Nurse Consulting, LLC, Green Cove
Springs, FL, USA
Katherine Vachon, CVT
Cape Cod Veterinary Specialists, Buzzards Bay and Cape Janelle R. Wierenga, DVM, Dipl. ACVECC, MPH, PhD
Dennis, MA, USA School of Veterinary Science, Massey University,
Palmerston North, New Zealand
Chiara Valtolina, DVM, DACVECC
Department of Clinical Science of Small Animals, Utrecht Kenichiro Yagi, MS, RVT, VTS (ECC), (SAIM)
University, the Netherlands Veterinary Emergency Group, White Plains, NY, USA
xvii
Preface to the Second Edition
The discipline of small animal emergency and critical care confidence in the recommendations contained herein and
medicine continues to advance and evolve. It has been see illustrations of how to perform procedures or interpret
11 years since publication of the first edition of our text- results. When high-quality references or guidelines were
book, and we believe that this new edition will help update unavailable, these qualified authors made recommenda-
our community on the monitoring and procedural aspects tions based on their experience; in such cases, such per-
of care. Our focus continues to be the core, daily hands-on sonal recommendation is noted in the text for transparency.
practice of the specialty. This edition features returning The textbook is organized roughly by organ system or
and new authors updating previous chapters, and return- general topic, but there is considerable overlap in some
ing and new authors providing additional chapters. We are areas. For instance, some authors of device insertion
excited about these additional chapters – among others, chapters included a maintenance section, and mainte-
they include a comprehensive review of point-of-care nance of that device may also be covered in another
ultrasound, an extensive discussion on nursing care of neo- chapter specifically on insertion site maintenance, and so
nates, and the unique and important considerations for on. Standardized protocols are included for procedures for
handling suspected cruelty cases. We continue to believe which they were deemed useful. These protocols are based
the veterinary community benefits from a single reference on best-available evidence and guidelines, and where such
written by informed, experienced people to improve and citations were unavailable, they are based on author expe-
expand the standard of care, and we hope this textbook rience. We hope that these protocols will continue to help
continues to serve that purpose as the first edition did. raise and equalize the standard of care across our profes-
Emergency and critical care practice is a team sport that sion and serve as the backbone for a protocol book to use
requires cooperation among all its members. Thus, some in your practice.
chapters are authored by a veterinarian, others by a veteri- We welcome corrections and ideas for future versions of
nary technician, and some by pairs or groups. The interde- this textbook. Should further editions follow, we are com-
pendence of all members of the ECC healthcare team mitted to their currency and relevancy, and thus will con-
requires that veterinary technicians understand why clini- tinue to push for best-practice, evidence- and guideline-based
cians do what they do, and that veterinarians understand recommendations. We are grateful to the previous contribu-
proper ECC nursing care and technical procedures. The tors, some of whom are now deceased, as their contribu-
collective knowledge and skills of the team fosters a proac- tions often served as the framework for chapters included
tive rather than reactive approach to each shift’s chal- here. Finally, we would like to thank each current contribu-
lenges. The book’s contributors come from around the tor; they did an amazing job stepping up to the challenges
world, from both university and private practice. We aimed that this unique textbook posed in this unprecedented time
to provide the best-referenced, highest-quality textbook in our world and our industry.
that we could. Contributors congenially answered our fre-
quent “Do you have a reference for this?” inquiries and Jamie M. Burkitt Creedon
high-quality image requests, so that the reader could have Harold Davis
xix
Acknowledgments
To all the lifelong learners in our profession doing this job Thank you to all the veterinary health care professionals
out there, thank you for your continual efforts to grow and for all you do to care for our patients, I trust this text will
improve for the sake of our teams and our patients. aid you in that endeavor.
To the generous, patient, kind people I am so fortunate to To my friends and colleagues, I appreciate your friend-
call my friends, you make my days better and I am grateful ship, support, and the fact that you challenge me to be better
for you. every day.
And most of all to my family, who remind me every day To my parents, sister, and extended family this is for you;
of what is most important – you are my sunshine and your love, support and guidance have made this possible
I love you. and all worthwhile. Harold
“We have two lives, and the second begins when we
realize we only have one.” – Confucius
May you all be on Life Two. Jamie
xxi
About the Companion Website
This book is accompanied by a companion website.
www.wiley.com/go/burkitt/monitoring
This website includes:

● Figures from the book available to download in Microsoft PowerPoint
● Videos
● Protocols from the book
1
Section One
Fundamental Elements of Emergency and Critical Care Practice
3
Triage
Harold Davis
The word “triage” comes from the French verb trier, Telephone Triage
meaning to sort. The concept of triage finds its origin in the
military, and the goals of triage in human medicine have In theory, telephone triage requires clinic staff to deter-
varied over the years depending upon the situation. After mine the urgency of a pet’s problem and to provide advice
World War II triage came to mean the process of identify- based on that determination. However, because the client
ing those soldiers most likely to return to battle after medi- may not possess the training to give an accurate account
cal care. During the Korean and Vietnam conflicts the of the pet’s problem(s), it is generally safest to recom-
goals of triage came to mean the greatest good for the great- mend that the client take the pet to a veterinarian for
est number of wounded [1]. In times of disaster, the goals evaluation. Particularly any patient experiencing breath-
of triage are like those of the military: to concentrate effort ing difficulty, seizures, inability or unwillingness to rise,
and resources on saving the largest number of people pos- or traumatic injury should be seen by a veterinarian
sible. Daily human emergency room triage began in the without question.
1960s and has evolved into a method to separate efficiently At the beginning of the telephone conversation, staff
those patients stable enough to wait for treatment from should establish the animal’s signalment (breed, sex, age,
those who require immediate medical attention. In veteri- and approximate weight) if possible. Questions asked of
nary medicine we have adopted the goals of our counter- the owner should be basic and straightforward using lay
parts in the human emergency room. Thus, we prioritize terminology. Questions should address the patient’s level
cases by medical urgency when presented with multiple of consciousness (LOC), whether the patient is breathing
emergencies at the same time. easily or with difficulty, has abnormal mucous membrane
Triage occurs both by telephone and in the hospital. A cli- color, experiencing seizures, has obviously broken or
ent often calls the hospital seeking advice for the care of exposed bones, or has any pre-existing medical conditions
their pet; the receptionist or veterinary technician must (Box 1.1). Based on the owner’s responses, advice can be
ascertain useful information about the pet in a short period given on first aid, assuming that the problem can be clearly
of time. Thus, the receptionist or technician should have the defined and is simple. See Box 1.2 for a list of problems
knowledge required to provide appropriate advice. The requiring immediate attention by the veterinary health-
information obtained during the telephone conversation care team.
will also be useful in preparing for patient arrival. On initial Information gathered during the phone conversation can
presentation to the hospital the veterinary technician is usu- aid the veterinary technician in preparation for the arrival
ally first to receive the patient and therefore to perform basic of the patient at the hospital. Knowing the animal’s breed
triage. This person must determine whether the patient or approximate weight allows the technician to pre-select
needs immediate care and, in the case of simultaneous appropriate sizes for vascular catheters, fluid bags, and
patient arrivals, prioritize treatment based on medical need. endotracheal tubes.
Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care,
Second Edition. Edited by Jamie M. Burkitt Creedon and Harold Davis.
© 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/burkitt/monitoring
4 Triage
Box 1.1 Questions Useful in Telephone Triage, and Suggested Responses

1) Is the animal breathing and conscious? A) If yes, take immediately to a veterinarian. In some
A) If neither, institute chest compressions and mouth- situations, if the client cannot or will not take the
to-snout; if yes to either of these, do not. pet immediately to a veterinarian, at-home emesis
2) Is the animal having difficulty breathing? may be recommended.
A) If yes, take immediately to a veterinarian. 6) Is there active bleeding, an obvious fracture, or
3) What color are the mucous membranes (gums)? Do exposed bone?
they appear their usual color? A) Recommend clean towel over the site, pressure if
A) If no, what color is noted? spurting blood. Warn clients to be VERY CAREFUL to
4) Is the animal actively experiencing a seizure? avoid being bitten.
A) If yes, remove from danger of falling, bodies of water, or 7) Does the animal have any ongoing medical problems
sharp objects. Take to veterinarian immediately after and or is it on any medications (including over the
seizure ends, or if it lasts longer than 1–2minutes, counter)?
bring during seizure. Instruct owners to stay clear of the A) Briefly restate your understanding of the probl-
animal’s mouth to avoid accidental bite wounds. em(s). If on medications and coming into the
5) Has the animal ingested something that may be hospital, instruct the owner to bring all
poisonous within the last two hours? medications.
When the caller is not a regular client of the facility, the

Box 1.2 Problems Requiring Immediate Attention by
staff member should obtain the client’s phone number
the veterinary healthcare team
early in the conversation in case of disconnection and
● Cardiopulmonary arrest (unconscious and making no make the caller aware of the address, location, or easiest
regular attempts to breathe) directions to the clinic. The client should be informed of
● Excessive bleeding the clinic’s payment policy.
● Respiratory distress Finally, the telephone conversation should be docu-
● Weakness mented, giving a complete summary of what transpired.
● Pale mucous membranes Logs are saved for whatever period is dictated by the regu-
● Rapid abdominal distension lating body. Telephone logs serve as an extension of the
● Neurological abnormalities legal medical record.
● Inability or persistent straining to urinate
● Protracted vomiting
● Ingestion or topical exposure to toxins Hospital Triage
● Burns
● Snake envenomation Three major body systems are assessed during the initial tri-
● Perforation, wound dehiscence, or open body cavities age: respiratory, cardiovascular, and neurological. Triage
● Open fractures begins when approaching the patient. Visually assess
● Prolapsed organs breathing effort and pattern; presence of blood or other for-
● Dystocia eign material on or around the patient; and the patient’s
posture and LOC. Note if there are airway sounds audible
without a stethoscope. Note whether the animal responds
Owners should be instructed on safe transport of the ani- as you approach. If the animal is conscious, ask the owner
mal. Animals that have suffered trauma are often in pain, about the patient’s temperament and take the appropriate
and owners should be coached on how to approach the pet precautions regarding physical restraint or muzzling. The
and place a makeshift muzzle using a necktie, belt, or strips veterinary technician cannot rely on the client’s statement
of cloth. If the animal is nonambulatory, owners may be that an animal “never bites,” but if the client states that the
told to place the animal in a box or carrier, or to use a blan- patient is aggressive, the patient should be muzzled.
ket or towel as a stretcher (Figure 1.1). The use of a blanket Physical restraint and muzzling should be performed with
stretcher makes it easier to get an animal in and out of a extreme caution in patients with respiratory distress, as
car. If the animal is a cat, it should be brought in a cat car- such steps can cause acute decompensation and respiratory
rier or box (with holes). arrest. If time permits, a brief history should be obtained.
Hospital Triage 5
(a) (b)
Figure 1.1 (a) Placing a dog in a box for transport. (b) Using a blanket as a stretcher. The animal is placed on a blanket and the edges
of the blanket used to lift the patient.
The ABCDEs membranes, usually indicates hypoxemia and warrants

immediate medical intervention. The chest wall may be
A reasonable and systematic approach to triage is the use
palpated to assess chest wall integrity. Crepitus about the
of the ABCDEs of emergency care, which are: (A) airway,
body may indicate subcutaneous emphysema, which can
(B) breathing, (C) circulation, (D) dysfunction of the cen-
be caused by tracheal tears or chest wall defects.
tral nervous system, and (E) exposure/examination
Assessment questions the triage technician should con-
(Figure 1.2). Patients with respiratory distress or arrest,
sider include:
signs of hypovolemic shock or cardiac arrest, altered LOC,
or ongoing seizure activity should be immediately taken to ● Is the patient having difficulty breathing?
the treatment area for rapid medical attention. Conditions ● Are breath sounds audible?
that affect other body systems are generally not life- ● Are facial injuries interfering with the airway?
threatening in and of themselves, but their effects on the ● Has a bite wound disrupted the larynx or trachea?
three major body systems may be life-threatening. For ● Is subcutaneous emphysema present?
example, a fractured femur bleeding into a limb can lead to ● What color are the mucous membranes?
life-threatening hypovolemia. ● Does respiratory distress get worse with patient posi-
tion change?
● Is there evidence of thoracic penetration or an unstable
Airway and Breathing
chest wall segment?
Expedient respiratory system assessment and rapid correc-
tion of abnormalities are critical. First, patency of airway
Circulation
and breathing effort should be assessed. This is done by
visualization, auscultation, and palpation. When looking Many of the signs suggestive of decreased cardiac output
at the animal, an experienced individual can determine are a result of a compensatory sympathetic reflex, which
whether the animal has increased breathing rate or effort. helps maintain arterial blood pressure. Clinical signs
Some animals with respiratory distress may assume a pos- suggestive of decreased cardiac output include tachycar-
ture with the head and neck extended and the elbows dia, pale or gray mucous membranes, prolonged capillary
abducted (held away from the body). Additional concern- refill time, poor pulse quality, cool extremities, and
ing signs include absent chest wall motion, exaggerated decreased mentation. Decreased cardiac output may be
breathing effort, flaring of the nares, and open mouth due to hypovolemia from blood or other fluid loss
breathing in cats. A “paradoxical” breathing pattern can (internally or externally; active or historical), trauma, or
occur when sustained high breathing effort leads to respir- cardiac disease.
atory fatigue or during upper airway obstruction; paradoxi- Circulation is assessed by visualization, palpation, and
cal breathing is characterized by opposing movements of auscultation if using a stethoscope. The focus of the cardio-
the chest and abdominal walls during inspiration and expi- vascular assessment is the six perfusion parameters
ration. Cyanosis, a blue or purplish tint to the mucous (Box 1.3).
6 Triage
Initial
Presentation
Respiratory Compromise
• Apnea
• Noisy breathing
Yes
• Respiratory distress
• Cyanosis
• Diminished breath sounds
No
Cardiovascular Compromise
• Pale mm color
PATIENT IS UNSTABLE • Abnormal CRT
Requires immediate • Tachycardia / Bradycardia
Yes
intervention
• Poor pulse quality
• Cool extremities
• Decreased mentation
No
Neurologic Compromise
• Altered mentation
• Abnormal pupils and light reflex
Yes • Abnormal posture
• Lack of response to pain?
• Seizure activity
No
PATIENT IS STABLE
Figure 1.2 Triage algorithm. CRT, capillary refill time; mm, mucous membranes.
Mentation
Box 1.3 The Six Perfusion Parameters As previously mentioned, evaluation of mentation starts
from afar. The patient’s attitude is evaluated without stim-
Mentation
ulation. A reduced level of mentation is indicated by a loss
●
Mucous membrane color

of interest in the surrounding environment and dimin-
●
Capillary refill time

ished or absent responses to stimuli such as noise and
●
Heart rate
touch. This can be described as obtundation or depression.
●
Pulse quality
As depression implies an assessment of the animal’s emo-
●
Extremity temperature
tional state, obtundation may be a more appropriate term.
●
Hospital Triage 7
If there is a loss of consciousness, mentation is either stu- Cyanotic or blue mucous membranes are an indicator of
porous or comatose. Stupor refers to a patient that is uncon- severe hypoxemia. The absence of cyanosis does not rule
scious and responsive only to noxious stimuli. Coma refers out hypoxemia. Icteric or yellow mucous membranes are
to a completely unconscious, non-responsive state. Most due to the breakdown of red cells (hemolysis) or hepatobil-
unconscious animals require intubation to protect iary disease. Methemoglobinemia results in brown or
their airway. chocolate-colored mucous membranes.
An altered level of mentation can be the result of primary
intracranial disease or significant systemic abnormalities Capillary Refill Time
such as hypoperfusion or hypoglycemia. Any abnormality Capillary refill time (CRT), the time it takes for mucous
in mentation should be considered serious and a complete membranes to regain their color following blanching by
triage examination is warranted immediately. digital pressure, reflects degree of local blood flow. When
perfusion is normal, CRT is one or two seconds.
Mucous Membrane Color Vasoconstriction reduces the flow of blood through the
After assuring it is safe to do so, evaluate the mucous mem- mucous membranes via arteriolar and precapillary sphinc-
branes by examining the color of the gums (Figure 1.3). As ter contraction and it will take longer for the color to return
an alternative in the fractious animal or patients with pig- to the tissue after blanching. In severe vasoconstriction the
mented gums, one may examine the conjunctiva, penis, or mucous membranes can appear white, and it can be impos-
the vulva. The normal pink color is a result of oxygenated sible to appreciate any CRT. In patients with vasodilation
hemoglobin in red blood cells in the capillary bed. Mucous the CRT can be more rapid than normal as there is less
membrane color may vary with circulation-related prob- resistance to blood flow and the capillary beds rapidly refill
lems. Pale or white mucous membranes are a consequence with blood after the digital pressure is removed. A slow
of a reduced quantity of red blood cells perfusing the capil- CRT is always a concern and suggests poor perfusion. A
lary beds of the mucosal tissue. This can be the result of rapid CRT in conjunction with other perfusion abnormali-
vasoconstriction in compensation to circulatory shock or ties can suggest vasodilatory shock.
severe anemia. This abnormality in combination with A study was undertaken to evaluate the relationship
other evidence of poor perfusion or inadequate tissue oxy- between a standardized method of evaluating CRT and var-
genation warrants emergency intervention. Vasodilation ious clinical parameters in hospitalized dogs. The authors
increases the flow of blood through the mucous mem- found that a CRT following blanching for four seconds may
branes making them a deep pink to red color. Vasodilation provide insight into the hydration status and hemodynamic
may be an appropriate response as seen in a hyperthermic stability of canine patients [2]. This study may also serve as
animal following exercise, or it can be pathological as seen a basis for establishing a standardized method for evaluat-
in vasodilatory shock. Patients with vasodilatory shock ing CRT (Box 1.4). It should be noted that a four-second
commonly present with concurrent hypovolemia and so on pressing time was used to minimize fluctuations in pressure
presentation may have pale mucous membranes that turn application time. The gingival mucosa was avoided due to
dark pink or red after adequate fluid resuscitation. the potential inflammatory changes associated with gingivi-
tis, which may alter CRT. A stopwatch was used to ensure
reliability. Avoid immediate (within two minutes) repeating
of CRT measurement at the same location as refills may be
falsely shortened on subsequent evaluations (presumably
due to warming of the site from repeated contact and subse-
quent vasodilation).
Box 1.4 Standardized Method for Measuring or

Assessing Capillary Refill Time
● Use inner lip oral mucosa taking care not to restrict
blood flow when everting lip
● Moderate direct pressure is applied for 4 seconds
● Use a stopwatch to determine the time for return of
color to the capillary bed
● Avoid immediate (within 2 minutes) measurement of
the same site
Figure 1.3 Assessing a patient’s mucous membrane color.
8 Triage
Heart Rate 70 mmHg. The systolic–diastolic pressure difference

Heart rate is a nonspecific parameter. It is usually meas- (pulse pressure) in this example is 50 mmHg. If there is a
ured by auscultation of the heart, palpation of the cardiac fall in blood pressure such that the patient is hypotensive
apex beat, or palpation over an artery. The normal heart with a systolic pressure of 90 mmHg, mean of 55 mmHg,
rate of a dog varies with body size. In general, large breed and diastolic of 40 mmHg, the pulse pressure would still
adult dogs have resting heart rates of 60–140 beats per min- reflect a systolic–diastolic difference of 50 mmHg. The
ute (bpm), medium adult dogs 70–160 bpm, and small dogs examiner may be challenged to detect any change in pulse
and puppies 100–180 bpm. Normal feline heart rate at a quality in such case.
veterinary hospital is usually 160–220 bpm. When arterial Vasoconstriction tends to diminish palpable pulse qual-
blood pressure is threatened either by a drop in stroke vol- ity, leading to the “thready pulse.” In contrast, vasodilation
ume or because of vasodilation, a baroreceptor-mediated increases vessel size and compliance. In addition, vasodi-
increase in sympathetic tone results in a reflex tachycardia. lated patients may have an increased stroke volume such
As tachycardia is a normal response to anxiety, excitement, that the pulse quality is often appreciated to be normal or
and exercise, it is a common physical examination finding. exaggerated (“bounding”) in these patients.
The presence of tachycardia in conjunction with other Studies have looked at the relationship between periph-
signs of abnormal perfusion (e.g. abnormal mentation, eral pulse palpation and Doppler systolic blood pressures
mucous membrane color, CRT) suggests hemodynamic in dogs and cats. In one dog study the authors concluded
compromise. that absent metatarsal pulses are highly specific in the
Tachycardia is the appropriate and expected response to diagnosis of hypotension. However, dogs with palpable
circulatory shock. The presence of normocardia or brady- metatarsal pulses can still be hypotensive [3]. In a cat study
cardia in canine shock patients (i.e. patients with abnor- it was concluded that peripheral pulse quality assessment
malities in the other five parameters) is of concern as it by emergency room veterinarians correlates with systolic
suggests decompensated shock and may be associated with blood pressure. With progressive decreases in blood pres-
greater severity of illness and a poorer prognosis. Feline sure, metatarsal pulses will disappear and it is only with
shock patients often present without tachycardia, and this severe hypotension that femoral pulses are absent [4]. In
is not considered to have the same prognostic relevance the case of peripheral pulse abnormities (weak or absent),
that it does in dogs. the index of suspicion for hypotension is high. Conversely,
Auscultable arrhythmias may or may not require imme- the presence of palpable pulses does not rule out hypoten-
diate medical therapy. Femoral pulse evaluation should be sion. Palpation of pulses does not replace the need for an
performed simultaneously with auscultation for both time actual blood pressure measurement. Other perfusion
efficiency and recognition of pulse deficits. Arrhythmias parameters should be taken into consideration when
without any other signs of poor perfusion are less concern- assessing peripheral pulses.
ing but these patients should always be prioritized for a
secondary evaluation including an electrocardiogram Extremity Temperature Compared with Core
(ECG), as the physical assessment of these abnormalities is The sympathetically mediated vasoconstriction that occurs
limited. in response to a fall in cardiac output tends to shunt blood
from venous capacitance vessels to the central circulation,
Pulse Quality preserving blood flow to vital organs at the expense of less
Pulse quality is subjectively determined by the digital pal- vital tissue. This reduction in peripheral circulation will
pation of the femoral pulse. Obvious abnormalities in pulse cause a fall in extremity temperature in comparison with
quality are concerning, and if present in conjunction with core body temperature. If the patient is generally hypother-
other signs of poor perfusion, the patient should receive mic, cool extremities that are essentially the same tempera-
immediate medical attention. Unfortunately, patients can ture as the rest of the animal does not indicate an
have considerable hemodynamic compromise without pal- abnormality in perfusion. For this reason, extremity tem-
pable changes in pulse quality. As a result, the palpation of perature (evaluated by manual palpation of the paws and
an adequate femoral pulse cannot be used to indicate a sta- distal limbs) should be interpreted with reference to the
ble patient. measured rectal temperature. Vasodilation is generally
The pulse quality is determined by the difference associated with warm extremities if the patient is fluid
between diastolic and systolic arterial blood pressure, as resuscitated.
well as the duration of the pulse and the size of the vessel. There has been renewed interest in veterinary medicine
The greater the diastolic–systolic difference, the to the measurement of toe web and rectal temperature dif-
“stronger” the pulse will feel. For example, a normal ference in the assessment of perfusion. Its use in the veteri-
arterial blood pressure would be a systolic blood pressure nary patient was first described in the late 1970s. Toe web
of 120 mmHg, a mean of 85 mmHg, and a diastolic of temperature had been shown to decrease far below body
Point-of-Care Ultrasound 9
(rectal) temperature during hemorrhagic shock and to

return toward body temperature following fluid resuscita-
tion [5]. In the more a recent study looking at rectal–
interdigital temperature gradient (RITG) as a diagnostic
marker of shock in dogs, RITG was determined by taking a
rectal temperature (with a standard, sheathed, battery-
operated rectal thermometer). The interdigital temperature
was taken with the same thermometer between the third
and fourth digit on a pelvic limb. The digits were manually
pressed together. Based on the study results, a gradient of
8.5°F may be used as a screen for circulatory shock, and a
cutoff of 11.6°F would indicate high suspicion for circula-
tory shock [6]. The cutoffs used were based on an ambient
temperature of 74°F. While the use of RITG should not Figure 1.4 A patient with suspected head and spinal trauma
replace more traditional methods of assessing perfusion, it restrained on a backboard. The cranial end of the board is elevated
may serve as an additional tool for the assessment of circu- slightly because of suspected increased intracranial pressure.
latory shock.
Assessment questions the triage technician should con- Exposure/Examination
sider include:
In people, skin exposure is an essential aspect of patient
● Is there evidence of hemorrhage? evaluation since clothing can hide serious injuries or
● Is there swelling associated with an extremity fracture? abnormalities. The same is true for animals, which require
● Are the mucous membranes pale or injected (deep red)? fuller examination once airway, breathing, circulation, and
● Is the capillary refill prolonged? neurologic status are evaluated and stabilized. Once an
● Are the femoral pulses weak and rapid? animal is considered safe for movement, the removal of
● Are the extremities cold/is there increased RITG? blankets or harnesses, and turning the lateral patient to
examine its other side are important. Any source of ongo-
ing harm is removed, such as by bathing the cat with
Dysfunction or Disability of the Neurologic System
topical permethrin application. Emesis may be induced if
Dysfunction or disability refers to the neurologic status of the animal recently ingested a toxin.
the patient. This may be assessed through visualization Finally, a rapid, whole-body examination is performed.
and palpation. A cursory neurologic examination is per- The goal is to determine and address any additional problems.
formed focusing on the patient’s LOC/mentation, pupils Assessment questions the triage technician should con-
(size and response to light), posture, and response to pain sider include:
(deep tested only if the patient lacks superficial pain per-
● Are there lacerations, wounds, or punctures?
ception). Depressed mentation may be a result of poor oxy-
● Is there bruising and is it getting worse?
gen delivery or trauma to the brain. Seizure activity may be
● Are there palpable fractures?
due to intra- or extracranial causes.
● Is the abdomen apparently painful or distended?
A patient with known or suspected trauma that is recum-
● Is there evidence of debilitation or other signs of disease?
bent, has an abnormal posture, or is not seen to ambulate
or make voluntary movements, should be assumed to have
spinal trauma and stabilized on a backboard (Figure 1.4) Body Temperature
until proven otherwise.
Body temperature is not addressed in the standard ABCs
Assessment questions the triage technician should con-
and may not be required for the assessment of every patient.
sider include:
Extremes of body temperature are, however, an indication
● Is the animal bright, alert, and responsive or obtunded for urgent medical attention and as a result the temperature
(depressed but rousable), stuporous (roused only with of at-risk patients should be measured during assessment.
painful stimulation), or comatose?
● Are the pupils dilated, constricted, of equal size, and
responsive to light? Point-of-Care Ultrasound
● What is the posture of the animal?
● Are there any abnormal breathing patterns? Over the past two decades, bedside ultrasonography
● Does the animal respond to painful stimuli? has become mainstream in the human emergency depart-
● Is there obvious seizure activity? ment [7]. It is an important skill that positively impacts
10 Triage
patient outcomes. Point-of-care ultrasound (POCUS; see Airway:

Chapter 6) is also beneficial in the veterinary emergency • Airway patency
room [8], including during triage [9]. Abdominal point- • Laryngeal/tracheal trauma
of-care ultrasound is used in the detection of free fluid in Breathing:
the abdomen (see Chapter 39). There are reports in the • Pulmonary embolism
• Alveolar–interstitial syndrome
veterinary literature that the size of the caudal vena cava
• Diaphragmatic lesions
can be assessed via ultrasound and aid in diagnosis of
Circulation:
hypovolemia in dogs [10]. Thoracic point-of-care ultra- • Intravascular volume estimation
sound is used to assess the pleural cavity, looking for free • Cardiac function
fluid in the pleural and pericardial spaces (see Chapter 17) Disability:
and for signs consistent with a pneumothorax [11] • Neurological impairment
(see Chapter 27). Exposure:
In 2007, it was suggested that the training for human • Among other injuries in a repeated manner
emergency and critical care professionals in ultrasound
should use the ABCDE and head-to-toe approach. Critical Figure 1.5 Potential problems [8] identified with the FAST
care problems are approached primarily according to the ABCDE protocol.
ABCDE or the head-to-toe sequence based on physiologi-
cal priority. The idea was that introductory ultrasound
Airway:
training should always follow the same pathways and pri- • Tracheal incongruity
orities, thus addressing findings in the real order of • Tracheal collapse
importance [12]. This POCUS approach or protocol is Breathing:
known as FAST-ABCDE (FAST including airway- • Pneumothorax
breathing-circulation-disabilities/deficits and exposure). • Lung contusion
• Pleural effusion
FAST-ABCDE is more comprehensive in evaluating
• Diaphragmatic hernia
patients for life-threating problems (Figure 1.5). The • Alveolar–interstitial syndrome
human ABCDE protocol has been adapted for the veteri- Circulation:
nary patient and studied in dogs [13]; it is called VetFAST • Abdominal effusion
ABCDE. The VetFAST ABCDE identifies problems related • Pericardial effusion
to airway, breathing, circulation, disability, and exposure • Cardiac tamponade
• Systolic impairment
(Figure 1.6). The study found that the VetFAST ABCDE • Retroperitoneal effusion
protocol in dogs suffering from trauma is feasible, can • Caudal vena cava collapse
detect cavitary effusion and pneumothorax with a higher Disability:
diagnostic accuracy than radiographs, and can detect • Presumed increased intracranial pressure
lesions outside the scope of traditional veterinary ultra- Exposure:
sound exams [13]. • Worsening or new development of injuries
Figure 1.6 Potential problems [8] identified with the VetFAST

ABCDE protocol.
Summary
In some emergencies, minutes count. The triage performed life-threatening conditions such as hypoxemia and inade-
by the veterinary technician should be rapid and efficient. quate perfusion. A systematic approach to patient assess-
The goal is rapid recognition of and intervention for ment is essential for the best possible patient outcome.
References
1 Bracken, J.E. (1998). Triage. In: Sheehy’s Emergency and relation to clinical parameters in hospitalized dogs.
Nursing Principles and Practice (ed. L. Newberry), 105–111. J. Vet. Emerg. Crit. Care 31: 585–594.
St. Louis: Mosby. 3 Ateca, L.B., Reineke, E.L., and Drobatz, K.J. (2018).
2 Chalifoux, C.V., Spielvogel, C.F., Stefanovski, D., and Evaluation of the relationship between peripheral pulse
Silverstein, D.C. (2021). Standardized capillary refill time palpation and Doppler systolic blood pressure in dogs
References 11
presenting to an emergency service. J. Vet. Emerg. Crit. 9 Lisciandro, G.R. (2011). Abdominal and thoracic focused
Care 28 (3): 226–231. assessment with sonography for trauma, triage, and
4 Reineke, E.L., Rees, C., and Drobatz, K.J. (2016). Prediction monitoring in small animals. J. Vet. Emerg. Crit. Care
of systolic blood pressure using peripheral pulse palpation 21 (2): 104–122.
in cats. J. Vet. Emerg. Crit. Care 26 (1): 52–57. 10 Johnson, P. (2016). Practical assessment of volume status
5 Kolata, R.J. (1978). The significance in changes of toe web in daily practice. Top. Comp. Anim. Med. 31: 86–93.
temperature in dogs in circulatory shock. Proc. Gaines Vet. 11 Lisciandro, G.R., Lagutchik, M.S., Mann, K.A. et al.
Symp. 28: 21–26. (2008). Evaluation of a thoracic focused assessment with
6 Schaefer, J.D., Reminga, C.L., Reineke, E.L., and sonography for trauma (TFAST) protocol to detect
Drobatz, K.J. (2020). Evaluation of the rectal-interdigital pneumothorax and concurrent thoracic injury in 145
temperature gradient as a diagnostic marker of shock in traumatized dogs. J. Vet. Emerg. Crit. Care 18: 258–269.
dogs. J. Vet. Emerg. Crit. Care 30 (6): 670–676. 12 Neri, L., Storti, E., and Lichtensteinv, D. (2007). Toward
7 Whitson, M.R. and Mayo, P.H. (2016). Ultrasonography in an ultrasound curriculum for critical care medicine. Crit.
the emergency department. Crit. Care 20 (1): 227. Care Med. 35 (5 Suppl): S290–S304.
8 Boysen, S.R. and Lisciandro, G.R. (2013). The use of 13 Armenise, A., Boysen, R.S., Rudloff, E. et al. (2019).
ultrasound for dogs and cats in the emergency room: Veterinary-focused assessment with sonography for
AFAST and TFAST. Vet. Clin. North Am. Small Anim. Pract. trauma-airway, breathing, circulation, disability and
43 (4): 773–797. (published correction appears in Vet. Clin. exposure: a prospective observational study in 64 canine
North Am. Small Anim. Pract. 2013; 43(6):xiii). trauma patients. J. Small Anim. Pract. 60 (3): 173–182.
13
The Small Animal Emergency Room

Martin D. Miller and Sean D. Smarick
Emergency medicine can be defined as “the diagnosis and Physical Plant

treatment of unforeseen illness or injury”; however, “emer-
gency medicine is not defined by location, but may be prac- The ER can range from sharing space in a treatment area
ticed in a variety of settings” according to the American within a primary care practice to encompassing a signifi-
College of Emergency Physicians [1]. In small-animal vet- cant area of a large referral hospital occupying in excess of
erinary medicine, emergency practice takes place on house 10 000 square feet and everything in between. The basic
calls, in primary care clinics, in dedicated “after-hours” needs of an ER and progressive primary care or specialty
free-standing emergency clinics, and in multispecialty clinic are similar. The differences between such facilities
referral hospitals. The establishment of a dedicated emer- can be found in the layout and organization of an ER dic-
gency room (ER), dual-use area, or the ability to make do tated by the level of emergency medicine to be practiced.
with some basic equipment must be given careful consid-
eration, as no small-animal clinical veterinary practice is
ER Design and Flow
immune to emergent patients: Vaccines can cause anaphy-
lactic reactions, anesthesia-related cardiopulmonary When creating a floor plan concept for an ER, a great deal
arrests occur, and without warning clients may present a of thought should be given to the specific aspects of the
pet with a traumatic injury or critical illness. emergency practice. Good “flow” is essential to an efficient
The Veterinary Emergency and Critical Care Society clinic. Flow represents the natural movements of patients,
(VECCS; www.veccs.org), whose mission includes “To pro- clients, doctors, and staff in the daily activity of the prac-
mote the advancement of knowledge and high standards of tice. Arranging for such movement is almost like choreo-
practice in veterinary emergency medicine and critical graphing a dance. Thought should be given on how best to
patient care,” provides guidelines for emergency facili- move clients from triage through discharge from the hospi-
ties [2]. In looking to these standards along with applicable tal and its systems [3].
state board regulations, a practice should define for its In larger facilities, the idea of a hub and spoke concept
patients, clients, the public, and, for itself, expectations for can be applied to the flow of a practice. The hub can be a
its emergency services and subsequently, the ER. centralized space such as the treatment area. The spokes
The ER, while similar to primary care and other specialty from the hub may be clinical areas such as the in-house
facilities, differs in the urgency and breadth of the patients’ laboratory, radiology, surgery, patient wards, isolation
conditions that must be addressed. Depending on the ward, and pharmacy. In larger facilities, multiple hub and
degree a practice wishes to diagnose and treat unforeseen spoke areas may exist, such as one for the intensive care
illnesses and injuries, varying degrees of adaptations in the unit (ICU) and one for the emergency service. For more on
physical plant, equipment, inventory, staffing, and hospital ICU design, see Chapter 3. Some considerations for the ER
systems are needed. are described here.
14 The Small Animal Emergency Room
Back-up Power Treatment Area

Dedicated ERs should have the ability to operate minimally The number and type of treatment tables often are
in the face of a power outage, with emergency back-up increased in an ER. With no lack of debilitated patients or
lighting and uninterrupted power supply for key equip- bodily fluids, lift and “tub tables” are recommended. It is
ment, but ideally with a centralized integrated generator or important to account for the space surrounding these
battery back-up system. tables to accommodate the staff and equipment often
needed in addressing emergent patients [7].
With the practice of emergency medicine comes an
Security
increase in the number of patient-side infusion pumps, heat-
Emergency practices have more security concerns because ing devices, medical gas outlets, and monitors. Integrating
they are open during nonbusiness hours and may be per- the equipment near the patient calls for space, power and
ceived to be rich in cash and narcotics. The perception about even connectivity between, above, or below the patient areas.
controlled drugs is a reality and internal security is equally Depending on the existence of an integrated ICU, the num-
important. To provide a safe environment for staff and cli- ber of observable and accessible cages and runs for holding
ents, enhanced security measures including well-lit public patients will vary but should not be underestimated.
areas both inside and out, limited-access security doors,
video monitoring and recording, alarm systems, and critical
The Isolation Ward
incident training and protocols should be considered [4, 5].
ERs ideally should have (or if dictated by state regulations,
may be required to have) an isolation ward distinctly sepa-
Entrance and Lobby
rate from the treatment area and other hospital areas to
Clear signage such as “Emergency” in red can be used to house patients with communicable diseases. A consultation
direct clients to the appropriate entrance and reception room may be incorporated into or adjacent to the space.
area. In shared use facilities, systems to ensure patients These spaces are not only physically separate from other
presenting to the ER are addressed as emergencies and not patient housing areas of the hospital but also have dedicated
confused with other patients waiting in the lobby or pre- heating, ventilation, and air conditioning systems.
senting for routine care. Large facilities may elect to have a Dedicating cage-side equipment such as heat support and
separate ER entrance, similar to human hospitals, which infusion pumps limit the potential for disease transmission
decreases the potential for such confusion. Strategically to the general hospital population. Stocking the isolation
placed gurneys and portable oxygen systems should be ward with treatment supplies limits foot traffic and increases
available to readily retrieve nonambulatory or dyspneic efficiency when treating patients in the ward [8, 9].
patients, respectively. Once presented, a patient should
undergo triage (see Chapter 1) following a protocol, to
In-House Laboratory
include a predetermined location, whether it be a dedi-
cated triage area, exam room, or the treatment area. Emergency medicine requires more point-of-care (POC) test-
An ER lobby must be large enough to accommodate a ing and in-house laboratory equipment often exceeding that
simultaneous influx of multiple clients and their pets. of other practices. The laboratory machines require counter
Considering an emergency presentation may last hours, space and deserve electrical considerations such as surge sup-
amenities may include comfortable seating, a beverage ser- pression, line conditioning, and potentially battery back-up.
vice in the form of a water cooler, coffee dispensers or vend-
ing machine, TV and/or wi-fi, and accessible restrooms.
Diagnostic Imaging
Diagnostic imaging, and minimally radiology, should be adja-
Comfort Rooms
cent to the ER. Additional considerations for imaging suites
The ER has emotional challenges for clients. Providing cli- include providing oxygen supplementation, anesthetic gas
ents private areas to visit their pet, receive difficult news, or scavenging, suction, and enough space to perform procedures.
have a pet euthanized, with a less clinical feel is common-
place. Such rooms include comfortable furniture, extra floor
Staff Spaces
space to accommodate an entire family, noncommercial
lighting, and home-like interior appointments. Having an In a dedicated ER, efficiency demands a semi-private area
exit from the hospital in close proximity facilitates a private for doctors and technicians to call clients, prepare medical
departure for a deceased pet or for emotional owners [6]. records, and consult with each other and be located within
Equipment 15
or adjacent to the ER. Some practices additionally include Imaging

traditional office space distant from the clinical areas to
Imaging and the rapidity of which it can be acquired plays
allow for more private and quiet work.
an important role in many emergency cases. A high-quality
Because emergency practice often involves a larger staff
radiographic system and a POC ultrasound machine (see
who work long shifts, the design of the staff area should
Chapters 6, 9, 17, 27, and 39 for point-of-care ultrasound)
include a place for their personal effects and to store, pre-
is the minimum for a dedicated emergency practice.
pare, and enjoy a meal while on break. Water fountains or
Diagnostic ultrasound and echocardiography, multislice
coolers should be available so that staff can remain
computed tomography and magnetic resonance imaging
hydrated throughout their shifts. The size of the area and
are commonplace in tertiary care emergency centers.
its complement of amenities, such as a refrigerator, micro-
wave, stovetop, seating, and tables are determined by shift
staff size and by other purpose(s) of the space (e.g. if the The In-House Laboratory
area also serves as a meeting or locker room). Adequate According to the VECCS guidelines, an ER should also be
restrooms for the staff, ideally close to the ER, should not able to evaluate packed cell volume, refractometric total sol-
be overlooked. The addition of showers may be an appreci- ids, complete blood count with manual differential, glucose,
ated benefit of the staff. lactate, chemistries, electrolytes, blood gases, prothrombin/
activated partial thromboplastin time, feline immunodefi-
Utility Spaces ciency virus and feline leukemia virus antigen testing, cytol-
ogy, urinalysis, fecal flotation, blood typing and cross match,
The ER is supported by several spaces ranging from storage
and parvoviral antigen testing [2]. In addition to the guide-
closets to server rooms to provide for the operations
lines, other POC testing may include heartworm, tickborne
of the ER.
or other infectious disease tests, co-oximetry, and thromboe-
“Janitor’s closets” are spaces that include fixtures such as
lastography. The most basic of practices may elect to keep a
mop sinks to support filling and emptying mop buckets
handheld glucometer, lactate monitor, or other POC analyz-
and have room for cleaning supplies and equipment. They
ers. See Section 7 and Chapters 25 and 26 for additional
should be strategically located to allow for easy access and
information on laboratory tests in the ER.
quick clean-up of any area in or around the ER.
A designated space for a free-standing or walk-in refrig-
erator or freezer to accommodate deceased pets waiting Patient Monitors and Equipment
disposition should ideally be located near the ER and an Patient monitors are needed to screen for physiological
exit that can allow an owner or service to discreetly remove abnormalities and to monitor ill patients for disease pro-
the deceased from the facility. gression. The monitors recommended include electrocar-
If the ER uses towels and bedding, laundry facilities diography (see Chapters 10 and 11), pulse oximetry (see
must be adequate to handle such large and often never- Chapter 25), capnography (see Chapter 30), temperature,
ending loads. This almost always goes beyond residential and blood pressure. Blood pressure can be measured by
equipment therefore adequate space as well as electrical/ doppler, oscillometric, and direct methods. direct methods
plumbing requirements should be considered. are recommended and are found in emergency centers (see
Storage space for the increased amount of equipment Chapters 13 and 14). The monitors may be standalone or
and expanded inventory of an ER needs to be considered in multiparameter and fixed or portable. Space, electrical
the design of the facility. needs, networking, use outside the ER and telemetry are
Advanced emergency practices may start to resemble considerations when selecting patient monitors. The most
small hospitals, with central oxygen storage and manifolds, basic of practices could consider refurbished electrocardio-
centralized medical or maintenance vacuums, anesthetic gram with or without a defibrillator to meet the standard
gas scavenging systems, and computer servers, which all of care for providing cardiopulmonary resuscitation (CPR;
require space and supporting mechanical systems. see Chapter 22.) Tonometry is needed to screen for
increased intraocular pressure and can be measured with a
Schiotz or POC indentation/applanation device.
Equipment
Fluid and Drug Administration
Additional equipment must be considered for a dedicated
ER because of case load, urgency, and severity of emergent Fluid infusion pumps, calibrated burettes, and syringe
conditions. VECCS provides guidelines for equipment for pumps are needed to accurately administer fluids and med-
different levels of emergency facilities [2]. ications in the ER. Fluid and blood warmers are also found
in dedicated ERs to combat hypothermia, where larger vol- Medical Vacuum

umes may be administered.
Besides providing for suctioning of a body cavity in sur-
gery, medical vacuum provides for airway suctioning and
Thermal Support continuous thoracic drainage, all commonly used in emer-
gency medicine. Minimally, a hand-powered device such
To address presenting, developing, or iatrogenic hypother-
as the Laerdal V-Vac™ mechanical suction unit (Laerdal
mia, circulating warm water, forced warm air, or electri-
Medical Cooperation, Wappingers Falls, NY) can be used
cally generated heat devices are warranted in the ER. Each
for airway suctioning, while dedicated ERs often use a cen-
system type has its own advantages based on cost, versatil-
tral system similar to the oxygen and waste gas scavenging
ity, reliability, and effectiveness.
systems with outlets in strategic areas. Portable, electrically
powered suction units can be used to address needs in
Oxygen between.
Emergent patients often require oxygen supplementation,
positive pressure ventilation, or anesthesia; oxygen access
is therefore vital in the ER. Inventory
Oxygen systems require a source and manifolds, special-
ized transfer piping or hoses and receptacles. These recep- Providing high-quality care for the acutely ill patient
tacles have a special fitting (the Diameter Index Safety requires a full inventory of supplies and drugs. Owing to the
System) to connect oxygen hosing or a regulator. Quick breadth and seriousness of disease encountered in emer-
connects are available in different popular configurations gency practice, an extensive inventory beyond that of a pri-
from different manufacturers. Oxygen receptacles can be mary care clinic is required for the dedicated ER. Even the
placed on walls or in ceilings and can be recessed or wall most basic of practices should have emergency drugs and
mounted. supplies on hand to perform CPR, address the preventable
A practice not employing oxygen regularly may use as causes of death encountered in their practice, such as aller-
a source of oxygen “E”-size tanks, small or portable oxy- gic reactions from vaccines and anesthetic complications,
gen generators, or disposable cans of oxygen, or even a and depending on the scope of their practice and distance
stationary “H” size cylinder(s); large ERs that have mul- from a referral facility, common life-threatening conditions.
tiple and high-flow needs will need centralized systems Because of the inconsistent nature of emergency practice,
with H tank banks (as a primary or secondary source), usage of inventory items and the inability to obtain such
liquid oxygen tanks and systems, and/or oxygen supplies on a moment’s notice during off-hours, a robust
generators. inventory system is needed. Inventory item usage can be
Patient oxygen administration systems can be simple tracked through physical markers signaling an item has
(i.e. a nasal cannula, e-collar hood or mask), but been depleted, daily physical inspections, or practice man-
dedicated ERs often employ specialized cages that are agement software that includes inventory control or a sup-
designed to create an atmosphere of higher oxygen ply management system, such as the computer-controlled
concentration. bank of drawers and cabinets (such as the Omnicell®,
Patients that do not respond to oxygen administration or Omnicell Corporation Mountain View, CA).
are severely hypoventilating require positive pressure ven- The emergency caseload, resources allocated to inven-
tilation. At the most basic level, this can be accomplished tory and equipment, and geographical location are relevant
with a bag-valve-mask device, nonrebreathing circuit, or to the inventory. For instance, an emergency hospital that
anesthesia machine. An anesthetic ventilator or ideally a is near a 24-hour human community hospital may be able
critical care ventilator are found in dedicated ERs (see to purchase or borrow medications such as antivenin. An
Chapters 24 and 31 for more information). ER without such resources will need a full complement of
medications. VECCS provides extensive guidelines for sup-
plies and equipment for an ER; however, a checklist of rec-
Anesthesia Waste Gas Scavenging
ommended emergency drugs and supplies for practices
In a dedicated ER, patients will undergo anesthesia in the without a dedicated ER are shown in Box 2.1. See also
radiology and other imaging areas, the treatment area, Figure 2.1 and 2.2 for an “ER in a box” that can provide the
and the surgical and associated preparation areas. A cen- drugs, supplies and equipment to address emergencies in
tralized scavenging system is recommended that can pro- practices without an ER, such as a mobile practice, a vac-
vide connections in strategic locations for anesthesia cination clinic, or other type of practice, without the over-
machines. lapping resources to address basic emergencies.
Inventory 17
Box 2.1 Basic Emergency Inventory Considerations

Supplies and equipment: ● Stethoscope
● Electrocardiogram and defibrillator, electrode gel
● Endotracheal tubes (various sizes)
● End tidal CO2
● Laryngoscope and blades (various sizes)
● Glucometer and strips
● Bulb syringe/suctions tips and device
● Bag-valve-mask Drugs (injectable unless specified):
● Polypropylene catheters
● Epinephrine
● Oxygen source
● Sodium bicarbonate
● Oxygen tubing and connectors, mask
● Atropine
● Soft Tubes (various Fr sizes)
● Lidocaine
● 1-inch tape
● Lactated Ringer’s solution and/or 0.9% saline 1-liter × 2
● Disinfectant and alcohol (pads)
● Diphenhydramine
● Intravenous catheters (24–14 gauge)
● Dexamethasone sodium phosphate
● Injection caps
● Dextrose
● Three-way stopcocks
● Narcotic
● Extension tubing
● Ketamine
● Fluid administration set
● Midazolam
● Syringes 1 ml to 60 luer tip
● Furosemide
● Needles (20 gauge × 1 inch)
● Albuterol inhaler and spacer
● Illinois bone marrow needle
● Calcium
● Christmas tree/other adapters
● Apomorphine
● Sterile procedure pack:
● Activated charcoal in suspension
– Scalpel handle and blades (#11 or 12)
● Ticarcillin + clavulanic acid
– Kelley forceps
● Famotidine
– Tissue forceps
● Ondansetron
– Needle drivers
● Propranolol
– Mayo scissors
● Diltiazem
– Tracheal hook
● Proparacaine ophthalmic
● Suture, monofilament, cutting and taper needle,
● Fluorescein dye strips
0 to 3-0
● Eye wash
● Bandaging: hemostatic/lap sponges, roll gauze, elastic
● Artificial tear (ointment)
tape or wrap, roll cotton
Medical Supplies
Basic supplies to support the ABCs (airway, breathing, and
circulation) should be stocked in every practice, while
additional supplies may be found in more advanced emer-
gency practices.
Airway Management
A laryngoscope with multiple appropriate blade sizes,
endotracheal tubes, and a bulb syringe for suctioning are
basic emergency airway supplies that all practices should
have. A source of medical vacuum as discussed above and
catheters or suction tips should be considered. Lidocaine
sprayed from an atomizer or directly instilled to a cat’s lar-
Figure 2.1 “ER in a box.” Adapted toolbox to store emergency ynx will help prevent laryngospasm. A polypropylene uri-
supplies where an emergency room is not available. nary catheter or bougie can act as a guide for the
option exists. Cost-effective bag-valve devices are available

through veterinary distributors. Practices that use general
anesthesia usually have an anesthesia machine and cir-
cuits that can be used to provide positive pressure
ventilation.
Many emergency patients need oxygen supplementation
even when they do not require endotracheal intubation. A
practice should therefore have other equipment to deliver
oxygen. Such items could include rigid plastic masks,
hoods, which are commercially available or can be made
from a plastic wrap-covered Elizabethan collar or a plastic
bag, and nasal cannulas, which can be made from red rub-
ber catheters or human bilateral nose prongs. Plastic wrap
over the front of a cage or around a cat carrier with some
area left for a vent can also be effective (see Chapter 24, for
more information).
Oxygenation and ventilation can be compromised by
pleural space filling defects and supplies to address should
be in the emergency area or kit. Butterfly needles, periph-
eral intravenous (IV) catheters, dedicated over-the-needle,
Seldinger, or trocar thoracostomy tubes compared with
other general use tubes should be considered, together
with extension tubing, three-way stopcocks, syringes, tube
connectors, and Heimlich valves (see Chapter 34 for more
Figure 2.2 Contents of the author’s “ER in a box.” Top tray: needle details).
and syringes, emergency drugs, sedatives and analgesics, eye wash,
If blood gases are measured in the practice, supplies (e.g.
stethoscope, disinfectant wipes. In main compartment: 1-liter bag
Lactated Ringer’s solution, administration set, disposable syringes, needles, and heparin), or specialized pre-
colorimetric CO2 detector, bag-valve-mask. Endotracheal tubes, heparinized vented syringes are needed (as discussed in
oxygen cannula, portable oxygen, manual suction device, saline Chapter 26).
prefilled syringes, intraosseous needle, intravenous catheters,
laryngoscope and blades, bulb suction syringe, bandaging supplies
and scissors. Not pictured: suture, scalpel, tracheal hook, forceps, Circulation
ophthalmic supplies, injection caps, gloves (exam and sterile)
additional bandaging supplies, three-way stopcock, butterfly Maintaining effective circulating volume is crucial for the
needles, extension set, and oxygen regulator.
emergency patient, and every practice should have the
ability to stop external hemorrhage and gain vascular
endotracheal tube during difficult tracheal intubation (see access or a bag-valve-mask with an oxygen tube and reser-
Chapter 28). voir. External bleeding can usually be addressed with direct
Ideally, supplies to perform a tracheostomy or cricothy- pressure and bandaging; such supplies should be readily
roidotomy should be available in all practices; such sup- available to arrest severe hemorrhage. Besides IV catheters
plies include self-retaining retractors or tracheal hook, ranging from 24- to 14-gauge for peripheral placement,
scalpels, sutures, needle drivers, and forceps. Commercially intraosseous cannulation, an often-overlooked vascular
available kits and devices are available via emergency med- access technique, can be accomplished with hypodermic
ical services suppliers and provide (in trained hands) alter- needles, spinal needles, or purpose-designed or mechani-
natives to the traditional surgical approaches. Many cally placed intraosseous needles. A pressure infusion bag
tracheostomy tubes are sold commercially but a shortened can assist in delivering large volumes of fluids in a short
endotracheal tube can be used if a tracheostomy tube is not amount of time See Chapter 7 for more specific information.
available (see Chapter 29). The goal of maintaining effective circulating volume is to
deliver oxygen to the tissues. When anemia is severe, an
oxygen-carrying fluid must be provided. Disposables
Breathing
required for transfusion to include equipment for blood
Rescue breathing can be delivered with mouth-to-snout or typing and crossmatch, blood administration sets, inline
endotracheal tube, but because such practice compromises filters, and collection supplies such as anticoagulant and
caregiver safety, it is recommended only when no other blood collection bags may be warranted if no blood
Pharmacy 19
products or emergency center is nearby See Section 9 for Every practice should be prepared to address anaphylac-
more information. tic or serious allergic reactions with epinephrine, diphen-
Advanced emergency practices may include long-term hydramine with or without a histamine type 2 receptor
single or multilumen central IV catheters to administer (H2) antagonist and corticosteroids.
multiple infusions simultaneously and obtain repeated Diuretics, antiarrhythmics, afterload reducers, and ino-
venous blood samples, all of which provide a continuum tropes may be needed to address cardiac emergencies. For
from emergent to critical care. disturbances in electrical rhythm that may compromise
cardiac output, atropine and antiarrhythmic drugs from
the sodium channel blocking, beta and calcium channel
Additional Supplies
blocker classes are recommended.
The dedicated ER should have specific supplies available to Bronchodilators and corticosteroids are warranted in the
cannulate any patient orifice or cavity, whereas soft generic patient compromised from allergic bronchitis and epi-
catheters are cost-effective versatile substitutes for, for nephrine can be used if severe and no other drugs are
example, urinary catheters, thoracostomy tubes, oxygen available.
cannulas. The type-specific tubes may offer the advantages Patients in septic shock, by definition, are not responsive
of less tissue reactivity, integrity of asepsis, and the ease of to IV fluids alone and require vasopressors and possibly
their intended use. With each tube comes the need for spe- positive inotropes. Many inotropes and vasoactive medica-
cific collectors (e.g. urinary catheter bags, chest tube drain- tions require constant rate infusions. Infusion or syringe
age systems), connector(s), and adapters, so appropriate pumps to deliver these medications along with appropriate
pieces should not be overlooked. See Section 4 for further diluents (e.g. dextrose 5% in water) are required for their
information. administration. Additionally, recent sepsis guidelines in
people recommend starting antibiotics early [10].
Pharmacy
Anti-Infectives
As with equipment, every practice should be able to mini- Antibiotics are used to treat, and in very specific situations
mally address cardiopulmonary arrest and shock and effect to prevent, bacterial infections. Parenteral antibiotics effec-
referral whereas dedicated ERs need to be able to address a tive against the organisms encountered in the emergent
wide range of conditions. setting requires stocking antibiotics to address Gram-
positive and Gram-negative, aerobic, and anaerobic organ-
isms. Beta-lactams, fluoroquinolone, and aminoglycoside
Shock and Cardiopulmonary Arrest
antibiotics are basic requirements, and metronidazole,
Current CPR guidelines call for a vasopressor (namely, epi- macrolides, and tetracyclines play important roles.
nephrine and justifiably vasopressin), atropine, and sodium Antiprotozoal and anthelmintic medications round out the
bicarbonate as a buffer and for treatment of hyperkalemia. anti-infective inventory, with consideration given to the
See Chapter 20 for more information. organisms and parasites encountered in the practice. Basic
Shock, defined as inadequate cellular energy production, practices may consider stocking a dose or two of a second-
is usually the result of hypovolemia, hypoglycemia, hypox- or third-generation cephalosporin, extended spectrum
emia, sepsis, or cardiac failure, and is the primary acute penicillin with a beta lactamase inhibitor, and/or fluoro-
condition that every practice should be prepared to address. quinolone injectable that can be administered prior to
Oxygen, not often thought of as a drug, was discussed referral. When used appropriately, early administration of
under supplies and can be a life-saving treatment for shock. antibiotics can affect outcome in conditions such as sepsis
The most common cause of shock is hypovolemia, and and wound management.
restoration of effective circulating volume with crystal-
loids and blood products may be needed. There is no uni-
Analgesics, Sedation, and Anesthesia
versally ideal solution for resuscitation, so the more
emergencies a practice sees, the more bags and types of With the standard of care including analgesia, the essential
fluids and blood products are warranted. Minimally, iso- emergency pharmacy should have drugs for parenteral
tonic saline (0.9% NaCl) or a buffered, balanced electrolyte administration that interfere with the transduction, trans-
solution such as lactated Ringer’s solution should be mission, modulation, and perception of pain. Local anes-
stocked. If blood products are not stocked, donors and thetics, alpha-2 agonists, N-methyl-D-aspartate (NMDA)
blood collection supplies may be considerations if distant antagonists, nonsteroidal anti-inflammatory drugs, and
from a referral facility. opioids are classes of drugs to stock for analgesia. An
analgesic that can also check the box for sedation and be intoxications. Hypercalcemia can be treated with IV fluids,
considered cardiac sparing should be considered for every a loop diuretic, an alkalinizing agent, and, in certain
practice to “relieve suffering” during referral or prior to instances, a corticosteroid. Hypocalcemia requires paren-
euthanasia. teral calcium supplementation.
Patients with an acute presentation usually raise cardi-
opulmonary concerns beyond those of a healthy patient;
Urogenital Emergencies
the drugs stocked for sedation and anesthesia in emer-
gency practice should reflect this. Balanced anesthetic Urogenital emergencies amenable to pharmacologic inter-
techniques with cardiovascular sparing drugs are most vention include dystocia and complications from hyper-
appropriate, and such drugs include opioids, benzodiaz- kalemia. Hyperkalemia’s effect on the heart may be
epines, and NMDA antagonists. Propofol, alpha-2 ago- antagonized by a slow IV push of calcium, while insulin
nists, and promazines still play important roles in the and alkalinizing agents shift the potassium into the intra-
emergent setting, despite their more profound cardiovas- cellular space. Oxytocin, along with dextrose and calcium
cular effects. Section 6 provides more in-depth supplementation, is used to treat uterine inertia.
information.
Ophthalmologic Emergencies
Intoxications
Ophthalmologic examinations require a topical anesthetic
Intoxications may vary by geographical location but uni- for the cornea, fluorescein stain, and sterile, buffered saline
versal considerations where timing is crucial (i.e. gut eye rinse. Artificial tears and ointment are needed to pre-
decontamination) justifies stocking emetics and acti- vent exposure keratitis in patients with decreased tear pro-
vated charcoal. Dedicated ERs should have specific duction or blinking, and in those under sedation or
antidotes in stock, such as ethyl alcohol for ethylene gly- anesthesia, even for a short time. Every practice should
col, vitamin K1 (phytonadione) for anticoagulant roden- consider stocking these basic supplies. Glaucoma in the
ticide intoxication, lipid solutions for fat-soluble acute setting requires lowering the intraocular pressure
intoxications. with a topical and/or systemic carbonic anhydrase inhibi-
tor, an osmotic diuretic, and/or prostaglandin analogues
and depending on available referral and pharmacy options,
Gastrointestinal Medications
the ER should consider having these medications on hand.
A patient presenting with signs referable to the gastrointes- Inflammatory diseases use a topical steroid product in the
tinal tract is one of the most common presenting emergen- absence of corneal ulceration, and most bacterial infec-
cies. As such an ER should consider carrying parenteral tions can be addressed with a few choices in antibiotic oint-
anti-emetics from several classes and proton pump inhibi- ments or drops. A dilating agent such as topical atropine
tors and/or H2 antagonists. offers relief from ciliary spasm and prevents synechia for-
mation in corneal lesions.
Endocrine Emergencies
Neurological Emergencies
While most endocrine emergencies can initially be treated
with supportive care if the patient is going to be immedi- Medications to control seizures (e.g. a benzodiazepine) and
ately referred (i.e. IV fluids), dedicated ERs should be pre- to address hypoglycemia should be found in every practice,
pared to treat hypoadrenocortism, diabetic ketoacidosis, while dedicated ERs may include drugs to lower intracranial
and aberrations in calcium homeostasis. For Addison’s dis- pressure and loading doses of long-term anticonvulsants.
ease, injectable dexamethasone is an important drug, as it
will not interfere with adrenocorticotropic hormone stimu-
lation testing due to the lack of mineralocorticoid activity Staffing the Emergency Practice
in dexamethasone. Hydrocortisone or prednisone will be
required for subsequent doses if a mineralocorticoid (such Depending on caseload variations of the season, day of the
as deoxycorticosterone pivalate or fludrocortisone) is not week, and time of the day, the scope of the practice, and the
available. Diabetic ketoacidosis requires intramuscular or population serviced, staffing of a dedicated emergency prac-
IV administration of insulin. tice can range from a single veterinarian and assistant to mul-
A high-percentage dextrose solution should be stocked to tiple veterinarians supported by a plethora of support staff.
address hypoglycemia from insulin overdose or secreting Typical veterinary staff (certified veterinary technicians/
tumors and complications from sepsis, neoplasia, and veterinary nurses, assistants, kennel aides, and
Summary 21
receptionists) have roles in an emergency practice as they Practice Management Software

would in primary care. It is ideal to have a high ratio of
A significant number of a patents medical record can be
technicians to veterinarians with the support staff in dedi-
managed by current veterinary practice software.
cated positions. This can be accomplished with consistent
Veterinary practice software is commonplace and addresses
and high caseloads; however, the caseload in an emergency
not only medical records but also client and patient data-
practice can vary tremendously and both veterinarians and
bases, inventory control, invoicing, and accounting.
support staff may be called upon to assume multiple or
Software designed for referral practices can also include
nontraditional roles.
treatment orders, white boards, and referring veterinarian
The specialized skills and knowledge of the emergent
databases and portals, which may be advantageous for ded-
practice staff will often find even certified veterinary tech-
icated ERs.
nicians and employees with years of experience in other
practices needing additional training. In-house training
programs are crucial at the basic level. The Academy of
Other Information Management
Veterinary Emergency and Critical Care Technicians and
Nurses offers an avenue to become a veterinary technician VECCS requires select references and continuing profes-
specialist and gain recognition in the field by pursuing sional education for staff to be a certified emergency facil-
advanced training. ity, but every practice should have resources including
The nature of an emergency practice means that unique textbooks, online group memberships, subscriptions, or
staffing considerations exist. Scheduling for a practice telemedicine options, poison control center information,
operating off-hours or continuously for 24 hours a day has professional memberships (e.g. VECCS, RECOVER), and
challenges of shift transitions and continuing education, associated resources to be able to meet the standard of
performance review, and staff meetings. The highly emo- emergency care for their type of practice.
tional environment of an emergency practice may also lead
to compassion fatigue; Section 11 addresses these issues.
Management
Management of a dedicated ER practice is similar to the
Hospital Management and Systems other practices; however, the chaotic nature of patient
presentations and a continuously operating hospital bring
As discussed, facility, equipment, supplies, pharmacies,
additional challenges. Managing these challenges requires
and staffing of a dedicated ER are often larger and more
more anticipation, implementation, and monitoring
complex than those for primary care practice. The off-
beyond that of a practice operating during more traditional
hours and possibly continuous operating nature of the
hours. Chapter 4 provides invaluable insight into address-
emergency practice makes communication among co-
ing some of these challenges.
workers and between management and staff difficult, yet
ER management is the focus of large corporate entities,
it is crucial for the successful delivery of emergency care.
specific veterinary management groups or veterinary study
The hospital systems in an emergency practice must
groups, and organizations such as VECCS. Also, there is no
address these challenges to keep operating smoothly.
lack of opinions on online forums in which to engage.
However, it is equally important for the non-emergency
Medical Records hospital to define, maintain, and even practice their emer-
gency policies and procedures to effect successful resusci-
Medical records contain the history and chronology of the
tation and referral.
medical care given to the patient. Their contents may be
regulated by the state veterinary board and the VECCS
recommends that the problem-oriented medical record as
outlined by the American Veterinary Medical Association Summary
be followed and be kept at the emergency facility.
While referral practices usually have robust record sys- Every clinical practice should have a minimal set of tools to
tems to ensure that everyone (internal staff, client, and treat common emergencies that are likely to be experi-
referring veterinarian) follows the same procedures, every enced in their practice. While an ER shares many features
emergency warrants a detailed record, even in the throw of with other types of veterinary facilities, the design, equip-
chaos, to document the care provided and to be beyond ment, inventory, staffing, and hospital systems become
reproach if that care is ever called into question (see more specialized to provide care for patients with unfore-
Chapter 5). seen illness and injuries.
References
1 American College of Emergency Physicians (2021). 6 Lewis, H.E (2019). Comfort rooms are cool. DVM360.
Definition of Emergency Medicine. Dallas, TX: ACEP. http:// https://www.dvm360.com/view/comfort-rooms-are-
www.acep.org/patient-care/policy-statements/definition- cool (Accessed 25 June 2022).
of-emergency-medicine (Accessed 25 June 2022). 7 Lewis, H.E. (2019). Hospital design: What Bailey
2 Veterinary Emergency and Critical Care Society. Minimum taught me. DVM360. https://www.dvm360.com/view/
Requirements for Certification of Veterinary Emergency and hospital-design-what-bailey-taught-me (Accessed
Critical Care Facilities (effective 1/14/2021). San Antonio, 25 June 2022).
TX: VECCS; 2021. 8 Stull, J.W., Bjorvik, E., Bub, J. et al. (2018). AAHA
3 Moser, S.A. (2012). Perfect the veterinary practice flow: infection control, prevention, and biosecurity guidelines.
traffic, technology, and talk. DVM360. http://www.dvm360. J. Am. Anim. Hosp. Assoc. 54 (6): 1–30.
com/view/perfect-veterinary-practice-flow-traffic- 9 Separate but equal: Your veterinary isolation ward doesn’t
technology-and-talk. Accessed 25 June 2022. have to be drab (2018). DVM360. https://www.dvm360.
4 Scheidegger J. (2015) Five signs your veterinary clinic is an com/view/separate-equal-your-veterinary-isolation-ward-
easy target for criminals. DVM360. https://www.dvm360. doesn-t-have-be-drab. (Accessed 25 June 2022).
com/view/five-signs-your-veterinary-clinic-easy-target- 10 Rhodes, A., Evans, L.E., Alhazzan, W. et al. (2017).
criminals (Accessed 25 June 2022). Surviving sepsis campaign: international guidelines for
5 Nolen, R.S. (2019). Safety first. J. Am. Vet. Med. Assoc. Management of Sepsis and Septic Shock: 2016. Crit. Care
254 (12): 1382–1386. Med. 45 (3): 486–552.
23
Intensive Care Unit Design

Joris H. Robben and Lindsey Dodd
The primary objective of an intensive care facility is to pro- into account staffing, the intended operations within it,
vide a high level of continuous patient care. A well-designed and should have standardized operating procedures
intensive care unit (ICU) is necessary for the creation of a described in protocols and guidelines. For a successful
safe, efficient, and, not the least, pleasant environment for design, all these aspects must be considered and put into
patients, personnel, owners, and other visitors. Safety context with one another. However, for reasons of con-
relates to several aspects, such as environmental services, straint and in accordance with the intention of this text,
ergonomics, and mental wellbeing. However, infection con- this chapter does not discuss the important aspect of staff-
trol and prevention will have an ever-increasing influence ing. The aspect of operations is discussed if relevant for
on the design. the design.
In veterinary medicine, no consensus or detailed stand-
ards exist regarding what should constitute an ICU for
The Design Process
companion animals. Currently, there is a wide variety of
ICU types in various clinical settings. Considering this
Development
variety, a description of current practices or effective design
options can never be complete. Nevertheless, as in human ICU design has a significant impact on daily patient care
intensive care medicine, veterinary medicine should strive and staff wellness. The extensive investment of time and
for unification and basic, general guidelines for ICU design effort in the long and complicated design process will be
to ensure a predefined and, preferably, centrally guided, rewarded when one experiences its positive impact on the
high quality of intensive patient care. The topics that are day-to-day operations. A stepwise approach helps to organ-
addressed here are intended to constitute a basis for such ize the development from initial concept to completed
future guidelines. structure (Box 3.1). The planning and design process
In smaller practices with a variable need for intensive should include research that leads to evidence-based rec-
care it may be most economically viable to combine the ommendations for materials in compliance with local leg-
ICU facility with the emergency and recovery rooms [1]. islation directives. A major step in the development process
Although these facilities are closely related, they should be is the description of the ICU program goals and objectives.
considered separate units with different operational func- These can be best defined by a planning team that includes
tions. Physical separation is particularly important for the ICU veterinarians and technicians, pet owners, adminis-
ICU as it helps to prevent unnecessary commotion and trators, and design professionals.
traffic, which aids with infection control (one of the pri- The intensive care facility and all its contents should
mary aims of ICU design in human medicine along with support, and be a logical extension of, the manner in which
improving patient comfort). This discussion focuses on the ICU is operated. Therefore, the design should crea-
intensive care medicine only, and the ICU will be consid- tively reflect the vision and spirit of ICU staff and pet own-
ered as an independent, functional unit. ers. It is important to allow everyone involved in the
A well-designed ICU should not only have a relevant development process to comment, as design aspects must
floor plan, interior design, and equipment, but also take be judged from different perspectives. A close interaction
24 Intensive Care Unit Design
Box 3.1 Steps in Planning and Designing a Veterinary Intensive Care Unit

1) Development of the vision and goals for the project. 9) Operations planning, including traffic patterns, func-
2) Education on design planning and processes for a tional locations, and relationship to ancillary
changing organizational culture. services.
3) Review of articles on delivery of patient care, team- 10) Interior planning.
building, (evidence-based) design, facility planning, 11) Surface material selection.
and other relevant aspects of clinical practice. 12) Review of blueprints, specifications, other docu-
4) Visits to new and renovated units. ments, and mock-ups.
5) Vendor fairs. 13) Preparation and planning for change in practice for
6) Legislation and local directives relating to the build. staff and pet owners in the new unit.
7) Development planning. 14) Building and construction.
8) Space planning, including methods to visualize 15) Post-construction verification and remediation.
three-dimensional space if available. 16) Post-occupancy evaluation.
Source: Based on White et al. [2].
between external experts in hospital construction and an helps in this conceptual phase to think of the ICU as a
internal interdisciplinary team is mandatory to reach a pro- group of concentric circles with the patient modules at
fessional design that agrees with user requirements. the center. (For the purpose of this discussion, each indi-
vidual patient care area, i.e. cage and direct surround-
ings, is considered a patient module.) By positioning the
Location in the Hospital different rooms, areas, and functions within the smaller
The ICU must be situated within the hospital in relation to and larger concentric circles surrounding the patient
other facilities such as emergency services, anesthesia modules, relationships can be discussed and adjusted
induction and recovery rooms, intermediate or general accordingly.
wards, and ancillary services. Close proximity to the surgi- The character of the relationship between areas, rooms,
cal theaters, recovery and emergency rooms reduces the and functionalities must also be described, and is based on
distance to move critically ill patients and enables the easy the need for visual or auditory contact with patients, and
transfer of staff, equipment sharing, and the common use the patterns of physical movement of patients, people, and
of ancillary functions. Furthermore, the sharing of engi- materials (being either clean or dirty, small or large)
neering services can more easily be accomplished during through the space.
the building process. The ICU should be located with con- The configuration of the facility has to be drawn within
sideration for other services that receive ICU patients or the limitations of the building and based on the priorities
personnel traffic. Such services include the diagnostic for ICU positioning within the hospital, the priorities for
imaging facilities, pathology, and the clinical laboratories if the supporting areas and functionalities within the ICU,
there is limited or no point-of-care testing available in the the need for shared engineering services, and the design
ICU. In the absence of imaging technicians and laboratory considerations from other services.
staff, ICU personnel should be able to use these facilities
promptly and with ease. ICU Size
Several aspects must be taken into consideration when
deciding on ICU size (Table 3.1). A facility that can
Facility Configuration
accommodate 6–12 patients with a mean occupancy of
An ICU can be divided into three major areas: the staff 60–70% is often considered a practical and viable compan-
work area, patient area, and ancillary services. The last is ion animal ICU size. Smaller units may not benefit from
either part of the facility or located elsewhere in the hos- economy of scale, and may receive an insufficient case-
pital and shared with other services. As with the location load to maintain skills and expertise of personnel. Larger
of the ICU within the hospital, the topographic position- units may reduce the overview of activities by the staff
ing of areas within the ICU should be considered and and present problems with clinical management [3, 4].
defined early on during the design process. The value of Larger units should only be considered when the facility
the relationships between different rooms, areas, and admits patients to the ICU that need less intensive care,
functions can be prioritized by a system of grading. It such as when a facility combines intensive care with
The Ground Plan 25
Table 3.1 Considerations to determine the size of the intensive The Ground Plan

care facility.
Staff Work Areas

Aspect Considerations
Technicians’ Station
Historical information Size of previous ICU facility A central technicians’ station can improve organization
History of patient refusals at and efficiency of patient care and improve comfort, con-
prior size venience, and wellbeing for technical staff [6]. Such a sta-
Regional influence Role in the regional tion should be an area of sufficient size to accommodate all
veterinary community
necessary work activities. The station should be situated
Hospital/practice Size such that it offers a clear, unobstructed view of the patient
Size and type of other Presence, size, and level of area. Sliding glass doors and glass partitions offer optimal
specialties and facilities the emergency service sight and at the same time function to separate the techni-
Presence, size, and level of cians’ station and the patient area acoustically (both ways)
other in-hospital specialties
(Figure 3.1a). If an isolation ward is part of the ICU, visual
Number of surgical theaters, and audible contact should be available from the station
surgical case load
(Figure 3.1b).
Organizational restrictions Space available
The station should contain an area or desk with com-
Staffing available puter terminals for patient record maintenance and
Type of patients (admittance Internet access. This setup facilitates more detailed record
policy) compilation, completion of requisitions, and into and out
Level of care of hospital telephone communications. The station could
Number of elective (planned) also accommodate storage facilities for protocols, patient
admissions chart material, request forms, and other medical station-
Financial restrictions ery. Depending on the space available a medical book col-
lection, printers, document scanner, fax, photocopier, and
a table to perform patient rounds can be made part of the
area. Anything that makes work efficient and the working
medium care functions. Larger institutions could con- experience attractive should be considered for this area.
sider the design of subunits that manage patient care If the technicians’ station cannot provide enough room
independently, such as a separate cat and dog patient for all these facilities and functions, a separate medical or
module area to provide enhanced and optimal care for administrative office should be available in close proximity
both species [5]. to the patient area.
(a) (b)
Figure 3.1 (a) The entire patient area can easily be surveyed from the technicians’ station through large glass windows. (b) With the
use of cameras in the isolation ward and wall-mounted monitors in the technicians’ station, the isolation ward can be monitored from
within the station. Auditory surveillance is possible through the installation of microphones and speakers.
Staff Break Room equipment, and larger medical equipment for monitoring
Work in an ICU can be physically and mentally demand- and treatment. However, the storage of such disposables
ing, and staff should have the opportunity to break away and equipment in the patient area should be minimized, as
from the clinical environment when necessary and as part it contributes to the impression of chaos and limited space
of scheduled breaks to aid their wellness. Staff break areas which can have a detrimental effect on patient care, efficacy
should provide private, comfortable, and relaxing environ- and staff wellbeing.
ments with external windows, comfortable seating and dis-
tractions such as magazines, radio, and television. Kitchen Patient Modules
facilities such as a sink, microwave, food refrigerator, and Patient modules consist of the patient’s cage and its direct
dishwasher may be integrated or directly adjacent. Lockers surroundings, the “cage-side”. The modules should be
for safekeeping of personal belongings can be installed. arranged and designed in such a fashion that observation
The room should be equipped with communication sys- of all patients by direct or indirect (e.g. by video monitor)
tems such as telephones, computers, intercom, and emer- visualization is possible from many locations in the
gency call buttons. ICU [3]. Such an arrangement permits the observation of
patient status during both routine and emergency
Conference or Multipurpose Room circumstances.
This room facilitates staff meetings, teaching sessions, and Patient modules should be designed to support all neces-
other group meetings. For this purpose, it should contain sary healthcare functions. Intensive care staff spend a con-
proper seating, projection facilities, a white board, and illu- siderable time monitoring, treating, and nursing patients.
minated viewing box. It can also be used as a library by Therefore, patients should be easily accessible, with special
equipping it with journals, reference books, internet- attention to ergonomics and infection control measures.
connected computer terminals and printers. Both the staff The more complex the care required, the more cage-side
break room and the conference room should be in close space needs to be available to position the supporting and
proximity to the ICU so that staff are not dispersed during monitoring equipment. However, this should not impede
their absence, but can certainly be shared with other access and nursing care to the patient.
services. These considerations force us to rethink the design of
the patient area with special attention to the concept of
the patient module. Different frequencies and intensities
Patient Area
of care may warrant different types of patient modules to
The patient area should be compact and offer close, unob- cater to different types of patients, their needs and nurs-
structed visual (and audible) contact with all patients. A ing requirements. The admittance policy should be con-
link between poor visualization of patients by nursing staff sidered when deciding on the type of patient modules to
and physicians and mortality in critically ill patients has use. A well-balanced mix of different patient module
been demonstrated in a human ICU [7]. The number of types or an adaptable cage concept to accommodate mod-
staff in a veterinary ICU is often limited, and one staff erate, advanced, and intensive one-on-one patient care
member should be able to observe multiple patients at options probably serves the overall needs best. This vari-
once. This factor should play a major role in the positioning ety allows for more economic use of the limited space
of the different patient modules. Furthermore, the require- available.
ment for a relatively small unit must be balanced with the
need for increasing numbers of cage-side monitors and “Cage-side” Utilities
therapeutic equipment, the importance of infection pre- One of the most valuable resources to have at the cage-side
vention and control (IPC) measures, and the need for a is space. Open space maximizes access for caregivers,
pleasant, comforting and ergonomically designed environ- reduces cross-contamination between patients, and pro-
ment for patients, staff, and owners. vides space for owners who are visiting [8]. A visiting room
The patient area should allow unobstructed movement for owners offers more privacy and comfort but many
of staff, owners, visitors, patients, and equipment. patients require continued care, and this will not always be
Therefore, doors, aisles, and corridors should be designed a suitable option.
to accommodate the transport of stretchers, patient carts, Every patient module should have its own lighting. This
and large equipment within the unit and into and out of enables the staff to care for one animal during quiet,
the facility. nightly hours without having to use the main light that
Besides the presence of patient modules and a treatment illuminates the whole patient area. Preferably, every cage is
area for specialized procedures, the patient area is often equipped with one or more devices for warming the patient,
used for storage of disposables, smaller (surgical) such as floor heating or a heating lamp.
The Ground Plan 27
Light switches, electrical power sockets, and other out- trolley. A combination of these arrangements may be suit-
lets must be organized to ensure safety, easy access, flexibil- able. Bedside monitoring equipment should be located to
ity, hygiene, and maintenance. Depending on the type of permit easy access and viewing, and should not interfere
cage, outlets can be mounted on the wall above or on both with the visualization of, or access to, the patient. The sta-
sides of the enclosure. Alternately, they may be brought tus of each patient should be readily observed at a glance.
from the wall or ceiling in a more free-standing arrange- This goal can also be achieved by a central monitoring sta-
ment to a boom or trunk over the cage, via a “stalactite” tion feed by telemetry or an internal camera system that
structure from the ceiling or via a “stalagmite” structure permits the observation of more than one patient simulta-
from the floor. The number and location of the power sock- neously, preferably from within the technicians’ station.
ets depend on the amount of electrical equipment, but a Storage units (cupboards, baskets, shelves) could be
minimum of eight per patient module seems reasonable placed in more advanced patient modules to provide easy
for most patient modules, especially with the routine use of access to specific drugs, disposable materials for specific
infusion pumps (Figure 3.2). The current standard in patient care procedures, such as mouth care and emer-
human medicine is as many as 16 power sockets per gency resuscitation equipment.
bed [9]. The patient’s daily record and flow sheet can be located
The number of outlets for vacuum, oxygen, and com- in the patient module or at the central technicians’ station.
pressed air may vary with the type of patient module, but Their position should be easily accessible to the nursing
every cage should have easy access to at least one of each. and medical staff (Figure 3.3). Complete paperless bedside
Patient modules designed for mechanical ventilation need recording as is now custom in human medicine may be
more service outlets and may need an extra outlet for scav- introduced in veterinary medicine in the near future.
enging of anesthetic gases.
Equipment may be supported on wall-mounted rails, Cage Designs
shelves, the top of the cage (when health and safety is care- As care and treatment of patients is the core duty of an ICU
fully considered), or on mobile service stands (“drip and is primarily performed in and around patients, the
poles”). When equipment is too heavy, too bulky, or is design of the cages is of the utmost importance. Many dif-
shared between patient modules, it can be mounted on a ferent “cage” designs can be found in veterinary ICUs
today (Figure 3.4).
A kennel or run can be described as a small, fenced space
with a door at the front (Figure 3.4a); such a space is often
used to enclose larger dogs. When the patient is recum-
bent, care and treatment must be performed on the floor of
the kennel, often with the patient positioned on padded
bedding or a mattress. Runs make it difficult to position
equipment, and often drip poles are used in or in front of
the run. From the perspective of infection control, practi-
cality, and working conditions for the staff this is less than
ideal for the treatment for most types of ICU patient.
“Stacked” cages can be made of stainless steel, fiberglass,
or plastic and can be stacked in different arrangements
(Figure 3.4b). The cages have a metal wire or plastic front
with a door and all other sides closed. This setup of cages
appears most widely used in companion animal ICUs.
Such a conformation uses limited space, which is often
important in an ICU. Although the construction is more
elevated than a run, the close contact between patients is
not ideal for maintaining hygiene and reducing cross-
contamination. Cages that are positioned in the second or
third row from the bottom offer an ergonomic advantage.
Patient visibility is not optimal, as one must stand directly
Figure 3.2 With the ever-increasing use of infusion pumps and in front of the cage to be able to see clearly inside.
other medical equipment, the need for power outlets increases.
Equipment, wires, and infusion lines can only reach the
Eight per patient module seems sufficient in most instances,
which can be reduced with new inventions like docking stations patient from the front. With several patients housed
servicing multiple infusion pumps on one power outlet. directly next to and on top of each other, this arrangement
(a) (b)
Figure 3.3 (a) A small writing tableau attached to the cage makes it easy to keep the patient’s flow sheet current. The tableau can be
folded away when not in use to increase space for maneuvering carts and equipment. (b) An alcohol dispenser is placed conveniently
alongside some tableaus so staff can disinfect hands and forearms between patients.
often makes the whole situation chaotic and difficult to cage with those of a fume cabinet. Three or all sides of the
oversee. Additionally, banks of cages such as these make cages are made of glass windows or bars that give ideal
procedures that require two or more staff members diffi- visualization of the patient. These cages can be opened
cult (or impossible) to perform with the animal in the cage. from two sides, which makes it possible for two or more
Adding equipment and lines to the front of the cage, this people to handle the patient at the same time. Equipment
setup makes patient care challenging. and lines can easily be organized around the cage. Of
Ideally, oxygen cages control not only the oxygen con- course, such a cage takes up more space, but it is ideal for
centration in the closed environment of the cage, but also dealing with ICU patients that need elaborate intensive
temperature, humidity, and carbon dioxide levels. Many care. These cages are primarily intended for smaller
ICUs are fitted with one or two oxygen cages, as they are patients because of their size and patients often need to be
an easy way to administer oxygen with minimal patient lifted into and out of the cage.
stress. Some ICUs have made the oxygen cage their stand- The “playpen” type cage is an excellent alternative for
ard cage, mainly because they are convenient. The oxygen large dogs (Figure 3.4d). Its bottom is conveniently lifted
cage makes it difficult to have frequent, direct physical about 40 cm from the floor: easy for the patient to step into
contact with the patient without sacrificing oxygen sup- and raised enough to contribute to hygiene. The whole
plementation. Furthermore, current oxygen cage designs construction is made of stainless steel, and the doors and
sometimes fail to maintain the environment at preset val- bottom can easily be taken out for proper cleaning and dis-
ues. Although the smooth inner surface of many designs infection. The bottom is lined with a watertight cushion.
makes cleaning of the cage easy, the disinfection of the The playpen height is more comfortable for staff than a
cages’ internal temperature and humidity control, and floor-level run. Equipment and lines can be easily organ-
carbon dioxide extraction systems can be cumbersome. ized around the cage.
Some oxygen cage designs provide more space for the
patient and service openings on the cage’s side; such “Mechanical ventilation” Station
designs make visual contact with and approach to the An ICU that has the resources to perform long-term
patient easier than with stacked cages. Auditory contact is mechanical ventilation should have one to three stations
often hampered by the closed environment and the noise specifically designated for this task (Figure 3.5). Rather
of the air conditioning. than being restrained by a cage, patients are immobilized
Wall-mounted or free-standing singular cages are by anesthesia or neuromuscular disease. Ventilated
designed such that the bottom of the cage is at table height patients need intensive care with frequent contact with
(Figure 3.4c). The design as shown in Figure 3.4c origi- caregivers and connection to many monitoring devices and
nates from combining the characteristics of a metabolic other equipment such as infusion pumps. An open area
The Ground Plan 29
(a) (b)
(c1) (c2)
(d1) (d2)
Figure 3.4 Different cage designs that are used currently in companion animal ICUs. (a) Kennel/run (Cummings School of Veterinary
Medicine at Tufts University); (b) stacked cages (Cummings School of Veterinary Medicine at Tufts University); (c1, c2) wall-mounted
singular type; (d1, d2) “playpen” type.
area is organized around one or two procedure tables. A

hydraulic tilt-top table offers advantages for some medi-
cal interventions. A wet table enables patient bathing
and wound care; however, close attention to hygiene is
imperative when considering such a construction in
the ICU.
High-intensity lights should be mounted above every
table. The table should be easily accessible by multiple staff
from different directions. On one or two sides, the proce-
dural table can be surrounded by countertops on which to
arrange and prepare disposables and equipment. A hands-
free handwashing station should be available in this area.
Positioning of rails or shelves for support of monitoring
equipment above the countertop permits easy access and
viewing. Light switches, electrical power, oxygen, com-
Figure 3.5 Mechanical ventilation station. pressed air, vacuum, and gas evacuation outlets must be
easy to access. They can be mounted on the wall above the
with a table for the patient in the center serves these needs counters. The number and location of the power sockets
best. The ventilator and most supporting equipment can be depend on the number of electrical appliances present on
arranged at the head of the table. the shelves or counter. A free-standing, ceiling-, or floor-
It is ideal to be able to change the height and tilt of the mounted utility column directly adjacent to the procedural
patient table. Patients that are immobile over a long period table improves access and flexibility; the column can also
need special attention to prevent pressure lesions. The contain controls for the lighting. The use of mobile devices
table surface should be padded and large enough for the such as poles, carts, and trolleys should be limited, as they
patient to lie comfortably without its legs extending beyond often hinder patient and staff mobility. However, there
the edge of the tabletop. For most hydraulic tables this should be room to place the crash cart, mechanical ventila-
means the top must be extended beyond the standard size. tor equipment, or other larger equipment that may be
required near the procedural table(s). Some storage facili-
Procedure Area ties such as cupboards, drawers, refrigerator, freezer, and
A procedure area is often included in the patient area incubator for fluids can be positioned under the counters
because many minor interventions such as catheter or above them. As the treatment area is often centrally
placement and wound management are performed in located in the patient area and used for cardiopulmonary
the ICU (Figure 3.6), and a different room would sepa- resuscitation (CPR) efforts, this is a suitable place to park a
rate staff from the patients for too long. The treatment fully equipped crash cart.
(a) (b)
Figure 3.6 (a) The procedure area contains all the necessary equipment to perform small surgical interventions. (b) When the ceiling
is not available for a service unit, a mobile arm mounted on the adjacent wall can bring all necessary wires and tubes to the table,
which prevents people from tripping over them.
The Ground Plan 31
Isolation Ward patient area. As this room is to isolate patients, only a lim-
The isolation ward is ideally maintained as a separate facil- ited number of cages (two to four) are necessary. Very
ity near to the ICU. The entrance to the isolation ward rarely do pets have to be isolated as a group and probably
should consist of a separation corridor (Figure 3.7a). This not many facilities can provide for that in a cost-effective
area should make it possible to prepare to enter the ward manner. Any disposables or contaminated equipment
with appropriate protection, and to leave it with minimal should leave the isolation area in sealed containers for fur-
risk of breaching isolation. The corridor should be divided ther processing.
into two separate areas, potentially separated with a Ventilation systems for isolation rooms should be inde-
shower. The corridor should enable the change from regu- pendent of other systems in the hospital with 100% exhaust
lar hospital clothing to personal protective equipment to the outdoors. Ideally, the system should have the capac-
(PPE)/barrier nursing attire (e.g. gowning, hair cap, foot- ity to create negative or positive air pressure (relative to the
wear, and gloves), and should include a hands-free hand- open area). If the room is designed to control airborne
washing station. When a completely separate facility is not infections, all walls, ceilings, and floors, including doors
feasible, a closed room adjacent to the ICU with a large and windows, should be sealed tightly.
glass window for easy observation of patients can be effec- Separate isolation facilities should have electronic means
tive. Sometimes the only practical and cost-effective alter- of communication. Remote patient monitoring capability
native is to isolate patients in part of the main ICU patient via cameras and microphones with a central viewing loca-
area; however, this puts the general ICU population at tion in the ICU is necessary (Figure 3.1b).
higher risk. Besides dedicated personnel, design considera-
tions such as temporary physical barriers should be Outside Runs
considered. ICU patients often have limited mobility. However, for a
The isolation ward should be designed to function inde- successful recovery the incentive of a small outside area
pendently as much as possible without needing to intro- close to the ICU can be important. The use of patches of
duce disposables or equipment (Figure 3.7b). Ideally, the (artificial if natural is not available) grass invites patients to
isolation area is a smaller version of the main patient area relieve themselves more easily, but hygiene is more diffi-
with storage facilities, refrigerator, a procedure area, and cult to maintain compared with a concrete surface. As
(b)
(a)
Figure 3.7 (a) The isolation ward can be accessed via a separation corridor, which enables staff to change clothing and wash and
disinfect hands. (b) As much as possible, the isolation ward should function as a stand-alone space. A small treatment area is thus part
of the isolation ward.
there is constant risk of cross-contamination, this outdoor permit visualization of patients and ICU activities while
area is dedicated to ICU patients alone and not shared with preparing medications if this area is enclosed.
other hospitalized animals, and (as much as possible) these
areas should be cleaned and disinfected after every Medical Equipment Storage
patient visit. Unused drip stands, trolleys, gurneys, pediatric incubators,
portable suctioning devices, ultrasound machine, mechani-
cal ventilator, and so on cannot stand in the patient area, as
Ancillary Rooms
they contribute to a cluttered, disorganized appearance of
Laboratory Facilities the ICU. This equipment is best stored in a separate room
The ICU should have easy access to a laboratory facility with easy access for retrieval (Figure 3.8). Appropriate,
which supplies emergency-directed 24-hour clinical labo- grounded electrical outlets should be provided within the
ratory services. When such services cannot be provided by storage area in sufficient numbers to permit recharging of
the central hospital laboratory, a satellite laboratory within battery-operated items. Lockable storage should be pro-
the ICU must serve this function. It is advantageous to vided for small but valuable items and fiberoptic equipment.
have the laboratory facility close to the patient area so that
technicians are never far away in case of an emergency in Consumable Supply Storage
the ICU. Any ICU depends heavily on a multitude of disposables
At a minimum, it is ideal to have 24-hour capability to and recyclable equipment, like sterile minor surgery pack-
measure packed cell volume, total protein, albumin, elec- ages. Depending on the size of the practice or hospital, a
trolytes, glucose, blood urea nitrogen, creatinine, coagula- three–stage storage management system may be desirable.
tion parameters, blood gas and lactate, urine specific The central supply of the hospital/clinic constitutes the
gravity, and to have a microscope to evaluate blood smears first storage area. The second storage area consists of a
and cytology [10]. The laboratory bench should offer utility room adjacent to the ICU. Storage can be organized
enough space and be equipped with enough power outlets on open scaffolding, on shelves, in cupboards, and in
for all the necessary equipment. Network connections may drawers. A desk with a computer and sufficient room for
be necessary to link laboratory equipment with the hospi- administrative papers allows for convenient management
tal network and download laboratory results directly into of inventory. The third and final storage space is situated
the patient’s medical record.
Fume hoods may be advantageous or even legally
required if stains for cytological preparations are used. A
sink and water tap can sometimes be fitted with a device to
produce laboratory quality deionized water. There should
be enough room to store instruction manuals and admin-
istrative records, and to stock laboratory disposables and
reagents, in a refrigerator or freezer if necessary. Also, a
refrigerator, freezer, and heating incubator dedicated to
the temporary storage of biological specimens must be
readily available. Connections and space for a computer
terminal and a communication system may be considered.
Local regulations may demand an emergency shower or
eye wash installation and first aid box.
Pharmacy
Guided by local considerations and organization, a satellite
pharmacy can be part of the ICU. A separate room is war-
ranted if the ICU is serviced by its own pharmacy. The air-
conditioned pharmacy should have room for storage of
medications including a lockable cabinet for controlled
substances, a refrigerator for pharmaceuticals, storage for Figure 3.8 A separate room for storage of medical equipment
intravenous (IV) fluids, and a refrigerator and a freezer for helps to keep the patient area organized and uncluttered. The
walls of the room can be fitted with shelves, rails and power
the storage for blood products. A small counter with stor-
sockets. Part of the wall should be kept clear to accommodate
age cabinets, drawers, a sink, and water tap must be pro- free-standing items. Shelving should be shallow for easy
vided to prepare medications. A glassed wall can be used to location of desired equipment.
Interior Design 33
in the patient area itself for items frequently used. Attempts Interior Design
to stock everything in the ICU itself causes overcrowding,
as needs always grow over time. Environment
Soiled Bedding and Waste Disposal Storage Lighting

There should be a dedicated area for storing soiled bed- Ambient lighting should be available throughout the ICU,
ding, waste materials, and material for recycling until col- and especially around the cages and in the treatment areas.
lection. This material should not be kept in the main ICU Disruptions in circadian rhythm may have a negative
patient care area. The size and nature of this space will impact on critical illness [11, 12]. It therefore seems pru-
depend on the arrangements for collection. If the practice dent to have adjustable lighting in the patient area, from
or hospital has a central facility, this can also be used. both natural and electrical sources. The lights should dim
without flicker. If windows or skylights are present, shad-
ing devices should be in place and easily controlled and
Facilities Outside the ICU Complex
cleaned. It may also benefit the unit to have tinted glass
What should be part of the ICU complex and what should panes in the exterior windows. During the night, the main
be supplied in the rest of the hospital or clinic is somewhat lights in the facility should be dimmed or turned off
arbitrary. In addition to the numerous previously men- completely.
tioned requirements, other functions and rooms that must The patient modules and treatment areas should have
be considered are a kitchen for preparation of patient food, spotlighting that can be controlled independently to pre-
a staff room for any onsite overnight watch, a medical vent increased lighting for other patients, especially during
office including a library, individual office space, a storage periods of rest or at night (Figure 3.9). Mobile spotlighting
area for patient records, a receptionist’s office and area, a and lighting at low level under the cages or tables to illumi-
waiting area, an owner visiting room, a patient groom nate drains and underwater seals (i.e. for thoracostomy
room, and a linen room. Furthermore, ICU staff require drainage systems) may be added. Treatment areas should
ready access to facilities for changing with showers, toilets, have separate procedure lighting with adjustable intensity,
and lockers. Both the changing room and lockers must be field size, and direction, to properly evaluate patients or
individually lockable. perform procedures. Independent lighting of support
(b)
(a)
Figure 3.9 (a) Every patient module should have its own light. (b) Each module is lit by bright LED lights that can be dimmed
stepwise and do not emit unwanted heat.
areas, such as the handwashing stations, medication prep- night and “seasonal affective disorder” [14, 15]. The pres-
aration area, and charting areas, can be beneficial. ence of natural daylight is also considered beneficial to staff
and owners.
Heating, Ventilation and Air Conditioning
The air-conditioning system to the ICU patient area should Patient There is a growing awareness that the design of the
provide a thermoneutral temperature of 60–80°F (16–27°C) ICU environment should support the wellbeing of patients.
and a relative humidity of about 30–60%, while avoiding It needs as much attention as anything else in the design
condensation on wall and window surfaces. Control of process. Disruptions of the circadian rhythm and the
humidity and condensation can be a challenge, as regular normal routine of the patient while hospitalized may even
cleaning of cages and floors requires abundant amounts of have a negative impact on the wellbeing of patients and
water. System capacity and room air change frequencies their recovery [16]. Besides the impact of light, noise and
should take this into account. Ventilated air delivered to temperature, the impact of odors, especially in veterinary
the ICU should be filtered and the ventilation pattern patients with a different sense of smell from humans,
should inhibit particulate matter from moving freely in the should not be underestimated [17]. Design measures to
space. The air-conditioning system should be accessible limit the effect of odors should be carefully considered.
such that regular monitoring and maintenance services In the ICU, cats and dogs are still often housed in the
may easily be performed. same patient area, with higher priority given to other inten-
sive care principles than patient comfort and stress reduc-
Acoustic Design tion. However, there is growing awareness and evidence
Reduction of both incoming noise and internally generated that both patient groups, but especially cats, need a species-
noise should be considered [13]. Background noise pro- specific approach also in the hospital [5]. Although an
duced by equipment and mechanical systems such as air appropriate balance and solution has not been reached yet,
conditioning should be minimal and absorbed as much as whenever possible, cats should be housed in a separate
possible. Floor coverings that absorb sound should be used, area to reduce visual, auditory but also odor stressors pro-
keeping the need for infection control, maintenance, and duced by dogs (see Recommended Reading).
movement of equipment under consideration. Walls and
ceilings should be constructed of materials with high Owner Owners are becoming more aware of their pet’s
sound absorption capabilities. Especially in smaller rooms medical status and want transparency in regard to it. It
such as the isolation ward, special attention should be paid enables them to cope with the anxiety caused by the
to unacceptable noise levels as a result of barking. hospitalization of their companion and enables them to
make informed decisions about their pet’s care. However,
Ambience visiting opportunities often need to be restricted with
Staff Everybody remembers the classic gloomy, white limited staffing and time. Video streaming of patient
appearance of hospitals. However, when patients are images over the Internet could be an additional means to
monitored, treated, and cared for around the clock, special address the need of the owner to be more involved and stay
attention should be paid to alleviate this strenuous working connected to their pet while hospitalized [18]. Images can
environment and aid wellness. The ambient atmosphere be produced by webcams that are directed at the ICU cage
can have an enormous and positive effect on potentially and are linked to the internet. Via a dedicated website,
stressed staff, owners, and sick animals away from their owners have access with the use of a password protected
familiar homes. Words like soothing, relaxed, bright, calm, logon. They can view the video images produced by the
organized, pleasant, and familiar should apply. Not only webcam if it has been turned on by the staff.
visual but also auditory input, such as from audio
equipment, helps to create this pleasant environment for
Utilities
both staff and patients. White or gray should not be the
dominating color in the ICU. Natural daylight with an Electrical Power, Network, and Communication Cables
outside view is essential for both patients and staff. Visual Electrical power, network, and communication cables
distractions such as pictures and other features such as should be routed via easily accessible conduits that are
plants should not be reserved for the owner visiting room wall-mounted or located above the ceiling to make addi-
but should be strategically placed throughout the ICU to tional cabling relatively simple. The power supply must be
enhance a positive atmosphere. single-phase with a single common safety ground. Supply
Consideration should be given to provide a space easily lines must not cause interference with monitoring or com-
accessible to all staff that will provide an opportunity puter equipment. Standard multiplex electrical outlets may
for exposure to higher-intensity light levels for at least not be suitable, since some outlets may not be accessible
15 minutes per shift to ameliorate the effects of working at when oversized equipment plugs are in use.
Interior Design 35
It is critical that the ICU staff have immediate access to The walls should be easy to clean, noise-reducing, and
the main electrical panel if power must be interrupted or durable with extra protection provided at points where
restored in case of an electrical emergency. A set of lights contact with movable equipment is likely to occur. Some
in the ICU and several power outlets supported by a backup walls may need to be reinforced if wall-mounted cages,
generator should be available in case of a power outage. rails, or shelves are used.
Ceilings should also be easy to clean, noise-absorbing,
Water Supply and Plumbing and invulnerable to dust accumulation, both on the ceiling
Sinks with hot and cold running water supplies must be itself and on ceiling-mounted light fixtures. The ceiling
located throughout the ICU. Depending on local regulations, structure in the patient module or procedure area should
heating boilers that reduce the risk of bacterial growth in the be strong enough to carry the weight of any suspended
plumbing system must be installed directly adjacent to each equipment.
water supply. Sinks, water taps, and their direct surroundings
are notorious for harboring bacteria that can cause nosoco-
Furnishings
mial infections. It is thus important to have separate stations
for handwashing (see the section on personal hygiene), In the patient area the use of cabinets with doors and draw-
cleaning of equipment, and disposal of (contaminated) bod- ers is preferred over shelves, as closed cabinets contribute
ily fluids. The installation of showerheads can help with to a visually uncomplicated environment. Designs specific
cleaning both equipment and the sink itself. The sinks should for use in medical facilities are ideal, as they have standard-
be large and deep enough to ensure that the direct surround- ized sizes and take into account unique requirements of
ings are not easily soiled. Screen barriers around the sink can the medical field.
help to prevent contamination of the direct surrounding Chairs and free-standing furnishings such as cabinets
(Figure 3.12b). Separate water fountains for drinking should and carts in the patient area and ancillary rooms should be
be supplied. easily cleanable with minimal seams (Figure 3.10).
Countertops, in particular, should have few or no seams.
Gas Supply Furnishings should be of durable construction.
The ICU patient areas should be fitted with connections for
central oxygen, compressed air, and vacuum. Gas scavenge Disposal of Waste
systems should be implemented at the design stage if seda- Separate receptacles for biohazardous and non-
tion with use of nitrous oxide or volatile anesthetic gases in biohazardous waste, according to local regulation, should
the ICU is planned. be available throughout the ICU (Figure 3.11; see
Service of the systems can be made easier by leading the
pipes through wall- or ceiling-mounted, water-resistant
conduits. The choice of service location (e.g. wall, stalac-
tite, stalagmite) will have a major impact on the service
arrangements and on operational use. The outlets must
consist of keyed plugs to prevent accidental interchanging.
For detailed requirements for pressures and flows, human
guidelines can be applied with specific local guidelines
taken into account (see Recommended Reading).
Floors, Walls, and Ceilings

There are many things to consider regarding the surfaces in
the patient area. Floor surfaces should be easy to clean and
should minimize the growth of microorganisms. They
should be highly durable and dense to withstand frequent
cleaning and heavy traffic. They should keep their new
appearance and glossiness, have acceptable acoustical prop-
erties, and give enough grip for staff and patients to walk
upon safely, even when wet. In addition, the floors should be
aesthetically pleasing to the eye. To choose an appropriate
floor for the patient areas is certainly a challenge. It helps in
Figure 3.10 Furniture that is used in the patient area and
the design phase to pay special attention to floors when visit- ancillary rooms should be easily cleanable, with the fewest
ing other facilities, with a focus on durability. possible seams.
Chapters 62 and 65 for more details). Sharps disposal con-

tainers should be present on or near every counter to facili-
tate quick and easy disposal.
Medical Equipment
A comprehensive list of required equipment is beyond the
scope of this chapter; Table 3.2 gives an abbreviated out-
line of ICU equipment possibilities. Many pieces of equip-
ment are discussed throughout this book, so the discussion
here has been limited to a general overview with some spe-
cific ICU-related considerations.
Laboratory Equipment
Equipment in an ICU laboratory must provide results
Figure 3.11 Separate disposal bins should be available for quickly. Furthermore, as nonspecialized personnel often
biohazardous and non-biohazardous waste throughout the ICU
according to local legislation. The use of a foot control limits the
need to make use of these machines, they should also be
contact of hands with the waste bin. easy to use, maintain, and calibrate.
Table 3.2 General overview of location and type of equipment in the intensive care unit.
General use Location Type Apparatus/function
Diagnostic/monitoring Laboratory Sample preparation Blood tube centrifuge

and storage Microtube centrifuge
Cytospin centrifuge
Freezer
Refrigerator
Heating incubator
Ice-making machine
Measurement Microscope
Hematology
Coagulation
Biochemistry
Blood gas machine
Patient module and Monitoring Electrocardiograph
procedure area Ultrasound machine
Blood pressure monitors (invasive and
non-invasive)
Pulse oximeter
Capnograph
Continuous body thermometers
Scale
Etc.
Therapeutic Patient module/medical Continuous infusion Syringe pump
equipment storage Volume fluid pump
Mechanical ventilation Mechanical ventilator
Humidifier
(oxygen/air blender)
Interior Design 37
Table 3.2 (Continued)
General use Location Type Apparatus/function
Renal replacement Hemodialysis

therapy Continuous renal replacement therapy
Plasmapheresis
Other Mobile suction unit
Procedure area Cardiopulmonary Crash cart
resuscitation Defibrillator
Other Patient area Patient care Central supply cart
ICU Temperature control Refrigerator
Freezer
Disposal Non-biohazardous waste receptacle
Biohazardous waste receptacle
Sharp safe
Procedure area Heating incubator
Soiled utility/holding room Disposal Receptacle for soiled fleeces and
blankets
Receptacle for surgical instruments
Monitoring Equipment Crash Cart

While in human ICUs the bedside monitoring setup is In settings such as the emergency room and ICU where
complete and committed to one bed only, this is seldom cardiopulmonary arrest has to be anticipated, it is impor-
financially feasible in veterinary medicine. To make more tant to have a complete set of equipment and supplies for
economic use of the expensive equipment, extensive mon- CPR available and ready for use at all times. As an arrest
itoring is either limited to those cages that are intended for can occur anywhere in the ICU, a mobile cart or trolley is
the most critically ill patients; monitoring devices are posi- preferred over a fixed CPR station [19]. However, the arrest
tioned in such a way they can service multiple cages; or cart should be placed in a designated, clearly indicated area
the equipment is mobile and can be moved between to retrieve it without delay in case of an emergency.
patient modules as necessary. In some situations, every
cage can be set up with monitoring modules that deliver a Advanced Supportive Therapies
basic set of monitoring parameters (Table 3.2). The setup Patients receiving mechanical ventilation, renal replace-
chosen is based on the design of the ICU, the type of ment therapy and plasmapheresis constitute the “high
patients admitted to the ICU, staff preferences, and finan- end” of patient care in the companion animal ICU. A
cial constraints. The introduction of a modular setup for mechanical ventilator for the ICU should have an easy-to-
multiparameter monitoring devices is a very attractive use interface, give a wide array of options for different
development. ventilation settings, and should be able to ventilate a wide
Of special interest are telemetry monitors, which offer range of patient sizes. Mechanical ventilators designed
several advantages. Telemetry is mostly used for electrocar- for use in anesthesia generally do not suffice. Equipment
diography, but larger setups can be used for multiple that specifically monitors respiratory parameters related
parameters. When used for one or two parameters, the to tidal volume, gas flow, and airway pressures should be
transmitter device is often small enough to tape to the part of the ventilation unit. The ventilator should be
patient. This allows freer movement and minimizes the equipped with a humidifier and heating unit, as a heat
patient getting caught in wires and leads. Also, all collected and moisture exchanger device does not work in all
data can be sent to a central monitor in the technicians’ patients. Though they are built into modern critical care
station, which supports continuous monitoring of the ventilators, some older units may need an ancillary oxy-
parameter(s). gen and air blender.
The options for renal replacement therapy in veterinary place are becoming a major focus. The spread of patho-
medicine are increasing. For more information the reader gens can occur by direct and indirect contact with peo-
is referred to the literature [20]. ple, other patients, equipment, and the environment.
The risk of infection may be relevant not only to patients
Central Supply Cart but also to the caretakers, as some of these microbes
Although the patient area may have enough room to stock have the potential to be zoonotic. The focus here is on
all necessities for direct patient care, it is often convenient the measures that can be taken from the point of design
to have one or two central supply carts that contain the to prevent the establishment and dissemination of infec-
commonly used equipment and disposables (Figure 3.10). tions in the ICU.
A limited range of frequently used drugs such as potassium Infection and prevention control measures dominate
chloride, sterile water, or sodium chloride 0.9% to use as the ICU design in human medicine [4, 9, 22] (see also
diluent for patients’ medications or flushing fluid lines, eye Recommended Reading). The concept for the necessity
lubrication, and xylocaine jelly can be stocked in this cart. of implementing effective measures that may limit the
The cart can be moved to anywhere in the patient area as number of nosocomial, and particularly multi-resistant,
needed. If the top of the cart is kept free, it offers an extra infections into veterinary hospital policies appears to lag
area to place, prepare, and organize equipment and dispos- behind [23]. Therefore, the next challenge will be to
ables prior to an intervention. implement the increasing knowledge and information
on IPC into the design process, as design aspects can sig-
nificantly affect discipline and behavior of staff. For
example, the absence of proper facilities can frustrate
Special Design Considerations and inhibit the intention to follow hand hygiene
protocols.
The discussion so far has addressed the physical compo-
However, adjustments in the ICU design will not be
nents (“hardware”) of the companion animal
effective by itself as an abundance of sinks will not neces-
ICU. However, the organization or “software” is also an
sarily ensure that handwashing behavior improves. The
essential aspect of ICU design [21]. Intensive care includes
lack of compliancy of personnel in the ICU is a great con-
many different staff, and intensive care medicine requires
cern and a challenge for anyone who is responsible for
and can only be successful with a team approach. The
developing hygiene measures in the ICU [24]. The estab-
team consists of different groups such as managers, veteri-
lishment of an IPC team can be very beneficial, not only to
narians, technicians, and animal care assistants, and
prepare policies and to initiate interventions to reduce the
cleaning staff. Staffing of the ICU regarding number, qual-
spread of pathogens but, more importantly, to educate and
ifications, individual job descriptions, and appropriate
continually encourage staff to follow these policies in their
training is the cornerstone of the ICU organization and
daily duties [25]. Packages of measures known as “care
the service it can provide its patients and clients. As in any
bundles” have been demonstrated to be an effective pre-
larger organization, cooperation and effective communi-
ventive method [4].
cation between the different groups determines the qual-
ity of the care provided and ultimately patient outcome. In
Personal Hygiene
recent years, several directives have been published by
Staff and visitors should be made aware that they may act
critical care organizations in human medicine to define
as a reservoir for nosocomial microbes and should under-
optimal staffing and operational requirements [4, 9, 22].
stand their roles in the possible introduction of these
Such directives have identified IPC and written communi-
pathogens to the ICU. They can also play a role in the
cations as important management aspects that contribute
spread of nosocomial infections within the ICU. The first
to the performance of a facility.
measure to reduce the introduction and spread of nosoco-
mial infections is to reduce any unnecessary contact. It is
important to reduce unnecessary traffic in and out of the
Infection Prevention and Control
ICU, but also between patients. Moving from one patient
The frequency and impact of hospital-acquired or noso- to another should trigger hand hygiene measures and a
comial infections and infections by multidrug-resistant change in barrier equipment (gloves, gown/apron etc.).
pathogens in veterinary ICUs is a growing concern. The team members’ personal equipment, such as ther-
Improvement and refinement of our antimicrobial strat- mometers and stethoscopes, should be cleaned and disin-
egies no longer suffice, and additional measures that fected between patients. Thermometers could have a
prevent these infections from developing in the first thermometer cover applied and changed between
Special Design Considerations 39
patients. Also, visitors should be made aware of their role animal and before touching pens, keyboards, and so
in spreading infections using posters and informational on [25, 28].
brochures. The ICU team should indicate and demon- Barrier nursing attires such as examination gloves and
strate to owners what, how and when to wear the required gowns are most effective in the event of contact with
PPE/barrier nursing attire to handle their pet within soiled materials and during the disposal of bodily fluids.
the ICU. Face and eye protection should be worn if aerosols are
There is an essential awareness that nosocomial infec- likely to be generated [25, 28]. The primary role of barrier
tions originate and are spread primarily by those parts of nursing attire is personal protection and to reduce con-
the body that make the most contact with the patient: the tact and soiling of one’s own hands and clothes. A con-
lower arms and hands of personnel. Extensive instruc- venient and easily accessible stock of protective barrier
tions have been described for proper hand and lower-arm materials and bin to dispose of them in the patient area
sanitation [24, 26, 27]. The ICU should be designed to supports staff to use, and more importantly, regularly
facilitate any attempt to maintain a high level of hygiene. exchange them.
Handwashing and disinfection facilities should be strate-
gically placed outside the entrance and within the ICU Patient-Related Considerations
(Figure 3.12). The stations should be used only for hand- Infected or colonized animals may act as reservoirs for fur-
washing and not to clean dishes or other equipment or to ther transmission to humans or other patients; this is an
dispose of organic materials such as bodily fluids. The important reason to limit interpatient contact and respect a
stations should have hot and cold running water that can certain distance between cages, which also can facilitate
be turned on and off by hands-free controls, and the the addition of temporary barriers. In the presence of a
basins should be large enough for surgical handwashing. known multidrug-resistant microbial infection or an
To dry one’s hands, disposable towels or hot air dryers extremely immunocompromised animal, pre-emptive iso-
can be used. An antimicrobial hand-rub (often alcohol- lation measures may be warranted and should be available
based) dispenser should be present at every handwash- within the facility.
ing facility. The setup should be complemented with But the main focus should be the awareness that an infec-
clear instructions on when and how to wash and disin- tion with all its detrimental consequences can only develop
fect hands and lower arms correctly. Additional antimi- after contamination. The risks of contamination and the
crobial hand-rub dispensers should be present at strategic way to reduce them are well known in relation to intravascu-
points throughout the ICU (Figure 3.3b). The dispensers lar catheters, urologic catheters, and mechanical ventila-
are a visual cue for cleanliness and when used appropri- tion [27, 29]. Every ICU should have protocols that address
ately, can be quickly used before and after handling an the proper application and standard care of these devices or
(a) (b)
Figure 3.12 (a) Initial handwashing station in pharmacy (b) Adjustment of station with the introduction of glass partitions
preventing water spillage from the handwashing station on the counter on which medications are prepared. The adjustment was
instigated by a Serratia marcescens epidemic in a Dutch human ICU caused by a contamination of infusion fluids as a consequence of
similar circumstances as shown in (a).
procedures, with emphasis on the prevention of contamina- While much can be done within the ICU itself, multidrug-
tion. Protocols may recommend the location where the resistant infections in the ICU often reflect difficulties else-
intervention should take place (cage, ICU treatment area, where in the hospital and in veterinary health service
surgical theater); the surgical preparation of the procedure generally, in terms of the control and prevention of
site, hand hygiene and the use of PPE/barrier nursing attire; healthcare-associated infection [30].
the use of sterile equipment and single-use disposable equip-
ment; and the proper disposal of contaminated material. Written Communications
Environmental Considerations Patient Record Keeping

Proper cleaning with removal of all (biological) dirt must Proper record keeping is an important part of patient man-
precede disinfection efforts, as many disinfectants are agement and serves a specific purpose. Primarily, it
inactivated prematurely if in contact with biological ensures and improves communication among ICU per-
material. It is important to screen the cleaning protocols sonnel regarding the patient. But it is also important for
and address the effectiveness of the disinfectants to eradi- retrospective evaluation of the care given to the patient,
cate pathogens. In this respect, surfaces that are in regu- both for internal quality control, research, and external
lar contact with personnel and patients are important to scrutiny.
address. These surfaces can be difficult to clean, such as
computer keyboards, monitoring equipment, infusion Medical Record The medical record (Chapter 5) is mainly
pumps, telephones, doorknobs, patient cages, and the kept by the veterinary staff and is often held in digital form.
handles of cabinets and drawers. During the design pro- The record describes the complete period of the patient’s
cess the choice of materials should receive explicit con- hospitalization until discharge. From any period of
sideration in this respect, for example, by the introduction hospitalization or visit the record should contain at least
of fully submersible keyboards that can easily be cleaned information on the patient’s signalment, history, physical
and disinfected. examination, problem list, rule-outs, additional diagnostic
The main contact area for a patient is its cage. Cages and and therapeutic plans and interventions, and progress
their bedding should be cleaned regularly, at least once a notes, including (presumptive) diagnosis, treatment, and
day and immediately after soiling. Disinfection should be prognosis [31].
performed after discharge or whenever sensible, such as
during a long patient stay. All these measures have proven Daily ICU Orders It is the responsibility of the overseeing
less effective if not combined with adequate numbers of veterinarian (closed ICU) or the case clinician (open ICU)
staff and suitable space and facilities [30]. to write the orders that describe diagnostic, therapeutic,
Decontamination measures are not the only strategy that monitoring, and nursing care instructions for the next
may be applied. The movement of people and patients 24 hours for each patient (Figure 3.13). These orders can
makes long-lasting decontamination of the floor an impos- be written directly in the patient treatment or “flow” sheet,
sible task. Therefore, the floor should always be considered but given the complexity of ICU patient orders and the
“contaminated,” and any contact with it should be followed frequency with which critically ill patients’ orders change
by stringent cleaning and disinfection of anything that has in a day, a separate order sheet is more useful. It is the task
been in contact with the floor. This strategy relates to per- of the technician to be able to read, interpret, and evaluate
sons, patients, equipment, disposables, and other materials. the orders, and to clarify with the clinician what is not
If it is not possible to clean and disinfect, the object (such as understood.
a blanket or a syringe that is accidently dropped) that has A dedicated sheet with patient-specific information
been in contact with the floor should be discarded. The floor related to the event of CPR, such as owner’s resuscitation
should not be considered a convenient “table”, and nothing wishes, drug dosages, and owner and primary veterinarian
should be stored on it without additional precautions. contact information, may be part of the daily ICU orders.
Routine Culturing of Patients and the Environment Flow Sheet The essence of critical care is continuous
An infection control team or infection control experts patient monitoring, which is beneficial only if the data is
should be consulted to advise on the use and sense of sam- collected and recorded in a useful manner. A patient flow
pling. Routine culturing may have some merit to establish or hospitalization sheet is the traditional method for
potential risk sites in the ICU. Results should be used to recording all information relevant to an ICU patient for a
change surfaces or equipment, and guide and improve 24-hour period. Maintaining the flow sheet is primarily the
cleaning and disinfection procedures. responsibility of the nursing staff caring for the patient
Figure 3.13 Daily order sheet with written instructions for the patient’s care.
(Figure 3.14a). The flow sheet is used to document the Every protocol or SOP should contain the following
results of “bedside” diagnostic, therapeutic, monitoring, information: title, classification or subject group, names of
and the associated nursing care instructions, and to author(s), date of compilation, names of author(s) who
document that the orders have been carried out with the made changes, dates of amendments, date of review, and
associated time of completion [32]. Flow sheets are helpful the persons to whom the protocol or SOP is of interest. For
in registering subtle trends, and as such, their design administrative purposes it may be helpful to introduce a
should include tables and graphs (Figure 3.14b). The flow coding system.
sheet can contain both subjective and objective assessments. Protocols and SOPs are often written by different people,
However, subjective assessments and observations are best with the ICU staff often performing the initial writing. It is
communicated verbally with the attending veterinarian a challenge to keep them as effective as possible by keeping
and others involved in the patient’s care and then recorded them concise, informative, and complete without becom-
on the record. ing too elaborate. Proper referencing can help the inter-
ested reader to find more background information if
Protocols necessary. The ICU protocol and SOP book is constantly
In a complicated environment such as an ICU, having con- under construction and never finished as a result of rigor-
sistent protocols and standard operating procedures (SOP) ous scrutiny and improvements, adaptation to the latest
to describe best practices and techniques is essential. The information, and adjustments to changes in the ICU organ-
development of such protocols should include the close ization. Books published in recent years can be very helpful
cooperation between all hospital groups, both within and in setting up an ICU procedure book [33]. Many protocols
outside the ICU, that are involved in patient care or the and SOPs are available throughout this textbook to serve as
organization of the ICU. Protocols and SOPs are necessary a starting point.
for several reasons:
● To improve, support, and reduce unnecessary repetition Bulletin Boards
of oral communications and instructions among There is always a need for brief communications among
the team. the staff. Bulletin boards are most often used to communi-
● To standardize patient care, organization, hygiene, and cate in this fashion and have the additional advantage of
other strategies among team members. being available to everyone with one quick glance.
● To disseminate the best available knowledge so that it A strategically placed patient board (Figure 3.15) con-
may be implemented if appropriate (evidence-based vet- tains the numbers of the patient modules, the patients’
erinary medicine). Protocols should contain references names that occupy them, their problems and/or diagnosis,
when available. their location if not in its cage, their therapies, the current
● To record and describe in clear detail any actions that plans, and the name of the staff member who bears pri-
need to follow legal instructions or legislation; for exam- mary responsibility. Additional patient identification num-
ple, the use of controlled substances in the ICU. bers and a telephone number or other contact information
● To scrutinize, audit and review the strategies that are of owner and staff can be helpful. This is of benefit during
described within the protocols. busy times to keep overview of all patient-related activities.
Figure 3.14 (a) At the ICU at the Department of Clinical Sciences

of the Utrecht University, the flow sheet consists of a folder with
divider sheets for different aspects such as patient particulars,
problem list, monitoring, fluid therapy, and medications. (b1, b2)
Tables and graphs are important means to present the collected
information in an orderly fashion that facilitates the interpretation
of data.
(a)
(b1)
Figure 3.14 (Continued)
(b2)
so that the information is kept relevant to the time and day.

It is especially helpful in maintaining communication
among staff on different shifts. With the use of different
bulletin boards, different groups or topics within the ICU
organization can be targeted on each board.
Safety and Security Measures

Depending on the hospital situation, it may be necessary to
have areas of the ICU that can lock from the inside to
secure the safety of personnel and patients, particularly
after regular office hours. Areas or storage units that con-
tain valuable equipment should be locked. However, ICU
staff should have use of all essential equipment and areas;
therefore, a key cabinet available to all personnel can be
Figure 3.15 A strategically placed patient board containing
accurate, current information gives anyone who requires it a located centrally in the ICU to allow such access.
quick and complete overview of ICU patient status. The safety of patients, personnel, and visitors can be
related to fire hazards, other hazards caused by failure or
When kept up to date bulletin boards can be used to facil- malfunction of services or equipment, and chemical or bio-
itate quick and important communication among ICU hazards. Local fire safety regulations determine certain
staff or between ICU staff and other hospital staff, such as aspects of ICU design, and the consultation of fire safety
the pharmacy or those responsible for ordering and stock- officials should be part of the design process. At least two
ing. The transferred information needs to be kept current independent escape routes should be available, both
References 45
accessible for personnel, mobile patients, and those on gur- within an ICU should be serviced by its own circuit breaker
neys. Most local regulations will require installation of a in the main panel. The electrical panel should be con-
sprinkler system. nected to an emergency power source that will quickly
Low-pressure warning systems for the gas services must resupply power in the event of power interruption. If
be visible and audible in the ICU. Shut-off valves or capacity of the backup power source is limited, special
switches for the ICU should be located adjacent to the unit attention should be paid during the design process to iden-
where their operations can be controlled by the staff. tify which operations need backup. Emergency power
The main electrical panel should preferably be located source sockets should be distinguishable, for example, by
with easy access to ICU personnel. Each outlet cluster color coding.
References
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Minimum Requirements for Certification of Veterinary pressure levels in 2 veterinary intensive care units. J. Vet.
Emergency and Critical Care Facilities (effective Intern. Med. 29 (4): 1013–1021.
1/14/2021). San Antonio, TX: VECCS; 2021. 14 Menculini, G., Verdolini, N., Murru, A. et al. (2018).
2 White, R.D., Smith, J.A., and Shepley, M.M. (2013). Depressive mood and circadian rhythms disturbances as
Committee to Establish Recommended Standards for outcomes of seasonal affective disorder treatment: a
Newborn ICU Design. Recommended standards for systematic review. J. Affect. Disord. 241: 608–626.
newborn ICU design, eighth edition. J. Perinatol. 15 Sun, Q., Jil, X., Zhou, W., and Liu, J. (2019). Sleep
33 (Suppl 1): S2–S16. problems in shift nurses: a brief review and
3 Thompson, D.R., Hamilton, D.K., Cadenhead, C.D. et al. recommendations at both individual and institutional
(2012). Guidelines for intensive care unit design. Crit. levels. J. Nurs. Manag. 27: 10–18.
Care Med. 40: 1586–1600. 16 Lefman, S.H. and Prittie, J.E. (2019). Psychogenic stress in
4 Faculty of Intensive Care Medicine and Intensive Care hospitalized veterinary patients: causation, implications,
Society (2019). Guidelines for the Provision of Intensive Care and therapies. J. Vet. Emerg. Crit. Care 29 (2): 107–120.
Services, 2e. London: Faculty of Intensive Care Medicine. 17 McGann, J.P. (2017). Poor human olfaction is a
5 Ellis, S.L., Rodan, I., and Carney, H.C. (2013). AAFP and 19th-century myth. Science 356 (6338): eaam7263.
ISFM feline environmental needs guidelines. J. Feline 18 Robben, J.H., Melsen, D.N., Almalik, O. et al. (2016).
Med. Surg. 15: 219–230. Evaluation of a virtual pet visit system with live video
6 Rechel, B., Buchan, J., and McKee, M. (2009). The impact streaming of patient images over the internet in a
of health facilities on healthcare workers’ well-being and companion animal intensive care unit in the Netherlands.
performance. Int. J. Nurs. Stud. 46 (7): 1025–1034. J. Vet. Emerg. Crit. Care 26 (3): 384–392.
7 Leaf, D.E., Homel, P., and Factor, P.H. (2010). 19 Fletcher, D.J., Boller, M., and Brainard, B.M. (2012).
Relationship between ICU design and mortality. Chest RECOVER evidence and knowledge gap analysis on
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8 Wilson, A.P. and Ridgway, G.L. (2006). Reducing Crit. Care 22 (S1): S102–S131.
hospital-acquired infection by design: the new University 20 Acierno, M.J. (2011). Continuous renal replacement
College London hospital. J. Hosp. Infect. 62 (3): 264–269. therapy in dogs and cats. Vet. Clin. North Am. Small
9 College of Intensive Care Medicine of Australia and New Anim. Pract. 41 (1): 135–146.
Zealand (2016). Minimum Standards for Intensive Care 21 Arrowood, A. and Waddell, L.S. (2022). Management of
Units. Prahran: CICM. the intensive care unit. In: Small Animal Critical Care
10 Shumacher, D. (2016). Monitoring of the critically ill or Medicine, 3e (ed. D.C. Silverstein and K. Hopper).
injured patient. In: Small Animal Emergency and Critical St Louis, MO: Elsevier (in press).
Care for Veterinary Technicians, 3e (ed. A.M. Battaglia and 22 Valentin, A., Ferdinande, P., and ESICM Working Group
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Cardiothorac. Vasc. Anesth. 19 (1): 49–60. Characteristics of biosecurity and infection control
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Control 41 (Suppl 5): S94–S96. Incidence of catheter-associated urinary tract infection
25 Stull, J.W., Bjorvik, E., Bub, J. et al. (2018). 2018 AAHA among dogs in a small animal intensive care unit. J. Am.
infection control, prevention, and biosecurity guidelines. Vet. Med. Assoc. 224: 1936–1940.
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26 Anderson, M.E.C. (2015). Contact precautions and hand and preventing methicillin – resistant Staphylococcus
hygiene in veterinary clinics. Vet. Clin. Small Anim. 45 (2): aureus (MRSA) in the intensive care unit (ICU)? Eur.
343–360. J. Clin. Microbiol. Infect. Dis. 27 (6): 409–413.
27 Boyce, J.M., Pittet, D., and Healthcare Infection Control 31 Van Sluijs, F.J. and van Nes, J.J. (2009). Medical records.
Practices Advisory Committee and HICPAC/SHEA/ In: Medical History and Physical Examinations in
APIC/IDSA Hand Hygiene Task Force (2002). Guideline Companion Animals, 2e (ed. A. Rijnberk and F.J. van
for hand hygiene in health – care settings: Sluijs), 27–39. Edinburgh, UK: Saunders Elsevier.
recommendations of the Healthcare Infection Control 32 McGee, M.L., Spencer, C.L., and Van Pelt, D.R. (2008).
Practices Advisory Committee and the HICPAC/SHEA/ Critical care nursing. In: Kirk’s Current Veterinary
APIC/IDSA Hand Hygiene Task Force. Morb. Mort. Therapy XIV (ed. J.D. Bonagura and D.C. Twedt),
Weekly Rep. 51(RR-16): 1–45. 106–110. Philadelphia, PA: Saunders.
28 Nuttall, T. (2016). Meticillin-resistant Staphylococci. 33 Matthews, K. (2017). Veterinary Emergency and Critical
Gloucester, UK: British Small Animal Veterinary Care Manual, 3e. Guelph, Ontario, Canada: Lifelearn.
Association.
Recommended Reading
The International Society of Feline Medicine has described Online educational materials, many available only to
standards for cat-friendly hospitalization facilities: SCCM members.
● Guidelines for Design and Construction of Health Care
● Cat Friendly Clinic: https://catfriendlyclinic.org/vets- Facilities (Facility Guidelines Institute): https://
nurses/hospitalisation-facilities fgiguidelines.org/guidelines/2018-fgi-guidelines
The following websites provide insight to the approach ● ESICM guidelines and recommendations (European
in human medicine to define and design intensive care Society of Intensive Care Medicine): https://www.esicm.
facilities. Although far from the reality of companion ani- org/resources/guidelines-consensus-statements
mal intensive care medicine, the information certainly ● Intensive Care Society guidelines: www.ics.ac.uk/
gives a lot to consider when designing a companion animal Society/Guidance/Guidance
ICU, and stimulates “out-of-the-box” thinking necessary to ● Faculty of Intensive Care Medicine guidelines: https://
explore design options to the maximum. www.ficm.ac.uk/standards-safety-guidelines
● College of Intensive Care Medicine of Australia and
● Learn ICU (Society of Critical Care Medicine): www.sccm. New Zealand: www.cicm.org.au/Resources/Professional-
org/LearnICU/Home Documents#Statements
47
Developing and Using Checklists in Practice

Elizabeth B. Davidow and Carmen King
“Just ticking the boxes is not the ultimate goal here. central line infections to near zero challenges the assump-
Embracing a culture of teamwork and discipline is.” tion that some complications are unavoidable. If a check-
Atul Gawande, The Checklist Manifesto [1] list could avoid central line infections, what other
complications could it avoid?
The results of these two studies spurred interest in fur-
Introduction ther uses for checklists in medicine. In 2009, the World
Health Organization’s (WHO) Safe Surgery Saves Lives
In 2005, research published in the Lancet [2] showed that program published its surgery checklist study [4]. This
providing handwashing instructions, soap and a six-point study demonstrated that the implementation of a simple
checklist of when to wash could dramatically decrease the checklist before, during and after surgery in eight hospitals
incidence of common diseases in children in Pakistan. in eight different countries decreased both complications
Households that were provided the soap, instructions and and mortality. This checklist added no cost and minimal
six-point list of when to wash had 53% less diarrhea, 50% time but on average, decreased postoperative complica-
less pneumonia, and 34% less impetigo than control house- tions by 36%.
holds. It did not matter if the soap was antibacterial or not. A similar surgery study [5] has now been done in veteri-
Many households already had soap prior to the study and nary medicine and has confirmed the human medical find-
much of the difference was attributed to the clear six-point ings. In a prospective clinical trial, 300 dogs and cats
checklist of when to wash. undergoing surgery were followed to document a baseline
A year later, Peter Pronovost published an article in the incidence of complications and mortality. A surgery check-
New England Journal of Medicine [3], which showed that list was then implemented and used with the following 220
use of a simple five-point checklist, when administered by surgeries. The research team found a statistically signifi-
nurses in 103 intensive care units across Michigan, could cant reduction in the incidence of all complications after
dramatically decrease the incidence of central line infec- the implementation of the checklist.
tions. The checklist is simple: Checklists and algorithms have now been widely adopted
in many areas of medicine. However, experience over the
1) Wash your hands.
last decade has shown that checklists are only successful in
2) Clean skin with 2% chlorhexidine.
saving lives when designed appropriately and implemented
3) All involved wear sterile gloves.
carefully.
4) No femoral insertion.
5) Ask daily about removal.
The checklist was developed by distilling pages of recom- Why Checklists?
mendations from the Centers for Disease Control and
Prevention into the five items with the most evidence and Humans have limitations in their attention span and in
the least barrier to use. This created a list short enough that their memory. Studies have shown that humans decline in
it could easily be read, checked off, and followed with every both accuracy and speed when problems have increasing
catheter placement. The finding that a checklist could drop complexity and more variables [6].
48 Developing and Using Checklists in Practice
Checklists are used in many industries to assist with these

Box 4.1 Steps in Checklist Design
limitations. They are not detailed “how to” instructions but
and Implementation
serve as precise directed reminders of crucial steps in a pro-
cess. The goal is not to teach professionals how to do their ● Decide that a checklist is needed:
job. Instead, they serve as reminders of steps that might be ○ Define need and desired outcome
forgotten, even by experienced professionals when they are ● Review the existing literature
tired or forced to multitask. They also can be used to bring ● Convene a multidisciplinary group to design:
items front of mind in situations that are less common. In – Who
addition, when designed to be read out loud as a group, they – When
promote teamwork within a work environment. Checklists – Where
can help a team agree to and provide consistent and reliable – How it fits in with other procedures
care by making sure certain tasks happen with every – Format (paper, electronic)
patient, every time. Finally, if updated regularly, they can – Content
help move new evidence into practice faster [7]. ● Rapidly test and revise prototypes to determine
initial version
● Train and implement the initial version:
Types of Checklists – Clear why and detailed how
– Anticipate concerns and answer
There are several different types of checklists that can be – Train in actual situations
used in medical settings. They can be roughly divided into – Debrief and revise if needed
three categories: do–confirm, read–do, and dynamic. ● Continually evaluate and revise
In do–confirm checklists, a set of tasks are done from ● Build accountability
memory but then a list is consulted and checked to confirm ● Celebrate successes and courageous moments
that all items have been completed. Another name for do–
confirm is static parallel. These types of checklists are use-
ful for tasks such as checking set up of an anesthetic checklists do add some time to a work process and thus
machine prior to a procedure. they need to be very targeted to the objective.
In a read–do checklist, each item is read, the task is done A review of the relevant medical literature can be helpful
and then the item is checked off. These checklists are also to determine which steps have the most evidence behind
known as static sequential. In a static sequential checklist them in helping to achieve the stated goal. In addition, a
with verification, one person reads the task while a second literature review may uncover previously developed and
verifies. This is the type of checklist used for a jugular line tested checklists that can be modified for use.
placement. In a static sequential checklist with verification Checklists will only be used if they are work site specific
and confirmation, there may be multiple people who verify and fit in a sensible manner with the flow of the day [9].
and confirm their specific tasks. This type of checklist is The most successful checklists are developed by the teams
used in surgery. that will use them, not by administrative staff. The team
Dynamic checklists are flowcharts that can be used to should involve all relevant parties. Surgery checklists are
guide through a complex process with decision points. best developed with both the veterinarians performing sur-
These checklists can be created as diagnostic and treat- gery and the veterinary nurses and veterinary anesthetists
ment pathways for specific diseases or medical situations. involved in these procedures.
A dynamic checklist has been used to improve time to anti- The multidisciplinary group should decide who is the
biotic administration in dogs with septic peritonitis [8]. best person to run the checklist. If a do–confirm checklist is
appropriate, the person doing the checklist is the same per-
son doing the task. In a read–do checklist, the reader has
Design Considerations the power to stop a procedure until the step is completed.
Both the jugular central line placement study and surgery
Recommended steps in checklist design and implementa- checklist study showed the highest compliance and success
tion are listed in Box 4.1. The first step is the decision that when nurses were set up to run the checklist [3,4].
a checklist is needed. It is important to be clear on the spe- The multidisciplinary group will also need to decide
cific goal of the checklist so that it is designed with its mis- when the checklist is performed, how it fits into the flow of
sion in mind. Are you trying to prevent a specific the procedure, whether the checklist is on paper or elec-
complication? Avoid missing an important treatment step? tronic, and what items make the list. Ideally, the most criti-
Move recent literature into practice? No matter how short, cal items are listed near the top. The listed items should be
odiiication 49
be a large barrier to implementation [12]. During imple-

Box 4.2 Important Elements in Successful
mentation, an effort should be made to anticipate and
Checklist Designs
counteract likely concerns [9]. A study of surgical checklist
● Sans serif font use in several Washington state hospitals demonstrated
● Lots of white space that successful implementation included a strong story of
● Minimal color why the checklist is needed and a detailed explanation of
● Precise, simple language exactly how to use the checklist [10].
● Most critical items at the beginning An important step in implementation is challenging the
● As short as possible myth that more experienced doctors do not need check-
● Fit on one page lists. A lesson from aviation can be used. In flight school,
pilots are taught that, even when experienced, that their
memory and judgment are unreliable and that lives depend
as short as possible and should fit on a single page. on their recognition of this fact [1].
Language should be precise and simple. In the author’s hospital, the first step in building a why
Studies in the aviation industry have shown that both the for the surgery checklist, was holding a journal club on the
content and the appearance matter in creating a successful book, The Checklist Manifesto [1]. Because the book is quite
checklist. Even the font used can influence its usability, compelling, the why was clear. The impetus for a checklist
with sans serif fonts such as Arial and Helvetica being rec- could also come out of a medical error, a missed process
ommended over serif fonts such as Times New Roman, step, or a post-surgical complication. In general, people are
which can be harder to read quickly [1, 9]. Other important more compelled to make a change from emotional stories
considerations for design are listed in Box 4.2. than from facts or studies [1].
A common skipped step in the WHO surgical safety
checklist is taking the time for each person to introduce
Testing themselves and state their role. While this step does not
appear to be related to patient safety, it is actually crucial to
Once an initial prototype is developed, it should be tested in build effective teamwork in the case of the unexpected. The
practice by the multidisciplinary group. Most checklists will most likely surgical complications to result in death are
need a rapid cycle of quick tests and revisions to get a ver- those that are rare such as thromboembolism and ventila-
sion that can then be tested by a larger group. In the process tor malfunction. Successful response depends on fast team-
of testing, it is common to find that the language may not be work. People work much better as a team if everyone
as precise as thought, that the timing of items needs to be knows each other’s name [1].
altered, that the list is too long, or that the placement of the Once a compelling why is described and the staff believes
checklist needs to be adjusted to fit into the flow of the day. in the process, they then need to be shown exactly how to
After a prototype is developed, it should be tested with a proceed. In-person training using the members of the
small group that was not on the development team. Further development team is likely to be most effective. Reference
modifications will likely be needed. The incorporation of materials for implementation should be developed.
suggestions by this additional group will provide multiple Figures 4.1 and 4.2 show a sample surgery checklist and
staff who are now vested in the success of the checklist. the associated training descriptions for each item on the
After this testing process, the preliminary checklist is first part of the checklist.
now ready to be implemented in the hospital. It can be difficult to incorporate a new process into a daily
workflow. Thus, when a new checklist is implemented,
reminders and visual clues should be used to encourage
Implementation habit building. This may include reminders in a weekly
staff memo, prominent colored signs around the hospital or
Studies of implementation of the surgery checklist across stickers to highlight a new checklist on a form (Figure 4.3).
hospital systems show that decreases in complications and
mortality are directly related to the strength of the imple-
mentation process [10–12]. When the WHO surgical safety Modification
checklist was implemented in hospitals across Britain, the
full expected drop in complications was not seen. A detailed Although the checklist has likely gone through testing prior to
study found that the full checklist was only finished in 62% implementation, it will likely need to be modified over time.
of cases and in 66% of those cases, not all items were read These modifications may happen due to unexpected issues
aloud [11] Resistance from senior clinicians was found to found during implementation. However, modifications may
Figure 4.1 Example of a surgery checklist.
Prior to anesthesia
Owner permission – either a signed authorization form or a verbal authorization provided by the admitting doctor
Deposit – check for a sufficient deposit for the surgical procedure. Look at the numbers. A deposit collected for ER admit and
hospitalization is not sufficient for surgery and follow up care.
CPR code – a CPR code is required.
Med Hx confirmed – Know what recent meds your patient has taken and how those affect the drug protocol provided by the doctor.
For instance, a patient that has received steroids should probably not receive an NSAID.
Preop BW reviewed by DVM – self explanatory
Blood trans – Is it possible that your patient will need a blood transfusion. Be prepared in advance with type and crossmatch. Be
sure there is adequate blood supply available for your patient.
RX allergies – are there any known prescription allergies? Check the chart and/or ask your doctor.
Appropriate suture available – not just any suture will do for every procedure. Ask the surgeon. A lar par requires specific suture.
Make sure you have the basics on hand – 0 PDS, 2-0 PDS, 3-0 monocryl, 3-0 ethilon and then ask if the surgeon will need a specific
suture for the procedure.
Special equip needs – make sure you can locate and set up anything special the doctor may need. Ligasure? Mixters? Delicate metz?
Ortho equipment? Not sure what these things are? Ask your doctor. Find them before you need them in surgery.
NPO time – double check the last time your patient ate. Inform the doctor if it was recent. Take precautions when intubating and
extubating.
Figure 4.2 Descriptors of elements listed on the surgery checklist (Figure 4.1).
also be needed in response to other flow changes in the hospi- manuals for new staff. New staff may not understand the
tal. Modifications may also be needed to reflect new evidence importance of checklists if stories of their development
or changes in standard of care practice. Willingness to change and use are not included in training and orientation.
the checklist to reflect changing conditions will further In the authors’ hospitals, a chart audit of surgery check-
encourage a culture of feedback and engagement. list completion was completed on several occasions and
then published to the hospital to demonstrate what was
happening and what was possible. While one department
Ongoing Accountability thought the checklist took too much time, another depart-
ment had no trouble reaching close to 100% completion.
Even with a successful implementation, the team must be Publication of the results and competition between
kept accountable over time. It is important to add new hos- departments encouraged better completion prior to the
pital checklists, with their why and how, into training next audit.
eierences 51
was celebrated, and also allowed us to figure out the prob-

lem and fix it before any pet was affected.
The Virginia Mason hospital system celebrates safety
success by giving a monthly “good catch” award that is
announced to the entire organization. This award is given
to a staff member who provides an alert of a safety concern
that helps to avoid ongoing problems. This recognition is
an ongoing way to tell stories of safety success and to
encourage staff to actively participate in continuous
improvement [13].
Checklists Help Build a Reliable Culture

of Safety
Figure 4.3 Brightly colored signs regarding the use of checklist
Checklists save lives, in part, by helping to remember easily
can serve as a reminder or visual cue when implementing the
new process. forgotten steps in a process. The goal is thus not to just tick
boxes [8]. The ultimate goal is to build a highly reliable
hospital that can handle complex cases with minimal to no
Celebrate Successes mistakes. Standardization helps add reliability into a com-
plex environment [13]. When checklists empower nurses,
The continuing successful use of checklists depends on it allows them to insist that those higher in the hierarchy
continuing to demonstrate why they are needed. In the adhere to safety procedures [7]. The use of multidiscipli-
authors’ hospital, an autoclave malfunctioned. Following nary teams to develop and refine new checklists creates a
the surgical checklist item, “check pack sterility,” it was culture of quality continuous improvement [8]. The idea
noted that although the outside pack indicator tape had that checklists need to be continuously improved, adds
changed, the interior sterility indicator showed lack of ade- additional safety for addressing emergency problems [14].
quate heat penetration. Because of the checklist, the Successful implementation and use can also change the
unsterile pack was not used and the autoclave was serviced culture of a hospital to one that emphasizes patient safety
and repaired in a timely fashion. The “catch” by the team and a team approach to care.
References
1 Gawande, A. (2009). The Checklist Manifesto. New York, 7 Winters, B.D., Gurses, A.P., Lehmann, H. et al. (2009).
NY: Metropolitan Books. Clinical review: checklists: translating evidence into
2 Luby, S.P., Agboatwalla, M., Feikin, D.R. et al. (2005). practice. Crit. Care 13 (6): 210.
Effect of handwashing on child health: a randomized 8 belson, A.L., Buckley, G.J., and Rozanski, E.A. (2013).
controlled trial. Lancet 366 (9481): 225–233. Positive impact of an emergency department protocol on
3 Pronovost, P., Needham, D., Berenholtz, S. et al. (2006). An time to antimicrobial administration in dogs with septic
intervention to decrease catheter-related bloodstream peritonitis. J. Vet. Emerg. Crit. Care 23 (5): 551–556.
infections in the ICU. N. Engl. J. Med. 355: 2725–2732. 9 Burian, B.K., Clebone, A., Dismukes, K., and Ruskin,
4 Haynes, A.B., Weiser, T.G., Berry, W.R. et al. (2009). A K.J. (2018). More than a tick box: medical checklist
surgical safety checklist to reduce morbidity and development, design, and use. Anesth. Analg. 126 (1):
mortality in a global population. N. Engl. J. Med. 360: 223–232.
491–499. 10 Conley, D.M., Singer, S.J., Edmondson, L. et al. (2011).
5 Bergstrom, A., Dimopoulou, M., and Eldh, M. (2016). Effective surgical safety checklist implementation. J. Am.
Reduction of surgical complications in dogs and cats by Coll. Surg. 212 (5): 873–879.
the use of a surgical safety checklist. Vet. Surg. 45 (5): 11 Mayer, E.K., Sevdalis, N., Rout, S. et al. (2016). Surgical
571–576. checklist implementation project: the impact of variable
6 Halford, G.S., Baker, R., McCreeden, J.E., and Bain, WHO checklist compliance on risk-adjusted clinical
J.D. (2005). How many variables can humans process? outcomes after National Implementation: a longitudal
Psychol. Sci. 16: 70–76. study. Ann. Surg. 263 (1): 58–63.
12 Russ, S.J., Sevdalis, N., Moorthy, K. et al. (2015). A Institute. http://www.virginiamasoninstitute.

qualitative evaluation of the barriers and facilitators toward org/2018/04/patient-safety-alert-system (Accessed
implementation of the WHO surgical safety checklist across 25 June 2022).
hospitals in England: lessons from the “surgical checklist 14 Patient Safety Network (2019). High reliability. Patient
implementation project.”. Ann. Surg. 26 (1): 81–91. Safety 101. https://psnet.ahrq.gov/primer/high-reliability
13 Virginia Mason Institute (2018). Case study: Embedding (Accessed on 25 June 2022).
a system to protect patient safety. Virginia Mason
53
Medical Charting
Karl E. Jandrey and Sharon Fornes
Veterinary medical records serve several purposes. Medical 3) The medical record allows for the documentation
records are a document of information that provides what of all communication between veterinary staff
has occurred to the patient while they have been in the care and clients. Whether it documents communication
of the veterinary health care team in the hospital. There are between the animal’s owner and the staff at the practice
four main reasons to maintain accurate and up-to-date or within the practice itself, the medical record is an
medical records. essential tool to maximize continuity of care. By facili-
tating effective communication, medical records ensure
1) A medical record is a legal document of patient
that all doctors and associated hospital staff members
care. As a legal document, a complete medical record
involved in the patient’s care are aware of the treatment
can be used in court as a representation of the treat-
plan. If documented correctly, a medical record can
ment that was planned and completed on an animal. If
thereby allow for consistent and accurate standardiza-
the record is incomplete or is in error, the courts may
tion of patient care [3].
rule in favor of the client even if no negligence can be
4) The medical record allows for documentation for
proven from the record [1]. The components of a com-
research, disease surveillance, and publica-
plete medical record will be discussed later in the
tion [3–5]. Along with the legal implications of medical
chapter.
records, the importance of a complete and comprehen-
2) The medical record makes the path of patient
sive medical record is underscored by its use in clinical
care obvious to all readers. A primary function of
research. Medical records provide data from which case
the medical record is to document the path of patient
reports or research papers may be written. Missing
care and the thought process behind it. To this extent,
medical record information can grossly diminish the
a complete medical record should detail all patient
impact of a research publication by reducing the
data and the assessment of those data. One study
amount of usable data, which then may function to
found only 64.4% of the observed and discussed prob-
reduce the sample size. To avoid this issue, the medical
lems during a consultation were actually recorded in
record should present its information in a clear and
the electronic medical record (EMR) [2]. This patient-
concise format that allows research personnel to obtain
centered information leads to the unique and particu-
the information quickly.
lar diagnostic and therapeutic path. For example, the
reader of a medical record should be able to easily
identify whether a patient’s data are within normal
reference intervals, whether a trend is improving over Medical Record Documentation
time, which procedures were performed on the
patient, and the results of a particular intervention. A Because a medical record is frequently referenced, an accu-
properly executed and comprehensive medical record rate and clearly written record is of the utmost importance.
will facilitate the development of future diagnostic or Taking care to appropriately document data can greatly facil-
therapeutic plans for the continuing treatment of itate the clarity and accuracy of a medical record. There are
the animal. seven components to proper medical record documentation.
54 Medical Charting
1) Documentation of authorization for patient care. with the record and may be used against the veterinary
Authorization for patient care is necessary before treat- healthcare team in a court of law [1, 6].
ment of the animal can commence. It is of great impor- 6) Use of proper writing implements. Permanent ink
tance to ensure that appropriate forms have been signed should be used to make entries in the handwritten med-
and that witnessed oral consent is documented [3]. ical record. There is controversy about the appropriate
These consent forms for each visit/procedure can be color of ink to use. Local regulation and clinic prefer-
placed in the plans and progress notes of the complete ences (standard operating procedures) may have some
medical record. The consent form also establishes a variation. The following are arguments for the exclusive
relationship between the veterinarian, the client and use of black pen in a medical record: [7] better repro-
the patient. duction on a photocopier, better contrast on white
2) Timely documentation of information in the paper, and the tendency to be more permanent.
record. This functions to better ensure accurate recol- However, an advantage of blue ink over black ink is to
lection of the data. It is important to time- and date provide contrast to the black ink of preprinted forms.
stamp any entry if possible. For example, if the animal With blue ink, new entries on preprinted forms may be
is unstable, information that was obtained in the initial more easily distinguished.
excitement of an emergency presentation may be 7) Use of acronyms and abbreviations. Acronyms and
recalled with less clarity hours later. Some computer abbreviations used in the clinic should be standardized.
software systems will not allow alterations after a set Confusion may arise, for example, in determining
period. Changing the information after this period may whether “mm” refers to millimeters or mucous mem-
render the medical record inaccurate as it may be branes. The Academy of Veterinary Technicians in
viewed as tampering of the information, should the Anesthesia and Analgesia (http://www.avtaa-vts.org)
record be called into court. Any history and pertinent has a published list of acceptable abbreviations. The
information should be recorded in the appropriate place development of a list of acceptable abbreviations for
in the chart as soon as it becomes possible. Alternatively, each individual hospital could also be helpful to avoid
an assistant can document information as it unfolds if miscommunication between staff members. Beware,
their participation is not essential to the emergency however, that records are often shared between facilities.
interventions ongoing for the patient. Other facilities may not understand a particular hospi-
3) Clear indication of the person who performed a tal’s abbreviation standards unless provided with a key.
task or treatment. This is usually accomplished by Success after implementation of a novel EMR with
documentation of the person’s initials on the record or adoption of a controlled vocabulary permitted standard-
treatment sheet. The purpose to initial the records will ized filing, as well as retrieval of information [8].
allow for questions to be directed to the appropriate par-
ties. If there is are many team members inputting infor-
mation into the medical record, a list of full names of Medical Record Organization
employees along with the initials should accompany
the record to add verity to the information in the entries. A standardized medical record organization is important
A date and time should also be entered to verify time of for many reasons. During a patient’s stay in a veterinary
treatment or communication. This can be done auto- hospital, much information is collected and assessed daily.
matically with an EMR. If these data are consistently written in the same format,
4) Legible handwriting. Legibility of the record is essen- information retrieval is timely and accurate. This may help
tial to prevent misinterpretation. If one cannot write in legal cases, to evaluate therapeutic goals, and to use the
legibly, one should consider typed or computerized medical record for clinical research. Data are most useful
medical records. and clinical efficiency is maximized when information is
5) Appropriate notation of corrections to the record. placed in a consistent location.
Care should be taken if a correction in a medical record An organized medical record is most commonly for-
is required. To overwrite, scratch out, erase, black out matted in a chronological order. Reverse chronological
with a marker, or use correction fluid or tape are inap- order (last visit on top and the first visit on the bottom) is
propriate methods for correction. The appropriate a common method for assembly of the medical record [9].
method of correction is to initial and draw a single line Medical records can also be organized by section (e.g.
through the entry that was created in error. The correc- financial, authorization forms, treatment sheets, pharmacy,
tion should then be written and initialed near the entry laboratory, plans, and progress notes). The creation of sec-
that was replaced. The use of any method other than the tions within a patient record facilitates quicker reference in
accepted convention could be considered as tampering a large comprehensive medical record.
ComCononts Cof a Compnnn nedi ap niCoe 55
Medical Record Format is kept. All contact information (physical and mailing
addresses, electronic contact, landline and mobile tele-
There are two common formats used for the documenta- phone numbers, and special notations) about the animal
tion of medical records: the conventional method and the owners should be placed here. These listed people are the
problem-oriented medical record (POMR). The conven- legal guardians of the animal and permit access to this
tional method documents information as it is obtained. It information. Those not listed in this are unable to access
may be less time-consuming than the POMR and tends to patient information under privacy and confidentiality
be used in general practice. The POMR records patient data agreements. Although these are not commonplace in vet-
according to the patient’s problem. POMRs are often used erinary medicine, patient confidentiality must be respected
in academic and specialty practices to clearly document by the hospital and all members of its staff. Release of
and transmit the logical forward-thinking approach that is patient information to a third party must be approved by
required for patients with complicated disease processes. the client.
POMRs are also used as effective teaching tools because
they allow the reader to readily uncover the thought pro- Patient Information
cess of the writer. However, although POMR records are
very organized and detailed, a disadvantage is that they The patient data is recorded here and includes the signal-
may be more time-consuming to produce [6]. ment (age, breed, sex, birth date). Pedigree or individual
A source-oriented veterinary medical record information medical information (allergies, behavioral, blood type/
is organized by subject areas rather than by the problem(s) previous transfusions) can be placed here.
of the patient’s visit. Information may be accessed in each
separate area of the record. Clinical findings and result may Presenting Complaint
be separated by tabs or dividers to separate the information.
Laboratory findings may be separated from plan notes and The presenting complaint is recorded by the reception or
treatment sheets from the same visit of the patient. It may medical records staff when the appointment is made.
be difficult to find information about one visit, because the This is the information in the words of the client that
information is found in many different locations. It is help- transmits the reason for which they seek veterinary med-
ful however to find all the radiological findings in one loca- ical care.
tion, so outcomes of the various visits can be compared [3].
History
Components of a Complete Medical Record A comprehensive history is obtained from the client on the
initial visit and is updated periodically as the animals’
A complete medical record should include a thorough and health status changes. A history needs to be taken every
accurate daily description of all data obtained for a par- time an animal presents for a new illness (known as the
ticular patient, the assessment of these data, and a discus- history of the presenting illness). Past pertinent history can
sion of the resultant plan (which is composed of diagnostic, be helpful in determining onset of the problem or relation-
therapeutic, and client education components). The com- ship to the history of the presenting illness. Past pertinent
plete medical record should include nine components: history may include recording previous treatment prior to
the current hospital visits or previous veterinary care from
1) Client information
other veterinary hospitals.
2) Patient information
3) Presenting complaint
4) History (from both the client as well as other prior med- Physical Examination
ical records)
A physical examination may be completed one or multiple
5) Physical examination
times daily and should be documented at least once daily
6) Problem lists
throughout the animal’s hospitalization. All the body sys-
7) Progress notes
tems should be examined and documented properly to
8) Communication log
ensure and prove that they were examined. Salient nor-
9) Comments
mal and abnormal findings need to be documented.
Abnormal findings should be well documented and can
Client Information
then be elevated to a level of a problem in the problem list,
This area of the medical record is devoted to the client as indicated by the problem-oriented approach of the
where all pertinent information about the animal owner(s) clinician.
56 Medical Charting
Problem Lists the primary care provider and, if applicable, primary vet-
erinarian should also be on the record.
Problem lists enumerate the conditions being managed
The information found in the communication log is often
during a hospitalization period. In a problem list, “prob-
equally as important as the daily SOAP. As this information
lems” can be created, resolved, combined with other prob-
is not likely to be organized in any other area of the POMR,
lems and renamed, or inactivated at any time. This provides
the communication log should be carefully and compre-
the veterinarian with a means of obtaining an overview of
hensively documented. EMRs may be finalized and locked
all problems that the animal may have had and whether
with a time and date stamp. However, communications logs
they were addressed or resolved, without the requirement
should not be locked. Added information via telephone
to examine the entire record [6].
communication may arrive without attachment to a hospi-
A master problem list (Figure 5.1) is often created and
tal visit and, therefore, no daily POMR. This message may
placed on the first page of the patient record. The master
be added into the record in chronological order when the
problem list is a summary of all the problems for which the
record is not locked. Information from delayed diagnostic
patient has been examined. This includes the date the
tests can be recorded back to the visit to which they pertain.
problem was identified, as well as when it was resolved (if
This communication is essential to provide continuity for
applicable). It functions as a quick glance into the patient’s
the patient’s medical and surgical treatment data since it
medical history and can thereby facilitate a focused search,
may alter the assessment of the patient problem.
much like a table of contents.
Progress Notes Comments
Progress notes are the daily subjective, objective, assess- The comments section is the part of a complete medical
ment, plan (SOAP) of the patient. Each day for each prob- record designed for other miscellaneous details. Often an
lem, an entry is created that contains the data relevant to additional page or pages are available if there was insuffi-
that problem. Subjective and objective data are placed in cient room in the space provided on a medical record or
this section and should include the information gained form. In some computerized medical record systems, this is
from diagnostics and therapeutic interventions, as well as the only other editable section to which information can be
the new physical examination or any physiologic measure- added once the medical record is finalized and locked.
ments. A patient’s response to treatments is also recorded
in this section. A differentiation is made in human medi-
cine between the information that comes from the patient Other Additions to the Patient Record
(subjective) and that measured in analysis (objective). In
veterinary medicine, the information given by the client Examples of additions to the patient record when applicable
may be treated as subjective. However, historical data from include: medications (particularly drug sensitivity), perti-
a client can be measured and clearly objective; therefore, nent patient information such as aggressive/caution, special
“data” is a more proper term. The SOAP would therefore be needs, mentation, appetite, food intake, visual analog pain
referred to as the data, assessment, and plan (DAP). An scales, body conditioning score, and lab results. Other addi-
assessment follows the data and should include informa- tions may include warning labels placed on the outside of
tion pertinent to the patient’s prognosis. The purpose of the the medical record or in the header of the computerized
assessment is to refine and document the new thoughts of medical record. Alternatively, these may be addenda to the
the clinician. Based on the assessment of all the previous plans and progress notes for hospitalized patients that are
data, a new plan is created. This plan must discuss at least included in the description of patient observations.
one of three distinct areas of focus: diagnostic plans, thera-
peutic plans, and/or client education plans.
linician Order Sheets and Treatment/
C
Communication Log
Flow Sheets
The communication log is the section of the POMR that In addition to details about patient data, future treatment and
contains the information about any and all contact between diagnostic plans, and client education, a medical record
members of the hospital staff with the client and/or refer- should include clinician order sheets and treatment/flow
ring veterinarian(s). This includes detailed phone calls, sheets. These function to help ensure quality and continuity
emails, text messages, or client visits. Proper documenta- of care for the veterinary patient. They are part of the pro-
tion also includes reference to client education, date, time, gress notes since pertinent data from these are abstracted into
names, and content of the communication. In a referral the computerized medical record. In paper medical records,
hospital, the names, contact information, and addresses of these sheets are inserted chronologically to accompany the
pdodid ao oeno Snnnts aoef on anonont/pCow Snnnts 57
VETERINARY MEDICAL
TEACHING HOSPITAL
UNIVERSITY OF CALIFORNIA, DAVIS
DATE DATE
NUMBER PROBLEM
ENTERED RESOLVED
D2760 (12/90) Form #48-R MASTER PROBLEM LIST
Figure 5.1 Master problem list is a summary of all the problems for which the patient has been examined. Source: Veterinary Medical
Teaching Hospital / The Regents of University of California.
58 Medical Charting
daily DAP. The following section focuses on the information assessment of need for other treatments. A patient’s weight
found in order sheets and flow sheets, and highlights appro- may also be used to calculate the charges for care provided.
priate methods to notate findings and interpret information. Recording of weight may be delayed until certain initial
interventions required for more life-threatening conditions
Clinician Orders are completed.
Many hospitals combine the clinician’s orders with patient

observation or flow sheets. Order sheets can be simple for Nutritional Considerations
wards patients that are stable (Figure 5.2 for general ward
patients and Figure 5.3 for intermediate care ward patients), What is to be fed and the frequency to offer food is essential.
or they can be elaborate for intensive care unit (ICU) The volume in cups/cans or weight in grams should be
patients (Figure 5.4). In all cases, the appropriate treat- noted for both the amount offered as well as the amount
ment, diagnostic, and monitoring plans should be legibly ingested. Special dietary needs and feeding instructions
written for clear documentation. should be clear, especially if using various enteral feeding
tubes or parenteral nutrition. In addition, nutritional consid-
Treatment Sheets erations should be notated on the record. The patient that
has no oral administration of food or medication should be
Treatment sheets are the part of the medical record that labeled “NPO” (non per os). This is important for animals
contain recorded data collected throughout the animal’s that are going to be anesthetized because preanesthetic pro-
hospitalization. Treatment sheets (Figure 5.5 for patients tocol may require the removal of food from the animal at a
on the general ward and Figure 5.6 for intermediate care certain time. Therefore, this information should be easily
ward patients) can be as simple as recording observations distinguished on a record so that the animal can undergo
and the treatments provided to an animal. The preferred anesthesia at the intended time. If a hospitalized animal is to
format is to write in the medical order using a clear format; be fed or given water, the amount, type of food, and appetite
for example: “lactated Ringer’s solution qs 20 mEq/l at or water consumption should be notated on the record.
120 ml/h IV” (as needed, 20 milliequivalents per liter at Some methods to indicate appetite are a number scale (0–5),
120 ml/hour intravenously) or “famotidine 10 mg IV q12h” where other methods use plus or minus (±) symbols to indi-
(10 mg intravenously every 12 hours). cate whether an animal did or did not eat/drink. Notation of
the patient’s nutritional considerations is important on two
Daily Patient Flow Sheets levels. First, the more nutritional information included in
the record, the more fully will the staff understand the indi-
Patient daily flow sheets may be complicated, multipage
vidual patient’s eating preferences. Second, because some
treatment sheets that give detailed information in areas of
owners may bring the patient’s own food or favorite treats to
subsections of the document outlining treatments, moni-
the hospital to encourage appetite, providing a record of
toring, and observations (Figure 5.6 for intermediate care
nutrition will allow the hospital staff to tally and keep watch
ward patients and Figure 5.7 for ICU patients). Although
on the patient’s ingested calorie content. Ideally, the exact
the format of these flow sheets is often tailored to the pur-
calorie content ingested should be documented.
pose and individual clinic, completed treatment sheets are
considered part of the patient’s medical record and must
contain basic information. Laboratory Measurements
Patient Identification The data obtained from patient-side laboratory evaluation
should be placed in the appropriate section of the medical
First, the patient’s basic identification must be found on
record and flow sheet. This notation in the record may be
each page of all forms on the flow sheet as well as every
the only area it is recorded since some point-of-care
piece of the medical record. This enables a page that
machines do not have hard-copy printouts of these data,
becomes detached from the record to be easily returned to
nor are these data automatically integrated into the EMR.
the record. The date should also be included on each page,
and a time may be appropriate for certain entries.
Patient Treatments and Observations
Patient Weight
Medications
The patient flow sheet should include the patient’s weight
at presentation as well as daily updates. This is important The “rights” of pharmacotherapy include right drug, right
to determine effective pharmaceutical treatment and the patient, right time interval, and right route. Accurate
Figure 5.2 Example of a patient general ward orders form. Source: Veterinary Medical Teaching Hospital / University of California, Davis.
Figure 5.3 Example of a patient intermediate care ward orders form. Source: Veterinary Medical Teaching Hospital / University of
California, Davis.
andnon on anononts aoef Otsnor andCots 63
Figure 5.4 Example of an order sheet for intensive care unit patients. Source: Veterinary Medical Teaching Hospital / University of
California, Davis.
64 Medical Charting
andnon on anononts aoef Otsnor andCots 65
Figure 5.5 Example of a general ward observation record.

Figure 5.6 Example of an intermediate care ward observation sheet.
Figure 5.7 Example of an intensive care ward observation sheet. Source: Veterinary Medical Teaching Hospital / University of California, Davis.
72 Medical Charting
notation of pharmacologic information into the flow sheet noted. Daily catheter evaluations should also be noted.
plays a major role in ensuring the correct method of adminis- How often the catheter was checked (every 24 hours at a
tration of a drug. Medications and treatment regimens minimum or as indicated) and by whom is also part of the
should be recorded in the sheet exactly as the veterinarian fluid orders. Any information regarding the catheter
prescribed [10]. Standardized orders require all medications replacement (date, personnel, anatomic site, catheter size
to be written in the exact amount of drug in milligrams and length) is also helpful for optimal patient care as well
administered. It is preferred to write the total dosage in mil- as troubleshooting in the event of a catheter mishap.
ligrams (mg) with the appropriate time interval and not just a Annotate the removal of the old catheter and the site of
dose per body weight (mg/kg). Drug volumes should not be placement of the new catheter (including gauge, length,
used due to the varying concentrations of preparations amount exposed, vessel quality, and whether it aspirates or
between manufacturers. It is expected that the veterinarian can be flushed easily). Other information to include on the
who prescribes the medication will write the order clearly record regarding a new catheter placement includes the
(e.g. ampicillin 250mg IV q8h). An order in total dose such as date of placement, the initials of the person who placed the
“250mg” is much clearer than “22mg/kg” because drugs catheter, site (i.e. left rear limb, lateral saphenous vein, or
dosed in milligram/kg (mg/kg) are also subject to computa- right jugular vein), and catheter size (e.g. 22-gauge 1½ inch
tional error. Before being written in the medical record or over-the-needle catheter or 5 Fr, 10-cm guidewire, double
delivered to the patient, any clarifications should be addressed lumen catheter). Notations of the patient’s hydration status
to the clinician who wrote the order. In some hospitals, the as measured by skin turgor, tear film, mucous membranes,
time for the treatment to be completed is indicated on the and/or ocular position will help to gauge efficacy of
treatment sheet by an open circle. When the treatment is therapy.
completed, the time at which it was delivered is written in the
circle. Alternatively, some hospitals prefer the treatment
order to be written as a number on the hour at which treat- Body Systems Evaluations
ment should be delivered. When the treatment is completed,
the number is then circled indicating completion. A hospital The veterinarian uses the information found in the flow
standard for consistency in format of the orders should be sheets to assess the response to treatment, to plan the next
followed. daily treatment, diagnostic, and monitoring plans, as well
As part of the medication section, special legal consider- as to predict recovery of the animal. The body systems used
ations and maintenance of a controlled drugs log is essen- for evaluation include: cardiovascular, respiratory, neuro-
tial. All controlled drugs administered to patients must be logic, and urinary. These body systems have parameters the
noted in both the patient record and in the controlled drug veterinary technician can evaluate and notate in the medi-
log. Some facilities have a drug log created at the time of cal record. Typically, data from individual body systems are
dispensation by the use of automated dispensing equip- organized in the medical record in proximity to one
ment (with or without a witness). This log will be proof another. This arrangement facilitates evaluation by the car-
required during audits by the Drug Enforcement Agency or egivers to organize constellations of data into a more global
the state veterinary board. This should include patient perspective of the patient’s status.
information as well as the amount and route of the drug
administered. The starting volume and remainder in a
multi-use vial are also recorded. The names or initials of Cardiovascular System
the dispensing and witnessing veterinary professional
should be included on the patient flow sheet. Initial or serial vital measurements (e.g. temperature
[temp], heart rate [hr], pulse rate [pr], respiratory rate [rr])
must be included in the patient flow sheet. These will help
Fluids to assess whether a particular treatment is successful and
sufficient. For example, a flow sheet should include the
Accurate fluid orders include many specific parameters. following pieces of information necessary for the under-
The type of fluid, dose and concentration, rate (per unit standing of the patients’ perfusion: heart rate/pulse rate,
time), additive solutions or medications, and total hourly/ pulse quality, mentation, extremity temperature, mucous
daily tallies should be clearly indicated to ensure adher- membrane color, and capillary refill time. Using these
ence. The complete measurement of fluid input can be parameters, poor distal perfusion may be assessed in shock,
compared with all net fluid output over time to direct where the rectal-extremity (interdigital) temperature dif-
adjustments in fluid treatment orders. Whether the fluids ference may be large (9°F; > 4°C) due to peripheral vaso-
were administered via intravenous (IV) or subcutaneous constriction. Similarly, pale mucous membranes with a
bolus with or without the use of a fluid pump should be slow capillary refill time, tachycardia, weak femoral pulses,
andnon odr aic 73
and decreased mentation are all signs of poor perfusion. Volumes more or less than this need to be addressed by the
Normal capillary refill time (CRT) should be less than clinician once discovered. An Elizabethan collar may also
2 seconds approximately. Conversely, an extremely rapid be required to prevent premature removal of the catheter by
CRT accompanied by bright pink or red mucous mem- the patient. This should also be notated on the record to
branes may indicate vasodilation [11, 12]. Electrocardiogram ensure that nursing personnel keep the collar on the patient
interpretations or rhythm strips should be part of this por- until the urinary catheter is removed.
tion of the medical record.
Computerized or Electronic Medical

Respiratory System Record
Important parameters to annotate in the section devoted to A large number of veterinary practices now utilize comput-
the pulmonary system are respiratory rate, effort (apparent ers and electronic software for documentation of veteri-
ease, origin of effort; e.g. thorax vs. abdomen), associated nary medical records. There are variety of software and
sound (type of sound, origin, volume change in reference products available for medical record keeping. The benefit
to phase of respiration), or irregularities in respiratory of these systems, if designed properly, is the ease of retriev-
pattern. ing information from the record and the sharing of infor-
mation electronically. With the adoption of standard
medical terminology and structured reporting, exchange of
Nervous System information across hospitals and institutions would be
simplified [13]. Multiple users may enter information in
Upon initial presentation or triage of the animal, observa- the record at the same time. Misplacement of the physical
tions of the patient’s level of consciousness and response to copy of the patient file is eliminated. Another potential
the surroundings is essential to the examining veterinar- benefit of an EMR is to link information resources directly
ian [7]. The mentation of an animal may range from alert to the record for references to enhance evidence-based
to obtunded to stuporus to comatose. In the daily flow practice and support clinical decision-making [14].
sheet, the writer must mention the level of consciousness Besides cost, considerations for choosing the appropriate
and any behavioral changes in the patient. Changes in level software for the hospital might be how easily it will be to
of mentation are important markers or improvement or integrate the current paper system to a paperless or paper-
decline in health status. Behavior may also give an indica- light record. How much training is needed to implement the
tion that there may be some neurologic changes in the ani- new software into the practice? How will it be to train new
mal. The animal may circle, head-press, or become employees to use the system? How will records be shared in
aggressive or withdrawn. Modifications of these mental the hospital and also with other hospitals? Will it contain all
states should be interpreted in light of the treatments given data needed in the record (i.e. diagnostic results, inventory
as well as in postoperative states after anesthesia or pain control, or client communications)? Ease of invoicing, bill-
control has been administered [9, 10]. ing and scheduling needs for the hospital must be consid-
ered. Is there availability of alerts systems to check for errors
in prescriptions and contraindicated or adverse treatments
Urinary System of the patient? Once the software is mastered, will it actually
increase the efficiency of the entry of the information into
Some animals have preference for the substrate on which to the record? [15, 16] Additional under-used benefits of the
eliminate or respond to special commands taught by the EMR, such as improved population health, identification of
owners. These unique data should be annotated in the area emerging disease, outweigh the perceived risks for techno-
related to the urinary system. Any urinary catheter, as is the logical problems, time constraints, and cost [17].
case with an IV catheter, should have information regarding
the date of placement (and by whom), catheter type and fre-
quency of care, and any problems encountered (e.g. posi- Patient Privacy
tional flow). The amount of urine production (hourly/daily)
is important to note in milliliters whether obtained as an Although there are strict regulations and laws in place to
estimates from voided urination or specific amounts meas- protect the identification of human patients in both verbal
ured from the urinary collection systems. Collected urine and research communications, veterinary medicine does
samples may be weighed and subtracted from the weight not have a global policy for client/patient privacy [17].
of hospital bedding to estimate the urine output (UOP) Veterinary caregivers should be sensitive to client/patient
as closely as possible. Normal UOP is 1–2 ml/kg/hour. privacy especially with the advent and growth of social
74 Medical Charting
networking sites. Written, photographic, and verbal confi- standardization within a practice enables clear and precise
dentiality should be maintained for clients and patients. communication among the veterinary healthcare team.
Client consent forms for the use of patient images and data Storage of records may vary by area. State veterinary
are used to avoid inappropriate use against the clients’ medical boards have mandated the minimum length of
wishes. There may be local or regional confidentiality time that records must be maintained. When records are
agreements. Be aware of the laws regarding the patient and purged, security must be maintained due to the confiden-
client confidentiality. Obtain a client release [6] for any- tial information therein. Shredding of documents is an
thing that you may need to disclose to a third party. acceptable and preferred method of securely purging medi-
cal records. Many companies provide this service when a
large number of medical records are culled.
Conclusions Standards and guidelines of veterinary medical record
keeping can be found at the local, state, and national veteri-
The most accepted charting methods are those that are nary associations. The following are some suggested asso-
found to be user-friendly. The choice of charting method lies ciations where the salient details can be found: American
within the judgment of each clinic. For example, the use of a Veterinary Medical Association (www.avma.org),
24-hour clock may be preferred to a 12-hour clock. Despite American Animal Hospital Association (www.aahanet.
the fact that a 24-hour clock is best used to avoid any confu- org), state veterinary medical boards (e.g. for California, go
sion in a hospital where 24-hour service is provided, most to www.vmb.ca.gov), and the Veterinary Emergency and
people are not comfortable with this method. Internal Critical Care Society (www.veccs.org).
References
1 Aiken, T.D. (2004). Ethics in nursing. In: Legal, Ethical, and K. Hopper), 2–5. St. Louis, MO: Saunders
and Political Issues in Nursing, 2e (ed. T.D. Aiken), 97–124. Elsevier.
Philadelphia, PA: F. A. Davis. 10 Rockett, J., Lattanzio, C., and Anderson, K. (2009).
2 Jones-Diette, J., Robinson, N.J., Cobb, M. et al. (2017). Veterinary technician practice model and documentation.
Accuracy of the electronic patient record in a first opinion In: Patient Assessment, Intervention and Documentation for
veterinary practice. Prev. Vet. Med. 148: 121–126. the Veterinary Technician, 3–17. Clifton Park, NY: Delmar.
3 Bassert, J.M. (2018). Medical records. In: Clinical Textbook 11 Pattengale, P. (2020). Veterinary business protocols. In:
for the Veterinary Technicians, 9e (ed. D.M. McCurnin and Tasks for the Veterinary Assistant, 4e (ed. P. Pattengale),
J.M. Bassert), 76–103. St. Louis, MO: Elsevier. 33–50. Hoboken, NJ: Wiley.
4 Anholt, R.M., Berezowski, J., MacLean, K. et al. (2014). The 12 Crowe, D.T. (2009). Patient triage. In: Small Animal
application of medical informatics to the veterinary Critical Care Medicine (ed. D.C. Silverstein and
management programs at companion animal practices in K. Hopper), 5–7. St. Louis, MO: Saunders Elsevier.
Alberta, Canada: a case study. Prev. Vet. Med. 113 (2): 165–174. 13 Awaysheh, A., Wilcke, J., Elvinger, F. et al. (2018). A
5 Jones-Diette, J.S., Brennan, M.L., Cobb, M. et al. (2016). A review of medical terminology standards and structured
method for extracting patient record data from practice reporting. J. Vet. Diagn. Invest. 30 (1): 17–25.
management software used in veterinary practice. BMC 14 Alpi, K.M., Burnett, H.A., and Bryant, S.J. (2011).
Vet. Res. 12 (1): 239. Connecting knowledge resources to the veterinary
6 Goebel, R.A. (1998). Recordkeeping, business transactions, electronic health record: opportunities for learning at the
and clinic adminstration. In: Principles and Practice of point of care. J. Vet. Med. Ed. 38 (2): 110–122.
Veterinary Technology (ed. P.W. Pratt), 44–46. St. Louis, 15 Bassert, J.M. (2018). Veterinary technology: an overview.
MO: Mosby. In: Clinical Textbook for the Veterinary Technicians, 9e (ed.
7 Babcock, S.L. and Pfeiffer, C. (2006). Laws and regulations D.M. McCurnin and J.M. Bassert), 72–74. St. Louis, MO:
concerning the confidentiality of veterinarian-client Elsevier.
communication. J. Am. Vet. Am. Assoc. 229: 3365–3369. 16 Wachter, R. (2017). The Digital Doctor-Hope, Hype and
8 Zaninelli, M., Campagnoli, A., Reyes, M., and Rojas, Harm at the Dawn of Medicine’s Computer Age. New York,
V. (2012). The O3-Vet Project: integration of a standard NY: McGraw Hill Education.
nomenclature of clinical terms in a veterinary electronic 17 Krone, L.M., Brown, C.M., and Lindenmayer, J.M. (2014).
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Programs Biomed. 108 (2): 760–772. and use by independent small animal veterinary medical
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Animal Critical Care Medicine (ed. D.C. Silverstein 324–332.
75
Point-of-Care Ultrasound for Emergency and Critical Care

Introduction well-defined clinical scenarios or problems with the

objective of expediting patient care (e.g. presence of free
With technological advances leading to smaller, more fluid yes/no, dilated left atrium yes/no, visible B-lines at the
portable ultrasound machines with better image quality, lung surface yes/no). VPOCUS is designed to interpret a
faster start up times, and more intuitive user interfaces, limited number of conditions and therefore follows a differ-
ultrasound is being employed more frequently and with ent standard of practice compared with consultative sonog-
greater efficacy by non-specialist veterinary clinicians. raphy (Table 6.1). For example, an emergency clinician may
Although ultrasound has been used by non-specialist clini- initially perform VPOCUS of the abdomen in a cardiovas-
cians for years, veterinary point-of-care ultrasound cularly unstable older Golden Retriever that presents for
(VPOCUS) has only recently evolved as a specific arm of collapse, pale mucous membranes, weak pulses, an abdom-
diagnostic imaging, tracing its origins back to the focused inal fluid wave, and a low hematocrit with a high pretest
assessment with sonography for trauma exam published by probability of hemoabdomen based on history and physical
Boysen et al. in 2004 [1]. As such, VPOCUS is now defined examination. The initial focused objective of the scan is to
as focused real-time ultrasonography brought to the patient identify the presence or absence of free abdominal fluid,
and performed by the attending clinician in conjunction which if present can be aspirated and evaluated, subse-
with the clinical examination to answer specific questions quently guiding further diagnostic tests. In contrast, a
(often binary) or to guide interventions [2–5]. Although cli- radiologist-performed, consultative ultrasound of the dog’s
nicians from diverse backgrounds have become adept at abdomen (when stable) would describe the entire anatomy
using VPOCUS, it continues to be most prevalent in veteri- of the abdomen, including a systematic, detailed descrip-
nary emergency and critical care (ECC), where it is one of tion of the solid and hollow viscus organs. By keeping
many point-of-care (POC) diagnostics designed to expedite VPOCUS focused to specific goal-directed questions, the
triage and time to diagnosis, with the ultimate goal of chance of errors is decreased, the most important clinically
decreasing morbidity and mortality. It is a diagnostic relevant questions are prioritized, and user confidence is
modality that provides clinically significant information increased.
that is otherwise unattainable on physical examination The ability of VPOCUS to interpret clinical findings in
alone, and is therefore complementary to triage, physical real time has led to its widespread use with the applications
examination, and other point-of-care (POC) diagnostic and continuing to expand rapidly as the capacity for research
clinical tests or findings; it does not replace them. increases. However, it must be kept in mind that despite
VPOCUS is not meant to replace comprehensive sono- human studies validating POCUS as a safe, expedient, and
graphic examinations, which are traditionally consultative cost-effective clinical adjunct that improves patient care,
in nature being performed and interpreted by radiologists, research in veterinary medicine is currently limited.
cardiologists, or other board-certified specialists. Depending on the question being asked, VPOCUS
Consultative sonography is intended to comprehensively involves a series of focused ultrasonographic examina-
evaluate extensive anatomy and physiology, often being per- tions restricted to certain organs or body regions to inter-
formed with numerous open differential diagnoses in mind. pret specific underlying conditions in patients with
VPOCUS applies specific goal-directed questions to defined clinical symptoms (e.g. dyspnea, hypotension,
76 Point-of-Care Ultrasound for Emergency and Critical Care
Table 6.1 Comparison of formal compared with point-of-care (iii) the cardiovascular system. Interventional ultrasound-
ultrasound. guided procedures are applicable within all three compo-
nents. Additionally VPOCUS is applied at four different
Formal ultrasound Point-of-care ultrasound time points: (i) triage VPOCUS is applied as a tool to rap-
idly identify the most immediately life-threatening and
Consultative assessing all Focused to key structures to
organs, anatomy, and answer specific (often binary) critical conditions; (ii) serial VPOCUS is applied to moni-
structures clinical questions tor progression or resolution of any pathology, and
Requires years of training Requires minimal experience response to therapy; (iii) systemic VPOCUS is aimed at
Often takes > 30–60 minutes Performed in < 5–10 minutes detecting asymptomatic conditions, new developments,
and/or to ensure sonographically detectable problems
Usually performed by Often performed by non-
specialists: cardiologists, specialists: emergency room have not arisen prior to undertaking procedures, anesthe-
radiologists doctors, general practitioners sia, or discharge; (iv) therapeutic VPOCUS is used to
Patients often stable Patients often unstable reduce complications of interventions where applicable
Patient taken to the machine Machine taken to the patient (Figure 6.1) [2]. The branches of VPOCUS often overlap
but may be assessed individually or concurrently depend-
Placed in lateral or dorsal Rarely if ever dorsal; lateral,
recumbency sternal, standing preferred ing on the triage examination and initial clinical findings.
Typically clipped Rarely clipped For example, if a dog presents with respiratory distress
and clinical signs suggestive of hypovolemic shock after
Gel preferred as the coupling Uses alcohol ± gel as the
agent coupling agent having been hit by a car, all three components of VPOCUS
are rapidly assessed to gain a systemic understanding of
the potential underlying causes. On the other hand, if a
acute abdomen). In general, ECC VPOCUS can be divided dog presents with sudden onset of respiratory distress fol-
into three major components to help facilitate learning: lowing an episode of vomiting, in the absence of abdomi-
(i) the abdomen; (ii) the pleural space and lungs; and nal discomfort or cardiovascular instability, the lungs are
Cardiovascular Pleural Space and

Abdominal VPOCUS
VPOCUS Lung VPOCUS
History
Triage exam
Diagnose
VPOCUS for triage
(trauma/triage)
MEDB Diagnosis Other imaging
VPOCUS Therapeutic
therapeutic/ diagnostic Treatment
(treatment)
intervention
Serial VPOCUS Monitor

Improvement No (tracking)
improvement
Screen
Systemic VPOCUS
(total VPOCUS)
Figure 6.1 Veterinary point-of-care ultrasound (VPOCUS) in the emergency and critical care (ECC) settings currently involves three
major components: (i) abdominal (ii) pleural space/lung and (iii) cardiovascular, which are assessed in a holistic manner. VPOCUS is
also applied at four key integrated time points: (i) At the time of presentation, concurrent with history, triage, and other clinical
findings, VPOCUS facilitates making a diagnosis or guiding further workup by thoroughly interpreting specific clinical scenarios. In this
manner, VPOCUS is applied as a triage tool to identify rapidly the most immediately life-threatening and critical conditions. (ii) Serial
VPOCUS is applied to monitor progression or resolution of any pathology, and response to therapy. (iii) Systemic VPOCUS is aimed at
detecting asymptomatic conditions, new developments and/or to ensure sonographically detectable problems have not arisen prior to
inducing anesthesia, performing procedures, or patient discharge. (iv) Finally, therapeutic VPOCUS is used to reduce complications of
interventions where applicable. MEDB, minimum emergency database. Source: Adapted from Soni and Lucas (2015) [6].
Introduction 77
assessed first, followed by the other VPOCUS as dictated ● Sedation is rarely required for VPOCUS since it is
by a systemic clinical assessment of the patient. Newer noninvasive and requires minimal restraint. In some situ-
and other specialty-specific applications of VPOCUS (e.g. ations, sedation may decrease anxiety and work of breath-
nerve blocks, optic nerve sheath diameter assessment) will ing, which may improve image acquisition in certain
likely play a future role in the ECC setting but are not settings, particularly for the lungs and heart.
covered here. ● If image resolution is questionable, clipping of fur with
addition of ultrasound gel may improve image quality.
Machine Settings, Transducers, and Materials
for ECC VPOCUS Transducer Movements
● Bring the ultrasound machine to the patient! Do not dis- Acquiring good sonographic images of the desired object
continue stabilization efforts or compromise patient requires both broad and fine adjustments to the transducer,
safety to perform ECC VPOCUS. in multiple planes and directions. Even the tiniest
● A designated ECC portable ultrasound unit, independ- movements of the transducer (millimeters or 1–2 degrees)
ent of specialist console units (e.g. cardiology, radiology), can have a significant impact on determining whether or
is recommended for busy emergency clinics to ensure not the desired object can be correctly imaged: applying a
ultrasound is available at the time of patient presentation single transducer movement at a time is often necessary to
and can be transported to the patient as needed. avoid simultaneously manipulating multiple imaging
● A 5–8 mHz frequency microconvex/curvilinear trans- planes and making it difficult to obtain the best image.
ducer can be used for all VPOCUS applications. A linear There are five key transducer manipulations that must be
array probe is helpful for ultrasound-guided procedures understood to perform VPOCUS: fanning, rocking,
such as ultrasound-guided intravenous (IV) catheter sweeping, sliding, and rotating:
placement, and a phased array probe can be used for
1) Fanning: the transducer head remains stationary while
echocardiography, but neither is essential.
the tail of the transducer is moved side to side relative to
● Although ultrasound consoles have many functions, the
the transducer’s widest axis, similar to the movement of
key machine functions for VPOCUS include frequency,
a handheld paper fan.
gain, depth, and focal position.
2) Rocking: the transducer head remains stationary while
● Frequency is adjusted to highlight structures of inter-
the tail of the transducer is moved side to side relative to
est, typically 5–7.5 mHz (see individual sections). As
the transducer’s shortest axis, similar to the motion
for any sonographic examination, higher frequency
made when cutting something with the side of a fork.
settings are indicated for more superficial structures,
3) Sweeping: the entire transducer is moved across the
while lower frequency settings are required to evaluate
area of interest (the point of contact between the probe
deeper structures.
and patient is changed) in the short axis direction, with-
● The received ultrasound signal can be modified by
out changing the angle of the probe relative to the target
adjusting the gain. Decreasing the gain yields a darker
structure.
(blacker) image with a loss of detail, while increasing the
4) Sliding: the entire transducer is moved across the area
gain yields a brighter (whiter) image. Gain is adjusted to
of interest (the point of contact between the probe and
user preference and the structures of interest, depending
patient is changed) in the long axis direction, without
on the binary question to be answered (see individual
changing the angle of the probe relative to the target
sections).
structure.
● Depth is adjusted to visualize the region of interest.
5) Rotating: the transducer head is rotated in a clockwise
Begin with a somewhat higher depth setting to obtain a
or counterclockwise direction while maintaining the
“big picture” assessment to find the structure of interest,
same point of contact and probe angle relative to the
and then gradually decrease the depth to visualize the
target organ.
desired structures in more detail.
● Focal position is adjusted to the area of interest. With fanning, rocking, and rotating transducer manipu-
● Isopropyl alcohol is often used as the coupling agent; lations, the contact point between the transducer and the
part the fur so the skin is visible before applying alcohol. patient remains the same, and the transducer is manipu-
Ultrasound gel can also be used alone or in combination lated around the point of contact. With sliding and sweep-
with alcohol. ing, the transducer head is moved away from the initial
● Alcohol can create artifact on subsequent radiographs. point of contact between the transducer and the body sur-
Alcohol should be replaced with gel if electrocautery or face of the patient. See Figure 6.2 for a visual representation
defibrillation is a possibility due to the risk of fire. of these movements.
78 Point-of-Care Ultrasound for Emergency and Critical Care
(a) FAN (b) ROCK (c) SWEEP
(d) SLIDE (e) ROTATE
Figure 6.2 (a) Fanning: the transducer head remains stationary while the tail of the transducer is moved side to side relative to the
transducer’s widest axis. (b) Rocking: the transducer head remains stationary while the tail of the transducer is moved side to side
relative to the transducer’s shortest axis. (c) Sweeping: the entire transducer is moved across the area of interest (the point of contact
between the probe and patient changes) in the short axis direction, without changing the angle of the probe relative to the target
structure. (d) Sliding: the entire transducer is moved across the area of interest (the point of contact between the probe and patient
changes) in the long axis direction, without changing the angle of the probe relative to the target structure. (e) Rotating: the
transducer head is rotated in a clockwise or counterclockwise direction while maintaining the same point of contact and probe angle
relative to the target structure.
Indications ● Patients not recovering as expected from surgery.

● Routine daily assessment of hospitalized patients.
There is no limit to the indications for VPOCUS, with new ● To assess for peritoneal effusion of any cause.
applications being developed as research grows; however, ● Suspicion of pneumoperitoneum.
the applications will vary depending on the clinical scenario ● Concern for adequate urine production.
encountered and the sonographer’s comfort and skill level: ● Suspicion of gastric retention or gastrointestinal ileus.
● Suspected pneumothorax.
● Any patient as part of the triage examination. ● Suspected pleural effusion.
● Trauma patients. ● Suspected alveolar or interstitial lung disease.
● Unstable patients. ● Patients with suspected congestive heart failure.
● Respiratory distress. ● Assessment of hypovolemia or volume overload.
References 79
Serial VPOCUS learning curve to VPOCUS and sonographers should know

their limitations; some skills are easier to acquire than oth-
Serial VPOCUS is recommended to: (i) monitor progres-
ers. Finally, although VPOCUS aims to answer POC binary
sion/resolution of patients with positive VPOCUS find-
questions, the clinical interpretation of VPOCUS is highly
ings (e.g. resolution or progression of cavitary fluid
dependent on concurrent clinical findings such as signal-
volumes, left atrial-to-aortic ratio in response to fluid ther-
ment, history, physical examination, as well as other binary
apy, or resolution/development of B-lines); and (ii) to
VPOCUS questions (e.g. a cat presenting for collapse with
detect new developments in patients over time, particu-
the VPOCUS finding of a thick left ventricular wall and a
larly those that become unstable in the absence of an iden-
small left atrium would be suggestive of pseudohypertro-
tifiable cause, and/or have received significant quantities
phy secondary to hypovolemia, while a thick left ventricu-
of IV fluids or other therapeutic interventions (Figure 6.1).
lar wall associated with an enlarged left atrium and
The frequency of serial VPOCUS examinations depends
increased B-lines would be suggestive of hypertrophic car-
on the patient and may vary from several minutes to hours.
diomyopathy). As mentioned above, VPOCUS is part of the
It should be repeated as often as required to identify the
holistic approach to patient care.
reason a patient is unstable if no cause is evident on ancil-
lary diagnostic tests, or to determine why a patient changes
from stable to unstable. If the patient is stable and the goal
is to simply follow resolution or progression of underlying Conclusions
pathology, VPOCUS can be repeated every two to
four hours. VPOCUS is focused, real-time ultrasonography brought to
the patient, performed by the attending clinician in con-
junction with the clinical examination, to answer specific
Limitations questions (often binary) or to guide interventions. It is best
applied as a problem-based assessment to enable the clini-
In most cases, VPOCUS is better at ruling in pathology cian to gather key pieces of information in real time to help
than ruling out pathology; a negative VPOCUS result does narrow or determine a diagnosis, streamline care, guide
not exclude pathology. In people, POCUS has low sensitiv- ongoing management, and reduce cognitive errors. The
ity for penetrating abdominal injury and retroperitoneal dynamic, real-time findings are correlated directly with the
injury, which is also likely to be true in veterinary patients. patient’s presenting signs, and scans can be repeated in a
However, it is still worth evaluating patients with penetrat- serial fashion. POCUS is a skill that is easily applied by
ing injury and suspected retroperitoneal injury since a pos- appropriately trained clinicians, particularly when using a
itive result may dictate further diagnostics and therapy. binary approach. Although evidence-based research for
Initial hypovolemia or severe dehydration may limit detec- the role of POCUS in veterinary medicine is lacking, pre-
tion of effusion, making it important to use serial VPOCUS liminary results suggest it can be used as a rapid and
during and following adequate resuscitation. There is a reliable diagnostic tool.
References
1 Boysen, S.R., Rozanski, E.A., Tidwell, A.S. et al. (2004). rate and accuracy of resident-performed examinations in
Evaluation of a focused assessment with sonography for the acute setting. Can. Assoc. Radiol. J. 66 (2): 153–157.
trauma protocol to detect free abdominal fluid in dogs 4 Abu-Zidan, F.M. (2012). Point-of-care ultrasound in
involved in motor vehicle accidents. J. Am. Vet. Med. Assoc. critically ill patients: where do we stand? J. Emerg. Trauma
225 (8): 1198–1204. Shock 5 (1): 70–71.
2 International Federation for Emergency Medicine (2014). 5 Jones, A.E., Tayal, V.S., Sullivan, D.M., and Kline,
Point-of-Care Ultrasound Curriculum Guidance. West J.A. (2004). Randomized, controlled trial of immediate
Melbourne, Victoria: IFEM. https://www.ifem.cc/ versus delayed goal-directed ultrasound to identify the
point_of_care_ultrasound_curriculum_guidelines cause of nontraumatic hypotension in emergency
(Accessed 25 June 2022). department patients. Crit. Care Med. 32 (8): 1703–1708.
3 Tewari, A., Shuaib, W., Maddu, K.K. et al. (2015). 6 Soni, N.J. and Lucas, B.P. (2015). PoCUS for hospitalists.
Incidental findings on bedside ultrasonography: detection J. Hosp. Med. 2: 120–124.
81
Section Two
Cardiovascular Procedures and Monitoring
83
Catheterization of the Venous Compartment

Andrea M. Steele and Jessica L. Oram
Intravascular catheter placement is the most common Table 7.1 summarizes the flow rates of one particular
method used to gain access to the vasculature to allow for catheter brand (each brand will have slight individual vari-
fluid therapy, medication administration, serial blood sam- ances), showing that even the smallest 24-gauge catheters
pling, and hemodynamic monitoring. Anatomical selec- can deliver a significant volume of fluid in one hour by grav-
tion and precise placement of an intravascular catheter are ity drip. This rate far exceeds the “shock rate” most com-
essential whether performing a single intravenous (IV) monly used in veterinary patients using realistic sizes and
injection or providing long-term vascular access in an ill or suggests that successful fluid resuscitation can occur with
injured patient. Understanding the care of intravascular smaller catheter sizes than previously thought. The use of a
catheters is key to avoiding adverse events. fluid pump or pressure bag may further increase this rate. As
a guideline, cats 24–22 G, small dogs less than 10 kg 24–22 G,
dogs 10–30 kg 22–20 G and dogs over 30 kg 20–18 G would
election of Catheter Insertion Site
S more than meet the needs of maximal fluid rates, and also be
and Type easier to place when a patient is in cardiovascular collapse.
In the author’s experience, obtaining a smaller catheter in
Many factors will influence the type of IV catheter used the emergency phase is better than delaying therapy attempt-
and the site chosen for its placement (summarized in ing to obtain the largest possible catheter.
Boxes 7.1 and 7.2). The length and diameter of the cathe- In a patient in cardiovascular collapse, the peripheral
ter selected must be appropriate for its intended use. veins may not be accessible, even with the smallest cathe-
Peripheral IV catheters are ideal in emergent patients as ter. In this case, consider the jugular veins, as they will
they are simple to place and allow for rapid fluid resuscita- often still be visible. A traditional over-the-needle catheter
tion. Central venous catheters may be preferable for long- (using a longer catheter for extra stability) can usually be
term patients, for serial blood sampling, central venous placed easily and sutured in place until the patient is stabi-
pressure monitoring and for additional therapies such as lized and the catheter can be replaced in a peripheral vein.
parenteral nutrition (PN). Emergently placed IV catheters should always be
Choosing the right catheter size is often left to the indi- replaced as soon as possible, as there was likely inadequate
vidual performing the task and it is rare to follow a protocol skin preparation (including minimum contact time and
in the veterinary field. In contrast, in human medicine, hand hygiene), and increased manipulation of the skin or
clear guidelines have been established for catheter size vessel, which could increase risk of contamination.
based on the type of therapy being initiated. The recom- There is a vast market of IV catheters (Figure 7.1).
mendation is to avoid catheter to vessel ratios greater than Catheters are generally categorized as over-the-needle,
45% (recently increased from 33%). For veterinary patients, through-the-needle, or winged (“butterfly”), and as either
there is often a desire to obtain the largest catheter possi- single or multilumen catheters.
ble, often fully occluding, or even stretching the vessel, in Butterfly catheters are not meant for extended use and
an effort to push fluids as fast as possible. This is often are best for blood collections or short injections. These are
unnecessary, and frequently delays therapy due to multiple nothing more than a steel needle with wings and a built-in
attempts at catheterization. extension set. Butterfly catheters should not be affixed to
84 Catheterization of the Venous Compartment
Box 7.1 Catheter Insertion Site Location

Considerations
● Patient size and species
● Venous accessibility
● Presence of physical barriers (wounds, fractures,
neoplasia, neurologic insufficiencies)
● Restraint requirements
● Temperament of patient
● Hemodynamic stability
● Coagulation abnormalities
● Vessel size
● Skill of the person placing the catheter
Box 7.2 Catheter Selection Considerations Figure 7.1 There are many different venous catheters available.
Catheter selection should be based on patient need and length of
● Length of hospitalization hospital stay. Source: Insyte Autoguard® Shielded Catheters, BD.
● Frequency of blood sampling
● Coagulation abnormalities in placing, have been tested in their patient population,
● Nutritional delivery and will train new personnel on their use, rather than
● Hemodynamic monitoring plan providing a selection of catheter brands.
Also available are specialty catheters impregnated with
Table 7.1 Gravity flow through various size and length radiopaque metal salts for radiographic confirmation of
catheters.
correct anatomical placement, or to locate accidentally
freed catheter fragments. In addition, IV catheters coated
Catheter gauge (G) Length Gravity flow
with antimicrobial substances marketed to decrease the
incidence of infection are now commercially available,
(inches) (mm) (ml/minute) (ml/hour)
although there is little evidence in veterinary medicine to
24 0.75 19 20 1200 support the claims of reduced infection.
Placement of any type of catheter should have a universal
22 1.00 25 37 2220
protocol in the hospital for placement. This protocol should
20 1.00 25 63 3780
encompass the selection of vessel and catheter type and size,
20 1.88 47 54 3240
hand hygiene and skin preparation, placement of the cathe-
18 1.16 29 95 5700 ter, affixing the catheter to the patient, and finally, care and
18 1.88 47 87 5220 maintenance of the catheter. Suggested placement protocols
16 1.16 29 193 11580 for each type of catheter discussed in this chapter are pre-
16 1.88 47 185 11100 sented below.
Care bundles for various procedures have been in use in
Source: Becton Dickinson Data: Insyte Autoguard® Shielded Catheters.
human medicine for many years, and provide a framework
the patient, and must be removed immediately upon for the placement and maintenance of many devices, with
completion of the procedure. the main goal of preventing device related hospital associ-
The structural material of the catheter can influence ated infection and complications, and critically evaluating
rigidity, ease of placement, and the potential for thrombo- the need of the device on a daily basis. The care bundle is
sis or phlebitis of the vessel. Common materials for IV essentially a checklist of “best practices,” and takes into
catheters include polytetrafluoroethylene, polypropylene, account preparation of supplies and patient, hand hygiene,
polyurethane, and silicone. Different brands of catheters wearing of caps/masks/sterile gloves and maintaining a
may be more flexible or have thicker-or-thinner walls, may sterile field, and ensuring all steps are followed. The care
be easier to affix than others (some catheters have wings on bundle is then used every 12–24 hours to ensure that
the hub which can make taping or suturing easier). Each the device is being maintained and closely monitored and
type has its advantages and disadvantages, and generally the veterinary team is critically evaluating whether the
speaking, users become comfortable with certain catheters device is still necessary. Care bundles can be created for any
over time, and rarely like to change brands/types. Ideally, device, such as IV catheter, central line, urinary catheter, or
each hospital will have a brand/type of catheter that the arterial catheters, to name a few. An example of a care bun-
majority of users are comfortable with, have good success dle created by the primary author is shown in Figure 7.2.
eeeetion of Catheter nsertion ite ann Tpe 85
CENTRAL LINE BUNDLE

Clinician’s Orders: Patient Label
Requested Catheter Type:

Requested Catheter Site: Jugular (Preferred) Saphenous
Procedure: Stable Patient Emergent
Sedation Orders:
Concerns:
Clinician Signature:
Insertion Checklist
Date Placed: New Catheter Replacement
Performed by:
Catheter Brand/Size/Lot #
Location R L
Jugular Saphenous
# of attempts: R Side L side New Catheter or Introducer each attempt?
Cutdown: Yes No Performed by:
Procedure Checklist
Safety Practice Yes
Assess location, clip area, apply Maxilene ointment & cover with plastic dressing
Assemble all supplies
Position patient and perform surgical skin prep of area, allow 5-minute contact time
Aseptically open catheter kit & prepare supplies
Wear a cap and mask
Hand Hygiene
Don sterile gloves
Use a sterile drape to cover field
Maintain a sterile field
Did the restrainer wear a cap and mask?
Apply sterile dressing to insertion site
Apply bandage to neck/limb to secure
Date & initial catheter
Form Completed by: Signature:
Figure 7.2 Central venous catheter care bundle example.

CENTRAL LINE BUNDLE

Catheter Care Checklist Date Placed:
Day # Bandage Catheter Assessed (Q12 hrs) and Comments Catheter Need Assessment (q 24
Changed* Care hrs)
Initials
1 am am Continue Remove
pm pm Clinician’s Initials
*Bandage change q 12 or 24 hrs: highlight preference (Minimum q 24 hrs)
Peripheral Catheter Placement over-the-needle catheter type include pericardiocentesis,

abdominocentesis, and thoracocentesis.
Peripheral venous catheters are the most commonly used Peripheral catheters are available in a variety of gauges
tools for obtaining vascular access in the small animal and lengths, typically ranging from 24 G to 12 G and from
patient. Ease and speed of insertion, low cost and versatil- 0.75 inches (1.9 cm) to 12 inches (30 cm) in length. Longer
ity of access in different anatomical locations make periph- catheters used for pericardiocentesis or abdominocentesis
eral catheters advantageous over other catheter types. Most are typically fenestrated for optimum fluid collection [1].
peripheral catheter types are categorized as over-the- Overall, ease of insertion and low costs associated with
needle, meaning that the catheter is fitted outside or over a placement and maintenance make the peripheral IV cath-
steel needle (Figure 7.3). The steel needle extends slightly eter ideal for initial venous access in the emergency patient.
beyond the catheter tip to facilitate venous entry. Once Peripheral over-the-needle catheterization is the most
venipuncture is accomplished, the catheter is slid off the common venous access technique in veterinary medicine.
needle into the targeted vessel. The technique is described in Protocol 7.1, however some
Anatomical locations for placement of peripheral cathe- common pitfalls that can be avoided are described below.
ters include the cephalic, accessory cephalic, or even the Peripheral catheters should not be placed on, or close to, a
jugular vein during stabilization. Other easily accessible moving joint (e.g. elbow) to avoid positional (flow) compli-
sites for placement include the lateral saphenous vein in the cations. The cephalic vein is the most common insertion
dog or medial saphenous vein in the cat. Less common site in dogs and cats and offers the radius and ulna as ideal
placement sites include the dorsal common digital vein, long bones to stabilize the catheter. Initiating catheter
auricular vein, or lingual vein. Other common uses for the insertion too high or using too long of a catheter should be
eripherae Catheter eaeement 87
avoided, as this can cause the catheter tip to terminate in

the elbow; or alternatively, too low a placement will require
hub stabilization over the carpus. Other insertion sites
described above can require more creative stabilization.
The authors do not recommend the routine use of a relief
incision (not to be confused with the mini-cutdown
described below) to gain access to the vessel, as it causes
trauma to the insertion site and increases mobility of the
final catheter. This is performed by using a similar, or
slightly larger size needle then the intended catheter, pierc-
ing the skin alongside the vein with the tip, and rotating so
the cutting edge of the bevel is facing up. The edge of the
needle is then pulled up and through the skin, resulting in
a small 1–2 mm incision. This technique is used by many as
a default for all insertions, however a proper insertion
angle, and using high-quality catheters can usually solve
insertion issues. Placing gentle traction on the skin and
using a 30-degree insertion angle to allow the bevel to cut
through the skin facilitates a smooth, atraumatic piercing
of the skin. A flat angle is a common mistake, requiring
additional force to pierce the skin resulting in burring of
Figure 7.3 The most common peripheral catheter is the the catheter and trauma to the skin.
over-the-needle type, meaning that the catheter is fitted outside After placement of the peripheral catheter, it is important
or over a steel needle. Such catheter types are very versatile and
can be placed in many different anatomical locations. that the catheter not move within the vein, as damage to the
Protocol 7.1 Peripheral Catheter Placement

Items Required 4) Perform hand hygiene.
5) Aseptically prepare the area using hospital protocol.
● Clippers
6) Perform hand hygiene again after prepping.
● Hand sanitizer or handwashing station
7) Restrain patient; avoid excessive stress to patient.
● Surgical scrub
Restrainer should occlude the vessel proximally to
● 1-inch porous medical tape
ensure maximum visualization.
● T-port or infusion cap
8) Unfold a sterile 3 × 3-inch gauze and place at the
● Saline flush
bottom of the prepped area (Figure 7.4). Use the
● Bandage material
gauze to apply gentle traction on the prepped area
● Appropriate work surface and at least one assistant
and minimize vessel roll. The gauze also prevents
the catheter from contacting hair at the bottom of
Procedure
the prepped area.
1) Select the best placement site, taking into considera- 9) Visualize targeted vessel, if palpation is necessary, do
tion patient comfort, ease of accessibility, and so away from the anticipated insertion site; point of
anticipated catheter dwell time. If chemical restraint is entry should be directly on top of or beside the
necessary, allow adequate time for optimum results. intended vessel.
Consider the use of a topical anesthetic. 10) Introduce catheter into the skin with bevel side up at
2) Collect necessary supplies. an angle of 30 degrees, the optimal angle to cut
3) Closely clip a generous area (2–2.5 inch – approximately through the skin. Once through the skin, reduce the
5 cm) around the intended insertion site and remove angle of the catheter to enter the superficial vessel.
any loose fur. There is no need to clip circumferentially 11) After a “flash” of blood is visualized in the stylet hub,
around the limb, but feathers should be trimmed to advance the catheter and stylet an additional
avoid hair contamination of the insertion site and make 1–2 mm, confirming blood is still flowing into stylet
tape removal more comfortable. and thus remains in the vessel.
13) Remove the stylet fully and attach a sterile infusion

cap to the catheter hub. If restrainer uses digital
pressure to staunch blood flow during this transi-
tion, ask them to occlude at the catheter tip, and
avoid touching near the insertion site.
14) If blood is required from the patient, remove from the
catheter at this point, using gentle negative pressure.
This may not be possible in small or cardiovascularly
collapsed patients.
15) Flush catheter with saline to ensure and maintain
patency. Replace injection cap with a preflushed
Figure 7.4 Demonstrating the use of an open piece of T-port if preferred.
gauze which keeps the catheter from contacting hair at the
bottom of the prepared area. The gauze can be used to place
16) Anchor catheter with adhesive tape. Avoid tape
traction on the skin to facilitate placement. Note the touching the insertion site, placing a sterile adhesive
30-degree angle used to enter the skin. Once through the bandage (“plaster bandage”) over the insertion site
skin layer, flatten the catheter to enter the vessel. prior to final taping (Figure 7.5).
17) Apply a light, protective bandage, again per hospital
12) Slide the catheter off the needle and into the vessel. protocol, and anchor infusion set to the outside of
During catheter advancement, ensure the stylet remains the bandage.
stationary, and the catheter is advanced off the stylet.
(a) (b) (c)
Figure 7.5 (a) Initial tape pieces secured only to the hub of the catheter, and do not contact insertion site. (b) A sterile adhesive
bandage is placed over the insertion site, with sterile pad contacting the insertion site. (c) Final tape is placed over top of the
bandage to secure.
vessel may occur and increase the risk of thrombus forma- angle as placed, avoiding kinks or bends. The use of a sterile
tion and phlebitis. There are numerous techniques for tap- adhesive bandage over the insertion site can act as a sterile
ing catheters in place, and this should be a hospital-wide buffer between the tape (which is frequently contaminated)
protocol that all technicians and nurses utilize. Avoid tech- and the insertion site and may reduce infection risk. If the
niques that use a single piece of tape as these are inherently patient is to be administered IV fluids, anchoring a small
unstable. The technique used must prevent movement of portion of the tubing line directly to the bandage will help
the catheter and should secure the catheter at the same reduce catheter migration and movement.
eripherae Catheter eaeement 89
Protocol 7.2 Mini-Cutdown

Items Required 3) Closely clip a generous area (2–2.5 inches, approxi-
mately 5 cm) over the intended insertion site and
● Clippers
remove any loose fur.
● Surgical scrub
4) Perform hand hygiene.
● 20- or 18-gauge hypodermic needle
5) Aseptically prepare the area using hospital protocol.
● Peripheral catheter
6) Perform hand hygiene and don sterile gloves.
● Saline flush
● T-port
Restrainer should occlude the vessel manually and
● Catheter cap
proximally to ensure maximum visualization.
● 1-inch medical tape
8) Visualize target vessel.
9) Use edge of bevel of 22–18G hypodermic needle as a
“scalpel” to cut the skin in a distal to proximal direction
Procedure
adjacent and directly parallel to the targeted vessel.
1) Select best placement site, taking into consideration 10) Dissect around vessel further as needed, using needle
patient comfort, ease of accessibility, and anticipated as a mini scalpel with bevel directed parallel to vein.
catheter dwell time. If chemical restraint is necessary, 11) Visualize vein and insert catheter.
allow adequate time for optimum results. 12) Secure catheter as usual and place a sterile dressing.
2) Collect necessary supplies. Suture or staple incision closed if necessary.
Peripheral Cutdown Techniques

In emergency situations, if traditional peripheral catheteri-
zation attempts are unsuccessful and the patient is in peril,
venous catheterization may require a cutdown procedure
(e.g. exposing the vein surgically). Cutdowns allow quick
vessel visualization and ensure catheterization on the first
attempt. In addition, cutdowns can allow placement of a
larger catheter than what can typically be placed percuta-
neously. Aseptic technique should be followed except in
dire situations. The veterinarian performing the cutdown
procedure should wear sterile gloves.
Mini-Cutdown
The mini-cutdown technique is performed to gain access
to either the cephalic or lateral saphenous vessel that Figure 7.6 A sterile 18–22-gauge hypodermic needle can be
may be collapsed or difficult to enter (Protocol 7.2). While used to create a mini “cutdown” when venous visualization is
this procedure does not isolate the vessel like a surgical difficult.
cutdown described below, it does provide better visuali-
zation, which can increase catheter insertion success.
tissue. Blunt dissection with mosquito forceps may be
Using a sterile 18–22 G hypodermic needle, hold the nee-
required to visualize the vein; minimal dissection is usually
dle with the bevel up and use the needle tip to cut the skin
required for the placement of an over-the-needle or
directly parallel to the targeted vessel (Figure 7.6). Infusion
through-the-needle catheter.
of subcutaneous lidocaine prior to the mini-cutdown is
rarely needed. Once the incision has been made, the skin
defect can be moved directly over the vessel. Tearing of the Surgical Cutdown
skin will release skin tension without damaging the under- A surgical cutdown is sometimes necessary to obtain vascu-
lying vessel, allowing for better visualization necessary for lar access in patients with hypovolemia or if central venous
rapid catheter placement. A small incision can also be made access is needed for hemodynamic monitoring, parental
adjacent to the vein with a number 11 scalpel blade, using nutrition or hemodialysis (Protocol 7.3). Surgical cutdowns
caution to avoid incising the vessel and subcutaneous can be used to access the external jugular, cephalic or lateral
Protocol 7.3 Surgical Venous Cutdown

Items Required occlusion during incision to avoid accidental vessel
laceration.
● Clippers
7) If chemical sedation or general anesthesia is not fea-
● Surgical scrub
sible, infuse lidocaine (0.2–0.5 ml) into the subcuta-
● Sterile gloves
neous region around the intended insertion site.
● Sterile mosquito forceps
8) Prepare skin with a final surgical scrub and maintain
● Sterile thumb forceps
a sterile field by placing eye drape over prepared area.
● Sterile sharp-sharp scissors
9) Make a skin incision immediately parallel to the ves-
● Sterile needle driver
sel with a #10 or #15 scalpel blade.
● Sterile catheter
10) Use blunt dissection to expose vein; dissect vein with
● Sterile syringes filled with saline
curved hemostats so minimal fascia remains attached.
● Sterile injection port and T-port
11) Slide hemostats under vein to level of handles to cre-
● Sterile absorbable monofilament suture
ate a platform.
● Sterile scalpel blades (#10, #11, #15)
12) Tie off vein distally (or cranially if jugular vein is
● Sterile 4 × 4-inch gauze squares
used) using absorbable monofilament suture; keep
● Small eye drape
ends long to use for traction.
13) Place second suture around vein proximally, but do
● Optional: catheter introducer, towel clamps
not tie.
14) Insert #11 scalpel blade parallel to vessel length,
Procedure
through center of vessel; turn 90 degrees and cut
1) Select best placement site, taking into consideration outward.
patient comfort, ease of accessibility, and anticipated 15) Using catheter introducer or blunt end of curved nee-
catheter dwell time. If chemical restraint is necessary, dle, open vessel and slide in largest bore catheter
allow adequate time for optimum results. possible.
2) Collect necessary supplies. 16) Tie second suture trapping vein to catheter; ensure at
3) Closely clip a generous area (2–2.5 inches – approxi- least 3 mm tissue bumper.
mately 5 cm) around the intended insertion site and 17) Secure catheter to fascia of neck or thigh muscles as
remove any loose fur. appropriate for location.
4) Aseptically prepare the area using hospital protocol. 18) Suture incision (leave partially open if not performed
5) Perform hand hygiene and don sterile gloves. under aseptic conditions).
6) Restrain patient; avoid excessive stress to patient. 19) Towel clamps can be used for temporary closure of
Restrainer should occlude the vessel proximally to incision.
ensure maximum visualization but should release 20) Place sterile dressing.
saphenous veins, with similar technique for all venous sites with mosquito forceps adjacent to the vein (Figure 7.7a).
(Figure 7.7). Complications of a surgical cutdown can The vein can be identified as a blue to-purple tubular struc-
include perforation of the vascular wall, shock or hematoma, ture within the subcutaneous tissue. Thumb forceps can be
thrombosis, venous transection, infection, and cellulitis. used to retract the subcutaneous tissues to expose the ves-
Cutdown incisions should be made (i) in the middle to sel. Dissection of adventitial tissue adjacent to the vein can
cranial portion of the jugular groove for catheterizing the be facilitated by the use of sharp-sharp scissors dorsally
external jugular vein; or (ii) on the dorsal antebrachium or and ventrally to the vein; dissecting in a parallel fashion
lateral aspect of the distal tibia, respectively, for the cephalic will minimize vessel trauma or rupture.
and lateral saphenous catheterization. Once the vessel is isolated from the subcutaneous tissue, a
After clipping and performing an aseptic preparation of blunt hemostat is slid beneath the vessel through tissue as a
the targeted area, a scalpel blade is used to incise the skin type of “platform” for the vessel to lie on top of the instru-
directly over, or adjacent to the vein. Either a transverse or ment (Figure 7.7b). A silk suture is then clasped by the hemo-
a parallel skin incision can be made, using caution to incise stat and drawn beneath the vessel. The suture can be used to
only the full thickness of the skin. If the vessel is not imme- retract the vein distally to provide adequate tension for cath-
diately identified, it may be necessary to bluntly dissect eterization in the case of peripheral vessels. Alternately, the
Centrae Venous Aeeess 91
(a) (b) (c)
Figure 7.7 (a) The isolation of the vessel can be accomplished by blunt dissection of the subcutaneous tissue adjacent to the vein. (b)
A hemostat can be slid underneath the vessel to create a “platform” to facilitate venous entry. (c) Tie off the vessel proximally using
absorbable suture.
jugular vein may be sacrificed by ligating it cranially and veterinary technicians should monitor the patient for edema
using the ligature to retract the vessel. A second suture is of the neck or sternum, pain with administration of medica-
placed beneath the vessel proximally (Figure 7.7c). The vein tions, sluggish flow through the catheter, or an inability to
is then cannulated through a venotomy (or by venipuncture) aspirate blood back from the catheter. It may be prudent to
between the two ligatures. Following catheterization, the dis- avoid central venous catheters in patients at risk of thrombo-
tal suture is tied, securing the catheter in the vein [1]. sis (e.g. immune-mediated hemolytic anemias) or in animals
The catheter should be replaced once the patient is resus- with known or suspected coagulopathy. In addition, occlu-
citated and hemodynamically stable. Remove the catheter sion of the jugular vein may increase intracranial pressure
by using gentle traction and applying direct pressure over during insertion, which is a relative-to-absolute contraindi-
the insertion site for several minutes. Allow the incision to cation in patients with head trauma or other central nervous
heal by second intention if it was not placed under aseptic system disturbances. In patients requiring central venous
conditions. access and whose intracranial pressure may be elevated, a
peripherally inserted central catheter (PICC) can instead be
placed via the medial saphenous or lateral saphenous vein.
Central Venous Access
Catheter Types for Central Veins
Central venous catheters have many advantages over
peripheral catheters, including that they allow for a longer Central venous catheter types include long over-the-
dwell time, measurement of central venous pressure, safer needle, through-the-needle, and guidewire catheters; all
administration of hyperosmolar solutions such as total types can be placed via a peripheral or central vessel.
parental nutrition, and serial blood sampling with mini- Shorter over-the-needle catheters are used primarily for
mal stress to the patient. The central venous catheter is peripheral vein catheterization but can be centrally placed
typically introduced via the jugular vein, but it can be in pediatric patients. One disadvantage of centrally located
readily inserted into the caudal vena cava via the lateral over-the-needle catheters is patient discomfort, as these
saphenous in the dog or the medial saphenous vein in the items tend to be stiff and can malfunction due to kinking.
cat. Central venous catheters are available with either a Guidewire central venous catheters are placed by the
single lumen or with multiple lumens, which allows for modified Seldinger technique and include single and multi-
the simultaneous delivery of incompatible fluid types as is lumen catheter systems (i.e. Arrow® Central Venous
often needed in the critical patient. Central venous cathe- Catheter, Teleflex Medical, Research Triangle Park, NC; see
ters are less likely to be affected by both patient position- Figure 7.8). Catheters placed by the modified Seldinger tech-
ing and motion at the point of insertion than peripheral nique are typically soft and flexible and made of a polyure-
catheters. Centrally situated catheters also allow for can- thane material, which is antithrombogenic and can dwell in
nulation of larger vessels. the patient for a longer period. These catheters are available
Disadvantages of central venous catheters include a longer in a multitude of gauge, length, and lumen number combi-
placement time, greater expense, slight patient discomfort nations. Certain guidewire central venous catheters are
during placement and the longer length may make rapid impregnated with antimicrobial substances that may reduce
fluid administration problematic. Monitoring for extravasa- the likelihood of catheter-related sepsis. Disadvantages of
tions with the central venous catheter can also be more dif- the modified Seldinger central venous catheter types are
ficult than in the peripheral over-the-needle catheter; expense, increased risk of local hemorrhage during
insertion, procedure time, and expertise needed for place-

ment. It is the authors’ opinion, however, that the risks and
expense of such central venous catheters are far outweighed
by the advantages in many critical patients.
Peel-Away® (Cook Medical, Bloomington, IN) sheath
introducers can be used to introduce similar catheters to
those inserted with the modified Seldinger technique: sin-
gle to multi-lumen, flexible, and long-term. They can also
be used to insert PICC which are very long, thin catheters
specifically designed for peripheral insertion (typically
saphenous vein). PICCs are usually made from silicone,
can be cut to length, can be single or double lumen, and
can stay in place for extended periods with proper mainte-
nance. Peel-Away sheaths are a specialized catheter that is
placed into the vein and advanced like an over-the-needle
catheter (Figure 7.9). The final catheter is inserted through
Figure 7.8 Central venous catheter kits using the guidewire
(modified Seldinger) technique; such catheters range from the lumen of the sheath until it is at the desired depth. Tabs
single to multilumen devices. on either side of the sheath are pulled, causing the sheath
(a) (b) (c)
(d) (e) (f)
Figure 7.9 The Peel-Away® (Cook Medical, Bloomington, IN) sheath introducer can be used for single or multilumen catheters. (a)
Insertion of sheath introducer. (b) Single lumen catheter inserted through the sheath. (c) Activating the peel-away. (d) Removing the
peel-away. (e) Affixed catheter with suture. (f) Final bandaged catheter. ouree: Courtesy of Carolyn Sidenberg.
to split down the middle and allow it to be removed by con-

tinued pulling of the tabs. This results in only the final
catheter remaining in the vein. This method offers advan-
tages of a high-quality catheter with a relatively simple
placement. Disadvantages are the large sheath size (larger
than the final catheter), which can be challenging to seat in
the vessel.
Through-the-needle long catheters are “all in one” sys-
tems that are passed through a needle and are typically
longer than over-the-needle catheters (8–12 inch, 20–30 cm)
and available in various diameters. These are usually found
in the 22–18 G range. Multiple varieties are commercially
available (e.g. VeinCath® or Drum Long Line Catheter,
MILA International, Erlanger, KY; see Figure 7.10). A plas-
tic sleeve or case around the catheter prevents its contami-
nation during placement. While previous versions of
through-the-needle catheters did not allow the needle to be
removed, requiring a needle guard to cover the needle, (a) (b)
modern versions allow the needle to be disconnected from
the system. Through-the-needle catheters can be placed in Figure 7.10 Two through-the-needle catheter examples. (a)
the jugular, or in a peripheral vessel (canine lateral saphen- Drum long line catheter (MILA International, Erlanger, KY). (b)
ous or feline medial saphenous) when the jugular vein is Long-line catheter (MILA International, Erlanger, KY). ouree:
Reproduced with permission from MILA International.
not a feasible option, such as in patients with coagulopathy
or severe bite wounds to the cervical region. Advantages to
Central Venous Catheter Placement Techniques
the through-the-needle catheter include low cost, and
speed and ease of placement. Disadvantages include the Guidewire Central Venous Catheter Technique
potential of shearing of the catheter on the sharp needle Guidewire catheters use the modified Seldinger technique
edges, and excessive bleeding (the hole made by the needle and can be placed percutaneously or via a mini or surgical
is slightly larger than the catheter that remains). These cutdown (Figure 7.6 and 7.7; Protocol 7.4). Commercially
catheters are usually only single lumen and require some available in single, double, or triple lumen, sizes range
creativity to keep them from kinking. from 22- to 16-gauge catheters for peripheral use, and from
Protocol 7.4 Modified Seldinger Technique–Placing a Vascular Catheter over a Guidewire

Items Required Procedure
● Clippers 1) Generously clip fur and place topical anesthetic such
● Surgical scrub as 4% liposomal lidocaine or lidocaine/prilocaine
● Sterile gloves ointment over the vessel. Cover in a non-absorbent
● Sterile drape with small hole (if not included in kit) dressing. Allow to sit for 15–30 minutes for optimal
● Over-the-needle catheter that fits guidewire analgesia.
● #11 scalpel blade (if not included in kit) 2) Analgesia ± sedation should be considered, allow ade-
● Guidewire catheter kit quate time for optimum results. Collect necessary
● Sterile gauze squares (if not included in kit) supplies.
● Saline flush 3) Patient should be placed in lateral recumbency with
● T-port(s) neck extended and thoracic limbs gently pulled cau-
● Suture material dally. It is recommended that two people restrain the
● Needle holders animal, one occluding the vessel and restraining
● Thumb forceps the cranial end of the patient, the other restraining the
● Bandage scissors patient’s caudal end.
● Bandage material 4) Remove dressing with topical anesthetic and wipe
● At least one assistant area. Assess clipping and expand as needed to avoid
contamination of insertion site, at least 2–2.5 inches 16) At all times when the wire is in the patient, it must be
(5 cm) around intended insertion site. held and stabilized. If necessary, have a second assis-
5) Perform hand hygiene, don cap and mask, have tant with gloved hands hold the wire while complet-
restrainer do the same. ing the next steps.
6) Aseptically prepare the area per hospital protocol. 17) Feed the vessel dilator over the guidewire, to the
7) Perform hand hygiene and don sterile gloves. level of the skin, again, taking care to avoid changing
8) Prepare skin with a final surgical scrub and maintain the depth of the wire. Tent the skin at the insertion
a sterile field. site, and using a #11 scalpel blade with the cutting
9) Sterilely drape the area with hole centered over edge pointing “up” and the tip entering the same hole
insertion site. Many catheter brands provide small as the guidewire, make a stab incision through the
drapes for this procedure, otherwise small “eye skin. Continue to tent the skin and gently rotate the
drapes” work well. dilator into the vessel (Figure 7.11b). Insert the full
10) Premeasure the central catheter length from the length of the dilator into the vessel (depending on
intended insertion site to the intended catheter tip patient size), and then remove the dilator from the
resting point. For jugular catheters, the ideal resting guide wire. Advancing the full length ensures that
point is in the cranial vena cava at approximately the the dilator has expanded tissues in the interstitial
level of the third to fourth intercostal space. The tip of space and entered the jugular. Expect bleeding from
the jugular catheter should rest in the cranial vena the insertion site, and use sterile gauze to apply pres-
cava just cranial to the right atrium if central venous sure while transitioning to the next steps.
pressure monitoring is anticipated. Most catheters have 18) Insert the catheter over the wire but no not enter the
markings every centimeter to assist with this placement. skin untie the wire ean be graspen from the nistae port
11) Clamp any additional lumens other than the “distal (Figure 7.11c). The wire should be held steady as the
port” (marked, often brown), and remove injection cap catheter is advanced off the wire, and into the vessel.
if present, from the distal port. Optionally, before If multilumen catheters are used, the wire will exit
clamping additional lumens can be flushed with the distal port. Once fully advanced to the premeas-
saline, then clamped. The distal port is not usually ured depth, remove the wire and leave the catheter
flushed, as it remains open and saline will run out. in place.
12) Ask restrainer to put pressure on the jugular vein at 19) Aspirate air from the catheter with a small syringe;
the thoracic inlet. They may also be asked to put blood should easily flow into the syringe. Flush the
some tension on the skin to help stabilize the vessel. catheter with sterile saline and clamp and cap port(s)
13) Place the introducer catheter into the vein, with the with a T-port or an injection plug. Repeat procedure
tip pointing in the direction of the heart; ensure a for each port if a multilumen catheter is used. It is
“clean” stick with adequate blood flow, advance cath- important to always aspirate the catheter first, before
eter and remove stylet. At this point, ask the restrainer flushing, so as not to create an air embolus, even if
to remove pressure from jugular vein. the catheter port(s) were preflushed.
14) Insert the flexible J end of the guidewire into the 20) If the entire length of catheter is not used, secure the
introducer catheter. Note, the J-wire must first be excess catheter with the plastic catheter holders pro-
straightened by pulling it back into the wire housing, vided. Secure the catheter in place with sutures
then inserting the pointed tip into the catheter hub. between the skin and the designated grooves or
Advanced the wire, using the thumb guide and not- holes on the catheter hub and/or the plastic catheter
ing the markings on the wire. These markings are at holders (Figure 7.11d). Place a sterile dressing over
10 cm intervals, and are visible through the wire the insertion site, preferably clear like Tegaderm, so
housing. Ideally, the wire should be inserted to the the insertion site can be monitored.
length of the catheter being placed (Figure 7.11a). 21) Apply a loose neck wrap containing cast padding or
Some brands do not have markings on the wire, and stretch bandaging followed by a water-resistant
depth must be estimated by watching the end of the bandage. Tape T-port or multilumen ports on outside
wire as it moves through the housing. of the bandage for easy access. Ensure the bandage is
15) While holding the wire steady at the insertion site, not tight; several fingers should easily slide under
remove wire housing, then the introducer catheter; the bandage. Recheck patency of the catheter by
ensure that the wire does not inadvertently back out aspirating blood once the bandage is in place.
or touch a nonsterile field. Have sterile gauze pre- 22) Label the catheter with size, date, initials and date of
pared as the insertion site often bleeds. bandage change.
(a) (b)
(c) (d)
Figure 7.11 (a) After aseptically preparing the area, straighten, then insert the J-end of the guidewire into the vessel via the short
over-the-needle catheter. (b) Passage of the dilator may be accomplished by “tenting” the skin and gently but firmly rotating the
dilator into the vessel. (c) Insert the catheter over the wire and guide into the vessel. (d) The catheter is secured in place with skin
sutures attached to the wings of the plastic applicator.
14- to 24-gauge catheters for central use; lengths range frequently as it may tighten with neck movement and rehy-
from 16 to 55 cm. Most guidewire catheters come in kits dration; the patient should be monitored for airway com-
containing the percutaneous introductory short catheter, promise and facial edema. When the catheter is removed,
the central venous catheter, guide wire (typically encased apply direct pressure to the insertion site for five minutes
in a protective plastic case for sterile insertion), dilator, followed by application of a neck bandage to prevent hem-
flush syringe and anchoring device (Figure 7.11). The orrhage. The neck bandage may be removed after one to
authors recommend using a standard over-the-needle two hours.
catheter that the operator is familiar with as the introducer,
rather than the introducer provided in the kit. It is impor- Through-the-Needle Catheters
tant however to ensure that the introducer size chosen will Placement of a through-the-needle catheter requires stand-
allow the guidewire to pass through the catheter (not the ard fur clipping and aseptic site preparation. Ideally, a
stylet), so always test this prior to insertion. With correct small drape will cover the neck, or an opened sterile gauze
placement and care these catheters can stay in place for will cover the bottom of the prepared site. With either the
longer periods, usually for the duration of hospitalization. neck or limb extended, and tension on the skin to prevent
(Table 7.2 summarizes the indications for the different needle drag, the needle is inserted at a 30-degree angle with
catheter types.) the bevel side up over the targeted vessel. The insertion site
Care of central venous catheters is critical to maintain should be close to, but not directly on, the targeted vessel.
patency, patient comfort and to prevent infection and com- After the needle is passed through the skin, the vein is then
plications (see Chapter 63 for more information). The cen- punctured directly from the top. Blood will usually flash
tral venous catheter bandage should be monitored back into the catheter, which confirms that the catheter is
Table 7.2 Indications for different catheter types.
Catheter type Indications Relative or potential complications
Peripheral Jugular vein not accessible Catheter shearing by introducer needle

through-the- Coagulopathy Excessive bleeding
needle long
catheter Severe bite wounds or edema to the cervical region
Frequent blood sampling needed
Aggressive cat; restraint often easier for medial saphenous
placement than for jugular placement
Cervical disease or pain (atlantoaxial luxation or cervical disk
disease)
Increased intracranial pressure; desire to avoid increasing
intracranial pressure through occlusion of jugular vein
Central venous Central venous pressure monitoring indicated Thromboembolic disease
catheter Infusion of total parenteral nutrition or other hyperosmotic Coagulopathic disease
fluid
Prolonged hospitalization expected Respiratory disease (increased
placement time)
Frequent blood sampling required Immune-mediated hemolytic anemia
(due to thromboembolic disease
potential)
Multiple ports required for simultaneous delivery of various Increased intracranial pressure (actual
fluids and medications or suspected)
Cervical disease or pain (atlantoaxial
luxation or cervical disk disease)
Vascular Chemotherapy Sepsis
access port Delivery of sedation for repeated radiation therapy treatments Thrombosis
Long-term delivery of intravenous medications or fluids
Repeated blood sampling
Total parenteral nutrition
Intraosseous Severe hypotension Pneumatic bones
catheterization Severe dehydration Metabolic or infectious bone disease
Extremely small body size (neonates, exotic animals, pocket Skin infection around proposed
pets) catheter insertion site
Inaccessible venous access (e.g. edema, thrombosis, severe
burns)
situated within the vessel; the catheter is then advanced Ultrasound-Guided Venous Access
into the vein. Depending on type of catheter used, the cath-
eter is advanced by pushing it through the plastic sleeve The availability of ultrasound in veterinary medicine is
into the vein, or the drum is rotated to feed the catheter increasing and has gained popularity not only for diagnos-
into the vein. Resistance to advancement should be mini- tics at the bedside, but also for procedures. Ultrasound-
mal. Once the catheter has been fed entirely into the vessel, guided venous access is a very useful skill, as it can assist in
the stylet, if present is pulled, the needle is removed and successfully catheterizing difficult veins. Many will use
the clamshell adapter is attached. The catheter is aspirated ultrasound when traditional attempts have not been suc-
to ensure blood flow, any samples necessary are obtained, cessful, however it is becoming more and more common to
and the catheter is flushed with 0.9% saline. The catheter use ultrasound for all attempts, particularly for central
should be anchored with skin sutures, covered in a clear veins. In human medicine, ultrasound-guided access has
dressing such as Tegaderm™ (3M™, St. Paul, MN), and become the norm for central venous access. This modality
protected with a soft bandage. is comprehensively discussed in Chapter 9.
Aeternate Vaseuear Aeeess ptions 97
Alternate Vascular Access Options infusions allow for infusion into the medullary cavity, a
highly vascular space, and uptake into the systemic circula-
Intraosseous Catheterization tion is similar to direct IV injection. Advantages of intraos-
seous catheter placement include speed and ease of
Intraosseous (IO) catheterization is a procedure in which a placement, minimal complication rates, ease of fluid
needle is placed into the medullary cavity of a bone, typi- administration and minimal cost of supplies.
cally when the need for vascular access is urgent and The IO route is most commonly used in cardiopulmonary
venous catheterization cannot be performed quickly arrest, cardiovascular collapse (shock), and may also be used
(Protocol 7.5). The IO space is easily accessible even in the in neonates in place of IV access. In many cases, placing an
most dehydrated or hypovolemic animal. IO catheter is much faster than attempting an IV catheter.
IO catheters are an alternative to IV access in critically ill The Reassessment Campaign on Veterinary Resuscitation
patients. Once placed, they may be used to deliver almost (RECOVER) Initiative has recognized IO to be superior to
any drug, fluid, colloid, or blood product to the patient. IO intratracheal administration of drugs during CPR.
Protocol 7.5 Intraosseous Catheterization

See also Figure 7.12. 9) Prepare skin with a final surgical scrub and maintain a
sterile field.
Items Required
For Needle Intraosseous Catheter Placement
● Clippers
1) Place a finger on the long axis of the bone in which
● Surgical scrub
the catheter will be placed, to determine its axis and
● 2% lidocaine in a 1-ml syringe with a 23–25 G needle
location.
● Suture material
2) If using the femoral trochanteric fossa, adduct the limb
● Saline flush
slightly (toward ventral midline) and rotate trochan-
● T-port
teric fossa laterally to avoid the sciatic nerve.
● Hypodermic needle appropriate for patient size (e.g.
3) Insert the catheter distally lengthwise into the medulla
22 G, ¾ or ½ inch long) for small patients or neonates,
of the femur or humerus cortex parallel to the finger
or spinal needles
held alongside the bone, aiming for the trochanteric
● EZ-IO® drill and catheters (MILA International, Erlanger,
fossa if the femoral trochanteric fossa is the insertion
KY) or bone marrow needles for adult patients whose
site. Simultaneously push and twist the needle in a
bones have already ossified.
single line (i.e. avoid movement in the third dimen-
Note that spinal needles, containing an outer needle sion). Expect initial resistance as the needle passes
and an inner stylet, work very well, as the shafts of hypo- through the cortex. If resistance is felt as the needle
dermic needles used on the neonate can become clogged passes through the cortex into the medulla, the bevel
during placement. of the needle may be seated incorrectly, causing block-
age. Gently turn the needle 90–180 degrees to
Procedure dislodge and attempt placement again.
4) Once the needle is in place, push the hub of the needle
1) Select best placement site, taking into consideration
back and forth, simultaneously moving the limb; the
patient comfort, ease of placement and anticipated
hub of the needle should be seated securely in the
catheter dwell time.
shaft of the bone and move along with the bone when
2) Collect necessary supplies.
the limb is moved.
3) Closely clip a generous area (2–2.5inches, c. 5cm) around
5) Aspirate needle or catheter; aspiration of bone marrow
the intended insertion site and remove any loose fur.
confirms placement. A radiograph can also confirm the
correct anatomical location.
5) Aseptically prepare the area as per hospital protocol.
6) Flush gently with a small amount of saline; little
6) Perform hand hygiene; if the patient is immunocom-
resistance should be felt. Attach a T-port.
promised, it is recommended to wear sterile gloves.
7) Anchor the catheter either by placing a stay suture
through the skin near the catheter hub and attaching
8) Administer a small amount of lidocaine to the level of
that suture to the tubing of the T-port, or by stapling a
the periosteum.
(a) (b)
(c)
Figure 7.12 (a) Potential locations for intraosseous catheter placement (as indicated by needles) include the trochanteric fossa of
the femur, the wing of the ileum, the proximal humerus, and the tibial tuberosity. (b) An intraosseous drill and catheter used for
rapid intraosseous access in adult animals (EZ-IO®, MILA International, Ehrlinger, KY). (c) A hypodermic or spinal needle appropriate
for patient size or a bone marrow needle can be used as an intraosseous catheter. Ideally, the catheter should be inserted with
gloved hands through an aseptically prepared site. ouree: Courtesy of Kathryn Powell.
small butterfly tape anchor from the catheter hub to 4) Disconnect drill and remove stylet.
the skin. 5) Aspirate and check for flash of blood to verify
8) Check for displacement of the catheter at least placement, then rapidly and forcefully infuse 5–10 ml
twice daily. of sterile saline. This will expand the cavity and allow
for better fluid flow.
For Drill Intraosseous Catheter Placement
6) Attach fluid line and begin fluid resuscitation.
1) The most common sites are the lateral proximal 7) EZ-IO catheter should be removed as soon as vessels
humerus and the medial proximal tibia. are obtainable, within 24 hours. In the author’s experi-
2) Perform a small stab incision with a #11 blade. Attach ence, vessels can usually be obtained within an hour of
catheter to drill and push the needle through the stab beginning fluid therapy.
incision. Have an assistant hold skin taught.
For All IO Catheters:
3) Push catheter against bone (perpendicular to the long
axis) and activate drill. Maintain pressure until catheter 1) Check surrounding tissue for fluid leakage
is at desired depth (it is easy to go too far and into the 2) If leakage is evident, the catheter may need to be
cortex on the other side of the bone). removed and another bone tried.
Care of ntraaaseuear eaiees 99
Dosages between IV and IO are identical, and blood sam- Catheter bandages should be removed fully to allow
ples can often be obtained by aspirating marrow from the inspection of the catheter site at least once daily. Adhesive
medullary cavity. tapes must be examined for tightness, dryness, or blood
Clinical indications for IO catheterization include staining; bandages contaminated with body fluids should
severe vascular collapse (e.g. hypovolemic shock), severe be replaced immediately. Another benefit of the sterile
vascular trauma, peripheral edema, thrombosis, small adhesive bandage at the insertion site of the catheter is that
patient size (e.g. neonates, exotics), or even obesity. the final piece of tape need only be removed so the sterile
Mastering IO catheterization, which is simple to perform, bandage can be lifted to examine the insertion site, before
can prevent patient death when timely vascular attempts replacing the tape and final bandage.
are not feasible or practical. Locations for intraosseous While sterile technique should be maintained for any
catheter placement include the trochanteric fossa of the vascular device intervention, nursing management of cath-
femur, the wing of the ileum, the proximal humerus and eters used for PN warrants special focus, since nutritional
the tibial tuberosity (Figure 7.12a). Potential complica- formulas are excellent media for bacterial colonization.
tions are minimal; fracture of the bone at the catheter site, Proper catheter care of a PN catheter includes strict aseptic
infection, osteomyelitis, edema and patient discomfort technique during insertion, including proper skin prepara-
associated with rapid fluid infusion are the reported com- tion, placement of a sterile underwrap over the insertion
plications to intraosseous catheterization [2]. The most site, and strict aseptic technique when handling PN admin-
common complication is dislodgement of the catheter due istration tubing and bags. The IV lines should not be dis-
to animal movement. When this technique is applied to connected; if diagnostic testing or frequent walking is
other species, care must be taken never to introduce fluids necessary, PN administration lines and bags should accom-
into pneumatic bones. Medications targeted for IV admin- pany the patient after clamping lines to avoid accidental
istration can be used via the IO catheter or needle. Rate of rapid infusion. If a multilumen catheter is placed, proper
maximal fluid administration is related to the diameter of identification of each port is necessary, with one line dedi-
the catheter or needle. cated to the PN solution only.
Catheter Flushing
Care of Intravascular Devices
Catheters should be flushed with a small volume of sterile
saline (0.5–2 ml, depending upon catheter length and size
Catheter care is important to avoid complications and to
of patient) at least every 8–12 hours. Several studies have
ensure patency for the desired duration of any indwelling
indicated that 0.9% saline is as effective as heparinized
intravascular device, as it predisposes a patient to device
saline in maintaining catheter (peripheral and central)
associated infection. All personnel involved with the
patency, although most have been conducted in the healthy
placement or handling of the catheter should use aseptic
patient population [3]. The evidence seems clear that rou-
technique when placing, changing bandages, administer-
tine use of heparinized saline is no longer necessary, and
ing fluids or medications, withdrawing blood, or while
may be reserved for only certain patients, and at the clini-
using monitoring devices attached to the catheter.
cian’s discretion. The authors recommend flushing any
Infection may occur as a result of contaminated IV solu-
unused central venous catheters or ports every four hours
tions, contaminated injection ports, catheter caps or
with 1.5–3 ml of flush using sterile technique. See
T-ports, poor skin preparation or insertion techniques or
Chapter 63 for more detailed information.
failure to routinely change the catheter bandage.
Monitoring equipment should be cleaned and disinfected
between patients. Multiple ports and lines should be
Peripheral Intravenous Catheters
labeled appropriately and handled with aseptic tech-
nique. Ports should be swabbed with alcohol and allowed A peripheral IV catheter can remain in place for as long as
to dry prior to introduction of a needle. Insertion sites it is functioning as expected, is clean and dry, there is no
should be routinely monitored for thrombosis, which redness at the insertion site, and there is no pain on injec-
causes a “ropey” feel to the vessel; for patient discomfort, tion or flushing. The exception to this is catheters placed
redness, heat, or swelling around the insertion site; for emergently, these catheters should be replaced as soon as
catheter migration either into or out of the skin in com- possible, as it is likely that steps were missed such as hand
parison with its depth at initial insertion; and for subcu- hygiene, and proper skin asepsis. Any cutdown incision
taneous extravasation, which can lead to discomfort upon made during placement can increase the potential for
injection and the accumulation of fluids or medications infection; these catheters should be replaced or removed as
under the skin. soon as possible. Any catheter should be removed when no
longer needed [4]. Intraosseous catheters are similar to IV for any catheter in any anatomical location. The authors
catheters, and it has been suggested that they can stay in recommend the use of commercially available sterile
place for over three days in veterinary patients if no signs syringes of flush. Any patient with an unexplained fever,
of infection are found [3]. pain upon injection, or inflammation at a catheter inser-
tion site should be investigated for a catheter-related infec-
tion. Suspicious catheters should be removed immediately
Central Intravenous Catheters
See Chapter 62 for in-depth discussion.
Central IV catheters may dwell for the length of patient Phlebitis is another commonly encountered complica-
hospitalization as long as there is no suspicion of catheter- tion of indwelling vascular catheterization. Phlebitis can
related infection [4], however, they require daily insertion- occur due to inflammation associated with movement of
site inspection for signs of thrombosis or leakage and daily the catheter in the vessel, irritation of the vessel from the
site maintenance. Evaluation of the patient for nasal or oral catheter or fluids/medications administered, or due to bac-
discharge, facial swelling, difficulty swallowing, and terial infection, which can lead to sepsis.
impaired breathing can be indicators of jugular vein throm- Air embolism can occur if lines become disconnected or
bosis [5]. Central venous catheter care also requires daily a significant volume of air is present within an administra-
inspection as indicated above for peripheral catheters. As tion set. Central venous catheters have the highest risk of
central catheters are significantly longer than peripheral incidence as air can be suctioned in due to negative pres-
catheters, signs of extravasation may not be as apparent. sure within the thorax [4]. Central venous catheters and
The midsternal region should be examined for edema large-bore catheters pose the risk of exsanguination if
related to any jugular venous catheter and the proximal patient interference or disconnection goes undetected.
aspect of the pelvic limb should be examined for edema Catheter embolism can occur if a fragment of the catheter
related to lateral or medial saphenous venous catheter becomes free within the vessel either due to placement
placement. Patency can be evaluated by ensuring blood can error or patient interference. Radiopaque catheters can
be aspirated. Note that neck bandages should follow the allow radiographic investigation to locate any such frag-
“two finger rule,” wherein the bandage is loose enough to ments and aid in planning for surgical retrieval.
slide two fingers underneath to help ensure patient com- Thrombus formation can occur with any venous or arte-
fort. If it is necessary to change a central catheter and rial cannulation, particularly if there is endothelial damage
catheter-related infection is not suspected, replacement within the vessel. Smaller veins with slower blood flow, the
can sometimes be done by passing a sterile guide wire use of rigid catheters, insertion over a joint, or pre-existing
through the existing catheter, removing the catheter and conditions such as immune-mediated hemolytic anemia,
aseptically placing a new one over the wire [4]. glomerulonephritis, or vasculitis may increase the risk of
thrombus formation. Severe thrombus formation could
lead to pulmonary thromboembolism.
Complications
Bacterial contamination of catheter sites can result from

Acknowledgment
skin contamination at insertion, contamination from
This chapter was originally authored by Mary Tefend
patient interference, soiled bandages, improper handling,
Campbell, CVT and Dr. Dougie K. Macintire* for the previ-
contaminated injectates, blood left inside an injection port
ous edition, and some material from that chapter appears
or T-port, and from the tops of multiuse IV medication bot-
in this one. The authors and editors thank Ms. Tefend
tles. Personnel should practice proper hygiene protocols,
Campbell and Dr. Macintire for their contributions.
including hand hygiene, swabbing ports and medication
*Deceased.
bottles with antiseptics as well as frequent bandage changes
References
1 Wohl, J. and Tefend, M. (2007). Vascular access 2 Mazzaferro, E.M. (2009). Intraosseous catheterization: an
techniques. In: Kirk’s Current Veterinary Therapy XIV, often underused, life-saving tool. Clin. Brief 7: 9–12.
8e (ed. J.D. Bonagura), 38–43. Philadelphia: WB 3 Vose, J., Odunayo, A., Price, J. et al. (2019). Comparison of
Saunders. heparinized saline and 0.9% sodium chloride for
Further Reaning 101
maintaining central venous catheter patency in healthy www.cdc.gov › hai › pdfs › bsi-guidelines-2011 (Accessed
dogs. Peer J 7: e:7072. July 11, 2021).
4 Centers for Disease Control website (2011). Guidelines for 5 Seguela, J. and Pages, J.P. (2011). Bacterial and fungal
the prevention of intravascular catheter-related infections. colonization of peripheral intravenous catheters in dogs
and cats. J. Small Anim. Pract. 52: 531–535.
Further Reading
Waddell, L. (2002). Advanced vascular access options. In: Lakewood, CO: American College of Veterinary Internal
ACVIM Proceedings May 29 – June 1, 2002, 719–722. Medicine.
103
Arterial Puncture and Catheterization

Elisa M. Mazzaferro and Nicole van Sant
Arterial puncture and catheterization aree among the most If using a standard 3-ml syringe and needle, pull a small
important techniques required for monitoring of the criti- amount of liquid heparin into the syringe, and pull the
cally ill small animal during hospitalization and while plunger to the 3-ml mark to coat the entire inner surface of
under general anesthesia. Arterial puncture is most com- the syringe with the heparin. Expel all the heparin and air
monly performed to obtain arterial blood samples for blood from the syringe. Pull air back into the syringe to the 3-ml
gas analysis. If repeated arterial blood sampling is required, mark and forcibly expel all the heparin and air from the
or if the patient requires continuous direct blood pressure syringe again; repeat this forced air expulsion procedure
monitoring, the placement of an arterial catheter is three times [1]. This syringe evacuation procedure mini-
necessary. mizes sample dilution with liquid heparin, which would
cause significant preanalytical error in blood gas and elec-
trolyte values. Even using this technique, ionized calcium
Arterial Puncture concentration should not be measured on heparinized
samples [1].
Arterial puncture is most commonly performed on the dor- Following aseptic preparation of the proposed needle
sal pedal artery (or one of its metatarsal branches) or the insertion site, palpate for the dorsal pedal pulse over the
femoral artery (Protocol 8.1). To perform an arterial punc- second and third metatarsal bones, or for the femoral pulse
ture, position the patient in lateral recumbency on the side over the cranial medial aspect of the proximal femoral dia-
of the targeted artery. Clip and clean (e.g. with isopropyl physis. Insert the needle at a 15–20 degree angle with
alcohol) the area over the artery. In most cases, a full surgi- respect to the skin over the point where the pulse is most
cal scrub is unnecessary unless an indwelling catheter is easily palpable. It is easiest to feel the pulse with the non-
going to be introduced into the artery, or if the animal is dominant hand. Advance the needle very slowly in 1–2 mm
immunocompromised and at risk of infection. increments; after each movement, look at the syringe hub
carefully for a flash of blood. If the needle has been
advanced to what seems a sufficient depth and a flash of
Procedure
blood has not been encountered, the needle should be
The supplies required to perform arterial puncture for slowly withdrawn in the plane of entry. As the needle is
blood sample collection are heparin and a 3-ml syringe withdrawn, watch closely for a blood flashback. In some
with a 22- or 25-G needle attached – or a lithium heparin cases, the needle has punctured through the deep portion
arterial blood gas (ABG) syringe with its needle attached – of the vessel wall and blood will enter the needle and
as well as pressure bandaging supplies appropriate for the syringe during withdrawal. If the needle must be redi-
sampling site. Prefabricated syringes that contain a pellet rected, pull it to the superficial subcutaneous tissues before
of lithium heparin can be purchased from a variety of man- redirecting.
ufacturers (e.g. Smith Medical; Vital Signs, Inc.; Becton Once the needle tip is seated in the artery, gently pull the
Dickinson; Cardinal Health). A simpler and less expensive plunger of the syringe to withdraw blood or allow arterial
technique, however, is to use equipment that is already pressure to fill the syringe. The latter technique confirms
stocked in the emergency room or intensive care unit. that the blood is arterial rather than venous. Gently
104 Arterial Puncture and Catheterization
Protocol 8.1 Arterial Puncture for Blood Sample Collection

Items Required 6) Closely clip a generous area (2–2.5inch, c. 5cm) around
the intended insertion site and remove any loose fur.
● Clean clippers and blade
7) Aseptically prepare the area. Alternate cleansing
● Skin-cleaning supplies: isopropyl alcohol-soaked cot-
scrub with isopropyl alcohol; prepare in circular
ton, or full surgical scrub as appropriate
motions, starting from the center and finishing at the
● Prefabricated lithium heparin ABG syringe or 3-ml
periphery with each swab.
syringe, liquid heparin, and a 25- or 22-gauge
8) Perform hand hygiene and don examination gloves.
needle
● Pressure bandage for post-puncture wrap
10) Palpate for the pulse over the second and third meta-
● An assistant (usually only one is required)
tarsal bones for the dorsal pedal artery, or over the
cranial aspect of the proximal femoral diaphysis for
Procedures
the femoral artery.
If using a prefabricated ABG syringe, begin at step 6. 11) Insert needle at 15–20 degree angle with respect to
the skin where the pulse is most easily palpable.
12) Advance needle very slowly, checking frequently for a
2) Equip the 3-ml syringe with the needle.
“flash” of blood. If the needle has been advanced a
3) Pull a small amount of the heparin into the syringe,
sufficient depth and no flash has been encountered,
then pull the plunger back to coat the entire inner
slowly withdraw the needle in the plane of entry,
surface of the syringe.
watching closely for a flash.
4) Expel all the heparin and air from the syringe.
13) Once the needle tip enters the artery, gently pull the
5) Pull air into the syringe to the 3-ml mark and forcibly
plunger or allow arterial pressure to fill the syringe.
expel contents from the syringe; repeat three times.
14) Gently withdraw the needle from the skin and apply
The syringe and needle hub should appear evacuated
pressure with a bandage for many minutes to an hour.
of liquid heparin.
withdraw the needle from the skin when an adequate sam- puncture. The sublingual veins are not usually used for
ple has been withdrawn. Apply pressure to the puncture catheterization in clinical patients.
site with a bandage for many minutes to an hour. When a
pressure bandage is applied with tape or vet wrap and left
on the patient for a period of time, it may be useful to write
“remove pressure bandage” on the patient’s order sheet so
Arterial Catheter Placement
the bandage is not left in place for a prolonged time
Although the placement of an arterial catheter can be more
(Protocol 8.1.)
technically difficult than placement of a peripheral venous
Following collection, the sample syringe should be
catheter, the equipment necessary and the procedures per-
capped, and the sample analyzed immediately to ensure
formed are largely the same. The materials and supplies
accurate results. Samples can be stored for up to one hour
required to attach an arterial catheter to a transducer for
if immersed in an ice bath to prevent ongoing cellular met-
continuous blood pressure monitoring are discussed in
abolic activity within the sample that can result in a change
Chapter 12. Special considerations for arterial catheter
in PaO2, PaCO2, and pH.
placement follow.
Sublingual Venipuncture
Site Selection
Sublingual veins are also used for sampling in anesthetized
patients because oxygenation in this vascular bed closely A variety of arteries can be used for arterial catheter place-
approximates arterial blood. Thus, samples from this site ment, including the dorsal metatarsal artery (commonly
can be used for ABG analysis. These superficial, soft-walled called the dorsal pedal artery) and the radial, coccygeal,
vessels are usually punctured with a 25 G needle. Firm digi- femoral, or auricular arteries. When selecting a site for
tal pressure on the vessel must be performed for a mini- placement, it is important to consider the patients’ mobil-
mum of five minutes to prevent hematoma formation after ity and activity level, and whether the patient has access to
Arterial Catheter Placeeent 105
the site and could potentially remove the catheter. As surgical preparatory scrub on the area over and around the
mentioned below, one should also consider risk of con- catheter insertion site.
tamination and practicality of keeping the area clean
when selecting an arterial catheterization site. More
Analgesia
peripheral arteries may be preferable in patients with
hemostatic concerns. Finally, the operator’s experience Placement of an arterial catheter can be uncomfortable, so
and expertise with different anatomic sites may impact some patients benefit from sedation or a local anesthetic
catheter site selection. during placement.
Aseptic Technique Percutaneous Facilitation

The most important aspect of minimizing the risk of The placement of the arterial catheter through a small hole
catheter-related infection is strict adherence to aseptic in the skin helps prevent the tip of the catheter from
technique when placing an arterial catheter [2]. An impor- becoming burred. If a burr develops, catheter insertion will
tant consideration when placing an arterial catheter is thus be difficult and there is increased risk of thrombus
whether the location has a high risk of contamination. For formation [6].
example, although the dorsal pedal arteries are perhaps the The concept of percutaneous facilitation involves mak-
simplest to catheterize, consider whether the patient has ing a small nick in the skin surface over a proposed site of
diarrhea that could potentially contaminate the arterial catheter placement in animals that are extremely dehy-
catheter site. It is generally recommended that no catheter drated or have very thick or tough skin. Percutaneous
be placed into an area of damaged skin, abrasion, or facilitation is most commonly performed with the bevel
pyoderma [3]. of an 18- or 20 G hypodermic needle. Locate the artery
In addition to site selection, adherence to cutaneous using gentle, digital palpation as to not occlude the vessel
antisepsis protocols is strongly recommended [4]. Many and obscure the pulse. Identify the catheter insertion site.
arterial catheter-related infections are acquired extralumi- Tent the skin over the catheter insertion site and make a
nally, from the invasion of skin microorganisms at the nick through the skin with the needle’s sharp bevel, tak-
insertion site. Incorporating preventive measures such as ing care to avoid underlying vessels. If the bevel of the
skin preparation with chlorhexidine or chlorhexidine needle nicks the underlying artery, the artery will spasm
impregnated dressings at greater than 0.5% strength has and the pulse will wane or disappear. When an artery
the potential to significantly reduce catheter-related infec- undergoes spasm, it is very difficult to cannulate until a
tion rates. Additionally, the use of sterile gauze or a semi- palpable pulse returns.
permeable transparent dressing to cover the insertion site In patients that are very small, obese, edematous, or
is preferred over the use of topical antibiotic ointment or hemodynamically unstable, digital palpation may be insuf-
creams, as topical preparations may promote fungal infec- ficient at locating arteries in peripheral sites [7].
tions and antibacterial resistance. Ultrasound-guided vascular access may be warranted to
One of the most common causes of hospital-acquired identify and evaluate targeted vessels, to provide guidance
infection is the transmission of disease-causing bacteria to improve arterial catheter placement success, and to min-
on the hands of hospital personnel. Therefore a very imize complications associated with arterial catheter
basic, and extremely important, tenet of infection control placement [8].
and antiseptic technique is for the operator to thoroughly Ultrasound-guiding can be employed using two tech-
wash their hands before placing an arterial catheter. The niques to image the artery and the surrounding structures.
Centers for Disease Control and Prevention has published Positioning the ultrasound probe over the artery in longitu-
handwashing guidelines that instruct on proper hand dinal orientation images the artery as a tubular structure
hygiene techniques for healthcare workers [5] (see also (Figure 8.1a,b) and can offer guidance for establishing the
Chapter 62 for more detailed information). For arterial needle path ensuring successful arterial cannulation
catheter placement, after carefully scrubbing the hands (Figure 8.1c) Positioning the probe over the artery in trans-
the operator should don examination gloves, unless the verse orientation or short axis images the artery in cross-
patient is immunocompromised, in which case sterile section as a circular structure and the needle appears as a
gloves should be worn. dot on the ultrasound screen. Both techniques provide a
Once an acceptable artery has been identified, carefully comprehensive image of the targeted vessel, and when
clip all fur over the artery and circumferentially around the incorporated into placement protocols have been shown to
patient’s extremity, leaving at least 2 inches (5 cm) between improve overall success rates and reduce complications
the fur margin and the proposed insertion. Next, perform a associated with arterial catheterization.
(a)
(b) (c)
Figure 8.1 Longitudinal of femoral artery (a), with color Doppler confirming arterial blood flow (b). Hyperechoic structure at left of
figure inserted into vessel lumen confirms needle insertion into artery (c).
Securing the Arterial Catheter To insert a dorsal pedal artery catheter (Protocol 8.2),
place the patient in lateral recumbency on the side in
If an arterial catheter accidentally becomes disconnected,
which the catheter is to be placed (i.e. if the proposed
excessive blood loss can quickly occur, which may increase
insertion is the right dorsal pedal artery, the patient should
morbidity in an already critical patient. As such, it is rec-
be positioned in right lateral recumbency). The limb
ommended that the infusion plug and T-port have Luer
should be extended comfortably for the patient, and the
lock connections (e.g. BD Luer-Lok™, Becton, Dickinson
distal limb gently rotated such that the dorsal pedal artery
and Company, Franklin Lakes, NJ). Any attached fluid-
is palpable and on the nondependent, medial surface of
filled monitoring system should likewise have Luer lock
the limb. Some people tape the digits to the table or a
connections. When securing the arterial catheter itself,
heavy sandbag to keep the limb in place during catheter
some clinicians prefer to use surgical glue to adhere the
placement. This positioning will help the operator to intro-
catheter hub to the patient’s skin. However, glue can be dif-
duce the catheter into the artery. Palpate the paw between
ficult and painful to remove. If the catheter hub and
the second and third metatarsal bones distal to the tarsus
patient’s skin are dry and free of debris, the catheter can
to locate the pulse. Ultrasound-guided assistance can also
usually be secured adequately with standard white medical
facilitate locating the artery. Using 70% isopropyl alcohol,
tape, as described below.
prepare the skin and apply the ultrasound probe to the
skin over the anatomical landmarks. Hold the probe in
Dorsal Pedal Artery Catheterization transverse orientation to image the artery and evaluate for
pulsatile blood flow.
The dorsal pedal artery and its metatarsal arterial branches Once the artery has been located, clip the fur at least
are located over the metatarsal bones. The most promi- 2 inches (5 cm) in all directions from the proposed catheter
nently palpable is usually found on the dorsomedial aspect insertion site, as patient size allows. You may choose to clip
of the foot between the second and third metatarsal bones, fur circumferentially from the metatarsal region to
just distal to the tarsus (the hock). maximize tape adhesion when securing the catheter.
orral Pedal Arterry Catheterization 107
Protocol 8.2 Dorsal Pedal (Dorsal Metatarsal) Arterial Catheterization

Items Required 9) Gently remove residual scrub with sterile gauze
moistened with sterile water or saline.
10) Place sterile gauze square over the fur on the distal
● Sandbag for limb positioning, if desired
limb, to avoid contamination of the catheter.
● Surgical scrub preparation supplies
11) Use gloved index finger to palpate dorsal metatarsal
● Examination or sterile gloves for operator
pulse in the surgically scrubbed area.
● Sterile gauze squares
12) Once pulse is found, perform percutaneous facilita-
● Surgical tape (½-inch and 1-inch widths)
tion with bevel of a 20–22 gauge needle, if needed.
● Cotton roll gauze
13) Gently insert over-the-needle catheter through the
● Water-resistant bandaging material, if desired
skin, directing the catheter at a 15-degree angle with
● 22–20 gauge needle
respect to the skin toward the pulsing artery.
● Over-the-needle or over-the-wire intravascular
14) Advance the stylet–catheter apparatus in 1–2 mm
catheter
increments into the area of the pulse. Observe cath-
● Luer lock T-port or Luer lock infusion plug
eter hub for a flash of blood.
● Preservative-free heparinized saline flush syringes
15) Once a flash is observed in the hub, insert the stylet
● “Not for IV infusion” label or indelible marker
1–2 mm more and push the catheter off the stylet
● One or two assistant(s)
into the artery.
16) Before removing the stylet from the catheter, place
Procedure
sterile gauze squares beneath catheter hub to
1) Collect necessary supplies, prepare tape, and prepare absorb blood.
and flush the T-port or male adapter with 17) Remove the stylet, and quickly place the male adapter
preservative-free heparinized saline. or T-port into the catheter hub. Take care to avoid
2) Place patient in lateral recumbency, with limb of pro- removing the catheter from the skin.
posed catheter insertion adjacent to the table. 18) With sterile gauze squares, wipe away excess blood,
3) Assistant should restrain the animal in lateral making sure that the skin under the catheter hub and
recumbency. around the limb is dry.
4) Secure patient’s digits to a sandbag or the table’s 19) Secure a length of ½-inch medical adhesive tape
edge with medical tape. around the catheter hub, then around the limb.
5) Palpate gently for arterial pulse over second and 20) Place sterile gauze over the insertion site.
third metatarsal bones to determine proposed inser- 21) Secure a length of 1-inch medical adhesive tape
tion site. under the catheter hub, around the limb, finishing
6) Clip fur over dorsal aspect of the metatarsus at least with the tape over the insertion site and
(2 inches, 5 cm) from the proposed catheter insertion catheter hub.
site. Wipe clipped fur away with a gauze square. 22) Secure a third length of tape around the male adapter
7) Aseptically prepare the proposed catheter insertion or T-port and then around the limb as described for
site using surgical scrub technique. Allow a minimum step 20.
of appropriate contact time of the cleanser with the 23) Bandage the catheter with cotton gauze and an
skin, according to manufacturer’s instructions. outer layer.
8) Perform hand hygiene and don examination gloves 24) Secure a “not for IV infusion” sticker over the catheter
(sterile gloves if the patient is immunocompromised). bandage or make a note with indelible marker.
Following aseptic preparation, feel again for the dorsal palpable. It is easiest to feel the pulse with the nondomi-
pedal pulse over the second and third metatarsal bones. nant hand, then insert the catheter through the skin under
Remember to palpate the artery gently, so as to not occlude the gloved fingertip (Figure 8.2a). Direct the catheter
the vessel and obscure the pulse. Once the pulse is located, through the skin and into the artery, taking care to advance
a nick can be made in the skin to facilitate catheter place- the needle and catheter very slowly in 1–2 mm increments.
ment (see Percutaneous Facilitation, above). Insert an After each movement, one should inspect the catheter hub
over-the-needle catheter through the nick or directly carefully for a flash of blood (Figure 8.2b). If the catheter
through the skin, at a 15–20 degree angle with respect to has been advanced to what seems a sufficient depth and a
the skin over the point where the pulse is most easily flash of blood has not been encountered, the catheter
(a) (b)
(c) (d)
Figure 8.2 (a) Angle of catheter insertion for dorsal metatarsal artery. Note that the operator palpates for the pulse between the
second and third metatarsal bones. (b) Watch for blood in the hub of the catheter. (c) Once a catheter is in place, pulsatile blood will
flow from the catheter hub. (d) Securing the catheter involves wrapping pieces of tape around the catheter hub, under the catheter
hub, and around the limb. The catheter should be labeled as an arterial catheter, so it is not inadvertently used for infusion.
system should be slowly withdrawn. While withdrawing catheter has been advanced into the vessel, the artery can
the catheter system, watch closely for a blood flashback. In spasm or bleed and thus complicate further attempts at
some cases, the catheter system has punctured through the catheter placement.
deep portion of the vessel wall. If there is blood in the cath- Once the catheter is inserted completely into the artery,
eter hub, advance the needle and catheter another 1–2 mm be careful! Once the stylet is removed, blood should pulse
in the plane of the artery, then gently push the catheter off readily from the catheter hub, which helps confirm place-
the stylet into the vessel. If the catheter does not easily ment in the artery rather than a vein. Prepare ahead of time
advance into the artery, gently withdraw the catheter back by placing several sterile 4 × 4-inch gauze squares under
over the stylet, and redirect the catheter system in small the catheter hub to prevent contamination of the site with
increments to replace it into the artery. If the catheter does blood (Figure 8.2c). Once the stylet is removed, quickly
not easily withdraw back over the stylet, it should not be secure a Luer lock male adapter or T-port (preflushed with
forced back over, as the stylet may perforate the catheter; preservative-free heparinized saline) to the catheter hub,
rather, if the catheter is difficult to pull back over the stylet, taking care not to inadvertently dislodge the catheter from
the whole system should be removed from the patient’s the artery.
skin and evaluated. In some cases, it is necessary to leave Carefully wipe any blood from the area, then place a
the original catheter and stylet in place and start over, length of half-inch white surgical tape around the catheter
attempting catheterization again proximal to the original hub. Squeeze the tape securely around the hub to ensure
site of catheter insertion. If the original catheter system is the hub of the catheter does not spin within the tape, as
removed after it has disturbed the artery but before the spinning catheters fall out easily. Once the tape is secured to
eeoral Arterry Catheterization 109
the catheter hub, wrap it snugly around the limb. Place a the femur near the inguinal region. The operator should
second length of 1-inch tape under the catheter hub, around palpate the femoral pulse with their nondominant hand,
the limb, finishing with the tape over the insertion site and then insert an over-the-needle catheter at a 15–20 degree
over the catheter hub. This piece of tape should be snug, but angle with respect to the skin, directing the stylet–catheter
not so snug that it constricts the limb and impairs venous apparatus toward the point where the pulse is palpable.
return. Secure a third piece of tape over the Luer lock T-port Watch carefully for a flash of blood in the catheter hub and
or male adapter and around the limb, such that it also redirect the stylet with incremental 1–2 mm changes in
encompasses the catheter hub. The distal limb and catheter direction. Once a flash of blood is observed in the catheter
can now be wrapped with gauze rolls of choice. The entire hub, the catheter angle should be dropped so that the cath-
apparatus should be labeled as an arterial catheter to help eter is in a good plane with the artery before attempting to
avoid accidental medication infusion (Figure 8.2d). feed the catheter into the vessel. Once the catheter is seated
into the femoral artery, the stylet is removed. Then quickly
place a flushed, Luer lock T-port or male adapter onto the
Femoral Artery Catheterization catheter hub. Tape the catheter in place as described for
dorsal pedal catheters, and flush it again with preservative-
Percutaneous placement of a femoral arterial catheter is free, sterile heparinized saline solution. Depending on
almost identical to placement of a dorsal pedal arterial patient size and limb conformation, the operator may
catheter, except for anatomical location. Percutaneous choose to reinforce the catheter hub’s security by suturing
facilitation is required less frequently at this site. the hub’s tape to the patient’s skin (Protocol 8.3; Table 8.1).
Place the patient in lateral recumbency, with the medial When using ultrasound guidance to facilitate femoral
aspect of the patient’s limb exposed. The person perform- arterial catheterization, the same steps apply as listed
ing the restraint can pull the nondependent limb proxi- above. The patient is positioned in lateral recumbency with
mally, cranially, or caudally, depending on patient comfort. the medial aspect of the limb exposed. The limb is clipped
The limb should be clipped and aseptically scrubbed over and aseptically scrubbed over its medial aspect from the
its medial aspect from the inguinal region to the stifle. The inguinal region to the stifle. The ultrasound machine is
femoral pulse is usually palpable on the cranial aspect of draped, and sterile transmission gel is applied to the
Protocol 8.3 Femoral Artery Catheterization

Items Required 3) Assistant should restrain the animal in lateral recum-
bency. The patient should be immobile, and top limb
should be well out of operator’s field.
4) Palpate gently for arterial pulse on cranial aspect of
proximal femoral diaphysis (near inguinal region) to
determine proposed insertion site.
5) Clip fur over the femoral artery, from inguinal area to
stifle, on medial aspect of dependent limb. If the
patient’s fur is long, clip limb circumferentially.
● Suture material, needle driver, thumb forceps, and
6) Aseptically prepare the proposed catheter insertion
suture scissors, if desired
site using surgical scrub technique. Allow a mini-
● Over-the-needle or over-the-wire intravascular catheter
mum of appropriate contact time of the cleanser
with the skin, according to manufacturer’s
instructions.
7) Perform hand hygiene and don examination gloves
● One or two assistants
(sterile gloves if the patient is immunocompromised).
8) Gently remove residual scrub with sterile gauze
Procedure
1) Collect necessary supplies, prepare tape, and prepare 9) Place sterile gauze square over the fur on scrubbed
and flush the T-port or male adapter with area’s distal margin, to avoid contamination of the
preservative-free heparinized saline. catheter.
2) Place patient in lateral recumbency, with limb of 10) Use gloved index finger to palpate femoral pulse in
proposed catheter insertion adjacent to the table. the surgically scrubbed area.
11) Gently insert over-the-needle catheter through 16) With sterile gauze squares, wipe away excess blood,
the skin, directing the catheter at a 20-degree making sure that the skin under the catheter hub and
angle with respect to the skin toward the puls- around the limb is dry.
ing artery. 17) Secure a length of ½-inch medical adhesive tape
12) Advance the stylet–catheter apparatus in 1–2 mm around the catheter hub, then around the limb.
increments into the area of the pulse. Observe cath- 18) Secure a length of 1-inch medical adhesive tape
eter hub for a flash of blood. under the catheter hub, around the limb, finishing
13) Once a flash is observed in the hub, drop catheter with the tape over the catheter hub.
angle to align with vessel and push catheter off the 19) Secure a third length of tape around the male adapter or
stylet into artery. T-port and then around the limb as described for step 18.
14) Before removing the stylet from the catheter, place 20) Suture catheter hub in place, if desired, by suturing
sterile gauze squares beneath catheter hub to the hub’s tape to the patient’s skin.
absorb blood. 21) Bandage the catheter with cotton gauze and an
15) Remove the stylet, and quickly place the male adapter outer layer.
or T-port into the catheter hub. Take care to avoid 22) Secure a “Not for IV infusion” sticker over the catheter
removing the catheter from the skin. bandage or make a note with indelible marker.
Table 8.1 Advantages and disadvantages of various sites proposed catheterization site. The probe is applied to the
for arterial catheter placement. skin in transverse orientation to visualize the artery. The
artery should be centered in the image and the probe
Location Advantages Disadvantages should then be rotated 90 degrees into longitudinal orienta-
tion to view the entire length of the vessel and catheter.
Auricular Easy to visualize Easily dislodged with
patient motion The stylet–catheter is advanced through the skin slightly
distal to the probe at approximately a 35 degree angle [7].
Easy to catheterize Can create thrombosis
Once a flash of blood is observed in the catheter hub, the
Not affected by obesity Best used for
anesthetized patients catheter angle should be dropped so that the catheter is in
a parallel plane with the artery before attempting to feed
Not for long-term use
the catheter into the vessel. Once the catheter is seated into
Coccygeal Easy to palpate Easily dislodged with
movement
the femoral artery, the stylet is removed. The placement of
the catheter can be confirmed with ultrasound image
Easy to secure Easily contaminated
with fecal material if needed.
Smaller catheters
necessary
Not for long-term use Auricular Artery Catheterization
Dorsal Easy to palpate May be affected by
metatarsal obesity Auricular arterial catheters can sometimes be placed in
Easiest to cannulate dogs with large, pendulous ears. This technique is gener-
Less danger of ally reserved for patients that are anesthetized, as the pinna
hemorrhage in patients is very sensitive to touch and has a twitch reflex that makes
with coagulopathies its artery difficult to catheterize when the animal is awake.
Radial Easy to palpate Metacarpal pad may The auricular artery is located on the dorsal aspect of the
interfere with placement pinna (Figure 8.3a). Palpate the pulse on the pinna surface
May easily become and trace it to the ear tip to determine the artery’s location.
thrombosed Clip and aseptically prepare the entire dorsal surface of the
Not for long-term use ear pinna as previously described, while supporting the
Femoral Easy to palpate Risk of hemorrhage, pinna with four fingers of the nondominant hand; fold the
particularly if ear tip with the thumb so that it is perpendicular to the
coagulopathy present
main portion of the pinna. Perform percutaneous facilita-
Affected by obesity
tion if needed and insert the catheter system through the
Easily dislodged with skin directly into the artery in 1–2 mm increments. Once a
movement
flash of blood is visible in the catheter hub, gently advance
adial Arterry Catheterization 111
(a) (b)
(c)
Figure 8.3 (a) The auricular artery is located approximately on the midline of the pinna’s dorsal surface. (b) Once the catheter is in
place, the hub should be secured by applying adhesive tape around the hub and extending the tape circumferentially around the
pinna. (c) Folded 4 × 4-inch gauze squares or rolls of gauze should be used to splint the pinna with the arterial catheter in place, to
enhance security.
the catheter into the auricular artery. Quickly remove the Radial Artery Catheterization
catheter stylet and replace it with a preflushed Luer lock
male adapter or T-port. Wipe the area clean; then secure a Catheterization of the radial artery is technically more diffi-
length of half-inch medical tape to the catheter hub and cult than for other anatomic locations because the radial
wrap it around the pinna (Figure 8.3b). Because the ear is artery is small. This technique can be performed in larger
floppy and can fold on itself, use several folded 4 × 4-inch dogs while the patient is under general anesthesia. To place a
gauze squares or a roll of cotton gauze to softly splint the radial arterial catheter, the patient is placed in lateral recum-
underside of the pinna such that the lateral aspects of the bency with the target limb adjacent to the table, and the pal-
pinna are folded around the rolls (Figure 8.3c). The cathe- mar aspect of the patient’s paw is clipped just proximal to the
ter and rolls of gauze or cotton are taped in place in a man- metacarpal footpad. After the aseptic scrub, the patient’s paw
ner similar to that used for dorsal metatarsal catheters. is held in the operator’s hand and the radial pulse palpated
Often, the weight of the bandage becomes too cumbersome with the forefinger. Percutaneous facilitation is often helpful
in an awake patient and stimulates head shaking. This can in this location. With the dominant hand, an over-the-needle
cause the catheter to become dislodged. Also, the pinna has catheter is inserted through the skin at a 15–20degree angle,
a relatively high risk of ischemia with prolonged arterial while the operator observes closely for a flash of blood. The
occlusion. Therefore, auricular artery catheterization is size and length of catheter depends on the size of the patient
often used only in extremely subdued, obtunded, or and the artery. Longer catheters (e.g. 1½ inches, 5–7mm)
anesthetized patients for a limited time (Protocol 8.4). should be chosen for larger dogs, as skin movement in this
Protocol 8.4 Auricular Artery Catheterization

Items Required 8) Hold pinna in the nondominant hand, folding the ear
over the fingers.
9) The auricular artery should be visible on dorsal mid-
line of the ear pinna.
10) Perform percutaneous facilitation, if desired. Insert
the catheter into the auricular artery.
● 4 × 4-inch gauze squares, or 3-inch roll gauze
11) Watch for a flash of blood in the catheter hub.
12) Once a flash of blood is visible in the catheter hub,
advance the catheter and stylet an addi-
● 22–20 gauge needle
tional 1–2 mm.
13) Feed catheter off the stylet into the artery.
catheter
sterile gauze squares beneath catheter hub to
absorb blood.
● “Not for IV Infusion” label or indelible marker
15) Remove the stylet and quickly place the flushed male
● An assistant, if needed
adapter or T-port into the catheter hub. Take care to
avoid removing the catheter from the skin.
Procedure
16) With sterile gauze squares, wipe away excess blood,
1) Collect necessary supplies, prepare tape, and prepare and make sure that the skin under the catheter hub
and flush the T-port or male adapter with preservative- and around the ear is dry.
free heparinized saline. 17) Secure a length of ½-inch medical tape around the
2) Place the patient in sternal or lateral recumbency. catheter hub, then around the ear.
3) If the patient is not anesthetized, an assistant should 18) Secure a length of 1-inch medical tape under the
restrain so the patient is immobile. catheter hub, around the ear, finishing with the tape
4) Clip the dorsal pinna surface on midline, 2 inches over the catheter hub.
(5 cm) from proposed insertion site in all directions. 19) Secure a third length of tape around the male adapter
5) Aseptically prepare the proposed catheter insertion or T-port and then around the pinna as described for
of appropriate contact time of the cleanser with the 20) Place a roll of gauze or rolled up gauze squares under
skin, according to manufacturer’s instructions. the ventral aspect of the ear.
6) Perform hand hygiene and don examination gloves 21) Tape the gauze roll in place with several lengths of
(sterile gloves if the patient is immunocompromised). surgical tape.
7) Gently remove residual scrub with sterile gauze 22) Secure a “not for IV infusion” sticker over the catheter
moistened with sterile water or saline. bandage or make a note with indelible marker.
area can dislodge shorter catheters. Once a blood flash is vis- recumbency, and the ventral aspect of the tail base is
ible in the catheter hub, the catheter is inserted and a flushed clipped. Circumferential clips of the tail base should be
Luer lock T-port or male adapter is attached in place of the considered in patients with long fur that could potentially
stylet. It is the author’s recommendation that radial arterial contaminate the catheter site. After an aseptic scrub and
catheters should not remain in place for longer than 24hours, proper hand hygiene, the coccygeal pulse is palpated on the
particularly in cats and smaller dogs, because of the risk of tail’s ventral midline. The pulse is palpable between coc-
arterial thrombosis and inhibition of perfusion to the distal cygeal vertebrae. Once the pulse is felt, an over-the-needle
extremity (Protocol 8.5) [9]. catheter is inserted at a 15–20 degree angle with respect to
the skin, into the artery, while the catheter hub is observed
for blood. Once a blood flash is visible in the catheter hub,
Coccygeal Artery Catheterization the catheter is inserted and a flushed Luer lock T-port or
male adapter is attached in place of the stylet. The catheter
The coccygeal artery can be catheterized in patients under is secured to the tail with medical tape and gauze as previ-
general anesthesia. For coccygeal arterial catheter place- ously described (see Protocol 8.6 for details). Coccygeal
ment, the patient is positioned in either dorsal or lateral arterial catheters usually clot within 24 hours, so they must
Coccryyeal Arterry Catheterization 113
Protocol 8.5 Radial Artery Catheterization

Items Required 8) Gently remove residual scrub with sterile gauze
9) Place sterile gauze square over the metacarpal pad
and fur on the distal limb, to avoid contamination of
the catheter.
10) Use gloved index finger to palpate radial pulse in
the surgically scrubbed area.
11) Once pulse is found, perform percutaneous facilita-
tion with bevel of a 20- to 22-gauge needle.
● 20–22 gauge needle, if desired
12) Gently insert over-the-needle catheter, directing
catheter at a 20˚ angle with respect to the skin
catheter
toward the pulsing artery.
13) Advance the stylet-catheter apparatus in 1- to 2-mm
increments into the area of the pulse. Observe
catheter hub for a flassh of blood.
14) Once a flash is observed in the hub, insert the stylet
1–2 mm more and push the catheter off of the stylet
Procedure
into the artery.
1) Collect the necessary supplies, prepare tape, and 15) Before removing the stylet from the catheter, place
prepare and flush the T-port or male adapter with sterile gauze squares beneath the catheter hub to
preservative-free heparinized saline. absorb blood.
2) Position the patient in lateral recumbency, with the 16) Remove the stylet, and quickly place the male adapter
limb of proposed catheter insertion adjacent to or T-port into the catheter hub. Take care to avoid
the table. removing the catheter from the skin.
3) If the patient is not anesthetized, have an assistant 17) With sterile gauze squares, wipe away excess blood,
restrain. making sure that the skin underneath the catheter
4) Palpate gently for arterial pulse on the caudomedial hub and around the limb is dry.
aspect of limb, just proximal to the metacarpal 18) Secure a length of ½-inch medical adhesive tape
footpad, to determine proposed insertion site. around the catheter hub, then around the limb.
5) Clip fur proximal to metacarpal footpad, at least 5 cm 19) Secure a length of 1-inch medical adhesive tape
(~2 inches) from the proposed catheter insertion under the catheter hub, then around the limb,
site in all directions. Wipe clipped fur away with a finishing with the tape around the catheter hub.
gauze square. 20) Secure a third length of tape around the male adapter
6) Aseptically prepare the proposed catheter insertion or t-port and the around the limb as described for
of appropriate contact time of the cleanser with the 21) Bandage the catheter with cotton gauze and an
skin, according to manufacturer’s instructions. outer layer.
7) Perform hand hygiene and don examination gloves (or 22) Secure a “Not for IV Infusion” sticker over the catheter
sterile gloves if the patient is immunocompromised). bandage, or make note with indelible marker.
be watched very closely and flushed carefully. Also, because cold to the touch, if the limb is painful, if the catheter is
of the risk of contamination by fecal material, and also not working well or is no longer patent, or if the arterial
because the catheters tend to become dislodged with pulse cannot be palpated, the artery may be thrombosed
patient movement, coccygeal arterial catheters should be and perfusion to the limb may be compromised. In such
removed after general anesthesia and/or surgery has been cases, remove the catheter immediately. Ischemic compli-
completed. cations of arterial catheterization are especially common
Monitor the extremity distal to the catheter site for poor in cats, which generally have poorer collateral circulation
perfusion. If the limb distal to the catheter feels cool or than dogs.
Protocol 8.6 Coccygeal Arterial Catheterization

Items Required 7) Using a gloved index finger, palpate ventral midline
of tail base, between coccygeal vertebrae.
8) Perform percutaneous facilitation with bevel of a
20–22 gauge needle, if desired.
9) Place sterile gauze square distal to the insertion site,
to avoid contamination of the catheter.
10) Insert the catheter at a 20-degree angle with respect
to the skin, between coccygeal vertebrae, toward the
palpable pulse.
● 22–20 gauge needle, if desired
11) Advance the stylet–catheter apparatus in 1–2 mm
increments into the area of the pulse. Watch the cath-
catheter
eter hub for a flash of blood.
12) Once a flash of blood is observed, align catheter
angle with the artery, then push the catheter off the
stylet, into the artery.
gauze squares under the catheter hub to
Procedure
absorb blood.
1) Collect necessary supplies, prepare tape, and prepare 14) Remove the stylet, and quickly place the male adapter
and flush the T-port or male adapter with preservative- or T-port into the catheter hub. Take care to avoid
free heparinized saline. removing the catheter from the skin.
2) Place the patient in lateral or dorsal recumbency. 15) Wipe away excess blood, and make sure that the skin
3) Clip fur circumferentially from tail base, at least under the catheter hub and around the tail is dry.
2 inches (5 cm) from the proposed catheter insertion 16) Secure a length of ½-inch medical tape around the
site in all directions. Wipe clipped fur away with a catheter hub, then around the tail.
gauze square. 17) Secure a length of 1-inch medical tape under the
4) Aseptically prepare the proposed catheter insertion catheter hub, around the tail, finishing with the tape
site using surgical scrub technique. Allow a minimum over the catheter hub.
of appropriate contact time of the cleanser with the 18) Secure a third length of tape around the male adapter
skin, according to manufacturer’s instructions. or T-port and then around the tail as described for
5) Perform hand hygiene and don examination gloves step 17.
(sterile gloves if the patient is immunocompromised). 19) Secure a “not for IV infusion” sticker over the catheter
6) Gently remove residual scrub with sterile gauze bandage or make a note with indelible marker.
Arterial Catheter Care Inadvertent disconnection of the catheter under a bandage

can result in significant blood loss.
Because significant hemorrhage can occur quickly if an The patency of arterial catheters is achieved either by
arterial catheter is dislodged, it is important that the cathe- intermittent or continuous flushing using either heparin-
ter be securely placed. The catheter should be labeled ized or 0.9% saline solutions. Although there is evidence to
appropriately to avoid intra-arterial infusion of drugs, intra- conclude that there is no difference with the use of hep-
venous fluids, or blood products. Except for small amounts arinized saline compared with 0.9% saline solution in pre-
of preservative-free, heparinized or non-heparinized flush, venting catheter occlusion, determining a protocol for
no other drugs, blood products, or solutions should be maintaining arterial catheters using intermittent flushing
administered through the arterial catheter [5, 6]. In human requires further investigation [11–13] and should focus on
patients, complications have been associated with patient safety. Intermittent catheter flushing should be per-
inadvertent intra-arterial administration of vasopressors, formed every four hours. If heparinize saline is used as a
dextrose, potassium chloride, antibiotics, and insulin [10]. flush solution, care must be taken in small patients not to
rouulerhootiny 115
over-heparinize or cause intravascular volume overload. Contraindications to Arterial

Additionally, if 0.9% saline is used, cannula occlusion may Puncture and Catheterization
occur. If the arterial catheter is being used for continuous
blood pressure monitoring, it can be attached to a pressure Arterial puncture and catheterization can be problematic
transducer attached to a bag of heparinized saline under in patients with hemostatic abnormalities. For example, if
pressure. Most pressure transducers contain a continuous an animal has severe thrombocytopenia with a platelet
flush system of saline that delivers approximately 3 ml/ count less than 40 000 platelets/μl [16], or if an animal has
hour of flush solution, which maintains catheter patency. vitamin K antagonist rodenticide intoxication, arterial
There is currently no evidence to support the addition of puncture or catheterization can result in hemorrhage from
heparin (1–2 iu/ml) for continuous flushing decreases risk the arterial puncture or catheter site. In the presence of
of arterial catheter occlusion [12, 13]. these conditions, placement of an arterial catheter is rela-
The catheter and bandage should be assessed frequently tively contraindicated until the platelet count increases or
for evidence of moisture, soiling, or blood staining. The cath- until the coagulopathy has been resolved. The risk of hem-
eter bandage should be removed, and the catheter evaluated orrhage must be outweighed by the need for direct arterial
at least once a day for evidence of redness, swelling, or dis- catheterization in very critical patients.
charge from the catheter insertion site. If there is pain when Hypercoagulable states, such as those associated with
the catheter is flushed, or if any of the above abnormalities immune-mediated hemolytic anemia or a protein-losing
consistent with inflammation are observed, the catheter nephropathy or enteropathy, can have an increased risk of
should be removed and a pressure bandage secured over the thrombosis; embolism of the artery distal to the catheter
catheter insertion site for at least an hour, to decrease the risk site also may be an increased risk [16]. This complication is
of hemorrhage from the arterial puncture site. See Chapter 63, uncommon, so a prothrombotic state is a relative contrain-
Care of Indwelling Device Insertion Sites, for more informa- dication to catheter placement. One must weigh the bene-
tion on regular maintenance of arterial catheters. fits of catheter placement in a prothrombotic animal
carefully with respect to the risks involved with its place-
ment. If an animal has a pulmonary thromboembolism
Complications Associated with Arterial and will require numerous ABG analyses during the course
Puncture or Catheter Placement of hospitalization, an arterial catheter may be necessary.
However, if a catheter is placed simply to obtain continu-
Artery puncture or inadvertent dislodgment of a catheter ous blood pressure monitoring, the use of an indirect
can result in arterial hemorrhage and hematoma formation method such as Doppler plethysmography or use of an
at the puncture or insertion site. While severe hemorrhage oscillometric monitor may be preferable.
from an arterial catheterization is rare, caution should be It is the author’s opinion that arterial puncture or cath-
exercised with the femoral artery in particular. Basic precau- eterization should not be performed if the skin and tissue
tions include inserting a catheter only as large as necessary overlying the artery are compromised in any manner [3].
to avoid premature clotting of the catheter, to obtain ade- Shearing injuries, pyoderma, burns, and even small abra-
quate blood samples, to obtain a good pressure waveform, sions potentially pose an increased risk of infection and, as
and to avoid lacerating the artery during puncture [14]. tissue heals, an increased risk of thrombosis and wound
Arterial occlusion from thrombosis is a potential compli- contracture. For this reason, alternative anatomic loca-
cation of arterial catheterization, and although rare, can tions should be considered for arterial puncture or
lead to ischemic injury. Catheter size in relation to the catheterization.
artery, the presence of a hematoma and the duration of the
catheter in the artery have been identified in human stud-
ies as factors that increase risk for arterial occlusion and Troubleshooting
should be considered when placing arterial catheters in
critically ill small animals. Ultrasound-guided placement The arterial catheter should be assessed frequently for
of arterial catheters can help aid in selection of appropriate patency and cleanliness. If the catheter is not patent, the
catheter size and minimize hematoma formation. first step should be to unwrap the catheter to see if the
Considerations regarding duration of arterial cannulation catheter has slipped or is no longer in the artery. It is not
are made based on individual patient need, although the uncommon for the catheter to kink at the insertion site,
associated risk of arterial occlusion likely increases with so this should be investigated before aggressively flush-
time. A rare complication of arterial catheterization is ing the catheter. Because embolism is a possibility, an
ischemic necrosis with subsequent infection, which could arterial catheter that is not flushing easily should always
lead to the need for amputation [14, 15]. be evaluated (see Chapter 63 for more detail).
References
1 Hopper, K., Rezende, M.L., and Haskins, S.C. (2005). 9 White, L., Halpin, A., Turner, M., and Wallace, L. (2016).
Assessment of the effect of dilution of blood samples with Ultrasound-guided radial artery cannulation in adult and
sodium heparin on blood gas, electrolyte, and lactate paediatric populations: a systematic review and meta-
measurements in dogs. Am. J. Vet. Res. 66: 656–660. analysis. Br. J. Anaesth. 116 (5): 610–617.
2 Scheer, B.V., Perel, A., and Pfeiffer, U.J. (2002). Clinical 10 NHS England. Our National Patient Safety Alerts. https://
review: complications and risk factors of peripheral arterial www.england.nhs.uk/patient-safety/patient-safety-alerts.
catheters used for haemodynamic monitoring in Acecessed 26 June 2022.
anaesthesia and intensive care medicine. Crit. Care 11 Lee, J. and Della, P. (2014). Saline and heparinized flush
6: 199–204. in maintaining patency of arterial catheters in adult
3 Mazzaferro, E.M. (2009). Arterial catheterization. In: Small patients – a systematic review. J. Health Sci. 2: 571–583.
Animal Critical Care Medicine (ed. K. Hopper and 12 Ziyaeifard, M., Alizadehasl, A., Aghdaii, N. et al. (2015).
D. Silverstein), 206–208. St. Louis, MO: Saunders Elsevier. Heparinized and saline solutions in the maintenance of
4 Safdar, N., O’Horo, J.C., and Maki, D.G. (2013). Arterial arterial and central venous catheters after cardiac surgery.
catheter-related bloodstream infection: incidence, Anesth. Pain Med. 5 (4): e28056.
pathogenesis, risk factors and prevention. J. Hosp. Infect. 13 Trim, C.M., Hofmeister, E.H., Quandt, J.E., and Shepard,
85: 189–195. M.K. (2017). A survey of the use of arterial catheters in
5 Centers for Disease Control and Prevention. Handwashing anesthetized dogs and cats: 267 cases. J. Vet. Emerg. Crit.
in Healthcare Settings. http://www.cdc.gov/handhygiene Care 27 (1): 89–95.
(accessed 26 June 2022). 14 Bowit, K.L., Bortolami, E., Harley, R. et al. (2013).
6 Beal, M.W. and Hughes, D. (2002). Vascular access: theory Ischaemic distal limb necrosis and Klebsiella
and techniques in the small animal emergency patient. pneumoniae infection associated with arterial
Clin. Tech. Small Anim. Pract. 15: 101–109. catheterization in a cat. J. Feline Med. Surg. 15 (12):
7 Pavlisko, N.D., Soares, J.H.N., Henao-Guerrero, N.P., and 1165–1168.
Williamson, A.J. (2018). Ultrasound-guided catheterization 15 Mooshian, S., Deitschel, S.J., Haggerty, J.M., and
of the femoral artery in a canine model of acute Guenther, C.L. (2019). Incidence of arterial catheter
hemorrhagic shock. J. Vet. Emerg. Crit. Care 28 (6): complications: a retrospective study of 35 cats
579–584. (2010–2014). J. Feline Med. Surg. 21 (2): 173–177.
8 Schmidt, G.A., Blaivas, M., Conrad, S.A. et al. (2019). 16 Hughes, D. and Beal, M.W. (2000). Emergency vascular
Ultrasound-guided vascular access in critical illness. access. Vet. Clin. North Am. Small Anim. Pract.
Intensive Care Med. 45: 434–446. 30: 491–507.
117
Ultrasound-Guided Vascular Access

In veterinary patients requiring rapid fluid resuscitation, ultrasound-guided central lines in dogs under anesthesia are
airway management, or injectable medications, the place- similar to those of blind peripheral catheter placement [3].
ment of intravenous (IV) devices is essential. In most The success rate of using ultrasound-guided catheter place-
patients, simple landmark-based blind placement of ment in canine cadavers is very high in situations where
peripheral vascular catheters is successful (see Chapter 7). edema and hematoma make palpation of landmarks diffi-
However, situations can be encountered where peripheral cult [4]. There is also evidence that ultrasound-guided femo-
vascular access is difficult or impossible to achieve due to ral arterial catheter placement has good success and low
thrombosis, edema, obesity, limited viable peripheral ves- complication rates in anesthetized dogs [5].
sels, or due to marked peripheral vasoconstriction and vas-
cular collapse. Being familiar with ultrasound-guided
vascular access, automated intraosseous catheter place- Indications for Ultrasound-Guided
ment, and vascular cutdown techniques is invaluable in Vascular Access
these patients, particularly given unsuccessful attempts at
obtaining vascular access may result in hematoma forma- Indications for ultrasound-guided catheter placement
tion and delayed treatment. include hematoma formation, inability to palpate land-
The decision to place an ultrasound-guided peripheral marks for peripheral percutaneous catheter placement,
catheter, or an intraosseous (IO) catheter, or to perform a edema formation, obesity, and failure to place a percutane-
vascular cutdown to gain vascular access depends on ous catheter after three attempts (defined as difficult vascu-
patient considerations, particularly patient stability, reason lar access) [1, 2, 4]. Contraindications and complications of
for vascular access, equipment available, operator experi- ultrasound-guided catheter placement are similar to those
ence, and client financial considerations. In general, either of standard percutaneous vascular access [1–3].
an IO catheter or vascular cutdown is preferred when the An advantage of ultrasound-guided catheter placement
patient is unstable (see Chapter 7) while ultrasound-guided is that the depth, radius (which may help in choosing the
catheter placement is reserved for the more stable patient catheter size), and patency (presence of thrombus) of the
in which vascular access is difficult. vessel can be assessed prior to placing a catheter [6].
Ultrasound-guided peripheral and central venous cathe- Although peripheral superficial vessels can be challenging
terization is commonly used in human emergency and to access via ultrasound guidance, human studies demon-
critical care settings as it has a higher success rate, lower strate very high success rates with ultrasound guidance
complication rate, and is faster than blind/landmark when vessels are only millimeters from the skin surface
techniques in people, particularly when peripheral vascular and of very small diameter [6]. Blood sampling, including
access is difficult [1, 2]. The success rates and time to dorsal pedal arterial access for blood gas analysis, can
place ultrasound-guided catheters in veterinary medicine be performed using ultrasound guidance, which has the
have not been well studied. Based on the limited evidence advantage of visualizing the vessel of interest to avoid
available, the complication rate and time to place accidental venous sampling.
118 Ultrasound-Guided Vascular Access
Techniques technique and sweeping (Figure 9.3) the transducer along

the vessel as the catheter is advanced (explanation of trans-
The two common techniques for ultrasound-guided cathe- ducer movements like “sweeping” are found in Chapter 6).
ter placement include out-of-plane (Protocol 9.1) and in- The out-of-plane technique works well for accessing vessels
plane (Protocol 9.2) techniques (Figures 9.1 and 9.2) [2]. when the vessel remains visible and can thus be centered as
The authors have the greatest success using an out-of-plane the transducer is swept and/or fanned to follow the tip of
(a) (b)
Figure 9.1 (a) Out-of-plane ultrasound-guided vascular access demonstrated on the cephalic vein of a Beagle using a linear array
transducer. (b) In-plane ultrasound-guided vascular access demonstrated on a Beagle using a linear array transducer. The large
footprint of the linear array transducer makes it more challenging to use an out-of-plane technique in smaller dogs and in cats. The
angle of the catheter and stylet should be adjusted depending on the depth of the vessel. In this example, the cephalic vein is quite
superficial so the angle of the catheter relative to the skin surface is about 30 degrees.
(a) (b)
Figure 9.2 (a) Ultrasound still image of a vessel acquired using the out-of-plane technique. The tip of the stylet (white dot) within
the vessel lumen (V) with the transducer in short axis (transverse) orientation to the catheter and vessel. Stylet tip identified by the
white arrow. The depth is adjusted and the transducer manipulated to center the vessel within the ultrasound image. (b) Ultrasound
still image of a vessel acquired using the in-plane technique. The tip of the stylet (white arrow) and catheter (white arrowhead) within
the vessel lumen (V) with the transducer in long axis (longitudinal) orientation to the catheter and vessel. The stylet and catheter are
visible traversing the proximal vessel wall to enter the lumen of the vessel.
ComplicalCons Cof patcnsCoond-olndn cnsiopct iidnsns 119
the catheter stylet (i.e. you do not slide off vessels). Keep the
stylet tip visible when using the out-of-plane technique to
avoid accidental puncture of the far vessel wall. The cathe-
ter tip should be adjusted as needed to keep it centered over
the vessel while the tip is still within the subcutaneous tis-
sue (proximal to the vessel wall); such adjustments are eas-
ily accomplished with out-of-plane ultrasound-guided
catheter techniques.
Aseptic technique should be followed, including the use
ROCK of sterile ultrasound gel applied in combination with iso-
propyl alcohol, and if necessary, covering the transducer
with a sterile glove or sleeve. Sterile standoff ultrasound
pads or jelly pads have been used in some human studies
to facilitate ultrasound-guided catheterization, although
their application in veterinary medicine has not been
evaluated [8].
Complications of Ultrasound-Guided
SWEEP
ROTATE SLIDE Vascular Access
Complications are uncommon and occur at a similar rate

to blind peripheral catheter insertion techniques [2, 3]. In
human medicine, reported complications vary depending
on which site is used for ultrasound-guided vascular access
and include paresthesias, brachial artery puncture, hema-
toma formation, and IV decannulation [2]. To avoid
complications:
FAN ● The best target will be the vessel that is the largest and
most superficial.
Figure 9.3 Summary of the five different probe manipulations
commonly used during point-of-care ultrasound; sweep, slide, ● For deep vessels, angle your catheter at a steeper angle
rotate, fan, and rock (see Chapter 6 for details). than you would for a superficial vessel (35–45 degrees).
Protocol 9.1 Ultrasound-Guided Vascular Catheterization Using the Out-of-Plane Technique

Machine and patient preparation 4) Depth should be set to maximize the size of the ves-
sel without losing it in the far field of the image.
1) A high frequency linear array transducer (8–13 MHz)
Sweep along the vessel to ensure it remains visible
is preferred, although a microconvex transducer can
within the ultrasound window.
be used if a linear transducer is unavailable.
5) Veins and arteries are easily distinguished by apply-
2) Align the ultrasound machine alongside the patient,
ing pressure to the ultrasound transducer, which will
in front of the sonographer, so the operator only has
collapse veins at much lower pressures than
to adjust their eye focus from the skin transducer
arteries [2].
interface to the ultrasound screen (up and down)
6) Avoid applying too much pressure to the transducer
without having to turn their head or neck to look over
when first identifying vessels or during venous
their shoulder when changing their focus from the
access, to avoid collapsing the vessel, particu-
transducer to the ultrasound image.
larly veins.
3) Position the patient in lateral recumbency when
7) “Holding off” the vein helps prevent venous collapse
accessing the jugular or saphenous veins and sternal
and increases the diameter of the vein.
recumbency to access the cephalic veins.
8) Stabilize the transducer by resting your hand on the 17) Veins will be thin-walled and easily compressible,
patient using the “afternoon tea technique” approach compared with arteries, which will be thick-walled
(Figure 9.4) [7]. and non-compressible (Figure 9.5) [2].
9) Scan the vessel of interest to gauge its depth from 18) When the vessel of interest has been identified, the
the skin surface, its diameter and patency, as well as operator focuses their attention to the ultrasound
the direction of the vessel prior to inserting the transducer–skin interface.
catheter. 19) The bevel of the stylet should be directed toward the
10) Using a longer (1.8 or 2.5 inch) catheter is often pre- ultrasound transducer as this will maximize the
ferred since ultrasound guidance is frequently used reflection of ultrasound waves and enhance needle
in patients with edema, obesity, or hematoma forma- tip visualization (cut surface reflects the most ultra-
tion where the vessel of interest will be located sound waves).
deeper within the tissues. 20) The angle of entry relative to the skin surface varies
11) Fur is clipped over the vessel of interest. depending how deep the vessel is within the tissues.
12) Clean the ultrasound transducer by wiping with soap Generally, the needle is inserted at an angle of
and water followed by a low-level disinfectant (e.g. 30–45 degrees to the transducer, just distal to the
hydrogen peroxide or diluted bleach) and apply ster- ultrasound transducer (Figure 9.1) [2].
ile lubricant. A gel-filled sterile glove can be placed 21) Once the tip of the needle has entered the skin,
over the ultrasound transducer to maintain a sterile the operator’s focus returns to the ultra-
field if desired. sound screen.
13) For venous access, have an assistant occlude the 22) Slowly sweep the transducer proximally along the
vein or apply a tourniquet proximal to the inser- vessel as the needle tip moves proximally. This is
tion site. typically performed by advancing the catheter tip, out
14) Prepare the skin surrounding the insertion site just of plane, until it becomes visible within the ultra-
distal to the transducer using aseptic technique. sound image as a “small white hyperechoic dot”
(Figure 9.2a, Video 9.1).
23) Failure to stop advancing the catheter as soon as the
Out-of-plane technique
stylet tip is seen as a white dot on the ultrasound screen
15) Place the transducer over the vessel of interest at a increases the risk of accidently traversing the vessel and
90-degree angle of insonation in short axis orienta- in the authors’ experience, is one of the most common
tion (perpendicular) to the vessel (Figure 9.4). mistakes made using out-of-plane technique. Advancing
16) Adjust the position/depth to center the vessel within the catheter tip beyond the ultrasound beam results in
the ultrasound image (Figure 9.2). uncertainty regarding catheter tip location.
Figure 9.4 Images depicting the “afternoon tea technique” to help stabilize the transducer. The concept involves keeping the
little finger extended away from the transducer and in contact with the patient’s skin, while the thumb and “pointer” finger are
used to grip the transducer head. Left image: the transducer is held like a cup demonstrating proper finger position of the “tea”
technique. Right image: the dotted lines represent the walls of a water-filled balloon, which is used to mimic a vessel within a
raw chicken phantom model. The transducer is situated perpendicular to the vessel in this example (i.e. out-of-plane). The fingers
are gently positioned against the skin (raw chicken breast in this case) to stabilize the probe.
Complications of Ultrasound-Guided Vascular Access 121
Probe
pressure
V
A
V
A
Figure 9.5 Schematic ultrasound image of an artery (A) and vein (V). With application of pressure to the transducer at the
transducer-skin interface, the thinner-walled vein collapses, sometimes disappearing completely, while the artery remains visible,
compressing less. This “compression” test helps to differentiate arteries and veins that often lie in close proximity.
24) Once the tip is visible discontinue advancing the ensure that the tip of the catheter and the stylet are
catheter and sweep the transducer proximally both within the vessel lumen.
along the vessel until the catheter tip is no longer 29) Hold the stylet with one hand as the catheter is com-
visible. pletely advanced off the stylet and into the vessel. If
25) Failure to slide the transducer completely off the sty- desired, advancement of the catheter off the stylet
let tip (tip completely out of the plane of imaging) can be performed by an assistant while the operator
can also result in the catheter tip being advanced ensures the catheter tip remains visible within the
beyond the ultrasound beam when the catheter is lumen of the vessel.
advanced again.
26) The process is repeated until the catheter tip, seen
Advantages and Disadvantages
as a white dot, can be visualized within the ves-
sel lumen. A major advantage of the out-of-plane technique is that it is
27) Once the catheter tip is visualized within the vessel, more forgiving; the operator does not have to maintain
a flash of blood will likely be visible in the cathe- both the catheter and the transducer in the same plane to
ter stylet. be able to visualize the stylet tip. It is also possible to adjust
28) The remainder of the procedure proceeds as with the the stylet tip location within the subcutaneous tissues to
blind technique for vascular catheter placement. recenter the catheter over the vessel if alignment is slightly
Ultrasound guidance can be continued for this step if off (Video 9.2). The disadvantage of out-of-plane technique
desired. Decrease the angle of the catheter and stylet is the risk of passing the catheter tip beyond the ultrasound
approximately 15 degrees relative to the skin surface beam without realizing this has occurred. A black shadow
and advance them together another 1–2 mm to will often appear below the white dot when this happens.
Protocol 9.2 Ultrasound-Guided Vascular Catheterization Using the in-Plane Technique

1) Follow Protocol 9.1, steps 1–14. 3) The stylet tip and catheter are followed in their entirety
2) The catheter and tip of the stylet are visualized as they as they traverse the subcutaneous tissues and the super-
enter the subcutaneous tissues within the ultrasound ficial wall of the vessel to enter the lumen (Figure 9.2b).
image (the transducer marker or ultrasound image can 4) Once in the lumen of the vessel, the angle between
be set to visualize the catheter entering from the left the skin surface and the catheter is reduced, and the
or right side of the ultrasound image depending on catheter and stylet advanced slightly within the vessel,
operator preference). taking care not to traverse the deep vessel wall.
5) Once the catheter is well situated in the vessel, the aligned in the plane of the ultrasound beam, as being off
catheter is advanced off the stylet and down the plane by even 1–2 degrees, or failing to maintain the
vessel lumen. catheter directly in the center of the ultrasound trans-
6) The entire procedure can be visualized using in-plane ducer, precludes catheter visualization. Achieving this
techniques. alignment is more difficult with smaller peripheral
vessels, particularly given the narrow width (1–2 mm) of
the ultrasound beam projected by linear array transduc-
Advantages and Disadvantages
ers. An advantage of in-plane technique is the fact that
The difficulty with the in-plane technique is that it surrounding structures can always be visualized as the
requires more practice to keep the catheter perfectly catheter is advanced.
Protocol 9.3 Phantom Chicken Breast Simulator for Ultrasound-Guided Vascular Access Training
1) A phantom model can be made using two raw chicken 4) A single balloon or two balloons can be used. Place
breasts, plastic kitchen wrap, and modeling balloons the balloons parallel to one another, 1–2 cm apart if
(Figure 9.6). using a two-balloon model (Figure 9.6).
2) One chicken breast is laid in the middle of a flat piece 5) A second chicken breast is placed on top of the
of plastic kitchen wrap that is large enough to wrap balloons to create a “sandwich” with the balloons
around two chicken breasts placed one on top of the in the middle of the two chicken breasts
other (Figure 9.7). (Figure 9.9).
3) A fluid-filled, tied-off modeling balloon (or similar 6) The plastic kitchen wrap is then wrapped around the
tubular structure designed to mimic a vessel such as a chicken breasts to secure the model.
small-diameter Penrose drain) is placed atop the
chicken breast (Figure 9.8).
Figure 9.6 Using short- or long-axis ultrasound guidance (long axis shown in this image) a raw chicken breast vascular access
simulator (made from two raw chicken breasts, water-filled balloons, and plastic kitchen wrap) can be used to practice identifying
and catheterizing a vessel. The chicken breast creates a more lifelike tissue structure with fascial planes than many other
simulator models.
Complications of Ultrasound-Guided Vascular Access 123
Figure 9.7 One raw chicken breast that has been scored with
a scalpel blade is laid in the middle of a flat sheet of plastic
wrap. To keep things contained, the model is built within a
shallow tinfoil cooking tray.
Figure 9.8 A modeling balloon (shown) or small-diameter

Figure 9.10 After attaching a balloon (shown) or Penrose
Penrose drain (not shown) is placed on the chicken breast,
drain to a fluid filled, 60 cc catheter tip syringe, air is first
within scored grooves created with a scalpel blade.
withdrawn from the balloon. Fluid is then injected into the
balloon until it is slightly overfilled, creating an “aneurysm”
that will allow air to accumulate without losing pressure
within the balloon. Draw back on the syringe a final time to
remove air, while still preserving the “aneurysm.” Remove the
balloon from the syringe and tie off. Food coloring can be
used to mimic blood if desired.
“aneurysm” also allows any residual air that might

remain within the balloon to become trapped in the
“aneurysm” which keeps the main vessel that will be
catheterized free of gas.
● Avoid overwrapping the chicken breasts with plastic
wrap because air can become trapped between the lay-
ers of wrap, which hampers tissue and vessel
Figure 9.9 A second raw chicken breast is placed over the first
visualization.
chicken breast and balloon. The authors prefer to reverse the
direction of the chicken breasts (i.e. one thick side to the left ● To help keep things nicely situated within the model,
and one thick side to the right), as shown, to optimize score the chicken breast with a scalpel or needle to
consistency of tissue thickness. make a shallow tunnel in the chicken breast before
placing the balloons. This helps keeps the balloon in
one place within the scored lines when pressure is
Pearls for Making The Raw Chicken Breast Simulator:
applied with the transducer to the outside of the model.
● Remove all air from the balloon prior to filling it with ● When placing the chicken breasts against each other it
fluid (air prevents visualization with ultrasound). is easier to keep objects aligned if the thickness of the
● The balloon can also be slightly overfilled, creating an chicken breasts is reversed (place the thick side of one
“aneurysm” that will allow air to be released without chicken breast in one direction and the second thick
losing pressure within the balloon (Figure 9.10). The side of the chicken breast in the opposite direction).
● To keep things contained, the model can be placed in long axis to the lumen of the balloon, allows trouble-
aluminum tinfoil trays (Figure 9.7). shooting of the technique to see if the J wire becomes
● The model also works well to train novices on ultrasound- caught on the far vessel wall or to see if the catheter tip
guided modified Seldinger techniques (Figures 9.11 has accidently traversed the far wall of the vessel (eas-
and 9.12). ily corrected with ultrasound guidance by slowly
● Following the passage of the stylet and catheter for the retracting the catheter until the tip is again situated in
modified Seldinger technique, with the transducer in the “vessel” lumen).
Figure 9.11 After placing an ultrasound-guided catheter into Figure 9.12 The catheter is then passed over the
the balloon, a guidewire is passed through the catheter into the guidewire as is normally done with the modified Seldinger
lumen of the balloon using a modified Seldinger technique. technique. Again, ultrasound does not need to be used for
Ultrasound is not necessary for this step (but it is cool to watch this step, but if used, the transducer is oriented in long axis
on the ultrasound image!). If ultrasound is used to monitor to the balloon to more easily allow the catheter to be seen
passage of the guidewire, the transducer should be in long axis sliding down the lumen of the balloon, as shown in
to the balloon (or vessel in a live patient) for this step. the image.
Ultrasound-Guided Vascular Access must follow proper hygiene, wear gloves, and wash hands
Simulators after handling raw chicken to avoid the risk of foodborne
illnesses. The technique can also be practiced on cadavers
Many low-cost simulation models have been used to train following euthanasia if clients allow.
clinicians in ultrasound-guided vascular access. The model
that the authors prefer is a raw chicken breast model, Video 9.1 Out-of-plane ultrasound-guided vascular access:
chicken phantom model.
which uses long, thin, fluid-filled “modeling” balloons or
Video 9.2 Recentering the catheter over the vessel.
small-diameter Penrose drains (Figure 9.6). Note that you
References
1 van Loon, F.H.J., Buise, M.P., Claassen, J.J.F. et al. (2018). 2 Gottlieb, M., Sundaram, T., Holladay, D., and
Comparison of ultrasound guidance with palpation and Nakitende, D. (2017). Ultrasound-guided peripheral
direct visualisation for peripheral vein cannulation in adult intravenous line placement: a narrative review of
patients: a systematic review and meta-analysis. evidence-based best practices. West. J. Emerg. Med.
Br. J. Anaesth. 121 (2): 358–366. 18 (6): 1047–1054.
References 125
3 Hundley, D.M., Brooks, A.C., Thomovsky, E.J. et al. (2018). 6 Cole, I., Glass, C., Norton, H.J., and Tayal, V. (2012).
Comparison of ultrasound-guided and landmark-based Ultrasound measurements of the saphenous vein in the
techniques for central venous catheterization via the pediatric emergency department population with
external jugular vein in healthy anesthetized dogs. Am. comparison to i.v. catheter size. J. Emerg. Med. 43
J. Vet. Res. 79 (6): 628–636. (1): 87–92.
4 Chamberlin, S.C., Sullivan, L.A., Morley, P.S., and 7 McMenamin, L., Wolstenhulme, S., Hunt, M. et al. (2017).
Boscan, P. (2013). Evaluation of ultrasound-guided vascular Ultrasound probe grip: the afternoon tea technique.
access in dogs. J. Vet. Emerg. Crit. Care 23 (5): 498–503. J. Intensive Care Soc. 18 (3): 258–260.
5 Ringold, S.A. and Kelmer, E. (2008). Freehand ultrasound- 8 Triffterer, L., Marhofer, P., Willschke, H. et al. (2012).
guided femoral arterial catheterization in dogs. J. Vet. Ultrasound-guided cannulation of the great saphenous
Emerg. Crit. Care 18 (3): 306–311. vein at the ankle in infants. Br. J. Anaesth. 108 (2): 290–294.
127
10
Principles of Electrocardiography
Cardiac Electrical Activity The Wave of Depolarization

Cardiac myocytes maintain an electrical gradient across
The heart’s main function is to pump blood. The myocar- their cell membranes called the “resting membrane poten-
dium is composed of muscle fibers linked by conduction tial.” This gradient is maintained by multiple systems of
system cells. Synchronized electrical stimulation of the active ion transport, including the sodium–potassium
cardiac myocytes is necessary for well-coordinated con- (Na+–K+) ATPase pump, which pumps sodium out of and
traction, which optimizes cardiac output. Myocytes are potassium into the cell. The intracellular potassium con-
responsible for the heart’s contractile function, whereas centration ([K+]) is thus significantly higher than the
the conduction system cells deliver the electrical impulse extracellular fluid [K+].
that leads to myocyte contraction [1]. A myocyte’s resting membrane potential is considered
The heart’s electrical stimulus originates at the sinus node negative because the myocyte’s intracellular fluid is more
(also called the sinoatrial node or SA node). The SA node is a negatively charged than the extracellular fluid. When the
group of cells in the right atrium that has the highest intrin- myocyte is stimulated by the conduction system or by a
sic (spontaneous) rate of depolarization in the normal heart. neighboring myocyte, its polarity is reduced (the myocyte’s
Because they depolarize more often than other cardiac cells, interior becomes more positive). The less-negative mem-
the SA node is the heart’s primary pacemaker. The three brane potential significantly alters sodium and potassium
internodal tracts (anterior, medial, and posterior) and permeability through the cell membrane. Sodium ions
Bachmann’s bundle transmit the electrical impulse to the rush into the myocyte and K+ ions move to the outside,
atrioventricular (AV) node and the left atrium, respectively [2]. creating what is called an “action potential.” Because the
By design, conduction through the AV node is slow, to allow action potential causes a change in the cell’s membrane
a pause between atrial and ventricular contractions. This AV polarity, this event is called depolarization. One myocyte’s
pause allows atrial contraction to push blood into the ventri- depolarization immediately stimulates the depolarization
cles before ventricular systole begins. Conduction then proof adjacent cells, and the depolarization continues cell-to-
ceeds from the AV node to the bundle of His, which is the cell throughout the myocardium. This chain reaction of
only conductive pathway between the atria and the ventricles cardiac myocyte depolarization is called the “wave of
in the normal heart. At the level of the aortic valve, the con- depolarization.”
duction pathway bifurcates into the left bundle branch and Coordinated cardiac myocyte depolarization is required
right bundle branch (Figure 10.1). Both bundles divide into a for coordinated cardiac contraction [5]. An electrocardio-
network of Purkinje fibers that are distributed to both ventri- gram (ECG) is a graphic representation of the summation
cles [4]. The wave of myocardial contraction follows the elec- vector of all the action potentials of the heart over time
trical impulse starting in the right atrium, continuing to the (Figure 10.2).
left atrium, and then to the ventricles.
128 Principles of Electrocardiography
Figure 10.1 Conduction system of the

heart. Source: Bruce et al. [3]/with
S-A node Bachmann’s bundle
permission of Elsevier.
LA
Left bundle branch
Internodal
pathways
RA LV Posteroinferior fascicle
of left bundle branch
A-V node
A-V bundle of His

RV
Anterosuperior fascicle
of left bundle branch
Right bundle branch
Septum
Purkinje fibers
R or in the heart (for intracardiac leads). The graphic repre-

sentation of the information gathered from an electrocar-
T
diographic lead is the ECG. Electrocardiogram setup and
P monitoring are detailed in Protocol 10.1.
Recording the Wave of Depolarization
Q If a negative electrode is placed in the vicinity of the right

atrium and a positive electrode is placed at the apex of the
S heart, the normal wave of depolarization travels toward the
Figure 10.2 Idealized lead II graphic representation of an positive electrode and by convention is represented by a
electrocardiogram from a dog, with the P, QRS, and T waves positive (upward) deflection on the ECG [1, 5, 6]. The elec-
labeled. The X axis measures time while the Y axis measures the trical impulse of a normal cardiac cycle starts at the SA
summation vector of the myocardium’s electrical activity in the
node. (Figure 10.1). The atrial depolarization originates at
lead being recorded. The P wave is the result of atrial muscle
depolarization. The QRS complex is the result of ventricular the SA node, travels through the internodal tracts and
muscle depolarization. The T wave occurs because of ventricular Bachmann’s bundle and terminates at the AV node. On the
muscle repolarization; T wave appearance can differ ECG, atrial muscle depolarization is represented by the
significantly from individual to individual, but it should
P wave, which is the first positive deflection on the ECG
generally be uniform within the same animal over time. More
information is available in Chapter 11. before the QRS complex [7]. Atrial muscle depolarization
leads to atrial muscle contraction, and consequently to
pumping of the blood from the atria into the ventricles.
The Electrocardiogram There is a physiologic (normal) delay in impulse conduc-
tion at the AV node that allows time for blood to flow from
The electrocardiograph is a galvanometer or voltmeter that the atria into the ventricles prior to ventricular systole. This
records the electrical impulses between nearby negative physiologic delay is the origin of the P–R interval, or the
and positive electrodes placed in or on the body. A system electroneutral “return to baseline” period between the P
of two points between which electrical impulses are con- and QRS waves. Ventricular depolarization starts in the
ducted is called a lead. The electrodes are usually posi- interventricular septum and is represented by a slight neg-
tioned on the animal’s limbs (for standard leads), but they ative deflection on the ECG, called the Q wave. When most
can also be placed on the thorax (for precordial chest leads) of the ventricular muscle depolarizes, it generates the
EECG eassreeent in the Eeergency ooe and ntensiie Eare nit 129
R wave, a large-magnitude positive deflection. The last I

RA LA
parts of the ventricles to depolarize are the basilar portions,
which create a negative deflection on the ECG that follows
the R wave, called the S wave.
After the S wave has occurred, the cardiac depolarization II III
phase is complete. Cardiac repolarization, or the myocytes’
re-establishment of their resting membrane potentials, is
necessary for another cardiac cycle to start. Ventricular
repolarization is represented by the T wave, which in health
LL
can be positive, negative, or biphasic [1, 2, 4–8]. For infor-
mation on ECG waveform interpretation, see Chapter 11. Figure 10.3 Equilateral triangle of Einthoven, oriented as one
would view a dorsoventrally oriented radiograph. This figure
illustrates standard leads I, II, and III (RA, right arm; LA, left arm;
Einthoven’s Triangle and the Principle of Leads LL, left leg).
A bipolar lead is the result of the difference in electrical

activity between electrodes when a negative electrode is Table 10.1 Electrode position for standard bipolar leads: arm,
paired with a positive electrode. Each lead “sees” and reg- thoracic limb; leg, pelvic limb.
isters a different view of a single electrical event (such as a
cardiac depolarization wave), which allows a more com- Lead Positive Negative/neutral
prehensive understanding of the heart’s electrical activity.

I Left arm Right arm
Imagine that the P–QRS–T complex is an event such as a
II Left leg Right arm
motor vehicle accident, and that each lead is a witness
located in a different position in relation to the event. The III Left leg Left arm
witness in the two-story building has a different view than
the person across the street, which is again different than
more commonly used for detailed diagnostic ECG in an
that of the witness seated in the coffee shop. All the wit-
outpatient cardiology specialty setting. Augmented leads
nesses saw the same event, but each from a different angle.
aVR, aVL, and particularly aVF can be useful when stand-
Thus, we make our interpretation of the event with the
ard limb leads do not answer the operator’s questions about
advantage of combined observations and not just a single
ECG rhythm, wave, and complex appearance. More infor-
point of view.
mation about these leads is available elsewhere [8, 9].
Standard ECG Leads ECG Measurement in the Emergency

In 1902, Willem Einthoven proposed the first fixed ECG
Room and Intensive Care Unit
lead system. Einthoven’s equilateral triangle illustrates the
Electrode Placement and Patient Positioning
three standard bipolar leads (Figure 10.3). To obtain these
leads, electrodes are placed on the right thoracic limb or The patient should ideally be positioned in right lateral
“arm” (RA; all ECG limb terminology is in arms and legs, recumbency on a nonconductive surface. If the animal is
by convention), the left thoracic limb or “arm” (LA), and mobile, a handler should rest the right arm over the patient’s
left pelvic limb or “leg” (LL). The right pelvic limb (RL) is neck and the left arm over the hindquarters so the limbs
the connection to the ground. are perpendicular to the body, still, and separated
As depicted in Figure 10.3, lead I detects the difference in (Figure 10.4) [8, 9]. An ECG can be recorded with the patient
electrical activity between the right thoracic limb (negative in sternal or standing position, but this recording should
electrode) and the left thoracic limb (positive electrode); only be used for rate measurement and detection of signifi-
lead II detects the difference between the right thoracic cant rhythm abnormalities. Fortunately, rhythm investiga-
limb (negative electrode) and the left pelvic limb (positive tion is the most common use for ECG measurement in
electrode); and lead III detects the difference between the emergency and intensive care settings. Standing technique
left thoracic limb (negative electrode) and the left pelvic is especially useful in a patient with respiratory distress.
limb (positive electrode; Table 10.1) [7]. Standard leads are More information about continuous ECG monitoring of
by far the most commonly used leads in the emergency acutely and critically ill animals is available in Chapter 11.
room and intensive care unit. Augmented unipolar leads The thoracic limb electrodes are usually placed close to
and unipolar precordial chest leads are additional leads the olecranon (elbow) and the pelvic limb electrodes in the
preferable to apply the chosen conduction medium before

placing the electrodes, as this will minimize interference
from the patient’s fur. Self-adhesive electrodes are also
available (Figure 10.5b), which usually must be secured
with a bandage to keep them in place. They can be applied
directly to the footpads or in an area of clipped skin.
Electrocardiogram Recording
The electrocardiograph (galvanometer) control settings
vary by manufacturer, but there should be an option for
Figure 10.4 Standard patient position for recording an paper speed, calibration, and filter settings.
electrocardiogram (right lateral recumbency). Note the four
standard electrocardiographic color-coded electrodes (RA, right Paper Speed
arm, white; LA, left arm, black; RL, right leg, green; LL, left An ECG can be recorded at any paper speed, but the most
leg, red).
used speeds in veterinary medicine are 25 mm/second and
50 mm/second. At a speed of 25 mm/second, 25 mm of
Table 10.2 Electrocardiograph color-coded cables. paper (five large boxes on the ECG paper) is used to record
one second of waves, while at 50 mm/second, 50 mm of
Cable Color Limb paper (10 large boxes) is used to record one second. Thus,
the same patient’s QRS complex appears wider on the X axis
White Right arm (RA), right thoracic limb on a 50 mm/second recording than on 25 mm/second
Black Left arm (LA), left thoracic limb because it is recorded faster, which corresponds to more
Red Left leg (LL), left pelvic limb space (twice as much in this example) on the ECG paper.
Green Right leg (RL), right pelvic limb When performing ECG wave and complex measure-
ments, a lead II recording at 50 mm/second should be used.
For rhythm recordings 25 or 50 mm/second can be used,
area of the patellar ligament (stifle). However, the electrodes with the choice largely dependent on the patient’s heart
may be placed at any point distal to the limb’s junction with rate and the desired ECG complex definition. A slower
the trunk without significantly affecting the ECG. The limb paper speed (e.g. 25 mm/second) will allow a longer record-
electrodes are color coded by industry standard, and they ing using the same amount of paper (e.g. as compared with
should be placed as indicated in Table 10.2 and Figure 10.4. 50 mm/second), which saves ECG paper. A minimum of
The cables should not be twisted or placed over the patient’s three complexes should be recorded for each standard lead,
body, as this is likely to cause artifacts on the ECG. and a longer recording is recommended when dysrhyth-
mias are present.
Types of Electrodes
Sensitivity
Electrodes are attached directly to the patient’s skin with Standard electrocardiographic calibration is 10 mm/mV,
alligator clips, smooth clips, electrode patches, or metal which means that a 1 mV electrical signal generates a
plates (Figure 10.5). Alligator clips are the most used elec- 10 mm deflection from baseline on the ECG paper. The
trodes in veterinary medicine since they are relatively sim- operator can recalibrate the electrocardiograph to produce
ple to apply, are durable, and do not disconnect easily when larger (double sensitivity: 1 mV corresponds to 20 mm) or
the patient moves [10]. Smooth clips can improve patient smaller (half sensitivity: 1 mV corresponds to 5 mm) ECG
comfort; they can be purchased ready-made or created by complexes. This feature is especially useful when the ECG
flattening the teeth of alligator clips with pliers. Before complexes are very small, as is common in cats, or are very
placing an electrode, a small skin fold should be made in large, as ventricular premature complexes can be.
the appropriate location. Isopropyl alcohol or electrocardi- The calibration mark is a graphic representation of a
ographic conducting gel must be applied to the area as a selected recording voltage, which is used to gauge the ampli-
conduction medium; fur clipping is rarely necessary. tude of the ECG waves. It should appear automatically at
Alcohol should be avoided in critically ill patients that may the beginning of the recording in the form of a rectangle or
be candidates for defibrillation since it is flammable. line that represents the machine’s current calibration
Electrocardiographic gel is also preferred when ECG (e.g. 10 mm high for standard calibration). The calibration
recording will be required for longer than 10 minutes. It is mark precedes the first recorded complex (Figure 10.6).
EECG eassreeent in the Eeergency ooe and ntensiie Eare nit 131
(a)
(b) (c)
Figure 10.5 (a) An example of an alligator electrode clip (bottom) and a modified metal plate (top). (b) Different types of adhesive
electrodes. (c) Alligator style skin clips without teeth. Note the electrodes have integrated snaps to attach to the system’s wires.
Figure 10.6 Electrocardiographic recordings

of the same dog’s ECG at (a) double,
(b) standard, and (c) half sensitivities.
(a)
I
(b)
I
(c)
Filter Settings usually appropriate, and 150 Hz filters can be used in cats.
Internal electrocardiographic filters are used to reduce Filtering can reduce the amplitude of the complexes on an
baseline artifacts, but they are not necessary for a good ECG; therefore, all complex measurements should be per-
electrocardiographic recording. In dogs, 50 Hz filters are formed on an unfiltered tracing.
Ambulatory Continuous ECG Equipment Problems Leading to ECG Artifacts

Monitoring and Telemetry
Artifacts can lead to incorrect ECG interpretation. It is thus
Ambulatory Continuous ECG Monitoring important to minimize the potential for artifacts such as elec-
trical interference, muscle tremors, patient and system move-
Ambulatory continuous ECG monitoring (Holter monitoring)
ment, and inappropriate patient or electrode positioning [13].
is an electrocardiographic method that allows recording for
See Table 10.3 for guidance regarding where to find the source
longer periods of time, such as 24–48hours. It is used for the
of interference based on affected lead(s). Incorrect electrode
diagnosis, monitoring, and therapeutic evaluation of dysrhyth-
placement causes one lead to take on the appearance of
mias. Most of these ECG monitors are powered by batteries
another. Many possible lead misplacements can occur, but
and provide a digital recording with multiple channels [9].
the most common mistake is switching the electrodes of the
Since most dysrhythmias have significant day-to-day
thoracic limbs, which will cause negative P waves in lead I
variation, there is a considerable advantage to obtaining
and inverted leads II and III. This is the result of lead II
this longer diagnostic sample. The technique is also useful
becoming lead III, and vice-versa (Figure 10.7). Information
in the evaluation of syncope and collapse since the patient
about other causes of ECG artifacts is found in Chapter 11.
can go home with the recording device in place to monitor
for such sporadic events [9, 11, 12].
Table 10.3 One can attempt to determine the location or direction
of the source of ECG interference by noting which lead(s) is/are most
ECG Telemetry affected by that interference. This guide may help the operator
Electrocardiographic telemetry is a monitoring technique identify and eliminate the underlying cause of interference.
that helps to monitor hospitalized patients, with digital
ECG tracings obtained through a wireless method. This Direction of source of
Interference observed in leads interference
technique allows the patient to move freely in its enclosure
without the inconvenience of wires. Telemetry units use a 1 and 2 Patient’s right thoracic limb
precordial lead system (over the cardiac apex), which usu- 1 and 3 Patient’s left thoracic limb
ally uses adhesive electrodes that are placed on a shaved
2 and 3 Patient’s left pelvic limb
area of the thorax.
Figure 10.7 Electrocardiogram performed with electrodes placed incorrectly. Top tracing is “lead I”; middle tracing is “lead II”; and
bottom tracing is “lead III.” The electrodes of the thoracic limbs were switched (the black electrode is on the right and the white on
the left thoracic limb). Therefore, the P waves are negative in “lead I” and the readings for leads “II” and “III” are switched.
eferences 133
Protocol 10.1 Electrocardiogram Setup and Monitoring in the Emergency Room and Intensive Care Unit
Items Required 4) For longer-term recording, adhesive patches work
best on the trunk for mobile animals: axillae for
● Electrocardiograph (ECG monitor) with recording paper
white/black electrodes, inguinal regions or caudola-
and appropriate electrode cables
teral flanks for red/green electrodes.
● Clippers
a) Clip the selected sites of fur. Clean away debris at
● Electrocardiographic conducting gel or isopropyl
intended electrode site with a swipe of isopropyl
alcohol
alcohol.
● Alligator clips (for brief recordings) or adhesive patches
b) Spray with adhesive and allow to dry partially
(for brief or prolonged recording)
so that the skin feels “tacky” prior to applying
● Adhesive spray (tincture of benzoin spray) if applying
electrode patches. Best removed with skin-safe
electrode patches to skin
adhesive solvent.
● Medical tape if applying electrode patches to paw
5) For ECG recording in non-ambulatory animals, paw
pads
pads work well as electrode sites and do not require
fur clipping. Clean away debris on paw pads with a
Procedure
swipe of isopropyl alcohol.
1) Determine whether the patient is a likely defibrilla- 6) Allow alcohol to dry completely, then apply adhesive
tion candidate, and if so, use only conducting gel and pad directly to animal’s skin. You may consider addi-
not isopropyl alcohol for electrode contact. tional adhesive spray to optimize electrode adhesion.
2) Decide the patient’s positioning and mobility during 7) Attach cables to buttons on electrode patches.
ECG recording and plan electrode placement 8) Turn on monitor to observe ECG tracing.
accordingly. 9) Select lead, screen/paper speed, and sensitivity setting.
3) Connect ECG cables to monitor and ensure cables 10) Observe ECG tracing and record findings in
reach intended patient location. standardized format for your unit.
Acknowledgments chapter appears in this one. The author and editors thank
Dr. Orvalho for his contributions.
This chapter was originally authored by Dr. Joao Orvalho
for the previous edition, and some material from that
References
1 Kittleson, M.D. and Kienle, R.D. (1998). Small Animal 7 Lauer, M.R. and Sung, R.J. (2001). Anatomy and
Cardiovascular Medicine. St. Louis, MO: Mosby. physiology of the conduction system. In: Cardiac
2 James, T.N. (1974). Anatomy of the conduction system of Arrhythmia: Mechanisms, Diagnosis and Management, 2e
the heart. In: The Heart, 3e (ed. J.W. Hurst, R.B. Logue, (ed. P.J. Podrid and P.R. Kowey), 3–36. Philadelphia, PA:
R.C. Schlant and N.K. Wenger), 52–62. New York, NY: Lippincott Williams & Wilkins.
McGraw-Hill. 8 Tilley, L.R. (1992). Essentials of Canine and Feline
3 Bruce, N.P., Flynn, J.M., and Roberts, F. (1993). ECG Electrocardiography, 3e. Philadelphia: Lippincott
interpretation. In: Introduction to Critical Care Skills, Williams & Wilkins.
(ed. J.M. Flynn and N.P. Bruce), 107. St. Louis, MO: Mosby. 9 Miller, M.S., Tilley, L.R., Fox, P.R. et al. (1999).
4 Racker, D.K. (1989). Atrioventricular node and input Electrocardiography. In: Textbook of Canine and Feline
pathways: a correlated gross anatomical and histological Cardiology, 2e (ed. P.R. Fox, D.D. Sisson and N.S. Moise),
study of the canine atrioventricular junctional region. 67–105. Philadelphia, PA: Saunders.
Anat. Rec. 224: 336. 10 Detweiler, D.R. (1988). The dog electrocardiogram: a
5 Cunningham, J.G. (1991). Textbook of Veterinary critical review. In: Comprehensive Electrocardiography:
Physiology. Philadelphia, PA: WB Saunders. Theory and Practice in Health and Disease (ed.
6 Katz, A.M. (1977). Physiology of the Heart. New York, NY: P.W. MacFarlane and T.D.V. Lawrie). New York, NY:
Raven Press. Pergamon Press.
11 Tilley, L.R., Miller, M.S., and Smith, F.W. (1993). Canine 13 Kossman, M.D., Brody, D.A., Burch, D.E. et al. (1967).
and Feline Cardiac Arrhythmias. Philadelphia, PA: Report of Committee on Electrocardiography, American
Lippincott Williams & Wilkins. Heart Association. Recommendations for standardization
12 Fox, P.R. and Harpster, N.K. (1999). Diagnosis and of leads and of specifications for instruments in
management of feline arrhythmias. In: Textbook of electrocardiography and vectorcardiography. Circulation
Canine and Feline Cardiology, 2e (ed. P.R. Fox, 35 (3): 583–602.
D.D. Sisson and N.S. Moise), 386–399. Philadelphia, PA:
Saunders.
135
11
Electrocardiogram Interpretation
Casey J. Kohen
Introduction echocardiography, assessment of chamber size based solely

on electrocardiography is rarely required.
Electrocardiography is a valuable diagnostic and monitor- Electrocardiography can be used as either a diagnostic or
ing tool in veterinary emergency and critical care (ECC). It a monitoring tool. The proper use of electrocardiography
provides continuous, real-time information about the car- depends on which of those roles the ECG is meant to serve.
diovascular and autonomic nervous systems noninvasively. To obtain a diagnostic ECG, which allows determination of
There are few other tools that provide the quantity and complex amplitude, complex or interval duration, and
quality of clinical information that electrocardiography mean electrical axis for comparison with normal values,
can provide in such a cost-effective way. Electrocardiography the operator must apply standardized methodology (see
is the gold standard for the detection and classification of below). These more rigorous standards are not generally
arrhythmias and for the assessment of treatment responses. applied when ECG is used as a continuous monitoring tool.
The ECC technician plays a vital role in electrocardiograph
use, both in acquiring data and in monitoring and screen-
The Diagnostic Electrocardiogram
ing for arrhythmias.
This chapter focuses on how to acquire a diagnostic elec- Patient Positioning
trocardiogram (ECG) and on specific skills that veterinary For short-term recording of a diagnostic ECG, it is standard
ECC staff should strive to master. A comprehensive discus- to position the patient in right lateral recumbency. This
sion of ECG interpretation and all possible arrhythmias is position is used by convention to assess multiple leads,
beyond the scope of this chapter and interested readers are measure amplitudes of specific wave deflections, and cal-
directed to several excellent texts on those topics (see also culate the mean electrical axis. If the animal is to be placed
Chapter 10). on a metal table or other conducting surface, a blanket or
rubber pad should be placed between the patient and that
surface to avoid conduction interference and artifacts.
Acquiring an Electrocardiogram
Options and Proper Placement of Electrodes
Electrocardiography is used to display or record the heart’s There are several methods of connecting ECG electrodes to
electrical activity. Electrocardiography performed in the a patient. Alligator clips are a common method for short-
emergency room (ER) or intensive care unit (ICU) is term recording and require very little patient preparation.
“surface” electrocardiography – it measures changes in the To minimize patient discomfort, the teeth on the alligator
overall electrical potential of the myocardium from elec- clips should be flattened or filed and recording time should
trodes placed on the body’s surface. This technique can be be limited. The clips should be placed on the caudal aspect
used to assess cardiac chamber size and conduction of each elbow near the olecranon, and on each stifle at the
pathway function, as well as to monitor heart rate and level of the patellar ligament. Some ECG machines provide
rhythm. Continuous rate and rhythm monitoring is a com- only three electrodes for connection to the patient. The
mon indication for electrocardiography in the ER and white electrode should be placed at the right elbow, black
ICU. With the widespread availability of radiography and (or brown) at the left elbow, and red at the left stifle. If a
136 Electrocardiogram Interpretation
fourth (green) electrode is present, it should be placed on augmented leads (aVR, aVL, and aVF) at 25 mm/second
the right stifle (see Chapter 10, Figure 10.4). Conducting paper speed. In addition, 1–2 minutes of lead II at 50 mm/
medium should be placed between the electrode and the second should be recorded to allow for rhythm and rate
patient’s skin. A gel designed for ECG electrodes is pre- analysis. The ECG should be evaluated for the presence of
ferred because these gels are formulated for high conduct- artifacts (see below) and measures taken to remove any
ance to reduce skin resistance and they are generally artifact noted. See Chapter 10 for more information about
hypoallergenic. Alcohol and many quaternary ammonia leads and diagnostic ECG acquisition.
compounds are flammable substances and should not be
applied if defibrillation may be required, for example dur-
Continuous Monitoring
ing cardiopulmonary resuscitation.
Adhesive pads are also available and can be applied for Commonly in the ER and ICU setting, the electrocardio-
longer periods if ECG monitoring is planned to follow the graph is used for longer-term monitoring, and maintain-
diagnostic ECG. Electrodes are available with snap adapt- ing the patient in a standard position (i.e. right lateral
ers to connect to the pads. If pads are used, the patient’s recumbency) is not feasible. Emergency and ICU patients
fur must be clipped, and the skin cleaned and dried to are monitored primarily for changes in heart rate and
maximize adhesion. The adhesive pads can be placed so rhythm, in which case specific positioning is less impor-
that two are on opposite sides of the thorax just caudal to tant. In this setting, the lead that produces the most readily
the scapulae (but cranial to the heart), and the third and identifiable complexes is used. The optimal lead often
fourth are placed in the inguinal regions (Figure 11.1). changes as the patient’s position changes.
The electrodes are connected in the orientation described For continuous monitoring, adhesive pad electrodes
previously (i.e. right thorax/axilla, white; right inguinal, offer substantial advantages over alligator clips (see above).
green; left thorax/axilla, black or brown; left ingui- If the patient’s fur cannot be clipped or the patient
nal, red). requires ECG monitoring only temporarily during anes-
If the waveform is difficult to interpret due to a patient’s thesia, the adhesive pads can be applied to the metacarpal
breathing, the cranial electrodes can be moved more dis- and metatarsal pads (Figure 11.1). Tape can be applied
tally to the thoracic limbs; likewise, the caudal electrodes circumferentially to better secure the pads and electrodes.
can be moved to the pelvic limbs. Once the electrodes are Some pads can adhere tightly to the skin and care should
connected to the patient, the ECG waveform is assessed for be taken when removing them, using adhesive remover as
quality and absence of artifacts (see below). Although any needed to prevent skin irritation and trauma. In patients
lead can provide information on heart rate and rhythm, with ventricular arrhythmias where there is concern for
lead II is conventionally used to determine rate and rhythm progression to ventricular fibrillation, the placement of
and to measure waveform amplitude, as well as waveform larger electrode pads that can be used for defibrillation is
and interval duration. The determination of mean electri- advisable (Figure 11.2) [1]. These pads may also be used
cal axis (although rarely done in the ER setting) requires for external cardiac pacing in patients with complete
that at least two leads be recorded for analysis. heart block or who are symptomatic for other bradyar-
rhythmias (see Chapter 23 for more details) [2]. If the
Recording patient is mobile, the electrode wires can be gathered and
A diagnostic ECG should include brief recordings of the secured to the patient with a stockinette fitted over the
three standard leads (I, II, and III) as well as the three thorax to avoid tangling. Regardless of the electrode
(a) (b) (c)
Figure 11.1 (a) Adhesive pads and snap electrodes for long-term monitoring. (b) Placement of adhesive pads on cranial thorax and
inguinal region. (c) Alternative placement on paw pads.
Electrocardiogram Waveforms 137
QRS
Complex
ST
PR Segment
T
P Segment
Q
PR Interval
Figure 11.2 Using pacing-capable pads for ECG monitoring. S
QT Interval
placement method used, after placement the ECG tracing
should be inspected for artifacts and measures taken to Figure 11.3 ECG waves as seen in lead II.
reduce them.
Continuous ECG monitoring provides both auditory and
visual data. Most modern monitors are capable of produc- beginning of the P wave to the beginning of the QRS com-
ing an audible signal synchronized to the QRS complex. plex and represents the time required for the electrical
This feature allows for qualitative monitoring of rate and impulse to travel from the SA node to the ventricles. A
rhythm and can alert clinic staff to substantial alterations. substantial portion of this time is taken up by conduction
When auditory changes are noted, it should prompt a vis- through the atrioventricular (AV) node. Slower AV node
ual inspection of the ECG display. Abnormalities noted conduction (e.g. when vagal tone is increased) results in
after visual inspection should be recorded for analysis and a prolonged P–R interval [3, 4]. When the AV node is
documentation if possible. While recordings made at bypassed (e.g. during ventricular pre-excitation) the P–R
25 mm/second allow for more complexes to be recorded interval is substantially shortened and the atria and ventri-
on a given length of paper, the authors recommend cles depolarize nearly simultaneously; in this case, the
50 mm/second recordings since they are generally easier to P wave and QRS complex are closer together or begin to
interpret in small animals. merge [5]. A P wave with increased duration or increased
amplitude may indicate left or right atrial enlargement,
respectively [6].
Electrocardiogram Waveforms The QRS complex is produced as a result of ventricular
depolarization. The typical appearance of the QRS is due to
As noted in Chapter 10, the process of myocardial depolari- the sequential depolarization of different portions of the
zation and repolarization (the re-establishment of resting ventricles such that the wave of depolarization is moving
membrane potential) leads to a series of deflections that away from a given lead at times (e.g. negative Q and S
are generally recognizable when displayed in sequence deflections on lead II) and toward it at others (e.g. positive
over time. Each portion of the normal ECG waveform is R deflection on lead II). The duration of the QRS complex
associated with a specific portion of the myocardial depo- indicates how long ventricular depolarization takes to
larization–repolarization cycle (Figure 11.3). occur. Ventricular depolarization typically occurs quite
In sinus rhythm, in which the electrical impulse begins rapidly (< 0.06 second) due to the presence of specialized
in the sinoatrial node (also called the SA node or sinus conducting tissue (the bundle of His and its branches; see
node), the P wave is the first deflection noted and reflects Chapter 10, Figure 10.1) that rapidly conducts the signal to
depolarization of both atria. As an impulse emerges from depolarize and distributes it throughout the ventricles.
the area of the SA node, atrial depolarization begins and Prolongation of the QRS complex can indicate a conduc-
progresses from the right atrial myocardium to the left. tion disturbance (e.g. bundle branch block, BBB), ectopic
The direction of this wave of depolarization is such that a origin of the complex (e.g. a ventricular premature com-
small positive deflection lasting less than 0.05 second is plex, VPC), ventricular hypertrophy, or some combination
observed on lead II. The P–R interval is measured from the thereof [5]. Increases in the amplitude and duration of
the QRS can be seen with ventricular hypertrophy in Determine the Heart Rate
some cases [7].
Instantaneous heart rate may be determined by measuring
The ST segment is a period of relative electrical inactivity.
the time between successive P waves or QRS complexes.
In the healthy myocardium, the ST segment is electrically
Mean heart rate may be calculated by determining the num-
silent and no differences in potential are detected on any
ber of cardiac cycles over a given length of time (e.g. 3–6sec-
lead. However, in the injured and/or ischemic myocardium
onds) and multiplying that number to give an average per
an “injury current” may occur between adjacent diseased
minute. Arrhythmias involving AV block or ectopic com-
and healthy sections of myocardium (although more com-
plexes and rhythms may create an overall rhythm in which
plex pathophysiology likely occurs) [8]. On the ECG this
the atrial heart rate and the ventricular heart rate are not the
injury current manifests as either elevation or depression
same. In such cases, it is recommended that both an atrial
of the ST segment compared with baseline (see ECG Skill
rate (based on P wave frequency) and a ventricular rate
Set 9 later in this chapter). ST segment alterations can be
(based on QRS frequency) be determined separately. An
important indicators of myocardial injury and should
example of a situation in which this approach may prove
prompt further investigation.
beneficial is given in ECG Skill Set 2 at the end of this chapter.
The QT interval is measured from the beginning of the
QRS to the end of the T wave. It represents the combined
duration of the depolarization and repolarization processes Evaluate the Overall Rhythm
for the whole ventricular myocardium. Although QT inter-
vals normally vary inversely with heart rate (i.e. longer QT Next, one may attempt to evaluate the overall cardiac
interval when heart rate slows), they are typically less than rhythm by inspecting the entirety of the recorded study.
0.25 second in duration at normal canine heart rates. Are there specific complexes appearing at unexpected
Hypercalcemia can result in shortening of the QT interval; intervals or with P or QRS morphology that differs from the
hypocalcemia results in prolongation of the QT interval. rest? This may indicate ectopic activity such as atrial pre-
Hypomagnesemia and hypokalemia can also result in QT mature complexes (APCs) or VPCs. The rhythm should be
interval prolongation. Despite the associations described evaluated for whether it is regular or irregular. If the R–R
above, there is minimal veterinary evidence to support the intervals (distance between two adjacent R waves) are
clinical significance of electrolyte effects on QT intervals in evenly spaced throughout the recorded strip, the rhythm is
dogs and cats. considered regular; if the spacing is variable, the rhythm is
The T wave is associated with ventricular repolarization termed irregular. However, there may at times be a pattern
and the re-establishment of resting membrane potential. to the irregularity; this is a “regularly irregular rhythm.”
T wave conformation is highly variable in populations of An example of a regularly irregular rhythm is respiratory
normal, healthy dogs and may be positive, negative, or sinus arrhythmia wherein the heart rate varies with the
biphasic [9]. However, in an individual patient the appear- phases of respiration (faster during inspiration and slower
ance of their T wave is generally consistent. An abrupt during expiration). In contrast, an “irregularly irregular”
alteration in the appearance of a patient’s T wave should rhythm is one for which there is no discernible pattern to
prompt evaluation of serum electrolytes, particularly the irregularity. Atrial fibrillation is a classic example of an
potassium, and assessment for hypoxemia. irregularly irregular rhythm.
Evaluate the Complexes and Intervals

tepwise Interpretation
S
of the Electrocardiogram Next, identify the complexes and the intervals, and deter-
mine their amplitude and/or duration. Prolongation of a
When interpreting electrocardiographic data, it can help to given parameter indicates that whatever process that
take a stepwise approach and consistently apply it in the parameter represents is taking longer than normal. An
same manner every time. While the steps may be taken in example is a prolonged P–R interval. The P–R interval is
any order, there is some benefit to following a specific the length of time it takes a signal to travel from the sinus
sequence such that the largest number of rule-outs is node to the ventricle. The bulk of that time is spent trave-
removed with each step. For example, determining heart ling through the AV node, so a prolonged P–R interval indi-
rate first has the advantage of excluding many possible cates slowed AV node conduction (termed first degree AV
rhythms and allows one to focus on the remaining possibili- block). Increased amplitude of a complex may also carry
ties. One such stepwise approach used is shown in important information (e.g. increased P wave amplitude
Protocol 11.1 and further details of each step are pro- indicating right atrial enlargement), but this information is
vided here. generally more heavily scrutinized during a multilead
Stepwit ISteeetStSwiI iofStt EteSeieterwioeta 139
Protocol 11.1 Stepwise Approach to Electrocardiogram Interpretation

● See accompanying text (Stepwise Interpretation of the 3) Identify the complexes and the intervals; determine
Electrocardiogram) for details of each step. their amplitude and/or duration:
a) P wave
Procedure b) P–R interval
c) QRS complex
1) Determine the heart rate(s):
d) Assess morphology of the Q, R, and S deflections.
a) Atrial rate (frequency of the P waves)
e) QT interval
b) Ventricular rate (frequency of the QRS complexes)
f) T wave
c) Are they the same?
4) Inspect the ST segment for evidence of elevation or
2) Evaluate the overall cardiac rhythm:
depression
a) Is the rhythm regular or irregular?
5) Compare the amplitudes, durations, and morphology
i) If irregular, is the rhythm regularly irregular or
with normal values (Table 11.1) for this species as
irregularly irregular?
well as previous values for this individual (if
ii) Are there specific complexes appearing at unex-
available).
pected intervals or with QRS morphology that is
different than the rest?
Table 11.1 Normal canine and feline electrocardiogram values [10].
Canine Feline
Heart rate Puppy: 70–220 beats/minute 120–240 beats/minute

Toy breeds: 70–180 beats/minute
Standard: 70–160 beats/minute
Giant breeds: 60–140 beats/minute
Rhythm Sinus rhythm Sinus rhythm
Sinus arrhythmia
Wandering pacemaker
P wave:
Amplitude Maximum: 0.4 mV Maximum: 0.2 mV
Duration Maximum: 0.04 second (Giant breeds 0.05 sec) Maximum: 0.04 second
PR interval 0.06–0.13 second 0.05–0.09 second
QRS:
Amplitude Small breeds: 2.5 mV Maximum: 0.9 mV
Duration Large breeds: 3 mV Maximum: 0.04 second
Small breeds: 0.05 second maximum
Large breeds: 0.06 second maximum
ST segment:
Depression < 0.2 mV None
Elevation < 0.15 second None
QT interval 0.15–0.25 second at normal heart rate 0.12–0.18 sec at normal heart
rate
T wave May be positive, negative, or biphasic Typically positive
25% of R wave amplitude Maximum 0.3 mV amplitude
diagnostic ECG study than when electrocardiography is Respiratory artifact is due to electrode motion during
being used as a continuous monitoring tool. Decreased exhalation and inhalation. It results in a baseline that cycli-
amplitude may occur in a number of settings. Those most cally rises and falls rather than remaining stable
relevant to the ECC setting include pleural space filling dis- (Figure 11.4a). Moving the cranial electrodes from the
orders and pericardial effusion [11]. chest wall to the thoracic limbs usually reduces or elimi-
The normal QT interval varies inversely with heart rate nates this artifact. Poor-contact artifact results in the loss of
but may be altered pathologically in electrolyte distur- recognizable complexes and coarse, ultra-high-frequency
bances (most often those involving alterations in calcium oscillations (Figure 11.4b). Using contact gel or applying
or potassium). Nomograms relating QT intervals and heart tape to secure electrode pads more firmly can reduce poor-
rates are available but are seldom used [12]. contact artifact.
The T wave arises from ventricular repolarization. The In most parts of the world, alternating current is used to
process of repolarization is a reflection of how depolariza- power devices plugged into outlets. This current alternates
tion occurred. If depolarization occurs slowly and atypi- polarity (direction) 60 times each second. This alternating
cally, then repolarization will occur abnormally as well. In current results in an electrical field that can be picked up by
clinical practice, this phenomenon is most often mani- ECG equipment. This type of artifact is termed 60-cycle
fested in the wide and prominent T waves associated with interference and produces a baseline with fine, persistent
VPCs. Electrolyte disturbances may also alter T wave mor- oscillations (Figure 11.4c); 60-cycle interference can be
phology as evidenced by the tall, peaked T waves seen in reduced by making sure that ECG equipment is plugged
hyperkalemia [13]. It should be noted that there is a vast into a properly grounded outlet and that other devices
array of T wave morphologies observed in normal plugged into this circuit are turned off or unplugged (if pos-
patients [9]. T waves may be positive, negative, or biphasic sible). Clippers and fluorescent lighting are common
in normal animals [9]. What is important to note is when sources of 60-cycle interference. Moving the patient and
a patient’s T wave morphology changes relative to what equipment away from walls containing electrical wiring
had been observed in that same patient previously, as the may help reduce 60-cycle interference. Table 10.3 in
change may herald the development of myocardial Chapter 10 provides guidance for locating the source of
injury [14]. interference.
The ST segment should be inspected for evidence of elev- Muscle activity can also produce an unstable, oscillating
ation or depression. The significance of these findings is baseline that limits one’s ability to interpret the ECG
explained further in ECG Skill Set 9 at the end of this chapter. (Figure 11.4d). Muscle tremors and shivering commonly
produce muscle activity artifact, as can purring in cats.
Removing muscle activity artifact often requires that one
Compare Measurements with Normal Ranges
address the underlying cause of the muscle activity (e.g.
Lastly, it is important to note that one should compare warm a patient that is shivering) or move the electrodes to
measurements with established normal values for this spe- a different location, or both.
cies and with any previous recordings made from this Most ECGs are recorded on thermal paper that darkens
patient. For example, has the QRS amplitude increased when heat is applied to it. The heated stylus moves up and
relative to the last visit, suggesting progressive left ventric- down while the paper is advanced at a predetermined
ular hypertrophy? Or is this elevation in heart rate some- speed (e.g. 50 mm/second). Stylus temperature should be
thing that has been observed every time this patient visits adjusted to provide a tracing with optimal clarity. A stylus
your clinic, suggesting white coat syndrome? [15] that is set at too low a temperature will yield a very faint
In all cases, abnormalities in rate, morphology, rhythm, tracing while an overheated stylus produces a tracing that
or interval durations should be noted in the patient record is overly wide and dark (Figure 11.4e). Either type of arti-
and brought to the attention of the clinician on duty so that fact can hamper interpretation.
a treatment or monitoring plan can be constructed in a
timely fashion.
Summary
Recognizing Artifacts Electrocardiography is one of the most valuable monitor-

ing tools available to ECC staff. It provides continuous,
Electrocardiography is prone to several common artifacts real-time information regarding cardiovascular status and
that can interfere with interpretation including respiratory autonomic tone and defines the nature of cardiac arrest.
artifact, poor-contact artifact, 60-cycle interference, muscle The ECC technician plays a vital role as a front-line inter-
activity artifact, and stylus temperature artifact. preter of ECG data. Ten essential skills for the ECC
Skill Sets 141
(a)
(b)
CAMCO NO. 40
LEAD II
(c)
(d)
(e)
Figure 11.4 ECG recordings showing different types of artifact: (a) respiratory motion artifact; (b) poor lead contact artifact;
(c) 60-cycle interference, lead II ECG at 50 mm/second; (d) probable muscle-tremor artifact; (e) excessive stylus heat artifact.
technician to master are discussed in the following “Skill baseline oscillates. A key difference between atrial flutter
sets” portion of this chapter. and 60-cycle interference is the rate of the oscillations. The
repetitive depolarization of the atrial myocardium that
occurs in atrial flutter is much slower than the 3600 oscilla-
tions/minute found with 60-cycle interference (60-cycle or
Skill Sets
60 Hz = 60 oscillations/second, which is 3600/minute).
Atrial fibrillation and atrial flutter can result in a base-
Skill Set 1: Distinguishing 60-Cycle
line with an undulating or oscillating appearance. There
Interference from Atrial Fibrillation or
are, however, key features that allow the technician to dis-
Atrial Flutter
tinguish these arrhythmias from 60-cycle interference.
The ICU and ER environments are frequently busy, Atrial fibrillation is demonstrated in the second ECG
crowded places with a great deal of equipment. The pace of (Figure 11.5b). Atrial fibrillation results in uncoordinated
clinical practice and the requisite instrumentation fre- atrial electrical activity and thus the baseline undulations
quently lead to poor-quality ECG recordings. One common are irregular and do not follow a repetitive pattern as seen
cause of poor-quality ECG recordings is 60-cycle interfer- in 60-cycle interference. An example of atrial flutter is
ence as described above and demonstrated in the first ECG shown in the third ECG (Figure 11.5c). One may note that
(Figure 11.5a). Note the extreme rapidity with which the this arrhythmia does produce a baseline with a repetitive,
CAMCO NO. 40
LEAD II
(a)
(b)
(c)
Figure 11.5 (a) Sixty-cycle interference, lead II ECG at 50 mm/second. (b) Atrial fibrillation, lead II ECG at 50 mm/second. (c) Atrial
flutter, lead II ECG at 50 mm/second.
oscillating appearance, just slower and with a less uniform that of the sinus node. When this happens, AV dissociation
morphology than 60-cycle interference. Also note that with may occur. AV dissociation is a class of arrhythmia wherein
both atrial fibrillation and atrial flutter the R-R interval the atria and ventricles are controlled by separate, inde-
typically is irregularly irregular, which is not expected when pendent pacemakers resulting in two different rhythms.
60-cycle interference is superimposed on a sinus rhythm. On a surface ECG, these two independent rhythms are
superimposed on one another and may appear to represent
a single disorganized rhythm. When the rate of the AV
Skill Set 2: Distinguishing Third-Degree
junctional pacemaker site is close to that of the sinus node,
Atrioventricular Block
the sinus node may be unable to pace the ventricles, as the
from Atrioventricular Dissociation
AV node is refractory to conduction because it has already
Disorders of conduction through the AV node can result in been depolarized by the ectopic pacemaker site. This repre-
many different types of arrhythmia, including many forms sents a form of functional AV block. No AV node pathology
of AV block. Many of these are easily distinguished from is required for this type of conduction disorder to occur.
one another based on the nature of the P–R interval and its The first ECG (Figure 11.6a) is an example of complete
relation to the QRS complex. However, a complete lack of heart block (also known as third-degree AV block). The
AV node conduction can result from many causes, includ- atria are being depolarized by the sinus node and thus reg-
ing AV node pathology, medications, excessive vagal tone ular P waves are noted. The QRS complex is wide, indicat-
(though this typically results in less severe AV conduction ing that ventricular depolarization is atypically prolonged.
disturbances), or physiologic refractoriness of the AV node In third-degree AV block, the QRS complexes are the result
due to non-sinus node pacemaker activity. The AV junction of a ventricular escape rhythm, and ventricular depolariza-
contains cells capable of intrinsic pacemaker activity simi- tion frequency (and thus heart rate) is typically slower than
lar to the sinus node cells. However, the activity of the AV normal. This form of AV dissociation is most commonly
junction site is usually suppressed (overridden) by the due to pathology of the AV nodal tissue.
higher intrinsic rate of the sinus node. On occasion, the The second ECG (Figure 11.6b) is an example of iso-
discharge rate of the AV junctional pacemaker site can rhythmic AV dissociation, which is a category of arrhyth-
become increased to the point that its rate is nearly equal to mia rather than a specific rhythm diagnosis, much like
Skill Sets 143
(a)
* **
Continued on image below
** *
(b)
Figure 11.6 (a) Third-degree atrioventricular block, lead II ECG at 50 mm/second (top tracing). (b) An example of isorhythmic
dissociation, lead II ECG at 25 mm/second (middle and bottom tracings).
tachycardia is a category not a specific rhythm diagnosis.

Skill Set 3: Distinguishing APCs from
In the case example provided, one should note that at
Ventricular Premature Complexes
the beginning of the strip, P waves and QRS complexes
are distinct and appear as expected. However, in the Ectopic depolarizations (often called premature com-
center of the upper portion of Figure 11.6b one can see plexes) may arise from supraventricular or ventricular foci.
the P waves and QRS complexes merging (*) and sum- They represent paroxysmal depolarizations arising from
mating (QRS amplitude appears increased). The P waves sites other than the sinus node. APCs could more correctly
then begin to reappear in the downstroke of the R wave be termed supraventricular ectopic depolarizations, which
(**) and then ultimately reappear just to the left of the more correctly describes them because (a) APCs may arise
QRS complexes where they are usually found (***). In from ectopic sites other than the atria, such as the AV junc-
this case, there are two independent rhythms present: a tion; (b) they are not always particularly premature; and (c)
sinus rhythm depolarizing the atria and an accelerated although APCs do result in depolarization, they may not
junctional rhythm depolarizing the ventricles. An impor- always result in myocardial contraction. VPCs (or ventricu-
tant distinguishing factor between the two ECGs lar ectopic depolarizations) arise from ectopic sites in the
(Figure 11.6a,b) is that in third-degree AV block there are ventricles.
many more P waves than QRS complexes, whereas in iso- Both APCs and VPCs may be identified in small animal
rhythmic dissociation rhythms there are typically a few patients in the ER and ICU setting. In dogs, APCs are
more QRS complexes than P waves. Also, in isorhythmic believed to result more often from primary cardiac disease
dissociation rhythms the most common source of ectopic than are VPCs, which frequently occur due to systemic dis-
pacemaker activity is the AV junction, and the QRS com- ease and may be identified in normal dogs on occasion. In
plexes are thus most often narrow and normal in appearance. contrast, APCs are thought to arise most often from under-
Third-degree AV block is typically a significant clinical lying myocardial disease and less often from extracardiac
problem whereas isorhythmic dissociation rhythms may problems in dogs.
be an incidental finding with fewer adverse effects on Since APCs originate from foci at or above the AV junc-
cardiovascular performance. tion, their transmission to the ventricle is typically via the
(a)
(b)
Figure 11.7 (a) VPC, lead II ECG at 50 mm/second; (b) Atrial premature complexes, lead II ECG at 50 mm/second.
Bundle of His and its branches. This normal path of followed by a “compensatory pause,” in which the next
impulse transmission means that ventricular depolariza- sinus complex occurs right on schedule (as if the VPC did
tion occurs in the same manner as with a sinus depolariza- not occur) because the VPC did not depolarize the SA node
tion. Thus, the QRS morphology and duration associated (Figure 11.7a: the gray bar is the same length as the black
with APCs should be comparable to the QRS complexes bars). The nature of the pause following an ectopic com-
observed after P waves (see the second ECG, Figure 11.7b). plex can on occasion assist in proper classification; in cases
In contrast, VPCs originate from foci within the ventricles; when the two types of ectopic depolarizations cannot be
thus, ventricular depolarization is slower and less organ- distinguished readily based on morphology, the differences
ized since the bundle of His does not distribute the impulse in the types of pauses that follow them may allow proper
as it does with a depolarization that originates from a characterization.
supraventricular focus. This pattern of depolarization leads
to the wide and bizarre morphology typical of VPCs. As
Skill Set 4: Distinguishing Ventricular
repolarization reflects the pattern of depolarization, the
Tachycardia from Supraventricular Tachycardia
T wave is also typically wide and prominent after a
VPC. Repolarization of some portions of the ventricle may Distinguishing supraventricular from ventricular tachyar-
begin before more distant portions of the ventricle have rhythmias accurately is an important skill for anyone
completed depolarization, leading to slurring of the QRS performing ECG interpretation. These types of tachyar-
and T wave together. See the first ECG (Figure 11.7a) for an rhythmias need to be distinguished not only to guide proper
example of a VPC and note that the ectopic complex both antiarrhythmic drug selection, but also because of their dif-
lacks a P wave and has a wide and bizarre morphology. ferent prognoses. Many drug agents that are effective for
APCs typically result in atrial depolarization and there- terminating supraventricular tachyarrhythmias (supraven-
fore generate a premature P wave (termed P′ wave) preced- tricular tachycardia, SVT; e.g. calcium channel blockers)
ing the normal-appearing QRS. An APC with a P′ wave (*) are less effective at addressing ventricular tachyarrhyth-
is depicted in Figure 11.7b. P′ waves may have a different mias. Moreover, rapid ventricular tachyarrhythmias carry
morphology than P waves on the same ECG due to differ- greater risk of degenerating into ventricular fibrillation or
ent patterns of atrial depolarization. This feature along flutter, which are associated with cardiac arrest. Rapid SVTs
with the normal QRS morphology is most helpful in distin- also need to be addressed promptly, as they compromise
guishing APCs from VPCs. diastolic filling and can result in markedly reduced stroke
APCs and VPCs also differ in that APCs may depolarize volumes and poor cardiac output.
and therefore reset the sinus node, whereas VPCs generally SVTs are usually associated with a QRS morphology that
do not. When an APC depolarizes and resets the sinus is narrow and normal in appearance (unless a conduction
node, that APC is then followed by a “non-compensatory disturbance such as BBB is also present). Supraventricular
pause” (Figure 11.7b: the gray bar is longer than the black tachycardias include atrial and junctional tachyarrhyth-
bar) – the complex following the APC occurs after a normal- mias and this class of arrhythmias is also referred to as nar-
length R-R interval. Conversely, VPCs are almost always row QRS tachycardias (this term therefore also includes
Skill Sets 145
(a)
(b)
Figure 11.8 (a) Example of a supraventricular tachyarrhythmia, lead II ECG at 25 mm/second; (b) example of a ventricular
tachyarrhythmia, lead II ECG at 25 mm/second.
atrial fibrillation and atrial flutter when ventricular rates

Skill Set 5: Distinguishing Ventricular
are rapid). P′ waves (see Skill Set 3) may be identified or
Premature Complexes from Ventricular
may be superimposed or merged with the T wave of the
Escape Beats
preceding complex (see the first ECG, Figure 11.8a). The
heart rate is rapid and often regular, except in the case of Ventricular ectopic activity is best assessed when consider-
atrial fibrillation. ing the context in which it is seen. Ectopic ventricular
Ventricular tachycardia and ventricular flutter are tach- activity may be pathologic (e.g. VPCs, ventricular tachycar-
yarrhythmias originating from within the ventricular dia) or physiologic (e.g. ventricular escape beats, ventricu-
myocardium. The bundle of His and its branches do not lar escape rhythms). VPCs and ventricular tachycardia are
distribute the impulse throughout the myocardium, which discussed in Skill Sets 3 and 4, respectively. Ventricular
results in slower wave propagation and widening of the escape beats are ventricular depolarizations that also arise
QRS complex as seen in the second ECG (Figure 11.8b). from a ventricular focus, but under very different circum-
These tachyarrhythmias may be referred to as wide QRS stances than VPCs. There are cells within the ventricles
tachycardias. The occasional P wave may be identified if capable of pacemaker activity at slow rates (20–40 beats/
there is any baseline available for inspection (which is minute), but their activity is usually suppressed (overrid-
unusual because the QRS rate is very rapid), but they do den) by the more rapid pacing activity of other sites (i.e.
not have a predictable relationship to the QRS complexes. sinus node and/or AV junction). However, when the heart
The widened appearance of the QRS and the lack of P (or rates initiated by these other sites fall below the intrinsic
P′) waves is usually sufficient to distinguish SVT from ven- rate of the ventricular pacing cells, ventricular escape com-
tricular tachyarrhythmias. However, there are times when plexes or rhythms should occur. Once the rate of the sinus
the QRS seems only slightly widened and P waves are node or AV junction again exceeds that of the ventricles,
not identifiable; the classification of tachyarrhythmias the escape complexes will be suppressed once again.
becomes more challenging in this setting. Response to a The pacemaking sites in the AV junction and ventricle
trial IV dose of an antiarrhythmic agent (e.g. lidocaine, provide an important “safety net” and likely developed to
diltiazem) and/or response to a vagal maneuver may be ensure that a minimum heart rate will be maintained when
required in some cases to accurately identify the rhythm. the sinus node pauses, temporarily arrests, or fails alto-
SVT often respond to vagal maneuvers while ventricular gether. A similar role is served when AV node conduction
tachyarrhythmias usually do not. disturbances prevent the sinus node’s depolarization signal
Figure 11.9 (a) Ventricular escape

complex (ventricular escape beat),
lead II ECG at 50 mm/second; (b)
ventricular premature complex, lead
II ECG at 50 mm/second.
(a)
(b)
from reaching the ventricles (e.g. complete or “third- thus a VPC. This ectopic beat does not reset the sinus node
degree” heart block; see Skill Set 2). and a compensatory pause follows it (see Skill Set 3). VPCs
The principal feature that distinguishes VPCs from ven- may be due to cardiac or extracardiac disease in dogs; they
tricular escape beats is whether the complex occurs before often indicate myocardial disease in cats. Frequent or mul-
the next QRS complex was expected (VPC) or after a QRS tiform VPCs may require antiarrhythmic therapy.
complex would have been expected (escape beat).
In the first ECG (Figure 11.9a), a ventricular escape com-
Skill Set 6: Recognition of Pulseless
plex (also called ventricular escape beat) follows the third
Electrical Activity
sinus complex. Once again, the lower black bar indicates
the R–R interval between two successive sinus beats. In Pulseless electrical activity (PEA) is a rhythm associated
this case, the wide and bizarre complex lacking a P wave with cardiac arrest in small animals. It was previously
occurs after the next sinus complex was expected to occur. termed electromechanical dissociation, which is a less cor-
Escape beats occur after pauses in sinus node activity as is rect term, and indicates that myocardial depolarization is
shown here. Escape beats are important to help maintain not leading to myocardial contraction; although this can
adequate cardiac output in the face of inadequate pace- occur, there are also situations when depolarization causes
maker activity from the sinus node or disruption of AV contraction but no effective stroke volume is ejected, which
node conduction and should not be suppressed with anti- is still effectively cardiac arrest. The importance of recog-
arrhythmic therapies. nizing the many causes for pulselessness when ECG activ-
In the second ECG (Figure 11.9b), a VPC is present fol- ity is still present has led to preference of the more general
lowing the third sinus complex. The lower black bar indi- term PEA.
cates the R–R interval between two successive sinus beats. Figure 11.10 shows the simultaneous electrocardiogram
The upper black bar indicates the time interval until the (upper tracing) and arterial blood pressure (lower tracing)
next sinus complex would be expected to occur based on from a veterinary patient with PEA. The upper tracing
this established R-R interval. The wide and bizarre com- demonstrates that repetitive (but not regular) cardiac depo-
plex lacking a P wave that occurs before the next sinus larization (QRS complex, which is widened) and repolari-
complex would be expected (i.e. occurs prematurely) is zation (T waves) are occurring. The absence of P waves
Figure 11.10 Pulseless electrical

activity, lead II ECG at 25 mm/second
ECG
with arterial blood pressure.
ABP
Skill Sets 147
suggests atrial electrical activity may be absent, but precor- treatment for mild, intermittent arrhythmias. When the
dial lead recordings (“chest leads”) should be obtained ectopic complexes have varying morphology, this may sug-
before this conclusion is made. Regardless of the exact gest more widespread ventricular myocardial injury and is
rhythm diagnosis, one should note the complete absence of more likely to prompt the initiation of therapy. In the
an arterial pulse wave associated with any of the three QRS “R-on-T” phenomenon the QRS complex of one beat
complexes. occurs before the T wave of the preceding beat has been
The identification of PEA should prompt the immediate completed. Ventricular arrhythmias exhibiting R-on-T
initiation of chest compressions (and other CPR measures) behavior are at greater risk of deteriorating into ventricu-
in the unconscious patient (see Chapter 20). The other set- lar fibrillation (a non-circulating rhythm) and thus war-
ting in which PEA is commonly identified is after euthana- rant therapy. Lastly, all antiarrhythmic agents are
sia with barbiturate or potassium solutions. Electrical inherently pro-arrhythmic so needlessly treating a benign
activity often persists for several minutes after meaningful arrhythmia may result in development of a more danger-
myocardial activity has stopped. ous arrhythmia.
The first ECG (Figure 11.11a) shows a simultaneous
recording of leads I, II, and III. Paroxysmal ventricular
Skill Set 7: Distinguishing Ventricular tachycardia is present. The rapid rate, polymorphic appear-
Tachycardia from Accelerated ance, and R-on-T phenomenon all indicate that treatment
Idioventricular Rhythm is warranted.
The second ECG (Figure 11.11b) shows a monomorphic,
Ventricular arrhythmias may be due to a number of differ-
intermittent ventricular arrhythmia that is termed
ent mechanisms (e.g. re-entry, enhanced automaticity) and
AIVR. This arrhythmia typically occurs at a rate that is too
may represent a finding that (a) must be treated (e.g. ven-
slow to be classified as a true tachyarrhythmia (as is the
tricular flutter); (b) often should be treated (e.g. ventricular
case in the example shown). Further, it often causes little
tachycardia); (c) may not require treatment (e.g. acceler-
impairment in cardiovascular performance and rarely pro-
ated idioventricular rhythm [AIVR]); or (d) should not be
gresses to a more life-threatening form. This arrhythmia is
treated (e.g. ventricular escape rhythms). The decision to
frequently identified in dogs presenting for splenic masses,
treat or not treat a ventricular arrhythmia is often subjec-
hemoabdomen, postoperative gastric dilatation-volvulus,
tive and based on clinical judgment; however, some gen-
or intracranial disease. ECC technicians play an important
eral guidelines are outlined in Box 11.1.
role in recognizing that this arrhythmia rarely requires
Excessively rapid heart rates reduce ventricular diastolic
treatment other than general supportive care and treat-
filling and can reduce stroke volume and cardiac output
ment of the primary problem.
while increasing myocardial workload. As such, ventricu-
lar tachyarrhythmias with rates greater than 160–180
beats/minute are more likely to require treatment than Skill Set 8: Recognition of Ventricular Flutter
those of slower rates. Similarly, sustained arrhythmias are and Fibrillation
more likely to compromise cardiovascular performance
Ventricular flutter and fibrillation represent two of the
than those that are brief and intermittent. Patients whose
most immediately life-threatening arrhythmias that the
markers of perfusion are normal often do not require
veterinary patient may develop. It is essential that the ECC
technician be able to recognize these rhythms. Once it is
recognized that ventricular flutter or fibrillation has devel-
Box 11.1
oped, one should immediately alert the clinician on duty
Ventricular arrhythmias likely should be treated if: without delay, and chest compressions should be initiated
and immediately followed by other CPR measures.
The rate is rapid (> 160–180 beats/minute).
Ventricular flutter (see the first ECG, Figure 11.12a) is a
●
The arrhythmia is sustained.

rapid, often regular-appearing rhythm with wide and
●
Cardiovascular performance appears diminished (e.g.

bizarre QRS complexes that slur into the T waves. The ST
●
poor perfusion parameters, hypotension) as a result

segment and other portions of the ECG that would nor-
of the arrhythmia.
mally appear flat are absent and a sinusoidal appearance to
The ectopic activity has a polymorphic appearance.
the rhythm is generally noted. Treatment options are simi-
●
“R-on-T” phenomenon is identified.

lar to those for ventricular tachycardia (i.e. direct current
●
● Risk associated with leaving it untreated appears

cardioversion, class I antiarrhythmics [e.g. lidocaine],
greater than the risks associated with the treatment
ultrashort-acting class II agents [e.g. esmolol], class III
selected.
agents [e.g. amiodarone], and/or magnesium sulfate).
II
III
(a) MAC55 009A 0.32-150 Hz 25.0 mm/s 10.0 mm/mV

0.109
LEAD II
(b) 1 CM = 1 MV 25 MM/SEC
Figure 11.11 (a) An example of ventricular tachycardia, leads I, II, and III ECG at 25 mm/second. (b) Accelerated idioventricular
rhythm, lead II ECG at 25 mm/second.
However, in many cases ventricular flutter deteriorates fibrillation. However, it is important to note that fine ven-
into ventricular fibrillation by the time intravenous antiar- tricular fibrillation can also occur, in which the waves are
rhythmic agents can be administered, and defibrillation quite small in amplitude. Fine ventricular fibrillation may be
equipment should be readied once ventricular flutter is mistaken for asystole. The only effective therapy for ventric-
recognized. ular fibrillation is electrical defibrillation, which should be
Ventricular fibrillation (see the second ECG, Figure 11.12b) performed without delay once this arrhythmia is recognized
represents a chaotic ventricular arrhythmia wherein organ- (see Chapter 22). Coarse ventricular fibrillation is thought to
ized electrical activity of the ventricular myocardium is respond more readily to electrical defibrillation than fine
absent. The lack of organized electrical activity results in the ventricular fibrillation. Epinephrine may be given prior to
absence of effective myocardial contraction, and cardiac out- defibrillation in an attempt to convert fine ventricular fibril-
put basically ceases. Ventricular fibrillation is a more com- lation to the coarse form before performing defibrillation.
mon arrest rhythm in people than in veterinary patients,
presumably due to the greater human predisposition to myo-
Skill Set 9: Recognition of ST Segment
cardial infarction. However, ventricular fibrillation is identi-
Elevation or Depression
fied in many cardiac arrest events in dogs and cats. The key
features of ventricular fibrillation on an ECG are the lack of The ST segment on an ECG is typically electrically silent
recognizable P–QRS–T complexes and the rapid rate cou- and has a flat appearance. The ST segment encompasses
pled with irregular, bizarre waveforms. The example pro- the period of time after ventricular depolarization but prior
vided in Figure 11.12b is an example of coarse ventricular to the initiation of repolarization. Little or no electrical
Skill Sets 149
II
(a)
(b)
Figure 11.12 (a) Ventricular flutter, lead II ECG at 25 mm/second. (b) Ventricular fibrillation, lead II ECG at 25 mm/second.
potential difference is detectable on any surface lead. radiography) may be warranted once this finding has been
However, in the injured myocardium an “injury current” detected.
may occur as current flows between diseased myocardium
and adjacent, healthier myocardium. This injury current
Skill Set 10: Distinguishing Bundle Branch
can result in an electrical potential difference being detect-
Block from Ventricular Rhythms
able during the ST segment that shifts its position above or
below baseline (Figure 11.13). Whether the ST segment The QRS complex may appear wide on an ECG for a num-
becomes shifted upward (elevation) or downward (depres- ber of reasons. Slight QRS widening may occur with left
sion) depends on the relative orientation of the diseased ventricular or biventricular hypertrophy (i.e. depolariza-
and healthier tissue to one another (e.g. epicardial injury tion takes a bit longer because there is more ventricular tis-
vs. endocardial injury). Myocardial hypoxia can result in sue to depolarize). Marked QRS widening is typically due
ST segment elevation or depression. ST segment changes to either (a) dysfunction of one or more of the branches of
should always be noted and brought to the clinician’s atten- the bundle of His (BBB); or (b) the process of depolariza-
tion when they develop. Investigation of myocardial injury tion bypassing the bundle of His entirely (e.g. ventricular
(e.g. echocardiography, arterial blood gas analysis, arterial escape beats, premature ventricular complexes). It is
blood pressure assessment, troponin assay, thoracic important that the ECC technician not assume that all QRS
Figure 11.13 ST segment elevation, lead II ECG at 25 mm/second.

P P P
(a)
P P P
(b)
(c)
Figure 11.14 (a) Left bundle branch block, lead II ECG at 25 mm/second. (b) Right bundle branch block, lead II ECG at 50 mm/second.
(c) A ventricular rhythm that lacks evident P waves, lead II ECG at 25 mm/second.
complexes with a “wide and bizarre” appearance are ven- pacemaker activity. Since atrial depolarization precedes
tricular in nature. One needs to stop and inspect the ECG ventricular depolarization, P waves are present and the P-R
tracing for evidence of aberrant conduction (e.g. BBB). interval is regular and normal (see labeled P waves in
The first two ECGs (Figure 11.14a,b) show examples of Figure 11.14a,b).
block of the left and right branches of the bundle of His
(left BBB, LBBB, and right BBB, RBBB), respectively. The
most notable difference between LBBB and a normally Acknowledgments
conducted sinus beat is the widening of the QRS complex.
With RBBB, the QRS appearance on lead II exhibits a deep, This chapter was originally co-authored by Drs. Matthew
slurred S wave (the complex appears “upside down” in lead Mellema and Casey Kohen for the previous edition, and
II) in addition to the widened appearance of the QRS com- some material from that chapter appears in this one. The
plex. If a six-lead ECG study is available, a right-axis devia- author and editors thank Dr. Mellema for his contribu-
tion of the mean electrical axis may be noted. With both tions. The author would like to thank Dr. Matt Mellema for
LBBB and RBBB the rhythm originates from sinus node his mentorship in the area of electrocardiography.
References
1 Link, M.S., Atkins, D.L., Passman, R.S. et al. (2010). cardiovascular care. Circulation 122 (18 Suppl 3):
Part 6: Electrical therapies: automated external S706–S719.
defibrillators, defibrillation, cardioversion, and pacing: 2 DeFrancesco, T.C., Hansen, B.D., Atkins, C.E. et al. (2003).
2010 American Heart Association Guidelines for Noninvasive transthoracic temporary cardiac pacing in
cardiopulmonary resuscitation and emergency dogs. J. Vet. Intern. Med. 17 (5): 663–667.
References 151
3 Bexton, R.S. and Camm, A.J. (1984). First degree MacFarlane and T.D.V. Lawrie), 1861–1908. New York,
atrioventricular block. Eur. Heart J. 5 (Suppl A): 107–109. NY: Pergamon Press.
4 Bexton, R.S. and Camm, A.J. (1984). Second degree 10 Tilley, L.P. and Burtnick, N.L. (2009). How to. In: ECG for
atrioventricular block. Eur. Heart J. 5 (Suppl A): 111–114. the Small Animal Practitioner (ed. C.C. Cann), 1–8.
5 Alzand, B.S. and Crijns, H.J. (2011). Diagnostic criteria of New York, NY: Teton NewMedia.
broad QRS complex tachycardia: decades of evolution. 11 Rush, J.E. and Hamlin, R.L. (1985). Effects of graded
Europace 13 (4): 465–472. pleural effusion on QRS in the dog. Am. J. Vet. Res. 46 (9):
6 Tsao, C.W., Josephson, M.E., Hauser, T.H. et al. (2008). 1887–1891.
Accuracy of electrocardiographic criteria for atrial 12 Tattersall, M.L., Dymond, M., Hammond, T., and
enlargement: validation with cardiovascular magnetic Valentin, J.-P. (2006). Correction of QT values to allow for
resonance. J. Cardiovasc. Magn. Reson. 10: 7. increases in heart rate in conscious Beagle dogs in
7 Nakayama, H., Nakayama, T., and Hamlin, R.L. (2001). toxicology assessment. J. Pharmacol. Toxicol. Methods
Correlation of cardiac enlargement as assessed by vertebral 53 (1): 11–19.
heart size and echocardiographic and electrocardiographic 13 Feldman, E.C. and Ettinger, S.J. (1977).
findings in dogs with evolving cardiomegaly due to rapid Electrocardiographic changes associated with electrolyte
ventricular pacing. J. Vet. Intern. Med. 15 (3): 217–221. disturbances. Vet. Clin. North Am. 7 (3): 487–496.
8 Yan, G.X., Lankipalli, R.S., Burke, J.F. et al. (2003). 14 Rosen, K.G. (1986). Alterations in the fetal
Ventricular repolarization components on the electrocardiogram as a sign of fetal asphyxia—
electrocardiogram: cellular basis and clinical significance. experimental data with a clinical implementation.
J. Am. Coll. Cardiol. 42 (3): 401–409. J. Perinat. Med. 14 (6): 355–363.
9 Detweiler, D.K. (1998). The dog electrocardiogram: a 15 Crowell-Davis, S.L. (2007). White coat syndrome:
critical review. In: Comprehensive Electrocardiography: prevention and treatment. Compend. Contin. Educ. Vet.
Theory and Practice in Health and Disease (ed. P.W. 29 (3): 163–165.
153
12
Fluid-Filled Hemodynamic Monitoring Systems

Intravascular pressures are commonly measured in acute measured pressure, it must be compared with a known
and critical illness. Intravascular or “blood” pressure is the pressure standard. For instance, one can only appreciate
physical pressure that blood exerts on the vessel wall. This the effect of pressure applied to the surface of a rubber
pressure is important because the difference in intravascu- band if one knows the pressure the rubber band exerts
lar pressure at any two points in the vascular network is the back on the operator – whether the band will stretch
driving force for blood circulation. The pressure at the root depends on the difference between these pressures. In
of the aorta is much greater than the pressure in the vena medicine, the accepted standard pressure against which
cava so that blood flows from the arterial to the venous physiologic pressures are compared is barometric pressure
side, delivering oxygen and other nutrients to cells along its (PB), or the pressure in the earth’s atmosphere, which is
path. Intravascular pressures commonly measured in small approximately 760 mmHg (1031 cm H2O) at sea level.
animals are peripheral arterial blood pressure (ABP) and Clinically, we often are more interested in knowing the
central venous pressure (CVP). Pulmonary arterial pressure intravascular pressure at a given site compared with PB (i.e.
(PAP) and pulmonary arterial occlusion pressure (also called “What is the ABP as measured in the femoral artery of this
pulmonary capillary wedge pressure or “wedge pressure”) cat?”) than in knowing the difference in pressure between
can also be directly measured; however, these measure- two different anatomic sites.
ments are less commonly performed in veterinary patients. To understand the physiologic determinants and impor-
Peripheral ABP may be directly evaluated by measuring tance of intravascular pressure, one must also understand
intraluminal pressure following placement of an intravas- Ohm’s law of hydrodynamics, which is expressed as
cular catheter measurement system, or it can be indirectly follows:
measured by surface-applied cuff pressure and flow-
detection methods such as Doppler ultrasound or oscillom- P Q R (12.2)
etry. CVP can only be measured directly by measuring where ΔP is the pressure difference between an upstream
pressure transmitted from the central vein into a catheter- and a downstream measurement site, Q is the flow of blood
associated measuring system. This chapter deals specifically between those sites, and R is the resistance between those
with the technical aspects of the direct measurement of sites. The ΔP can be referred to as the driving pressure,
intravascular pressure using fluid-filled monitoring systems. which in the case of intravascular pressures is the pressure
differential between the “upstream” and “downstream”
portions of a blood vessel. Blood flow (Q) is the volume of
Driving Pressure, Resistance, and blood movement per unit time and is directly correlated
Blood Flow with ΔP. Resistance to flow, R, is the force opposing for-
ward fluid movement. In very basic terms, the higher the
Pressure is defined as a force per unit area: driving pressure, the more likely blood will flow through
(12.1) the blood vessel; the higher the resistance across the vessel,
P F/A
the less likely blood will flow through that vessel. An
where P is pressure, F is applied force, and A is the cross- important concept herein is that blood flow through a
sectional area over which force is applied. To interpret vessel or to an organ is not guaranteed by a “normal”
154 Fluid-Filled Hemodynamic Monitoring Systems
driving pressure if high resistance is present; conversely, cycle) and pulmonary venous pressures. A thorough review
blood flow may be adequate at low driving pressure if the of these factors is available elsewhere [4].
resistance through the blood vessel or organ is also low.
I ndications for Direct Intravascular

eterminants of Intravascular
D Pressure Monitoring
Pressure
Direct intravascular pressure measurement is an integral
part of the critically ill patient’s monitoring plan. CVP can
Determinants of Systemic Arterial Pressure
only be measured directly via central venous catheteriza-
Systemic ABP is the product of cardiac output (CO) and tion. Indications for CVP monitoring are discussed in
systemic vascular resistance (SVR) such that Chapter 15. PAP is commonly estimated in small animals
via Doppler echocardiographic evaluation using the modi-
ABP CO SVR (12.3) fied Bernoulli equation rather than measured directly.
This equation is derived from Ohm’s law, where CO is However, any time precise, continuous, or frequent meas-
blood flow (Q), SVR is vascular resistance (R), and ABP is urements of PAP are desirable, it must be measured directly
driving pressure (ΔP). with a pulmonary arterial catheter (see Chapter 16).
Systemic ABP is determined by cardiac factors such as Systemic ABP can be measured either by a direct method
heart rate and contractility, by blood volume, and by sys- using a peripheral arterial catheter system or indirectly by
temic (also called peripheral) vascular tone. Blood pressure using surface-applied pressure from an inflatable cuff part-
is under tight minute-to-minute and long-term control by an nered with flow-detection methodology (sphygmoman-
integrated neural, endocrine, and paracrine system. Full dis- ometry). The most common methods of indirect ABP
cussion of these physiologic influences is outside the scope measurement in dogs and cats are Doppler ultrasonic or
of this chapter, and details can be found elsewhere [1, 2]. oscillometric techniques, which are discussed in Chapter 14.
Most human intensive care references consider direct
pressure monitoring the “gold standard” against which
Determinants of Central Venous Pressure indirect methods are compared [5–8]. Direct pressure
CVP can be used as a surrogate for right atrial pressure measurement is considered more accurate because detec-
when the tricuspid valve functions normally and there is tion and measurement of arterial pressure occurs directly
no blood flow obstruction between the catheter tip and in the vessel lumen. Cuff measurement techniques depend
the right atrium. CVP is very close to right ventricular on blood flow to provide pressure estimates. Cuff methods
end diastolic pressure; its value represents the filling are particularly poor in patients with low blood pressure
pressure of the right side of the heart. Factors determin- secondary to myocardial failure or in cases where signifi-
ing central venous (right atrial) pressure include effective cant alteration in vascular resistance occurs (shock) [5, 7].
blood volume at the site of measurement, pleural pres- In these cases, there can be large differences between val-
sure (which influences pressure across the walls of the ues provided by indirect methods compared to gold stand-
great veins and the right heart), venous vascular resist- ard direct measurement. An international consortium has
ance, and right heart function. Changes in CVP were tra- set performance standards for indirect ABP monitors in
ditionally used to estimate blood volume in critically ill people [9]. No veterinary studies have yet shown that indi-
patients. Despite its historical use for this purpose, evi- rect methods meet these standards in dogs and cats, and
dence suggests that there is no reliable relationship study methods have not necessarily matched those set out
between fluid responsiveness and either CVP or change by the consortium [10–13]. Therefore, continuous invasive
in CVP [3]. pressure monitoring is indicated in many critically ill
patients, and particularly in those experiencing shock
states (Box 12.1).
Determinants of Pulmonary Arterial Pressure
Despite the advantages of direct intravascular pressure
PAP is the intravascular pressure that drives blood from the measurement, the technique is technically challenging and
right side of the heart to the left side of the heart. PAP is the measurement errors occur even when equipment is prop-
product of CO and pulmonary vascular resistance (PVR): erly calibrated, leveled, and zeroed (information about
these procedures below). Directly measured systolic and
PAP CO PVR (12.4)
diastolic ABP are often inaccurate in dogs and cats; directly
PVR is affected by multiple factors such as pleural pres- measured mean arterial blood pressure (MAP) is more con-
sure variation (in disease or secondary to the respiratory sistent and is a useful value to monitor, as it is the mean
Types of Dipect Ictiraresecuri ipesescip IDct iDIng Tesctpees 155
Box 12.1 Indications for Continuous Direct Arterial

Blood Pressure Measurement
● Hypotensive states with actual or potential tissue
hypoperfusion
● Significant peripheral vasoconstriction
● Severely hypertensive states
● During vasodilator therapy
● Intraoperative and postoperative monitoring of
critically ill patients
(continuous) pressure the tissues experience. The inherent

pitfalls of even this gold standard pressure monitoring pro-
cedure underscore the importance of evaluating the whole
Figure 12.1 A water manometer being used to measure central
patient. Reported values that do not fit the clinical picture venous pressure (CVP) in a ferret. Note the bottom of the
should be considered suspect, and the monitoring system manometer, at 0 cm in height, is being leveled with the ferret’s
investigated for sources of error. System inaccuracy and right atrium, establishing the right atrium as the “zero” reference
sources of error are addressed later in this chapter. point with which the CVP will be compared.
Central venous and direct arterial pressure monitoring
require large venous and arterial catheterization, respec- used properly, this technique allows for direct measure-
tively, and therefore carry the risks of these techniques. ment of the pressure at the catheter tip. Measurements are
Complications, troubleshooting, and contraindications for manually performed intermittently. Water manometers
central venous and arterial catheterization are discussed in are calibrated in centimeters of water (cm H2O) and are
Chapters 7 and 8, respectively. generally only used for CVP measurement in veterinary
practice. Peripheral ABP is too high to allow for practical
measurement with a water manometer (ABP is higher
ypes of Direct Intravascular Pressure
T than the pressure produced by the standard fluid column,
Monitoring Systems so arterial blood would shoot out the top of the water
manometer). Water manometers generally report a single
Direct pressure monitoring systems in veterinary practice value, which is considered the mean intravascular pres-
usually consist of fluid-filled tubing that connects a vascu- sure in the cavity (vessel, cardiac chamber) of interest at
lar catheter at or near the site of interest to a measuring the reference height (more regarding reference height, lev-
device. Pressure waves move throughout the blood from eling, and zeroing below).
the area of interest within the body (such as the cranial For direct ABP measurement, a fluid-filled catheter sys-
vena cava for CVP measurement), through the catheter tem is attached to a pressure transducer–processor–display
and fluid-filled tubing, either to a water manometer or to a system. This system is commonly used for systemic blood
pressure transducer–processor–display system. Fluid must pressure because it is designed to accommodate the higher
completely fill the system because fluid is relatively non- pressures generated in arterial blood vessels and permits
compressible and therefore transmits pressure waves well; continuous monitoring. There is a continuous fluid col-
air is too compressible to accurately transmit pressure umn between the catheter tip within the patient’s body and
waves. The fluid column between the site of interest and a pressure transducer, which changes (transduces) the
the measurement system must be unobstructed for the physical pressure wave into an electronic signal (see
measuring system to provide accurate information. Chapter 13, Figure 13.1). The electronic signal is transmit-
The water manometer is the simpler of the two common ted via a cable to a processor where the signal is amplified
measurement systems. The intravascular catheter is and processed into a real-time display of graphic waveform
attached to a fluid-filled system of tubing and a manome- and numeric pressure values. Digital monitors generally
ter (Figure 12.1). There is a continuous fluid column display pressure in millimeters of mercury (mm Hg), and
between the catheter tip within the patient’s vessel or right report systolic, mean, and diastolic pressures. Transducer–
atrium and the manometer. The pressure at the catheter processor–display systems are often part of multiparameter
tip supports a column of fluid within the vertically ori- patient monitors, which simultaneously report multiple
ented manometer; the pressure is then reported as the physiologic parameters (e.g. temperature, respiratory rate,
height of the fluid within the column. Therefore, when electrocardiogram, multiple pressures, pulse oximetry;
system increases as the catheter’s inner diameter decreases

or the catheter lengthens. Therefore, the ideal catheter for
pressure wave transmission would be short with a large
bore. However, because the catheter itself increases resist-
ance within the vessel at the insertion site and thus alters
pressure, the catheter would ideally occupy no more than
10% of the vessel lumen [5]. The reality for dogs and cats is
somewhere in the middle: in general, the catheter should
easily fit within the vessel with minimal risk of vascular
occlusion.
The catheter insertion site should be chosen for cleanli-
ness, ease of placement, and maintenance. If a stiff cathe-
ter is used, it should remain straight along its entire path to
minimize kinks. Catheters for CVP monitoring are usually
inserted into the external jugular vein in both dogs and
Figure 12.2 The screen of a multiparameter monitor cats and threaded into the cranial vena cava. Alternatively,
displaying a simultaneous lead I ECG, heart rate, arterial blood a long, flexible catheter may be placed into a saphenous
pressure waveform, arterial blood pressure values, central
vein and threaded cranially into the thoracic vena cava.
venous pressure waveform, mean central venous pressure value,
and rectal temperature. A square wave test is visible in the Because saphenous-inserted thoracic caval catheters yield
arterial pressure tracing between the second and third arterial similar values to those placed through the external jugular
pressure waveforms. vein [14], this is common practice in dogs and cats. Venous
catheter insertion is discussed in detail in Chapter 7.
Figure 12.2). Blood pressure waveforms are displayed on Common insertion sites for arterial catheters in dogs are
the monitor screen in addition to numerical pressure values. the perforating metatarsal artery (commonly called the
dorsal pedal artery) and the radial, coccygeal, femoral, and
auricular arteries. In cats, the femoral artery is often used;
Measurement System Components the dorsal pedal or coccygeal artery can be used for short
durations, such as for anesthetic procedures. Information
Both the manometer system and the pressure transducer– regarding arterial catheter insertion can be found in
processor–display system begin with an intravascular cathe- Chapter 8. Mean pressure is lower in distal portions of the
ter and specialized fluid-filled tubing. Beyond the tubing, arterial tree compared with the aorta because pressure
the manometer system consists of one three-way stopcock, a wave energy is lost as heat generated by frictional flow
water manometer, and a fluid reservoir (source). Beyond the resistance along the vessel length. The pressure difference
tubing, the electronic system consists of at least one stop- along the arterial tree is minimal and is thus not consid-
cock, a pressure transducer, a pressurized fluid reservoir, a ered when selecting measurement sites.
flush device, a cable connecting the transducer to a processor, Catheter tip orientation in relation to direction of blood
and the processor–display, which is generally a single unit. flow affects the measured pressure value in both arterial
For the pressure (and waveform, with an electronic sys- and venous systems. A catheter tip facing into the blood
tem) to be reported faithfully, each of the system compo- flow (upstream) will measure a slightly higher pressure
nents must meet certain physical and technical criteria. value than the actual intravascular pressure; a catheter tip
Even if each of the system components meets the required facing away from the flow of blood (downstream) will
criteria, combining the components alters the system’s over- measure a pressure value slightly lower than actual pres-
all physical properties such that it may not provide accurate sure. These differences are due to alteration in kinetic and
information. The operator should therefore be able to do the potential energy at the catheter tip and are relatively small
following: appropriately set up the system; recognize wave- in the vascular catheters commonly placed in veterinary
form patterns in electronic systems consistent with system practice.
malfunction; and test the electronic system for fidelity.
Noncompliant Tubing
Intravascular Catheter
The tubing that connects the intravenous catheter and
The catheter’s gauge, length, insertion site, orientation, pressure transducer must be made of specialized material
and proximity to the vessel wall all affect reported pres- to prevent pressure wave energy from being absorbed
sures. Frictional resistance to fluid movement within the (or “dampened”) by the tubing wall. This tubing is called
pecIDeru esypectes ofctcp upecti IDe Dipect ipesescip prescipepIct Tesctpe 157
rigid, noncompliant, or high-pressure tubing. The tubing is the transducer. The bag of isotonic crystalloid fluid is main-
filled with fluid and all air bubbles removed. Use of stand- tained under constant pressure such that a small volume of
ard (softer) fluid extension tubing between the vascular fluid continuously flushes through the system, preventing
catheter and the pressure transducer causes error in the blood from flowing back and contaminating the monitoring
pressure measurement and the waveform. Noncompliant system. The infused volume is generally 2–4 ml/hour (see
tubing is less important for CVP measurement than it is for manufacturer’s specifications for more precise value). Most
systemic arterial pressure but is still desirable. transducers have a pigtail or lever protruding from the hous-
ing that activates an integrated “flush valve” that allows
rapid infusion (“fast flush”) of fluid from the pressurized
Water Manometer
fluid bag through the system to clean the transducer head.
Water manometers are used for intermittent measurement Handled with care, disposable transducers may be cleaned
of CVP, which is detailed in Chapter 15. The water manom- and reused following ethylene oxide re-sterilization. Re-
eter is a plastic tube marked in centimeters along its length sterilization can lead to damage of the pressure-sensitive
with a “zero” mark near the bottom of the column height membrane, which can lead to inaccurate pressure reporting.
(sometimes the bottom is the zero mark, as in Figure 12.1). When a re-sterilized transducer is used, the operator should
The zero mark is used as a reference site for aligning the always recalibrate it prior to performing clinical measure-
manometer at the level of the right atrium prior to CVP ments (see below for information about calibration).
measurements (see Zeroing the Transducer, below). If a
commercially produced water manometer is unavailable,
one can create a water manometer from standard fluid ssembling the Electronic Direct
A
extension tubing hand-marked with centimeters indicated
Pressure Measurement System
along its length (see Chapter 15, Figure 15.2). The base of the
water manometer fits into the three-way stopcock in vertical
A full list of supplies required and step-by-step instructions
orientation with the noncompliant tubing–catheter system
to assemble the electronic direct pressure measuring sys-
on the second port and the fluid reservoir on the third.
tem are available in Protocol 12.1. Figure 12.3 shows a por-
Although it is called a “water” manometer, the tubing
tion of a direct arterial pressure monitoring system in use.
column is filled with a biologically compatible crystalloid
fluid to perform the measurement. The fluid reservoir for
the water manometer is usually a 20-ml syringe filled with
isotonic crystalloid. Full details regarding assembly and echnical Aspects of the Electronic
T
use of the water manometer pressure measurement system Direct Pressure Measurement System
are available in Chapter 15, specifically in Protocol 15.1.
Direct pressure monitoring is relatively complex and far
from foolproof. There are many technical points that must
Pressure Transducer be followed for accurate measurement. It is important that
When an electronic pressure monitoring system is used, the operator understand the technical principles that affect
the noncompliant tubing is attached to a pressure trans- the system’s fidelity, how to properly configure and test the
ducer (see Chapter 13, Figure 13.1). The transducer has a system for fidelity, and how to recognize and correct for
pressure-sensitive membrane that distorts in response to system error.
pressure changes that are created when pressure waves
strike it. The transducer converts the membrane distortion
Zeroing the Transducer
into an electronic signal using an integrated electronic cir-
cuit that functions by the “Wheatstone bridge” princi- To interpret measured pressure, it must be compared with
ple [5]. The generated electrical signal is transmitted to the a known pressure standard. The standard pressure against
processor–display unit by a shielded electrical cable. Most which direct intravascular pressure measurements are
pressure transducers used in veterinary medicine are clas- compared is barometric pressure (PB), which is approxi-
sified as “disposable,” meaning that they are intended for mately 760 mmHg (1031 cm H2O) at sea level.
single use in people. Disposable transducers are sterile in The electronic pressure measurement system is cali-
their packaging and electronically pre-calibrated; some brated to standard pressure, or “zeroed,” by opening the
models come with high-pressure tubing attached. transducer’s stopcock port (see Chapter 13, Figure 13.1) to
Pressure transducers have a female adapter for connec- the atmosphere and depressing the “zero” button on the
tion to the fluid reservoir. The fluid reservoir is a bag of ster- electronic pressure monitor (see Protocol 12.2 for instruc-
ile isotonic crystalloid and administration set attached to tions on zeroing a transducer). Zeroing the transducer to
Protocol 12.1 Assembling the Electronic Direct Pressure Measurement System for Central Venous or Arterial
Blood Pressure Monitoring
Items Required using gravity flow, then reclamp the fluid line. Handle
fluid line such that the line’s end remains sterile.
● Indwelling vascular catheter at the appropriate site
7) Insert the fluid bag into a pressure bag and inflate to
● ≤ 2 lengths of high-pressure tubing with locking
approximately 300 mmHg. Hang the pressurized bag
fittings – keep as short as feasible
and fluid line near the patient area.
● Stopcocks with locking fittings – ≤ 2
8) Remove the pressure transducer from its packaging
● One to two sterile infusion plugs with locking fittings
and manipulate all moving parts to ensure they move
● Sterile pressure transducer with integrated fast
as intended. Handle such that all ports remain sterile.
flush device
Inspect for any evidence of damage, particularly if the
● Sandbag and medical tape, or another stabilizing device
unit has been re-sterilized.
to which to affix the transducer
9) Attach the primed flush fluid line to the transducer. If
● Bag of isotonic crystalloid flush solution with standard
necessary, attach one length of high-pressure tubing
administration set attached; standard extension set(s)
to the transducer on the patient side. If necessary, add
as needed
more high-pressure tubing to reach the patient, to a
● Confirm with clinician whether or not to add heparin to
maximum of two lengths total. Place a sterile, locking
flush solution
injection port to the transducer’s zeroing (air) port.
● Pressure bag of appropriate size for fluid bag used
10) The vented cap on a new transducer’s stopcock
● Monitor, with its power cord and transducer-to-
should be thrown away, as its vents may allow con-
monitor cable
taminants to enter the system and be injected into
● Power source
the patient.
11) If blood sampling from the catheter is desired, place
Procedure
a stopcock between the high-pressure tubing and the
1) Collect necessary supplies. catheter or catheter’s T-port. The unused port should
2) Plug the monitor in, turn it on, and attach the have a sterile, locking injection port attached to the
transducer-to-monitor cable to the monitor. Configure third port.
the monitor per manufacturer instructions to display 12) Use the fast flush device on the transducer to prime
pressure from the socket into which you have inserted the system until fluid drips from the end of the high-
the transducer-to-monitor cable. pressure tubing. Flush slowly to avoid air bubble for-
3) Perform hand hygiene and don clean examina- mation in the tubing.
tion gloves. 13) Attach the monitoring system to the patient’s vascu-
4) Aseptically prepare the patient’s catheter port onto lar catheter or the catheter’s T-port.
which the monitoring system will be attached. 14) Tighten all connections and engage all fitting locks
Flush the patient’s catheter gently to ensure to prevent inadvertent disconnection and subsequent
patency. blood loss.
5) Heparinize the flush solution if the clinician has so 15) Plug the monitor cable into the transducer and fix the
ordered. Standard dilution is 4 units heparin per mil- transducer to its stabilizing device (e.g. sandbag with
liliter of flush (1 ml of 1000 iu/ml heparin added to tape) such that the transducer’s zeroing (air) port is at
250 ml 0.9% NaCl). Mark the fluid bag to indicate the appropriate height (the level of the right atrium).
any additives. Remove all air from the fluid bag by 16) Zero the system at the appropriate level (see the
inserting a 22-gauge needle into the medication sections Zeroing the Transducer and Leveling the
port and withdrawing gas until none remains. This Transducer for more information).
minimizes the risk of air embolism from the pressur- 17) Turn all stopcocks in the system so that they are open
ized system. to the patient.
6) Attach a standard fluid administration set, with the 18) Perform a fast flush test and make any necessary
roller clamp closed, to the heparinized fluid bag and adjustments to the system to optimize the system’s
squeeze the drip chamber until it is approximately dynamic response. (See text for more information
half-filled with fluid. Prime the fluid line with flush about dynamic response.)
pecIDeru esypectes ofctcp upecti IDe Dipect ipesescip prescipepIct Tesctpe 159
system fails to zero, the transducer, the monitor, or the con-

necting cable may be faulty (most often it is the transducer,
especially when using a re-sterilized disposable trans-
ducer). These items should be sequentially changed and
zeroing re-attempted until the faulty component is identi-
fied and replaced.
Water manometers are always open to the atmosphere
and are thus inherently “zeroed” to atmospheric pressure.
Therefore, no zeroing actions need to be performed on a
water manometer, but it must be oriented vertically for
measurement and its top has to be open to the air or
readings will be inaccurate.
Figure 12.3 Part of a direct arterial pressure monitoring
system in a dog. The dog’s perforating metatarsal (dorsal pedal)
arterial catheter is attached to a T-port, which is connected to Calibrating the System
noncompliant, fluid-filled tubing by a three-way stopcock. This
stopcock is optional to the system and is in place here for serial After the system is zeroed to the atmosphere, it must be
arterial blood sampling. The noncompliant tubing is attached to calibrated prior to use. To calibrate a measuring instru-
the pressure transducer, which is secured to a yellow sandbag
ment is to compare and align its readings with known
with medical tape; the sandbag provides a stable base for the
transducer and helps raise the transducer’s zero point (top of the standards so that the measuring instrument can provide
transducer’s stopcock) to the level of the patient’s right atrium. accurate information. Calibrating a water manometer
The red pigtail on the transducer can be used to provide rapid device simply involves comparing the markings on the
system flush from the pressurized fluid bag (not pictured; its
manometer against those on a centimeter ruler. Such cali-
tubing leads from the pigtail to the fluid bag out the top of the
frame). The gray cable runs from the transducer to the electronic bration is unnecessary on commercially available manom-
processor-display unit (not pictured). eters, since they come premarked, but is required if regular
fluid extension tubing is used to contain the fluid column.
Calibration is required for electronic systems each time
atmospheric pressure makes discussion of physiologic the system is assembled and again any time problems arise.
pressures easier (i.e. “The patient’s MAP is 98 mmHg” The transducer must be calibrated to confirm that when
rather than “The patient’s MAP is 760 + 98 = 858 mmHg”). standard pressure is applied to the transducer, the correct
Transducer zeroing should be done at initial system setup, pressure is reported. Calibration should be conducted with
any time system components are removed or replaced, or if the transducer attached to the monitor, as instructed by the
any problems occur with system readings. If a transducer monitor’s manufacturer. Alternatively, a water manometer
Protocol 12.2 Zeroing a Pressure Transducer

Items Required 4) Remove the injection cap from the stopcock, maintain-
ing system asepsis.
● An assembled electronic direct pressure measurement
5) Depress the “zero” button on the monitor.
system (see Protocol 12.1), attached to its monitor via
6) The pressure tracing should be a flat line at the zero
the transducer cable
mark on the display.
7) If the pressure reads a number other than 0, or if the
Procedure
pressure tracing is not a flat line at the zero mark on
1) Plug in and turn on the monitor. Configure the the graph, the transducer may be faulty, in which case
monitor such that it displays an option to zero the it must be replaced with another flushed, sterile trans-
transducer (see manufacturer’s instructions for ducer. If this does not remedy the issue, the transducer
specific steps). cable or monitor itself may be faulty and may need to
2) Perform hand hygiene and don clean examina- be replaced.
tion gloves. 8) Once the monitor displays “0” with the transducer’s fluid
3) Turn the transducer’s stopcock “off” to the patient’s side interface open to the atmosphere via the stopcock, asep-
of the system so there is a continuous fluid column tically replace the injection cap and turn the stopcock
between the stopcock’s injection cap and the trans- “off” to the injection cap, opening the fluid column
ducer’s pressure diaphragm. between the transducer and the patient end of the system.
filled with fluid to a set height may be attached to the the top of the dorsal spinous process just caudal to the
transducer’s stopcock and the display’s reading compared shoulder.
with the known applied pressure from the fluid column, Once the transducer is leveled (zeroed at right atrial
remembering that 1.36 cm H2O exerts the same pressure as height), it must remain level at right atrial height for every
1 mmHg. Calibration problems can be due to transducer, measurement. The reason for this requirement may best be
monitor, or connecting cable problems. explained by example. In a patient undergoing CVP moni-
toring, if the transducer falls below right atrial level by
10 cm (approximately 4 inches), a 10-cm blood fluid col-
Leveling the Transducer
umn is exerting pressure on the transducer in addition to
A transducer is both zeroed, to eliminate the influence the actual CVP. Though this additional pressure is not a
of atmospheric pressure from vascular pressure readings, change in CVP, the transducer will “see” both the actual
and leveled, to eliminate the influence of gravity. For both CVP and the additional 10 cm blood column and will report
CVP and ABP, the “level” reference point is the right a value equal to the CVP plus 10 cm H2O. The opposite is
atrium; thus, the right atrium is called the zero reference true if the transducer sits higher than its zeroed reference
point. To level the measuring system, the transducer should point: the pressure reported will be falsely low in such
be placed at the vertical height of the right atrium and cases (Figure 12.4). For peripheral ABP monitoring, such
zeroed at that point (by opening the three-way valve to air, changes are less likely to create clinical confusion because
as above). This step should be performed prior to every as a proportion of the pressure of interest, the error is
measurement (Protocol 12.3). An external anatomic land- smaller. For instance, while a difference of 10 cm H2O
mark that correlates well with the right atrium reference (7.4 mmHg) in CVP could influence a clinician’s decision-
point is the sternum of the cat or dog lying in lateral recum- making process, that same 7.4 mmHg difference in MAP is
bency. As stated in Chapter 15, in a sternally recumbent less likely to cause an error in clinical judgment. This
animal the right atrium lies at a point roughly 40% the example underscores the importance of evaluating the
height of a vertical line that extends from the sternum to whole clinical picture before making treatment decisions,
Protocol 12.3 Leveling a Pressure Transducer at the Zero Reference Point (the Right Atrium)
Items Required a) With the patient in lateral recumbency, right atrial
height is approximately the height of the sternum.
● An electronic direct pressure measurement system,
b) For a dog or cat in sternal recumbency, right atrial
attached to a powered-on monitor and to the patient
height is approximately 40% the distance from
● Carpenter’s level
the sternum to the dorsal spinous process at the
● Piece of string
plane just caudal to the scapula.
6) Secure the monitor at this height if performing
Procedure
continuous monitoring and the patient is immobile.
1) Configure the monitor such that it displays an option 7) Depress the “zero” button on the monitor.
to zero the transducer (see manufacturer instructions 8) The pressure tracing should be a flat line at the zero
for specific steps). mark on the display.
2) Perform hand hygiene and don clean examina- 9) If the pressure reads a number other than 0, or the
tion gloves. pressure tracing is not a flat line at the zero mark on
3) Turn the transducer’s stopcock “off” to the patient’s the graph, the transducer may be faulty, in which case
side of the system so there is a continuous fluid col- it must be replaced with another flushed, sterile
umn between the stopcock’s injection cap and the transducer. If this does not remedy the issue, the
transducer’s pressure diaphragm. transducer cable or monitor itself may be faulty and
4) Remove the injection cap from the stopcock, main- may need to be replaced.
taining system asepsis. 10) Once the monitor displays “0” with the transducer’s fluid–
5) Ensure the transducer’s fluid–air interface is at the air interface open at right atrial level (height), aseptically
level (vertical height) of the right atrium. Assess replace the injection cap and turn the stopcock “off” to the
this level using the string and carpenter’s level for injection cap, opening the fluid column between the
accuracy – this step will enhance accuracy and transducer and the patient end of the system.
repeatability from one operator to the next for 11) Allow the system to equilibrate and record the
repeated measures. measured value.
oopect ofctcp presciDIng Tesctpemes rctciru ipecpIeT 161
B
A
175
Part
0 25 ∆ = 8 mm Hg
10 cm
Ppao B
20 0 A
A
CVP B
Figure 12.4 Illustration of what happens when the patient’s right atrium (level shown by dashed line A) falls below the transducer’s
zero reference point (at the level of dotted line B) as the bed is lowered: (left) change in recorded pressures (Part, peripheral arterial;
Ppao, pulmonary arterial occlusion [wedge]; CVP, central venous pressure); (right) water manometers (tubes A and B) that demonstrate
how lowering the right atrium relative to the transducer lowers the measured pressures. In this example, the bed was lowered by
10 cm, which means that the patient’s right atrium (the proper level) is 10 cm lower than the current zero reference point (B),
which translates to a pressure drop of 10 cm H2O, or approximately 8 mmHg. Source: Magder (2007)/with permission of Elsevier.
Invasive intravascular hemodynamic monitoring: technical issues.
and the importance of proper transducer leveling at the structure’s natural frequency, fundamental frequency, or
zero reference point (the right atrium) prior to every meas- resonant frequency. Adding components together (such as
urement, particularly when monitoring CVP. connecting a catheter, noncompliant tubing, and trans-
ducer) alters a system’s natural frequency. It is important
Dynamic Response of the System that the natural frequency of a fluid-filled monitoring
system not coincide with the frequency of physiologic pres-
Intravascular pressures are pulsatile in nature. Reflection sure waves, because frequency overlap causes summation
of pressure waves through the vessel creates multiple oscil- (the patient plus the system) and results in exaggerated
lating waves of different amplitude and frequency (Fourier waveforms and numerical values. Exaggerated results are
series) that summate to create the observed waveform. An due to too low a system natural frequency, and such exag-
intravascular pressure monitoring system must have the geration leads to what is often called overshoot, ringing, or
physical properties required to measure pressures within resonance of the waveform [15]. Ringing causes pointy,
the expected range and must be able to respond adequately spiked waveforms, falsely high systolic pressure readings,
to physiologic pressure pulsations. The ideal system would and falsely low diastolic pressure readings.
report the pressure waves of interest and no others. The A fluid-filled monitoring system will have optimal
ability of a system to accurately display the shape and responsiveness if its natural frequency is as high as pos-
amplitude of the pulse pressure waveform is determined by sible. Though individual materials made for intravascu-
the system’s dynamic response, also called the system’s lar pressure monitoring are designed with this principle
frequency response. The system’s dynamic response is in mind, once a catheter–tubing–transducer system is
determined by its physical properties, specifically its mass, assembled, the natural frequency drops to minimal
elasticity, and friction [15]. Dynamic response is discussed requirements for people [5]. Because dogs and cats gen-
in terms of natural frequency and damping coefficient, erally have pulse rates that exceed people’s, their pulse
both of which are measurable and have significant impact pressure waveforms have a higher frequency, and thus
on a waveform’s appearance. almost certainly overlap the natural frequency of most
measurement systems. This overlap means that without
correction through damping (see below), our patients’
ffect of the Measuring System’s
E pulse pressure waveforms will almost always ring,
Natural Frequency systolic pressures will be falsely high, and diastolic
pressures will be falsely low. One way to maximize a
When stimulated, every structure naturally vibrates at system’s natural frequency is to keep the system as sim-
a characteristic frequency, which is expressed in cycles ple as possible, for instance with as short a tubing length
per second or hertz (Hz). This frequency is called the and as few components as is feasible.
ffect of a System’s Damping

E etermining the System’s Dynamic
D
Coefficient Response
Damping is loss of the pulse pressure energy between the Many catheter–tubing–transducer systems have weak
catheter tip and the transducer. Damping is due to fric- natural frequencies to faithfully reproduce physiologic
tional resistance along the system’s length, absorption of pressure data; thus, these systems are inherently under-
energy by the tubing and other materials, and larger air damped. Within a certain range, adjusting the system’s
bubbles, which are more compressible than fluid. The damping can help produce more accurate values and
more damped a system is, the more quickly it returns to waveforms (Figure 12.5). To know whether a system has
zero after an applied stimulus, due to energy loss. adequate dynamic response, its natural frequency and
Damping in a pressure system is measured and expressed damping coefficient should be determined and plotted
as the damping coefficient; the higher the coefficient, the onto a graph such as Figure 12.5. These properties are
more significant the damping. An overdamped pressure measured by performing a fast flush or “square wave” test
waveform has slurred upstrokes and downstrokes, loss of on the system. When the transducer’s fast flush device
detail, and a generally flattened appearance; overdamped is activated, the transducer–tubing–catheter system is
systems cause a falsely narrowed pulse pressure with falsely exposed to the high pressure in the flush fluid bag
low systolic and falsely high diastolic pressure readings. (300 mmHg). To perform the test, the fast flush device
Conversely, underdamped waveforms contain non- should be opened briefly (< 1 second) and released quickly
physiologic points and spikes, extra waves, and appear several times to produce multiple square waves for analy-
exaggerated; they are overshot or have excessive ringing, sis. The high pressure should appear on the recorder as a
as discussed previously regarding natural frequency. square waveform as shown in Figure 12.6. A normal
Underdamping causes falsely high systolic and falsely low square wave has a nearly 90° upstroke, a flat plateau at
diastolic pressure readings. A system with an infinitely high 300 mmHg, and a rapid downstroke as the fast flush
natural frequency does not require damping to produce device is released. The top is squared, as the test’s name
accurate results (Figure 12.5), but because available systems implies. Protocol 12.4 describes how to determine a sys-
have natural frequency overlap as noted previously, they tem’s natural frequency and damping coefficient, and
usually require some operator-implemented damping. thus the system’s dynamic response, using waveforms
1.6 1.6
1.4 1.4
Amplitude Ratio
1.2 1.2
Damping Coefficient, ζ
1.0 1.0
0.8 0.8
Best
Area
0.6 0.6 0.1
0.2
0.4 0.4
0.3
0.4
0.2 0.2
0.6
0.8
0 0 1.0
0 5 10 15 20 25 30 35 40 45 50
Natural Frequency, Hz
Figure 12.5 Use of natural frequency and damping coefficient to determine whether the catheter–tubing–transducer system is
producing accurate pressure waveforms and values. Plot the system’s frequency and damping coefficient; the intersection falls in
the gray area for an adequately responsive system. Overdamped readings fall above the gray area and underdamped readings fall
below the gray area. Note that above approximately 35 Hz natural frequency, the system should be accurate regardless of
damping coefficient. Source: This figure and its legend were altered and used here with permission from Ahrens and Taylor [16],
© Saunders, 1992.
pctpieDIDIng ctcpf Tesctpemes TIreDe pesy Iesp 163
Figure 12.6 Performing a square wave test. The fast flush device is activated at point 1. Squaring of the waveform occurs as the
transducer is exposed to 300 mmHg pressure from the flush fluid bag and has a flat plateau (point 2) with right angles on both sides.
A rapid downstroke occurs as the fast flush device is released (point 3). This test should be performed several times and the square
waves analyzed to determine the system’s natural frequency and damping coefficient. These values can then be plugged into the
graph in Figure 12.5 to determine whether the system has adequate dynamic response. Source: Ahrens and Taylor (1992)/with
permission of Elsevier.
Protocol 12.4 Determining the Dynamic Response of a Fluid-Filled Monitoring System

Items Required 3) Perform a square wave test during diastole by activat-
ing the transducer’s fast flush device briefly (for < 1 sec-
● An electronic direct pressure measurement system,
ond) and quickly releasing the device. A square wave
attached to a powered-on monitor (with printer) and to
should appear on the monitor. Print this waveform
the patient
with one to two seconds of strip on either side. Repeat
● Calculator
this process three to five times and collect the square
● Straightedge (i.e. ruler)
waves for analysis.
● Pen and paper
4) Evaluate the square waves to determine the system’s
natural frequency. The Irctciru oipecpIeT is the frequency
Procedure
with which the waveform oscillates after the fast flush
1) Ensure the pressure bag containing the flush fluid is device is released. For example: The paper speed in
pressurized to 300 mmHg. Figure 12.7 is 25 mm/second. Note the number of blocks
2) Perform hand hygiene and don clean examina- between oscillation peaks: in this case just over two
tion gloves. blocks between oscillations. Divide the paper speed by
2 blooks between oscillations
Figure 12.7 Step 4, determine system’s natural frequency. Paper speed 25 mm/second. First, note the number of blocks between
oscillation peaks – in this case just over two blocks between oscillations. Then divide the paper speed by the number of blocks to
determine the system’s natural frequency: (25 mm/second) ÷ (2 mm) = 12.5 cycles/second = 12.5 Hz, which is a minimally
acceptable natural frequency for measurements in people. Source: Ahrens and Taylor (1992)/with permission of Elsevier.
28
Figure 12.8 Step 6, calculating the amplitude ratio to determine damping coefficient. Paper speed 25 mm/second. First measure
the length of two successive oscillations (i.e. from peak to valley, and from that same valley to the next peak). Then divide the
smaller oscillation by the larger to determine the amplitude ratio. Here, 6 mm ÷ 28 mm = 0.21, which is the amplitude ratio.
ciep: Ahrens and Taylor (1992)/with permission of Elsevier.
the number of blocks to determine the system’s natural 1.0

frequency: (25 mm/second) ÷ (2 mm) = 12.5 cycles/ 0.9
second = 12.5 Hz, which is a minimally acceptable natu-
0.8
ral frequency for measurements in people.
5) Determine the frequency on all the square waves col- 0.7
lected and average the values to reach the mean natu-
Amplitude Ratio
0.6
ral frequency. Use this mean natural frequency in the
0.5
dynamic response graphic plot (see step 8).
6) Evaluate the square wave to determine the system’s 0.4
damping coefficient. This is done by comparing the 0.3
length of two successive oscillations and dividing the
0.2
second (smaller) oscillation by the first (Figure 12.8).
The number generated is called the amplitude ratio. 0.1
For example: The paper speed in Figure 12.8 is 25 mm/ 0
second. Measure the length of two successive oscilla- 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
Damping Coefficient
tions (i.e. from peak to valley, and from that same val-
ley to the next peak). Divide the smaller oscillation by Figure 12.9 Step 7, Use this graph to determine the damping
the larger to determine the amplitude ratio. Here, coefficient from the amplitude ratio. Source: Ahrens and Taylor
6 mm ÷ 28 mm = 0.21, which is the amplitude ratio. (1992)/with permission of Elsevier.
7) Determine the amplitude ratio for all square waves
collected and average the values to reach the mean
amplitude ratio. Use the graph in Figure 12.9 to
determine the damping coefficient from the ampli- Figure 12.5. If the intersecting point falls into the gray
tude ratio. area, the system is adequately responsive. Overdamped
8) Use a straightedge to plot the damping coefficient readings fall above the gray area and underdamped
against the mean natural frequency on the graph in readings fall below the gray area.
yctDeDiDIng TIreDe pesy Iesp T uctpiDIng r IDct iDIng Tesctpemes rctciru ipecpIeT rInd reyDIng pooDeDpIct 165
from square wave tests. A square wave test should be per- Underdamping is far more common in dogs and cats than
formed when the system is initially assembled and any overdamping. An example from a ringing, underdamped
time there are questions about the fidelity of measure- system and one from an overdamped system are shown in
ment results. the square wave tests in Figure 12.10. Further discussion of
the effects of underdamping and overdamping on ABP
waveforms and values is found in Chapter 13. Measures to
take that may help optimize the system’s dynamic response
Optimizing Dynamic Response by are listed in Box 12.2.
Altering a Monitoring System’s Despite its relevance for accurate pressure readings and
Natural Frequency and interpretation, it is unclear that the systems in clinical use
Damping Coefficient today commonly have adequate dynamic response [15]. It is
important to remember both this source of inaccuracy and
There are many steps one can take to optimize the meas- that pressure waveforms and pressure values are altered by
urement system’s dynamic response by either increasing simple changes the operator makes to the system such as alter-
the natural frequency or altering the damping coefficient. ations in system components and damping. Thus, the gold
13JUL02 8:20AM Source: ART 25 mm/s

b
300
150
0
c
(a)
a
(b)
Figure 12.10 Square wave test waveforms: (a) Example of a square wave generated from an underdamped system. Note the spiky,
pointy nature of the arterial pressure waveform and the excessive ringing of the square wave test compared with the normal
example in Figure 12.6. To confirm underdamping, calculate the amplitude ratio: measure vertically from point a to point b, 37mm;
then from point b to point c, 34 mm; then divide the smaller length by the larger, 34 mm ÷ 37mm = 0.92. An amplitude ratio of 0.92
corresponds to a damping coefficient of less than 0.1, which is extremely low and corroborates the impression of an underdamped
waveform. (b) Example of a square wave generated from an overdamped system. Note the slurred arterial pressure waveform with
no apparent dicrotic notch, and the slurred downstroke of the square wave test with lack of oscillations at baseline (arrow). It is very
difficult to determine damping coefficient in the absence of any measurable oscillations, but the damping coefficient here is high,
probably greater than 0.6 [16]. Source: Ahrens and Taylor (1992)/with permission of Elsevier.
standard invasive pressure monitoring system is also inher-

Box 12.2 Steps to Help Optimize a System’s Dynamic
ently flawed by inevitable operator manipulations.
Response
The corrections for overdamped and underdamped sys-
tems are similar, so the following actions can be tried in Summary
the case of either problem [16, 17].
Fluid-filled monitoring systems provide important informa-
● Simplify the system as much as possible to increase tion in patients with cardiovascular instability. Though they
its natural frequency: are more complicated than noninvasive measurement tech-
⚪ Remove as many lengths of tubing between the niques, they can provide continuous monitoring and may be
catheter and the patient as possible such that the more accurate. As with any technique, one becomes more
tubing does not exceed 3–4 feet (approximately proficient with practice and use. A solid understanding of
1 m) in length. the principles behind fluid-filled monitoring systems allows
⚪ Remove any unnecessary stopcocks. the clinician to make the most of these systems’ capabilities
⚪ Consider removing T-ports or other connections. and to avoid technical errors. There is a potential for techni-
● Ensure only noncompliant tubing is present between cal error if equipment is incorrectly configured, inaccurately
the catheter and the transducer, particularly for arte- zeroed, uncalibrated, or poorly leveled. Also, actions we take
rial pressure monitoring. to optimize the dynamic response of a system (altering natu-
● Check for and remove visible clots or air bubbles. ral frequency and damping) can change the reported pres-
● Check tubing for kinks or occlusions. sure results and mislead the clinician.
● Gently aspirate and flush the catheter to assess for
occlusion.
● If the catheter is < 18-gauge (or 7-Fr), compliant, or Acknowledgments
long, consider replacement with a larger-bore, stiffer,
or shorter catheter. This chapter was originally co-authored by Drs. Jamie M.
● If the waveform is underdamped, consider insertion Burkitt Creedon and Marc Raffe for the previous edition,
of a damping device into the system. and some material from that chapter appears in this one. The
author and editors thank Dr. Raffe for his contributions.
References
1 Boulpaep, E.L. (2017). Regulation of arterial pressure and 7 Shoemaker, W.C. and Parsa, M.H. (2000). Invasive and
cardiac output. In: Medical Physiology, 3e (ed. W.F. Boron noninvasive monitoring. In: Textbook of Critical Care,
and E.L. Boulpaep), 533–555. Philadelphia, PA: Elsevier. 4e (ed. A. Grenvik, A.M. Ayres, P.R. Holbrook and
2 Kittleson, M.D. and Kienle, R.D. (1998). Normal clinical W.C. Shoemaker), 74–91. Philadelphia, PA: Saunders.
cardiovascular physiology. In: Small Animal Cardiovascular 8 Vincent, J.-L. (2019). Arterial, central venous, and
Medicine (ed. M.D. Kittleson and R.D. Kienle), 11–35. pulmonary artery catheters. In: Critical Care Medicine:
St. Louis, MO: Mosby. Principles of Diagnosis and Management in the Adult,
3 Marik, P.E., Baram, M., and Vahid, B. (2008). Does central 5e (ed. J.E. Parrillo and R.P. Dellinger), 40–49.
venous pressure predict fluid responsiveness?: a systematic Philadelphia, PA: Elsevier.
review of the literature and the tale of seven mares. Chest 9 Stergiou, G., Alpert, B., Mieke, S. et al. (2018). A universal
134 (1): 172–178. standard for the validation of blood pressure measuring
4 Boron, W.F. (2017). Ventilation and perfusion of the lungs. devices: Association for the Advancement of Medical
In: Medical Physiology, 3e (ed. W.F. Boron and Instrumentation/European Society of Hypertension/
E.L. Boulpaep), 675–699. Philadelphia, PA: Elsevier. International Organization for Standardization (AAMI/
5 Fessler, H.E. and Shade, E. (1998). Measurement of ESH/ISO) collaboration statement. Am. J. Hypertens.
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Care Monitoring (ed. M.J. Tobin), 91–106. New York, 10 Binns, S.H., Sisson, D.D., Buoscio, D.A. et al. (1995).
NY: McGraw-Hill. Doppler ultrasonographic, oscillometric
6 Lodato, R.F. (1998). Arterial pressure monitoring. In: sphygmomanometric, and photoplethysmographic
Principles and Practice of Intensive Care Monitoring techniques for noninvasive blood pressure measurement
(ed. M.J. Tobin), 733–749. New York, NY: McGraw-Hill. in anesthetized cats. J. Vet. Intern. Med. 9: 405–414.
popipIepes 167
11 Haberman, C.E., Kang, C.W., Morgan, J.D. et al. (2006). vena cava of sedated cats. J. Vet. Emerg. Crit. Care 5 (2):
Evaluation of oscillometric and Doppler ultrasonic 121–129.
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conscious dogs. Can. J. Vet. Res. 70: 211–217. pressure measurement. In: Atlas of Cardiovascular
12 MacFarlane, P.D., Grint, N., and Dugdale, A. (2010). Monitoring (ed. J.B. Mark), 100–126. New York, NY:
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Commun. 34: 217–227. considerations in obtaining hemodynamic waveform values.
13 Bosiack, A.P., Mann, F.A., Dodam, J.R. et al. (2010). In: Hemodynamic Waveform Analysis (ed. T.S. Ahrens and
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169
13
Direct Systemic Arterial Blood Pressure Monitoring

Edward Cooper and Stacey Cooper
Arterial blood pressure (ABP) measurement is one of the provided to veterinary patients continues to grow, especially
major hemodynamic monitoring tools used in patient in a critical care setting, the value and availability of direct
assessment because adequate systemic blood pressure is arterial blood pressure (dABP) monitoring has increased
required to perfuse vital organs. ABP, or more specifically significantly. This chapter explores the practical and techni-
mean arterial blood pressure (MAP), is a function of car- cal aspects of dABP measurement in small animals.
diac output (CO) and systemic vascular resistance (SVR).
This relationship is represented by the following equation:
MAP CO SVR (13.1)

I ndications for Direct Arterial
Pressure Monitoring
While ABP is often measured to assess whether systemic
blood pressure is adequate to perfuse vital organs, as equa- Blood pressure measurements provide insight into the car-
tion 13.1 indicates, a normal blood pressure value does not diovascular status of a patient. In patients that are critically
guarantee adequate blood flow because MAP is affected by ill or have cardiovascular compromise, it is generally
vascular tone. The body’s compensatory response to home- accepted that dABP monitoring is more accurate than
ostatic insult, largely mediated by the sympathetic nervous methods used to obtain blood pressure indirectly (i.e.
system, results in tachycardia and vasoconstriction and Doppler or oscillometric monitors) [1–6]. Direct ABP
serves to sustain blood pressure and core organ perfusion. measurement is considered to be the “gold standard” for
Increasing SVR through vasoconstriction can diminish blood pressure monitoring. There are numerous clinical
flow to peripheral tissues, even when ABP is maintained. scenarios in which accurate and continuous dABP moni-
Therefore, just because blood pressure is normal does not toring would be beneficial (Box 13.1) [7]. The information
mean blood flow is normal or that global tissue perfusion is obtained using dABP measurement can be used to help tai-
adequate. Hypotension occurs only when sympathetic lor administration of medications affecting blood pressure
compensatory mechanisms have failed after an insult (e.g. titration of vasopressors or antihypertensive medica-
(decompensated shock). tions) or to help guide fluid therapy (e.g. resuscitation of
Other monitoring techniques including serial physical hypovolemic shock) on a minute-to-minute basis [6]. To
examination, assessment of blood lactate concentration or further understand why dABP measurement might be cho-
central venous hemoglobin saturation, the determination sen over indirect blood pressure measurement methods, it
of cardiac output, or even direct imaging of the microcircu- is important to understand the benefits and limitations of
lation potentially offer greater insight into blood flow and each modality.
tissue perfusion. However, apart from serial physical exami-
nation and blood lactate concentration, these techniques
Advantages and Disadvantages of Indirect
are of limited availability and largely impractical for most
Blood Pressure Monitoring
practitioners. Despite the limitations of the information
provided by its measurement, ABP is thus still the most As indirect arterial blood pressure (iABP) monitoring is
used modality to assess hemodynamic stability (following covered in depth in Chapter 14, in this chapter it is only
examination) in veterinary medicine. As the level of care briefly discussed in the context of comparison with dABP
170 Direct Systemic Arterial Blood Pressure Monitoring
frequent iABP measurements. The “hands-off” nature of

Box 13.1 Clinical Scenarios Benefitting from Direct
dABP monitoring, once it is established, may also minimize
Arterial Blood Pressure Monitoring [7]
the effect that patient handling can have on the ABP values.
● Patients in shock with hypotension or cardiovascular In addition to its role in hemodynamic monitoring, place-
collapse ment and maintenance of an arterial catheter also allows for
● Patients requiring vasopressors repeated arterial blood sampling to monitor acid–base and
● Titration of medications for afterload reduction in blood-gas parameters, which are typically of interest in criti-
patients with congestive heart failure cal care (see Chapter 8 for more information on arterial
● Patients receiving pharmacotherapy for severe catheterization and sampling).
hypertension Although the technique may be more accurate in criti-
● Patients being mechanical ventilated cally ill patients, dABP monitoring is not without draw-
● Patients with high anesthetic risk backs and complications. Obtaining and maintaining
arterial access can be technically challenging. Further, the
equipment necessary to monitor dABP can be expensive
monitoring. Indirect methods (such as Doppler ultrasound compared with the techniques used for indirect measure-
or oscillometry) are noninvasive to the patient and there- ment. While it is considered the most accurate method for
fore do not require arterial catheterization or setting up a blood pressure determination, there are numerous techni-
fluid-filled monitoring system. As such, indirect methods cal and mechanical factors that can interfere with blood
are generally less technically demanding. While there is pressure signal transduction and overall accuracy of the
cost associated with acquiring equipment for iABP moni- readings, making even this gold standard prone to error.
toring, it is typically less expensive than the equipment Technical issues that contribute to inaccuracy (overdamp-
required for dABP measurement (e.g. pressure transducing, underdamping, zeroing errors, etc.) are discussed in
ers, special hemodynamic monitors). For these reasons, detail in Chapter 12. Potential complications associated
iABP is measured more commonly than dAPB in both with arterial catheterization include hematoma or bleeding
human and veterinary medicine. at the catheter insertion site, infection, arterial thrombosis
Perhaps the greatest limitation to the use of iABP moni- and associated tissue ischemia, and significant hemorrhage
toring is its accuracy. Direct ABP measurement has been if the transducer system becomes disconnected.
shown to be more accurate in both dogs and cats, whether
awake or anesthetized [1–6]. This appears to be especially
true in hypotensive, hypothermic, and small patients [3, 8]. ontinuous Direct Arterial Blood Pressure
C
There are factors such as cuff size, differences in technique, Equipment and Setup
and the possibility of operator error that can further affect
the reliability of iABP determination. In addition, iABP Once the decision is made to measure dABP, all the neces-
measurement provides less information than does dABP sary equipment must be available (see Chapter 12,
measurement. For example, Doppler ultrasound technique Protocols 12.1–12.4).
only measures systolic arterial pressure (SAP), or poten- The first step in establishing dABP monitoring is obtain-
tially more so, MAP for cats [5], whereas the direct method ing arterial access. Arterial catheter placement is discussed
measures systolic, diastolic, and mean arterial pressures. in depth in Chapter 8; what follows here is a brief overview.
While oscillometric machines provide all three pressures, Placement of an arterial catheter can be done percutane-
standard oscillometry may be less reliable in cats and small ously or by a cutdown method. The most common arteries
dogs compared with dABP or Doppler ultrasound meas- used for dABP monitoring in small animals are the dorsal
urement techniques [2, 4, 6, 9]. pedal and femoral, though coccygeal or auricular can also
be used. There appears to be no significant difference in the
accuracy of pressures obtained from a peripheral compared
Advantages and Disadvantages of Direct Arterial
to a central arterial catheter in people, particularly with
Pressure Monitoring
regard to MAP [10]; however, there may be significant dif-
Direct ABP measurement offers the benefit of beat-to-beat ferences between central versus peripheral blood pressure
blood pressure monitoring. This allows clinicians and tech- measurement in dogs, particularly with regard to SAP [11].
nicians to monitor trends in both blood pressure and arterial The same may be true for cats.
waveform, which facilitates rapid recognition of changes in Patient size plays a role in catheter insertion site since
status and prompt intervention. Continuously visible blood dorsal pedal access can be challenging in cats and small
pressure values allow the technician to perform other treat- dogs. Femoral or coccygeal arteries may be better options
ments and monitoring, rather than spending time making in these patients. The catheter site should be clipped and
Continuous Direct Arterial Blood Pressure Equipment and Setup 171
aseptically prepared. Subcutaneous local anesthetics such concentration). The pressure bag must be inflated to a pres-
as 2% lidocaine can be injected locally prior to the proce- sure greater than the patient’s systolic blood pressure or
dure to decrease patient discomfort, especially if a cut- blood will flow back into the line. Typically, a pressure
down is performed. Specialized arterial catheters are between 250 and 300 mmHg is adequate unless the patient
commercially available; they are generally more rigid, has significant hypertension. Heparinized saline is flushed
may contain a guide wire to facilitate placement, and are through the system to prime the tubing, making sure to
intended for longer-term use. These catheters are more evacuate any air bubbles. When connected to the pressur-
typically used for femoral arterial access. More commonly ized saline bag, the transducer will allow a slow forward
an over-the-needle peripheral intravenous (IV) catheter is flow of fluid through the system to decrease the risk of clot
used. Once the area has been prepared, the artery is pal- formation and catheter occlusion. It is important to check
pated and the catheter advanced through the skin toward the manufacturer’s materials for exact flow rates through a
the pulse. Given the relatively small lumen of arteries given transducer as this could result in a significant amount
compared with veins, it is important that small incremen- of fluid administration for smaller or fluid-restricted
tal advances are made until there is a flash of blood in the patients. Most pressure transducers also have a unidirec-
catheter hub. Once this occurs the catheter is advanced tional flush valve (“fast flush valve”) that can be used to
off the stylet and into the artery. The catheter is secured prime the noncompliant tubing (Figure 13.2). At the other
with tape and appropriate protective wrap, keeping the end of the transducer is rigid, noncompliant (“high-
insertion site clean and dry. It is further important to label pressure”) tubing that will be attached to the arterial cath-
the catheter as “arterial line” so that injections intended eter (Figure 13.2). If your transducer system does not come
for IV administration are not inadvertently introduced equipped with noncompliant tubing, you will need to sup-
arterially (Figure 13.1). The insertion site should be ply your own and use it to complete the circuit. It is impor-
inspected daily to ensure there are no signs of bleeding or tant that standard extension tubing is not used for this
inflammation. Warmth of the extremity distal to the purpose, as its compliant nature will result in signal distor-
insertion should be assessed regularly to monitor for arte- tion and affect the accuracy of blood pressure readings (see
rial thrombosis. Abnormal Arterial Pressure Waveforms, below). Once the
Once arterial access has been established, the pressure tubing is connected to the patient, the catheter is flushed
transducer and monitoring system can be attached to the using the fast flush valve to verify patency. The use of Luer
catheter (see Chapter 12, Protocols 12.1–12.4). At one end, lock adapters (such as Luer-Lok® from Becton, Dickinson
the pressure transducer is attached via an administration and Company, Franklin Lakes, NJ) throughout the system
set to a pressurized 500 ml or 1.0 l bag of 0.9% NaCl to aids in safety and integrity. Finally, the pressure transducer
which heparin has been added (to achieve a 1–2 iu/ml is connected to the hemodynamic monitor via a trans-
ducer cable.
Before you can begin monitoring patient blood pressure
you must zero the transducer. This sets a reference point
(called a zero point) to which the pressure readings from
the system are compared. To zero the system, the trans-
ducer should be placed at the level of the right atrium to
best approximate central venous pressure. If peripheral
pressures are preferred, the transducer should be placed at
3-way stopcock
Zeroing port cap Fast flush valve Heparinized
flush
solution
High pressure
tubing (to the Pressure transducer
patient)
Transducer holder Transducer

cable
Figure 13.1 Labeling arterial catheters so there is not

confusion or inadvertent use for administration of fluids or Figure 13.2 Pressure transducer for a fluid-filled hemodynamic
medications. monitoring system.
Systolic Pressure
Dicrotic notch
Pulse Pressure
Ejected Wave Reflected Wave

Diastolic Pressure
Figure 13.4 Idealized arterial pressure waveform.
Figure 13.3 Multiparameter hemodynamic monitor screen pressure (initial downslope). Once aortic pressure exceeds
capture demonstrating standard output of arterial waveform left ventricular pressure (with left ventricular relaxation),
with systolic and diastolic pressures displayed. Simultaneous
electrocardiogram and pulse oximetry waveforms are displayed
the aortic valve closes. Elastic recoil of the arterial tree in
above the arterial waveform. the presence of a closed aortic valve causes a slight rebound
(increase) of ABP and results in the dicrotic notch, also
the level of the catheter. Once the transducer is positioned, called the incisura (Figure 13.4). This notch causes disrup-
the stopcock is closed to the patient and opened to the tion in the downslope of the waveform as pressures return
atmosphere, and the “zero transducer” or similar button to diastolic values. The presence of the dicrotic notch is
on the monitor is engaged. The waveform line should flat- largely a function of arterial elasticity and can be dimin-
ten and the screen should read “0/0 (0).” When zeroing is ished or absent due to vasoconstriction [15].
complete the stopcock is closed to the atmosphere and There are changes in waveform appearance as the pres-
opened to the patient and the arterial waveform should sure wave moves from central to peripheral arterial circu-
appear on the screen, providing continuous ABP measure- lation. This phenomenon is referred to as distal pulse
ments (Figure 13.3). amplification. As such there can be slight differences in
tracings obtained depending on where the catheter tip is
located. In general, the initial upstroke becomes steeper,
Normal Arterial Pressure Waveforms the systolic pressure increases, the dicrotic notch appears
later, and the end-diastolic pressure decreases as the
The waveform generated by the hemodynamic monitor waveform moves from central to peripheral
reflects the pressure changes transmitted along the arterial (Figure 13.5) [16]. Despite the higher SAP and wider pulse
tree and sensed by the transducer. An idealized schematic pressure obtained peripherally, the lower peripheral DAP
of an arterial pressure waveform is depicted in Figure 13.4. results in little net effect on the MAP from central to
The “baseline” of the waveform represents diastolic arte- peripheral measurement sites. Preservation of MAP
rial pressure (DAP) and indicates the minimum blood throughout the arterial tree is supported by a study com-
pressure, which is present during ventricular relaxation paring central versus peripheral ABP measurement in
(diastole). DAP is a function of blood viscosity, arterial dis- anesthetized dogs [11].
tensibility, SVR, and the length of the cardiac cycle [12, In addition to differences in arterial pressure and wave-
13]. The initial upstroke in the waveform represents the form referable to catheter location, there can also be nor-
rapid rise in arterial pressure from DAP to SAP, which mal, minor variations in blood pressure seen between
occurs with aortic valve opening and stroke volume ejec- inspiration and expiration with spontaneous or mechani-
tion. SAP represents the peak blood pressure during ven- cal ventilation. During spontaneous breathing, SAP is
tricular contraction (systole), and its determinants are slightly lower during inspiration than it is during expira-
stroke volume, velocity of left ventricular ejection, SVR, tion. During mechanical ventilation the opposite is true:
arterial distensibility, and left ventricular preload [13, 14]. SAP slightly increases during inspiration and decreases
The difference between DAP and SAP is called the pulse during expiration (Figure 13.6). Arterial pressure changes
pressure, which is responsible for the intensity of palpated during the respiratory cycle because alterations in pleural
peripheral pulses. As the stroke volume runs off into the pressure affect thoracic vasculature and cardiac function,
arterial tree toward the end of systole, there is a decline in which in turn cause changes in stroke volume [17]. During
CalcaCations DetiDed eiomatD eaDetCa eDnsnsceD CiD ieo 173
Central Peripheral
Waveform Waveform
Figure 13.5 Comparison of idealized arterial waveforms from a catheter placed either centrally (left) or peripherally (right).
Inspiration Inspiration
Expiration
Figure 13.6 Respiratory-associated variation in arterial pressure for a patient undergoing mechanical ventilation.
mechanical inspiration, any positive pressure transmitted variability associated with catheter location and transducer
across the lung to the pleural space results in an increase in signal distortion. As such, determination of MAP is impor-
left ventricular preload and a decrease in left ventricular tant for assessing clinical status as well as guiding thera-
afterload. The net effect is an increase in left ventricular peutic decisions. Using dABP measurement, most
stroke volume and thereby SAP. However, pleural pressure hemodynamic monitors calculate MAP by averaging the
changes result in decreased stroke volume leading to area under the arterial pressure waveform over several
decreased SAP during passive expiration in the mechani- beats. It is also possible to approximate MAP through a cal-
cally ventilated patient. Under normal circumstances this culation based solely on SAP and DAP. Based on the prem-
pressure variation, which typically does not exceed ise that approximately two-thirds of the cardiac cycle is
5 mmHg, is not clinically significant [17]. However, as dis- spent in diastole, the equation:
cussed later, there are certain pathological conditions that
can lead to exaggeration of this respiratory cycle-related MAP DAP SAP DAP 3 (13.2)
arterial pressure variation, making the variation more
important both diagnostically and therapeutically. provides a good estimate of MAP. However, patients with
Normal ABPs in dogs have been reported in the ranges of tachycardia have decreased diastolic filling time, and
110–190 mmHg for systolic and 55–110 mmHg for diastolic thus equation 13.2 will underestimate MAP (i.e. actual
pressure, whereas cats have systolic pressure ranges of MAP will be closer to SAP than calculated). In addition,
120–170 mmHg and diastolic pressures ranging from this equation may overestimate MAP in patients with
70–120 mmHg [8]. MAP normally ranges from 80 to narrow arterial pulse pressure waveforms, since narrow
130 mmHg in both species. waveforms have a smaller area under the curve (and
thereby a lower true MAP), regardless of the SAP
and DAP.
alculations Derived from the Arterial
C
Pressure Waveform Calculations of Arterial Blood Pressure Variation
MAP is generally considered superior to systolic pressure As previously stated, there are normally minor variations in
as an indicator of true driving pressure for tissue perfu- SAP during both spontaneous and mechanical ventilation.
sion [18]. In addition, MAP is much less susceptible to Hypovolemia magnifies this effect because during
hypovolemia the heart and the thin-walled intrathoracic SPmax SPmin

vessels (such as the vena cava and pulmonary veins) are
more collapsible [17]. Under such circumstances, the
changes in pleural pressure that occur during the respiratory SPV
cycle can have more significant hemodynamic impact and
thus result in greater pressure variation. This phenomenon
led to the notion that respiratory cycle-associated arterial PPmax
pressure variation could be used as an indicator of volume PPmin
responsiveness in mechanically ventilated patients. Figure 13.7 Variables used to determine volume

Spontaneously breathing patients generally have wide varia- responsiveness based on ventilation-associated variation in
tion in tidal volume, and thereby variable changes in blood pressure. PPmax, maximum pulse pressure; PPmin, minimum
intrathoracic pressures, which unfortunately makes respira- pulse pressure; SPmax, maximum systolic pressure; SPmin,
minimum systolic pressure; SPV, systolic pressure variation [17].
tory effects on arterial pressure less consistent and interpre- Source: Adapted from Michard 2005.
tation challenging. Systolic pressure variation (SPV) and
pulse pressure variation (PPV), dynamic markers of respira-
tory cycle-associated arterial pressure variation, have been Compared with SPV, PPV appears to have stronger corre-
explored as indicators of volume responsiveness for mechan- lation to hypovolemia and volume responsiveness, with
ically ventilated patients and are discussed here briefly: higher PPVs correlating to greater degrees of volume
responsiveness in human studies [25, 26]. Several studies
Systolic Pressure Variation have also investigated the use of PPV in canine patients,
SPV is either the absolute difference between the maxi- showing good correlation and suggesting values >11–16%
mum systolic pressure (SPmax) present during inspiration being consistent with a volume-responsive state in a vari-
and the minimum systolic pressure (SPmin) present during ety of clinical circumstances [23, 27–29].
expiration, or as a percentage indexed against the average There are several limitations to using these techniques.
systolic pressure: Perhaps the most significant is that, as previously mentioned,
ABP variation equations can only be used in patients under-
SPV SPmax SPmin or (13.3) going positive-pressure ventilation. This limits the applica-
tion to patients needing ventilatory support for hypoxemia,
SPV % SPmax SPmin SPmax SPmin 2 100 hypoventilation, or during anesthesia. In addition, factors
such as technical issues, the presence of arrhythmias, effects
(13.4) of chest wall and lung compliance, or right or left ventricular
An SPV greater than 10 mmHg has been shown to corre- failure could all interfere with the accuracy and utility of
late to hypovolemia in human patients [19]. In addition, in these values in determining volume responsiveness [17].
people SPV has been shown to correlate with pulmonary
capillary wedge pressure and left ventricular end-diastolic
area, both correlates of intravascular volume status [20, 21]. ther Uses for the Arterial Pressure
O
Recent investigation suggests some potential application in Waveform
dogs, with one study showing an SPV greater than 4.5%
consistent with volume responsiveness [22]. Another study In addition to use in assessment of volume status, arterial
also found reasonable correlation to parameters of volume waveforms have also been used to determine cardiac out-
responsiveness in canine goal-directed therapy [23]. put through pulse contour analysis. Pulse contour analysis
provides beat-to-beat cardiac output values based on com-
Pulse Pressure Variation putation of the area under the systolic portion of the arte-
PPV offers yet another way to quantify respiratory varia- rial pressure curve after calibration with a known cardiac
tion in arterial pressures associated with ventilation output (typically determined by either lithium dilution or
(Figure 13.7). PPV is obtained by dividing the difference thermodilution). Cardiac output determination from the
between the maximum and minimum pulse pressures arterial pressure waveform requires additional equipment
(PPmax and PPmin) over a single breath by the mean of the and software. Available systems include PulseCO™
two values [24]. The PPV, expressed as a percentage, is (LiDCO Ltd., London, UK), PiCCO (Pulsion Medical
given by the following equation: Systems, Munich, Germany), and Flotrac® (Edwards
Lifesciences, Irvine, CA), all of which have been validated
PPV % 110 PPmax PPmin PPmax PPmin 2
in a variety of clinical scenarios in humans [30, 31]. While
(13.5) potentially useful in clinical veterinary medicine, cardiac
AoieoCa eaDetCa eDnsnsceD CiD ieons 175
output determination by pulse contour analysis has been generally considered accurate. Normal arterial pressure
shown to have poor correlation compared with lithium waveforms have no “pointy” or jagged parts – waveforms
dilution or thermodilution techniques and frequent recali- with points or sharp peaks are therefore likely under-
bration is required [32–34]. damped. The length of tubing connecting the arterial
catheter to the transducer can contribute to underdamp-
ing in a direct relationship – increased length of tubing
worsens underdamping.
bnormal Arterial Pressure
A
Overdamping, on the other hand, results in attenua-
Waveforms tion or muting of the arterial pressure waveform, leading
to falsely low SAP and falsely elevated DAP. The net
Recognition of abnormal pressure waveforms is an essen-
effect is a significant reduction in the pulse pressure
tial component of dABP monitoring (Protocol 13.1).
though the MAP generally remains accurate. Overdamped
Alterations in waveform morphology could reflect true
waveforms are overly smooth with loss of many defining
changes in clinical condition, thereby warranting interven-
characteristics, such as the systolic upstroke and dicrotic
tion for the patient. On the other hand, they could indicate
notch (Figure 13.8). Potential causes of overdamping
a technical or mechanical issue that would require trouble-
include air bubbles in the line, line occlusion from kink-
shooting the system rather than the patient.
ing or clotting, or use of overly compliant tubing. More
detail concerning system damping and technical issues
of fluid-filled monitoring systems can be found in
Technical Problems that Cause Abnormal Arterial
Chapter 12.
Pressure Waveforms
One of the major technical issues that can arise with use
Patient Problems that Cause Abnormal Arterial
of a dABP transducer system is pressure waveform over-
Pressure Waveforms
damping or underdamping. Damping is the inherent ten-
dency for the system itself to alter the pressure signal as it Alterations in arterial waveforms can also manifest because
is transmitted from the patient to the transducer. of significant changes in patient hemodynamics. For exam-
Underdamping occurs when the resonant frequency of ple, various arrhythmias can impact cardiac output and
the monitoring system too closely matches the frequency blood pressure, and can result in diminished to completely
of the pressure waveform. The result is a summation or absent arterial waveforms despite the presence of electrical
resonance of the two frequencies, amplification of the sig- activity (Figure 13.9).
nal, overestimation of SAP, and underestimation of Significant hypotension secondary to low cardiac output
DAP. All dABP monitoring systems have some inherent (as from hypovolemic or cardiogenic shock) can result in
underdamping effects and, as such, tend to report falsely muted waveforms secondary to small stroke volumes com-
high SAPs and falsely low DAPs. The degree of inaccuracy bined with peripheral vasoconstriction. As such, pressure
can be minor or significant. The MAP reported is waveforms from patients with hypotension can be difficult
Protocol 13.1 Suggested Step-by-Step Approach for Assessing Direct Arterial Blood Pressure
Procedure b) Does this value reflect bradycardia or tachycardia?
c) Does the rate match the auscultated and ECG
1) Determination of arterial blood pressure:
heart rate?
a) What is the reported systolic pressure?
d) Is the pulse rhythm regular or irregular? Does it
b) What is the reported diastolic pressure?
match changes in the ECG (i.e. is there a pulse
c) What is the reported or calculated mean pressure?
waveform for each QRS complex)?
d) What is the calculated pulse pressure?
3) Assessment of waveform morphology:
e) Do these values reflect hypotension or hypertension?
a) Has the waveform morphology changed
f) Do these values match the patient’s clinical condition?
significantly?
g) Do these values coincide with palpated pulse
b) Is the morphology consistent from beat to beat?
quality?
c) Is a dicrotic notch present?
h) Is there significant ventilation-associated variation?
d) Has the waveform become muted (significant
2) Assessment of pulse rate and rhythm:
decrease in pulse pressure)?
a) What is the pulse rate reported by the monitor?
Figure 13.8 Arterial waveform from a patient with sudden and marked overdamping of the pressure signal (arrow) associated with
catheter occlusion. Note the sudden loss of waveform morphology, slight decrease in systolic pressure, increase in diastolic pressure,
and loss of dicrotic notch, all without any change in heart rate.
(a)
(b)
(c)
Figure 13.9 Examples of arrhythmia-associated changes in arterial waveform morphology. (a) Ventricular premature contractions
associated with diminished (solid arrow) to absent (dashed arrow) pressure tracings. (b) Tachycardia (heart rate 210 beats/minute)
resulting in progressively diminished waveforms and blood pressure (arrows). (c) Atrial flutter with prolonged periods of absent
ventricular contraction resulting in absent arterial waveforms.
to distinguish from those caused by overdamped systems. and will be low with hypotension) can be helpful to distin-
Clearly, recognizing the difference is essential to taking guish between the two. Alternately, a fast flush test
appropriate action if the patient is truly hypotensive. The (described in Chapter 12) can be performed to assess the
patient’s clinical status (mental responsiveness, heart rate, system for damping.
manual palpation of pulses) as well as the MAP (remem- Another manifestation of respiratory arterial pressure
bering that MAP is typically preserved with overdamping variation can occur in the form of pulsus paradoxus, most
AoieoCa eaDetCa eDnsnsceD CiD ieons 177
commonly associated with pericardial effusion that has marked hypertension, generally defined as SAP greater
resulted in cardiac tamponade. As with hypovolemia, the than 180–200 mmHg or MAP greater than 140 mmHg,
decrease in venous return from increased pericardial pres- could cause significant end-organ injury and requires
sure results in an exaggeration of the difference between intervention [36]. The presence of ventilatory variation in
the SAP during inspiration and the SAP during expiration. systolic pressure greater than 10 mmHg is consistent with
Provided the patient is breathing spontaneously, SAP will hypovolemia (prompting fluid resuscitation) or pericar-
be higher on expiration and lower on inspiration dial effusion (prompting pericardiocentesis). Arrhythmias
(Figure 13.10a). that result in a sustained impact on blood pressure or
Finally, there are certain clinical scenarios whereby a even intermittent hypotension may require antiarrhyth-
patient has waveforms with increased pulse pressure mic medications or a pacemaker. This could include tach-
(“tall”) but are of fairly short duration (“narrow;” ycardia with heart rate above 180–200 beats/minute
Figure 13.10b). This morphology is typically caused by an
increased SAP and a very rapid falloff to DAP, the latter Table 13.1 Guidelines indicating need for clinician
occurring either because of decreased blood viscosity, intervention based on direct arterial blood pressure monitoring.
peripheral vasodilation, or backward flow of blood.
Potential causes of “tall and narrow” waveforms, also Change assessed by dABP Measurement
referred to as water hammer or Corrigan’s pulses, include
aortic regurgitation, patent ductus arteriosus, hyperten- Hypotension [7] SAP < 80 mmHg
sion, sepsis, and dilutional anemia [35]. MAP < 60 mmHg
Hypertension [33] SAP > 180–200 mmHg
MAP > 140 mmHg
Thresholds of Concern for Arterial Pressure Value
and Waveform Abnormalities Arrhythmias [35] Tachyarrhythmias:
HR > 180–200 (dog)
Significant changes in blood pressure or waveform mor-
HR > 240 (cat)
phology should prompt assessment of clinical condition
Bradyarrhythmias:
and intervention as indicated (Table 13.1). Onset or wors-
ening of hypotension, generally defined as SAP less than HR < 60 (dog)
80 mmHg or MAP less than 60 mmHg, should be HR < 80–100 (cat)
addressed as soon as possible to limit tissue hypoxia and HR, heart rate; MAP, mean arterial pressure; SAP, systolic arterial
potential for cardiac arrest [8]. Along similar lines, pressure.
Inspiration
(a)
Expiration
(b)
Figure 13.10 (a) Arterial waveforms from a patient with pulsus paradoxus demonstrating respiratory-associated arterial pressure
variation. (b) Arterial waveforms from a patient with dilutional anemia demonstrating “tall and narrow” morphology.
(bpm) in dogs or 240 bpm in cats, or bradycardia with any air bubbles or clots should be removed. If the cathe-
heart rate less than 60 bpm in dogs and 80–100 bpm in ter does not readily aspirate, the system can be gently,
cats [37]. manually flushed to assess patency and to evacuate any
air bubbles or clots. A fast or forceful flush of an arterial
catheter that does not readily aspirate carries the risk of
Troubleshooting Abnormal Waveforms introducing air or small thrombi into distal arterial circu-
lation. If the system does not flush or aspirate readily, the
One of the primary objectives in troubleshooting abnormal arterial catheter should be closely inspected to confirm
waveforms is to determine whether changes in blood pres- its position and functionality. If the catheter appears to
sure or waveform morphology truly reflect changes in be at least partially patent then a “fast flush test”
patient hemodynamics or if they are due to technical or (described in detail in Chapter 12) can be performed to
mechanical issues. These issues arise most commonly with assess for the presence of overdamping or underdamp-
the apparent presence of significant hypotension (and ing. If underdamping is present, it may be necessary to
muting of the arterial waveform) or hypertension (and use shorter noncompliant tubing between the pressure
exaggeration of the waveform). transducer and the arterial catheter. If overdamping is
Several steps can be followed to systematically work present and does not resolve with flushing, it may be nec-
through the potential causes for these changes (Protocol 13.2). essary to confirm the presence of noncompliant rather
When an abnormal waveform is detected, the first step is to than standard extension tubing between the catheter and
determine whether there are concurrent changes in patient the transducer, and to assess all system connections,
clinical status such as alteration in mentation, heart rate, or lines, and the arterial catheter itself for bubbles, kinks, or
palpable pulse quality that might require immediate inter- other abnormalities that might interrupt pressure wave
vention. In addition, if not already being continuously moni- transmission.
tored, an electrocardiogram (ECG) should be obtained to
determine whether an arrhythmia is present. If there are no
changes in clinical condition or ECG, the transducer setup Conclusions
should be assessed to ensure that the noncompliant tubing is
not kinked and that there are no air bubbles present in the Despite the potential limitations and technical difficulties
fluid column. It is also important to ensure the pressure bag associated with its use, dABP monitoring offers valuable
is still inflated to 250mmHg or higher. If there has been sig- information regarding hemodynamic status. If equipment
nificant change in patient position, it may be beneficial to re- is available and one becomes accustomed to the process,
level and re-zero the transducer. dABP measurement could be used in any 24-hour veteri-
To assess patency of the arterial catheter, the catheter nary hospital and is especially useful if critically ill patients
should be aspirated to ensure arterial blood is obtained; are routinely seen.
Protocol 13.2 Troubleshooting Abnormal Arterial Pressure Waveforms

Procedure iii) There are no air bubbles in the fluid column.
iv) Pressure bag is inflated to ≥ 250 mmHg.
1) Assess patient for changes in clinical status to explain
b) Re-level transducer to level of the patient’s heart
change in morphology:
base and re-zero the transducer if patient position
a) Assess mentation, heart rate, pulse quality, mucous
has changed significantly.
membrane color, capillary refill time, and extremity
c) Assess patency of arterial catheter:
temperature.
i) Aspirate arterial catheter.
b) Assess ECG for changes in rate and rhythm
● Ensure arterial blood is easily obtained.
coinciding with changes in waveform.
● Remove air bubbles and clots from line.
2) If patient parameters have not changed:
ii) Flush arterial catheter.
a) Assess transducer setup and make sure:
● Ensure catheter flushes easily – do not force.
i) Noncompliant tubing is used between patient
● Evacuate air bubbles or small clots from system.
and transducer.
3) Perform “fast flush test” to assess for system over-
ii) Noncompliant tubing is not kinked.
damping or underdamping.
References 179
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181
14
Noninvasive Arterial Blood Pressure Monitoring

Christopher L. Norkus and Nicholas L. Rivituso
Oxygen delivery to tissue (DO2) is required for normal cel- systole. This principle is demonstrated by the following
lular function. Oxygen delivery to tissue may be calculated equation, which estimates MAP:
as the product of cardiac output (CO) and arterial oxygen
content (CaO2): MAP SAP DAP 3 DAP (14.2)
(14.1) Systemic MAP is the product of cardiac output and SVR;

DO2 CO CaO2
see equation (14.3). Cardiac output is blood flow provided by
Blood pressure is the pressure that blood exerts on the the heart and is the product of stroke volume (SV), the volume
vessel wall. Cardiac output, not blood pressure, is a of blood ejected with each heartbeat, and the heart rate (HR):
constituent of delivery of oxygen to tissue, as shown in
MAP CO SVR (14.3)
equation 14.1. However, the measurement of cardiac
output in the clinical setting is labor intensive and CO SV HR (14.4)
challenging. Blood pressure is related to cardiac output in
Stroke volume is determined by cardiac preload, contrac-
that it is determined by a combination of cardiac output
tility (inotropy) and relaxation (lusitropy), and afterload.
and systemic vascular resistance (SVR). Additionally, blood
SVR is influenced by vasomotor tone (degree of vasodila-
pressure dictates blood delivery to certain vital organs such
tion or vasoconstriction) and blood viscosity. While
as the brain, heart, and kidneys. Because blood pressure
increased SVR for a static cardiac output leads to increased
is easier to measure than cardiac output and because it is
blood pressure, the increased vascular resistance decreases
of vital importance physiologically, blood pressure meas-
blood flow, as described by Ohm’s law:
urement is an important method to monitor the cardiovas-
cular system in small animal patients. Failure to achieve Q P/R (14.5)
and maintain adequate blood pressure is associated with
In this equation, Q is blood flow, ΔP is the driving pres-
increased short- and long-term morbidity and mortality in
sure of blood from one point in the systemic circulation to
anesthetic and critical care settings [1–6]. As such, the rou-
another, and R is resistance. When cardiac output is substi-
tine evaluation of blood pressure has been integrated into
tuted for Q (blood flow); the difference between MAP and
numerous established human medical scoring systems
right atrial pressure (RAP) is selected as ΔP (driving pres-
such as the Simplified Acute Physiology Score, Acute
sure); and SVR is applied for R (resistance), the equation
Physiology and Chronic Health Evaluation, and the
can be rewritten as follows:
Sequential Organ Failure Assessment.
Blood pressure can be broken down into three distinct CO MAP RAP SVR (14.6)
reported components: the systolic arterial pressure (SAP),
the diastolic arterial pressure (DAP), and the mean arterial It is important to acknowledge, therefore, that increases
pressure (MAP). The SAP and DAP correlate to their in blood pressure do not guarantee improvements in blood
respective phases of the cardiac cycle while MAP is the flow or oxygen delivery to tissue.
average of the arterial pressure over time. MAP is not equal When monitoring blood pressure, it is critical to remem-
to the arithmetic mean or “average” of SAP and DAP ber its determinants, since therapy should target the aber-
because more of the cardiac cycle is spent in diastole than rant underlying component, whether that be preload,
182 Noninvasive Arterial Blood Pressure Monitoring
contractility, heart rate, SVR, or a combination thereof. For may fail to perform accurately during arrhythmia; and
example, a patient with hypotension associated with septic that they are not truly beat-to-beat continuous. The
shock may need targeted therapy to address preload due to Doppler method additionally requires that an operator be
hypovolemia, inotropy due to decreased cardiac contractil- physically involved during each measurement. Despite
ity, as well as SVR due to systemic vasodilation. these limitations, given the technical requirements and
costs associated with dABP monitoring, NIBP has become
a commonplace method to obtain arterial blood pressure
omparison of Blood Pressure
C measurement.
Monitoring Modalities
Blood pressure monitoring is an integral part of modern alidation of Noninvasive Arterial Blood
V
small animal emergency and critical care practice. The Pressure Monitoring
evolution of noninvasive arterial blood pressure (NIBP)
monitors has led to easier monitoring and management of The ease and widespread availability of NIBP monitoring has
both hypertensive and hypotensive states. Invasive, direct made it the most common for measuring blood pressure in
arterial blood pressure (dABP) monitoring remains the veterinary emergency and critical care medicine. Therefore,
gold standard in both veterinary and human medicine; it is important that NIBP monitoring devices are adequately
dABP monitoring involves intra-arterial catheterization, accurate for clinical use. Given that direct blood pressure
connective tubing, a pressure transducer, and a monitor measurement is considered the gold standard, NIBP devices
allowing continuous reporting of SAP, DAP, and MAP (see have been evaluated for accuracy primarily by comparing
Chapter 11). Alternatively, an aneroid manometer can be dABP and NIBP measurements in both human and veteri-
used in the absence of a pressure transducer and monitor nary patients. The Association for the Advancement of
to allow for continuous evaluation of MAP. Medical Instrumentation (AAMI) has developed guidelines
In general, dABP monitoring is considered more accurate for validation of NIBP measuring devices in people, which
than indirect methods. Additional advantages of dABP involve comparison of NIBP measurements to dABP meas-
monitoring are that it is continuous, allowing for beat-to- urements. Few indirect blood pressure monitoring devices
beat monitoring of the most critically ill patients, and that have met these criteria in people, and to date, no indirect
the arterial pressure waveform generated is helpful in moni- blood pressure measuring devices have been validated by
toring and diagnosis. While it is considered the most accu- these criteria in conscious dogs or cats [8].
rate method, dABP monitoring has several drawbacks, Discrepancies between direct and indirect arterial blood
including that it is technically challenging to establish and pressure measurements can be attributed largely to the fact
maintain, arterial catheterization can be uncomfortable, it that the dABP technique measures blood pressure directly,
poses a risk of catheter-related bloodstream infection and whereas most indirect techniques measure some variable
arterial bleeding, and that more equipment and expertise are related to blood flow. The NIBP measurement techniques
required than for NIBP measurement. A 2017 retrospective commonly used in small animal practice estimate blood
study evaluating the use of arterial catheters in anesthetized pressure by detecting return of blood flow distal to an
dogs and cats did not identify tissue ischemia as an associ- occlusive cuff by Doppler ultrasonic technology as the cuff
ated complication; however, 22.3% of animals evaluated had is slowly released, or by sensing oscillometric arterial wall
a temporary loss of peripheral pulse at the catheterized site motion beneath an occlusive cuff as the cuff is slowly
following use [7]. Another potential drawback of dABP released. Indirect methods are also somewhat limited by
monitoring is increased cost to the client, as the required the fact that they require a large superficial artery on a
equipment and advanced training of nursing staff are more distal extremity that can be occluded by the pressure cuff.
extensive and expensive than for NIBP measurement. The limited presence of these vessels, the variability in size
NIBP monitoring techniques depend on detection of and shape of the limbs, and the potential inaccessibility of
blood flow that passes beneath an occluding cuff, though these arteries due to trauma or peripheral venous catheters
the sensor differs between methods. In general, all NIBP can make it difficult to obtain reliable NIBP readings in
techniques offer the advantages over direct techniques of dogs and cats.
being faster, noninvasive, easier to perform, and requiring Comparison with the dABP measurement method
relatively minimal technical expertise. The primary disad- should not be the only way in which NIBP measurement
vantages of NIBP monitoring are that they have relatively devices are judged. Inherent limitations such as patient
poor accuracy during peripheral vasoconstriction (e.g. noncompliance, significant differences in patient size and
hypovolemic shock); are less accurate at high and low conformation, and lack of protocol standardization make
pressures and heart rates compared with dABP methods; NIBP measurements in dogs and cats inherently more
IndicadiIns ior iIdIncnsdnve Biin ovensnssove iIdaiodIn 183
difficult to obtain than in people. Thus, validation of from inadequate SVR, cardiac preload, cardiac contractil-
veterinary devices should likely take into consideration ity, heart rate, or a combination thereof. Common condi-
these inherent difficulties in our unique clinical setting. In tions that may result in hypotension include congestive
2007 and 2018, a panel of experts on systemic hypertension heart failure, sepsis, anaphylaxis, hemorrhage, severe vom-
in the American College of Veterinary Internal Medicine iting or diarrhea, trauma, and gastric dilatation–volvulus.
(ACVIM) made recommendations for the validation of Anesthesia itself is also a common cause of hypotension
NIBP methods in veterinary patients [8, 9]. These in dogs and cats. Many injectable and inhalant anesthetic
recommendations are based on the AAMI guidelines for agents cause peripheral vasodilation and depression of car-
NIBP monitoring in people and state that the tested NIBP diac contractility, either of which can result in hypoten-
monitoring device should be compared against a dABP sion. The 2009 updated recommendations for monitoring
measurement device or another NIBP measuring device anesthetized veterinary patients by the American College
for which validation has been published in a refereed of Veterinary Anesthesia and Analgesia state that blood
journal; that a device is validated for only the species and pressure monitoring should be performed for all
condition in which the validation test was conducted; and patients [11]. NIBP allows monitoring of trends and allows
that a device may be validated for systolic, diastolic, or both for rapid therapeutic intervention.
types of measurements [8, 9]. The ACVIM panel stated that
the investigational criteria and recommendations of the
Hypertension
AAMI should be followed; criteria for validation of system
efficacy are detailed and strict [8, 9]. Although there are no Hypertension is a sustained increase in systemic blood
validated NIBP measuring devices for use in veterinary pressure. Systemic arterial hypertension is becoming more
patients, NIBP monitoring is nevertheless more commonly commonly recognized as a complication of several disease
used than direct monitoring in clinical practice. processes in dogs and cats. This increased index of suspi-
cion for hypertension has made screening and monitoring
with NIBP measurement devices invaluable in clinical
I ndications for Noninvasive Blood practice. There are two clear indications for measuring
Pressure Monitoring blood pressure in the context of hypertension: evidence of
end-organ damage consistent with a hypertensive episode
There are many indications for monitoring blood pressure and the presence of a disease or condition that is known to
in dogs and cats in the emergency and critical care setting. cause hypertension [8, 9]. The four major end-organs
Blood pressure should be measured in patients with known affected by hypertension are the kidneys, eyes, brain, and
hypotension or hypertension, in patients with diseases or heart [8, 9]. Sustained or acute increases in blood pressure
conditions that may lead to hypotension or hypertension, can have detrimental effects on these organ systems. See
and in all patients undergoing anesthesia. Table 14.1 gives Table 14.2 for specific clinical signs of “end-organ” dam-
arterial blood pressure values that are considered normal age. Table 14.3 shows the risk for hypertension-induced
for dogs and cats. target organ (“end-organ”) damage.
Systemic arterial hypertension can be either situational
hypertension (white coat hypertension), primary or essential
Hypotension
(idiopathic), or secondary to another disease. Secondary
Hypotension, or low arterial blood pressure, is not a pri- hypertension can also occur in response to therapeutic agents
mary disease but is rather a clinical manifestation of that are known to cause hypertension, such as erythropoietin,
another problem. Hypotension most commonly results mineralocorticoids, phenylpropanolamine, phenylephrine,
ephedrine, pseudoephedrine, toceranib, glucocorticoids, and
Table 14.1 Normal arterial blood pressure values in dogs and chronic, high-dose sodium chloride [8]. Additionally, intoxi-
cats [10]. cants such as cocaine, methamphetamine/amphetamine, and
5-hydroxytryptophan have also been associated with second-
Values (mmHg) ary systemic hypertension [8]. Both dogs and cats are affected
Arterial by diseases and conditions known to cause hypertension. In
pressure Dogs Cats dogs, diseases commonly associated with hypertension
include acute or chronic kidney disease, hyperadrenocorti-
Systolic 90–140 80–140
cism, diabetes mellitus, obesity, hyperaldosteronism, pheo-
Diastolic 50–80 55–75
chromocytoma, brachycephaly, and hypothyroidism. In cats,
Mean 60–100 60–100 chronic kidney disease, diabetes mellitus, hyperthyroidism,
Source: Simmons and Wohl, 2009/with permission of Elsevier. obesity, primary hyperaldosteronism, pheochromocytoma,
Table 14.2 Common target organ (“end-organ”) damage urine production, and pale mucous membrane color all
secondary to hypertension. suggest poor perfusion and should raise suspicion for
hypotension. Palpation of peripheral pulses and relative
Tissue Hypertension injury Clinical findings pulse “quality” or pressure has also been proposed as a
potential method to assess blood pressure. Pulse pressure is
Kidneys Progression of Increased creatinine,
chronic or acute SDMA, or decreased an assessment of stroke volume and is the difference
kidney disease GFR between SAP and DAP:
Proteinuria or
Pulse pressure SAP DAP (14.7)
microalbuminuria
Eyes Choroidopathy Acute blindness The difference between SAP and DAP tends to be greater
Retinopathy Exudative retinal during normotension than during hypotension. Hence,
detachment patients with small pulse pressures may be more likely to
Retinal hemorrhage have low blood pressure whereas those with normal pulse
Hyphema pressure may be more likely to have normal blood pres-
Brain Encephalopathy Central neurologic
sure. However, many factors, such as peripheral vasocon-
signs striction, can influence this difference. Recent prospective
Vascular accident
evaluation of the relationship between peripheral pulse
Heart and Left ventricular Hemorrhage (e.g.
quality and Doppler SAP in dogs and cats has found weak
circulation hypertrophy epistaxis)
correlation between peripheral pulse palpation and an
Left-sided Left ventricular
congestive heart concentric actual blood pressure measurement [12, 13]. In dogs, the
failure hypertrophy median SAP was not significantly different between ani-
Gallop heart sound mals in which femoral pulses were present versus those in
Systolic heart murmur
which they were absent. In the same study, dogs with
absent metatarsal pulses were 7.6 times more likely to be
Increased respiratory
rate/effort hypotensive, though palpable metatarsal pulses did not
rule out hypotension [13]. Cats with absent metatarsal and
GFR, glomerular filtration rate; SDMA, symmetric dimethylarginine. femoral pulses had a median SAP of 30 mmHg with a
range of measured SAPs between 30 and 105 mmHg,
Table 14.3 Risk for hypertension-induced target organ whereas cats with strong metatarsal pulses had a median
(“end-organ”) damage. SAP of 135 mmHg with a range of 58–210 mmHg [12].
From these studies it could be broadly said that peripheral
Systolic arterial pulse quality worsens as blood pressure decreases but that
pressure (mmHg) Risk classification
peripheral pulse quality is imprecise and should never be
<140 Minimal used as a substitute for systemic arterial blood pressure
monitoring. Additionally, it is important to note that no
140–159 Low
correlation can be estimated regarding pulse pressures
160–179 Moderate
and hypertension.
≥180 High
Doppler Ultrasound
and hyperadrenocorticism are conditions associated with
hypertension [8]. A clinician is likely to order blood pressure Principles
measurements in patients with these conditions for both ini- Doppler ultrasonic blood pressure monitoring is one of the
tial screening and serial monitoring. most common NIBP measurement methods. In this tech-
nique, a Doppler probe containing two piezoelectric crystals is
placed against the skin overlying a peripheral artery, distal to
Noninvasive Blood Pressure a pressure cuff applied circumferentially to the patient’s limb.
Monitoring Methods The Doppler probe emits ultrasonic waves into the tissue that
are reflected to the probe. The difference between the emitted
The two most common noninvasive ways to monitor blood and returning signal frequencies, called the frequency shift, is
pressure include Doppler ultrasound and oscillometric detected by the transducer and converted to an audible signal
sphygmomanometry. Clues obtained from a detailed physi- emitted from the Doppler unit. Pressure is read from a sphyg-
cal examination including weakness, decreased mentation, momanometer connected to the pressure cuff proximal to the
tachycardia in dogs and abnormal heart rate in cats, pro- Doppler transducer. The cuff is inflated, which occludes the
longed capillary refill time, cool extremities, decreased artery, until no sound is audible from the Doppler monitor’s
Noninvasive Blood Pressure Monitoring Methods 185
Figure 14.2 Proper measurement technique to determine size

of a blood pressure cuff: approximately 30–40% of limb
circumference at site of intended cuff placement. Source: Photo
Figure 14.1 Equipment required for Doppler blood pressure
courtesy of Christopher Norkus.
measurement including a pressure cuff of appropriate size,
ultrasonic gel, Doppler machine, sphygmomanometer.
Source: Photograph courtesy of Christopher Norkus. Table 14.4 Cuff selection for noninvasive arterial blood
pressure monitoring. The cuff width (size) should be 30–40%
speaker. The cuff is then gradually deflated until the first audi- the extremity circumference at the site of cuff placement [8].
ble arterial sound returns, which is documented as the
SAP. The use of headphones is recommended [14]. Basic Limb circumference
equipment required is shown in Figure 14.1. Cuff size

(cm) (inches) (cm)
The Doppler technique is inexpensive, easy to perform,
and widely used in dogs and cats. It cannot be used in dogs 1.0 1.0–1.5 2.5–3.7
and cats to determine MAP or DAP. Doppler is a relatively
2.0 1.5–2.4 3.8–6.2
sensitive NIBP measurement method in low-flow states
3.0 2.5–3.4 6.3–8.7
and in smaller patients, compared with standard oscillom-
etry. Doppler ultrasound has been found to have poor 4.0 3.5–4.4 8.8–11.2
agreement with dABP in dogs weighing less than 5 kg; it 5.0 4.5–5.4 11.3–13.7
has high specificity (97%) and poor sensitivity (56%) for 6.0 5.4–6.4 13.8–16.2
detecting hypotension [15, 16]. Work in cats has suggested 7.0 6.4–7.4 16.3–18.7
that measurements from Doppler ultrasound may correlate 8.0 7.4–8.3 18.8–21.2
better with MAP in this species [17]. Another study in cats, 9.0 8.4–9.3 21.3–23.7
however, suggested that measurements were significantly
10.0 9.4–10.3 23.8–26.2
lower than SAP obtained from a femoral artery catheter
11.0 10.4–11.3 26.3–28.7
and thus a calibration adjustment of 14 mmHg should be
added to Doppler ultrasonic measurements to better cor- Source: Adapted from Acierno et al. 2018.
relate with SAP obtained by femoral dABP [18].
Systemic arterial blood pressure is generally referenced
Cuff Selection to the level of the right atrium, which would require that
The pressure cuff size is key to obtaining accurate results. the site of measurement (i.e. the blood pressure cuff) be
The cuff width should be approximately 30–40% the cir- positioned at right atrial level. If the cuff is positioned
cumference of the limb at the point where it will be placed lower than the right atrium, readings will be falsely ele-
(Figure 14.2). If the cuff size is too small, there can be erro- vated; the opposite is true if the cuff is positioned above the
neously high SAP readings, whereas if the cuff is too large, right atrium [8, 9]. It is suggested that, if the vertical dis-
the readings may be erroneously low due to compression of tance between the cuff and the right atrium is 4 inches
a larger portion of the artery. See Table 14.4 for appropriate (10 cm) or more, a correction factor be applied as in
pressure cuff sizing. Table 14.5. Rather than applying correction factors, it is
Table 14.5 Correction factors for a vertical distance of ≥ 4inches medical adhesive tape, various size pressure cuffs, sphyg-
(10cm) between the right atrium and the pressure cuff. momanometer, and Doppler ultrasound machine. See
Protocol 14.1 for detailed instructions regarding perfor-
If the cuff is . . . Then . . . Because . . . mance of Doppler ultrasonic NIBP measurements. The
environment in which to measure blood pressure should
≥ 10 cm below Subtract 0.8 mmHg The reading
the right for every 1 cm the from the blood be isolated, quiet, and away from other animals, and ide-
atrium cuff is below the pressure monitor ally the animal’s owner should be present [8, 9]. The patient
right atrium is falsely high should not be sedated and should be allowed to acclimate
≥ 10 cm above Add 0.8 mmHg for The reading to the measurement room for 5–10 minutes before a meas-
the right every 1 cm the cuff from the blood urement is attempted [8]. Novelty and anxiety have been
atrium is above the right pressure monitor
atrium is falsely low
shown to falsely elevate blood pressure in dogs [19]. Many
of the preceding recommendations are not possible in the
emergency room and intensive care unit settings, but
recommended that the cuff be as close as possible to the should be followed if possible. The same individual should
horizontal plane of the right atrium. However, these cor- perform all measurements following a standard protocol.
rection factors can be helpful in animals in situations that Training of this individual is essential.
prevent the operator from repositioning the patient. The patient should be gently restrained in a comfortable
position, ideally in sternal or lateral recumbency to limit
Performing Doppler Ultrasound Blood Pressure Measurement the vertical distance from the heart base to the cuff [8].
Equipment required for Doppler ultrasonic blood pressure Measurements in dogs, however, appear to be significantly
measurement includes clippers with blade, ultrasonic gel, affected by body position, with sitting dogs having higher
Protocol 14.1 Doppler Ultrasonic Blood Pressure Measurement

Items Required rear limb, secure the cuff proximal to the hock.
Medical adhesive tape should be applied circumfer-
● Clippers with clean blade
entially around the limb on the proximal and distal
● Ultrasonic conductance gel (Figure 14.5)
edges of the cuff/limb interface to secure the cuff to
● Medical adhesive tape
the limb (Figure 14.4).
● Various size pressure cuffs
5) Apply ultrasonic gel to the concave surface of the
● Sphygmomanometer
Doppler probe. Electrode gel should not be used as
● Charged (or plugged in) Doppler ultrasound machine,
this will destroy the protective coating of the
with headphones
Doppler probe (Figure 14.5).
● Assistant, if required
6) Place gelled probe on the clipped skin overlying the
artery, keeping the probe’s cord parallel to the limb.
Procedure
Using medical adhesive tape, secure the probe to
1) Collect all necessary supplies. the patient. Turn on the device and adjust with fine
2) Position the patient in lateral or sternal recumbency movements until a clear rhythmic “whooshing”
while holding the planned cuff site at approximately the sound is audible with the arterial pulse.
level of the right atrium. If positioning the cuff at 7) Inflate the sphygmomanometer to 30–40 mmHg
approximately the vertical level of the right atrium is past the point at which the arterial sounds are no
not possible, a correction factor is then used. If the cuff longer detectable.
is ≥ 10cm below the right atrium, then subtract 0.8mmHg 8) Deflate the cuff at a rate of around 2mmHg/second
for every 1cm the cuff is below the right atrium. If the until the first rhythmic “whooshing” sounds are detected,
cuff is ≥ 10cm above the right atrium, add 0.8mmHg for marking this point as the systolic blood pressure (SAP).
every 1cm the cuff is above the right atrium. 9) Allow the cuff to completely deflate, allowing blood
3) Clip fur from area over artery. flow to return to the limb.
4) Secure a deflated cuff proximal to the artery and 10) The first measurement should be discarded and the
attach the sphygmomanometer. The cuff should be average of five to seven consistent, consecutive
of a size that is approximately 30–40% of limb cir- readings should be recorded.
cumference at the cuff’s application site (Figure 14.2). 11) Record the name of the person making the measure-
When measuring Doppler on a forelimb, secure the ments, the cuff size, the cuff location, the results, and
cuff over the antebrachium. When measuring on a the veterinarian’s interpretation in the patient’s record.
Noninvasive Blood Pressure Monitoring Methods 187
blood pressure readings than dogs in lateral recumbency [20].

Additionally in dogs, it would appear that blood pressure
measurements made in lateral recumbency are less variable
than those obtained in the sitting position [20]. The cuff may
be placed on a limb or the tail, taking into account animal
conformation and tolerance, and user preference [8, 9]. The
authors prefer a front limb or tail when possible. If a rear
limb is selected, cuff placement above the hock is recom-
mended [21]. If the cuff is to remain in place for some time,
medical tape can be used to secure the cuff as long as the tape
does not apply pressure to the limb (Figure 14.3).
The first measurement obtained should be discarded.
Then a total of five to seven consecutive, consistent values
should be recorded. In some patients, measured readings
trend downward as the process continues. In these ani-
mals, measurements should continue until the decrease
plateaus and then five to seven consecutive consistent val-
ues should be recorded [8]. If in doubt, repeat the measure-
ment subsequently. Written records should be kept on a
standardized form and include the individual taking meas- Figure 14.3 The limb of a dog wearing an appropriately sized
pressure cuff. Note that the cuff has been secured using medical
urements, the cuff size and location, the values obtained, tape circumferentially around the limb on the proximal and
rationale for excluding any values, the final averaged result, distal edges of the cuff/limb interface without compressing the
and then interpretation of the results by a veterinarian. limb. Source: Photo courtesy of Christopher Norkus.
and decrease at DAP. The oscillometric machines gener-

Standard Oscillometry
ally display MAP, SAP, DAP, and pulse rate. Many oscillo-
Principles metric machines calculate SAP and DAP from the MAP
The oscillometric measurement technique is less time using proprietary algorithms; therefore, MAP is probably
consuming and requires less technical skill than the the most reliable reading obtained by standard oscillome-
Doppler ultrasonic technique. Oscillometry involves the try. Calibration of the device should be performed semian-
connection of a pressure cuff to a device that detects arte- nually either by the user, when self-test modes are included
rial wall oscillations during blood flow. Inflating the cuff in the device, or by the manufacturer [8]. Figure 14.4
occludes the artery. As the cuff is deflated, the arterial wall shows two different types of standard oscillometers used
oscillations increase at SAP, reach a maximum at MAP, in small animals.
Figure 14.4 (a) One example of a

standard oscillometric blood pressure
monitor. Source: Photo courtesy of
Christopher Norkus. (b) An
oscillometric sphygmomanometer
measurement device. Source: Photo
courtesy of Maria Battaglia.
(a) (b)
standard oscillometry as for the Doppler method and are

given in the preceding discussion on Doppler ultrasound.
Limitations of Standard Oscillometry

The oscillometric techniques measure pulse rate, which
should always be compared with the patient’s pulse rate as
determined manually [8]. If the oscillometer’s reported
pulse rate is inaccurate, the blood pressure results may be
inaccurate as well. Although oscillometry is routinely used
reliably in non-sedated dogs and for monitoring feline and
canine blood pressures during anesthetic procedures, this
technique may be less reliable in non-sedated cats and
small dogs than the Doppler method. This is likely due to
smaller peripheral artery size, which may not generate suf-
ficient pulse pressure to generate detectable cuff pressure
oscillations. Additional reasons for invalid results using
standard oscillometry include cardiac arrhythmia, signifi-
cant bradycardia or tachycardia, vasoconstriction, hypo-
Figure 14.5 Use only ultrasound gel (blue, on the right of the
image) on Doppler ultrasound probes. Electrode gel (green, on thermia, and patient movement, regardless of patient size.
the left of the image) should not be used because it damages
the Doppler probe’s protective coating and causes the device to Performing Standard Oscillometry
malfunction. Source: Photo courtesy of Christopher Norkus.
The equipment required for standard oscillometric blood
pressure measurement includes various size pressure cuffs,
adhesive medical tape, and the oscillometer. See
Protocol 14.2 for detailed instructions regarding perfor-
Cuff Selection mance of oscillometric NIBP measurements. As with
For oscillometry, the bladder of the cuff should be positioned Doppler ultrasonic measurement, the operator should per-
over the artery for maximum sensitivity to oscillations. Other form several consecutive blood pressure measurements,
instructions regarding pressure cuff size and the pressure discarding the first reading and averaging the following
cuff position in relation to the right atrium are the same for five to seven consecutive, consistent readings [8].
Protocol 14.2 Standard Oscillometric Sphygmomanometry Blood Pressure Measurement

Items Required 3) Secure a deflated cuff of a size that is approximately
30–40% of the limb at the cuff’s application site.
● Various size pressure cuffs
When performing oscillometry on a forelimb, secure
● Medical adhesive tape
the cuff over the antebrachium. When measuring on a
● Oscillometer, with power cord
rear limb, secure the cuff proximal to the hock. Medical
● Assistant, if required
adhesive tape should be applied circumferentially
around the limb on the proximal and distal edges of
Procedure
the cuff/limb interface to secure the cuff to the limb.
1) Collect all necessary supplies. The bladder of the cuff (the portion that fills with air)
2) Position the patient in lateral or sternal recumbency should be centered over the palpable pulse if possible.
while holding the planned cuff site at approximately 4) Push the button on the oscillometer that begins pres-
the level of the right atrium. If positioning the cuff at sure readings. Discard the first reading and record the
approximately the vertical level of the right atrium is average of at least five to seven consecutive, consist-
not possible, a correction factor is then used. If the cuff ent readings.
is ≥10cm below the right atrium, then subtract 0.8mmHg 5) Record the name of the person making the measure-
for every 1cm the cuff is below the right atrium. If the ments, the cuff size, the cuff location, the patient’s
cuff is ≥10cm above the right atrium, add 0.8mmHg for position, the average SAP, DAP, and MAP, and the vet-
every 1cm the cuff is above the right atrium. erinarian’s interpretation in the patient’s record.
References 189
High Definition Oscillometry measurement devices should not be compared (for instance
for trending purposes), even in the same patient [26].
High-definition oscillometry (HDO) blood pressure moni-
Emergent and critically ill patients are often highly
tors are relatively new to the veterinary industry. The devel-
stressed and may be in cardiovascular shock. In this patient
opers claim that HDO monitors have many advantages over
population, acquiring accurate and reliable NIBP measure-
conventional oscillometric blood pressure measurement
ments is very challenging even when using all recommended
devices. Contrary to standard oscillometric sphygmoma-
techniques. Therefore, one should reassess a patient’s physi-
nometry, in which the MAP is measured and the SAP and
cal examination and vital signs frequently and use additional
DAP are calculated, HDO devices perform real-time analy-
diagnostic and monitoring tools (e.g. lactate concentration,
sis of arterial wall oscillations to obtain pressure wave
shock index, mixed venous oxygen saturation, point-of-care
amplitudes. Unfortunately, several recent studies of HDO
ultrasound) to corroborate findings.
in dogs and cats have not shown good correlation, accuracy,
or precision with dABP or other NIBP measurement meth-
ods [22–25]. Some authors of these works have therefore Conclusion
recommended that HDO not be used in patients under gen-
eral anesthesia and have questioned the clinical value of Hypotension and hypertension are both common findings in
HDO. Thus, the future role of HDO in small animal emer- small animal emergency and critical care patients. Numerous
gency and critical care remains uncertain. disease conditions and clinical presentations warrant NIBP
monitoring [8, 9]. Using blood pressure in conjunction with
other modalities to help guide fluid resuscitation and specific
Optimizing Reliability of Noninvasive pharmacologic interventions will help reduce morbidity and
Arterial Blood Pressure Measurements mortality in these patients. Familiarizing the nursing staff
and clinicians with normal arterial pressure values, along
The ACVIM consensus panel established some guidelines with use of a standardized protocol for NIBP devices, will
for optimizing the reliability of NIBP measurements [8, 9]. facilitate their use and optimize their reliability.
The panel cited operator experience as the most likely cause At this time there are no machines validated to perform
of inaccurate values; hence, an experienced operator should NIBP measurement in dogs and cats, but that does not
perform measurements, and appropriate training cannot be mean these methods are not useful in clinical practice.
overemphasized. The panel’s recommendations also Standardization of hospital protocols and staff training for
include the use of a standardized protocol (Protocols 14.1 use of NIBP devices is highly recommended. Following the
and 14.2), allowing the animal to acclimatize to its environ- ACVIM guidelines for blood pressure measurement is
ment prior to measurement, proper and comfortable cuff advised although in emergency and critical situations often
placement, and performance of several readings as recom- it is not entirely possible. Adhering as closely as reasonably
mended previously. Although these recommendations are possible to standard protocols and using physical examina-
valid and should be followed when possible, some of them tion findings, along with other diagnostic and monitoring
are not always possible in the emergency room and inten- modalities, will improve the utility of NIBP devices and
sive care unit. Thus, it is important at the least that an expe- their measurement results.
rienced operator measure the blood pressure and to ensure
appropriate cuff size and location. The consensus panel also
recommends calibrating each NIBP device twice yearly for Acknowledgments
best accuracy [8].
As stated previously, confirming that the pulse rate This chapter was originally authored by Dr. Jill A.
reported by the NIBP device matches the patient’s actual Williamson and Stephanie Leone, CVT, for the previous
pulse rate may help ensure more accurate results. Also, NIBP edition, and some material from that chapter appears in this
modalities should not be used interchangeably. Specifically, one. The author and editors thank Dr. Williamson and Ms.
blood pressure readings obtained from different NIBP Leone for their contributions.
References
1 Silverstein, D.C., Wininger, F.A., Shofer, F.S. et al. (2009). 2 Monk, T., Bronsert, M., Henderson, W. et al. (2015).
Relationship between Doppler blood pressure and survival Association between intraoperative hypotension and
or response to treatment in critically ill cats: 82 cases hypertension and 30-day postoperative mortality in
(2003-2004). J. Am. Vet. Med. Assoc. 232 (6): 893–897. noncardiac surgery. Anesthesiology 123: 307–319.
3 Monk, T.G., Saini, V., Weldon, B.C., and Sigl, J.C. (2005). in anesthetized dogs weighing < 5 kg. J. Am. Anim. Hosp.
Anesthetic management and one-year mortality after Assoc. 51 (5): 300–305.
noncardiac surgery. Anesth. Analg. 100: 4–10. 16 Moll, X., Aguilar, A., and Garcia, F. (2018). Validity and
4 Walsh, M., Devereaux, P.J., Garg, A.X. et al. (2013). reliability of Doppler ultrasonography and direct arterial
Relationship between intraoperative mean arterial blood pressure measurements in anaesthetized dogs
pressure and clinical outcomes after noncardiac surgery: weighting less than 5 kg. Vet. Anaesth. Analg. 45 (2):
toward an empirical definition of hypotension. 135–144.
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5 Silverstein, D., Kleiner, J., and Drobatz, K. (2012). A comparison of indirect blood pressure monitoring
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191
15
Central Venous Pressure Monitoring

Rosalind S. Chow
Optimizing cardiovascular function is fundamental to the and circulating blood volume, whereas right-sided cardiac
clinical management of anesthetized and critically ill ani- output is determined by heart rate, preload, afterload, and
mals. Achieving optimization requires regular assessments contractility. Therefore, any normal physiological process,
of the adequacy of intravascular blood volume and venous disease, or medical intervention that alters one or more of
return, and the administration of intravenous (IV) fluids to these factors may affect CVP. This includes changes in
correct fluid deficits. However, determining the ideal vol- sympathetic tone that occur during stress and illness,
ume of IV fluids to administer is not always a simple task, structural and functional diseases of the heart, and vasoac-
as both insufficient and excessive fluid replacement can be tive drugs such as vasopressors, sedatives, and general
detrimental [1, 2]. Central venous pressure (CVP) is a com- anesthetics.
mon method of estimating circulatory filling and cardiac In some cases, extravascular forces, such as increases in
preload in these settings to help guide fluid resuscitation intrathoracic, pericardial, or intra-abdominal pressures
and assess fluid balance in veterinary patients [3–6]. can also change CVP [11, 12]. Increased intrathoracic pres-
CVP represents the direct measurement of venous blood sure may develop secondary to a variety of causes includ-
pressure from a catheter inserted into a large central vein ing pleural effusion, presence of a space-occupying mass, a
such as the cranial vena cava or caudal vena cava, or the forced expiratory respiratory pattern, or positive end-
right atrium. In the absence of vascular obstruction, CVP expiratory pressure (PEEP) during mechanical ventilation.
measured from the vena cava is a close approximation of A sufficient rise in intrathoracic pressure will compress the
right atrial pressure [7], which in turn is a determinant of vena cava and right atrium and raise the CVP. Similar
right ventricular preload. effects on CVP can be caused by increases in intra-
However, using CVP to guide fluid therapy can be challeng- abdominal pressure such as with ascites, acute abdominal
ing due to its non-linear relationship to blood volume and syndrome, neoplasia, or increased expiratory abdominal
poor correlation with cardiac output following a fluid effort. When there is significant disease in the thoracic or
bolus [8], although some argue that these criticisms reflect a abdominal cavities, it is important for the clinician to be
misunderstanding of how the results should be inter- aware that CVP interpretation will be more complicated.
preted [9]. CVP provides useful information about right-sided
cardiovascular function, but a clear understanding of the ben-
efits and limitations of this common monitoring technique is I ndications for the Measurement
essential to determining the situations where CVP measure- of Central Venous Pressure
ment may provide the most benefit in patient management.
CVP is commonly used to help guide fluid therapy in ani-
mals with abnormalities in circulating blood volume or
Determinants of Central Venous Pressure abnormal right heart function. CVP cannot be used to
make inferences about left ventricular preload or func-
CVP is determined primarily by the relationship between tion [13]. Specific indications for CVP measurement
venous return and right heart function [10]. Venous return include the presence of persistent hypotension despite
is affected by venomotor tone, venous wall compliance, fluid resuscitation, vasopressor therapy, extensive third
192 Central Venous Pressure Monitoring
space losses, oliguria or anuria, hemorrhage, trauma, sep- Measurement Technique

sis, burns, and heart failure. Patients undergoing emer-
gency surgical procedures and those with multiple medical CVP is the direct measurement of venous pressure within
problems are predisposed to developing cardiovascular the vena cava or right atrium. It is obtained by inserting a
instability while anesthetized. In these animals it may be specialized catheter into a peripheral vein (typically the
practical to insert a central venous catheter and begin mon- external jugular vein) and advancing the catheter until the
itoring preemptively to allow earlier detection of abnor- tip rests within the cranial vena cava or the right atrium.
malities in the perioperative period. Right atrial pressure can also be obtained from the proximal
lumen of a pulmonary artery catheter. In the absence of
vascular obstruction, pressure measurements from the vena
Risks cava and the right atrium are generally considered inter-
changeable at rest [18, 19] although their responses are not
Risks associated with central venous catheterization identical following fluid bolus or vasopressor therapy [20].
include thrombosis, thromboembolism, carotid arterial Several alternative catheterization approaches have been
puncture, infection, phlebitis, bleeding, and vascular ero- described in animals, including catheter insertion into the
sion. Cardiac arrhythmias, or rarely cardiac wall perfora- omobrachial vein in dogs [21] followed by advancement
tion, can develop if the catheter tip is accidentally advanced into the cranial vena cava, or catheter placement in the
into the right atrium or right ventricle. There are fewer femoral vein and passage into the caudal vena cava in
problems associated with CVP measurement itself dogs [22] and cats [23]. In human patients, peripheral
although accidental introduction of air or bacteria into the venous pressure has also been used as an estimate of CVP
venous system may occur, particularly if poor technique is due to the similarities between centrally and peripherally
practiced. The cranial vena cava is a low-pressure system measured venous pressures [24, 25]. Unfortunately, this
and opening the system to the atmosphere may result in air technique has shown poor correlation in dogs and cats [26].
embolism formation. Fortunately, this is a rare occurrence More recently in clinical human and experimental
with intermittent CVP measurement technique and negli- canine studies, researchers have investigated the possibility
gible with a continuous monitoring technique as the latter of estimating CVP non-invasively using sonographic meas-
system is closed to the outside environment. Additionally, urements of caudal (inferior) vena caval diameter [27–29],
several straightforward precautions will reduce the inci- vena cava collapsibility [28, 29] or hepatic venous blood
dence of complications. These include following proper flow velocity [27]. These techniques have demonstrated
hand hygiene measures prior to handling the jugular cath- moderate correlation when used to predict broad trends in
eter or CVP system, careful inspection of the tubing and CVP. However, these methods require specialized sono-
transducer to assess for defects, the use of threaded con- graphic views and their clinical utility in veterinary patients
nectors such as Luer-Lok® (Becton, Dickinson and remains unknown. Direct CVP measurement from a cen-
Company, Franklin Lakes, NJ), and periodic verification of tral venous catheter remains the gold standard.
the tightness of these connections, particularly in mobile
patients.
Catheter Selection and Placement
Either single-lumen or multilumen vascular catheters can
Reference Interval be used if they are of sufficient length to reach the thoracic
vena cava from the point of insertion. Selection of a multi-
The most frequently used reference range for CVP is lumen catheter has the added advantage of allowing con-
around 0–5 cm H2O in cats [4] and dogs [14, 15] but values tinued infusion of IV fluids and drugs through the proximal
of up to 10 cm H2O can be normal in awake and anesthe- ports while simultaneously measuring CVP from the cath-
tized dogs [3, 4, 16, 17]. The broad reference range reflects eter’s distal port. The rate of fluid administration has no
the wide variability seen between individuals, caused by effect on the CVP in people, even during pressurized saline
the collective influence of blood volume, venous tone, and infusions of up to 9120 ml/hour via a double-lumen cathe-
cardiac function on venous pressure. ter and up to a combined rate of 14,340 ml/hour through
CVP is measured in millimeters of mercury (mmHg) or the proximal ports of a triple-lumen catheter [30]. These
centimeters of water (cm H2O), depending upon the results are likely similar in veterinary patients although
method of measurement. To convert from mmHg to cm specific experiments have not yet been published.
H2O, multiply by a factor of 1.36: It is important to determine the appropriate depth of inser-
tion prior to catheter placement. A good estimate of depth
CVP in cmH 2O CVP in mmHg 1.36 (15.1)
can be obtained by measuring the distance between the
Measurement Technique 193
planned insertion site and the caudal aspect of the shoulder, level of technical knowledge and skill is needed to set up
which should appropriately position the tip within the cranial and troubleshoot continuous CVP monitoring, and it also
vena cava. Following placement, the catheter’s position can requires the purchase of a specialized monitor. When avail-
be verified with radiography as well as by visualization of a able, refurbished or used monitors in good working condi-
characteristic CVP waveform (see Waveform Analysis). All tion may be an economical solution for many hospitals.
central venous catheters have a radiopaque marker and
radiographic confirmation is particularly important when
Zeroing and Leveling
alternative catheter insertion sites, such as the saphenous
vein, are used because the proper depth of insertion is more To obtain reliable pressure measurements, two principles are
difficult to estimate. Catheters unintentionally advanced into important. First, blood pressure is measured relative to a
the right atrium should be backed out slightly as they can standard reference point, atmospheric pressure, which
occasionally generate arrhythmias. Accidental advancement measures approximately 760 mmHg at sea level. Atmospheric
of the catheter tip into the ventricle should be avoided. pressure is created by the weight of air pressing down on the
However, if it occurs, it is not difficult to recognize once a body and everything within and around it, including the
pressure measurement is obtained, as peak right ventricular central veins and the CVP measurement system. Since it
pressures approach 20–30mmHg in the normal animal [3]. exerts the same magnitude of pressure on each object, its
These large magnitude waveforms are visible as extreme fluc- effects cancel out, allowing atmospheric pressure to be set at
tuations of the fluid column of the water manometer during 0 cm H2O (0 mmHg) for purposes of CVP measurement. This
intermittent CVP measurement, or large peaks on the elec- allows a CVP of 770 mmHg to be read as 10 mmHg and elim-
tronic monitor display with continuous CVP measurement. inates the need to adjust CVP measurements for fluctuations
in barometric pressure [31]. The process of correcting for
atmospheric pressure is called zeroing. Pressure transducer
General Principles
systems have an integrated stopcock and port that can be
CVP can be measured intermittently or continuously. With opened to the atmosphere to calibrate, or zero, the transducer.
both methods, the catheter is connected via a fluid-filled The second principle is the importance of aligning the
tubing system to a pressure-measuring device that displays transducer system (or manometer) with the vascular struc-
the venous pressure. Intermittent measurement involves ture containing the pressure of interest, also known as the
connecting the catheter to a water manometer, infusing a zero reference point, in order for the measurements to accu-
predetermined volume of saline, and allowing the fluid rately reflect the pressure within the intended vessel. In the
level to equilibrate with the patient’s CVP. The height of case of CVP, the zero reference point is the center of the
the fluid column within the manometer is recorded in cm right atrium. The stopcock (for continuous CVP measure-
H2O. Continuous CVP measurement is obtained by linking ment) or the 0 cm H2O mark on the manometer (for inter-
the catheter and fluid-filled tubing to a pressure transducer mittent measurement) must be positioned, or leveled, on
that converts the venous pressure wave to an electrical sig- the same horizontal plane as the patient’s right atrium dur-
nal. The monitor displays the venous pressure waveform in ing zeroing and thereafter during measurement, as demon-
real time as well as a mean venous pressure in mmHg. In strated in Figure 15.1. See Chapter 12 for more information
both cases, the ideal tubing is specialized non-compliant regarding zeroing and leveling transducers.
tubing manufactured for blood pressure measurement. Due to species- and breed-related variability in thoracic
As is commonly the case where more than one method conformation, there is no completely foolproof method of
of measurement is available, there are advantages and dis- determining where the right atrium lies. However, in gen-
advantages to each technique. The equipment needed to eral, the sternum is a good approximation for a dog or cat
perform intermittent CVP monitoring is simple and inex- in lateral recumbency. For an animal in sternal recum-
pensive. However, repeated measurements are relatively bency, draw an imaginary vertical line at the caudal aspect
time-consuming to obtain and effort must be made to of the shoulder that extends from the top of the dorsal
ensure continued sterility of the system between measure- spinous process to the sternum. The right atrium lies at a
ments. In contrast, once the system for continuous CVP point that is roughly 40% of the height of this line.
monitoring is assembled, moment-to-moment changes in Proper determination of the zero reference point is cru-
CVP are displayed on the monitor without the need for cial, because failure to level the transducer (or manometer)
additional intervention. The ability to view CVP continu- relative to the right atrium will result in an erroneous CVP
ously is particularly useful for unstable patients in the reading. The value will be falsely high if the transducer is
intensive care unit and in the operating room. Frequent resting below the right atrium and falsely low if the trans-
measurements also permit better and timelier information ducer is above the right atrium. Since physiologically sig-
about a patient’s response to therapy. However, a higher nificant changes in CVP exist in a relatively narrow range,
A simpler homemade alternative consists of a short section

of IV fluid extension tubing that can be affixed to a ruler.
Either standard fluid tubing or noncompliant tubing man-
ufactured specifically for blood pressure monitoring can be
used. The equipment required to perform intermittent CVP
measurement is shown in Figure 15.2.
To ensure accuracy, the patient should rest in the same
position for each measurement period and this position
should be recorded on the patient’s treatment sheet for
future reference. Both lateral and sternal recumbency are
acceptable. It may be more difficult to obtain accurate read-
ings from an animal that is sitting or standing. Whenever
possible, use the same position for subsequent measure-
ments. In some situations, it will be impractical or unsafe
to position the patient in a certain way. If this is the case, it
is important to adjust the height of the manometer so that
the 0 cm H2O mark is level with the zero reference point
(the right atrium) prior to recording the CVP. Alternatively,
as CVP can occasionally fall below zero, it can be helpful to
align the 10 cm H2O mark with the zero reference point to
facilitate measurement of negative pressures. However, in
this situation, it is necessary to subtract 10 cm H2O from
the height of the fluid column in the manometer to obtain
Figure 15.1 Leveling of the manometer with the zero reference the true CVP measurement.
point. Although this ferret’s heart is caudal to the manometer,
measurements will be accurate as long as the zero value rests
on the same horizontal plane as the patient’s right atrium.
patient harm could result if the error is missed, and the

resulting measurements are used as the basis for fluid ther-
apy decisions. For this reason, the height of the transducer
and stopcock system should always be evaluated prior to
each pressure reading. Their position may need to be
adjusted depending on whether the animal is recumbent,
sitting, or standing. Gentle restraint in lateral recumbency
may be helpful for mobile patients to ensure accurate CVP
readings. The transducer should also be periodically re-
zeroed – always at the level of the right atrium – due to the
potential for drift [32]. Progressive upward or downward
trends in CVP measurements are significant, particularly if
they fall outside expected or target values.
I ntermittent Central Venous Pressure

Measurement
Prior to initiating CVP measurement, it is important to

verify the patient has a correctly positioned central venous
catheter, as described earlier in this chapter. Two types of
water manometers can be used for intermittent CVP meas-
urement. The best one is a rigid, narrow, cylindrical tube
made of glass or plastic specifically manufactured for this Figure 15.2 Equipment required for intermittent central
purpose that has centimeter markings along its length. venous pressure measurement.
Continuous Central Venous Pressure Measurement 195
The CVP is read at the bottom of the meniscus in the availability, but a reasonable place to start is to space read-
manometer (or at the center of the floating ball in the ings one to four hours apart. If more frequent measure-
manometer, if present). Patient heartbeat or respiration ments are desired, continuous CVP measurement should
may cause millimeter fluctuations in the meniscal level. In be considered.
a spontaneously breathing animal, the CVP reading will
decrease during inspiration and increase during expira-
tion. The pressure reading should be obtained at end-
expiration if the patient is breathing normally. If there is ontinuous Central Venous Pressure
C
pronounced expiratory abdominal effort, the measurement Measurement
should be obtained at the beginning of the expiratory
phase, prior to the onset of active abdominal effort [7, 10]. The list of supplies and equipment needed for continuous
Detailed instructions on performing intermittent CVP CVP measurement is more extensive than it is for intermit-
measurement are available in Protocol 15.1. tent measurement. To better familiarize the reader with the
The time interval between measurements will depend on materials and monitoring technique, additional details are
the patient’s cardiovascular status as well as personnel provided here.
Protocol 15.1 Intermittent Central Venous Pressure Measurement

Items Required venous catheter. If a multi-lumen catheter is being
used, connect the tubing to the central lumen (the
● Indwelling central venous catheter (inserted to the
most distal port).
proper depth)
8) Orient the stopcock valve so that it is closed to the
● Disposable water manometer (calibration in centimeters),
patient’s central venous catheter and open between
or a centimeter ruler and extension tubing
the manometer and the fluid-filled syringe. Using the
● 0.9% NaCl
20-ml syringe, fill the manometer with 0.9% NaCl to
● Three-way stopcock with locking fittings
a level that is approximately 10–20 cm H2O greater
● 20-ml syringe
than the patient’s expected CVP. Do not allow the
● Ideally, noncompliant tubing; alternatively, standard
manometer to overflow while filling.
fluid extension tubing
9) The manometer may be attached to an IV pole to
● Heparinized saline flush
facilitate height adjustments, held vertically in the
● One assistant
operator’s hand, or taped to the wall of the cage.
Locate the 0 cm H2O mark and position the manom-
Procedure
eter so that it is level with the zero reference point
1) Collect the necessary supplies. (the patient’s right atrium).
2) Perform hand hygiene and put on examination gloves. 10) Close the stopcock valve toward the syringe, and
3) The patient may lie in lateral or sternal recumbency. unclamp the central venous catheter line, which will
This position should be recorded on the patient open a fluid column between the manometer and the
treatment sheet for future reference. patient. The fluid level in the manometer will initially
4) If applicable and safe to do so, have the patient rest fall as it flows into the patient and then stabilize as
in the same position that was recorded in the treat- the fluid level equilibrates with the CVP.
ment sheet for prior CVP measurements. 11) The operator should ensure consistent readings by per-
5) Flush the patient’s central venous catheter with hep- forming three or more consecutive measurements and
arinized saline solution to ensure patency. calculating an average. Record the average pressure
6) Assemble the CVP monitoring setup. First orient the and patient position on the patient’s treatment sheet.
manometer vertically. Then connect the three-way 12) When the measurements have been completed,
stopcock to the manometer, to the saline-filled reclamp the central venous line, turn the stopcock off
syringe, and to the fluid tubing. to the manometer and disconnect the pressure tubing
7) Orient the three-way stopcock valve so that it is from the central venous catheter. Reconnect the line to
closed to the manometer and open to the tubing and IV fluid therapy if it is intended to be resumed,
fluid-filled syringe. Then, prime (fill) the stopcock and otherwise flush the central venous catheter with
fluid tubing with 0.9% NaCl from the syringe. Connect heparinized saline and cap the port with an injec-
the fluid tubing to the patient’s indwelling central tion plug.
Pressure transducer kits are presterilized and typically Prior to beginning measuring, the transducer must be
consist of a disposable pressure transducer, three-way stop- zeroed at the proper level by exposing it to atmospheric
cock with zeroing port cap, and a flush mechanism pressure in approximately the same horizontal plane as
(Figure 13.1). Some kits also include noncompliant (“high- the right atrium (see Intermittent Measurement instruc-
pressure”) tubing that is needed to join the pressure trans- tions for more details). The fluid-filled system is zeroed
ducer to the patient’s central venous catheter. The tubing and leveled by turning the stopcock lever off toward the
may also be sold separately. Additional tubing can be added patient, loosening (or temporarily removing) the zeroing
between the transducer and the patient if more length is port cap and setting the monitor to zero. The reader
needed. Standard fluid extension tubing is soft and compli- should consult the reference manual for their specific
ant, whereas the specialized tubing made for blood pres- monitor for additional details. Once this has been done,
sure measurements is flexible but non-distensible. In the monitor will display 0 mmHg and the waveform trac-
theory, excessively long or compliant tubing could sup- ing should overlap zero on the displayed scale. If the
press, or dampen, transmission of the pressure waveform, transducer does not zero, the transducer is the most
resulting in waveform distortion [33, 34]. Owing to the low likely culprit, and it should be replaced and the proce-
vascular pressures of the venous system, damping from dure reattempted. After the zeroing step, the zeroing port
overly compliant tubing is less of a concern with CVP cap is replaced and tightened, and the stopcock is turned
measurement than it is with direct arterial blood pressure so it points off toward the port cap to create a continuous
monitoring [34]. Optimization of the CVP waveform will fluid column between the pressure transducer and the
be achieved with noncompliant tubing specifically manu- patient’s central vein. CVP measurement may then begin.
factured for blood pressure monitoring. The reader is As with intermittent CVP measurement, it is important
referred to Chapter 12 for more details regarding tubing to ensure the transducer is at the level of the zero refer-
characteristics. ence point (the right atrium) prior to zeroing or obtain-
The last element of the continuous monitoring setup is ing a reading. This is best achieved by having the patient
assembly of the flush system, which is pressurized and lie in the same position for each measurement period.
provides a simple method of flushing the catheter by pull- Specific instructions for assembling the continuous CVP
ing the rapid flush valve (usually referred to as a pigtail) on measurement system are included in Protocol 15.2.
the transducer. The flush solution consists of heparinized Common issues and solutions that may be encountered
saline and it is prepared by adding unfractionated heparin during continuous CVP monitoring are summarized in
to a bag of 0.9% NaCl to a final concentration of 4 IU/ml. Table 15.1.
Protocol 15.2 Continuous Central Venous Pressure Measurement

Items Required 3) The patient may lie in lateral or sternal recumbency.
This position should be recorded on the patient treat-
● Indwelling central venous catheter inserted to the
ment sheet for future reference.
proper depth
4) Flush the patient’s central venous catheter with hep-
● Pressure transducer kit
arinized saline solution to ensure patency.
● Bag of 0.9% NaCl heparinized to a concentration
5) Assemble the heparinized saline flush system by
of 4 iu/ml
spiking the heparinized saline fluid bag with the
● Standard fluid administration set
standard fluid administration set and flushing fluid
● Pressure bag of appropriate size for heparinized
through the tubing. Clamp the tubing and cap the
saline bag
set’s open end.
● Ideally, noncompliant fluid tubing; alternately, standard
6) Place the pressure bag over the bag of heparinized
fluid extension tubing
saline, hang it on an IV pole placed next to the patient,
● Electronic blood pressure monitor and its associated
and inflate the pressure bag to 300 mmHg.
transducer cable
7) Assemble the transducer system by connecting it
to the noncompliant tubing, to the assembled
Procedure
heparinized saline flush system, and to the trans-
1) Collect the necessary supplies. ducer cable and electronic monitor, as shown in
2) Perform hand hygiene and put on examination gloves. Figure 11.1.
Continuous Central Venous Pressure Measurement 197
8) Prime (fill) the transducer and noncompliant tubing 11) Flush the catheter by pulling on the pigtail and wait
system with heparinized saline by pulling the trans- for the pressure to equilibrate.
ducer’s fast flush valve (pigtail). 12) The system must be calibrated (zeroed) before any
9) Connect the fluid-filled pressure tubing to the cen- measurements can be interpreted. To perform zero
tral venous catheter. If using a multilumen catheter, calibration, with the stopcock at the height of the right
the CVP measurement should be obtained from the atrium, turn the stopcock off toward the patient.
most distal lumen, reserving the other lumens for IV Remove the zeroing port cap on the stopcock to open
fluid therapy, drug administration, or blood it to the atmosphere. Select the zeroing function on the
withdrawal. It is not necessary to discontinue IV fluid display monitor and wait for it to read 0mmHg. Replace
or drug administration through the other ports the zeroing port cap and turn the stopcock toward the
during CVP measurement. zero port, which will allow the pressure to equilibrate
10) Position the height of the transducer and stopcock between the patient’s vena cava and the transducer.
system so that the stopcock is aligned at the same 13) Once the pressure has stabilized, record the CVP
height as the zero reference point (the right atrium). measurement.
The transducer may be attached to an IV pole, to the 14) For subsequent measurements, verify the transducer
cage door, or taped to a stable support that is resting height is correctly positioned at the zero reference
on the floor of the cage. level before recording the CVP measurement.
Table 15.1 Troubleshooting tips for continuous central venous pressure measurement.
Problem Possible cause
Pressure is displayed as a flat line Complete occlusion of the catheter, stopcock, or fluid line (displayed pressure will be far
rather than a waveform above the normal reference range)
Partial occlusion of the catheter, stopcock, or fluid line
Patient is small (cats and small dogs occasionally lack a visible waveform although the
mean pressure can still be used for trending purposes)
Air bubble or leak in the system
No pressure is displayed on the monitor Monitor display settings are incorrect
Transducer was not zeroed
Transducer cable is malfunctioning or is not plugged into the monitor
Pressure reading is higher than Intrathoracic or intra-abdominal pressure is significantly increased
expected Central venous catheter is clamped off or occluded
Transducer is below the level of the right atrium
Transducer is defective
Pressure reading is lower than expected Transducer is above the level of the right atrium
Transducer is defective
Waveform is “noisy” Patient movement
Panting
Catheter tip is within the heart
Arrhythmia
Sudden change in pressure Hemodynamic instability
Transducer position relative to the zero reference point (right atrium) has changed
System does not flush Stopcock position is incorrect
Pressure bag is not sufficiently inflated
Heparinized saline bag is empty
Heparinized saline administration line is clamped off or occluded
Central venous catheter is clamped off or occluded
Maintenance of the Continuous CVP System In hemodynamically unstable patients, the primary objec-
tive of fluid therapy is to optimize right ventricular preload
For the patient undergoing continuous CVP monitoring,
in an effort to improve cardiac output and tissue perfusion.
certain maintenance procedures should be included in the
The rationale for performing CVP measurement is its ability
patient’s treatment orders, listed in Box 15.1. The patient
to serve as an estimate of right atrial pressure, which is a
can be disconnected from and reconnected to the CVP
major determinant of right ventricular end-diastolic
measurement system without the need to re-zero the trans-
pressure. Right atrial and right ventricular pressures are
ducer as long as the disconnection occurs between the
equal when the tricuspid valve is open and pressures have
transducer and the central venous catheter. However, if the
equilibrated at the end of ventricular diastole. Right
transducer cable is disconnected from the monitor, it will
ventricular end-diastolic pressure is in turn related to right
be necessary to re-zero the transducer prior to obtaining a
ventricular end-diastolic volume, which determines end-
CVP reading.
diastolic myocardial wall stretch, or preload.
While the initial temptation would be to assume that low
values of CVP correspond to hypovolemia, and high values
CVP Interpretation indicate volume overload, in reality, the association between
CVP and preload is not straightforward. Critics note that
CVP should never be used as the sole monitoring parame-
isolated CVP values do not correlate well with intravascular
ter to determine the adequacy of circulating blood volume.
blood volume, nor does CVP accurately predict stroke vol-
It must always be evaluated in conjunction with the
ume or cardiac output following a fluid challenge [1, 8].
patient’s history, signalment, and physical examination,
Despite these limitations, CVP can still provide useful infor-
and ideally with knowledge of the animal’s cardiac and
mation about preload and right-sided heart function [31]. A
kidney function. Laboratory data and additional markers
review of the physiological principles behind venous return
of hemodynamic status, if available, such as arterial blood
and venous pressure is useful here to highlight the benefits
pressure, urine output and cardiac output, should also be
and limitations to using CVP in the clinical setting.
factored into the clinical assessment.
Venous return describes the flow of blood from the
Due to the number of factors that can influence CVP, an
systemic circulation back to the heart. Proper flow depends
isolated value is clinically meaningless. However, serial
on the maintenance of an adequate pressure gradient,
measurements over time may document trends in venous
often referred to as the driving pressure, between the
blood pressure that can provide useful information to assist
peripheral and central venous circulation. The magnitude
in the assessment of circulating volume status. Apart from
of driving pressure in the venous circulation is small with
its usefulness as a diagnostic tool when hypovolemia is sus-
the peripheral venous pressure averaging only 5–10 mmHg
pected, CVP measurement can also be used to monitor the
greater than the pressure within the central veins.
effectiveness of fluid therapy to treat low circulating blood
Homeostatic adjustments ensure continued return blood
volume. However, in a similar manner, its success or fail-
flow as variables change [11].
ure should be determined by concurrently evaluating a
The dynamic properties of the venous system that allow
combination of other clinical markers.
it to regulate venous return also govern its other role, which
is to serve as a blood reservoir. Veins contain approximately
Box 15.1 Maintenance of the Continuous Central 65% of the systemic blood volume [35]. A major portion of
Venous Pressure System that blood is contained within the splanchnic veins, which
function as capacitance vessels capable of significant
● The transducer and catheter system should be
adjustments in wall compliance to accommodate changes
periodically flushed by pulling on the fast flush
in blood volume. When effective circulating volume is low,
device. This should be performed at least once every
constriction of the splanchnic veins increases the circulat-
four hours.
ing pool of blood to help support adequate venous
● The transducer should be re-zeroed no less
return [11]. CVP may change minimally during this time
frequently than every 12 hours due to the potential
despite the recruitment of additional volume and clinically
for drift.
the patient may appear to be coping quite well. However,
● Change the flush solution and tubing every 48 hours.
once the blood reservoir has been depleted and other
● Ensure there are no air bubbles in the fluid line at
compensatory mechanisms have been exhausted, the
any time.
patient will decompensate and CVP will fall.
● Periodically inspect and reinflate the pressure bag to
The complex relationship between CVP and circulating
300 mmHg as necessary and verify the heparinized
blood volume explains why a CVP within the normal refer-
saline bag is not empty.
ence range cannot distinguish the normovolemic patient
Poteotial Pourtes Pof eoturutoiotPe uuPues 199
from one with compensated hypovolemia or hypervolemia, Table 15.2 Clinical interpretation of central venous pressure
since homeostatic mechanisms will attempt to maintain measurements.
an adequate pressure gradient for venous return for as long
as possible. Likewise, a severely elevated CVP often reflects Interpretation Possible cause
cardiovascular pathology, but it would be difficult to dis-
Falling trend Hypovolemia
tinguish between normovolemia in the presence of severe
Vasodilation
cardiac dysfunction, or hypervolemia with adequate car-
diac performance on the basis of CVP measurement Within normal Normovolemia
reference range Compensated hypovolemia
alone [19]. The complexity of these interactions may and static
explain why studies have consistently failed to find a Compensated hypervolemia
threshold CVP pressure below which fluid loading will Rising trend Hypervolemia
always improve cardiac output [36, 37]. From the opposite Vasoconstriction or systemic
vantage point, there is no compelling physiological ration- hypertension
ale to support a therapeutic strategy of designing a fluid Right-sided heart disease:
therapy plan to target a specific CVP goal, due to the ina- ● Tricuspid regurgitation
bility of CVP to predict fluid responsiveness with a high ● Tricuspid stenosis
degree of certainty [8, 9].

Pericardial disease:
Despite these limitations, several generalizations about
Pericardial effusion
CVP interpretation can be made that support its continued
●
usefulness in the ICU and in anesthetized patients. First, ● Constrictive pericarditis

CVP should be regarded as a probable, rather than an abso- ● Vena caval obstruction
lute, indicator of volume status. In other words, in the pres- Pulmonary disease:
ence of normal cardiac function, patients with a low CVP
Pulmonary hypertension
are more likely to respond to volume than patients with a
●
normal or high CVP. In human patients with severe circu- ● Pulmonary thromboembolism
latory dysfunction, a CVP less than 5 mmHg has been Increased intrathoracic pressure:
shown to be an excellent positive predictor of fluid respon- ● Pleural effusion
● Intrathoracic mass
siveness [38]. In contrast, patients with a CVP greater than
● PEEP
10–12 mmHg are unlikely to benefit from a fluid bolus,
● Positive-pressure ventilation in
although some still can [7, 31]. Those that do respond may
the presence of hypovolemia
have a condition such as elevated intrathoracic or intra-
● Pneumothorax
abdominal pressure that is causing the CVP to overesti-
Increased intra-abdominal pressure
mate the true transmural pressure [7, 12].
The second generalization that can be made is that ris- Occlusion of the catheter, fluid line,
or stopcock
ing or falling trends are clinically meaningful. An experi-
mental study of induced hypovolemia and hypervolemia
in mechanically ventilated dogs showed that despite con- Potential Sources of Interpretation Errors
siderable variability in CVP between individuals, the
directional change in CVP in these dogs paralleled blood As discussed earlier, extravascular forces such as significant ele-
volume as it rose and fell [17]. Therefore, a progressive vations in the pressure within the thoracic or abdominal cavi-
drop in CVP should alert the clinician to the possibility of ties, can raise CVP. An increase in CVP of approximately
ongoing and excessive internal or external fluid losses, 3mmHg was seen at PEEP levels of 10cm H2O in humans [39]
particularly if supported by the presence of other markers and 15cm H2O in pigs [40]. However, in the absence of PEEP, an
of hypoperfusion. In contrast, a rising CVP with concur- alteration of tidal volume alone (8ml/kg vs. 16ml/kg) did not
rent evidence of worsening tissue perfusion may indicate result in a similar effect [39]. The degree to which PEEP would
declining cardiac function as the cause and could suggest be expected to affect CVP depends on pulmonary compliance,
that additional fluid loading may be unwise [7]. With the since pressure (e.g. PEEP) applied to less compliant lungs would
latter scenario, additional caution is warranted if hypoal- not affect intrathoracic (pleural) pressures as much as pressure
buminemia or systemic inflammation is present, as either applied to more compliant lungs. Large elevations in intra-
of these conditions may increase the risk of edema forma- abdominal pressure secondary to acute abdominal syndromes,
tion with IV fluid therapy. A summary of the possible clin- ascites, or a forced expiratory respiratory pattern, can also alter
ical interpretations of rising or falling trends in CVP is the CVP due to transmission of the increased abdominal pres-
provided in Table 15.2. sure across the diaphragm to the thoracic cavity [12, 37].
It is important to recognize that the higher CVP gener- higher central venous oxygen saturation, as well as
ated by an elevation in intrathoracic or intra-abdominal improvement in physical examination findings. See
pressure does not necessarily result in an increase in driving Chapter 19 for more information about many of these
pressure and venous return. This is because the physiologi- indirect perfusion indices.
cal variable that ultimately governs distension of the cen- A fluid challenge is performed by rapidly infusing a
tral veins is transmural pressure, not CVP [7, 10]. small volume of crystalloid or colloid using a pressure bag
The concept of transmural pressure is best understood or fluid pump. Useful crystalloid test volumes are 15 ml/kg
by recognizing that venous distension depends not only on in the dog and 5 ml/kg in the cat. If a colloid is used, 5 ml/
the pressure exerted on the vascular wall from the inside kg in the dog and 2.5 ml/kg in the cat are reasonable. The
(intravascular pressure or CVP), but also on the pressure fluid bolus is given over 10–15 minutes and the animal is
exerted on the wall from the outside (extravascular pres- monitored for signs of improved perfusion and CVP. The
sure, or pleural pressure). The net difference (intravascu- classic response to a fluid challenge in the euvolemic ani-
lar pressure minus extravascular pressure) is called mal is a rise in CVP of 2–4 cm H2O, followed by a rapid
transmural pressure. An increase in pleural or abdominal return to the original value within 15 minutes [41].
pressure will be transmitted to both intravascular and However, if the starting CVP is low and it rises minimally
pleural spaces, resulting in no net change in transmural or rapidly returns to baseline (within 5–15 minutes) follow-
pressure despite a higher CVP measurement. Venous ing a fluid challenge, hypovolemia is likely [41, 42], par-
return depends ultimately on driving pressure, previously ticularly when corroborated by other findings as mentioned
described as the difference between peripheral and CVPs. previously. The fall in CVP is due to the redistribution of
However, it is more accurately defined as the difference fluid from the intravascular to the interstitial space, stress-
between peripheral and central transmural venous pres- induced relaxation of venous tone, and pooling of blood
sures. In this example, although there has been an abso- within the splanchnic vascular bed [43]. In contrast, a per-
lute increase in measured CVP, transmural central and sistent, marked elevation in CVP following a fluid chal-
peripheral venous pressures have remained steady. lenge, or a prolonged return to baseline (greater than
Therefore, there is no change in the rate of return of blood 30 minutes) may support volume overload, decreased car-
to the heart. diac performance, or restrictive pericardial disease such as
tamponade [41].
It should be noted that these guidelines reflect general
Performing a Fluid Challenge trends, not absolute rules. A low CVP will not always indi-
cate that a patient has inadequate blood volume, just as a
When CVP is falling or is extremely low, the index of suspi- high CVP does not necessarily signify fluid excess or car-
cion for hypovolemia should be high. Usually, an evalua- diac dysfunction [19]. Normovolemic animals may show a
tion of other clinical markers will support an assessment of rise in CVP following a test bolus, even though they do not
low circulating blood volume and fluid resuscitation can be actually require fluid. The concept of CVP serving as a
started immediately. However, on occasion, these findings marker of the probability of fluid responsiveness, rather
will be unclear or contradictory. When this occurs, a fluid than an absolute predictor of fluid responsiveness, is criti-
challenge is the classic method of verifying fluid cal. Therefore, there is no substitute for careful patient
responsiveness. assessment and clinical judgment when using CVP meas-
The procedure involves giving a small test volume as a urement to help guide fluid therapy.
rapid bolus and then monitoring for an improvement in
clinical perfusion parameters such as patient alertness,
pulse quality, pulse rate, mucous membrane color, and The Normal CVP Waveform
capillary refill time. Faster administration reduces the vol-
ume needed to achieve a certain magnitude of effect. If a Blood pressure in the central veins is pulsatile because of
beneficial response is seen following the volume chal- pressure changes in the right heart during the cardiac
lenge, additional fluid is given until the desired endpoint cycle. The baseline pressure also fluctuates from changes
is reached. Under ideal monitoring circumstances this in intrathoracic pressure generated by the phases of respi-
endpoint would be an increase in cardiac output. However, ration. Both intermittent and continuous CVP measure-
because cardiac output is difficult to measure without car- ment techniques provide a mean CVP, although in the case
diac catheterization or other specialized techniques, sev- of intermittent measurement, small pulsations are often
eral indirect indices are more commonly used, such as evident in the fluid column [41].
improved systemic arterial blood pressure, lower blood In a similar manner, the CVP reported during continu-
lactate concentration, increased urine production, and ous measurement represents a mathematical average of
Abnormal CVP Waveforms 201
this variable pressure. The pressure waveform is displayed Determining the CVP from the Normal Waveform
on the monitor and classically consists of three waves (pos-
During continuous CVP measurement, the monitor displays
itive deflections from baseline: the a wave, c wave, and v
a single pressure reading that represents an average pressure
wave) and two descents (negative deflections: the x descent
measurement over time. The mean CVP is often sufficient
and the y descent), which correspond to specific right atrial
for clinical assessment in patients lacking significant pri-
and right ventricular cardiac events (Figure 15.3) [44]. Not
mary cardiovascular or respiratory disease. However,
all waves and descents will be evident in all CVP tracings
changes in respiratory pattern, cardiac arrhythmias, and dis-
and considerable individual variability in waveform
eases that alter filling, emptying, or compliance of the right
appearance can be seen. Waveforms can be small or impos-
heart can lead to an inaccurate estimation of ventricular end-
sible to discern in cats and small dogs and may be absent if
diastolic pressure (preload), resulting in errors in clinical
the catheter lumen becomes partially occluded (such as by
interpretation. When any of these problems are evident, it is
a blood clot).
important to determine the CVP directly from the printed
The a wave is generated by atrial contraction and
venous pressure tracing to ensure accuracy. In these situa-
appears shortly after the P wave on an electrocardiogram.
tions, the mean of the a wave is considered a better estimate
The a wave is followed by the x descent, which reflects a
of CVP because its timing coincides with ventricular end-
decrease in right atrial pressure caused by atrial relaxa-
diastole [45]. At that brief moment of time immediately
tion. The c wave is sometimes visible as a secondary peak
before the onset of systole, the tricuspid valve is open and
following the a wave and is caused by bowing of the tri-
there is a continuous column of blood extending between the
cuspid valve into the atrium during early right ventricular
vena cava, the right atrium and right ventricle. This allows
systole. As atrial diastolic filling proceeds, the v wave is
CVP to reflect the filling pressure, or right ventricular
created and it is generated soon after the T wave on an
preload, of the heart [45].
electrocardiogram. When ventricular systole ends and the
To determine the mean of the a wave, obtain a printed
ventricle relaxes, atrial pressure exceeds ventricular pres-
tracing that simultaneously displays the CVP and electro-
sure, the tricuspid valve opens, and blood flows from the
cardiogram (ECG) waveforms. From the tracing, locate the
right atrium into the ventricle. Atrial emptying leads to a
a wave in the CVP waveform, which appears during the PR
decrease in atrial pressure, thus producing the y descent.
interval on the ECG. It will be necessary to differentiate the
The a wave is usually larger than or similar in size to the
a wave from the c wave, which is found in the RT interval,
v wave [44].
and the v wave, which appears after the T wave [46]. Once
the a wave is identified, find the peak pressure (top of the a
R
wave) and nadir pressure (bottom of the x descent) and cal-
culate the mean of the a wave according to the following
equation [44]:
CVP estimate a wave peak x descent base / 2 (15.2)
T Two alternative methods that have been described to

P
determine the CVP are to locate the R wave [46] or the
end of the QRS complex [44] on the ECG. A perpendicu-
ECG
lar line is drawn extending from here toward the CVP
S
Q waveform and the point of intersection represents the
true CVP.
a
c v
CVP x y
Abnormal CVP Waveforms
diastole Systole Waveform analysis provides a method of obtaining an
Figure 15.3 The relationship between the waves and descents accurate estimate of preload in the presence of cardiovas-
of the central venous pressure (CVP) waveform and the cular or respiratory disease. It can also provide important
electrocardiogram (ECG). Under normal circumstances, the mean supplementary information about cardiovascular function
of the a wave provides the best estimate of CVP because it
to help diagnose or confirm the presence of certain abnor-
corresponds to the venous pressure at the end of diastole.
Ventricular systole begins immediately following the malities. Several of these situations are described in the fol-
appearance of the QRS complex on the electrocardiogram. lowing subsections.
Respiratory Changes (a) Normal (b) “Cannon” a wave

R
Venous return varies with respiratory phase and respira-
tory muscle activity. During inspiration, there is a decrease
in pleural pressure generated by expansion of the chest VPC
wall and caudal movement of the diaphragm [47]. This
decrease in pleural pressure is transmitted across the wall T
P
of the vena cava and causes a small decrease in CVP, ECG
which returns to baseline following passive, unforced Q S a
expiration. For this reason, in the spontaneously breath- a
ing, relaxed patient, the CVP reading (the mean of the a c v a
c v
wave) should be measured at the end of the expiratory
x y CVP
phase to best correspond to right ventricular end-diastolic
pressure [7, 10, 47]. As with the method described earlier
for normal waveforms, the CVP measurement is deter- (c) Atrial fibrillation (d) Pericardial effusion
mined by calculating the mean of the a wave. c v ac v
When there is increased expiratory effort, which may 20
be seen in patients that are vocalizing or dyspneic, CVP x
15
will be overestimated with this method. In that situation,
CVP is best obtained during early expiration prior to the
onset of active abdominal muscle contraction [10]. Again, (e) Tricuspid regurgitation (f) RV pressure overload
the mean of the a wave is used but it is necessary to evalu- v a a
c
ate the printed CVP waveform to determine the most 20
accurate place to obtain this measurement (Figure 15.4).
Similarly, positive-pressure ventilation may also raise the y
displayed mean CVP. The waveform should be examined
0
and CVP measured from a time point corresponding to
end-expiration. Figure 15.5 Illustration demonstrating (a) normal and (b–f)
abnormal central venous pressure (CVP) waveforms. (b) Large
“cannon” a waves are produced by simultaneous contraction of
Arrhythmias the right atrium and right ventricle and they can intermittently
appear with certain arrhythmias, including second- and
Figure 15.5a shows a normal CVP waveform. Certain car- third-degree atrioventricular block, and some ventricular
diac rhythm disturbances, such as atrial fibrillation and arrhythmias such as the ventricular premature complex (VPC)
shown here. (c) Atrial fibrillation produces a prominent c wave
junctional and ventricular arrhythmias, can lead to a lack with no a waves. (d) Cardiac tamponade arising from pericardial
of atrial contraction and therefore loss of the a wave on a effusion causes the CVP waveform to become flattened and
CVP tracing. During atrial fibrillation, there is also a prom- there is a prominent x descent and small or absent y descent. (e)
inent c wave resulting from overfilling of the right atrium, A broad and tall c–v wave is characteristic of tricuspid
regurgitation. (f) Right ventricular (RV) pressure overload arising
since it is unable to generate normal contractions from pulmonary hypertension or pulmonic stenosis produces
(Figure 15.5c) [46]. The most accurate CVP estimate will be large, prominent a waves.
obtained by viewing the CVP tracing and ECG simultane-
ously and selecting the pressure that is present toward the
Ventricular premature contractions (seen as ventricular
end of the QRS complex, which best represents ventricular
premature complexes on an ECG), atrial fibrillation, atrial
end-diastole [34].
premature contractions (seen as atrial premature com-
plexes on an ECG), and second- or third-degree atrioven-
20 tricular node block can intermittently produce large
(“cannon”) a waves due to atrioventricular dissociation,
CVP
10 a v
where there is a transient increase in atrial pressure caused
0
Expiration Inspiration Expiration Inspiration by contraction of the atrium against a closed tricuspid
valve during ventricular systole (Figure 15.5b) [48]. When
Figure 15.4 Baseline fluctuation in central venous pressure
one of these arrhythmias is present, the CVP should be
(CVP) waveform seen during forced expiration. The CVP should
be estimated by calculating the mean of the a wave during early estimated from the normal a waves visible on the wave-
expiration (dashed line). The a wave and v wave are labeled. form tracing [47].
Conclusion 203
Pericardial Effusion with Cardiac Tamponade centralization of blood volume, renal sodium and water
retention, and peripheral vasoconstriction. Initially,
Increased pericardial fluid pressure inhibits diastolic filling
few clinical changes will be apparent when homeo-
of the heart. This results in an increase in the mean CVP
static mechanisms are sufficient to restore tissue perfu-
and flattening of the CVP waveform due to greater equali-
sion. However, as the volume deficit worsens, these
zation of the pressures within the atria and ventricles. A
changes typically manifest as the development of men-
prominent x descent is seen due to a rapid reduction in
tal obtundation, pale mucous membranes, delayed cap-
atrial pressure during ventricular systole, and the y descent
illary refill time, tachycardia, poor pulse strength, and
is small or absent (Figure 15.5d) [47].
cool extremities. When physical findings are equivocal,
blood lactate concentration can provide a quantitative
Tricuspid Regurgitation measure of the severity of impaired tissue perfusion
and anaerobic metabolism. As shock worsens, arterial
Tricuspid valvular disease results in obliteration of the x blood pressure will fall, and oliguria or anuria will
descent during ventricular systole by a large wave created develop. A high urine specific gravity will also be seen
by the backward flow of blood through the incompetent unless a concurrent disorder is present that is impair-
valve [47, 48]. This wave is composed of the merging of the ing renal concentrating ability. See Chapter 17 for more
c wave and v wave. Both may be clearly visible when there information about many of these other indices of
is mild insufficiency, but they combine to form a broad perfusion.
wave with a single peak when severe insufficiency is pre- Conversely, in the absence of hypoalbuminemia or
sent (Figure 15.5e) [48]. cardiac dysfunction, clinical signs suggestive of exces-
sive intravascular blood volume include peripheral
Pulmonic Stenosis and Pulmonary Hypertension edema, chemosis, pleural or peritoneal effusion, serous
nasal discharge, and in some cases, development of a
Conditions such as pulmonic stenosis and pulmonary new heart murmur or an increase in murmur intensity.
hypertension can result in large a waves as the right atrium Urine output is typically high and urine specific gravity
contracts against the elevated right ventricular pressure low. If pulmonary edema is present, pulmonary crackles
(Figure 15.5f) [48]. and respiratory difficulty may be evident. These find-
ings, particularly when combined with rising CVP meas-
urements, provide convincing evidence of volume
lternative Techniques for Assessing
A overload.
Vascular Volume
The gold standard of fluid therapy decision-making would Conclusion

be to assess appropriateness based on its effect on cardiac
output. Unfortunately, the technical challenges associated In summary, the measurement of CVP is a useful adjunc-
with cardiac output measurement preclude its frequent use tive hemodynamic monitoring tool in critically ill patients
in veterinary medicine (see Chapter 14 for more informa- and it is readily performed in any patient that has a central
tion regarding cardiac output assessment). Owing to its venous catheter. However, proper interpretation of CVP
simpler measurement technique and clinical utility, CVP requires an understanding of the strengths and limitations
measurement has become a commonly used hemodynamic of this diagnostic modality. Trends, rather than isolated val-
monitoring tool in veterinary critical care. However, it does ues, should be followed and the information provided
not reliably correlate with cardiac output. Therefore, CVP should be considered in terms of probabilities rather than
should always be interpreted in conjunction with other absolutes. A severely low or falling CVP suggests a high
clinical and biochemical markers of intravascular volume probability of hypovolemia. A severely elevated or rising
status as well as with the knowledge of the animal’s cardiac CVP supports hypervolemia. However, similar increases are
and kidney function. also seen with increased venous tone, reduced cardiac com-
In the critical patient, the importance of performing pliance, diminished cardiac function, or increased intratho-
serial, systematic physical examinations cannot be racic or intra-abdominal pressures. In conjunction with
overemphasized, as these examinations may allow the other clinical markers of cardiovascular function, CVP
clinician to detect early changes supportive of low cir- remains a useful guide in the assessment and treatment of
culating blood volume. Compensatory cardiovascular problems related to intravascular volume status and right-
and renal changes in response to hypovolemia result in sided heart function.
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207
16
Cardiac Output Monitoring

Mack Fudge
Hemodynamic monitoring is a cornerstone of critical therapy is insufficient to restore normal-range cardiovas-

patient care management. Evaluation of the cardiovascular cular values. In these cases, subsequent therapeutic inter-
status of critically ill patients can be broadly divided into ventions require additional information. A second level of
parameters that relate to venous return to the heart and cardiovascular information is gained by measuring param-
those that relate to forward flow from the heart. Parameters eters like CVP, caudal vena cava diameter, end-diastolic left
that evaluate venous return (preload) include ease of jugu- ventricular volume, ABP, and parameters of metabolic
lar vein distention, central venous pressure (CVP), caudal acid–base balance. (There are chapters in this textbook
vena cava diameter (radiography or ultrasonography), and describing these techniques.) Often this additional infor-
end-diastolic ventricular volume (ultrasonography). mation helps clarify the patient’s cardiovascular status and
Parameters that evaluate forward flow are generally: facilitates consequent therapeutic decisions. However,
(i) those related to cardiac output, such as heart rate, stroke there are a few residual patients that still cannot be clini-
volume, pulse quality, and cardiac output; (ii) arterial blood cally defined or do not respond to therapy. In these patients,
pressure (ABP); (iii) those affected by arteriolar vasomotor additional information is required. It is at this point that
tone, such as mucous membrane color and capillary refill forward flow information such as cardiac output and oxy-
time; and (iv) those linked to tissue perfusion, like append- gen delivery could be helpful.
age temperature, urine output, gastric CO2 tension, oxygen Cardiac output is typically thought of in the context of
extraction ratio, venous oxygen tension, and metabolic being the product of heart rate and stroke volume. Heart
acid–base balance including blood lactate concentration. rate is straightforward. In a clinical setting, it can be either
too high or too low. The therapeutic goal is simply to keep
it within a normal physiologic range. Stroke volume is the
Indications for Cardiac Output Measurement volume of blood expelled by the heart (right or left ventri-
cle) with each heartbeat. It is influenced by preload, after-
There are various levels of knowledge involved in the eval- load, and cardiac contractility. Preload is effectively the
uation of a patient’s cardiovascular status. Clinicians typi- venous return to the heart, or the end-diastolic ventricular
cally start with historical data and a physical examination filling volume. Afterload relates to arteriolar vasomotor
including mental status, hydration, ease of jugular vein tone or systemic vascular resistance against which the
distention, heart rate, pulse quality, mucous membrane heart works to affect forward blood flow. Contractility can
color, capillary refill time, and a distal appendage tempera- be conceptualized as the intrinsic ability of the individual
ture. Based on the findings of this examination, a strong patient’s heart to pump blood. Cardiac output is also influ-
case can frequently be made for hypovolemia, low cardiac enced by vasomotor tone where blood flow is directly pro-
output, or poor tissue perfusion; and a therapy plan can be portional to blood pressure and indirectly proportional to
formulated. If the patient responds to therapy, no addi- systemic vascular resistance.
tional cardiovascular information is necessary. In other Even though cardiac output can be measured many
cases, the information derived from the initial history and ways, common clinical techniques are somewhat limited
physical examination is insufficient to comfortably define a in veterinary patients. This is usually due to cost and
patient’s status, or the patient’s response to the initial complexity. In a recent unpublished survey of the 50
208 Cardiac Output Monitoring
American Veterinary Medical Association accredited

colleges of veterinary medicine around the world, an
overwhelming majority of schools reported that they do
not monitor cardiac output in clinical patients. Of the 46
Temperature
respondents, only two reported occasional clinical cardiac
output monitoring. Others reported cardiac output moni-
toring as a component of their research efforts, demon-
strating that although it may not be practical in the
clinical setting, the concept is important in critical
patient care.
Time
Cardiac Output Measurement Figure 16.1 Temperature–time curve of a thermodilution

cardiac output measurement. (Tracing can be displayed in either
an upward or a downward direction.)
Classically, clinically applicable techniques used to meas-
ure cardiac output involved use of large multiple-lumen
Cardiac output V1 Tb Ti computation constant
catheters connected to expensive, complex monitoring
integratedd area of the measured
devices. These somewhat invasive techniques were usually
temperature change over time T2
done in the intensive care unit or anesthesia setting.
Monitoring cardiac output commonly involved indicator (16.2)
dilution. In the past 30 years, there have been many
advances in human medicine that have led to less-invasive where V1 is the volume of the injectate, Tb is baseline blood
hemodynamic monitoring techniques [1]. temperature, and Ti is the injectate temperature. The com-
putation constant is calculated from the density and spe-
cific heat of the injectate compared with the density and
Indicator Dilution Techniques
specific heat of blood, and the change in temperature of
Indicator dilution techniques involve the injection of a the injected fluid as it traverses the catheter. The computa-
known volume (V1) of indicator with a known concentration constant is provided by the manufacturer of the equip-
tion (C1) into an unknown larger volume (V2), and then ment used. The computer calculates cardiac output in
measuring the concentration (C2) of the indicator in the milliliters or liters per minute. This value can be indexed to
larger volume of fluid. The unknown volume (V2) is then body size as kilograms of body weight or square meters of
calculated by the following formula: body surface area (Table 16.1).
Thermodilution has been demonstrated to be accurate
C1 V1 C2 V2 (16.1) and repeatable in in vitro models [3–6] and when com-
pared in vivo with dye dilution [7], electromagnetic flow-
In a moving fluid such as the cardiovascular system, C2 is metry [8], and transit-time flowmetry [9].
calculated as the average change in indicator concentration Transpulmonary thermodilution cardiac output meas-
over time. urements, with a thermistor placed in a peripheral artery,
were reported to accurately reflect traditional thermodilu-
Thermodilution tion cardiac output measured with a pulmonary arterial
With indicator dilution techniques, any indicator can be catheter [10–14]. This technique appears highly reproduc-
used if it can be measured with a rapidly responding sensor. ible for monitoring cardiac output in critically ill patients,
In thermodilution, the indicator is temperature. A small especially with children [15]. Using the transpulmonary
volume of fluid (V1) at a known temperature (T1) is injected thermodilution method, extravascular lung water (pulmo-
into the cranial vena cava or right atrium. This injected nary edema) can also be estimated.
fluid flows and mixes with the blood through at least two Cardiac output can be measured continuously with spe-
heart valves. The change in temperature as the blood–fluid cialized thermodilution catheters that incorporate a ther-
mix flows past a rapid-acting thermistor in the pulmonary mal filament near the proximal port of a catheter
artery or a peripheral artery is measured (Figure 16.1). The positioned in the cranial vena cava or right atrium. The
average change in temperature (T2) is integrated from the thermal filament cycles on and off. The change in tem-
change in temperature over time. The unknown volume of perature of the heated blood is sensed by the downstream
blood (V2, the cardiac output) is then calculated by the thermistor in the pulmonary artery. Values for cardiac out-
Stewart–Hamilton formula: put, ejection fraction, end-diastolic volume, end-systolic
Cardiac Output Measurement 209
Table 16.1 Body weight to body surface area and height conversion table.
Weight (kg) BSA (m2) Height (m) Weight (kg) BSA (m2) Height (m) Weight (kg) BSA (m2) Height (m)
0.5 0.06 0.30 11 0.5 0.85 31 1.00 1.21

1 0.1 0.38 12 0.53 0.88 32 1.02 1.22
1.5 0.13 0.44 13 0.56 0.90 33 1.04 1.23
2 0.16 0.48 14 0.59 0.92 34 1.06 1.24
2.5 0.19 0.52 15 0.61 0.94 35 1.08 1.25
3 0.21 0.55 16 0.64 0.97 36 1.10 1.27
3.5 0.23 0.58 17 0.67 0.99 37 1.12 1.28
4 0.25 0.60 18 0.69 1.00 38 1.14 1.29
4.5 0.28 0.64 19 0.72 1.02 39 1.16 1.30
5 0.30 0.66 20 0.74 1.04 40 1.18 1.31
5.5 0.31 0.67 21 0.77 1.06 41 1.20 1.32
6 0.33 0.70 22 0.79 1.07 42 1.22 1.33
6.5 0.35 0.72 23 0.82 1.09 43 1.24 1.34
7 0.37 0.73 24 0.84 1.11 44 1.26 1.35
7.5 0.39 0.75 25 0.86 1.12 45 1.28 1.36
8 0.40 0.76 26 0.89 1.14 46 1.30 1.38
8.5 0.42 0.78 27 0.91 1.15 47 1.32 1.39
9 0.44 0.80 28 0.93 1.16 48 1.33 1.39
9.5 0.45 0.81 29 0.95 1.18 49 1.35 1.40
10 0.47 0.83 30 0.98 1.20 50 1.37 1.41
BSA, body surface area. Source: Ricco 2020/with permission of John Wiley & Sons.
volume, and stroke volume are generated as an average increased monitoring should provide the means for
over the prior 5–10 minutes. This methodology was improved patient care, there is no overwhelming evidence
reported to compare well with intermittent thermodilu- for improved outcomes. The lack of statistically significant
tion cardiac output measurements [16–19], although low- survival benefit does not, however, prove that the
range cardiac outputs may be overestimated while thermodilution catheter is a useless monitoring tool.
high-range cardiac outputs may be underestimated [20]. Thermodilution catheters were used ubiquitously in
Thermodilution cardiac output measurements were human critical care and without regard for selecting
traditionally the standard of practice for clinical measure- patients who might truly be benefited. Of course, ultimate
ments of cardiac output in people. Balloon-tipped ther- survival depends upon the effectiveness of the manage-
modilution catheters are, however, invasive, expensive, ment of the underlying disease process, regardless of the
and variably difficult to place. Measurements are subject to tools used to monitor patients.
significant inter-measurement variation. Repeated meas-
ures to obtain an average are necessary and take time. Chemical Indicator Dilution
Many studies compare the cardiac output estimates of vari- Lithium and indocyanine green (ICG) indicators can also
ous methodologies with thermodilution. Variance and bias be used to measure cardiac output. The measurement is
are usually blamed on the compared methodology without made by injecting a known amount of indicator into a cen-
regard to the inherent variability of thermodilution. This tral vein and withdrawing blood at a constant rate from an
approach elevates thermodilution to “gold standard” status arterial catheter, past a lithium sensor or densitometer,
and perhaps unfairly biases against the tested methodol- respectively. Newer methods of ICG cardiac output use a
ogy [21, 22]. transcutaneous finger photosensor [30] or ICG fluores-
While thermodilution catheters permit the measure- cence [31] rather than an ex vivo cuvette densitometer.
ment or calculation of many important cardiovascular With the lithium indicator, cardiac output is calculated
parameters, their use has a variable record with regard to from the lithium dose and the area under the lithium
improved patient survival [23–29]. Although seemingly concentration-versus-time curve:
Cardiac output lithium dose mM 60 introducer catheter. Catheters can be placed via the jugu-
lar, saphenous, or femoral vein. Introducer wires, intro-
integrated area under the concentration
ducer catheters, and thermodilution catheters are long,
time curve mM / sec 1 PCV floppy, and easily contaminated. Sepsis is a major hazard
of these catheters. Once placed, they are “busy” cathe-
(16.3)
ters, frequently used throughout the day to make meas-
urements and collect blood samples for testing. Aseptic
In this equation, PCV stands for packed cell volume.
introduction must be assured. Large sterile drapes are
Lithium dilution was reported to compare well with ther-
used to extend the sterile field to facilitate safe catheter
modilution in dogs [32], cats [33], and foals [34]. One limi-
placement.
tation to lithium and dye dilution techniques is the number
First, an introducer catheter is placed and secured with
of measurements that can be performed before background
sutures. The balloon-tipped catheter is attached to a pres-
indicator concentrations start to interfere with subsequent
sure transducer and a physiologic monitor for pressure
measurements.
measurements to identify the location of the catheter dur-
ing introduction. As the catheter is advanced toward the
Balloon-Tipped Thermodilution Catheter right atrium, a CVP tracing should appear on the monitor.
Balloon-tipped catheters are available as two-lumen cath- When the catheter enters the right ventricle, the tracing
eters for measuring pulmonary artery pressure and pulmo- changes to a ventricular pressure waveform. Once in the
nary artery occlusion pressure; as four-lumen catheters for right ventricle, the catheter’s balloon is inflated and further
measuring CVP, pulmonary artery pressure, and cardiac advanced until it enters the pulmonary artery. The inflated
output (Figure 16.2); and as five- and six-lumen catheters balloon acts as a sail, aiding the direction of the catheter’s
for measuring CVP, pulmonary artery pressure, and car- forward movement along the route of blood flow from the
diac output, for placement of pacing electrodes, and for right ventricle into the pulmonary artery. Once in the pul-
continuous reflectance oximetry. Catheters are available in monary artery, with the balloon still inflated, the catheter is
lengths of 80 cm (for pediatrics) or 110 cm (for adults) and advanced until it occludes a branch of the pulmonary
in diameters of 4–8.5 Fr, depending upon the number of artery. Here, the pressure tracing will change to a typical
lumens and intended use. The 4-Fr catheter is the smallest occlusion pressure (Figure 16.3). Deflation of the balloon
diameter four-lumen catheter with thermodilution capa- allows the measurement of pulmonary artery pressure.
bilities and can be used in cats and small dogs (1–3 kg). The Reinflation of the balloon allows the measurement of pul-
5- and 6-Fr catheters are suitable for dogs of 3–10 kg; 7-Fr monary artery occlusion, or “wedge” pressure.
four-lumen catheter can be used in dogs over 10 kg. If during placement the catheter is introduced as far as
50 cm and has not entered the right ventricle, it has likely
either coiled in the right atrium or passed into the caudal
Insertion of the Balloon-Tipped
vena cava. The catheter should be withdrawn and rein-
Thermodilution Catheter and Complications
serted. There is little directional control over the tip of the
Introduction of a balloon-tipped thermodilution catheter catheter, so on subsequent reintroduction, the catheter
can be a technically and technologically intensive proce- should be rotated in one direction or another and advanced
dure. Catheter placement and its later repositioning after until it ultimately (“accidentally”) falls into the right ven-
placement are facilitated using an appropriately sized tricle. If the catheter end-hole butts up against a vessel or
Figure 16.2 Schematic of a four-lumen,

Cross-sectional a view of catheter
thermodilution, balloon-tipped catheter. CVP,
Yellow access port central venous pressure.
to distal hole 30 cm
110 cm
Blue access
port to Thermistor
proximal hole Distal hole for
measuring
Red access pulmonary
port for Proximal hole Balloon for artery
balloon for measuring occluding pressure and
CVP and pulmonary for collection
White access port injecting saline artery of mixed
for thermistor
venous blood
Cardiac Output Measurement 211
30 Thermodilution Cardiac Output Measurement

A pressure transducer and physiologic monitor are required
Right Ventricle Pulmonary Artery
to measure pressures. A compatible cardiac output com-
Pulmonary puter is used for measuring cardiac output. A compatible
15 Artery
oximeter is needed for venous blood oxygen saturation
Occlusion
measurements.
Right Atrium To make a cardiac output measurement, the thermistor
connection is attached to the cardiac output computer.
0 Some systems incorporate an injectate-measuring thermis-
tor at the injection port. The computer will calculate a com-
Figure 16.3 Schematic of representative pressure waveforms pensated value for the change in temperature of the
while introducing the balloon-tipped catheter into the injectate as it traverses the catheter, otherwise the tempera-
pulmonary artery. ture of the injectate (room temperature or iced) will need
to be measured and entered into the computer. Usually,
chamber wall, there will be a sudden cessation of pressure
room temperature fluid is used. Ice water temperature
waveform on the monitor. If all else fails, fluoroscopy can
fluid may be necessary for signal detection when smaller
be used to guide the introduction of the catheter.
volumes of fluid are used in larger patients. Usually, a
When the catheter is first introduced, there is usually a
small volume of an isotonic crystalloid fluid (3–5 or 10 ml;
big loop of catheter in the right ventricle. Over time the
smaller volumes for smaller patients) is used. After record-
catheter will migrate further into smaller branches of the
ing all the measured pressures, the operator must indicate
pulmonary artery. Full inflation of the balloon could rup-
to the computer that an injection is about to be made. The
ture these smaller pulmonary vessels. If less than full bal-
computer will indicate when it is ready for injection to
loon inflation occludes a vessel (indicated by the appearance
begin. The designated volume of fluid is injected into the
of a typical occlusion pressure waveform on the monitor),
cranial vena cava or right atrium. The operator should try
the balloon should be deflated, and catheter withdrawn a
to make the injection at the end of exhalation and as fast as
short distance until it requires the full 1-ml inflation to
possible. The computer will measure the change in tem-
occlude the vessel. The balloon should be inflated only for
perature as the fluid–blood mixture passes by the thermis-
the measurement of occlusion pressure and then deflated.
tor in the pulmonary artery and calculate the average
It should not remain inflated for an extended duration
change in temperature and cardiac output. Typically, outli-
because of the potential for vessel damage. Pulmonary ves-
ers are discarded; three to five consistent measurements
sel trauma and rupture has been reported in people due to
are taken and averaged to obtain a representative cardiac
leaving the balloon inflated or by fully inflating the balloon
output value.
after the catheter has migrated [35]. Once the catheter is
The balloon-tipped thermodilution catheter has a use-
ideally positioned, so that all measurements (central
ful role in the characterization and management of
venous, pulmonary artery, and occlusion pressure) can be
hemodynamic alterations in critically ill patients. The
obtained, it is secured to the patient and bandaged
use of these catheters has decreased in the past 30 years
aseptically.
because of recent advances in less invasive hemodynamic
Physical contact of these catheters against the endocar-
monitoring techniques, combined with the results of sev-
dium, especially during introduction, is occasionally asso-
eral randomized trials failing to show improvement in
ciated with arrhythmias. Simply stopping or withdrawing
outcomes with their use. Although it is obvious that
the catheter slightly should fix the problem. Persistent
balloon-tipped catheters should not be commonly used
arrhythmia problems may be treated with a common
in most critically ill patients, they are still potentially use-
antiarrhythmic.
ful in some patients with circulatory and/or respiratory
Catheter-associated clot emboli may occur. There is not
failure, especially when associated with pulmonary
much one can do to prevent it. It is not typical to adminis-
hypertension or left heart dysfunction. As with any tech-
ter anticoagulants to veterinary patients with these cathe-
nique, their use requires expertise in insertion, acquisi-
ters or any other type of catheter. Heparin-coated catheters
tion, and interpretation of measurements. The decrease
are available that may decrease this problem. Air emboli
in use of the balloon-tipped thermodilution catheters
may occur if air is inadvertently injected into the catheter
may unfortunately limit exposure of junior doctors and
or into the balloon port if the balloon has ruptured. Rarely
technicians to this device, so that they become less famil-
reported complications include pneumothorax, hemotho-
iar with their use, making it even more complicated and
rax, and knotting of the catheter (in the right ventricle)
less optimal [1].
during removal.
Lithium Cardiac Output Measurement Table 16.2 Standard formulas for calculated variables.
A central venous and an arterial catheter are placed. A lith-

Parameter Formula
ium sensor is attached to an arterial catheter and to a cardiac
output computer. Arterial blood is withdrawn past the sen- Body surface area (10.1 × kg0.67)/100
sor at a constant rate and into a collection container. Alveolar PO2 (room [(barometric pressure – 50) × 0.21] –
Hemoglobin and sodium concentration are pre-measured air) (PaCO2/RQ), where 50 is the
and entered into the computer. A sensor constant and the saturated water vapor pressure at
intended lithium dose are also entered into the computer. 38.5°C, 0.21 is the fractional
inspired oxygen, and RQ = 0.9
The calculated dose of lithium is placed into an extension set
Arterial, mixed venous, ([38,848/(202 × PO2 + 1.17 × PO22 +
attached to a jugular catheter. The pump for withdrawal of
and capillary PO23)] + 1) − 1 × 100a
arterial blood and the cardiac output computer are started. oxyhemoglobin
The dose of lithium is flushed into the cranial vena cava after saturation
5–10 seconds. The sensor measures the change in lithium Arterial, mixed venous, (1.34 × Hb × SO2) + (0.003 × PO2),
concentration over time and the computer calculates cardiac and pulmonary where 1.34 is 100% saturated
output. The measurement should be repeated at least once, capillary oxygen hemoglobin oxygen content, SO2 is
content hemoglobin saturation, PO2 is
outliers excluded, and remaining values averaged. partial pressure of oxygen in
arterial, mixed venous, or capillary
blood
Other Measurements and Calculations Cardiac index Cardiac output per square meter
BSA or kilogram of body weight
The measurements that can be obtained from the ther-
modilution catheter are CVP, pulmonary artery pressure, Stroke volume index CI/heart rate
pulmonary artery occlusion pressure, and cardiac output. Systemic vascular (ABP–CVP) × 79.92/CI m2 or
In addition, mixed-venous blood samples can be obtained resistance index (ABP-CVP)/CI kg
Pulmonary vascular (PAP–PAOP) × 79.92/CI m2 or
from the distal port of this catheter for pH and blood gas resistance index (PAP-PAOP)/CI kg
analysis. If a separate arterial catheter is placed, ABP and
Left and right cardiac CI × ABPm × 0.0144 CI ×
arterial blood samples for pH and blood gas analysis can be work index PAPm × 0.0144
obtained. In addition to cardiac output, measurements that
Left and right SVI × ABPm × 0.0144 SVI ×
can be obtained during lithium cardiac output measure- ventricular stroke work PAPm × 0.0144
ments include CVP and blood sampling, and arterial pres-
Oxygen delivery CaO2 × (CI m2 × 10) or (CI kg/100)
sure and blood sampling (for pH and blood gas analysis).
Oxygen consumption (CaO2 – CmvO2) × (CI m2 × 10) or
Once cardiac output is measured, heart rate is measured (CI kg/100)
separately, and stroke volume can be calculated. When arte-
Oxygen extraction VO2/DO2 or CaO2 – CmvO2/CaO2
rial pressure, pulmonary pressure and cardiac output are
Venous admixture (CcO2 – CaO2)/(CcO2 – CmvO2)
measured; systemic arterial and pulmonary vascular resist-
ance and left and right heart work indices can be calculated. Arterial and venous (2.226 × 0.0299 × PCO2 ×
blood carbon dioxide (1 + 10[pH −6.085])) ×
When hemoglobin concentration and partial pressure of content (1 − ((0.0289 × Hb)/
oxygen (PO2) are known, oxygen content can be calculated. ((3.352 − (0.456 × (SO2/100))) ×
When cardiac output and oxygen content are known, oxygen (8.142 – pH))))b
delivery can be calculated. When cardiac output and arterial Carbon dioxide (CaCO2 – CmvCO2) × CI × 10
and mixed-venous oxygen content are known, the oxygen production
consumption and extraction and the venous admixture can a
Reeves et al. (1982) [36].
be calculated. Table 16.2 contains standard calculations. b
Douglas et al. (1988) [37].
to the blood flow velocity that can be easily and accurately

Other Methods of Estimating Cardiac Output calculated. Flow is calculated from flow velocity and con-
duit diameter. Other methods of measuring cardiac output
Electromagnetic flowmetry is the gold standard for experi- have been recently reviewed [38, 39].
mental blood flow measurement. Flow probes are surgi-
cally placed around a suitably size-matched vessel of
The Fick Method
interest or flow catheters can be introduced into a large
vessel. The application of a magnetic field perpendicular to The Fick principle assumes that flow is proportional to the
the blood flow induces an electrical potential proportional rate of uptake of an indicator gas, and the difference
Carbon Dioxide-Based Fick 213
between the concentration of the indicator gas entering increasing to 7.0 ± 1.9 ml/dl in moderately hypovolemic
and exiting the organ being studied: dogs [42]. In this same report, oxygen extraction increased
from 21 ± 6% to 42 ± 10%. Oxygen extraction is calculated
Flow indicator gasuptake
(16.4) by the following formula:
gasconc.in gasconc.out
Oxygen extraction Cont Art O2 Cont Ven O2
Various marker gases have been used: oxygen, carbon (16.5)
Cont Art O2
dioxide, acetylene, and nitrous oxide. If any two parame-
ters in this equation are known, the third can be calculated. Central venous oxygen (PO2 or saturation, SO2) alone
When cardiac output is measured, for instance, arterial (without calculating oxygen content) can also be used in
and venous oxygen content can be calculated from PO2 and this same context. Normal central venous PO2 and SO2
hemoglobin measurements (Table 16.2). Oxygen consump- were reported to be 49 mmHg ± 6 and 78% ± 6, respec-
tion (VO2) can be calculated from the product of flow and tively, in normal dogs and decreased to 35 mmHg ± 5 and
arterial–venous O2 content. The venous blood sample used 56% ± 9 in moderate hypovolemia [42]. In another canine
for these calculations must come from a central vein: pul- acute hemorrhage model [43], partial pressure of oxygen in
monary artery or vena cava. Unfortunately, cephalic or mixed venous blood (PvO2) decreased from 46 to 34 mmHg.
saphenous venous blood oxygen measurements will not Venous PO2 was reported to be significantly correlated
suffice for this calculation. By the Fick equation, cardiac with cardiac output in cats; however, there was notable
output can be calculated from oxygen consumption divided variability [40]. In a cohort of critically ill people, dobu-
by arterial–venous O2 content. Oxygen consumption is cal- tamine augmentation of cardiac output, decreased oxygen
culated as the difference between inspired tidal volume extraction from 48% to 36% and increased mixed-venous
and oxygen concentration and expired tidal volume and oxygen saturation from 49 to 61% [44]. Other studies
oxygen concentration. It is usually measured in intubated reported weak correlations between venous oxygen satura-
patients. Fick cardiac output estimates compared well with tion and cardiac output in human patients in intensive
thermodilution cardiac output measurements in cats at care [45] and in a piglet hemorrhagic shock model [46].
low (r = 0.89) and normal (r = 0.69) cardiac outputs but
overestimated high (r = 0.75) cardiac outputs [40]. Fick
cardiac output estimates compared well with dye dilution Carbon Dioxide-Based Fick
cardiac output measurements in anesthetized dogs [41]
and pigs [16]. The Fick principle and formula can also be used with
carbon dioxide production:
rterial–Venous Oxygen Content,

A Flow carbon dioxide production
Oxygen Extraction, Venous Oxygen, CvCO2 CaCO2 (16.6)
Arterial–Venous Oxygen Saturation
A commercial, noninvasive method for measuring car-
Oxygen consumption is usually not measured in clinical diac output in intubated patients is available (NICO,
veterinary medicine, so the whole Fick equation (Eq. 16.4) NICO2, and NM3; Philips-Respironics, Murrysville, PA).
usually cannot be used. However, assuming oxygen con- The method involves the transient partial rebreathing of
sumption has not changed too much, the arterial–venous carbon dioxide (for 50 seconds every 3 minutes). Cardiac
oxygen content difference alone can be used to estimate the output is calculated from end-tidal CO2 concentrations
adequacy of tissue perfusion. In clinical situations, this during normal and CO2 rebreathing episodes. End-tidal
assumption may be flawed since oxygen consumption can CO2 (measured) and CO2 solubility are used to calculate
easily halve (hypothermia; general anesthesia) or double arterial CO2 concentration. Inspired oxygen and arterial
(increased muscular activity). Similarly, the adequacy of oxygenation are used to calculate a shunt fraction, which is
tissue perfusion is directly related to cardiac output only if used to correct for the shunted portion of cardiac out-
the animal is not vasoconstricted. When oxygen delivery put [47, 48]. This method of analysis compared favorably
decreases and oxygen uptake continues at its previous with normal-range thermodilution cardiac output meas-
level, a greater proportion of oxygen is removed from the urements (but overestimated cardiac output at low-range
blood (oxygen extraction). This will result in a decrease in cardiac outputs and underestimated high-range cardiac
venous oxygen and a greater difference between arterial outputs) [20]. The NICO2 system compared acceptably well
and venous oxygen content. Arterial–venous oxygen con- with ultrasound transit-time flowmetry and thermodilu-
tent was reported to be 3.6 ± 1.2 ml/dl in normal dogs, tion during and after cardiopulmonary bypass [9]. It also
compared acceptably with lithium cardiac output meas- recalibrated). There are several commercial devices that
urements across a spectrum of low to high cardiac outputs continuously measure and assess the pulse pressure
in anesthetized dogs and foals [48, 49]. The NICO family of waveform.
monitors are noninvasive, easy to use, and provide near- The PiCCO2™ (pulse index continuous cardiac output)
continuous measurements. system (Pulsion Medical Systems, Irving, TX) requires a
central venous and an arterial catheter, typically placed
peripherally. The PiCCO2 system uses transcardiopulmo-
enous–Arterial Partial Pressure of
V nary thermodilution to intermittently measure cardiac
Carbon Dioxide output. Saline is injected into a jugular catheter and the
change in temperature is measured by a thermistor in a
Carbon dioxide production is not measured in clinical vet- special arterial catheter. The system integrates a wide array
erinary practice, so the whole Fick equation (Eq. 16.6) can- of both static and dynamic hemodynamic data through a
not be used. However, if CO2 production has not changed combination of trans-cardiopulmonary thermodilution
too much, the venous–arterial partial pressure of carbon and pulse contour analysis. The PiCCO2 system also esti-
dioxide (PCO2) difference alone can be used to estimate the mates cardiac filling volume, intrathoracic blood volume,
adequacy of tissue perfusion. In common clinical situa- and extravascular lung water. The requirement for intra-
tions, the CO2 production can easily halve (hypothermia or arterial and central venous catheterization limits the use of
general anesthesia) or double (increased muscular activ- PiCCO2 to those patients with critical illness or at high risk
ity). When blood flow decreases, and CO2 production of severe hemodynamic derangement. While the accuracy
continues at its previous level, an increase in venous CO2 of transcardiopulmonary thermodilution as a measure of
results in a greater difference between venous and arte- cardiac output is well established, several other
rial PCO2. Venous–arterial PCO2 was reported to be PiCCO2 measurements require further validation within
4.2 mmHg ± 1.5 in normal dogs, increasing to the context of their intended clinical use. As with all
10.7 mmHg ± 3.9 in moderately hypovolemic dogs [42]. In advanced hemodynamic monitoring systems, efficacy in
a canine acute hemorrhage model, venous–arterial PCO2 improving patient-centered outcomes has yet to be conclu-
increased from 5.2 to 12.9 mmHg [43]. Venous–arterial sively demonstrated [51].
PCO2 was 4.9 mmHg in critically ill people with normal The PiCCO2 system compared well with thermodilution
cardiac output measurements and was 7.4 mmHg in cardiac output measurements in critical human
patients with low cardiac output [50]. Venous–arterial patients [11, 12, 14, 52–54], a piglet hemorrhagic shock
PCO2 decreased from 9 to 5 mmHg with dobutamine aug- model [46], and in healthy dogs both with thermodilution
mentation of cardiac output [44]. and lithium dilution techniques [55, 56]. Another study
showed poor trending ability when compared to pulmo-
nary artery thermodilution and suggested that it not be
Pulse Contour Methods
used in critically ill patients [57].
The area under the pulse pressure waveform bears some The LiDCO™ Plus system (LiDCO Ltd., Cambridge, UK)
correlation to stroke volume. The pulse pressure waveform uses a pulse power analysis algorithm (PulseCO™) that
can be qualitatively characterized by digital palpation of an mathematically calculates changes in stroke volume to pro-
arterial vessel. A tall, wide pulse is likely associated with a vide a real-time continuous assessment of hemodynamic
large stroke volume. A short, narrow pulse is likely associ- status. Independent lithium indicator dilution cardiac out-
ated with a small stroke volume. The pulse pressure can be put measurements are needed to calibrate the system.
measured by indirect sphygmomanometry or by direct There is good agreement with thermodilution cardiac out-
arterial measurement. put measurements, but with large variability. Accuracy
Pulse contour methodologies calculate stroke volume falls off with time and periodic recalibration by remeasur-
from measured pulse pressure waveforms using algorithms ing cardiac output may be necessary [14]. The PulseCO sys-
that consider arterial impedance, compliance, and resist- tem compared well with thermodilution and lithium
ance. At a given arterial compliance there is a directional cardiac output measurements; but it overestimated cardiac
relationship between the change in the area under the output at low-range cardiac outputs and underestimated
pulse pressure waveform and the change in stroke volume. high-range cardiac outputs [20, 39, 58, 59]. Early canine
Unfortunately, arterial compliance is not measured, so studies of pulse contour cardiac output estimates reported
cardiac output must be periodically and independently good correlation and accuracy compared with implanted
verified. Once this measured cardiac output is fed into the electromagnetic flowmeter measurements [60, 61] and
computer, it back-calculates correction factors that will be thermodilution cardiac output measurements [62]. Several
used in future pulse contour assessments (until it is again subsequent canine studies have reported a high variability
Venous–Arterial Partial Pressure of Carbon Dioxide 215
and poor correlation between pulse contour cardiac output through the thorax, and the voltage change with each
estimates and lithium calibration cardiac output [63–65]. heartbeat is measured. This change in voltage is considered
The MostCare™ device (Vytech Health, Padova, Italy) the result of a change in thoracic impedance. The current is
uses the pressure recording analytical method (PRAM), via introduced by a pair of electrodes placed on both sides of
perturbation theory, to estimate cardiac output just from the the neck and both sides of the lower thorax. The drop in
analysis of the pulse pressure wave profile. It requires only voltage is detected by another pair of electrodes placed
an arterial catheter. The PRAM algorithm characterizes the below the current introducing electrodes on the neck, and
elastic properties of the arterial system from the analysis of another pair above the current injecting electrodes on the
the pulse pressure profile. The PRAM system also provides a lower thorax [72]. Over a cardiac cycle, the only intratho-
parameter called cardiac cycle efficiency, which is an index racic fluid volume change is intrathoracic blood volume.
of heart–vascular response coupling (+1 = best; −1 = worst). The magnitude and rate of change reflects myocardial con-
Cardiac cycle efficiency is a ratio between myocardial work tractility. Baseline impedance may be affected by other
and energy consumed and represents an index of heart fluid accumulation diseases such as pleural effusion and
stress. PRAM compares well with thermodilution cardiac pulmonary edema. A meta-analysis of thoracic impedance
output in people [66], and with electromagnetic flowmetry technology concluded that the technique may only be suf-
and thermodilution cardiac output measurements in pigs ficiently accurate as a trend monitor [73]. There are several
across a wide range of cardiac outputs [67]. commercial devices that measure the thoracic impedance.
The Flo Trac™ sensor and Vigileo™ monitor system The BioZ™ impedance cardiography system
(Edwards Lifesciences, Irvine, CA) employ user-entered (Cardiodynamics, San Diego, CA, subsidiary of Sonosite,
anthropomorphic data (sex, age, weight, height, and sur- Bothel, WA) evaluates heart rate, blood pressure, cardiac
face area) to assign a value to compliance and vascular tone output, systemic vascular resistance, systolic time ratio (an
independent of external cardiac output measurements and index of myocardial contractility), and thoracic fluid con-
system recalibration. The sensor can be used with any arte- tent. Studies report moderate correlation with thermodilu-
rial catheter and no external calibration is required. For use tion cardiac output measurements [74, 75] and between
in veterinary medicine, either the algorithms would need thoracic fluid content and the amount of fluid removed by
to be changed or false information would have to be entered hemodialysis [76].
to enable correct surface area calculations. Although Flo Electrical cardiometry (Icon™ and Aesculon™; Cardio-
Trac compared well with thermodilution cardiac output tronic, Inc. La Jolla, CA) uses electrical velocimetry
measurements in people [39, 54], it was reported to be (changes in thoracic conductivity caused by the alignment
unsuitable for use in dogs as it overestimates cardiac out- of red blood cells) to calculate heart rate, stroke volume,
put with a high rate of error [68, 69]. cardiac output, systolic time ratio, and thoracic fluid index.
Pulse wave transit time (PWTT) is the time it takes for a Electrical velocimetry estimates of cardiac output com-
pulse to travel from the aorta to a peripheral artery. It is a pared favorably with transpulmonary thermodilution car-
non-invasive parameter that can detect changes in blood diac output measurements in piglets [13].
pressure. PWTT can be used to calculate an estimated stroke The RheoCardioMonitor™ (ACMA, Ltd., Singapore)
volume, which subsequently can be used to calculate an assesses cardiac output and compared well to thermodilu-
estimated cardiac output. PWTT is measured continuously tion cardiac output measurements in pigs [77] and
by monitoring the electrocardiogram (ECG) and a periph- people [78].
eral arterial pulse wave. It is the time from the peak of an The Niccomo™ instrument (Medis, Ilmenau, Germany)
ECG R-wave until the rise point on a distal pulse wave [70]. measures heart rate and blood pressure. It uses a physiologic
The peripheral pulse wave can be measured from either a adaptive signal analysis (PASA) algorithm to calculate stroke
distally placed SpO2 probe or directly from an arterial cath- volume, cardiac output, systemic vascular resistance, tho-
eter. This method showed a good trending ability to detect racic fluid content, left cardiac work index, several indices of
15% changes in stroke volume. However, it offered an unac- contractility, and systolic time intervals. The company also
ceptable agreement of estimated cardiac output measured produces computer-based impedance cardiography inter-
by traditional thermodilution in anesthetized dogs [71]. faces, using the same technology as the Niccomo, that can
run on any personal computer (Cardioscreen 1000 and
2000). The PASA algorithm-derived cardiac output corre-
Transthoracic Impedance and Bioreactance
lated well with thermodilution in people [79]. Other studies
The transthoracic impedance method uses two pairs of reported modest to poor correlation between impedance-
electrodes to measure changes in transthoracic electrical estimated cardiac output and transthoracic Doppler cardiog-
impedance during the cardiac cycle and then calculates an raphy [80], thermodilution [81], and lithium dilution cardiac
estimate of stroke volume. An electrical current is passed output (LiDCO) [82].
Whole-body impedance estimates of cardiac output cor- stroke volume. Cardiac output monitoring, assessment of
related well with thermodilution cardiac output measure- volume status, and evaluation of left ventricular function
ments in one study [83] but not in another [84]. are examples of transesophageal-derived informa-
Bioreactance (NICOM and Starling SV, Cheetah Medical, tion [90, 91]. A major assumption of this technique is that
Newton Center, MA) uses time delay, or phase shifts, that a constant proportion of the cardiac output flows through
occur when an alternating electrical current is passed the descending aorta with the remainder going through
through the thorax to evaluate the flow of blood in the tho- the brachiocephalic and coronary arteries. Unfortunately,
rax. Proprietary algorithms interpret the signal to provide this is variable. Hypovolemia decreases and vasodilation
stoke volume. Findings in various studies using the NICOM increases the proportion of the cardiac output entering
have been equivocal and have varied including feasible, the descending aorta. Transesophageal probes are large,
satisfactorily approximating, and acceptably accu- and anesthesia is required to introduce them. They can-
rate [85–87]. At least one study found that the NICOM not be fixed in place for continuous measurements.
device cannot accurately estimate cardiac output in criti- Although some reports in people suggest good correlation
cally ill patients and could not predict patients’ response to with thermodilution cardiac output [53, 92–95], other
saline volume expansion [88]. reports suggest a variable correlation [96]. Although less
reliable during hypotension, some studies suggest that it
can serve as a minimally invasive alternative to monitor-
Doppler Ultrasound
ing cardiac output in dogs during anesthesia [95, 97],
Standard echocardiography, operated by experienced indi- while others report that it is not accurate in measuring
viduals, can be used to measure aortic or pulmonary valve cardiac output in dogs [98, 99]. It has shown an accepta-
diameter and the velocity–time integral, from which stroke ble trending ability and could be a valuable tool in guid-
volume can be calculated. Accurate assessment of the ing therapy, including in cats [100–102].
diameter of the outflow tract can be challenging.
Measurements are intermittent and not always a readily
Other Methods
viable option for critical care settings. Echocardiographic
estimated cardiac output did not correlate well with ther- Velocity encoded phase contrast magnetic resonance imag-
modilution cardiac output measurements in cats [40]. In a ing is an accurate technique for measuring flow in large
hemorrhage model in dogs, the pulmonic valve, compared vessels [103]. Nuclear scintigraphy can also be used to eval-
with the aortic valve, and proximal and distal aorta, was uate cardiac output [104]. The equipment is very expen-
the site that generated the most repeatable Doppler sive, requires considerable training to operate, and the
measurements [43]. None of the echocardiographic cardiac measurements are intermittent. Thus, these techniques do
output determinations compared very well with not lend themselves to use in the intensive care setting.
thermodilution.
The USCOM (Ultrasound Cardiac Output Monitor)
device (Uscom Ltd., Sydney, Australia) uses continuous- Interpreting Measurements
wave Doppler and human anthropomorphic aortic and
pulmonary valve data to calculate stroke volume. The There is a large amount of cardiopulmonary function
extrapolation of animal to human data would prove a sub- information that can be derived when cardiac output is
stantial challenge in using this technology. The USCOM measured (Figure 16.4 and Table 16.3). This allows for
was reported to provide reliable measurements of cardiac broader characterization of patient status and may improve
output over a wide range of values in a study of six anesthe- survival opportunities in some patients. Since forward flow
tized dogs [89]. There are no reports of its clinical use in depends on venous return, it is appropriate to first evaluate
dogs or cats. preload parameters. CVP represents preload pressure to
Doppler probes can be placed into the esophagus and the right heart (0–10 mmHg), and pulmonary artery occlu-
positioned to face the descending thoracic aorta sion pressure represents preload pressure to the left heart
(Hemosonic™ 100, Arrow International, Reading, PA; (2–12 mmHg). Low pressures suggest that there is room for
Dynemo™ 3000, Sometec, Paris; CardioQ-ODM™ additional blood volume augmentation if other parameters
Doppler Monitor, Deltex Medical Ltd., Chichester, UK). corroborate hypovolemia. High pressures may represent
The phase shift in the reflected ultrasound waves as they hypervolemia or heart failure and suggest that additional
are carried downstream by the flowing blood is used to volume loading may be unwarranted. Preload pressure has
calculate blood flow velocity. Flow velocity and time are a variable relationship to preload volume, depending upon
used to calculate stroke distance. The product of stroke ventricular compliance. High preload pressure does not
distance and aortic cross-sectional area (measured or necessarily define high preload volume, but it always
anthropomorphically determined) is used to calculate necessitates a conservative fluid plan.
Interpreting Measurements 217
Preload First, evaluate ABP. Low mean ABP (< 60 mmHg) could
Visceral Perfusion be caused by hypovolemia (check preload parameters),
Contractility poor cardiac output (measure cardiac output and check for
Systemic Cerebral
& cardiac disease), or vasodilation (calculate systemic vascu-
Afterload Vascular
Resistance Arterial Coronary lar resistance and check clinical vasomotor tone signs).
Blood Perfusion High mean systemic arterial pressure (> 140 mmHg) is
Stroke Volume
Cardiac Pressure usually attributable to high vasomotor tone (iatrogenic
Output hypervolemia is possible; high cardiac output and arterio-
Heart Rate
Oxygen sclerosis are unlikely).
Delivery
Second, evaluate cardiac output. Low cardiac output
Hemoglobin
Oxygen Oxygen could be caused by the following: hypovolemia (check the
Content Consumption preload parameters); cardiac disease (atrioventricular
Oxygen
insufficiency, aortic stenosis, fibrosis, pericardial tampon-
Venous ade); poor contractility (if not measured, then presumed if
Oxygen
preload parameters are high and forward flow parameters
Figure 16.4 Integrated cardiopulmonary function: preload are low, in the absence of anatomic cardiac disease). Low
determines diastolic filling of the heart; contractility is the cardiac output should be treated if it is associated with
strength of load-independent contraction of the ventricles; hypotension or evidence of poor tissue perfusion.
afterload is the pressure against which the heart must contract
Third, evaluate systemic vascular resistance. Low vas-
to generate a stroke volume; stroke volume and heart rate
determine cardiac output; hemoglobin concentration and the cular resistance (vasodilation) may be associated with
amount of oxygen loaded onto it determine oxygen content; hypotension, in which case it should be treated by admin-
cardiac output and systemic vascular resistance determine istering a vasoconstrictor. Low vascular resistance associ-
arterial blood pressure; arterial blood pressure is primarily
ated with acceptable blood pressure does not need to be
important as a determinant of cerebral and coronary perfusion;
systemic vascular resistance is primarily important as a treated. High vascular resistance (vasoconstriction) may
determinant of visceral tissue perfusion; cardiac output and be associated with poor tissue perfusion. If associated
oxygen content determine oxygen delivery; oxygen delivery with high blood pressure, the situation may benefit from
minus oxygen consumption determine venous oxygen.
Table 16.3 Cardiopulmonary values in normal dogs.
Parameter Units Baseline n = 97 (mean ± SD) 95% Confidence interval
Body weight kg 20.5 ± 6.9

2
Body surface area m 0.74 ± 0.17
Temperature °C 38.4 ± 0.6 38.3–38.5
pHa iu 7.381 ± 0.025 7.376–7.387
PaCO2 mmHg 40.2 ± 3.4 39.5–41.0
HCO3a mEq/l 23.1 ± 2.0 22.7–23.5
BDa mEq/l −2.1 ± 2.3 −1.7 to −2.6
pHmv Units 7.362 ± 0.027 7.356–7.367
PmvCO2 mmHg 44.1 ± 3.8 43.3–44.9
HCO3mv mEq/l 24.2 ± 2.1 23.7–24.6
BDmv mEq/l −1.9 ± 2.3 −1.4 to −2.3
a–mv pH iu 0.020 ± 0.012 0.018–0.022
a–mv PCO2 mmHg −3.9 ± 1.6 −3.6 to −4.2
a–mv HCO3 mEq/l −1.1 ± 0.7 −0.9 to −1.2
a–mv BD mEq/l 0.2 ± 0.7 0.1–0.4
PaO2 mmHg 99.5 ± 6.8 98.1–100.8
SaO2 % 96.3 ± 0.9 96.1–96.5
Hb g/dl 13.6 ± 1.8 13.3–14.0
CaO2 ml/dl 17.8 ± 2.3 17.4–18.3
(Continued)
Parameter Units Baseline n = 97 (mean ± SD) 95% Confidence interval
PmvO2 mmHg 49.3 ± 5.8 48.2–50.5

SmvO2 % 77.1 ± 5.5 75.6–78.2
CmvO2 ml/dl 14.2 ± 2.2 13.8–14.7
Ca–vO2 ml/dl 3.6 ± 1.0 3.4–3.8
PAO2 mmHg 105.8 ± 3.7 105.1–106.9
A–aPO2 mmHg 5.5 ± 6.9 3.6–7.4
ScO2 % 96.9 ± 0.5 96.8–97.0
CcO2 ml/dl 18.0 ± 2.3 17.5–18.5
Venous admixture % 3.6 ± 4.1 2.8–4.4
CaCO2 ml/dl 45.8 ± 4.3 44.9–46.6
CmvCO2 ml/dl 48.5 ± 4.4 47.6–49.4
Ca–vCO2 ml/dl 2.7 ± 1.4 2.5–3.0
CVP cm H2O 3.1 ± 4.1 2.3–4.0
PAOP mmHg 5.5 ± 2.9 4.8–6.2
Heart rate bpm 87 ± 22 83.0–91.8
ABPm mmHg 103 ± 15 99.9–106.0
PAPm mmHg 14.0 ± 3.2 13.4–14.7
CO ml/minute 3360 ± 1356 3086–3633
CI l/minute/m2 4.42 ± 1.24 4.17–4.67
ml/minute/kg 165 ± 43 156–174
2
SVI ml/beat/m 51.9 ± 13.5 49.2–54.7
ml/beat/kg 1.93 ± 0.46 1.84–2.02
−5 2
SVRI dyne·second·cm /m 1931 ± 572 1815–2045
mmHg/ml/minute/kg 0.641 ± 0.173 0.606–0.676
5 2
PVRI dyne·second/cm /m 196 ± 78 179–210
mmHg/ml/minute/kg 0.065 ± 0.026 0.060–0.070
2
LCWI kg·minute/m 6.6 ± 2.3 6.2–7.1
mm Hg/ml/minute/kg 17 045 ± 5393 15 957–18 132
2
LVSWI g·minute/m 76.7 ± 24.5 71.7–81.6
mm Hg/ml/minute/kg 199 ± 54 188–210
LVRPP Beats/minute mmHg 9057 ± 2937 8465–9649
RCWI kg·min/m2 0.91 ± 0.41 0.83–0.99
mm Hg/ml/minute/kg 2353 ± 981 2156–2551
RVSWI g·minute/m2 10.4 ± 3.9 9.6–11.2
mm Hg/ml/min/kg 27.1 ± 9.1 25.2–28.9
RVRPP Beats/minute mmHg 1247 ± 510 1144–1350
DO2 ml/minute/m2 790 ± 259 737–842
ml/minute/kg 29.5 ± 8.8 27.7–31.3
2
VO2 ml/minute/m 164 ± 71 148–181
ml/min/kg 6.0 ± 2.6 5.5–6.5
O2 extraction % 20.5 ± 5.7 19.4–21.7
VCO2 ml/minute/m2 128 ± 46 114–136
a, arterial; A, alveolar; ABPm, mean arterial blood pressure; a–v, arterial–mixed venous; A–a, alveolar–arterial; BD, base deficit; c, capillary; bpm, beats/
minute; C, content; CI, cardiac index; CO, cardiac output; CO2, carbon dioxide; CVP, central venous pressure; DO2, oxygen delivery; Hb, hemoglobin;
HCO3, bicarbonate; LCWI, left cardiac work index; LVRPP, left ventricular rate pressure product; LVSWI, left ventricular stroke work index; m, mean;
mv, mixed venous; O2, oxygen; PAPm, mean pulmonary arterial blood pressure; PAOP, pulmonary artery occlusion pressure; PCO2, partial pressure of
carbon dioxide; PO2, partial pressure of oxygen; PVRI, pulmonary vascular resistance index; RCWI, right cardiac work index; RVRPP, right ventricular
rate pressure product; RVSWI, right ventricular stroke work index; SO2, hemoglobin saturation with oxygen; SVI, stroke volume index; SVRI, systemic
vascular resistance index; VO2, oxygen consumption; VCO2, carbon dioxide production. Source: Haskins et al. (2005)/American Association for
Laboratory Animal Science [105].
References 219
judicious vasodilator therapy. However, if associated with artery catheter use have declined greatly, there has been an
marginal blood pressure, the condition should not be spe- increase in the number of alternatives for monitoring car-
cifically treated because it is probably compensation for diac output as well as greater understanding of the meth-
hypovolemia or marginal cardiac output. In this instance, ods and criteria with which to compare devices [51].
vasodilator administration will likely cause hypotension. Widespread use of these alternatives has not been seen in
Fourth, evaluate oxygen content, delivery, consumption, veterinary medicine. This is likely due to cost, technical
and extraction. Low oxygen content is most likely caused complexity, requirement for large or specialized equip-
by anemia. Low oxygen delivery may be caused by low oxy- ment, or no easy extrapolation of the technology into ani-
gen content and/or low cardiac output. Low oxygen con- mal patients. Perhaps more commonly in veterinary
sumption may be caused by low oxygen delivery or medicine is the measurement of routinely monitored
impaired metabolism. High oxygen extraction usually indi- parameters influencing cardiac output such as CVP, caudal
cates low oxygen delivery. Low oxygen extraction may be vena cava diameter, end-diastolic left ventricular volume,
caused by impaired cellular metabolism or peripheral arte- subjective ultrasonographic assessments of cardiac con-
rial–venous shunting. Venous oxygen is low when oxygen tractility, ABP, and parameters of metabolic acid–base bal-
extraction is high, and vice versa. ance. Though it is unclear whether use of advanced cardiac
output monitoring improves outcome, certainly outcome
can only be improved if the technique is performed prop-
erly, the results are interpreted correctly, and appropriate
Conclusion therapy is instituted in a timely manner.
Advanced hemodynamic monitoring remains a keystone
in the management of critical illness. Determination of
cardiac output and systemic oxygen delivery can be helpful Acknowledgments
in patients with perfusion status that is poorly defined by
other methods or in patients that do not respond well to The current author and editors would like to acknowledge
therapy. In past years, the more common clinical tech- Steve Haskins’ authorship of this chapter in the first edi-
niques involved indicator dilution, usually either ther- tion of Advanced Monitoring and Procedures for Small
modilution with the balloon-tipped pulmonary arterial Animal Emergency and Critical Care, upon which this
catheter or lithium dilution. While rates of pulmonary chapter is based.
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225
17
Point-of-Care Cardiac Ultrasound

Valerie Madden and Søren Boysen
Cardiac veterinary point-of-care ultrasound (VPOCUS), specialist/cardiologist, whereas cardiac VPOCUS refers to
also referred to as focused cardiac ultrasound or FOCUS, or a narrowly focused ultrasonographic examination often
a two-minute screening echocardiogram, is an extension of performed by a nonspecialist clinician [1, 2, 4]. With car-
and often used in conjunction with thoracic (Chapter 27) diac VPOCUS, interpretation is often subjective and
and abdominal (Chapter 39) VPOCUS scanning. As with involves one or a few preselected targets to interpret, typi-
other VPOCUS examinations, cardiac VPOCUS is used to cally classified as present or absent by using a predefined
obtain clinically relevant patient data that cannot be deter- specific imaging protocol (e.g. right parasternal short-axis
mined on clinical examination alone. It is not a replace- left atrial-to-aortic root ratio). The practitioner focuses
ment for a consultative echocardiogram, which is often on making a specific diagnosis or answering a certain,
performed by cardiologists, because it is not intended to often binary, question or series of questions [2]. Cardiac
provide highly detailed cardiac measurements [1, 2]. VPOCUS generally requires less training and expertise
Rather, cardiac VPOCUS is applied by the attending clini- than performing limited echocardiography, and much
cian at the bedside in light of clinical and historical find- less training than consultative echocardiography [1, 2].
ings to help discern a preliminary diagnosis (e.g. cardiac vs. The results of cardiac VPOCUS are used in conjunction
noncardiac cause of dyspnea) and/or to direct further diag- with other point-of-care and clinical findings, such as the
nostic and therapeutic interventions [1, 2]. As such, it physical examination, to formulate a diagnostic impres-
tends to be a time-sensitive examination most often per- sion and guide appropriate early patient management.
formed in symptomatic or at-risk patients [3]. It is indi- Evidence suggests that cardiac VPOCUS can be performed
cated in cats and dogs presenting with respiratory distress, by non-specialist clinicians to help direct further patient
pleural effusion, significant arrhythmias, hemodynamic care [4–6].
instability, suspected pericardial effusion, and to assist Clinical studies in cardiac VPOCUS have involved pri-
with the diagnosis of heart failure. marily the interpretation of key aspects of a patient’s car-
The specific clinical question to be investigated and the diovascular status, including but not limited to:
cardiac abnormalities that can be ruled in or out with
● Volume status
cardiac VPOCUS are few. In human medicine, it is
● Cardiac function
often limited to the following abnormalities: left-
● Pericardial effusion.
ventricular enlargement, left-ventricular hypertrophy,
left-ventricular systolic function, left-atrial enlargement,
right-ventricular enlargement, right-ventricular systolic Equipment, Patient Preparation, and
function, pericardial effusion, and inferior vena cava Image Acquisition for Cardiac
size [1, 2]. Although clinical studies are lacking, most of Veterinary Point-of-Care Ultrasound
these variables have also been evaluated with cardiac
VPOCUS in companion animals. Cardiac VPOCUS ● Although a phased array transducer is advantageous
should be distinguished from “limited echocardiography,” in obtaining echocardiographic images, the authors
in that limited echocardiography refers to a reduced num- perform all cardiac VPOCUS using only a micro-convex
ber of images that are often still interpreted by a curvilinear transducer.
226 Point-of-Care Cardiac Ultrasound
● Conventional echocardiographic modalities applicable between the heart and the chest wall (i.e. the cardiac
in the emergency setting include two-dimensional (2D) notch), which is in the region of the fourth to sixth inter-
and M-mode, although subjective assessment of 2D costal spaces, near the sternum.
images is used to answer the vast majority of cardiac Patients that are dyspneic are often scanned in sternal
VPOCUS questions. recumbency or while standing and receiving oxygen sup-
● Doppler and color mode are rarely used to interpret cardiac plementation and anxiolytics. Although it is more difficult
VPOCUS questions and are not covered in this chapter. to obtain good quality images in dyspneic patients, most
cardiac VPOCUS specific questions can still be answered
The majority of views interpreted are obtained from the in these cases. Extending the right forelimb cranially often
right side of the patient with either the patient positioned makes identification of the heart easier (Figure 17.1).
in sternal/standing or right lateral recumbency, the latter Good quality images can usually be obtained without
often on a table with the transducer applied from under- clipping fur; this is achieved by applying isopropyl alcohol
neath the patient along the right thoracic wall (Figure 17.1). to the skin after parting the fur and applying a generous
Although the size of the cardiac window varies with amount of ultrasonographic coupling gel to the ultrasound
respiratory effort and patient positioning, all images of the transducer head. This creates an air-free zone between the
heart are obtained where lung tissue is not interposed skin and the transducer.
(a) (b)
(c)
Figure 17.1 (a) Patient positioning and “cutout” tabletop. The patient is restrained in right lateral recumbency with the thoracic limbs
extended cranially. (b) An “L-shaped” table can also be used to obtain the right parasternal views or can be created by placing two
tables together at 90-degree angles and positioning the patient such that the heart is positioned over the gap in the tables with the
thoracic limbs extended cranially. (c) In less stable patients, and most commonly used, the heart can be scanned with the patient in a
sternal or standing position, with the right forelimb extended forward. In all cases, pulling the thoracic limb forward facilitates image
acquisition of the heart.
Cardiac Veterinary Point-of-Care Ultrasound Windows and Views 227
Two-Dimensional Echocardiography include (i) the four-chamber view (Figure 17.2), and
(ii) the left ventricular outflow tract view (five-chamber
Two-dimensional echocardiography is used for nearly all
view (Figure 17.3), while the short-axis views, from apex
cardiac VPOCUS specific questions. A 2D echocardio-
to base (Figure 17.4), include (i) the apex; (ii) left ventri-
graphic image is generated from the data obtained by fan-
cle and papillary muscles (mushroom view); (iii) left ven-
ning the ultrasound beam across the tomographic
tricle at the level of the chordae tendinae; (iv) mitral valve
plane [7–10]. For each patient and echocardiographic view,
(fish mouth view); (v) left atrium-to-aortic root ratio
optimal image quality depends on transducer selection and
(peace sign and the whale) with the right ventricular
instrument settings [8, 9].
outflow tract and the pulmonic valve; and finally, (vi) the
In addition to patient positioning and good contact, two
pulmonary artery branches, the right auricle and caudal
settings commonly altered to obtain optimal images include
vena cava (CVC; not shown in Figure 17.4). Although all
gain and depth [10, 11]. The depth should be adjusted to
eight right parasternal views are useful in evaluating
allow the entire heart, particularly the far wall, to be visual-
cardiac structure and function, there are three short-
ized in the near around two-thirds of the ultrasound image.
axis views that are most often used during cardiac
Set the focal point at the level of the far field wall of the
VPOCUS: [4, 5]
heart. Gain is adjusted to allow the cardiac free wall and
lumen to be easily differentiated from one another. Cardiac
presets use higher contrast, which makes cardiac chamber
assessment easier. Becoming familiar with the freeze func-
tion and scrolling the cine loop through frames is helpful in
optimizing the cardiac image during cardiac VPOCUS.
M-Mode Echocardiography
M-mode is the modality in which ultrasound beams are
aimed manually at targeted cardiac structures to give a
graphic recording of their positions and movements [7, 8].
M-mode recordings allow quantitative measurement of
cardiac dimensions and analysis of motion patterns
depending on transducer positioning [12]. These analyses
are not traditionally part of cardiac VPOCUS and often
require more training to master. Figure 17.2 Two-dimensional long axis view, right parasternal
window. Four-chamber view of the heart showing the left
ventricle (LV), left atrium (LA), right atrium (RA) and right
ventricle (RV).
Cardiac Veterinary Point-of-Care
Ultrasound Windows and Views
Cardiac VPOCUS incorporates right parasternal short- and

long-axis views, the subxiphoid view, and occasionally left-
sided views (Protocols 17.1–17.3). Acquiring all views is often
unnecessary. For example, even if only the left atrial-to-aortic
ratio can be obtained evidence suggests that cardiac VPOCUS
can still have diagnostic value [4, 13, 14]. Furthermore,
although left-sided views provide nice windows to assess
spontaneous echogenic contrast and/or intracardiac thrombi
in cats, they are not required to answer most cardiac VPOCUS
questions and are not covered in this chapter.
Two-Dimensional Right Parasternal Views Figure 17.3 Two-dimensional long axis view, right parasternal
window; five-chamber left-ventricular outflow tract view of the
There are eight standard 2D echocardiographic views
heart showing the left ventricle (LV), aorta (Ao), aortic valve
obtained from the right parasternal window: two long- (white arrow), left atrium (LA), right atrium (RA) and right
axis and six short-axis views [15]. The two long-axis views ventricle (RV).
La:Ao
le
w ha
the
nd
igna Fish mouth
c es
Pea
m outh
Fish
Mushroom
dow for
Good win
ss essment
volume a
Good papillary = mushroom
Don’t confus
e for hypovo
lemia
Left apex
Left ape
x
Figure 17.4 Schematic image of the different right parasternal short-axis views starting at the apex level and moving toward the
heart base through the papillary muscle level, mitral valve, and finally the left atrium-to-aortic root. The corresponding cardiac still
images are labeled; “left apex”, “mushroom view” at the level of the papillary muscles where chordae tendinea are just becoming visible
(small lighter dots at the tips of the papillary muscles represent the chordae tendinae), “fish mouth view” at the level of the mitral
valves, and LA : Ao represents the “Peace sign and the whale” at the heart base level. The heart base image above the left atrial-to-
aortic root is not shown in this figure. LA, left atrium; RA, right atrium; RV, right ventricle; PA, pulmonary artery; LV, left ventricle.
1) The “Mushroom view” (Figure 17.5): Often the first

view obtained and a common site to estimate volume
status and contractility at the left midventricular/papil-
lary muscle region just below the mitral valve.
2) The “Fish mouth view” (Figure 17.6): Serves as a land-
mark to obtain other views and allows assessment of
the mitral valve.
3) The “Peace sign and whale view” (Figure 17.7): Allows
assessment of the left atrium-to-aortic root ratio
(La : Ao), which is helpful in estimating volume status
and deciding if heart failure is present.
Being able to confidently identify the fish mouth view
provides the reference point above and below which the
Figure 17.5 Two-dimensional short-axis view, right parasternal
two key views used to answer most cardiac VPOCUS ques-
window; mushroom view. The initial view obtained is often the
tions can be found: the peace sign and whale view, and the midventricular region of the right parasternal short-axis window
mushroom view, respectively. at the level of the papillary muscles (white arrows), referred to
as the “mushroom” view. LV, left ventricle; IVS, intraventricular
septum; RV, right ventricle.
Subxiphoid View
Because of the liver, the subxiphoid view provides a nice Interpretation of Cardiac Veterinary
acoustic window into the caudal thorax, which is often Point-of-Care Ultrasound Findings
used to determine if pericardial and/or pleural effusion are
present. The CVC can also be evaluated to assess patient All cardiac VPOCUS findings should be interpreted in light
volume status at the subxiphoid site. of clinical examination and other VPOCUS findings.
InteretntntiI iof terttac tntetItery itInt-iot- tet UnetaioIr tIrtIna 229

Figure 17.6 Two-dimensional short-axis view, right parasternal window; Peace sign and the whale view to evaluate the left
window; fish mouth view. After obtaining the “mushroom” view atrium-aortic root ratio (La : Ao). Obtained by fanning the
with the transducer in the right parasternal short-axis plane, ultrasound beam toward the base of the heart from the
slowly fan the transducer dorsally directing the ultrasound mushroom/fish mouth view while in the right parasternal
beams toward the base of the heart until the mitral valve (MV) short-axis plane. Image contains a short-axis view of the left
becomes apparent within the left ventricular lumen (LV). This is atrium (La, whale) and aortic root (Ao, peace sign).
the “fish mouth view”. RV, right ventricle.
Protocol 17.1 Cardiac Point A-of-Care Ultrasound to Obtain the Right Parasternal Short-Axis Views
1) Place the transducer on the area of the right thorax Note: Transducer marker orientation varies by operator
where the strongest apical heartbeat can be palpated preference. The right parasternal short-axis images
or where the point of the flexed elbow meets the tho- presented in this chapter are obtained with the trans-
rax. This will be between the fourth to six6th intercos- ducer marker directed toward the elbow and the cor-
tal spaces, at the level of the costochondral junction or responding marker on the ultrasound image to the left
slightly closer to the sternum (Figure 17.8). of the ultrasound screen.
2) Orientate the transducer at a 30–45 degree angle to 3) The initial view obtained is often at the level of the
horizontal, with the marker directed cranially and ventricular apex or the midventricular region, which
toward the elbow (Figure 17.9). This will align the yields an image referred to as the “mushroom” view
ultrasound beam parallel and in short-axis to the left (Figure 17.5). Adjusting the depth and gain, as well as
ventricle. using standard transducer manipulations such as
sweeping, sliding, and rocking (Figure 17.10) are used
to obtain the best acoustic window of the heart. If
Figure 17.8 The transducer is placed on the right thorax

where the strongest apical heartbeat can be palpated; between Figure 17.9 Orientate the transducer at a 30–45 degree angle
the fourth to sixth intercostal spaces, at the level of the (red dotted arrow) to horizontal (green solid line), with the
costochondral junction or slightly closer to the sternum. marker directed cranially and toward the elbow.
image quality remains poor try applying more pressure fanning depending on the size of the patient), the
to the transducer, particularly in obese patients, or operator can examine the successive two-dimensional
clipping the fur. Details of specific transducer move- planes with their related cardiac structures (Figure 17.4).
ments can be found in Chapter 6. 7) Final image acquisition of the La : Ao is often obtained
4) The transducer may need to be rotated slightly in either by making small “fanning” transducer movements from
a clockwise or counterclockwise direction until circular the mushroom view (left ventricle and papillary mus-
symmetry of the left-sided ventricle is achieved. cles) or fish mouth view (mitral valve) to the peace
5) Once the optimal acoustic cardiac window is obtained sign and whale view (La : Ao).
keep the transducer relatively static on the thoracic ● In cats and smaller dogs, the transducer is kept at
wall and use smaller subtle transducer manipulations the initial mushroom view and fanned (tilted) from
(e.g. rotation and fanning, Figure 17.10) to complete this fixed external thoracic location toward the head
the cardiac VPOCUS exam. It is often easier if only a of the patient to image the left atrial-to-aortic root
single transducer manipulation is used at one time ratio (avoid sweeping movements because the car-
(e.g. avoid sweeping and fanning simultaneously). diac notch is small and the transducer will rapidly
6) By moving the plane of the ultrasound beam from the transition from the heart to lung). This often requires
apex to the base of the heart (slow sweeping and/or the transducer to be “angled” from the cardiac notch
below the lung toward the spine, particularly in ster-
nal or standing patients (Figure 17.11).
● In larger dogs, the transducer can often be swept
dorsally in small increments between the ribs until

the fish mouth view is obtained. From the fish mouth
view the transducer is then fanned dorsally from a
fixed external thoracic location until the left atrium-
to-aortic root ratio is visualized.
● In some cases, the transducer will need to be
advanced cranially one or two intercostal spaces
ROCK
SWEEP
ROTATE SLIDE
Figure 17.11 Figure of the transducer on the right thorax

angled (fanned) toward the heart base to obtain the La : Ao ratio.
Owing to the small size of the cardiac notch in standing patients,
the ventral lung border (lung in pink, lung border in red) is
superimposed over the heart base (heart not shown). To be able
FAN to find the La : Ao it is often necessary to fan the head of the
transducer dorsally from a fixed external chest point (solid green
Figure 17.10 Summary of the five different probe line) below the ventral lung border until the left atrium and
manipulations commonly used during point-of-care ultrasound; aorta are visible (dotted green line). The initial starting point to
sweep, slide, rotate, fan, rock. See Chapter 6 for details. fan is often the mushroom view in cats and small dogs.
● The left atrial diameter is divided by the aortic root size

to obtain a numerical value representing the La : Ao.
● Alternatively, a subjective “eyeball” assessment of
how many “aortas” fit inside the left atrium can also
be made (Figure 17.14).
In summary, the key transducer movements to locate the

ideal cardiac VPOCUS windows involve broader move-
ments to identify the heart followed by finer rotation and
fanning movements once the fish mouth view identified;
rotating the transducer transitions between long and
short-axis views, and fanning (tilting) the transducer pro-
vides multiple cross-sections of the structure while main-
Figure 17.12 In some patients it is necessary to advance the taining a particular axis orientation.
transducer cranially a rib space or two (depicted by yellow
dotted arrows). Given that the heart is “tilted cranially,” moving
a rib cranially often “shifts” the image obtained toward the
heart base. For example, if the transducer is over the mushroom
view of a large dog, green dotted line, and then advanced
horizontally a rib space without performing any other probe
manipulations, the image obtained at the more cranial rib
space will often be closer to the heart base (blue dotted line).
from the starting position (maintaining the same

transducer angle and orientation), and then fanned
in order to obtain the La : Ao (Figure 17.12).
8) When the correct La : Ao window is obtained, the
aorta should be round to three-leaf clover shaped,
and during diastole the three cusps of the closed aor-
tic valve should form the Y shaped “peace sign.” The window, left atrial-to-aortic root ratio measurement. The image
left atrium should be “tear drop” or “whale” shaped is frozen to obtain a still image from which measurements (blue
(Figure 17.7). dotted lines) can be obtained. A caliper is used to obtain a
diameter based measurement from one side of the left atrium
● Note that the aortic cusps may be less visible when
across to the other. If a pulmonary vein enters the left atrium at
a microconvex vs a phased array transducer is used. the desired measurement point, the measurement is made at an
● If the aorta is not “closed” and part of the outflow extrapolation of the atrial border or immediately medial or
track is visible to the left of the aorta, the transducer lateral to the vein. Ao, aorta; LA, left atrium; PV, pulmonary vein.
is likely under rotated (slowly rotate the transducer
clockwise) to “close” the aorta, and if part of the out-
flow track is visible to the right of the aorta, the
transducer is likely over rotated (slowly rotate the
transducer counterclockwise).
9) Once an acceptable image is obtained the size of the
left atrium should be evaluated (see interpretation of
views for diagnosis of pathology).
● Although precise caliper measurements can be
made, the left atrial size and La : Ao ratio are often
subjectively assessed.
● If desired, the image can be frozen, and calipers used
to determine the size of the left atrium and aorta

individually (Figure 17.13).
● If a pulmonary vein enters the left atrium at the Figure 17.14 Two-dimensional short-axis view, right
parasternal window, subjective left atrial-to-aortic root ratio
desired measurement point, the measurement is
measurement. A subjective estimate of the number of areas of
made at an extrapolation of the atrial border or the aorta (yellow dotted line) that can fit into the left atrium
immediately medial or lateral to the vein. has been validated in cats. Ao, aorta; LA, left atrium.
Protocol 17.2 Cardiac Point-of-Care Ultrasound from the Right Parasternal Long-Axis View
1) From the right parasternal short-axis mushroom or small and the walls remain thick pathology should be
fish mouth view, rotate the transducer 90 degrees suspected (see interpretation below). The chamber
clockwise to lie almost parallel to the ribs at or just size and wall thickness should be compared with the
below the costochondral junction. short-axis views for consistency.
2) If the ventricular lumen size appears short and narrow 3) To advance from the four-chamber to the five-chamber
with very thick ventricular walls, the ultrasound beam view, use a slow steady movement to rotate the trans-
might be traversing the ventricles obliquely. This may ducer 10–15 degrees clockwise until the left ventricu-
be corrected by slowly fanning the ultrasound beam lar outflow tract is visible. Gentle fanning of the probe
caudally and then cranially until the ventricular lumen cranially may be necessary in some cases.
diameter is maximized. If the lumen diameter remains See also Ware (2007) [9]; Boon (2002) [10].
Protocol 17.3 Cardiac Point-of-Care Ultrasound to Obtain the Subxiphoid View

1) To obtain this view, the transducer is positioned at a 3) It is often easier to start in long-axis orientation
45-degree angle just caudal to the xiphoid process in (Figure 17.15a).
either a long or short-axis plane. 4) The caudal thoracic cavity, including the pleural and
2) In the long-axis plane the marker is directed cranially pericardial spaces are assessed. The liver should be
while in short-axis it is directed toward the patient’s right. visible in the near field and the apex and
Liver
Normal
RE
(a)
LIVER LIVER
GB GB
PE
LV LV
RV RV
(b) (c)
Figure 17.15 (a) Schematic image of transducer location to image the pericardial space and heart from the subxiphoid location. The
dog is in right lateral recumbency in this figure, and the probe is placed just caudal to the xiphoid process. The depth is increased,
and the transducer is rocked more parallel to the spine to be able to image the apex of the heart, where it is more likely to come in
contact with the diaphragm. The heart may lie just left or right of midline (just left in this figure) which also necessitates fanning the
transducer in long axis to identify it. (b) Schematic ultrasound image of the heart in contact with the diaphragm in a healthy dog. (c)
Schematic ultrasound image of a dog with pericardial effusion obtained at the subxiphoid location. This window can also be used to
assess the heart for cardiac contractility in some animals during external cardiac compressions during cardiopulmonary resuscitation.
GB, gall bladder; PE, pericardial effusion; RV, right ventricle; LV, left ventricle. Source: Images courtesy of J McMurray DVM.
left-ventricular free wall of the heart will be visible in ● With the transducer in long-axis, and at roughly a
the far field contacting and appearing to “blend” into 45-degree angle, slowly fan the probe to the right
the diaphragm and liver (Figure 17.15b). and left of midline while watching for a “break” in
5) If the heart is not initially visible the transducer should the diaphragm.
be fanned left and right of midline and rocked cranially ● In most dogs and cats, the CVC can usually be identi-
in the long-axis plane until the heart becomes visible. fied just to the right of the heart, often in the same
This often results in the transducer head being “tucked” plane the gall bladder is visible.
under the xiphoid process and orientated almost paral- ● Once the CVC is located the transducer should be
lel to the spine (Figure 17.15a). slowly fanned off either side of the CVC to locate its
6) In the majority of normal canine patients, the pericar- widest diameter.
dium contacts the diaphragm, and the heart can be ● Keep the ultrasound beam at the widest diameter of
visualized; this is not necessarily the case in cats the CVC through several respiratory cycles to deter-
where air-filled lung may occupy the space between mine the CVC index: calculated by measuring the
the diaphragm and the heart, hampering cardiac widest and narrowest diameters of the CVC during
assessment from the subxiphoid site. expiration and inspiration respectively (see Caudal
● With pericardial effusion and cardiomegaly, a Vena Cava section).
greater percentage of the heart tends to contact the 8) Avoid applying too much pressure to the transducer
diaphragm, making it visible in both cats and dogs. or pressure artifact may result in a “falsely” col-
7) The CVC can also be identified and assessed at the lapsed CVC.
subxiphoid site in the longitudinal plane where it
crosses the diaphragm (Figure 17.16) [15, 16].
Expiratory Inspiratory
LIVER LIVER
GB GB
LV LV
RV RV
McMurray 2015
(b) Hypovolemic
LIVER
LIVER
GB GB
LV LV
RV RV
McMurray 2015
(c) Euvolemic
(a) LIVER LIVER
GB GB
LV LV
RV RV
McMurray 2015
(d) Increased right atrial pressure
Figure 17.16 (a) Image of the subxiphoid site and transducer angle used to locate the caudal vena cava where it crosses
diaphragm. (b)–(d) Schematic images depicting the caudal vena cava collapsibility index in a spontaneously breathing
hypovolemic, euvolemic, and a patient with increased right atrial pressures. A subjective assessment is made by comparing the
widest diameter of the caudal vena cava (CVC) during expiration to the narrowest diameter of the CVC during inspiration. GB, gall
bladder. Source: Images courtesy of J McMurray DVM.
Interpretation of the Left Atrium–Aortic Root Ratio

The La : Ao is primarily used to evaluate the size of the left
atrium relative to the aorta. Although objective left atrial
measurements can be made, in the emergency and critical
care setting, evidence suggests that a subjective assessment
of left atrial size is sufficient for most cardiac VPOCUS
applications [4, 13].
The La : Ao ratio reference range varies slightly depend-
ing on reference used, where measurements are made, and
the angle at which it is measured, which may vary between
patients in lateral vs. standing, and by the operator skill
level. In general, a normal La : Ao should be between 1 and
1.5 in cats and dogs (slightly higher in cats) [5, 9, 10]. There
is a gray zone regarding the cut off La : Ao to determine left
atrial enlargement, up to 1.7 in cats. Fortunately, assess- Figure 17.17 Two-dimensional short-axis view, right
parasternal window; mushroom view. A patient with significant
ment of left atrial enlargement during cardiac VPOCUS
left-atrial enlargement reflective of advanced cardiac disease
tends to be well outside the gray zone and reference limits, and congestive heart failure. Ao, aorta; LA, left atrium.
meaning most patients presenting with respiratory distress
secondary to congestive heart failure have La : Ao ratios ≥ 2.
Interpretation of an Increased La : Ao

If the left atrium is enlarged, it suggests increased left atrial
volume and/or pressure which is often associated with left-
sided congestive heart failure or iatrogenic fluid overload.
Patients presenting with respiratory distress, an enlarged
left atrium, and B lines on lung ultrasound (Chapter 27)
should elicit concern for congestive heart failure or iatro-
genic volume overload. Patients who present to the emer-
gency department in respiratory distress are unlikely to be
experiencing iatrogenic volume overload (in the absence of
recent fluid administration), as opposed to patients in
intensive care who have received high fluid volumes or sev-
eral days of fluid therapy. Figure 17.18 Same image as Figure 17.17 with estimation of
Novice sonographers should begin with La : Ao ratios the number of aorta areas (red circles) that can be fit within the
≥ 2 : 1 in cats and dogs. Such a ratio is likely to be present left atrium.
in patients presenting in respiratory distress secondary to
congestive heart failure. Therefore, the finding of an overload. The absence of B lines on lung ultrasound in
La : Ao ratio ≥ 2 : 1 should elicit consideration for left atrial patients presenting with respiratory distress makes left-
enlargement and severe cardiac pathology or volume over- sided congestive heart failure unlikely [13]. When using the
load, which are easily assessed subjectively and is valid left atrial size to assess volume status, it should be inter-
regardless of patient position Figure 17.17. Alternatively, in preted in light of other clinical examination findings and
cats, if more than three aortas can be subjectively fit within complimented with CVC assessment (see Interpretation of
the left atrium, the left atrium should be considered Ventricular Contractility below).
enlarged (Figure 17.18) [4]. Using both subjective methods
is a good way to double check if the left atrium is truly Interpretation of a Decreased La : Ao
enlarged. (This subjective means of assessing atrial enlarge- A decrease the left-atrial size should be suspected when the
ment in dogs has not yet been investigated.) La : Ao is less than 1.0. A small La : Ao suggests hypovolemia
History, assessment of cardiac function (see Interpretation due to a phenomenon referred to as pseudohypertrophy.
of Ventricular Contractility below), and left-ventricular Pseudohypertrophy results from hypovolemia and decre-
lumen size and wall thickness (see Interpretation of the ased ventricular filling, which causes decreased left atrial
Left Ventricular Mushroom View, below) can often distin- and ventricular chamber size, and the appearance of a
guish between left-sided heart failure and iatrogenic fluid thickened intraventricular septum and ventricular free
wall [17, 18]. This resolves with restoration of effective cir- obliteration at the end of systole. With HCM, the left
culating volume. A loss of the visible ventricular chamber atrium is often enlarged while it tends to be unchanged or
during systole, known as ventricular chamber obliteration, small with pseudohypertrophy.
may reflect severe hypovolemia due to markedly decreased
ventricular filling pressures and represents severe hypov- Interpretation of Ventricular Contractility
olemia and potential impending cardiovascular collapse. Left-ventricular systolic function can be assessed through
To help differentiate pseudohypertrophy from hyper- fractional shortening. Fractional shortening (FS) is the per-
trophic cardiomyopathy (HCM), left atrial size should be centage change of the short-axis of the ventricular cham-
evaluated: left atrial size is normal to small in patients with ber during systole [7, 11]. It is reported to be 30–50% in
pseudohypertrophy and is often enlarged in patients with dogs and 40–60% in cats. It can be subjectively assessed by
cardiomyopathy. estimating the change in size of the ventricular lumen dur-
ing diastole and systole, or objectively assessed using the
Interpretation of the Left Ventricular Mushroom View following formula obtained using M-mode (in mm):
The “mushroom” view should be evaluated for left ventric-
FS LVEDD LVESD / LVEDD 100
ular chamber size, contractility (2D and M-mode), and wall
thickness. Less commonly, right-ventricular size and ven-
tricular septal flattening are assessed. where LVEDD is the left ventricular end diastolic diameter
and LVESD is the left ventricular end systolic diameter.
Interpretation of Increased Left-Ventricular Lumen Size With practice and by scanning healthy animals, a subjec-
Specific measurements of the left ventricular chamber size tive evaluation of ventricular contraction is usually suffi-
are not commonly performed during cardiac VPOCUS. The cient to determine whether cardiovascular abnormalities
subjective assessment of an enlarged left-ventricular lumen in are present. This skill does require becoming familiar
the emergency and critical care setting may suggest volume with normal values, which can be achieved by evaluating
overload or conditions causing myocardial dysfunction (e.g. healthy animals. M-mode requires more skill to obtain
dilated cardiomyopathy). With volume overload ventricular accurate repeatable measurements and is less frequently
contractility is generally increased giving the heart a hyperki- used by novice sonographers.
netic appearance on ultrasound (see Interpretation of Conditions that increase FS include:
Ventricular Contractility below).In contrast, myocardial dys- ● Hypervolemic patients without myocardial dysfunction.
function secondary to dilated cardiomyopathy is associated ● Patients with a history of aggressive fluid therapy and
with decreased contractility giving the heart a hypokinetic combined cardiac VPOCUS findings of a hyperkinetic
appearance on ultrasound (see Interpretation of Ventricular heart (increased FS), an enlarged left atrium, distended
Contractility below). Both volume overload and dilated car- CVC, with or without increased B lines on lung ultra-
diomyopathy can cause an enlarged left atrium and increased sound should prompt consideration of fluid overload.
B lines on lung ultrasound; assessing the contractility of the (Note that hypervolemic patients with normal FS (as
left ventricle is important to differentiate the two conditions. opposed to increased) and increased ventricular systolic
dimensions likely have some degree of myocardial
Interpretation of Decreased Left-Ventricular Lumen Size failure.)
The subjective finding of a decreased ventricular lumen ● Patients that have decreased afterload (e.g. arterial vaso-
size with thickened ventricular walls may suggest pseudo- dilation) without myocardial dysfunction.
hypertrophy secondary to volume depletion or true myo-
Conditions that that decrease FS include:
cardial hypertrophy. The two can be differentiated by
assessing the left atrial size (see Interpretation of the Left ● Hypovolemia in the absence of myocardial dysfunction
Atrium–Aortic Root Ratio, above). (due to decreased myocardial stretch).
● Conditions associated with poor myocardial contractility
Interpretation of Increased Left-Ventricular Wall Thickness (e.g. dilated cardiomyopathy or sepsis).
In the absence of systemic diseases (e.g. hyperthyroidism, ● Increased afterload (e.g. severe arterial vasoconstriction).
systemic hypertension, subaortic stenosis, and acromeg-
aly), increased left-ventricular wall thickness is often asso- Interpretation of Interventricular Septal Flattening
ciated with HCM in cats, but may also be seen with Flattening of the interventricular septum combined with
pseudohypertrophy in both dogs and cats. With both HCM an enlarged right ventricular chamber, and/or increased
and pseudohypertrophy, there will be wall thickening, right ventricular wall thickness suggests increased right
enlarged papillary muscles, and/or left ventricular cavity ventricular pressures or volume. These findings arguably
take more skill to assess and interpret. However, if this

triad of right heart findings is present, causes of pulmonary
arterial hypertension should be considered (e.g. heartworm
disease, chronic bronchopulmonary disease – e.g. dynamic
airway disease/obstruction, chronic bronchitis, or pulmo-
nary fibrosis – and pulmonary thromboembolism).
Interpretation of Right Parasternal Long-Axis Views

From the four-chamber right parasternal acoustic window,
the sonographer can subjectively evaluate the size of all
cardiac chambers; left atrium, left ventricle, right atrium,
and right ventricle. The right atrium and the left atrium
should be of similar size (1 : 1 ratio). The intra-atrial
septum should be relatively neutral and should not bulge
into either atria. The right ventricular chamber is approxi- Figure 17.19 Two-dimensional short-axis view, right parasternal
mately one-third of the left ventricular internal diameter. window; pericardial effusion. LA, left atrium; LV, left ventricle; RA,
The free wall of the right ventricle is equal to one-third or right atrium; RV, right ventricle; PE, pericardial effusion.
one-half the thickness of the left ventricular free wall. The
interventricular septum and the left ventricular free wall
are normally similar in thickness.
Interpretation of changes in chamber size, wall thickness
and contractility in the right parasternal long-axis views is
similar to interpretation of changes in the right parasternal
short-axis views.
Interpretation of Pericardial Effusion

Pericardial effusion appears sonographically as an ane-
choic space adjacent to cardiac structures. Sensitivity and
specificity for detection of a pericardial effusion is high
regardless of patient position. To avoid missing loculated
pericardial effusion, multiple acoustic windows should be
assessed.
Figure 17.20 Two-dimensional short-axis view, right

Right Parasternal Views
parasternal window; pericardial effusion. Obtaining a cardiac
The right parasternal approach demonstrates the extent of view in the short-axis and fanning the transducer to move from
pericardial fluid accumulation in both long- and short-axis apex to base helps differentiate heart chambers from pericardial
views (Figures 17.19 and 17.20). Pericardial effusion effusion. Pericardial effusion will appear as a circular
accumulation of fluid adjacent to the cardiac chambers, with the
appears as a circular accumulation of fluid adjacent to and pericardial sac often being visualized as a hyperechoic line on
surrounding the cardiac chambers, with the pericardial sac the side of the anechoic effusion opposite of the cardiac
often being visualized as a hyperechoic (white) line on the structures. LV, left ventricle; RV, right ventricle; PE, pericardial
side of the anechoic effusion opposite the cardiac struc- effusion.
tures. Be sure to extend the depth to visualize the entire
heart. In the short-axis view, fan from the cardiac apex to (see Chapter 27). The PD window is identified by locating
the base through all planes to ensure all cardiac anatomy is the abdominal curtain sign caudally (transition from the
correctly identified and pericardial effusion is not confused lung to the soft-tissue abdominal structures at the costo-
for cardiac chambers. phrenic recess) and then following it ventrally until the
If it is unclear whether anechoic fluid accumulation is heart and abdominal structures are visible within the same
pericardial or pleural in origin, assess the pericardiodia- sonographic window, or sliding caudally off the heart until
phragmatic (PD) windows; parasternal transthoracic the diaphragm and soft-tissue structures of the abdomen
windows found on both the right and left side of the thorax are identified (Chapter 27). This site often allows
S ki n su rf a c e S ki n s u rf a c e
Rib Rib Rib
Rib
Pleural line Pleural line
MT
Pleural RV
Effusion
Rib
Rib
adow
Liver
shad
adow
shad
Liver
sh
RV
ow
ow
ion
Rib
sh
Diaphragm
Rib
Effu s
LV
ia l
a rd
ric
LV
Pe
Figure 17.21 Schematic images of the pericardiodiaphragmatic window; from a dog with pleural effusion (left) and from a dog with
pericardial effusion (right). In dogs with pericardial effusion the mediastinal triangle (MT), which is normally found in healthy dogs, is often
still visible but tends to be lost in dogs with significant pleural effusion. RV, right ventricle; LV, left ventricle; MT, mediastinal triangle.
pericardial and pleural effusion to be differentiated

(Figure 17.21). Pericardial fluid is contained and tracks
around the heart (away from the diaphragm). Pleural effu-
sion is uncontained and tracks along the diaphragm filling
the costophrenic recess, which allows the diaphragm to be
visualized curving away from the chest wall in the near
field of the ultrasound image.
The Subxiphoid Window

Pericardial effusion may be detected between the dia-
phragm and cardiac apex via the subxiphoid view
(Figure 17.22). If the left-ventricular free wall and apex are
directly adjacent to and appear to blend into the diaphragm
and liver, significant pericardial effusion is ruled out
(Figure 17.15b). If pericardial effusion is present, it will be Figure 17.22 Still ultrasound image of pericardial effusion
seen form the subxiphoid view of a dog. LVFW, left-ventricular
visible between and separating the left ventricular wall free wall; PE, pericardial effusion; AE, abdominal effusion; LV,
from the diaphragm, arching around cardiac apex away left ventricle.
from the liver and diaphragm (Figure 17.15a and 17.22).
This is different from pleural effusion, which can also be However, it should be kept in mind that tamponade is a
identified at the subxiphoid view; pleural effusion tends to clinical diagnosis and the findings of shock in a patient
track along the diaphragm (Chapter 27). with identifiable pericardial effusion should prompt a
diagnosis of tamponade.
Interpreting Tamponade
Tamponade occurs when the pressure in the pericardium
Caudal Vena Cava Assessment at
exceeds the pressure in the cardiac chambers, particularly
the Subxiphoid Window
the right atrium, resulting in impaired cardiac filling. It
may be easiest to diagnose using the right parasternal Although somewhat controversial in human medicine, the
four-chamber long-axis view and appears as a compres- diameter of the inferior vena cava and collapsibility index
sion of the right atrial free wall into the atrium, intermit- have become well-established as a means of assessing vol-
tently reducing atrial chamber size (right-atrial wall ume status in people [19]. In dogs and cats, the CVC diam-
compressed inwards during systole; Figure 17.23). eter (CVCd) and collapsibility index (CVCCI) have been
described at several VPOCUS windows, including the sub-

xiphoid site (Figure 17.24a) [16, 20].
Although small animal research is limited, a small
clinical study (n = 27) in spontaneously breathing dogs
with compromised hemodynamics or tissue hypoperfusion
suggested that CVCCI can accurately predict fluid respon-
siveness, although the authors also concluded that research
is necessary to extrapolate their results to larger popula-
tions of hospitalized dogs [21].
Caudal Vena Cava Collapsibility Index

Breathing changes intrapleural pressures, generating
heart–lung interactions, thereby influencing the intravas-
Figure 17.23 Still ultrasound image from a dog with cular volume within the thorax and abdomen [22]. Owing
tamponade; the right atrial wall (white arrow) is visible
collapsing into the right atrium. LV, left ventricle; LA, left atrium; to the elastic nature of the CVC, changes in the intravascu-
RV, right ventricle; PE, pericardial effusion. lar volume with the respiratory cycle result in a dynamic
(a)
(b) (c)
Figure 17.24 (a)–(c) Still ultrasound images depicting (a) a euvolemic patient with a normal caudal vena cava (CVC). (b) A patient
with increased right atrial pressures and a “fat” CVC with almost no collapsibility index (in this case due to pericardial effusion [not
visible]). Also note there is gall bladder (GB) wall edema (halo sign) in this example, which is very common in patients with pericardial
effusion. (c) A hypovolemic patient with a “flat” CVC and subjectively narrow collapsibility index. Although a large CVC collapsibility
index is suggestive of hypovolemia if the CVC is close to collapsed and very “flat” the change from flat to fully collapsed can be
difficult to see creating the impression of small CVC collapsibility index.
References 239
change in the CVC diameter in proximity to the dia- Cardiac Veterinary Point-of-Care Ultrasound
phragm [22]. This change in size of the CVC between inspi- for Assessment of Mechanical Cardiac Activity
ration and expiration is referred to as CVC collapsibility, During Cardiac Arrest
and can be expressed as the collapsibility index (CVCCI)
Cardiac VPOCUS may be helpful during cardiopulmo-
using the following formula:
nary resuscitation (CPR) to determine whether mechani-
CVCCI = (CVCd max – CVCd min)/CVCd max [22]. cal cardiac activity is present. However, it should not
interfere with CPR efforts. In the authors’ experience,
Although considerable variation exists for cats and dogs, the subxiphoid window can often be assessed in dogs and
the reference interval for the CVCCI at the subxiphoid site is cats during active chest compressions, without interfer-
roughly 20–45% [16, 20]. An enlarged or “fat” CVC with less ing with efforts, and does allow rapid assessment of
than a 20% change in the CVCCI suggests increased right atrial mechanical activity when exchanging chest compressors.
pressures, which may be secondary to hypervolemia, conges- Pulseless electrical activity is characterized by cardiac
tive heart disease or cardiac tamponade (Figure 17.24b). electrical activity without a palpable pulse. However,
Assessment of other cardiac VPOCUS findings should weak cardiac contractions may not generate peripheral
differentiate causes of an enlarged CVC (see above). In pulses. Echocardiography may help differentiate pseu-
contrast a thin “flat” CVC with no change in the CVCCI, or dopulseless electrical activity (cardiac contractions that
a change in the CVCCI of more than 50% suggests hypov- do not generate a pulse) from pulseless electrical activity.
olemia (Figure 17.24c). Video 17.1 depicts a period of cardiac VPOCUS during
In people, increased respiratory effort is reported to external chest compressions with spontaneous cardiac
cause a greater change in the CVCCI, which is also likely activity visible during a pause in compressions. Video 17.2
present in small animals. It is possible to confuse normov- demonstrates cardiac VPOCUS being used to show
olemic dyspneic patients as being hypovolemic. pulseless electrical activity in a cat with cardiopulmo-
Increased intra-abdominal pressure (e.g. abdominal nary arrest.
masses or effusions) can decrease the size of the CVC. Avoid
confusing patients with increased abdominal pressure and Video 17.1 A period of cardiac VPOCUS during external
normal right-atrial pressure and intravascular volume chest compressions with spontaneous cardiac
status as being hypovolemic. Patients with conditions activity visible during a pause in compressions.
resulting in increased right atrial pressure and abdominal Video 17.2 Cardiac VPOCUS being used to show pulse-
effusion are still likely to have a distended CVC (e.g. patients less electrical activity in a cat with cardiopul-
with right-sided heart failure and/or pericardial effusion). monary arrest.
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241
18
Pericardiocentesis
Simon P. Hagley
Pericardiocentesis is a lifesaving yet daunting proce- Pericardial Space Disease

dure, primarily required to improve cardiovascular sta-
bility in patients with an accumulation of fluid or air in Congenital malformation of the pericardium is uncom-
the pericardial space. This chapter reviews the origins of mon and infrequently results in complication. Partial
such conditions and provides a step-by-step approach to defects or agenesis may be an incidental finding on post-
enable the reader to perform this procedure safely and mortem examination [1, 3]. Peritoneal–pericardial dia-
successfully. phragmatic hernia (PPDH) is one congenital defect that
may result in complication if abdominal organs become
entrapped in the pericardial cavity, causing varying clinical
The Pericardium signs, and requiring surgical intervention. The prevalence
appears to be higher in cats than in dogs [4].
The pericardium is composed of an outer fibrous layer Pneumopericardium has been reported in several dogs
made up of collagen and elastin, and an inner serous layer secondary to trauma, esophageal foreign body penetration,
comprised of a single sheet of mesothelial cells. This serous spontaneous rupture of communicating pulmonary bullae,
layer can be divided into parietal and visceral components and following exploratory laparotomy in a dog with a previ-
that are continuous with each other; the parietal layer is ously undiagnosed PPDH [5–7]. However, the most fre-
adhered to the outer fibrous pericardium but reflects back, quently encountered pericardial space disease is pericardial
at the base of the heart, to lie on top of the myocardium effusion, with commonly reported causes in dogs being
and form the visceral layer (also known as the epicardium). neoplastic and idiopathic in origin [8].
The space between the two layers of this inner serous peri- In feline patients, congestive heart failure was the most
cardium is the pericardial cavity, which in health contains prevalent cause of pericardial effusion with feline infec-
a small volume (approximately 0.25 ± 0.15 ml/kg) of a tious peritonitis also being common [9, 10]. A comprehen-
clear, low-protein fluid [1]. This fluid, derived from plasma, sive list of etiologies can be found in Box 18.1. Pericarditis
serves to lubricate the layers and drains via the lymphatic can occur in association with pericardial effusion, either as
system into the mediastinum and right side of the heart. the instigating cause of the effusion, or following repeated
Abnormal or excessive accumulation of fluid in this area is pericardiocentesis over several weeks.
termed pericardial effusion and can lead to profound
effects on a patient’s circulation.
Although the pericardium can be partially removed or Hemodynamic Changes Associated
perhaps congenitally malformed, it serves several func- with Pericardial Effusion
tions including stabilizing the position of the heart within
the thoracic cavity, reducing resistance during cardiac con- The elasticity of the pericardium means it has little effect
traction, balancing left and right cardiac output, and acting on cardiac chamber filling [1, 11]. Complications arise
as a barrier against extension of infection or malignancy when the intrapericardial pressure increases, equilibrates
from surrounding tissues [2]. with and then ultimately exceeds right-atrial and
242 Pericardiocentesis
Box 18.1 Causes of Pericardial Effusion in Dogs Clinical Signs Associated with
and Cats Pericardial Effusion
Idiopathic
In those patients with a low volume of effusion, clinical
●
Neoplasia (e.g. hemangiosarcoma, chemodectoma,

signs will more likely be related to the underlying disease
●
mesothelioma)
process with pericardial fluid identified incidentally on
Congestive heart failurea (more commonly cats)
imaging. As an example, cats with congestive heart failure
●
Coagulopathy
may present to the clinic due to respiratory distress from
●
Left atrial rupture secondary to mitral valve disease

pulmonary edema and have evidence of a heart murmur or
●
Septic pericarditis (e.g. bacterial, fungal, foreign

gallop sound on examination. However, if cardiac tampon-
●
body-associated)
ade is present then signs consistent with low-output car-
Feline infectious peritonitisa
diac failure will be evident. Acute disease is often associated
●
Systemic diseasea (e.g. uremia, hypoalbuminemia)

with cardiogenic shock, syncope, hypotension, respiratory
●
Trauma
distress, or even death [15]. Chronic presentations usually
●
Iatrogenic hemorrhage
are more related to increases in systemic venous pressure
●
Thyroid diseasea (thyrotoxicosis in cats, hypothyroid-

and signs include exercise intolerance, weight loss, ano-
●
ism in dogs)
rexia, lethargy, abdominal distension, tachypnea, or a
Nicotine toxicosisa
cough [15, 16]. A study showed that 51% of canine patients
●
a
Unlikely to result in cardiac tamponade. with pericardial effusion had vomited recently, with this
symptom being more common in severely hyperlactatemic
dogs, regardless of the underlying etiology of the pericar-
dial effusion [17].
right-ventricular diastolic filling pressures (0–3 mmHg and

0–5 mmHg, respectively), which is typically a result of peri- Physical Examination
cardial fluid accumulation [12]. This results in diastolic
collapse of the right side of the heart, reducing venous Physical examination usually reveals evidence of compro-
return and increasing central venous pressure. Such a phe- mised perfusion such as tachycardia, reduced pulse qual-
nomenon is referred to as cardiac tamponade. A reduction ity, pallor, and reduced mentation, with the possible
in right-sided cardiac output results, via the Frank–Starling addition of tachypnea and muffled heart sounds.
mechanism, in reduced stroke volume and explains many Chronicity may be implied by the presence of hepatomeg-
of the typical clinical signs. The pericardial pressure may aly, ascites, and jugular venous distension as recognized in
continue to increase and reach a point where it exceeds left right sided congestive heart failure, though it should be
cardiac chamber filling pressures, resulting in more pro- noted that these patients can also present after acute
found cardiovascular compromise. Compensatory neuro- decompensation with signs of poor effective circulating
humoral mechanisms are stimulated in an attempt to volume [15, 16].
maintain cardiac output by increasing cardiac contractility,
heart rate, and systemic vascular resistance, and by retain-
Pulsus Paradoxus
ing sodium and water; however, these processes are readily
exhausted [1]. Pulsus paradoxus may or may not be present in either the
Several factors influence the onset of tamponade includ- acute or chronic presentation. This term describes the
ing the rate of fluid accumulation and distensibility of the exaggeration of a normal physiological variation in arte-
fibrous pericardium. In an acute process such as hemor- rial pulse pressure depending upon the phase of respira-
rhage, even a small volume of pericardial effusion rapidly tion. During spontaneous inspiration there is a slight
increases the intrapericardial pressure since there has decrease in systemic arterial blood pressure due to
been inadequate time for the pericardium to stretch or reduced left ventricular preload from pulmonary venous
hypertrophy [13]. This will result in acute cardiovascular pooling; the result is a weaker pulse quality. Conversely,
collapse. However, with slower, more chronic effusion the palpable pulse pressure is stronger during expiration.
accumulation, gradual hypertrophy of the pericardium This cyclical variation is more prominent in the presence
can occur, allowing a larger volume of fluid to accumulate. of pericardial effusion due to reduced venous return to
This increased pericardial compliance delays the onset of the heart. Pulsus paradoxus is defined as an inspiratory
tamponade and any associated signs of right sided heart decrease in systolic arterial blood pressure of greater than
failure [1, 14]. 10–12 mmHg [18].
DiagnoDo nof PeDiierDial oofoDng 243
Diagnosis of Pericardial Effusion without left atrial rupture, hypertrophic cardiomyopathy,

myocarditis, and concurrent pleural effusion.
The clinician may have a suspicion for the presence of peri- Cardiac masses might be more easily identified in the
cardial space disease based on a patient’s signalment, his- presence of pericardial effusion; however, if the patient is
tory, and physical examination findings. To confirm their unstable due to cardiogenic shock, therapeutic pericardio-
suspicion and identify the underlying etiology, diagnostic centesis should take precedence over a complete echocar-
imaging, blood testing, and pericardial fluid analysis may diogram, which can be delayed until the patient is more
be required. stable [8]. When attempting to identify the presence of a
cardiac mass, particular attention should be paid to the
right atrial area; however, there is only moderate correla-
Echocardiography tion between the presumptive tumor type based on echo-
It is now commonplace for veterinary practices to have cardiographic tumor location and histopathology [20].
access to ultrasonography. A point-of-care ultrasound is a
quick and easy method to identify pericardial effusions and Radiography
has demonstrated improved sensitivity and specificity
compared to radiography [19]. This procedure is also less Thoracic radiographs may reveal a spherical cardiac sil-
invasive in that the patient may choose its own body posi- houette without evidence of the movement blur com-
tion, which is beneficial when the animal is already cardio- monly associated with cardiac contractions
vascularly compromised. Pericardial effusion appears as an (Figure 18.2) [1, 15]. Cardiac enlargement is reported in
anechoic or hypoechoic, rounded space between the heart up to 87% of dogs and 95% of cats depending on the vol-
(epicardium) and an often clearly demarcated fibrous peri- ume of pericardial effusion [15, 21]. In those patients
cardium (Figure 18.1; refer to Chapter 15 for additional with cardiogenic shock, pulmonary vessels may appear
information regarding point-of-care ultrasonography). A smaller. The presence of cardiac tamponade may also
more detailed assessment is required to determine the reveal distension of the caudal vena cava and hepatomeg-
presence of cardiac tamponade, evidenced by collapse of aly [22]. Pleural effusion may be evident and abnormal
the right atrium and sometimes right ventricle during lung patterns have been reported in up to 60% of cats,
diastole. likely due to the high incidence of congestive heart failure
Echocardiography is the reference standard diagnostic as a cause of pericardial effusion in feline patients [10].
modality for pericardial effusion in human and veterinary Dorsal tracheal deviation may be noted in association
medicine, with the ability to detect even small volumes of with a heart based tumor and pulmonary metastases may
fluid accumulation. In addition, it can evaluate for the
presence of a cardiac mass, valvular endocardiosis with or
Figure 18.1 Pericardial effusion (white arrow) identified as an

anechoic space between the epicardium and the fibrous
pericardium in a cat with congestive heart failure. Pleural Figure 18.2 Dorsoventral radiograph of a dog with a
effusion (red arrow) can also be seen external to the pericardial effusion evidenced by the enlarged, globoid cardiac
pericardium. silhouette.
be noted when pericardial effusion is secondary to a neo- swinging of the heart within a fluid-filled pericardial cav-
plastic process [8]. Lastly, it is important to consider that ity, shifting the heart’s electrical axis in relation to the elec-
in the acute presentation, thoracic radiography may trocardiograph leads (Figure 18.3). This is more prevalent
be normal. in large volume effusions [1, 26].
Alternative Imaging Modalities Blood Testing

Less commonly employed diagnostics include computed If the patient’s clinical condition permits, it is recom-
tomography (CT), magnetic resonance imaging (MRI), and mended to obtain a packed cell volume (PCV), serum total
non-selective venous angiography. Cardiac MRI yielded protein concentration, and coagulation profile (prothrom-
useful descriptive information regarding extent, anatomi- bin time, activated partial thromboplastin time or activated
cal location, and potential tumor type in a case series of clotting time) prior to performing pericardiocentesis. A
eight dogs but did not substantially improve the diagnosis baseline hematology and biochemistry evaluation may
of a tumor compared with echocardiography [23]. Similarly, help elucidate the underlying etiology of the effusion but
multidetector CT did not improve detection of cardiac are often low yield. Serum cardiac troponin I (cTnI) has
masses in 11 dogs; however, it was considered advanta- been evaluated in a series of dogs and was significantly
geous in confirming the presence of pulmonary metastases higher in dogs with pericardial effusion compared with
and extra-cardiac lesions using a single imaging those without. Studies have also suggested patients with
modality [24]. hemangiosarcoma have a higher cTnI (2.77 ng/dl; range
0.09–47.18 ng/dl) than dogs with idiopathic effusion
(0.05 ng/dl; range 0.03–0.09 ng/dl) [27].
Electrocardiography
Although not a sensitive diagnostic test compared with
Pericardial Fluid Analysis
echocardiography [10], it is important to assess these
patients for the presence of dysrhythmias. Most commonly, Cytological evaluation of pericardial fluid is generally low
the electrocardiogram (ECG) is normal or a sinus tachycar- yield, especially in hemorrhagic effusions [28]; however,
dia is present; however, atrial and ventricular tachydys- submission for fluid analysis is recommended as it can be
rhythmias (including atrial/ventricular premature beneficial for the diagnosis of lymphoma or bacterial and
complexes) can be seen [25]. ST segment elevation and fungal agents [8]. Given the variation in underlying etiolo-
low-amplitude QRS complexes are commonly noted [1, 15]. gies, cytological analysis may be more rewarding in cats.
Electrical alternans refers to a beat-to-beat variation in Diagnosis of a malignancy is difficult since most types of
amplitude of the QRS complexes, caused by the phasic cardiac neoplasia exfoliate minimally into the fluid, and
Figure 18.3 Two electrocardiogram leads from different patients with pericardial effusion showing elevated ST segment (top) and
electrical alternans (bottom). SnfeiP: Courtesy of Dr. Elizabeth Bode and Dr. Meredith Daly.
EPeaPgicy ePiaEPga nof PeDiierDial oofoDng 245
the discrimination between reactive and neoplastic meso-

Box 18.2 Items Required for Performing
thelial cells is challenging. The diagnostic yield is improved
Pericardiocentesis
if the PCV of the effusion is less than 10% [28]. Some stud-
ies have compared other markers in the pericardial fluid ● Clippers with clean blade
such as pH, lactate, and bicarbonate to peripheral whole ● Surgical antiseptic solutions for skin preparation
blood in an attempt to identify the underlying cause, ● Surgical drape
though study results are conflicting [29, 30]. ● Sterile gloves
Culture of the sample may be based upon cytological ● 14- to 22-gauge, over-the-needle catheter
findings and clinical suspicion, and can help target antimi- or
crobial therapy. Samples should be collected in sterile tubes ● Pericardiocentesis multifenestrated catheter with
without anticoagulant for culture and in EDTA for cytology. guidewire
● Scalpel blade #11
● Three-way stopcock
Fluid extension tubing
Emergency Treatment of Pericardial
●
● 5–50 ml syringe
Effusion ● Receptacle for collecting removed effusion
● Sterile sample tubes (EDTA for cytology, without anti-
Patients with cardiovascular compromise from cardiac tam- coagulant for culture, as needed)
ponade require immediate intervention. Pericardiocentesis ● 2% lidocaine for local anesthetic block (safe dosage)
as outlined below should be attempted together with shock- ● Lidocaine 2 mg/kg intravenous preparation
dose intravenous fluid resuscitation. If the patient has a ● Electrocardiogram
known coagulopathy, then fresh frozen plasma or whole ● Non-invasive blood pressure monitor
blood may be the fluid of choice. Given the high prevalence ● Portable ultrasound if available
of cardiac disease in cats, the use of fluids should likely be ● Chemical restraint as needed
avoided; fortunately, in this species tamponade is rare. ● Oxygen supplementation
● Two or more assistants
Pericardiocentesis
An intravenous catheter should be placed to facilitate fluid taking advantage of the larger cardiac notch. In lateral
administration, chemical restraint if required, and as a pre- recumbency, it is thought the apex of the heart may also
caution in case of complications, such as cardiac arrest or “fall away” from the site of catheter entry due to gravity.
ventricular dysrhythmias. Some clinicians advocate for Proponents of a left-sided approach reason that inadvert-
having a pre-drawn syringe of 2 mg/kg lidocaine in canine ent puncture of the left ventricle would yield brightly
patients, so that it is readily available should it be needed. colored oxygenated blood that would grossly contrast the
Sedation is rarely required in the compromised canine classic “port” colored hemorrhagic pericardial effusion
patient, particularly if local anesthetic is used. However, if typically seen in dogs. Sternal recumbency may be pre-
necessary (as is the case for most cats), the author recom- ferred in a less stable patient.
mends the use of an opioid possibly in combination with a The best location for catheter insertion into the pericar-
benzodiazepine, as these sedative agents have minimal dium must be identified. Echocardiography can be used to
hemodynamic impact. Alfaxalone or etomidate are addi- visualize the largest volume of fluid between the thoracic
tional considerations should further restraint be required. wall and the heart and with a sterile cover over the probe,
Continuous ECG and frequent blood pressure monitoring which can also be used to guide insertion of the catheter. If
should occur throughout the procedure to ensure rapid bedside ultrasound is unavailable, pericardiocentesis can
identification of any complications, and flow-by oxygen be performed blindly at the fourth or fifth intercostal space
should be provided. Care should be taken to ensure that all just ventral to the costochondral junction, where the
equipment potentially needed for the procedure is availa- precordial pulse is most readily palpable. Either the left or
ble prior to commencing (Box 18.2). right lateral thorax must be clipped and aseptically pre-
Pericardiocentesis can be performed from either the left pared, between the second and eighth intercostal spaces
or the right side of the thorax with the patient in sternal or encompassing at least two-thirds the height of the chest.
lateral recumbency. Many clinicians prefer to perform the Hand hygiene should be performed, and sterile gloves used
procedure with the patient in left lateral recumbency, throughout the procedure. The procedure site should be
approaching the pericardium from the right side to avoid surgically draped. A local block of 2% lidocaine can be
the coronary circulation and reduce iatrogenic lung injury, administered at the intended site of catheter insertion,
Figure 18.4 An example of a pericardiocentesis catheter set. (a) Needle. (b) Dilator. (c) Guidewire. (d) Pericardiocentesis catheter.
ensuring infiltration into the underlying intercostal mus- of the catheter may be felt as it contacts the fibrous pericar-
culature and pleura. A stab incision through the skin using dium, and the catheter should be advanced through into
a number 11 scalpel blade should be made at the location the pericardial space. If scratching persists once inside the
of the local block. space, the catheter should be retracted slightly and the
There are a few different catheter choices available. A ECG evaluated for abnormal complexes, which may appear
standard 14- or 16-gauge, 5.5-inch over-the-needle catheter if the catheter is touching the epicardium or within the
for medium and large sized dogs, or an 18- or 20-gauge, 1- ventricle. Ultrasound can also be used to confirm location.
to 1.5-inch over-the-needle catheter for small dogs and If using an over-the needle catheter, once confident the
cats, is readily available in most practices. Alternatively, stylet is in the pericardial space, advance the catheter off
commercially available pericardiocentesis catheter sets the tip and remove the stylet. The catheter can then be
may be preferred and typically include a needle, a guide- attached to extension tubing, a three-way stopcock, and a
wire, and a large bore multifenestrated silicone catheter 5–60 ml syringe based on patient size.
(Figure 18.4). Advantages of the catheter include compara- If using a pericardiocentesis set, once the needle is posi-
tively less irritation to the epicardium and better stability tioned within the pericardial space, the guidewire is passed
within the pericardial space during drainage. However, through the needle into the space and the needle subse-
one study suggests that placement of pericardial catheters quently removed (Figure 18.5c, d). The multifenestrated
may increase the rate of dysrhythmias requiring catheter is then placed over the guidewire and into the peri-
treatment [31]. cardial space, with the guidewire being subsequently
The chosen catheter should be inserted perpendicular to removed (Figure 18.5e). As previously, a three-way stop-
the skin, on the cranial aspect of the rib so that the inter- cock and syringe can now be attached to the catheter and
costal vessels and nerves near the caudal rib margin are the effusion can be drained (Figure 18.5f). No more than
avoided (Figure 18.5a). The needle is directed toward the 2 ml of negative pressure should be placed on the syringe.
heart and advanced slowly until penetration into the peri- Once a small volume of pericardial fluid is obtained, it is
cardial space is suspected (Figure 18.5b). A syringe may be important to evaluate it to ensure draining of the correct
attached to the catheter prior to insertion into the patient space. Observing the fluid in a glass tube (containing no
and a small amount of negative pressure applied as the anticoagulant) or a syringe for several minutes to assess for
catheter is advanced. In the absence of pleural effusion, clotting is essential. Pericardial fluid should not clot (unless
entry into the pericardial space may be evidenced by the very recent hemorrhage) whereas whole blood from unin-
appearance of fluid in the catheter hub or syringe. In tentional cardiac puncture will clot readily (unless effusion
patients with pleural effusion, a yellow to serosanguinous is due to severe coagulopathy). The PCV of the effusion is
fluid may be obtained upon entry into the thorax and often lower compared with the peripheral PCV [30], whereas
should not be confused with pericardial fluid, which is blood from inside the heart would be similar; again, this may
more commonly hemorrhagic. Subtle scratching on the tip not hold true in acute hemorrhage. Lastly, evaluation of the
EPeaPgicy ePiaEPga nof PeDiierDial oofoDng 247
(a) (b)
(c) (d)
(e) (f)
Figure 18.5 Pictorial representation of various stages of pericardiocentesis. The patient has been aseptically prepared and the
operator is wearing sterile gloves. (a) Insert catheter in the fourth or fifth rib space, cranial to the rib or use ultrasound guidance.
(b) Successful insertion into the pericardial space evidenced by the presence of hemorrhagic fluid. A three-way stopcock and syringe
could be attached at this stage and the effusion removed. No further steps required. If using a pericardiocentesis catheter set,
(c) Insert guidewire through the needle. (d) Remove the needle, leaving the guidewire in place. If required, the dilator could be passed
over the guidewire, tunneled through the thoracic wall, and then removed. (e) Place the pericardiocentesis catheter over the guidewire
always keeping hold of the wire. Once in place, remove the guidewire. (f) Attach a three-way drainage system and remove the effusion.
SnfeiP: Courtesy of Dr. James McMurrough.
supernatant (formed from centrifugation for five minutes at improvement in the patient is often noted during the pro-
3400 rpm) of pericardial effusion will often be xanthochro- cedure with a reduction in heart rate and improved arterial
mic or yellow in color, due to the by-products of hemoglobin pressure. Once all the effusion is drained the catheter can
breakdown from previous bleeding. Supernatant from whole be carefully removed. A dressing, skin staple, or tissue glue
blood is more classically clear. In an unstable patient it may can be applied over the skin incision if necessary.
be prudent to continue slow aspiration of the fluid pending The final volume of fluid should be quantified and reso-
the results of these tests. lution of tamponade and effusion confirmed with echocar-
Following confirmation of correct catheter placement diography. Persistence of significant pericardial effusion
and evaluation of pericardial fluid, continued drainage following the procedure may imply active hemorrhage or
should proceed until as much fluid as possible is retrieved, puncture of the myocardium. Refer to Protocol 18.1 for
so long as active bleeding is not suspected. Hemodynamic step-by-step instructions.
Protocol 18.1 Pericardiocentesis

1) Collect necessary supplies. 14) Once pericardial fluid is seen in the hub of the cath-
2) Obtain baseline peripheral blood samples and eter or syringe, either:
patient vitals. a) Advance catheter and stylet an additional 0.5 cm,
3) Aseptically assemble drainage tubing, three-way then feed catheter off and remove the stylet.
stopcock, and syringe and/or separate pericardiocen- b) If using a pericardiocentesis kit, remove syringe and
tesis set so each component is readily available. advance guidewire through the needle into the peri-
4) Place patient in preferred recumbency. cardial space. Subsequently remove the needle and
5) Determine optimum site for pericardiocentesis with insert the catheter over the guidewire into the peri-
ultrasound or by palpation. cardial space.Remove the guidewire (Figure 18.5b–e).
6) Connect patient to ECG and blood pressure monitor. 15) Attach catheter hub to available three-way stopcock
7) Clip and aseptically prepare pericardiocentesis site. port and aspirate fluid (Figure 18.5f).
8) Perform hand hygiene and put on sterile gloves. 16) Aseptically place fluid samples in plain and EDTA
9) Drape the patient. tubes. Examine aspirated fluid for evidence of clotting;
10) Administer local block of 2% lidocaine through the determine PCV and serum total protein concentration
subcutaneous tissues and intercostal musculature. of fluid and compare with peripheral blood to confirm
11) An assistant should administer chemical restraint appropriate catheter placement in pericardial space.
if needed. 17) Deposit remaining fluid into collection bowl. Quantify
12) Make a stab incision through the skin with scal- volume of retrieved fluid and store samples in refrig-
pel blade. erator prior to submission for cytologic analysis.
13) Incrementally advance the catheter–stylet pair (or 18) Once all fluid is removed, withdraw catheter from
pericardiocentesis needle ± syringe) through the skin, pericardial space (or suture in place if indwelling
subcutaneous tissues, and intercostal musculature catheter was chosen).
cranial to a rib, directed toward the heart 19) Verify reduction of the effusion via echocardiography
(Figure 18.5a). if possible.
Longer-Term Treatment of Pericardial Complications

Effusion
Pericardiocentesis is a relatively safe procedure if appropri-
Treatment and prognosis depend on the underlying cause ate precautions are taken to reduce potential risks.
of the effusion. Approximately 50% of idiopathic effu- Commonly recognized complications include ventricular
sions will resolve following initial pericardiocentesis; or supraventricular dysrhythmias, inadvertent ventricular
however, the remainder will recur within hours to puncture, cardiac or coronary artery laceration, hemor-
years [15]. Depending on the rate of fluid accumulation rhage, dissemination of infectious agents or neoplasia, and
surgical intervention may be considered, such as a subto- cardiopulmonary arrest [25].
tal pericardectomy, thorascopic pericardial window, or a Penetration of the ventricular wall may occur if the cath-
fluoroscopy-guided balloon pericardiotomy [32–34]. eter is advanced too far into the pericardial space and will
These surgical procedures are especially beneficial in the likely result in a ventricular dysrhythmia on surface ECG. In
treatment of infectious causes, alongside long-term anti- addition, the catheter may move with each cardiac contrac-
microbial therapy. The treatment for neoplastic effusions tion. This is often not a serious complication and resolves
will vary based on tumor type though in most cases chem- when the catheter is withdrawn from the myocardium. If
otherapy alone provides a similar mean survival time not recognized and corrected, however, it could lead to inad-
compared with the combination of chemotherapy and vertent removal of large volumes of blood from circulation.
mass resection, which is infrequently feasible [10, 15, 35]. Manipulation of the catheter within the ventricular wall
Lastly, appropriate management of congestive heart fail- increases the risk of cardiac laceration and fatal hemorrhage.
ure should result in resolution or delayed progression of As described previously, continuous ECG monitoring,
associated small volume pericardial effusion. blood pressure evaluation, ultrasound guidance, monitoring
References 249
of the retrieved pericardial fluid for clotting, and readily These will most likely manifest as hemodynamic instabil-
available anti-arrhythmic medication should allow rapid ity, meaning that evaluation of cardiovascular parame-
recognition of complications and immediate intervention. If ters, respiratory rate and effort, demeanor, and urine
coronary artery laceration or cardiac rupture occurs, the output for a minimum of 24 hours is advisable. Ventricular
patient is unlikely to survive. dysrhythmias can range from mild to severe and may
The clinician must consider relative contraindications to necessitate antiarrhythmic therapy. Serial or continuous
performing pericardiocentesis, such as the presence of a ECG, heart rate and blood pressure monitoring, thoracic
coagulopathy, atrial rupture, actively bleeding neoplasia, auscultation, and intermittent echocardiography will
or a small volume effusion in the absence of tamponade. facilitate prompt recognition of complications.
Post-Pericardiocentesis Monitoring Acknowledgments
Following the procedure patients should be closely moni- The current author and editors would like to acknowledge
tored for recurrence of the pericardial effusion, ongoing Dr. Meredith Daly’s contributions to the first edition of
hemorrhage, or development of ventricular dysrhyth- Advanced Monitoring and Procedures for Small Animal
mias. Fluid can leak from the pericardial space into the Emergency and Critical Care, upon which this chapter
pleural cavity resulting in life-threatening blood loss. is based.
References
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251
19
Monitoring Tissue Perfusion

Clinicopathologic Aids and Advanced Techniques
Alexandra Nectoux and Guillaume L. Hoareau
Cells depend on oxygen delivery for energy production to disturbances may persist despite normal macrocirculatory
maintain homeostasis. Failure to achieve sufficient tissue parameters such as blood pressure (i.e. hemodynamic inco-
oxygen delivery results in cell dysfunction and ultimately herence). Second, normal systemic arterial blood pressure
death. Insufficient oxygen delivery to cells can be focal (e.g. does not equate to normal blood flow since profound vaso-
ischemic limb, infarcted spleen) or systemic, which is then constriction, for instance, may result in normal or even
termed shock. high systemic blood pressure in the face of reduced blood
Whether hypoxia is focal or systemic, restoring adequate flow. Conversely, vasodilation may result in increased
tissue oxygen delivery is a cornerstone of resuscitation. blood flow despite a reduction in blood pressure. Such
Oxygen delivery to tissues depends on arterial oxygen con- decrease in systemic vascular resistance is often associated
tent and tissue perfusion. This chapter focuses on the with increased cardiac output in the hyperdynamic phase
importance of monitoring tissue perfusion (Table 19.1). of sepsis.
Blood pressure measurement can be either non-invasive
(oscillometric, Doppler, or pressure wave analysis technol-
Clinical Monitoring of Tissue Perfusion ogies; see Chapter 14) or invasive. Invasive blood pressure
monitoring depends on direct pressure measurement
Physical Examination
within the lumen of an artery. Most systems rely on pres-
Physical examination is an inexpensive and rapid way to sure wave transmission through a column of water to a
monitor a patient’s perfusion serially. Assessment of global pressure transducer (see Chapter 12), though solid-state
perfusion, a core part of a triage examination, should blood pressure transducing catheters are also available.
include evaluation of mentation, heart rate, pulse quality, Regardless of the method of acquisition, arterial blood
extremity-to-core temperature difference, mucous mem- pressure can be used to calculate cavity or organ-specific
brane color, and capillary refill time. This focused assess- perfusion pressures. Clinical interventions or research
ment of a patient’s circulatory function provides a global applications often rely on myocardial, cerebral, abdominal,
evaluation of tissue perfusion and assists in the diagnosis or spinal perfusion pressures, which are the driving pres-
of shock. The evaluation of circulatory function by physi- sures for blood from the arterial to the venous sides of
cal examination may also help in the diagnosis of focal per- organs. The use of such perfusion pressures in clinical
fusion disturbances such as an ischemic limb if the femoral practice as resuscitation endpoints has been studied in var-
pulse is absent, for instance. ious settings. Myocardial perfusion pressure (diastolic aor-
tic pressure minus central venous pressure) and cerebral
perfusion pressure (CPP; mean arterial pressure [MAP]
Arterial Blood Pressure Monitoring
minus intracranial pressure) are critical prognostic indica-
Systemic arterial blood pressure measurement is also com- tors in cardiopulmonary resuscitation (CPR). Data summa-
monly used to monitor a patient’s cardiovascular status. rized in current veterinary CPR guidelines suggest that
Unfortunately, normal blood pressure does not indicate myocardial perfusion pressures above 20 mmHg are associ-
adequate capillary perfusion and thus cannot guarantee ated with increased likelihood of return of spontaneous
adequate oxygen delivery to cells. First, microcirculatory circulation [1]. Post-cardiac arrest CPP was higher in
252 Monitoring Tissue Perfusion
Table 19.1 Summary of commonly available tissue perfusion monitoring tools.
Clinicopathologic aids Advanced techniques
Physical examination Near-infrared spectroscopy

Arterial blood pressure Diastolic, mean, systolic Microcirculation visualization Orthogonal polarized
spectroscopy
Perfusion pressures Sidestream dark field
Urine output Incident dark-field
Clinical imaging Transcutaneous ultrasound Transcutaneous O2 and CO2
Transesophageal Regional capnography

echocardiography
Metabolic biomarkers Lactate concentration Thermography
Lactate clearance Cutaneous laser Doppler
Oxygen extraction ratio Urine oxygen partial pressure
SmvO2 Microdialysis
ScvO2
PCO2 gradients
PCO2, partial pressure of carbon dioxide; SmvO2, mixed venous hemoglobin oxygen saturation; ScvO2, central venous hemoglobin oxygen
saturation.
survivors than nonsurvivors following cardiac arrest [2] as a urine output less than 0.5 ml/kg/hour [6] and anuria is
and CPP optimization is an area of active research. the absence of urine production. A urine output above the
Abdominal perfusion pressure (MAP minus intra- normal range is considered polyuria. In human medicine,
abdominal pressure) is a significant focus for the manage- plasma renin concentration is well correlated to urine out-
ment of abdominal compartment syndrome, although put and represents a useful tool to assess tissue perfu-
studies suggest that it should not be used as a resuscitation sion [7]; however, it is not always increased in response to
endpoint [3]. Spinal cord perfusion pressures (MAP minus ischemia–reperfusion injury. For instance, pigs subjected to
intraspinal pressure, between the dura and the surface of hemorrhagic shock and endovascular aortic occlusion
the cord) over 50 mmHg have been associated with favora- developed increased serum angiotensin II concentration
ble neurological outcomes following traumatic spinal cord without significant changes in circulating levels of renin [8].
compression [4, 5]. The concept of perfusion pressure fur-
ther supports why a resuscitation strategy solely based on Clinical Imaging
MAP may not maintain adequate perfusion to individual
organs (e.g. two patients may have identical MAPs but Imaging tools routinely used in the hospital can be used to
vastly different intra-abdominal pressures, and hence will some extent to monitor cardiovascular status. Various
have different abdominal tissue perfusion pressures). approaches may assess cardiac filling and systolic function.
Different point-of-care ultrasound protocols have been
described in the veterinary literature [9]. Tissue perfusion to
Urine Output
a specific organ can be confirmed using Doppler ultrasound,
Quantification of urine output reflects renal perfusion but this remains a diagnostic rather than a monitoring tool.
through glomerular filtration, tubular reabsorption, and Transesophageal echocardiography (TEE), whereby an
patency of the urinary tract. Urine output is part of the ultrasound probe is inserted near the heart through the
essential monitoring of critically ill patients, especially esophagus, is gaining popularity in human emergency med-
those with particular risk for acute kidney injury. Urine out- icine and has been used extensively in people undergoing
put can be quantified hourly or less frequently, depending anesthesia. In the human emergency room, TEE has proved
on the patient’s status. Urine output is an integral factor in a valuable tool in CPR and can assist in improving hand or
fluid therapy planning and overall patient care. It can be chest compression device placement to increase stroke vol-
easily and precisely measured by placing a urethral catheter ume and optimize perfusion [10]. TEE is also often used to
connected to a closed collection system. Normal urine out- monitor and optimize perfusion in patients undergoing
put is 1–2 ml/kg/hour in dogs and cats. Oliguria is defined extracorporeal membrane oxygenation [11].
ClilicC MiliMoling Mof liisue ueoosilMi 253
Standard Clinicopathologic/Metabolic Markers Box 19.1 Calculating the Oxygen Extraction Ratio

of Tissue Perfusion
OER % CaO2 CmvO2 CaO2
Metabolic markers of tissue perfusion are another crucial
part of patient management and provide information regard- CaO2 1.34 Hb SaO2 0.003 xPaO2
ing systemic or organ-specific perfusion derangements.
CmvO2 1.34 xHb x SmvO2 0.003 PmvO2
CaO2, arterial oxygen content, ml/dl
Lactate
CmvO2, mixed venous oxygen content, ml/dl
Plasma lactate concentration has long been used for the
Hb, hemoglobin concentration, g/dL
monitoring of systemic or focal (e.g. limb) ischemia.
OER, oxygen extraction ratio
Lactate production has traditionally been classified as type
PaO2, partial pressure of arterial oxygen, mmHg
A (insufficient oxygen delivery) or B (increased lactate pro-
PmvO2, partial pressure of microvacular venous oxygen,
duction in the face of adequate oxygen availability) [12].
mmHg
Type A hyperlactatemia has been further characterized as
SaO2, oxygen saturation
relative, from increased oxygen demand (e.g. in exercise,
SmvO2, mixed venous oxygen saturation
shivering, seizure) or absolute, from decreased oxygen
delivery (e.g. in hypoperfusion, severe anemia, severe
hypoxemia). Type B hyperlactatemia has been observed
with certain diseases (e.g. lymphoma, pheochromocy- combination of cranial and caudal vena cava blood along
toma), toxins or drugs (e.g. glucocorticoids, xylitol, met- with coronary sinus blood; thus, mixed venous blood is the
formin), or congenital metabolism disorders. Spurious most globally representative venous blood sample obtain-
readings can be observed with ethylene glycol intoxica- able. This mixed venous sample better reflects systemic
tion [13]. Much of the evidence about the usefulness of venous oxygen content than central venous blood acquired
plasma lactate concentration in veterinary medicine has from the jugular vein or vena cava.
originated from studies of gastric dilation volvulus. While While OER increases in shock states to compensate for
measurements at single time points do not always provide reduced oxygen delivery, in more severe shock states, cells
meaningful information, serial plasma lactate concentra- have extracted nearly all oxygen in the capillary blood, OER
tion measurements may better correlate with outcome. stops increasing, and oxygen consumption becomes depend-
Lactate concentration-derived parameters such as time to ent on oxygen delivery. Scientists have argued that the rela-
lactate less than 2 mmol/l and lactate clearance can differ- tionship between oxygen consumption and delivery is
entiate between survivors and non-survivors in dogs diag- actually linear in certain conditions, which would dictate
nosed with shock [14, 15]. that oxygen consumption would always depend directly (lin-
Lactate measurement may also reflect locoregional early) on oxygen delivery [21, 22]. Extraction ratios can be
hypoxia in patients with various conditions. Venous lactate calculated for specific tissue beds via selective sampling of
concentration measured from a limb with suspected arterial and venous blood. For example, renal arterial and
ischemia may be higher than that of the systemic circula- venous blood can be sampled to calculate the renal OER. This
tion [16, 17]. Similarly, lactate concentration measured approach is generally limited to the research setting.
in cerebrospinal fluid reflects the magnitude of spinal The balance between oxygen delivery and oxygen con-
cord [18, 19] or cerebral ischemia [20]. sumption is often evaluated via analysis of central venous
(cranial caval, most often) saturation of oxygen (ScvO2), as
Blood Gas Parameters and Oxygen Extraction Ratio it is a single number and thus eliminates the need for cal-
Under baseline physiologic conditions, oxygen is delivered culations. ScvO2 can be measured via blood gas analysis or
to cells in excess of metabolic demand. When tissue oxygen continuous fiber tip spectrophotometry. ScvO2 was part of
delivery is decreased, cells and therefore organs can the early goal-directed therapy protocol for the manage-
increase the fraction of oxygen they consume from the ment of septic shock in people [23]. In a study of dogs with
arterial supply to a higher percentage of the oxygen being sepsis or septic shock associated with pyometra, a goal-
delivered. Thus, oxygen consumption remains independ- directed resuscitation therapy guided by physical examina-
ent of oxygen supply over a wide range of normal to lower- tion, ScvO2, lactate concentration, and base deficit showed
than-normal-but-adequate oxygen delivery. This principle that ScvO2 and base deficit were superior to lactate in
can be quantified by calculating the oxygen extraction ratio predicting survival [24]. Importantly, in critically ill people,
(OER; Box 19.1) there is no uniform correlation between lactate concentra-
A mixed venous sample is obtained from the pulmonary tion and ScvO2 [25, 26]. In isolated studies, resuscitative
artery via a pulmonary artery catheter and comprises a efforts in patients with early sepsis aiming at improving
lactate clearance or normalizing ScvO2 did not yield before pulse oximetry, plasma lactate concentration, or
significant survival benefit [27]. However, a meta-analysis physical examination [31]. Assuming no significant change
reported superiority of lactate clearance-driven algorithms in arterial oxygen content, a decrease in tissue oxygenation
when compared to those aiming at improving ScvO2 [28]. directly reflects reduced perfusion. StO2 is mostly measured
Partial pressure of carbon dioxide (PCO2) can be meas- in peripheral muscle or brain with dedicated probes; since it
ured on mixed or central venous blood to calculate the ten- measures local oxygen saturation, readings depend on probe
sion difference with that of arterial blood (Pv-aCO2) [29]. location [32, 33]. Moreover, changes in blood volume in
Pv-aCO2 depends mostly on cardiac output and systemic brain tissue, peripheral vasoconstriction, pain, hypothermia,
CO2 production and is not reflective of tissue hypoxemia; as well as hypovolemia, meaningfully influence the intravas-
rather it reflects the adequacy of venous blood flow to cular compartment and alter readings. In the human litera-
remove the CO2 produced in the tissues, an approximation ture, several studies showed that tissue desaturation in the
of tissue perfusion. Pv-aCO2 could be used to guide resusci- frontal cortex of the brain and peripheral muscles (thenar,
tation in conjunction with other markers of tissue perfu- leg, and masseter muscles) was associated with poor out-
sion, in particular ScvO2, to match oxygen delivery to CO2 comes [34, 35]. However, these results remain controver-
production. A Pv-aCO2 greater than 6 mmHg may suggest sial [36]. In pigs exposed to various cardiovascular
insufficient resuscitation. derangements, NIRS readings from the pelvic limbs showed
More sophisticated calculations leveraging arterial and good agreement with more invasive parameters [22]. NIRS
venous O2 and CO2 contents may refine the specificity of evaluation of cerebral blood flow has been described in dogs
tissue perfusion monitoring. In patients with septic shock, in an experimental setting, where the probe was applied
following restoration of MAP, increased Pv-aCO2 corre- directly onto the skull [37]. Non-invasive NIRS readings
lated with lower tissue oxygen saturation, a reflection of have been reported in healthy conscious and unconscious
global flow. PcvaCO2/CavO2 ratio (where PcvaCO2 is the Chihuahuas [38]. StO2 declines in various states of shock in
central venous-to-arterial carbon dioxide difference and canine patients [39, 40]. StO2 readings were associated with
CavO2 is the arterial–venous oxygen content difference) disease severity but did not predict survival [40]. Care
was a good indicator of local oxygen consumption and providers should consider establishing clear protocols, as
microvascular dysfunction [30]. various factors such as probe location may introduce varia-
bility in the readings. For instance, in healthy dogs, the sar-
torius muscle provides a good assessment of tissue oxygen
dvanced Tissue Perfusion Monitoring
A saturation and could be consistently used [41]. Similar to
Techniques many other monitoring devices, there can be significant var-
iability in readings when using different NIRS devices [42].
The previously described techniques may not reflect
changes in microcirculation. Direct microcirculation assess-
Microcirculation Visualization
ment tools can provide important information to guide
resuscitation. Unfortunately, these techniques sometimes Direct observation of the microcirculation is a dynamic
require expensive, large, or impractical tools, and are thus field of research that has rendered this approach more
primarily used in laboratory or research settings at this time. available for clinical use, even in veterinary medicine.
There are various technologies to visualize the microcircu-
lation. The following devices are listed from oldest
Near-Infrared Spectroscopy
to newest:
Spectroscopy is optical monitoring that relies on the appli-
cation of different wavelengths of light to tissue. In healthy Orthogonal Polarized Spectroscopy Imaging
tissues, hemoglobin, myoglobin, cytochromes, melanins, Two polarizers oriented perpendicularly to one another are
carotenes, and bilirubin absorb light in a concentration- respectively used to emit and collect light on a specific tis-
dependent manner. Tissue oxygenation measurement sue region. The light collected passes through a spectral
relies on the distinct light wavelength absorption charac- filter to isolate the wavelength region and linearly polarize
teristics of hemoglobin in its oxygenated and deoxygen- it. A beam splitter reflects the light toward the target tissue,
ated forms. and an objective lens focuses the light onto a region of
Near-infrared spectroscopy (NIRS) is an optical monitor- approximately 1 mm in diameter. The device then gener-
ing technique that relies on the Beer–Lambert law correlat- ates an image of the illuminated region. Contrast is
ing the concentration of a substance to its light absorption. obtained from the absorption of linearly polarized light
NIRS assesses oxygen saturation of hemoglobin in the capil- by both oxygenated and deoxygenated hemoglobin in the
laries of a tissue (StO2) and can detect oxygenation disorders blood. Subsequently, red blood cells in the microcirculation
Advanced Tissue Perfusion MonitoringTechniques 255
appear black on the white background of the surrounding within the field of the camera; (ii) proportion of perfused
tissue, which creates a high-contrast image. This technique vessels, which represents the proportion of perfused vessels
was first described in the human literature in comparison in the field; and (iii) perfused vessel density, which is a meas-
with a standard fluorescence method [43]. A study estab- ure of perfused vessels’ length within the field. The potential
lished baseline values in 15 healthy dogs and assessed clinical benefits of perfused vessel density, which is derived
the reproducibility of this technique [44], but it offers a from total vessel density and proportion of perfused vessels,
limited field of view, as only a focal area of tissue can be are outlined by experimental data. A normal perfused vessel
visualized. density, for example, strongly correlates with tissue survival
in rodents [53]. Hemodilution can decrease the perfused
Sidestream Dark Field Imaging vessel density [54]. Finally, (iv) the microcirculatory flow
Sidestream dark field (SDF) imaging uses the same concept index quantifies the velocity of microcirculatory perfusion.
as orthogonal polarized spectroscopy imaging. In this case,
the illuminated light and the reflected light travel via differ-
Transcutaneous O2 and CO2 Monitoring
ent pathways to not interfere with the image quality. Using
a videomicroscope, a green light-emitting diode produces a Transcutaneous blood gas monitoring is a noninvasive and
light beam, which is absorbed by hemoglobin. This tech- reliable technique to approximate oxygen and carbon dioxide
nique is limited to experimental use because it requires con- tensions in a tissue. It detects early changes in tissue blood
stant user interactions and long measurements to obtain gases compared to invasive methods [55]. This technique is
only a few seconds of video for analysis [45, 46]. Despite more reliable and more accurate than capnography in human
those limitations, SDF imaging allows real-time imaging of patients [56]. Gas tension is measured via polarography. The
the microvasculature and was able to demonstrate altered skin is heated to 43–45°C to increase transcutaneous gas dif-
microcirculatory variables in dogs with hemorrhagic shock, fusion. Accuracy of this technique can be affected by skin
when compared to normal dogs [47]. SDF shows an increase thickness, peripheral vasoconstriction, hypoperfusion, or
in vessel density in dogs receiving various rates of fluid peripheral edema [57]. Consistent measurement protocols
under general anesthesia, which demonstrates the link are therefore paramount for reliable measurements.
between SDF findings and perfusion changes [48]. Finally, Moreover, a decrease in cardiac output reduces the ability of
whereas SDF is a reliable bedside tool to assess microcircu- transcutaneous partial pressure of oxygen (PtcO2) to approxi-
lation, it did not correlate with current standard analysis for mate partial pressure of oxygen (PO2) [58], which is a signifi-
different perfusion parameters in healthy dogs [49]. cant limitation when monitoring tissue perfusion in critically
ill animals. Recently, research in critically ill dogs showed
Incident Dark Field Imaging that transcutaneous blood gas monitoring overestimated
First described in 1970, incident dark field imaging (IDF) is PaO2 and PaCO2 and should not be used in those patients [59].
similar to SDF imaging in that it uses light-emitting diodes In ventilated patients, an oxygen challenge test is performed
arranged circumferentially to illuminate a target tissue. In to evaluate the change in PtcO2 value in response to an
this method, the strobe speed is significantly decreased, increase in fraction of inspired oxygen. This test predicted
which induces less distortion of the red blood cells’ images. outcome in patients with septic shock [60].
The device is a small, light, handheld camera, which makes
it easier for the operator to manipulate compared to the
Regional Capnography
previous devices. This camera also has a higher optical
resolution and a wider field of view that enable the user to The tissue-to-arterial PCO2 gap is a reliable marker of tis-
identify suitable areas of microcirculation more rapidly. sue hypoperfusion [61, 62]. This gap can be measured
Additionally, in contrast to the previous device, the IDF using a tonometer that assesses PCO2 in a tissue based on
imaging device has a dedicated integral automated soft- the gas’s partial pressure equilibrium. Gastric, esophageal,
ware, decreasing the time needed to acquire images [50, sublingual, cutaneous, and urinary bladder tissues have
51]. In comparison with SDF technique, IDF showed com- been studied in experimental animals and human
parable vessel detection and significantly better vessel con- patients [62, 63]. The sublingual-arterial PCO2 gradient has
trast in pigs undergoing a shock state [52]. been described to be a better prognostic indicator than
Several microcirculatory indices can be calculated by physical markers of hypoperfusion (cardiac index, DO2,
semi-automated software using the images acquired by the plasma lactate) [64]. In healthy dogs under anesthesia, gas-
three previous techniques. Care providers can assess and tric and bladder tonometry both correlated to sevoflurane-
monitor the microcirculatory system in a peripheral region induced hypotension in dogs [65]. In that study, gastric
using the following parameters: (i) Total vessel density, tonometry was a better reflection of global hemodynamics
which is a measure of total vessels’ length over the area when compared to bladder tonometry.
Thermography Urine Partial Pressure of Oxygen

Thermography is a reproducible, non-invasive, rapid
.
Perfusion to the kidney can be determined from PO2 in the
imaging technique to measure the heat emitted by a urine, assuming there is no change in arterial oxygen con-
surface. This method is used in human medicine to diag- tent. This technology was developed in animals and has
nose venous and arterial thromboembolism [66]. A recent been used in people. Current technologies rely on either a
publication in cats showed that infrared thermography had probe immersed in urine (whether in the bladder or a urine
a high accuracy in diagnosing arterial thromboembo- collection system) or optical fiber that can measure urine
lism [67]. The technique could also be used to evaluate rep- PO2 without contact with the urine. Alterations in global
erfusion, as evidenced by an increase in thermal signature hemodynamics translate to changes in urine PO2 [73]. In
with return of blood flow [68]. This is a promising tech- sheep, resuscitation from septic shock with fluids and nor-
nique for clinical practice application to assess peripheral epinephrine outlined the positive correlation between
macrocirculation; however, further studies are needed to urine PO2 and renal medullary blood flow. Studies in rab-
evaluate its ability to monitor microcirculation. bits have also suggested the potential for urine PO2 to pre-
dict the risk of acute kidney injury [74]. This technology
relies on the absence of oligoanuria.
Cutaneous Laser Doppler
This technology can be used to monitor both blood flow Microdialysis
and endothelial dysfunction. The laser Doppler probe
(LDP) is placed on an area of clipped and cleaned skin with Microdialysis is another tool to monitor cell function and
adhesive tape. The LDP emits laser beams and records sig- changes in perfusion. A microdialysis catheter (outer
nals generated by refracted beams. Signal refraction is cre- diameter 0.24–0.5 mm and length 1–10 mm) is inserted in
ated by the flow of blood cells, which is a function of blood the tissue of interest or inside a blood vessel and then con-
flow in the tissue under the probe. The machine provides a nected to a syringe pump. Similar to hemodialysis, the tip
computer-generated flow unit, which is proportional to of the microdialysis catheter will allow for solute exchange
how much blood flow the probe is sensing. The probe across a permeable membrane. Upon equilibration, the
evaluates flow at a depth of approximately 1 mm, therefore concentration of markers of cell metabolism and hypoxia
providing information about arteriolar, capillary, and venu- (lactate, glutamate, glucose, glycerol, pyruvate, urea) in the
lar flow. After a few minutes, the probe is heated to a tem- dialysate reflect that of the interstitium. Other biomarkers
perature of 42 °C (107.6 °F). In health, this rise in such as cytokines or biomarkers of brain injury can also be
temperature leads to an increase in blood flow, mostly retrieved, and this microdialysis sample better reflects their
mediated by NO [69], which is reflected as an increase in local concentration compared with systemic samples.
flow units. If the endothelium is dysfunctional, this flow Analyte concentration can then be measured on a bench-
rise is blunted as a result of decreased NO synthesis or bio- top machine. As for renal replacement therapy, membrane
availability. It can be argued that this technique only pro- cutoff size impacts the nature of solutes retrieved in the
vides information about the microcirculation immediately dialysate [75]. This technology is currently being used in
under the skin rather than throughout the body. In the both clinical and research settings. The clinical use of
research setting, cutaneous laser Doppler flowmetry has microdialysis is especially relevant for neurointensive care
been used in dog models for assessing wound healing and patients. A microdialysis probe can be inserted into the spi-
grafts. Laser Doppler technology has also been applied to nal cord [76] or the brain [75]. Brain perfusion monitoring
non-cutaneous tissues. Clinical reports of the use of laser via microdialysis has been recommended as part of the
Doppler flowmetry (LDF) in dogs are limited. LDF has management of people with traumatic brain injury and
been used to measure capillary flow in the gastric mucosa subdural hematoma [77]. In the laboratory, the authors
of dogs with gastric dilation volvulus [70]. Intra-operative have used microdialysis in various tissues, such as the kid-
LDF technology has successfully measured spinal cord ney or liver. Furthermore, placing the microdialysis cathe-
blood flow in canine patients with intervertebral disc dis- ter in a large vessel such as the caudal vena cava allows for
ease. Spinal cord blood flow increased immediately follow- frequent evaluation of plasma lactate concentration with-
ing decompression but did not correlate with degree of out the need to remove blood from the animal.
compression on magnetic resonance imaging or neurologi-
cal outcome 24 hours following surgery [71]. The same Conclusion
group more recently used the same technology to demon-
strate that durotomy did not increase spinal cord blood Care providers have a wide range of tools available to guide
flow following spinal decompression in dogs with interver- resuscitation. Optimizing tissue oxygen delivery relies on
tebral disc disease [72]. normalizing arterial oxygen content and tissue perfusion.
References 257
Owing to the limitations of markers of macrocirculation, Acknowledgment

there are ongoing efforts to refine advanced techniques to
make them more suitable for clinical practice. Continuing The current author and editors would like to acknowledge
research efforts often focus on perfusion to a specific organ Dr. Brian Young’s contributions to first edition of Advanced
(kidney, brain, heart), which may not always reflect global Monitoring and Procedures for Small Animal Emergency
perfusion. Acute care providers should therefore employ a and Critical Care, upon which this chapter is based.
diverse range of monitoring tools to improve patient care.
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261
20
Cardiopulmonary Resuscitation
Sean D. Smarick
Cardiopulmonary arrest (CPA) is the sudden cessation of Staff Training in Preparation for Cardiopulmonary Arrest
spontaneous and effective circulation and ventilation. It is
A CPR training program includes both didactic instruction
the common pathway to death from any disease process.
and hands-on skill development. The RECOVER initiative
Cardiopulmonary resuscitation (CPR) is the treatment to
offers training and certification based on the evidence-
establish effective perfusion to the heart and brain with the
based guidelines it has developed.
ultimate goal of returning the patient to a normal life.
Staff members should understand their potential roles on the
Every small-animal veterinary practice, from a vaccination
CPR team (to perhaps include initial leader), understand closed
clinic to a multispecialty referral hospital, should have sys-
loop communication, and should be trained appropriately.
tems in place to address CPA. No practice is exempt from
From initial hire orientation, the individual team member can
experiencing patients in CPA; however, a recent survey
become familiar with the CPR systems in place. Having a new
indicates that the awareness and the incorporation of vet-
technician participate in completing the checklist and subse-
erinary CPR guidelines is lacking in primary care prac-
quent supply stocking may help develop familiarity with the
tices [1]. Considering the expectation and therefore
location of the practice’s drugs and equipment. Without regular
potential fallout to a primary care practice that experiences
training every few months, skills diminish; thus, drills using
a CPA for a “routine” procedure and that successful resus-
commercial pet resuscitation mannequins or even simply a toy
citation are overrepresented in, for example, elective sur-
stuffed animal give the team the opportunity to maintain its
geries and allergic reactions, every practice should be
resuscitation skills. Debriefing after training or an actual CPR
prepared to perform CPR [2–5].
event is very valuable [7].
Preparing for a Cardiopulmonary Arrest

Notifying the Staff of Cardiopulmonary Arrest
Studies regarding preparation for CPR have given credence The veterinary care team must be alerted immediately
to the rules of the 5 P’s – “proper preparation prevents poor when a CPA occurs. Therefore, each practice should have
performance” – as preparation does affect outcome. in place a system that notifies the team of a CPA event.
Appropriate equipment and drugs must be available, and Notification can be in the form of an overhead page or an
just as importantly, staff members at all levels must be ade- internal audible alarm. Either or both should be predeter-
quately trained to fulfill their roles during an arrest event. mined and universally recognized by the hospital team.
The Reassessment Campaign on Veterinary Resuscitation Ideally, the signal chosen is one that does not alarm cli-
(RECOVER) initiative has developed guidelines for veteri- ents; ubiquitous terms such as “code blue” strike fear into
nary CPR. These guidelines are the collaborative product every client whose pet is not with them. Once a CPA is
of over a hundred specialists modeled after human CPR suspected, the system is activated, and the resuscitation
guidelines. The RECOVER Guidelines serve as a primary team reports immediately to the predetermined resuscita-
reference for veterinary CPR; they are available open access tion area or the location where the CPA has taken place.
on the RECOVER website [6]. The ideal size of the resuscitation team in veterinary
262 Cardiopulmonary Resuscitation
medicine has yet to be determined as conflicting data

Box 20.1 Basic Supplies for Cardiopulmonary
from academic institutions exist [4, 5]. While it may
Resuscitation
impair performance to have too many people present,
having too few rescuers results in resuscitator fatigue, Ventilation:
lack of efficient execution, and inadequate record keeping
● Laryngoscope with blades and endotracheal tubes
and client communication.
and/or tight-fitting face masks
● Muzzle gauze or tubing to secure endotracheal tubes
Cuff inflation syringe(s)
Equipment and Drugs Required
●
● Suction device
Equipment and drugs used in CPR should be readily avail- ● Lidocaine 2% solution in an atomizer or needle-
able. A tackle box with CPR supplies kept in a consistent less syringe
place, usually near the surgery suites or treatment area, is ● Bag–valve (adult, pediatric, neonatal) or other equip-
the minimum recommended for day practices that do not ment that can provide positive pressure ventilation
routinely see emergency cases. A list for basic resuscitation ● Oxygen source
supplies can be found in Box 20.1. Emergency hospitals
Monitoring:
usually designate a central area for all CPR supplies, often
with a multidrawer resuscitation (or “crash”) cart, oxygen, ● electrocardiograph with leads attached
and suction readily available. ● Electrode conductive gel
Resuscitation boxes and carts are available from medical ● End-tidal CO2 monitor (capnometer) with airway adapters
suppliers; however, tackle boxes and tool carts can provide
Intravenous (IV) access:
alternatives (Figure 20.1). Some practices maintain
mechanical means to seal the crash box or cart to ensure its ● IV and intraosseous access supplies
integrity, whereas others incorporate CPR supplies with ● IV fluids and administration sets
those used in intravenous (IV) access, treatments, or anes- ● IV flush (0.9% saline)
thetic inductions to maintain familiarity and maximize
Drugs:
efficiency of space and resources [7, 8].
A checklist is necessary to ensure the crash cart or box ● Emergency drugs
and other related equipment are adequately stocked and in – Atropine
working order. The checklist and any necessary restocking – Epinephrine ± vasopressin
should be performed as personnel begin and end shifts, – Sodium bicarbonate
and after each resuscitation (Chapter 4). Specific consider- – Amiodarone or lidocaine
ations for CPR-related supplies follow. ● Syringes (1–6 ml) and needles
● Anesthetic reversals
Items Used During Cardiac Compressions to Enhance – Naloxone

Blood Circulation – Atipamezole
While the current paradigm dictates starting compres- – Flumazenil
sions as soon as a CPA is suspected, no specialized equip- Defibrillator
ment is needed to provide closed-chest compressions; Reference and records:
however, open-chest cardiac massage requires an emer-
CPR algorithm chart
gency thoracotomy. Equipment ranging from a pair of
●
Drug chart
mayo scissors to a complete thoracotomy pack can be con-
●
Post-arrest algorithm chart

sidered. See Chapter 19 for more information. IV fluids are
●
CPR patient record

only warranted in patients suffering a CPA with underly-
●
ing hypovolemia [7]; nevertheless, having IV fluids and

administration set(s) accessible is ideal. Impedance
threshold devices continue to be evaluated in veterinary does not routinely intubate or intubation cannot be per-
CPR and are a consideration in dogs over 10 kg [9–11]. formed, tight-fitting face masks are an alternative [12].
Lidocaine in an atomizer or needleless syringe is often
Items Required to Secure the Airway and Provide Positive needed for cats with laryngospasm, even in CPA situations.
Pressure Ventilation The suction system may range from a bulb syringe to a cen-
Laryngoscopes, cuffed endotracheal tubes of various sizes, tral suction outlet with a collection bottle, tubing, and
3- and 6-ml syringes to inflate tube cuffs, ties to secure Yankauer tip. A tracheostomy or cricothyroidotomy pack
endotracheal tubes, and a suction system are recom- or kit (Chapter 29) may also be a consideration to address
mended to gain control of the airway; however, if a practice true upper airway obstructions.
PrepPring fP p pPrrfepulfipPry PPres 263
during CPR and there is no substitute to evaluate the

effectiveness of chest compressions short of return of
spontaneous circulation (ROSC). As with ECGs, capnom-
eters can be purchased for a reasonable price on the used
human medical supply market; the fact that capnometers
are also valuable monitors of anesthesia makes acquiring
one reasonable for most practices [7, 14].
Intravenous Access and Drugs

To administer drugs in CPR, vascular access is achieved
through cephalic IV catheter, jugular catheter, or intraosse-
ous (commercial, spinal, or hypodermic) needle placement.
Cutdown supplies (i.e. scalpel blade, Kelly or mosquito
hemostats, and suture) are considerations for trained pro-
viders (Chapter 7).
If vascular access has failed, it is reasonable to deliver
drugs via a long, flexible catheter (e.g. red rubber tube,
infant feeding tube) threaded down the endotracheal tube
past the carina to deliver increased dosages of mediations
that are diluted in sterile water for injection. Naloxone,
atropine, vasopressin, epinephrine, and lidocaine (referred
to by the acronym NAVEL) can all be administered via this
route [7, 9]. In general, when drugs are given intratrache-
ally, one may consider the “three Ds”: double the IV dose,
dilute in a large volume of sterile water, and deliver at
the carina.
Appropriately sized syringes, needles, and perhaps ster-
ile water for injection should be stocked with the drugs.
Figure 20.1 “Crash” or resuscitation cart. Equipment and drugs Emergency Drugs Injectable atropine, and a vasopressor
used in cardiopulmonary resuscitation should be kept together
in a readily available, standard place. They can be easily stored (epinephrine and/or vasopressin) are the basic drugs used
in a tool chest or a purpose-specific box. in asystole and pulseless electrical activity, which are
common rhythms encountered in veterinary CPA. A
vasopressor, and possibly amiodarone or lidocaine, may be
Positive pressure ventilation is generally performed dur- useful in ventricular fibrillation or pulseless ventricular
ing in-hospital CPR; it can be provided by an adult or pedi- tachycardia; however, they are only adjuvants and not
atric bag–valve–mask (without the mask), a nonrebreathing substitutes for electrical defibrillation. Sodium bicarbonate
circuit, or an anesthetic machine connected to an oxygen is used in cases of prolonged arrest, pre-existing acidemia,
source [7, 13]. and hyperkalemia [7, 9].
Monitoring Anesthetic Reversals Anesthetic reversals such as naloxone,

Beyond basic life support of compressions and ventilation. atipamezole, and flumazenil are recommended if narcotics,
an electrocardiogram (ECG) is required to assess the car- alpha-2 agonists, and benzodiazepines are used in the
diac arrest rhythm to determine specific CPR treatments practice, respectively [7, 9].
(e.g. drugs, need for defibrillation). With the wide range of
ECGs available at many price points (including refurbished Ventricular Fibrillation/Pulseless Ventricular
ones) and the fact an ECG is an important monitoring tool Tachycardia Treatment
for anesthesia, it is reasonable that every practice should The only consistently effective treatment for pulseless ven-
consider having one. Electrode gel is needed to obtain a tricular arrythmias is electrical defibrillation; therefore,
diagnostic ECG, while isopropyl alcohol is avoided during serious consideration should be made to acquire a defibril-
CPR due to the explosion hazard in the presence of an elec- lator. There are two basic types of electrical defibrillators:
tric defibrillator. monophasic and biphasic, which refers to the pattern of
Post-apneic end-tidal carbon dioxide (PetCO2) measured energy delivery between the paddles. Biphasic defibrillators
by a capnometer has proven to correlate with circulation require less energy than monophasic ones, which means
less myocardial damage during defibrillation. Biphasic defi- Post-Cardiac Arrest Care
brillators are available on the veterinary market, and refur- Immediate and prolonged critical care of the reanimated
bished human models can be purchased online. Monophasic patient is crucial to avoid rearrest and to maximize the
defibrillators continue to be available primarily on the potential for a good (neurological) outcome. Maintaining
resale market. Defibrillation units usually include an ECG adequate ventilation, oxygenation, and blood pressure is
monitor, which helps justify their cost. paramount. Monitoring blood pressure directly with a
The unit should remain connected to an electrical outlet transducer system or indirectly with a Doppler or oscillo-
to keep the internal battery charged. Electrode gel is required metric monitor allows titration of pressors such as norepi-
as a coupling substance between the paddles and the patient; nephrine, vasopressin, or epinephrine. Dysrhythmias,
as mentioned previously, isopropyl alcohol and other chem- which are often encountered after ROSC, can compromise
icals are strictly avoided because they can create an explo- perfusion and further tax the myocardium, so continuous
sion hazard [7, 9]. See Chapter 22 for more information. ECG monitoring is warranted, together with appropriate
antiarrhythmic use. Oxygen supplementation may be
References and Records needed to maintain normoxemia, monitored by arterial
Copies of the RECOVER algorithms and drugs charts should blood gas analysis or pulse oximetry. Normocapnia,
be readily available to reference during a CPA. The algorithms assessed by arterial or central venous blood gas analysis or
act as a checklist even for the most experienced clinician. capnometry (measuring PetCO2), is maintained as needed
Drugs charts provide for the efficient and accurate adminis- with PPV. A critical-care ventilator is ideal in this situation;
tration of drug and defibrillation dosages. They can be down- however, anesthetic ventilators and “hand bagging” (man-
loaded from the RECOVER website or wall size ones can be ual inflation using a bag–valve, Bain’s circuit, or anesthetic
purchased at the Veterinary Emergency and Critical Care machine and circle system) may be adequate.
Society website. A dedicated recording sheet allows for CPR Lastly, as every organ system will have suffered some
treatment documentation during real time and can also be degree of ischemia and secondary reperfusion injury, mul-
used to accumulate data for research (Figure 20.2) [7, 15]. tiple organ dysfunction syndrome should be anticipated
Figure 20.2 Standard Reporting Form for cardiopulmonary resuscitation. Source: Reprinted with permission from Boller et al. [15].
PrepPring fP p pPrrfepulfipPry PPres 265
Figure 20.2 (Continued )
and addressed as needed with appropriate monitoring and allows for the determination of systolic blood pressure.
treatment beyond the scope of this chapter [7, 16]. Because Precipitously decreasing heart rates, pulse intensity, severe
of the frequency and severity of post-resuscitation compli- tachyarrhythmias or bradyarrhythmias, or hypotension
cations, hospitalization at a 24-hour emergency and spe- can all lead to CPA. An ECG provides more detailed infor-
cialty facility is recommended. mation regarding the heart’s rate and rhythm and is a
valuable tool for rhythm evaluation. Pulse oximetry has
technical challenges but any changes in the waveform or
oxygen saturation should be investigated rather than
Recognizing Cardiopulmonary Arrest assumed to be a false alarm. Precipitously decreasing
PetCO2 values or a downward stair-stepping capnogram
Early recognition of a CPA and institution of resuscitative can signal an impending CPA (Chapter 30). While not
efforts are paramount to a successful outcome. The deci- every alarm or abnormality signals an impending arrest,
sion to initiate CPR will often fall on the veterinary techni- the integration of available information into an accurate
cian caring for a pet in the intensive care unit, in the clinical picture can help prevent CPA or give the care-
surgical suite area, or during triage. Depending on the indi- giving team some warning that CPR will be required soon.
vidual state board rules, standing orders should be devel-
oped by the veterinarians in the practice so that veterinary
technicians can initiate CPR and lead the effort until a vet- Initiating Basic Life Support
erinarian is available to direct the resuscitation effort.
The veterinary technician should be vigilant in monitor- Chest compressions should be initiated immediately when
ing anesthetized patients and those that are critically ill for any caregiver recognizes unconsciousness combined with
signs of impending arrest and should be proficient in triage apnea; the decision to start compressions based on these
to recognize patients presenting to the practice with imme- clinical findings should be made and compressions initiated
diately life-threatening signs. The best treatment for CPA is within 10seconds. While assessing and starting compres-
not CPR but rather prevention of the CPA in the first place. sions, this caregiver signals the team with the predetermined,
Once a CPA is suspected, CPR is instituted immediately universally understood signal. The team may include non-
by the closest available caregiver unless a do not attempt traditional caregivers such as receptionists and kennel or
resuscitation order is in place. The caregivers should be maintenance personnel, who can be invaluable by assisting
aware of the desires of the pet owner regarding advance in the resuscitation or record keeping. As stated previously,
resuscitative directives (i.e. “code status”) of hospitalized these individuals should not only be acquainted with their
pets. Code status should be communicated in patient roles prior to being called upon, but also have ample practice
rounds and should appear in a predetermined, consistent, and be proficient in the tasks they are being asked to carry out.
and standardized fashion in the patient’s record, treatment Each member of the resuscitation team plays a key role
orders, cage card, and/or identity collar. in executing CPR. Many of the skills and much of the
Patients that collapse, lose consciousness, or have absent knowledge are general nursing skills and not specific to
spontaneous respirations (i.e. no chest movement) have CPR, such as endotracheal intubation; however, there are
signs that suggest CPA. All patients undergoing CPA experi- caveats to those basic skills and specific ones to resuscita-
ence these signs, but not all patients with these signs are tion that cumulate into effective CPR.
necessarily dying. That being said, chest compressions are Ideally, interventions are executed simultaneously but if
immediately indicated if evaluation over a period of no activities must be prioritized, they are in this order [7, 13].
longer than 10 seconds reveals the animal is unconscious
and making no attempts to breathe.
In the anesthetized or critically ill patient, monitoring
Compressions
equipment provides useful information in a nonrespon-
sive, perhaps not spontaneously breathing patient. Once the diagnosis of pulselessness is established, circula-
Esophageal stethoscopes, Doppler blood pressure flow tion must be established and maintained until the underly-
detectors, and multiparameter monitors that measure and ing cause of the CPA is addressed and ROSC is obtained.
report vascular pressures, pulse oximetry, PetCO2, and ECG The primary goal of this assisted circulation is to support
are invaluable in the recognition of an impending arrest. the heart and brain, and external chest compressions are
The esophageal stethoscope is a cost-effective tool that initiated immediately.
can alert the anesthetist to real-time changes in the apex Closed-chest CPR is theorized to propel blood forward by
beat’s rate, rhythm, or intensity; a Doppler blood pressure the cardiac pump and the thoracic pump models. The car-
flow detector does the same for peripheral pulses and diac pump theory states that blood circulates during chest
Initiating Basic Life Support 267
compressions due to direct compression of the ventricles injuries) and pulling the tongue rostrally may open a closed
with intact atrioventricular valves preventing retrograde airway and allow for spontaneous breathing. Suction any
flow. The thoracic pump theory states that blood circulates material from the caudal pharyngeal or laryngeal area. The
during external chest compressions because compression endotracheal tube must be secured to ensure the airway
increases intrathoracic pressure, which results in a pres- remains patent and to minimize tracheal trauma.
sure gradient from the thin walled and valved veins to the While the endotracheal tube is in place, any time the
thick-walled arteries; release of compression leads to patient is moved, and intermittently during the resuscita-
venous refilling. Both theories are probably at work, but tion, tube placement should be confirmed. This is accom-
the cardiac pump is suspected to predominate in smaller plished by (bilateral) thoracic and stomach auscultation to
animals or in keel shaped chests. In such patients, hand ensure that breath sounds and not bubbling are heard, by
placement is over the heart (fifth–sixth intercostal space, visualization of the tube traveling through the arytenoids,
just caudal to the elbow) in lateral recumbency or circum- by direct palpation of tissue (larynx) around the tube
ferentially around the thorax. In patients with larger and 360 degrees, and supported by capnometry with measure-
barrel shaped chests, the hands are probably best placed ment of some carbon dioxide.
over the widest portion of the thorax in lateral recumbency Once the endotracheal tube is in place, it is connected
or over the caudal sternum in dorsal recumbency (be care- to a bag–valve or an anesthetic circuit with bag reservoir.
ful to avoid the xyphoid). The bag is squeezed to provide a breath and is then
Compressions are performed at a rate of at least allowed to recoil completely to avoid positive end-
100 compressions/minute, decreasing the thoracic diameter expiratory pressure; expiration occurs passively and
by approximately one-third, and maintaining a ratio (“duty should occur without resistance. When using an anes-
ratio”) of 1 : 1 for compression and relaxation. During the thetic machine, before attaching the system to the
non-compression phase, all pressure should be released patient’s endotracheal tube, the circuit must be flushed of
from the thorax to allow for low intrathoracic pressures and any anesthetic gas by depressing the oxygen flush valve
thus venous return to the right heart. It is imperative that and squeezing the reservoir bag into an open pop-off
chest compressions are not interrupted for greater than valve. The expiratory pop-off valve is then closed to gener-
10 seconds as coronary perfusion pressures return to zero ate a good breath using the reservoir bag, then opened
and take minutes to return. This lag time from compres- again to avoid excessive gas accumulation in the system
sions to a perfusing coronary and cerebral perfusion pres- and high pressure in the airways. The opening and clos-
sure is justification to start CPR with compressions. ing of the pop-off valve must be repeated to generate
If closed-chest CPR is not effective (see below under breaths. When using a Bain’s nonrebreathing circuit, the
monitors), several alternatives can be employed. Changing tip of the reservoir bag must be occluded as with the pop-
compressors, altering placement of hands, varying the off valve.
compression rate, and varying compression depth may Oxygen flow is required to provide a volume of gas in the
offer some benefit. Interposed abdominal compressions, reservoir bag. Even the standard “semi-closed” anesthetic
which are performed midway between the umbilicus and circuit, when used as described above, requires relatively
xyphoid to generate a pressure of 100 mmHg, are reasona- high fresh gas flow rates to fill the reservoir bag such that
ble if trained personnel are available. If the patient’s size fresh gas is available for each breath. Bain’s and other non-
and conformation are amenable, you can place one hand rebreathing circuits generally require fresh gas flows twice
on the chest and one hand on the belly; interposed abdomi- the minute volume (200–250 ml/kg/minute) to avoid
nal compressions are then accomplished by alternating rebreathing.
compressions between the left and right arm [7, 13]. Bag–valve systems can be used with just room air; while
In veterinary and human medicine, debate continues there is some consideration given to detrimental effects of
regarding the use and timing of open-chest compressions. hyperoxia during CPR, the recommendation is to still sup-
If there is a chest-wall defect or loss of compliance, pene- plement oxygen as per the manufacturer and models rec-
trating thoracic trauma, cardiac tamponade, or pleural ommendations, especially if hypoxia has contributed to
space disease, an emergency thoracotomy is recommended. the arrest.
See Chapter 21 for a discussion of open-chest CPR. PPV should be performed at a rate of 10 breaths/minute,
a tidal volume of 10 ml/kg and a short inspiratory period of
one second, as more aggressive ventilation has negative
Providing Ventilation
effects on coronary perfusion pressure, cardiac output, and
Simultaneous to starting compressions, an airway should survival. Ventilation should be provided in this pattern
be established with a cuffed endotracheal tube (Chapter 28); without regard for compressions; compressions are not
extending the neck (in the absence of suspected cervical paused for ventilation.
While pharmacologic respiratory stimulants are avoided, bicarbonate will increase PetCO2; and note that pressor
the acupuncture GV 26 site has been reported to increase administration will cause the PetCO2 to drop. A dramatic
respiratory rates in CPA and is stimulated by placing an rise in PetCO2 often reflects ROSC as the increased concen-
approximately 25-gauge needle into the nasal philtrum [17]. trations of carbon dioxide are washed out from the newly
perfused venous system [7, 14, 18].
Electrocardiogram evaluation is needed to decide on
Cardiopulmonary Resuscitation Basic Life
appropriate interventions based on cardiac rhythm, so
Support Cycle
ECG leads are connected prior to completion of the first
Two minutes of chest compressions completes a cycle. If a cycle, avoiding alcohol as a conductor in the presence of a
caregiver is a sole rescuer, two breaths are given at the end defibrillator.
of the two-minute cycle rather than breaths being deliv-
ered every six seconds throughout. At the completion of
Vascular Access
each two-minute cycle, advanced life support interventions
are considered, and chest compressors are exchanged to Vascular access is obtained in anticipation of administering
prevent fatigue. During this exchange between cycles, drugs. In CPR, drugs are ideally delivered by the central
compressions are interrupted for no more than 10 seconds. intravenous route; however, the intraosseous or cranial
peripheral intravenous routes (such as the cephalic veins)
are acceptable as well. Intraosseous needles can be placed
Advanced Life Support into the proximal humeral condyle, medial proximal tibia,
or the proximal lateral femur; the trochanteric fossa of the
Ideally simultaneous to instituting basic life support, femur can be used in neonates. If vascular access cannot be
advanced interventions are initiated to include attaching obtained, the intratracheal route can be used. The desire for
monitors, namely ECG and a capnometer, obtaining vascu- central/cranial vascular access must be weighed against the
lar access, and administering reversal agents for pertinent vascular access present at the time of a CPA and the team’s
anesthetics or sedatives on board. ECG evaluation leads to experience in gaining access through cutdown and intraos-
rhythm-specific interventions consisting of drug adminis- seous methods. While flushing 5–20 ml of 0.9% saline after
tration and/or electrical defibrillations. an intravenous administration can be helpful in getting the
drug distributed, routine fluid administration should only be
considered in known cases of hypovolemia as fluid adminis-
Monitors
tration in normovolemic CPA is associated with worse
Pulse checks and pupil size do not offer dependable feed- outcomes.
back to the quality or effectiveness of CPR in dogs and cats. Intratracheal administration can be used for NAVEL. For
While direct arterial pressure monitoring with an indwelling intratracheal administration, drug doses should be at least
arterial line with a diastolic arterial pressure greater than doubled (and in the case of epinephrine, the “high dose”
30 mmHg is associated with ROSC, having this in place is used); suspended in 5–10 ml of sterile water for injection
rare. A capnometer to measure PetCO2 is a simple and inval- (preferable) or 0.9% NaCl; injected via long red rubber or
uable monitor that attaches to the endotracheal tube and polypropylene catheter to the level of the carina; and fol-
provides real-time feedback regarding effectiveness of chest lowed with two breaths [7, 9].
compressions. The presence of CO2 in exhaled gas requires
the delivery of oxygen from the lungs to tissues, respiration
Anesthetic or Sedative Drug Reversal
at the level of the cells, then return of CO2 to the lungs that
is subsequently ventilated to the detector. Poor chest com- Anesthetic or sedative drugs that may have contributed to or
pression technique leads to poor blood flow to and from tis- are in effect during a CPA should be reversed. For example,
sues, and subsequently lower PetCO2. Thus, when PetCO2 is naloxone should be administered when a narcotic has been
less than 15 mmHg during a CPR event, every effort should used, flumazenil with a benzodiazepine, and atipamezole
be made to improve chest compression technique by altering with an alpha-2 agonist. As discussed under ventilation,
hand position, optimizing rate, ensuring adequate compres- inhalant anesthetic gas should have already been flushed
sion depth and full chest recoil between compressions, and from the system if one was in use at the time of CPA [7, 9].
minimizing hands-off time. End-tidal expired CO2 tensions
exceeding 15–18 mmHg increase the likelihood of ROSC
Electrocardiogram and Patient Evaluation
and survival in veterinary and human studies. When using
PetCO2to monitor the efficacy of CPR, the team must pro- As discussed above, compressors are changed after a two-
vide a steady breathing rate because alterations in breathing minute basic life support cycle while the ECG is evaluated for
rate affect PetCO2; be aware that administration of a brief (<10seconds) period. The protocols for treating the
fest- pPrrpac PPres pPr 269
bradyarrhythmias (pulseless electrical activity or asystole) harmful than monophasic. After delivering the appropri-
differ from those used to treat ventricular fibrillation and ate monophasic dose of 4–6 J/kg or biphasic dose of 2–4 J/
pulseless ventricular tachycardia. Thus, the ECG is invalua- kg, compressions are immediately resumed to feed the
ble in distinguishing these two arrest rhythm patient heart much needed oxygen and energy and the ECG is
populations. It is important to remember that the CPA evaluated at the end of a complete two-minute cycle.
patient’s ECG rhythm can change through the CPR effort. As Antiarrhythmics have a very limited role during ventric-
an example, in a recent study, 15% of the dogs had a present- ular fibrillation. Amiodarone has replaced lidocaine as
ing ECG finding of ventricular fibrillation but over more adjunctive therapy in people for shock-resistant ventricu-
than twice that number experienced ventricular fibrillation lar fibrillation and the suggested veterinary dose is 5 mg/kg
during the CPR event [5, 7]. IV. If amiodarone is unavailable and shock-resistant ven-
tricular fibrillation persists despite countershocks, lido-
caine at 2 mg/kg IV may be considered.
Vasopressors
Caregiver safety is paramount during defibrillation and is
Compressions alone are unlikely to provide enough circu- ensured by not using isopropyl alcohol for electrode conduc-
lation to the heart to enable its return to function. A vaso- tivity (either for defibrillator or ECG electrode contact), observ-
pressor is warranted in CPA to help increase coronary ing for caregiver-patient contact prior to paddle discharge, and
perfusion pressures to a level associated with ROSC, no announcing the impending delivery of the shock to ensure all
matter the initial ECG rhythm. caregivers including the defibrillator is “CLEAR!” [7, 9].
Currently, epinephrine is still considered the first-line For a more detailed discussion of defibrillation see Chapter 22.
vasopressor and is administered at a dose of 0.01–0.02mg/kg,
repeated every three to five minutes. “High-dose” (0.1–0.2mg/kg)
epinephrine has not been shown to be superior (except in Return of Spontaneous Circulation
intratracheal administration or in prolonged CPR) over “low-
dose” (0.01–0.02mg/kg) epinephrine. For endotracheal ROSC should occur in one-third to one-half of all CPA
administration, a higher dose is used to ensure high enough patients, and while survivors tend to respond sooner, there
blood concentrations that vasoconstriction is achieved. are documented successful efforts exceeding 20 minutes in
Vasopressin is an alternative to epinephrine in CPR, and reversible causes of death in otherwise healthy patients.
it may be used once at 0.8 iu/kg as an alternative to epineph- Veterinary studies have survival to discharge at 2–5%, so
rine, either initially or in place of subsequent doses [7, 9]. there is a large gap between the percentage of patients
undergoing a CPA that experience ROSC and those that are
discharged home. This gap represents an opportunity to
Parasympatholytics
improve post-cardiac arrest care [5, 7].
Atropine has been used regularly in CPR but its usefulness
especially beyond cases with high vagal tone continues to
be questioned. It is reasonable to administer atropine at a Post-Cardiac Arrest Care
dose of 0.04 mg/kg IV every other cycle in cases of bradyar-
rhythmias (but not fibrillation) [7, 9]. Post-cardiac care should be addressed with the same urgency
and intensity of CPR for a CPA; an algorithm is available
from RECOVER to address this precarious time. Like CPR,
Buffers
ideally several interventions are occurring simultaneously,
Sodium bicarbonate continues to be the buffer recommended but if resources are limited, they are prioritized to normocap-
in CPR for cases of pre-existing severe metabolic acidosis or nia, normoxemia, normotension, and then neuroprotection.
after prolonged (>10minutes) of CPA. Additionally, alkalini- Normocapnia requires evaluation of PetCO2 or arterial
zation is suggested in hyperkalemia, a reversible cause of blood gases and likely some degree of PPV for some time.
CPA. Currently, sodium bicarbonate is recommended at Normoxemia can be evaluated with pulse oximetry or arte-
1mEq/kg slow IV, repeated every five minutes [7, 9]. rial blood gases and may require oxygen supplementation
and PPV. In the face of a stunned heart and acid–base
abnormalities, hypotension is likely to ensue after the CPR
Fibrillation Treatment
vasopressor is metabolized; monitoring blood pressure
The definitive treatment for ventricular fibrillation is elec- with vasopressors, fluids and inotropes at the ready is rec-
trical defibrillation. A precordial thump can be attempted ommended. Pain, residual pressor, or brain dysfunction
in the absence of a defibrillator, but electrical defibrilla- may result in hypertension and should be addressed if
tion is by far the most effective treatment with biphasic noted. Normalizing serum lactate and keeping the PCV
(energy flowing in two directions) more effective and less greater than 25% rounds out hemodynamic optimization.
Neuroprotection is an area with ongoing research, but Intensive care is needed to address the complex pathol-
seizures are known to be detrimental and should be treated ogy in the post-resuscitation phase following ROSC. As for
if observed. Hyperosmotic agents can be used to address any patient with global ischemia and reperfusion, systemic
known or highly suspected cases of increased intracranial inflammatory response syndrome, multiple organ dysfunc-
pressure. Targeted temperature management is also a con- tion syndrome, or disseminated intravascular coagulation,
sideration. In a dedicated intensive care unit, induction of the caregiver is faced with vigilant monitoring of and com-
mild hypothermia at 32–34°C for 12–24 hours after ROSC prehensive care for every organ system to affect a success-
is recommended, whereas active rewarming above these ful outcome in providing CPR. If that care cannot be
temperatures may best be avoided if referral is being provided, referral should be considered but only after res-
considered. piratory and hemodynamic optimization as above [7, 16].
References
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2 Waldrop, J.E., Rozanski, E., Swanke, E.D. et al. (2004). emergency, critical care groups hold symposium.
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Emerg. Crit. Care 2 (2): 57–65. during cardiopulmonary resuscitation in dogs. Front. Vet.
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5 Mcintyre, R.L., Hopper, K., and Epstein, S.E. (2014). 14 Brainard, B.M., Boller, M., Fletcher, D.J. et al. (2012).
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6 Reassessment Campaign on Veterinary Resuscitation. 15 Boller, M., Fletcher, D.J., Brainard, B.M. et al. (2016).
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cpr-guidelines/current-recover-guideline (Accessed hospital cardiopulmonary resuscitation in dogs and cats.
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7 Fletcher, D.J., Boller, M., Brainard, B.M. et al. (2012). (1): 11–34.
RECOVER evidence and knowledge gap analysis on 16 Smarick, S.D., Haskins, S.C., Boller, M. et al. (2012).
veterinary CPR. Part 7: clinical guidelines. J. Vet. Emerg. RECOVER evidence and knowledge gap analysis on
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271
21
Open-Chest Cardiopulmonary Resuscitation

Janelle R. Wierenga and Katherine R. Crosse
Cardiopulmonary arrest (CPA) is the single pathway to through closed-chest CPR is a potential indication for
death from any underlying disease and is common in small OCCPR with direct cardiac massage. The 2020 American
animal emergency and critical care medicine. Some under- Heart Association Guidelines for Cardiopulmonary Resus-
lying disease conditions are treatable in the acute CPA set- citation and Emergency Cardiovascular Care state that
ting if they can be identified. Other disease conditions are OCCPR is recommended or may be considered for specific
not treatable or not identifiable in the acute setting, mak- indications [10]. The guidelines recommend OCCPR in the
ing resuscitation efforts from CPA difficult. Immediate car- case of intraoperative arrest during a laparotomy or thora-
diopulmonary resuscitation (CPR) is indicated in sudden cotomy procedure, or in the case of CPA shortly following a
cardiac arrest. Delay in initiation of cardiac compressions cardiothoracic surgery (class IIa, level of evidence C), and
in CPR has been shown to decrease the likelihood of return previous guidelines state that it may be useful in some cases
of spontaneous circulation (ROSC). In human studies eval- of CPA secondary to penetrating trauma (class IIb, level of
uating delay of CPR in CPA due to ventricular fibrillation, evidence C) [11]. The emergency room thoracotomy, also
every minute of untreated ventricular fibrillation decreases called resuscitative thoracotomy, is recommended in the
survival by 7–10% [1]. Even with immediate CPR the most recent guidelines for human trauma patients: (i) with
chances of ROSC and survival to discharge are low in vet- signs of life (pupillary response, spontaneous ventilation,
erinary medicine at only 1–16% [2–6]. Survival rates presence of a (carotid) pulse, measurable or palpable blood
depend on the underlying disease condition, the inciting pressure, extremity movement, or cardiac electrical activity)
cause of the arrest, and the resuscitation efforts and timing. and penetrating trauma (strong recommendation); (ii) with
no signs of life and penetrating trauma (conditional recom-
mendation); (iii) with and without signs of life and pene-
I ndications for Open-Chest trating trauma in extrathoracic regions (conditional
Cardiopulmonary Resuscitation recommendation); (iv) with signs of life and blunt trauma
(conditional recommendation) [12]. Similarly, the recom-
“Open-chest” or “internal” CPR (OCCPR) through an mendations from the 2012 Reassessment Campaign on
emergency thoracotomy was the standard of care for CPA Veterinary Resuscitation guidelines state that OCCPR
in the early twentieth century [7]. Today, closed-chest CPR should be considered for dogs and cats “in cases of signifi-
is generally instituted first unless specific situations or dis- cant intrathoracic disease, such as tension pneumothorax
ease conditions exist that may be indications for immediate or pericardial effusion” (class IIB, level of evidence C)
OCCPR [7, 8]. A full discussion of closed-chest CPR can be though specific situations such as blunt or penetrating
found in Chapter 20. Few veterinary studies have evaluated trauma or massive caudal hemorrhage are unknown
outcomes of OCCPR, usually due to low case numbers; at this time [13, 14].
however, the likelihood of survival to discharge with closed After closed-chest CPR has been chosen as the first
compared with OCCPR does not appear to be clearly differ- method of CPR, there is controversy regarding whether
ent in these reports [2, 4–6, 9]. and when one should abandon closed-chest efforts and
Any condition that prevents healthcare workers from proceed to OCCPR. Some literature recommends initiat-
achieving adequate perfusion to the lungs, heart, and brain ing OCCPR if there is no response to external chest
272 Open-Chest Cardiopulmonary Resuscitation
28, 29]. Studies have shown significant increase in cardiac

Box 21.1 Possible Indications for Open-Chest
output, arterial blood pressure, forward blood flow, CoPP,
Cardiopulmonary Resuscitation
and cerebral perfusion pressure with internal cardiac mas-
● Failure of closed-chest cardiopulmonary resuscitation sage, and an increase in ROSC and improvement in neuro-
efforts logical outcome in canine models of CPA [19, 23, 27, 28,
● Pericardial effusion 30–32]. Nevertheless, the 2020 American Heart Association
● Pleural space disease Guidelines for Cardiopulmonary Resuscitation and
⚪ Pneumothorax Emergency Cardiovascular Care state that OCCPR “can be
⚪ Moderate to severe pleural effusion useful” as recommended in the specific situations men-
⚪ Diaphragmatic hernia tioned above [10].
● Thoracic wall trauma There are additional potential benefits of OCCPR. Unlike
⚪ Rib fractures external chest compressions, OCCPR allows direct visuali-
⚪ Penetrating thoracic injuries zation of the heart and assessment of ventricular filling.
The healthcare worker can directly evaluate for ventricular
fibrillation, asystole, or an atonic heart muscle during
compressions within two to five minutes [8, 15–19], while internal cardiac massage, which can help direct therapy
others allow 5–10 minutes of closed-chest CPR before con- when appropriate treatment is unclear during closed-chest
verting to OCCPR [20, 21]. There is a consensus, however, efforts. OCCPR also allows for the occlusion of the descend-
that if the healthcare team is going to perform OCCPR, it ing aorta, which maximizes cardiac output to the most cru-
should be initiated relatively early in the resuscitation cial organs: the heart, brain, and lungs. Descending aortic
effort. When instituted after 20 minutes of closed-chest compression is also useful in critical hemorrhage into the
compressions, internal cardiac massage does not increase abdomen by decreasing further blood loss.
the chances of ROSC [21–23]. When OCCPR is indicated in
blunt or penetrating trauma in people, it is recommended
that resuscitative thoracotomy be performed within 10 or reparing for Open-Chest
P
15 minutes, respectively [24]. It has been suggested that Cardiopulmonary Resuscitation
inadequate forward blood flow during closed-chest efforts
is more likely to occur in animals over 20 kg, in which the Equipment and Environmental Preparedness
thoracic pump mechanism probably predominates (see
Chapter 20) [25, 26]. Situations in which OCCPR may The equipment for open-chest CPR should be ready and
be indicated in dogs and cats are listed in Box 21.1. immediately available in a crash cart. Emergency thora-
cotomy equipment should be readily accessible in the crash
cart, preferably contained within a single sterilized surgical
ationale for Performing Open-Chest
R pack to improve the ease and speed of obtaining all neces-
Cardiopulmonary Resuscitation sary equipment. The sterile surgical pack equipment is
listed in Box 21.2 and shown in Figure 21.1. Sterile #10
Coronary blood flows from the proximal aorta into the scalpel blades should be readily available anywhere patient
myocardium via the coronary arteries during diastole; most CPA is likely, along with sterile gloves, clippers, aseptic
blood returning from the myocardium drains into the right scrub, and isopropyl alcohol. Devices for clamping the
atrium. Thus, coronary perfusion pressure (CoPP) is equal
to the difference between diastolic aortic pressure (DAoP) Box 21.2 Equipment in Surgical Pack for Open-Chest
and right-atrial pressure (RAP): Cardiopulmonary Resuscitation
CoPP DAoP RAP (21.1) ● Scalpel handle
● Mayo and Metzenbaum scissors
Research in animal models and in people with CPA has
● Hemostats
shown that adequate CoPP is associated with ROSC. A
● Needle holder
CoPP 15 mmHg or greater during CPR has been associated
● Sharp and blunt suture scissors
with increased ROSC and survival to discharge [19, 22, 27,
● Tissue forceps
28]. Clinical studies in people demonstrate an increase in
● Sterile gauze
CoPP and increased ROSC with internal cardiac massage
● Sterile drape
compared with external chest compressions [16, 22].
● Finochietto rib retractors if the lateral thoracotomy
Internal cardiac massage has been shown to produce CoPPs
approach is likely in your environment
three times greater than external chest compressions [19, 22,
PrepPring fPr erin-Crest pPrrfepulfipPry repesrstpstrfi 273
Figure 21.2 Penrose drain, umbilical tape, and vascular clamps

for clamping the descending aorta.
Figure 21.1 Surgical pack for emergency thoracotomy for
open-chest cardiopulmonary resuscitation.
The umbilical tape is passed around the descending aorta

descending aorta should also be aseptically prepared, such with both ends of the tape facing toward the operator
as Rumel tourniquet, Penrose drain, umbilical tape, or vas- (Figure 21.3a). A mosquito hemostat is fed through the
cular clamps (Figure 21.2). A device with similar function sterile tubing and used to grasp and thread the umbilical
to a Rumel tourniquet can be created using sterile, flexible tape through the tubing (Figure 21.3b). The length of tub-
tubing, umbilical tape, and hemostats. ing is then moved toward the vessel (Figure 21.3c) and the
vessel is compressed by the umbilical tape. The umbilical
Building a Tourniquet for Temporary tape is held in place around the compressed vessel by
Aortic Compression placing the hemostats perpendicularly on the umbilical
A 12–18 Fr red rubber catheter (or similar sterile tubing) tape next to the tubing on the operator’s side, as shown in
is cut to 3–4 cm in length with openings on both ends. Figure 21.3d.
(a) (b)
(c) (d)
Figure 21.3 Sterile tubing, umbilical tape, and hemostats that can be made (a–c) into a tourniquet for compression or clamping (d)
of the descending aorta (pink vertical structure).
Choice of Approach blade or Metzenbaum scissors to the level of the pleura.

Care should be taken to avoid lacerating intercostal ves-
In dogs and cats, OCCPR is traditionally performed
sels that run along the caudal aspect of each rib if possi-
through a lateral thoracotomy at the fourth, fifth, or sixth
ble. It is also recommended not to penetrate the pleural
intercostal space [31, 33]. However a transdiaphragmatic
space with the scalpel blade or scissors due to the poten-
approach via midline celiotomy has also been described,
tial for trauma to the lung parenchyma, heart muscle, or
with OCCPR being undertaken either during abdomi-
coronary vessels; this can be very difficult in the emer-
nal surgical procedures [34, 35] or as a stand-alone
gency setting.
approach [36]. The transdiaphragmatic approach to the
Manual ventilation of the patient should cease briefly
heart is done for other cardiac procedures including epicar-
while the pleura is bluntly penetrated with hemostats and
dial pacemaker placement and pericardiectomy [37–40].
the pleural entry extended dorsally and ventrally. Care
Although a lateral thoracotomy is current standard of care
should be taken to avoid laceration of the relatively large
for OCCPR, many practitioners are more experienced and
internal thoracic artery running parallel and dorsal to the
confident with a midline celiotomy versus a lateral thora-
sternum if possible. Finochietto rib retractors are placed
cotomy, which is a viable alternative.
between the ribs to provide intrathoracic exposure with
enough space to insert the hand for internal cardiac mas-
Performing an Emergency Lateral Thoracotomy sage. A rapid, careful partial pericardiectomy should be
performed if there is restrictive pericarditis. To achieve a
The patient should be placed in right lateral recumbency to
rapid, safe partial pericardiectomy, the pericardium is
prepare for a left lateral thoracotomy at the left fourth,
grasped with tissue forceps and an incision is made with
fifth, or sixth intercostal space as shown in Figure 21.4.
Metzenbaum scissors ventral to the phrenic nerve through
Throughout, external chest compressions should continue
the pericardium and extended ventrally. Pericardiotomy or
as is possible. The region is prepared quickly with minimal
partial pericardiectomy should be adequate to relieve tam-
fur clipping at the fourth through sixth intercostal spaces
ponade in the case of effusion. Direct manual cardiac mas-
and minimal cleaning with a surgical scrub. Sterile gloves
sage is then initiated (see Video 21.1).
are worn and the patient’s skin is incised along the cranial
aspect of the chosen rib extending from the dorsal aspect of
the scapula to 3–5 cm dorsal to the sternum. Performing an Emergency Transdiaphragmatic
Rapid transection of the latissimus dorsi, serratus ven- Thoracotomy
tralis, scalenous, and pectoral muscles will be necessary
The patient should be placed in dorsal recumbency.
to reach the external and internal intercostal muscles.
Throughout, external chest compressions should continue
The external and internal intercostal muscles are incised
in dorsal recumbency as is possible. The abdomen should
along the cranial aspect of the rib with either a scalpel
be prepared with clipping of the fur from the umbilicus to
just cranial of the xiphoid in a narrow strip and cleaned
with surgical scrub. A skin incision is made starting 5 cm
cranial to the xiphoid and extending at least 10 cm caudal
to the xiphoid using a #10 scalpel blade to ensure adequate
visualization of the fascial layer.
Following exposure of the xiphoid and linea alba, the
cranial linea alba is tented and punctured with the scalpel
blade, sharp aspect oriented upwards (as in a mid-line celi-
otomy). The incision in the linea alba is extended cranially
along the lateral aspect of the xiphoid and caudally to the
extent of the skin incision. This length of incision is to
ensure the operator’s hand and wrist can easily pass into
the incision. The diaphragm is visualized and may already
be punctured at the cranial aspect of the linea alba inci-
Figure 21.4 Placement of patient and location of incision for sion. Ventilation should be paused while the diaphragm is
emergency thoracotomy to perform internal cardiac massage. incised at the xiphoid. This incision is extended ventrally
Patient is placed in right lateral recumbency for a left lateral from the xiphoid with either a scalpel or mayo scissors to
thoracotomy at the left fourth to sixth intercostal space. The
end ventral to the central tendon. The incision should be
skin is incised along the cranial aspect of the left fourth to sixth
rib extending from the dorsal aspect of the scapula to 3–5 cm only large enough for the operator to pass their flat hand
dorsal to the sternum. through to the thorax. If required, a pericardotomy or
Augmentation Techniques 275
partial pericardiectomy can be performed prior to initia- minimal interruption to compression to avoid decreased
tion of compressions [37] (see Video 21.2). coronary perfusion that could occur with hand fatigue.
Each compressor should wear sterile gloves for internal
cardiac massage [10, 11, 44, 47]. Hand placement is impor-
omplications of Thoracotomy in the
C tant, as inadvertent penetration of the heart muscle with
Emergency Setting fingers can occur, leading to catastrophic hemorrhage
(Figure 21.5d). It is recommended to cup the hand around
Complications associated with emergency thoracotomy the heart using either the one- or two-handed technique
include laceration of vessels such as the lateral thoracic for internal cardiac massage.
vessels along the sternum, intercostal vessels, or coronary
vessels; laceration of the lung parenchyma, leading to leak-
age of air from the lungs and the potential need for suture Internal Defibrillation
closure or a partial or complete lung lobectomy; laceration
of the liver parenchyma (via transdiaphragmatic approach), The heart should be evaluated visually and by gentle palpa-
leading to hemorrhage; laceration of the heart muscle, tion for adequate filling, atonic musculature, and ventricu-
leading to profound hemorrhage; penetration into a car- lar fibrillation during OCCPR. The heart is directly
diac chamber, leading to exsanguination; or rib fractures accessible for defibrillation if indicated. In small animals,
secondary to overzealous retraction with the rib retrac- asystole and pulseless electrical activity are the most com-
tor [6, 36]. The complication rate associated with the proce- mon arrest rhythms, although one study found that ven-
dure has been documented to be low in people even with tricular fibrillation was nearly as common [5, 6, 9, 14, 48].
the invasive, urgent nature of OCCPR. Fewer than 2% of Defibrillation in OCCPR can be performed with internal
people undergoing OCCPR experience iatrogenic cardiac defibrillator paddles wrapped in sterile saline-soaked gauze
trauma or injury associated with the thoracotomy [41, 42]. sponges and placed on either side of the heart. The energy
recommended for defibrillation in OCCPR is approxi-
mately one-tenth of the energy used for external defibrilla-
Performing Internal Cardiac Massage tion, using 0.5–1 J/kg of body weight [13, 14, 49, 50]. It is
recommended to perform internal cardiac massage imme-
Direct compression of the heart has been shown to triple the diately after defibrillation for one to three minutes before
CoPP compared with external chest compressions [19, 22, performing further defibrillation [13, 14, 49]. It is recom-
28, 29]. The heart can be massaged in a single hand, between mended to use the least amount of energy required to defi-
two hands, or between a hand and the internal thoracic wall. brillate the heart. Ventricular fibrillation is more difficult
Studies have shown that two-handed cardiac massage can be to convert if the patient has been in ventricular fibrillation
more beneficial than providing cardiac massage with one hand, for longer than five minutes or is refractory to increasing
although this is limited by patient size, heart size, patient con- doses of energy in defibrillation [13, 14, 49, 50]. See
formation, the entry site into the thoracic cavity, and the avail- Chapter 22 for more information.
ability of appropriate instruments such as rib retractors [43].
The heart can be palmed if it is small enough, squeezed between
two hands, or pressed up against the inside of the thoracic cav- Augmentation Techniques
ity to compress the chambers (Figure 21.5). Cardiac compres-
sion rates should be greater than 100 compressions/minute Internal cardiac massage increases the likelihood of ROSC
according to the 2020 American Heart Association Guidelines by improving CoPP. Augmentation techniques available
for Cardiopulmonary Resuscitation and Emergency during the thoracotomy required for OCCPR may help fur-
Cardiovascular Care [10, 44]. Rates of ≥120compressions/min- ther increase CoPP. For instance, compression of the
ute and up to 150compressions/minute have been associated descending aorta can increase CoPP and cerebral perfusion
with increased CoPP and perfusion to vital organs in dogs [26]. pressure by directing the cardiac output to cranial aspects
To allow for adequate refilling of the heart and to account for of the body. Descending aortic compression can also help
operator hand fatigue, realistic compression rates for internal prevent hemorrhage distal to the site of aortic occlusion.
cardiac massage of 100–120 compressions/minute are recom- The aorta can be compressed using a Rumel tourniquet,
mended [14, 26, 45, 46]. sterile tubing, Penrose drain, or umbilical tape that is
Sterile gloves should be used to decrease contamination passed around the major vessel (Figures 21.2 and 21.3).
of the thoracic cavity during the emergency thoracotomy Digital compression of the descending aorta can be per-
and internal cardiac massage. The compressor should be formed as an alternative to a tourniquet by gently com-
changed no less often than every two minutes with pressing the vessel dorsally against the ventral aspect of the
(a) (b)
(c) (d)
Figure 21.5 Hand placement techniques for internal cardiac massage: (a) a one-handed technique performed by palming the heart. Note
the flat orientation of fingers, parallel to the heart muscle; (b) a one-handed technique performed by compressing the heart against the rib
cage; (c) a two-handed technique for internal cardiac compression. Pane (d) depicts inappropriate finger orientation to demonstrate how
inadvertent penetration of the heart muscle can occur if the fingers point inward toward the heart during internal cardiac massage.
vertebral bodies [8]. After ROSC, aortic compression closing the thoracotomy or diaphragm [15, 54]. Closure of
should be gradually released over 10–15 minutes to help the thoracotomy or diaphragm and abdomen should be
minimize ischemia–reperfusion injury and cardiovascular performed aseptically, usually involving consultation with
collapse [15]. Another method used to control massive or closure by an experienced surgeon in a controlled envi-
traumatic hemorrhage in people, which has also been eval- ronment [54] (Videos 21.3 and 21.4).
uated in dogs, is a technique called resuscitative endovas- Absorbable monofilament suture (e.g. polydioxanone) or
cular balloon occlusion of the aorta (REBOA) [51–53]. wire is passed around the ribs cranial and caudal to the
REBOA is a less invasive technique using either anatomi- thoracotomy site, taking care to avoid entrapment of the
cal landmarks or fluoroscopy to deploy a catheter and bal- intercostal vessels on the caudal aspect of the ribs. This can
loon device into zones in the aorta to limit massive be done by passing the needle backward or using hemo-
hemorrhage, thereby salvaging cardiac output. REBOA is stats to bluntly pass suture around the ribs. The sutures are
not yet used in clinical veterinary medicine. tightened with a square knot closure with a minimum of
four throws. After the closure around the ribs, the tissue is
sealed and there is no longer communication with the
Post-Resuscitation Care
pleural space. Sometimes no fur clipping or surgical scrub
is possible prior to emergency thoracotomy; in such cases,
Surgical Closure
fur probably should not be clipped even once the thorax is
Emergency thoracotomy for OCCPR is invasive, traumatic closed, to prevent excessive intrathoracic fur contamina-
to the tissues, and is a clean to clean-contaminated tion (see Video 21.3). A thoracostomy tube can be placed
procedure that involves unique post-resuscitation care. aseptically prior to complete closure or thoracocentesis can
The opened cavity (or cavities) should be lavaged with be performed after closure to evacuate air from the pleural
sterile saline and intrathoracic samples should be collected space. Information on thoracostomy tube placement and
for anaerobic and aerobic cultures after lavage, prior to thoracocentesis is available in Chapter 34.
References 277
If a transdiaphragmatic approach has been made for system is recommended with serial neurological examina-
OCCPR, the diaphragmatic incision should be closed with tions, pupil size and symmetry, pupillary light reflex, palpe-
continuous or simple interrupted sutures using an absorb- bral reflex, and changes in mentation to evaluate for injury to
able monofilament material. The suture line should be the brain secondary to compromised perfusion [48, 55].
closed in a dorsal to ventral direction for surgical ease. The blood glucose and electrolyte concentrations and
After the diaphragm and therefore thoracic cavity is closed, acid–base status should be monitored frequently and
pleural drainage via chest drain or thoracocentesis can be abnormalities corrected as indicated. The patient should be
performed aseptically to resolve the pneumothorax. The monitored for organ dysfunction such as acute kidney
external fascia of the rectus sheath is then closed with a injury; insult to the gastrointestinal tract resulting in
simple continuous suture, or per the surgeon’s preference hematemesis, hematochezia, or melena; or injury to the
for routine mid-line celiotomy closure [36] (Video 21.4). liver leading to hepatic insufficiency or failure.
Antimicrobials and Analgesia
Summary
Owing to the need to enter the thoracic cavity quickly,
minimal preparation is performed prior to emergency thor- In summary, OCCPR may be indicated in specific disease
acotomy. Despite this, infection rates following OCCPR conditions such as those associated with pericardial dis-
are low, reportedly less than 10% in people [8, 41, 42]. eases, pleural space diseases, and thoracic wall injury.
Appropriate-spectrum intravenous antimicrobials should OCCPR may be indicated when external chest compres-
be instituted after ROSC; antimicrobials should be contin- sions do not result in adequate forward flow of blood dur-
ued as indicated based on patient status and degree of con- ing closed-chest CPR. OCCPR has been shown to result in
tamination during the thoracotomy. It is also important to increased coronary and cerebral perfusion pressures, and
remember that the patient successfully resuscitated after consequently increased ROSC and survival in certain cir-
an OCCPR effort has not usually received anesthesia or cumstances. The procedure to enter the thoracic cavity is
analgesia unless the arrest occurred intraoperatively. performed quickly to minimize the time that forward blood
Therefore, analgesia should be administered at safe doses flow is compromised. Emergency thoracotomy or transdia-
once ROSC has been established. phragmatic approach can lead to traumatic complications
such as vessel and intrathoracic or intra-abdominal organ
laceration along with infection, though reported complica-
Post-Resuscitation Monitoring
tion rates are low. Specific care is taken to decrease the inci-
Post-resuscitation monitoring and care measures are similar dence of infection and provide analgesia. Post-resuscitative
to those for patients resuscitated with external CPR. The car- care and monitoring is like that for any patient that has a
diovascular system should be evaluated frequently to contin- sudden cardiac arrest, with monitoring of all organ systems
uously by monitoring blood pressure and electrocardiogram, and intensive monitoring of the cardiovascular, respira-
and by serially evaluating the patient’s perfusion parameters tory, and neurologic systems.
such as mucous membrane color, heart or pulse rate, pulse
quality, and capillary refill time. The respiratory system Video 21.1 Left-lateral thoracotomy for emergency cardi-
should be monitored with pulse oximetry or arterial blood opulmonary resuscitation, fourth or fifth
gases for hypoxemia, end-tidal capnography for hypercapnia intercostal space.
secondary to hypoventilation, respiratory rate and effort eval- Video 21.2 Transdiaphragmatic approach for emergency
uation, and frequent auscultation of the thorax for decreased cardiopulmonary resuscitation.
lung sounds associated with a persistent or worsening pneu- Video 21.3 Left-lateral thoracotomy closure.
mothorax or pleural effusion. Monitoring of the neurologic Video 21.4 Transdiaphragmatic approach closure.
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281
22
Defibrillation
Casey J. Kohen
Fibrillation can be defined as a form of cardiac arrhythmia and giant breed dogs. Dogs in atrial fibrillation may present
marked by fine, irregular contractions of the cardiac mus- in congestive heart failure or for signs associated with
cle due to rapid, repetitive excitation of myocardial fibers decreased forward flow such as weakness, lethargy, or exer-
without coordinated contraction of the affected chambers. cise intolerance. Atrial fibrillation in cats is most often
Fibrillation reflects unsynchronized, random, and continu- associated with myocardial disease such as hypertrophic
ously changing electrical activity in the myocardium. cardiomyopathy. Atrial fibrillation may be managed medi-
Fibrillation is typically further categorized by defining the cally or through electrical cardioversion, which is a form of
chambers of the heart affected (i.e. atrial fibrillation or ven- defibrillation that is performed in a controlled setting and
tricular fibrillation). This additional level of categorization timed around ventricular conduction (see details later in
is essential because fibrillation of the atria and the ventri- chapter). Additionally, it is important to determine whether
cles have markedly different effects on cardiac output and atrial fibrillation is due to structural cardiac disease, as car-
usually have different underlying causes. dioversion in these cases is often unrewarding [1, 2].
Ventricular fibrillation and pulseless ventricular tachy-
cardia are far more acutely life threatening than atrial
Atrial Compared fibrillation. While atrial fibrillation leads to a loss of
with Ventricular Fibrillation atrial contraction, animals can survive without effective
atrial contraction if ventricular rates are not excessively
Atrial fibrillation results in the loss of coordinated atrial high. However, ventricular fibrillation results in ineffec-
contraction (the “atrial kick”), which reduces ventricular tive ventricular contraction and cardiac arrest, which is a
filling during diastole. Loss of coordinated atrial contrac- life-ending event unless a circulating heart rhythm is
tion during ventricular diastole can cause up to a 25% immediately restored. While atrial fibrillation is often the
reduction in diastolic filling. This lack of atrial contraction result of structural heart disease in dogs and cats, ventric-
can be overcome if there is adequate time for passive dias- ular fibrillation has been associated with a wide range of
tolic filling. However, when the atrioventricular (AV) node extracardiac causes, including shock, hypoxemia, electro-
conducts a high number of atrial impulses, the ventricular lyte and acid–base disorders, electrical shock, excessive
rate can be high (e.g. > 160 beats/minute in a dog). This sympathetic tone (or sympathomimetic agents), hypother-
form of supraventricular tachycardia compromises passive mia, and drug reactions. Structural heart disease or dam-
diastolic filling and, along with the loss of atrial contrac- age can also lead to ventricular fibrillation; examples
tion, can result in decreased cardiac preload and subse- include aortic stenosis, primary myocardial disease, and
quently smaller stroke volumes (Starling’s law of the heart). secondary myocardial disease (e.g. contusion, myocarditis,
Global tissue perfusion can suffer as a result. myocardial infarction) [3–7]. Heritable causes of ventricu-
Atrial fibrillation is often the result of atrial myocyte lar fibrillation must also be considered. A congenital dis-
injury secondary to structural cardiac disease (e.g. AV valve ease in a group of German Shepherd Dogs has been
insufficiencies, primary myocardial dysfunction); however, described in which related dogs are predisposed to sudden
atrial fibrillation can also occur in the absence of structural death due to ventricular arrhythmias including fibrilla-
heart disease (lone atrial fibrillation), particularly in large tion [7]. Boxer dogs with arrhythmogenic right ventricular
282 Defibrillation
cardiomyopathy are also at risk of ventricular tachycardia Generally, this is done in an attempt to convert an arrhyth-
and fibrillation [8]. mia to a sinus rhythm. Although in most patients, arrhyth-
Ventricular fibrillation is a noncirculating rhythm in that mias are addressed by administration of antiarrhythmic
stroke volume and thus cardiac output drop to nearly zero. drugs, electrical cardioversion may be attempted in refrac-
Within seconds of onset, patients with ventricular fibrillatory cases. The mechanism is the same as was described pre-
tion lose consciousness and pulses are absent. This is viously for defibrillation: the disruption of conduction
important to keep in mind when simultaneously evaluat- through aberrant re-entry pathways. Cardioversion is typi-
ing the patient and the electrocardiogram (ECG). If the cally reserved for supraventricular or ventricular tachyar-
ECG appears to indicate ventricular fibrillation yet the rhythmias that are severe enough that cardiovascular
patient is conscious and has pulses, then ECG artifacts due performance is compromised, the patient is symptomatic,
to such processes as muscle tremors or shivering should be and pharmacologic approaches have failed.
investigated. Conversely, the identification of ventricular
fibrillation in an unconscious patient with no palpable
pulses should prompt the immediate initiation of cardio- Equipment
pulmonary resuscitation (CPR) unless such resuscitation
has been previously identified as inappropriate for the It is strongly recommended that defibrillators be kept in
patient (see Chapter 20). Cardiac compressions should be the same area as a “crash cart” (Figure 20.1) or other area
started while the equipment for defibrillation is prepared. where CPR supplies are stored. Defibrillation equipment
should be routinely tested and maintained as per the man-
ufacturer’s instructions. All personnel who might be called
Defibrillation Compared upon to assist in CPR or cardioversion should be instructed
with Cardioversion in the operation of the equipment and where supplies and
accessories for the equipment are stored. Accessories and
Defibrillation is a process by which the entire myocardium supplies may include coupling gel, adhesive pads, pediatric
is depolarized simultaneously. Fibrillation rhythms depend external paddles, and a variety of sizes of internal paddles
on sustained activity of re-entry pathways, and the goal of for internal (direct epicardial) defibrillation. A minor sur-
defibrillation is to disrupt the aberrant conduction occur- gical pack and rib retractors should also be stored in the
ring via these pathways and thus terminate the fibrillatory same area for times when internal defibrillation is to be
rhythm. In theory, defibrillation may be achieved via elec- attempted.
trical, mechanical (e.g. precordial thump), or chemical Until the late 1980s, all defibrillators used monophasic
means. However, chemical and mechanical defibrillation waveforms to deliver defibrillatory energy. Monophasic
are rarely successful and should be considered only when defibrillators deliver a single pulse of positive current.
electrical defibrillation is unavailable [9, 10]. For the Monophasic current is unidirectional, traveling from one
remainder of this chapter the term defibrillation will refer paddle to the other (hopefully across the myocardium on
only to the application of electric current to the myocar- its way). Defibrillators manufactured after 1990 began
dium and not to chemical or mechanical defibrillation. using biphasic waveforms; biphasic defibrillators initially
Defibrillation is achieved via the delivery of electric cur- deliver a similar (but not identical) positive current fol-
rent to the myocardium and, as such, success depends par- lowed by a negative current in the opposite direction. The
tially on how much of the current applied to the patient application of biphasic current, when successful, allows for
reaches the myocardium. The current is delivered via the depolarization of the myocardium with the application of
paddles of an electrical defibrillator. Paddles may be lower total energy and thus less risk of myocardial damage.
applied either externally to the thorax, or internally to the All major manufacturers currently produce and sell bipha-
pericardium or epicardium. Impedance to current flow sic defibrillators.
depends on some factors that the clinician controls and Another recent development in defibrillators is the
some that they do not control. Factors that the caregiver degree to which the device can make decisions regarding
influences include dose of energy administered, paddle the diagnosis and treatment of the arrhythmia.
size, quality of tissue-paddle contact, and how much gas is Automated external defibrillators (AEDs) are designed to
in the chest (delivering energy at end-exhalation rather assist rescuers with minimal training to perform CPR,
than during inhalation is recommended). Factors outside defibrillation, and cardioversion in people. Currently
of the caregiver’s control include the absolute amount of there is no evidence regarding the effectiveness of AEDs
gas and tissue in the chest as well as the chest width. in veterinary medicine. Failure of the diagnostic algo-
Cardioversion involves the use of defibrillator equipment rithm used in an implantable defibrillator used to treat
to convert rhythms other than ventricular fibrillation. ventricular tachycardia in a Boxer dog should raise
Safety Concerns 283
Table 22.1 Recommended energy doses for defibrillation or synchronized cardioversion using monophasic or biphasic equipment.
Defibrillation Synchronized cardioversion
Monophasic Biphasic Monophasic Biphasic

Body
weight (kg) External (J) Internal (J) External (J) Internal (J) Lower dose (J) Higher dose (J) Lower dose (J) Higher dose (J)
2.5 10 2 6 1 1.25 10 1.25 10

5 20 3 15 2 2.5 20 2.5 20
10 40 5 30 3 5 40 5 40
15 60 8 50 5 7.5 60 7.5 60
20 80 10 75 6 10 80 10 80
30 120 15 100 9 15 120 15 120
40 160 20 150 15 20 160 20 160
50 200 25 150 15 25 200 25 200
60 240 40 150 15 30 240 30 200
concern about the risk of using AEDs designed for peo- Box 22.1 Critical Measures to Prevent Accidental
ple in veterinary medicine [11]. Recommended defibril- Shock in Health Care Workers
lation dosage ranges are listed in Table 22.1.
● The patient should lie on a nonconducting surface.
● No personnel should touch the patient or any surfaces
in contact with the patient at the time of shock delivery.
Safety Concerns
● Contact gel should not extend beyond the metallic
surface of the paddles.
Therapeutic application of electrical current can be done
A warning shout such as “Clear!” should be given
safely even in the hectic environment of CPR if specific
●
prior to shock delivery, with sufficient time for per-

procedural steps are taken. Attempting defibrillation with-
sonnel to actually get clear if they are not.
out having taken such steps runs the risk of significant
The operator should visually verify that personnel,
adverse events occurring such as accidental delivery of cur-
●
including themselves, are clear before delivering

rent to clinic personnel, burning the patient, or igniting the
the shock.
patient’s hair coat. These hazards may be particularly rele-
vant to the veterinary clinical setting wherein patients
often have thick, matted hair and may be receiving oxygen excessive coupling gel can lead to tracts of gel extending
(a flammable gas) via unsealed facemasks. These factors toward (or reaching) the hands of the person holding the pad-
may increase the risk of ignition compared with human dles, which could lead to inadvertent shock to the operator.
patients receiving similar care. The accidental delivery of Coupling gel is not applied to the surface of internal defibril-
current to clinic personnel can result in painful shocks, lator paddles. Instead, internal paddles are wrapped in one or
burns, and arrhythmias in the person accidentally dosed. two layers of saline-soaked gauze sponges (4 × 4-inches) prior
To avoid such a scenario, safety measures are imperative; to application to the pericardium or epicardium (depending
such measures are detailed in Box 22.1. on whether the pericardium has been opened).
Accidental patient burns are most likely to occur when While small- to medium-sized dogs may be placed in
skin–paddle contact is poor and arcing of electrical current dorsal recumbency for defibrillation, this position may
occurs, or when isopropyl alcohol is used for contact rather prove unsafe in some larger patients. Stabilizing a large dog
than gel. Contact gel intended for defibrillation paddles is pre- in dorsal recumbency using only the defibrillator paddles
ferred over other types of gels and pastes. These gels not only may place the person holding the paddles in such a posi-
enhance contact between the paddles and patient skin, but tion that they are at risk of touching the patient or the table
they can also prevent arcing and reduce energy impedance. during the delivery of current. Further, other personnel
Gel should be applied to the paddle surface liberally while may reflexively reach out to try to stabilize a patient that is
ensuring that an excessive amount has not been applied such tipping over while the energy is being applied. For such
that it extends beyond the paddle itself. The application of large patients, it is advised that a posterior plate or
284 Defibrillation
performed, external defibrillation will typically be the

means initially employed. If ventricular fibrillation cannot
be converted with external defibrillation, then internal
defibrillation may be more successful and could be
attempted. If internal cardiac massage is being attempted,
then internal defibrillation is likely to be the first mode
attempted although external defibrillation can still be per-
formed even if the chest is open [19–21].
Ideally, defibrillation should be performed as soon as
possible once ventricular fibrillation is identified. However,
there is evidence that one two-minute cycle of high-quality
chest compressions should be performed prior to defibril-
lation [22]; thus, if an early ECG identifies ventricular
fibrillation as an early arrest rhythm, a full two-minute
chest compression cycle should be completed prior to
Figure 22.1 Adhesive electrocardigram/external pacing/ attempting defibrillation. If ventricular fibrillation has
defibrillation pads in place on the thorax of an adult dog.
Clipping the area prior to placement will reduce thoracic
been identified or is highly suspected, the defibrillator
impedance and decrease energy requirements relative to should be prepared during the chest compression cycle.
placement on an unclipped site. Defibrillation can be achieved in most patients without
clipping fur; however, in dogs with thick or matted hair,
clipping prior to defibrillation may prove more successful.
adhesive pads (Figure 22.1) be used to enhance patient and
There is evidence from people that human chest hair can
personnel safety. Lastly, patients should always be placed
significantly increase thoracic impedance and impair cur-
on a nonconducting surface rather than directly on a metal
rent delivery during defibrillation attempts [23]. Standard
examination table prior to defibrillation.
adult paddles are used for medium- and large-sized dogs
(> 13.5 kg); pediatric paddles (Figure 22.2) can be used for
Indications for Defibrillation cats and small dogs. It is better to have paddles too large
than too small, generally. An experimental study using a
The predominant indication for defibrillation is for the treat- dog model of ventricular fibrillation has demonstrated that
ment of ventricular fibrillation or ventricular flutter (pulse- defibrillation is somewhat more effective when larger
less ventricular tachycardia). In one retrospective study of paddles (12.8 cm diameter) are used rather than smaller
in-hospital cardiac arrest in dogs and cats, defibrillation was paddles (8 cm diameter) in dogs ranging approximately
indicated in 28% of dogs and 16% of cats [12]. Ventricular 15–30 kg in body weight [24]. After gel has been applied
flutter is an unstable rapid ventricular tachyarrhythmia that
often converts to ventricular fibrillation in a short time. It
should be noted that many patients may develop ventricular
fibrillation during CPR even when it is not the initial arrest
rhythm. Induced ventricular fibrillation may spontaneously
resolve in young, healthy animals in a research laboratory
setting, but in clinical patients, time should never be wasted
waiting to see if ventricular fibrillation is going to resolve on
its own [13]. Immediate action is indicated and required.
Survival rates decrease by 7–10% for each minute the ventri-
cles fibrillate and thus survival approaches 0% after
10–12 minutes of ventricular fibrillation [14–18].
Defibrillation Procedure and

Technique
Figure 22.2 Adult and pediatric paddles from a biphasic
defibrillator. Some models may have separate pediatric paddles
Defibrillation is nearly always done concurrently with CPR
that must be plugged into the base. In the model shown, the
and needs to be properly integrated into the overall resusci- pediatric paddles are located beneath the larger paddles (which
tation attempt (Chapter 20). If closed-chest CPR is being have been partially removed on the paddle shown to the left).
Cardiovardion iof voaCaciary, vovav voncadacuCa CacraCardC 285
liberally to the surface of the paddles, they should be held As described previously and in Table 22.1, energy dos-
as firmly as possible against each side of the chest wall age is based on body weight in kilograms and differs for
directly over the area of the heart. If possible, compressing monophasic versus biphasic as well as for internal ver-
the thorax between the paddles and discharging the energy sus external defibrillation (see Energy Dose Selection,
while the lungs are deflated is advised. The optimal force below, for a more detailed discussion of dose determina-
for the application of the paddles to the thorax has been tion). It is essential to recall that dosages for internal
shown to range from 8 to 12 kgf; however, it has been defibrillation are approximately one-tenth those needed
shown that as few as 14% of humans performing defibrilla- for external defibrillation. Regardless of the initial
tion are able to generate this much force, nor is force appli- energy dosage used, it is generally advised that on subse-
cation readily measurable in the clinical setting [25]. As so quent attempts the energy delivered be increased by
few human operators are able to generate the optimal force 50–100% after an unsuccessful defibrillation attempt. It
required, the author advises applying the paddles with as should also be noted that the practice of delivering mul-
much force as can be sustained for the duration of the defi- tiple shocks in rapid succession is no longer recom-
brillation attempt. mended [22, 26].
Defibrillating the patient with a permanent pacemaker
in place bears special mention. If the patient has a pace-
maker, the electrodes for the defibrillator should not be Cardioversion of Refractory, Severe
placed over or close to the pacing generator to minimize Ventricular Tachycardia
the risk of damage during defibrillation [26].
The recommended sequence of events in external and Cardioversion involves the use of defibrillator equipment
internal defibrillation is described in Protocols 22.1 to convert rhythms other than ventricular fibrillation. The
and 22.2, respectively. For internal defibrillation, the proto- major differences between cardioversion and defibrillation
col is similar in most regards to that for external defibrilla- involve the setting (i.e. usually performed outside of the
tion. However, as noted previously, saline-soaked gauze is emergency room or intensive care unit), circumstances
substituted for gel or paste. Also, the internal paddles (i.e. nonventricular fibrillatory rhythm), and the timing
(Figure 22.3) are concave and intended to cradle the heart (i.e. usually a scheduled procedure) of the process.
between them. Firm but not excessive contact should be Cardioversion for lone atrial fibrillation is generally a
maintained between the internal paddles and the cardiac scheduled procedure done under general anesthesia or
structures. with significant pre-emptive analgesic administration.
Protocol 22.1 External Defibrillation

Items Required 7) Interrupt chest compressions and apply paddles to
each side of the chest at the level of the heart with as
● Defibrillation dosage chart
much pressure as can be sustained.
● Electrocardiograph
8) Temporarily suspend positive-pressure ventilation if
● Defibrillator and paddles of appropriate size for the
it is being provided.
animal
9) Announce to those present that energy is about to be
● Coupling gel
delivered (yell “Clear!”) and visually verify that all per-
● Clippers, as needed for excessive fur
sonnel (including oneself) are clear of the animal, table,
and any instruments touching the animal or table.
Procedure
10) Deliver the energy by discharging the paddles.
1) Analyze the ECG and confirm ventricular fibrillation 11) Evaluate ECG rapidly (< 1 second) while compressor is
is present. getting ready to begin again.
2) Collect necessary supplies. 12) Restart CPR, including compressions and positive
3) Ensure that isopropyl alcohol or other flammable pressure ventilation and perform a complete two-
solvents are not present on the thorax (dilute with minute cycle.
water and dry rapidly if needed). 13) In approximately two minutes, re-evaluate ECG and
4) Calculate dosage and set defibrillator to appropriate restart at step 1 if ventricular fibrillation is still present.
energy setting.
5) Apply coupling gel across the surface of the paddles. Note: In patients with thick or matted hair, it may be necessary to
rapidly clip the coat over the thorax to successfully and safely deliver
6) Charge paddles. the energy dose.
286 Defibrillation
Protocol 22.2 Internal Defibrillation

Items Required 4) Plug internal paddles into defibrillator base per
manufacturer’s instructions.
● Defibrillation dosage chart
5) Calculate dosage and set defibrillator to appropriate
● Electrocardiograph
energy setting. (Table 22.1).
● Defibrillator with internal paddles
6) Cover each paddle with one to two layers of
● Saline-soaked sterile gauze
4 × 4-inch gauze.
● Patient undergoing open-chest CPR
7) Moisten each gauze wrapping with sterile 0.9% NaCl.
8) Charge paddles.
Procedure
9) Interrupt cardiac massage and apply paddles to the
1) Analyze the ECG and confirm ventricular fibrillation is heart with one paddle over the region of the right
present. atrium and one over the area of the left ventricle.
2) Direct access to the thoracic cavity may be achieved by Apply gentle but firm pressure.
one of several means, depending on the setting (see 10) Positive pressure ventilation may be briefly sus-
also Chapter 21): pended if necessary to properly place paddles.
a) Lateral thoracotomy: If emergency access to the 11) Announce that energy is about to be delivered (yell
thoracic cavity is needed solely for the purpose of “Clear!”) and visually verify that all personnel (including
open chest CPR, then a lateral thoracotomy is the oneself) are clear of the animal, table, and any instru-
preferred approach. ments touching the animal or table.
b) Median sternotomy: This approach is generally 12) Deliver the energy by discharging the paddles.
reserved for intraoperative CPR when a median 13) Evaluate ECG rapidly (< 1 second) while the person
sternotomy has already been performed prior to performing cardiac massage is getting ready to
the arrest. begin again.
c) Transdiaphragmatic approach: If open-chest CPR is 14) Restart CPR, including cardiac massage and positive
to be attempted when the abdomen is already pressure ventilation and complete a full two-
open (e.g. an arrest during a laparotomy), then the minute cycle.
thorax may be entered via an incision in the 15) In approximately two minutes, re-evaluate ECG. If
diaphragm. ventricular fibrillation is still present, proceed to
3) Collect necessary supplies. step 5 (steps 1–4 already having been completed).
Prescheduled cardioversion of stable animals is not an

emergency procedure and thus will not be covered fur-
ther herein.
Indications
Cardioversion may be performed in the acute setting for
ventricular tachycardia that is life threatening, severe, and/or
refractory to pharmacological treatment. This arrhythmia
should be distinguished from pulseless ventricular tachy-
cardia (ventricular flutter), which should be considered an
“arrest” rhythm and managed with the defibrillation tech-
nique described previously. Cardioversion for supraventricu-
lar tachycardia (SVT) could also be considered, although
these patients are typically not as hemodynamically compro-
mised and thus cardioversion may not be clinically warranted.
Figure 22.3 Internal paddles are concave with elongated As patients requiring cardioversion are usually conscious, it is
handles to remove the operator’s hands from where the current
will be discharged. One paddle should be placed over the right advised that they receive analgesics or be anesthetized prior to
atrium and one over the left ventricle. attempting cardioversion (which is painful).
Energy Dose Selection 287
Synchronization with the Cardiac Cycle

One major difference between cardioversion in these circum-
stances compared with defibrillation, as discussed above, is the
timing of the energy delivery during the cardiac cycle.
Ventricular fibrillation is a chaotic rhythm and timing the
delivery to a specific phase of the cardiac cycle is not applicable
or possible. However, in the treatment of rapid ventricular
tachycardia or SVT, timing becomes relevant. The application
of electrical current to the myocardium during the repolariza-
tion process (during the T wave on an ECG) can lead to ven-
tricular fibrillation. As such, many modern defibrillators come
with a synchronization option that can be activated to help
avoid delivering the energy during this most vulnerable period.
The synchronization setting will prompt the equipment to
deliver the energy during the R or S wave of the QRS complex Figure 22.5 Adhesive electrocardiogram/external pacing/
and avoid the more vulnerable period associated with the T defibrillation pads can be placed in advance if a patient is at
wave. If cardioversion of a refractory ventricular tachycardia increased risk of developing ventricular fibrillation or requires
external cardiac pacing. These same pad types are shown in
or SVT is to be attempted using a defibrillator, it is strongly
place on a patient in Figure 22.1.
advised to use equipment in which the synchronization fea-
ture is available and switched on (Figure 22.4). As a rule, defi-
brillators should always be used in synchronized mode unless
ventricular fibrillation is the arrhythmia being treated. the calculated dosage for defibrillation in the same sized
Unfortunately, achieving synchronization is not always possi- patient. The protocol for cardioversion is similar to the pro-
ble even with the best equipment. Although limited informa- tocol described above for defibrillation except that time
tion is available in veterinary medicine, the American Heart should be taken to ensure that the synchronization mode is
Association guidelines recommend the administration of a working properly. Many modern defibrillators will give a
high-energy unsynchronized shock in such cases [26]. visual indication of what complexes are being recognized
as QRS complexes (Figure 22.4). Additionally, as cardiover-
Procedure sion is often attempted in a less acute setting than defibril-
lation it may be possible to clip fur from the thorax and
When electrical cardioversion is being attempted, the initial apply adhesive pads rather than using handheld paddles
energy setting may be selected at approximately half of (as an additional safety measure to reduce risk of shocking
personnel). These adhesive pads (Figure 22.5) can also be
left on during the initial monitoring period in case fibrilla-
tion occurs or cardioversion is again required.
Energy Dose Selection
Selecting the proper energy dose (Table 22.1) is important to

successfully terminate the arrhythmia while avoiding patient
injury. One of the most important determinants of the proper
energy dose is body size. Smaller animals can be defibrillated
with smaller doses of energy than larger animals. While there
is a strong correlation between body size and the energy
required for defibrillation, the relationship appears to be non-
linear requiring 0.73 × BW1.52 joules (where BW = body weight
in kg) using a monophasic defibrillator [27, 28]. The nonlinear
relationship between size and dose means that smaller ani-
Figure 22.4 A close-up view of a biphasic defibrillator. Note
mals would be expected to be defibrillated using fewer joules
the synchronization option and the indicator arrows marking
each detected R-wave (red circles). This synchronized mode is per kilogram than larger animals. The amplitude, duration,
employed when cardioversion is attempted. and polarity of electrical current delivered to the heart also
288 Defibrillation
affect the dose required. Defibrillators using biphasic wave- Table 22.2 Common cardiac drug effects on defibrillation
forms require approximately 30% less energy to defibrillate threshold.
than monophasic waveforms [29]. The probability of success-
ful defibrillation increases as the energy dose increases, but so Drug Effect
does the risk of injury. In one study, the median effective dose
Amiodarone
for monophasic defibrillation in dogs weighing an average of Increase (more energy required
Lidocaine
14kg was 1.5J/kg. The median dose required to cause injury for defibrillation)
was 30J/kg and the median lethal dose was 470J/kg [30]. Mexiletine
Examination of dose–response curves shows that the overlap Procainamide Little effect (no major alteration
in energy required)
between effective and injurious doses occurs at approximately
10J/kg in dogs [30]. Patients can be defibrillated at a lower Sotalol Decrease (less energy required
Beta-adrenergic blockers for defibrillation)
energy using biphasic waveforms; however, using a biphasic
defibrillator at energy doses recommended for monophasic
defibrillators does not appear to increase the risk of patient
injury [26]. Additionally, it should be noted that the doses
Medications that decrease the defibrillation threshold
needed to defibrillate the heart when paddles are placed
include sotalol and beta-blockers. In studies that investi-
directly on the heart (internal defibrillation) are approximately
gated the effects of medications on defibrillation threshold,
10% of the doses used for external defibrillation.
the effects were more pronounced with monophasic wave-
Recommended doses of energy for monophasic defibril-
form defibrillators than the more modern biphasic defibril-
lators are 4–6 J/kg for external defibrillation and 0.5–1 J/kg
lators. This suggests that the contributions of concurrent
for internal defibrillation. For biphasic defibrillators, rec-
medications on successful defibrillation may be less clini-
ommended doses are 2–4 J/kg for external defibrillation
cally important if using a biphasic defibrillator.
and 0.2–0.4 J/kg for internal defibrillation [31].
External cardioversion of arrhythmias is often successful
at lower doses of 0.5–2 J/kg, although higher doses may be Patient Care in the Post-Cardioversion
required, especially for ventricular tachycardia, where or Post-Defibrillation Period
energy must travel through a thicker portion of the myocar-
dium. Increasing doses can be attempted until the rhythm is The care for post-cardioversion patients depends on the
converted or the maximum output of the machine has been severity of illness present prior to cardioversion. If the patient
reached. was in congestive heart failure prior to cardioversion, then
continued care for this syndrome will likely be required. If
the patient was predominantly exhibiting signs of forward
Drug and Defibrillator Interactions failure from poor cardiac output, such signs may abate post-
cardioversion; however, significant morbidity secondary to
The defibrillation threshold, which is unknown in any reperfusion injury may necessitate ongoing care for some
individual patient, determines the dose of energy needed time. Continued monitoring of perfusion parameters and
to depolarize enough myocytes to terminate the fibrilla- cardiac rhythm are indicated until the patient is deemed stable.
tion. Although the amount of time a patient remains in Most patients having undergone emergency defibrillation
ventricular fibrillation is the most important determinant (which is only given during CPR for cardiopulmonary arrest)
of successful defibrillation, certain medications can con- require extensive monitoring and care following a return to
tribute to the ease (lowered threshold) or difficulty spontaneous circulation. Standard post-resuscitation proto-
(increased threshold) of converting a fibrillatory rhythm. cols should be followed and are covered elsewhere, as they
This threshold can be altered by certain medications com- are beyond the scope of this textbook. Care may be required
monly used in emergency patients [32]. An increase in this for surface wounds as a result of the defibrillator use.
threshold requires increased energy settings for successful
defibrillation. Medications that have been shown to
increase defibrillation threshold include amiodarone, lido- Acknowledgments
caine, and mexiletine (Table 22.2). Unfortunately, these
medications are used commonly in the emergency setting This chapter was originally co-authored by Dr. Matthew
to treat ventricular tachyarrhythmias. Regardless of con- Mellema, Mr. Craig Cornell, and Dr. Casey Kohen for the
current use of these medications, defibrillation should still previous edition, and some material from that chapter
be attempted as soon as possible. Procainamide has been appears in this one. The author and editors thank
shown to have little effect on defibrillation threshold. Dr. Mellema and Mr. Cornell for their contributions.
vovavonavr 289
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291
23
Temporary Cardiac Pacing

Anna Grimes and H. Edward Durham, Jr
Cardiac pacemakers maintain cardiac function in patients An artificial electrical pacing system consists of two
whose hearts have slowed or stopped beating. Artificial major components: a pulse generator and an electrode.
pacemakers were developed by people who observed the These may be placed externally or internally, using both
tragic and premature deaths of patients whose hearts were external generator and electrode, external generator and
capable of contraction but lacked the stimulus to initiate a internal electrode, or both internal generator and elec-
heartbeat. Techniques for artificially stimulating a heart- trode. The generator controls the rate and strength of the
beat have been known for hundreds of years. William electrical stimulus and senses the intrinsic electrical activ-
Harvey used his finger to pace the heart of a dove in the ity of the patient’s heart. The electrode is the electrical con-
seventeenth century [1], and Galvani used electricity to duit from the generator to the heart. In temporary pacing,
stimulate muscular contraction in the eighteenth cen- the generator is typically external, and the electrode may
tury [2]. It was not until the twentieth century that devices be either internal or external. Examples of temporary pac-
were developed that could stimulate, or pace, the heart in a ing electrodes are patches placed externally on the thorax,
reliable manner, and it is only in the last 50–60 years that or electrode-tipped pacing catheters placed in the right
artificial pacemakers have been practical. In the 1950s, ventricle via the venous system. Permanent pacemaker
transcutaneous cardiac pacing was one of the first types of electrodes are implantable leads that may be placed endo-
temporary pacing used clinically [3], though it only became cardially via the venous system, or epicardially through a
truly practical in the early 1980s after improvements to the surgical thoracotomy.
design made the associated discomfort more tolerable [4]. More advanced pacemaker technology allows for dual-
Today, epicardial, transvenous (endocardial), percutaneous chamber pacing, in which separate electrical signals are
transmyocardial, and transesophageal pacing techniques sent to the atria and the ventricles. The generator also con-
are available. Because dogs were used as research subjects, trols the delay between the atrial and ventricular stimuli
development of techniques for pacing the canine heart allowing for an improved physiological pacing profile. The
generally preceded the introduction of these techniques in latest advancements in permanent pacemakers include
people. The first clinical use of an implantable pacemaker leadless pacemakers, in which there is only a very small
in a dog occurred relatively early in the history of artificial generator that is implanted directly into the right ventricu-
pacing, in 1968 [5]. lar myocardium. This system is limited to ventricular pac-
Permanent and temporary pacing techniques are used in ing only as no atrial tissue is contacted by the pacemaker,
different ways. Permanent, implantable pacemakers are making atrial pacing or sensing impossible. Some devices
used for long-term therapy of bradyarrhythmias. Temporary can be interrogated trans-telephonically without the
pacemakers are used for emergency treatment of bradyar- patient needing to return to the physician’s office [6].
rhythmias: as a prophylactic measure in patients that are at All the technology discussed herein is designed for
risk of developing a serious bradyarrhythmia, maintaining a human use and has been adapted to veterinary medicine.
normal heart rhythm until the patient recovers from a To date no specific veterinary temporary or permanent pac-
reversible cause of a bradyarrhythmia, and/or until a perma- ing systems have been developed; although one company
nent pacemaker is implanted. In general, temporary pacing manufactures pacemakers for the veterinary market, their
techniques are used only for a few hours to a few days. technology is human medicine-based.
292 Temporary Cardiac Pacing
Indications for Temporary Pacing percussion pacing, fist pacing, and manual external pacing
have all been used by different authors to describe pacing
Temporary pacing is the therapy of choice for emergency accomplished by striking the chest wall or heart.
treatment of hemodynamically unstable patients with any of Transesophageal pacing is often called transesophageal
the electrocardiogram (ECG) diagnosed arrhythmias listed in atrial pacing. The technique of using a needle to insert a
Box 23.1. Temporary pacing is useful as a prophylactic meas- pacing lead into the ventricular chamber has been called
ure for support of asymptomatic bradyarrhythmic patients transthoracic pacing, transmyocardial pacing, and percuta-
that require anesthesia since anesthesia can exacerbate brad- neous transthoracic pacing.
yarrhythmias in some individuals. Temporary pacing is also In this chapter, temporary pacing techniques are defined
widely used as a bridge to permanent pacemaker implanta- as follows: Placing a pacing electrode into the right ventricle
tion both during initial hospitalization and the general anes- by way of a vein is transvenous pacing (Figure 23.1a). Pacing
thesia required for permanent pacemaker placement. using adhesive electrodes placed on the skin on the chest is
Some patients with bradyarrhythmias have concomitant transcutaneous pacing (Figure 23.1b). Transesophageal pac-
tachyarrhythmias. Since most drugs used to treat tachyar- ing uses an electrode inserted in the esophagus. Striking the
rhythmias can exacerbate bradyarrhythmias, prophylactic
temporary pacing can prevent life-threatening bradycardia
during early antiarrhythmic therapy for tachyarrhythmia in Jugular Vein
these brady-tachyarrhythmic animals. When long-term anti-

arrhythmic therapy is required to control a tachyarrhythmia
in these patients, temporary pacing can stabilize the heart
rate during implantation of a permanent pacemaker.
Temporary pacing may also be indicated in patients under-
going a procedure that risks damage to the sinoatrial (SA)
node, atrioventricular (AV) node, bundle of His, or any bun-
Temporary Transvenous Pacing
dle branches that could lead to complete bundle branch block.
(a)
Terminology
The terms used to describe different types of temporary

pacing are varied and often confusing. Transthoracic pac-
ing, for example, has been used to describe three different
techniques: electrodes placed on the skin of the chest, elec-
trodes passed through the chest wall and sutured to the
epicardium, and electrodes inserted through the chest wall
and ventricular wall and contacting the endocardium.
Temporary transvenous pacing is sometimes referred to as Transcutaneous Pacing
temporary endocardial pacing. Transcutaneous pacing is (b)

sometimes known as external pacing, noninvasive pacing,
or transthoracic pacing. Temporary epicardial pacing has
also been called transthoracic pacing. Thump pacing,
Box 23.1 Arrhythmias for which Temporary Pacing is

the Therapy of Choice for Emergency Treatment
in Hemodynamically Unstable Patients
● Third-degree atrioventricular block
● Second-degree atrioventricular block
Temporary Epicardial Pacing
● Persistent atrial standstill
(c)
● Symptomatic sinus arrest
● Sinus bradycardia that does not respond to drug Figure 23.1 Schematics depicting three different methods of
therapy temporary cardiac pacing: (a) temporary transvenous pacing; (b)
transcutaneous pacing; (c) temporary epicardial pacing.
Pulse Generators and Their Operation 293
precordium with the fist is thump pacing. A pacing elec- inappropriate pacing during ventricular repolarization,
trode inserted percutaneously into the right or left ventricle which could induce fibrillation (which causes cardiopul-
is transthoracic pacing. Temporary epicardial pacing uses monary arrest). Some pacemakers directly pace both the
detachable electrodes attached to the epicardium and right atrium and ventricle, while some pace only one or the
passed through the chest wall during a thoracotomy other. Dual-chamber pacing may improve hemodynamic
(Figure 23.1c). function compared to ventricular pacing alone.
Pulse generators operate in one of two electrical systems:
unipolar or bipolar. Unipolar systems use the electrically
Types of Temporary Pacing conductive properties of the patient’s body to complete a
circuit; that is, the stimulus is discharged to the heart
The ideal temporary pacing system is minimally invasive, through a single pacing electrode and returns to the pulse
applied quickly, carries low risk of serious injury, and generator via the patient’s body. A bipolar pacing system
causes minimal patient discomfort during pacing. While uses a pacing lead with two integrated electrodes so that
several techniques are available, no single technique meets the stimulus is discharged from one electrode, passes
all these conditions (Table 23.1). Transvenous and transcu- through the myocardium, is then conducted to the second
taneous pacing techniques are used most frequently, while electrode, and finally returned to the pulse generator to
others are used more often in specific situations such as complete the circuit.
following cardiac surgery. Temporary pulse generators designed for electrodes in
direct contact with the endocardium or epicardium can be
used for transvenous, epicardial, or transthoracic pacing.
Pacing Physiology Transesophageal and transcutaneous pacing require much
stronger stimuli to depolarize the heart; both the ampli-
Pacemaker technology applies an electrical stimulus to the tude and the duration of the output pulse are much larger
heart muscle to elicit a contraction from the ventricles. than what is required for techniques in which electrodes
This is generally accomplished by directly stimulating the directly contact the heart (Figure 23.2). Because they dis-
ventricles. Atrial pacing can be used to create a more physi- charge less energy, generators designed for transesopha-
ologic cardiac output profile (providing the “atrial kick” to geal or transcutaneous pacing should not be used for any
fill the ventricle prior to ventricular systole) and is more other type of pacing. Some pacemakers allow more sophis-
often used in permanent pacing therapy. ticated functions than the basic ones described below.
Pulse Generators and Their Pacing Modes

Operation Temporary pacemakers have user-programmed parameters,
which vary based on the type of pacemaker lead and patient
Pulse generators provide the electrical stimulus that initi- needs. Transvenous, epicardial, and transthoracic electrodes
ates a heartbeat. Some generators can sense the patient’s can pace the atrium, ventricle, or both (“dual” pacing).
intrinsic heartbeats and are programmed to pause pacing Transcutaneous electrodes pace the ventricle and do not
when those occur. This is a safety feature to prevent have dual modality. Transesophageal electrodes, in contrast,
Table 23.1 Characteristics of different modalities of temporary cardiac pacing.
Characteristic Transvenous Transcutaneous Transesophageal Thump Transthoracic Epicardial
General anesthesia required Sedation and No Yes N/A Yes Yes

for lead placement local anesthesia
Anesthesia required when No Yes Yes Yes No No
pacing
Atrial pacing Yes No Yes No No Yes
Ventricular pacing Yes Yes No Yes Yes Yes
Dual chamber pacing Yes No No No No Yes
a a
Easy to start in an emergency No Yes Yes Yes Yes No
a
Requirement of fur clipping increases application time.
8.0 Permanent on the patient’s activity level, making them more physiologi-
cally appropriate when the patient is active. If rate respon-
7.0 Pending
siveness is programmed, there is an additional letter “R”
6.0 ® © Threshold added to the end of the mode, in position 4.
Synchronous pacing describes the pacemaker’s inhibition
V. Amplitude (V)
5.0
ability, which uses sensitivity and refractory settings to
4.0
allow the pacemaker to pause when it recognizes intrinsic
3.0 cardiac activity. Synchronous pacing is preferred, as the
generator is less likely to send an impulse during
2.0
the patient’s natural refractory period (during the T wave
1.0 © 2X Amp on the ECG), which can cause ventricular fibrillation.
®
0.0 Asynchronous pacing is when the generator sends an
0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 impulse at a programmed rate independent of the patient’s
V. Pulse Width (ms) inherent cardiac activity.
Advancement in temporary pacemaker technology has
Figure 23.2 A graphic representation of a strength and made temporary dual pacing possible, which allows the
duration curve with values typical of transvenous pacing. The
vertical axis represents the stimulus amplitude. The horizontal
pulse generator to pace and/or sense and inhibit not just
axis represents the pulse width or time over which each the ventricle, but also the atrium. This may be advanta-
stimulus is delivered. The output or current is the product of geous in certain underlying causes of bradyarrhythmias to
amplitude and pulse width. The shaded area under the curve optimize patient stability prior to permanent pacemaker
represents the area of capture loss (threshold). The single line
represents an accepted margin of safety at two times the
implantation or during cardiac surgery.
threshold. The “X” indicates the pacemaker’s present settings,
and the crossed box represents the computer’s suggested
setting to preserve battery life. Source: Durham 2017/with Output Pulse
permission of John Wiley & Sons.
Output is the strength of the stimulus delivered to the
heart. The term capture means that the pacemaker stimu-
lus successfully depolarized the heart and caused myo-
can only pace the atrium. Temporary pacemaker modes are cardial contraction. Output is the combined effect of
referenced using a three-letter system (Table 23.2), which electrical amplitude and duration in milliseconds (ms) of
describes the pulse generator’s activity and is always listed in the stimulus applied and is known as pulse width.
the same order: the paced chamber in position 1, the sensed Amplitude is usually measured in milliamperes for trans-
chamber in position 2, and the ability to pause when intrin- cutaneous pacing and in volts for transvenous and epi-
sic beats arise in position 3. Some permanent pulse genera- cardial pacing. Longer duration stimuli can achieve
tors can change rate (known as rate responsive) depending capture at a lower output than briefer stimuli. The ampli-
tude of the stimulus required varies with the type of pac-
ing: transcutaneous pacing requires the strongest output,
Table 23.2 Modes of temporary pacing leads.
while transvenous and epicardial pacing require the
least. Thus, transcutaneous pacing devices use a lower
Mode Paced chamber Sensed chamber Inhibited
amplitude delivered for a longer duration to avoid dis-
comfort and tissue trauma, whereas transvenous or epi-
VOO Ventricle None None
cardial pacing employs higher voltage for very short
VVI Ventricle Ventricle Inhibited
durations. This idea is graphically represented with a
AOO Atrium None None
strength–duration curve (Figure 23.2).
AAI Atrium Atrium Inhibited On the surface ECG, evidence of pacemaker stimulus is
DDD Dual Dual Dual seen as a vertical line, called the pacing spike. If the pacing
VDD Ventricle Dual Dual spike is not followed immediately by a QRS complex, this
represents “failure to capture” and the myocardium was
V: ventricle; A: atrium; O: off; I: inhibited; D: dual = both atrium and
ventricle. The mode describes, in order, which chamber the pulse neither depolarized nor did it contract. The output required
generator paces, senses, and if the pulse generator inhibits itself for capture is also affected by the area of the transcutane-
when it senses an inherent beat. Note that the sensed chamber and ous pacing electrode, its location in relation to the heart,
inhibit feature work together, such that if sensing is off, the pulse
drug therapy, and serum electrolyte concentrations.
generator will not inhibit itself and will pace at the prescribed rate
regardless of intrinsic heart activity. This is called asynchronous Pacing spikes vary in amplitude depending on the ECG
pacing. lead placement, the pacing lead polarity (bipolar vs. unipolar),
Pulse Generators and Their Operation 295
and the amplitude of the stimulus. Output settings are deter-

mined by the threshold, or the minimum output necessary to
achieve capture. When pacing begins, the amplitude, pulse
width, or both are increased until capture is achieved. Only
the newest transcutaneous pacing systems allow manipula-
tion of the pulse width. Excessive output settings worsen
patient discomfort associated with transcutaneous or
transesophageal pacing and increase the risk of skeletal mus-
cle contraction, pacing the diaphragm, and causing skin or
esophageal burns.
Sensitivity
Currently available pacing generators can detect electrical
activity that originates in the heart (intrinsic beats aka
native beats) and pause artificial pacing when intrinsic
depolarizations occur. The sensitivity function is impor-
tant because a stimulus delivered during the repolariza-
tion phase of the heartbeat may cause ventricular
fibrillation. Transvenous pacemaker generators detect
intrinsic beats by using the pacing lead, while transcuta-
neous pacemaker generators use standard limb leads to
Figure 23.3 External pulse generator for a transvenous
measure the amplitude of the intrinsic QRS complex. The temporary pacemaker. The light at the top indicates that the
sensitivity control sets the minimum amplitude that is generator is sensing a patient’s intrinsic heartbeat. From the top
assumed to identify an intrinsic QRS complex. If, for right, the knobs indicate the following: stimulus measured in
volts (V); pacing mode (VVI is ventricular pacing, ventricular
example, the sensitivity control is set for 4 mV (millivolts),
sensing, pacemaker inhibition of intrinsic beats); pacing rate per
signals that are detected with an amplitude greater than minute (p/min); and sensitivity in millivolts (mV). Source: Prague
4 mV are assumed to be intrinsic beats and will cause the ICU/YouTube, LLC.
pacemaker to pause. Transvenous pacing generators indi-
cate a sensed intrinsic beat with a light on the generator’s signals in the body and the environment that can be detected
display (Figure 23.3), while transcutaneous pacing genera- by the pacemaker. P waves, T waves, and shivering are com-
tors insert an indicator mark over the beat on the ECG dis- mon sources of other myopotentials in the body.
play (Figure 23.4). Electrocautery units, clippers, and the electric motors in
The failure of the generator to detect intrinsic beats is adjustable-height tables can also produce signals that may
called undersensing. There are other sources of electrical be detected by the pacemaker. Since the pacemaker senses
Figure 23.4 The screen display of a LifePak 15 defibrillator on the pacing setting. The small, white notch above the QRS complex
indicated by the blue arrow is the generator sensing the patient’s intrinsic heart beats. Source: Resuscitation Management/
YouTube, LLC.
only these signals’ amplitudes and is blind to their origins, if depolarizations but not respond to them. This feature
these signals exceed the pacemaker’s sensitivity setting, they allows for the pulse generator to ignore repolarization of
will prevent pacing. This is known as oversensing, which the ventricle (T wave) and not misinterpret it as intrinsic
could result in periods of ventricular asystole. The objective ventricular activity. While the sensitivity setting allows the
in adjusting the sensitivity setting is to exceed the amplitude generator to identify electrical activity, the refractory period
of P waves, T waves, and environmental noise but not exceed inhibits the generator from responding to it. These settings
the amplitude of the intrinsic QRS. Appropriate sensing work in conjunction to optimize the patient’s physiological
may not be possible in every case and if the source of the profile.
interference cannot be eliminated, another option is to
switch the pacemaker to asynchronous mode in which the
pacemaker delivers stimuli regardless of the patient’s Temporary Transvenous Pacing
intrinsic cardiac electrical activity.
Temporary transvenous pacing (endocardial pacing) is one
of the most reliable and frequently used types of temporary
Atrioventricular Delay
pacing. The technique is relatively safe and carries the
Transvenous and transthoracic pacing techniques can be advantage that both electrode insertion and pacing can occur
used to pace the atrium in addition to the ventricle (termed, in the conscious patient. Transvenous pacing is also one of a
dual). During dual-chamber pacing there must be a delay few techniques that can be used to temporarily pace patients
after the atrial stimulus to allow complete atrial contrac- for longer periods, such as a day or more. With appropriate
tion before delivering the ventricular stimulus; this pause venous catheters and pulse generators, transvenous AV
is called the A–V delay. Dual pacing duplicates the delay sequential pacing (dual-chamber pacing) or physiological
that normally occurs between atrial and ventricular con- ventricular pacing (such as VDD) can be accomplished.
traction, which is represented on the ECG as the P–R inter-
val. In some patients A–V synchrony such as by dual pacing Patient Preparation
can augment stroke volume by >25% [7]. Ideally, the A–V Insertion of a transvenous temporary pacing lead often can
delay should be adjusted to optimize hemodynamic func- be performed with heavy sedation and may not require
tion by monitoring changes in stroke volume or cardiac general anesthesia. Continuous monitoring of ECG, pulse
output in near-real time with the echocardiographic– quality, and blood pressure is essential to detect hypoten-
Doppler velocity time integral, contour analysis of the pression or severe bradycardia during the catheter placement.
sure waveform, change in pulse pressure, or continuous
mixed venous oxygen saturation. If this is not possible, a Insertion Site Selection
delay of 120 ms may be used [7]. Several factors should be considered when selecting the site
for inserting the transvenous pacing lead. Although vascular
anomalies are uncommon, they can complicate insertion of
Rate
the pacing lead [8]. One of the most frequently encountered
The rate setting determines the interval between generator anomalies is a persistent left cranial vena cava, which has
output stimuli: it determines the heart rate. Typically, a heart been reported in 5% of dogs with congenital cardiac dis-
rate between 60 and 100 beats/minute is used in dogs (with ease [7, 9, 10]. A persistent left cranial vena cava renders it
smaller dogs receiving the higher rate) and 140–180 beats/ virtually impossible to insert the pacing lead into the right
minute in cats. During transcutaneous temporary pacing, heart via the left jugular vein. Thus, the right jugular vein is
lower rates may be used during permanent pacemaker preferred for permanent pacing lead placement since vascu-
implantation to ease the surgical procedure itself, especially lar anomaly of the right jugular is less likely and facilitates
if significant muscle contraction occurs. Providing the the use of commonly available 45–58cm pacemaker leads. If
patient’s blood pressure is adequate, the surgeon may opt for a transvenous temporary pacemaker is used during perma-
a lower paced rate to facilitate rapid placement of a permanent pacemaker implantation, it is beneficial to save the right
nent transvenous lead. Long-term rapid pacing should be jugular vein for the permanent pacing lead and use a periph-
avoided because it can lead to myocardial failure. eral approach for the temporary. The right or left lateral
saphenous veins can be used for insertion of a temporary
pacing lead, though they may be too small to accommodate
Refractory Period
an introducer for a 4 or 5-Fr temporary pacing catheter in
Advanced temporary pulse generators may have program- dogs weighing less than 15kg. In some large dogs a 110-cm
mable refractory periods. The refractory period is a time pacing lead may not reach the right ventricle from a saphen-
when the pulse generator may sense intrinsic cardiac ous vein. Bulmer [11] described a technique for inserting an
Temporary Transvenous Pacing 297
introducer into the femoral vein. Once the temporary inser-

tion site has been selected, the fur should be clipped and the
skin aseptically prepared. The patient should be protected
from electrical hazards like faulty electrical equipment and
static electricity to avoid microshock (see later).
Venous Access and Placement

A percutaneous introducer sheath with a hemostasis valve
or a specialized over-the-needle catheter with or without a
hemostasis valve is used for venous access (Figure 23.5).
The catheter or introducer selected must be large enough
to accommodate the temporary pacing lead. The intro-
ducer sheath is inserted using a modified Seldinger tech-
nique and secured (Chapter 7). The temporary pacing lead
is then inserted through the introducer. See Protocol 23.1
for detailed instructions on temporary transvenous pace-
maker placement.
Prior to inserting the temporary pacing lead, one should
inspect and test the equipment. For instance, some tempo-
rary transvenous pacing catheters have a balloon at the tip
(Figure 23.6). When inflated, blood flow helps direct the
catheter by pulling the balloon across the tricuspid valve
into the right ventricular apex. Balloon integrity should be
tested prior to catheter insertion. While the easiest, most
reliable way to insert a transvenous pacing lead is with fluor- Figure 23.5 Individual components of the Avanti+ Sheath
oscopic guidance, other methods can be used to determine Introducer made by Cardinal Health. From left: Introducer
the location of the pacing lead. An ECG recorded from the catheter with hemostasis port and three-way stopcock;
catheter tip can be used to determine the location of the tem- tapered-tip vessel dilator; mini-guidewire; insertion needle.
Source: Cordis.
porary pacing lead by observing the polarity and amplitude
Protocol 23.1 Placement of a Temporary Transvenous Pacemaker

Items Required Procedure: Introducer Placement Using the Modified
Seldinger Technique
● Fluoroscope or ECG to determine electrode location
● 2% lidocaine solution in syringe with needle, for subcu- 1) Collect necessary supplies.
taneous infiltration 2) Select insertion site, position patient appropriately,
● Percutaneous introducer kit, or a suitable intravenous and place monitoring equipment.
(IV) catheter and an access port (Figure 23.5) 3) Clip fur at least 2 inches (5 cm) in all directions from
● Temporary pacing lead (bipolar or unipolar) planned insertion site and aseptically prepare the
● Pacing generator with fresh batteries skin. Inject local anesthetic agent (2% lidocaine
● Sterile #11 scalpel blade on handle, scissors, needle 0.5 mg/kg) [47] subcutaneously around the planned
driver, thumb forceps insertion site.
● Sterile suture 4) Don cap and mask. Perform hand hygiene, don sterile
● Sterile surgical drapes gloves and gown, and drape the prepared insertion field.
● Sterile sponges 5) Use the scalpel blade to create a small skin incision
● Sterile gloves, gown at intended insertion site.
● Surgical caps, masks 6) Insert an arterial needle (provided with introducer
● Bandage material kit) or IV catheter into the vein. This catheter must
● Assistants be large enough to allow a guidewire to pass
● Patient monitoring equipment (ECG, blood pressure through it.
monitor) 7) If using an IV catheter, remove the stylet.
8) Pass the guide wire through the arterial needle/IV a) Use either fluoroscopy or an ECG to determine loca-
catheter and into the vein. tion of the pacing lead throughout this process, as
9) Remove the arterial needle/IV catheter while stabi- described in the chapter text.
lizing the guidewire in the vein. b) Pass the end of the pacing lead that will be inserted
10) Place the tapered dilator into the introducer sheath into the generator to a non-sterile assistant.
and pass the dilator and sheath over the guide wire. c) If the introducer is in the lateral saphenous vein,
11) Dilate the vein and insert the introducer. Push the insert the lead through the access port, saphenous
dilator and sheath combination over the guide wire vein, femoral vein, caudal vena cava, right atrium,
through the hole in the skin, through the wall of the tricuspid valve, and right ventricle until it contacts
vein, and into the lumen of the vein. the right ventricular endocardium. If resistance is
12) Remove the dilator and guide wire from the intro- encountered as the lead reaches the inguinal
ducer sheath, leaving the introducer in the vein. Flush region, abduct the limb to allow the lead to pass. To
thoroughly. avoid venous perforation, DO NOT force the cathe-
13) Suture the introducer to the skin. Check to see that ter forward.
there is no leakage from the port of the hemostasis 3) For bipolar leads, with the help of a non-sterile assis-
valve on the introducer. tant, connect the distal end of the lead to the negative
14) Cover the opening on the hemostasis valve to main- terminal of the generator and the proximal end of the
tain asepsis. lead to the positive terminal of the generator.
4) Set the rate on the generator and increase the strength
of the stimulus until it captures the ventricle, both
Procedure: Temporary Pacing Lead Placement
electrically and mechanically (produces a ventricular
Through Introducer
complex on the ECG and a palpable pulse; Figure 23.10).
1) If the temporary pacing lead does not have a bend in 5) Adjust the generator sensitivity and/or refractory
the tip, form one to facilitate passage into the right period to recognize intrinsic beats while ignoring
atrium. Most catheters are packaged to produce this T waves, P waves, shivering, and other artifacts that
bend, but the bend may be lost if the catheter has been could inhibit pacing.
re-sterilized. 6) Secure the lead to the access port.
2) Pacing lead introduction: 7) Protect the access port with a bandage.
muscular contractions to show the location of the electrode.

Observation of the ECG, using standard limb leads, will
show when the atrium or ventricle is being paced.
Echocardiography has also been used to assist in determin-
ing the location of the temporary pacing lead [15–17].
Temporary Transcutaneous Pacing
Transcutaneous pacing is particularly well suited for emer-

gency use and for prophylactic use in situations in which
there is a risk for life-threatening bradyarrhythmia. Many
modern defibrillators include a transcutaneous pacing
Figure 23.6 Example of a temporary transvenous pacing function. Transcutaneous pacing is commonly used during
catheter with a balloon at the tip. When inflated, blood flow implantation of a permanent pacemaker system to main-
helps direct the catheter by pulling the balloon across the tain cardiac output while the permanent pacing lead is
tricuspid valve toward the right ventricular apex. implanted. Once the permanent lead is properly placed
within the right ventricle, temporary transvenous pacing
of the P waves and QRS complexes (Figure 23.7). Bing [12] can be performed through the permanent lead until the
described this technique in people, and Moïse described it in permanent external pulse generator is surgically placed
dogs [13]. Baird [14] described a technique in which the pac- and connected to the lead. This allows for the transcutane-
ing generator is turned on while the temporary lead is ous pacing to cease, alleviating the muscle contractions
inserted blindly. The stimulus from the pacing lead causes associated with this method of pacing.
Temporary Transcutaneous Pacing 299
A B C D E
CrVC CaVC
RA
RV
F
Figure 23.7 Schematic of the electrical activity recorded in

lead II ECG as a pacemaker lead enters the right heart. CrVC:
cranial vena cava; CaVC: caudal vena cava; RA: right atrium; RV:
right ventricle. An ECG can be used to determine the location of
the pacing lead by observing the polarity and amplitude of the P
waves and QRS complexes (A–F), which change as they move
toward the positive pole near the RV. Note that in lead II, as the
pacing lead reaches the right ventricular apex, the P wave
appears large and positive, and ventricular depolarization
appears as a large negative complex (Letter F). Letter E depicts
the ECG tracing if the lead bypasses the RA.
The procedure for transcutaneous pacing is relatively

simple. Once adhesive electrodes are applied to the appro-
priate location (discussed in the next section) on the
clipped skin of the thorax, pacing can begin. Proper appli-
cation of the electrodes is important for successful pacing
(capture). The size of the electrodes, their contact with the
patient’s skin and location on the patient, as well as their
polarities are important factors that influence capture. The
pacing electrodes/patches are sized for human medicine as
“adult” or “pediatric” (Figure 23.8). Figure 23.8 Examples of transcutaneous pacing electrode
patches, which come in both adult and pediatric sizes. Source:
Owens & Minor, Richmond VA, Covidien LLC, Mansfield,
Transcutaneous Pacing Electrode Location MA. Courtesy of HE Durham.
Several studies regarding electrode size, placement, and
polarity have been published [18–23]. Falk et al. [23] tested location for electrode placement was directly over the heart
the pacing threshold in people and found that electrode on the left and right hemithoraces. The negative electrode
polarity is critical: reversing the polarity resulted in was placed on the left side near the sternum and the posi-
extremely high capture thresholds or failure to capture. tive electrode was placed on the right side more dorsally.
Geddes et al. [18] mapped the thoraces of 18 dogs and Lee et al. [19] tested several different electrode configura-
determined that the specific positive electrode location on tions and found that the most effective position was with
the right hemithorax was not critical, but that a distinct the electrode centered on the costochondral junction of the
window for optimal pacing corresponded with placement sixth rib on the right and left hemithoraces. Unfortunately,
of the negative electrode over the apical beat on the left the authors did not indicate the polarity of the electrodes.
hemithorax. DeFrancesco et al. [20] found that the optimal The studies performed by Geddes, DeFrancesco, and Lee
conclude that the location for optimal placement of the people report that minor skin nicks or cuts exacerbate
electrode on the left hemithorax is sternally over the apical the discomfort.
impulse of the heart. Perhaps because placement of the ECG electrodes must be attached to the patient as well as
right electrode appears to be less critical, the three studies pacing electrodes so that the patient’s intrinsic QRS com-
found slightly different optimal locations for electrode plexes can be monitored by the user. Asynchronous pacing
placement on the right hemithorax. mode, in which the pacemaker does not stop in response to
the patient’s intrinsic cardiac activity, may be used with lit-
tle risk to the patient [24, 25] if the pacemaker is inhibited
Transcutaneous Pacing Electrode Size
by artifacts or does not sense the QRS complexes. An exam-
Optimal electrode size appears weakly correlated to body ple of an ECG tracing during transcutaneous pacing is
size [18]. DeFrancesco et al. [20] used adult pacing electrodes depicted in Figure 23.9.
on dogs 3.8–40 kg of various breeds. Lee [20] found that for Pacing is initiated by selecting the desired heart rate and
Beagles the optimal electrode size was 4 × 5 cm (20 cm2). increasing the strength of the stimulus until the ventricle is
Geddes [18] found that there was little advantage in using captured and a pulse detected. A Doppler flow detector
electrodes greater than 5 cm in diameter in dogs. Both ZOLL secured to the metacarpal or metatarsal is one convenient
Medical and Physio Control recommend using pediatric method of verifying capture, because the user will be able
electrodes for patients less than 15 kg. to hear the arterial pulse. Transcutaneous pacing causes
contraction of the chest muscles, which causes patient
movement and may lighten the plane of anesthesia. See
Performing Transcutaneous Cardiac Pacing
Protocol 23.2 for detailed instructions on transcutaneous
To ensure that the electrodes make adequate skin contact to cardiac pacing.
allow capture, the skin should be clipped of fur and clean
so that the electrode patch adhesive adheres. DeFrancesco
et al. [20] recommended using ECG paste and an elastic Temporary Epicardial Pacing
bandage to hold the electrodes in place. Multifunction elec-
trode patches may be advantageous if future defibrillation Temporary epicardial pacing is a specialized technique that
is considered likely; fortunately, the optimal pacing and is generally used in patients recovering from cardiac sur-
defibrillation windows are nearly identical [24]. gery. Temporary epicardial pacing allows more flexibility in
All steps to prepare for pacing can be performed with where the electrode(s) can be located and the mode of pac-
the patient awake; however, before electrical stimulus is ing than any other temporary pacing technique. The elec-
delivered the patient should be anesthetized or at least trodes used for temporary epicardial pacing are thin and
heavily sedated because transcutaneous pacing is pain- resemble wire suture. They have needles on both ends; one
ful. The need to clip the thorax may contribute to dis- end of each electrode is attached to the heart, while the
comfort associated with transcutaneous pacing, as other end passes through the chest wall and skin and is
Figure 23.9 ECG tracing of transcutaneous pacing using the LifePak 15 Defibrillator. The ECG shows electrical capture as evidenced
by a pacing spike followed by a QRS complex. This machine is using the pacing mode and is set to pace 70 beats/minute.
Thump Pacing 301
Protocol 23.2 Transcutaneous Cardiac Pacing

Items Required 5) Place the electrode patches on the right and left
hemithoraces, ideally directly over the palpable
● Transcutaneous pacing generator
precordial impulses.
● Pacing electrode patches of appropriate size, remem-
6) Inspect the electrodes to be sure there is complete
bering that if the patch is not designed for defibrilla-
contact with the skin.
tion, it may interfere with defibrillation.
7) Bandage the electrodes if desired to help them stay
● ECG paste for the pacing electrodes
in position.
● Clippers
8) Turn on the pulse generator.
● Saline to clean skin after clipping
9) Connect the standard limb lead ECG electrodes to
● Bandage material to keep pads in place
both the pulse generator and patient. A good ECG
● ECG electrodes for standard limb lead placement (these
tracing is required for demand pacing. The QRS com-
often also attach to the pulse generator).
plex should be of greater magnitude compared to the
● Doppler blood pressure monitor to verify mechanical capture
T and P waves; if this is not the case, select a different
ECG lead setting on the pulse generator in which the
Procedure
QRS complex is significantly greater in magnitude
1) Prepare to monitor the ECG, pulse quality, and blood (positive or negative) than the P or T waves.
pressure. 10) Anesthetize the patient if not already unconscious.
2) Collect necessary supplies. 11) Set the sensitivity and desired pacing rate.
3) Clip fur from planned electrode site. Avoid abrading 12) Gradually increase the output of pacing generator
or cutting skin. until the ventricle is captured: ventricular complexes
4) Clean newly shaved area with saline to remove small will appear on the ECG after a pacing spike, and
hairs and oil from skin. pulses should be produced (Figure 23.10).
Figure 23.10 ECG of patient being maintained with thump pacing, courtesy of Craig Cornell. Every QRS complex on this ECG
tracing was initiated by a thump delivered to the chest. Each QRS produced a pulse wave that could be seen on a direct arterial
pressure monitor.
connected to a pacing generator. The surgeon usually “fist”) pacing, which uses a series of thumps to the precor-
decides where the electrodes will be placed. Since several dium to maintain a physiological heart rate, is still not well
electrodes may be used, it is important to identify the func- known. Several authors have described it as an almost
tion of each lead. The pacemaker is operated by inserting forgotten technique [28, 29].
the electrode into the appropriate connector on the genera- The use of precordial thumps for the treatment of brad-
tor. The pacing leads should be secured to the patient’s yarrhythmias is much safer and more effective than the use
body so that the leads will not be dislodged if the patient of a thump for treating tachyarrhythmias. The 2012
moves or the generator is dropped. When pacing is no RECOVER (Reassessment Campaign on Veterinary
longer needed the electrode is designed to be removed by Resuscitation) guidelines by Fletcher et al. [30] mention
gently pulling on it. A two-part 2007 review [26, 27] pro- the use of a single precordial thump as a technique for ter-
vides a more detailed description of the technique. mination of pulseless ventricular tachycardia or ventricu-
lar fibrillation, not for bradyarrhythmias, specifically when
means of electrical defibrillation is not possible. However,
Thump Pacing in human medicine, examination of evidence that supports
thump pacing has led to newer resuscitation guidelines of
Mechanical force applied to the heart or precordium has a thump pacing for emergency treatment of bradycardia
long history of being used to treat bradyarrhythmias. caused by complete AV block when electrical pacing is not
Nevertheless, the technique of thump (aka “percussion” or available [31, 32]. The 2021 European Resuscitation
Council Guidelines support thump pacing as a bridge to

Protocol 23.3 Transesophageal Cardiac Pacing
electrical pacing in hemodynamically stable, conscious
patients with bradyarrhythmias [33]. Items Required
Successful thump pacing is as effective as transcutane-
● Transesophageal pacing generator
ous or transvenous pacing [34]. Zoll [35] examined thump
● Transesophageal pacing lead
pacing in dogs and people and found that the force
● Mouth gag
required to stimulate a heartbeat was 0.04–0.7 J in dogs ● ECG
and 0.04–1.5 J in people. The human subjects were able to
tolerate thump pacing at this degree of force and com- Procedure
plained of severe discomfort only when the force increased
to 2–3 J. This chapter’s previous author was able to use
2) Anesthetize the patient.
thump pacing to maintain normal heart rate and blood
3) Attach the ECG to the pacing electrode catheter.
pressure in a large dog for 10 minutes while a temporary
4) Insert the pacing electrode catheter into the esopha-
transvenous pacing lead was inserted. In the ECG shown
gus until it reaches a point close to the atrium. It is
in Figure 23.10, every QRS complex was initiated by a
assumed that the electrodes are closest to the atrium
thump delivered to the chest. Each QRS produced a pulse
when the ECG shows maximum amplitude of the
wave that could be seen on a direct arterial pressure mon-
P wave.
itor. The heart rate dropped precipitously whenever
5) Set the desired pacing rate.
thump pacing was stopped.
6) Adjust the output of the pacing generator until the
atrium is captured electrically and mechanically.
Transesophageal Pacing
Transesophageal pacing has not been widely used or Transthoracic Pacing

extensively studied in clinical veterinary medicine, but the
technique has been used successfully in dogs in research. The use of percutaneously inserted pacing electrodes
Transesophageal pacing is minimally invasive and can be dates back to at least 1958; if intracardiac injection of
initiated quickly in an emergency. The transesophageal drugs was possible, it was also possible to insert a pacing
method has been shown in dogs to pace the atria, but electrode into the ventricle through a needle. Although
unfortunately, it does not reliably pace the ventri- the risk of injury associated with transthoracic pacing is
cles [36, 37]. Therefore, if the bradyarrhythmia is due to significant, it can be started much more quickly in an
AV block or complete bundle branch block, another type emergency than transvenous pacing. Gessman [41] dem-
of pacing method should be used. Once the atria are paced, onstrated the use of the technique experimentally in 24
the depolarization will produce a QRS complex similar to dogs using a subxiphoid and parasternal approach.
that of an intrinsic complex. Recent studies report that Although no acute deaths occurred, examination after
curved electrophysiology catheters with electrodes approx- euthanasia showed significant complications, including
imately 4 mm apart provide the best capture of the atria, hemothorax, hemopericardium without tamponade, and
with the least amount of extraneous muscle contrac- laceration of a coronary vein.
tion [38, 39]. The sensed ECG of the transesophageal cath- As the reliability and comfort of transcutaneous pacing
eters can be used to optimally position the pacing improved in the 1980s, the transcutaneous method essen-
catheter [40]. Transesophageal pacing is indicated when tially replaced transthoracic pacing. Today, transthoracic
drug therapy is not effective in treating sinus bradycardia, pacing is largely obsolete, and the equipment needed to
sinus block, or sinus arrest, particularly during anesthesia. perform the technique is difficult to obtain. However, it is
These bradyarrhythmias are often caused by sick sinus possible to improvise an introducer and electrode.
syndrome or by cholinergic or beta-blocking drugs. Roberts [42] described a method to make a pacing elec-
Generators used for transesophageal pacing now include a trode using a 20-gauge spinal needle and 4–0 stainless steel
sensing function and operate in synchronous mode. suture wire. Transthoracic pacing should only be consid-
Transesophageal pacing can cause patient movement by ered in extreme life-threatening situations when safer
stimulating muscular contraction. See Protocol 23.3 for options have failed or are unavailable. See Protocol 23.4 for
guidance on transesophageal cardiac pacing. instructions on transthoracic pacing.
MoniMonong ithe Pinhoi niteP hemMoPory PahePaho 303
Protocol 23.4 Transthoracic (Transmyocardial) Cardiac Pacing

Items Required 6) If using spinal needles and suture wire, thread a
strand of suture through each spinal needle, and fol-
● Transthoracic pacing kit with adapter or 4–0 stainless
low same instructions as step 5. The second needle is
steel suture wire (two 40-cm pieces) and two 20-g
placed subcutaneously (SQ) near the cardiac apex.
spinal needles [42].
Remove the needle and skip to step 9.
● Pulse generator
7) Remove the obturator/stylet from the needle and
● ECG
insert the curved end of the pacing lead.
● Sterile gloves
8) Once the curved portion of the pacing lead is inside
● Clippers
the ventricle, withdraw the needle, leaving the pac-
● Aseptic preparation of user’s choice
ing lead in place.
● Bandage material to secure leads to body wall
9) Use the adapter to connect the lead to the generator.
The distal portion of the lead should be connected to
Procedure
the negative pole of the pulse generator. If using
1) Transthoracic pacing is generally only performed in suture and spinal needle, attach the suture directly to
extreme life-threatening situations when the patient the generator. Secure SQ lead to body wall with non-
is unconscious. conductive bandage material.
2) Collect necessary supplies. 10) Set the desired pacing rate on the generator.
3) Shave and aseptically prepare the insertion site. 11) Adjust the output of the pulse generator until the
4) Perform hand hygiene and don sterile gloves. ventricle is captured both electrically and
5) Insert the needle percutaneously into either the mechanically.
left or right ventricular chamber. Use ultrasound 12) Determine whether the pacemaker is sensing intrin-
guidance or insert blindly in the fifth intercos- sic beats for demand pacing and adjust the sensitiv-
tal space. ity accordingly.
ursing Care of the Patient

N preventable. Staff who care for patients with invasive pace-
Undergoing Temporary Pacing makers should be aware of sources of microshock and how
to avoid it. Faulty electrical equipment, current leakage,
The nursing care required for patients with temporary and static electricity are all potential sources of electrical
pacemakers depends on the type of pacing being per- current that could cause microshock [43]. Many modern
formed. Patients being paced by invasive pacing techniques medical devices use symbols to indicate when they may be
such as transvenous, temporary epicardial, or transthoracic safely used around a patient with a pacemaker
pacing should have a dressing applied at the lead insertion (Figure 23.11). Class B equipment is designed to prevent
site. Whenever the wires or catheters are covered with injury if the equipment is attached to the patient’s skin.
bandages it is possible to damage or sever them when the Class C equipment is designed to be safe when equipment
bandage is being removed. It is easy to dislodge the elec- breaches the skin, such as pacing leads, central lines, and
trodes used for invasive pacing, so the cables and generator pulmonary arterial catheters [44]. See Box 23.2 for proce-
must be secured to the patient in a way that avoids tension dures used to prevent microshock in patients with
if the patient moves or the generator is dropped. The use of pacemakers.
a vest with pockets for the generator helps secure the gen-
erator to the patient.
Patients with invasive temporary pacemakers have a onitoring the Patient with a
M
direct, low-resistance electrical pathway to the heart, which Temporary Pacemaker
theoretically puts them at increased risk of ventricular
fibrillation or other arrhythmias with only very small elec- One of the most important parameters to monitor is the
trical shock impulses, called microshocks. Death due to patient’s pulse. Every stimulus produced by the generator
electrical shock is uncommon and almost completely should produce a pulse, and every intrinsic beat should
by a QRS complex indicating ventricular depolarization that

is generally wider in duration than an intrinsic QRS complex.
The objective of pacing is to maintain adequate blood
pressure and cardiac output, so it is important to monitor
blood pressure, physical perfusion parameters, urine pro-
Electrocution hazard duction, and plasma lactate concentration in these cases.
Class B Designed to prevent macroshock

Troubleshooting
Failure to Capture
The pacing indicator shows that the pacemaker has pro-
duced a stimulus. The ECG may show a pacing spike, but
the stimulus does not produce a ventricular complex (no
Floating circuit Defib safe QRS complex on the ECG) or a contraction (no palpable
pulse). See Table 23.3 for recommendations on trouble-
Class C Designed to prevent microshock shooting capture failure.
Undersensing
Undersensing is the pacemaker’s failure to detect intrinsic
beats: the pacemaker does not recognize or pause when
intrinsic beats occur. The ECG may show a pacing spike in
Floating circuit Defib safe the QRS or T wave. See Table 23.4 for troubleshooting tips
for undersensing.
Figure 23.11 Symbols related to electrical safety. Some pieces
of medical equipment bear symbols to indicate their safety for
use around patients with pacemakers.
Oversensing
produce a pulse as well as be sensed by the pulse generator. Oversensing is used to describe the situation in which the
Palpation of the apical impulse is ideal because there is min- pacemaker interprets non-ventricular sources of electrical sig-
imal delay between mechanical capture and a palpable nal as a ventricular depolarization, and therefore fails to
pulse. Auscultation of heart sounds, Doppler pulse detec- deliver an output impulse as scheduled. During oversensing,
tion, pulse oximetry, and/or direct arterial pressure wave- the pulse generator indicates that the patient has produced a
form monitoring are also useful. A surface ECG is required heartbeat when it has not. If the pacemaker is in demand
to confirm whether the generator senses correctly, and that mode, pacing will pause. The ECG will not show a QRS com-
the output stimulus correctly captures the ventricle (or plex at the time the generator sensed a beat. Instead, a P wave,
atrium). Every pacing spike should be immediately followed T wave, muscle tremor, panting, electrocautery, or some other
Box 23.2 Procedures Used to Prevent Microshock [44–46]

● Identify electrically sensitive patients. Some institu- ● Electrically powered devices that come into contact
tions post a warning sign on the patient’s cage. with patients such as clippers, fans, and warming
● Never use damaged or poorly maintained electrical devices can be dangerous.
equipment. Avoid using extension cords. ● Touching a grounded metal object before touching a
● Wear rubber gloves whenever the leads or terminals of patient and touching the patient away from the leads
the pacemaker must be touched. or pacemaker first, reduces the risk of microshock from
● Pacing leads should always be insulated whenever they static electricity.
are not connected to a pacing generator. They should ● Certain modern electrical devices designed to be in
never be allowed to touch electrically conductive or contact with a patient are labeled to show whether
wet surfaces. they are safe to use around electrically sensitive
● Water, urine, and other fluids can conduct electricity. Keep patients and patients that may require defibrillation
the patient and pacing equipment as dry as possible. (Figure 23.11).
References 305
Table 23.3 Troubleshooting capture failure. There may be more Table 23.4 Troubleshooting undersensing.
than one cause of capture failure, and troubleshooting may
be trial and error.
Possible cause of undersensing Troubleshooting method
Possible cause of Sensitivity control is set too Lower the sensitivity setting
capture failure Troubleshooting method high
Transvenous electrode is not Reposition the electrode
Transvenous electrode Reposition the electrode in contact with the heart
is not in contact with
the heart Poor-quality ECG or Remove sources of
improper lead selection for interference. Ensure ECG
Transcutaneous a) Use a bandage to hold electrode transcutaneous pacing electrodes have adequate
electrode is not in against the skin patient contact. Select an
contact with the skin b) Be sure skin has been properly ECG lead that produces large
prepared QRS complexes
c) Replace electrode patch if Pacemaker is set for Switch to demand mode
necessary asynchronous pacing
Polarity of the Switch the lead’s connections to the Intrinsic activity occurring Reset pulse generator
electrode is reversed pulse generator. Confirm that within the pacemaker refractory period for a
bipolar pacing lead is used with refractory period shorter duration
bipolar or unipolar pulse generator
(unipolar pacing leads will not pace
using a bipolar pulse generator) Table 23.5 Troubleshooting oversensing.
Connections are loose Inspect and tighten connections to
the pulse generator Possible causes of oversensing Troubleshooting method
Battery has failed Replace the battery in the pulse
generator Electrical interference is Identify and eliminate the
Output is inadequate Increase the output stimulus from present source of the interference
the pulse generator Sensitivity setting is too low Increase the sensitivity setting
The heart cannot Assess for electrolyte abnormality. Low-amplitude QRS complex Select an ECG lead with a
respond to stimulus Consider reversing any is lost in noise in the lead larger QRS amplitude for
cardiovascularly depressive drugs. selected for transcutaneous sensing
If non-responsive and apneic, start pacing
CPR
P waves or T waves are larger Select an ECG lead with a
The ECG shows a QRS Increase the output stimulus of the than QRS in lead selected for larger QRS amplitude for
is produced by pulse generator. If this does not transcutaneous pacing sensing
pacemaker, but no produce a pulse, treat as if the
Generator appears to be The pacing lead may not be in
palpable pulse found. patient has pulseless electrical
sensing P waves in the apex of the right ventricle.
activity, and initiate CPR
transvenous pacing Check lead position and
reposition as necessary
form of electrical interference may be visible on the ECG. See few complications, most of which can be remedied with
Table 23.5 for methods of troubleshooting oversensing. basic care and troubleshooting procedures.
Summary Acknowledgment
Temporary cardiac pacing can be a life-saving measure for This chapter was originally authored by Mr. Craig Cornell
patients with or at risk of severe bradyarrhythmia. There for the previous edition, and some material from that
are many different methods by which temporary pacing chapter appears in this one. The authors and editors thank
can be achieved, some of which are simple and relatively Mr. Cornell for his contributions.
noninvasive considering the benefit. Temporary pacing has
References
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309
Section Three
Respiratory Procedures and Monitoring
311
24
Oxygen Therapy
Kate Farrell
Respiratory distress is a common presenting complaint to 2–3% of the total oxygen content of arterial blood in
the emergency room and a frequent cause for admission to health [2]. The bulk of oxygen is carried by hemoglobin,
hospitals and intensive care units. Oxygen therapy plays a and the saturation of hemoglobin with oxygen in arterial
crucial role in treatment of patients with hypoxemia and blood (SaO2) is directly related to PaO2. The oxygen content
respiratory failure. Responsiveness to oxygen is dependent of arterial blood (CaO2) is dependent on PaO2, SaO2, and
on the patient’s underlying disease process. As oxygen is the concentration of hemoglobin. The arterial oxygen con-
typically benign in the short term, supplementation is tent equation is noted in Box 24.1.
essential for patients exhibiting signs of respiratory distress The term hypoxemia refers to inadequate oxygenation of
during triage and stabilization. Oxygen administration can arterial blood, and this is defined by a PaO2 of less than
result in complications, and thus judicious use and appro- 80 mmHg. The term hypoxia, on the other hand, refers to
priate concentrations are warranted in the long term. There decreased oxygen at the level of the tissues. Oxygen deliv-
are numerous techniques for the administration of oxygen, ery to cells is dependent on both CaO2 and cardiac output;
and the best method for supplementation will depend on this equation is noted in Box 24.1. While total cardiac out-
multiple patient factors and equipment available. put affects global oxygen delivery, transport to individual
organs is also affected by distribution of blood flow.
Hypoxemia is dangerous because it reduces CaO2 and can
Normal Oxygenation and Hypoxemia result in hypoxia.
Causes of hypoxemia include three major categories:
Oxygen is critically important for cellular metabolism and (i) low partial pressure of inspired oxygen; (ii) hypoventila-
energy production. To reach the cellular level, oxygen must tion; and (iii) venous admixture. Venous admixture encom-
travel down its partial pressure gradient starting from the passes ventilation/perfusion (V/Q) abnormalities,
atmosphere. The atmosphere is composed of 20.9% oxygen. right-to-left anatomic shunts, and diffusion defects. The
The partial pressure of oxygen (PO2) in dry air at sea level most common of these causes to result in hypoxemia and
is 21.2 kPa (159 mmHg), and this partial pressure decreases respiratory distress in veterinary patients is V/Q mismatch,
with elevation [1]. Oxygen and other gases from the atmos- which can include low V/Q regions in which alveoli are
phere travel down the airways by bulk flow into the alveoli, perfused but inadequately ventilated, or it can include no
where oxygen diffuses across the respiratory membrane V/Q regions, also known as physiologic or intrapulmonary
into the plasma. Oxygenated blood travels from the arteries shunt. Ultimately, the response to oxygen supplementation
to the capillaries, and oxygen diffuses into the tissues to the is dependent on the underlying mechanism of hypoxemia.
level of the mitochondria, where it is consumed. Most causes of hypoxemia are readily improved with oxy-
Oxygen is carried in the blood in two forms: (i) as dis- gen administration. The exceptions include right-to-left
solved gas; and (ii) bound to hemoglobin in red blood cells. anatomic shunts and diseases resulting in intrapulmonary
The dissolved portion is measured as the partial pressure of shunting; with both processes, blood bypasses gas exchange
oxygen in arterial blood (PaO2) and encompasses only units where oxygenation can occur [1, 3].
312 Oxygen Therapy
typically recommended for patients with a PCO2 greater

Box 24.1 Equations for Oxygen Delivery and Arterial
than 55–60 mmHg.
Oxygen Content
Decreased oxygen delivery to the tissues can also be
Oxygen Delivery caused by severe anemia, dyshemoglobinemias (elevated
DO2 (ml O2/minute) = Q (ml/minute) × CaO2 (ml O2/ carboxyhemoglobin or methemoglobin), and poor tissue
perfusion. Additionally, increased oxygen demand in the
dl) × 10
● DO2 = oxygen delivery
tissues can occur in disease states resulting in elevated met-
● Q = cardiac output
abolic rate or body temperature, such as sepsis, prolonged
● CaO2 = arterial oxygen content
seizures, and heat stroke [4]. Therefore, under certain cir-
cumstances, patients with these abnormalities may also
Arterial Oxygen Content benefit from oxygen supplementation, even if they are not
hypoxemic.
CaO2 (ml O2/dl) = [1.34 (ml O2/g) × SaO2 (%) × Hb (g/dl)]
+ [PaO2 (mmHg) × 0.003 (ml O2/dl/mmHg)]
● SaO2 = arterial hemoglobin saturation with oxygen Methods of Oxygen Supplementation
● Hb = hemoglobin
● PaO2 = partial pressure of oxygen in arterial blood Once it has been determined that a patient requires oxygen
supplementation, there are multiple methods of delivery
that vary in their level of invasiveness. The technique uti-
lized will depend on multiple factors, including length of
Indications for Oxygen Supplementation supplementation needed, patient requirements and toler-
ance, patient size, severity of hypoxemia, degree of FiO2
The aim of oxygen supplementation is to elevate the frac- required, equipment available, and experience and skill of
tion of inspired oxygen (FiO2) to cause an increase in PaO2 the clinical team [6]. The oxygen source for each technique
and SaO2, which results in an increase in the content of discussed may vary and can include portable oxygen tanks
arterial oxygen and thus increased oxygen delivery to the or a central source with wall- or ceiling-mounted outlets. A
tissues. The decision to supply oxygen to a patient may be tank or central oxygen source may also be connected to an
dependent on clinical signs, objective data indicating anesthesia circuit for delivery of oxygen.
hypoxemia, or evidence of decreased oxygen delivery to In each of the techniques discussed below, some form of
tissues. humidification is required to avoid drying and irritation of
Clinical signs of respiratory distress may include, but are the respiratory mucosa. This is less critical for short-term
not limited to, increased respiratory rate and effort, open- therapy, such as during the administration of flow-by or
mouth breathing, extended head and neck, abducted face mask oxygen while a patient is initially being assessed.
elbows, retraction of the lip commissures or “fish-mouth” However, long-term desiccation can result in irritation,
breathing, nasal flare, severe stertor or stridor, shallow mucosal damage, impaired function of the mucociliary
chest movements, recruitment of abdominal muscles for apparatus, and increased potential for infection [4, 6, 7].
breathing, paradoxical movement of the chest wall and While some methods may have built-in humidification
abdomen, abnormal lung sounds (crackles, wheezes, techniques, such as designed in commercial oxygen cages
absent lung sounds), or evidence of respiratory fatigue or and in heated humidified high-flow machines, most sup-
exhaustion. plemental oxygen sources will need humidifying by bub-
When assessing for hypoxemia, supplemental oxygen bling air through a bottle of sterile water or saline. It is
is often indicated in patients with a PaO2 less than important that the water is sterile to avoid contamination
70 mmHg, an SaO2 less than around 93%, or cyanosis [4, of the respiratory tract with nosocomial infections.
5]. Cyanosis, or the blue discoloration of mucous mem- Warming delivered oxygen will also help improve humidi-
branes secondary to significant quantities of deoxygen- fication. Bubble humidifiers are commercially available
ated hemoglobin, is indicative of severe hypoxemia. (Figure 24.1).
Unfortunately, its absence does not rule out hypoxemia.
It must be noted that in chronic disease, a patient may
Flow-by Oxygen
tolerate a significantly lower PaO2 than a patient that is
acutely hypoxemic. If there is concern for a disease pro- Flow-by oxygen is administered by placement of a tube
cess that may be contributing to hypoventilation, assess- connected to an oxygen source in close proximity to a
ment of the partial pressure of carbon dioxide in the patient’s nose if nasal breathing or mouth if open-mouth
blood (PCO2) is required, and oxygen supplementation is breathing (Protocol 24.1; Figure 24.2). The oxygen source
Methods hof OxyMen SuupMeMenetethen 313
dyspneic dogs may not tolerate consistent flow-by oxygen

close to the nose, which can preclude appropriate mainte-
nance of oxygenation. This technique is not practical or
economical long-term given the fact that constant supervi-
sion is required and significant quantities of oxygen are
wasted into the surrounding environment.
Face Mask
Oxygen administration via a face mask is equally simple to
flow-by methods and can provide convenient oxygen dur-
ing triage and initial treatment of a patient (Protocol 24.1).
Delivery is similar to flow-by oxygen, but a face mask is
placed at the end of the oxygen tubing (Figure 24.3a). Some
masks are also designed to function as muzzles (or a muz-
zle can be secured around a face mask), and these can be
attached to a patient to facilitate ease of oxygen administra-
tion and to free up an attendant to perform other functions
(Figure 24.3b). Higher oxygen concentrations can be
Figure 24.1 A bubble humidifier connected to an achieved compared to the flow-by technique [8, 9]. With a
oxygen source.
tight-fitting face mask in healthy anesthetized dogs, an
oxygen flow rate of 0.5 l/minute provided a mean FiO2 of
can be a central source, portable tank, or anesthesia
46.5% (range 30–70%) [8]. The FiO2 provided by a face
machine. Flow-by provides a simple and rapid mechanism
mask in this study was consistently higher than that pro-
for administration of oxygen to a patient in respiratory dis-
duced with flow-by at equivalent oxygen flow rates. In
tress. Most animals will tolerate flow-by tubing, and oxy-
another study, oxygen delivered at 3 l/minute to healthy
gen can be provided easily while a clinician is initially
sedated dogs achieved significantly higher PaO2 values
evaluating and treating a patient. Flow-by oxygen adminis-
when provided via face mask compared to flow-by (mean
tered to healthy, anesthetized dogs supplied 2 cm from the
PaO2 of 371.3 mmHg with a face mask, 182.2 mmHg with
nose with a flow rate of 2 l/minute was able to achieve a
mean FiO2 of 37.2% (range 25–48%) [8]. However, awake
Protocol 24.1 Flow-by or Face-Mask Oxygen Setup
and Application
Equipment Required
● Oxygen source with regulator
⚪ Wall- or ceiling-mounted central source
⚪ Oxygen tank
⚪ Anesthetic machine (with central source or oxygen
tank)
⚪ Oxygen tubing or hose
● Face mask ± muzzle (if desired) of appropriate size
Procedure
2) Hold tubing 2 cm in front of the patient’s face and
adjust the flowmeter of the oxygen source as
desired, with a minimum of 2–3 l/minute.
3) If a mask is used, connect this to the oxygen source
and place closely around the patient’s muzzle, ensur-
ing some escape of air. A muzzle may be attached to
Figure 24.2 Oxygen is provided for a trauma patient using a the patient’s head to allow hands-free use.
flow-by technique.
314 Oxygen Therapy
(a) (b)
Figure 24.3 (a) Oxygen is administered to a patient using a face mask connected to oxygen tubing. (b) A commercial face mask
designed as a muzzle is used to deliver hands-free oxygen, allowing personnel to be freed to perform other tasks. A nylon dog muzzle
may also be placed around a face mask and secured to a patient to function similarly.
flow-by, and 82.4 mmHg on room air) [9]. In general, the plastic wrap over an E-collar or the zipper of a com-
lower flow rates may be adequate for smaller dogs while mercially available hood must be opened to ensure venting
higher flow rates will be required for larger dogs. With a of CO2 and escape of heated and humidified air
loose-fitting face mask, higher oxygen flow rates of 2–5 l/ (Protocol 24.2). While this is accepted in many patients, not
minute (or up to 5–10 l/minute in large dogs) have been all will tolerate an oxygen hood and there is the potential
suggested to meet peak inspiratory needs of patients in res- for overheating and CO2 rebreathing if a patient is not care-
piratory distress and to minimize rebreathing of exhaled fully attended to. The oxygen concentration that can be
carbon dioxide (CO2) [4, 6]. Unfortunately, not all patients achieved in the hood is variable and dependent on patient
will tolerate a face mask and can become more panicked size, minute ventilation, fit of the collar, and size of the
and tachypneic. Care must be taken to ensure no damage vent. An oxygen hood should initially be filled at a higher
to the eyes with positioning of the face mask, and, impor- rate (at least 1–2 l/minute), and then flow rates of 0.75–1 l/
tantly, enough venting from the face mask must be provided minute can be used [4]. In healthy anesthetized dogs, an
to prevent rebreathing of CO2. oxygen flow rate of 1 l/min into an E-collar hood provided
a mean tracheal FiO2 of 40.6% (range 29–56%) [10]. An
additional study demonstrated that the E-collar method
Oxygen Hood or Elizabethan Collar
could achieve an FiO2 of 95% with a 300 ml/kg/minute
Multiple types of oxygen hoods are manufactured com- flow rate in dogs [11].
mercially for purchase (Figure 24.4a), but they can also be
made cheaply and easily in hospital with the use of a snug-
Oxygen Cage
fitting Elizabethan collar (E-collar), cling wrap, and tape
(Figure 24.4b). In general, this technique requires minimal Oxygen cages offer multiple advantages, including admin-
equipment, is non-invasive, allows access to the patient, istration of oxygen in a non-invasive and non-stressful
and has the potential to achieve high FiO2 values. To manner with the ability to achieve high FiO2 values typi-
assemble a hood in hospital, an E-collar can be placed cally up to 60% [4, 6]. Oxygen delivery into a cage is hands-
around a patient’s neck, and the front of the E-collar can be free, convenient for patients presenting in respiratory
covered with clear plastic cling wrap. An oxygen line is distress when minimal handling is desired, and also easy
positioned inside the collar on the neck and adhered to the for long-term administration of oxygen. Commercial cages
hood. Very importantly, a small opening must be made in allow venting of CO2 and control of FiO2, temperature, and
(a) (b)
Figure 24.4 (a) Tubing secured at the collar provides oxygen to a commercial hood. Note small holes present in the oxygen hood
that provide venting for carbon dioxide and escape of heated and humidified air. (b) An oxygen hood can also be made with an
E-collar, clear plastic wrap over the front of the cone, and oxygen tubing adhered within the hood. A sufficient gap in the plastic wrap
must also allow heat and CO2 to escape.
Protocol 24.2 Oxygen Hood or Elizabethan Collar Setup and Application

Equipment Required 3) Position oxygen tubing/hose under the patient’s collar
at the neck and secure to the inside of the hood with
adhesive tape.
4) If a commercially available hood is used, zip the front
⚪ Oxygen tank
most of the way closed, leaving approximately 25% of
the zipper open.
tank)
5) If an E-collar is used, cover the front of the E-collar
● Oxygen tubing or hose
with clear plastic wrap, leaving an opening for carbon
● Commercially available oxygen hood or E-collar
dioxide, moisture, and heat to escape. Secure the plas-
● Clear plastic wrap (if using an E-collar)
tic wrap in place with adhesive tape.
● Adhesive tape
6) Fill the hood with oxygen rapidly initially and then use
flow rates of 0.75–1.0 l/minute at a minimum depend-
Procedure
ing on patient size and oxygen requirements.
1) Collect necessary supplies. 7) An oxygen monitor can be used to determine the FiO2
2) Place an oxygen hood or E-collar over the patient’s within the hood if desired.
head and secure to the neck.
humidity (Figure 24.5). Optimal temperature is 70°F stabilization, or completion of a procedure, additional
(22°C) with a humidity of 40–50% [4, 6]. Ideally, cages have flow-by or face mask oxygen may be required.
a transparent Plexiglas front to enable visualization of the Smaller portable and collapsible oxygen cages are avail-
patient, access ports for intravenous lines and monitoring able for purchase and can be used for short-term oxygen
equipment, and small doors or sleeves to allow manipula- administration or transport (Figure 24.6). Temporary oxy-
tion of a patient without significant oxygen loss. An oxygen gen cages can also be easily manufactured from an incuba-
cage does limit hands-on access to a patient to some degree, tor (Figure 24.7) or a pet carrier covered with a plastic bag
but pulse oximetry, electrocardiogram, and blood pressure (Figure 24.8) with placement of an oxygen hose into the
monitoring can all be added as needed to enhance patient cage. However, caution must be exercised to always pro-
monitoring. Disadvantages include declining FiO2 when vide ventilation. If there is no mechanism for outflow of
the cage is opened, oxygen waste, expense of a commercial gas, CO2 can accumulate and result in rebreathing. An
cage, and potential inability to accommodate large patients. additional potential complication is the risk for heat accu-
If the oxygen cage door requires opening for further triage, mulation. Patients should be checked frequently to ensure
316 Oxygen Therapy
Figure 24.5 A commercial cage allows hands-free, non-invasive delivery of oxygen with control of FiO2, temperature, humidity, and
ventilation.
Figure 24.6 Oxygen is administered to a patient in a commercial transportable oxygen cage, and an oxygen sensor is used to
monitor the FiO2 within.
that they have not become hyperthermic and that cage but care should be taken to avoid direct contact with the
temperature is not excessive. Even in commercial cages patient. Commercial O2 sensors, CO2 monitors, and ther-
with temperature control, large patients can overheat. Ice mometers can all be added to temporary cages to improve
packs can be placed within a cage as needed for cooling, monitoring and safety.
Figure 24.7 A human infant incubator is adapted for oxygen use by delivery of oxygen through tubing into the cage.
Figure 24.8 A pet carrier or box can be covered with a plastic bag with oxygen delivered via a hose or tube to make a temporary
oxygen cage. A hole must be made in the plastic bag to allow for venting of CO2, and care must be taken to ensure a patient does not
overheat. An oxygen sensor here displays FiO2.
Nasal Oxygen and can allow patients greater mobility and accessibility
for treatments and monitoring [7, 12]. It is also typically
Nasal prongs or cannulas are also an effective delivery
more economical and less wasteful than flow-by oxygen or
method for oxygen to patients that will need more pro-
oxygen cages. It may provide a good option for patients that
longed oxygen administration. Nasal oxygen is advanta-
are too large for an oxygen cage. This method is not indi-
geous because it is generally well tolerated, easy to provide,
cated for patients with facial trauma or respiratory signs
318 Oxygen Therapy
attributed to nasal obstruction or other upper airway dis- toxicity [14]. Oxygen concentration will vary if a patient is
ease, such as brachycephalic breeds with obstructive air- panting or open-mouth breathing. These studies have eval-
way syndrome. This technique may also be contraindicated uated the use of nasal catheters, but unfortunately little
in coagulopathic patients that are more prone to mucosal data exists in patients with the use of nasal prongs. It is
hemorrhage. Adverse effects can include gastric distension likely that FiO2 with be lower with nasal prongs than values
at very high flow rates, nasal irritation or inflammation, that can be achieved with nasal catheters, but this could be
discharge, sneezing, and epistaxis, which may preclude use variable and dependent on patient conformation, compli-
in some animals [7, 13]. If local nasal irritation occurs, the ance, and frequency of dislodgement.
catheter can be relocated to the other nare to reduce jet Placing nasal prongs or cannulas can be facilitated by the
lesions on the mucosa, avoid pressure necrosis, and pre- use of topical anesthetics such as 2% lidocaine or propa-
vent occlusion of the tube with mucus [13]. Humidification racaine in the nares prior to placement. Human nasal
of inspired air is recommended to reduce local irritation prongs, which can be purchased from medical suppliers
and improve patient comfort. online, are particularly easy to place and may be less stress-
It has been demonstrated that there is a nearly linear rela- ful than the placement of cannulas (Protocol 24.3). The
tionship between increases in nasal oxygen flow rate and prongs are approximately 1 cm in length but can be cut
concurrent FiO2 and PaO2 [7, 14]. Previous studies in dogs shorter as needed for the patient. The tubing associated
have shown that using unilateral nasal catheters with flow with the prongs can be tightened behind the ears to secure
rates of 50–100 ml/kg/minute can increase tracheal FiO2 up them, and tape across the bridge of the nose can help to
to 50% [7, 10, 15]. By using one or two nasal catheters, flow stabilize them (Figure 24.9). However, depending on the
rates of 50–400 ml/kg/minute can provide tracheal FiO2 in anatomy of the patient, their fit may be variable, they can
the range of 30–77% [14]. The advantage to the use of bilat- be dislodged easily, and the FiO2 they provide is unknown,
eral nasal catheters is the ability to reduce flow rates in each so close monitoring is warranted. An E-collar may help to
side, as flow rates above 100 ml/kg/minute have been shown prevent patient removal of nasal prongs.
to cause discomfort [14]. The nasal passages are unable to Nasal cannulas or catheters are often placed into the
adequately heat and humidify incoming air at higher flow nasal cavity by premeasuring tubing from the nose to the
rates. Administration of oxygen at a flow rate of 100 ml/kg/ medial canthus of the eye (Figure 24.10), but they can
minute in bilateral nasal catheters can achieve an FiO2 of be placed into the nasopharyngeal region by measurement
60% while avoiding patient discomfort and risk of oxygen from the nose to the ramus of the mandible. After
Protocol 24.3 Nasal Prong Setup and Application

Equipment Required 2) Place a few drops of 2% lidocaine or proparacaine
ophthalmic drops into the nose and wait a few min-
utes for the local anesthetic to take effect. This step
may be less necessary than for placement of a nasal
⚪ Oxygen tank
catheter. Administer less than 2 mg/kg lidocaine in
dogs and 1 mg/kg lidocaine in cats.
tank)
3) Seat the nasal prongs within each nare. The ends of
⚪ Heated humidified high-flow nasal oxygen machine
the prongs can be cut as needed for patient conforma-
● Nasal prongs set appropriate for the patient size or
tion. The prongs should not fill the entire opening of
high-flow nasal cannula (HFNC) set
the nares.
● 2% lidocaine or proparacaine ophthalmic drops
4) Tighten the tubing associated with the prongs behind
● ½–1 inch adhesive medical tape
the patient’s ears to secure them. Connect the tubing
● Nonabsorbable suture material and suturing instru-
across the bridge of the nose with adhesive tape to
ments, or skin staple gun
help stabilize the prongs.
● Additional oxygen tubing as needed
5) The tubing of the prongs can also be positioned and
● Christmas tree adapter, 1-ml cut syringe or other
stabilized by suturing or stapling butterfly tabs to the
adapter as needed for connection to oxygen source
skin on either side of the nares.
● Bubble humidifier
6) Attach the tubing to an oxygen source and bubble
● E-collar
humidifier. Use additional tubing and connectors
as needed.
Procedure
7) Place an E-collar on the patient.
treatment with a topical anesthetic, a lubricated rubber

catheter (size 3.5–10 Fr depending on the size of the
patient) can be placed into the ventral nasal meatus
(angling ventromedially) to the premeasured distance
(Protocol 24.4). Multiple fenestrations at the end of the
catheter will help to avoid jet lesions on the mucosa. The
tubing should be secured with suture immediately adja-
cent to the nostril with a finger-trap or other suture pattern
and secured again to the side of the face or forehead with
sutures, staples, or an adhesive agent such as cyanoacrylate
(Figure 24.11). The patient can then be connected to oxy-
gen via the shortest and widest tubing possible to allow the
least resistance to airflow.
Figure 24.9 Nasal prongs are secured and stabilized by Transtracheal Oxygen

tightening tubing behind the ears and placing tape across the
bridge of the nose. The tubing for the nasal prongs is attached Oxygen can be administered directly into the tracheal via a
to an oxygen source. percutaneous catheter, thus bypassing the upper airway.
This may be a more effective technique for patients that
have an upper airway obstruction, are panting, or do not
tolerate other methods. Transtracheal oxygen is reported to
be well tolerated in dogs and cats, provides easy access to
patients, and can achieve higher FiO2 and PaO2 at lower
flow rates than nasal insufflation [15]. A flow rate of 50 ml/
kg/minute through a transtracheal catheter can provide an
FiO2 of 40–60%, similar to a flow rate of 100 ml/kg/minute
through a nasal cannula [15]. As this technique can pro-
vide FiO2 above 60%, close monitoring of PaO2 and adjust-
ment to the lowest required flow rate is important to reduce
the risk of oxygen toxicity. Disadvantages of this technique
include difficulty in placement and maintenance and the
requirement for constant monitoring and avoidance of
kinking or displacement of a catheter. Complications can
Figure 24.10 A red rubber catheter is measured to the level of include tracheal irritation, subcutaneous emphysema, and
the medial canthus of the eye and marked at the tip of the nose obstruction of the catheter with mucus or secretions. This
prior to placement into the ventral nasal meatus for delivery of method should be avoided in patients with tracheal
nasal oxygen.
Protocol 24.4 Nasal Catheter Setup and Application

Equipment Required ● Additional oxygen tubing as needed
● Christmas tree adapter, 1 ml cut syringe, or other
adapter as needed for connection to oxygen source
⚪ Oxygen tank
● E-collar
tank)
Procedure
● Red rubber catheter or infant feeding tube (size
3.5–10 Fr depending on patient size) 1) Collect necessary supplies.
● 2% lidocaine or proparacaine ophthalmic drops 2) Place a few drops of 2% lidocaine or proparacaine
● Lubricating jelly or lidocaine gel ophthalmic drops into the nose and wait a few min-
● ½–1 inch adhesive medical tape utes for the local anesthetic to take effect. Administer
● Non-absorbable suture material and suturing instru- less than 2 mg/kg lidocaine in dogs and 1 mg/kg lido-
ments, or skin staple gun caine in cats.
320 Oxygen Therapy
3) Premeasure the catheter to the medial canthus of the facilitated by gently pushing the nasal philtrum dor-
eye (if placement in the nasal cavity is desired) or to sally. Advance carefully and expect some nasal irri-
the ramus of the mandible (if placement in the naso- tation. If significant resistance if met, withdraw the
pharynx is desired). A marker or piece of adhesive catheter and re-direct to avoid causing epistaxis by
tape can be used to designate the premeasured dis- hitting the ethmoid turbinate if located in the dor-
tance for placement. If a patient does not tolerate sal nasal meatus. Advance to the premeasured
placement in the nasal cavity, attempt advancement location.
into the nasopharynx for improved comfort. The cath- 7) Secure the tubing with suture immediately adjacent
eter should not fill the entire opening of the nare(s). to the nostril with a finger-trap or other suture
4) Catheters with premade fenestrations can be pur- pattern.
chased, or additional fenestrations can be made in 8) Additionally secure the tubing to the side of the face
the distal end of the nasal catheter if desired to help and/or forehead with an adhesive agent
prevent jet lesions on the mucosa. This can be per- (e.g. cyanoacrylate) or sutures/staples applied to but-
formed if high flow rates are anticipated. terfly tape tabs on the tubing.
5) Apply lubricating jelly or lidocaine gel to the end of 9) Attach the catheter to an oxygen source and bubble
the catheter to facilitate smooth placement into the humidifier. Use additional tubing and connectors
nasal passage. as needed.
6) Restrain the patient with an elevated head. Direct 10) Start with a flow rate of 50–100 ml/kg/minute and
the catheter ventromedially to place it into the ven- adjust as needed.
tral nasal meatus of the nasal cavity. This may be 11) Place an E-collar on the patient.
lidocaine bleb and nick incision through the skin can be

performed prior to placement of the catheter. Sedation may
be required in some patients to allow placement. A large-
gauge over-the-needle or through-the-needle catheter is
placed percutaneously between two tracheal rings caudal
to the larynx and directly into the trachea, angling caudally
toward the carina. The needle is removed and the catheter
is secured and attached to a humidified oxygen source with
a light wrap around the neck.
Heated Humidified High-Flow Nasal Oxygen

In human medicine, a non-invasive oxygen delivery method
known as high-flow nasal cannula (HFNC) has emerged
over the past decade as an alternative to conventional oxy-
gen therapy and has been investigated as a method to treat
hypoxemic respiratory failure and potentially avoid invasive
mechanical ventilation [16–20]. HFNC has more recently
been adapted and employed for use in dogs. This method is
advantageous because it is able to achieve flow rates up to
40–60 l/minute and can more reliably deliver high FiO2.
Figure 24.11 The bilateral nasal catheter tubing is sutured HFNC systems use an air-oxygen blender connected to a
adjacent to the nares with a finger-trap pattern and sutured to flow meter that can deliver an FiO2 of 21–100%. The air is
the forehead with the use of adhesive tape butterflies in this heated and humidified, then delivered to the patient
patient. Tubing may also be secured to the side of the face. through a heated breathing circuit and specialized nasal
prongs sized to occlude about 50% of the nares. The system
collapse or coagulopathies. Because this technique allows 100% humidification and control of temperature,
bypasses the upper airway, humidification is necessary to thereby enhancing patient comfort and tolerance of these
reduce tracheal irritation. high flow rates while preventing airway desiccation, epithe-
To place a transtracheal catheter, a patient’s ventral neck lial injury, airway constriction, and impairment of muco-
is clipped and aseptically prepped (Protocol 24.5). A 2% ciliary function. High flow rates reduce entrainment of
Protocol 24.5 Transtracheal Oxygen Setup and Application

Equipment Required distance, as passage too far distally could result in
airway damage or penetration.
4) Clip the fur from just caudal to the larynx to the tho-
racic inlet, as well as laterally 3–5 cm off midline on
⚪ Oxygen tank
both sides. Aseptically prepare the patient’s
⚪ Anesthetic machine
ventral neck.
● Clippers with a clean blade
5) Place a small bleb of 2% lidocaine subcutaneously at
● Surgical aseptic preparation materials
the proposed insertion site and allow time for it to
● Sterile gloves
take effect. Administer less than 2 mg/kg lidocaine in
● 2% lidocaine
dogs and 1 mg/kg lidocaine in cats.
● #11 scalpel blade (if desired)
6) A small nick incision with a #11 scalpel blade can be
● Large-gauge over-the-needle catheter, through-the-
performed to decrease drag and facilitate smooth
needle catheter, or commercial tracheal catheter
placement of the catheter.
● ½–1 inch adhesive medical tape
7) Aseptically prepare the skin again.
● Non-absorbable suture material and suturing instru-
8) Put on sterile gloves after appropriate hand hygiene.
ments, or skin staple gun
9) Relocate the insertion site, ensuring placement on
● Oxygen tubing
midline between tracheal rings. Using aseptic tech-
● Christmas tree adapter or other adapter as needed for
nique, insert the catheter into the trachea and direct
connection to oxygen source
caudally toward the carina. A pop may be felt as the
needle enters the tracheal lumen. Once in the tra-
chea, the catheter can be advanced gently without
Procedure
the needle until it is buried to its hub. The needle is
1) Collect necessary supplies. then removed and the catheter left in place.
2) Palpate the patient’s ventral cervical region to locate 10) Secure the catheter to the neck by applying an adhe-
a proposed insertion site. The transtracheal catheter sive tape butterfly to the hub and attaching it to the
is typically inserted on ventral midline between tra- patient with stay sutures or staples. Ensure the cath-
cheal rings, usually between the third and fifth tra- eter does not kink at its insertion site.
cheal rings caudal to the cricoid cartilage depending 11) Connect the catheter to a humidified oxygen source,
on patient conformation. with additional tubing and adapters as needed.
3) Measure the distance from the proposed insertion 12) Start with a flow rate of 50 ml/kg/minute and adjust
site to the level of the carina, located at the fourth to as needed.
fifth intercostal space or caudal border of the scap- 13) Place a loose wrap around the patient’s neck for
ula. The catheter length should not exceed this security and cleanliness.
room air, enable washout of upper airway dead space, and which resolved upon discontinuation of HFNC; it is
may generate some degree of continuous positive airway unknown whether the pneumothorax could have been
pressure (CPAP) with a closed mouth. CPAP can be achieved exacerbated by HFNC [22]. Caution may be required in
in healthy awake and sedated dogs using HFNC with flow patients with hypercapneic respiratory failure, as PCO2 has
rates of 1–2 l/kg/minute.21 been shown to increase slightly, with possible concern for
While data are somewhat limited in veterinary species, air trapping caused by the CPAP effect [21, 22]. However,
initial studies in both healthy dogs and hypoxemic dogs decreased work of breathing due to initiation of HFNC
assessed to be failing traditional oxygen therapy have cannot be ruled out in these patients.
shown HFNC to be efficacious for achieving higher PaO2 The specialized nasal prongs are attached to the patient’s
compared with traditional oxygen therapy [21–24]. These face as described for standard nasal prongs (Protocol 24.3),
studies have also demonstrated good tolerance and patient with the exception that the oxygen source is a HFNC
comfort with minimal safety concerns [21–24]. machine (Figure 24.12). Adequately high rates of inspired
Complications include mild discomfort in patients espe- oxygen can be achieved that monitoring of PaO2 and reduc-
cially at high flow rates (above 2 l/kg/minute), aerophagia, tion to minimal required FiO2 is warranted to avoid oxygen
and gastric distension [21–23]. One patient experienced toxicity. It may also be justified to monitor PCO2 in patients
persistence of a pre-existing traumatic pneumothorax, with concern for hypercapnea.
322 Oxygen Therapy
patients have severely altered mentation, they will likely

require sedation or anesthesia to achieve and maintain
intubation. Initial IPPV may be provided with a bag–valve–
mask (or Ambu bag), a nonrebreathing circuit and reser-
voir bag attached to a central oxygen source or tank, or an
anesthesia machine. Short-term intubation and manual
ventilation may permit the emergency team to gain suffi-
cient diagnostic information to give owners a better idea of
prognosis or to provide stabilizing treatments such as
thoracocentesis or a procedure to relieve an upper airway
obstruction. For long-term IPPV, most often a mechanical
ventilator will be required and intensive 24-hour manage-
ment is necessary. For hospitals that cannot provide long-
term mechanical ventilation, these patients may require
stabilization and subsequent transport to another facility.
Tracheostomy Tube Placement

For some patients requiring an artificial airway, oxygen can
be delivered via a temporary tracheostomy tube. Indications
for a tracheostomy tube include upper airway obstruction
Figure 24.12 A patient in the intensive care unit is connected (with rare circumstances necessitating emergency trache-
to a high-flow nasal cannula system that is delivering heated ostomy tube placement), oral or pharyngeal surgery, and
(98.6°F; 37°C) and humidified gas at a rate of 40 l/minute with a mechanical ventilation for select patients (such as those
fraction of inspired oxygen of 100%. This particular model is with respiratory paralysis) [25]. Similar to endotracheal
manufactured by Vapotherm.
intubation, tracheostomy tube placement allows adminis-
tration of 100% oxygen and requires anesthesia if a patient
Oxygen Delivery via Artificial Airway is not unconscious. Once placed, tracheostomy tubes may
be tolerated in awake patients. See Chapter 29 for further
While many patients in respiratory distress can be stabi- discussion of temporary tracheostomy.
lized, diagnosed, and treated with the oxygen supplemen-
tation methods discussed above, a subset of these patients
have severe enough respiratory failure or hemodynamic Hyperbaric Oxygen
instability that they may benefit from intubation and the
use of intermittent positive pressure ventilation (IPPV). Hyperbaric oxygen therapy (HBOT) has been used infre-
Indications for immediate intubation include lack of a pat- quently in veterinary medicine but has become slightly
ent airway (due to airway obstruction), lack of a gag or more accessible with the availability of portable hyperbaric
normal protective airway reflexes, apnea, unconscious- chambers designed for veterinary patients. In HBOT, a
ness, and cardiopulmonary arrest [25]. Indications for patient is delivered 100% oxygen into a chamber at an ele-
intubation and long-term mechanical ventilation include vated atmospheric pressure (above 760 mmHg or 1 atm).
severe hypoxemia despite oxygen therapy, severe hypoven- Because hyperbaric oxygen leads to alterations in oxygen
tilation refractory to intervention, excessive work of pressure and solubility, there is a marked increase in PaO2
breathing with potential for respiratory fatigue, and severe and the amount of oxygen transported to the tissues. At
hemodynamic compromise refractory to therapy [26–29]. typical working pressures of 2–2.5 atm with an FiO2 of
In subsequent chapters, significantly more detail is dis- 100%, the oxygen dissolved in plasma increases by almost
cussed regarding tracheal intubation (Chapter 28) and 17-fold [30]. Ultimately this results in enhanced diffusion
mechanical ventilation (Chapter 31). of oxygen into the tissues due to an increase in the diffu-
sion gradient.
Unlike for the majority of uses of oxygen discussed
Endotracheal Intubation
above, HBOT is rarely employed to treat primary respira-
Endotracheal intubation enables control of a patient’s air- tory disease. In people, HBOT is used for the treatment of
way, allows provision of an FiO2 of 100%, requires low oxy- carbon monoxide poisoning, helping to accelerate the dis-
gen flow rates, and eliminates patient distress. Unless sociation of carbon monoxide from hemoglobin by
heuptitethends hof OxyMen tMetux 323
increasing PaO2. It is also used for gas embolism reduction, underlying disease process improves, room-air trials
enhanced oxygen delivery to cells, wound healing, antimi- should be considered to assess a patient’s tolerance for dis-
crobial activity, angiogenesis, modulation of inflammation, continuation of oxygen supplementation.
and vasoconstriction [30, 31]. Data on HBOT in small ani-
mal clinical patients are limited mostly to case reports,
small populations studies, and anecdotal reports. A pro- Complications of Oxygen Therapy
spective clinical trial designed to evaluate safety assessed
230 HBOT treatments in 78 dogs and 12 cats and demon- Although supplemental oxygen is valuable in many clini-
strated that it was well tolerated with no major adverse cal scenarios and necessary for the prevention of poten-
effects [32]. A prospective, controlled study evaluating tially life-threatening hypoxia, excessive or inappropriate
experimentally induced dermal incisions in 10 dogs administration can be deleterious. The term oxygen toxic-
showed that an HBOT protocol was safe but did not ity is typically reserved for changes caused by oxidative
enhance wound healing [33]. injury to the pulmonary epithelium, but additional gas
Complications of HBOT can include pulmonary oxygen exchange problems associated with high FiO2 can include
toxicity and oxidative injury, pneumothorax, ruptured tym- worsening hypoxemia secondary to absorption atelectasis
panic membrane, decompression sickness (gas bubble for- and exacerbation of hypercapnia due to reduced ventila-
mation in tissues), and oxygen-induced seizures [31]. tory drive and worsening V/Q mismatch. While the lungs
There are also practical limitations to the use of HBOT in are normally the initial target of injury with exposure to
small animals. When a patient is in an enclosed chamber high FiO2, excessive oxygen in the blood and tissues (hyper-
undergoing therapy, the clinical team does not have access oxemia and hyperoxia, respectively) resulting from high
to the patient to allow for monitoring or administration of FiO2 or HBOT can also potentially result in adverse effects
treatments. In case of emergency, several minutes may be on the cardiovascular system, central nervous system, and
required to decompress the chamber. Because of the 100% other organs.
oxygen environment, any spark or electrical fire can result While minimal evidence exists in clinical veterinary
in ignition of the pressurized oxygen and patient death. patients, there is concern in the human literature for poten-
Patient contraindications may include pneumothorax or a tial increased mortality secondary to hyperoxia in some
predisposing disease (e.g. pulmonary bullae), prior tho- patient populations [34–36]. Given the associated risks,
racic or ear surgery, upper respiratory infection, uncon- human guidelines recommend aiming to achieve normal or
trolled seizures, confinement anxiety, and pregnancy [31]. near-normal oxygenation for most acutely ill patients [37].
onitoring the Response to Oxygen

M Oxygen Toxicity
Therapy While short-term oxygen supplementation is rarely prob-
lematic, long-term therapy can be deleterious, as oxygen is
Once a patient is placed on oxygen supplementation, it is directly toxic to the pulmonary epithelium. Because pul-
important to monitor clinical signs and objective measures monary tissue PO2 is the highest in the body, and addi-
of oxygenation to assess a patient’s response to oxygen tional oxidizing substances such as air pollutants can be
therapy. Serial assessments of a patient’s respiratory rate inhaled, the lung is the most vulnerable organ to oxygen
and effort, mucous membrane color, lung sounds on aus- toxicity [38]. The main determinants of injury are FiO2
cultation, and other signs of respiratory distress are neces- and length of oxygen therapy. Patients are typically thought
sary. Additional vital parameters such as temperature, to be at risk for oxygen toxicity when oxygen is adminis-
pulse rate and quality, capillary refill time, and mentation tered at an FiO2 greater than 60% for over 24 hours. Dogs
are essential in critically ill patients. Arterial blood gas exposed to an FiO2 of 100% developed altered lung func-
analysis (Chapter 26) and pulse oximetry (Chapter 25) are tion in 24 hours and died within an average of
also helpful for objective assessment of oxygenation and 50–60 hours [39]. Dogs exposed to an FiO2 of 80% devel-
are discussed at more length in their respective chapters. oped lung dysfunction but survived, while dogs exposed to
Ongoing evidence of respiratory distress or hypoxemia an FiO2 of 50% did not develop clinical signs of lung dys-
warrants re-evaluation of FiO2, method of oxygen delivery, function or lung pathology [40]. Susceptibility to oxygen
and other potential medications or techniques to alleviate toxicity varies between species, and cats may be more sen-
distress. To avoid complications associated with oxygen sitive than dogs [5]. Additionally, neonates appear more
therapy, in particular oxygen toxicity, the minimum resistant to oxygen toxicity compared to adults [41]. In all
required FiO2 to maintain adequate oxygenation and animals, it is recommended to titrate FiO2 to the lowest
patient comfort should be used at all times. As the patient’s possible level to achieve acceptable oxygenation. If
324 Oxygen Therapy
titration to an FiO2 less than 60% is not possible on conven- during the time it takes for CO2 to be unloaded from the
tional oxygen, mechanical ventilation may need to be tissues. Although this “blue bloater” syndrome has been
considered. well documented in humans, particularly those with
Diagnosis of oxygen toxicity can be difficult, since many chronic obstructive pulmonary disease, it is uncommon in
times FiO2 is unknown, clinical signs may mimic worsen- small animal patients and rarely a significant concern.
ing of the underlying disease process, and histopathology An exacerbating factor in some of these patients is that
is indistinguishable from acute respiratory distress syn- oxygen administration can diminish the normally protec-
drome. Injury occurs in multiple stages [42]. During the tive hypoxic pulmonary vasoconstriction that occurs in
initiation phase of oxygen toxicity, which occurs within poorly ventilated areas of the lung. As alveolar PO2 is
24–72 hours of exposure to high oxygen concentration, known to contribute to regulation of hypoxic pulmonary
oxygen-derived free radicals are responsible for direct dam- vasoconstriction, elevated alveolar PO2 can increase blood
age to pulmonary epithelial cells as antioxidant stores are flow to low V/Q areas, resulting in worsening of V/Q mis-
depleted. This leads to the inflammatory phase, during match and CO2 retention [44].
which recruitment of inflammatory cells and release of
inflammatory mediators causes increased tissue permea-
Extrapulmonary Toxicity
bility and pulmonary edema, resulting in a marked destruc-
tion phase with potential mortality. In survivors, type II Hyperoxia may result in alterations to multiple organ sys-
pneumocytes multiply during the proliferative stage, and tems. In regard to cardiovascular function, it has been
permanent damage occurs during the fibrotic stage with demonstrated in dogs and humans that hyperoxia can
collagen deposition and interstitial fibrosis. cause systemic arterial vasoconstriction, increased sys-
temic vascular resistance, coronary and cerebral vasocon-
striction, bradycardia, and reduced stroke volume and
Absorption Atelectasis
cardiac output [37, 45, 46]. Nonetheless, the clinical signifi-
While alveoli are normally replenished with fresh gas dur- cance of these potential hemodynamic changes remains
ing ventilation, if airways become obstructed in a patient unclear.
on oxygen, the alveoli distal to those airways can experi- Central nervous system complications reported in people
ence absorption atelectasis [43]. Normally, nitrogen makes primarily include tonic–clonic seizures secondary to the
up the majority of inhaled gas that fills the alveoli on room use of HBOT but can include a variety of other neurologic
air. However, almost no net nitrogen exchange occurs signs [38]. There is conflicting evidence but evolving con-
across the respiratory membrane because the body is cern regarding the effects of hyperoxia in various disorders
already saturated with nitrogen. Thus, nitrogen remains in involving the central nervous system, including traumatic
the alveoli, preventing their collapse and minimizing brain injury, acute ischemic strokes, and post-
absorption atelectasis. However, high concentrations of cardiopulmonary arrest patients [37]. However, for veteri-
inhaled oxygen displace nitrogen in the alveoli. Oxygen nary patients, the clinical evidence again is lacking.
readily travels down its concentration gradient from the High inspired oxygen in neonates has also been shown to
alveoli into the pulmonary capillaries. If an airway becomes cause vision-impairing abnormalities in retinal vascular
obstructed and there is no fresh gas flow, the oxygen in the development known as retinopathy of prematurity. While
alveoli distal to that airway diffuses into the blood and this has mostly been described in premature human
leaves inadequate gas to hold open the alveoli, causing infants, it is well demonstrated in animal models, includ-
their collapse. High concentrations of oxygen can therefore ing dogs and cats [47]. As such, oxygen therapy should be
accelerate absorption atelectasis. minimized in neonates if possible.
Hypercapnia
Summary
In normal patients, hypercapnia serves as the primary
stimulus for respiration. However, in patients with chronic Oxygen supplementation should be considered for all
lung diseases resulting in hypercapnia, hypoxia replaces patients presenting to the emergency room in respiratory
hypercapnia as the primary drive for ventilation. If oxygen distress. Conventional oxygen therapy techniques, which
is administered to these patients and hypoxemia is relieved, are relatively non-invasive for the patient, include flow-by,
ventilatory drive may diminish markedly, resulting in face mask, oxygen hoods/E-collars, oxygen cages, and
severe hypercapnia and potentially respiratory failure nasal oxygen. Intratracheal oxygen supplementation is
requiring positive pressure ventilation [44]. If oxygen sup- more difficult but has the potential to achieve higher FiO2
plementation is discontinued, severe hypoxemia can occur values. Heated humidified high-flow nasal oxygen systems
MoMeMeniMds 325
have recently been adopted in veterinary medicine and patients in respiratory failure. The choice of technique will
used as an advanced oxygen supplementation technique depend on patient requirements, response to oxygen,
for patients failing traditional oxygen therapy. HFNC may methods available, and owner investment. Patients need-
provide an additional option to prevent some patients from ing oxygen supplementation must be closely monitored
requiring mechanical ventilation. Intubation and IPPV are and therapy adjusted as indicated to maximize efficacy and
invasive but can provide the highest level of support for minimize complications.
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327
25
Pulse Oximetry and Co-Oximetry

Kate Farrell
Pulse oximetry and co-oximetry have become ubiquitous and advancements were made in the microprocessing tech-
monitoring tools for the assessment of hemoglobin satura- nology to improve pulse oximeter performance [1]. Prior to
tion and oxygenation in anesthetized and critically ill that time, there was no method of easily and continuously
human patients, and they have found widespread use in monitoring a patient’s arterial hemoglobin oxygen satura-
veterinary medicine as well. While a small percentage of tion. Instead, evaluation of a patient’s oxygenation required
oxygen travels in the blood as dissolved gas, the bulk of blood sampling and ex vivo analysis, which only allowed for
oxygen is bound to hemoglobin in red blood cells. Oxygen intermittent monitoring and could be challenging, invasive,
binding changes the light absorption pattern of hemo- and expensive. Since its inception, pulse oximetry has sig-
globin. Oximetry monitoring takes advantage of this fact nificantly reduced the incidence of lethal hypoxemia in
and uses light absorbance characteristics to determine the anesthetized human patients and has become a standard
percentage of oxygenated hemoglobin compared with monitoring tool for patients in emergency departments and
other hemoglobin species (described later). Hemoglobin intensive care units.
oxygen saturation of arterial blood (SO2) can be meas-
ured with pulse oximetry (peripheral capillary oxygen
saturation, SpO2) or co-oximetry (SaO2). Pulse oximetry Hemoglobin Oxygen Saturation
uses two wavelengths of light (red and infrared) to deter-
mine the percentage of oxyhemoglobin compared with Oxygen is delivered from the lungs to the tissues via the
deoxyhemoglobin in arterial blood of a patient’s tissues. blood and is carried in two forms. Approximately 2–3% of
SpO2 has been used as a surrogate marker for the partial the total oxygen content of blood in health is dissolved in
pressure of oxygen in arterial blood (PaO2), although in plasma, and this is measured as the partial pressure of oxy-
veterinary patients there is potential concern for its gen (PO2) [2]. Most oxygen in the blood is bound to hemo-
accuracy. Co-oximetry, on the other hand, uses multiple globin in red blood cells. Hemoglobin consists of four
wavelengths of light to detect numerous hemoglobin polypeptide subunits (globins), each of which is associated
forms, including carboxyhemoglobin and methemoglobin, with an iron-containing heme. Each iron is capable of
in a blood sample. binding oxygen, and thus hemoglobin can carry four oxy-
gen molecules. Once one oxygen becomes bound, this
changes the conformation of hemoglobin, which increases
History of Oximetry Monitoring its affinity for additional oxygen molecules; this is known
as cooperative binding. When hemoglobin is bound to oxy-
The laboratory use of oximetry originated in the 1930s, while gen, or “saturated,” it is called oxyhemoglobin, and it
the earliest patient bedside oximeters date to the 1960s. imparts a bright red color to arterial blood. Deoxygenated
However, these bedside monitors did not become common or reduced hemoglobin, known as deoxyhemoglobin, gives
as they frequently overheated and became uncomfortable venous blood its darker color.
for patients. In the 1970s, Takuo Aoyagi invented the pulse Although PO2 is only a small portion of the content
oximeter that we use today [1]. In the early 1980s, this tech- of oxygen in arterial blood, its value determines SO2.
nology was integrated into commercial monitors for people This relationship is described by the oxyhemoglobin
328 Pulse Oximetry and Co-Oximetry
Table 25.1 Correlation between partial pressure of oxygen in

100 arterial blood (PaO2) and saturation of hemoglobin with oxygen
Shift to left in arterial blood (SaO2) based on the human oxyhemoglobin
90 ↓PaCO2 dissociation curve [3, 4].
↓Temperature
80 ↑pH
Oxemia PaO2 (mmHg) SaO2 (%)
70
% Hemoglobin saturation
Shift to right
↑PaCO2 Severe hyperoxemia 500 100
60
↑Temperature
↓pH Hyperoxemia 150 99
50
Normoxemia 80–110 96–98
40
Hypoxemia <80 <95
30 Normal Severe hypoxemia <60 <90
20
10
0
Dyshemoglobinemias
10 20 30 40 50 60 70 80 90 100
PO2 (mm Hg) Oxyhemoglobin and deoxyhemoglobin are known as func-
tional hemoglobin because they can bind, carry, and unload
Figure 25.1 The oxyhemoglobin dissociation curve, oxygen. Non-functional hemoglobin forms, known as
demonstrating the relationship between the partial pressure of dyshemoglobins, are not capable of binding oxygen and
oxygen (PO2) and the percentage of hemoglobin oxygen include carboxyhemoglobin, methemoglobin, and
saturation. The position of the curve, and therefore hemoglobin’s
affinity for oxygen, is affected by numerous physiologic factors, sulfhemoglobin.
including the partial pressure of carbon dioxide (PCO2), Carboxyhemoglobin is formed when hemoglobin binds
temperature, and pH. to carbon monoxide rather than oxygen. Because hemo-
globin’s affinity for carbon monoxide is greater than 200
times its affinity for oxygen, carboxyhemoglobin forms
dissociation curve (Figure 25.1), which is sigmoidal in even in the presence of very low concentrations of carbon
shape given the cooperative binding of oxygen to hemo- monoxide [12, 13]. As this prevents the binding and trans-
globin described above. Accurate determination of PO2 port of oxygen, and also results in a significant left shift of
from SO2 (or vice versa) depends on a normal position of the oxyhemoglobin dissociation curve, toxic levels can lead
the curve. However, the position of the curve, and there- to tissue hypoxia and death. The most common reason for
fore hemoglobin’s affinity for oxygen, is affected by multi- excessive exposure to carbon monoxide in small animals is
ple physiologic factors, and these may be altered in critical smoke inhalation. In healthy adult dogs, carboxyhemo-
illness [3–5]. An increase in pH and decreases in the par- globin has been reported to compose a median of 2.3% of
tial pressure of carbon dioxide (PCO2), temperature, and total hemoglobin (reference interval 1.3–2.7%) [14]. With
2,3-diphosphoglycerate shift the curve to the left, increas- carboxyhemoglobin levels exceeding 20%, the brain and
ing hemoglobin’s affinity for oxygen (which is beneficial heart may become severely affected. Progressive clinical
in the lungs where pH is higher and PCO2 and tempera- signs described in people include nausea, dizziness, head-
ture lower). The opposite changes result in a right-shifted ache, weakness, difficulty breathing, disorientation, sei-
curve, promoting unloading of oxygen in the tissues zures, coma, and death [12]. Veterinary literature is more
where pH is lower and PCO2 and temperature higher. limited, but reported consequences of carbon monoxide
Approximate corresponding values for PO2 and SO2 are intoxication include altered mentation, respiratory
presented in Table 25.1 [3, 4]. However, these values are changes, hypothermia, acute and delayed neurologic signs,
based on a human oxyhemoglobin dissociation curve, and and death [15]. Carboxyhemoglobin can impart a bright
the position of the curve varies between species [6]; p50 is cherry-red color to blood, though this is rarely clinically
a common method of expressing the position of the curve seen [16]. Treatment consists of high concentrations of
and represents the PO2 at which 50% of hemoglobin is sat- inspired oxygen to displace carbon monoxide.
urated. The reported p50 for human hemoglobin is a PO2 of Methemoglobin is produced when the ferrous form of
approximately 26–27 mmHg, for canine hemoglobin is iron (Fe2+) in the heme group is oxidized to the ferric form
28–31 mmHg, and for feline hemoglobin is 34–36 [6–11]. (Fe3+) due to oxidative injury. Because there are multiple
As cats have a significantly right-shifted curve compared protective mechanisms that diminish oxidative injury and
with people and dogs, their corresponding SO2 values (for a reduce methemoglobin to functional hemoglobin, methe-
given PO2) are lower. moglobin composes a very small proportion of total
Pulse Oximetry 329
hemoglobin in normal dogs and cats. One study reported a and methemoglobin; in the less common case that the co-
median value of 0.2% (reference interval 0.1–0.4%) in oximeter measures sulfhemoglobin, that species is also
healthy adult dogs [14]. However, elevated levels can included in the calculation.
occur from a congenital abnormality or secondary to drugs
or toxins that overwhelm antioxidant defenses. Toxins
known to cause methemoglobinemia include acetami- Types and Technology of Oximeters
nophen, nitrites, nitrates, topical benzocaine, phenazo-
pyridine, hydroxycarbamide, and skunk musk. At levels Spectrophotometry is a technology that uses light reflec-
greater than 10%, methemoglobin can impart a brown dis- tion and absorption properties of substances to determine
coloration to blood, and chocolate-brown mucous mem- their concentration in liquid or gaseous environments.
branes and cyanosis can be noted [17]. Clinical signs are When applied to determine the relative percentage of oxy-
typically seen with methemoglobin levels above 20% and genated hemoglobin in blood, this is called oximetry. This
can include tachycardia, tachypnea, weakness, anorexia, technology uses the Beer–Lambert law, which relates the
vomiting, ataxia, hypothermia, ptyalism, and seizures. concentration of a substance to the intensity of light trans-
Coma and death can be seen at methemoglobin levels of mitted through a solution [18]. These principles can be
80% [17]. applied to the detection of hemoglobin species given the
Sulfhemoglobin is another non-functional hemoglobin fact that binding of oxygen and other substances to hemo-
that occurs rarely when hemoglobin reacts with sulfide globin alter its light absorbance properties.
and oxygen. However, unlike carboxyhemoglobin and Pulse oximeters use two wavelengths of light to detect
methemoglobin, sulfhemoglobin is not typically detected relative concentrations of oxyhemoglobin and deoxyhemo-
by co-oximeters. globin. Alternatively, co-oximeters use several wavelengths
of light to distinguish multiple hemoglobin species, includ-
ing dyshemoglobins discussed above. Hemoglobin oxygen
unctional Compared with Fractional
F saturation measured by pulse oximeter is typically referred
to as SpO2, while measurement by co-oximeter is typically
Hemoglobin Saturation
referred to as SaO2. Pulse co-oximeters use the technology
of co-oximeters but in a continuous, non-invasive bedside
Oxyhemoglobin and deoxyhemoglobin, as discussed above,
format. They have been employed in people for noninva-
can bind and unbind oxygen, and for this reason they are
sive testing for carbon monoxide poisoning and methemo-
called functional hemoglobin species. The percentage of
globinemia resulting from drug overdoses, but they are not
oxyhemoglobin compared with all functional hemoglobin
generally used in clinical veterinary medicine.
is known as functional hemoglobin saturation. It is calcu-
lated as follows:
Functional SO2 HbO2 / HbO2 HHb 100 (25.1) Pulse Oximetry

where HbO2 is oxyhemoglobin and HHb is deoxyhemo- Understanding the Technology
globin. Because pulse oximeters only use two wavelengths
Pulse oximeters are non-invasive bedside monitors that
of light to detect oxyhemoglobin and deoxyhemoglobin
determine arterial functional hemoglobin saturation in a
(discussed in more detail below), they report functional
patient’s tissue. To determine SpO2, a pulse oximeter emits
hemoglobin saturation.
two wavelengths of light, red light at 660 nm and infrared
In contrast, fractional hemoglobin saturation refers to the
light at 940 nm, from the probe’s light-emitting diodes
percentage of oxyhemoglobin compared with all measured
(LED) into a patient’s tissue. Depending on the probe’s
hemoglobin forms, including dyshemoglobins. The equa-
style, transmitted light either reflects off tissue or passes
tion to calculate fractional hemoglobin saturation is as
through to a receiving probe, where a photodetector col-
follows:
lects a signal to be analyzed by the machine’s micropro-
Fractional SO2 HbO2 / HbO2 HHb COHb (25.2) cessing unit. Oxyhemoglobin absorbs more infrared light,
MetHb 100 while deoxyhemoglobin absorbs more red light. Because
of their differing light absorption characteristics, the ratio
where COHb is carboxyhemoglobin and MetHb is methe- of the two can be determined to calculate the percentage of
moglobin. Co-oximeters can measure multiple hemoglobin oxyhemoglobin based on total functional hemoglobin.
species, and thus they report fractional hemoglobin satura- Pulse oximetry relies on the detection of light absorption
tion. Typically, this calculation includes carboxyhemoglobin through tissue, and the technology was developed based on
Given these advantages, in human medicine pulse oxi-

metry is standard of care for monitoring anesthetic patients
and is used for a wide variety of monitoring needs for
patients in emergency departments and intensive care
units. It has also become a common tool in veterinary med-
icine to monitor anesthetic patients, evaluate and triage
patients in respiratory distress in the emergency room, and
to assess oxygenation in patients in intensive care. In some
hospital and in out-of-hospital settings, SpO2 may be the
only objective measurement available to a veterinarian.
Equipment Options and Care

When electing to purchase a pulse oximeter, considerations
may include brand/model, convenience or ease of use, avail-
Figure 25.2 A multiparameter monitor displaying a pulse able probes, presence of a plethysmograph, battery life, and
oximeter’s hemoglobin oxygen saturation (SpO2) reading of 92%
and accompanying high-quality plethysmograph (blue
cost. Because of their utility in human medicine and now
waveform). extensive use in veterinary medicine, pulse oximeter models
and probes have been adapted and marketed for veterinary
use, and their costs have been adjusted for veterinary audi-
the absorption spectrum of human oxyhemoglobin. It has ences [5]. Models are available from Nellcor, Masimo, Apexx,
been demonstrated, however, that hemoglobin isolated Respironics, and multiple other companies. Because the
from multiple species, including people, dogs, cats, horses, algorithms built into each model vary, investigating any data
cows, and pigs, showed only minor and statistically insig- related to accuracy of an individual unit may be worthwhile.
nificant differences in absorbance spectra of oxyhemo- Many manufacturers and distributors will also allow for trial
globin and deoxyhemoglobin [19]. Therefore, it is likely periods within a facility prior to purchase.
that the same pulse oximetry technology can be applied In regard to probe selection, a clip-style sensor is the most
across these species. commonly available and provides versatile options for use.
To differentiate arterial blood from venous or capillary Some pulse oximeters offer other choices, including reflec-
blood and surrounding tissue, pulse oximeters use an tance probes for rectal or esophageal monitoring. While the
optical technique known as photoplethysmography to LED on rectal sensors may become obscured with feces, they
evaluate only pulsatile wavelengths. For this reason, are useful for acquiring a reading from the ventral tail base.
pulse oximeters function best when placed over tissue Pulse oximeters that function as hand-held mobile units
with good arterial blood flow, and the pulse rate read by provide the greatest flexibility, as opposed to those that are
the machine should match the patient’s. To enhance part of multiparameter monitors. These units allow for con-
evaluation of the pulse oximeter’s accuracy, many venient bedside monitoring and may have longer battery
machines display a plethysmograph, or peripheral pulse life. Additional considerations may include ease of alarm
waveform, the amplitude of which corresponds to pulse setting, company warranties, and costs of probes, batteries,
strength (Figure 25.2). A normal waveform should have a and chargers.
dicrotic notched appearance similar to that of an arterial For long-term care of pulse oximeters, they should avoid
waveform. contact with excessive water, chemicals, and direct sunlight.
The wires for the probes should be looped loosely around or
next to the machine during storage, as tight winding of the
Indications for Pulse Oximetry
wires may damage them. In between use, probes should be
Because SpO2 correlates with PaO2 according to the oxy- cleaned according to the manufacturer’s instructions. For
hemoglobin dissociation curve, pulse oximetry is used as a many, mild soap and water will be sufficient. Disinfection
non-invasive surrogate for PaO2. Arterial blood gas analy- with isopropyl alcohol or chlorhexidine may be appropriate,
sis, which is necessary to obtain a PaO2, requires arterial though some diodes can be damaged by chemicals.
sampling; however, this can be challenging, invasive, and
costly. Additionally, not all patients in respiratory distress
Performing Pulse Oximetry
tolerate the handling required for arterial sampling, and
some patients are too small for easy sampling. Pulse oxime- When acquiring an SpO2, multiple steps should be consid-
try, on the other hand, is easy to perform, can provide con- ered to maximize the accuracy of the measurement
tinuous monitoring, and carries minimal cost. (Protocol 25.1). First, it should be ensured that the machine
Pulse Oximetry 331
Protocol 25.1 Obtaining a Pulse Oximetry Measurement

Equipment Required 5) Wait for the monitor to obtain a pulse rate and con-
firm that this matches the patient’s pulse.
● Pulse oximeter, charged with a clean probe
6) If a plethysmograph is available, check to ensure a
● Moistened gauze squares, as needed
strong signal and adequate waveform.
● Clippers, if fur removal is needed
7) If the pulse rate does not match or plethysmograph
waveform is poor, attempt another site.
Procedure
8) Wait until a stable SpO2 is obtained, then record.
1) Collect necessary supplies. 9) If the SpO2 is dangerously low (< 90%) or unex-
2) Turn monitor on and ensure that it is functioning pected, notify the doctor immediately. Attempt to
and has battery life. confirm at another site.
3) Select and prepare a site. Choose a location that is 10) If an SpO2 is obtained, consider whether it matches
well perfused, warm, thin, and has minimal pigmen- the patient’s clinical condition. If not or if further
tation; unpigmented mucous membranes are ideal. assessment is required, obtain another reading or
4) Place the probe sensor on the selected site. consider an arterial blood gas.
is charged and the probe is clean and undamaged. Testing ventral tail base in anesthetized or poorly mobile animals but
the pulse oximeter on one’s own finger can help to ensure should be checked for cleanliness and tissue damage (burns).
it is functioning accurately. Choosing an appropriate site, Particular problems can be encountered with obtaining
monitoring plethysmograph waveform and matching pulse readings from small animals, especially cats. The size and
rate, and comparing the acquired SpO2 to patient status are shape of available probes are not always appropriate for
important steps. very small animals. While data are limited, it may be more
When selecting a site for probe placement, the location difficult to achieve reliable readings in cats [5]. However, as
should be well perfused, warm, thin enough for probe clip it is also more difficult to acquire arterial blood gases in
application, and have minimal pigmentation (Figure 25.3). cats given their size, obtaining objective measures of oxy-
Mucous membranes are typically ideal; potential sites are genation in cats can be challenging. Cats in general may be
listed in Table 25.2. The site should be cleaned and clipped more resistant to handling and easily stressed with both
of fur as needed. If a patient is vasoconstricted or hypother- types of monitoring.
mic, locations such as the ears, distal tail, or digits may not Once a probe has been placed at the designated site, it
provide accurate or any readings. In these conditions, sites may require at least several seconds to provide an SpO2
should be chosen as close to a central vessel as possible, reading. If the measured value is variable or inconsistent,
such as the tongue or lips, to provide the best results [20]. allowing more time or switching to another site may be
Site selection in awake animals may depend on accessible necessary. To ensure accuracy, the pulse rate noted on the
areas. For instance, in aggressive or non-compliant ani- machine should match the patient’s, and the plethysmo-
mals, application to the lips or tongue may be impossible. graph (if available) should display an adequate waveform.
The pinna may provide an accessible site but in one study Some pulse oximeters designed for people have neonatal,
was shown to give erroneous readings [20]. pediatric, and adult settings, and this should be set to
In anesthetized animals, common sites include the tongue reflect the patient’s pulse rate rather than its size (neonatal
and lips. However, when probes are left in place for a pro- for high heart rates, adult for lower heart rates). It may be
longed time, the SpO2 reading may decrease over time due to helpful to trend values over time or to monitor changes in
pressure on the arterioles and reduced blood flow in the the SpO2 reading with oxygen delivery.
underlying tissue [5]. Gradual drying of the mucous mem-
branes may also lead to false results. These factors can be cor-
Interpreting the SpO2 Reading
rected with repositioning of the probe and repeated
moistening of the tissue. With protracted pulse oximetry Once an SpO2 measurement has been achieved, careful
monitoring, for instance in cases of mechanical ventilation, interpretation of the value and the patient’s circumstances
the slight heat and pressure from the probe can lead to injury is required. A normal PaO2 for an animal breathing room
and necrosis of underlying tissue in extreme circumstances. air at sea level is 80–110 mmHg, and this corresponds to an
This is easily avoided by relocating the probe every two to SpO2 value of approximately 96–98%. Values less than
four hours during careful routine ventilator patient manage- this indicate hypoxemia and warrant investigation. If a
ment [21]. Reflectance probes can be secured in place on the dog curve, as opposed to a human curve, is used for
(a) (b)
(c) (d)
Figure 25.3 Probe placement for pulse oximeter measurements. (a) Probe placement on the pinna of an awake dog. The pulse
oximeter provides a hemoglobin oxygen saturation (SpO2) value of 96%, which is appropriate for a dog on room air. (b) Placement of a
pulse oximeter probe interdigitally in a cat receiving supplemental oxygen. Awake cats will not typically tolerate lip or tongue
measurements. (c) A probe placed on the tongue of an anesthetized dog receiving supplemental oxygen. A matching pulse rate (82)
and indicator of a strong pulse signal (full-sized gray bar, which pulsates with the pulse rate) help confirm the accuracy of the reading.
An SpO2 value of 90% on supplemental oxygen indicates marked lung dysfunction. (d) A probe placed on pigmented mucous
membranes is unlikely to give a reliable reading.
Table 25.2 Locations for pulse oximeter probe placement. interpretation of corresponding PaO2 and SpO2 values, a
PaO2 of 80 mmHg actually equates to an SpO2 of approxi-
Canine Feline mately 93%, while a PaO2 of 60 mmHg corresponds to an
SpO2 of around 86% [8]. Although theoretically altered
Tongue Tongue compared with people, the SpO2 cutoff values of 95% and
Lips Lips 90% may be more reliable for the identification of hypox-
Pinna Pinna emia and severe hypoxemia, respectively, in clinical dogs
Vulva/prepuce Interdigital given limitations of the technology (discussed below) [22].
Interdigital Ventral skin Because the cat oxyhemoglobin dissociation curve is
Ventral skin Ventral tail base further right-shifted, corresponding SpO2 values could be
expected to be lower.
Ventral tail base
Further complicating interpretation of pulse oximeter
Gastrocnemius tendon
readings is the fact that SpO2 and PaO2 are not linearly
Pulse Oximetry 333
related. The oxyhemoglobin dissociation curve is sigmoidal Table 25.3 Factors affecting the accuracy of pulse oximetry.
in shape, which means that very small changes in SpO2 indi-
cate substantial changes in PaO2. For instance, if an SpO2 Patient factors Machine factors
measurement decreases from 95% to 90%, this correlates to a
decline in PaO2 of approximately 20 mmHg. This patient has Movement artifact Monitor broken
(tachypnea, tremoring, shivering) Monitor not charged
gone from having close to normal lung function (if on room
Hypoperfusion (vasoconstriction,
air) to being markedly hypoxemic. Therefore, slight errors in Probe damaged
poor cardiac output, hypotension)
the pulse oximeter reading in this range could result in dra- Improper probe
Hypothermia placement
matically different and incorrect interpretations of patient
Severe anemia
status, which can be problematic for clinical decision making. Dirty probe
Given the shape of the oxyhemoglobin dissociation curve, Dyshemoglobinemias Ambient light
pulse oximetry is very sensitive (when accurate) for detecting Skin pigmentation
changes in PaO2 when SpO2 is in the 80–97% range. However, Excessive hair
above this range, only minuscule changes in hemoglobin Dry mucous membranes
saturation can occur even with large increases in PaO2. This
flattening of the curve limits the ability of SpO2 to predict
PaO2, particularly in patients receiving supplemental oxygen.
For example, a patient with normal lung function breathing in inaccurate readings, as pulse oximetry is dependent on
100% oxygen should have a PaO2 of 500mmHg; at this value, light absorption by hemoglobin within red blood cells. One
an SpO2 would read 100%. However, if the animal’s PaO2 on veterinary study revealed that severe anemia affected bias
100% oxygen dropped from 500mmHg (normal lung func- and precision of the pulse oximeter, finding unacceptable
tion) to 175mmHg (severely abnormal lung function), the accuracy with a hematocrit less than 10% [27].
SpO2 would remain 100% and the operator would be unable Additionally, variations in probe location and instru-
to detect the compromised lung function. Thus, a pulse oxi- ment selection have been demonstrated to alter SpO2
meter is an insensitive indicator of changing lung function readings [20, 28, 29]. Placement of probes on haired or pig-
when the patient is receiving supplemental oxygen. On the mented tissue may result in erroneously low readings or no
other hand, an SpO2 less than 99–100% on supplemental oxy- readings at all [30]. Fiberoptic and fluorescent lighting can
gen clearly indicates a problem. also interfere with pulse oximeter readings, and care
While SpO2 can estimate oxygenation, it does not assess should be taken to cover the probe from this lighting.
ventilation, which requires a PCO2 value on blood gas anal- Methylene blue has been reported to interfere with SpO2
ysis or end-tidal monitoring. SpO2 also gives no indication measurements as well [31].
of a total hemoglobin value (just its saturation), and there- Dyshemoglobinemias are another factor that can result
fore anemia as a cause of decreased tissue oxygen delivery in false SpO2 readings. As discussed previously, pulse oxi-
could be missed. meters typically emit only two wavelengths of light and are
meant to detect exclusively functional hemoglobin species
(oxyhemoglobin and deoxyhemoglobin). Unfortunately,
Factors Affecting Pulse Oximetry Measurements
carboxyhemoglobin and methemoglobin can confuse this
Though pulse oximetry is a popular and convenient moni- technology. Carboxyhemoglobin absorbs red light like oxy-
toring tool, unfortunately many factors affect its accuracy hemoglobin, and thus elevated levels can falsely increase
or the ability to acquire a reading, including patient fea- SpO2 [32, 33]. Methemoglobin, on the other hand, absorbs
tures and technologic limitations. Factors known to affect both red and infrared light. Concentrations above 30% will
the accuracy of pulse oximetry include motion, hypoperfu- cause the SpO2 to plateau at ~85% [34, 35]. If both an SpO2
sion, hypothermia, pigmentation at the probe site, ambient and SaO2 are acquired, a gap between these values should
light, severe anemia, and dyshemoglobinemias [3, 23–25]. raise suspicion for dyshemoglobinemia.
See Table 25.3 for a summarized list of these factors. See Table 25.4 for methods of troubleshooting pulse oxi-
Movement artifact, such as that seen with tachypnea, metry problems.
tremoring, and shivering, can be common in veterinary
patients. With excessive motion, the monitor can mistake
Accuracy Concerns in Pulse Oximetry
venous blood for arterial blood and SpO2 values may be
falsely low [26]. Poor perfusion, peripheral vasoconstriction, While pulse oximetry carries no direct risk for a patient,
or hypotension may affect the ability of the pulse oximeter to its danger lies in the potential for inadequate unders-
evaluate pulsatile blood flow as well. Anemia can also result tanding of the equipment’s limitations and excessive
Table 25.4 Guidelines for troubleshooting pulse oximeter confidence in the values obtained. As discussed above,
readingsa. many factors affect the accuracy of pulse oximetry and
research confirming its validity in small animal veteri-
Potential problems Solutions nary patients is lacking. Many human and veterinary
studies have shown good correlation between SpO2 and
1) No reading or poor signal/waveform:
SaO2; however, these correlations deteriorate when SO2
Monitor off/out of battery Charge and turn on
is less than 70% or less than 80% [20, 30, 36–38].
monitor
Unfortunately, in clinical small-animal patients, there
Probe off patient Place probe on patient
has been little direct comparison of SpO2 and PaO2. One
Site is dirty, haired, dry Prepare site – clean, shave,
study recently demonstrated that in awake dogs breathing
moisten
room air, SpO2 was not a clinically suitable surrogate for
Site is pigmented Reposition probe to
unpigmented site
PaO2 [22]. Pulse oximetry did perform better in a popula-
tion of mechanically ventilated dogs on supplemental
Hypothermia Warm patient if stable
oxygen [22]. In both groups, pulse oximetry performed
Hypoperfusion Correct underlying problem
poorly at detecting hypoxemia, which is concerning in a
2) Pulse rate is inaccurate: screening test.
Tachypnea Reposition probe to For these reasons, clinical judgments based exclusively
minimize effects of
on SpO2 could be misguided and inappropriate. Because
respiration
of these concerns, clinicians should always rely on mul-
Other motion artifact Reposition probe to less
affected site
tiple factors, including clinical assessment of the patient,
when determining a patient’s pulmonary function
Dysrhythmia May not read; consider
arterial blood gas analysis and oxygen requirements. If possible, pulse oximetry
should be correlated with arterial blood gas findings, as
Poor signal/waveform Consider solutions for
Problem 1 PaO2 remains the gold standard for assessment of
3) SpO2 is unexpectedly/falsely high oxygenation.
Carboxyhemoglobin Perform co-oximetry
Methemoglobin (if PaO2 Perform co-oximetry
severely low) Co-Oximetry
Ambient light Remove ambient light
source or cover probe site Understanding the Technology
4) SpO2 is unexpectedly/falsely low:
Co-oximeters are benchtop analyzers that use spectropho-
Problem 1 tometry to distinguish hemoglobin species in a blood sam-
Motion artifact Reposition probe to less ple rather than through tissue. Whereas pulse oximeters
affected site use two wavelengths of light and are thus limited to identi-
Methemoglobin Perform co-oximetry fying oxyhemoglobin and deoxyhemoglobin, co-oximeters
Severe anemia Transfuse as needed;
often use four or more wavelengths of light to differentiate
consider arterial blood gas and quantify multiple hemoglobin species. In addition to
analysis oxyhemoglobin and deoxyhemoglobin, most co-oximeters
Ambient light Remove ambient light also report carboxyhemoglobin and methemoglobin,
source or cover probe site though rarely sulfhemoglobin.
Intravenous pigmented dyes Typically transient; Once concentrations of individual hemoglobin species
consider arterial blood gas are known, they are typically reported as a percentage of
analysis
total hemoglobin (tHb). For instance, the equation for car-
5) SpO2 obtained is variable: boxyhemoglobin (COHb) percentage would be as follows:
Problem 1; attempt other COHb % CoHb / tHb 100 (25.3)
probe locations
Dysrhythmia or variable pulse May not read; consider In addition to percentages of hemoglobin species, many
pressure arterial blood gas analysis
analyzers also provide blood gas values, acid–base param-
a
If patient appears to be in respiratory distress and user is unable to eters, electrolytes, glucose, lactate, and potentially other
obtain an SpO2 that fits the clinical picture, provide oxygen and values. These machines can thus provide much useful
attempt later or consider other monitoring options.
information for emergency or ICU patients (Figure 25.4).
Co-Oximetry 335
requires replacement of consumables required for running

samples, calibrations, and quality control. Errors noted dur-
ing calibrations and quality control will alert users and some
machines will not report the failing parameter until the prob-
lem is fixed to minimize inaccurate readings.
Performing Co-Oximetry
Co-oximetry analyzers are typically able to produce rapid
results with a small volume of blood. If assessment of arte-
rial oxygen content is desired, an arterial blood sample is
necessary. This can be obtained via direct arterial puncture
with a needle and syringe or by placement of an indwelling
arterial catheter (see Chapter 8). The most commonly sam-
pled arterial sites are the dorsal pedal and femoral arteries,
Figure 25.4 A multiparameter benchtop analyzer that includes
a co-oximeter. although brachial, radial, auricular, and sublingual sites can
also be considered depending on the size of the patient and
whether it is anesthetized. If the diagnosis of a dyshemo-
Indications for Co-Oximetry globinemia is desired, a venous blood sample is sufficient. In
hypoperfused patients, a more central vein is ideal for the
Co-oximetry, like pulse oximetry, can detect oxyhemoglobin most accurate values. Follow appropriate scavenging tech-
and deoxyhemoglobin. However, because co-oximetry can niques if a sample is taken from an arterial or venous cath-
quantify all types of hemoglobin, its use is typically indi- eter (Chapter 53).
cated when a dyshemoglobinemia is suspected. A dyshemo- Careful sampling and handling of blood samples is
globinemia may be suspected with a history of appropriate essential to minimize in vitro alterations of blood gases and
toxin or environmental exposure, when clinical signs are other values [4]. Samples must be anticoagulated prior to
consistent (e.g. bright red, brown, or cyanotic mucous testing, and this is usually performed with sodium or lith-
membranes), when evidence of unexplained respiratory ium heparin. Dilution of samples with excessive heparin
distress or hypoxia persists despite oxygen supplementa- has been shown to significantly alter PO2 and other values,
tion, or when there is a discrepancy between a pulse oxime- so this must be performed carefully [40]. Because blood
try reading and a PaO2 or SaO2 obtained from an arterial cells continue to be metabolically active, samples are most
blood gas (performed on an analyzer without co-oximetry). accurate when analyzed as soon as possible, but they can
Because co-oximeters detect multiple hemoglobin spe- be held anaerobically in an ice bath for up to one hour if
cies, they report fractional SO2. If a dyshemoglobinemia is necessary. Attention is warranted to prevent exposure of
present, only fractional SO2 accurately reflects the blood’s the sample contents to air or bubbles, as this will alter
oxyhemoglobin content. This value (compared with func- PaO2 and SaO2 due to gas diffusion. Follow all manufa-
tional SO2) will be a better indicator of blood oxygen con- cturer guidelines and see Chapter 53 for additional
tent and thus oxygen delivery to the tissues. Despite the recommendations.
advantages of fractional SO2, functional SO2 more closely
corresponds with PaO2 and thus provides a better assess-
ment of pulmonary function [39].
Factors Affecting Co-Oximetry Measurements
Most problems related to co-oximetry measurements are
Equipment Options and Care
due to sample handling errors. These include inadequate
Many co-oximeters are available from human biomechani- sample mixing, air exposure or air bubbles, excessive dilu-
cal companies and some are marketed to the veterinary tion or incorrect anticoagulant use, clotting of the sample,
field, but currently there are no veterinary-specific models. delay in testing leading to erroneous results, or interfer-
Because of this, co-oximeters available for use in veterinary ence of particular substances in the blood with spectropho-
species still base their calculations on human algorithms, tometric testing. Case reports, animal studies, and
and thus the accuracy in dogs and cats is unknown. laboratory studies have demonstrated that treatment with
Large multi-parameter analyzers with co-oximeters can be hydroxocobalamin or cyanocobalamin, which are used as
preset or manually designated to undergo quality control antidotes for cyanide poisoning, can result in measurement
monitoring and calibrations. Maintenance of these machines interference due to their dark red color [41–43]. Interference
from high serum lipids has also been described to cause Summary
falsely high carboxyhemoglobin levels [44]. Sulfhemoglobin
can cause falsely elevated methemoglobin and decreased Pulse oximetry has become an important tool in human
carboxyhemoglobin [45]. and veterinary medicine for monitoring the oxygenation
status of anesthetized and critically ill patients. While
pulse oximetry is easy to perform, is non-invasive, and can
Pulse Co-Oximetry provide potentially valuable information, users must
understand the limitations of the technology and thus the
In 2005, a lightweight point-of-care pulse co-oximeter risks in over-reliance on SpO2 measurements. Ultimately,
(RAD-57™, Masimo Corporation, Irvine, CA) was pulse oximetry cannot replace the information gained from
approved for use in clinical practice in people. It uses mul- an arterial blood gas analysis. Co-oximetry, although gen-
tiple wavelengths of light to noninvasively measure car- erally less available to veterinarians, is also a helpful moni-
boxyhemoglobin and methemoglobin. There has been toring tool and enables diagnosis of dyshemoglobinemias.
particular interest in employment of the technology as a The strengths and limitations of these technologies must
first-line screening tool to enable rapid identification of be fully understood to provide the best patient care.
patients with carbon monoxide poisoning presenting to
human emergency departments. However, clinical data
regarding its accuracy are still sparse and have shown Acknowledgment
somewhat conflicting results [46–48]. Thus far, this tech-
nology has been minimally used or studied in veterinary The current author and editors would like to acknowledge
patients. For the diagnosis of dyshemoglobinemias in Devon Ayers’ contributions to first edition of Advanced
small-animal patients, co-oximetry will continue to be Monitoring and Procedures for Small Animal Emergency
required until further data arises. and Critical Care, upon which this chapter is based.
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46 Suner, S., Partridge, R., Sucov, A. et al. (2008). Non- non-invasive pulse CO-oximeter. Respir. Physiol.
invasive pulse CO-oximetry screening in the emergency Neurobiol. 182 (2–3): 88–92.
department identifies occult carbon monoxide toxicity. 48 Sebbane, M., Claret, P.G., Mercier, G. et al. (2013).
J. Emerg. Med. 34 (4): 441–450. Emergency department management of suspected carbon
47 Zaouter, C. and Zavorsky, G.S. (2012). The measurement monoxide poisoning: role of pulse Co-oximetry. Respir.
of carboxyhemoglobin and methemoglobin using a Care 58 (10): 1614–1620.
339
26
Blood Gas Analysis

Sarah Gray
bnormalities in Oxygenation
A but (due to the collapse or nongas substance) are not venti-
and Ventilation lated at all (zero ventilation) – thus all blood passing
through no V/Q lung regions returns to the left atrium as
Hypoxemia is defined as a partial pressure of oxygen (also venous (nonarterialized) blood. Diseases such as aspiration
called oxygen tension) in the arterial blood (PaO2) of less pneumonia and pulmonary edema commonly cause this
than 80 mmHg. There are five main causes of hypoxemia: intrapulmonary shunting, though any lung disease that
decreased inspired oxygen content; hypoventilation; venti- becomes adequately severe to block or flood airways and
lation/perfusion (V/Q) mismatch, including intrapulmo- alveoli can lead to “no V/Q.” Congenital vascular anoma-
nary shunt and anatomic right-to-left shunt; and diffusion lies such as patent ductus arteriosus or septal defects can
impairment (Box 26.1). Decreased inspired oxygen content also cause blood to flow from the right side of the heart to
is associated with altitude or from anesthetic machine the left side of the heart without being oxygenated (shunt-
errors. Hypoventilation (increased partial pressure of caring), although these conditions are less common than the
bon dioxide, PaCO2, in arterial blood) can be caused by V/Q mismatch caused by lung disease. Diffusion impair-
central nervous system disease, medications that suppress ment results in incomplete arterialization of the pulmo-
ventilation (opioids, other anesthetic agents), neuromus- nary capillary blood due to thickening of the gas exchange
cular disease (tick paralysis, botulism), upper airway layer in the alveoli, which is typically the result of type II
obstruction, severe pleural space disease, chest wall injury (thick) pneumocyte proliferation following severe pulmo-
(flail chest, pain), or respiratory muscle fatigue. nary inflammation. Under normal conditions the equili-
V/Q mismatch is the most common cause of hypoxemia bration of oxygen occurs rapidly, but with a thickened gas
in dogs and cats. It is a state in which fresh gas (oxygen) exchange layer more time is needed, resulting in hypox-
delivery to the alveolus is inadequate despite continued emia. Diffusion impairment is believed to be an uncom-
perfusion of the pulmonary capillary serving that alveolus. mon cause of hypoxemia in small animals.
Thus, blood coming from the right side of the heart passes When evaluating a patient’s oxygenation and ventilation
through the gas exchange region of the lung without being status, the gold standard is to obtain an arterial blood sam-
properly oxygenated. “Low V/Q” is a state in which nar- ple for direct analysis of the partial pressures of dissolved
rowed airways such as from inflammatory lower airway oxygen and carbon dioxide in the blood: a blood gas analy-
conditions (asthma, chronic bronchitis), interstitial lung sis. Blood gases analyzers, results, and interpretation are
disease like neoplasia, inflammatory disease like pneumo- the topics of this chapter.
nia or pneumonitis, or other conditions limit oxygen entry
into the alveolus. When conditions that cause low V/Q
become severe and fresh gas flow cannot reach the alveoli, Blood Gas Analyzers
or when fluid or cell accumulation in the airways lead to
alveolar collapse, a “no V/Q” state occurs; this phenome- Benchtop and portable blood gas analyzer models are avail-
non can also be called intrapulmonary right-to-left shunt- able. Dedicated blood gas benchtop analyzers are generally
ing or a “zero V/Q” state. In the no V/Q state, collapsed only used in academic facilities and large institutions due
alveoli or alveoli filled with nongas substance are perfused to their maintenance requirements and expense. Benchtop
340 Blood Gas Analysis
Box 26.1 Causes of Hypoxemia and Hypoventilation Transcutaneous Blood Gas Monitoring

Hypoxemia Transcutaneous (tc) monitoring allows continuous meas-
● Decreased inspired oxygen content urement of PtcO2 and PtcCO2 by placement of a probe on
● Hypoventilation the patient’s skin. It is less invasive and allows the clinician
● Ventilation/perfusion (V/Q) mismatch to monitor the patient’s response to therapy on an almost
⚪ Low V/Q
interactive basis. These monitors are widely used in human
⚪ No V/Q (intrapulmonary shunt)
medicine.
● Diffusion impairment Traditional arterial blood gas analysis requires challeng-
ing arterial sample collection, appropriate sample han-
Hypoventilation dling, and clinically appropriate interpretation on serial
samples to best manage critical patients. Thus, the use of
● Central nervous system disease transcutaneous monitoring in critically ill veterinary
● Medications (opioids, other anesthetic agents) patients would be helpful. One study evaluated the use of
● Neuromuscular disease transcutaneous blood gas monitoring in dogs to determine
● Upper airway obstruction its agreement with arterial samples [2]. Unfortunately, the
● Pleural space disease (severe) authors concluded that agreement was inferior to that
● Respiratory muscle fatigue reported for people as the transcutaneous monitor consist-
ently overestimated PaO2 and PaCO2 in critically ill
dogs [2]. While it may play a role in veterinary patients in
analyzers use a polarographic oxygen electrode and the the future, currently the technology would have to be
Severinghaus carbon dioxide (CO2) electrode to analyze paired with intermittent arterial blood gas analysis.
the partial pressures of gases in the blood sample. The
amount of CO2 in the sample is evaluated based on com-
parison to a known amount of CO2, which is supplied by Measuring Arterial Blood Gases
conventional gas tanks. This severely limits the portability
of the benchtop analyzers. To be clinically useful, the arterial blood sample must pro-
Portable (or “bedside”) blood gas analyzers accurately vide an accurate reflection of the patient’s status. This
measure oxygen and CO2 using a small foil-wrapped car- requires appropriate blood sampling and handling (see
tridge containing a pH electrode, a polarographic oxygen Chapters 8 and 53 for more information). Accurately deter-
(O2) electrode, and a CO2 electrode. When the cartridge is mining arterial blood gas content involves obtaining an
sealed, the CO2 equilibrates with bicarbonate within the arterial blood sample and inserting it into the blood gas
cartridge. Upon removal of the foil package, the gas sur- analyzer within a short period of time, to minimize sample
rounding the CO2 electrode is the known partial pressure gas equilibration with the atmosphere.
of CO2 in the ambient air, and the electrode calibrates to
this pressure upon insertion into the machine.
There are many advantages to the use of portable blood Arterial Blood Sampling
gas analyzers. These machines are usually less expensive The most commonly sampled arterial sites are the dorsal
than the benchtop devices, can analyze full blood gases on pedal (dorsal metatarsal) and femoral arteries. Less com-
a very small blood sample, and are portable. A 2016 study monly sampled sites are the brachial, radial, or auricular
compared four commonly used point-of-care analyzers and arteries, or sublingual vessels. Sampling is generally done
found differences between the analyzers for PO2, PCO2, using palpation and knowledge of anatomy. The dorsal
and pH measurements from both healthy dogs and those pedal artery can be palpated over the dorsomedial aspect of
with respiratory disease [1]. The availability of bedside the proximal metatarsal region; the femoral can be pal-
analyzers has enhanced the care of critically ill veterinary pated on the medial aspect of the thigh. A single sample
patients, but since there is variation in measured values can be drawn using a needle and heparinized syringe, or a
from different bedside analyzers, obtained values should catheter can be placed for repeated blood gas sampling and
be interpreted considering the analyzer’s own reference for direct blood pressure monitoring. The catheter material
interval. Bedside blood gas analyzers allow for frequent can affect catheter handling during placement and the like-
patient monitoring, diagnosis of ventilation and oxygena- lihood of thrombophlebitis [3]. Monitoring for evidence of
tion problems, and tailored therapy and prognostication thrombosis is important, especially in peripherally placed
for patients with respiratory disease. anatomic sites because the catheter and associated
Evaluating Arterial Blood Gas Results 341
thrombosis may compromise blood flow to distal tissues. The PCO2 measurement is made by measuring the
Refer to Chapter 8 for more information. hydrogen ion difference between two solutions after
allowing a chemical reaction that results in hydrogen
ion production. Resultant hydrogen ion production is
Arterial Blood Sample Handling
determined using a pH-sensitive membrane similar to
To ensure accuracy of blood gas results, knowledge of that used for the pH measurement. The hydrogen ion
appropriate sample handling is important. Exposure of the production is directly proportional to the PCO2 of the
sample to room air alters results, so sampling should be blood sample.
anaerobic if possible (disallowing a sample/room air inter- The PO2 is measured using a Clark electrode, which
face). Air bubbles in the sample syringe should be expelled uses oxidation and reduction reactions involving the
immediately. Owing to gas diffusion, exposure to room air oxygen in the sample to quantify the partial pressure of
causes a drop in the sample PaCO2 (PCO2 of room air is oxygen present. The change in current as a result of the
approximately zero) and change in the sample PaO2 (PO2 oxidation–reduction reactions is proportional to the PO2
of room air is approximately 150 mmHg at sea level). of the blood gas sample. Once pH, PCO2, and PO2 are
Analysis delay also alters the accuracy of the blood gas measured, a microprocessor then calculates the bicarbo-
results. Blood cells remain metabolically active for some nate, base deficit, and temperature-corrected gas values
time ex vivo, consuming O2 and producing CO2. Holding (see later) [6].
the sample on ice decreases the cells’ metabolic rate and
preserves the sample’s true gas levels. If sample analysis Temperature Correction
must be delayed, the sample should be stored anaerobi- Blood gas analysis is performed at 37°C, which may or may
cally in an ice water bath at 4°C; this allows up to a one- not reflect patient body temperature and thus in vivo blood
hour delay in analysis without significantly affecting gas values. When the patient’s body temperature is entered
results [4]. into the blood gas analyzer, the machine calculates the
Blood gas analysis requires whole blood samples, and as blood gas results accurate for the individual. However,
such anticoagulants must be used to prevent clot forma- changes in temperature alter gas solubility (Charles law)
tion. Unfortunately, dilutional errors associated with anti- and alter hemoglobin’s affinity for oxygen. Taken together
coagulants can affect results. Heparin is commonly used as with the fact that the metabolic, vascular, and respiratory
the anticoagulant for arterial blood. Dilution of the sample effects of hyper- and hypothermia are not fully understood,
with liquid heparin can lower the PaCO2, affects the meas- the value of temperature correcting blood gases remains
ure of oxygen, and can affect electrolytes, lactate, and controversial [7].
bicarbonate results. A less than 10% dilution with heparin
minimizes effects on the analytes; this dilution can be
achieved with the evacuated syringe method using a 3-cc Evaluating Arterial Blood Gas Results
syringe and 22-gauge needle. Liquid sodium heparin
(1000 iu/ml) 0.5 ml is drawn into the syringe, and then the Normal arterial blood gas values for dogs and cats are listed
plunger is drawn to the 3-cc mark to allow the heparin to in Box 26.2 [8].
coat the interior of the entire syringe. Then the contents of
the syringe are removed by expelling all the air and any
heparin forcibly. The expulsion procedure (pulling the
plunger back to the 3-cc mark followed by forceful expul- Box 26.2 Normal Arterial Blood Gas Values for Dogs
sion of contents) is repeated three times. Finally, the and Cats Breathing Room Air at Sea Level
syringe is filled with at least 1 cc of blood, which represents
a 3.9% dilution [5]. See Chapter 8 for further details about Dog [8]
this technique. PaO2: 92 mmHg (80–105)
PaCO2: 37mmHg (32–43)
Measurement with a Blood Gas Analyzer SaO2: > 95%
The blood gas analyzer measures the pH, the PO2, and the Cat [8]
PCO2 of the sample; the bicarbonate concentration and
base deficit are calculated. The pH is measured using a pH- PaO2: 105 mmHg (95–115)
sensitive membrane. The pH is determined by measuring PaCO2: 31 mmHg (26–36)
the voltage difference across this membrane. SaO2: > 95%
Assessment of the Partial Pressure acidosis due to hypoventilation. Diseases of the pleural
of Carbon Dioxide space, such as severe pleural effusion or pneumothorax, or
diaphragmatic hernia can also result in hypoventilation
The partial pressure of carbon dioxide (PCO2) is the
but are more likely to cause severe hypoxemia before
amount of CO2 dissolved in blood and is determined by the
hypoventilation is clinically relevant. Obstructive diseases
balance between production in the tissues and elimination
of the upper and lower airway alter airway resistance and
from the body; inhaled carbon dioxide from environmental
can lead to hypercapnia. Tracheal collapse, an upper air-
air is negligible.
way mass, or a foreign body can lead to upper airway
PaCO2 is determined primarily by ventilation because
obstruction and hypercapnia. Lower airway diseases such
when tissue CO2 production increases, increases in respira-
as asthma or bronchitis can also cause hypercapnia due to
tory rate and/or tidal volume (i.e. minute ventilation) nor-
gas trapping in lower airways and decreased fresh gas
malize PaCO2 in a healthy animal. Alterations in PaCO2 are
introduction. Respiratory acidosis will result when there is
usually associated with neurologic or neuromuscular
increased CO2 production in the tissues without the appro-
disease, respiratory depressant medications, or severe
priate compensation in ventilation, as in heat stroke and
pathology of the upper or lower airways, pleural space, or
malignant hyperthermia; however, such situations are
chest wall.
much less common than inadequate CO2 elimination as
Control of ventilation is primarily driven by the medulla.
the cause for hypercapnia.
Increased PCO2 diffuses into the cerebrospinal fluid and
Depending on the cause, interventions may vary signifi-
lowers its pH, which stimulates local chemoreceptors and
cantly, so the primary goal is to determine the underlying
triggers increased ventilation. Hypoxemia can also trigger
cause and attempt to fix it (e.g., reverse respiratory depres-
central chemoreceptors to increase ventilation when the
sant medications, decrease anesthetic depth, relieve pleu-
PaO2 is less than 60 mmHg. The carotid and aortic bodies
ral space disorders). A PaCO2 greater than 60 mmHg is a
are peripheral chemoreceptors that can stimulate ventila-
significant problem and warrants immediate correction of
tion secondary to decreased PaO2, increased PaCO2, or a
the underlying problem.
drop in pH [9].
Although this chapter focuses on arterial blood gas anal-
Decreased PCO2 (Hypocapnia)
ysis, note that given adequate cardiovascular performance,
Respiratory alkalosis, or hypocapnia, is a decrease in the
PCO2 (unlike PO2) is similar in the venous and arterial
partial pressure of carbon dioxide below the reference
blood. Therefore, venous blood can and is used to evaluate
interval of your analyzer for the species. Hypocapnia can
PCO2 in cardiovascularly stable animals, with normal val-
occur secondary to lung disease, which stimulates pulmo-
ues expected to be only a few millimeters of mercury higher
nary afferents to drive ventilation. Inadequate cellular
in venous than in arterial samples. The same is not true for
energy production also triggers both central and peripheral
evaluation of PO2, which must be performed on arterial
chemoreceptors and increases ventilation. Examples of
blood to provide information about the lung’s ability to
non-pulmonary conditions that cause inadequate cellular
oxygenate the blood; venous PO2 cannot provide this
energy production include anemia, decreased cardiac out-
information.
put (shock, poor cardiac contractility), and mitochondrial
dysfunction (as with sepsis or cyanide intoxication).
Increased PCO2 (Hypercapnia) Animals with metabolic acidosis also may develop com-
Respiratory acidosis (also called hypercapnia) is an increase pensatory respiratory alkalosis in an attempt to normalize
in the partial pressure of carbon dioxide above the analyz- blood pH. See Chapter 57 for more information about acid–
er’s reference interval for the species. This most commonly base status. A drop in the PaCO2 below 25 mmHg can result
occurs due to decreased alveolar ventilation, which can in compromised cerebral blood flow [10] and should be
occur for several reasons. Central nervous system dysfunc- addressed immediately by determining the underlying
tion, as with anesthetics, traumatic brain injury, neoplasia, cause and addressing it.
infections, or cerebral edema, can affect ventilatory drive.
Diseases affecting the cranial cervical spinal cord such as
Assessment of the Partial Pressure of Oxygen
intervertebral disk disease, neoplasia, infection, or inflam-
in Arterial Blood
mation can also lead to hypoventilation due to effects on
the upper and lower (phrenic nerve) motor neurons Oxygen is carried in the blood in only two forms. One form
responsible for diaphragmatic innervation. Peripherally is the portion of gas dissolved in the blood and measured as
mediated neuromuscular disease such as tetanus, botu- a partial pressure (PO2). This represents only 2–3% of the
lism, and tick paralysis can also lead to a respiratory total arterial blood oxygen content [11]. The other form is
Pulmonary Function Assessment Using Arterial Blood Gas Data 343
the oxygen bound to hemoglobin in the red blood cells. In capillaries as they head to the left heart for systemic circu-
arterial blood gas analysis, the PaO2 is measured to evalu- lation. Hence PaO2 is used as a primary measure of pulmo-
ate the lung’s ability to oxygenate blood, often called sim- nary function.
ply “lung function.” The movement of oxygen from the A PaO2 less than 80 mmHg is considered hypoxemia, and
alveoli into the pulmonary capillaries occurs via diffusion oxygen supplementation should be considered. A PaO2 less
down a concentration gradient. Alveolar partial pressure of than 60 mmHg is considered severe hypoxemia, and imme-
oxygen (PAO2) is higher than the partial pressure of oxygen diate intervention is necessary.
in the pulmonary capillary as it leaves the pulmonary arte-
riole and approaches the alveolus. At the alveolar–pulmo-
nary capillary junction, oxygen passively diffuses across ulmonary Function Assessment Using
P
the alveolar membrane into the pulmonary capillaries. The Arterial Blood Gas Data
rate of diffusion is driven by Fick’s law, which states that
the diffusion of a gas across a membrane is directly propor- Once arterial blood gas values are attained, further analysis
tional to the area of the tissue membrane and the pressure may be helpful to determine the severity of the pulmonary
gradient, and inversely proportional to the thickness of the dysfunction and to rule out hypoventilation as the cause of
membrane [12]. Clinically, this means that diffusion will hypoxemia. A summary of these analyses is available in
be altered if the surface area for gas exchange is decreased Box 26.3.
or if the respiratory membrane is thickened (which is
uncommon in small animals). Decreased surface area for
Alveolar to Arterial Oxygen Gradient
gas exchange occurs secondary to airway constriction (low
V/Q) or lung unit collapse or consolidation (no V/Q: After gas exchange occurs, the dissolved oxygen content in
intrapulmonary shunting). PaO2 is essentially a measure of the pulmonary capillary is normally the same as the oxy-
the proportion of perfused lung units that are ventilated gen content in the alveolus (PaO2 ∼ 105 mmHg at sea level
adequately to allow oxygen to diffuse into the pulmonary on room air) because diffusion is complete. Oxygenated
Box 26.3 Pulmonary Function Assessment Using Arterial Blood Gas Data
Alveolar–Arterial Oxygen Gradient consistent with acute lung injury 200–300 mmHg;
A a gradient PAO2 PaO2 severe pulmonary dysfunction consistent with acute
respiratory distress syndrome < 200 mmHg.
FiO2 PB PH2 0 PaCO2 / RQ PaO2 (26.1)
● Use: At FiO2 > 0.21 (ideally used when oxygen is sup-
plemented, as PaCO2 is not taken into account).
● Normal ≤ 15 mmHg at FiO2 0.21 (room air), normal
● Expected values apply only to sea level; extrapolated,
≤ 150 mmHg at FiO2 1.0 (100% oxygen); values in
reliable values would be available at other PB.
excess of 15 mmHg on room air indicate pulmonary
dysfunction.
● Use: At any PB, at any PaCO2. FiO2 × 5 Rule
● Reliable only at room air or 100% oxygen. Normal PaO2 ≥ (FiO2, %) × 5 (26.4)
Use: At FiO2 > 0.21 (ideally used when oxygen is sup-

The “120” Rule
●
plemented, as PaCO2 is not taken into account)

PaCO2 + PaO2 ≥ 120: adequate lung function ● Expected value of PaO2 ≥ 5 × FiO2 applies only to sea
PaCO2 + PaO2 < 120: abnormal lung function (26.2) level; extrapolated, reliable values would be available
at other PB
● Use: Only at sea level on room air.
PaO2/FiO2 Total Arterial Oxygen Content
PaO2/FiO2 = “P : F ratio” (26.3) CaO2 SaO2 Hgb 1.34 0.003 PaO2 (26.5)
● Normal ≥ 500 mmHg; mild pulmonary dysfunction ● Normal in dogs: 16.9–18.0 ml/dl

300–500 mmHg; moderate pulmonary dysfunction ● Relevant at all PB, PCO2, and FiO2
pulmonary capillary blood then flows to the left heart for A-a gradient and the 120 rule. The value is acquired by
systemic circulation. However, a small amount of blood dividing the PaO2 by the FiO2:
(from bronchial and Thebesian circulations) normally
returns to the left heart deoxygenated; this small amount of P : F ratio PaO2 / FiO2
deoxygenated blood mixes with the arterialized blood
where the FiO2 is expressed as a decimal. With normal pul-
returning from the pulmonary capillaries, which drops the
monary function, the P : F ratio should exceed 500 mmHg.
PaO2 below the PAO2. The normal difference between
The P : F ratio can be used to approximate the severity of
PAO2 and PaO2 (the “A–a gradient” or “A–a difference”)
pulmonary dysfunction. Animals with P : F between 300
should be less than 15 mmHg and is generally considered
and 500 mmHg have mild lung dysfunction; those with P : F
“physiologic shunting.” However, when an increased
between 300 and 200 mmHg have moderate dysfunction,
amount of blood enters the left atrium without being oxy-
and those with P : F less than 200 mmHg are considered to
genated (for instance, because it perfused lung units that
have severe dysfunction. This calculated ratio, along with
were not well ventilated due to a low V/Q or no V/Q sce-
several other criteria such as acute onset of respiratory dis-
nario), the excessive deoxygenated blood further dilutes
tress, bilateral dorsocaudal pulmonary infiltrates, absence of
the properly arterialized blood coming from functional
fluid overload or congestive heart failure, and an appropri-
lung units. This situation is commonly referred to as
ate underlying disease process, is used to identify veterinary
venous admixture. To determine whether there is patho-
patients with acute lung injury and acute respiratory distress
logic venous admixture, the A–a gradient can be calcu-
syndrome [14]. Values less than 500 mmHg indicate that
lated (see Box 26.3, equation 26.2); increased gradients are
there is compromised pulmonary function and diagnostics
associated with underlying pathology and help direct diag-
are indicated. The advantage of this method is that it is sim-
nostic tests and intervention.
ple, quick, and can be used at any FiO2. The main disadvan-
Where the FiO2 is the fraction of inspired oxygen (0.21 or
tage of the method is the disregard for the effect of ventilation
21% on room air), PB is the barometric pressure
(PCO2), although this is only really an issue when making
(∼ 760 mmHg at sea level), and PH20 is the vapor pressure of
the calculation on room air. The P : F is thus most appropri-
water. PH2O does vary with temperature, but generally
ately used in animals receiving supplemental oxygen.
47 mmHg is used because this is the vapor pressure of
water at 37°C (human body temperature). The PaCO2 is
measured from the arterial blood gas sample, and RQ is the FiO2 × 5
respiratory quotient, which is approximately 0.8. This
Another way to approximate the expected PaO2 is to multi-
assessment also works when the patient is receiving 100%
ply the FiO2 (as a whole number percentage) by five. With
oxygen, in which case the expected gradient is less than
normal pulmonary function the PaO2 on room air at sea
150 mmHg. For fractional inspired oxygen levels between
level is approximately 100 mmHg, which is about five times
room air and pure oxygen, the expected gradient has not
the FiO2 expressed as a whole number (21). This can then
been established and must be extrapolated [13].
be extrapolated out to estimate what the PaO2 should be
with normal pulmonary function for any given FiO2.
The “120” Rule Values attained that are less than 5 indicate lung dysfunc-
tion [13]. Advantages and disadvantages are identical to
Because the PCO2 affects PAO2 (see Box 26.3, expanded
those described for the P : F ratio.
Eq. 26.3), when an animal is at sea level breathing room air,
one can estimate what PaO2 to expect when one knows the
PaCO2 by using the “120 rule.” When an animal is breath- Calculation of the Total Oxygen Content
ing room air at sea level, the sum of PaCO2 and PaO2 is
As stated earlier, O2 is carried in the blood two ways: dis-
generally 120–160 mmHg. When the sum of PaCO2 and
solved in plasma and attached to hemoglobin. Total blood
PaO2 is less than 120, pulmonary dysfunction is pre-
O2 content can be calculated easily using the blood gas ana-
sent [13]. The major inherent limitation to this method is
lyzer results if a hemoglobin (Hgb) concentration is known
the requirement for room air, sea level conditions. The
(or estimated). For arterial blood,
major advantage is its ease of use.
CaO2 , ml / dl Hgb 1.34 SaO2 PaO2 0.003
PaO2/FiO2 (“The P : F Ratio”)
where CaO2 is the total arterial blood oxygen content, SaO2
Equation Eq. (26.4) can be used to evaluate pulmonary is the saturation of hemoglobin with oxygen expressed as
function at any FiO2, which provides an advantage over the a decimal (see later), and 1.34 and 0.003 are constants.
Acknowledgment 345
Normal O2 content in dogs is reported to be 16.9–18.0 ml/ determine the cause should be considered if the patient’s
dl [15], although an idealized canine value is closer to clinical condition supports this finding.
20 ml/dl. Note that red blood cell mass has a far more pro-
found effect on total blood oxygen content than does PO2
within the survivable range. Saturation of Hemoglobin with Oxygen
Blood gas analyzers often report the saturation of oxygen

Venous Samples (SO2). This value represents the amount of oxygen bound
to the hemoglobin molecule and is reported as a percentage
Although arterial samples are preferable for assessment of
of hemoglobin saturation with oxygen. Blood in which all
both oxygenation and ventilation, a venous sample can
hemoglobin oxygen sites are bound with oxygen is 100%
also help evaluate the respiratory system.
saturated; blood in which 75% of hemoglobin oxygen sites
are bound with oxygen is 75% saturated. The arterial hemo-
Venous Partial Pressure of Carbon Dioxide globin oxygen saturation (SaO2) is calculated in most blood
gas analyzers from the pO2, pH, and bicarbonate values;
There is an expected arterial–venous gradient for venous the analyzer assumes normal conditions for the calcula-
PCO2 (PvCO2). Venous blood contains CO2 from the meta- tion [13]. Some blood gas analyzers may have co-oximetry
bolically active tissue bed(s) upstream from where the sam- functionality that allows direct measurement of SO2 from
ple was acquired, and as such, it generally has a PCO2 the blood sample, but this is uncommon in veterinary med-
approximately 5 mmHg higher than arterial blood. CO2 icine. The oxyhemoglobin equilibrium curve (also called
produced in the tissues is carried in several forms by the the oxyhemoglobin dissociation curve) shows the relation-
blood to the lungs for removal. The dissolved PCO2 repre- ship between the PO2 and the SO2 graphically; it is a sig-
sents approximately 10% of the total CO2 [13]. Most of the moid curve where initially there is rapid binding of oxygen
CO2 is buffered within the red blood cell and then trans- to the hemoglobin molecule. Pulse oximetry is a noninva-
ported as bicarbonate to the lungs where this process is sive method of estimating the PaO2 using the oxyhemo-
reversed to facilitate removal of CO2 by the lungs. The dis- globin dissociation curve. See Chapter 25 for more
advantage of venous samples is that in certain disease information about the oxyhemoglobin equilibrium curve
states, the arterial-to-venous PCO2 gradient may increase. and these monitoring tools.
Such disease states include anemia, where there is a
decrease in the ability to buffer the CO2. Venous stasis (as
in cardiovascular instability from hypovolemia or cardio-
genic shock) also increases the gradient. As a general Summary
guide, a PvCO2 greater than 48 mmHg indicates hypoventi-
lation assuming no concurrent perfusion compromise. Blood gas analysis allows detailed assessment of a patient’s
respiratory function. Arterial blood gases provide the
opportunity to monitor a patient’s pulmonary function in
Venous Partial Pressure of Oxygen response to time and therapy, particularly when tools like
The venous PO2 (PvO2) cannot be used to determine lung the A–a gradient and the P : F ratio are used. Arterial and
function; however, it can be used for other purposes. For venous blood gases can be used to inform the clinician and
instance, PvO2 can be used to determine the oxygen extrac- technician about the patient’s ventilatory adequacy. Venous
tion ratio (OER), a ratio that sheds some light on the ade- partial pressure of oxygen can be used as a marker of ade-
quacy of oxygen delivery in comparison with the patient’s quacy of tissue perfusion. Blood gas analysis is readily
oxygen consumption. Traditionally, calculation of the OER available and relatively inexpensive with the use of bedside
requires a mixed venous sample collected from the distal monitoring equipment.
port of a pulmonary arterial catheter; however, blood from
a central venous line (a catheter with a distal port near the
right atrium) is probably adequate for most purposes. See Acknowledgment
Chapter 19 for more information regarding the
OER. Normal PvO2 values range from 40 to 50 mmHg. This chapter was originally co-authored by Drs. Sarah Gray
Generally, when PvO2 is less than 30 mmHg, this may be an and Lisa Powell for the previous edition, and some material
indication of inadequate oxygen delivery (via any of the from that chapter appears in this one. The author and edi-
mechanisms mentioned above), and diagnostics to tors thank Dr. Powell for her contributions.
References
1 Roels, E., Gommeren, K., Farnir, F. et al. (2016). 9 Campbell, V.L. and Perkowski, S.Z. (2004).
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352–359. 10 Johnson, R.A. and de Morais, H.A. (2006). Respiratory
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Care 24 (5): 545–553. 11 Pierce, L.N.B. (2007). Practical physiology of the
3 Waddell, L. (2004), Advanced vascular access. Paper pulmonary system. In: Management of the Mechanically
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4 Srisan, P., Udomsri, T., Jetanachai, P. et al. (2011). Effects MO: Saunders.
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measurements in dogs. Am. J. Vet. Res. 66 (4): 656–660. measurements. In: Textbook of Respiratory Disease in Dogs
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St. Louis, MO: Mosby. and ARDS in veterinary medicine. J. Vet. Emerg. Crit.
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347
27
Point-of-Care Lung and Pleural Space Ultrasound

Two major structures assessed during thoracic veterinary Indications for Pleural and Lung
point-of-care ultrasound (VPOCUS) include the pleural Ultrasound
space and lungs, both of which are commonly associated
with pathology in companion animals presenting in res- There are a variety of indications for PLUS in the emer-
piratory distress. Historically, pleural space pathology has gency and critical care setting. Primary indications include
been evaluated with thoracic focused assessment with assessment of the pulmonary parenchyma for evidence of
sonography for trauma (TFAST), while lung pathology has pathology and/or volume overload as well as assessment
been evaluated using regional lung scanning protocols for pleural space disease [1–7]. This, in conjunction with
such as Vet BLUE® or more comprehensive protocols that point-of-care abdominal and cardiac ultrasound performed
scan a larger lung surface area [1–8]. As it is not possible to in the clinical setting, provides additional relevant infor-
assess the lungs without concurrently visualizing the pleu- mation to patient assessment and management (Chapter 6).
ral space, the two have been assessed concurrently in
human medicine as pleural and lung ultrasound (PLUS) [9].
PLUS has been described in companion animals and has
the advantage of incorporating both TFAST and regional atient Positioning and Machine
P
lung ultrasound principles into a single rapid protocol that Settings
takes advantage of sonographically identifiable borders
(Figure 27.1) to orientate operators and assesses the most PLUS is ideally performed with the patient in a standing
sensitive sites for pathology, which vary based on patient position or sternal recumbency, especially those presenting
positioning [2]. The other advantage of PLUS is that it in respiratory distress [2]. This minimizes restraint, limits
scans more regions of the thorax than some regional lung stress (work of breathing), and avoids potential respiratory
ultrasound protocols and takes advantage of different decompensation in dyspneic patients. Patients with respira-
transducer orientations, both of which have been shown to tory distress should be provided oxygen therapy, anxiolytics,
increase the chances of finding pleural and lung pathol- and other stabilization measures performed concurrently
ogy [2, 8, 10–13]. with PLUS, to ensure patient safety. Do not compromise
Like other VPOCUS protocols, PLUS can be applied at patient safety to complete any VPOCUS evaluation. An
triage, keeping the examination focused to the most likely exception to standing/sternal positioning is a patient with a
cause of dyspnea as suggested by signalment, triage evalu- flail chest, as these patients ideally should be placed in lat-
ation, history, and/or clinical examination. It can be used eral recumbency with the flail side down as a stabilization
serially to monitor progression or resolution of identified measure. If necessary, lung ultrasound may be performed in
pathology (e.g. severity of B-lines following furosemide lateral recumbency in more stable patients that tolerate lat-
therapy for congestive heart failure). In addition, it can be eral restraint or in patients with concurrent injuries that
used to guide interventions (e.g. ultrasound-guided thora- may preclude sternal positioning (e.g. spinal fracture) [2].
cocentesis). Finally, PLUS can be applied systemically as Patient positioning has a significant effect on where pleural
part of routine patient assessment (Chapter 6). space pathology accumulates; fluid falls to gravity-dependent
348 Point-of-Care Lung and Pleural Space Ultrasound
with pneumothorax will accumulate caudodorsally while

fluid with pleural effusion accumulates ventrally; in lateral
recumbency, air accumulates at the widest gravity independ-
ent point, fluid at the widest most gravity-dependent point).
PLUS should be modified based on the specific questions
asked and patient positioning [2].
Recognizing the sonographically identifiable PLUS bor-
ders helps to orientate the sonographer where the trans-
ducer is positioned on the thorax and ensures assessment of
the most sensitive areas where pleural space pathology accu-
mulates [2, 10]. The thoracic borders that can be identified
during PLUS include the caudal border (abdominal curtain
sign, see below), dorsal border (hypaxial/lumbar muscles),
cranial border (flexor muscles of the shoulder, thoracic inlet)
and ventral border (pectoral/sternal muscles). Pleural space
pathology often is localized at these borders and regional
lung scanning occurs within the borders (Figure 27.1) [2, 10].
Figure 27.1 Identifying the sonographically identifiable pleural Depth is determined by the body condition score of the
and lung ultrasound (PLUS) borders is essential to orientate the
operator, and ensures assessment of the most sensitive areas
patient and is typically set at 4–6 cm for PLUS. Generally,
pleural space pathology accumulates. The sonographically the depth is adjusted until the pleural line occupies the
identifiable PLUS borders include the caudal border (abdominal proximal third of the image.
curtain sign, outlined in red), dorsal border (hypaxial/lumbar Lung sliding, also known as the “glide sign” is often
muscles, outlined in dark blue), cranial border (flexor muscles of the
shoulder, thoracic inlet, outlined in green) and ventral border
easier to see with shallow depths (2–3 cm), but the depth
(pectoral/sternal muscles, outlined in pink). Pleural space pathology should be increased again after assessing lung sliding
often accumulates at these borders and regional lung scanning because other pathology (B-lines, Figure 27.2) and land-
occurs within the borders. It should be noted that the ventral marks such as the abdominal curtain sign (Figure 27.3) can
border of the lung deviates dorsally at the cardiac notch, which is
important if the goal is to look for ventral lung pathology or pleural
be missed with shallow depth settings.
space pathology (ventral border of the lung at the cardiac notch is Decreasing the gain often makes the pleural line appear
shown in light blue). The black arrow indicates the most caudal grainy, subsequently allowing lung sliding to become more
dorsal location in the standing patient, which will be the most visible; however, if gain is reduced to assess lung sliding it
sensitive site for detection of the pneumothorax in the standing or
sternal patient. The nongravity-dependent widest part of the chest
should be increased again to allow B-lines and other find-
will be the most sensitive location for detection of pneumothorax ings to be more easily identified.
in the laterally recumbent patient (not shown in the image). Placing the transducer over a single rib (centered in the
ultrasound image) may allow lung sliding to be more easily
regions while air rises to non-gravity-dependent areas [2]. visualized. This ultrasound image is referred to as the
Therefore, the most sensitive sites to identify pleural effusion “dead bat” [14] (Figure 27.4) or “one-eyed gator” sign [15].
and pneumothorax are not the same for patients in lateral If the transducer is oriented across intercostal spaces
compared with standing/sternal (i.e. in standing/sternal air (perpendicular or transverse to the ribs), the “bat sign” is
Figure 27.2 Ultrasound still and schematic images of a single B-line. B-lines appear as white vertical narrow (individual) to broad
(coalescing) bands that extend vertically from the lung surface that move with lung sliding during respiration. B-lines often obliterate
A-lines and usually extend to the far field of the ultrasound image (see text for more detail on B-lines).
Patiea PotatPeteng Pend Pactei iaatengo 349
Figure 27.3 Chest radiograph demonstrating the location, and schematic image demonstrating the appearance, of the abdominal
curtain sign in a healthy animal. When the transducer is situated such that it is partially over aerated lung (blue shaded half of the
ultrasound transducer) and partially over the soft tissue structures of the abdomen (green shaded half of the transducer), a sharply
demarcated vertical artifact (vertical dotted white line) becomes sonographically visible at the transition of aerated lung to soft tissue
abdominal structures (marked by the red arrow). In this example the transducer is positioned over the liver, which makes up the soft
tissue structures caudal to the curtain sign. The abdominal curtain sign helps with directing the transducer to the most gravity
independent (pneumothorax caudodorsally) and dependent (pleural effusion caudoventrally) sites with the patient in standing/sternal
recumbency and may help differentiate pleural from pericardial effusion and/or confirm the presence of pneumothorax. A, A-lines.
created (Figure 27.5), which provides orientation by identi- and achieves good depth for identification of translobar
fying proximal rib surfaces, rib shadows, and the pleural lung consolidation (see below).
line. The bat sign thus allows lung sliding to be assessed,
and orientation is achieved [14].
Linear Transducer
Placing the transducer parallel to the intercostal space
allows an extended view of the pleural surface and may be If a higher resolution transducer is required once pathology
preferred in some situations (see below) [2, 10, 11]. There is is found, a change to the linear transducer is reasonable.
also evidence in both the human and veterinary literature The linear transducer operates at a higher frequency and is
that a parallel transducer orientation relative to the ribs good at interrogating finer or more shallow structures such
improves detection of some pleural space and lung pathol- as the pleural surface. This is the transducer of choice for
ogy [2, 10–12]. examining the ribs for fractures (not covered here).
The appearance of pathology is different when using a
phased array transducer, although evidence suggests linear
Phased Array Transducer
and microconvex transducers can be used interchangea-
bly [16, 17]. The advantage of the phased array transducer is that the
small transducer footprint means that it is easier to achieve
a view in a small intercostal space. The limited field of view
Curvilinear Transducer
thus increases the risk of missing pathology that is local-
The curvilinear transducer is most commonly used and is ized distant from the transducer. It is reasonable to use
the authors’ preference for PLUS scanning. Its larger foot- when diffuse pathology is suspected (pleural effusion, pul-
print enables examination of a wider field of the pleural monary edema). Note that the appearance of pathology,
surface. This transducer may operate at low frequencies, such as B-lines, differs based on the transducer used;
Figure 27.4 Schematic images of the “dead bat sign” formed when a rib is centered within the ultrasound image. When a single rib is
visible it creates the image of an upside down “dead bat” where the body of the bad forms the proximal rib and the wings of the bat
form the pleural line. Centering the transducer over a single rib reflects more of the ultrasound beam away from the transducer, which
makes the pleural line appear “grainier” and lung sliding (aka the glide sign) easier to visualize (the curved dotted white lines
represent the pleural line).
Figure 27.5 Still image and schematic representations of the BAT sign when the transducer is orientated perpendicular to the ribs.
BAT is used as it makes the mnemonic “bone and air with the transducer transverse to the ribs,” which helps novice operators know
they should be looking for bone (ribs) and the soft tissue air interface (air filled lung in healthy animals) when the transducer is
transverse (perpendicular) to the ribs. Two ribs are identified in the image as downward facing white curvilinear structures (bat wings),
both of which cast an acoustic shadow (black lines extending through the far field of the image) obstructing the view of anything
deep to them. Between the two ribs is a thin white line approximately 0.5 cm deep to the proximal rib surface (varies by patient size
and body condition score), joining the rib shadows, which is the pleural line. The pleural line demarks the soft tissue air interface and
the “body” of the bat. A-lines are visualized as horizontal white lines that appear parallel to the pleural line and extend throughout
the depth of the ultrasound image at regular intervals. The intensity of the A-lines decreases with depth as some of the ultrasound
beam is absorbed each time the beam returns to the transducer. PL, Pleural line.
iacetiqi Pend nieatitaPatPe Pi PorPal qeng alaoPoPqen rPngio PrmPoin tacdPacPalPngg 351
therefore, operators should only use a transducer with abdominal curtain sign until the heart becomes visible or
which they are comfortable, which will be the microconvex the costochondral junctions are reached (Figure 27.7). This
curvilinear transducer in many cases [17]. is the pericardiodiaphragmatic window (Figure 27.8). If
obvious pleural fluid is not seen with the transducer per-
pendicular to the ribs, the transducer can be rotated until it
echnique and Identification of
T is parallel to the ribs with the marker directed dorsally.
Normal Lung Ultrasound Images Slide the transducer ventrally, maintaining a parallel orien-
tation, until the pectoral/sternal muscles fill one-third of
Compared With Pathology
the sonographic image, which the authors refer to as the
“ski jump” sign (Figure 27.6) [2, 14].
Pleural and Lung Ultrasound
Scanning Technique
Technique for Pneumothorax
The most sensitive thoracic location to sonographically To scan the pleural space for pneumothorax, the most cau-
identify pathology varies depending on the clinical sce- dodorsal regions should be scanned with the patient in a
nario, patient position, and specific question asked [2]. standing/sternal position, or the widest, non-gravity-
Therefore, the choice of the first point of investigation of dependent point of the thorax for patients in lateral recum-
PLUS often depends on patient assessment and suspicion bency [2]. To locate the most caudodorsal site in the
of type of pathology present. For example, the pleural standing or sternal patient, the transducer is slid caudally
space may be evaluated first if pleural space disease is from the mid-thoracic region until the abdominal curtain
anticipated compared with the lungs in patients with sus- sign is identified, and then slid dorsally along the abdomi-
pected primary parenchymal disease. nal curtain sign until the pleural line disappears in the
The transducer may be oriented either perpendicular or hypaxial muscles (Figure 27.9). Slide the transducer ven-
parallel to the ribs [2]. A parallel orientation allows more trally until the pleural line is again visible: this is the most
lung surface to be visualized and may be more sensitive for caudodorsal location [2]. The appearance of lung sliding at
detection of pathology [11, 12]. For novice sonographers, this location rules out pneumothorax for the pertinent
perpendicular orientation allows for easier recognition of hemithorax in the sternal/standing patient; lung sliding
normal structures via identification of the “bat sign” need not be assessed elsewhere on this hemithorax. The
(Figure 27.5) [14]. other hemithorax should be similarly interrogated. The
The transducer orientation should remain consistent. objective of the remaining PLUS exam should focus on
The indicator marker on the transducer should be oriented pathology that arises from the pleural line (e.g. B-lines,
toward the patient’s head when scanning perpendicular to pleural effusion, subpleural consolidation).
the ribs and oriented dorsally (toward the spine) when
scanning parallel to the ribs [14]. Regional Lung Scanning
Much of lung ultrasound is based on the interpretation of
Technique for Pleural Effusion artifacts produced at the lung surface and relates to the way
When scanning the pleural space for effusion, moderate to ultrasound and air interact with each other at this location.
large volumes can easily be identified in the ventral third of Ultrasound can only be used to interpret the characteristics
the thorax at the level of the costochondral junction with the of the surface of a soft tissue–air interface because the
patient in sternal recumbency. For patients in lateral recum- ultrasound beam cannot penetrate gas. Since pathology
bency, the widest, most gravity-dependent area should be lying deep to a soft tissue to gas interface cannot be visual-
scanned. With large volume pleural effusion, the accuracy of ized, lung ultrasound is a surface imaging modality.
detecting fluid in the ventral third of the thorax is high Fortunately, most pulmonary pathology involves the pleu-
regardless of ultrasound transducer orientation [10]. ral surface to some extent.
To identify smaller volumes of pleural effusion, the most There are several lung ultrasound protocols published in
ventral borders of the pleural space should be scanned with veterinary medicine, all of which have similar findings
the patient in a standing or sternal position, with the trans- with regards to lung pathology, and no studies have com-
ducer parallel to the ribs; this creates the “ski jump” sign pared the accuracy of one lung protocol over another [2–7].
(Figure 27.6) [2, 10, 14]. A canine study published as an abstract in 2014 [13], and a
To identify the most ventral pleural borders of the tho- feline study (in press at time of writing) [8] suggest that
rax, a change in orientation of the transducer and the win- lung ultrasound protocols that evaluate more lung surface
dow into the thorax is required. The transducer is slid area can detect more pathology. Regardless of the actual
caudally from the mid-thoracic region until the abdominal lung ultrasound protocol chosen, they all tend to have two
curtain sign is identified, and then ventrally along the things in common: (i) they scan multiple lung regions
(a)
Figure 27.6 Schematic and still images depicting the “ski jump” sign with the transducer oriented parallel to the ribs at the most
ventral regions of the thorax. The proper image is obtained by first finding the pericardiodiaphragmatic window (or costochondral
junction), turning the transducer parallel to the ribs with the marker directed dorsally and sliding the transducer ventrally until
pectoral/sternal muscles fill one-third to half of the sonographic image. The transducer angle may need to be rocked slightly to
maintain contact in round chested patients. (a) Still ultrasound image obtained when the transducer is situated over lung and slid
ventrally until the pectoral/sternal muscles fill one-third of the sonographic field on the right side of the thorax. The curved white
dotted line represents the interface between the pleura, which resembles an Olympic ski jump. (b) Still ultrasound image obtained
when the transducer is situated over the heart at the cardiac notch and slid ventrally until the pectoral/sternal muscles fill one-third of
the sonographic field on the right side of the thorax. The curved white dotted line represents the interface between the pericardium
and the parietal pleura, which resembles an Olympic ski jump. (c) Each intercostal space is assessed by sweeping the transducer cranial
a rib space at a time, while also sliding ventrally and dorsally within each intercostal space to assess the ventral lung and ventral
pleural space borders (blue double headed arrows represent sliding the transducer parallel to the ribs between the ventral sternal and
ventral lung regions). LV, left ventricle; LVFW, left ventricular free wall; RV, right ventricle; RVFW, right ventricular free wall.
bilaterally, and (ii) they often start at the most caudodorsal assessed as described above; or (iii) the dorsal pleural space
site in a sternal/standing patient (Figure 27.10) [2–7]. can be assessed as described above. With experience, struc-
To assess the lungs, novice sonographers should begin by tures are more easily identified and the operator can begin
placing the transducer caudal to the cranial lung border closer to the sonographic thoracic borders.
(thoracic limb; between the fifth and sixth intercostal Many protocols also include the subxiphoid site for eval-
spaces), at the level of the middle to upper 2/3 of the thorax uation of the lungs using the liver as an acoustic window
(Figure 27.11) [2, 18]. This will allow identification of the into the thorax, which is also the authors’ preference
pulmonary parenchyma and avoid inadvertent identification (Figure 27.13) [2].
of the “abdominal curtain sign,” cardiac notch, abdominal
cavity, or musculature (the transducer should be over only
Normal Structures and Signs
ribs and lung to start). From this point, depending on the
clinical scenario and specific clinical question to be answered, The BAT or Gator Sign
different pleural space and lung pathologies can be assessed The BAT sign is the term preferred by the authors, as it
(Figure 27.12): (i) multiple lung regions can be scanned for creates the mnemonic “bone and air with the transducer
lung surface pathology; (ii) the ventral pleural space can be transverse to the ribs,” which helps novice operators know
(b)
(c)
that they should be looking for bone (ribs) and the soft identify the rib shadows in the far field of the ultrasound
tissue–air interface (air-filled lung in healthy animals) image and follow them toward the near field until the rib
when the transducer is transverse (perpendicular) to the surface is located (i.e. where the rib shadow ends in the
ribs [14]. Two ribs are identified in the image as downward- near field of the ultrasound image). Between the two ribs
facing white curvilinear structures (bat wings), both of is a thin white line approximately 0.5 cm deep to the proxi-
which cast an acoustic shadow (black lines extending mal rib surface (varies by patient size and body condition
through the far field of the image) and obstruct the view of score), joining the rib shadows, which is the pleural line.
anything deep to them. It is often easiest for novices to The pleural line demarcates the soft tissue–air interface
Figure 27.7 To identify the most ventral pleural borders of the

thorax, the transducer is slid caudally from the mid-thoracic
region until the curtain sign is identified, and then ventrally along
the curtain sign until the heart becomes visible or the
costochondral junctions are reached (orange curved arrow). This is
the pericardiodiaphragmatic window. Moderate to large volumes
of pleural effusion can be identified at this location.
Figure 27.8 Photograph, schematic and still image from a dog depicting the pericardio-diaphragmatic window ventrally where the
heart and the diaphragm can be visualized within the same sonographic image. The dog (upper image) is positioned in sternal
recumbency (frog legged, head to the left of the photo) with the traducer placed perpendicular to the ribs on the left side of the chest,
and the indicator marker directed cranially. The transducer will be situated close to the costochondral junction at roughly the sixth
intercostal space, although the exact location of the transducer will vary slightly between patients as sonographic landmarks are used
to find the correct window. LV, left ventricle; MT, mediastinal triangle; RV, right ventricle.
Figure 27.9 To locate the most caudal–dorsal site the Figure 27.11 To assess the lungs or to consistently find the
transducer is slid caudally from the cranial–mid-thoracic region abdominal curtain sign, novice sonographers should begin by
until the abdominal curtain sign is identified, and then slid placing the transducer just behind the cranial lung border
dorsally along the curtain sign until the pleural line disappears (thoracic limb; between the fifth and sixth intercostal spaces), at
in the hypaxial muscles (blue arrow). Slide the transducer the level of the middle to upper two-thirds of the thorax
ventrally from the hypaxial muscles until the pleural line is (purple arrow). This allows identification of the pulmonary
again visible; this is the most caudal–dorsal location. parenchyma and avoids inadvertent identification of the
“abdominal curtain sign,” cardiac notch, abdominal cavity, or
musculature (the transducer should be over only ribs and
lung to start).
“Glide Sign” or Lung Sliding

The visceral and parietal pleura are usually closely apposed
with a minute volume of fluid between them, sliding over
one another with each respiration. Unfortunately, the two
pleura and scant pleural fluid are not normally identifia-
ble with ultrasound. Instead, a sliding/shimmering of a
single thin white pleural line can be seen, which indicates
the two pleural surfaces are in contact. Two criteria are
needed to see lung sliding: (i) the visceral (lung) and pari-
etal (chest wall) pleura must be in contact; and (ii) the
pleura must move or “slide” along each other. Identification
of lung sliding rules out the presence of a pneumothorax
at that transducer location. The appearance of the glide
sign or lung sliding is best appreciated with experience.
Use of a high frequency transducer may enhance ability to
Figure 27.10 The sliding pleural and lung ultrasound protocol
begins at the most caudodorsal site and scans the dorsal third, identify lung sliding in some instances.
middle third, and ventral third of the thorax bilaterally between
sonographically defined lung borders to ensure multiple lung A-Lines
regions are assessed in a systematic “S” shaped fashion (red A-lines are a horizontal reverberation artifact created by the
arrow). Pulling the skin toward the starting location (like when
placing a chest tube) will significantly reduce the quantity of reflection of the ultrasound beam back and forth between
alcohol required to scan the lungs sites as the transducer and two highly reflective surfaces: (i) the ultrasound transducer;
skin can be moved together. and (ii) a soft tissue–air interface. With lung ultrasound, the
normal soft tissue–air interface is comprised of the two
and the “body” of the bat. With the gator sign, the wings of pleura and the air-filled lung below the pleural line. A-lines
the bat are exchanged for the “eyes” of an alligator and the are visualized as horizontal white lines that appear parallel to
body of the bat is exchanged for the “bridge of the nose” of the pleural line and extend throughout the depth of the ultra-
an alligator [15]. sound image at regular intervals (Figure 27.14). The intensity
Figure 27.12 Depending on the clinical presentation and triage findings different clinically relevant questions may need to be ruled
out with greater urgency than others. The advantage of pleural space and lung ultrasound is that it allows the operator to rule in/out
the most urgent life-threatening conditions first. Novices should start at the purple arrow and identify the curtain sign and then tailor
the protocol depending on the most probable life-threatening condition; (i) pneumothorax, blue arrow; (ii) alveolar interstitial disease
or lung consolidations, red arrow; (iii) pleural effusion, orange arrow. With experience structures are more easily identified and
operators can begin closer to the sonographically defined PLUS borders.
B-Lines
B-lines (also called “comet tails” or “lung rockets”) occur
when there is decreased aerated lung at the lung periphery,
most often secondary to increased extravascular lung water
(i.e. pulmonary edema) [20–22]. If lung is in contact with
the chest wall, B-lines originate at the pleural line and
extend perpendicularly into the lung. As many as three
B-lines per sonographic window may be normal, with one
Figure 27.13 Schematic image of the subxiphoid site, which is a to three B-lines occurring in 10–30% of healthy dogs and
great location to identify pericardial, lung and pleural pathology cats [6–8]. It is more common to see only one B-line at one
and may allow some degree of cardiac function to be estimated. to two locations on either hemithorax, or two B-lines at a
The depth setting must be increased at this location to be able
to sonographically visualize regions beyond the diaphragm. The
single location when scanning the lung surfaces. Although
transducer may also need to be rocked almost parallel to the three B-lines at a single location has been described in
spine to assess the ventral pleural and lung regions, as well as healthy cats and dogs, this number of B-lines in a single
the apex of the heart. D, diaphragm; H, heart; L, liver. sonographic window is rare and should not occur at multi-
ple lung locations over the same hemithorax [7, 8].
of the A-lines tends to decrease with depth because some of There are five criteria used to define a B-line (Figure 27.2):
the ultrasound beam is absorbed each time the beam returns
to the transducer. A-lines can be seen with any thoracic soft 1) They are white vertical narrow (individual) to broad
tissue air interface (i.e. they are present with aerated lung (coalescing) bands.
and with pneumothorax). A-lines are considered a “normal 2) They extend vertically (perpendicularly) from the lung
finding.” Also, because only a 2–3mm depth of aerated lung surface.
need be present to create reverberation artifact, lung pathol- 3) They move in sync with lung sliding during respiration.
ogy that is separated from the pleural surface by as little as 4) They often obliterate A-lines.
2–3mm of aerated lung cannot be seen, and only reverbera- 5) They usually extend to the far field of the ultrasound
tion artifact and A-lines will be visualized [19]. image.
Table 27.1 Causes of diffuse and localized B-lines,

with common history and clinical findings.
Focal/unilateral/localized
Multiple diffuse bilateral B-lines B-lines
Interstitial pneumonia or Focal pneumonia/

pneumonitis (e.g. lymphocytic pneumonitis, particularly
interstitial pneumonitis, aspiration: often a history
eosinophilic pneumonia, drug of vomiting
reactions)
Pulmonary edema – cardiogenic Pulmonary contusions:
or non-cardiogenic: heart often a history of trauma
murmur common with
cardiogenic causes, may have
history of seizures, chewing an
electrical cord, upper airway
obstruction or smoke inhalation
Diffuse parenchymal lung Atelectasis: often a
disease (e.g. pulmonary fibrosis) history of prolonged
recumbency and/or
anesthesia
Acute respiratory distress Pleural disease: interpret
syndrome: may have spared B-lines cautiously when
lung regions pleural effusion is present
as compression atelectasis
can cause B-lines
Figure 27.14 Schematic image depicting the creation of Neoplasia: often
A-lines caused by the reflection of the ultrasound beam associated with
between two highly reflective surfaces (transducer surface and sonographic areas of focal
the soft tissue air interface). Red zigzag arrow represents the lung consolidation,
beam being reflected between the pleural line and the particularly nodules
transducer surface. Dotted red arrows represent the “perceived
distance” the ultrasound machine detects A-lines each time the
beam is reflected back to the transducer surface. may help differentiate pleural from pericardial effusion or
confirm the presence of pneumothorax (see pleural effu-
Multiple individual to coalescing B-lines (more than sion and abnormal abdominal curtain signs below).
three per sonographic window) indicate the presence of The abdominal curtain sign is created by the combina-
decreased aerated lung at the lung periphery, often referred tion of two factors:
to as “wet lung” [7, 23]. However, it should be kept in mind
1) The acoustic impedance mismatch between air (air-
that increased B-lines can result from any decrease in aer-
filled lung in healthy animals) and soft tissue (abdomi-
ated lung, including atelectasis [21, 22], and therefore,
nal structures) that casts the characteristic sharp vertical
although the most common cause is increased extravascu-
artifact at the interface between the two; and
lar lung water (hence the term “wet lung”), there are other
2) The anatomical relationship of the thorax with the
causes of increased B-lines (Table 27.1).
abdomen, resulting in the costophrenic recess covering
parts of the cranial abdomen and the diaphragm, which
Abdominal Curtain Sign
abuts against air-filled lung cranially in healthy patients.
Once lung sliding is identified, the transducer is moved
caudally along the thorax to achieve identification of the The overlap of the costophrenic recess onto the abdomen
abdominal curtain sign. In healthy animals, the abdominal creates a sharp, vertically demarcated lung–air–soft-tissue
curtain sign is sonographically identified as a sharply artifact. In essence, the caudal aerated lung border acts
demarcated vertical artifact that occurs at the transition of similarly to a “curtain”; when it fills with air, it expands
aerated lung to soft tissue abdominal structures and demar- sliding caudally into the costophrenic recess and over visi-
cates the caudal border of PLUS (Figure 27.3) [2]. The cur- ble abdominal organs, momentarily obscuring them from
tain sign helps with directing the transducer to the most view, like a curtain is drawn across a window obscuring
gravity independent (caudodorsally to find pneumothorax) what is visible through the window. The underlying organs
and dependent (caudoventrally to find pleural effusion) disappear as the lung expands across them on inspiration
spots with the patient in standing/sternal recumbency and and reappear as the lung deflates on exhalation.
Ventral Pleural Border and the “Ski Jump” Sign Locating the pericardiodiaphragmatic window (Figures 27.7
The ski jump sign is used to describe the normal appear- and 27.8) helps to differentiate pleural effusion from pericar-
ance of the sonographically defined ventral pleural border dial effusion (Figure 27.15). While pericardial effusion is con-
in the absence of pleural space pathology (Figure 27.6) [14]. tained within the pericardial space and curves away from the
When the transducer is oriented parallel to the ribs at the diaphragm and around the heart, pleural effusion is not con-
sonographically defined ventral pleural border either lung tained and may be identified as triangular hypoechoic to ane-
or heart can be seen curving away from the chest wall along choic structures along the borders of the diaphragm filling the
the pectoral sternal muscles. This creates an ultrasound costophrenic recess and outlining lung lobes.
image with a similar appearance to an Olympic ski jump. In the absence of pericardial effusion, the pericardium
The ski jump sign comprises either sternal/pectoral mus- should appear as a bright white line surrounding the border
cles interfacing with lung (Figure 27.6a) or sternal/pectoral of the myocardium. Pleural effusion may be located adja-
muscles interfacing with cardiac muscle (Figure 27.6b) cent to the pericardium in addition to surrounding other
depending on whether the transducer is situated over the normal thoracic structures (lungs, diaphragm, mediasti-
lung or the cardiac notch, respectively. The ski jump sign is num, vessels) or thoracic pathology (e.g. intrathoracic mass).
used to rule out smaller volumes of pleural effusion that The “sail sign” is most readily identified by placing the
might otherwise be missed with the transducer oriented transducer parallel to the ribs. It appears as an accumula-
transverse to the ribs (see pleural effusion below) [2, 10]. tion of fluid between the lung and ventral sternal muscles,
which creates a triangular shape of anechoic fluid like that
Abnormal Findings in Patients with Pleural of a sail (Figure 27.16) [14]
Space and Pulmonary Pathology The “jellyfish sign” shows consolidated lung floating in
a volume of pleural effusion, so named because the lung
Pleural Effusion takes on the shape of a jellyfish suspended in water
Pleural effusion appears as an anechoic/hypoechoic accumu- (Figure 27.17) [24].
lation of a fluid medium between the body wall and the vis-
ceral pleura/lung surface. Note that lung sliding is lost when
pleural effusion is present because the fluid separates the vis-
ceral from the parietal pleural surfaces. However, because the Pneumothorax
ultrasound beam can transverse fluid, the lung surface (the
visceral pleura) is still visible distal to the fluid. The appear- Pneumothorax is defined by the interposition of gas
ance of the effusion varies depending on volume, location, between visceral and parietal pleural layers. Thoracic ultra-
cellularity, and presence of fibrin within the pleural space. sound has been shown to be a rapid, noninvasive, sensitive,
(a) (b)
Figure 27.15 Schematic images of pericardial and pleural effusion at the right pericardiodiaphragmatic window. (a) Pericardial
effusion is contained within the pericardial sac and curves away from the diaphragm. (b) Pleural effusion is uncontained and tends to
track along the diaphragm, filling the costophrenic recess which allows the diaphragm to be seen curving away from the chest wall.
LV, left ventricle; RV, right ventricle.
eiqrPacPoPa 359
Figure 27.16 Still ultrasound images of the ventral pleural border with the transducer oriented parallel to the ribs and the indicator
marker directed dorsally. The image on the left is referred to as the “ski jump” sign and rules out significant pleural effusion. The
image on the right is referred to as the “pleural sail sign” and describes the elevation of the lung away from the ventral chest wall and
sternal muscles which creates a fluid silhouette like a billowing spinnaker sail from a boat. PLE, pleural effusion.
more sensitive test for pneumothorax than radiography and

an excellent early diagnostic screening tool for this condition.
The sensitivity and specificity of ultrasound to diagnose
pneumothorax in companion animals is not well established.
Means of Assessing for a Pneumothorax

When sonographically assessing pneumothorax, the patient
is often maintained in a standing position or in sternal
recumbency to limit restraint and respiratory compromise.
The transducer is placed in the intercostal space either par-
allel or perpendicular to the ribs, using a high frequency
setting with the depth decreased to maximize evaluation of
the body wall and parietal–visceral pleural interface.
Figure 27.17 The finding of consolidated lung floating within There are four criteria that are used to help rule out or
pleural effusion is referred to as the “jellyfish” sign.
confirm the presence of a pneumothorax: lung sliding and
B-lines rule out the presence of a pneumothorax at the loca-
and specific diagnostic modality for ruling out or confirm- tion at which they are identified, while the lung point and
ing the presence of a pneumothorax. the double/asynchronous abdominal curtain signs rule in
PLUS is often preferable to standard survey radiography pneumothorax (see below) on that side of the thorax [2].
in the emergency clinical setting because it requires mini-
mal patient manipulation and may limit transport and
Lung Sliding/Glide Sign Rules Out
restraint of critical patients. In addition, PLUS allows rapid
Pneumothorax Where Sliding is Identified
identification of patients with pneumothorax with limited
operator skill necessary. As previously discussed, as a standard rule, identification
Timely identification of a pneumothorax with limited of lung sliding or the glide sign rules out the presence of a
restraint may provide the safest means of identifying this pneumothorax at the transducer location [26]. Look for the
issue and allows for rapid institution of life saving inter- classic “shimmering” of the pleural line as the lung slides
ventions, such as thoracocentesis. along the thoracic wall with respiration. If lung sliding is
Regarding sensitivity and specificity of lung ultrasound detected in the dorsal one-third of the thorax, then a sig-
compared with standard survey thoracic radiography, human nificant pneumothorax is unlikely on that side of the chest.
studies demonstrate a sensitivity and specificity of 87% and Absence of lung sliding in a patient with a history or
97% for lung ultrasound and 28% and 100% for thoracic radi- clinical signs consistent with a pneumothorax should alert
ography, respectively [25]. Thus, thoracic ultrasound is a the clinician to the potential presence of this condition.
One challenge is that lung sliding, even without pneumo- The lung point can be identified by sliding the trans-
thorax, can be difficult to identify, which is particularly ducer toward the hilus of the lung. Given air rises to the
true when the patient has a rapid shallow breathing highest nongravity sites, in the standing or sternal patient
pattern [25]. Therefore, the absence of lung sliding should this will often involve sliding the transducer from the cau-
prompt consideration of a pneumothorax. If the history dodorsal regions toward the elbow, from an area where no
and signalment are supportive, along with other clinical lung sliding was detected. Using the lung point the degree
findings (e.g. absence of breath sounds), thoracocentesis is of pneumothorax is estimated by dividing the chest
indicated. into thirds.
If the patient is sufficiently stable and the operator If lung sliding is detected in the dorsal one-third of the
wishes to further rule in pneumothorax, a search for the thorax, pneumothorax is likely ruled out or very mild on
lung point and/or abnormal curtain signs should be under- that side of the chest. To increase the sensitivity of detect-
taken (see below) [2]. If the clinician is uncertain, diagnosing small volume pneumothorax that might get larger
tic thoracentesis may be performed to confirm or rule out over time, the sonographically identifiable caudodorsal
this condition or a single thoracic radiograph may be per- border can be identified by first locating the abdominal
formed if the patient is adequately stable to tolerate trans- curtain sign and then following it dorsally until the
port and restraint for this diagnostic. pleural line disappears in the hypaxial muscles. Slide the
transducer ventrally again until the pleural line reappears.
This is the most caudodorsal location of the lung within
B-Lines Rule Out Pneumothorax at
the thorax.
the Location Where They are Identified
If a lung point is detected in the middle third of the tho-
Like lung sliding, B-lines rule out the presence of a pneu- rax (one-third down the thorax from the spine, again mov-
mothorax as they should move with the pleural line and ing down the thorax toward the elbow), a moderate
should be identified with lung sliding [27]. They appear as pneumothorax is likely present. Thoracocentesis may be
bright white lines originating at the pleural line, extending indicated depending on the patient’s clinical signs.
vertically downwards and should move with the lung dur- If a lung point is only detected in the lower third of the
ing respirations (see B-lines, above). Note that A-lines can height of the thorax and glide sign/lung sliding is absent in
still be present with a pneumothorax (see A-lines, above). the dorsal two-thirds, a severe pneumothorax is likely pre-
sent. These patients tend to demonstrate marked respira-
tory distress warranting immediate thoracocentesis to
Lung Point Confirms Pneumothorax
evacuate gas and stabilize the patient.
Lung point is the point over the thorax where the return of The lung point will not be seen if the lung fails to recon-
lung sliding (with or without underlying B-lines) is identi- tact the chest wall in cases of massive/complete pneumo-
fied in patients with pneumothorax (Figure 27.18) [27]. thorax. These patients are in severe respiratory distress and
Note that where the lung regains contact with the thoracic can usually be diagnosed based on history and clinical
wall, it creates lung sliding within only a portion of the findings, which justifies thoracocentesis in the absence of
ultrasound image when the patient breathes. performing PLUS.
Figure 27.18 Computed tomography images and schematic representation of the lung point. The lung point is the location over the
thorax where the return of lung sliding (with or without underlying B-lines) is identified in patients with pneumothorax. The lung
point can be identified by moving the transducer toward the lung hilus. As lung sliding is most often assessed in the caudodorsal
regions, this typically involves moving the transducer from the caudodorsal regions toward the elbow. The more severe the
pneumothorax the lower on the chest wall the lung point will be located.
Alveolar Consolidation 361
Abnormal Abdominal Curtain Signs Rule

in Pneumothorax
A 2019 case series described abnormal abdominal curtain
signs in dogs with pneumothorax, referred to as asyn-
chronous curtain signs and double curtain signs [2].
Asynchronous curtain signs occur when movement of the
vertical edge of the curtain sign moves in the opposite
direction to the abdominal contents, or minimal move-
ment of the vertical edge is seen while abdominal contents
move caudally. The double curtain sign occurs when two
vertical edges (two soft tissue–air interfaces) are visible in
the same sonographic window, disappearing and reappear-
ing at a single focal point without sliding out of the sono-
graphically visible ultrasound image. The sensitivity and
specificity of these signs in relation to pneumothorax have
not been assessed, and it is unknown what role they will
play in diagnosing pneumothorax compared with current
sonographic criteria used to make the diagnosis. Readers Figure 27.19 Schematic representation of increased B-lines. In
are referred elsewhere for more detail regarding abnormal this example, four B-lines can be seen within the intercostal
curtain signs [2]. space. An increase in the number of B-lines may be identified in
cases of alveolar interstitial disease, including pulmonary
edema, pulmonary hemorrhage, pneumonia, atelectasis,
infiltrative neoplasia, and in certain cases of chronic interstitial
lveolar Interstitial Syndrome
A disease (e.g. pulmonary fibrosis, asthma).
(Wet Lung)
the ultrasound beam back to the transducer, allowing it to
An increase in the number of B-lines may be identified in pass through the lung as it would through a soft tissue
cases of alveolar interstitial diseases such as pulmonary structure [27]. Consolidation can be translobar (traversing
edema, pulmonary hemorrhage, pneumonia, atelectasis, the entire lung lobe from one surface to the other), or par-
infiltrative neoplasia, and in certain cases of chronic inter- tial (partial thickness where the consolidated region within
stitial disease (e.g. pulmonary fibrosis, asthma). Therefore, the lobe encounters air-filled lung distal to the consoli-
when three or more B-lines are present in a single window dated region) [28]. Although many pathologies can result
(Figure 27.19), or more than two sites are positive on a sin- in consolidation, most will result in three common ultra-
gle hemithorax, they should prompt a similar set of differ- sonographic appearances:
ential diagnosis as the radiographic presence of alveolar The “shred sign” represents a form of partial lung con-
interstitial disease [27]. solidation. The appearance occurs when there is a focal
B-lines may be used as part of patient volume assessment area of consolidated lung that abuts air-filled lung deep to
as they correlate with extravascular lung water. An increas- it. The deep border (fractal/“shredded” border) of the con-
ing number of B-lines in a patient with other signs of vol- solidated lung appears shredded at the boundary of con-
ume overload lends additional confirmation of interstitial solidated and aerated lung (Figure 27.20).
overhydration [27]. “Hepatization” of the lung lobe is when the alveoli of an
Identification of B-lines rules out the presence of a pneu- entire lobe are fluid-filled and, together with the intralobu-
mothorax at that transducer location [2, 27]. lar septa, create a macroscopic image pattern referred to as
the tissue-like sign (Figure 27.21). This is a translobar form
of consolidation. The term hepatization equates this
Alveolar Consolidation pathology with the echogenic appearance of liver on ultra-
sound. The lung dimensions appear relatively conserved
Lung consolidation can occur as a result atelectasis, and the lung parenchyma appears similar to liver paren-
hemorrhage, bronchopneumonia, thromboembolism, lung chyma. Air bronchograms, if present, can be seen within
lobe torsion, neoplasia, and inflammatory conditions such lung consolidation as small white hyperechoic pointed foci
as pulmonary contusions and acute lung injury. or lines.
Consolidation occurs when lung pathology is severe The “Nodule sign” is a specific type of partial lung-lobe
enough that insufficient air is present (< 10% air) to reflect consolidation that differs from the shred sign in that the
Figure 27.20 Schematic image depicting the “shred sign.” The Figure 27.22 Schematic representation of a “nodule sign.” A
shred sign represents a form of partial lung consolidation (does nodule sign is a specific type of partial lung lobe consolidation
not traverse the entire lung lobe). The appearance occurs when that differs from the shred sign in that the distal border
there is a focal area of consolidated lung that abuts air-filled between the consolidation and aerated lung is usually smooth
lung deep to it. The deep border (fractal/shredded border) of the and circular. Ring down artifact is often visible deep to and
consolidated lung appears shredded at the boundary of arising from the distal border of a nodule.
consolidated and aerated lung. Air bronchograms (white
punctate and short lines) may be visible within consolidated
lung that creates a shred sign. Ring down artifact is often visible distal border between the consolidation and aerated lung is
deep to and arising from the distal border of a shred sign. smoother and usually circular. The differential diagnosis
for a sonographic nodule sign is similar to radiographic
nodules, with neoplasia and fungal disease being two of
the more common causes of nodule signs (Figure 27.22).
In human studies, lung ultrasound has been shown to be
more sensitive and specific than thoracic radiography at
identifying consolidation because pathology is often evi-
dent at earlier stages [26–28]. A “wedge sign” has also been
described in human medicine, which appears as a partial
consolidation that is triangular shaped. The wedge sign is
often associated with pulmonary thromboembolism and is
often seen in people that also have deep vein thrombosis.
The significance of the “wedge sign” requires further inves-
tigation in veterinary medicine.
Figure 27.21 Schematic image of translobar “hepatization.” Limitations of Pleural and

Translobar hepatization occurs when alveoli of an entire lung
lobe (or region of a lung lobe from one surface to the other)
Lung Ultrasound
contain so little gas (e.g. atelectasis, fluid, pus, blood) that,
together with the intralobular septa, they create a macroscopic Lung ultrasound can be routinely performed as a point-of-
image pattern resembling a tissue. This is a translobar form of care test by non-specialist clinicians and may provide accu-
consolidation. The term hepatization equates this pathology
rate information on lung status with diagnostic and
with the echogenic appearance of liver on ultrasound. Unlike a
shred sign the lung consolidation is continuous from one therapeutic relevance. Limitations for lung ultrasound do
surface to the other with no aerated lung below the exist, however, and may include operator skill and equip-
consolidated region. The lung dimensions appear relatively ment characteristics. The diagnosis of pneumothorax can
conserved and the lung parenchyma appears similar to liver
be challenging because lung sliding can be difficult to iden-
parenchyma. Air bronchograms, if present, can be seen within
lung consolidation as small white hyperechoic pointed foci tify even in healthy animals. Panting and rapid shallow
or lines. breathing also make it difficult to identify lung sliding,
References 363
which emphasizes the importance of identifying the lung difficult to image. Obese patients are frequently difficult to
point or abnormal curtain sign, particularly in patients examine with PLUS as excess fat thickens their thoracic
with smaller volume pneumothorax that may not show wall and impedes image acquisition. Chest-wall thickness
signs of marked respiratory distress. may require alterations in transducer selection and ultra-
If several lung ultrasound examinations are performed sound settings to acquire a good diagnostic image. The
daily, the learning curve for acquiring skills for diagnosing presence of subcutaneous emphysema, subcutaneous fluid
pleural effusion, lung consolidation and alveolar intersti- accumulation (e.g. hemorrhage, edema), or body-wall dis-
tial syndrome is short, and proficiency is reported to be ruption may alter or preclude the propagation of ultra-
achievable in less than six weeks. Patient size and body sound beams to the pleural line. Finally, it should be noted
condition score may affect the ability to obtain relevant that PLUS cannot detect lung overinflation resulting from
information with PLUS, in that very large patients are an increase in airway pressures.
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365
28
Tracheal Intubation
Marc Raffe and Rachel Bassett
The ability to establish airway support through endotracheal Neuromuscular weakness of respiratory muscles can result
(ET) intubation is a skill that all members of the veterinary in inadequate respiratory excursion producing hypoventila-
team should master. Team members should be comfortable tion, hypercapnia, respiratory acidosis, and hypoxemia.
with ET tube (ETT) types and be familiar with ancillary Neuromuscular weakness may be a result of cervical injury
materials needed to perform ET intubation. Understanding (damage to tracts of the phrenic nerve, which serves the dia-
airway anatomy and oropharyngeal conformation are criti- phragm), thoracic spinal cord damage (intercostal muscles),
cal factors in selecting the most appropriate intubation tech- or peripheral neuromuscular disease (myasthenia gravis, tick
nique when airway access is required (Figure 28.1). If initial paralysis, acute polyradiculoneuritis, botulism). Electrolyte
attempts to gain airway access are unsuccessful, all team disturbance (hypokalemia) can also produce marked muscu-
members should know advanced techniques that can be lar weakness. Care should be taken to monitor PCO2, ideally
used to quickly provide a secure airway. arterial, or at a minimum, diaphragmatic movement (dia-
phragm moving caudally and causing expansion of the abdo-
men during inhalation) and chest wall expansion in these
Indications patients due to increased risk of hypoventilation. Severe
cases may require ventilatory support (see Chapter 31).
Tracheal intubation is indicated for a variety of clinical sce- Megaesophagus may require airway protection to prevent
narios (Table 28.1). In the emergency and critical care setting, aspiration secondary to regurgitation.
intubation may be required to facilitate treatment of upper Severe hypoxemia (partial pressure of oxygen in arterial
airway obstruction, anaphylaxis, trauma, oropharyngeal blood, PaO2, < 60 mmHg) that persists despite oxygen sup-
tumors, laryngeal paralysis, brachycephalic obstructive air- plementation is an indication for intubation and mechani-
way syndrome, and tracheal collapse. Intubation is indicated cal ventilation. In these cases, sterile equipment and
in any patient with decreased or absent gag reflex (including intubation technique are important because bacterial con-
sedated animals) to maintain a functional and protected air- tamination can increase the risk of ventilator-associated
way. In these cases, the primary purpose of intubation is to pneumonia and sepsis. Sterile ETT placement requires the
protect the airway from regurgitated gastric contents and oral use of sterile gloves, a disinfected laryngoscope, and a ster-
secretions. In certain cases, ETT placement cannot be per- ile ETT. Placement of a sterile ETT is also important for
formed due to the location of the obstruction; in these cases, diagnostic airway washes.
alternative intubation techniques or tracheostomy tube
placement (discussed in detail in Chapter 29) are indicated.
Severe head trauma or other intracranial disease (e.g. Equipment Needed for Intubation
brain tumor, meningitis) may cause increased intracranial
pressure and altered level of consciousness (semi-coma, Intubation requires equipment beyond the ETT itself;
coma). Neurologic dysfunction carries a risk of hypoventila- necessary equipment and supplies vary slightly by species
tion and carbon dioxide (CO2) retention, which can further (see Protocols 28.1 and 28.2). It is recommended that a
increase intracranial pressure. Intubation and positive pres- dedicated area with readily accessible space for all
sure ventilation may be required to remove excess CO2. equipment and supplies needed for intubation be
366 Tracheal Intubation
(a) (b)
Figure 28.1 Anatomy of the oropharynx of the (a) dog and (b) cat. A laryngoscope is placing pressure on the base of the tongue to
expose the larynx and surrounding anatomy. The arrows are pointing to the arytenoids (vocal folds). The asterisk indicates the soft
palate. The O indicates the epiglottis.
Table 28.1 Indications for tracheal intubation. identified. This may be the same space that is dedicated to
cardiopulmonary resuscitation (CPR). This designated
Indication Possible cause space should be inventoried and restocked regularly to
assure that all supplies are present and in proper working
Cardiopulmonary Upper airway obstruction order. Having dedicated space set aside will increase effi-
resuscitation Foreign body ciency and minimize stress in an emergency scenario.
Soft tissue swelling
Anatomical defect
Trauma Endotracheal Tubes
Laryngeal paralysis
Cuffed Endotracheal Tubes
Masses
ETTs are manufactured using silicone (Figure 28.3a), rub-
Tracheal collapse ber (Figure 28.3b), or polyvinyl chloride (PVC; Figure 28.3c).
Decreased level of Sedation Both silicone and PVC have greater flexibility compared
consciousness General anesthesia with red rubber tubes; silicone tubes are the most flexible.
Head trauma PVC and silicone tubes are clear to semiopaque, which per-
Intracranial disease mits visualization of airflow or airway secretions within
Decreased ability to Neuromuscular disease: the tube. These materials are less irritating to airway epi-
ventilate thelium than red rubber tubes. PVC tubes have a preformed
Tick paralysis
curve; silicone tubes are straight (the authors curved the
Polyradiculoneuritis (including
coonhound paralysis) ETT pictured in Figure 28.3 with a piece of purple suture to
fit it in the image; without the suture, it is straight).
Botulism
Rubber ETTs are less desirable for routine use. Rubber is
Myasthenia gravis
prone to drying out and cracking with repeated use, which
Neuromuscular blocking agent use results in air leaks. Rubber is opaque, which makes it dif-
Epidural complication ficult to assess air movement within the tube and cleanli-
Phrenic nerve damage ness of the tube’s interior surface. Rubber is porous and
Cranial cervical spinal cord lesion more likely to absorb cleaning agents that can cause tra-
Head trauma cheal irritation. A Murphy tip is the most common style of
Hypokalemia cuffed ETT (Figures 28.2 and 28.3). This tube style has a
beveled tip with an eye hole (“Murphy eye”) in the wall
Mechanical ventilation
opposite the bevel to ensure airflow if the end hole becomes
Endotracheal wash
occluded.
Equipment mmeme for entqubntufe 367
Protocol 28.1 Endotracheal Intubation in a Dog

Items Required 6) Intubator: Place the laryngoscope blade into the oral
cavity. Depress the tongue just rostral to, but not
● 3 × endotracheal tubes, cuffs previously checked if
touching, the base of the epiglottis. The epiglottis
applicable:
should flip ventrally to reveal the arytenoids.
⚪ 1 × estimated size
7) Select the appropriately sized ETT and apply sterile
⚪ 1 each of size smaller and larger
aqueous lubricant to the distal end, avoiding the
● Laryngoscope handle and straight Miller blade
Murphy eye.
● Sterile aqueous lubricant
8) Advance the ETT over the epiglottis without contact
● Gauze squares for grasping the tongue
and through the arytenoids. Orient the ETT with the
● Length of roll bandage gauze for securing ETT
bevel oriented to the right of the person inserting
● Appropriately sized cuff inflation syringe:
the tube (in tubes with Murphy eyes, the Murphy eye
⚪ 3–5 ml (small dog)
would be on the left).
⚪ 5–10 ml (large dog)
9) The adapter (Figure 28.2) should remain just ros-
● Atraumatic clamp if using rubber ETT
tral to the incisors on midline. Secure the tube
● Cotton-tipped applicators
with a length of roll bandage gauze or similar
● Oxygen, mask
material. Tie the gauze around the ETT near the
● Assistant
junction of the adapter. In large dogs, the gauze
should be secured around the muzzle caudal to the
Procedure
canines. In small dogs, the gauze can be secured
1) Collect necessary supplies. around the head behind the ears.
2) For conscious animals, heavy sedation to light anes- 10) With an appropriately sized syringe, inject air into
thesia will be required. the pilot balloon to inflate the cuff to a maximum
3) Position the dog in sternal recumbency (lateral pressure of 20–25 cm H2O. If the ability to measure
recumbency can be used if needed in large dogs, and pressure is unavailable, use the smallest amount
during CPR). needed to maintain a slight leak when breaths are
4) Provide preoxygenation if possible. manually delivered. If using a red rubber ETT,
5) Assistant: Open the mouth by using thumb and one occlude the pilot balloon tubing with an atrau-
finger of the dominant hand to grasp caudal to the matic clamp.
maxillary canine teeth and the nondominant hand to 11) While the ETT is being secured and the cuff inflated,
grasp the distal portion of the tongue using a dry a manual resuscitator can be connected to the
gauze square. Pull the tongue out over the lower inci- adapter to provide breaths. If general anesthesia is
sors and ventrally, opening the oral cavity widely. Pull being performed, the breathing circuit is connected
the head rostrally and dorsally, to facilitate intuba- to the ETT adapter.
tor’s visualization of the pharynx and larynx.
The ETT cuff serves two purposes: (i) it prevents gas leaks available with both cuff styles. If possible, select a low-
around the ETT; and (ii) it reduces gastric and oral secretion pressure, high-volume cuff type to reduce injury. Rubber
aspiration risk (Figure 28.2). There are two ETT cuff styles: tubes are only available in high-pressure, low-volume cuff
a high-pressure, low-volume cuff which is a thicker mate- design. PVC and silicone ETTs have a self-sealing valve built
rial that conforms to the ETT when deflated (Figure 28.3a,b), into the cuff pilot tube to retain cuff volume following infla-
and a low-pressure, high-volume cuff made of thinner tion. Rubber ETTs do not have a valve on the pilot tube and
material that is not tightly adherent to the ETT when thus require use of an external clamp (Figure 28.4).
deflated (Figure 28.3c). Low-pressure, high-volume cuffs
are preferred because they generate less surface contact Uncuffed Endotracheal Tubes
pressure for a given inflation volume compared with high- When smaller animals (small cats, pediatric patients,
pressure, low-volume cuffs. Low-contact pressure between avian and exotic species) require intubation, an uncuffed
the cuff and tracheal mucosa reduces tracheal mucosal ETT may be the only option. It is difficult to find cuffed
injury. High-contact pressure between the cuff and tracheal ETTs with an internal diameter less than 2.5 mm. Uncuffed
mucosa can produce mucosal injury, mucosal necrosis, car- ETTs are commercially available in several styles. Murphy
tilaginous ring injury, and rupture of the dorsal tracheal style tubes similar in appearance to cuffed tubes are avail-
membrane. PVC and silicone ETTs are commercially able from 1.0 to 3.0 mm internal diameter. Cole tubes are
Protocol 28.2 Endotracheal Intubation in a Cat

Items Required 6) Intubator: Place the laryngoscope blade into the
oral cavity. Depress the tongue ventrally just rostral
● 3 × endotracheal tubes, cuffs previously checked if
to, but not touching, the base of the epiglottis. The
applicable:
epiglottis should flip ventrally to reveal the
● 1 × estimated size
arytenoids.
● 1 each of size smaller and larger
7) Apply 2% lidocaine injectable solution to the aryte-
● Laryngoscope and curved Macintosh blade, if available
noids (vocal cords): either one drop applied to each
● Sterile aqueous lubricant
vocal cord with a needleless tuberculin syringe or
● Gauze squares for grasping the tongue
sprayed using an atomizer. Do not contact the aryte-
● Length of roll bandage gauze for securing ETT
noids. Usually, 30–60 seconds are required for the
● Appropriately sized cuff inflation syringe (3 ml usually
lidocaine to take effect, during which time flow-by or
sufficient)
mask oxygen should be supplied to the cat.
● Atraumatic clamp if using red rubber ETT
8) Select the appropriately sized ETT and apply sterile
● 2% lidocaine injectable solution to prevent laryngo-
aqueous lubricant to the distal end, avoiding the
spasm, in either needleless 1-ml syringe or in an
Murphy eye. If a stylet is used, it must not protrude
atomizer
past the end of the ETT.
● Stylet
9) Advance the ETT over the epiglottis and through the
● Cotton-tipped applicators
arytenoids. Orient the ETT with the bevel facing the
● Oxygen, mask
right of the person inserting the tube (in tubes with
● Assistant
Murphy eyes, the Murphy eye would be on the left).
10) The adapter should remain just rostral to the incisors
Procedure
on midline. Secure the tube with a length of roll
1) Collect necessary supplies. bandage gauze or similar material. First tie the gauze
2) For conscious animals, heavy sedation to light anes- around the ETT near the junction of the adapter, and
thesia will be required. then tie the gauze around the head caudal to the ears.
3) Position the cat in sternal recumbency. Lateral recum- 11) With a 3-ml syringe, inject air to inflate the cuff to a
bency is preferred in CPR. maximum pressure of 20–25 cm H2O. If the ability to
4) Provide preoxygenation if possible: more important measure pressure is unavailable, use the smallest
than in most dogs due to potential for laryngospasm. amount needed to maintain a slight leak when
5) Assistant: Open the mouth by using thumb and one breaths are manually delivered. If using a red rubber
finger of the dominant hand to grasp caudal to the ETT, occlude the pilot balloon tubing with an atrau-
maxillary canine teeth and the nondominant hand to matic clamp.
grasp the distal portion of the tongue using a dry 12) While the ETT is being secured and the cuff inflated,
gauze square. Pull the tongue out over the lower inci- a manual resuscitator can be connected to the
sors and ventrally, opening the oral cavity widely. Pull adapter to provide breaths. If general anesthesia is
the head rostrally and dorsally, to facilitate visualiza- being performed, the breathing system would then
tion of the pharynx and larynx. be connected to the patient.
commonly used in veterinary medicine in this size range. anesthesia, limiting air/gas leaks, and minimizing the risk
The Cole tube is designed with a narrow tube diameter at for aspiration.
the patient end and a widening of the tube diameter
approximately 10–15 mm proximal to the tip; the area
Oropharyngeal Airway (Laryngeal Mask)
where the tube widens is called the shoulder. Cole tubes
are designed so the narrow portion of the tube is inserted An alternative device for feline and lagomorph airway sup-
into the larynx and trachea while the shoulder portion of port is an oropharyngeal airway (OA). An OA incorporates
the tube is seated at the level of the arytenoids to form a a tight-fitting laryngeal mask embedded in a silicone cast
seal (Figure 28.5a). When using uncuffed tubes, it is of the feline and lagomorph oral cavity. By placing the
important to use the largest size that can be fit into the device in the oral cavity, the airway mask is seated on the
trachea without causing injury; this helps to create the laryngeal opening. In felines, it is then sealed by cuff infla-
best seal for providing positive pressure breaths during tion to provide airway support. The OA is an adaptation of
Equipment mmeme for entqubntufe 369
Figure 28.2 Anatomy of an endotracheal tube. (A) Murphy eye; Figure 28.4 Because the pilot balloon (asterisk) on a rubber
(B) cuff; (C) adapter; (D) pilot balloon; (E) cuff inflation syringe. tube does not have an incorporated one-way valve, an
atraumatic clamp should be applied to the cuff tubing to
prevent accidental deflation of the cuff.
(a)
Figure 28.3 Three different types of large-cuffed endotracheal
tubes. (A) silicone; (B) rubber; (C) polyvinyl chloride (PVC). Note
the differences in the cuff between (A) and (B) (low volume, high
pressure) and (C) (high volume, low pressure). Note that the
silicone tube has been curved for the purpose of this image with
a length of suture; silicone endotracheal tubes are straight.
the laryngeal mask airway (LMA) that has been popular for
airway management in human anesthesia. The advantage
of the LMA or OA is airway support without tracheal
mucosal damage, thus avoiding post-intubation tracheitis
and cough. The disadvantage of an OA is that the airway
support may not be as secure as ET intubation.
(b)
Laryngoscope with Illumination
Laryngoscope use during intubation dramatically improves Figure 28.5 (a) Options for intubation of smaller animals such
airway visualization and facilitates timely and accurate as cats and pediatric patients: an uncuffed Cole endotracheal
intubation. Laryngoscopes are particularly valuable in tube (ETT; top) and a smaller cuffed ETT and metal stylet.
(b) The metal stylet inserted into the smaller cuffed ETT, with
facilitating intubation when abnormal or distorted upper
care that the tip of the stylet does not protrude from the
airway and oropharyngeal anatomy is present. They are distal end of the tube. The stylet provides support to the more
also essential in species that have long oropharynx and flexible tube to facilitate intubation.
Figure 28.6 Illuminated laryngoscope. The top blade, a Figure 28.7 An atomizer used to distill lidocaine onto the
pediatric Macintosh blade, is most useful in cats. The straight arytenoids to facilitate intubation.
Miller blades (middle and bottom) are most useful for dogs.
purpose is to facilitate intubation when small or extremely
limitations in oral cavity opening (rabbits, rodents, guinea flexible ETTs are used. Preplacement of a stylet into the
pigs). Today, several laryngoscope styles are available. The lumen of the tube aids in tube placement by helping to
“traditional” style uses a power source in the laryngoscope direct the tube tip to the laryngeal opening. Care should be
handle and a detachable blade/light unit. Numerous blade taken to ensure that the tip of the stylet does not protrude
styles are commercially available. Laryngoscope blade beyond the tip of the ETT to minimize injury to the larynx
styles commonly used in veterinary medicine include the and trachea (Figure 28.5b).
Miller and Macintosh blades. Each type comes in a variety
of lengths to match oropharyngeal and laryngeal depth. In
general, short, curved blades (Macintosh) work best in Lidocaine Injectable Solution (2%)
cats, whereas straight blades (Miller) work best for dogs Lidocaine can be topically applied to the arytenoid folds
(Figure 28.6). The light source may be a local bulb or via prior to intubation. Local desensitization helps minimize
fiberoptic transmission from a remote bulb location. Either laryngospasm and facilitate intubation. In addition, a
style works well in most cases. Laryngoscope blades should lighter plane of anesthesia can be maintained while intu-
be correctly attached to the laryngoscope handle and tested bation occurs because airway reflexes are blunted.
to ensure that the light source is operational. Light sources Lidocaine can be delivered via a needleless syringe or an
should be routinely checked and repaired to ensure the atomizer (Figure 28.7). If syringe delivery is used, a stand-
light bulb is in working order. Laryngoscopes should be ard intravenous (IV) catheter can be attached to the syringe
disinfected prior to use. to direct topical lidocaine delivery. Cats are more sensitive
In recent years, fiberoptic laryngoscopes have been com- to the toxic effects of lidocaine; a dose of 0.5 ml or less of 2%
mercialized. Fiberoptic laryngoscopes are either flexible or lidocaine should provide laryngeal desensitization without
rigid in design; in both styles, the fiberoptic shaft is attached intoxication.
to a light source, viewing controls, and an optical port or
camera interface. The laryngoscope performs two func-
tions: airway visualization and guide for ETT placement. Securing the Endotracheal Tube
To accomplish these goals, the ETT is placed over the shaft
Once the ETT is introduced into the airway, securing the
and positioned for placement. The scope is used to visual-
tube in place is essential to stabilize location, limit airway
ize, and in some cases enter, the laryngeal orifice. Once
trauma, and prevent accidental extubation. Several meth-
positioned, the tube is advanced into the airway and
ods for securing the ETT have been used in dogs and cats.
secured. Fiberoptic laryngoscopes are sterilized after each
A common method is to use standard 1-inch bandage
use to reduce risk of cross-contamination and infection.
gauze that is loop tied around the ETT caudal to the adapter
but rostral to the pilot balloon tubing, positioned just
Stylets
behind the canine teeth and secured to the upper or lower
Stylets are used to facilitate ETT placement. Stylets are jaw or behind the ears. Alternatively, a section of IV fluid
made of malleable material; they are generally either tubing can be used in place of gauze. One advantage of IV
coated wire or a small diameter aluminum rod. Their fluid tubing is that it can be washed and reused between
Choosing Appropriate Endotracheal Tube Size 371
patients, limiting waste. However, it provides a less secure accurate in certain animals such as brachycephalic breeds
grip on the ETT. A second advantage is the ability to with- and those animals with abnormal body condition score
stand moisture and ease of removal when wet, especially (those that are excessively thin or overweight) [2].
during dental prophylaxis or oral and maxillofacial sur- Measuring the width of the nasal septum is another
gery. Care should be taken so that excessive tightening of method for selecting ETT size. An ETT is held up to the
the tie does not compromise the lumen of the tube with the narrowest point between the nares (Figure 28.8a). An ETT
above methods. A third option is use of wide rubber bands. with an outer diameter that best matches the width of the
A rubber band is loop secured to the ETT and positioned as nasal septum should be selected. Unfortunately, one study
described above. Care should be taken so that excessive found that this technique was accurate only 21% of the
tightening does not create a tourniquet effect. time [2].
Palpation of tracheal width just above the thoracic inlet
can estimate ETT size (Figure 28.8b). This technique was
Choosing Appropriate Endotracheal found to be more accurate than measuring nasal septum
Tube Size width, but it still had a wide margin of error [2]. Palpation
of the trachea can be difficult in brachycephalic breeds and
Selecting an appropriate ETT size is important to facilitate in obese pets.
rapid intubation, minimize tracheal trauma, and ensure
airway protection. Too large a tube may cause airway
trauma; too small a tube will result in leaks around the cuff Choosing the Endotracheal Tube Length
and incomplete airway protection. Cuff overinflation to
ETT length measurement is much easier to perform.
compensate for an undersized ETT may cause tracheal
Following intubation, the ETT adapter should be posi-
necrosis and rupture [1]. In addition, increased resistance
tioned just cranial to the incisor teeth while the tube tip
to gas flow through the tube may be seen when the ETT is
should end at the thoracic inlet. This length can be easily
too small.
measured by holding an ETT up next the patient’s neck and
Various methods for choosing an appropriately sized
confirming tube length is the distance from the tip of the
ETT have been described. Unfortunately, no single method
nose to the thoracic inlet. This length is important because
is routinely reliable due to variation in airway anatomy.
placement of too long an ETT contributes to mechanical
Time and experience will allow one to confidently select
dead space and increases work of breathing. Too long a
the correct ET size based on patient size and head anatomy.
tube also carries the risk of extending beyond the tracheal
In general, it is prudent to have available an ETT that is one
bifurcation into a bronchus, resulting in ventilating only
size larger and one size smaller than the tube you initially
one portion of the lung (single bronchus or “one-lung”
choose in case visual inspection reveals an airway size that
intubation).
is different than expected.
If the tube is too long, it can easily be cut to the appro-
priate length. Remove the adapter at the rostral end, cut
to size, and reattach the adapter to the tube. Be careful not
Choosing the Endotracheal Tube Width
to accidentally cut into the cuff inflation tube or the
One method of selecting an ETT is by correlating body molded channel in the ETT wall below the cuff
weight to tracheal size [2–4]. Size charts may not be inflation tube.
(a) (b)
Figure 28.8 Techniques for estimating endotracheal tube (ETT) size. (a) The width of the nasal septum is measured and used as a
guide for selection of ETT size. (b) The extra thoracic trachea is palpated and used as a guide for selection of ETT size.
Intubation Techniques The appropriately sized ETT is selected and sterile aque-
ous lubricant applied to the distal end. Care is taken not to
Intubating Dogs occlude the Murphy eye (if applicable) with sterile lubri-
cant. The ETT is advanced over the epiglottis and between
Sternal recumbency is the preferred intubation posture; the vocal cords (Figure 28.9d). The ETT should be oriented
lateral recumbency can be used in large dogs and should be with the bevel facing the right of the person inserting the
used during CPR (Chapter 20). Lateral recumbency intuba- tube (in tubes with Murphy eyes, the Murphy eye is ori-
tion should be avoided in patients with increased risk of ented to the left). In this orientation, the curve of the ETT
regurgitation. If the dog is spontaneously breathing, pre- follows the curve of the trachea. The ETT may be rotated so
oxygenation is ideal. An assistant opens the mouth by plac- that its curvature is parallel with the tracheal lumen as it is
ing the thumb and index finger (thumb and middle finger advanced into the airway. The tube adapter should be
in large dogs) of one hand on the maxilla just caudal to the seated on the midline just rostral to the incisors. The tube
canine teeth (Figure 28.9a). The other hand grasps the tip is secured with roll bandage gauze or similar material as
of the tongue using a dry gauze square. The tongue is described above.
extended over the lower incisors and moved ventrally, While the ETT is being secured, a manual resuscitator or
opening the oral cavity for easier visualization. The head anesthesia breathing circuit can be attached to provide
should be pulled rostrally and dorsally, which straightens breathing support. See Protocol 28.1 for concise step-by-
the neck and facilitates full view of the pharynx and larynx step instructions for intubating dogs.
for the person performing intubation (Figure 28.9b).
Caution must be exercised if cervical or cranial injury, dis-
ease, or malformation is suspected. In these cases, the Intubating Cats
head–neck angle should not be hyperextended beyond The preferred posture for feline intubation is sternal
what is natural. recumbency. Cats may be positioned in lateral or dorsal
The person performing intubation should insert the recumbency if required. Lateral recumbency is preferred
laryngoscope blade into the caudal part of the oral cavity. during CPR (Chapter 20). Dorsal recumbency is used in
The tongue should be depressed in a ventral direction just cats to facilitate visualization of airway in brachycephalic
rostral to, but not touching, the base of the epiglottis. The breeds. If the cat is breathing spontaneously, preoxygena-
epiglottis, which normally sits covering the laryngeal open- tion is ideal. An assistant opens the mouth by placing one
ing, should fall ventrally to reveal the arytenoids (vocal hand just caudal to the maxillary canine teeth with the
cords; Figure 28.9c). At times, the epiglottis is caught thumb and index finger. The other hand should grasp the
behind the soft palate; the laryngoscope can be used to gen- tip of the tongue using a dry gauze square. The tongue
tly release entrapment. Care should be taken not to apply should be pulled rostrally over the lower incisors and ven-
pressure to the epiglottis because edema can result. trally, thus opening the oral cavity for easier visualization.
(a) (b) (c) (d)
Figure 28.9 Images of the intubation sequence of a dog. (a) The dog is placed in sternal recumbency and the upper jaw should be
grasped caudal to the canine teeth while the tongue is pulled rostrally between the canine teeth and the lower jaw is opened.
(b) View of the caudal oropharynx when the mouth is properly opened for intubation. Note that the epiglottis is elevated, obscuring
view of the glottis and arytenoids. (c) The laryngoscope is inserted into the mouth and the tip is used to place ventral pressure on the
base of the tongue. Care should be taken to avoid touching the epiglottis with the laryngoscope blade to minimize airway trauma.
When properly positioned, a good view of the glottis and arytenoids is achieved. (d) Following intubation, direct visualization of the
endotracheal tube between the arytenoids is the most accurate way to ensure proper intubation.
entqubntufe f r u uiqunt uorbay 373
The head should be pulled rostrally and dorsally, which Cuff Inflation
straightens the neck and facilitates full view of the pharynx
and larynx. Caution must be exercised if cervical or cranial The ETT cuff is intended to fill the space between the ETT
injury, disease, or malformation is suspected. In these and the trachea. It is used to “seal” the airway to protect
cases, the head–neck angle should not be hyperextended against introduction of blood, gastric secretions, and saliva
beyond what is natural. into the airway. It is also required to provide positive pres-
Short, curved laryngoscope blades (Macintosh style) sure ventilation to the patient. Cuff inflation volume is
tend to work better in cats. The operator introduces the critical to ensure good ETT sealing while minimizing tra-
laryngoscope blade into the oral cavity. The tongue cheal mucosa damage due to excessive cuff pressure on the
should be depressed rostral to, but not touching, the base tracheal mucosa. To minimize mucosal injury, the cuff
of the epiglottis. The epiglottis should drop down to should be inflated to the lowest pressure that achieves air-
reveal the arytenoids (vocal cords). Care should be taken way sealing. Cuff inflation pressure should not exceed
when intubating a cat because they are prone to ETT- 25 cmH2O. Cuff pressure can be measured with commer-
induced laryngeal edema and inflammation secondary to cial devices that measure and/or limit cuff inflation pres-
intubation trauma. sure. These devices attach to the cuff pilot tube for
The feline larynx is prone to laryngospasm from mechan- measurement. If a device is not available, either the mini-
ical stimulation. To avoid laryngospasm, 2% lidocaine mal occlusive volume technique or the minimal leak tech-
injectable solution is used to desensitize the vocal cords to nique should be used to inflate the cuff.
facilitate intubation. A needleless tuberculin syringe is The minimal occlusive volume technique is performed
used to deliver the lidocaine. One drop of lidocaine applied by injecting air into the cuff pilot tube while tracheal aus-
to each vocal cord is adequate to produce desensitization. cultation during breath delivery is performed. Air is slowly
The vocal cords should not be touched by the syringe or injected until no air leak can be heard. Small aliquots of air
laryngospasm may result. Alternatively, an atomizer may are then removed until a leak can be auscultated. Small air
be used to spray each vocal cord. Commercially available volumes (0.1 ml) are instilled until the leak can no longer
10% lidocaine dental spray is also safe and effective in vocal be heard. This technique minimizes risk of aspiration but
cord desensitization. Following application, 30 seconds to may result in a higher incidence of tracheal injury com-
one minute is needed for the lidocaine to take effect. pared with the minimal leak technique.
During this time, preoxygenation is suggested to avoid The minimal leak technique is performed by injecting
hypoxemia secondary to hypoventilation. air into the cuff pilot tube during a support breath while
The appropriately sized ETT is selected and sterile aque- auscultating the trachea. Air is injected until no leak is
ous lubricant applied to the distal end. Care should be noted when the breathing circuit or resuscitation bag is
taken not to occlude the Murphy eye (if applicable) with inflated to 20 cm water pressure. At that point, air is
the aqueous lubricant. Because ETT sizes used in cats are removed from the cuff in 0.1 ml aliquots until a small leak
small, the tube itself is more flexible. A stylet may be used can be detected. This technique results in less injury to the
allow better directional control and easier passage between tracheal wall but may increase the risk for aspiration. It
the vocal cords. Care must be taken to ensure that the stylet can only be performed with ETTs that have a pilot
tip does not protrude past the end of the ETT because lar- balloon valve.
yngotracheal injury can result. The ETT is advanced over While the ETT is being secured and the cuff inflated, a
the epiglottis and between the vocal cords. The ETT should manual resuscitator can be connected to the adapter to pro-
be oriented with the bevel oriented to the right of the per- vide breaths. For general anesthesia the breathing system
son inserting the tube (in tubes with Murphy eyes, the eye would be connected to the patient. Cuff inflation pressure
would be on the left). In this orientation, the curve of the should be re-evaluated after desired anesthetic depth is
ETT follows the curve of the trachea. achieved and when changing patient recumbency.
The tube adapter should be seated just cranial to the inci-
sors on midline with the nasal septum. The tube should be
tied in with a length of roll bandage gauze or similar mate-
rial. The gauze is first tied around the ETT caudal to the Intubation of Difficult Airways
adapter and can be secured around the head caudal to
the ears. Intubation challenges should be expected and planned for
While the ETT is being secured, a manual resuscitator or in animals with oropharyngeal trauma, upper airway
anesthesia breathing circuit can be attached to provide obstruction, and brachycephalic obstructive airway syn-
breathing support. See Protocol 28.2 for concise, step-by- drome. In many situations, difficult intubation can be rem-
step instructions for intubating cats. edied by providing a deeper level of sedation with injectable
anesthetic agents, optimizing patient positioning, using a Once the ETT is engaged into the larynx, the guidewire is
laryngoscope, and illuminating the oral cavity. If excessive removed and tube advanced to its final location.
oropharyngeal secretions are present, they should be If ET intubation cannot be accomplished, transtracheal
removed with gauze, cotton-tipped applicators, or suction oxygen delivery can be used as an emergency support
to improve airway visualization. If intubation cannot be procedure. A 16-gauge × 2-inch catheter (Venocath-16,
accomplished, a smaller size ETT than expected may be Venisystems, Abbott Ireland, Sligo, Ireland) is percutane-
used to establish airway control. Once the patient is stabi- ously inserted into the trachea through the cricothyroid liga-
lized, the tube can be replaced with a larger tube if a leak is ment or between two tracheal rings and directed distally. It
present. is important to secure this catheter with sutures to the out-
If the ETT is flexible, a stylet can be inserted into the tube side of the neck to prevent catheter migration producing
to stabilize it. As noted above, a stylet is frequently used subcutaneous emphysema. The catheter can be connected
with small size ETTs to facilitate placement. It is also help- to the anesthesia machine via an adapter (i.e. connect a 1-ml
ful in cases of partial airway obstruction to direct the tube syringe to the catheter, and then cut off the end and attach
around the obstruction point. Care should be taken to that to noncompliant oxygen tubing). Constant flow oxygen
ensure that the stylet does not extend beyond the tip of the is delivered by using the oxygen flowmeter to determine the
tube to prevent airway injury. best flow rate to support oxygen without causing airway
A quality light source is helpful to facilitate intubation. pressurization. The flush valve on the anesthesia machine is
Use a rigid or flexible fiberoptic device for directing addi- used to provide breaths to the animal [5].
tional light into the caudal pharynx. These devices are also In most instances, airway access can be obtained via the
used as an ETT stylet to assist in directing the ETT into the one of the techniques described here. If unsuccessful, tra-
laryngeal opening. A headlamp positioned to increase light cheostomy can be performed in a controlled manner (see
in the caudal pharynx may also be helpful. Chapter 29).
A guidewire, such as a 5 or 8 Fr polyurethane or red rub-
ber catheter, can be used to facilitate difficult intubations.
The catheter can be inserted into the airway and then the Techniques to Confirm Endotracheal
ETT directed over the catheter into the airway. The cathe- Tube Location
ter is then removed once an airway has been established.
Care should be taken not to drop any wire or catheter into ETT placement into the trachea should always be verified
the airway. An oxygen source may be attached to catheter for correct location. Accidental esophageal placement is a
to provide insufflation during intubation. possible risk, due to close proximity of the esophagus and
Retrograde intubation is a minimally invasive technique trachea in the caudal pharynx. Verification of ETT location
that can be used to facilitate ET intubation when standard is performed by visually confirming its passage between
techniques are unsuccessful. There are two options to per- vocal cords. Other methods to confirm placement have
form retrograde intubation: a flexible guidewire or long been described; the following techniques should be used in
through-the-needle catheter. Either method requires the addition to direct visualization:
guide to be introduced into the airway through the cricothy-
roid ligament. If the long catheter option is used, the cath- ● The animal coughs when the ETT is advanced into the
eter bevel is directed cranially when inserted into the trachea. This usually occurs if the animal is not heavily
airway. Once introduction is made, the needle hub is low- sedated.
ered toward the thorax so that the needle tip and catheter ● Condensation is seen through the tube on exhalation.
point toward the head; the catheter is then advanced in an ● Only one tubular structure is palpable in the ventral cer-
orad direction up through the larynx. Once visualized in the vical region. The presence of two tubular structures indi-
oral cavity using a laryngoscope, it is grasped with forceps cates placement of the ETT in the esophagus.
and advanced to exit the oral cavity. The catheter is then ● Bilateral auscultation of the lungs for respiratory sounds
used as a guide over which to pass the ETT into the airway. when an assisted breath is delivered.
The catheter is removed when the ETT enters the larynx. ● Chest wall expansion during an assisted breath. The
If a vascular guidewire is used, the same principles apply. abdomen should not be distended.
The difference is that a short, large bore catheter is inserted ● Capnometry confirmation. If the tube is correctly placed
into the cricothyroid membrane and cranially directed. in the trachea, CO2 should be measured and a capno-
Following catheter insertion, a vascular guidewire is intro- graph waveform should be associated with individual
duced into the catheter lumen and advanced cranially until breaths. If the ETT is in the esophagus, no CO2 value is
it exits into the oral cavity. It is then grasped with forceps reported or waveform detected (see Chapter 30). Note
under laryngoscope visualization to exit the mouth. An that this technique is not useful in cardiac arrest due to
ETT is placed over the wire and advanced into the airway. the absence of circulation and CO2 presence in the lungs.
icefrumedpment 375
Extubation obstruction and the need for aggressive airway support

(tracheostomy) to maintain airway patency.
Extubation should proceed only after airway reflexes have When patient repositioning is required, the ETT should
returned. Prior to extubation, the oral cavity should be be disconnected from the breathing circuit or oxygen sup-
examined for saliva, blood, or regurgitant. All secretions port device to prevent excessive traction or torsion on the
should be suctioned or swabbed from the oral cavity prior ETT. Mucosal injury from ETT traction or torsion can
to ETT removal to minimize the chance of aspiration into result in mucosal injury or necrosis.
the upper airway. ETT cuff overinflation is a major cause of tracheal injury.
The cuff should be fully deflated before extubation except Cuff overinflation is more common in cats due to the small
in cases with concern for airway protection, such as in ani- inflation volume required for cuff sealing. Inflated cuff con-
mals with megaesophagus or brachycephalic breeds. In tact with the tracheal wall produces increased pressure and
these cases, a small amount of residual air volume in the decreased mucosal blood flow at the point of contact.
cuff may be beneficial to reduce risk of aspiration. If airway Prolonged high-pressure contact can result in tracheal
protection is a concern, delayed extubation until the ani- necrosis, tearing, and stenosis. When long-term cuff infla-
mal is actively coughing and attempts self-extubation is tion (longer than two hours) is required (mechanical venti-
preferred. It is important to keep the ETT on midline with lation, longer general anesthesia), it is recommended that
the nasal septum so that shearing of tracheal mucosa does the cuff be deflated, repositioned, and reinflated every two
not occur. hours. This will allow blood flow to be periodically restored
Once extubated, the animal should be closely monitored to cuff contact areas on tracheal mucosa. Cuff overinflation
for hypoxemia or respiratory distress. These scenarios may can also produce tracheal wall or dorsal tracheal membrane
warrant re-intubation. Sternal posture with head elevation tears. This is more commonly seen in cats than dogs [6, 7].
is preferred to minimize risk of saliva or gastric content Tracheal tears result in subcutaneous emphysema and
aspiration. Flow-by oxygen should be administered to pneumomediastinum. In severe cases, secondary pneumo-
assist in transition from high oxygen support to room air thorax, pneumoretroperitoneum, and pneumoperitoneum
oxygen concentration. Respiration and oxygenation should have been reported. Most tracheal tear cases do not require
be monitored until the animal is fully awake. surgery but can take several weeks before the air leak site
heals and subcutaneous emphysema reabsorbs [6, 7].
Excessive pressure created by too tight a tie securing the
ETT to the muzzle or face can produce tissue edema and
isks and Complications
R injury due to vascular occlusion and lymphatic stasis (tour-
of Tracheal Intubation niquet effect). Irrespective of material, all tube securing
methods should be tied to allow a finger to be inserted
ETT placement has many benefits; however, complications between the tie and skin.
can occur if proper technique is not used. Cats have a
greater risk for intubation-associated complications com-
pared with dogs [6–8]. Cats are prone to laryngospasm, Summary
which can make tracheal intubation a challenge. Excessive
pressure on the ETT to overcome laryngospasm carries an ET intubation is an essential skill for all veterinary team
associated risk of tissue injury. Dogs are susceptible to members to master. It is a lifesaving measure in patients
vagal stimulation during intubation, which can cause brad- with cardiopulmonary arrest or severe respiratory distress.
ycardia and bradyarrhythmias. Dogs with elongated soft It is required during most general anesthetic procedures.
palate have an increased risk for epiglottic entrapment and Proper equipment and technique help minimize trauma
airway occlusion. Brachycephalic breeds have redundant and complications associated with intubation. Special
perilaryngeal tissue and hypoplastic tracheal lumen size, techniques exist to help facilitate difficult intubation. The
making intubation more difficult. Multiple intubation veterinary team should practice these skills frequently to
attempts in brachycephalic breeds can result in pharyngeal be prepared in case of an emergency.
and laryngeal edema.
Choosing the correct diameter and length ETT can make
the difference between rapid, successful intubation and Acknowledgment
multiple failed attempts with increased risk of oropharyn-
geal and laryngeal trauma. Forceful intubation and exces- This chapter was originally authored by Jeni Dohner and Dr.
sive laryngoscope blade pressure can produce perilaryngeal Rebecca Syring for the previous edition, and some material
tissue edema and iatrogenic arytenoid tears [8]. from that chapter appears in this one. The authors and editors
Perilaryngeal tissue edema can lead to upper airway thank Ms. Dohner and Dr. Syring for their contributions.
References
1 Alderson, B., Senior, A.H.A., and Dugdale, J.M. (2006). with transtracheal high-frequency jet ventilation in dogs
Tracheal necrosis following tracheal intubation in a dog. and cats. J. Vet. Emerg. Crit. Care 2: 6–10.
J. Small Anim. Pract. 47 (12): 754–756. 6 Hardie, E.M., Spodnick, G.J., Gilson, S.D. et al. (1999).
2 Lish, J., Ko, J.C., and Payton, M.E. (2008). Evaluation of Tracheal rupture in cats: 16 cases (1983–1998). J. Vet. Med.
two methods of endotracheal tube selection in dogs. J. Am. Assoc. 214 (4): 508–512.
Anim. Hosp. Assoc. 44: 236–242. 7 Mitchell, S.L., McCarthy, R., Rudloff, E., and Pernell,
3 Waddell, K.W. (2008). Ponder CA. In: Small Animal R.T. (2002). Tracheal rupture associated with intubation in
Anesthesia and Analgesia (ed. G.L. Carroll), 260–265. cats: 20 cases (1996–1998). J. Vet. Med. Assoc. 216 (10):
Ames, IA: Blackwell. 1592–1595.
4 McKelvey, D. and Hollingshead, K.W. (2003). Veterinary 8 Hofmeister, E.H., Trim, C.M., Kley, S., and Cornell, K.
Anesthesia and Analgesia, 3e. St. Louis, MO: Mosby. (2007). Traumatic endotracheal intubation in the cat. Vet.
5 Haskins, S.C., Orima, H., Yamamoto, Y. et al. (1992). Anaesth. Analg. 34 (3): 213–216.
Clinical tolerance and bronchoscopic changes associated
377
29
Temporary Tracheostomy
F. A. (Tony) Mann
Indications the inner cannula, there is more emphasis on tracheal suc-

tioning, and more frequent tube changes may be necessary.
The primary indication for temporary tracheostomy tube Single-lumen tubes must be removed and replaced with a
placement is to relieve life-threatening upper airway new tube or reinserted into the stoma site after each
obstruction due to trauma, foreign body, laryngeal paraly- cleaning.
sis, or neoplasia. Other indications include facilitating When an appropriate commercial tracheostomy tube is
removal of lower airway secretions when there is compro- not available, a tracheostomy tube may be fashioned from a
mised cough reflex, allowing manual or mechanical venti- standard endotracheal tube (ETT; Figure 29.3). Choose an
lation when orotracheal intubation is not practical, ETT that is approximately one size smaller than would be
reducing airway resistance in patients where increased chosen for orotracheal intubation. Remove the ETT con-
intracranial pressure is a concern, and permitting inhalant nector and bisect the tube along its length until the uncut
anesthesia during certain intraoral surgical procedures. portion of the tube is the necessary tracheostomy tube
length. If the need to inflate the cuff is anticipated, the cuts
can be carefully made to preserve the inflation channel.
Equipment The two halves of the bisected portion of the tube may be
used as flanges to which umbilical tape ties can be attached.
Most commercially available tracheostomy tubes are made Reattach the ETT connector at the flange–tube junction.
of plastic or silicone, but reusable metal tracheostomy The flanges may be shortened to a convenient length prior
tubes are also available. The most versatile tubes contain to attaching the ties. One disadvantage of this modified
an inflatable cuff and inner cannula as well as the standard tube when the inflation channel is preserved is that the
obturator and tube tie (Figures 29.1 and 29.2). Some tube natural curve of the tube is about 90 degrees rotated;
sizes are too small in diameter to include a cuff and inner however, no untoward patient consequences with this
cannula, so many small dogs and cats do not benefit from deviation have yet to be reported.
those two accessories. The cuff is only needed when The size of tracheostomy tube is important to a successful
positive-pressure ventilation is necessary, such as with procedure and good outcome. Ideally, the tracheostomy
patients requiring general anesthesia or ventilator therapy. tube should be one-third to one-half of the tracheal diame-
In fact, the cuff may be disadvantageous in management ter to minimize iatrogenic tracheal trauma and decrease the
of airway obstruction in awake patients because of the incidence of postintubation stenosis. Also, an appropriately
possibility of secretions accumulating around the sized tube that allows some airflow around it may prevent
deflated cuff. respiratory arrest should tube occlusion occur. However, a
High-volume, low-pressure cuffs are preferred for tube that is too small may cause resistance to airflow if the
patients requiring ventilation, and when these cuffs are patient must breathe entirely through the tube with no air-
deflated there is significant surface area of the wrinkled flow around it. Tube size should allow air passage both
cuff to harbor accumulations of secretions. The inner can- around and through the tube for uncuffed tubes and for
nula is helpful for tube hygiene and maintenance because tubes with deflated cuffs. Available tracheostomy tube sizes
the cannula can be easily removed and replaced. Without that may be applied to dogs and cats range from 00 to 10.
378 Temporary Tracheostomy
Figure 29.1 Commercially available uncuffed tracheostomy

tube with disassembled components: (a) obturator, which is
inserted into the tracheostomy tube immediately before
placement and removed as soon as the tube is in the trachea;
(b) tracheostomy tube, which is secured with umbilical tape
attached to eyelets in the flange and tied behind the neck; (c)
inner cannula, which is placed in the tracheostomy tube and
replaced at regular intervals, and (d) closed-end cannula, which
can be used to temporarily occlude the tracheostomy tube to
see if the patient can breathe around the tube.
Figure 29.3 Tracheostomy tube fashioned from a standard

endotracheal tube. Note that the inflation channel can be
preserved if the cuff is needed. Preserving the inflation channel
results in a curve to the tube that is rotated about 90 degrees to
the desired curve.
determine whether the tube will fit appropriately into the

trachea.
Tube length should extend six to seven tracheal rings
down from the placement site. Ideal tube length may not
be achieved in all veterinary patients because of the limits
(a) (b) of what is commercially available, but tailormade tubes
fashioned from ETTs can be used when the length of com-
Figure 29.2 Commercially available cuffed tracheostomy tube mercially available tubes is too far from appropriate.
(a) without inner cannula and (b) with inner cannula locked in
place and umbilical tape tied to eyelets in the flange. Note that
Other equipment needed for tracheostomy tube place-
the cuff would only be inflated when positive-pressure ment includes an ETT for orotracheal intubation, standard
ventilation is necessary, and the deflated cuff would increase anesthetic supplies, clippers, prepping scrub and solution,
the surface area on which secretions could accumulate, thereby barrier drape, sterile surgical gloves, sterile gauze, surgical
complicating tracheostomy hygiene.
instruments, suture material, and, if not supplied with the
tracheostomy tube, umbilical tape for securing the tube
Sizes 00–5.5 are neonatal/pediatric sizes and are too small to after it is in place. The minimally suggested surgical instru-
be available with inner cannulas, whereas sizes 6.0 or larger ments, which may be packaged together in a tracheostomy
may come with removable inner cannulas. Tracheostomy pack, are two towel forceps, a scalpel handle to accommo-
tube sizes are equivalent to endotracheal tube sizes but can date a #10 or #15 scalpel blade, thumb forceps (Adson–
be misleading because they do not necessarily correlate to Brown or DeBakey tissue forceps), Metzenbaum scissors,
the millimeter diameters of the tubes. For example, a size 6.0 needle holders, two mosquito hemostatic forceps, and
tracheostomy tube may have an inner diameter of 6.4 mm suture scissors. It is also handy to have some self-retaining
but an outer diameter of 10.8 mm. Therefore, one should retractors, such as a Gelpi perineal retractor (preferably
always check the inner and outer diameter dimensions typi- two) or a Weitlaner retractor, which may be included in the
cally located on the tube flange to choose the tube that will tracheostomy pack or packaged separately. Suction capa-
best fit the trachea in question. The largest possible inner bility and an oxygen source should be readily available dur-
diameter is always desired, but the outer diameter will ing the procedure (Box 29.1).
Procedure 379
dorsal to the neck is essential to keep the trachea elevated

Box 29.1 Suggested Minimum Surgical Instruments
toward the surgeon.
Required for Tracheostomy
An area large enough for a ventral midline skin incision
● 2 × towel forceps made longitudinally from the cricoid cartilage to the fourth
● Scalpel handle to accommodate a #10 or #15 blade or fifth tracheal ring is clipped and prepared; this area
● Thumb forceps (Adson–Brown or DeBakey tissue should extend sufficiently far laterally to create an area on
forceps) each side wide enough to allow easy skin cleaning and tube
● Metzenbaum scissors maintenance. In most cases, a sufficient surgical field can
● Needle holders be achieved by clipping the ventral neck from the angle of
● 2 × mosquito hemostatic forceps the mandibles to the manubrium and laterally past the
● Suture scissors level of the jugular veins (Figure 29.4). For longhaired dogs
● Ideally, self-retaining retractors, such as Gelpi and cats, overhanging fur should be trimmed. Breeds with
perineal retractors (preferably × 2) or a Weitlaner excessive skin folds may require skin to be deflected dor-
retractor sally and taped or temporarily tacked with sutures to pre-
vent the skin folds from contaminating or occluding the
tracheostomy area when the animal is no longer in dorsal
Positioning and Aseptic Preparation recumbence.
After clipping and vacuuming, a rolled towel should be
The emergent “slash” tracheostomy should be a rare occur- placed underneath (dorsal to) the neck to stabilize the neck
rence; there is usually time to capture the airway with an and prevent the surgical site from sinking away during
endotracheal tube and prepare the patient for a controlled surgical manipulations, and a standard aseptic surgical
surgical approach (Chapter 28). Once intubated and in an skin preparation is performed.
appropriate plane of general anesthesia, the patient is
placed in dorsal recumbence (Figure 29.4). The neck is
extended and the thoracic limbs are pulled caudally and Procedure
secured to the table with ties or tape. A positioning aid,
such as a thoracic positioning trough, may be used to keep The prepared surgical site is isolated with a barrier drape
the patient from leaning to one side, and a rolled towel secured with two towel forceps (Figure 29.5). A single
drape fenestrated over the proposed skin incision is usually
sufficient, but quarter draping may be performed if desired.
Quarter draping requires at least four towel forceps. Make
a ventral midline cervical skin incision just caudal to the
larynx for a distance of approximately 3–4 cm, depending
on the size of the patient (Figure 29.5a). Apply a self-
retaining retractor to hold open the skin edges and clear
just enough subcutaneous tissue to identify the midline
division of the sternohyoideus muscles (Figure 29.5b).
Using Metzenbaum scissors, bluntly separate the sternohy-
oideus muscles on the midline (Figure 29.5c), taking care
to avoid the thyroidea caudalis vein on the midline between
these two muscles (Figure 29.5d). Retract the thyroidea
caudalis vein to one side along with one of the sternohyoi-
deus muscles (Figure 29.6a). Reposition the self-retaining
Figure 29.4 Positioning and preparation for tracheostomy tube
placement. The dog is in dorsal recumbence with the thoracic retractors on the sternohyoideus muscles to expose the tra-
limbs pulled caudally. A rolled towel (not shown here) placed chea, then clear the loose fascia off the ventral trachea at
dorsal to the neck is helpful to keep the trachea elevated toward the proposed tracheotomy site (Figure 29.6b). Application
the surgeon. The airway is captured with an endotracheal tube
of a second self-retaining retractor at a right angle to the
which is attached to anesthetic tubing. The curved mark on the
skin represents the area of the caudal aspect of the thyroid original retractor to retract the skin in a craniocaudal direc-
cartilage, the straight mark immediately caudal to the curved tion enhances exposure of the tracheal rings and interan-
mark represents the cricoid cartilage, and the midline straight nular ligaments (Figure 29.6c).
mark indicates the proposed skin incision. Note the widely clipped
and prepared surgical field. The syringe is present as a reminder
Using a scalpel blade, incise the interannular ligament
that the endotracheal tube will need to be deflated and the between the appropriate tracheal rings, in this case the sec-
endotracheal tube removed as the tracheostomy tube is inserted. ond and third rings (Figure 29.7). This tracheal location is
Figure 29.5 Surgical approach to the trachea for tracheostomy tube placement. Cranial is to the left in all frames. (a) The skin
incision is made immediately caudal to the cricoid cartilage over approximately the first through fourth tracheal rings. (b) The skin
edges are retracted with a Gelpi perineal retractor to facilitate identification of the sternohyoideus muscles and their midline division.
(c) Metzenbaum scissors are used to bluntly separate the sternohyoideus muscles on the midline. (d) The thyroidea caudalis vein
located on the midline on the dorsal aspect of the sternohyoideus muscles is avoided to minimize bleeding.
Figure 29.6 Isolating the trachea prior to tracheotomy for tracheostomy tube placement. Cranial is to the left in all frames. (a) The
thyroidea caudalis vein is retracted laterally with one of the sternohyoideus muscles, the right sternohyoideus muscle in this case.
(b) The Gelpi perineal retractor is repositioned to retract the sternohyoideus muscles, and the loose fascia covering the ventral surface
of the trachea is incised with Metzenbaum scissors. (c) A second Gelpi perineal retractor is placed for craniocaudal retraction of skin
and loose fascia exposing the tracheal rings.
Procedure 381
Figure 29.7 Incising the interannular ligament for tracheostomy tube placement. Cranial is to the left in both frames.
(a) The interannular ligament between the second and third tracheal rings is isolated. (b) After the initial interannular incision,
the scalpel blade is turned upward to extend the incision, taking care to not damage the underlying endotracheal tube or its cuff.
The tracheotomy is limited to 50% or less of the tracheal circumference.
(a) (b)
(c) (d)
Figure 29.8 Placing tracheal stay sutures immediately before tracheostomy tube placement. Cranial is to the left in all frames.
(a) The suture needle is placed around the second tracheal ring, the ring just cranial to the tracheotomy. (b) The suture is knotted such
that a long loop will be retained. (c) The free ends of the stay suture are tagged temporarily with a mosquito hemostatic forceps distal
to the knot. (d) A second identical stay suture is placed around the third tracheal ring, the ring just caudal to the tracheotomy.
chosen because the area of the second through fourth tra- postoperative course, the stay sutures can be used for
cheal rings is the preferred stomal site for permanent tra- manipulation during reinsertion of a tube that has been
cheostomy should it be required later. Do not incise the inadvertently dislodged or requires changing; therefore, it
interannular ligament beyond 50% of the tracheal circum- is recommended that they not be removed intraoperatively.
ference. Place stay sutures (3-0 or 2-0 nylon for cats/small Insert the tracheostomy tube with the obturator in place
dogs or medium/large dogs, respectively) around the sec- (Figure 29.9b), and quickly remove the obturator and
ond and third tracheal rings, knot the sutures to create replace with an inner cannula as soon as the tracheostomy
large suture loops, and tag the suture strands with mos- tube is positioned in the trachea (Figure 29.10; note that
quito hemostatic forceps distal to the knot (Figure 29.8). removing the self-retaining retractors before inserting the
Use the stay sutures to manipulate the interannular open- tracheostomy tube is recommended because it is awkward
ing while the endotracheal tube is removed and the trache- to remove them once the tube is in place). Secure the tra-
ostomy tube is inserted (Figure 29.9). During the cheostomy tube by attaching umbilical tape to the flange
(a) (b)
Figure 29.9 Preparing to insert a tracheostomy tube. (a) Cranial is to the lower left. The cranial and caudal stay sutures are retracted
to pull open the tracheotomy. Note the endotracheal tube within the tracheal lumen. The cuff will now be deflated and the
endotracheal tube removed as the tracheostomy tube is inserted. (b) Cranial is to the left. The obturator is inserted into the
tracheostomy tube immediately before placing the tube into the trachea. The purpose of the obturator is to keep blood and other
secretions from being scraped into the tracheostomy tube lumen during placement.
(a) (b)
(c)
Figure 29.10 Insertion of a tracheostomy tube. Cranial is to the left in all frames. Contrary to what is illustrated, the Gelpi perineal
retractors should be removed prior to tube insertion because removing them is awkward once the tube is in place. (a) The obturator is
removed as soon as the tracheostomy tube is in place. (b) After removing the obturator, the inner cannula (inset) is placed into the
tracheostomy tube. (c) The inner cannula has been inserted into the tracheostomy tube and locked in place. The hemostatic forceps
are removed from the stay sutures and the stay sutures are left in place.
eyelets and tying the tapes behind the neck (Figure 29.11). Once the surgical procedure is completed, the area is
Secure ties firmly behind the animal’s neck, leaving gently cleaned. Tape tabs are applied to the two stay sutures
enough room for two fingers to be placed between the neck (in place of the hemostatic forceps), one tab bearing the
and ties. There should be no need to suture the tracheos- word “UP” on one side and “CRANIAL” on the opposite
tomy wound, unless the incision was made too large. In side, and the other tab bearing the word “DOWN” on one
that case, a few interrupted sutures may be placed in the side and “CAUDAL” on the opposite side, to clearly indi-
subcutaneous tissue and/or skin to decrease the size of the cate which way one should hold the stay sutures in the
wound; however, care should be taken not to make the event of a tube dislodgement emergency. Duct tape is pre-
wound too small because the wound is contaminated and ferred over medical tape for these tabs for more effective
must be able to drain. See Protocol 29.1 for concise step-by- cleaning and disinfection. It is usually best to leave the
step instructions. incision area uncovered for easy observation of swelling,
(a) (b)
Figure 29.11 Completed tracheostomy tube placement. (a) Umbilical tapes are tied to the eyelets in the tracheostomy tube flange.
The knotted stay sutures are left in place. Labeled tape tabs will be placed where the hemostatic forceps were. The stay sutures are
used to facilitate replacement of the tracheostomy tube in the case of inadvertent or planned removal. (b) The umbilical tapes are tied
on the back of the neck.
Protocol 29.1 Temporary Tracheostomy Tube Placement

Items Required to avoid the thyroidea caudalis vein on the midline
between these two muscles. Retract the thyroidea
● Appropriate type and size tracheostomy tube
caudalis vein to one side, together with one of the
○ Alternatively, standard endotracheal tube (ETT) fash-
sternohyoideus muscles.
ioned into tracheostomy tube, one size smaller than
9) Reposition the self-retaining retractors on the ster-
for endotracheal intubation
nohyoideus muscles to expose the trachea and clear
● Appropriately sized ETT for endotracheal intubation,
the loose fascia away at the proposed tracheotomy
with cuff syringe
site. Application of a second self-retaining retractor
at a right angle to the original retractor to retract
● Surgical scrub supplies
the skin in a craniocaudal direction enhances
● Barrier drapes
exposure.
● Sterile surgical gloves
10) Using a scalpel blade, incise the interannular liga-
● Sterile gauze
ment between the appropriate tracheal rings. Do not
● Surgical instruments (Box 29.1)
incise the interannular ligament beyond 50% of the
● Suture material for stay sutures (3-0 or 2-0 nylon)
tracheal circumference.
● Umbilical tape
11) Place stay sutures around the tracheal rings on the
● Assistant
cranial and caudal borders of the interannular liga-
● Suction capability
ment incision, knot the sutures to create large suture
● Oxygen/standard anesthetic supplies and equipment
loops, and tag the suture strands with mosquito
hemostatic forceps.
Procedure
12) Use the stay sutures to manipulate the interannular
1) Collect necessary supplies. opening while the orotracheal tube is removed.
2) Anesthetize and orotracheally intubate the patient Insert the tracheostomy tube with the obturator in
with a cuffed ETT. place, and then quickly remove the obturator and
3) Position the animal in dorsal recumbence with a towel replace it with an inner cannula.
rolled under the neck. Clip and aseptically prepare a 13) Leave the stay sutures in place for postoperative
large surgical field on the ventral cervical surface. nursing care manipulations. Apply labeled tape tabs
4) Perform hand hygiene, and don cap, mask, and to the stay sutures.
sterile gloves. 14) Secure the tracheostomy tube by attaching umbilical
5) Isolate the prepared surgical site with a barrier drape. tape to the flange eyelets and tying the tapes behind
6) Make a ventral midline cervical skin incision just cau- the neck.
dal to the larynx for a distance of approximately 3–4 cm. 15) Do not suture the tracheostomy wound unless the
7) Apply a self-retaining retractor to hold open the skin incision was made too large. In that case, place a few
edges and clear just enough subcutaneous tissue to interrupted sutures in the subcutaneous tissue and/
identify the midline division of the sternohyoideus or skin to decrease the size of the wound, taking care
muscles. not to make the wound too small.
8) Using Metzenbaum scissors, bluntly separate the 16) Once the surgical procedure is completed, the area is
sternohyoideus muscles on the midline, taking care gently cleaned and left uncovered for easy observation.
bleeding, accumulated secretions, and tube position, and is a single midline vein on the dorsal aspect of the sterno-
for prompt intervention as needed. If a bandage is applied, hyoideus muscles, which can be avoided by careful separa-
wait until the animal is awake and standing or in ventral tion of these muscles, but care must also be taken not to
recumbence. A bandage applied to the neck in a recum- tear or puncture the vessel with self-retaining retractors.
bent patient could change position when the patient recov- Recurrent laryngeal nerve damage can be prevented by
ers and becomes more active. The altered bandage position limiting the clearing of peritracheal fascia to the ventral
could cause patient discomfort or interfere with tube posi- aspect of the trachea over the intended interannular liga-
tioning and thus breathing. The bandage must be changed ment and associated tracheal rings. Incising an interannu-
at least once daily to observe for tube site complications. lar ligament that is too close to the larynx or too far caudal
Simply peeking under the bandage is insufficient. can be avoided by precise attention to the regional anat-
omy. Inadvertent puncture of the endotracheal tube cuff
during interannular ligament incision or puncturing the
cuff during stay suture placement can be avoided by palpa-
Contraindications tion of the inflated cuff and close communication with the
anesthetist to deflate and reposition the ETT and cuff
There is no absolute contraindication for placing a trache-
before making the tracheal incision and placing sutures.
ostomy tube when upper airway obstruction is causing res-
piratory distress. However, endotracheal intubation is
always the preferred method of capturing an airway in an Nursing Care Considerations for Patients
animal with airway distress. Once the airway is controlled,
with Temporary Tracheostomy Tubes
tracheostomy may be performed under controlled condi-
tions. The quick “slash” tracheostomy is rarely needed but
Patient management and monitoring begin immediately
may be necessary if endotracheal intubation is not possible.
after the procedure to minimize the risk of airway obstruc-
Relative contraindications for tracheostomy tube place-
tion from dislodgment or occlusion of the tube. Regular
ment include uncorrected coagulopathy, symptomatic
care may be scheduled every 2–3 hours but may be needed
thrombocytopenia, unstable cervical spine, increased intrac-
as often as every 15 minutes if a patient’s condition war-
ranial pressure, presence of a cervical mass that would inter-
rants. The objectives of regular management are to prevent
fere with the surgical approach, and recent cervical surgery.
buildup of secretions that may block the tube, provide
If tube tracheostomy is indicated in patients with any of
aseptic wound care, and humidify inspired air. Frequent
these conditions, the condition is brought under control or
observation is the best way to gauge the need for increased
preparations are undertaken to deal with the consequences
tube care. Abnormal respiratory pattern, coughing, or paw-
prior to placement of the tracheostomy tube. Plasma may be
ing at the tube or face should signal the need to check for
given to coagulopathic patients, and meticulous hemostasis
occlusions and increase the frequency of tube care.
should be exercised during surgical placement to avoid
excessive blood loss in patients with coagulopathy and
thrombocytopenia. Careful positioning and cautious manip- Airway Humidification
ulation must be performed in patients at risk for cervical
One may humidify inspired air by instilling sterile isotonic
and intracranial neurologic complications. The conse-
saline (small patients, 0.5 ml; large dogs, up to 3 ml) into the
quences of invading a cervical mass or previous surgical site
tube hourly. Aseptic instillation is achieved by cleansing the
in the neck must be weighed against the need for tracheos-
external portions of the tracheostomy tube and surrounding
tomy tube placement. Tracheostomy tube placement may be
skin with 0.05% chlorhexidine solution, drawing sterile
lifesaving in the face of relative contraindications, as long as
saline into a sterile syringe, removing the hypodermic nee-
proper preparations and precautions are used.
dle used to aspirate the saline, and quickly injecting the
saline into the tracheostomy tube without coming in contact
with surroundings. Alternatively, the airway can be humidi-
Possible Complications During fied with a humidity exchange filter (also called a heat mois-
the Procedure ture exchanger or “artificial nose”) if the tube is attached to
a rebreathing circuit, or a nebulizer can be used. Humidity
Intraoperative complications with tracheostomy tube exchange filters are disposable devices that interface
placement can be avoided by diligent attention to surgical between the tracheostomy tube and breathing circuit of a
technique. Hemorrhage can be minimized with meticu- ventilator or anesthetic machine and trap exhaled moisture,
lous attention to hemostasis and avoidance of inadvertent which then humidifies the inhaled gas. Aerosol therapy
vessel damage. The thyroidea caudalis vein (Figure 29.5d) (nebulization) can be used as a means of airway
Nursing Cure CirsireuCasCir Cur Casreiar sat reemCuCury uCatreCraCery Nurer 385
humidification. Nebulization with sterile isotonic saline can whereas ties that are too loose will allow the tube to slide
be used in sessions of 10–15 minutes every 4–6 hours. Sterile freely within the trachea and can cause mucosal damage.
water can be nebulized if humidification is the sole purpose, When changing soiled ties, secure the clean ties before
but saline is better for loosening thick airway secretions to removing the old ones.
facilitate their removal. Nebulization produces particles
small enough to oversaturate the lungs if used excessively.
Tracheostomy Tube Suctioning
Regular suctioning of the tracheostomy tube helps prevent
Tracheostomy Site Hygiene
accumulation of secretions that may cause occlusions but
The tracheostomy site and surrounding skin should be must be done gently to minimize patient discomfort and to
examined frequently, at least whenever the tube is cleaned. avoid adverse effects such as tracheal mucosal irritation,
Good wound care decreases bacterial growth and facilitates gagging, and bradycardia due to vagal stimulation. Patients
patient comfort. Prior to tending to the tracheostomy should be preoxygenated for several breaths from an oxygen
wound, the caregiver should disinfect hands and don source held at the tracheostomy tube opening. Using aseptic
gloves. Sterile gloves are preferred, but clean examination technique, a small sterile suction catheter made of pliable
gloves suffice when sterile gloves are not practical. Skin tubing with side fenestrations is then introduced. Suctioning
surrounding the incision, especially under the flange of the is not begun until the suction catheter is in place; intermit-
tube, should be gently cleansed with sterile cotton-tipped tent light suction is then applied as the catheter is with-
applicators or gauze sponges soaked in dilute (0.05%) chlo- drawn with a circular motion. Most suction catheters are
rhexidine solution. Begin at the wound edges and work controlled by a thumb port to allow adjustment of the
away from the incision. Squeeze excess solution from the amount of suction. The entire suctioning procedure should
cleaning materials before the skin is cleaned. Keep antisep- be completed in less than 15 seconds. The patient is allowed
tic soaps and antibacterial ointments away from the inci- a few moments to “catch its breath,” supplemental oxygen is
sion and wound area because they can irritate exposed again held near the tracheostomy tube opening, and suc-
tracheal mucosa. Remove exudate from the incision tioning is repeated if necessary. If power-driven suction is
promptly to prevent abscess formation and skin macera- unavailable, a handheld suction unit (available at automo-
tion. If gauze pads or fenestrated tracheostomy sponges are tive stores) fits medical suction tubing and can be used for
used, apply fresh ones after each wound care session. The patient care. Because the action of suctioning can initiate
area of cleaned skin must be completely dry before new gagging or vomiting, patients should not be suctioned imme-
sponges are placed. Gauze pads should never be trimmed diately after eating. Stop suctioning immediately if respira-
or cut because fibers could embed in secretions from the tory or cardiac changes or excessive patient discomfort occur.
surgical incision or be inhaled into the airway. Fold sponges
in a triangle pattern and place them on each side of the site
Tracheostomy Tube Cleaning
under the flange and ties. Triangular folding allows the
long base of the triangle to contact the wound, leaving a For cannulated tubes, the inner cannula is removed as
pointed apex more externally located for ease of grasping often as the patient’s condition warrants but no less often
during dressing changes. Special fenestrated sponges are than every four to six hours. The inner cannula is removed
placed above the tube, with the side panels extending down and immediately replaced with a second sterile (or ade-
under the flange and ties. Wound areas can also be main- quately sanitized) inner cannula, making sure that the
tained without pad materials to allow easier visualization locking mechanism is secured. When copious secretions
of the tissue around the tube and incision area. are noted, it may be necessary to instill saline into the outer
lumen tube and suction that tube before placing the new
inner cannula. The removed cannula is meticulously
Tube Tie Inspection
cleaned and placed in a soak solution of 0.05% chlorhex-
The wound maintenance session is an excellent time to idine until the next tube change. When the inner cannula
inspect the ties. Ties should be checked regularly for secu- is next changed, the sanitized cannula is removed from the
rity. Umbilical tape tied with a double bow will hold firmly antiseptic solution and thoroughly rinsed with sterile water
but can be easily loosened. Ties secured with a knot may be or saline before being reused.
difficult to remove, and thus scissors should be hanging on If an uncannulated tube is used, periodically replace the
the cage or readily available near the patient. A tube that is tube with a fresh one. However, if frequent tube changes
untied even briefly is in danger of being dislodged. If not are needed, less damage and irritation to the tissue occurs
secured, a tube can be expelled in an instant with unex- if saline is instilled and suction applied while the tube
pected force. Ties that are too tight will cause discomfort, remains in place. The frequency of suctioning depends on
the patient. Patients with conditions that produce excessive hair shed by the patient. Fur inevitably accumulates in
secretions may need frequent suctioning or more frequent the cage and creates a hazard. For patients that seem to be
humidification than those with minimal secretions. at greater risk for aspiration of such debris, a gauze shield
Patients with conditions that produce moderate secretions can be placed over the tube opening; human stoma shields
may be suctioned every four to six hours. Cats seem to need might also be adapted for this purpose. Cats should be
more frequent maintenance than dogs because they have a provided with long strips of cut paper for litter rather than
tendency to produce thick mucus, especially on the second clay or any material that could produce dust or small par-
and third day after tube placement. Blockage of the tube by ticles that could adhere to the incision or be inhaled. For
secretions is the most common life-threatening occurrence cats that refuse to void except in their customary litter
in patients with a temporary tracheostomy tube. Increasing materials, the litter box should be offered regularly and
amounts or changes in consistency of secretions can be a then removed from the cage, especially because many
warning of greater risk of tracheal occlusion and warrant hospitalized cats seem to prefer to sleep in their litter
more frequent suctioning, humidification, or nebulization. boxes. Tracheostomy patients require general hygiene
If an occlusion is suspected, remove the inner cannula or care as with any hospitalized patient, but common sense
replace the tube. Attempts to force a suction catheter tip dictates modification of certain nursing procedures. For
down the tube or to clear the tube by running any form of example, tub bathing could result in aspiration of soap
stylet through it will force material into the patient’s airway and water into the tracheostomy tube or the wound
and should thus be avoided. around the tube; animals with tracheostomies should
never be bathed.
Replacement of Tracheostomy Tubes
Attention to Hydration Status
Tracheostomy tubes (cannulated or not) should be replaced
no less often than every 24 hours. All materials should be Close monitoring of hydration is important in patients
prepared and available, and an assistant should restrain the with a temporary tracheostomy tube in place. Normally,
patient. After untying the tube ties, pull the tape tabs oppo- inhaled air is heated and humidified by the nasopharynx
site each other so that the stay sutures open the tracheos- and tracheobronchial tree so that alveolar air is 100%
tomy, and remove the tube. The new tube is then inserted, humidified at body temperature and contains four to
ensuring that it enters the trachea and not the subcutaneous six times the water vapor content of room air. Inspired air
tissue, and new neck ties are secured. This procedure should that bypasses the upper airways increases humidification
be done as quickly as possible after preoxygenation, and requirements and desiccates the respiratory mucosa,
oxygen should remain available in case the patient becomes resulting in viscous secretions, impaired mucociliary trans-
distressed. A mask and eye protection are recommended for port, inflammation, small airway collapse, decreased func-
the caregiver when the patient’s condition produces exces- tional residual capacity, reduced pulmonary compliance,
sive secretions to keep expelled secretions out of the car- and increased risk of infection. The flow of un-humidified
egiver’s face during inspection of the incision and tube care. inspired air causes evaporation on the surface of the res-
piratory mucosa, resulting in a loss of heat from the epithe-
lial surface and, ultimately, patient hypothermia. Therefore,
General Patient Observations
monitoring body temperature goes hand in hand with
When respiratory distress is relieved, patients often relax attention to hydration status. Animals on diuretic therapy
and are able to rest. Many dogs and most cats assume a and small, hypermetabolic patients must be encouraged to
position with the head down or neck bent that will seem to drink or be given continuous parenteral or enteral fluid
block the free flow of air to and from the tracheostomy support. Patients should be weighed no less often than
tube; however, the flexed neck rarely causes a problem. once daily to aid in the evaluation of patient hydration.
The rate and character of respiration should be closely Most patients capable of food and water intake seem to
observed rather than constantly waking, disturbing, or have little trouble eating and drinking with a tracheostomy
repositioning the patient. Any abnormal breathing pat- tube in place. However, it is still good nursing practice to
tern, such as dyspnea, tachypnea, or hyperpnea, warrants observe animals while they are eating and drinking. Food
intervention. and water bowls may need to be adjusted to avoid possible
aspiration, especially in short-necked or brachycephalic
animals. If problems are noted with bowls or the acts of
Environmental Considerations and Patient Hygiene
eating and drinking, food and water should be kept out of
Cages must be kept clean and free from materials that the cage and offered intermittently while the patient is
could be inhaled, such as lint from bedding and excess supervised.
aciC wreingreereia 387
Tracheostomy Tube Removal by second intention. The area is cleaned daily of any drainage
with sterile saline-moistened gauze, avoiding excess liquid
The longer a tracheostomy tube must remain in place, the near the stoma. Patients with temporary tracheostomy tubes
more likely intubation complications and stenosis become. require 24-hour observation and are almost never released to
The tube should be removed as soon as assisted ventilation is home care. Patients with tracheostomy wounds in the pro-
no longer needed, the patient can move a normal volume of cess of healing may be returned to an owner’s care with strict
air around or without the tube, or the condition that required instructions that the animal must not be bathed, cannot be
the procedure is resolved. When a patient is to be weaned allowed to swim, cannot wear collars or neck leads, and
from the tube, replace the existing tube with a tube of the should be returned for reexamination and further directions.
next smaller size and closely observe the patient for
10–15minutes for signs of dyspnea. If no distress is noted,
then a smaller diameter tube is placed at the next scheduled Summary
maintenance session. If a patient shows signs of respiratory
distress, the tube that was just removed (i.e. the larger tube) Temporary tracheostomy tube placement is a skill all emer-
is replaced and tube removal attempted again in 12–24hours. gency and intensive care veterinarians should master. A
If breathing is adequate with the smaller tube in place, this well-prepared technical staff with a good nursing plan in
tube is occluded with a cap or occlusion cannula and the place makes care of patients with temporary tracheosto-
patient is observed for 30minutes. If no dyspnea is noted, the mies less stressful for all concerned and helps to ensure a
tube is removed. If a patient already has the smallest availa- satisfactory outcome.
ble tube in place, then weaning must be attempted by com-
plete removal of the tube and close observation of the patient
for 15minutes. If distress occurs, the tube must be immedi- Acknowledgement
ately replaced. Do not remove the tape-tabbed stay sutures
until it is certain that the tracheostomy tube will no longer be The author and editors would like to acknowledge the
needed. These sutures are easily removed even if still in place contribution of Mary M. Flanders (deceased) to the chapter
48 or more hours after tube removal; therefore, leave the stay that appeared in the first edition of Advanced Monitoring
sutures in place until there is no doubt that the tube will no and Procedures for Small Animal Emergency and Critical
longer be needed. Tracheostomy wounds are allowed to heal Care, upon which this chapter is based.
389
30
Capnography
Linda S. Barter and Alessia Cenani
Terminology system and its removal by ventilation. In the steady state,

alveolar partial pressure of CO2 is directly related to the
A continuous plot of carbon dioxide (CO2) in the respired metabolic production of CO2 and inversely related to alveo-
gas against time is called a capnogram and is recorded by lar ventilation. CO2 is highly diffusible such that in per-
an instrument known as a capnograph. A capnometer fused alveoli, alveolar and arterial partial pressures of CO2
detects the highest and lowest values for CO2 in the respired are considered equivalent. Gas sampled at the end of expi-
gas and reports them as inspired and end-expired (also ration (end-expired gas) is representative of alveolar gas;
known as end-tidal) partial pressures or concentrations. thus, the end-expired CO2 measured by a capnograph is
The practices of measuring and recording CO2 are called used as an estimate of arterial PCO2.
capnometry and capnography, respectively. Many monitors Under the control of both the central and peripheral
function as both capnometers and capnographs, displaying chemoreceptors, the body normally maintains arterial
both numerical and graphical information about CO2 in PCO2 within a tight range by adjusting ventilation to the
the respired gas. As with all monitoring tools, a capnogram amount of CO2 produced. Normal range for arterial PCO2
is only a snapshot in time of one aspect of the patient’s resis 35–45 mmHg, with some minor variations between spe-
piratory system function and should be evaluated in light cies [1, 2].
of the patient’s clinical condition. Hyperventilation describes the situation where alveolar
ventilation exceeds metabolic CO2 production resulting in
alveolar (and thus arterial) PCO2 levels below the normal
Physiology range (hypocapnia). Low values for PCO2 in arterial blood
(PaCO2) are associated with respiratory alkalosis and
Aerobic metabolism in tissues consumes oxygen, glu- reduced cerebral blood flow. Hypoventilation describes
cose, and other substrates and eventually produces the opposite situation in which alveolar ventilation is
energy, CO2, and water. CO2 produced in cells easily dif- insufficient to remove the metabolically produced CO2
fuses into the surrounding interstitial fluid raising local causing alveolar (and arterial) PCO2 to rise above the nor-
partial pressure of carbon dioxide (PCO2). Arterial blood mal range (hypercapnia). Most anesthetic and sedative
entering the tissues has a lower PCO2 than the interstitial drugs result in dose-dependent respiratory depression and
tissue and thus CO2 diffuses from the interstitial fluid respiratory acidosis. A PaCO2 greater than 60 mmHg is
into blood. Venous blood leaves the tissues with a PCO2 generally considered respiratory depression significant
higher than that of arterial blood but equal to that of enough to warrant positive pressure ventilation in small
interstitial fluid. Venous blood carries the CO2 produced animal patients.
by metabolism to the lungs to be removed from the body
by ventilation. The process of ventilation replaces
CO2-rich gas from the alveoli with CO2-free gas from the Types of Carbon Dioxide Analyzers
atmosphere or breathing circuit.
Alveolar partial pressure of CO2 reflects a balance There are two types of CO2 analyzers: mainstream and
between CO2 delivery to the alveoli by the cardiovascular sidestream.
390 Capnography
Mainstream sampling tube. Ports onto which a sample line can be attached
can be found on some endotracheal tube adapters, some
In mainstream analyzers, a sample cell or cuvette is
breathing circuit Y-pieces, or most commonly, lightweight
inserted directly in the artificial airway between the tra-
connectors designed to be inserted between the endotracheal
cheal tube and the breathing circuit. An infrared sensor fits
tube or mask and the breathing circuit (Figure 30.2).
over the sample cell and emits light through windows in
With sidestream capnography, gas analysis is delayed
the sample cell (Figure 30.1). Light reaching the photode-
because it takes time for the gas to reach the monitor and
tector on the opposing side of the sensor measures PCO2.
some time to make the measurement (depending on the
Because the measurements are made directly in the airway,
technology used). The effect of this delay is that capno-
this technology eliminates the need for sampling tubes and
graphic waveforms generated by sidestream analyzers do
scavenging but limits its use to the intubated patient. The
not appear synchronously with each breath as is the case
capnographic waveforms generated by mainstream analyz-
with mainstream capnography. Additionally, capnographic
ers are crisper than those from sidestream analyzers
waveforms produced by sidestream monitors tend to be
because they reflect real-time CO2 measurements and suf-
more rounded than those produced by mainstream devices
fer no deformity due to dispersion of gases in a sample line.
in the same situations (Figure 30.3). The delay due to tran-
To prevent condensation on the sample cell windows,
sit time depends on the length and diameter of the tubing
which can cause falsely high CO2 readings, the mainstream
and the rate at which gas is aspirated (this can vary from 50
sensor is heated. Thermal injury to the patient is possible;
to 250 ml/minute depending on the monitor). As gas aspi-
however, newer analyzers now have limited upper tempera-
rated from the airway travels through the tubing to the
tures to avoid such problems. Disadvantages of mainstream
monitor, the gas molecules can move around and start to
analyzers are that they can be bulky and can have relatively
mix (i.e. the CO2-containing gas starts to mix with non-
large internal volume. This bulk puts traction on the endotra-
CO2-containing gas). The faster the transit time between
cheal tube, which may increase the risk of inadvertent extu-
the airway and the monitor, the less mixing will occur and
bation, and their internal volume adds to apparatus dead
the more representative will be the capnogram of actual
space. These factors are more troublesome in smaller
changes in respiratory gas composition. Slow rates of aspi-
patients. The sensor unit in older models was fragile and eas-
ration, long sample lines, and large-bore sample lines
ily broken; however, newer models are of simpler design and
result in capnogram waveforms with slurred up- and
are lightweight, increasing their durability and suitability to
downstrokes (see section on capnographic interpretation).
daily use in veterinary practice. Many models use disposable
Sidestream analyzers remove gas from the patient’s
sensor windows, available in standard and pediatric sizes
breathing circuit. This must be accounted for when calcu-
(Figure 30.1), which can be changed between patients, to
lating fresh gas flow rates and means that if patients are
prevent contamination and minimize apparatus dead space.
anesthetized with an inhaled anesthetic agent, then the gas
must be appropriately scavenged or returned to the
Sidestream
patient’s breathing system. Gas may pass through conduits
In sidestream capnography, the CO2 measuring unit (moni- within the analyzer that cannot be cleaned or sterilized.
tor) is remote from the patient. A small pump within the This may pose an infectious disease risk to subsequent
monitor aspirates gas from the patient’s airway through a long patients if analyzed gas is returned to the patient. The
(a) (b) (c)
Figure 30.1 Mainstream capnography. (a) From left to right are micro cuvette, standard cuvette, and standard cuvette inside the gray
infrared sensor, connected between an endotracheal tube and the white patient breathing circuit. (b) The display screen of a portable
mainstream capnograph. (c) Mainstream capnograph in use on an anesthetized dog.
Equipment Setup 391
(a) (b) (c) (d)
Figure 30.2 Different connection options for a sidestream capnograph gas sampling line. (a) Endotracheal tube adaptor with sample
line adaptor. No additional apparatus dead space is added by attaching the capnograph in this way. (b) An elbow connector with
adaptor port through which a small-bore catheter has been placed, which will be situated in the distal third of the endotracheal tube
lumen to improve accuracy of sidestream gas sampling. (c) Short in-line connector between endotracheal tube and breathing circuit to
which gas sampling line can be attached. (d) Some circuit Y-pieces have built-in sampling line connection ports.
anesthetic agents. A unique advantage of sidestream cap-

Inspiration
nographs is the ability to use them to monitor non-
Gas Flow
intubated patients. For example, expired gases may be
Expiration
sampled from the nasal cavity using nasal cannulas, or
these monitors may be connected to a feeding tube to
40 obtain information to ensure correct placement (see indi-
Mainstream cations section for more detail).
PCO2
(mm Hg)
0
40 Equipment Setup
Sidestream
PCO2
(mm Hg) In smaller patients mainstream CO2 analyzers are techni-
0 cally superior to sidestream analyzers [3, 4]. Owing to their
Time (s)
faster response time, PCO2 measurements are more reliable,
Figure 30.3 Comparison of capnograms obtained from especially when tidal volumes are small and respiratory
mainstream and sidestream capnographs. The upper tracing rates are high. Mainstream analyzers are less susceptible
depicts gas flow during the respiratory cycle, with gas flow than sidestream ones to artifacts caused by the small tidal
above the line representing inspiration and gas flow below the
line representing expiration. The middle tracing is a mainstream volumes and high fresh gas flows encountered when using
capnogram and the lower a sidestream capnogram recorded non-rebreathing systems in small patients. The main disad-
from the same patient at the same time. The dashed lines vantage of mainstream measurements is the addition of
connecting the flow tracing with the capnograms illustrate the apparatus dead space. This can lead to rebreathing of CO2
delay in registering changes in partial pressure of carbon
dioxide (PCO2) by capnography. The magnitude of this delay with and either elevation in PaCO2 or increased work of breath-
a sidestream analyzer varies with the monitor settings and ing and altered ventilatory patterns to maintain a normal
equipment (see text for details). A major difference between the PaCO2 [5]. The size of the sampling cuvette relative to the
two types of analyzers can be seen in the shape of the tidal volume of the patient should be considered when
capnograms. Mainstream capnograms tend to record sharper
changes in PCO2, creating more vertical up-and-down strokes on choosing the type of analyzer to use on an individual (main-
the capnogram when compared with sidestream capnograms stream vs. sidestream). Other considerations in making that
(see text for more details). decision would include whether there is any additional
apparatus dead space as well as the length of time you intend
to use the monitor. Routine mainstream capnography would
small-bore sample lines used by sidestream analyzers can not be recommended for long-term use in small patients [6].
easily become obstructed with moisture or aspirated secre- It is always good to minimize apparatus dead space; how-
tions, and methods must be instituted to collect moisture, ever, small internal volume connectors or cuvettes have a
such as the use of Nafion tubing (Nafion, E. I. du Pont de small internal diameter. As such a compromise is made to
Nemours and Company) or water traps. avoid unnecessary increases in airway resistance due to
Sidestream CO2 analyzers may be single-purpose moni- reduced airway diameter. It would be generally recom-
tors or part of a larger monitoring unit with capabilities mended not to use a connector with an internal diameter
to analyze other respiratory gases as well as inhaled any smaller than that of the patient’s endotracheal tube.
392 Capnography
Sidestream analyzers can be connected to the patient air- measured CO2. Water must therefore be removed from the
way with the addition of minimal to no apparatus dead space expired gas by use of water traps or Nafion tubing (Nafion,
(Figure 30.2d). The cost of making this choice is reduced E. I. du Pont de Nemours and Company). There is some
accuracy. A general figure for total minute ventilation is overlap between the absorption characteristics of
200 ml/kg/minute. Gas aspiration rates of the monitor must nitrous oxide and CO2. Most newer monitors that measure
be considerably lower than the patient’s total minute ventila- nitrous oxide in addition to CO2 can correct for the effect
tion to prevent dilution of expired gas with fresh gas during of nitrous oxide on CO2 readings.
sampling. If the sampling rate is too near minute ventilation, Microstream capnographs are based on a modified
the capnograph waveform will be deformed and end-expired approach to infrared absorption. Molecular correlation
CO2 underestimated. However, slow aspiration rates mean a spectroscopy is used to generate a narrow band of infrared
long delay before gas is analyzed and distortion of the capno- light that precisely matches the absorption spectrum of
graphic waveform. The sampling line should thus be as short CO2 and eliminates interference with other gases. The high
as possible to minimize this delay time. Microstream aspira- CO2 specificity and sensitivity allows for a very short light
tion technology with miniaturized sample chambers should path, and measurements can be made on a very small gas
be used if expired CO2 is to be measured on spontaneously sample. In turn, this allows the use of low sample rates
breathing small patients (< 3–4 kg) for any length of time for (50 ml/minute compared with typical rate of 150 ml/
improved accuracy and reduced dead space [7, 8]. minute for conventional infrared analyzers) without com-
The closer to the alveolus that respiratory gas is sampled, promising accuracy or response time. This reduces entry of
the more faithfully the capnogram represents alveolar gas. moisture into the sample line and reduces the competition
However, a major problem with sampling from within the for tidal volume that may compromise measurement accu-
airways as is required with the sidestream technique is racy in small patients or those with high respiratory rates.
machine aspiration of secretions and water vapor. In intu-
bated patients, sampling catheters placed within the lumen
Raman Scatter
of the endotracheal tube reduce mucus aspiration
(Figure 30.2b). Raman scatter is a technique able to measure CO2, oxygen,
nitrogen, nitrous oxide, and halogenated anesthetic agents.
Gas is sampled into an analyzing chamber where it is illu-
Technology of Carbon Dioxide Measurement minated by a high-intensity monochromatic argon laser
beam. When the laser beam hits molecules with intera-
Several techniques are available for measuring CO2 includ- tomic bonds, a fraction of the energy is absorbed and re-
ing infrared absorption, Raman scattering, and mass emitted at various wavelengths characteristic of the
spectrometry. particular molecule that absorbed it. These monitors have
a short warmup period, fast response time, require little
maintenance, and are very accurate.
Infrared Absorption
Infrared absorption is the most popular technique for CO2
Mass Spectrometry
measurement. Monitors using infrared technology are typi-
cally the most compact and least expensive. Infrared Mass spectrometry is not commonly used for CO2 measure-
absorption is the only technique used for CO2 measurement in clinical practice because these machines tend to be
ment in mainstream analyzers. Polyatomic gases like CO2 expensive and bulky. A unique feature of mass spectrometers
have specific and unique absorption spectra of infrared is that a single unit can be used to measure gas concentration
light. The amount of light absorbed in a specific spectrum is from up to 30 different locations. As such these are most
proportional to the concentration of the absorbing mole- commonly found in large hospitals. Gases are aspirated into
cule. The concentration of gas can then be determined by a vacuum chamber where an electron beam ionizes and frag-
comparing the measured light absorbance with that of a ments the components of the sample. Ions are then acceler-
known standard. Infrared absorption can be used to meas- ated through a magnetic field that separates them based on
ure any polyatomic gas (e.g. nitrous oxide and the halogen- their mass-to-charge ratio. Individual detector plates allow
ated anesthetic agents), which may be advantageous if for determination of the concentration of each component of
purchasing a single monitor for use in anesthetized patients. the gas mixture. These analyzers typically measure only
Infrared monitors have a short warmup period and a fast gases for which they have been preprogrammed to find.
response time for CO2 measurement, allowing them to Adding the capability to measure new gases may require new
measure inspired and expired concentrations. Water vapor hardware and/or software and may be costly. Because these
absorbs infrared light and thus can spuriously increase units measure gases in concentrations (as opposed to
InteretntntiI iofntt trIioeta 393
infrared analyzers and Raman spectrometers that measure Monitoring Ventilation

gases as partial pressures), they assume that the sum of the
The gas exhaled at the end of expiration should be primarily
gases they can detect is 100%. If an unmeasured gas is pre-
alveolar gas, and thus end-expired PCO2 is representative of
sent in significant concentrations, this may result in errone-
alveolar PCO2. Due to the high diffusivity of CO2, alveolar
ously high measured CO2 concentrations.
and arterial PCO2 equilibrate and end-expired PCO2 is used
to estimate arterial PCO2. Capnography and capnometry
can therefore be used to assess the adequacy of ventilation
Indications for Capnography/Capnometry in spontaneous or mechanically ventilated patients.
Indications for performing capnography or capnometry are Monitoring Pulmonary Perfusion

listed in Box 30.1.
Large drops in cardiac output (hypovolemic shock or car-
diac arrest) result in exponential drops in expired PCO2.
Confirming Correct Endotracheal Tube Placement Therefore, very low or precipitously dropping PCO2 should
lead the operator to suspect cardiovascular collapse.
Capnography or capnometry may be useful into situations Capnography may be useful in monitoring cardiopulmo-
in which it is challenging to determine visually the correct nary resuscitation (CPR) efforts, and a sudden increase in
endotracheal tube placement. Repeated upstrokes in the continuously monitored expired PCO2 during CPR is asso-
capnogram (repetitive increases in the PCO2) suggest the ciated with the return of spontaneous circulation [9]. End-
presence of respiratory gas (rather than gastrointestinal or expired PCO2 has been used to predict the survivability
atmospheric gas). It is theoretically possible to sample CO2- from cardiac arrest. A successful outcome from CPR is
containing gas from the stomach, but the values for end- more likely if expired PCO2 levels are greater than 15 mmHg
expired partial pressure of CO2 are likely to be much lower, during resuscitation efforts [10].
reduce with time, and not fluctuate in a pattern consistent
with respiration. Positioning of the endotracheal tube tip Correct Nasogastric Tube Placement
just inside the glottis may produce acceptable end-expired
PCO2 levels and a normal capnogram. Such tube place- Connection of a sidestream analyzer to gastric tubes may
ment risks easy dislodgement and inadequate airway pro- provide additional evidence for correct placement.
tection. In low perfusion states (e.g. cardiac arrest, shock) Detection of any significant level of CO2 should create sus-
verification of correct endotracheal tube placement by cap- picion of placement in an airway.
nography is complicated by the presence of abnormally
low end-expired PCO2 and a dampened waveform because Equipment Problems
little CO2 is being delivered to the lung for expiration.
Capnography may be used to detect malfunctioning or
incorrect assembly of breathing circuits, anesthetic
Detection of Apnea machines, and ventilators. Problems such as malfunction-
ing unidirectional valves, exhausted CO2 absorbers, and
If a patient becomes apneic, the capnograph or capnome-
inadequate fresh gas flows may be detected by alterations
ter typically sounds an alarm when CO2 stays at zero for a
in the capnogram waveform (see next section).
given period of time. Such monitoring is easily achieved if
the patient is intubated. The sampling line of a sidestream
analyzer can be attached to nasal prongs for the detection Interpretation of the Capnogram
of apnea in non-intubated patients.
The normal capnogram, seen in Figure 30.4, can be divided
into four phases (I–IV).
Box 30.1 Clinical Indications for Capnography
● To ensure correct placement of an endotracheal tube Phase I
● To detect apnea
Phase I is the normally flat baseline segment of the capno-
● To monitor adequacy of ventilation
gram. During the first part of this phase, inspiration is
● To monitor pulmonary perfusion during cardiopul-
occurring. At the very end of this phase, the direction of
monary resuscitation
gas flow reverses as expiration begins. During early expira-
● To ensure correct placement of a nasogastric tube
tion, expired gas comes from anatomic dead space.
● To detect equipment problems
Anatomic dead space has not participated in gas exchange,
394 Capnography
Expiration the lungs. The angle between phases III and IV is known as
I II III IV & Pause Inspiration
40 the beta angle and normally close to 90 degrees.
PCO2 α β
(mm Hg)
20
Abnormal Capnograms
0 Abnormal Phase I
Time (s)
If the capnogram fails to return to baseline during inspira-
Figure 30.4 The normal capnogram. The capnogram can be tion, then the shape of the waveform should be considered.
divided into four phases, I through IV, and forms two angles, the If the response time of the analyzer is slow, particularly in
alpha (α) and beta (β) angles. The phases of the respiratory cycle the face of high respiratory frequencies, then the capno-
have been superimposed on the capnogram to the right side of
the figure. End-tidal CO2 is the highest partial pressure of gram may adopt a sine wave formation (Figure 30.5a). This
carbon dioxide (PCO2) value, found at the end of the expiratory is a relatively common capnographic waveform in cats.
plateau, just before the next inspiration begins. Such a waveform has no distinct alveolar plateau, and erro-
neous values for inspiration and expiration may result
and as such gas from these regions is identical in composi- (falsely elevated baseline and underestimated peak expired
tion to inspired gas (normally CO2 free). CO2, respectively).
If the capnogram fails to return to baseline during
inspiration and is not the result of a slow response time (i.e.
Phase II the shape of the waveform is relatively normal), then there
Phase II is the upstroke of the capnogram waveform. This must be CO2 in the inspired gas. Common reasons for this
corresponds to the period of expiration where CO2-containing include exhausted CO2 absorber in a circle system,
alveolar gas begins to be exhaled in a mixture with gas from malfunctioning inspiratory valve in a circle system, or
anatomic dead space (CO2-free gas). As expiration proceeds inadequate fresh gas flow in a non-rebreathing system
the expired gas is composed of rapidly increasing proportions (Figure 30.5b).
of alveolar gas and the CO2 levels quickly rise. Periodic elevations in baseline can occur if external pres-
sure is applied to the patient’s chest during the inspiratory
period. If this pressure forces gas out of the lungs, a small
Phase III rise in PCO2 is registered on the capnogram during what
Phase III is the plateau of the capnogram. During this would normally be the baseline period (Figure 30.5c).
phase PCO2 is normally almost constant while alveolar
gas, normally of nearly uniform composition, is expired.
Abnormal Phase II
Expiration actually ends partway through this phase and
is usually followed by a pause. During this pause PCO2 With sidestream capnographs, gas sampling rate affects the
typically remains constant on the capnogram even though shape of the capnogram. Slow sampling rates decrease the
no gas is flowing in or out of the patient. This occurs slope of phase II, shorten the alveolar plateau, and decrease
because there is expired alveolar gas remaining stationary the slope of phase IV. This delayed equipment response
within the region of breathing circuit from which the gas time typically results in increases in both the alpha and
is being sampled by the capnograph. This part of the pla- beta angle of the capnogram. If the slope of phase II is
teau may be cut short by small tidal volumes, high fresh decreased in the absence of delayed equipment response
gas flow rates, and/or high gas sampling rates (see abnor- time, it suggests slow expiration. Such an abnormality
mal capnograms for more details). The angle between is often also associated with a sloped alveolar plateau
phases II and III of the capnogram is known as the alpha and increases in alpha angle but normal beta angle
angle and is normally close to 100–110 degrees. End-tidal (Figure 30.5d). Important causes of slow expiration are
CO2 is the highest PCO2 value, found at the end of the patient conditions causing airway narrowing such as bron-
expiratory plateau just before the next inspiration begins. choconstriction, or external conditions such as a partially
obstructed or kinked endotracheal tube.
Phase IV
Abnormal Phase III
Phase IV is the rapid downstroke on the capnogram corre-
sponding to inspiration. During this phase fresh, normally Normally, peak expiratory PCO2 values are only a few
CO2-free gas passes the sampling port as it is inspired into mmHg lower than PaCO2. A normally shaped capnogram
Abnormal Capnograms 395
PCO2 40 PCO2 40 PCO2 40

(mm Hg) (mm Hg) (mm Hg)
0 0 0
(a) Time (s) (b) Time (s) (c) Time (s)
40 40
PCO2 40 PCO2 PCO2
0 0 0
(d) Time (s) (e) Time (s) (f) Time (s)
40 40 40
PCO2 PCO2 PCO2
0 0 0
(g) Time (s) (h) Time (s) (i) Time (s)
40 40 40
PCO2 PCO2 PCO2
0 0 0
(j) Time (s) (k) Time (s) (l) Time (s)
Figure 30.5 Examples of common capnogram waveforms. (a) Sine wave form common with sidestream analysis on small patient
with high respiratory rate; (b) rebreathing of CO2-containing gas; (c) expiratory effort between regular breaths; (d)
bronchoconstriction/airway obstruction; (e) hypoventilation; (f) hyperventilation; (g) slow-speed capnogram suggesting reduced
pulmonary blood flow; (h) slow-speed capnogram indicating accidental extubation, patient disconnection, or sudden apnea; (i) uneven
alveolar emptying; (j) spontaneous inspiratory efforts during mechanical ventilation; (k) cardiogenic oscillations; (l) faulty inspiratory
valve. PCO2, partial pressure of carbon dioxide.
Figure 30.6 The effect of reduced pulmonary blood flow on the capnogram. The upper tracing is arterial blood pressure recorded
from the dorsal pedal artery of an anesthetized dog. The lower tracing is a capnogram recorded concurrently from the same patient.
Note that the period of hypotension results in a corresponding reduction in the height of the alveolar plateau on the capnogram.
with an elevated alveolar plateau (Figure 30.5e) reflects production (hypothermia) or reduced delivery of CO2 to
hypoventilation. This is very common in anesthetized or the lungs (low cardiac output). Trends in peak expired CO2
sedated patients. If the patient is not receiving supplemen- over time can be useful to demonstrate the effect of reduced
tal oxygen, hypoventilation is a common cause of pulmonary blood flow on the capnogram. Figure 30.6 dis-
hypoxemia. plays tracings of a systemic arterial pressure waveform and
A normally shaped capnogram with lower than normal corresponding capnogram recorded at slow paper speed. A
alveolar plateau (Figure 30.5f) may reflect hyperventila- period of hypotension can be seen to correspond to reduced
tion. If the patient is being mechanically ventilated, venti- alveolar plateau levels on the capnogram, which returned
lator settings should be evaluated. Other causes for lower to previous levels when systemic blood pressure was
than normal alveolar plateau include reduced CO2 restored.
396 Capnography
The existence of alveolar dead space (ventilated but evident. This is a common and inconsequential finding
unperfused lung regions), such as would occur second- in dogs.
ary to pulmonary thromboembolism, creates a situation
in which peak expired PCO2 levels are substantially
Abnormal Phase IV
lower than arterial PCO2 measurements. Unperfused
alveoli will not have participated in gas exchange and so Normally the capnogram returns briskly to baseline from
contain gas identical in composition to inspired gas, the alveolar plateau, creating a beta angle of almost
which is normally CO2 free. During expiration this gas 90 degrees as fresh gas is inspired and replaces the CO2-
mixes with the gas from perfused alveoli and dilutes the containing gas at the sampling site. If the slope of this
PCO2 in the expired alveolar gas. When examining a phase is reduced (i.e. the beta angle is increased;
capnogram recorded at slow paper speed, the alveolar Figure 30.5l), then either inspiration is occurring abnor-
plateaus of each wave are typically fairly uniform in a mally slowly (not common because it does not take much
stable patient (see early part of Figure 30.5g). Sudden gas to replace the small volume of exhaled gas at the sam-
reductions in pulmonary blood flow, such as occurs pling site) or there is CO2 in the inspired gas. This could
with pulmonary thromboembolism, typically result occur with inadequate fresh gas flows on a nonrebreathing
in exponential decreases in the peak alveolar plateau circuit or malfunctioning inspiratory valve on a circle sys-
as long as ventilation continues (see progression of tem. Box 30.2 describes questions to ask about capnogram
Figure 30.5g) as opposed to an abrupt disappearance of interpretation.
the capnogram waveform as would occur with
disconnection or accidental extubation of a patient
(Figure 30.5h). Summary
An abnormally low alveolar plateau could also be seen
if a sidestream analyzer were to have a leak in the gas Capnography is a noninvasive method for continuous
sampling line and constantly aspirate room air, thus dilut- assessment of ventilation because end-expired CO2 pro-
ing the exhaled gas and creating falsely low PCO2 vides a very good estimate of PCO2 in most cases. Gas sam-
measurements. pling can be either mainstream or sidestream, each of
Conditions that cause filling and emptying of alveoli which has advantages and disadvantages. Capnography is
across the lung to be uneven (regions of ventilation perfu- most accurate in intubated patients but can also be used in
sion mismatch) result in a slanted plateau phase of the cap- awake, non-intubated patients for continuous noninvasive
nogram (and an increased alpha angle; Figure 30.5i). If PCO2 monitoring. Finally, evaluation of capnographic
exhalation is particularly slow, then peak PCO2 levels may waveforms can aid in the detection of patient or equipment
not be reached before inhalation occurs, and as such end- abnormalities.
expired PCO2 values will be below alveolar and thus arte-
rial PCO2 values.
The normal alveolar plateau is roughly horizontal Box 30.2 Capnogram Interpretation
(Figure 30.4). Artifactual dips and bumps in the plateau
1) Are there regular waves of CO2 providing evidence
phase may result from pushing on the thorax of an anes-
of ventilation?
thetized patient causing gas to move out and into the lungs.
2) Does the baseline return to zero (normal) or is there
In an animal being mechanically ventilated, spontaneous
evidence of rebreathing (elevated baseline)?
ventilatory efforts may be interspersed among mechanical
3) Is the upstroke steep (normal) or is there evidence
breaths and cause dips or clefts in the alveolar plateau
of slow expiration (slanted upstroke)?
(Figure 30.5j). Reasons for these respiratory efforts should
4) Is the alveolar plateau even (normal) or is there
be investigated including insufficient anesthetic depth,
evidence of uneven alveolar emptying (slanted
inadequate mechanical ventilation, hypoxemia, inade-
plateau) or interruption of the expiratory period by
quate analgesia, and hyperthermia.
inspiratory efforts (clefts in plateau)?
Cardiogenic oscillations are undulations in the capno-
5) Are end-expired PCO2 values within an acceptable
gram that are synchronous with cardiac contractions
range, and are they consistent with the patient’s
(Figure 30.5k). Contraction of the right ventricle and fill-
respiratory parameters?
ing of the pulmonary vasculature expels a small volume
6) Is the downstroke steep (normal), or is there
of gas from the lungs with each beat. In combination
evidence of slow inspiration or rebreathing (slanted
with gas aspiration by a sidestream analyzer, oscillations
downstroke)?
in PCO2 during the respiratory pause may become
References 397
References
1 Middleton, D.J., Ilkiw, J.E., and Watson, A.D. (1981). 7 Kugelman, A., Zeiger-Aginsky, D., Bader, D. et al. (2008).
Arterial and venous blood gas tensions in clinically healthy A novel method of distal end-tidal CO2 capnography in
cats. Am. J. Vet. Res. 42: 1609–1611. intubated infants: comparison with arterial CO2 and with
2 Ilkiw, J.E., Rose, R.J., and Martin, I.C.A. (1991). A proximal mainstream end-tidal CO2. Pediatrics 122:
comparison of simultaneously collected arterial, mixed e1219–e1224.
venous, jugular venous and cephalic venous blood samples 8 Hagerty, J.J., Kleinman, M.E., Zurakowski, D. et al.
in the assessment of blood-gas and acid–base status in the (2002). Accuracy of a new low-flow sidestream
dog. J. Vet. Intern. Med. 5: 294–298. capnography technology in newborns: a pilot study.
3 Badgwell, J.M. and Heavner, J.E. (1991). End-tidal carbon J. Perinatol. 22: 219–225.
dioxide pressure in neonates and infants measured by 9 Pokorná, M., Nečas, E., Kratochvíl, J. et al. (2010).
aspiration and flow-through capnography. J. Clin. Monit. A sudden increase in partial pressure end-tidal carbon
7: 285–288. dioxide (PETCO2) at the moment of return of
4 Pascucci, R.C., Schena, J.A., and Thompson, J.E. (1989). spontaneous circulation. J. Emerg. Med. 38 (5):
Comparison of a sidestream and mainstream capnometer 614–621.
in infants. Crit. Care Med. 17: 560–562. 10 Brainard, B.M., Boller, M., Fletcher, D.J. et al. (2012).
5 Schmalisch, G., Foitzik, B., Wauer, R.R. et al. (2001). Effect RECOVER evidence and knowledge gap analysis on
of apparatus dead space on breathing parameters in veterinary CPR. Part 5: Monitoring. J. Vet. Emerg. Crit.
newborns: “flow-through” versus conventional techniques. Care 22 (Suppl 1): S65–S84.
Eur. Respir. J. 17: 108–114.
6 Pearsall, M.F. and Feldman, J.M. (2014). When does
apparatus dead space matter for the pediatric patient?
Anesth. Analg. 118 (4): 776–780.
399
31
Mechanical Ventilation
Kate Hopper and Julie Eveland-Baker
A mechanical ventilator is a machine that performs some diseases that impair the ability of patients to maintain an
or all of the work of breathing. It is used to support respira- adequate respiratory rate and/or tidal volume. Such dis-
tory function in patients with respiratory failure. The pri- eases include brain disease, cervical spinal cord disease,
mary functions of the lung are oxygenation of the arterial peripheral neuropathies, diseases of the neuromuscular
blood and removal of carbon dioxide (CO2) from the venous junction, myopathies, respiratory muscle fatigue, and air-
blood. The ability of the lung to oxygenate the pulmonary way obstruction. Not all patients that have severe hypox-
capillary blood depends largely on the surface area availa- emia or severe hypoventilation require mechanical
ble for gas exchange and the preservation of the delicate ventilation, but these criteria help identify candidates for
structure of the gas exchange barrier. In contrast, removal ventilation. An understanding of the primary disease pro-
of CO2 primarily depends on the movement of fresh gas cess and other patient data will help determine the neces-
into the alveoli, thereby flushing out CO2-rich gas on exha- sity of mechanical ventilation in individual patients.
lation, a process known as ventilation. Patients with res- The third indication for mechanical ventilation is exces-
piratory failure can generally be divided into one of two sive respiratory effort and/or impending fatigue, even if the
groups: those with oxygenation failure and those with ven- patient can maintain acceptable blood gas values (i.e.
tilatory failure. PaO2 > 60 mmHg and PaCO2 < 60 mmHg). Determination
of excessive respiratory effort or fatigue is based on clinical
judgment, and mechanical ventilation is indicated in these
Indications for Mechanical Ventilation patients to avoid imminent exhaustion and subsequent
arrest. These patients most commonly have lung disease.
There are three main indications for mechanical ventila-
tion [1]. The first is severe hypoxemia despite oxygen ther-
apy. Severe hypoxemia is indicated by cyanosis, a partial Ventilator Settings
pressure of oxygen in arterial blood (PaO2) less than
60 mmHg, or an oxygen saturation (SpO2) less than 90%. The ventilator makes gas flow into the lungs by the genera-
Patients with severe hypoxemia have significant lung dis- tion of positive airway pressure in a manner similar to that
ease such as pneumonia, acute respiratory distress syn- achieved by squeezing the rebreathing bag on an anesthetic
drome, pulmonary edema, or pulmonary contusions. machine when “bagging” a patient. Every ventilator has a
The second indication for mechanical ventilation is variable number of available settings that can be altered to
severe hypoventilation despite therapy. Severe hypoventi- change the nature of the breath delivered. Despite the
lation is marked by a partial pressure of CO2 in arterial apparent complexity of many ventilators, there are only a
blood (PaCO2) greater than 60 mmHg, which is discussed few key settings that are essential to understand to provide
in depth in Chapter 26. The PaCO2 is controlled primarily effective ventilation. The theory of mechanical ventilation
by alveolar minute ventilation. This is the total amount of includes many specific terms. Common ventilator terms
fresh gas that reaches the alveoli in a minute and is equal to are defined in Table 31.1. When choosing ventilator set-
the product of the respiratory rate and alveolar tidal vol- tings, the operator must first choose a mode of ventilation
ume. Consequently, causes of severe hypoventilation are and then select machine settings based on general
400 Mechanical Ventilation
Table 31.1 Definitions of common ventilator terms. guidelines (described later). These initial settings may be
adjusted based on some understanding of the nature of
Term Definition Comments the patient’s respiratory disease. Following initiation of
mechanical ventilation, the ventilator settings are then
Mandatory A ventilator breath titrated as necessary to achieve the respiratory and blood
breath that is initiated,
generated, and ended gas goals desired.
by the machine
Assisted A ventilator breath Assist control Ventilator Breath Types
breath that is initiated ventilation describes a
(triggered) by the mode of ventilation The three main ventilator breath patterns commonly used
patient but the breath with all mandatory
in veterinary medicine are assist control ventilation (ACV),
is generated and breaths with the
ended by the trigger variable set to synchronized intermittent mandatory ventilation (SIMV),
machine allow the patient to and continuous spontaneous ventilation [1, 2]. Some
increase its own machines only have one breath pattern option, such as an
respiratory rate if it
anesthetic-type ventilator, whereas more modern intensive
chooses
care unit ventilators usually offer all three options.
Spontaneous A ventilator breath Most commonly
breath that is initiated, achieved on a The two primary breath patterns used to provide positive
generated and ended ventilator using pressure ventilation are ACV and SIMV. In ACV, all the
by the patient continuous positive breaths delivered are generated entirely by the machine
airway pressure (mandatory breaths). In this mode of ventilation, a mini-
Supported The breath is Most commonly mum respiratory rate is set by the operator (the person
breath initiated and ended achieved using
adjusting the ventilator settings). If the trigger sensitivity is
by the patient but the pressure support
machine augments ventilation set appropriately, the patient can increase the respiratory
the tidal volume rate, but all breaths delivered will be full ventilator (manda-
Compliance How easily stretched Healthy lungs have tory) breaths. The size of these ventilator breaths will
the lung is; defined high compliance depend on machine settings entered by the operator.
as the change in (large change in Ventilator breaths can either be pressure- or volume-
volume for a given volume for small
change in pressure change in pressure);
controlled breaths. In volume-controlled ventilation, the
lung disease decreases operator presets the desired tidal volume, and the peak
compliance inspiratory airway pressure generated depends on the size
Trigger Determines when the Most commonly set as of the tidal volume chosen and the compliance (how stiff or
variable or machine will deliver a change in pressure stretchy the lung is) of the respiratory system. In pressure-
Sensitivity a breath. This or a change in flow
controlled ventilation, the operator presets the desired peak
variable can be time
or a patient-derived airway pressure, and the tidal volume generated depends on
variable if the animal the level of airway pressure chosen and the compliance of
is making respiratory the respiratory system. ACV provides maximum support of
efforts
the respiratory system and is used in patients with severe
Tidal volume The quantity of gas Many ventilators disease or patients with no respiratory drive (those making
that moves in or out measure both
of the lungs in one inspiratory and
little or no attempts to breathe on their own).
breath expiratory tidal In SIMV, the operator can set the number of full ventila-
volume tor (mandatory) breaths delivered, and between these
Inspiratory The duration of the Most commonly set as breaths the patient can breathe spontaneously as much or
time (I time) inspiratory phase of a 0.8–1.0 seconds as little as it wishes. The machine tries to synchronize the
ventilator breath ventilator breaths with the patient’s own respiratory efforts.
Inspiratory to The ratio of the Aim to keep at 1 : 1 or As this mode combines full ventilator breaths with sponta-
expiratory duration of lower
neous patient breaths, it is generally used for animals that
ratio inspiration to the
duration of need less than 100% assistance from the ventilator, such as
expiration neurologically abnormal animals with a less reliable res-
Peak inspired The highest airway piratory drive, or patients with lung disease that are
pressure pressure measured improving and do not need as much support as ACV
during a ventilator provides.
breath
The two common options for provision of continuous
spontaneous ventilation are continuous positive airway
Ventilator Settings 401
pressure (CPAP) and pressure support ventilation (PSV). In lung disease. When using pressure-controlled ventilation,
CPAP, the ventilator delivers no breaths; all breaths are the desired airway pressure is preset by the operator. Once
spontaneous breaths, meaning that they are completely the animal is connected to the machine, the tidal volume
patient generated: the respiratory rate, inspiratory time achieved with that airway pressure can be assessed. Initially
(time spent in the inspiratory phase), and tidal volume are airway pressures of 8–15 cm H2O should be targeted; higher
all determined by the patient. CPAP provides just that: a airway pressures can be used as necessary.
constant level of positive airway pressure (the amount is
preset by the operator) throughout the respiratory cycle. It
Trigger Variable
decreases resistance to gas flow and increases respiratory
system compliance, enhancing gas exchange and oxygena- The trigger variable determines when the machine will
tion. In addition, the machine alarms if the animal does deliver a breath. If the patient is not making any respira-
not generate adequate breaths or develops apnea, so it is a tory efforts the trigger variable is most commonly time.
useful monitoring mode for weaning patients or for moni- Most modern ventilators allow the patient to trigger
toring intubated patients. machine breaths, allowing ventilation to be better matched
As in CPAP, all PSV breaths are spontaneous breaths; the to the patient’s efforts. The trigger, or sensitivity setting, on
ventilator does not initiate any breaths. In PSV, the tidal the ventilator determines what the machine will recognize
volume generated by the patient is augmented by the as a patient’s inspiratory effort. Appropriate trigger sensi-
machine. The amount of support provided during inspira- tivity is essential to ensure the ventilator recognizes genu-
tion depends on how much pressure is selected by the ine respiratory efforts made by the patient. This increases
operator. This mode reduces the effort required to maintain patient comfort and allows the patient to increase its own
spontaneous breathing in patients with adequate respira- respiratory rate, if desired. The trigger variable can be too
tory drive and inadequate ventilatory strength. PSV can be sensitive so that nonrespiratory efforts such as patient han-
used alone, in conjunction with CPAP, or to augment the dling may initiate breaths; this should be avoided. An
spontaneous breaths during SIMV. airway pressure drop of −2 cm H2O or a gas flow change of
2 l/minute are reasonable trigger sensitivity settings in
medium or larger dogs. In smaller animals, a lower sensi-
Tidal Volume
tivity is usually more appropriate. Once the animal is con-
The normal tidal volume reported for dogs and cats is in nected to the ventilator the trigger setting should be
the range of 10–15 ml/kg. Lower tidal volumes (6–8 ml/kg) evaluated to ensure that breaths can be initiated by
are generally targeted in animals with significant lung dis- the animal.
ease. When using volume-controlled ventilation, the oper-
ator presets the desired tidal volume. Because overdistension
Positive End Expiratory Pressure
of the lung is extremely dangerous, it is recommended to
start with no more than 10 ml/kg as a preset tidal volume; Positive end expiratory pressure (PEEP) maintains pres-
the tidal volume can always be increased if it is determined sure in the breathing circuit during exhalation so that the
to be insufficient once the patient is connected to the patient cannot exhale completely. This pressure holds the
machine. If pressure-controlled ventilation is used, then lung open, improves oxygenating efficiency of the lung,
the operator presets a desired increase in airway pressure, and helps recruit collapsed alveoli. Additionally, it may
and once the animal is connected to the machine the tidal reduce ventilator-induced lung injury. A small amount of
volume achieved with the preset pressure is assessed. A PEEP (2–3 cm H2O) is commonly set in all ventilator modes
tidal volume of around 10–12 ml/kg would be a very accept- to reduce atelectasis. In patients with lung disease, much
able result. higher levels of PEEP may be required to improve oxygen-
ating ability. In continuous spontaneous ventilation, CPAP
provides PEEP during the exhalation period.
Airway Pressure
Patients with normal lungs such as anesthetic patients
Inspiration to Expiration Ratio/Respiratory Rate
or patients with ventilatory failure should only require
low peak inspiratory pressures (PIP) in the range of An operator-set respiratory rate is available on most if not
8–15 cm H2O, ideally not exceeding 20 cm H2O. Animals all ventilators. A normal respiratory rate of 15–20 breaths/
with lung disease have stiff lungs and consequently require minute with an inspiratory time of around one second is
higher airway pressures to achieve an adequate tidal usually selected when the patient is initially established
volume. Peak inspiratory airway pressures as high as on the machine. This can then be changed as appropriate
30–35 cm H2O may be required in animals with very severe for the patient. The ratio of the duration of inspiration to
exhalation (I : E ratio) may be preset by the operator, may Table 31.2 Suggested initial ventilator settings for patients
be a default setting within the machine, or is the byprod- with normal lungs.
uct of the respiratory rate and inspiratory time selected by
the operator. Ideally an I : E ratio of 1 : 2 is used to ensure Ventilator parameter Initial settings: normal lungs
the patient fully exhales before the onset of the next
Fraction of inspired oxygen 100%
breath. As respiratory rates are increased, the expiratory
Tidal volume (volume 8–15 ml/kg
time is sacrificed to “squeeze” in the necessary number of
control)
breaths in one minute. High respiratory rates can lead to
Inspiratory pressure (pressure 8–15 cm H2O
a situation known as “breath stacking” or intrinsic PEEP control)
because the animal is not able to fully exhale before the
Respiratory rate 10–30 breaths/minute
start of the next inspiration. To avoid this problem, it is
Positive end expiratory 0–5 cm H2O
recommended to use an I : E ratio of 1 : 1 or lower. If a pressure
higher respiratory rate is required, a shorter inspiratory
Inspiratory time 0.8–1 second
time will allow maintenance of an acceptable I : E ratio.
Inspiratory-to-expiratory ratio 1:2
Inspiratory trigger −1 to −2 cm H2O or 1 to
Alarms 2 l/minute
Before connecting the patient to the ventilator, a review of

the ventilator alarm settings is essential. The exact alarms
available will vary with machines but changes of particular of the patient has been verified. After connection to the
importance include high- and low-pressure alarms and ventilator, the patient’s chest is observed for appropriate
high- and low-minute ventilation. Alarms should be set movement. If there is insufficient or excessive chest infla-
with some allowance of patient variability to avoid alarm tion, the ventilator settings should be adjusted appropri-
fatigue but not so extreme that patient harm could occur ately. The chest is then auscultated bilaterally to be sure
before the alarm is activated. there is ventilation of both lungs present and all monitor-
ing is evaluated (blood pressure, electrocardiogram (ECG),
pulse oximeter, end-tidal CO2, ETCO2, etc.). Any concern-
ing changes should be addressed immediately. Once the
Guidelines for Initial Ventilator Settings patient appears to be stable, arterial blood gas analysis is
ideal for accurate titration of ventilator settings. If an arte-
As previously stated, the ideal ventilator settings for a rial blood gas in not available, venous blood gas and ETCO2
given patient cannot be predicted. It is likely that animals can be used to assess PCO2, and oxygenation is evaluated
with lung disease will need more aggressive settings than by pulse oximetry. Venous PO2 provides minimal guidance
those with ventilatory failure. It is necessary to choose in this scenario because it is not a direct reflection of
some initial settings prior to connecting the patient to the oxygenation (Chapter 19).
machine. First the type of ventilation must be selected (see
ventilator breath types, above). The initial machine set-
tings can be based on guidelines such as those shown in Lung Disease
Table 31.2. These settings can then be altered as necessary When setting the ventilator up for a patient with lung dis-
once the patient is connected to the ventilator. It is best to ease, it is likely that the pressure settings will need to be
have the ventilator turned on and confirm it is working higher than those needed for animals with normal lungs.
appropriately before connecting the patient. It is impera- This is because pulmonary parenchymal disease reduces
tive to have a method by which to perform manual ventila- the compliance of the lung (i.e. makes the lung stiffer).
tion close at hand at all times during mechanical This means that higher pressures will be needed to achieve
ventilation in case of equipment malfunction, power the same tidal volume. It is now recognized that excessive
failure, or operator error. distension of the lung is a major cause of ventilator-induced
lung injury [2]. For this reason it is recommended to mini-
mize the tidal volume when ventilating patients with sig-
Initial Stabilization on the Ventilator
nificant lung disease. In very severe lung disease, such as
When the patient is first connected to the machine, a frac- the acute respiratory distress syndrome, it may be neces-
tion of inspired oxygen (FiO2) of 100% is advised as a sary to target a tidal volume as low as 6–8 ml/kg, whereas
safety measure. The FiO2 can be reduced once the stability in more moderate lung disease tidal volumes no greater
Weanang from Wanniennra 403
Table 31.3 Suggested initial ventilator settings for patients option is to increase the FiO2. If there is an acute and severe
with lung disease. drop in PaO2, placing the animal on 100% oxygen is appro-
priate until the issue can be evaluated and more definitive
Ventilator parameter Initial settings: lung disease therapy can be provided. Ultimately, it is hoped that
manipulation of ventilator settings will increase the oxy-
Fraction of inspired oxygen 100%
genating efficiency of the lung and allow lowering of the
Tidal volume (volume control) 6–10 ml/kg
FiO2. Increases in PEEP and peak airway pressure are the
Inspiratory pressure (pressure 10–20 cm H2O main ventilator setting adjustments that may improve pul-
control)
monary oxygenating efficiency. An acute hypoxemic epi-
sode in a patient that was previously not hypoxemic is a
Positive end expiratory pressure 4–8 cm H2O potentially life-threatening complication that requires
Inspiratory time 0.8–1 second immediate intervention.
Inspiratory-to-expiratory ratio 1 : 1 to 1 : 2
Inspiratory trigger −1 to −2 cm H2O or 1 to
2 l/minute Partial Pressure of Carbon Dioxide in Arterial Blood
The PaCO2 depends primarily on effective alveolar minute
ventilation, which in turn is the product of the effective
than 10 ml/kg may be best [3]. Table 31.3 provides some
tidal volume and the respiratory rate. If the PaCO2 is higher
suggested initial ventilator settings for patients with lung
than the desired range, the respiratory rate or tidal volume
disease.
or both should be increased and the patient reevaluated. If
When ventilating patients with lung disease, it can be
the PaCO2 is too low, the respiratory rate and/or tidal
beneficial to keep them in sternal recumbency for the ini-
volume should be decreased. An abrupt increase in PaCO2
tial stabilization period. These animals almost always
in the ventilated patient may indicate a life-threatening
oxygenate better in sternal compared to lateral
complication.
recumbency.
Goals of Mechanical Ventilation Weaning from Ventilation

The goal of ventilator therapy is to maintain acceptable Weaning from the ventilator is generally a continuous pro-
blood gas values with minimally aggressive ventilator set- cess of gradually reducing the ventilator settings [1, 2].
tings. The ideal ventilator settings for each individual ani- Often, as the patient improves, the mode of ventilation
mal cannot be predicted and are determined through a may be changed to one that requires the animal to perform
process of trial and error. The patient should be fully eval- a greater proportion of the work of breathing. Such modes
uated after every change in ventilator settings, including include SIMV, pressure support, and CPAP. If animals have
blood gas analysis if possible. It is advisable to make only been anesthetized for prolonged periods of time, it may
one change in ventilator settings at a time to evaluate take some time for them to wake up (hours to days). It is
accurately the effect of each individual change on the important to consider reducing the anesthetic dose or
patient. changing to shorter acting anesthetic drugs when the
Common blood gas goals of mechanical ventilation are animal begins improving and weaning is becoming a
as follows: possibility.
● PaO2 of 80–120 mmHg (SpO2 > 95%) Prior to disconnection from the machine, the patient
● PaCO2 of 35–55 mmHg (35–40 mmHg in patients with must have obtained certain physiologic goals. These
brain disease) include:
● The original disease process is stable or improving
A normal respiratory drive and initiating its own breaths
PaO2
●
in a reliable manner
If the PaO2 is higher than the desired range (> 120 mmHg), ● The patient no longer requires significant ventilator sup-
the first priority is to decrease the FiO2 until it is less than port to achieve acceptable minute ventilation and blood
or equal to 60%. Once FiO2 is reduced, more emphasis is gas values
placed on reducing PEEP and peak airway pressure. If the ● Adequate oxygenation (PaO to FiO2 ratio of at least
PaO2 is lower than desired (< 80 mmHg), the simplest 150 to 200 is recommended)
Box 31.1 Suggested Standard Contingencies Box 31.2 Minimum Recommended Ventilator
for Clinician Notification for Mechanically Ventilated Settings and Patient Values to Record
Patients
● FiO2
● PaO2 < 80 mmHg or SpO2 < 95% ● Mode of ventilation
● PaCO2 or ETCO2 or PvCO2 > 60 mmHg ● Peak inspiratory pressure
● Temperature increase > 1°F ● Tidal volume
● Persistent tachypnea, panting, fighting ventilator ● Respiratory rate:
● Mean arterial pressure < 70 mmHg or systolic arterial ○ Machine set rate
pressure < 100 mmHg ○ Total rate
● Tachycardia ● Minute ventilation

● Urine output <1 ml/kg/hour ● I : E ratio
● Positive end expiratory pressure
Reasons for an animal not being weaned include cardio-

vascular instability, requirement of high FiO2 (> 50%), high
PIP (> 25 cm H2O), and/or high PEEP levels (> 5 cm H2O). ventilator settings and patient values are worth recording,
When a patient has improved sufficiently to consider but the most important ones are listed in Box 31.2.
removing it from the ventilator, it is safest to first test
whether the animal can maintain spontaneous breathing
while still intubated. During such a spontaneous breathing Ventilator Patient Monitoring
trial, the patient requires intensive monitoring. The use of
CPAP is ideal during a spontaneous breathing trial because Monitoring of the ventilated patient is very similar to mon-
the tidal volume, respiratory rate, and ETCO2 can be closely itoring any anesthetized patient, with an emphasis on real
monitored. The development of any of the following may time, continuous monitors where possible in an effort to
indicate that the trial has failed and that positive pressure recognize changes in patient status quickly. Meticulous
ventilation should be reinstituted: hypoxemia, hypercapnia, record keeping of all monitored parameters is essential and
hyperthermia, tachycardia, hypotension, or tachypnea an understanding of common complications in the ventila-
(Box 31.1). In human medicine, it is now recommended to tor patient will aid in responding to changes appropriately.
perform spontaneous breathing trials daily once the patient While recommended monitoring for the anesthetized
qualifies according to the physiologic goal criteria previ- patient is reviewed in detail in Chapter 50, a general over-
ously listed. When the patient can maintain adequate blood view with specific relevance to the mechanically ventilated
gases without anxiety or fatigue, it can be woken up from patient is provided here.
anesthesia and extubated. As veterinary patients are recov- Standard parameters that are monitored in the ventilator
ering from anesthesia at the same time as ventilator wean- patient include continuous ECG, continuous pulse oxime-
ing, signs such as tachycardia, tachypnea and hyperthermia try, continuous ETCO2, and continuous temperature meas-
may be acceptable. Clinical judgement is needed to decide urement. Of all these parameters, the ETCO2 is generally
if changes seen during the weaning period are anesthesia the best evaluation of life or death in the ventilator patient.
related or reflect physiologic stress from excessive respira- A sudden drop of ETCO2 to a very low value is consistent
tory demands. with cardiovascular collapse. The loss of an ETCO2 wave-
form can also occur if the animal is inadvertently extu-
bated. Like all monitors, the capnograph can malfunction
Record Keeping but a sudden change in ETCO2 readings should always
prompt immediate patient evaluation.
An essential aspect of management of the ventilated Most modern ventilators provide a lot of patient data
patient is detailed record keeping. This allows evaluation related to the respiratory performance such as tidal vol-
of patient progress and a review of patient responses to ume, respiratory rate, airway pressure, and end expiratory
changes in ventilator settings. Hourly recording of patient pressure. Calculated parameters of respiratory physiology
vital signs, blood pressure, pulse oximeter, and ETCO2 such as airway resistance and respiratory system compli-
readings is ideal. Current ventilator settings should be ance also provide valuable information. Continuous venti-
recorded at the time of every blood gas measurement and lator waveforms, such as pressure–time scalars and
every time a change in ventilator settings is made. All flow–time scalars, should be displayed at all times if
Artificial Airway Care 405
possible, as these can help identify problems such as a cir- unstable patient. Particular attention to the oral examina-
cuit leak, inadequate anesthetic depth, or change in pul- tion, looking for ulceration or tissue swelling, ocular exam-
monary function. All ventilator settings and related patient ination, evaluation of hydration, and surveillance for any
variables provided by the ventilator should be recorded fre- evidence of pressure related tissue damage related to
quently to allow evaluation of trends. It is particularly recumbency is recommended.
important to capture these data at the time of arterial blood
gas analysis.
Blood pressure measurement is essential as in all anes- Artificial Airway Care
thetized patients and is further emphasized in the mechan-
ically ventilated patient since positive pressure ventilation Appropriate patient care can determine whether mechani-
can have cardiovascular consequences. In systemically ill cal ventilation is successful or unsuccessful. To provide
ventilator patients, continuous direct arterial blood pres- appropriate care, staff training is essential in addition to
sure monitoring is recommended, while in more stable developing clearly defined patient care protocols and
ventilator patients on mild to moderate ventilator settings, detailed record keeping. Chapter 51 reviews the key points
intermittent indirect blood pressure monitoring is usually for care of the ventilator patient other than care of the arti-
adequate. ficial airway, which are reviewed here.
Frequent evaluation of anesthetic depth in the anesthe-
tized ventilator patient is important and may need to be
Humidification
performed every five minutes during the initial stabiliza-
tion period; monitoring frequency often can be reduced to The artificial airway should be humidified appropriately to
every hour once a stable plane of anesthesia has been maintain the mucociliary function, keep respiratory secre-
reached. Careful documentation of all “ins” and “outs” tions from drying out, and reduce the likelihood of airway
including blood collected for laboratory analysis, urine occlusion from thick secretions [1, 4]. There are two basic
output, and any drain production is important since options for airway humidification: active heated water
abnormal fluid balance is often a challenge in the ventila- devices and passive devices that retain heat and moisture
tor patient. Serial body weights can also be helpful in from the exhaled gas and return it to the inhaled gas. There
assessing fluid balance but is not always feasible in these are several types of both humidification options; the most
patients. common types are described here. A heat–moisture
Blood gas analysis, evaluation of packed cell volume, exchanger (HME or “artificial nose”) is an inexpensive pas-
and plasma total protein, electrolyte, blood glucose and sive humidification device that fits between the endotracheal
lactate concentrations are all ideally performed fre- tube the Y-piece of the ventilator circuit. The HME adds dead
quently in the ventilator patient. The frequency of these space to the patient and can increase airway resistance; thus,
tests is determined by individual patient scenario but in HMEs are generally avoided in patients under approximately
animals with rapidly changing disease states it may be 3kg. Given their structure, HMEs can easily occlude and for
necessary to perform blood work every four hours or this reason should be avoided in patients with significant air-
more frequently. Arterial blood gas analysis to review way secretions. HMEs should be changed if they malfunc-
arterial oxygenation and carbon dioxide is recommended tion or become soiled; otherwise they should not be changed
in ventilator patients when possible. PaO2 is the most more often than every 48hours [5].
accurate measure of oxygenation available and is impor- Heated water humidifiers are part of the inspiratory limb
tant for evaluation of lung function and accurate titra- of the ventilator circuit and provide excellent gas humidifi-
tion of FIO2. PaCO2 is the ideal measure of ventilatory cation, but as the gas cools before reaching the artificial
status (hypoventilation vs. hyperventilation) but in the airway, condensation or “rain out” can occur, which leads
cardiovascularly stable patient, the venous PCO2 and to fluid accumulation in the circuit. This fluid can be a
ETCO2 provide relevant information. In animals in source of ventilator associated pneumonia and in large
which arterial catheterization is not possible, intermit- quantities it can cause occlusion of the circuit. Heated wire
tent arterial puncture can be a valuable adjunct to pulse circuits provide heating along the length of the inspiratory
oximetry and venous blood gas analysis (Chapter 8). limb (dual heated wire circuits also provide heating of the
Other blood work such as a complete blood count and expiratory limb) of the circuit to prevent condensation. The
biochemistry profile should be performed as indicated by optimal form of airway humidification is yet to be deter-
the individual’s disease state. mined, as studies to date have not shown a difference in
A full physical examination should be performed at least prevention of airway occlusion or pneumonia between
twice daily in the ventilator patient, more frequently in the HMEs or heated water humidifiers [6].
Artificial Airway microorganisms may proliferate on the device prior to

reintroduction to the airways. Most studies have found no
Care of the artificial airway is one of the most important
difference in the risk of ventilator associated pneumonia
management aspects of the ventilator patient. This care
with open versus closed-circuit suction systems. One
includes securing the airway, maintaining airway patency,
study found a small benefit associated with closed-circuit
and monitoring cuff pressure. Animals can be ventilated via
suction [7]. The external diameter of the suction catheter
an endotracheal tube (ETT) or a temporary tracheostomy
size should be less than 50% of the internal diameter of
tube. ETTs are usually secured using some form of tie. For
the tracheal tube for most animals. In small patients
long term intubation, it is important to ensure that the ETT
(< 5 kg), suction of catheter size should be less than 70%
tie does not damage tissue or cause tissue edema; reposition-
of the tracheal tube diameter [8]. As a rough guide, to
ing the tube tie every four hours can be of benefit. Gauze or
determine the appropriately sized French catheter, divide
material ETT ties cannot be cleaned effectively, and thus
the internal tracheal tube size by two and multiply this
plastic tube ties are ideal. At each evaluation, it is important
number by three.
to ensure the ETT is not causing mucosal injury, or pressure
For airway suctioning, the following supplies are required:
sores in the oral cavity, or commissures of the lips. Temporary
(i) suction catheter, (ii) suction machine, and (iii) container
tracheostomy tubes are tied or sutured in place. The insertion
with sterile water. When an open circuit suction technique is
site should be inspected and cleaned every four hours using
used, two people are required and the person handling the
aseptic technique and any exposed tissue around the inser-
catheter must wear sterile gloves. One person can operate
tion site is covered with sterile gauze or non-adherent dress-
the closed system suction catheter with non-sterile gloves.
ing material.
Prior to suctioning, the patient is placed on 100% oxygen for
Artificial airway suctioning is important for the removal
one to two minutes since airway suctioning can lower the
of tracheobronchial and upper airway secretions. Intubated
concentration of oxygen in the lungs and can cause small
patients cannot cough to clear their airway and accumu-
airway collapse. The catheter is passed down the tracheos-
lated secretions increase airway resistance and can cause
tomy tube or ETT without suction. Airway suctioning can be
airway obstruction. Airway suctioning should be per-
deep (beyond the tip of the tracheal tube) or shallow. There
formed every four to six hours, or on an as needed basis. To
is limited evidence to show that deep airway suctioning is
minimize the risk of infection the inner lumen of any arti-
more effective than shallow suctioning, and it may be associ-
ficial airway and breathing circuit should be handled using
ated with more adverse effects. At this time shallow suction-
aseptic technique.
ing techniques are recommended [8]. Once the catheter is
Whether for a tracheostomy or an ETT, suction tech-
advanced into the airway, suction is applied for no longer
nique is essentially the same. For tracheostomy tubes that
than 10 seconds while the catheter is backed out using a
have an inner cannula, the permanent inner cannula is
twirling motion. Continuous pulse oximetry during the pro-
replaced with a temporary inner cannula during the suc-
cedure is recommended and the patient is monitored con-
tioning procedure. Meanwhile, the permanent inner can-
tinuously for desaturation. For open suction techniques, the
nula is placed in a 1 : 1 dilution of sterile water and 2%
animal is placed back on 100% oxygen immediately follow-
hydrogen peroxide for cleaning. Following the suctioning
ing suctioning. Any secretions removed are evaluated and
period, the permanent inner cannula is rinsed in sterile
characterized. Suctioning can be repeated if significant
water or saline and replaced. The temporary inner can-
secretions are present and the patient tolerated the procedure.
nula is then similarly cleaned and stored aseptically for its
The practice of instilling sterile saline down the trachea
next use. For tracheostomy tubes without an inner can-
during suctioning to help loosen airway secretions is contro-
nula, the suctioning technique is the same but routine
versial. Although many feel it makes suctioning more effec-
replacement of the tracheostomy tube maybe necessary to
tive there is concern that the saline can wash bacteria from
allow effective cleaning of accumulated airway secretions.
the upper airway or colonized endotracheal tube down into
There are two types of suction catheters available for
the lung. Saline instillation is not currently recommended.
ventilator patients: open and closed. Open circuit suction
catheters require the patient to be disconnected from the
ventilator circuit and the catheter is passed down the tra- Summary
cheal tube. The advantage of this approach is that a new
sterile catheter can be used each time. A closed-circuit Mechanical ventilation can be a lifesaving intervention for
suction catheter is an integrated part of the ventilator cir- patients with severe lung disease or ventilatory failure.
cuit and can be used without patient disconnection. This Critical care ventilators offer multiple modes and options
allows maintenance of airway pressure and does not for ventilation that allow the operator to tailor therapy to
expose the circuit to the outside environment. However, the individual. Although complications certainly exist,
since the catheter remains in the circuit following use, proper precautions can help minimize risks.
References 407
References
1 Hess, D.R. and Kacmarek, R.M. (2018). Essentials of Healthcare Infection Control Practices Advisory
Mechanical Ventilation, 4e. New York, NY: McGraw-Hill. Committee. MMWR Recomm. Rep. 53(RR-3): 1–36.
2 MacIntyre, N.R. and Branson, R.D. (2009). Mechanical 6 Gillies, D., Todd, D.A., Foster, J.P., and Batuwitage, B.T.
Ventilation, 2e. St. Louis, MO: Saunders. (2017). Heat and moisture exchangers versus heated
3 The Acute Respiratory Distress Syndrome Network (2000). humidifiers for mechanically ventilated adults and
Ventilation with lower tidal volumes as compared with children. Cochrane Database Syst. Rev. 9 (9): CD004711.
traditional tidal volumes for acute lung injury and the 7 David, D., Samuel, P., David, T. et al. (2011). An open-
acute respiratory distress syndrome. N. Engl. J. Med. 342: labelled randomized controlled trial comparing costs and
1301–1308. clinical outcomes of open endotracheal suctioning with
4 Plotnikow, G.A., Accoce, M., Navarro, E., and Tiribelli, closed endotracheal suctioning in mechanically ventilated
N. (2018). Humidification and heating of inhaled gas in medical intensive care patients. J. Crit. Care 26 (5):
patients with artificial airway. A narrative review. Rev. Bras. 482–488.
Ter. Intensive 30 (1): 86–97. 8 American Association for Respiratory Care (2010). AARC
5 Tablan, O.C., Anderson, L.J., Besser, R. et al. (2004). Clinical Practice Guidelines. Endotracheal suctioning of
Guidelines for Preventing Health-care-associated mechanically ventilated patients with artificial airways
Pneumonia, 2003. Recommendations of CDC and the 2010. Respir. Care 55 (6): 758–764.
409
32
Ventilator Waveform Analysis

Deborah Silverstein and Justina Gerard
volume–time, and pressure–time. Time is typically plotted

on the horizontal (x) axis and the other parameter is plotted
Ventilator waveforms can aid the veterinarian and veteri- on the vertical (y) axis. Additional graphs, such as flow–
nary technician in adjusting ventilator settings, assessing volume (F–V) or pressure–volume (P–V) loops plot pres-
lung function, troubleshooting problems, understanding sure, volume, and flow against each other without respect
the interactions between patient and ventilator, reducing to time. The loops provide information regarding changes
the incidence of complications, fine-tuning the ventilator in lung function.
to decrease the patient’s work of breathing (WOB), and Five basic flow waveforms are most commonly gener-
monitoring patient progress. The three elemental parts to ated by a mechanical ventilator: a rectangular (or “square”)
respiratory function monitoring are scalars (also known as wave, an ascending ramp, a descending ramp, a sinusoidal
waves), loops, and indirect measurements (values that are (or “sine”) wave, or an exponential decaying waveform
calculated, such as compliance and resistance). A basic (Figure 32.1). The control variable and ventilator model
understanding of pulmonary physiology and mechanical used determine the possible options because some modes
ventilation is necessary to interpret ventilatory waveforms. of ventilation only offer certain waveform characteristics.
Recent studies in human medicine have also found that the For example, volume control ventilation typically offers
waveform analysis of automated systems is more effective several choices of flow patterns, whereas pressure control
in detecting ineffective triggering and dyssynchrony in ventilation commonly uses either a descending ramp or
mechanically ventilated intensive care unit patients com- decaying flow pattern only.
pared with clinician assessment based on visual waveform
analysis. It is important that clinicians recognize and prop-
erly treat ventilator dyssynchrony to maximize patient Scalars
comfort, oxygenation, ventilation, and WOB (Video 32.1).
A mechanical ventilator is programmed to deliver a pre- A mechanical breath can be divided into six stages
set pressure, volume, or flow rate; whichever of these is the (Figure 32.2):
programmed cause of inspiration is called the control vari-
able. The four parameters most useful to examine a 1) Beginning of inspiration
mechanical breath include pressure, volume, flow, and time. 2) Inspiration
The location of the sensors for detecting these variables 3) End of inspiration
depends on the ventilator manufacturer and monitoring 4) Beginning of expiration
system used. For example, most ventilators measure pres- 5) Expiration
sure, volume, and flow inside the ventilator, but monitor- 6) End of expiration.
ing devices attached to the end of the endotracheal tube Which factor initiates inspiration depends on the trigger-
can also be used. In general, the closer the sensor is to the ing mechanism (trigger variable) of the ventilator. When
patient, the more accurate is the measurement because using a control mode or in instances where a backup breath
the compliance and resistance of the breathing circuit as is provided by the ventilator, the breath is initiated based
well as the compressibility of the gas may significantly on a predetermined amount of lapsed time. When using
alter the pressure, volume, and flow values. Using the the assist mode or a synchronized intermittent mandatory
measured variables, three scalars can be created: flow–time, ventilation (SIMV) mode, the mechanical breath is
410 Ventilator Waveform Analysis
C&D
B
+ +
PRESSURE
A F
FLOW
0 0
SQUARE ASCENDING DESCENDING SINE DECAY
– –
TIME (a) TIME
Figure 32.1 The five basic flow waveforms that are most

commonly generated by a mechanical ventilator (from left to
C&D
right): rectangular (or “square”) wave, an ascending ramp, a
descending ramp, a sinusoidal (or “sine”) wave, and an +
B
exponential decaying waveform.
E
A
VOLUME
F
0
initiated by the patient’s effort and is referred to as a
patient-triggered or patient-initiated breath. During inspi-
ration, the mechanical breath is delivered, and the flow,
volume, and pressure of the breath depend on various fac- –
tors such as airway resistance, lung compliance, type and TIME
(b)
magnitude of flow, and the delivered volume of each
breath. Spontaneous breaths can also be pressure sup-
ported to enhance tidal volume.
B
The attending veterinarian determines the cycling mech- C
+
anism (cycle variable), or the parameter that is responsible
for termination of inspiration. Possible choices include
volume cycling, pressure cycling, time cycling, and flow A
FLOW
cycling. 0
F
Typically, when inspiration ends, the expiratory phase
E
begins. There are specific instances, however, when the
expiration valve does not open even though inspiratory gas – D
flow has stopped (e.g. when inspiratory pause or inflation
TIME
hold controls are activated). The delivered volume is (c)
retained within the lungs to obtain static or plateau airway
Figure 32.2 (a) The six stages of a mechanical breath as seen
pressures; delayed opening of the expiratory valve then in this pressure–time scalar include: A. Beginning of inspiration;
allows expiration to occur. B. Inspiration; C. End of inspiration; D. Beginning of expiration;
Expiration is a passive phenomenon and the properties E. Expiration; F. End of expiration. (b) The six stages of a
mechanical breath as seen in this volume–time scalar include
of expiration depend on the resistance of the animal’s air-
A. Beginning of inspiration; B. Inspiration; C. End of inspiration;
ways and the artificial airway, as well as pulmonary com- D. Beginning of expiration; E. Expiration; F. End of expiration.
pliance. The end of expiration is heralded by the beginning (c) The six stages of a mechanical breath as seen in this
of the next breath. flow–time scalar include A. Beginning of inspiration;
B. Inspiration; C. End of inspiration; D. Beginning of expiration;
E. Expiration; F. End of expiration.
Scalars in Different Modes of Ventilation
Volume Assist Control Mode
The scalar waveforms vary in their appearance depending
Some important curve characteristics to note in Figure 32.3
on the mode of ventilation used. Sample scalars for the five
(volume assist control ventilation) include:
ventilation modes most commonly used (volume assist
control, pressure assist control, SIMV, SIMV with pressure ● The inspiratory time and expiratory time on these graphs
support, and continuous positive airway pressure), are correspond to termination of inspiration and expiration,
described below. respectively.
Scalars 411
generating negative pressure and flow that is sensed by

the ventilator. The initial rise in pressure corresponds to
+ the pressure necessary to overcome airway resistance.
After this point, any increase in pressure depends on pul-
monary compliance and volume delivered. As the end of
PRESSURE
0 the tidal volume is delivered, the pressure wave has flat-

tened because the lungs are almost full.
● Flow delivery ceases at the end of inspiration because all
the tidal volume has been delivered and the peak inspira-
–
tory pressure (PIP) has been achieved.
TIME ● The dynamic pressure–time scalar has been used to
(a)
determine stress index, which is the slope of the pressure
scalar and may indicate under-recruitment (convex
curve) or overdistention (concave curve).
+
Synchronized Intermittent Mandatory Ventilation Mode
It is important to note the following in the SIMV mode of
VOLUME
0 ventilation (Figure 32.4):
● The inspiratory flow tracing during spontaneous breaths

is on the positive side of the graph and is located in the
– space between mechanical breaths. During the expira-
tory phase, the flow is depicted below the baseline.
(b) TIME
● The inspiratory pressure during spontaneous breaths is
traced on the negative side of the baseline (unlike flow
and volume) and expiration is shown on the positive side
of the tracing.
+ ● The stages of each breath occur in the same order on all
three scalars.
FLOW
0
Synchronized Intermittent Mandatory Ventilation
with Pressure Support
Some important concepts to note in SIMV with pressure
– support (Figure 32.5) include:
(c) TIME ● On the flow–time scalar, the pressure-supported breath

delivers a decreasing flow and terminates inspiration
Figure 32.3 (a) A pressure–time scalar from a normal patient
when the flow decreases to a certain level (also known as
receiving volume assist-control mechanical ventilation. (b) A
volume–time scalar from a normal patient receiving volume flow cycling).
assist control mechanical ventilation. (c) A flow–time scalar ● A set pressure is maintained throughout the inspiratory
from a normal patient receiving volume assist-control phase when a pressure-supported breath is delivered.
mechanical ventilation.
There is a decrease in pressure down to baseline during
the expiratory phase. All breaths are patient triggered in
● A negative tracing below baseline is observed during this example, as demonstrated by the small negative
expiration for the flow–time curve. This is because the deflection at the beginning of inspiration on the pres-
flow transducer measures inspiratory flow as a positive sure–time scalar.
deflection and expiratory flow as a negative deflection.
● A square flow tracing represents a constant flow pattern. Synchronized Intermittent Mandatory Ventilation
● Because flow is constant, the delivery of volume is with Pressure-Controlled Ventilation and Continuous
rectilinear. Positive End Expiratory Pressure Mode
● When the patient triggers an assisted breath, there is a Important facts to note in Figure 32.6 (only a pressure–
small negative deflection on the pressure–time graph. time scalar is shown because the flow-time and volume-time
This bulge occurs as the patient starts to inhale, thus scalars would be identical to those in Figure 32.5) are:
+ +
PRESSURE
PRESSURE
0 0
– –
(a) TIME (a) TIME
+ +
VOLUME
VOLUME
0 0
– –
(b) TIME (b) TIME
+ +
FLOW
FLOW
0 0
– –
(c) TIME (c) TIME
Figure 32.4 (a) A pressure–time scalar from a normal patient Figure 32.5 (a) A pressure–time scalar from a normal patient
receiving synchronized intermittent mandatory mechanical receiving synchronized intermittent mandatory mechanical
ventilation. The initial mandatory breath is followed by two ventilation with pressure support. The figure depicts a
spontaneous unsupported breaths and another mandatory mandatory breath followed by a spontaneous breath with
breath. (b) A volume–time scalar from a normal patient pressure support and another mandatory breath. (b) A volume–
receiving synchronized intermittent mandatory mechanical time scalar from a normal patient receiving synchronized
ventilation. The initial mandatory breath is followed by two intermittent mandatory mechanical ventilation with pressure
spontaneous unsupported breaths and another mandatory support. The figure depicts a mandatory breath followed by a
breath. (c) A flow–time scalar from a normal patient receiving spontaneous breath with pressure support and another
synchronized intermittent mandatory mechanical ventilation. mandatory breath. (c) A flow–time scalar from a normal patient
The initial mandatory breath is followed by two spontaneous receiving synchronized intermittent mandatory mechanical
unsupported breaths and another mandatory breath. ventilation with pressure support. The figure depicts a
mandatory breath followed by a spontaneous breath with
pressure support and another mandatory breath.
Scalars 413
+ +
PRESSURE
PRESSURE
0 0
– –
TIME (a) TIME
Figure 32.6 A pressure–time scalar from a normal patient

receiving synchronized intermittent mandatory mechanical
ventilation with pressure support and positive end expiratory
pressure (PEEP). The figure depicts a mandatory breath followed +
by a spontaneous breath with pressure support and another
mandatory breath. PEEP is evident by the elevated baseline
VOLUME
pressure.
0
● When positive end expiratory pressure (PEEP) is used,

the baseline on the pressure–time graph will be equal to –
the PEEP value. Upon initiating or increasing PEEP, PIP
will also increase. (b) TIME
● The airway pressure decreases to the new baseline PEEP
at the end of expiration.
● Although not shown, the baseline does not generally
change on the flow–time or volume–time scalars when +
PEEP is begun.
FLOW
Pressure-Controlled Ventilation 0
Some points to note in pressure-controlled ventilation
(Figure 32.7) are:
● The ventilator terminates inspiration when a preset time –
has elapsed. The pressure remains at the set pressure
TIME
throughout the inspiratory time. (c)
● The flow decreases to zero on the flow–time scalar before Figure 32.7 (a) A pressure–time scalar from a normal patient
the end of inspiration (before expiration begins). receiving pressure-controlled mechanical ventilation. (b) A
volume–time scalar from a normal patient receiving pressure-
Diagnosing and Interpreting Auto-Positive End controlled mechanical ventilation. (c) A flow–time scalar from a
normal patient receiving pressure-controlled mechanical
Expiratory Pressure from Scalar Graphs
ventilation. The expiratory phase of the second breath is not
Auto-PEEP (also known as intrinsic PEEP or air trapping) shown here.
often occurs in patients requiring high respiratory rates,
high minute volumes, or PEEP settings greater than
10 cm H2O. In these situations, inspiration begins before a examining the flow–time graph, there is an abrupt move-
complete expiration has occurred, leading to air trapping ment up to baseline at the end of expiration, with an imme-
within the small airways and increased patient effort diate increase in inspiratory flow for the next breath before
required for a patient-initiated breath. Additionally, auto- expiration is completed and reaches baseline (Figure 32.8b).
PEEP leads to flattening of the diaphragm, which decreases The presence of auto-PEEP may indicate an airway
the efficiency of diaphragmatic contractions during inspi- obstruction. Possible treatment strategies include broncho-
ration. During expiration on the volume-time scalar, the dilator therapy, placement of a larger endotracheal tube,
waveform approaches baseline but then starts upward increasing the inspiratory flow rate (to minimize the ratio
again before reaching baseline (Figure 32.8a). When of inspiratory to expiratory time), decreasing the tidal
volume, or applying extrinsic PEEP. Alternatively, the res-

piratory rate may be too high (in which case the clinician
+ can decrease the rate while increasing the tidal volume per
breath). Sometimes a different mode of ventilation is ben-
eficial in these animals if the troubleshooting methods pre-
VOLUME
0 viously mentioned are not effective.

Occasionally, auto-PEEP is caused by airway collapse, as
in patients with chronic obstructive airway disease. In
– these cases, increasing PEEP may help to prop the airways
open and decrease air trapping. Protocol 32.1 is a rapid ref-
TIME
(a) erence for initial pressure–time and flow–time scalar
evaluation.
+
Pressure–Volume and Flow–Volume
Loops
FLOW
0
P–V and F–V loops are best studied after becoming famil-
iar with the pressure, flow, and volume scalars previ-
ously described. Similar to the scalar graphs, both the
–
numeric values and waveform graphs reveal information
(b) TIME about the patient. A loop is really just inspiratory and
expiratory curves that are connected. These loops allow
Figure 32.8 (a) A volume–time scalar showing auto-positive
the clinician to analyze the inspiratory and expiratory
end expiratory pressure (auto-PEEP) in an animal with lung
disease receiving mechanical ventilation. Note that the waveform phases of each breath using either F–V or P–V tracings.
approaches baseline but immediately starts upward again before These loops can prove challenging initially because
returning to zero. (b) A flow–time scalar showing auto-PEEP in an there is no unit of time involved; an entire breath is fol-
animal with lung disease receiving mechanical ventilation. Note
lowed throughout the loop without any reference to the
that there is an abrupt movement up to baseline at the end of
expiration, with an immediate increase in inspiratory flow for the passage of time. It is helpful for clinicians to make
next breath before expiration is completed and reaches baseline. changes in ventilator and nonventilator treatment
Protocol 32.1 Rapid Reference for Initial Pressure–Time and Flow–Time Scalar Evaluation

Procedure during SIMV? For example, the pressure-supported
breath has a decelerating flow pattern and has a
First look at the pressure–time scalar:
flat-topped airway pressure wave, and the synchro-
1) Determine the continuous positive airway pressure or nized breath has a triangular-shaped pressure wave.
PEEP level so baseline pressure is known. 7) Is the patient triggering a controlled or supported
2) Determine whether the patient is triggering any breath? The main difference between these is the
breaths and identify this on the tracings. duration of the breath because the patient determines
3) Determine the intended shape of the pressure wave the inspiratory time with supported breaths. In other
(e.g. a flat top is pressure controlled; a “shark words, the inspiratory time of a supported breath is
fin”– shaped top is volume controlled). variable in duration, but the inspiratory time of a con-
Now look at the flow-time scalar: trolled breath is uniform and unchanging since it is
4) What is the flow pattern? For example, a square-shaped based on the ventilator settings.
tracing indicates a volume-controlled breath, but a 8) Is the patient synchronizing with the ventilator? If
decelerating shape can be present with any mode. the number of triggering episodes is greater than the
5) Is the patient air trapping? If expiratory flow does not number of breaths delivered, patient–ventilator
return to baseline before the next breath begins, air dyssynchrony is present. If the peak flow rate of
trapping (auto-PEEP) is present. the ventilator is inadequate, the inspiratory flow will
6) Is the patient triggering breaths? Is the breath be “scooped” inward and the patient may appear to be
controlled, pressure supported, or a compulsory breath fighting the ventilator.
PreesPre–Vosur and oVoe–Vosur VVoe 415
variables incrementally so the ventilator waveforms can

be used to guide fine-tuning of the ventilator settings
and to assess patient changes.
When examining a loop on the monitor screen, the scale
VOLUME (mL)
of the axes must be set so that the loop images are displayed
as large as possible for easy viewing. For example, the slope
of the P–V loop, which represents dynamic compliance, is
normally around 45 degrees. The clinician can readily
observe the slope at a glance to determine whether the ∆P
dynamic compliance is abnormal. INTRAPLEURAL
Unfortunately, there is no convention for how the PRESSURE (cm H2O)
inspiratory and expiratory limbs of the F–V loops are
oriented with respect to the horizontal axis. Traditionally, Figure 32.10 A pressure–volume graph from a normal animal
receiving mechanical ventilation showing how the largest
the F–V loop is displayed with the inspiratory curve below volume change for a given change in pressure is obtained at the
the horizontal axis and the expiratory curve above the steepest portion of the curve, typically in the middle.
axis; however, this is commonly reversed. This chapter
depicts the inspiratory curve above the horizontal axis. Table 32.1 Common causes of increased pulmonary resistance
There is also no consensus as to how the axes should be and decreased pulmonary compliance in mechanically ventilated
oriented, but flow is depicted on the vertical scale in this animals.
chapter to maintain consistency with the scalars previ-
ously discussed. Increased resistance Decreased compliance
(Video 32.3) (Video 32.2)
The change in volume in relation to the change in intra-
pleural pressure is commonly referred to as compliance.
Bronchospasm Pleural space disease
Figure 32.9 shows how varying degrees of compliance can
Airway secretions Pulmonary parenchymal disease
affect the inspiratory limb of a P–V curve. The largest vol-
Small-diameter Single-lung intubation
ume change for a given pressure is obtained at the steepest
endotracheal tube
portion of the curve, typically in the middle (Figure 32.10).
Mucosal edema of Abdominal distention, disease
Spontaneous tidal breathing commonly occurs in this airways or deformity
region of the curve, which allows for spontaneous ventila-
Chest wall disease or deformity
tion at the most efficient portion of the curve (where the
least pressure change is needed for the greatest volume
gain). Pulmonary disease may significantly change the dynamic and static respiratory compliance and distortion
baseline volume or pressure prior to each breath (e.g. due (especially of the P–V loop). Table 32.1 lists some common
to atelectasis or air trapping) and subsequently decrease causes of decreased compliance.
ventilatory efficiency by forcing the lung into a less efficient
portion of the P–V curve. This leads to a decrease in
Pressure–Volume Loops
The pressure (horizontal axis) and volume (vertical axis)
are typically plotted against each other, and a loop as in
Figure 32.11 is generated (A represents the inspiratory
limb and B represents the expiratory limb of the breath).
VOLUME (mL)
N
Conceptual renderings of the loop are often elliptical or
“football shaped,” but the loops are not typically so sym-
metrical. When a ventilator delivers a “control breath,” it is
initiated in the lower-left corner of the graph and follows
the counterclockwise path as indicated by the arrows,
eventually returning to the starting point. The upper-right
INTRAPLEURAL
PRESSURE (cm H2O) corner represents the end of inspiration and the beginning
of expiration. This is the point of maximal pressure and
Figure 32.9 A pressure–volume graph from a normal animal volume, and it represents the dynamic compliance of the
receiving mechanical ventilation showing how varying degrees
respiratory system for that breath. Remember that the loop
of compliance can affect the inspiratory limb of a pressure-
volume curve. N, normal; up arrow, increased compliance; down will not begin at zero pressure if PEEP is applied to the
arrow, decreased compliance. patient.
a gap between the inspiratory and expiratory curves of the

P–V loop. Subsequently, the inflection points obtained
from a dynamic P–V loop are difficult to use when setting
PEEP or the upper pressure limit.
VOLUME (mL)
B
When an animal triggers a breath spontaneously (in con-
trast to a controlled breath, which is triggered solely by the
timing mechanism of the ventilator), there will be a small
A bulge on the negative side of the pressure axis (Figure 32.13)
This bulge occurs as the patient starts to inhale, thus gener-
ating negative pressure and flow. Spontaneous breaths trace
PRESSURE (cm H2O)
a loop in a clockwise direction (this is discussed further
Figure 32.11 A pressure–volume loop from a normal animal later). If the ventilator senses the patient’s effort and begins
receiving mechanical ventilation in which the pressure (horizontal a machine breath, the line shifts rightward into the positive
axis) and volume (vertical axis) are plotted against each other, side of the pressure axis and loops counterclockwise.
and a loop therefore generated. A represents the inspiratory limb
and B represents the expiratory limb of the breath. Conventionally, compliance is assessed by tracing a line
from the beginning to the end of inspiration, with a
45-degree angle created to the horizontal axis in a normal
animal. An increase in compliance results in a shift to the
left of the 45-degree line (Figure 32.14) because less pres-
B sure is required to produce a given change in lung volume,
VOLUME (mL)
whereas a decrease in compliance causes a rightward shift
A
VOLUME (mL)
PRESSURE (cm H2O)
Figure 32.12 A pressure–volume loop from a normal animal

receiving mechanical ventilation demonstrating the two
inflection points. One point is found during inspiration (a) and
the other during expiration (b). Point A is commonly called the
lower inflection point and point B, the upper inflection point. If
the inflection points are difficult to discern, a straight line can PRESSURE (cm H2O)
be drawn along the straight portions of the inspiratory and
expiratory limbs of the loop, and the point of intersection for the Figure 32.13 A pressure–volume loop from a normal animal
two drawn lines will estimate the inflection point (see that triggers the delivery of an assisted positive pressure
dashed lines). ventilation breath (in contrast to a controlled breath that is
triggered solely by the timing mechanism of the ventilator).
Note the small bulge on the negative side of the pressure axis
The P–V loop is commonly used to evaluate changes in due to the patient’s active inspiratory effort.
respiratory compliance. The point of change in the slope of
a line is called the inflection point. As seen in Figure 32.12,
the loop has two inflection points, one during inspiration
and one during expiration. Point “A” is commonly called
the lower inflection point and point “B” the upper inflec-
VOLUME (mL)
tion point. If the inflection points are difficult to discern, a

straight line can be drawn along the straight portions of the
inspiratory and expiratory limbs of the loop, and the point
of intersection for the two drawn lines will estimate the
inflection point (see dashed lines). When examining a
static P–V loop, the inflection points are believed to repre-
sent a sudden change in alveolar recruitment during inspi- PRESSURE (cm H2O)
ration and de-recruitment during expiration. The dynamic
Figure 32.14 A pressure–volume loop from an animal
P–V loop includes the effect of resistance to flow; the vol- receiving mechanical ventilation with increased compliance.
ume increase lags behind the pressure increase and causes Note how the loop is left-shifted from the 45-degree dotted line.
PreesPre–Vosur and oVoe–Vosur VVoe 417
loops is the best way to gauge overall resistance and its

changes. Table 32.1 lists some common causes of
increased airway resistance and Video 32.3 shows an
example of how waveforms can be used to diagnose
VOLUME (mL)
increased resistance and monitor for treatment response

in a cat with asthma.
The WOB describes the amount of pressure required
to move a specific volume of gas. A decrease in compli-
ance or a decrease in functional residual capacity
PRESSURE (cm H2O)
increases the WOB. There are several ways to measure
the WOB, but this information focuses on the ventilatory
Figure 32.15 A pressure–volume loop from a mechanically graphics, termed mechanical WOB. The patient, ventila-
ventilated animal with decreased compliance. Note how the tor, or both are able to do the WOB. The components of
loop is right-shifted from the 45-degree dotted line. the WOB are shown in Figure 32.17. The WOB to over-
come airway resistance is labeled (A) and that required
in the loop (Figure 32.15) because more pressure is required to overcome the elastic nature of the lung is labeled (B).
to produce a given change in lung volume. Refer to The combination of A and B represent the total mechan-
Table 32.1 for some common causes of decreased respira- ical work done during the breath. The WOB equals the
tory system compliance and Video 32.2 for an example of area under the changing pressure curve as the volume
how to use waveforms to improve compliance in a dog with increases from zero to its peak at the end of inspiration.
aspiration pneumonia. Most ventilator graphics only display the mechanical
An increase in the width of the loop indicates an work as measured at the endotracheal tube connector,
increased resistance in the respiratory system. and therefore they do not reveal ventilatory efforts made
Subsequently, the area of the P–V loop and its horizontal by the patient. The WOB performed by the patient dur-
distance increases (Figure 32.16). These changes are the ing the mechanical breaths can be indirectly measured
result of hysteresis, a lag in the change in volume com- by plotting esophageal pressures because esophageal
pared with the rate of change in pressure that results from pressures are a surrogate for measuring intrapleural
resistance to deformation (elasticity) and resistance of the pressure and intrapleural pressure changes as a result of
airways. The rightward shift of the loop indicates that the patient work.
resistance is creating a decreased compliance effect. It is
often easier for the clinician to use the F–V loop to evalu-
ate changes in airway resistance because the changes to
the P–V loop can be subtle. However, superimposition of
two loops on each other may prove helpful in determining
changes in the P–V loop. Using both the F-V and P–V
VOLUME (mL)
A
VOLUME (mL)
PRESSURE (cm H2O)
Figure 32.17 A pressure–volume loop from a mechanically

ventilated normal animal with the components that determine
the mechanical work of breathing (WOB) separated. The WOB to
overcome airway resistance is labeled (A), and that required to
overcome the elastic nature of the lung is labeled (B). The
PRESSURE (cm H2O) combination of A and B represent the total mechanical work
done during the breath. The WOB equals the area under the
Figure 32.16 Superimposed pressure–volume loops from a changing pressure curve as the volume increases from zero to
mechanically ventilated normal animal (center) and a its peak at the end of inspiration. Most ventilator graphics only
mechanically ventilated animal with increased airway resistance display the mechanical work as measured at the endotracheal
(outer loop). Note how the increase in airway resistance causes tube connector, and therefore they do not reveal ventilatory
the loop to widen, leading to an increase in the area of the efforts made by the patient. The WOB performed by the patient
pressure–volume loop and an increase in the horizontal during the mechanical breaths can be indirectly measured by
distance (arrows). plotting esophageal pressures.
Flow–Volume Loops
The vertical axis of an F–V loop represents flow rate (liters
per minute or per second), and the horizontal axis represents
volume (milliliters or liters); however, this is not standard-
FLOW (L/min)
ized, so it is important to read the axis labels. The inspiratory
portion of the F–V loop is above the horizontal axis, and the VOLUME (mL)
expiratory portion is below this line in this chapter but recall
that this may be reversed in some graphic displays or refer-
ences. In Figure 32.18, point A represents the start of inspira-
tion; point B represents the start of expiration. The shape of
(a)
the F–V curve can be altered by patient changes, ventilator
settings, circuit conditions, and the way the ventilator gener-
ates and delivers a breath. The transition from inspiration to
expiration and back to inspiration is seen where the loop
crosses the horizontal axis and the flow rate is transiently
zero. The inspiratory curve shape reflects the flow pattern of
VOLUME (mL)
the ventilator (see note later). The lowest point below the x
axis depicts the peak expiratory flow rate (PEFR) during pas-
sive expiration (point C in Figure 32.18). Anything that leads
to obstruction of the airways or endotracheal tube influences
the shape of this curve, as discussed later.
(b) PRESSURE (cm H2O)

Flow–Volume Loops when Flow Delivery Is Constant
When the ventilator uses constant flow to deliver a breath, a Figure 32.19 (a) A flow–volume loop from a normal animal
square waveform pattern is displayed (Figure 32.19a). This while receiving positive pressure mechanical ventilation on a
results in a constant volume delivery, since flow is volume machine that delivers constant flow to deliver a breath. Note the
square waveform pattern that is displayed. (b) A pressure–volume
per unit of time. Although a descending flow pattern may be loop from a normal animal while receiving positive pressure
used more commonly, the square waveform can be more mechanical ventilation on a machine that delivers a constant flow
helpful for detecting abnormalities in the P–V loop because to deliver a breath. This is often the preferred waveform for
the flow and volume delivered are constant (Figure 32.19b). detecting abnormalities in the pressure–volume loop.
Spontaneous Breath Loops The F–V loop is similar, but the inspiratory curve of a spon-
taneous breath (above the horizontal axis) is rounded
Spontaneous breaths create loop waveforms that differ (Figure 32.20a). The main difference is a lower peak flow
from those produced during positive pressure ventilation. rate during spontaneous breathing. The expiratory wave-
form (below the horizontal axis) is passive, creating a
descending ramp-like shape for both spontaneous and
ventilator-created breaths.
The P–V loop during spontaneous respiration is very differ-
ent than the P–V loop created due to positive pressure. During
FLOW (L/min)
a spontaneous breath, the negative pressure generated during

A B
inspiration causes a leftward bulge of the P–V loop that extends
VOLUME (mL) into the negative side of the pressure axis (Figure 32.20b). The
loop is then traced in a clockwise fashion, and expiration
occurs on the positive side of the pressure axis.
Loop Interpretation
C
The interpretation of abnormal loop patterns requires
Figure 32.18 A flow–volume loop from a mechanically
practice and patience. Some of the abnormalities that may
ventilated normal animal. Point A represents the start of
inspiration and point B represents the start of expiration. Point C be gleaned from analysis of the loops include airway
is showing the peak expiratory flow rate during passive expiration. obstruction, the presence of an air leak, or air trapping.
Basic Pulmonary Mechanics Measured During Mechanical Ventilation 419
FLOW (L/min)
FLOW (L/min)
VOLUME (mL) VOLUME (mL)
(a)
Figure 32.21 A flow–volume loop from a mechanically

ventilated animal with airway obstruction. Note the decrease in
peak expiratory flow rate. The descending segment of the
expiratory curve appears more curvilinear, also known as
“scooping,” which is commonly seen in animals suffering from
VOLUME (mL)
obstruction of the medium and small airways.
occurring during inspiration. If a leak occurs downstream

(on the patient side) from the flow transducer used to gener-
ate loop graphics, this appears as part of the inspiratory vol-
ume in the loop, but the lost volume is not returned through
(b) PRESSURE (cm H2O) the flow transducer and therefore the loop does not close
Figure 32.20 (a) A flow–volume loop from a normal animal (see Figure 32.22). If the delivered inspiratory volume is less
during a spontaneous breath. The inspiratory curve of the than the set volume but has an equivalent expiratory vol-
spontaneous breath is above the horizontal axis and appears ume, a leak in the ventilator circuit between the flow trans-
rounded. (b) A pressure–volume loop from a normal animal ducer and ventilator should be suspected.
during a spontaneous breath. Note that the negative pressure
generated during inspiration causes a leftward bulge that
extends into the negative side of the pressure axis. The loop Air Trapping
continues in a clockwise fashion, and expiration occurs on the If the expiratory time is not sufficient or the smaller airways
positive side of the pressure axis. collapse prematurely, air trapping may occur, causing the
expiratory portion of the loop never to return to baseline (to
Airway Obstruction never reach zero flow rate) prior to beginning the next breath
The location and severity of airway obstruction determine (Figure 32.23). It is important to note that the F–V loop for a
the changes that result on the F–V loop. Most significant pressure support ventilation (PSV) breath can appear similar
obstructions decrease the PEFR, as seen in Figure 32.21. to the loop seen with air trapping. When air trapping is pre-
When the medium and small airways obstruct, the descend- sent, the expiratory flow never returns to zero. As with a nor-
ing segment of the expiratory curve often turns into a more mal F–V loop in PSV, an abrupt change in the slope of the
curvilinear shape, referred to as “scooping” (also seen in loop at the end of inspiration is seen. This is due to the venti-
Figure 32.21). Comparison of F–V loops over time can help lator cycling into expiration based upon the preselected flow
the veterinarian assess the effectiveness of bronchodilator target. When looking at a P–V loop, it is important to consider
therapy in patients with asthma or bronchospasm. The the trigger setting for the patient-initiated breaths. This is
scooped-out appearance often changes to a more linear typically seen around 2cmH2O, making it appear that vol-
shape from the peak expiratory flows down to the end of ume is trapped, but this is a normal P–V loop (Figure 32.24).
expiration, reflecting the beneficial effect of therapy in
relieving the airway obstruction.
Basic Pulmonary Mechanics Measured
Air Leak During Mechanical Ventilation
The presence of an air leak during a breath is often evident
in both the scalar and loop graphs. Leaks may originate from To measure compliance of the lungs, a pressure–time
the endotracheal tube cuff, air leaks through chest tubes, or scalar is commonly used. Volume control ventilation is
a bronchopleural fistula. The waveform’s expiratory volume used, and once PIP is reached (Figure 32.25, point 1), an
appears smaller than the inspiratory volume if a leak is end-inspiratory pause is applied for 0.5–2.0 seconds for
VOLUME (mL)
FLOW (L/min)
VOLUME (mL)
PRESSURE (cm H2O)

(a)
Figure 32.24 A pressure–volume loop from a normal animal
receiving a pressure-supported breath. Note how the inspiratory
and expiratory lines cross each other at around 2 cm H2O as the
patient attempts to inspire.
VOLUME (mL)
+ 2
* PRESSURE

0
Inspiratory
Figure 32.22 (a) A flow–volume loop from an animal receiving Hold
mechanical ventilation. There is evidence of an air leak
downstream (on the patient side) of the flow transducer used to
–
generate the loop. The lost volume is therefore not returned
through the flow transducer upon expiration and the loop does
TIME
not close. (b) A pressure–volume loop from an animal receiving
mechanical ventilation. There is evidence of an air leak
downstream (on the patient side) of the flow transducer used to Figure 32.25 A pressure–time scalar during an inspiratory
generate the loop. The lost volume is therefore not returned breath hold in a normal animal receiving volume-controlled
through the flow transducer upon expiration and the loop does mechanical ventilation. The peak inspiratory pressure (point 1) is
not close. The asterisk represents volume loss. seen prior to the inspiratory breath hold. The plateau pressure,
also known as the peak alveolar pressure, is the pressure
observed at point 2.
alveolar pressure, commonly referred to as the plateau pres-

sure or static compliance (as seen in Figure 32.25, point 2).
The difference between PIP and the peak Palv is due to the
FLOW (L/min)
resistive properties of the system (either patient airways or

VOLUME (mL)
artificial airway). The difference between the PIP and end
expiratory pressure (EEP; or PEEP if applicable) is referred
to as dynamic compliance; dynamic compliance is a less
accurate measurement of compliance than static compli-
ance, but its measurement does not require an inspiratory
breath hold. Dynamic compliance is more a measure of
Figure 32.23 A flow–volume loop from an animal receiving impedance because it consists of both resistance and com-
mechanical ventilation. The expiratory portion of the loop never pliance components. The difference between the peak Palv
reaches a zero flow rate prior to the next breath, indicating the and total PEEP is due to the elastic properties of the system
presence of air trapping. (lung and chest wall compliance combined).
During pressure control ventilation, PIP and peak Palv
only one breath. During the pause, there is no flow between may be equal due to the flow waveform that occurs
the patient and the ventilator, which allows for equilibra- (Figure 32.7a). Since the pressure often remains at the set
tion between proximal airway pressure and alveolar pres- point during a majority of the inspiratory time when using
sure (Palv). The pressure at the end of the pause is the peak pressure control ventilation, static compliance cannot be
Basic Pulmonary Mechanics Measured During Mechanical Ventilation 421
determined while using this mode (it must be determined decrease with increases in compliance. Figure 32.26b dem-
while the patient is receiving volume control ventilation). onstrates a P–V loop with the same compliance changes as
Flow decreases during inspiration and is typically followed in Figure 32.26a. Airway resistance does not change
by a period of no flow at the end of inspiration (Figure 32.7c). between the three loops but notice the “right shift” of the
During the no-flow time, proximal pressure may be equal P–V loop that occurs as compliance decreases. Although
to the peak Palv. To determine effective respiratory system not present in this figure, increased hysteresis sometimes
compliance, the tidal volume is divided by the difference accompanies a decrease in compliance.
between PIP and EEP. Dynamic compliance is calculated An increase in inspiratory airway resistance may be sub-
as PIP minus EEP and includes a component of airway tle on the F–V loop if the driving force of the ventilator is
resistance. sufficient to overcome the increased resistance, as seen in
The P–V and F–V loops can also be used to assess respira- the loop labeled with the arrow in Figure 32.27a. The loop
tory system compliance. In Figure 32.26a, a constant flow does reveal a slight decrease in the PEFR and volume com-
mode is used and the three F–V loops represent varying pared with the normal (N) curve. The same scenario is seen
compliance levels. The “up” arrow shows increased com- in the P–V loop of Figure 32.27b, where the expiratory
pliance, the “down” arrow shows decreased compliance, curves are similar, but the volume of the normal curve is
and “N” is normal compliance. Note how the tidal volume again greater than the abnormal curve and the pressure
increases with increases in compliance. Inspiratory peak during inspiration is markedly higher in the abnormal loop
flows are fairly constant, but expiratory peak flow rates labeled with the arrow. Potential causes of increased inspir-
atory resistance include patient–ventilator dyssynchrony,
secretions or exudate within the endotracheal tube or large
FLOW (L/min)
VOLUME (mL)
FLOW (L/min)
VOLUME (mL)
N
(a)
N
(a)
N N
VOLUME (mL)
VOLUME (mL)
Figure 32.26 (a) Flow–volume loops depicting varying degrees

of compliance in three animals receiving mechanical ventilation (b) PRESSURE (cm H2O)
with constant flow delivery during inspiration. Increased
compliance is evident in the loop marked with an up arrow, Figure 32.27 (a) Two flow–volume loops from animals
decreased compliance in the loop with a down arrow, and receiving mechanical ventilation. The loop labeled with an up
normal compliance in the loop marked “N.” Note how the tidal arrow depicts the decrease in peak expiratory flow rate and
volume increases with increases in compliance during flow volume in an animal with increased inspiratory airway resistance
control ventilation. (b) Pressure–volume loops depicting varying compared with a normal (N) animal. The changes are subtle
degrees of compliance in three animals receiving mechanical because the force of the ventilator is sufficient to overcome the
ventilation, as in Figure 32.26a. Increased compliance is evident increased resistance. (b) Two pressure–volume loops from
in the loop marked with an up arrow, decreased compliance in animals receiving mechanical ventilation. The loop labeled with
the loop with a down arrow, and normal compliance in the loop an up arrow depicts the decrease in volume and increase in peak
marked N. Note the “right shift” of the pressure-volume loop that pressure in an animal with increased inspiratory airway
occurs as compliance decreases. resistance compared with a normal (N) animal.
for a cervical disk herniation. You notice that the inspira-

tory peak pressures have been getting higher and higher
during volume-controlled ventilation, so you decide to
perform a one-second inspiratory pause to assess static
and dynamic compliance and compare it with yesterday’s
FLOW (L/min)
scalar (A). What is your interpretation of this pressure

VOLUME (mL)
scalar (B)?
(a)
+
PRESSURE
0
A B
VOLUME (mL)
TIME
(b) PRESSURE (cm H2O) Figure 32.29
Figure 32.28 (a) Two flow–volume loops from animals Answer

receiving mechanical ventilation. The loop labeled with the up An increase in PIP with an unchanged pause pressure
arrow shows an increase in expiratory resistance that causes a
reveals increased respiratory resistance. Upon changing
decrease in the peak expiratory flow rate. The absence of
scooping is consistent with a large airway obstruction. A small the endotracheal tube, you find a large blood clot inside.
leak is also present as indicated by the shortened return of the
abnormal loop. (b) Two pressure–volume loops from animals
receiving mechanical ventilation. Small airway obstruction is
evident in the expiratory portion of the loop labeled with an up
arrow compared with the normal (N) loop.
+
airway, or collapse or a mass of the trachea beyond the

length of the endotracheal tube.
FLOW
0
Resistance during expiration leads only to a decrease in
PEFR, as seen in the loop labeled with the “up” arrow in
Figure 32.31a; this pattern is consistent with large airway
obstruction. Note there is no scooping on the F–V loop. A –
small leak is also present as indicated by the shortened
TIME
return of the abnormal loop. Small airway obstruction
leading to increased expiratory resistance, as seen in
Figure 32.30
animals with bronchial collapse or narrowing or emphy-
sema, markedly affects the P–V loop as seen in the loop
with the “up” arrow in Figure 32.28b. Problem 2
A 5-kg domestic shorthair cat is on volume-controlled ven-
tilation following a severe asthmatic attack. You look at the
Practice Problems
flow scalar shown here. What is wrong?
A set of eight practice problems follows in this section.
Answer
Remember that the flow pattern does not change with
Problem 1
changes in resistance or compliance. The expiratory flow
A 20-kg mixed breed dog is on its second day on the ven- has not reached zero before the next inspiration begins,
tilator for hypoventilation following ventral slot surgery indicating air trapping and auto-PEEP. A longer
Practice Problems 423
expiratory time with or without bronchodilator therapy, Answer

especially if peak expiratory flow has declined, may prove The slope of the loop is well below 45 degrees and the com-
helpful. pliance with and without resistance characteristics of the
respiratory system is poor. Perhaps an increase in PEEP is a
good place to start to maximize pulmonary function by
Problem 3 opening airways, allowing for improved volume change for
You try switching the cat in Problem 2 to pressure- change in pressure and prevent ventilator-induced
controlled ventilation and get the flow scalar labeled B here lung injury.
and compare it with the normal flow scalar labeled A. Did
this change help the cat?
Problem 5
A five-year-old Chihuahua is on the ventilator for pulmo-
Normal nary contusions after being hit by a car. Volume-controlled
ventilation is being used and you see the F–V loop shown
here. What do you suspect?
+
A B
FLOW
FLOW (L/min)
TIME VOLUME (mL)
Figure 32.31
Answer
No. The expiratory flow does not reach zero before the next
breath begins, and the decrease in expiratory flow indicates
a continued expiratory flow limitation. Figure 32.33
Problem 4 Answer
A nine-year-old Labrador Retriever is placed on positive A marked decrease in the expiratory flow rate indicates
pressure ventilation following a witnessed vomiting and expiratory flow limitation. Upon examination of the patient,
aspiration episode. Following initial setup, you examine you find no obvious airway obstruction. However, your
the P–V loop. What do you conclude? veterinary technician notices that the water trap in the
expiratory limb of the circuit is quite full and overflowing
into the breathing circuit, thus increasing resistance to air
flow. Upon emptying the water, the F–V loop returns
to normal.
VOLUME (mL)
Problem 6
This two-year-old German Shepherd required mechanical
ventilation for lower motor neuron disease. The dog is cur-
rently on SIMV with pressure support, but the clinician
reports that the dog is not yet showing any evidence of trig-
PRESSURE (cm H2O) gering an assisted or a supported breath. You look at the
pressure scalar below and then change a ventilator setting
Figure 32.32 at point A. What did you do?
+ +
PRESSURE
FLOW
0 0
–
–
TIME
TIME (a)
Figure 32.34
Answer
There are negative pressure deflections that are not
FLOW (L/min)
followed by a delivered pressure support breath, indicating
that the trigger sensitivity is set too high. You reduced the VOLUME (mL)
trigger sensitivity from 5 to 2 l/minute at point A and then
observed two pressure-supported breaths.
Problem 7 (b)
A 10-year-old Siamese cat was placed on pressure assist

control ventilation for severe pulmonary parenchymal
disease of unknown origin. You look at the cat and the flow
VOLUME (mL)
scalar (Figure 32.35a), F-V loop (Figure 32.35b), and P–V

loop (Figure 32.35c). What do you conclude?
Answer
The cat is making an expiratory effort toward the end of
inspiratory phase of the breath, thus creating a negative PRESSURE (cm H2O)
(c)
deflection in flow and pressure during the normally posi-
tive inspiratory time. This is patient–ventilator dyssyn- Figure 32.35
chrony and may lead to inadequate inspiratory volumes
and poor oxygenation and ventilation. The clinician should
try to change the settings to improve patient comfort based Answer
on the specific patient, respiratory parameters, and blood The spike in the pressure scalar at the beginning of inspira-
gas values. For example, an increase in inspiratory pres- tion indicates an excessive flow delivery during a fast rise
sure, respiratory rate, or flow rate may prove beneficial if time. The excessive flow and pressure do not necessarily
the animal has inadequate minute ventilation. Unless the translate into increased tidal volume delivery and are
cat appears too lightly anesthetized, it is best to give anes- therefore undesirable. Possible changes that may prove
thetics or paralytics only after all other strategies have helpful would include increasing the rise time (especially if
failed. Dyssynchrony is often the patient’s way of telling the endotracheal tube is very narrow) or decreasing the
the clinician that the ventilator settings are inappropriate. flow rate.
Problem 8
Summary
A three-month-old Labradoodle has suspected noncardio-
genic pulmonary edema after chewing on an electric cord. Respiratory waveforms generated during mechanical
The puppy is on pressure-controlled assist control ventilation can be helpful in bedside patient monitoring.
ventilation with PEEP, and the following pressure scalar With practice, interpretation of scalars and loops can be a
(Figure 32.36a) and P–V loop (Figure 32.36b) are observed. rapid way to evaluate the patient from a distance using
What might you do after seeing this pressure scalar? graphic information.
Recommended Reading 425
Figure 32.36
PRESSURE
0
TIME
(a)
VOLUME (mL)
Video 32.1 The patient is a 25 kg dog that is on the ventila- with decreased tidal volumes. As the PEEP is
tor for postoperative hypoventilation following increased on the ventilator, the patient
cervical disc decompression. The dog dis- receives larger tidal volumes with the same
played ventilatory dyssynchrony due to inade- peak inspiratory pressure. More of the lung is
quate ventilator support and inappropriate recruited and able to be ventilated.
inspiratory time. This was corrected by increas- Video 32.3 The patient is a 7 kg cat who presented with
ing the patient’s peak inspiratory pressure. The severe asthma. The patient is on a ventilator
dog also has a shorter inspiratory time than and given a bronchodilator. After the bron-
what the ventilator is delivering. The inspira- chodilator is administered, the patient’s tidal
tory time of the ventilator must be decreased volumes increase, and the peak inspiratory
so the patient is exhaling at the same time as pressure decreases. The patient also has a
the ventilator. The patient and the ventilator decreased respiratory rate after medication
become in sync after the settings are adjusted. administration. The patient’s ventilator set-
Video 32.2 The patient is a 25 kg dog that is on the venti- tings can be adjusted. The inspiratory time
lator for severe aspiration pneumonia. The can be increased to ensure patient–ventilator
dog has high peak airway pressures along synchrony.
Recommended Reading
Arnal, J.M. and Chatburn, R.L. (2018). Monitoring Phan, T.S., Costa, R., Haddad, W.M. et al. (2019). Validation of
Mechanical Ventilation Using Ventilator Waveforms. an automated system for detecting ineffective triggering
New York, NY: Springer International Publishing. asynchronies during mechanical ventilation: a retrospective
Hess, D.R. and Kacmarek, R.M. (2014). Essentials of study. J Clin Monit Comput. 34 (6): 1233–1237.
Mechanical Ventilation, 3e. New York, NY: McGraw-Hill. Ranieri, V.M., Zhang, H., Mascia, L. et al. (2000).
Oakes, D., Shortall, S., and Jones, S. (2015). Ventilator Pressure–time curve predicts minimally injurious
Management: A Bedside Reference Guide, 4e. Orono, ME: ventilatory strategy in an isolated rat lung model.
Health Educator Publications. Anesthesiology 93 (5): 1320–1328.
Sun, X.M., Chen, G.Q., Chen, K. et al. (2018). Stress index pressure–time curve profiles for estimating stress index in
can be accurately and reliably assessed by visually patients with acute respiratory distress syndrome. J. Clin.
inspecting ventilator waveforms. Respir Care. 63 (9): Monit. Comput. 33 (2): 281–290.
1094–1101. Yartsev, A. (2015). Interpreting the shape of the ventilator
Tobin, M.J. (2012). Principles and Practice of Mechanical flow waveform. Deranged Physiology (last updated 1 July
Ventilation, 3e. New York, NY: McGraw-Hill. 2022). https://derangedphysiology.com/main/
Waugh, J.B., Deshpande, V.M., Brown, M.K., and Harwood, cicm-primary-exam/required-reading/respiratory-system/
R. (2006). Rapid Interpretation of Ventilation Waveforms, Chapter%20553/interpreting-shape-ventilator. Accessed
2e. Upper Saddle River, NJ: Prentice Hall. 7 July 2022.
Wongsurakiat, P. and Yuangtrakul, N. (2019). Performance
and applications of bedside visual inspection of airway
427
33
Alternative Methods of Augmented Ventilation

Jessica Schavone and Elizabeth Rozanski
Intermittent positive pressure ventilation (referred to in approximately 300 breaths/minute (5 Hz), which is very
this chapter as conventional mechanical ventilation or close to the resonant frequency of the respiratory system
CMV) can be lifesaving in patients with respiratory or (RFRS) [1].
ventilatory failure. However, CMV with high inspiratory The RFRS is the natural frequency of the system at which
pressures exacerbates lung damage and perpetuates lung vibrations will occur with the least amount of energy
injury, and so modalities that allow less aggressive settings, required. Matching the RFRS is important because it mini-
or that replace CMV altogether, have gained traction in mizes the metabolic cost of panting. If dogs pant at a rate
human and veterinary medicine. Three other methods of quite different from the RFRS, it results in heat gain and
alternative ventilation may be considered to support can negate the cooling benefits. This cost is appreciated in
patients with respiratory failure. This chapter briefly dogs that are tachypneic due to disease, as their energy
describes the following basic alternatives or augmentations requirements for ventilation can increase dramatically. The
to CMV: high-frequency ventilation (HFV), including actual influence on caloric needs associated with increased
high-frequency jet ventilation (HFJV) and high-frequency respiratory rate and effort is poorly studied in dogs,
oscillatory ventilation (HFOV); high-flow oxygen therapy although in people there can be marked increase in caloric
(HFOT); and the use of a pediatric helmet. needs associated with respiratory effort associated with
acute and chronic respiratory diseases.
Normal panting dogs also ventilate adequately; dogs can
High-Frequency Ventilation have adequate gas exchange with these small tidal volumes
and rapid respiratory rates [2]. In our sea-level lung func-
Compared with CMV, HFV is a method by which to pro- tion laboratory, arterial blood gas samples collected from
vide ventilation and oxygen supplementation with less healthy panting dogs document high values for partial
potential for biotrauma, which is lung inflammation pressure of oxygen in arterial blood, often greater than
incited by the over-distention and repetitive opening and 100 mmHg, and lower partial pressure of carbon dioxide in
closing of lung units. HFV has not been widely adopted in arterial blood, often in the 28–32 mmHg range.
companion animals, although it may be helpful to be
familiar with its background, definitions, applications,
Definitions
indications, and contraindications, as well as the equip-
ment required. HFV is any technique that ventilates a patient at a respira-
tory rate higher than normal for that species, usually
greater than 10 times the typical rate. For a cat or a dog, this
Background
would be approximately 200 breaths/minute or greater.
The ability of the panting dog to remain normoxemic HFJV provides ventilation at rates of 60–400 breaths/
initially triggered early interest in the concept behind HFV minute in people. Inspiration is active; expiration is passive.
as a therapeutic entity. Panting in normal dogs is used for HFOV provides ventilation at rates greater than 400 breaths/
temperature regulation as heat is lost across the respiratory minute. In this form, both inspiration and expiration are
system. The respiratory rate of panting dogs is commonly active, and the gas flow is sinusoidal rather than the
428 Alternative Methods of Augmented Ventilation
Conventional Ventilation
HFOV
20
15
Mean
AW 10
Pressure
(cmH2O) 5
0
0 0.2 0.4 0.6 0.8 seconds
HFJV
Figure 33.1 Comparison of ventilatory rates and pressure

patterns with different ventilatory approaches. AW, airway; HFJV, Figure 33.2 High-frequency jet ventilator. The larger green
high-frequency jet ventilation; HFOV, high-frequency oscillatory hose coiled on the left of the image is the oxygen input hose.
ventilation. Source: Courtesy of Bunnell Inc., Salt Lake City, Utah. The smaller light green hose coiled on the right is the gas
output hose through which HFJV would be delivered to the
patient. Note that the supply to the patient has a male tubing
adapter at the end to attach to a standard vascular catheter or
triangular flow seen with HFJV. Figure 33.1 shows a infant feeding tube, which would be inserted into the animal’s
graphic depiction of the differences in the rates and pres- trachea.
sure tracings for these different forms of ventilation.
Any of these HFV techniques can be combined with pos- ventilator. The inspiratory time may be changed but is
itive end expiratory pressure (PEEP) if needed to help usually left at 20 milliseconds. As is true of all ventilation
recruit lung units and improve oxygenation. The applica- (spontaneous as well as mechanical), the volume of the
tion of PEEP is often required in patients with significant breath in milliliters is determined by the relationship
pulmonary disease but is generally not required or possible between the pressure difference between the airway open-
when HFV is used for interventional procedures such as ing and the intrapleural cavity as well as the compliance
routine bronchoscopy. (distensibility) of the lung. Expiration is passive. Sighs are
often provided by the ventilator at 2–10 breaths/minute.
The ventilatory pressure waveform in HFJV is peaked
How High-Frequency Ventilation Works
(Figure 33.1). Figure 33.2 depicts a jet ventilator.
Normal CMV relies primarily on bulk convection and dif- HFOV is provided with a piston and diaphragm, which
fusion to eliminate carbon dioxide (CO2) and to provide makes both inspiration and expiration active. There is no
oxygenation. In all forms of HFV, convection and molecu- need for a conventional ventilator. The inspiratory-to-
lar diffusion are still the primary mechanisms of gas expiratory ratio is usually fixed at 1 : 2, although it may be
exchange, but additional mechanisms of CO2 elimination adjusted. The mean airway pressure (mPaw) and oxygen
include pendelluft (“sloshing” back and forth of gas), concentration can be adjusted. The pressure waveform in
Taylor-type dispersion (gas mixing enhanced by turbu- HFOV is sinusoidal (Figure 33.1).
lence), and asymmetrical gas velocity profiles. These addi-
tional effects help HFV to provide adequate ventilation at
Major Applications and Indications
lower airway pressures than CMV. Fresh gas is introduced
into the system both to displace CO2-rich gas from the res- In general, HFV is considered beneficial because it uses
piratory system and to provide oxygen. This fresh gas is the smaller tidal volumes and it improves ventilation : perfu-
source of the tidal volume and is introduced at an angle sion matching in the lungs. The alveoli remain in a rela-
into the high-frequency system; thus, it is often referred to tively constant region on the pressure–volume curve,
as bias flow because it is introduced “on the bias.” which may minimize biotrauma.
HFJV is often used in tandem with a conventional venti- Practically, HFV has found clinical application in two
lator, with the conventional ventilator providing the bias major areas: in neonatal medicine in people, and for
oxygen flow, PEEP, and occasional sighs (larger breaths). supportive ventilation during interventional procedures in
An endotracheal tube adapter is used so the patient does human and veterinary medicine. Occasionally, HFJV is
not require reintubation. Ventilation is controlled by alter- used in human medicine for patients with severe lung dis-
ing the rate and peak inspiratory pressure on the jet ease, although a multitude of clinical trials have failed to
ther ovel Ventilation Strategies 429
identify a survival benefit in adults with acute respiratory incorrect. The initial fears were based on the potential for
distress syndrome (ARDS). HFJV has been used to some air trapping or hyperinflation because lungs with a delayed
extent during the recent COVID-19 pandemic. time constant (high resistance/low compliance) do not
Currently, HFV is used most commonly in neonatal have as a favorable response to HFV.
medicine. Techniques for the support of critically ill and
premature neonates have improved tremendously in the
Veterinary Studies of High-Frequency Ventilation
past 30 years with the advent of surfactant therapy and
other advances. Current recommendations for ventilation Although HFV and airway pressure release ventilation
of neonates include consideration of transition to HFJV or (see later) have been used extensively in research set-
HFOV when peak inspiratory pressures exceed 25 cm H2O, tings [4], there are no clinical descriptions of their use in
if tidal volume greater than 6 ml/kg is required, if rapid dogs or cats with naturally occurring acute lung injury.
respiratory rates are required, if air leak syndrome is pre- HFJV is used during bronchoscopy procedures by some
sent, if extracorporeal membrane oxygenation is being clinicians [5], and there exists a report of a premature foal
considered, or in extreme prematurity [3]. The use of HFV supported by HFJV [6]. Owing to the propensity of dogs to
is advised when high respiratory rates are required pant, it is conceivable that HFV would be a favorable ven-
because conventional ventilators are not responsive at tilation scheme in dogs with ARDS. Most recently, HFJV
such rates, and air trapping (auto-PEEP) is a potential was described as a method of limiting motion in dogs
concern due to breath stacking (see Chapters 31 and 32 receiving radiation therapy for heart-base tumors [7].
for more information). HFOV is emerging as the more
popular method of HFV in neonates.
Interventional procedures commonly use HFJV to pro- Other Novel Ventilation Strategies
vide adequate oxygenation during a procedure when a rou-
tine endotracheal tube is impractical. Some veterinary While CMV can be lifesaving, it is invasive, carries its own
internists and criticalists use this technique during bron- risks, and requires considerable client emotional and
choscopy or other airway manipulations. HFV is used dur- financial investment. Two other modalities of respiratory
ing bronchoscopy through a catheter placed with its tip at support that are gaining popularity for treatment of small
the level of the mid-trachea or carina, depending on the animals are HFOT and continuous positive airway pres-
area being evaluated. Some veterinary pulmonologists sim- sure support using a pediatric helmet.
ply provide supplemental oxygen during the procedure
rather than jet ventilation.
High Flow Oxygen Therapy
The goals for both HFJV and HFOV are maintenance of
optimal lung volume and adequate blood gases. For HFJV HFOT delivers up to 40 l/minute of warmed, humidified
and HFOV, lung volume is primarily maintained by PEEP, gas to a patient. Studies have shown that HFOT is well-
which limits the need for high peak inspiratory pressures. tolerated in dogs, and that it may decrease the need for
As with all ventilators, the training and skill set of those CMV. HFOT is delivered using specialized equipment but
using the ventilator is more important than the specific does not require one-to-one nursing care as does CMV.
type of ventilator chosen. HFOT requires nasal cannulas, and importantly consumes
Patient assessment is similar to that performed during a large amount of oxygen, which can be challenging if only
other forms of ventilation. Animals that require HFV gen- small oxygen tanks are available. Cats tolerate HFOT less
erally are critically ill animals, and minute-to-minute well than dogs. Brachycephalic dogs in particular may
assessments may be required. As in CMV, oxygenation benefit from HFOT due to the added benefit of the gas
goals may be reduced, such that oxygen saturation of 88% pressure stenting open some of the upper airway. See
or greater could be acceptable. Depending on the tech- Chapter 24 for more details about the use of HFOT (or
nique used, capnography may or may not be possible high-flow nasal cannula) in dogs and cats.
(Chapter 30); standard capnographic waveforms would not
be expected due to the very rapid respiratory rate.
Pediatric Helmet
Oxygen therapy may also be delivered by pediatric helmet,
Contraindications
which effectively delivers continuous positive airway pres-
There are few absolute contraindications to HFV. The sure without the need for tracheal intubation. This tech-
major one is lack of familiarity with the equipment and nique has been used in cats and dogs and may offer another
monitoring techniques. Asthma is occasionally listed as a less invasive option compared to intermittent positive pres-
contraindication, though recent studies suggest this is sure ventilation in some cases.
430 Alternative Methods of Augmented Ventilation
Summary whether HFV is more effective than CMV in companion

animal medicine, particularly in ARDS. Noninvasive venti-
HFV, particularly HFOV, is an exciting and possibly under- latory methods, including HFOT and helmet-associated
used option for ventilatory support in dogs with acute lung ventilation, may provide novel opportunities for veterinary
injury. Future studies would be helpful to determine medicine.
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Gilgen-Ammann, R., Koller, M., Huber, C. et al. (2017). Meira, C., Joerger, F.B., Kutter, A.P.N. et al. (2018).
Energy expenditure estimation from respiration variables. Comparison of three continuous positive airway pressure
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characteristics at the onset of a severe asthma attack Anaesth. Analg. 45 (2): 145–157.
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severe asthmatic patients. Eur. J. Emerg. Med. 5 (4): Conventional versus high-flow oxygen therapy in dogs
451–451. with lower airway injury. Can. J. Vet. Res. 85 (4): 241–250.
Hahn, G. (1990). Resonant frequency of the chest-lung Ritacca, F.V. and Stuart, T.E. (2003). Clinical review: high-
system by analysis of the respiratory flow curve. Comp. frequency oscillatory ventilation in adults – a review of the
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C.L. (2020 Jul). High-flow nasal cannula oxygen therapy in reviews: high-frequency oscillatory ventilation (HFOV)
acute hypoxemic respiratory failure in 22 dogs requiring and airway pressure release ventilation (APRV): a practical
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431
34
Pleural Space Drainage

Amanda Arrowood and Lori S. Waddell
The pleural space is a potential space that can be occupied pneumothorax has also been associated with leakage of gas
by tumor, fluid, gas, or abdominal organs. Drainage of the from sites of pulmonary abscessation, primary and meta-
pleural space is indicated for patients with pleural fluid or static pulmonary neoplasia, foreign body migration, pneu-
gas accumulation. The choice of technique, whether thora- monia, and feline asthma. In addition, parasitic disease such
cocentesis or thoracostomy tube placement, depends on sev- as Dirofilaria, Paragonimus, and Filaroides osleri have been
eral factors, including the patient’s stability, the rate of associated with acute pneumothorax in dogs [2]. Physical
reaccumulation of gas or fluid, and the underlying disease examination findings include dull lung sounds and often
process. Pleural effusion can be secondary to a wide variety dull heart sounds. If the lung sounds are dull ventrally, a
of disease processes and may be characterized as exudative, pleural effusion should be suspected, whereas dullness
transudative, chylous, or hemorrhagic. These may be caused dorsally is usually associated with a pneumothorax. The
by a variety of disease processes. Septic exudative effusions respiratory rate is often increased, and an asynchronous or
are seen with pyothorax, which may arise secondary to pen- inverse breathing pattern is associated with pleural space
etrating chest wounds, hematogenous spread, extension disease is both dogs and cats. The findings of dull lung
from adjacent structures or fascial planes, aspirated foreign sounds, together with this respiratory pattern, have a high
bodies, ruptured pulmonary abscesses, ruptured esophagus, sensitivity but low specificity for pleural space disease [3].
and iatrogenic causes. Non-septic exudates can occur from
infection with feline infectious peritonitis virus. Transudates
(pure and modified) are most often caused by congestive Thoracocentesis
heart failure but can also develop or be exacerbated by fac-
tors such as hypoproteinemia or vasculitis. They can be seen Thoracocentesis is a quick and relatively easy method of
in patients with sepsis or pancreatitis and in patients with removing gas or fluid from the pleural space. If a patient is in
pulmonary thromboembolism. Neoplasia and lung lobe tor- respiratory distress and pleural effusion or pneumothorax is
sions may also cause a modified transudate. Chylous effu- suspected, thoracocentesis should be performed before radi-
sions can be caused by trauma, neoplasia, cardiac disease, ographs to optimize patient stability. Thoracocentesis can be
and idiopathic causes. Hemothorax is most often caused by both diagnostic and therapeutic. When either gas or fluid is
trauma, coagulopathy, or neoplasia, but can also be caused found, the chest cavity should be evacuated, which often
by infection with Spirocerca lupi or Dirofilaria; or by jugular eliminates the patient’s respiratory distress.
venipuncture or catheter placement, thoracocentesis, or fine
needle aspiration or biopsy of intrathoracic structures.
Indications
Blunt thoracic trauma can result in rupture of the lung
and cause gas leakage from the alveoli or airways into the Any patient that presents in severe respiratory distress
pleural space, resulting in lung lobe collapse and pneumo- with decreased lung sounds is a candidate for immediate
thorax. Pneumothorax is the most common complication of thoracocentesis. In particular, patients that have sustained
blunt thoracic trauma in dogs [1]. Pneumothorax can also thoracic trauma such as being hit by a car, sustaining bite
occur spontaneously, most commonly secondary to gas leak- wounds, or falling from a height may develop pneumotho-
age from ruptured pulmonary bullae or blebs. Spontaneous rax or, less commonly, hemothorax. Thoracic radiographs
432 Pleural Space Drainage
can be used to confirm the diagnosis before thoracocente- Patients receiving positive pressure ventilation have an
sis but are not always tolerated by unstable patients. increased risk of pneumothorax and warrant thoracocente-
Thoracic ultrasound can be used to confirm the presence sis if they develop signs of respiratory distress, hypoxemia,
of gas or fluid and is usually much less stressful to the decreased tidal volumes, or increased airway pressures
patient (Chapter 27). Patients that present with pleural with diminished lung sounds.
effusion benefit from thoracocentesis to remove the fluid, The major contraindication for thoracocentesis is severe
both to stabilize the patient’s respiratory status and to coagulopathy, due to the risk of creating a potentially life-
obtain samples for diagnostic testing. Thoracocentesis can threatening hemothorax. Efforts should be made to correct
be a valuable diagnostic tool, even in cases with small vol- the coagulopathy prior to thoracocentesis, if possible.
ume pleural effusion that is not causing clinical signs.
Thoracic ultrasound is helpful in determining the location
Procedure for Thoracocentesis
of any fluid pockets and can help guide the site for thora-
cocentesis. When fluid is obtained, it should be submitted Thoracocentesis (Protocol 34.1) is an essential skill because
for cytology, fluid analysis, and culture and sensitivity if it can be both therapeutic and diagnostic for patients with
indicated. pleural space disease. The required equipment is listed in
Protocol 34.1 Procedure for Thoracocentesis

Items Required chest wall, just cranial to the rib to avoid intercostal
blood vessels.
● Clippers
8) Once through the chest wall, the needle can be
● Surgical scrub
directed either dorsally (if gas is expected) or ven-
● Large syringe (10–60 ml), ideally with Luer lock
trally (if fluid is expected) so that the needle is almost
● Sterile gloves
parallel to the chest wall.
● Three-way stopcock, ideally with Luer lock
9) Observe hub of needle for fluid.
● Extension tubing, two sets if expecting fluid
a) If small amount of frank blood is aspirated sud-
● Needle or a butterfly catheter
denly or unexpectedly or if lungs can be felt
⚬ Large dogs: 1.5-inch needle or longer catheter
rubbing against needle, needle should be
⚬ Medium dogs and large cats: 1-inch needle or catheter
removed and replaced at a slightly different
⚬ Cats and small dogs: ¾- to ⅞-inch butterfly needle
location.
● Bowl and tubes for samples including one with EDTA
b) If a larger volume of blood is obtained, place
and one without anticoagulant (if expecting fluid)
1–2 ml in a blood collection tube that does not
contain anticoagulant, to evaluate for clotting.
Procedure
c) Blood from hemothorax should not clot; blood from
1) Gather supplies. the heart or a blood vessel should clot normally, if
2) Perform hand hygiene and don clean examina- patient does not have a significant coagulopathy.
tion gloves. d) For any other fluid, aspiration should continue
3) Position patient, preferably in sternal recumbency or until no more can be removed.
standing. Lateral recumbency is also acceptable for pneu- 10) Directing the needle ventrally, rolling the patient
mothorax. Patient comfort should determine position. slightly to the side that thoracocentesis is being per-
4) Have assistant available to restrain patient or give formed, and re-aspirating from a more ventral location
sedation as needed. In many cats, a minimal restraint can facilitate removal of as much fluid as possible.
technique is preferred and generally better tolerated. 11) Fluid is saved for analysis, cytology, and culture if
5) Clip and aseptically prepare the appropriate rib space: indicated.
a) If expecting fluid, the seventh or eighth intercostal 12) Aspiration of gas will turn the tubing a slightly foggy
space, at approximately the level of the costochon- white color as the warm, humid gas from the thoracic
dral junction, or as directed by ultrasound. cavity encounters the room temperature tubing.
b) If expecting gas, the eighth or ninth intercostal 13) Aspirate until negative pressure is reached. If nega-
space approximately one-third of the way down the tive pressure is never achieved, a tension pneumo-
chest (about halfway between the spine and costo- thorax may be present, and chest tube(s) with
chondral junction). continuous suction are needed (see section on thora-
6) Perform hand hygiene and don sterile gloves. costomy tube placement). Continued aspiration of
7) Insert the appropriate size needle or butterfly catheter, gas may be required while thoracostomy tube sup-
bevel directed dorsally, slowly perpendicular to the plies are collected to optimize patient stability.
Thoracocentesis 433
to determine where the largest accumulation of fluid is and

Box 34.1 Equipment for Thoracocentesis
therefore the best site for thoracocentesis. If gas is expected,
● Clippers a more dorsal approach, about one-third of the way down
● Surgical scrub the chest, in the eighth or ninth intercostal space is used
● Large syringe (10–60 ml), ideally with Luer lock (about halfway between the spine and costochondral junc-
● Three-way stopcock, ideally with Luer lock tion; Figure 34.1). Sterile gloves should be worn for the
● Extension tubing and a needle or a butterfly catheter insertion of the appropriate size needle or butterfly cathe-
● Bowl and tubes for samples including one with EDTA ter. Large dogs may require a 1.5-inch needle to penetrate
and one without anticoagulant (if tapping for fluid) the chest wall, whereas a three-quarters or seven-eighth-
inch butterfly needle is sufficient for most cats and small
dogs. In very large dogs, a 16-gauge, 3.25 inch or 14-gauge,
Box 34.1. Extension tubing is used when tapping with a 5.25-inch catheter can be used, which are longer and much
needle to prevent movement of the needle in the chest as less prone to collapsing than most smaller catheters due to
the three-way stopcock is operated. A short over-the-needle their larger gauge. The needle tip should be placed just cra-
catheter can be used to reduce the risk of laceration of the nial to the rib to avoid intercostal blood vessels and nerves,
lung or blood vessels, but these often kink once the stylet is which run along the caudal border of each rib. The needle
removed. Cardiovascularly-sparing sedation may be needed is then gently inserted into the thorax perpendicular to the
depending on the patient’s stability and temperament. chest wall with the bevel of the needle directed dorsally
Oxygen supplementation should be provided if the patient while carefully observing the hub of the needle and exten-
is in respiratory distress. With an assistant restraining the sion tubing for any signs of fluid. Once through the chest
animal (preferably in sternal recumbency or standing), the wall, the needle can be directed either dorsally (if gas is
appropriate rib space should be clipped and aseptically pre- expected) or ventrally (if fluid is expected) so that the nee-
pared. Patient comfort often determines which position is dle is almost parallel to the chest wall (Figure 34.2).
best, as well as whether gas or fluid is expected to be aspi- If a small amount of frank blood is suddenly and unex-
rated. If gas is expected, sternal or lateral recumbency may pectedly aspirated from the thorax, or if the lungs can be
be acceptable because the gas will rise to the top of the felt rubbing against the tip of the needle, the procedure
chest in either position. If fluid is to be aspirated, sternal should be stopped, and the needle removed and replaced
recumbency or standing is best because the fluid will accu- at a slightly different location. If a large amount of blood is
mulate in the ventral portion of the pleural space. When withdrawn from the thorax, 1–2 ml should be placed in a
pleural fluid is expected, the seventh or eighth intercostal blood tube containing no anticoagulant, to make sure the
space is recommended, at approximately the costochon- blood does not clot. Blood from a hemothorax should not
dral junction. If available, bedside ultrasound can be used clot within the tube, whereas blood from the heart or a
Figure 34.1 Schematic showing

thoracocentesis in a dog in
sternal recumbency using a
butterfly catheter. The needle is
inserted in the eighth intercostal
space, just cranial to the rib.
(a)
(b) (c)
Figure 34.2 (a) Equipment for thoracocentesis using a 1-inch, 22-gauge needle; an extension set; a three-way stopcock; and a
syringe. (b) Thoracocentesis in a bearded collie that presented with a spontaneous pneumothorax. Note that the ninth intercostal
space is being tapped, one-third of the way down the chest (about halfway between the spine and costochondral junction) because
gas is expected. (c) Close-up of thoracocentesis in the bearded collie. The needle is inserted with the bevel of the needle oriented
dorsally.
blood vessel is expected to clot normally, providing there is volume of fluid or gas needs to be removed or if the
no significant concurrent coagulopathy. If any other fluid effusion has a lot of fibrin or is very pocketed.
type is seen in the hub of the needle, aspiration of fluid
should continue until no more fluid can be removed. If the
Complications
patient tolerates it, the needle can be directed ventrally
while the patient is rolled slightly toward the side on Complications of thoracocentesis include iatrogenic
which thoracocentesis is being performed, and reaspirat- pneumothorax from lung laceration, intrathoracic hem-
ing from a more ventral location can facilitate removal of orrhage from laceration of blood vessels, or rarely
as much fluid as possible. A fluid sample should be saved re-expansion pulmonary edema in situations of chronic
for fluid analysis, cytology, and possibly culture in appro- pleural effusions. Thoracocentesis without imaging con-
priate tubes (Chapter 59). If gas is aspirated from the tho- firmation of pleural space disease risks tapping an empty
rax, it usually turns the butterfly tubing a slightly foggy pleural space. Although this can lead to iatrogenic pneu-
white color as the warm, humid gas from the thoracic cav- mothorax or hemorrhage, these are relatively uncommon
ity encounters the room temperature tubing and conden- complications and are usually self-limiting unless the
sation occurs. If gas is aspirated, continue aspiration until patient has severe, chronic pulmonary pathology. Acute
negative pressure is reached. If negative pressure is never death from the stress of restraint is also possible.
achieved, a tension pneumothorax may be present, and Appropriate sedation may reduce these risks, and care
placement of a chest tube(s) with application of continu- should be taken in choosing drugs with minimal respira-
ous suction is recommended. Diagnostic thoracocentesis tory suppression. After thoracocentesis, the patient
is a relatively quick procedure (< 5 minutes), though should be monitored for reoccurrence of respiratory dis-
therapeutic thoracocentesis can be prolonged if a large tress that may indicate return of either gas or fluid to the
Thoracostomy Tube Placement 435
pleural space or the development of an iatrogenic pneu-

Box 34.2 Equipment for Thoracostomy Tube
mothorax or hemothorax (less common).
Placement
● Clippers
Thoracostomy Tube Placement ● Surgical scrub
● Surgical blade
Indications ● Local anesthetic
● Small surgical pack
Indications for placement of a thoracostomy tube (chest
● Suture material
tube) include recurrent pneumothorax requiring repeated
● An assistant (if possible)
thoracocentesis, tension pneumothorax, pyothorax, rapidly
● Thoracostomy tube or guidewire-assisted thoracos-
forming pleural effusion, and postoperative management
tomy tube kit
of patients having undergone thoracotomy. A tension
● Catheter adapter (or Christmas tree adapter)
pneumothorax occurs as gas progressively accumulates in
● Chest tube clamp
the pleural space through a one-way valve leak of the lungs
● Three-way stopcock with Luer lock
or airways into the pleural space. This leads to pressure
● Injection caps with Luer lock
atelectasis of the lungs and decreased venous return to the
● 20-gauge orthopedic wire or zip ties to secure
heart. A tension pneumothorax can cause fatal respiratory
connections
arrest in seconds to minutes. If a tension pneumothorax is
present, thoracocentesis and chest tube placement should
be performed immediately. The other indications for chest
tube placement usually allow a less urgent approach to
orthopedic wire or zip ties may be used. Bandaging material
placement.
should also be available.
Thoracostomy tube placement allows for frequent intermit-
There is a variety of commercially available thoracos-
tent evacuation of the pleural space or continuous evacuation
tomy tubes made of silicone or polyvinyl that are pack-
if attached to continuous suction. As with thoracocentesis, a
aged with stylets. These tubes typically have a radiopaque
major contraindication for thoracostomy tube placement is a
line that allows for easier visualization on radiographs.
severe coagulopathy, which should be corrected prior to place-
Small-bore chest tubes that are placed via a guidewire are
ment of a thoracostomy tube if possible.
available and can usually be placed quite rapidly but may
Thoracostomy tubes should be placed under cardio-
not be ideal for thick or loculated effusions [5]. Pigtail
vascularly-sparing sedation or intubation and general
catheters are used as thoracostomy tubes in human
anesthesia. In unstable patients, general anesthesia with
medicine but currently have not been widely adopted in
intubation is recommended so that ventilation can be
veterinary medicine. Red rubber tubes can also be used
assisted if needed. The patient’s oxygenation should
but are more difficult to place (must use surgical tech-
be monitored with pulse oximetry while sedated or
nique) and are more likely to collapse; red rubber tubing
anesthetized.
is also irritating to tissues and can thus perpetuate fluid
Positive pressure ventilation worsens a closed pneumo-
accumulation.
thorax, so if the patient requires ventilation, the chest
The size of the tube should be based on the size of the
cavity should be evacuated by thoracocentesis while pre-
patient and whether gas or fluid is expected. Smaller tubes
paring for thoracostomy tube placement. This can be
can be used for aspiration of gas. If fluid is expected, larger
accomplished by either continuous thoracocentesis or via
sized tubes are used, but care should be taken not to place a
an open pneumothorax. An open pneumothorax may be
tube as large or larger than the patient’s intercostal space to
created by inserting a catheter into the thoracic cavity or
avoid discomfort. If the fluid is thick or loculated, extra
by performing a mini-thoracotomy. If a tension pneumo-
drainage holes can be made in the tube prior to placement
thorax is present, continuous evacuation of the pleural
with a scalpel blade, making sure the holes are less than
space via thoracocentesis will be needed until the chest
50% the diameter of tube. If the fenestrations are more than
tube is in place.
50% the tube’s diameter, or are made too closely together,
there is risk of the distal portion of the tube breaking off in
the thorax, requiring surgical removal.
Thoracostomy Tube Placement
Three common techniques for placement of a thoracostomy
Box 34.2 lists the equipment needed for chest tube tube are described: noninvasive surgical (Protocol 34.2),
placement. To secure the connections of the chest tube, guidewire-based (Protocol 34.3) and trocar (Protocol 34.4)
catheter adapter, and three-way stopcock, 20-gauge methods. All methods require the same approach.
Protocol 34.2 Noninvasive Surgical Method of Chest Tube Placement
● For items required see Box34.2. large dogs 1.0 ml/site [4]. The total feline dose should
not exceed approximately 1 mg/kg bupivacaine.
Procedure 12) Bluntly dissect into the pleural space using hemostats,
1) Gather supplies. and then spread them wide enough to allow the tube
2) General anesthesia or sedation is usually required. to be passed between the hemostat’s jaws and through
General anesthesia allows for more control of the hole that was created. Insert the tube and stylet
patient’s respiratory function and is preferred. into the pleural space and advance cranio-ventrally
3) Place patient in lateral recumbency. 1–2inches, orienting the tube parallel to the thoracic
4) Clip the lateral thorax from just caudal to the scapula wall. The tube should then be fed off the stylet cranio-
to the last rib and from dorsal spine to ventral ventrally. Tubes without trocars can also be placed
midline. using this technique.
5) Aseptically prepare the hemithorax. 13) Stop positive pressure ventilation while inserting the
6) Perform hand hygiene and don sterile gloves. tube, to allow lungs to deflate and decrease risk of
7) Drape the area. trauma to lungs.
8) Loosen stylet from chest tube. Extra holes can be 14) Assess placement of the tube by using the stylet (or a
carefully made in the chest tube to aid drainage if same-size tube, if using a tube without a stylet) to meas-
fluid is present in pleural space. The holes are made ure the distance the tube has been advanced within the
with a scalpel blade and should not exceed 50% the thorax. Ideal placement results in the tube tip lying just
diameter of the tube to prevent tube breakage within caudal to the ipsilateral elbow. Once placement is
the thoracic cavity. determined to be adequate, the assistant can release the
9) Make a small stab incision in the skin over the wid- skin and allow skin to create a subcutaneous tunnel for
est point of the thorax when the patient is in lateral a portion of the tube that remains outside the thorax;
recumbency at intercostal space 9–10 (about half- this helps create an airtight seal to prevent room air
way between the spine and costochondral junction). entering the thorax through the insertion site.
10) Pull the skin cranially (assistant) to allow the chest 15) Connect the tube to a Luer-locking three-way stopcock
tube to be placed in intercostal space 7–8. and screw-on injection caps or a pleural drain-
11) For dogs, 0.25–1.0 ml of 0.25 or 0.5% bupivacaine age system.
(maximum total dose of 3 mg/kg) can be injected into 16) As soon as the tube is in place, aspirate the gas or
the subcutis and intercostal muscles at the planned fluid present.
tube insertion site. Alternatively, an intercostal nerve 17) Once finished aspirating, place chest tube clamp on tube.
block can be performed by injecting 0.25–1.0 ml of 18) Secure the tube to the skin with a purse-string suture
0.25 or 0.5% bupivacaine per site just ventral and around the tube at the entry site and a finger trap
caudal to the transverse processes of the thoracic suture pattern.
vertebrae/head of ribs one space cranial and caudal, 19) Place sterile dressing and light bandage over the
and at the site of insertion. Before injecting, the insertion site.
syringe should be aspirated to ensure that the nee- 20) Secure tube connection with orthopedic wire or zip ties.
dle is not in an artery or vein. Small dogs should 21) Perform thoracic radiographs (two orthogonal views)
receive 0.25 ml/site, medium dogs 0.5 ml/site, and to check tube(s) placement.
Noninvasive Surgical Method by injecting 0.25–1.0 ml of 0.25% or 0.5% bupivacaine per

The patient should be placed in lateral recumbency, and the site just ventral and caudal to the transverse processes of the
lateral thorax should be clipped from just caudal to the scap- thoracic vertebrae/head of ribs one space cranial and
ula to the last rib and from dorsal spine to ventral midline. caudal, and at the site of insertion. Before injecting, the
The area should be aseptically prepared (Figure 34.3a) and syringe should be aspirated to ensure that the needle is not
draped. The chest tube should be loosened from the stylet if in an artery or vein. The total dose of bupivacaine should
a styletted tube is being used. For dogs, 0.25–1.0 ml of 0.25% not exceed 3 mg/kg in dogs. Small dogs should receive
or 0.5% bupivacaine can be injected into the subcutis and 0.25 ml/site, medium-size dogs 0.5 ml/site, and large dogs
intercostal muscles at the planned tube insertion site, or 1.0 ml/site [4]. For cats, 1 mg/kg bupivacaine is an appropri-
alternatively, an intercostal nerve block can be performed ate total (maximum) dose for all sites combined.
Protocol 34.3 Guidewire-Assisted Thoracostomy Tube Placement

● For items required see Box 34.2. the wire can be grasped at the proximal end of
the catheter before the catheter is fully advanced
into the chest.
Procedure
10) The guidewire is removed, and the catheter
1) Gather supplies. sutured in place via the eyelets and the neck of the
2) Provide local anesthesia and sedation as needed. catheter. Adapters can be used to adjust the length
3) Initial preparation as previously described of the catheter that remains in the pleural space,
(Protocol 34.2). with additional sutures through the eyelets of the
4) A stab incision is made in the skin of the seventh adapters to secure the tube.
or eighth intercostal space. 11) Stop positive pressure ventilation any time a sty-
5) An 18- or 14-gauge introducer catheter is placed let or other sharp object enters the thorax, to
cranial to the rib and advanced cranially into the allow lungs to deflate and decrease risk of
pleural space. trauma to lungs.
6) A 60-cm guidewire is inserted through the cath- 12) Connect the tube to a three-way Luer-locking
eter and directed cranially, leaving approxi- stopcock and screw-on injection caps or a pleu-
mately 20 cm or more outside the thorax. ral drainage system.
7) The catheter introducer is removed, leaving the 13) As soon as the tube is in place, aspirate the gas
guide wire in place. or fluid present.
8) If using the kit’s semi-firm dilating catheter, at 14) Once finished aspirating, clamp the tube.
this stage it is threaded over the guidewire, 15) Place sterile dressing and light bandage.
twisted firmly but gently through the soft tissues 16) Perform thoracic radiographs (two orthogonal
to create the tunnel, and removed. views) to check tube(s) placement.
9) The 14-gauge catheter is fed over the guidewire
and inserted into the pleural space, ensuring that
Protocol 34.4 Trocar Method of Chest Tube Placement

● For items required see Box 34.2. 7) Assess placement of the tube by using the stylet
outside the animal to measure the distance the
Procedure tube has been advanced within the thorax.
8) Connect the tube via an adapter piece to a Luer-
1) Gather supplies
locking three-way stopcock and screw-on injection
2) Provide sedation or anesthesia if possible.
caps or a pleural drainage system.
3) Initial preparation as previously described
9) As soon as the tube is in place, aspirate the gas or
(Protocol 34.2).
fluid present.
4) Incise just the skin, tunnel the tube subcutaneously
10) Once finished aspirating, place chest tube clamp
two to three rib spaces, and then position it perpen-
on tube.
dicular to the chest wall and grasp in a tight fist to
11) Secure the tube to the skin with a purse-string suture
allow only 1–2 inches of the tube to penetrate the
around the tube at the entry site and a finger trap
chest (to prevent iatrogenic trauma from the tube
suture pattern.
penetrating too deeply).
12) Place sterile dressing and light bandage.
5) Bluntly strike the top of the tube with the palm of
13) Secure tube connection with orthopedic wire or zip ties.
other hand, popping the tube through into the
14) Perform thoracic radiographs (two orthogonal views)
pleural space.
to check tube(s) placement.
6) Lower the top portion of the tube toward the table,
decreasing the angle of insertion as the tube is advanced This is a very rapid placement technique but is not rec-
slightly. Once an additional 1–2inches of the tube and ommended unless in an emergency situation in dogs with
stylet are in the chest cavity, the tube is advanced off no other options, due to increased risk of iatrogenic
the stylet, directing it cranially and ventrally. trauma. It is never recommended in cats.
(b)
(a) (c)
(d) (e) (f)
(g) (h)
Figure 34.3 (a) A bearded collie is anesthetized, placed in lateral recumbency, and has had the lateral chest clipped and aseptically
prepared in preparation for thoracostomy tube placement. (b) An assistant pulls the skin cranially to create the subcutaneous tunnel for
the thoracostomy tube. (c) The chest is draped, and an incision approximately 1 cm in length is made between the 9th and 10th ribs,
approximately one-third of the way down the chest. (d) Carmalt clamps are used to bluntly dissect through the subcutis and muscles of
the chest wall. Carmalt clamps were chosen because of the size of this patient. (e) The thoracostomy tube is inserted into the chest
between the jaws of the Carmalt. (f) The thoracostomy tube is introduced into the pleural space while still on the trocar, angled to
become more parallel with the chest wall, advanced several centimeters, and then the tube is fed off the stylet. (g, h) The thoracostomy
tube is secured with a purse string suture around the tube and then a finger trap pattern to prevent the tube from slipping.
For the surgical technique, a small stab incision should tube to be placed in intercostal space 7–8, causing a tun-
be made in the skin over the highest point of the thorax at nel under the skin of two to three intercostal spaces. Blunt
intercostal space 9–10 (about halfway between the spine dissection with hemostats through the intercostal mus-
and costochondral junction). The skin should be stretched cles and parietal pleura is used to enter the thorax
forward by an assistant (Figure 34.3b,c) to allow the chest (Figure 34.3d). Then, without removing the hemostats,
the tip of the chest tube is placed into the thorax at a right screw-on injection caps and clamped with a chest tube
angle to the chest wall (Figure 34.3e). During this part of clamp or connected to a pleural drainage system for
the procedure, the anesthetist should cease positive pres- continuous suction. The insertion site is covered with a
sure ventilation to allow lung deflation, therefore decreas- sterile dressing and light bandage. Both lateral and ven-
ing the chance of iatrogenic trauma to the lungs. Then the trodorsal or dorsoventral thoracic radiographs should be
external end of the chest tube is lowered to decrease the taken to confirm the cranial and ventral position of the
angle of insertion and allow the tube to be placed along tube(s) (Figure 34.4a,b).
the inside of the thoracic wall, and the tube and stylet are
advanced in a cranio-ventral direction as the tube is fed Guidewire-Assisted Thoracostomy Tube Placement
off the stylet (Figure 34.3f). The tube is generally advanced The guidewire-based technique allows for placement of
toward the thoracic inlet. Placement of the tube can be small-bore chest tubes very quickly with just local anesthesia
assessed using the stylet to measure the distance that and sedation. (Figure 34.5a)
the tube has been advanced within the thorax, or if A modified Seldinger technique is used, in which an
using a red rubber catheter, by using another catheter of introducer catheter is placed first, then a guidewire, fol-
the same size. The tube is sutured in place with a purse- lowed by the catheter or thoracostomy tube. This method
string around the base of the tube and a finger trap requires the same initial approach as the surgical method.
(Figure 34.3g,h). This suture pattern helps prevent the Local anesthesia should be provided as described above in
tube from slipping out of the thoracic cavity by tightening the surgical method and sedation given as needed. A small
if the tube is pulled. This is accomplished by first suturing stab incision should be made in the skin where the catheter
with a single knot to the patient’s skin just cranial to the will be placed, typically in the seventh or eighth intercostal
purse-string suture, leaving both ends of the suture long, space. An 18- or 14-gauge introducer catheter is placed
and then crossing the ends of the suture beneath the chest into the pleural space along the cranial aspect of the rib
tube, making a single throw on top of the tube, then (Figure 34.5b) and directed cranially (Figure 34.5c). A 60-cm
repeating this pattern five to six times, finally tying off the guidewire is inserted through the catheter, directing the
suture. This allows the suture to climb the tube in a wire cranially, leaving at least 20 cm of wire outside the
crisscross pattern. The tube is then connected via an thorax. (Figure 34.5d) The introducer catheter is removed,
adapter piece to a Luer-locking three-way stopcock with leaving the guidewire in place. The kits usually contain a
(a) (b)
Figure 34.4 (a) Lateral radiograph of a cat with pyothorax to check placement of bilateral thoracostomy tubes. (b) Ventrodorsal
radiograph of the same cat. Both views are needed to confirm correct placement. Note the right thoracostomy tube enters the chest
too cranially (solid white arrows show where tubes enter thoracic cavity), at the fourth intercostal space, and it has one fenestration
outside the pleural space (striped arrow). This tube should be repositioned.
(a)
(b) (c) (d)
(e) (f) (g)
Figure 34.5 Placement of a guide wire based thoracostomy tube in a cadaver dog. (a) A guidewire based thoracostomy tube kit.
(b) The introducer catheter is passed through a skin nick perpendicular to the chest wall just cranial to the rib. (c) The catheter is
angled cranially as it is advanced into the pleural space. (d) The catheter’s stylet is removed and the guidewire is fed through the
catheter. (e) The introducer catheter is removed and the thoracostomy tube catheter is passed over the wire. (f) Once the wire is
grasped at the proximal end of the catheter, the catheter is fed fully into the pleural space. (g) The wire is removed and the catheter is
sutured in place.
semi-firm dilating catheter, which can be used to widen the tube. The tube is then connected and secured as described
diameter of the soft tissue tunnel through which the chest earlier for surgical placement, with radiographic confirma-
drain will be placed, if desired. If it is used, the dilator is tion of correct placement.
threaded over the guidewire, twisted firmly but gently The small diameter and flexible material of the guidewire-
through the soft tissues to create the tunnel, and removed placed catheter makes it well tolerated, especially in cats
before placing the indwelling catheter. The 14-gauge thora- and small dogs. These thoracostomy tubes should be used
costomy catheter is then fed over the guidewire and with caution in some cases; they can become obstructed if
inserted into the pleural space (Figure 34.5e), ensuring that the effusion is very thick or loculated, and can kink if
the wire can be grasped at the proximal end of the catheter placed in animals with a thick chest wall such as large or
before the catheter is fully advanced into the pleural space, obese dogs.
to prevent loss of the wire into the thorax (Figure 34.5f).
The guidewire is then removed, and the catheter is sutured Trocar Method
in place via the eyelets and the neck of the catheter The trocar technique is an alternative technique that is
(Figure 34.5g). Adapters can be used to adjust the length of more rapid but also has more risk of complications. This
catheter that remains in the pleural space, with additional method requires the same initial approach as the surgical
sutures through the eyelets of the adapters to secure the method in that it begins with a stab incision through only
the skin over the widest point of the thorax when the patient
is in lateral recumbency (about halfway between the spine
and costochondral junction) at intercostal space 9–10. The
tube is then tunneled subcutaneously two rib spaces cranial
to the skin incision. The tube is then positioned perpendic-
ular to the chest wall and the end closest to the animal’s
chest grasped tightly in the surgeon’s fist, so that only an
additional 1–2 inch of the tube will be available to penetrate
into the thoracic cavity. The top of the tube is struck bluntly
with the palm of other hand, popping the tube through
intercostal musculature and the pleura, into the chest cav-
ity. The angle of the tube is then lowered, decreasing the
angle of insertion as the tube is advanced slightly cranially
into the thorax. Once 1–2 inch of the tube and stylet are in
the chest, the tube is advanced off the stylet, directing it cra-
nially and ventrally. The tube is then connected and secured Figure 34.6 Use of orthopedic wire to secure thoracostomy
tube, clamp, three-way stopcock, and injection caps to prevent
as described earlier for surgical placement, with radio- accidental uncapping and iatrogenic pneumothorax.
graphic confirmation of correct placement.
Complications that can occur with the trocar technique
include impaling the heart or lungs with the trocar (espe- in the patient’s record. An increasing amount of subcutane-
cially if the hand at the distal end of the tube slips), pulmo- ous emphysema or an enlarging seroma may indicate the
nary contusions, and placement of the tube into the chest tube has migrated out of the pleural space. To prevent
abdominal cavity. This technique is generally not used accidental removal of the tube, it may be secured to the
unless it is an emergency situation with no other options, patient several ways, such as wrapping the tube with band-
and it is never recommended in cats because it is ineffec- age material, placing a stockinette, or making butterfly tags
tive and even more dangerous, due to cats’ more compliant from 1-inch tape that can be sutured to the patient’s skin.
chest walls. With any method of placement, pain manage- Additionally, an Elizabethan collar may be necessary to pre-
ment is important for patients with chest tubes. See the vent the patient from removing the chest tube.
section on pain management later in this chapter. The condition of the chest tube bandage should be
monitored several times daily for strikethrough. Soiled
or damp bandages should be changed immediately to pre-
Thoracostomy Tube Maintenance
vent bacteria from the patient’s surroundings migrating
A thoracostomy tube requires 24-hour monitoring because through the bandage toward the thoracostomy tube inser-
of the risk of detachment, obstruction, or leakage. The tube tion site. The pleural space may be evacuated either by
should be capped with a Luer-locking three-way stopcock continuous suction drainage or manual evacuation.
fitted with screw-on injection caps. The stopcock must be Generally, if continuous suction is not being used, the
positioned “off” to the patient when not in use. The chest thoracostomy tube should be manually evacuated every
tube itself should also be clamped using a chest tube clamp four to six hours. Each time the tube is aspirated, the
in the event the three-way stopcock detaches from the tube pleural space should be evacuated until negative pressure
(Figure 34.6). A cerclage wire or zip tie may help secure the is obtained, unless re-expansion pulmonary edema is a
stopcock to the tube. Thoracostomy tubes should be checked concern. This is most commonly a concern in patients
daily for migration and removed as soon as possible to with prolonged pleural space disease such as a postopera-
reduce discomfort and the risk of nosocomial infection. tive chronic diaphragmatic hernia. In these cases, the
Thoracostomy tube handling and insertion site evalua- pleural space should not be fully evacuated initially,
tion require strict aseptic technique. Prophylactic use of allowing the lungs to reinflate gradually thus reducing
antimicrobials is not recommended [6]. The thoracostomy the risk of pulmonary edema [7]. Depending on the
tube insertion site should be evaluated at least once daily for patient’s disease, the tube may require evacuation more
signs of inflammation or infection including redness, pain, or less often. Frequent assessments are required for
heat, swelling, subcutaneous emphysema, and/or purulent patients with thoracostomy tubes. Bilateral chest auscul-
discharge. The integrity of the purse-string, finger trap, and tation, pulse oximetry, and respiratory rate and effort
any sutures used to fix the tube to the body wall should also should be monitored regularly for any changes [8].
be noted. Presence of subcutaneous emphysema or seroma Increased respiratory rate and effort, dyspnea, diminished
formation around the insertion site should be documented lung sounds, and/or patient’s posture (i.e. orthopnea), as
well as a rise in gas or fluid production, may indicate the Thoracostomy Tube Removal
need for more frequent evacuation or further diagnostics.
When removing the thoracostomy tube a smooth, quick
During chest tube evacuation, the tubing should be eval-
motion should be used. Prior to removal, analgesia should
uated to ensure there are no leaks in the system, kinks,
be considered to reduce patient discomfort. The thoracos-
accumulation of fibrin material or other proteinaceous
tomy tube insertion site should be left to heal by second
material. An unnoticed kink or obstruction in the chest
intention; no sutures are generally needed. The site should
tube yields negative pressure on aspiration. This “false”
be covered with a light bandage including a sterile, nonad-
negative pressure is misleading and leads to the incorrect
herent pad [9]. The bandage should be monitored for any
assumption that the pleural space has been evacuated. If
strikethrough of residual fluid and changed as indicated.
the tube is clogged it can be flushed, paying strict attention
to aseptic technique, with a small amount of sterile 0.9%
NaCl instilled to dislodge the blockage [9].
A loose connection within the evacuation system can lead Chest Tube Drainage Systems
to the incorrect assumption that the patient has a continu-
ous pneumothorax or has developed a pneumothorax if this Chest tube drainage systems are indicated when large
was not the patient’s initial problem. To check the tube for quantities of gas or fluid are accumulating in the pleural
leaks, first all connections of the chest tube and three-way space rapidly. These systems prevent the patient from
stopcock should be tightened. A chest tube clamp should be developing respiratory distress between aspirations of
placed on the tube proximally. If all connections are tight the tube and help to keep the lungs fully inflated in their
and the chest tube is clamped, aspiration should yield nega- normal expanded position. Otherwise, each time the
tive pressure. If gas is aspirated, there is a leak in the system. chest tube is aspirated, the lung reinflates from a rela-
All connections should be rechecked, and the chest tube tively collapsed position, which may cause a seal that is
should be evaluated for any small holes or cracks. If repeated forming to break apart. For patients with pyothorax that
attempts to evacuate the thoracotomy tube fail to yield nega- are producing a large volume of effusion, continuous
tive pressure and a leak is not identified during inspection drainage of the pleural space is indicated to reduce the
of the system, this suggests a rapidly accumulating pneumo- volume of purulent material in the chest cavity. For other
thorax and continuous suction drainage may be indicated. causes of pleural effusion including chylothorax,
After manually evacuating a thoracostomy tube and continuous drainage may be indicated if the effusion is
achieving negative pressure, the patient’s clinical status accumulating rapidly.
should be reassessed. Any increase in respiratory rate and
effort, orthopneic posture, or diminished lung sounds on
Continuous Suction Drainage Systems
auscultation may warrant further diagnostics such as pulse
oximetry, arterial blood gas analysis, and/or thoracic imag- Active drainage of the pleural space can be accomplished
ing. Radiographs may reveal tube malposition/migration by connecting the patient to a continuous suction source
leading to unaspirated fluid or gas in the pleural space or and a drainage system. The various drainage systems are
the presence of pulmonary parenchymal disease. Other based on the three-bottle system (Figure 34.7). In this
causes of increased respiratory rate and effort, such as model, the first bottle acts as a fluid trap, the second bottle
pain, should be considered. provides the underwater seal, and the third bottle regulates
The volume of gas and/or fluid obtained from the chest the amount of suction that is applied to the pleural space.
tube should be monitored daily. The tube should be The three-bottle system is cumbersome and can be difficult
removed once there is negative pressure in the chest on to use because the bottles are hard to transport and main-
several consecutive aspirations or the fluid obtained on tain in the upright position [10].
aspiration decreases significantly. Normally, small volumes For ease of use, the commercially available continuous
of fluid (up to 1–2 ml/kg/day) are generated because of the chest drainage systems combine the three-bottle system
body’s natural inflammatory response to a foreign object into one compact plastic unit (Protocol 34.5). The left-most
(thoracostomy tube) in the pleural space [10]. In general, if section of the unit is the collection chamber. The patient’s
tube aspiration yields little or no gas and no greater than chest tube connects to the collection chamber of the drain-
2–4 ml/kg of pleural fluid over a 24-hour period, the tube age unit via the included tubing and tube adapter in most
can be removed. If it is yielding negative pressure and dis- cases. If the chest tube is small, the adapter may be too
ease within the pleural space is still suspected, diagnostic large to connect to it and a Christmas tree adapter and a
imaging such as thoracic ultrasound or thoracic radio- short piece of sterile nonconductive connecting tubing
graphs are indicated to determine whether a new chest (6-mm diameter is commonly used, available from Medline
tube should be placed, and the existing chest tube removed. Industries, Mundelein, IL) may be needed to attach to the
Chest Tube Drainage Systems 443
Figure 34.7 Schematic of an airtight three-bottle AIR VENT TO

TO
system for continuous drainage of a chest tube. TUBE SUCTION
PATIENT
The chamber on the left accumulates and
measures the volume of fluid from the pleural
space. The middle chamber is the water seal to
prevent gas from flowing backward into the
patient’s pleural space, and the chamber on the
right is the suction control chamber. It is the depth
of the vent tube below the water level that
determines the amount of suction.
1500
1400 30
1300
1200 25
1100
1000
900
20
Illustrated by Michael Behle

800
700 15
600
500 0
400
300
200
100
FLUID UNDERWATER SUCTION

TRAP SEAL REGULATOR
tubing adapter. Fluid from the chest tube collects in this the Argyle™ Thora-Seal™ III chest drainage unit (Cardinal-
chamber, which allows for easy measurement and record- Health™, Dublin, OH) and the Pleur-evac® chest drainage
ing of the volume of drainage. The middle chamber of the system (Teleflex Medical OEM, Gurnee, IL).
chest drainage system provides the water seal. The purpose The chest drainage system must be kept on a flat, level
of the water seal is to prevent gas from flowing backward surface. If the unit is not level, it could disrupt the water
through the tubing and into the pleural cavity. It is recom- seal. The gentle bubbling causes evaporation of the water
mended that the water seal chamber be filled with sterile in the chambers over time. It is necessary to check the
water up to the 2-cm line, so a 2-cm water seal is estab- water levels every few hours to ensure the proper water
lished. To maintain an effective seal, it is important to seal and suction. Careful inspection of all chest tube con-
maintain the chest drainage unit upright at all times and to nections to the chest drainage system is warranted to avoid
monitor the water level in the water seal because it may potential leaks. The system can be checked for leaks by
evaporate. Bubbling in the water seal chamber is caused by briefly clamping off the chest tube and watching for bub-
gas flowing from the tubing into the chamber. This indi- bling in the water seal chamber. If bubbles are still occur-
cates gas is being removed from the patient’s pleural space ring in the water seal chamber while the chest tube is
or there is a leak in the system. The amount of gas bubbling clamped, there is a leak in the system distal to the clamp.
in this chamber cannot be quantitated but does allow a All connections should be checked, and then the process
subjective evaluation of the amount of gas coming off the should be repeated.
pleural space. The right-most chamber of the unit is the The chest drainage tubing should be checked for kinks.
suction control chamber. Traditional chest drainage units Any fluid that accumulates in the tubing should periodi-
regulate the amount of suction by the height of the column cally be encouraged to flow into the collection chamber by
of water in the suction control chamber. It is important to elevating the tubing (but not above the level of the chest
remember that it is the height of the water, not the setting tube) so gravity will aid in its drainage. The fluid collection
of the suction source, that limits the amount of suction chamber has a capacity of approximately 2000 ml, depend-
transmitted to the pleural cavity. The recommended height ing on the type of drainage system. The fluid collection
of water is 15–20 cm [9, 10]. The unit is then attached via a chamber should be monitored closely and emptied or
6-mm diameter sterile nonconductive connecting tubing to replaced if it becomes filled. Aseptic technique should be
a suction source such as wall suction or a portable suction used if the collection chamber is emptied. Many units do
machine like the Schuco Vac (Allied Healthcare Products, not allow for emptying, so a new unit is required if the col-
Inc., St. Louis, MO). lection chamber fills. If the chest drainage tubing becomes
A few brand-name continuous suction drainage units are clogged with thick secretions, the chest drainage unit
commonly used in critical care. Some examples include needs to be replaced.
Non-suction Drainage
A passive continuous drainage method is also available.
The Heimlich valve consists of a rubber one-way valve
inside a plastic tube that connects to a standard chest tube.
These units only allow gas and fluid to move from the chest
into the environment or collection bag. They are not rec-
ommended for animals under 15 kg because smaller
patients do not generate sufficient increases in intrapleural
pressure during exhalation to allow the valve to operate
properly. Heimlich valves (Figure 34.8) are best suited for Figure 34.8 A Heimlich valve, which allows for passive
removal of gas from the pleural space because fluid may continuous drainage of a thoracostomy tube.
cause the valve to stick and no longer function [11]. Even
when pneumothorax is the primary problem, small stopcock should be positioned open to both the patient and
amounts of fluid, blood, or fibrin may cause the Heimlich the syringe. To avoid pleural damage, a maximum of 3–5 ml
valve to stick, so they should only be used with constant of negative pressure should be applied during chest tube
supervision [12]. drainage [13]. The chest tube should be evacuated via
gentle aspiration of the syringe plunger, until negative
pressure is obtained. Once negative pressure is achieved,
Manual Drainage of the Thoracostomy Tube
the patient should be repositioned and the chest tube
Strict attention to aseptic technique must be followed re-aspirated to determine whether changing the patient’s
whenever the chest tube is handled or aspirated. The chest position yields any additional gas or fluid from the tube.
tube may be manually evacuated by attaching a chest tube Occasionally, there may be a pocket of fluid that cannot
adapter to a Luer-locking three-way stopcock. An empty be drained by the chest tube unless the patient is
syringe should be attached to the stopcock, and the repositioned.
Protocol 34.5 Setting up a Continuous Chest Drainage System

Items Required unclamp the chest tube(s) to allow evacuation of the
pleural space.
● Continuous chest drainage system (Thora-Seal III™ or
5) Two chest tubes can be connected into one chest
Pleur-evac™)
drainage system by using a Y connector (Figure 34.9)
● Christmas tree adapter
and a piece of 6-mm diameter sterile nonconductive
● Short piece of sterile nonconductive connecting tubing
connecting tubing.
(6-mm diameter)
● Sterile water
● Y connector (optional)
● Suction source
Procedure
1) Place the suction unit on a flat surface, and secure if
needed to prevent it from falling over.
2) Pour water into the water seal chamber to the level
indicated on the unit, then pour water into the suction
control chamber to the required level (usually
15–20 cm of water) [9, 10].
3) The level of water in the suction control chamber
determines the degree of suction, not the vacuum
meter.
4) Connect drainage tubing to the chest tube, and con- Figure 34.9 A sterile plastic Y piece and tubing are used to
nect the suction tubing to the vacuum source, then connect bilateral chest tubes to a single drainage system.
Handlang Hamdles for dlln aHdlesles 445
The total volume of gas and fluid aspirated from the NaCl to a total volume of 10–20 ml, depending on the size
chest tube should be measured and documented in the of the patient.
patient’s record. Changes in the volume of gas or fluid The use of bupivacaine in animals that have had a
aspirated from the thoracostomy tube from one intermit- pericardiectomy is controversial due to the possibility of
tent evacuation to the next should be closely monitored. If cardiotoxicity [18]. Injectable opioids offer excellent anal-
increased gas is aspirated, the system should be evaluated gesia but may be associated with decreased respiratory
for any leaks. If negative pressure is suddenly obtained drive at higher doses (Chapter 48). The combination of
and the patient is still showing signs of respiratory dis- opioids and intrapleural bupivacaine can provide excel-
tress, an obstruction should be considered. If the chest lent pain relief for most patients. A tranquilizer such as
tube is proven functional, it may indicate improvement of acepromazine (Butler Animal Health Supply, Dublin,
the patient’s pleural space disease. In addition to changes OH) or a benzodiazepine can be administered with an
in the volume of aspirated fluid or gas, any gross changes opioid to treat anxiety. If the patient is eating, oral traza-
in the appearance of fluid (e.g. changes in consistency and done at 3–10 mg/kg orally every eight hours (Teva
color of pleural fluid) should be noted. A sudden increase Pharmaceutical Industries) may also help reduce anxi-
in the volume or change in the type of fluid being aspi- ety [19]. It is important to keep patients calm to prevent
rated could indicate a secondary problem such as infec- them from disconnecting the chest drainage system or
tion, hemorrhage, severe hypoalbuminemia, or other pulling out the chest tube. Nonsteroidal anti-inflammatory
causes. Fluid analysis may be indicated to further drugs may also be used for analgesia if the patient has no
investigate. contraindications (Chapter 48) and may provide the best
pain relief.
Pain Management
Handling Samples for Fluid Analysis
Indwelling chest tubes can be very painful; therefore, it is
important to provide analgesia to these patients. Analysis of the pleural fluid may indicate whether the
Bupivacaine 0.5% (Hospira Inc., Lake Forest, IL) can pro- effusion is a transudative, modified transudative, chylous,
vide local analgesia when administered via the thoracos- exudative, neoplastic, or hemorrhagic effusion [20, 21]. A
tomy tube at a total dose of 1.5 mg/kg every six to eight sample of the effusion should be submitted for fluid analy-
hours for dogs [14, 15]. A lower dose of 1 mg/kg every six sis to aid in identification of the disease process causing
to eight hours is recommended for cats [16, 17]. Cats are the effusion. Fluid analysis should include cell counts,
more sensitive to local anesthetics than dogs and should protein concentration, and cytology [14] (Table 34.1).
be carefully monitored when these drugs are used. After Fluid should be submitted for bacterial culture (aerobic
injecting into the chest tubes, 2–3 ml of sterile 0.9% NaCl and anaerobic) if bacteria or suppurative inflammation
should be used to flush the bupivacaine out of the tube are seen on cytology or an infectious process is suspected.
and into the patient’s pleural space. If a single chest tube If a chylothorax is suspected, triglyceride concentrations
is present, placing the patient with the chest tube side of both the effusion and serum should be measured and
down after instillation of bupivacaine may allow for bet- compared [21]. A diagnosis of chylothorax can be made if
ter local analgesia. The bupivacaine dose can be split and triglyceride concentrations are greater in the effusion than
given via two tubes in patients that have bilateral thora- in the serum and fluid cytology shows a large number of
costomy tubes. Bupivacaine should not be used in mature lymphocytes. A sterile red top tube (without anti-
patients that are attached to a chest drainage unit with coagulant) should be used for cell counts, cytology, and
continuous suction because it will be suctioned back out triglyceride levels. Hemorrhagic fluid samples should be
of the thoracostomy tube immediately after administra- submitted in a purple-top tube (with EDTA anticoagu-
tion. Similarly, the thoracostomy tube should not be aspi- lant). An iatrogenic hemothorax may result if the needle
rated immediately after administration of a local used during thoracocentesis contacted the patient’s heart
anesthetic. Bupivacaine can sting on initial injection due or a blood vessel. Active hemorrhage can be ruled out by
to the acidity of the solution. Sodium bicarbonate can be placing a small volume of the effusion into a red top tube
used to buffer the solution at a dose of one part sodium or a tube with diatomaceous earth and monitoring for clot
bicarbonate to nine parts bupivacaine [16]. If the total formation. If samples are to be submitted for culture, a
volume of bupivacaine or bupivacaine plus sodium bicar- sterile red top tube or anaerobic and aerobic culturettes
bonate is very small, it can be diluted with sterile 0.9% should be used.
Table 34.1 Pleural effusion types and characteristics [21].
Cell counts Protein

Fluid type Appearance (cells/μl) concentration (g/dl) Triglyceride present Cytology
Transudate Clear, pale yellow < 1500 < 2.5 No Predominately acellular,
occasional RBC
Modified Yellow or pink; clear 1500–5000 ~ 3.0 No Moderately cellular, some
transudate to slightly cloudy RBC, macrophages, and
mesothelial cells
Chylous Milky/white; turbid 500–20 000 ≥ 3.0 Yes (triglyceride Mature lymphocytes,
more than serum neutrophils, and
triglyceride) macrophages
Exudate Yellow to > 5000 > 3.0 No Primarily nondegenerate
orange-brown to degenerate neutrophils;
bacteria may or may not be
present
Hemorrhagic Red Resembles > 3.0 Yes; triglyceride level Resembles peripheral
peripheral blood equal to serum blood
triglyceride level
RBC, red blood cells
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449
Section Four
Urinary and Gastrointestinal Procedures
451
35
Urethral Catheterization
Urethral catheterization is a reasonably simple procedure changes in urethral cells than did silicone, Teflon-coated
that is performed most commonly in emergency and criti- latex, or red rubber (polyvinylchloride) catheters [3]. General-
cal care practice to relieve obstruction of the lower urinary use catheters such as polyvinyl, polypropylene, or feeding
tract or to monitor urine output. Catheters are generally tubes are also used. While its stiffness makes polypropylene
placed retrograde from the urethral orifice into the urinary the easiest insert, it may also be the least desirable because it
bladder, opposite the natural flow of urine. As with all can directly traumatize the urethra and, if left indwelling,
devices, insertion and maintenance of a urethral catheter can traumatize the bladder wall. An experimental study in
carries risks, and the risks should be weighed against the cats showed that both polypropylene and polyvinyl catheters
potential benefits whenever the procedure is considered. caused inflammatory lesions in the urethra and bladder, with
polypropylene causing the most lesions [4]. That being said,
one more recent retrospective study in male cats found no
Indications for Urethral difference in recurrence of urethral obstruction when the
Catheterization indwelling urethral catheter was made of polypropylene as
opposed to polyvinyl chloride, although overall recurrence
Indications are to alleviate urethral obstruction, empty the rate was so low that finding a difference would have been
bladder, monitor urine output, acquire samples for analy- unlikely [5]. Silicone catheters appear to resist kinking better
sis, and aid in diagnostic procedures and urologic sur- than latex-based catheters [6].
gery [1]. Indwelling urethral catheters should not be used Bacteria colonize indwelling urinary catheters and grow
in place of good nursing care to keep patients clean and as biofilms embed in a gel-like polysaccharide matrix.
dry. Urine samples for analysis and culture are generally Bacteria growing in the biofilm are resistant to antimicro-
better procured by cystocentesis or free catch. bials, and unfortunately all types of catheters, including
antimicrobial-coated ones, are vulnerable to biofilm forma-
tion [7]. One small study in dogs showed a decrease in bio-
Urethral Catheters film formation with use of a sustained-release chlorhexidine
varnish coating on indwelling urethral catheters [8]. In an
Urethral catheters are made of materials such as silicone, extensive review of scientific studies in humans comparing
latex, or a latex base with various coatings. The ideal material types of standard catheters (silicone, latex, hydrogel-coated
would be atraumatic and would not elicit inflammation; it latex, siliconized latex), none of the standard catheter types
would resist kinking and would inhibit bacterial adherence. was found better than another at reducing bacteriuria [2].
Latex and latex-based catheters may cause more inflamma- Marked bacterial adherence to polyvinyl (red rubber) cath-
tion than some other flexible materials of which indwelling eters compared with other materials has been shown [9].
urethral catheters are made. For instance, latex-based cathe- Antimicrobial or antiseptic-impregnated and hydrophilic
ters may be more likely to cause urethritis in people com- catheters may reduce infection in people, but they can be
pared with silicone catheters [2]. In an experimental dog less comfortable and are more expensive; more research is
model, latex catheters tended to cause more inflammatory needed [2]. One small veterinary in vitro study and one
452 Urethral Catheterization
small clinical study in dogs suggest that silver-coated

urinary catheters may decrease biofilm formation and bac-
teriuria [10, 11]; further investigations are needed to deter-
mine whether silver coating leads to decreased bacterial
cystitis in small animals.
Design
Foley-type urinary catheters have an inflation balloon at
the distal end, which, when inflated with sterile water,
retains the catheter in the bladder. We prefer these for
indwelling use. There are lengths suitable for both males
and females (Figure 35.1) and sizes as small as 4 Fr. Some
catheters come fitted with an integrated stylet.
For male cats, tomcat-style urethral catheters of 3.5 Fr or
5 Fr do not have an inflation balloon and must be sutured Figure 35.2 Stylet protruding from side hole of a closed-ended
catheter.
in place. Some have a removable stylet. These catheters are
either open ended (having a single opening at the tip) or
passage of the catheter into the urethra and traumatizing the
closed ended (having openings along the side). The open-
mucosa with the exposed stylet tip (Figure 35.2). Use a stylet
ended catheter allows retrograde flushing of an obstructed
with proper caution. Make sure that it is properly positioned
urethra. The rounded tip of the closed-ended catheter
before attempting insertion. With practice and a good tech-
might reduce urethral trauma. The Minnesota olive-tip
nique, most catheters can be placed without a stylet.
urethral catheter is a 22-gauge metal catheter with an
olive-shaped open-ended tip. It is inserted into the distal
urethra of an obstructed male cat to assist in retropulsion Diameter
of debris from the urethra into the bladder. We recommend using the smallest diameter catheter that
will achieve good urine flow and will not kink. Approximate
Stylets requirements are 3.5 Fr or 5 Fr for cats or small dogs, 8 Fr
for medium dogs, and 8 Fr to 12 Fr for large dogs.
A stylet can make it easier to advance a catheter, especially
one of small diameter. However, a stylet can cause mucosal
trauma or even rupture of the urethra because it allows
Length
excessively vigorous efforts to advance the catheter. A stylet Catheters should be premeasured so that the operator
can also be dislodged during placement attempts such that it knows when the tip should reside within the lumen of the
exits through a side hole in the catheter, thus preventing trigone – not in the urethra and not at the bladder apex. This
is particularly true for catheters without a Foley balloon. In
general, the trigone of the bladder lies at or just caudal to the
cranial aspect of the ilial wing; this is the point to which we
premeasure when placing non-Foley urethral catheters.
When correctly placed, the catheter tip rests in the bladder
near the trigone. As the patient moves or the bladder size
changes, the catheter should remain in the bladder (not
retract into the urethra) but should not be so far advanced
that it contacts the cranial bladder wall. Catheter tip (or
Foley balloon) placement can be confirmed with point-of-
care abdominal ultrasound if desired (Chapter 39).
Closed Collection Systems
In human medicine, it is accepted practice and strongly

Figure 35.1 Foley catheter in lengths for females (above) and recommended to connect all indwelling urinary catheters
males (below). to a sterile closed urine collection system [1]. Closed urine
Cathaher PCahehea Cend CaeaheCeah 453
drainage systems facilitate aseptic emptying of the urine catheterization increases the risk of catheter-associated
from the bag without disconnection from the catheter. urinary tract infection [19, 21, 22]. In the studies with the
They have a check valve to prevent retrograde flow of lowest catheter-associated urinary tract infection, the
urine from the bag to the bladder, and often include a sam- authors speculated that their use of a strict protocol to
pling port for acquiring urine samples. In veterinary prac- maintain asepsis during insertion and maintenance of
tice, urine collection systems are often created from indwelling catheters contributed to the lower rate [12, 19].
available materials using a macrodrip fluid line set and a Those protocols are the ones recommended in this chapter.
sterile, empty fluid bag. This is considered an open system Antimicrobial treatment of patients with indwelling uri-
because, when the fluid bag is filled with urine, it must be nary catheters is variously reported to increase [21],
disconnected from the tubing and replaced with a new decrease [19], or not affect [22] the development of a uri-
bag. The disconnection carries the risk of introducing nary tract infection. In human medicine, the Centers for
bacteria into the system. These systems were reported not Disease Control and Prevention (CDC) strongly recom-
to be associated with nosocomial bacteriuria in dogs with mend against the routine use of systemic antimicrobials to
short-term urinary catheterization, but the authors cau- prevent catheter-associated urinary tract infections either
tioned that asepsis must be maintained when changing with short-term or long-term catheterization [1]. The avail-
the collection bag [12, 13]. These open urine collection able evidence does not support administering prophylactic
systems must not be confused with leaving a catheter antimicrobials for an indwelling urinary catheter but does
unattached to any urine collection system, referred to as not preclude administering them for other purposes.
an open catheter. Forty years ago, it was common practice Moreover, the International Society for Companion Animal
to treat urethral obstruction in male cats by placing an Infectious Diseases guidelines for the diagnosis and man-
indwelling urinary catheter and not attaching a urine agement of bacterial urinary tract infections in dogs and
collection system but instead leaving the catheter open to cats recommends against the routine use of antimicrobials
the environment. Although an experimental study in cats as prophylaxis for urinary tract infection during indwelling
with these open indwelling catheters showed that 20 of 36 urethral catheterization in small animals [23].
developed bacteriuria [14], this practice may still be fairly The risk of infection is reduced by proper patient selec-
common [15]. We recommend that all indwelling catheters tion; aseptic practices by trained caregivers in insertion and
be attached to a sterile urine collection system. If an open maintenance of indwelling catheters and collection sys-
urine collection system using a sterile empty fluid bag as tems and by removing indwelling catheters as soon as pos-
the reservoir is used, it is essential to maintain sterility in sible [24]. The known risk of catheter-associated urinary
setting up and maintaining the system. The purpose- tract infections should be considered in patient manage-
specific closed urine collection systems have advantages ment after catheter removal.
as previously discussed.
Basic Guidelines
Catheter Placement Based on our experience and informed by the CDC 2009
and Maintenance guidelines [1] for prevention of catheter-associated urinary
tract infections in people, we use and recommend the fol-
Asepsis and Infection Control lowing guidelines.
Infection is a complication of urinary catheterization. 1) Ensure that only properly trained caregivers who
Bacteria might be introduced into the bladder during cath- know the correct aseptic techniques perform catheter
eterization or while maintaining an indwelling system. insertion and maintenance.
Organisms can ascend into the bladder from the catheter 2) Perform hand hygiene before and after insertion or
insertion site or through the catheter lumen from the col- manipulation of catheter or collection system.
lection system. In people, urinary tract infection is the 3) Use sterile gloves, drape, and sterile lubrication for
most common hospital-acquired infection, and indwelling catheter insertion.
urinary catheters are the major associated cause [2]. One- 4) Follow a protocol (preferably written) for catheter
time urethral catheterization in healthy dogs resulted in insertion and indwelling catheter care to ensure con-
catheter-associated urinary tract infection in 20% of female sistency in maintaining good technique between
dogs and 0% of the males [16]. Hospitalized dogs and caregivers.
cats with indwelling urinary catheters develop catheter- 5) Use the smallest bore, softest catheter possible consist-
associated urinary tract infection at a rate from 10% to ent with good drainage to minimize urethral and blad-
52% [12, 17–22]. Increasing duration of indwelling urinary der trauma.
6) Secure indwelling catheters to prevent movement and

Box 35.1 Preparation of Materials for Urethral
urethral traction.
Catheter Placement
7) Attach all indwelling catheters to a closed, sterile col-
lection system. If breaks in aseptic technique occur, Items Required
replace the catheter and collection system.
● Urinary catheter in sterile wrap.
8) For indwelling catheters attached to a sterile collection
● If using a Foley catheter: sterile syringe containing
system, maintain unobstructed flow, keep the catheter
appropriate volume of sterile water for Foley balloon
and collecting tubes from kinking, and keep the collect-
inflation (volume indicated on catheter hub)
ing bag lower than the bladder to prevent retrograde ● If catheter will be indwelling: sterile urinary collec-
urine flow. For closed systems, empty the collecting bag tion system, cable ties
regularly using a clean container, avoid splashing, and ● Sterile barrier drape
prevent contact of the collecting bag drainage tube ● Sterile gloves
with the collecting container. For open systems, follow ● Examination gloves
aseptic technique when breaking the line to replace the ● Clean gauze pads soaked in chlorhexidine (or other
urine collection bag. Use sterile gloves and gowns as surgical) scrub
needed for aseptic technique and for protection of car- ● Clean gauze pads soaked in water to rinse off
egivers if public health considerations are present. the scrub
9) Do not change indwelling catheters and drainage bags ● 0.05% chlorhexidine solution
at fixed intervals but rather based on clinical indica- ● Sterile syringe to use to flush the vestibule or pre-
tions such as infection, obstruction, or compromise of puce with chlorhexidine solution
the closed collection system. ● Sterile lubricant
10) Do not routinely instill antiseptics or antimicrobials ● For females: sterile 2% lidocaine jelly and sterile 1-
into the bladder or collection system. or 3-ml syringe for injecting jelly into vestibule
11) Use good nursing care to minimize contamination of ● Clippers for fur
the catheter and periurethral area from contact with ● If catheter will be indwelling: suture material, instru-
soiled hospital surfaces, wound discharge, or feces. ments, medical tape, and cable ties for securing cath-
eter and collection system
Catheter Placement ● Sterile syringe for collection of urine sample, if desired
Catheter placement must be according to good aseptic

practice taking into consideration the patient, environ-
Patient Preparation
ment, operator, and equipment. Assemble the material for
placement before beginning the procedure (Box 35.1). The Clip fur from the perivulvar or peripreputial area to establish
procedure varies according to species and sex. A summary a 5-cm fur-free zone that can be cleaned and to allow for
of the steps is provided for female dog or cat (Protocol 35.1), insertion of sutures if needed. Take care to avoid damage to
male dog (Protocol 35.2), and male cat (Protocol 35.3). the skin during clipping. Local irritation causes discomfort,
increases risk of skin infection, and decreases patient toler-
ance of the indwelling catheter. Clean the skin with anti-
Catheter Selection
septic scrub such as chlorhexidine scrub and rinse well with
Measure from the vulva or prepucial tip to the bladder to tap water. Do not contact mucosal surfaces with the scrub.
determine the length of catheter needed. The bladder can Next, use 5–10 ml of 0.05% chlorhexidine solution (add
be located by palpation or estimated to be just cranial to the 6.25 ml of 2% chlorhexidine to 250 ml sterile water) as an
pubis. Alternatively, estimate the bladder position as the antiseptic solution to flush the vulva and vestibule or pre-
cranial aspect of the proximal femur with the patient in puce five times. Sterile water or saline, or another antisep-
lateral recumbency and the limb in neutral position. Select tic solution at concentrations suitable for mucosal contact,
the softest, smallest diameter catheter that will serve the could be used as the flush. The remaining portion of the
purpose. sterile solution is maintained aseptically and stored for
catheter maintenance if the catheter is to be indwelling.
In males, after positioning the patient and extruding the
Sedation
penis, gently clean the area of the external urethral orifice
Sedation is needed for conscious cats and is often needed with the solution. Thereafter, do not allow the penis to
for dogs. Patient compliance is important for success, so retract into the prepuce until the catheter has been placed
sedation or anesthesia should be provided as indicated. into the bladder and will not be further advanced.
Cathaher PCahehea Cend CaeaheCeah 455
Protocol 35.1 Patient Preparation and Urethral Catheter Placement Using Digital Technique in a Female Dog or Cat
Items Required 13) Remove catheter from sterile wrap.
14) If the catheter has a stylet, verify that it is in the
● See Box 35.1 for appropriate supplies.
correct location.
15) If using a Foley catheter, test the balloon with the
Procedure
volume of sterile water indicated on the cathe-
1) Ensure that only properly trained caregivers perform ter’s hub.
catheter insertion, and that sterility is maintained 16) While maintaining sterility, mark the catheter or
throughout. otherwise indicate the length needed to reach the
2) Sedate patient if indicated. bladder.
3) Position the patient. 17) Lubricate the end of the catheter.
4) Determine the length of catheter needed to reach the 18) Lubricate the operator’s gloved palpating finger
bladder trigone by measurement on the patient. This is (generally the index finger of the dominant hand).
generally the length from the urethral opening to a point 19) Insert the gloved palpating finger between the labia
at or just caudal to the cranial aspect of the ilial wing. of the vulva.
5) Clip fur to maintain an adequate fur-free zone adja- 20) If patient size permits, advance the finger to palpate
cent to the vulva, ideally ≥ 5 cm in each direction the urethral papilla on ventral midline.
from the vulva. 21) If patient size does not permit advancing, leave the
6) Perform hand hygiene and don clean examination gloves. finger between the labia of the vulva.
7) Wash off visible dirt from the patient’s perineal area. 22) Insert the catheter ventral to the finger and advance
8) Perform surgical scrub of the skin surrounding the into the urethra and bladder.
vulva; rinse off the scrub with water. 23) If urine is not obtained, verify the proper placement
9) Flush the vulva and vestibule five times with 0.05% of the catheter in the bladder or reposition if needed.
chlorhexidine solution. 24) Withdraw the palpating finger without disturbing the
10) Instill sterile 2% lidocaine jelly into the vestibule placement of the catheter.
using a 1- or 3-ml sterile syringe. 25) Inflate the Foley balloon with the indicated volume
11) Don sterile gloves (operator). of sterile water if using a Foley catheter.
12) Position barrier drape to provide adequate sterile field: 26) If the catheter is to be indwelling, attach a sterile col-
there should be an opening for catheter insertion and lection system; secure the catheter and the collec-
a tabletop field caudal to the animal’s perineal area tion system to prevent urethral traction and catheter
where the catheter can rest and remain sterile. movement.
Catheter Preparation the inflation port. Inflate and verify that the balloon main-
tains inflation with the syringe disconnected from the
While maintaining sterility, mark the catheter or otherwise
valve; then deflate the balloon in the opposite order. The
indicate the spot where it will exit the body when the tip is
proper method to deflate the balloon is to attach the empty
in the bladder. During insertion it is easy to lose track of
syringe to the inflation port and let the fluid drain without
how much catheter has been inserted. If a flexible catheter
aspirating. If the balloon does not deflate, reseat the syringe
curls up in the bladder, it can form a knot that requires
firmly and try again.
surgical removal, so it is important to avoid overinsertion.
If using a Foley catheter with a balloon, test the balloon
before insertion (Figure 35.3). The inflation port is
Lubrication and Local Anesthesia
imprinted with the volume of sterile water required. Follow
the manufacturer’s directions regarding the fluid type and In males, apply lubricant to the tip of the catheter and the tip
volume for inflation. Under or overinflation can cause an of the extruded penis. As the catheter is passed, continue to
asymmetrical balloon that can deflect the catheter tip and apply lubricant on the catheter body at the tip of the penis.
cause occlusion or irritation of the bladder wall. Water is In females, we have found that both local anesthesia and
recommended because saline can cause crystal formation lubrication are important to improve patient compliance.
in the balloon and prevent deflation of the balloon at the After aseptic preparation we use 2% lidocaine jelly in addi-
time of removal. Inflation with air causes the balloon tip to tion to sterile water-based lubricant. While maintaining
float in the urine [25]. To test the balloon, fill a syringe with sterility, fill a syringe barrel with a suitable volume of ster-
the recommended volume of sterile water and attach it to ile lidocaine jelly, replace the plunger, and gently insert the
Protocol 35.2 Patient Preparation and Urinary Catheter Placement in a Male Dog
Items Required 9) Assistant extrudes the penis with gloved hands and
maintains it in that position until catheter is placed.
10) Perform surgical preparation of the extruded penis
with 0.05% chlorhexidine solution.
Procedure
11) Don sterile gloves (operator).
1) Ensure that only properly trained caregivers perform 12) Position barrier drape to provide adequate sterile
catheter insertion, and that sterility is maintained field: there should be an opening for catheter inser-
throughout. tion and a tabletop field ventral to the dog’s abdomen
2) Position the patient. where the catheter can rest and remain sterile.
3) Determine the length of catheter needed to reach the 13) Remove catheter from sterile wrap.
bladder by measurement on the patient. This is gen- 14) If using a Foley catheter, test the balloon with the
erally the length from the urethral opening, follow- volume of sterile water indicated on the catheter’s hub.
ing the path of the urethra, to a point at or just caudal 15) While maintaining sterility, mark the catheter or other-
to the cranial aspect of the ilial wing. wise indicate the length needed to reach the bladder.
4) Clip fur to maintain an adequate fur-free zone adja- 16) Lubricate the end of the catheter.
cent to the opening of the prepuce; ideally ≥ 5 cm in 17) Insert the catheter into the penis and gently advance
each direction from the preputial opening, including it into the bladder.
on the ventral abdomen. 18) Verify correct position of the catheter in the bladder
5) Perform hand hygiene and don clean examination radiographically or with point-of-care ultrasound and
gloves. reposition if needed.
6) Wash off visible dirt from the prepuce and periprepu- 19) Inflate the Foley balloon with the indicated volume
tial area. of sterile water if using a Foley catheter.
7) Perform surgical scrub of the skin surrounding the 20) If the catheter is to be indwelling, attach a sterile
prepuce; rinse off the scrub with water. collection system; secure the catheter and the collec-
8) Flush the prepuce five times with 0.05% chlorhex- tion system to prevent urethral traction and catheter
idine solution. movement.
catheter tip between the labia and into the vestibule. Then Female Dog
inject the jelly. Lidocaine is absorbed through the mucosa,
Female dog urethral catheterization is a skill that takes
so limit the total volume to no more than 0.2 ml of 2% lido-
concentration, correct technique, and some practice. The
caine jelly per kilogram of body weight. Wait 10 minutes
required skills are similar to those needed to place a venous
for the lidocaine to take effect. Use plain sterile water-based
catheter dependably. In both cases, the target is identified
lubricant on a gloved finger and the catheter during inser-
by knowing the relevant anatomy and by palpation. In both
tion, as the lidocaine jelly is not as effective a lubricant as
cases, the operator must line up the catheter carefully
the purpose-made lubricant products. If you plan on using
along the long axis of the structure one is attempting to
a speculum or otoscope cone technique for placing the
enter (vein or urethra), and the catheter tip must be
catheter, lubricate the instrument and catheter tip, but do
directed downward. Small, controlled motions are better
not fill the vestibule with jelly because it will obscure visu-
than large ones. As with any procedure, it is important to
alization of the urethral papilla.
know when to stop and seek assistance. The patient is the
primary concern.
We prefer the digital technique with the patient com-
Species and Sex-Specific Instructions fortably restrained in lateral recumbency. This has been
successfully used at the University of California Davis’s
This section outlines instructions for catheter placement in Veterinary Medical Teaching Hospital and taught in wet
female dogs (digital, guidewire, speculum, and otoscope labs for many years. Other techniques using a guidewire,
cone techniques); female cats or small female dogs (guide- speculum, or otoscope cone require specialized equip-
wire, two-catheter, speculum); male cats; and male dogs. If ment, and some may be less comfortable for the animal.
the catheter is to be indwelling, see the section “Indwelling However, it is valuable to know more than one way of
Catheters” for instructions on securing and maintaining performing a procedure, and so we also describe these
the catheter and collection system. techniques.
Shaahes CendhexShaaiaa eesaerraaaiees 457
Protocol 35.3 Patient Preparation and Urinary Catheter Placement in a Male Cat
Items Required is placed. (This step performed after donning sterile
gloves if operator will extrude penis.)
11) Perform aseptic preparation of the extruded penis
● For difficult placements, consider different catheter
with 0.05% chlorhexidine solution.
options, including polypropylene (open- or closed-tip);
12) Don sterile gloves (operator).
22-gauge vascular catheter with the stylet removed;
13) Position barrier drape to provide adequate sterile
olive-tipped catheters.
field: there should be an opening for catheter insertion
● For difficult placements, consider a hydrophilic guidewire
and a tabletop field caudal to the cat’s perineal area
(Weasel Wire, Infiniti Medical, Palo Alto, CA) lubricated
where the catheter can rest and remain sterile. Try to
with sterile isotonic crystalloid.
exclude the anus from the opening.
14) Remove catheter from sterile wrap.
Procedure
15) While maintaining sterility, mark the catheter or other-
1) Ensure that only properly trained caregivers perform wise note the length needed to reach the bladder.
catheter insertion, and that sterility is maintained 16) Lubricate the end of the catheter.
throughout. 17) Insert the catheter into the penis and advance it toward
2) Sedate the cat unless it is severely obtunded or the bladder while applying caudodorsal traction to
already anesthetized. the penis to straighten the sigmoid flexure. For diffi-
3) Position the patient. cult placements, consider:
4) Determine the length of catheter needed to reach the a) Different catheter types as above
bladder by measurement on the patient. This is gen- b) Decompressive cystocentesis prior to catheter
erally the length from the urethral opening to a point placement
at or just caudal to the cranial aspect of the ilial wing. c) Hydrophilic guidewire placement first, followed
5) Clip fur to maintain an adequate hair-free zone adja- by urethral catheter placement over the guidewire
cent to the opening of the prepuce, ideally ≥ 5 cm in 18) Verify correct position of catheter in the bladder using
each direction from the preputial opening. radiography or point-of-care ultrasound as desired;
6) Perform hand hygiene and don clean examination reposition if needed.
gloves. 19) If the catheter is to be indwelling, attach a sterile
7) Wash off visible dirt from the patient’s perineal area. collection system; secure the catheter and the collec-
8) Perform surgical scrub of the skin surrounding the tion system to prevent urethral traction and catheter
prepuce; rinse off the scrub with water. movement. As these are usually non-Foley catheters,
9) Flush the prepuce five times with 0.05% chlorhex- they are generally secured by suturing the catheter
idine solution. flange to the prepuce and taping the collection
10) Assistant or operator uses gloved hands to extrude the system to the ventral aspect of the tail at a length
penis and maintain it in that position until catheter that allows for normal tail movement.
Anatomy
The relevant anatomy from caudal to cranial is the vulva,
vestibule, and vestibulovaginal junction (Figure 35.4). The
vagina is cranial to this junction and not entered during
this procedure. When attempting to enter the vestibule,
avoid the clitoris, which is in a blind-ending pouch located
just inside the labia of the vulva (Figure 35.5). The urethral
opening is in the vestibule on the ventral midline, at or just
caudal to the vaginovestibular junction. Various strips and
bands of tissue can form strictures in the vestibule or,
uncommonly, in the vulva. They may prevent digital palpa-
tion. Nonetheless, a catheter can often still be placed by
directing it without palpation as described in the section
Figure 35.3 Test the balloon of the Foley before placing the catheter. for small dogs.
into the vestibule until the vestibulovaginal junction is

palpated as a circumferential thickening that usually does
not allow passage of the palpating finger into the vagina.
This is a normal structure, not a stricture. With the fingertip
in contact with the vestibulovaginal junction, move the
fingertip ventrally and caudally to palpate on ventral
midline for the urethral papilla as a soft mound of tissue
surrounding the urethral opening, about 0.5 cm caudal to
the vestibulovaginal junction in a medium-size dog. It may
be obvious or subtle. It is not absolutely necessary to
palpate the papilla because the correctly directed catheter
will enter the urethra if the catheter is properly aligned and
moved forward exactly along the ventral midline.
Figure 35.4 Contrast vaginourethrogram showing the relevant Placing the Catheter with Digital Technique Once you have
anatomy in the female dog. familiarized yourself with the anatomy, withdraw the
palpating finger and use that hand to grasp the catheter near
the tip. Use the non-dominant hand to keep the length of the
catheter aligned along the midline. With the palpating finger,
re-enter the vestibule as before, taking the catheter tip along
(Figure 35.6). Use the palpating finger to guide and the non-
dominant hand to guide and advance the catheter. Make sure
not to twist or turn the hand as you maneuver the catheter in.
Position the catheter tip in the vestibule caudal to the
perceived location of the urethral papilla and exactly on the
midline. Place the palpating finger back into position over
the papilla (but not compressing it) and check the position of
the finger and catheter to ensure that all is aligned along the
midline. Use the non-dominant hand to keep that portion of
the catheter protruding from the vulva lined up along the
midline. It is better if the catheter enters between the dorsal
Figure 35.5 The clitoris is in a blind ending pouch, which must rather than the ventral aspect of the vulvar labia because this
be avoided when inserting the finger into the vestibule.
Digital Technique
Positioning The dog should be sedated and provided
analgesia, as indicated. Position the patient in lateral
recumbency. For a right-handed operator, position the
patient in right lateral recumbency and use the right index
finger for palpation; for left-handed operators, the opposite
is recommended. Let the pelvic limbs rest in a relaxed,
normal position. Move the tail out of the way, but do not
elevate it because that position can narrow the vulvar
opening and make entering through it more difficult.
Palpation First, familiarize yourself with the anatomy in

this patient by gentle digital palpation. In this procedure,
you are not palpating in the vagina but rather in the
Figure 35.6 Digital technique for a right-handed operator inserting
vestibule. Insert the palpating finger under the dorsal fold a urethral catheter in a female dog. The dog’s head is to the left of
of the vulva in a vertical (not horizontal) orientation and the image and tail toward the right; the dog is positioned in right
direct it dorsally toward the spine so the fingertip passes lateral recumbency. Note the angle of the right wrist and index finger
to help direct the catheter ventrally – the wrist should be straight or
under the dorsal fold and avoids the clitoris. Once your
nearly so. The non-dominant (here, left) hand holds the catheter very
finger passes over the pelvic brim, change the angle to close to the vulva and makes advancing motions to push the
one parallel with the spine, and advance the finger cranially catheter forward. No stylet in needed with this technique.
will help direct the catheter ventrally. Let the tip of the
palpating finger hover over the urethral papilla, and gently
advance the catheter using the other hand (Figure 35.7).
When you think the catheter tip is near to engaging the slit of
tissue that is the urethral papilla, flex the palpating finger,
press very gently down on the catheter just behind the tip,
and extend the finger to push the catheter tip cranially under
the slit of tissue (Figure 35.8). Attempt to move the catheter
only a few millimeters at a time. Think of sliding a piece of
cooked spaghetti along the top of a wet surface. The idea is to
get the catheter tip to engage the slit of tissue that is the
papilla instead of moving over it (Figure 35.9). Be sure the
palpating finger is not pressing down on the urethral papilla
Figure 35.9 Cadaver preparation of sagittal section of female

dog in right lateral recumbency with the head toward the left of
the image. The cut surface of the midline of the pubic bone is
visible. The catheter has now entered the urethral papilla and
can be advanced into the bladder.
because that pressure will close the opening. Other operators

insert the palpating finger firmly into the vestibulovaginal
junction to obstruct it and prevent the catheter from entering
it. They then use the non-dominant hand to advance the
catheter and let the catheter tip engage the papilla on its own.
During the blind catheterization procedure, the catheter
tip will either slip into the urethral papilla and enter the
urethra or will slide over the top of it and move cranially
toward the vestibulovaginal junction. With experience, you
Figure 35.7 Cadaver preparation of sagittal section of female dog in will be able to discern the friction as the catheter passes
right lateral recumbency with the head toward the left of the image. through the urethra compared with the relatively free pas-
The cut surface of the midline of the pubic bone is visible. The urethral
sage if it slips over the papilla and moves forward in the
papilla is seen just cranial to the tip of the catheter. Note that the
guiding finger is not pressing down on the urethral papilla. To do so is vestibule. If it seems that the catheter has entered the
likely to close off the papilla and prevent the catheter from entering. papilla, continue to advance it in small increments until
the tip of the catheter has reached the premeasured dis-
tance to the bladder or until there is good urine flow.
Verify Catheter Placement If urine is not obtained (and the

bladder is known to contain urine), palpate along the length
of the catheter in the vestibule from caudal to cranial to
determine its location. If the catheter has entered the urethra,
you will feel the catheter disappear into a hole on the ventral
surface of the vestibule, and no catheter will be palpable
cranial to the hole. If the catheter has passed over the papilla,
you will be able to palpate the catheter going through the
vestibulovaginal junction or curling up in the vestibule. If the
catheter needs to be repositioned, pay particular attention to
meticulous technique in aligning the entire catheter along the
vestibule’s ventral midline and keeping it on the midline as
you advance it. Be sure to withdraw it sufficiently caudally to
Figure 35.8 Cadaver preparation of sagittal section of female ensure that the urethral papilla has not already been passed
dog in right lateral recumbency with the head toward the left of before the catheter is advanced again. If you are not sure of
the image. The cut surface of the midline of the pubic bone is
visible. The catheter has just contacted the urethral papilla and
the location of the papilla, advance the catheter on ventral
the finger is being flexed to help advance the catheter. (See text midline in small increments. If the catheter is correctly
for description of this technique.) oriented, it is likely to engage the urethral papilla on its own.
If you think the catheter tip is in the bladder, but no you may still be able to place the catheter by gently advanc-
urine is flowing, attach a sterile syringe to the catheter and ing the catheter tip into the mucosal tissue in the area where
gently aspirate for urine or infuse sterile saline and aspi- the papilla should be located, in other words, by using the
rate. If injected fluid comes back around the vulva, the tip of the catheter as a probe to identify the papilla. When
catheter tip is likely in the vestibule and should be reposi- the catheter tip is positioned in the bladder, inflate the bal-
tioned. One can also place an ultrasound probe over the loon if there is one, and gently withdraw the catheter to seat
bladder and either see the tip of the catheter in the bladder the balloon at the neck of the bladder. Withdraw the device.
or see the flow of fluid as it is flushed through the catheter. If using an otoscope, disconnect the cone from the handle
and leave the cone on the catheter outside the body.
Speculum or Otoscope Cone Technique
Preparation is as described for the digital technique except Guidewire Technique
the vestibule is not filled with sterile anesthetic lubricant Recently a guidewire-assisted technique has been described
because that would obscure visualization. Lubricate the for placement of urethral catheters in female dogs [26].
device and the catheter before insertion. Patient preparation and positioning are identical to that
described above for the digital technique; sedation is likely
Patient Positioning Sedation is generally required for these to be required because the guidewire’s introducer is semi-
techniques. The patient may be positioned in lateral or rigid and may be more uncomfortable to the patient than a
sternal recumbency. Some operators place the patient more flexible catheter. A specialized catheter kit is available
sternally and drape the pelvic limbs off the end of a table. (MILA International, Inc., Florence, KY) that contains a
semi-rigid, flexible-tip introducer catheter with an open
Speculum A separate light source is needed, preferably a end through which a flexible, stainless-steel guidewire is
headlamp. The correct orientation for a speculum is with passed into the urethra to facilitate finding and entering the
the handles pointing dorsally (toward the spine), not down. urethral opening. After being lubricated with isotonic fluid,
This allows an assistant to grasp the handles once the the introducer catheter is inserted using the digital or spec-
speculum has been inserted into the vestibule with the ulum technique; the guidewire is then advanced through
assistant’s hand out of the way of the operator. the introducer and the introducer removed. A specialized
fluid-lubricated, open-ended, balloon-tipped (Foley) cathe-
Otoscope Cone Attach the cone to the otoscope handle in ter is then fed over the guidewire and into the urinary blad-
the usual way and use the handle to manipulate the cone der; the guidewire is removed and the remainder of the
into the vestibule. Visualize the urethral papilla, pass the procedure is the same as for other Foley catheter placements.
catheter through the cone, and advance it into the urethral
papilla. Once the catheter is placed into the bladder and Female Cat or Small Female Dog
the cone removed from the handle, the cone is left on the
If the patient is too small to allow digital palpation of the
portion of the catheter outside the body because the
urethral papilla, the catheter can nonetheless often be
external end of the catheter will not fit through the tip of
placed successfully.
the cone. Although this may look a little odd, it does not
cause problems (other than the potential to act as a fomite),
Anatomy
and the cone is retrieved when the catheter is removed.
The relevant anatomy for female cats is as described for
female dogs, except the urethra opens to the floor of the
Placing the Catheter Insert the speculum (in closed
vestibule in a groove that facilitates catheterization.
position) or otoscope cone between the labia of the vulva,
directing it first vertically to avoid the clitoris and then Positioning
horizontally to enter the vestibule. If using a speculum, Sedation is generally required in female cats. Position the
open the blades and have an assistant hold it in position. patient in lateral recumbency. For cats, some operators pre-
Look through the device and locate the urethral papilla as fer dorsal recumbency with the pelvic limbs drawn crani-
a slit of tissue on the ventral floor of the vestibule slightly ally to expose the vulva. However, this position tends to
caudal to the vestibulovaginal junction. Because you will decrease the opening of the vulva and can make it more
not be able to touch the catheter tip to guide it into the difficult to insert the catheter into the vestibule.
papilla, a stylet will be required unless you are using a
catheter made of stiff material, such as polypropylene. Placing the Catheter
Insert the catheter between the blades of the speculum or Follow the preceding instructions for preparation for inser-
through the otoscope cone and advance it into the urethral tion. Then gently separate the labia of the vulva and pass
papilla and into the bladder. If you cannot see the papilla, the catheter between the most dorsal aspects of the labia,
or see the flow of fluid within the bladder as it is flushed

through the catheter.
Male Cat
Many male cats in need of a urinary catheter have urethral
obstruction. Sometimes the obstructing material is at the
distal tip of the penis and can be removed by gently mas-
saging the most distal part of the penis to dislodge obstruct-
ing substances. If successful, this will result in immediate
urine flow because of increased pressure from the overdis-
tended bladder.
Anatomy
The feline prepuce is a short, fur-covered sheath facing
Figure 35.10 Urinary catheter placed by blind (without internal caudally and covering the nonerect penis. The penis is
palpation) technique. Note that the catheter is entering the
dorsal aspect of the vulva and directed ventrally to engage the
directed caudoventrally and covered by the prepuce. When
urethral papilla which helps avoid the more ventrally located the penis is extruded sufficiently by reflection of the pre-
clitoral fossa. puce off the surface of the penis, about 1–1.5 cm of penile
tissue can be seen. Penile barbs are visible near the tip of
directing it to the ventral midline aiming toward the bladder the penis in the non-castrated male cat.
(Figure 35.10). Even in small patients, the operator can usu- In its course from the bladder to the tip of the penis, the
ally insert at least the tip of the finger between the labia to urethra has a marked sigmoid flexure. To pass a catheter up
help direct the catheter ventrally. The urethral papilla is very the urethra, the penis must be drawn caudally and dorsally
close to the vulva, and most missed insertions occur because to straighten out the urethra.
the catheter tip has already passed the urethral opening
before it is properly positioned on the ventral midline. The Positioning
operator can usually feel the slight resistance as the catheter Heavy sedation to general anesthesia is generally required
tip enters the urethra. Advance the catheter into the bladder. unless the cat is severely obtunded. Position the patient in
Recently, a two-catheter technique has been described lateral or dorsal recumbency. In dorsal recumbency, the
for urethral catheter placement in anesthetized small pelvic limbs can be drawn cranially to expose the prepuce.
female dogs and female cats [27]. In this technique, a The goal is to extrude the penis caudally and dorsally out of
larger-bore red rubber (polyvinyl chloride) catheter is first the prepuce and keep it in this position as the catheter is
advanced into the vestibule until abrupt resistance is noted. passed. To extrude the penis, gently grasp the prepuce with
In the study, a 10 Fr red rubber catheter was used for cats thumb and finger and press gently onto the ischial arch to
and 18 Fr for small dogs. Once this large catheter can be provide a firm base for the procedure and to align the penis
inserted no farther, it is grasped in the operator’s non- parallel to the spine. If the penis is extruded facing in a ven-
dominant hand and flexed dorsally. The operator then tral direction, it will be difficult to pass the catheter. Then,
introduces the intended indwelling catheter into the vesti- gently move the prepuce cranially to expose the penis. The
bule along midline, ventral to the larger catheter. In this penis should now be extruded far enough to see the reflection
study, authors reported more successful catheterizations of the prepuce off the penile surface, about 1–1.5cm from the
using this two-catheter technique compared with the tradi- tip. The operator can digitally grasp the penis near the reflec-
tional blind insertion method, regardless of prior familiar- tion of the prepuce to stabilize it or can use an instrument to
ity with the technique. grasp the preputial tissue (not the penile tissue) at the site of
its reflection off the penis. Hold all structures in a horizontal
Verify Catheter Placement straight line with the tip of the penis facing caudally, not
If you think that the catheter tip is in the bladder but no ventrally, and apply gentle but firm traction caudodorsally to
urine is flowing, attach a sterile syringe to the catheter and straighten the sigmoid flexure. Insert the lubricated catheter
gently aspirate for urine, or infuse sterile saline and aspi- into the tip of the penis, and gently advance into the bladder
rate. If injected fluid comes back around the vulva, the without losing control of the extruded penis. As the catheter
catheter tip is likely in the vestibule and should be reposi- is moved cranially, continue to put traction on the penis in a
tioned. You can also place an ultrasound probe over the caudodorsal direction; otherwise, the catheter might not
bladder and either see the tip of the catheter in the bladder advance into the bladder. Once the catheter is positioned
properly in the bladder, allow the penis to withdraw into its balloon, the inflation port is imprinted with the volume of
normal position within the prepuce. sterile water required. Fill a syringe with this amount and
firmly attach it to the inflation port. Slowly inflate the bal-
loon and thereafter, gently withdraw the catheter to seat
Male Dog
the balloon at the neck of the bladder. If the patient exhib-
Anatomy its discomfort during inflation, the balloon may be in the
The prepuce is the tubular sheath of integument covering urethra. Deflate the balloon, reposition the catheter, and
the nonerect penis. The penis in nonerection is entirely try again. Point-of-care ultrasound guidance can be used to
withdrawn into the prepuce. Within the penis, the os penis visualize a Foley balloon in the urinary bladder.
surrounds the dorsal surface of the urethra. The distal end Catheters without an inflation balloon must be secured
of the os penis has a fibrocartilaginous projection that is at the site where the catheter exits the body to keep the
curved slightly ventrally. catheter tip in the bladder. To do this, first dry the catheter
and apply an adhesive tape butterfly on the catheter where
Positioning it exits the vulva or prepuce. Catheters can easily slip
With the male dog in left lateral recumbency (for a right- through a tape butterfly unless the tape is kept closely
handed operator) the assistant stands at the patient’s spine adhered to the catheter surface, so we recommend placing
with the patient’s head on the assistant’s left, reaches over an encircling suture around the catheter: insert the needle
the abdomen, presses the left hand against the body wall at through the tape as close as possible to the catheter, draw
the place where the prepuce reflects from the ventral body some suture material through, and insert the needle up
wall, and exerts pressure caudally. With the right hand, the through the tape on the opposite side of the catheter. Tie
assistant grasps the os penis through the prepuce at its most the suture securely but do not occlude the catheter. To
proximal aspect (meaning away from the tip) and pushes secure the adhesive butterfly to the patient, we recommend
the penis out of the prepuce while moving the left hand placing stay sutures in the patient and then suturing the
more caudally to stabilize it and keep the penis as parallel to adhesive butterfly to them. Some veterinary-specific cath-
the spine as possible. The penis must now be held in this eters come fitted with a plastic disk with prepared holes for
position and not allowed to withdraw into the prepuce suturing to the prepuce.
while the catheter is being placed. Gently wipe the tip of the All indwelling catheters must be attached to a sterile col-
penis with 0.05% chlorhexidine solution (Protocol 35.2). lection system. Cable ties can be useful to provide extra
security, especially between the catheter and the collection
Placing the Catheter system, if an integrated Luer-locking mechanism is not
Gently insert the catheter tip into the fibrocartilaginous present. Secure a portion of the collection system tubing to
projection of the os penis and then direct it ventrally to the patient’s leg, tail, or ventral abdomen (using tape or
advance within the urethra. Orienting the catheter in a sutures) to prevent dislodging or discomfort caused by
direction parallel to the body wall and slightly ventrally pulling on the catheter as the patient moves.
once the fibrocartilaginous tip has been negotiated facilitates
passage. The penis must remain exposed during catheter
Management of Indwelling Urinary Catheter
passage to assure that the catheter tip is entering the penis
and Collection System
and to prevent contamination of the catheter. Resistance is
usually felt as the catheter tip enters the os penis because it Make sure that personnel handling catheters and collec-
is narrow at this site and again as the catheter changes tion systems are properly trained and perform hand
direction at the ischial arch and passes through the prostatic hygiene before and after handling the system. Inspect the
section of the urethra. Use the softest catheter possible to system several times a day. Make sure all connections are
ease passage and minimize discomfort. Advance the cath- secure. Use good nursing care to minimize contamination
eter into the bladder. of the catheter and periurethral area from contact with
soiled hospital surfaces, wound discharge, or feces.
Maintain unobstructed flow, keep the catheter and collect-
Care and Maintenance of Indwelling ing tubes from kinking, and keep the collecting bag lower
than the bladder to prevent retrograde urine flow.
Catheter Systems
Catheter Care
Securing the Catheter and Collection System
Perform catheter care every eight hours or whenever the
Once the catheter is properly placed, it must be secured if system is visibly soiled. Use surgical scrub followed by
it is to remain indwelling. For Foley catheters with a water rinse to clean any visible soiling on the exposed
Cesaa hateairhes iierd aiiaarPa CathaheraiCaaiees 463
portion of the catheter, the collection system, or the Basic Techniques

patient’s skin in the perivulvar or peripreputial area. Do for Difficult Catheterizations
not let scrub contact mucosal surfaces. Wipe the exposed
portion of the catheter and the skin of the perivulvar or Decompressive Cystocentesis
peripreputial area with 0.05% chlorhexidine solution. This for Urethral Obstruction
solution can be that saved from the preparation for catheter
placement as described earlier. Flush the prepuce or vulva For difficult urethral catheterizations in cats and dogs with
and vestibule five times with the 0.05% chlorhexidine solu- urethral obstruction, decompressive cystocentesis may be
tion using a sterile syringe. considered. Decompressive cystocentesis may decrease the
anterograde pressure applied to an obstructive object
Emptying or Changing the Urine Collection Bag (stone, plug, grit) in the urethra, allowing easier retrograde
Wash hands and put on examination gloves. Use gowns urethral catheter passage. Also, if repeated urethral cathe-
and barriers as needed for aseptic technique or if public terization attempts are unsuccessful and, for example, a
health considerations are present. For closed systems, surgical procedure is planned to resolve or circumvent the
drain the urine into a clean container. Do not let the drain- obstructive process, decompressive cystocentesis can be
age tube contact the container and avoid splashing. Close used as a bridge therapy to definitive care.
the drainage tube. Decompressive cystocentesis appears to be relatively safe
For open systems, assemble the needed materials to in cats [28, 29], though little information is available about
replace the bag while maintaining sterility. Disconnect the the procedure in dogs. It is unclear whether the technique
full bag from the macrodrip set and aseptically attach an improves one’s ability to pass a retrograde urethral cathe-
empty sterile fluid bag. ter, but it should be considered in challenging cases in
Do not change indwelling catheters and drainage bags at which other options pose challenges.
fixed intervals but rather based on clinical indications such We prefer to perform decompressive cystocentesis
as infection, obstruction, or compromise of the closed col- using point-of-care ultrasound guidance to assess for free
lection system (Protocol 35.4). abdominal fluid prior to and following the procedure.
Protocol 35.4 Indwelling Catheter Maintenance

To be performed by trained veterinary healthcare workers 4) Make sure that the catheter and the collection system
every eight hours or whenever the system is visibly soiled. are properly secured. Keep the collection bag lower
than the patient to prevent retrograde flow of urine.
Items Required 5) Use surgical scrub followed by water rinse to clean
soiling on catheter, collection system, or the perivulvar
● Water
or peripreputial area as needed.
● Gauze pads
6) Wipe the exposed portion of the catheter and the skin
● Surgical scrub
of the perivulvar or peripreputial area with gauze
● Sterile syringe
sponges soaked in 0.05% chlorhexidine solution.
● Examination gloves
7) Clean the perivulvar or peripreputial area with 0.05%
● 0.05% chlorhexidine solution
chlorhexidine-soaked gauze sponges and flush the
● Empty, sterile fluid bag if the current bag is full and the
vulva and vestibule or prepuce with 0.05% chlorhex-
patient does not have a purpose-made, closed urinary
idine solution using the syringe.
collection system attached
8) Empty or change the urine collection bag as needed.
d) For the closed system, open the urine drainage
Procedure
spout and drain the urine into a container. Avoid
1) Gather supplies. touching the container with the drainage tubing
2) Perform hand hygiene and don clean examina- and avoid splashing. Close the urine drainage tube.
tion gloves. e) For the open system, disconnect the full bag from
3) Minimize contamination of the catheter, collection sys- the macrodrip and sterilely attach an empty sterile
tem, and periurethral area from contact with soiled hos- fluid bag.
pital surfaces, wound discharge, or feces during handling 9) Perform hand hygiene after discarding urine and
and procedure. examination gloves.
With ultrasound guidance, a 22-gauge vascular catheter of ventrally onto the pelvic floor. In a large dog, two fingers
appropriate length can be inserted percutaneously into the may be inserted to better trap the urethra against the pelvis.
urinary bladder, the stylet removed, and the flexible vascu- Briskly inject 5–20 ml of flush into the urethra, depending
lar catheter attached to an extension set and syringe. The on the patient’s size. The assistant occluding the urethra
bladder can then be emptied partially or completely, and should be able to feel the urethra dilate. The assistant then
the percutaneous catheter removed. abruptly releases the urethral occlusion as injection of
flush continues and the operator attempts to advance the
catheter.
Retropulsion for Urethral Obstruction If unsuccessful, and the patient is not already anesthe-
tized, consider providing full general anesthesia before
Retropulsion is the process of expanding the urethra with
retrying the procedure (Protocol 35.6).
fluid to flush an obstructing substance retrograde and
deposit it back into the bladder. It is not desirable to use a
catheter to force an obstructing substance retrograde
because this may damage or even rupture the urethra.
Retropulsion is most commonly needed in males and
required uncommonly in females because their urethra is
shorter and of larger diameter. The goal of retropulsion is
to expand the diameter of the urethra with fluid to suspend
the obstructing substance in a fluid column that will carry
it back into the bladder. Be aware that the urethra can be
ruptured by overly aggressive flushing technique or by
overly aggressive attempts to advance the catheter against
an obstruction (Protocol 35.5).
For male dogs, a supplement to retropulsion is to
also occlude the urethra proximal to the obstruction
(Figure 35.11). To occlude the urethra proximal to the
obstruction, an assistant inserts a gloved finger into the Figure 35.11 Retropulsion with occlusion of the urethra per
rectum and occludes the urethra by compressing it rectum in a male dog.
Protocol 35.5 Retropulsion for Urethral Obstruction

Items Required up the urethra. If the catheter cannot be advanced far
enough to seat it inside the urethra, try a smaller or
● See Box 35.1 for appropriate supplies
stiffer catheter. Remember that in male cats, the penis
must be pulled caudally to straighten the sigmoid
Procedure
flexure in the urethra before the catheter can be
1) The procedure can be painful. Provide analgesia and passed. For male cats, an olive-tip catheter or a 22-
sedation as indicated. The relaxation of the urethra gauge venous catheter (with the stylet removed) may
that occurs during general anesthesia might be needed be easier to place in the most distal urethra. Once the
for difficult obstructions. obstruction is relieved, a regular catheter can be
2) Evaluate bladder size to determine whether it would placed indwelling.
be safe to add more fluid. If not, perform cystocentesis 5) Attach the syringe to the end of the catheter.
before retropulsion. If performed correctly (small- 6) Occlude the tip of the penis around the catheter with
gauge needle inserted as atraumatically as possible), digital pressure to prevent the flush from flowing
cystocentesis even of a distended bladder is probably back out.
lower risk than adding fluid to an already pathologi- 7) An assistant should briskly inject flush while the oper-
cally distended bladder. ator gently advances the catheter. If the catheter can
3) Fill a syringe (5- to 20-ml size) with sterile saline be advanced, continue to inject fluid until the catheter
for flush. tip is in the bladder. Keep track of the volume of flush
4) Follow all the protocols as previously described to injected, do not overdistend the bladder, and decom-
maintain sterility. Pass the catheter as far as possible press the bladder by cystocentesis if needed.
hiherheahes 465
Protocol 35.6 Retropulsion with Proximal Urethral Compression for Challenging Urethral Obstruction in Male Dogs
Items Required 6) Follow procedure for catheter insertion and advance
the catheter gently until the obstruction is reached.
● See Box 35.1 for appropriate supplies
7) Operator occludes tip of penis around the catheter to
● Sterile flush solution
prevent backflow of flush.
● Several sterile syringes (for flushes)
8) Assistant 1 injects sterile flush briskly while operator
● Two assistants
gently attempts to advance the catheter.
9) Occlusion of the urethra per rectum, if step 7 was
● Lubricant
unsuccessful:
a) Assistant 2 inserts a gloved finger into the rectum
Procedure
and prepares to apply firm ventral digital pressure
1) Gather necessary supplies. on the proximal urethra to occlude it.
2) Ensure that only properly trained caregivers perform the b) Repeat step 6.
procedure, and that sterility is maintained throughout. c) Assistant 2 firmly occludes the urethra per rectum.
3) Consider heavy sedation or anesthesia. d) Assistant 1 injects flush briskly and continues
4) Evaluate bladder size. Perform decompressive cysto- injecting.
centesis if needed. e) Assistant 2 feels the urethra dilate and abruptly
5) Assure that sufficient personnel are available to releases the pressure while assistant 1 continues
perform the various aspects of the procedure: catheter the flush and the operator attempts to advance
insertion by operator; flushing the catheter by assistant the catheter.
1; digital occlusion of the proximal urethra per rectum 10) If unsuccessful and the patient is not yet anesthetized,
by assistant 2; and patient restraint or anesthetic consider anesthesia before repeating the procedure.
monitoring, as appropriate by assistant 3.
Deflating a Foley Balloon balloon was inflated to allow fluid to egress, which will
deflate the balloon. In the rare situation in which cutting
The correct method for deflating a Foley balloon is as fol- the channel does not facilitate balloon deflation, the Foley
lows. Attach a Luer slip syringe to the catheter valve. balloon can be aspirated percutaneously with ultrasound
Allow the pressure in the balloon to force the water into guidance in the anesthetized animal to allow catheter
the syringe to deflate the balloon completely. Do not apply removal.
aspirating pressure at this time. If the balloon does not
deflate, reseat the syringe gently and try again. If unsuc-
cessful, reposition the patient; ensure there is no traction Acknowledgment
on the catheter, and then try again. If the balloon still
does not deflate, apply gentle, slow aspiration, remember- The current author and editors would like to acknowledge
ing that rapid or forceful aspiration can collapse the infla- Dr. Janet Aldrich’s contributions to first edition of Advanced
tion tube and prevent balloon deflation. If the balloon Monitoring and Procedures for Small Animal Emergency
cannot be deflated, cut the channel through which the and Critical Care, upon which this chapter is based.
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10 Ogilvie, A.T., Brisson, B.A., Singh, A., and Weese, infection in dogs with thoracolumbar intervertebral disc
J.S. (2015). in vitro evaluation of the impact of silver herniation and urinary bladder dysfunction managed by
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11 Ogilvie, A.T., Brisson, B.A., Gow, W.R. et al. (2018). Effects 23 Weese, J.S., Blondeau, J., Boothe, D. et al. (2019).
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14 Lees, G.E., Osborne, C.A., Stevens, J.B. et al. (1981). 26 Robben, J.H. (2020). A novel insertion technique for
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989–991. single decompressive cystocentesis prior to
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467
36
Peritoneal Dialysis
Michael D. Santasieri, Carolyn Tai, and Mary Anna Labato
Despite its long-term use in human medicine for the treat- if available [3]. However, if transfer to a hemodialysis
ment of both acute kidney injury (AKI) and chronic kidney center is not possible due to local availability or cost, peri-
disease, the use of renal replacement therapies in veteri- toneal dialysis is a reasonable alternative. It may also be
nary medicine is still uncommon. The most likely explana- preferable in cases where vascular access is difficult to
tion for this is that owners are deterred by the relatively obtain, where refractory hypotension or small patient size
high cost and clinicians by the relatively high amount of (Figure 36.1) make the risks of performing hemodialysis
specialized knowledge required for these therapies. greater than the potential benefits.
However, peritoneal dialysis is an accessible therapy for Even though peritoneal dialysis is less efficient and argu-
most specialty hospitals and may be less financially taxing ably as labor intensive as hemodialysis, there are still some
than extracorporeal hemodialysis modalities. definite therapeutic advantages. Peritoneal dialysis is tech-
nologically simple, relatively inexpensive, and more effica-
cious in removing uremic middle molecules that are in the
Indications 500–15 000 Da range, including parathyroid hormone, lep-
tin, β-2 microglobulin, and tumor necrosis factors [4, 5].
In veterinary medicine, the primary indication for perito- Hemodialysis is more efficacious overall at altering water
neal dialysis is AKI. AKI is defined as the inability of the and solute balance but requires a high level of expertise as
kidneys to regulate water and solute balance, which is typi- well as expensive equipment and supplies.
cally recognized by an accumulation of nitrogenous wastes
such as urea and creatinine [1]. Dialytic therapies may be
the only option to treat severe uremia that is unresponsive Performing Peritoneal Dialysis
to fluid therapy and post-renal uremia resulting from ure-
teral obstruction [2]. Severe electrolyte derangements, Dialysis is defined as the transfer of water and solutes from
refractory metabolic acidosis, and the metabolites and neu- one compartment to another across a semipermeable
rotransmitters responsible for the clinical signs of hepatic membrane. Peritoneal dialysis uses the lining of the
encephalopathy are all responsive to peritoneal dialysis. abdominal cavity, the peritoneum, as this membrane.
Volume overload, which can occur iatrogenically in oligu- Dialysate solution is instilled into the abdominal cavity,
ric and anuric patients with AKI, or secondary to conges- and allowed to dwell so that solutes can pass through the
tive heart failure, can also be treated with peritoneal peritoneum, and then the solution is drained and dis-
dialysis through the use of hyperosmolar dialysate to cause carded. This is repeated as frequently as needed for resolu-
ultrafiltration. tion of clinical signs. This process is governed by diffusion
Peritoneal dialysis can also be used for the treatment of and osmosis, convection, and ultrafiltration.
some toxicities if the offending toxin is diffusible across the Diffusion is the movement of molecules from an area of
peritoneal membrane. Such toxins include ethylene glycol high concentration to an area of low concentration in an
and its toxic metabolites, ethanol, and barbiturates [2, 3]. attempt to reach equilibrium. Osmosis refers to diffusion of
Hemodialysis is about 75% more efficient than peritoneal water across a semipermeable membrane from an area of
dialysis, so it should be considered as a first-line treatment low solute concentration to an area of high solute
468 Peritoneal Dialysis
Figure 36.1 Peritoneal dialysis is an effective dialysis modality for patients that are too small for extracorporeal therapies, such as
small dogs and cats, or exotic mammals like rabbits and ferrets.
concentration. For diffusible molecules, the processes of

Box 36.1 Items Required for Performing Peritoneal
solute diffusion and water osmosis ultimately results in
Dialysis
equal concentrations on both sides of the membrane.
Ultrafiltration is the movement of water across a semi-
Peritoneal dialysis catheter
permeable membrane caused by differences in hydrostatic
●
Dialysate solution
pressure or osmolality in the two compartments, which
●
○ Note that some commercially available dialysate

results in excess fluid removal from the patient. This is
solutions require brand-specific adaptors to “spike”
accomplished during peritoneal dialysis by instilling
the bag
dialysate into the peritoneal cavity that is of a higher osmo-
Volumetric infusion pump
lality than plasma, usually accomplished by adding dex-
●
Fluid warmer and/or inline fluid line warmer

trose or glucose to the dialysate.
●
2 sterile intravenous fluid administration sets

Convection is the movement of solutes when carried
●
Sterile collection bags

along with the flow of water (called “solute drag”) during
●
Three-way stopcock
ultrafiltration. Convection does not play a significant role
●
Sterile gauze sponges

in peritoneal dialysis but can explain the loss of some
●
2- to 4-inch conforming gauze bandage

higher weight molecules, such as albumin, during aggres-
●
2- to 4-inch cast padding

sive ultrafiltration.
●
2- to 4-inch cohesive bandage (e.g. Vetrap)

The necessary equipment needed for peritoneal dialysis
●
(optional) 2- to 4-inch fabric elastic tape (e.g.

consists of items that are readily available in most specialty
●
Elastikon)
practices (Box 36.1). Catheters designed specifically for
Waterproof bandage tape
peritoneal dialysis are recommended, but alternatives
●
Chlorhexidine solution 1–2%

are listed.
●
● Sterile gloves
● Exam gloves (non-sterile)
Catheter Types
functional for 12–36 hours before they become occluded
There are many different types and brands of peritoneal with omentum, which prevents dialysate from draining out
dialysis catheters (Table 36.1); most are variations of a of the body. Peritoneal dialysis catheters for long-term use
fenestrated silicone elastomer or polyurethane tube [6]. should be placed surgically. Catheters explicitly made for
According to the International Society for Peritoneal this purpose often have polyethylene terephthalate cuffs,
Dialysis, the ideal peritoneal dialysis catheter “provides usually referred to by the brand name Dacron™ (Invista,
reliable, rapid dialysate flow rates without leaks or infec- Wichita, KS), to promote fibrous attachments at the perito-
tions” [7]. For acute short-term dialysis, a percutaneously neal and cutaneous exit sites. The use of these cuffs has
placed catheter can be used. These catheters are typically been shown to reduce the incidence of dialysate leakage
Catheter Types 469
Table 36.1 Some peritoneal dialysis catheter options

for veterinary patients.
Catheter Manufacturer
Argyle™ Tenckhoff peritoneal Covidien, LLC

dialysis catheter www.covidien.com
Argyle™ Swan Neck Missouri Figure 36.2 A Tenckhoff-style catheter with a curled tip
peritoneal dialysis catheter (Medcomp, Harleysville, PA).
Argyle ™ Swan Neck Curl Cath
peritoneal dialysis catheter
Universa® Malecot drainage catheter Cook Medical, Inc. found the Swan Neck Missouri Catheter (Covidien,
www.cookmedical.com Mansfield, MA) to be successful for many long-term appli-
Blake® Silicone drain Ethicon, Inc. cations. It consists of a fenestrated tube that is curled at the
www.ethicon.com end, with two Dacron cuffs and a hard silicone bead to help
Percutaneous peritoneal drain kit MILA International, Inc. prevent dialysate leakage. However, because of these cuffs
(peritoneal dialysis) www.milaint.com and bead, this catheter requires surgical removal. The
Jackson Pratt drain with trocar Swan Neck Curl Cath (Covidien, Mansfield, MA) is a simi-
Silicone chest tube lar catheter that does not include the silicone bead but still
Centesis catheter (fenestrated) has two Dacron cuffs (Figure 36.3).
Based on our experience, although the Tenckhoff,
Swan Neck Missouri, Swan Neck Curl Cath, and T-fluted
and peritonitis in both human and veterinary patients catheters are all designed to be placed by either laparos-
[1, 3, 4, 8–13]. Owing to the high prevalence of omental copy or blind trocarization in humans, we recommend
occlusion of peritoneal dialysis catheters, it is highly rec- placing them surgically in veterinary patients for better
ommended to perform an omentectomy at the time of results.
placement. For emergent, short-term peritoneal dialysis, a percuta-
Historically, the authors have found the T-fluted catheter neously placed catheter can be considered. The authors
(Ash Advantage, Ash Access Technology, Lafayette, IN) to have the most experience with the Malecot Drainage
be most successful for long-term peritoneal dialysis; how- Catheter (Cook Medicial, Bloomington, IN), which is easy
ever, at the time of writing, these catheters are no longer to place with minimal experience and without anesthesia
manufactured. This catheter featured long channels (called (Figure 36.4). However, we find that it only tends to work
“flutes”) rather than fenestrations to prevent omental for 12–36 hours before becoming occluded with omentum.
adhesion and to decrease resistance during the influx and Other alternatives include the previously mentioned Blake
efflux of fluid [3, 14]. surgical drain, the Jackson Pratt surgical drain, fenestrated
A readily available alternative is the Blake® surgical chest tube, or centesis catheter (Figure 36.5). At the time of
drain (Ethicon Inc., Somerville, NJ). Although not specifi-
cally manufactured for peritoneal dialysis, this catheter
would be expected to perform similarly owing to its
employment of the same type of “flutes” as the T-fluted
catheter. In a retrospective study conducted in 2008, the
use of a Blake surgical drain combined with an intermit-
tent closed suction system was an effective peritoneal dial-
ysis system for 100% of the cats included in the study [15].
Although the study was underpowered (only six cases were
included), it demonstrates that the Blake surgical drain
may be a reasonable alternative to the T-fluted catheter.
The main disadvantage is that there are no Dacron cuffs to
help prevent leakage from the peritoneal space.
The Tenckhoff catheter is a straight catheter with either
a straight or curled fenestrated end, and one or two Dacron
cuffs. It is the most frequently used catheter for humans
undergoing peritoneal dialysis, and versions are made by Figure 36.3 Argyle™ Swan Neck Missouri Catheter and Argyle
several manufacturers (Figure 36.2) [5–7, 16]. We have Swan Neck Curl Cath (Covidien, Mansfield, MA).
trocar should be inserted subcutaneously and tunneled for

several centimeters, pointing toward the pelvis and ingui-
nal canal, before piercing through the abdominal muscles.
The catheter should then be advanced over the trocar until
it is seated fully in the abdomen. A purse-string and finger-
trap suture pattern should be used to secure the catheter
in place.
Figure 36.4 Universa® Malecot Drainage Catheter (Cook Surgical placement is highly preferable when treatment
Medical, Bloomington, IN).
is expected to last longer than 24 hours. The patient should
be prepared in the same way as for emergent catheter
placement: in dorsal recumbency, shaved from xiphoid to
pubis, and cleaned with a suitable antiseptic. Current
human guidelines recommend the use of a single periop-
erative dose of a prophylactic antibiotic that provides anti-
staphylococcal coverage, such as cefazolin, and the authors
consider that this is also beneficial to veterinary patients [6,
13, 18]. Surgical omentectomy is necessary to prevent
omental entrapment and should be performed at the same
(b)
time as catheter placement. After omentectomy, an inci-
sion should be made off midline by 3–5 cm on either side,
and a subcutaneous tunnel made as previously described
for percutaneous placement. The catheter should termi-
nate in the inguinal area and be oriented in a roughly cra-
nial to caudal plane. Care should be taken to ensure that
(a) the catheter does not kink at either the internal or external
exit sites.
If a cuffed catheter is used (current human guidelines
(c) recommend silicone catheters with at least two Dacron
cuffs), the cuffs should be soaked in sterile saline before
Figure 36.5 Improvised peritoneal dialysis catheters: (a) chest placement to remove air and facilitate fibroblast inva-
tube (MILA International, Florence, KY); (b) Jackson Pratt drain sion [13]. The deeper cuff should be placed in the rectus
(Jorgensen Labs, Loveland, CO); (c) Blake® silicone drain (Ethicon,
muscle, and the more superficial cuff should be placed in
Somerville, NJ).
the subcutaneous tunnel. The silicone bead of a Missouri
catheter, if used, should be positioned just inside the peri-
this writing, MILA International Inc. has just released a toneum to prevent dialysate leakage.
new “percutaneous peritoneal drain kit” that looks poten-
tially helpful for short-term use, but the authors have no
personal experience with this product [17]. Dialysate Solutions
Dialysate solutions are buffered, slightly hyperosmolar

Site Selection, Preparation, and Catheter crystalloid solutions designed to osmotically pull fluid, cre-
Placement atinine, urea, electrolytes, phosphorous, and other solutes
from the plasma into the dialysate. These solutions also
For emergent percutaneous placement of a peritoneal dial- provide diffusible buffer and other needed compounds
ysis catheter, the patient should be administered mild seda- such as magnesium and calcium [19]. Most commercially
tion and a local anesthetic block. An indwelling urinary available dialysate solutions do not contain potassium, as
catheter should be placed to ensure that the urinary blad- many dialysis patients are hyperkalemic. For normoka-
der is empty so that the trocar does not inadvertently pierce lemic and hypokalemic patients, potassium chloride can be
it. With the patient restrained in dorsal recumbency, the added to the dialysate up to a maximum concentration of
abdomen should be shaved from the xiphoid to the pubis 4 mmol/l (4 mEq/l), or potassium can be supplemented
and aseptically cleaned with a suitable antiseptic, such as orally or parenterally [20, 21].
chlorhexidine or povidone-iodine. A stab incision should Hyperosmolar dialysate solutions are effective in mini-
be made 3–5 cm lateral to the umbilicus on either side. The mizing edema in overhydrated patients and enhancing
Dialysate Solutions 471
Table 36.2 Recommended hyperosmotic sugar concentrations.
Concentration of dextrose/
glucose monohydrate Patient fluid status
1.5%/1.36 mg/dl Euvolemic or dehydrated

2.5%/2.27 mg/dl Mildly overhydrated
4.25%/3.86 mg/dl Severely overhydrated
ultrafiltration. The most frequently used hypertonic solu-

tion is sugar, either as dextrose or as glucose monohydrate,
though other solutions have seen use in human medicine
in recent years [16]. These sugars appear to favor capillary
vasodilation and promote solute drag, so small concentra-
tions are frequently used in even euvolemic or dehydrated Figure 36.6 Fibrin deposits, which may occlude the catheter
patients to maximize the permeability of the peritoneal (as pictured here), can be avoided by adding heparin to the
membrane (refer to Table 36.2 for recommended hyperos- dialysate for the first few days after catheter placement.
motic sugar concentrations). Intermittent use of 4.25% dex-
trose or 3.86 mg/dl glucose monohydrate dialysate may fluid volume status. It is also possible to make a suitable
increase the efficiency of dialysis in all patients, regardless dialysate solution for immediate short-term use with sup-
of fluid status [2]. plies readily available in all specialty practices until com-
Heparin (250–1000 iu/l) should be added to dialysate mercial dialysate solutions can be acquired (Box 36.2,
for the first few days after catheter placement to help pre- Figure 36.7). Once treatment has been initiated, commer-
vent occlusion of the catheter by fibrin deposits cial solutions should be used as soon as possible. It is
(Figure 36.6) [2, 22]. There is minimal systemic absorp- worth noting that although 0.9% NaCl (physiological
tion of this heparin, making it unlikely to prolong clot- saline) may be considered in severely hyperkalemic
ting times [2, 22–25]. patients as it contains no potassium, it has also been
Many different formulations of dialysate solutions are shown to predispose human chronic peritoneal dialysis
commercially available (Table 36.3). Dialysate solutions patients to the formation of peritoneal adhesions and
should be chosen based on patient serum electrolyte and fibrosis [6]. Because of this, it is advisable to change to
Table 36.3 Common commercially available and homemade peritoneal dialysis dialysate solutions [6, 16, 20, 26].
Na Ca Mg Lactate Bicarb
Brand Namea Osmotic agent pH (mmol/l) (mmol/l)b (mmol/l)c (mmol/l) (mmol/l)
Baxter Dianeal™ PD-1 Glucose 5.5 132 1.75 0.75 35 0

Dianeal™ PD-4 Glucose 5.5 132 1.25 0.25 40 0
Extraneal™ Icodextrin 5.5 132 1.75 0.25 40 0
Nutrineal™ Amino acids 6.5 132 1.25 0.25 40 0
Physioneal™ 35 Glucose 7.4 132 1.75 0.25 10 25
Physioneal 40 Glucose 7.4 132 1.25 0.25 15 25
Fresenius Balance® Glucose 7.4 134 1.25/1.75 0.5 35 2.5
Medical Bicavera® Glucose 7.4 134 1.25/1.75 0.5 0 34
Care
Stay Safe® 2/4/3 Glucose 5.5 134 1.75 0.5 35 0
Stay Safe 17/19/18 Glucose 5.5 134 1.25 0.5 35 0
Homemade Lactated Ringer’s solution Dextrose 6.5 130 1.4 0 28 0
0.9% NaCl and sodium bicarbonate Dextrose 5.5 154 0 0 0 35
a
Solutions may differ slightly in name and formulation depending on region.
b
To convert to mg/dl: Ca × 4
c
To convert to mg/dl: Mg × 2.43.
Box 36.2 Recipe for Homemade Dialysate Solutions Catheter Management
● 1 liter crystalloid solution: To avoid catheter-related infections, asepsis should be

○ lactated Ringer’s solution
practiced and maintained at all times. After placement of
or the peritoneal dialysis catheter, the exit site should be
○ 0.9% NaCl (physiological saline); if using, add 35 ml
bandaged and connected to the inflow and outflow lines.
8.4% sodium bicarbonate (35 mEq) All manipulations of lines, daily bandage changes, and
● 50% dextrose solution: daily line changes should be performed wearing sterile
○ 30 ml = 1.5%
gloves. All contact with the patient, including physical
or exams and treatments, should be performed wearing clean
○ 50 ml = 2.5%
examination gloves. Ports should be swabbed with 70% iso-
or propyl alcohol prior to any injections.
○ 85 ml = 4.25%
Central to managing the peritoneal dialysis catheter is
proper bandaging of the exit site and stabilization of the
Before adding dextrose or sodium bicarbonate, asep- catheter and exiting lines. The items needed are shown in
tically remove the same volume of crystalloid from the Figure 36.8.
bag as the volume of dextrose and/or sodium An antimicrobial ointment should be applied over the
bicarbonate, and discard. See references [2, 12, 22]. exit site after placement of the catheter, followed by a ster-
ile dressing. Current human guidelines recommend either
mupirocin or gentamycin ointments, although the authors
either a buffered electrolyte solution or commercially have also used bacitracin/neomycin/polymyxin (triple
available dialysate as soon as possible. Sodium bicarbo- antibiotic ointment) to good effect [13, 18]. For dressings,
nate can be added to 0.9% NaCl to buffer the solution and the authors prefer the Tegaderm™ +Pad (3M), which is
potentially negate some of these effects [6]. If renal func- available in several sizes. This dressing has an adhesive
tion is still not adequate after acute peritoneal dialysis and backing which allows it to stick to the catheter and the skin
the decision is made to pursue chronic peritoneal dialysis, around it. In the middle of the dressing there is a non-
the use of amino acid- or icodextrin-based dialysate will adherent, absorbent pad that will wick away any effusion
likely be advantageous [16, 27–29]. from the catheter exit site.
Figure 36.7 Commercially available and homemade dialysate solutions.

Catheter Management 473
Once the bandage is applied and the catheter is stabi-

lized, it should be attached to lines in preparation for
exchange. In veterinary peritoneal dialysis, there are two
main types of catheter connecting systems. In the standard
or straight connecting system, the catheter is connected to
the dialysate solution bag using a straight piece of tubing
and intravenous (IV) fluid administration set. The con-
tainer of dialysate is drained into the patient and the empty
bag is rolled up and remains attached until the next
exchange is initiated. At the beginning of the next exchange,
the effluent is drained into the empty dialysate bag,
removed, measured, and discarded. A new connection
must be made for each exchange.
Studies in humans have shown the Y-connection system,
as compared with the standard connection, is associated
with a lower incidence of peritonitis [30]. With the
Y-connection system, one line is connected to the patient,
the second line is connected to an empty “effluent” bag,
while the third line is connected to the dialysate. The items
Figure 36.8 Supplies needed for bandaging an indwelling needed are shown in Figure 36.9.
peritoneal dialysis catheter. An extension set should be connected to the peritoneal
dialysis catheter and then attached to a three-way stopcock.
The abdomen should then be wrapped with cast pad- The dialysate should be spiked with an IV fluid administra-
ding, taking care that the catheter is stabilized without tion set. The authors recommend using a volumetric fluid
kinking or occluding it. This should be followed by a layer pump to control and monitor the volume of infusion for each
of conforming gauze and finished with a layer of cohesive exchange. The fluid administration set should be primed
bandage (e.g. Vetrap™, 3M). If needed, a layer of four-inch with dialysate and attached to the T-side of the three-way
fabric elastic tape (e.g. Elastikon®, Johnson & Johnson) can stopcock. A second IV fluid administration set should be con-
be applied around the cranial aspect of the bandage to keep nected to a sterile empty collection bag and attached to the
it from sliding. remaining port of the stopcock. This line should be
(a)
(c)
(b) (d) (e)
Figure 36.9 Supplies needed for Y-connection. (a) Volumetric intravenous (IV) fluid administration set. (b) Extension set.
(c) Three-way stopcock. (d) IV fluid administration set. (e) Empty fluid bag (sterile).
Figure 36.10 Peritoneal dialysis Y-connection system set up

with appropriate labeling.
positioned so that it is in a direct, straight route from the

patient’s dialysis catheter through the stopcock and into the
empty collection bag. To maintain sterility, all connections
should be wrapped in gauze soaked with chlorhexidine 1–2%
and secured with waterproof tape. All the lines and connec-
tions should be labeled in a manner that all personnel will
understand: “dialysate in” or “inflow;” “patient;” “drain” or
“outflow” or “effluent” (Figure 36.10). Figure 36.11 shows all
equipment set up as it would be for a patient.
The abdominal bandage should be removed every
24 hours, and the catheter exit site should be inspected.
Any redness, swelling, discharge, catheter slippage, or
other abnormalities should be reported to the doctor imme-
diately. Before rebandaging, the catheter exit site should be
cleaned with chlorhexidine 1–2%, dried thoroughly, and
new antimicrobial ointment applied. All lines, including
the effluent bag and any unused dialysate, should also be Figure 36.11 Mock peritoneal dialysis setup featuring the
changed every 24 hours. If the dialysate bag is consumed in authors’ dialysis training model “Lepto Louie.” For this setup,
both a heating pad to warm the dialysate and an inline warmer
less than 24 hours, only the bag needs to be changed at that have been used to keep the dialysate at an optimal temperature,
time. Any direct contact with the catheter, including as well as a volumetric fluid pump for accurate infusion dosing.
changing the lines, should be performed in an aseptic man-
ner while wearing sterile gloves. The exposed portion of
the catheter and all lines should be wiped down with chlo- occur. Initially, in the acute setting, these may be hourly.
rhexidine 1–2% every four to six hours. Patients undergoing chronic peritoneal dialysis may have
dwell times of two to four hours, though they can last up to
12 hours. These are interspersed with 4 to 12 hour “dry”
Performing Peritoneal Dialysis times, during which the peritoneal cavity is devoid of
Exchanges dialysate.
Once everything is attached, secured, and labeled,
The type of dialysate, the amount infused, and the dwell exchanges may begin. The dialysate dose is usually infused
and dry times are collectively referred to as the dialysis pre- over 10–20 minutes, depending on the volume and speed at
scription. A dialysis cycle refers to how often exchanges which it can be given. The use of a fluid pump is
Complications 475
advantageous in assuring accuracy in the delivery of pre- Monitoring

scribed infusions over a set amount of time.
The dialysate should be warmed to physiologic tem- Accurate and complete record keeping is a critical aspect of
peratures, 100.4–102.2°F (38–39°C), prior to instillation. peritoneal dialysis. The following values should be recorded
This will improve the permeability of the peritoneum with each exchange: IV fluids infused, including all IV
and will be more comfortable for the patient [23]. medications, dialysate infused, effluent drained, and urine
Instilling room-temperature dialysate may dramatically output. A running total comparing the volumes infused to
and detrimentally lower the patient’s body temperature. the outputs should also be recorded. A digital spreadsheet
An inline fluid warmer may be used on the end of the is effective in recording and tracking these values
inflow line between the stopcock and dialysate bag. (Figure 36.12). The advantage of a digital spreadsheet is
However, it is important to ensure that it will sufficiently that it can be programmed to calculate totals and deficits
warm the fluid at the rate at which the dialysate is being automatically.
infused. A drawback to this methodology is the extra Body weight, which can be a useful tool in assessing fluid
weight pulling on the catheter, especially if the patient is volume status, should be measured every six to eight hours.
ambulatory. This should be done in a “dry” state before an infusion of
Another strategy is to wrap the dialysate fluid bag in a dialysate. Rapid decreases in body weight may be an indi-
warming blanket. A limitation of this method is that the cator that the patient is becoming volume-depleted, or
fluid in the line cools during the dwell and drain period. alternatively could signify successful fluid removal from an
With small infusion volumes, the cool dialysate fluid in the overhydrated patient (ultrafiltration). Acute increases in
fluid line could amount to a large portion of the total infu- weight may indicate that an oliguric patient is in jeopardy
sion. A combination of the inline and around-the-bag fluid of developing volume overload, or that a significant vol-
warming techniques is ideal. ume of dialysate is being retained during draining.
At the beginning of each exchange, a minimum of 2 ml Initially, temperature should be monitored every six to
of dialysate should first be flushed through the stopcock. eight hours. Temperature should be evaluated at least once
This serves to rinse bacteria that are potentially trapped in after the first infusion of dialysate to determine if the
the stopcock into the outflow line, and subsequently, the exchanges are affecting body temperature. As with any
effluent bag. This is referred to as the “drain first proto- patient that has compromised kidney function, blood pres-
col” [18]. An added benefit to this technique is that the vol- sure should be assessed every six to eight hours to ensure
ume that has cooled in the fluid line can be added to the that the patient does not become either hypo- or hypertensive.
rinse volume so that only warmed fluid will be infused into Heart rate, respiratory rate, and respiratory effort should
the patient. The “rinse” volume must be excluded from the be evaluated every one to two hours. If there is any change
measured volumes during monitoring. in respiratory rate or effort, it should be noted how these
To initiate an exchange, the pump should be set for the changes correlate with dialysate infusion. Distension of the
rinse volume. The stopcock should be turned “off” to the peritoneal cavity with dialysate will increase the pressure
patient, or “on” to the effluent bag, depending on the on the diaphragm, potentially making respiration difficult.
design of the stopcock. After the rinse volume is infused Increases in heart rate, respiratory rate, and respiratory
into the effluent bag, turn the stopcock “off” to the efflu- effort could indicate hypovolemia, volume overload, or
ent bag or “on” to the patient. The fluid pump should be pain, and should be addressed appropriately.
programmed to deliver the prescribed amount of Changes in kidney and electrolyte values can occur rap-
dialysate over the prescribed amount of time. When the idly in the first few days of peritoneal dialysis. These values
infusion is complete, turn the stopcock “off” to the should be checked two to three times a day during this
patient, or “on” to the effluent bag. The patient is now critical period, and then daily when it is determined that
“dwelling” with dialysate remaining within the perito- the patient is tolerating exchanges well.
neum. Any time the patient is not receiving an infusion
or actively draining, the stopcock should be turned “off”
to the patient. At the end of the prescribed dwell time, Complications
the stopcock should be turned “off” to the dialysate or
dialysis inflow line. Dialysate fluid, now referred to as Complications of peritoneal dialysis include dialysate
effluent, should flow freely from the patient into the out- retention, dialysate leakage, hypothermia, electrolyte dis-
flow line and effluent collection bag. After the drain turbances, hypoalbuminemia, and bacterial peritonitis.
period, the effluent should be measured and discarded, Poor fluid efflux generally occurs if the catheter was
and another exchange can be initiated. placed percutaneously, and it has become occluded by
Figure 36.12 A peritoneal dialysis monitoring sheet that has been programmed to perform calculations automatically in
Microsoft Excel®.
omentum, thus resulting in dialysate retention. The ideal than a kink in the catheter, which should lead to difficulty
way to avoid this complication is to perform an omentec- with both fluid influx and efflux.
tomy at the time of surgical placement of the peritoneal At our institution, Cummings School of Veterinary
dialysis catheter, discussed earlier in this chapter. However, Medicine, pericatheter leakage into the subcutaneous tis-
even with a surgically placed peritoneal dialysis catheter in sue, usually through the abdominal incision site, is the
an omentectomized patient, there are times that fluid will most frequent complication (Figure 36.13). A total of 62%
not drain freely. of cats with percutaneously placed catheters and 50% of
Manipulating the patient’s position may facilitate drain- cats with surgically placed catheters experienced subcuta-
age. Changing recumbency or standing the patient on its neous leakage [31]. Ensuring a closely apposed abdominal
rear limbs with the head elevated or elevating the pelvis incision closure, using a simple interrupted suture pattern
with the thoracic limbs on the ground may move dialysate
within the abdomen and encourage drainage through the
catheter. Instilling or flushing a small amount of dialysate
through the catheter may clear an outflow problem due to
omentum covering the drainage holes. These methodolo-
gies are sometimes successful, but often, once the catheter
is clogged with omentum, it is difficult to correct.
Another potential cause of slow fluid outflow may be a
kink in the catheter or drainage tubing. Manual inspection
of all lines leading from the patient should reveal any kinks
or occlusions. If there are no obvious occlusions in the dis-
tal lines, but fluid efflux remains poor, the bandage should
be removed so that the catheter and catheter exit site can be
inspected for possible kinks or occlusions. Unfortunately,
kinks within the patient are difficult to distinguish from
omental clogging. However, if dialysate flows freely into
the patient but efflux is slow, an omental clog is more likely Figure 36.13 Dialysate leakage into the subcutaneous space.
The FuFuhe of heuru oheeal reallyry 477
only, can minimize dialysate leakage. Generally, patients Additionally, exit site infection is a reported complication
receiving peritoneal dialysis require immediate therapy; in humans [37]. In studies performed at our institution,
however, if it is possible to delay the first exchange for peritonitis was not identified in any of the peritoneal dialy-
12–24 hours, it may help the site to “seal” and therefore sis cases in dogs reviewed during a four-year period and
minimize leakage. If treatment cannot be delayed, initial was reported in only 1 of 22 cats over a five-year period [31,
exchange volumes should be started at a quarter of the cal- 38]. Peritonitis is diagnosed when two of the following cri-
culated infusion amount. If leakage does occur, intermit- teria are recognized: cloudy dialysate effluent, greater than
tently wrapping the limbs may assist in promoting 100 inflammatory cells per microliter of effluent or positive
mobilization of the edema. The dialysate solution should culture results, and/or clinical signs of peritonitis. The
be changed to the lowest possible osmolality formulation most common source of peritonitis is contamination of the
available; otherwise, the hyperosmolar glucose solution in bag spike or tubing by the handler, although intestinal,
the dialysate will continue to bring body water with it into hematogenous, and exit site sources of infection do
the subcutaneous tissue. occur [37]. It is important to recognize pericatheter leaks to
Hypokalemia and hypoalbuminemia may both develop minimize exit site sources of infection [22]. At our institu-
in patients undergoing peritoneal dialysis, so both serum tion, the incidence of peritonitis has dramatically decreased
potassium and albumin concentrations should be moni- with the use of the closed Y-system and drain first protocol.
tored daily. Hypokalemia develops due to the nature of dif-
fusion of potassium across the peritoneal membrane from
the patient into the dialysate and subsequently into the Contraindications
effluent. Hypoalbuminemia may be the result of low die-
tary protein intake, gastrointestinal or renal protein loss, There are only a few situations in which peritoneal dialysis
loss into the dialysate due to inflammatory changes in the is absolutely contraindicated, including recent gastrointes-
peritoneum, uremic catabolism, or concurrent diseases. tinal surgery (due to the risk of dehiscence from increased
Protein losses can be clinically important in patients under- intrabdominal pressure), pleuroperitoneal leaking, dia-
going peritoneal dialysis [32]. In a review of peritoneal phragmatic herniation, or the presence of peritoneal fibro-
dialysis cases in dogs and cats, hypoalbuminemia was the sis or adhesions [1–3, 12]. Adhesions are frequently
most common complication, with 41% of animals reported in humans but much more rarely so in dogs and
affected [33]. In another study, 16% of cats developed cats [3, 12]. Relative contraindications include recent
hypoalbuminemia during peritoneal dialysis [33]. abdominal or thoracic surgery, the presence of inguinal or
Adequate enteral nutrition may be difficult to achieve in abdominal hernias or masses, marked obesity, or patients
uremic patients. Nutritional support should be initiated with severe catabolic disease states that may be worsened
early in the course of therapy for the uremic patient. This by protein loss during peritoneal dialysis exchanges [1–3, 12].
includes feeding tubes, partial or total parenteral supplemen-
tation, and the technique of using 1.1% amino acid solutions
during peritoneal dialysis exchanges [22, 28, 29, 34, 35]. The Future of Peritoneal Dialysis
Gastrostomy and jejunostomy tubes are contraindicated
during peritoneal dialysis due to increased risk of infection Although currently only used for the treatment of acute
and pericatheter dialysate leakage. reversible kidney injury in veterinary medicine, it is possi-
Regular temperature monitoring is crucial to maintain- ble that continuous ambulatory peritoneal dialysis could
ing an appropriate body temperature for the patient. be a viable maintenance modality for patients with chronic
Thermoregulation is challenging due to the constant kidney disease in the future; especially for patients for
changes in the patient’s treatment, influx versus dwell time whom hemodialysis or transplantation is not an option.
versus efflux, which all affect the body temperature. As This would require a dedicated owner that is not intimi-
previously discussed, hypothermia can be prevented by dated by the complex nature of the home medical care
adequate warming of the dialysate solution before instilla- required.
tion. Additionally, providing the patient with external Peritoneal dialysis may continue to be more accessible to
warming support, such as a warming blanket or heating clinicians and owners as automatic peritoneal dialysis
pad, can help prevent hypothermia. An increase in body cycler machines, such as those used for human patients,
temperature may be a sign of infection or peritonitis and become more available and less expensive. A few veteri-
should be thoroughly investigated. nary specialty centers have already begun using human
The prevalence of peritonitis in veterinary patients peritoneal dialysis cyclers to good effect, but patient size is
receiving peritoneal dialysis has been reported as higher limited to medium and large breed dogs as these machines
(22%) than that reported in human patients (15%) [33, 36]. are designed to deliver higher volumes of dialysate than
can be administered to smaller veterinary patients. hemodialysis circuits with donor blood or performing tra-
Although there are no veterinary-specific peritoneal dialy- ditional peritoneal dialysis .
sis cyclers currently on the market in the United States, the Finally, new advances in dialysate and catheter products
authors are currently testing a prototype that may become may lead to safer and easier administration of peritoneal
available soon. This would significantly reduce the burden dialysis. The addition of amino acid-based dialysates to the
on technical staff when treating peritoneal dialysis patients, market for nutritional support of peritoneal dialysis
and could, in theory, be useful to owners performing peri- patients is relatively recent and shows the potential for fur-
toneal dialysis at home. ther advancement in dialysate technology. Likewise, new
Recently, a new dialytic therapy has been developed in catheter development is expected to be ongoing and may
human medicine called “continuous flow peritoneal dialy- shape future peritoneal dialysis treatment strategies in
sis.” This technique uses two peritoneal dialysis catheters human and veterinary patients alike.
and a hemodialysis machine capable of performing con-
tinuous renal replacement therapy [21]. Rather than dia-
lyzing blood, dialysate is run continuously in and out of the Summary
abdomen and filtered through a dialyzer (“artificial kid-
ney”) in a continuous loop [21]. This allows for solute Peritoneal dialysis is a viable and technically simple option
clearance rates close to that of traditional hemodialysis for the treatment of patients with AKI that is accessible to
modalities, but for patients who cannot tolerate hemodial- almost every veterinary practitioner. The objectives of peri-
ysis due to hemodynamic instability or poor vascular toneal dialysis are to resolve the clinical signs of uremia,
access [21]. Further research is warranted to see if this pro- reduce azotemia, and to correct electrolyte, fluid, and acid–
cedure can be adapted for veterinary use, but the authors base abnormalities. Peritoneal dialysis is also a realistic
postulate that it could be a safer and more effective therapy treatment for dialyzable toxin exposure if referral to a
for small patients than our current practices of priming the hemodialysis center is not possible.
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481
37
Technical Management of Hemodialysis

Karen Poeppel and Cathy Langston
Hemodialysis is a therapy by which blood is removed from implies, patients are treated continuously rather than
the patient, run through an artificial kidney called a dia- intermittently. There are increasingly more veterinary
lyzer where uremic toxins are removed, and then returned facilities that provide forms of extracorporeal therapies,
to the patient (Figure 37.1). Removal of these toxins is including IHD, CRRT, hybrids of the two, and some non-
achieved by diffusion across a semipermeable membrane renal therapies [1–3].
in the dialyzer. Blood is circulated on one side of the mem-
brane and a balanced electrolyte solution called dialysate
is circulated on the other side. Molecules small enough to
Patient Selection
pass through the pores in the membrane move from the
side with higher concentration to the side with lower con-
Acute Kidney Disease
centration. Used dialysate, which is on the opposite side of
the semipermeable membrane from the patient’s blood There are a number of indications for IHD (Box 37.1), but
and contains the patient’s uremic waste products, is then in veterinary medicine IHD is used most commonly to
washed down the drain. Blood continuously circulates in treat patients with acute kidney injury (AKI) or failure [4,
this loop for the duration of the dialysis treatment, usually 5]. Standard medical therapy should always be attempted
four to five hours for intermittent hemodialysis (IHD). before initiating hemodialysis, but a certain number of
This way the entire blood volume of the patient is treated patients do not respond adequately. Anuria or oliguria is
many times over while minimizing the actual volume of often present in patients with more severe kidney injury.
blood in the extracorporeal circuit at any given time. Life-threatening volume overload can develop in these
Vascular access for this circuit is obtained by placing a patients as a result of aggressive intravenous (IV) fluid diu-
large double-lumen catheter into the jugular vein. In addi- resis, excessive volumes of medications, or total or partial
tion to removing uremic waste products, hemodialysis can parenteral nutrition. In the absence of urine production,
restore appropriate patient hydration via ultrafiltration, as the body has very limited methods of removing extra fluid,
well as electrolyte and acid–base balance via diffusion or so hemodialysis is indicated to remove the accumulated
convection. Ultrafiltration is the removal of excess patient fluid [4, 5].
fluid from the vascular compartment and is achieved Anuric or oliguric patients, patients with severe renal
when a pump on the side of the outgoing dialysate creates impairment, and patients receiving overly aggressive
a negative pressure across the semipermeable membrane potassium supplementation are at risk of hyperkalemia.
in the dialyzer. Emergency treatment (i.e. insulin, dextrose, bicarbo-
IHD is a renal replacement therapy performed for a set nate) only shifts the potassium to the intracellular space,
period of time per day, generally three days per week dur- but if urine production cannot be established, there is no
ing the maintenance phase of treatment. Continuous renal way for the patient to excrete the excess potassium.
replacement therapies (CRRT) exist that rely on the same Hemodialysis is indicated in these patients to remove
concepts of diffusion, ultrafiltration, and convection across the potassium [4]. Presence of uremic signs, progressive
an extracorporeal semipermeable membrane. As the name azotemia, or azotemia that does not improve over a
482 Technical Management of Hemodialysis
Chronic Kidney Disease

Hemodialysis can also be used to treat patients with
chronic kidney disease. In these patients, there is no hope
for renal recovery because the disease is degenerative. The
patients are thus dialysis dependent for the remainder of
their lives. Chronic dialysis is indicated when medical
management fails to control uremic symptoms, which
include vomiting, nausea, anorexia, and weakness.
It is not uncommon for patients with end-stage chronic
kidney disease to present in an acute uremic crisis. In this
setting treatment progresses similarly to treatment for
AKI until the crisis is stabilized. The difference is that the
owner and the medical staff know that the patient will
always be dialysis dependent, so they can make decisions
accordingly. If the patient is severely decompensated,
prolonged intermittent renal replacement therapy or
CRRT may be appropriate, but as the patient stabilizes, it
would be transitioned to intermittent therapy that would
allow the patient to leave the hospital and return for out-
patient dialysis.
Toxin Removal
Hemodialysis can be used to treat certain toxicities and
drug overdoses. For effective removal by dialysis, the sub-
Figure 37.1 A cat being dialyzed. Patients are not sedated for stance must be small enough to pass through the semiper-
dialysis treatments. meable membrane, and it cannot be protein bound or
sequestered in extravascular tissues [4, 5]. The dialysis
treatment must be initiated before the toxin causes irre-
Box 37.1 Indications for Hemodialysis
versible damage to the patient. Antifreeze (ethylene gly-
col), alcohol, and digoxin are a few substances that can be
● Severe electrolyte or acid–base disturbances
effectively removed by dialysis. For a more complete list,
● Life-threatening volume overload
see Box 37.2.
● Azotemia refractory to conventional medical
Hemodialysis is superior to CRRT for clearing most tox-
management
ins because diffusion happens much more quickly in the
● Chronic kidney disease
dialyzer during an IHD treatment than it would during a
● Toxicities and drug overdoses
CRRT treatment. A continuous therapy may be beneficial
for removal of toxins that have a high post-dialysis
24-hour period with standard medical therapy is also an rebound, meaning that they are sequestered in the
indication for dialysis. extravascular space and diffuse more slowly into the blood
In all cases of AKI, the ultimate goal of dialytic therapy compartment [6].
is to provide a supportive therapy to allow time for the For toxins that are larger or have more extensive protein
kidneys to recover sufficiently so dialysis can be discon- binding, addition of carbon hemoperfusion will enhance
tinued. Renal recovery generally takes at least a few clearance [7–10]. With carbon hemoperfusion, the blood is
weeks, and sometimes months, so without dialytic ther- passed over a carbon substrate, or other substrate that can
apy the patient would die of uremic complications before bind the offending molecule, and the toxin/offending mol-
renal recovery could occur. Of the patients that survive, a ecule binds to the carbon and is thus removed from the cir-
certain percentage have full renal recovery, some no culation. The carbon cartridge is generally connected to the
longer require dialysis but have renal insufficiency, and blood tubing delivering blood to the dialyzer, although
the final group remain dialysis dependent for the machines or tubing sets are available that do not
remainder of their lives. simultaneously provide hemodialysis.
Equipment 483
Box 37.2 Substances Removed by Dialysis or Carbon Equipment

Hemoperfusion [11]
Machines
Removed by hemodialysis The IHD and CRRT machines used in veterinary medi-
● Acetaminophen cine are all manufactured for human use. In the United
● Asprin
States, most units performing IHD or CRRT use either
● Aluminum
Gambro or Fresenius machines (Figure 37.2). Machines
● Baclofen
for CRRT are different in appearance than IHD
● Bromides
machines (Figure 37.2c). Regardless of the model or
● Caffeine
manufacturer, all modern dialysis machines have cer-
● Diethylene glycol
tain common characteristics. First, they all contain a
● Ethanol
display screen. This screen displays the current operat-
● Ethylene glycol
ing mode (such as “set-up,” “autotest,” “dialysis”), all
● Isopropyl alcohol
options available in that mode, treatment parameters,
● Lithium
alarm conditions, and any necessary instructions.
● Mannitol
During the dialysis treatment, the screen also displays
● Metaldehyde
treatment status information such as time remaining in
● Methanol
treatment, total fluid removed, and liters of blood pro-
● Metformin
cessed (passed through the dialyzer).
● Methyl alcohol
The main difference between IHD and CRRT machines
● Theophylline
is the source of dialysate. IHD machines house a dialysate
Removed by Carbon Hemoperfusion proportioning system. This system mixes incoming puri-
● Amanita toxins fied water with the appropriate volume of bicarbonate
● Baclofen
and electrolyte concentrate solutions to create dialysate.
● Cannabinoids
It is essential for patient safety that the dialysate is pro-
● Cyclosporine
portioned consistently and accurately to the operator’s
● Ibuprofen
specifications. To that end, the machines also have sen-
● Metaldehyde
sors to assure the dialysate meets concentration and tem-
● Methotrexate
perature requirements. CRRT machines use prepackaged
● Paraquat
dialysate that is generally supplied in 5-l bags, and thus,
● Pentobarbital
machines of this type do not need a water treat-
● Phenobarbital
ment system.
Each machine has a blood pump and clamps for the
blood lines. There are housings for the blood cartridge,
blood lines, and dialyzer. The vast majority of patients are
Patient Considerations
anticoagulated with heparin to prevent blood clotting in
Hemodialysis involves prolonged and intimate operator the extracorporeal circuit, so all modern dialysis have a
contact with the patient. It would be unsafe for both the built-in syringe pump for heparin administration.
patient and technician to treat an aggressive patient. Finally, the machines contain a number of additional
Repositioning of the catheter or patient for continuous sensors that monitor for pressure changes in the extracor-
blood flow is frequently necessary. Inability to handle the poreal circuit, air in the return line, blood leaks in the
patient can lead to inadequate dialysis treatment, signifi- dialyzer, and other unsafe conditions. In any alarm situa-
cant blood loss from clotting in the dialyzer, physical harm tion, the machine automatically takes actions to ensure
to the technician, or inadvertent dialysis catheter removal. patient safety. For example, if a problem is detected in the
Sedation for several hours daily is likely counterproductive dialysate, dialysate is diverted from the dialyzer so as not
to renal recovery. to affect the patient, but the blood continues to circulate
Patients weighing less than 2.5 kg are difficult to treat to minimize the chances of clotting. If a problem is
due to their low blood volume. The smallest priming vol- detected in the extracorporeal circuit, the blood pump
ume currently available for the extracorporeal circuit is stops and a clamp occludes the return line to prevent fur-
52 ml. Treatment of small patients requires priming the ther removal of blood from the patient or unsafe return of
circuit with blood from the blood bank. blood to the patient. In extreme situations, the machine
(a) (b) (c)
Figure 37.2 (a) Baxter Phoenix hemodialysis machine; (b) Fresenius 2008T hemodialysis machine (c) Baxter PrisMax CRRT machine.
requires the operator to perform an emergency stop

treatment procedure.
Water Treatment System

A water treatment system is essential to providing a safe
hemodialysis treatment with an IHD machine. The patient
is exposed to roughly 20 gallons of water in the form of
dialysate in an average IHD treatment, so even trace
amounts of impurities can have detrimental effects [12, 13].
Water treatment systems vary in size and water output, (a)
(b)
from a small unit that fits the back of a dialysis machine
(Figure 37.3) to an entire room full of equipment that pro-
(c)
vides water for up to 30 dialysis machines (Figure 37.4), but
they all have certain common features. A typical system
contains a mixing valve (to blend hot and cold water to the
optimal temperature), sediment filter (to remove debris),
potentially an ion exchange tank (to remove calcium and
magnesium), carbon tanks (to remove organic compo-
nents), and reverse osmosis or deionization (to remove any
remaining contaminants and ions). Daily monitoring
of the product water is required to assure patient safety.
The technician performing the hemodialysis treatment Figure 37.3 A portable water treatment system. (a) carbon
generally performs this task. filter; (b) pre-filter; (c) reverse osmosis system.
Equipment 485
Blood in
Dialysate out
Dialysate in
Blood out
Figure 37.5 Diagram of a hollow fiber dialyzer. Countercurrent

flows of blood and dialysate allow for more effective clearance
of waste products.
They are a hollow fiber design, which means the semiper-

Figure 37.4 Water treatment system with, from left to right, an
meable membranes form thin straw-like tubes through
ion exchange tank, carbon tanks, back-up deionization tanks, and which the blood passes. The dialysate then bathes these
the reverse osmosis system. Not pictured are the mixing valve blood-filled fibers (Figure 37.5). This design allows for
and sediment filter. smaller priming volumes than other dialyzer configura-
tions, and it also provides greater membrane surface area
Extracorporeal Circuit for greater efficiency.
Dialyzer membranes are made of either natural or syn-
The extracorporeal circuit used in IHD consists of a blood thetic material. The natural fiber membranes are no longer
cartridge, blood tubing, and the dialyzer. Infusion lines are readily available in the United States. Synthetic membranes
generally built into the cartridge for fluids, medications, usually have larger pore sizes, which allow for better clear-
and heparin. The entire circuit is discarded at the end of ance of middle molecular weight uremic toxins in addition
each dialysis treatment. The extracorporeal circuits used in to small molecule clearance. They are also reportedly more
veterinary medicine are manufactured for human use, so biocompatible and less thrombogenic than the natural
generally neonatal and pediatric sizes are used. Adult sizes fiber membranes [14, 15].
are used for the largest patients (Table 37.1). Dialyzers come in a variety of different sizes. Priming
The variation in length and diameter of the tubing allows volumes for dialyzers commonly used in veterinary medi-
for maximal blood flow in larger patients and minimal cine range from 28 ml to more than 150 ml. The larger dia-
priming volumes in smaller patients. lyzers have more membrane surface area, so they are more
A number of different dialyzers are used for veterinary efficient at clearing waste products, and the smaller dialyz-
patients, but they all have certain common characteristics. ers, although less efficient, allow for treatment of very
small patients because of the small priming volumes.
Table 37.1 Recommended extracorporeal volumes [4].
Body Dialyzer Total Catheters

weight volume extracorporeal Blood
Consistent long-term vascular access is key in providing
(kg) (ml) volume (ml) volume (%)
adequate dialytic therapy via intermittent and continuous
Cats, dogs <6 < 20 < 60 13–40 modes. In veterinary medicine, this is almost always
Cats >6 < 30 < 70 < 23 achieved by placing a double-lumen catheter into the jugu-
Dogs 6–12 < 45 < 90 9–19
lar vein [4, 14]. The catheter should be large enough to sup-
ply a blood flow of 80–125 ml/minute in cats or small dogs
Dogs 12–20 < 80 100–160 6–17
and 250–500 ml/minute in medium or large dogs. This gen-
Dogs 20–30 < 120 150–200 6–13
erally means placing the largest-bore catheter that will fit
Dogs > 30 > 80 150–250 6–10 into the patient’s vein. A number of different catheters
Source: Adapted from Cowgill et al. 2012. manufactured for human dialysis patients are suitable for
Several double-lumen or multilumen catheters may be

adequate for small patients (Mila, Arrow). These catheters
are designed to be placed percutaneously. The proximal
(a) lumen is used as the access lumen, and the distal lumen is
used as the return lumen. Use of a multilumen catheter is
not recommended for dialysis because the more lumens in
a catheter, the smaller the size of each lumen, and there-
fore the slower the blood flow. Also, use of a catheter
(b) smaller than 7 Fr is not recommended for the same reason,
although a smaller catheter can be placed when there is no
other option.
(c)
Placement
Figure 37.6 (a) Picture of the tip of a hemodialysis catheter
demonstrating the staggered lumens. (b) Diagram indicating
preferred direction of blood flow into the proximal lumen and As previously discussed, hemodialysis catheters can be
out of the distal lumen. (c) Diagram showing how access placed percutaneously or surgically, depending on the type
recirculation occurs when blood flows into the distal lumen and of catheter and the personnel involved. Strict attention to
out of the proximal lumen. aseptic technique during placement is mandatory for both
temporary and permanent catheters [15]. These catheters
veterinary use. Most of these catheters have two lumens, are generally placed in a clean procedure room with
referred to as the access lumen and the return lumen. The restricted traffic. All personnel involved in the procedure
access lumen, sometimes called arterial, has blood flow should wear caps and masks. A large barrier drape and
from the patient to the extracorporeal circuit, and the sterile gloves are necessary. Because of the “springiness” of
return lumen, sometimes called venous, is for return of the guidewire, a surgical gown should be worn to decrease
blood to the patient from the dialysis machine. Regardless the risk of contaminating it during placement. Permanent
of terminology, all blood flowing through the catheter is catheters are placed with a surgical technique and so
venous blood due to its location in the jugular vein or vena should be placed in an operating room.
cava. The ends of the lumens are staggered such that the tip The person placing the catheter must be skilled and
of the access lumen is proximal to the tip of the return should use the method with which he or she is most com-
lumen (Figure 37.6). This is meant to reduce the reuptake fortable. In addition to dialysis personnel, emergency and
of “clean” blood by the arterial lumen (called access recir- critical care personnel are often equally skilled at placing
culation), which could reduce the clearance of waste prod- percutaneous catheters. A dialysis nephrologist, criticalist,
ucts during the dialysis treatment. or surgeon may have the most experience in placing a per-
Dialysis catheters are referred to as temporary (nontun- manent dialysis catheter. In some cases, catheter place-
neled) or permanent (tunneled). Temporary catheters are ment is facilitated by either ultrasound guidance or a
noncuffed, tapered at the tip, and usually placed percutane- cutdown procedure to isolate the vessel, followed by the
ously. These catheters are meant to stay in place for only a percutaneous technique.
few weeks. In most cases, temporary catheters are the Sedation or anesthesia is often needed for catheter place-
appropriate choice, as long as chronic dialysis therapy is not ment. Some compliant or severely depressed animals may
anticipated, and they are the mainstay in veterinary dialy- only require a local anesthetic. A short-acting or reversible
sis. Permanent catheters have an external cuff, frequently drug can be used for percutaneous placement. General
are blunt at the end, and they must be placed surgically. The anesthesia should be used if catheter placement is expected
catheter is tunneled in a subcutaneous pocket that extends to be problematic, and it is required if an esophagostomy
from the skin exit site to the vessel before being inserted feeding tube is being placed at the same time or for place-
into the vessel. The subcutaneous pocket is a few centime- ment of a permanent, tunneled catheter.
ters in length, and the external cuff of the catheter is posi-
tioned in this pocket. Fibroblasts attach to the cuff, which
secures the catheter in the pocket and creates a physical Location
barrier inhibiting bacteria around the skin exit site from
moving along the catheter and into the vessel. These cathe- The jugular veins generally are the only vessels large
ters can stay in place one to two years and are the preferred enough for a dialysis catheter in most animals because of
choice for a patient receiving chronic dialysis [14]. the catheter size needed relative to patient size. All attempts
Care and Maintenance 487
should be made to preserve at least one jugular vein in any catheter is unwrapped for treatment, the catheter exit
patient that may eventually need hemodialysis. There is no site should be cleaned and assessed (Figure 37.7). The
documented difference in veterinary medicine between the bandaging material should be changed as needed if it
right and left jugular vein in dialysis treatment aside from becomes wet, blood soaked, or otherwise compro-
individual preference during placement. mised [14]. If dialysis is not being performed, the cathe-
The tip of the catheter should be positioned at the junc- ter locking solution (see later) should be changed at least
tion of the cranial vena cava and the right atrium to provide every three to four days, and the exit site can be cleaned
maximum blood flow. Whether placed percutaneously or at that time. Guidelines for accessing the catheter for
surgically, fluoroscopy can be used during the procedure to dialysis treatments or changing the catheter locking
assure proper placement [16]. If fluoroscopy is not used, a solution are outlined in Protocol 37.1.
post-procedure radiograph should be taken. In either case, When the catheter is not in use, it is wrapped securely to
blood flows are evaluated by rapidly aspirating blood into a protect it from dislodgement or inadvertent opening. The
10- or 12-cc syringe before the procedure is complete. Blood wrap should completely cover the catheter, and the cathe-
should flow from both lumens with ease. ter should not be accessed regularly for heparinized saline
flushes. Instead, an anticoagulant locking solution is
placed in each lumen to prevent clotting between dialysis
Care and Maintenance treatments. The locking solution has historically been
sodium heparin (500–5000 iu/ml), but a number of studies
The dialysis catheter should be handled aseptically at all have shown that sodium citrate at a 4% or higher concen-
times. The catheter should only be handled by personnel tration is as effective an anticoagulant as heparin, does not
trained in dialysis catheter care, and it should not be stimulate biofilm production, is bacteriostatic, and is less
used for purposes other than dialysis. Each time the expensive than heparin [17–19]. For that reason, 4%
(a) (b) (c)
(d) (e) (f)
(g) (h) (i)
Figure 37.7 Hemodialysis catheter care. (a) Careful removal of catheter bandage. (b) Draped catheter. (c) Scrubbing the catheter ports.
(d) Aspirating the anticoagulant lock. (e) Replacing the anticoagulant locks. (f) Placing caps on the catheter. (g) Secured catheter ports.
(h) Wrapping the catheter. (i) Final bandage with reminder not to use the catheter.
Protocol 37.1 Hemodialysis Catheter Care
Items Required 9) Perform a surgical-type scrub on both ports, extend-

● Bandage scissors ing from the clamps to the tops of the injection ports
● Two sterile barrier drapes (Figure 37.6c).
● Clean examination gloves 10) Place another sterile barrier around catheter.
● Surgical mask 11) Have two squares of sterile gauze within reach, as
● Surgical scrub and solution (chlorhexidine or povidone- well as all syringes that are needed.
iodine) 12) Open access/proximal port by removing injection cap.
● Sterile gauze pads 13) Wipe port opening with sterile gauze.
● Syringes 14) Withdraw the exact volume (the exact volume for
● Heparinized saline each side is printed on the catheter) of the lumen
● Injection caps and discard. This is the locking solution, so you must
● Antiseptic cream never flush the catheter first (Figure 37.6d).
● Porous tape 15) Flush lumen with 6 cc fresh (prepared within
● Cohesive bandage 24 hours) heparinized or 0.9% saline.
● Cast padding 16) Repeat steps 13–16 on the return/distal side.
● Conforming bandage 17) Replace the locking solution by injecting the exact
volume of each lumen (Figure 37.6e).
Procedure
18) Place a new injection cap on each lumen (Figure 37.6f).
1) Gather materials.
19) At this point, you can remove your gloves and mask.
20) Tape both clamps shut.
3) Unwrap catheter bandage by cutting bandage on
21) Place a piece of cohesive bandage around both ports.
opposite side of neck from where catheter is
22) Place a gauze square with an antiseptic cream over
(Figure 37.6a).
the catheter exit site (Figure 37.6g).
4) Clean area around catheter exit site.
23) Wrap catheter with cast padding, conforming band-
5) Assess catheter exit site for redness, swelling, odor,
age, and then a flexible cohesive bandage. Wrap
or discharge, and assess subcutaneous tunnel for
tightly enough that the bandage stays in place but
signs of infection or excess bruising.
not too tightly (Figure 37.6h).
6) Remove cohesive bandage and the tape that is on
24) Place a strip of porous white tape around both ends
the clamps.
of bandage to anchor it to skin and prevent slipping.
7) Place a sterile barrier around catheter to prevent
This is especially important for active animals.
ports from touching fur or skin (Figure 37.6b).
25) Place a final piece of tape with the words “DO NOT
8) Don a surgical mask and exam gloves (mask and
CUT/DO NOT USE” on the outside of the wrap
gloves should be worn from here until you begin
(Figure 37.6i).
wrapping the catheter again).
sodium citrate is used as a locking solution in some units. treatment. Each model of dialysis machine has a specific
Higher concentrations of citrate can be used but create a and detailed set-up protocol, but all include these same
risk of hypocalcemia if inadvertently flushed into the general steps.
patient [20]. Each dialysis catheter has the exact volume of First, for IHD machines, the water treatment unit is
the two lumens printed on the catheter and/or in the pack- turned on and any daily water testing is done. Then the
age insert, which informs the handler of the volume of dialysis machine is turned on and the acid and bicarbonate
anticoagulant solution to instill. concentrate containers are attached. The machine runs
through a series of internal tests as the dialysate is being
proportioned. During this time, the extracorporeal circuit
Performing Hemodialysis
is loaded onto the machine. The next step is to prime the
extracorporeal circuit, which on some machines can be
Hemodialysis Machine Preparation
done immediately, and on others must wait until the inter-
The structure and function of dialysis machines was nal tests are complete or the dialysate is ready. Priming
described earlier; the following is instruction regarding the involves filling with saline all sections of the extracorporeal
steps necessary to prepare a machine for a hemodialysis circuit that will contain blood, thus removing all air. Air
erforming Hemodialysis 489
removal is essential because blood that comes into contact hypotension when the dialysis treatment is started. In our
with any trapped air will be more likely to clot. experience, if the PCV is not at least 22%, a blood prime or
Once the circuit is filled with saline, the machine is put blood transfusion will likely benefit the patient. The body
through a recirculation phase. The access and return weight and total protein will help assess the patient’s hydra-
patient lines are connected to each other, and the saline is tion, and the weight pre- and post-treatment will aid in
then circulated throughout the loop created by the tubing assessing fluid balance during the dialysis treatment
and the dialyzer. The purpose of this phase is to remove because any weight changes in that short a period of time
any residual substances from the manufacturing and steri- are due to fluid gain or loss. Finally, the activated clotting
lization process of the dialyzer and tubing [21]. During time will help to determine how much heparin to give the
recirculation, the blood pump is running quickly, so saline patient initially, and how much to infuse during the dialysis
flow through the circuit is rapid. This aids in propelling any treatment.
remaining air bubbles from the dialyzer fibers or the sides Prior to each dialysis treatment, a set of serum biochemi-
of the blood tubing into the pressure chambers, which also cal parameters is generally measured that includes, at the
act as air traps. With most machines, there is no one spe- least, urea, creatinine, phosphorus, and potassium concen-
cific point during set-up at which the treatment parameters trations. It is not always essential to have these results
(treatment time, fluid to be removed, dialysate concentra- before starting the dialysis treatment, but it is often useful
tion, anticoagulant protocol) must be set. Each hemodialy- to see the results within an hour of beginning treatment.
sis unit, though, should have an established protocol that Re-measuring these same parameters at the end of the
defines when these parameters are set to ensure that they treatment provides a useful method of determining the
are set appropriately for each treatment. adequacy of the dialysis treatment, which is discussed in
When the recirculation phase is complete, the saline in the monitoring section of this chapter.
the tubing and dialyzer is flushed out by the priming solu- The hemodialysis catheter needs to be prepared with
tion. The priming solution is the fluid given to the patient great care. As discussed previously, only properly trained
to replace the volume of blood removed when the dialysis personnel should handle this catheter. The catheter should
treatment begins. The blood pump is used to flush the cir- be opened using the same protocol as for changing the
cuit with twice the priming volume, using the desired locking solution (Protocol 37.1). After the locking solution
priming solution (e.g. 0.9% NaCl, hetastarch solution, is removed, blood samples for pretreatment blood work are
blood). At this point, some machines are ready to start a taken through the catheter. The loading dose of heparin
treatment. Other machines need to run through another can be administered through the catheter at this time if
set of internal tests before they are ready. prescribed.
With CRRT machines, set-up involves loading the cir-
cuit, priming it with saline, attaching the bags of dialysate
Starting Treatment
and replacement fluid, followed by automatic testing to
ensure correct machine function. After preparation, the When both the machine and the patient are ready, it is time
prescription parameters are entered. to connect the patient and start dialyzing. The access
For most machines, whether IHD or CRRT, machine set- patient line of the extracorporeal circuit is connected to the
up and preparation will take 15–30 minutes with an experi- proximal lumen of the dialysis catheter, and the return
enced operator. patient line of the circuit is connected to the distal lumen
of the catheter. This connection should be covered with
gauze soaked in antiseptic to minimize contamination dur-
Patient Preparation
ing the treatment. The patient lines are anchored to the
Patient preparation includes an assessment of a standard patient in some manner (attached to harness or thoracic
set of pretreatment parameters as well as preparation of the limb) to prevent excess pressure directly on the dialysis
hemodialysis catheter. Parameters to be assessed prior to catheter.
each dialysis treatment should include a blood pressure, As the blood is removed from the patient through the arte-
heart rate, packed cell volume (PCV), total protein, body rial circuit line, the priming solution is infused into the
weight, temperature, activated clotting time or other meas- patient through the venous circuit line. The blood is removed
ure of coagulation, and the patient’s attitude, mentation, slowly to try to prevent a sudden drop in blood pressure. The
and hydration status. If the systemic arterial blood pressure blood will fill more and more of the extracorporeal circuit
is less than 80 mmHg systolic, we generally recommend use and eventually fill the dialyzer. A button is pressed to start
of pressor agents to increase blood pressure before initiating the dialysis treatment when blood has filled the dialyzer.
hemodialysis. If the blood pressure cannot be maintained When this button is selected, treatment time begins to count
above 80 mmHg, the patient can experience life-threatening down, heparin infusion begins, programmed fluid removal
begins, and any other programs that run during the dialysis parameters that are routinely measured; additional param-
treatment will begin. eters may need to be assessed in individual patients. These
parameters are recorded in the patient chart.
Ending Treatment
Blood Pressure
The dialysis machine alerts the operator when the specified
treatment time is finished. The operator can also elect to end Blood pressure may decrease for a variety of reasons,
the treatment early, usually in emergency situations. About including acute decrease in effective circulating blood vol-
10 minutes before the end of treatment, the catheter is pre- ume associated with filling the extracorporeal circuit with
pared for disconnection by uncovering and scrubbing the blood, inflammatory reactions associated with exposure of
connection site. The procedure is the same as for opening blood to the dialysis membrane, rapid ultrafiltration, exces-
the catheter. When treatment time is complete, blood for sive ultrafiltration, and bleeding from excessive anticoagu-
post-treatment laboratory work is drawn. The exact time of lation or uremic thrombocytopathy. The patient’s
sampling (i.e. immediately, two minutes after treatment underlying disease can also lead to hypotension.
ends) and site of sampling (i.e. extracorporeal circuit, dialy- The frequency of blood pressure monitoring depends
sis catheter) may vary between different dialysis units but on the circumstances, and certainly patients with unsta-
should be consistent within a unit. Then the patient’s blood ble or marginal blood pressure measurements or those
is returned in a procedure called rinseback. Most commonly, developing clinical signs of hypotension should be moni-
the access patient line is attached to saline. The blood pump tored frequently. In our dialysis unit, blood pressure
is started and the saline is drawn in so that it flushes the measurements generally are recorded 15 and 30 minutes
blood from the circuit back into the patient. In especially after starting the dialysis treatment and then every
monitored situations, the access line can be left open to the 30 minutes thereafter.
air without attaching the saline bag, if there is a concern
about volume overload in the patient, but this risks creating
Coagulation
a massive air embolus for the patient. When rinseback is
complete, the locking solution is infused into both lumens of When blood is removed from the patient and circulated
the dialysis catheter and the catheter is wrapped. Finally, through the tubing and dialyzer, it usually clots within an
post-treatment patient parameters, which are the same as hour in the absence of an anticoagulant. The majority of
pretreatment parameters, are assessed and recorded. IHD treatments are performed using heparin as the antico-
agulant. The ACT is generally used to monitor heparin
therapy. As previously mentioned, the ACT is assessed
Monitoring During the Hemodialysis prior to starting treatment, and this value is used to deter-
Treatment mine the initial heparin dose. The ACT should be checked
30 minutes after starting dialysis to determine if a dose
There are a number of patient and machine parameters adjustment is necessary [4]. The normal range for ACT
that should be monitored throughout the hemodialysis using a Medtronic ACT-Plus machine is 80–100 seconds in
treatment (Box 37.3). The following is a summary of the dogs and 100 seconds in cats (Poeppel and Bogue, unpub-
lished data). The target ACT during a dialysis treatment is
1.6–2 times normal [5]. If the ACT is in the target range
and no dose adjustments are needed, it is monitored hourly
Box 37.3 Parameters to Monitor During Dialysis thereafter. The ACT is measured 30 minutes after any dose
adjustment. Partial thromboplastin time evaluates the arm
Recommended Optionala of the coagulation cascade affected by heparin and could
Blood pressure Blood volume be used instead of ACT.
For patients where systemic anticoagulation is contrain-
Heart rate Hematocrit (inline)
dicated, regional citrate anticoagulation can be used. This
Ultrafiltration rate Temperature
involves infusing citrate into the blood as it is removed
Blood flow/Access pressures Oxygen saturation
from the patient, to chelate calcium and thus prevent clot-
Heparin rate ting. Simultaneously, calcium is infused into the patient to
Activated clotting time prevent hypocalcemia. The ionized calcium concentration
Adequacy in the circuit needs to be monitoring to ensure adequate
a chelation/anticoagulation, and the ionized calcium of the
Based on patient status.
patient needs to be monitored to avoid symptoms of
Monitoring uring the Hemodialysis Treatment 491
hypocalcemia. This process is more labor intensive than dialysis treatment, the inline monitor provides information
heparin anticoagulation [22]. that helps the clinician avoid severe hemodilution.
Regional citrate anticoagulation may become the pre-
ferred method of anticoagulation in continuous therapies
Blood Volume
because continuous systemic anticoagulation is more prob-
lematic than intermittent. Citrate anticoagulation is rela- Changes in blood volume during a dialysis treatment can
tively contraindicated in patients with severe liver failure, be measured using the inline hematocrit monitor also.
due to their inability to metabolize citrate [5]. Presuming that the red blood cell mass remains constant
(i.e. there is no continuing bleeding or blood administra-
tion), any changes in the hematocrit reflect changes in
Access Pressure and Blood Flows
plasma volume. An increase in hematocrit concentration
The pressure transducers that attach to the blood cartridge indicates plasma volume removal (via ultrafiltration),
allow the dialysis machines to determine pressure in the whereas a decrease in hematocrit concentration would be
access and return tubing segments. The dialysis technician expected if fluid is being administered at a rate exceeding
should monitor these pressures throughout the treatment. fluid removal via ultrafiltration. A rapid decrease in intra-
The access pressure is negative when the blood pump is vascular volume may precipitate symptomatic hypoten-
running. The access pressure will be excessively negative if sion. It is not advisable to have more than a 10% decrease in
the arterial lumen of the dialysis catheter is functioning blood volume within one hour [4, 5]. Some of the newest
poorly. Causes of poor function include kinking, being dialysis machines include an integrated hematocrit moni-
lodged against the vessel wall, or partial occlusion by a tor so that an external monitor is not necessary.
thrombus. Return pressure is positive when the blood
pump is running. This return pressure will be excessively
Oxygenation
positive if there is an obstruction to the return of blood to
the patient. High return pressure could be due to kinking It is not always necessary to measure oxygen saturation in
or thrombosis of the venous lumen of the dialysis catheter a stable patient undergoing hemodialysis, but it is gener-
or a clot obstructing the filter in the venous chamber. ally part of the overall treatment plan in the unstable
In addition, two specific values are routinely measured patient or the patient with respiratory or cardiovascular
for each dialysis treatment. One is the maximum blood compromise. It can be useful to measure oxygenation in
flow maintained during the treatment. If this value patients receiving aggressive ultrafiltration because a
decreases over time, it may indicate impending catheter decrease in oxygen saturation is often a precursor to a
malfunction. The other value is the blood flow at a certain decrease in blood pressure [4]. An inline hematocrit moni-
access pressure, for example at minus 200 mmHg. If the tor measures the oxygen saturation of the blood in the
blood flow at this same pressure decreases over time, it extracorporeal circuit, which in veterinary patients is cen-
may also indicate an impending problem with the catheter. tral venous blood. This is an effective method of measuring
Blood flow can be affected by other factors, such as the changes in oxygen saturation that can adversely affect the
patient’s blood pressure and intravascular volume, which patient’s blood pressure. The inline monitor is convenient
must be taken into account when blood flows are being because the sensor is attached to the tubing and thus is not
evaluated. These factors have usually stabilized within the dislodged by patient movement.
first week of dialytic therapy.
Adequacy
Hematocrit
The adequacy of dialysis treatments, meaning the amount
The patient’s hematocrit is measured at the beginning and of waste product that has been cleared from the patient,
end of every dialysis treatment. An inline hematocrit mon- should be measured, ideally every dialysis treatment ini-
itor (Crit-Line®, HemaMetrics, Kaysville, UT) records real- tially, then on a routine basis (i.e. weekly). By tracking
time hematocrit throughout the dialysis treatment. This adequacy, the dialysis team is assured that the patient is
information is very helpful in some cases. The hematocrit receiving the prescribed dose of dialysis. A complete dis-
tends to drop at the beginning of the treatment because the cussion of dialysis adequacy is beyond the scope of this
patient’s blood volume is diluted with the priming solu- chapter, so only the two most commonly used methods are
tion. Blood transfusions are sometimes administered dur- briefly discussed here. More detailed discussions have been
ing a dialysis treatment, so an inline monitor immediately published for IHD [4, 23].
displays the efficacy of the transfusion. Finally, if fluid The most straightforward method of measuring ade-
therapy is required to maintain blood pressure during the quacy is by calculating the urea reduction ratio, which is
calculated by subtracting the post-treatment blood urea directly related to the dialytic therapy. Finally, the clinician
nitrogen (BUN) from the pretreatment BUN and then may encounter long-term complications of uremia that are
dividing that value by the pretreatment BUN. The ratio rarely seen because of limited patient survival time with
typically exceeds 90%, except during the initial few dialysis traditional medical therapy of the end-stage renal disease
treatments for each patient. patient. This section focuses mainly on complications
The most common measure of dialysis dose in human directly related to dialysis therapy.
hemodialysis is Kt/V, in which K is a clearance constant of
the dialyzer, t is time on dialysis, and V is volume of distri-
Technical Complications
bution [24]. The constant K for each dialyzer is calculated
in vitro under specific conditions and is published on the Technical complications due to machine errors or mal-
package insert. The actual K during the treatment can be functions are rare because of the number of redundant
calculated using the blood flow and the simultaneous BUN monitors and alarms built into modern hemodialysis
of blood flowing into and out of the dialyzer. Most newer machines. When they occur, they may range from mild to
dialysis machines have a program that measures a treat- devastating problems. Complications related to the water
ment Kt/V, so this may become the most common measure treatment system include chemical or infectious contami-
of adequacy in veterinary medicine as well. nation [13]. It is therefore essential to maintain and moni-
tor the function of both the dialysis machine and the water
treatment system to achieve peak performance. The opera-
Other Parameters
tor must also have superb knowledge of the machines so as
Any patient parameters that are monitored in the intensive to be able to troubleshoot quickly during a dialysis treat-
care unit or patient ward should also be monitored during ment to prevent minor problems from escalating. The
hemodialysis. Examples are continuous electrocardiogram hemodialysis technician is generally responsible for main-
or temperature monitoring, pulse oximetry for arterial oxy- taining the dialysis equipment and monitoring dialysis
gen saturation, and urine output. treatments.
Operator errors can also occur, and the number and
severity depend on a variety of factors, including the train-
Record Keeping ing and experience of the operator, the work environment,
and some patient factors. Again, it is important to have
Record keeping for a hemodialysis treatment should be highly trained personnel to minimize these errors and their
thorough and descriptive. This entails documenting the consequences.
dialysis prescription itself, a summary of what was accom-
plished during the treatment, patient or machine compli-
Hypotension
cations, all values obtained while monitoring the patient,
and any medical treatments done on the patient during A decrease in blood pressure is common at the start of a
dialysis. As with any monitoring record, the best way to hemodialysis treatment [13]. The volume of blood required
assure all parameters are recorded is to have a template for to fill the extracorporeal circuit in relationship to the
recording. This template can be a preprinted form or an patient’s total blood volume can be considerable, up to 40%
electronic veterinary dialysis database. It is essential that in smaller cats (Table 37.1). Priming the circuit with a col-
the dialysis technician performing the treatment maintain loid (i.e. 50 : 50 mixture of 0.9% NaCl and hetastarch) helps
meticulous records to keep track of what parameters work mitigate the drop in blood pressure in cats and small dogs
best for a particular patient and to aid in troubleshooting if but is not generally necessary for medium to large dogs (in
problems should arise. which a saline prime suffices). There are concerns about
the use of synthetic colloids such as hetastarch inducing
AKI. Most patients are able to autoregulate and return
Complications and Special blood pressure to almost baseline values within 30–60 min-
Considerations utes of the start of dialysis, but some cannot. These patients
may require intervention if the blood pressure drops too
Patients with kidney disease severe enough to require low. The blood pressure generally returns to predialysis val-
hemodialysis are complex patients, and case management ues when all the patient’s blood is returned at the end of
is rarely straightforward. Patients exhibit the usual mani- the dialysis treatment.
festations of uremia commonly encountered in uremic Exposure of the blood to a bioincompatible dialyzer
patients managed with traditional medical therapies. membrane can activate the complement and coagulation
Hemodialysis patients may also develop complications cascades, releasing several mediators that may cause
Complications and Special Considerations 493
hypotension [25, 26]. Use of synthetic membranes can Prevention of DDS is clearly desirable. Decreasing the
minimize this problem. Rapid ultrafiltration may lead to efficiency of hemodialysis during the first few treatments is
hypotension, if the rate of removal from the vascular com- the main method of prevention. Methods of accomplishing
partment exceeds the capacity for refilling from the inter- this goal include slow blood flows, slow dialysate flow or
stitial compartment. A general guideline of keeping the intermittently interrupting dialysate flow, reversing the
ultrafiltration rate below 10–20 ml/kg/hour is recom- dialysate lines so dialysate flows concurrent to blood, and
mended, although this value may be adjusted up or down reversing the access and return ports on the catheter to
depending on patient status. Monitoring blood volume increase recirculation. To achieve adequate clearance,
(e.g. with an inline hematocrit monitor) may predict symp- treatment times need to be extended, providing a long,
tomatic hypotension, allowing intervention before hypo- slow, gentle treatment. Mannitol may be given prophylacti-
tension occurs [3, 4]. If hypotension occurs despite cally in high-risk patients such as severely uremic patients
decreasing or stopping ultrafiltration (temporarily or for (BUN > 150 mg/dl), small patients (< 5 kg), or those with
the duration of the treatment), small boluses of crystalloid preexisting central nervous system disease. The dose is
or colloidal solutions, or use of pressor drugs may be used administered in the first one-third to one-half of the dialy-
to correct the blood pressure. sis treatment for the first one to three treatments, although
using the prescription guidelines above make this unneces-
sary in most situations [4, 14]. Sodium profiling, in which
Dialysis Disequilibrium Syndrome
the dialysate sodium is initially higher and gradually
Dialysis disequilibrium syndrome (DDS) is a syndrome decreases during the treatment, is another preventive
induced by rapid, or highly efficient, dialysis in severely measure. Sodium profiling is a specific program set on the
azotemic patients. The cause of this syndrome is not well dialysis machine when prescribed.
described, but it results secondary to the development of
cerebral edema induced by rapid changes in the osmolality
Hemorrhage
of the blood [4, 5, 27]. More widespread adoption of long
slow initial treatment prescriptions has made DDS a rare Anticoagulation is necessary during hemodialysis, so a
occurrence. It was most likely to occur during the first few risk of hemorrhage is present if the anticoagulation dose
dialysis treatments when uremia was more severe. is too high for the patient’s metabolism. Mild forms may
However, DDS can occur at any time, even with chronic involve bleeding from the skin exit site of the dialysis
dialysis. catheter or other insertion sites. Internal bleeding,
Clinical signs of DDS include agitation, disorientation, including bleeding from gastric ulceration, central nerv-
seizures, vomiting, coma, and death. Dogs usually have ous system hemorrhage, or massive pulmonary hemor-
premonitory signs such as restlessness in a previously quiet rhage, have been encountered [28]. Discontinuation of
dog. Cats frequently have no noticeable premonitory signs the anticoagulant (usually heparin), administration of a
and may rapidly go from a normal appearance to a coma- reversal agent (i.e. protamine sulfate for heparin), and
like state. DDS may occur at any time during dialysis or up red cell or plasma transfusion may be required. Bleeding
to 24 hours after dialysis [4]. Therefore, it is essential that problems can be minimized by careful control of antico-
patients be monitored for signs of DDS continually for a agulation and minimizing sources of bleeding. It is best
full day after each of the first few dialysis treatments. The not to do any procedures, place catheters, or even pierce
signs of DDS may reverse entirely within a few hours, par- the skin in any manner immediately before or after a
ticularly if the signs are mild or treatment for DDS was dialysis treatment.
started early. More severe signs may persist for up to To prevent or minimize hemorrhage after the hemodi-
24 hours. Some patients do not regain consciousness or die alysis treatment, heparin is usually stopped 30 minutes
acutely. before the end of treatment. The patient should receive
Treatment of DDS involves dissipating the blood–brain no needle sticks for eight hours after the treatment. Even
osmotic gradient by infusing osmoles into the bloodstream. removal of a catheter can lead to excessive bleeding in a
Mannitol is the most commonly used treatment in veteri- heparinized patient. All procedures such as thoracocen-
nary hemodialysis [4]. Hypertonic saline has the same tesis or feeding tube placement should be performed at
short-term effect as mannitol but creates an undesirable least eight hours after the dialysis treatment. Surgeries or
sodium load. Some dialysis machines have the capacity to more invasive procedures are best scheduled on nondi-
increase the sodium concentration of the dialysate quickly, alysis days. If the patient requires a treatment or proce-
to cause rapid diffusion of sodium from dialysate into the dure that could cause bleeding within the eight-hour
bloodstream, having the same effect as an IV bolus of period, a reversal agent (such as protamine sulfate)
hypertonic saline. should be used.
Respiratory Complications be instilled in the catheter for a period of time. This seems to
be effective in the short term, but treatment frequently needs
Mild to severe hypoxemia is common during dialysis both
to be repeated within a week [32].
in human and animal patients. Contact of blood with the
Thrombolytic therapy should be initiated as soon as
dialyzer membrane activates the alternate complement
aggressive flushing is not effective so that thrombi do not
pathway. This causes leukocyte and platelet aggregation in
continue to grow and completely obstruct the catheter. If
the pulmonary microvasculature that interferes with oxy-
these measures are unsuccessful, the affected catheter
gen diffusion [29]. The maximal effect of this is seen
can be replaced. A percutaneous catheter is relatively
within 30–60 minutes of the start of dialysis and resolves
easy to replace over a guidewire with no or minimal seda-
within 120 minutes after discontinuation of dialysis.
tion [14, 33]. Replacement of a tunneled catheter requires
Therefore, oxygen therapy that began during a dialysis
heavy sedation or general anesthesia and is technically
treatment may need to be continued for a few hours after
more difficult. Both techniques carry a risk of contamina-
the treatment, but improvement is expected. Some patients
tion of the new catheter if the exit site or tunnel are
come to dialysis with respiratory compromise from pul-
infected, and they are more likely to result in loss of the
monary edema or pleural effusion resulting from volume
vessel. If the catheter cannot be replaced due to technical
overload. Pulmonary hemorrhage is common in dogs with
issues or other factors, a new catheter may be placed in
leptospirosis [30].
the opposite jugular vein. Extraluminal thrombosis can
be even more troublesome. A thrombus may be attached
Gastrointestinal Complications to the outside of the catheter, but it can act as a flap or ball
valve that occludes catheter flow. Aggressive flushing
Anorexia, nausea, and vomiting are common complica-
may remove the thrombus if the attachment is weak.
tions of kidney disease but also may be seen at the start of
Thrombolytic therapy may not be very effective because it
hemodialysis secondary to diversion of blood flow from the
is hard to direct this therapy to an extraluminal thrombus.
gastrointestinal tract caused by hypotension, bioincompat-
Systemic thrombolytic therapy can lead to uncontrollable
ibility reactions to the membrane, or contaminants in the
hemorrhage [34]. Replacement of the affected catheter is
dialysate. Dialysis disequilibrium can also cause centrally
the last option, which carries with it the risk that the
mediated nausea and vomiting [31]. Using slow blood flow
thrombus will be stripped off the catheter during removal
rates at the beginning of dialysis treatments with a gradual
and enter the patient’s circulation.
increase to the prescribed rate minimizes these signs and
patient discomfort. It is not standard to fast a patient the
morning of a hemodialysis treatment, but it is advisable to
allow at least an hour between feeding and initiation of
Systemic
dialysis in case one of these complications arise. If the
Patients who have hemodialysis catheters in place for more
patient routinely vomits at the start of dialysis regardless of
than two weeks are at risk of developing a right atrial
preventive measures, a morning fast may be considered.
thrombus. Pulmonary thromboembolism from platelet
aggregation or thrombus formation induced by the cathe-
ter can cause acute onset of mild to severe dyspnea during
Thrombosis
or between dialysis treatments [14].
Catheter
Catheter thrombosis may be intraluminal or extraluminal. It Prevention
can occur at any time but is uncommon within the first week
after catheter placement unless there have been major prob- Patients with indwelling hemodialysis catheters routinely
lems with anticoagulation in that time period [15]. receive anti-platelet therapy (e.g. clopidogrel or low-dose
Intraluminal thrombosis can affect catheter flow when aspirin) to prevent systemic thrombus formation. As previ-
severe enough. Aggressive flushing of the affected lumen ously mentioned, the catheter lumens are filled with an
may restore blood flow but usually does not remove all rem- anticoagulant lock between dialysis treatments to prevent
nants of thrombi. Mechanical disruption of thrombi by feed- intraluminal thrombosis.
ing a stylet into the lumen may be slightly more effective.
Despite the ever-present risk of inducing significant or fatal
Infection
thromboembolic complications with these maneuvers,
rarely have we encountered clinically detected problems. A There are multiple potential sites of infection in the
thrombolytic agent such as tissue plasminogen activator can hemodialysis patient. Uremia decreases immune
Prevention 495
function, and indwelling catheters (vascular or urinary) the dialysis treatment, particularly taurine and carnitine,
and feeding tubes are potential portals of entry for bacte- so patients on long-term dialysis therapy should receive
ria [35, 36]. Other open sites, such as surgical incisions or taurine and carnitine supplementation [40].
pressure sores, are possible entry sites for bacteria as well. Nausea, vomiting, and the dialysis treatments them-
Finally, the dialysis catheter and the extracorporeal cir- selves can interfere with feedings, which adds to the prob-
cuit are potentially large sources of bacteria. If bacteria lem of malnutrition. A feeding tube is often placed at the
from any site enters the vascular system, they can then time of dialysis catheter placement to allow early nutri-
reach the dialysis catheter and adhere to it. Once bacteria tional support. Nausea and/or vomiting can often be allevi-
adhere to the dialysis catheter, they can produce a biofilm ated by medications and control of uremia via hemodialysis.
that adheres to the walls of the catheter and protects the Patients do not need to be fasted before dialysis treatments,
bacteria from removal or destruction. Then the only way and feedings scheduled during dialysis should not be
to eliminate all bacteria is to remove the dialysis skipped unless necessary. If feedings have to be missed
catheter [15]. during a treatment, they can be supplemented when dialy-
For this reason, extra vigilance is required to prevent sis is complete.
infections from developing in hemodialysis patients. All
drugs and flushes given through any catheter should be
Aluminum Toxicity
freshly prepared (we prefer less than 24 hours old). Aseptic
technique must be maintained for catheter placement, Aluminum is used in many municipal water treatment
feeding tube placement, and other procedures. Urinary plants as one stage of the water purification process. If the
catheters are typically removed once hemodialysis has hemodialysis water treatment process is not sufficient,
been initiated. Examination gloves are worn when setting trace amounts of aluminum can appear in the dialysate.
up the dialysis machine, and examination gloves and a sur- Aluminum-containing phosphate binders provide an addi-
gical mask are worn when accessing the dialysis catheter. tional and greater source of aluminum. Acute aluminum
Finally, as mentioned previously, only trained personnel toxicity can occur if water treatment is inadequate, but it is
should handle the dialysis catheter. generally encountered only after long-term exposure with
chronic dialysis. Aluminum accumulation can lead to a
microcytic, hypochromic anemia. Clinical signs associated
Edema
with aluminum toxicity include neurologic or neuromus-
Volume overload may manifest as pulmonary edema, cular signs including mild weakness, paresis, dullness,
pleural effusion, ascites, and generalized peripheral obtundation, or coma. There have been two cases of
edema. Ultrafiltration during dialysis and careful atten- hemodialysis-related aluminum toxicity reported in veteri-
tion to fluid balance can help minimize this problem [4]. nary medicine [41].
The problem may persist longer in anuric or oliguric
patients than nonoliguric or polyuric patients. Facial,
Anemia
intermandibular, and forelimb edema may occur in dogs
over time and can be severe. Edema in these specific loca- Small amounts of blood are lost with each dialysis treat-
tions may be an indication of partial cranial vena caval ment, and this combined with any gastrointestinal losses
occlusion by the catheter itself, or thrombosis or stenosis and iron deficiency leads to anemia in almost all dialysis
induced by the catheter [37]. In many dogs, hypoalbu- patients [39]. Patients receiving dialysis treatment for more
minemia is a concurrent problem due to ongoing renal than two to three weeks generally require iron supplemen-
albumin loss, loss in the extracorporeal circuit, gastroin- tation and some erythropoietin hormone replacement
testinal loss, and suppressed synthesis due to systemic therapy such as darbepoetin.
inflammation. Hypoalbuminemia can exacerbate edema
formation.
Medication Dosing
It is often necessary to adjust the dose and timing of medi-
Malnutrition
cations given to a patient receiving hemodialysis. Many
Malnutrition is common in uremic patients due to uremia- drugs are removed from the blood during dialysis, some to
induced gastrointestinal complications and high metabolic a significant degree [42]. For this reason, it is best to give all
needs associated with AKI and other critical illness. Early once-a-day medications in the evening. It also may be nec-
and aggressive nutritional support is prudent. It is unclear essary to withhold a medication until after dialysis or to
how to determine the exact protein requirements of the supplement the dose when dialysis is complete. This may
AKI patient [38, 39]. Certain amino acids are lost during be particularly important when administering antibiotics,
pain medications, cardiac medications, or antiseizure Outcomes

medications.
Overall, 40–60% of veterinary patients with acute uremia
treated with hemodialysis survive [4, 43]. In recent studies,
Patient Care
the reported survival rates for AKI from infectious causes
The typical IHD treatment lasts from four to five hours, were 58–100% [44–46]. Hemodynamic and metabolic causes
which means an animal is away from the patient care ward of AKI had a 40–72% survival rate [46, 47]. Only 20–40% of
for a significant period. In addition to feedings and medica- patients with AKI from toxic causes survive [44, 46]. Of the
tion, therapies such as peripheral catheter care, wound patients receiving hemodialysis that do not survive, about
management, turning, bathing, and physical therapy may half of those die or are euthanatized due to extrarenal condi-
be indicated during this time. Considerations must be tions (e.g. pancreatitis, respiratory complications). About
made to determine if these therapies are safe to perform one-third of nonsurvivors are euthanized due to failure of
while the patient is undergoing hemodialysis. recovery of renal function. Continuing uremic signs, dialysis
During an IHD treatment, patients are essentially complications, and unknown causes account for the remain-
tethered to the hemodialysis machine because the blood ing patient deaths. As with patients treated medically,
lines of the extracorporeal circuit are attached to the approximately half of hemodialysis patients regain normal
dialysis catheter. The IHD machine must remain con- renal function (defined by normal serum creatinine concen-
nected to the incoming water source, so it is not freely tration) and half have persistent chronic kidney disease [5].
mobile. This means the patients are not free to walk
around to urinate, defecate, and exercise during the dial-
ysis treatment, so it is beneficial to allow ambulatory Summary
patients time to walk outside or around a room before
and after the treatment. Box 37.4 provides a summary of the chapter. IHD is a
Patients are generally anticoagulated during an IHD highly advanced therapy used primarily to treat patients
treatment, so any therapies that have the potential to cause with kidney disease. For patients with AKI, IHD is initiated
bleeding, such as wound debridement or nail trims, should when medical management fails, and it is a means of stabi-
be avoided. Peripheral catheter care should be avoided if lizing the patient long enough to allow for renal repair. For
there is a high probability that the catheter will be removed. patients with chronic kidney disease, IHD is a method of
Gentle wound cleaning and application of topical oint- extending the animal’s life. IHD can also be used to remove
ments is acceptable. excess fluids or electrolytes, restore acid–base balance, or
Patient temperament will dictate whether certain thera- treat toxicities and drug overdoses.
pies, such as oral medication administration, can be per- Overall survival rate of animals undergoing IHD for AKI
formed. The dialysis catheter is unwrapped during is 40–60%. The patient population in this case generally has
hemodialysis, so any therapy that would cause the patient a prognosis of 0% survival without some type of renal
to struggle and possibly damage or remove the catheter replacement therapy. Hemodialysis is therefore a viable
must be done only after the catheter has been safely alternative to euthanasia for veterinary patients.
wrapped.
Finally, dialysis catheter flow can dictate how much
the patient should be moved. A well-placed catheter in a
Box 37.4 Summary
medium to large patient often flows very well when the
patient is in a variety of different positions. In this case,
● Hemodialysis is a method of clearing the blood of
turning the patient, expressing the bladder, doing pas-
uremic toxins when the kidneys are not functioning
sive range-of-motion exercises, and any similar therapy
properly.
is unlikely to pose problems while the patient is under-
● Patients with acute kidney injury, chronic kidney dis-
going hemodialysis. Changes in intrathoracic pressure
ease, toxicities, and fluid or electrolyte imbalances
can affect catheter flow, so coupage is not recommended
are candidates for hemodialysis.
until after the treatment. Catheter flow problems can
● Hemodialysis requires equipment that must be main-
occur in any patient during any given treatment, so the
tained and operated by highly trained personnel.
hemodialysis technician often determines on a day-to-
● Patients receiving hemodialysis can experience com-
day basis how much to allow or prevent movement of a
plications directly related to treatment in addition to
patient. There will be times when it is best to keep the
complications related to their disease.
patient very still throughout the entire hemodialysis
● Overall survival of hemodialysis patients is 40–60%.
treatment.
References 497
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499
38
Peritoneal Evaluation
Laura Osborne and Lindsey Strang
Peritoneal evaluation, particularly via point of care ultrasound which the intra-abdominal contents reside, and the terms
(POCUS), has become a routine part of a comprehensive are used interchangeably throughout this chapter.
and thorough assessment of small animal emergency and
critical care patients. Dogs and cats with an acute condition
of the abdomen, often characterized by abdominal pain, Signalment and History
represent a common emergency presentation. Complica-
tions involving the peritoneal cavity, such as ileus and Signalment can help to raise the index of suspicion for the
ascites, are common in hospitalized critically ill patients. cause of acute abdominal pain. For example, foreign body
Patients with abdominal pain typically have abnormalities or toxin ingestion and infectious disease should be consid-
within the peritoneal cavity. However, disease of the retro- ered in young animals, while prostatic disease and pyome-
peritoneal cavity, as well as the lumbar and sacral spine, tra should be considered in older, intact animals.
can also result in referred or simulated abdominal pain. Furthermore, an accurate and complete history can be
Clinical signs that accompany abdominal pain, such as informative in patients presenting for acute abdominal
nausea, vomiting, diarrhea, and abdominal distention, can pain. In some circumstances, complete history taking will
aid in making an accurate diagnosis. need to be delayed until after stabilization efforts are per-
In general, abdominal pain is caused by capsular stretch of formed. Potential for exposure to toxins or dietary indiscre-
solid organs, or distention, traction, or forceful contractions tion and the possibility of foreign material ingestion should
of hollow organs. Additionally, inflammation and ischemia be assessed. The patient’s past medical history should be
initiate production of proteinases and other vasoactive sub- established, and current medications and supplements doc-
stances that can stimulate abdominal nerve endings. Intra- umented. Vaccination status and preventive routine, as well
abdominal pathology can result in tissue necrosis and loss of as tick exposure and travel history should be recognized.
organ function; therefore, rapid identification and treatment The possibility of trauma should be considered. It is impor-
of the underlying abnormality is essential to minimize the tant to establish the time course and progression of clinical
occurrence of serious complications. signs. This will help to establish the urgency of further
Diagnostic procedures used to evaluate the peritoneal diagnostic pursuit, with severe, acute, or rapidly progressive
cavity include physical examination with thorough abdom- clinical signs warranting a more proactive approach.
inal palpation; abdominal imaging such as radiographs,
ultrasound, or computed tomography (CT); and evaluation
of peritoneal fluid obtained by abdominocentesis, diagnos- Physical Examination
tic peritoneal lavage, or from a previously placed abdomi-
nal drain. Additionally, intra-abdominal pressure (IAP) Physical examination with an emphasis on careful abdominal
can be monitored in patients at risk of the development of palpation is the initial step in evaluation of the peritoneal
intra-abdominal hypertension (IAH). In some cases, an cavity. The abdomen should be examined systematically,
exploratory laparotomy may be indicated for diagnostic starting with the spinal column and abdominal wall before
and therapeutic reasons. Clinically, the terms “peritoneal” evaluation of the deeper structures. Direct palpation of the
and “abdominal” synonymously describe the space in spine and body wall will aid in the differentiation of back
500 Peritoneal Evaluation
and/or muscle pain from conditions affecting the perito- characterize internal bleeding and the likelihood of blood
neal structures. The integrity of the abdominal wall should transfusion requirement [4]. While more challenging, with
be carefully evaluated to rule out penetrating injuries. some additional training, POCUS can also be used to iden-
Abnormalities in the contour of the abdomen suggest dis- tify pneumoperitoneum by identifying the enhanced peri-
tention and/or enlargement of intra-abdominal structures toneal stripe sign, typically at the paralumbar region when
or accumulation of fluid and/or air in the peritoneal cavity. the patient is placed in lateral recumbency [5].
Gentle, persistent digital pressure should be used to evalu- Beyond evaluation for the presence of free fluid and air
ate the size and position of organs and for the presence of within the peritoneal cavity, POCUS can be used to identify
abdominal masses. Pain should be noted and localized. Pain gastric stasis and intestinal ileus. This can be achieved
localized to the cranial right quadrant suggests a pancreatic, through identification of a distended, fluid-filled stomach
duodenal, or pyloric abnormality. Caudal abdominal pain is and the absence or decreased frequency of peristaltic con-
associated with abnormalities of the reproductive or urinary tractions [6]. This may help support the suspected diagno-
tract. Diffuse abdominal pain suggests peritonitis or involve- sis of gastroenteritis or post-operative ileus, identify
ment of a significant portion of the intestinal tract. patients at risk of regurgitation and enteral nutrition intol-
Percussion (striking the body wall with short sharp blows erance, and prompt timely medical intervention such as
and noting the tone of the resultant sound) aids in the nasogastric tube placement for gastric evacuation and ini-
detection of fluid or gas accumulation within the perito- tiation of prokinetic therapies.
neal cavity or within a distended hollow viscus. Abdominal POCUS can also be used to select an area and provide
auscultation has been recommended to detect hypermo- guidance for diagnostic or therapeutic abdominocentesis.
tility or ileus but lacks reliability (see Chapter 40 for more Causes of abdominal fluid accumulation are listed in
information). Table 38.1. Urinary bladder volume can also be estimated
A rectal examination should be completed to evaluate using ultrasound in dogs and cats. Using measurements
for the presence of abnormal stool, especially melena or from the cystocolic ultrasonographic view, a noninvasive
hematochezia. In male dogs, the prostate gland should be estimate of urine production can be made [9]. This avoids
assessed for size, symmetry, and presence or absence of the technical challenges, risks, and financial implications
pain. The urethra should be smooth and compressible, and associated with urinary catheterization. It can be used in
any masses or irregularities should be noted. The pelvic the management of acute kidney injury with anuric or olig-
canal should be palpated for evidence of pain, crepitus, or uric renal failure, as well as to tailor fluid therapy.
asymmetry and the lumbosacral lymph nodes evaluated. In addition to aiding diagnosis and monitoring of
The anal sacs should be palpated for any masses. peritoneal disease, abdominal POCUS can be employed to
further assess patient stability and guide resuscitation
efforts. The technique shows promise in estimating the
Abdominal Imaging
intravascular volume status of small animal patients, with
evaluation of the caudal vena cava (CVC) diameter, CVC to
Veterinary Point of Care Ultrasound (POCUS)
aorta ratio, and the change in CVC diameter between
Abdominal imaging should be performed in all patients inspiratory and expiratory phases of respiration reflecting
presenting with acute abdomen. In the emergency setting, volume status [10–12]. The CVC diameter normally changes
POCUS is an invaluable first step and can provide a wealth approximately 50% throughout the respiratory cycle, being
of information with limited training and minimal compro- larger at the end of expiration. A flat or small-diameter CVC
mise to the patient. It is also an essential monitoring tool that lacks dynamic change (< 10%) during inspiration and
for serial evaluation of patients hospitalized in critical care expiration indicates hypovolemia. Alternatively, a wide,
for peritoneal complications such as surgical site dehis- large-diameter CVC that lacks dynamic change during
cence or ileus. inspiration and expiration is consistent with volume over-
The utility of POCUS in the emergency and critical care load [13]. Information regarding volume status can be
setting is vast and continuing to expand (Chapters 6 combined with evaluation of the gall bladder to provide
and 39) [1]. One of the most familiar techniques is the further insight in some cases. The gall bladder halo sign
abdominal focused assessment with sonography for trauma (double-rimmed gall bladder wall) indicates gall bladder
scan (AFAST), which aids in rapid detection of free abdom- wall edema and supports the diagnosis of anaphylaxis when
inal fluid [2, 3]. Serial AFAST examination may allow for the CVC is flat. This is in comparison to right-sided volume
detection of delayed fluid accumulations and can be used overload seen with right-sided heart failure, pericardial
to monitor progression or resolution of free fluid accumu- effusion, or pulmonary hypertension when the CVC is
lations over time. A further application of this technique concurrently wide [14]. See Table 38.2 for a summary of
is the abdominal fluid scoring system, which helps to diagnostic criteria regarding abdominal imaging.
Abdominal Imaging 501
Table 38.1 Effusions classified by cause and associated Table 38.2 Imaging peritoneal evaluation diagnostic criteria.
disorders [7, 8].
Abnormalities Diagnostic criteria
Classification of
effusion Cause/associated disorders Radiographic
Dog ratio of maximal small < 1.4 unlikely to be
Transudate: intestinal diameter to the obstructed
Protein-rich Congestive heart failure narrowest width of L5 on lateral > 2.4 likely to be obstructed
radiograph
Post-sinusoidal hypertension (portal
hypertension) Cat ratio of maximal small > 2 consistent with
intestinal diameter to the height obstruction
Protein-poor Hypoalbuminemia (PLN, PLE, burns) of cranial endplate of L2
Lymphatic obstruction (neoplasia, abscess,
thrombosis, lymphangiectasia) Cat maximal small intestinal > 12 mm consistent with
Presinusoidal and sinusoidal hypertension diameter obstruction
(cirrhosis, idiopathic portal hypertension) Ultrasonographic
Exudate:
CVC characterization Flat or fat with < 10%
Septic Gastrointestinal/biliary tract leakage dynamic change is consistent
Penetrating wounds with hypovolemia
Migrating foreign bodies Gall bladder halo sign Double-rimmed gall bladder
wall
Disruption of the urogenital tract
With concurrent flat or wide
Bacterial translocation
CVC consistent with
Hematogenous spread anaphylaxis
Nonseptic Pancreatitis Tree-trunk sign Distended hepatic veins
Feline infectious peritonitis draining into a distended
CVC is consistent with
Ruptured vessel Hemorrhage right-sided volume overload
or viscus Chylous effusion Urinary bladder volume Length (cm) × width (cm) ×
Uroabdomen estimation formula (ml) height (cm) × 0.2 × Pi (0.625)
Bile peritonitis Peristaltic contractions of the < 4–5 contractions/minute
stomach and proximal duodenum consistent with hypomotility
Cell exfoliation Neoplasia
Reactive mesothelial proliferation CVC, caudal vena cava.
PLE, protein-losing enteropathy; PLN, protein-losing nephropathy.

should trigger further evaluation for free abdominal fluid
via ultrasound or abdominocentesis.
Abdominal Radiographs
Radiographs should be examined for the presence of free
A complete set of three-view survey abdominal radio- gas in the peritoneal cavity. In the standard lateral view,
graphs should be obtained in any patient presenting with free gas can be most easily detected between the stomach
abdominal pain. The abdominal and extra-abdominal or liver and the diaphragm. The sensitivity for detecting
structures should be evaluated in a systematic fashion. free gas can be increased by positioning the patient in left
Deviation from normal density, shape, size, and/or loca- lateral recumbency and making a horizontal beam radio-
tion of abdominal organs may provide clues to abnormali- graph focused at the least dependent area of the abdomen.
ties within the peritoneal cavity. Radiographs are most The presence of free peritoneal gas in a patient with no pre-
valuable in detecting organ size and location, and disten- vious open needle technique abdominocentesis or recent
tion of a hollow viscus; they are less useful in detecting abdominal surgery that could introduce air indicates a pen-
solid organ injury or dysfunction. etrating injury of the abdominal wall, rupture of a hollow
The serosal detail of both the peritoneal and retroperito- viscus, or rupture of an abscess or necrotic mass containing
neal space should be evaluated. Decreased visualization of gas-producing microorganisms into the peritoneal cavity.
the kidneys, distention, or a streaky or mottled appearance These conditions are considered surgical emergencies.
of the retroperitoneal space is seen with abnormal fluid Next, intestinal gas patterns should be evaluated. Ileus,
accumulation (urine, blood) or a space-occupying mass in resulting in the accumulation of fluid and gas within the
the retroperitoneum. Differentials for decreased detail in intestine, may be seen with a number of conditions.
the peritoneal space include free abdominal fluid, lack of Segmental ileus supports a diagnosis of intestinal obstruc-
abdominal fat, and carcinomatosis. Loss of serosal detail tion. The normal diameter of the small intestine in the dog is
approximately two to three times the width of a rib, or less An upper gastrointestinal positive contrast study may be
than the width of an intercostal space. In dogs, bowel obstruc- needed to make a definitive diagnosis of gastrointestinal
tion is considered likely if the internal diameter of a small obstruction in a patient with generalized ileus or inconclu-
bowel segment is four times or more the width of a rib, two sive findings on plain radiographs. Barium sulfate provides
times or more the width of a vertebral body, or if the ratio of the highest diagnostic quality contrast study but has a pro-
the diameter of the bowel to the height of the narrowest pensity to cause severe intraperitoneal inflammation and
point of the body of the L5 vertebra is greater than 1.6 [15]. A granuloma formation if leakage occurs. This complication
more recent study found that dogs with a maximum small can be mitigated if abdominal surgery with extensive perito-
intestinal diameter-to-L5 vertebral body height ratio less than neal lavage is performed immediately, as would be pursued
1.4 are very unlikely to be mechanically obstructed, while for gastrointestinal perforation. Iodine-based contrast media
dogs with a ratio greater than 2.4 are very likely obstructed, can be used to reduce this risk; however, the quality of the
particularly if segmental dilation is present. Dogs with a ratio study is reduced. When performing a contrast study, it is
between 1.4 and 2.4 should be evaluated further [16]. In cats, important to use an adequate volume of the contrast agent.
a ratio of the maximum diameter of small intestine to the Low volume administration causes inadequate filling and a
height of the cranial endplate of the L2 vertebra greater than nondiagnostic study. The recommended dose of barium
2.0 or intestinal diameter greater than 12mm is concerning (60% wt/wt) is 5–10 ml/kg for large dogs and 10–12 ml/kg for
for intestinal obstruction [17, 18]. Additionally, all small dogs and cats given by mouth or orogastric tube [20].
small bowel loops should be of a similar diameter. The pres-
ence of “two populations” of small bowel, where one seg-
Diagnostic Abdominal Ultrasound
ment is 50% larger than the other segment of small bowel,
strongly suggests bowel obstruction secondary to a foreign Abdominal ultrasound by a trained radiologist can be used
body, neoplasia, or intussusception. Generalized small bowel to further evaluate the peritoneal cavity. Ultrasound pro-
distention can be associated with a distal bowel obstruction, vides valuable information about the abdominal viscera,
mesenteric torsion, or with a number of nonobstructive con- lymph nodes, and vascular structures. While a thorough
ditions that cause generalized ileus. Gastric dilation and vol- discussion of the diagnostic utility of abdominal ultra-
vulus (GDV) can be identified on a right lateral abdominal sound in peritoneal evaluation is beyond the scope of this
radiograph showing compartmentalization of the stomach chapter, a few points can be highlighted.
and displacement of the pylorus dorsally, giving the stomach Ultrasound is superior to radiography to evaluate solid
a “double bubble” or “Popeye arm” appearance. Identification organ structure and abnormalities in blood flow to organs,
of compartmentalization or displacement allows distinction for instance as seen with splenic torsion or portal vein
between GDV and bloat or food bloat, where the stomach is thrombosis. Abdominal ultrasound, when performed by an
distended with air or food but not displaced. experienced radiologist, also has greater accuracy than
If gastrointestinal obstruction is suspected but not iden- radiographs at identifying gastrointestinal obstruction,
tified radiographically, additional imaging should be pur- with the presence of distension of the jejunal lumen greater
sued. One option is to fast and rehydrate the patient and than 1.5 cm a useful supportive finding of small intestinal
repeat plain radiographs 4–24 hours later. If the bowel obstruction [21].
remains distended in the same area, this suggests a bowel Abdominal ultrasound is particularly useful for evalua-
obstruction. When the position of the colon cannot be tion for pancreatic and biliary disease. Ultrasonographic
determined on survey radiographs, pneumocolonography findings consistent with pancreatitis include an enlarged
can be performed to allow identification of the colon by pancreas that can be hypo- or hyperechoic or have a mixed
creating a pneumocolon. This allows differentiation of pattern of echogenicity, hyperechoic surrounding mesen-
colon from dilated small intestine and determination of the tery, and localized peritoneal effusion. Partial or complete
location of foreign material to the colon or small intestinal obstruction of the biliary tract characterized by dilation of
tract. Approximately 10–12 ml/kg of air is instilled into the the common bile duct and gall bladder enlargement can
rectum and colon via a lubricated red rubber catheter to fill also be seen in patients with pancreatitis. Gall bladder
the colon to the cecum [19]. Another technique that can be mucoceles are characterized by the presence of nongravity-
of assistance in detecting the presence of foreign material dependent granular biliary sludge that is organized, typi-
is compression radiography. With the patient in lateral cally having a kiwi-like pattern or stellate appearance.
recumbency, the area in question is mildly compressed Ultrasonographic signs of gall bladder rupture include the
with a large wooden or plastic spoon or paddle to displace presence of echogenic free fluid around the gall bladder,
adjacent abdominal contents and increase radiographic hyperechoic fat near the gall bladder, inability to confirm
conspicuity, resulting in improved visualization of poten- gall bladder wall continuity, or a mucocele protruding from
tial foreign material, plicated bowel, or intestinal masses. the gall bladder or free in the abdomen [22].
Abdominal Fluid Sampling 503
Abdominal Computed Tomography (CT) restraint, eliminating the need for sedation or anesthesia,
with a local block used to facilitate patient compliance during
Abdominal CT is the gold standard primary imaging tech-
the procedure if needed. The veterinary team should pre-
nique for the diagnosis of acute abdominal pain in peo-
pare for the procedure and have all necessary equipment in
ple [23]. Contrast-enhanced CT has also been shown to
place before attempting abdominocentesis. The procedure is
differentiate surgical from non-surgical causes of acute
detailed in Protocol 38.1. It is simple and specific, but not
abdominal pain in dogs accurately [24]. Despite its superi-
sensitive. It has been estimated that 5–6ml of fluid/kilogram
ority, CT is not used extensively in veterinary medicine due
body weight within the abdominal cavity is required to obtain
to its limited availability, requirement for sedation/anes-
fluid by blind centesis [5]. Ultrasound guidance increases the
thesia, and associated cost. It should be pursued in cases
sensitivity of the procedure by allowing the clinician to view
where other imaging studies have not achieved a diagnosis.
and aspirate small accumulations of fluid (Figure 38.1). In
addition, with the use of ultrasound guidance the procedure
Abdominal Fluid Sampling can be performed with the patient in sternal recumbency
with the catheter placed into the fluid pocket through the
The detection, collection, and analysis of free abdominal lateral body wall and directed ventrally; this will reduce drip-
fluid is extremely useful in peritoneal evaluation. ping and seroma formation afterwards as the insertion site is
not gravity dependent.
Blind and Ultrasound-Guided Abdominocentesis
Open Compared With Closed Needle Technique
Blind abdominocentesis, also known as abdominal paracen-
tesis, is a simple way to obtain an abdominal fluid sample for Either a closed or open needle technique can be used.
evaluation. The procedure is usually performed with manual In the closed technique, the needle is slowly inserted
Protocol 38.1 Abdominocentesis

Items Required
● Clippers
● Surgical scrub, alcohol, and gauze sponges for skin
preparation
● Sterile gloves
● Blood tube with EDTA additive (lavender-top tube)
● Blood tube with no additive (red-top tube)
● Culturette swab
● Needles: 18–22-gauge × 1.5 inches (gauge should be
based on the patient’s size and body wall thickness;
alternatively, an over-the-needle catheter of similar
size may be selected. A larger bore, fenestrated catheter
is preferred when draining large volume effusions)
● Several ≥ 3-cc syringes for sample collection
● Sedative agent(s) (if required)
● Ultrasound for guidance (preferred) Figure 38.1 Position catheter in line with the ultrasound
probe, at a 30–45 degree angle. This will allow for optimal
For therapeutic abdominocentesis, also include: visualization of the needle within the field of view.
● Three-way stopcock
● Two fluid extension sets 2) Place patient in left-lateral recumbency or in a stand-
● Appropriately sized syringes ing position. Positioning in left-lateral recumbency is
● Collection bowl or graduated cylinder preferable to avoid inadvertent puncture of
the spleen.
Procedure
3) Clip and scrub the ventral abdomen. If using ultra-
1) Gather supplies and administer patient sedation (if sound guidance, clip over the proposed site and
required). perform a scrub of the ultrasound probe.
4) Perform hand hygiene and don sterile gloves. b) Ultrasound guided: Identify the needle or catheter in
5a) Ultrasound guided: Locate the largest fluid pocket with the field of view and redirect within the fluid pocket.
an unobstructed path. Using one hand to stabilize the c) Consider four-quadrant centesis, or diagnostic peri-
ultrasound probe (this becomes the non-sterile hand), toneal lavage.
advance the needle or catheter with the sterile hand.
The needle should be advanced in plane with the Four-Quadrant Centesis Technique
probe, entering the skin at a 30–45 degree angle to
1) Place patient in left-lateral recumbency.
allow adequate visualization of the needle (Figure 38.1)
2) Clip and scrub the ventral abdomen 10 cm cranially
5b) Blind: Insert the needle or catheter caudal to the
and caudally from the umbilicus and laterally to the
umbilicus (avoiding the falciform fat), at or within
mammary chain on either side.
2 cm of midline.
3) Perform hand hygiene, and don sterile gloves.
a) Closed technique: The needle or catheter is attached
4) Using the umbilicus as a center point, divide the abdo-
to a syringe (or extension set) before penetration
men into four quadrants. Serially sample the right cra-
into the abdominal cavity.
nial, left cranial, right caudal, and left caudal quadrants
b) Open technique: An unattached needle or catheter
(Figure 38.2) as directed in the abdominocentesis pro-
is inserted into the abdominal cavity.
tocol. Avoid puncturing the superficial and deep epi-
6) Once the bevel of the needle has been advanced through
gastric vessels that lie parallel to, and in the vicinity of
the skin and body wall (depth of needle insertion is
the mammary chain.
relative to patient size), pull back on the plunger of the
5) Continue collection of the sample as described in the
syringe to apply suction if using the closed technique.
abdominocentesis protocol.
a) If using the open technique, observe for a flash of
fluid in the hub of the needle.
b) If using an over-the-needle catheter, after the
catheter is inserted into the abdominal cavity, feed
the catheter off the stylet and remove the stylet to
collect the sample.
7) If blood is aspirated unexpectedly, the needle should
be removed from the abdomen and the sample
placed in a red-top tube to observe for clot formation.
a) Blood from inadvertent laceration of a vessel or
organ will clot.
b) Hemorrhagic free abdominal fluid will not clot.
8) Allow fluid to drip into sterile collection tubes or
apply gentle suction with a syringe to collect sample.
The fluid should be collected into sterile tubes for
further analysis.
9) If no fluid is retrieved:
a) Blind: Gently rotate the needle within the abdo- Figure 38.2 Four-quadrant centesis technique: sample the
right cranial, left cranial, right caudal, and left caudal
men. If required, advance or withdraw the needle quadrants in turn, avoiding the superficial and deep epigastric
slowly then reapply gentle pressure on the syringe vessels (marked in red). The dog’s head is to the left of the
once stationary. image and the tail to the right.
perpendicular to the abdomen and advanced a few milli- radiographs have been obtained to prevent misinterpreta-
meters at a time. Following each advancement, the syringe tion of iatrogenically introduced abdominal free air. There
is aspirated. If fluid is not obtained by the closed technique, are minimal associated risks, but risks may be increased in
conversion to the open technique can be done by removing patients with a coagulopathy, or with marked organomeg-
the syringe from the needle and slowly backing the needle aly or distention of an abdominal viscus. The patient
out. The open needle technique reduces the chance of should be placed in left lateral recumbency to decrease the
omentum or viscera occluding the needle, but it may intro- chance of accidental puncture or laceration of the spleen.
duce free air into the abdominal cavity. Ideally, open abdom- Negative pressure should not be applied while the needle
inocentesis should only be performed after abdominal and syringe are advanced, as this can cause the omentum
Abdominal Fluid Sampling 505
to occlude the end of the needle, resulting in a false nega- which can result in faster reaccumulation, electrolyte
tive abdominocentesis. The needle should not be redirected derangements, and renal impairment [25].
once within the abdominal cavity, as this may increase the
chance of lacerating an organ. Diagnostic Peritoneal Lavage
If no fluid can be obtained by abdominocentesis using
Four-Quadrant Technique
the above techniques and abdominal pathology is highly
To increase diagnostic yield, the four-quadrant technique can suspected, diagnostic peritoneal lavage (DPL) can be per-
be used, as described in Protocol 38.1 and depicted in formed to obtain abdominal fluid samples for evaluation.
Figure 38.2. The four areas for abdominocentesis are 1–2cm This technique is seldom required in patients that have
cranial and caudal to the umbilicus on the right and left side been adequately fluid resuscitated if ultrasound is available
of the abdomen. This is a modification of the open needle to enhance the detection of small fluid pockets. The tech-
technique, with abdominocentesis performed at all four sites nique is described in Protocol 38.2. The procedure is per-
in turn. Gravity dependency or changes in transabdominal formed with local anesthesia, with or without additional
pressure between the needles may increase the likelihood of sedation. General anesthesia should be avoided as turgid
successful fluid retrieval. If a needle becomes occluded by abdominal musculature will facilitate catheter placement.
mesentery during active aspiration or passive drainage, rapid There are several different commercially available, multi-
reinfusion of a small volume of the retrieved fluid or gentle fenestrated catheters that can be used including peritoneal
external abdominal palpation can sometimes restore patency dialysis catheters, chest tubes, or abdominal drainage
by displacing the mesentery from the needle tip. catheters (Figure 38.3). Alternatively, readily available
A possible complication of large volume evacuation of over-the-needle catheters, red rubber catheters, or large
ascites is paracentesis-induced circulatory dysfunction, single-lumen intravenous catheters can be used if
(a) (b)
Figure 38.3 Examples of multifenestrated catheters: MILA fenestrated centesis catheter (a) and guidewire-inserted chest tube (b) shown.
Protocol 38.2 Diagnostic Peritoneal Lavage

Items Required ● 14–16 gauge × 2–5.5 inch over-the-needle catheter
(with manual fenestrations, no further than one-third
● Clippers
of the catheter length)
● Surgical scrub, alcohol, and gauze sponges for skin
● Fenestrated chest tube
preparation
● Warmed, sterile 0.9% sodium chloride (attached to drip set)
● Sterile gloves
● Sterile collection system (drip set, three-way stopcock,
● Sterile drape
collection bag)
● 2% lidocaine
● Blood tube with EDTA additive (lavender-top tube)
● No. 11 scalpel blade
● Blood tube with no additive (red-top tube)
● Sterile 10–14-gauge catheter for abdominal drainage
● Sedative agent(s)
● Peritoneal dialysis catheter
Procedure (avoiding the falciform fat), or within 2–3 cm lat-

erally of midline.
1) Gather supplies and administer patient sedation.
ii) Introduce the trocar and catheter through
2) Ensure that the urinary bladder is empty (manual
the body wall at a 45-degree angle, directed
expression or catheterization).
caudodorsally toward the urinary bladder.
3) Place patient in left lateral recumbency.
iii) Advance the catheter off the trocar, ensuring
4) Clip and aseptically prepare a wide margin, centered
that all fenestrations are within the perito-
around the umbilicus.
neal cavity.
b) Catheters may also be introduced via the modified
6) Place drape with the fenestration centered over the
Seldinger and peel-away methods. A slow, rotating
umbilicus.
motion is recommended while advancing the
7) Infuse lidocaine into proposed puncture location, from
catheter to facilitate passage through the fascia
the skin into the peritoneum.
and linea alba (Figure 38.5).
8) Catheter placement will vary depending on the type of
9) If no fluid is obtained when the catheter is placed,
drainage catheter used:
lavage the abdomen by instillation of 22 ml/kg of
a) Trocar-type catheter (or over-the-needle catheter;
warmed, 0.9% sodium chloride through the catheter
Figure 38.4):
and into the peritoneal cavity.
i) Create a small stab incision no larger than the
diameter of the catheter either at the umbilicus
(a) (b)
(c)
Figure 38.4 (a) Create a small stab incision over proposed site (no larger than the diameter of the catheter). (b) Introduce the catheter
through the body wall at a 45-degree angle, caudodorsally. (c) Advance the catheter off the trocar once approximately 50% of the catheter
has been inserted, ensuring that all fenestrations are within the peritoneal cavity. In these images, the animal is in left lateral recumbency
with the head to the upper right and the tail to the lower right.
Analysy of Pesi APna oofys A 507
Figure 38.6 Secured catheter for continuous abdominal

drainage. Cover with occlusive bandage to prevent contamination.
12) Gently massage the patient’s abdomen, or carefully

Figure 38.5 Use a slow, rotating motion for large bore roll the patient to ensure adequate distribution of
drainage catheters to facilitate passage through the fascia and saline within the peritoneal cavity.
linea alba.
13) Open the infusion set and allow the fluid to drain
through the catheter by gravity into a sterile collec-
tion bag. Collect samples in sterile empty and EDTA-
10) While the fluid is being infused, monitor the containing tubes for evaluation.
patient carefully for signs of respiratory distress or 14) If the catheter is being used for continuous abdominal
discomfort. drainage, suture the catheter in place and cover with
11) Clamp the infusion set. a sterile dressing (Figure 38.6).
additional fenestrations are added. Fenestrations in an over- abdominal pain, especially if peritonitis is suspected.
the-needle or red rubber catheter can be made using a scal- Evaluated parameters and their clinical associations are
pel blade or biopsy punch. They should be small and summarized in Table 38.3.
smooth, less than 40% of the circumference of the catheter, The peritoneal fluid sample should be separated into one
and should not be placed directly across from one another tube containing EDTA to prevent clotting and another tube
as this will weaken the catheter, risking kinking or breakage. containing no additives. The additive-free tube will be used
The patient’s urinary bladder should be emptied either by for biochemistries and for cultures because EDTA is bacte-
voiding or manual expression to avoid accidental puncture. riostatic. To prevent contamination by sample handling,
Other complications include omental obstruction of the any microbial cultures should be performed aseptically,
catheter fenestrations and incomplete fluid retrieval. The immediately after fluid sampling. Slides should be made
stab incision can be made 2–3 cm lateral to the umbilicus to soon after fluid collection to prevent degeneration of cells
avoid the falciform fat. It is uncommon to aspirate large vol- in the fluid (Chapter 59).
umes of fluid following a DPL due to dispersion of the fluid Color and clarity should be noted before additional
in the abdomen. Contraindications for DPL include preg- sample handling occurs. Peritoneal fluid color can range
nancy, marked organomegaly, cardiovascular or respiratory from colorless to red tinged, red, white, yellow, brown,
compromise, diaphragmatic hernia, previous celiotomy, or green, and anything in between. Fluid color is not specific
patients suspected to have abdominal adhesions. for, but could indicate, an organ system as the primary
cause for the effusion. For example, red-colored fluid sug-
gests intra-abdominal hemorrhage, while green-tinged
Analysis of Peritoneal Effusion fluid is seen with bile leakage. Clarity of the fluid is noted
as clear to slightly turbid or turbid. The degree of turbidity
Gross, cytologic, and biochemical evaluation of peritoneal indicates the presence of cellular material and other par-
fluid collected either by centesis or peritoneal lavage can ticulate matter. Foul-smelling fluid is associated with
provide important diagnostic clues in the patient with anaerobic infection.
Table 38.3 Clinicopathologic peritoneal evaluation diagnostic peracute. Typically, hemorrhagic peritoneal effusion does
criteria. not clot due to the fibrinolytic activity of the mesothe-
lium [27]. If the sample clots, abdominocentesis should
Clinicopathologic tests Diagnostic criteria/interpretation be repeated to obtain a true sample of the effusion.
Retrieval of non-clotting fluid is most consistent with
Peritoneal fluid packed > 5% consistent with significant
cell volume intra-abdominal hemorrhage peritoneal effusion, but a coagulopathy should be ruled
out through evaluation of platelet number, platelet func-
Blood to peritoneal fluid > 20 mg/dl consistent with
glucose difference septic peritonitis tion, and clotting times. A packed cell volume (PCV) and
Plasma to peritoneal fluid > 38 mg/dl consistent with total protein concentration should be obtained on any
glucose difference septic peritonitis in dogs red-colored fluid to differentiate hemorrhage from sero-
Blood to peritoneal fluid < −2 mmol/l consistent with sanguineous effusion. A PCV greater than 5% is suspi-
lactate difference septic peritonitis in dogs cious for abdominal hemorrhage. Following peritoneal
Peritoneal fluid to blood Dogs: > 1.4 : 1; cats: > 1.9 : 1 lavage, the volume of blood in the abdomen can be esti-
potassium radio consistent with uroabdomen mated by the following formula [5]:
Peritoneal fluid to blood Dogs and cats: > 2:1 consistent
x L V /P L (38.1)
creatinine ratio with uroabdomen
Peritoneal fluid to blood > 2:1 consistent with bile where x = volume of blood in the abdominal cavity;
bilirubin ratio (also may peritonitis L = PCV of the returned lavage fluid; V = volume of
see bile piment/crystals
lavage fluid infused into the abdominal cavity; and P = PCV
in abdominal fluid)
of the peripheral blood before intravenous infusion of
Peritoneal fluid lipase > Fourfold upper reference limit
activity [7] for serum lipase activity
fluids.
consistent with pancreatitis; A direct smear for cytology allows for estimation of cel-
effusion to serum lipase activity lularity, while cytology of a sedimented sample increases
ratio > 2 consistent with the chances of detecting bacteria or atypical cells. Fluid
pancreatitis
obtained from a DPL should be evaluated using a sedi-
Specific cPLI < 200 μg/l not consistent with mented sample due to dilution from the infusate. Total
(serum) [26]a pancreatitis
nucleated cell counts can be estimated by running the sam-
201–399 μg/l gray zone
ple through the in-house complete blood count machine or
> 400 μg/l consistent with estimated microscopically by trained personnel (see
pancreatitis
Chapter 61 for more information). Normal abdominal fluid
Specific fPLI < 3.5 μg/l: not consistent with
contains less than 1000 nucleated cells/mm [3]. Cytology
(serum) [26]a pancreatitis
includes evaluation for degenerate or toxic neutrophils,
3.6–5.3 μg/l: increased, gray zone
intracellular bacteria, neoplastic cells, bile stain or crystals,
> 5.4 μg/l: consistent with and any other abnormalities. An elevated white blood cell
pancreatitis
count (> 5000 nucleated cells/mm) indicates an inflamma-
Peritoneal fluid Effusion triglyceride
tory process [3]. Increased numbers of neutrophils and
triglyceride concentration > concurrent
concentration [7] serum triglyceride concentration degenerate neutrophils support a diagnosis of peritonitis.
or > 100 mg/dl consistent with Intracellular bacteria can be seen with septic peritonitis.
chylous effusion Leukocyte morphology and the presence of bacteria are
Abdominal perfusion Mean arterial pressure – IAP more important than absolute leukocyte numbers.
pressure > 12 mmHg consistent with IAH Identification of many bacteria with no white blood cells is
seen with inadvertent aspiration of the gastrointestinal
cPLI, canine pancreatic lipase immunoreactivity; fPLI, feline
pancreatic lipase immunoreactivity; IAH, intra-abdominal tract. Gram staining of septic effusions can assist with
hypertension; IAP, intra-abdominal pressure. empirical selection of antibiotics.
a
Insufficient for diagnosis in absence of clinical findings. Once PCV, total protein, cell count, and cytologic mor-
phology has been assessed, the fluid should be classified
to narrow differential diagnoses and guide further diag-
Red-colored fluid should be evaluated for clotting by nostics and therapies. Transudation occurs due to altered
being placed in a non-anticoagulant (red top) tube or hydrostatic and oncotic forces within the vessels or lym-
observed in the syringe for evidence of clotting. Clotting phatics, while exudation is caused by increased capillary
suggests that the fluid was obtained from inadvertent permeability. Traditionally, effusions have been classified
aspiration of a vessel or organ, or that the hemorrhage is by protein concentration and cellularity as transudates,
Exploratory Laparotomy 509
modified transudates, or exudates. This system is contro- It is considered primary if the disease process arises
versial, and classification based by etiology has been within the abdominal cavity (e.g. fractured liver or
proposed to be more clinically useful, with effusions spleen) or secondary if the inciting disease is extraperi-
divided into transudates (protein-poor and protein-rich), toneal in origin (e.g. high-pressure mechanical ventila-
exudates, effusions resulting from vessel or viscous dis- tion). Elevated pressure in the closed abdominal space
ruption, and effusions resulting from cell exfoliation can compromise perfusion to the abdominal organs and
(Table 38.1) [28]. predisposes patients to developing multiple organ dys-
Based on the patient’s physical examination, history, function and failure. IAP should be measured in patients
and suspected disease, specific chemistry analysis on the at risk of IAH.
sample may be indicated. In most cases, the peritoneal IAP is most commonly measured in veterinary patients
chemistries are compared with a simultaneously collected via a catheter placed in the urinary bladder. Excluding
peripheral blood sample. Samples obtained via DPL are gas in the gastrointestinal tract, the abdominal contents
diluted by the infused saline, so biochemical analysis is are non-compressible. Consequently, bladder pressure
less likely to be diagnostic. Abdominal fluid bilirubin measurements reflect the overall intra-abdominal pres-
twice as high as the bilirubin in the peripheral blood is sure. The technique is relatively easy and is described
diagnostic for bile peritonitis [29]. A uroabdomen can be in Protocol 38.3. Measurements can be taken in either
diagnosed by comparing blood and fluid creatinine and lateral or sternal recumbency, but the position should be
potassium levels. Fluid that has creatinine levels twice as consistent across serial measurements, as IAP is affected
high as blood, and potassium levels 1.4 times as high in by body position. The measured value has also shown
dogs and 1.9 times as high in cats is consistent with uroab- to be affected by the volume of saline instilled into the
domen [30, 31]. urinary bladder, body condition, pregnancy, external
The gold standard for differentiating septic peritoneal abdominal pressure application, and by the presence of
effusions from inflammatory nonseptic processes such as abdominal wall or detrusor muscle contractions. End-
pancreatitis is the identification of intracellular bacteria expiratory readings are standard, and reported normal
in the fluid. Intracellular bacteria are not always seen in IAP is 0–5 cm H2O in dogs, 4–8 cm H2O in sedated cats,
patients with septic peritonitis, especially if the patient and 6–11 cm H2O in awake cats [35]. The frequency of
has been receiving antibiotic therapy or there is a walled- IAP monitoring can be adjusted according to patient risk,
off process such as a hepatic abscess. Comparison of and should be evaluated every four hours in the at-risk
blood glucose in the peripheral blood and abdominal critically ill patient [36]. When an indwelling urinary
effusion can be helpful in differentiating septic from non- catheter is contraindicated, measurements can be made
septic effusions. Peripheral whole-blood glucose ≥ 20 mg/dl from a catheter tip located in the intra-abdominal
higher than peritoneal fluid glucose has been shown to vena cava.
be highly specific but insensitive for septic peritonitis in
dogs and cats [32]. A plasma glucose to fluid glucose
difference of greater than 38 mg/dl using a point of care
glucometer is more accurate for detecting septic peritonitis Exploratory Laparotomy
in dogs [33]. Similarly, a peritoneal fluid lactate concen-
tration higher than blood lactate, resulting in a negative The decision to proceed with an exploratory laparotomy
blood to fluid lactate difference of less than −2.0 mmol/l often needs to be made swiftly in cases of acute abdomen.
is predictive of septic peritonitis in the dog, but not in the Clear indications for immediate abdominal surgery include
cat [32, 34]. abdominal wall perforation, septic peritonitis, persistent
abdominal hemorrhage, complete intestinal obstruction,
free abdominal gas (not associated with previous surgery,
pneumomediastinum, or invasive procedures), abdominal
Intra-Abdominal Pressure (IAP) Monitoring abscess, ischemic bowel, gastric dilation volvulus, mesen-
teric volvulus, and bile peritonitis. Uroabdomen is also
Elevated pressure in the abdomen is referred to as intra- often listed as an indication for prompt abdominal surgery
abdominal hypertension (IAH), whereas pathologic but can be managed medically initially with an indwelling
derangements that occur because of IAH are referred to peritoneal catheter in some cases to improve patient stabil-
as abdominal compartment syndrome. IAH is caused by ity prior to general anesthesia for definitive repair. An
increased pressure within the abdominal cavity, for exploratory laparotomy can also be used as a diagnostic
example due to tissue edema or free fluid accumulation. tool in patients with an open cause for acute abdomen.
Protocol 38.3 Intra-abdominal Pressure Measurement

Items Required Procedure (Manometer Method)
● Sterile gloves 1) Gather supplies.
● Foley urethral catheter (size appropriate) 2) Perform hand hygiene, and don sterile gloves.
● Sterile urine collection system 3) A Foley urinary catheter should be aseptically placed,
● Two three-way stopcocks with the catheter tip located just inside the trigone of
● Water manometer the urinary bladder (Chapter 35).
● 35–60-ml syringe 4) Connect the Foley catheter to a sterile urine collec-
● Sterile 0.9% sodium chloride tion system, with two three-way stopcocks incorpo-
● Two intravenous (IV) administration extension sets rated into the collection system (Figure 38.7a).
5) Attach a water manometer to the first upright stop-
If using a pressure transducer, also include:
cock. Attach the syringe to the second stopcock for
● Pressure transducer kit filling the manometer and infusion of the bladder.
● 500 ml bag of sterile 0.9% sodium chloride 6) Place the patient in lateral or sternal recumbency (patient
● Pressure bag position should be consistent for repeat measurements).
Figure 38.7 Intra-abdominal

pressure measurements.
(a) Manometer method set-up.
Ensure that the manometer is
zeroed at the patient’s midline (tip
of black arrow indicates zero mark
in this case). (b) Pressure transducer
method set-up. Elevate the
transducer to the level of the
patient’s midline, then zero the
transducer.
(a)
(b)
References 511
7) Empty the urinary bladder. stopcock. Attach the syringe to the second stopcock
8) Instill 1.0 ml/kg of sterile saline into the urinary blad- for infusion of the bladder (Figure 38.7b).
der (to 25 ml/patient maximum). 5) Place the patient in lateral or sternal recumbency.
9) Zero the manometer to the patient’s midline at the 6) Empty the urinary bladder.
symphysis pubis, and fill manometer with sterile saline. 7) Instill 1.0 ml/kg of sterile saline into the urinary blad-
10) Close the stopcock to the fluid source to allow the der (to 25 ml/patient maximum).
meniscus in the manometer to equilibrate to the 8) Position the transducer at the patient’s midline at the
pressure within the urinary bladder. symphysis pubis (a towel can be used to elevate the
11) Take the measurement at end expiration. The differ- transducer as required).
ence between the equilibration point and the zero 9) Zero the transducer (this may vary depending on the
reference point is the IAP measurement. monitor used) to current atmospheric pressure, ensur-
ing the transducer stopcock is turned off to the
Procedure (Pressure Transducer Method) patient and the cap is removed (see Chapter 12 for
1) Complete steps 1–4 as described above. further details).
2) Attach a 500 ml bag of sterile saline to the pressure 10) Open the transducer stopcock to allow flow between
transducer IV spike set and insert the IV bag into the the patient and monitor.
pressure bag. 11) Close the stopcock to the fluid source, allowing the
3) Inflate the pressure bag to 50 mmHg. monitor to equilibrate to the pressure within the uri-
4) Flush the line to remove any air from the system and nary bladder.
attach the patient connection to the first upright 12) Take the measurement at end expiration.
References
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assessment with sonography in nontraumatized dogs and and Cat. Hoboken, NJ: Wiley.
cats in the emergency and critical care setting. J. Vet. 9 Lisciandro, G.R. and Fosgate, G.T. (2017). Use of urinary
Emerg. Crit. Care 26: 64–73. bladder measurements from a point-of-care cysto-colic
2 Boysen, S.R., Rozanski, E.A., Tidwell, A.S. et al. (2004). Evaluation ultrasonographic view to estimate urinary bladder volume
of a focused assessment with sonography for trauma protocol in dogs and cats. J. Vet. Emerg. Crit. Care 27: 713–717.
to detect free abdominal fluid in dogs involved in motor 10 Kwak, J., Yoon, H., Kim, J. et al. (2018). Ultrasonographic
vehicle accidents. J. Am. Vet. Med. Assoc. 225: 1198–1204. measurement of caudal vena cava to aorta ratios for
3 Boysen, S.R. and Lisciandro, G.R. (2013). The use of determination of volume depletion in normal beagle
ultrasound for dogs and cats in the emergency room. Vet. dogs. Vet. Radiol. Ultrasound. 59: 203–211.
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4 Lisciandro, G.R., Lagutchik, M.S., Mann, K.A. et al. (2009). (2018). Ultrasound measurements of the caudal vena
Evaluation of an abdominal fluid scoring system cava before and after blood donation in 9 greyhound
determined using abdominal focused assessment with dogs. Can. Vet. J. 59: 973–980.
sonography for trauma in 101 dogs with motor vehicle 12 Cambournac, M., Goy-Thollot, I., Violé, A. et al. (2018).
trauma. J. Vet. Emerg. Crit. Care 19: 426–437. Sonographic assessment of volaemia: development and
5 Kim, S.Y., Park, K.T., Yeon, S.C. et al. (2014). Accuracy of validation of a new method in dogs. J. Small Anim. Pract.
sonographic diagnosis of pneumoperitoneum using the 59: 174–182.
enhanced peritoneal stripe sign in beagle dogs. J. Vet. Sci. 13 Drobatz, K.J. (2018). Textbook of Small Animal Emergency
15: 195–198. Medicine. Newark, NJ: Wiley.
6 Sanderson, J.J., Boysen, S.R., McMurray, J.M. et al. (2017). 14 Quantz, J.E., Miles, M.S., Reed, A.L. et al. (2009). Elevation
The effect of fasting on gastrointestinal motility in healthy of alanine transaminase and gallbladder wall abnormalities
dogs as assessed by sonography. J. Vet. Emerg. Crit. Care 27: as biomarkers of anaphylaxis in canine hypersensitivity
645–650. patients. J. Vet. Emerg. Crit. Care 19: 536–544.
7 Dempsey, S.M. and Ewing, P. (2011). A review of the 15 Graham, J.P., Lord, P.F., and Harrison, J.M. (1998).
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16 Finck, C., D’Anjou, M.A., Alexander, K. et al. (2014). 27 Louagie, Y., Legrand-Monsieur, A., Remacle, C. et al.
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880–886. Surgical treatment of bile peritonitis in 24 dogs and 2 cats:
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19 Bradley, K. (2005). Practical contrast radiography 2. and potassium ratios for diagnosis of uroperitoneum in
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diagnosing small-intestinal mechanical obstruction in Comparison of peritoneal fluid and peripheral blood pH,
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253: 31–46. fluid supernatant glucose concentrations obtained by a
24 Shanaman, M.M., Schwarz, T., Gal, A. et al. (2013). veterinary point-of-care glucometer to identify septic
Comparison between survey radiography, b-mode peritonitis in dogs with peritoneal effusion. J. Am. Vet.
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513
39
Point-of-Care Abdominal Ultrasound

Most currently published abdominal veterinary point- atient Positioning and Machine

P
of-care ultrasound (POCUS) protocols incorporate sono- Settings
graphic windows from the original abdominal focused
assessment with sonography for trauma (AFAST) study To maximize success, the operator should consider gravita-
published in 2004 [1]. Despite abdominal FAST and abdom- tional effects when deciding on patient positioning. Minor
inal POCUS sharing many common applications it is impor- protocol adjustments may be necessary when searching for
tant to highlight the distinction between the two: abdominal specific pathology: fluid falls while gas rises, and thus the
FAST was designed to detect the presence of free abdominal location at which to find fluid or gas changes based on patient
fluid while abdominal POCUS incorporates a broader array positioning.
of clinically relevant questions that can be answered in the Given that patient status may preclude positioning
point-of-care setting [1–10]. As new research expands the patients in particular ways (e.g. in respiratory distress or
body of evidence, the number of clinical questions and sce- spinal cord injury), sonographers should become com-
narios that can be rapidly answered by non-specialist clini- fortable performing POCUS with patients in all posi-
cians using abdominal POCUS will also expand. For tions (lateral, sternal, standing). The authors prefer to
example, in addition to searching for free fluid, POCUS scan patients in the position they are most comfortable,
includes assessment of duodenal motility at the right par- which is often lateral recumbency. Lateral recumbency
alumbar region, a search for pneumoperitoneum, and can be contraindicated when respiratory distress is
assessment of ureteral obstruction at the left and right par- present, in which case the patient is scanned while
alumbar regions, among other advances. It is therefore standing or sternal. The choice of left or right lateral
important to consider the clinical question at hand, as this recumbency is often based on the position of the patient
dictates which abdominal organs, and specific organ anat- at the time of presentation and operator preference.
omy, will be evaluated. For example, the assessment of There is no difference between left or right lateral
renal pelvic dilation for suspected ureteral obstruction recumbency for the detection of free abdominal fluid [2],
involves a different approach to imaging the kidney than although the time to complete abdominal POCUS is
the detection of free fluid around the kidney [1, 10]. faster in left-lateral recumbency compared with right
Randomly placing the transducer on the patient without a lateral recumbency [2].
specific question to interpret should be avoided, as this may Identification of the right kidney is easier when patients
lead to false positive results. Failing to assess each site thor- are in left-lateral recumbency than in right-lateral recum-
oughly for pathology (fanning and/or sweeping through bency because the right kidney is located more cranially
multiple planes in both the longitudinal and transverse ori- (under the ribs), compared with the left kidney; this likely
entations) or performing “a quick peek” without asking a explains why it is faster to scan dogs in left-lateral than in
specific question is likely to lead to false negative results. right-lateral recumbency [2].
514 Point-of-Care Abdominal Ultrasound
Patients initially placed in lateral recumbency can be 1) The subxiphoid window

gently repositioned into sternal recumbency to assess the 2) The umbilical window
gravity-dependent paralumbar region, if necessary (e.g. for 3) The urinary bladder window
renal pelvis diameter assessment), following evaluation of 4) The right paralumbar window
other sites. 5) The left paralumbar window (Figure 39.1).
Dorsal recumbency is often contraindicated in patients
Given that the internal organs being evaluated have
with respiratory or cardiovascular instability, and thus the
expanded beyond the liver, kidneys, spleen, and bladder,
authors never scan patients in dorsal recumbency.
the authors prefer to use external landmarks to locate the
A microconvex/curvilinear transducer is used for all
correct sonographic windows. Fanning and rocking the
abdominal POCUS scanning, with a frequency generally
transducer through 45-degree angles in both longitudinal
between 5 MHz (for patients > 15 kg) and 7.5 MHz
and transverse axes at all sites maximizes the chance of
(for patients < 15 kg). Gain can be set to maximize detec-
detecting pathology while minimizing false negative and
tion of anechoic fluid by using either bile in the gall blad-
false positive results [1].
der or urine in the urinary bladder as a reference
echogenicity for fluid. Adjust the gain, depth, and focal
position as needed during the scan to maximize image Subxiphoid
quality and thoroughly answer each abdominal POCUS
The diaphragm, liver, gallbladder, ventral stomach wall,
question. Extending the depth at the subxiphoid location
and areas between these structures are evaluated. The cau-
allows evaluation of the pleural and pericardial spaces
dal vena cava, pleural space, and pericardial space can also
(see below).
be evaluated at the subxiphoid site by extending the depth
of the transducer beyond the diaphragm (see Chapter 17).
To find the correct subxiphoid site palpate the ribs and
Abdominal Point-of-Care Ultrasound follow them cranioventrally until the “V” at the xiphoid
Technique region is identified. To begin with, place the transducer in
the point of the “V” in longitudinal axis to the body, at
It is essential that all key organs at each site be thoroughly roughly a 45-degree angle to the spine (Figure 39.2). Several
evaluated to ensure that the specific question being asked transducer movements are used to perform abdominal
is answered confidently. The five sites currently evaluated POCUS (Figure 39.3); details of specific transducer move-
during abdominal POCUS include: ments can be found in Chapter 6.
Right paralumbar
Umbilical
Urinary bladder
Subxiphoid
Left paralumbar
Figure 39.1 Abdominal point-of-care ultrasound windows with the patient in left-lateral recumbency: subxiphoid, umbilical, urinary
bladder, right paralumbar, and left paralumbar. Each location is evaluated in longitudinal and transverse planes with rocking and
fanning of the transducer to maximize the area evaluated, to ensure all target structures/sites are thoroughly evaluated, and to
decrease false positive and negative results. All five sites are evaluated in all patients regardless of patient positioning; however, the
area scanned can be modified slightly depending on the pathology one is attempting to rule in or out, and in light of how patient
positioning will affect where pathology accumulates. For example, if the patient is in a standing position and the goal is to detect free
peritoneal fluid, the transducer is placed directly on ventral midline over the umbilical and urinary bladder regions with the
ultrasound beam directed toward the spine (vs. toward the tabletop when the patient is in a lateral position). With the patient in
lateral recumbency, as shown, the transducer should be directed from the nongravity-dependent side of the patient toward the
gravity-dependent body wall areas where fluid is most likely to accumulate. Source: Courtesy of Vivian Leung, 2020, with permission.
Abdominal Point-of-Care Ultrasound Technique 515
Figure 39.2 Transducer orientation and

positioning at the subxiphoid view. The dog
is in right-lateral recumbency. The
transducer is placed on midline just caudal
to the xiphoid process in the longitudinal
orientation at roughly a 45-degree angle to
the spine. L, liver.
Liver
Diaphragm
ROCK
(a)
Liver
SWEEP
ROTATE SLIDE
Diaphragm
(b)
FAN
Figure 39.4 Schematic (a) and ultrasound still image (b) of
Figure 39.3 Summary of the five different probe manipulations liver and diaphragm obtained at the subxiphoid window with
commonly used during point-of-care ultrasound: sweep, slide, the transducer in long axis orientation.
rotate, fan, rock. See Chapter 6 for further details.
Rock the transducer cranially and adjust the depth abnormal (Figure 39.5). The gallbladder is visualized to
until the liver and diaphragm are visible within the the right of midline and assessed for wall thickening,
ultrasound image (Figure 39.4). Fan the transducer which may suggest edema or other abnormalities (see
through all planes of the liver and rock the transducer to below). The transducer can be rocked caudally so it is
assess all parts of the liver. Small fluid accumulations nearly perpendicular to the spine at the subxiphoid
can collect between the liver and diaphragm and/or region, which should allow the stomach to be visualized
between liver lobes; seeing individual liver lobes is (Figure 39.6). By slowly fanning left and right, the
Figure 39.5 The transducer should be

fanned (a) and rocked (b) through all planes
of the liver and other key structures at the
subxiphoid site to increase the chance of
finding pathology.
(a)
(b)
Figure 39.6 Schematic image

demonstrating how the transducer, in long
axis orientation, is rocked caudally at the
subxiphoid site to locate the stomach. L,
liver; S, stomach.
Figure 39.7 Once subxiphoid organs have

been evaluated in long axis, the transducer
should be rotated 90 degrees and the
transducer fanned and rocked through
multiple planes to allow key subxiphoid
structures to be evaluated in the short axis
orientation.
ventral stomach wall can be assessed for motility (see and directed toward the tabletop with the patient in lateral
below). Following longitudinal plane scanning, the recumbency (Figure 39.1). The protocol is modified slightly if
transducer is rotated into transverse axis and again the patient is in sternal or standing. The transducer is then
fanned and rocked through all planes (Figure 39.7). rocked and fanned through all longitudinal and transverse
planes looking for specific pathology, typically free peritoneal
fluid. Other pathology may be detected at the umbilical site,
Umbilical
depending on the specific clinical question asked.
The gravity-dependent body wall, intestines, spleen, and Early abdominal FAST protocols did not include the
regions between these structures are evaluated. To find the umbilical site; however, if the goal is to rule out free perito-
correct site, the transducer is placed over the umbilical region neal fluid, the umbilical site is important to assess prior to
Abdominal Point-of-Care Ultrasound Technique 517
evaluating the gravity-dependent paralumbar site with the If the patient is standing or sternal, the transducer is
patient in lateral recumbency. This is because sliding the placed on midline with the ultrasound beam directed
transducer under the patient to assess the gravity- toward the spine to ensure the most gravity-dependent area
dependent paralumbar window may displace gravity- between the abdominal wall and ventral urinary bladder
dependent fluid to either side of the transducer, causing it wall is assessed.
to be missed (Video 39.1). The umbilical site is also a grav- Urine volume, in millileters, can be estimated and moni-
ity dependent and sensitive site to identify free peritoneal tored serially at this site as follows (Figure 39.8) [7]:
fluid in the standing patient. Be sure not to apply too much
● With the transducer in longitudinal axis to the urinary
pressure to the transducer when assessing the umbilical
bladder, measure the length of the bladder in centimeters
site in the standing patient as it may displace free fluid,
at its widest point (sweep the transducer through all planes
prohibiting it from being visualized.
in longitudinal orientation to identify the widest point).
Take the measurement at this location. This is the length or
Urinary Bladder “L” measurement. Be sure to keep the ultrasound beam at
a 90-degree angle to the bladder once the widest point is
The urinary bladder, gravity- and nongravity-dependent
identified to get the most accurate measurements.
body walls, and the areas between these structures are evalu-
● The depth of the bladder is also measured in longitudi-
ated. To find the urinary bladder, the transducer is initially
nal. This is the “DL” measurement.
placed in the longitudinal axis to the body, between the pel-
● With the transducer oriented in transverse axis, sweep
vic limbs. Avoid applying too much pressure to the trans-
through all planes (apex to trigone) to find the widest
ducer as this tends to compress and displace the urinary
point of the bladder. At the widest point a width meas-
bladder. Adjust the depth settings to allow both the dorsal
urement is taken in centimeters. This is “W.” A depth
and ventral walls of the urinary bladder to be visualized.
measurement is also taken in transverse which is the
If the patient is in lateral recumbency, slide the trans-
“DT.” Be sure to keep the ultrasound beam at a 90-degree
ducer to the nongravity-dependent side of the patient and
angle to the bladder once the widest point is identified to
angle the ultrasound beam through the urinary bladder,
get the most accurate measurements.
while fanning, to identify fluid that might accumulate in
the deeper, gravity-dependent sites along the far body wall. ● The following formula, with measurement values entered
Slide the transducer cranially to locate the apex of the in centimeters, is then used to calculate the urinary
bladder and fan the transducer through all planes at volume in milliliters [7]:
the bladder apex. Slide the transducer caudally to evaluate
the trigone and urethral areas, fanning through all planes L W DL DT / 2 0.625
of the trigone and visible urethra. Following thorough
longitudinal scanning, rotate the transducer to a transverse Note that, although some authors only measure the
axis and again scan the same sites in the orthogonal plane. depth in a single plane, we prefer to measure it in both
Short axis Long axis
(a) (b)
Figure 39.8 (a) Transverse (short) axis of the urinary bladder at its widest point demonstrating where the width (W) and depth (DT)
are measured. (b) Longitudinal (long) axis of the urinary bladder at its widest point demonstrating where the length (L) and depth (DL)
are measured. Note that the measurements are taken to best estimate the shape of a sphere.
planes and divide by two to get an average depth. This may be easier to find the spleen and slide the transducer
provides an easy way to check that the widest diameter of caudally until the left kidney is located. The spleen is
the urinary bladder was correctly identified in both planes; relatively mobile, and the tip may sometimes be seen
if the two depth measurements vary greatly (e.g. more than contacting the left kidney. If it is not encountered when
10–15%), consider repeating the measurements as the scanning the left kidney, it can often be located cranial
transducer may be oriented obliquely to the urinary blad- and lateral to the left kidney.
der, or the measurement obtained to either side of the wid-
est urinary bladder diameter.
Specific Questions
Right Paralumbar
Abdominal Effusion
The right caudal liver lobe, right kidney, body wall, duode-
num, and areas between these structures are evaluated. To Free (uncontained) abdominal fluid appears black (ane-
find the right paralumbar region in smaller patients, trace choic or hypoechoic) and forms sharp angles and trian-
the last rib dorsally with your finger until the hypaxial/ gles between organs. To be certain that fluid is free and
lumbar muscles are encountered. The transducer is then not contained within a structure (such as stomach, uri-
placed caudal to the last rib, just ventral to the hypaxial/ nary bladder, gallbladder), the operator should evaluate
lumbar muscles, in longitudinal axis to the body. Increase thoroughly all key organs at every site, fanning through
the depth setting and then fan and rock the transducer at all planes in both the longitudinal and transverse axes.
this location until the kidney is visualized. Once found, Decrease the depth to highlight concerning areas if
decrease the depth until the kidney fills the proximal half needed [1–3].
of the ultrasound image. In larger dogs it may be necessary If free fluid is identified, fluid samples should be col-
to place the transducer between the most caudal ribs (i.e. at lected for urgent analysis (packed cell volume, total protein
the 11th or 12th intercostal spaces) to locate the key concentration, cell count, cytology, and more specific anal-
abdominal VPOCUS structures in this view. yses such as glucose, lactate, creatinine, triglycerides, and
In dogs, if the liver is visualized first, the transducer can bilirubin as indicated; see Chapter 38), which may assist
be slid caudally until the kidney is identified. The kidney with diagnosis, guide further diagnostics, and dictate
sits caudal to the liver in the hepato-renal fossa. Note that immediate interventions. Ultrasound guidance is very
the right kidney is often quite lateral (relative to midline). helpful as it allows the aspiration needle to be visualized so
When the correct site is identified, the transducer is fanned that fluid can be collected with confidence and fewer com-
and rocked in both longitudinal and transverse axes to plications. Consider sample submission to a reference lab-
assess the right kidney and its surrounding structures. oratory for cytology and culture.
Depending on the skill of the operator the renal pelvis can
also be assessed (see below).
Pneumoperitoneum
The duodenum is located at the right paralumbar loca-
tion by first locating the right kidney in longitudinal axis, Pneumoperitoneum is abnormal in patients that have not
and then sweeping the transducer medially toward midline recently undergone laparotomy and should prompt consid-
until the largest small intestinal segment is found. The eration of hollow organ rupture (i.e. gastrointestinal perfo-
duodenum can be assessed for motility at this location ration) [4]. Although the learning curve for detecting
(see below). pneumoperitoneum using POCUS is steep, given the accu-
racy of ultrasound to detect free abdominal gas, and the
fact that emergency surgery is indicated in positive cases, it
Left Paralumbar
is a valuable skill to learn. To increase the chances of
The spleen, left kidney, intestines, body wall, and areas detecting free abdominal gas, place the animal in lateral
between these structures are evaluated. To find the left recumbency for several minutes to allow gas to rise to the
paralumbar region, start by finding the left kidney: use nongravity-dependent body wall.
your index finger to trace the last rib from the mid- There are three key steps that should be followed to
abdominal region caudally and dorsally until the last rib standardize the detection of pneumoperitoneum with
contacts the hypaxial/lumbar muscles. The kidney is abdominal POCUS (Figure 39.9) [8]. Note that abdominal
usually located at this site. The transducer is fanned and POCUS is better at ruling in than ruling out the presence of
rocked through all longitudinal and transverse axes to free gas, as pneumoperitoneum might be missed if free
assess the left kidney. Depending on operator experience, abdominal gas fails to reach the nondependent peritoneal
the renal pelvis may be assessed at this site (see below). It surface, and free gas is only detectable at sites scanned by
Specific Questions 519
Reverberation artifact resulting from free abdominal gas

that reaches the peritoneal lining will be associated with
an EPSS. With practice it is also possible to detect free
abdominal gas in contact with the serosal surfaces of
abdominal organs as it will also create a brighter enhanced
region where gas contacts these serosal surfaces.
Gastrointestinal Ileus
There is insufficient evidence to state whether gastrointesti-
nal motility can be definitively assessed with abdominal
POCUS; however, it is helpful in identifying the presence of
ileus, defined as a transient cessation of gastrointestinal
Figure 39.9 Image depicting free abdominal gas. The kidney (K)
motility or an abnormal pattern of gastrointestinal motil-
is in contact with the peritoneal lining (PL), which helps to ensure
that there are no intestinal segments or other structures between ity [5]. On average, the normal number of peristaltic con-
the kidney and peritoneum. A segment of reverberation artifact tractions of the stomach and proximal duodenum that can
(RA) can be seen originating from the peritoneal lining extending be detected with ultrasound in dogs is four to five contrac-
toward the far field of the image, obliterating the view of the
tions per minute. The number of contractions is fewer and
normal kidney architecture. Where free gas is in contact with the
peritoneal lining the peritoneal lining appears more hyperechoic, less consistent in other sections of the gastrointestinal tract.
giving rise to the term enhanced peritoneal stripe sign (EPSS). Therefore, the stomach and duodenum are often assessed
for motility in postoperative and hospitalized patients, par-
ticularly if they are anorexic and regurgitation is noted. To
the operator. False positive results are also possible if intes- measure the number of contractions per minute, the total
tinal gas is confused with free abdominal gas. number of contractions is recorded over three minutes and
divided by three. If contractions are decreased or absent, a
1) Identify the peritoneal lining. The peritoneal lining is
diagnosis of decreased motility/ileus should be considered.
important to identify because it allows gas in the abdo-
The detection of food within the gastrointestinal tract in
men to be differentiated from gas contained within the
the absence of visible contractions is a strong indicator of
gastrointestinal tract. The peritoneal lining can be visu-
ileus because luminal content is a strong stimulus for gas-
alized directly or identified by locating structures that
trointestinal contraction.
contact it (e.g. liver, kidney, spleen).
2) Search for the presence of reverberation artifact that
originates at the peritoneal lining extending a few mil-
limeters to several centimeters into the far field of the
ultrasound image. Reverberation artifact originating
from free abdominal gas in contact with the peritoneal
lining passes through and obscures the structures
beyond it. This can be very helpful in confirming the
presence of free abdominal gas; if there is no visible
intestinal wall between a solid organ (e.g. liver, spleen,
or kidney) and the peritoneal lining, but there is oblite-
ration of that solid organ by reverberation artifact aris-
ing from the peritoneal lining, it most likely indicates
the presence of free abdominal gas. If the gas originates
from the intestinal tract and is not free in the abdomen
then the intestinal wall will be visible between the oblit-
erated organ and the peritoneal lining (and the enhanced
peritoneal stripe sign (EPSS) will be absent; see below). Figure 39.10 Ultrasound still image of gall bladder wall
3) Look for an EPSS. EPSS occurs when free abdominal gas edema (aka halo sign). The gallbladder wall is thickened (white
comes in contact with the peritoneal lining, causing the arrow) with the appearance of three distinct wall layers: an
outer hyperechoic layer, a middle hypoechoic layer (edema), and
peritoneal lining to become more hyperechoic (whiter)
an inner hyperechoic layer. When these three distinct layers are
than the surrounding peritoneal lining not in contact with noted, it is termed the halo sign. A small volume of free fluid
free abdominal gas. This finding can be subtle. (FF) is also noted cranial to the gall bladder (GB).
Gall Bladder Wall Thickening (Halo Sign) (longitudinal to transverse and vice versa) it is easier to
confirm free abdominal fluid vs. contained fluid (blood)
With edema of the gall bladder wall, the wall becomes
within vessels.
thickened and may develop three distinct layers: an outer
hyperechoic layer, a middle hypoechoic layer (edema), and
an inner hyperechoic layer. The presence of all three layers Edge Shadowing
is referred to as the halo sign (Figure 39.10). The halo sign Edge shadowing is where the ultrasound beams create
is a nonspecific finding, being caused by several condi- dark shadows on the edges of a structure (e.g. gall bladder),
tions [6]. However, conditions that impede right heart fill- which can be mistaken for fluid. This artifact can cause the
ing (right sided heart failure or pericardial effusion), sepsis, wall of a structure to partially disappear, which should not
and anaphylaxis should be considered in unstable patients. be confused for rupture of an organ (e.g. do not confuse
It may be associated with sedation using dexmedetomidine edge artifact for rupture of the urinary bladder). Edge
[11]. If patients are serially evaluated and gall bladder wall shadowing from structures such as the gall bladder, stom-
thickening develops following fluid therapy, volume over- ach wall, or urinary bladder, for instance, should not be
load should be suspected. Other supporting evidence of confused with free fluid. Edge shadowing will disappear
volume overload can be assessed with POCUS (Chapter 17). depending on the angle the ultrasound beam strikes the
structures of interest; changing the angle of insonation by
Urine Production manipulating the transducer to change this angle is helpful.
Although not perfectly accurate, a lack of change in

bladder size (volume) despite appropriate fluid therapy Intestinal and Stomach Wall and Contents
in a well-hydrated patient could indicate anuria or Intestinal and stomach wall and contents can also be mis-
oliguria [7]. taken for abnormal fluid or structures, particularly when
intestinal wall edema is present. By moving the transducer
Ureteral Obstruction and assessing multiple planes (longitudinal and trans-
verse), it will be easier to determine whether the structure
Preliminary research in companion animals suggests that is intestine or stomach.
assessment of the right and left kidneys at either paralum-
bar region allows the nonspecialist clinician to sonographi-
Mirror Image Artifact
cally screen for pyelectasia, gross renal asymmetry, ureteral
dilation, and visualization of calculi with high sensitivity Mirror image artifact of the gall bladder or hepatic vessels,
and specificity when compared to consultative ultra- which are often distorted, can be confused for pleural effu-
sound [10]. Identification of nephromegaly, perirenal fluid, sion, or even misinterpreted as a diaphragmatic hernia.
and hydronephrosis is also possible [9]. Together, these
findings are suggestive of acute kidney injury and/or ure-
Acute Hemorrhage or Very Cellular Effusions
teral obstruction [9, 10]. For example, identifying these
findings in the feline patient with acute azotemia and sus- Acute hemorrhage or very cellular effusions can some-
pected oligoanuria may help to guide a diagnosis and fur- times be so echogenic that they mimic soft tissue struc-
ther complement physical examination. In cases with tures or gastric contents, making it more difficult to
confirmed ureteral obstruction in which medical manage- identify as free abdominal fluid. Transducer manipula-
ment is attempted, following the renal pelvic diameter seri- tions (e.g. applying pressure to the transducer to displace
ally may assist with the decision regarding the need for and underlying free abdominal fluid) can sometimes create
timing of surgery. “swirling,” which may help differentiate such cellular
effusions from tissues. Fanning and rocking the trans-
ducer will also often identify “structures” within the
itfalls of Abdominal Point-of-Care
P fluid (e.g. floating omentum or intestines) and may allow
sharp angles/triangles to be visualized, which helps to
Ultrasound
differentiate free abdominal fluid from fluid contained
within hollow organs.
Hepatic Vessels
Hepatic vessels can sometimes be mistaken for fluid. It is Video 39.1 This video demonstrates point-of-care ultra-
important to remember that ultrasound is a dynamic imag- sound of the umbilical site to assess for
ing modality and therefore by fanning, rocking, sweeping, gravity-dependent peritoneal fluid. This video
sliding, changing the depth, and rotating the transducer includes audio narration.
References 521
References
1 Boysen, S.R., Rozanski, E.A., Tidwell, A.S. et al. (2004). 7 Kendall, A., Keenihan, E., Kern, Z.T. et al. (2020).
Evaluation of a focused assessment with sonography for Three-dimensional bladder ultrasound for estimation of
trauma protocol to detect free abdominal fluid in dogs urine volume in dogs compared with traditional
involved in motor vehicle accidents. J. Am. Vet. Med. Assoc. 2-dimensional ultrasound methods. J. Vet. Intern. Med.
225 (8): 1198–1204. 34: 2460–2467.
2 McMurray, J., Boysen, S.R., and Chalhoub, S. (2016). 8 Kim, S.Y., Park, K.T., Yeon, S.C. et al. (2014). Accuracy of
Focused assessment with sonography for triage in non- sonographic diagnosis of pneumoperitoneum using the
trauma dogs and cats in the emergency and critical care enhanced peritoneal stripe sign in Beagle dogs. J. Vet. Sci.
setting. J. Vet. Emerg. Crit. Care Jan-Feb; (1): 64–73. 15 (2): 195–198.
3 Lisciandro, G.R., Lagutchik, M.S., Mann, K.A. et al. (2009). 9 Beeston, D. and Cole, L. (2020). Evaluation of the utility
Evaluation of an abdominal fluid scoring system of point-of-care ultrasound in detecting ureteral
determined using abdominal focused assessment with obstruction in cats. Abstracts from the Veterinary
sonography for trauma in 101 dogs with motor vehicle Emergency and Critical Care Ultrasound Society.
trauma. J. Vet. Emerg. Crit. Care 19 (5): 426–437. Ultrasound J. 12 (Suppl 1): 45.
4 Boysen, S.R., Tidwell, A.S., and Peninck, D.G. (2003). 10 Lamb, C.R., Dirrig, H., and Cortellini, S. (2018).
Ultrasonographic findings in dogs and cats with Comparison of ultrasonographic findings in cats with
gastrointestinal perforation: a retrospective study and without azotaemia. J. Feline Med. Surg. 20 (10):
(1995–2001). Vet. Radiol. Ultrasound 44 (5): 556–564. 948–954.
5 Sanderson, J.J., Boysen, S.R., McMurray, J. et al. (2017). 11 Seitz, M.A., Lee, A.M., Woodruff, K.A., Thompson,
Fasting and its effects on gastro-intestinal motility as assessed A.C. (2021). Sedation with dexmedetomidine is
by Sonography. J. Vet. Emerg. Crit. Care 27 (6): 645–650. associated with transient gallbladder wall thickening
6 Quantz, J.E., Miles, M.S., Reed, A.L. et al. (2009). Elevation and peritoneal effusion in some dogs undergoing
of alanine transaminase and gallbladder abnormalities as a abdominal ultrasonography. J. Vet. Intern. Med. 35 (6):
biomarker for anaphylaxis in canine hypersensitivity 2743–2751.
patients. J. Vet. Emerg. Crit. Care 19: 536–544.
523
40
Specialized Gastrointestinal Techniques

Lisa Smart and Joyce Lau
uscultation of Gastrointestinal
A medications. Although many of these techniques are used
Sounds routinely in veterinary emergency and critical care medicine,
all these procedures have the potential for complication, and
The association between abdominal auscultation and gas- it should always be considered whether the benefits of the
troenterological disease was first described in 1905 in procedure outweigh the risks.
human medicine [1]. Since then, very few studies have
been conducted to validate or refute this assumption. Orogastric Intubation
Current gastrointestinal auscultation methods are subject
Orogastric intubation involves inserting a tube through the
to a physician’s individual techniques and preferences,
oropharyngeal cavity to the stomach while the patient is
resulting in frequent conflicting conclusions on patient
under sedation or, ideally, general anesthesia with a secure
gastrointestinal status, diagnosis, and treatment recom-
airway (Protocol 40.1; Box 40.1; Figures 40.1–40.4).
mendations [1–4]. Owing to the lack of standardized
guidelines to perform and interpret abdominal ausculta-
Indications
tion, the clinical utility of this technique as part of a physi-
The indications for orogastric intubation include decom-
cal assessment has come under scrutiny.
pression of gastric dilation, removal of ingested toxins
In veterinary medicine, abdominal auscultation has
via gastric lavage and administration of medications,
been described as an adjunctive tool for the diagnosis of
such as activated charcoal. Complications can include
abdominal diseases or gastrointestinal dysfunction [5]. At
damage to or perforation of the esophagus or gastric wall,
least five minutes of abdominal auscultation to determine
regurgitation and aspiration of gastric contents, and
whether borborygmus is increased or decreased has been
adverse events related to sedation or general anesthesia.
described. However, there have been no studies evaluating
The risk of complications related to anesthesia may be
the diagnostic utility of borborygmus evaluation in dogs or
increased if the animal is showing clinical signs of intoxi-
cats, and the link between the presence of gastrointestinal
cation. Although in the authors’ experience, these com-
sounds and normal motility is dubious. Until these studies
plications are uncommon if the correct technique is
are performed, therefore, the presence or absence of borbo-
followed, the true prevalence of these complications has
rygmus should be interpreted cautiously.
not been specifically reported. The following technique
described is for conscious dogs. Cats do not tolerate this
procedure sedated and are at risk of laryngospasm; there-
Gastric Intubation
fore, general anesthesia and endotracheal intubation to
secure the airway are necessary in cats. An exception
Introduction
is made for neonatal and newborn kittens, which are
There are two basic goals for intubation of the gastrointes- often fed by orogastric tube when they are unable to
tinal tract: removing contents or administering food and nurse (Chapter 74).
Protocol 40.1 Orogastric Intubation
1) Determine whether the patient is an appropriate can- 6) Location of the tube within the esophagus must be
didate for gastric decompression, and whether seda- confirmed by one or more of the techniques described
tion or anesthesia is required. (Box 40.1). If there remains any doubt as to whether
2) Choose a single-lumen orogastric tube with the larg- the tube is in the trachea as opposed to the esophagus,
est diameter that will reasonably fit within the remove the tube and start again.
patient’s esophagus (Figure 40.1). 7) Once the location of the tube within the esophagus is
3) Measure the length of tube that will be required to confirmed, advance the tube gently up to the mark pre-
pass into the stomach, which is the distance from the viously made on the tube (Figure 40.4). A rush of gas
nares to the last rib. Mark the tube with either tape or may be heard at the proximal end of the orogastric
indelible marker (Figure 40.2). tube when passed into the stomach. In the case of GDV,
4) For the conscious dog, unroll approximately 30 cm if there is resistance, apply gentle pressure with a
from a roll of adhesive bandage material, and leave twisting motion to aid entry through the cardia. If
this attached to the roll. With someone restraining the there is still resistance, clean gauze may be placed
dog’s head from behind, place the roll of bandage into over the end of the tube, to protect the operator’s
the dog’s mouth with the long plane parallel with the mouth from contamination, and a small amount of air
long axis of the muzzle, holding the mouth closed. blown into the tube while gently advancing it. If the
Then wrap the free end of the bandage around the tube still cannot be passed into the stomach in a
dog’s mouth to hold the roll in place (Figure 40.3). If patient with severe gaseous dilation, then the stomach
the dog starts to regurgitate or vomit, the roll can be should be trocarized percutaneously to relieve tension
removed quickly out of the mouth rostrally without on the fundus (see below for technique); the tube will
the need to unwrap the bandage from around often then pass more easily. If there is no gastric fluid
the muzzle. flow into the collection container below the level of
5) Lubricate the end of the orogastric tube and slowly the patient, gentle ballottement of the abdomen may
feed the tube through the hole in the middle of the help to dislodge any obstruction. If there is still no
bandage roll (Figure 40.3). Aim to push the tube flow, 10–60 ml of water can be infused into the tube to
through the left dorsal aspect of the dog’s pharynx to flush any obstruction (see also Protocol 40.5).
avoid intubating the larynx. Try to advance the tube 8) Before removing the tube, tightly kink the tube
when the dog swallows. Leave the other (distal) end of 10–15 cm from the operator’s end. Hold the tube firmly
the tube below the level of the animal in a collection in this kinked position while removing the tube to pre-
container, so that any fluid within the tube will drain vent fluid leakage as it is removed from the esophagus
by gravity. and pharynx.
Box 40.1 Techniques to Distinguish Between Intubation of the Esophagus/Stomach and the Trachea
Indications That the Tube is Within the Esophagus or Stomach
● Seeing the presence of esophageal fluid or gastric reflux fluid in the tube. The fluid should look like saliva as well
as any other substances such as ingesta, bile pigment, or blood.
● Palpation of the tube on the left side of the neck adjacent to the trachea confirms its placement in the esophagus.
● Either a rush of gas or gastric fluid will confirm its location in the stomach. Air blown into the tube by the operator
(see Step 7 of technique for orogastric tube placement) with simultaneous auscultation of borborygmus within the
stomach also confirms its location.
Indications That the Tube is Within the Trachea

● If humidified air is seen within the tube during each exhalation, the tube may be within the trachea.
● Coughing, though the absence of coughing does not confirm placement within the esophagus
● The tracheal rings may be felt as vibrations along the tube in a very large dog if the tube is passed down the trachea.
● A capnometer may be placed at the end of the tube. An increase in carbon dioxide while the dog exhales confirms
its location in the trachea (Chapter 30, Capnography).
● If placing a nasogastric tube, intubation of the trachea is likely if a copious amount of air is aspirated via syringe
from the end of the tube (ensure any side ports of the tube are sealed when aspirating).
NasoNastric IstuNsrsI str Nastric DicsomtDaarsI 525
Figure 40.1 Various tubes used in gastrointestinal techniques.

A: Simple orogastric tube stained with activated charcoal;
B: Double lumen orogastric tube used for gastric lavage; Figure 40.3 Advancement of an orogastric tube through the
C: Orogastric tube with fenestrations and intraluminal side middle of a bandage roll in a patient with gastric dilation and
port for flushing, suitable for smaller patients or for enemas; volvulus. The free end of the bandage roll can be seen wrapped
D: Enema tube with insufflation bulb to aid flushing. around the nose and mouth to keep it in place.
Figure 40.2 Measurement of the length of tube needed for Figure 40.4 Passing an orogastric tube up to the premeasured
orogastric intubation in a dog. The person to the dog’s left is mark (white medical tape) while listening for a rush of gas,
indicating the level of the final rib with their index finger. indicating passage into the stomach.
asogastric Intubation
N to either aerophagia or gastric fluid accumulation
for Gastric Decompression (Box 40.2). This technique is not appropriate for the man-
agement of food engorgement (see below). Placement of a
Nasogastric intubation involves placing a tube through the nasogastric tube in cats for aerophagia is not recom-
nasal cavity down into the stomach and is best placed in a mended, as stress will usually exacerbate the cause of aer-
conscious animal that can swallow. ophagia. However, if a nasogastric tube is already in place
for enteral nutrition, it may be used for air evacuation in
Indications
the cat. Discretion should be used as to whether or not the
Nasogastric intubation may be useful in patients that are patient will benefit from nasogastric tube placement for
experiencing discomfort due to gastric dilation secondary the purpose of gastric decompression.
526 SmDicrNlrzDd NastsrIsDasrINl TDichIrqtDa
Box 40.2 Nasogastric Intubation for Gastric onsiderations for the Patient

C
Decompression with Gastric Dilation and Volvulus
Indications
Risk factors for, presentation of, and management of shock
Gastric dilation caused by aerophagia or gastric stasis in the patient with gastric dilation and volvulus (GDV)
AND one of the following: have been reviewed elsewhere [6–8]. Diagnosis of GDV
may be confirmed by the presence of a dorsally displaced
Increased work of breathing
pylorus on a right lateral abdominal radiograph [9].
●
● Frequent regurgitation
● Signs of nausea, such as hypersalivation and frequent
swallowing Analgesia/Sedation
● Signs of abdominal pain on palpation
Moderate to severe vasoconstrictive shock in animals with
Contraindications GDV is caused by lack of venous return from the caudal
half of the body, leading to decreased cardiac output and
● Respiratory distress, whereby the stress of plac- organ ischemia, including the myocardium. Therefore,
ing a nasogastric tube may worsen the patient’s shock fluid therapy is a priority in these patients. Analgesia
condition should also be given as soon as possible, such as a pure mu
● Cats with aerophagia agonist opioid. Nonsteroidal anti-inflammatory drugs and
● Coagulopathy corticosteroids should not be used in GDV patients.
● Thrombocytopenia (< 50 000/μl) To facilitate orogastric intubation, sedation may be given,
although it is usually not needed. A combination of opioids
and benzodiazepines, such as diazepam or midazolam,
For the patient with gastric dilation secondary to gastric usually suffices. There is an increased risk of ventricular
stasis, intermittent emptying of stomach contents every arrhythmias due to decreased myocardial perfusion [10–12];
six to eight hours via a nasogastric tube may decrease therefore an electrocardiogram (ECG) should be performed
vomiting and abdominal discomfort (see section on gas- if an arrhythmia is detected. Standard guidelines should
tric residual volume monitoring). Gastric fluid pH may be followed on the decision to treat ventricular arrhyth-
also be monitored by this procedure (see section on moni- mias [13], with awareness that those that occur during
toring gastric fluid pH) and the nasogastric tube may be general anesthesia may require more aggressive treatment.
used for enteral feeding, which may stimulate some gas- Ideally, the dog’s stomach should be decompressed by either
tric motility (Chapter 44). It is unknown whether the orogastric intubation or trocarization (see below) before
presence of a nasogastric tube through the lower esopha- general anesthesia is induced to achieve more rapid cardio-
geal sphincter promotes reflux of gastric contents into the vascular stabilization.
esophagus but, anecdotally, this does not appear to con-
tribute to esophagitis.
Trocarization
Gastric trocarization (Protocol 40.2; Figure 40.5), also
Technique
referred to as gastrocentesis or gastric needle decompres-
The technique for placing a nasogastric tube has been cov- sion, is often required in the patient with GDV because
ered elsewhere (Chapter 44). The nasogastric tube is most orogastric intubation is difficult or impossible in the
easily placed in conscious animals; however, sedation presence of severe gastric distention (see technique for
should be used in most cases of gaseous gastric dilation, as orogastric intubation). Gastric trocarization often
placement of the nasogastric tube can be stressful and decreases the time to gastric decompression and there-
exacerbate aerophagia. Once the nasogastric tube is in fore may decrease the risk of gastric necrosis. The risk of
place, gentle suction should be applied to evacuate air or gastric tear due to trocarization is likely small, and studies
fluid until negative pressure is reached. Blockages of the that include trocarization as a part of the gastric decom-
nasogastric tube with food material or thick saliva may pression protocol do not report the presence of gastric
impede evacuation; therefore, intermittent flushing of the perforation on exploratory laparotomy [14–18]. One study
nasogastric tube with 3–5 ml of water or air may be neces- used trocarization alone for pre-surgical decompression,
sary. Record volumes of fluid removed (see section on gas- without orogastric intubation, and reported a low overall
tric residual volume monitoring). mortality rate of 10% [19].
sIardDtNsrsIa str ssd IostoDoDIs 527
Protocol 40.2 Gastric Trocarization
1) Provide analgesia for the patient.

2) Choose a tympanic area on the lateral abdomen, which is usually the left dorsolateral abdomen just caudal to the
last rib.
3) Ideally, confirm presence of a gas interface with point-of-care ultrasonography, and the absence of a solid organ
abutting the body wall (e.g. spleen; see Chapter 39).
4) Clip the area and prepare aseptically. Perform hand hygiene and don sterile gloves.
5) Insert a 16-gauge over-the-needle catheter at a right angle to the abdominal wall, with the bevel facing up, into
the abdomen. Once gas flow is heard, or gastric fluid seen in the hub, advance the catheter off the stylet into the
abdomen up to the hub of the catheter. Remove the stylet.
6) Hold the catheter in place with a sterile hand and allow the gas to passively escape until the abdomen becomes
flaccid or noticeably reduced in size (Figure 40.5). If the catheter becomes occluded, it may be withdrawn slowly
from the abdomen until gas flow resumes or the catheter comes out. Never advance the catheter back into the
abdomen. Do not ballotte the abdomen with a catheter in place, as it may dislodge the catheter from the stomach
and contaminate the abdomen.
7) If the flow of gas from the first catheter is insufficient, a second catheter may be placed near the first using the
same technique.
8) Once the abdomen has reduced in size, orogastric intubation (OGI) may be attempted again in a gentle manner to
fully evacuate the stomach. Any catheters used for trocarization should be removed before repeat OGI.
9) Alternatively, OGI may be performed under general anesthesia before surgery, if trocarization has facilitated cardio-
vascular stabilization.
gastropexy is not performed [17, 19–21]. In addition, if

there is gastric necrosis present and only conservative ther-
apy is provided, the patient is likely to suffer a painful
demise. Conservative treatment should only be undertaken
for gastric dilation in a stable patient with the absence of
volvulus; however, gastropexy should still be considered in
breeds at high risk of subsequent GDV. Immediate surgical
intervention of GDV after decompression is recommended
to improve the chance of survival.
Considerations for Food Engorgement
Food engorgement or “food bloat” with subsequent gastric

dilation is a normal occurrence for carnivores, given their
Figure 40.5 Gastric trocarization in a dog with gastric dilation evolutionary adaptation for intermittent feeding. However,
and volvulus. An 18-guage catheter (note green hub) has been cases of engorgement associated with clinical signs are
placed in the region of most tympany and is facilitating gas usually secondary to ingestion of large amounts of dry
escape from the stomach.
commercial food, which absorbs fluid and slowly expands
in the stomach. This leads to gross distension of the
stomach and considerable abdominal pain. A diagnosis of
Conservative Management of Gastric Dilation
engorgement is confirmed by evidence of a dilated, ingesta-
and Volvulus
filled stomach in its correct anatomical position on a right-
There is a low chance of a good long-term outcome after lateral abdominal radiograph. Despite the large gastric
decompression only for a GDV patient. Several studies distension that can be associated with this syndrome,
have described techniques for gastric repositioning during dogs usually have an excellent outcome with conservative
decompression; however, short-term survival is compro- medical management only, such as analgesia and fluid
mised and recurrence by one year is highly likely if therapy [22]. Unlike in cases of GDV, dogs with food
engorgement do not typically display signs of shock, measurement and the minimal evidence for an association
although they may be tachycardic, mildly hyperthermic, with improving clinical outcome [25]. However, lack of
and appear vasodilated. These signs often resolve with gastric aspirate pH monitoring to guide antacid dosing in
analgesia. Acid–base and electrolyte abnormalities can human critical care has recently been challenged, and it is
also develop during treatment [22], so monitoring of these possible this practice may experience a revival [26].
parameters along with hydration status is warranted. In the The use of pH colorimetric indicator paper or pH
authors’ opinion, if cardiovascular compromise is evident, strips provides a practical alternative to indwelling pH
then the problem may be surgical and another underlying monitoring probes. pH strips with multiple test squares
cause should be sought, such as volvulus. Interventions provide a higher degree of accuracy, and are easier to
such as emesis, gastric lavage, and gastrotomy are not indi- read than single square pH test strips [27, 28]. Although
cated in simple food engorgement and may increase risk of excellent agreement has been shown between pH measured
adverse events. However, if the dog has ingested a sub- on gastric aspirate fluid using litmus paper and gastric
stance that has solidified, such as polyurethane adhesive pH measured by a nasogastric pH probe [29], litmus
(Gorilla Glue®, Gorilla Glue Inc., Ohio), which does not paper may generate a small, although clinically relevant,
have a chance of passing through the intestinal tract, then positive bias when compared with a pH meter [30]. This
gastrotomy may be warranted. means that pH strips could potentially give a reading up
to three units higher than pH measured by a probe. How-
ever, there is minimal evidence regarding the accuracy of
Gastric Fluid Aspirate pH Monitoring modern pH strips.
Maintenance of a gastric pH greater than 4.0 has been
Gastric pH monitoring can be achieved by various meth- recommended in human medicine to optimize healing of
ods: estimating pH of gastric fluid aspirate, use of an gastric ulcers and reduce the risk of gastric bleeding
indwelling nasogastric pH monitoring probe, or place- [26, 31, 32]. A gastric pH greater than 6.0 may be impor-
ment of a gastric radiotelemetric capsule (Protocol 40.3). tant for people at risk of life-threatening gastric hemor-
Although continuous pH monitoring increases accuracy rhage, as an acidic pH promotes blood clot dissolution [31].
for assessing gastric pH [23], the two latter methods are Given pH strips may be inaccurate or have a positive bias,
usually reserved for research purposes, such as measuring it seems prudent to aim for a gastric aspirate pH greater
efficacy of antacid therapy or detecting esophageal reflux, than 5.0 using strips if there is a concern for adverse
and will not be discussed further. The use of gastric aspi- effects of gastric acidity. Measurement of gastric aspirate
rate pH to guide antacid therapy has been advocated in pH has also been suggested to guide treatment of chemi-
human medicine [24]; however, there has not been cal exposure in human emergency medicine or to assist
widespread uptake due to pitfalls associated with this with correct placement of nasogastric tubes [25]. How-
ever, fasting gastric pH in healthy Beagles has been shown
to fluctuate more widely, between pH 2.0 and 8.0 [33],
than in healthy people, where fasting pH is approximately
Protocol 40.3 pH Monitoring of Gastric Fluid Aspirates
1.0–2.0 [34, 35]. Gastric pH in cats has also shown a wide
variation over 24 hours, albeit mostly staying in the acidic
1) Ensure that some time has lapsed since the last
range [36]. Therefore, single measurements of pH should
feeding or administration of water down the
be interpreted with caution in dogs and cats, especially
nasogastric tube (at least four hours).
in regards to guiding nasogastric tube placement or
2) Aspirate ≥ 1 mL of gastric fluid from the nasogastric
attempting to use gastric pH to diagnose caustic chemical
tube with a catheter-tip syringe and place on a
ingestion.
multi-square pH-sensitive paper or strip or single
square.
3) Determine pH of the gastric aspirate by comparing a Indications
colorimetric scale to the pH strip (Figure 40.6).
Owing to the lack of veterinary consensus and clinical
4) If fluid pH is less than 5.0, and gastric healing is of
standards on the utility and frequency of gastric aspirate
concern, increase acid suppressive therapy dose or
pH monitoring using pH strips, we have included the
frequency, depending on drug.
preferred approach based on our experience. Clinicians
5) Repeat procedure at next aspiration of the nasogas-
should bear in mind the pitfalls of gastric pH estimation in
tric tube after new therapy regimen instituted.
regard to accuracy.
Timing will depend on pharmacokinetics of antacid
Gastric aspirate pH measurement is most often used for
therapy of choice.
assessing efficacy of antacid dosing. In our clinical
Nastric DardtNl sltoD sIrsstrIo 529
validity of this technique for reducing risk of aspiration

has been questioned in recent times. Multiple human
studies have shown the retrieved volume to range 14–136%
of gastric volume [38–41]. In addition to inaccuracy of the
measurement itself, interruption of enteral nutrition
based on GRV has not been shown to reduce the risk of
aspiration, vomiting, or ventilator-associated pneumo-
nia [42–45]. Therefore, interruption of feeding for this
reason may only lead to inadequate caloric intake. Recent
human clinical guidelines have recommended against
routine use of GRV monitoring in patients receiving
enteral nutrition, and only withholding feeding if GRV is
greater than 500 ml in combination with signs of gastroin-
testinal intolerance [46].
In veterinary medicine, most patients receiving enteral
nutrition via a nasogastric tube are not anesthetized
or intubated. However, given that conscious veterinary
patients, particularly dogs, are still at risk of aspiration if
frequently vomiting or regurgitating, GRV monitoring
Figure 40.6 Syringe filled with scavenged gastric fluid from a may still be pursued. Abdominal distension due to
nasogastric tube placed next to a multi-square pH sensitive strip
(Fisherbrand pH indicator sticks, ThermoFisher Scientific,
gastrointestinal intolerance may also cause discomfort.
Australia). A pH of 6 is determined by comparing the colorimetric Increased GRV might prompt a reduction in administered
scale to the pH strip. enteral nutrition volume [47] or addition of prokinetic
drugs. Unfortunately, there is very little evidence to sup-
port or refute the practice of GRV monitoring. A rand-
practice, gastric aspirate pH is measured using multis- omized controlled trial of continuous versus intermittent
quare pH strips on fluid scavenged from nasogastric tubes nasogastric tube feeding in dogs could not demonstrate a
(Figure 40.6) if gastric acidity poses a concern. Gastric correlation between GRV and the occurrence of vomiting,
aspirate pH estimation may be made for a patient with regurgitation, or percentage of nutrition delivered [48].
signs of continuing upper gastrointestinal discomfort to Prospective studies are required in veterinary medicine
interrogate efficacy of antacid therapy and adjust dose or to determine whether GRV monitoring impacts clinical
frequency if indicated. outcome.
Given the lack of standard veterinary definitions of
excessive GRV and lack of consensus on frequency of
monitoring and return of gastric fluid, we have included
Gastric Residual Volume Monitoring
our typical preferred approach (Box 40.3, Protocol 40.4).
However, the clinician should determine whether GRV
Gastric residual volume (GRV) monitoring is the meas-
monitoring is necessary and how frequently it should be
urement of the volume of fluid that is aspirated from the
performed on an individual case basis.
stomach through a nasogastric tube. It is used to assess
gastric emptying and, subjectively, the degree of dysmo-
tility in human and veterinary patients receiving enteral
nutrition.
Box 40.3 Clinical Signs that may Warrant Gastric
Residual Volume Monitoring in Patients Undergoing
Assisted Enteral Feeding
Indications
Distended abdomen
Historically, increased GRV has been used in human criti-
●
Signs of abdominal discomfort

cal care to trigger a pause in enteral feeding to decrease
●
Restlessness after feeding

the risk of vomiting, aspiration, and ventilator-associated
●
Signs of nausea, such as ptyalism

pneumonia. This led to measurement of GRV becoming a
●
Retching
routine nursing care procedure in human medicine, with
●
Vomiting
one survey reporting that 89% of nurses withheld enteral
●
Regurgitation
nutrition at GRVs greater than 300 ml [37]. However, the
●
Protocol 40.4 Monitoring Gastric Residual Volume

GRV monitoring can be performed in the conscious 5) Consider pH testing of the aspirated fluid.
patient every 6–12 hours. It is performed before deliver- 6) If aspirated fluid volume is more than 50% of the pre-
ing the subsequent bolus of enteral nutrition formula. vious volume of administered enteral nutrition for-
mula, consider returning only 50% of that volume back
1) Don clean examination gloves and attach a syringe to
to the patient.
the proximal end of the nasogastric tube.
7) If GRV is greater than 4–8 ml/kg, or more than 50% of
2) Apply gentle suction to evacuate gastric fluid until
the previous infused volume of enteral nutrition for-
negative pressure is reached.
mula, and there are other signs of intolerance (see
3) Measure and record aspirated gastric fluid. The clinician
indications above), consider the presence of persistent
may order “return” of all or a portion of the GRV to the
gastrointestinal dysmotility.
stomach in an attempt to avoid electrolyte or acid–base
8) Do not increase volume of enteral nutrition formula
disturbances. Re-instill the ordered volume (0–100%) of
per feed (or hourly rate if continuous) until signs of
gastric fluid slowly via the nasogastric tube.
gastrointestinal intolerance abate.
4) Note any abnormal coloration of the fluid, such as
frank blood.
Gastrointestinal Decontamination Indications, risks, and drug choice for emesis have been
covered elsewhere and will not be addressed in this
Gastrointestinal decontamination (GID) for ingested toxins chapter [53–62].
includes emesis, gastric lavage, whole-bowel irrigation,
enema, and activated charcoal administration. In human Gastric Lavage
medicine, the routine use of GID has become controversial
because of a lack of evidence that GID has a significant Gastric lavage includes orogastric intubation and removal
impact on patient outcome, except for specific indications of gastric contents (Protocol 40.5). In human clinical stud-
that will be addressed below [49–52]. No studies in veteri- ies, gastric lavage has shown no clear benefit over activated
nary medicine have been conducted to assess whether or charcoal administration alone [49, 50]; however, there still
not GID changes patient outcome for routine poisoning remain some indications for this procedure in veterinary
cases; however, it still remains as the current recommenda- medicine.
tion for ingested toxins within certain guidelines [53, 54].
Veterinary poisoning cases may differ from those in human Indications
medicine, in that there may be a large volume of toxin Gastric lavage is indicated for intoxication cases where the
within the gastrointestinal tract, and the time from amount of toxin ingested is potentially harmful, it was
ingestion to presentation can be short. Therefore, there still ingested within one to two hours of performing gastric
remains a role for GID in veterinary medicine. lavage, and emesis cannot be achieved due to altered
Protocol 40.5 Gastric Lavage

Refer to Protocol 40.1 for guidance regarding insertion on abdominal palpation. After instilling a volume of
and removal of the orogastric tube. water, allow the effluent to passively drain by gravity,
aided by gentle ballottement of the abdomen. A
1) The patient must always be orotracheally intubated double-lumen tube can also be used to aid continuous
with an appropriately inflated cuff and placed in lat- drainage of the stomach while flushing (Figures 40.7
eral recumbency before lavage is performed. and 40.8). Never attach a hose to the tube to instill
2) With the orogastric tube in place, use room tempera- water, nor attach suction to the end to empty the stom-
ture water to lavage the stomach by use of a siphon. ach. It is useful to record the volume of the effluent
Although it is stated as common practice [63–65] to water to monitor the degree of water ingestion and
use approximately 5–10 ml/kg of water for each avoid hyponatremia.
cycle, more is usually needed to lavage the stomach 3) Check that the cuff of the endotracheal tube is still
adequately and the authors commonly use up to adequately inflated, then shift the patient onto the
20–30 ml/kg/cycle to achieve mild gastric distension other lateral side.
NastsrIsDasrINl DicsIsNorINsrsI 531
Figure 40.7 Insertion of a double bore orogastric tube for

gastric lavage.
4) Repeat the lavage as above. A third lavage on the first

lateral side may be considered for snail pellet inges-
tion, where pellets can stick to the stomach wall
Figure 40.8 Gastric lavage for snail pellet ingestion. A double
(termed a three-sided lavage). bore tube is being used. A funnel (black) is attached to the
5) Save the contents of the effluent for toxicological ingress tube while water flows out of the stomach through the
analysis, if desired. egress tube into a receptacle (white).
6) If activated charcoal administration is indicated, it may be
instilled into the stomach before removal of the tube; 8) Keep the patient tracheally intubated with an inflated
however, be careful not to significantly distend the stom- cuff until it is able to maintain sternal recumbency and
ach, as this leads to increased risk of aspiration during is swallowing. This may reduce the risk of aspiration. It
anesthetic recovery. It seems reasonable to limit the dose is not advised to delay extubation in cats due to risk of
of activated charcoal to 2–3ml/kg while under anesthesia. laryngospasm; therefore, activated charcoal should
7) Kink the tube when removing. either not be given after lavage or the volume reduced
in this species.
mentation or other neurologic signs (Box 40.4). If the substances, due to the risk of esophageal reflux and subse-
patient has already vomited after ingestion of the toxin, quent esophageal damage, and aspiration. These patients
gastric lavage is unlikely to recover a significant amount of also have an increased risk of esophageal and gastric
toxin. One exception is where there has been a large perforation.
amount ingested, such as in snail pellet ingestion. In our If the animal has ingested a small volume of toxin, such
geographic region, snail pellet ingestion is by far the most as tablets or capsules, then gastric lavage is unlikely to be
common reason for gastric lavage; however, other reasons rewarding and activated charcoal administration alone
include neurotoxic substance ingestion such as puffer fish, should be considered instead. It is unusual for cats to ingest
sodium monofluoroacetate (1080), and strychnine. a large volume of toxin and thus this procedure is rarely
The risks of gastric lavage include those associated with performed in a cat; however, the principles remain the same.
general anesthesia, aspiration, and gastrointestinal tract
trauma. The incidence of esophageal or gastric perforation
Nasogastric Intubation for Decontamination
secondary to gastric lavage is unknown in veterinary
medicine, but rarely occurs in human medicine [50] and Nasogastric intubation may be useful for removal of large
the same is likely true for veterinary patients. volumes of liquid toxin in which emesis is contraindicated
It is not necessary to perform gastric lavage for food (Box 40.4). It will only be useful within 30 minutes of inges-
engorgement (see section on considerations for food tion unless delayed gastric emptying is present. The
engorgement). It is also contraindicated to perform gastric nasogastric tube can then be used for activated charcoal
lavage for animals that have ingested caustic or volatile administration (see below).
Techniques
Box 40.4 Gastrointestinal Decontamination
Voluntary Consumption Some dogs, especially puppies, will
Gastric Lavage drink activated charcoal suspension if it is mixed with
canned commercial food or water. Often, though, they will
Indications:
not consume the required dose and one of the other
● Toxin ingested within one to two hours and emesis techniques below may be required.
contraindicated
Large volume of ingested toxin, such as snail bait pellets
Syringe Feeding Animals may be restrained and syringe-
●
Contraindications: fed activated charcoal. The risks include undue stress and
aspiration, especially if the solution is administered with
● Food engorgement
pressure. The solution is given by dribbling small amounts
● Ingestion of caustic or volatile substances
in the commissure of the animal’s mouth and allowing
● Ingestion of a small volume of toxin or number of
them time to swallow. Gloves and gowns will need to be
tablets or capsules
worn as it becomes quite messy. Another technique for
Nasogastric Intubation larger dogs is to place the sleeve of a disposable gown
over the dog’s head, allowing only the nose and mouth to
Indications:
protrude, leaving the eyes covered (Figure 40.9). The
● Large volume of liquid toxin person can then dribble the solution in the corner of the
● Ingestion of caustic substances dog’s mouth slowly and patiently. As the eyes are covered,
Contraindications: the dog does not try to get away from the syringe and often
accepts administration of the suspension. Also, the gown
● Respiratory distress keeps the rest of the dog clean.
● Cats with aerophagia
● Coagulopathy Nasogastric Tube Nasogastric intubation can be useful for
● Thrombocytopenia (<50 000/μl) slow activated charcoal administration. The technique of
placing a nasogastric tube is described in Chapter 44.
In humans with caustic substance ingestion, endoscopy Orogastric Tube In some poisoning cases, an orogastric
for identification of perforations and placement of a tube has been placed for gastric lavage. Activated charcoal
nasogastric tube is used, as the tube reduces the incidence may be administered into the stomach via an orogastric
of esophageal stricture development and allows for admin- tube at the end of the gastric lavage procedure. However, be
istration of enteral nutrition [66, 67]. A nasogastric tube aware that as the animal recovers from sedation/anesthesia,
may also aid in dilutional therapy of the caustic substance there is risk of aspiration, so only small volumes (2–3 ml/
if the animal will not drink water or milk, by instilling kg) should be instilled into the stomach at this point.
small amounts down the tube. This is in contrast to gastric
lavage, which, as stated above, is contraindicated in caustic
substance ingestion.
Activated Charcoal Administration

Indications
The indications for activated charcoal administration have
been covered elsewhere [53, 64]. Systemic absorption of
many ingested toxins is decreased by activated charcoal if
the charcoal is given within two hours of toxin ingestion.
Activated charcoal may be beneficial greater than two
hours post-ingestion for toxins that undergo enterohepatic
recirculation or for delayed release capsules.
Contraindications of activated charcoal administration
include oral administration in patients with abnormal
Figure 40.9 Administration of activated charcoal by syringe
mentation, hydrocarbon ingestion, and gastrointestinal feeding. The disposable gown over the head prevents the dog
tract perforation. from seeing the advancing syringe and keeps the dog clean.
IDoNa 533
Catharsis it can be removed digitally. Be careful with the use of

instruments to aid extraction, such as sponge forceps, as
Catharsis involves the use of an orally administered,
they can cause perforation of the colon. This procedure
osmotically active, nonabsorbed substance to speed
takes patience and, sometimes, multiple days of repeated
transition of a toxin through the gastrointestinal tract.
enemas if obstipated.
Cathartics, such as sorbitol, are often combined with
activated charcoal in commercially available suspen-
sions. Multiple doses are not recommended as cathartics Enema for Gastrointestinal Decontamination
may contribute to excessive fluid loss and electrolyte Colonic enemas can be useful in the management of
imbalances. ingestion of large amounts of toxin. In particular, colonic
lavage techniques are useful for removing snail pellets
from the colon. The technique is similar to that described
Enemas above, but the animal is anesthetized and the cycle is
repeated until the effluent is clear. It is usually per-
Indications formed at the same time as gastric lavage (Figure 40.10).
If there is resistance during passage of the tube, do not
Enemas are used to relieve constipation and for GID.
force the tube any further into the colon. Siphon water
They can also be used in the treatment of hepatic
by gravity feed into the colon, allowing the effluent to
encephalopathy.
pass around the tube. This cycle is repeated until the
effluent is clear.
Techniques
Enemas for Constipation Whole-Bowel Irrigation
An enema is required if there is distension of the colon Whole-bowel irrigation, also known as a through-and-
with hard, dry feces and the animal is straining to defecate. through enema, involves oral administration of large
If there are hard feces in the rectum only, a small amount quantities of an iso-osmotic polyethylene glycol electrolyte
of lubricant administered by syringe into the rectum may
help passage. Alternatively, commercially available micro-
enemas, containing osmotically active substances and
lubricant, may be used to relieve mild cases of constipa-
tion. If there is gross distension of the colon with hard
feces, then a complete enema will need to be performed.
The animal, in some cases, will need to be sedated or anes-
thetized. Rehydration fluid therapy should also be included
in the treatment plan.
To perform an enema, pass a lubricated soft red rubber
catheter or similar tube (Figure 40.1) through the anus to
the level of the mid-abdomen, or until obstruction is felt,
and gently infuse 5–10 ml/kg of warm water into the colon.
Allow time for the animal to defecate voluntarily [68].
Other substances can be added to the enema solution,
such as water-based lubricant, lactulose (5–10 ml) or
mineral oil (5–10 ml) to aid the removal of feces. The
enema can be repeated if the colon is not emptied by
voluntary defecation.
If a simple enema is not successful in relieving the
patient’s constipation, manual fecal extraction may be
needed. The dog or cat should be anesthetized and orotra-
cheally intubated to avoid pain and stress, and to reduce Figure 40.10 Colonic lavage of a patient that has ingested
the risk of aspiration as manipulation of the colon may snail pellets. The green pellets can be seen around the perineal
area. The enema tube (green) is being inserted into the rectum.
induce vomiting. Repeat the enema as above and gently
Note the use of a gravity feed for flushing (metal container) and
palpate the colon via external abdominal palpation to help the orange bulb within the tubing, which can be used to
break up the feces and move it into the rectum, where increase pressure during flushing.
solution to irrigate the entire gastrointestinal tract to are wide-bore tubes, with or without an inflatable balloon
prevent absorption of a toxin. It is also used to prepare the on the distal end, connected to a collection system similar
colon for colonoscopy and surgery. The technique is to to a closed urinary collection system. The risks of using
administer the solution via a nasogastric tube at approxi- these tubes include colonic or rectal ulceration, pressure
mately 100–500 ml/hour until the rectal effluent is clear. necrosis of the bowel wall, or obstruction of the tube lead-
This dose has been adapted from human pediatric ing to colonic distension and possibly perforation [73].
doses [69]. This method is rarely employed in veterinary People can also develop temporary or permanent anal
medicine. This technique may be considered for large sphincter incompetence with prolonged use. Rectal tubes
ingestions of sustained release drugs or iron tablets, or are now being replaced with fecal or bowel management
packets of illicit drugs, which would be a rare scenario for systems such as the Flexi-seal Fecal Management System
veterinary medicine. Although one study in dogs showed (ConvaTec, NJ), which can be used for up to 29 days [74].
improved evacuation of paraquat with whole-bowel irriga- There have been reports of rectal trauma associated with
tion compared with no GID [70], there is little evidence in these devices [75–77].
the literature supporting its clinical efficacy in removing No studies have evaluated the risk of use of rectal tubes
toxins or improving outcome. Benefits exceeding that of in veterinary medicine; however, use of rectal tubes for
activated charcoal alone are questionable, even in inges- less than 24 hours likely carries a low risk as it does in
tion of sustained release drugs [71]. human postoperative patients (Box 40.5) [78]. In our
Contraindications include gastrointestinal perforation clinical experience, rectal Foley catheters with a closed
or gross hemorrhage, ileus, intractable vomiting, or cardio- collection system are used routinely for dogs with frequent
vascular instability. Risks include electrolyte and fluid voluminous diarrhea, without appreciable adverse effects
losses, abdominal pain, vomiting, and aspiration. (Protocol 40.6; Figures 40.11 and 40.12). Veterinary-
specific fecal management systems have recently become
Retention Enema available that are designed specifically for this use, with
Retention enemas introduce substances such as lactulose an open-ended distal tip rather than a side-hole, which
that are not absorbed by the colon; hence, they are retained urinary catheters have (Fecal Management System, MILA
in the colon and may encourage water movement into the International, Florence, KY).
colon by osmosis. This method is most commonly used for Rectal Foley catheters are also used in human medi-
treatment of hepatic encephalopathy. Lactulose reduces cine to remove some rectal foreign bodies, such as bottles
absorption of ammonia from the colon by lowering colonic or jars [79]. Feeding the balloon past the foreign body
pH and by osmotic catharsis [72]. and injecting some air through the catheter disrupts
The most common technique is to instill 5–10 ml/kg of a the vacuum created around the foreign body. The balloon
30% lactulose solution into the colon, leave for 20–30 min- can then be used to pull the foreign body out of the
utes and then flush out using warm water. A routine enema rectum.
(such as that described for constipation) may also suffice
for treatment of hepatic encephalopathy.
Rectal Catheters
Box 40.5 Rectal Tube Placement
Recumbent patients with liquid diarrhea pose many nurs-
Indications
ing challenges in terms of cleanliness, contamination of
the environment, and wound infection. Each institution ● Recumbent patients with large-volume diarrhea
has their own technique of keeping patients and bedding ● Post-operative patients with liquid stool that are at
clean, including absorbent products, skin barrier creams, high risk of infection from fecal contamination
and frequent washing of the rear end. It remains difficult,
though, to keep the area clean and to prevent contamina- Contraindications
tion of surgical wounds. These patients also inevitably
● Rectal bleeding or compromised rectal/colonic mucosa
develop perineal dermatitis and ulceration due to fecal
● Patients with bleeding disorders
scalding and frequent, abrasive cleaning.
● Patients with formed stool
In human medicine, rectal catheters or rectal tubes are
● Use beyond 48 hours
used to collect feces over a short-term period [73]. These
DicsNl NshDsDta 535
Protocol 40.6 Rectal Tube Placement

1) Perform a digital rectal examination in the patient to 6) Attach the catheter to a closed collection system,
ensure there is no obstruction or frank blood suggest- such as a urinary closed collection system. Tape the
ing lack of rectal mucosal integrity. catheter and collection system to the tail or hindlimb
2) Choose a large bore Foley catheter, for example of the animal to reduce traction on the catheter
24–32 Fr for a medium-sized dog. (Figures 40.11 and 40.12).
3) Inflate the balloon with saline to ensure integrity. No 7) The bag should be emptied intermittently, and the
more than 10–20 ml should be used to inflate the eliminated volume recorded to monitor fluid balance.
balloon, depending on the size of the catheter. As a 8) If the catheter becomes repeatedly blocked with
guide, the balloon should be no wider than slightly solid fecal material, or it repeatedly comes out of the
larger than the anus in the dog. For instance, this patient, it should be removed. If the catheter is not
would be 3–4 cm in a medium sized dog. The goal is draining fecal material adequately, then colonic dis-
not to prevent the tube coming out but rather to tension will stimulate defecation and therefore the
encourage liquid material to flow down the tube catheter is no longer suitable.
rather than around it. 9) The balloon should be deflated, repositioned, and
4) Lubricate the catheter and gently insert into the rec- reinflated every 6–12 hours to avoid pressure necro-
tum so that the tip lies several centimeters beyond the sis of the rectal wall.
anal sphincter. 10) The catheter should be removed if bleeding becomes
5) Slowly inflate the balloon to the predetermined vol- evident.
ume, watching the animal for signs of discomfort. Stop Note: Be aware that if the balloon is residing in the
inflating the balloon if the patient shows signs of dis- colon, it is possible to palpate the balloon externally
tress, as this may indicate over-distension or trauma of within the colon, which may be mistaken for a mass
the rectal wall. or foreign body.
Figure 40.11 A rectal Foley catheter placed in a dog in dorsal

recumbency to prevent fecal contamination of the perineal area
with liquid feces. The collection tubing has been taped and Figure 40.12 A rectal Foley catheter placed in a dog with
bandaged (green) to the dog’s tail to prevent the catheter watery diarrhea to facilitate cleanliness and estimate fluid
migrating out of the anus. The dog also has an indwelling losses. The catheter has been secured to the limb due to lack of
urethral catheter (white). availability of a tail. Source: Courtesy of Claire Sharp.
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41
Postoperative Peritoneal Drainage Techniques

Margo Mehl
There are numerous indications for abdominal drainage, organ entrapment and strangulation. A detailed description
some of which include peritonitis, uroperitoneum, increased of the surgical technique for performing open abdominal
abdominal pressure, and peritoneal dialysis. The type of drainage is outside the scope of this chapter but has been
peritoneal drainage chosen by the overseeing clinician described in several surgical textbooks [1–3].
depends on the primary disease process. The techniques After the abdominal wall is loosely closed, a sterile non-
for postoperative peritoneal drainage discussed in this adherent dressing is applied over the incision. The second
chapter include maintaining an open abdomen, vacuum- layer (Figure 41.1b) is a thicker and more absorbent sterile
assisted peritoneal drainage, closed-suction abdominal layer, and the third layer is usually one or more sterile tow-
drains, and intermittent drainage using a percutaneous els. The bandage is then secured in place with a stretchy
catheter. Several types of passive drains, such as Penrose bandage material that wraps around the patient’s body.
drains or dialysis catheters, have been described for use There are many good material choices for the external
in abdominal drainage. These passive drains rely on grav- bandage layers, some of which include 3M Vetrap®, cling
ity and are less effective and associated with higher compli- gauze, and elastic adhesive tape, such as Elastikon®
cation rates compared with other abdominal drainage (Johnson & Johnson). Additionally, per the clinician’s
techniques. I do not recommend their use for abdominal request, a water barrier layer (Figure 41.1c) may be incor-
drainage. porated into the bandage layers before the final layer is
placed (Figure 41.1d). The bandage should extend far
enough cranially and caudally to ensure coverage of the
Open Abdominal Drainage incision even in the case of bandage migration. The abdom-
inal bandage should be changed once or twice a day
The underlying cause of contamination must be determined depending on fluid production and strikethrough of the
and controlled, the abdominal cavity copiously lavaged, and bandage. The patient with open peritoneal drainage does
then open peritoneal drainage techniques can be used [1]. In not require an increased level of analgesics. Certainly, most
all patients with open abdominal drainage, it is ideal to have patients managed with open peritoneal drainage have sig-
an indwelling urinary catheter to prevent urine soiling the nificant systemic disease and have recently undergone a
abdominal bandages and to allow for the measurement of laparotomy; these conditions are indications for pain medi-
urine output (Chapter 35). The technique for open abdomi- cations, but the technique of leaving the abdominal wall
nal drainage involves leaving a gap in the midline abdominal slightly open does not increase the patient’s level of pain.
wall closure. This is accomplished by loosely suturing the
ventral rectus sheath in close proximity while not pulling
Changing the Abdominal Bandages
the suture tight. The span of the gap in the midline abdomi-
nal closure depends on patient size and generally ranges In a patient with open abdominal drainage, the bandages
from 1 to 4 cm (Figure 41.1a). This space or gap in the should be monitored for strikethrough and changed once or
abdominal wall closure allows for fluid to drain easily out of twice in 24 hours. The bandages should be weighed before
the peritoneal cavity. Ideally, the suture chosen is monofila- and after removal to estimate continuing fluid loss, which
ment and suture bites are close together to prevent bowel or should be considered when calculating a patient’s fluid
540 Postoperative Peritoneal Drainage Techniques
(a) (b)
(c) (d)
Figure 41.1 (a) Open abdominal drainage. Note the gap in the midline abdominal wall closure. This is accomplished by loosely
suturing the ventral rectus sheath in close proximity. The span of the gap in the midline abdominal closure generally in the range
1–4 cm. A sterile, nonadherent dressing is applied over the open incision (not shown). (b) The second layer, a thicker and more absorbent
sterile layer (laparotomy pads) is applied. To secure the pads, sutures are preplaced along the full length on both sides of the incision.
The pads are held in place with umbilical tape tied through the stay sutures. (c) An infant diaper is used as a water barrier layer and is
incorporated into the bandage layers before the final layer is placed. (d) An elastic bandage wrap is applied as the final layer.
requirement. When weighing the bandages and converting recumbency. Each layer is carefully removed, and then the
weight into volume, the bandages should first be weighed midline incision is visually evaluated to make sure no
prior to placement and then when removed the bandages bowel loop or intra-abdominal structure is outside the peri-
should be reweighed. The weight of the wet bandages toneal cavity. Then the bandage is replaced in the same
minus the weight of the dry bandage will give you the fluid order as previously described: (i) sterile nonadherent band-
weight, though some volume may be lost by evaporation if age material over the incision; (ii) sterile, thicker more
the bandage is not waterproof. One gram of fluid is equiva- absorbent layer; (iii) sterile surgery towels; and (iv) outer
lent to 1 ml in volume, and this quantity should be recorded nonsterile layers including gauze and dry cast padding and
as a fluid loss in the patient’s daily record. Changing the elastic tape to secure the bandage around the patient. Some
bandages involves the following steps (Protocol 41.1). clinicians advocate including a water-impermeable barrier
First, the patient often requires sedation, the choice of in the bandage (potty training pads or infant diapers),
which depends on its cardiovascular status. Second, any which would decrease contamination wicking from the
person handling the bandages should perform hand exterior into the peritoneal cavity. Ideally, the bandage is
hygiene, wear sterile gloves, and use aseptic technique. The changed before strikethrough occurs; however, if the
patient may have the bandage changed either while in a situation arises in which the bandage cannot be changed
standing position with support or while in dorsal or lateral that often, then a water-impermeable barrier incorporated
Active Closed-Suction Drains 541
Protocol 41.1 Open Abdominal Drainage: Changing the Bandages

Items Required 4) Carefully remove bandages and weigh them.
5) Visually evaluate midline incision to make sure no
● Sterile gloves
bowel loop or intra-abdominal structure is outside
● Sterile nonadherent bandage material
the peritoneal cavity.
● Sterile absorbent layer
6) Place sterile nonadherent bandage material over the
● Sterile surgery towels
incision.
● Outer nonsterile gauze (dry cast padding)
7) Place second layer of sterile, thicker, absorbent band-
● Elastic tape
age material such as laparotomy pads.
● Optional: water-impermeable barrier in the external layers
8) Place sterile surgery towels.
of bandage (drapes, potty training pads, or infant diapers)
9) Incorporate water impermeable layer as needed.
Procedure 10) Use outer nonsterile layers to secure bandage to the
patient using stay sutures and umbilical tape as a tie-
1) Sedate and position the patient.
over bandage, followed by a water-resistant layer if
desired.
3) Don sterile gloves using aseptic technique.
into the bandaging layers will assist in preventing outer gap in closure is covered with a foam sponge connected to
contamination wicking from the environment into the fenestrated evacuation tubing and covered with an adhe-
patient’s peritoneal cavity. sive draping material. The evacuation tubing is connected
When the volume of fluid produced within the abdomi- to a vacuum pump to provide continuous negative pres-
nal cavity has significantly decreased and the cytologic sure. Bandage changes or changing the foam is typically
characteristics of that fluid indicate the abdominal cavity is done every 24–48 hours, which is less frequently than that
free of infection (i.e. non-degenerate neutrophils, lack of with open abdominal drainage. After peritoneal drainage
intracellular bacteria), the overseeing clinician will recom- is complete, the patient requires general anesthesia for
mend closure of the abdominal wall. removal of the vacuum-assisted drainage system and
The patient undergoes an anesthetic procedure for clo- abdominal wall closure. As with open abdominal drain-
sure of the abdominal incision. At the time of closure, I age techniques, we recommend re-exploring the abdo-
recommend re-exploring the abdominal cavity, copiously men at the time of closing the abdominal cavity and
lavaging the abdominal cavity, and obtaining aerobic and obtaining cultures. Complications with this technique are
anaerobic cultures. similar to those seen with open abdominal drainage,
Complications of open abdominal drainage predomi- including hypoproteinemia and bacterial peritonitis [6].
nantly include hospital-acquired infections and loss of
plasma proteins [4, 5]. The risk of hospital-acquired infec-
tions can be reduced if aseptic techniques are always insti- Active Closed-Suction Drains
tuted for bandage changes and during abdominal wall
closure. The clinician should expect loss of plasma proteins The use of closed-suction drains allows the clinician to
such as albumin that maintain oncotic pressure; fluid ther- close the abdominal cavity and may be associated with
apy that supports oncotic pressure should be used as needed. less protein loss than open abdominal drainage. Closed-
Additionally, patients with continuing protein loss may ben- suction drains may still be associated with hospital-
efit from enteral feeding and thus may have an esophageal acquired infections, although potentially to a lesser
or nasogastric feeding tube in place (Chapter 44). degree than with open peritoneal drainage [7]. The dis-
advantage of the closed-suction drainage technique is it
does not allow the clinician to re-explore or re-evaluate
Vacuum-Assisted Drainage the abdominal cavity. Closed-suction drains permit
measurement of fluid production from the peritoneal
The technique of vacuum-assisted peritoneal drainage cavity and also allow for cytologic evaluation. The pres-
begins in a similar manner to the open peritoneal drain- ence of a drain in a body cavity will stimulate fluid pro-
age, in which after the abdominal cavity is explored, a duction; therefore, waiting for cessation of fluid
portion of the linea alba is closed with a 1–6 cm gap production before drain removal is unnecessary. The
between the edges. The region of the linea alba with the time at which to remove the abdominal drains is guided
by when the cytology demonstrates the abdominal cavity

is free of infection and when the fluid production has
decreased to less than 2.2–5 ml/kg/day [8, 9].
A number of closed-suction drains are available. All these
drains aim to increase the surface area for drainage and
reduce the incidence of drain obstruction by omentum,
other tissue, or cellular debris. Closed-suction drains can be
placed in a closed manner (see later), but I advocate placing
the drains surgically. Placing the drains surgically allows for
evaluation of the abdominal cavity and treatment of the pri-
mary disease. Also, closed placement of abdominal drains
can cause damage to intra-abdominal organs. After the
abdominal cavity has been explored and the cause of con-
tamination controlled, the drains are placed away from the Figure 41.3 Jackson-Pratt drains, a closed drainage system,
midline incision, either laterally or cranial or caudal to the used in a cat following abdominal surgery.
incision. The drains should never exit through the midline
abdominal incision. The size of the drain and the number of
sterile bandage and an abdominal bandage to reduce hospi-
drains placed is determined by the weight of the patient. I
tal contamination.
advocate using one to two drains in a cat or small dog
(< 10 kg) and two to four drains in larger patients. Once the
drains are placed and exiting through the abdominal cavity, Managing Closed-Suction Drains
they are secured with an anchoring suture and a finger trap
The vacuum created by the reservoir does not pull as
pattern (Figure 41.2) up the tubing of the drain, not so tight
effectively once the drain reservoir expands with fluid.
as to occlude the drain. Once the abdominal cavity is closed,
Therefore, it is recommended to empty the drain reservoir
the drain tubing should be attached to a vacuum-assisted
when it is full two-thirds or more. Wear examination
chamber that has an anti-reflux valve, to collect fluid and
gloves when handling the drains. The reservoir bulb is
reduce the risk of ascending infection (Figure 41.3). In the
disconnected from the drain tubing, and both openings/
absence of a commercial product, an active drainage system
surfaces are wiped with isopropyl alcohol prior to collect-
can be constructed by connecting the intra-abdominal drain
ing or emptying fluid. All fluid collected is measured and
to an extension set with a needle attached, or a butterfly
cytology is performed every 24–48 hours. The drain exit
needle, which is then inserted into a large vacuum blood
sites from the abdominal cavity should be evaluated for
collection tube to generate negative drain pressure. This
infection or fluid accumulation and addressed as indi-
technique is further described elsewhere [10]. Once drains
cated. These drain exit sites should also be cleaned daily
are secured in place, the drain exit holes are covered with a
with an antimicrobial scrub, wiped with sterile saline,
and rebandaged with new clean dressings (Protocol 41.2).
As previously stated, all drains incite production of some
amount of fluid; therefore, the drains are removed when
the patient’s clinical status improves, the fluid production
decreases to an acceptable level, and the cytology of the
collected fluid shows no evidence of infection. The patient
does not often require additional analgesics for drain
removal. The drains are gently pulled from the abdominal
cavity and the exit holes are evaluated; if no evidence of
infection is seen, the holes can be covered with a sterile
dressing and allowed to heal by second intention.
Percutaneous Catheter Drainage
Figure 41.2 Once the drains are placed and exiting through

Abdominal drainage can be achieved by percutaneous
the abdominal cavity, they are secured with an anchoring suture drain placement. This technique can be used to assist with
pattern, such as a finger trap pattern. abdominal fluid collection, rapid decompression of large
Conclusion 543
Protocol 41.2 Closed-Suction Drain Management

Items Required 4) Disconnect the reservoir bulb from drain tubing and
wipe both openings with isopropyl alcohol prior to
● Closed-suction drain (Jackson-Pratt) in place
emptying or collecting fluid.
5) Measure all fluid collected; cytology may be performed.
● Alcohol-soaked gauze pad
6) Evaluate drain exit sites from the abdominal cav-
● Laboratory specimen tubes and culturette (optional)
ity; notify clinician of excessive redness, heat,
● Graduated cylinder
swelling, apparent pain, or discharge from inser-
● Surgical scrub
tion site(s).
● Sterile saline
7) Clean drain exit sites daily with an antimicrobial scrub,
● Materials for light dressing
wipe with sterile saline, and keep bandaged with light,
Procedure clean dressings.
8) When closed suction drains are no longer needed,
1) Gather materials.
drains can be removed by gently pulling drain tubing
2) Empty drain reservoir when the bulb is no more than
from the abdominal cavity.
two-thirds full.
9) Once drains are removed, evaluate exit holes and
3) Perform hand hygiene and don examination gloves
apply dressings as needed.
prior to handling the drains.
abdominal effusions, or to stabilize a patient prior to surgi- mini-laparotomy technique requires strict asepsis, and a
cal intervention such as in the case of a uroabdomen. small incision is made on the ventral midline. Through the
Peritoneal dialysis catheters can also be placed in this man- skin incision the linea alba is accessed, and a stab incision is
ner. This therapy is described in Chapter 36. Percutaneous made through a tented portion of the linea alba. The cathe-
catheter drainage is not indicated for treatment of septic ter is introduced through a separate skin opening and associ-
peritonitis because continuing contamination of the abdo- ated subcutaneous tunnel and then passed into the
men would not be controlled. There are a number of cath- previously made stab incision through the linea alba. The
eters available on the market that could be placed in a small midline approach incision is closed, and then the skin
closed manner or via a mini laparotomy. A fenestrated incision is closed in a routine manner. The catheter is
catheter is likely to be more effective than a non-fenestrated secured with a pursestring suture and finger trap suture pat-
catheter because it is less likely to become occluded by tern, making sure it is not occluding the catheter lumen.
omentum or other tissue. There are commercially available Lastly, a sterile dressing is applied over the catheter exit site.
fenestrated catheters (Cook peritoneal dialysis catheters),
or alternatively a regular over-the-needle catheter or red
rubber tube can be fenestrated for this purpose. It is essen- Managing a Fenestrated Catheter
tial to be very careful when manually fenestrating these
The management of a percutaneously placed catheter is
catheters to avoid weakening the integrity of the catheter
similar to those techniques previously described.
and to maintain sterility. Fenestrations are made with a
Intermittent or continuous drainage can be used. The per-
scalpel blade and should be staggered and each hole less
son handling the catheter should always wear examination
than the diameter of the catheter.
gloves and use aseptic techniques. Wipe the opening to the
A closed method of placement can be used with any over-
catheter with isopropyl alcohol before aspirating and use
the-needle type catheter, and local anesthetic can be infused
sterile syringes and tubing.
into the site prior to placement. The catheter is placed
through the abdominal wall, with careful technique to avoid
damage to intra-abdominal structures. The site of placement Conclusion
is best identified with ultrasound guidance. In the absence
of ultrasound, the catheter is usually placed caudal to the Managing peritoneal drainage is a key step in treating
umbilicus in an effort to minimize the chance of puncturing patients with abdominal disease. Effective nursing care
the liver or spleen. A mini-laparotomy technique can also be with abdominal drainage techniques will maximize the
used for placement of catheters, and it allows use of cathe- therapeutic benefits of abdominal drainage and minimize
ters without a trocar, such as a red rubber tube. The complications.
References
1 Slater, D.H. (ed.) (2003). Textbook of Small Animal Surgery, peritoneal drainage for the treatment of septic peritonitis
3e. Philadelphia, PA: Saunders. in dogs and cats: 8 cases (2003–2010). J. Vet. Emerg. Crit.
2 Fossum, T.W. (ed.) (2019). Small Animal Surgery, 5e. Care 22 (5): 601–609.
Philadelphia, PA: Elsevier. 7 Mueller, M.G., Ludwig, L.L., and Barton, L.J. (2001). Use
3 Johnston, S.A. and Tobias, K.M. (ed.) (2018). Veterinary of closed-suction drains to treat generalized peritonitis in
Surgery: Small animal expert consult, 2e. Philadelphia, PA: dogs and cats: 40 cases (1997–1999). J. Am. Vet. Med. Assoc.
Elsevier Saunders. 6: 789–794.
4 Staatz, A.J., Monnet, E., and Seim, H.B. III (2002). Open 8 Miller, C.W. (2003). Bandages and drains. In: Textbook of
peritoneal drainage versus primary closure for the Small Animal Surgery, 3e, vol. 1 (ed. D.H. Slater),
treatment of septic peritonitis in dogs and cats: 42 cases 244–249. Philadelphia, PA: WB Saunders.
(1993–1999). Vet. Surg. 31: 174–180. 9 Fossum, T.W. (2007). Surgery of the lower respiratory
5 Parsons, K.J., Owen, L.J., Lee, K. et al. (2009). system: pleural cavity and diaphragm. In: Small Animal
A retrospective study of surgically treated cases of septic Surgery, 3e (ed. T.W. Fossum), 901. St. Louis, MO: Mosby.
peritonitis in the cat (2000–2007). J. Small Anim. Pract. 10 O’Dwyer, L. (ed.) (2007). Wound Management in Small
50: 518–524. Animals: A practical guide for veterinary nurses and
6 Cioffi, K.M., Schmiedt, C.W., Cornell, K.K., and Radlinsky, technicians. Philadelphia, PA: Elsevier
M.G. (2012). Retrospective evaluation of vacuum-assisted Butterworth-Heinemann.
545
Section Five
Nutrition
547
42
Nutritional Requirements in Critical Illness

Daniel L. Chan
asic Physiology of Malnutrition

B state of refractory or irreversible shock characterized by
in Critical Illness severe lactic acidosis, decreased tissue perfusion, multiple
organ failure, and death. Nutritional intervention during
Appropriate nutritional support has long been considered the ebb phase is associated with a high risk for complica-
essential for the recovery of critically ill people. Although tions such as electrolyte abnormalities, which may result in
there is convincing evidence of the deleterious effects of further detrimental effects to some critically ill ani-
malnutrition in people, the optimal nutritional strategies mals [4–7]. Following successful resuscitation, patients
for critically ill animals remain largely unknown. Despite enter the flow phase, during which profound metabolic
the lack of definitive answers, recommendations for nutri- alterations occur. Increases in energy expenditure, glucose
tional support of critically ill animals are based on having a production, insulin and glucagon concentrations, cardiac
good understanding about the disease processes involved output, and profound protein catabolism are the hallmarks
and the limited information available. The fact that there is of this response [1, 4, 8]. Provision of nutritional support
limited information available should not discourage the during this stage of illness can attenuate and sometimes
implementation of nutritional support for critically ill ani- reverse the detrimental effects of malnutrition [9].
mals. In fact, with proper patient selection, sound nutri- One of the major metabolic alterations associated with
tional planning, and careful monitoring, nutritional critical illness involves body protein catabolism, in which
support can be an integral part in the successful recovery of protein turnover rates may become markedly elevated.
many critically ill animals. Whereas healthy animals primarily lose fat when deprived
The metabolic responses to illness or severe injury are of sufficient calories (simple starvation), sick or trauma-
complex and place critically ill animals at high risk for mal- tized patients catabolize lean body mass when they are not
nutrition and its deleterious effects. These effects, which provided with sufficient calories (stressed starvation) [8, 9].
are likely to have a negative impact on overall survival, During the initial stages of fasting in the healthy state, gly-
include alterations in energy and substrate metabolism, cogen stores are used as the primary source of energy.
compromised immune function, and impaired wound Within days, a metabolic shift occurs toward the preferen-
healing [1–3]. Although generalizations tend to oversim- tial use of fat deposits, sparing catabolic effects on lean
plify these complex systems, the concept of “ebb and flow” muscle tissue.
offers a basic description of the metabolic response to criti- In diseased states, the inflammatory response triggers
cal illness or severe injury. According to this model, there is alterations in cytokines and hormone concentrations,
an initial hypometabolic response (“ebb phase”), followed which rapidly shift metabolism toward a catabolic state.
by a period of a more prolonged course of hypermetabo- Glycogen stores are quickly depleted, especially in strict
lism (“flow phase”). The ebb phase refers to a period of carnivores such as the cat, and this leads to an early mobi-
hemodynamic instability associated with decreased energy lization of amino acids from muscle stores. Because cats
expenditure, hypothermia, mild protein catabolism, undergo continuous gluconeogenesis, the mobilization of
decreased cardiac output, and poor tissue perfusion. amino acids from muscles is more pronounced than that
Without intervention, this instability may progress to a observed in other species. In both cats and dogs, continued
548 Nutritional Requirements in Critical Illness
inadequate food intake leads to further changes in urgent when a dog or cat has not eaten for more than five
metabolism where the predominant energy source is days because by this time there are detectable changes in
derived from accelerated proteolysis, which in itself is an metabolism and immune function directly related to the
energy-consuming process. Muscle catabolism that occurs prolonged period of poor food intake [15, 16].
during stress provides the liver with glucogenic precursors However, even in patients with severe malnutrition, the
and other amino acids for glucose and acute-phase protein immediate therapy of critically ill patients should focus on
production [8, 9]. The resultant negative nitrogen balance resuscitation, stabilization, and identification of the pri-
or net protein loss has been documented in critically ill mary disease process. As steps are made to address the pri-
dogs and cats [10, 11]. One study in particular estimated mary disease, formulation of a nutritional plan should
that 73% of hospitalized dogs across four different veteri- strive to prevent (or correct) overt nutritional deficiencies
nary referral centers were deemed to be in a negative and imbalances. By providing adequate energy substrates,
energy balance [12]. A more recent study documented that protein, essential fatty acids, and micronutrients, the body
84% of hospitalized dogs in a veterinary teaching hospital can support wound healing, immune function, and tissue
consumed less that 25% of their daily resting energy repair. A major goal of nutritional support is to minimize
requirements (RER) [13]. The consequences of continued metabolic derangements and catabolism of lean body tis-
lean body mass losses include negative effects on wound sue. During hospitalization, repletion of body weight is not
healing, immune function, strength (both skeletal and res- the top priority because regaining body weight is best
piratory), and ultimately on overall prognosis [9, 13, 14]. achieved once the animal has recovered from the primary
It is becoming increasingly evident that the metabolic disease. Therefore, there is little justification to feed exces-
consequences of critical illness are part of an integrated sive calories to critically ill animals.
response to the initial insult, driven in part by cytokines
and counterregulatory hormones [6, 8]. These mediators
may result in changes in energy expenditure, substrate Nutritional Assessment
metabolism, and body composition. The most well-known
cytokine to affect metabolism is perhaps tumor necrosis The formal assessment of patients in terms of their nutri-
factor-α, which is responsible for increased energy expend- tional needs and what precautions need to be considered in
iture, hepatic gluconeogenesis, protein breakdown, activa- formulating a plan is referred to as “nutritional assess-
tion of the hypothalamic–pituitary–adrenal axis, lipolysis, ment.” Because all nutritional support techniques carry
and peripheral insulin resistance [6]. some risk of complications, appropriate patient selection is
Owing to the metabolic alterations associated with criti- crucial in ensuring the full benefits of nutritional support.
cal illness, and in part to an inability or reluctance of many Careful patient selection is the first step in performing
critically ill dogs and cats to ingest sufficient calories, this nutritional assessment. This subjective clinical assessment
patient population is at increased risk for rapid develop- process remains the predominant method of identifying
ment of malnutrition. Given the serious sequelae of mal- malnourished patients that require immediate nutritional
nutrition, preservation of lean body mass or reversal of support as well as identifying patients that are not cur-
deteriorating nutritional status via nutritional support is rently malnourished but where nutritional support is
paramount. aimed at preventing the development of malnutri-
tion [17–19]. The next step in nutritional assessment
involves assessing how urgently nutritional support is
ationale for Providing Nutrition
R required. This involves consideration of various risk factors
in Critical Illness for developing malnutrition including periods with inade-
quate food intake, unintended weight loss, loss of body
Identification of overt malnutrition in animals can be chal- condition, evidence of muscle wasting, presence of gastro-
lenging because there are no established criteria of malnu- intestinal dysfunction, hypoalbuminemia, and estimation
trition in companion animals. In dogs, a period as short as of when the patient may recover [18, 19]. Table 42.1 out-
three days of anorexia has been documented to produce lines a nutritional assessment scheme to help to identify
metabolic changes consistent with starvation in peo- patients in need of immediate nutritional support.
ple [15]. In cats, detectable impairment of immune func- Nutritional assessment also allows identification of fac-
tion can be demonstrated in healthy individuals subjected tors that can have an impact on the nutritional plan, such
to acute starvation by day four, and therefore, nutritional as electrolyte abnormalities, hyperglycemia, hypertriglyc-
support should be also considered in any ill cat with inad- eridemia, hyperammonemia, or comorbid illnesses (e.g.
equate food intake for more than three days [16]. The need kidney or liver disease) that should lead to alterations of
to implement a nutritional intervention becomes more the composition of the diet used. In summary, nutritional
Nutritional Requirements 549
Table 42.1 Process for identifying patients in need of urgent reasonable to consider a similar approach in companion
nutritional support animals receiving mechanical ventilation. Patients with
severe laryngeal or esophageal dysfunction could be fed via
Risk gastrostomy or enteric feeding tubes. On the basis of the
nutritional assessment, the anticipated duration of nutri-
Parameter Low Moderate High
tional support, and the appropriate route of delivery (i.e.
Food intake:
enteral or parenteral), a nutritional plan is formulated to
meet the patient’s nutritional needs.
< 80% RER for < 3 days ✓
The first steps of instituting nutritional support include
< 80% RER for 3–5 days ✓
achieving hemodynamic stability, restoring proper hydra-
< 80% RER for > 5 days ✓ tion status, and correction of electrolyte or acid–base dis-
Presence of weight loss ✓ turbances [18]. Beginning nutritional support before these
Severe vomiting/diarrhea ✓ abnormalities are addressed can increase the risk of com-
Body condition score < 4/9 ✓ plications (e.g. regurgitation, vomiting, hypotension) and,
Muscle condition score of ✓ in some cases, further compromise the patient [4–7]. For
moderate to severe example, feeding leads to mesenteric vasodilation, which
Hypoalbuminemia ✓ could compromise systematic mean arterial pressure in
Expected course of illness: some patients. It should be emphasized that this strategy is
< 3 days ✓
not counter to the concept of “early nutritional support,”
which has been documented to result in positive effects in
2–3 days ✓
several animal and human studies [20–24]. Early nutri-
> 3 days ✓
tional support advocates feeding as soon as possible after
A patient with two or more high-risk factors should receive achieving hemodynamic stability rather than delaying
nutritional support as soon as they are stabilized. Patients with fewer nutritional intervention for several days [21, 22].
than two high-risk factors should be closely monitored and
Implementation of the nutritional plan should be gradual,
reassessed every few days.
with the goal of reaching target level of nutrient delivery in
48–72 hours.
assessment involves performing a risk assessment of a Rapid feeding has several potential complications. First,
patient in terms of its nutritional status and the considera- animals that have not eaten for several days have signifi-
tions required in providing safe and effective nutritional cant delays in gastric emptying and compromised overall
support. intestinal motility. In some patients, this situation leads to
significant ileus. Feeding these patients rapidly leads to
abdominal pain, distension, and potentially vomiting and
Nutritional Plan regurgitation. Second, because of various hormonal distur-
bances associated with poor food intake (e.g. low insulin,
The key to successful nutritional management of critically high glucagon, high cortisol), there is a potential for severe
ill patients lies in the proper diagnosis and treatment of the metabolic derangements such as refeeding syndrome
underlying disease. Another crucial factor is the selection whereby a sudden spike in insulin concentrations leads to
of the appropriate route for nutritional support. Providing life-threatening electrolyte abnormalities.
nutrition via a functional digestive system is the preferred
route of feeding, and so particular care should be taken to
evaluate whether the patient can tolerate enteral feedings. Nutritional Requirements
Even if the patient can only tolerate small amounts of
enteral nutrition, this route of feeding should be pursued Whereas the protein requirements of critically ill people
and supplemented with parenteral nutrition as necessary to have been determined based on nitrogen balance studies,
meet the patient’s nutritional needs. In some circumstances this information is not readily available in critically ill ani-
feeding patients enterally may seem to be contraindicated mals. One method of estimating the extent of amino acid
(e.g. animal anesthetized for mechanical ventilation, ani- catabolism is to measure urinary urea nitrogen content.
mals with upper airway dysfunction); however, there is a Although measurement of urinary urea nitrogen in criti-
strong argument that in such a situation there should be cally ill dogs has been shown to be a feasible tool in assess-
some consideration for feeding enterally as long as the coming nitrogen balance in an experimental setting, further
promised area is avoided. Ventilated human patients are studies are warranted to better characterize the protein
commonly fed via nasogastric tubes, and it would be requirements of critically ill animals seen in practice
[10, 11]. A study [25] demonstrated significant changes in growth would necessitate the actual measurement of the
amino acid status in critically ill dogs; however, further patient’s total energy expenditure. However, precise meas-
studies are required to determine whether correction of urements of energy expenditure (i.e. calorimetry) in clinical
these amino acid changes is beneficial. veterinary patients are still in the developmental phases.
Currently, it is generally accepted that hospitalized dogs The basic premise of calorimetry is to measure the total
should be supported with 4–6 g protein/100 kcal (15–25% of heat lost by an animal, as a reflection of total energy pro-
total energy requirements); cats are usually supported with duced by metabolism. With direct calorimetry, the animal is
6–8 g protein/100 kcal (25–35% of total energy require- placed in an airtight insulated chamber, and precise ther-
ments) [26]. Patients with protein intolerance (e.g. hepatic mal measurements are made of the chamber. This method
encephalopathy, severe azotemia) should receive reduced is only suitable for experimental models because clinical
amounts of protein. Similarly, patients with hyperglycemia cases would not be able to be managed in this environment.
or hyperlipidemia may require decreased amounts of these Indirect calorimetry, in contrast, is more commonly used in
nutrients. Other nutritional requirements depend on the human hospitals and by veterinary clinical researchers to
patient’s underlying disease, clinical signs, and laboratory extrapolate energy requirements. This method provides
parameters. relatively noninvasive means of estimating energy expendi-
When an animal is unable to synthesize adequate ture by measuring the rate of oxygen consumption and the
amounts of a nutrient and must rely on dietary sources, rate of carbon dioxide production and applying the obtained
that nutrient is qualified as essential. However, during cer- values to a mathematical equation known as the Weir for-
tain conditions including critical illness, nutrients usually mula [34, 35]. Because consumption of oxygen and produc-
considered nonessential become in short supply due to tion of carbon dioxide can directly be related to glucose,
increased demands. These nutrients have been termed con- protein, and fat metabolism, energy expenditure can be cal-
ditionally essential, and glutamine is one such example. A culated from the measured variables. However, indirect
number of recent human studies have evaluated the modu- calorimetry also requires specialized equipment, so-called
lation of disease with these so-called immuno-modulating metabolic carts, making the technique available only in a
nutrients such as glutamine, arginine, omega-3 fatty acids, few select sites. Oxygen and carbon dioxide exchange is
and nucleotides [7, 10, 27–31]. Although study results have measured with a hood, canopy, or expiratory collection
been mixed, glutamine supplementation has been associ- device. These systems are portable and easier to use in clini-
ated with the most beneficial results [7, 27, 28, 30–32]. cal situations than previous calorimetry units where the
Glutamine is the primary energy source for enterocytes patient needed to be confined within the device. A few stud-
and cells of the immune system, and its supplementation ies have used indirect calorimetry to estimate energy
may attenuate gastrointestinal permeability and improve expenditure in select populations of clinical veterinary
overall immune function [28–31]. In select populations of patients, but the use of mathematical formulas currently
critically ill people, supplementation with either enteral or remains the most practical means of estimating a patient’s
parenteral glutamine has been shown to reduce infectious energy requirement (Box 42.1) [35, 36].
complications and improve survival [30, 31]. Studies in Results of indirect calorimetry studies in dogs support the
dogs and cats have failed to demonstrate clear benefits of recent trend of formulating nutritional support to meet
glutamine supplementation [32, 33]. Nevertheless, it is RER as a starting point, rather than more generous illness
increasingly evident that the requirements of specific energy requirements, which require multiplying resting
nutrients during critical illness may be considerably differ- or even maintenance energy requirements by an illness
ent than those in health. Future studies are warranted to
evaluate whether “critical care diets” designed for dogs and
cats should be enriched with these conditionally essential
nutrients. Box 42.1 Estimating Total Daily Energy
Requirements in Dogs and Cats
Calculation of Nutritional Requirements 0.75
RER kcal / day 70 current body weight inkg
Ideally, nutritional support should provide ample substrates For animals weighing 2–20 kg, the following linear
for gluconeogenesis, protein synthesis, and adenosine formula may be used as an estimate:
triphosphate (ATP) production necessary to maintain
homeostasis. Ensuring that enough calories are being pro- RER kcal / day 30 current body weight inkg 70
vided to sustain critical physiologic processes such as
RER, resting energy requirement.
immune function, wound repair, and cell division and
Commlications oo rooiiinng Nutrition in tte Criticallly Ill 551
factor [37]. RER is defined as the number of calories increased amino acid oxidation [39, 41]. In light of lim-
required for maintaining homeostasis at rest in a thermon- ited clinical data, current recommendations are to start
eutral environment while the animal is in a postabsorptive nutritional support as soon as it is deemed safe and ini-
state [38, 39]. Although several formulas are proposed to tially target RER, and then to continually reassess the
calculate the RER, a widely used allometric formula can be patient as energy requirements are likely to exceed three
applied to both dogs and cats of all weights. For animals times the RER. The goal of aggressive nutritional support
weighing between 2 and 20 kg, there is also a linear formula is to optimize protein synthesis and preserve lean body
that provides reasonable estimation of RER (Box 42.1). mass. Feeding at least 6–8 g protein/100 kcal (25–35% of
Until recently, it was recommended to multiply the RER total energy) may be necessary, even in dogs. It is
by an illness factor between 1.0 and 2.0 to yield an illness unknown whether nutrients such as glutamine and argi-
energy requirement to account for increases in metabolism nine would provide extra benefits in this patient
associated with different diseases and injuries. However, population.
less emphasis is now being placed on such subjective and
extrapolated factors, and the current recommendation is to
Tetanus
use more conservative energy estimates (i.e. start with the
animal’s RER) to avoid overfeeding. Overfeeding can result Another population that may merit more vigilant attention
in metabolic and gastrointestinal complications, hepatic to energy requirements is dogs with tetanus. A recent study
dysfunction, and increased carbon dioxide production [4, 7]. demonstrated that despite feeding a median of 1.4 times
It should be emphasized that these general guidelines RER, dogs lost a median of 5% body weight during the
should be used as starting points, and animals receiving course of hospitalization [42]. It is proposed that increased
nutritional support should be closely monitored for toler- muscle activity in this disorder increased energy require-
ance of nutritional interventions (see the section on comments despite the fact that dogs were mostly recumbent.
plications of providing nutrition in the critically ill).
Continual decline in body weight or body condition should
Sepsis
prompt the clinician to reassess and perhaps modify the
nutritional plan (e.g. increasing the number of calories Animals with sepsis are perhaps another population in
provided by 25%). which nutritional requirements may be altered. The
intense inflammatory response, coupled with changes in
substrate handling, likely alters the metabolic rate and
utritional Requirements
N nutrient requirements. Experimental data in dogs suggest
in Special Cases that during the early phase of sepsis, energy expenditure
may increase by 25%, which appears to be accompanied by
Much remains unclear regarding the nutritional require- an increase in oxidation of free fatty acids and triglycer-
ments of critically ill animals in general. In certain circum- ides [43]. However, it is also recognized that energy
stances assumptions are made that nutritional requirements expenditure can be quite variable in sepsis and may even
in animals are similar to people afflicted with similar dis- decrease in septic shock [44]. Depending on the etiology of
eases. However, it is important to recognize that there may sepsis (e.g. septic peritonitis, pyothorax), protein require-
be significant species and disease differences that make ments may also dramatically increase, and therefore gen-
direct comparisons or extrapolations less applicable. For eral nutritional recommendations for animals with septic
example, pancreatitis in people is often related to gallstones peritonitis may involve initially feeding at RER with 35% of
or alcoholism. Because pancreatitis in animals is often total calories derived from protein, 40% from fats, and 25%
related to high-fat diets or is idiopathic, the nutritional from carbohydrates [26]. Further studies are warranted to
requirements for treatment of this disease in each species determine whether these recommendations are optimal for
are likely different. clinical veterinary patients with sepsis.
Burns omplications of Providing Nutrition

C
Experimental data suggest dramatic changes in energy in the Critically Ill
requirements in animals with thermal burns; however,
there is a paucity of clinical data in animals in this Body weights should be monitored daily in critically ill
regard [40]. In experimental models, dogs with thermal animals. However, the clinician should consider fluid
burns experienced increased energy requirements, accel- shifts in evaluating changes in body weight. For this rea-
erated gluconeogenesis, glucose oxidation, lipolysis, and son, assessing body condition scores is very important.
The use of the RER as the patient’s caloric requirement is composition of the parenteral nutrition solution
merely a starting point; however, there is growing evi- (hyperglycemia, electrolyte shifts, hyperammonemia,
dence that this conservative approach or even feeding less and hypertriglyceridemia). Avoiding serious conse-
than RER may be preferable in the critically ill patient [45]. quences of complications associated with parenteral
The number of calories provided may need to be increased nutrition requires early identification of problems and
to keep up with the patient’s changing needs, typically by prompt action. Frequent monitoring of vital signs, cath-
25% if well tolerated. In patients unable to tolerate the eter exit sites, and routine biochemistry panels may alert
prescribed amounts (e.g. start to vomit), the clinician the clinician to developing problems. The evolution of
should consider reducing volumes of enteral feedings and persistent hyperglycemia during nutritional support may
supplementing the nutritional plan with some form of require adjustment to the nutritional plan (e.g. decreas-
parenteral nutrition. ing dextrose content in parenteral nutrition) or adminis-
Possible complications of enteral nutrition include tration of regular insulin. This obviously necessitates
mechanical complications such as clogging of the feeding more vigilant monitoring.
tube or premature tube removal by the patient. Metabolic With continual reassessment, the clinician can deter-
complications of enteral or parenteral feeding include elec- mine when to transition the patient from assisted feeding
trolyte disturbances, hyperglycemia, fluid overload, and to voluntary consumption of food. The discontinuation
gastrointestinal signs (e.g. vomiting, diarrhea, cramping, of nutritional support should only begin when the patient
bloating). can consume approximately its RER without much
In rare instances, a condition known as refeeding syn- coaxing.
drome may develop [46, 47]. This syndrome occurs when
severely malnourished patients (particularly cats) are fed
perhaps too aggressively, and the sudden increase in insu- Summary
lin concentrations results in severe hypophosphatemia and
hypokalemia [46]. During prolonged fasting, cells become ● Nutritional support of the critically ill patient is an
metabolic inactive, and sudden reintroduction of sub- essential part of the overall treatment plan.
strates leads to rapid synthesis of ATP, leading to consump- ● Metabolic responses to illness or severe injury place criti-
tion of phosphate, which causes severe hypophosphatemia. cally ill patients at high risk for development of
Other electrolytes such as potassium and magnesium also malnutrition.
translocate intracellularly in response to insulin [46]. More ● Consequences of malnutrition include altered substrate
recently, the development of hyperglycemia has also been metabolism, compromised immune function, impaired
documented in cats with refeeding syndrome, though the wound healing, and potentially increased mortality.
mechanism of glucose dysregulation remains ● Energy expenditure in critically ill animals may vary
unknown [47]. Recommendations for reducing the risk for considerably depending on the patient, underlying dis-
the developing refeeding syndrome include gradually ease, and illness severity; therefore, initial nutritional
introducing feeding, limiting the proportion of calories support should target RER.
derived from carbohydrates, and preemptively supple- ● Specific nutritional requirements for critically ill dogs
menting patients with phosphorus, potassium, magne- and cats have not been determined, but recommended
sium, and thiamine [46, 47]. levels of protein provision include feeding 4–8 g pro-
In critically ill patients receiving enteral nutritional sup- tein/100 kcal or 15–35% of total calories derived from
port, the clinician must also be vigilant for the develop- protein.
ment of aspiration pneumonia. Monitoring parameters ● Before implementation of nutritional support, patients
recommended for patients receiving enteral nutrition must be cardiovascularly stable and have hydration,
include daily checks of body weight, serum electrolytes, acid–base, and electrolyte abnormalities addressed first.
feeding tube patency, the appearance of the feeding tube ● Monitoring of patients receiving nutritional support is
stoma site, gastrointestinal signs (e.g. vomiting, regurgita- extremely important because this population is prone to
tion, diarrhea), and signs of volume overload or aspiration various metabolic complications.
pneumonia. ● Upon reassessment, nutritional support may be
Possible complications associated with parenteral increased, decreased, or discontinued depending on
nutrition include sepsis (such as seen with catheter infec- patient response and disease progression.
tions, contamination of the parenteral solution bag), ● With appropriate patient selection, accurate nutritional
mechanical complications associated with the catheter assessment, and careful execution of the nutritional
and lines (obstructed catheters, line breakage), thrombo- plan, nutrition can play an instrumental role in the suc-
phlebitis, and metabolic disturbances related to the cessful recovery of many critically ill patients.
Reoerences 553
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555
43
Enteral Diets for Critically Ill Patients

Sally C. Perea
When selecting an enteral diet, there are several factors to overestimation of true energy needs in hospitalized patients
consider, including route of delivery, nutritional status, and may lead to complications associated with
and underlying disease. Because veterinary specific enteral overfeeding [2].
formulas are limited, other options such as blended canned
slurries, home-cooked formulations, and enteral products
designed for people can be used to help tailor the diet to the Protein
patient’s individual needs. Like energy needs, protein needs in critically ill patients
should be focused on minimizing muscle catabolism and
maintaining lean body mass. A healthy animal under condi-
utrient Considerations for Critical
N tions of starvation adapts by decreasing muscle breakdown
Care Diets and converting to the use of fatty acids and ketones for
energy. However, in critically ill patients, muscle catabolism
Energy is not appropriately downregulated, and elevations in endog-
enous corticosteroids, catecholamines, and inflammatory
One of the primary goals of nutrition support in critically
cytokines promote a hypercatabolic state [3]. In critically ill
ill patients is to provide energy to limit the loss of lean body
dogs, urinary nitrogen excretion has been shown to be two to
mass and to sustain critical physiologic processes such as
six times the obligatory nitrogen excretion reported in
immune function and wound healing. Because individual
healthy dogs, demonstrating the significant protein catabo-
energy needs vary, the most accurate method of determin-
lism occurring in these patients [4]. Furthermore, the amino
ing energy expenditure in hospitalized patients is by indi-
acids generated from muscle breakdown are primarily used
rect calorimetry [1]. However, indirect calorimetry is costly
for gluconeogenesis and production of acute-phase proteins,
and unavailable in most veterinary hospitals; therefore,
whereas synthesis of other selected proteins (such as albu-
calculated requirements remain the most practical tool to
min, transferrin, prealbumin, retinol-binding protein, and
estimate energy needs. During hospitalization, patients’
fibronectin) is decreased [5].
energy needs are estimated to be equivalent to their calcu-
Common adult maintenance dog and cat foods provide
lated resting energy requirement (RER). Multiple RER
20–25% and 30–35% protein on a metabolizable energy (ME)
equations have been recommended, but exponential equa-
basis, respectively. For the critical care patient, a protein
tions (which estimate the patient’s metabolically active
level on the higher end of this range is commonly recom-
body mass from its body weight in kg) are the most accu-
mended; however, the appropriate level of dietary protein
rate, such as:
also depends on individual patient’s needs and underlying
0.75 disease. For example, animals with advanced kidney disease
RER 70 body weight in kg or hepatic encephalopathy should be provided with reduced
protein levels, whereas growing animals and patients with
The use of illness energy factors is no longer recommended, significant protein losses (e.g., patients suffering from burns)
as multiplying RER by these factors generally results in may require increased protein levels.
556 Enteral Diets for Critically Ill Patients
Fat Amino Acids

Foods designed for critically ill patients are commonly high Many critical care foods are enriched with select amino
in fat content to help increase energy density. Because acids, such as branched chain amino acids, arginine, and
some patients have difficulty tolerating food volumes when glutamine. The branched chain amino acids valine, leu-
initiating enteral feeding, increased fat and energy density cine, and isoleucine are metabolized by skeletal muscle,
can help to reduce the required daily volume. whereas other amino acids are metabolized by the
Typical adult maintenance dog and cat dry foods range liver [15]. For this reason, some foods designed for criti-
from 20% to 35% fat ME, while critical care enteral foods cally ill patients are supplemented with branched chain
range typically from 40% to 58% fat ME. Animals that have amino acids to supply energy for lean body tissue and help
been without food for more than three days are using pri- maintain lean body mass. Additionally, recent studies have
marily endogenous fat for energy, making the transition to demonstrated benefits of branched chain amino acids to
a higher fat food a fairly smooth transition for most protect against ischemia/reperfusion injury [16, 17]. One
patients. Because of the high fat content of many critical study in critically ill dogs showed that concentrations of
care diets, caution should be used when refeeding a patient branched chain amino acids were significantly higher in
with a condition associated with fat intolerance, such as survivors compared with nonsurvivors [18]. Similarly, the
hyperlipidemia, pancreatitis, or lymphangiectasia. For ratio of branched chain amino acids to aromatic amino
patients such as these, a lower fat enteral diet, canned food acids was also significantly higher in surviving dogs. This
slurry, or home-cooked diet slurry may be required. study supports the nutritional philosophy of supplement-
ing with branched chain amino acids in critically ill
patients; however, no studies have been conducted to date
Carbohydrates
evaluating the efficacy of supplementation and its impact
Dietary carbohydrates help to provide needed energy and on patient outcome in dogs or cats.
spare the use of protein for gluconeogenesis. Carbohydrates Because branched chain amino acids are not metabolized
also help to reduce the proportion of calories coming from in the liver, they also have a theoretical benefit in patients
fat, which can be helpful in patients with fat intolerance. with liver disease and hepatic encephalopathy. Like in criti-
However, carbohydrates are not a required nutrient, and cally ill dogs, it is known that the ratio of plasma branched
for some patients, a lower carbohydrate diet may provide chain amino acids to aromatic amino acids is decreased with
some benefits. Patients experiencing hyperglycemia are declining liver function [19]. However, although branched
some in which limiting dietary carbohydrates may be help- chain amino acids have many theoretical benefits, studies
ful. Increased risk of mortality has been associated with evaluating their use in dogs with hepatic encephalopathy
hyperglycemia in human, canine, and feline critically ill have failed to demonstrate measurable benefits [20].
patients [6–10]. Although hyperglycemia is more com- Glutamine is another amino acid commonly incorpo-
monly seen as a metabolic complication in patients receiv- rated into critical care diets. Glutamine is preferentially
ing parenteral nutrition, hyperglycemia has been reported used by enterocytes as an energy source, and it may help to
in a feline patient with pancreatitis following implementa- promote the health of the small intestine and reduce the
tion of enteral nutrition [11]. risk of bacterial translocation. In addition, glutamine is
Hyperglycemia in critically ill cats is also commonly seen also used as a fuel source by immune cells and may aid in
prior to nutritional intervention; therefore, careful moni- improving the patient’s immune response. Despite the
toring and adjustment of treatment protocols is recom- numerous theoretical benefits of glutamine supplementa-
mended as nutrition support is implemented in these tion, clinical studies evaluating its impact on outcome have
patients. Critically ill cats have been shown to have signifi- reported mixed results.
cantly higher glucose, lactate, cortisol, glucagon, and nor- Studies evaluating the use of glutamine-supplemented
epinephrine concentrations, and significantly lower enteral diets in veterinary patients are limited. One study
insulin concentrations, when compared with controls [12]. evaluating a glutamine-enriched enteral diet for cats with
These findings are consistent with those from human stud- experimentally induced gastrointestinal disease did not
ies, showing higher concentrations of counterregulatory find a significant clinical benefit [21]. Another experimen-
hormones and insulin resistance in critically ill patients [13, tal study evaluating radiation injury in dogs also failed to
14]. Further research in this area is needed to determine show a benefit of glutamine supplementation [22].
the most appropriate management strategies for hypergly- Studies in experimental animals have demonstrated that
cemic veterinary patients. However, maintaining tighter glutamine supplementation helps to maintain mucosal
glycemic control in patients receiving nutritional support barrier function, but other studies evaluating hospitalized
may help to improve patient outcome. surgery and trauma patients have failed to demonstrate a
Enteral Diets 557
benefit on outcome [23–25]. Human studies evaluating rare, and many human formulations are “semi-elemental,”
free glutamine versus glutamine-rich protein supplemen- containing hydrolyzed proteins, di- and tripeptides, disac-
tation have shown that feeding glutamine from complete charides, oligosaccharides, and/or dextrin. Elemental diets
protein sources is more efficacious in increasing mucosal have the advantage of requiring little to no digestion, which
glutamine concentrations [26]. Further studies are needed is ideal for patients with severe gastrointestinal disease,
to determine how to use glutamine most effectively in short bowel syndrome, or those being fed at the level of the
enteral diets for critical care veterinary patients [27]. jejunum. The potential disadvantage of elemental formula-
Arginine is another amino acid that may provide benefits tions is that some may have a higher osmolality when com-
in critically ill patients [27–29]. Arginine is an essential pared with polymeric formulations.
amino acid for dogs and cats but is not normally essential Studies in human patients with pancreatitis receiving
in people. In recent years, arginine has gained attention in jejunal enteral nutrition have shown that both polymeric
human medicine as “conditionally essential” during peri- and semi-elemental formulations are well tolerated; how-
ods of stress, due to its important roles in wound healing, ever, some advantages were seen with semi-elemental for-
immune function, and nitric oxide synthesis [30]. Studies mulations including reduced length of hospital stay and
in people and rodents have demonstrated that arginine- less marked weight loss [34]. Currently available liquid
supplemented enteral support can help to improve wound canine and feline enteral foods are limited to polymeric for-
healing, decrease length of hospital stay, and change mulations (Table 43.1).
cytokine expression from a pro- to an anti-inflammatory Although the selection of liquid enteral foods designed
profile [31, 32]. Arginine supplementation has not been for dogs and cats is limited, those available generally meet
evaluated in veterinary critical care patients, but studies the needs of most hospitalized patients. For those patients
showing lower plasma arginine levels in critically ill dogs that may require semi-elemental or hydrolyzed ingredi-
and dogs with early chronic valvular disease suggest that ents, a human liquid diet or enteral formulation may be
arginine supplementation may be beneficial [18, 33]. used. It should be noted that human liquid products often
contain vitamins and minerals but are not necessarily com-
plete and balanced to meet the nutrient needs of dogs and
Other Nutrients
cats. This is especially true in cats, in which protein and
Like supplemental amino acids, many of the other amino acid supplementation is generally required to meet
enhanced nutrients in critical care diets have theoretical protein and essential amino acid needs. For these more
benefits but have not been evaluated in critically ill dogs or challenging cases, consultation with a board-certified vet-
cats. Antioxidants may benefit by counteracting the gener- erinary nutritionist should be considered.
ation of free radicals associated with inflammation or rep-
erfusion injury. Increased levels of long-chain omega-3
polyunsaturated fatty acids can aid in modulating inflam- Canned Enteral Diets
matory reactions associated with underlying inflammatory Canned foods for critical care veterinary patients are designed
processes. Finally, the addition of prebiotics, such as fer- to be highly digestible, energy dense, and provide a moderate
mentable fibers and oligopolysaccharides, may be benefi- to high protein content. Diets may be enriched with addi-
cial in critically ill animals with a compromised tional nutrients such as antioxidants, specific amino acids
gastrointestinal tract by promoting production of short- (arginine, glutamine, branched chain amino acids), omega-3
chain fatty acids and energy for colonocytes. fatty acids, prebiotics, and soluble or insoluble fibers. These
canned diets are also designed with a smooth consistency
that facilitates syringe feeding through a feeding tube. These
Enteral Diets products can generally be delivered through a 12–14Fr feed-
ing tube without additional water dilution; however, they
Liquid Enteral Diets may need to be slightly warmed and mixed well to facilitate
Liquid enteral diets are required when feeding through a delivery. Current commercially available canned enteral
nasoesophageal or jejunostomy feeding tube. Liquid foods for dogs and cats are outlined in Table 43.1.
enteral diets can be categorized as polymeric or elemental
formulations. Polymeric formulations are composed of
Blended Commercial Diet Slurries
proteins, carbohydrates, and fats in a high molecular
weight form. Technically, a true “elemental” formulation Blended commercial dry (presoaked) or canned foods can
would be comprised of free amino acids, monosaccharides, be used when feeding through an esophagostomy or gas-
and fatty acids; however, true elemental formulations are trostomy tube. Food provision through feeding tubes is
Table 43.1 Veterinary canned and liquid enteral foodsa.
Caloric distribution Energy density Ca P Na K
Veterinary Foods Protein (%) Fat (%) Carb. (%) kcal/g g/Mcal
Canned
Hill’s Prescription Diet® 33 55 12 1.2 2.6 2.4 1.8 2.4
a/d® (canine/feline)
Royal Canin Recovery® 38 58 4 1.6 3.2 2.7 3.0 2.3
ultra-soft mousse
(canine/feline)
Liquid
Royal Canin Recovery 32 48 20 0.9 2.3 1.8 1.0 2.3
Liquid(canine/feline)
Royal Canin Low Fat™ 35 19 46 0.9 2.3 2.0 1.1 2.4
Liquid (canine)
Royal Canin Renal 13 41 46 1.3 1.4 0.9 1.0 1.6
Support Liquid (canine)
Royal Canin Renal 26 50 24 0.9 1.3 0.8 0.9 1.8
Support Liquid (feline)
Ca, calcium; Carb., carbohydrate; K, potassium; kcal, kilocalories; Mcal, megacalories (1000 kcal); Na, sodium; P, phosphorus.
a
Nutrient and caloric composition of products as of March 2021.
discussed in detail in Chapter 44. The use of blended

slurries helps immensely to expand the dietary options and
allows the diet to be more easily tailored to the pet’s spe-
cific dietary needs. Canned foods are used the most com-
monly, but dry food can also be used if presoaked in water
to allow softening for blending. To achieve the highest pos-
sible energy density, it is recommended to add water slowly
to the slurry while blending until a smooth consistency
that can be delivered through the tube is achieved
(Figures 43.1–43.3). The amount of water required to
achieve a consistency for delivery through a 12 or 14 Fr
feeding tube will range from diet to diet depending on the
ingredient composition. Typical water amounts are
8–15 ml/oz canned diet for canine formulas, and 5–10 ml/
oz canned food for feline formulas. Once an appropriate
consistency has been achieved, the energy density and
moisture level of the slurry can be determined and feeding
volumes can be calculated (Box 43.1).
Home-Cooked Diet Blended Slurries

Figure 43.1 Blended food slurries can be used for
Home-cooked (or hospital-prepared) blended slurry for- esophagostomy and gastrostomy enteral feedings. Slowly add
water to the canned food and blend mixture for four to five
mulations can be helpful when commercially available
minutes until a smooth texture is achieved.
products do not meet patient needs (Figure 43.4). Dietary
fat intolerance is one of the most common complications
that leads to the need for a home-cooked formulation. formulations are designed to be simple and require mini-
Highly digestible/low fat, uncommon ingredient/low fat, mal preparation in a hospital setting.
and renal disease/low fat canine and feline formulations When preparing these slurries, the water should be
are outlined in Tables 43.2–43.7. The ingredients in these slowly added to the mixture during the blending step,
Enteral Diets 559
Figure 43.2 Once the slurry has been adequately blended,

measure the final slurry volume for energy density calculations. Figure 43.3 Test the final slurry to ensure that it can be easily
For blenders that do not provide volume designations, volume delivered through the appropriate feeding tube size.
guidelines can be premeasured and marked on the side of the
blender using known volumes of water.
Box 43.1 Enteral Feeding Worksheet

Step 1: Calculate patient’s resting energy requirement Day 2 = 50% × 587 ml = 294 ml
Day 3 = 75% × 587 ml = 440 ml
Resting energy requirement (RER) kcal/day = 70 × body
Day 4 = 100% × 587 ml = 587 ml
weight (kg)0.75
Example Step 4: Calculate water contribution from blended slurry
10 kg adult dog:
RER = 70 × 100.75 = 393 kcals/day Moisture of canned food (%) × g/can = water from
food (ml)
Step 2: Calculate energy density of blended slurry Water from food (ml) + water added to slurry (ml) =
total water volume (ml)
Energy per can food (kcal)/final slurry volume (ml) = kcal/ml Total water volume (ml)/slurry volume (ml) = moisture
Example of final slurry (%)
Veterinary intestinal formula 400 kcal/can ml daily slurry × moisture of final slurry (%) = total
Added 200 ml water to reach desired consistency water delivered daily (ml)
Total volume of final slurry (canned food + water) = Example
600 ml slurry Veterinary intestinal formula = 78% moisture; 396 g/can
400 kcal/600 ml = 0.67kcal/ml 0.78 × 396 = 309 ml water from food
309 ml water from food + 200 ml water added = 509 ml
Step 3: Calculate feeding daily volume total water
RER (kcal/day)/energy density of slurry (kcal/ml) = ml 509 ml water/600 ml total slurry = 84.8% moisture
slurry/day 587ml daily slurry × 0.848 = 498 ml total water deliver daily
Day 1 = 25–33% × total ml slurry/day = total day 1
volume (ml) Step 5: Calculate additional water needs
Patient’s water requirement (ml) minus water deliv-
volume (ml)
ered from blended slurry (ml) = additional water
needed daily (ml)
volume (ml)
Day 4 = 100% × total ml slurry/day = total day 4 Example
volume (ml) Patient’s water requirement = 132 ml × 10.75 = 742 ml
742 ml water – 498 ml from slurry = 244 ml additional
Example
water needed
393 kcal/day/0.67kcal/ml = 587ml/day
Day 1 = 25% × 587 ml = 147 ml
Figure 43.4 Highly digestible low-fat

ingredients can be used to create low-fat
recipes, and supplemental ingredients can be
used to improve energy density of the diet.
Table 43.2 Feline low-fat recipea. Table 43.3 Feline low-fat uncommon ingredient recipea.
Quantity Common Measures Ingredient Quantity Common Measures
Hormelb canned chicken breast 142 1 can (not Bumble Beeb canned 120 1 × 6-oz can, drained
in water, no salt added (g) drained) white crab meat (g)
White rice, long grain, 118.5 ¾ cup Betty Crockerc mashed 23 ⅓ cup dry amount
regular, cooked (g) potato buds, dried potato mixed with equal
Canola oil (g) 3.4 ¾ teaspoon flakes (g) parts hot water
Nordic Naturalsc pet cod 1.2 ¼ teaspoon Canola oil (g) 3.4 ¾ teaspoon
liver oil (g) Balance ITd feline (g) 2.9 1 red scoop
Balance ITd feline (g) 4.9 1 red and Water (ml) 80
7 white scoops
Total recipe kcal 211
Water (ml) 150
Total slurry volume (ml) 280
Total slurry moisture (%) 82
Energy density of slurry 0.75
Total slurry moisture (%) 82 (kcal/ml)
Energy density of slurry 0.83 Caloric distribution (g):
(kcal/ml)
Protein (% ME) 45.9
Caloric distribution (g):
Fat (% ME) 18.5
Protein (% ME) 37.4
Carbohydrate 35.6
Fat (% ME) 20.6
kcal, kilocalories; ME = metabolizable energy; oz, ounces.
Carbohydrate (% ME) 42.0 a
Guidelines developed by Dr. Sally Perea, Mason, OH.
b
kcal, kilocalories; ME, metabolizable energy. Bumble Bee Foods, LLC, San Diego, CA.
c
a
Guidelines developed by Dr. Sally Perea, Mason, OH. General Mills, Inc., Minneapolis, MN.
d
b
Hormel Foods Corporation, Austin, MN. Davis Veterinary Medical Consulting, Inc., Woodland, CA.
c
Nordic Naturals, Inc., Watsonville, CA.
d
Davis Veterinary Medical Consulting, Inc., Woodland, CA.
as adding all of the water at the beginning step can result in recommended for the home-cooked formulations (minimum
a soupy blend, leaving fragments of rice or other ingredi- of five minutes). Allowing ample time for blending helps
ents that are not well blended. A slightly longer blending ensure that the ingredients are broken down and smoothly
time than required for the canned food slurries is also distributed throughout the mixture.
Table 43.4 Feline low-fat renal recipea. Table 43.6 Canine low-fat uncommon ingredient recipea.
Ingredient Quantity Common Measures Ingredient Quantity Common Measures
Hormelb canned chicken breast 71 ½ can (not Bumble Beeb canned 120 1 × 6-oz can,
in water, no salt added (g) drained) crab meat (g) drained
White rice, long grain, regular, 118.5 ¾ cup Betty Crockerc potato 52 ¾ cup dry amount
cooked (g) buds (dried potatoes) (g) mixed with equal
Canola oil (g) 3.4 ¾ teaspoon parts hot water
c
Nordic Naturals pet cod liver 1.2 ¼ teaspoon Canola oil (g) 4.5 1 teaspoon
oil (g) Balance ITd canine (g) 3.75 1½ teaspoons
Balance ITd feline-K (g) 3.9 1 yellow and Water (ml) 150
1 white scoop Total recipe kcal 324
Water (ml) 170 Total slurry volume (ml) 460
Total recipe (kcal) 262 Total slurry moisture (%) 83
Total slurry volume (ml) 315 Energy density of slurry 0.70
Total slurry moisture (%) 83 (kcal/ml)
Energy density of slurry 0.83 Caloric distribution (g):
(kcal/ml) Protein (% ME) 32.0
Caloric distribution (g): Fat (% ME) 15.5
Protein (% ME) 25.9 Carbohydrate 52.5
Fat (% ME) 21.2
Carbohydrate 52.9 a
b
kcal, kilocalories; ME, metabolizable energy. Bumble Bee Foods, LLC, San Diego, CA.
c
a
Guidelines developed by Dr. Sally Perea, Mason, OH. General Mills, Inc., Minneapolis, MN.
d
b
Hormel Foods Corporation, Austin, MN. Davis Veterinary Medical Consulting, Inc., Woodland, CA.
c
d
Davis Veterinary Medical Consulting, Inc., Woodland, CA. Table 43.7 Canine low-fat renal recipea.
Table 43.5 Canine low-fat recipea. Ingredient Quantity Common Measures
Hormelb canned chicken breast 71 ½ can (not

Ingredient Quantity Common Measures in water, no salt added (g) drained)
White rice, long grain, regular, 237 1½ cups
Cottage cheese, 2% milk fat (g) 339 1½ cups
cooked (g)
White rice, long grain, regular, 158 1 cup
Light corn syrup (g) 66 3 tablespoons
cooked (g)
Corn oil (g) 6.8 1½ teaspoons
Light corn syrup (g) 88 4 tablespoons
c
Nordic Naturals pet cod liver 2.5 ½ teaspoon
Corn oil (g) 4.5 1 teaspoon
oil (g)
Nordic Naturalsb pet cod liver 1.2 ¼ teaspoon
Balance ITd canine-K (g) 6.5 1 blue and
oil (g)
8 white scoops
Balance ITc canine (g) 10.6 4¼ teaspoons
Water (ml) 250
Water (ml) 20
Total recipe (kcal) 808
Energy density of slurry (kcal/ 1.15
Energy density of slurry 1.54 ml)
(kcal/ml)
Protein (% ME) 12.6
Protein (% ME) 26.6
Fat (% ME) 14.0
Fat (% ME) 13.9
Carbohydrate 73.3
Carbohydrate 59.5
kcal, kilocalories; ME, metabolizable energy. a
a
Guidelines developed by Dr. Sally Perea, Mason, OH. b
Hormel Foods Corporation, Austin, MN.
b
Nordic Naturals, Inc., Watsonville, CA. c
c
Davis Veterinary Medical Consulting, Inc., Woodland, CA. d
Davis Veterinary Medical Consulting, Inc., Woodland, CA.
Preparation Instructions for Blended Slurries onsiderations for Specific

C
Measure out the ingredient and add to a blender. Add one Underlying Conditions
quarter of the estimated water volume and begin to blend
the mixture, adding an additional quarter of estimated water When providing assisted enteral feeding to patients with
every 30 seconds until the full volume has been added. Blend underlying conditions, the nutrient modifications and
the mixture for an additional four to five minutes and test recommendations mirror those of oral diets. Thus, efforts
the final slurry to ensure that it can easily be delivered should be made to select a food that first addresses the
through the appropriate feeding tube size. If needed, addi- patient’s underlying illness, and then consider how to pre-
tional water can be added to create a more dilute mixture for pare the food for enteral delivery.
easier delivery. If additional water is added, slurry energy
density and moisture content should be recalculated to Gastrointestinal Disease
reflect the new slurry volume. Unused slurry may be tightly
covered and stored in the refrigerator for a later feeding; Highly digestible diets are recommended for patients with
however, the slurry may require reblending and heating to underlying gastrointestinal diseases. There is a variety of
room temperature to regain a smooth and fluid consistency highly digestible veterinary diets available that serve as
prior to feeding. Slurry should be discarded after three days excellent choices for blended canned food slurries. These
to prevent spoilage. highly digestible foods generally provide moderate protein
and fat levels, also making them good choices when look-
Supplements ing for a more equally distributed caloric composition of
protein, fat, and carbohydrates compared with some of the
When using or adding human foods or supplemental ingre- critical care formulas.
dients, it is important to consider the impact on the overall
balance of the diet. When adding more than 10% of the
Adverse Reactions to Food
total calories from a supplemental ingredient to a commercial
food, additional nutrients such as vitamins and/or minerals For patients with adverse reactions to food such as food allergy
may be required to ensure that minimum nutrient require- dermatitis or inflammatory bowel disease, a hydrolyzed pro-
ments are met. For short-term in-hospital management tein or uncommon/limited ingredient canned food may be
(less than one to two weeks), adding additional vitamins used to create a blended slurry for esophagostomy or gastros-
and minerals to create a complete and balanced formula- tomy feedings. If the patient is currently being managed on an
tion may not be necessary. However, for patients that require uncommon ingredient food, then a canned food with the
long-term enteral nutrition support, consultation with a same ingredients or hydrolyzed protein source should be
board-certified veterinary nutritionist is recommended to selected. For patients recently diagnosed with food allergies,
ensure that the diet formulation is complete and balanced or with suspected food allergies, a food with ingredients that
for long-term feeding. the pet has not previously been exposed to should be selected.
Fat Supplements
Fat Intolerance
Oils can be added to solutions to increase fat and energy
density, as well as to provide specific fatty acids of interest. It should be noted that although canned diets designed for
Vegetable oils, such as corn and canola oil, can be used to intestinal disease and food allergies generally provide less
increase both total dietary fat and linoleic acid levels of the fat than those designed for critical care, many are still rela-
diet; fish oils can be used to provide long-chain omega-3 tively high in fat, especially when compared with their dry
polyunsaturated fatty acids. food equivalent. For patients with disease conditions
related to dietary fat, such as hyperlipidemia, pancreatitis,
Carbohydrate Supplements and lymphangiectasia, a lower fat formulation should be
Light corn syrup is an energy-dense, highly digestible car- selected. Patients with decreased gastrointestinal motility
bohydrate ingredient that can be added to formulations to and chylothorax may also benefit from a low-fat diet.
boost energy density without increasing the fat level. The While common commercial canned foods typically run
addition of light corn syrup can be very helpful to boost higher in fat, there are a limited number of low-fat canned
calories for canine formulations but is not recommended food options available that can be used in a blended slurry.
for feline formulations due to the fructose content. As an Low-fat home-cooked recipes provided in this chapter can
alternative, glucose or dextrose powders or solutions could also serve as low-fat dietary options when commercial
be used in cat formulations. options are unavailable.
Monitoring 563
Kidney Disease versus intermittent bolus feedings in dogs with gastrostomy

tubes showed no differences in weight maintenance, gas-
For patients with kidney disease, a canned kidney food can
trointestinal adverse effects, glucose tolerance, nitrogen
be used to create a blended slurry for esophagostomy and
balance, or feed digestibility [38]. Continuous infusions
gastrostomy feedings. If a liquid food is required, liquid
may be better tolerated for nasoesophageal feedings if
kidney canine and feline formulas are also commercially
large volumes of liquid formulas are required to meet
available. These liquid formulas may be fed alone or
daily energy needs, and they are recommended for jejunal
blended with the canned diet to help increase energy den-
feedings to help minimize malabsorption and diarrhea
sity of the blended slurry. Some human liquid diets, such as
associated with feeding large volumes of nutrients directly
Ensure® (Abbott Nutrition), are lower in protein but are
into the jejunum.
not phosphorus restricted, making them less than ideal for
When feeding via intermittent bolus, four or more feed-
longer-term management.
ings per day are generally required. The amount fed per
feeding should not exceed 5–10 ml/kg of body weight dur-
Liver Disease ing initial introduction of feedings [39]. Maximum gastric
capacities for dogs and cats are reported as high as
For patients with hepatic encephalopathy, a canned
45–90 ml/kg body weight [28]. However, meeting the
protein-restricted liver disease veterinary food can be
patient’s RER should be achievable at volumes far below
used to create a blended slurry for esophagostomy and
these maximum capacities. Feeding boluses should be
gastrostomy feedings. Although kidney failure canned
given slowly to allow for gastric expansion. Patients should
foods are also protein restricted, they may contain higher
be monitored for signs of nausea such as salivating, gulp-
inclusions of meat and organ-based protein sources com-
ing, or retching during the feeding. If any of these signs
pared with liver-disease diets, and these are not as ideal
develop, the feeding should be temporarily discontinued or
for patients with hepatic encephalopathy compared with
stopped. Further details and guidelines for enteral feeding
plant and dairy based proteins [35]. Care should there-
are provided in Chapter 44.
fore be taken when selecting a diet for hepatic encepha-
lopathy to ensure that both the protein level and source
are appropriate.
Monitoring
For liver disease patients that are not suffering from
hepatic encephalopathy, protein restriction is not neces-
Patients receiving enteral nutrition should be monitored
sary or recommended. A standard critical care diet or a
daily for potential complications and to ensure that the
highly digestible canned food blended slurry are both
nutritional plan is continuing to meet the patient’s needs.
acceptable options for these patients.
Daily physical examinations should include assessment
of body condition and measurement of body weight.
Because of the risk of aspiration and fluid overload, care
Initiating Nutritional Support should be taken to assess respiratory parameters, and
thoracic radiographs should be made if respiratory dis-
Patients should be slowly introduced to full energy needs, tress or fever develops. The stoma site of enteral feeding
starting at approximately 25–33% of RER, followed by tubes should be cleaned with dilute antiseptic (e.g. chlo-
25–33% increases every 12–24 hours until full RER is rhexidine or povidone-iodine) and carefully examined
reached [36, 37]. Patients that have been without food for daily for signs of infection (see Chapter 63 for more
an extended period of time are at increased risk of devel- information).
oping hyperglycemia or electrolyte abnormalities upon Serum potassium, magnesium, and phosphorus concen-
refeeding (i.e. hypokalemia, hypophosphatemia, and trations should be measured within 12–24 hours of start-
hypomagnesemia, as well as low thiamine) and may ing enteral nutrition. Daily monitoring of electrolytes
require a slower introduction and increased frequency of should be continued during the weaning on period, and
monitoring. Once full RER is reached, the patient may be no less than once every 48 hours once at goal rate of infu-
reassessed to determine whether increased caloric levels sion for critically ill hospitalized patients. A complete
are needed to maintain body weight. blood count and full serum biochemistry panel should be
Enteral formulas can be fed via continuous infusion or measured within 24 hours of instituting enteral nutrition.
via intermittent bolus feeding. Esophagostomy and gas- Continued monitoring of a complete blood count and
trostomy feedings are generally given by intermittent chemistry panel every two to three days is recommended
bolus feedings. One clinical study evaluating continuous for critically ill patients.
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567
44
Assisted Enteral Feeding

Avalene. W. K. Tan
Introduction may have demands exceeding this baseline [16, 17].

Gradually increasing enteral feeding in increments of 25%
Adequate nutritional intake is vital to support the immune RER daily, over four days is typical (Box 44.2). This chapter
system, for synthesis of important biological molecules, for focuses on techniques for assisted enteral feeding.
wound healing, and to maintain intestinal mucosa integ-
rity. As such, animals with decreased nutritional intake are
at a higher risk of infection, increased catabolic states, Enticing Voluntary Eating
wound dehiscence, and intestinal villous atrophy [1].
Uncertainty persists about the best method of nutritional Improving the palatability of the diet and/or offering a
support in critically ill patients. While there is insufficient variety of different foods are common first steps, in the
evidence to say that enteral nutrition alone is superior to hope that the animal will consume sufficient calories vol-
parenteral nutrition in improving mortality rates, enteral untarily. Force-feeding, including syringe feeding or plac-
nutrition is associated with reduced sepsis, and the combi- ing small boluses of food in the mouth, is discouraged, as
nation of both routes appears to be associated with reduced many animals find the procedure stressful. There is also a
mortality [2, 3]. Dogs with septic peritonitis that receive risk for food aspiration with force-feeding. This practice
enteral nutrition are more likely to survive than dogs may increase the risk of learned food aversions, making it
receiving parenteral nutrition alone [4]. Enteral nutrition challenging to feed the patient when it has recovered or to
remains the preferred route, as it is more physiologic than introduce therapeutic diets for disease states [18, 19]. A
parenteral nutrition and directly maintains gastrointestinal more strategic approach is to entice voluntary intake with a
motility, hormone secretion, and barrier function [5, 6]. single diet initially and to use supplemental assisted enteral
Human critical care guidelines suggest commencing and parenteral techniques as needed.
enteral over parenteral nutrition if there are no contraindi- There are many causes of anorexia, such as disease, nau-
cations (Box 44.1) [7, 8]. There are currently no formal vet- sea, pain, or stress, and addressing these causes may be suf-
erinary guidelines. Furthermore, there is growing support ficient to encourage partial voluntary intake (summarized
for early enteral nutrition in both human and veterinary in Figure 44.1) [20]. Medications are also a common cause
medicine alike [6–11]. While more high-quality studies are of anorexia, nausea, and vomiting and clinicians should
required, the current evidence does not suggest harm from take them into account when treating an anorexic dog or
early enteral feeding within 48–72 hours [7, 10, 12–14]. cat (Box 44.3).
Detailed nutritional assessment of critically ill patients is Improving diet palatability by modifying the moisture,
discussed in Chapter 42 and involves the use of historical fat, protein, sugar, or salt content may also be helpful [22].
and physical parameters. Checklists have also been pro- Feeding canned diets with 70–85% moisture, rather than
posed to help determine a patient’s requirement for nutri- dry diets with 7–10% moisture, increases food palatability.
tional support (Table 44.1) [1]. Resting energy requirement However, canned diets often contain higher protein and
(RER) is the recommended target for critical patients, but fat, which may be contraindicated in some patients. Dry
continuing reassessment is still required, as some patients kibble can be soaked to increase the moisture content.
568 Assisted Enteral Feeding
Box 44.1 Indications and Contraindications Box 44.2 Calculations and Steps for Enteral
for Enteral Feeding [1, 15] Feeding Plans
Indications
1) Calculate resting energy requirement (RER):
3 days of anorexia/withheld food (sooner for puppies,
RERin kcal / day 70 body weight in kilograms 0.75
●
kittens, and overweight cats)

● Inability to voluntarily consume food 2) Calculate energy density of diet:
● Low body condition score (dogs ≤ 3, Cats ≤ 4 on a
Energy density kcal / ml
9-point scale)
● Weight loss of ≥ 10% Total kcal diet
● Hypoalbuminemia Totalml diet water added
● Requirements for post-pyloric feeding
3) Calculate amount of feed per day:
Contraindications RER kcal / day
Amount to feed ml / day
● Prolonged recumbency Energy density kcal / ml
● Regurgitation
● Risks of aspiration (e.g. poor gag reflex, protracted Feeding plan Day 1 Day 2 Day 3 Day 4
vomiting)a
● Intolerance to enteral nutrition RER Option 1 1⁄³ ²⁄³ Full
● Risks of cardiovascular decompensation during seda- Option 2 ¼ ½ ¾ Full
tion/anesthesia
● Coagulopathy limiting tube placement 4) Calculate amount to feed per meal:
● Concerns for intra-cranial hypertensiona Volume / day
Amount per meal
● Facial traumaa Number of meals / day
● Ascitesb
Volume / day
● Infiltrative disease of gastric/abdominal wall# Constant rate infusion ml / hour
Hours of infusion
a
Nasoesophageal or nasogastric tube.
b
Percutaneous feeding tubes.
Increasing the fat content of the diet also improves palat-

Table 44.1 Assessment for need of nutritional support [1].
Source: Adapted from Chan 2020.
ability, and additionally improves the energy density, so
that less volume is required to meet caloric targets.
Parameter Low risk Moderate risk High risk
However, higher fat content is contraindicated in dogs
with pancreatitis and animals with impaired gastrointes-
Food intake <80% resting energy requirements tinal motility. Amino acid receptors are the most common
< 3 days ✓ taste receptors in cats and dogs, and these receptors are
3–5 days ✓
particularly responsive to amino acids l-proline and l-
cysteine [23, 24]. Increasing protein may therefore
> 3 days ✓
enhance palatability but may not be appropriate for ani-
Weight loss ✓
mals with hepatic encephalopathy or renal disease. Dogs
Severe vomiting/diarrhea ✓ show a preference for sugars, such as lactose, sucrose, and
Body condition score < 4/9 ✓ fructose, and adding sugars or syrups to foods can aug-
Muscle mass score < 2 ✓ ment food palatability [25, 26]. Cats lack sweet receptors
Hypoalbuminemia ✓ and are indifferent to sweetened foods [23, 27]. Any added
Expected course of illness sugar or syrup should not constitute more than 10% of the
< 3 days ✓ total calories to avoid the risk of creating an imbalance in
the balanced base diet [22]. Sweetened diets with rapidly
2–3 days ✓
digestible and absorbed carbohydrates should be avoided
> 3 days ✓
in diabetic patients, and artificial sweeteners, such as
Patients with ≥ 2 high risk factors should receive nutritional support xylitol, should be avoided due to risks of toxicosis.
as soon as they are stabilized. Salt receptors are absent in cats and dogs, but interest-
Patients with high risks factors should be monitored closely and
reassessed every few days.
ingly, the amino acid receptors are stimulated by high
Nasoesophageal and Nasogastric Tubes 569
concentrations of sodium chloride [23]. Salt may also

increase taste responses to sugars in dogs [24]. Therefore,
adding salt or using diets with a higher sodium content
may improve food palatability. However, caution is
required with patients suffering from renal disease, car-
diac disease, ascites, or hypertension [22].
Other factors, such as texture, “mouth feel,” and temper-
ature preference, are recognized but have not been studied
to the same degree as flavor preference in small animals.
Cats prefer foods near body temperature (101.5°F; 38.5°C)
and warming food can increase its olfactory stimulus [22].
The “mouth feel” of the food is also important for cats, and
they may reject foods with a powdery or greasy texture or a
different kibble shape [21].
If voluntary enteral intake is still not adequate, then
other means of increasing intake should be considered.
Appetite stimulants may be helpful as an adjunctive to
improve intake, but can have unpredictable efficacy, and
over-reliance on pharmacological stimulation may delay
the institution of assisted nutrition methods or addressing
of the underlying disease process. A list of appetite stimu-
lants currently used, and their potential adverse effects, is
provided in Table 44.2 [28–32]. Enteral nutrition with feed-
ing tube placement or use of parenteral methods should be
considered in the persistently hyporexic or anorexic patient
or individuals with severe illness.
Tube Route Selection
The indications, concerns, and contraindications for each

assisted enteral feeding tube route are shown in Table 44.3,
Figure 44.1 Considerations or options for addressing anorexia.
which can be used to determine which technique to
use [1, 33–35].
If the tube is likely to be required long term, polyure-
thane or silicone tubes should be selected in preference to
Box 44.3 Medications that May Cause Anorexia, the red polyvinyl chloride (PVC) tubes, because they do not
Nausea, and Vomiting in Dogs and Cats [21] become brittle or disintegrate in situ when exposed to
● Aminocaproic acid digestive juices [33]. The internal diameter of the polyure-
● Amoxicillin thane tubes is slightly larger than the silicone tubes of the
● Amoxicillin/clavulanate same French size, because they are stronger with thinner
● Cardiac glycosides walls. A French unit is equivalent to 0.33 mm and meas-
● Cephalexin ures the external diameter of the tube [33].
● Chloramphenicol
● Erythromycin
● Most chemotherapeutic agents Nasoesophageal and Nasogastric Tubes
● Most narcotic analgesics
● Nonsteroidal anti-inflammatory drugs Placement and Verification
● N-Acetylcysteine
Placement equipment and technique of nasoesophageal
● Tetracyclines
(NE) and nasogastric (NG) tubes are described in
● Trimethoprim/sulphadiazine
Protocol 44.1 and shown in Figure 44.2 [36]. NE and NG
● Tranexamic acid
tube types include weighted and non-weighted feeding
Table 44.2 Appetite stimulants [28–31].
Drug Dogs Cats Drug class Adverse effects
Diazepam ✓ Benzodiazepine Non-purposeful eating, sedation, worsening hepatic

Oxazepam encephalopathy, idiosyncratic hepatic necrosis
Flurazepam
Mirtazapine ✓ ✓ Tetracyclic antidepressant Sedation
Cyproheptadine ✓ ✓ Serotonin antagonist Hyperexcitability, aggression, vomiting
Antihistamine
Prednisolone ✓ ✓ Glucocorticoid Polyuria/polydipsia, impaired wound healing
Prednisone
Capromorelin ✓ ✓ Ghrelin-receptor agonist Vomiting, diarrhea, hypersalivation, hyperglycemia,
bradycardia and hypotension in cats
Nandrolone Anabolic steroid Uncommon
Megestrol acetate ✓ ✓ Synthetic progestin Polyuria/polydipsia, diabetes mellitus,
hepatotoxicity, adrenocortical suppression
Cannabidiol oil Cannabinoid receptors Sedation, hyperexcitability
Cyanocobalamin Vitamin
Table 44.3 Indications, concerns, and contraindications of feeding tubes [1, 33–35].
Type Indications Concerns Contraindications Time to use
NE/NG Short-term tube feeding (< 10 days). Unable to evaluate Vomiting, comatose/ Immediate
Functional nasal cavity, pharynx, gastric residual volumes laterally recumbent,
esophagus, stomach, and intestines. with NE tube; liquid respiratory disease, lack of
High anesthesia risk diets only due to tube gag reflex, facial trauma
size involving nose/nasal cavity
E Medium-term feeding Unable to evaluate Vomiting, respiratory Immediate
(1–20 weeks). Facial/oral trauma, gastric residual volumes; disease, megaesophagus
surgery, chronic illness, cancer anesthesia required esophageal stricture,
impaired wound healinga
G Long-term feeding (months to Cost; complications Anesthesia risk Wait 24 hours
years). Esophageal disorders. Oral from early inadvertent Impaired wound healinga,
surgery/trauma. Pancreatitis removal of tube persistent vomiting
without vomiting. Hepatic
lipidosis. Specific dietary need
J Long-term feeding (weeks to Cost; limited diet Anesthesia risk, impaired Within 24 hours
months). Resting upper selection; complications wound healinga from placement
gastrointestinal tract (e.g. from early inadvertent (i.e. 2–6 hours)
pancreatitis, recent gastric surgery). removal of tube; can
Intestinal anastomosis. Coma only use in hospital
NE, nasoesophageal; NG, nasogastric; E, esophageal; G, gastrotomy; J, jejunal.

a
Skin and alimentary tract incisions are required to place these tube types.
tubes (Figure 44.3a,b, respectively). Weighted feeding It is essential to confirm that the tube placement is cor-
tubes with guidewires are preferred in patients with rect before commencing tube feedings, to avoid inadvertent
esophageal disease at the author’s institution (William feeding into the airways. A lateral thoracic radiograph is
R. Pritchard Veterinary Medical Teaching Hospital, University considered the gold standard for verification of NG and NE
of California). NG tubes have the added function of tube positioning and is the most common method (Figure
gastric decompression, while NE tubes are used mainly 44.4a) [37]. The available methods of checking tube place-
for feeding. ment are detailed and described in Box 44.4 [20, 37–42].
Protocol 44.1 Nasogastric and Nasoesophageal Tube Placement [36]

Items Required
● 5–8 Fr, 22–43 inch (55.9–109 cm) tube for dogs < 15 kg and cats
● 8–10 Fr, 43 inch (109 cm) tube for dogs > 15 kg
● 2% lidocaine or 0.5% proparacaine
● Water-soluble lubricant or 5% lidocaine ointment
● Nylon suture material
● Luer slip catheter plug
● Elizabethan collar
● Tape or marker
Procedure
● Gather the equipment needed for placement (Figure 44.2a).
● Measure the tube from the nasal meatus to the last rib (region of the stomach) for nasogastric tubes and from the
nasal meatus to the seventh to ninth rib space for nasoesophageal tubes (Figure 44.2b).
● Mark the tube at the measured point with tape or a permanent marker.
● Drip a few drops of local anesthetic into the nostril and allow time for the anesthetic to take effect.
● Generously lubricate the tube.
● With the animal’s head held in a normal static position, insert the tube in a caudoventral medial direction into the
ventromedial aspect of the nasal cavity (Figure 44.2c).
○ In dogs, the external nares are pushed dorsally after the tube has been introduced into the nose (approximately
0.80–1.2 inches; 2.0–3.0 cm) to open the ventral meatus and aid the tube’s passage into the oropharynx (Figure 44.2d).
● Brace the introducing hand against the animal’s maxilla and introduce the tube in short, well-controlled insertions
up to the premeasured mark (Figure 44.2e).
○ Positioning the head in a slightly flexed position makes swallowing easier to help with passage of the tube into
the esophagus.
● Secure the tube to the lateral portion of the nares with a stay suture and then a finger-trap suture around the tube.
Then secure the tube lateral or medial to the eye with a stay suture to the skin, that will then be tied around a taped
portion of the tube (Figure 44.2f,g).
● Place an Elizabethan collar to prevent removal of the tube by the animal.
● Check correct placement (Box 44.4)
methods [43–45]. The chosen option is often dependent on

Feeding
clinician preference, hospitalization set-up, and nursing
Feeding through NE and NG tubes may begin as soon as care. For bolus administration, the daily diet is divided up
the tube position has been confirmed, unless the animal into three to six meals that are given slowly over 15–20 min-
has been sedated. The tube should be flushed with warm utes [1]. It is recommended that the volume of meal boluses
water before feeding (3–5 ml) to ensure patency and tube (including flushes) are less than the gastric volume, which
location [29]. Flushing the tube with 5–10 ml of warm is approximately 10–12 ml/kg [1, 29]. For a CRI, the vol-
water after each meal is also essential to prevent a block- ume is given over a set period of time (e.g. 4–6 hours,
age [29]. It is advisable to monitor total fluid intake in 24 hours) via a syringe pump. Highly mobile patients are
because excessive water administration may lead to more likely to cause a line disconnection and may be less
hyponatremia. amenable to a continuous feeding plan.
Only liquid enteral diets can be used for NE and NG Food should be warmed to between room and body tem-
feeding because of the small diameter of these tubes [33]. perature prior to feeding, for patient comfort. The patient
The amount of the chosen diet to be administered can be should also be monitored during the feed for salivation,
calculated using Box 44.2. Feeding may be given as planned retching, or vomiting. After feeding, flush the tube as previ-
boluses or as a constant rate infusion (CRI). There does not ously described, and close the port at the end of the tube to
appear to be any differences in gastrointestinal complica- prevent ingestion of air, which could cause distension and
tions, like vomiting or regurgitation, between the two discomfort in the stomach [33].
(b)
(a) (d)
(c) (e) (f) (g)
Figure 44.2 (a) Equipment for nasogastric/nasoesophageal tube placement. (b) Measuring the length of tube required. (c) Insert tube in a
caudoventral medial direction into ventromedial aspect of the nasal cavity. (d) Pushing nares dorsally in the dog. (e) Tube inserted up to
desired mark. (f) Stay suture placed at lateral nares, then finger-trap suture tied around tube. (g) Secure tube to face with stay suture and tape.
(a) (b)
Figure 44.3 Weighted (a) and non-weighted (b) nasogastric/nasoesophageal tubes.

(a) (b)
Figure 44.4 (a) Radiograph showing course of nasogastric tube into fundus. (b) Ultrasound confirmation of nasogastric tube in
stomach.
Box 44.4 Methods to Verify Correct have increased risks of such complications compared with
Nasoesophageal/Nasogastric Tube Positioning NE tubes [46]. The tube can be dislodged by vomiting or
sneezing, and if vomiting has been witnessed, the position
1) A lateral thoracic radiograph looking for the outline of the tube should be checked [34]. The tube may be visible
of the feeding tube or radiopaque weight, is consid- inside the mouth or protruding from the mouth if it has
ered gold standard [37]: been dislodged. The mark made during placement may
● A nasogastric tube should end in the fundus of the also be checked, or another radiograph may be taken. If the
stomach (Figure 44.4a). tube has been dislodged, removal and replacement is indi-
● A nasoesophageal tube should be course dorsally cated. Tube removal by the animal is common if appropri-
to the carina and end between the seventh to ate steps are not taken, and may be prevented by the
ninth rib space. placement of an Elizabethan collar.
● If the location is not definitive, then thoracic radio- Using the correct diet, avoiding administration of bulky
graphs in an orthogonal view should be taken to medications via the NE and NG tube, and flushing after each
attain further information about the course of the tube. meal will reduce the risk of tube blockage. Implementation
2) Ultrasound to identify the tip of the tube within the of a continuous feeding method with a syringe pump may
fundus (Figure 44.4b) [38, 39]. also decrease the risk of a blockage. If a tube has become
3) Capnography which should have a zero to low car- blocked, flushing and suctioning with warm water may dis-
bon dioxide reading [40–42]. lodge the obstruction. Other alternatives are listed in
4) Fluoroscopy if already available and convenient. Box 44.5 [48]. If all fails, the blocked tube can be removed
5) Visual confirmation during concurrent exploratory and replaced with a new tube. Epistaxis may occur during
laparotomy. tube placement and is self-resolving unless a coagulopathy is
6) Injecting 3–15 ml sterile water and assessing for
coughing.
7) Injecting 5–10 ml air and auscultating the cranial
abdomen for borborygmus (nasogastric tubes only). Box 44.5 Methods to Unclog Feeding Tubes [48]
8) Measurement of pH of aspirated fluid which ● 5 ml warm water
should be < 5. ● ¼ teaspoon of pancreatic enzymes with 325 mg
sodium bicarbonate in 5 ml water
● 5 ml cranberry juice
Complications and Troubleshooting
● 5 ml carbonated beverages
The risks associated with NE and NG tubes are generally
Solutions may be injected with mild pressure and
considered to be low. Commonly reported complications
suctioned, or left in-situ for 5–120 minutes before
are vomiting, regurgitation, diarrhea, and inadvertent tube
flushing again.
removal [46, 47]. The use of NG tubes does not appear to
present. Animals may also develop rhinitis or sinusitis. placement, and accidental intravenous infusions of enteral
Patients with repeated removal of gastric fluid may trend diets, but these are rare [50–54].
toward a hypochloremic metabolic alkalosis. If frequent gas-
tric emptying is performed via NG aspirations, daily acid–
base evaluation should be considered [49].
Esophageal Tubes
Placement of the tube in the trachea is the most serious
Placement and Verification
complication and can be life threatening. It is essential to
confirm correct placement before initiating feeding, as The equipment and placement technique of an esophagos-
described in Box 44.4. If there is coughing or discomfort tomy (E) tube are shown in Protocol 44.2 and Figure 44.5 [29,
during the pre-feed water flush or feeding, the planned 34, 55]. A modified technique has also been described
feeding should not be continued, and a repeat lateral tho- whereby the distal tip of the tube is immediately fed into the
racic radiograph should be taken [34]. Once the proper tube caudal esophagus with the forceps, rather than being guided
position is confirmed, feeding can then be restarted at a rostrally out of the mouth [56]. Radiographic confirmation of
smaller volume and slower rate of infusion. Other fatal tube positioning is most common, but endoscopic visualiza-
complications include induced pneumothorax, intrapleural tion is also a viable method if it is conveniently available [34].
Protocol 44.2 E Tube Placement [29, 34, 55]

Items Required extend the incision through the subcutaneous con-
nective tissues and wall of the esophagus. The inci-
● 8–14 Fr tube in cats and small dogs
sion should only be large enough to allow the tips of
● 14–20 Fr tube in medium to large dogs
the forceps to be pushed through.
● Mouth gag
5) Grasp the distal end of the tube in the forceps, taking
● Mayo scissors
care not to catch the tissues in the mouth in the
● Right-angled/curved forceps (Carmalt)
hinge of the forceps (Figure 44.5f).
● #10 or 11 scalpel blade
6) Pull the distal end of the tube grasped in the forceps
● Nylon/polypropylene suture material
rostrally out through the mouth (Figure 44.5g).
● Marker
7) Unclamp the distal end of the tube and gently push
the distal end caudally with gentle digital manipula-
● Conforming bandage/light bandage material
tion. The forceps can be used to direct the tube into
the esophagus. The proximal end of the tube can be
Procedure
manipulated to facilitate the progression of the dis-
1) Gather the equipment for E-tube placement tal end of the tube into the esophagus to prevent the
(Figure 44.5a,b). tube from forming hard kinks that could remain dur-
2) Anesthetize, endotracheally intubate, and position ing tube advancement (Figure 44.5h).
the animal in right lateral recumbency. Measure the 8) Once the tube is in place, the proximal end will flip
tube from the center of the neck to the eighth to from caudal to cranial. Check that enough of the
ninth intercostal space and mark with a permanent tube has been inserted to the premeasured mark.
marker. Clip the left side of the neck and aseptically 9) Confirm correct tube placement by radiographs. The
prepare the area (Figure 44.5c). outline of the tube should be visible and show the
3) You may trim off the distal end of a red rubber tube tube coursing dorsally to the carina and ending
to create a distal opening with the Mayo scissors between the seventh to ninth intercoastal space
(Figure 44.5d). This allows for future rewiring of the (Figure 44.5i).
E tube with a weasel wire for replacements. Round 10) Place a loose purse-string suture around the tube
and smoothen the cut edges of the distal opening entrance site (Figure 44.5j).
with the Mayo scissors. 11) Place a finger trap suture around the base of the
4) Insert the curved forceps (Figure 44.5e) into the tube where it enters the skin to secure it in place
esophagus until the midpoint in the cervical esoph- (Figure 44.3k). At the author’s institution, a second
agus, and then push outward to tent the skin. Ensure finger-trap suture is commonly placed on top of the
that the jugular vein, carotid artery, and trachea are first for added security (Figure 44.3l).
not overlying the incision site. Make an incision 12) Wrap the E-tube comfortably around neck
through the skin over the tip of the forceps and (Figure 44.5m).
Esophageal Tubes 575
(a) (b)
(c) (d) (e)
(f) (g) (h)
Figure 44.5 (a) Equipment for esophagostomy tube placement. (b) Curved Carmalt forceps. (c) Animal in right lateral recumbency and
aseptic preparation of left neck. (d) Trimming of distal feeding tube. (e) Insert forceps into esophagus and push outwards to tent the
skin. An incision is made over the tip of the forceps. (f) Distal end of tube grasped in the forceps. (g) Distal end of tube pulled rostrally
out through the mouth. (h) Distal end of tube being pushed caudally with fingers while manipulating the proximal end.
(i) Radiographic confirmation of correct positioning of esophageal tube dorsal to the carina and at seventh to ninth intercostal space.
(j) Purse-string suture placement in skin. (k) Finger-trap suture placement on esophagostomy tube. (l) Appearance of double finger-
trap suture placement. (m) Temporary esophagostomy tube wrapping with conforming bandage.
(i) (j)
(k) (l) (m)
Feeding a weak (0.05%) chlorohexidine solution should be

performed. The site should be thoroughly dried after
Feeding may be initiated when the position of the tube has
cleaning. Checking the stoma site for redness, swelling,
been confirmed and the animal has recovered from the
heat, and discharge at least daily is recommended. For
anesthetic. The larger diameter of these tubes compared
more information on the care of the stoma site, see
with the NE or NG tubes allows the use of blended or liquid
Chapter 63. A light bandage (e.g. a conforming bandage
diets [29]. The amount of water that needs to be added to
or commercial fabric collar) may be placed, taking care
the diet will depend on the tube size and the initial compo-
not to occlude the airway.
sition of the diet; however, enough water should be added
to achieve a consistency that allows passage through a
syringe tip. See Box 44.2 for calculating feeding amounts.
As for NE and NG tubes, the tube should be flushed before
and after feedings with 5–10 ml of warm water to prevent Complications rates relating to E tubes are reported to be
blockage. Warm the food to between room and body tem- between 35% and 45% in dogs and cats and are mostly
perature prior to feeding and infuse slowly. Close the port at minor [57, 58]. The most frequent complications are tube
the end of the tube after feeding to prevent ingestion of air dislodgements by patients and stoma site infections [57,
that may cause distension and discomfort in the stomach. 58]. Marking the skin exit point of a tube with a permanent
marker when the position is initially radiographed can
help to detect subsequent movement of the tube [59].
Stoma Site Care
Minor dislodgements may only require readjustments and
The stoma site should be kept as clean and dry as possible resuturing but could also require full replacement with a
at all times. Routine daily cleaning with sterile saline or rewiring procedure under sedation or anesthesia. Stoma
Gastrostomy Tubes 577
site infections can be prevented by daily hygiene routines

and monitoring. If serious cellulitis or abscessation
develop, antibiotics are required, and surgical debridement
may be indicated [57]. Changing the material of the tube
can also be considered to reduce inflammation and risks
for future infections [29].
Vomiting is another complication. If vomiting is wit-
nessed, the oral cavity should be inspected for a possible
tube dislodgement. If the tube has been dislodged, it should
be removed and another placed. If the patient vomits,
regurgitates, salivates, or shows discomfort during feeding,
feeding should be stopped and repeat radiographs should
be taken to ensure that the tube has not migrated caudally
toward the lower esophageal sphincter or dislodged else-
where. When feeding is resumed, feed a smaller amount at
a slower rate, and ensure that food is freshly prepared and
warmed prior to feeding.
Tube blockages can be prevented and addressed simi-
larly to NE and NG tubes as mentioned earlier (Box 44.5).
Only liquid medications should be delivered through the
tube. Where tablets are required, these should be crushed
to a fine powder, where possible, before mixing with Figure 44.6 Standard gastrostomy tube.
water [59].
Severe complications, such as inadvertent placement in
the trachea or periesophageal space, can be avoided with
Feeding
careful placement technique and verification of the loca-
tion with radiographs (Figure 44.5i) [34]. Water may be given within 6–12 hours of tube placement
but feeding should not be initiated until 12–24 hours after
placement to allow formation of a fibrin seal at the
stoma [29, 34]. A permanent stoma will form in 10–14 days
Gastrostomy Tubes at the gastrocutaneous junction, after which time the tube
may be removed [29, 33].
Placement
Diets of gruel consistency can be fed due to the larger
There are two forms of gastrostomy (G) tubes: standard- caliber of the G tubes. To calculate the feeding amount, see
length and low-profile. The standard tubes have a length of Box 44.2. Warm food before feeding, infuse food slowly,
tubing extending from the skin when placed (Figure 44.6), and flush with 5–10 ml of warm water before and after
while low-profile devices are designed to sit flush with the feeding as with other enteral feeding tubes. Close the port
skin (Figure 44.7). The advantages and disadvantages of at the end of the tube after feeding.
the two types of tubes are shown in Table 44.4 [60]. Low-
profile devices are generally used to replace a standard per-
Stoma Site Care
cutaneous endoscopic gastrostomy (PEG) tube after three
months when a permanent stoma has formed, but it is also G tube stoma site care is the same as E tube stoma site care,
an option to use one-step low-profile gastrostomy devices described earlier.
as the initial G tube [60–63].
G tubes may be placed surgically or percutaneously, with
no differences in complication rates [64]. Percutaneous
placement can be performed blindly or with the use of an Complication rates vary widely between studies and are
endoscope [29, 34]. The equipment required for percutane- reported to be up to 46%, but are usually minor in
ous endoscopic placement is shown in Box 44.6. Surgical nature [60, 64, 67, 68]. Complications that may occur dur-
placement of a G tube is often done when the animal is ing placement include gastric hemorrhage, splenic lacera-
undergoing abdominal surgery for another reason and is tion, and pneumoperitoneum. Complications that may
described in surgical texts [65]. A modified surgical proce- occur after tube placement include vomiting, aspiration
dure has also been recently reported [66]. pneumonia, inadvertent tube removal, peritonitis, gastric
(a) (b)
Figure 44.7 (a) Low-profile gastrostomy tube in a cat. (b) Low-profile gastrostomy tube before placement.
Table 44.4 Advantages and disadvantages of standard-length placement in dogs with septic peritonitis have shown
and low-profile gastrotomy devices [60].
minimal development of major complications and con-
clude that G tubes can be safely considered for this popu-
Standard length Low profile
lation of patients [68, 71]. One study suggests that
Positives ● Lower initial cost ● Less frequent replacement patients on concurrent corticosteroids may have a higher
● Lower cost for and reduced overall cost risk of developing severe complications and advises care-
short-term use for long-term use ful consideration of tube placement in this group of
● Well tolerated ● More esthetically pleasing animals [72].
Readily available to owners
● Pressure necrosis can be prevented by ensuring that the
in most clinics Fewer complications
tube can be rotated after it has been placed, with a 5-mm
●
(blockage, inadvertent
removal) space between the skin and the external flange [73].
Negatives Higher risk of Higher initial cost Marking the tube at the level of the skin on initial place-
blockage and ment with a pen or tape can help to detect subsequent
inadvertent removal movement of the tube. An Elizabethan collar can be placed
to help prevent tube removal by the patient. Where the
Box 44.6 PEG Tube Placement Equipment [29, 34] tube is being removed by another pet in the household, a
low-profile device should be considered.
● 20–24 Fr tube If inadvertent removal or dislodgement occurs before a
● Endoscope stoma has formed, surgical intervention is advised. 5–15 ml
● Endoscope grasping instrument of iodinated contrast can be administered via the tube to
● Scalpel blade confirm displacement [29]. The presence of contrast in the
● 14- to 16-gauge needle or catheter peritoneal cavity is suggestive of a gastric leak due to tube
● 2-0 nylon suture material displacement. Interrogation with ultrasound is also an
● Catheter guide alternate option.
● Sterile lubricant Tube obstruction may occur, although it is less likely in
● Luer slip catheter plug larger-diameter tubes, and it can be prevented by flushing
before and after feeding, blending the diet with sufficient
pressure necrosis, tube migration, and infection of the tube water, only using elixir medications, or thoroughly crush-
site [15, 60, 64, 67–70]. ing medications and flushing well after administration.
Hesitations exist with the use of G tubes with specific Use of sucralfate and antacids via enteral feeding tubes
groups of patients. Retrospective studies evaluating tube should be avoided, as they commonly precipitate and cause
Summary 579
blockages [29]. Methods to address a tube blockage are feeding amount to be provided each day (step 3), and then
described in Box 44.5. divide this amount by 24 (hours/day).
Most minor complications relate to irritation or infection
of the stoma site. These can be minimized by routine clean-
ing and monitoring as described for E tubes. Systemic pro- Tube and Site Care
phylactic antibiotics are not recommended but may be Flush the tube with water every four hours and after any
required with infections. disruption in CRI feeding [59]. The syringe and tubing (or
other delivery equipment) through which the diet is deliv-
ered should be replaced every 24 hours to minimize bacte-
Jejunostomy Tubes rial growth [33]. J tube exit site care is the same as described
earlier for other enteral tubes.
Placement
Jejunostomy (J) tubes are most commonly placed surgi-
cally, often in animals that are identified as requiring
post-pyloric feeding and require surgery for other rea- Common complications are vomiting, osmotic diarrhea,
sons. Surgical placement of J tubes is described in surgi- tube migrations, tube kinking, stoma erythema or celluli-
cal texts [65]. The equipment used for surgical placement tis, accidental dislodgement, and tube obstruction [33,
of J tubes is shown in Box 44.7. Laparoscopic-assisted 81–83]. Gastrointestinal complications may be alleviated
placement of J tubes has also been used and is an option by decreasing the administration rate or by adding fiber to
for J tube placement when the animal does not require a the liquid diet for diarrhea. Tube clogging can be mini-
celiotomy for another purpose [74]. Other options mized by using suitable diets, and by flushing the tube well
include placements of a percutaneous endoscopic gas- every four hours and after any interruption in CRI feed-
trojejunal tube, percutaneous radiologic gastrojejunos- ing [33, 83]. Previous methods described for unblocking
tomy tube, endoscopically or fluoroscopically guided tubes may also be employed to relieve the obstruction.
nasojejunal tubes, and esophagojejunal tubes [75–79]. Alternatively, the tube may be replaced surgically or left in
Low-profile jejunostomy devices are also available and place until a stoma has formed while using parenteral
may be a feasible option for long-term nutritional sup- nutrition.
port [80]. J tubes are recommended to be left in place for Peritonitis is a serious complication that may occur
at least 7–10 days to allow for adhesions to form around from leakage of small intestinal contents at the enteros-
the tube site, which help prevent leakage into the abdo- tomy site from dislodgement or premature removal of the
men [29, 33]. tube. In non-surgically placed tubes, retrograde move-
ment may occur, which is best prevented by placing the
tube as far into the small intestine as possible on initial
Feeding
placement [84].
Feeding may be initiated within 24 hours after tube place-
ment and are often started within two hours after anes-
thetic recovery [29, 75]. Owing to the small diameter of Summary
these feeding tubes, only a liquid enteral diet can be used.
A CRI is recommended because bolus feeding may cause ● Adequate nutritional intake is required to support the
cramping and diarrhea [29]. See Box 44.2 to calculate the immune system, wound healing, and intestinal structure
and function.
● Enteral nutrition is the preferred route of nutrition if
there are no contraindications.
Box 44.7 J Tube Placement Equipment [65] ● It is recommended to initiate early enteral feeding within
48–72 hours if there are no contraindications.
● 3.5 Fr for animals < 4 kg
● RER is the minimum caloric goal for animals in the
● 5 Fr for animals 4–10-kg
hospital.
● 8 Fr for animals > 10 kg
● Use a strategic approach to entice voluntary consump-
● #11 scalpel blade
tion and reduce the risk of learned taste aversions.
● 4–0 absorbable suture material
● Tube selection is based on multiple factors, including the
● 2–0 nonabsorbable suture material
disease or condition being treated, functionality of gas-
● Hemostat
trointestinal tract, anticipated length of feeding
assistance, and cost of administration.
● Tube position should always be verified prior to initiat- ● Patients should be monitored closely during enteral
ing feeding. meals for adverse reactions.
● Tubes should be flushed with enough warm water to fill
the tube prior to and after feeding to maintain tube Acknowledgment
patency.
● Ensure that an appropriate diet consistency is used to This chapter was originally authored by Scott Campbell
reduce the risk of tube blockage. and Natalie Harvey for the previous edition, and some
● Delivery of medications through E tubes and G tubes material from that chapter appears in this one. The authors
should be done with caution. and editors thank them for their contributions.
References
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585
45
Parenteral Nutrition
Jennifer Larsen
Malnutrition in hospitalized patients is an ongoing problem or absent gag reflex. Likewise, many patients with head
in veterinary medicine and is associated with poor out- trauma, those that need ventilator-assisted respiratory sup-
comes. One study showed that hospitalized dogs and cats port, those requiring medications that impair consciousness,
that received less than one third of their target energy or those with severe pancreatic or malabsorptive gastrointes-
requirements had a higher rate of poor outcomes [1]. tinal diseases sometimes cannot safely be fed enterally; how-
Another study reported lower odds of dying in dogs that ever, nutritional support is still essential. In such patients,
consumed their calorie requirements [2]. It is difficult to parenteral nutrition (PN) can be the only way to administer
separate the impacts of more severe or chronic disease calories and nutrients (Figure 45.1).
from the effect of nutritional support; however, overall the
data in both humans and animals strongly suggest that
early and adequate feeding promotes better outcomes. It is When to Initiate Support
well known that illness and other physiologic stressors are
associated with a hypermetabolic state characterized by The ideal time to initiate nutritional support varies by indi-
increases in circulating cytokines, catecholamines, and vidual and depends on nutritional status (current and
other stress mediators, which then result in an inflamma- serial body weights and when the patient last consumed
tory response with undesirable effects including increased adequate energy and nutrients), the disease process, and
protein catabolism and impaired healing ability [3, 4]. The prognosis for voluntary intake. Assessment tools for assign-
preferential catabolism of lean body mass over glycogen ing and monitoring body and muscle condition scores
and fat stores in animals that are critically ill has a pro- should be used routinely in the clinic for healthy pets as
foundly negative impact on healing, immune function, and well as hospitalized patients (Figures 45.2, 45.3). For
recovery. As such, timely intervention and provision of acutely ill or injured patients in good condition, nutritional
appropriate and adequate nutritional support is indicated. support should be implemented within three to five days of
anorexia. Longer periods of starvation are certainly of no
Indications for Parenteral Nutrition benefit and carry the risk of negatively impacting immune
function, healing, and overall condition [1, 2, 13]. For
Feeding by the enteral route is the preferred method of pro- patients that are more debilitated, are growing, have inad-
viding energy and nutrients to maintain the functional equate muscle mass or adipose stores, have recent or con-
integrity of the gastrointestinal tract and prevent dysfunc- tinuing weight loss, or that are not expected to consume
tion of the immune barrier [5–7]. The evidence from the vet- food voluntarily within two or three days, intervention
erinary literature shows early enteral nutrition is well should be more immediate. Feline patients that are at risk
tolerated [8–10] and is associated with improved out- of hepatic lipidosis from inadequate energy consumption
comes [11, 12]. However, enteral feeding may not be possible should also have their nutritional needs addressed within a
in patients with an increased risk of aspiration or that are shorter time frame. Please refer to Chapter 42 for specific
not candidates for feeding tube placement. Contraindications guidelines. For all hospitalized cases, the initial medical
of gastrointestinal feeding may include protracted vomiting management plan, as well as the owner’s cost estimate,
or regurgitation, decreased consciousness, and a decreased should consider the need for nutritional support.
586 Parenteral Nutrition
Regardless, since hyperglycemia may be more likely with

shorter times to increase PN to maximal rate [18], this may
be at least partially controlled by starting with an initial
infusion rate of 25% of RER (calculated to be administered
over 24 hours). If this is well tolerated, the rate should be
increased in 25% increments every 4–12 hours depending
on patient response, until full RER is successfully reached
(Box 45.2). Body weight should be assessed at least once
daily, and if PN is used for a prolonged period without
complications and weight loss is noted, slowly increasing
the rate by 10–20% increments is reasonable.
Figure 45.1 Mechanically ventilated patients are at higher risk
of complications when fed enterally; parenteral nutrition can be
used to provide support. Central and Peripheral Nutrition
Parenteral nutrition is sometimes called “total” or “par-

How Much to Feed tial.” These terms refer to the completeness of the diet with
respect to required nutrients or calories. In human medi-
For all hospitalized patients, regardless of feeding method, cine, PN is often used for prolonged periods, and the solu-
the ultimate goal is the provision of resting energy require- tions include all required nutrients, including trace
ment (RER) calculated for the current weight regardless of elements. In contrast, the average length of PN administra-
body condition. RER is the amount of energy needed by a tion in veterinary patients is between three and five
resting, awake animal that is lying down in a thermoneu- days [14–18], and veterinary PN formulations do not typi-
tral environment. The RER is estimated by this equation cally include the full complement of required nutrients. As
(Box 45.1): such, the veterinary nomenclature is more accurate in ref-
erence to the route of administration, with central paren-
0.75
70 body weight kg teral nutrition (CPN) being administered through catheters
that terminate in the caudal or cranial vena cava, and
This amount is adequate to maintain weight in a peripheral PN (PPN) being administered through standard
majority of hospitalized patients but may vary due to short catheters that terminate in peripheral vessels.
underlying disease and nutritional status. Regardless, Both types of PN are appropriate for delivery of full
overfeeding has risks and should be avoided. An initial caloric requirements, despite differences in energy density
target of RER allows assessment of patient tolerance and osmolarity (Table 45.1). This can be achieved with PPN
during incremental increases in the PN infusion rate. because of its higher fat content. Fat solutions contribute
Adjustments based on the individual patient’s response more calories per milliliter than protein and carbohydrate,
are necessary. but the osmolarity is much lower. Recommendations for
Overfeeding can result in hyperglycemia and hyper- maximum osmolarity values are 750 mOsm/l for PPN and
lipidemia, which are also the most commonly recognized 1400 mOsm/l for CPN [22]. This upper limit for PPN is
adverse effects associated with use of PN in veterinary intended to reduce the risk of phlebitis; however, other
patients [14–18]. Hyperglycemia has been identified as a characteristics of the formula and its administration (espe-
risk factor for poor outcome in both human and feline cially pH and flow rate), as well as patient factors, also con-
patients [17, 19]; however, a causal relationship remains tribute to the risk of phlebitis. The higher limit for CPN
unclear and some evidence suggests that tight glycemic formula osmolarity reflects the delivery into a large, high-
control is not ideal [20]. In addition, increases in blood volume and high-flow vessel, which results in rapid dilu-
glucose concentration that develop after PN is initiated tion of the solution.
typically normalize within one to four days without insu-
lin therapy, especially in dogs [15, 18]. Hyperglycemia is
a common feature of critical illness in both dogs and cats Composition of the Solution
even without PN [18, 21]. In addition, insulin does not
always achieve normoglycemia in canine and feline PN solutions are composed primarily of three base ele-
patients that develop hyperglycemia after initiation of ments: amino acid solution, fat emulsion solution, and
PN [18], which suggests other mechanisms may be dextrose solution. The most commonly used amino acid
contributing. solutions have concentrations of 8.5% or 10% and include
Figure 45.2 Canine and feline body condition score charts. Source: Courtesy of the World Small Animal Veterinary Association (WSAVA), https://wsava.org/global-
guidelines/global-nutrition-guidelines (accessed 20 September 2022).
ComCosisCon Cofithe ColisCon 589
Figure 45.3 Canine and feline muscle condition score charts. Source: Courtesy of the World Small Animal Veterinary Association
(WSAVA), https://wsava.org/global-guidelines/global-nutrition-guidelines (accessed 20 September 2022). © Tufts University, 2014.
ComCosisCon Cofithe ColisCon 591
Table 45.1 General characteristics of central and peripheral

Box 45.1 Examples of Calculations for Meeting parenteral nutrition (PN)
Energy Requirements with Parenteral Nutrition
Equation for resting energy requirement (RER): Characteristic Central PN Peripheral PN
0.75
70 body weight in kg RER in kcal / day Catheter termination In vena cava In peripheral
vessel
For a 35-pound (15.9 kg) canine patient, calculate RER: Osmolarity < 1400/l < 750/l
Energy density 1.0–1.4 kcal/ml 0.7–1.0 kcal/ml
70 15.9 kg3/ 4 557 kcal / day
Fat content ∼ 50% of ∼ 70% of calories
557 kcal / day / 1.15 kcal / ml calories
484 ml / day 484 ml / day / 24 hours Delivery of energy Yes Yes
20 ml / hour requirement
If the parenteral solution provides 1.15 kcal/ml,

all amino acids required by dogs and cats except taurine.
the calculations above demonstrate that the patient
Lipid emulsion products are primarily composed of long-
needs approximately 484 ml/day or 20 ml/hour to
chain polyunsaturated fatty acids from plant oils. This
achieve full RER. This final RER goal is generally
ingredient is iso-osmolar and can be used in high concen-
attained by starting at a fraction of the final goal
trations in PN while contributing little to the osmolarity of
infusion rate and increasing it over 2–4 days to
the overall solution. There is some interest in the use of
ensure tolerance.
omega-3 fatty acid-containing infusions in veterinary
patients, but these are not clearly beneficial and not com-
monly in use at this time [23]. Dextrose solutions are 5% or
50% concentration products typically found in veterinary
Box 45.2 Guidelines for Increasing to Goal Rate pharmacies. In this context, dextrose is the injectable form
of Parenteral Nutrition Infusion of the 6-carbon monosaccharide glucose with an attached
Adapted from Campbell et al. [22]. water molecule (d-glucose monohydrate).
When increasing the infusion rate up to full resting Additives providing electrolytes, B vitamins, and trace
energy requirement, start with 25%–33% of the rate, minerals may also be included in the PN formulation. The
and increase by 25–33% increments every 4–24 hours inclusion of B vitamins in particular is important. With the
if tolerated, with blood glucose within target ranges exception of a small amount of cobalamin in the liver,
(between 100 and 250 mg/dl). there is no storage of B vitamins in the body. These are
Assess blood lipids, phosphorus, potassium, magne- important nutrients for metabolism and efficient use of
sium, and hematocrit within 24 hours of initiation of energy, protein, fat, and glucose. Further, B vitamins can be
parenteral nutrition. lost in the urine due to their water-soluble nature; this is an
After full infusion rate is achieved, assess at least important consideration for patients with polyuria second-
once daily: ary to their underlying disease or due to parenteral fluid
administration. Other micronutrients are also critical, and
● Body weight some amino acid solutions include electrolytes; however,
● Catheter insertion site many clinicians prefer to adjust these more precisely for
● Plasma lipemia index individual patients by using additives such as potassium
● Blood glucose concentration phosphate, potassium chloride, magnesium sulfate, and
● Magnesium concentration sodium chloride. Any of these can be added to the PN solu-
● Thoracic auscultation tion or to a crystalloid fluid solution. Other components
● Rectal temperature including medications should not be introduced into the
● Hematocrit PN solution unless compatibility can be assured to avoid
adverse effects; consultation with an experienced pharma-
Assess at least every other day: cist is appropriate.
Formulations can also be customized in other ways, with
● Phosphorus concentration
modification of the macronutrient energy distribution of
● Potassium concentration
the solution the most common. For example, low-
● Blood urea nitrogen concentration
carbohydrate solutions may be useful for patients with
● Albumin concentration
compromised pulmonary function and hypercapnia, and
low-protein solutions are used for patients with hepatic sensitive to temperature, light, and oxygen (Box 45.3).
encephalopathy or kidney disease. For some patients with Degradation or destruction of the solution constituents is
severe hepatic disease, fat may also be poorly tolerated. possible, for example fatty acid oxidation.
Provided that blood lipid clearance is normal, parenteral Solution stability may also be impacted due to mixing
fat infusions are generally safe for patients with pancreati- procedures. Some components of PN solutions may interact
tis because exocrine pancreatic stimulation results from with others, or react with additives, which may result in
nutrients in the small intestine. To some extent, the osmo- instability of the product. For example, the dextrose and
larity and energy density of the solution can also be amino acid components should be mixed to allow for pH
adjusted to address issues such as phlebitis or volume equilibrium and dilution of cations prior to adding the lipid
intolerance. solution. Alternatively, all three components can be added
simultaneously, with gentle agitation to ensure proper
homogeneity of the solution. Care should be taken to avoid
ompounding Parenteral
C
Nutrition Solutions
Box 45.3 Factors Influencing Stability of Parenteral
Aseptic procedures are required for safe compounding of Nutrition Solutions
PN solutions (Protocol 45.1). To ensure a safe and quality
● Microbial contamination
product, the solution must remain both sterile and stable.
● Temperature
Because several ingredient components are added to the
● pH
solution, multiple needlesticks are used and contamina-
● Light
tion is possible. Further, the solution itself is a good
● Oxygen exposure
medium for bacterial growth. The stability of the solution
● Continuous agitation of solution
may be impacted not only by microbial contamination but
● Lipid emulsion stability
also by storage or transport conditions. Many nutrients are
Protocol 45.1 Protocol for Compounding Parenteral Nutrition

Items Required
● Isolation chamber or laminar-flow hood (Figure 45.4)
● Empty, sterile, and unused intravenous (IV) solution bags with attached transfer tubing set and tubing clamps
● Alcohol swabs for cleansing injection ports
● Needles and syringes for additives
● Amino acid solution, lipid emulsion solution, dextrose solution, vitamin B complex, electrolyte additives (potassium
chloride or potassium phosphate, magnesium sulfate)
● Sterile gloves
Procedure
1) Gather supplies.
2) Always use aseptic technique.
4) Assemble all necessary components and supplies in the chamber or hood (Figure 45.4).
5) Hang the dextrose and amino acid solutions, swab the ports with isopropyl alcohol and allow to dry completely,
and connect the tubing from the empty IV bag to each container.
6) Open the tubing to mix the specified volumes of dextrose and amino acid solution in the empty bag, and then add
the lipid emulsion (or add all three simultaneously with gentle agitation to ensure thorough mixing; do not mix
dextrose and lipid together).
7) Clamp and remove the transfer tubing from the IV solution bag.
8) Add any desired additives (potassium phosphate or potassium chloride, B vitamin complex).
9) Limit needlesticks as much as possible.
10) If solution will not be used immediately, omit the additives for refrigerated storage and add them just prior to use,
using aseptic technique.
MsoniheonMonnhe Cofithe onolosCon MonnfMitheihee 593
the mixing of dextrose and lipid solutions together. The

amino acid solution will buffer the low pH of the dextrose
solution and protect the lipid component, which is sensitive
to excessive acidity as well as higher concentrations of reac-
tive cations such as ionized calcium and magnesium.
PN solutions without additives can be premade and
stored in the refrigerator for convenience, with the addition
of a vitamin B complex injection to the solution just before
beginning the infusion. Premade bags without additives
may be stable for up to 28 days when stored at refrigerated
temperature [24]. If the lipid becomes unstable (referred to
as “breaking” or “oiling out”), visible separation, yellow
streaking, and/or precipitation of particulate matter can be
noted in the solution. PN solutions should always be visu- Figure 45.4 To avoid contamination, parenteral nutrition
ally examined prior to infusion and at regular intervals solutions should be mixed in a sterile environment such as an
thereafter to assess for breaking and other stability prob- isolation chamber or laminar-flow hood.
lems. If signs of instability are noted (Box 45.4), the animal
is at risk of adverse events related to lipid emboli, and the
solution should be discontinued and discarded.
There are currently no formal practice guidelines regard-
ing the use of PN from the American Veterinary Medical
Association or many state veterinary medical boards.
However, as of 2008 the United States Pharmacopeia (USP)
Chapter 797 is enforceable by the US Food and Drug
Administration and has been adopted by most state phar-
macy boards [25]. This statute describes the procedures
and requirements for compounding sterile preparations
and applies to all settings, veterinary or otherwise. The
stringency of enforcement may vary; however, these proce-
dures and guidelines should be followed in all veterinary
practices and pharmacies to ensure patient safety.
Among other restrictions and guidelines, USP Chapter 797
guidelines specify the use of a clean room or isolation Figure 45.5 Hand mixing of PN solution in a laminar
flow hood.
chamber (such as a laminar flow hood) to prepare sterile
parenteral products (Figure 45.4). For most veterinary prac-
tices, the feasibility of compliance is challenging if not human error, increase efficiency, and improve accuracy of
impossible, and options for in-house preparation are lim- the measurements of each component, but these are not
ited. Large practices or academic institutions typically use cost effective for most veterinary practices. However, many
isolation chambers or laminar flow hoods for hand mixing human home healthcare pharmacies and hospitals can pro-
or automatic compounding machines to mix parenteral vide parenteral mixtures for use in almost any veterinary
solutions (Figure 45.5). Automatic compounders reduce practice. A prescription can be submitted that specifies the
type and amounts of each component to create an appropri-
ate parenteral solution. The product can be sent the same
Box 45.4 Signs of Lipid Instability Indicating day or overnight to the veterinary practice, making this
an Unsafe Parenteral Nutrition Solution option more practical, albeit still potentially costly.
● Any change in color of solution from the typical white

or off-white resulting from addition of B vitamins aintenance of the Infusion
M
Yellow steaks in solution
●
and Catheter
● Visible oil layer in solution
● Appearance of particulate matter or “clumping” in
Peripherally inserted central catheters are often used in
solution
veterinary patients for the administration of CPN; these are
● Any loss of appearance of homogeneity of solution
inserted in the limbs but are long enough to terminate in
the caudal or cranial vena cava. These devices may be more diagnostic procedures, and to visits with owners. If the line
difficult to keep clean compared with those in other loca- is disconnected anywhere between the bag and the patient’s
tions, especially if the bandaging is exposed to urine or intravenous catheter, the administration set and solution
feces. Shorter CPN catheters inserted into the jugular vein are no longer considered sterile and must be discarded.
and that terminate in the cranial vena cava are also com-
mon; these typically have multiple lumens so that a dedi-
cated line is possible. Dedicated lines are strongly Contraindications and Complications
recommended for PN administration to avoid incompati-
bility issues with other infused substances, minimize con- PN should be used cautiously in patients that are volume
tamination, and maintain line integrity. intolerant. The energy density of the solution is the pri-
Catheters intended for PN infusion use should be placed mary determinant of the infusion rate; if the rate must be
aseptically, using standard techniques for skin preparation decreased to address volume intolerance, full RER may
including clipping and proper cleansing. Procedures not be delivered. Regardless, the provision of partial
should also include the use of appropriate barriers (drapes, energy requirements is preferable to none. Patients with
gloves), as well as proper handling of all equipment (see vasculitis or that are septic or hypercoagulable are not
Chapter 7). Catheter maintenance during the infusion ideal candidates for PN. If PN is instituted is such a patient,
period should follow accepted protocols for cleansing and additional monitoring and precautions may be necessary
bandaging to avoid contamination and infection (see to reduce complications. All patients should be monitored
Chapter 63). The insertion site should be visually inspected for metabolic, mechanical, and septic complications
for signs of inflammation and cleansed every 12–24 hours. (Box 45.5).
Catheter removal may be necessary if swelling, redness, or
discharge is present.
Metabolic Complications
Owing to the sensitivity of some nutrients to ultraviolet
light, the solution bag and infusion lines should be kept Commonly Reported Metabolic Complications
covered. Amino acids and B vitamins are most susceptible Metabolic complications of PN are commonly recognized
to such degradation. After the addition of B vitamins and in veterinary patients, amounting up to 70% of total
gentle mixing of the solution, the solution is stable at room recorded PN-associated complications in dogs in one
temperature during the infusion period for at least 48 hours; study [15]. Although hyperglycemia is common in dogs
continuous agitation is not necessary and may destabilize and cats receiving PN, and has been associated with poor
the solution [26]. The bag should be labeled with the date outcome in cats in one study [17], other studies did not
and time it was hung to ensure that it is discarded after show an association between hyperglycemia and mortality
48 hours along with the entire infusion tubing set. Once
the infusion has started, any disconnection of the line
should be prevented to maintain sterility (Figure 45.6). In Box 45.5 Examples of Complications Associated
all cases this means that the bag and line must accom- with Parenteral Nutrition Administration
pany the patient on walks outside, trips to undergo
● Metabolic:
⚪ Abnormalities in serum biochemical values (e.g.
hyperglycemia, hyperbicarbonatemia)
⚪ Lipemic serum (or elevated serum triglyceride
concentration)
⚪ Refeeding syndrome
● Mechanical:
⚪ Catheter dysfunction (dislodgement, occlusion,
kinking)
⚪ Disconnection or leakage of the infusion line
⚪ Inadvertent removal by the patient
⚪ Equipment failure (pump dysfunction, etc.)
● Septic:
⚪ Inflammation at catheter insertion site
⚪ Fever
Figure 45.6 The catheter should be wrapped to protect it from ⚪ Elevated white blood cell count
contamination or damage and should only be disconnected to ⚪ Positive culture of blood or catheter
replace the infusion lines and bag.
ConieMsonnsnMisCono MonnfComosnMisCono 595
in either dogs or cats [16, 18]. As previously discussed, The binding of insulin to its receptors in peripheral
critically ill cats show abnormalities in carbohydrate tissues results in an intracellular phosphorylation cascade.
metabolism associated with hyperglycemia, hyperlac- This in addition to the upregulation of glycolysis and sub-
tatemia, and hypoinsulinemia [21], which may contribute sequent production of adenosine triphosphate (ATP; the
to intolerance of dextrose-containing infusions of PN. Despite main energy source for cellular functions) creates a sink
the consistently high incidence of hyperglycemia reported such that phosphorus moves from the extracellular into the
in veterinary patients both prior to and during PN infusion, intracellular compartment, which depletes the extracellu-
the importance of this remains unclear. lar (interstitium, plasma) compartment; this can result in
clinical signs of phosphorus deficiency, including hemoly-
Intolerance of Parenteral Nutrition sis and anemia.
Patients that do not appear to tolerate PN (Box 45.6) due Insulin also promotes a dramatic shift of potassium from
to hyperlipidemia, hyperglycemia, or hyperammonemia the extracellular to the intracellular compartment, primar-
should be assessed for new or progressing underlying ily due to the transmembrane sodium–potassium ATPase
conditions; however, the first steps should include confir- pump, the action of which is essential for nerve impulse
mation of proper formulation and mixing of the solution, transmission and muscle function as well as the action of
given that even minor errors may result in a drastically sodium-coupled glucose transport proteins. The sodium
different nutritional profile than intended. The formula- gradient across the cellular membrane enables inward
tion calculations should be rechecked, as well as the vol- movement of glucose and is maintained with intracellular
ume and specifications of the individual components. movement of potassium. As such, insulin stimulation of
Once the composition of the solution has been confirmed, sodium-potassium ATPase can reveal poor whole-body
measures can be taken to reduce adverse effects. In all potassium status in many malnourished patients. This can
cases the infusion rate should be decreased or the infu- result in clinically significant hypokalemia manifested by
sion discontinued if the adverse effect is severe. In some hypotension, neuromuscular dysfunction including weak-
cases, insulin can be used to control hyperglycemia, and ness and intestinal ileus, cardiac arrhythmias, and car-
unfractionated heparin can be used to induce lipoprotein diac arrest.
lipase, which increases peripheral uptake of lipids to Likewise, magnesium is an important cofactor for the
address hyperlipidemia. first steps in glycolysis, so that when glucose is being used
to produce ATP, there is a sink for magnesium in the intra-
Refeeding Syndrome cellular space. Deficiency results in cardiac arrhythmias
Another potential metabolic complication is refeeding syn- and neuromuscular signs. Assessment of magnesium sta-
drome, which can be seen in any animal fed enterally or tus in veterinary patients remains a challenge. There is no
parenterally after a period of reduced food intake. The syn- consensus regarding the most accurate yet practical
drome is characterized by hypophosphatemia, hypoka- method, given that whole-body magnesium status is not
lemia, hypomagnesemia, thiamine deficiency, and fluid reliably reflected by serum measurements. Current recom-
imbalances. During starvation and critical illness, reserves mendations suggest that either serum ionized or total mag-
of metabolically important compounds are depleted, and nesium concentrations are most useful if low; however,
the main energy sources are fatty acids, ketone bodies, and when values are normal, clinical suspicion may still sup-
amino acids. Despite typically normal serum concentra- port diagnosis of deficiency [27]. Hypokalemia may be
tions, the whole-body pool of nutrients such as phospho- refractory to treatment with parenteral supplementation
rus, potassium, magnesium, and thiamine is significantly unless adequate magnesium concentrations are restored
reduced. When calories are delivered by any route, espe- because magnesium closes passive potassium channels in
cially from digestible carbohydrate including glucose, the cellular membranes.
pancreas responds by releasing insulin, and there is an Lastly, thiamine is important for the metabolism and use
abrupt shift in the substrates used for energy production as of carbohydrates for energy, and many patients have sub-
glucose becomes available. optimal thiamine status from decreased intake and/or
increased loss. When demand increases during refeeding,
subclinical or overt thiamine deficiency may result, includ-
Box 45.6 Signs of Parenteral Nutrition Intolerance ing severe neurologic abnormalities.
Unlike in people, refeeding syndrome appears to be
● Hyperglycemia
uncommon in dogs and cats, and usually causes mild to
● Hyperammonemia
moderate adverse events in veterinary patients. However, in
● Hyperlipidemia
some cases the problem can result in catastrophic complica-
● Fluid overload without other identifiable cause
tions. Anemia requiring transfusion in 7 cats and acute
kidney injury affecting 6 cats was recently reported in a case are at higher risk of infectious complications. However,
series of 11 cats with refeeding syndrome; only 8 cats sur- septic complication rates in clinical canine and feline
vived to discharge and only after being hospitalized for a patients receiving PN solutions range from 0% to 8% and
mean of 14 days [28]. Given the potentially serious sequalae, are typically the least common types of complication iden-
monitoring and ideally preventing such occurrences should tified [14–18]. In addition, septic complications are either
be implemented for any at risk cases. Patients with preexist- not clearly associated, or are statistically not associated
ing metabolic derangements such as diabetic ketoacidosis with mortality [14–18]. Regardless, all patients receiving
or those with a prolonged history of malnourishment are PN solutions should be monitored for catheter insertion
likely at higher risk and should be assessed closely. Initiation site infection, fever, and leukogram abnormalities. If
of either enteral or parenteral nutrition should be done con- catheter-related sepsis is suspected, the catheter should be
servatively, with very gradual increases in the amount pro- removed, and blood or other appropriate culture tech-
vided to assess tolerance and address any potential problems niques performed to institute appropriate antimicrobial
very early (no more than 25% of RER for at least six to eight therapy.
hours, in this author’s opinion). When identified and
promptly addressed, actions to correct these issues may
improve outcome and reduce morbidity and mortality asso- Conclusion
ciated with this useful treatment modality.
PN can be a useful modality to provide nutritional support
to critically ill patients unable to tolerate enteral feeding.
Mechanical Complications
Proper formulation, compounding, administration, and
Mechanical complications include catheter dysfunction patient monitoring are necessary to ensure the delivery of
(dislodgement, occlusion, kinking), disconnections in the a safe and effective product. Metabolic complications are
infusion line, and inadvertent catheter removal by the the most frequently documented adverse effects; septic
patient. Such situations occur in 9–26% patients receiving complications are uncommon. Nutritional support using
PN [15–18]. Preventing patient access to the catheter site, PN solutions can be safely and effectively implemented in
maintaining appropriate bandaging, and instituting proce- most 24-hour veterinary practice settings.
dures to maintain line integrity during patient care can
help reduce the incidence of mechanical complications.
Although infusion line obstructions are not commonly Summary
encountered, administration sets are available that include
inline filters. Occlusions may be due to coalescing fat glob- ● Critically ill patients are often malnourished or are con-
ules that would indicate an unstable or broken solution. suming inadequate diets.
The PN solution should be carefully inspected in the event ● When enteral feeding is impossible or impractical, provi-
of an occlusion because significant adverse effects may sion of nutritional support via the parenteral route is
occur if a broken lipid solution is infused. indicated.
● Parenteral feeding is an excellent option for providing
adequate amounts of energy to patients with a wide
Septic Complications
range of needs.
Owing to the nature of the parenteral solution and the ● Parenteral feeding can be easily employed in most prac-
need for direct intravenous access, patients receiving PN tice settings with 24-hour monitoring.
References
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(APACHE II > or =6). Pancreatology 3 (5): 406–413. 20 Yamada, T., Shojima, N., Noma, H. et al. (2017). Glycemic
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599
Section Six
Analgesia and Anesthesia
601
46
Drug Administration
Damion Asselin and Jane Quandt
The patient that undergoes treatment and monitoring in with either a red sticker on the outside of the paper record
the intensive care unit (ICU) setting receives numerous or an electronic warning on computer records. This indica-
drug therapies. How these therapies are administered is tor is vital to prevent the administration of a drug or a
crucial to the success of the treatment and the wellbeing of blood product to which the patient has reacted in the past.
the animal. Either a prominent note should be made on the treatment
sheet or a sign should be posted on the patient’s cage so
that everyone in contact with that patient is made aware of
Treatment Sheet Orders
the patient’s drug sensitivities.
The pharmacy should also be a source of safeguards
All patients in intensive and intermediate care should have
against drug administration error. Pharmacy personnel
an order sheet (Figure 46.1) delineating the treatment
should check medication requests for accuracy of dosing
requested, the dose, the route of treatment administration,
and administration route. To prevent accidental overdose,
and frequency of administration. The order sheet is also the
single drug doses should be dispensed, each in its own
place to note any potential interaction that may occur
labeled syringe, unless the medication comes in a multiuse
between drugs. For example, a dog on a constant rate infu-
vial or container.
sion (CRI) of diazepam should not receive an intravenous
It is common in veterinary medicine to use extra-label
(IV) antibiotic through the same IV line as the diazepam.
drugs. This is the use of an approved drug in a way that is
Diazepam is incompatible with other drugs and would form
not in accordance with the manufacturer’s approved
precipitates (small particles) in the line. The written order
instructions. Animals have diseases that require treatment
for the treatment drugs should match the label from the
with agents that have been registered for use only in human
pharmacy in that it is the same name, be it generic or a trade
patients. When an animal-approved drug product to treat a
name; for example, Torbugesic® (Zoetis) is the trade name of
condition is not available, extra-label use may be author-
butorphanol. The name on the order sheet and the name on
ized when the health of the animal is threatened, the
the drug when it is received from the pharmacy should be
patient is suffering, or death may occur without the treat-
one or the other, or both names, to avoid confusion. When a
ment. The Animal Medicinal Drug Use Clarification Act
treatment is administered to the animal, the initials of the
explains extra-label drug use. It states that a veterinarian
person giving the medication should be placed next to the
must be involved; only Food and Drug Authority-approved
treatment time. When questions arise, initialized treatments
drugs are to be used; a client–veterinarian relationship
allow for tracking of the individual responsible for the action.
must exist; the drug must be for therapeutic use only; and
there are to be no residues that may present a risk to public
Medical Records health. When using an extra-label drug, it is important to
fully document the dose, route, administration times, dis-
All administered medications should be clearly noted in ease being treated, and any withdrawal times. It is not a
the medical record, whether it is paper or electronic. Any requirement that the client be told it is an extra-label use
known allergies or adverse drug reactions should be flagged of a drug.
602 Drug Administration
Figure 46.1 Intensive/intermediate care unit order-treatment sheet examples. Source: Reproduced with permission from the
University of Georgia Veterinary Medical Center.
Routes of Drug Administration death. The route of administration should be specified in the
order sheet, and the drug must be verified as having been
The route of drug administration must be appropriate to pre- administered in the manner requested. When using a multi-
vent serious adverse effects or even death. Drugs can be use vial, the top of the vial should be cleaned with an alcohol
given by various routes, but deviation from an established swab prior to insertion of the needle to prevent possible con-
safe route could lead to severe complications, including tamination of the bottle. In the same regard, prior to drug
Routes Rof Doug AdmimesuDrumRi 603
administration into an IV catheter port, the site should be fluid line for incompatible drugs, the line must be flushed
cleaned with an alcohol pad. For convenience, the swabs between the administrations. The flushing can be done
should be kept in multiple locations throughout the ICU. with 0.9% NaCl or the fluid pump on the line can be allowed
The most common route of drug and fluid administra- to run for 10 minutes before administering the second
tion in the ICU setting is via an indwelling IV catheter. drug, to allow time for the first drug to be moved through
Many of the medications given in the ICU can be delivered the line. Incompatibilities may range from immediate pre-
through the Y-port of the IV fluid line. Compatibility with cipitation (formation of particles) to an undetectable but
the fluid and additives must be established prior to drug potentially dangerous pH change. A compatibility chart of
administration through any IV port. When using the same commonly used drugs in the ICU can be found in Table 46.1.
Table 46.1 Compatibility chart for commonly used drugs in the ICU. The following are the sources for this chart:
Dexamethasone SP
Compatibility chart
Calcium gluconate
Diphenhydramine
Cefazolin sodium
Buprenorphine
Aminophylline
Butorphanol
Dobutamine
Epinephrine
Doxycycline
Furosemide
Famotidine
Dopamine
Ampicillin
Diazepam
Diltiazem
Fentanyl
Atropine
Heparin
Aminophylline c c c c c c x ? x x c x c c c
Ampicillin c c ? x ? x x x x x c c ?
Atropine c c c x c c c c c
Buprenorphine c
Butorphanol c c x c c c c x c
Calcium gluconate c ? c ? ? x c c c c
Cefazolin sodium c ? c x c x x x x ? ? c
Dexamethasone SP c ? c x c x x c x c c c
Diazepam x x x x x x c x x x x x x x x
Diltiazem ? ? c c x c c c c c c x ?
Diphenhydramine x x c c x ? x c c c x ?
Dobutamine x x c c x x x x c c c c c c x x
Dopamine c x x c x c c c c c c x c
Doxycycline x x x x c c c c
Epinephrine x x c c c c c c c c c
Famotidine c c c c c ? c x c c c c c x c
Fentanyl c c c c c c c c c c
Furosemide c c c c c x x x x x c c x c c c
Heparin c c c c c c x ? ? x c c c c c c c
Hydromorphone c ? c c ? ? x c c c c c c c c
Insulin x c x ? x x x ? ?
Ketamine x c ? c c x
LRS c c c c ? c c c ? c c c ?
Lidocaine HCl c x c x c x c c c c x c c c c
Magnesium sulfate c x c ? x x x c c c c
Mannitol x c c
Maropitant
Metoclopramide HCl c x c c x ? x c c ? c c x c
Metronidazole c ? c x c x c
Midazolam c x c ? c c c x x c c x c c c x c
Morphine x c c c c c ? c c c c c c c c x x
Ondansetron x x c c ? ? c c c c c c x c
Pantoprazole c c x x ? ? ? x x x x ? ? c ? x ? ? ?
Pentobarbital sodium c c x x x x x x x x
Phenobarbitol c c c x x x x x x c
Potassium chloride c c c c c c c x c c ? c c c c c c
Potassium phosphate x ? c x x c
Propofol c c ? c c c c x c ? ? c c c c c c
Ranitidine c ? c x c ? c c c c c c c c c
Sodium bicarbonate c x c x x c ? x x x x x ? c c c
Sodium chloride c c c c c c x c c c c c c c c c c
Trimethoprim–
x x x x c x x x x c
sulfamethoxazole
Unasyn c c x x x x x c c
c, compatible; x, incompatible; ?, conditional; LRS, lactated Ringer’s solution.Sources: Plumb (2015) [1]; Trissel (2013) [2]; Lexi-Comp (2019) [3].
Lactated Ringers soln
Pentobarbital sodium
Potassium phosphate
Metoclopramide HCl
Sodium bicarbonate
Potassium chloride
Magnesium sulfate
sulfamethoxazole
Sodium chloride
Hydromorphone
Trimethoprim -
Metronidazole
Phenobarbitol
Lidocaine HCl
Pantoprazole
Ondansetron
Maropitant
Midazolam
Ranitidine
Morphine
Ketamine
Mannitol
Propofol
Unasyn
Insulin
c x ? c c x c c c x x x c c c c c c c c x ?
? c x x ? x x ? x c x c c c ? x c x c
c c c c c c ? c c c ? c c
x
c x c c ? c ? x c c x c
c c ? x c ? c c x c x x
? c x ? c c c c ? x c c x c c x
c ? c x ? ? c ? x c c c c c x
x x c ? x x x x x x ? ? x x x x x x x ? x x
c ? c c c c c c x x x c c c ? c c x
c x c c ? c c c x x x c x c c x c x
x c c x c x c ? x x ? x ? c x c x x
x c c c ? x c c ? c ? c x c x x
c ? c c c c x x c c x c x x
c c x c c ? c c c x c
c ? c c c c c c x c c c ? c x c
c c c c c c c c c ? x x c c c c c x
c ? x c c ? c x ? ? x ? c c c c c x
c ? x ? c c c c x x c ? c c c c c c ? c
c c c c c c c c c x c x c c c x c c c
c x c c c ? ? ? ? x x ? c x x c
c ? c c c c ? x x c x c x
c c c c c c x c c c c c c c ? c c
c c c c c c x x ? c ? c x c x
c c c c c c c c ? c c ? x c ?
c c c x x c c c x
c x
c c c c c c c c c c x c c x c x c x
c c c c c c ? ? c
c ? c x c c c c c ? x x ? ? c x c x x
c ? c c c c c c c c c ? x x c ? c x c ? c
c ? c c c c c c c x x x c c x c x x
x ? ? c x ? x x x ? ? ? x c x c x x ? c c
c x c x x x x c c x c x
x x c ? x x x c c x c c x
c c c c x c c c c c c c c c c x
x c c c ?
c c ? ? c x ? ? ? x c c c c c c c x
c ? c c c x c c x x x c c c c x
x c x ? x x c x x x x ? x c c c c c c x
c c c c c c c c c c c c c c c c c c ? c
c x c x ? x x x ? x x x x ? x x ? c x
c c x c x c x c x c
To minimize errors, one person should be responsible for patient is disconnected from fluids, patency can be difficult
setting up the fluids. When a patient is initially set up on IV to assess because bandages are in place for catheter protec-
fluids, the tubing should be purged of air by filling the line tion and support. Since catheters may not spontaneously
with fluid; this is done to prevent air embolus. Only one per- bleed back when aspirated, palpation of the vessel that is
son should be responsible for the addition of fluid additives to being flushed may be necessary to ensure patency. If the
avoid the potential of exceeding the ordered concentration. flush is given in a pulsatile fashion, the fluid can be felt
Certain drugs, such as mannitol or blood products, may traversing the vein. Fluid that diffuses into the surrounding
require the use of an in-line filter to prevent the infusion of tissue, resulting in tissue swelling, may be due to a catheter
crystals, particulate matter, or clots. Microfilters of that is extravascular.
150–170 μm pore size are commonly used with blood prod- In the neonate or very small patient, an intraosseous (IO)
ucts to remove clots, larger red blood cells, and platelet catheter may be used. IO catheterization provides rapid
aggregates. Finer filters with 18–40 μm pore size can be access to the central circulatory system [6]. IO catheteriza-
used with drugs such as mannitol to remove microaggre- tion should not be performed if there are skeletal abnor-
gates and crystals. Crystals can be seen as small white pre- malities, overlying skin or wound infections, abscess over
cipitates or cloudiness in the IV line. The use of filters with the bone, bone fractures, or sepsis. The bony sites most
blood products prevents the possible infusion and forma- commonly used include the flat medial surface of the prox-
tion of emboli. Drug crystals can be irritating to the vein. imal tibia, tibial tuberosity, trochanteric fossa of the femur,
Filters should be changed if they become occluded or with wing of ilium, ischium, and the greater tubercle of the
each new syringe drug or bag of blood product. Frequent humerus. If more than one hole is placed through a bone
changing of the filter will assure its proper filtering function. cortex, extravasation of fluid or medication into the subcu-
taneous (SC) tissue may occur. When administering IO flu-
ids, observe for fluid extravasation; if it occurs, the needle
Drug Delivery: Venous Access should be removed and another bone site chosen. A bone
should not be reused for 12–24 hours after perforation of a
When an IV catheter is used for fluid or drug administra- cortex [6]. If the needle is correctly placed and fluid does
tion, the catheter must be verified to be in the vein and pat- not flow freely, rotate the needle 90–180 degrees to move
ent. Although catheters are generally flushed each time the the beveled edge away from the inner core.
Case Study 46.1

A four-year-old 6.8 kg domestic shorthair male cas- initiated. The cat was immediately intubated, and exter-
trated cat was presented to the ICU for recovery follow- nal cardiac compressions were instituted. An IV dose of
ing emergency surgery for a suspected liner foreign atropine at 0.04 mg/kg was given followed by an IV
body. At surgery, a single enterotomy was performed at dose of epinephrine at 0.01 mg/kg. Resuscitation
the distal jejunum to remove a string foreign body. The attempts continued for 10 minutes, with ventilation at
gastrointestinal tract was deemed to be healthy. Closure 10 breaths/minute and cardiac compressions 100 times/
was done in a routine manner. The cat was stable minute. Red fluid was seen flowing up into the endotra-
through the surgical procedure with blood pressure, cheal tube and resuscitation efforts were discontinued.
heart rate, respiratory rate, mucous membrane color, It was determined that when the fluid therapy was
body temperature, and pulse oximetry monitored every begun, the administration set had not been purged of
five minutes. Fluid therapy was to continue with air; when the fluid pump was started; the air in the set
Plasma-Lyte 148 with potassium chloride (KCl) added at was given as a bolus to the cat via the IV catheter. This
20 ml/hour IV in the ICU. The ICU technician hung the resulted in a fatal air embolism. A standard IV adminis-
bag of Plasma-Lyte 148 with the administration set tration set either 60 drops/ml or 10 drops/ml contains
attached into the fluid pump. A CRI dose of metoclopra- 10 ml air. The drip set and extension line used in this
mide had yet to be added to the fluid bag so the line case had an air volume of 24 ml.
had not been filled with fluid. Unknowingly, the sur- The actual cause of death is entrapment of air in the
geon hooked the administration set to the cat’s IV port, right ventricular outflow tract leading to outflow obstruc-
set the drip rate and started the fluid administration tion and increased venous pressure due to an air lock
pump. Approximately 10 minutes later, the cat suffered and decreased myocardial contractility [4, 5]. The lesson
a sudden cardiac arrest. The cat was taken from the of this case underscores the importance of having only
cage and placed in left lateral recumbency on a central one person responsible for setting up and instituting
table; cardiopulmonary cerebral resuscitation was fluid therapy in the patient.
Drug Delivery: Enteral 607
A standard administration set is used to deliver fluids. clogging of the tube should occur, first try to aspirate the
The IO needle or catheter is secured by placing a tape but- tube with a 6- or 12-cc syringe. If aspiration does not clear
terfly around the hub and then suturing it to the skin. The the tube, it may be cleared by flushing the tube with an
entrance area should be covered and wrapped as with an acidic brown soda such as cola. It is advisable to use a 1-cc
IV catheter. The needle should be protected from break- syringe for the purpose.
age or bending. The fluid rate in 18–25 gauge IO needles is
limited to 11 ml/minute with gravity flow and 24 ml/min-
Oral Medications
ute with 300 mmHg pressure [6]. It is suggested that an IO
needle or catheter can remain in place for 72 hours if Oral medication should be given only to those patients that
aseptic catheter maintenance is performed [6]. The risk are capable of active swallowing. Active swallowing is nec-
factors for osteomyelitis are sepsis and catheter use that essary to prevent aspiration or possible erosion of the
persists for several days. Substances that can be infused esophagus. A caustic medication that is not properly swal-
via an IO needle or catheter include blood and blood lowed can remain within the lumen of the esophagus.
products, crystalloid and colloid fluids, amino acids, When a patient is allowed food and is eating it is usually
dextrose, aminophylline, antisera, antitoxins, atropine, best to give oral medication in some type of food, which
aureomycin, calcium gluconate, cefoxitin, dexamethasone, may ease administration of the medication. If a patient is
diazepam, digitalis, diphenhydramine hydrochloride, not allowed food, it may be helpful to follow the oral medi-
dobutamine, dopamine, epinephrine, insulin, morphine, cation with a dose of water that is delivered via a small
penicillin, procaine hydrochloride, radiopaque dyes, syringe. This helps to ensure that the medication is swal-
streptomycin, sulfadiazine, sulfathiazole, thiopental lowed and decreases the likelihood of its adherence to the
sodium 5%, and vitamins [6]. The use of alkaline or hyper- esophagus, where it could potentially cause esophagitis or
tonic solutions results in edema, pyknotic marrow nuclei, stricture. Timing of oral medication administration in rela-
and decreased cellularity. The changes will spontaneously tionship to feeding can be important. Certain medications
resolve within four to six weeks. should be given with food, prior to feeding, or on an empty
stomach. Medication administration should be avoided
with certain types of food; for example, the antibiotic doxy-
cycline is not to be administered with dairy products.
Drug Delivery: Enteral
Trazodone, an oral human-labeled product, is a seroto-
nin type 2a antagonist/reuptake inhibitor that is commonly
Feeding Tubes
used to provide short-term relief of anxiety in hospitalized
Critically ill patients often have indwelling nasogastric dogs and cats. It is contraindicated in patients receiving
(NG), nasoesophageal (NE), or gastrostomy tubes. These monoamine oxidase inhibitors such as amitraz and possi-
ports can be used to administer medications that are bly selegiline. When trazodone is used with other seroton-
labeled to be given orally. When dealing with a fractious ergic drugs it is possible to precipitate serotonin
patient that makes administration of oral medication syndrome [7]. Other drugs that could also contribute to
impossible, most oral medications can be crushed and serotonin syndrome include amitriptyline, tramadol, and
dissolved in water to administer through the enteral feed- ondansetron [8]. This points to the importance of knowing
ing tube. An oral medication that has a film coating or is the type of drugs a patient is on when they may be taking
a sustained release preparation should not be crushed, as several medications at the same time.
this will change the rate of delivery of the drug, usually Sucralfate is commonly given to treat gastrointestinal
resulting in a more rapid uptake and possible overdose. ulcers and esophagitis. It is an orally administered agent,
Many oral medications can be administered via NE, NG, frequently given as a slurry, as the pill will readily dissolve
or gastrotomy tube; it is important to confirm how the in a syringe of water. Sucralfate may interfere with the
oral medication is to be given prior to administration. absorption of other oral medications such as fluroquinolo-
Enteral medications should not be delivered via jejunal nes, fat-soluble vitamins, digoxin, and tetracyclines, and
feeding tubes, as many of these drugs require the acidity therefore dosing should be separated by at least two hours.
of the stomach to allow their absorption. Oral vitamins Sucralfate is most effective in an acidic environment; there-
could be given via a jejunal tube. Sucralfate is often used fore, an oral H2 blocker should be given 30–60 minutes
to coat the esophagus that has been injured by the pres- after the administration of sucralfate. The best effect will
ence of an esophageal foreign body; therefore, it must be be seen if the sucralfate is given on an empty stomach, one
given via the oral cavity. It is necessary to flush with a hour prior to feeding or two hours after feeding [9].
volume of water adequate to fill the feeding tube after Activated charcoal is used as an absorbent in the acutely
drug administration to prevent the tube from clogging. If poisoned patient. Charcoal is administered orally, and
some patients will eat the charcoal if it is mixed with a medication or fluid needs to be delivered, a larger gauge
small amount of baby food, cheese, or canned pet food. needle such as an 18–20 gauge may be used to deliver the
This mixing technique makes administration easier and volume in a timely manner. Note that some fluid may leak
potentially cleaner than using a dose syringe. If the patient from the skin hole.
will not readily eat the charcoal mixture, the liquid char- A new formulation of buprenorphine, Simbadol®
coal is given via a dose syringe orally. If the animal will not (Zoetis) has been developed for use in the cat. It is given
tolerate an oral dosing syringe, an NG tube can be placed once daily SC, for up to three days to treat postoperative
for administration. The NG tube is placed in the same man- pain. It is a higher concentration than the traditional
ner as for feeding. The tube length is measured to the last buprenorphine products. The extended duration should
rib to ensure placement in the stomach. The nostril is be taken into account when used in combination with
numbed with a drop of viscous 2% oral topical lidocaine other agents. In addition, buprenorphine can be more dif-
solution. The tube is gently passed through the ventral ficult to reverse compared with other opioid agents, so
nasal meatus; as the animal swallows it is threaded down adverse effects may be more persistent due to the long
the esophagus into the stomach. Proper tube placement is duration of this agent [11].
verified via a lateral radiograph of the thorax. The charcoal Nocita® (Elanco US), a new bupivacaine liposome sus-
is then administrated through the NG tube. Owing to the pension is used as a single-dose infiltration into tissues at a
viscosity of charcoal suspension, it may require dilution surgical site incision closure. The slow release of the bupi-
with water to allow passage through the NG tube. Following vacaine from the liposomes will provide local analgesia for
administration of the charcoal, the NG tube can be removed 72 hours. This agent is not meant to be delivered by any
or drawn back to the appropriate NE location for continued route other than tissue infiltration. When administering
treatment. If the charcoal is given too rapidly, it can induce other amide local anesthetics such as lidocaine or bupiv-
emesis and increase the risk for aspiration. The administra- acaine, the dosage may need to be reduced due to the lipo-
tion of charcoal should be separated by at least three hours somal bupivacaine [12].
from other orally administered agents.
Buprenorphine is commonly given by a parenteral route
but can be given via the oral transmucosal (OTM) route. Drug Delivery: Transdermal Patch
This can be useful in patients that object to needles and do
not have an IV catheter in place. The volume required A human-labeled fentanyl transdermal patch can be used
makes it easier to deliver in small dogs and cats. The OTM to provide long-term analgesia to dogs and cats. The patch
route has improved bioavailability as compared to oral. The is applied to clipped and clean dry skin. Holding the patch
injectable buprenorphine is placed on or beneath the in place for two to three minutes with a warm hand will
tongue or into the cheek pouches via a syringe [10]. help the patch to adhere. People handling a patch should
either wear gloves or rinse their hands with water after-
wards to remove any residue. The patch has a highly vari-
Drug Delivery: Subcutaneous Route able absorption and efficacy among individual animals,
this can impact the effect seen when used in conjunction
The SC route is commonly used for insulin, famotidine, with other agents. Dose of other agents may need to be
and metoclopramide. When giving a SC medication after decreased to avoid bradycardia and depression. Onset of
entry under the skin the needle should be aspirated to action may take several hours and the duration can vary
ensure it is not in a vessel and still under the skin. Doses of from three to five days. Patches should be dated when
SC medication are checked after injection to ensure that placed to keep track of duration of application. Patches are
the site is not wet. If there is question as to whether the commonly applied to the lateral thoracic wall or lumbar
medication was administered or went through the skin, areas. The patch should not be exposed to exogenous heat
the clinician should verify and determine whether the sources such as heating pads or forced hot air warming
patient should be redosed. When administering a SC med- blankets as this may lead to increased drug release and
ication it is best to administer the dose between the shoul- absorption. The patch should be kept dry and clean. Patches
der blades with the skin tented. If the area between the can be repeated but monitor the skin at the patch site as
shoulder blades is not available due to trauma, bandage, rashes may develop, if this should occur a new site should
skin infection, or scarring, the SC dose is administered be chosen for the next patch. If is it suspected that the
where an appropriate skin tent can be obtained. When patient has a developed severe respiratory depression or
performing SC drug administration, it is best to use a small bradycardia from the fentanyl the patch should be removed,
gauge needle such as a 25 gauge to avoid leakage of the and if necessary, the adverse effects may be reversed with
agent out of a larger skin puncture. If a large volume of naxolone [13].
Constant Rate Infusion 609
Drug Delivery: Intramuscular Route labeled and facing the front of the cage for easy visualiza-
tion (Figure 46.3).
Intramuscular (IM) injection can be used for the adminis- The drug label on the fluid bag should be large and easy
tration of agents such as analgesics and insulin. The com- to see (Figure 46.4). The label is to alert personnel that the
monly used muscles for the site of injection are the epaxial, bag has an additive, and therefore these fluids should not
biceps femoris, semitendinosus, or the triceps. The gauge be used to give a fluid bolus to the patient. A fluid bolus
and length of the needle are important to ensure that the
medication is properly deposited in the muscle belly and
not in the fat or fascial plane, which could diminish drug
absorption or result in delayed adsorption.
Insulin can be given IV or IM for the treatment of the
unregulated diabetic. Once the critical state resolves, long-
term insulin therapy is usually initiated; long-term insulin
therapy is generally administered by the SC route.
Furosemide can be given as a single IV or IM injection or
as a CRI in the treatment of renal failure, heart failure, and
pulmonary edema.
Constant Rate Infusion
A CRI consists of a calculated volume of medication at a

specific concentration that is added to a set volume and
type of fluid for continuous delivery. A CRI can increase
the efficacy of a drug because it delivers a steady dose of
the agent, which can help maintain steady plasma concen-
tration and enhance safety through slower delivery. A CRI
may be used to deliver antibiotics, long-term analgesics, or Figure 46.3 Multiple syringe pumps clearly labeled and facing
even sedative drugs for animals that require longer-term the front of the cage.
sedation or anesthesia. The drugs can be given either
mixed in the daily fluids with the fluid bag clearly labeled
with the type, amount, and rate the additive is to be admin-
istered or via a separate syringe pump or fluid bag
(Figure 46.2). Critically ill patients may require more than
one infusion for treatment and hemodynamic support,
when using multiple syringe pumps all should be clearly
Figure 46.2 Syringe pump with a proper label. Figure 46.4 Fluid bag with additive label.
from a bag containing an additive could be unsafe and every separate dose syringe. Drawing up a one-hour vol-
potentially lethal, such as a fluid bolus containing KCl. It ume and using a syringe pump are recommended to pre-
may be safer for certain agents to be given via a separate vent crystallization of the mannitol and to ensure
fluid bag or a syringe pump. The separate bag or syringe appropriate changing of the filter. Sodium or potassium
pump will allow for a more accurate rate of delivery and chloride can cause mannitol to precipitate out of solution if
easier monitoring, and avoid potential under or overdosing the mannitol concentration is 20% or greater [17]. Owing to
when fluid rates are changed. Accurate and obvious labe- its hyperosmotic nature, it is best to administer mannitol
ling is fundamental for all medications delivered by through a large central vein catheter.
CRI. When labeling, the volume of diluent should be listed Metoclopramide is commonly given as a CRI within the
in case there is a question as to concentration; listing the animal’s regular IV fluid therapy. Metoclopramide is light
quantity of diluent allows calculations to be verified. sensitive so the fluid bag should have a covering to prevent
When insulin is given as a CRI, it should be infused light interaction. It is compatible with 5% dextrose in water,
through an administration line separate from the fluid 0.9% NaCl, 2.5% dextrose in 0.45% NaCl, Ringer’s and lac-
therapy line. This separation of insulin from the fluids tated Ringer’s solutions (LRS).
allows for adjustments to be made in the insulin dose with-
out alterations in the fluid therapy rate. Regular insulin
adsorbs to the surfaces of IV infusion tubing and filters. Intravenous Nutritional Support
Insulin adsorption to the administration equipment can
lead to a 20–30% decrease in its potency. The adsorption Total parenteral nutrition (TPN) is administered through a
process is instantaneous, with most insulin adsorption central venous catheter that is specifically designated for the
occurring within the first 30–60 minutes. To saturate bind- purpose. The catheter is placed using aseptic technique into
ing sites and therefore deliver a more predictable dose the jugular, medial, or lateral saphenous vein and advanced
when giving an IV infusion, run 50 ml of the insulin- to a central position. TPN is hyperosmolar, so a central vein is
containing solution through the IV tubing, discard this vol- needed for administration. If a central catheter cannot be
ume, and then begin the infusion [14]. obtained, partial parenteral nutrition (PPN), which has a
Drugs such as diazepam are used as a CRI to treat severe lower osmolality, can be provided by use of a peripheral
seizure disorders. This light-sensitive drug may adhere to venous catheter. This catheter should also be placed in a ster-
the plastic tubing of the IV line and should not be stored in ile manner. Once administration of PPN or TPN has begun,
plastic syringes long term. It has been found that diazepam the administration IV line is never disconnected until the bag
10 mg in a 2-ml volume can be stored in a polypropylene- is empty. The bag travels everywhere with the patient to
polyethylene syringe for four hours; longer-term storage in ensure sterility. If the patient is going to a visiting room the
a syringe results in absorption of the drug to the plastic sur- fluid pump can be placed on a mobile IV pole to allow the
face, which deceases the amount of drug available [15]. administration to continue. If the bag must be removed from
The propylene glycol in diazepam is incompatible with the fluid pump, the line backflow of blood is prevented by
most other fluids, and thus the drug requires a dedicated clamping the roller clamp of the line and by clamping the
delivery system. Do not administer if a precipitate forms T-port at the catheter. No other products should be given via
and does not clear [16]. Diazepam is irritating to veins and this administration line or catheter to maintain sterility and
should only be given IV via a large central vein. It is sug- decrease the potential for bacterial contamination.
gested that high-dose dextrose, 7.5% or greater, is also best
delivered by a central vein because of its hypertonicity. It is
recommended that drugs or agents that have an osmolality Fluid Additives
greater than 600 mOsm/l be infused via a large or central
vein to avoid the possible complication of vein irritation or Additives are commonly added to the fluid bag. They
phlebitis that may occur if small peripheral veins are used. should be noted on the bag label (Figure 46.4). The label
Light-sensitive drugs are generally stored in brown bottles should note the amount of the product added; if it is an
and should be protected from the light if they are being electrolyte, the final electrolyte concentration per liter
delivered as a CRI. should also be listed.
The hyperosmotic agent mannitol is commonly used for Additives commonly given to patients in the ICU include
treatment of head trauma, renal failure, and glaucoma. potassium salts such as KCl or potassium chloride (KPO4).
Warming of the fluid line decreases the likelihood that the Potassium must be diluted as noted on the bottle and given
mannitol will recrystallize. Mannitol should be adminis- slowly when administered intravenously. Undiluted and
tered with a filter to prevent precipitates from being intro- rapid IV administration may result in a fatal hyperkalemia.
duced intravenously. The filter should be changed with The rate of IV potassium chloride should not exceed
Antibiotics 611
0.5 mEq/kg/hour. The potassium chloride can be supple- temperature. The reconstituted solution can be further
mented, and is compatible with commonly used IV replace- diluted with 5% dextrose in water or 0.9% NaCl. The agent
ment fluids. The fluid bag should be clearly labeled that it is given intravenously [22].
contains potassium and the concentration of the potas- Vitamin K1 is used in the treatment of anticoagulant
sium. It is best to have a consistent method for noting the rodenticide toxicities. Oral absorption is enhanced when
concentration, such that all measurements of potassium given with fatty foods or by giving canned dog food with
are denoted as per liter volume regardless of the bag vol- the vitamin K. IV administration is not recommended due
ume. For example, to a 1000 ml bag of LRS with 4 mEq to the potential for anaphylactoid reactions, and IM injec-
already present is added 16 mEq of KCl; the final concen- tions may result in bleeding. An initial SC dose is usually
tration would be noted as 20 mEq/l KCl total on the bag given, then long-term oral therapy is instituted. When giv-
label. In some patients, there is a deficiency in potassium ing the SC dose, use a small-gauge needle and administer
and phosphate, making the use of KPO4 warranted. KPO4 at multiple sites [23].
must also be diluted prior to IV administration, and is com- Pralidoxime chloride is used to treat organophosphate
patible with dextrose in water and 0.9% NaCl [18]. As with poisoning. It works best as an antidote when used in com-
KCl, KPO4 should not be delivered at a rate greater than bination with atropine. It can be given as IM or slow IV
0.5 mEq K + /kg/hour. KCl and KPO4 can be combined injection initially, with subsequent IM or SC doses [24].
within the same fluid bag as long as the concentration of
each potassium source is labeled and the appropriate rate
of administration for the combined volume is listed on the Antibiotics
order sheet.
Calcium gluconate or calcium chloride 10% are used to Antibiotics that must be diluted prior to administration
treat hypocalcemia. Calcium should be given slowly intra- should have the dilution instructions listed on the bottle. It
venously over a 10-minute period and the electrocardio- is important to note concentration, date, and time of recon-
gram monitored during the infusion to watch for the stitution, as the shelf life can vary with different concentra-
development of bradycardia. If bradycardia develops, the tions; this is also important for medications that come with
calcium infusion should be slowed or stopped temporarily. a vial of diluent for dilution. Not all staff in the hospital may
Calcium chloride is extremely caustic if administered be clear on the procedure for dilution of that particular
extravascularly. Calcium gluconate can be given SC if medication and may dilute the drug to a different concen-
diluted with an equal volume of 0.9% NaCl [19]. tration. How the dilution was prepared and how the antibi-
Sodium bicarbonate is used to treat metabolic acidosis. A otic was given must be recorded. The antibiotic ampicillin
calculated dose is given slowly IV; an initial bolus dose can at a dilution of 100 mg/ml has a shelf life of 30 minutes
be given over 20–30 minutes with the remainder of the before degradation of the product. The antibiotic ampicillin
dose given over the next several hours. It can be given with sodium/sulbactam sodium, Unasyn® (Pfizer), diluted to
fluids such as 5% dextrose in water, 2.5% dextrose in 0.45% 30 mg/ml has a refrigerated storage time of 72 hours.
NaCl, Ringer’s solution with dextrose, and 0.9% NaCl [20]. Amikacin sulfate should be used cautiously – if at all –
with the loop diuretics such as furosemide or osmotic diu-
retics such as mannitol, as there may be in increase in the
Agents Used to Treat Specific Toxicities nephrotoxic or ototoxic effect of the amikacin [25]. The
concern for nephrotoxic and ototoxic effects will also hold
N-acetylcysteine (NAC) is considered the treatment of true for the other aminoglycoside, gentamicin sulfate.
choice for acetaminophen toxicity [20]. The recommended Enrofloxacin is used extra-label as an IV injection. It is
regimen for use of NAC is an initial dose of 140 mg/kg IV diluted 1 : 5 with 0.9% NaCl for slow IV administration
up to 280 mg/kg if the toxicosis is severe, followed by over 10–45 minutes. The injectable form of enrofloxacin
70 mg/kg every six hours for seven additional treatments. must not be mixed with or come in contact with any
NAC may cause nausea and vomiting when given orally. magnesium-containing solution such as Normosol and
Hypotension and bronchospasm can occur with rapid IV Plasma-Lyte, as microprecipitants may form and lodge in
administration. Phlebitis occurs with perivascular leaks. It the patient’s lung leading to morbidity and mortality.
is best given as an IV infusion of a 5% solution, made by Enrofloxacin should be used cautiously in cats, as doses
diluting 10–20% NAC in 5% dextrose or 0.9% NaCl, over higher than 15 mg/kg have been associated with ocular tox-
30–60 minutes through a 0.2-μm filter [21]. icity and subsequent blindness [26].
Fomepizole 4-methylpyrazole is used to treat ethylene Metronidazole is commonly used to treat anaerobic bac-
glycol poisoning. Once the agent is reconstituted it should terial infections. Accurate dosing is important as neuro-
be used within 72 hours; it can be stored at room logic toxicity may result in dogs that receive a high dose
either acutely or long term. An aluminum hub needle within 12 hours and any unused portion remaining in the
should not be used with this drug, as the aluminum can vial should be discarded.
cause a reddish-brown discoloration of the solution [27]. Nitroprusside sodium is used intravenously to treat
severe hypertension. When using this agent, blood pres-
sure must be monitored diligently to prevent severe hypo-
Inotropes and Vasoactive Agents tension. Excessive doses, prolonged therapy greater than
three days, or severe hepatic or renal insufficiency may
Inotropes and vasopressor agents may be necessary for the lead to profound hypotension or cyanogen or thiocyanate
treatment of hypotension. Dobutamine and dopamine are toxicity. Nitroprusside powder is diluted in 5% dextrose in
commonly used. If the hypotension is severe and does not water and protected from light by covering the fluid bag.
respond to initial treatments, vasopressor agents such as The solution may have a slight brownish tint, which is nor-
norepinephrine, epinephrine, phenylephrine, and vaso- mal. Discard the product if the fluid is blue, dark red, or
pressin may be used. Dobutamine when diluted for admin- green in color. Once reconstituted, the nitroprusside solu-
istration should be used within 24 hours. The diluent can tion will be stable for 24 hours. Nitroprusside should be
be 5% dextrose in water or 0.9% NaCl. Dobutamine is com- given IV in a dedicated line, and extravasation should be
patible with 0.9% NaCl, dextrose–0.9% NaCl combinations, avoided. An infusion pump is recommended for delivery,
and LRS, and is administered as a CRI [28]. to avoid a sudden bolus of the agent [31].
Dopamine is also administered as a CRI. It is commonly
diluted with 5% dextrose in water, 0.9% NaCl, or LRS and
should be used within 24 hours. Solutions that are pink, Analgesics and Anesthetics
yellow, brown, or purple tinged indicate decomposition of
the drug and should be discarded [29]. Animals that require mechanical ventilation often need
Phenylephrine is used treat severe hypotension via its heavy sedation or light anesthesia to tolerate the endotra-
alpha-adrenergic effects. It is given intravenously via CRI cheal tube. Propofol is commonly used to help maintain
and is diluted in 0.9% saline or 5% dextrose in water. It ventilator patients or to treat refractory seizure condi-
should not be used if the solution is brown or contains a tions. Propofol is an IV anesthetic agent. It can be given
precipitate. Phenylephrine is compatible with the standard as an IV bolus or as a CRI to maintain anesthesia.
IV fluids [30]. Propofol does not contain any antibacterial agent and
Additional agents used to treat hypotension include nor- has the potential to become bacterially contaminated. It
epinephrine and vasopressin. Both are compatible with is not recommended to be used beyond 24 hours once the
standard IV crystalloid fluids. They are commonly diluted bottle has been opened. Cats may develop Heinz body
in 0.9% NaCl to ease administration. As with other ino- anemia from long-term use of propofol [32]. The product
tropes and vasopressors, it is recommended that each agent should not be used if the emulsion has separated.
be in a separate bag or syringe to allow for independent Propofol is compatible with the commonly used IV
adjustment of individual doses. replacement and maintenance fluids, and can be injected
Clevidipine is a dihydropyridine calcium channel blocker into a running IV line. When used as a CRI, propofol is
and is a smooth muscle vasodilator. It is used to treat fulmi- best delivered via syringe pump to assure an accurate
nant heart failure or severe hypertension and must be delivery rate. A new formulation of propofol has recently
administered as a CRI. The goal of administration is the become available, PropoFlo™ 28 (Zoetis). The preserva-
reduction in blood pressure. It is titrated to effect by dou- tive benzyl alcohol is added, allowing a shelf life of
bling the dose every 90 seconds. As the blood pressure 28 days. This product is only labeled for IV use in the dog
approaches goal, the infusion rate should be increased in and should not be used in the cat. Benzyl alcohol is
smaller increments and titrated less frequently. A primary potentially toxic to the cat, owing to the cat’s lack of ade-
concern is hypotension. Heart rate and blood pressure quate glucuronic acid conjugation [32].
should be measured continually during the infusion along
with perfusion parameters until the patient is stable. If the
patient becomes hypotensive, the drug is reduced or turned Chemotherapeutic Agents
off and its effects will dissipate within a few minutes.
Aseptic technique should be used when handling this med- Many chemotherapeutics are given IV or even SC. Patients
ication. Clevidipine should not be diluted and should not are given IV fluids to help maintain renal perfusion.
be administered in the same line as other medications. Cisplatin, streptozocin, L-asparaginase, pamidronate, and
Once the stopper is punctured, Clevidipine should be used dicarbizine are all commonly used chemotherapeutic
Drug Overdose 613
Case Study 46.2

A four-year-old domestic short-hair castrated male cat
was presented for upper airway dyspnea and ret-
ropharyngeal swelling. The cat developed cyanosis. He
had a right arytenoidectomy and a temporary tracheos-
tomy tube placed to improve ventilation and oxygena-
tion. While in ICU the cat had several episodes of
difficult breathing through the tracheostomy tube;
each time the cat received IV propofol to facilitate
removal of the tracheostomy tube for it to be cleaned
of mucous plugs. As the cat improved the tracheostomy
tube was removed for short periods of time; IV propofol
was used to reinsert the tube. The cat was in the ICU
and received multiple doses of propofol over a seven-
day period. On the seventh day a routine complete
blood count showed a hematocrit of 14% and 25–50%
Heinz bodies. On presentation the HCT was 40%; this
was a significant anemia that required treatment with
a packed red blood cell (RBC) infusion. The packed RBC
infusion improved the hematocrit to 19%, and the cat
recovered. It is important when sedating on multiple
days to be aware of the possible consequences that
sedative and anesthetic drugs may have. This may be
species or age related, as older or debilitated animals
will take longer to metabolize drugs, resulting in a pos-
sible prolonged effect [33]. Figure 46.5 Cage label for chemotherapeutic agents and
warning.
Lidocaine is used to treat cardiac arrhythmias and as
an analgesic. When used as a CRI, an initial loading dose
is administered to achieve an effective plasma concen-
tration, which is then maintained with the CRI. Lidocaine Drug Overdose
should be used cautiously in cats due to a high risk of
adverse events [34]. Lidocaine has the potential to be When a drug is inadvertently overdosed, an incident
toxic, with clinical signs of ataxia, nystagmus, depression, form should be completed and the clinician immediately
vomiting, seizures, bradycardia, and hypotension. notified of the event (Figure 46.6). The incident form is
Lidocaine is compatible with the commonly used IV used not to place blame but to track errors within the
replacement fluids. hospital and to improve and refine protocols. The
The fluid bag should be properly labeled as contain- patient’s vital signs should be assessed to gather baseline
ing lidocaine. The lidocaine solution containing epi- data and to evaluate patient stability in the event an over-
nephrine should not be infused IV; this product is used dose leads to a reaction. If the drug is capable of being
for local analgesia application, and IV use of this prod- reversed, the patient’s clinician will determine if reversal
uct could lead to cardiac arrhythmias [35]. is warranted. Reversal agents include naloxone for opi-
oids, flumazanil for benzodiazepines, and atipamazole
for the alpha-2 agonists. The possible adverse effects of
the overdosed drug should be investigated. If the over-
agents for the treatment of osteocarcoma. Gloves should be dose is severe and leads to increased length of hospitali-
worn when handling and administering these compounds. zation, higher costs, or the death of the patient, the
Gloves should also be worn when handling any bodily flu- hospital director should be informed. The owners should
ids from these patients (Figure 46.5). be made aware of the situation.
Figure 46.6 Incident reporting form. Source: Reproduced with permission from the University of Georgia Veterinary Medical Center.
References 615
Case Study 46.3

A male intact Akita was seen for a several-month history condition worsened and he went into cardiac arrest and
of collapse and paralysis. A neurological exam was per- died. It was later determined that the neostigmine was
formed. A test for myasthenia gravis was performed. The inadvertently administered at 10 times the recom-
dog received IV edrophonium and the response was mended dosage. It is important to question drug doses
noted. The dog immediately improved and was able to that seem to be wrong either in amount, in type, in route
move freely. This was considered a positive test for myas- of delivery, or for the species. If there is any doubt as to
thenia gravis, and the dog then received IM neostigmine the validity of a drug administration, the clinician in
for treatment. At the time of neostigmine administration, charge of the case should be notified and the proper
it was noted by technicians involved with the case that dosing information verified.
the amount of drug seemed to be a large volume. The The medical therapies that are required in an ICU situ-
drug was given, even though there was concern about ation can vary with each patient. The patient treatment
the amount of drug. The dog subsequently seizured, vom- sheet should have clear instructions as to dosage and
ited, and defecated but seemed to recover. Vomiting per- routes of administration. It is vital to be aware of all drug
sisted; treatment with IV and IM atropine was not interactions and effects of those medications in that
effective. The dog developed cyanosis and dyspnea. patient. Mistakes can be made by anyone; if there is a
Thoracaic radiographs reveled aspiration pneumonia. question regarding a drug, a dose, or route of administra-
The dog required mechanical ventilation to treat hyper- tion, it is better to investigate rather than make an error.
carbia and hypoxemia. The dog became hypotensive and Record keeping is instrumental to the successful treat-
developed acute respiratory distress syndrome. The dog’s ment and well-being of the patient in ICU.
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617
47
Pain Recognition and Management

Chiara Valtolina and Liza Lindeman
Accurate recognition and effective management of pain (neuropathic pain). This type of pain is pathologic and
are vital to veterinary critical care. Optimal pain control implies that tissue damage has already occurred. Pathologic
depends on a sound understanding of the physiology of pain is characterized by a low stimulus threshold and an
nociception, an ability to recognize pain behaviors, diligent exaggerated pain response to noxious stimuli (hyperalge-
and thorough pain assessment, and an understanding of sia) [3, 5]. Pathologic pain is felt at sites of injury (primary
the principles of multimodal therapy. We must also be cog- hyperalgesia) and in surrounding areas (secondary hyper-
nizant of potential analgesic-related adverse effects to rec- algesia or extraterritorial pain) [6–9].
ognize and manage them appropriately. Pain may also be classified as adaptive or maladap-
tive [10]. Adaptive pain encompasses nociceptive and
inflammatory pain, and it is a normal response to tissue
Nociceptive Physiology damage and confers tissue protection. Inadequate manage-
ment of adaptive pain may alter brain and spinal cord func-
The International Association for the Study of Pain (IASP) tion leading to maladaptive pain, which does not have
defines pain as an unpleasant sensory and emotional expe- protective properties and is challenging to control. The
rience associated with actual or potential tissue damage or longer the duration of pain, the more likely this switch to
described in terms of such damage (Table 47.1) [1]. maladaptive pain [5, 7, 10]. Intense or prolonged noxious
Because the IASP definition relies mainly on the indi- stimuli can alter nervous system function peripherally by
vidual patient describing the pain, Molony and Kent (1997) decreasing the threshold of nociceptors or centrally by
proposed an alternative definition for animals: “animal increasing the spinal neuron responsiveness through
pain is an aversive sensory and emotional experience rep- altered neuronal gene expression [5, 9, 11].
resenting an awareness by the animal of damage or threat Pathologic pain is pain that ceases to serve a protective
to the integrity of its tissues; it changes the animal’s physi- function and becomes maladaptive, degrading health, and
ology and behavior to reduce or avoid damage, to reduce functional capabilities. Pathologic pain may be acute or
the likelihood of recurrence, and to promote chronic. In a study evaluating pain in canine and feline
recovery” [2]. emergency admissions to a teaching hospital, inflamma-
Pain may be classified as physiologic or pathologic. tion was identified as the cause in 70% of patients [12]. By
Nociceptive or physiologic pain is an acute pain that arises contrast, chronic pain persists beyond the time frame
from noxious stimuli associated with the risk of tissue expected for a given disease or injury and has been arbitrar-
injury. Physiologic pain is proportional to stimulus inten- ily defined as persisting for more than three to six
sity, transient, and characterized by a high stimulus thresh- months [1, 5, 9]. Chronic pain may arise from sustained
old and narrow localization. Physiologic pain is protective noxious stimuli due to continuing inflammation or may be
because it induces withdrawal reflexes and avoidance independent of tissue injury. More than 200 clinical syn-
responses but it is rare in a clinical setting [3–5]. dromes are associated with chronic pain including cancer,
In the clinic, noxious stimuli are persistent and perpetu- osteoarthritis, and postamputation “phantom limb”
ated by inflammation (inflammatory pain) or nerve injury syndrome [3, 5].
618 Pain Recognition and Management
Table 47.1 Pain definitions.
Type of pain Definition
Adaptive pain (inflammatory) Spontaneous pain and hypersensitivity to pain in response to tissue damage and inflammation.
Occurs with tissue trauma, injury, surgery. Causes suffering. Responds to treatment.
Adaptive pain (nociceptive) Transient pain in response to a noxious stimulus. Small aches and pains that are relatively
innocuous and that protect the body from the environment.
Allodynia Pain caused by a stimulus that does not normally result in pain.
Analgesia Absence of pain in response to stimulation that would normally be painful.
Anesthesia Medically induced insensitivity to pain. The procedure may render the patient unconscious
(general anesthesia) or merely numb a body part (local anesthesia).
Causalgia A syndrome of sustained burning pain, allodynia, and hyperpathia after a traumatic nerve lesion,
often combined with vasomotor and sudomotor dysfunction and later trophic changes.
Distress Acute anxiety or pain.
Dysphoria A state of anxiety or restlessness, often accompanied by vocalization.
Hyperalgesia An increased response to a stimulus that is normally painful.
Hypoalgesia Diminished pain in response to a normally painful stimulus.
Hyperesthesia Increased sensitivity to stimulation, excluding the special senses.
Hyperpathia Painful syndrome characterized by an abnormally painful reaction to a stimulus and an increased
threshold.
Maladaptive pain (functional) Hypersensitivity to pain resulting from abnormal processing of normal input.
Maladaptive pain (central) Pain initiated or caused by a primary lesion or dysfunction in the CNS. Often called “central pain.”
Maladaptive pain Spontaneous pain and hypersensitivity to pain in association with damage to or a lesion of the
(neuropathic) nervous system.
Multimodal analgesia Use of more than one drug with different actions to produce optimal analgesia.
Neurogenic pain Pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in the
peripheral or central nervous system.
Neuropathic pain Pain initiated or caused by a primary lesion or dysfunction in the peripheral or central nervous
system.
Nociceptor A receptor preferentially sensitive to a noxious stimulus or to a stimulus that would become
noxious if prolonged.
Nociception Physiologic component of pain consisting of the processes of transduction, transmission, and
modulation of neural signals generated in response to an external noxious stimulus.
Noxious stimulus A noxious stimulus is one that is damaging to normal tissues.
Paresthesia An abnormal sensation, whether spontaneous or evoked.
Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Preemptive analgesia Administration of an analgesic before painful stimulation.
Wind-up pain Heightened sensitivity that results in altered pain thresholds both peripherally and centrally.
Nociception Peripheral nociception begins with specialized free nerve

endings (nociceptors) of primary afferent fibers located in
Nociception involves perception of noxious stimuli at cutaneous tissues, muscle, and viscera. These nociceptors
the site of injury, transduction into electrical signals, transduce high-threshold stimuli into electrical activity
transmission of that signal to the spinal cord, signal and transmit this information to the spinal cord [5, 8, 9, 13].
modulation by amplification or inhibition, and finally Nociceptors encode the localization, intensity, and dura-
supraspinal conduction and central integration to pro- tion of noxious stimuli. Most nociceptors are nonselective
duce a pain experience unique to the individual ion channels gated by temperature, chemical ligands, or
(Figure 47.1). This multiple component system of trans- mechanical shearing forces [5, 9, 10]. Once activated, the
mission and integration also permits modulation of channels permit sodium (Na+) and calcium (Ca2+) ion
nociceptive information [5, 9]. influx, producing an inward depolarizing current, which if
Nociception 619
Physiologic pain
Peripheral
Nerve
Dorsal
root ganglion Aβ Low Threshold (Pressure, Vibration)
Mechanoreceptors
Spinal cord
Aδ Aβ Aδ High & Low Threshold (Pressure, Pain)
C
I II Mechanoreceptors
III
Nociceptors (high)
IV
V
VI C High Threshold (Pain)
Mechanoreceptors
Thermoreceptors Aβ
Dorsal Aδ
root Nociceptors
C
Perception
Cortex
Projection Minimal
Thalamus Modulation or No
Tissue
Damage
Transient
Spinothalamic Transmission Protective
tract
Skin Transduction
Muscle
Bone Noxious Stimulus:
Joint Mechanical
Viscera Chemical
Thermal
Figure 47.1 Schematic diagram of the pathways of physiologic pain sensation. Minimal or non-tissue-damaging stimuli are
transduced by thermal, mechanical, and chemical peripheral nociceptors and transmitted to the dorsal horn of the spinal cord by Aδ
and C fibers that release glutamate, activating dorsal horn neuron receptors that mediate reflex responses and transient pain. The
pathways of nociception then involve stimulus transduction, transmission, modulation, projection, and perception. Source: Adapted
from Muir and Woolf (2001) [6].
of sufficient magnitude, activates voltage-gated Na+ chan- sensation of physiologic pain, fast pain, or “first pain,” which
nels, further depolarizing the membrane and initiating is sharp, localized, and transient. Aδ fibers have small recep-
bursts of action potentials. These are conducted from the tive fields and specific high-threshold ion channels activated
periphery to the central nervous system (CNS) along pri- by noxious thermal or mechanical input [5, 9, 13].
mary afferent nociceptive fibers [14]. Nociceptors, by vir- C fibers constitute most of the cutaneous nociceptive
tue of their specificity and threshold, constitute the first innervations, but they are also found extensively in mus-
and most important filter in nociceptive processing [8]. cle and viscera. They are small (0.25–1.5 μm in diameter)
Sensory nerve fibers are divided into three groups and unmyelinated with conduction velocities of only
(Figure 47.1). Aβ fibers are large myelinated sensory fibers 0.5–2 m/s. Their receptive fields are large compared with
activated by low-intensity stimuli; these fibers normally those of Aδ fibers. These characteristics contribute to the
conduct non-noxious information (touch, vibration, pres- nature of pathologic pain, slow pain, or “second pain,”
sure, and rapid movement). Aδ and C fibers are the princi- which is a poorly localized, dull, aching, or burning sen-
pal nociceptive primary afferents responsible for fast and sation that persists despite termination of the noxious
slow pain [5, 9, 13]. stimulus. C fibers are considered polymodal because they
Aδ fibers are small (1–5 μm in diameter), myelinated, rap- can be activated by thermal, mechanical, or chemical
idly conducting (5–30 m/s) fibers responsible for the stimuli [3, 5, 9, 13].
Afferent sensory nerve fibers enter the spinal cord via these neuropeptides are the mediators of pathologic pain,
the dorsal nerve root and then separate to innervate the development of neuropeptide antagonists offers the
second-order neurons within the gray matter. Aδ fibers hope of improved therapies for chronic pain states [5, 16].
terminate in laminae I, II, and IIa, whereas C fibers termi- Nociceptive pathways permeate the medulla, pons,
nate in laminae II, IIa, and V. Sensory fibers synapse first mesencephalon, diencephalon, and cerebrum.
at the level of the dorsal horn of the spinal cord where Modulation of pain responses occurs on four levels: spi-
initial integration and modulation of nociceptive input nal cord dorsal horn, the rostroventral medulla (RVM) of
occurs. Three principal paths are possible. Primary affer- the brainstem, the periaqueductal gray matter (PAG) in
ents may synapse with local interneurons (excitatory or the midbrain, and the thalamocortex. The thalamocorti-
inhibitory) causing modulation, with neurons involved in cal system produces both the sensory, discriminative
segmental spinal reflexes or with neurons that project to aspects of pain and the motivational, behavioral aspects
supraspinal structures [3, 5, 9]. of the pain experience. The thalamus integrates the pain
Three types of nociceptive neurons project from the dor- experience with other brain centers. Relay nuclei exist
sal horn to supraspinal centers [3]. Wide dynamic range between the thalamus; the limbic system (involved in
(WDR) neurons receive innocuous input from low- behavior and emotion), which includes the amygdala
threshold Aβ fibers in addition to nociceptive input from (conditioned fear and anxiety); the prefrontal cortex; the
Aδ and C fibers. WDR neurons respond in a graded man- hypothalamus (sympathetic autonomic activity); and the
ner over large receptive fields and often receive convergent PAG (fight-or-flight behavior), stress-induced analge-
inputs from visceral and nociceptive-specific (NS) neurons. sia [5, 6, 9]. The PAG is a key structure in the endogenous
NS neurons involved in stimulus localization and discrimi- analgesia system consisting of endorphin- and encephalin-
nation have small receptive fields and respond to noxious, containing neurons. Excitatory and inhibitory projections
mechanical, and thermal stimuli via Aδ and C fibers. WDR extend from the PAG to the brainstem. The RVM inte-
and NS fibers define the spatial and temporal qualities of grates and processes ascending nociceptive information
pain. NS neurons may be persistently sensitized by repeti- and modulates descending output. Within the RVM, there
tive noxious stimuli. WDR neurons exhibit prolonged after- are unique populations of cells referred to as facilitative
response generated by primary afferent input, intensifying, and inhibitory or on and off cells involved in transmission
and continuing nociceptive transmission [3, 5, 9, 13]. WDR of nociceptive stimuli, nociceptive reflexes, and behavio-
and NS neurons project to the reticular formation and thal- ral responses. These cells are critical in producing hyper-
amus via multiple parallel pathways, including the spi- algesia after peripheral tissue injury by maintaining
nothalamic and spinocervicothalamic tracts and the dorsal central sensitization. At the level of the spinal cord, high
column [3, 5, 9]. concentrations of gamma-aminobutyric acid, glycine,
serotonin, and the endogenous opioid peptides (encepha-
lin, endorphin) produce inhibition of nociceptive stimu-
Transmission and Modulation lus transmission [3, 5, 6, 16].
Interneuronal transmission in the dorsal horn occurs via

excitatory and inhibitory amino acid-mediated signal- Allodynia
ing [5, 15]. Glutamate is the principal excitatory synaptic
neurotransmitter in both the spinal cord and brain. Tissue inflammation may lead to an exaggerated response
Different types of glutamate receptors exist: kainate, α- to noxious stimuli (hyperalgesia) or a reduction in the
amino-3-hydroxy-5-methylisoxazole-4-proprionate intensity of the stimulus necessary to induce pain (allo-
(AMPA), and N-methyl-d-aspartate (NMDA) receptors. dynia) [6]. This sensitization is caused by changes in the
Glutamate initially binds to AMPA receptors inducing chemical environment of nociceptor peripheral terminals
ligand-gated sodium and calcium channel activation and following release of adenosine triphosphate and hydrogen
rapid depolarization, which then activates NMDA recep- (H+) and potassium (K+) ions from damaged cells at the
tors. Normally, NMDA receptors are blocked by magne- site of injury. Proteases, cyclooxygenase-2, and nitric oxide
sium (Mg2+) ions, but intense stimuli may remove this synthase induced by inflammation, together with
blockade. This in turn allows generation of a greater post- cytokines, chemokines, serotonin, and histamine produced
synaptic depolarizing response causing pain to remain by recruited inflammatory cells, act synergistically to lower
after the stimulus has disappeared [16]. C fibers also release the threshold for Aδ and C fiber activation [5, 17]. This
various neuropeptides, particularly those of the tachykinin threshold reduction recruits silent nociceptors producing
family including substance P and the neurokinins. Because allodynia.
Pain Recognition 621
Central Sensitization/“Wind-Up” and water retention, and decreased glomerular filtration.

Such catabolism may have direct consequences for the
Hypersensitivity also occurs due to dynamic modification immune system, decreasing wound healing and reducing
of the receptive field properties of dorsal horn neurons in an individual’s capacity to respond to infection [3, 23, 24].
the spinal cord. Temporal summation and cumulative Pain also reduces appetite, mobility, and leads to postop-
depolarization of dorsal horn neurons causes “wind-up,” erative weight loss. Immobility promotes urine and fecal
which is due to NMDA receptor disinhibition. NMDA retention [25].
stimulation leads to intracellular Ca2+ mobilization An important addition to the definition of pain states
increasing responsiveness to glutamate [3, 5, 10]. Wind-up that “the inability to communicate in no way negates the
increases dorsal horn neuron excitability, which in con- possibility that an individual is experiencing pain and is in
junction with decreased spinal cord neuron inhibition cre- need of appropriate pain relieving treatment” [26]. As car-
ates central sensitization. Peripheral sensitization involves egivers, we have two important reasons to address pain: a
sensitized Aδ and C fibers while central sensitization moral and ethical obligation toward animals that are suf-
allows low-threshold Aβ fibers to induce pain by increasing fering and cannot speak for themselves, and a medical duty
spinal neuron excitability and altering spinal cord sensory to reduce the morbidity and mortality associated with pain.
processing. The American Animal Hospital Association published
Glial cells, particularly those in the spinal cord, previ- guidelines in 2015 and the World Small Animal Veterinary
ously thought only to provide neuronal support and nutri- Association Global Pain Council guidelines for recogni-
tion, are now considered key players in the creation and tion, assessment, and treatment of pain highlighting
maintenance of pathologic pain states [18]. Glial cell acti- advances in pain management, and both focus on the rec-
vation due to nerve trauma or inflammation results in pro- ognition and assessment of pain, pharmacological inter-
inflammatory mediator production, which contributes to vention, non-pharmacological interventions, and the
central sensitization. These cells may also play a role in importance of a team approach and education of the
reducing opioid efficacy [18, 19]. client [27, 28].
Importance of Pain Control Pain Recognition
The word pain derives from Greek and Latin words mean- Effective pain management can only be achieved if pain
ing punishment or penalty [20]. Numerous definitions of can be accurately and consistently assessed to enable
pain exist in the human literature where terms such as dis- evaluation of therapeutic response. Pain is considered an
tress, suffering, and stress have been associated with individual experience, and the way this experience trans-
pain [21–23]. When left untreated, pain may have conse- lates into observable and measurable behavior depends
quences beyond unnecessary suffering [23, 24]. Pain on numerous factors. Animals are unable to describe
increases sympathetic tone and causes catecholamine their pain as most humans do, so the potential for observer
release, resulting in tachycardia, vasoconstriction, bias is inherent in any attempt to measure pain in
decreased gastrointestinal blood flow, and the potential for animals [22].
gastrointestinal ulceration, decreased bladder tone, and The assessment and treatment of pain is greatly influ-
increased muscle tone [3, 23, 24]. Pain-induced anxiety and enced by knowledge of the specific animal’s normal behav-
fear enhance sympathetic outflow and may increase blood ior, of normal species behavior, and the caregiver’s
viscosity, prolong clotting times, and induce fibrinolysis observational skills and attitude toward pain [22].
and platelet aggregation. Intense vasoconstriction may Differences in attitude toward pain and analgesia exist
lead to decreased tissue oxygen delivery and shock. Pain- within the veterinary profession [29–32]. These differences
induced tachycardia causes an increase in myocardial work appear primarily due to gender and age, with female veteri-
and oxygen demand, and high levels of catecholamines narians and those recently graduated being more proactive
predispose to arrhythmias. in the evaluation and management of pain [33]. A recent
Pain activates the renin-angiotensin-aldosterone system article showed a better implementation of the analgesic
and induces the secretion of cortisol, glucagon, antidiu- plan and an increase in postoperative analgesic when vet-
retic hormone, growth hormone, and interleukin-1; it erinarians are working alongside with veterinary techni-
decreases insulin secretion [3, 23, 24]. Increased counter- cians and nurses [29, 34, 35].
regulatory hormone levels generate a catabolic state char- The difficulties inherent in assessing pain in animals
acterized by hyperglycemia, proteolysis, lipolysis, sodium may result in analgesia being withheld inappropriately.
Patients may not demonstrate expected signs of pain, or Table 47.2 General and species-specific behavioral
assessment may fail to identify these signs. Such problems manifestations of pain.
have been cited by various studies as a major cause of vet-
erinarians withholding analgesia [36–38]. Conversely, Aspect of
behavior General
analgesia may be administered unnecessarily based on an
anthropomorphic evaluation of the animal’s condition, a Temperament A change in temperament becoming
scenario that increases the likelihood of adverse drug reac- aggressive or withdrawn. Aggression in
tions (ADRs). response to forceful movement of painful
In human medicine, despite most patients being able to area. Insomnia.
report their pain verbally, the ideal method of pain assess- Vocalization Vocalization in response to palpation or
movement of painful area.
ment remains unidentified. In 2000, the Joint Commission
on Accreditation of Healthcare Organizations adopted Posture, Guarding of the painful area. Severe
locomotion abdominal pain may result in hunched
pain as the fifth vital sign (after heart rate, respiratory rate, posture, prayer position, falling and/or
temperature, and blood pressure) [39]. In veterinary medi- rolling. Reluctance to lie down. Trembling;
cine, pain is considered to be the fourth vital sign, with increased muscle tension.
temperature, peripheral pulse and respiratory rate, which Facial Dull eyes, “staring into space,” drooping
should be assessed by all clinicians [27, 28]. expression ears.
In veterinary medicine, in which our patients are unable Grooming Decrease of normal grooming, unkempt hair
to report pain verbally, physiologic and behavioral responses coat. Piloerection. Licking, kicking, biting, or
scratching painful area. Self-mutilation if
used to form the basis for pain scoring scales. Physiologic pain is severe.
responses to pain include tachycardia, tachypnea, hyperten-
Activity level Restlessness or overall decrease in activity
sion, pyrexia, and mydriasis, reflecting increased epineph- level. Failure to use litter box; increased or
rine, norepinephrine, and cortisol concentrations. These decreased urination.
physiologic alterations are also induced by disease processes Food and Decreased.
other than pain, however, making them nonspecific and of water
limited discriminant value [2, 5, 22, 40]. consumption
Because our patients do not speak our observational Aspect of Species specific.
skills are fundamental in evaluation of animal behavior behavior
and it is an essential part of the assessment of pain but is Cats Vocalization is rare. Hissing or growling
when approached or handled. Tendency to
subject to limitations. Observers must be familiar with the
hide in enclosed space. Tendency to hide
typical behavioral changes associated with pain painful body parts. Decreased activity, lack
(Figure 47.2; Table 47.2). Animals undergoing veterinary of grooming, hunched posture, dissociation
examination in a strange environment may display altered from the environment and lack of interaction
with severe pain. Aggression if approached
or when painful area is manipulated.
Dogs Attention seeking, whimpering, whining,
and howling. Vocalization often stops when
animal is comforted. Hunched or “prayer”
posture with abdominal pain. Shivering,
panting.
behaviors that mask signs of pain. It is essential to gain as

much information as possible from the primary caregiver
regarding the animal’s normal behavior prior to attempting
pain assessment because an animal’s character and tem-
perament influences its response to pain [41, 42]. It is
widely recognized that changes in behavior secondary to
pain may be difficult to distinguish from that due to anxi-
Figure 47.2 A young canine patient in the intensive care unit ety [41, 42]. Dogs especially may vocalize, whimper, or
at the faculty of Veterinary Medicine, Utrecht University, become agitated when anxious, and these signs are not
The Netherlands with abdominal pain demonstrating a
pain specific [41].
characteristic “prayer” position. This abnormal posture is far
more common in dogs than in cats, which tend to adopt a Attempts to assess pain responses are complicated by the
hunched posture or become recumbent and reluctant to move. high degree of variation across species, between patients,
Pain Scales 623
and within individual patients themselves. In a recent depressed, immobile, inappetent amputee suggested by
study, thermal pain sensitivity was evaluated in three dif- Hansen [49].
ferent dog breeds, the Harrier Hound, Greyhound, and The need to assess the intensity, sensory, and motiva-
New Zealand Huntaway. Their study showed that the tional or behavioral aspects of pain formed the basis for the
Huntaway appeared to be less sensitive to thermal pain development of multifactorial or composite-measure pain
than the other breeds [43]. In humans and mice, an inter- scales, which provide better interobserver repeatability.
esting correlation between hair color and pain sensitivity The Colorado State University Veterinary Teaching
has been discovered [44, 45]. Hospital pain score for cats and dogs is based on eight cat-
Critically ill animals may be unable to display classical egories of behavioral and physiologic signs [50]. Comfort,
signs of pain (Table 47.2) despite being painful. Critically movement, appearance, unprovoked behavior, interactive
ill animals may be obtunded, stuporous, or immobile, and behavior, vocalization, heart rate, and respiratory rate are
unable to shift position in response to noxious stimuli. assessed. Each category is assigned a score of 0–4 according
They may not vocalize as otherwise healthy animals to predefined criteria. The total score is the sum of the cat-
would [25]. Caregivers must be aware of the potential for egory scores. Unfortunately, the detailed rationale for the
underrecognition of pain causing inadequate analgesia selection of these categories is obscure, which has limited
provision in our sickest patients who may be in greatest its use by other researchers working in this field. In a recent
need. The absence of perceptible behavioral displays asso- study the interrater reliability and convergent validity of
ciated with trauma or illness may be a factor in the Colorado State University feline acute pain scale (CSU-
undertreatment. FAPS) was assessed. The CSU-FAPS showed moderate-to
good interrater reliability when used by veterinarians to
assess pain in cats after ovariohysterectomy. Unfortunately,
Pain Scales this scale showed a wide interrater reliability, which makes
its use in a clinical setting not yet recommended [51].
Over recent years, there has been more attention to the The Glasgow composite measure pain scale (GCMPS)
treatment and evaluation of pain, especially in cats, which designed using psychometric principles (reliability, valid-
has led to the publication and validation of different pain ity, standardization, freedom from bias), has been validated
scoring in this species. The number and diversity of pain for assessing acute pain in dogs [52–55]. The GCMPS is a
scales in use demonstrates there are deficiencies in each behavior-based system based on a structured questionnaire
and suggests that none has been universally adopted. In that includes clinical observation, assessment of spontane-
addition, scales used to evaluate pain in the acute setting ous and evoked behavior, and animal–observer interaction.
may be less useful in the assessment of chronic pain. The questionnaire is structured around seven categories:
Numerous pain assessment scales have been developed posture, activity, vocalization, attention to wound/painful
for humans, including the simple descriptive scale (SDS), area, demeanor, mobility, and response to touch. To stand-
visual analog scale (VAS), numerical ratings scale (NRS), ardize scoring by multiple observers, each category con-
and the multifactorial pain scale. All have been used and tains descriptors from which those best matching the dog’s
adapted for veterinary patients, with variable clinical behavior are selected. A rapid, easy-to-use short form was
utility. developed to facilitate use in a busy clinical setting
Unfortunately, SDS, VAS, and NRS may all be unreliable (Figure 47.3) [56].
in assessing acute pain in dogs in a hospital setting because Assessment of pain in cats can be extremely challenging
they are all unidimensional. They measure only the inten- because behavioral manifestations may be subtle especially
sity of pain rather than also encompassing its sensory and in the clinical setting [57–59]. Observation of behavior
affective (behavioral) qualities [41, 46, 47]. remains the best means of assessing the degree of pain in
Attempts have been made to overcome this unidimen- feline patients (Figure 47.4) [42, 59]. A VAS that includes
sional limitation by refining the assessed behavioral char- physical interaction called the dynamic and interactive
acteristics and including more objective physiologic data. visual analog scale has been used in cats by several groups
The Melbourne pain scale (MPS), developed in the late to improve sensitivity [47, 60]. Most information can be
1990s, consists of six broad categories divided into levels acquired if the animal is observed first from a distance, its
with associated scores [48]. The maximum possible response to a person’s approach assessed, and finally its
score using this scale is 27. The MPS represents a refine- response to physical interactions such as stroking or palpa-
ment of the scales previously described but also has lim- tion evaluated. Wound sensitivity and response to palpa-
itations. Again, significant interobserver variability tion correlates well with VAS scoring in cats. Manipulation
occurs and the MPS is insensitive to non-overt behavio- of the affected area appears to be of value in feline pain
ral displays as demonstrated by the example of a quiet, evaluation [47, 59, 61].
SHORT FORM OF THE GLASGOW COMPOSITE PAIN SCALE
Dog’s name
Hospital Number Date / / Time
Surgery Yes/No (delete as appropriate)
Procedure or condition
In the sections below please circle the appropriate score in each list and sum these to give the total score.
A. Look at dog in Kennel
Is the dog?
(ii)
(i)
Ignoring any wound or painful area 0
Quiet 0
Looking at wound or painful area 1
Crying or whimpering 1
Licking wound or painful area 2
Groaning 2
Rubbing wound or painful area 3
Screaming 3
Chewing wound or painful area 4
In the case of spinal, pelvic or multiple limb fractures, or where assistance is

required to aid locomotion do not carry out section B and proceed to C
Please tick if this is the case then proceed to C.
B. Put lead on dog and lead out of the kennel. C. If it has a wound or painful area
including abdomen, apply gentle pressure 2
inches round the site.
When the dog rises/walks is it?
Does it?
(iii)
Normal 0 (iv)
Lame 1 Do nothing 0
Slow or reluctant 2 Look round 1
Stiff 3 Flinch 2
It refuses to move 4 Growl or guard area 3
Snap 4
Cry 5
D. Overall
Is the dog? Is the dog?
(v) (vi)
Happy and content or happy and bouncy 0 Comfortable 0
Quiet 1 Unsettled 1
Indifferent or non-responsive to surroundings 2 Restless 2
Nervous or anxious or fearful 3 Hunched or tense 3
Depressed or non-responsive to stimulation 4 Rigid 4
© University of Glasgow Total Score (i+ii+iii+iv+v+vi) =
Figure 47.3 Short form of the Glasgow Composite Measure Pain Scale. Copyright 2008University of Glasgow. Permission granted to
reproduce for personal and educational use[HDR1] only. Commercial copying, hiring, lending is prohibited. The short form composite
measure pain score (CMPS-SF) can be applied quickly and reliably in a clinical setting and has been designed as a clinical decision-
making tool that was developed for dogs in acute pain. It includes 30 descriptor options within 6behavioral categories, including
mobility. Within each category, the descriptors are ranked numerically according to their associated pain severity, and the person
carrying out the assessment chooses the descriptor within each category that best fits the dog’s behavior/condition. It is important to
carryout the assessment procedure as described on the questionnaire, following the protocol closely. The pain score is the sum of the
rank scores. The maximum score for the 6 categories is 24, or 20 if mobility is impossible to assess. The total CMPS-SF score has been
shown to be a useful indicator of analgesic requirement, and the recommended analgesic intervention level is 6/24 or 5/20.
In recent years, three different composite pain scales have parasympathetic tone activity and the bispectral index as
been described and validated for cats (Box 47.1) [42, 58, 59]. objective tools for perioperative pain evaluation dogs and
Future directions in the field of pain assessment may cats. Such systems have not been clinically validated [67].
involve computerized behavior and activity monitor- The evaluation of pain with the use of a scoring system
ing [49, 67]. One study reviewed the use of monitoring should be performed with every patient deemed to be in
Pain Scales 625
(a) (b)
Figure 47.4 Observation of posture and behavior are key components of pain assessment in cats. (a) A feline patient recovering
following a thoracotomy. The cat is laterally recumbent, inactive, and disinterested in the environment. (b) The same cat following
pain assessment and augmentation of the analgesic plan. The cat appears more comfortable and is seen adopting a more typically
feline curled-up pose. Source: Images courtesy of Dr. J. H. Robben (Intensive Care Unit, Utrecht University).
Box 47.1 Composite Pain Scales for Cats
UNESP-Botucatu Multidimensional Composite Pain assessment

Pain Scale This revised version was developed using psychometric
principles (Calvo et al. [64]) and embedded a three-point
Created assessing postoperative pain in cats undergoing
facial expression (ear position and muzzle) scale within
ovariohysterectomy [62].
the tool [58, 64, 65]. It is a behavior-based system, struc-
Link: www.animalpain.com.br/assets/upload/escala-en-
tured around seven behavioral categories.
us.pdf
Scoring
Pain assessment
Within each category, the descriptors are ranked numerically.
The pain assessment is divided in to three subscales:
Maximum score for the seven categories: 20.
● Pain expression: including miscellaneous behavior, vocal- The recommended analgesic intervention level is > 4/20.
ization, reaction to abdomen/flank and surgical wound.
● Psychomotor changes: including evaluation of the cat’s Feline Grimace Scale
attitude, posture, comfort, and activity. The newest among pain scales [66].
● Physiological variables: including appetite and arterial
blood pressure measurement. Pain assessment
The scale relies on facial expressions that can be objec-
Scoring tively assessed using a facial action coding system that
Maximum score: 30. measures the individual movements or “action units” of
Analgesia is recommended with a score of 7/30 or the face that comprise an expression. A feline-specific
higher. coding scheme (CatFACS) had been previously developed
Limitations by studying the facial musculature of the domestic cat.
The limitations of this pain scale: time consuming, the Five action units were highlighted in cats that could easily
inclusion of blood pressure measurement and the single discern cats in pain versus control cats: ear position,
surgical procedure used to develop it [59]. whiskers position, orbital tightening, muzzle tension, and
lowering of the head.
Glasgow Revised Composite Measure Pain Scale: Feline
Scoring
Designed to be a clinical decision-making tool for use in The scale detected response to analgesic treatment
cats in acute pain [63]. (scores after analgesia were lower than before) and a
Link: https://www.newmetrica.com/acute-pain-measurement. cut-off score was determined (total pain score > 0.39/1.0).
pain and the same scoring system should be used to re- specialists [78, 79]. Kissin, in 1994, proposed that
evaluate and titrate the effect of the administered analge- preemptive should mean “preventive” rather than simply
sic. The PLATTER approach (plan, anticipate, treat, “before” because ineffective afferent blockade cannot be
evaluate and return) has been proposed to describe the preemptive even if administered before the noxious stim-
continuum of care loop for pain management [27]. ulus of surgery [77]. Preventive analgesia differs from
preemptive analgesia in that it considers all three periop-
erative phases (preoperative, intraoperative, and postop-
Multimodal Analgesia erative) and that factors within all three phases can
contribute to the development of central sensitiza-
Multimodal analgesia is an approach to pain relief provi- tion [76, 78]. Preventive analgesia is based on the assump-
sion that involves the use of multiple drug types or tech- tion that the only way to prevent central sensitization
niques with complementary mechanisms and sites of might be to completely block any nociceptive input from
action within the peripheral and central nervous systems. the surgical wound from the time of incision until final
Some authors have used the term solely in reference to wound healing. The blockade of nociceptive pathways
systemic administration of multiple drugs with different must therefore be maintained from the preoperative
mechanisms of action [68] whereas others refer to sys- stage, throughout surgery, and into the postoperative
temic drug administration combined with regional period approach [76, 78].
anesthesia [69]. Whether preemptive analgesic interventions are more
The aim of this approach is to target different points in effective than conventional regimens in managing acute
the nociceptive pathways so more complete analgesia can postoperative pain remains controversial. Some anesthesi-
be provided while minimizing adverse effects. The multi- ologists now favor use of a multimodal approach to therapy
modal approach uses the additive or synergistic analgesic with less concern about the timing of their interven-
effects of multiple drug classes, maximizing patient com- tions [75]. Others believe that for a preemptive technique
fort and allowing lower doses of individual analgesic to be effective, it must be multimodal and active before,
agents to be used, reducing the potential for ADRs [70]. during, and after surgery [80].
Effective implementation of multimodal analgesia requires
an understanding of physiology and pathophysiology so
that complementary drugs and methods can be selected. Contraindications and Complications
This approach has been adopted by the medical and veteri- of Pain Management
nary medical world [27, 69, 71–74].
Recent shifts in veterinarian attitudes toward pain man-
agement and the use of the multimodal approach have
Timing of Analgesic Administration greatly increased the frequency and diversity of analgesic
prescribing [27, 28, 76]. Although concerns about the
The motto of the Global Year Against Acute Pain was potential for adverse reactions associated with analgesic
“anticipate, assess, alleviate.” In humans, universal agree- administration have been reported, it is likely these have
ment that pain management should begin before surgery been overemphasized [34, 37, 81–83]. Despite improve-
using an effective preemptive approach, involving multi- ments in our understanding of feline drug disposition,
modal analgesia is well established [75]. Preemptive analge- such concerns have slowed progress in provision of pain
sia is an analgesic intervention begun before the onset of relief to cats [31, 84]. There is no longer a rationale for
noxious stimuli to block peripheral and central nociception, withholding analgesics from cats because previously held
thereby preventing postoperative pain amplification [75, misconceptions about complications associated with anal-
76]. Continuing nociceptive input modulates the CNS gesics in the species have been largely discredited [27, 40,
through activation-dependent plasticity resulting in periph- 42, 85–87]. But we must remain vigilant for adverse effects
eral sensitization, allodynia, and hyperalgesia. Sensitization to manage them correctly.
causes increased spontaneous activity and afferent respon- An ADR is defined as any unexpected, undesirable, or
siveness, reduced threshold, and prolonged discharge after harmful consequence associated with the administration
repeated stimulation (“wind-up”). Neuronal plasticity of a medication. ADRs may be common, mild, and reversible
induces “pain memory” allowing a more rapid response or rare, severe, and permanent [88]. As with any medications,
from the CNS following future similar stimuli. Maladaptive analgesic agents have the potential to cause such negative
plasticity thereby leads to central sensitization [71, 76, 77]. effects. Indeed, in human hospitals, analgesics are associ-
The concept of preemptive analgesia has been much ated with a large number of adverse effects that can lead to
debated among anesthetists and pain management an increase in the duration of stay in the intensive care unit
References 627
(ICU) or potentially be fatal [89–91]. A prospective study of Although we must consider the potential for ADRs, such
analgesic prescribing in a veterinary ICU suggested that concerns should not prevent us from improving efforts to
ADRs or concerns about adverse effects affect the prescrib- control pain in our patients. It should also be remembered
ing of analgesic medication for small animals [92]. The that the risk of analgesia-related complications is reduced
authors identified that although 64% of analgesic medica- in patients in pain. When in doubt if a patient is (still) in
tion was administered as prescribed, 23% of prescribed pain, a test dose of an analgesic drug can be administered
doses were reduced or not administered. Dose reductions and monitored closely for any signs for ADRs. We should
were primarily due to concerns about levels of sedation, be vigilant for signs of adverse reactions but proactive in
hypotension, and hypothermia associated with analgesic our provision of pain relief because pain itself reduces the
administration. likelihood of a successful outcome for our patients.
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631
48
Systemic Analgesia
Sarah Haldane and Angela Chapman
Pain can occur in small animals as a result of trauma, (Table 48.2). These drugs have strong analgesic effects and
disease, or surgery. The detrimental effects of pain include can be used for patients with moderate to severe pain.
tachycardia, altered respiration, aggravation of the sympa- Analgesia provided by mu agonists is dose related;
thoadrenal response, and behavioral changes. Pain can increased dose will increase analgesia. Similarly, the inci-
also lead to alteration of glucose metabolism, increased dence of adverse effects increases when higher doses are
protein catabolism, and impaired wound healing and it can administered.
severely compromise the ability of a patient to recover Buprenorphine is a partial mu agonist opioid with a long
from severe illness or trauma [1]. duration of action. It has a high affinity for the mu receptor
Although analgesia is an essential component of therapy but only moderate efficacy. It is an antagonist at kappa
for many patients, analgesic medications can have adverse receptors.
effects. The objective of a balanced analgesic regimen is to Butorphanol is a mixed agonist–antagonist drug and acts
combine medications to provide the best pain relief with the as a kappa agonist and mu antagonist. This drug has lim-
fewest complications. To choose the most appropriate medi- ited analgesic activity and duration and it is used primarily
cations for the individual patient, a basic knowledge of the for its sedative effects [2].
effects of these drugs on essential organ systems is required. Opioid antagonists include naloxone and naltrexone.
They have very high affinity for opioid receptors, so will
block the effects of any of the agonist opioids.
Opioids
Analgesic Effects
Opioids can be used for moderate to severe pain. The range of
medications within this class of drugs allows for flexibility in Opioids have a central analgesic effect that works within
route and frequency of administration. Opioids exert their the brain and the spinal cord to reduce transmission of
analgesic effects by activating opioid receptors located within pain signals. There are also opioid receptors located on the
the brain, spinal cord, and peripheral neurons. There are three presynaptic terminals of the peripheral nociceptors. When
main families of opioid receptors: mu, kappa, and delta, and opioid receptors are activated, they inhibit the transmis-
each has differing clinical effects when activated (Table 48.1). sion of painful stimuli through these fibers. In addition,
Every opioid activates each of the receptors to a different activation of receptors in the brain decreases the amount of
degree, so the activity of each drug can vary in terms of strength the neurotransmitter gamma-amino-butyric acid (GABA)
of analgesia, degree of sedation, and adverse effects (Box 48.1). that is released from neurons. GABA is an inhibitory neu-
Opioids can be generally classified into (i) mu receptor ago- rotransmitter that reduces the production and release of
nists, (ii) partial mu receptor agonists, (iii) mixed agonist– the stimulatory neurotransmitter dopamine. Stimulation
antagonist drugs, and (iv) opioid antagonists. of opioid receptors thus increases available dopamine,
Some common mu receptor agonists include morphine, which is responsible for the pleasurable sensation associ-
fentanyl, oxymorphone, hydromorphone, and methadone ated with opioid administration [5].
632 Systemic Analgesia
Table 48.1 Opioid receptors.
Central nervous Respiratory Gastrointestinal

Receptor Location Analgesic effects system effects effects effects
Mu Brain (medial thalamus), Supraspinal analgesia Euphoria, Respiratory Decreased

brainstem sedation, depression gastrointestinal
dependence motility
Kappa Brain (diencephalon, Spinal analgesia Sedation, Dyspnea,
including limbic system), dependence, respiratory
brainstem, spinal cord dysphoria depression
Delta Brain Possible pronociceptive Dysphoria
effects. Development of
tolerance to opioids
opioids can lead to dysphoria and, in some cases, vocalization.

Box 48.1 How Strong Is your Opioid?
These effects will usually resolve if the patient is changed
to a different opioid medication or to a lower dose of the
1) The affinity of an opioid is a measure of how strongly
same medication [2].
it interacts and binds with its receptor. For example,
buprenorphine has a higher affinity for mu receptors
than morphine, so it will bind more strongly to these Cardiovascular Effects
receptors and can competitively antagonize the
Administration of opioids at therapeutic doses has little
effects of morphine.
clinical effect on the cardiovascular system [9]. Opioids
2) The efficacy is a measure of the strength of the effect
are considered relatively safe drugs in cardiovascularly
the drug has after binding to its receptor. For exam-
compromised patients. However, bradycardia can develop
ple, morphine has a higher efficacy at mu receptors
if these medications are administered at high doses in
than buprenorphine, which means that when it binds
combination with sedative drugs or to patients not in
to the receptor it will stimulate a stronger analgesic
pain [2, 9]. Opioid-induced bradycardia is vagally medi-
response.
ated so can be effectively treated with atropine or glyco-
3) The potency of a drug is the amount of drug required
pyrrolate. In most cases, the effects of pain counteract the
to produce an effect. For example, fentanyl is a more
vagal effects, so bradycardia is an indication that the
potent drug than morphine as a much smaller
patient’s degree of pain has reduced and the opioid dose
amount (micrograms rather than milligrams) is
can be decreased.
required to activate the receptor.
In feline studies, both morphine and fentanyl have been
● An agonist opioid binds strongly to the receptor
shown to cause pulmonary vasodilation [10, 11]. In a study
and stimulates them to high activity. These drugs
using desflurane-anesthetized dogs, butorphanol also
are considered to have both affinity and efficacy.
caused pulmonary vasodilation [12]. For this reason, opi-
● An antagonist opioid binds to the receptor (has
oids are often recommended for use as anxiolytic agents in
high affinity) but does not stimulate the receptor
patients with congestive heart failure.
(no efficacy). Its antagonist action comes from
binding to the receptor as it stops other opioids
from exerting their effects. Respiratory Effects
● A partial agonist opioid has affinity but less effi-
At high doses, opioids can cause respiratory depression.
cacy than pure agonists; they bind strongly to opi-
This effect tends to be more marked when patients are
oid receptors but have a weaker effect on them [2].
being treated with concurrent sedative or anesthetic agents.
Respiratory depression occurs soon after bolus administra-
tion of opioid drugs but tolerance to this effect develops
Central Nervous System Effects
quickly, so that repeated or long-term opioid use will have
Opioids act in the central nervous system to cause seda- little effect on the respiratory system [5].
tion. They are often used as premedication agents prior to Morphine, methadone, oxymorphone, and hydromor-
anesthesia and have an anesthetic-sparing effect in addi- phone have all been associated with panting in dogs.
tion to their analgesic activity [6–8]. They are also effective Panting usually starts soon after administration of the
anxiolytic agents. Chronic administration or high doses of medications and tends to be transitory [13, 14].
Opioids 633
Table 48.2 Opioid agonist and antagonist drugs.
Agonist Antagonist
Opioid activity activity Dose in dogs Dose in cats Notes
Morphine μκδ – 0.1–0.5 mg/kg IM, SC 0.1 mg/kg IV, IM, SC Histamine release if given IV
every 4–6 hours; CRI every 4–6 hours in dogs, leading to
0.1–0.2 mg/kg/hour vasodilation, panting
Fentanyl μ – 2–5 mcg/kg IV, IM, SC 2–5 mcg/kg IV, IM, SC
then CRI 2–10 mcg/kg/ then CRI 2–10mcg/kg/
hour hour
Remifentanil μ – 0.1–0.5 mcg/kg/ 0.1–0.5 mcg/kg/
minute IV minute IV
Hydromorphone μ (δ) – 0.1–0.2 mg/kg IV, IM, 0.1 mg/kg IV, IM, SC Panting
SC every 4–6 hours every 4–6 hours
Oxymorphone μ – 0.1–0.2 mg/kg IV, IM, 0.1 mg/kg IV, IM, SC Panting
SC every 4–6 hours every 4–6 hours
Methadone μ NMDA 0.1–0.5 mg/kg IV, IM, 0.1–0.2 mg/kg IV, IM, Panting
receptor SC every 4–6 hours SC every 4–6 hours
Buprenorphine μ κ 0.01–0.03 mg/kg IV, 0.01–0.03 mg/kg IV, Dysphoria, euphoria (cats),
IM, SC, TM every 6–8 IM, SC, TM every 6–8 mydriasis
hours [3] hours [4]
Butorphanol κ μ 0.1–0.4 mg/kg IV, IM, 0.1–0.4 mg/kg IV, IM, Sedative effects much longer
SC; 0.5–1 mg/kg PO SC duration (2–4 hours) than
every 6–8 hours analgesic effects (30 minutes)
Codeine μ – 0.5–2 mg/kg PO every 0.5–2 mg/kg PO every Care with products that
6–12 hours 6–12 hours contain paracetamol in dogs;
do not use these products in
cats
Naloxone – μκδ 0.04 mg/kg IV IM SC 0.04–0.1 mg.kg IV Can be given via endotracheal
tube during cardiopulmonary
resuscitation
Naltrexone – μκδ 1–2 mg/kg PO once 25–50 mg/kg PO once Bitter taste
daily daily
CRI, intravenous constant rate infusion; IM, intramuscular; IV, intravenous; PO, per os (orally); SC, subcutaneous; TM, transmucosal.
Many opioid drugs have a cough suppressant (antitussive) effects occur due to stimulation of the chemoreceptor
effect, making them useful for bronchial disease or trachei- trigger zone. This zone lies outside the blood–brain bar-
tis [15]. They also reduce laryngeal sensitivity, increasing the rier so it is rapidly penetrated by any drug in the plasma.
ease of tracheal intubation and prolonging a patient’s toler- The vomiting center lies inside the blood–brain barrier.
ance of endotracheal intubation after anesthesia. Interestingly, stimulation of the opioid receptors in the
vomiting center has an antiemetic effect. As opioids easily
Urinary Effects cross the barrier, they can counteract the initial vomition
impulse and have an ongoing antiemetic effect [18].
Administration of mu agonist opioids has been shown to
Animals are more likely to vomit with administration of
cause decreased urine production by the kidneys.
pure mu agonist opioids than with partial agonist or
Conversely, kappa agonist opioids have been shown to
mixed agonist-antagonists.
have a diuretic effect in rats[16]. The exact mechanism for
Opioids can decrease gastric emptying and alter intesti-
these effects are unknown [17]. Opioid use has also been
nal motility, leading to intestinal ileus and, more chroni-
associated with urinary retention in the bladder due to an
cally, constipation [2, 9, 18, 19]. These effects are mediated
increase in urethral sphincter smooth muscle tone [5].
through opioid receptors in the central nervous sys-
tem [18]. Decreased intestinal motility, in combination
Gastrointestinal Effects
with opioid-induced sedation, can contribute to a patient’s
Two of the most common and most undesirable effects of lack of appetite which is a common complication of pro-
opioid administration are nausea and vomiting. These longed illness in small animal patients.
Hepatic Effects Similar mechanisms lead to development of opioid

dependency and withdrawal. Stimulation of delta recep-
Opioids are primarily metabolized in the liver, although
tors and upregulation of the NMDA receptors lead to
some extrahepatic metabolism does occur [13]. Animals
increased pain sensation, so patients become uncomforta-
with hepatic insufficiency may require lower doses of opi-
ble and disoriented if opioid therapy is rapidly withdrawn.
oids to achieve adequate analgesia. The sedative effects of
In people the pleasurable sensation (mediated by dopa-
opioids can be pronounced in patients with hepatic
mine) associated with opioid use and the adverse sensation
dysfunction.
when opioids are withdrawn can lead to addiction [5, 21,
Opioids that do not require hepatic metabolism (e.g.
22]. There is no evidence that dogs and cats become
remifentanil) or with a short duration of action adminis-
addicted to opioids.
tered as a constant rate infusion (CRI; e.g. fentanyl, sufen-
Use of a balanced analgesic regimen (multimodal anal-
tanil, alfentanil) are the most appropriate choice for
gesia) can be effective in preventing development of opioid
patients in hepatic failure so that the dose can be titrated to
tolerance. Abrupt cessation of opioid analgesia should be
achieve adequate analgesia with minimal sedation.
avoided to reduce symptoms of opioid withdrawal in vet-
erinary patients. Instead, weaning the patient from a pure
Effects on Body Temperature mu agonist drug to a partial agonist such as buprenorphine
In dogs, mu agonist opioids have been shown to reduce or gradually decreasing the dose prior to discontinuation is
body temperature by altering the central thermoregulatory recommended.
set point. Opioid-induced panting could also contribute to a
decrease in body temperature as heat loss via the respiratory Regulations Involved in Clinical Use of Opioids
system is a major factor in canine thermoregulation [13].
The phrase “controlled drugs” refers to drugs of addiction
In cats, opioid administration has been associated with
or high abuse potential that are supplied to registered prac-
post-anesthetic hyperthermia. In one retrospective study,
titioners for medical use. Opioids are classified as con-
47% of 125 cats became hyperthermic at least once within a
trolled drugs because they have the potential to produce
20-hour period after anesthesia and opioid administration.
addiction in people. Legislative requirements for controlled
In 2 of 125 cats, palliative therapy did not reduce the rectal
drugs vary slightly from country to country and state to
temperature and naloxone was administered. In both cats,
state. An overview of the general legislative requirements
naloxone was effective in reducing temperature. The mecha-
is provided here; however, reference should be made to the
nism for opioid-induced hyperthermia in cats is not known.
specific country or state’s individual legislation for full
It does not tend to be responsive to the anti-pyretic effects of
details.
nonsteroidal anti-inflammatory drugs (NSAIDs) [20].
In the United States, limitations on production and pre-
scription of opioids have been introduced by the Drug
Opioid Tolerance and Addiction
Enforcement Agency in an effort to reduce opioid abuse in
With prolonged administration opioids become less effec- people. This has impacted the supply of these drugs for vet-
tive as analgesic agents in a phenomenon known as opioid erinary use. Prescription drug monitoring programs have
tolerance. Doses often need to be increased markedly to been developed, with associated laws and regulations, on a
maintain analgesia in patients that require analgesia for state-by-state basis. Awareness has also been raised within
more than a few days, and in experimental trials, tolerance the veterinary industry around identification of people
has been shown to begin after a single dose of opioid. The who visit multiple veterinary clinics with their pet to obtain
mechanisms associated with development of tolerance are drugs for personal use, and drug diversion, which is the
complex; tolerance is mediated in part by the opioid recep- acquisition of veterinary drugs or prescriptions for per-
tors themselves. With chronic activation the mu receptors sonal use rather than for the intended recipient.
become less sensitive to opioid binding, grow less effective
in reducing transmission of pain signals and in some cases, Supply of Controlled Drugs
internalize within the cell membrane and become inacces- Licensed wholesalers or pharmacists must only supply
sible to circulating opioids. As mu receptors become resist- drugs to an authorized or licensed person. Details of regis-
ant to opioids, delta receptors are upregulated. It has been tered practitioners and/or license numbers must be
hypothesized that activation of delta receptors decreases recorded by the supplier.
the effectiveness of mu receptor stimulation. N-methyl-d-
aspartate (NMDA) receptor activation also contributes to Storage Requirements
opioid tolerance by increasing production of pronocicep- Controlled substances must be stored in a securely locked,
tive neurotransmitters [21, 22]. substantially constructed cabinet or safe, fixed to the floor
Opioids 635
or wall. Controlled drugs should not be stored with any absorbed transmucosally, so patients should not be allowed
items other than other drugs of dependence. The recepta- to lick or chew the patch [27].
cle should be kept locked at all times other than when in Most opioids are relatively ineffective if given orally as
immediate use and should be accessed only by authorized they are subject to a strong “first pass” effect, meaning that
personnel. they are absorbed from the gastrointestinal tract and
metabolized in the liver to inactive substrates before ever
Record Keeping Requirements entering systemic circulation. Opioids that can be used as
A drug registry must be maintained in a form that shows oral medications in dogs and cats include codeine and
the balance remaining after each dose is administered or butorphanol. An oral form of morphine is available but has
supplied and cannot be altered without detection. A sepa- varying absorption in dogs and thus is difficult to dose
rate page is required for each drug and for each different effectively. The doses required for oral administration are
formulation of the drug. The date, patient’s name, owner’s up to 10 times higher than those given parenterally. The
name, amount of the drug dispensed, balance, and details main adverse effect of orally administered opioids is
of prescribing veterinarian and their signature, are the constipation.
minimum inclusions required on a drug register. Details of Injectable preparations of buprenorphine are well
incoming stock, date, invoice number, supplier, and the absorbed through the oral mucosa in cats. This is an effec-
balance of stock are also required. Records are to be tive route of administration in this species as long as the
retained for periods of two to three years in most countries drug is not swallowed into the digestive tract. To prevent
and must be readily available for the regulatory authorities this, the buprenorphine should be squirted under (rather
should an audit occur. than on top of) the tongue or along the gum line. This route
is also effective for administration of buprenorphine to
Disposal dogs. However, in one study transmucosal (TM) adminis-
The legal requirements for the disposal of controlled drugs tration to dogs achieved approximately 30–40% of the
varies; however, disposal generally needs to be witnessed serum plasma concentration of buprenorphine than an
and co-signed on the drug register along with the quantity equivalent IV dose and had a shorter duration of analgesic
of drug disposed. action. Therefore, higher dose rates of buprenorphine are
indicated for TM administration in dogs [28–31]; the cost
can be prohibitive for larger dogs in the current veterinary
Systemic Administration of Opioids
market. Buprenorphine tablets are also available for trans-
Opioids can be administered parenterally via the intrave- mucosal administration.
nous (IV), intramuscular (IM), and subcutaneous (SC)
routes [14]. Morphine is usually administered IM or SC
Morphine
to dogs or very slowly via the IV route, as it has been asso-
ciated with histamine release when given as a rapid IV Morphine is the prototypical mu agonist opioid. It is an
bolus, which causes vasodilation and potentially hypo- excellent analgesic and sedative in both dogs and cats. At
tension [23, 24]. high doses (1–2 mg/kg) it has been associated with hyper-
Most opioids can be administered by either intermittent excitability in cats, but these effects are rarely witnessed at
bolus injections or as a CRI. Longer acting opioids (such as analgesic doses of 0.1 mg/kg. Morphine can cause vomiting
buprenorphine) are rarely given as a CRI, while this is the after bolus administration and in some cases is used as an
primary method of administration of very short acting opi- emetic agent. Bradycardia, gastrointestinal stasis, constipa-
oids like fentanyl. tion, reduced urine output, and urinary retention have all
Transdermal patches can be used to provide long-term been associated with morphine administration. Morphine
administration of an opioid at a constant rate. Fentanyl is is metabolized in the liver; codeine and hydromorphone
often administered via this route and buprenorphine are two of the metabolites produced. Intravenous mor-
patches are also available. Onset of action can take phine administration can cause histamine release in dogs
12–18 hours for fentanyl patches and duration of action is (see section on systemic administration of opioids) [5, 6,
three to five days. As there is significant interindividual 17, 18, 32–38].
variation in the plasma concentration of fentanyl reached
when transdermal patches are applied, the patient’s com-
Fentanyl, Remifentanil, Sufentanil, Alfentanil
fort level should continue to be monitored while the
patches are in place [25, 26]. Effective administration of Fentanyl is approximately 80 times more potent than
the drug can be adversely affected by the loss of adherence morphine because it binds very strongly to the mu opioid
of the patch. Fentanyl from the patches can also be receptor, so preparations of the drug have a much lower
concentration. It has a rapid onset of action and rarely people; the oral form is used to treat heroin addiction [5].
causes gastrointestinal side effects such as vomiting or nau- In dogs and cats, the duration of action of methadone is
sea. It is also an extremely effective sedative. Administration much shorter. When administered IV, the onset of action is
can lead to bradycardia and decreased temperature. 5–10 minutes and duration of action is four to six hours.
Fentanyl can have respiratory depressant effects similar to After SC administration, absorption is variable and it can
morphine, [39] and although these effects are relatively take more than an hour to reach maximal plasma concen-
minor at therapeutic doses [40], fentanyl’s rapid onset can trations. The plasma half-life is longer (10 hours as com-
result in acute hypoventilation [41]. Fentanyl’s duration of pared to four hours for IV administration) and dogs are more
action is very short and so it is primarily used as a CRI or likely to vocalize after subcutaneous administration [49].
administered in a transdermal patch. Aside from decreased
nausea, the primary advantage of using fentanyl as a CRI
Pethidine (Meperidine)
is the ability to rapidly change the dose and hence the
analgesic and sedative effects. Fentanyl can be used during Pethidine is mu agonist opioid that has excellent analgesic
anesthesia to reduce the requirement for gaseous anesthetic activity. It has a short duration of action (45-60 minutes)
agent [7] and is often used in combination with other seda- and is associated with a relatively high incidence of
tives for patients requiring mechanical ventilation. dysphoria [50]. It is rarely used in small animal clinical
Remifentanil is an ultra-short-acting opioid with a half- practice.
life of three to six minutes. It can be used as an anesthetic-
sparing agent and analgesic in small animals. Its primary
Buprenorphine
advantage is that it is broken down by cholinesterase
enzymes in the plasma, so metabolism is not dependent on Buprenorphine is a partial agonist (Box 48.1) at mu recep-
hepatic or renal function. Also, with such a short half-life, tors and an antagonist at kappa receptors. It is effective in
it is very easy to rapidly change the plasma level of the dogs for mild to moderate pain [5]. Buprenorphine appears
drug, which can be of benefit in animals that have cardiac to have better analgesic efficacy in cats than dogs and can
or respiratory dysfunction [42–44]. also cause euphoria and mydriasis in feline patients[4, 50,
Sufentanil and alfentanil are very rapid-acting deriva- 51]. It has not been proven to be associated with post-
tives of fentanyl. Both have anesthetic-sparing effects and anesthetic hyperthermia in cats in contrast to the pure mu
sedative and analgesic efficacy in small animal patients, agonist opioids [20].
and both allow rapid recovery from anesthesia. Both drugs Buprenorphine has a long duration of activity in com-
can cause bradycardia in dogs but have minimal effect on parison with other opioids and has a higher affinity for mu
heart rate in cats. In clinical trials, alfentanil was associ- receptors than the full mu agonist opioids. This means that
ated with hypotension when administered with propofol as it can be used to wean patients from full mu agonist opioids
total IV anesthesia, but this effect was not seen when it was or as a partial antagonist if mu agonists are causing adverse
administered with isoflurane [45]. effects.
This can be an undesirable effect if buprenorphine is
given to a patient with severe pain, as it will blunt the
Oxymorphone and Hydromorphone
effects of any other opioids that are subsequently adminis-
Oxymorphone and hydromorphone are semi-synthetic mu tered for the duration of its activity (6–12 hours) [52].
agonist opioids with similar analgesic efficacy to mor- Buprenorphine causes minimal sedation compared with
phine [13, 14]. Although they can display a similar range of full mu agonists and has less of an inhibitory effect on the
adverse effects to morphine, the incidence of occurrence is gastrointestinal tract [4].
reduced. Histamine release is not associated with IV admin-
istration of either of these drugs [23]. Hydromorphone has
Butorphanol
a shorter half-life than morphine in dogs [46]. In both
canine and feline clinical trials, hydromorphone appears to Butorphanol is a kappa agonist and provides good sedation
have a similar duration of sedative and analgesic action as with minimal cardiovascular or respiratory effects. It is a
oxymorphone (four to six hours) [8, 47, 48]. weak analgesic with a short duration of activity. The dura-
tion of analgesic effect is one to two hours, while its seda-
tive effects last two to four hours [52–54]. Its analgesic and
Methadone
sedative activities have a “ceiling” effect, whereby increas-
Methadone is a synthetic mu agonist opioid that also has ing the dose of the medication will not increase its efficacy.
antagonist activity at NMDA receptors. Methadone has a Butorphanol can antagonize the effects of pure mu agonist
prolonged duration of activity and good oral availability in opioids if they are used in combination [55].
Opioids 637
Butorphanol is an excellent antitussive agent so is often tramadol is scheduled as a controlled drug in the United
used as a short-term agent to control coughing. It also has States, although this is not the case in all areas of
some antiemetic effects. The primary adverse effect of the world.
butorphanol is dysphoria.
Route of Administration
Oral and IV forms of tramadol are available. Although
Codeine
maximum plasma concentration is reached more quickly
Codeine has greater oral availability than any of the other when the drug is given IV, the oral form is rapidly absorbed
opioids. It has weak activity at mu receptors. Codeine is from the gastrointestinal tract. The oral medication comes
used in veterinary medicine for chronic pain or as an anti- in tablets, capsules, and liquid form, making it easy to dose
tussive agent[15]. The main adverse effect of codeine is in any size cat or dog. It is generally prescribed in an
constipation, making it a difficult drug to use long term. It intermediate-release form that can be administered two to
can also cause vomiting, even at low doses, through stimu- three times a day. There is also a sustained-release form
lation of the chemoreceptor trigger zone [5]. that is used for once-daily dosing in people. Dogs metabo-
lize tramadol rapidly, so sustained-release tablets still need
to be given twice a day in this species. Additionally, admin-
Naloxone and Naltrexone
istration of the sustained-release tablets to dogs provides a
These drugs have antagonist activity at mu, kappa, and lower maximum plasma concentration of tramadol than
delta receptors. Naloxone has a short duration of action the intermediate-release tablets and it takes more time to
and poor oral availability so is used primarily as a paren- achieve maximum plasma concentration [56, 59]. Tramadol
teral agent for opioid overdose or to rapidly reduce the has a longer elimination half-life in cats than in dogs (3.4
effects of opioids in patients at risk of respiratory or car- hours vs. 1.7 hours); however, time to maximum plasma
diac arrest. Naltrexone has good oral availability and a concentration is similar [57, 59].
long duration of action, so it is more frequently used in
people recovering from opioid dependence than in veteri- Clinical Efficacy of Tramadol
nary medicine. It is sometimes effective for behavioral The analgesic efficacy of tramadol varies between indi-
disorders such as tail chasing and excessive licking in viduals as well as between species. In cats it can be an
dogs and cats. effective analgesic when used in a variety of situations,
including management of postoperative pain and
osteoarthritis [62–65].
Tramadol
In dogs, the majority of published studies evaluate the
Tramadol is a unique, centrally acting analgesic that has effect of tramadol as a postoperative analgesic. While it
multiple mechanisms of action. It is a codeine analog and can be an effective analgesic after some soft tissue surger-
has some activity at mu opioid receptors. It also has a cen- ies [36, 66, 67], it is not as useful as NSAIDs or mu opiate
trally acting GABA effect. In addition, tramadol has activ- agonists after orthopedic procedures or in dogs with osteo-
ity at alpha-2 adrenergic receptors and serotonin receptors, arthritis [68–72]. However, it may have some benefit as an
preventing norepinephrine and serotonin reuptake respec- adjunctive analgesic in this species [73–76].
tively [36, 56, 57]. Tramadol reduces the minimal alveolar concentration of
sevoflurane in anesthetized cats [77]; however, it is less
Opioid Effects effective than opioid drugs as a sedative in dogs [35].
Tramadol has a weak affinity for mu and delta opioid There are few adverse effects noted with clinical use of
receptors [56]. Mu receptor activation provides some of its tramadol in dogs and cats. Administration of tablets and
analgesic activity, as well as mild sedation and respiratory liquid can cause excessive salivation due to their bitter
depressant effects [56–60]. It is metabolized in the liver to taste. Dispensing the liquid into a gelatin capsule can
an active metabolite (O-desmethyl tramadol) that binds to reduce this effect and allow for easier administration,
opioid receptors with a higher affinity than the parent though this needs to be done just prior to giving the
drug [57]. These metabolites are produced in most species medication or the liquid will permeate through the cap-
of animals but in differing amounts. There are also species sule. Seizures have been associated with the use of tram-
differences in elimination half-life and time to maximum adol in people, but this has not been reported in
plasma concentration, with dogs generally metabolizing veterinary medicine. Tramadol can be administered to
and excreting the drug more rapidly than cats [57, 59, 61]. both dogs and cats. The dose in dogs is 2–4 mg/kg every
Despite its weak affinity for mu receptors, tramadol 8–12 hours. In cats, a dose of 1–2 mg/kg every 12 hours
has not been associated with dependence in people; is used.
Nonsteroidal Analgesic Effects

Anti-Inflammatory Drugs There is considerable proof of the efficacy of analgesia in
dogs and cats provided by NSAIDs. NSAIDs provide
NSAIDs are a diverse group of medications that act to peripheral analgesia and, unlike opioids, are very effective
decrease the production of inflammatory mediators at the at reducing pain during movement. They also have a mild
site of tissue injury. Inflammatory mediators increase antagonistic effect at NMDA receptors. The analgesic
transmission of pain signals by stimulating previously effects of many NSAIDs, including carprofen, ketoprofen,
unaffected nociceptors surrounding the area of injury. meloxicam, deracoxib, tepoxalin, and firocoxib (Table 48.3),
have been favorably compared to opioid administration in
Cyclo-Oxygenase 1 and 2 various studies of osteoarthritic and surgical pain [50, 51,
53, 83–90].
After a tissue has been damaged, arachidonic acid is
NSAIDs are nonaddictive and nonsedating, so animals
released from cell membranes. The family of inflammatory
often feel better and are more alert on these medications
mediators that are derived from arachidonic acid are
than when being treated with opioid analgesics [50, 51, 53,
known as eicosanoids. Two enzyme groups act to metab-
83–96]. Individual animals may respond better to one
olize arachidonic acid: the lipoxygenases and the
NSAID than another, so if analgesia is not adequate with
cyclo-oxygenases (COX). Eicosanoids produced from the
one NSAID, it is often worth trialing a different nonsteroi-
lipoxygenase cascade include leukotrienes and chemotac-
dal medication. However, different NSAIDs should never
tic factors. Products of the COX cascade include prosta-
be used in combination as the risk of adverse effects greatly
glandins, prostacyclin, and thromboxanes.
outweighs the potential benefits and a “washout period,”
NSAIDs are potent inhibitors of COX enzymes, thereby
where no anti-inflammatory medications are adminis-
reducing prostaglandin production. In some situations,
tered, of 5–7 days (or 7–10 days for aspirin) is recommended
this can have adverse consequences as many prostaglan-
if changing from one NSAID to another [97].
dins have protective or homeostatic functions. The prosta-
glandins required for normal homeostasis are continuously
produced, and so are known as constitutive prostaglandins. Adverse Effects
Inducible prostaglandins are produced in response to tis-
In healthy dogs, most new generation NSAIDs have a wide
sue injury. Inducible prostaglandins act to escalate the
margin of safety. Few NSAIDs are licensed for use in cats
inflammatory response and increase peripheral nerve sen-
and none for long-term use. Chronic use or overdose of new
sitization; they also have protective actions and play a role
generation prescription NSAIDs in small animals has been
in tissue repair [78, 79].
reported to cause adverse effects, but the risk is much less
There are two main COX enzymes known as COX-1 and
than with older generation NSAIDS, such as flunixin,
COX-2. A COX-3 enzyme also exists in the CNS. COX-1 is
important in producing many constitutive prostaglandins,
important for normal function of the gastrointestinal tract, Table 48.3 Nonsteroidal anti-inflammatory drug doses.
kidneys, and primary hemostasis [78]. COX-2 produces
more inducible prostaglandins that play an important role Drug Dog Cat
in gastric mucosal healing and systemic inflammation, as
Carprofen 2–4 mg/kg/day IV, SC, 2–4 mg/kg SC, PO
well as in regulating homeostatic mechanisms in the nor-
PO once
mal brain, kidney, and reproductive systems. COX-2 also
Deracoxib 2 mg/kg PO every 24
catalyzes production of prostacyclin, and a balance exists hours
between this anti-coagulant molecule and the pro-
Firocoxib 5 mg/kg PO every 24
coagulant thromboxane A2 regulated by COX-1 [79–81]. hours
NSAIDs are described as being nonspecific or dual act-
Ketoprofen 1–2 mg/kg IV, SC 1–2 mg/kg IV, SC
ing if they inhibit both COX-1 and COX-2. Aspirin is the then 1 mg/kg PO for then 1 mg/kg PO for
classic example of a dual-acting NSAID. Others include no longer than 5 days no longer than 5 days
ketoprofen and tepoxalin, which also have lipoxygenase- Meloxicam 0.1 mg/kg IV, PO then 0.1 mg/kg IV, PO once,
suppressing effects. COX-2-selective drugs, which inhibit 0.01–0.03 mg/kg PO then 0.01–0.03 mg/kg
COX-2 with relatively less suppression of COX-1, are com- every 24 hours PO every 1–2 days [82]
monly administered in veterinary medicine. It is important Tepoxalin 10 mg/kg PO every 24
to realize that all COX-2-selective NSAIDs will still inhibit hours
COX-1 to some degree. Examples include carprofen, IM, intramuscular; IV, intravenous; PO, per os (orally); SC,
meloxicam, deracoxib and firocoxib. subcutaneous.
Nonsteroidal Anti-Inflammatory Drugs 639
indomethacin, ibuprofen, or naproxen. However, in animals NSAIDs are administered to hypovolemic or dehydrated
with perfusion deficits, gastrointestinal, renal, or hepatic patients, the prostaglandin-mediated effect of local vaso-
disease, or with disorders of primary coagulation, NSAID dilation is diminished or lost. Significant damage to the
administration can have significant detrimental effects. kidneys can result, and in severe cases this can lead to
acute kidney injury. COX-2-selective medications may
Gastrointestinal Effects increase the relative production of thromboxanes, which
Gastrointestinal ulceration is a common adverse effect of have local vasoconstrictive effects and can exacerbate kid-
NSAID administration with prolonged use, high doses, or ney damage. Ketoprofen, carprofen, and tepoxalin at ther-
administration to hypovolemic or inappetent animals [97, apeutic doses have all been shown to have little effect on
98]. COX-1 induced prostaglandins in the gastric mucosa renal perfusion in healthy anesthetized dogs [111–113];
have protective effects as they increase gastric mucous pro- however, overdose or accidental ingestion of large doses
duction and enhance local blood flow. COX-2 is induced of NSAIDs can lead to acute kidney failure despite normal
once damage has occurred to the intestinal mucosa and blood volume [97].
produces prostaglandins that play an important role in
mucosal healing [78, 80, 98–100]; thus, COX-2 suppression Hepatic Effects
can delay ulcer healing [101]. Some NSAIDs, such as aspi- NSAIDs are metabolized in the liver and their use has been
rin, also cause direct injury to the gastric mucosa by disrup- associated with an increase in liver enzymes and hepato-
tion of surface phospholipids [80]. cellular injury in some patients. This toxicity is not depend-
Despite the increased safety margin of COX-2 selective ent on dose or duration of treatment so is classified as an
NSAIDs, adverse gastrointestinal effects are still their most idiosyncratic reaction. In one report describing hepatoxic-
common adverse effects [97, 98]. In one experimental ity secondary to carprofen administration, there was a
study assessing long-term NSAID use, carprofen had the marked similarity in the course of disease in Labrador
lowest incidence of gastrointestinal effects when compared Retrievers, which may indicate a possible underlying
to meloxicam, ketoprofen, flunixin meglumine, and genetic basis in this breed. However, this result may have
etodolac [53]. Multiple endoscopic and mucosal permea- been biased by the large number of Labradors that require
bility studies have been performed evaluating the effects of NSAID administration for degenerative joint disease [114].
short-term NSAID use and no significant adverse effects Owing to the risk of hepatic toxicity, NSAID administra-
have been found. However, only a few dogs were assessed tion is not recommended for animals with concurrent
in each trial making it difficult to evaluate the importance hepatic disease.
of their findings [101–106].
Both deracoxib and meloxicam have been associated Coagulation Effects
with gastrointestinal perforation in dogs. In most cases the Prostacyclin (prostaglandin I2) is produced from epithe-
drugs were administered at higher than recommended lial cells via COX-2 synthesis and acts to inhibit platelet
dosages (greater than 2 mg/kg for deracoxib or 0.1 mg/kg aggregation and cause vasodilation. Conversely, COX-1
for meloxicam) or were administered concurrently with a mediates production of thromboxane A2 (TXA2) from
corticosteroid or another NSAID [107–109]. platelets and increases platelet aggregation and causes
The incidence of these highly undesirable adverse effects vasoconstriction [115]. The balance between TXA2 and
means that client education is vitally important if patients prostacyclin is important in maintaining a functional
are discharged with NSAIDs for administration at home. coagulation system.
The dose and duration of administration should be care- Aspirin is the most effective NSAID at reducing platelet
fully explained, and clients should be advised not to admin- aggregation as it binds permanently to platelets and
ister the medications if their pet is not eating, has vomiting decreases TXA2 production for the life of the platelet.
or diarrhea, or if they see hematochezia or melena. NSAIDs Conversely, the COX-2 inhibitor (coxib) class of drugs has
should never be administered concurrently with other been associated with increased risk of thrombosis-related
NSAIDs or with corticosteroids. cardiac events in people [116]. In veterinary medicine,
ketoprofen, carprofen, tepoxalin, meloxicam, and dera-
Renal Effects coxib have been studied to assess their effects on primary
When perfusion to the kidney declines, glomerular filtra- haemostasias. Ketoprofen and carprofen have been asso-
tion rate decreases accordingly. The juxtaglomerular ciated with decreased platelet function and deracoxib
apparatus in the kidney releases prostaglandins that act to with potential for increased thrombosis in experimental
vasodilate the afferent renal arteriole to maintain renal trials; however, there are no published reports of clini-
blood flow and glomerular filtration rate. This effect is cally relevant hemostatic complications in dogs or
mediated by both COX-1 and COX-2 enzymes[110]. When cats [113, 115, 117, 118].
Drug Interactions with Nonsteroidal Anti-Inflammatory Drugs of alpha-2 agonists can be reversed by administration of
Concurrent administration of an NSAID with corticoster- yohimbine or atipamezole [120–123].
oids or other NSAIDs significantly increases the risk of
gastrointestinal and kidney injury [97, 107, 119]. Analgesic Effects
Administration of COX-2 inhibitors also delays healing of The analgesic effects of alpha-2 agonists are mediated
gastrointestinal ulcers [100, 101]. Concurrent administra- within both the brain and the spinal cord. Their mecha-
tion of aspirin with other NSAIDs or corticosteroids nism of antinociceptive action is complex (Box 48.2). The
increases the risk of bleeding and gastrointestinal injury alpha-2 adrenoreceptors also interact with opiate receptors
due to both COX inhibition and direct mucosal injury [80, in a synergistic fashion. The combination of alpha-2 ago-
98, 119]. nists and opioids has an analgesic effect that can last sev-
NSAIDs displace other highly protein-bound drugs from eral hours. Unfortunately, the sedative and cardiovascular
plasma proteins, leading to their enhanced bioavailability effects of alpha-2 agonists limit their general use as analge-
and possibly toxic plasma concentrations. Such drugs sics, although the sedation induced makes them very effec-
include other anti-inflammatory agents, warfarin, pheny- tive premedication agents [120–122].
toin, penicillins, and sulfonamide antibiotics. NSAIDs may
also increase plasma levels of digoxin and can decrease the Cardiovascular Effects
efficacy of furosemide. Alpha-2 agonists have a two-phase effect on the cardiovas-
Use of NSAIDS with other nephrotoxic drugs (including cular system. During the first phase, they cause peripheral
aminoglycoside antimicrobials) and diuretics (due to risk vasoconstriction and bradycardia. Vasoconstriction is
of hypovolemia) is relatively contraindicated but studies mediated by activation of post-synaptic adrenoreceptors in
have not been performed to prove a clinical interaction. the peripheral blood vessels. Bradycardia occurs by direct
Drugs that induce the cytochrome P450 metabolic pathway and indirect mechanisms. The direct effect is due to
in the liver (e.g. phenobarbital) can increase NSAID metab-
olism, reducing their analgesic efficacy.
Box 48.2 Alpha-2 Adrenoreceptors
Nonsteroidal Anti-Inflammatory Drugs in the ● Alpha adrenergic receptors are classified into type 1
Critical Patient and type 2.
● The type 2 receptors are further sub-divided into 2A,
NSAIDs are contraindicated in patients with hypovolemia
2B, and 2C.
or dehydration, gastrointestinal, hepatic, or renal dysfunc-
● Stimulation of alpha-2A and B receptors in the brain
tion, increased sympathetic stimulation (such as in
and spinal cord will inhibit pain sensation and
trauma), or cardiac disease (particularly with concurrent
wakefulness.
administration of furosemide or digoxin). When this popu-
● 2C receptors are more often located on peripheral
lation is further expanded to include patients with coagula-
nociceptors and conversely, stimulation of 2C recep-
tion disorders, recent history of anti-inflammatory
tors increases the transmission of painful stimuli.
administration, or inappetence, it seems that NSAID
● 2C receptors are upregulated after neuronal injury and
administration is appropriate in a fairly small proportion of
may have a pro-nociceptive effect in inflammatory and
critically ill patients. However, NSAIDs are highly recom-
neuropathic pain syndromes[124]. Alpha-2 receptors
mended for use in cardiovascularly stable patients that
are predominantly stimulated by norepinephrine.
have a functional gastrointestinal tract and normal kidney
● Alpha-2 receptors are found in the vasculature, liver,
function. This subset of patients would include stable post-
pancreas, kidney, platelets, adipose tissue, and the
operative patients and patients with musculoskeletal inju-
eye. They have distinct physiologic function in each
ries that are well perfused, have an adequate urine output,
of these organs.
and are eating or receiving enteral nutrition. Their excel-
● Receptors are also found in many areas within the cen-
lent analgesic properties make them indispensable in the
tral nervous system, including the dorsal horn of the
critical care pharmacopeia.
spinal cord, the vagus nerve, and the locus coeruleus.
● The locus coeruleus is a small nucleus within the
Alpha-2 Agonists brainstem that is responsible for controlling wakeful-
ness and is also an important mediator of analgesia.
Alpha-2 agonist drugs stimulate the alpha-2 adrenorecep-
● Activation of alpha-2 receptors in this area inhibits
tors around the body. The most important clinical effects of
impulse transmission, leading to sedation and
alpha-2 agonists include profound sedation, centrally
analgesia [120].
mediated analgesia, and hypotension. The clinical effects
Adjunctive Analgesia 641
stimulation of the vagus nerve, slowing impulse conduc- Xylazine

tion through the atrioventricular node in the heart, thereby
Xylazine is an alpha- 2 agonist medication that is used
reducing the rate of ventricular contraction. Indirectly,
primarily for sedation in large animal practice. It is no longer
bradycardia results from the cardiac response to increased
recommended for use in small animals due to its propensity
systemic vascular resistance, which is to lower heart rate to
to cause vomiting, severe bradycardia, and hypotension.
prevent hypertension. During phase two, the initial vaso-
constrictive response declines and a centrally mediated
hypotensive phase predominates, with continuing brady-
cardia as well as peripheral vasodilation due to decreased Adjunctive Analgesia
sympathetic stimulation [120].
The cardiovascular effects of alpha-2 agonists occur even Adjunctive analgesics are medications that have synergis-
when the drugs are administered at low doses. In one study tic activity with, or potentiate the effects of, the primary
of medetomidine in dogs, cardiovascular effects were near analgesic (usually opioids or NSAIDs). In many cases they
maximal at a dose of 5 μg/kg and were not significantly dif- have mild analgesic activity on their own, but this is greatly
ferent with doses ranging from 1 to 20 μg/kg [125]. Alpha-2 outweighed by the benefit they have in combination with
agonists are therefore not recommended for use in patients other medications. As the pain pathway is affected by many
with an unstable cardiovascular system. different neurotransmitters, mediators, and receptors, it is
logical that we need to use analgesics with differing mech-
anisms of action to effectively treat pain. In addition, a
Medetomidine multimodal analgesic approach will allow lower doses of
Medetomidine is a highly selective alpha-2 agonist that pro- primary analgesics to be used, reducing the potential for
duces profound, dose-dependent sedation and analgesia [37, adverse effects and complications from these drugs.
121, 122]. The analgesic effects occur 20–60 minutes after a Multimodal analgesia in its simplest form would com-
single injection [37]. In combination with an opioid, the bine opioid and NSAID medications, as these drugs act at
analgesic efficacy of medetomidine is enhanced, but there is different levels of the pain pathway. For patients with acute
little improvement in the cardiovascular effects [126]. It is an pain, a combination of opioid with ketamine and/or lido-
effective sedative, with doses as low as 1 μg/kg causing a caine can be used as a CRI (Box 48.3). Oral adjunctive
reduction in the amount of induction agent required for agents can be used for chronic, inflammatory, or neuro-
anesthesia [127]. Even at low doses, bradycardia and hypo- pathic pain. Examples of these include gabapentin, aman-
tension are common in patients treated with medetomi- tadine, and acetaminophen (paracetamol).
dine [128–130]. It has also been used as a CRI for prolonged
sedation (doses from 1-3 μg/kg/hour) and as an adjunctive
Lidocaine
analgesic during spinal surgery in dogs for its opioid sparing
effects [131]. Medetomidine has been administered in com- Lidocaine is a sodium channel blocker that is primarily
bination with opioids via the epidural route, but with mini- used as a local anesthetic agent. It is also an effective anti-
mal improvement in analgesic activity [132]. arrhythmic for ventricular tachyarrhythmias as it acts on
The most common use of medetomidine is as a sedative the fast sodium channels in the myocardial cells. When
or premedication agent. Generally, a dose of 5–20 μg/kg IV administered as a systemic analgesic, it can reduce dis-
or IM is effective in dogs and cats. The low end of the dose charge from injured nociceptors in peripheral tissues and
range is used if medetomidine is administered in combina- thus decrease the transmission of pain sensation to the spi-
tion with an opioid [133]. nal cord [135]. Intravenous lidocaine has also been hypoth-
esized to interact with opioid receptors [136] as well as
having a systemic anti-inflammatory effect by reducing
Dexmedetomidine
cytokine production [137, 138]. Low doses have been
Medetomidine is a racemic mixture of two compounds: shown to have antagonist effects at NMDA and neurokinin
dexmedetomidine and levomedetomidine. Most of the receptors in rats [139].
analgesic and sedative effects are due to dexmedetomidine Lidocaine is effective as an adjunctive treatment for neu-
and it is thought that levomedetomidine interferes with the ropathic pain, cancer pain, and postoperative pain in peo-
function of dexmedetomidine. It has been suggested that ple [140–142]. It has also been reported as an effective
dexmedetomidine alone provides more consistent sedation postoperative analgesic in dogs after intraocular surgery
and longer lasting analgesia than medetomidine [120–123]. and ovariohysterectomy [143, 144]. However, it is most
Dexmedetomidine can also be administered as a CRI for commonly used in combination with an opioid rather than
sedation or analgesia [134]. as a sole systemic analgesic agent [67, 145, 146].
Box 48.3 Constant Rate Infusion Recipes

MLK CRI for Syringe Pump Infusiona
1) Make sure that each of your components is compatible with the others, then determine your dose rate for each
component.
e.g. morphine 0.1 mg/kg/hour, lidocaine 3 mg/kg/hour, ketamine 0.6 mg/kg/hour
2) Calculate the dose/hour for each component required for your patient, based on its body weight. Using the concen-
tration of each drug, calculate the rate in ml/hour.
Example: MLK CRI for a dog, body weight 20 kg:
Morphine 0.1 × 20 = 2 mg/hour. Using morphine 10 mg/ml, rate is 0.2 ml/hour.
Lidocaine 3 × 20 = 60 mg/hour. Using lidocaine 20 mg/ml, rate is 3 ml/hour.
Ketamine 0.6 × 20 = 12 mg/hour. Using ketamine 100 mg/ml, rate is 0.12 ml/hour.
3) Determine the volume of each component required. A 12-hour infusion of this mixture would require:
2.4 ml morphine (0.2 ml/hour × 12 hour)
36 ml lidocaine (3 ml/hour × 12 hour)
1.5 ml ketamine (0.12 ml/hour × 12 hour)
4) Mix components and determine the rate at which the mixture will be infused. The MLK can be mixed together in a
syringe and the rate calculated as the sum of the rates for each of the three components. In this case, the MLK
mixture would be administered at 3.3 ml/hour.
MLK CRI for Fluid Pump Infusiona

1) Make sure that each of your components is compatible with the others and with the crystalloid fluid you are using
for the CRI. In most cases, 5% dextrose is the fluid of choice for drug infusions.
2) Determine the dose of each component:
Morphine 0.1 mg/kg/hour, lidocaine 2.4 mg/kg/hour, ketamine 0.6 mg/kg/hour
3) Draw 65 ml of fluid from a 500-ml bag of 5% dextrose and discard.
4) Add 1200 mg (60 ml of 20 mg/ml) lidocaine to the bag.
5) Add 50 mg of morphine to the bag
6) Add 300 mg of ketamine to the bag.
● The resulting mixture contains 0.1 mg/ml morphine, 2.4 mg/ml lidocaine and 0.6 mg/ml ketamine.
● The rate of administration (ml/hour) of the mixture is equal to the body weight of the patient in kilograms
(e.g. for a 20 kg patient, run this mixture at 20 ml/hour).

a
Other opioids (usually mu agonist drugs) can be used in place of morphine in these recipes. The appropriate CRI
doses for each should be used (Table 48.2).
CRI, constant rate infusion; MLK, morphine, lidocaine, ketamine.
Administration of intravenous lidocaine can reduce the Ketamine

duration of postoperative ileus [138, 147, 148]. This effect
Ketamine is an NMDA receptor antagonist. NMDA recep-
may be due to the combination of reduction in opioid dose,
tors are found in the dorsal horn of the spinal cord as well as
its anti-inflammatory action, and a decrease in sympa-
within the brain parenchyma. When the NMDA receptors in
thetic tone.
the dorsal horn are activated by peripheral nociceptors, they
Bolus dosing or high CRI rates of lidocaine (rates > 5 mg/
affect the neurons leading to the brain, making them hyper-
kg/hour) have been associated with drowsiness and light-
excitable and increasing the sensation of pain. This process
headedness in people [140]. Other adverse effects include
is known as central sensitization or “wind up.” NMDA
vomiting or nausea in dogs [141]. It can also cause seda-
receptor activation is also intrinsic to development of hyper-
tion [149]. Cats are more prone to neurologic adverse effects
algesia, neuropathic pain, and opioid tolerance [151, 152].
(including seizures) with use of lidocaine, so lower doses
Ketamine has been shown to be effective as an adjunctive
are used in this species (Table 48.4). Transdermal patches
analgesic and to reduce opioid requirement in human
are also available for lidocaine administration [150].
Adjunctive Analgesia 643
Table 48.4 Doses for adjunctive analgesic agents. activation of GABA receptors is not its principal mode of
action. Its primary mechanism of action as an analgesic
Drug Dog Cat agent is to block voltage-sensitive calcium channels in pain
fibers, which are crucial to transmission of pain sensation
Amantadine 1.25–4 mg/kg every 3 mg/kg every 24 through the nerves [124, 165, 166].
12–24 hours PO hours PO
Gabapentin may also have some NMDA receptor antago-
Gabapentin 10 mg/kg every 8–12 10 mg/kg every
nist activity in the spinal cord which can reduce hyperalgesia
hours PO 8–12 hours PO
associated with chronic pain. In addition, it has been shown
Lidocaine 1.5–3 mg/kg/hour 0.75–1.5mg/kg/hour
(25–50mcg/kg/minute) to act in the locus coeruleus similarly to alpha-2 receptor ago-
(12.5–25 mcg/kg/
CRI IV minute) CRI IV nists to cause centrally mediated analgesia [166].
Gabapentin has been used in combination with opiates
Ketamine 0.6–1.2 mg/kg/hour 0.6–1.2 mg/kg/hour
(10–20 mcg/kg/ (10–20 mcg/kg/
or NSAIDs for postoperative analgesia in people and has
minute) CRI IV minute) CRI IV been shown to be an effective analgesic for soft-tissue and
Acetaminophen 10–15 mg/kg every DO NOT USE spinal surgery [167–169]. The combination of gabapentin
(paracetamol) 8–12 hours IV, PO and NSAIDs tends to provide better analgesia than NSAIDs
alone and use of gabapentin in a balanced analgesic regime
CRI, intravenous constant rate infusion; IV, intravenous; PO, per os
(orally). can also decrease the postoperative requirement for opi-
oids [167, 168]. The main adverse effect of administration
patients after abdominal and orthopedic surgeries [153–155]. is sedation.
Ketamine has dissociative properties that also make it useful There are few clinical studies assessing the efficacy of
as an anesthetic agent in veterinary medicine, particularly in gabapentin as an adjunctive analgesic in dogs and cats and
combination with a sedative agent. The analgesic effects of results are mixed, generally due to the confounding effect
ketamine become apparent at doses far lower than those of concurrent opiate administration [170–174]. The dose
required for anesthesia. recommendation in both cats and dogs is 10 mg/kg every
Ketamine has also been evaluated for use as a periopera- 8–12 hours [175, 176]. The anti-epileptic dose is 10–30 mg/kg
tive and postoperative analgesic in dogs and cats and has every eight hours [133].
been shown to be effective in improving comfort after both
soft-tissue and orthopedic surgery [156–158]. Ketamine Acetaminophen
does not slow gastrointestinal motility, so can be useful in
patients with postoperative ileus to reduce the opioid Although acetaminophen (paracetamol) is loosely classi-
requirement [159]. It will also increase catecholamine fied within the NSAID class of drugs, it does not have sig-
expression so it can have a mild positive inotropic nificant anti-inflammatory effects and its analgesic activity
effect[160]. The primary adverse effects of ketamine infu- is more effective centrally than peripherally. In dogs, aceta-
sion are dysphoria and sedation [156, 157]. In some cases, minophen has been shown to have some COX-3 inhibiting
the dysphoria is severe enough to warrant discontinuation effects in the CNS but different mechanisms have been pro-
of the ketamine infusion. posed to account for its analgesic and anti-pyretic effects.
One such mechanism is as a serotonin antagonist, by
inhibiting 5HT-3 receptors in the brain and inhibiting
Amantadine descending serotonin-dependent pain pathways. Similar to
Amantadine is an oral anti-viral agent that has some other NSAIDs, acetaminophen has an antagonist effect at
antagonist activity at NMDA receptors. It has been evalu- NMDA receptors [177].
ated as an effective adjunctive postoperative analgesic in Acetaminophen also inhibits the metabolism of arachi-
people as well as for neuropathic and refractory osteoar- donic acid to COX-2. Acetaminophen partially reduces a
thritis pain in dogs [151, 161, 162]. free radical iron cation (Fe4+) thereby making it unavaila-
ble for use as a co-factor in the metabolism of arachidonic
acid. Acetaminophen is more effective in the brain than in
Gabapentin
other body tissues due to the relatively low amount of
Gabapentin was first used as an anti-epileptic medication COX-2 that is produced in cerebral cells and the low iron
in human and veterinary patients but has subsequently stores in the brain. In peripheral tissues, where the arachi-
been shown to be very effective in treatment of chronic and donic acid cascade is initiated in a rapid burst of activity and
neuropathic pain syndromes [163]. Gabapentin has multi- there are far greater stores of iron, the effects of acetami-
ple actions within the central nervous system [164]. nophen are overwhelmed and are of little consequence to
Structurally, gabapentin is an analog of GABA, however the production of inflammatory mediators [177].
Acetaminophen can be used as an adjunctive analgesic greater than 150–200 mg/kg [178]. Acetaminophen is
in dogs and can be of particular benefit in cases where extremely toxic to cats and should not be given under any
NSAIDs are contraindicated. It is also an effective anti- circumstances. Intravenous and oral preparations are avail-
pyretic agent. The therapeutic dose in dogs is 10–15 mg/kg able. Care must be taken when prescribing over-the-
every 8–12 hours. Toxicity in dogs has been seen at doses counter liquid formulations that they do not contain xylitol.
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49
Local Anesthesia
Christopher L. Norkus
Local anesthetics are among the safest and most effective Local anesthetics work by inhibiting action potential
analgesics for the treatment of acute pain. Because local formation by blocking neuronal voltage-gated sodium chan-
anesthetics directly block nerve impulses, their use in nels, specifically Nav 1.2 in a reversible and concentration-
locoregional techniques decreases pain in a different way dependent fashion [1, 2]. The binding site for local
than systemic analgesics like opioids or nonsteroidal anti- anesthetics is located in domain IV, loop S6 of the sodium
inflammatory drugs, often with fewer potential risks and channel. By inhibiting action potentials in nociceptive fib-
systemic adverse effects. When used preemptively, locore- ers, the local anesthetic effectively blocks the transduction
gional techniques decrease the likelihood of central sensi- and transmission of pain impulses.
tization (wind-up) of pain pathways, ultimately helping to The absorption of a local anesthetic depends on the site
prevent hyperalgesia and chronic pain, and aiding in a of injection, rate of injection, dosage, and effect on vaso-
multimodal approach to patient analgesia. Despite these motor tone of the agent. Amide local anesthetics are highly
known benefits, local anesthetics and locoregional tech- protein bound. Tissue distribution following administra-
niques are often underused in the emergency department tion is generally proportional to the tissue/blood partition
and critical care unit. This chapter focuses on local anes- coefficient of the specific local anesthetic, as well as to the
thetics and specific locoregional techniques that have valu- mass and degree of perfusion of the tissue.
able application to this setting. Ester and amide local anesthetics differ in how they are
biotransformed by the body. Esters are hydrolyzed in
plasma by pseudocholinesterase to para-aminobenzoic
Pharmacology acids, which can result in hypersensitivity reactions.
Conversely, amide local anesthetics undergo biotransfor-
Local anesthetics are water soluble salts of lipid soluble mation in the liver and therefore can accumulate in the
alkaloids. They consist of three structural components: a presence of hepatic failure or reduced hepatic blood flow;
lipophilic aromatic group, an intermediary link, and a however, this is rarely a clinical concern. Some metabolites
hydrophilic amine group (Figure 49.1). Variation to the of amides, such as lidocaine’s metabolite monoethylgly-
intermediary link results in the local anesthetic being cinexylidide, may have active properties themselves.
classified as either an ester or an amide. Amides are the Amides have a low potential for hypersensitivity reactions;
most widely used local anesthetics in veterinary medi- observed adverse reactions are more commonly caused by
cine. Agents such as lidocaine, mepivacaine, bupivacaine, additives such as methylparaben or vasoconstricting agents
ropivacaine, and levobupivacaine are all amide local (e.g. epinephrine) that were added to the amide to increase
anesthetics and are emphasized in this chapter, as they are duration, rather than by the amide itself. Elimination of
the most widely used. Agents such as prilocaine, tetracaine, amides occurs via renal excretion.
procaine, benzocaine, and proparacaine are esters. The speed Besides producing sensory blockage to numb a specific
of onset, potency, and duration of the local anesthetic location or region of the body, local anesthetics can also
depends on the pKa, lipid solubility, and protein binding cause complete loss of motor function, depending on the
of the agent, respectively. properties of the drug, nerve location, myelination of the
652 Local Anesthesia
has an onset of action of approximately 5 minutes and

duration of action of approximately 60–120 minutes.
However, these numbers can be easily influenced by the
agent’s proximity to a nerve, additives, and other factors
Figure 49.1 The three structural components of all local
such as tissue pH. Dosing of lidocaine for local infiltration
anesthetics: a lipophilic aromatic group (green), an intermediary is generally 1–10 mg/kg in dogs and 1–5 mg/kg in cats.
link (orange), and a hydrophilic amine group (blue). Changes to Adverse drug reactions are uncommon when lidocaine is
the intermediary link result in the local anesthetic being used as a local anesthetic. Most reactions are associated
classified as either an ester or an amide. Source: Artwork by
Natalia Pisano.
with accidental intravenous (IV) injections, so care should
be taken to avoid this when local effects are the goal.
In dogs, IV administration of lidocaine at a dose of
nerve, dose, and size of the nerve fibers. Generally, local
22 ± 6.7 mg/kg induces convulsions and other signs of cen-
anesthetics cause nerve blockade in a particular order by
tral nervous system (CNS) toxicosis, such as salivation and
first numbing pain, then warmth, touch, deep pressure,
muscle tremors [3]. In cats, IV administration of lidocaine
and finally, motor function. However, large peripheral
at a dose of 11.7 ± 4.6 mg/kg induces convulsions [4].
nerves are an exception to this pattern and tend to have
Based on these results, dogs should not exceed a dose of
motor blockade before sensory blockade, as well causing
12 mg/kg IV, whereas cats should not exceed a dose of
proximal extremity analgesia prior to distal extremity
6 mg/kg IV. Lidocaine with epinephrine should not be used
blockade.
in peripheral extremities (e.g. pinnae) due to vasoconstric-
tion and potential tissue necrosis.
Common Local Anesthetics
Bupivacaine
Lidocaine
Bupivacaine hydrochloride is a long-acting local anesthetic
Lidocaine is the most commonly used local anesthetic in that also belongs to the amino amide group and is a race-
veterinary medicine. It belongs to the amino amide group mate [5]. It comes in three different concentrations, 0.25%,
and is biotransformed by liver microsomal enzymes, as 0.5%, and 0.75%, available with or without epinephrine.
previously discussed. It is available in concentrations of Bupivacaine has a first onset of action of around 5 minutes,
0.5–5% with or without epinephrine. In addition to the but it may take up to 20 minutes for full blockade of larger
injectable preparation, various other forms of lidocaine can nerves. Bupivacaine has a typical duration of action of
also be found, including transdermal patches, viscous gels 240–360 minutes and may last longer in some tissue sites.
for use on mucous membranes, topical creams to be used The cumulative IV dose resulting in CNS toxicosis and con-
on intact tissue, and nasal sprays (Figure 49.2). Lidocaine vulsive activity in conscious dogs was 4.3 mg/kg [6]. In
cats, the mean IV convulsant dose was 3.8 ± 1 mg/kg [4].
Based upon these studies, the dose of bupivacaine should
not exceed 1–2 mg/kg for either dogs or cats. Caution must
be taken if repeat doses are necessary. Accidental IV injec-
tion of bupivacaine is cardiotoxic and may lead to death;
therefore, syringe aspiration before injection is crucial.
Further discussion on local anesthetic toxicosis is available
later in this chapter. Bupivacaine with epinephrine should
not be used on peripheral extremities due to its vasocon-
strictive properties and the potential for tissue death.
Liposomal Encapsulated Bupivacaine

Liposomal encapsulated bupivacaine is an extended-release
formulation of bupivacaine that became available for use in
people in 2011 (Exparel®, Pacira Pharmaceuticals, San
Francisco, CA) and for use in cats and dogs in 2016 (Nocita®,
Figure 49.2 Various forms of lidocaine are available. This
Elanco, Greenfield, IN). The suspension comprises multive-
image shows a 5% transdermal patch, a 2% viscous gel for use
on mucous membranes, a 4% cream for use on intact skin, and sicular liposomes which, following injection, gradually
2% lidocaine for injection. degrade and slowly release bupivacaine into surrounding
Local Anesthetic Adjuvants 653
Ropivacaine
Ropivacaine hydrochloride is a long-acting local anesthetic
that also belongs to the amino amide group and is a pure
S(−) enantiomer, unlike bupivacaine. It comes in 0.2%,
0.5%, 0.75%, and 1% concentrations. Ropivacaine has a full
onset of action of approximately 20 minutes and duration
of action of 180–360 minutes. Dosing of ropivacaine is sim-
ilar to bupivacaine at 1–2 mg/kg for both dogs and cats.
Ropivacaine has been found to have less cardiotoxicity
than bupivacaine in animal models; however, the IV route
is generally still avoided.
Levobupivacaine
Levobupivacaine is the S(−) enantiomer of the drug bupiv-
acaine hydrochloride. It was developed for use in humans,
as enantioselectivity has been shown to reduce cardiotoxic-
ity and CNS toxicity. Levobupivacaine has properties and
Figure 49.3 A single liposome containing a phospholipid dosages essentially identical to those of bupivacaine.
bilayer and an aqueous core that contains bupivacaine Currently, the main factor limiting its use in veterinary
molecules that slowly release into tissue. Source: Artwork by
Natalia Pisano. medicine is increased cost compared to bupivacaine.
tissue, thereby providing local analgesia for up to 72 hours Mepivacaine

(Figure 49.3). Nocita is an off-white, preservative-free,
Mepivacaine is a medium duration amide local anesthetic.
13.3 mg/ml solution that comes in 10-ml and 20-ml vials.
It has a rapid onset of action of approximately 5 minutes
The suspension should not be shaken. The onset of action
and a duration of 120–180 minutes. It is used at 1–6 mg/kg
in dogs and cats is not known. Because liposomes are large
in the dog and 1–3 mg/kg in the cat. Cardiotoxicity and
in size (10–30 μm), they move poorly through tissue com-
neurotoxicity can result. The IV route is contraindicated.
pared with standard bupivacaine. For this reason, the prod-
uct should be deposited as close to the affected site as
possible. Nocita is approved as a single dose of 5.3 mg/kg
into the surgical site following cranial cruciate ligament
Local Anesthetic Adjuvants
surgery. Since its release, the product is widely used off-
Dexmedetomidine
label at lower doses and for other locoregional techniques.
Volume expansion can be achieved by diluting the product The alpha-2 adrenergic agonist dexmedetomidine can be a
with an equal volume of sterile saline if needed. An admix- useful adjunct when combined with amide local anesthet-
ture with bupivacaine can be made by mixing bupivacaine ics [8, 9]. The addition of dexmedetomidine may result in
and liposomal encapsulated bupivacaine, as long as one synergistic analgesic effects due to norepinephrine inhibi-
ensures the ratio of the milligram dose of bupivacaine tion at the nerve endings, as well as enhanced peripheral
hydrochloride to liposomal encapsulated bupivacaine does nerve blockade for a duration of up to 24 hours. Doses of
not exceed one to two (Exparel, Pacira Pharmaceuticals, 0.001–0.005 mg/kg are commonly selected. Systemic effects
Inc., Tampa, FL). The author commonly uses 0.5 mg/kg following dexmedetomidine use may include nausea, vaso-
bupivacaine hydrochloride mixed with 1 mg/kg liposomal constriction, bradycardia, and decreases in cardiac output.
encapsulated bupivacaine for nerve blocks. Recent litera-
ture suggests that Nocita may be used as a multidose vial for
Opioids
up to four days as long as aseptic technique, including wear-
ing gloves and alcohol swabbing the bottle, is used [7]. The Systemic opioids can be combined with amide local anes-
product is always stored refrigerated. Liposomal encapsu- thetic agents to prolong the duration of local blockade [9,
lated bupivacaine should not be used IV and is generally 10]. The most widely used opioid for this purpose in vet-
avoided epidurally as well. Because of its exceptionally long erinary medicine is buprenorphine, which may extend
duration of action, Nocita has largely replaced the need for the duration of amide local anesthetics beyond 24 hours.
and use of soaker wound infusion catheters. A dose of 0.003 mg/kg combined with a local anesthetic
is commonly used. Other opioid adjuvants appear to be deeper sedation or general anesthesia. The most common
less successful at extending analgesic duration of local indications for these blocks include lacerations, wounds,
anesthetics. incisions, toe injuries and amputations, tail injuries and
amputations, and surgical sites.
A strict contraindication for these blocks is a previously
Selected Locoregional Techniques documented hypersensitivity reaction to a local anesthetic.
Local anesthetics do not appear to hinder wound healing
Many locoregional techniques can be quickly, safely, and in dogs and cats, nor do they hinder the ability for a pathol-
effectively performed in dogs and cats. For the purpose of ogist to perform histopathology on excised tissue [11].
this chapter, however, the author has selected a handful of Local infection may alter tissue pH and may inhibit the
techniques that he most frequently uses in the emergency effectiveness of local anesthetics. Lidocaine is acidic and
and critical care setting. Many other techniques such as
femoral and sciatic nerve blocks, transversus abdominis
plane blocks, brachial plexus nerve blocks, paravertebral Box 49.1 Supplies Needed for Most Local
nerve blocks, and others can be useful but are beyond and Regional Anesthetic Blocks
the scope of this chapter and are described elsewhere.
Clean examination gloves or sterile gloves, depend-
Additionally, such techniques are often best achieved using
●
ing on procedure and hospital protocol

a peripheral nerve locator or under ultrasound guidance,
Fur clippers
as well as under the mentorship of a board-certified veteri-
●
Sterile 4 × 4-inch gauze

nary anesthesiologist. A list of supplies needed for most
●
Aseptic preparation (e.g. chlorhexidine scrub, 70%

local anesthetic blocks is available in Box 49.1.
●
isopropyl alcohol)
● Sterile syringes (e.g. 3-, 6-, 12-ml sizes)
Local Infiltration and Line Blocks ● Sterile needles of various gauges, including epidural
needles if indicated
Local anesthetic infiltration, including incisional block, is
Local anesthetic agent of choice (e.g. 2% lidocaine,
simple and quick to perform (Protocol 49.1). These tech-
●
0.5% bupivacaine), dosed appropriately to body

niques involve the infusion of a local anesthetic in and
weight and diluted if so recommended for procedure
around the site of a wound or surgical incision. Such blocks
Sterile 0.9% NaCl
may reduce the need for other systemic drugs such as
●
Protocol 49.1 Local Infiltration and Line Blocks

Items Required 6) With a syringe attached to either a 25-gauge, ⅝-inch
needle, or a 22-gauge, 1-inch needle, insert the needle
● See Box 49.1 for supplies list.
subcutaneously, aspirate to confirm the needle is not
inside a blood vessel, and inject the local anesthetic while
withdrawing the needle, thereby making a small fluid bleb.
Procedure
7) Repeat this process around the target area in a rectan-
1) Clip the affected area. gular or circular pattern. Make sure to divide the vol-
2) Aseptically prepare the area. ume of drug equally throughout the area. It is best to
3) Wash hands. anticipate how large the blocked area will be to avoid
4) Don clean examination gloves or sterile gloves exceeding the maximum mg/kg dose or running out of
depending on nature of procedure. drug before blocking the entire target.
5) Select a single local anesthetic agent such as 2% If your target area is a surgical incision, inject the local
lidocaine or 0.5% bupivacaine. The author commonly anesthetic along the anticipated incision, using either
selects up to 5 mg/kg of lidocaine in the cat, 8 mg/kg a 25-gauge, ⅝-inch, or a 22-gauge, 1-inch needle (size
of lidocaine in the dog, or 2 mg/kg of bupivacaine. depends on the size of the animal). Alternatively, you
When using lidocaine, consider making an admixture can use a 22-gauge, 1.5–3.0-inch spinal needle (length
with 8.4% sodium bicarbonate to reduce pain on depends on size of incision).
injection. Mix 8.4% sodium bicarbonate with 2% 8) It is ideal to make these injections before any surgical
lidocaine in a volume ratio of 1 part to 9 parts (for a procedure has begun; however, these local anesthetics
total of 10 parts). are still beneficial if done after incision.
Selected Locoregional Techniques 655
for this reason can be painful upon administration. To intrapleural local analgesia to be effective in addressing
reduce this effect, 8.4% sodium bicarbonate can be mixed pain that results from cholecystectomy [19, 20]. A flail
with 1% or 2% lidocaine in a volume ratio of 1 part to 9 chest segment may cause local anesthetic to leak out of the
parts (for a total of 10 parts), respectively [12, 13]. This pleural space and into the subcutaneous tissue, resulting in
admixture will turn cloudy and neutralize the pH to less effective intrapleural coverage. Complications in peo-
7.4 [14]. Infection at the site of local anesthetic administra- ple from this technique appear low but may include tran-
tion, adverse drug reactions, bleeding, and incomplete or sient discomfort, pneumothorax, bleeding or hemothorax,
ineffective block are possible complications. Importantly, local infection, pleural effusion, and, rarely, Horner syn-
different local anesthetics (e.g. lidocaine and bupivacaine) drome [5, 21]. The use of intrapleural lidocaine and bupiv-
should not be mixed together, as this practice has consist- acaine has not been shown to cause hemodynamic changes
ently been shown not to produce a faster onset and actually or arrhythmia in dogs that have undergone pericardiec-
reduces the duration of the block [15–18]. tomy [22]. As the procedure may cause transient discom-
fort, the author prefers to perform this technique on
patients that are sedated or anesthetized when possible.
Intrapleural Local Anesthesia
Intrapleural local anesthesia administration is commonly
Intercostal Nerve Blocks
performed through a chest tube that has already been
placed (Protocol 49.2), but it can also be performed by Intercostal nerve blocks (Protocol 49.3) can be performed
direct injection into the pleural space. This technique is at any intercostal nerve. This technique is most frequently
believed to enable the spread of the local anesthetic to mul- performed to provide analgesia for broken ribs and flail chest
tiple intercostal nerves via a single injection. Intrapleural segments to improve ventilation, and can also be performed
local anesthesia may be used to treat acute postoperative for thoracotomy and cranial abdominal pain. A strict con-
pain that results from thoracotomy as well as pain resulting traindication for these blocks is a previously documented
from cranial abdominal surgery or disease (e.g. liver lobec- hypersensitivity reaction to a local anesthetic. Intercostal
tomy, pancreatitis). Multiple studies in people have found
Protocol 49.3 Intercostal Nerve Blocks

Protocol 49.2 Intrapleural Local Anesthesia
Items Required
Items Required
Procedure
Procedure
1) Select an intercostal nerve to anesthetize.
1) Wash hands and don clean examination or ster- 2) Clip and aseptically prepare two adjacent intercos-
ile gloves. tal spaces cranial and two adjacent intercostal
2) Aseptically prepare the chest tube for injection. spaces caudal to selected site.
3) Aspirate the chest tube and remove any fluid or air 3) Wash hands and don clean examination gloves.
from the pleural space. 4) Palpate the caudal border of each rib head to locate
4) Slowly inject a long-acting local anesthetic such as the approximate site of each intercostal nerve,
bupivacaine or ropivacaine into the pleural space. A artery, and vein.
new, previously unopened vial of local anesthetic is 5) Using a 90-degree angle, insert a 25-gauge, ⅝-inch,
recommended to ensure sterility. The total dosage or a 22-gauge, 1-inch needle through the skin caudal
should not exceed 2 mg/kg. If bilateral chest tubes and perpendicular to the rib head, as close to the dorsal
are placed, divide the drug in half and administer aspect of the intervertebral foramen as possible.
one half of the drug into each chest tube. 6) Aspirate the syringe to confirm accidental arterial or
5) Follow the injection with several milliliters of sterile venous puncture has not occurred. If no blood is
saline or air to clear the chest tube of the local anes- observed, slowly inject the selected local anesthetic
thetic and ensure dispersion into the thoracic cavity. at each site. Lidocaine up to 5 mg/kg total in the cat
6) If a single lateral thoracotomy has been performed, and 8 mg/kg total in the dog or bupivacaine at 2 mg/
the local anesthetic may be more effective if you kg are most commonly selected. Ensure that the vol-
position the patient in lateral recumbency for ume of this total dosage is divided evenly between
10–15 minutes with the affected side down. all sites.
A strict contraindication for this technique is a previ-

ously documented hypersensitivity reaction to local anes-
thetic. If performing through a closed abdomen,
intraperitoneal local anesthesia should be avoided in
patients with skin disease over the site of injection, coagu-
lopathy, severe thrombocytopenia, or advanced thrombo-
cytopathy. The presence of abdominal effusion may render
intraperitoneal local anesthesia less effective. In a closed
abdomen, complications following intraperitoneal local
anesthesia are rare and are similar to that of abdominocen-
tesis; these complications may include transient discom-
Figure 49.4 The approximate landmark at which to perform
intercostal nerve blocks. The orange line signifies the intercostal fort, hematoma, abdominal bleeding, local infection, and
vein, artery, and nerve. Note that the needle is placed along the entrance of local anesthetic into viscera (intestine or blad-
caudal border of each rib and as dorsal on the rib as possible. der). The author greatly prefers to perform this technique
Source: Artwork by Natalia Pisano.
under direct visualization during laparotomy prior to clo-
sure and does so at the conclusion of most abdominal sur-
nerve blocks should be avoided in patients with skin disease geries. Complications with this approach are rare but could
over the site of injection, coagulopathy, severe thrombocyto- include increased systemic toxicosis and infection. To miti-
penia, or advanced thrombocytopathy. When performed gate these risks, a new, previously unopened vial of local
correctly, complications from this technique are rare but anesthetic is recommended to ensure sterility is maintained.
may include transient discomfort, pneumothorax, hematoma,
bleeding or hemothorax, and local infection (Figure 49.4).
Radial, Ulnar, Median, and Musculocutaneous
Nerve Block
Intraperitoneal Local Anesthesia
In recent years, the radial, ulnar, median, and musculocu-
Intraperitoneal local anesthesia (Protocol 49.4) is an under- taneous nerve block (RUMM) has widely replaced the use
used but safe and effective modality to provide analgesia in of the brachial plexus nerve block for providing local
patients undergoing laparotomy or in patients with abdom- anesthesia in the forelimb below the elbow (Protocol 49.5)
inal pain secondary to disease (e.g. pancreatitis) [23–27]. [28, 29]. This is due to the relative ease of administration
The practice is widely used in people and is believed to and wider safety margin compared with the brachial plexus
work via blockade of free afferent nerve endings in the nerve block.
peritoneum as well as via possible anti-inflammatory The RUMM block requires two separate approaches to
effects. It is most commonly performed by depositing local complete (Figures 49.5, 49.6). The radial nerve is
anesthetic into the abdomen during laparotomy with direct approached via the lateral aspect of the forelimb, and the
visualization prior to abdominal closure, but it can also be ulnar, median, and musculocutaneous portions of the
performed by blind injection or via ultrasound guidance block are approached from the medial aspect. The radial
through the intact abdominal wall. nerve runs between the long head of the triceps and the
brachial muscle on the caudolateral aspect of the humerus,
along approximately one third of the bone. It feels much
Protocol 49.4 Intraperitoneal Block like a spaghetti noodle or a guitar string. The median and
ulnar nerves run caudal to the brachial artery on the medial
Items Required
aspect of the distal humerus. The musculocutaneous nerve
● See Box 49.1 for supplies list. runs immediately cranial to the brachial artery on the
medial aspect of the distal humerus.
Procedure The RUMM block is indicated for surgery or injury of the
distal forelimb (e.g. the antebrachium, carpus, or paw). The
1) Perform laparotomy, including abdominal lavage
block can be performed blindly by digital palpation, using
as needed.
a peripheral nerve finder, or via ultrasound guidance. A
2) Using a previously unopened vial of local anesthetic,
strict contraindication for this technique is a previously
aseptically withdraw 3–5 mg/kg of bupivacaine or
documented hypersensitivity reaction to local anesthetic.
ropivacaine and deposit the volume throughout the
Other rare complications include accidental systemic drug
open abdominal cavity.
administration following venous or arterial injection,
3) Close the abdomen as planned.
hematoma, bleeding, or local infection.
Protocol 49.5 Radial, Ulnar, Median, and Musculocutaneous Nerve Block

Items Required 5) Aspirate. As long as no blood is aspirated, slowly inject
a long-acting local anesthetic such as 0.5–1 mg/kg of
bupivacaine or ropivacaine at the site. Dexmedetomidine
or buprenorphine can be added to this block to extend
Procedure
the duration of its effects. Alternatively, Nocita with or
1) Clip and aseptically prepare the medial and lateral without bupivacaine can also be used.
aspects of the humerus over the anticipated injec- 6) Position the patient in lateral recumbency with the
tion sites. affected limb down. Palpate the pulse of the brachial
2) Wash hands and don clean examination gloves. artery between the biceps brachialis and the medial
3) Position the patient in lateral recumbency with the head of the triceps, approximately one third of the way
affected limb up. Palpate the radial nerve on the dis- up the humerus.
tal third of the humerus by pushing the brachialis 7) Insert a 25-gauge, ⅝-inch, or a 22-gauge, 1-inch nee-
muscle cranially so that your finger rests on the dle through the skin adjacent to the pulse. Advance
humerus between the brachialis muscle and the tri- the needle until there is contact on the humerus near
ceps. The radial nerve can be felt crossing the the nerve.
humerus at this location and feels like a piece of spa- 8) Aspirate back on the syringe to check for blood. If no
ghetti or a guitar string. blood returns, slowly inject a long-acting local anes-
4) Insert a 25-gauge, ⅝-inch, or a 22-gauge, 1-inch nee- thetic such as 0.5–1 mg/kg bupivacaine or ropivacaine
dle through the skin from a caudal direction perpen- at the site. Dexmedetomidine or buprenorphine can be
dicular to the length of the humerus at the level of the added to this block to extend the duration of its effects.
nerve. Advance the needle until there is contact on the Alternatively, Nocita with or without bupivacaine can
humerus near the nerve. also be used.
Figure 49.6 The radial, ulnar, median, and musculocutaneous

Figure 49.5 The radial, ulnar, median, and musculocutaneous nerve block requires two approaches to complete the technique.
nerve block requires two approaches to complete the technique. The medial approach to the left thoracic limb, shown here,
The lateral approach to the left thoracic limb, shown here, achieves blockade of the ulnar, median, and musculocutaneous
achieves blockade of the radial nerve. The dog is drawn in right nerves. The dog is drawn in left lateral recumbency with its head
lateral recumbency with its head to the left and tail to the right to the right of the image and its tail to the left. Source: Artwork
of the image. Source: Artwork by Natalia Pisano. by Natalia Pisano.
Protocol 49.6 Sacrococcygeal Epidural

Sacrococcygeal Epidurals
Items Required Sacrococcygeal epidurals, also referred to as coccygeal

nerve blocks, are safe, fast, improve analgesia, and reduce
● See Box 49.1 for supplies list. the need for systemic drugs during surgery or urethral
catheterization (Protocol 49.6) [30, 31]. They can be used
Procedure for a wide variety of procedures in dogs and cats includ-
1) Sedate or anesthetize the patient. ing catheterization for relief of urethral obstruction, tail
2) Clip and aseptically prepare the sacrococcygeal amputations, perineal urethrotomy, anal sac disease
area. This is easily found by palpating the space including sacculectomy, and other surgeries of the penis
between the sacrum and the first coccygeal verte- or perineal region (Figure 49.7). Contraindications for
bra, which can be identified by moving the patient’s the procedure include skin infection over the sacrococ-
tail to isolate the joint. cygeal space, coagulopathy, severe thrombocytopenia,
3) Wash hands and don clean examination gloves. and thrombocytopathy. The procedure is most safety
Palpate the sacrococcygeal space with the index performed in a sedated patient. Complications from the
finger of the nondominant hand. Once you have technique are uncommon but could include local infec-
located it, use your dominant hand to insert a 25- tion, epidural abscess, epidural bleeding or hematoma,
gauge, ⅝-inch, or a 22-gauge, 1-inch needle through and injury to the cauda equina. To mitigate infection, a
the skin along the midline into the sacrococcygeal new, previously unopened vial of local anesthetic is
space. A 30–45 degree angle through the skin is recommended to ensure sterility is maintained. Because a
often best. If blood is noted in the needle hub, the smaller volume of local anesthetic is used and thus there
needle should be completely removed and the is less cranial drug migration, many of the possible
technique restarted. Blood suggests entrance into adverse effects of lumbosacral epidurals such as motor
the ventral vertebral venous plexus. If bone is weakness, sympathetic block, and intrathecal injection are
encountered, the needle may need to be partially avoided. Most commonly, local anesthetics such as lido-
withdrawn, redirected slightly steeper or flatter, and caine, bupivacaine, or ropivacaine are used alone in this
reinserted to enter the sacrococcygeal space. technique; however, opioids (e.g. morphine, buprenorphine)
4) Inject 0.1 ml/kg of either 2% lidocaine or 0.5% bupiv- or other adjuncts (e.g. dexmedetomidine, ketamine) could
acaine or ropivacaine into the sacrococcygeal space. also be included. Agents with or without preservatives
Note that there should be no resistance to injection, can safely be used.
and if resistance is present, the subcutaneous space
or musculature may have been accidently entered.
Lumbosacral Epidurals
5) If effective blockade has occurred, tail, anus, and
preputial relaxation may be noted 5–10 minutes Lumbosacral epidurals (Protocol 49.7) are performed in
following injection. heavily sedated or anesthetized patients at the L7 and S1
vertebral space and commonly use a combination of a
local anesthetic and an opioid (Figure 49.8). Once injected
into the epidural space, these agents gradually diffuse
across the dura into the subarachnoid (intrathecal) space.
Here, local anesthetics provide sensory blockade by acting
primarily on the spinal nerve roots. Conversely, opioids
provide segmental analgesia by reducing neurotransmitter
release (e.g. substance P, neurokinin A, glutamate) at the
presynaptic level and by hyperpolarizing the membrane of
the dorsal horn neurons at the post synaptic level. Injection
directly into the intrathecal space is widely done in people,
but because of the anatomic differences between species,
this technique is far more challenging in dogs and cats,
Figure 49.7 Sacrococcygeal epidurals using 0.1 ml/kg of either and thus epidural injections are more commonly per-
2% lidocaine or 0.5% bupivacaine are commonly administered formed. Catheterization of the epidural space can also
into the sacrococcygeal space for cats with urethral obstruction.
be performed, allowing for bolus or constant rate infu-
The animal is drawn in right lateral recumbency with the head
to the left of the image and the tail to the right. Source: Artwork sions of medication to be delivered into the epidural space
by Natalia Pisano. (Protocol 49.8).
Protocol 49.7 Lumbosacral Epidural

Items Required glass (if available) syringe with 0.5–2 ml sterile
saline and a small volume of air. Invert the syringe
so the small volume of air rises above the saline.
Attach the syringe to the epidural needle and
Procedure
slowly inject some of the saline into the epidural
1) The patient should be heavily sedated or space. There should be no resistance to the injec-
anesthetized. tion and no compression of the air within the
2) Place the patient in either sternal or lateral recum- syringe. Resistance or back pressure on the
bency, depending on personal preference. The patient’s plunger during injection suggests that your
pelvic limbs can be positioned cranially to increase attempt to enter the epidural space has failed.
the size of the epidural space. Repeat the preceding steps until no resistance or
3) Clip a small area of fur over the lumbosacral junction back pressure is encountered. This is the author’s
and aseptically prepare the site. preferred method for epidural administration.
4) Wash your hands and don sterile gloves. b) The second technique that can be used to confirm
5) With your nondominant hand, palpate the wings of correct epidural placement is the hanging drop
the ilium with your thumb and middle finger. Using technique. This technique must be performed with
your index finger, palpate the spinous process of the the patient in sternal recumbency. Once the nee-
seventh lumbar vertebra. dle is placed through the skin, the stylet is removed,
6) Slide the index finger caudally down the spinous pro- and the hub of the epidural needle is filled with
cess until the lumbosacral space is palpable. A slight saline or local anesthetic. The needle is then
divot can usually be palpated here, between L7 and S1. slowly advanced. Once the needle enters the epi-
7) Keeping the index finger in place to maintain posi- dural space, the fluid within the hub of the needle
tioning, insert a 20- or 22-gauge, 1.5- to 3.0-inch drops, confirming that is has fallen into the
Quincke-type spinal needle (length and size of needle epidural space, indicating epidural placement.
depend on patient size) perpendicular to the skin, Unfortunately, because the epidural space of dogs
ensuring the needle is precisely on midline. In cats and and cats is not as negatively pressured as in other
small dogs, a 25-gauge, 0.75-inch Quincke-type spinal species (e.g. cows), a lack of response commonly
needle can be used if available. occurs, resulting in a false negative test.
8) Continue to advance the spinal needle slowly, adjust- 10) Once epidural needle placement is verified, examine
ing the needle angle as needed, cranially or caudally, the needle for blood or cerebrospinal fluid. If blood is
until the needle advances smoothly and is believed to encountered, the needle has inadvertently entered
be in the epidural space (see point 9, below). The diam- the ventral venous plexus. No drug administration is
eter of the lumbosacral epidural space is 2–4 mm in made, and the needle is removed. The procedure is
medium sized dogs and less than 3 mm in cats. then restarted. If cerebrospinal fluid is encountered,
9) The epidural space sits just ventral to the ligamen- the intrathecal space has been encountered, and the
tum flavum. As the needle is advanced, it must pass volume (dose) to be injected is reduced by 50%,
through the skin, subcutaneous fat, supraspinous liga- regardless of drug(s) used.
ment, interspinous ligament, and, lastly, the ligamen- 11) Slowly inject lidocaine 2–5 mg/kg, bupivacaine
tum flavum. A “pop” or distinct change in resistance is 0.25–1.5 mg/kg, or ropivacaine 0.25–1.5 mg/kg with
often felt upon puncturing through the ligamen- or without morphine 0.05–0.15 mg/kg. Within the
tum flavum. ranges, higher doses of local anesthetic will result in
a) Two techniques are commonly used to ensure cor- more cranial drug migration and more cranial effect.
rect epidural placement of the needle tip. The first For most abdominal, pelvic, or pelvic limb procedures,
method is the loss of resistance technique. Remove bupivacaine 0.5 mg/kg and morphine 0.1 mg/kg is a
the stylet of the epidural needle. Fill a plastic or commonly selected combination.
Epidural drug administration is an excellent modality to repeated larger doses of parenteral opioids since a small
provide analgesia in the emergency and critical care setting. dose of opioid can be targeted directly at the dorsal horn of
The technique can greatly reduce systemic effects such as the spinal cord. Additionally, epidural drug administration
sedation, nausea, vomiting, and ileus that might be seen with reduces inhalant anesthesia requirements, often has a long
surgery (e.g. tibial plateau leveling osteotomy), or pelvic limb

amputation. Beyond hind limb orthopedic disease, epidurals
are beneficial for patients with soft tissue trauma to the pelvic
limb, orthopedic pelvic disease, and those with abdominal
pain. If opioids are used as part of the epidural, central anal-
gesia is produced via the dorsal horn, which also provides
analgesia for those with thoracic or thoracic limb pain.
Commonly used local anesthetics for epidural adminis-
tration include bupivacaine, ropivacaine, and lidocaine.
Given epidurally, these agents typically have a similar onset
of action to what they would have if they were administered
Figure 49.8 Epidural drug administration or a locoregional elsewhere. Liposomal encapsulated bupivacaine is not
anesthesia technique, such as a femoral sciatic nerve block, is widely recommended for use in the epidural space. Morphine is
considered standard of care for invasive hindlimb orthopedic
surgical procedures such as fracture repair, stifle surgery (e.g. tibial the mostly widely used opioid for epidural administration
plateau leveling osteotomy), or pelvic limb amputation. The animal because it is comparatively the most hydrophobic (least
is drawn in right lateral recumbency with the head to the left of the lipophilic) of available opioids, thereby resulting in the
image and the tail to the right. Source: Artwork by Natalia Pisano. longest duration of action. The onset time for morphine in
the epidural space is approximately 60 minutes and it may
duration of action, is cost effective, and has few adverse provide analgesia for 16–24 hours. Other opioids such as
effects. Epidural drug administration or a locoregional buprenorphine or fentanyl can be used epidurally but with
anesthesia technique, such as a femoral sciatic nerve block, is much shorter duration of action. Occasionally, other agents
widely considered standard of care for invasive hindlimb such as dexmedetomidine, ketamine, or corticosteroids
orthopedic surgical procedures such as fracture repair, stifle may also be administered in the epidural space. Either
Protocol 49.8 Epidural Catheter Placement

Items Required through the needle; doing so could potentially lacer-
ate the catheter, resulting in it breaking off and embo-
● Supplies listed in Box 49.1
lizing in the epidural space.
● Commercial epidural catheter kit
6) The procedure is best done under fluoroscopy.
● Supplies for aseptic procedure, including sterile gloves
However, because epidural catheters are designed to
● Light sterile dressing, such as iodophor-impregnated
be radiopaque, a radiograph can also be performed to
adhesive dressing
verify correct placement of the epidural catheter.
7) Once the catheter is confirmed to be in the correct
Procedure
location, a locking mechanism is attached, together
1) Follow steps 1 through 8 of Protocol 49.7 for Lumbosacral with a filter and injection port.
Epidural. 8) It is important to keep the injection port of the catheter
2) The procedure for entering the epidural space is nearly sterile at all times. The insertion site should be covered
identical to epidural injection, but instead of using a with an iodophor-impregnated adhesive drape (e.g.
Quinkie-type epidural needle, a Tuohy-type epidural Ioban®, 3M Healthcare, Maplewood, MN) to provide
needle is selected. The Tuohy-type epidural needle has antimicrobial activity over the site. Aseptic technique
a curved tip, which allows a catheter to be passed should be used when delivering drugs through the
through the needle and its tip directed cranially within injection port. The insertion site should be inspected
the epidural space. daily for signs of inflammation or infection.
3) Once entrance into the epidural space has been con- 9) If an epidural catheter stops functioning, placement
firmed, the epidural catheter is advanced through the should be checked by fluoroscopy or radiographs.
Tuohy needle. If the catheter is correctly in place, the catheter can
4) The tip of the epidural catheter should be placed just be flushed with a small volume of sterile saline and,
caudal to the painful area. Therefore, premeasuring if necessary, slightly withdrawn until patency is
the catheter prior to placement is important. reestablished. The epidural catheter should not
5) Remove the Tuohy needle while leaving the catheter be readvanced once any aspect of it has been
in place. The catheter should NEVER be withdrawn withdrawn.
References 661
preservative-free or preservative-containing medications bupivacaine to accumulate during diastole, can slow car-
can be used for epidural injection. Only preservative-free diac conduction, and can induce reentry arrhythmias.
medications should be utilized for intrathecal injection. Conversely, drugs like ropivacaine and levobupivacaine
Strict contraindications for epidural drug administration have lower risk for cardiac toxicosis as they have lower
include pyoderma over the injection site, the use of antico- affinity for these channels.
agulants (e.g. low molecular weight heparins, antiplatelet The first step to avoiding local anesthetic toxicosis is
drugs, anti-Factor Xa medications), coagulopathy, thrombo- appropriate drug dosing. Dosing of lidocaine for local infil-
cytopenia, or thrombocytopathy, and if local anesthetics are tration is generally 1–10 mg/kg in dogs and 1–5 mg/kg in
to be used, uncorrected hypovolemia or hypotension. Pelvic cats. Dosing of bupivacaine, ropivacaine, and levobupiv-
fractures may make anatomic landmarks difficult to palpate acaine is lower than lidocaine at 1–2 mg/kg for both dogs
and the epidural more technically challenging to do, but and cats. Clinicians should also be mindful of drug duration
they are not a strict contraindication for the procedure. and avoid premature repeated injections. When administer-
Adverse effects of epidurals may include nausea, motor ing local anesthetics, care should be taken to aspirate prior to
weakness, delayed hair regrowth at the site of the epidural, injection, to avoid intravascular anesthetic administration.
and urinary retention if opioids are used [32–37]. Compli- If early neurological toxicosis is present, supportive care
cations of epidurals may include epidural abscess, epidural including IV fluid therapy, anti-convulsant therapy, and
hematoma, pruritus, transient Horner syndrome, hyperes- discontinuation of the local anesthetic may be adequate. In
thesia, myoclonus, and if local anesthetics were used in more severe cases of toxicosis, including cardiac involve-
unstable patients, sympathetic blockade leading to pro- ment, IV lipid emulsion should be used [38]. Although
found vasodilation and hypotension [32–37]. Sympathetic evidence-based dosing regimens are lacking, this author
blockade can also be seen if epidural catheters or large uses intravenous lipid emulsion at 1.5 ml/kg IV over
volumes of local anesthetic are used, thereby resulting in 2–3 minutes followed by a constant rate infusion of 0.25 ml/
more cranial migration of the local anesthetic. Sympathetic kg/minute for 30–60 minutes.
blockade is addressed by crystalloid volume replacement If cardiac arrest occurs, RECOVER-based cardiopulmo-
and the use of vasoconstrictive agents such as phenylephrine nary resuscitation should be started immediately, with sev-
or norepinephrine. eral small adjustments. The use of IV regular insulin at
1–2units/kg IV followed immediately by 50% dextrose at 1g/
kg IV diluted one to one with saline appears to be an effective
Local Anesthetic Toxicosis therapy during resuscitation [39–41]. The use of epinephrine
during resuscitation of local anesthetic toxicosis in dogs has
Regional toxicosis from local anesthetics is uncommon. been associated with worsening cardiac arrhythmia and
Systemic toxicosis, although also uncommon, can be life therefore small doses are preferred (e.g. <0.001mg/kg) [42].
threatening. Systemic amide toxicosis can include CNS and Vasopressin should be avoided, as pulmonary hemorrhage
cardiac toxicosis including tremoring, seizures, coma, has been reported in people. If ventricular arrhythmias occur
arrhythmia, hypotension, and death. Bupivacaine has a during stabilization, amiodarone is the preferred antiar-
greater risk for cardiac toxicosis than other drugs as it binds rhythmic in people, as lidocaine and procainamide can exac-
to cardiac sodium channels (NaV 1.5) with higher affinity erbate the existing toxicosis. Electrolytes and blood glucose
and dissociates more slowly than other agents. This causes should be serially evaluated following the use of IV insulin.
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obstruction. J. Vet. Emerg. Crit. Care 21 (2): 50–52. 983–986.
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intrathecal administration of morphine and bupivacaine bupivacaine-induced sudden-onset circulatory collapse in
in a cat. Vet. Anaesth. Analg. 45 (2): 238–239. dogs. Can. J. Anaesth. 60 (5): 471–478. Erratum in: Can.
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665
50
Monitoring the Anesthetized Patient

Benjamin M. Brainard and Jessica Perlini
Monitoring anesthesia of the critically ill patient is an Most anesthetic drugs are potent respiratory depressants,
important aspect of veterinary critical care. Each monitor- and hypoventilation is a common occurrence in the anes-
ing data point adds to a larger picture, which reflects the thetized or sedated patient. Measurement of ventilation
condition of a patient under general anesthesia. Although (partial pressure of CO2) can be accomplished using arterial
single values may be useful, trends of measured physical or venous blood gas analysis, and estimated with end-tidal
parameters are more commonly used to guide decisions for carbon dioxide (ETCO2) monitoring. ETCO2 greater than
anesthetic adjustments. Critically ill patients are either at 55 mmHg is an indication to identify patient problems that
risk of, or already experiencing, compromise of the body’s may result in decreased tidal volumes (e.g. pneumothorax,
ability to maintain homeostasis and tissue oxygen delivery. unibronchial intubation) and to evaluate the machine for
Many critically ill animals cannot tolerate high concentra- problems such as stuck valves or expired soda lime (this will
tions of single anesthetic drugs (such as inhalant anesthet- usually result in an increased inspired CO2 as well).
ics), requiring multiple intravenous (IV) drugs to Cardiac arrhythmias can be secondary to myocardial
supplement or maintain anesthesia in a more balanced hypoxia or hypoperfusion, or due to systemic acidosis. They
technique. The anesthetist must continually monitor the can also occur in response to specific anesthetic drugs such
patient to ensure that anesthesia and analgesia are ade- as thiopental or ketamine, or secondary to specific myo-
quate for the duration of the procedure. cardial injury (e.g., contusions). Electrocardiogram (ECG)
The most common perturbations expected in the anes- monitoring will give information on both cardiac rhythm as
thetized patient are hypoxemia, hypotension, hypoventila- well as any conduction disturbances. Some arrhythmias,
tion, cardiac arrhythmias, acidosis, and volume overload. such as ventricular tachycardia or R on T phenomenon,
Hypoxemia may be present prior to anesthesia in some may require drug therapy during the anesthetic period.
cases and may develop during anesthesia in others. Critically ill animals are frequently anesthetized prior to
Common intraoperative events that can result in hypox- full resuscitation from shock. A shock state represents
emia may be patient related (e.g. pneumothorax, pulmo- decreased tissue oxygen delivery and is usually accompa-
nary embolism, pulmonary edema) or may be machine nied by a metabolic acidosis. Resuscitation must continue
failure (i.e. inadequate supply of oxygen, malfunctioning into the anesthetic period, and frequent monitoring of blood
flow meter, or a circuit disconnect). Systemic oxygenation gas values and blood lactate concentration will allow assess-
can be monitored with arterial blood gas analysis and esti- ment of systemic perfusion and oxygen delivery. Keeping a
mated with pulse oximetry. Normal oxygen saturation record of intraoperative blood loss (which is not necessarily
(SpO2) in an animal breathing 100% oxygen should not be represented by packed cell volume/total solids measures)
less than 98%. An ideal partial pressure of oxygen in arte- may indicate the need for transfusions of fresh whole blood
rial blood (PaO2) for a patient breathing 100% oxygen is or packed red blood cells to maintain oxygen delivery.
500 mmHg, although ventilation/perfusion (V/Q) mis- Although many critically ill patients will benefit from
match from atelectasis and other causes (e.g. physiologic expanded intravascular volume, some risk hypervolemia
shunts) usually makes this slightly lower. An SpO2 below from excessive crystalloid administration, and others
95% should spur a reevaluation of the patient for the risk the development of edema, especially if they are
problems listed above. hypoproteinemic. In patients at risk for hypervolemia, the
666 Monitoring the Anesthetized Patient
placement of a jugular catheter will allow the measure- When the anesthetist notes abnormal monitoring values,
ment of central venous pressure (CVP), which estimates a series of steps should be followed. First, a brief physical
the pressure and volume in the right side of the heart. As examination should be performed to assess the patient.
the CVP approaches 8 cm H2O, the patient is approaching Second, the abnormal values should be verified (e.g. by
fluid overload and may be at risk for pulmonary edema readjusting the pulse oximeter probe or repeating a blood
and congestive heart failure. Hypoalbuminemic patients pressure). This process should take less than one minute to
can have the colloid osmotic pressure measured; if it is accomplish. With verification of abnormal values, specific
less than 15 mmHg, colloid may be considered as part of therapy should be instituted. In the event of problems with
the fluid therapy plan. oxygenation or ventilation, it should be verified that the
The most important tools of the anesthetist are his or her anesthetic machine is functioning properly (i.e. that the
senses. Palpation of the pulse and observation of the delivery of oxygen has not been interrupted or that any
mucous membranes give information about perfusion, valves are stuck) and that an acute change has not hap-
oxygenation, and blood pressure. Assessment of eye posi- pened to the patient (e.g. a pneumothorax or pulmonary
tion, jaw tone, and palpebral reflex give information about aspiration). If there is a problem with the machine, an
the patient’s anesthetic depth, and auscultation of the Ambu bag can be used to maintain ventilation while the
Doppler pulse or the ECG beep can alert the anesthetist to machine is switched, and anesthesia may be maintained
the development of cardiac arrhythmias. Monitoring with IV methods.
devices are available to supplement the senses; these If hypotension is detected, in addition to verifying proper
devices allow objective evaluation of the anesthetized cuff placement or arterial catheter function, the patient
patient. assessment must include an evaluation of the depth of
Anesthetists should place emphasis on physical param- anesthesia. An assessment of the circulating blood volume
eters and physical assessment of the patient. Jaw tone, of the patient should also be made. If hypovolemia is prob-
pulse rate and pulse quality, mucous membrane color, and able, the anesthetist can consider a bolus of IV fluids
other types of hands-on information can be more accurate (either crystalloid or colloid) and should discuss with the
and important than a number read from a monitoring surgeon if it is indicated to consider other fluids, such as
screen. In addition, the anesthetist should perform a thor- packed red blood cells or fresh frozen plasma (or whole
ough physical examination of the patient and be familiar blood). In some cases, IV pressor or inotropic agents may
with the proposed procedure prior to premedication for be necessary for therapy of intraoperative hypotension.
anesthesia. Table 50.1 lists normal ranges for commonly
measured physical examination parameters.
Anesthesia Monitoring Record
Table 50.1 Normal values for physiologic parameters in awake
dogs and cats. The physiologic data gathered before, during, and after
anesthesia are recorded on the anesthesia monitoring
Parameter Dog Cat record. This record is a legal document and an important
part of the medical record. Anesthesia monitoring sheets
Heart rate (beats/ 70–110 160–200 for a practice should be standardized with sections for
minute)
patient name and signalment, and areas for preanesthetic
Respiratory rate 12–20 12–20 history and laboratory values. This allows quick access of
(breaths/minute)
this information during the anesthetic period. A sample
Rectal 99.5–101.5°F 100–102°F anesthetic record is shown in Figure 50.1. Separate sections
temperature (37.5–38.6°C) (38–38.9°C)
of the anesthetic record should also be available to describe
PaO2 at sea level 85–100 95–115
the type of drugs administered, dosage administered, and
(mmHg)
the effect on the patient for the premedication, induction,
SpO2 (%) 97–100 97–100
maintenance, and recovery phases of anesthesia. An area
PaCO2 (mmHg) 35–45 30–40
for notes or descriptions of events that occurred during the
ETCO2 (mmHg) 30–40 30–40 anesthetic episode is also necessary. Documentation
Systolic blood 90–140 90–150 should always be in ink and should be as complete as pos-
pressure (mmHg) sible. Some human hospitals and veterinary practices use a
Mean blood 60–100 60–100 computer-based anesthetic record. A carbon copy form or
pressure (mmHg)
other mechanism to create a duplicate of the record is also
Diastolic blood 50–75 60–100 useful. One copy may stay with the record, and another
pressure (mmHg)
may be cataloged separately in an anesthesia database.
ANESTHESIA CODE PCV PERTINENT HISTORY
PULSE RATE T.P.
SYSTOLIC B.P. WBC
DIASTOLIC B.P.
MEAN B.P. CREAT.
RESPIRATORY RATE TEMP.
START – END ANES. H.R.
START – END SURG. R.R.
O.R. W.T. Kg
OTHER P.S. 1 2 3 4 5 E
DATE DRUG THERAPY:
PROCEDURE TOTAL FLUIDS TOTAL ANESTHESIA TIME

CLINICIAN ANESTHETIST NORM-R ml hrs. mins.
POSITION BLOOD LOSS mls N. SAL ml RECOVERY
NUMBER SPONGES: BEFORE SURG. AFTER SURG. ml ARRIVAL TEMP.
EKG: YES NO DRUG CODE AMT. in MLS DISPENSER EPIDURAL: DRUG
I.V. CATH LOC VOL. (ml) INJ. SITE NEEDLE
I.V. CATH LOC GA
YES YES
ART CATH LOC CSF BLOOD L
NO NO CATHETER
B.P. MONITOR: DIRECT INDICRECT
ONSET (mins) CRANIAL LIMIT
PRE. ANES RTE TIME ENDO SIZE MAINTENANCE
EFFECT H.R. R.R. ENDO ATTEMPTS
INDUCTION AGENTS: DRUG/mgs DRUG/mgs
CIRCLE ANESTHETIC SCCS → CCS NRS MASK LIQUID INJ.

TECHNIQUES USED: STEVENS IV BOX OTHER
HALOTHANE%
ISOFLURANE%
O2L/min
:00 :15 :30 :45 :00 :15 :30 :45 :00 :15 :30 :45
260 260
240 240
220 220
200 200
180 180
160 160
140 140
120 120
100 100
80 80
60 60
40 40
20 20
0 0
UNIVERSITY OF PENNSYLVANIA D-1

VERTERINARY HOSPITAL
Figure 50.1 Typical anesthesia record. Note provision of areas for preoperative history and blood work, American Society of
Anesthesiologists classification, planned procedure, and patient identification. The anesthetist can record the blood pressure and
other parameters using the grid and the legend in the upper left corner. There are spaces to note preoperative and induction
medications, as well as a space to note the quality of recovery. The open area on the right side allows the anesthetist to take notes
during the procedure and is referenced to numbers written on the timeline of the grid. Note also spaces available for notation of SpO2,
ETCO2, and percentage inhalant administered.
A well-organized record allows veterinary technicians Physical Parameters Under Anesthesia

and veterinarians to quickly review the anesthetic record
in the event of problems in the perioperative period. Depth of anesthetia is most accurately monitored by serial
Accurate recording of the entire anesthetic episode also physical examination of the anesthetized patient. Small ani-
provides a reference for future anesthetics in the same mal patients progress through a predictable series of physi-
patient. If a patient had a previous difficult intubation or cal changes as they become more deeply anesthetized, and
adverse reaction to premedicant drugs, a review of the pre- they encounter these signs in reverse as they become more
vious anesthetic record will highlight these facts. lightly anesthetized (Figure 50.2). These stages are labeled
Patient monitoring as it pertains to the anesthetic proce- with Roman numerals: I represents an awake animal
dure begins with administration of the premedication drug through to V, which represents a dangerously deeply anes-
or combination of drugs. The premedication regimen, route thetized animal (Figure 50.2). Because some physical
of administration (intramuscular, IV, subcutaneous), and parameters can be similar between animals that are rela-
the effect of the drugs on the patient should be recorded. tively lightly anesthetized and those that are overly anesthe-
Events such as emesis, defecation, bradycardia, excitation, tized (e.g. a central eye position), only serial examination
or sedation are particularly important to note. If animals will make it possible to accurately assess the patient’s depth
experience emesis prior to the securing of a protected air- of anesthesia. For surgical anesthesia, a patient should be in
way, they may be in danger of aspiration pneumonia, and a plane of light to medium stage III anesthesia. Physical
oxygenation will have to be closely monitored in the intra- parameters should be assessed no less frequently than every
and postoperative periods. Other adverse responses to the five minutes in the anesthetized patient.
chosen anesthetic protocol can include respiratory arrest,
abnormal excitation, or aggressive behavior.
Monitoring of the patient continues into induction. The
Eye Position
type and amount of induction agent(s) used, as well as route The eye position of an awake animal is a central eyeball,
of administration, should be recorded. Any adverse effects which remains constant into light anesthesia. As the patient
during induction (e.g. emesis, arrhythmias, hypotension, or becomes more deeply anesthetized, the eyeball rotates to a
excitation) are important to note, in addition to any difficul- ventromedial position and remains this way through mod-
ties associated with endotracheal intubation (this may also erate anesthesia. As the patient’s anesthetic plane deepens,
be graded on a scale of 1–4, with 1 representing a smooth the eye rotates back to a central position. Thus, a central
intubation and 4 representing the most difficult intuba- eyeball in an anesthetized animal can indicate a patient that
tion). There should be a place on the anesthetic record to is either not deep enough for a surgical procedure or one
note the size of endotracheal tube used for intubation. that is excessively deeply anesthetized. Used in combina-
During the maintenance phase of anesthesia, parameters tion with other physical examination findings, eye position
such as heart rate, respiratory rate, blood pressure, tempera- is an important part of the anesthesia physical examination.
ture, end-tidal CO2, oxygen flow rate, and end-tidal inhalant
(if available) or delivered inhalant percentage should be
Jaw Tone
recorded at five-minute intervals or more frequently. If acute
changes occur, these should be noted on the record as well. Jaw tone varies among different canine patients; animals
The type and amount of fluid therapy should also be recorded, with muscular jaws tend to have higher basal tone and less
in addition to any adjunctive drugs used during anesthesia overall change during anesthesia. In most patients, how-
(e.g. fentanyl or norepinephrine administered as a constant ever, high tone and a tight jaw is associated with lighter
rate infusion). Notes should be made in the anesthetic record anesthetic states that gradually lessens as the animal
about adjustments in fluid therapy, changes in anesthetic becomes more deeply anesthetized. Jaw tone is a reliable
depth, changes in position or recumbency, occurrence of indicator of anesthetic depth in cats.
reflux, administration of additional drugs, surgical progress,
or any other event that occurred during the anesthetic epi-
Mucous Membranes/Capillary Refill Time
sode. The time of extubation, postoperative analgesic ther-
apy, and other pertinent details are recorded on the recovery Mucous membrane color and capillary refill time (CRT)
section of the sheet. Following extubation, patient monitor- allow the anesthetist to estimate perfusion and oxygena-
ing should continue until the body temperature reaches a tion of the anesthetized patient. Well-perfused mucous
satisfactory level (>99°F, 37.2°C) and the patient is able to membranes are pink with a CRT of 1.5–2 seconds. The
perform purposeful movement such as swallowing. During most accessible mucous membranes to the anesthetist are
the recovery phase of anesthesia, measurement of tempera- the gums. Because oxygenated hemoglobin produces the
ture, pulse rate, and respiration rate should take place no less pink color of mucous membranes, factors that affect hemo-
frequently than every 15minutes. globin concentration or saturation of hemoglobin with
Phhsiiaal Paraaeters nder Anesthesia 669
VENTILATION
Inter- Dia- Eyeball Eyeb Lacri- Response to

Pattern Pupil
costal phragm position reflexes mation surgical stim.
Irregular
Awake
panting
Irregular
Stage II breath- Palpebral
holding
Stage III
Regular
LIGHT
Plane I
MEDIUM Regular
Plane 2 shallow
DEEP Jerky
Plane 3
Corneal
Stage IV
Figure 50.2 A diagram of the physiologic changes that occur in patients as they progress through the stages of anesthesia (noted in
the left-hand column). Source: From Hall, Clarke, and Trim, Veterinarh Anaesthesioalogh, 10th edn.; reproduced with permission.
oxygen can result in changes in the membrane color. In to have a blue or purple hue (sometimes described as
addition, if there is a disturbance that results in decreased “muddy”). Cyanosis noted during anesthesia requires
blood flow to the gums (i.e. vasoconstriction), the mucous immediate action to determine the cause and to restore ade-
membrane color may be altered. quate oxygenation. Possible causes of cyanosis may be due to
Pale mucous membranes are most associated with ane- patient problems (e.g. pneumothorax, pulmonary embo-
mia, and the color can range from a paler pink with moder- lism, aspiration pneumonia) or machine failure (i.e. inade-
ate anemia to almost white in cases of severe anemia. quate supply of oxygen, malfunctioning oxygen flow meter,
Other causes of pale mucous membranes include vasocon- or a circuit disconnect). Suspected abnormalities derived
striction or hypothermia, both of which result in decreased from mucous membrane assessment should be rapidly con-
peripheral perfusion. Decreased perfusion may be physio- firmed with other methods (e.g. pulse oximetry, arterial
logic (e.g. response to α-2 agonist drug administration) or blood gas analysis), and the supply of oxygen to the anesthe-
may indicate a serious problem (e.g. hemorrhage or cardiac sia machine checked. The bobbin in the oxygen flowmeter
arrest). Membrane color and CRT should be monitored no will not float if gas is not traveling through the machine
less frequently than every five minutes in animals under (unless it has become stuck). Other descriptions of mucous
anesthesia. Changes in the membrane color should be membrane color are covered earlier in this book.
evaluated in the context of other physical examination and CRT is measured by an initial blanching of the oral
monitoring parameters. mucosa from pressure with a finger and followed by evalu-
A bluish tinge to the membranes, called cyanosis, indi- ation of the time for the color to return. Normal CRT is
cates a severe decrease in hemoglobin saturation with oxy- 1.5–2 seconds. In animals with pigmented mucous mem-
gen. The blue color is due to the presence of deoxyhemoglobin, branes, CRT may be difficult to assess. A slow return of
which is hemoglobin without oxygen molecules attached. In color may indicate impaired systemic perfusion. In animals
some cases of extremely decreased perfusion (i.e. decom- with pale mucous membranes secondary to vasoconstric-
pensatory shock), the mucous membranes may also appear tion, the CRT may also be slower than normal or difficult to
assess. The converse is also true. Animals with vasodilation anesthesia depends on a number of variables including
have bright pink to red mucous membranes. With an species, patient size, the anesthetic regimen (especially if
increase in cardiac output such as might be seen with com- anticholinergic or α-2 agonist drugs are administered), and
pensatory or hyperdynamic shock, the CRT will be faster the patient’s normal heart rate.
than normal, usually less than one second. The most com- The most basic approach for monitoring heart rate is digi-
mon reason for brick red membranes and a fast CRT is tal palpation of the pulse. The anesthetist palpates the pulse
septic shock. by placing two fingers (not a thumb) over an artery and
applying gentle pressure. Pressing down too firmly may
occlude or collapse the artery and eliminate the pulse. The
Response to Stimulation
most commonly used arteries for digital palpation are the
A patient’s response to stimulation is decreased with ade- femoral, dorsal pedal, caudal (ventral aspect of the tail),
quate anesthesia. Responses are manifested as increases in buccal, and lingual arteries (Figure 50.3). These areas are
sympathetic tone (e.g. tachycardia, hypertension) or a easily accessible during induction and surgical preparation.
lightening of the anesthetic plane (e.g. an increase in jaw When patients are positioned with their head away from the
tone). If these responses occur in response to a surgical or anesthetist, the dorsal pedal, caudal, and femoral arteries
other procedure, the animal may not be adequately anes- are the best choice. However, if the head of the patient is
thetized, and the depth of anesthesia should be verified toward the anesthetist, the lingual artery is most accessible.
using other physical examination or monitoring parame- Other palpable pulses are the radial pulse, as well as the
ters. The use of local anesthetic blocks or total IV anesthe- apex beat in the thorax. In some cases of cardiac arrhyth-
sia may result in a patient that retains more tone or reflexes mias (e.g. ventricular premature contractions), the palpated
than animals anesthetized with inhalant anesthetic alone. pulse rate will differ from the actual heart rate seen on the
The palpebral reflex, a blink elicited by light touch over ECG. Arrhythmias will be palpated as weak or irregular
the upper or lower eyelids (or in the medial canthus of the pulses and should be verified with other monitoring
eye), is gradually decreased as the depth of anesthesia equipment.
increases. In general, for a surgical plane of anesthesia, the The pulse rate is calculated by counting the pulse over a
reflex may be sluggish but does not need to be absent. The set number of seconds and multiplying this time by a value
corneal reflex, a withdrawal of the orbit when the cornea is to equal 60 seconds. The resulting value is the heart rate in
touched, is maintained to even deeper anesthesia. If the beats/minute:
corneal reflex is absent, the patient may be over anesthe- Beats in 15 seconds × 4 = heart rate (beats/minute)
tized or near death.
Beats in 10 seconds × 6 = heart rate (beats/minute)
The longer the period over which the pulse is counted,
Heart Rate
the more accurate is the recorded pulse rate. It is good prac-
Cardiac output is the product of heart rate and stroke vol- tice for the anesthetist to keep a hand on the pulse at all
ume, indicating the amount (volume) of blood pumped times when not otherwise occupied, to monitor pulse rate
from the heart each minute. Stroke volume, the amount of and quality.
blood pumped with each contraction of the heart, can be Pulse quality is a subjective value that is not always
difficult to measure directly; therefore, it is important to recorded, but with experience anesthetists may gain valu-
closely monitor heart rate because it is directly related to able information about the patient from pulse palpation.
cardiac output. An acceptable heart rate under general The palpated pulse is the difference between the systolic
(a) (b) (c)
Figure 50.3 Commonly used arteries for digital palpation: (a) femoral; (b) dorsal pedal; and (c) sublingual.
and diastolic arterial blood pressure (DAP). Animals with a The ECG is used to monitor both the heart rate and
large difference in systolic and diastolic blood pressure rhythm. ECG interpretation is addressed in Chapter 11.
(due to a lower diastolic, higher systolic pressure, or both) A lead II ECG is used to monitor basic cardiac rate and
have a strong or bounding pulse. Bounding pulses may rhythm in small animal patients, and leads may be
result from conditions such as normovolemic anemia or attached to the patient’s skin either using alligator clips
compensatory septic shock. If there is a low pulse pressure, or patches with snap leads. In some exotic species, the
the animal will have a weak pulse. Weak or “thready” leads may be attached to the metal part of 25- to 30-gauge
pulses represent lower arterial blood pressure due to poor needles inserted through the skin. It is not necessary to
cardiac output or cardiovascular tone. If weak pulses are clip the fur to attach alligator clips but doing so provides
palpated, or if pulses become weak during a procedure, a better contact and a better signal. Either alcohol or con-
more accurate determination of blood pressure (such as ductive gel must be applied to optimize electrical con-
with Doppler or direct arterial pressure monitoring) and duction from the patient’s skin to the electrode. Hair
reevaluation of the patient should be performed. Weak must be clipped when using patches, and the area should
pulses may be consistent with hypovolemia, hemorrhage, be wiped with alcohol and allowed to dry before patches
or decreased cardiac output due to anesthetic drugs or car- are applied to optimize their adherence. Patches may also
diac arrhythmias [1]. Pulse pressure should be evaluated in be placed directly on the paw pads. Owing to evaporation
concert with mucous membrane color and CRT. of alcohol or drying of conductive gel, leads may need to
Another reliable method for monitoring heart rate is an be moistened periodically to maintain optimum
esophageal stethoscope (Figure 50.4). This device is an conductance.
esophageal probe connected to a listening device. The The ECG lead placement is similar to that used for other
esophageal probe comes in a variety of sizes and lengths. purposes; however, the standard arrangement may not be
The probe is connected to either a Doppler unit or standard possible for some procedures. In the case where the proce-
stethoscope earpieces. After anesthetic induction and dure interferes with lead placement (e.g. forelimb amputa-
endotracheal intubation, the probe is advanced into the tion), ECG leads should be placed as close to the appropriate
esophagus until the heartbeat can be heard. The probe area as possible, to maintain the principles of Einthoven’s
should be advanced only to the point where the heartbeat triangle and surgical sterility (see Chapter 10 for more
is clearly heard; additional advancement past this point of details). It is most important to keep the leads on the cor-
maximal intensity may result in the placement of the probe rect side of the body and in the correct plane with the heart.
into the stomach. Using the stethoscope, heart rate can be Thoracic limb leads can be moved cranially, and pelvic
directly measured. An advantage of using the esophageal limb leads may be moved further caudal on the limb.
stethoscope is that the heart and lungs may be auscultated
constantly and directly. Changes in rate, or in the quality of
Respiratory Rate
a heart murmur or lung sounds, may be detected as they
happen. Some esophageal stethoscopes are combined with The respiratory rate can be calculated by observation of the
temperature probes and ECG electrodes. patient or the rebreathing bag. Adequate respiration is
essential to a safe and smooth anesthetic episode because
anesthesia is most frequently maintained using volatile
inhalant gas anesthetics, which can suppress respiratory
drive. If a patient is not taking regular breaths with an ade-
quate tidal volume, anesthetic will not be inhaled, and the
patient may not become anesthetized. Respiratory minute
volume (RMV) is the amount of gas exhaled by the lungs
over one minute and is the product of respiratory rate and
respiratory tidal volume. The actual RMV can be measured
by a respirometer (Figure 50.5), such as the Wright
respirometer, inserted into the anesthetic circuit. Some
machines that measure exhaled CO2 also contain a
respirometer feature. The anesthetized patient should take
deep breaths at regular intervals. RMV is related to ventila-
tion (and thus blood CO2 concentration); an increase in
RMV results in a decreased CO2 concentration, and vice
versa. Normal RMV in awake dogs and cats is approximately
Figure 50.4 Esophageal stethoscope. 200 ml/kg/minute.
Figure 50.6 The NICO 2 Respiratory Profile Monitor (Phillips-

Respironics, Murraysville, PA) a multiparameter monitor that
continuously measures and reports inspired and expired PCO2,
respiratory rate, and oxygen saturation. Source: Photo courtesy
Figure 50.5 A Wright respirometer (black dial) placed in the of Kate Hopper BVSc, PhD, DACVECC.
expiratory limb of the anesthesia circuit. The respirometer
measures tidal volume and respiratory minute volume.
and may result in increased intracranial pressure, cardiac
arrhythmias, hypoxemia, and ultimately cardiac arrest.
Another way to monitor respiratory rate is to use an air- Decreased RMV may be due to a decreased respiratory
way monitor. This device produces a humming sound as rate (or complete apnea), seen with patients with an irregu-
the patient exhales, which signals to the anesthetist that a lar breathing pattern or breath holding, or it may be due to
respiratory cycle has taken place (i.e. the animal has a decrease in tidal volume, despite a normal respiratory
inhaled and exhaled once). The monitor’s sensor is placed rate. If hypercarbia or hypoventilation is identified, the
in the anesthetic circuit between the endotracheal tube and anesthetist must increase the RMV by manually or
the Y-piece. The sensor is connected to a small speaker, mechanically ventilating the patient. Assisted ventilation
which amplifies the sound of the patient’s exhalation. The may be used to increase the respiratory rate, tidal volume,
produced sound does not reflect the quality of ventilation, or both. Assisted ventilation also increases the inhalant
just the fact that exhalation is taking place. The monitor anesthetic delivered to the patient.
does not remove any gas samples from the circuit. When hypoventilation is identified, the anesthetist
Modifications to these monitors can make them apnea should first evaluate the patient (Table 50.2), as well as the
monitors as well, and some will alarm if the patient has not positioning of the endotracheal tube. Unibronchial intuba-
taken a breath in a specified amount of time. Other moni- tion occurs when the endotracheal tube is advanced beyond
tors, such as the capnograph, also provide an apnea alarm. the carina into the bronchus of one of the lung lobes. V/Q
The most comprehensive realtime bedside ventilatory mismatch ensues because an entire lung is without effec-
monitor is the capnograph. It continuously measures and tive ventilation. Ideally, the endotracheal tube should be
reports respiratory rate along with inspired and expired placed so that the distal end of the tube is located in the
PCO2. Some capnographs (e.g. the NiCO 2, Phillips- caudal extrathoracic trachea. If there is a possibility that
Respironics, Murraysville, PA) also function as a respirom- the tube has been introduced too far into the trachea
eter (Figure 50.6); these machines measure tidal volume (resulting in one lung intubation), it may be incrementally
and can estimate pulmonary compliance (see Chapter 31). removed until the cuff of the endotracheal tube is palpated
The ETCO2 is a practical estimation of arterial CO2. in the caudal extrathoracic trachea. The tube cuff should
Capnography is covered in depth in Chapter 30. be deflated before readjusting the tube, should adjustment
Hypoventilation (decreased RMV) occurs due to a be necessary.
decrease in respiratory rate, tidal volume, or both. The patient with elevated RMV is hyperventilating,
Hypoventilation leads to hypercarbia (also called hyper- which causes a decreased PCO2, called hypocarbia (or
capnia), which is an increase in dissolved carbon dioxide in hypocapnia). Hyperventilation in the anesthetized patient
the blood (PaCO2 or PvCO2). Hypercarbia results in a resis most commonly a result of an inadequate anesthetic
piratory acidosis, and as the blood pH decreases, deleteri- plane or an elevated body temperature. In some cases,
ous effects can be seen on vascular tone and cardiac where the patient exhibits extreme hypoxia, hyperventila-
function. High blood levels of CO2 can also cause narcosis tion may be a reflection of hypoxic drive because the need
Table 50.2 Assessment and approach to common abnormalities of ventilation in the anesthetized patient.
Problem Assessment steps Actions
Hypoventilation Is the patient unable to Auscultate the thorax and rule out pulmonary dysfunction such as
(PaCO2 or ETCO2 generate an adequate tidal a pneumothorax. If tidal volume is limited, consider repositioning
> 65 mmHg) volume by spontaneous the patient or increasing the respiratory rate. Ventilators that
ventilation or mechanical deliver a breath to a certain airway pressure will deliver a smaller
ventilation? breath if there is increased pressure in the thorax. Rule out
endotracheal tube obstruction.
Is the patient unable to Consider the use of a mechanical ventilator for maintenance of
generate an adequate tidal anesthesia, or increase the number of assisted breaths delivered to
volume by spontaneous the patient by the anesthetist. If neuromuscular blocking agents
ventilation? (e.g. atracurium) have been used during the procedure, consider
reversal.
Is the patient’s level of Efforts should be made to lighten the plane of anesthesia, and if
anesthesia excessive? the patient is breathing spontaneously, manual ventilation may be
(Figure 50.2) necessary.
Have opiate medications been If anesthetized, increase either tidal volume, respiratory rate, or
administered recently? both. If awake, consider reversal of the opiate medication using
naloxone (which also removes any opioid-related analgesia).
Is there a kink or obstruction Inspect the system (including endotracheal tube) for kinks or
in the breathing system? obstructions; address as necessary.
Is there a leak in the Leaks will prevent the delivery of a full tidal volume breath to the
anesthetic system? patient; if a leak is suspected, it may be necessary to change the
tubing, the ventilator bellows, the rebreathing bag, or the entire
system. If a leak cannot be readily detected, breathing for the
patient with an Ambu bag will allow time to switch out the system
and to correct the hypoventilation. It should also be verified that
the cuff on the endotracheal tube is adequately inflated.
Is there a leak in the ventilator Leaks in the bellows of a mechanical ventilator will prevent the
bellows? bellows from returning completely to the full position between
breaths. The patient may be hand ventilated using the rebreathing
bag or an Ambu bag while the bellows are changed.
Is the soda lime expired? Check the soda lime canister for heat and color, as well as the last
time the soda lime was changed. Expired or used soda lime will not
remove adequate CO2 from the system and may cause it to build
up. Switch machines or breathe for the patient with an Ambu bag
while the soda lime is changed. Also verify that the soda lime
canister is filled correctly; if it is packed too tightly or above the fill
line, it may not remove CO2 appropriately. These patients will also
have a high inspired CO2 as measured by the capnograph.
Is there a leak in the valves of Incompetent inspiratory or expiratory valves will not allow air to
the anesthesia machine? travel in a circle system; these patients will show a high inspired
CO2 level.
Hyperventilation Is the respiratory rate or tidal Verify that the patient is adequately anesthetized for the
(PaCO2 or ETCO2 volume excessive procedure. Verify that the patient’s temperature is not elevated.
< 25 mmHg) (spontaneous ventilation)?
Is the respiratory rate or tidal If a mechanical ventilator is in use, adjust either the rate or tidal
volume excessive (mechanical volume to decrease the respiratory minute volume.
ventilation)?
Is the patient hypoxemic? Assess SpO2 and/or an arterial blood gas to verify patient
oxygenation.
Very low ETCO2 Was intubation successful? Verify that the endotracheal tube is not in the esophagus.
Sudden drop in Any acute changes in patient Severe drops in ETCO2 may reflect circulatory collapse or the
ETCO2 condition? occurrence of a pulmonary thromboembolism. The patient should
be assessed for stability immediately and additional diagnostics or
CPR performed as necessary.
Is the anesthetic circuit intact? Evaluate the circuit for any disconnections.
for oxygen overwhelms any depressant effects of anesthet- Blood Pressure

ics on the respiratory center. Hyperventilation due to inad-
equate anesthesia may be accompanied by tachycardia and Chapters 12–14 provide an in-depth analysis of the vari-
hypertension. The anesthetist may address this either by ous methods for blood pressure measurement. For the
increasing ventilation or administered inhalant percentage anesthetized patient, the same types of monitors and cri-
(both of which provide more anesthetic to the patient), or teria for evaluation may be used. Although blood pres-
by administering analgesic drugs (e.g. opioids) to provide sure is not a direct measure of perfusion in the
additional analgesia. anesthetized patient, it is the closest and most conveni-
The normal physiologic response to elevated arterial ent surrogate measure that we have to determine that
PCO2 is an increase in RMV (either by increasing the res- organ perfusion is appropriate. Actual perfusion of indi-
piratory rate or tidal volume). This normal response to high vidual organs is determined by a host of local mecha-
PaCO2 is blunted by anesthesia, but an elevated respiratory nisms and is extremely difficult to measure, even under
rate may be seen in patients with a PaCO2 above 65 mmHg. experimental circumstances.
Owing to the effects of anesthesia on the normal responses In general, mean arterial blood pressure (MAP) of
to PCO2 as well as effects on RMV (e.g. due to smaller tidal 70–100 mmHg is acceptable for the anesthetized patient.
volumes), it is difficult to determine the patient’s PaCO2 Systolic arterial blood pressure should be 100–140 mmHg.
based solely on observation of the respiratory rate; the only DAP should be 40–65 mmHg. A MAP below 60 mmHg may
true way to assess ventilation is to measure the arterial or be associated with decreased perfusion of and oxygen
venous CO2 partial pressure. delivery to the kidney and brain [4]. A DAP less than
Malignant hyperthermia causes increased respiratory 40 mmHg may result in poor coronary artery perfusion (the
rate accompanied by hyperthermia and hypercapnia. heart is only perfused during diastole), and decreased oxy-
Some anesthetic drugs, such as halothane and succinyl- gen delivery to the heart [5]. In patients who are chroni-
choline, have been linked as triggers for malignant cally hypertensive prior to anesthesia (e.g. those with
hyperthermia in susceptible animals. If malignant hyper- chronic kidney disease), an effort should be made to main-
thermia is suspected, anesthesia should be discontinued tain MAP at levels toward the higher end of the range (i.e.
as soon as possible, the anesthetic lines detached from toward the normal values for that patient).
the endotracheal tube, flushed thoroughly with oxygen, Low blood pressure in critically ill patients may be
and reattached to the patient. It may be easier to switch caused by hypovolemia, hemorrhage, a gas-filled viscus
to an unused anesthetic machine. The patient’s ETCO2, (e.g. the stomach in patients with gastric dilatation and
rectal or esophageal temperature, and oxygenation volvulus), anesthetic drugs, heart disease, cardiac arrhythmias,
should be closely monitored. External warming and heat or vasodilation (e.g. as a result of vasoplegic shock).
support should be discontinued and if the temperature Individual patients have individual reasons for hypotension,
continues to rise, the patient should be made wet, and a and the anesthetist’s knowledge of the disease state and the
fan used to encourage convective cooling. Dantrolene patient’s physical examination will help to determine ther-
may help to reverse the signs of malignant hyperthermia apy and plan a safe anesthetic. As an example, patients
by altering intracellular calcium kinetics. This drug may with heart disease such as dilated cardiomyopathy may
be given at a dose of 1–10 mg/kg, IV. At-risk patients need a positive inotropic drug to support blood pressure by
should be treated with dantrolene orally prior to elective supporting cardiac output. By contrast, a patient that is
surgeries [2]. hypotensive due to hypovolemia may require IV fluid ther-
ETCO2 is directly proportional to cardiac output and tis- apy to resolve low blood pressure.
sue perfusion, except in rare conditions of mitochondrial Hypotension associated with anesthetic drugs may have
dysfunction (usually as a result of septic shock). If the res- components of myocardial depression and vasodilation,
piratory rate and tidal volume have remained the same but depending on the drug. When hypotension is detected, the
the ETCO2 has decreased, the patient is experiencing anesthetic plane of the patient should be reevaluated to
either a decreased metabolic rate (e.g. due to hypother- ensure that they are not too deeply anesthetized (if they
mia) or a decrease in cardiac output (e.g. due to hemor- are, the anesthetic plane may be lightened). An assessment
rhage or arrhythmias). If a sudden decrease in ETCO2 is of the degree of blood or fluid loss should also be under-
seen, the anesthetist should evaluate the patient’s vital taken, and if the animal is hypovolemic, an IV bolus of flu-
signs immediately to verify adequate perfusion because a ids (crystalloid or colloid) may help to restore adequate
precipitous drop in ETCO2 is seen with cardiac arrest. blood pressures. In cases of excessive vasodilation causing
Once it is clear that the patient is not in distress, additional hypotension, pressor drugs such as phenylephrine, dopa-
evaluation of the equipment for leaks or disconnections mine, norepinephrine, or vasopressin may be indicated to
may take place [3]. cause vasoconstriction.
Oxygen Saturation 675
Although hypertension is uncommon in veterinary Chapter 14. Oscillometric monitors are more automated
patients, it may also have consequences such as retinal than the Doppler devices. They can be programmed to
detachment or cerebral hemorrhage. Anesthetized animals cycle at various intervals and to give a regular readout of
with a pheochromocytoma may have paroxysmal tachycar- systolic, diastolic, and mean blood pressure. Because these
dias and hypertensive episodes that may merit therapy. monitors rely on a machine-based interpretation of the
blood pressure oscillations, they may be less accurate than
the Doppler probe, especially for critically ill patients who
Doppler Blood Pressure Measurement
may be hypotensive (thus diminishing the strength of
The most widely used blood pressure monitor is the oscillations) or in animals experiencing cardiac arrhyth-
Doppler flow probe. The Doppler uses a probe containing a mias (the machines require a regular heartbeat to accu-
piezoelectric crystal which emits sound waves that are rately sense oscillations). Unlike the Doppler probe, these
reflected by the red cells in pulsatile arterial blood. When machines do not produce an audible signal to reflect heart
the sound is reflected from the cells, the shift in the fre- rate (and in fact may continue to give readings even in the
quency of the sound is transduced into an audible signal. absence of a good pulse). It is thus imperative to compare
The placement of a pneumatic blood pressure cuff and the heart rate displayed on the machine to a heart rate
sphygmomanometer proximal to the probe allows the obtained by another source (e.g. auscultation or ECG). If
measurement of blood pressure (see Chapter 14). Common the heart rate does not match that of the patient, the blood
areas used for Doppler probe placement in the anesthe- pressure reading should not be trusted. Despite these cave-
tized animal are the palmar common digital artery on the ats, the oscillometric blood pressure monitor is a useful
palmar surface of the thoracic limb below the carpus; the tool for monitoring blood pressure in most anesthetized
dorsal pedal artery on the plantar surface of the pelvic patients.
limb; the plantar metatarsal artery on the plantar surface
of the pelvic limb, proximal to the foot; and the coccygeal
Direct Arterial Blood Pressure Measurement
artery located on the ventral surface of the tail.
For measurement of blood pressure, an appropriate size Direct arterial blood pressure is covered in Chapter 13 and
blood pressure cuff (ideally with a width that is 40% of the considered the gold standard for monitoring arterial blood
circumference of the limb) is placed proximal to the probe pressure. Critically ill or emergent patients under anesthe-
and inflated with the sphygmomanometer until the artery sia can experience fluctuations in blood pressure that may
is occluded; this will result in a cessation of the Doppler not be detectable using intermittent measurement. In these
sound. As the pressure in the cuff is slowly released, the cases, or in cases where it is necessary to use vasoactive
audible signal will return as soon as the cuff pressure is drugs to support blood pressure, a direct arterial pressure
below that of the systolic blood pressure. The anesthetist monitor is ideal. Direct arterial blood pressure also allows
can repeat this reading as often as desired. Changes in the the anesthetist to directly observe the effects of arrhyth-
intensity of sound on the Doppler may be consistent with mias that occur during anesthesia, and it provides a simple
arrhythmias or a decreased pulse strength (as may occur way to obtain samples for blood gas analysis. Direct arterial
from sudden hypotension). The placement of the probe catheters for use during anesthesia may be placed in the
and cuff should be checked to verify that nothing has dorsal pedal, caudal, or auricular arteries. The femoral
changed after a patient assessment. artery may also be used but is associated with more compli-
An advantage of the Doppler is early detection of cations on catheter removal.
decreased flow, along with the ability to hear changes in
heart rhythm and measure blood pressure despite arrhyth-
mias. A disadvantage is that the signal may become diffi- Oxygen Saturation
cult to hear with noise in the operating room, although
most Doppler units allow the use of headphones to improve Oxygen saturation is a measure of how much oxygen the
focus on the pulse. hemoglobin in the blood is carrying, described as a per-
centage of the maximum it could carry, and it is an impor-
tant component of oxygen content. Adequate oxygen
Oscillometric Blood Pressure Measurement
content in the arterial blood, in combination with cardiac
Oscillometric noninvasive blood pressure monitors (e.g. output, determines oxygen delivery to tissues.
the Cardell, Midmark Corp., Versailles, OH, or Dinamap, Oxygen saturation is routinely monitored with a pulse
GE Healthcare, Wauwatosa, WI) are excellent tools for oximeter. Pulse oximetry is covered extensively in
monitoring trends in blood pressure in the anesthetized Chapter 25. The most common site for placement of the
patient. The theory behind these machines is discussed in pulse oximeter probe in the anesthetized patient is the
tongue or lips. If the tongue cannot be used, the probe can become relevant during anesthesia recovery when the
be placed on an area of thin skin such as the skin between patient transitions to breathing room air (21% oxygen). For
the toes, the abdomen, or on the vulva or prepuce. Using this reason, the pulse oximeter does not replace arterial
the transmission (clip) probe, the tissue must be thin blood gas analysis but is useful for a continuous estimate of
enough to allow the probe to pass light through the tissue oxygen saturation.
to the sensor on the other side of the clip. Reflectance Many critically ill patients may have compromised lung
probes may be used rectally or on thin areas of skin to function, whether it is due to primary lung pathology such
obtain a saturation reading without using the clip. as pneumonia or due to decreased lung function from
The pulse oximeter provides an oxygen saturation read- pleural effusion or ascites (which decrease the ability to
ing given as a percentage, a pulse waveform, and a heart fully expand the lungs). Animals that have been recum-
rate. The oxygen saturation is related to the dissolved oxy- bent frequently develop atelectasis, or lung collapse, on
gen content (PaO2) by the oxyhemoglobin dissociation the dependent side. Atelectasis causes a ventilation/perfu-
curve (Figure 50.7; see also Chapter 25). Normal hemo- sion mismatch and decreases the ability of the animal to
globin is expected to be 100% saturated with oxygen at a oxygenate the blood. Atelectasis may also develop during
PaO2 of 95–100 mmHg (most normal animals breathing surgery when the patient is immobile for a period. If ate-
room air have a PaO2 of 80–100 mmHg and an SpO2 of lectasis occurs during anesthesia, oxygenation during the
96–100%). Under anesthesia and breathing 100% oxygen, recovery period may be affected. The pulse oximeter may
an animal’s PaO2 is expected to be greater than 500 mmHg. be used for serial evaluation of patients during anesthesia
Consequently, an anesthetized animal with normal lung recovery.
function is expected to have a SpO2 of 99–100% (hemo- Significant changes in oxygen saturation rarely occur
globin cannot be saturated more than 100% with oxygen). acutely. It is thus important to watch the overall trend of
If SpO2 readings below 98% are obtained in the anesthe- the readings. A gradual decrease in saturation will be clear
tized patient breathing 100% oxygen, there is a problem on the anesthesia monitoring sheet. Changes in saturation
with oxygenation in the patient. In the event of low SpO2, may be accompanied by changes in other parameters, such
the patient and subsequently the anesthesia circuit should as respiratory rate or ETCO2, and can help the anesthetist
be inspected for causes of the abnormal reading. to determine the possible cause and treatment. A common
Because the SpO2 only reflects a percent saturation, a cause of hypoxemia may be endotracheal tube obstruction
patient breathing 100% oxygen that has a PaO2 of 200 mmHg with blood or mucus during anesthesia, especially in
will have the same SpO2 as a patient with a PaO2 of patients undergoing thoracic surgery, or in those with
500 mmHg. The first patient may have some significant pneumonia. Other causes of a low intraoperative SpO2
lung pathology (preventing a normal PaO2), which may include the development of a pneumothorax (which will
be accompanied by hypotension and tachycardia) and the
development of atelectasis (which will cause a slower
100 decrease in SpO2).
Shift to left
80 ↓PaO2
When a low SpO2 is detected, it is important to check the
↓Temperature patient (Table 50.3) and to verify that the anesthesia
90 ↑pH machine is providing adequate oxygen. If surgery is occur-
ring, verify that there is not a chance of an iatrogenic pneu-
70 Shift to right
Hemoglobin (% saturation)
mothorax or excessive hemorrhage. If a mechanical

↑PaO2
60 ↑Temperature ventilator is in use, switch to manual breaths; this will
↓pH allow an increase in respiratory rate and tidal volume, and
50 it will allow the anesthetist to gauge the pulmonary com-
40
pliance. If it is very difficult to inflate the lungs when
squeezing the rebreathing bag, a pneumothorax may be
30 Normal present. If atelectasis has caused the low SpO2, administra-
tion of a slightly larger tidal volume (15–20 ml/kg) for two
20
to three breaths or held for 10–15 seconds may help to open
10 the collapsed alveoli (this is also called a recruitment
maneuver). If these actions do not improve oxygenation,
0 other diagnoses, such as pulmonary thromboembolic dis-
10 20 30 40 50 60 70 80 90 100
ease, should be considered. If it is possible, confirmation of
PaO2 (mm Hg)
a low SpO2 with an arterial blood gas is indicated because
Figure 50.7 Oxyhemoglobin dissociation curve. this will give an actual measure of PaO2.
Oxygen Saturation 677
Table 50.3 Assessments and actions for patients with a low pulse oximeter reading (SpO2 < 95%) under anesthesia.
Problem origin Assessmenta Action
Respiratory Has the patient experienced an adverse Auscultate the chest to rule out presence of pneumothorax,
system pulmonary event? congestive heart failure, or other lung/pleural space disease.
If pneumomediastinum is suspected, radiographs may be
necessary for diagnosis. Thoracic ultrasound may identify
pneumothorax, pleural effusion.
Is the patient intubated properly? Verify Reintubate if necessary.
endotracheal intubation using a laryngoscope.
ETCO2 will not read if esophageal intubation
Is the airway patent? Are there kinks or Address as necessary, potentially switching machines,
obstructions in the breathing circuit? endotracheal tube, or breathing circuit.
Obstruction in the endotracheal tube?
Is oxygen still being supplied to the circuit If oxygen supply has been depleted, use Ambu bag, or other
(check that the flowmeter bobbin is still device to breathe for the patient while a new source is
floating)? established.
Has unibronchial intubation occurred? If the endotracheal tube has been inserted too far into the
bronchial tree, slowly back it out until breath sounds can be
auscultated bilaterally.
Circulatory Does the patient have a pulse? Palpate pulse, or verify heart beat using stethoscope,
system esophageal stethoscope, or preplaced Doppler flow probe.
Is the patient hypotensive? Measure blood pressure and adjust anesthetic protocol to
alleviate hypotension.
Is the patient peripherally vasoconstricted? If the vasoconstriction is related to administered drugs,
consider alternative protocols or alternative placement of
the pulse oximeter probe. If high doses of pressors are used,
it may be difficult to achieve an accurate pulse oximeter
reading.
Other patient Is the patient hypothermic? Vasoconstriction that may accompany hypothermia may
factors result in a variable pulse oximeter reading; the patient
should be aggressively rewarmed if the temperature is
< 96°F.
Is the tongue (or other probe site) dry? Moistening the tongue with warm water or saline may allow
the pulse oximeter to generate a more accurate reading.
Is the patient moving/seizuring/shivering? Calming the patient and limiting movement will allow the
pulse oximeter to focus on the arterial pulse.
Has the probe been placed on pigmented Attempt to locate a probe site that is not pigmented.
skin?
Environmental Is the probe in direct line of the surgical or Try to cover the probe site or redirect the lights to eliminate
factors fluorescent lights? interference from room lighting.
a
Factors are generally listed in order of importance, with emphasis on an immediate physical examination and patient assessment,
and secondarily addressing possible machine malfunction.
The pulse oximeter is an indirect indicator of peripheral heart rate to ensure that the machine is focusing on the
perfusion; when vasoconstriction results in decreased correct pulse. Whereas vasoconstriction will affect the
peripheral perfusion, the probe may be unable to sense a pulse oximeter reading, anemia will not, unless it is very
strong enough pulse, and the monitor may display errors, severe (PCV < 10%). In addition, fluorescent surgical or
noise, or incorrect values. This may also happen in the con- overhead lights may affect the ability of the pulse oximeter
text of severe hemorrhage; the compensatory vasoconstric- to register an accurate pulse. If the probe is positioned on
tion and decreased perfusion to the periphery will impair the tongue, the signal may become attenuated as the tongue
the pulse available for the pulse oximeter to monitor. It is becomes dry from exposure during anesthesia. For a more
imperative to always compare the pulse reported by the in-depth discussion of possible artifacts and errors in pulse
pulse oximeter with another reliable measure of the patient oximetry, refer to Chapter 25.
Plethysmographic Variability Index severely hypothermic. Monitoring temperature is done

using either a rectal thermometer or an esophageal tem-
The continuous indirect information that the pulse oxi- perature probe.
meter gives us about perfusion and specifically the Steps that can be taken to minimize loss of body heat
peripheral arterial pulse may be used to the advantage of during surgery and anesthesia include the use of warm
the anesthetist. The plethysmographic variability index water circulating blankets, forced-air warming units (e.g.
(PVI) is a non-invasive way of predicting fluid responsive- Bair Hugger, 3M Co, Minneapolis, MN), and the adminis-
ness, which may be superior to CVP (see Chapter 15) in tration of warmed IV fluids. Some procedures make patient
monitoring for volume responsiveness under anesthe- warming difficult. For prolonged radiologic procedures,
sia [6]. Using a pulse oximeter, a PVI value is calculated such as myelography or computed tomography, forced-air
by monitoring changes in the amplitude of the SpO2 warming units and water blankets can interfere with imag-
waveform during the respiratory cycle. The perfusion ing. In magnetic resonance imaging units, both metal mon-
index is a measurement of the pulse oximeter signal itoring devices and metal probes are contraindicated due to
strength, and thus overall perfusion in the capillaries over interference with the magnet. In these cases, blankets
which the pulse oximeter is placed. Generally, hypov- placed over the patient can help to minimize heat loss but
olemic patients are more likely to have changes in cardiac are not as effective as active warming devices. Whenever
output caused by increased intrathoracic pressure (i.e. active warming devices of any kind are used, patient tem-
positive pressure breaths), which causes a dampening of perature must be closely monitored to ensure the patient is
the perfusion index due to cyclic decreases in perfusion of not overheated. If a patient is to undergo many procedures
peripheral tissues. The PVI calculation is: during which it is exposed to room temperature for long
periods of time (e.g. wound debridement, central line
PVI PI max PI min / PI max 100 placement), a radiant heat source may be used; these
ceramic heaters warm the environment around the patient
where PImin is the lowest perfusion index and PImax is the and limit radiant and convective heat loss. Because they
highest for a given respiratory cycle. Higher PVI is associ- are located over the patient, they are not suitable for use
ated with more variability, and thus hypovolemia. during surgery that involves an open body cavity. These
A similar concept can be used in evaluation of the direct devices usually are required to be placed a certain distance
arterial blood pressure tracing, where pulse pressure varia- (usually about 90 cm) above the patient to prevent burns.
tion can indicate hypovolemia [7]. Although most accurate Some (e.g. Radiant Heater, Fisher-Paykel, Auckland, NZ)
when used in patients receiving positive pressure ventila- are also equipped with a thermometer feedback system
tion (identical tidal volumes for each regular breath), PVI that adjusts the radiant temperature based on the skin tem-
may also be useful in spontaneously breathing humans [8]. perature of the patient.
In clinical human use, PVI values above 20% suggest Hyperthermia may cause complications as well. When
hypovolemia and predict positive fluid responsiveness. Not using active warming devices, the temperature setting
all animals, especially those with reduced cardiac function, should be lowered or use discontinued altogether when a
are able to increase cardiac output via increasing preload patient is at or near normal temperature because the ani-
(this depends on the patient’s position on the Starling mal’s rectal temperature may continue to rise after cessa-
curve) [7], and will not show a decrease in PVI following tion of active warming. Should a patient become
fluid therapy. The patient’s cardiac function and clinical hyperthermic and the cause is determined to be other than
exam should be considered when managing patients malignant hyperthermia (by evaluation of PaCO2 and
using PVI. blood lactate), cool the patient slowly. The forced-air warm-
ing unit can be switched to a cool setting, and the warm
water blanket should be turned off. If the patient is already
Body Temperature recovered from anesthesia, it may be placed on a cool sur-
face like a metal cage floor, and all blankets should be
The body temperature of an anesthetized patient affects removed. Continue to monitor temperature every 15 min-
heart rate, respiratory rate, blood pressure, and oxygen utes until the patient’s temperature has normalized.
saturation. Patients should be kept as close to normother- Opioids are associated with the development of postopera-
mic as possible during anesthesia. This not only helps tive hyperthermia in cats. This hyperthermia may be
maintain normal physiology during anesthesia but it also treated in a similar manner to other causes of hyperther-
correlates to a decreased recovery time [9]. It is also easier mia, and it may also respond to low doses of naloxone (this
to maintain a patient’s temperature in the normal range therapy may also reverse the analgesia) but is usually
than it is to warm the animal up after it has become self-limiting [10].
End-Tidal Inhalant Concentrations 679
End-Tidal Inhalant Concentrations Manufacturers include Datex-Ohmeda (GE Healthcare,

Wauwatosa, WI), SurgiVet (Waukesha, WI), and Criticare
The partial pressure (usually expressed as a percentage of Systems (Waukesha, WI).
alveolar gasses) of inhalant anesthetic circulating in a The use of analgesic drugs such as the opioids and α-2
patient is essentially equivalent to the amount that is agonists decrease the amount of inhalant anesthetic neces-
exhaled, once the anesthesia has reached steady state. By sary to maintain anesthesia. In this context, monitoring of
comparing the exhaled percentage of inhalant anesthetic the endotracheal inhalant can show the effects of premedi-
with the dose required for anesthesia (usually a multiple cant drugs and analgesics given during anesthesia. If ani-
of the minimum alveolar concentration, or MAC), objec- mals have been adequately premedicated and have
tive data can be obtained as to the dosage of anesthesia intraoperative analgesia provided by other drugs, the over-
provided by inhalant drugs at any given time. This is a all requirement for inhalant anesthetic is decreased (i.e. the
similar concept to the measurement of plasma drug levels MAC is effectively lowered). Because of this, it is recom-
after administration of an injectable drug. The MAC val- mended that the endotracheal inhalant be used as a guide,
ues for the commonly used anesthetic agents are given in but it is more important to rely on the patient’s physical
Table 50.4. examination signs of anesthesia (discussed earlier), rather
Machines that measure end-tidal inhalant concentra- than trying to target an actual MAC value for each patient.
tions (Figure 50.8a) are attached to the anesthetic circuit The inhalant concentration is directly related to the
by tubing that will constantly aspirate small amounts appearance of adverse effects from inhalant anesthetics. As
(50–150 ml/minute) of gas from the system into the the inspired concentration of inhalant increases, hypoten-
machine (Figure 50.8b). Once in the machine, the per- sion and hypoventilation become more pronounced. From
centage of inhalant in the aspirated gas is determined and this perspective, the endotracheal inhalant concentration
reported. Many different companies manufacture can help avoid overdoses of inhalant anesthetic and at the
machines to determine end-tidal inhalant concentrations, same time predict that adequate anesthesia is present. In
and these monitors frequently measure ETCO2 as well. critically ill patients, the adverse effects of inhalant anes-
thetics may be magnified, and sometimes only a fraction of
Table 50.4 Minimum alveolar concentration values for the MAC dose (if any at all) may be used safely. In addition,
veterinary species. patients with diseases such as septic shock, severe hypov-
olemia, and severe hypothermia have lower MAC values
Species Isoflurane (%) Sevoflurane (%) Desflurane (%)
than similar healthy patients. The endotracheal inhalant
can help to document the overall dose of anesthetic as well
Cat 1.7 3.1 10.3
as any residual anesthetic in the patient if administration is
Dog 1.3 2.1 7.2
discontinued.
(a) (b)
Figure 50.8 (a) Multiparameter patient monitor that has the capabilities of displaying ECG, SPO2, end-tidal CO2, and anesthetic
inhalant concentrations. The percentage of inhaled anesthetic is displayed (black arrow). (b) The adapter placed in the anesthetic
circuit that continually aspirates small amounts of gas from the system. Once in the machine, the percentage of inhalant in the
aspirated gas is determined and reported.
Anesthesia in the critically ill patient can be challenging physical examination parameters, changes may be recog-
due to the sensitive nature of the cardiorespiratory systems nized early, and interventions may be subsequently taken
and the possibility for decompensation. With appropriate to restore homeostasis.
monitoring equipment and regular attention paid to
References
1 Aldrich, J. (2005). Global assessment of the emergency 6 Cannesson, M., Le Manach, Y., Hofer, C.K. et al. (2011).
patient. Vet. Clin. N. Am. Small Anim. Pract. 35 (2): Assessing the diagnostic accuracy of pulse pressure
281–305. variations for the prediction of fluid responsiveness: a
2 Rosenberg, H., Davis, M., James, D. et al. (2007). Malignant "gray zone" approach. Anesthesiol. 115 (2): 231–241.
hyperthermia. Orphanet. J. Rare Dis. 2: 7 Teboul, J.L., Monnet, X., Chemla, D., and Michard,
21–41. F. (2019). Arterial pulse pressure variation with
3 Hartsfield, S.M. (2007). Anesthetic machines and mechanical ventilation. Am. J. Respir. Crit. Care Med. 199
breathing systems. In: Lumb and Jones’ Veterinary (1): 22–31.
Anesthesia and Analgesia, 4e (ed. W.J. Tranquilli, 8 Yin, J.Y. and Ho, K.M. (2012). Use of plethysmographic
J.C. Thurmon and K.A. Grimm), 453–494. Ames, IA: variability index derived from the Massimo® pulse
Blackwell. oximeter to predict fluid or preload responsiveness: a
4 Earle, S.A., de Moya, M.A., Zuccarelli, J.E. et al. (2007). systematic review and meta-analysis. Anaesthesia 67 (7):
Cerebrovascular resuscitation after polytrauma and fluid 777–783.
restriction. J. Am. Coll. Surg. 204 (2): 261–275. 9 Pottie, R.G., Dart, C.M., Perkins, N.R. et al. (2007). Effect
5 Farhi, E.R., Canty, J.M. Jr., and Klocke, F.J. (1989). Effects of hypothermia on recovery from general anaesthesia in
of graded reductions in coronary perfusion pressure on the the dog. Aust. Vet. J. 85 (4): 158–162.
diastolic pressure-segment length relation and the rate of 10 Posner, L.P., Pavuk, A.A., Rokshar, J.L. et al. (2010).
isovolumic relaxation in the resting conscious dog. Effects of opioids and anesthetic drugs on body
Circulation 80 (5): 1458–1468. temperature in cats. Vet. Anaesth. Analg. 37 (1): 35–43.
681
51
Nursing Care of the Long-Term Anesthetized Patient

Yekaterina Buriko and Bridget M. Lyons
Basic Indications for Long-Term Physical Complications Associated with

Anesthesia Long-Term Anesthesia and Immobility
A small number of veterinary patients require long-term Immobility Complications

anesthesia during their hospitalization. The three major
An inevitable consequence of long-term anesthesia is an
groups of patients in this category are patients that require
extended period of immobility. Prolonged recumbency can
positive pressure ventilation due an to inability to oxygen-
result in a plethora of complications, including decubitus
ate or ventilate appropriately, endotracheal intubation for
ulcers, tissue necrosis, peripheral limb edema, contracture
large airway disease (e.g. tracheal collapse), and those that
and stiffening of muscles and ligaments, muscle atrophy,
require general anesthesia for control of refractory sei-
nerve damage, atelectasis, and the accumulation of airway
zures. Typical indications for positive pressure ventilation
secretions in dependent lung regions.
include partial pressure of arterial oxygen (PaO2) less than
60 mmHg with oxygen supplementation, hypoventilation
with partial pressure of arterial carbon dioxide (PaCO2)
Neuromuscular Weakness
higher than 60 mmHg, and an unacceptable degree of Neuromuscular weakness is a condition that is recognized
dyspnea associated with increased work of breathing. in critically ill human patients. Depending on the method
Long-term anesthesia and immobility are associated of diagnosis, it occurs in 25–100% of human patients in
with a number of complications, affecting nearly all body intensive care [1]. During the first week of immobilization,
systems of a patient. Recognizing these effects is of particu- up to 40% of muscle strength may be lost [1]. The patho-
lar importance to a veterinary technician because much of physiology of critical care neuromuscular dysfunction is
requisite nursing care is focused on preventing and address- complex and likely multifactorial. Several factors contrib-
ing the complications particular to the anesthetized ute, such as disuse due to immobility, microvascular dys-
patient. This chapter focuses on the specifics of manage- function, and a catabolic state that can be caused by
ment of this patient population and describes the compli- malnutrition, systemic inflammation, and metabolic
cations associated with the key body systems, methods to derangements [1–3]. Prolonged immobility is associated
prevent the complications, and treatment modalities, with a proinflammatory state that increases the production
should a problem arise. of reactive oxygen species, together with simultaneous
All anesthetized patients require an endotracheal or a decrease in antioxidant defense mechanisms [1, 3]. This
tracheostomy tube, as well as indwelling intravenous may result in contractile dysfunction and atrophy, as well
access as a part of their care. Please refer to Chapters 31 as protein loss [1, 3]. In mechanically ventilated patients,
and 63, respectively, for details on artificial airway manage- the neurologic and muscular dysfunction may increase the
ment and care of indwelling devices. duration of ventilation, extend the length of stay in the
682 Nursing Care of the Long-Term Anesthetized Patient
hospital, prolong recovery time, and contribute to mortal- Decreased tear production and loss of blink function
ity [1–3]. Although this condition has not been formally during long-term anesthesia leave the eye vulnerable.
recognized in dogs and cats, it is likely that a similar disor- Tears are essential for ocular health and have many func-
der exists in veterinary patients as well. tions, including lubrication of the ocular surface, provi-
sion of oxygen to the cornea, and prevention of bacterial
colonization [7, 14]. Blinking spreads lacrimal secretions
Atelectasis
over the ocular surface, moistening the eye [8]. The evap-
Atelectasis is a major complication of both prolonged immo- oration of these tears changes the temperature of the sur-
bility and anesthesia [2]. Atelectasis refers to the collapse of face, making it unfavorable for bacterial growth [8]. A
the small airways and alveoli, resulting in portions of lung loss of blink also results in incomplete closure of the eye
that are perfused but not ventilated. This may occur second- and thus prolonged exposure of the cornea and conjunc-
ary to mechanical compression of the lung from the weight tiva to the environment. When the ocular surface is dry,
of the nondependent lung, airway obstruction or collapse, small corneal defects develop that can lead to exposure
loss of surfactant, and improperly positioned endotracheal keratopathy [8].
tubes. Atelectasis, when severe enough, may cause hypox-
emia by causing intrapulmonary shunt [2]. If the patient is
mechanically ventilated, atelectasis may increase the possi-
Complications Associated with the Oral Cavity
bility of ventilator-associated lung injury because of both
overdistention of aerated lung and shear injury. An anesthetized patient has decreased saliva production
and loses the ability to swallow, clean, and protect oral
structures from mechanical damage. Healthy animals
Venous Stasis
rely on antimicrobial peptides such as lysozymes, hydro-
Immobility promotes venous stasis, which may lead to gen peroxide, mucins, cathelicidins, and lactoferrin in
many deleterious effects [2]. Human patients who are their saliva and on dental surfaces to help protect the
immobile are at increased risk of venous thrombosis, oropharynx from colonization by pathogenic bacte-
which, in turn, increases their risk of pulmonary thrombo- ria [15]. Critically ill patients with decreased saliva pro-
embolism [2, 4]. In addition, direct compression of the duction are consequently predisposed to bacterial and
venous vasculature may occur from prolonged contact of fungal overgrowth in the oral cavity. Additionally, these
extremities with bedding, which may contribute to stasis, patients cannot swallow appropriately and lack oral cav-
as well as result in vascular endothelial damage [2]. ity hygiene, further predisposing them to colonization
Vascular compression, in turn, may result in diminished with Gram-negative bacteria and the formation of bio-
blood supply to the skin and puts immobilized patients at film on the tooth surface [15–17]. The change in oral
risk of impairment in skin integrity [5]. Skin damage and flora from Gram-positive to Gram-negative occurs in
ulceration are important consequences of prolonged mechanically ventilated human patients within
immobility, and they can cause significant morbidity. The 48–72 hours of admission to intensive care [18]. These
etiology of skin damage is multifactorial and, in addition to bacteria are frequently the causative agents of ventilator-
impaired blood supply, includes malnutrition, as well as associated pneumonia (VAP). Migration of bacteria from
direct pressure to points of contact during prolonged the oropharynx to the respiratory tract, as well as micro-
immobility [2, 6]. Skin ulceration may create severe soft- aspiration of the contents of the oropharynx are leading
tissue damage, cause osteomyelitis of adjacent bones, and causes of VAP [17, 19]. VAP increases both morbidity and
may result in systemic infection and sepsis [2]. the length of intensive care required, as well as the cost
of hospitalization [20].
Ranulas and oral ulcers are potential complications of
Ocular Complications
long-term sedation and intubation (Figure 51.1). Ranula
Patients that are anesthetized lose the ability to protect refers to the accumulation of salivary gland contents, such
their eyes and have a significantly higher incidence of ocu- as mucin, in the soft tissues surrounding the gland, because
lar surface disorders, such as exposure keratopathy and of trauma or obstruction to the gland. Oral ulcers are often
corneal ulceration [7–9]. Peak incidence occurs during the caused by mechanical injury to the structures of the mouth;
first two to seven days of hospitalization in humans [10]. ulcers have been documented in 8% of dogs and cats under-
Decreased tear production has been documented in dogs going mechanical ventilation [11, 18]. Persistent pressure
undergoing anesthesia, and one veterinary study found from pulse oximeter probes, mouth gags, the endotracheal
that 5% of mechanically ventilated dogs develop corneal tube and its tie applied to the tongue and other soft-tissue
ulcers [11–13]. structures leads to ulceration [18].
Recumbent Patient Care 683
(a) (b)
Figure 51.1 Ranulas may form during general anesthesia as a result of trauma to the salivary glands. This may be secondary to
equipment in the oral cavity or manipulation of the tongue and the mandible.
Complications Associated with the Urogenital Tract Recumbent Patient Care

Anesthetized patients typically do not voluntarily void
their bladders on a regular basis. Moreover, if patients The long-term anesthetized patient requires recumbent
under anesthesia urinate, they do not always empty their patient care (Protocol 51.1). Three components contribute to
urinary bladder completely. Urine retention increases the recumbent patient care: proper patient positioning, decubi-
risk of urinary tract infection (UTI) and detrusor atony [21]. tal ulcer prevention and management, and early mobility.
Additionally, urine overflow secondary to incomplete emp-
tying may result in soaking of the skin and fur with urine.
Urine is irritating to the skin and can cause significant Protocol 51.1 Recumbent Patient Care
inflammation and scald, if not removed promptly and
Procedure
completely, which can be difficult to accomplish in larger
patients. To be performed every four hours:
Gastrointestinal Complications 2) Ensure that the bedding is clean, dry, and appropri-
ate for the patient; elevate the head slightly com-
Gastrointestinal (GI) complications of prolonged anesthe-
pared with the rest of the body.
sia can be significant, especially during mechanical venti-
3) Perform passive range of motion exercises and mas-
lation. They include splanchnic hypoperfusion and
sage on the nondependent limbs.
vasoconstriction, as well as diminished GI motility. Patients
4) If the patient is in sternal recumbency, turn hips and
undergoing mechanical ventilation, particularly those with
reposition the rest of the body slightly; if in lateral
high levels of positive end-expiratory pressure, can experi-
recumbency, turn the patient onto the other side.
ence poor venous return, which can lead to decreased car-
5) Check for potential sites of ulceration (e.g. bony
diac output and poor splanchnic perfusion [22]. Suboptimal
protuberances).
splanchnic perfusion impairs GI tract and pancreatic func-
6) If pressure ulcers exist, inspect all dressings to
tion. Mechanical ventilation has also been associated with
ensure they are clean and cover the wound
increased levels of endogenous catecholamines, which can
appropriately.a
result in splanchnic vasoconstriction and ischemia, mak-
7) Perform passive range of motion exercises and mas-
ing this population of patients at increased risk of GI ulcer-
sage on the nondependent (previously depend-
ation and bleeding [22]. Moreover, sedatives, including
ent) limbs.
narcotic agents, further diminish GI motility and contrib-
ute to ileus [2, 22]. Gut barrier function may be impeded by a
The pressure ulcer dressing may be changed once to twice daily,
hypoperfusion, malnutrition, and systemic inflammation. depending on the extent of the wound and the amount of exu-
The break in normal gut barrier may result in intestinal date produced. Every time the dressing is changed, the size, depth,
and extent should be evaluated and recorded.
bacterial translocation [22].
Patient Positioning to reduce pressure compared with sheets or a polyester

mattress in dogs placed in lateral recumbency [27]. If avail-
Patients undergoing long-term anesthesia should be pro-
able, memory foam mats could be considered in patients
vided with clean, dry, and well-padded bedding [14, 19].
undergoing long-term anesthesia to potentially reduce risk
All eliminations should be cleaned immediately to main-
of pressure ulcer formation; however, a nonporous cover is
tain dry skin at all times; use of absorbent pads may assist
recommended if used with multiple patients to reduce the
with nursing care. Any bony protuberances should be care-
risk of infection transmission. A number of specially
fully padded [23]. The extremities should be completely
designed mattress and support surfaces have been devel-
supported at all times and should have contact with a pad-
oped in human medicine to aid with recumbency care, and
ded surface. A turning schedule should be established
these surfaces may become available to veterinary practi-
early in the patient’s care [24]. It is recommended that the
tioners in the near future. Alternating pressure mattresses
animal be turned every two to four hours [14, 19, 25].
and special soft surfaces that spread the pressure over a
Potential sites for ulcer development should be checked
larger area may help to decrease formation of decubi-
every time a patient is turned [23]. Regular turning is also
tus ulcers.
a key component to the prevention of atelectasis [19].
Should a decubitus ulcer develop, it is important that an
Compression of dependent lung leads to airway collapse
effort be made to reduce pressure on the site. Ring devices
and subsequent perfusion of alveoli that are not ventilated,
placed around the wound are contraindicated because they
creating decreased gas exchange and contributing to
contribute to venous congestion and local edema, which
hypoxemia. Turning the patient shifts the pressure and
may prolong healing [24]. The ulcer should be cleaned
allows the airways to remain open.
with a pH-neutral, nonirritating, nontoxic solution, such as
Animals that are anesthetized for long periods of time
saline, and any necrotic tissue debrided [24]. Unless bacte-
are most commonly those being mechanically ventilated.
rial infection is suspected, chlorhexidine and other antimi-
In many patients, the need for mechanical ventilation is
crobial solutions should be avoided [24]. These agents are
due to lung pathology and severe hypoxemia. Patients with
toxic to granulomatous tissue and may delay wound heal-
pulmonary parenchymal disease may not be able to toler-
ing [24]. Dressings that provide a moist wound environ-
ate certain positions, such as lateral recumbency, for pro-
ment, keep the skin around the wound dry, control exudate,
longed periods of time. Positioning and turning in these
and eliminate dead space should be chosen [28]. Some
patients may be complicated by their disease process. In
examples include moist gauze, hydrocolloid, or calcium
dogs, there is evidence to support sternal positioning as the
alginate dressings [28]. Wet-to-dry dressings are not recom-
optimal position for best oxygenation [26]. If an animal is
mended because they are not continuously moist and
in sternal recumbency, the hips should be turned every two
therefore not appropriate for wound dressing [24]. Negative
to four hours and the position of the rest of the body slightly
pressure therapy could be considered for select types of
altered to shift pressure points. Oxygenation should be
wounds that are deep, have a large surface area, or are
closely monitored after a turn because decompensation
infected. The wound should be reassessed with each dress-
may occur during position shifts. Preoxygenating the
ing change to determine whether amendments are needed
patient with higher fraction of inspired oxygen prior to
in the treatment plan as the wound heals or deteriorates.
manipulation is advisable, in case decompensation occurs.
The size, depth, whether debridement is required, and
amount of exudate produced by all ulcers should be docu-
mented in the medical record each time the wound is eval-
Decubitus Ulcer Prevention and Management
uated [24]. A pressure ulcer grading system could be
One of the primary goals of nursing a recumbent patient is implemented to allow for a more objective evaluation of
the prevention of decubitus ulcers. Decubitus ulcers occur the degree and severity of ulceration when multiple people
over bony prominences and are the result of soft tissue care for the animal [29]. Adequate nutrient intake and
compression between the bone and a hard surface, hydration status should be ensured to maximize the poten-
impaired circulation, malnutrition, and humidity [2]. In tial for wound healing [30].
dogs laying in lateral recumbency, the skin over the scapu-
lohumeral joint, greater trochanter, and 13th rib are at
Early Mobility
greatest risk, although any bony protuberance may be
prone to ulceration [27]. Animals that are naturally thin or A number of serious complications arise from prolonged
have a poor body condition are at greater risk for ulcer immobility, such as muscle and ligament contracture, mus-
development [27]. However, any animal that is recumbent cle disuse atrophy, and limb edema due to venous stasis. The
for an extended period should be considered at risk. In a importance of early mobilization and physical exercise has
small canine cadaver study, memory foam mats appeared been highlighted in humans, where trends toward lower
Eye Care 685
mortality, decreased duration of mechanical ventilation, and

Protocol 51.2 Eye Care
decreased days in intensive care have been documented if
early mobility is engaged [3]. Feasibility of early mobiliza- Procedure
tion in veterinary patients is of concern, especially in those To be performed every two hours:
that are endotracheally intubated and cannot voluntarily
move on their own. In these patients, a physical exercise 1) Perform hand hygiene.
regimen should be established and instituted early in the 2) Clean periocular surfaces with saline-soaked gauze.
hospitalization, as there is evidence that neuromuscular 3) Check eyes for chemosis or inflammation.
dysfunction happens rapidly after onset of mechanical ven- 4) Ensure that the endotracheal tube tie and any neck
tilation and recumbency [31]. If a physical therapy service is wraps are not tight.
available, collaboration with the service may be useful to 5) Place artificial tear ointment in each eye, ideally
establish a tailored protocol for the particular patient. using a separate designated tube of ointment for
At minimum, the physical exercise regimen should each eye. The ointment may be alternated with arti-
include passive range of motion exercises and massage. ficial tear drops.
These exercises should be performed every 4 hours for To be performed every 24 hours:
10–15 minutes and should ideally involve every joint of the
extremities and all the possible dimensions of movement 1) Perform hand hygiene.
for the particular joint [32, 33]. The joints may be moved 2) Fluorescein stain each eye to check for corneal
separately or concurrently in a motion resembling walking ulceration.
or running [33]. Stretching may also be used. Body mas- 3) If corneal ulcers are visualized, note their location,
sage is useful and may include gentle to deeper stroking, size, and depth in the progressives section of the
kneading, or skin rolling parallel to the muscle bellies [32, medical record.
33]. There is evidence to suggest that even simple passive
exercises are beneficial in preserving muscle mass; there-
fore, they should not be overlooked [34]. It is evident, how- gauze, and artificial tear ointment should be placed in the
ever, that exercises that actively engage the muscles are eyes [10, 19, 25]. The ointment may be alternated with arti-
required for better return to function [33]. In a select group ficial tear drops [1]. Use of a dedicated ointment tube for
of patients, active range of motion exercises may be used, if each eye is recommended, particularly in patients with
the pet’s condition permits. These patients may include suspected ocular infections [8]. In humans, use of moisture
animals that are sedated, but not anesthetized, such as chambers have proven significantly more effective for the
those mechanically ventilated via a tracheostomy tube. A prevention of corneal ulceration compared with lubricat-
wide variety of exercises, from resisted withdrawal to sit- ing ointments [9]. The varied skull anatomy of dogs and
ting and standing exercises, may be performed, depending cats makes getting a good seal using goggles or covers dif-
on the patient’s status [32, 33]. In addition, other modali- ficult; however, if a patient under long-term anesthesia has
ties, such as electrical stimulation, cryotherapy, ultra- a skull conformation amenable to moisture chamber use,
sound, and heat therapy, may be used, if available [33]. these may be used to reduce corneal exposure.
Early and adequate nutrition (Chapter 42) is paramount Aerosolization of bacteria occurs during suctioning of
in mitigating the effects of prolonged immobility, weak- the airway and oral cavity [14, 35]. Care should be taken
ness, and muscle loss. Many patients that undergo pro- not to withdraw the suction catheter near or over the eye,
longed anesthesia suffer from a catabolic state and specific as contamination of the eye with the same pathogen caus-
disease processes that may require careful evaluation of ing pneumonia in mechanically ventilated patients has
their nutritional needs. A nutrition plan should be devised been documented [8, 35].
early in the course of hospitalization and evaluated regu- Fluorescein staining of the corneas should be performed
larly to accommodate patient needs. once daily to check for ulceration [10, 14, 19, 25]. If
detected, a broad-spectrum antibiotic ointment can be
used to prevent corneal infection [14, 19, 36]. Topical anti-
Eye Care biotics containing polymyxin B, neomycin, bacitracin, or
oxytetracycline should not be used in cats due to the risk of
The anesthetized patient is unable to produce and spread anaphylaxis [37]. If the ulceration does not resolve or
tear film adequately; thus, protecting the patient’s eyes is improve within 48–72 hours, or if there is evidence of pro-
an essential aspect of nursing care. Eye care (Protocol 51.2) gression, such as increased area of stain uptake or depth of
should occur every two hours [10, 14, 19, 25]. Every two the defect, cytology, as well as culture and sensitivity test-
hours, the eyes should be cleaned with saline-soaked ing, are indicated to determine the infectious agent [36].
Severe infection may require the hourly application of an

Protocol 51.3 Oral Care
antimicrobial agent [36]. Topical atropine is also indicated
in the treatment of deep corneal ulcers [36]. Atropine pro- Procedure
vides analgesia and prevents synechiae formation and bar- To be performed every four hours:
rier [36]. All corneal ulcers and their progression should be
documented daily by noting the location, size, and depth of 1) Perform hand hygiene and don examination gloves.
the ulcer in the record. 2) Remove any pulse oximeter probes, mouth gags,
Chemosis may occur in any patient that is immobilized or gauze.
for prolonged periods of time, and it may be in part respon- 3) Inspect oral cavity for pooling oral secretions, ranulas,
sible for incomplete eye closure and undesired exposure of and ulcers.
the cornea and conjunctiva. Decreased drainage, increased 4) Note the approximate size and location of any
vascular permeability, and increased venous pressure con- ulcers or ranulas in the medical record.
tribute to this condition [8]. Incidence is increased in 5) Check the endotracheal cuff for appropriate inflation.
patients who are maintained at a positive end-expiratory 6) Gently suction the mouth and oropharynx.a
pressure greater than 5 cm H2O [35]. Periorbital edema and 7) Adjust the position of the endotracheal tube tie
chemosis may also be the result of an overly tight endotra- if needed.
cheal tube tie, if tied behind the ears, or snug neck wraps 8) Wipe the mucous membranes and tongue with
covering central catheters or feeding tubes [35]. Precautions gauze soaked with 0.05% chlorhexidine solution;
should be taken to avoid edema formation, and steps to flush the back of the oral cavity with 0.05% chlo-
resolution of edema should be taken once observed. These rhexidine solution; thoroughly suctioning afterward.
include carefully monitoring the patient’s fluid balance, 9) Reposition the tongue, avoiding draping the
frequently checking for tightness of the endotracheal tube tongue over the teeth, and wrap in dilute glycerin-
tie, and positioning the patient’s head in such a way as to soaked gauze.
optimize venous return (head slightly higher than the rest 10) Replace mouth gag and pad teeth with dilute
of the body, taking care not to occlude the jugular veins). glycerin-soaked gauze.
11) Replace pulse oximeter probe, changing the posi-
tion of the probe.
Oral Care a
Patients with copious oral secretions and/or persistent regurgi-
tation may require hourly suctioning and/or the placement of an
The importance of oral care (Protocol 51.3) in the nursing orogastric or nasogastric tube.
regimen of patients anesthetized for extended periods of
time cannot be stressed enough. Oral care has been docu-
mented to decrease the incidence of VAP and is thus of cru- The oral cavity should be decontaminated with a dilute
cial importance in the management of patients undergoing chlorhexidine solution or gel (0.05%) every four hours, con-
long-term anesthesia [17, 20, 38, 39]. centrating on any oral ulceration that may be present [14,
Despite a cuffed endotracheal tube, microaspiration of 16, 18, 19]. Oral ulcers provide a route for bacteria to enter
oral secretions may occur [20]. For this reason, any fluid the systemic circulation, and early and thorough treatment
that pools in the mouth or pharynx should be suctioned is essential. Chlorhexidine is bacteriostatic and bactericidal
every four hours [11, 16, 19, 25]. The oral cavity may also be and has been shown to promote gingival healing [18].
rinsed by instilling small amounts (5–20 ml, depending on Chlorhexidine use should be instituted regardless of the
size of the patient) of sterile saline with a syringe prior to presence of ulceration, as a method of selective oral decon-
suctioning [14, 19]. Care has to be taken to make sure the tamination. Chlorhexidine has been shown to reduce the
endotracheal tube is appropriately inflated during rinsing. incidence of VAP in human patients undergoing mechani-
The oral cavity should also be suctioned prior to adjust- cal ventilation when compared to saline, and there is
ment of the endotracheal or tracheostomy tube, reintuba- stronger evidence for its use compared with other oral
tion, or a patient position change [39]. It has also been solutions [17].
shown that continuous subglottic suctioning, as well as Although an inflated endotracheal tube cuff may not
intermittent, regular subglottic suctioning, leads to a reduc- prevent aspiration, an effort should be made to protect the
tion in the incidence of VAP in humans [20, 25, 39]. New- airway as much as possible by checking that the cuff is
generation endotracheal and tracheostomy tubes, some appropriately inflated. A Posey Cufflator® (J. T. Posey
equipped with subglottic suctioning lines, are available and Company, Arcadia, CA) may be used to ensure that the
could be incorporated into care of veterinary patients. No correct pressure is achieved (Figure 51.2). This device
evidence exists for their use in veterinary medicine. attaches to the endotracheal tube cuff, which allows one to
Oral Care 687
Figure 51.2 A Posey Cufflator® (J. T. Posey Company, Arcadia, CA) Figure 51.3 Endotracheal tube tie made out of nonporous
may be valuable in ensuring appropriate pressure of the material, such as intravenous tubing, reduces the possibility of
endotracheal or tracheostomy tube cuff. bacterial contamination.
measure the pressure in the cuff while it is being inflated

by the bulb of the device. The recommended intracuff
pressure is 20–30 cm H2O. Alternatively, administering a
breath while listening for a leak as the cuff is being inflated
by an air syringe can be performed. This ensures that the
least amount of air to inflate the cuff sufficiently is
instilled, minimizing cuff overinflation. The presence of
an air leak may also be observed on the displayed ventila-
tor scalars and loops. If the cuff pressure can be moni-
tored, it should be checked every four hours. There is no
evidence that repositioning of the endotracheal tube is
necessary if the cuff pressure is optimized. In fact, some
evidence exists in human patients that repositioning of the
tube during mechanical ventilation may potentiate com-
plications such as pneumonia and tracheal and airway
damage [40–42]. No information is available on the bene- Figure 51.4 Packing of the oral cavity with saline- or dilute
glycerin-moistened gauze diminishes desiccation of the mucous
fits and adverse effects of tube repositioning in veterinary membranes and minimizes soft tissue damage that occurs
medicine. It is currently accepted that if the intracuff pres- secondary to the equipment, such as endotracheal tube and
sure cannot be measured, the endotracheal tube cuff pulse oximetry monitor.
should be deflated and the tube’s position adjusted every
four hours to prevent damage to the trachea [19]. When saline- or glycerin-moistened gauze to reduce trauma
securing the tube, a tie made of a nonporous material is (Figure 51.4) [11]. This is especially important in pediat-
ideal [19]. Cloth that is moistened by oral secretions pro- ric patients because the primary teeth are sharper than
vides an excellent medium for bacterial growth. As an adult teeth [11]. The tongue and other soft tissue struc-
alternative to muzzle gauze, a tie may be fashioned from tures should be kept moist with gauze soaked in dilute
IV tubing (Figure 51.3) [19]. glycerin [11, 14, 18, 19]. Any pressure that may have con-
Monitoring equipment, such as the pulse oximeter tributed to a lesion should be relieved (Figure 51.5).
probe, and the endotracheal tube and its tie should be Persistent regurgitation may further complicate oral
moved every four hours [11, 14, 18, 19]. A cushion made care. Aspiration of gastric contents is a cause of VAP [11].
of saline- or glycerin-moistened gauze should be placed Additionally, regurgitation of gastric contents decreases
between the tie and the soft tissues it comes into contact the pH of the mouth and increases the severity of oral
with [11, 18, 19]. If possible, placement of the tongue ulcers [18]. A nasogastric or orogastric tube may be passed
directly over the teeth should be avoided [11, 18, 19]. If to relieve the stomach of its contents and prevent further
this is not possible, the teeth should be packed with regurgitation.
been shown to reduce biofilm formation, their use is not cur-

rently recommended as there is inadequate evidence to sup-
port their use for prevention of catheter-associated bacterial
cystitis [45, 46]. If the urinary catheter is indwelling, a closed
collection system should be used and the collection bag kept
below the level of the patient. The catheter and collection
system should be inspected every at least eight hours to
ensure there is no gross contamination, and the exposed por-
tion of the catheter and vulvar or preputial area leaned with
0.05% chlorhexidine solution. See Chapter 35 for more
details on placement and maintenance of urinary catheters.
Gastrointestinal Tract
Figure 51.5 A part of a 1-cc syringe may be used as a mouth Patients undergoing long-term anesthesia should be evalu-
gag to diminish pressure of the teeth on the tongue.
ated frequently for abdominal distension, presence of bowel
sounds, and frequency of bowel movements [2]. Bowel
Bladder Care sounds may be auscultated over the four quadrants of the
abdomen with a stethoscope. Frequency varies quite a bit
The urinary bladder should be palpated every four to six between patients and the relation to a meal, but in general,
hours and expressed as needed. Urinary catheterization bowel sounds should be auscultated approximately four to
should be considered if effective expression cannot be five times a minute. If a gastric feeding tube is in place, the
achieved due to patient’s size or bladder dysfunction, or if volume and characteristics of gastric aspirates should be
measurement of exact urinary output is important. noted in the record. Frequency of gastric tube aspiration
Urinary bladder catheterization may be intermittent or varies among patients but typically occurs every four to six
indwelling. The decision as to which method is used hours. Bedside ultrasound may be used to evaluate the pres-
depends on the needs of each individual patient. UTI is a ence of fluid in the stomach and intestines, as well as to
risk factor for urinary bladder catheterization, regardless of evaluate gastrointestinal motility by counting the number
method [43]. Duration of catheterization in dogs has been of contractions of the pyloric antrum and the small intes-
shown to be a more important factor for development of a tines per minute. Normal values have been documented in
UTI than the method of catheterization [43]. Bladder colo- dogs but are subject to a number of variables, such as recent
nization may occur via intraluminal or extraluminal bacte- water or food intake, composition of ingested material, as
rial migration, introduction during catheter placement, or well as many other factors [47]. Prokinetic agents may be
secondary to bacteremia [44]. It is important to note that considered if significant gastrointestinal dysmotility is
the presence of bacteriuria does not necessarily indicate highly suspected or is present. Human patients undergoing
infection [44]. mechanical ventilation are at high risk for development of
Regardless of the method of catheterization, aseptic tech- gastrointestinal ulceration, and they are routinely adminis-
nique during catheter placement cannot be overempha- tered medications aimed at reducing production of gastric
sized. Hair should be clipped around the catheter insertion acid such as histamine blockers and proton pump inhibi-
site, and the area should be disinfected with chlorhexidine tors [48]. Whereas the same information is not available in
scrub and rinsed with sterile saline. Sterile gloves and lubri- the veterinary population, it is reasonable to believe that the
cant should be used. A 0.05% chlorhexidine solution is used veterinary patients undergoing mechanical ventilation may
to flush the vestibule or prepuce prior to the catheter inser- be at risk for gastrointestinal ulceration and therefore would
tion. In females, catheterization is achieved by blind palpa- benefit from ulcer prophylaxis.
tion of the urethral papilla or by direct visualization of the Both diarrhea and constipation may be observed in the
urethra using a speculum and a light source. If a Foley cath- patient population under general anesthesia. Care should
eter is used, the balloon is inflated after the catheter is be taken to keep the anal and perineal area clean and dry;
advanced into the bladder. Afterward, the catheter is gently removal of hair may facilitate this, and may also allow
pulled back until resistance is met. If a different type of monitoring of the skin for irritation. Careful abdominal
indwelling catheter is used, the catheter is sutured in place palpation should be performed daily to assess for constipa-
after measurement has been taken to ensure correct place- tion. Enemas may be required to facilitate gastrointestinal
ment. Although antibiotic-coated urinary catheters have tract emptying [14].
References 689
Techniques to Decrease Stimulation weakness, and contributes to delirium, making it more

challenging to rehabilitate these patients. Cotton balls may
Patients undergoing long-term anesthesia are frequently be placed in the external ear canals to minimize auditory
intubated for the duration of the event; however, some may stimuli. This should be noted in the record, so that the cot-
have a tracheostomy tube placed to minimize the amount of ton can be removed when it is not needed. Ambient noise
sedative and anesthetic agents used, as well as to avoid com- should be kept as minimal as possible. When not absolutely
plications associated with orotracheal intubation, such as necessary, lights should be turned down to minimize visual
oral ulcerations or laryngeal edema. Drugs used to maintain stimulation. When that is not possible, placing a towel over
heavy sedation are titrated to the lowest level that is required the eyes may aid in reducing stimuli.
for immobilization and patient comfort. Occasionally,
patients may be rousable and responsive to stimuli.
Therefore, several techniques may be used to minimize Summary
stimulation. Treatments should be grouped together in
such a way that the patient is stimulated as infrequently as General anesthesia and long-term immobilization may be
possible. Additional sedation may be used during periods of necessary in a subset of critically ill patients. A number of
stimulation, which may include anesthetics, opioids, anxio- factors may negatively impact these animals, and vigilant
lytics, or tranquilizers. However, whenever possible, the and well-structured nursing care program is paramount in
need for sedation should be critically evaluated, as heavy preventing and addressing commonly encountered com-
sedation furthers immobility, compounds neuromuscular plications for optimal patient care.
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691
52
Neuromuscular Blockade
Manuel Martin-Flores and Karen L. Basher
Introduction of general anesthetic so that hypnosis is ensured by anes-

thetics and muscle relaxation is provided by the neuromus-
Neuromuscular blocking agents (NMBAs), also called cular blocker.
muscle relaxants, are used in combination with anesthetic Aside from balanced anesthesia, NMBAs are particularly
agents as part of balanced anesthetic techniques. They dif- useful to prevent or treat ventilator–patient asynchrony.
fer from all other agents used in anesthesia in that they do Asynchrony results in ineffective alveolar ventilation and
not contribute to hypnosis or analgesia; rather, these agents increases the risks of reaching inadequately high peak air-
produce skeletal muscular relaxation that can range from way pressures. Ventilated patients, especially during the
mild weakness to complete flaccid paralysis, in a dose- initial ventilator setup, may have a high respiratory drive,
dependent manner. Paralysis is produced by interrupting resulting in hypercapnia, hypoxemia, or both. In this sce-
neuromuscular transmission. Both pre- and post-synaptic nario, and providing the depth of anesthesia is judged to be
effects are exerted in the neuromuscular junction, result- adequate, the inclusion of a NMBA provides an efficient
ing in both the reduced availability and release of acetyl- means for treating asynchrony. Modern NMBAs are usu-
choline (ACh), and the competitive antagonism of nicotinic ally devoid of substantial cardiovascular effects, making
ACh receptors (nAChR) in the post-synaptic cell. As a con- this therapy clinically useful for ill animals. A summary of
sequence, when blockade is complete, impulses arriving to different NMBAs and commonly used doses is shown in
the neuromuscular junction through a motor nerve do not Table 52.1.
trigger a skeletal muscular contraction, and paralysis
ensues. Because it is the neuromuscular transmission that
is interrupted, monitoring is focused on evaluating this Reversal of Neuromuscular Block
transmission. To this purpose, a motor nerve must be stim-
ulated, and the muscular response assessed. The effects of NMBAs dissipate gradually as the agent is
redistributed and metabolized. As the plasma levels
decrease, the agents move away from the neuromuscular
Indications junction and function is restored gradually. This process
can be enhanced or abbreviated by the use of anticholinest-
While the effects of NMBAs are restricted to skeletal mus- erase drugs, also called acetylcholinesterase (AChE) inhib-
cle relaxation, there are clinical advantages to their use. itors, such as edrophonium or neostigmine. AChE
Muscle relaxation and immobility can also be achieved inhibitors are not direct antagonists to NMBAs, and hence,
with general anesthetics, but the doses required for immo- cannot directly reverse their effects. Rather, these agents
bilization are significantly higher than those necessary for inhibit the activity of the acetylcholinesterase enzyme,
unconsciousness [1–3]. Such an increase in the dose of resulting in increased levels of acetylcholine (ACh) at the
general anesthetics is often accompanied with hemody- neuromuscular junction. It is the ACh that will ultimately
namic instability, an undesirable occurrence in ill patients. compete with the NMBAs for the nicotinic acetylcholine
Hence, the addition of NMBAs allows to reduce the doses receptors (AChRs).
692 Neuromuscular Blockade
Table 52.1 Different neuromuscular blocking agents and commonly used doses.
Family Agent Dose (mg/kg) Duration (minutes) Comments
Benzylisoquinolines Atracurium 0.2–0.5 20–30 Extrahepatic metabolism resulting in

Cisatracurium 0.05–0.2 20–40 predictable duration under various conditions.
Atracurium has a tendency to release
histamine when administered at high doses.
Aminosteroid Rocuronium 0.3–0.6 20–30 Hepatic and renal biotransformation. No
Vecuronium 0.05–0.1 20–40 histamine release but might have a tendency
for vagolytic effects.
Pancuronium 0.05–0.1 40–60
This process carries several important clinical implica- it has been demonstrated that mild neuromuscular block
tions: first, the release and accumulation of ACh requires cannot be diagnosed without the use of objective monitor-
time; hence, reversal of the block is not instantaneous. ing, and that even shallow residual weakness can nega-
Studies in anesthetized dogs using neostigmine show that tively affect laryngeal function [10–12]. Hence, it is
complete reversal may require up to 10 ± 2 minutes, depend- imperative to avoid residual neuromuscular block upon
ing on the dose of neostigmine used [4]. Second, there is a termination of anesthesia, particularly in animals with res-
limit to the amount of ACh that can be released from the piratory impairment, as the effects of residual block on
presynaptic neuron; once complete AChE enzyme inhibi- laryngeal and respiratory functions could be magnified
tion is reached, no further accumulation of ACh will occur. under those conditions. To date, the most effective method
This results in a ceiling effect whereby increasing the dose for detecting and avoiding residual block is the systematic
of the AChE inhibitor will have no further effect on the con- use of objective monitoring of neuromuscular transmis-
centration of ACh. As a consequence, deep levels of neuro- sion. Routine reversal, while recommended, does not
muscular block, which result from high concentrations of guarantee that neuromuscular function will be restored in
NMBAs, may not be easily antagonized. This is the reason all cases [13]. Likewise, subjective observation of sponta-
why it is often recommended that reversal with AChE neous movements including ventilation, measurement of
inhibitors may not be attempted until there is evidence of respiratory variables, or time from last dose, cannot relia-
continuing spontaneous return of neuromuscular function. bly predict when complete neuromuscular transmission
In the clinical setting, neostigmine (0.02–0.07 mg/kg) or will return restored [10, 14, 15].
edrophonium (0.5–1.0 mg/kg) will act more quickly and As importantly, the provider must ensure that hypnosis
completely as the spontaneous process of recovery pro- is adequate. In people, the use of NMBAs has been asso-
gresses [5]. Lastly, it should be remembered that as the lev- ciated with higher incidences of awareness under gen-
els of ACh increase, systemic effects such as bradycardia, eral anesthesia; that is, inadequate depths of anesthesia
may ensue. Hence, it is recommended to administer atro- were masked by the use of these agents. The presence of
pine (0.02 mg/kg) or glycopyrrolate (0.01 mg/kg) either with residual weakness during emergence of anesthesia can
or prior to the injection of AChE inhibitors. also lead to cases of awareness combined with immobil-
ity. In humans, it has been suggested that the combina-
tion of neuromuscular block, lack of monitoring of
Complications neuromuscular transmission, and absence of reversal
contribute to the incidence of awareness under
The use of relaxants, while ordinarily devoid of important anesthesia [16].
hemodynamic effects, is not without risks and potential
negative consequences. The effects of these agents may
extend into the early post-anesthetic period, resulting in Monitoring of Neuromuscular Function
inadvertent residual weakness. Residual block is a com-
mon complication in humans when neuromuscular moni- While there are different methods to monitor neuromuscu-
toring and reversal are omitted, with studies showing lar transmission, all rely on the same principle: the stimu-
incidences of up to 64% [6]. Residual block, even if mild, lation of a motor nerve and the evaluation of the evoked
increases the incidence of hypoxemia and upper airway response. Two motor nerves are routinely used for clinical
obstruction [7–9]. There are no data on the incidence or monitoring in dogs and cats: the peroneal and the ulnar
consequences of residual block in dogs and cats. However, nerves (Figure 52.1).
MoniMonong Mof NeoMoeuseulo eosinMo 693
PN UN
(a)
(b) (c)
Figure 52.1 (a) Schematic representation of the peroneal (PN) and ulnar (UN) nerves in a dog on dorsal recumbency. The expected
evoked responses to stimulation of those nerves (flexion of the tarsus and carpus, respectively) are indicated with dashed lines.
Placement of alligator clips for nerve stimulation for both nerves are shown in (b) and (c).
Evoked responses can be judged subjectively (by obser- measurement of the isometric force of contraction (mech-
vation or tact) or can be measured objectively. As men- anomyography) has long been considered the gold stand-
tioned above, subjective observations of evoked muscular ard. However, this technique is cumbersome and is not
twitches can only provide limited information. It can easily applied in the clinical setting. The most commonly
inform the provider on whether some response to stimula- used method, and likely the most user friendly, is the meas-
tion is present or absent, but it cannot discern whether urement of the acceleration of a free-moving limb in
function is adequate or partially affected; that is, it cannot response to motor nerve stimulation (acceleromyography,
detect residual block. The presence of responses to stimula- AMG). AMG is commonly used in dogs and cats, both for
tion is useful to determine when to redose the NMBA, or research and in the clinical setting. Its accuracy has been
when to begin reversal with AChE inhibitors, as reversal reported in reference to mechanomyography, and it has
should not be attempted during deep neuromuscular block been shown to detect residual block when visual inspec-
(i.e. in the absence of evoked responses). Hence, the visual tion fails [10, 17]. AMG monitors are affordable and easy to
assessment of neuromuscular stimulation is not without use, and many devices can also be used for locoregional,
clinical uses. There are several peripheral nerve stimula- electrolocation guided blocks. Examples of currently avail-
tors in the veterinary market that can fill this role. able AMG monitors are shown in Figure 52.2.
If the depth of neuromuscular block is to be accurately During AMG, two electrodes are placed in close proxim-
assessed, then an objective monitor is needed. The ity to either the peroneal or ulnar nerve. While adhesive
(a) (b)
Figure 52.2 Neuromuscular transmission monitors. (a) The Stimpod® NMS450X (Xavant Technology, Pretoria, South Africa).
(b) The ToFscan® (IDMED, Marseilles, France).
surface electrodes can be used, we commonly use subcuta- adhesive tape, parallel to the surface, dorsally to the carpus
neous needles connected to the AMG via alligator clips. An (Figure 52.1). A similar procedure is performed for the
acceleration-sensitive crystal is taped to the paw of the hindlimb, with the limb secured above the tarsus. This
limb being stimulated. Modern monitors measure the method is also applied with animals in lateral recumbency.
evoked movement in three axis and hence, it is of little rel- If the patient is resting in sternal recumbency, we prefer to
evance over which aspect of the paw the crystal is secured. displace both hindlimbs to one lateral and monitor using
It is important, however, that the carpus or tarsus is allowed the peroneal nerve (Figure 52.1). A summary of how AMG
to flex freely during nerve stimulation while the rest of the is instrumented in dogs or cats is described in Protocol 52.1.
limb remains stable. For animals in dorsal recumbency, the Electromyography (EMG), the measurement of the com-
front limb can be extended cranially and secured with pound action potentials, can also be used to evaluate
Protocol 52.1 Items Needed for Placing Acceleromyograph
● [2] 21–25 g needles 6) Attach the alligator clamp on the needle tip (this
● Acceleromyography monitor or peripheral nerve also prevents accidental needle stick in people and
stimulator other objects).
● Alligator clamps 7) Place needles approximately 1 inch apart.
● Snap attachments for alligator clamps 8) Place the sensor over the metacarpals/metatarsals
● Medical grade tape and secure with tape (or reusable hook and loop tape).
9) Select stimulating current. Current should be suffi-
cient to elicit 4 twitches during train-of-four (TOF). If
Procedure for Placing an Acceleromyography Monitor
the patient is already paralyzed when the monitor is
1) Locate the part of the animal’s body that will be instrumented, select at least 40 mA.
stimulated (forelimb or hindlimb). 10) Use the deliver button to deliver a TOF.
2) Extend leg to isolate the area to apply alliga- 11) Select an interval for cycling so that TOF stimuli are
tor clamps. delivered automatically over a desired interval.
3) If using the forelimb, use medial aspect of the ulna and Otherwise, manual measurements can be performed.
the epicondyle of the humerus to locate the ulnar nerve. 12) If using other TOF monitors that require calibration,
4) If using a pelvic limb, locate the peroneal nerve over such as the TOF-Watch series, calibration should be
the lateral or medial aspect of the knee. performed prior to NMBA administration.
5) Tent and place hypodermic needles through the skin 13) The patient should not be moved once calibration is
so that the needle is exposed out the other side. obtained, to ensure adequate reversal.
MoniMonong Mof NeoMoeuseulo eosinMo 695
neuromuscular transmission. The same principle is fol- stimuli do not commonly produce direct muscle stimula-
lowed: a motor nerve is stimulated, and the response (mus- tion. Since it is the neuromuscular transmission that is
cular EMG) is quantified. Modern monitors quantify the evaluated, it is imperative that the motor nerve is stimu-
amplitude of the EMG waveform and report the magnitude lated, and not the muscle directly. Direct muscle stimula-
of evoked twitches in reference to a baseline value (in the tion may result in muscular contractions, even when
absence of block), or as fade during train-of-four (TOF) neuromuscular transmission is in fact impaired. The stim-
stimulation (see below). For this purpose, a number of ulating electrodes are placed over the nerve, approximately
electrodes must be placed in particular locations over the an inch apart, with the positive electrode dorsal. The elec-
muscle being evaluated. EMG is a practical method as, trodes may also be placed on both sides of the nerve, so that
since it is cellular activation and not movement that is nerve courses between both electrodes.
measured, it can be performed in any recumbency, even if There are several patterns of stimulation available. The
the limb is not allowed to move freely. Unfortunately, this most commonly used and most clinically useful is the TOF,
monitors are often available as part of larger multiparam- which consists in a sequence of four stimuli, each sepa-
eter monitors with a much limited availability. The rest of rated by 0.5 seconds. Within each TOF, the magnitude of
this chapter therefore focuses on AMG monitoring. each twitch is assessed. In the absence of NMBAs, all four
twitches are of equal magnitude (Figure 52.3). During
complete neuromuscular block, all twitches disappear;
Patterns of Stimulation
that is, there is no response to nerve stimulation. As neuro-
To make correct assessments of evoked responses, some muscular transmission recovers, twitches reappear in order
care is necessary when stimulating the motor nerve. Square of one to four; the “TOF count” then, can range from zero
wave impulses of 0.1–0.2 msec are used, as such short to four. Once all four twitches have return (TOF count of
Response
Onset Recovery
(a)
(b)
Figure 52.3 Schematic representation of train-of-four (TOF) responses. In (a), normal neuromuscular transmission is first observed
(no fade during TOF). Both the magnitude of each twitch, and a fade, is observed during onset of neuromuscular block. During recovery,
a progressive return of responses is observed. A trace of neuromuscular block and recovery measured with acceleromyography (AMG)
obtained from an anesthetized dogs is shown in (b). The blue represent the magnitude of the first twitch in the TOF, and the
superimposed red dots represent the TOF ratio (i.e. the ratio of T4 : T1). Recovery of neuromuscular function is adequate when the TOF
ratio approximates 1.0 (no fade between twitches).
four), the magnitude of each twitch will increase progres- Clinical Monitoring, Maintenance,
sively, following the order of reappearance. That is, the and Reversal of Neuromuscular Block
increase in the magnitude of twitch one will be followed by
two, three and four. As a result, a progressive decay, or fade, Neuromuscular monitoring is not only necessary to avoid
is observed within the TOF (Figure 52.3). The presence of residual paralysis, but it is also a useful to guide adminis-
fade during TOF is a clear indication of residual block. This tration of NMBAs and to plan reversal. Complete block,
fade can be quantified by measuring the magnitude of that is, the total absence of responses to nerve stimulation,
the fourth twitch over that of the first twitch (TOF ratio is generally both unnecessary and undesirable. While only
T4 : T1). In the absence of block, the TOF ratio is 1.0. A a small number of procedures benefit from such practice,
TOF ratio of 0.9 or less is evidence of impaired neuromus- most surgeries, and certainly mechanical ventilation, can
cular transmission. While fade may be visually apparent be achieved with a depth of neuromuscular block charac-
during moderate residual block, fade during mild to shallow terized by the presence of one response to TOF stimula-
block (TOF ratio 0.5–0.9) is not detectable by subjective tion. Maintaining a TOF count of one ensures an adequate
methods [10]. The fact that assessment of neuromuscular depth of relaxation for most procedures while permitting
transmission is performed with values obtained within reversal in a reasonable period with AChE inhibitors.
each train is an important clinical advantage; baseline val- With this goal in mind, NMBAs administration, whether
ues are not needed. Hence, monitoring can begin even by repeated boluses or infusions, can be titrated so that a
after neuromuscular block has been established. Moreover, TOF count of one is present. If boluses are administered,
the patient’s position may be altered, or even the site of doses are usually injected when the second response
stimulation, without affecting the ability to detect residual becomes apparent. In the case of infusions, the infusion
paralysis. This is an important feature in animals venti- rate is increased if a TOF count of two is observed and is
lated for long periods, where positioning may need to be decreased when the TOF count is zero. The practice of
altered periodically. Moreover, since modern devices administering doses of NMBAs at fixed predetermined
measure triaxial AMG, no calibration is necessary. This intervals, or to infuse the agent at a rate that produces com-
differs from older devices (such as the TOF-Watch® series, plete block (no responses to TOF) carries the risk of over-
Organon, Swords Co., Dublin, Ireland) which only meas- dosing. Once all responses are absent, assessing
ured AMG in one axis. In those devices, a baseline calibra- accumulation of the NMBA becomes a difficult task; any
tion was required, and lateral movement introduced errors increase in plasma levels of the NMBA from that point
during monitoring. onward will not be reflected by TOF stimulation. The post-
The use of submaximal current is yet another advan- tetanic count is an alternate pattern of stimulation that
tage of TOF stimulation. Other patterns of stimulation, allows some differentiation on depth of block beyond a
such as the single twitch, which is used in dose-finding TOF count of zero. However, and as mentioned above,
studies of NMBA, rely on supramaximal current for nerve such depth of blockade is generally unnecessary.
stimulation. The response to nerve stimulation (i.e. the Effective reversal with AChE inhibitors is possible
magnitude of muscular contraction) increases as the cur- when at least a TOF count of one is present. Hence, main-
rent delivered is increased, until a plateau in the response taining that depth of relaxation ensures that reversal
is seen. At that point, maximal current has been reached. agents can be administered at any point. If the TOF count
Supramaximal stimulation is typically carried out with is zero, it is advisable to discontinue the administration of
currents 10–20% above the maximal current. In dogs, the NMBA and delay reversal until at least one twitch
supramaximal currents are in the order of 40–60 mA. Such returns in response TOF stimulation. The period until
currents generate discomfort when applied and the anes- return of T1 will vary, depending how much agent had
thetic depth needs to be adjusted to prevent a response. accumulated while the TOF count was zero. In general,
Because TOF examines the ratio between twitches within the more shallow the level of block, the quicker and more
each train (T4 : T1), the absolute magnitude of a twitch is consistent will AChE inhibitors restore neuromuscular
not important. As a result, lower, submaximal currents transmission [5].
can be used, as long as all four twitches can be evoked As mentioned above, AChE inhibitors will produce brad-
with said current. Studies in humans demonstrated that ycardia unless they are preceded by an antimuscarinic
both twitch magnitude as well as discomfort increased as agent, such as atropine or glycopyrrolate. If the changes in
the current was increased from 20 to 50 mA. However, the hemodynamics that can result from these agents are to be
TOF ratio with the lowest current did not differ from that avoided, reversal can be omitted as long as neuromuscular
with the highest, suggesting that lower, less painful cur- transmission is assessed objectively so that residual block
rents, can be used reliably to evaluate neuromuscular can be prevented. In such cases, NMBA administration is
transmission with TOF [18]. interrupted and recovery occurs spontaneously. The time
References 697
of spontaneous recovery will vary depending on the NMBA promising alternative for restoring neuromuscular func-
that has been used, the total dose administered, the dosing tion after the injection of several NMBAs.
regimen, and other factors such as temperature, pH, elec- Unlike sugammadex or calabadion, which are new rever-
trolyte abnormalities, and use of concomitant agents such sal agents, gantacurium and CW002 are novel NMBAs
as aminoglycoside antibiotics or volatile anesthetics, which belonging to a new family, the fumarates. Gantacurium is
can potentiate NMBAs. A slow recovery of neuromuscular an ultrashort-acting neuromuscular blocker, whereas
function is generally not a problem as long as the patient CW002 is an intermediate-acting agent. Both agents have
remains unconscious, the airway is secured, and ventila- undergone tests in different species [24–27]. Regardless of
tion is provided [19]. the expected duration of action, their effects can be termi-
nated almost instantly by administration of l-cysteine.
These novel agents may offer the practitioner both an
urrent and Future Advancements
C ultrashort-acting nondepolarizing blocker, which currently
in Neuromuscular Blockade does not exist, and an intermediate-acting agent with the
availability of complete, almost immediate reversal, devoid
Several new agents have either reached the market or are of significant hemodynamic effects.
in active research. Despite a wide variety of compounds,
efforts seem to be targeted to an easier and more complete
recovery of neuromuscular function. Troubleshooting
Sugammadex is the first specific relaxant binding agent
commercially available [20, 21]. When injected, it binds Open Circuit
to rocuronium in an irreversible manner. The sugamma- An open circuit exists when disconnections at the monitor
dex–rocuronium complex is devoid of relaxing proper- or between the monitor and the patient occur. Most com-
ties. As sugammadex binds to rocuronium, the monly, an electrode has become disconnected from the
concentration of free rocuronium in plasma drops and patient. This also occurs when alligator clips are placed
rocuronium moved out of the neuromuscular junction directly on the patient rather than attached to a needle.
and into the systemic circulation, only to be rendered
ineffective by sugammadex. As a result, neuromuscular
transmission is restored almost immediately. Although Inability to Calibrate and Erroneous Values
sugammadex is designed to bind with rocuronium, simi- This is frequent problem with older AMG monitors that
lar effects have been demonstrated when vecuronium measured acceleration only over one axis. In such circum-
was used. Because sugammadex is free from adverse stances, lateral movement of the acceleration-sensitive
hemodynamic effects, this technique is not only faster crystal would produce errors. This is solved only by secur-
than the more traditional reversal with AChE inhibitors ing the animal’s limb in a way that evoked twitches (carpal
but also more stable. The risk of incomplete reversal, or tarsal flexion) occurs over one axis only.
while possible, is decreased, as long as the dose of sug-
ammadex is appropriate. These virtues of sugammadex
Unstable Values
have been documented in dogs [22].
Calabadion is unrelated to sugammadex (it belongs to Unstable readings (consecutive up and down results) may
the cucurbit[n]uril family), but it can also bind to NMBAs, occur if the limb is not secured and there is excessive move-
rendering them devoid of relaxing properties. Unlike sug- ment if the patient moves voluntarily from discomfort dur-
ammadex, which is selective for rocuronium, calabadion ing nerve stimulation, or if carpal or tarsal flexion become
binds to agents of both the aminosteroid and isoquinoline impeded (for example, if the limb is dragging over the table
families [23]. While still under research, calabadion is a or drapes rather than flexing unopposed).
References
1 Reilly, S., Seddighi, R., Egger, C.M. et al. (2013). The effect isoflurane necessary to prevent movement in dogs. Vet.
of fentanyl on the end-tidal sevoflurane concentration Anaesth. Analg. 38 (3): 195–202.
needed to prevent motor movement in dogs. Vet. Anaesth. 3 Seddighi, R., Egger, C.M., Rohrbach, B.W. et al. (2012).
Analg. 40 (3): 290–296. Effect of nitrous oxide on the minimum alveolar
2 Seddighi, R., Egger, C.M., Rohrbach, B.W. et al. (2011). The concentration for sevoflurane and the minimum alveolar
effect of midazolam on the end-tidal concentration of concentration derivatives that prevent motor movement
and autonomic responses in dogs. Am. J. Vet. Res. 73 (3): function from vecuronium in dogs: effects of dose and
341–345. dosing protocol. Vet. J. 248: 14–17.
4 Martin-Flores, M., Lorenzutti, A.M., Litterio, N.J. et al. 16 Pandit, J.J., Andrade, J., Bogod, D.G. et al. (2014). 5th
(2017). Speed of reversal of vecuronium neuromuscular National Audit Project (NAP5) on accidental awareness
block with different doses of neostigmine in anesthetized during general anaesthesia: summary of main findings
dogs. Vet. Anaesth. Analg. 44 (1): 28–34. and risk factors. Br. J. Anaesth. 113 (4): 549–559.
5 Lorenzutti, A.M., Martin-Flores, M., Baldivieso, J.M. et al. 17 Sakai, D.M., Romano, M., Tseng, C.T. et al. (2018). Bias,
(2014). Evaluation of neostigmine antagonism at different limits of agreement, and percent errors between
levels of vecuronium-induced neuromuscular blockade acceleromyography and mechanomyography in
in isoflurane anesthetized dogs. Can. Vet. J. 55 (2): anesthetized dogs. Vet. J. 233: 3–7.
156–160. 18 Brull, S.J., Ehrenwerth, J., and Silverman, D.G. (1990).
6 Murphy, G.S. and Brull, S.J. (2010). Residual neuromuscular Stimulation with submaximal current for train-of-four
block: lessons unlearned. Part I: Definitions, incidence, and monitoring. Anesthesiol. 72 (4): 629–632.
adverse physiologic effects of residual neuromuscular block. 19 Kopman, A.F. and Sinha, N. (2003). Acceleromyography
Anesth. Analg. 111 (1): 120–128. as a guide to anesthetic management: a case report.
7 Murphy, G.S., Szokol, J.W., Marymont, J.H. et al. (2008). J. Clin. Anesth. 15 (2): 145–148.
Intraoperative acceleromyographic monitoring reduces 20 Adam, J.M., Bennett, D.J., Bom, A. et al. (2002).
the risk of residual neuromuscular blockade and adverse Cyclodextrin-derived host molecules as reversal agents
respiratory events in the postanesthesia care unit. for the neuromuscular blocker rocuronium bromide:
Anesthesiol. 109 (3): 389–398. synthesis and structure–activity relationships. J. Med.
8 Sauer, M., Stahn, A., Soltesz, S. et al. (2011). The Chem. 45 (9): 1806–1816.
influence of residual neuromuscular block on the 21 Bom, A., Clark, J.K., and Palin, R. (2002). New
incidence of critical respiratory events. A randomised, approaches to reversal of neuromuscular block. Curr.
prospective, placebo-controlled trial. Eur. J. Anaesthesiol. Opin. Drug Discov. Dev. 5 (5): 793–800.
28 (12): 842–848. 22 Mosing, M., Auer, U., West, E. et al. (2012). Reversal of
9 Norton, M., Xara, D., Parente, D. et al. (2013). Residual profound rocuronium or vecuronium-induced
neuromuscular block as a risk factor for critical neuromuscular block with sugammadex in isoflurane-
respiratory events in the post anesthesia care unit. Rev. anaesthetised dogs. Vet. J. 192 (3): 467–471.
Esp. Anestesiol. Reanim. 60 (4): 190–196. 23 Ma, D., Zhang, B., Hoffmann, U. et al. (2012). Acyclic
10 Martin-Flores, M., Sakai, D.M., Tseng, C.T. et al. (2019). cucurbit[n]uril-type molecular containers bind
Can we see fade? A survey of anesthesia providers and neuromuscular blocking agents in vitro and reverse
our ability to detect partial neuromuscular block in dogs. neuromuscular block in vivo. Angew. Chem. Int. Ed. Engl.
Vet. Anaesth. Analg. 46 (2): 182–187. 51 (45): 11358–11362.
11 Sakai, D.M., Martin-Flores, M., Romano, M. et al. (2017). 24 Heerdt, P.M., Sunaga, H., and Savarese, J.J. (2015). Novel
Recovery from rocuronium-induced neuromuscular neuromuscular blocking drugs and antagonists. Curr.
block was longer in the larynx than in the pelvic limb of Opin. Anaesthesiol. 28 (4): 403–410.
anesthetized dogs. Vet. Anaesth. Analg. 44 (2): 246–253. 25 Heerdt, P.M., Sunaga, H., Owen, J.S. et al. (2016).
12 Tseng, C.T., Sakai, D.M., Libin, M. et al. (2017). Partial Dose–response and cardiopulmonary side effects of the
neuromuscular block impairs arytenoid abduction during novel neuromuscular-blocking drug CW002 in man.
hypercarbic challenge in anesthetized dogs. Vet. Anaesth. Anesthesiol. 125 (6): 1136–1143.
Analg. 44 (5): 1049–1056. 26 Sunaga, H., Malhotra, J.K., Yoon, E. et al. (2010). Cysteine
13 Murphy, G.S. and Kopman, A.F. (2018). Neostigmine as reversal of the novel neuromuscular blocking drug
an antagonist of residual block: best practices do not CW002 in dogs: pharmacodynamics, acute cardiovascular
guarantee predictable results. Br. J. Anaesth. 121 (2): effects, and preliminary toxicology. Anesthesiol. 112 (4):
335–337. 900–909.
14 Martin-Flores, M., Sakai, D.M., Campoy, L., and Gleed, 27 Sunaga, H., Savarese, J.J., McGilvra, J.D. et al. (2016).
R.D. (2014). Recovery from neuromuscular block in dogs: Preclinical pharmacology of CW002: a nondepolarizing
restoration of spontaneous ventilation does not exclude neuromuscular blocking drug of intermediate duration,
residual blockade. Vet. Anaesth. Analg. 41 (3): 269–277. degraded and antagonized by l-cysteine-additional
15 Lorenzutti, A.M., Zarazaga, M.P., Sakai, D.M. et al. studies of safety and efficacy in the anesthetized rhesus
(2019). Context-sensitive recovery of neuromuscular monkey and cat. Anesthesiol. 125 (4): 732–743.
699
Section Seven
Clinicopathologic Techniques
701
53
Blood Sample Collection and Handling

Courtney Waxman and Tami Lind
The information obtained from collection and analysis of such as syringes equipped with self-capping needles
blood samples often plays a critical role in the diagnostic (Figure 53.1) and catheters should be used whenever pos-
process. It is therefore crucial that blood samples are sible. Additionally, needleless ports (Figure 53.2) allow for
obtained and handled properly to preserve the integrity of the administration of fluids and drugs, as well as collection
the specimen and to provide accurate results. of samples from intravenous (IV) lines and catheters with-
A number of issues can adversely affect the quality of out the risk of a sharps injury.
blood specimens. Aggressive collection techniques includ- Aseptic technique should be used when collecting sam-
ing rapid aspiration of blood through a small-bore needle, ples, especially in immune-compromised patients. Proper
prolonged or improper tourniquet use, excessive redirec- hand hygiene and the use of examination gloves signifi-
tion of the needle (or “fishing”) to access a vein, delay cantly reduces the risk of infection to both the patient and
between the time of sample collection and time of sample the handler [1, 2].
analysis, and other practices are frequently associated with Once the sample is collected, all tubes must be labeled
poor sample quality. Improper handling issues including with the patient’s name, identification number, and date.
failure to invert collection tubes adequately to mix the anti- Blood is considered a biohazard; proper packaging is essen-
coagulant and blood, improper or delayed centrifugation, tial for specimens submitted to commercial laboratories.
inadequate filling of blood tubes, improper storage of col- Failure to label or package samples according to the labora-
lected samples, and other handling errors may also have a tory’s specifications may result in rejection of the sample.
negative impact on sample integrity and quality. Serum and/or plasma must be separated from whole blood
by centrifugation. All personnel using the centrifuge
should be cognizant of safety and appropriate use guide-
Safety Concerns lines and should read the operator manual for each piece of
equipment to ensure proper use. Ideally, centrifuges should
Several safety issues need to be considered during collec- not be operated without a cover or lid in place. When in
tion and handling of blood samples. Conscious patients use, covered centrifuges should never be opened until the
need to be restrained in a manner that provides for the rotor has come to a complete stop. Tube caps or stoppers
safety of the person performing the venipuncture, the should be securely in place on all samples placed in the
assistant, and the patient. It is imperative that personnel centrifuge, and any spills need to be cleaned immediately,
providing restraint are properly trained in techniques that following all appropriate safety precautions.
facilitate control of the patient while minimizing the risk
of injury to the animal or staff. Fear-free handling of
patients during venipuncture can also be beneficial to the Venous Blood Sample Collection
patient as well as the staff.
Sharps safety practices must be strictly observed to mini- Venous blood samples may be collected by direct insertion
mize the risk of injury from needles or catheters. Needles of a needle into a vein (venipuncture) or by aspiration of
should not be recapped and must be disposed of in blood through a peripheral or central IV catheter. The steps
puncture-resistant biohazard containers. Safety devices, involved in collecting a blood sample are similar for all
702 Blood Sample Collection and Handling
achieve accurate results. Needle selection is based on the

size and fragility of the vein, the volume of blood required,
and the frequency of sampling anticipated. Needle sizes
most commonly selected for venipuncture are 20–22 gauge;
smaller needles ranging from 23 to 28 gauge may be used
when veins are extremely small or fragile, or when fre-
quent sampling is required (i.e. bi-hourly glucose curves).
Needles at the larger end of the spectrum are preferred
when large sample volumes are required. The size of the
needle used for venipuncture is a prime determinant of the
rate at which a sample may be aspirated; the larger the nee-
dle, the faster the rate. Rapid aspiration of blood through a
small-bore needle creates shear forces resulting in hemoly-
sis and may adversely affect test results.
Syringe size is determined by the volume of sample
required. The use of large syringes has been associated
with application of excessive negative pressure during
sample aspiration and may cause hemolysis and vascular
collapse. To ensure sample quality, the person performing
the venipuncture should apply steady, gentle traction on
the syringe plunger in such a manner that the syringe fills
at the same rate at which the plunger is retracted. Repetitive
application and release of negative pressure on the syringe,
or “pulsing,” does not increase the rate or volume of sam-
ple collection; this technique causes the vessel to collapse
and frequently results in hemolysis.
Besides the traditional needle and syringe setup, alterna-
Figure 53.1 Syringe with safety recapping device for needle. tive venipuncture equipment includes butterfly catheters
and Vacutainer® (Becton, Dickinson, Franklin Lakes, NJ)
systems. Butterfly catheters come in a variety of gauges and
can be especially useful in fractious patients or when col-
lecting samples from small or fragile veins. Vacutainer sys-
tems (Figure 53.3) allow blood to be drawn directly into the
collection tube(s), facilitating immediate contact with the
anticoagulant to ensure the correct blood/anticoagulant
ratio and decrease hemolysis to help preserve the integrity
of the sample.
Figure 53.2 Luer-lock needleless ports.
veins, with slight variations in the patient positioning/

restraint and technique.
Venipuncture Equipment
Several factors play a role in the quality of a blood sample,
and the person performing the venipuncture should be Figure 53.3 Vacutainer® system (Becton, Dickinson, Franklin
familiar with these variables to ensure sample quality to Lakes, NJ).
Venous Blood Sample Collection 703
visualization difficult. Patients in respiratory distress may

Box 53.1 Order of Blood Tube Collection for Venous
not tolerate lateral positioning and restraint, so an alterna-
Blood Samples [11]
tive site, patient position, or restraint technique should be
1) Blood culture (yellow or blood culture bottles) considered.
2) Sodium citrate (light blue) If there is any concern regarding the patient’s coagula-
3) Serum or serum separator (red or red/gray) tion status, samples should be collected from a peripheral
4) Lithium/sodium heparin (green) vein using the smallest-bore needle that is practical for the
5) EDTA (lavender or pink) volume of blood needed. It has been suggested that sam-
ples should not be collected from the jugular vein of coagu-
lopathic patients. Jugular venipuncture should also be
Order of Draw
avoided in patients with head trauma or other neurologic
When blood is drawn for sample collection in multiple disorders because occlusion of the jugular vein may result
blood tubes, it is important that the samples are collected in a significant increase in intracranial pressure. Trauma
in a specific order (Box 53.1). Filling tubes in the improper patients may have significant injuries to various body
order may result in unintended contamination of the sam- regions (e.g. cervical spine, thoracic/pelvic limbs) that may
ple with anticoagulants and erroneous results (i.e. false affect the person’s ability to perform a venipuncture. The
elevation of potassium levels and decreased levels of cal- person performing the venipuncture may need to select an
cium due to serum or plasma contamination with potas- alternate venipuncture site while keeping the patient’s con-
sium EDTA from the lavender-top tube). dition and comfort in mind. Cephalic venipuncture should
Whenever feasible, extra blood should be collected above be reserved for patients not requiring IV catheterization, as
the minimum amount required to run diagnostic tests; this the cephalic vein is the ideal site for peripheral catheteriza-
is done to allow for human error, machine error, and the tion and the vessel should be kept intact.
possibility of needing to dilute the sample. When filling the
blood tubes, it is best to remove the needle from the syringe Jugular Venipuncture
so that the blood is directly instilled inside the tube rather The jugular vein (Protocol 53.1) is located centrally on the
than sticking the syringe needle into the rubber stopper, to neck on the lateral aspect of the trachea and esophagus in
minimize hemolysis. If the blood is instilled in a tube with the jugular furrow and above the thoracic inlet. When a
anticoagulant, it should be gently inverted to mix the sam- large sample volume is required, it is generally advisable to
ple. If the blood is instilled in a tube without an anticoagu- select this vessel, as it is the largest (Figure 53.4).
lant, it should be stored in an upright position to allow the
sample to clot; this prevents the cells from affixing to the Cephalic Venipuncture
rubber stopper or inner wall of the blood tube. The diag- The cephalic vein (Protocol 53.2) is located on the cranial
nostic testing ordered will determine whether the sample aspect of the thoracic limb between the elbow and the car-
needs to be stored at room temperature or refrigerated. pus. This site is commonly used in dogs and cats as it is the
next largest vessel after the jugular. The cephalic vein is
readily visible and easily accessible (Figure 53.5).
Venipuncture Sites and Considerations
The most common sites for venipuncture include the jugu- Lateral Saphenous Venipuncture
lar, cephalic, medial saphenous or femoral, lateral saphen- The lateral saphenous vein (Protocol 53.3) is located on the
ous, and dorsal pedal veins. Factors influencing site lateral aspect of the pelvic limb between the knee and
selection include the sample volume required, the accessi- hock. This site is most commonly used in dogs for lesser
bility of the vein, the skill of the person performing the blood volume collection as this is a smaller vein
venipuncture, the condition of the skin over the site, the (Figure 53.6). The distal lateral saphenous vein is typically
patient’s condition and behavior, and the potential need for readily visible and easily accessible, but the vessel tends to
vascular access (i.e. IV catheter placement). The vein move or “roll” more; applying mild pressure to the proxi-
selected should be easily accessible; excessive probing or mal portion of the vein helps the distal portion be less
redirection of the needle is associated with hemolysis and prone to movement.
poor sample quality. To minimize the risk of infection, ven- The lateral saphenous may be an alternate site to the
ipuncture should not be performed at any site where there cephalic vein if the patient is fractious or uncooperative.
is evidence of pyoderma or loss of skin integrity.
The patient’s condition may play a significant role in the Medial Saphenous (Femoral) Venipuncture
site selection. Patients with heart disease, poor perfusion, The medial saphenous (femoral) vein is located on the
or anemia may have reduced vessel filling, making medial aspect of the pelvic limb between the knee and
Protocol 53.1 Jugular Venipuncture Protocol Protocol 53.2 Cephalic Venipuncture Technique
Procedure Procedure
1) Restrain the patient in sternal, standing, sitting, or 1) Restrain the patient in sternal, standing, sitting, or
lateral recumbency, with the head elevated. lateral recumbency, with the head and pelvic
Note: Dorsal recumbency may also be used, pro- limbs controlled and the thoracic limb extended
vided that the jugular vein is readily accessible forward.
(reverse the direction of the needle, performing the 2) Clip the area over the distal cephalic vein if pre-
venipuncture with the needle facing the thoracic ferred. Prepare the area aseptically according to
inlet rather than the chin). hospital policy.
2) Clip the area over the jugular vein if preferred. Prepare 3) Perform hand hygiene.
the area aseptically according to hospital policy. 4) An assistant occludes the vessel by applying
3) Perform hand hygiene. pressure with their thumb immediately distal to
4) Occlude the vessel by applying pressure in the jugu- the elbow.
lar furrow lateral to the thoracic inlet. Once the ves- 5) Once the vessel is occluded, palpate for the vein
sel is occluded, palpate for the vein horizontally horizontally across the limb.
across the furrow. Note: An alternative to having an assistant occlude
Note: The purpose of occluding the vein is to con- the vessel is to use a tourniquet.
fine its movement and allow it to fill with blood for 6) Grasp the distal portion (metacarpal) of the tho-
easier palpation and sample collection. racic limb and apply traction to minimize move-
5) Insert the needle, bevel (opening) up, through the ment. The vein may be stabilized by placing the
skin and into the vein (∼20-degree angle); once thumb along the lateral aspect of the vein and
blood is noted in hub, decrease the angle of the stretching the skin downwards.
syringe and advance the needle around 0.5–1.0 cm 7) Insert the needle, bevel (opening) up, through the
into the lumen of the vessel. skin and into the vein (∼20-degree angle); once
6) Apply gentle negative pressure to aspirate blood blood is noted in hub, decrease the angle of the
into the syringe. syringe and advance the needle around 0.5–1.0 cm
7) Once the desired sample volume is obtained, release into the lumen of the vessel.
negative pressure and withdraw the needle from 8) Apply gentle negative pressure to aspirate blood
the vein. into the syringe.
8) Apply direct pressure to the jugular site for a mini- 9) Once the desired sample volume is obtained,
mum of 30 seconds or until there is no evidence of release negative pressure and withdraw the nee-
continued bleeding. dle from the vein.
10) Apply direct pressure to the cephalic site for a min-
imum of 30 seconds or until there is no evidence of
continued bleeding.
Note: A pressure wrap may be used if bleeding is
excessive.
Figure 53.4 Jugular venipuncture. Figure 53.5 Cephalic venipuncture.

Venous Blood Sample Collection 705
Protocol 53.3 Lateral Saphenous Venipuncture Protocol Protocol 53.4 Medial Saphenous (Femoral)
Venipuncture Technique
Procedure
Procedure
1) Restrain the patient in right or left lateral recum-
bency with the head and thoracic limbs controlled 1) Restrain the patient in semi-sternal, right, or left
and the pelvic limb extended forward. lateral recumbency with the head and thoracic
Note: Large patients may require two assistants to limbs controlled and the pelvic limb extended
provide safe restraint. forward.
2) Clip the area over the distal saphenous vein if pre- 2) Clip the area over the distal medial vein if pre-
ferred. Prepare the area aseptically according to ferred. Prepare the area aseptically according to
hospital policy. hospital policy.
3) Perform hand hygiene. 3) Perform hand hygiene.
4) An assistant occludes the vessel by applying pres- 4) Flex the non-dependent pelvic limb and hold it
sure with their hand wrapped around the proximal tucked against the caudal abdomen. The assistant
aspect of the hindlimb, slightly cranial to over uses the side of their hand to occlude the medical
the knee. saphenous (femoral) vein. An alternative to having
Note: An alternative to having an assistant occlude an assistant occlude the vessel is to use a
the vessel is to use a tourniquet. tourniquet.
5) Once the vessel is occluded, palpate for the vein 5) Once the vessel is occluded, palpate for the vein
horizontally across the limb. horizontally across the limb.
6) Grasp the distal portion (metatarsus) of the pelvic 6) Grasp the distal portion (metatarsus) of the
limb and apply traction to minimize movement. dependent pelvic limb and apply traction to mini-
The vein may be stabilized by placing the thumb mize movement. The vein may be stabilized by
along the lateral aspect of the vein and stretching placing the thumb along the lateral aspect of the
the skin downwards. vein and stretching the skin downwards.
7) Insert the needle, bevel (opening) up, through the 7) Insert the needle, bevel (opening) up, through the
skin and into the vein (∼20-degree angle); once skin and into the vein (∼20-degree angle); once
blood is noted in hub, decrease the angle of the blood is noted in hub, decrease the angle of the
syringe and advance the needle around 0.5–1.0 cm syringe and advance the needle around 0.5–1.0 cm
into the lumen of the vessel. into the lumen of the vessel.
8) Apply gentle negative pressure to aspirate blood 8) Apply gentle negative pressure to aspirate blood
into the syringe. into the syringe.
9) Once the desired sample volume is obtained, 9) Once the desired sample volume is obtained,
release negative pressure and withdraw the nee- release negative pressure and withdraw the
dle from the vein. needle from the vein.
10) Apply direct pressure to the lateral saphenous site 10) Apply direct pressure to the medial saphenous
for a minimum of 30 seconds or until there is no (femoral) site for a minimum of 30 seconds or until
evidence of continued bleeding. there is no evidence of continued bleeding.
excessive.
excessive.
hock (Protocol 53.4). This site is most commonly used in

cats for lesser blood volume collection as this is a smaller
vein (Figure 53.7). The medial saphenous/femoral vein is
typically readily visible and easily accessible and can vary
in its depth below the skin.
The medial saphenous may be an alternate site
to the cephalic vein if the patient is fractious or
uncooperative.
Figure 53.6 Lateral saphenous venipuncture.
Figure 53.7 Medial saphenous (femoral) venipuncture.
Dorsal Pedal Venipuncture

The dorsal pedal vein is located on the dorsal aspect of the
pelvic limb between the hock and metatarsus (Protocol
53.5). This site is less commonly used as a primary veni-
puncture site, often being reserved when other veins have
been exhausted (Figure 53.8). The dorsal pedal vein is
Figure 53.8 Dorsal pedal venipuncture.
somewhat visible and accessible, and venipuncture of this
vessel typically causes slightly more patient discomfort.
directly proportional to the size of the catheter used. In a

Venous Blood Sample Collection study comparing samples collected by venipuncture
from a Catheter using a 21-gauge Vacutainer needle and evacuated sam-
ple tubes to samples collected through a peripheral IV
Blood samples may be collected from both peripheral and catheter at insertion, hemolysis was noted in 3.8% of the
central IV catheters. Hemolysis has been associated with samples obtained through venipuncture and in 13.7% of
samples collected from IV catheters and appears to be those obtained through a catheter [3]. Further analysis
Protocol 53.5 Dorsal Pedal Venipuncture Protocol

Procedure aspect of the vein and stretching the skin
downwards.
1) Restrain the patient in sternal or lateral recumbency
7) Insert the needle, bevel (opening) up, through the
with the head and thoracic limbs controlled and the
skin and into the vein (∼20-degree angle); once
pelvic limb extended.
blood is noted in hub, decrease the angle of the
2) Clip the area over the pedal vein if preferred. Prepare
syringe, and advance the needle around 0.5–1.0 cm
the area aseptically according to hospital policy.
into the lumen of the vessel.
8) Apply gentle negative pressure to aspirate blood
4) An assistant occludes the vessel by applying pres-
into the syringe.
sure with their hand wrapped around the distal
9) Once the desired sample volume is obtained, release
aspect of the hindlimb, caudal to the hock.
negative pressure, and withdraw the needle from
Note: An alternative to having an assistant occlude
the vein.
the vessel is to use a tourniquet.
10) Apply direct pressure to the dorsal pedal site for a
5) Once the vessel is occluded, palpate for the vein
minimum of 30 seconds or until there is no evidence
horizontally across the limb.
of continued bleeding.
6) Grasp the distal portion (paw) of the pelvic limb and
apply traction to minimize movement. The vein may Note: A pressure wrap may be used if bleeding is
be stabilized by placing the thumb along the lateral excessive.
Discard Method 707
showed that the primary variable was the diameter of the

Protocol 53.6 Blood Sample Collection from a
IV catheter as demonstrated by the percentage of
Peripheral Intravenous Catheter
hemolyzed samples obtained. Specifically, this study doc-
umented that there was no evidence of hemolysis in sam- Procedure
ples obtained from 16-gauge catheters, whereas all 1) An assistant restrains the patient based on the
samples drawn from 24-gauge catheters were hemolyzed; venous access site chosen.
a small percentage of samples drawn from catheters 2) Clip the selected venous access site and prepare
ranging from 18 to 22 gauge also demonstrated aseptically according to hospital policy.
hemolysis [3]. 3) Perform hand hygiene.
4) Place the peripheral IV catheter aseptically.
Note: Catheters intended for blood sample collec-
Sample Collection from Peripheral
tion should not be preflushed to avoid sample dilution.
Intravenous Catheters
5) Attach a syringe (size appropriate for sample vol-
Peripheral catheters are most commonly used for sample ume required) to the hub of the catheter and apply
collection immediately following catheter placement gentle traction to aspirate blood.
(Figure 53.9), which minimizes the number of needlesticks Note: It is imperative that the catheter be stabi-
for the patient and possibly expedites sample collection lized throughout the collection procedure.
(Protocol 53.6). 6) Following sample collection, carefully disconnect
the syringe and insert a luer-lock T-port or male
adapter plug into the catheter hub.
Sample Collection from Central 7) Inject the blood sample into the appropriate collec-
Intravenous Catheters tion tubes.
8) Secure the catheter and flush with 0.9% sodium
Central venous catheters include peripherally inserted
chloride according to hospital policy.
central catheters and jugular central catheters; these
devices are frequently used to facilitate multiple fluid type
administration and serial blood sampling in hospitalized
patients. The concerns associated with blood sampling Discard Method
through central lines include an increased risk of catheter
complications including infection and occlusion, the pos- The discard method (Protocol 53.7) involves drawing a vol-
sibility of inaccurate results due to sample dilution from ume of blood from the catheter and discarding it to mini-
IV fluids and/or medications, or hemolysis due to improper mize the risk of sample dilution or interfering substances.
collection technique [4]. Both the discard method and the Significant concerns with this method include iatrogenic
push–pull method of sample collection have been shown anemia, as well as an increased risk of catheter-related
to yield accurate results when properly performed. infections due to the handling of the catheter hub or port.
(a) (b)
Figure 53.9 Blood collection from a peripheral catheter. (a) Apply slight digital pressure over the end of the catheter to occlude the
catcher and minimize blood loss following catheter placement. (b) Attachment of a syringe to the catheter hub to collect the blood sample.
Protocol 53.7 Discard Method Protocol 53.8 Push–Pull Method

Procedure Procedure
1) Discontinue administration of all fluids and medi- 1) Discontinue administration of all fluids and medi-
cations prior to sample collection. cations prior to sample collection.
2) Disinfect the catheter port hub according to hospi- 2) Disinfect the catheter port hub according to hospi-
tal protocol. tal protocol.
3) Perform hand hygiene and don exam gloves. 3) Perform hand hygiene and don exam gloves.
4) Flush the catheter with 3–5 ml 0.9% sodium 4) Attach a syringe to the catheter hub and aspirate
chloride. blood (minimum of three times the catheter prim-
5) Attach a syringe to the catheter hub and aspi- ing volume).
rate blood. 5) With the syringe still attached to the hub of the
Minimum of three times: priming volume of the catheter, reinfuse the blood.
catheter for routine assays [4]. 6) Repeat steps 3 and 4 at least three times.
Six to twelve times: priming volume for coagula- 7) Discard the empty mixing syringe and attach a
tion assays [8]. fresh syringe.
6) Remove the discard syringe and attach a fresh 8) Aspirate the required sample volume and inject it
syringe for sample collection; apply gentle traction into the appropriate blood collection tubes.
to aspirate blood. 9) Following sample collection, flush the catheter
7) Depending on the patient’s condition, the discard with 3–5 ml 0.9% sodium chloride or heparinized
sample may be reinfused. Preheparinizing the dis- saline according to hospital policy.
card syringe will minimize clotting if reinfusion is 10) Restart infusion of intravenous fluids and
planned. medications.
8) Following sample collection, flush the catheter
with 3–5 ml 0.9% sodium chloride or heparinized
saline according to hospital policy.
9) Restart infusion of intravenous fluids and
medications.
Push–Pull or Mixing Method

The push–pull or mixing method of sample collection
(Protocol 53.8) involves aspiration and injection of blood
through the catheter hub or port (repeatedly four times),
followed by sample collection into a fresh syringe. The
potential advantages of this method include decreased
risk of iatrogenic anemia with frequent sampling and Figure 53.10 Inline blood sampling system.
decreased risk of catheter-associated infections through
minimizing extraneous handling of the catheter. As in
the discard method, all fluids or medications being the IV line and the catheter. With these devices, “discard”
administered through the catheter are temporarily blood is drawn into the reservoir and then returned to the
stopped, and the catheter hub or port is cleaned with patient without the use of multiple syringes. This is a
antiseptic solution [5]. newer method being made available for our veterinary
patients.
Inline Sampling
Blood Culture Samples
Another method that is very effective for collection of sam-
ples from central catheters is the use of an inline sampling Blood cultures may be helpful to identify causative
system. These systems feature a reservoir, stop cock, and a agents in patients with suspected bacteremia. Samples
sampling port (Figure 53.10). They are connected between collected for blood culture (Protocol 53.9) require strict
Arterial Blood Sample Collection 709
Protocol 53.9 Blood Culture Collection

● It is recommended that a minimum of three samples 5) Insert the needle, bevel (opening) up, through the
be obtained from different vascular sites over a period skin and into the vein (∼20-degree angle); once
of time [9]: blood is noted in hub, decrease the angle of the
⚪ 10–30 minutes for critical or septic patients syringe and advance the needle around 0.5–1.0 cm
⚪ 24 hours for noncritical patients into the lumen of the vessel.
● The general sample volume recommendations are as 6) Apply gentle negative pressure to aspirate blood
follows: into the syringe.
⚪ Cats and small dogs: 1 ml 7) Once the desired sample volume is obtained, release
⚪ Medium dogs: 2–3 ml negative pressure and withdraw the needle from
⚪ Large dogs: 3–5 ml the vein.
● Volume must be sufficient for a 1 : 10 ratio of blood to 8) Apply direct pressure to the venipuncture site for a
broth [9]. minimum of 30 seconds or until there is no evidence
of continued bleeding.
Procedure
excessive.
1) Disinfect the diaphragm of the culture tube/bottle 9) Following sample collection, place a new needle on
with 70% isopropyl alcohol or iodine according to the syringe and inject the blood into the culture
hospital policy and allow to air dry. tube/bottle, dividing the sample between aerobic
Note: Keep the blood culture tubes in an upright and anaerobic media.
position. Note: Avoid injection of air into the culture tube/
2) Clip the area over the venipuncture site and per- bottle.
form an aseptic preparation according to hospi- Note: Invert each bottle two to three times to
tal policy. thoroughly mix the blood and broth.
3) Perform hand hygiene. 10) Maintain samples at room temperature; sensitive
4) Don sterile gloves to collect the blood sample. bacteria may perish under refrigeration.
aseptic technique, and proper sample handling is essen- commercial market (Figure 53.12). These syringes are
tial for successful and accurate culture results available in either vented or unvented styles and typically
(Figure 53.11). In most bacteremic patients, the number range from 1 to 3 ml in volume. The unvented syringe is
of organisms in circulation is very small; the volume of handled like a standard syringe; the needle is inserted into
blood collected needs to be sufficient to account for the the artery with the plunger positioned at the base of the
low concentration of bacteria. The current recommen- barrel and then gently retracted to draw blood into the
dations are that multiple samples be collected from dif- syringe. The vented syringe allows the person performing
ferent vascular sites over a period of several minutes to the venipuncture to position the plunger at the desired
several hours. Venipuncture is the preferred sample col- draw volume in the barrel; once the needle enters the
lection method; indwelling catheters have been shown artery, blood should fill the syringe to the level of the
to have a higher percentage of false-positive results due plunger.
to colonization of the catheter. Commercial ABG syringes are preferred for arterial sam-
pling. Blood gas syringes may be created in the hospital by
drawing 1000 IU/ml heparin into the syringe, allowing it to
Arterial Blood Sample Collection coat the interior of the barrel, and then expressing the hep-
arin from the syringe prior to sampling. Note that samples
Arterial blood samples are useful for assessment of obtained using non-commercial syringes with liquid hepa-
blood gas status, which includes oxygenation, ventila- rin may lead to dilutional error [6]. To minimize hematoma
tion, and acid–base balance. These samples may be col- formation, small-bore needles (25 or 27 gauge) should be
lected by direct arterial puncture or through an arterial used for sample collection.
catheter. It is important to note that arterial puncture is consid-
A number of arterial blood gas (ABG) syringes prefilled ered to be significantly more painful than peripheral veni-
with lyophilized heparin are readily available on the puncture. It is crucial that the patient be properly restrained
(a) (b)
(c) (d)
Figure 53.11 Blood culture collection. (a) Blood sample collection following sterile technique (sterile preparation, sterile gloves).
(b) Replacing the blood draw needle with a sterile needle. (c) Disinfecting of the culture tube diaphragm using a 70% alcohol wipe.
(d) Instilling the blood sample into the blood culture tube.
(a) (b)
Figure 53.12 Arterial sample commercial kit. (a) The outer packaging. (b) Replacing the kit contents – 1-ml syringe with lyophilized
lithium heparin anticoagulant. After arterial blood collection, the needle can be placed directly into the orange needle stopper, or the
needle can be removed, and the black rubber stopper can occlude the syringe.
Arterial Blood Sample Collection 711
for the procedure; the use of a small volume of local or

topical anesthetic at the site is often beneficial.
Direct Arterial Puncture

The dorsal pedal and femoral arteries are most commonly
chosen sites for arterial puncture (Protocol 53.10). On rare
occasions, samples may be collected from the radial artery,
the artery in the pinna of the ear, or from the sublingual (a)
artery in anesthetized or unconscious patients. The dorsal
pedal artery is the preferred sampling site because there
appears to be a lesser incidence of mixed arterial/venous
samples, and it is relatively easy to apply a pressure band-
age following sample collection (Figure 53.13). The draw-
back to the dorsal pedal artery is that it is significantly
smaller than the femoral artery and may be difficult to
access in some patients. The femoral artery is typically easy
to palpate and may be easier to access, but it appears more
(b)
likely to yield mixed samples, and it is difficult to place a
pressure bandage to control bleeding following arterial
puncture. If an arterial puncture is needed and there is
concern for coagulopathy, it is recommended to choose a
site where a pressure wrap can be applied, such as the dor-
sal pedal artery.
Arterial Catheter Sampling

Arterial catheters are placed for the purposes of continu- (c)
ous, direct blood pressure measurements and the repeated
Figure 53.13 Direct arterial puncture technique. (a) Initial puncture
sampling of arterial blood. Sampling from an arterial cath-
into the dorsal pedal artery. (b) The syringe filling with each arterial
eter (Protocol 53.11) minimizes the need to perform arte- pulse to mix with the lyophilized lithium heparin anticoagulant.
rial punctures. (c) The syringe continues to fill with each arterial pulse.
Protocol 53.10 Arterial Puncture Technique

Procedure
Note: Hold the syringe in a “pencil” grip and insert the
1) Restrain the patient in right or left lateral recumbency needle bevel (opening) upward.
with the head and thoracic limbs controlled and the 6) During arterial puncture, blood should pulsate into
pelvic limb extended forward. You may require two the syringe; gentle aspiration of the plunger may be
assistants to provide safe restraint. necessary.
2) Locate the artery by palpating the patient’s arte- 7) Once the sample volume has been allowed to fill
rial pulse. the syringe (minimum of 0.5–1 ml), apply direct
3) Clip the area over the artery and aseptically prepare pressure for a minimum of 20 minutes and monitor
the puncture site according to hospital policy. the site closely to ensure that there is no continued
4) Perform hand hygiene and don exam gloves. bleeding.
5) Palpate and stabilize the artery: 8) Expel all air is from the syringe immediately after
● A single digit may be placed directly over the artery; sample collection and plunge the needle into a rub-
with a heparinized syringe, the needle is advanced ber stopper to occlude exposure of the sample to
into the vessel at a 45-degree angle directly below room air.
the finger Note: It is recommended that samples are analyzed
or immediately, but they may be placed in an ice bath for up
● Place a digit on each side of the artery (∼1 inch to one hour [8].
apart); have the needle between the fingers and
advance into the vessel at a 90-degree angle [10].
Following inversion, it is recommended that serum and

Protocol 53.11 Arterial Catheter Sampling
serum separator tubes sit at room temperature for 30 min-
Procedure utes to facilitate adequate clot formation [7]. Plasma sepa-
1) Perform hand hygiene and disinfect the sampling rator and all other additive tubes may be submitted for
port or catheter hub according to hospital protocol. analysis or centrifuged immediately following inversion.
2) Attach a non-heparinized syringe and aspirate a dis- Serum and gel tubes should be centrifuged within two
card sample: hours of collection.
● Minimum of three times: priming volume of the
Proper centrifugation techniques also play an important
catheter for routine assays [4]. role in sample quality. All personnel using the centrifuge
● Six to twelve times: priming volume for coagula-
should be cognizant of safety and appropriate usage guide-
tion assays [8]. lines. Ideally, centrifuges should not be operated without a
3) Remove the discard syringe and attach a new hep- cover or lid in place. Stoppers should be securely in place
arinized syringe to the catheter; turn the stopcock (if on all samples placed in the centrifuge, and any spills must
present) to a 45-degree angle during syringe change. be cleaned immediately.
Note: Discard samples from an arterial catheter Centrifuges must be properly balanced (Figure 53.14)
should be reinfused into a venous catheter. when in use, both to obtain quality samples and to promote
4) Aspirate the sample, disconnect the syringe from safety of personnel using the instrument. This is achieved
the catheter; immediately expel all air, then occlude by ensuring that tubes are filled with equal volumes of
the syringe tip to prevent exposure of the sample to fluid and placed opposite each other in the centrifuge. If
room air. tubes are filled unequally or an uneven number of tubes
Note: It is recommended that blood gas samples need to be centrifuged, balance tubes may be used by filling
are analyzed immediately, but they may be placed in the same size tubes with an equivalent amount of water.
an ice bath for up to one hour. Atypical noise or vibration are good indicators that the cen-
5) Following sample collection, flush the arterial cath- trifuge is unbalanced and should be immediately turned
eter with 0.9% sodium chloride or heparinized off; once the samples are correctly balanced, the centrifuge
saline according to hospital protocol. may be restarted.
Gel tubes include serum separator and plasma separator
tubes and should be centrifuged at room temperature at
1000–1300 RCF (relative centrifugal force) or
Proper Specimen Handling 2000–2500 RPM (rotations/minute) for 10 minutes in a
swinging-bucket centrifuge or 15 minutes in a fixed-angle
The accuracy of hematology, blood chemistries, and other centrifuge [7]. Sodium citrate tubes should be spun at
laboratory results is directly related to the quality of the 1500 RCF or about 2500–3000 RPM for 15 minutes; all other
sample submitted for analysis. Although the first step in tubes (EDTA, heparin, serum, etc.) should be centrifuged
acquiring a high-quality sample requires using appropriate at 1300 RCF or 2500 RPM for 10 minutes [7]. To ensure
collection techniques as previously noted, the manner in sample quality, it is important to make certain that all simi-
which the sample is handled following collection is equally lar samples are centrifuged for the same length of time; a
important.
Handling of Venous Samples

During or immediately after collection, blood samples should
be injected into the appropriate sample tubes for the tests
required; all tubes must be properly labeled. Each tube needs
to be inverted several times to ensure appropriate mixing of
the sample with the tube’s anticoagulant. Inversion should be
smooth and requires a complete turn of the wrist 180degrees
and back [7]. Tubes should never be shaken or mixed aggres-
sively. The number of inversions is dictated by the tube being
filled: Serum separator, serum, and clot activator tubes require
five inversions; sodium citrate tubes require three to four
inversions, and all other additive tubes (EDTA, heparin,
plasma separator, etc.) require eight to ten inversions [7]. Figure 53.14 Correctly balanced centrifuge.
Toouleesooting atient Touleme eeociated its Blood Sampling 713
packed cell volume obtained from a sample centrifuged for

Protocol 53.12 Hemolysis Troubleshooting Checklist
three minutes may yield significantly different results from
one centrifuged for four minutes. Following centrifuga- Procedure
tion, plasma or serum should be immediately removed 1) Choose an appropriate size needle and syringe or
from the tube and placed in an appropriate sample con- Vacutainer™ needle and tubes; avoid very small
tainer labeled with the patient’s identification information. needles and large syringes.
Most serum and plasma samples, once removed from the 2) Aspirate sample gently; avoid excessive negative
red blood cells, are stable for up to 8 hours at room tempera- pressure or pulsing. Ensure that tourniquet use or
ture or up to 48 hours in the refrigerator; samples needing to vessel occlusion is limited to two minutes or less;
be kept beyond 48 hours should be placed in plastic tubes one minute is preferred.
and frozen. Special handling is required for certain speci- 3) Avoid excessive isopropyl alcohol use; allow alcohol
mens. Adrenocorticotropic hormone, angiotensin-converting to dry prior to venipuncture.
enzyme, ammonia, acetone, lactic acid, pyruvate, and renin 4) Invert the sample tubes following collection; allow
specimens are temperature sensitive and should be placed serum samples to stand in a vertical position for
in an ice bath immediately following collection; these sam- 30 minutes to promote adequate clot formation
ples also require transport in a chilled container. Bilirubin prior to centrifugation.
and erythrocyte protoporphyrin are very light sensitive;
wrapping the tubes in aluminum foil decreases exposure to
light and helps maintain the stability of the sample. It is of blood. Coagulation testing demands a correct blood to
advisable to contact the reference laboratory for detailed anticoagulant ratio because dilute samples will not yield
collection, handling, and submission protocols whenever accurate results.
there is a concern about a specific sample or test.
Platelet Clumping
Troubleshooting Technical Problems Platelet clumping is commonly encountered and may be

due to prolonged collection times, delayed mixing of blood
Associated with Blood Sample
and anticoagulants, or other factors. It is acceptable to use
Collection and Handling blood from a sodium citrate tube for platelet counts when
there is clumping in the EDTA sample; counts performed
Hemolysis
on sodium citrate samples should be multiplied by 1.1 to
Hemolysis can interfere with a number of laboratory test account for the dilutional differences between the tubes.
results. Potassium and lactate dehydrogenase may be
falsely elevated due to release of intracellular material;
Delayed Sample Separation or Analysis
tests requiring analysis by spectrophotometry may be inva-
lid due to interference. Hemolysis may be secondary to dis- Delays in separating or analyzing samples may have a sig-
ease processes such as immune-mediated hemolytic nificant negative effect on the quality of the specimen.
anemia, heavy metal toxicity (zinc), or parasitism (Babesia); Delayed analysis of arterial and venous blood gas samples
improper collection or handling of blood samples is also may result in considerable changes in the partial pressure
commonly implicated in hemolysis (Protocol 53.12). To try of oxygen or carbon dioxide in arterial blood and
to prevent hemolysis, use the largest bore needle possible. pH. Delayed centrifugation of serum and plasma samples
allows prolonged contact with red blood cells and often
results in erroneous sample results, including decreased
Sample Dilution
glucose results and elevations in ammonia.
Blood samples may be inadvertently diluted during collec-
tion, which can result in erroneous results. Sample dilution
is typically attributed to inadequate sample to anticoagulant Troubleshooting Patient Problems
ratio, inadequate discard volume during sample collection Associated with Blood Sampling
from a central line or arterial catheter, and aspiration of tis-
sue fluids during venipuncture (relatively rare). Information obtained from blood tests is often vital to the
A common dilemma that arises in veterinary medicine is diagnostic process, and serial blood tests are frequently
the need to collect sodium citrate samples from very small required to monitor a patient’s condition and the efficacy
patients for coagulation assays. Commercially available of the treatment regimen. In some cases, obtaining blood
sodium citrate collection tubes require either 1.8 or 2.7 ml samples can be problematic for the patient.
Iatrogenic Anemia from Frequent Sampling sampling or with coagulopathies may benefit from a cen-
tral catheter to allow for administration of fluids and medi-
Frequent blood sampling, especially from small or anemic
cations as well as to facilitate serial blood sampling.
patients, can be associated with significant blood loss to a
degree that is detrimental to the patient’s condition. This is
especially concerning in small patients, neonates, geriatric
animals, and patients with anemia. The volume of blood
Summary
that is safe to collect from a patient is no more than
● The venipuncturist needs to be cognizant of safety con-
10–15 ml/kg, with a maximum collection volume of 20 ml/
cerns at all times.
kg. For instance, if a patient weighs 10 kg, the volume of
● The quality of a blood sample and the accuracy of test
blood that is safe to collect is 100–150 ml (maximum
results are significantly affected by collection and han-
200 ml) over a two-week period. When blood sample col-
dling techniques.
lection exceeds 10 ml/kg, the patient’s intravascular vol-
● The venipuncturist should assess each case individually
ume should be replaced with isotonic crystalloids. There
and choose venipuncture sites and techniques best suited
are several strategies to minimize blood loss in these
to that patient.
patients:
● Blood cultures require strict aseptic technique and spe-
1) Use Microtainer™ or other “mini” collection tubes to cialized handling.
minimize sample volume requirements. ● Arterial and venous samples for blood gas analysis
2) Use point-of-care testing equipment that requires mini- require special handling and must not be contaminated
mal sample volumes instead of sending blood to refer- with room air.
ence laboratories that require larger sample volumes. ● Hemolysis is a significant issue that affects sample qual-
3) Use the push–pull or mixing method rather than the ity and can be minimized when proper techniques
discard method when pulling blood samples from an IV are used.
catheter. ● Risks to the patient including catheter-related infections
and iatrogenic anemia can be significantly decreased by
using aseptic techniques and minimizing the volume of
Hematoma Formation
blood drawn or discarded.
Hematomas (bruises) form when blood leaks from a vessel
and pools under the skin. Hematomas may be minimized
by holding direct pressure over a venipuncture site for at Acknowledgment
least 30 seconds and for a minimum of 20 minutes over an
arterial puncture site. Pressure bandages may be placed This chapter was originally authored by Lori Baden Atkins
over sampling sites on the limbs; these bandages need to be for the previous edition, and some material from that chap-
removed and the site should be carefully checked within ter appears in this one. The authors and editors thank Ms.
15–30 minutes of application. Patients requiring frequent Atkins for her contributions.
References
1 Anderson, M.E.C., Montgomery, J., Weese, J.S., and 4 Moureau, N.L. (2004). Drawing blood through a central
Prescott, J.F. (2008). Infection Prevention and Control Best venous catheter. Nursing 34 (2): 28.
Practices for Small Animal Veterinary Clinics. Guelph, 5 Adlard, K. (2008). Examining the push-pull method of
Ontario: Canadian Committee on Antibiotic Resistance. blood sampling from central venous access devices.
2 Boyce, J.M. and Pittet, D. (2002). Healthcare Infection J. Pediatr. Oncol. Nurs. 25 (4): 200–207.
Control Practices Advisory Committee. Guideline for hand 6 Hopper, K., Rezende, M.L., and Haskins, S.C. (2005).
hygiene in health-care settings: recommendations of the Assessment of the effect of dilution of blood samples with
Healthcare Infection Control Practices Advisory sodium heparin on blood gas, electrolyte, and lactate
Committee and the HICPA/SHEA/APIC/IDSA Hand measurements in dogs. Am. J. Vet. Res. 66 (4): 656–660.
Hygiene Task Force. Infect. Control Hosp. Epidemiol. 23 (12 7 Becton, Dickinson and Company. Venous blood collection.
Suppl): S3–S40. BD Vacutainer Blood and Urine Collection—FAQs. http://
3 Kennedy, C., Angermuller, S., King, R. et al. (1996). A www.bd.com/vacutainer/faqs (accessed 10 August 2022).
comparison of hemolysis rates using intravenous catheters 8 Halm, M.A. and Gleaves, M. (2009). Obtaining blood
versus venipuncture tubes for obtaining blood samples. samples from peripheral intravenous catheters: best
J. Emerg. Nurs. 22: 566–569. practice? Am. J. Crit. Care 18 (5): 474–478.
dditional Reading 715
9 Calvert, C.A. and Wall, M. (2006). Cardiovascular Technicians (ed. A.M. Battaglia), 15–18. St. Louis, MO:
infections. In: Infectious Diseases of the Dog and Cat, 3e Saunders.
(ed. C.E. Greene), 847–849. St. Louis, MO: Saunders. 11 Becton, Dickinson and Company. BD Vacutainer® Order
10 Moses, L. and Curran, A. (2007). Basic monitoring of of Draw for Multiple Tube Collections. http://www.
the emergency and critical care patient. In: Small bd.com/vacutainer/pdfs/plus_plastic_tubes_wallchart_
Animal Emergency and Critical Care for Veterinary orderofdraw_VS5729.pdf (accessed 10 August 2022).
Additional Reading
Cornell University College of Veterinary Medicine. Blood Magee, L.S. (2005). Preanalytical Variables in the Chemistry
culture technique. https://www.vet.cornell.edu/animal- Laboratory. In: LabNotes, vol. 15(1). Franklin Lakes, NJ:
health-diagnostic-center/testing/protocols/blood-culture- Becton, Dickinson and Company.
technique (accessed 10 August 2022). Norkus, C.L. (2019). Veterinary Technician’s Manual for Small
Jack, C.M. and Watson, P.M. (2014). Veterinary Technician’s Animal Emergency and Critical Care. Hoboken, NJ: Wiley.
Daily Reference Guide, 3e. Hoboken, NJ: Wiley.
717
54
In-House Hematologic Evaluation

Karl E. Jandrey and Andrew Burton
Introduction Composition of Blood
In-house evaluation of hematologic samples has many Blood comprises cells (including erythrocytes, leukocytes
advantages, and the information obtained may be life sav- and platelets) suspended in a fluid component called
ing for some critically ill patients. The ability to rapidly plasma. Plasma, in turn, consists mostly of water, as well as
identify the presence and cause of anemia (such as review- plasma proteins, inorganic salts, lipids, hormones, carbo-
ing blood smears for infectious disease or spherocytes hydrates, and vitamins. Plasma contains clotting factors
indicative of immune-mediated hemolytic anemia, IMHA), and is obtained when blood is collected in tubes with anti-
evaluate platelet adequacy, or perform blood typing for coagulant (e.g. EDTA or lavender-top tubes) is centrifuged.
blood transfusions can facilitate immediate treatment of Fluid obtained from centrifugation of whole blood is called
emergency and critically ill patients which may improve serum, and is devoid of clotting factors and fibrinogen. The
outcomes. Some measurements may also be more accurate total protein of serum is typically 0.2–0.5 g/dl lower than
if performed in-house, owing to the stability of the sample that of plasma.
or reduction in processing, which may induce errors.
Completion of these tests requires not only the correct
instruments and supplies, but also personnel who are
trained and knowledgeable in the use of equipment and
Sample Collection and Handling
interpretation of results. This was highlighted in one study
Safety
which showed that in-house interpretation of canine and
feline blood smears by emergency room personnel at a ter- The safety of clinic personnel and patients is of utmost
tiary referral hospital frequently showed poor agreement importance. Biologic samples should be treated with cau-
with review by a clinical pathologist. Many important tion, as the potential for zoonotic infection may exist, and
abnormalities such as spherocytes, toxic changes in neutro- some diseases may be transmissible to other patients.
phils, nucleated red blood cells, infectious agents, and Materials for collection and processing of blood, such as
neoplastic cells frequently were not accurately identi- needles and glass slides, may also cause harm to personnel
fied [1]. Additionally, accuracy of in-house testing requires or patients if not handled correctly.
knowledge of quality control and diligent maintenance of Clinic personnel handling blood should wear appropri-
supplies and tests. In-house hematologic evaluation is thus ate personal protective equipment (PPE), including latex,
not a replacement for send-out laboratory analysis but a rubber, or nitrile gloves, as well as protective clothing such
complementary tool that is incredibly useful in the care of as a lab coat or scrubs. Protective eyewear such as safety
emergency and critically ill patients. glasses should also be worn. Sharp implements such as
This chapter reviews the components of blood that are needles and glass slides should be disposed appropriately
routinely assessed in-house, as well as the supplies and in biohazard containers. Such supplies should never be
steps to evaluate these parameters with accuracy, precision reused, and needles should never be recapped. In the event
and highest quality. of broken glass or other sharp objects that may puncture
718 In-House Hematologic Evaluation
the skin, use only mechanical means such as forceps or a Microhematocrit Tube Evaluation
brush and pan to remove hazardous material.
If blood or other biologic waste is spilled, ensure that Evaluation of a microhematocrit tube is a common starting
appropriate PPE is worn. Cover the spill area with paper point for hematologic evaluation of the patient and offers a
towel, and then pour a freshly mixed (no more than plethora of information quickly with minimal supplies.
24 hours old) 10% bleach and water solution over the area, The packed cell volume (PCV) can be measured to help
starting from the outside edges of the spill inward. Allow assess erythrocyte mass. The plasma or serum can be eval-
the mixture to sit for up to 20 minutes (especially if there uated visually, and the total protein can also be measured.
is concern for infectious disease), prior to cleaning the Protocol 54.1 provides more details about preparing the
surface with more paper towel and bleach solution as microhematocrit tube. Briefly, the tube is filled to around
required. Waste from the clean-up procedure (including 75% capacity, and one end is plugged with clay. The tube is
gloves worn) must be disposed of with other biohazard- centrifuged at 10 000 rpm for five minutes, which deline-
ous waste. Wash hands thoroughly after clean-up is ates the blood sample into three distinct layers within the
complete. tube: a layer of red blood cells adjacent to the end of the
tube sealed with clay, a layer of white blood cells and plate-
Blood Collection and Handling for lets (also known as the “buffy coat” above the red blood cell
Hematologic Evaluation layer), and the acellular plasma layer above the buffy coat
(Figure 54.1). From this tube, parameters including the
For details on blood sampling from patients, refer to PCV, buffy coat, plasma appearance, and total protein can
Chapter 53. EDTA is the preferred anticoagulant for com- be evaluated.
plete blood counts in cats and dogs, and is present in pur-
ple- or lavender-top tubes. Other anticoagulants are
Packed Cell Volume
available, and citrate (pale blue-top tube), for example, is
the preferred anticoagulant for assessment of coagulation. There are many methods available to assess erythrocyte
Collection of blood directly into a vacuum tube is pre- mass, including hematocrit, PCV, hemoglobin concentra-
ferred, as this can reduce clot formation and activation/ tion and red blood cell concentration. PCV is the term
clumping of platelets. This method may also reduce iatro- used when the hematocrit is determined via centrifuga-
genic hemolysis, which can affect erythrocytes (including tion, evaluating the red blood cells as a percentage of
hematocrit and erythrocyte indices), as well as plasma pro- blood volume. Results of PCV can be available quickly,
tein and fibrinogen measurements. Ensure that the tubes and when performed appropriately are accurate and repro-
are filled completely to the recommended levels. ducible, making PCV determination ideal for serial moni-
Underfilling of tubes may reduce hematocrit due to dilu- toring of erythrocyte mass within patients. PCV will
tion from anticoagulants. Excessive EDTA may also cause overestimate the hematocrit slightly, due to the trapping
osmotic shifts of fluid from erythrocytes and affect mor- of plasma between red blood cells. Values for PCV typi-
phology and erythrocyte indices. Once filled, the tubes cally are 2–3% higher than calculated hematocrit [2]. Refer
should be gently inverted multiple times to thoroughly mix to Protocol 54.1 for further details about performing a PCV
the blood and anticoagulant. measurement.
Blood should be visually inspected within the tube. PCV values can be determined from a microhematocrit
Samples should be checked for any gross clots, which may tube using of a variety of methods, including scales on the
affect platelet concentrations or estimates, as well as centrifuge, handheld cards, or specialized microhematocrit
hematocrit and leukocyte concentrations/differentials. readers. One popular tube reader is a plastic sheet called a
The color of the blood should also be evaluated and Critocaps™ chart (Critocap, Oxford Labware/Sherwood
logged. A pink discoloration may be seen with lipemia, Medical, St. Louis, MO). With this reader, the centrifuged
and brown discoloration can be present in cases of methe- microhematocrit tube is placed perpendicular to the chart
moglobinemia. Additionally, red granules present within lines with the clay–erythrocyte interface on the zero line.
well-mixed blood may indicate agglutination of red The tube is moved along the chart until the 100% line inter-
blood cells. sects the plasma–air interface in the center of the meniscus
Aggregation of platelets and leukocytes tends to increase in the microhematocrit tube. The PCV is read as a percent-
with both storage and cooling of blood, and it is recom- age directly from the chart at the erythrocyte–buffy coat
mended that samples are processed and evaluated as interface (Figure 54.2).
quickly as possible. Blood smears should be made immedi- PCV can also be obtained by dividing the length of red
ately, and it may be beneficial to make smears from fresh blood cell layer by that of all three layers of the microhema-
whole blood that has not been anticoagulated. tocrit tube (red blood cells, buffy coat, and plasma) and
Microhematocrit Tube Evaluation 719
Protocol 54.1 Packed Cell Volume Determination
Principle 8) Centrifuge samples at 10 000 RPM for 5 minutes.

9) Once the centrifuge has stopped completely, remove
Packed cell volume is the ratio of erythrocyte relative to
the microhematocrit tube and read the packed cell
whole blood, expressed as a percentage. This value can be
volume on a capillary reader or card reader per the
used as a measure of erythrocyte mass in a patient to deter-
instructions below.
mine if they have normal erythrocyte mass, low erythrocyte
mass (anemia) or elevated erythrocyte mass (erythrocytosis).
Operation
Specimen Reading the Packed Cell Volume Using
Anticoagulated blood (e.g. EDTA) a Hematocrit Card
1) Place the reading card on a flat surface.
Materials and Equipment
2) Place the microhematocrit tube on the left side of the
● Plain microhematocrit tubes (blue ring) card, aligning the clay sealant/red blood cell interface
● Microhematocrit centrifuge with the line at the bottom of the card.
● Clay or tube sealing compound 3) Slide the tube along the card, keeping the clay/red
● Microcapillary reader or hematocrit card blood cell interface aligned with the bottom line,
● Kimwipes® or gauze until the top of the plasma–air interface is aligned
with the line at the top of the card.
Notes 4) Check to ensure both portions of the tube align with
The end of the microhematocrit tubes with the blue ring their respective lines.
is fire-sealed by the manufacturer to prevent breakage 5) Find the line that intersects the tube at the red cell/
during centrifugation. Always place the clay/sealant into buffy coat interface. Do not include the buffy coat as
the end with the blue ring. part of the erythrocyte volume.
6) Read and record the value to the nearest whole num-
Procedure ber. Read the value from directly overhead to avoid
1) Correct mixing of blood is imperative. Samples should parallax error.
be thoroughly mixed, ideally for 5minutes on a rocker, or
by inverting the samples gently a minimum of 25 times. Reading the Packed Cell Volume Using a Capillary Tube
2) Remove the rubber stopper of the EDTA tube, pointing Reader (Rectangular Type)
the tube away from the face. 1) Place the microhematocrit tube into the groove of the
3) Insert the end of the microhematocrit tube without hematocrit reader.
the blue ring, and fill the tube to 75% capacity. Do not 2) Align the clay sealant/red blood cell interface with
fill the tube to capacity. the line at the bottom of the reader.
4) Gently wipe the outside of the tube to clean off any blood. 3) Slide the microhematocrit tube until the plasma–air
5) Seal the end of the microhematocrit tube with the interface is aligned with the top line of the reader
blue ring with clay or sealing compound until the (corresponding to 100 on the scale).
entire space under the blue ring is sealed. 4) Slide the horizontal bar up/down so that the line
6) Place the microhematocrit tube into the centrifuge intersects at the red cell/buffy coat interface. Do not
with the sealed end toward the rubber gasket and include the buffy coat as part of the erythrocyte volume.
balance the centrifuge with another sample or empty 5) Read and record the value from the scale to the near-
tube in the opposite position of the centrifuge. est whole number. Read the value from directly
7) Secure both lids of the centrifuge (inner screw lid and overhead to avoid parallax error.
outer latch).
multiplying by 100 to obtain the percentage of blood Buffy Coat

volume of erythrocytes:
The buffy coat refers to the layer between the red blood
Length of erythrocyte layer in microhematocrit tube cells and the acellular plasma. The buffy coat is typically a
100
Length of all 3 layers of microhematocrit tube very narrow layer, but may be enlarged in patients with
PCV % elevated white blood cell concentrations or platelet
Total Protein
Air at top of tube
After PCV has been measured and the buffy coat and
plasma have been visually inspected and reported, the
microhematocrit tube is broken just above the buffy coat. A
Plasma layer small amount of plasma is then placed on a refractometer
to determine total protein. See Protocol 54.2 for details of
total protein determination. Note that hemolysis or lipemia
Buffy coat layer
may falsely elevate total protein measurements.
Erythocyte layer Total Protein and Total Solids

The angle of refraction produced by a serum or plasma
sample is due to the combined concentration of all its sol-
Clay plug utes, also called “total solids.” Protein is the predominant
Figure 54.1 Diagram depicting the layers of the solute; however, nonprotein substances such as urea, glu-
microhematocrit tube. Erythrocytes are spun to the bottom of cose, electrolytes and lipids contribute to the angle of
the tube above the clay plug. A small clear layer sits above the refraction. Total protein and total solids are not inter-
erythrocytes known as the ‘buffy coat’ which contains leukocytes changeable terms. In health, serum/plasma concentration
and platelets. Acellular plasma then sits atop the buffy coat.
of total solids is approximately 1.5–2 g/dl higher than the
concentration of total protein. Almost every refractometer
uses a conversion factor, such that they are measuring total
protein and not total solids [3].
Maintenance of Refractometers
The zero scale can be tested using distilled water. This
should be checked daily for non-temperature corrected
models, and adjusted as needed. Temperature affects refrac-
tometer results, and the instruments should be kept at room
temperature. The glass platform in the refractometer should
be cleaned with distilled water between each measurement.
Fibrinogen
Fibrinogen can be measured in microhematocrit tubes, due to
Figure 54.2 A common microhematocrit card reader. precipitation of fibrinogen exclusively when tubes are heated
to 56°C (± 1°C) for three minutes [4]. The difference between
the total protein of plasma from a normally processed micro-
concentrations. The buffy coat may also be difficult to see
hematocrit tube, and that of one incubated under the above
in patients with low white blood concentrations.
conditions gives an estimate of fibrinogen concentration.
Protocol 54.3 gives details of the fibrinogen heat precipitation
Plasma Appearance method. It is important to note that this technique is useful to
determine elevations in fibrinogen but is not accurate in iden-
The microhematocrit tube allows visualization of plasma,
tifying low fibrinogen concentrations [5].
which may offer important clinical information. Plasma in
dogs and cats is normally clear, and any discoloration of
the plasma should be noted. Yellow discoloration may sug-
gest hyperbilirubinemia, which can be seen secondary to
Blood Smear Preparation
liver disease or hemolysis. Red discoloration may also indi-
For detailed instructions on blood smear preparation,
cate intravascular hemolysis; however, this will not differ-
please refer to Protocol 54.4. Some important points to
entiate between pathologic intravascular hemolysis in the
keep in mind when preparing blood smears:
patient (e.g. secondary to IMHA or Heinz body anemia)
and hemolysis that occurred due to traumatic venipunc- ● Blood smears should be prepared soon after collection –
ture or prolonged storage of samples. White or opaque ideally within one to two hours to prevent storage
plasma is indicative of lipemia. artifact.
Blood Smear Preparation 721
Protocol 54.2 Plasma Protein Assessment with Refractometer
Principle 3) Seal the end of the tube with clay or tube sealing
compound.
Proteins in solution alter the refractive index propor-
4) Place the microhematocrit tube in the centrifuge
tional to their concentration, allowing an estimation of
with the clay end toward the rubber gasket.
plasma protein.
Balance the centrifuge with another microhemato-
Specimen crit tube (empty or another sample). Secure both
lids of the centrifuge (inner screw lid and
Anticoagulated blood (e.g. EDTA) outer latch).
5) Centrifuge samples at 10 000 RPM for 5 minutes.
6) Remove microhematocrit tube from the centrifuge
● Microhematocrit tube and score the tube with a glass slide or etcher just
● Microhematocrit centrifuge above the buffy coat.
● Clay or tube sealing compound 7) Using both thumbs and forefingers, place gentle,
● Glass slide or etcher (for scoring) even pressure either side of the scored region away
● Refractometer calibrated for plasma protein reading from the face to break the microhematocrit tube.
● Deionized water 8) Using the end that was not scored (to avoid placing
glass fragments on the refractometer), place
Notes
1–2 drops of plasma onto the glass measuring
Check refractometer daily with deionized water to verify prism of the refractometer and close the cover plate
reading of 1.000. immediately.
9) Press the cover plate gently with fingers to spread
Procedure plasma evenly over the reading prism.
1) Mix blood in EDTA tube thoroughly (gently invert at 10) Point the instrument toward a bright light source.
least 25 times). 11) Take the reading at the interface where the light and
2) Remove the rubber stopper of the EDTA tube, point- dark fields cross the scale.
ing the tube away from the face, and fill the 12) Clean the prism surface with deionized water and
microhematocrit tube to 75% capacity. dry with a soft cloth immediately after reading.
● Blood in EDTA tubes should be at room temperature be affected in thin smears. Platelet estimates also criti-
prior to slide preparation and should be thoroughly cally require a monolayer to be present.
mixed prior to removing blood by gently inverting the 3) The body makes up the majority of the smear and
tubes at least 20 times. should blend smoothly into the monolayer region.
● Blood smears should be dried immediately after being
Blood smears may lack the above components or suffer
made to prevent contraction of red blood cells, which
from other artifacts of preparation. These errors, as well as
can impede evaluation of morphology (including echi-
possible causes and solutions for these artifacts are sum-
nocyte formation, or refractile inclusions).
marized in Table 54.1.
A good quality blood smear will have three major
components: a feathered edge, a monolayer, and a body. Staining Samples
1) The feathered edge should give the smear a bullet Romanowsky-type (Wright or Wright–Giemsa) are the
or thumbprint shape and have a fine, feathery most common stains used for blood films in veterinary
appearance. medicine. These stains contain a mixture of eosin (staining
2) The monolayer is the area just behind the feathered red/pink) and oxidized methylene blue dyes (staining
edge, where 50% of red blood cells are touching their blue). Many rapid stains for in-house use also are available,
edges, while 50% of red blood cells are not touching including Diff- Quik® (Dade Behring Inc., Newark, DE) and
other cells. It is imperative for a monolayer to be present Hema 3™ (Fisher Scientific, Pittsburgh, PA). Although
for accurate cellular assessment, and it is in this area methanol is used as the fixative, these are aqueous stains.
where cellular morphology and platelet estimates will Blood films should be fixed in methanol within one to four
be performed. If slides are too thick, red blood cell mor- hours (preferably within one hour) of preparation, and only
phology is distorted, while leukocyte morphology will when the slide is completely dry. Quality of rapid stains may
Protocol 54.3 Fibrinogen Heat Precipitation Method
Principle 2) Remove the rubber stopper of the EDTA tube, point-

ing the tube away from the face, and fill
Heating plasma to 56 ± 1°C will precipitate fibrinogen,
2 microhematocrit tubes to 75% capacity.
but not albumin and other noninflammatory globulins.
3) Seal the end of the tube with clay or tube sealing
compound.
Specimen
4) Place the microhematocrit tubes in the centrifuge
EDTA or citrate anticoagulated blood with no clots. with the clay end toward the rubber gasket in
opposite positions to balance the centrifuge. Secure
Materials and Equipment both lids of the centrifuge (inner screw lid and
outer latch).
● Plain microhematocrit tubes
● Clay or tube sealing compound
6) Remove microhematocrit tubes from the centrifuge.
● Microhematocrit centrifuge
7) Place one of the tubes into the heat bath and start
● Heat bath
timer for 5 minutes.
● Thermometer
8) Immediately score the other microhematocrit tube
● Timer
with a glass slide or etcher just above the buffy coat
● Glass slide or etcher
and read the plasma protein using a refractometer
● Refractometer
(refer to Protocol 54.2). Record this value.
9) Repeat step 8 for the heated sample after the
Notes
5-minute incubation period.
● Heparinized samples cannot be used. 10) Using the plasma protein readings from the unheated
● Clotted samples cannot be used. and heated samples, calculate the fibrinogen esti-
● Hemolysis or lipemia may give erroneous results. mate per the calculation in the next section.
Procedure Calculation
1) Mix blood in EDTA tube thoroughly (gently invert at Fibrinogen (mg/dl) = (unheated plasma protein [g/dl] –
least 25 times). heated plasma protein [g/dl]) × 1000
be increased by allowing the blood film to remain in the fixa- commercially available but can also be produced by dis-
tive for one to two minutes. Slides cannot be overfixed; how- solving 0.5 g of new methylene blue (NMB) and 1.6 g of
ever, underfixation of slides may lead to cellular lysis or poor potassium oxalate in 100 ml of distilled water [8]. To pre-
staining quality. See Protocol 54.5 for more details on using pare a slide with reticulocyte stains, equal volumes of blood
Romanowsky-type stains. It is important to note that aqueous and stain (following filtration to avoid stain precipitation
stains may not stain mast cell and basophil granules well [6]. artifact) are mixed together in a test tube and incubated at
Stain abnormalities may include excessive pink or blue room temperature for 10–20 minutes. Short incubation
coloration of the cells, or excessive stain precipitation: times may result in poor staining and underestimation of
reticulocyte counts and Heinz bodies. After incubation,
● Excessively pink: Low stain pH, inadequate staining
blood slides are made and examined See Protocol 54.6 for
time, degraded stains or excessive washing.
more details on reticulocyte evaluation.
● Excessively blue: High stain pH, prolonged staining,
insufficient washing [7].
● Stain precipitation: may be present if the slide was Blood Smear Evaluation
stained too long, if the slide was not washed sufficiently,
or if the stains need to be filtered or replaced. Blood smears should be evaluated in a routine fashion to
ensure that all components are assessed. A good approach
Reticulocyte stains are used to quantitate reticulocytes in
is to divide the blood smear into four components:
circulation (i.e. they help to determine the regenerative
response by the bone marrow in cases of anemia) and to 1) Background, quality and feathered edge
highlight Heinz bodies in erythrocytes. These stains cause 2) Erythrocytes
precipitation of ribosomal ribonucleic acid in immature 3) Leukocytes
red blood cells, which stains deep blue. These stains are 4) Platelets.
Blood Smear Evaluation 723
Protocol 54.4 Blood Smear Preparation
Principle ○ Gently invert the tube around 20 times to thor-

oughly mix the blood immediately prior to slide
Examination of a blood smear is an integral part of a
preparation.
complete blood count. Many important findings that can
be seen on blood smear evaluation cannot be accurately
Procedure
identified by automated machines, including neoplastic
cells, toxic changes within neutrophils, immature granu- 1) Use a pencil to write the patient details on the frosted
locyte precursors and infectious agents. edge of the slide.
2) If not using premium, precleaned slides, brush the slide
Specimen with a camelhair brush to remove any glass grit or debris.
3) Place the glass slide on a flat surface.
Anticoagulated whole blood (EDTA preferred)
4) Fill a plain hematocrit tube with blood from the EDTA
tube and place a finger over the end of the tube to
prevent blood from dripping.
● Latex or nitrile gloves 5) Place an approximately 3–5 mm diameter drop of
● Pencil blood at one end of the slide. Do not tap the hemato-
● Premium, precleaned glass microscope slides with a crit tube against the glass slide.
frosted edge (at least 3) 6) Use a finger on one hand to hold the slide in place.
● ± Camelhair brush Hold a second spreader slide between the thumb and
● Anticoagulated blood in EDTA tube that is at room index finger of the dominant hand at a 30–45° angle,a
temperature and thoroughly mixed in front of the drop of blood.
● Plain hematocrit tube 7) Back the spreader slide into the drop of blood, and
as soon as the blood starts to spread along the edge
Notes of the spreader slide, push the spreader slide for-
ward in a smooth, moderately fast motion. Use only
● Latex or nitrile gloves should be worn when handling
enough pressure to keep the spreader slide on the
blood and making blood smears.
glass slide.
● Blood smears should be prepared soon after collec-
8) Dry the slide quickly by waving it or blowing gently
tion; ideally within 1–2 hours.
on the slide.
● If using blood from an EDTA tube:
○ Blood must be at room temperature. If the EDTA tube a
This angle may be increased if blood is thin (e.g. in cases of severe
has been stored in the refrigerator, bring to room anemia), or decreased if blood is thick (e.g. in cases of erythrocytosis)
temperature prior to slide preparation. to create a better monolayer.
Background, Quality and Feathered Edge pushed to the feathered edge (Figure 54.4). Platelet clumps
as well as leukocyte clumps also are often seen at the feath-
It is important to assess the quality of the slide prior to
ered edge, and should be noted, as these may affect both
evaluation of the various components. The slide should
automated results and estimates made on blood smears.
have the three major components (feathered edge, mon-
Finally, large, atypical cells such as mast cells or neoplastic
olayer and body) and should be well stained. The back-
cells may also be seen more frequently at the feathered
ground may offer important information about the patient.
edge of the slide.
The background may have a deep blue or scalloped appear-
ance in patients with high total protein concentrations, and
Erythrocytes
pools of smooth blue material may be seen in patients with
cryoglobulinemia, which can be seen secondary to some Erythrocyte Distribution
neoplasms such as multiple myeloma (Figure 54.3). Evaluation of erythrocytes starts at lower magnification
It is also important to evaluate the feathered edge of the (e.g. 100 × or 200 × magnification) looking at distribution of
slide, as many components (particularly large elements) of the red blood cells. Patients with anemia (decreased red
blood may be pushed to the edge of the smear. Infectious blood cell mass) frequently will have a long monolayer, and
agents such as microfilaria from heartworm disease the body of the smear will be short. Patients with erythrocy-
(Dirofilaria immitis) or Hepatozoon spp. frequently are tosis (increased red blood cell mass) may have a very short,
Table 54.1 Artifacts of Blood Smear Preparation.
Problem Potential cause Potential fix
Too thin Drop of blood too small Increase size of blood drop
Wrong spreader slide angle Increase angle of spreader slide
Too thick Drop of blood too big Decrease size of blood drop
Wrong spreader slide angle Decrease angle of spreader slide
Blood pushed off edge Drop of blood too big Decrease size of blood drop
of slide
Streaking (linear) Slow spreading Spread blood in smooth constant motion.
Dried blood on spreader slide Clear end of spreader slide if reusing for multiple smears
Particulate matter on slide Clean surface of slides used for blood smears
Streaking (horizontal) Hesitation or irregular pressure Push spreader slide in smooth, single motion
when spreading
Uneven distribution of Excessive downward pressure Apply only enough pressure to keep spreader slide on
red blood cells blood smear slide
Flat end of smear (no Slow spreading Spread blood in smooth, constant motion
feathered edge) Abrupt end to motion of Push spreader slide to end of smear; do not stop abruptly
spreading during spreading
Lifting spreader slide at end of Do not lift up with spreader slide at the end of the
motion smearing process
Narrow smear Smear made before blood spread Allow blood to spread along full edge of spreader smear
across spreader slide
Wobbling of spreader slide Hold spreader slide stable with even pressure
Protocol 54.5 Romanowsky-Type Rapid Staining of Blood Smears
Principle ● The number of dips and time spent in the eosin and
methylene blue stains can be tailored to the needs of
Romanowsky-type rapid stains can be used to highlight
the sample and observer to increase or decrease stain
cytoplasmic and nuclear features of cells on peripheral
intensity.
blood smears.
● Ensure clean stain solution is used to prevent stain
precipitation or contamination artifact.
Specimen
Completely dry blood smear prepared on a glass slide. Procedure
1) Hold the slide with forceps and dip it into the fixative
Materials and Equipment: solution multiple times to completely cover the slide.
2) Leave the slide in the fixative solution and set timer
● Clean benchtop with absorbent pads
for 1–2 minutes.
● Timer
3) After the timer alarms, use forceps to remove the slide
● Alcohol fixative solution
from the fixative and allow excess fixative to drain by
● Romanowsky rapid stains (eosin and methylene blue)
holding the slide onto an absorbent pad.
● Forceps
4) Use forceps to dip the slide into solution 1 until the
● Distilled water
stain completely covers the slide. Dip the slide a fur-
● Lint-free wipes (e.g. Kimwipe®) or gauze
ther 4–6 times for approximately 1 second per dip.
5) Allow excess stain to drain from the slide by using
Notes
forceps to hold the slide onto an absorbent pad.
● Ensure that the blood smear is completely dry prior to 6) Repeat steps 4 and 5 for solution 2.
staining. 7) Rinse the slide thoroughly using distilled water.
● Slides cannot be overfixed, but they can be underfixed. 8) Stand the slide vertically to dry with the feathered edge
Leave slides in the fixative solution for 1–2 minutes to facing upward. The backside of the slide may be wiped
improve staining quality. with a Kimwipe or gauze to speed the drying process.
Protocol 54.6 New Methylene Blue Staining for Reticulocytes and Heinz Bodies
Principle ● Immature erythrocytes will contain RNA that will

appear as fine dots (punctate reticulocytes) or larger
Methylene blue reagent in supravital stains precipitates
strings of granules (aggregate reticulocytes).
aggregates of RNA. These aggregates are visible under the
● Count both punctate AND aggregate reticulocytes in
microscope as dark blue granules within immature red blood
dogs. Count only aggregate reticulocytes in cats.
cells (RBC), and are classified as reticulocytes. Increased
numbers of such cells in circulation indicates release of Procedure
immature red blood cells by the bone marrow, and typically a
regenerative response by the bone marrow. Such stains also 1) Scan the dried, stained smear on low power
stain aggregates of oxidized hemoglobin (Heinz bodies). (20 × objective) to find a monolayer of erythrocytes.
2) Using the 100 × oil objective, count the number of
Specimen reticulocytes seen per 250 erythrocytes counted. Use
one manual hand counter to tally the total number or
Anticoagulated sample (EDTA preferred).
red blood cells counted, and another to tally the num-
Reagents ber of reticulocytes counted. Record this number.
3) Move to a different monolayer area of the slide and
● Commercially prepared reticulocyte stain (NMB). Reagent repeat this count.
contains 1.6% (w/v) reagent grade potassium oxalate mono- 4) Repeat steps 2 and 3 until a total of 1000 cells has
hydrate, 0.5% (w/v) NMB in distilled, reagent grade water. been counted.
● Mix reagent well prior to use. Filtering the reagent is 5) Calculate the percentage of reticulocytes using the
preferable – use Whatman #4, 11-inch paper. following formula:
● Periodic filtering may be required if increased precipi-
# reticulocytes
tation is seen in stored solution. %reticulocytes 100
1000
Notes or use the following condensed formula:
● Optimal results obtained on fresh samples (refriger- %reticulocytes # reticulocytes / 1000 RBC 0. 1
ated < 48 hours old).
● Gently mix NMB stain prior to use. 6) The absolute reticulocyte concentration is much more
meaningful than percentage, and can be calculated as
Materials and Equipment follows:
absolute reticulocyte concentration
● Microscope slides
● Disposable pipettes RBC count 106/ l %reticulocytes
● Glass or plastic test tubes
● Timer Counting Heinz Bodies
● Microscope with 100 × oil objective
1) Scan the dried smear on low power (20 × objective) to
● Immersion oil
find a monolayer of erythrocytes.
● Manual hand counters (× 2)
2) Using the 100 × oil objective, count the number of
Procedure Heinz bodies seen per 100 erythrocytes. Use one
manual hand counter to tally the number of red blood
1) Place 1 drop of reticulocyte stain into a test tube. cells counted, and another to tally the number of
2) Add 1 drop of well-mixed patient blood to the test Heinz bodies seen.
tube containing reticulocyte stain and mix thoroughly. 3) Move to a different monolayer area of the slide and
3) Set the timer for 10minutes and allow the mixture to sit. repeat the count.
4) After 10minutes, mix the contents of the test tube again. 4) Repeat steps 2 and 3 until a total of 400 cells has
5) Use a clean pipette and place 1 small drop of well- been counted.
mixed sample onto a glass slide and prepare a blood 5) Calculate the percentage of Heinz bodies:
smear per Protocol 54.4.
# Heinz bodies
6) Allow slide to dry completely. %Heinz bodies 100
400
Counting Reticulocytes or use the following condensed formula:
● Mature erythrocytes have a homogeneous blue/green Heinz bodies Heinz bodies / 400RBC 0.25
appearance.
Figure 54.3 Large pools of pale blue cryoglobulin can be seen Figure 54.5 Agglutination in a dog with immune-mediated
interspersed between erythrocytes and leukocytes. Cat blood, hemolytic anemia. Note the clumping of red blood cells, giving
200 × magnification, Wright-Giemsa. them the appearance of bunches of grapes. Dog blood,
1000 × magnification, Wright-Giemsa.
Figure 54.4 Dirofilaria immitis microfilaria. Dog blood

500 × magnification, Wright-Giemsa. Figure 54.6 Rouleaux formation. Note the distribution of red
blood cells in long chains, giving them the appearance of stacks
of coins. The total protein in this patient was 10 g/dl. Dog blood,
or non-existent monolayer. This may be helpful as a qualita- 500 × magnification, Wright-Giemsa.
tive assessment of erythrocyte mass if PCV is not available.
Also important is to evaluate for any agglutination or rou-
leaux formation. Agglutination is characterized by dense agglutination test may be performed (see Protocol 54.7 for
aggregation of red blood cells often with the appearance of details of this procedure). A rapid way to differentiate rou-
“bunches of grapes” (Figure 54.5). Agglutination indicates leaux from agglutination is to mix five drops of 0.9% NaCl
the presence of surface-bound immunoglobulins to eryth- with a drop of anticoagulated blood on a glass slide, with a
rocytes, usually immunoglobulin (Ig)M type due to the coverslip placed on top. This slide is then examined as a
greater number of binding sites, and distance between these wet mount under the microscope. Dilution with saline will
binding sites (vs. other immunoglobulins such as IgG) [9]. disperse red blood cells individually if rouleaux is present,
Rouleaux on the other hand is characterized by linear but agglutination will persist.
arrangements of red blood cells, like linear stacks of coins
(Figure 54.6). Mild rouleaux can be normal in cats. Erythrocyte Morphology
Prominent rouleaux in cats, and any rouleaux in dogs, is It is essential to evaluate erythrocyte morphology within
most commonly associated with hyperglobulinemia. the monolayer of the slide, where half the erythrocytes are
The distinction between agglutination and rouleaux is touching each other and half are not touching other red
not always easy by visual inspection, and a saline blood cells. The morphology of erythrocytes can reveal a
Protocol 54.7 Saline Agglutination Test
Principle ● If agglutination is confirmed, it may be appropriate to

heat the EDTA sample to 37°C for 15 minutes prior to
Agglutination refers to clumping of red blood cells.
running (or rerunning) through automated machines.
Autoagglutination is caused by surface-bound immunoglob-
ulins. Rouleaux formation refers to stacking of red blood
Procedure
cells (RBC), which is commonly due to increased concentra-
tions of fibrinogen or globulins. Cats may have increased 1) Label the test tube and glass slide with patient
rouleaux formation normally. Agglutination and rouleaux information.
formation can be difficult to differentiate on blood smears. 2) Use a pipette to place 1 drop of well-mixed antico-
Agglutination may cause erroneous automated erythrogram agulated blood into the test tube.
results including decreased RBC and increased MCV. 3) Use a new pipette to place 4 drops of saline into the
test tube.
Specimen 4) Gently mix the blood and saline mixture.
5) Place 1 drop of the 1 : 5 dilution onto the glass slide,
Anticoagulated whole blood (EDTA preferred).
and cover with a coverslip.
6) Examine the slides using the 10 × and 40 × objectives
Reagent
on the microscope.
Phosphate buffered normal saline.
Interpretation
● If red blood cells disperse and are no longer clumped,
● Glass slides and coverslips rouleaux is present and the saline agglutination test is
● Disposable pipettes said to be negative.
● Microscope ● If red blood cell clumping persists, or if red blood cells
● Glass or plastic test tubes separation is unclear, a 1 : 10 dilution may be per-
formed. This may be required in patients with marked
Notes hyperglobulinemia.
● If red blood cell clumping does not disperse after a 1:10
● It may be useful to create a coverslip slide with 1 drop of
dilution, the sample is positive for autoagglutination.
undiluted blood to compare with the results of the dilution.
wide range of pathology within the critically ill patient. erythrocytes (e.g. hemolysis) or hemorrhage. The
Some of the most important morphologic changes are dis- presence of polychromasia on a blood smear is more
cussed below. accurate at predicting a bone marrow regenerative
response than red blood cell indices from automated
● Normal morphology:
machines such as mean corpuscular volume or mean
Erythrocytes in both dogs and cats are anucleate, bicon-
corpuscular hemoglobin concentration [10]. It takes
cave cells that appear round. In dogs, normal erythro-
approximately three to five days for a regenerative
cytes have central pallor, which should take up about one
response by the bone marrow, so the absence of poly-
third of the cell. Normal erythrocytes of cats lack any
chromatophils does not preclude an emerging
central pallor. Canine red blood cells are approximately
regenerative response.
6–8 μm in diameter; feline red blood cells are smaller but
have more size variation normally.
● Polychromasia: Reticulocyte Evaluation
Polychromatophils appear as blue-tinged erythrocytes Protocol 54.6 provides details on preparing slides for retic-
when stained with routine hematologic stains, owing ulocyte evaluation. To determine the reticulocyte percent-
to the presence of increased residual ribosomes and age, 1000 erythrocytes are examined. The cells are
polyribosomes, indicating immature cells. These cells examined for any blue granular inclusions (“reticulum”)
are counted as reticulocytes by automated machines. indicative of precipitation of ribosomal RNA present in
Presence of these cells in circulation typically indi- immature red blood cells. As red blood cells mature, the
cates a regenerative response by the bone marrow amount of this material decreases from coarse aggregates
toward anemia, which is helpful as it generally indi- (known as aggregate reticulocytes), to fine stippled inclu-
cates that the anemia is due to either destruction of sions (known as punctate reticulocytes). In dogs, mostly
aggregate reticulocytes are typically present, and correlate of the slide. Evaluation of red blood cell morphology too
closely to the number of polychromatophils that would be close to the feathered edge may result in a false positive
seen in slides stained with Romanowsky-type stains. In diagnosis of spherocytes, as red blood cells are able to
cats; however, it is important to classify reticulocytes as sphere and lose central pallor toward the feathered edge.
either aggregate or punctate type, because maturation of
reticulocyte to mature erythrocytes is slower in cats than Schistocytes
dogs. The number of aggregate reticulocytes will still cor- Schistocytes are fragments of red blood cells, often appear-
relate closely with the number of polychromatophils seen ing as elongated cells with sharp extremities (Figure 54.8).
on Romanowsky-type stained slides, but punctate reticulo- They can be seen secondary to microangiopathy associated
cytes will not stain as polychromatophils, despite indicat- with disseminated intravascular coagulation (DIC) in dogs,
ing a regenerative response. and less commonly in cats [16, 17]. Importantly, the
Once determined, the percentage of reticulocytes can be absence of schistocytes does not preclude DIC, and other
multiplied by the red blood cell count (RBCC) to determine diagnostic tests such as platelet concentration, D-dimer
a concentration of reticulocytes in circulation. Manual levels, activated partial thromboplastin time (aPTT)/pro-
erythrocyte counts are not accurate enough to be useful. thrombin time and fibrinogen concentration should be
evaluated if there is suspicion for DIC [18]. Schistocytes
Poikilocytosis can also be seen in other disease states, such as liver dis-
Poikilocytosis is the term used to describe any deviation in ease, iron deficiency anemia, and glomerulonephritis.
the normal shape of erythrocytes. It is important to review
red blood cell morphology on 1000 × magnification. There Leptocytes
are many classic shape changes linked to underlying patho- Leptocytes have an increased surface membrane area to
physiology. Some are of particular importance in critically volume ratio, which often gives them a folded appearance.
ill patients, and are described in detail below. A classic form of leptocyte is a codocyte or “target cell”.
These cells have a central region of density, giving a “bulls
Spherocytes eye” appearance. Low numbers of target cells can be nor-
Spherocytes are smaller than normal erythrocytes, lack cen- mal in dogs, but are seen in increased numbers in regen-
tral pallor, and have dense coloration (Figure 54.7). They erative anemias, especially as polychromatophils may
form due to loss of cell membrane, that frequently occurs in appear as target cells. They are also seen in increased num-
cases of IMHA, in which spherocytosis is a hallmark find- bers in iron deficiency, and rarely in cases of liver disease.
ing [11]. Spherocytes are not pathognomonic for IMHA,
however, and may also be seen (albeit less commonly) in Inclusions
cases of zinc toxicity [12], bee sting or snake envenoma- It is important to look for any inclusions within erythro-
tion [13, 14], or secondary to some hemic parasites [15]. It is cytes, as these can have important clinical significance. It is
essential to evaluate for spherocytes within the monolayer also important to be able to distinguish true inclusions
Figure 54.7 Spherocytes from a dog with immune-mediated

hemolytic anemia. Note that the spherocytes that have no Figure 54.8 Schistocytes. Note the schistocyte in the middle of
central pallor, and are smaller and more dense than other red the image as a fragmented cell with sharp borders. Dog blood,
blood cells. Dog blood, 1000 × magnification, Wright-Giemsa. 1000 × magnification, Wright-Giemsa.
from artifacts, such as stain precipitation that might cover

cells, or refractile inclusions that can result if blood smears
are not dried quickly, or if they are still wet during staining.
A good rule to keep in mind is that true inclusions will
always be in the same plane of focus as the rest of the red
blood cell and will never be refractile if moving the fine
focus of the microscope up and down.
Heinz Bodies
Heinz bodies often appear as small round projections from
the side of the cells, but may also be seen as pale, round inclu-
sions within the cell (if viewed from above) (Figure 54.9).
These inclusions represent aggregates of precipitated, oxi-
dized hemoglobin, and hence are the same color, or slightly
paler than that of a normal red blood cell when using routine
Romanowsky-type stains. Heinz bodies stain deep blue using Figure 54.10 Heinz bodies, new methylene blue stain. The
stain highlights the Heinz bodies seen in Figure 54.9. Cat blood,
reticulocyte stains such as NMB, which can make them much 1000 × magnification.
easier to visualize and quantitate (Figure 54.10).
Feline hemoglobin has eight reactive sulfhydryl groups round, densely purple inclusions even using routine
(compared with four in canine hemoglobin), predisposing Romanowsky-type stains and represent small remnants of
this species to oxidative damage [19]. Additionally, cats nuclear material; hence, their other name of micronuclei
have non-sinusoidal spleens that are less able to remove (Figure 54.11). Howell–Jolly bodies are normally removed
denatured hemoglobin [20]. Heinz bodies may therefore be by the spleen as red blood cells pass through inter-
present in up to 5% of erythrocytes in normal cats [21]. endothelial slits of the splenic sinuses. Low numbers may
Oxidative damage can result from exposure to some drugs be an incidental finding (especially in cats, due to a non-
or toxins, including acetaminophen [19], zinc, propylene sinusoidal spleen), and increased numbers may be present
glycol or ingestion of garlic or onions, as well as in some disin cases of regenerative anemia, post splenectomy, or sec-
ease conditions such as diabetes/diabetic ketoacidosis [21], ondary to some drugs including glucocorticoids or chemo-
hyperthyroidism, and secondary to lymphoma [22]. therapeutic agents [23].
Howell–Jolly Bodies
Parasites
Howell–Jolly bodies should not be confused with Heinz Many important infectious agents may affect erythrocytes
bodies and are easily distinguishable. They appear as small, of dogs and cats, and it is important to evaluate red blood
cells closely at 1000 × magnification, especially in cases of
Figure 54.9 Heinz bodies. Numerous Heinz bodies are present,

seen both as small round projections from the side of some Figure 54.11 Howell–Jolly bodies. Numerous red blood cells
cells, and as clear round inclusions overlying other red blood contain small, densely blue, round inclusions knows as Howell–
cells. Cat blood, 1000 × magnification, Wright-Giemsa. Jolly bodies. Dog blood, 500 × magnification, Wright-Giemsa.
regenerative anemia. These may be intracellular (including

protozoa such as Babesia spp. (Figure 54.12), Cytauxzoon
felis (Figure 54.13) or viral inclusions (e.g. associated with
Distemper in dogs), or may be epicellular (such as bacterial
Mycoplasma spp.). As mentioned previously, it is impor-
tant to differentiate infectious agents from artifacts such as
stain precipitation or refractile artifacts.
Nucleated Red Blood Cells

Mature red blood cells lack nuclei, but immature red blood
cells in the bone marrow have nuclei. As the cells mature,
the nucleus becomes smaller and more condensed, prior to
the cells losing nuclei before release from the bone mar-
row. Nucleated red blood cells can be difficult to differenti-
ate from lymphocytes. Metarubricytes have condensed
nuclei and a moderate rim of hemoglobinized cytoplasm, Figure 54.14 Nucleated red blood cells, including
metarubricytes, polychromatophilic rubricytes and basophilic
rubricytes. Dog blood, 1000 × magnification, Wright-Giemsa.
while rubricytes have round nuclei with clumped chroma-

tin, and the cytoplasm may be deep blue (basophilic rubri-
cytes) or the same color as polychromatophils
(polychromatophilic rubricytes) (Figure 54.14). Rarely,
very young, immature red blood cell precursors may be
present, and the presence of rubriblasts may indicate an
erythroleukemia, particularly in cases of non-regenerative
anemia [24]. A mild increase in nucleated red blood cells
can be seen with regenerative anemia; however, large
numbers in circulation indicate a breakdown of the blood/
bone marrow barrier, which can be seen secondary to
hypoxia (associated with severe anemia), drug or toxin
exposure (including lead poisoning and chemotherapeutic
agents) [25], heatstroke [26], or primary bone marrow dis-
Figure 54.12 Babesia canis. Teardrop-shaped B. canis organisms
are seen within some erythrocytes. Dog blood, ease, including neoplastic and infectious etiologies. The
1000 × magnification, Wright-Giemsa. presence of nucleated red blood cells is also associated with
increased mortality in acute trauma patients [27].
Leukocytes
Estimating the Leukocyte Concentration
Estimation of the leukocyte concentration can be per-
formed on a blood smear. The estimation should be per-
formed in the monolayer of the slide. The estimation can
be performed on any microscope objective where the
observer feels they can most accurately count the number
of leukocytes present. If there are very few leukocytes pre-
sent (e.g. leukopenia), a lower objective should be chosen
(e.g. 20 × objective) so that the estimate is not underesti-
mated. Conversely, in cases of leukocytosis, a higher objec-
tive (e.g. 40 × or 100 × objective) should be chosen to avoid
double counting of cells and for efficiency of the proce-
dure. Within the monolayer, count the number of leuko-
Figure 54.13 Cytauxzoon felis. Small, round C. felis organisms
are seen within red blood cells. Cat blood, 1000 × magnification, cytes present per field. Repeat this step for a total of 10
Wright-Giemsa. fields to account for any variation in leukocyte distribution
across the slide, and then divide the sum of leukocytes in patients that must be identified. These include a left shift
all 10 fields by 10 to obtain the average number of leuko- and toxic changes within the neutrophil line, infectious
cytes per field. This value is then multiplied by the square agents, and neoplastic cells. These will be described in
of the objective on which the leukocytes were counted more detail below.
(Eq. 54.1):
Neutrophil Morphology
Sum of leukocytes inten1000 x magnification fields
Two important morphologic changes that should be
10
2 assessed in neutrophils include immature neutrophils (left
objective Estimate of leukocyte concentration / l (54.1)
shift) and toxic changes.
For example, if there is an average of 13 leukocytes
counted per field on the 40 × objective, the leukocyte con- Left Shift
centration estimate would be 13 × 1600 = 20 800 cells/μl. Neutrophils are produced in the bone marrow from matu-
ration of precursor cells, starting with myeloblasts, and
Manual Total Leukocyte Counts maturing through promyelocytes, myelocytes, metamyelo-
Manual total leukocyte counts can also be performed cytes, band neutrophils to mature segmented neutrophils.
using commercially available kits using reservoirs and Neutrophils are released into circulation from a storage
pipettes to dilute samples and lyse red blood cells prior pool of cells, that in dogs is equal to approximately a five-
to counting cells in a hemocytometer chamber. Such day supply of neutrophils based on normal rates of utiliza-
counts require special equipment and training and also tion [30]. The presence of immature neutrophils such as
are labor/time intensive. In an emergency or critical bands, or even earlier precursors, in circulation is referred
care setting, such procedures may not offer any more to as a “left shift” and indicates that the stimulus for neu-
clinically useful information than the leukocyte esti- trophils from the bone marrow exceeds what the bone mar-
mates outlined above, especially in cases of marked leu- row can release from storage pools alone. Left shifts
kopenia or leukocytosis when animals likely are to be typically indicate underlying inflammation in the patient,
the most critical. and this finding should prompt investigation for a nidus of
inflammation or infection.
Performing a Leukocyte Differential
In addition to an appreciation of the total number of leuko- ● Degenerative left shift:
cytes present in circulation, the types of cells present is also A degenerative left shift refers to when the number of
critically important. If possible, a 200-cell differential (vs. a granulocytic precursors (bands, metamyelocytes, myelo-
100-cell differential) should be performed to increase the cytes, etc.) exceed that of mature neutrophils in circula-
accuracy of the differential [28]. This may not be possible tion. The presence of a degenerative left shift suggests an
in cases of severe leukopenia. Additionally, manual differ- exhausted supply of leukocytes and is associated with an
ential counts are inherently imprecise. It is important to increased risk of death or euthanasia in hospitalized
scan the entire slide to gain an appreciation of the types of dogs and cats [31, 32].
leukocytes present, as well as any clumping of cells which ● Toxic changes:
may affect the differential [29]. Toxic changes suggest dysplasia from accelerated granu-
The differential should be performed in a systematic lopoiesis, most frequently associated with inflammation.
fashion within the monolayer to avoid counting the Changes mostly affect the cytoplasm, and may include
same leukocytes multiple times. The differential is per- Döhle bodies, vacuolation, and increased basophilia
formed by identifying 200 consecutive leukocytes, and (Figure 54.15). Giant neutrophils may also be seen. Toxic
should include cells from both the center and edges of changes in neutrophils have diagnostic and prognostic
the slide to account for different distribution of cell significance. They can be helpful to differentiate inflam-
types. After completion of the differential, the percent- mation from redistribution of neutrophils (e.g. neutro-
ages of each cell type are multiplied by the total leuko- philia associated with a corticosteroid or epinephrine
cyte concentration to obtain the absolute number per response) when bands are absent. The presence of toxic
microliter of blood. changes is associated with increased hospitalization time
To perform an accurate differential, the observer must be in both dog and cats, and increased severity of toxicity
able to accurately identify granulocytes (neutrophils, confers an increased risk of mortality in hospitalized
eosinophils, basophils) and mononuclear cells (lympho- dogs [33, 34]. It is important to note that automated
cytes and monocytes). In addition to normal morphology machines, including those at diagnostic laboratories, do
of these cells, there are important morphologic changes not reliably evaluate neutrophils for toxic changes, and
that frequently are seen in emergency or critically ill evaluation of a blood smear is essential.
Figure 54.15 Band and metamyelocyte neutrophils with Figure 54.17 Chronic lymphocytic leukemia. A monomorphic
moderate toxic changes including Dohle bodies and increased expansion of small, mature lymphocytes is present, with a
cytoplasmic basophilia. Dog blood, 1000 × magnification, perinuclear packet of granules in a case of chronic lymphocytic
Wright-Giemsa. leukemia. Dog blood, 1000 × magnification, Wright-Giemsa.
Infectious Agents
Infectious agents may be seen within leukocytes, and care-
ful examination of the slides at 1000 × magnification is rec-
ommended. Some infectious agents that may be seen
include Rickettsial organisms, other bacteria (such as cases
of bacteremia), viral inclusions (e.g. distemper), and even
fungal organisms.
Neoplastic Cells
Neoplastic cells may be seen in circulation. These cells may
be large, immature and blastic, such as in the case of the
leukemic phase of large cell lymphoma, or cases of acute
leukemia (Figure 54.16). They may also be small; however,
such as in cases of chronic lymphocytic leukemia, where
lymphocyte concentrations may exceed 1 000 000 cells/μl,
and this disease is mostly indolent and slowly progres- Figure 54.18 Mast cells in circulation (mastocytemia) in a cat
sive [35] (Figure 54.17). with visceral mast cell neoplasia. Cat blood,
1000 × magnification, Wright-Giemsa.
Mast cells may be present in circulation, and evaluation of

a buffy coat preparation may be useful to increase the chance
of finding mast cells (Figure 54.18). For more information
about preparing buffy coat smears, see Protocol 54.8. The sig-
nificance of mast cells in circulation (mastocytemia) differs
dramatically between cats and dogs. In cats, mastocytemia is
most commonly associated with mast cell neoplasia such as
visceral or cutaneous mast cell neoplasia. Rarely, masto-
cytemia may be associated with other neoplasms such as
lymphoma, or with non-neoplastic conditions such as
chronic renal disease [36]. Conversely, mastocytemia in dogs
is most commonly associated with inflammatory disease,
and only rarely indicate underlying mast cell neoplasia [37].
If any atypical cells are seen, it is recommended that
Figure 54.16 Acute lymphoid leukemia. Large, immature
lymphocytes in circulation in a case of acute lymphoid leukemia. slides and blood are submitted for review by a board-certified
Dog blood, 1000 × magnification, Wright-Giemsa. clinical pathologist.
Protocol 54.8 Buffy Coat Slide Preparation

Platelets
Enumeration of platelet concentration and assessment of
Principle platelet adequacy is a critical component of evaluating pri-
Buffy coat preparations concentrate nucleated cells. mary hemostasis in critically ill patients, especially those
This may facilitate the identification of mast cells, with clinical signs such as petechiae on the skin, or bleed-
other atypical nucleated cells, or infectious agents such ing from mucosal surfaces. Platelets may clump, causing
as Rickettsial bacteria. spuriously low results on automated machines, and evalu-
ation of a blood smear should be performed in every patient
Specimen with a low automated platelet concentration.
Anticoagulated whole blood (EDTA preferred); less Evaluation of platelet adequacy on a blood smear begins
than 24 hours old. with scanning of the feathered edge on low power magnifi-
cation; typically 100 × or 200 × magnification, looking for
Materials and Equipment platelet clumps or aggregates (Figure 54.19). Clumping of
● Microhematocrit tubes platelets is common, particularly in cats, and after trau-
● Clay or tube sealing compound matic venipuncture. Such aggregates may affect the plate-
● Microhematocrit centrifuge let concentration reported by CBC analyzers, which can
● Glass slide or etcher result in a spuriously decreased platelet concentration. If
● Glass slides platelet clumps are present, a smear made from fresh whole
blood from a non-traumatic venipuncture may be useful to
Procedure better assess platelet adequacy.
1) Proper mixing of blood is imperative. Samples
should be thorough mixed, ideally for five minutes Estimating the Platelet Concentration
on a rocker, or by inverting the samples gently a Estimation of the platelet concentration can be performed
minimum of 25 times. on a blood smear. This should ideally be performed on a
2) Remove the rubber stopper of the EDTA tube, with blood smear prepared from fresh whole blood, as some
the tube pointing away from the face. anticoagulants can promote platelet aggregation and cause
3) Fill 4 microhematocrit tubes to 75% capacity. a spuriously low platelet estimate. It is also essential that
4) Gently wipe the outside of the tube to clean off the platelet estimate is within the monolayer of the slide,
any blood. so that the platelet concentration is not overestimated
5) Seal the end of the microhematocrit tube with clay (if performed in the body of the smear) or underestimated
or sealing compound. (if performed too close to the feathered edge).
6) Place the microhematocrit tubes into the centri- Within the monolayer, count the number of platelets
fuge with the sealed end toward the rubber gasket present in a 1000 × magnification field. Repeat this step for
and balance the centrifuge with the tubes on a total of 10 fields to account for the variation in platelet
opposite sides. distribution across the slide, and then divide by 10 to obtain
7) Secure both lids of the centrifuge (inner screw lid
and outer latch).
9) Use a glass slide or etcher to score the tubes just below
the white blood cell and platelet (buffy coat) layer.
10) Place gentle pressure at the score line to break the
tube, breaking in the direction away from the face.
11) Tap the section of the microhematocrit tube with
the white blood cell layer gently onto a clean glass
slide, mixing cells and a small amount of plasma.
12) Make a pulled smear by placing a second clean glass
slide on top of the slide with the white blood cell–
plasma mixture and gently pull the top spreader slide
over the bottom slide to create a monolayer of cells.
13) Repeat steps 9–12 for all microhematocrit tubes
to make several buffy coat smears.
14) Allow the slides to completely dry before staining
the slides per Protocol 54.5. Figure 54.19 Large platelet clumps. Cat blood, 500 ×
magnification, Wright-Giemsa.
an average number of platelets per 1000 × magnification performed manually and not by an automated machine.
field. Within the monolayer, 1 platelet is representative of Severe thrombocytopenia (< 10 000 platelets/μl) may also
approximately 10 000 to 20 000 platelets/μl, so multiplying prolong ACT [41].
the average number of platelets by 15 000 will give an esti- ACT may be performed either by visual clot detection or
mate of the platelet concentration per μl (Eq. 54.2): using point-of-care devices. Visual clot detection involves a
special tube that contains clot activators such as kaolin or
Sum of platelets inten1000 magnification fields celine–kaolin glass beads such as those in MAX-ACT™
10 (Helena Laboratories, Beaumont, TX). Diatomaceous earth
15, 000 Estimate of platelet concentration / l (54.2) is no longer available as a clot activator, and any reference
intervals based on this activator may no longer be appropri-
Mean Platelet Volume ate. Reference intervals for normal patients using the
The mean platelet volume (MPV) is the average volume of a MAX-ACT tubes in one published study were 55–85 sec-
single platelet. This value can only be obtained from auto- onds for cats, and 55–80 seconds for dogs [42]. The tube
mated hematology analyzers and is available from most in- should be kept at 37 degrees C and gently rotated every
house machines. There is an inverse correlation between 5–10 seconds with visualization for clot formation. The
platelet concentration and MPV in dogs and cats [38]. MPV time taken to the start of clot formation is recorded as the
values are highly susceptible to preanalytical and analytical ACT. Refer to Protocol 54.9 for further details on
errors, particularly in cats, because of platelet clumping [39]. manual ACT.
Automated evaluation of ACT may also be performed
Evaluating Platelet Morphology using point-of-care machines such as iSTAT® (Abbott
Platelets are clear to pale purple with variably prominent Laboratories, Abbot Park, IL), which use cartridges con-
pink granules (typically more prominent in cats) and are taining clot activators such as kaolin or cellite. These
approximately 2–4 and 2–6 μm in diameter in dogs and machines use electrochemical sensing to measure throm-
cats, respectively. Cats have greater variability in platelet bin generation (rather than fibrin formation).
size, possibly due to an altered M-loop region in β1-tubulin
compared to other species, which results in a higher MPV
than other domestic animals [40]. Activated Partial Thromboplastin Time and
Giant platelets are approximately the size of a red blood Prothrombin Time
cell, and can be seen in cases of thrombocytopenia if the The aPTT is used to assess the intrinsic and common path-
bone marrow is mounting a regenerative response. Platelet ways of coagulation, while the prothrombin time is used to
mass, and not platelet concentration, provides negative assess the extrinsic and common pathways. In general, the
feedback on thrombopoietin. tests will be prolonged if there is a greater than 70%
decrease in any given coagulation factor.
Agreement between point-of-care analyzers and labora-
Coagulation tory methods generally is good (up to 87.5% for aPTT and
97% for prothrombin time) [43]. Interestingly, the pro-
Major tests of coagulation available in the emergency room thrombin time test on most point-of-care instruments has
and intensive care unit include the activated clotting time high specificity, but low sensitivity, while the aPTT has
(ACT), prothrombin time (PT), activated partial thrombo- very high specificity (up to 100%), but low sensitiv-
plastin time (aPTT), and buccal mucosal bleeding ity [43–45]. In another study using blood from healthy
time (BMBT). dogs, prothrombin time and aPTT results from in-house
analyzers had moderate correlation with results from a
laboratory, but results were still considered clinically relia-
Activated Clotting/Coagulation Time
ble [46]. It is important to note that such studies are per-
The ACT tests the intrinsic and common pathways of formed in controlled settings with trained personnel and
coagulation. It does not test factors in the extrinsic path- excellent quality control, and may not translate to clinical
way (i.e. factors III and VII). The ACT has many limita- practice. Point-of-care tests should be calibrated with con-
tions; the first is poor sensitivity. The test may require trol tests frequently and maintained per manufacturer
greater than 90–95% deficiency of a single factor to be pro- recommendations.
longed. The other major problem of the test is reproduci- It is recommended that citrated whole blood be used for
bility, due to many factors that may affect results, including in-house testing of prothrombin time and aPTT. Both tests
temperature and length of incubation period, as well as may be falsely prolonged if the citrate tube is underfilled,
how the tube is inverted and inspection times if the test is or if erythrocytosis is present. Platelet concentrations and
Coagulation 735
as much as 87 and 120 seconds in cats and dogs, respec-

Protocol 54.9 Activated Clotting Time
tively [49, 50]. Factors that may affect results include
Principle how the incision is created [51], how tightly the lip is
held/tied back, and any disruption of the incision.
Activated clotting time assesses the intrinsic and com- Additionally, bleeding times may be falsely prolonged in
mon pathways of coagulation. Surface activators within patients with anemia [52]. Protocol 54.10 provides
ACT tubes activate coagulation via the intrinsic path- further details of the BMBT procedure.
way, and the time to clot formation is measured as the
activated clotting time.
Specimen
Protocol 54.10 Buccal Mucosal Bleeding Time
Fresh whole blood.
Principle
Materials and Equipment The buccal mucosal bleeding time (BMBT) is a point-of-
● ACT tube (e.g. MAX-ACT (Helena Laboratories, care test used to evaluate primary hemostasis.
Beaumont, TX))
● Timer Materials and Equipment
37°C water bath
Bleeding time device (to create standard incision)
●
●
● Gauze
Notes ● Filter paper
● Do not use tubes past their expiration date. ● Timing device
● Use fresh whole blood from a fresh, non-traumatic
venipuncture. Do not use blood from sampling lines. Notes
Factors that may artifactually prolong ACT include
Factors that may affect BMBT results:
●
●
hypothermia,h emodilution,or severe thrombocytopenia.
● Device used to create incision
● How tightly the lip is held back
Procedure ● Use of sedation
1) Fill ACT tube with fresh whole blood per manufac- ● Disruption of the incision
turer guidelines. ● Anemia
2) Begin timer as soon as tube is filled with blood.
3) Gently mix blood in tube at 37°C for 30 seconds. Procedure
4) Place tube in 37°C water bath and assess for clot
1) Restrain the patient in lateral recumbency, prefera-
formation every 5–10 seconds by tipping the tube
bly without sedation.
gently on its side.
2) Evert the upper lip to expose the mucosal surface;
5) Record the time taken for a clot to be first seen. This
use gauze tied around the maxilla to hold the lip in
time is the activated clotting time.
place. There should be congestion of the mucosal
vessels but blood flow should not be occluded by
function will not affect results. It has been suggested that the gauze tie.
citrate tubes for coagulation testing be stored on ice; how- 3) Place bleeding time device flush against the
ever, multiple studies report that storage of citrated whole mucosal surface of the lip, avoiding obvious surface
blood from clinically ill dogs at room temperature for vessels.
24 hours does not result in statistically or clinically signifi- 4) Activate the trigger mechanism in the bleeding
cant changes in prothrombin time or aPTT [47, 48]. time device.
Changes can occur, however, after 48 hours of storage at 5) Start the timer and allow the incision to bleed
room temperature. freely.
6) Use filter paper to blot excess blood from the area
but be careful not to disturb the incision or clot
Buccal Mucosal Bleeding Time formation.
7) Stop the timer when blood no longer stains the
BMBT is used to assess platelet function. The test is
filter paper.
highly imprecise, with repeat bleeding times varying by
Blood Typing results [53]. It is less sensitive than both CARD and the
gold standard gel column test.
Dogs
Cats
Dog erythrocyte antigen (DEA) 1.1 and 1.2 are the most
important surface antigens, owing to their high antigenic- Major blood types in cats include blood type A, B or
ity. Dogs do not have natural antibodies for 1.1 and 1.2, but AB. Recently, the MiK antigen has also been identified.
do have natural antibodies for DEA 3, 5 and 7, but reac- There is no universal blood type in cats, and cats have natu-
tions from these antigens are generally mild or delayed. rally occurring antibodies to these surface antigens. Type B
In a laboratory, typing is performed using polyclonal cat that receive type A blood may have fatal reactions, mak-
antibodies using a tube agglutination method. In-house ing blood typing essential.
typing kits are available that test for DEA 1.1. The most Two major in-house blood typing kits for cats include
common tests are the DMS CARD test (CARD; DMS Rapid® VetH Feline (CARD, DMS Laboratories, NJ), and
Laboratories, NJ) and the Quick Test DEA 1.1 (CHROM; Quick Test A + B, (CHROM, Alvedia, France). In a study
Alvedia, France). The benefit of the CHROM testing sys- comparing these kits to the gold standard (tube agglutina-
tem is that is it not affected by autoagglutination. In one tion test), CARD had 91.4% agreement, and CHROM had
study, CHROM was 93% accurate and 100% specific, which 94.8% agreement [54]. Presently, there is no in-house
is important because there were no false positive testing kit for the MiK antigen.
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6 Allison, R.W. and Velguth, K.E. (2010). Appearance of 15 Adachi, K. and Makimura, S. (1992). Changes in
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interobserver and intraobserver study of buccal
739
55
In-House Evaluation of Hemostasis

April Summers, Jocey Pronko, and Julien Guillaumin
Hemostasis is defined as the ability of the body’s systems to plasminogen activator (tPA), which converts plasminogen
maintain both blood fluidity and blood vessel integrity to to plasmin [2].
preserve normal blood function. It is a complex physiologic Hemostatic testing can be used to identify and character-
process that stops bleeding at the site of vascular damage. ize hemostatic defects in patients. It is important to note
When the vasculature is damaged, there is a cooperative that the tests performed in vitro may not accurately reflect
response in both the endothelium and the blood that ulti- changes occurring in vivo.
mately results in the formation of a clot. Hemostasis
involves not only primary and secondary hemostasis but
also fibrinolysis and amplification of inhibitory pathways. esting for Defects
T
The process of hemostasis is usually divided into two disin Primary Hemostasis
tinct but overlapping phases: primary hemostasis and sec-
ondary hemostasis. Primary hemostasis refers to the Primary hemostatic problems refer to platelet disorders,
formation of the initial platelet plug following vascular either decreased numbers (i.e. thrombocytopenia) or
damage, whereas secondary hemostasis refers to the for- decreased function (i.e. thrombocytopathia). Platelets (also
mation of crosslinked fibrin across that platelet plug. The called thrombocytes) are small anuclear cellular fragments
traditional model of coagulation simplifies secondary derived from larger cells called megakaryocytes in the bone
hemostasis into two distinct pathways: the intrinsic path- marrow. Platelets are a major component of the blood and
way and the extrinsic pathway, both of which converge into play an integral role in primary hemostasis, the repair of
the common pathway. This model is particularly useful for damaged vasculature, the inflammatory cascade, and
interpreting in vitro tests of coagulation [1]. In vivo, how- wound healing. They have a mean circulating lifespan of
ever, coagulation is more accurately depicted by the cell- four to six days in dogs and cats.
based model of coagulation, which is separated into three
distinct phases: initiation, amplification, and propagation.
Platelet Count
Initiation begins when a vessel is damaged and tissue fac-
tor is exposed on tissue factor-bearing cells. This results in The platelet count is the number of platelets per microliter
the generation of small amounts of thrombin. The amplifi- of blood and is used to assess total platelet mass. A decreased
cation phase is marked by platelet activation and the accu- platelet count is referred to as thrombocytopenia and an
mulation of large amounts of tenase and prothrombinase. increased platelet count is called a thrombocytosis.
Afterwards, stabilization of the clot is achieved via large- Thrombocytopenia can be caused by a number of different
scale thrombin generation (the propagation phase) and the mechanisms including loss (e.g. from acute hemorrhage),
activation of factor XIII (fibrin stabilizing factor) [1, 2]. decreased production (e.g. from primary bone marrow dis-
Fibrinolysis refers to the breakdown of the clot, which ease), increased consumption (e.g. in abnormal clot forma-
then returns the vasculature to its normal patency. It is the tion, or thrombosis), destruction (i.e. immune-mediated
enzymatic dissolution of fibrin into fibrin degradation thrombocytopenia), sequestration in the spleen, or artifac-
products by plasmin. This reaction is catalyzed by tissue tual (i.e. clumping). Thrombocytosis may be due to a
740 In-House Evaluation of Hemostasis
myeloproliferative disorder or increased bone marrow important to thoroughly assess the feathered edge of the blood
production of platelets secondary to cytokine release or smear to investigate for platelet clumps, which can falsely
erythropoietin production. decrease the platelet count, causing a pseudothrombocytope-
Platelet counts can be obtained via impedance analyzers, nia [7]. While platelet clumping invalidates platelet counts and
laser flow cytometers, quantitative buffy coat analyzers, platelet estimates, abundant numbers of platelet clumps gen-
and peripheral blood smears. erally rule out a clinically significant thrombocytopenia.
Clumped platelets occur commonly in cats and less commonly
in dogs, though platelet clumping can be noted in either spe-
Platelet Evaluation via Thrombogram
cies since platelets can become activated during blood sam-
Platelets can be evaluated via a thrombogram, the term pling and subsequently clump together [9]. Spontaneous
used to refer to the portions of a complete blood count bleeding typically does not occur when platelet counts exceed
related to platelets. The thrombogram includes analysis of 10000–20000/μl, and surgical bleeding typically does not
total platelet count, mean platelet volume (MPV) and size, occur when platelet counts exceed 50000–60000/μl [10].
platelet distribution width, platelet morphology, and
thrombocrit (or plateletcrit) [3]. MPV is a measure of the
Buccal Mucosal Bleeding Time
mean platelet size; increases in this value can suggest the
presence of young platelets due to increased produc- Buccal mucosal bleeding time (BMBT) is the time to form the
tion [4]. A decrease in MPV can be associated with immune primary hemostatic plug in vivo and is therefore used to
mediated destruction. MPV, like most parameters, should detect defects in primary hemostasis. It is usually performed
be interpreted in light of the sample preparation and ana- to assess platelet function after thrombocytopenia has been
lyzer used to assess it. Sample storage time, temperature, ruled out. A platelet count should always be performed prior
and the use of anticoagulants can all affect MPV. This value to assessing BMBT, since thrombocytopenia affects the
may be falsely increased when lipid droplets or cell frag- results of the test. Indications for BMBT include patients that
ments are mistakenly labeled as platelets by impedance have a suspected defect in primary hemostasis but have an
analyzers and flow cytometers [4]. Platelet distribution adequate platelet count. BMBT is used to measure the dura-
width reflects platelet anisocytosis as calculated from indi- tion of hemorrhage resulting from a small, standardized inci-
vidual platelet volume and gives an estimate of total varia- sional injury made with a spring-loaded disposable device to
tion in platelet size [3]. Plateletcrit, the product of MPV the mucous membrane on the inside of the lip (the buccal
and platelet count, and expressed in percentage, is gener- mucosa). The incisional injury is small enough such that a
ated by certain analyzers [3]. platelet plug alone is adequate to stop the bleeding regardless
It is important to interpret thrombogram data in light of of secondary hemostatic (clotting factor) status. Prolonged
the analyzer used. For instance, impedance analyzers sepa- bleeding times can be seen in patients with von Willebrand
rate platelets and erythrocytes based on size. Impedance disease (vWD), other thrombocytopathia (e.g. inherited or
analyzers can thus be inaccurate when the sizes of platelets acquired diseases, aspirin administration), thrombocytope-
and erythrocytes overlap [5]. This can occur when there nia, and endothelial diseases. For this reason, BMBT is used
are large platelets or when erythrocytes are small (such as preoperatively as a screening test for patients suspected to
with iron deficiency anemia). Cats are known to have small have vWD or other thrombocytopathias.
erythrocytes and large platelets; thus, impedance analyzers Normal BMBT is less than 4.0 minutes in dogs and less
may have inaccurate counts in this species. Impedance than 1.5 minutes in cats. It may be prolonged in patients
analyzers can also incorrectly count clumps of platelets as with severe anemia due to decreased blood viscosity [11].
leukocytes. In contrast, flow cytometers provide more reli- While BMBT can be useful to detect primary hemostatic
able cell counts because these machines sort cells accord- defects, there is high intra- and interobserver variability as
ing to their internal complexity, and therefore can more many technical variables can alter the results [12]. For
accurately identify platelets. instance, one must be careful that the filter paper does not
touch the cut surface and thus interfere with formation of
the platelet plug. Often a gauze tie is placed around the
Blood Smear Platelet Estimate
muzzle to fix the lip in an everted position for this proce-
Microscopic examination of a peripheral blood smear allows dure; if the tie is overly tight, it can occlude blood flow or
for rapid, bedside estimation of the platelet count. The number cause engorgement, either of which could falsely affect
of platelets/μl can be estimated by counting the number of bleeding times. Finally, if excessive pressure is placed on
platelets seen per high power (100×) field in the monolayer in the spring-loaded incisional device, the incision may be
at least 10 high power fields, then multiplying the average deeper than intended and trigger secondary in addition to
count in those 10+ fields by 15000–20000/μl [6–8]. It is primary hemostasis. Care must be taken when performing
Secondary Hemostasis 741
Specifically, factors X, VII, V, II (prothrombin), and I

Protocol 55.1 Acquiring Buccal Mucosal
(fibrinogen) are evaluated. The activated partial thrombo-
Bleeding Time
plastin time (aPTT; also known as partial thromboplastin
Items Required time) is used to evaluate the intrinsic and common path-
● Appropriately sized spring-loaded device ways of the classic model of the clotting cascade. As such,
● Gauze tie the aPTT evaluates factors XII, XI, X, IX, VIII, V, II (pro-
● Filter paper thrombin), and I (fibrinogen). Both PT and aPTT may not
● Stopwatch be prolonged until factor activity has decreased to 60–70%
of normal.
Procedure Normal hemostasis depends on a balance between pro-
and anticoagulant proteins as well as the fibrinolytic system.
1) Remove the spring-loaded device from the packag- It is important to note that the division of the intrinsic and
ing without touching the aperture slot. extrinsic pathways is an artifactual by-product of in vitro
2) Remove the safety clamp. coagulation testing and is not how coagulation works inside
3) Place the patient in lateral recumbency. the animal. In vivo, these two pathways interact and both
4) In dogs, a gauze strip can be used as a tie to expose must be activated for appropriate hemostasis.
the buccal mucosal surface, hold the lip up, and PT and aPTT are useful in diagnosis of coagulation disor-
provide moderate mucosal engorgement. However, ders and for monitoring anticoagulant therapy. Heparin
it should not be placed too tightly as to occlude therapy, by inhibiting the intrinsic pathway, is known to
blood flow. An alternative is to manually lift and prolong aPTT [13]. Measurement of PT and aPTT is war-
hold the lip steadily for the duration of the test. ranted in animals suspected of having coagulation disor-
5) Choose an area on the buccal mucosa that is devoid ders such as liver failure, vitamin K antagonism, and
of visible blood vessels. consumptive coagulopathies like disseminated intravascu-
6) Place the device on the mucosa. lar coagulation. Because it affects factor VIII, patients with
7) Press the release button of the incision device. vWD may have a prolonged aPTT.
8) Start the stopwatch immediately after bleed- Vitamin K deficiency, usually secondary to anticoagu-
ing begins. lant rodenticide toxicosis, affects factors II, VII, IX, and
9) Allow for undisturbed bleeding of the cut surface. X. PT is a particularly useful diagnostic test in patients
10) Absorb draining blood every 10 seconds with the exposed to anticoagulant rodenticide because factor VII
filter paper without touching the cut surface. has the shortest half-life of these vitamin K-dependent fac-
11) Stop the stopwatch immediately after bleeding tors, at 6.2 hours in dogs. Because of the short half-life of
stops and read the buccal mucosal bleeding time. factor VII, the PT is usually first to be prolonged, usually
24–36 hours after ingesting an anti-vitamin K rodenticide.
As time progresses without treatment, and the functional
the BMBT to ensure the most reliable result (Protocol 55.1).
vitamin K factors are depleted, aPTT becomes prolonged
If BMBT is prolonged, vWF assessment and platelet func-
as well.
tion testing may be indicated.
The PT and aPTT are generally measured using plasma
Although BMBT can be easily performed in clinical prac-
from blood collected into a blue-top tube with 3.2% sodium
tice, the gold standard for platelet function assessment is tur-
citrate as an anticoagulant with a ratio of nine-to-one for the
bidimetric aggregometry, which can be done in some
blood-to-citrate. Collection tubes need to be filled to the
reference laboratories. Other point-of-care devices, such as
appropriate level to ensure the correct blood-to-anticoagulant
the PFA-100® (Siemens Medical Solutions, Malvern, PA), can
ratio [14]. The samples should then be gently inverted at least
provide bedside platelet function analysis. As they are uncom-
six times to ensure appropriate mixing of citrate with the
mon in practice, these devices are not covered in this chapter.
blood. These assays are generally performed within one hour
of sample collection, although longer storage times have been
reported [15]. In fact, some reports show that aPTT is not sub-
Secondary Hemostasis
stantially affected by refrigeration for at least 24hours follow-
ing sampling [16].
Prothrombin Time and Activated Partial
Thromboplastin Time
Manual Measurement of Prothrombin Time
The prothrombin time (PT), also known as one-stage pro- PT can be measured manually (Protocol 55.2) by adding
thrombin time, is used to evaluate the extrinsic and com- tissue thromboplastin reagent followed by a reagent
mon pathways of the classic model of the clotting cascade. (such as calcium chloride) to recalcify the sample and
impeded and the blood movement slows. The PT and aPTT

Protocol 55.2 Manual Prothrombin Time
are recorded when the movement of blood decreases below
Items Required a predetermined rate. Studies have shown that abnormali-
● Citrate tube ties detected by point-of-care assays are similar to clinical
● Blood collection supplies laboratory tests [18, 19].
● Tissue thromboplastin – calcium chloride reagent PT and aPTT are generally considered to be prolonged if
● 12 × 75 test tube the patient’s time is 25–30% longer than the upper end of
● Stopwatch the reference interval. Although rare, a shortened PT can
● Heat block 37°C be caused by an excessive plasma-to-anticoagulant ratio,
increased tissue factor concentrations due to traumatic
Procedure venipuncture, a hypercoagulable state, or may merely rep-
resent the normal range for the patient [20]. Inflammatory
1) Perform venipuncture and place whole blood into conditions may also shorten PT and aPTT times due to
sodium citrate tube for a ratio of 9 : 1. Invert the tube increased fibrinogen concentration [21]. Artifactual results
gently at least six times to ensure adequate mixing can be caused by improper collection, storage, and process-
of blood and anticoagulant. ing. Results that do not correlate with the clinical picture
2) Centrifuge as soon as possible and collect the should thus be interpreted with caution.
plasma (i.e. the supernatant after centrifugation).
3) Incubate plasma for two to three minutes until it
reaches 37°C. Activated Clotting Time
4) Incubate a 12 × 75 mm tube with 0.2 ml of the Activated clotting time (ACT) is used to detect defects in
thromboplastin-calcium reagent until it reaches 37°C. the intrinsic and common pathways. Abnormally increased
5) Inject, with force, 0.1 ml of the plasma into the tube ACT indicates that the activity of one or more of the coagu-
with the tissue thromboplastin–calcium chloride lation factors is reduced by at least 85–95%. ACT is fre-
reagent. The thromboplastin triggers the clot for- quently used for monitoring heparin anticoagulation
mation while calcium reverses sodium citrate’s anti- therapy, especially with high doses of heparin when aPTT
coagulant effects. Confirm volumes with reagent cannot be used. It is most commonly used in settings of
manufacturer’s recommendations. invasive intravascular procedures including cardiac cathe-
6) A clot should fully form in 6–20 seconds. A clot that terization, vascular surgery, and hemodialysis [22]. aPTT is
takes longer than 20 seconds to form is considered a test that involves an in vitro clotting reaction and is not
to demonstrate a prolonged prothrombin time. clinically useful with high-dose heparin administration, as
7) If the result is achieved in less than 20 seconds, the the blood will not clot. ACT uses whole blood that is added
results should be repeatable within ± 1 second. If to a tube containing an activator of the intrinsic coagula-
the result is achieved in longer than 20 seconds the tion cascade such as kaolin, celite, glass beads, phospho-
test should be repeatable within ± 2 seconds. lipid tissue extract, diatomaceous earth, or other substance,
followed by measurement of the time required for clot for-
mation. While the two tests are used for similar purposes,
reverse citrate’s effects [17]. Clot formation should be ACT is less sensitive than aPTT and relies on the patient’s
detected within 20 seconds. platelets, phospholipids, and calcium to support the reac-
tion. ACT can be affected by a number of different factors
Analyzer Measurement of Prothrombin Time including hemodilution, hypothermia, factor deficiency,
and Activated Partial Thromboplastin Time and platelet dysfunction. Severe thrombocytopenia is also
Point-of-care analyzers are available for measuring PT and known to prolong ACT.
aPTT using non-anticoagulated or citrate anticoagulated The ACT can be evaluated manually (Protocol 55.3) by
whole blood [18]. These point-of-care analyzers are benefi- collecting blood into a gray-top vacutainer that contains dia-
cial in that results are obtained within minutes. To achieve tomaceous earth. In this method, the ACT is the time in sec-
adequate mixing of blood and sodium citrate, the blood onds to the first visible clot formation while gently rocking
should be collected five minutes prior to testing and well the tube every 5–10 seconds after initially incubating the
mixed with the citrate prior to analysis. The analyzer tube for 60 seconds at 37 °C. ACT can also be performed with
accepts a very small sample of blood and moves it into the the use of specialized point-of-care coagulation analyzers.
testing chamber, where clot formation occurs within the There are assays that use mechanical methods such as a
cartridge. The clot is detected by light-emitting diode opti- mechanical plunger (ACT Plus®, Medtronic, Minneapolis,
cal detectors and, as the clot is formed, blood flow is MN) or displacement of a magnet (Hemochron®, Werfen,
Viscoelastic Testing 743
blood sample. The difference between TEG and ROTEM is

Protocol 55.3 Manual Activated Clotting Time
which part of the system rotates, although the information
Evaluation
provided is quite similar. With TEG, the cup rotates clock-
Items Required wise and counterclockwise around the static pin as the
● Vacutainer tube with diatomaceous earth (gray top) blood clots. Fibrin strands and platelet aggregates form
● Blood sample between the pin and the walls of the cup, which result in
● Stopwatch torque on the pin. The pin movements are monitored and
● 37°C incubator converted into an electrical signal. The opposite happens
with ROTEM, as the pin oscillates and the cuvette is held
Procedure stationary [23]. The impedance of pin rotation as fibrin
strands are formed is detected and a tracing is gener-
1) Collect 2 ml of blood directly into a gray-top vacu- ated [24]. Although both tests are useful in rapidly diagnos-
tainer tube that contains diatomaceous earth. ing coagulopathies, and although the various time points
2) Begin a timer as soon as the blood enters the tube. and other variables provided by those devices appear simi-
3) Gently invert the tube to mix its contents and place lar, differences in activators and other variabilities limit
it in a 37°C incubator. direct comparison of VHA variables between the two
4) Rock the tube back and forth gently every methodologies [25, 26]. Differences in results of VHA vari-
5–10 seconds. ables have been noted even with the use of the same
5) Examine the tube for clot formation at 60 seconds, machine at different institutions, and it is recommended
and then every 5 seconds thereafter. that each institution establish its own reference intervals.
6) Record the time to blood clot formation. Normal TEG provides information on initiation, amplification,
time to clot is less than 120 seconds. and propagation of coagulation in addition to fibrinolysis.
Several different result parameters are reported in the
machine’s graphical tracing and the tracing’s associated
Bedford, MA). ACT can be tested on i-STAT® machines numerical values. Time is represented on the TEG tracing’s
(Abbott Point of Care, Princeton, NJ) using ACT cartridges X axis while the Y axis represents the clot formation kinet-
with either kaolin or celite as activators. The benefits of this ics. Specific values reported from the TEG tracing include
type of equipment include increased automation and the reaction time (R), which is the time to first clot detec-
decreased sample volume compared with other methods, tion and reflects coagulation factor activity; the kinetics of
including manual ACT evaluation. clot formation (K), which is the time from R until the trac-
ing reaches 20 mm on the Y axis, which reflects the speed
of clot formation; and the alpha angle (α) is the angle cre-
Viscoelastic Testing ated by the tangent from R on the X axis and point K, and
represents conversion of fibrinogen to fibrin. Maximum
Viscoelastic hemostatic assays (VHA) are used for the clot strength is represented by maximum amplitude, and
global assessment of hemostasis. In human medicine, data associated with fibrinolysis are provided by the clot
VHA is commonly used to monitor for response to treat- lysis time and the percent lysis 30 minutes after maximum
ment, while in veterinary medicine it is commonly used for amplitude.
the diagnosis of different hemostatic states including: nor- ROTEM provides information similar to that from
mocoagulable, hypocoagulable, hypercoagulable, excessive TEG. The time to initiation of clotting, thrombin forma-
fibrinolysis, or decreased fibrinolysis. This method of tion, and the start of clot polymerization are reported as
assessing hemostasis provides a graphical tracing of clot the clotting time. The kinetics of clotting are reported as
formation and breakdown as well as numerical informa- two closely linked parameters: clot formation time and
tion reflecting the time it takes for initial fibrin formation, alpha angle, similar to K and alpha angle from the TEG. The
the kinetics of the fibrin clot to reach maximum strength, maximum clot firmness and amplitude obtained at 10 min-
as well as the overall strength and stability of the clot. utes, which correlate with platelet count and function, are
Many different analyzers are available. provided. Lysis 30 minutes after clotting time and maxi-
Thromboelastography (TEG) and rotational thromboe- mum lysis are also provided for information regarding the
lastometry (ROTEM) are the most commonly studied stability of the clot and fibrinolysis.
point-of-care tests for viscoelastic testing in small animals. There are newer viscoelastic testing devices designed
Both systems use whole blood and measure coagulation by with miniaturization and automation in mind for rapid,
assessing the shear elasticity as it clots. Whole blood is global, point-of-care coagulation assessment (e.g. VCM
placed into a heated cuvette and a vertical pin is held in the Vet®, Entegrion, Durham, NC). This instrument uses fresh
whole blood and is available as an in-house diagnostic.

Protocol 55.4 Acquiring Whole Blood Clotting Time
Once the fresh whole blood is loaded into the cartridge, the
cartridge can be inserted into the fully automated system. Items Required
The system provides similar information about time to ini-
● Clean, dry, glass blood tube
tiation of clot formation, rate of clotting, maximum clot
● Blood sample drawn with any gauge needle
strength, and fibrinolysis. Owing to its ease of use, these
● Stopwatch
smaller viscoelastic testing devices are commonly found in
veterinary emergency clinics, although peer-reviewed data
Procedure
are scarce. The TEG 6s® system (Haemonetics Corp.,
Braintree, MA) is a newer VHA that uses a multichannel 1) Obtain 2 ml of venous blood via venipuncture.
microfluidic cartridge, which enhances portability and 2) Transfer directly into a clean, dry glass tube and hold
eliminates the need for pipetting. These cartridges mix at 21°C (room temperature).
small blood samples with reagents automatically and can 3) Gently rock the tube back and forth every 30 seconds.
run up to four assays in parallel. It offers the potential for 4) The time to the beginning of clot formation should
more reliable measurements due to decreased user-related be recorded.
and vibrational errors, though some studies have shown 5) Normal animals generally have clotting times of
that this assay is still susceptible to vibrational artifact [27, 3–13 minutes.
28]. Thus far, clinical experience with the use of this assay 6) If the clot breaks down or fails to coagulate, this
is limited. indicates coagulopathy.
clot formation is not assessed until 20 minutes of room

Whole-Blood Clotting Time temperature incubation have passed [31]. Other studies
using human blood have been performed with clot forma-
Whole-blood clotting time (WBCT), also known as the tion assessed at the 30 minute mark [31]. At the end of the
Lee–White clotting time, red-top tube clotting time, or designated time, the clot is graded 0, 1, or 2. Grade 0 would
glass-tube clotting time, is a very simple, useful, point-of- refer to normal coagulation as a solid clot. Grade 1 refers to
care diagnostic test used in the assessment, diagnosis, and a partial or semisolid clot that breaks apart and grade 2
monitoring of patients with coagulopathies (Protocol 55.4). refers to uncoagulated blood that would easily pour out of
It is commonly used as an alternative bedside test when the tube if inverted [31]. The clot, once formed, should
more sophisticated coagulation assessment devices are retract to 50% within one to two hours of formation [30].
unavailable or in resource-poor countries for detecting WBCT can be an imprecise test as it is not standard-
coagulopathies in patients that have sustained snake ized [32]. Specifically, as platelets are needed for activation
bites [29]. The premise of this test is to take a small volume of the clotting cascade, prolonged clotting times can be
of blood and transfer it directly into a glass tube incubated seen in thrombocytopenic patients due to a phospholipid
at room temperature and assess formation of a clot. In nor- deficiency. As such, its use has decreased as the availability
mal animals a clot should form in 3–13 minutes and the of automated devices have increased. However, it can be a
time to clot formation is referred to as WBCT [30]. A varia- useful test in veterinary clinics where point-of-care auto-
tion of this test is referred to as 20-minute WBCT, in which mated devices are unavailable.
References
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2 Palta, S., Saroa, R., and Palta, A. (2014). Overview of the 5 Boulassel, M.-R., Al-Farsi, R., Al-Hashmi, S. et al. (2015).
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3 Budak, Y.U., Polat, M., and Huysal, K. (2016). The use of methods in patients with Thrombocytopaenia and
platelet indices, plateletcrit, mean platelet volume and Microcytosis. Sultan Qaboos Univ. Med. J. 15 (4): e463–e468.
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abdominal surgery: a systematic review. Biochem. Med. peripheral blood smear in platelet count estimation. Int.
26: 178–193. J. Res. Med. Sci. 7 (2): 434–437.
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483–485. of hypercoagulability in dogs: 25 cases (2006–2011):
8 Umarani, M. and Shashidhar, H.B. (2016). Estimation of shortened coagulation times and hypercoagulability.
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aggregation and deaggregation. BMC Vet. Res. 11 (1): 276. clotting time (ACT) test in different clinical settings in a
10 Johnstone, I. (2002). Bleeding disorders in dogs. In Pract. large academic urban medical center: comparison with
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18 Dixon-Jimenez, A.C., Brainard, B.M., Cathcart, C.J. et al. Delayed double reading of whole blood clotting test
(2013). Evaluation of a point-of-care coagulation analyzer (WBCT) results at 20 and 30 minutes enhances diagnosis
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402–407. Sensitivity of whole blood clotting time and activated
19 Tseng, L.W., Hughes, D., and Giger, U. (2001). Evaluation partial thromboplastin time for factor IX: relevance to
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747
56
Electrolyte Evaluation
Louisa J. Rahilly and Katherine Vachon
Electrolytes are pivotal players in maintaining homeosta- evaluated in the clinic using point-of-care (POC) analyzers
sis. They have key roles in such physiologic functions as because changes in electrolyte concentrations can alter the
maintaining intracellular and extracellular fluid volumes treatment course on an hour-by-hour basis. Understanding
and distribution, energy production and use, electrical con- the methodology and potential artifacts that may be caused
ductivity and muscle contraction in cardiac, skeletal, and by the POC analyzer in use is important, as some physio-
vascular smooth muscle, and clot formation. Many disease logic abnormalities, such as lipemia or hyperbilirubinemia,
processes can cause electrolyte abnormalities including necessitate particular methodology and submission to a
gastrointestinal disease, endocrine diseases such as diabetes, reference laboratory for accurate electrolyte measure-
hyperadrenocorticism, hypoadrenocorticism, and thyroid ment [5]. This chapter introduces methods of electrolyte
disorders, renal and urinary disease, various neoplasms, quantification and commonly used veterinary electrolyte
sepsis, and skin disorders. Treatment interventions in criti- analyzers, the physiologically significant electrolytes,
cally ill animals can also precipitate electrolyte disorders or disease states or treatments that may affect them, and
clinically significant shifts in electrolyte distribution and recommendations on sample handling to ensure correct
levels within the body. measurement and interpretation.
Both abnormally high and low electrolyte changes have
been demonstrated to increase mortality in dogs and cats
[1, 2]. Appropriate treatment of electrolyte abnormalities may ethods of Electrolyte
M
result in decreased morbidity and mortality. Many of the Quantification
clinical signs of electrolyte abnormalities can be masked by
or are thought to be due to the underlying disease state. The Methods of electrolyte evaluation include flame photome-
role of the emergency and critical care technician is to monitor try, ion-selective electrode (ISE) assays, and enzymatic
for potential detrimental effects of electrolyte abnormalities, spectrophotometry (ESP) [5, 6]. When serially evaluating a
appropriately obtain samples and use in-house analyzers, patient’s electrolytes, values should always be measured
and alert the clinician to important changes noted on labora- with the same methodology and, ideally, the same analyzer
tory monitoring over the course of hospitalization. because reference intervals and readings vary among dif-
Electrolyte concentrations in serum, plasma, or whole ferent methodologies and analyzers [5, 7–9]. Flame pho-
blood samples are ultimately the results of the combina- tometry is typically only available in reference laboratories,
tion of intake, excretion, shifts between the intracellular making it impractical to use this methodology for POC
and extracellular space (note that we sample the extracel- analysis. It was the gold standard for electrolyte analysis
lular space in the clinical setting), and artifactual influ- but has become obsolete due to both logistics and inaccura-
ences in vitro [3, 4]. Accurate measurement of electrolytes cies in measurement with concurrent lipemia, hyperpro-
in the critical care setting is both necessary and challeng- teinemia, hemolysis, or hyperbilirubinemia [4, 6]. ESP has
ing, owing to common artifacts such as dilution or binding clinical value in enabling electrolyte measurement using
with anticoagulants, sample exposure to air, and concur- in-house chemistry analyzers but it has demonstrated the
rent sample or patient abnormalities that spuriously alter most interference in situations of hemolysis, hyperpro-
electrolyte measurements. Electrolytes often need to be teinemia, and lipemia [6, 10, 11]. Uremic samples with
748 Electrolyte Evaluation
alterations in bicarbonate and potassium may also affect should be used only as guidelines because each analyzer
samples analyzed by ESP [11]. Updated chemistry analyz- has its own manufacturer-determined reference inter-
ers that use ESP, such as the Catalyst One® chemistry ana- vals [5]. A reference interval specific to the analyzer used
lyzer (IDEXX, Westbrook, ME) and the Vetscan® (Abaxis, should be consulted when interpreting all electrolyte
Union City, CA) use filters to attempt to minimize the measurements. These ranges should be specific for sample
interference created by these abnormalities. One should type (i.e., plasma versus serum) and species within each
interpret results in severely lipemic, icteric, hemolyzed, or analyzer.
hyperproteinemic samples carefully, however, and submit
a paired sample to a reference laboratory that uses ISE to
Sodium
confirm in-house results.
ISE is now the method of choice and the reference method Sodium is the most abundant extracellular ion. It functions
recommended by the Lab Medicine and Clinical and in determining the distribution of water throughout the
Laboratory Standards Institute for the validation of POC ana- body in the extracellular and intracellular compartments
lyzers [6, 7, 11]. The basic principle of ISE measurement is [4, 16–20]. Disorders in sodium concentration are nearly
the comparison of an unknown value against a known value always the result of changes in the volume of body water [4, 16,
to compute the sample’s electrolyte concentration (VetLyte® 17, 19, 21]. The sodium concentration should therefore be
electrolyte analyzer, IDEXX, Westbrook, ME). Essentially, an viewed as a reflection of relative free water in the body, rather
ion-sensitive membrane undergoes a reaction based on the than necessarily the amount of sodium in the body [16, 17,
electrical charge of the ion (electrolyte) causing a change in 19, 21]. “Free water” is water that is free of sodium.
the specific ion-generated voltage. The analyzer then com- An increased sodium concentration is due to either the
pares the change in voltage on the sample side of the mem- loss of body fluid containing relatively less sodium than
brane with a reference solution. An algorithm using the plasma (hypotonic fluid), fluid containing no sodium (free
measured voltages and a calibration curve derived from the water), or the ingestion or iatrogenic administration of
ion concentration of known solutions determines the electro- relatively high-sodium substances [4, 16, 17, 20]. Disease
lyte concentration within the sample. Commonly used in- processes that can result in hypotonic fluid loss include
house veterinary analyzers that use ISE include the i-STAT® gastrointestinal and kidney disease; osmotic diuresis from
(Abbott, Abbott Park, IL) Nova® (Nova Biomedical, Waltham, hyperglycemia, ketonuria, or mannitol administration; or
MA), VetLyte, iSmart-30, and EasyLyte® (Medica, Duluth, postobstructive diuresis [17, 22]. Lack of access to water
MN). Table 56.1 details each of these analyzers, which elec- and neurologic disease resulting in decreased water intake
trolytes they measure, and select operator information. can also result in hypernatremia [17, 19]. Animals with
Electrolytes vary as to the best sampling method and pos- underlying metabolic disorders such as hyperadrenocorti-
sible artifacts associated with measurement, the specifics cism, hyperthyroidism, and hepatic disease have decreased
of which are covered in the subsequent sections. However, urine concentrating abilities and are at risk of developing
overall electrolyte analysis should be performed on serum hypernatremia in the critical care setting if the patient
samples that are collected anaerobically [3, 7, 8, 12–14]. experiences decreased water intake due to nausea or seda-
Anaerobic conditions are most important for ionized cal- tion [17]. Although not significantly hypernatremic,
cium and magnesium analysis [8, 13–15]. Whole blood, Greyhound dogs have slightly higher sodium concentra-
anticoagulated whole blood, and plasma can also be used, tions than non-Greyhound dogs; the reason for this is still
but one must consider various possible artifacts and the being elucidated [23]. Processes resulting in the loss of
risk of clot formation prior to the completion of analysis fluid that contains virtually no sodium (i.e. pure free water
when using whole blood. Careful attention to the timing of loss) include diabetes insipidus and panting [17, 19].
sample collection and measurement is pivotal because var- Hypernatremia can also result from excess sodium reten-
ious electrolyte concentrations can be affected by increased tion or intake as opposed to excessive free water losses.
exposure time to platelets, exposure time to white blood Hyperaldosteronism, a rare disorder in dogs and cats,
cells, and alterations in protein binding associated with results in increased sodium retention [17, 24]. Dietary
continuing cellular metabolism [7, 8, 15]. indiscretion can cause hypernatremia if the animal ingests
excessive salt in the form of substances such as table salt,
sea water, homemade playdough, solid ice melts, or paint-
Individual Electrolytes balls [17]. Iatrogenic causes of hypernatremia include the
administration of high-sodium-containing solutions (sodium
Table 56.2 details normal intervals and critical alert values bicarbonate, hypertonic saline, and sodium phosphate
for each of the physiologically significant electrolytes. It enemas), cathartics such as activated charcoal, and drugs
is important to remember, however, that these intervals that can affect the kidney’s ability to concentrate urine
Individual Electrolytes 749
Table 56.1 Common POC electrolyte analyzers used in veterinary medicine.
Sample Type Based

Electrolytes Measured on Manufacturer
Analyzer Method (Reportable Range) Recommendation Sample Size Maintenance/ Operator tips
Catalyst One ESP Na+(85–180mmol/L) WB 700μL ● Monthly quality control checks

Veterinary K+(0.8–10mmol/L) Serum with internal and external cleaning
Chemistry Cl–(50–160mmol/L) Plasma ● Reboot analyzer weekly
Analyzer Slides should be stored in the
iPhos(0.2–16.1mg/dL) Urine ●
Idexx freezer; warming is not required
tMg (0.5–5.2mg/dL)
prior to running sample
Easy-Lyte PLUS Direct Na+(20–200mmol/L) WB Blood:100μL ● Automatic or on demand
Hemagen ISE K+(0.2–40mmol/L) Serum Urine: 400μL calibration
iCa++(0.1–6.0mmol/L) Plasma ● Easy to use; two button operation
Cl–(25–200mmol/L) Urine
Urine:
Na+(25–1000mmol/L)
K+(1.0–500mmol/L)
Cl–(25–500mmol/L)
EPOC ISEa Na+(85–180mmol/L) WB >92μL ● Real time samples must be
(Element POC) K+(1.5–12.0mmol/L) Serum heparinized as calibrates and
Heska iCa++(0.25–4.0mg/dL) internal QC automatically prior
to each sample (170sec)
● Minimal maintenance
● Handheld
● Cartridges have a 180 Day shelf life
● Sample run window 7.5min such
that real time blood draws must
happen in this window
Gem Premier Direct Na+(100–200mmol/L) WB 150μL ● Monthly internal cleaning with
5000 ISE K+(1.0–20.0mmol/L) supplied wipes
iCa++(0.11–5.0mmol/dL) ● Change GEM PAK montly to
Cl–(40–170mmol/L) perform automated QC
● Performs continuous analyzer
checks before, during and after
every sample run
i-Smart 30 VET Direct ISE Na+(20–250mmol/L) WB 60μL ● No user maintenance required
electrolyte K+(0.5–20.0mmol/L) Plasma ● Autocalibration
analyzer- Cl–(20–250mmol/L) ● Cartridges stored in refrigerator,
Woodleyb run at room temperature
● Cartridges good for 4 weeks once
warmed to room temperature
● Results in 35 sec
i-STAT Alinity ISE* Na+(100–180mmol/L) WB with or 150μL ● Handheld, portable, and has
Abaxis Abbott K+(2.0–9.0mmol/L) without heparin touch screen
iCa++(0.25–2.5mg/dL) ● Rechargeable battery
Cl–(65–140mmol/L) ● Calibration performed
automatically each time a cartridge
requiring calibration is use
● Only maintenance required is a
software update every 6 months
● Cartridges must be refrigerated.
When removed from the fridge
cartridges must be stored at room
temperature and are good for up
to 2 weeks
(Continued)
Sample Type Based

Electrolytes Measured on Manufacturer
Analyzer Method (Reportable Range) Recommendation Sample Size Maintenance/ Operator tips
Radiometer ISE* or Na+(116–180mmol/L) WB 65μL ● Clot detection

ABL90 Flex ESPc K+(2.1–10.5mmol/L) ● Automatic QC management
iCa++(0.5–2.48mg/dL) ● Automatic sample mixing
Cl–(86–151mmol/L) ● Cassettes stored at 36-46°F,
refrigerated
● Can use syringe, capillary tube or
test tube to enter a sample
Response910 VET ESP Na+(100–180mmol/L) WB 2–30μL ● Minimal maintenance
Veterinary K+(1.5–8.5mmol/L) Plasma ● Monthly calibration
Chemistry tCa(1.0–16.0mg/dL) Serum ● Store reagent 35.6°–77°F
Analyzer-Diasys
Cl–(40–170mmol/L) CSF ● Reagent life is 12 months
tMg(0.2–5.0mg/dL) Urine
iPhos(0.2–30mg/dL
Rapidpoint 500 ISEa Na+(100–200mmol/L) WB Capillary ● ~60 sec to results
Siemens K+(0.5–15.0mmol/L) tube: ● Automatic QC
iCa++(0.2–5.0mg/dL) 100μL ● No maintenance requirements
Cl–(65–140mmol/L) Syringe: ● Cartridge life is 28 days
200μL
Stat Profile Direct Na+(80–200mmol/L) WB, heparinized 135–250μLd ● Automatic QC
Critical Care ISE K+(1.0–20.0mmol/L) ● Automated maintenance
Xpress Nova iCa++(0.1–2.7mg/dL)
iMg++(0.1–2.5mmol/L)
VetLyte Idexx ISEa Na+(40–205mmol/L) WB 95μL ● No longer being
K+(1.5–15.0mmol/L) Serum ● Weekly maintenance and
Cl–(50–200mmol/L) Plasma cleaning
● Daily conditioning
● Monthly cleaning of electrode
+
Vetscan VS2 ESP Na (110–170mmol/L) WB 100μL ● Minimal Maintenance: clean
Analyzer K+(1.5–8.5mmol/L) Serum filter on back of analyzer
Zoetis tCa(4.0–16.0mg/dL) Plasma ● Self Calibrates
Cl–(80–135mmol/L) ● Automatic QC and calibration
iPhos(0–20mg/dL) ● Results in 12 minutes
a +
Xpedite ISE VET ISE Na (40–200mmol/L) WB 95μL ● No daily maintenance required
Veterinary K+(1.7–15.0mmol/L) Serum ● Automatic QC checks
Electrolyte iCa++(0.3–5.0mmol/L) Plasma
Analyzer-Diasys
Cl–(50–200mmol/L) Urine
Urine:
Na+(3–300mmol/L)
K+(5–120.0mmol/L)
FF, flame photometry; ESP, enzymatic spectrophotometry; ISE, ion selective electrode; Na+, sodium; K+, potassium; Cl–, chloride; iPhos,
inorganic phosphate; iCa++, ionized calcium; iMg++, ionized magnesium; tMg, total magnesium; WB, whole blood; QC, Quality Control; min,
minutes.
a
Machine methodology stated as potentiometric or ion sensitive electrodes without specification of direct or indirect.
b
i-Smart 30 PRO is a similar analzyer which measures hematocrit in addition to electrolytes
c
Radiometer methodology for electrolytes is determined by settings for electrolytes as ISE vs. ESP
d
Volume required for Nova dependent on which chemistry is being run
Table 56.2 Reference ranges and alert values of each electrolytea.
Electrolyte Normal Range Canine Normal Range Feline Critical Care Alert Valuesb Common Situations that may Cause Erroneous Results
Na+ 139–150mmol/L 139–150mmol/L <120mmol/L ● Lipemia

>170mmol/L ● Hemolysis
Change: ● Hyperbilirubinemia
>1.0mmol/L/hr ● Hyperproteinemia
>10mmol/L/24h ● Sodium heparin
+
K 3.4-4.9mmol/L 147-162mmol/L <2.5mmol/L ● Thrombocytosis
>6.0mmol/L ● Leukocytosis
● Potassium EDTA
● Delay in serum or plasma separation
Cl– 106-127mmol/L 112-129mmol/L <90mmol/L ● Lipemia
● Hemolysis
● Hyperbilirubinemia
● Hyperproteinemia
● Sodium heparin
iPhos 2.5-6.0mg/dL 3.1-7.5mg/dL <1.5mg/dL ● Hemolysis
● Citrate, Oxalate and EDTA anticoagulation
● Hyperlipidemia
● Hyperbilirubinemia
● Delay in serum or plasma separation
iCa++ 1.12-1.40mmol/L 1.2-1.32mmol/L <0.75mmoL/L ● Aerobic sampling
>2.0mmol/L ● Heparin dilution
● Heparin binding
● Delay in analysis
++
iMg 0.42-0.58mmol/L 0.47-0.60mmol/L ● Heparin dilution
tMg 1.5-2.5mg/dL 1.5-3.0mg/dL ● Heparin binding
● Delay in analysis
a
Catalyst DX chemistry analyzer (IDEXX Laboratories, Westbrook, ME), operator ’s guide, and iSTAT Alinity (Abaxis, Union City, CA), user manual.
b
Critical care alert values refer to values that suggest impending severe physiologic compromise. Any value outside of the reference range is
considered clinically significant, however.
(gentamicin, amphotericin B, methoxyflurane, and vinca Decreased sodium concentrations are caused by a rela-
alkaloids) [17, 19, 22]. As evident by this extensive list of tive gain of free water or hypotonic fluid within the extra-
causes, many animals admitted to a veterinary intensive cellular space [16, 21]. This may be due to a true increase in
care unit are at risk of having or developing hypernatremia. total body water or a decrease in body fluids with sodium
Serial measurements to monitor for a rising sodium con- losses exceeding water losses [16, 20]. Measured hypona-
centration are necessary to catch an animal trending tremia may be due to an increase in osmotically active par-
toward hypernatremia before the clinical signs of hyperna- ticles such as glucose or mannitol in the extracellular fluid
tremia develop, at which point irreversible neurologic causing a dilution of sodium molecules in the serum [16,
damage may have occurred. 20, 21]. Puppies have been documented to have lower
Hypernatremia results in cellular dehydration in the sodium concentration than adult dogs, with some puppies
brain as water moves from the intracellular to the extracel- being below the reference interval up until approximately
lular space along its osmotic gradient [19, 20]. The brain 11 weeks old [25]. Gastrointestinal disease, severe burns,
tissue shrinks, which can result in tearing of blood vessels and hemorrhage all cause fluid loss that can result in hypo-
and subarachnoid and intracerebral hemorrhage [17, 19]. volemia with normal sodium concentration [20, 21].
Clinical signs are related more to the rate of increase of the Sometimes, however, these clinical syndromes result in
sodium concentration rather than to the absolute concen- hyponatremia from an increase in antidiuretic hormone
tration, and they include lethargy, nausea, depressed men- (ADH) levels in the face of hypovolemia, also called nonos-
tation, ataxia, and weakness [17, 20]. Neurologic signs can motic ADH release; ADH functions to retain free water and
progress to seizures, coma, and death [17, 20]. in this scenario prioritizes blood volume over the sodium
Table 56.3 Various fluid solutions and their sodium and potassium concentrationsa (mEq/L).
Fluid Type Sodium Chloride Potassium Calcium Magnesium
5% Dextrose in water 0 0 0 0 0
0.45% Saline 77 77 0 0 0
2.5% Dextrose in 0.45% Saline 77 77 0 0 0
Lactated Ringers Solution 130 109 4 3 0
Plasma-Lyte A 140 98 5 3
Normosol-R 140 98 5 0 3
0.9% NaCl 154 154 0 0 0
Vetstarch 154 154 0 0 0
7.5% Hypertonic NaCl 1232 1232 0 0 0
a
Values reported based on each fluid type’s drug insert
concentration, something that is typically kept relatively hyponatremia) and relatively hypotonic (in the case of
constant in the body [21]. Water retention and resultant hypernatremia) fluids. Table 56.3 details the sodium con-
hyponatremia can occur in cases of hypothyroidism with centration of various electrolyte solutions that can be used
myxedema coma and in water intoxication [20, 26]. Loss of to treat sodium abnormalities. Diuretic administration
sodium through the kidneys can occur with hypoadreno- may be necessary to encourage sodium or water excretion
corticism, diuretic administration, or sodium-wasting [16, 17, 19–21]. The fluid of choice depends on the desired
renal disease [20]. A pathologic syndrome known as the rate of sodium drop and the volume status of the patient.
syndrome of inappropriate antidiuretic hormone secretion Cases of chronic sodium concentration abnormalities
(SIADH) has been described in people as well as veterinary (> 48 hours) should be treated with the goal of gradually
patients [16, 20, 21, 27]. It is characterized by inappropriate correcting the sodium concentration; acute cases can be
release of ADH resulting in the retention of free water [16, addressed more aggressively [20, 21]. Sodium concentration
20, 21, 27]. This syndrome has been associated with certain should not be changed more frequently than 0.5–1.0mEq/kg/
neoplasms, pulmonary disease including pneumonia in a hour, 10mEq/l over 24hours, or more quickly than 18mEq/l
dog, central nervous system disease, perioperative status, over 48 hours [17, 20, 21]. Rapid adjustment of sodium
and certain drugs [16, 20, 21, 27]. There is documentation concentration can result in neurologic sequelae.
of SIADH in human patients associated with the adminis- In the case of hyponatremia, neuronal dehydration
tration of fentanyl, a drug used commonly in critically ill or resulting in a syndrome known as osmotic demyelination
injured veterinary patients [28]. Disease processes associ- syndrome (ODS, previously called central pontine mye-
ated with decreased effective circulating volume such as linolysis) can occur if the sodium concentration is raised
hepatic disease and primary cardiac disease can cause too fast during treatment [20, 21]. ODS is characterized by
hyponatremia as the thirst center is activated, increasing water moving out of brain cells during the correction of
water consumption [16, 20, 21]. Administering relative free hyponatremia [20, 21]. Signs of ODS can be delayed one to
water in the form of intravenous nutrition has also been six days and neuronal damage can be irreversible, making
associated with hyponatremia [29]. careful sodium monitoring vital because clinical signs may
Similar to hypernatremia, the severity of the clinical not immediately be apparent [20]. In the case of hyperna-
signs associated with hyponatremia depend on the rate of tremia, rapid drops in sodium concentration can cause cere-
drop as well as the absolute sodium concentration [20, 21]. bral edema as extracellular water moves into neurons [20].
Signs often do not occur unless the sodium concentration Unlike in ODS, the signs of cerebral edema and rising
is less than 125 mmol/l. [20, 21] Vomiting, ataxia, depres- intracranial pressure due to overzealous correction of
sion progressing to obtundation, seizures, and coma may hypernatremia appear at the time of treatment and include
occur as a result of cerebral edema as water moves into depressed mentation, pupillary changes, thoracic limb
neurons [21, 26]. rigidity, and seizures. The technician must monitor closely
Treatment of sodium concentration abnormalities for these signs and pay close attention to serial sodium
involves addressing the underlying cause and slowly concentrations. Initially, sodium concentration should
returning the sodium concentration to normal with the be reassessed every two to six hours during the treatment
administration of relatively hypertonic (in the case of of sodium derangements, depending on the severity of
clinical signs, the degree of abnormality, and the duration

Protocol 56.1 Preparation of a Heparinized Syringe
of the disorder [20, 21].
or “Evacuated Syringe” for Blood Sampling
Sodium Concentration Measurement Items Required

The reference standard for sodium measurement was tra-
● 3-ml syringe with a 22-gauge needle attached
ditionally flame photometry [16], which evaluates the
● Liquid sodium heparin 1000 iu/ml concentration
entire volume of the sample, including both the aqueous
and the nonaqueous phases [16]. Plasma is 93% water by Procedure
volume, and sodium is present in the aqueous phase of
1) Aspirate 0.5 ml heparin into the syringe and set the
plasma [16]. The distribution of sodium within only the
heparin bottle aside. Leave the 22-gauge needle
aqueous portion of the sample results in an artifactually
attached to the syringe.
lower measured concentration of sodium than is truly pre-
2) Draw the plunger back to the 3-ml mark to coat the
sent [16]. This difference is typically negligible, but in situ-
inner surface of the syringe
ations of hyperlipidemia and hyperproteinemia the
3) Expel all the air and heparin.
nonaqueous portion of plasma increases [16]. When the
4) Draw 3ml of air into the syringe and expel it forcefully.
nonaqueous portion of plasma is increased, the measured
5) Repeat step 4 a total of three times.
concentration of sodium will be significantly lower than
6) Perform venipuncture.
the actual value, invalidating the results [16]. This artifact
● 0.5 ml sample is 7.8% Na heparin: inaccurate for
is known as pseudohyponatremia [16].
all electrolyte measurements
Direct measurement via ISE measures sodium in water
● 1.0 ml sample is 3.9% Na hHeparin: accurate for
only, avoiding the artifact caused by increased lipid or pro-
Na+ and K+ measurements
tein in samples [16, 20, 21]. Indirect ISE, however, involves
● 3.0 ml sample is 1.3% Na heparin: likely accepta-
a dilution step that is accounted for by adjusting the sodium
ble for iCa++ and iMg++ measurements
concentration by a correction factor of 0.93 (93%), the
plasma component of water in a “normal” sample [21]. iCa++, ionized calcium; iMg++, ionized magnesium.
Indirect ISE will therefore also reduce the “measured”

sodium concentration if protein or lipid reduce the relative Chloride
amount of the aqueous phase of the sample [21]. Low pro-
Chloride is an extracellular ion that functions with sodium in
tein in the sample can result in falsely elevated values if
maintaining water balance and has an important role in
measured via indirect ISE [21].
acid–base balance [30]. Chloride concentration often changes
ESP can be used to measure sodium concentrations but
with the sodium concentration as a reflection of free water,
can be inaccurate for hemolyzed, icteric, or hyperproteine-
but certain situations can alter chloride concentration inde-
mic samples and therefore should be used with caution in
pendent of changes in sodium. To determine whether the
these circumstances [6]. Serum should be submitted to a
change in chloride concentration is due to an alteration in
reference laboratory that uses ISE for sodium and chloride
sodium, formulas were developed (Eq. 56.1) that function to
concentration evaluation in icteric, lipidemic, or hyperpro-
determine the chloride concentration as high, low, or normal
teinemic patients if the in-house electrolyte analyzer uses
outside of the influences of free water [30]:
ESP to verify the in-house results. It also has higher normal
reference intervals for sodium concentration than flame DogC1 corrected C1 146 / Na
photometry or ISE, so analyzer-specific intervals must be (56.1)
used when interpreting results [5, 6]. Cat DogC1 corrected C1 156 / Na
Sodium heparin contains relatively high concentration
of sodium (160 mEq/l) and chloride (166 mEq/l) and can Hypochloremia can be caused by vomiting, gastrointesti-
falsely increase the measurement of both these electrolytes nal obstruction, metabolic alkalosis, and therapy with diu-
when whole blood is anticoagulated with sodium heparin retics that block absorption of chloride in the kidneys (e.g.
at concentrations greater than 3.9% [3]. Thus, if one uses furosemide) [31, 32]. Hypochloremia is more common
sodium heparin to anticoagulate the sample prior to meas- than hyperchloremia in cats with sepsis and the systemic
urement of sodium or chloride concentrations, preparation inflammatory response syndrome; the hypochloremia in
of an “evacuated syringe” (Protocol 56.1) or the purchase these patients may represent a compensatory change asso-
of commercially available syringes containing lyophilized ciated with metabolic acidosis primarily due to uremia or
40 iu/ml heparin is necessary to avoid artifact [3]. One ketosis, in which non-chloride, non-bicarbonate anions
could also use lithium heparin for measurement of sodium accumulate [33, 34]. Hyperchloremia is often the result of
or chloride concentrations [3]. loss of bicarbonate-rich, chloride-poor fluid in diarrhea
and renal disease, and it is associated with a metabolic aci- of intake (primarily through nutrition), loss into the gastro-
dosis [32]. The administration of bicarbonate-free fluids intestinal tract (a factor exacerbated in animals with gas-
such as 0.9% NaCl is thought to contribute to hyperchlo- trointestinal disease), kidney function, as the bulk of
remia associated with illness and can potentially cause iat- potassium is eliminated through the kidneys, and transcel-
rogenic hyperchloremia in critically ill patients [32, 35, 36]. lular potassium shifts as occurs in some acid–base disor-
The clinical signs of chloride derangements are typically ders and under the influence of insulin [32, 39].
associated with the underlying disease process or acid–base Hyperkalemia can be caused by decreased renal excretion
abnormality. Hyperchloremia may exacerbate cardiovascular in acute kidney failure, end-stage kidney disease, or hypoad-
compromise, acute kidney injury, coagulation disturbances, renocorticism, urinary obstruction or intra-abdominal urine
and gastrointestinal dysfunction [35, 36]. Treatment of chlo- accumulation, and syndromes of massive cell death such as
ride derangements involves addressing the underlying disor- tumor lysis syndrome or rhabdomyolysis [32, 39]. Drug
der and stopping any iatrogenic cause. therapy with angiotensin-converting enzyme inhibitors (e.g.
benazepril and enalapril), nonsteroidal anti-inflammatory
Chloride Concentration Measurement agents, beta-blockers (e.g. atenolol), potassium itself,
Chloride measurement is similar to that for sodium in that it potassium-sparing diuretics (e.g. spironolactone), and hepa-
can be falsely lowered by lipemia and hyperproteinemia and rin have been shown to cause hyperkalemia in people and
falsely increased by the use of sodium heparin for anticoagu- may result in similar changes in small animal patients [16].
lation [3, 6]. Direct ISE, particularly in the presence of low Patients at higher risk are those prescribed a combination of
bicarbonate concentrations, is the more accurate method of these drugs and those with decreased renal delivery of potas-
measuring chloride concentration [37]. Chloride concentra- sium, as might be seen in dogs and cats with cardiac disease
tion is more affected by dilution with sodium heparin than and dehydration [39, 40]. A group of disease processes can
sodium concentration [3]. The sensitivity of chloride con- cause concurrent hyperkalemia and hyponatremia with a
centration measurements to sodium heparin anticoagulant decreased sodium-to-potassium ratio. This is the classic elec-
is likely caused by the high concentration (166 mmol/l) of trolyte picture with hypoadrenocorticism [41]. A decreased
chloride within sodium heparin. Because the concentration sodium-to-potassium ratio can also be seen in dogs and
of chloride within sodium heparin is significantly higher cats with gastrointestinal disease, kidney disease, preg-
than normal chloride concentrations, it spuriously increases nancy, body cavity effusions, and cardiac disease resulting in
the chloride measurement of the sample. Accurate chloride decreased effective circulating volume. Decreased effective
analysis should either be performed on serum, plasma, or circulating volume triggers free water retention and hypona-
whole blood that is anticoagulated with lithium heparin. tremia with concurrent decreased renal delivery of potas-
Red blood cells in venous blood carry more intracellular sium for excretion, resulting in hyperkalemia [40, 42, 43].
chloride than red blood cells in arterial blood, and the chlo- Hyperkalemia can be life threatening as a result of the
ride concentration in venous blood is 3–4 mEq/l lower than increased potassium concentration’s effect on cardiac cell
arterial blood [30]. This variation is due to chloride shifting conduction and function [32, 39]. Clinical signs include
out of red blood cells in the presence of higher oxygen and muscular weakness with progression to paralysis [32, 39].
lower carbon dioxide (generally the environment within Cardiac toxicity is manifested by classic electrocardiogram
arterial blood and room air relative to venous blood) [30]. (ECG) abnormalities, including tall, tented T waves, a
If a sample is exposed to room air and permitted to “arteri- prolonged PR interval, loss of the P wave, bradycardia,
alize,” the chloride concentration measurement will be and widening QRS complexes (see Figure 56.1) [32, 39].
falsely increased. Anaerobic sampling is therefore neces- Ventricular tachycardia and fibrillation can occur [32]. In
sary when determining and interpreting chloride concen- severe hyperkalemia, the ECG progresses to a sine-wave
trations from venous blood [30, 38]. pattern as the QRS complexes merge with the T wave. This
latter rhythm is an indication of impending cardiac arrest,
and rapid intervention is indicated [39]. Life-threatening
Potassium
hyperkalemia generally occurs at potassium concentrations
Potassium is the most abundant cation in the body, but it is greater than 7.5 mEq/l [32], but concurrent abnormalities
located primarily intracellularly, making measurement in such as hypovolemia, acidemia, hypocalcemia, and hypona-
whole blood, serum, or plasma an imperfect reflection of tremia may exacerbate the condition and trigger rapid car-
total body stores [16, 39]. The large concentration gradient diac collapse at lower potassium concentrations [39].
of potassium across cell membranes enables potassium Treatment of hyperkalemia involves diuresis with intrave-
to be a key player in the excitability and function of nerve nous fluid therapy, relieving urinary obstruction if present,
and muscle cells, including those in cardiac and vascular cardiac protection with calcium gluconate or calcium chlo-
smooth muscle [39]. Potassium concentration is a reflection ride administration, and initiating intracellular movement
increased P wave amplitude, and prolonged PR and QRS

intervals [32]. Multiple arrhythmias may also occur [32, 39].
Treatment of hypokalemia involves potassium supple-
mentation orally or parenterally, depending on the severity
of hypokalemia and whether or not the patient is tolerant of
enteral treatments [32, 39]. Concurrent magnesium admin-
istration may be necessary to treat hypokalemia effec-
tively [32]. Charts exist with recommended potassium
supplementation based on the degree of hypokalemia, but
these should be viewed as a starting point. Rate of potas-
sium administration depends on the degree of total body
depletion, renal and gastrointestinal losses of potassium,
and rate of diuresis. Potassium concentration should be
monitored at least once a day in patients on potassium sup-
plementation and more frequently in animals with docu-
Figure 56.1 A 6-lead ECG showing some classic changes mented hypokalemia or pathophysiologic processes that
associated with hyperkalemia: tall, tented T waves; loss of the
P wave; and widening QRS complexes. may cause hypokalemia. Parenteral potassium supplemen-
tation should rarely exceed 0.5 mEq/kg/hour and should
never exceed 1.0 mEq/kg/hour because rapid potassium
of potassium with insulin, dextrose, beta agonists (e.g. terb- administration can cause cardiac arrest [32]. The rate of
utaline or albuterol) or bicarbonate therapy [32, 39, 44]. In potassium supplementation should be checked frequently,
the ICU, management of hyperkalemia also includes reduc- and fluids with potassium additives should not be admin-
ing potassium supplementation in fluids and drugs, and istered rapidly as a bolus. Box 56.1 demonstrates how to
using only potassium-restricted diets for nutritional support. determine the rate of potassium supplementation based on
In refractory kidney failure, hemodialysis or peritoneal dial- the concentration of potassium in the solution. When
ysis is required to treat hyperkalemia [32, 39]. administering potassium in particular, but true of all hyper-
Low potassium concentration, or hypokalemia, is typi- osmolar electrolyte additives, the infusate should be diluted
cally the result of excessive potassium loss through the gas- to less than 550 mOsm/l to avoid phlebitis in peripheral,
trointestinal tract or through the kidneys due to renal small, lower-flow veins [47]. Potassium additives in fluids
disease or osmotic diuresis (e.g. hyperglycemia, ketonuria, have been found to be inaccurate in terms of actual potas-
postobstructive diuresis); hypokalemia can also result from sium concentration of the fluid delivered compared with
intracellular potassium shifts in the face of metabolic alka- intended concentration [48]. However, adequate mixing of
losis [32, 39]. Hypokalemia is often confounded by the fluid bag characterized by inversion of the bag four
decreased potassium ingestion due to nausea or ano- times results in more accurate potassium delivery [48].
rexia [32, 39]. Iatrogenic causes of hypokalemia include
diuretics, steroids, beta agonists (e.g. terbutaline, albuterol), Potassium Concentration Measurement
or insulin and dextrose therapy [32]. Hypomagnesemia can Artifactually increased potassium concentrations can be
cause refractory hypokalemia in which the potassium con- caused by anticoagulation with potassium EDTA as well as
centration does not return to normal despite aggressive prolonged exposure to potassium-containing cells such as
supplementation [32]. Re-feeding of cats and dogs that platelets and white blood cells [16, 43]. Thrombocytosis
have suffered prolonged starvation can result in hypoka- and leukocytosis have both been shown to cause pseudohy-
lemia due to insulin release in the face of depleted electro- perkalemia [12, 43]. Artifactual hyperkalemia can be seen
lyte stores [45, 46]. Hyperaldosteronism causes increased in blood samples from Japanese dog breeds (e.g. Akita,
renal excretion of potassium and is a rare cause of severe Shiba Inu) because of leakage of potassium from these
hypokalemia in dogs and cats [24]. breeds’ potassium-rich red blood cells [12]. Potassium con-
Clinical signs of hypokalemia generally occur with serum centrations are generally higher in serum than in plasma
potassium concentrations less than 2.5mEq/l and include due to release of potassium from platelets during clot-
generalized weakness characterized classically by cervical ting [12]. Canine serum potassium concentrations are gen-
ventroflexion that can progress to paralysis and respiratory erally 0.35 mmol/l higher than in canine plasma, and feline
failure, inability to concentrate urine, anorexia, vomiting, serum potassium was found to be 0.47 mmol/l higher than
and decreased bowel motility [32, 39]. Cardiac conduction in feline plasma [12]. This expected variation between
abnormalities can occur and manifest on ECG by a depressed serum and plasma samples necessitates consideration of
ST segment, decreased amplitude or inversion of the T wave, the sample type used to create the reference interval on the
Box 56.1 Back-Calculation to Ensure Safety of Potassium Supplementation in mEq/kg/hour

Method
1) Determine the amount of potassium in the solution by adding the amount of supplemented potassium to the
amount already present in the stocked fluid (Table 56.3).
2) Divide the total amount of potassium by the total volume of the fluid to determine the concentration of potassium
in the solution.
3) Determine the total amount of potassium being administered/hour by multiplying the amount of potassium/milli-
liter by the fluid rate of the patient in ml/hour.
4) Determine the rate of administration in mEq/kg/hour by dividing the amount of potassium/hour by the weight of
the patient in kilograms.
Case example
A 10-kg Boston terrier being treated with lactated ringer solution with potassium 40 mEq/l added at a rate of 40 ml/hour.
1) Total amount of potassium in 1L of solution:
40mEq supplemented 4mEq already present in fluid 44mEq
2) Concentration of potassium in solution:
44 mEq total amount potassium 1000 ml total volume 0.044 mEq / ml
3) Amount of potassium administered/hour:
0.044mEq / ml 40ml / hr 1.76mEq / h
4) Rate of administration:
1.76mEq / h 10kg 0.18mEq / kg / hour
analyzer being used [12]. Serial samples on the same Syringes should be prepared for blood sampling using
patient should always be run using the same sample type the “evacuated syringe” technique (Protocol 56.1) [3]. Use
(i.e. serum or plasma) on the same machine. Although the of a commercially available syringe coated with lyophi-
changes caused by anticoagulation with potassium EDTA lized 40 iu/ml heparin is also an option to avoid dilutional
or potassium leakage from cells are typically minimal, they artifact [3].
may result in pseudohyperkalemia or pseudonormoka-
lemia if the patient’s actual value is at the high end of nor-
Phosphorus
mal or just below the reference interval, respectively [12].
Ideally, potassium concentration should be determined Phosphate is a vital intracellular ion in many physiologic
from whole blood, heparin anticoagulated whole blood, or processes including maintenance of cell membrane
plasma rapidly separated from the cell pellet to minimize integrity, enzyme activation and deactivation, acid–base
length of exposure to potassium-containing cells [12]. balance, clot formation, and energy production and
Hemolysis and elevated total protein concentration use [49–51]. Most of the phosphorus in the body is within
appear to have less of an effect on potassium measurement the mineralized bone matrix with the remainder mostly
than on sodium and chloride measurements, although intracellular [49, 50]. Only a small portion (< 1%) is present
analysis with ESP showed more variation in potassium in the extracellular fluid [49, 50]. Only one third of total
measured in hemolyzed samples than either flame pho- plasma phosphorus, in the form of inorganic phosphate,
tometry or ISE [6]. Like sodium and chloride, however, is measured by chemistry analyzers [50]. Similar to potas-
values obtained via ESP are generally higher than sium, changes in total body stores of phosphorus are not
those obtained via flame photometry or ISE [6]. Because necessarily reflected by blood phosphate concentration [49,
ESP potassium concentration measurement can show 50]. An increased blood phosphorus concentration may
more variation than other methods, samples for plasma occur in situations of normal or low total body phosphorus
potassium measurement should be submitted for ISE levels. Transcellular shifts contribute to many of the
analysis to a reference laboratory in patients with severe alterations seen in phosphate concentrations measured
hemolysis or hyperbilirubinemia if the available POC ana- in critically ill patients [49, 50].
lyzer uses ESP. Hypophosphatemia can be caused by a number of
Samples anticoagulated with heparin can cause dilution disease processes, as well as arising secondary to treatment
and artifactual lowering of potassium concentrations [3]. of various disease states. It can be seen in patients with
decreased intestinal absorption, increased renal losses, to six hours to ensure appropriate supplementation [49].
hypomagnesemia, rapid tissue regeneration (i.e. liver Toldimfos sodium is a derivative of phosphoric acid that
regeneration after an episode of acute hepatic failure), has been used to treat severe hypophosphatemia [51].
head trauma, sepsis, hypothermia, hyperparathyroidism, Sodium, potassium, and ionized calcium concentrations
vitamin D deficiency, and hypercalcemia associated with should also be closely monitored while patients receive
certain cancers. Hypophosphatemia can also be caused by phosphorus therapy because it can cause increases in these
the shifting of phosphorus into cells with respiratory or electrolytes, and calcium concentration can drop due to
metabolic alkalosis, insulin, or dextrose administration binding of calcium to phosphorus [49].
(particularly in diabetic ketoacidosis), or re-feeding after Hyperphosphatemia is generally caused by decreased
prolonged starvation [45, 46, 49–51]. Respiratory alkalosis urinary excretion of phosphorus due to kidney disease or
with associated hypophosphatemia can be seen in critically urinary obstruction; increased phosphorus release during
ill patients who are hyperventilating as a result of pain, cell death (e.g. tumor lysis syndrome), hypoparathyroidism,
anxiety, fever, or seizures [49]. Treatment of patients with or iatrogenically through administration of phosphate-
phosphate-binding antacids (e.g. aluminum hydroxide) or containing enemas [50]. Phosphate concentration is normally
aggressive diuresis in the face of decreased intake can higher in growing animals up to one year of age due to
result in hypophosphatemia [50]. rapid bone turnover; therefore, adult reference intervals
Clinical signs generally do not occur unless hypophos- usually underestimate the normal growing animal’s phos-
phatemia is severe [49–51]. The most significant clinical phorus concentration [50]. Intoxications with vitamin
sequelae of hypophosphatemia are decreased delivery of D-containing rodenticides, anti-psoriasis creams (e.g. cal-
oxygen to the tissues due to an increased affinity of hemo- cipotriol and calcipotriene), or zinc phosphide (a rodenti-
globin for oxygen, impaired white blood cell function, and cide used in gopher bait) can cause serious and potentially
the development of hemolytic anemia a result of altered fatal hyperphosphatemia [50].
integrity of the red blood cell membrane [49, 50]. Decreased Clinical signs of hyperphosphatemia include weakness,
oxygen delivery to tissues may cause subtle clinical signs, tetany, seizures, tachycardia, and torsades des pointes, a
but severe cases may demonstrate neuromuscular depres- potentially fatal cardiac arrhythmia [50]. Initial treatment
sion first noted with diaphragmatic weakness, muscle fas- should directly address severe sequelae of hyperphos-
ciculations, and progressive neurologic signs such as ataxia phatemia such as seizures and torsades des pointes. Following
and seizures [49, 51]. Other signs of hypophosphatemia stabilization, therapy to lower phosphorus concentration
such as ileus, anorexia, and vomiting are often thought to includes diuresis with crystalloid therapy and potentially
be part of the underlying disease [49]. Hemolysis in dogs dextrose administration to drive phosphorus into cells [50].
has not been documented until phosphorus concentrations
are less than 0.5 mg/dl, but cats appear to be more sensitive Phosphate Concentration Measurement
and have been shown to hemolyze at 1mg/dl [49]. A decreased Phosphate should be measured on serum or heparinized
hematocrit may take 24–48 hours to become apparent fol- plasma using ESP or flame photometry [49, 52]. Citrate,
lowing hemolysis triggered by hypophosphatemia [49, 50]. oxalate, and EDTA can interfere with the enzymatic assays
In addition to hemolysis, severe hypophosphatemia can and should therefore not be used [49]. Hemolysis of the
cause myocyte damage with neuromuscular pain and pig- sample causes artifactual hyperphosphatemia as inorganic
menturia [51]. Treatment of hypophosphatemia involves phosphate is released from red blood cells and quantified
managing the underlying condition, addressing any acid– along with the serum fraction. Similar to potassium, serum
base abnormalities contributing to transcellular shifts, and or plasma should be separated from cells within one hour
administering phosphorus supplementation either enter- of sampling to prevent leakage of cellular phosphorus into
ally or parenterally in more severely affected or nauseated the sample [49]. Hyperlipidemia and hyperbilirubinemia
animals [49]. It is recommended to treat phosphorus con- may falsely decrease the phosphate concentration due to
centrations under 3 mg/dl [49]. Parenterally administered interference with colorimetric determination [49].
potassium phosphate should be diluted before use because
it is hypertonic and can cause tissue irritation [49]. It
Calcium
should be administered in calcium-free fluids (0.9% saline
or 5% dextrose in water) to prevent precipitation of calcium Like phosphorus, most of the body’s calcium is stored in
salts [49]. Similar to other electrolytes, the dose depends on bone with less than 1% readily available in plasma. Calcium
the rate of phosphorus loss and the underlying cause of exists in three forms in plasma or serum: ionized or “free”
hypophosphatemia. Recommended doses of parenteral calcium (iCa++), complexed or chelated calcium bound to
phosphorus range from 0.01–0.06 mmol/kg/hour [49, 50]. other substances such as phosphate and sulfate, and protein-
Phosphorus concentrations should be monitored every three bound calcium [13]. Ionized calcium is the biologically
active form of calcium and has a role in many physiologic Calcium Concentration Measurement
functions including intra- and extracellular messaging,
Calcium can be measured as either total calcium (a reflection
cardiac conduction, and muscle contraction [53].
of ionized and bound forms in plasma) or ionized cal-
The most common cause of hypercalcemia in veterinary
cium [16]. Total calcium can be affected by protein concentra-
patients is neoplasia, specifically lymphoma [18, 53]. Other
tion, as a portion of total calcium is protein bound. Historically,
neoplasms can also cause hypercalcemia [18, 53]. Other
formulas were created to correct total calcium for the influ-
causes of hypercalcemia include kidney failure, hyperpar-
ence of hypoalbuminemia [13, 54]. However, these formulas
athyroidism, hypoadrenocorticism, and systemic pyogran-
have since been shown to cause inaccurate interpretation of
ulomatous disease [18, 53]. Intoxications that can result in
calcium concentration in the face of hypoproteinemia [13,
hypercalcemia include vitamin D rodenticides, anti-
54]. Total calcium measurements correlate poorly with ion-
psoriasis creams (e.g. calcipotriol, calcipotriene), and day-
ized calcium in situations of renal insufficiency and acid–base
blooming jasmine ingestion [18].
imbalance [8, 15]. Total calcium measurement can also be
Hypercalcemia results in nausea, anorexia, abdominal
spuriously affected by hemolysis, hyperbilirubinemia, and
pain, constipation, polyuria and polydipsia, and soft tissue
lipemia [13]. Ionized calcium assessed by ISE, which mini-
mineralization [18]. It is treated with promotion of calciu-
mizes interference by other ions, protein, hemolysis, and
resis by intravenous fluid therapy, furosemide, and gluco-
lipemia, is considered the most accurate and clinically appro-
corticoids; treatment of the underlying cause; and
priate way to measure calcium [13, 54].
medication to inhibit bone resorption (e.g. calcitonin and
Measurement of ionized calcium must be carefully planned
bisphosphonates) [18].
and performed due to potential artifact associated with expo-
Hypocalcemia is common in critically ill humans and has
sure to air, the anticoagulant used, hemodilution with the
been documented in hospitalized cats and dogs [54, 55]. It
anticoagulant, and alterations in ionized calcium with
can occur in many disease states such as kidney failure, dia-
prolonged handling time. Calcium can be measured in whole
betic ketoacidosis, pancreatitis, eclampsia, malabsorptive
blood, plasma, or serum, but reference intervals for each
syndromes, feline lower urinary tract obstruction, ethylene
sample type may vary slightly depending on the analyzer.
glycol toxicosis, tumor lysis syndrome, hypomagnesemia,
Ionized calcium concentration is affected by pH because
and sepsis [56]. The systemic inflammatory response syn-
hydrogen ions compete with ionized calcium for binding
drome in a number of disease states including neoplasia,
sites on albumin and displace ionized calcium from the
trauma, and gastrointestinal disease seems to be linked
protein [13, 14]. Acidemia, therefore, is associated with an
to hypocalcemia [55]. Iatrogenic causes of hypocalcemia
increase in ionized calcium concentration. Exposure of the
include parathyroidectomy, phosphate enema, sodium
sample to air decreases a sample’s carbon dioxide tension,
bicarbonate, and furosemide. Multiple blood transfusions
raising its pH and falsely lowering the ionized calcium con-
can cause hypocalcemia because the anticoagulant in the
centration [7, 8, 13, 15]. The change in ionized calcium
transfused blood products chelates calcium [56].
with exposure to air appears to be about 7.2% and thus will
Clinical sequelae of hypocalcemia include restlessness
only yield results in a different category (high vs normal vs
or excitation, facial rubbing, muscle tremors, tetany, sei-
low) if a patient has a mildly increased or low end of nor-
zures, tachycardia, hyperthermia, and cardiopulmonary
mal calcium concentration [14]. It has been found that
arrest [56]. Hypotension has been documented in human
there is acceptable correlation between ionized calcium
patients [56]. ECG changes include a prolonged QT inter-
concentration measurements sampled anaerobically and
val [56]. Symptomatic hypocalcemia is life threatening and
those measured aerobically with correction to a pH of
should be treated. Emergent treatment involves intrave-
7.4 [13]. Automatic correction using formulas based on the
nous administration of 10% calcium gluconate at a dose of
predictable linear change in ionized calcium with changes
1.0–1.5 ml/kg over 20–30 minutes with continuous ECG
in pH are available with some POC analyzers [3, 8, 13]. One
monitoring to watch for bradycardia [18]. If bradycardia
must be very careful in veterinary medicine, however,
occurs, the infusion should be discontinued until a normal
because most POC analyzers are using an algorithm to cor-
heart rate returns [18]. Severe cases may require a constant
rect the ionized calcium to a pH of 7.4 based on human
rate infusion of 10% calcium gluconate (5–10 ml/kg over
data that are not validated in dogs and cats [3, 8, 13]. If an
24 hours) or repeated doses every six to eight hours [18].
analyzer has an algorithm for ionized calcium correction to
Calcium solutions should not be added to bicarbonate-
a pH of 7.4 that has been validated in dogs and cats, cor-
containing solutions because calcium carbonate can pre-
rected aerobic measurements can be considered accurate.
cipitate [18]. Careful monitoring of ionized calcium
In most cases, however, this is not the case, and these
concentration to watch for over-correction and repeated
authors recommend strictly anaerobic sampling for meas-
patient assessment for the clinical signs of hypercalcemia
urement of ionized calcium concentrations.
or relapsing hypocalcemia are necessary [18].
Anaerobic blood sampling is best performed using cats are more likely to clot prematurely. Samples obtained
Vacutainer® tubes (Becton Dickinson, Franklin Lakes, NJ). from animals with a known or suspected hypercoagulable
Silicone serum separator tubes should be avoided because state should be anticoagulated with a low ( 30 iu/ml) con-
the silicone releases calcium and falsely increases the ion- centration of heparin.
ized calcium value [13]. Once the blood is clotted, the sam-
ple is centrifuged for serum separation. Serum can be
Magnesium
removed from the tube using a spinal or other long needle
attached to a non-air-containing syringe through the red- Magnesium functions mainly in the production and use of
top stopper without exposing the sample to air [13]. energy, maintenance of the sodium-potassium gradient
Anaerobic sampling can also be achieved through the use across cell membranes, regulation of intracellular calcium,
of a sampling line (a central venous catheter or arterial and muscle and cardiac contraction [57]. Magnesium is a
catheter). Anaerobic sampling from a sampling line and predominantly intracellular ion distributed mostly in bone
gentle negative pressure avoiding air bubbles or air spaces and muscle. Similar to calcium and phosphorus, approxi-
from a venous sampling line. A rubber stopper can be mately 1% exists in plasma and interstitial body fluid [57].
placed on the needle if the sample cannot be placed directly The plasma component has three portions: ionized, protein
into the cartridge or analyzer. bound, and complexed to molecules such as phosphate and
Calcium concentration also changes with time after a bicarbonate [57]. Ionized magnesium is the physiologically
sample has been collected as cells undergo metabolism and active form [57].
produce lactic acid, which drops the pH in the sample [7]. Hypomagnesemia is a common condition in critically ill
Various studies have demonstrated slightly different results people, dogs, and cats [57–59]. It is linked to a number of
regarding the length of time an ionized calcium sample is other electrolyte disorders including hypokalemia, hypoc-
stable at varying temperatures, but conservative collective alcemia, hypophosphatemia, and hyponatremia [57, 60].
interpretation of these studies indicates that if a sample is Causes of hypomagnesemia include gastrointestinal losses,
not analyzed within eight hours of collection, it should decreased intake or malabsorption, acute pancreatitis,
refrigerated (4°C) for up to 48 hours or frozen at −20°C for kidney disease, diabetes mellitus, hyperthyroidism, hyper-
up to one week [7, 8, 15]. parathyroidism, sepsis, hypothermia, re-feeding after pro-
Sodium and lithium heparin bind or chelate calcium, longed starvation, and massive blood transfusion [57, 60].
which causes ionized calcium in the sample to drop [3, 7, 13]. Iatrogenic causes of hypomagnesemia include insulin
Zinc heparin displaces calcium from binding sites and administration causing intracellular shifts, increased renal
causes ionized concentrations to increase [13]. Oxalate, cit- losses of magnesium due to the administration of furosemide,
rate and EDTA also bind calcium. Therefore, none of these and osmotic agents such as mannitol, as well as medica-
anticoagulants should be used when collecting a sample tions such as cyclosporine, pamidronate, beta agonists, and
for measurement of ionized calcium concentration [13]. angiotensin-converting-enzyme inhibitors (e.g. enalapril,
It has been shown that 40 iu/ml of dry coated lithium hepa- benazepril) [32, 57].
rin syringes or 3-ml syringes specially self-prepped with Clinical sequelae of hypomagnesemia include cardiac
liquid sodium heparin do not cause significant dilution or arrhythmias, anemia, neuromuscular weakness that can
binding of ionized calcium or magnesium [3]. manifest as dysphagia or dyspnea if the esophagus or
Ionized calcium concentrations are lower in plasma respiratory muscles are affected, muscle twitching, ataxia,
than in whole blood or serum [8, 15]. This may be due to seizures, coma, hypertension, refractory hypokalemia, and
increased exposure time to heparin, causing increased hypocalcemia [32, 57, 60]. ECG changes include prolonged
binding to heparin [8, 15]. We recommend using either PR interval, widened QRS complex, depressed ST segment,
non-anticoagulated whole blood or low concentration and a tented T wave [60]. Multiple arrhythmias can occur,
( 30 iu/ml) heparin anticoagulated whole blood for meas- including torsades des pointes [57]. Additionally, hypomag-
urement of ionized calcium concentrations. Samples must nesemia can trigger systemic inflammatory changes [57].
be run relatively quickly after they are obtained to avoid Treatment of hypomagnesemia involves the parenteral
premature clotting or prolonged exposure to heparin. administration of magnesium sulfate or magnesium chlo-
Whole blood can be used to measure calcium concentra- ride at a rate determined by the degree of depletion, level of
tion with the Vetscan i-STAT 1 to avoid error caused by kidney function and the estimated rate of ongoing
anticoagulant, but efficient sampling and running are nec- losses [32, 57]. Parenteral magnesium should be diluted to
essary to avoid the sample clotting. Most other POC analyz- below a 20% solution as some of the formulations are
ers that measure ionized calcium require anticoagulation hyperosmolar [57]. Some balanced electrolyte fluids
(Table 56.1), and low concentration ( 30 iu/ml) heparin including Plasmalyte-A® (Abbot Laboratories, Abbott Park,
should be used. Animals with hypercoagulable states and IL) and Normosol-R® (Hospira, Lake Forest, IL) contain
magnesium, and magnesium concentrations in these fluids Magnesium Concentration Measurement

should be taken into account in calculating magnesium Because magnesium is primarily intracellular, it is still
dosages [57]. Magnesium infusions are being used thera- unclear which clinical magnesium sample best reflects
peutically as treatment beyond supplementation in human total body stores [57]. Clinicopathologic options for mag-
critical care for an array of critical syndromes including nesium concentration quantification include ionized mag-
systemic inflammatory response syndrome, severe tetanus, nesium, total serum or plasma magnesium, intracellular
and reperfusion injury [57]. The use of this electrolyte as quantification of magnesium via nuclear magnetic reso-
adjunctive therapy requires critical care staff awareness of nance spectroscopy and fluorescent dye labeled magne-
treatment complications and necessary monitoring during sium, or magnesium loading tests to determine total body
infusions. Magnesium supplementation can cause burning depletion [57]. A study evaluating intracellular versus total
at the catheter site, cutaneous vasodilation, and hypoten- serum magnesium in dogs with gastric dilatation and vol-
sion [57]. Iatrogenic overdose of magnesium can cause vulus demonstrated no correlation between the two meth-
vomiting, hypotension, bradycardia, flaccid paralysis, and ods [62]. Because ionized magnesium is the biologically
severe mental obtundation [61]. Intravenous calcium glu- active form, and total magnesium concentration is influ-
conate counteracts the physiologic effects of magnesium enced by factors similar to those that affect total calcium
and can be used along with 0.9% NaCl diuresis to reverse concentration (protein concentration, kidney function,
these complications [61]. Blood magnesium concentrations acid–base balance), ionized magnesium concentration is
should be monitored during magnesium supplementation theoretically the POC analyte of choice [7, 8, 57, 63]. ISE
as well as concentrations of potassium, sodium, calcium, assay is the method of choice for determining magnesium
and chloride [57]. concentration because there is less interference caused by
Hypermagnesemia appears to be less common than icterus, lipemia, and hemolysis [54].
hypomagnesemia [57–59]. It is most commonly caused by Sample handling and causes of artifact are similar for ion-
decreased renal clearance due to kidney disease but can ized magnesium as they are for ionized calcium. Aerobic
also be seen with some endocrinopathies such as hyper- sampling causes artifactual decreases in ionized magne-
parathyroidism, hypoadrenocorticism, and thyroid disorders sium due to an increased pH and increased protein bind-
[32, 57]. Hypermagnesemia can be caused iatrogenically ing [8]. Both lithium and zinc heparin formulations can
through overdosing parenteral magnesium formulations interfere with the magnesium electrode and cause falsely
or through the administration of multiple doses of increased ionized magnesium concentrations [15, 64].
magnesium-containing cathartics or antacids, particularly Serum values of ionized magnesium may be higher than for
in patients with renal insufficiency [32, 57, 61]. whole blood or plasma due to possible release of magne-
As noted in the description of magnesium overdose, sium from platelets during clotting. Despite this, anaerobi-
hypermagnesemia can cause obtundation, weakness, and cally obtained serum samples are considered the most
hypotension [57, 61]. ECG changes include a prolonged PR accurate for determination of magnesium and calcium con-
interval and widened QRS complexes [57, 60]. Severe centrations due to lack of dilution, binding, or interference
hypermagnesemia can cause respiratory depression to the from anticoagulant. Sample storage for measurement of
point of apnea, coma, and cardiac arrest [57, 60]. Therapy magnesium is similar to that for calcium; ionized magne-
for hypermagnesemia includes diuresis with fluid therapy sium concentration should be analyzed within eight hours
and potentially furosemide [32, 57]. Calcium gluconate if kept at room temperature (22°C), within 24 hours at 4°C,
therapy should be used in severe cases if severe obtunda- and within one week if stored at −22°C [8]. Ionized magne-
tion, respiratory depression, hemodynamic instability, or sium concentration drops with time if samples are held too
arrhythmias are present [17, 57]. Dialysis may be necessary long or stored inappropriately. Feline samples are stable for
if kidney function is severely decreased [57]. 24 hours at 2°C, 72 hours at 4°C, and 4 weeks at −20°C [63].
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763
57
Acid–Base Evaluation
Kate Hopper
Acid-base evaluation is recommended for all patients with Overview of Acid–Base Interpretation
significant illness or injury. In these patients, the magni-
tude of acid–base derangement is difficult to ascertain by Acid–base balance is the evaluation of hydrogen ion con-
clinical signs alone, and the measurement of acid–base centration [H+] in the body. Hydrogen ions are important
status is an important component of the initial assessment to normal physiology and severe abnormalities in [H+] can
and ongoing patient monitoring. directly impact cell and organ function. In clinical medi-
cine, evaluation of acid–base balance is even more impor-
tant as a diagnostic and monitoring tool. Blood gas
ampling and Storage of Blood
S machines need very small volumes of blood and provide
for Acid–Base Measurement immediate results, making them ideal for use in the emer-
gency room and intensive care setting. Clinically [H+] is
For acid–base measurements, venous or arterial blood can be measured as pH, a unitless value that has an inverse rela-
used. In health, there is a small but clinically unimportant dif- tionship with [H+]. Increased [H+] causes a decrease in
ference between venous and arterial acid–base values pH, an acidemia. A decreased [H+] causes an increase in
(Table 57.1) [1]. In clinical scenarios of poor perfusion such as pH, an alkalemia.
circulatory shock, there can be a significant variation between The contributions to acid–base balance are divided into
arterial, central venous, and peripheral venous values. respiratory (controlled by the lungs) and metabolic (all
The technique for collecting a blood sample for pH and other mechanisms) components. The respiratory contribu-
blood gas analysis is outlined in Protocol 57.1. Dilution of tion to the acid–base disturbance is defined by the partial
the blood sample by anticoagulant should be minimized. pressure of carbon dioxide (PCO2), while the metabolic
Use of commercially available blood gas syringes or filling contribution is defined by the bicarbonate concentration or
anticoagulated hematocrit tubes or cartridges designed for base deficit. We will focus on bicarbonate concentration
blood gas evaluation is ideal. [HCO3−] at this time. The pH is determined by the ratio of
Blood should be collected anaerobically. Exposure to [HCO3−] to PCO2:
small air bubbles allows equilibration of gases between the
blood and the air. Air mixing will lower the partial pressure HCO3
of carbon dioxide, which will change the pH. The sample pH ~
should be analyzed as soon as possible after collection to PCO2
minimize in vitro changes due to metabolism and diffusion
of gases into and through the plastic wall of the syringe. From this relationship, it can be appreciated that an
For acid–base evaluation (not partial pressure of oxygen), acidemia (low pH, high [H+]) may be due to decreased
samples can be kept in a syringe at room temperature for [HCO3−], increased PCO2, or both these changes, while an
up to two hours before analysis [2]. It is not recommended alkalemia (high pH, low [H+]) may be due to increased
to store samples in vacuum tubes or screw top tubes for [HCO3−], decreased PCO2 or both these changes
acid–base evaluation. (Figure 57.1).
764 Acid–Base Evaluation
Table 57.1 Arterial versus venous blood gas values for normal dogs (mean ± standard deviation) [1].
Measure Arterial Mixed venous Jugular venous Cephalic vein
pH 7.40 ± 0.03 7.36 ± 0.02 7.35 ± 0.02 7.36 ± 0.02

PCO2 (mmHg) 37 ± 3 43 ± 4 42 ± 5 43 ± 3
Base deficit (mmol/l) −2 ± 2 −1 ± 1 −2 ± 2 −1 ± 1
Bicarbonate (mmol/l) 21 ± 2 23 ± 2 22 ± 2 23 ± 1
Total CO2 (mmol/l) 22 ± 2 24 ± 2 23 ± 2 24 ± 2
PO2 (mmHg) 102 ± 7 53 ± 10 55 ± 10 58 ± 9
Source: Adapted from Ilkiw 1991.
Protocol 57.1 Protocol for Collecting a Blood Sample for pH and Blood Gas Analysis
Items Required
● Use either a commercial blood gas syringe with dry anticoagulant or prepare a sampling syringe by drawing an ali-
quot of liquid heparin solution into it and then blowing as much of the liquid heparin out of the dead space of the
syringe as possible. If acid–base analysis is to be performed in anticoagulated hematocrit tubes or cartridges, a
small volume of whole blood in a plain syringe is collected and immediately transferred.
● If blood is to be taken from a catheter:
⚪ Use a separate syringe with about 0.5 ml of heparinized saline to scavenge 3–5 ml fluid and blood from the cath-
eter prior to sample collection.

⚪ Use a separate syringe with about 3 ml of heparinized saline to flush the catheter after the fluid-scavenged blood
mixture has been returned to the patient (see Chapter 53).
Procedure
Blood taken via direct vessel puncture:
1) Gather supplies.
2) Perform hand hygiene ± wear gloves.
3) Clip the fur and aseptically prepare the skin over the intended puncture site.
4) Aseptically puncture the vessel and anaerobically obtain an appropriate volume of blood.
Blood taken from a catheter:
1) Scrub the injection port with antiseptic solution. The fluid infusion must be stopped.
2) Remove (scavenge) at least 3 ml blood from the catheter into syringe containing 0.5 ml heparinized saline.
3) Switch to a new, empty blood collection syringe and collect the desired volume of blood.
4) Return the scavenged blood-heparinized saline mixture to the patient.
5) Flush the catheter with heparinized saline.
Storage and analysis:
1) Analyze the samples immediately.
2) If the sample cannot be analyzed within 30 minutes, store anaerobically at room temperature. If analysis will be
delayed for greater than 30 minutes, samples should be collected in a glass syringe and stored in ice water.
3) Mix the sample prior to analysis by vigorously rolling the syringe between your hands.
4) Insert the blood anaerobically into the analyzer as per the manufacturer’s guidelines.
5) Input the patient’s identification and temperature.
Other Measures of the Metabolic Contribution

machines. The terms base deficit and base excess have
The metabolic component is commonly evaluated from the become interchangeable; the measured value defines if
[HCO3−] but other parameters can be used instead. Base there is a deficit or gain in base. For the purpose of this
deficit/excess is a value calculated by many blood gas chapter, the term base deficit will be used. The normal
Acid–Base Analysis 765
Figure 57.1 Algorithm for acid–base

evaluation.
pH
Low High
(High [H+]) (Low [H+])
Low HCO3– High PCO2 High HCO3– Low PCO2
Metabolic Respiratory Metabolic Respiratory

Acidosis Acidosis Alkalosis Alkalosis
range for base deficit in dogs and cats is slightly negative as Acid–Base Analysis
a result of their carnivorous diet. If the measured patient
value for base deficit is more negative than the reference When making an acid–base diagnosis, the patient values of
interval for the species, it represents a metabolic acidosis pH, PCO2 and [HCO3−] are compared to a species-specific
while values more positive than the reference interval are a reference interval as shown in Table 57.2.
metabolic alkalosis. The pH should be evaluated to determine if it is normal,
Total carbon dioxide (TCO2) is another measure of the low (acidemia), or high (alkalemia). The PCO2 is evaluated
metabolic contribution to acid–base balance. It is often a as either normal, low (respiratory alkalosis), or high (res-
parameter reported on biochemistry panels and is a value piratory acidosis). The [HCO3−] is either normal, low (met-
similar to [HCO3−]. Given the confusing name, it is impor- abolic acidosis), or high (metabolic alkalosis). Once these
tant not to confuse the metabolic parameter TCO2 with the evaluations have been made, the next step is to determine
respiratory parameter PCO2. if a primary process (respiratory or metabolic) can be iden-
tified. The primary process is the one responsible for the
Compensation abnormality in pH. When a primary process is identified,
the opposing system should then be evaluated for appropri-
In response to a primary disturbance of the respiratory or ate compensation (Examples 57.1 and 57.2).
metabolic system, the body will attempt to correct the In Example 57.1, the only process that can be considered
abnormality in pH with changes in the opposing system. responsible for the acidemic pH is the metabolic system;
For example, a metabolic acidosis will normally be accom- the primary disturbance is therefore a metabolic acidosis.
panied by a compensatory respiratory alkalosis. As a result, Respiratory compensation is fast and should always be
the abnormality in pH is minimized (the ratio of HCO3/
PCO2 is less abnormal). Compensation returns the pH Table 57.2 Arterial acid–base values for normal individuals;
toward normal but does not return the pH completely to mid-normal (reference interval).
normal. Respiratory compensation to a primary metabolic
abnormality is very rapid and expected to be evident at the Measure Human [4] Dog [1, 5, 6] Cat [6–8]
time of blood gas evaluation [3]. The absence of respiratory
compensation is always considered abnormal. Primary res- pH 7.40 7.39 7.39
(7.35–7.45) (7.35–7.43) (7.33–7.45)
piratory acid–base disorders will have a small degree of
“acute metabolic compensation,” but full metabolic com- PaCO2 (mmHg) 40 (35–45) 37 (31–43) 32 (26–38)
pensation takes hours to begin and days to complete [3]. Bicarbonate 24 (22–26) 22 (19–25) 18 (15–21)
(mmol/l)
For this reason, the absence of any substantial metabolic
compensation to a primary respiratory disorder may sim- Base deficit 0 (−2 to +2) −2 (+1 to −5) −6 (−3 to −9)
(mmol/l)
ply reflect insufficient time for compensation.
Example 57.1 Acid–Base Disorder 1 Example 57.3 Acid–Base Disorder 1
Reference Reference
Parameter Patient interval Interpretation Parameter Patient interval Interpretation
pH 7.26 7.35–7.45 Acidemia pH 7.036 7.35–7.45 Acidemia
PCO2 (mmHg) 30 32–43 Respiratory PCO2 (mmHg) 62 32–43 Respiratory
alkalosis acidosis
Bicarbonate 12 18–24 Metabolic Bicarbonate 14 18–24 Metabolic
(mmol/l) acidosis (mmol/l) acidosis
Base deficit –10 –4 to –2 Metabolic Base deficit −8 −4 to −2 Metabolic
(mmol/l) acidosis (mmol/l) acidosis
Example 57.2 Acid–Base Disorder 2 Example 57.4 Acid–Base Disorder 2
Reference Reference
Parameter Patient interval Interpretation Parameter Patient interval Interpretation
pH 7.50 7.35–7.45 Alkalemia pH 7.396 7.35–7.45 Normal
PCO2 (mmHg) 15 32–43 Respiratory PCO2 (mmHg) 59 32 − 43 Respiratory
alkalosis acidosis
Bicarbonate 18 18–24 Normal Bicarbonate 30 18 − 24 Metabolic
(mmol/l) (mmol/l) alkalosis
Base deficit −2 −4 to −2 Normal Base deficit +10 −4 to −2 Metabolic
(mmol/l) (mmol/l) alkalosis
present to a primary metabolic abnormality. A respiratory disorder since compensation alone will not return pH to
alkalosis would be the appropriate compensation for a pri- normal. In example 57.3, both the respiratory system
mary metabolic acidosis so in this example the acid–base and the metabolic system contribute to the acidemia.
analysis is a primary metabolic acidosis with respiratory This animal has two problems (not one disorder with
compensation. In example 57.2, the respiratory alkalosis is compensation). As such, this is a mixed disorder of both
clearly responsible for the alkalemia. There is no evidence respiratory and metabolic acidosis.
of metabolic compensation, but as metabolic compensa- In example 57.4, there is a normal pH, but abnormalities
tion is slow to occur, its absence suggests an acute respira- are present in both the PCO2 and bicarbonate. By defini-
tory acid–base disorder. The acid–base analysis is an acute tion, this is a mixed disorder. There are two acid–base dis-
respiratory alkalosis. orders present: a respiratory acidosis and a concurrent
metabolic alkalosis. These abnormalities are of similar
magnitude so their effect on pH effectively cancels each
Simple Versus Mixed Disturbances other out, ultimately leaving the patient with a normal
Acid–base abnormalities can be simple disorders of only pH. It is important to recognize that this cannot be a pri-
one system (respiratory or metabolic), and any change in mary disorder with “excellent” compensation (i.e. primary
the other system is purely compensatory (such as metabolic alkalosis with “excellent” respiratory compensa-
Examples 57.1 and 57.2). When there are abnormalities in tion) as even perfect compensation does not return the pH
both the respiratory and metabolic systems, neither of back to the normal range.
which can be considered compensatory, it is classified as a
mixed disorder. In this situation, there is no primary
disturbance since both disturbances are “primary” he Respiratory Component of the
T
(independent of one another). For example, when both Acid–Base Balance
the respiratory and metabolic systems have the same
abnormality (both have an alkalosis or both have an The respiratory contribution to the acid–base balance is
acidosis), it is a mixed disorder. A normal pH in the face defined by the PCO2. The arterial PCO2 is regulated by the
of abnormal PCO2 and HCO3− also indicates a mixed respiratory center of the brain by adjusting how the animal
The heetabolic bomboheoe bof iclid–tahe –totoiche 767
Box 57.1 Common Causes of Respiratory Acid–Base Disorders

Respiratory Acidosis (Hypercapnia)
● Hypoventilation – diseases causing reduced respiratory rate and/or tidal volume
⚪ Brain disease
⚪ Cervical spinal cord disease
⚪ Peripheral nerve or neuromuscular junction disease
⚪ Muscle fatigue or myopathy
⚪ Airway obstruction
⚪ Anterior displacement of the diaphragm by abdominal space filling disorders
● Carbohydrate-rich parenteral nutrition solutions in debilitated patients

● Bicarbonate therapy in patients with respiratory compromise
● Rebreathing of exhaled alveolar gases due to mechanical dead space
● Malignant hyperthermia
● Venous blood gas only - poor tissue perfusion
Respiratory Alkalosis (Hypocapnia)

● Hyperventilation – diseases causing increased respiratory rate and/or tidal volume
⚪ Hypotension
⚪ Fever and heat-induced illness
⚪ Systemic inflammatory response
⚪ Pulmonary thromboembolism
⚪ Pulmonary parenchymal disease
⚪ Excitement and exercise
⚪ Pain
breathes. Breathing faster and/or deeper (hyperventila- Respiratory Alkalosis

tion) will decrease PCO2 in arterial blood (PaCO2), while
The causes of respiratory alkalosis are listed in Box 57.1. A
breathing slower and/or shallower (hypoventilation) will
decreased PCO2 level can also be described as hyperventila-
increase PaCO2. In most situations, there is only a small
tion or hypocapnia. Treatment for respiratory alkalosis is
difference between arterial and venous PCO2 (PvCO2). But
largely focused on resolution of the underlying disease that
in states of poor tissue perfusion (e.g. circulatory shock),
is causing the hyperventilation.
PvCO2 may not accurately reflect PaCO2.
Respiratory Acidosis
he Metabolic Component of Acid–Base
T
The causes of respiratory acidosis (elevated PCO2) are cited Balance
in Box 57.1. An elevated PCO2 level can also be described
as hypoventilation or hypercapnia. Significant elevations Unlike the respiratory component of acid–base balance,
in PaCO2 (> 60 mmHg) may warrant treatment. Without there are many different contributors to the overall meta-
supplemental oxygen therapy, this magnitude of hypoven- bolic acid–base balance. Evaluation of the primary disease
tilation is likely to be associated with hypoxemia. processes evident in the patient and additional parameters
Hypercapnia causes cerebral vasodilation, which increases such as the anion gap and lactate concentration are all con-
cerebral blood flow that may be harmful in patients with sidered when determining the cause of metabolic acid–
intracranial disease. With proper support and time for base disorders.
compensation, and in patients without intracranial dis-
ease, considerably higher PCO2 values may be permissible
Metabolic Acidosis
without apparent harm to the patient.
The first treatment for primary respiratory acidosis is The causes of metabolic acidosis are listed in Box 57.2.
effective treatment for the underlying disease process. The Metabolic acidosis can occur by one of two mechanisms:
symptomatic therapy for hypoventilation is support of the the gain of acid or the loss of bicarbonate. In the clinical
respiratory system and may require positive pressure venti- setting, acid gain is usually associated with an increase in
lation if severe. anion gap, while diseases associated with the loss of
Box 57.2 Common Causes of Metabolic Acid–Base Disorders

Metabolic acidosis with normal anion gap
● Gastrointestinal losses of bicarbonate
● Renal loss of bicarbonate/acid retention (renal tubular acidosis; hypoadrenocorticism)
● Large-volume 0.9% saline administration
Metabolic acidosis with increased anion gapa

● D = diabetic ketoacidosis
● U = uremia
● E = ethylene glycol intoxication
● L = lactic acidosis
● Methanol intoxication
● Salicylate poisoning
Metabolic alkalosis
● Gastric losses of acid (vomiting due to a pyloric obstruction, gastric suctioning)
● Furosemide administration
● Hyperaldosteronism
● Organic anion (lactate, acetate, citrate) administration
● Bicarbonate administration
a
Anion gap may not always be elevated as predicted.
bicarbonate are associated with a normal anion gap. See hypokalemia potentiate metabolic alkalosis and should
below for more explanation of the anion gap. Common also be treated.
causes of a high anion gap metabolic acidosis can be
recalled with the acronym DUEL: D, diabetic ketoacidosis;
Anion Gap
U, uremia; E, ethylene glycol intoxication; L, lactic acidosis.
The treatment of metabolic acidosis should be primarily The anion gap is a calculated value that can be useful in
aimed at correction of the underlying disease process, and determining the cause of a metabolic acidosis. It is calcu-
should be the only therapy necessary if the metabolic acido- lated using the equation:
sis and the pH disturbance is mild to moderate and the
underlying disease is readily treatable. The kidney plays an
AG Na K HCO3 Cl (57.1)
important role in regulation of the metabolic acid–base bal-
ance. As such, kidney disease commonly causes metabolic
where Ag is the anion gap; Cl, chloride; HCO3, bicarbo-
acidosis in dogs and cats. If there is no immediate treatment
nate; K, potassium; Na, sodium.
to improve kidney function, bicarbonate administration to
There is no anion gap in reality (the number of cations
improve the acid–base abnormality maybe considered.
always equals the number of anions). In this calculation,
Bicarbonate therapy may also be considered in severe meta-
Na + K normally exceeds Cl + HCO3 by 15–20 mmol/l (var-
bolic acidosis of other causes in some circumstances.
ies between laboratories). Normally, the negative charges
Guidelines for the calculation of bicarbonate dosage are
on albumin comprise most of this apparent gap. Phosphate
detailed in Protocol 57.2. Sodium bicarbonate administra-
and lactate make up a small portion of the gap in the nor-
tion may be associated with a number of adverse effects;
mal animal, but this can increase in disease states [9].
these problems and their avoidance are detailed in Box 57.3.
Metabolic acidosis due to a gain of acid is usually associ-
ated with an increased anion gap. Common causes include
Metabolic Alkalosis lactic acid, ketoacids, elevated phosphate levels, or acid
intoxicants such as glycolic acid from ethylene glycol and
The causes of metabolic alkalosis are listed in Box 57.2.
salicylic acid from salicylate (aspirin).
The treatment of metabolic alkalosis relies on effective
Metabolic acidosis can also be caused by renal or gastro-
treatment of the underlying disease process. Coexistent
intestinal bicarbonate losses without an increase in anion
electrolyte abnormalities such as hypochloremia and
gap. As a result, evaluation of the anion gap can provide
Acknowledgment 769
Protocol 57.2 How to Calculate and Administer a Dose of Sodium Bicarbonate

Procedure
1) Use the base deficit value determined by the blood gas machine or estimate the base deficit from the equation:
Patient HCO3 normal HCO3
2) Estimate the total bicarbonate deficit from the equation:
Bicarbonate mmol base deficit 0.3 body weight kg
3) Administer 50–75% of this calculated dose to avoid creating an iatrogenic metabolic alkalosis.
4) Administer dose slowly over a minimum of about 30 minutes (more commonly over several hours).
a) Undiluted sodium bicarbonate (1mmol/ml) has an osmolality of ~2000mOsm/l, which can cause phlebitis with
extended infusions and a sodium concentration of 1000mmol/l, which can cause hypernatremia with large infusions.
b) Recommend diluting sodium bicarbonate with a sodium-free fluid such as dextrose 5% in water or sterile water.
See Table 57.3 for some possible dilutions.
c) Sodium bicarbonate can be administered with other fluids but is not compatible with many drugs. Compatibility
should be verified before co-administering drugs.
Table 57.3 Suggested dilutions for sodium bicarbonate 8.4% (1 mmol/ml).
Sodium bicarbonate (1 mmol/ml) D5W or sterile water Total number of parts Approximate Final osmolality
1 part 1 part 2 parts 100 mOsm/l

1 part 2 parts 3 parts 667 mOsm/l
Box 57.3 Adverse Effects of Sodium Bicarbonate sodium bicarbonate; where possible, dilute for
Administration administration.
● Volume overload: if not diluted sodium bicarbonate
● Excessive alkalinization of the patient: calculate is a hypertonic saline solution that can impact vascu-
dosages carefully; monitor acid–base balance. lar volume. When diluted it becomes a significant
● Hypokalemia: administer carefully and with concur- volume for administration and should be used with
rent potassium supplementation in hypokalemic caution in at-risk patients.
patients; monitor potassium concentration.
● Low ionized calcium concentration: administer
carefully, potentially with concurrent calcium supple- diagnostic insight regarding the potential cause of a meta-
mentation in hypocalcemic patients; monitor ionized bolic acidosis. Unfortunately, the anion gap may not be
calcium. elevated despite the presence of added acids, and should be
● Hypercapnia: administer carefully with carbon diox- considered supportive information for diagnosis, but not
ide monitoring in patients with mild hypoventilation. definitive. In the presence of hypoalbuminemia, the anion
Sodium bicarbonate administration is contraindi- gap loses sensitivity and can be normal despite the pres-
cated in patients with moderate or severe ence of gained acid [10].
hypoventilation.
Phlebitis with continuous infusions through a periph-
●
Acknowledgment
eral vessel: ideally dilute fluid for infusion to an
osmolality < 600 mOsm/l unless administering
This chapter was originally authored by Steve C. Haskins
through a central catheter.
(deceased) for the previous edition, and some material
● Hypernatremia with large infusions of undiluted
from that chapter appears in this one. The author and
solution: monitor sodium with repeated dosages of
editors thank Dr. Haskins for his contributions.
References
1 Ilkiw, J.E., Rose, R.J., and Martin, I.C.E. (1991). A 6 Haskins, S.C., Pascoe, P.J., Ilkiw, J.E. et al. (2005).
comparison of simultaneously collected arterial, mixed Reference cardiopulmonary values in normal dogs.
venous, jugular venous and cephalic venous blood samples Comp. Med. 55: 156–161.
in the assessment of blood gas and acid-base status in dogs. 7 Herbert, D.A. and Michell, R.A. (1971). Blood gas
J. Vet. Intern. Med. 5: 294–298. tensions and acid-base balance in awake cats. J. Appl.
2 Kennedy, S.A., Constable, P.D., Sen, I., and Couetil, Physiol. 30: 434–436.
L. (2012). Effects of syringe type and storage conditions on 8 Middleton, D.J., Ilkiw, J.E., and Watson, A.D.J. (1981).
results of equine blood gas and acid-base analysis. Am. Arterial and venous blood gas tensions in clinically
J. Vet. Res. 73: 979–987. healthy cats. Am. J. Vet. Res. 42: 1609–1611.
3 de Morais, H.A. and DiBartola, S.P. (1991). Ventilatory and 9 Figge, J., Mydosh, T., and Fencl, L. (1992). Serum proteins
metabolic compensation in dogs with acid base and acid-base equilibria: a follow-up. J. Lab. Clin. Med.
disturbances. J. Vet. Emerg. Crit. Care 1: 39–42. 120: 713–719.
4 Lawler, D.F., Kealy, R.D., Ballam, J.M., and Monti, 10 Feldman, M., Soni, N., and Dickson, B. (2005). Influence
K.L. (1992). Influence of fasting on canine arterial and of hypoalbuminemia or hyperalbuminemia on the serum
venous blood gas and acid-base measurements. J. Vet. anion gap. J. Lab. Clin. Med. 146: 317–320.
Emerg. Crit. Care 2: 80–84.
5 DiBartola, S.P. (2006). Fluid, Electrolyte, and Acid-Base
Disorders in Small Animal Practice, 3e. Philadelphia, PA:
WB Saunders.
771
58
Osmolality and Colloid Osmotic Pressure

Elke Rudloff and Angel Rivera
Water is the most essential nutrient of the body. Within the water is the solvent in biological systems, the terms osmo-
vessel, water is the transport medium that delivers oxygen, larity and osmolality are often used interchangeably when
solutes, and hormones to the interstitium while removing discussing the composition of body water, except when
waste products for breakdown and excretion. Within the significant hyperlipidemia exists.
interstitial space, water provides the environment for these Water moves freely across nearly all membranes separat-
substances to move between the capillary and the cell. ing the intravascular, interstitial, and intracellular com-
Within the cell, water provides a medium for organelles partments in the body. The two important factors that
and for cell membrane expansion. Water also provides a affect the movement of water across the membranes are:
means to dissipate heat through evaporation. (i) the difference in the concentration of water molecules
Identifying water imbalance in the critically ill animal (which relates to the number of solutes or osmoles) on one
can be one of the most important challenges of patient side of the membrane compared with the other, and (ii) the
management. Qualitative information of a patient’s water difference in the hydrostatic pressure on one side of the
needs is obtained through evaluation of physical parame- membrane compared with the other.
ters of perfusion and hydration [1]. Quantitative informa- Water is an uncharged molecule, and its movement is
tion can be obtained with laboratory evaluation of governed passively by its chemical gradient, also called a
osmolality as well as colloid osmotic pressure (COP). This concentration gradient, across a membrane: Water mole-
chapter focuses on the basic concepts behind the role of cules will move from areas of higher water concentration
osmolality and COP in the movement of water in the body, to areas of lower water concentration. The pressure that
as well as understanding, measuring, and interpreting generates this passive water movement (diffusion) along a
osmolality and COP. concentration gradient is called osmotic pressure. Areas of
high osmotic pressure have relatively low water concentra-
tion in relation to solute, whereas areas of low osmotic
Physiology of Water Movement: Osmolality pressure have relatively high water concentration in rela-
tion to solute. Osmotic pressure is therefore a chemical
An osmole is a unit term used to describe a particle that pressure generated by the particles (solutes) dissolved in
contributes to the osmotic pressure of a solution; 1 osmole water that tends to hold water on the particles’ side of a
is equivalent to 1 mole (6.02 × 1023 particles) of any non- membrane permeable only to water.
dissociable substance, regardless of the substance’s com- Hydraulic pressure in the vessels is the physical pressure
position, charge, size, or weight [2]. Osmoles are often generated by the heart and conveys a hydrostatic pressure
expressed in terms of milliosmoles (1 osmole = 1000 milli- of blood at the level of the capillary network. Hydrostatic
osmoles). Osmolarity describes the total concentration of pressure in the interstitium is created by the interaction of
all solutes dissolved in a volume of water and is expressed collagen fibrils, fibroblasts, and the lymphatics, which are
as milliosmoles/liter (mOsm/l). Osmolality describes the dynamic. By expanding, contracting, and pumping, they
total concentration of all solutes dissolved in a mass of solu- influence interstitial hydrostatic pressure, which is kept
tion and is expressed as milliosmoles/kilogram (mOsm/kg). more negative than the intravascular space in health. Water
Because 1 l of water weighs approximately 1 kg and because is in equilibrium across a membrane when the net driving
772 Osmolality and Colloid Osmotic Pressure
force for water movement is zero. In other words, at equilib- act as an effective osmole when changes in urea concentra-
rium, water does not move across a membrane because the tion occur more rapidly than its equilibrium occurs across
osmotic pressure gradient (“holding water in”) is equal to the cell membrane, such as urea extraction during dialysis
the hydrostatic pressure gradient (“pushing water out”) or intravenous infusions of urea.
across that membrane. The osmolality in the plasma and interstitial (taken together,
The primary solutes that produce osmotic pressure in the the “extracellular”) compartments is equal because the
extracellular (intravascular and interstitial spaces combined) solutes that contribute the most to osmolality (i.e. sodium and
compartment of dogs, cats, and people are the most plentiful its accompanying anions, glucose, and urea) pass freely across
dissolved substances: sodium and its accompanying anions, the endothelial membrane, as does water. However, changes
glucose, and urea [2, 3]. The primary solutes that produce in plasma osmolality affect water movement between the
intracellular osmotic pressure are potassium and magne- intracellular and extracellular compartments since those
sium because they are the most plentiful dissolved intracel- solutes do not cross the cell membrane freely. Rapid increases
lular molecules [2, 3]. Effective osmolality (also called in plasma (and thus extracellular compartment) osmolality
tonicity) is generated by solutes that are unable to pass cause water to move from the cells into the extracellular fluid
between the intracellular and extracellular compartments. space, dehydrating the cells. This is the principle by which
Because they do not freely cross the cellular membrane, they hypertonic saline helps treat cerebral edema.
can affect water movement (they are “effective”). When Isotonic solutions that contain added dextrose and par-
there is a difference in tonicity between the intracellular and enteral nutrition are hyperosmolar compared with normal
extracellular compartments (i.e. an osmotic gradient), water plasma. Their infusion in peripheral veins can create a
will freely move from the compartment with fewer solutes to local osmolar gradient causing water to move out of the
the compartment with more solutes until the osmolality endothelial cell and into the plasma, leading to endothelial
(concentration of water in relation to solutes) is equal cell dehydration and damage at the site of injection with
between compartments. This process is called osmosis, a term localized pain and tissue swelling (phlebitis). In contrast,
that specifically denotes the diffusion of water molecules when large volumes of 5% dextrose in water are rapidly
(Figure 58.1). infused, the dextrose is quickly metabolized and the
Like water, urea passes across most mammalian mem- remaining hypotonic water will decrease plasma osmolal-
branes without energy and is therefore considered an ity, resulting in water moving from the extracellular space
ineffective osmole, except under rare conditions. Urea can into the cells, causing cell swelling.
8 mmol/l 0 mmol/l 4 mmol/l 4 mmol/l
2 mmol/l 10 mmol/l 6 mmol/l 6 mmol/l
Figure 58.1 Osmotic forces across a semipermeable membrane. The top figure demonstrates that when more solutes (star-shaped
dots) exist on one side of a semipermeable membrane (dashed lines) and the membrane is permeable to those solutes, solute
particles will diffuse across the membrane until they are in equal concentration on either side of the membrane. Permeable solutes
are thus considered ineffective osmoles because their presence on one side of the membrane (or the other) is ineffective at causing
water to move across the membrane; the solutes move instead. The bottom figure demonstrates that when more solutes exist on one
side of a semipermeable membrane and the membrane is not permeable to those solutes, water moves across the membrane until
the solutes are in equal concentration; this movement is caused by osmotic pressure. Note that the water movement in the bottom
figure has caused the right-hand compartment to expand in size, denoted by the large blue arrow in the lower right image. When the
impermeable solutes that generate the osmotic pressure are colloidal particles (by convention in medicine, particles that are too large
to pass freely from the intravascular into the interstitial space), then the pressure generated is called colloid osmotic pressure.
PPysiolooy oo ater ooementt: Colloid Osmotic Pressure 773
The brain is most susceptible to rapid changes in plasma used, or fluids can be modified by mixing with concen-
osmolality (changes in excess of 30–35 mOsm/kg), and trated NaCl solutions to make the infusion fluid osmolality
damage caused by rapid swelling or shrinking of neurons similar to the patient’s osmolality, so that they produce less
can result in altered mentation, seizures, and intracranial of an osmotic gradient.
bleeding [4]. The brain is encased in the skull, such that
any type of increase in brain volume from neuronal swell-
ing will compress and damage functional neurons and hysiology of Water Movement: Colloid
P
brain vessels. However, when plasma osmolality increases Osmotic Pressure
slowly, brain cells accumulate organic osmolytes (e.g.
amino acids, glutamine, inositol) that prevent the develop- The sum of all forces that affect water movement across
ment of a transcellular osmotic gradient and maintain the endothelium have traditionally been summarized in
intracellular water content [5]. the Starling principle, which holds that the capillary
When a patient is hyperosmolar (e.g. a diabetic cat with endothelium is the working barrier between the plasma
hyperglycemia and ketosis), special attention should be and the interstitium [6]. Across that barrier, the plasma
given to the type and rate of fluids infused. It could be COP is the greatest force that opposes hydrostatic pressure
highly detrimental to infuse large volumes of hypotonic and prevents movement of water out of the vessel and into
fluids (e.g. lactated Ringer’s solution or “half-strength” the interstitium [3, 7]. COP is the osmotic pressure gener-
hypotonic solutions) because a large osmotic gradient ated by the large molecules (primarily proteins) that do
could result in a rapid shift of water into brain cells. To pre- not readily move across the capillary membrane, which
vent rapid osmotic shifts during fluid administration, iso- creates an osmotic effect (Figure 58.2) As it pertains to pro-
tonic fluids with an osmolality closer to the patient (e.g. teins, synonyms of COP include protein osmotic pressure
Normosol®-R, Abbott Laboratories, North Chicago, IL) are and oncotic pressure. Albumin is the most abundant
CO SVR Interstitial
HP
Intracellular
COP
Intravascular
Lymph
Protein
Solutes
Figure 58.2 Relationship of forces governing water movement between the fluid compartments. Total body water is distributed between
two major body compartments: the intracellular space and the extracellular space. The extracellular compartment is further divided into
the interstitial space and intravascular space. The cell membrane is freely permeable to solute-free water (white arrows), which moves in
and out of the cell as a result of osmotic gradients established between the intracellular and interstitial fluid compartments. The
concentration gradient of solutes on either side of a membrane dictates how water will move by osmosis across the cell membrane.
Changes in the intracellular solute concentration affect the osmolar gradient and depend on the various molecules’ abilities to move
through the cell membrane by active membrane pumps and restricted channels. The capillary membrane is permeable to water and small
solutes, and is relatively impermeable to blood cells and large molecules such as proteins. The capillary endothelium is coated by a
complex matrix called the glycocalyx, and the space between endothelial cell and glycocalyx is called the “subglyceal space.” The most
abundant small solutes in the extracellular fluid are sodium (and its major paired anions chloride and bicarbonate), glucose, and urea,
which pass freely across the vascular membrane and thus at equilibrium are at equal concentrations in the vascular and interstitial spaces.
Modified Starling’s forces dictate fluid movement and retention in the intravascular space. The capillary hydrostatic pressure (HP) is
produced by the forces generated by cardiac output (CO) and systemic vascular resistance (SVR). The intravascular colloid osmotic pressure
(COP) opposes the HP, retaining fluid in the vessel. The endothelial surface layer creates a barrier that under normal conditions prevents
the movement of large molecules, primarily proteins, out of the vessels. Under normal conditions, the concentration of proteins is greater in
the blood vessel than in the subglyceal space, promoting water retention within the capillary. Lymphatic vessels (lymph) are within the
interstitial matrix and carry excess fluid, proteins, and solutes from the interstitium back to the circulation.
sodium ions, increasing the water attraction of albumin.

This additional water-holding effect is called the Gibbs–
Donnan effect and increases the COP by approximately 20%.
Recently, the traditional Starling principle has been
modified to take into consideration the osmotic asymme-
try to the continuous endothelium (Figure 58.3). The new
exchange pathway model (the modified Starling principle)
recognizes the presence of the endothelial glycocalyx, a
fur-like structure that is composed of a polysaccharide mix
of proteoglycans, glycoproteins, and glycosaminoglycans
that lies along the surface of and is in contact with the
endothelium, forming an endothelial surface layer (ESL) [8].
The ESL functions as the actual oncotic barrier between
the vessel lumen and the interstitium. A subglyceal space
between the endothelial glycocalyx and the endothelial
cells is completely separated from the plasma by the
ESL. In health, this space remains protein-free, and the
COP of the sub-endothelial glycocalyx space has replaced
the interstitial COP as the oppositional force to the capil-
lary hydrostatic pressure. Solute-free fluid and small
solutes pass through inter-endothelial pathways of the
Figure 58.3 Functional compartments involved in transvascular ESL into the interstitium.
fluid flux. Plasma proteins are largely reflected off the surface of When there is inflammation or injury to the ESL and/or
the endothelial glycocalyx (EG), while water and small solutes pass
according to the transendothelial hydrostatic pressure gradient.
endothelium, protein molecules can pass from the intravas-
This leads to the generation of a space immediately underlying the cular compartment into the interstitial compartment caus-
endothelial glycocalyx (i.e. subglyceal space) that contains fluid of ing a decrease in plasma COP and an increase in subglyceal
very low colloid osmotic pressure. Protein diffusion from the and interstitial COP. When plasma COP is significantly
interstitium into the subglyceal space is mitigated by the filtrate
convection in the opposite direction. ESL, endothelial surface layer;
reduced, intravascular water retention is reduced. This can
SMC, smooth muscle cell. Sourcet: © Veterinary Emergency and result in hypovolemia, interstitial edema, and fluid losses
Critical Care Society, 2020; reproduced with permission [8]. into body cavities (e.g. pleural space, abdominal cavity, gas-
trointestinal tract; Figure 58.4). Hypovolemia reduces oxy-
protein dissolved in the plasma, and at normal concentra- gen delivery to the tissues. Significant interstitial edema
tions, it produces approximately 75% of the total intravas- inhibits transport of metabolic substances to and from the
cular COP. Other proteins such as fibrinogen and globulins cell. Significant leakage of fluid into the lung interstitium,
contribute the remaining 25%. The albumin molecule pleural space, and abdominal cavity may negatively impact
expresses a negative charge that attracts positively charged oxygenation, ventilation, and work of breathing.
Figure 58.4 Decreased intravascular colloid

Interstitial osmotic pressure. Decreased intravascular colloid
osmotic pressure results in movement of
intravascular water into the interstitium due to
consistent hydrostatic forces in that direction,
which can lead to reduced blood flow through the
capillary, interstitial edema, and decreased tissue
Intravascular oxygen delivery.
Intracellular
Protein
Solutes
easurino Plasma Osmolality 775
Synthetic colloid fluids (e.g. hydroxyethyl starches) and

Box 58.1 Substances that Increase Osmolar Gap
hemoglobin-based oxygen carriers contain large molecules
that generate COP. When the molecules are larger than the
● Acetone
inter-endothelial gaps, they can support intravascular COP
● Ethylene glycol
during states of hypoproteinemia and increased capillary
● Ethanol
permeability. Synthetic colloid fluids are commonly used
● Ether
to resuscitate and maintain intravascular volume in criti-
● Glycerol
cally ill patients with hypovolemic shock and with diseases
● Inositol
causing a systemic inflammatory response (e.g. pancreati-
● Isopropyl alcohol
tis, severe gastroenteritis, pneumonia) associated with
● Ketones
increased endothelial permeability. Albumin-containing
● Lactate
transfusions and lyophilized albumin are also used to sup-
● Mannitol
port intravascular COP and may play a role in maintaining
● Methanol
the endothelial glycocalyx.
● Paraldehyde
Frequent monitoring of both the patient as well as labo-
● Sorbitol
ratory monitoring of osmolality and COP can provide the
veterinary team with information on a patient’s needs and
response to specific therapy affecting fluid balance. due to normal solutes that are not included in the osmolality
calculation (e.g. albumin, cholesterol) [7]. If the osmolar
gap is significantly increased, toxin exposure should be
Calculating Plasma Osmolality considered, as well as certain conditions such as diabetic
ketoacidosis (Box 58.1).
Osmolality can be calculated by knowing a patient’s blood
urea nitrogen (BUN), glucose, and sodium (Na+) concentra-
tions. Four equations are reported to be used in the calculation Measuring Plasma Osmolality
of osmolality [7]. The two that correlate most accurately to
measured plasma osmolality are as follows: [7] A variety of osmometers are available for clinical labora-
tory monitoring. Some measure osmolality using a freezing-
Osmolality, mOsm / kg 2[Na K ], mEq / l point depression method (Figure 58.5), and others use
glucose, mg / dl / 18 room-temperature controls and vapor-point depression
(Figure 58.6). The freezing-point depression determination
BUN, mg / dl / 2.8
of osmolality compares the freezing point of solute-free
water and the freezing point of the sample. Water has a
Osmolality mOsm / kg 1.86 Na, mEq / l K, mEq / l
freezing point of 0°C, and a solution with saline
glucose, mg / dl / 18
concentration of 1 mOsm/kg has a freezing point of
BUN, mg / dl / 2.8 / 0.93 −1.858°C. Osmotically active substances decrease the
freezing point, and the freezing-point depression differ-
Both equations assume that 1 l = 1 kg. ence is translated by a thermistor into measured mOsm/kg.
The constants 18 and 2.8 convert the mg/dl of glucose and A vapor-point depression osmometer analyzes the vapor
BUN, respectively, to mOsm/l [2]. In the second equation, pressure of an osmotically active solution: the lower the
the 1.86 accounts for the incomplete dissociation of the salts, vapor pressure, the higher the osmolality of a solution. A
and the 0.93 accounts for the body percentage of water sample of solution is pipetted onto a small solute-free paper
when measuring whole blood [9, 10]. Because they are the disk that is inserted into the sample chamber that contains
only elements in these equations, an increase or decrease a thermocouple hygrometer. The temperature of the sample
in calculated osmolality is always caused by an increase or and the temperature of the chamber equilibrate. An electri-
decrease in sodium, potassium, glucose, or BUN. Other cal current is passed through the thermocouple, cooling it
substances will increase osmolality, but the only way to to a temperature below dew point. Water condenses from
detect them is by measuring osmolality using an osmometer. air in the chamber to form microscopic droplets on the sur-
In contrast to calculating osmolality, an osmometer measures face of the thermocouple. When the temperature of the
osmolality and thus not only accounts for the normal solutes thermocouple reaches the dew point, condensation ceases,
(BUN, glucose, Na+) but also for other small solutes, includ- causing the thermocouple temperature to stabilize.
ing toxins. There is normally a 10 mOsm/kg difference In contrast to freezing-point depression osmometers,
between calculated and measured osmolality (osmolar gap) vapor-point depression osmometers are not affected by
Freezing-point depression osmometers can detect not only

nonvolatile particles but also commonly encountered toxic
volatile alcohols that can increase the osmolar gap. The
Advanced Micro Osmometer Model 3300 (Advanced
Instruments, Inc., Norwood, MA), a freezing-point depres-
sion osmometer, has been validated for measuring plasma
and whole blood samples in normal dogs [7].
Osmometers can test a variety of bodily fluid and tissue
samples. Plasma, serum, whole blood, and urine are the
most commonly tested samples in veterinary medicine.
Serum can be separated using a serum separator. Plasma
and whole blood samples can be collected into lithium
heparin tubes, while other anticoagulants could affect
results. Technical support and equipment manuals should
be consulted on sample handling in case there are nuances
related to the specific osmometer being used. Serum osmo-
lality can be compared with urine osmolality to evaluate
Figure 58.5 Fiske 210 freezing-point depression osmometer for water imbalances. As the serum osmolality rises, the
(Cardinal Health). Osmotically active substances decrease the urine osmolality should also rise. The normal kidney will
freezing point, and the freezing-point depression difference is
translated by a thermistor into measured milliosmoles. This type
reabsorb water from the renal tubules in the hyperosmotic
of osmometer has been the most common one encountered in patient, which concentrates the urine. When there is an
veterinary medicine because it can detect consumed alcohol- excess of water in the body, normal kidney function dilutes
based toxins such as ethylene glycol. Single-sample freezing- the urine, eliminating extra body water to return serum
point depression osmometers for clinical use have largely been
discontinued; however, many are still available refurbished from
osmolality to normal. Normal serum osmolality ranges
medical suppliers or on resale websites. from 290 to 310 mOsm/kg in the dog and from 290 to
330 mOsm/kg in the cat [11]. Whole blood osmolality is a
little higher than plasma osmolality [7]. Normal urine
osmolality can range between 161 and 2830 mOsm/kg in
dogs [12]. The urine osmolality will increase when water
intake is withheld as long as kidney function is normal.
Each individual laboratory should establish the normal ref-
erence interval in each species for its osmometer.
Measuring Colloid Osmotic Pressure
COP cannot be accurately predicted and must be directly

measured using a colloid osmometer (Figures 58.7 and 58.8).
The colloid osmometer uses a semipermeable membrane to
simulate the role of the natural vascular membrane in the
Figure 58.6 VAPRO® 5520 vapor pressure osmometer (Wescor, determination of COP responsible for water flow between
Logan, UT). Sample volumes of 10 μl are typically used, but the interstitial fluid and blood. The colloid osmotic effects of both
osmometer allows for testing of sample volumes as small as natural and synthetic colloid molecules are measured by col-
2 μl. Results are available in 20 seconds and expressed as mmol/
loid osmometers. The normal values reported for plasma COP
kg. The osmometer stores up to 32 sample results and can be
easily connected to a printer or computer to download data. The are 16.7–28.9mmHg in the healthy dog and 18.3–30.8mmHg
instrument needs to be calibrated and has control solutions for in the healthy cat [12–15]. Whole blood COP is reported to be
high, normal, and low osmolality. 17.9–27.1mmHg in the healthy dog and 18.9–30.4mmHg in
the healthy cat [16, 17] When whole blood is being measured,
artifacts caused by increased viscosity of a solution, sus- the sample should be collected with lyophilized heparin. Each
pended particles, or other conditions. However, because individual laboratory will establish the normal reference
vapor-point depression osmometers require larger sample interval in each species for its colloid osmometer.
volumes and do not detect alcohols such as ethylene glycol, Severe hemolysis (with release of hemoglobin into
they are used less frequently in clinical medicine. plasma), as well as severe hyperglobulinemia (caused by
eoerences 777
Sample
Chamber A Semi-permeable
membrane
Chamber B
Pressure
transducer
Figure 58.7 Model 4420 Colloid osmometer (Wescor, Logan,
UT). Heparinized whole blood, plasma, and serum can be
analyzed. Sample volume requirements are normally 350 μl;
however, special procedures allow for measurements of sample
volume as low as 125 μl. The osmometer requires frequent Figure 58.8 Principles of the colloid osmometer. The sample
calibration with high (25 mmHg), low (15 mmHg), and normal is injected into chamber A and allowed to equilibrate with the
(20 mmHg) reference solutions. The membrane requires periodic reference chamber B, which contains 0.9% NaCl. The artificial
changing, and saline solution is regularly infused to prevent the membrane does not allow molecules greater than 30 000 Da in
membrane from drying out. size to pass. The colloid osmotic pressure (COP) of the sample
causes water and small solutes to move from chamber B to
chamber A, which causes a reduction in pressure in chamber
B. The negative pressure produced is measured by the pressure
transducer and equals the COP of the sample in chamber A. The
Box 58.2 Causes of Hypoalbuminemia results are displayed in mm Hg, cm H2O, or kilopascals (kPa).
Decreased production (liver failure):

● Portosystemic shunt multiple myeloma or feline infectious peritonitis) and
● Chronic active hepatitis hyperalbuminemia can increase COP. A decrease in COP
● Acute hepatotoxicity can indicate dilution of the blood or a deficiency in intra-
vascular albumin molecules (Box 58.2).
Increased loss: In summary, osmolality and COP play an important role
● Protein-losing glomerulonephropathy in water homeostasis of our patients. Veterinary techni-
● Protein-losing enteritis cians who understand the physiology and monitoring of
● Systemic inflammatory response syndrome osmolality and COP, and how it relates to abnormal water
● Acute allergic reaction balance, will have a greater ability to anticipate and pre-
vent morbidity in their patients.
References
1 Kirby, R. and Rudloff, E. (2017). Fluid balance. In: Cellular and Molecular Approach (ed. W.F. Boron), 50–86.
Monitoring and Intervention for the Critically Ill Small Philadelphia, PA: Elsevier Saunders.
Animal: The Rule of 20 (ed. R. Kirby and A. Linklater), 4 Lien, Y.H.H., Shapiro, J.I., and Chan, L. (1990). Effects of
9–28. Ames, IA: Wiley-Blackwell. hypernatremia on organic brain osmoles. J. Clin. Invest. 85:
2 Wellman, M.L., DiBartola, S., and Kohn, C.W. (2012). 1427–1435.
Applied physiology of body fluids in dogs and cats. In: Fluid, 5 Argyropoulos, C., Rondon-Berrios, H., Raj, D.S. et al.
Electrolyte and Acid-Base Disorders in Small Animal Practice (2016). Hypertonicity: pathophysiologic concept and
(ed. S. DiBartola), 2–25. St. Louis, MO: Elsevier Saunders. experimental studies. Cureus 8 (5): e596.
3 Aronson, P.S., Boron, W.F., and Boulpaep, E.L. (2005). 6 Starling, E.H. (1896). On the absorption of fluids from the
Physiology of membranes. In: Medical Physiology: A convective tissue spaces. J. Physiol. (Lond.) 19: 312–326.
7 Barr, J.W. and Pesillo-Crosby, S.A. (2008). Use of the 12 van Vonderen, I.K., Kooistra, H.S., and Rijnberk,
advanced microosmometer model 3300 for determination A. (1997). Intra- and interindividual variation in urine
of a normal osmolality and evaluation of different osmolality and urine specific gravity in healthy pet dogs
formulas for calculated osmolarity and osmole gap in of various ages. J. Vet. Intern. Med. 11: 30–35.
adult dogs. J. Vet. Emerg. Crit. Care 18: 270–276. 13 Smiley, L.E. and Garvey, M.S. (1994). The use of
8 Gaudette, S., Hughes, D., and Boller, M. (2020). The hetastarch as adjunct therapy in 26 dogs with
endothelial glycocalyx: structure and function in health hypoalbuminemia. A phase two clinical trial. J. Vet.
and critical illness. J. Vet. Emerg. Crit. Care 30: 117–134. Intern. Med. 8 (3): 195–202.
9 Dorwart, W.V. and Chalmers, L. (1975). Comparison of 14 Thomas, L.A. and Brown, S.A. (1992). Relationship
methods for calculating serum osmolality from chemical between colloid osmotic pressure and plasma protein
concentrations, and the prognostic value of such concentration in cattle, horses, dogs and cats. Am. J. Vet.
calculations. Clin. Chem. 21 (2): 190–194. Res. 53: 2241–2243.
10 McQuillen, K.K. and Anderson, A.C. (1999). Osmol gaps 15 Rudloff, E. and Kirby, R. (2000). Colloid osmometry. Clin.
in the pediatric population. Acad. Emerg. Med. 6 Tech. Small Anim. Pract. 15 (3): 119–125.
(1): 27–30. 16 Odunayo, A. and Kerl, M.E. (2011). Comparison of whole
11 DiBartola, S. (2012). Disorders of sodium and water: blood and plasma osmotic pressure in healthy dogs. J. Vet.
hypernatremia and hyponatremia. In: Fluid, Emerg. Crit. Care 21 (3): 236–241.
Electrolyte and Acid Base Disorders in Small Animal 17 Jackson, M.L., Kerl, M.E., Tynan, B., and Mann, F.A. (2014).
Practice (ed. S. DiBartola), 45–79. St. Louis. MO: Comparison of whole blood and plasma colloid osmotic
Elsevier Saunders. pressure in cats. J. Vet. Emerg. Crit. Care 24 (4): 408–413.
779
59
Body Fluid Collection and Handling

Adesola Odunayo and Eric Hilton
Laboratory tests are used in diagnosis and monitoring of identifying number, and type of specimen should always
responses to treatment in healthy and sick veterinary be included on the label. Multiple samples from the same
patients. It is estimated that about two thirds of important patient on the same day should be labeled with the time of
clinical decisions about patients are based on laboratory collection, as well as the site of collection, if appropriate.
test results [1]. Many of these tests usually require acquisi- All samples designated to be transported to an external
tion and analysis of bodily fluid samples (i.e. blood, urine, laboratory should be packaged appropriately to prevent
effusion samples). spillage or breakage. Cool packs should be used for
Errors in laboratory tests are common. These errors temperature-sensitive specimens and the sample should be
may occur prior to the testing (preanalytical), while the transported as quickly as possible to minimize transport
test is being run (analytical) or after the test is completed artifacts.
(postanalytical) [1]. Body fluid collection method, method
of storage, length of storage, and sample processing tech-
niques (all sources of preanalytical error) can affect the Urine
results and interpretation of specific laboratory tests.
Thus, it is important that veterinary professionals follow Urine is a major diagnostic specimen in veterinary patients.
standardized recommendations to minimize preana- Common tests performed on urine samples include
lytic errors. urinalysis, urine culture and sensitivity, urine protein/
This chapter focuses on handling techniques for body creatinine ratio, urine electrolytes, fungal antigen tests,
fluid sample to maximize the accuracy of the diagnostic and urine cortisol concentrations [2].
test and provides an overview of sample collection meth-
ods (see Chapter 53 for blood sample collection and
Collection
handling).
Body fluid samples should be collected in a clean and There are multiple ways of obtaining urine samples in vet-
sterile way (if appropriate) with minimal stress on the erinary patients. Collection technique may depend on
patient. The samples should be transferred to the appropri- operator preference, patient compliance, and the diagnos-
ate storage tubes immediately. Storage tubes should be tic rationale obtaining the urine sample; for example, a cys-
clean, sterile (if appropriate) and should not be expired. tocentesis may be preferred for urine sample collected for
Table 59.1 provides an outline of the commonly available urine culture and sensitivity, while a free-catch collection
storage tubes used for storage and transport of body fluid is perfectly acceptable to evaluate urine protein : creatinine
samples to a reference laboratory. ratios [2, 3].
To ensure positive identification and optimal patient out- Asepsis should be strictly maintained during urine
come, all patient samples should be labeled as soon as they collection. Urine samples should be collected into a clean
are collected. While specific details should align with the container with minimal contact of the urine sample with
preferences of the reference laboratory performing the test, the animal’s body [4]. Ideally, new (plastic or glass) clean
the patient name, client’s last name, patient’s unique containers with tight-fitting lids should be used [4].
780 Body Fluid Collection and Handling
Table 59.1 Storage tubes commonly used for transport of body fluid samples.
Tube type Tube contents/preservative Common indications
EDTA (lavender/ Dipotassium EDTA Tube of choice for cytology samples. Prevents clotting. Allows
purple top) (ethylenediaminetetraacetic acid) preservation of white and red blood cells, platelets, and
infectious agents. Used to determine the total nucleated cell
count, white blood cell count and total protein. (Note that
underfilling an EDTA tube can result in falsely increased
refractometric total protein). The EDTA tube can also be used
for tests such as PCR and virus isolation. EDTA is bacteriostatic
and is not appropriate for culture.
Heparinized (green top) Sodium heparin Rarely used for body fluid analysis. May occasionally be useful
for fluid samples that require biochemical analysis of their
contents (sodium, potassium, glucose, creatinine). Note that
potassium cannot be measured from an EDTA tube sample
because the EDTA additive is potassium EDTA.
Slides/freshly made None Direct or concentrated/centrifuged smears should be provided
smears with EDTA samples for cytology.
Glass non-anticoagulant None Good for urinalysis, as well as for samples that require culture
(red top) and sensitivity. Can also be used for CSF, PCR, virus isolation,
or biochemical assay evaluation.
Plastic non-anticoagulant Contains a clot activator but Best used for PCR, virus isolation tests, biochemical assay
(red top) no anticoagulants evaluation. Crystalline clot activator in the plastic red-top tube
may inhibit bacterial growth or introduce artifact in urinalysis
or cytology.
Plastic containers None Some plastic containers may be sterile and can be used for
cultures and sensitivities. May also be used for urinalysis, CSF
samples, biochemical assays, PCR testing, or virus isolation.
Anaerobic transport Soft agar and reducing agents Designed to maintain viability of anaerobic organisms. Ensure
medium that the cap of the tube is replaced and tightened before
transport.
Blood culture medium Growth medium to enhance the Helps in isolation of bacteria from synovial fluid and blood.
culture of bacteria
CSF, cerebrospinal fluid; PCR, polymerase chain reaction.
Cystocentesis collection. While sedation is generally not necessary for

Cystocentesis involves the introduction of a sterile needle male dogs, it is usually required for cats and female dogs.
directly into the urinary bladder to obtain a sterile urine The sample collected may be contaminated with cells and
sample. It is the preferred method of obtaining urine for a bacteria from the lower urinary tract so culture and sensi-
culture and sensitivity, although the urine collected this tivity results should be interpreted cautiously.
way can be used for any test requiring a urine sample. In
brief, the patient is placed on its back (dorsal recumbency) Free-Catch Collection
with an assistant helping to restrain it (cystocentesis may Free-catch is a non-invasive urine collection method
also be performed standing or in lateral recumbency). The and the least stressful for the patient. The urine sample
caudoventral abdomen is shaved and aseptically prepared. is collected while the animal is voiding. A midstream
A sterile needle is introduced through the skin and directly sample is recommended to minimize contamination
into the urinary bladder and urine is collected into a with cells and flora of the lower urinary tract. This can
syringe. This method is best performed with ultrasound be challenging in a cat and is sometimes challenging in
guidance. Complications associated with cystocentesis are female dogs. Employing a long-handled ladle or shallow
few but may include hemorrhage, vasovagal collapse, sep- tin may maximize success in dogs. Voided samples may
tic peritonitis, and seeding of urinary tract neoplasia [5, 6]. be considered for urine culture and sensitivity following
previously defined bacterial cut-off values of
Catheterization 100,000 colony-forming units (CFU)/ml or greater, as
Urinary catheterization (see Chapter 35) is the most time long as the specimens are refrigerated and plated on the
consuming and labor/resource intensive method of urine day of collection [7].
Urine 781
Surface Collection While not commonly recommended, urine sample integ-

Surface collection is the least invasive way of collecting rity can be maintained by chemical preservatives like
urine. The urine sample is retrieved from a surface on formalin or sodium fluoride (Table 59.2). Chemical pre-
which the animal has voided, including but not limited to servatives are usually used when refrigeration is not an
the cage, litter box, hospital floor, or outdoor surface. This option. The appropriate preservative should not alter urine
sample is usually contaminated with debris and bacteria constituents or interfere with analytical tests [14].
from the surface where it was collected. This sample is usu- Refrigerated urine samples are generally adequate for
ally unsuitable for determination of bactiuria or bacterial non-urinalysis or urine culture tests (urine cortisol, urine
culture. It may be used for other tests, such as fungal anti- protein : creatinine ratio, or urine fungal antigen tests).
gen testing, urine cortisol concentration, or urine pro- Urine samples can be stored and submitted in the syringe
tein : creatinine ratio. used for urine collection, additive-free red-top tubes (tubes
with additives may inhibit bacterial growth), glass tubes, or
Manual Expression clean additive-free plastic containers. Urine samples sub-
Manual expression of the urinary bladder is usually not mitted to an external laboratory for culture and sensitivity
recommended because of the risk of urinary tract rupture can be submitted in an additive-free plastic or glass tube,
and the vesicoureteral reflex. on swabs, or in boric acid tubes (Figure 59.1) [15]. It is
important to fill boric acid tubes to the line indicated
Sample Handling and Preservation
Table 59.2 Chemical preservatives for urine samples.
Once the urine sample is collected, it should be grossly
evaluated and the urine color, as well as the transparency,
Chemical
should be noted [4]. Urine samples should be analyzed as preservative Advantage Disadvantage
quickly as possible after collection, ideally within 30 min-
utes, as there is no substitute for a fresh urine sample Sodium Inhibits Interferes with dipstick test:
when urine is collected for urinalysis and urine culture fluoride glycolysis glucose, blood, leukocyte esterase
and sensitivity [4]. If this is not possible, the sample Formalin Preserves Interferes with dipstick tests:
should be refrigerated immediately and stored for no sediment glucose, blood, leukocyte
esterase
longer than 6–12 hours after collection, although urine
may be stable for slightly longer or shorter periods [4, Source: Modified from Sink and Weinstein (2012) [14].
8, 9]. The refrigerated sample should be brought to room
temperature before analysis.
It is important to note that when a urine sample is
obtained for culture and sensitivity, it should ideally be
plated immediately. Storage of urine samples at room
temperature for extended periods (longer than two hours)
leads to false positive and false negative culture
results [8, 10]. In one study, while CFU count was not
affected, refrigeration appeared to affect sensitivity
results, which may skew patient treatment, although a
recent study concluded that there is minimal clinical
impact if refrigerated urine samples are plated within
24 hours [11, 12]. Prolonged refrigeration (≥ 24 hours)
may lead to false negative culture results. Refrigeration of
urine samples may also cause changes in urine pH (falsely
elevated), glucose (falsely low) in the presence of bacte-
ria [9]. Crystals may form in samples kept at room tem-
perature or in the fridge. If there is clinical concern about
crystalluria, the urine sample should be evaluated imme-
diately [9]. Presence of crystals observed in stored sam-
ples should be validated by reevaluation of a fresh urine
Figure 59.1 Storage containers that can be used for culture
sample [13]. Freezing of urine samples is discouraged as
and sensitivity of body fluid samples; (l to r): micro culture swab,
this leads to disintegration of cells and casts, as well as culture swab, sterile plastic container, red-top tube, red-top tube,
inducing changes in the urine pH [4]. sterile syringe, petri dish.
because high concentrations of boric acid may – kill bacte- In general, it is advisable to submit both. Fluid submission
ria [15]. Urine should not be stored in any tubes with confers the advantage of enabling the laboratory to use
additives (e.g. heparinized or EDTA tubes). cytocentrifugation technique to concentrate samples with
a low cell count; however, submitting a freshly prepared
smear with the fluid sample allows for interpretation of
Transtracheal and Endotracheal Tube changes that occur secondary to storage [16, 19]. Slides
Washes and Bronchoalveolar Lavage should not be refrigerated but should be stored and trans-
ported at room temperature.
Transtracheal and endotracheal tube washes and bron- For best results, processing of transtracheal and endotra-
choalveolar lavage (BAL) are used to obtain lower air- cheal tube washes and BAL samples should be performed
way samples. The airway sample can be employed to within one hour of collection as cell quality changes may
make a diagnosis of bacterial or fungal pneumonia, neo- happen quickly. Samples should be transported on ice
plasia, or inflammatory airway disease, using cytological within 60 minutes to maximize cell preservation and mini-
evaluation. Culture and sensitivity can also be per- mize bacterial growth [17, 19, 20]. A delay of about 48 hours
formed on the airway wash sample to identify predomi- is acceptable if the sample is refrigerated and the fluid
nant microorganisms and to determine the best sample sent on ice, if shipped to a reference laboratory
therapeutic agent. In addition, special diagnostics, such overnight [19].
as polymerase chain reaction (PCR), virus isolation, or EDTA tubes are recommended for samples submitted for
specific antigen assays can be performed on the sample cytology to preserve cellular morphology (Figure 59.2) [16].
obtained [16]. EDTA tubes can also be used for PCR, virus isolation, or
A transtracheal wash is usually done with the patient specific antigen identification, depending on the labora-
awake or lightly sedated. This technique is easier in tory and the specific diagnostic test run. Samples for bacte-
medium to large-sized dogs. Briefly, the area of the trachea rial cultures can be submitted in a sterile tube free from
is surgically clipped and prepped and about 5–20 ml of ster- additives (red-top tubes, glass tubes) although samples
ile saline in a syringe is injected into the lower airway using may also be submitted in tightly sealed syringes or plastic
an over-the-needle catheter or polypropylene catheter fed tubes. Samples for bacterial cultures should ideally be
through a needle [16, 17]. The patient is then vigorously plated within one hour of collection but refrigerated sam-
coupaged to obtain about 10% of the infused volume of ples are also acceptable.
saline back into the syringe [17]. This technique has the
benefit of being performed awake but has been shown to be
inferior compared with samples obtained by bronchoalveo-
lar lavage [17, 18].
Endotracheal tube wash is performed in cats and small
dogs under general anesthesia. Briefly, the patient is
induced and a sterile endotracheal tube is placed in the tra-
chea, with care taken to avoid contaminating the tube with
oropharyngeal secretions. A red rubber (or similar) cathe-
ter is passed through the endotracheal tube and saline is
infused through the red rubber catheter into the lower air-
way and then aspirated back. Bronchoalveolar lavage is
performed under general anesthesia using specialized
equipment (bronchoscope). Veterinarians with advanced
training most commonly perform BAL and the technique
is not discussed in this chapter.

Samples should be collected using sterile techniques and
immediately labeled with the patient information. The
sample should be grossly evaluated and the fluid color and
consistency should be noted. Cytological samples may be
submitted as fluid or prepared slides, depending on the ref- Figure 59.2 EDTA tube used for storage of body fluids that
erence laboratory and the nature of material obtained [16]. require cytological evaluation.
Pleural Effusion 783
Pericardial Effusion made concurrently. The EDTA tube should be refrigerated

if immediate evaluation is not possible but should be evalu-
Pericardial effusion can present as a life-threating emer- ated within 24 hours of collection. A PCV/total protein
gency in veterinary patients. Pericardiocentesis, the act of should be obtained from the EDTA sample to determine
removing fluid from the pericardial sac, acts as a therapeu- whether it is a hemorrhagic or serosanguinous effusion.
tic and diagnostic intervention in those patients. The fluid With hemorrhagic samples, the PCV of the fluid should be
removed may help to identify the cause of the effusion at least 10–25% of the peripheral blood [22].
(lymphoma, bacterial, or fungal pericarditis), although in In patients where there is concern for peritonitis, an
most cases, cytological evaluation of pericardial fluid is abdominal fluid glucose and lactate is compared with the
often nondiagnostic. In brief, pericardiocentesis (see peripheral glucose and lactate as a diagnostic test. The
Chapter 18) is performed awake in most patients, although abdominal fluid glucose and lactate can be analyzed as soon
light sedation may be required. After aseptic preparation, a as the fluid is removed from the abdominal cavity without
needle is inserted between the third and sixth rib spaces on transferring the sample to a storage tube. However, a hep-
the right side, while the patient is in lateral or sternal arinized tube can be used to store the sample for delayed
recumbency. The patient should be closely monitored dur- analysis. It is important to remember that prolonged storage
ing the fluid collection for cardiac arrhythmias. In most will lead to lower glucose and higher lactate readings.
cases, the pericardial fluid is hemorrhagic, although it may A red-top tube (additive free), sterile plastic tube or cul-
be serosanguinous in cats with heart failure. ture swab should be used for bacterial culture and sensitiv-
ity (Figure 59.1). A red-top tube can also be used for
biochemical analysis (creatinine, potassium), as indicated,
Sample Handling and Preservation such as when one is ruling out a uroabdomen.
Some of the pericardial effusion should be stored in an Samples should be prioritized based on the volume of
EDTA tube to obtain a packed cell volume (PCV) and total fluid available for analysis and the suspected underlying
protein, as well as for fluid cytology, which may be helpful disease [24].
to identify lymphoma [21] or infectious pericarditis.
Another sample should be stored in a red-top tube to help
differentiate hemorrhagic pericardial effusion (unlikely to Pleural Effusion
clot) from iatrogenic hemorrhage from cardiac puncture
(more likely to clot) [22]. The red-top tube sample can also Pleural effusion is removed via thoracocentesis. Many ani-
be used for culture and sensitivity of the pericardial effu- mals present with evidence of respiratory distress and a
sion, if indicated. Culture and sensitivity is rarely performed thoracocentesis provides almost immediate relief if the
on pericardial effusion but any sterile additive-free tube pleural effusion is the main cause of their respiratory diffi-
can be used for that purpose. culty. Common causes of pleural effusion includes heart
failure, pyothorax, chylothorax, and hemothroax. Like the
abdominocentesis procedure, thoracocentesis can be used
Abdominal Effusion both as a diagnostic and therapeutic tool.
Briefly, when possible, an intravenous catheter should be
Abdominocentesis, the process of removing free intraab- placed before thoracocentesis. Sedation may be required in
dominal fluid, is a common diagnostic and therapeutic agitated or anxious patients. After aseptic preparation of
skill. There are various methods to remove fluid from the the thoracic body wall, a small-gauge needle or catheter
abdominal cavity, including, blind abdominocentesis, (18–22 gauge) is introduced into the pleural space between
ultrasound guided abdominocentesis, four-quadrant cente- the sixth and ninth intercostal space. The needle should be
sis, as well as a diagnostic peritoneal lavage (see Chapter 38). placed along the cranial curvature of the rib or in between
ribs, with care taken to avoid the caudal margin of the ribs,
where the nerves and blood vessels run. More specific
details about thoracocentesis are outlined in Chapter 34.
The abdominal fluid sample should be grossly evaluated
and the color noted. If the fluid is clear initially, then turns
red, iatrogenic hemorrhage is likely [23].
Abdominocentesis fluid samples should be cytologically The thoracic fluid sample should be grossly evaluated and
evaluated as soon as possible. A sample should be saved in the color noted. If the fluid is clear initially, then turns red,
an EDTA tube and some smears (ideally direct and centri- iatrogenic hemorrhage is likely [23]. A PCV/total protein
fuged sample with slides labeled appropriately) should be should be performed to identify true hemorrhage or
serosanguinous effusion. With hemorrhagic samples, the analysis before collection. This includes a plan for other
PCV of the fluid should be at least 10–25% of the peripheral diagnostic tests indicated for that patient, which will dic-
blood [22]. Pyothorax effusions may have a marked unpleas- tate what type of sample collection tube is to be used [26].
ant odor, increasing the index of suspicion for an infectious The sample should be inspected grossly once collected.
etiology. Chylothorax effusions are white or milky in color Normal CSF should be colorless and clear [28]. Iatrogenic
and the color does not clear after centrifugation [25]. blood contamination from sampling can be determined by
As with abdominal effusions, pleural fluid should be saved centrifuging the sample. A red cellular pellet after centrifu-
in EDTA tubes for cytological evaluation, as well as to obtain gation (and the supernatant is clear) indicates peripheral
PCV/total solids and total nucleated cell count. Smears blood contamination or recent hemorrhage [28]. If the
should also be made at the same time and should ideally be supernatant is xanthochromic, it may indicate previous
transported to the reference laboratory with the EDTA sam- hemorrhage [28]. CSF samples should be collected into
ples. Cytology samples should be evaluated immediately but sterile plain tubes. EDTA tubes are not recommended for
refrigerated samples are acceptable when immediate evalu- routine sampling as the additive can falsely elevate total
ation is not feasible. An additive free red-top tube or sterile protein concentration [27, 29].
plastic or glass container can be used for culture and sensi- Cytological analysis of CSF should be performed within
tivity samples, as well as biochemical evaluation of the fluid 30–60 minutes of collection due to distortion of cell struc-
if needed (e.g. cholesterol and triglyceride concentrations to tures and reduction of total nucleated cell count from cell
rule out a chylothorax) (Figure 59.1). Culture swabs can also lysis [30]. However, some studies have suggested that the
be used for culture (aerobic, anaerobic, and Mycoplasma cul- addition of fetal calf serum, hetastarch, 10% formalin, and/
tures). Samples for culture and sensitivity should be plated or fresh frozen autologous clear plasma or serum may sta-
immediately but refrigerated samples are acceptable when bilize CSF samples for 4–48 hours, depending on the
immediate culture is not feasible. medium used [30–32]. However, in a 2020 study, vetstarch
did not reduce the time-dependent cellular degeneration
compared with serum or saline [33].
Cerebrospinal Fluid If cytological analysis requires a delay, two aliquots of
CSF can be collected and placed in sterile plain tubes. A
A cerebrospinal fluid (CSF) evaluation is indicated in preservative should be used in one of the tubes for cytology
patients with neurologic disease affecting the central nerv- and cell count. The other tube can be used for protein
ous system. A CSF evaluation is useful in diagnosing infec- quantification and antibody titer analysis [27]. The analy-
tious and inflammatory diseases in dogs and cats and may sis of protein and other analytes in CSF have no time-
also be useful to diagnose neoplastic diseases (such as lym- dependent requirements and can be handled just like any
phoma). CSF collection may carry significant risks (hemor- other fluid [28]. Sterile additive-free tubes can be used for
rhage, brain herniation, infection) and is usually performed CSF culture.
by clinicians with specialized skills [26].
The two most common sites for CSF collection are the
cisterna magna (atlantooccipital) and the caudal lumbar Synovial Fluid
subarachnoid space. If focal central nervous system disease
is suspected, the site of collection should be caudal to the Arthrocentesis is the aspiration of synovial fluid from a joint
suspected lesion [27]. If diffuse disease is suspected, CSF space for diagnostic evaluation [34]. Synovial fluid samples
should be obtained from both sites if possible. A spinal are used in the diagnosis of joint disease (immune mediated,
needle is inserted in to the subarachnoid space while the neoplastic, or infectious) but is also used to evaluate the
patient is under general anesthesia. Once CSF is obtained, response of such diseases to treatment [34]. Arthrocentesis is
the stylet is removed from the spinal needle, and the CSF is performed under heavy sedation in most patients, although
allowed to flow freely in to a red-top tube. Aspiration of the general anesthesia may be required in some cases [34]. In
fluid with a syringe is not recommended [26]. general, joints that contain excessive fluid should be sam-
Approximately 1 ml of CSF can be safely removed per 5 kg pled; however, if none exists, at least two to three joints
of body weight, however, most routine sampling only should be sampled [35]. If possible, the carpal and tarsal
requires a total volume of 1 ml for any patient [26]. joints should be included in the joints sampled [35].
Sample Handling and Preservation Sample Handling and Preservation

The cells in CSF begin to degenerate within 30 minutes of Arthrocentesis of normal joint yields only a small
collection, so it is important to have a plan for sample amount of synovial fluid (less than 0.5 ml) [34].
References 785
A sample of more than 1 ml from any joint is abnor-

mal [34]. The sample should be visually inspected once
obtained. Normal synovial fluid sample is colorless or
light yellow and clear in appearance [34]. The viscosity
can be assessed by placing a drop of the sample between
two fingers and slowly pulling them apart. Normal syno-
vial fluid should form a strand, which usually extends to
about 2–5 cm before it breaks. Reduced viscosity is indic-
ative of joint disease [34].
The top test priority is the microscopic examination of
the fluid. A smear of the sample should be made for cytol-
ogy and the rest of the fluid (if applicable) should be
divided between a pediatric EDTA tube (owing to the
small volume collected) and blood culture media tubes or
bottles [35]. The EDTA tube is used for cytological evalu-
ation and cell count. Aerobic bacteria is cultured most
reliably from the joint by using blood culture medium,
since synovial fluid culture generally has a low yield (up
to 50–70% false negative results) [36, 37]. The liquid blood
culture medium prevents coagulation of the fluid, dilutes
inhibitors, inactivates aminoglycoside antibiotics, and
limits in vitro phagocytosis of bacteria [35]. Thus, blood Figure 59.3 Storage containers that may be used for
culture medium significantly enhances the recovery of arthrocentesis samples; (l to r): pediatric blood culture tube,
blood culture tube, micro culture swab, culture swab, red-top
organisms from septic joints [35]. However, aerobic cul-
tube, and red-top tube.
ture transport media or plain sterile tubes can also be
used if blood culture medium is not available Fluid samples for cell counts and cytological assessment
(Figure 59.3) [35, 36]. Isolation of anaerobic bacteria can can be stored in the refrigerator for 24 hours but it is best to
be accomplished using an anaerobic transport media. The make smears immediately the sample is collected [35]. If
reference laboratory should be alerted if Mycoplasma only a few drops of fluid are obtained, preparation of
infection is suspected, as these organisms grow better on stained smears for cytology will provide the most diagnos-
a specialized medium [35]. tic information for that patient [35].
References
1 Plebani, M. (2009). Exploring the iceberg of errors in 7 Sørensen, T.M., Jensen, A., Damborg, P. et al. (2016).
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2 Manfredi, S., Gnudi, G., Miduri, F. et al. Diagnostic and diagnosing canine urinary tract infection by quantitative
therapeutic cystocentesis in dogs and cats: considerations. bacterial culture. Vet. J. 216: 168–173.
Crit. Care 12: 183–187. 8 Padilla, J., Osborne, C., and Ward, G. (1981). Effects of
3 Silverstein, D. and Hopper, K. (2014). Small Animal storage time and temperature on quantitative culture of
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Saunders. 9 Gunn-Christie, R.G., Flatland, B., Friedrichs, K.R. et al.
4 Parrah, J., Moulvi, B., Gazi, M. et al. (2013). Importance of (2012). ASVCP quality assurance guidelines: control of
urinalysis in veterinary practice: a review. Vet. World 6: preanalytical, analytical, and postanalytical factors for
640–646. urinalysis, cytology, and clinical chemistry in veterinary
5 Odunayo, A., Ng, Z.Y., and Holford, A.L. (2015). Probable laboratories. Vet. Clin. Pathol. 41: 18–26.
vasovagal reaction following cystocentesis in two cats. 10 Hindman, R., Tronic, B., and Bartlett, R. (1976). Effect of
J. Fel. Med. Surg. Open Rep. 1: 2055116915585021. delay on culture of urine. J. Clin. Microbiol. 4: 102–103.
6 Manfredi, S., Carvalho, C., Fonti, P. et al. (2018). 11 Acierno, M.J., Partyka, M., Waite, K. et al. (2018). Effect
Complications of ultrasound-guided cystocentesis in of refrigeration of clinical canine urine samples on
companion animals: 21 cases (2005–2016). Turk. J. Vet. quantitative bacterial culture. J. Am. Vet. Med. Assoc.
Anim. Sci. 42: 459–466. 253: 177–180.
12 Coffey, E.L., Little, K., Seelig, D.M. et al. (2020). 26 Ortinau, N. (2017). 5 Cisternal cerebrospinal fluid taps.
Comparison of immediate versus delayed streak plate In: Current Techniques in Canine and Feline
inoculation on urine bacterial culture and susceptibility Neurosurgery (ed. A. Shores and B.A. Brisson), 55–57.
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13 Albasan, H., Lulich, J.P., Osborne, C.A. et al. (2003). 27 Di Terlizzi, R. and Platt, S.R. (2009). The function,
Effects of storage time and temperature on pH, specific composition and analysis of cerebrospinal fluid in
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14 Sink, C.A. and Weinstein, N.M. (2012). Practical Vet. Clin. Small Anim. Pract. 18: 475–499.
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24 Mondal, D., Kumar, M., Saravanan, M. et al. (2012). biopsy, and blood culture medium in detection of canine
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787
60
Urinalysis in Acutely and Critically Ill Dogs and Cats

Lucy Kopecny and Sean Naylor
Urinalysis is a key component of the evaluation of acutely therefore important that urine collection method is
and critically ill dogs and cats. It provides information on reported (Table 60.1).
not just the urinary system but also systemic diseases such Selection of urine collection technique is determined by
as diabetes mellitus and liver disease. Urinalysis is rela- the type of urine testing planned and the presence of cer-
tively simple and inexpensive and can be combined with tain systemic disorders and drug administration. For exam-
more advanced techniques. ple, samples for measurement of the urine protein to
creatinine ratio can be collected by free catch [1].
Cystocentesis should be avoided in dogs and cats with
What Is Urinalysis? coagulation disorders or that are receiving drugs that affect
coagulation, owing to the risk of hemorrhage. Common
Urinalysis includes evaluation of the physical and chem- drugs that affect coagulation are those that inhibit platelet
ical properties of urine, urine specific gravity (USG) function (e.g. clopidogrel or aspirin) and drugs that affect
measurement and urine sediment evaluation. In-house clotting factors (e.g. unfractionated heparin, low molecular
testing is preferred due to faster turnaround times and weight heparin, or rivaroxaban).
improved accuracy of results, as delays in analysis can If a dog or cat is sufficiently stable, urine should be col-
alter some urine characteristics. Urinalysis requires only lected before any therapeutic interventions such as admin-
basic laboratory supplies and is readily performed by istration of fluid therapy or antimicrobials as these can
trained staff. alter some urine testing results.
A summary of recommended equipment and disposable Urine samples should be stored in a sterile, airtight con-
supplies for urinalysis is provided in Box 60.1. When per- tainer and analyzed within 30–60 minutes. If testing is
forming urinalysis, a standardized urinalysis report should delayed, refrigeration of the urine sample is recom-
be completed. An example of a urinalysis report form is mended [2, 3]. Both refrigeration and increased storage
provided in Table 60.1. time can result in crystal formation and bacterial over-
growth. Storage time and temperature do not significantly
affect urine pH or USG measurement [3]. It is recom-
Urine Sample Collection mended that urine be stored for a maximum of 24 hours
and Handling and that refrigerated samples be returned to room temper-
ature before analysis [2].
Urine collection techniques are reviewed in Chapter 59. For samples collected for urine culture, if immediate
Cystocentesis is preferred for urine collection, although processing is not possible, urine should be placed in a ster-
these samples can have blood contamination if collection ile container and refrigerated during storage and shipping
is traumatic. Catheterized (see Chapter 35) samples or to the laboratory. However, if samples will be exposed to
samples collected by midstream free catch can have con- room temperature during storage and shipping, urine
tamination from both the lower urinary and genital tracts; transport tubes are preferred [4]. Urine transport tubes
this can influence urine sediment examination results. It is contain a preservative.
788 Urinalysis in Acutely and Critically Ill Dogs and Cats
Box 60.1 Summary of Recommended Equipment Urine Specific Gravity

and Disposable Supplies for Urinalysis
USG is defined as the ratio of the weight of urine to the
Equipment weight of an equal volume of distilled water and depends
on the number of solutes and their weight. It is a measure
● Centrifuge – low rotation/minute capability
of urine concentration. USG varies in healthy animals,
● Refractometer (feline and canine specific scales
although dogs and cats with normal renal function are con-
preferable)
sidered to have a USG greater than1.030 and greater than
● Microscope
1.035, respectively.
● Timer
Collection of first morning urine samples is recom-
● Automated dipstick reader (optional)
mended for determination of urinary concentrating ability
● Pipettor – fixed or variable volume (optional)
as this is thought to be the most concentrated urine sample
● Refrigerator – if unable to analyze sample in appro-
of the day [6]. However, the USG of first morning urine
priate timeframe
samples can still be variable enough to alter clinical
● Automated urine electrolyte analyzer (optional)
decision making between days in dogs [7].
Glucosuria causes minimal changes to USG in dogs and
Disposable supplies
cats [8].
● Specimen container – sterile, clear and tight lid
● Multiple reagent dip sticks
Methods
● Conical centrifuge tubes
● Disposable pipettes USG is measured by refractometers. Temperature-
● Disposable pipette tips (optional) compensated refractometers are preferred as they provide
● Glass slides and coverslips accurate readings between 60 and 100 degrees
● Sediment stain (optional) F. Refractometers with scales calibrated for human urine
● Urinalysis report form result in falsely increased USG measurements in cats, espe-
cially in concentrated samples. Refractometers with sepa-
rate calibration scales for feline urine samples should
Urinalysis therefore be used. Quality control can be performed using
distilled water, which has a specific gravity of 1.000 [9].
Physical Properties When USG exceeds the scale on the refractometer, the
urine should be mixed with an equal volume of distilled
Physical properties of urine include its color and clarity. water and USG remeasured. The numbers to the right of
Normal urine is yellow or amber in color and clear. Changes the decimal point are multiplied by 2 to calculate the
to urine color can be caused by several endogenous and USG [5].
exogenous pigments. The most common color changes are Dipstick methods for measurement of USG are unrelia-
red, black, or brown caused by hematuria, hemoglobinu- ble in dogs and cats.
ria, myoglobinuria, and bilirubinuria. Where urine is red,
hematuria can be differentiated from hemoglobinuria and
Chemical Properties
myoglobinuria by centrifugation of urine. If hematuria is
present, with centrifugation, red blood cells should settle at Evaluation of the chemical properties of urine is most com-
the bottom of the sample, leaving the remainder of the monly performed semiquantitatively with reagent strips
sample clear. In contrast, urine color change will persist if (dip sticks). These have color-coded pads with specific rea-
it is caused by hemoglobinuria or myoglobinuria. Plasma gents. Tests include urine pH, glucose, ketones, bilirubin,
color can aid in differentiation between hemoglobinuria occult blood, protein, urobilinogen, nitrites, and leukocyte
and myoglobinuria: dogs and cats with hemoglobinuria esterase. Both nitrite and leukocyte esterase pads are unre-
have pink- to red-tinged plasma whereas plasma is typi- liable in dogs and cats.
cally clear when myoglobinuria is present. Urine color can-
not be accurately used to assess urine concentration.
Methods
Urine clarity is affected by urine concentration as well as
the presence of red blood cells, white blood cells, epithelial Chemical analysis of urine using reagent strips is per-
cells, bacteria, crystals, and mucus in the urine. Aggregates formed using well-mixed, uncentrifuged urine. Supernatant
of white blood cells, epithelial cells, and crystals can cause from a centrifuged urine sample can be used if the urine is
urine to appear flocculent [5]. discolored due to blood. Urine chemistry is performed by
Urine Seciiic raaity 789
Table 60.1 Example of a urinalysis report form.
Collection Analysis Patient name:

Date: Date:
Time: Time: Client name:
Free catch:
Urine collection type Cysto U-Cath Early mid late surface Comment:
Reference
Report Result interval Units Comments
Color Visual
Clarity Visual
Specific gravity Refractometer
pH, urine pH U
Protein, urine Neg mg/dl
Glucose urine Neg mg/dl
Ketones, urine Neg mg/dl
Bilirubin, urine Neg mg/dl
Hemoprotein, urine Neg Ery/ul
Sediment volume <0.1 ml
Volume, urine 4.5–5.0 ml
Lipid layer Visual
WBC, urine 0–3 /HPF
RBC, urine 0–2 /HPF
Crystals, urine None /HPF
Epithelial cells, transitional None /HPF
Epithelial cells, squamous None /HPF
Epithelial cells, renal None /HPF
Epithelial cells, caudate None /HPF
Casts, hyaline None /LPF
Cast, granular None /LPF
Cast, waxy None /LPF
Cast, cellular None /LPF
Bacteria None /HPF
Lipid droplets /HPF
Sperm None /HPF
Other
Other comment:
dipping the reagent strip in urine, then removing excess

Urine pH
urine by tapping the strip against the side of the container.
The reagent strip should be placed on a horizontal surface Measurement of urine pH by urine reagent strips is less
to prevent contamination between different test pads, with accurate than pH meters as urine reagent strips tend to
timing of the reaction according to the manufacturer’s overestimate pH values. As a result, where accurate meas-
instructions. Color changes on test pads are evaluated by urement is necessary, urine pH should be measured by pH
direct visual inspection using the manufacturer provided meter [11, 12].
key [10]. An automated analyzer can also be used. Normal urine pH in dogs and cats is 5.0–7.5. Urine pH
The reagent pads have a limited shelf life and should be varies due to factors including diet and acid–base status. It
protected from sunlight, moisture, and heat. can also be impacted by the presence of urinary tract
infections with urease-producing bacteria, such as Urine Ketones

Staphylococcus spp. [11] Urine pH cannot be used alone for
Ketones include acetoacetic acid, acetone, and
evaluation of acid–base status in dogs.
β-hydroxybutyrate. The ketone test pad contains nitroprus-
Falsely low urine pH can occur if acid buffer from the
side, which reacts with acetoacetic acid and acetone to
protein test pad contaminates the pH test pad.
cause a color change. The test pads do not detect
β-hydroxybutyrate and are more sensitive to acetoacetic
Urine Occult Blood acid than acetone. If there is concern for false negative
results for ketones on urine reagent strips due to the pres-
Heme is detected on the test pad for occult blood and posi-
ence of β-hydroxybutyrate only, addition of a few drops of
tive results for occult blood can occur with hemoglobin,
hydrogen peroxide to urine results in β-hydroxybutyrate
myoglobin, and intact red blood cells in urine. Thus, urine
being converted to acetoacetate [10].
sediment must be examined to determine whether red
Ketones are not normally present in the urine of dogs
blood cells are present. Centrifugation of urine also facili-
and cats. Ketonuria most commonly occurs in dogs and
tates differentiation of hematuria from hemoglobinuria
cats with diabetic ketoacidosis, and as a result, glucosuria
and myoglobinuria, with urine persistently red, brown, or
is also detected. Starvation or prolonged fasting in puppies
black following centrifugation when hemoglobinuria or
or kittens can result in ketonuria.
myoglobinuria is present. Myoglobinuria can be distin-
guished from hemoglobinuria based on plasma color:
myoglobin is excreted in urine before reaching plasma con- Urine Bilirubin
centrations that would cause discoloration of the plasma,
Bilirubin results from degradation of hemoglobin and is
whereas plasma is pink to red with hemoglobinuria as free
conjugated in the liver, where it is mostly excreted through
hemoglobin is only excreted when plasma haptoglobin is
bile. Some conjugated bilirubin is also excreted by the kid-
saturated.
ney. In dogs, the kidneys can form some bilirubin by
Hematuria can affect other urine dipstick results in dogs
metabolism of hemoglobin. As a result, small amounts of
and cats, including measurement of urine pH, bilirubin,
bilirubin (trace or 1+) can be identified in concentrated
and ketones [13].
urine in normal dogs, particularly male dogs. Bilirubinuria
Hematuria can occur with diseases of the lower urinary
is not normal in cats and therefore any bilirubinuria is sig-
or genital tracts and less commonly, the upper urinary
nificant. Clinically significant bilirubinuria indicates that
tract. Systemic disorders, particularly those that affect
hyperbilirubinemia is present.
coagulation such as severe thrombocytopenia, can also
False negative results for urine bilirubin can occur if
lead to hematuria. Hemoglobinuria occurs due to hemoly-
there are testing delays where the sample is exposed to air
sis, such as with immune-mediated hemolytic anemia and
at room temperature. Bilirubin can be oxidized to biliver-
certain toxins and infectious agents. Myoglobinuria indi-
din or hydrolyzed to unconjugated bilirubin, both of which
cates muscle damage.
are not detected by the test pad [5].
Urine Glucose
Urobilinogen
The glucose pad on urine reagent strips is specific for glu-
cose, using a glucose oxidase reaction. Urobilinogen forms when conjugated bilirubin excreted
Glucosuria should be interpreted in combination with into bile in the intestinal tract is degraded by bacteria. A
blood glucose to allow differentiation of glucosuria asso- small amount is reabsorbed and excreted in urine.
ciated with hyperglycemia from that due to a renal tubu- Urobilinogen is unstable in urine. Positive results indicate
lar defect (renal glucosuria). Hyperglycemia causes that the bile duct is patent, but negative results can occur
glucosuria when the renal threshold for reabsorption of because of urobilinogen instability in urine, diurnal
glucose is exceeded: this occurs when blood glucose is variation in excretion or due to bile duct obstruction. It is
approximately 180 mg/dl in dogs and 280 mg/dl in cats. therefore considered to be of limited use clinically.
Cats can have transient hyperglycemia due to stress that
results in glucosuria; in some cases, hyperglycemia
Urine Protein
might resolve by the time of blood sampling. In renal
glucosuria, blood glucose is normal as glucosuria occurs Urine reagent strips provide a semiquantitative estimate of
due to decreased reabsorption of glucose in the renal proteinuria. The test pad is more sensitive for detection of
tubules. albumin than globulins; most urine protein is albumin. A
ettods 791
small amount of protein is present in urine normally, examination is summarized in Protocol 60.1.
detected as trace to 1+ proteinuria in concentrated urine. If Standardization of urine sediment examination is
proteinuria is identified on urine reagent strips, the urine important for accurate results.
protein to creatinine ratio should be measured to quantify Approximately 5 ml of urine is centrifuged for five min-
proteinuria and therefore determine if it is clinically utes. Low centrifuge speeds (1500 rpm) decrease disrup-
significant. tion of cellular elements and casts. As the quantity of
False positive results can occur with very alkaline or con- sediment is related to the volume and concentration of
centrated urine. Blood in the urine does not affect urine urine being centrifuged, it is important that the volume
dipstick protein measurement until the sample is grossly centrifuged for urine sediment examination is standard-
hematuric [13]. ized. After centrifugation, the supernatant is evaluated
visually, then removed. The supernatant can be used for
measurement of USG or urine chemistry if the sample
Urine Sediment Examination was grossly discolored. The urine sediment is resus-
pended in the remaining supernatant (approximately
Microscopic examination of urine sediment is an impor- 0.5 ml). Using a pipette, a drop of resuspended urine sedi-
tant part of urinalysis as normal chemical analysis of the ment is placed on a glass slide with a coverslip for micro-
urine does not indicate that sediment examination is also scopic evaluation.
normal [14]. Urine sediment examination should be per- The urine sediment is examined under low power (10×)
formed as soon as possible after urine collection to pre- for casts, crystals, and cells. Bacteria and specific cell types
vent degradation of components of the sample such as are evaluated at higher power (40×). At least 5–10 fields
casts and cells. Crystals can also form with prolonged should be examined at each power. The number of red and
storage times. white blood cells in each high power field (HPF) is counted
and the average used to report the number per HPF. Contrast
of unstained urine sediment can be improved by closing
Methods the iris diaphragm and lowering the condenser of the
microscope. Dimming the microscope light can also
Urine sediment examination is performed after evalua- improve contrast.
tion of the physical and chemical properties of urine and Although evaluation of unstained urine sediment is pre-
measurement of USG. The procedure for urine sediment ferred, stained preparations of urine sediment may assist
Protocol 60.1 Summary of Procedure for Urine Sediment Examination
Handling Procedure
1) Transfer the urine to a clear and sterile conical 1) Visually inspect the supernatant, then decant or aspi-
test tube. rate via a pipette into a separate test tube.
2) Store the urine in tube with a tightly sealed lid to 2) Record the results of your visual inspection.
avoid evaporation and/or contamination. 3) Save the supernatant; check and record the urine spe-
3) Take the sample (5 ml, volume is standard in our cific gravity; sediment volume of 0.5 ml remains (vol-
facility). ume standardized in facility).
4) Analysis timing should be < 60 minutes after collection 4) Prepare a glass slide, adding 1 drop with a coverslip.
5) Resuspend the sediment using either a “finger-
Storage flicking” technique or gentle mixing with a pipette.
6) View under a microscope: 10× (for crystals, casts, and
● Refrigerate at 39.2°F (4°C).
cells) and 40× (for cells and bacteria) magnification.
● Refrigerated samples are brought to room tempera-
7) Scan the entire field (average of 10 fields reported).
ture prior to being analyzed.
8) The sediment is best unstained. Abnormal cell identi-
fication can be facilitated by fixing a drop of resus-
Centrifuge
pended sediment on a slide (same as blood smear)
● Speed 1500 rpm for 5 minutes and staining with Wright–Giemsa stain.
urine sediment examination for those who are less experi- Epithelial Cells
enced. Urine sediment stains include supravital stains and
Epithelial cells on urine sediment examination can arise
the Wright–Giemsa stain. Automated urine sediment ana-
from the kidneys, ureters, bladder, urethra, or genital tract,
lyzers have also been developed, such as the SediVue Dx™
depending on urine collection method. Their appearance
(IDEXX, Westbrook, ME).
varies. Squamous epithelial cells are large, polygonal cells
with small nuclei (Figure 60.3). They arise from the ure-
Red Blood Cells thra, vagina, or prepuce, and as a result can be seen in
voided or catheterized urine samples. Transitional epithe-
Red blood cells are round to biconcave (Figure 60.1).
lial cells vary in size; they are found in the kidney, ureter,
Normal urine has less than two red blood cells per
bladder, and proximal urethra; small numbers can be seen
HPF. Increased red blood cells in the urine (hematuria) can
normally in urine samples. Increased numbers of
arise from the kidney, ureter, bladder, urethra, prostate
gland, and, depending on urine collection method, the gen-
ital tract. Traumatic urine collection by cystocentesis or
catheterization can also cause hematuria.
In urine where the concentration is decreased (USG
< 1.006), red blood cells can lyze or become ballooned
ghost cells.
White Blood Cells

White blood cells, also called leukocytes, are round and
granular on unstained urine sediment examination
(Figure 60.2). They are larger than red blood cells but
smaller than epithelial cells. Some white blood cells (less
than three white blood cells/HPF) can be present normally
in urine. Increased numbers of white blood cells in the
urine is called pyuria. This indicates inflammation or infec-
Figure 60.2 Urine sediment examination (unstained) showing
tion in the urinary tract; the most common cause is urinary
pyuria (arrowhead), bacteriuria (thin arrow), and struvite crystals
tract infection. Mildly increased numbers of white blood (thick arrow). Source: Courtesy of Dr. Demitria Vasilatis, Veterinary
cells can also be detected with hematuria. White blood Medical Teaching Hospital Clinical Diagnostic Laboratory,
cells can degrade in urine stored for prolonged periods. University of California, Davis.
Hypotonic or alkaline urine can lead to lysis.
Figure 60.3 Clump of transitional epithelial cells (thick arrow),

Figure 60.1 Urine sediment examination (unstained) showing squamous epithelial cells (thin arrow) and hematuria
red blood cells (arrowhead) and bacterial rods (arrows). (arrowhead) in a dog with transitional cell carcinoma on urine
Source: Courtesy of Dr. Demitria Vasilatis, Veterinary Medical sediment examination (unstained). Source: Courtesy of
Teaching Hospital Clinical Diagnostic Laboratory, University of Dr. Demitria Vasilatis, Veterinary Medical Teaching Hospital
California, Davis. Clinical Diagnostic Laboratory, University of California, Davis.
ettods 793
transitional epithelial cells can be observed with inflamma-

tion, infection, and neoplasia of the urinary tract (e.g. tran-
sitional cell carcinoma) (Figure 60.3). Clumps of epithelial
cells are called rafts. Renal epithelial cells originate from
the renal pelvis or tubules and are small and round. It is
abnormal to find renal epithelial cells on urine sediment
examination.
Crystals
Crystals in the urine are called crystalluria. Crystals are
commonly identified in dogs and cats on urine sediment
examination. Urine pH, temperature, concentration of the
crystals and the presence of any crystal inhibitors or pro-
moters influence the solubility of crystals in urine. Crystals
uric acid and amorphous urate crystals (×25).
can form during storage and refrigeration of urine samples
and as a result, fresh urine samples should be used for eval-
uation of crystalluria [3].
Struvite, amorphous phosphate, and calcium oxalate
dihydrate crystals can be detected in the urine of normal
dogs and cats. Struvite (Figure 60.2) and calcium oxalate
dihydrate can also be identified in dogs and cats with uro-
lithiasis. Other common crystals include urate and cystine.
Both urate and cystine crystalluria are pathologic. Urate
crystalluria (Figures 60.4, 60.5) can be observed in certain
breeds such as the Dalmatian and English Bulldogs, as well
as dogs and cats with portosystemic shunts. Cystine crys-
tals (Figure 60.6) are associated with decreased renal tubu-
lar reabsorption of cystine as an inherited defect, with
affected breeds including Scottish Deerhounds,
Newfoundlands, English Bulldog, Pitbull Terrier, and
Mastiff breeds. Calcium oxalate monohydrate crystals can
be detected in dogs and cats with ethylene glycol poisoning cystine crystals (×250). Source: Taken from previous edition
(Figure 60.7). figure 32.3f page 416.
Figure 60.4 Urine sediment examination (unstained) showing Figure 60.7 Urine sediment examination (unstained) showing
“thorn-apple” ammonium urate crystals (×40). calcium oxalate monohydrate crystal (×40).
Casts Other Techniques

Casts are cylindrical structures that are composed of a
matrix of Tamm–Horsfall mucoprotein. They form in the Urine Protein to Creatinine Ratio
distal tubules and structures such as cells in the tubule at the Measurement
time that the cast forms can become embedded. Some types When protein is identified in the urine on chemical analy-
of casts can be detected in the urine of healthy dogs and cats. sis, the urine protein to creatinine ratio (UPC) is used for
Increased numbers of casts in the urine is called cylindruria. quantification. This ratio estimates the daily excretion of
Hyaline casts are clear and homogenous. They can dis- protein in urine. To calculate UPC, urine protein concen-
solve in dilute or alkaline urine and are generally of mini- tration (mg/dl) is divided by urine creatinine concentration
mal clinical significance. Granular casts are detected more (mg/dl); the UPC does not have any units. As results are
commonly and indicate the presence of tubular degenera- expressed as a ratio to creatinine, USG does not need to be
tion. They can be composed of mucoproteins, plasma pro- considered when interpreting results [16, 17].
teins, degenerated cells, and tubular debris. It is recommended that UPC measurement be consid-
Cellular casts can contain white blood cells, red blood cells, ered when there is 2+ protein on the urine reagent strip,
and epithelial cells and indicate that renal degeneration, regardless of USG, and where there is 1+ protein if USG is
inflammation, or hemorrhage is present. They are not normally 1.012 or less, as these values can be associated with an
present in urine. They disintegrate rapidly and as a result, are increased UPC [18]. Measurement of UPC on pooled urine
only identified on fresh urine sediment examinations. samples, where an equal volume from each urine sample is
Waxy casts are homogenous and translucent with a high mixed, can be used rather than measurement of UPC on
refractive index. Their ends may be sharply broken or multiple separate samples [19]. Collection of multiple sam-
square and their edges notched as they are brittle. They ples for measurement (either pooled or separately) is par-
form as a result of degeneration of granular and cellular ticularly important when UPC is greater than 4, as these
casts. They suggest that tubular disease is chronic and are dogs have greater day-to-day variation in UPC [20].
associated with a poor prognosis. In dogs and cats, UPC less than 0.2 is nonproteinuric
Fatty casts are comprised of fat globules from degenerat- (normal). Proteinuria is defined as UPC greater than 0.5 in
ing tubular epithelial cells. They are most commonly dogs and greater than 0.4 in cats. Results between the non-
observed in cats. proteinuric and proteinuric ranges are considered border-
line [21]. Renal proteinuria can occur due to both tubular
or glomerular disease, with glomerular disease more likely
Bacteriuria
when UPC greater than 2 [22].
Urine is normally sterile from the kidneys to the mid- Proteinuria can also arise from pre- and post-renal dis-
urethra. Bacteria may be seen in samples collected by cath- eases. Prerenal proteinuria occurs due to small molecular
eterization or free catch due to contamination from the weight proteins passing through a normal glomerulus (e.g.
distal urethra or genital tract. Examples of bacteria in hemoglobin or myoglobin). Postrenal proteinuria is due to
unstained urine sediment examinations are shown in protein entering the urine from the ureter, bladder, pros-
Figures 60.1 and 60.2. tate, or urethra, most commonly due to infection or inflam-
Rod-shaped bacteria are detected when their concentra- mation, neoplasia or hemorrhage.
tion is greater than 104 bacteria/ml urine and cocci-shaped
bacteria when their concentration is greater than 105 bacte- Urine Osmolality
ria/ml urine. Use of the modified Wright stain for urine Urine osmolality is the number of particles of solute
sediment examination improves the sensitivity and speci- per kilogram of water, with urine solutes including
ficity for identification of bacteriuria compared with urea, sodium, potassium, ammonium, chloride, and
unstained samples [15]; however, stain precipitates can other anions. Urine osmolality is measured by an
resemble bacteriuria to cause false positive results for osmometer [23]. Urine osmolality is used to assess the
bacteria. concentrating ability of the kidney. It differs from USG
by not being affected by the size of solutes, although
there is a linear correlation between urine osmolality
Others
and USG [23].
In intact male dogs and cats, sperm can be seen in the Normal urine osmolality is approximately 360–2500
urine. Strands of mucus or fibrin can be present in dogs mOsm/kg in the dog and 600 and 3000mOsm/kg in the
and cats with inflammation of their lower urinary or geni- cat [6, 24, 25]. Normal plasma osmolality is 290–310mOsm/
tal tracts. Lipid droplets are normal in cats. kg in dogs and 290–330mOsm/kg in cats [26].
References 795
Table 60.2 Urinary biomarkers of tubular damage or dysfunction in dogs and cats [28].
Urinary biomarker Information provided Mechanism of change Species
Clusterin Tubular damage Increased production with tubular damage Dogs

Cystatin B Tubular damage Increased release from rupture and death Dogs, cats
of tubular cells
Gamma glutamyl-transpeptidase Tubular damage Release from tubular brush border Dogs, cats
Kidney injury molecule 1 Tubular damage or dysfunction Increased production in renal tubules Dogs, cats
Neutrophil gelatinase-associated Tubular damage Decreased re-absorption and increased Dogs
lipocalin production
N-acetyl-β-D-glucosaminidase Tubular damage Cellular leakage Dogs, cats
Source: Adapted from Hokamp and Nabity, 2016.
Urine Electrolytes Measuring the fractional excretion of sodium can help to

differentiate prerenal azotemia (e.g. due to dehydration or
Measurement of urine electrolytes can be used to evaluate
hypovolemia) from acute kidney injury, with fractional
renal function and, specifically, renal handling of electro-
excretion expected to be normal in dogs with prerenal
lytes and minerals such as sodium, potassium, chloride,
azotemia as the kidneys conserve sodium.
phosphate, calcium, and magnesium. Fractional excretion
is defined as the proportion of a solute that is excreted in
Urinary Biomarkers
urine compared to the proportion filtered through the glo-
merulus [27]. In normal dogs and cats, fractional excretion Urinary biomarkers of kidney injury and dysfunction are
values of various solutes vary due to factors such as age and emerging in veterinary medicine. Their goal is to identify
dietary intake as well as any nonurinary excretion [27]. It is kidney injury or dysfunction at an earlier stage than tradi-
performed on urine prior to centrifugation. Fractional tional biomarkers such as creatinine when interventions
excretion is calculated as follows: are more likely to be effective (Table 60.2) [28]. As some of
these techniques become more readily available, their use
U electrolyte Pcreatinine
Fractional excretion electrolyte in acutely and critically ill dogs and cats is likely to increase.
Pellectrolyte U creatinine
Toxin Screening
Where:
Urine can be used for screening for some toxins and drugs.
Uelectrolyte = urine concentration of electrolyte
This can be important in determining the cause of certain
Ucreatinine = urine concentration of creatinine
clinical signs in dogs in an emergency and critical care
Pelectrolyte = plasma concentration of electrolyte
setting. A human rapid on-site urine multidrug test
Pcreatinine = plasma concentration of creatinine
has been evaluated in dogs and was able to identify
Fractional excretion is most commonly calculated for sodium barbiturates, opiates, benzodiazepines, and amphetamines/
and potassium. Normal fractional excretion of sodium is less methamphetamines, but not marijuana or methadone [29].
than 1% in dogs and cats. Normal fractional excretion of Urine can be used for testing for other drugs, some metals,
potassium is less than 20% in dogs and less than 24% in cats. ethylene glycol, paraquat, and alkaloids [30].
References
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collected by cystocentesis versus free catch in dogs. J. Am. and crystal formation in urine samples from dogs and cats.
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2 Harr, K.E., Flatland, B., Nabity, M. et al. (2013). 4 Patterson, C.A., Bishop, M.A., Pack, J.D. et al. (2016).
ASVCP guidelines: allowable total error Effects of processing delay, temperature, and transport
guidelines for biochemistry. Vet. Clin. Pathol. 42: tube type on results of quantitative bacterial culture of
424–436. canine urine. J. Am. Vet. Med. Assoc. 248: 183–187.
5 Chew, D.J., DiBartola, S.P., and Schenck, P.A. (2011). the urine protein to creatinine ratio from a random,
Urinalysis. In: Canine and Feline Nephrology and Urology, voided sample. Am. J. Vet. Res. 46: 2116–2119.
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Saint Louis, MO: Saunders. of a urine dipstick test for confirmation or exclusion of
6 vanVonderen, I.K., Kooistra, H.S., and proteinuria in dogs. Am. J. Vet. Res. 71: 235–240.
Rijnberk, A. (1997). Intra- and interindividual variation 19 LeVine, D.N., Zhang, D.W., Harris, T. et al. (2010). The
in urine osmolality and urine specific gravity in healthy use of pooled versus serial urine samples to measure
pet dogs of various ages. J. Vet. Intern. Med. 11: 30–35. urine protein:creatinine ratios. Vet. Clin. Pathol.
7 Rudinsky, A., Cortright, C., Purcell, S. et al. (2019). 39: 53–56.
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8 Behrend, E.N., Botsford, A.N., Mueller, S.A. et al. (2019). in female dogs with stable glomerular proteinuria caused
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61
Cytology
Rebecca J. Greer
Cytology is the study of individual cells at the microscopic cells (red and white blood cells, neoplastic cells, cells from
level specifically to aid in diagnosis of abnormalities and the tissue of origin) and infectious organisms (bacteria,
malignancies. Microscopic examination of tissue aspirates protozoa, and fungi).
and fluid is a valuable tool for the emergency clinician and Effusions are separated into three major classifications
technician as it can provide a quick diagnosis, help guide (Table 61.1) based on protein and cellular content [1], with
treatment, and give information about prognosis. Most some overlap between the classes. Pure transudates have a
samples for cytology are obtained by fine-needle aspiration low protein concentration (< 2.5 g/dl) and cellular content
(FNA) or impression smears. The FNA technique is fairly (< 1000/μl) [1]. Transudates are colorless and clear, and
benign in most cases, which makes cytology a useful tool in they typically occur due to decreased plasma colloidal
critically ill patients that may not tolerate more invasive osmotic pressure. Common causes of transudate formation
procedures. A high-quality sample is necessary for accurate are those that cause hypoalbuminemia or panhypopro-
interpretation. This chapter discusses some of the common teinemia, like protein-losing nephropathy or protein-losing
situations encountered by the emergency care providers enteropathy, respectively [1].
where cytology is useful. It also details the equipment The second class of effusions is exudates. Exudates are
required and preparation necessary to obtain the most characterized by high protein concentration (> 3.0 g/dl) and
information from cytology samples. high cellularity (> 7000/μl) [1]. Exudates are then subclas-
sified as septic or nonseptic. Septic exudates result from
infectious causes (bacterial, viral, protozoal, fungal); non-
Indications for Cytologic Evaluation septic exudates are a result of sterile inflammation (as is
often seen in pancreatitis) or neoplasia. Fluid that accumu-
There are many indications for evaluating cytology in lates in the body cavity due to feline infectious peritonitis
emergency practice (Box 61.1). Below are the descriptions (FIP) is a unique example of a septic exudate. In FIP, the
of common indications. cell count may be less than a typical exudate (< 7000/μl),
but the protein concentration in the fluid is generally very
high (> 4.5 g/dl). The high protein concentration is what
Effusion Analysis
classifies the FIP fluid as an exudate. On cytological exami-
Fluid accumulation in body cavities is a common present- nation of FIP fluid there is usually granular pink material
ing complaint in the emergency setting. Healthy dogs and in the slide background due to precipitated protein [1].
cats have very little fluid in the pleural, peritoneal, and The third class of effusions is modified transudates.
pericardial spaces. Accumulation of fluid in these potential Modified transudates have total protein and cell concentra-
spaces is pathologic and can be caused by a variety of tions between pure transudates and exudates. The protein
disease processes. Collection of this fluid can be both concentration is typically at least 2.5 g/dl and can be as high
therapeutic and diagnostic (see Chapters 18, 34, and 38 for as 7.5 g/dl [1]. The cell count is usually 1000–7000/μl [1].
more information regarding sample collection from these Modified transudates result from leakage of fluid from the
spaces). Samples should be evaluated for the presence of lymphatics or capillaries due to increased vascular hydrostatic
798 Cytology
etiology. Mesothelioma cells do exfoliate, but when they do

Box 61.1 Indications for Cytology
it can be difficult to distinguish the mesothelioma cells
Presence of effusions: from reactive, non-neoplastic cells. The preceding discus-
sion explains why it can be challenging to make a diagnosis
● Pleural
of neoplasia using cytologic evaluation of pericardial effu-
● Pericardial
sion, even when neoplasia is the underlying etiology.
● Peritoneal
Cytology can be useful in diagnosing infectious etiologies
● Joint
of pericardial effusion, especially if organisms can be
Lymphadenopathy/lymphadenomegaly identified [2].
Masses
Dermatologic problems Joint Effusions
Skin lesions
In animals with joint effusion, cytology often can identify
Ear canals
the cause and therefore guide treatment. Cytology is the
most important evaluation to perform on joint effusions, so
Table 61.1 Evaluation of Effusions. if only a small sample can be obtained, cytology should be
prioritized over total protein concentration or cell counts.
Total Normal synovial fluid is grossly viscous and has a low pro-
Effusion Cell count protein Causes tein concentration (< 2.5 g/dl) and cell count (< 3000/μl) [1].
There is very little fluid present in healthy joints. Pathologic
Transudate < 1000 cells/μl < 2.5 g/dl Hypoalbuminemia, joint effusions can be septic or nonseptic. Septic arthritis is
panhypoproteinemia usually caused by a bacterial or fungal infection and is usu-
Modified 1000–7000 2.5–7.5 g/dl Most common: heart ally localized to one joint, though multiple joints can be
transudate cells/μl failure, neoplasia,
affected. Infection can be caused by hematogenous spread
Inflammation,
chylous, or by direct inoculation. The cell count in septic arthritis is
hemorrhagic typically high (5000–10 000/μl), with neutrophils as the
Exudate > 7000 cells/μl > 3 g/dl Bacterial, viral, predominant cell [1]. Often in septic arthritis the neutro-
Septic Visualize protozoal, fungal phils are degenerate. Neutrophil degeneration may not
exudate infectious always be apparent, and organisms may not be identified in
organism(s)
septic arthritis. If enough fluid can be obtained, a culture
Nonseptic No infectious Inflammation, should also be performed. Joint fluid in nonseptic arthritis
exudate organism(s) pancreatitis,
seen peritonitis, neoplasia has an increased cell count (1000–10 000/μl) but not usu-
ally as high as seen with septic arthritis [1]. The neutro-
phils are nondegenerate and no infectious organisms are
pressure or increased vessel permeability, such as the ascites present. Causes of nonseptic arthritis include ehrlichiosis,
seen with right-sided congestive heart failure, pericardial Lyme disease, drug mediated, immune mediated, and sys-
effusion, or portal hypertension. Modified transudates are temic lupus erythematosus. Nonseptic arthritis can also be
the most common effusions in dogs and cats. Hemorrhagic secondary to neoplasia or infection in distant areas of the
and chylous effusions fall into this category. body. Neoplastic cells may be present in cases of synovial
cell sarcoma, but histopathology is generally required to
differentiate between reactive synovial cells and neoplasia.
Pericardial Effusions
Trauma or coagulopathies may also cause joint effusion. In
The etiology of pericardial effusions can be difficult to this case the fluid resembles peripheral blood [1].
determine cytologically. Pericardial effusions can be pure
transudates, modified transudates, or exudates; however,
Lymph Node Evaluation
most are modified transudates (hemorrhagic). Some peri-
cardial effusions are idiopathic and no underlying etiology Enlarged lymph nodes may be noted by owners or may be
can be identified. Neoplasia is the most commonly identi- found on physical examination. Lymph nodes may be
fied etiology, and premortem identification generally enlarged due to a primary problem within the nodes them-
requires imaging such as echocardiography [2]. The com- selves or in response to disease elsewhere in the body. The
mon neoplasms that cause pericardial effusion in dogs are prescapular (“superficial cervical”) and popliteal nodes are
hemangiosarcoma and chemodectoma, neither of which the sites of choice to aspirate when generalized lymphade-
tends to exfoliate cells; thus, cytology rarely identifies the nomegaly is present. The mandibular lymph nodes are not
Equipment Required 799
the best diagnostic nodes because they often have a strong substage condenser to provide optimal contrast and eliminate
inflammatory component secondary to draining the mouth artifact. Most microscopes have four standard objectives:
that can mask other diseases. The size of the nodes should 4×, 10×, 40×, and 100× oil immersion. A good quality
also be considered. Very large lymph nodes tend to have microscope is essential.
necrotic centers, which makes diagnosis difficult. It is The microscope must be adjusted before each use to
advisable to sample slightly or moderately enlarged nodes provide the best image. First the oculars should be
if possible [1]. Common conditions that cause lymphade- adjusted for the width of the examiner’s eyes. Each ocular
nomegaly include lymphoma, metastatic neoplasia, infec- can be individually focused to account for differences in
tion (bacterial, fungal, rickettsial), inflammation, and the focusing abilities of the viewer’s eyes. Once an image
immune mediated disease. is visible, a combination of adjustments will be made to
achieve the best focus. Protocol 61.1 lists the general
sequence of events.
Mass Evaluation
For the best images, the Kohler method of illumination
Masses are commonly found on and in small animals. (Protocol 61.2) should be used and readjusted every time
Intra-abdominal and intrathoracic masses are generally an objective is changed. This method optimizes the path
aspirated with ultrasound guidance (Video 61.1). The that light takes from the light source to the viewer’s eye
sample is then evaluated to help determine whether the and will help eliminate scatter. The sample must first be
mass is neoplastic, inflammatory, or benign. Dermal or
subcutaneous masses are generally only evaluated in the
emergency setting if there is concern that they are related Protocol 61.1 Adjusting the Microscope
to significant disease pertinent to the current visit.
Items Required
Examples of skin or subcutaneous masses related to sys-
temic disease include mast cell tumors, cutaneous lym- ● Microscope
phoma, and blastomycosis. ● Specimen slides
● Immersion oil, if 100× viewing is anticipated
Skin and Ears
Procedure
Dermatologic diagnoses are not typically intensely pursued
1) Place the slide on the stage; secure slide in place
in the emergency setting; however, there are certain urgent
with the stage clips.
care situations when cytology of the skin and external ear
2) Move the 4× or 10× objective into use. Adjust the
canals can be beneficial. It is not uncommon for an animal
coarse focus knob to move the slide up as close as
to present to the emergency clinic with severe skin lesions,
possible to the objective, taking care not to bump
itchy skin, or otitis. Cytology is beneficial in making a cor-
the slide into the lens. Using the 4× or 10× it should
rect diagnosis and therefore selecting appropriate initial
not be possible to touch the slide to the objective.
treatment. Excessive amounts of bacteria may require sys-
3) Illuminate a stained area of the slide.
temic antibiotics. Severely pruritic animals require skin
4) While looking through the ocular lenses, slowly
scraping with cytologic evaluation to look for evidence of
adjust the coarse focus knob (moving the speci-
mites. Animals with signs of ear disease require ear cytol-
men away from the objective) until the specimen is
ogy to determine whether topical treatment alone will be
visible.
adequate or if systemic treatment is necessary. Furthermore,
5) Change to the fine focus knob and bring the image
cytologic examination of skin lesions may give a diagnosis
into sharper view.
in debilitated patients not stable enough for more invasive
6) Adjust the individual oculars for the best focus.
diagnostic tests or general anesthesia. For example, patients
7) Adjust the condenser lens and/or light source so
with systemic blastomycosis may have skin lesions that
the illumination is optimal.
allow for rapid noninvasive cytologic diagnosis of the sys-
8) Readjust the fine focus knob as needed to improve
temic problem.
the image.
9) Move to higher objectives without changing the
focus from the previous objective. Use the fine
Equipment Required
focus knob to bring the image into sharp focus.
10) Prior to viewing at 100×, apply a small drop of
A compound binocular microscope with a set of high-
immersion oil to the slide where the objective will
quality objectives is required for diagnostic cytologic exam-
contact the slide to provide optimal image.
ination. The microscope should have a light source with a
800 Cytology
Protocol 61.2 Kohler Illumination Box 61.3 Equipment for Acquiring Samples

Items Required ● Glass slides, preferably frosted on one end
● Coverslips: glass or plastic
● Microscope
● Needles: 21–25-gauge
● Specimen slides
● Syringes: 3–20-ml
● Serum tubes
Procedure
● EDTA tubes
1) Bring image into focus (Protocol 61.1). ● Centrifuge for separating fluid samples
2) Completely close diaphragm. ● Stains: Romanowsky type
3) Raise or lower condenser until circle of light is in ● Pencil
sharp focus.
4) Center light in the field of view.
5) Open diaphragm until only the field of view is pre-
paper or materials may scratch the lens surface. The ocular
sent (i.e., circle of light just outside field of view).
pieces can be removed from the eyepiece tubes and wiped
6) Open or close condenser aperture to allow best
down, but do not attempt to take the actual lenses apart.
contrast.
The objectives should be wiped with plain lens paper at
least once a day and the high-power oil objective (100×)
should have the oil removed with plain lens paper every
in focus, following the steps listed in Protocol 61.1 for
time it is used. If the microscope is not properly main-
focusing. The diaphragm is then closed all the way,
tained, the lenses will become damaged and a clear, focused
resulting in a blurry area of light in the field. Using the
image cannot be achieved. The stage should be wiped as
condenser knob, raise or lower the condenser until the
needed. This area of the microscope can be cleaned with
circle of light is in sharp focus then use the condenser
ordinary cleansing materials; oil spills and water will cause
placement screws to center the light circle in the field of
the slides to stick to the stage, preventing appropriate
view. Open the diaphragm until only the field of view is
movement. The owner’s manual of each microscope lists
illuminated, so the circle of light is just outside the field
specific solutions and cleaning recommendations for that
of view. Open or close the condenser aperture to allow
microscope. The microscope should be serviced regularly
the best contrast [3, 4].
as recommended by the manufacturer. The supplies needed
If the image is difficult to get into focus, the lenses may
to acquire diagnostic samples are inexpensive and readily
need to be cleaned or the light source adjusted. Opening or
available (Box 61.3).
closing the aperture and/or adjusting the strength of the
light source may help.
Maintenance of the microscope (Box 61.2) includes
weekly cleaning of the objective and ocular lenses with a Slide Preparation
lens cleansing solution. Use the recommended solution
for the particular microscope but not alcohol or water Slide preparation varies by the type of sample to be ana-
because standard immersion oil is not dissolved by these lyzed (i.e. tissue vs. fluid).
substances [5]. The lens is then wiped with lens paper that
has the appropriate solution applied to the paper and wiped
Fluid
in a circular motion. Lens paper is the only material that
should be used to actually wipe the lenses because other Examination can be performed on fluid directly, or samples
can be centrifuged to concentrate cells. Slides from fluid
samples are prepared in the same way as a blood smear. A
Box 61.2 Microscope Maintenance small drop is placed near the frosted end of the slide. A
second slide is backed into the sample with the acute angle
Wipe the 100× objective with lens paper after every
toward the operator (frosted end of the slide). The second
●
use.
slide is then drawn away from the operator. The speed at
Wipe objectives, oculars, and stage once daily.
which the slide is moved depends on the viscosity of the
●
Clean lenses with cleansing solution weekly. Use the

fluid [1]. Thinner samples should be spread faster than
●
recommended solution for the particular microscope.

more viscous samples to ensure even distribution over the
Follow manufacturer recommendations regarding
slide. All fluid applied to the slide originally should remain
●
regular service.
on the slide. Care should be taken not to allow excess fluid
Slide Preparation 801
to be drawn off the end of the slide. Neoplastic cells tend to sample is drawn into the microhematocrit tube and is then
clump and stick to the spreader slide. If excess fluid is spun just like a packed cell volume. The buffy coat or cellular
removed with the spreader slide and discarded, valuable layer is then applied to a slide [1]. The slide is prepared using
diagnostic material may be lost. If excess fluid is a problem, the squash technique described later.
the spreader slide can be stopped before it reaches the end
of the specimen slide. Excess fluid on the spreader slide
Tissue
can then be transferred to another slide. An alternative
method is to allow the excess fluid to run back on itself for Slides of tissue samples can be obtained in several different
a short distance. With this procedure the thin part of the ways. FNA is a common method to obtain samples [1]. Once
specimen can be used to estimate cell numbers while the the tissue sample has been obtained in the needle, the nee-
area of excess fluid can be evaluated for abnormal cells or dle is removed from the syringe. A syringe filled with 1–3 ml
infectious organisms. of air is attached to the needle. The sample is then blown
Samples can be centrifuged to concentrate fluids of low onto the slide using the air in the syringe. The air blowing
cellularity. After centrifuging for five minutes, the pellet is process may be repeated a few times to ensure complete
resuspended in one or two drops of supernatant. This solu- transfer of sample material to a slide (Figure 61.1a,b). Once
tion is then prepared as previously described. Microhematocrit the sample material is on a slide, a compression (squash)
tubes can be used if there is a small volume of fluid. The preparation can be made (Videos 61.2 and 61.3).
(a) (b)
(c) (d)
Figure 61.1 Preparing squash sample from an aspirate. (a) Aligning the needle above the slide; needle aspiration has been
performed and sample is inside the needle’s lumen. (b) The sample was blown out of the needle using the air in the syringe. This
results in a small amount of sample on the slide. (c) A second, clean slide is aligned over the slide with the sample, the weight of the
slide is used to squash the sample, and then the top (second) slide is drawn off the end of the sample slide. (d) Finished squash
sample, unstained.
802 Cytology
Squash Preparation
A squash preparation is accomplished by placing a sample
on the slide and then placing a second glass slide over the
sample at a right angle to the specimen slide. The sample is
gently but firmly compressed. Generally, the only pressure
for compression is the weight of the second slide. The sec-
ond slide is then drawn away from the frosted end of the
specimen slide. This process should be performed with a
smooth and continuous motion [1]. Care should be taken
especially with lymph node aspirates because lymphoma
cells rupture easily [6]. The resulting specimen should be
oblong in shape and have a cellular monolayer at the end
(Figure 61.1c,d and Video 61.3 and 61.4).
Impression Smear
Slides can also be prepared by making an impression
smear. This technique can be used for skin or excised tis-
sue. With excised tissue, the cut surface is blotted with a
paper towel to remove blood or other fluids. The tissue is
then gently pressed or touched against a slide at several
different places. The tissue should lightly stick to the slide. Figure 61.2 Sample labeled and ready to be stained.
A clean slide can also be pressed against skin to obtain skin
cytology. A variation of the slide-to-skin technique uses a characterized by the use of a combination of eosin and
clear adhesive tape preparation. A piece of transparent methylene blue. Characteristically, these stains color a cell’s
acetate tape is used. The adhesive side of the tape is pressed nucleus purple and its cytoplasm blue or pink [9]. A propri-
against the area of interest, being sure to leave adhesive etary example is the Diff-Quik stain. The Diff-Quik brand
that has not been compromised on each side for affixing to (Figure 61.3a) is one of the most commonly used
the slide. The sample area is placed on the middle of a glass Romanowsky-type stains due to the quick results and ease
slide and the tape edges used to affix the tape to the slide. of use. Staining times with Diff-Quik vary depending on the
The slide with adhered tape can then be stained. If using thickness of the sample. Thick samples may require as
the Diff-Quik® (Andwin Scientific, Tryon, NC) solution, much as 60–120 seconds in each solution. A general guide
the fixative step is skipped because it will dissolve the for staining with Diff-Quik solutions is as follows (Protocol
adhesive, and the slide is dipped into the stains and rinsed 61.3): 60–120 seconds in fixative, 30–60 seconds in solution
in standard fashion. An alternative staining method is to 1, and 5–60 seconds in solution 2. The slide should then be
place a single drop of stain on the slide and then affix the rinsed with cold water for 15–20 seconds to remove any
tape with the sample section in the stain. In this method, stain precipitate and then allowed to air dry in a nearly ver-
the stain is not rinsed off but the tape, drop of stain, slide tical position [1]. If time is of the essence, the samples could
combination is directly viewed with the microscope [7]. be dried by blotting with bibulous paper or a hair dryer on
The tape method of obtaining samples is especially useful low. Common errors in staining are discussed later.
for the paws and around the eyes and nose [1]. New methylene blue is another valuable stain to have in
After the sample is obtained and placed on a slide, the the emergency practice because it stains nuclei, bacteria,
slide should be labeled with patient identification and type fungi, platelets, and mast cell granules [8]. Diff-Quik solu-
of sample (Figure 61.2). A pencil will write easily on the tions may not always stain mast cell granules adequately;
frosted end and remain visible even after staining. Marks therefore, a new methylene blue stain may help distinguish
made by pens and permanent markers will rinse off during the cells in low-granule mast cell tumors. New methylene
the staining process. blue can also be used in cases with anemia to look for retic-
ulocytes, which contain blue precipitating granules when
stained this way. New methylene blue is more labor inten-
Staining sive than Diff-Quik because it requires preparing the solu-
tion and proper disposal of formalin. To prepare the
Many different stains are available for staining cytology solution, new methylene blue is mixed with 0.9% saline
samples. The most commonly used in veterinary medicine and a small volume of formalin. The solution is passed
are the Romanowsky-type stains [8], including Wright, through filter paper before using to remove precipitates.
Giemsa, and Jenner stains. Romanowsky-type stains are The stain should be replaced and filtered weekly [1].
Slide Scaalang caid EcSlcalia 803
(a) (b)
(c) (d)
(e)
Figure 61.3 (a) Quick stain in glass vials for easy “dipping.” (b) In fixative. (c) Solution 1. (d) Solution 2. (e) Stained sample drying.
A drop of the prepared solution is then placed on a slide, that will be of highest diagnostic yield. The slide should be
and a coverslip is placed on top. The slide should be exam- scanned in a consistent manner to be sure the entire slide is
ined immediately because the stain evaporates quickly. evaluated. Starting at one corner of the slide, a back-and-
forth pattern is used until the entire slide has been evalu-
ated. Large objects such as parasites and some fungal
Slide Scanning and Evaluation elements may be seen at this low power. Once the initial
evaluation is performed, a more detailed study is made. The
Slides should be examined first with the 4× or 10× objective best area to examine is the area where the cells are in a
to evaluate overall sample quality and staining. Slides that monolayer. The 40× objective is used to obtain an overview
are too lightly stained can be re-stained to improve quality. of the cell population. At this magnification it is possible to
The slide is then scanned at 10× to find the area of the slide compare cell sizes and determine the proportions of
804 Cytology
Protocol 61.3 General Guidelines for Diff-Quik Stain

Items Required
● Diff-Quick stains
● Specimen slides
Procedure
1) Place the specimen slide in fixative for 60–120seconds.
2) Place the specimen slide in solution 1 for 30–60seconds.
3) Place the specimen slide in solution 2 for 5–60seconds.
4) Perform a 15- to 30-second slide rinse in cold water.
5) Air dry or blot gently with bibulous paper.
6) Time for staining will vary depending on thickness
of sample (longer for thicker samples).
different cell types. This power should provide enough

detail to make a presumptive diagnosis if there is not
enough time to thoroughly examine the slide in the emer-
gency setting. To further improve resolution, a drop of
immersion oil is applied directly to the stained surface (or
on top of the coverslip if one is in place), and the slide is
reexamined with the 100× oil immersion objective. Take Figure 61.4 Image of a septic abdominal exudate on 100× oil
care not to touch immersion oil to any objective other than immersion, intracellular bacteria at black arrowhead.
the oil immersion (generally 100×) because this is the only
objective that is sealed and designed for oil use [10]. Oil can
ruin the other unsealed objectives. This objective shows
Troubleshooting
greater detail of individual cells (Protocol 61.4). Nuclear
Making a diagnosis from cytology can be very rewarding.
structures and cytoplasmic granules can be seen at this
However, there are some pitfalls that can make examining
magnification (Figure 61.4). Cellular inclusions may also be
slides frustrating. Here is a list of commonly encountered
seen at this magnification [1].
problems and their solutions.
Protocol 61.4 Slide Scanning and Evaluation

Nondiagnostic Samples
Items Required
Obtaining nondiagnostic samples can be frustrating, espe-
● Microscope cially in an emergency situation. One of the most common
● Immersion oil causes for nondiagnostic samples is hemodilution. This
● Specimen slides phenomenon occurs commonly when aspirating vascular
organs such as the spleen. If a large amount of blood is
Procedure aspirated, it can be smeared like a blood film to look for
diagnostic cells. The best way to avoid blood contamination
1) Systematic scan at low power (4× or 10×).
in vascular organs is to use a fine-needle biopsy approach
a) Use back-and-forth technique.
without aspiration, also called a fenestration approach [6].
b) Evaluate staining technique.
A needle (alone or attached to a syringe) is directed into the
c) Identify monolayer.
area of interest. Multiple fenestrations are made in the tis-
d) Look for large organisms (fungus or parasites).
sue without applying negative pressure to the syringe. The
2) Increase magnification (40×).
needle is then attached to a syringe with air, or if already
a) Evaluate cellular structure.
attached to a syringe, the air is used to blow the sample out
3) Increase magnification (100×).
and it is prepared as a squash (Videos 61.3 and 61.4). If
a) Place drop of immersion oil on slide before rotat-
using the aspiration technique in a tissue where peripheral
ing objective fully into place.
blood contamination is expected to be a problem, release
b) Evaluate for more detailed cellular structure.
the negative pressure on the syringe before removing the
Conclusion 805
needle from the tissue. This precaution will prevent blood

Protocol 61.5 Troubleshooting
from being drawn into the syringe as the needle is removed.
It will also prevent the sample from being sucked into the Nondiagnostic Sample
barrel of the syringe when the pressure in the syringe 1) Retake sample.
equilibrates with room air [6]. 2) Decrease force of aspiration.
Nondiagnostic samples are also obtained if the material 3) Use needle biopsy technique (fenestration approach).
on the slide is too thick or if there is poor separation of cells.
A common mistake is to place too much material on a slide. Staining (too lightly stained)
It is then impossible to obtain a monolayer of cells with a
squash preparation. This problem can be avoided by making 1) Re-stain.
sure only a small amount of sample is applied to a slide [1]. 2) Replace old or used stain solution.
Multiple slides can be made from a single FNA. It takes prac-
tice to know the right amount of material to apply to a slide. Stain Granules
Fractured cells and naked nuclei also make diagnosis dif- 1) Rinse slide thoroughly.
ficult. Certain neoplastic cells are fragile and break when 2) Re-stain new sample in fresh stain.
preparing the sample. One step to help avoid this problem
is to not apply excessive vacuum when aspirating the sam-
ple. In general, 0.5–1-ml of vacuum is all that is needed. patient may be taken for an abdominal exploration resulting
Overzealous compression of the sample during squash in an unstable patient undergoing a risky, unnecessary, and
preparation can also fracture cells [1]. Care should be taken costly procedure. This problem can be avoided by changing
when preparing slides, especially of enlarged lymph nodes the stain regularly. The time frame varies from clinic to clinic
because lymphoma cells rupture easily. depending on the number of slides stained and the type of
stain used. Manufacturer recommendations should be fol-
lowed regarding how often to change the solutions. It is good
Staining Problems
practice to have separate stains for clean (blood, aspirates,
Most errors that occur with staining are due to inadequate fluid) and dirty (skin, ear canals, fecal, abscess) samples.
time in the solutions or use of old solutions. Slides may Bacteria from dirty samples can contaminate the stain,
appear dull or washed out. In most cases the problem can resulting in bacteria on the slide of a sample that did not
be remedied by replacing the slide into one or all of the truly contain bacteria. If only one staining station is availa-
staining solutions. Staining times vary depending on the ble, the stain should be changed immediately if has come in
kind of material being stained. In general, thicker cellular contact with infectious organisms or debris.
material requires more contact time than thinner, less cel-
lular material. Stain precipitates may be present on the
slide if it has not been rinsed adequately [8]. The same Conclusion
problems can be seen if the staining solutions are not
maintained properly. Manufacturer recommendations Cytology is an important tool for the emergency clinician.
should be followed regarding maintenance and changing A diagnosis made by in-house cytology can prevent a delay in
or replacement of the solutions and their containers. definitive treatment. A quick diagnosis benefits the patient
Prolonged contact time in the stain may also result in and the owner. If a diagnosis cannot be made in the clinic,
problems. When using the Romanowsky-type stains, slides samples should be submitted to a diagnostic laboratory for
may appear too pink or too blue. It is important to use the analysis. Good sample collection technique and sample prep-
same brand of stain consistently to obtain a feel for the aration will ensure that the pathologist has the best chance of
appropriate length of time to stain different material [8]. making a diagnosis. There are some instances in which cytol-
If technique is followed properly and the slide is still not ogy will not provide an answer. In these instances, biopsies
stained appropriately, there may be a problem with the stain should be taken after the patient has been stabilized.
itself. This problem usually occurs as the stain deteriorates
with age [8]. The stain should be replaced with fresh solu- Video 61.1 Fenestrating mass with ultrasound. This video
tion when this occurs (Protocol 61.5). Aggregates of stain shows ultrasound guidance with the fenestra-
precipitate can form and give the false appearance of cocci tion technique to obtain a cytology sample.
bacteria or inclusion bodies. False results can have life- Note in the ultrasound image as the operator
threatening consequences in an emergency situation. For performs repeated advances and withdrawals
example, if these cocci-appearing aggregates are seen in a of the needle (fenestrations) to acquire tissue
sample of abdominal fluid from a critically ill patient, that in the needle, rather than aspirating the
806 Cytology
syringe plunger. This video does not include acquire tissue in the needle. After blowing
audio commentary. the first part of the sample onto the slide,
Video 61.2 Squash preparation. This video reveals how to the operator removes the syringe from the
make a “squash” preparation. This video does needle, pulls more air into the syringe, then
not include audio commentary. attaches the air-filled syringe to the needle a
Video 61.3 Fenestrating mass and making slides. This second time to blow any remaining sample
video shows the fenestration technique with onto the slide. This video does not include
a needle only, then “blowing” the sample audio commentary.
out onto a slide and creating a “squash” Video 61.4 How to make a “squash” preparation. This
preparation for staining. Note that the oper- video demonstrates the procedure in greater
ator performs repeated advances and with- detail than in Video 61.3. This video does not
drawals of the needle (fenestrations) to include audio commentary.
References
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Feline Cytology. Philadelphia, PA: Saunders. review of an indispensable test. DVM 360 https://www.
2 Rush, J.E. and Shaw, S.P. (2007). Canine pericardial dvm360.com/view/cutaneous-cytology-quick-review-
effusion: diagnosis, treatment, and prognosis. Compend. indispensable-test (accesses 28 September 2022).
Cont. Educ. Pract. Vet. 29: 405–411. 8 Jorundsson, E., Lumsden, J.H., and Jacobs, R.M. (1999).
3 Brunel Microscopes. Setting up Kohler illumination: Rapid staining techniques in cytopathology: a review and
https://www.youtube.com/watch?v=BBW2Su0SZpI comparison of modified protocols for hematoxylin and
(accessed 8 October 2022). eosin, Papanicolaou and Romanowsky stains. Vet. Clin.
4 Oldfield, R. (1994). Light Microscopy an Illustrated Guide. Pathol. 28: 100–108.
Aylesbury, UK: Wolf Publishing. 9 Turgeon, M.L. (2005). Clinical Hematology: Theory and
5 Microscope World. Microscope maintenance. https://www. Procedures, 4e. Baltimore, MD: Lippincott Williams &
microscopeworld.com/t-microscope_maintenance.aspx Wilkins.
(accessed 8 October 2022). 10 Fankhauser, D.B. (2001). Immersion oil microscopy.
6 LeBlanc, C.J., Head, L.L., and Fry, M.M. (2009). https://fankhauserblog.wordpress.com/2001/07/11/
Comparison of aspiration and nonaspiration techniques immersion-oil-microscopy (accessed 8 October 2022).
for obtaining cytologic samples from the canine and feline
spleen. Vet. Clin. Pathol. 38: 242–246.
807
Section Eight
Infection Control
809
62
Minimizing Healthcare-Associated Infections

Jane E. Sykes
Nosocomial infections are infections that develop more catheters, increased duration of hospitalization, increase in
than 48 hours after a patient has been hospitalized or that intensive care techniques such as mechanical ventilation,
occur in a patient that has been hospitalized in the two and the wider use of antimicrobial and potent immunosup-
weeks prior to the current admission [1]. The term health- pressive drugs [4, 5]. Importantly, many of the bacteria
care- (or hospital-) associated infection (HAI) describes associated with nosocomial infection are normal commen-
infections associated with healthcare delivery in any set- sal organisms that may be found on the skin/mucosa or in
ting. This reflects the difficulty in determining with cer- the gastrointestinal tract of healthy dogs and cats. Although
tainty where a pathogen was acquired in many patients. As the relationship between colonization and subsequent
nosocomial infections are, by definition, acquired in a infection is complex, patients entering an ICU with prior
healthcare setting, the veterinary team, and especially vet- colonization may be at higher risk of subsequent infection
erinary technicians who spend most time interacting with and may act as reservoirs for other noncolonized patients [6].
the patient, have a very important role to play in minimiz- HAIs may complicate the course of both medical and
ing their occurrence. surgical diseases. They may range from mild superficial
At the time of writing, 2022 figures from the Centers for skin infections to bacteremia with sepsis and septic shock.
Disease Control and Prevention (CDC) suggest HAIs occur In human medicine, common HAI sites include blood-
in 1 of every 31 hospitalized patients a year in the United stream infections, urinary tract infections, surgical site
States, with an annual cost of at least US$28.4 billion. The infections, infectious diarrhea, and pneumonia.
COVID-19 pandemic has adversely impacted the incidence Many bacterial species can contribute to HAIs. An
of HAIs, with rises in reported rates and clusters of infec- increasing proportion appear to be resistant to multiple
tions [2]. Both in the United States and Europe, HAIs occur antimicrobial drug classes. These bacteria are of particular
with the greatest frequency in patients in intensive care concern as they often resist first-line treatments and are
units (ICU). Nosocomial infections in small-animal hospi- expensive to treat. Moreover, they may represent a zoonotic
tals, including outbreaks, have been well documented in risk to veterinary staff attending infected patients as well
the veterinary literature, but the overall rate of HAIs is less as being a risk to other patients in the ICU. Viruses such as
well understood. One study estimated that the endemic feline calicivirus are also capable of causing HAIs, and the
rate of HAIs in critical care units at small-animal hospitals fungal organism Candida may cause opportunistic infec-
was 16.3% of dogs and 12% of cats [3]. HAIs increase mor- tions following overtreatment with antibacterial drugs.
bidity and mortality, prolong hospitalization, and increase
the overall cost of care, so it is important to prevent them.
They also have the potential to be zoonotic, with associated Bacteria Associated with
public health implications. Healthcare-Associated Infections
Factors associated with an increased risk of acquiring an
HAI in human hospitals are also likely to be associated with HAIs may be caused by a large number of different bacterial
increased risk in veterinary patients; in particular, the more species. Much of the published information focuses on
intensive treatment of critically ill animals with increasing infection with specific multidrug-resistant bacteria
use of invasive devices such as urinary and intravenous (IV) (as described below). Although not specifically covered
810 Minimizing Healthcare-Associated Infections
here, bacteria such as Pseudomonas aeruginosa, Acinetobacter Vancomycin-Resistant Enterococci

baumanii, Serratia marcescens, and Bordetella bronchisep-
tica are also important nosocomial pathogens. Enterococci belong to normal human and animal gut flora.
They are Gram-positive cocci with Enterococcus faecium
Methicillin-Resistant Staphylococci and Enterococcus faecalis being the most frequent isolates.
Enterococcus faecium is generally more resistant than E. fae-
Methicillin-resistant Staphylococcus aureus (MRSA) is one calis. Vancomycin-resistant Enterococcus spp. (VRE) are
of the most significant bacterial species associated with multidrug-resistant bacterial species associated with HAIs
HAIs in human medicine. Staphylococci are Gram-positive that were first identified in human hospitals in the United
cocci that are commensals of mucosa and skin. They can States in the 1980s, and have been increasingly identified in
cause a wide range of infections following opportunistic small-animal patients. A small number of cases of clinical
tissue invasion, including postoperative wound infections, infection have been reported in companion animals [12,
implant infections, bacteremia, infective endocarditis, and 13], and VRE have been found to colonize healthy dogs in
catheter-associated infections. The majority of MRSA iso- both Europe and the United States [14]. If not susceptible to
lates are also resistant to most other commonly used anti- beta-lactams, treatment is challenging due to pan drug
biotics, making infections hard to treat once they have resistance. In some cases (e.g. bacteriuria), the host may
occurred. Humans are generally considered to be the clear the infection spontaneously if the underlying cause/
source of MRSA infections in dogs. Veterinary staff (includ- predisposing factors for the infection can be resolved.
ing veterinary technicians) may be at increased risk of col-
onization with MRSA than the general human population,
with colonization rates of approximately 10% being ransmission of Infection
T
reported in several studies [7, 8]. Methicillin-resistant and Colonization
Staphylococcus pseudintermedius (MRSP) is a greater con-
cern for HAIs in veterinary patients as it is the primary The majority of bacteria that cause HAIs are commensal
staphylococcal species that colonizes healthy dogs. MRSP organisms that invade opportunistically. The hands of
infections have been well documented following surgical healthcare workers represent the main mode of transmis-
procedures in dogs that involve implants, especially tibial sion of these bacteria among patients, with the main reser-
plateau leveling osteotomies. Such procedures require voir being other infected or colonized patients or colonized
meticulous attention to infection control in order to pre- healthcare workers [15]. Contamination of the environ-
vent devastating consequences of resistant surgical site ment may also play a role in infection, with veterinary staff
infections such as amputation or euthanasia. transferring bacteria that contaminate environmental sur-
faces to patients. Some pathogens, such as enterococci, can
Extended Spectrum Beta-Lactamase- survive in conditions similar to those found in the hospital
Producing Escherichia coli environment for long periods (days) and thorough cleaning
of the environment is necessary to prevent outbreaks of
Escherichia coli is a Gram-negative commensal of the infection.
gastrointestinal tract. Multidrug-resistant E. coli, including
extended spectrum beta-lactamase (ESBL)-producing E. coli
infections, are emerging nosocomial threats in veterinary Control Strategies for Nosocomial
patients and are well established causes of HAIs in humans.
Infection
Cultures of fecal specimens from healthy dogs and pet ther-
apy dogs have identified colonization by ESBL E. coli [9, 10].
Infection control measures and prevention strategies are
Escherichia coli isolates, including drug-resistant strains, are
critical considering the potential for HAIs to cause increased
commonly implicated in HAIs, especially urinary tract infec-
morbidity and mortality, zoonotic infections, and hospital
tions. Prolonged ICU stay has also been shown to be associ-
financial losses in association with litigation or closure. All
ated with increasing proportions of resistant E. coli isolates
hospital personnel play a vitally important role in preven-
from rectal swabs in veterinary patients [11]. ESBL-
tion of HAIs. When designing a clinic strategy to minimize
producing E. coli are of particular concern as they are
nosocomial infection, the following should all be considered:
resistant to many different antibiotics including the third-
generation cephalosporins, limiting the choice of therapy for ● Hand hygiene
these pathogens to carbapenems (e.g. meropenem) and ● Barrier environmental nursing hygiene technique and
occasionally aminoglycosides, which can only be adminis- isolation, including identification of at-risk patients
tered parenterally when used to treat systemic infections. ● Antimicrobial stewardship.
Hand Rubs 811
Many veterinary teaching hospitals have formalized

Protocol 62.1 How to Perform an Antiseptic
infection control programs to reduce the incidence of
Handwash
HAIs. The National Association of State and Public Health
Veterinarians has developed a model infection control pro- Use free-flowing water at a temperature suitable for
gram for veterinary practices, [16] and the Ontario Animal thorough wetting and rinsing of hands.
Health Network also provides recommendations for the Procedure
development of a comprehensive infection control pro-
gram [17]. The reader is also referred to other resources on 1) Wet hands thoroughly and apply hand soap.
healthcare-associated pathogens and infection prevention 2) Rub hands together palm to palm.
and control [18]. When designing prevention and control 3) Rub right palm over back of left hand and
programs, all routes of transmission should be considered, vice versa.
including contact (direct or indirect), airborne (aerosol or 4) Rub hands together palm to palm with fingers
droplet), and vector borne. It also should be recognized interlaced.
that not all infectious agents are transmissible from one 5) Bend and interlock fingers (as if holding hands with
patient to another. yourself).
6) Clean thumbs by grasping right thumb in left palm
and vice versa.
Hand Hygiene 7) Use fingers of right hand to rub left palm focusing
on base of left fingers and vice versa.
Diligent hand hygiene is arguably the single most impor- 8) Use left hand to rub right wrist and vice versa
tant measure used in the control of nosocomial infec- (optional).
tion [15]. Although the need and technique for surgical
scrubbing is well recognized, techniques for hand hygiene Notes
outside the surgical suite are often overlooked, and experi-
ence suggests that hand hygiene is often a neglected prior- ● Faucets should be turned off using a no-touch
ity in day-to-day veterinary practice. Hand hygiene can be technique.
performed in a number of ways, including: ● Hands should be dried using paper towel.
● Paper towel should be disposed of in a foot-operated
● Handwashing with a biocide-containing hand soap (e.g. pedal bin.
triclosan, chlorhexidine) and water ● The whole process should take around 1 minute.
● Using alcohol-based hand sanitizers
● Surgical hand hygiene/antisepsis.
using an antiseptic, it must also be in contact with the skin
The aim of all hand hygiene procedures is to reduce the
for a suitable period according to the manufacturer’s
number of potentially pathogenic bacteria on the hands.
instructions, which for a chlorhexidine-based solution, for
Handwashing will mechanically remove organic material
example, is typically one minute. The most effective way to
and transient microbes on the skin, and, when combined
ensure that all parts of the hands are cleaned is to follow a
with an antimicrobial soap, can inactivate microflora.
staged handwash protocol (Protocol 62.1), illustrated in
Furthermore, the multiplication of resident flora is also
Figure 62.1. The CDC also provides useful information on
temporarily reduced if the antiseptic has persistent or
hand hygiene [19].
residual activity. Surgical hand hygiene describes the con-
When a protocol is not followed routinely, handwashing
ventional presurgical scrub procedure. This takes longer to
is often inadequately performed, with some areas of the
perform than a simple antiseptic handwash but leads to a
hands not cleaned properly. The efficacy of a handwashing
greater reduction in resident flora. When nursing patients
protocol can be tested using hand creams that fluoresce
in critical care, handwashing with a biocide-containing
under ultraviolet light if not properly washed off (e.g.
soap or use of an alcohol hand rub represents the most
GlitterBug®, Brevis Coirp., Salt Lake City, UT).
appropriate form of hand hygiene in the majority of
situations.
Hand Rubs
How to Perform a Hygienic Handwash
Complete and diligent handwashing takes time, and in a
Although it sounds simple, numerous studies have shown busy critical care environment it can be difficult to
that handwashing is rarely performed correctly. To be effec- achieve on all the occasions in which it is required.
tive, all surfaces of the hand and wrist must be washed. If Alcohol-based hand rubs are an alternative to antiseptic
(a) (b) (c)
(d) (e) (f)
Figure 62.1 The six steps of hand hygiene. (a) Rub hands together palm-to-palm. (b) Rub right palm over back of left hand and vice
versa. (c) Rub hands together palm-to-palm with fingers interlaced. (d) Bend and interlock fingers. (e) Clean thumbs by grasping right
thumb in left palm and vice versa. (f) Use fingers of right hand to rub left palm focusing on base of left fingers and vice versa.
Source: Courtesy of Professor S. Gregory MRCVS, Royal Veterinary College, UK.
handwashing that can be used provided the hands are should not be used [20]. All jewelry should be removed,
not grossly dirty; that is, hands must be free of visible and sleeves should be short.
dirt, blood, or other proteinaceous material or body flu-
ids. Use of an alcohol-based hand rub is the preferred
means for hand hygiene in most clinical situations. iming of Hand Hygiene and Use
T
Alcohol hand rubs should contain 60–95% ethyl or iso- of Gloves
propyl alcohol, and they typically also contain an emol-
lient. Both liquid and gel formulations are available. There are many occasions when hand hygiene is indicated
They can be bought as wall dispensers or small bottles. (Box 62.1). For basic care procedures such as physical exam-
A total of 2–3 ml typically obtains 90% hand coverage, ination, correct use of an alcohol-based hand rub is suffi-
regardless of hand size, and should be applied to all parts cient. Handwashing should be used if hands are visibly
of the hands (using a protocol similar to that used for soiled and after the healthcare worker performs any per-
antiseptic hand washing) for 15–20 seconds, allowing the sonal hygiene procedures, such as visiting the bathroom.
hands to air dry. Hand rub use may be encouraged by Use of gloves can reduce bacterial contamination of hands
wearing the small bottles on clinical clothing and/or by as well as acting as barrier protection during contact with
placing them strategically on kennel doors. body fluids. Gloves do not, however, completely protect
The advantages of alcohol-based hand rubs compared against hand contamination; contamination may occur via
with antiseptic handwashing include a reduction in the small defects in the glove or during glove application and
time taken to complete effective hand hygiene, more removal. Gloves should be worn whenever it can be reason-
rapid action, and less skin irritation. In addition, alcohol- ably anticipated that there will be contact with potentially
based hand rubs do not require the presence of a sink or infectious material or nonintact skin. Gloves should be
hand drying facilities. All these factors have been dem- removed after each procedure and when moving from a
onstrated to improve hand hygiene compliance in human contaminated body site to another site on the same patient.
medicine. Hands should always be washed after removing gloves, and
Regardless of the technique chosen, it is important that glove use should not reduce the frequency of handwashing.
fingernails are kept short and clean and any cuts or abra- Studies in human hospitals reveal that there are many
sions are covered with waterproof dressings. Artificial nails factors associated with poor hand hygiene compliance,
Environmental Cleaning 813
Box 62.1 Hand Hygiene Guidelines Environmental Cleaning

Hand hygiene should be carried out: Although specific responsibility for environmental clean-
● Before and after touching or examining the patient. 1 ing may reside with one group of staff, all personnel
● Before and after touching any invasive devices such should take some degree of responsibility for maintaining
as intravenous catheters and urinary catheters.1 a clean clinical environment, and the policy of “clean as
● After contact with any body fluids or excretions, you go” should be adopted. This also applies to senior staff
mucosal surfaces, nonintact skin, or wound dressings.1 and veterinarians, who should model good practice.
● If moving from a contaminated/infected body site to Positive feedback is also extremely important, and the
another body site of the same patient.1 value of performing a cleaning task well should never be
● After contact with inanimate objects in the immedi- overlooked. All clinics should have a fixed cleaning sched-
ate vicinity of the patient. ule with checks to ensure regular cleaning is being
● Before handling medication or preparing food. performed.
● When arriving and leaving work. Floors and all surfaces should be cleaned at least once
● Before and after performing any personal hygiene daily. Floors should be constructed of nonporous, nonslip
procedures such as visiting the bathroom or blowing materials, and ideally the junction between floor and wall
the nose. should be curved to facilitate cleaning. Gross debris should
● Before and after eating. be swept up and the floors cleaned with a disinfectant that
● Before and after removing gloves. is ideally virucidal, bactericidal, mycocidal, nonirritant,
noncorrosive, and nonstaining (see Chapter 64 for more
1
Glove use should be considered if there is a high risk that the information). Disinfectants should be used according to
hands may come into contact with potentially infectious material the manufacturer’s instructions. Mops should be kept
or nonintact skin.
clean and replaced on a regular basis. Mop buckets should
be emptied and rinsed after each use and should also
including being a doctor or nursing assistant (as opposed to undergo regular full bucket disinfection. Floors should be
a nurse), being male, working in a critical care environ- deep cleaned on a regular basis with the frequency depend-
ment, a high intensity of patient care, wearing gloves and ent on use and soiling.
gowns, undertaking activities with a high risk of cross- Examination and operating tables should be disinfected
transmission, being too busy and failing to think about it, after each use, using a suitable disinfectant with proper-
lack of easy availability of facilities such as sinks, and skin ties similar to those used on the floor. As most disinfect-
irritation with frequent hand hygiene [21]. A lack of ants are not effective in the presence of organic matter,
knowledge is also often highlighted with some reports of any gross contamination should be removed using soap
skepticism about the effectiveness of hand hygiene and and water first.
lack of knowledge of hospital protocols. Additional per- Work surfaces in clinical areas and kennels should be
ceived barriers include lack of role models [22] and low constructed of material that can be thoroughly cleaned and
institutional priority, with lack of administrative sanctions is impervious to disinfectant. Seams should be sealed to
for noncompliers [23]. Barriers reported for veterinary prevent accumulation of contaminated material, and junc-
practitioners are forgetfulness, being too busy, skin damage tions should be rounded to facilitate cleaning. They should
from frequent handwashing, and lack of available supplies. be regularly disinfected at least twice daily but more regu-
Methods to improve hand hygiene compliance include larly if they become soiled. Movement of patients between
education and teaching with constant reinforcement kennels should be minimized. Sinks and showers must be
within the workplace, getting senior staff to set a good kept clean, and in hard water areas limescale should be
example, reminder signage, and making sure the staff-to- controlled and soap scum removed daily with a scouring
patient ratio is favorable. The introduction of conveniently preparation. Areas not immediately visible, such as the
placed alcohol hand rubs, which removes the need to tops of kennels, should not be forgotten, and the cleaning
handwash after every patient contact and allows opportu- schedule should include a frequent (e.g. weekly) general
nities for hand hygiene remote from washing facilities, also cleaning and inspection of these areas.
facilitates compliance. Every member of the healthcare Garbage bins used for clinical waste should be covered
team has a large role to play both in ensuring they them- and the cover should be foot operated and not allowed to
selves comply and in reminding the rest of the veterinary overflow. Animal bedding should be cleaned of gross soil-
team as to its importance. It is also important that dispensing and then washed using a hot cycle (140°F, 60°C) with a
ers be refilled or replaced regularly so that they are never biological washing powder. Drying in a hot tumble dryer is
found empty. Posting of signage may also be of benefit. recommended. Food and water bowls should also be made
of a material that can be disinfected. Use of disposable bed- it may be a color different from that used in the rest of the
ding and feeding bowls is recommended when contamina- clinic. The location of the medical record should also be
tion with transmissible pathogens is possible. considered; if paper records are used, they should not then
“High touch surfaces” such as infusion pumps, kennel be carried to other sites in the clinic. Dedicated pens or
doors, monitoring equipment, door handles, computer computer terminals should be used.
keyboards, and telephones, should be disinfected more Isolated patients should not have contact with other
regularly than other sites. Medical equipment used for patients. Procedures such as radiography or ultrasound
physical examination (e.g. stethoscopes, thermometers) that must be carried out in other areas of the clinic should
may also be considered in the same way. Disinfectant wipes be scheduled for the end of the day (if not urgent), and all
(preferably hydrogen peroxide based) and hand rubs staff involved should be alerted as to the nature of the
should be readily available near these sites. patient’s disease. These areas should be thoroughly cleaned
and disinfected after use.
Staffing of isolation areas will depend on the size of the
Barrier Nursing and Isolation clinic. Ideally, one veterinary technician should be allo-
cated to this area and this veterinary technician should
All practices should have facilities and policies for isolation have minimal responsibilities in other animal areas, espe-
and barrier nursing. These facilities may be used for ani- cially with any high-risk patients. Protective attire (gowns,
mals with a known infectious disease but also on occasion which should be water impermeable if splashes/sprays are
for patients with a known risk of contracting an infectious possible; footwear protection; disposable gloves, face
disease (e.g. unvaccinated or immunosuppressed animals). shields, and caps) should be worn when entering the area
Barrier nursing may also be used for patients in which and must be removed on exit. For true isolation areas, a
there is a high index of suspicion for infection with a path- foot bath or foot mat containing an appropriate disinfect-
ogen that could be associated with HAIs pending receipt ant that is properly replenished should be available on
of microbiological culture results. An example might be entry and exit of the area. These measures can also act to
a patient with a chronic nonhealing wounds that has deter traffic. Personal and environmental hygiene must be
received multiple courses of antibiotics. strict and all waste must be disposed of safely. Staff and
True isolation facilities are completely self-contained owners should be apprised of any possible zoonotic risks,
areas that do not share an air space with other animal and owners should be allowed to enter only in exceptional
accommodation areas. As the facility must be completely circumstances. If owners are allowed to visit, they should
self-contained, it must have its own equipment for feeding, observe the same hygiene and clothing precautions as staff
nursing, and cleaning, including hot and cold water, medi- members. Notices should be placed at the entrance of the
cal supplies, and an examination table. Not all practices isolation area or around the barrier nursing area clearly
have an area that fulfills all these requirements. stating what measures must be instituted on entry
For animals where strict isolation is not required or avail- (Protocol 62.2).
able, barrier nursing may be more appropriate. This may The cost of isolating or barrier nursing patients is high in
include patients where an increased level of vigilance is terms of both consumables and staffing, and therefore
appropriate to protect the animal from infection or where additional fees should be set and owners apprised of the
the animal has a known infection but is considered a low rates. Owners should also be warned that intensive moni-
contagious risk. Barrier nursing may be provided within a toring and treatment may not be possible to deliver in the
separate ward or a partitioned area of an existing ward. It isolation unit.
should be remembered that animals that are isolated are In some cases, it may be preferable or necessary to treat a
inevitably barrier nursed; however, not all animals that are patient with an HAI as an outpatient. Many patients with
barrier nursed are effectively isolated. HAIs are clinically well and with appropriate owner infor-
Regardless, each animal being isolated or barrier nursed mation and consent may be managed at home. It is vital
should have dedicated equipment. Any piece of equipment that the owners are educated as to zoonotic risks and that
can act as a fomite and can facilitate transmission to other if there are any concerns that humans in the animal’s envi-
patients [24]. The isolation or barrier nursing area should ronment are at risk, advice should be sought from medical
have dedicated leads or leashes, thermometers, and steth- professionals as to whether management at home is appro-
oscopes. As far as possible, equipment including bedding priate from the human health perspective. If patients are
and feeding bowls used in this area should be disposable, managed on an outpatient basis, it is essential that they are
and robust cleaning protocols should be in place for any clearly identifiable on revisits. Owners should be educated
equipment that will be used subsequently with other to wait outside the clinic until their appointment time
patients. If bedding is to be reused, it should be clearly to reduce the risk of transmission to other patients in
identifiable as belonging to the isolation area; for example, the waiting room. As far as possible, revisits should be
Role Rof Scleleeneng oRc PatRngleenS PSalecnP 815
Protocol 62.2 Barrier Nursing an Isolated Patient
Note 2) Remove and dispose of all protective clothing on

exiting the isolation area.
Only designated personnel should enter the isolation
3) Using an antiseptic hand wash, clean hands both
unit; visitors are permitted only with the express permis-
before entering and on leaving the isolation area.
sion of the attending clinician and must be accompanied
4) Provide all patients in the isolation area with a lead/
at all times.
leash, stethoscope, feeding utensils, litter tray (if
appropriate), and thermometer for their sole use. Keep
Procedure for Isolation Area
together in a plastic box and sterilize/disinfect
1) Wear protective clothing when entering the area, between patients.
including: 5) Do not remove medications from the isolation area.
● Disposable, water impermeable apron or gown 6) Dispose of all clinical waste in the garbage bin within
● Shoe covers the isolation area; seal the bag and double-bag before
● Disposable gloves removal from the area.
● Caps 7) Use disposable bedding.
● Depending on the infectious agent, face shields or 8) Thoroughly clean the isolation area once the patient
N95 masks. has been discharged.
scheduled such that thorough cleaning of the examination they occur in animals that lack a history of antimicrobial
room can be performed following the visit. therapy. For most important HAIs (e.g. those caused by
multidrug-resistant staphylococci, enterococci and E. coli),
prior colonization of the skin, mucosa, or gastrointestinal
Antimicrobial Stewardship tract results in a much-increased risk of nosocomial infection
with the multidrug-resistant strain [29, 30]. Thus, antimicro-
Antimicrobials are commonly prescribed drugs and are bial therapy should be used judiciously even when consider-
often used on an empirical basis, especially while awaiting ing the individual patient. One study documented changes in
bacterial culture results. In human medicine, the CDC esti- fecal flora in dogs hospitalized in a veterinary ICU and
mates that 50% of outpatient prescriptions are inappropri- showed that the proportion of dogs colonized with resistant
ate, and in 28% of prescriptions, no antibiotic was indicated bacteria increased with duration of hospitalization regardless
at all [25]. Moreover, inappropriate antibiotic use is associ- of antimicrobial use. Dogs treated with enrofloxacin were
ated with higher mortality, which is not necessarily 25.6 times more likely to be colonized by a resistant strain [11].
reversed if the antibiotic is changed once culture results Guidelines are available from the International Society
are known [26, 27]. A 2022 survey of 2410 US veterinary of Companion Animal Infectious Diseases to assist practi-
practitioners suggested that widespread inappropriate pre- tioners regarding appropriate selection and dosing of
scribing of antimicrobials also exists in companion animal appropriate antimicrobials for different clinical situa-
medicine [28]. The use of most antimicrobials is uncom- tions [31–34]. Familiarity with the antimicrobial use guide-
monly associated with observable adverse effects for that lines was shown to be associated with reduced antimicrobial
individual patient; most of the commonly prescribed drugs prescribing for conditions when antimicrobial use is typi-
have a high therapeutic index and it is easy to feel that by cally not indicated, specifically feline lower urinary tract
prescribing an antibiotic we “may be doing some good and disease, feline upper respiratory tract disease, and canine
are unlikely to be doing harm” to the individual patient. acute diarrhea [28].
However, inappropriate antimicrobial therapy can contrib-
ute to gut dysbiosis and adds unnecessary costs and incon-
venience to the animal owner. Importantly, any commensal ole of Screening for Pathogenic
R
or colonizing microbes that display mechanisms of resist- Bacteria
ance will enjoy a selective advantage.
The clustering of multiple resistance genes on plasmids Screening involves taking microbiological samples from
and other genetic elements makes the problem especially the environment, patients, or staff to look for the presence
challenging, as exposure to one antimicrobial may coselect of multidrug-resistant bacteria. Culture and molecular
for bacteria that are resistant to several unrelated agents. methods such as nucleic acid amplification tests have been
When infections occur in animals with a history of antimi- used for this purpose. Routine environmental screening is
crobial therapy, they are more likely to be resistant than when costly and the results of routine environmental screening
generally do not correlate with rates of HAIs, and so has associated with litigation. With advancements in treatment
not been recommended by the CDC [35]. The CDC has for critically ill, nosocomial infections will become more
outlined four indications for environmental screening: common. Moreover, many of these infections may be with
multidrug-resistant organisms, and the age of relying on
1) To support an investigation of an outbreak of disease.
ever more powerful antibiotics seems to be drawing to a
2) For research purposes.
close. To minimize the risk of nosocomial infection, it is
3) To monitor a potentially hazardous environmental con-
vitally important that we use multiple infection control
dition, confirm the presence of a hazardous chemical or
strategies based on an understanding of the epidemiology
biological agent, and validate the successful abatement
and transmission of these microbes. Diligent handwash-
of the hazard.
ing, good environmental cleaning, and appropriate barrier
4) To evaluate the effects of a change in infection control
nursing and isolation are all key parts of an infection con-
practice or to ensure that equipment or systems perform
trol strategy where veterinary technicians have a very large
according to specifications and expected outcomes.
role to play.
Although advocated in the past, screening of patients and
staff for colonization by MRSA is generally not recom-
mended, because decolonization has had questionable
Acknowledgment
efficacy [36].
This chapter was originally authored by Dr. Amanda Boag
Summary and Katherine Jayne Howie for the previous edition, and
some material from that chapter appears in this edition.
HAIs can be associated with significant morbidity and The author and editors thank Dr. Boag and Ms. Howie for
mortality and can lead to increased expense and stress for their contributions.
owners, the possibility of clinic closures, and costs
References
1 Crowe, M.J. and Cooke, E.M. (1998). Review of case and pets in a small animal referral hospital in the
definitions for nosocomial infection: towards a consensus. UK. J. Antimicrob. Chemother. 56: 692–697.
Presentation by the Nosocomial Infection Surveillance 8 Anderson, M.E., Lefebvre, S.L., and Weese, J.S. (2008).
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819
63
Care of Indwelling Device Insertion Sites

Helen Philp
Indwelling medical devices play an essential role in the morbidity; for instance, the device may need to be removed
emergency room and intensive care unit. They assist in or may cease to function. Alternatively, it may become dis-
diagnosis and patient monitoring, enable administration of placed due to disruption of local tissue or loss of securement.
intravenous fluids, blood products, nutrition and medica- There are four recognized routes for contamination of
tion, and aid support of organ function [1]. Despite their intravenous catheters [8]. The most common in short-
widespread application, a number of complications may be term catheters is migration of skin organisms from the
encountered. insertion site. Direct contamination of the catheter by con-
tact with hands or contaminated fluids or devices is
another potential route. Finally, catheters may become
Complications hematogenously seeded from another focus of infection or
infusate may be contaminated; these final two routes are
Infection is a major concern with indwelling medical less common than the first two. Contamination and bacte-
devices, mainly due to their circumvention of innate rial colonization do not automatically lead to infection.
defenses. For example, any device traversing the skin Factors that can compound the likelihood of infection
bypasses the protective epithelial barrier including its anti- associated with a device include the material of which the
microbial secretions, cutaneous microflora, and resident device is made, host factors such as thrombus and fibrin
phagocytic cells [2]. Devices placed via natural orifices may sheath formation and the intrinsic virulence of an infect-
similarly compromise host defenses; for example urethral ing organism, including its propensity for biofilm forma-
catheters interfere with protective mechanisms such as the tion [8, 9]. Biofilm itself may become a continuing source
unidirectional flow of urine, periodic bladder emptying of bloodstream infection by intermittent release of cell
and the antimicrobial properties of urine. Potential seque- clusters or individual planktonic cells [10]. Additional
lae to intravenous (IV) and/or urinary catheter-associated indwelling devices and longer dwell time both appear to
infections include pyelonephritis, endocarditis, and septic increase the risk of a hospitalized patient developing a
arthritis [3]. nosocomial infection [1, 9].
The consequences of device-associated infections range Potential noninfectious device complications include
from localized signs to bloodstream infection, sepsis, and dislodgement, lumen occlusion, patient injury (e.g. infil-
death. Significant association between the presence of tration, extravasation, vascular occlusion, thrombosis, or
indwelling medical devices and increased risk of sepsis has phlebitis in the case of vascular catheters), or loss of func-
been documented in human medicine [4–7]. Nosocomial tion for another reason.
infections increase morbidity and mortality, lengthen hos- The consequences of losing function of an indwelling
pital stays, and add cost to patient care (for further infor- device for any reason could be serious. For example, a dis-
mation, see Chapter 62). In veterinary medicine, increased placed thoracostomy tube may rapidly compromise a
morbidity or cost can lead to euthanasia, as most owners patient’s ability to breathe while the loss of even a simple
have a finite amount of money to spend. Even localized venous catheter can make effective patient treatment chal-
infections without systemic effects increase patient lenging and delay procedures or drug administration.
820 Care of Indwelling Device Insertion Sites
The Value of Protocols
Adherence to protocols for the placement, handling, and

maintenance of indwelling devices significantly decreases
the incidence of complications [8, 11–13]. Hand hygiene is
one of the most important aspects of these protocols as
healthcare workers’ hands represent the principal route of
pathogen transmission [3, 14–17]. Transient pathogenic
microorganisms are readily removed with hand hygiene
and strict adherence to hand hygiene protocols has been
reported to reduce nosocomial infections by as much as
40% [3, 18]. Hand hygiene also prevents colonization and
infection in the healthcare worker as well as contamina-
tion of the environment [3]. An alcohol-based hand rub is
generally preferred, unless hands are visibly soiled, because
these rubs reduce skin irritation and improve healthcare
worker compliance compared with hand washing [19]. The
Centers for Disease Control and Prevention (CDC) has
developed extensive recommendations for how and when
to perform hand hygiene measures [14], which are detailed
in Chapter 62. A hygienic handwashing protocol is availa-
Figure 63.1 Patient with esophagostomy tube and
ble in Protocol 62.1.
hemodialysis catheter in place (patient in right lateral
recumbency with its head to the left). Care must be taken to
avoid cross-contamination between these sites during
inspection, cleaning, and rewrapping.
General Care of Insertion Sites
Insertion site care varies somewhat by patient and device,

catheter or central line (Figure 63.1) can present a challenge
but some principles generally hold true across the board.
in avoiding contamination of the vascular catheter insertion
site. In this scenario, it is recommended to clean the cath-
Bandaging eter insertion site first and to change gloves after handling
the esophagostomy tube site.
Insertion sites that penetrate the skin (excepting tracheos-
tomy sites) should be kept covered with a sterile, nonad-
herent pad or a sterile, self-adherent bandage, and Maintenance
wrapped with gauze. Cast padding may be placed over the
Most sites should be unwrapped, evaluated, and rewrapped
gauze to help secure it, and an outer, water-resistant wrap
at least once daily. The insertion site should appear clean
may be applied as a final barrier. This general bandage will
with no redness, swelling, oozing fluid, or other signs of
work in many situations but is not appropriate for all
inflammation. The area should not feel excessively warm
devices. More specific wraps are described later in the
and should not be unduly painful. If the device is sutured in
chapter.
place, the sutures should be assessed for functionality and
suture sites evaluated for inflammation. The device should
be securely in place with no signs of slippage or migration.
Handling
When a device is inserted, a note should be made on the
As stated above, good hand hygiene is paramount in the treatment sheet as to the device’s size, functionality (e.g. for
basic care of indwelling devices. After proper hand an IV catheter: Does it flush? Does it aspirate?), and place-
hygiene is performed, clean examination gloves should be ment depth. Some devices have depth markers on them that
worn before handling any device or insertion site. Sterile can be used as a reference when performing daily evalua-
gloves may be indicated in some instances, such as when tion. If there are no markers, the length of the device
handling the inner cannula of a tracheostomy tube extending from the body can be measured and a note made
(Chapter 29). Care must be taken to avoid cross- in the treatment sheet. If the site shows signs of inflamma-
contamination between devices. For example, the pres- tion or infection, it should be scrubbed with a 2% tincture of
ence of both an esophagostomy tube and hemodialysis chlorhexidine preparation, the chlorhexidine should be left
eneral anageeent of Device Insertion Site Infection 821
on the site, and the site should be allowed to air dry before ports or needle-free connectors rather than direct attachment
rewrapping [8]. A clinician should be notified of the inflam- of syringes is recommended where possible [16]. Each
matory change and the patient should be assessed for signs additional access point to a device increases the risk of con-
of systemic infection. Similarly, any migration from the tamination, so port number should be kept to a minimum.
original position or altered functionality should be reported Integrated devices and Luer lock design are recommended
to the clinician. Device removal is at the clinician’s discre- where possible [26, 27].
tion. Insertion sites should be kept clean and dry.
Care of Associated Lines and Connections General Management of Device Insertion

The ideal replacement interval for infusion sets has not Site Infection
been established. The purpose of routine replacement is to
reduce infection via colonization. However, there is some If a device site infection occurs, the clinician must decide
argument that replacing administration sets risks contami- whether to remove the device or leave it in place. Risks
nation during handling. Recommendations in human and benefits must be considered, and close monitoring of
medicine range from intervals of four to seven days [19–25]. rectal temperature, blood pressure, complete blood count,
For veterinary patients, it would seem reasonable that dis- and blood glucose concentration may aid in decision
posable lines or connections used with an indwelling making. If the infection appears to be localized, it is some-
device can remain in place for 72–96 hours. Tubing used to times best to leave the device in. For instance, in the
administer blood, blood products, or fat emulsions (includ- author’s experience, localized feeding tube insertion site
ing propofol infusions) should be replaced no less often infections are often treated successfully with diligent,
than every 24 hours [8]. Immediate infusion sets should be daily site cleaning with a 2% chlorhexidine scrub; thor-
replaced in the event of contamination. For arterial lines, ough site drying before bandaging; and sometimes sys-
disposable, closed flush transducer assemblies are pre- temic antimicrobial therapy (Figure 63.2). Minor
ferred and should be replaced at 96-hour intervals, together infections related to central venous catheters in human
with the tubing, continuous-flush device, and flush solu- pediatric patients are sometimes managed with diligent
tion [8, 25]. site care and systemic antimicrobials for up to three days,
Injection ports should be swabbed with 70% isopropyl after which time the device is usually removed if the
alcohol or an iodophor (e.g. povidone-iodine) prior to being infection persists [1]; however, the CDC recommends
punctured with a sterile needle [8]. Stopcocks should be removal of vascular catheters if there is evidence of phle-
aseptically capped when not in use and access via injection bitis or purulence [8].
Figure 63.2 Sequential pictures taken over a 48 hour period show localized esophagostomy tube site infection managed with topical
treatment (patient’s head is to left). The tube had been removed several days prior due to owner request. The patient remained
systemically well throughout.
Insertion Site Preparation for Peripheral (Chapter 9) could be useful in patients that are difficult to
Venous and Arterial Catheters catheterize [31]. For example, shining a bright light
through areas such as a dog’s pinna may help to locate the
Venous access is required in most acutely or critically ill artery while ultrasound guidance can be invaluable for dif-
patients for parenteral administration of fluids and medi- ficult CVC placement if it is used by an operator with some
cations [28]. Many critically ill patients require multiple experience in the technique.
simultaneous constant rate infusions, which necessitates The proposed insertion site should be completely clean
multiple venous catheter ports. Arterial catheters are indi- and free of local trauma and infection. The region is clipped
cated for direct blood pressure monitoring or frequent sam- of fur as close to the skin as possible with a clean blade.
pling of arterial blood. Because vascular access plays a Clipper blades must be well maintained to avoid iatrogenic
dominant role in quality veterinary care, the proper care of trauma and bacterial contamination [36]. When possible, a
venous and arterial catheters is a top priority. margin of 1.5–2 inches (5 cm) of fur should be removed on
Many catheter-related infections begin with catheter all sides of the proposed puncture site [37].
placement. Pathogen migration from the insertion site After performing hand hygiene using either soap and
along the cutaneous catheter tract is the main cause of water or an alcohol-based hand rub (see Chapter 62
infection in peripheral intravenous catheters (PIVC) while Protocol 62.1), new gloves should be donned and the pro-
contamination of the catheter hub is often the source of posed insertion site scrubbed [8, 25].
central venous catheter infections [8]. Systemic antimicro- Chlorhexidine, 70% isopropyl alcohol, or tincture of
bials administered at the time of insertion appear to iodine or iodophor may be used to prepare the catheter
decrease catheter colonization, but the overall risk of cath- insertion site [8]. The effectiveness of skin antisepsis is
eter infection is not reduced and antimicrobials should not directly related to the length of time the antiseptic is
be administered solely for this purpose [28, 29]. allowed to act, and insufficient contact time has been
cited as a reason for increased contamination rates in the
fast-paced emergency department of human hospi-
Catheter Selection tals [38]. A 30-second scrub with 2% chlorhexidine may
be the most effective at preventing catheter-related infec-
Choosing the appropriate catheter is important in the pre- tions; a 10% povidone-iodine scrub for two minutes is also
vention of catheter-associated infections. According to the acceptable [8, 16, 26]. Potential benefits of chlorhexidine
CDC, catheters made of Teflon® or polyurethane are pre- over iodine include prolonged efficacy against most noso-
ferred over those made of polyvinyl chloride or polyethyl- comial pathogens, less risk of neutralization by protein-
ene, to help reduce the incidence of infection [8]. Also, rich biomaterials on the skin (including blood), and
catheter diameter plays a role in the formation of thrombi reduced risk of adverse effects following repeated expo-
and the smallest catheter diameter required to meet patient sure [27, 39].
needs should be utilized [30–32]. While 70% isopropyl alcohol is an effective antimicrobial
for the skin, it should not be used on sensitive or delicate
skin, as it is drying and therefore can be damaging; sterile
Site Selection and Preparation
water can be used instead as a damp wipe/rinse in alterna-
Site selection for placement of peripheral catheters will tion with the scrub solution [15]. Additionally, alcohol inacti-
depend on the patient’s vasculature, reason for hospitaliza- vates povidone-iodine, so alternating these two antiseptics
tion, mobility, and purpose for placement [32]. Distal for site preparation is not recommended (Chapter 64). See
extremity sites are ideally used first, saving more proximal Protocol63.1 for instructions on vascular device insertion site
sites for subsequent cannulation [33]. However, a PIVC preparation. Care should be taken to avoid contamination of
placed over a joint or area of flexion (for example the acces- multiple use products (for example multi-use containers of
sory cephalic branch over the carpus in a dog), will be at antiseptic solution or presoaked gauze sponges) [19].
higher risk of movement, occlusion, or dislodgement [25, Scrubbing technique has also been the focus of some
33]. Although saphenous catheters in dogs and cats may be human studies. The rationale for use of the classic outward
expected to be at greater risk of soiling with urine and circular motion is in removing bacteria from the top layer
feces, this site does not appear to be associated with of skin and avoiding contamination [33], although some
increased bacterial colonization [34, 35]. human sources consider a back-and-forth scrubbing tech-
It is recommended that once a PIVC site has been nique to be more effective [25, 33, 39]. Whichever tech-
selected, no more than two placement attempts should be nique is used, the scrub should not be too vigorous, as
made by a single person and no more than four attempts damage to the skin increases the risk of infection.
total [25]. This may not be practical in all cases but Once the site has been cleaned, it should not be palpated
techniques such as transillumination and ultrasound again before catheter insertion [8, 25]. Gloves worn during
Care and aintenance of Eisting eriiperal ascclar Catpeter Insertion Sites 823
Protocol 63.1 Site Preparation for Peripheral Intravenous and Arterial Catheters
Items Required
● Skin scrub
⚪ 2% chlorhexidine scrub (preferred)
⚪ 10% povidone-iodine scrub (acceptable)
● Skin rinse
⚪ 70% isopropyl alcohol
⚪ Sterile water (for sensitive or delicate skin, or for alternating with 10% povidone-iodine)
Procedure
2) Clip fur with a radius of around 2 inches (5 cm) from proposed insertion site. Clip fur as close to the skin as possible.
3) Perform hand hygiene and don clean examination gloves.
4) Perform a gentle 30-second scrub with 2% chlorhexidine, or a gentle 1-minute scrub if using 10% povidone-iodine.
Do not scrub so vigorously that skin is damaged.
5) Rinse the skin with 70% isopropyl alcohol if using chlorhexidine and the skin is not overly delicate or damaged.
Rinse the skin with sterile water if using povidone-iodine or the skin is delicate or damaged.
6) Remove gloves, perform hand hygiene, and don clean gloves appropriate to the task prior to catheter insertion.
site preparation should be removed and hand hygiene quickly become colonized with bacteria by being exposed
again performed. For PIVC placement, clean gloves should to multiple individuals and manipulation with ungloved
be worn while the CDC recommends more strict aseptic hands. If nonsterile tape must be used directly at a catheter
technique be used with a minimum of a cap, mask, sterile insertion site, discarding the outer layer may help to reduce
gloves, and a small sterile fenestrated drape for peripheral the risk of infection. The site may then be dressed with
arterial catheter placement [8]. Instruction on catheter clean gauze or cotton cast padding, as listed above in gen-
placement can be found in Chapters 7 and 8. eral recommendations.
The catheter must be protected so that the animal does
Dressing not chew or lick the area. Many commercial products are
available to limit animal access to vascular catheters,
The role of dressings and securements in reducing catheter-
including Elizabethan collars, no-bite collars, catheter
associated complications should not be underestimated. In
guards, various wrapping materials, and noxious-tasting,
human medicine, suboptimal dressing integrity has been
anti-lick sprays.
implicated in over 20% of catheter-associated complica-
tions while 21–71% of PIVC dressings have been found to
be soiled, moist, loose, or inadequately secured at any sin-
gle timepoint [40–42]. Creation of a physical barrier Care and Maintenance of Existing Peripheral
between the insertion site and the environment reduces Vascular Catheter Insertion Sites
microbial colonization while adequate stabilization
reduces the risk of catheter dislodgement or kinking [8, Human guidelines recommend that PIVCs be assessed no
40]. Stabilization of the catheter within the vessel is also less often than every four hours; every one to two hours
important as pressure and micro-motion of the catheter tip for patients who are critically ill/sedated; hourly for neo-
irritate the vessel wall, predisposing to infiltration, occlu- natal/pediatric patients; and more often for patients
sion, and/or phlebitis [27]. The catheter insertion site may receiving infusions of potentially irritating medica-
be covered with sterile gauze or a sterile, transparent, adhe- tions [25]. The dressing should be snug, clean, and dry.
sive dressing [8]. In a human study on optimal catheter Loose or soiled dressings should be changed immediately,
dressing, securement with sterile gauze and overlying tape and if the dressing is soiled or wet to the level of the cath-
was associated with fewer site complications and better eter insertion site, the clinician should be notified. During
dressing integrity [41]. However, direct application of non- the dressing change, the site should be cleaned with 2%
sterile tape to the catheter insertion site led to increased chlorhexidine scrub; allowed to air dry or dried with ster-
phlebitis and infection rates. Partially used tape rolls ile gauze; and rewrapped with new, clean materials.
Topical antibiotic ointment or cream should not be low-flow techniques [19]. However, one human study
applied to the catheter insertion site due to its tendency found no difference in PIVC catheter patency time between
to promote fungal growth and encourage bacterial the two techniques [43]. Flushing catheters with heparin-
resistance [8]. ized saline does not seem to be more effective at preventing
The vessel above the site should not be hard or “ropey” catheter failure than using 0.9% saline in people [44, 45] or
on palpation, the skin above the site should not be exces- in dogs with short-term PIVCs [46]. Similarly, the addition
sively warm, there should be no edema proximal or distal of heparin to the flush solution has not been shown to
to the catheter, and there should be no bandage strike- increase arterial catheter patency or integrity of arterial
through or oozing at the site. If any of these abnormalities waveforms compared with 0.9% saline [47].
are noted, the clinician should be notified, and a dressing Any vascular catheter that is no longer essential should
or catheter change considered. be removed; however, the need for routine replacement
There are no clear guidelines as to how often a vascular of PIVCs is less clear. Earlier CDC guidelines recom-
insertion site should be directly evaluated [8]. Standard mended replacement of PIVCs in people every
veterinary practice is to unwrap and evaluate, and dress 24–48 hours because of higher complication rates associ-
vascular catheter insertion sites with clean, new materials ated with longer dwell times. Current data seem to refute
once daily, or more often if dressings are visibly soiled. this necessity and the latest CDC guidelines have relaxed
Proper hand hygiene (washing or alcohol-based hand rub) the recommendation, advising that there is “no need to
should be performed prior to any contact with a catheter or replace peripheral catheters more frequently than every
its insertion site, and clean gloves should be worn every 72–96 hours.” [8] A Cochrane meta-analysis found “no
time the catheter is accessed (see Chapter 62 Protocol 62.1). evidence to support changing catheters every 72–96
Assessment of the catheter insertion site should be per- hours” [48]. Patel et al. cite some disadvantages to rou-
formed by palpation through the dressing to discern swell- tine catheter replacement, including patient discomfort
ing or tenderness and by inspection if a transparent and unnecessary cost, which is also relevant to veterinary
dressing is in use [8, 32]. CDC guidelines recommend that practice [49]. An exception to this rule is if a catheter is
gauze and opaque dressings should not be removed if the placed during an emergency situation in which proper
patient has no clinical signs of infection or discomfort [8]. protocol may have been compromised. Such catheters
The catheter should be handled gently. Irritation of the should be replaced as soon as possible (within 48 hours).
vessel caused by catheter handling increases the risk for PIVC failure from infiltration and extravasation was
phlebitis. When accessing the catheter, be aware of the almost 13% higher in PIVCs inserted in the emergency
anatomy of the vessel and try to avoid bending the cathe- department compared with other departments in a sys-
ter against the direction of the vessel. Take care not to dis- tematic review [50].
lodge the catheter when accessing it. The catheter can be Replacement of arterial catheters is only recommended
gently grasped by the hub with one hand (properly cleaned when there is a clinical indication [8]. This recommenda-
and gloved) while accessing it with the other hand so as tion has been challenged by data showing bacterial coloni-
not to dislodge the catheter or its connections during zation of arterial catheters over time, and thus replacement
manipulations. after seven days has been suggested in people [51].
There should be no redness or swelling at the site. The However, routine arterial catheter replacement is often
site should be clean and dry with no oozing blood or limited by the number of arterial access sites and the risk
fluid. Abnormalities should be brought to the clinician’s of mechanical complications.
attention.
It is recommended that a catheter be flushed after each use
and at least once every six hours [32]. Flushing helps to reduce Complications of Indwelling
contact between incompatible drugs or fluids, limits the risk Vascular Catheters
of thrombosis and phlebitis, and reduces fibrin accumulation
in the internal lumen of the catheter, thereby reducing the Despite all attempts at best practice, complications can
risk of thrombosis and bacterial colonization [27]. arise and a PIVC complication rate of 21.4% was reported
It may be presumed that the turbulent flow created by in a population of cats in intensive care in one study [52].
pulsatile flushing would be more effective than the laminar Localized infection at the site, bloodstream infection or
flow created by continuous flushing for maintaining cath- sepsis, phlebitis, thrombosis, and edema are all potential
eter patency. In vitro studies have shown that short boluses consequences of intravascular catheters. The severity of
of flush solution interrupted by brief pauses may be more these complications ranges from mild to life threatening.
effective at removing solid deposits (e.g. fibrin, drug pre- See Table 63.1 for some common complications of vascular
cipitate, intraluminal bacteria) compared with continuous catheters.
Coeilications of Indwelling ascclar Catpeters 825
Table 63.1 Signs of and appropriate actions for phlebitis and thrombosis of vascular catheter insertion sites.
Condition Signs Action
Phlebitis Redness around site Inform clinician; consider catheter removal. If clinician elects
Heat to leave catheter in place, clean site with 2% chlorhexidine,
allow to dry, and redress with new, clean materials
Swelling
Pain on palpation of site or upon catheter flushing
Thrombosis Pain on palpation of site or upon catheter flushing
Vessel feels firm or “ropey”
Vessel appears distended without being occluded
Edema above or below site
Catheter becomes difficult to flush or aspirate
Catheter, Line, or Dressing Damage flow [25]. To reduce the risk of infiltration/extravasation, it

or Dislodgement is recommended that two thirds of the catheter length
should be within the vessel lumen.
In the event of catheter, line, or dressing complication, the
The insertion site of an intact vascular catheter should be
catheter should be unwrapped carefully. If the catheter or
re-dressed with new materials, as previously mentioned,
insertion site is wet or dirty, the site should be cleaned with
and protected from self-induced damage by using an
2% chlorhexidine scrub and allowed to air dry before being
Elizabethan collar or by wrapping more extensively and
rewrapped [8]. If air drying is impossible, the insertion site
applying a commercial anti-lick product. Commercial plas-
can be dried with sterile gauze prior to rewrapping. A wet
tic catheter guards are also available. Secure the fluid line
site should not be rewrapped, as this encourages pathogen
in such a way as to minimize pulling on the catheter itself,
growth. Before rewrapping, make sure the catheter is at the
as trauma to the vessel leads to phlebitis and thrombosis.
proper angle in relation to the vessel.
Flush and attempt to aspirate blood back from the cath-
eter while it is unwrapped to ascertain that the catheter is Edema Distal to the Catheter Insertion Site
still in the vessel. If no blood appears after aspiration, place Swelling distal to the catheter wrap usually indicates that
clean, gloved fingers just proximal to the point where the the wrap is too tight. Swelling for this reason should be
catheter tip should lie and inject saline into the catheter; if “cool” and should pit with pressure from a finger. In such
the catheter is still in the vessel one can sometimes feel a cases, remove the bandage, rewrap the site more loosely
“jet” or “stream” of fluid as it flows up the vessel (particu- with new bandage materials, and monitor. Evaluate the
larly in a vein). If no intravascular fluid stream is palpable, patient’s other limbs and its skin turgor for evidence of
watch this area closely while flushing. If the catheter tip is generalized edema, which could indicate a compromise in
in the subcutaneous space, fluid will accumulate subcuta- the patient’s vascular retention status due to low colloid
neously. Whenever flushing a catheter (wherever its tip osmotic pressure (see Chapter 58 for more details). If distal
may be), consider the size of the animal, the prescribed swelling persists despite a loosened bandage, inform the
fluid rate, and the animal’s ability to tolerate volume (and clinician, who may elect to replace the catheter.
heparin, if flushing with heparinized saline). This is espe- If the swelling distal to the catheter is warm, the skin is
cially important when working with very small animals reddened, the limb seems painful, or the swelling does not
such as toy breeds, neonates, and small mammals such as pit with pressure from a finger, it may be due to phlebitis or
ferrets. infection. The clinician should always be notified in such
If unable to ascertain whether an IV catheter is in the cases, and the catheter will likely need to be removed.
vessel, but the clinician is reluctant to remove the catheter,
it should only be used to infuse balanced, isotonic fluids.
Swelling Extending Proximal to the
Infuse slowly while observing closely for leaking or the
Insertion Site
subcutaneous accumulation of fluids. If fluids accumulate
subcutaneously, the catheter must be removed. Catheters Swelling above the insertion site often indicates phlebitis
at highest risk of infiltration/extravasation are those in or thrombosis of the vessel. The site should be unwrapped
areas of flexion, inadequately secured and/or with vessel and evaluated. If no signs other than edema are present,
thrombosis or stenosis proximal to the tip, limiting blood consider the patient’s overall hydration status as above.
However, if redness, heat, or pain is noted, phlebitis or Redness, Heat, Swelling, Pain, or Purulence at
thrombosis may be present. Signs are described in the Catheter Insertion Site
Table 63.1.
Taken together, redness, heat, swelling, and pain are signs
Phlebitis describes inflammation of a vessel wall and
of inflammation or infection although differentiating these
may be mechanical, chemical, or bacterial in origin [50,
etiologies can be difficult. Fever and/or local signs includ-
53]. It may manifest as pain, erythema, swelling, puru-
ing phlebitis do not confirm the presence of infection while
lent discharge, induration, pyrexia, and/or a palpable
catheter-related infection can occur in their absence [35,
venous cord beyond the catheter tip [50]. It may remain
55]. Only 15–25% of catheters removed due to local signs
localized to the insertion site or travel along the ves-
proved infected upon quantitative catheter-tip culture in
sel [54]. If phlebitis is present, the catheter should ide-
one human study [55]. Nonetheless, the CDC recommends
ally be removed. If vascular access is limited and the
removal of PIVCs if the patient develops signs of phlebitis,
catheter is still needed, the catheter should be flushed
infection, or a malfunctioning catheter [8]. If the doctor
while unwrapped to make sure there is no leakage at the
decides to leave the catheter in place, the site and the
site. If the site leaks when flushed the catheter must be
patient should be monitored closely and cared for in the
removed. If there is no leakage at the site, the doctor
same manner as for phlebitis, detailed above. In dogs and
should evaluate the patient and the site. If the phlebitis
cats, positive catheter-tip culture rates of 15.4–39.6% have
is minor and no signs of systemic inflammation are pre-
been reported with isolates including Enterobacter,
sent, the clinician may elect to leave the catheter in
Escherichia coli, Staphylococcus, Acinetobacter, Klebsiella,
place. At minimum, the site should be cleaned with 2%
and Pseudomonas species [35, 56]. Dextrose infusion and/
chlorhexidine scrub, air dried or dried with sterile gauze,
or corticosteroid administration have been variably associ-
and rewrapped. If phlebitis has been found, the wrapped
ated with increased risk of catheter-related infec-
site should be checked every 2 hours, unwrapped, and
tion [34, 56].
evaluated every 6–12 hours, and the patient must be
monitored closely for signs of systemic inflammation. If
infectious phlebitis is suspected, systemic antimicrobi- Oozing at the Catheter Insertion Site
als are sometimes used. If there is no improvement in
the phlebitis within one to three days, or if systemic Ascertain whether the tissue itself is oozing or whether flu-
inflammatory signs have evolved and are believed sec- ids being placed into the catheter are leaking out at the site.
ondary to the catheter, the catheter must be removed. This is done by unwrapping the catheter and flushing it
Blood cultures may be taken aseptically, one from the with sterile saline. Watch the insertion site closely for leak-
infected catheter, and at least one from a different site, to age while flushing the catheter. Tissue oozing may indicate
help confirm and diagnose a catheter-related infection infection and should be treated as such (see above). If flu-
(see Chapter 53 Protocol 53.9). ids administered are leaking, the catheter should be
Vessel thrombosis occurs with thrombus formation at removed.
the tip of or along the outer length of the catheter. A
thrombosed vessel can be painful and increases the
Complications Specific to Arterial Lines
chance of pulmonary thromboembolism. Thrombosis
varies in severity and common sense must be used when The overall complication rate for arterial catheters in dogs
deciding when to leave or remove a catheter. The location and cats has been reported as 17.2–23.7% [57, 58]. The most
and degree of edema should be considered. For instance, commonly reported complications include catheter occlu-
swelling only near the insertion site might warrant less sion and inability to flush or aspirate blood, which could
drastic action than swelling that involves a large portion result from vasospasm or thrombosis [57–59]. Ischemic
of a limb, and more severe edema may warrant catheter complications appear to be uncommon in dogs but may
removal more often than milder edema. The degree of result from arterial occlusion in the absence of sufficient
hardness or “ropiness” of the vessel should also be con- collateral circulation [59]. Particular care should be taken
sidered. Is it mild or severe, and how much of the length in the thoracic limb of the dog because the distal part of the
of the vessel is affected? Once the vessel begins to harden, median artery is the principal source of blood supply to the
a catheter may be left in for a short period of time (usually forepaw. Cats have poor collateral circulation in general. It
12–24 hours) before the condition worsens and the cath- has been recommended to avoid indwelling times of
eter needs to be pulled or ceases to function (leaking at greater than 12 hours for dorsal metatarsal arterial cathe-
site, no longer patent). If leaving a catheter in place, one ters and 24 hours for coccygeal arterial catheters in cats to
may consider massaging and wrapping the limb to inhibit minimize the risk of arterial occlusion, as subsequent
fluid retention. ischemic damage may necessitate tail or limb amputation.
Central enocs Catpeters and eriiperallly Inserted Central Catpeters 827
Central Venous Catheters and Peripherally extended periods, good hand hygiene and donning of
Inserted Central Catheters clean gloves when handling these catheters are impera-
tive. The catheter should be unwrapped and the site eval-
Indications uated at least every 48 hours if wrapped in gauze, or at
least every seven days if covered with a transparent, adhe-
Central lines may be used for the administration of intrave- sive dressing [8].
nous fluids, medications, blood products, parenteral nutri- Generally, sites are cleaned every time they are directly
tion, vasoactive medications, hemodialysis, and evaluated with a 2% chlorhexidine scrub and allowed to air
hemodynamic monitoring [60]. They can generally be dry or are dried with sterile gauze, then dressed again with
maintained for longer than PIVCs, allow repeated blood new materials. Direct site evaluation, cleansing, and re-
sampling, and are less prone to phlebitis [31]. dressing should also be done any time the area is soiled or
the site becomes exposed.
Site Preparation and Insertion The access ports of the central venous catheter are a
potential source of contamination and should be scrubbed
Central venous catheters and peripherally inserted central
with an antiseptic solution, such as 2% chlorhexidine in
catheter (PICC) lines travel to the vena cava, and because
isopropyl alcohol or 70% isopropyl alcohol prior to use [61].
they can dwell much longer than peripheral catheters, the
Use of 10% povidone-iodine is effective but slow to dry so
CDC recommends they be placed with a more stringent
may not be practical [64]. All access ports should be kept
aseptic technique than is necessary for PIVCs [8]. During
covered with caps [8, 61, 65]. No advantage of heparinized
central venous catheter or PICC insertion, the operator
saline over normal saline was demonstrated in maintain-
should don a sterile gown, sterile gloves, cap, and mask,
ing catheter patency in a population of healthy dogs with
and a large sterile drape should be used to create a sterile
central venous catheters [66].
field. Skin insertion site preparation is the same as for
Catheters should be removed as soon as they are no
peripheral venous and arterial catheters, although a gener-
longer necessary but there are no standard recommenda-
ous margin of fur should be clipped. Increased infection
tions regarding timelines [32, 60, 61]. Longer dwell time
rates have been variably associated with the number of
and administration of irritant medications have been asso-
central catheter lumens [61, 62]. Guidelines recommend
ciated with increased risk of complications in dogs and
using a catheter with the minimum number of ports or
cats [67]. Conversely, a study of hemodialysis catheters in
lumens essential for patient management [8, 61].
dogs found no difference in the prevalence of infection
Ultrasound guidance is frequently used in people to avoid
according to age, sex, reason for hemodialysis, catheter
numerous insertion attempts and can be very useful in small
complications, duration of catheterization, or out-
animal patients where catheter insertion is proving difficult.
come [68]. Routine replacement of catheters in people has
Central venous catheters are sutured to the surrounding skin
actually been shown to increase the incidence of infection
to prevent accidental dislodgement. While suture is a secure
at insertion sites and is not recommended [60].
way to keep catheters in place, it does increase the potential for
Catheter insertion sites should be assessed for signs of
localized skin infections and can be uncomfortable [61].
infection or migration daily [8]. The site should be checked
Attention should be paid to ensuring sutures are not too tight
for any redness, swelling, leakage of administered fluids, or
and do not cause kinking or occlusion of the catheter.
oozing. The area around the insertion site should be gently
palpated for any signs of pain or hardening of the vessel.
Dressing The area should also be checked for excessive warmth. If
The central venous catheter insertion site should be covered any of these signs are present, the clinician should be noti-
with either sterile gauze or a sterile, transparent dressing fied and the situation addressed.
(semipermeable to avoid moisture trapping) [8, 60]. The use
of antibacterial preparations on the site after insertion is not Complications
routinely recommended because of their potential to pro-
mote fungal infections and antimicrobial resistance [8, 60, Some risks related to central venous catheter insertion
63]. Hemodialysis catheters may be an exception to this rule. include infection, accidental arterial puncture, vein lacera-
tion, thrombosis, pneumomediastinum, and catheter mis-
placement [32]. The most common complications reported
Care and Maintenance
in dogs and cats include mechanical obstruction, skin irri-
A central catheter should be maintained in much the tation, malposition, and inflammation [67]. The risk of
same manner as a peripheral catheter. Since these cathe- colonization increases with catheter duration [61].
ters are accessed frequently and are expected to dwell for However, it is recommended that a catheter should not be
removed based solely on the presence of fever [60]. Other Maintenance

noninfectious causes of fever should be considered, and
IO catheters usually dwell for only a short period of time
other evidence of infection should be sought before replac-
(three to four hours), until direct venous access is achieved.
ing an existing catheter [8].
If left in for an extended period, they should be maintained
If a malfunctioning catheter must be replaced, then
in much the same manner as an IV catheter. Hand hygiene
exchange over a guidewire is an option [61]. However, in a
should be performed, and clean examination gloves worn
systematic review of catheter replacements in people, cath-
every time the catheter is handled. Standard practice is to
eters exchanged over a guidewire were found to have a
flush the IO catheter with a small volume of heparinized or
higher rate of colonization, exit-site infection, and catheter-
plain saline every six hours. Rewrapping an IO catheter is
related bacteremia than those placed at a new site [69].
not always feasible. There may be cases in which the
Therefore, in the setting of infection, replacement at a new
patient is too small, too young, or too critical to make rou-
site is preferred. There are small, nonrandomized studies
tine rewrapping possible. Once again, common sense must
suggesting that, in difficult circumstances where obtaining
be used to decide what is best for the patient. An IO cathe-
access is difficult or may lead to further long-term compli-
ter should be left in place for no longer than 48 hours [79].
cations (such as in hemodialysis patients), exchange over a
guidewire may be considered [61].
As with PIVCs, having protocols in place for decision Complications of Intraosseous Catheters
making regarding management of central venous catheters As with all indwelling devices, IO catheters carry some
has been shown to significantly decrease the rate of risks including extravasation, air embolism, skin abscessa-
infection [70]. tion, and osteomyelitis. However, infection is rare with
adherence to aseptic placement and care of the site and
catheter [71, 79].
Intraosseous Catheter Insertion Sites
Fluid Extravasation
The intraosseous (IO) catheter is a life-saving device, pro- Extravasation of fluid may be the most common complica-
viding access to a noncollapsible venous complex in emer- tion of IO catheters. This usually occurs when the needle is
gency situations where peripheral access cannot be misplaced upon insertion, either because the catheter does
achieved [71]. It is particularly useful for small, hypov- not penetrate fully through the cortex and into the medul-
olemic, and neonatal patients where PIVC placement may lary cavity or because it has passed out of the bone’s
be very difficult and may be more efficient than a venous medulla and through the far cortex, into the muscle. Fluid
cutdown [72]. IO catheters can be used for infusion of extravasation can also occur when the patient moves exces-
drugs, fluids, and blood products [73]. IO access for drug sively after proper placement of the IO catheter. When
administration during cardiopulmonary resusciation when hypertonic fluids or caustic medications extravasate, mus-
IV access cannot be attained is recommended over tracheal cle necrosis can occur.
administration of epinephrine in people [74, 75]. IO cath- There are a few ways to confirm an IO catheter’s position.
eters can also be used for blood sampling although certain When the IO catheter is properly positioned, it should flush
parameters such as potassium and glucose may not be easily with little resistance. Radiographic imaging shows
accurate and samples must be drawn prior to drug or fluid the catheter’s placement as well. If administered drugs or
administration [76, 77]. fluids leak at the site, one should suspect the catheter is not
properly seated, and it should be removed. Replacing the IO
Insertion catheter in the same site is not recommended, as fluid may
escape from the defect left by the first catheter. For the same
IO catheter insertion site preparation is the same as for reason, it is not recommended to make more than one
peripheral venous and arterial catheters, though sterile attempt at the same site when placing the IO catheter.
gloves should be worn. The femur and humerus are readily
accessible and allowed the highest IO flow rates in dogs in Compartment Syndrome
one study [78]. Once placed, the catheter should be secured Compartment syndrome occurs when fluids extravasate
by wrapping a tape butterfly around the hub and suturing from an IO site for an extended period of time. When a
the butterfly to the skin or periosteum. Some IO catheters large volume of fluid leaks into the muscle, a pocket is
come with their own permanent butterflies. If possible, the formed within the muscle, which can cause muscle necro-
secured catheter should be protected by an outer bandage. sis. It is recommended that there be no repeated attempts
For more detail on placing and securing an IO catheter, see in the same bone if the first IO catheterization fails.
Chapter 7. Another site should be chosen, as fluid will sometimes leak
eiprostoely cue Insertion Site aintenance 829
from the hole made on the first attempt. The best way to Any animal with a thoracostomy tube requires constant
prevent compartment syndrome is to monitor the catheter monitoring and an Elizabethan collar. No matter how closely
site and associated limb closely, and if any swelling appears, watched, some animals still manage to open or remove their
remove the catheter immediately. tubes, and sometimes tubes can migrate out of the thorax
and into the subcutaneous space just through the movement
Infection and Osteomyelitis of the animal’s body. Thus, respiratory rate and effort should
Localized site infection or osteomyelitis occurs rarely, par- be watched closely and the chest auscultated frequently
ticularly if the IO catheter is removed after only a few (every two to four hours). Care should be taken to ensure
hours [72]. Infection most often occurs when proper asep- that the tube is not accidentally pulled upon, as this can
tic technique was not followed during insertion. The IO cause inflammation of the pleura and the insertion site.
catheter should be removed if signs of infection are pre-
sent; systemic antimicrobials are usually indicated.
Nephrostomy Tube Insertion
Site Maintenance
Thoracostomy Tube Insertion
Site Maintenance The collecting tip of a nephrostomy tube is placed within
the renal pelvis and the tube travels through the body wall
Great care must be taken to keep the insertion site of a with its egress end outside the skin. The draining end of
thoracostomy tube healthy. Having to remove a tube due to the tube is outside of the animal, attached to a sterile,
infection, or having the tube migrate out of the pleural closed urinary collection system. Keeping the insertion site
space due to breakdown of the tissue at the site due to infec- clean helps to decrease pathogen introduction into the ret-
tion, can greatly compromise the patient. Care must also be roperitoneal space and the kidney. The bandaged tube
taken not to introduce bacteria into the pleural space. should be evaluated every two hours, checking for any wet-
Prior to contacting the thoracostomy tube or insertion site, ness, and making sure that the bandage and tube are still
hands should be cleaned using good hand hygiene practice wrapped in the proper position. At the author’s institution,
as described in Chapter 62. Clean examination gloves should the site is unwrapped and evaluated every 8–12 hours.
be worn any time the site or tube system is handled. The Whereas most indwelling devices are situated in a fairly
insertion site should be kept clean and dressed. Although large space such as the pleural space, or a lumen as with a
specific, evidence-based recommendations are unavailable, central line or a feeding tube, the nephrostomy tube is
the site should probably be unwrapped, evaluated, and placed inside a tiny space within a delicate organ. Therefore,
redressed at least as often as a vascular catheter insertion it is vital that there be no tugging or pulling of the tube by
site, so at least every 24 hours if no obvious complications handlers or the animal. The tubes are usually long enough
are present. The site should be covered with a sterile, nonad- to allow them to be curled several times before being
herent pad before bandaging. Self-adherent, transparent wrapped closely to the body. A “butterfly” can be made of
bandages can be used in place of the nonadherent pad and tape wrapped around the tube and then sutured to a stocki-
are preferable in smaller animals where a bulky wrap would nette, which is worn by the patient, or, if the surgeon
be uncomfortable. A body stockinette can be placed to fur- chooses, sutured directly to the patient. Most cats and
ther cover the site, and the tube itself can then be fastened to small dogs seem to prefer the stockinette to a bandage
the stockinette with tape and suture, or plastic clamps. wrap. A sterile, transparent, self-adherent bandage works
It can be very challenging to keep a thoracostomy tube well over the site. The stockinette provides a clean covering
site properly bandaged. Large, deep-chested dogs are espe- and takes the brunt of any pulling that may occur. Enough
cially difficult because of their body conformation. It may slack must be left in the tube so that when the stockinette
help to crisscross the bandage across the dog’s chest. is pulled, it does not affect the site. If a bandage wrap is
Howver, when a patient is mobile, all attempts at keeping used, the excess tubing can be curled and incorporated in
the site covered sometimes fail. One solution is to cover the the wrap so any tugging will not disturb the tube site. An
site with a sterile, self-adherent bandage. A clean T-shirt is Elizabethan collar should be used, and the animal watched
then put on the dog and tied to a close on top of the dog’s closely.
back. A hole is cut in the shirt and the thoracostomy tube is In addition to monitoring the site for signs of infection,
passed through the hole and clamped to the T-shirt. This the nephrostomy tube site should be watched for leakage.
method works well to keep the site covered and helps to While this could imply infection, it could also indicate ret-
stabilize the tube from excessive movement. This would roperitoneal urine leakage. If effusion is noted from the
not be suitable for a dog attached to a continuous suction insertion site, a doctor should be alerted immediately so
device, in which case a more stabilizing wrap is needed. that uroretroperitoneum can be ruled out.
Another complication of the nephrostomy tube is the blood count, serum biochemistry, abdominal ultrasound,
tube becoming clogged with mineral material or debris. and urine culture will help inform management of such
Once approved by the clinician, gentle aspiration and ret- complications. Following removal of the tube, the stoma is
ropulsion can be attempted. If this is not successful, imag- expected to granulate closed in three to five days.
ing may be necessary to determine the cause of the
occlusion, and tube removal may be necessary.
Surgical Drain Insertion Site Maintenance
Cystostomy Insertion Site Maintenance Closed-Suction Drain Insertion Sites
A cystostomy tube allows drainage of urine in dogs and cats Jackson-Pratt and other closed-suction drains are typically
with urinary outflow obstruction or dysfunction. An example placed in the abdomen to drain peritoneal effusion postop-
of a cystostomy tube candidate would be a cat with neuro- eratively. They can also be used to drain effusion from the
logic damage secondary to sacrococcygeal (“tail-pull”) injury subcutaneous space postoperatively in cases where excessive
that may regain bladder function within days to weeks [80]. fluid production is expected. These systems consist of a surgi-
The tip of a Foley catheter, mushroom-tipped catheter, or cal drainage tube placed inside the body, which attaches to
low-profile gastrostomy tube is placed within the urinary thin rubber tubing that passes through the body wall to the
bladder and the tube exits the abdominal wall via a stab inci- outside and is then attached to a rubber squeeze bulb (in the
sion. Low-profile systems usually have an exterior button or case of Jackson-Pratt drains) or other suction device. When
flange that sits flush with the skin. When a long tube is used, squeezed and then closed, the Jackson-Pratt bulb creates suc-
it is secured to the skin with a finger-trap suture and may be tion, which draws fluid into the bulb where it is collected
connected to a sterile, closed-collection system for continu- (Chapter 41).
ous urine drainage. The tube can be capped and urine emp- Closed-suction drain insertion sites should be kept clean,
tied intermittently (three to four times daily), which also dry, and covered. The site should be covered with a nonad-
allows observation for normal urination. Animals may be herent pad or a sterile, self-adherent bandage and then
discharged with the tube in place and owners taught how to wrapped. The bandaged site should be checked every two
use it at home. Cystostomy tubes may even be maintained for hours, and the bandage should be dry. At the author’s insti-
several years in some cases. Beck et al. reported an overall tution, the site is unwrapped and evaluated every 8–12 hours.
complication rate of 49% [81]. Major complications included Insertion sites into the cranial abdomen are fairly easy to
inadvertent removal of the tube or displacement from the keep covered. Insertion sites into the inguinal area are
bladder (which could lead to uroperitoneum), patient chew- more difficult. The variations in the size and shape of the
ing of the tube, breakage of the tip of the catheter during many breeds of dog make it necessary to be creative with
removal, and fistula formation following tube removal. Other the bandage material. It is often necessary to rewrap these
complications included irritation or inflammation around sites often, as bandages seem to slide off of them easily. The
the tube exit site, urine leakage around the tube, bandage bandage may sometimes become soiled with urine or feces,
complications, and breakage of the suture securing the tube which can wick up toward the insertion site. If urine or
to the skin. Urinary tract infections are also common and bio- feces would not come into contact with the insertion site
film formation may complicate this. However, prophylactic without the wrap acting as a wick, it may be better to forgo
antimicrobials should not be administered. the wrap and use only a sterile, self-adherent bandage.
It has been recommended that cystostomy tubes should The tubing of the Jackson-Pratt drain is long and can be
be left in place for a minimum of 14 days to allow a stoma curled and then wrapped into the bandage material, with
to form between the urinary bladder and the body wall [82]. slack enough between the site and the wrapped portion of
The risk of dislodgement can be reduced by keeping the tubing that the weight of the bulb will not pull on the site.
tube properly secured and careful handling to avoid unnec- The bulb itself can also be taped or otherwise affixed to the
essary traction. Low-profile tubes have an advantage here, bandage. In cases where the site is only covered with a ster-
as they do not protrude from the body. ile, self-adherent bandage, a clean T-shirt can be worn by
The stoma site should be examined and cleaned daily the patient, brought to the top of the back, and tied. The
and kept covered with a sterile dressing. Clean gloves drain is passed through a hole cut in the shirt and attached
should be worn when handling the tube. Long tubing can to the shirt with a plastic clamp. A stockinette can be used
be secured using a light bandage, stockinette, or T-shirt. in place of the T-shirt in smaller animals.
Ascending infection could lead to pyelonephritis or peri- The drain insertion site should be monitored for infec-
tonitis and animals should be monitored closely for fever, tion, and treated accordingly, as stated earlier in this chap-
abdominal pain, changes in urine character and inflamma- ter for other sites. When a site is inflamed, it may allow
tion, swelling, or discharge from the stoma site. Complete effusion to leak out at the site. If the drain is to be left in,
eeding cue Insertion Sites 831
some sterile gauze sponges should be added to the wrap to authors’ institution to supplement analgesia following
absorb the fluid. In cases where it is not physically possible limb amputation, large mass removal, and thoracotomy.
to keep a bandage on, care should be taken to keep the site The catheter tip is usually located in the deepest part of the
and area around the site as clean and dry as possible. Fluid incision and care must be taken to ensure all fenestrations
should be gently and aseptically wiped from the site, taking are below the skin surface.
care to wipe in motions away from the site and not toward Commercial catheters may have a butterfly attachment
it. A 2% chlorhexidine scrub should be used to clean the that can be sutured to the skin, or the tube may be secured
area. The area should be allowed to air dry if possible or be using a finger-trap suture. Potential complications include
dried with sterile gauze. If the animal is recumbent, the lidocaine or bupivacaine toxicosis, infection, hematoma
limbs can be propped apart with clean towels to aid in formation, and nerve damage secondary to intraneural
keeping the area dry. Also, if the animal is recumbent, ster- infusion [84]. Accidental intravascular injection is also
ile gauze can be placed around the site without an outer possible and could lead to serious adverse consequences.
wrap. Good hand hygiene as described in Chapter 62 Clear labeling of catheters and medications is strongly rec-
should be employed any time the site or the drain itself is ommended to avoid this. Catheters should be kept covered
handled, and clean examination gloves worn. with a sterile dressing and handled using clean gloves.
Care should be taken to ensure that the tubing does not Wound infusion catheters are generally removed after one
become kinked, preventing suction. The bulb should be to three days, or sooner if complications are encountered.
kept empty of air and fluid to ensure adequate suction.
Fluid should be emptied from the drain as often as needed,
and fluid volumes recorded in the patient treatment sheet. Feeding Tube Insertion Sites
Nasoesophageal and Nasogastric Tube

Penrose Drain Insertion Sites
Insertion Sites
The Penrose drain is a passive drain. It consists of a simple
Nasoesophageal (NE) tubes enter the nares and terminate
rubber tube placed in a wound or incision to drain fluid
in the esophagus; nasogastric (NG) tubes terminate in the
from the site out of the animal. This helps to prevent infec-
stomach. The tube is generally secured with a sutured or
tion, and also aids in patient comfort.
stapled tape “butterfly” or finger-trap suture just caudal to
The Penrose drain site is a messy site, with fluid draining
the nostril and then again into the cheek of the animal. The
out freely and being caught only by any bandage material.
nostril housing the tube should be monitored for signs of
If present, the external bandage should be checked every
inflammation or infection such as pain or exudate, and
two hours for strikethrough. When strikethrough is pre-
treated accordingly.
sent the bandage should be removed and the site exam-
There is risk of the tube leaving the esophagus and enter-
ined, cleaned with 2% chlorhexidine, dried with sterile
ing the trachea; while such migration is rare, this complica-
gauze, and redressed. At the author’s institution, if there is
tion has dire consequences. At placement, the tube should
no strikethrough present, the site is examined, cleaned,
be measured, and a note made in the record as to how
and rebandaged every eight hours.
much tubing is external. Every time the tube is used, exter-
Care should be taken to prevent the animal licking or
nal placement should be checked to ensure the tube has
chewing the drain or site. This is best achieved with an
not migrated. The sutures should all be in place and the
Elizabethan collar.
tube seated securely with no slippage visible. The tube
should be aspirated and negative pressure achieved if the
tube is in the esophagus; negative pressure or gastric fluid
Postoperative Wound Infusion
if the tube is in the stomach. If gas is aspirated, a radio-
Catheter Maintenance graph should be taken to check tube placement before any-
thing is instilled into the tube. Animals with NE or NG
A wound infusion catheter (also known as a “soaker” cath-
tubes should always wear an Elizabethan collar.
eter) delivers local analgesia to a surgical site via intermit-
tent or continuous infusion of local anesthetic agents.
Esophagostomy, Percutaneous, Endoscopically-Placed
Commercial wound infusion catheters are available or can
Gastric and Jejunostomy Tube Insertion Sites
be fashioned from red rubber or polyurethane catheters.
They are pliable and have multiple fenestrations to allow The insertion sites of these devices should be evaluated at
diffusion of the infused solution along the entire wound least once daily. The site should be covered with a sterile,
bed [83]. They are usually capped for intermittent infusion non-adherent pad or a sterile, self-adherent bandage, and
or can be attached to an intravenous administration set for wrapped with clean, soft bandage material. The animal
continuous infusion. They are most commonly used in the should always wear an Elizabethan collar and the wrap
should be substantial enough to protect the site and tube in Epidural Catheter Insertion Sites
the event that the animal escapes or evades the collar.
Esophagostomy tubes are especially vulnerable to clawing. Epidural catheters are often placed in cases in which pain
In addition to monitoring for infection, it is imperative management is expected to be difficult (Chapter 49).
that the device’s proper placement is evaluated, as much as These catheters must be placed aseptically and main-
can be determined from the insertion site. Feeding tubes tained with stringent aseptic technique. After placement,
can migrate due to breakdown of the site, or tugging or povidone-iodine can be applied to the area around the site
pulling by the animal. If the tube is displaced, food may with sterile iodine-soaked swabs. Sterile gauze sponges
end up in the airways, the peritoneal cavity, or the subcuta- can be placed under the injection cap, both to aid in keep-
neous space. It is impossible to ascertain whether the ing the catheter laying evenly along the animal’s back,
device is placed properly just from evaluation of the inser- and to absorb any leaking fluid. The site should be cov-
tion site, but a healthy insertion site supports that assump- ered with a clear, sterile, self-adherent bandage. It is not
tion. All feeding tubes should be checked for negative recommended to unwrap an epidural catheter, so the
pressure or reflux to ensure proper placement prior to feed- clear bandage allows for visual site evaluation every few
ing through the tube. The tube should be marked in some hours. It is not unusual to note clear fluid leaking from
way so that tube migration can be assessed. The site should the site. This is one reason to place sterile gauze sponges
also be checked for leakage of food or other fluid. If any beneath the epidural catheter. If any colored fluid, swell-
food or fluid leaks from the site, the feeding should be ing, or other signs of inflammation are seen, a doctor
stopped immediately and a clinician notified. should evaluate the site immediately. If any sign of infec-
These types of feeding tubes generally remain functional tion is seen, the catheter should be removed.
for extended periods of time (up to months) and can be main- To avoid introducing bacteria into the epidural space, the
tained and used by the owner at home if they are properly injection cap to the catheter should be scrubbed with a 2%
educated in the care of the tube. Because of the length of time solution of chlorhexidine and a gauze sponge soaked in 2%
that the tube remains in the patient, a moist dermatitis some- chlorhexidine placed over it for a full three minutes prior to
times develops. If the tube and sutures are all securely in place being punctured with a sterile needle. Proper hand hygiene
it may help to leave the site unwrapped for 15–20minutes should be followed, as stated above, and sterile gloves must
after each cleaning and drying. The animal should be held be worn when using this device.
during this time to ensure that it does not remove the tube. Extreme care should be taken to not displace the cathe-
In the author’s experience, minor infections of enteral ter. Although rare, epidural hematomas, epidural abscesses,
feeding tube insertion sites can often be successfully treated and arachnoiditis are possible complications. There is a
by frequent (two to three times a day) cleaning and rewrap- limit to the volume that can be injected into an epidural
ping. Systemic antimicrobial therapy may be considered. catheter. The doctor’s orders should be specific as to
These patients should be closely monitored by a doctor. that volume.
An infected, soiled, or exposed site should be cleaned
with a 2% chlorhexidine solution, allowed to air dry or
dried with sterile gauze, and rewrapped with new, clean Summary
material. If the tissue at the site is oozing, sterile gauze can
be placed over the site to absorb the fluid. It is important to The importance of properly caring for the insertion sites of
keep the site as dry as possible. If the site is red and indwelling devices cannot be overstated. Most insertion
inflamed, but not oozing fluid or overly moist, povidone sites will remain healthy and the device functional for as
iodine may be helpful in eliminating the infection. In gen- long as needed if well maintained. Paying close attention to
eral, it is not recommended to use iodine or triple antibiotic the site can greatly reduce the incidence of infection and
ointment on these sites, as the excess moisture promotes other complications.
the growth of certain pathogens.
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64
Antiseptics, Disinfectants, and Sterilization

Samantha Jones, Krystle Reagan, and Nicole Saunders
Proper hygiene within a veterinary clinic is critical to surgical implants, or other invasive devices. Several meth-
decreasing the risk of hospital-acquired infections (HAIs). ods of sterilization are used in the veterinary setting,
Understanding the principles of proper cleaning, antisep- including gas, pressure, and chemical sterilization.
sis, disinfection, and sterilization is essential for the devel- This chapter focuses on the properties of individual anti-
opment of hygiene protocols that are the pillar of infection septics, disinfectants, and sterilization procedures. Proper
control programs in veterinary hospitals. In a five-year selection and use of these chemicals and methods are cru-
period, over 80% of veterinary teaching hospitals reported cial to aid in the prevention of HAIs, whether the patient is
the outbreak of an HAI. This finding underscores the need undergoing a surgical procedure, has an indwelling device,
for infection control programs and impeccable hygiene to is being mechanically ventilated, or is simply hospitalized.
improve patient health. See Chapter 62 for an expanded discussion of other precau-
Hygiene is a concept that encompasses several different tions against HAI.
terms. Cleaning refers to the mechanical process of remov-
ing organic material with soap and water and is an indis-
pensable first step prior to antisepsis, disinfection, or Antiseptics
sterilization. When these techniques are used properly,
they can decrease the risk of HAI; however, when per- An antiseptic is a chemical agent or substance that kills or
formed incorrectly or inconsistently, microorganisms can prevents the growth of microorganisms on living tissue
persist on surfaces or in the environment and can pose a through topical application. A variety of different antisep-
threat to patient safety. In this chapter, we discuss the most tics are available for use in veterinary medicine. Each has
common methods of achieving antisepsis, disinfection, advantages and disadvantages, and none is effective against
and sterilization within a veterinary hospital. all organisms (Table 64.1). Commonly used antiseptics
Antiseptics and disinfectants are antimicrobial agents include alcohol, iodophors, and chlorhexidine.
that act to decrease the microbial burden, while steriliza- Many antiseptics are available as aqueous solutions;
tion completely eradicates microorganisms. Antiseptics are some are also available as scrubs, which are detergents or
applied to the surface of living tissue to decrease the micro- soaps. Detergents and soaps are irritating and cytotoxic,
bial burden, while disinfectants are applied to inanimate and thus should only be used on intact skin, and should
objects to perform the same action. Antiseptics and disin- never contact mucous membranes or subcutaneous tis-
fectants typically have a broad range of biologic activity sues. Product labels must always be consulted for proper
depending on the chemical structure, and some will have mixing and diluting instructions. Over- or underdiluting
activity against bacterial spores. There is a wide variety of the product can result in poor efficacy or exacerbation of
antiseptics and disinfectants available, and it is critical that skin irritation and toxicity, respectively.
instructions regarding dilution and contact time are Antiseptics are often used to clean the hands of person-
adhered to for maximal effect. nel or to decrease the microbial burden on a region of a
Sterilization refers to the process by which there is the patient. It is important to ensure antiseptic techniques are
complete eradication of microorganisms, and typically practiced during the placement and management of intra-
refers to inanimate objects such as surgical instruments, vascular devices, urinary catheters, and feeding tubes, and
838 Antiseptics, Disinfectants, and Sterilization
Table 64.1 Commonly used antiseptics.
Antiseptic Spectrum of activity Ineffective activity Residual activity Decreased effectiveness
Alcohol Bacteria, nonenveloped viruses, Variable enveloped viruses, no None Organic material
some fungi, mycobacteria spores
Chlorhexidine Gram-positive bacteria, some Variable Gram-negative bacteria, 4–6 hours, Organic material
(biguanide) Gram-negative bacteria, variable enveloped viruses, no occasionally up
nonenveloped viruses, fungi, mycobacteria, no spores to 2 days
mold, yeast
Povidone-iodine Bacteria, enveloped viruses, Variable enveloped viruses, no Up to Organic material,
(iodophores) fungi, yeast, mycobacteria spores 4–6 hours alcohol
during any sterile procedure. Contamination from sources Bisguanides have a lower incidence of causing allergic
within the hospital including surfaces, equipment, person- reactions and skin irritation, and are less cytotoxic than
nel, and the patient itself can lead to an HAI. Proper use of iodine-based solutions; however, prolonged skin contact
antiseptics to personnel and the patient can help to reduce with concentrations of greater than 0.5% may be harmful
these risks. and may impair fibroblast activity.
Chlorhexidine should never come in contact with eye tis-
sue as it is toxic to eyes and should only be used in ears
Alcohol
when the tympanic membrane is intact. Chlorhexidine is
Alcohol is a commonly used product in the veterinary set- considered effective against most Gram-positive bacteria,
ting as both an antiseptic and a disinfectant. The most some Gram-negative bacteria, including Escherichia coli
effective forms are ethyl and 70% isopropyl alcohol. Within and Pseudomonas aeruginosa, mold, yeast, and many
two minutes 90% kill is expected, although effective kill of viruses. It has variable activity against many Gram-negative
many bacteria occurs within 10 seconds of sustained expo- bacteria and enveloped viruses and is ineffective against
sure. Its main mechanism is denaturing proteins and dis- rabies virus. Chlorhexidine is ineffective against bacterial
rupting metabolic function. This causes precipitation of spores and mycobacteria. When using chlorhexidine as
cell proteins and cell lysis. Alcohol may also help to part of aseptic preparation, it is suggested that there is an
enhance the effectiveness of other antiseptics by contribut- approximately 90% kill within 30 seconds of contact time,
ing to fat solubilization. It has variable effectiveness against and although a preparation time of five to seven minutes is
bacterial spores, and it is not effective in inactivating rabies recommended, it is possible that two 30 second prepara-
virus. However, it is effective against most Gram-positive tions are sufficient. Owing to the keratin-binding proper-
and -negative bacteria, some fungi, and some enveloped ties of chlorhexidine, contact time may be a lesser issue
viruses. Alcohol rapidly evaporates, so it leaves no residual than with other antiseptics. It has immediate antimicrobial
effects and extended exposure is needed for maximum effi- effects and lasting residual effects when used as a wound
cacy. A quick swipe of alcohol on an animal’s skin prior to lavage, and is generally not negatively impacted by the
venipuncture is minimally effective in antisepsis. It is presence of alcohol, soaps, or lavage fluids. The effective-
important to note the flammable nature of alcohol and to ness of chlorhexidine may be interfered with by a moderate
exercise extreme caution when using certain equipment amount of organic material present. As chlorhexidine’s
like cautery and lasers. activity is pH-dependent, it is more soluble and more effec-
tive at a lower pH.
Chlorhexidine
Iodophors
When attempting antiseptic skin preparation for sterile
procedures, such as catheter and feeding tube placements, Povidone-iodine is the most commonly used iodophor in
a 2% chlorhexidine solution is the product of choice over veterinary medicine and is usually used as a scrub or solu-
70% alcohol or povidone-iodine. Chlorhexidine is the most tion commonly known as Betadine® (Purdue Frederick
commonly used bisguanide antiseptic in veterinary medi- Company, Stamford, CT), which is a 10% povidone-iodine
cine. Bisguanides work by disrupting the cell wall by bind- formulation. Cadexomer iodine is available as an ointment
ing with proteins within the wall. This, in turn, causes or dressing. Iodophors contain polymerized iodine so the
leakage and precipitation of the cell contents. There are free iodine is slowly released, with the goal of minimizing
both scrub and aqueous solution forms of this product. tissue irritation and enhancing the delivery of iodine to the
Disinfectants 839
tissues. The iodine penetrates the cell wall where it causes predispose some to delayed wound healing in cases with
oxidation of the intracellular contents and replaces micro- underlying conditions or chronic wounds requiring
bial contents with iodine. It has a broad spectrum of activ- repeated contact. Iodophors are more irritating to the skin
ity against Gram-positive and -negative bacteria, fungi, than bisguanides and can cause contact dermatitis and
enveloped viruses, yeast, and mycobacteria. It is consid- pruritus at concentrations as low as 0.1%.
ered ineffective against bacterial spores and nonenveloped Tincture of iodine is a commercially available solution of
viruses. Approximately 90% kill is expected within 30 sec- 2% iodine in 50% ethyl alcohol and is intended for use on
onds of contact time although a minimum of two minutes intact skin only.
of contact time is advised and a five- to seven-minute scrub
time is recommended. Povidone-iodine has a very rapid
onset of activity and up to four to six hours of residual Disinfectants
activity. It is inactivated by the presence of blood, plasma,
and organic material, so the presence of any of these sub- Hospital surface disinfection, or removal of most of the
stances rapidly diminishes activity. Alternating povidone- microbes from a surface, is paramount in preventing the
iodine with alcohol is not advised and can decrease the spread of infectious disease, as many bacteria, fungi, and
effectiveness of the iodine by decreasing the contact time viruses can persist in the hospital environment.
of the povidone-iodine with the skin. The presence of alco- Nonenveloped viruses, such as parvovirus, and microor-
hol and other detergents decreases the effectiveness of ganisms that sporulate can pose a particular challenge, and
povidone-iodine. Alcohol-based iodophors, however, have surface disinfection products must be applied properly to
been shown to decrease central venous catheter coloniza- be effective. Disinfectants are chemicals that reduce the
tion when compared with aqueous solutions. microorganisms present on inanimate objects but do not
The stock solution of povidone-iodine is usually 10%. completely eradicate them. Many of the antiseptic agents
Dilution of one part stock solution and nine parts water discussed above can be used as disinfectants, but the
creates the commonly used 1% solution (Protocol 64.1). inverse is not necessarily true. Disinfectants are often cyto-
Either water or an electrolyte solution can be used to dilute toxic to living tissue, therefore cannot be used as antisep-
the stock solution. Dilution both increases the bactericidal tics. A wide variety of chemical disinfectants are available,
activity and decreases the cytotoxicity, although even at and each has a different spectrum of action against patho-
concentrations of 0.5% povidone-iodine can impair tissue gens. Factors that determine the spectrum of action include
fibroblast proliferation. At concentrations greater than the chemical makeup, concentration, and the surface to
0.05% povidone-iodine can impair lymphocyte blastogene- which the disinfectant is applied (i.e. presence of organic
sis and granulocyte and monocyte viability and migration. material or biofilms). It is critical that manufacturers’ rec-
Given that the most commonly used solution in practice is ommendations are used when applying disinfectants
1%, it should be kept in mind that at this concentration including dilution and surface contact time.
there may be adverse effects. These effects do not appear to Disinfectants should be applied to surfaces after patients
be clinically relevant in most patients, but it may have been in contact with them, including exam room sur-
faces and cages. They should also be used on any medical
equipment that comes into contact with patients such as
Protocol 64.1 Formulating a 1% Povidone-Iodine stethoscopes. The most commonly used disinfectants are
Solution further described here (Table 64.2).
Items Required
Aldehydes
● Povidone-iodine stock solution (stock povidone-
iodine solution is 10%) The aldehydes include formaldehyde and glutaraldehyde,
● Water or electrolyte solution which can be used as disinfectants. Glutaraldehyde, when
used at a concentration of 2.4% and proper contact time, is
Procedure considered a high-level disinfectant or chemical sterilant.
Because of this property, glutaraldehyde can be used for
● To make 250 ml total volume, add 25 ml of 10%
equipment that requires sterilization, but cannot be placed
solution to 225 ml of water.
into an autoclave, such as endoscopes. Glutaraldehyde pro-
● To make 500 ml total volume, add 50 ml of 10%
vides broad-spectrum disinfection and is relatively noncor-
solution to 450 ml of water.
rosive, and has good activity in the presence of organic
● Solution can be made using water or an electrolyte
material. Glutaraldehyde is toxic and will cause irritation
solution.
to mucous membranes. Orthophthalaldehyde is also used
Table 64.2 Commonly used disinfectants.
Antiseptic Spectrum of activity Disadvantages Decreased effectiveness
Aldehydes Broad spectrum, bacterial spores Irritant to skin N/A

Halogens/ Broad spectrum, bacterial spores Inactivated readily with organic material Organic material,
hypochlorites and soaps. Irritant and corrosive detergents/soaps
Oxidizing agents Broad spectrum Corrosive N/A
Phenols Broad spectrum Irritant, toxic to cats N/A
Quaternary Gram-positive, enveloped viruses. Inactivated with Organic material, hard
ammoniums Variable for Gram-negative water, soaps/detergents,
bacteria, fungi, and protozoa cotton, iodine, rubber
N/A, not applicable.
for high-level disinfection, is less irritating to mucous occurs, approximately 10 minutes of contact time ensures
membranes, and requires shorter contact times, so is the destruction of most microorganisms. Bleach is unsta-
favored over glutaraldehyde. ble in solution and deteriorates rapidly, a process that is
hastened with exposure to metal, high temperatures, light,
and acid. Because of this instability, the solution should be
Halogens/Hypochlorites
made up immediately prior to use and any remaining solu-
Sodium hypochlorite (household bleach) is an alkali that tion should be discarded.
when mixed with an acid releases free chloride and oxy-
gen. The chloride combines with water to form hypochlo-
Oxidizing Agents
rous acid. It oxidizes and inactivates bacterial membranes
and cytoplasmic enzyme systems, kills bacteria, and liq- Hydrogen peroxide (H2O2) is a commonly used, foaming
uefies necrotic tissue. It has a broad spectrum of activity wound irrigant that dislodges bacteria and debris by
against Gram-positive and -negative bacteria, mycobacte- effervescence. It releases oxygen, which causes lipid per-
ria, spores, fungi, enveloped and nonenveloped viruses, oxidation of cell walls. At the high concentrations com-
and protozoa except for Cryptosporidium. It is also effec- monly found in disinfectants it is effective against
tive against biofilms. It has diminished activity in the Gram-positive and -negative bacteria, mycobacteria,
presence of organic material and cationic detergents. It is fungi, enveloped and nonenveloped viruses, and proto-
corrosive and cytotoxic with a detrimental impact on neu- zoa; is variably effective against fungi, and is a good
trophils, fibroblasts, and endothelial cells at higher sporicide. Significant tissue damage can occur at con-
concentrations. centrations of greater than 3%. At the 3% concentration
For wound antisepsis, sodium hypochlorite is used as a used in antiseptic solutions, it is likely only effective
0.5% solution (commonly called Dakin’s solution) which is against Gram-positive bacteria, unless the bacteria con-
made by diluting one part regular laundry bleach with nine tain catalase, in which case it is rendered ineffective. Its
parts water (Protocol 64.2). Although some rapid kill duration of effect is short-lived since it is not absorbed
and has no residual activity.
Accelerated hydrogen peroxide is a proprietary product
Protocol 64.2 Formulating 0.5% Sodium containing hydrogen peroxide, a surfactant, and an acid
Hypochlorite (Dakin’s) Solution resulting in a solution that has shorter contact times com-
pared to H2O2 alone. These products are sporicidal and
Items Required
have good activity against non-enveloped viruses such as
● Household bleach canine parvovirus. Accelerated hydrogen peroxide is nonir-
● Water ritating and noncorrosive, so has become a popular disin-
fectant in health care settings.
Procedure Potassium peroxymonosulfate, an oxidizing agent, is
another high-level disinfectant. When proper concentra-
1) To make 250 ml total volume, add 25 ml of house-
tions are used, these products can inactivate nonenveloped
hold bleach to 225 ml of water.
viruses such as canine parvovirus. The powder concentra-
2) Use immediately.
tions are corrosive and toxic, but the solutions typically
3) Discard any unused solution.
used (1%) are less corrosive and less irritating.
Sterilization 841
Phenols organic debris. Jointed instruments should be opened or

unlocked to allow steam to penetrate all surfaces appropri-
Phenols are effective antiseptics with a variable spectrum
ately. Avoid overcrowding as this prevents the steam from
of activity that depends on the formulation. Phenol has a
properly circulating, which can lead to a failed cycle. Cycles
broad spectrum of activity against Gram-positive and
are typically complete in under 30 minutes, but times may
-negative bacteria at a 0.1–1% concentration, and mycobac-
vary depending on the autoclave and how the instruments
teria and fungi at a 1–2% concentration. It has variable
are packaged. Once the cycle is complete, allow for roughly
activity against enveloped viruses, is ineffective against
30 minutes for the instruments to dry. After drying is com-
spores except at very high concentrations (5%) and has
plete, store the instruments in a closed cabinet away from
questionable activity against protozoa. Because phenol is
possible contamination.
highly toxic to tissues, it is not used commonly. It is highly
Routinly clean your autoclave following the manufac-
corrosive and extended exposure can cause neurotoxicity.
turer’s recommendations. Biological assessments should
be done regularly by autoclaving a bacterial spore-
Quaternary Ammoniums impregnated strip and sending it in for culture to a micro-
biological laboratory or culturing it in hospital. If bacterial
Quaternary ammonium compounds are cationic sur-
growth is reported, the autoclave should be thoroughly
factants, also known as detergents, that act by disrupting
investigated, cleaned appropriately, and retested before use.
cell membranes, denaturing proteins, and inactivating
enzyme systems. They are effective against Gram-positive
bacteria and enveloped viruses but have variable effective- Gas Sterilization
ness against Gram-negative bacteria, fungi, and protozoa. Gas sterilization works by destroying the organisms
They are mycobacteriostatic and sporostatic. They are inef- through the alkylation of DNA. It is used to sterilize mois-
fective against nonenveloped viruses. They are inactivated ture or heat-sensitive equipment; most items that cannot
by hard water, soaps and detergents, cotton, iodine, rubber, be autoclaved, such as plastics and endoscopes, can be
and organic material; this list should be considered when safely gas sterilized. Gases available include ozone gases,
applying quaternary ammonium compounds. These com- hydrogen peroxide vapor, formaldehyde, or ethylene oxide.
pounds are corrosive at higher concentrations, are irritating Gas sterilized items must be allowed to vent for an appro-
to membranes, and can cause dermatitis after repeated use. priate length of time prior to use per the manufacturer’s
instructions, the entire sterilization process can take
24 hours or more to complete, which is significantly longer
Sterilization when compared with steam sterilization. Caution should
be used as the gas is extremely flammable, carcinogenic,
Sterilization is defined as the use of a physical or chemical and irritating to the mucous membranes and eyes.
process to kill all microorganisms including bacteria, viruses,
fungi, mycobacteria, protozoa, and spores. Methods of steri-
Flash Sterilization
lization include gas, pressurized steam, and liquid. Gas and
steam sterilization require the items to be packaged in a spe- Flash sterilization is a modification of steam sterilization
cific manner to permit penetration of the steam or gas. All and can be performed when an instrument is needed on an
packs to be sterilized, whether by autoclaving or gas, should emergency basis. Flash sterilization refers to an instrument
contain appropriate indicator strips that turn a specific color being sterilized in an open, unwrapped tray without wrap-
once the contents have been appropriately sterilized. ping or packaging that allows for steam to easily surround
Indicators should always be checked to ensure that sterility the instrument and achieve sterilization rapidly. Flash ster-
has been achieved prior to use of the pack contents. ilization is not recommended for devices that are going to
be implanted as they have been occasionally associated
with intraoperative infections. Special handling is required
Autoclaves
during the removal of the instrument from the sterilizer
Steam sterilization causes denaturation and coagulation of and during transport to avoid recontamination.
microorganism proteins by using saturated steam under
pressure in an autoclave. Autoclaves are inexpensive, non-
Glutaraldehyde
toxic, and effective, making them one of the most common
methods for sterilization in the small-animal hospital Glutaraldehyde is considered a chemical sterilant since it
today. Prior to sterilization, all instruments should be has a broad spectrum of activity including being sporicidal.
cleaned thoroughly with detergent and be free from any It acts by alkylating microorganism proteins. To ensure it is
sporicidal the solution must be made alkaline. Unfortunately, Aseptic Techniques

this leads to a steady loss of activity, which makes the gluta-
raldehyde solution ineffective after a maximum of 30 days. Handwashing
The shelf life varies depending on the formulation; there-
fore, the manufacturer’s guidelines must be followed. In a Handwashing plays a vital role in preventing infection in
2% glutaraldehyde solution, most bacteria are killed within the workplace. Despite this knowledge and continued con-
two minutes of contact; fungi, virus, and mycobacteria firmation that infection is often transmitted by healthcare
within 10 minutes; and spores within three hours. It is non- workers’ hands, compliance rates remain poor. Even when
corrosive and most objects that can be submerged in water handwashing occurs, often not all surfaces of the hands
may be safely sterilized using glutaraldehyde. Like all chem- come in contact with the soap or antiseptic. Medical staff
ical disinfectants, it is toxic to cells and irritating to the skin, should wash their hands before coming on duty, before and
membranes, and airways, so all materials sterilized with glu- after direct or indirect contact with patients, after exposure
taraldehyde must be rinsed thoroughly immediately to any bodily fluids from self or a patient, before and after
prior to use. eating, before and after wearing gloves, before preparing
and administering medication, after cleaning cages, and
after completing a shift.
The primary action of soap is the mechanical removal of
Bacterial Resistance to Antiseptics viable transient microorganisms. Regular soap with water
and Disinfectants should be used if gross contamination is present, and then
followed with an antiseptic if needed. Good hand hygiene
Intrinsic Resistance can also be achieved by using a waterless alcohol-based
Bacteria can have natural resistance to antiseptics and dis- product. Alcohol-based products are less damaging to the
infectants, and they can develop resistance to these chemi- skin and stations can easily be installed throughout the
cals in the same way they develop resistance to antibiotics. hospital. If an antimicrobial soap is being used, hands
Gram-negative bacteria, mycobacteria, and spores have should be washed for at least 30 seconds. Multiuse cloth
natural resistance. This is primarily due to the presence of hand towels should be avoided. Artificial nails and nails
a complex cell wall and the inherent difficulty in penetrat- longer than 0.25 inch have been associated with an
ing the membrane of the organism. Occasionally, the increased likelihood of HAIs, so are not recommended. See
organism has intrinsic properties that allow it to avoid the Chapter 62 for an in-depth discussion of hand hygiene and
action of the antiseptic. This intrinsic resistance often for a handwashing protocol.
means antiseptics are ineffective at concentrations that are
safe to be used in patients.
Methicillin-resistant Staphylococcus aureus can be resist- Aseptic Surgical Preparation:
ant to phenols and quaternary ammonium compounds. Personnel
P. aeruginosa are often resistant to antiseptics due to the
structure of their outer membrane. More information Surgical hand antisepsis is crucial in reducing the risk of
about these resistant bacteria is found in Chapter 62. contamination during surgical procedures. All jewelry
should be removed and proper surgical attire should be
worn, which includes, clean surgical scrubs, a surgical cap
Biofilms
over the head, and a face mask. Gross contamination
Pseudomonas spp. and Serratia marcescens can rapidly should be removed using soap and water, and debris
develop resistance to chlorhexidine by forming a biofilm. A should be removed from under the nails. Arms should be
similar problem has been noted with povidone-iodine. A bio- held upright to allow water and soap to drip toward the
film is a community of bacteria covered in an extracellular elbows thus preventing recontamination of the hands and
matrix that have strongly adhered to the surface of an object. fingers. Antisepsis can typically be achieved in two to four
Bacteria inside biofilms are 1000 times more resistant to anti- minutes by using an alcohol–chlorhexdine combination
microbial agents than when they are not in biofilms. Because or other antiseptic product. A one- to two-minute scrub
of the fact that Pseudomonas spp. and Serratia marascens can with chlorhexidine followed by application of an alcohol-
develop a rapid resistance to chlorhexidine, the common based solution has been shown to be more effective than
practice of having containers of gauze squares soaking in the typical antiseptic scrub, which has made this the rec-
chlorhexidine should not be permitted, nor should large ommended presurgical handwashing technique over the
multiuse containers of chlorhexidine-based ointment be used. traditional method.
Futher Reading 843
Aseptic Surgical Preparation: Patient wearing a cap and mask. Concentric circles should be used
starting from the location of the incision and working out-
Surgical site infections can occur if proper aseptic prepara- ward toward the periphery. There have been very few stud-
tion is not performed. Most surgical infections are caused ies examining the effects of using different antiseptics on
by the patient’s own bacteria that are introduced into the both surgical site colonization and surgical site infection.
surgical site from the skin, membranes, or hollow viscera Chlorhexidine 2% solution is the most commonly recom-
such as intestines during the surgical procedure. mended antiseptic. It does not have as good in vitro effec-
Hair or fur should be clipped immediately before the tiveness as 10% povidone-iodine; however, it has better
procedure rather than in advance, since advanced shaving in vivo effectiveness, especially against Staphylococci, as
has been associated with an increased incidence of infec- well as a longer residual effect. In addition, iodine-based
tion. A wide area should be clipped. In the case of wounds compounds may cause a hypersensitivity reaction in
or a surgical exploratory celiotomy or thoracotomy, the healthcare personnel.
clip should be wide enough to ensure adequate prepara-
tion has been performed in case drains or feeding tubes
need to be placed away from the primary surgical site. Summary
In traumatic wounds, this clip should extend at least 5 cm
circumferentially beyond the known extent of the wound. Proper selection and use of antiseptics, disinfectants, and ster-
In other situations, such as vascular catheter insertion ilization are crucial to the prevention of HAIs. Chlorhexidine
sites, care should be taken to ensure that fur is clipped is currently the antiseptic documented to have the broadest
from the area immediately around the site, and that no fur spectrum of activity and least toxicity. Disinfectants should be
can contact the catheter or insertion site during or after chosen for their specific activities against target organisms.
placement. New antiseptics are constantly being developed to overcome
Gross contamination should be removed prior to using microbial resistance and reduce toxicity.
any antiseptic. In heavily contaminated wounds, this may
require the use of large volumes of tap water. Tap water has
not been shown to increase infection rates or interfere with Acknowledgment
wound healing. Once this has been completed a surgical
preparation with an antiseptic should be performed This chapter was originally authored by Drs. Jennifer
(Protocol 64.1; see also Chapter 63). In surgical patients, Devey and Connie Schmidt for the previous edition, and
this preparation should be performed using sterile gauze some material from that chapter appears in this edition.
in a sterile bowl, sterile saline, and personnel should be The authors and editors thank Dr. Devey and Ms. Schmidt.
Futher Reading
Boyce, J.M. and Pittet, D. (2002). Guideline for hand hygiene in Tract Infections 2009. Washington DC: Centers for Disease
health-care settings, Recommendations of the Healthcare Control and Prevention.
Infection Control Practices Advisory Committee and the Lambrechts, N.E., Hurter, K., Picard, J.A. et al. (2004). A
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. prospective comparison between stabilized glutaraldehyde
Society for Healthcare Epidemiology of America/Association and chlorhexidine gluconate for preoperative skin prep
for Professionals in Infection Control/Infectious Diseases antisepsis in dogs. Vet. Surg. 33: 636–643.
Society of America. MMWR Recomm. Rep. 51 (RR-16): 1–45. Larson, E.L., Aiello, A.E., Lyle, C. et al. (2001). Assessment of
Chlebicki, M.P. and Safdar, N. (2007). Topical chlorhexidine two hand hygiene regimens for intensive care unit
for prevention of ventilator-associated pneumonia. Crit. personnel. Crit. Care Med. 29: 944–951.
Care Med. 35: 595–602. Lozier, S., Pope, E., and Berg, J. (1992). Effects of four
Fernandez, R. and Griffiths, R. (2008). Water for wound preparations of 0.05% chlorhexidine diacetate on wound
cleansing. Cochrane Database Syst. Rev. (1): CD003861. healing in dogs. Vet. Surg. 21: 107–112.
Fossum, T.W. (2018). Preparation of the operative site. In: Mangram, A.J., Horan, T.C., Pearson, M.L. et al. (1999).
Small Animal Surgery, 5e (ed. T.W. Fossum), 36–41. Guideline for prevention of surgical site infection. Infect.
Philadelphia, PA: Elsevier. Control Hosp. Epidemiol. 20 (4): 250–278.
Gould, C.V., Umscheid, C.A., Rajender, K. et al. (2009). Mathews, K.A. and Binnington, A.G. (2002). Wound management
Guideline for Prevention of Catheter-Associated Urinary using honey. Compend. Contin. Educ. Pract. Vet. 24: 53–60.
Mathews, K.A., Brooks, M.J., and Valliant, A.E. (1996). A Disinfection and Sterilization of Healthcare Facilities.
prospective study of intravenous catheter contamination. Washington DC: Centers for Disease Control and
J. Vet. Emerg. Crit. Care 6: 33–43. Prevention.
McDonnell, G. and Russell, A.D. (1999). Antiseptics and Sanchez, I.R., Swaim, S.F., Nusbaum, K.E. et al. (1988).
disinfectants: activity, action and resistance. Clin. Effects of chlorhexidine diacetate and povidone-iodine on
Microbiol. Rev. 12: 147–179. wound healing in dogs. Vet. Surg. 17: 291–295.
O’Grady, N.P., Alexander, M., Burns, L.A. et al. (2011). Fossum, T.W. and Schutz, H.B. (2002). Care and Handling of
Guidelines for the Prevention of Intravascular Catheter- Surgical Equipment. In: Small Animal Surgery, 5e (ed.
Related Infections. Washington DC: Centers for Disease T.W. Fossum), 4–17. St Louis, MO: Mosby.
Control and Prevention. Schutz, H.B. and Fossum, T.W. (2002). Principles of surgical
Osuna, D.J., DeYoung, D.J., and Walker, R.L. (1990). asepsis. In: Small Animal Surgery, 5e (ed. T.W. Fossum),
Comparison of three skin preparation techniques, part 2: 1–3. St Louis, MO: Mosby.
clinical trial in 100 dogs. Vet. Surg. 19: 20–23. Stubbs, W.P., Bellah, J.R., Vermaas-Hekman, D. et al. (1996).
Parienti, J., du Cheyron, D., Ramakers, M. et al. (2004). Chlorhexidine gluconate versus chloroxylenol for
Alcoholic povidoneiodine to prevent central venous preoperative skin preparation in dogs. Vet. Surg. 25:
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845
65
Personnel Precautions for Patients with Zoonotic Disease

Sarah Fritz and Christopher G. Byers
One of the inherent risks of working in veterinary medi- 3) A method of transmission – via contact (ingestion, cuta-
cine is the possibility of contracting a zoonotic disease, also neous, percutaneous, mucus membranes, or fomite
known as a zoonosis. A zoonosis (from the Greek zoo transmission); aerosol (on mucus membranes or non-
meaning animal and nosos meaning illness) is defined as a intact skin, inhaled); or vector borne (insects on the ani-
disease of animals transmissible to humans. Owing to the mal or insects or rodents that enter the building).
unique proximity of animals and humans in veterinary
hospitals, the risk of zoonotic pathogen transmission is
higher than for the general population. This chapter covers Types of Zoonotic Diseases
types of zoonoses that small-animal emergency and critical
care personnel may encounter, methods of transmission, Bacterial Diseases
prevention methods, and legal and public health issues
Bacterial diseases are some of the most common zoonotic
surrounding zoonoses in veterinary medicine. As there are
pathogens seen in small animal hospitals. Most will be
more than 250 zoonotic organisms known to cause human
instantly recognizable to veterinary personnel.
disease, it is not possible to cover the full spectrum in this
chapter; this text addresses some of the zoonotic pathogens
Bordetellosis
known to be transmissible from dogs and cats to humans
Bordetella bronchiseptica is a Gram-negative bacterium
(Table 65.1). Veterinary professionals should remember
that primarily causes tracheobronchitis in dogs. The
there are far greater numbers of zoonoses prevalent in
patient will often have a harsh, honking cough (kennel
large animal and exotic/special species veterinary work.
cough). These bacteria may cause respiratory disease in
cats, but infections are usually subclinical. The pathogen
spreads via aerosol transmission. Any patients with sus-
Zoonotic Disease Transmission
pected bordetellosis should be isolated and staff should fol-
low protective measures against aerosol transmission.
If an animal is ill with or potentially carrying one of a
Immunocompromised individuals and people with preex-
zoonotic pathogen, they represent the first step in the
isting respiratory disease are most at risk for contracting
Centers for Disease Control and Prevention’s (CDC) neces-
bordetellosis. The disease usually involves the respiratory
sary three steps for disease transmission [1]:
tract but has been associated with endocarditis, peritonitis,
1) A source of infection – including clinically ill animals, meningitis, and wound infections in people [2].
asymptomatic carriers, or unaffected reservoirs.
2) A susceptible host – due to physical susceptibility (i.e. Brucellosis
non-intact skin, loss of cough reflex, or gastric acid Brucellosis is caused by the Gram-negative bacterium
reduction) or immunological susceptibility (i.e. immu- Brucella canis in dogs. This disease is usually transmitted
nocompromised individuals, people with underlying through contact with vaginal secretions, placental tissue,
disease, pregnant women, and unvaccinated people). semen, and sometimes urine and blood. In dogs and
846 Personnel Precautions for Patients with Zoonotic Disease
Table 65.1 Major zoonoses in cats and dogs.
Disease Vector Method of transmission to humans
Acariasis (mange) Sarcoptes scabiei, Notoedres cati, etc. Contact

Brucellosis Brucella melitensis, B. abortus, B. suis, B. canis Aerosol, contact
Bartonellosis (cat scratch fever) Bartonella henselae Contact
Cryptococcosis Cryptococcus neoformans Aerosol
Dermatophytosis (ringworm) Microsporum spp., Trichophyton spp., Contact
Epidermophyton spp.
Echinococcus Echinococcus granulosus, E. multilocularis Contact
Giardiasis Giardia intestinalis, G. lamblia Contact
Visceral, ocular, neuro larval migrans Toxocara canis, T. cati Contact
(roundworm)
Leptospirosis Leptospira spp. Contact, aerosol
Pasteurellosis Pasteurella multocida Contact
Q fever Coxiella burnetii Contact, aerosol, vector
Salmonellosis Salmonella spp. Contact
Staphylococcosis Staphylococcus spp. Contact
Toxoplasmosis Toxoplasma gondii Contact
Bordetellosis (kennel cough) Bordetella bronchiseptica Aerosol
Campylobacteriosis Campylobacter jejuni, C. fetus, C. coli Contact
Chlamydiosis (mammalian) Chlamydophila abortus, C. felis Aerosol, contact
Cryptosporidiosis Cryptosporidium parvum Contact
Dipylidium (tapeworm) Dipylidium caninum Vector
Ehrlichiosis, anaplasmosis Ehrlichia spp., Anaplasma spp. Vector
Cutaneous larval migrans (hookworm) Ancylostoma spp. Contact
Leishmaniasis Leishmania spp. Vector
Listeriosis Listeria monocytogenes Contact
Plague Yersinia pestis Vector, contact, aerosol
Rabies Lyssavirus Contact
Sporotrichosis Sporothrix schenckii Contact
Streptococcosis Streptococcus spp. Contact, aerosol
Tularemia Francisella tularensis Vector, contact, aerosol
humans, the bacterium can be transmitted venereally. Bartonellosis

Presenting signs in dogs may include spontaneous abor- Bartonellosis, commonly known as “cat scratch fever,” is
tion, epididymitis, orchitis, scrotal dermatitis, or scrotal caused by the Gram-negative bacterium Bartonella hense-
necrosis in intact males. Discospondylitis and uveitis in lae (less commonly Bartonella clarridgeiae). The disease is
dogs of either sex have also been documented [3]. In peo- transmitted to people primarily through cat bites or
ple, the disease is often subclinical, but symptoms may scratches but may also be transmitted via flea or tick vector,
occur after a one- to two-month incubation period. Clinical from a dog bite or scratch, or from saliva contact with bro-
illness is manifested as intermittent fever, headaches, ken skin. The feline patient presented to a small-animal
chills, weakness, arthralgia, myalgia, weight loss, orchitis/ clinic will typically be a young kitten, feral, or stray cat, and
epidydimitis in males, and spontaneous abortion. In rare be a subclinical carrier as disease in cats is uncommon. If
cases, brucellosis has been linked to sacroilliitis, hepatic the organism does cause clinical signs in cats, the signs are
disease, endocarditis, colitis, and meningitis [3]. Brucellosis usually mild and self-limiting, and can include pyrexia,
is suspected to be transmissible in breast milk [2]. uveitis, and lymphadenomegaly. Human disease is also
Brucellosis is a nationally notifiable disease for people in mild in immunocompetant individuals. Symptoms may
the United States [4]. include papules/pustules at inoculation site, which may
Tyes of Zoonotic Diseases 847
progress to nonhealing wounds with regional lymphade- fluids [9, 10]. Infection can also occur through ingesting
nomegaly, fever, headache, and general malaise. There has unpasteurized dairy products. Wind has also been known
been a reported case of optic neuritis stemming from an to carry the pathogen long distances [9].
infection with B. henselae [5]. Fatalities have been reported In animals, abortion and weak offspring are common,
in immunocompromised individuals from infections pro- however some animals do not show any signs of the
gressing to bacteremia, meningitis, and hepatitis [5]. disease. Prevention in the animal population includes
isolating any animals that have aborted fetuses, disposal of
Capnocytophaga any materials contaminated with fluids from aborted
Capnocytophaga species live in the mouths of humans, fetuses, and cleaning of contaminated equipment with a
dogs, and cats. They are considered normal oral flora. phenolic disinfectant [9, 10].
Capnocytophaga canimorsus is the species most commonly In the human population, Coxiella can produce flu-like
implicated in zoonotic infection. Research has shown up to symptoms, including fever, chills, fatigue, and muscle
74% of dogs and up to 57% of cats carry C. canimorsus in pain [9]. Treatment involves doxycycline for approximately
their mouths [6]. Happily, these Gram-negative bacteria two weeks. The condition can become a chronic illness
rarely, if ever, cause illness in our companions. C. canimor- lasting several months and becoming potentially life
sus may be spread to humans through bites, scratches, and/ threatening. In these cases, treatment includes doxycycline
or after close contact with dogs and cats. The major mode and hydroxychloroquine [9, 10]. Q Fever has been a nation-
of transmission is via exposure of broken human skin to a ally notifiable disease in the United States since 1999 [9].
pet’s saliva. For example, humans with diabetes have been
infected after allowing their dog to lick skin ulcers. Based Leptospirosis
on epidemiological studies in human medicine, 54% of Leptospirosis may be caused by any of several serovars of
human infections were caused by bites and 8.5% were the gram-negative spirochete, Leptospira interrogans. The
caused by scratches. Just over 25% of all human cases were pathogen is transmitted via contact between infected urine
reportedly caused simply through close contact with an or tissue and mucus membranes and/or non-intact skin.
animal [7]. The disease is seen primarily in dogs. Although cats are
Infection is considered to be opportunistic. Humans with susceptible to infection, they seldom develop clinical symp-
weakened immune systems are most susceptible to C. cani- toms. The patient with leptospirosis may present with a
morsus infection. Interestingly, approximately 40% of peo- variety of symptoms as the infection may be peracute,
ple are seemingly healthy with no immune system acute, subacute, or chronic. The peracute form of the dis-
issues [8]. In this patient population, being male, having ease results in sudden death with few or no clinical signs.
diabetes mellitus, and being older than 50 years of age have In the acute form, dogs may have pyrexia, icterus, myalgia,
been identified as risk factors for infection. Veterinarians vomiting, diarrhea, and peripheral vascular collapse. The
have developed eye infections caused by C. canimorsus subacute form symptoms include pyrexia, anorexia, vomit-
after tooth fragments hit their eyes during dental proce- ing, dehydration, polydipsia, and often severe renal disease
dures. Symptoms of infection often manifest five days after marked by oliguria or anuria. The chronic form is fre-
exposure. Most commonly, infected individuals develop quently characterized by pyrexia and renal and/or hepatic
flu-like symptoms, including headache, fever, fatigue, skin failure with no known cause [11].
rashes, muscle pain, difficulty breathing, and abdominal The majority of cases seen in animal hospitals are suba-
discomfort. Scarily, symptoms can progress to life- cute and chronic. In humans, leptospirosis may range from
threatening proportions within 24 hours and around 30% asymptomatic infections to flu-like illness with pyrexia,
with septicemia die from infection [8]. Treatment with an headache, myalgia, nausea, vomiting, diarrhea, abdominal
appropriate antibiotic is essential. pain, rash, conjunctivitis, and conjunctival hemorrhage.
There is also the hepatic-renal form of the disease caused
Coxiella burnetii (Q Fever) by the serovar Leptospirosis.icterohemorrhagiae, and results
Coxiella burnetti, the causative agent of Q fever, is an obli- in jaundice due to hepatocellular dysfunction and renal
gate intracellular bacterium. This organism has been insufficiency from renal tubular damage; this form has a
known to infect a whole host of animals ranging from live- 20% mortality rate [2]. Rarely, leptospirosis may cause neu-
stock to birds. In the human population, veterinary and rologic, respiratory, and cardiac manifestations [11].
livestock workers are the most at risk as cattle, sheep, and A form of leptospirosis characterized by acute renal failure
goats are the most common reservoir [9, 10]. The pathogen with fever, anorexia, lethargy, vomiting, polyuria, polydip-
is commonly found in the placental/amniotic fluid, urine, sia, and abdominal pain has been documented in dogs and
feces, and milk of infected animals, and is passed via humans in Wisconsin, Michigan, New York, New Jersey,
inhalation of dust particles contaminated with these and Georgia [3].
The leptospirosis vaccine may protect dogs from clinical Septicemic plague may progress from the bubonic form
illness, but vaccinated dogs are still able to acquire the but is not always associated with bubo formation. In this
pathogen and shed it in their urine [2]. Leptospirosis is form, the bacteria spread through the blood or lymphatic
nationally notifiable for humans in the United States [12]. system to any organ in the body; the lungs and spleen are
most commonly affected in cats and people. Clinical signs
Pasteurellosis are due to septic shock and include fever, anorexia, vomit-
Pasteurella species are Gram-negative coccobacillary bacteria ing, diarrhea, tachycardia, weak pulses, hypotension, cold
responsible for disease in several animal species, though they extremities, disseminated intravascular coagulopathy, and
are considered host specific [13]. Diseases in animals include leukocytosis [8]. This form is usually rapidly fatal [16].
gastrointestinal, respiratory, and hemorrhagic illnesses, as The pneumonic form of plague may be secondary to
well as septicemia. Pasteurella multocida is commonly found bubonic or septicemic forms or may be primarily con-
in the mouths of dogs and cats and is known to cause disease tracted from aerosolized plague bacteria. Cats do not typi-
in humans, with involvement in approximately 75% of cat cally contract primary pneumonic plague, but they have
bite and 50% of dog bite wounds [14]. Both localized and sys- been implicated in the aerosol transmission of pneumonic
temic infections can occur as a result of bite wounds from plague to people [16]. Clinical signs may include fever,
both dogs and cats. Localized infection is characterized by cough, hemoptysis, and respiratory distress. Since 1977,
inflammation of the tissues immediately surrounding the the CDC has reported 23 human cases of plague associated
bite, as well as redness and pain. If left untreated, abscess for- with aerosolized pneumonic plague droplets from infected
mation and septic arthritis can occur. Systemic illness, cats. One fifth of these patients died and one quarter were
though rare, can include meningitis, sepsis, and pneumonia. veterinary staff [17]. Plague has caused millions of human
Immunocompromised human patients are at risk for devel- fatalities through the ages and is a nationally notifiable dis-
opment of a fatal form of pasteurellosis [14]. ease for humans and animals in the United States [4, 12].
Treatment in human patients includes broad-spectrum
antibiotics. Potentiated amoxicillin, concurrent doxycy- Staphylococcal Infections
cline and metronidazole (patients with penicillin aller- Staphylococci are Gram-positive bacteria whose primary
gies), concurrent clindamycin and a fluoroquinolone habitats are the skin and mucus membranes of mammals
(children) or ceftriaxone (pregnant women) are among the and birds. Most staphylococci cause no disease to animals;
common antibiotic therapies [15]. however, all species are potentially pathogenic [18]. Of par-
Prevention in animals involves good husbandry (fresh ticular concern to small animal veterinary personnel is
water, clean litterboxes for rabbits, etc.). Cockroaches have methicillin-resistant Staphylococcus aureus (MRSA). This
been noted as a potential vector, so good sanitation is impor- is a nosocomial and/or community acquired human patho-
tant. Prevention in human beings centers around hand gen, reportedly transmissible between small animals and
hygiene and proper restraint methods to avoid animal bites. people [18] (see Chapter 62). As of yet, it appears MRSA
Potentially contaminated surfaces may be cleaned with a infections in dogs have been cases of “reverse zoonosis”
variety of cleaning products such as phenolic cleaners, 70% acquired from humans as opposed to the other way
ethanol, and glutaraldehyde cleaners [13]. around [18]; still, the possibility of hospital-acquired zoon-
oses exists and further study is required. MRSA is nation-
Plague ally notifiable for humans in the United States [4].
Plague is caused by the Gram-negative bacterium, Yersinia While Staphylococcus pseudintermedius is commonly part
pestis. In the United States, rodents (rats, squirrels, and of the normal flora of healthy dogs, it is also a significant
prairie dogs), and cats are typically infected by fleas or pathogen, commonly included in skin, ear, urinary, and
ingestion of the aforementioned rodents. People contract postoperative infections. Approximately 69–87% of dogs are
the disease through contact with blood, purulent exudate, carriers; it is not well-established in cats [19]. While the
or aerosols from infected cats. Dogs may contract the path- prevalence of infection in humans is not as great as S. aureus,
ogen, but infection is often subclinical and results in mild it has been isolated in healthy owners whose pets are
pyrexia and lymphadenomegaly. In cats and people, plague infected, as well as veterinary workers, and can lead to bacte-
may present in one of its three classic forms: bubonic, sep- rial infections that can become quite severe [19].
ticemic, and pneumonic. Methicillin-resistant S. pseudintermedius (MRSP) has
Bubonic plague is associated with fever, dehydration, been a growing problem within veterinary medicine since
lymphadenomegaly, and hyperesthesia. This form, usually the first observation in 1999, particularly in surgical
acquired by cats ingesting infected rodents, causes regional patients. Dogs who carry the pathogen are at increased risk
lymph nodes (submandibular, cervical, and retropharyngeal) of infection, most commonly following tibial plateau leve-
to abcessate (buboes) and drain [16]. ling osteotomy surgery [20]. Healthy dogs may also be
asymptomatic carriers of MRSP, leading to a growing con- Patients that present clinically ill with blastomycosis
cern for zoonosis both for pet owners and veterinary staff, commonly have clinical signs from inhaling infective
although prevalence of these carriers is relatively low at spores. These may include weight loss, cough, dyspnea,
1.6–4.6% [19]. anorexia, skin lesions, ocular disease, and lameness. A
Treatment for infections with MRSP typically includes patient presenting with uveitis and concurrent skin or res-
tetracycline antibiotics, with 50% of doxycycline resistant piratory disease in an endemic region should raise marked
strains susceptible to minocycline. Other antibiotics suspicion for blastomycosis [21]. In people, blastomycosis
include amikacin and chloramphenicol, although resist- also affects the lungs and may cause fever, chills, sweating,
ance to these drugs is emerging on the west coast and in the chest pain, coughing, and difficulty breathing. The fungus
south of the United States [20]. Prevention can be accom- may also spread systemically affecting skin, bones, menin-
plished by keeping wounds covered, washing hands/wear- ges, and the genitourinary tract [5].
ing gloves, and limiting contact with infected patients [20].
Dermatophytosis
Tularemia Dermatophytosis, often referred to as ringworm, is a fungal
Tularemia is caused by the Gram-negative bacterium dermatological disease caused by species of Microsporum
Francisella tularensis. This disease is endemic in temperate or Trichophyton. Transmission to people is via contact
regions of the world, where rodents and rabbits are the pri- with infected animals and/or asymptomatic carriers.
mary reservoirs. In small-animal medicine, cats are the pri- Dermatophytosis is a disease with widely varying signs and
mary source of infection. Transmission is commonly via imperfect diagnostic tests; personnel should therefore fol-
bites or scratches but it may also be contracted from aero- low precautions in dealing with any animal evincing der-
solized particles and vectors. Cats may present with a myr- matologic disease. The fungus attacks the follicle and
iad of clinical signs including pyrexia, lymphadenomegaly, clinical signs often include hair loss, scaling, and crusting.
splenomegaly, hepatomegaly, oral ulcers, icterus, and pan- Some animals may have the classic ringlike lesion, but the
leukopenia [18]. Dogs appear to be relatively resistant to disease can look like almost any other dermatological dis-
infection. In humans, clinical disease causes flu-like symp- ease affecting cats and dogs. Cats are the primary species of
toms with fever, headache, and general malaise [2]. The concern with regards to zoonotic transmission. People
infection may develop into either of the two main syn- often develop the ring lesions with circular alopecia, scal-
dromes: ulceroglandular or typhoidal. In the ulceroglandu- ing, crusting, and ulceration [22]. The disease can be more
lar form, ulcerative skin lesions develop at the inoculation serious in immunocompromised individuals.
site, with regional lymphadenomegaly. The typhoidal form
may present as systemic with diarrhea, vomiting, and Sporotrichosis
abdominal pain; or as pneumonic with fever, cough, hem- Sporotrichosis is caused by the fungus Sporothrix schenckii,
optysis, and chest pain [2]. Tularemia is nationally notifia- which is found in soil throughout the world. Transmission
ble for animals and humans [4, 12]. occurs via inoculation with the fungi, and in dogs (particu-
larly hunting or free-roaming dogs) it is thought to arise
from contaminated thorns or wood splinters. In cats, trans-
Fungal infections
mission is commonly via scratches or bites from other cats;
Fungal organisms compose an important category of poten- it is seen most often in intact males that are outdoors.
tial zoonotic infection. The more commonly seen fungal The dog with sporotrichosis will typically have cutaneous
infections in small-animal veterinary hospitals include blas- or cutaneolymphatic form. Clinical signs of the cutaneous
tomycosis, dermatophytosis, and sprorotrichosis. form include nodules in the dermal and subcutaneous lay-
ers of the trunk and head that may be ulcerated. Those with
Blastomycosis the cutaneolymphatic form will have nodules on the distal
Blastomycosis is a systemic mycotic infection caused by the part of a limb that progress along lymphatic vessels and is
fungus Blastomyces dermatitidis. This organism is endemic associated with regional lymphadenomegaly. In cats, nod-
to many areas of the United States, including the ules will occur in areas where inoculation occurred and
Mississippi, Ohio, and Missouri river valleys, the mid- typically resemble non-healing abscesses and may progress
Atlantic states [21]. Most human infections are directly to necrosis of the surrounding area. The organism may
from the environment as they are for dogs and cats; how- become systemic in cats and may spread to many organs.
ever, transmission has been documented in the veterinary Veterinary personnel are most at risk from cats, as the fun-
field via inoculation from contaminated sharps during gus replicates easily and in large numbers in the exudate
fine-needle aspiration, necropsies, and from the bite of an from ulcerated nodules, as well as the tissues and feces of
infected dog [5]. infected cats [23]. Most infections in people present as
ulcerative, cutaneous lesions with purulent discharge and Influenza

localized lymphadenomegaly [23]. Systemic sporotrichosis is Influenza viruses from the Orthomyxoviridae family are
a danger to immunocompromised people and has been docu- infectious to humans and many species of animals, includ-
mented in people with AIDS, alcoholism, diabetes mellitus, ing dogs and cats. In the 1970s, an influenza epidemic in
and those receiving immunosuppressive medications [24]. people resulted in the contraction of clinical flu in dogs [25].
Canine influenza virus (CIV) was initially caused by equine
influenza A H3N8 virus, and the first reported infections
Viral Infections
were documented in racing greyhounds in Florida in 2004.
Viruses are another classification of zoonotic disease to Essentially the virus “jumped ship” from horses and is now
which small-animal veterinary personnel are exposed. considered a dog-specific lineage of H3N8. In 2009, there
Within this category, rabies is of paramount concern but was an outbreak of influenza A (H1N1), also known as
there is growing evidence influenza is also transmissible “swine flu.” The American Veterinary Medical Association
between small animals and humans. confirmed clinical disease in 14 cats and 3 dogs that had
been in contact with infected humans [26]. In spring 2015,
Rabies an outbreak of CIV was noted in several midwestern states,
Rabies is caused by a Lyssavirus in the Rhabdoviridae fam- including Illinois, Wisconsin, Ohio, and Indiana [27]. The
ily. These viruses are found nearly worldwide, and all documented strain, H3N2, was first identified in southern
warm-blooded animals are susceptible to infection. China and the Republic of Korea in 2006, and infectious
Pathogen transmission is nearly always via inoculation disease experts thought that this strain was isolated only to
with saliva (bite) or contact with saliva and broken skin or parts of Asia. No one yet knows exactly how H3N2 came to
mucus membranes. A rabid patient may have a variety of the United States.
clinical signs and a bite wound history. Commonly, the In cats and dogs, influenza may present with coughing,
prototypical manifestations of fury and paralysis may be sneezing, nasal and ocular discharge, anorexia, pyrexia,
present but they are not required for definitive diagnosis. lethargy, and occasionally secondary pneumonia. To date,
The prodromal phase in dogs and cats may result in influenza is considered a “reverse” zoonotic disease in dogs
pyrexia, apprehension, nervousness, anxiety, avoidance of and cats. This means that they contract the disease from
company, and/or radical behavioral changes from the ani- humans as opposed to humans contracting the disease
mal’s norm. Licking, biting, or scratching at wound site from them. However, influenza does pass back and forth
may be present. In dogs, the furious stage of rabies may between humans and other animals such as pigs and birds,
develop following the prodromal phase and lasts for up to so the risk of zoonotic transmission is there.
seven days. Classic signs include irritability, restlessness,
photophobia, ataxia, disorientation, generalized seizures, Noroviruses
viciousness, and pica. Death usually occurs during seizure Norovirus is a common cause of non-bacterial gastroen-
activity. Cats have a more classic furious stage with erratic, teritis and is found worldwide. There have been as many as
vicious behavior, tremors, ataxia, and weakness. 10 genogroups and 40 genotypes categorized. Noroviruses
The patient with paralytic rabies will develop lower are highly contagious, found in stools and vomit of infected
motor neuron paralysis spreading from the infected bite species [28]. In humans, the virus is spread through con-
wound. The classic clinical sign in dogs is a hanging jaw taminated food and drinking water. Human norovirus has
with concurrent ptyalism as the animal loses its ability to the ability to infect a large variety of animal species includ-
close its mouth or swallow. This results in death from res- ing companion animals and livestock. These species act as
piratory failure within a few days [2]. Cats primarily pre- a reservoir for the human virus. It is not clear whether
sent with paralysis progressing from the infected bite area norovirus causes clinical disease in dogs [28]. However, in
and in increase in vocalization with a marked change in humans, the virus causes vomiting, diarrhea, headaches,
voice [2]. fever, and other flu-like symptoms [29]. These signs will
In people, rabies manifests in the prodromal stage as last 24–72 hours, generally. Prevention includes good hand
fever, headache, pain at the bite site, and agitation. The hygiene and disinfecting contaminated surfaces and
furious phase includes violent behavior, restlessness, anxi- objects with bleach [27].
ety, and seizures that may result in death. The paralytic
stage symptoms include the inability to swallow, progres-
Fecally Transmitted Zoonotic Pathogens
sive paralysis, and death due to respiratory failure. The
mortality rate for rabies in veterinary and human patients Within zoonotic diseases, there is a special subset that is
is virtually 100%. Rabies is a nationally notifiable disease transmitted primarily in fecal matter. These fecally transmit-
for animals and humans in the United States [4, 12]. ted zoonotic pathogens, Campylobacter, Cryptosporidium,
Giardia, Salmonella, and Toxoplasma are some of the most young puppies and kittens, or adults that are immunocom-
commonly seen in small animal veterinary medicine. promised, stressed, or from kennel situations [2].
In humans, Giardia is one of the most common intesti-
Campylobacter nal parasites worldwide [2]. The vast majority of cases stem
Campylobacteriosis is most commonly caused in dogs, from contaminated water, however, direct transmission via
cat, and people, by the Gram-negative bacterium the feces of infected animals is possible. Symptoms in peo-
Campylobacter jejuni. Transmission is primarily via the ple may include acute gastroenteritis with diarrhea or a
fecal–oral route in veterinary setting. Patients will com- more chronic infection with malabsorptive diarrhea,
monly present with symptoms including diarrhea, vomit- weight loss, and abdominal pain that waxes and wanes [2].
ing, pyrexia, and anorexia. Clinical disease typically lasts Giardia is nationally notifiable for humans in the United
about one week and is most common in puppies and kit- States [4].
tens less than six months old. In people, C. jejuni is the
most common cause of bacterial diarrhea in the United Salmonella
States, with an estimated two million cases a year [2]. The Salmonella enterica is a Gram-negative bacterium with
disease causes enteritis with symptoms of fever and over 2400 pathogenic serovars that cause primarily intesti-
malaise, progressing to diarrhea and abdominal pain. The nal disease. Salmonella is a fecal pathogen that can survive
disease is generally self-limiting in healthy adults but has for a long time in the environment and be transmitted via
been linked to the development of Guillain–Barre syn- the direct fecal–oral path, in contaminated food and water,
drome (GBS) in approximately 1 in 1000 cases [2]. GBS is on fomites, via contact with cat saliva, and even aerosolized
an immune-mediated myelitis/neuropathy [2]. Another in dried airborne particles [31]. The majority of affected
secondary development that has been identified in human dogs and cats are subclinical carriers, but when illness does
Campylobacter infections is Reiter’s syndrome, which present it is typically an acute enterocolitis with pyrexia,
causes tenosynovitis, skin lesions, uveitis, and urethritis anorexia, lethargy, diarrhea with mucus or blood, abdomi-
in approximately 7% of cases [2]. nal pain, and mesenteric lymphadenomegaly [31]. In some
cases, clinical infection can result in septicemia, endotox-
Cryptosporidium emia, and localized organ infection such as Salmonella
Cryptosporidium parvum is a coccidian protozoan that pneumonia [31].
causes intestinal disease in dogs, cats, and humans and is A unique clinical presentation is “songbird fever” in
transmitted via the fecal–oral route. Cats with domestic cats. Symptoms include acute pyrexia, anorexia,
Cryptosporidium may have diarrhea, weight loss, tenes- depression, diarrhea, and vomiting. This illness is named
mus, blood in the stool, and abdominal discomfort. Disease for its suspected link to the predation of migratory
in cats is typically seen in kittens or in immunocompro- birds [31]. In humans, salmonellosis usually follows a
mised or stressed adults [30]. In dogs, Cryptosporidium 12–36 hour incubation period, and includes symptoms
usually only causes disease in young puppies with concur- such as headache, fever, vomiting, diarrhea, abdominal
rent parvovirus or distemper. Symptoms include diarrhea, pain, nausea, myalgia, and dehydration. Of special concern
weight loss, and malabsorption. is the transmission of highly drug resistant strains of
In humans, the majority of people will develop mild, Salmonella typhimurium DT 104, which has been isolated
self-limiting diarrhea with the disease. However, crypto- in dogs and cats and been reported as the causative agent in
sporidiosis is a leading cause of life-threatening chronic an outbreak of salmonellosis in cats and people at three
diarrhea in immunocompromised patients, such as those small veterinary hospitals [32]. Salmonella is nationally
with HIV [2]. Of primary concern to veterinary staff, notifiable for humans in the United States [4].
oocysts present in fecal matter are highly infectious, highly
resistant to environmental deactivation, and there is no Toxoplasmosis
routinely successful treatment for infections [2]. Toxoplasmosis is caused by the coccidian protozoa
Cryptosporidium is nationally notifiable for humans in the Toxoplasma gondii. Domestic cats and other felines are the
United States [4]. definitive hosts for this parasite; all other species, includ-
ing dogs and humans, are intermediated hosts. The para-
Giardia site causes tissue cysts. Transmission is via oocyte ingestion
Giardia duodenalis is a protozoan parasite transmitted via from cat feces, undercooked meat, or contaminated water.
the fecal–oral passing of infective cysts. Dogs and cats may In veterinary hospitals, cat feces are of primary concern.
present as asymptomatic carriers or evince clinical disease The Toxoplasma oocyte is not infectious when first
with pale, malodorous, steatorrheic stool, and weight excreted. It takes one to five days depending on tempera-
loss [2]. Animals with clinical disease are primarily very ture and humidity, to sporulate into the infective form.
Once the oocyst has entered its infective phase, it can soil contamination, removing stool from the environment
remain infectious in the environment for 18 months and is quickly can prevent eggs from developing into the infec-
extremely hardy and difficult to eradicate. tive stage.
A cat presenting with clinical toxoplasmosis may have var-
ied symptoms, as the parasite can affect virtually any organ
system. The most common systems affected are pulmonary, Personnel Protection
nervous, hepatic, pancreatic, cardiac, and ocular. Symptoms
may include pyrexia, pancreatitis, hepatitis, encephalitis, Zoonotic disease prevention can start before the patient
polymyositis, pneumonitis, uveitis, chorioretinitis, fading enters the hospital. Identification of potential zoonotic risk
kitten syndrome, vomiting, diarrhea, and anorexia [2]. In starts with knowledge of the associated clinical signs of
dogs, disease is uncommon but may result in a rapidly fatal disease and methods of transmission of a given disease.
systemic disease involving the gastrointestinal tract, the res- Solid knowledge of disease states may allow the technician/
piratory system, the neuromuscular system, and the liver [2]. nurse or receptionist to identify possible zoonoses based on
Cats can shed oocytes for up to two weeks following initial an animal’s symptoms, history, geographic region, and
infection and have been shown to be susceptible to contract- other risk factors, such as age, underlying illness, and prox-
ing the parasite again after a previous infection. Cats with imity to certain high-risk areas or wildlife. The best-case
latent infections can sometimes reshed oocytes after second- scenario is identification over the telephone and isolation
ary infections [2]. In people, infection with toxoplasmosis of the incoming animal prior to entering the building.
can cause abortion, chorioretinitis, blindness, hydrocepha- More commonly, rapid isolation of the patient in an exami-
lus, epilepsy, mental retardation, myelitis, and paralysis, nation room once the risk is identified, and limitation of
fever, malaise, myalgia, lymphadenomegaly, and hepatos- personnel contact, are instrumental in reducing the likeli-
plenomegaly [2]. A 2003 study proposed a possible link hood of disease transmission. Signs should be used to
between toxoplasmosis and schizophrenia [33]. notify other personnel and clients that an infectious dis-
ease may be present and what precautions to take.
Other Zoonotic Diseases
Hand hygiene
Despite the low occurrence of two zoonotic disease catego-
ries, a chapter on this subject would not be complete with- The single most important precaution veterinary personnel
out a mention of both vector-borne zoonoses such as can take to prevent the transmission of zoonotic disease is
anaplasmosis (Anaplasma spp.), ehrlichiosis (Ehrlichia good hand hygiene [5]. Washing with regular soap and
spp.), leishmaniasis (Leishmania spp.), Rocky Mountain water removes debris and is effective in reducing the num-
spotted fever (Rickettsia rickettsii), borreliosis (Borrelia ber or organisms on the skin. The added use of antimicro-
burgdorferi), intestinal cestodes, nematodes, and ascarids. bial soaps and hand cleansers kill or prevents the replication
Vector-borne diseases require an insect such as a flea, of many viruses and bacteria. The use of gel, liquid, or cloth
tick, or mosquito to pass a pathogen from a reservoir spe- hand sanitizers is helpful in situations where there is no
cies to humans. Most cats and dogs are not definitive hosts access to handwashing facilities but should primarily be
for these diseases and so their role in transmission is to used in conjunction with handwashing and not in place of it.
bring the shared vectors into close contact with humans. The proper procedure for hand washing is seen in
Good insect and rodent control within the hospital and Protocol 65.1. Soap should be liquid- or foam-based, and
quick response to flea and tick infestation on incoming not bar soap, as the latter may serve as a reservoir for
patients can be preventive.
Intestinal cestodes, nematodes, and ascarids, also known
Protocol 65.1 Effective Handwashing for Veterinary
as “worms,” are also zoonotic disease-causing agents. Most
Personnel
intestinal parasites, such as the cestodes (tapeworms),
Dipylidium caninum and Echinococcus multiocularis are
1) Wet hands with running water.
acquired by humans through the ingestion of fleas, or as in
2) Place liquid or foam soap in palms.
the case of the ascarids and nematodes, Toxocara cati,
3) Rub hands together to form lather.
Toxocara.canis (roundworms), Ancylostoma spp. (hook-
4) Scrub all surfaces of hands (including between
worms), and Strongyloides stercoralis, through the inges-
fingers and backs) for 2 minutes.
tion or skin penetration of infective eggs from contaminated
5) Rinse.
soil. Again, as in the case of vector borne diseases, rodent
6) Dry with disposable towel.
and insect control as well as immediate treatment of any
7) Turn off sink with disposable towel.
animal infested with fleas can be preventive. In the case of
Personnel Protection 853
bacterial growth. Soap dispensers should be able to be should be used when entering and exiting designated isola-
loaded with disposable soap containers and/or be emptied tion areas.
completely, cleaned, and disinfected before being refilled As discussed earlier in this chapter, some pathogens may
to prevent the colonization of the dispensers with patho- be transmitted via aerosolization. Facial protection, such as
gens. When used, hand sanitizers should be rubbed into masks and face shields or goggles should be worn when
hands until dry. Veterinary personnel should not wear long dealing with potential aerosolized pathogens. These pro-
fingernails, particularly artificial nails, as they may inhibit tections should also be in place when performing proce-
adequate hand hygiene. Rings may also harbor organisms dures that may cause aerosolization of pathogens, such as
that are not killed during hand washing and should be dental procedures, wound flushing, abscess draining,
removed during procedures and hand washing. nebulization and coupage, suction, lavage, and necropsy.
In addition, avoid performing resuscitation by breathing
into a patient’s mouth, nose, or endotracheal tube; rather
Barrier Protection
one should always use a bag valve mask or mechanical ven-
Barrier protection is the next protective measure veterinary tilator. Respiratory protection using particulate respirators
personnel should take to prevent the transmission of is not common in small-animal veterinary practice but may
zoonotic diseases. The most important and regularly used have a place if certain diseases such as Coxiella burnetii, the
barrier is gloves. Gloves should be worn when handling causative agent of “Q fever,” become more prevalent.
any animal with unknown history or vaccination status, Information on respiratory protection is available through
for handling feces, blood, or other bodily fluids, including the Occupational Safety and Health Administration (OSHA).
during venipuncture and aspiration procedures. They
should also be worn when cleaning litter boxes, handling
Prevention of Transmission
soiled bedding, cleaning any surface in possible contact
with bodily tissues or fluids, and when handling any ani- As many zoonotic pathogens are transmitted through bites
mal with blood or bodily fluid on them. Gloves should be or scratches, prevention is very important in the veterinary
removed immediately after use without touching the exter- hospital. Knowledge of aggressive tendencies in patients is
nal surfaces. Gloves should be removed from the wrist and key to preventing personnel injury. Proper restraint from
pulled inside out to prevent hand contamination. Hands trained staff, muzzles, heavy gloves, and sedation all play
should be washed immediately after removing gloves as an instrumental part in injury prevention.
there may be small defects and/or hands may have been There are certain procedures in veterinary hospitals that
contaminated during glove removal. require full barrier protection. Birth, cesarean sections, and
Disposable or washable gowns, such as surgery gowns, abortions are all considered high-risk events, as some
may be worn when holding or restraining a potentially extremely virulent zoonotic diseases may be passed in
infectious patient or in any situation where there is a risk birthing tissue and fluids. Necropsies are also high-risk
of bodily contact with pathogens. Normally permeable procedures, particularly due to the use of saws and drills
gowns are typically used but waterproof gowns should be that may aerosolize zoonotic pathogens. Respiratory pro-
used in cases where there is a risk of contamination with tection should be used if any power tools are used on a
large volumes of bodily fluids. Any time a barrier gown is potentially zoonotic cadaver.
worn, gloves should also be worn. Gowns should only be Patients with possible zoonotic diseases should be iso-
used for one patient at a time and must be removed with- lated from other patients, the visiting public, and all per-
out touching the contaminated outer surface. To do this, sonnel except those essential to their care. If possible, these
untie the gown with gloved hands, pull away from the patients should enter the facility via a separate entrance
body by grasping the chest, again with gloved hands, pull directly into an isolation ward or a dedicated exam room. If
down cuffs on each arm and slide gown off arms and a separate entrance is not available, the patient should be
away from the body. Then remove the gloves and wash transported directly through the waiting room by person-
hands thoroughly in case of accidental contamination. If nel wearing barrier protection. Cats and small dogs should
bodily fluid penetrates a semi permeable gown, remove be transported in a carrier, and larger dogs on a gurney or
the gown and contaminated clothing, and shower stretcher. The animal should be moved into a designated
immediately. isolation area as soon as possible and this area should have
Foot covers and foot baths are useful in reducing the a separate entrance from the main patient care area; only
transmission of pathogens on personnel shoes. Disposable personnel needed for zoonotic patient’s care should enter
surgical booties may be worn and removed just as with the isolation area. Personnel entry should be restricted and
gloves to avoid hand contamination. Foot baths are typi- monitored, and a record of all staff that have contact with
cally composed of a 10% hypochlorite (bleach) solution and the patient must be made. Signs must be posted at the
entrance to the isolation area to alert staff to the zoonotic effective against the particular pathogen. No one disin-
disease potential, notify them of necessary precautions to fectant is effective against every pathogen. Table 65.2 lists
take, and warn away other staff. The isolation area should a number of classes of disinfectants and their efficacy
have its own ventilation system to prevent the aerosoliza- against different pathogens. These products should be
tion of pathogens to the rest of the hospital. used according to their manufacturer’s instructions for
Many diseases are transmissible via needlestick inju- maximum efficacy.
ries. Clinicians should rigorously follow safety guidelines In dealing with potentially contaminated bedding, the
when dealing with all sharps. The primary way of pre- fabric should initially be shaken gently over a contained
venting needlesticks is never to recap a needle. Dispose of area such as a garbage bag to dislodge potentially over-
used needles and syringes in a puncture-proof sharps looked sharps and gross fecal matter. Full barrier protec-
container. If it is necessary to recap a needle, use the one- tion, particularly gloves should be worn in dealing with all
handed scoop method or a tool such as a hemostat to hold bedding. The bedding should be washed and dried nor-
the needle cap away from your hand. The one-handed mally. Litter boxes should be emptied into a closed garbage
scoop method involves placing the cap on a horizontal container as soon as they are soiled. Again, the use of dis-
surface such as a treatment table, holding the syringe, posable litter boxes is ideal, but if regular litter boxes are
sliding the needle into the cap, and pressing down to used, they can be cleaned and disinfected the same way as
tighten on a hard surface. Scalpels come with disposable the overall environment. Food and water bowls can be
handles and blades and these are ideal when dealing with washed normally with dish detergent if they are
potential zoonoses. If a scalpel blade must be removed nondisposable.
from a handle, use hemostats to grasp the blade at the If a bodily fluid from a patient with potential zoonoses is
base with the sharp edge facing away from that hand and spilled, it should be sprayed with disinfectant and wiped up
gently work the blade up and off with constant light pres- with absorbent material. All contaminated refuse should
sure and wiggling. be bagged within the isolation area using gloves, and then
After a confirmed or potentially zoonotic patient has rebagged in a second garbage bag outside the isolation area
left the designated isolation area, the location should be using a clean pair of gloves. The bags should be transported
fully cleaned and disinfected to prevent pathogens from out of the hospital to an external garbage area immediately.
living in the environment. Cleaning a potentially contam- Medical waste, including sharps and deceased animals
inated area involves general removal of large waste and should be handled according to OSHA bloodborne patho-
debris: ideally a filtered, central vacuum unit should be gen standards [34]. It should be reiterated that no handling,
used to clean an area and remove potentially aerosolized transporting, or cleaning of an area with potential zoonotic
pathogens. If this is not possible, personnel should take contamination should be done without full barrier protec-
all recommended precautions against aerosolized patho- tion, gloves and gowns minimum, and shoe covers, masks,
gens. After removal of large debris, the area should be goggles, face shields, and/or respirators depending upon
cleaned with a disinfectant (see Chapter 64) shown to be the suspected pathogen.
Table 65.2 Common disinfectants and their targets.
Variable/limited
Disinfectant Effective against effective against Not effective against
Alcohols (isopropyl) Bacteria, Mycobacteria, Non-enveloped viruses Spores

enveloped viruses, fungi
Biguinides (chlorhexidine) Bacteria Mycobacteria, viruses, fungi Spores
Hypochlorites (bleach) Bacteria, Mycobacteria, Spores
viruses, fungi
Iodine compounds Bacteria, enveloped Mycobacteria, non-enveloped viruses,
viruses, fungi spores
Oxidizing agents (hydrogen Bacteria, Mycobacteria, Spores, fungi
peroxide) viruses
Phenols Bacteria, enveloped Mycobacteria Spores
viruses Non-enveloped viruses, fungi
Quaternary ammonium Gram-positive bacteria Gram-negative bacteria, Mycobacteria, Non-enveloped
compounds enveloped viruses, fungi viruses, spores
eeal ann Puulic ealth ssues 855
Vector Control Staff Awareness and Training

Vector control is another important way to minimize the
potential exposure to zoonotic pathogens. Insects and All methods and guidelines for prevention of zoonotic dis-
rodents are attracted to veterinary hospitals and are com- ease transmission hinge on veterinary personnel being
mon vectors of zoonotic disease. Proper facility cleanli- aware of them. Staff training is of paramount importance
ness, food storage, prevention of standing water, and in every step of zoonotic disease prevention. Frequent
blocking points of entry are necessary to prevent these training and evaluation, in addition to written hospital
vectors from entering the hospital. If an animal carrying guidelines, should be in place so staff are knowledgeable in
fleas or ticks enter the hospital, they should be separated prevention of zoonotic disease transmission. In addition,
from other patients, personnel working with them should hospitals must keep personnel food storage separate from
wear protective clothing, and they should be immedi- patient food and medicine storage, and prohibit eating,
ately treated with the appropriate and safe insecticidal drinking, or smoking in patient care areas.
medications. There is a subset of veterinary personnel that are of par-
ticular concern with regards to zoonotic disease transmis-
sion. Immunocompromised individuals, such as those
Client Education with HIV, diabetes mellitus, asplenia, and some congenital
abnormalities, as well as pregnant women and those
Client education is instrumental in prevention of zoonotic
receiving immunosuppressive medications, are at increased
disease transmission. Veterinary personnel should take an
risk for contracting zoonotic diseases and experiencing
active role in informing clients of the importance of pro-
much more severe symptoms. These staff members must
phylactic vaccination against diseases such as rabies, bor-
be aware of the dangers involved when handling patients,
datellosis, borreliosis (Lyme disease), and leptospirosis.
particularly high-risk patients such as ferals, strays, those
Control of ecto- and endoparasites is also an important pre-
with unknown vaccination histories, puppies and kittens
ventive measure as is prohibition of predation on reservoir
less than three months of age, animals consuming raw
species. All of these steps not only protect the client them-
diets, and those with known zoonotic diseases. Ideally, an
selves, but also veterinary personnel who may encounter
immunocompromised staff member should alert their
the client’s pet.
employer/manager so that policies may be enacted to mini-
mize their risks. These individuals should also notify their
Vaccination personal physician of the zoonotic risks involved with their
employment so familiarity with symptoms and proactive
Prophylactic vaccination of veterinary personnel is another
monitoring may be established. Pregnant women face a
method of prevention. The CDC Advisory Committee on
unique immunocompromised situation. Pregnancy sup-
Immunization Practices recommends that all veterinary
presses the body’s cell-mediated immunity and may
personnel who have contact with animals should be vacci-
increase a women’s risk for contracting certain zoonotic
nated against rabies. Preexposure prophylaxis is a series of
diseases [35].
three shots that offer protection against unknown rabies
exposure or when post-exposure vaccination is delayed.
Rabies titers should be checked every two years and Legal and Public Health Issues
boosted if the titer is too low to offer protection.
Another aspect of zoonotic disease in the veterinary hospi-
tal is the legal issues involved in potential transmission to
Reporting Procedures veterinary personnel and pet owners. This is a newly evolv-
ing field of inquiry, as the liability issues involved have yet
In case of possible exposure to a zoonotic disease, a veteri- to be definitively established. In most cases, veterinary per-
nary hospital must have a protocol for documenting and sonnel who contract a zoonotic disease from a patient
responding to the incident. Most hospitals have reporting while at work are covered under workers’ compensation
procedures for bites or other injuries, and these may be regulations and state workers’ occupational disease acts.
readily altered to include contact with possible zoonotic However, with the increasing focus on zoonotic disease
pathogens. This written documentation should include a risks, liability issues have yet to be determined. In 1986, a
list of all personnel involved, specifics of the incident veterinarian was sued for failure to provide a safe work-
(including the date, time, and location), information on the place in a case involving the death of a kennel worker from
animal involved, any medical treatment sought, any leptospirosis [36]. This case highlights the potential legal
agencies notified, and follow-up. issues still to be resolved.
With regard to client risk, the legal ramifications of physicians were diagnosing patients with GBS, meningitis,
zoonotic diseases are still evolving. Veterinarians and vet- encephalitis, and aspiration pneumonia [39]. However, a
erinary staff have an ethical obligation to notify owners of veterinary pathologist at the Bronx Zoo linked the human
potential zoonotic disease and to advise them to seek infor- and animal outbreaks based on the deaths of crows and
mation from their personal physicians. There have been other birds, allowing identification of West Nile virus as the
malpractice claims filed against veterinarians for human cause of human illness in these perplexing cases [40].
injury and exposure to rabid or potentially rabid ani-
mals [37], and such may be the future avenue of legal pro-
ceedings for zoonotic diseases. Summary
In terms of public health and zoonotic disease, there are
varying guidelines in most states and within the federal gov- The goal of any infection prevention protocol is to substan-
ernment defining which diseases must be reported and to tially lower the risk of disease transmission. It is unrealistic
whom. In response to this, the National Academy of Sciences to believe taking rigorous personnel precautions can eradi-
(NAS) presented a report in 2005 calling for the establish- cate all risk of zoonotic disease. In small- animal veterinary
ment of a federal level, centralized coordinating mechanism medicine, the emergency and critical care staff will
for animal health oversight [38]. This body would purport- encounter patients with zoonotic diseases. By instituting
edly organize animal health data for industry, local, state, the procedures outlined in this chapter and expanding
and federal agencies. Such an oversight body such as the one knowledge of zoonotic diseases, personnel and hospitals
proposed by the NAS may have facilitated the earlier recog- can protect themselves, their clients, the public, and their
nition of West Nile virus in people. In the 1999 outbreak, patients against these pathogens.
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859
Section Nine
Transfusion Medicine
861
66
Blood Typing and Crossmatching

Sarah Musulin and Kenichiro Yagi
Knowledge of small animal blood types and understanding follow the DEA system, such as Dal and Kai 1 and 2. Typing
of precompatibility testing are paramount when making sera are available on a limited basis for DEA 1, 3, 4, 5, 7,
transfusion decisions. Blood group nomenclature is based Dal, and Kai 1 and 2. For most blood groups, individual
on the characterization of inherited red blood cell (RBC) dogs exhibit one phenotype for each system; for example, a
antigens located on the surface of the RBC. The prevalence dog may be DEA 3, 4, and Dal positive, and 5, 7, and Kai 1
of blood types and RBC antigens varies according to geog- and 2 negative. The DEA 1 blood type is an exception to
raphy and breeds. Precompatibility testing includes blood this, where a dog can be DEA 1(−) or weakly to strongly
type determination and crossmatching. DEA 1(+). The distribution of DEA 1 in the canine popula-
A basic understanding of transfusion immunology ter- tion is nearly equal. DEA 1 is considered the most immu-
minology is helpful when discussing blood types and com- nogenic and clinically significant RBC antigen. Naturally
patibility testing. Antibodies can be classified as naturally occurring anti-DEA 1 antibodies have not been docu-
occurring or immune (inducible). Naturally occurring mented in dogs, although sensitization with transfusion
anti-RBC antibodies are found in individuals that have not does occur. Transfusion of a DEA 1(−) dog with strongly
been sensitized by previous transfusion. Immune anti-RBC DEA 1(+) blood will lead to the formation of hemolyzing
antibodies are found in individuals that have been sensi- and strongly agglutinating immune antibodies against
tized by previous transfusion and antigen exposure. Blood DEA 1(+) within days and reexposure can lead to an acute
group antibodies, whether naturally occurring or immune, hemolytic transfusion reaction. Point of care (POC) typing
can have pathologic effects that result in RBC agglutina- kits are available to guide DEA 1 type-specific transfusions.
tion and destruction (acute or delayed hemolytic transfu- Given the clinical relevance of the DEA 1 blood type, its use
sion reaction). Agglutination or hemagglutination refers to is highly recommended.
the clumping of RBCs secondary to antibodies recognizing
surface antigens. Allogenic denotes tissue (e.g. blood cells)
that are from the same species. An alloantibody is an anti- Feline Blood Types
body specific for an alloantigen that occurs in some mem-
bers of a species. Alloimmunization is the immune Traditional feline blood group classification is based on an
response to foreign antigens after exposure to genetically AB system, where a cat is designated type A, B or, rarely,
different cells or tissues from members of the same species. AB. The majority of domestic short- and long-hair cats in
Immunogenicity refers to the ability to provoke an immune the United States are type A, but variability in prevalence
response. exists across breeds and geography. Cats do possess clini-
cally significant naturally occurring alloantibodies neces-
sitating type-specific transfusion of RBC and plasma
Canine Blood Types products. Type A cats have relatively weak or absent anti-B
alloantibody titers (generally 1 : 32 and often 1 : 8),
The primary canine blood group classification is based on which can cause agglutination and hemolysis [1]. Type B
the dog erythrocyte antigen (DEA) system. Newly identi- cats have strong, high-titered (1 : 64 – 1 : 1024) anti-A
fied canine RBC antigens have been discovered that do not alloantibodies, which can result in severe agglutination,
862 Blood Typing and Crossmatching
acute hemolytic transfusion reactions, and neonatal iso- specialized and commercial laboratories. Because dogs do
erythrolysis [1]. Type AB cats do not possess anti-A or anti- not possess naturally occurring anti-DEA 1 alloantibodies,
B alloantibodies. In 2007, a novel feline RBC antigen, the transfusion of DEA 1(+) cells to a transfusion naïve
coined Mik, was identified after a hemolytic transfusion DEA 1(−) dog does not cause acute hemolysis ( 24 hours)
reaction occurred in a cat receiving AB-type compatible but may lead to a delayed hemolytic transfusion reaction
blood [2]. POC feline blood typing kits are available and are after a few days. This principle guides some practitioners to
recommended for AB determination. forgo recipient typing in first-time emergent canine trans-
fusions despite the short post-transfusion RBC lifespan and
consequential sensitization and incompatibility with
Blood Typing future transfusions. DEA 1(−) dogs that have been trans-
fused with DEA 1(+) RBCs are at risk for life-threatening
The utility of determining blood type in small animals acute hemolytic transfusion reactions with reexposure to
prior to transfusion is multifactorial. Type-compatible DEA 1(+) blood. Because the consequences of DEA 1 mis-
transfusions are necessary to improve the likelihood of matched transfusions are severe, type matching of canine
RBC survival post-transfusion and to avoid sensitization. transfusions is recommended. If the patient is unable to
Blood type should be determined in both blood donors and afford the time to obtain a blood type, the use of DEA 1(−)
recipients. will prevent sensitization.
POC blood typing is available for DEA 1, 4, 5, and Dal in In cats, AB blood type determination is necessary to
dogs (Protocols 66.1 and 66.2). More comprehensive canine ensure type-specific transfusion of both RBC and plasma
blood typing and antibody screening is available in products, owing to the presence of clinically significant
Protocol 66.1 Canine (DEA 1, 4, 5, or Dal) Blood Type: DMS Card
(b)
(a) (c)
Figure 66.1 (a) Canine DEA1 test with autoagglutination saline screen, positive control, and patient test wells. (b) Canine
DEA4 test with autoagglutination saline screen, positive control, and patient test wells. (c) Canine DEA5 test with
autoagglutination saline screen, positive control, and patient test wells. Source: Courtesy of DMS Laboratories, Inc.
Blood Typing 863
Items Required 3) Mix each test thoroughly with a wooden stick with
downward pressure to agitate the lyophilized mate-
● Whole blood (in EDTA) – 150 μl is required for the test,
rial in the well for 10 seconds; use a separate stick or
but sample should be large enough for appropriate
stick end for each well so not to cross-contaminate.
blood to EDTA ratio
4) Rock the card for one minute being careful to prevent
● Rapid-Vet®-H (canine DEA1, 4, 5, or Dal) kit containing:
spills outside of the wells; observe for agglutination.
⚪ 50 μl pipette
⚪ Wooden stirrer
Interpretation
⚪ Diluent
⚪ Agglutination test card ● Autoagglutination saline screen:

⚪ Hemagglutination – the animal is autoagglutinating;
Procedure wash cells.

⚪ No agglutination – proceed with blood type test.
The procedures are the same for all four blood type kits. ● Positive control:
⚪ Hemagglutination – the test is functioning as intended.
Autoagglutination Saline Screen ⚪ No agglutination – the test is defective; contact
manufacturer.
1) Apply one drop of diluent and canine whole blood (in
● Patient test:
EDTA) to the well.
⚪ Hemagglutination – the animal is positive for the
2) Mix thoroughly with the provided wooden stick for
DEA tested.
10 seconds.
⚪ No agglutination – the animal is negative for the
3) Rock card for 30 seconds to a slight angle looking for
DEA tested.
agglutination:
a) If negative, proceed to typing.
Notes
b) If positive, consider washing cells to retest.
● Store at room temperature (20–25°C) for 24 months.
● Agglutination characteristic between the control well
Blood Type Test Wells
and patient well will often look different.
1) Apply one drop of diluent into the “Positive Control” ● Fine, granular appearance can occur over one minute
and “Patient Test” wells. into testing and should be disregarded.
2) Apply one drop of canine whole blood (in EDTA) into ● Anemic samples can form pinhead-like aggregations
each well (patient, positive control). of red cells instead of gross agglutination.
Protocol 66.2 Immunochromatographic (IC) Canine Blood Typing Test

Items Required 3) Remove the cover on the Quick Test strip and set the
exposed membrane strip into the red cell suspension
● Whole blood (in EDTA, ACD, or CPD) –10 μl is required
in a vertical position.
for the test, but sample should be large enough for
4) Allow the red cell solution to migrate up the strip
appropriate blood to anticoagulant ratio
and remove for interpretation in two to five
● Quick Test DEA1 kit containing:
minutes.
⚪ Collector strip
⚪ Buffer solution
Interpretation
⚪ Quick Test strip
⚪ Sample well ● Control: A red line showing at the “C” mark indicates
proper function.
Procedure ● DEA1 negative: a blank space at the “DEA1” mark indi-
1) Add three drops of buffer solution into sample well. cates DEA1 negative (Figure 66.2a).
2) Collect anticoagulated whole blood with collector strip, ● DEA1 positive: a red line showing at the “DEA1” mark
and then suspend into the buffer solution by gently stir- indicates DEA1 positive (Figure 66.2b).
ring the collector strip in the solution for seven seconds.
(a) (b)
Figure 66.2 (a) Canine LabTest DEA1 test strip with interpretation kit. This strip shows a DEA1 negative result. (b) Canine
QuickTest DEA1 kit set up for demonstration. This kit shows a DEA1 positive result. Source: Courtesy of Alvedia, Limonest, France.
Notes packed cells with the collector strip will to help make
the band more visible.
● The IC test is reliable for testing through autoaggluti-
● Laboratory test kits containing bulk amounts are also
nation as the agglutinated cells will be retained at the
available.
bottom of the membrane.
● The IC band will be visible through low packed cell
volume, although centrifuging red cells to collect
naturally occurring alloantibodies. POC is available for AB The card agglutination typing kits are available from
typing (Protocols 66.3, 66.4, 66.5, 66.6), but unavailable for DMS Laboratories for rapid determination of canine
Mik determination. DEA 1, 4, 5, or Dal (Protocol 66.1), and feline A, B, or AB
Blood typing methods detect visible in vitro hemaggluti- blood types (Protocol 66.4). The blood-typing card aggluti-
nation of patient RBCs with known RBC antibody or anti- nation assay is based on a visible agglutination reaction
sera to determine blood type. There are three commercially when the sample RBC surface antigens interact with a
manufactured tests available for canine and feline blood known lyophilized monoclonal antibody impregnated on
typing – the tube gel test, the card agglutination assay, and the typing card. Interpretation of the visible agglutination
the immunochromatographic cartridge (IC) method. DMS reaction in an RBC suspension can be subjectively graded
Laboratories manufactures a one-tube gel test for identify- on intensity from 0 (no agglutination) to 4+ agglutination.
ing feline AB typing (DMS RapidVet®-H GEL, DMS When typing canine blood donors for DEA 1, sensitivity is
Laboratories, Inc., Flemington, NJ) (Protocol 66.3). These paramount to prevent misidentification of DEA 1(+)
one-tube gel tests are stored in the refrigerator and are donors as DEA 1(−). Conversely, when typing recipients,
designed to be run on a centrifuge with a fixed-angle rotor. maximum specificity in testing is necessary to prevent the
Gel-tube methodology is an agglutination system that uses administration of DEA 1(+) blood to a DEA 1(−) patient.
a reaction tube containing gel and antibody reactive to When interpreting card agglutination tests for donors,
varying degrees with feline types A, B and AB whole blood. sensitivity may be improved by interpreting any agglutina-
Gel-tube methodology is highly accurate demonstrating a tion (≥ 1 agglutination) as positive [5]. When interpreting
high level of agreement with gold standard laboratory test card agglutination tests for recipients, an agglutination
tube typing [3, 4]. cutoff point of ≥ 2+ improves specificity.
Blood Typing 865
Protocol 66.3 Feline (A, B, AB) Blood Type: DMS One-Tube Gel Test
Items Required 5) Allow both tubes to incubate at room temperature for
five minutes.
6) Centrifuge at settings specified by DMS Laboratories.
7) Examine the tubes to interpret the results.
blood to EDTA ratio
● Fixed-angle rotor centrifuge
Interpretation
● RapidVet®-H GEL feline kit containing:
⚪ 50 l μl pipettes ● Positive control tube: a red line of agglutinated cells at
⚪ Blood preparation tube with diluent or near the top of the gel column indicates proper
⚪ Positive control gel tube function.
⚪ Patient test gel tube (reaction tube) ● Reaction tube (Figure 66.3):
⚪ Type A – vast majority of red blood cells (RBCs) are
Procedure found at the top of the tube.
⚪ Type B – vast majority of RBC are found at the bot-
1) Add one drop of blood to the blood preparation tube
and gently invert several times. tom of the tube.
⚪ Type AB – RBCs are evenly dispersed within the tube.
2) Use a new pipette for steps 3 and 4 (same pipette can
be used for both steps).
3) Transfer one drop of blood from the blood prep tube Notes
into the positive control tube. Increase to three drops ● Store refrigerated at 2–7°C upright for a shelf life of
if the animal’s packed cell volume (PCV) is less than 24 months. If not stored upright, set upright in refrig-
15%. Recap without mixing. erator for 10 minutes before use.
4) Transfer one drop of blood from the blood prep tube ● If autoagglutination is present, wash cells.
into the reaction tube. Increase to three drops if the
animal’s PCV is less than 15%. Recap without mixing.
Feline Feline Feline

Type A Type B Type AB
Figure 66.3 Result interpretation guide for RapidVet®-H Feline GEL. Source: Courtesy of DMS Laboratories, Inc.
Protocol 66.4 Feline (AB) Card Blood Type

Items Required 3) Mix each test thoroughly with a wooden stick with
downward pressure to agitate the lyophilized mate-
rial in the well for 10 seconds; use a separate stick or
stick end for each well so not to cross-contaminate.
blood to EDTA ratio
4) Add a second drop of diluent to the well labeled type
● Rapid-Vet®-H (feline) kit containing:
A. Do not stir the fluid in this well a second time.
⚪ 50 μl pipette
5) Rock the card for two minute or less until hemagglutina-
⚪ Wooden stirrer
tion has occurred in one of the Patient Test wells. Take care
⚪ Diluent
not to cross-contaminate the samples within the wells.
⚪ Agglutination test card
Interpretation
Procedure
● Blood type A: strong hemagglutination in well labeled
Autoagglutination Saline Screen
type A (Figure 66.4a).
1) Apply one drop of diluent and feline whole blood (in
● Blood type B: strong hemagglutination in well labeled
EDTA) to well.
type B (Figure 66.4b).
2) Mix thoroughly with the provided wooden stick for
● Blood type AB: strong hemagglutination in wells
10 seconds.
labeled type A and type B (Figure 66.4c).
3) Rock card for 30 seconds to a slight angle looking for
agglutination.
a) If negative, proceed to type A and B typing. Notes
b) If positive, consider washing cells to retest.
● Store at room temperature (20–25°C) for 24 months.
Blood Type Test Wells ● Fine, granular appearance can occur over one minute
1) Apply one drop of diluent into each of the two remain- into testing and should be disregarded.
ing wells labeled Patient Test. ● Severely anemic samples of type A can prevent forma-
2) Apply one drop of feline whole blood (in EDTA) into tion of agglutination and is recommended to be run
each of the wells. without using the diluent.
(a) (b) (c)
Figure 66.4 RapidVet®-H Feline Agglutination Card Test Kit. (a) Results of type A. (b) Results of type B. (c) Results of type
AB. Source: Courtesy of DMS Laboratories, Inc.
Blood Typing 867
Protocol 66.5 Immunochromatographic Feline Blood Typing Tests

(Alvedia® QuickTest A+ B Kit)
Items Required
● Whole blood (in EDTA, ACD, or CPD) – 10 μl is required
for the test, but sample should be large enough for
appropriate blood to anticoagulant ratio
● QuickTest A+ B kit containing:
⚪ Collector strip
⚪ Buffer solution
⚪ Quick Test strip
⚪ Sample well
Procedure
1) Add three drops of buffer solution into sample well.
2) Collect anticoagulated whole blood with collector
strip, and then suspend into the buffer solution by
gently stirring the collector strip in the solution for (a)
seven seconds.
3) Remove the cover on the Quick Test strip and set the
exposed membrane strip into the red cell suspension
in a vertical position.
4) Allow the red cell solution to migrate up the strip and
remove for interpretation in two to five minutes.
Interpretation
● Control: a red line showing at the “C” mark indicates
proper function. (b)
● Type A: a red line showing at the “A” mark indicates
type A (Figure 66.5a). Figure 66.5 (a) Feline QuickTest A+ B kit set up for
● Type B: a red line showing at the “B” mark indi- demonstration. This kit shows a type A result. (b) Feline
QuickTest A+ B kit. This kit shows a type AB result.
cates type B. Source: Courtesy of Alvedia, Limonest, France.
● Type AB: a red line showing at both the “A” and “B”
marks indicates Type AB (Figure 66.5b).
Notes
packed cells with the collector strip will help make the
● The immunochromatographic (IC) test is reliable for band more visible.
testing through autoagglutination as the agglutinated ● Laboratory test kits containing bulk amounts are also
cells will be retained at the bottom of the membrane. available.
Protocol 66.6 DMS Laboratories RapidVet®-H IC Feline Test Kit

Items Required Interpretation
● Whole blood (in EDTA) – 30 μl is required for the test, ● Control: a red line showing at the “Control” window
but sample should be large enough for appropriate indicates proper function. Use a new kit and contact
blood to EDTA ratio the manufacturer if no line is visible.
● RapidVet-H immunochromatographic (IC) feline kit ● Type A: a red line showing at the “Type A” window indi-
containing: cates type A (Figure 66.6a).
⚪ Red-top blood preparation tubes ● Type B: a red line showing at the “Type B” window indi-
⚪ Buffer solution cates type B (Figure 66.6b).
⚪ Pipettes ● Type AB: a red line showing at both the “Type A” and
⚪ IC test device “Type B” window indicates type AB (Figure 66.6c).
Procedure
Notes
1) Pipette one drop of blood into the blood preparation
● The IC test is reliable for testing through autoaggluti-
tube, replace cap, and invert several times.
nation as the agglutinated cells will be retained at the
2) Using a new pipette, place three drops of diluted
bottom of the membrane.
blood from prep tube into the sample port and allow
several seconds to absorb.
3) Place three drops of buffer solution into the same
packed cells with the collector strip will help make the
sample port.
band more visible.
4) Rest the device on a flat surface and record test results
based on visible lines formed after 5–10 minutes.
(a) (b)
(c)
Figure 66.6 RapidVet®-H IC feline blood typing kit. (a) This test shows a type A result. (b) This test shows a type B result.
(c) This test shows a type AB result. Source: Courtesy of DMS Laboratories, Inc.
Crossmatching ethods 869
The most recent technology in POC blood typing is the in vitro crossmatching are unclear, although an immune
IC method. IC kits are available for DEA 1 (Protocol 66.2) reaction such as delayed hemolysis and shortened post-
and feline AB typing (Protocols 66.5 and 66.6). RBCs in an transfusion viability should be considered. When possible,
anticoagulated (EDTA) whole blood sample are mixed the administration of fully compatible blood is recom-
with a provided buffer solution and allowed to diffuse mended. Crossmatching evaluates the current immuno-
across a membrane containing monoclonal antibodies logical state of a recipient and should be performed just
against a known RBC antigen (canine DEA 1 or feline AB) prior to transfusion.
creating a visible line when positive for blood type. The IC A major crossmatch is necessary for all cats and dogs that
methodology is reliable in patients with autoagglutination have been previously transfused with an appropriate time
as agglutinated RBCs will be retained at the starting end of interval for alloantibody formation. In dogs sensitized by
the membrane whereas non-agglutinated RBCs will migrate transfusion, alloantibody formation has been demon-
to the distal end of the dipstick membrane. In patients strated at four days [7] aligning with the recommendation
exhibiting autoagglutination, it is necessary to serially wash to ensure crossmatch compatibility in dogs that have been
serum separated RBCs prior to performing the gel-tube and previously transfused four or more days prior. In cats sensi-
card agglutination methodologies for accurate results. tized by transfusion, alloantibody formation has been dem-
onstrated as early as two days post-transfusion (range
2–10 days, median 5 days) of AB-type compatible blood [8].
Crossmatch Considerations Further research is indicated to determine the optimal tim-
ing for post-transfusion crossmatching in cats.
Crossmatch testing determines in vitro pretransfusion com- The necessity of determining crossmatch compatibility in
patibility between recipient and donor blood to ensure recip- transfusion-naïve dogs and cats is debated. As dogs lack
ient safety and maximize transfusion product efficacy. The naturally occurring hemolyzing alloantibodies, namely
major crossmatch assesses for recipient plasma alloantibod- anti-DEA 1 alloantibodies, an acute hemolytic transfusion
ies against donor RBC alloantigens. A major crossmatch reaction has never been described in a dog receiving a first-
may be used prior to administering any RBC-containing time transfusion. The Association of Veterinary Hematology
transfusion product, such as whole blood or packed RBCs and Transfusion Medicine (AVHTM) Transfusion Reaction
(pRBCs). The minor crossmatch assesses for donor plasma Small Animal Consensus Statement (TRACS) suggests that
alloantibodies against recipient RBC alloantigens. A minor major crossmatching may not be necessary in transfusion-
crossmatch may be considered when transfusing any plasma naïve dogs [9]. Naturally occurring alloantibodies against
containing product, such as whole blood or fresh frozen other canine blood types (e.g. DEA 3, 5, and 7) have been
plasma, although minor crossmatches are rarely performed identified with no evidence of acute hemolysis. The clinical
in veterinary medicine. Selected blood donors should have significance of these naturally occurring canine alloanti-
no history of prior transfusion and associated alloimmuni- bodies is unknown as well as the ability of various cross-
zation. For blood donors with unknown histories, antibody matching technologies to identify their presence, especially
screening can be performed prior to admittance into the in low levels. The decision can also differ between dogs that
donor program. Because dogs do not possess naturally are known to be transfusion-naïve as opposed to those with
occurring alloantibodies associated with acute hemolysis, unknown transfusion histories. The discovery of clinically
minor crossmatching is not indicated with the transfusion of significant naturally occurring anti-Mik alloantibodies
plasma products [6]. The transfusion of AB-type specific in some cats suggests the utility of assuring crossmatch
plasma products from feline donors with no history of trans- compatibility in AB-type matched transfusion-naïve cats.
fusion avoids the need for minor crossmatching. Several contradictory studies have investigated pretransfu-
The objective of crossmatch technology is to assess for sion compatibility in transfusion naïve cats, as well as
hemolysis and/or hemagglutination. A positive crossmatch outcomes in crossmatched versus non-crossmatched trans-
test exposes visible hemolysis and/or hemagglutination fusions in naïve cats. The AVHTM statement suggests that
consistent with incompatibility. A negative test lacks major crossmatching be performed in addition to AB
hemagglutination (macroagglutination ± microagglutina- typing in transfusion-naïve cats [9].
tion depending on crossmatch methodology) or hemolysis
and implies compatibility. Crossmatching is performed to
prevent acute immune-mediated hemolytic transfusion Crossmatching Methods
reactions, but delayed hemolysis and other transfusion
reactions cannot be predicted. The identification of acute Crossmatch testing is more time-consuming and techni-
hemolysis during in vitro crossmatching implies that acute cally challenging than blood typing. A variety of laboratory
hemolysis of donor cells would occur. The consequences of and POC crossmatching methods are available. In veteri-
various degrees of agglutination with no hemolysis on nary medicine, there is a lack of standardization in
crossmatch test procedures and test result interpretation. is time consuming and reliant on highly experienced per-
The standard tube agglutination crossmatch procedure is a sonnel, it has been replaced by gel column technology in
laborious method used in many university veterinary labo- many human blood banks as the gold standard. Gel col-
ratories. Tube agglutination crossmatching requires experi- umn technology is easy to perform and standardized but
enced trained personnel, such as licensed clinical pathology requires specialized centrifuge equipment and specially
technologists, for optimal and consistent results prepared gel column test cards, often reserved for larger
(Protocol 66.7). Blood samples are incubated at body tem- clinical laboratories. Canine and feline gel column test
perature (37°C) in the tube agglutination crossmatch pro- crossmatch kits (Alvedia®, Limonest, France) are available
cedure, while some institutions also evaluate at 25°C to that require the Hettich EBA 270 centrifuge.
evaluate for cold agglutinating antibodies (i.e. cold aggluti- POC crossmatch testing kits available in veterinary med-
nins). Because the tube agglutination crossmatch method icine are RapidVet-H Crossmatch Test Kit (DMS
Protocol 66.7 Major Tube Crossmatch Procedure

Includes major crossmatch, recipient autocontrol, ± a) Using a pipette, place two drops of recipient’s
donor autocontrol. plasma or serum to each tube.
Items Required b) Using a pipette, add one drop of donor RBC sus-
pension to each tube.
● Recipient whole blood (EDTA tube); ± recipient serum
5) Label a tube recipient autocontrol:
● Donor whole blood (EDTA tube or stored blood bag
a) Using a pipette, place two drops of recipient’s
segment, i.e. pigtail)
plasma or serum to the tube.
● Centrifuge (capable of 1000× G or 3400 rpm)
b) Using a pipette, place one drop of recipient RBC
● 37°C incubator (heat block)
suspension to the tube.
● 12 × 75 mm test tubes
6) Label a tube donor autocontrol (performed if using
● Disposable pipettes
donor EDTA sample):
● 0.9% or phosphate-buffered saline (NaCl)
a) Using a pipette, place two drops of donor’s plasma
● Timer
or serum to the tube.
● Microscope, microscope slides, coverslips (optional)
b) Using a pipette, place one drop of donor RBC sus-
pension to each tube.
Procedure
7) Mix all tubes gently.
1) Centrifuge blood and separate plasma/serum from 8) Cover each tube or the entire group with plastic or
red blood cells (RBCs). Label tubes “Recipient RBCs,” Parafilm® to prevent condensation from entering
“Recipient serum/plasma,” “Donor RBCs,” “Donor any of the tubes.
plasma.” If crossmatching to multiple donors, label 9) Incubate all tubes at 37°C for 15–30 minutes.
tubes accordingly. 10) Centrifuge (1000× G or 3400 rpm) the tubes for
2) Prepare a suspension (~3%) of washed donor red cells 15–20 seconds.
in 0.9% saline: 11) Read each tube and grade according to the chart
a) Washing – add around 3 ml saline to a small below. Reactions should be read in a well-lit area, pref-
amount of RBCs (100 μl or around 2–3 drops), mix, erably with a white background to maximize visualiza-
and centrifuge (1000× G or 3400 rpm for 60 section. A 3×5 magnification lens can be used, if needed.
onds). Decant the saline and repeat three times,
filling the tube with saline, mixing, centrifuging
Grading
and decanting leaving RBCs in tube.
b) Preparing 3% suspension – add 3.2 ml of saline to 1) Remove one tube from the centrifuge at a time, taking
washed RBC pellet. Mix thoroughly. Trained labora- care not to dislodge the red-cell button.
tory personnel may prepare suspension visually to 2) Note the color of the supernatant. Free hemoglobin
approximate the appearance of red Kool-Aid®. See (red-tinged supernatant) greater than the amount in
Figure 66.7a for appropriate RBC suspension color. the original blood sample denotes hemolysis.
3) Prepare a suspension (~3%) of washed recipient red Hemolysis is considered a positive reaction.
cells in 0.9% saline. 3) While viewing the tube and red cell button, gently
4) Label a tube for each donor (red cell suspension) shake the tube back and forth to dislodge the red
being tested: cell button.
(a) (b) (c)
(d) (e)
Figure 66.7 (a) Appropriate red blood cell suspension color. (b) A 2+ incompatible reaction is occurring in the tube on the left and
the tube on the right (patient autocontrol) reveals no hemagglutination. (c) 3+ incompatible reaction in tube on right. Patient
autocontrol (tube on left) is negative. (d). 4+ incompatible reaction in tube on right. Patient autocontrol (tube on left) is negative.
(e) Positive microscopic hemagglutination, 40×.
4) Observe the manner in which the red cells leave eye) hemagglutination, a drop of the resuspended
the button. RBC-plasma mixture is placed on a microscope
5) Microscopic evaluation (optional): For samples slide followed by a coverslip and evaluated at 40×.
lacking obvious macroscopic (visual to the naked 6) Grade the reaction based on the following criteria:
Result Description
Negative No hemagglutination
Negative Rouleaux (see below)
Positive Hemolysis
Positive microscopic Negative macroscopic
Red cell aggregates (look like clusters of grapes, Figure 66.7e, rather than stacks of coins)
Result Description
Weak positive Minimal hemagglutination

1+ Small red cell aggregates
2+ Small and large red cell aggregates (Figure 66.7b)
3+ Many large red cell aggregates (Figure 66.7c)
4+ One solid button of red cells (Figure 66.7d)
Rouleaux 4) Centrifuge for 15 seconds.

5) Read and grade reaction as above. If hemagglutina-
Suspected rouleaux (“stacked coin” appearance) must be
tion persists, it suggests true incompatibility. If
confirmed by saline replacement as follows:
hemagglutination resolves, it confirms rouleaux.
1) Recentrifuge the tube containing suspected rouleaux.
Note: True red-cell antigen–alloantibody reactions will
2) Remove the residual serum/plasma.
not disperse with the addition of saline.
3) Resuspend the cells using two drops of 0.9% saline.
Tube/test Result Interpretation
Recipient Autocontrol Positive Patient has formed autoantibodies against self RBCs; these
autoantibodies may also cause hemagglutination of donor RBCs
in vitro and/or in vivo. Recommend finding a compatible donor or
the “least incompatible” donor (hemagglutination in major is less
than in autocontrol).
Recipient autocontrol Negative No detectable autoantibodies.
Major (recipient) Positive Recipient of intended whole blood or pRBCs has alloantibodies
against an antigen(s) on the donor RBC surface.
Major (recipient) Negative Recipient of intended whole blood or pRBCs is compatible with
donor RBCs.
Rouleaux Present Hemagglutination that disperses following saline replacement
suggests an increase in plasma proteins is causing RBCs to
aggregate loosely. This is not thought to be of clinical relevance in
transfusion of red blood cells.
pRBC, packed red blood cells.
Laboratories) and Alvedia’s IC crossmatch tests (Quick impregnated with anticanine antiglobulins in a detector
Test XM Canine®, LabTest XM Canine®, EmMa XM Feline®, line area. The anticanine antiglobulins can detect immu-
LabTest XM Feline®, Alvedia, Limonest, France). The noglobulins G and M, and C3 complement components
RapidVet-H Crossmatch Test is a modified gel-tube aggluti- bound to donor RBCs, and trap these RBCs within the
nation test where after room temperature incubation and detector line, indicating incompatibility. A reported advan-
centrifugation, the gel allows compatible RBCs to filter to tage of the IC methodology is reliability in patients with
the bottom of the tube, but traps agglutinated RBCs at the autoagglutination as agglutinated RBCs will be retained at
top or the near the top of the gel (Protocol 66.8). The DMS the starting end of the membrane whereas non-agglutinated
website provides complete instructions with illustrations, RBCs will migrate to the distal end of the dipstick
centrifuge specifications and photo identifiers of compati- membrane [10].
ble and incompatible results. The Alvedia IC crossmatch Veterinary studies comparing POC crossmatch kits with
cartridge tests (Protocol 66.9) are similar in methodology to the laboratory standard tube agglutination crossmatch pro-
their blood typing kits. Donor RBCs and recipient plasma cedure as gold standard suggest that POC crossmatch kits
are combined, allowed to incubate, washed three times and lack sensitivity and may result in false negatives and the
then the washed RBC pellet is combined with a second inadvertent administration of incompatible blood [11–14].
buffer solution and allowed to wick-up a membrane Conversely, it may be that the tube agglutination
Protocol 66.8 Companion Animal Crossmatch Test: RapidVet®-H
(a)
(b) (c)
Figure 66.8 (a) RapidVet®-H Canine Crossmatch kit. (b) RapidVet-H Canine Crossmatch kit. Positive control (first tube, red line),
positive reaction from a sensitized dog (second tube, yellow line), negative control (third tube, green line), negative reaction from
a transfusion naïve dog (fourth tube, yellow line). (c) RapidVet-H Feline Crossmatch Kit Positive control (first tube, red line), A
blood with B serum (second tube, yellow R), B blood with A serum (third tube, yellow line), negative control (fourth tube, green
line), A blood with A serum (fifth tube, yellow line). Source: Courtesy of DMS Laboratories, Inc.
Items Required Procedure

● Recipient serum or plasma – 1.0 ml 1) Gel tubes should remain upright at all times. A clean
● Donor blood sample – 0.1 ml (100 μl) EDTA anticoagu- pipette must be used for every step to prevent
lated whole blood or 0.05 ml (50 μl) packed red blood contamination.
cells (pRBCs) 2) For each donor being tested, remove one test stand
● Centrifuge (centrifuge list provided by DMS containing seven tubes, one pipette bag and one
Laboratories with speed and time required report card.
specifications) 3) Write donor name/identification on all seven tubes.
● RapidVet-H kit containing: 4) Write recipient name/identification on yellow-top
⚪ Test stand containing seven tubes reaction tube and clear-top reaction gel tube
⚪ One pipette bag (yellow-bordered labels).
⚪ Instructions, procedure diagram, photo result identi- 5) Insert blue-top blood preparation tube upright into
fier, centrifuge specifications list, report card the well provided in the test stand.
6) Pipette donor sample – two drops (100 μl) whole d) Incubate: let all tubes stand for five minutes at
blood or one drop (50 μl) pRBCs – to a blue-top blood room temperature (20–25°C/68–77°F).
preparation tube; cap tightly and gently invert several e) Transfer one drop (50 μl) from yellow-top reac-
times to mix thoroughly. Place upright in the test stand. tion tube to clear-top reaction gel tube (yellow-
7) Pipette four drops (200 μl) recipient plasma or serum bordered labels). Cap tightly.
to yellow top reaction tube. f) Transfer one drop (50 μl) from green-top negative
8) From blue-top blood preparation tube, using a clean control tube to clear-top negative gel tube
pipette for each transfer: (green-bordered labels). Cap tightly.
a) Transfer two drops (100 μl) to yellow-top reaction g) Transfer one drop (50 μl) from red-top positive
tube. Replace cap, tighten, and gently invert sev- control tube to clear-top positive gel tube (red-
eral times to mix thoroughly. bordered labels). Cap tightly.
b) Transfer two drops (100 μl) to green-top negative h) Place gel tubes in centrifuge and spin for a cumu-
control tube. Replace cap, tighten, and gently lative G-force of 6500 (refer to crossmatch centri-
invert several times to mix thoroughly. fuge list within kit or at DMS Laboratories (http://
c) Transfer two drops (100 μl) to red-top positive rapidvet.com) for speed and time settings for
control tube. Replace cap, tighten, and gently common models).
invert several times to mix thoroughly. i) Interpret and report results.
Tube Result Interpretation
Negative control tube Negative The negative control gel tube should demonstrate a collection of red
blood cells at the bottom of the gel column (Figure 66.8b,c)
Positive control tTube Positive A red line of agglutinated red blood cells at or near the top of the gel
column indicates proper function (Figure 66.8b,c)
Reaction tube Negative The vast majority of the red blood cells are at or near the bottom of the
gel matrix and no firm line of agglutinated cells remains at the top of the
gel (Figure 66.8b,c); a negative reaction suggests the donor is compatible
Reaction tube Positive The reaction tube demonstrates agglutinated red blood cells at or near the
top of the gel column (Figure 66.8b,c); a positive reaction indicates an
incompatible donor
Notes ● A large number of cells suspended without a firm line

of cells at the top is likely due to incompatibilities to
● Store upright at room temperature for a shelf life of
something other than DEA1 (such as other DEA types).
24 months.
Protocol 66.9 Immunochromatographic Canine Crossmatch Test – Quick Test XM Canine (Alvedia, Limonest, France)
See also Figure 66.9a (video tutorial available at: http:// ⚪ One green top buffer 2
alvedia.com/movie-procedure-chromatography-tests). ⚪ One wash buffer
⚪ One test tube (1.2 ml)
Items Required
⚪ One empty well plastic stand
● Recipient plasma – EDTA, ACD, or CPD anticoagulants ⚪ One pipettes (1 drop = 40 μl)
only; do not use heparin ⚪ Instructions
● Donor whole blood – EDTA tube or stored blood-bag
segment (pigtail) in ACD or CPD Procedure
● Centrifuge
Takes around 25 minutes.
● Timer
1) Preparation of blood samples:
● Quick Test XM canine kit containing (Figure 66.9b):
a) Donor EDTA tube – centrifuge EDTA blood tube
⚪ One XM Quick Test (5 minutes at 1000× G). Discard the plasma to col-
⚪ Two blood collector strips lect pRBCs. Donor blood-bag segment – collect
⚪ One blue top buffer 1 packed red blood cells (pPRBCs).
(a)
(b)
Result Interpretation
INCOMPATIBLE / DO NOT TRANSFUSE COMPATIBLE / SAFE TRANSFUSE
XM C XM C
XM C XM C
Weak line = positive result Weak line = negative result
C = Control Line
XM = Antiglobulin Test for detection of Canine CrossMatch
(c) The XM test line will often be weaker than the control line.
Figure 66.9 (a) QuickTest XM test kit. (b) QuickTest XM test kit content. (c) QuickTest XM result interpretation guide.
(d) QuickTest XM. Top – negative result (crossmatch compatible). Middle – strong positive result (crossmatch incompatible).
Bottom – weak positive result (crossmatch incompatible). Source: Courtesy of Alvedia, Limonest, France.
(d)
b) Recipient plasma – centrifuge blood tube (5 min- 12) Third washing procedure – fill the test tube up to
utes at 1000× G). Collect plasma. 1.2 ml with wash buffer. Mix the suspension three
2) Add four drops of buffer 1 in the test tube times minimum to resuspend completely.
3) Collect donor pRBCs with the blood collector strip, 13) Centrifuge at 1000× G for two minutes. Be sure to
and then suspend into the buffer 1 solution by gen- counterbalance in centrifuge.
tly stirring the collector strip in the solution for 14) Using a new pipette, discard the entire supernatant
seven seconds. Discard collector strip. (a few RBCs may be captured when pipetting the
4) With the pipette collect the recipient plasma and supernatant). Keep washed RBCs pellet to be used
transfer three drops in the test tube. Discard pipette immediately for XM test procedure. Discard pipette.
and mix gently. 15) Add three drops of buffer 2 into the empty well of
5) Incubate at room temperature for 10 minutes the plastic stand.
6) Washing procedure – fill the test tube up to 1.2 ml 16) Collect the RBCs pellet with the blood collector strip
with wash buffer. Mix the suspension three times (~10 μl).
minimum. 17) Dip the blood collector strip into the well to mix
7) Centrifuge at 1000× G for two minutes. Be sure to with buffer 2 solution, gently stirring the collector
counterbalance in centrifuge. strip in the solution for seven seconds. Discard col-
8) Discard the supernatant. The RBC pellet must stay at lector strip.
the bottom of the test tube. 18) Remove the cover of the XM Quick Test strip and set
9) Second washing procedure – fill the test tube up to the exposed membrane strip into the red cell sus-
1.2 ml with wash buffer. Mix the suspension three pension well in a vertical position.
times minimum to resuspend completely. 19) Wait 5–10 minutes to allow complete migration up
10) Centrifuge at 1000× G for two minutes. Be sure to the membrane strip and remove for interpretation.
counterbalance in centrifuge. You must see the Control line (C).
11) Discard the supernatant. The RBC pellet must stay at 20) Read results (Figure 66.9c,d).
the bottom of the test tube.
References 877
crossmatch procedure is too sensitive and identifying incompatibility and post-transfusion RBC viability.
clinically irrelevant incompatibilities [11]. Further work Continued research determining the accuracy of POC
is needed to determine what grade of tube agglutination and laboratory crossmatch methods in predicting clinically
crossmatch incompatibility is predictive of in vivo relevant incompatibilities is warranted.
References
1 Bucheler, J. and Giger, U. (1993). Alloantibodies against A 9 Davidow, E.B., Blois, S.L., Goy-Thollot, E. et al. (2021).
and B blood types in cats. Vet. Immun. Immunopath. 38: Association of Veterinary Hematology and Transfusion
283–295. Medicine (AVHTM) Transfusion Reaction Small Animal
2 Weinstein, N.M., Blais, M.C., Harris, K. et al. (2007). A Consensus (TRACS) part 2: prevention and monitoring.
newly recognized blood group in domestic shorthair cats: J. Vet. Emerg. Crit. Care 31: 167–188.
the Mik red cell antigen. J. Vet. Intern. Med. 21: 287–292. 10 Goy-Thollot, I., Giger, U., Boisvineau, C. et al. (2017).
3 Seth, M., Jackson, K.V., and Giger, U. (2011). Comparison Pre- and post-transfusion alloimmunization in dogs
of five blood-typing methods for the feline AB blood group characterized by 2 antiglobulin-enhanced crossmatch
system. Am. J. Vet. Res. 72: 203–209. test. J. Vet. Intern. Med. 31: 1420–1429.
4 Seth, M., Jackson, K.V., Winzelberg, S., and Giger, U. 11 Guzman, L.R., Streeter, E., and Malandra, A. (2016).
(2012). Comparison of gel column, card and cartridge Comparison of a commercial blood crossmatching kit to
techniques for dog erythrocyte antigen 1.1 blood typing. the standard laboratory method for establishing blood
Am. J. Vet. Res. 73: 213–219. transfusion compatibility in dogs. J. Vet. Emerg. Crit. Care
5 Proverbio, D., Perego, R., Baggiani, L., and Spada. (2019). A 26: 262–268.
card agglutination test for dog erythrocyte antigen 1 12 Villarnovo, D., Burton, S.A., Horney, B.S. et al. (2016).
(DEA 1) blood typing in donor dogs: determining an Preliminary evaluation of a gel tube agglutination
appropriate cutoff to detect positivity using a receiver major crossmatch method in dogs. Vet. Clin. Pathol.
operating characteristic curve. Vet. Clin. Path. 48: 630–635. 45: 411–416.
6 Santa-Domingo, N.E. and Lewis, D.H. Indications for use 13 Humm, K.R. and Chan, D.L. (2020). Prospective
and complications associated with canine plasma products evaluation of the utility of crossmatching prior to first
in 170 patients. J. Vet. Emerg. Crit. Care 31: 263–268. transfusion in cats: 101 cases. J. Small Anim. Pract. 61:
7 Goulet, S. and Blais, M.C. (2018). Characterization of 285–291.
anti-Dal alloantibodies following sensitization of two 14 Marshall, H., Blois, S.L., Abram-Ogg, A.C.G. et al. (2021).
Dal-negative dogs. Vet. Pathol. 55 (1): 108–115. Accuracy of point-of-care crossmatching methods and
8 Hourani, L., Weingart, C., and Kohn, B. (2017). crossmatch incompatibility in critically ill dogs. J. Vet.
Alloimmunisation in transfused patients: serial Emerg. Crit. Care 35: 245–251.
crossmatching in a population of hospitalized cats. J. Feline
Med. Surg. 19 (12): 1231–1237.
879
67
Blood Transfusion
Julien Guillaumin and Kristin Kofron
Blood transfusion is common in small-animal practices, 28–30-day shelf life. Other additives (e.g. Optisol®, Adsol®)
especially in multispecialty or tertiary centers. It is impor- can be added as a source of energy, increasing the shelf-life
tant for both clinicians and technicians to be familiar with to 35 or 42 days, respectively [4].
the various types of blood products available, as well as their
indications and adverse effects. Blood components can be
Indications
used to improve tissue oxygen delivery with red blood cells
(RBC), to replace blood proteins (e.g. coagulation factors, The main indication for pRBC transfusion is to treat anemia
albumin) with plasma, or to replace blood volume in an and improve oxygen delivery. Oxygen delivery is cardiac
exsanguinating patient [1–3]. Platelet products, used to output and arterial oxygen content (CaO2), expressed as:
replace depleted platelet stores, are used less commonly.
1.34 Hb SaO2 0.003 PaO2 g / dl
Blood component transfusion is privileged in blood
banking. Separating fresh whole blood (FWB) in its various
where Hb = hemoglobin, SaO2 = saturation of hemoglobin
components allows for better individual use, improved
with oxygen in arterial blood, PaO2 = partial pressure of
storage and fewer adverse effects (Table 67.1) [4]. In dogs,
oxygen in arterial blood.
the most common reason for using packed red blood cells
Using normal values for each component, CaO2 is equal
(pRBC) is hemorrhage, and for plasma it is coagulopa-
to approximately 20 g/dl, with 19.7 g/dl being the oxygen
thy [5, 6]. In some circumstances, blood can be delivered as
present at the RBC surface, and only 0.3 g/dl being the dis-
FWB, therefore providing all components at the same time.
solved oxygen. Thus, the RBC is the most important part of
In cats, both component therapy and FWB transfusion is
oxygen transportation in the blood, whereas PaO2 becomes
common, although it is less documented than in dogs.
the most important part of oxygen diffusion to the cells, for
Pretransfusion testing, especially the correct blood type
use in cellular ATP formation. Transfusion of RBC also
and blood cross-matching, is important to limit the risks of
increases blood volume and can improve oxygen delivery
transfusion reactions [7]. Reactions can vary from life-
by increasing stroke volume and cardiac output. In a retro-
threatening hemolysis in cases of incompatible transfu-
spective study on over 3000 canine cases, the most com-
sions, especially in cats, to mild febrile reactions [4, 8].
mon reason for pRBC transfusion was hemorrhage (68%),
with neoplasia (36%) being the leading reason for hemor-
rhage before trauma (13%) and surgical blood loss (12%).
Packed Red Blood Cells
Hemolysis was the major cause of anemia in those dogs
(16%), with immune-mediated hemolytic anemia account-
Definitions
ing for 90% of these cases [6].
pRBC is the most commonly transfused blood product. The decision to transfuse is based on clinical signs [9]. If
pRBC is a refrigerated (2–6°C) stored product obtained the anemia is chronic, compensatory mechanisms develop,
after FWB fractionation. Storage medium consists of acid- aimed to maintain energy production. It includes mainte-
citrate-dextrose, which allows for a 21 days shelf life or nance of normal blood volume (through the renin-
citrate-phosphate-dextrose-adenine, which allows for a angiotensin-aldosterone and antidiuretic hormone
880 Blood Transfusion
Table 67.1 Types of blood products, and their components, response, as the absence of regenerative response makes
available in veterinary medicine. the patient at risk for more prolonged periods of anemia.
Listed as the last criteria on purpose is the hemoglobin
Blood product Contains (or hematocrit) level. In critically ill humans, pRBC trans-
fusions are recommended at a hemoglobin level of 7 g/dl
Fresh whole blood Red blood cells, white blood cells,
plasma, platelets (hematocrit of 21%), decreased for the hemoglobin of 10 g/dl
(hematocrit of 30%) rule, unless the patient has clinically
Packed red blood cells Red blood cells, plasma
significant heart disease, severe hypoxemia, or acute hem-
Fresh frozen plasma Clotting factors, albumin,
immunoglobulins, plasma orrhage [10, 11].
Frozen plasma (> 1 year Clotting factors (except FV and
or > 6 hours) FVIII), immunoglobulins, Dose
albumin plasma
Cryoprecipitate Factors VIII, XIII, von Willebrand Studies showed that dogs receiving a pRBC transfusion
factor, fibrinogen (factor I) have an average hematocrit of 18% [6]. The usual goal of
Cryopoor plasma Factors other than VIII, XIII, I, transfusion is to abate clinical signs, and reach a safer hem-
and vWF, including vitamin atocrit, usually between 25% and 30%. Therefore, a hema-
K-dependent factors tocrit increase of around 10 points is usually needed. The
Platelet-rich plasma or Platelets, plasma current belief is that 1.5 ml/kg is required to increase
platelet concentrate
1 point hematocrit [12], which is a higher volume that the
previous dogma that 1 ml/kg will increase 1 point of hema-
systems), improvement of PaO2, local vasoconstriction tocrit. Clinicians may also use the following formula to pre-
directing blood flow to the most important organs, decreas- dict a volume of pRBC (ml) to transfuse:
ing activity to lower oxygen consumption, and changes in
Volume = body weight (kg) × blood volume (90 ml) ×
cellular metabolism toward anaerobic ATP production (i.e.
[(desired PCV − recipient PCV)/donor
hyperlactatemia). PCV] [12].
Clinicians can use various criteria to determine a
patient’s need for a pRBC transfusion [9]. First, age and If using FWB, the calculation uses 2–3 ml/kg FWB to
comorbidity of the patient, as it can be related to the ability increase hematocrit by 1 point.
to develop compensatory mechanisms or increased oxygen
consumption. Second, the chronicity of the anemia,
Blood Types and Pretransfusion Testing
directly related to the development of compensatory mech-
anisms, should also be considered. Eight dog erythrocyte antigens (DEAs) exist, with DEAs
Presence of clinical signs related to the anemia is a com- 1.1, 1.2, and 7 being clinically significant. It has been
mon criterion for clinicians to decide whether a transfu- shown that the DEA 1 group is a continuum from negative
sion is needed. However, it is a challenging criterion, as to strongly positive antigen expression, meaning that previ-
100% of anemic patients will have clinical signs, varying ously typed DEA 1.2-positive and 1.3-positive are just DEA
from mild (e.g. lethargy, pale mucous membranes) to more 1-positive [13]. The rule of thumb in canine pRBC transfu-
severe (e.g. syncope, severe tachycardia, hyperlactatemia). sion is that dogs do not have naturally occurring antibodies
With the risks associated with pRBC transfusion, it should against DEA 1 blood type, but they will develop anti-DEA
be done when clinical signs are more severe, for example in 1 antibody when in contact (i.e. transfused) with DEA
a failure in the maintenance of energy production, usually 1-positive RBCs. Those antibodies will cause agglutination
represented by hyperlactatemia. Presence of blood loss and and hemolysis if DEA 1-positive blood is transfused again.
hypovolemia is different than the euvolemic, hemolytic Put in simple words, dogs may have a “free pass” on the
anemia patient. Euvolemic patients have more risks of first transfusion of RBCs. However, dogs have naturally
fluid overload when transfused. Hypovolemic bleeding occurring antibodies for some DEA types that may result in
patients benefit the most from a blood transfusion to delayed reaction (e.g. DEA 3, DEA 4, DEA 5, and DEA 7).
expand the blood volume and provide oxygen carrying Testing for canine blood types other than DEA 1.1 is con-
capacity. Several criteria are used in the decision to trans- troversial and complicated by reagent availability. A new
fuse, the cause of anemia (e.g. the transfused RBC will common blood type named Dal has been identified in
likely be destroyed by a hemolytic patient), the risks associ- Dalmatians, with a presumed prevalence of 20%.
ated with transfusion, including screening availability (i.e. Dalmatians lacking the Dal antigen are likely at risk of
blood type and crossmatch) or history of previous transfu- acute and delayed hemolytic reactions [14]. Although ini-
sion, and the presence or absence of a regenerative tially described in the Dalmatian breed, the prevalence of
Packed Red Blood Cells 881
Table 67.2 Prevalence of blood types and naturally occurring DEA 1-positive blood leading to a strong, acute hemolytic
antibodies. reaction if transfused again with DEA 1-positive blood.
Cross-matching is done by mixing the RBCs of the donor
Presence of with the plasma of the recipient (major cross-match) or the
Population naturally
DEA prevalence occurring
RBCs of the recipient with the plasma of the donor (minor
group (%) antibody Transfusion significance cross-match) and observing for agglutination [4]. Cross-
matching answers the question regarding current compat-
1a 62 No Acute hemolytic ibility between a specific donor and a specific recipient
reaction (< 12 hours) blood type “profile.” Because of current concerns regarding
3 6 Yes (20%) Delayed reaction (i.e. Dal antigen and delayed hemolytic reactions, it may be
decreased RBC survival)
prudent to both blood type and cross-match canine
4 98 No None patients, regardless of whether they have already received
5 23 Yes Delayed reaction (i.e. a blood transfusion, as recommended in cats.
decreased RBC survival)
Cats have three major blood types A, B, and AB. A is the
6 98–99 No Unknown most common blood type (95–99% of cats in the United
7 45 Yes Delayed reaction (i.e. States). Type B is less common in domestic breeds but is
(20–50%) decreased RBC survival) seen with more frequency in other breeds (e.g. Devon Rex,
8 40 No None British Shorthair) or in other geographic locations (e.g.
a
Previously known as 1.1 and 1.2. The blood group system DEA 1 is Turkey). Cats have naturally occurring circulating alloanti-
a continuum from negative to strongly positive antigen expression, bodies targeting the blood type they do not carry. Type B
meaning that previously typed DEA 1.2+ and DEA 1.3+ appears to cats have more antigenic anti-A antibodies, and transfusion
be DEA 1+ [13].
of a type B cat with A blood could result in severe hemolytic
DEA, dog erythrocyte antigen; RBC, red blood cell.
Source: Adapted from Hale [16]. transfusion reaction. Type A cats have fewer antigenic anti-B
antibodies, so transfusion of a type B blood to a type A cat
may result in lower lifespan of the transfused cells. Another
dogs lacking the Dal antigen (i.e. Dal negative) and risking erythrocyte antigen, Mik, has also be described and can
a transfusion reaction, is actually higher in Shih Tzu result in acute hemolytic reaction due to circulating alloan-
(almost 60%) and Doberman Pinscher (over 40%), with tibodies. Owing to the risk of reaction, it is recommended
other small breeds such as Lhasa Apso and Bichon Frise that all cats should be blood typed before transfusion.
between 20% and 30% Dal negative [15]. The prevalence of Because no test is available for detecting the Mik antigen, a
blood types and naturally occurring antibodies presence is cross-match is also recommended before transfusing a cat,
shown in Table 67.2. No anti-Dal alloantibodies were even if the cat has not been previously transfused.
detected in plasma of the 23 Dal-negative dogs tested with-
out prior transfusion history in a 2017 study [15]. It is rec-
In Practice
ommended that the blood type of all donors and recipients
be known prior to transfusion (for at least DEA 1) so type- pRBC are administered through a 170–210 μm filter, avail-
specific blood can be administered. able in commercial blood delivery sets. pRBC are usually
With the findings regarding the Dal antigen, and transfused over four hours in normovolemic patients, but
although we used to say that dogs could get a “free pass” for can be transfused much faster, even as a bolus, in hypov-
their first transfusion, clinical practice is changing. In a olemic patients, such as the ones actively bleeding and
2017 study, it was shown that 17% of 148 of transfusion- exsanguinating. Blood should not be given concurrently
naïve dogs were incompatible with one or two of the three with hyper- or hypotonic solutions. Calcium-containing
potential donors. Interestingly, the change in hematocrit solutions (e.g. lactated Ringer’s solution) should also be
after transfusion was significantly higher in dogs whose avoided, as calcium may bind to citrate and “neutralize”
blood had been cross-matched (12.5 ± 8.6%) compared the anticoagulant in the fluid line. It has been shown that it
with dogs whose blood was not cross-matched is preferable to use gravity instead of fluid pump to better
(9.0 ± 4.3%) [17]. These findings suggest that incompatibil- preserve transfused cells [18].
ity can still happen in DEA 1-compatible patients.
It is important to recognize that blood typing and cross-
Adverse Effects and Reactions
matching are answering two different questions. Blood typ-
ing technically only answers the question, “what is the Transfusion reactions are usually divided in between
patient’s DEA 1 status?” We cannot tell whether a patient acute immune-mediated transfusion reactions and
will develop strong anti-DEA 1 antibody if transfused with nonimmune-mediated transfusion reactions (Table 67.3).
Table 67.3 List of transfusion reactions, clinical signs, and appropriate therapy.
Reaction Type Clinical signs Treatment
Hemolytic II hypersensitivity Vomiting, hypotension, Stop the transfusion, treat

tachycardia, tachypnea, symptomatically, intravenous fluids to
pyrexia promote diuresis
Anaphylactic I hypersensitivity Urticaria, pruritus, often Stop the transfusion, administer
with plasma products antihistamines or a small dose of steroids
Anaphylactic shock I hypersensitivity Cardiovascular collapse, Stop the transfusion, treat symptomatically
dyspnea, seizures with intravenous fluids, epinephrine
Leukocytes and platelet Increase in body Stop the transfusion, may be restarted at a
sensitivity temperature of at least 1°C lower rate
Nonimmune-mediated reactions include hemolysis (e.g. Frozen plasma is thought to be depleted of co-factors V and
inappropriate collection, storage, or administration), bac- VIII, although this human dogma has been challenged in
terial contamination, transfusion-associated circulatory veterinary medicine [25]. The maximum storage length is
overload, hypothermia (i.e. in case of rapid transfusion of five years for fresh frozen or frozen plasma [4]. FFP can be
inappropriately warmed products), citrate toxicity (caus- further divided in cryoprecipitate and cryopoor plasma,
ing hypocalcemia), transfusion-related immunomodula- because different factors have different freezing points.
tion, or transfusion-associated acute lung injury (TRALI), Cryoprecipitate is made by partially thawing FFP at
which has been described in humans. Although TRALI is 4 degrees C for 24 hours and removing the supernatant,
the leading cause of transfusion-related morbidity and which leaves the semisolid cryoprecipitate, containing fac-
mortality in humans, it is caused by antibodies directed tor VIII, fibrinogen and von Willebrand factor (vWf) [4].
against human neutrophil antigens present in the plasma The supernatant is cryopoor plasma, also known as cryosu-
of predominantly multiparous female blood donors. It is pernatant or cryodepleted plasma. Cryoprecipitate is indi-
thus unclear whether other species can develop cated for bleeding associated with vWf deficiency or
TRALI. Leukoreduction (the removal of white blood cells, hemophilia A, as well as hypofibrinogenemia cases such as
WBC, from pRBC) has been shown to decrease inflamma- the exsanguinating patient, whereas cryopoor plasma is
tion markers post-transfusion in experimental dogs, but listed for use in vitamin K antagonist rodenticide toxicities
not presently in clinical patients [19, 20]. and hypoalbuminemia [4]. Albumin therapy is covered in
Acute transfusion reactions to pRBC are documented in Chapter 68.
15% of cases in a retrospective study of 136 dogs, with fever
and vomiting documented in 53% and 18%, respectively [21].
Indications
Neonatal isoerythrolysis is possible in cats, but its pres-
ence in dogs necessitates a previously sensitized (i.e. trans- The major indication for FFP transfusion is coagulopathies
fused) bitch with an incompatible sire [22, 23]. (e.g. anticoagulant rodenticide intoxication, hemophilia A
Finally, the age of the transfused pRBCs may be a varia- or B). FFP transfusion is considered to be inappropriate for
ble affecting the risk of transfusion-related hemolysis. In a treating increased clotting times without evidence of clini-
retrospective study of 210 dogs, the age of stored pRBC cal bleeding (including for a minor procedure), or for
products was associated with increased risk of transfusion- α-macroglobulin replacement in pancreatitis, or antithrom-
related hemolysis, but not with fever [24]. bin replacement in disseminated intravascular coagula-
tion [4, 26]. A secondary indication is species-specific
albumin replacement.
Plasma Products
Dose
Definitions
Considering that clotting times become increased when
Fresh frozen plasma (FFP) is plasma separated from pRBC 70–80% of clotting factors are missing, and that a
after FWB donation, and frozen within six to eight hours of 10–20 ml/kg of FFP will provide a 10–20% replacement of
collection or stored for less than one year at 30 degrees C or clotting factors, the rule of thumb is to transfuse 10–20ml/kg
lower. Frozen plasma is FFP stored for more than one or of FFP to patients with clinical bleeding due to a coagu-
two years, or frozen after six to eight hours of collection. lopathy. When FFP is used as an albumin replacement
Platelets 883
fluid, the dose is 20–50 ml/kg/day, or approximately 1 ml/ and anxiety. Adverse effects were noted in less than 1% of
kg/hour (depending on reference and formula used). It cases [5].
may predispose some patients to volume overload, and
there is an increased cost of hospitalization. When FFP
transfusion is provided in exsanguinating patients, where
Platelets
it is recommended to provide a one to one ratio of pRBC
to plasma products [27]. In this case, the volume trans-
Definition
fused may reach a total of approximately 20–40 ml/kg.
The dose of cryoprecipitate is 12–20 ml/kg (correspond- Platelets are extremely fragile, and their viability may be
ing usually to 1 unit /10 kg). The dose for cryopoor plasma compromised with manipulation. The gold standard in
is 10–20 ml/kg. human medicine is therefore platelet concentrate har-
vested from FWB kept at room temperature under constant
agitation for up to five days [33]. The American Association
In Practice
of Blood Banks currently recommends as a cut-off point
After thawing in (ideally) a warm water bath at 37 degrees greater than 5.5 × 1010 platelets/unit of random donor
C (which usually takes around 35–45 minutes), FFP can be platelets (i.e. 50–60 ml) [34]. The US Food and Drug
administered to patients over four hours in normovolemic Administration (FDA) decreased the expiration date for
patients, or faster if hypovolemia is present. If plasma room-temperature stored platelets from seven to five days
product is used as a constant-rate infusion, for example for in 2016, except when the platelets are stored in a container
albumin replacement, it can be given as a rate of 1–2 ml/ approved by FDA for seven-day storage and the individual
kg/hour [28]. platelets units are tested for bacterial detection [35].
Several methods have been described regarding thawing Although a platelet-concentrate product is commercially
FFP. Although FFP has been thawed using a regular micro- available in veterinary medicine, because of the nature of
wave oven using approximately 15 cycles of 10 seconds, the need for platelet concentrate many veterinarians
and has been shown to have similar activated partial mostly rely on FWB, fresh platelet-rich plasma (PRP) or
thromboplastin times, one-stage prothrombin times, con- fresh platelet concentrate [36]. Any fresh product must be
centrations of fibrinogen, factor VIII coagulant activity, used within six to eight hours.
and vWf antigen levels to aliquots thawed in a warm water Platelets can be harvested following a PRP protocol
bath, it is not a preferred method of thawing [29]. One (i.e. hard and soft spin) or a buffy coat technique [37].
study has shown that a running water bath had the shortest In veterinary medicine, the comparison of both meth-
thaw time (i.e. 15 minutes) compared with a dry plasma ods showed that the PRP-derived platelet concentrate
thawer or warm water bath, while maintaining levels of had lesser white blood cell and pRBC contamination
clinically similar hemostatic proteins [30]. Finally, one and superior platelet function compared with the buffy
study has shown that using commercial microwave plasma coat technique [37]. Platelets can also be harvested by
defrosters allows thawing in three to five minutes while pheresis (a standard of > 3 × 1011 platelets/unit of
maintaining clinically relevant activities of clotting factors apheresed platelet concentrate, with a volume around
and fibrinogen concentration, although no control group 300 ml) [38]. During the platelet pheresis procedure,
was used and some measurements of factor VIII activity blood is removed from the donor through an extracor-
fell below the reference interval [31]. poreal circuit, anticoagulated and separated into com-
Finally, the hemostatic activity of liquid phase (i.e. refrig- ponents by centrifugation, allowing production of a
erated) canine plasma has been investigated [32]. This platelet concentrate, while the other blood components
product is used in humans with catastrophic hemorrhage are returned to the donor. The advantages of platelet
needing massive transfusion. The study showed that refrig- concentrates prepared by apheresis in comparison with
erated storage resulted in significant decreases in the activ- PRP or from a unit of FWB are greater platelet yield and
ity of all clotting factors, although no values were outside negligible pRBC and WBC contamination [36].
of the reference interval. Importantly, none of the bacterial Apheresis has also been used in veterinary medi-
cultures at days 7 and 14 yielded growth [32]. cine [39–42]. Preservation of platelets using cryopreser-
vation or freeze–dry cycle (i.e. lyophilized) are being
investigated. A lyophilized canine platelet product is
Adverse Effects and Reactions
commercially available but its hemostatic activity is
Transfusion reaction to plasma has been documented in unknown [41]. In humans, it appears that some cryo-
a retrospective study of more than 300 canine plasma preserved or lyophilized platelets may preserve some
transfusion. The only adverse effects were fever, pruritis, hemostatic activity through microparticles [43].
Table 67.4 Platelet products that are available in veterinary practice, approved by the US Food and Drug Administration in humans
and current alternatives to fresh platelet products, either available commercially or in development.
Product Storage Advantages Disadvantages
Fresh whole 6–8 hours May be the only option; should have good Donor availability
blood post-transfusion platelet recovery and function. Lack of time for donor testing
Short shelf-life
Fresh platelet 5–7 days Good post-transfusion platelet recovery (dog, Short shelf-life
rich plasma or 80%), survival (dog, half-life 3.8 days), and Limited availability
platelet function; FDA approved in humans; Risk of bacterial proliferation during room
concentrate commercially available in veterinary medicine temperature storage
Cold stored Up to 3 days Decreased risk of bacterial proliferation; do not May be cleared more rapidly compared to
platelets require bacterial testing; can be stored with fresh platelets
agitation FDA approval restricted only for the
resuscitation of actively-bleeding trauma
patients
Canine Shelf life is Long term storage; commercially available Reduced post-transfusion platelet recovery
lyophilized 1 year (BodeVet Inc., Rockville, MD) (dog, 49%) and half-life (dog, 2 days);
platelets Stable impaired in vitro function, although
Plate RX™ evidence of hemostatic efficacy in vivo
Cryopreserved Shelf life not Long-term storage; commercially available Lack of preclinical or clinical data
platelets available on (Animal Blood Resources International,
package insert Stockbridge, MI)
Synthoplate™ Unknown Long-term storage; not species specific Lack of preclinical or clinical data; not
(synthetic nanoparticles); commercially available for sale
available (Haima Therapeutics, Cleveland, OH)
Various platelet products characteristics are presented severe, life-threatening bleeding due to thrombocytopenia,
Table 67.4 [36]. There are minimal clinical data regarding with intracranial bleeding or pulmonary bleeding being the
the use of fresh platelet products in veterinary medicine. principal indications [36, 46]. Prophylactic platelet transfu-
sion is rare in veterinary medicine. Also, in clinical practice,
bleeding secondary to thrombocytopenia is caused in the vast
Indications
majority of cases by immune thrombocytopenia, where it is
Historically, many physicians have transfused platelets to unclear whether transfused platelets will survive [46].
maintain platelet count above 20 × 109/l, with the belief However, in dogs with immune thrombocytopenia experi-
that this level was required to prevent spontaneous bleed- encing uncontrolled or life-threatening bleeding (e.g. sus-
ing [44]. However, there is difficulty in defining an pected bleeding into the brain, myocardium, or lungs),
optimal transfusion trigger because major hemorrhage is platelet transfusions may provide short-term hemostasis
rare, even at very low platelet numbers (i.e. < 5 × 109/l), despite a negligible increase in platelet count following
minor clinical bleeding is difficult to quantify, and transfusion [36].
platelet counts are less accurately determined at the low Platelet numbers commonly quoted as a transfusion trig-
platelet numbers found in severely thrombocytopenic ger that put the veterinary patient at risk for spontaneous
patients, making the distinction between 5 × 109 and bleeding are 5–20 × 109/l [36, 46]. It is worth noting that the
20 × 109/l challenging [44]. Unfortunately, even in common transfusion trigger of 20 × 109/l comes from a case
human medicine, there is no clear consensus of clinical report/small case series in human cancer patients from
indications for prophylactic platelet transfusion, only 1962 [47]. Besides the platelet count, the presence of active
guidelines [38, 44, 45]. There is little evidence for the bleeding (e.g. dropping hematocrit, visible bleeding) in life-
effectiveness of therapeutic platelet transfusions or the threatening places (e.g. lungs, brain), or invasive procedures
optimal dose when a patient with thrombocytopenia is are indications for platelet transfusion [4, 36, 48].
actively bleeding [45]. In a veterinary study investigating the use of lyophilized
There is also no consensus in veterinary medicine, partly platelets, dogs were eligible to receive platelet products if
because platelet transfusion is challenging in veterinary med- they had a platelet count of less than 70 × 109/l and evi-
icine. Most clinicians recommend platelet transfusion for dence of active bleeding [41]. In a retrospective study on
Platelets 885
the use of cryopreserved platelet concentrate in 43 dogs, with pRBC transfusion [50]. In humans, 2% of the platelet
indications were retrospectively divided between prophy- transfusions were associated with a severe reaction defined
lactic (i.e. < 10 × 109/l in absence of other risks factor for as increase in temperature of more than 2 degrees C, shak-
bleeding, or < 20 × 109/l if other risks factors such as dis- ing, chills, extensive urticaria, dyspnea, cyanosis, or bron-
seminated intravascular coagulopathy, sepsis, or elevating chospasm [51]. In veterinary medicine, a canine study
clotting times) and therapeutic (i.e. < 50 × 109/l prior to using lyophilized platelet concentrate, 14% of the
surgery or < 60 × 109/l with major bleeding requiring RBC lyophilized groups had a possible mild transfusion reac-
transfusion) [49]. tion, including a 2-degree F (1°C) rise in rectal tempera-
ture, sinus tachycardia, and one episode of emesis. Thirteen
percent of the dogs receiving fresh platelets had a mild
Dose
transfusion reaction, one dog developed urticaria and peri-
Most consensus recommendations quote 1 unit of platelet orbital swelling and one experienced emesis. No delayed
concentrate/10 kg body weight as their platelet dose, which transfusion reactions were recognized [41].
the author assumed consisted of a pooled unit (i.e. four to The main risks of platelet transfusion are the role of leu-
six whole blood units) of whole blood-derived platelets, kocytes and platelets in acute inflammation, as well as bac-
containing greater than 4 × 1010 platelets/pooled unit, for a terial contamination. Febrile, nonhemolytic transfusion
final volume of 300 ml, or one apheresis platelet unit, con- reactions, defined as a temperature increase of greater than
taining greater than 3 × 1010 platelets/unit, also for a final 1 degree C associated with transfusion and without any
volume of 300 ml [38, 44]. other explanation, are often accompanied by chills or rig-
For a “typical” human being of 70 kg/2 m2, the low dose ors and occur with a reported frequency of up to 38% of
corresponds to a 3 × 1010 platelets/10 kg, and the high dose platelet transfusions [34, 36].
would be around 10 × 1010 platelets/10 kg. Dosage recom- Because platelet concentrate is stored at room tempera-
mended by the package insert for the lyophilized platelet ture, contaminating bacteria introduced during phlebot-
product StablePlate Rx™ is 3 × 1010 particles/10 kg. omy or, less likely, during blood processing or transient
In therapeutic platelet transfusion, the goal may not be a donor bacteremia, may rapidly proliferate with administra-
platelet increment but an improvement in clinical tion of the contaminated unit potentially causing
bleeding [48]. transfusion-associated sepsis. A study investigating more
than 100 000 platelet units found 50 contaminated units.
Forty-two of those were transfused, resulting in 16 septic
In Practice
transfusion reactions, including 1 fatality [52]. However,
As many in veterinary medicine rely on FWB for platelet since then, interventions such as leukodepletion, the use of
transfusion, it requires the availability of a blood donor and male donor plasma, irradiation and bacterial screening,
blood typing and/or cross-matching precautions, as pRBC have significantly reduced the risk of harm from platelet
will also be transfused. The product should be transfused transfusions [53].
rapidly after donation and procession, usually within six to
eight hours after the blood donation. As the dose is the
Alternatives to Platelet Transfusion
equivalent of 1 unit/10 kg of platelet concentrate, which
comes from 1 unit FWB, then the dose of FWB is Owing to the lack of availability of platelet transfusion, cli-
1 unit/10 kg, or around 40 ml/kg. This represent both an nicians have been relying on pRBC or plasma transfusion
unsurmountable number of blood donors for a large dog, as alternatives. The rationale for use of pRBC is that ane-
but also increases the risk of blood overload for the patient. mia increases bleeding times, which can be corrected with
Finally, the clinician should expect no increase in platelet reversal of the anemia [36, 54]. Proposed mechanisms for
count following a FWB transfusion, and sometimes a the role of pRBC in hemostasis include the relocation of
decrease due to hemodilution, as the platelets will be platelets from the center of the blood vessel toward the ves-
immediately consumed during hemostatic processes. sel wall, improving contact between platelets and endothe-
However, a decrease in clinical bleeding should be expected lial cells; improvement of platelet function through release
if the transfusion is successful. In humans, 1- and 24-hour of ADP and increased production of thromboxane, as well
increments are usually measured. as scavenging of endothelial cell nitric oxide (inhibiting
platelet function) [54]. It has been suggested that a PCV
above 20% could be an appropriate target [55].
Reactions
The use of FFP, as source of microparticles, has also been
In humans, acute transfusion reactions associated with advocated [56]. This strategy can be implemented for ane-
platelet transfusion are three times more frequent than mic and/or hypoproteinemic patients, especially with
non-life-threatening bleeding secondary to thrombocyto- The actual measured total platelet counts for the lyophi-
penia. This includes surgical or gastrointestinal bleed. The lized platelets used for that clinical trial material ranged
use of desmopressin (1-deamino-8-D-arginine vasopressin, from 52 to 57 × 109/units. The dosing regimen provided
abbreviated DDAVP), as a platelet function stimulator, and approximatively 3.3 × 109 lyophilized platelets/kg. There
the use of antifibrinolytics such as aminocaproic acid and was no difference between groups in all outcome variables
tranexamic acid, has also been advocated [57]. (i.e. transfusion reaction rates, the need for additional
Preservation of platelets using cryopreservation or lyo- transfusions, 24-hour bleeding scores, hospitalization time,
philization have been investigated in both veterinary and survival to discharge, or 28 days’ survival) [41]. The manu-
human medicine. A commercial dimethyl sulfoxide- facturers’ recommended dose of StablePlate RX is 3 × 109/kg,
stabilized frozen canine platelet concentrate is availa- equivalent to one 8 ml vial for 5 kg. A 2020 clinical trial
ble [53], although in vitro studies indicated that there was enrolled 88 dogs with bleeding associated with thrombocy-
a decrease in platelet quantity and function as well as an topenia and found that StablePlate RX was clinically not
increase in platelet activation during the freeze-and-thaw inferior to dimethyl sulfoxide (DMSO) frozen platelets [61].
process [58, 59]. However, it is possible that frozen platelets Early trends indicated that StablePlate RX may reduce
retain some hemostatic activity through microparti- bleeding score in patients and show an increased one-hour
cles [43]. Ng et al. retrospectively reported the clinical use post-infusion platelet count compared with DMSO plate-
of the commercially available cryopreserved PC in 43 dogs lets, although the DMSO platelets are higher than
and compared it to 43 control dogs [49]. Although there StablePlate RX at 24 hours (no statistics available). A lyo-
was a statistically significant increase in platelet count philized human platelet product, Stasix™ from Entegrion,
after transfusion and the transfusion was well tolerated, has been tested in an uncontrolled bleeding model in pigs
the cryopreserved platelet concentrate was not found to be and prevented blood loss and improved survival [62].
effective in improving clinical bleeding or increasing sur- However, the testing and manufacturing of this product
vival compared with the control group [49]. has been halted. In an experimental model of splenecto-
A lyophilized canine platelet concentrate, Stable Plate mized canines on cardiopulmonary bypass with prolonged
RX™ (BodeVet, Rockville, MD), is also commercially avail- bleeding times, infusion of lyophilized platelets showed
able. The improvement of preparation and fixation of lyo- consistent and persistent lowering of bleeding times com-
philized platelets have led to a renewed interest in such pared with control [63].
product. Lyophilized platelets has been tested in rabbit, Finally, a synthetic platelet nanoparticle (SynthoPlate™,
dogs, swine, and baboon models, and seemed to improve Haima Therapeutics, Cleveland, OH) is being investigated
hemostasis [60]. A multicentric pilot study tested a lyophi- for both human and animal use. This non-species-specific
lized canine platelet product that is different from the com- nanotechnology has been shown to reduce bleeding in a
mercially available lyophilized platelet concentrate in 22 porcine model of hemorrhagic shock and in a murine
dogs and compared it with 15 dogs receiving fresh platelets. model of thrombocytopenia [64, 65].
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(2008). Correction of the bleeding time with lyophilized 65 Hickman, D.A., Pawlowski, C.L., Shevitz, A. et al. (2018).
platelet infusions in dogs on cardiopulmonary bypass. Intravenous synthetic platelet (SynthoPlate)
Clin. Appl. Thromb 14 (1): 38–54. nanoconstructs reduce bleeding and improve “golden
64 Dyer, M.R., Hickman, D., Luc, N. et al. (2018). hour” survival in a porcine model of traumatic arterial
Intravenous administration of synthetic platelets hemorrhage. Sci. Rep. 8 (1): 3118.
891
68
Administration of Other Biological Products

Jennifer E. Prittie and Jasmine De Stefano
The administration of biologic products to veterinary a disease. These are biologic products widely administered
patients has become common practice in emergency and to animals, both to protect the individual patient from dis-
critical care. Indications include treatment of anemia, ease and as a component of herd medicine.
coagulopathy, hypoalbuminemia, immune-mediated dis-
ease, snake envenomation, various intoxications, and occa-
Adverse Reactions
sionally local thrombosis. While these products can have a
positive impact on morbidity and mortality in selected can- Immune-mediated vaccine reactions in veterinary medi-
didates, their use is not without risk. Acute allergy, the cine are widely appreciated. In particular, inactivated viral
most severe form of which is anaphylaxis, and delayed vaccines contain cell growth media products (e.g. bovine or
hypersensitivity are the most adverse reactions to adminis- egg protein), stabilizers (e.g. gelatin) and/or adjuvants
tration of these products. Bleeding is an additional specific (alum) that function as nontarget antigens [1]. While small
complication that can occur subsequent to pharmacologi- amounts of immunoglobulin (Ig)G produced against these
cal thrombolysis. antigens are usually harmless, IgE-mediated reactions, or
Detrimental effects from biologic product use can be type I hypersensitivity reactions, can result in serious clini-
minimized through thoughtful selection of candidate and cal manifestations. Type I hypersensitivity reactions, also
product, appropriate administration practices, and careful termed acute hypersensitivity, allergy, or anaphylaxis,
monitoring to ensure early recognition and treatment of occur when patient/recipient mast cell IgE molecules are
adverse reactions. Red blood cell (RBC) and plasma prod- cross-linked by biologic product (vaccine, in this case) anti-
ucts are reviewed in Chapter 67. Other routinely adminis- gen. Mast cell activation and degranulation results in the
tered biologic products, their uses, recommended release of various preformed vasoactive substances from
administration protocols, and associated adverse effects the mast cells, such as proteases, serotonin, and histamine.
are covered in this chapter. Among the products discussed Leukotrienes, prostaglandins, and thromboxane are subse-
are vaccines, human and canine albumin, human intrave- quently released following activation of the arachidonic
nous immunoglobulin (hIVIG), and thrombolytic agents. acid cascade. Clinical signs associated with systemic
Specific immunoglobulin therapies for snake envenoma- release of these mediators and the resultant systemic
tion, tetanus, and digitalis glycoside toxicosis are also sum- inflammation, increased vascular permeability and periph-
marized. Those biologic products less frequently used in eral vasodilation include pruritus, facial swelling, ery-
small animal emergency and critical care (e.g. bacterial thema, urticaria, vomiting and diarrhea [2].
extracts or toxoids, erythropoietin, and arsenic compounds) It has been shown that the severity of acute hypersensi-
are beyond the scope of this chapter and are not discussed. tivity vaccine reactions is higher in dogs with higher IgE
levels against vaccine stabilizers and adjuvants [3].
Anaphylaxis represents the most severe form of acute
Vaccines hypersensitivity, and in addition to cutaneous and gastro-
intestinal signs, is manifested by respiratory distress and
Vaccines are killed, living attenuated, or living virulent cardiovascular collapse secondary to fluid extravasation
microorganisms given to increase or produce immunity to and maldistribution of blood flow [4]. While anaphylaxis
892 Administration of Other Biological Products
can occur subsequent to exposure of any foreign substance, Table 68.1 Therapies for Type 1 Hypersensitivity Reactions.
vaccines are one of the most common causative antigens in
veterinary patients, along with venoms, antimicrobials, Type of reaction Therapeutic considerations
blood components, and contrast agents [4, 5].
Acute hypersensitivity reactions are frequently reported Allergy Diphenhydramine, 2–4 mg/kg IM
following administration of other biologic products. These ± Dexamethasone sodium phosphate,
0.125–0.5 mg/kg IV, IM
products contain white blood cells (WBCs), RBCs, hemo-
globin (Hb), platelets, clotting factors, albumin, immuno- Methylprednisolone sodium succinate,
30 mg/kg IV
globulins, and/or animal-derived lipids, which can act as
Anaphylactic/ Epinephrine (1 : 1000), 0.01 mg/kg IM
antigens in the recipient animal. Hypersensitivity is par-
anaphylactoid (can repeat every 5–15 minutes);
ticularly likely upon repeat exposure to an antigenic prod- reaction alternatively, if shock present, as slow IV
uct (i.e. after prior sensitization). Previous exposure to a CRI, 0.05 μg/kg/minute
foreign substance primes the body’s immune system, and Diphenhydramine, 2–4 mg/kg IM
the body’s secondary (called “anamnestic”) response Famotidine, 0.5 mg/kg IV
involves recruitment of preformed antibodies and augmen-
Ranitidine, 0.5–2.5 mg/kg IV
tation of the original humoral immune response [2].
Dexamethasone sodium phosphate,
0.125–0.5 mg/kg IV
Administration Protocols, Monitoring, Methylprednisolone sodium succinate,
and Interventions 30 mg/kg IV
Aminophylline 5–10 mg/kg IM or slow IV
Management strategies for type 1 hypersensitivity reac-
Intravascular volume expansion
tions are similar across antigenic sources and are outlined
Vasopressors as needed: norepinephrine,
in Table 68.1. These strategies involve stopping any biologic
0.25–2 μg/kg/minute
product infusion and parenteral administration of antihis-
tamines. Product infusion can sometimes be subsequently CRI, constant rate infusion; IM, intramuscular; IV, intravenous.
reinstituted with careful monitoring (e.g. blood products;
hIVIG). Anaphylaxis is a medical emergency that require controls, respectively. Formation of a wheal at the site
aggressive intravenous (IV) fluid resuscitation and admin- 15–20 minutes later might indicate increased risk for IgE-
istration of epinephrine for α1- (vasoconstriction and blood mediated vaccine-associated hypersensitivity [1].
pressure restoration), β1− (positive inotropy and chronot- Another immune-mediated vaccine reaction is the
ropy) and β2-adrenergic (bronchodilation) actions. Possible Arthus reaction, which is a local type III hypersensitivity
ancillary therapies include administration of antihista- reaction. It is characterized by activation of complement,
mines, glucocorticoids, and bronchodilators [4–8]. The use local vasculitis, and deposition of antigen–antibody com-
of glucocorticoids for acute immune-mediated hypersensi- plexes at the injection site within the first few days of vac-
tivity is controversial [9–15]. These drugs inhibit nuclear cination [1]. While this particular reaction is typically
factor κB, which reduces production of several proinflam- self-limiting, immune complexes (biologic product antigen
matory cytokines, decreases transcription of cyclooxyge- and recipient antibody) that form from administration of
nase-2 (which converts arachidonic acid to its more active other biologic products can cause serious illness.
mediators of inflammation), and inhibits release of hista- Systemic deposition of these immune complexes that
mine and serotonin from mast cells [9–15]. However, these form within the vascular space may result in vasculitis,
anti-inflammatory effects are delayed by several hours, synovitis, arthralgia, myalgia, fever, lymphadenopathy,
likely limiting their usefulness during life-threatening neuritis, and glomerulonephritis (serum sickness). This
allergy. Given their theoretical uses, various specific steroid syndrome typically follows antigen exposure by one to
agents are still incorporated into veterinary treatment algo- three weeks. The treatment for serum sickness is largely
rithms for hypersensitivity reactions (Table 68.1) [4, 5, 9]. supportive. Plasmapheresis may be considered for severe
One additional “therapy” for acute hypersensitivity asso- cases [2, 3].
ciated with vaccination is avoidance. Certain states allow Other vaccine reactions reported in veterinary literature,
measurement of serum antibody titers as a substitute for including feline vaccine-associated fibrosarcoma, vaccine-
rabies vaccination, for example. Alternatively, potential induced disease exacerbation, and autoimmune disease
vaccine reactivity may be assessed via intradermal skin (e.g. immune-mediated hemolytic anemia, IMHA), are not
testing. To this end, 0.1 ml of vaccine is injected under the discussed in this chapter [1].
furred skin of the lateral thorax. Concurrent sterile saline Hypersensitivity reactions seen in association with bio-
and histamine injections can serve as negative and positive logic product administration are summarized in Table 68.2.
Allumin olutions 893
Table 68.2 Classification of Hypersensitivity Reactions.
Immune reaction Mechanism Clinical manifestations Timing
Type I Binding of antigen-IgE Fever, facial swelling, pruritus, urticaria, Minutes to hours
(IgE-mediated) complex with mast cells and vomiting, diarrhea, anaphylaxis following administration
release of inflammatory of biologic product
mediators
Type II (cytotoxic) Interaction between specific Intravascular hemolysis: fever, vomiting, Minutes to hours
AHTR IgG or IgM antibodies and dyspnea, hypotension, hemoglobinemia/uria following RBC
red cell-surface antigens Extravascular hemolysis: fever, jaundice, transfusion
decline in PCV
Type II (cytotoxic) Interaction between specific Extravascular hemolysis: 3–21 days post-RBC
DHTR IgG antibodies and RBC Hyperbilirubinemia/bilirubinuria, decline in transfusion
surface antigens PCV
Type III (immune Deposition of antigen– Fever, vasculitis, arthralgia, myalgia, 1–3 weeks post-infusion
complex); serum antibody complexes in lymphadenopathy, glomerulonephritis of biologic product
sickness tissues with complement
activation and inflammation
AHTR, acute hemolytic transfusion reaction; DHTR, delayed hemolytic transfusion reaction; Ig, immunoglobulin; PCV, packed cell volume;
RBC, red blood cell.
Type II hypersensitivity reactions occur specifically when a negative acute phase protein. The consequences of
administration of RBC products to a genetically dissimilar hypoalbuminemia in this patient population include
recipient of the same species (an allogenic transfusion) enteral feeding intolerance, hypercoagulability, poor
results in an immune response directed at donor RBC sur- wound healing, and multiple organ failure. Additionally,
face antigens. This immune response results in RBC serum albumin concentration is inversely related to mor-
destruction (hemolysis). tality in both human and veterinary patients [16–18].
Two main categories of hemolysis exist: extravascular Despite the well-documented detrimental effects of
and intravascular. Extravascular RBC destruction is medi- hypoalbuminemia, the merits of albumin transfusion in
ated by the mononuclear phagocytic system and results in critically ill patients remain unclear. Studies evaluating
decreased life expectancy of transfused cells but no signifi- the safety and efficacy of transfusion with albumin prod-
cant clinical patient decline. Acute intravascular hemolysis ucts have yielded conflicting results, and a survival benefit
is the most dangerous RBC product hypersensitivity reac- associated with their administration has yet to be docu-
tion and occurs secondary to donor–recipient incompati- mented in any specific patient population [19–21].
bility or previous sensitization (in dogs). Further Correction of underlying cause of hypoalbuminemia and
characterization of this type of transfusion reaction, provision of nutrition remain fundamental goals of treat-
including clinical signs and recommended therapies are ment in all sick patients. The use of artificial colloids to
discussed elsewhere [15]. support COP and maintain IV volume has come into ques-
tion in sick patient cohorts. Several randomized controlled
trials in sick people have demonstrated the development
Albumin Solutions of coagulation disorders, acute kidney injury (AKI), and
increased mortality following synthetic colloid adminis-
Albumin is the major osmotically active protein in the tration [22–24]. Administration of hydroxyethyl starch
body and is responsible for 80% for the plasma colloid (10% 250/0.5/5 : 1) has also been reported in a single retro-
osmotic pressure (COP) and preservation of intravascular spective veterinary study to increase the risk of AKI and
volume (Chapter 58). Albumin’s additional roles include death in dogs [25].
maintenance of endothelial integrity, mediation of coagu- Given the paradigm shift away from use of artificial col-
lation, scavenging of toxic compounds, transportation of loids for maintenance of COP and IV volume, supplemen-
exogenous and endogenous substances, and inhibition of tation of albumin may be prudent in select patients. Patient
oxidative injury. Hypoalbuminemia is common in critically cohorts include those with severe continuing fluid losses
ill patients with systemic inflammation and is due to fluid and resultant IV volume depletion and/or those with
shifts from the intravascular space to the interstitium, gas- significant peripheral and organ edema and associated
trointestinal and renal losses, and decreased production as organ dysfunction.
Concentrated Human Serum Albumin Solution with HSA to filter macroaggregates that may form in
solution, but according to the manufacturer, a filter is not
Historically, the only readily available source of species-
required. The product may be directly administered or
specific albumin was plasma transfusion, limitations of
diluted with crystalloids [26, 28, 30].
which include cost, availability, and the potential for vol-
ume overload and other adverse transfusion-related effects. Dosage Dosages are based on either a calculated albumin
An alternative and more effective means of affecting serum deficit or an extrapolated empirical dosage of 2–5 ml/kg of
albumin concentration is infusion of 25% human serum 25% HSA. Albumin deficit can be estimated using the
albumin (HSA) produced from fractionation of human following equation [31]:
plasma (25% Human Serum Albumin, Octapharma USA
Inc., Hoboken, NJ). However, while pharmaceutical HSA 10 serum albumin desired serum albumin of patient
does increase albumin concentration, this product has no body weeight kg 0.3 albumin deficit (68.1)
proven survival advantage and is associated with signifi-
cant complications in veterinary patients [26–30]. The
Monitoring Baseline vitals are obtained prior to HSA
most clinically relevant adverse effects are related to the
administration, and frequent monitoring of perfusion
highly antigenic nature of HSA. As a foreign protein, HSA
parameters, including capillary refill time (CRT), heart rate,
elicits immune responses in both critically ill and healthy
pulse rate and quality, respiratory rate and effort, and
dogs. Anti-HSA IgG antibodies have been demonstrated in
temperature, is required throughout transfusion. Infusion
some dogs with no prior exposure to HSA and in most dogs
rates are typically started at a decreased rate and slowly
following a single HSA infusion (typically two to six weeks
increased to full rate if no sign of reaction occurs (Figure 68.1).
after transfusion) [29].
Signs of acute hypersensitivity reaction warrant cessation of
transfusion or decrease of transfusion rate. Emergency
Adverse Reactions management of these reactions is outlined in Table 68.1.
Reported acute reactions in canine HSA recipients include Owing to the hyperoncotic nature of HSA solution, volume
mild type 1 hypersensitivities, and less commonly, hemo- overload may complicate therapy, and close monitoring of
dynamic collapse and signs of hypovolemic shock that respiratory parameters and volume status is also indicated.
characterize anaphylactic responses [27, 28, 30]. These After HSA administration, reevaluation of the patient’s
reactions are documented following both initial and repeat interstitial edema status, serum albumin concentration,
exposure to HSA. More recently, occurrence of serum sick- and/or COP will determine transfusion efficacy. While sig-
ness has been documented in canine HSA recipients [28]. nificant continuing protein losses may interfere with
Facial and peripheral edema, vomiting and inappetence, reaching target albumin level, repeat administration of this
urticaria, joint effusion and lameness, acute kidney failure, foreign protein is ill advised.
and death several days to weeks following HSA infusion
are reported. The more severe clinical signs attributable to
serum sickness occur in healthy dogs. This dichotomy may Canine Albumin
be related to immunocompetence and normal serum albu- Animal Blood Resources International have developed a
min concentrations in these recipients [29]. lyophilized 98% pure canine albumin by pooling source
plasma from their donors (Lyophilized Canine albumin,
Administration Protocols 5 g. Animal Blood Resources International, Stockbridge,
Risk assessment, careful recipient selection, and close MI). Advantages over HSA include species specificity and
patient monitoring are paramount to safe administration decreased risk of transfusion adverse effects.
of HSA. Reasonable goals for HSA administration are to
increase serum albumin to 2.0–2.5 g/dl and/or COP to Adverse Reactions
14–20 mmHg, respectively. In one study in which canine albumin was administered to
healthy Beagles weekly for one month, no adverse reac-
Preparation Prior to administration, the product is tions or anti-canine albumin antibody formation were doc-
inspected for turbidity or discoloration, and if they are umented up to five weeks post-infusion. In a single clinical
present, the product is discarded. Human albumin is study in dogs with septic peritonitis, albumin level, COP,
administered within four hours of opening the vial to and blood pressure increased following infusion of canine
decrease potential of bacterial contamination. A vented albumin. No adverse reactions were documented [32].
delivery set may be used as HSA is supplied in a glass vial, However, as with any biologic product, acute type I hyper-
or the contents can be aseptically transferred to a buretrol sensitivity is possible from administration of canine
for administration. Transfusion filters are routinely used albumin and has been personally observed by the authors.
Allumin olutions 895
Date: Technician Initiating Transfusion:
Transfusion Product:
Donor/Unit ID:
Product Volume:
Full rate: 1/2 rate: 3/4 rate:
Start Time: End Time:
Total Volume of Transfusion:
Pre PCV TS Post PCV TS
If there is a significant change in vitals at ANY time please notify the DVM.
Time Actual Rate of Volume

Time Time due RR HR Temp Rate ml/hr
Increment time done Infusion infused
Pre transfusion
0
If no change with 15 minute vitals, continue at 1/2 transfusion rate
15 minutes post
start 15
If no change with 30 minute vitals, increase to 3/4 tranfusion rate

30 minutes post
start 15
If no change with 45 minute vitals, increase to full tranfusion rate.
45 minutes post
start 15
60 minutes post
start 15
75 minutes post
start 15
90 minutes post
start 15
120 minutes post
start 30
150 minutes post
start 30
180 minutes post
start 30
240 minutes post
start 60
300 minutes post
start 60
360 minutes post
start 60
Transfusion must be completed within 6 hours or discard remainder of blood
Figure 68.1 Biologic product transfusion log.

Administration Protocols Human Intravenous Immunoglobulin

Close patient monitoring is paramount to the safe adminis-
tration of canine albumin. Reasonable goals for adminis- hIVIG is fractionated from plasma pooled from 1000–10 000
tration are to increase serum albumin to 2.0–2.5 g/dl and/ blood donors. This product is composed of at least 90% bio-
or COP to 14–20 mmHg, respectively. logically active immunoglobulin (Ig)G and smaller
amounts of IgE, IgA, IgM, and IgD. The immunomodulat-
Preparation Lyophilized canine albumin A is stored at ing properties of hIVIG have proven beneficial in a variety
39.2–42.8°F (4–6°C). According to the manufacturer, this of human immune-mediated disorders, including systemic
biologic product can be reconstituted with 0.9% NaCl or 5% lupus erythematosus, myasthenia gravis, pure RBC aplasia,
dextrose in water.2 Varying concentrations can be achieved immune-mediated neutropenia, vasculitis, and toxic epi-
with dilution (Table 68.3). A more hypertonic bolus (e.g. dermal necrolysis [34, 35].
16%) may be preferable in hypovolemic patients to achieve The mechanisms of action of hIVIG are complex but are
acute volume expansion and maintenance of effective postulated to include phagocyte Fc receptor blockade and
circulating blood volume. resultant decreased phagocytic activity of mononuclear
cells, modulation of T-cell function (inhibition of cytotoxic
Dosage Optimal dosing for canine albumin has not been T cells), neutralization of harmful autoantibodies, clear-
determined. Various dosing regimens for veterinary ance of IgG, and attenuation of complement-mediated
patients have been published and are outlined in Box 68.1. damage and proinflammatory cytokines [34].
Once reconstituted, the manufacturer recommends Commercially available hIVIG has been used with some
administration within six hours. However, a 2020 veterinary success in dogs and cats affected with IMHA, immune-
study demonstrated no bacterial growth and a stable mediated thrombocytopenia, myasthenia gravis, sudden
albumin concentration when 5% canine albumin in saline acquired retinal degeneration syndrome, myelofibrosis,
was stored for 24 hours at 4°C [33]. erythema multiforme, and a variety of other immune-
mediated dermatologic disorders (e.g. toxic epidermal
Monitoring Hypersensitivity and volume overload are necrolysis, Stevens–Johnson syndrome) [36–40].
potential adverse reactions secondary to administration of
canine albumin. Monitoring of the patient during and
following product administration is as outlined above with Adverse Reactions
HSA. Repeat transfusions are unlikely to cause immune
Adverse effects in human patients following hIVIG admin-
reactions due to the species-specific nature of the product.
istration are uncommon, affecting <15% of patients, and
However, a history of allergy to either human or canine
are typically limited to fever and malaise. More serious
albumin is a contraindication for its use. The manufacturer
effects reported include hypotension during infusion, AKI,
recommends a maximum daily dose of 2 g/kg.
aseptic meningitis, hemolytic anemia, thromboembolic
Table 68.3 Albumin Reconstitution Recommendations. events, and anaphylaxis in patients with IgA deficiency.
Volume overload and resultant pulmonary edema and
Desired albumin concentration (%) Amount of diluent (ml) transfusion-related acute lung injury have also been
reported [34, 36].
16 30 Similarly, complications associated with hIVIG admin-
10 49 istration in veterinary patients are infrequently reported.
5 100 Dogs with IMHA treated with this product have devel-
oped transient thrombocytopenia (60%) and thromboem-
bolism (71%), but these findings may be unrelated to
Box 68.1 Canine Albumin Dose Recommendations hIVIG and instead associated with the patients’ underly-
ing diseases [36–40]. Vomiting was reported following
Recommended canine albumin dose
infusion of hIVIG in a healthy dog [40]. Other potential
Albumin deficit (grams) = 10 × (desired albu-
complications are related to the product’s hyperoncotic
min – patient albumin) × patient weight (kg) × 0.3 [31]
nature (i.e. volume overload, especially in patients with
Albumin dose (ml of 5% solution) = patient weight
underlying cardiovascular disease) and antigenicity,
(kg) × 90 ml/kg × (desired albumin – patient albu-
which may result in acute or delayed hypersensitivity
min) × 0.2 dl/g [conversion factor for 5% albumin]
reactions. The potential for sensitization in veterinary
450 mg/kg to raise the serum albumin by 0.5 g/dl
patients has been postulated. This may preclude safe
800–884 mg/kg over 6 hours [32]
repeat infusion of this product.
Secific mmunoglolulin heraSp 897
Administration Protocols Snake Envenomation

Preparation Approximately 20 species of snakes native to the United
Lyophilized hIVIG (10%; Gammagard S/D, Hyland Division, States are venomous. Most small animal envenomations
Baxter Healthcare, Westlake Village, CA) products can be occur in the southwestern part of the country, and are
stored at room temperature for up to 24 months prior to attributable to Crotalidae species, or pit vipers (rattle-
rehydration [41]. A variety of diluents may be used for snakes, cottonmouths, and copperheads). Of the pit vipers,
reconstitution; these vary with product and manufacturer, the Eastern diamondback rattlesnake is responsible for
but include sterile water, 0.9% NaCl, and 5% dextrose. most human fatalities annually. Less frequently, envenom-
Rehydration is recommended over 15–20 minutes, and gen- ations are due to Elapidae (coral snakes) [42–45].
tle handling of the product during this process is advisable Snake venom consists of mixtures of enzymatic proteins
to prevent foaming. Refrigeration is required following (hylauronidase, collagenase, proteases, and phospholi-
reconstitution, and the product must be administered pases) that cause local tissue injury and vasculitis, enhanc-
within 24 hours to reduce risk of contamination [41]. ing spread of the venom. Other proteins and enzymes,
Immunoglobulin is administered via a designated including fibrinolysins and thrombin-like enzymes, result
peripheral or central venous catheter. Most hIVIG manu- in defibrination (depletion of fibrinogen and fibrin) and
facturers advocate the use of an in-line filter during trans- friable clot formation, respectively. The end result is coagu-
fusion; filter size recommendations vary. The product is lopathy characterized by bleeding propensity. Victims of
administered at room temperature for optimal patient snake bites are also at risk for AKI and for neurotoxicosis
comfort [41]. associated with neuromuscular blockade, the latter typi-
cally caused by Elapidae envenomation. Lethality follow-
Dosage ing envenomation is associated with the smaller
The optimal dosage of hIVIG in veterinary patients is low-molecular-weight polypeptides in the venom that
unknown. Historical doses of hIVIG in animals range from result in increased capillary permeability, intravascular
0.5 to 1.5 g/kg [36–40]. In five dogs with immune-mediated volume depletion from third spacing of fluids, and hypov-
thrombocytopenia, a low-dose therapy (0.28–0.34 g/kg) olemic shock [42–45].
was used and was deemed efficacious [38]. While supportive measures such as administration of IV
fluids, analgesics, and antibiotics (for documented concur-
Monitoring rent bacterial infection) are the standard of care for victims
An infusion period of 6–12 hours is recommended in of snake bites, administration of antivenom plays the most
human patients to ensure safe delivery; hang times of important role in morbidity and mortality reduction in
4–8 hours are reported in veterinary patients [36–40]. In all many of these animals. A mortality reduction of 36% was
species, transfusion is initiated at a slow rate (0.01 ml/kg/ observed comparing dogs that were treated with antivenom
minute) and gradually increased every 30–60 minutes to a with those who were not in one study [46]. The two
maintenance rate not to exceed 0.08 ml/kg/minute. Fluid- approved antivenom products in the United States for
sensitive patients may not tolerate high fluid rates. Frequent treatment of rattlesnake bites in human patients are
monitoring during administration includes CRT, heart and Antivenin™ crotalid polyvalent (ACP; Boehringer
pulse rates and quality, respiratory rate and effort, blood Ingelheim Vetmedica, St. Joseph, MO) and CroFab®
pressure, and temperature (Figure 68.1). Signs of acute Crotalidae polyvalent immune antigen-binding fragment
hypersensitivity warrant prompt, temporary cessation of (Fab; Boston Scientific, Marlborough, MA) (Table 68.4) [45].
the infusion and antihistamine administration (Table 68.1). ACP is an antiserum composed of equine gammaglobulins.
Most patients tolerate reinstitution and completion of the This product is rich in antibodies that target the venoms of
transfusion at a slower infusion rate. all endemic pit viper species, but in addition contains aller-
genic equine protein contaminant. CroFab has approxi-
mately five times the potency of ACP, and is more
Specific Immunoglobulin Therapy efficacious than ACP for treatment of crotalid-induced
neurotoxicity [45, 47]. CroFab is also less allergenic than
Very few small animal intoxications exist for which a spe- ACP, as it is pure Fab immunoglobulin, and as such con-
cific antidote can be provided. Three such intoxications are tains less contaminant than ACP antivenom [45, 47, 48]. A
poisonous snake envenomation, tetanus, and intoxication potential drawback to CroFab is its shorter half-life, which
with digitalis glycosides. In each case, the antidote pro- may allow for recurrence of the effects of unneutralized
vided is a specific immunoglobulin that targets the toxi- venom and may necessitate repeat dosing [48, 49]. While a
cant, limiting host toxicity via immunomodulation. multicenter trial evaluating the efficacy of CroFab in
Table 68.4 Comparison of Crotalid Antivenoms. Administration Protocols

Antivenom therapy is recommended for victims of snake
Property Antivenina
CroFab b
bites with worsening local injury, clinically significant
coagulopathy, or systemic signs of shock. The recom-
Source Horse Sheep mended initial dosage of antivenom varies with amount of
Immunoglobulin Immunoglobulin G Fab venom injected, time elapsed since envenomation, severity
fragment
of clinical signs, and patient size.
Potency + +++
Antigenicity +++ + Preparation Skin testing for prediction of allergic response
Initial dose 10–50 ml (1–5 vials) 4–6 vials may be performed by injecting a 1 : 10 dilution of antivenom
Clearance/need for + +++ at 0.02 ml subcutaneously. A positive reaction, manifested
repeat administration by a wheal surrounded by erythema, occurs within
Approximate cost $250/vial $3500/vial 30 minutes [56]. A negative skin test does not guarantee
Licensure Human, animal Human that a severe reaction will not take place, and the time it
a
takes to perform the test delays prompt administration of
Antivenin™ (Boehringer Ingelheim Vetmedica, St. Joseph, MO);
b
CroFab® (Boston Scientific, Marlborough, MA).
the antivenom (the sooner the product is administered, the
more effective it is) [57, 58]. Routine skin testing is therefore
not recommended.
veterinary patients is underway, ACP is currently the only Antivenom is reconstituted with the provided diluent. It
product licensed for use in animals in the Western should be swirled but not shaken, and the vial should be
hemisphere. warmed to body temperature to facilitate reconstitution,
which usually takes 10–15 minutes [57]. The reconstituted
Adverse Reactions antivenom is diluted at a ratio of one vial to 100–250 ml of
Adverse effects associated with antivenom therapy are isotonic crystalloids, adjusting the volume to prevent fluid
uncommon, and most are related to patient hypersensitiv- overload in at-risk patients [56]. The initial dosage is
ity to foreign proteins in the antiserum. Mild, self-limiting administered IV over 30 minutes.
type 1 hypersensitivity reactions have a reported preva-
lence of 14–56% and 4% in humans and dogs, respec- Dosage The suggested starting dose ranges from one to
tively [45, 48–52]. In two reports of rattlesnake five vials. Redosing depending on product and clinical
envenomation in dogs, ACP therapy resulted in type 1 efficacy may be necessary. Antivenom is costly and
hypersensitivity in 1/22 and 0/23 patients, respectively [51, financial constraints may need to be considered before
52]. Clinical signs referable to allergy in affected dogs were administration [57]. A CRI protocol has recently been
limited to facial swelling and pruritus. Anaphylaxis has not reported using CroFab for North American rattlesnake
been reported in veterinary patients. The reported inci- bites, where rates of infusion varied from two to four vials
dence of serum sickness in human snake bite victims per day, for 6–14 days post-envenomation. Continuous
treated with ACP or CroFab is 18–86% and 16%, respec- infusion appeared safe and effective [59].
tively [45]. A single case of serum sickness resulting from
ACP administration to a dog following Crotalus adaman- Monitoring Careful patient monitoring during infusion is
teus envenomation has been reported [53]. The dog devel- paramount for early detection of allergy or anaphylaxis
oped fever, anorexia, lethargy, and generalized pitting (Table 68.1). Frequent measurement of tissue swelling and
edema three days after ACP therapy. The dog made a full reassessment of coagulation status will help to determine the
recovery. need for antivenom redosing. The dose may be repeated as
The antivenom formulated from hyperimmune equine needed every two hours for clinically significant coagulopathy
serum (IgG) that was available for small animal victims of or if local swelling worsens despite therapy [43].
systemic elapid snake envenomation (associated with one
documented acute anaphylactic reaction in a dog) is no
Tetanus
longer available [54, 55]. Coralmyn® (Instituto Bioclon,
Mexico City, Mexico) is a polyclonal antivenom F(ab’) [2] Tetanus is an acute toxigenic illness that occurs subsequent
product available in Mexico and obtainable in the United to infection with the spore-forming bacillus Clostridium
States with a US Department of Agriculture importer’s per- tetani. In dogs and cats, the source of the infection is typi-
mit. Although this antivenom has less extraneous protein cally a contaminated penetrating wound, and clinical signs
than its predecessor, acute and/or delayed hypersensitivity of illness occur 5–10 days following inoculation of the
reactions may complicate therapy [56]. organism.
Secific mmunoglolulin heraSp 899
C. tetani spores produce two toxins, tetanolysin and Digitalis Glycosides

tetanospasmin, the latter of which is responsible for the
Digitalis glycosides (digoxin) are occasionally prescribed
neurologic signs associated with infection. The toxin trav-
by practitioners for cardiovascular disease in veterinary
els up peripheral nerves and hematologically to the central
patients. These agents exert positive inotropic effects via
nervous system and inhibits the release of the inhibitory
dose-dependent inhibition of the cardiac Na-K-ATPase
neurotransmitters gamma aminobutyric acid (GABA) and
pump, and subsequent increased intracellular calcium and
glycine. Loss of neuronal inhibition of skeletal muscle and
force of cardiac contraction (Figure 68.2). Antiarrhythmic
autonomic dysfunction ensue.
effects are mediated through an increase in parasympa-
Clinical signs associated with infection include severe
thetic tone and include decreased sinus rate, depressed
muscle rigidity and cranial nerve deficits (e.g. facial mus-
impulse conduction through the atrioventricular (AV)
cle spasms – risus sardonicus, lockjaw – trismus, third
node, prolonged AV refractory period, and decreased
eyelid protrusion, and dysphagia). Additionally, disinhi-
automaticity of specialized atrial fibers. These effects make
bition of the sympathetic nervous system and excessive
glycosides appropriate agents for management of supraven-
catecholamine levels may result in tachycardia and
tricular tachycardias and systolic dysfunction.
hypertension [60–62].
These agents have low therapeutic-to-toxic ratios, and
Specific immunoglobulins that target unbound tetanos-
inadvertent overdose can be fatal. Extracardiac effects asso-
pasmin in the blood are available but their efficacy
ciated with digitalis glycoside toxicosis are common and
remains unproven [62, 63]. Two products exist for treat-
include depression and inappetence, nausea, vomiting,
ment of tetanus in veterinary patients: Tetanus Antitoxin
and diarrhea. More importantly, overdose can result in a
(equine; Zoetis, Parsippany-Troy Hills, NJ) and Tetanus
variety of cardiac conduction disturbances (atrioventricu-
Antitoxin Behring (MSD Animal Health, Rahway, NJ).
lar block and bundle branch block), atrial and ventricular
The Zoetis product has been used off-label in small ani-
arrhythmias, and life-threatening hyperkalemia with
mals; the latter product is not recommended for use in
resultant cardiac dysrhythmias.
cats but has been used without complication in dogs [56,
Treatment of toxicosis may include gastric decontamina-
60, 62–64].
tion, IV fluid therapy, administration of cardioprotective
drugs (calcium and antiarrhythmic agents), and cardiac
Adverse Reactions
pacing. Additionally, in cases of life-threatening toxicosis
As both products are comprised of foreign proteins, hyper-
in human patients and sporadically in veterinary case
sensitivity reactions are possible during and following
reports, digoxin-specific antibody is administered [65–69].
administration. While mild, self-limiting hypersensitivities
Digibind® (digoxin immune Fab, ovine; GlaxoSmithKline
have been documented in case series, anaphylaxis has
LLC, Research Triangle Park, NC.) is ovine-derived,
not [62, 64].
Administration Protocols Na+

Preparation Historically, intradermal skin testing was Cardiac Glycoside
widely practiced to predict local hypersensitivity. However,
recent reports have demonstrated both false-positive and
false-negative results, calling into question this routine K+ ↑ Force of ↑ [Ca++]
practice [62]. Contraction
↑ i[Na+]
Dose Recommended antitoxin dosage varies widely from
100 to 1000 units/kg, with doses of up to 1900 units/kg ↑ Cellular Ca++
↑ SR Ca++
reported in dogs [56, 64]. Antitoxin may be administered Na+ content
intravenously, intramuscularly, or subcutaneously. Other
reported dosing regimens include 1000 units at the wound
site or 1–10 units intrathecally. However, intrathecal
administration has been shown to increase morbidity and
Ca++
mortality in human patients and is not currently
recommended [60]. Figure 68.2 Mechanism of action of cardiac glycosides. Cardiac
glycosides inhibit the cardiac Na+/K+ATPase pump. This
inhibition leads to an accumulation of intracellular Na+,
Monitoring Patients receiving antitoxin are monitored
decreased Na+/Ca2+ exchange and a resultant increase in
closely for signs of acute hypersensitivity, and emergency intracellular Ca2+. Higher intracellular Ca2+ concentration leads
drugs (Table 68.1) should be readily available. to increased force of ventricular contraction.
digoxin-specific Fab antibody fragment with a reported Thrombolytic Agents

efficacy of greater than 80% in patients with refractory, life-
Endothelial injury, alterations in blood flow, and hyperco-
threatening digitalis glycoside toxicosis [67].
agulable states increase the risk for thrombosis (clot forma-
An additional intoxication for which Digibind might be
tion). These risk factors (known together as Virchow’s
beneficial is following ingestion of Nerium oleander (olean-
triad) are associated with many conditions common to
der). The toxic metabolites of this ornamental plant are ste-
critically ill veterinary patients, including but not limited
roidal glycosidic cardenolides, cardiac glycosides, and
to sepsis, systemic inflammatory response syndrome,
rarely cardiac arrhythmias have been reported in associa-
hyperadrenocorticism, diabetes mellitus, cardiomyopathy,
tion with its consumption by small animals [70].
neoplasia, protein-losing nephropathy or enteropathy,
Adverse Reactions IMHA, bite wounds, snake envenomation, polytrauma,
Potential adverse effects associated with Digibind adminis- heat stroke, and burns. The end results of thrombosis are
tration are infrequently reported in human reviews, but maldistribution of blood flow (which may cause signs of
include allergic reactions (< 1%), severe acute hypokalemia shock), tissue ischemia, and hypoxia.
from reversal of pump paralysis (4%), and exacerbation of The fibrinolytic system is responsible for clot dissolution
congestive heart failure [65–68]. No detrimental effects through the formation of the enzyme plasmin. Plasmin is
have been reported in the few veterinary cases to which this derived from the inactive proenzyme plasminogen via the
therapy has been applied. However, the foreign nature of action of the body’s plasminogen activators. Once gener-
the Fab fragments (ovine-derived) imparts the potential for ated, plasmin is responsible for fibrinolysis (fibrin degrada-
more serious allergic or anaphylactic reactions, and repeat tion and subsequent clot lysis) (Figure 68.3).
dosing is currently not recommended in veterinary patients. Thrombolytic agents augment fibrinolysis via conver-
sion of plasminogen to plasmin and have been used in
Administration Protocols
the treatment of thrombi in both human and veterinary
Preparation Digibind (38 mg digoxin immune Fab) is
patients. Available agents include streptokinase,
diluted with 4 ml sterile water to achieve a concentration of
urokinase-type plasminogen activator, and tissue-type
9.5 mg/ml. If not used immediately, storage for up to
plasminogen activator (tPA). Streptokinase is a bacterial
four hours at 35.6–46.4 degrees F (2–8°C) is acceptable. The
protein produced by hemolytic species of Streptococci
reconstituted product can be further diluted with 0.9%
that indirectly activates plasminogen to plasmin. Because
saline to achieve a desired volume; the dose is administered
of its bacterial origin, this protein can elicit an immune
through a 0.22 μm filter [66, 69]. It may be given as a bolus
response in the recipient, particularly in patients with
in emergency situations, but an infusion over 1–2 hours is
previous β-hemolytic streptococcal infection. Circulating
recommended when possible [66].
antibodies to streptokinase limit the efficacy of the agent
(necessitating a loading dose initially) and may result in
Dosage Determination of appropriate Digibind dose is
hypersensitivity reactions. Reported signs in human
based on the digoxin body load, which is estimated by
patients include pruritus, rash, hypotension, and brady-
either the serum concentration or the amount ingested [66].
cardia, more commonly following rapid infusion and
The serum digoxin concentration obtained eight hours
thought to be associated with histamine and/or
after the last dose is incorporated into Eq. (68.2):
bradykinin release. Additional detrimental effects associ-
Serum glycoside concentration ng / ml *
V ated with streptokinase administration are systemic
body weight kg
DBL (68.2)
1000
where DBL = digoxin body load and *V = volume of distri- Plasminogen Streptokinase
bution (5.6 l/kg for digoxin and 0.56 l/kg for digitoxin). The activator Urokinase
tPA
dose of Digibind is then calculated using Eq. (68.3):
DBL / 0.5mg per vial # of 38mg

(68.3) Plasminogen Plasmin
Digibind vials to administer
where DBL = digoxin body load [66, 69]. Each 38 mg vial of

Fibrin degradation
digoxin-specific Fab fragments binds approximately 0.5 mg Fibrin
products
digoxin or digitoxin. The reader is referred to the product
package insert for alternate dosing strategies. Figure 68.3 Initiation of fibrinolysis.
ummarp 901
hemorrhage due to activation of fibrin-bound (thrombus- and can be fatal. Allergic reactions and anaphylaxis are
associated) and circulating plasminogen, and ischemia– not well documented in the veterinary patient, but result
reperfusion injury when blood flow to ischemic areas is in pruritus, rash, and fever in humans [71].
reestablished. Reperfusion of such areas leads to sys-
temic release of reactive oxygen species, metabolic acido- Administration Protocols
sis, and hyperkalemia. Dosage Alteplase (Cathoflo® Activase® 2mg, Genentech,
tPA is secreted by endothelial cells and circulates in San Francisco, CA) is tPA and is reconstituted with 2.2 ml
the blood. Human recombinant tPA is derived from sterile water and swirled, not shaken, until dissolved. The
mammalian cell tissue culture, and hypersensitivity solution can be further diluted with 0.9% saline or 5%
reactions are possible in veterinary patients, as are sys- dextrose to achieve a concentration of 0.5 mg/ml as desired.
temic bleeding and reperfusion injury. However, as tPA Without preservatives, sterility cannot be ensured greater
is more specific for thrombus-associated plasminogen than eight hours following reconstitution.
(as opposed to circulating plasminogen), severe hemor- A published IV dose for tPA in veterinary patients is
rhage is less likely than with streptokinase. Urokinase is 0.5 mg/kg over 30–60 minutes (not exceeding 9 mg), with
found in the urine and produced from human neonatal repeat doses up to three times within 24 hours [82]. For
kidney cells in tissue culture. This enzyme has clot spec- local infusion protocols, the reader is referred to the
ificity in between that of streptokinase and tPA. This included references [80, 81].
product has been infrequently administered to veteri-
nary patients and carries risks similar to other thrombo-
Monitoring The patient receiving thrombolytic therapy
lytic agents.
requires intensive monitoring and nursing care. Catheter-
Indications for thrombolytic agents in human patients
associated bleeding may be subtle and go undetected until
include massive pulmonary embolism complicated by
a substantial volume of blood is lost, as hemorrhage can
right heart failure and/or hypotension, and greater than
migrate down fascial planes or be covered by catheter
50% obstruction of a major pulmonary artery.
wraps [76]. Direct manual pressure may be applied to a
Contraindications include acute myocardial infarction,
hemorrhaging catheter site, and bleeding patients may
intracranial hemorrhage, head trauma, and ischemic
require therapy with blood components. Frequent
stroke [71–73]. Specific indications and contraindications
assessment of mucous membrane color and CRT,
are not established for veterinary patients.
respiratory rate and effort, heart rate, pulse quality, blood
Despite lack of established indications, thrombolytic
pressure, and temperature can aid in detection of
agents have been used in dogs and cats with clots of
continuing bleeding. Continuous electrocardiogram
the arterial and venous circulation. No survival advan-
(ECG) monitoring is indicated as rising serum potassium
tage has been documented associated with their sys-
causes a progression of ECG changes. Narrow, peaked or
temic administration, and reported adverse effects
“tented” T-waves, flattening and disappearance of the P
including fever, hyperkalemia, significant hemor-
waves, and widening of the QRS complexes typify the
rhage, and acute death are common [74–79]. There are
cardiotoxicity associated with progressive hyperkalemia.
isolated case reports documenting successful use of
Tachypnea is nonspecific and may indicate a metabolic
thrombolytics (tPA) more locally to address catheter-
acidosis with respiratory compensation, pain, pulmonary
related thromboses and urinary bladder blood clots
thromboembolism, or hemorrhage.
without adverse consequences [80, 81]. Most recently,
administration of tPA directly at the site of either arte-
rial or venous clots (catheter directed thrombolysis,
CDT) has been described by veterinary interventional Summary
radiologists [82].
Most veterinarians would consider biologic products as an
Adverse Reactions essential component of their armamentarium. These
The most common complication of thrombolytic agents is agents are indicated for a variety of clinical syndromes in
hemorrhage, which may manifest as a dropping packed critically ill patients but do carry significant risks. Safe
cell volume (PCV) in association with hematuria, gastro- administration of biologic products involves appropriate
intestinal or oral mucosal bleeding, bleeding from cathe- patient selection, awareness of associated adverse effects
ter insertion sites, dyspnea, or changes in neurologic and timely interventions if an untoward reaction is sus-
status [74]. Metabolic acidosis and electrolyte abnormali- pected. Implementation of evidence-based guidelines and
ties such as hyperkalemia associated with tissue reperfu- standardized hospital protocols for administration of these
sion are common complications of thrombolytic therapy products are recommended.
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specific fab fragments as single first-line therapy in 79 Welch, K.M., Rozanski, E.A., Freeman, L.M. et al. (2010).
digitalis poisoning. Crit. Care Med. 36: 3014–3018. Prospective evaluation of tissue plasminogen activator in
68 Antman, E., Wenger, T., Butler, V. et al. (1990). Treatment 11 cats with arterial thromboembolism. J. Fel. Med. Surg.
of 150 cases of life-threatening digitalis intoxication with 12: 122–128.
digoxin-specific fab antibody fragments. Circulation 81: 80 Langston, C., Eatroff, A., and Poeppel, K. (2014). Use of
1744–1752. tissue plasminogen activator in catheters used for
69 Senior, D., Feist, E., Stuart, L. et al. (1991). Treatment of extracorporeal renal replacement therapy. J. Vet. Intern.
acute digoxin toxicosis with digoxin immune fab (ovine). Med. 28: 270–276.
J. Vet. Intern. Med. 5 (5): 302–303. 81 Pineda, C., Guisado, A., Aguillera-Tejero, E. et al. (2015).
70 Milewski, L.M. and Khan, S.A. (2006). An overview of Dissolution of bladder clots in a dog with alteplase. J. Vet.
potentially life-threatening poisonous plants in dogs and Intern. Med. 29: 1627–1628.
cats. J. Vet. Emerg. Crit. Care 16 (1): 25–33. 82 Dunn, M.E. and Weisse, C. (2015). Thrombectomy and
71 Jaffe, A. (1994). Thrombolytic therapy. In: The Pharmacologic thrombolysis: the interventional radiology approach. In:
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347–364. Philadelphia, PA: Williams & Wilkins. B. Allyson), 464–468. Wiley.
905
69
Blood Banking
Marie K. Holowaychuk and Kenichiro Yagi
Introduction Commercial Blood Banks

There are several commercial blood banks located in large
The caseload of patients requiring blood transfusions is metropolitan areas that can be used as sources for blood
growing as more pet owners seek advanced care for their products (Box 69.1). These blood banks tend to have on-site
animals. As such, emergency and specialty hospitals are donors or a large pool of established donors. Because com-
required to have a supply of blood products available. mercial blood banks are not regulated in most jurisdic-
Alternatively, blood donors may be on standby for collections, hospitals must exert due diligence to ensure that the
tion of blood when urgent needs arise. Hospital teams quality of the blood products obtained is satisfactory. Blood
must therefore identify commercial or other sources of banks can be asked to provide information regarding the
animal blood products and must possess appropriate maintenance of on-site donors, donor screening protocols,
means to store those products. For those hospitals choos- strategies for preservation of donor health and prevention
ing to use blood donors, protocols must be established for of vector-borne disease, plans for on-site donors once they
donor selection and screening, blood processing, and retire, and steps to sustain the health and supply of
maintenance of quality assurance for donors and recipi- community-acquired donors. It is also appropriate to con-
ents. Meeting the transfusion needs of patients with an firm whether there is a consistent supply of blood prod-
appropriate supply of blood products can be extraordi- ucts, whether the product with the longest shelf life is
narily challenging and rewarding for the veterinary team. always shipped, and the anticipated delivery once an order
Because there are currently no regulations for acquiring is placed, including additional fees assessed for overnight
blood products for in-hospital use, each hospital is or expedited shipments [1].
responsible for establishing their own protocols and Before and after a blood product is shipped, it is the
remaining diligent in evaluating the sources of their responsibility of the receiving hospital to ensure that the
blood products. product was collected, stored, and shipped appropriately,
and remains viable. Questions related to method of collec-
tion, sterile procedure, leukoreduction protocol, and pres-
Obtaining Blood Products ervation additives are necessary to determine blood product
sterility and viability. Upon shipment, the temperature of
Because the demand for blood products is inconsistent and the shipping container and time spent in transit are impor-
unpredictable, and since blood products have a finite shelf tant to note. For example, packed red blood cells (PRBCs)
life, many emergency and referral hospitals choose to meet are typically shipped overnight or within two business days
blood product demands with a combination of products and should be shipped at refrigerated temperatures
obtained from commercial blood banks, other local hospi- (33.8–42.8°F; 1–6°C). Alternatively, plasma products must
tals, or in-hospital collections. arrive frozen and are typically shipped on dry ice
906 Blood Banking
unavailable or insufficient to meet emergent need.

Box 69.1 A Selection of Commercial Blood Banks
Regardless of the situation, the hospital must establish pro-
Located in Canada and the United States
tocols for donor selection and screening, precollection
screening, and collection procedures, to assure the quality
● Animal Blood Bank (California)
of the blood product and safety of the donor.
● Animal Blood Bank DBA (Michigan)
● Animal Blood Resources International (Michigan)
Best Friends Blood Bank (Georgia)
Donor Sources
●
● Blue Ridge Veterinary Blood Bank (Virginia)

● BodeVet (Maryland)
Most hospitals that perform in-hospital collections do so
● Buddies for Life Canine Blood Bank (Michigan)
using donors procured from different sources such as
● Canadian Animal Blood Bank (Manitoba)
employee-owned animals, client-owned animals, or ani-
● Canine Blood Bank of Central Iowa (Iowa)
mals specifically acquired for in-hospital donation (i.e.
● Hemopet (California)
from research colonies or breeders). Unfortunately, secur-
● HemoSolutions (Colorado)
ing donors that can be used on-call for urgent or emergent
● LifeStream Animal Blood Bank (Ontario)
purposes tends to be more difficult than those who are
● Nine Lives Blood Services (Michigan)
scheduled for donation every three to six months.
● North American Veterinary Blood Bank (Virginia)
Therefore, it is important to establish with the employee or
● Northwest Veterinary Blood Bank (Washington)
client the extent of their ability to volunteer on an on-call
● Rocky Mountain Blood Services (Colorado)
basis and to have several contact numbers at which they
● St. Louis Blood Bank (Missouri)
can be reached. Alternatively, some hospitals acquire ani-
● Sun States Animal Blood Bank (Florida)
mals that are fostered by hospital employees and are desig-
● The Pet Blood Bank (Texas)
nated as on-call donors [1].
● The Veterinarians’ Blood Bank (Indiana)
● Twin Cities Animal Blood Bank (Minnesota)
Canine Donors
overnight. The blood bank must be able to provide infor- Selection and Screening
mation related to any adverse events encountered during Canine donors must be selected and screened judiciously
collection, processing, or storage of the product. to protect donors and recipients from harm. A complete
history, comprehensive physical examination, blood tests,
and bloodborne pathogen screening are recommended
Other Hospitals
before collecting blood for transfusion. Canine donors
Nearby specialty, emergency, or teaching hospitals may should be between one and eight years of age, apparently
also serve as sources of blood products for hospitals with healthy, and have a history that rules out prior transfu-
an emergent or urgent need. Products obtained from other sions, acute or chronic illness, and current pregnancy.
hospitals may have been originally sourced from commer- Dogs without a known history (e.g. rescues) can be consid-
cial blood banks or collected in-hospital. The same recom- ered at the discretion of the attending veterinarian who
mendations apply in that the hospital requesting the blood must weigh the risks and benefits of using blood collected
product must assess the product’s quality in terms of steril- from a dog that is not an ideal donor [2]. Dogs previously
ity and viability as outlined above. Unfortunately, other used in breeding programs can still be used as donors,
hospitals may elect not to sell or give blood products to given that pregnancy does not sensitize dogs to erythrocyte
requesting hospitals if their own supply is low or their antigens [3]. A calm temperament is preferred, such that
anticipated need is high. Some other hospitals would rather restraint in lateral or sternal recumbency can be achieved
the requesting hospital refer the patient so that they can without sedation. An owner that is reliable, responsible,
receive the transfusion in their own hospital. and committed is also best to ensure honest responses to
history questions and dedication to the program.
A lean body weight of at least 50 lbs (22.7 kg) is recom-
In-Hospital Collection
mended for standard collections of 450 ml of blood (the
Blood collected from animals in hospital can replenish volume collected with most human blood collection sys-
stores of blood products or meet urgent or emergent needs tems used for canine donors). Alternatively, dogs that
for whole blood or component transfusions. Some emer- weigh less can be used to collect a smaller volume of blood
gency or referring hospitals may choose only to perform for whole blood transfusion. Most dogs can tolerate having
in-hospital collections during circumstances when com- 11–19 ml/kg of blood collected with minimal cardiovascu-
mercial or other hospital sources of blood products are lar compromise [2]. However, careful attention should be
Donor Sources 907
paid to small donors to ensure that they do not exhibit car- pertaining to illness, medications, travel, vaccinations, and
diovascular or other complications. A physical exam must preventatives is strongly advised. Dogs receiving a short
elicit no abnormalities and detection of ectoparasites course of medication(s) for an acute illness should be
should prohibit donation [4]. healthy for at least two weeks after the medications are fin-
A complete blood count and serum biochemistry profile ished before donating. Dogs should also receive routine
should yield normal results and must be repeated annually. ectoparasite prevention as recommended for the geograph-
Additional screening tests, such as urinalysis and fecal par- ical region. The form should also outline the risks of dona-
asite testing, can be performed at the discretion of the tion and complications to monitor for afterwards and
attending veterinarian. Blood typing is also recommended request consent from the owner/employee. A packed cell
to ascertain whether the donor is dog erythrocyte antigen volume (PCV) and total solids are minimum requirements
(DEA) 1 positive or negative. Additional screening for DEA to assess hematologic status and should be at least 35%
4 and 7 is available through commercial laboratories; how- (preferably higher than 40%) and between 6.0–9.0 g/dl
ever, most donor pools are limited such that maintaining a (60–90 g/l), respectively. Visual inspection of the plasma
pool of DEA 1 and 7 negative dogs can be difficult. Therefore, should also be performed and discolorations (e.g. hemoly-
most in-hospital donor programs only test for DEA 1 posi- sis, icterus, or lipemia) investigated [7].
tive or negative status and administer type-specific transfu-
sions whenever possible. It is important to characterize Collection Supplies and Equipment
DEA 1 weak positive donors as DEA 1 positive (rather than Various combinations of collection containers and antico-
negative). This is because transfusion of DEA 1 weakly pos- agulant solutions can be used for the collection depending
itive blood to DEA 1 negative recipients will result in allo- on the volume of blood collected; 450 ml collection sizes
immunization of the negative recipient [5]. Given the are most often used in dogs, with the appropriate amount
tendency for most dogs to express Dal and Kai antigens (like of citrate-based anticoagulant. Acid citrate dextrose (ACD)
the majority of dogs who are DEA 4 positive) [6] and that and citrate phosphate dextrose adenine (CPDA) are
testing for those antigens is not widely available, antigen commonly used for whole blood collection, while citrate
testing in donors outside of DEA is uncommon. phosphate dextrose (CPD) in conjunction with additive
It is imperative that canine donors also be screened for any nutrient solutions (such as AS-1, AS-3, AS-5, and SAGM)
vector-borne diseases that have the potential for transmission are used for preparation of PRBC.
from the donor to the recipient within the blood product. Single-chambered collection bags are used for the collec-
Testing recommendations are derived from an American tion of whole blood (Figure 69.1). Multichambered bags,
College of Veterinary Internal Medicine (ACVIM) consensus available in double, triple, or quadruple bag versions, are
statement, which denotes minimal and optimal standards for used for component separation (Figure 69.2). Historically,
screening canine donors [4]. The testing performed by the the availability of these bags has fluctuated based on
attending veterinarian will vary depending on the breed and changes driven by demand in the human blood banking
geographical location, as well as test cost and availability. The industry. Blood collection bags with leukoreduction filters
consensus panel recommends annual testing of canine
donors with the potential need to test more often for some
pathogens in endemic regions or in donors that have repeated
exposure to risk factors such as ticks [4]. Minimum standards
recommend that canine donors test negative for Anaplasma
phagocytophilum, Anaplasma platys, Babesia canis vogeli,
Babesia gibsoni, Bartonella henselae, Bartonella vinsonii var.
berkhoffi, Ehrlichia canis, and Mycoplasma haemocanis.
Optimal standards include additional tests for Brucella canis,
Trypanosoma cruzi, Neorickettsia risticii, Leishmania dono-
vani, Hepatozoon canis, and other Bartonella and Ehrlichia
spp. when indicated [4].
Precollection Screening
A dog’s eligibility for donation is screened upon acceptance
into the program and again prior to blood collection. This
includes confirming the dog’s recent health history, obtain-
ing owner consent, performing a physical examination
including measurement of vital signs, and measuring Figure 69.1 Single chambered 450-ml blood collection bags
hematologic parameters. A form asking questions filled with CPDA-1 used for canine blood collection.
908 Blood Banking
Figure 69.3 Handheld heat tubing sealer.
Box 69.2 List of Supplies Required for Canine Blood

Collection [7]
Figure 69.2 Triple-chambered 450-ml blood collection bags
filled with CPD and separate bag with AS-5 as nutrient solution. ● Topical anesthetic cream
● Collection system:
are also available, although the benefits of leukoreduction ⚪ If whole blood, single-bag collection system
among canine transfusion recipients are still being investi- ⚪ If component processing, multiple-bag collection
gated [8]. For now, the practice of leukoreduction is at the system

discretion of the hospital and blood bank. ● Gram scale
For collection of blood volumes less than 450 ml, 250 ml ● Clippers and #40 blade
bags with CPDA-1 may be available. Alternatively, the use ● Surgical scrub and gauze
of syringes with 1 ml citrate-based anticoagulant for every ● Blood tubing clamp
7 ml of blood collected can be used as an open-collection ● Blood tubing stripper
system that is unsuitable for storage but can be used for ● Heat sealer or metal sealing clip
immediate transfusion. ● Treats/cookies
In addition to the container and anticoagulant for blood ● Vacuum chambera
collection, several instruments and pieces of equipment are ● Suction machinea
needed. A blood tube stripper is used to apply pressure on ● Blood collection mixera
the blood tube through rollers that push the blood into the a
Optional equipment
blood bag once the collection has concluded. An atraumatic
tubing clamp will allow for temporary clamping of the blood
tubes without causing damage during the collection process. all supplies (Box 69.2) and secure a quite environment to
A tubing heat sealer will allow for permanent closure of perform the blood collection.
blood tubing by melting and fusing the plastic to form a seal Canine donors are often able to donate without any seda-
and can be a handheld (Figure 69.3) or benchtop device. tion. The blood banking community prefers these “volun-
Aluminum loops with crimpers can be a substitute for heat teer” donors as the perception is that the donor is not being
sealing, but they are not as stable and can result in acciden- forced to donate and it removes any concern about seda-
tal uncrimping during handling. Hospitals might also opt to tives in the blood that is collected. Sedation might be con-
use vacuum collection chambers with a suction machine, or sidered at small doses to introduce donors to the collection
blood collection mixers. For hospital performing component process or in emergency situations where donors with
separation, a refrigerated large volume centrifuge, plasma desirable blood types can only donate with sedation.
extractor, and blood tube welders are recommended. A combination of mu-agonist opioids and benzodiazepines
are used most, while alpha-2 agonists are a less favorable
Collection Procedure option due to cardiovascular compromise. Oxygen supple-
The collection process should be conducted in the least mentation is recommended for donors that are sedated
stressful manner for the donor. The use of positive rein- during collection.
forcement, stress-free handling, maintaining a calm envi- Administration of subcutaneous fluids post-donation is
ronment, and staff expertise in reading the donor’s stress commonplace. Intravenous (IV) catheters can be placed in
level and preventing negative experiences is vital. Gather donors to facilitate fluid administration, although this is
Donor Sources 909
not routine since the standard collection volume is unlikely monitoring of the collection (for detailed steps, see
to lead to hypotension. Protocol 69.1). The external jugular vein is use for blood
Collection of the blood requires two to three team mem- collection. The positioning that allows the donor and the
bers to perform the tasks of restraint, venipuncture, and phlebotomy team to stay comfortable for the duration of
Protocol 69.1 Canine Blood Collection Procedure [7]

1) Place blood collection system on the gram scale. from the donor. Apply pressure digitally or with a
a) If using the vacuum-assisted collection: pressure wrap to the venipuncture site.
i) Place the collection bag in the chamber, hang- 12) Promptly use the line stripper to move the blood in
ing it from the clip on the lid. the tubing into the collection bag and then gently
ii) Close the lid with the tubing positioned rock the bag to mix the blood with the
exiting the notched portion of the chamber, anticoagulant.
leaving slack in the tubing within the chamber 13) Allow blood to fill back into a length of tubing so that
to prevent occlusion of the tubing. aliquots (“pigtails”) can be made. Use metal sealing
iii) Connect the vacuum chamber to the suction rings or a heat sealer to create several 2–4 inch
machine and set it at 50 mmHg. Lightly push (5–10 cm) segments.
up on the lid to confirm a negative pressure 14) Label the unit with blood type, donor identification,
seal. A light push on the lid above the notch collection date, type of blood product, and expiration
and tubing is often needed to form a seal. Turn date.
the suction machine off once this is confirmed.
iv) The chamber and bag assembly are placed on
the gram scale.
b) If using gravity-assisted collection, simply place
the collection bag on the gram scale.
2) Temporarily clamp the tubing to prevent air from
entering the bag when the needle cap seal is broken.
3) Turn on scale. Tare the scale with the collection
system to zero.
4) Have the assistant restrain the donor comfortably in
lateral or sternal recumbency.
5) Clip the venipuncture site in a gentle manner. Confirm
adequate margins and location of shaving by occlud-
ing the jugular below the venipuncture site. Figure 69.4 Canine blood donor in lateral recumbency during
blood collection. Note the gentle handling with light pressure
6) Inject lidocaine intradermally if topical analgesic applied to the muzzle.
cream was not applied during the pre-donation
preparation.
7) Prepare venipuncture site by scrubbing gently.
8) Remove the needle cap and perform the
venipuncture.
9) Release the clamp from the tubing and confirm blood
flow (Figure 69.4). If using vacuum-assisted collec-
tion, turn on the suction machine using pressures
≤ 101.6 mmHg. If there is no flow, check for occlusion
of the tubing and reposition the needle as needed.
10) Monitor the progress of the blood collection via the
gram scale reading (Figure 69.5) while periodically
mixing the blood until the target weight is met
(450 ml = 474 g). If blood flow is disrupted, troubleshoot
by adjusting the needle or removing occlusions.
11) Once the desired amount is collected, reclamp the Figure 69.5 The volume of blood entering the bag is
blood line close to the needle and remove the needle measured through weight conversion during the donation.
910 Blood Banking
the collection should be used to maximize the chances of a fully recovered without complications, they can be sent
successful collection. The donor is typically positioned on home with a plan to follow up with the owners after
an elevated surface such as a treatment table if gravity col- 24 hours to ensure an uneventful recovery at home.
lection is used, while the donor can remain on the ground
if vacuum chamber collection sets are used.
Feline Donors
The venipuncture site is clipped and prepped with surgi-
cal scrub with care taken to prevent irritation of the skin. Selection and Screening
After clipping of the hair but before scrubbing, the use of Feline donors must be selected and screened carefully to
topical anesthetic cream (e.g. liposomal lidocaine) will protect donors and recipients from harm. A complete his-
reduce the discomfort caused by venipuncture and is rec- tory, comprehensive physical examination, blood tests, and
ommended with the appropriate contact time necessary for bloodborne pathogen screening are recommended before
it to take effect. Applying the cream with piece of gauze collecting blood for transfusion. Feline donors should be
and a light bandage wrap around the neck at the time of between one and eight years of age, apparently healthy,
predonation examination and bloodwork typically allows and have a history that rules out prior transfusions or preg-
enough contact time. nancies and current or chronic illness. Indoor-only cats are
A decisive puncturing of the skin and vein without the preferred, whenever possible. Cats without a known his-
need to redirect the needle will minimize pain and the tory (e.g. strays) can be considered at the discretion of the
chance of coagulation of blood during collection. Collection attending veterinarian who must weigh the risks and ben-
of the blood is continued until the desired volume of blood efits of using a donor who may have a history that could
is collected. When collecting blood with a bag, a scale is put the recipient at risk [9]. An agreeable temperament is
used to weigh the amount of blood collected, calculated at ideal; cats that are stressed by car rides and trips to the hos-
a weight of 1.053 g/ml. A typical 450 ml collection will pital should only be used as donors if necessary. Conscious
measure 474 g of blood, although 405–495 ml (426–521 g) is (i.e. without sedation) blood collections are increasingly
acceptable. During collection, the collection bag is rocked being performed from cats, with similar success rates com-
to mix the blood with anticoagulant as it enters the bag. As pared to sedated collections, suggesting that behavior and
the blood is collected, the donor is monitored closely for personality should be prioritized when selecting a feline
any signs of hypotension or hypovolemia and discomfort. donor [10]. Having a reliable, responsible, and committed
Once the desired collection weight is reached, the blood owner is also advantageous to ensure compliance with the
tubing clamp is placed on the tubing to cease the flow and program.
the needle gently removed from the donor as pressure is A lean body weight of at least 4.5 kg (ideally 5 kg) is recom-
applied to the venipuncture site. The mixing and monitor- mended for standard collections of 60 ml of blood [11].
ing of the collection weight can be automated using a blood Alternatively, cats that weigh less can be used during exten-
collection mixer, which functions as a scale and rocker uating circumstances but the volume collected must be
simultaneously, with many having the additional feature of decreased to 12 ml/kg or less to avoid cardiovascular com-
clamping the line when the desired weight is reached. promise [12]. A comprehensive physical examination must
As soon as the needle is removed from the donor, the be performed to rule out a heart murmur of gallop rhythm,
blood within the tubing should be stripped and pushed as well as any other abnormalities. An echocardiogram is
into the blood bag with a tubing stripper to allow mixing recommended for all feline donors in which a murmur or
with the anticoagulant before clotting occurs. Once the gallop rhythm has been auscultated [13]. Alternatively,
blood is mixed, a length of the blood tube can be allowed to some feline donor programs may elect to screen all cats with
refill to create several 10-cm length blood aliquots or “pig- an echocardiogram prior to donation, given the number of
tails” (the tubes are marked at the appropriate lengths) and cats without murmurs that have structural heart disease,
sealed to provide blood samples for crossmatching or qual- which should automatically exclude cats as donors [14].
ity control testing. The blood bag is then taken for immedi- Visualization of ectoparasites should disallow donation due
ate processing or stored. to risk of exposure to vector-borne disease [4].
Post-donation care of the donor involves applying gentle A complete blood count and serum biochemistry profile
pressure on the venipuncture site for at least five minutes should yield normal results and must be repeated annually.
to allow for hemostasis. The donor is continuously moni- Additional screening tests such as urinalysis and fecal par-
tored for signs of hypotension or hypovolemia. The donor asite testing can be performed at the discretion of the
is then provided with water and treats and given praise to attending veterinarian. Blood typing is also recommended
provide positive reinforcement for the donation process. If to ascertain whether the donor is type A, B, or C (also
fluids are administered, that can be performed any time known as AB) [15]. Unfortunately, screening for additional
after the conclusion of the donation. Once the donor is antigens such as Mik are not currently available.
Donor Sources 911
It is imperative that feline donors also be screened for hematologic status and should be at least 30–35%.
any vector-borne diseases that have the potential for trans- Performing in-hospital testing for feline leukemia virus
mission from the donor to the recipient within the blood and feline immunodeficiency virus is also recommended
product. Testing recommendations are derived from an prior to each blood collection if the donor has contact with
ACVIM consensus statement, which denotes minimal and other cats or access to the outdoors [12].
optimal standards for screening feline donors [14]. The
consensus panel recommends annual testing of feline Collection Supplies and Equipment
donors with the potential need to test more often for some Collection supplies required for feline blood collection vary
pathogens in endemic regions or in donors that have depending on the chosen protocol (Box 69.3). For the basic
repeated exposure to risk factors (e.g. ticks) or in donors task of blood collection, a semiclosed collection system that
who access the outdoors and have potential exposure to includes a 21–19gauge butterfly catheter attached to a 60-ml
other untested cats. Minimum standards recommend that syringe and small collection bag that has been sterilized is
feline donors test negative for A. phagocytophilum, B. hense- most often used. The system is considered “semiclosed” since
lae, Mycoplasma haemofelis, feline leukemia virus, and sterility is broken to add the anticoagulant just prior to blood
feline immunodeficiency virus. Optimal standards include collection. Some hospitals choose to use an open system
additional tests for A. platys, other Bartonella spp., using a butterfly catheter and collecting blood into three 20-
Cytauxzoon felis, and E. canis when indicated [4]. ml syringes with a single venipuncture. While a semiclosed
system is likely to provide a smaller chance of bacterial con-
Precollection Screening tamination, whole blood collected by an open system and
A cat’s eligibility for donation must be screened before stored for up to 35days has shown acceptable levels of hema-
acceptance into the program and again prior to each blood tologic and biochemical changes and no bacterial contami-
collection. This includes confirming the cat’s recent health nation [16]. Closed collection systems can be custom made
history, obtaining owner consent, performing a physical using tubing welders to add anticoagulant to a smaller bag
examination including measurement of vital signs and car- and attaching an apheresis needle to the bag under a laminar
diac auscultation, and measuring hematologic parameters. flow hood. Blood collections using custom made closed sys-
A form asking questions pertaining to illness, medications, tems have similar success rates, hematologic parameters, and
travel, vaccinations, and preventatives is recommended. bacterial contamination rates compared to blood collections
Cats receiving a short course of medication(s) for an acute using open systems, but the use of a vacuum collection set
illness should be healthy for at least two weeks after the significantly shortens the collection time [17].
medications are finished before donating. Cats should also
receive routine ectoparasite prevention as recommended Collection Procedure
for the geographical region. The form should also outline Unless a custom closed collection system is used, the col-
the risks of donation and complications to monitor for lection process starts with the addition of anticoagulant to
afterwards and request consent from the owner/employee. the collection system just prior to the collection (for
A PCV or hematocrit are minimum requirements to assess detailed instructions, see Protocol 69.2).
Box 69.3 List of Supplies Required for Feline Blood Collection [12]
● Sedation suitable for the donora ● Endotracheal tube(s) and laryngoscope

● Clippers and #40 blade ● Oxygen source
● Aseptic scrub for the peripheral intravenous (IV) ● Blood pressure and pulse oximetry monitoring equipment
cathetera placement and jugular venipuncture ● 250-ml or 500-ml bag isotonic crystalloid fluid
● Topical anesthetic cream ● IV fluid administration set
● Open blood collection system: ● For subcutaneous fluids: 19-gauge butterfly catheter or
⚪ 3 × 20-ml or 6 × 10-ml syringes 18-gauge needle
⚪ Sterile syringe caps ● For IV fluids:a
⚪ 21-gauge or 19-gauge butterfly catheters (extras in ⚪ 22-gauge IV catheter
case needed) ● Materials to secure the IV catheter in place

● Semiclosed collection system: if not using an open ● Flush for the IV catheter
system ● Fluid administration pump
● Anticoagulant a
Optional equipment
● Ocular lubricant
912 Blood Banking
Protocol 69.2 Feline Blood Collection Procedure Using a Semi-Closed System [12]
1) Fill the 60 ml syringe with the chosen anticoagulant 10) Remove the needle and apply pressure to the veni-
(1 ml/7ml intended collection volume) through one of puncture site for a minimum of 5 minutes.
the injection ports using aseptic technique. Prime the 11) Turn the three-way stopcock open to the bag from
three-way stopcock and butterfly catheter with the the syringe and push the blood into the bag gently
anticoagulant (Figure 69.6). so as not to damage the red blood cells
2) If needed, administer the sedation and allow it to take (Figure 69.10).
effect. If desired, place an intravenous (IV) catheter. 12) Using metal sealing rings or a heat sealer, seal off the
3) Gently position the donor in either lateral, sternal, or tubing from the three-way stopcock, leaving three
dorsal recumbency, apply ocular lubrication to both 2–4 inch (5–10 cm) segments.
eyes, and have an assistant extend the neck. 13) Label the bag appropriately, including the date of
4) Clip the fur at the venipuncture site. Using the skin collection, donor information, blood type, product
preparation materials and surgical scrub technique, type, and expiration date.
clean the skin over the jugular vein (Figure 69.7). 14) Provide IV or subcutaneous/. fluids to the donor and
5) Pass the syringe to the second assistant while the reverse sedation if indicated.
phlebotomist holds the butterfly catheter.
6) When the position of the jugular vein is confidently
determined, perform the venipuncture (Figure 69.8).
7) Request that the assistant with the syringe very gently
create a small amount of negative pressure by pulling
the plunger to approximately the 1 ml mark. This will
allow blood to flow into the catheter if the needle is
positioned within the vessel.
8) Draw the blood into the syringe while rocking the syringe.
a) Care must be taken not to cause collapse of the
vein or a “flutter,” as both will restrict blood flow
and promote coagulation. A “flutter” occurs when
the bevel of the needle gets drawn against the ves-
sel wall. The phlebotomist will feel the “flutter” as
the collection line will vibrate, and the vessel will
visibly collapse. Reducing the negative pressure on
Figure 69.7 Feline donor in lateral recumbency with the
the syringe can alleviate both situations. venipuncture site prepared.
9) Once the entire 60 ml has been drawn, turn the three-
way stopcock off to the syringe (Figure 69.9).
Figure 69.6 Semiclosed collection system with a double- Figure 69.8 Venipuncture being performed with the butterfly
chamber blood bag set attached, primed with anticoagulant to catheter attached to the semiclosed system for feline blood
ready for blood collection. collection.
Donor Sources 913
Figure 69.9 Full collection of blood totaling 60 ml in the Figure 69.10 Collected blood being pushed gently into the
collection syringe of the semiclosed system. blood bag through the three-way stopcock.
A quiet environment and the use of topical anesthetic

Box 69.4 Sedation Protocols used for Feline
cream is essential for all feline donations. Minimizing the
Donations
amount, frequency, and stress caused by handling, main-
Option A: taining a calm environment, and staff expertise in reading
● Midazolam 0.2 mg/kg intravenous (IV) the donor’s stress level and preventing negative experi-
● Ketamine 3 mg/kg IV ences is vital. Collection of the blood requires two to three
● Butorphanol 0.1 mg/kg IV team members to perform the tasks of restraint or position-
ing, venipuncture, handling of the collection syringe, and
Option B:
monitoring of the donor. During collection, the donor can
● Midazolam 0.25 mg/kg intramuscular (IM)
be positioned laterally, sternally, or ventrally to perform
● Ketamine 5 mg/kg IM
venipuncture of the external jugular vein.
● ± Butorphanol 0.2 mg/kg IM
The venipuncture site is clipped and prepped with surgi-
Option C: [18] cal scrub with care taken to prevent irritation of the skin.
● Alfaxalone 2 mg/kg IM The same considerations for application of topical anes-
● Butorphanol 0.2 mg/kg IM thetic cream in dogs should be applied to cats. A decisive
puncturing of the skin and vein without the need to redi-
rect the needle will minimize pain and chances of coagu-
Unlike dogs, feline blood donors are commonly sedated to lation of blood during collection. Gentle suction on the
allow for a stress-free collection. Various sedation protocols syringe and rocking the syringe gently to mix the incom-
are used, with combinations of butorphanol, midazolam, ing blood with the anticoagulant are continued through-
ketamine, and/or dexmedetomidine reported (Box 69.4). out the collection. While the blood is being collected, the
Alfaxalone and butorphanol administered intramuscularly donor is monitored closely for any signs of hypotension or
result in adequate sedation and equal quality of recovery hypovolemia and discomfort. Once the desired collection
compared to a dexmedetomidine and butorphanol combina- volume (typically a total of 60 ml with the anticoagulant
tion [18] and is the typical sedation combination of choice. included) is reached, the needle is gently removed from
When sedation is used, monitoring the blood pressure, and the donor as pressure is applied to the venipuncture site.
administering oxygen supplementation is recommended. The blood is then pushed into the collection bag with
While anesthetic induction agents such as propofol or inhal- some left in a length of blood tubing to create several blood
ant anesthetics have been used historically, they are no aliquots.
longer recommended due to concerns for hypotension. Post-donation care of the donor involves applying gentle
An IV catheter can be placed in feline donors to facilitate pressure on the venipuncture site for at least five minutes
post-donation fluid administration and to provide venous to allow for hemostasis. Sedative agents can be reversed to
access should there be any emergent complications that reduce recovery time and if it will not cause added stress to
occur during the donation. Alternatively, fluid administra- the donor. The donor is continuously monitored in a quiet
tion can be provided subcutaneously at the discretion of environment for signs of hypotension or hypovolemia until
the attending veterinarian. The supplies gathered will vary fully recovered. If subcutaneous fluids are used, they
depending on the method of fluid administration. should be administered prior to the sedatives wearing off.
914 Blood Banking
If IV fluids are given, 10 ml/kg of isotonic crystalloids over

0.5–3 hours is recommended [12]. Once the donor has fully
recovered without complications, food and water can be
offered. The donor can then be discharged with a plan to
follow up with the owners after 24 hours to ensure an une-
ventful recovery at home.
Processing and Storage of Blood Products
Processing
The benefits of component therapy have led to a wide-
spread practice in veterinary medicine. Because of this,
commercial blood banks have had a difficult time keeping
up with demand and some veterinary practices are choos-
ing to collect and process their own components. While
there is no regulation that prevents hospitals from pro-
cessing their own blood components, the hospital must
take into consideration the resources, expertise, and effort
required to produce blood products of proper quality. The
simplest form of blood component separation to achieve
in-hospital is the separation of whole blood into PRBCs
and plasma. Separation of blood into other components is Figure 69.11 A large volume, refrigerating centrifuge for blood
processing.
beyond the scope of this chapter and readers are encour-
aged to consult other resources [19].
Separation Supplies and Equipment

A multichambered collection bag is required for component
processing, otherwise the supplies and equipment used for
blood collection do not differ between products administered
as whole blood or components. In addition to the instruments
and equipment mentioned above, the hospital will require a
refrigerated centrifuge with rotor cups that can accommodate
the 450-ml multichambered collection bags, as well as a
plasma extractor to separate the blood components.
There are two types of centrifuges: benchtop and floor
models. The benchtop centrifuge has the advantage of Figure 69.12 Plasma extracted using a manual plasma extractor.
using less physical space to store and operate, however, it
often has physical limitation in the relative centrifugal that presses against a second surface to move the plasma
force (RCF) it can create because of the shorter rotor out vertically into the satellite bag and requires close atten-
length and motor strength. It will also have limits as to the tion during operation (Figure 69.12). Automated plasma
number of rotor cups it can hold. A floor model is physi- extractors are also available, which reduce the manual
cally larger but has the advantages of achieving a higher operation required to separate plasma from the red blood
RCF, accommodating a larger number of rotor cups, and cells, although at significantly higher expense.
tends to be more physically stable during operation
(Figure 69.11). Modern centrifuges can program tempera- Separation and Processing Protocols
ture, acceleration, and deceleration settings with preset If there will be a delay in processing the whole blood into
memory, and can include features such as balance stabili- components, the blood should be stored at refrigeration
zation and imbalance alarms. temperatures (33.8–42.8°F; 1–6°C) unless there is consid-
A plasma extractor is a device that presses the plasma eration for using the whole blood as a source of platelets, in
into one of the satellite bags after separation by the centri- which case room temperature (68–75.2°F; 20–24°C) stor-
fuge. Manual plasma extractors use a spring-loaded panel age is appropriate. The processing of whole blood into
Proceesing ind SrP ngc ro Brrn PrndoSe 915
PRBCs and plasma should be conducted within 24 hours was intentionally left with the PRBCs to serve as a nutrient
(maximum) of collection. solution, but with the advent of additive solutions that
The first step in component separation is to centrifuge contain combinations of adenine, glucose, and mannitol
the whole blood to separate it into cellular components and to serve as storage nutrients, as much of the plasma as
plasma. The RCF, temperature, and duration of spin vary possible is extracted. The additive solution is added
depending on the desired product (see Protocol 69.3 for approximately at 1 ml solution per 2 ml RBCs, resulting in
detailed steps and settings). a 55–70% PCV depending on the donor’s PCV and the
amount of plasma extracted. The PCV of the processed
Packed Red Blood CellsPlasma is extracted from whole PRBCs should be measured and written on the label to
blood to obtain PRBCs. Historically, 20% of the plasma facilitate accurate dosing.
Protocol 69.3 Blood Component Processing Protocols for Packed Red Blood Cells and Plasma [19]
1) Turn the centrifuge on and allow it to cool down to a shut while stopping the pressing plate from further
target temperature of 33.8–42.8°F (1–6°C). plasma expression. Raising the plasma bag to the
2) Weigh the whole blood collection, including satellite same level as the RBCs can also assist to prevent
bags, and record the weight. further fluid transfer.
3) Place the whole blood collection into the centrifuge 13) Seal the line between the RBCs and plasma using the
bucket. Ensure that the placement within the bucket available method. Ensure that the seal allows both
meets recommendations of the the centrifuge the plasma and red cells to remain sterile once
manufacturer (e.g. place toward the outside of a physically separated from each other.
circular centrifuge bucket).
4) Fold the attached bags and lines securely into the Additional instructions for PRBCs:
bucket next to the unit. If using a set that contains a
1) Snap the seal between the additive solution and
leukoreduction filter, ensure that it is tucked away so
concentrated red cells.
that it will not cause damage to the unit while
2) Suspend the additive solution and allow the fluid to
centrifuged.
run onto the concentrated RBCs.
5) Weigh the filled centrifuge buckets and select the heav-
3) Remove the additive solution bag if not required, using
iest bucket to balance all others against. The centrifuge
the method of tube sealing available and leaving a
buckets must be accurately balanced. Suitable balances
tubing segment long enough to later generate several
include pieces of tubing, unused blood collection bags
sub78segments.
filled with saline, weights provided by manufacturers, or
4) Gently mix to resuspend the red cells in the additive
other soft plastics or rubbers.
solution.
6) Check that all the buckets swing freely in their axis.
5) Use a tube stripper to strip the line content into the
7) Centrifuge the unit(s) following the appropriate
bag. Repeat three or four times to ensure a representa-
protocol.
tive sample of the final RBC product remains in the line.
a) Hard spin: 5000 g, 7minutes (for PRBCs and plasma)
6) Subdivide the tubing into segments or “pigtails” using
b) Soft spin: 2000 g, 3 minutes (typically used for
the available method of tube sealing.
platelet products)
7) Remove a “pigtail” for measurement of final PCV and
8) Prepare all other equipment: plasma extractor, tube
record value.
sealer, tube stripper, and scissors.
8) Weigh the unit if desired to establish
9) At completion of the centrifugation, carefully inspect
approximated volume.
the units to ensure that the plasma is clear.
9) Label the bag, then store in the refrigerator.
10) Carefully remove the bucket from the centrifuge,
gently remove the unit, place it in the prepared
Additional instructions for plasma:
plasma press, and gently release the pressing plate.
11) Snap the seal at the top of the blood collection pack 1) Label the bag and weigh if desired.
to allow plasma to run into the satellite bag. 2) Place in a freezer at −0.4°F (−18°C) or colder, or a blast
12) For manual plasma presses, use thumb and index freezer. Lay the unit flat and in single layers to freeze
finger or an atraumatic tube clamp to pinch the line as rapidly as possible.
916 Blood Banking
Plasma Products Plasma is traditionally considered fresh Table 69.1 Shelf life of blood products [19].
frozen plasma when separated and frozen within eight
hours of collection and contains viable levels of all Blood product Shelf life
coagulation factors. It is considered frozen plasma if
separation occurs longer than eight hours after collection, Red blood cell products
(33.8–42.8°F; 1–6°C):
which affects the activity of unstable coagulation factors.
Whole blood CPDA-1: 28 days
There is, however, evidence supporting plasma frozen
within 24 hours of collection having minimal changes in Packed red blood cells CPDA-1: 20–21 days
coagulation factor activity and hemostatic protein content, CPD w/AS-1: 35 days
possibly extending the length of time before plasma must CPD w/AS-3 or AS-5;
be frozen for its maximum benefits [20]. 35–37 days
CPD w/SAGM: 42 days
Leukoreduction The removal of white blood cells can be Plasma products ( 0.4°F; 18°C):
performed before or after processing using leukoreduction Fresh frozen plasma 1 year
filters. Because white blood cells can release cytokines during Frozen plasma 5 years
storage, preprocessing leukoreduction seems to have
CPD, citrate phosphate dextrose; CPDA, citrate phosphate dextrose
additional benefits in reducing the cytokine concentration
adenine.
and subsequent inflammatory response by recipients upon Source: Mansell and Boller 2016.
transfusion [21, 22]. Blood collection bags with leukoreduction
filter attachments (Figure 69.13) are available and allow for have temperature monitoring capabilities that include a
filtration of the blood shortly after the collection of blood and minimum–maximum thermometer inside the refrigerator,
before component separation. Alternatively, post-processing digital readout, and chart recorder, or a temperature probe
leukoreduction can be performed cage side prior to attached to a recording device. Independently operated
administration of the blood product. temperature monitoring devices can also be used and are
especially helpful should a power outage occur. Temperature
monitoring devices using insulating liquid mimicking ther-
Storage
mal consistency of blood enables an accurate measurement
Refrigerator of the temperature the blood bags are experiencing during
The shelf life of whole blood and PRBCs varies depending storage (Figure 69.16). Alarms should be set such that per-
on the anticoagulant and nutrient solution used (Table 69.1). sonnel can be alerted about harmful temperature deviations
PRBCs and whole blood should be stored in a refrigerator that could damage stored products.
designated only for blood products (Figures 69.14
and 69.15). Household refridgerators have traditionally Freezer
been used for blood product storage; however, they are not Freezers designed for research specimens or blood banks
designed to maintain narrow temperature ranges. are also recommended for plasma product storage over tra-
Refrigerators designed for use in laboratories or blood banks ditional refrigerator-freezer combinations, to maintain the
are recommended. A designated refrigerator will ensure temperature between −0.4°F (−18°C) to −22°F (−30°C;
unnecessary opening and closing of the door, which can Figures 69.15 and 69.17). Freezing of plasma products is
lead to temperature fluctuations. The refrigerator must traditionally performed at −0.4°F (−18°C); however, there
(a) (b)
Figure 69.13 (a) Prestorage leukoreduction filter incorporated in blood collection bag tubing. (b) Prestorage leukoreduction filter in use.
d BsSty eedP ioc 917
Figure 69.16 Insulating liquid container installed inside the

Figure 69.14 Inside view of a benchtop blood storage blood storage fridge to accurately measure temperature.
refridgerator.
Figure 69.15 Benchtop blood storage refrigerator (left) and

plasma freezer (right).
are recommendations from human blood banking to freeze

plasma products at −22°F (−30°C) or colder to better pre-
serve coagulation factors [19].
Figure 69.17 Inside view of a benchtop plasma freezer.

Quality Assurance
collection, processing, and storage of the blood product. As
Quality assurance in the context of blood banking is the such, standard operating procedures are recommended
maintenance of a desired level of quality of a blood product and must include protocols for blood collection, blood pro-
and occurs by carefully attending to each stage of the cessing, maintenance of storage equipment, maintenance
918 Blood Banking
of blood product logs, and assessment of the quality of

blood products prior to administration.
Maintenance of Equipment
Centrifuge
The hospital’s blood product centrifuge must be inspected
regularly for wear and tear such as cracks or stress frac-
tures on the rotor. The centrifuge should also be kept clean
and dry without the use of corrosive or abrasive solvents,
and it should be periodically serviced and calibrated
according to its level of use [19].
Refrigerator
Daily temperature checks should be a routine part of main-
tenance and periodic recalibration is recommended to con-
firm the set temperature is accurate. The refrigerator
should also be routinely wiped clean with appropriate
cleaning agents and dust removed from filters, condensers, Figure 69.18 A bag of packed red blood cells containing
and motors [19]. visible blood clots, and must not be administered.
Source: Courtesy of Laura Call, LVT.
Freezer
Freezer maintenance is as described above, with the addi- should not be used from donors if their screening tests are
tion of periodic defrosting and cleaning of door seals to incomplete. Aliquots of blood from donors can be stored
prevent excessive buildup of ice. The freezer designated for long term for repeat testing should a recipient develop a
blood product storage should be temperature monitored as transfusion-acquired infection.
described above, so that defrosting and refreezing cycles All blood products must be visually inspected prior to
are detected. Otherwise, two methods are available to administration. PRBC or whole blood units that appear dis-
detect unintentional thawing of frozen products. A rubber colored (e.g. dark purple to black, green) or contain visible
band may be placed around a plasma bag prior to freezing clots and/or fibrin strands (Figure 69.18), must not be used
and then removed once the product is frozen. If the inden- and should have a bacterial culture submitted prior to
tation on the product disappears during storage or trans- being discarded. The presence of cell aggregates that
port, the product has been thawed. Alternatively, an air appear as white clumps that do not dissipate with gentle
bubble can be left within the plasma product after which rocking also indicate a red cell product should not be used.
the product is frozen while lying flat, such that the bubble However, small white specks that dissolve with warming of
remains in the middle of the top side of the bag. The plasma the blood are more likely to be lipid aggregates, which do
should then be stored upright and if the bubble moves to not typically require disposal [23]. Percentage hemolysis
the top of the bag, this is an indication that the product has can also be calculated to quantify the degree of red cell deg-
thawed [19]. radation (Eq. 69.1). Units with hemolysis greater than 1%
should not be administered [24].
Maintenance of Blood Product Logs
Total hemolysis of the unit (100 – Hct)
Hospitals must maintain a blood product usage log that
plasma Hemoglobin (g / dL) / total Hb (g / dL) (69.1)
that includes the date a blood product was received from
another source or collected in the hospital, the source or
donor from which it was obtained, and whether adverse Plasma units may appear lipemic, indicated by a milky
events were noted during its administration. appearance, which typically occurs with blood collected
from donors postprandially (Figure 69.19). The presence of
lipemia does not compromise the efficacy or safety of the
Blood Product Quality Control
product and transfusion of lipemic products remains
All items used for blood product collection and storage acceptable [23]. Because not all plastics are suitable for fro-
should have sterility certificates attached and must be used zen storage, cracks or breaks in the frozen product bag
within any designated expiration dates. Blood products should be noted and the product discarded (Figure 69.20).
cocPcioce 919
Figure 69.20 A blood product contains a visible crack and

must be discarded. Courtesy of Anna Bakirova, Chance
Bio, Moscow.
Acknowledgment
Figure 69.19 Lipemia is noted within the plasma during
separation. Source: Courtesy of Anna Bakirova, Chance The authors wish to acknowledge Anna Bakirova and Laura
Bio, Moscow. Call, for the use of their photographs in this chapter.
References
1 Lester, S. (2016). Blood product sources. In: Manual of 2 in difference canine breeds from a diagnostic laboratory
Veterinary Transfusion Medicine and Blood Banking (ed. in Germany. Front. Vet. Sci. 7: 85.
K. Yagi and M.K. Holowaychuk), 259–270. Ames, 7 Yagi, K. (2016). Canine blood collection. In: Manual of
IA: Wiley. Veterinary Transfusion Medicine and Blood Banking
2 Yagi, K. and Bean, B.L. (2016). Canine donor selection. In: (ed. K. Yagi and M.K. Holowaychuk), 199–211. Ames,
Manual of Veterinary Transfusion Medicine and Blood IA: Wiley.
Banking (ed. K. Yagi and M.K. Holowaychuk), 189–198. 8 Bosch Lozano, L., Blois, S.L., Wood, R.D. et al. (2019).
Ames, IA: Wiley. A pilot study evaluating the effects of prestorage
3 Blais, M.C., Rozanski, E.A., Hale, A.S. et al. (2009). Lack of leukoreduction on markers of inflammation in critically
evidence of pregnancy-induced alloantibodies in dogs. ill dogs receiving a blood transfusion. J. Vet. Emerg. Crit.
J. Vet. Intern. Med. 23 (3): 462–465. Care 29 (4): 385–390.
4 Wardrop, K.J., Birkenheuer, A., Blais, M.C. et al. (2016). 9 Russo, C. and Humm, K. (2016). Feline donor selection.
Update on canine and feline blood donor screening for In: Manual of Veterinary Transfusion Medicine and Blood
blood-borne pathogens. J. Vet. Intern. Med. 30 (1): 15–35. Banking (ed. K. Yagi and M.K. Holowaychuk), 212–222.
5 Guidetti, M., Goy-Thollot, I., Boisvineau, C., and Giger, Ames, IA: Wiley.
U. (2019). Alloimmunization of a dog erythrocyte antigen 10 Doolin, K.S., Chan, D.L., Adamantos, S., and Humm,
1- dog transfused with weakly dog erythrocyte antigen 1+ K. (2017). Retrospective evaluation of unexpected events
blood. J. Vet. Intern. Med. 33 (5): 2037–2045. during collection of blood donations performed with and
6 Ebelt, A.K., Fuchs, S., Weber, C. et al. (2020). Survey of without sedation in cats (2010–2013). J. Vet. Emerg. Crit.
blood groups DEA 1, DEA 4, DEA 5, Dal, and Kai 1/Kai Care 27 (5): 555–560.
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11 Barfield, D. and Adamantos, S. (2011). Feline blood 18 Reader, R.C., Barton, B.A., and Abelson, A.L. (2019).
transfusions: a pinker shade of pale. J. Fel. Med. Surg. 13 Comparison of two intramuscular sedation protocols on
(1): 11–23. sedation, recovery and ease of venipuncture for cats
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collection. In: Manual of Veterinary Transfusion Medicine (2): 95–102.
and Blood Banking (ed. K. Yagi and M.K. Holowaychuk), 19 Mansell, C.L. and Boller, M. (2016). Blood
223–236. Ames, IA: Wiley. component processing and storage. In: Manual of
13 Cote, E., Edwards, N.J., Ettinger, S.J. et al. (2015). Veterinary Transfusion Medicine and Blood Banking
Management of incidentally detected heart murmurs in (ed. K. Yagi and M.K. Holowaychuk), 237–255. Ames,
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14 Fuentes, V.L., Abbott, J., Chetboul, V. et al. (2020). ACVIM 20 Walton, J.E., Hale, A.S., Brooks, M.B. et al. (2017).
consensus statement guidelines for the classification, Coagulation factor and hemostatic protein content of
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921
Section Ten
Nursing Care of Specific Populations
923
70
Care of the Patient with Intracranial Disease

Marie K. Holowaychuk and Charlotte E. Donohoe
Animals with intracranial disease may have any number of or fluid, the ICP will increase because of the additional
underlying disorders such as traumatic brain injury (TBI), intracranial volume (Figure 70.1) [2]. If surgery is not an
idiopathic epilepsy, meningitis, encephalitis, or neoplasia. option to remove the structural abnormality contributing to
Signs associated with the disease will vary and the patients the increase in intracranial volume, other treatments must be
will differ in terms of the intensity of the nursing care they employed. These might include the administration of ster-
require. For example, one patient may be a dog hospital- oids to reduce tumor-associated inflammation in patients
ized for observation after cluster seizures, while another with neoplasia or to reduce the production of cerebrospinal
may be a cat recovering from a craniotomy to remove a fluid (CSF) in patients with hydrocephalus. Alternatively,
brain tumor. Regardless of the underlying disease or sever- mannitol or hypertonic saline may be given to decrease ICP
ity of signs, the goal for all patients with intracranial dis- (Box 70.1). Ultimately, the goal with these treatments is to
ease is to preserve their brain function. This is achieved by reduce intracranial tissue or fluid volume.
ensuring adequate cerebral blood flow (CBF) by maintain- Intracranial volume and thus ICP can also be increased due
ing a normal cerebral perfusion pressure (CPP) of to physiologic increases in blood volume. These physiologic
50–60 mmHg [1]. In the normal or uninjured brain, pres- alterations can be monitored and addressed by veterinary
sure autoregulation maintains a constant CBF despite a technicians/nurses, to prevent increases in ICP. For example,
wide range of mean arterial blood pressures (MAP, increases in venous blood volume might occur due to jugular
50–150 mmHg) [1]. When MAP is maintained within that venous obstruction, a head-down position, or increases in
range and CPP increases, cerebral blood vessels constrict to central venous pressure [2]. Therefore, to decrease ICP, it is
decrease overall cerebral blood volume and intracranial important that patients with intracranial disease are carefully
pressure. However, as MAP decreases to below 50 mmHg, positioned so as not to place pressure on the jugular veins or
CBF decreases and is dependent on MAP [1]. In addition to increase blood flow to the head. Additionally, increases in
MAP, CPP is affected by changes in ICP (Eq. 70.1). arterial blood volume and subsequently ICP can occur due to
Elevations in ICP will decrease CPP, resulting in worsening systemic hypertension, hypoventilation, hypoxemia, or
of brain function [1]. The aim in all patients hospitalized increases in cerebral metabolic rate due to seizures, agitation,
for intracranial disease is to ensure stability of cardiovascu- or elevations in body temperature [2]. Thus, it is imperative
lar parameters, namely, blood pressure, and most impor- that patients with intracranial disease maintain normal blood
tantly, to prevent elevations in ICP. pressure, ventilation, and oxygenation, and that seizures are
treated quickly and any temperature elevations are elimi-
CPP MAP ICP (70.1)
nated. Clearly, the veterinary technician or nurse has the par-
ICP may increase for many reasons, including the underly- ticularly important task of monitoring for changes that could
ing disease process itself. For example, masses such as tumors lead to ICP elevations and, if possible, preventing some of the
or abscesses, cerebral edema or hemorrhage following a trau- physiologic changes that can increase ICP.
matic injury, or hydrocephalus due to a congenital malforma- Because these physiologic changes can occur very
tion, are all space-occupying lesions that can cause elevations quickly, resulting in rapid deteriorations in a patient’s sta-
in ICP. Because a rigid nonexpandable skull surrounds the tus, animals with intracranial disease must be constantly
brain, if there are pathologic increases in intracranial tissue and closely monitored. Therefore, it is imperative that
924 Care of the Patient with Intracranial Disease
these patients receive 24-hour monitoring. This ensures

that nursing care and appropriate monitoring is provided
continuously, so that changes in a patient’s status can be
detected quickly and treated appropriately. Many of the
Intracranial Pressure
monitoring devices or treatment modalities required for

patients with intracranial disease are available only at
24-hour or specialty hospitals. For these reasons, to provide
the best care possible it is recommended that patients with
intracranial disease are transferred to a facility capable of
providing 24-hour monitoring and nursing care.
Intracranial Volume Serial Neurologic Examinations

Figure 70.1 Relationship between intracranial pressure (ICP) Patients with intracranial disease require constant moni-
and volume. At low intracranial volumes, increases in intracranial
volume produce minimal changes in ICP. However, small increases in toring, including serial neurologic examinations. Because
intracranial volume will eventually cause dramatic increases in ICP. the patient’s condition can change very quickly, it is
Box 70.1 Medications [3]
Mannitol ● Cautions:
● Hypovolemia
Mechanism of action
● Severe dehydration
●Increases the osmotic gradient between the vasculature
● Pulmonary edema
and brain causing fluid to move out of the brain and
● Hyperosmolar states (e.g. ethylene glycol toxicity).
into the blood.
Storage
Hypertonic saline (7–7.5% NaCl)
● Room temperature for lower concentrations.
● Incubator for higher concentrations (> 15%) to avoid Mechanism of action
crystal formation. ● Increases the osmolality of the blood to cause water to
● Bottles stored at room temperature can be heated in a shift from the brain into the intravascular space.
warm water bath or incubator up to 140°F (60°C) to
dissolve crystals, but should be cooled to body Administration
temperature prior to administration. ● Dose: 3–5 ml/kg [4]:
● Discard if unsuccessful in dissolving the precipitate. ● Typically drawn into a syringe and administered via
syringe pump or slow push (over 15 minutes).

Administration
● Administer in conjunction with isotonic crystalloids.
● Dose: 0.5 g/kg IV:
● Constant rate infusions are not recommended.
● Draw up using a filter needle (Monoject™ filter
● Monitor:
needle, Kendall Healthcare, Mansfield, MA) or
● Urine output.
administer with an inline filter (Hemo-Nate® filter,
● Electrolytes (sodium and chloride).
Gesco International, San Antonio, TX).
● Respiratory rate and effort (risk of fluid overload).
● Give slowly via a syringe pump or slow push (over
● Blood pressure and heart rate (transient hypotension
15–20 minutes).
and vagally mediated bradycardia can occur during
● Can be repeated every 6–8 hours as needed.
rapid administration).
● Constant rate infusions are not recommended.
● Cautions:
● Use a dedicated line (i.e. do not mix with other
● Significant hypernatremia or hyperchloremia
medications).
● Intravascular overload
● Monitor:
● Dehydration
● Urine output
● Repeated doses can cause phlebitis (give via a central
● Electrolytes (sodium, potassium) and osmolality
line if available).
● Respiratory rate and effort (risk of fluid overload)
● Blood pressure
erial eerolooic Eaminations 925
Box 70.2 Serial Neurologic Examinations
Normal Findings ● Absent pupillary light reflex

● Miotic (i.e. pinpoint) pupils
● Alert and responsive to the environment
● Recumbency ± extensor rigidity of the forelimbs
● Normal pupillary light reflex
● Normal pupil size bilaterally
Severe Intracranial Disease
● Normal gait and normal spinal reflexes
● Comatose and unresponsive to noxious stimuli
Mild Intracranial Disease ● Absent pupillary light reflex
● Depressed or inappropriate mentation ● Mydriatic (i.e. dilated) pupils
● Slow pupillary light reflexes ● Recumbent ± loss of muscle tone and spinal reflexes
● Normal pupil size bilaterally ● Loss of facial sensation or gag reflex
● Paresis
Moderate Intracranial Disease

● Stuporous/semicomatose but responsive
to noxious (i.e. painful) stimuli
important that the neurologic status is assessed frequently

Box 70.3 Assessing Mentation and Level
to detect changes as they arise. The veterinary technician/
of Consciousness
nurse must contact a veterinarian immediately if the
patient’s neurologic status is deteriorating, or if the results ● Normal: alert and responsive to the environment.
of the neurologic examination are difficult to interpret. ● Altered: abnormal or decreased response to
Neurologic examination findings will vary depending on environmental stimuli.
the severity of the intracranial disease and can include ● Stuporous/semicomatose: responsive only to painful
mild to pronounced neurologic deficits. It is especially stimuli.
important that the technician/nurse coming on shift ● Comatose: unresponsive to painful stimuli.
immediately assesses any patients with intracranial disease
to obtain a baseline from which to compare subsequent
examinations. If an initial examination is not performed, Additionally, some patients will exhibit an inappropriate
observations by the technician/nurse might be assessed as response to environmental stimuli, such as excessive vocal-
“normal” for that patient when in fact they may have pro- ization. Patients that progress to a stuporous or semicoma-
gressed from previous evaluations. Such a circumstance tose state will be less responsive to visual or auditory
could result in a devastating failure to detect deterioration stimuli in their environment until they are responsive only
in a patient’s status in a timely manner. to painful (i.e. noxious) stimuli. Finally, an animal that is
The patient should be assessed frequently to determine comatose is unresponsive to all environmental stimuli
its level of consciousness, pupillary light reflexes (PLRs), including repeated noxious stimuli [5].
pupil size, posture, and reflexes (Box 70.2). Almost all It is important when assessing patients with intracranial
patients with intracranial disease will have an abnormal disease never to assume that a patient is “sleeping,” and for
level of consciousness varying from a mildly altered menta- that reason not assess its mentation. A patient that has oth-
tion to a coma. If the patient is sedated, it may be difficult erwise been responsive to environmental stimuli may pro-
to assess its level of consciousness. Regardless, patients gress into a semicomatose to comatose state, and if one
receiving sedative medications should be intermittently assumes that the patient is “sleeping,” their condition may
“woken up” (i.e. sedation briefly stopped) to enable proper continue to deteriorate without intervention. Thus, patients
assessment of their mentation and level of consciousness should always be awakened every one to two hours if they
(Box 70.3). Normally, patients with mild intracranial disappear to be sleeping, to assess their level of consciousness
ease will still have periods of alertness and responsiveness accurately and ensure that it is not deteriorating.
to their environment. As the severity of intracranial disease It is also important that PLRs and pupil size are assessed
progresses, patients will become increasingly altered and in patients with intracranial disease on a frequent basis.
less capable of responding to their environment. PLR is tested by shining a bright light into the pupil and
assessing for constriction of the pupil (direct reflex) [5]. swallow and protect its airway. Therefore, if a patient has
The opposite pupil should constrict at the same time lost its gag reflex, a veterinarian should be contacted imme-
(consensual reflex). It is not necessary to assess the con- diately, and endotracheal intubation considered. Facial
sensual reflex if the direct PLR is present in both eyes [5]. sensation is assessed by touching the medial or lateral can-
Generally, a critically ill patient with mild elevations in thus of the eye to cause a blink (palpebral reflex), stimulat-
ICP will have normal PLRs that will progress to slow or ing the nasal mucosa with a pen or hemostats to cause
completely unresponsive pupils in patients with moder- withdrawal of the head, or pinching the skin of the face
ate to severe elevations in ICP [6]. In addition to altera- with a hemostat and observing for a blink or facial twitch
tions in the PLR, patients with moderate to severe on that side [5]. Loss of facial sensation also indicates
elevations in ICP will also exhibit changes in their pupil severe intracranial disease, and if it is a new finding, the
size. While patients with mild elevations in ICP will have veterinarian should be contacted immediately.
normal to slightly miotic (i.e. constricted) pupils, patients While a patient with intracranial disease might seem
with moderate to severe elevations in ICP will have pro- “stable” and its condition is unlikely to change, patients
gressively altered pupil sizes ranging from miotic or pin- with intracranial disease can deteriorate rapidly and with-
point pupils to unilateral or bilateral mydriatic (i.e. out warning. Therefore, the importance of frequent and
dilated) pupils that are completely unresponsive to thorough neurologic examinations cannot be stressed
light [6]. Miotic or mydriatic pupils in a patient with enough, with the goal of detecting subtle changes in a
intracranial disease and previously normal-sized pupils patient’s neurologic status before they have progressed to a
represents an emergency and a veterinarian should be state in which the changes are irreversible.
contacted immediately.
Ideally, patients with intracranial disease that are not
sedated should have their posture and reflexes assessed Nursing Care
frequently. Patients with mild intracranial disease will
exhibit a normal posture, gait, and reflexes. As the sever- Managing hospitalized patients with intracranial disease
ity of intracranial disease worsens, patients will exhibit requires intensive monitoring and special attention to the
varying degrees of paresis (weakness) progressing to full animal’s comfort. A substantial component of nursing care
recumbency [6]. Additionally, patients may exhibit other for patients with intracranial disease is avoiding further
abnormalities including circling, a head tilt, decerebellate brain injury as a result of increased ICP. Superior nursing
rigidity, or decerebrate rigidity. Decerebellate rigidity is care for these patients relies primarily on the ideal setup of
characterized by opisthotonus (extension of the head and the patient’s cage or kennel to reduce the risk of further
neck), with the forelimbs extended [5]. Animals exhibit- brain injury. By selecting a cage that is free from unneces-
ing decerebellate rigidity also typically have flexed hips sary stimulation but easily visible for constant monitoring,
and normal mentation. In contrast, patients with decere- th technician/nurse can quickly recognize any change in a
brate rigidity have a stuporous or comatose mentation patient’s mentation that may be indicative of an increase in
that is associated with opisthotonus and extension of all ICP. Whether the patient is active or recumbent will also
limbs [5]. Finally, a patient with severe intracranial dis- guide the arrangement of the animal’s cage or kennel.
ease may have a complete loss of muscle tone and Appropriate bedding should be selected that provides ade-
decreased to absent spinal reflexes. The simplest spinal quate cushioning, allows the patient to be kept clean, and
reflex to test in patients with intracranial disease is the optimizes the comfort of the patient.
withdrawal reflex. This reflex is elicited by applying a The cage location for a dog or cat with intracranial dis-
noxious stimulus to the tested limb by pinching the nail ease can play a major role in reducing unnecessary stimu-
bed or toe with fingers or a hemostat [5]. The normal lation. Environmental stressors can induce an unsafe and
reflex is contraction of the flexor muscles and withdrawal prolonged increase in ICP. Ideally, these patients should be
of the tested limb. placed in a location free from loud noises, such as barking
Cranial nerve reflexes should also be assessed, the easiest dogs. Avoid selecting a cage in an area with heavy foot traf-
of which include the gag reflex and facial sensation. To fic, and place signs on or near the cage alerting staff to keep
assess the gag reflex, stimulate the pharynx with a finger to loud noises at a minimum. If auditory stimulation cannot
elicit a gag [5]. An absent gag reflex may be due to excessive be minimized simply by cage location, cotton can be placed
sedation if the patient is receiving sedatives; however, in in the patient’s ears if tolerated. To avoid misinterpretation
the absence of sedating medications, loss of the gag reflex of decreased response to auditory stimuli or sending the
represents severe intracranial disease. The loss of a gag animal home with cotton in its ears, always put white tape
reflex is especially concerning because it puts the patient at on the patient’s head and write “cotton in ears” on the tape
risk for aspiration since the patient cannot normally (Figure 70.2).
ersino Care 927
Figure 70.3 A Chihuahua with vestibular disease is surrounded

by padding and blankets to prevent it from injuring itself
when it rolls.
in which they can be readily monitored and accessed

quickly if necessary. Additionally, it is important that treat-
ment orders are already available if the patient experiences
a seizure, so that the animal can be treated immediately
rather than after a veterinarian is called.
The safety and comfort of patients with intracranial dis-
ease are controlled by a carefully designed cage or kennel.
Figure 70.2 A Bulldog is intubated following treatment for Depending on the disease affecting the patient, the animal
cluster seizures and has cotton in his ears to prevent auditory
stimulation. An end-tidal CO2 monitor is attached to the end of may be active or recumbent. Active or moving patients,
the endotracheal tube for continuous capnography. such as those with vestibular signs that are circling or roll-
ing, or animals experiencing generalized seizures will ben-
Visual and tactile stimulation should also be reduced. efit from a cage that is heavily padded on all sides. A cradle
Select a cage far away from bright lights in a darker corner can also be made using rolled towels or foam padding on
of the intensive care unit. A cage isolated from others can either side of smaller dogs and cats, to protect them from
reduce the number of technicians/nurses, doctors, and injury (Figure 70.3). Keep in mind that a patient sur-
other animals passing by that could disturb the patient. rounded by extra bedding or moving excessively may
Reduce tactile stimulation by clustering treatments develop hyperthermia; therefore, more frequent monitor-
together, which will minimize the frequency of entering ing of body temperature may be warranted in these
the cage or kennel throughout the day. For example, treat- patients. A patient who continuously circles in the kennel
ments such as examination of PLRs, auscultation, and or cage should not have any unnecessary fluid lines or
venipuncture can be conducted when the patient is due to monitoring cords in their path. Coiled intravenous fluid
be turned. administration sets prevent lines from lying on the cage
While reduction of stressors is important in cage selec- floor and getting tangled and can be mounted to the ceiling
tion, it is also important to keep in mind that the patient of the cage (Figure 70.4).
needs to be monitored closely. Technicians/nurses should Recumbent patients are those who are stuporous or
be able to identify any change in the animal’s level of con- comatose, heavily medicated, sedated for mechanical ven-
sciousness, as this is one of the first signs of an increase in tilation, or recovering from surgery. These animals require
ICP. Other parameters such as the patient’s respiratory rate more padding, such as a thick mattress, to limit pressure on
and character, blood pressure, heart rate and rhythm, pulse joints and prevent the formation of decubital ulcers.
oximetry, end-tidal CO2 (ETCO2), and body temperature Nonambulatory patients should ideally be kept in sternal
can all be monitored without disturbing the patient and recumbency or, if lateral, should be turned frequently
can provide additional indications that a patient’s condi- (every four to six hours) to prevent atelectasis of the
tion is changing. Patients with intracranial disease are also dependent lung [7]. Patients in sternal recumbency should
prone to have seizures and therefore must be in a location still have their rear limbs or hips rotated.
Figure 70.5 A tetraparetic dog benefits from standing

exercises on an inflatable therapy peanut. Source: Courtesy of
Ontario Veterinary College.
an exercise peanut between their legs (Figure 70.5), by

using a sling, or by using a hoist. This exercise has the
added benefit of allowing the lungs to be in a neutral non-
dependent position for brief intervals. Treatment using
other modalities such as neuromuscular electrical stimula-
tion can be employed to minimize muscle atrophy in
patients that are recumbent for extended periods [9].
Figure 70.4 A coiled fluid administration set is used on a cat
Ideally, rehabilitation treatments should be incorporated
to prevent tangling of the fluid lines with excessive movement
or circling. into the patient’s daily care routine at regular intervals.
It is important to keep inactive patients clean and to pre-
vent urine scald by frequently checking for urine and pro-
Physical rehabilitation is an important part of the viding bedding that can wick away moisture. Intermittent
patient’s recovery and should be started as early as possi- urinary catheterization or placement of an indwelling
ble. After consultation with a rehabilitation practitioner, catheter may be necessary in patients that are unable to
the nursing team can pair exercises with regular treatment void on their own and when bladder expression is not pos-
times to minimize sleep disruption and any handling asso- sible or contraindicated.
ciated stress. Muscle strength rapidly deteriorates with lack Another concern for the recumbent patient with intrac-
of use. Weight bearing is important for maintaining muscle ranial disease is the positioning of the patient’s body. By
strength and joint health. With an appropriate exercise using slanted grates or boards, or additional towels and
plan, the nursing team can minimize muscle atrophy, bedding, the patient’s forelimbs and head should always be
strengthen postural muscles, reduce the risk of muscle elevated at a 30–45 degree angle. This positioning maxi-
contractures, and provide pain relief for the recumbent mizes CSF outflow and cerebral venous drainage, thus alle-
patient [8]. viating risks of ICP elevation [10]. Additionally, many of
Passive range of motion (PROM) exercises and massage the comatose or sedated patients have a loss of protective
of limbs should be performed to reduce edema and stimu- reflexes, such as a gag reflex. Positioning the patient on an
late blood flow to the extremities (see Chapter 51 for more incline can reduce the risk of aspiration if the patient vom-
information regarding how to perform PROM exercises). its or regurgitates [11]. When placing the patient’s cranial
Gentle stretching of all joints in limbs can be performed end in this elevated position, obstruction of the jugular
during PROM exercise times and will also be of benefit veins should be prevented. Placing extra blankets or bed-
once the patient is mobile again. ding under the patient’s forelimbs, neck, and head to angle
Assisted standing exercises activate unused muscles and the cranial portion of the body on an incline can accom-
allow joints to briefly bear weight. Small patients can be plish this most easily (Figure 70.6).
held and helped to stand by supporting under the sternum Bedding must be distributed carefully, with even place-
and the pelvis. Larger patients can be supported by placing ment under the patient, not just under the neck. Uneven
Patient Monitorino 929
infusion can be discontinued if assessment of neurologic

function is required. Similarly, its effects can be reversed
with naloxone if immediate evaluation of the neurologic
status is desired.
Nutrition is an important aspect of nursing care for
patients with intracranial disease. Many patients maintain
a normal appetite; however, not all can safely be given food
and water without supervision. The technician/nurse must
use discretion when providing nutrition by mouth and
must ensure that patients have an appropriate gag reflex
and that their level of consciousness enables them to
swallow normally. Patients should be placed in sternal
recumbency if they are not able to sit or stand on their own.
If there is any uncertainty, a gag reflex should be tested to
ensure that the patient is able to swallow. Next, a small
Figure 70.6 A Maltese Terrier recovers after being hit by a car amount of water can be offered via bowl or syringe, to
and sustaining head and cervical trauma. Note that the dog is
positioned on a 30–45 degree incline to help prevent elevations
ensure that the patient is able to drink normally and does
in intracranial pressure or aspiration. not cough. If the patient can drink water, food can be
offered. It is recommended that those patients that are lat-
erally recumbent be maintained elevated on a 30–45-degree
placement can position the patient in such a way that incline postprandially to prevent aspiration.
jugular blood flow is compromised. Occlusion of the jugu- Fluid therapy is also required in patients with intracra-
lar veins for venipuncture, or catheterization of the jugular nial disease to ensure normovolemia and normal blood
veins should be avoided. If bandaging of the cervical region pressure and to minimize electrolyte abnormalities. Fluids
is mandatory, bandage placement must be done with care are typically administered intravenously at a maintenance
to avoid the possibility of compromised jugular flow. rate unless the patient has abnormal continuing losses
Patients with intracranial disease frequently require oxy- such as with a fever. Patients receiving steroids may be
gen therapy for treatment of hypoxemia. It is important to polyuric and may have higher fluid requirements. Similarly,
be cautious regarding the route of oxygen supplementation patients that have received mannitol or hypertonic saline
(see Chapter 24). Although administration of oxygen via will also have increased fluid requirements. Fluids should
nasal cannulae is relatively easy, it is imperative not to be administered until the patient is able to eat and drink its
stress the animal or cause it to sneeze during cannula recommended maintenance requirements. The adequacy
placement as this could lead to elevations in the patient’s of fluid administration can be determined by monitoring
ICP and subsequent deterioration of the neurologic status. daily body weight. Urine output can be measured in
For that reason, veterinarians may elect to provide oxygen patients with indwelling urinary catheters; urine produc-
supplementation via flow-by, face mask, oxygen cages, tion is expected to be 1–2 ml/kg/hour.
or hoods.
Pain assessment is an important aspect of nursing care
often carried out by the technician/nurse. Among patients Patient Monitoring
with intracranial disease, those most likely to exhibit pain
due to this condition are those with TBI. Unfortunately, It is extremely important to monitor patients with intracra-
assessment for pain in all patients with intracranial disease nial disease closely to ensure that blood pressure, oxygena-
can be difficult given that patients are often heavily medi- tion, ventilation, and temperature are normal (Table 70.1).
cated, sedated, or exhibiting inappropriate mentation. This Because alterations in these findings can contribute to fur-
is an important task for the technicians/nurses because ther brain injury, it is important that any abnormalities are
pain or anxiety that is untreated can lead to elevations in identified immediately. Blood pressure should be meas-
ICP that can worsen the patient’s condition [2]. Therefore, ured regularly, especially in patients with moderate to
if the patient exhibits any signs associated with pain, a vet- severe intracranial disease. Hypotension, as indicated by a
erinarian should be notified immediately so that appropri- systolic blood pressure (SBP) less than 100 mmHg or a
ate analgesics can be administered. Fentanyl, a short-acting MAP less than 80 mmHg, can lead to decreased cerebral
opioid, is typically the drug of choice because it provides perfusion in patients with elevated ICP [12]. The patient’s
immediate effective analgesia and can be titrated to normal response to a decrease in cerebral perfusion is to
effect [12]. Additionally, because it is short-acting, the vasodilate its cerebral vessels, which can lead to an increase
Table 70.1 Desired parameters for monitoring patients identified by the technician/nurse, the veterinarian should
with intracranial disease. be contacted as manual or mechanical ventilation may be
indicated.
Measure Parameter Blood gas monitoring is another method by which the
patient’s oxygenation and ventilation can be assessed.
Blood pressure 80 mmHg < MAP < 110 mmHg
Monitoring of arterial blood gases is especially helpful in
Pulse oximetry SpO2 > 95%
patients with intracranial disease that are stuporous or
Heart rate Within normal limits for the species comatose or have an abnormal respiratory pattern. A PaO2
and size of the patient
less than 80 mmHg indicates hypoxemia, and if this is iden-
tified during patient monitoring, oxygen supplementation
Temperature 98.5–100.5°F (37–38°C) should be provided immediately as mentioned above.
Blood gases PaO2 > 80 mmHg, 35 mmHg < PaCO2 Likewise, an ideal PaCO2 is in the low end of the normal
< 45 mmHg, 40 mmHg < PvCO2 range given that hypercapnea intensifies ischemic damage
< 50 mmHg
to the brain. A PaCO2 greater than 50 mmHg indicates
End-tidal CO2 ETCO2 40–50 mmHg
hypoventilation and is of concern in a patient with intrac-
Plasma lactate < 2.5 mmol/l ranial disease. Partial pressure of carbon dioxide in venous
Blood glucose 80–120 mg/dl (4.4–6.6 mmol/l) blood (PvCO2) is typically 5 mmHg higher than PaCO2 [14]
and can be used as a guideline when arterial samples are
not available. Hypercapnea or hypoventilation is an indica-
in ICP. Likewise, elevations in blood pressure such as a tion that intervention with mechanical ventilation may be
MAP greater than 120 mmHg are undesirable because that required, and the veterinarian must be notified regarding
can lead to reflex cerebral vasoconstriction, thus decreas- the change in patient condition.
ing cerebral perfusion [13]. If blood pressure measure- Should an animal need to be intubated for manual or
ments are outside the normal range (SBP < 100 or mechanical ventilation, it is imperative that the intubation
120 mmHg MAP < 80 mmHg), the technician/nurse should be efficient and effective to avoid coughing or gagging that
contact a veterinarian immediately. could further increase the patient’s ICP [3]. Once the
In patients with severe intracranial disease, a Cushing’s patient is intubated and manually ventilated, continuous
reflex can occur and typically is a near-death event. It is monitoring of CO2 via blood gases or ETCO2 is crucial.
characterized by systemic hypertension that occurs as the Overventilation of patients with intracranial disease can be
patient mounts a final effort to maintain cerebral perfusion detrimental, as decreases in PaCO2 to less than 25 mmHg
in the face of an elevated ICP [2]. The patient’s heart rate will cause cerebral vasoconstriction and reduced CPP [15].
may decrease dramatically in a vagal response to the hyper- In an emergent situation, hyperventilation can be used to
tension. Thus, bradycardia in conjunction with systemic reduce ICP by reducing CBF; however, if the patient is sta-
hypertension represents a life-threatening emergency in a ble and being maintained with manual or mechanical ven-
patient with intracranial disease, and the veterinarian tilation, a target of 35–45 mmHg for PaCO2 (40–50 mmHg
should be contacted immediately. for PvCO2) should be the goal.
Pulse oximetry should also be performed regularly to It is also important that patients with intracranial disease
assess oxygenation in patients with intracranial disease. maintain body temperature within the normal range.
Hypoxemia, as indicated by oxygen saturation (SpO2) less Patients with TBI or those undergoing intracranial surgery
than 95% can hasten the progression of brain damage. If a can have impaired thermoregulation [3]. Ideally, tempera-
reliable SpO2 measurement is less than 95%, the techni- ture should be monitored continuously in the recumbent
cian/nurse should immediately initiate oxygen supple- patient with the placement of a rectal probe, and appropri-
mentation and contact a clinician [13]. If the patient is ate measures to maintain the temperature in the normal
intubated or has a nasal cannula in place, an ETCO2 moni- range should be employed. An esophageal probe is another
tor can be applied to provide a noninvasive method of option for monitoring the temperature of intubated patients.
measuring ventilation. Adapters are available for both Hyperthermia is associated with a poor outcome in patients
endotracheal tubes and nasal oxygen lines. with intracranial disease, as it can increase CBF and lead to
ETCO2 correlates with partial pressure of carbon dioxide elevations in ICP [16]. As such, steps should be taken to
in arterial blood (PaCO2); therefore, an elevation in ETCO2 externally cool intracranial disease patients with elevated
greater than 50 mmHg is suggestive of hypoventilation. body temperatures. Hypothermia decreases the cerebral
Hypoventilation can have serious consequences in patients metabolic rate and is thought to be neuroprotective; how-
with intracranial disease, as it can lead to cerebral vasodila- ever, controlled hypothermia is not routinely practiced in
tion and elevations in ICP. Therefore, if increased ETCO2 is veterinary medicine and is not recommended at this time.
Addanced Monitorino echniiees 931
Because most patients with intracranial disease are not of the electrical activity of the brain and is helpful for
highly mobile, and because their condition can change determining the presence and type of cerebral disease [22].
from moment to moment, continuous electrocardiogram The amount of voltage, speed of activity, and presence or
monitoring is beneficial and recommended. This allows for absence of “spikes” (very fast activity) indicates inflamma-
rapid identification of changes in heart rate as well as early tory or degenerative changes and seizure activity [22]. The
detection of arrhythmias such as ventricular premature EEG can change over time with progression or resolution
contractions, ventricular tachycardia, sinus tachycardia, of the disease; therefore, patients are sometimes monitored
sinus bradycardia, or atrioventricular block; all of which continuously (Figure 70.7). The EEG varies with the level
can be seen in patients with intracranial disease. of consciousness, and drugs such as sedatives, tranquiliz-
In addition, patients with intracranial disease should ers, and anesthetic agents can also alter results [22]. An
have electrolytes, plasma lactate, and blood glucose moni- investigation of wireless video EEG was able to clarify
tored regularly for diagnostic, treatment, and prognostic whether unusual behavioral events were seizures in unse-
purposes. Electrolyte derangements, especially sodium, are dated dogs [23] and may also be considered for hospitalized
common in patients with intracranial disease that receive patients with intracranial disease.
medications to reduce ICP. In patients receiving repeat ICP monitoring is used frequently in human hospitals
doses of these medications, frequent monitoring of electro- but only rarely in the clinical veterinary setting.
lytes is recommended. Hyperlactatemia is often detected in Measurement of ICP can be useful in patients in which
patients with intracranial disease and can be caused by neurologic signs cannot detect deterioration or improve-
hypoperfusion, hypoxemia, seizures, or tremors [17]. ment in neurologic status due to the loss of other observa-
Hyperlactatemia has also been associated with some forms ble neurologic functions or because the patient is sedated
of neoplasia and seems to occur frequently in dogs with or anesthetized. Available methods for invasive ICP moni-
brain tumors, the mechanism of which is unknown at this toring include the use of an intracranial bolt or screw
time [18]. Concentrations of plasma and CSF lactate are attached to a fluid-filled system with a pressure transducer
also higher among dogs with intracranial disease com- or a fiberoptic transducer [24]. Complications of invasive
pared with healthy dogs [19]. ICP monitor placement include focal edema, hemorrhage,
Blood glucose monitoring is an important aspect of nurs- parenchymal injury, and infection [24]. Miniaturized sili-
ing care in intracranial disease patients. Hypoglycemia con ICP transducers inserted in subdural locations are
causes changes in clinical signs including mentation and easier to operate, better tolerated, and less prone to adverse
can lead to seizures. Because seizures can also signify wors- effects and have been minimally investigated in healthy
ening of neurological status, regular monitoring of blood dogs [25].
glucose is essential to clarify the cause of alterations in Noninvasive methods for monitoring ICP have been
patient status and provide treatment as indicated. sparsely investigated and include optic nerve sheath
Stress and inflammatory responses are both significant diameter (ONSD) measurements, magnetic resonance
causes of hyperglycemia in patients with TBI. Hyperglycemia imaging (MRI), and transcranial Doppler ultrasound.
post TBI leads to increases in proinflammatory cytokine Ultrasonographically measured ONSD is positively
concentrations, electrolyte abnormalities, edema, ICP and,
potentially, brain herniation [20]. Blood glucose monitor-
ing and management strategies are important roles for the
veterinary team as hyperglycemia is associated with poor
outcome in TBI patients [21]. Studies indicate that higher
blood glucose is associated with more severe head trauma
and that more profound hyperglycemia is associated with a
poorer prognosis in TBI patients [20]. In addition, the asso-
ciation between hyperglycemia and poor outcome is more
prominent with persistent hyperglycemia than in patients
that exhibit hyperglycemia briefly after injury [20].
Advanced Monitoring Techniques
Electrophysiologic techniques such as electroencephalog-

raphy (EEG) are available primarily at teaching institutions Figure 70.7 A Boxer is continuously monitored with an EEG
and specialty hospitals. EEG provides a graphic recording while undergoing mechanical ventilation.
associated with epidural ICP measurements in healthy ● Serial neurologic examinations including assessment of
dogs and holds promise for patients with intracranial dis- the level of consciousness, PLR, pupil size, posture, spi-
ease [26]. MRI abnormalities [27] and MRI-obtained meas- nal reflexes, and cranial nerves is recommended.
urements of ONSD [28] might also provide evidence to ● Veterinary technicians/nurses must ensure that patients
support the presence or absence of ICP elevations in dogs with intracranial disease are housed in an environment
with intracranial disease. Alternatively, transcranial that has minimal visual and tactile stimuli but that ena-
Doppler ultrasound is a tool increasingly used to diagnose bles continuous monitoring and easy access if emer-
ICP elevations. In dogs with neurologic signs, transcranial gency treatment is required.
Doppler ultrasound examination of the basilar artery has ● Patient comfort is imperative and might necessitate the
been performed under anesthesia for MRI and an increased use of a padded cage and thick bedding to prevent fur-
ratio of systolic to diastolic mean velocity associated with ther injury.
MRI findings of suspected intracranial hypertension in ● Patients with intracranial disease should be positioned
dogs with intracranial disease [29]. on an incline with minimal pressure on the jugular veins
to reduce ICP and prevent aspiration.
Patients with intracranial disease require intensive care
Summary
●
that often includes fluid therapy, nutritional support,

oxygen supplementation, physical rehabilitation, and
The goal for all patients with intracranial disease is to
pain management.
●
protect brain function by preserving cerebral perfusion

● Monitoring of blood gas values, electrolytes, plasma lac-
and preventing elevations in ICP.
tate, and blood glucose is important as abnormalities can
Steps must be taken to ensure that temperature, oxygen-
necessitate treatment and might worsen the prognosis of
●
ation, ventilation, and blood pressure are maintained

patients with intracranial disease.
within the normal range and that pain, agitation, and
● Advanced monitoring techniques such as EEG, ICP
seizure activity are treated expeditiously.
monitoring, advanced imaging, and other newly
Patients with intracranial disease can deteriorate rapidly;
researched modalities may be considered in certain
●
therefore, continuous monitoring by veterinary techni-

settings.
cians/nurses at a 24-hour hospital is recommended.
References
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Intracranial hypertension. Semin. Neurol. 28 (5): 9 Frank, L.R. and Roynard, P.F. (2018). Veterinary neurologic
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3 Plumb, D.C. (2018). Veterinary Drug Handbook, 9e. Ames, Top. Companion Anim. Med. 33 (2): 49–57.
IA: Wiley Blackwell. 10 Dos Santos, L.O., Caldas, G.G., Santos, C.R., and Junior,
4 Fletcher, D.J. and Syring, S.S. (2015). Traumatic brain D.B. (2018). Traumatic brain injury in dogs and cats: a
injury. In: Small Animal Critical Care Medicine, 2e (ed. systematic review. Veterinarni Medicina. 63(8): 345–357.
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Elsevier. Falagas, M.E. (2009). Impact of patient position on the
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and Feline Neurology, 4e. Gloucester, UK: British Small analysis of randomized controlled trials. J. Crit. Care 24
Animal Veterinary Association. (4): 515–522.
6 Platt, S.R., Simona, S.T., and McDonnell, J.J. (2001). The 12 Armitage-Chan, E.A., Wetmore, L.A., and Chan,
prognostic value of the modified Glasgow coma scale in D.L. (2007). Anesthetic management of the head trauma
head trauma in dogs. J. Vet. Intern. Med. 15 (6): 581–584. patient. J. Vet. Emerg. Crit. Care 17 (1): 5–14.
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16 Greer, D.M., Funk, S.E., Reaven, N.L. et al. (2008). Impact Philadelphia, PA: Saunders.
of fever on outcome in patients with stroke and 25 Sturges, B.K., Dickinson, P.J., Tripp, L.D. et al. (2019).
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18 Sullivan, L.A., Campbell, V.L., Klopp, L.S., and Rao, and optic nerve sheath diameter in healthy dogs. Am.
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Veterinary Neurology, 5e. St. Louis, MO: Saunders.
935
71
Care of the Burned Animal

Steven Epstein
Introduction weeks to heal. Scarring after healing should be expected for

all wounds that have dermal or deeper involvement. Third-
Burns in cats and dogs are rare presentations to the or fourth-degree wounds are wounds that often need surgi-
emergency room and can caused by chemical, electrical, cal interventions and because of this healing times can
radiation, or thermal induced injury. Thermally induced vary greatly. It is important to note that it may be difficult
burns is the most common type of injury and have been to classify burn wounds on presentation as the degree of
reported in small animals from fires, heating pads, damage may not be readily apparent and it may take up to
boiling water, stoves, radiators, automobiles, and sun 72 hours for a burn wound to fully declare the extent of
exposure in high environmental temperatures [1, 2]. the injury.
Burned animals often have both immediate needs (fluid The other method of classifying burn wounds involves
therapy, pain control, and potential treatment of smoke determining the total body surface area (TBSA) affected.
inhalation), as well as long-term needs (metabolic This can be done in conjunction with depth analysis to
derangements and wound care) that can require pro- help determine whether the patient is likely to have sys-
longed treatment and nursing care resulting in a large temic effects. Patients with either epidermal or epider-
financial commitment from owners. mal and superficial dermal wounds are unlikely to have
systemic effects, while those with deeper wounds have a
higher likelihood of developing systemic metabolic
Classification of Burns derangements. When calculating TBSA, it is useful to
separate out the area that has superficial injury (first-
Burn wounds can be classified two different ways, and likely degree), from that which has a deeper component, as it
the combination of the two will yield the most information is only the deeper components that are relevant to
about the patient. First, burns can be classified as to the quoted prognosis and expected complications. Human
depth of the injury. These systems use either first- through patients with more than 20% of TBSA burned are consid-
fourth-degree terminology, which is considered outdated, or ered as severe burn injuries and the American Burn
directly classify the wound depending on depth of the injury. Association recommends that they are managed at a
A combination of these classification schemes is summa- burn center [3]. Although no burn centers exist in veteri-
rized in Table 71.1 with examples shown in Figure 71.1. nary medicine, a referral to a multispecialist 24-hour
Classifying burn wound by depth provides the healthcare facility should be considered if more than 20% of
care team and owner with an idea of the length of time it TBSA is seen.
may take the wounds to heal. First-degree wounds tend to To estimate the TBSA, there are two different methods
heal rapidly (around one week) and do not require daily that can be used, with the simplest being the “rule of nine.”
interventions as they heal by re-epithelization. Second- For this technique, which is based on an adult human, the
degree wounds that only involve the superficial part of the body is split into areas of approximately 9%. The head and
dermis tend to heal in one to two weeks, while those that neck compromise one set of 9%, each thoracic limb is 9%,
involve the deeper aspects of the dermis need two to four each pelvic limb is 18%, and the dorsal and ventral trunk
936 Care of the Burned Animal
Table 71.1 Classification of burn wounds by depth.
Degree Depth Skin layers involved Clinical appearance of skin
First Superficial Epidermis only Erythematous and dry

Second Superficial, partial thickness Epidermis and superficial dermis Erythematous and either moist or
blisters, hair follicles spared
Second Superficial, deep thickness Epidermis and deep dermis Often blackened or yellowed skin
color, hair follicles destroyed
Third Full thickness Entire epidermis and dermis Often brown and leathery or
blackened, eschar may be present
Fourth Full thickness with muscle, Entire epidermis and dermis Same as above
tendon or bone involvement
(a) (b)
(c) (d)
Figure 71.1 Images of different wound depths in cats from the recent California wildfires. (a) Superficial or first degree burn over the
right eye. (b) Superficial partial thickness or second-degree burn of foot pads. (c) Full thickness or third-degree burns of foot pads.
(d) Full thickness with bone involvement, or fourth-degree burns. The black arrows point to the distal aspect of the third phalanges of
that digit.
each make up 18%. This sums to 99% with 1% left for geni- An alternative method has been developed is using a
talia and perineum. To use this technique, the healthcare resuscitation burn card. This is achieved by cutting a piece
team would assess what fraction of each area is estimated of plastic or other device to the size of a standard credit
to be burned, then they are all summed up to achieve an card, as the area of this card is 45 cm2. On one side of the
estimated TBSA. This technique is easy to use, although it card, a weight to body surface area conversion chart is
is recognized that body shape, condition score and experi- printed. This resuscitation burn card is then placed over
ence of user can affect results in humans [4] and this tech- the various parts of the body that are burned to get an esti-
nique has not been validated in cats or dogs. mated number of cards that would be needed to
ediial Conniderationn 937
completely cover the burn area. Alternatively, a standard- hydromorphone, morphine or methadone, are used in the
sized plastic credit card can be used (8.5 × 5.3 cm). The initial period. After a full evaluation of the patient and a
patient is then weighed, and a body surface area calculated longer period for pain assessment, the decision for what
in square meters (m2) or read from the burn card. The level of analgesia is needed can be made. In severe cases,
TBSA is then calculated by the formula (Eq. 71.1): constant rate infusions (CRIs) of full mu opioid agonists
such as fentanyl, with or without adjunctive CRIs of keta-
number of cards to cover mine or dexmedetomidine, may be needed to control pain.
burn area 0.45 (see Chapters 47 and 48). Alternatively, if patients are not
TBSA burned % (71.1)
calculated body acting as if they are in pain, a partial mu opioid agonist such
surface area m 2 as buprenorphine can be considered in the initial period.
Patients who have been burned in a house or wildfire
This method overcomes the limitations of the “rule of may also experience complications of smoke inhalation.
nine” and can be applied to either cats or dog of any body Smoke inhalation injury can cause airway obstruction
condition score. from the nasal cavity to the small airways, develop pneu-
monitis from particulate matter inhalation or pneumonia,
or present with carbon monoxide or cyanide toxicity
Medical Considerations depending on the material that burned. Airway obstruc-
tion in the upper airways can occur from direct thermal
In treating a burned cat or dog, there are both immediate injury or the particulate matter inciting an inflammatory
(need for fluid resuscitation, evaluation for smoke inhala- reaction and usually occurs in the first 24 hours. Tracheal
tion, pain management) and later-stage (ocular and car- and small-airway obstruction can result from thermal
diac health, nutritional assessment) considerations for the injury or (trachea) or from pseudomembranous casts that
clinician when a severe burn injury has occurred. migrate into the lower airways with necrosis of the airways
Following a burn of over 20% TBSA, there are multiple being a possible sequela [5].
metabolic derangements that can occur, with hemody- Carbon monoxide toxicity is one of the major sources of
namic effects being one of the most urgent to address. With early morbidity and mortality in fire victims [6]. It is pro-
this degree of epidermal/dermal injury, it is not surprising duced when combustion of carbon containing material
that the body may lose large quantities of protein-rich occurs. Significant quantities of carbon monoxide can be
fluid, as well as having a severe inflammatory insult result- inhaled in short periods and as the affinity for hemoglobin
ing in intravascular volume depletion. This can lead to is 200–250-fold greater than oxygen, tissue hypoxia can rap-
hypovolemic shock at presentation or can occur anytime idly result from a left-shifted oxyhemoglobin saturation
during the first 72 hours following the burn injury. Initial curve. Carbon monoxide can also directly depress central
treatment of shock should be treated with standard doses nervous system function and indirectly injures the brain by
of isotonic crystalloids or synthetic colloids. If the patient increasing nitric oxide production, facilitating white blood
does not present with hypovolemic shock, and the burn cell migration into brain with resulting leukoencephalopa-
injury has just occurred, it is recommended to give 2–4 ml/ thy among multiple other poorly characterized mechanisms.
kg per percentage of TBSA affected of an isotonic crystal- For most veterinarians, diagnosing carbon monoxide
loid in the first 24 hours to combat the development of toxicity is difficult. A tentative diagnosis is based on com-
shock due to future fluid losses. Commonly, half of the cal- patible history with a decreased mentation plus or minus
culated amount is given in the first six to eight hours, hyperlactatemia. Standard pulse oximeters are not able to
“front-loading the fluid plan.” For the following 24–48 hours detect carbon monoxide in blood; however, specialized
when fluid exudate may be large, the patient should be pulse co-oximeters can accurately detect carboxyhemo-
reassessed frequently to determine its fluid need. Serum globin [7]. If arterial blood gases are measured, the result-
albumin concentrations may be tracked and if hypoalbu- ing partial pressure of oxygen in arterial blood is typically
minemia develops with concurrent interstitial edema of normal unless concurrent pulmonary dysfunction has
non-burned areas, synthetic colloids should be considered. already resulted. The gold standard would be direct meas-
Patients with severe burn injuries may present with mild urement of carboxyhemoglobin levels in blood via co-
to extreme pain. When burn injuries reach the deep dermis oximetry, which is rarely an option for veterinarians.
or are third-degree burns, the tissue is often no longer pain- Because of this difficulty, any animal who has been in a
ful as nerve endings are also damaged. However, the depth house or wildfire that presents acutely after the fire should
of the burn should not preclude appropriate analgesia while be given oxygen supplementation. The rationale for this is
the clinician is completing their evaluation of the patient. because the half-life of carboxyhemoglobin is 250 minutes
Typically, full mu opioid agonist medications, such as for the victim breathing room air. This is reduced to
40–60 minutes with inhalation of 100% oxygen. In one

study of dogs in a kennel fire that received oxygen therapy
(via nasal canula or oxygen cage), those that had oxygen
administration had a significantly reduced carboxyhemo-
globin compared with those that did not [8]. Although the
higher the fraction of inspired oxygen achieved, the more
quickly the carboxyhemoglobin leaves the blood, the clini-
cian must weigh the risks of anesthesia and intubation for
100% oxygen against the benefits of that step. If the patient
initially recovers, delayed neurologic effects may occur
days to week later from the injury that may or may not be
reversible with time [9, 10].
Once the patient has been stabilized for the above
medical considerations, the focus can shift to wound
care and later stage medical issues. Patients that have
burn wounds to the face or have sustained injuries in a
fire should have careful evaluation of their eyes includ-
ing evaluation of eyelid closure and application of fluo- Figure 71.2 A cat with burn wounds over the left eye that led
rescein stain to look for corneal ulceration at the time to lagophthalmos and subsequent corneal ulceration.
of admission. It has been documented that humans
with facial burns have abnormal tear film predisposing
to future ulcer formation [11], and anecdotally at the in human populations and experimental animal mod-
UC Davis William R. Pritchard Veterinary Medical els [12, 13]. A 2020 clinical report of 51 cats with burns
Teaching Hospital, a large proportion of the cats treated from a wildfire showed that 18 had evidence of myocar-
in various California wildfires had a presumed qualita- dial thickening on echocardiogram and 16 had spontane-
tive deficiency in their tear film in addition to corneal ous echocardiographic contrast and thrombi
ulcer formation. Because of this concern for a qualita- formation [14]. Careful auscultation for murmurs, gal-
tive tear film deficiency in patients with facial burns, lops, or arrhythmias should occur daily, and if they
the clinician should consider treating all animals sus- develop, judicious use of fluid therapy is indicated to
taining significant burn injuries from fires (house or avoid a fluid overload state, as these animals may be pre-
wildfire) with a topical ocular lubricant that contains disposed to developing heart failure. If any cardiac abnor-
hyaluronic acid. The mucinomimetic properties of hya- malities are auscultated, performing an echocardiogram
luronic acid have been shown to improve tear film is warranted to look for myocardial dysfunction and spon-
quality and promote corneal health, two properties that taneous contrast, a predisposing factor for blood clot for-
can help prevent corneal ulcer formation. If there are mation. Based on these results, antithrombotic use may
burn wounds to the face of the patient, special atten- be warranted to prevent cardiac or arterial thrombi; how-
tion should be paid to determining whether the patient ever, this needs to be balanced against the need for surgi-
has lagophthalmos, which will predispose them to cal intervention from the patient’s wounds.
ulcer formation (Figure 71.2). If present, an ointment- As burn wounds are often associated with a hypermeta-
based tear film replacement should be used, either bolic state and protein loss through exudation, careful
instead of or together with a lubricant that contains daily assessment of nutritional intake is warranted. As this
hyaluronic acid, given the beneficial increased corneal hypermetabolic state is associated with muscle catabolism
contact time with ointment use. The owners should be and loss of muscle mass, adequate intake of protein is key
advised that when a burn-related eyelid wound heals, for patient health. If the nasal cavity has been injured from
eyelid contracture is possible, which may lead to the thermal injury of inhaled gas, this is likely to reduce the
need for future surgical intervention if lagophthalmos patients sense of smell and interest in food and a feeding
subsequently worsens. tube is more likely to be needed in these patients. If the
Another organ system that can develop dysfunction if animal is not eating their metabolic energy requirements
the burn injuries are due to a fire is the cardiovascular for two consecutive days, placement of a feeding tube
system. A patient may develop hypovolemia from fluid should be considered. Either nasogastric or esophageal
transudation from wounds, but cardiac changes and can be placed depending on the health of the nasal cavity,
thrombi formation may occur as well. Significant cardio- if burn wounds are present over the neck, and the risk of
vascular effects secondary to thermal burn injury and anesthesia in deciding which location of feeding tube
accompanying smoke inhalation have been demonstrated to place.
riniiilen of Burn ound anaaement 939
rinciples of Burn Wound

P until healed. Superficial partial thickness burns should be
Management cleaned with a chlorhexidine solution and then bandaged.
There is no consensus on the optimal concentration of
General Recommendations chlorhexidine to use, with the range of 0.05–4% being used
in human medicine [15]. The author recommends a dilute
As the skin represents a barrier to infection, when it is solution of no more than 0.1% chlorhexidine. Following
burned this normal barrier function no longer exists. cleaning and debridement, silver sulfadiazine ointment
Special care to prevent a nosocomial infection is therefore can be applied with a bandage covering it until healed.
indicated and good hand hygiene is critical. Hands should Both deep partial and full thickness wounds should be
be washed before handling any burn patient and clean surgically debrided of dead tissue and debris at initial eval-
examination gloves should be worn. If a full physical exam- uation in addition to topical cleaning of the wound. If there
ination is being performed, gloves should be changed doubt about the viability of the tissue, it should be left until
between handling the wounds and the rest of the animal to the next day’s evaluation, as it may take two or three days
prevent bacteria that flourish in areas like the armpit and for the tissue to declare its viability. In human medicine,
groin to be transmitted to the wounds. Stethoscopes should eschars are recommended to be removed as they may be
be cleaned with alcohol prior to use to prevent them acting covering evidence of infection and delay wound healing.
as a fomite. If there are large surface-area burns that are However, if there is no evidence of surrounding tissue
deep partial or full thickness, a barrier gown should be inflammation or seepage from the edges of the area, the
considered when handling the wounds. author has successfully managed patients with large
Strict hygiene requirements should also occur when han- eschars intact until the wound contracted and reepithelized
dling any invasive device (intravenous catheters, feeding under the eschar when more aggressive surgical manage-
tubes, etc.) to help prevent nosocomial infections. These ment was not an option. This prevented the need for daily
consist of all ports being wiped with alcohol prior to injec- sedation and bandage changes and the eschar acted as a
tions, fresh examination gloves before handling devices, biologic bandage. It should be acknowledged, however,
and daily inspection of the site for signs of inflammation that delayed primary closure after eschar removal produces
with removal if present. better functional and cosmetic results than those achieved
If the burn wounds are on the limbs, mobility is likely to if the escharotomies are allowed to close by secondary
be decreased in these animals. Careful notation of body intention in humans [16].
position every four hours is indicated with patients who Surgical excision or grafting are recommended for burn
are not moving being turned at that time frame. Checking wounds that are estimated to take longer than two to three
for eliminations every four hours and making sure the ani- weeks to heal with conservative management in human
mal is not soiled can help to prevent infections and fecal or medicine. This is because if the wounds are left to heal on
urine scald developing due to decreased mobility. Passive their own with conservative management, patients experi-
range of motion exercises can be considered depending on ence longer hospital stays, increased pain, and decreased
where the burn wounds are located. function of the area. In veterinary medicine, skin grafting is
not always an option. Even though some deep partial- and
full-thickness wounds are large and not expected to heal in
Wound Management
that time frame, conservative management with bandage
On initial evaluation of wounds, the patient should be heavily changes may be the best option. Conservative management
sedated or anesthetized to allow for a thorough evaluation. If involves daily sedation and evaluation initially and the
the patient is presented acutely after the burn, the skin should application of topical antimicrobial agents until the wound
have cool water (45–65°F; 7–18°C) applied for 15–30minutes closes by second intention or graft application is later
to dissipate any residual heat and prevent further injury. Ice possible.
should not be applied as this can cause excessive vasoconstric- Which topical antimicrobial agent to use has been the
tion and worsen the extent of tissue damage. After the wounds subject of much research. A 2017 Cochrane review came to
have been cooled, or if this step was not necessary, the initial the conclusion that it was often uncertain whether topical
evaluation should include a thorough clipping of hair around antimicrobial agents were associated with any difference in
the area to fully evaluate the extent of the wound. healing, infections, or other outcomes when compared
Specific recommendations for wound management will with each other [17]. Moderate to high certainty findings
depend on the depth of the wound, but the general princi- from this review include:
ples involve initial daily evaluation, debridement of
necrotic tissue, and bandaging of the wound in between 1) Moderate certainty that burns treated with honey are
evaluations. Superficial burns often only need initial clip- probably more likely to heal over time compared with
ping of the hair and covering of the wound to keep it moist topical antimicrobials.
2) High certainty evidence that treating burns with honey suspected to be present, the tissue should be cultured, and a
reduced mean times to healing in comparison with non- susceptibility performed to enable the appropriate antimi-
antibacterial and non-conventional treatments. crobial choice. Gram-positive infections are more likely to
3) Moderate certainty evidence that burns treated with colonize the wound in the first five days, with Gram-
nanocrystalline silver dressings probably have a slightly negative pathogens two to four days later. There is a multi-
shorter mean time to healing than those treated with tude of organisms that may be the cause of the infected
petroleum jelly gauze. wound with Staphylococcus spp., Streptococcus spp.,
Enterococcus spp. being the most common Gram-positive
As there is still a large degree of variability in results, vet- pathogens, and Pseudomonas aeruginosa and Acinetobacter
erinarians can use silver sulfadiazine as the topical antimi- baumannii being the top two Gram-negative pathogens, fol-
crobial agent of choice or consider the use of medical grade lowed by the Enterobacterales family [18]. Because of this
honey products. wide range of pathogens, broad-spectrum intravenous anti-
Systemic antimicrobial therapy is not recommended for microbial therapy should be considered pending culture
management of routine burn wounds but should be results when a wound infection is thought to have occurred.
reserved for where there is evidence of infection present at With time, most burn wounds that do not become
the wound. Signs of infection include change in wound infected will heal well with appropriate therapy. For poorly
color, increased exudate, increased pain, increased wound healing or large burn wounds, referral to a board-certified
depth, or early separation of eschars. If a wound infection is surgeon for optimal care should be considered.
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941
72
Care of the Environmentally Injured Animal

Michael S. Lagutchik, Rufus W. Frederick, and James O. Barclay
This chapter addresses emergent management of dogs and nonfreezing injuries can be accomplished by moving the
cats with environmental injuries, including cold-induced patient to a warm room and gently wrapping the patient or
injury (frostbite and hypothermia), heat-induced injury, affected body part in warm blankets or towels.
nonsurgical management of open wounds and necrotic tis-
sues, and open fractures. The chapter emphasizes special-
Freezing Injury
ized nursing guidelines critical to improve likelihood of
successful outcome. Freezing injury or “frostbite” is the development of cold
injury in which tissues actually become frozen, with crys-
tallization (ice formation) of tissue and cell water [2].
Cold-Induced Injury Frostbite develops at environmental temperatures below
32°F (0°C) and primarily affects the distal extremities, ears,
Cold-induced injuries include local or regional injuries nose, scrotum, and tail. Frostbite varies in severity from
(i.e. nonfreezing and freezing injuries of extremities) superficial (first-degree frostbite) to deep injury (fourth-
and generalized cold injury (i.e. systemic hypothermia). degree frostbite) [2].
Hypothermia is very common in veterinary practice, Clinical signs of superficial frostbite include a gray to
although the true incidence is unknown [1]. Frostbite is white, waxy appearance of affected skin (first degree); blis-
uncommon in dogs and cats and tends to be related to tering of affected skin may also be present (second degree).
geographic location (i.e. freezing climates), use of the Clinical signs of deep frostbite include involvement of the
animal (e.g. as sled dogs), or in neglect cases. entire epidermis, either without subcutaneous tissue
involvement (third degree) or with subcutaneous tissue
involvement, to possibly include muscle and bone (fourth
Nonfreezing Injuries
degree). Tissues affected with deep frostbite may be black
Nonfreezing injuries typically involve the extremities; they and friable. In all cases of frostbite, pain may be intense,
occur despite the tissue not actually freezing and are com- especially during rewarming of tissues.
monly caused by prolonged exposure to cold. With non- Management of patients with freezing injury is detailed in
freezing injuries, extremities (ear pinnae, paws, tail tip, Protocol 72.1. Treatment of frostbite involves rapid warming
scrotum) are exposed to cold temperatures above freezing of affected tissues, comprehensive management of concur-
for prolonged periods (> 12 hours), causing intense ery- rent problems, analgesia, and protection of affected tis-
thema of the skin, pain, and pruritus. If skin is exposed to sues [3]. Careful warming of frozen tissues is critical to avoid
damp conditions or submerged and exposed to cold, tissue further trauma and pain. Provide systemic analgesia, as
edema and maceration may also develop. frostbite is extremely painful. Antibiotic use is not generally
Treatment of nonfreezing cold injuries involves remov- recommended [3]. Aseptically aspirate large blisters that
ing the animal from the cold environment and passively develop [3]. In some cases, open wounds, infected wounds,
warming the affected tissues slowly. Passive warming of or necrotic wounds may develop in frostbitten tissue.
942 Care of the Environmentally Injured Animal
Complications Related to Hypothermia

Protocol 72.1 Management of Freezing
Hypothermia can cause many complications [1, 3–6]. The
Injury (Frostbite)
duration and severity of hypothermia, type of hypothermia
1) Treat whole-body hypothermia (Protocol 72.2), (primary or secondary), and the patient’s ability to adapt
trauma, or shock. directly affect which complications develop and how severe
2) Provide systemic analgesia. those complications become. The clinician must recognize
3) Warm frozen tissues gently and slowly, using one of that potential problems are common and anticipate them,
two methods: regardless of the patient’s type or severity of hypothermia.
a) Immerse in a water bath that is 104–108°F Hyperglycemia is common in mild and moderate hypo-
(40.3–42.6°C) for at least 20 minutes or until thermia; specific measures to reduce blood sugar are sel-
thawing has occurred. dom necessary. Hypoglycemia can develop in severely
b) Wrap with warm, wet towels for 15–20 minutes, hypothermic patients, and dextrose supplementation
changing the towels every 5 minutes. may be necessary. Hypokalemia is common in mild to
c) Do not use dry heat or rub or massage tissues to moderate hypothermia, and supplementation may be
warm tissues. necessary. Hyperkalemia is reported in severe hypother-
4) Protect affected tissues mia; specific measures may be necessary to reduce the
a) Apply loose protective bandages. potassium concentration if potassium is greater than
b) Minimize movement (confine to a cage). 7–8 mmol/l. Metabolic and respiratory acidosis are
c) Apply an Elizabethan collar to prevent self-trauma. reported in most types and degrees of hypothermia; these
5) Aseptically aspirate large blisters that develop. typically correct with fluid therapy and patient warming.
6) Manage open, infected, or necrotic wounds Glucose, electrolyte, and venous blood gas measure-
(Protocol 72.4). ments should be performed at least every 6–12 hours
initially.
Hemostatic defects are common. Patients are commonly
in a hypocoagulable state with prolonged clotting times.
Hypothermia
Platelet abnormalities are also noted. Patients with mild
Hypothermia is defined as a core body temperature that hypothermia typically have increased platelet aggregation,
is subnormal and is subdivided into primary and second- whereas patients with severe hypothermia have decreased
ary hypothermia [1, 3–6]. Core temperature refers to the platelet aggregation. Serial platelet counts and coagulation
temperature of the blood in the pulmonary artery. In vet- testing to screen for abnormalities should be performed
erinary patients, rectal or esophageal temperature meas- upon admission and every 6–12 hours afterward until
urements are more practical, even though they may be patients are stable.
lower than core temperature in many instances. Primary Tachycardia and hypertension are common in mild to
hypothermia is caused by exposure to low environmental moderate hypothermia. As hypothermia worsens, hypo-
temperatures; secondary hypothermia has multiple tension and bradycardia develop, and other cardiac
causes, to include secondary to trauma, toxicity, underly- arrhythmias may occur. For these reasons, continuous
ing illness, anesthesia, surgery, and other factors. This electrocardiogram (ECG) and blood pressure monitoring is
differentiation is important, as patients with primary recommended until the patient stabilizes. It is recom-
hypothermia can apparently tolerate much more severe mended [3] to avoid giving drugs, to include antiarrhyth-
hypothermia than patients with secondary hypothermic agents, until the body temperature is above 86–90.3°F
mia [4] and complications are more commonly reported (30–32°C), as drugs are believed ineffective at temperatures
in patients with secondary hypothermia at significantly below this.
closer-to-normal temperatures than patients with pri- Measures to correct hypothermia can actually cause
mary hypothermia [4]. Regardless of the type of hypo- complications to develop, such as afterdrop and rewarming
thermia, the mechanisms that lead to hypothermia are shock [4, 5]. Careful warming and close monitoring are
excessive heat loss, decreased heat production, or both. essential. Afterdrop is the continued decrease in the
Primary hypothermia is classified as mild (90–99°F; patient’s core temperature as warming is provided and is
32.5–37.5°C), moderate (82–90°F; 28.0–32.5°C), severe caused by the return of cold peripheral blood to the central
(68–82°F; 20.2–28.0°C), or profound < 68°F; (<20.2°C) circulation. To prevent afterdrop, it is important to warm
[1, 4, 5]. Secondary hypothermia is classified as mild the patient’s chest and abdomen, not the extremities.
(98–99.9°F; 37.0–37.5°C), moderate (96–98°F; 35.8–37.0°C), Rewarming shock develops with excessively rapid warm-
severe (92–96°F; 33.6–35.8°C), or profound < 92°F; ing and is due to the sudden development of systemic
(<33.6°C) [1, 4, 5]. vasodilatation. This vasodilatation causes hypotension at a
eatt-Induued Injury 943
Protocol 72.2 Management of Hypothermia

1) Warm rapidly but carefully. pleural lavage, warm IV fluids, and urinary bladder and
a) Increase the body temperature by 2–4°F rectal lavage with warm fluids).
(0.06–0.13°C)/hour. 2) Perform active and passive warming as above.
b) Warm to a temperature of 98.5°F (37.2°C) and then 3) Provide cardiovascular support:
cease use of all warming methods except passive a) Provide IV fluids at relatively moderate rates (2–3
warming. times maintenance rates, or 2–10 ml/kg/hour) until
normothermic.
Mild Hypothermia b) Once resuscitated and stabilized, provide mainte-
nance IV fluids.
Adequate blood volume: c) Provide oxygen supplementation for severe to pro-
1) Warm using passive surface warming (wrap patient in found hypothermia to reduce risk of cardiac
blankets or towels; hospitalize in warm environment). arrhythmias.
4) Anticipate and manage complications:
Moderate to Severe Hypothermia a) Monitor ECG continuously, and treat arrhythmias as
directed, but do not treat until body temperature is
Mild hypothermia with inadequate blood volume:
86–90.3°F (30–32°C).
1) Warm using active surface warming (use of externally b) Monitor for glucose, electrolyte, and acid–base
applied heat sources such as forced-air devices, warm abnormalities every 6–12 hours.
water bottles, heating pads or lamps, or dryers). c) Monitor platelet count and coagulation parameters
2) Apply heat to the thorax and abdomen, and not the every 6–12 hours.
extremities. d) Provide and reassess analgesia.
3) Continue passive warming as above. e) Perform continuous or intermittent blood pressure
monitoring, lactate clearance, serial body weight,
Severe to Profound Hypothermia changes in mentation, and urine output to monitor
for rewarming shock.
1) Warm using active core warming (warm inhaled air f) Perform continuous temperature measurement, to
provided by endotracheal tube, warm peritoneal or monitor for correction of hypothermia and afterdrop.
time when the circulatory system may not be able to react. In summary, patients with cold-induced injuries require
The systemic hypotension is aggravated by the increased intensive management. Rapid but careful rewarming of the
metabolic demand that develops as hypothermic patients patient is critical. Minimizing complications and providing
are rewarmed, which increases the demand for perfusion. supportive care are essential.
To prevent or reduce rewarming shock, intravenous (IV)
fluid therapy must be provided and volume status, sys-
temic blood pressure, and tissue perfusion must be moni- Heat-Induced Injury
tored carefully. Other possible problems are due to changes
in regional blood flow (e.g. development of cerebral edema, Heat-induced injury, primarily seen in dogs, develops
cerebral ischemia), reperfusion of tissue beds (e.g. develop- when a patient accumulates a severe heat load that can-
ment of systemic reperfusion injury, pancreatitis), and not be dissipated rapidly enough to prevent injury, exceed-
other factors (e.g. pneumonia, pulmonary edema, acute ing the capability of the patient to compensate [7–15].
respiratory distress syndrome) [4]. There are three types of heat-induced injury in veterinary
Management of patients with hypothermia is detailed in patients based on the severity of the resulting injury: mild
Protocol 72.2. Hypothermic patients must be warmed rap- (heat stress), moderate (heat exhaustion), or severe (heat
idly but carefully, and with anticipation for possible com- stroke) [7–9].
plications. Cardiovascular support (principally IV fluid
therapy), management of coexisting problems, and preven-
Classification of Heat-Induced Injuries
tion of rewarming complications are necessary [5]. The
recommended rate of rewarming is to increase the core Heat stress is characterized by development of excessive
body temperature by 2–4°F (0.06–0.13°C)/hour [4–6]. thirst, discomfort associated with physical activity, and
Treatment recommendations are provided in the protocol. sodium and chloride abnormalities, but with controlled
panting (i.e. the patient can control or reduce panting A common cause and frequent finding in patients with
when exposed to a noxious inhalant such as alcohol) [7, 14, heat injury is partial or intermittent airway obstruction.
15]. Heat exhaustion is present when the signs of heat The obstruction can be due to anatomical conditions or for-
stress are present, as well as weakness, anxiety, and uncon- eign objects. Conditions such as elongated soft palate, sten-
trolled panting (i.e. the patient cannot reduce panting otic nares, everted laryngeal saccules, narrow trachea, or
when exposed to a noxious inhalant) [7]. Heat stroke is pre- laryngeal paralysis are predisposing factors to heat
sent when signs of heat exhaustion are present, with any injury [10]. Although pulmonary artery temperature meas-
degree of central nervous system (CNS) abnormality [7]. urement is the gold standard for evaluating core body tem-
The most common CNS abnormalities include changes in perature, rectal temperature compares well and can be
mentation and level of consciousness (e.g. obtunded, stu- performed with little risk or expense. Note that rectal tem-
por, coma), seizures, abnormal pupil size, cortical blind- perature may lag behind core body temperature by up to
ness, head tremors, and ataxia [8]. Heat stroke is a 15 minutes [14, 15, 21]. In an abnormal state of hyperther-
life-threatening condition. It often leads to widespread mia, the initial physiological response is to move blood to
multiple organ injury with risk of progression to multiple surface vessels to maximize conductive cooling. This phase
organ dysfunction syndrome. No specific body tempera- will generally include renal and splanchnic vasoconstric-
ture defines heat stroke in veterinary patients; however, tion, peripheral vasodilatation, and an increased cardiac
temperatures as low as 105.8°F (41.3°C) have been associ- output [11]. Over time, if the body temperature remains
ated with pathology [16]. Studies have established that high, splanchnic and renal vasoconstriction will eventually
heat directly induces tissue injury and that the severity of fail, creating conditions favorable for venous pooling and
tissue injury and cell death is a function of the degree and hypovolemia or distributive shock [10].
duration of hyperthermia [17]. Retrospective veterinary Emergency management of hyperthermic patients is
studies report multiple serious complications and high shown in Protocol 72.3. Emergency interventions must be
fatality rates in heat stroke patients despite proper treat- performed immediately to optimize outcome [7, 9, 10, 13,
ment [18, 19]. 16, 19, 20, 22, 23]. If the patient is intubated, the airway
must be protected during the cooling phase to prevent aspi-
ration of running water. Supplemental oxygen therapy is
Causes of Heat Injury
necessary; the method of oxygen delivery used should not
Heat injury is a rise in core body temperature due to physi- interfere with cooling efforts during initial care. Avoid oxy-
cal activity or endogenous sources (exertional heat stroke), gen cages and oxygen masks that can create increased
or exposure to increased ambient temperature or exoge- humidity and prevent maximal heat dissipation.
nous sources (classical or environmental heat stroke) [7–9, Patients presenting with heat injury with a rectal tem-
11, 17]. In veterinary patients, the cause of heat stroke is perature above 105°F (40.9°C) require emergency cooling
often a combination of exertional and environmental fac- measures. Numerous cooling methods are described; no
tors, to include high ambient temperatures, confinement one technique has been shown to be superior or ideal [16].
in unventilated or poorly ventilated areas, and high ambi- Use a combination of cooling methods for optimal care.
ent humidity. A retrospective study [18] conducted at a vet- The rate of cooling should be as rapid as possible until the
erinary teaching hospital found large-breed dogs and rectal temperature is 105°F (40.9°C) [7]. The most practi-
brachycephalic dog breeds were more likely than smaller cal, most expedient, and most rapid method to reduce body
breeds to present for heat stroke. Additionally, studies [18, temperature is to soak the patient to the skin with room-
20] show the mean environmental temperature on the days temperature water [8]. The patient can be placed under
when animals presented with heat stroke was significantly running water in a well-drained tub or run, submerged
increased when compared with average temperatures. partially in a tub of water, or sprayed with a hose. The key
is to soak the entire patient as rapidly as possible, and to
soak through the hair coat to soak the skin thoroughly.
Initial Management Considerations
Intravenous fluid therapy is essential, unless there are
Mentation in heat injured patients can range from alert specific contraindications, using room-temperature flu-
and responsive to stuporous or comatose. Patients present- ids [8]. Adequate circulating blood and plasma volume are
ing in stupor or coma are in imminent danger of death. required to maximize heat dissipation by conduction [17].
Some patients with heat stroke present actively seizuring[8]. Additionally, IV administration of room-temperature flu-
They may be hypothermic, hyperthermic, or normother- ids reduces core body temperature.
mic on presentation, based on cooling measures initiated Use additional cooling methods such as directing fans on
by the owner or handler and length of time since onset of the patient to increase surface cooling, remembering that it
heat stroke. is essential that the skin be thoroughly wet for fans to be
eatt-Induued Injury 945
Protocol 72.3 Management of Heat-Induced Injury

1) Triage the patient as for other types of injury or illness: to check for shock hypotension. Continue IV fluid
carefully assess mentation, airway and breathing, cir- therapy as directed by the attending veterinarian.
culation, and body temperature. b) Monitor blood glucose and venous blood gas analy-
a) Establish and protect the airway if apneic. ses every 6–12 hours. Maintain normoglycemia
b) Provide supplemental oxygen therapy. with supplemental dextrose.
c) Establish at least one IV catheter and resuscitate c) Monitor arterial blood gas analysis or pulse oxime-
for shock and persistent hypotension. try and capnography to assess oxygenation and
2) Emergently cool the patient if rectal temperature is ventilation. IV fluids should be supplemented with
> 105°F (> 40.9°C), cooling as rapidly as possible until dextrose as needed to maintain normoglycemia.
the body temperature is 105°F (40.9°C). d) Monitor for occult or active bleeding and petechiae
a) Soak the patient to the skin with copious amounts and ecchymoses; perform coagulation tests every
of room-temperature water. 6–12 hours and serial complete blood counts every
b) Administer room-temperature IV fluids at rates 12–24 hours to screen for thrombocytopenia and
necessary to combat shock or persistent coagulopathies.
hypotension. e) Monitor the ECG continuously to detect cardiac
c) Direct fans on the patient to facilitate surface arrhythmias, especially ventricular arrhythmias.
cooling. Provide specific anti-arrhythmic therapy as directed
d) Reduce the room temperature, if possible. for hemodynamically unstable patients.
e) Avoid cold IV fluids, iced water baths, or surface f) Monitor for vomiting and diarrhea, provide excel-
cooling with ice water or ice packs. lent nursing care to maintain patient hygiene, pro-
3) Reduce the rate of cooling once the patient’s body vide gastrointestinal protectants as directed, and
temperature is < 105°F (< 40.9°C) to avoid rebound provide enteral or parenteral nutrition as directed.
hypothermia. g) Monitor urine output hourly and assess creatinine
a) Cease cooling with water and dry the hair/skin. every 12–24 hours. Place and maintain urethral
b) Remove fans. catheters as directed.
c) Return room temperature to normal. h) Monitor respiratory rate hourly, perform thoracic aus-
4) Provide supportive warming once the patient’s tem- cultation at least every 4hours, and perform thoracic
perature has been reduced to 103°F (39.8°C). radiographs if pulmonary edema or other abnormali-
a) All active cooling efforts must cease. ties are suspected. Perform arterial blood gas analysis
b) Continue temperature monitoring. or pulse oximetry and capnography every 4–6hours
c) Actively warm the patient to prevent rebound initially, then as needed, to assess oxygenation and
hypothermia if temperature is at or below ventilation. Consider mechanical ventilation if the
100°F (38°C). patient cannot oxygenate or ventilate adequately.
5) Monitor for and treat concurrent problems. i) Monitor mentation and level of consciousness,
a) Monitor blood pressures, lactate clearance, urine vision, gait, and postural responses, and monitor for
output, mentation, and other measures of perfusion seizures.
effective. Manage patients in an air-conditioned environ- footpads is commonly done, but is generally ineffective
ment. Cooling of carotid arteries (e.g. by ice packs placed because the paw pads have such a small surface area.
over the neck) induces vasodilatation, which may increase Wetting a large percentage of the pet’s surface area to the
cerebral perfusion, based on studies in people [24]. Future skin with alcohol is required for adequate cooling, but risks
veterinary studies may reveal positive therapeutic modali- combustion, and should not be performed [8].
ties that include advanced brain hypothermia. Once the patient’s body temperature is lower than 105°F
Although debatable and poorly researched, avoid cold IV (40.9°C), reduce the rate of cooling to avoid rebound hypo-
fluids, iced water baths, and surface cooling with iced thermia. Discontinue ancillary cooling measures and dry
water or ice packs because these cause peripheral vasocon- the patient’s skin. Supportive warming is necessary once
striction with sustained increase in core temperature; cause the patient’s temperature has been reduced to 103°F
shivering, generating more internal heat; and promote (39.8°C) or below. At this point, cease all cooling efforts,
capillary sludging, which contributes to coagulopathy monitor temperature frequently, and be prepared to actively
[8, 11, 17, 21, 24, 25]. Placing isopropyl alcohol on the warm the patient to prevent rebound hypothermia [10].
Although warming a patient with a temperature of 103°F shaved, tails wrapped, and patients bathed. Gastrointestinal
(39.8°C) may seem counterintuitive, anticipate a period of protection agents may be administered [12]. Nutritional
rebound hypothermia. Additionally, the delay between rec- support may be necessary during the hospital stay, to
tal temperature and true core temperature probably means include enteral or parenteral feeding [16].
that the true core temperature may be lower [21]. Renal insufficiency may develop. Anticipate placing a
urinary catheter with a closed collection system to monitor
adequacy of urine output or perform intermittent urethral
Monitor for and Treat Concurrent Problems
catheterization. Urine production should be maintained at
Patients with heat injury often present in shock and may 1–2 ml/kg/hour.
develop sustained hypotension. IV fluid therapy should be As heat injury often induces multiple organ dysfunction,
continued not only to cool the patient but also to maintain careful monitoring of the respiratory system is necessary.
adequate tissue perfusion. In some cases, fresh frozen During initial resuscitation and for the next 12 hours, the
plasma or albumin transfusions may be indicated to treat respiratory rate should be monitored hourly, thoracic aus-
concurrent problems such as disseminated intravascular cultation should be performed at least every four hours,
coagulation (DIC) or hypoalbuminemia. Continuous or and thoracic radiographs should be taken if pulmonary
intermittent blood pressure measurement, lactate clear- edema is suspected. Arterial blood gas analysis or surro-
ance, clinical assessment of perfusion, and assessment of gates should be performed as needed to assess oxygenation
volume status should be monitored over time. and ventilation, as discussed above. Mechanical ventila-
Glucose, acid–base, and electrolyte abnormalities are tion may be necessary if the patient cannot oxygenate or
common due to shock and reduced tissue perfusion. Blood ventilate adequately.
glucose measurement and venous blood gas analyses, to Generally, CNS abnormalities resolve with mild or mod-
include measurement of blood lactate concentration, are erate cases of heat injury. However, severe heat injury may
necessary, generally at intervals of every 6–12 hours, cause cerebral edema and necrosis, and thus careful moni-
depending on the severity of the derangements. If concur- toring is necessary. Cortical blindness usually resolves but
rent pulmonary abnormalities are present, arterial blood may take several days. Persistence of altered mentation,
gas analysis (or surrogates such as pulse oximetry and cap- ataxia, tremors, or seizures strongly suggest increased
nography) may be necessary to optimally assess oxygena- intracranial pressure; specific therapy may be necessary
tion and ventilation. IV fluids should be supplemented (e.g. mannitol infusion).
with dextrose as needed to maintain normoglycemia. A study in 40 dogs [23] demonstrated that 90% of dogs
Patients with heat injury are at an increased risk for presenting with heat stroke had increased peripheral
developing hypercoagulable and consumptive coagulo- nucleated red blood cells (nRBC) at presentation, with a
pathic states (e.g. DIC) [8, 16]. Be prepared to run the full cutoff point of 18 nRBC/100 leukocytes corresponding to
spectrum of coagulation testing. In many cases, thrombo- a sensitivity and specificity of 91% and 88%, respectively,
cytopenia will develop in the first 24 hours; observe for for death. Dogs with nRBC above this cutoff point were
clinical signs (e.g. petecchiae, ecchymoses) and perform also significantly more likely to have life-threatening
serial complete blood counts at least daily. Additionally, complications such as kidney failure and disseminated
careful monitoring for signs of clotting abnormalities (e.g. intravascular coagulopathy. Thus, rapidly screening for
hematoma formation, intracavitary bleeding, epistaxis, the presence of nRBC may be useful to confirm clinical
hematuria) is necessary throughout the hospital stay [17], suspicion of heatstroke, and guide aggressiveness of ther-
and coagulation testing should be considered every apy and monitoring.
6–12 hours until the patient is stabilized. It is common for A severity scoring system [22] has been validated in dogs
these patients to require blood component therapy [16]. with heat stroke that may prove useful to gauge severity of
Heat injury patients are at increased risk for develop- injury and prognosis based on key clinical and laboratory
ment of cardiac arrhythmias, especially ventricular parameters noted within the first 24 hours of admission.
arrhythmias. Continuous or intermittent ECG monitoring Parameters useful to measure include heart rate, blood glu-
is necessary to identify arrhythmias. Specific anti- cose, and coagulation tests. Clinically, the presence of obe-
arrhythmic therapy may be indicated if the patient devel- sity, acute collapse, shock, seizures, altered mental status,
ops hemodynamic instability due to the arrhythmia. coagulopathy, acute kidney injury, and acute lung injury
Patients suffering from heat injury often will have con- are documented risk factors for death.
current vomiting and diarrhea. In some cases, the diarrhea In summary, patients with heat injury require rapid
will be hemorrhagic [16]. Hemorrhagic diarrhea is com- reduction in body temperature and intensive management.
mon and can create husbandry challenges. Hygiene is criti- Targeted temperature reduction using thorough soaking of
cal, and bedding should be changed as needed, long hair the skin with water is followed by cessation of cooling
Oen oundds and eurotiu idsdsue 947
measures at an appropriate temperature to prevent rebound life-threatening injuries; triage and management of more
hypothermia. Intensive monitoring and supportive care severe concurrent injuries takes precedence.
will minimize development of complications.
Considerations in Wound Management
Open Wounds and Necrotic Tissue Protocol 72.4 details the management of open wounds and
necrotic tissue. Wound management goals are to create a
Wounds commonly result from animal bites, motor vehicle healthy wound bed with adequate blood supply to support
or other trauma, and are classified as contaminated or dirty repair and without contamination or necrotic tissue that
or infected wounds, depending on the length of time since impedes healing and increases infection risk [26–28].
injury. Contaminated wounds are those less than six hours Wounds may require frequent evaluation and care. Many
old, and dirty or infected wounds are those six or more wounds must be managed as bandaged open wounds
hours old, generally with obvious exudate or infection [26]. before definitive surgical repair. Management recommen-
Wounds are often noted in conjunction with potentially dations are provided in the protocol. Wound lavage is
Protocol 72.4 Management of Open or Necrotic Wounds

1) Triage the patient for life-threatening problems: f) Lavage the wound to remove particulate debris and
a) Provide appropriate resuscitation and stabilization reduce bacterial contamination:
before wound management. i) Thoroughly lavage the wound bed with at least
b) Apply direct pressure followed by a temporary pres- 1 l for this final lavage.
sure bandage to stop active hemorrhage at ii) Lavage under pressure, using a lavage pressure
wound sites. of 7–8 mmHg: use a 16-gauge hypodermic nee-
2) Manage potential local and systemic infection: dle attached to an IV administration set
a) Collect and submit samples for microbial culture attached to a 1 l bag of saline pressurized to
and sensitivity testing, preferably before starting 300 mmHg using a pressure cuff.
antibiotic therapy. g) Bandage the wound:
b) Initiate empiric antibiotic therapy within the first i) Apply a primary layer to provide mechanical
6 hours of the wound’s development, or as soon as debridement initially, using a wet-to-dry band-
possible thereafter. age of sterile gauze sponges saturated with
c) Culture the wound if obvious infection develops sterile saline, gently wrung to eliminate exces-
during any phase of wound management, the sive moisture, and applied directly to the wound.
wound fails to heal normally, or systemic signs of ii) Apply several dry gauze sponges over the pri-
infection develop. mary layer.
3) Provide initial wound management: iii) Apply a secondary layer over the primary layer,
a) Provide effective analgesia or anesthesia based on using cast padding or roll cotton ± splints to
wound severity, location, and other factors. provide support.
b) Apply sterile water-soluble lubricant to the wound iv) Apply a tertiary layer of nonadherent conforming
bed. Then clip the hair generously around the wound. bandage (e.g. VetWrap®), adhesive bandage (e.g.
c) Gently cleanse the skin around the wound, but not Elastikon®), or both, using light compression.
the wound bed, with surgical scrub. 4) Provide daily wound care, using appropriate analgesia,
d) Gently lavage the lubricant and gross contaminants sedation, or anesthesia.
from the wound using sterile saline or lactated a) Change bandages at least once daily, but more fre-
Ringer’s solution. quently if heavy discharge is present or the band-
e) Debride grossly necrotic and nonviable tissues age is soiled or partially removed by the patient.
carefully using aseptic technique and sharp dissec- b) Lavage the wound as above at every band-
tion in accordance with hospital policy: age change.
i) Do not mass ligate tissues or use cautery excessively. c) Debride the wound as above at every band-
ii) Do not damage, transect, or ligate major blood age change.
vessels (unless actively hemorrhaging) or d) Apply a new bandage as above; change the primary
nerves, as these are crucial to maintain effective layer to a nonadherent dressing once a healthy
blood flow and innervation distally. granulation bed is formed.
essential, ideally under specific pressure [29]. One modal- quickly remove gross contaminants from the fracture site,
ity to consider after emergency management of the wound but do not attempt to clip hair or clean open wounds at
is negative pressure wound therapy [26]. this stage. Do not attempt to reduce open fractures. Cover
the fracture and wound with sterile nonadherent dressing
and apply a light bandage to protect open wounds and
Antibiotic Use in Patients with Open
exposed bone from further contamination during initial
or Necrotic Wounds
patient resuscitation; fractures are not placed in an attempt
Systemic antibiotic use is ideally based on culture results. to stabilize or immobilize the fracture at this time. Culture
Empiric antibiotics are often used, based on expected micro- open fracture sites as soon as possible after presentation
bial presence [29, 30]. Many contaminated wounds, with and before antibiotic use if possible. The majority of open
proper management, can be converted to clean-contaminated fractures are infected on admission, and in the majority of
wounds, and systemic antibiotics may not be indicated. cases, the organism cultured on admission is the same
Most dirty/infected wounds require antibiotic use. organism involved in later infections [29, 31, 33].
Administer antibiotics as directed, focusing on use of IV
antibiotics based on likely contaminants. Never withhold
Open Fractures antibiotic therapy in any patient with an open fracture.
Address pain with appropriate analgesia; reassess every
Fractures are generally not considered life-threatening four to six hours. Manage soft-tissue injuries over the frac-
emergencies. Open fractures, in which the skin and subcu- ture site appropriately to optimize outcome (Protocol 72.4).
taneous tissues overlying a fracture are injured and expose Once the patient is stable, immobilize the fracture if pos-
fracture ends and fragments to external contamination, are sible, to minimize pain, improve function, and prevent
significant and risk increasing morbidity and mortality further injury to the neurovascular bundle and bone.
because they provide access to microbial organisms that Consider spoon splints, lateral plastic splints, or Robert
can cause local infection (i.e. osteomyelitis, cellulitis) and Jones bandages. It may be better to leave the fracture alone
serve as a nidus of infection for systemic infection [27, 31, 32]. than to apply an immobilizing device incorrectly. If an
Thus, proper management of open fractures is an impor- immobilizing device is not applied, apply a sterile wet-to-
tant part of the overall management of trauma patients. dry bandage to open fractures (Protocol 72.4). Always use
Early and proper management of open fractures is criti- a wet dressing over open fractures to keep soft tissues and
cal, and open fractures should be treated as a medical bones moist for optimal healing. Change bandages at least
emergency, once more pressing problems are addressed. once daily, based on degree of strike-through, soiling, or
The majority of fractures are caused by motor vehicle loosening.
trauma, but gunshot, entrapment injury, and blunt In summary, patients with open fractures require care-
trauma from non-motor vehicle causes are also common. ful management, with utmost attention to identifying
Recognize the intense forces involved in trauma that and treating life-threatening problems first. Protect
cause fractures, and address the overall patient for life- wounds and immobilize fractures initially. Provide
threatening injuries, first. subsequent appropriate antibiotic therapy, effective
Management recommendations for open fractures are analgesia, daily wound care, and supportive care until
shown in Protocol 72.5. While providing initial resuscitation, definitive repair.
Protocol 72.5 Management of Open Fractures
1) Address life-threatening problems first: iii) Cover the fracture and wound with sterile non-
a) Use a standardized approach to trauma management. adherent dressing and apply a light bandage.
b) Focus on the “ABCs” of initial trauma patient 2) Prevent bacterial infection, provide analgesia, and
management. promote normal healing pending surgical fracture
c) Protect the open fracture site: repair:
i) Do not attempt to reduce any bone protruding a) Culture open fracture sites as soon as possible after
at the fracture site. presentation and before antibiotic use if possible.
ii) Remove any large gross contaminants from the b) Administer antibiotics as directed by the attending
wound (e.g. leaves, rocks, stick fragments), but veterinarian.
do not attempt to clip the hair or cleanse the c) Never withhold antibiotic therapy in any patient
wound at this point. with an open fracture.
References 949
d) Provide appropriate analgesia; reassess pain every b) Recognize common complications due to open
4–6 hours using a pain scoring system. fractures:
e) Manage soft tissue injuries over the fracture site i) Assess pain frequently and provide appropriate
appropriately (Protocol 72.4). analgesia.
3) Manage orthopedic injuries once the patient is stabilized: ii) Base continued antibiotic use on the initial cul-
a) Immobilize the fracture, if possible, to minimize ture and sensitivity results.
pain, improve function, and prevent further injury to iii) Monitor the open fracture site at least daily
the neurovascular bundle and bone. for evidence of local infection and monitor the
b) If an immobilizing device is not applied, apply a sterile patient frequently for evidence of systemic
wet-to-dry bandage to open fractures (Protocol 72.4). infection.
Change bandages at least once daily, based on degree iv) Assess adequacy of immobilization, if applied,
of strike-through, soiling, or loosening. and monitor for complications of immobilizing
4) Monitor patients with open fractures: devices (e.g. chafing, distal swelling, pain, skin
a) Focus on the overall status of the patient. wounds, tissue maceration).
References
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951
73
Blood Glucose Monitoring and Glycemic Control

Erica L. Reineke
In animals, blood glucose concentration is maintained 53–117 mg/dl (2.9–6.5 mmol/l) in the resting state in adult
within a very narrow range due to a dynamic balance dogs and 57–131 mg/dl (3.1–7.2 mmol/l) in adult cats [3].
between production, storage, and release of glucose. These values may differ slightly depending on the clinical
Quantitively, glucose is the most abundant carbohydrate laboratory in which concentration is measured. In general,
that exists in the circulation and serves as the principal fuel puppies and kittens may have slightly higher resting blood
for peripheral tissues except during prolonged fasting [1]. glucose concentration compared with adult animals [4].
Glucose comes from intestinal absorption through diges- The appearance of clinical signs related to altered blood
tion of carbohydrates, from breakdown of glycogen, or from glucose concentration depends on the absolute glucose
production of glucose via precursors such as lactate, pyru- concentration, and also on the duration, degree, and rate of
vate, amino acids, and glycerol. When blood glucose con- decline or rise of glucose.
centration rises, the anabolic hormone insulin is secreted
from the β-cells in the pancreas [2]. Ultimately, the effect of
insulin is to lower blood glucose concentration by causing Hypoglycemia
increased transport of glucose into cells, where it is used to
Clinically relevant hypoglycemia occurs when the blood glu-
form energy or stored in the form of glycogen. In addition,
cose concentration reaches less than 50 mg/dl in both dogs
insulin also decreases the production of additional glucose
and cats. Clinical signs of hypoglycemia primarily manifest
by inhibiting gluconeogenesis and glycogenolysis. When
as cerebral dysfunction such as behavioral changes, ataxia,
hypoglycemia develops, there is increased secretion of the
collapse, seizures, stupor, and coma [5–7]. These clinical
counter regulatory hormones glucagon, catecholamines,
signs occur because the brain, unlike most other tissues in
cortisol, and growth hormone. These hormones increase
the body, has an obligatory need for glucose for the produc-
blood glucose concentration through inhibition of periph-
tion of ATP [8]. The brain has limited glycogen store, so it
eral glucose uptake, increasing hepatic glycogenolysis and
relies on hepatic glycogen breakdown to supply the glucose
gluconeogenesis, and inhibition of insulin secretion. The
it requires for normal function. Other clinical signs of hypo-
maintenance of a normal blood glucose concentration
glycemia that may occur in the small animal patient, such
depends on appropriate hormone secretion in response to
as pacing, vocalizing, restlessness, shaking and trembling,
changing concentrations in addition to normal hepatic gly-
likely result from activation of the adrenergic system in
cogen synthesis, glycogenolysis, and gluconeogenesis [2].
response to impending hypoglycemia [6].
Abnormalities in any of these physiologic functions can
When neuroglycopenia, or hypoglycemia of the central
lead to either high or low blood glucose levels.
nervous system, occurs, the reduction in cerebral ATP pro-
duction results in dysfunction of the membrane-associated
Abnormalities in Glucose Homeostasis Na-K-ATPase pumps. The result of this pump failure is cell
swelling and release of excitatory neurotransmitters such as
Abnormalities in glucose homeostasis (low or high blood glutamate and aspartate, which ultimately results in the clin-
glucose concentrations) occur commonly in the small ical signs associated with cerebral dysfunction. Severe and
animal patient. Normal blood glucose concentration is prolonged hypoglycemia can lead to neuronal cell death
952 Blood Glucose Monitoring and Glycemic Control
[9, 10]. Early recognition and emergency treatment of hypo- Hyperglycemia that occurs secondary to critical illness in
glycemia is thus essential to prevent permanent neuronal nondiabetic patients has been termed stress hyperglycemia
damage. In a recent single-center study of 660 dogs, hypogly- or diabetes of injury. Stress hyperglycemia likely results
cemia (<80mg/dl) was present at emergency admission in from a combination of low or normal insulin concentra-
9% of dogs and was associated with increased mortality [11]. tions, increased counter regulatory hormone secretion,
Hypoglycemia may occur in the small animal patient due peripheral tissue insulin resistance, and deranged hepatic
to decreased production of glucose by the body or increased autoregulatory mechanisms [16]. Initially, this was consid-
uptake. Common causes of hypoglycemia include juvenile ered to be an adaptive response of the body during illness
and toy breed hypoglycemia, insulinoma or iatrogenic insu- or injury to maintain an energy supply to non-insulin-
lin overdose, hepatic failure, sepsis, and xylitol intoxication. dependent tissues such as the brain and immune sys-
tem [21]. However, a large body of evidence in the human
medical literature suggests that even moderate hyperglyce-
Hyperglycemia
mia can contribute to both morbidity and mortality in criti-
Hyperglycemia is considered to be present when the blood cally ill people with severe brain injury, trauma, burns,
glucose concentration exceeds 117 mg/dl in dogs. In cats, sepsis, myocardial infarction, and stroke [22–28].
hyperglycemia is less well defined but is usually considered As seen in people, hyperglycemia has been documented
to be present when the concentration exceeds 130 mg/dl. to occur in critically ill veterinary patients, and evidence is
When only mild elevations occur, clinical signs are gener- accumulating that it is also associated with worse out-
ally absent. However, with severe elevations, clinical signs comes. In a study of dogs and cats sustaining head trauma,
can include increased thirst and urination, dehydration, hyperglycemia at admission was associated with worse
alterations in mental status, and coma. neurologic disease but not outcome [17]. In a different
Since glucose contributes to the osmolality of the blood, it study evaluating dogs and cats presenting to an emergency
is capable of causing the movement of water between body service with congestive heart failure, hyperglycemia at
compartments. Hyperglycemia results in fluid shifting from admission was found to be associated with a worse out-
the intracellular compartment into the intravascular space come [20]. Critically ill cats admitted to an intensive care
resulting in cellular shrinkage [12]. Once the glucose con- unit were found to have a higher median blood glucose
centration in the blood exceeds the renal transport maxi- concentration (183 mg/dl, range 51–321 mg/dl) than
mum, glucosuria will occur. The result is an osmotic diuresis, healthy controls and found to have similar hormonal
which may potentiate dehydration and hypovolemia in ani- derangements as critically ill people [29]. Similarly, 16% of
mals who are unable to drink water to compensate for these critically ill dogs admitted to an intensive care unit were
fluid losses [13]. In addition, chronic hyperglycemia and found to have hyperglycemia. In this study, nonsurvivors
hyperosmolality induces the formation of osmotically active had significantly higher blood glucose concentrations than
idiogenic osmoles in the brain. The purpose of idiogenic survivors, had longer hospitalization, and more septic
osmoles is to protect the brain against cerebral dehydration complications [19]. Finally, in the single-center study of
by preventing water movement from the brain into the blood 660 dogs mentioned above, hyperglycemia (> 120 mg/dl)
(for more information, see Chapter 58) [14]. was found in 40% of dogs at hospital admission and was
In addition to its effects on water distribution in the body, associated with a higher mortality compared with dogs
hyperglycemia can also contribute to the suppression of that had normal blood glucose concentration [11]. Despite
the immune system. Hyperglycemia has been found to accumulating evidence that hyperglycemia is common in
alter cytokine release from macrophages and to impair critical illness, it is still unknown whether these increases
phagocytosis and free radical production from leuko- in blood glucose concentration actually have detrimental
cytes [15, 16]. Finally, hyperglycemia can contribute to an consequences in our patients or whether hyperglycemia is
overall proinflammatory and prothrombotic state because instead a reflection of disease severity.
it may incite leukocyte release of proinflammatory
cytokines and activation of the coagulation system [15, 16].
Documented causes of hyperglycemia in veterinary Blood Glucose Monitoring
patients include diabetes mellitus, hyperadrenocorticism,
acromegaly, stress, and pancreatitis. There are also iatro- As derangements in blood glucose concentration are com-
genic causes such as the administration of glucose- mon, blood glucose measurements and serial blood glucose
containing fluids, parenteral nutrition, and glucocorticoids. monitoring should be performed on all critically ill patients.
In addition, hyperglycemia has been documented to occur For patients presenting on an emergency basis, a blood glu-
in critically ill animals including those with head trauma, cose measurement should be taken at the time of presenta-
sepsis, and congestive heart failure [17–20]. tion to the veterinary hospital, especially if clinical signs
Blood Glucose Monitoring 953
such as altered mental status, seizures, or coma are present. artifactually low measurements is to separate plasma
Hospitalized patients should have blood glucose measure- promptly from the cellular components in blood and meas-
ments performed at least once daily or more often depend- ure the plasma glucose concentration instead.
ing on the underlying disease process or administration of
therapies, such as dextrose-containing fluids or insulin,
Methods of Measuring Glucose Concentration
which are known to affect blood glucose concentration.
The method by which glucose is measured and the type Glucose measurements are based on one of three enzyme
of blood drawn (arterial, venous, or capillary) may lead to systems – glucose oxidase, glucose-1-dehydrogenase, or
differing glucose measurements. It is therefore important hexokinase – which cause glucose conversion [31, 33].
to become familiar with the various methods available to These enzymatic reactions are either colorimetrically
measure glucose concentration and possible confounding detected through reflectance or absorbance photometry, or
issues a veterinary technician and clinician might amperometrically (electrochemically) detected. For exam-
encounter. ple, glucose oxidase catalyzed reactions result in the pro-
Blood glucose measurements can be performed on whole duction of gluconic acid and hydrogen peroxide. In
blood, serum, or plasma. Glucose measurements performed colorimetric detection systems, hydrogen peroxide reacts
on plasma or serum are approximately 12–13% higher than with various hydrogen donors to produce a color change
whole blood measurements [30]. This is because the water that is proportional to glucose concentration. This color
content of red blood cells (73%) is less than that of plasma change is measured using a reflectance photometer that
(93%), and because glucose is freely diffusible between converts that reflected light to an electronic signal for digi-
plasma and erythrocytes. The greater water content of plasma tal display [34]. Amperometric detection systems use the
means that the glucose concentration per unit volume of glucose oxidase or glucose-1-dehydrogenase enzymes. In
plasma is higher than in whole blood [30]. In addition, as the amperometric measuring devices, an electrical current is
water content of whole blood is the sum of plasma water and produced from the reaction that is directly measured.
red blood cell water, glucose concentration depends on the Finally, for systems using the enzyme hexokinase, NADH
hematocrit of the sample. For example, in severe anemia, (nicotinamide adenine dinucleotide) reacts with a dye to
whole blood glucose and plasma glucose concentration will produce a color change detected by the machine [34].
be nearly equal. With rising hematocrits, the disparity
between whole blood and plasma glucose concentration Instruments Used to Measure Glucose
increases [31, 32]. In general, the difference in glucose con- Blood glucose measurements are typically performed
centration between plasma and whole blood is minor (<20% either in a central laboratory or cage-side using portable
difference) and typically does not affect clinical decision devices. As pathologic changes in glucose concentration
making. However, in human medicine, to avoid any potential require immediate intervention, blood glucose measuring
clinical misinterpretation, it has been suggested that only devices need to provide rapid and accurate results. Unfor-
glucose concentration in plasma be reported. The current tunately, reporting of central laboratory measurements
recommendation is to apply the constant factor of 1.11 for of blood glucose concentration may take too long to be
the conversion between concentration of glucose in blood clinically useful. Therefore, cage-side glucose measuring
and the equivalent concentration in plasma [31]. No similar devices are typically used in the clinical setting. In addition
recommendations currently exist in veterinary medicine. to providing rapid results, these cage-side portable blood
Measured glucose concentration may also vary depend- glucose measuring devices also use minimal volumes of
ing on the location of the blood draw. For example, venous blood, thereby helping to limit anemia that may result from
blood samples will give slightly lower results than capillary frequent blood sampling.
samples. However, in fasting subjects the glucose values Common instruments currently used to rapidly evaluate
obtained in arterial, capillary, and venous samples are blood glucose concentrationin small animals include port-
practically the same. Differences are seen primarily after able blood glucose meters (PBGM) and point of care (POC)
meals when glucose uptake by the periphery may be rapid, analyzers such as the i-STAT® (Abbott Point of Care Inc.,
resulting in arterial and capillary glucose samples that may Princeton, NJ), the NOVA Stat Profile® (NOVA Biomedical,
exceed the concentration from venous samples [28]. Waltham, MA), or the RAPIDPoint® systems (Siemans
Glucose concentration, if not measured immediately, Medical Solutions, Malvern, PA). Point-of-care refers to any
will decrease after blood collection due to continuing glyc- laboratory test performed outside a clinical laboratory by
olysis by red blood cells and leukocytes. Thus, delay may nonlaboratory personnel [35]. It is important for the veteri-
lead to an artifactual lower measurement [29]. Addition of narian and technician to understand and recognize poten-
preservatives, such as sodium fluoride, may help to avoid tial interferences that may exist with glucose measurements
or delay this loss [28]. Another option for avoiding obtained by these devices, particularly with PBGMs.
Portable Blood Glucose Meters Increases in hematocrit decrease whole blood glucose
Many PBGMs are available from different manufacturers to measurements and vice versa. In PBGMs, this may be
measure blood glucose concentration. These devices were caused by mechanical impedance of plasma diffusion into
originally developed to allow for self-monitoring of blood the reagent layer of the strip at higher hematocrits, result-
glucose by people with diabetes mellitus. The benefits of ing in slower diffusion of glucose and hence lower glucose
blood glucose measurements provided by PBGMs include measurements [44]. In patients with anemia, artifactually
rapid results, ease of use, minimal blood requirements, and increased measurements may be obtained, which may
cost effectiveness. PBGMs use test strips that consist of an mask hypoglycemia.
enzyme-impregnated reagent pad that is either sponge-like Substances such as drugs may also affect glucose meas-
or covered with a mesh or membrane. When a drop of blood urements obtained by PBGMs. In a study evaluating the
is applied to the surface, plasma soaks through into the rea- effect of 30 different commonly used drugs on glucose con-
gent layer and red cells are retained on the surface [36]. centration measured by seven different PBGMs, the inves-
Depending on the particular device, it may use colorimetric tigators found that ascorbic acid (vitamin C),
or amperometric detection systems to measure glucose con- acetaminophen, dopamine, and mannitol were all found to
centration. PBGMs developed for use in people report the interfere with glucose measurements. Acetaminophen
blood glucose concentration as a plasma equivalent by increased glucose measurements on several PBGMs [45].
applying an internal equation to allow for more accurate This effect may be clinically relevant in small animals
comparisons with laboratory measurements. when acetaminophen ingestion can lead to hepatic failure
The accuracy of PBGMs has been extensively evaluated and hypoglycemia. Dopamine falsely increased glucose
in the human literature. In several human studies, large measurements in some devices primarily at high drug con-
variations in the accuracy of different PBGMs in different centrations, as did the drug mannitol [45].
glycemic ranges have been found [37–39]. Other factors Partial pressure of oxygen, pH, and temperature have also
such as hematocrit, inadequate sample volume, drugs, par- been evaluated to determine their effects on blood glucose
tial pressure of oxygen (PO2), and user error have also been concentrations obtained with PBGMs. When oxygen ten-
documented to affect the accuracy of glucose measure- sion is high (partial pressure of oxygen in arterial blood,
ments obtained with PBGMs [40–43]. User errors most PaO2, > 100 mmHg) investigators have found falsely low-
commonly cited to affect the accuracy of measurements ered glucose readings in glucose oxidase systems [46]. This
obtained by PBGMs include failure to maintain the meter may be relevant in patients receiving high concentrations of
properly, incorrect techniques or operating procedures, or supplemental oxygen, such as those under general anesthesia.
failure to follow instructions for meter use. Table 73.1 is a Conversely, lower oxygen tensions (PaO2 < 40 mmHg) had
summary of some of the variables that may affect measure- a negligible effect on glucose concentration. Blood pH, on
ments obtained by PBGMs. the other hand, has not been shown to be a major source of
error at a pH range of 6.8–7.84 [47, 48]. Finally, some data
Table 73.1 Variables that may affect blood glucose suggest that cold temperatures may adversely affect the
concentration measurements obtained with a portable blood accuracy of glucose measurements [49, 50].
glucose meter. Multiple studies evaluating different PBGMs have been
published in the veterinary literature [51–55]. However,
Effect on glucose the number of commercially available PBGMs is constantly
Variable measurement increasing and older models are continually being replaced
by newer ones, making some of these previous investiga-
Hematocrit:
tions obsolete. These previous veterinary studies have
Increased hematocrit (polycythemia or Decreases
found that PBGMs results may consistently overestimate,
dehydration)
underestimate, or accurately reflect a laboratory measure-
Decreased hematocrit (anemia) Increases
ment depending on the PBGM being evaluated. The
Drugs:
AlphaTrak® (Abbott Laboratories, Abbott Park, IL), a
Dopamine Increases PBGM marketed for dogs, did not consistently provide
Mannitol Increases results that were either higher or lower than the laboratory
Acetaminophen Increases values in one study. Even though the measurements
Oxygen tension (PaO2): obtained by the PBGMs were different from the reference
Hyperoxia (PaO2 > 100 mmHg) Decreases laboratory values, they were unlikely to adversely affect
Hypoxia Negligible
clinical decision making [54]. In the most recent study
investigating the Accu-Chek® Performa (Roche Diagnostics
Small sample size (< 3 μl) Decreases
Corp, Indianapolis, IN) it was found that whole blood,
Blood Glucose Monitoring 955
serum, or plasma blood glucose measurements were veterinary medicine as an attractive method by which to
strongly correlated with laboratory measurements for dogs monitor patient glucose concentrations. Interstitial glucose
and cats [55]. concentration has been extensively studied and found to
Moreover, despite pitfalls that may be encountered when mimic blood glucose concentration in a variety of species
using PBGMs, they will continue to be a valuable tool to including rats, rabbits, dogs, and people [59]. This knowl-
measure blood glucose in the veterinary setting. To prevent edge has led to the development of a CGMS that measures
user error, it is important to always follow the manufac- interstitial glucose concentration within the subcutaneous
turer’s instructions on maintenance and calibration of the space. The CGMS has been approved by the US Food and
device. In addition, whenever a new PBGM is obtained by Drug Administration (FDA) for use in human diabetic
a veterinary hospital, results should be compared with lab- patients and has resulted in significant improvements in
oratory measurements to ascertain whether these results glycemic control [60].
are consistently higher or lower than expected. Finally, if There are now a number of different CGMSs available.
a patient is identified as hypoglycemic on a PBGM, the The two most common systems in use in veterinary medi-
clinician should be notified; however, treatment may be cine include the Medtronic Guardian™ (Medtronic
recommended only if the patient is exhibiting clinical Diabetes, Northridge, CA) and the FreeStyle Libre®
signs consistent with low blood glucose concentration. (Abbott, Abbott Park, IL). Both systems consist of a record-
Alternatively, a comparison laboratory measurement of blood ing device and a flexible electrode glucose sensor. The sen-
glucose concentration could be obtained [54]. Recently the sor is implanted in the subcutaneous space via a
American Society of Veterinary Clinical Pathologists released spring-loaded insertion device and is wirelessly connected
guidelines for the use of PBGMs in veterinary clinical prac- to a small monitor or mobile device that can be worn by the
tice. The reader is referred to another source for additional patient or placed in a cage. The sensor contains an elec-
recommendations [56]. trode covered by a glucose diffusion limiting membrane.
When glucose flows onto the membrane in the electrode, it
Point of Care Analyzers is oxidized to hydrogen peroxide by glucose oxidase.
The use of POC analyzers is becoming increasingly com- Glucose is then determined amperometrically for glucose
mon in veterinary clinical practice. Similar to PBGMs, concentrations of 40–400 or 500 mg/dl, depending on the
these analyzers require a minimal volume of blood and device. The Medtronic CGMS measures interstitial glucose
results are rapid. The i-STAT is the only POC analyzer that concentrations every 10 seconds, and an average value is
has been evaluated in dogs thus far [57]. The i-STAT meas- recorded by the device every 5 minutes whereas the
ures glucose amperometrically through the glucose oxida- FreeStyle Libre measures interstitial glucose concentra-
tion reaction. In one study, investigators found that the tions every 15 minutes. Because changes in blood glucose
i-STAT provided accurate glucose concentration results concentrations are related to changes in interstitial glu-
that varied from the reference method by only 15% and did cose, the CGMS can be used to estimate levels from the
not result in altered clinical decision making [52]. interstitial measurements. The Medtronic Guardian sys-
To the author’s knowledge, the accuracy of the NOVA tem must be calibrated with at least two to three blood glu-
Stat Profile and RAPIDPoint in measuring glucose concen- cose measurements during a 24-hour period whereas the
tration has not yet been evaluated in small animal patients. FreeStyle Libre does not require calibration.
However, both of these devices have been validated for Since its development, the CGMS has been used in clini-
use in people and are likely to provide results consistent cally normal animals, as well as in diabetic dogs and
with laboratory methods. Both the NOVA Stat Profile and cats [61–63]. In 1999, Rebrin et al. found that subcutaneous
RAPIDPoint use an electrode that is covered by a three- interstitial glucose sensing accurately mimics plasma glu-
layered membrane in which glucose oxidase is immobilized. cose irrespective of changes in plasma insulin in experi-
As glucose flows through the membrane, it reacts with mental dogs. However, in this same study, it was shown
glucose oxidase, resulting in the generation of hydrogen that rapid changes in blood glucose concentrations result
peroxide. The instrument is calibrated using an aqueous in slower changes in interstitial glucose concentration,
glucose standard solution [36]. Similar to measurements with a time delay between changes in blood and interstitial
obtained by PBGMs, hematocrit may affect blood glucose glucose concentrations of typically less than 10 min-
concentration values obtained by this method [58]. utes [59]. Clinical veterinary studies have since been per-
formed to evaluate the accuracy of the CGMS in stable
Newer Glucose Monitoring Devices diabetic dogs and cats. The investigators found that there
In the past 20 years, continuous glucose monitoring sys- was significant correlation (dogs, r = 0.81; cats, r = 0.82)
tems (CGMSs) that measure interstitial glucose concentra- between the CGMS device and blood glucose concentra-
tion have received intense interest in both human and tion [62, 63]. Two veterinary studies have evaluated the use
of a CGMS in diabetic ketoacidotic dogs and cats. The both are covered with a clear adherent bandage. After an
results of these studies also found that the CGMS provides approximately two-hour initialization period, the Guardian
clinically accurate estimates of blood glucose concentra- CGMS device will begin to continuously display estimates
tions and that these measurements were not affected by tis- of blood glucose once it has been calibrated with data from
sue perfusion or metabolic variables, body condition score, a measurement. The CGMS will then need to be recali-
or degree of ketosis [64, 65]. brated every 8–12 hours with either a PBGM or POC ana-
The benefit of using a CGMS device is that they allow lyzer measurement of blood glucose. If there is any concern
clinicians to identify fluctuations in blood glucose concen- that inaccurate estimates are being obtained by the CGMS
trations as they are occurring in the patient. Additionally, (either extremely high or low readings), the patient’s blood
these real-time devices allow the clinician to avoid placing glucose should be checked directly. If this measurement is
catheters for the sole purpose of blood sampling or per- different from the CGMS readings, the CGMS should be
forming repeated venipuncture to measure blood glucose recalibrated. If the problem persists, the sensor should be
concentrations, both of which can contribute to morbidity removed and replaced.
in the patient by contributing to patient stress, catheter In contrast with the Guardian CGMS, the FreeStyle Libre
complications, and anemia in small patients. The CGMS is has a one-hour initialization period after placement of the
useful in patients in which repeated phlebotomy is either sensor. No calibrations are required and interstitial glucose
contraindicated due to underlying disease or cannot be measurements are taken every 15 minutes and only dis-
performed. Compared with intermittent glucose monitor- played when the monitor or mobile device is passed over
ing, continuous monitoring of interstitial glucose concen- the sensor.
tration may help to identify rapid changes, which may be
missed in patients in which blood glucose is measured
intermittently. This may be important in diabetic patients Glycemic Control
that are having blood glucose curves plotted to evaluate
insulin dose. The addition of alarms that can notify techni- Glycemic control implies the maintenance of blood glu-
cians and clinicians of either dangerously high or low glucose within a clinically acceptable range. This is achieved
cose excursions make these devices even more clinically through the administration of dextrose, insulin, or medica-
useful. Many veterinary hospitals currently use CGMSs as tions known to raise or lower blood glucose. Patients in
the main method of monitoring estimated blood glucose which interventions are required to maintain clinically
concentration, especially in critically ill diabetic patients acceptable blood glucose concentrations should be moni-
receiving insulin infusions that require frequent glucose tored frequently to avoid complications associated with
monitoring. hypo- and hyperglycemia. Frequent monitoring is particu-
Several disadvantages of the CGMS include the initial larly important in the short- and long-term management of
cost for the device, the cost of the sensors, and the need to diabetic patients, in which glycemic control is achieved
obtain blood glucose measurements for calibrations in the through adjustments in insulin therapy.
Medtronic Guardian CGMS. Another potential disadvan- The benefits of glycemic control in people with diabetes
tage of the interstitial glucose monitoring system is the mellitus include a reduction in mortality, as well as a reduc-
time delay for rapid changes in glucose concentrations to tion in diabetes-related complications such as blindness,
be reflected in the interstitial space. Therefore, data kidney failure, and heart failure [66]. Insulin is also used
obtained from these devices should be interpreted cau- in critically ill people who develop hyperglycemia during
tiously when large changes in glucose concentrations are hospitalization [67–69]. The use of insulin therapy to control
suspected. In these situations, evaluating glucose concen- critical illness-associated hyperglycemia has yet to be
tration trends over time may be more clinically useful. evaluated in veterinary medicine.
Finally, these devices have not been fully investigated for
clinical accuracy in patients with hypoglycemia.
Treatment of Hyperglycemia
Placement of the CGMS in dogs and cats is a simple pro-
cess. Figure 73.1 shows the placement of the Guardian RT The treatment of hyperglycemia in veterinary medicine
device in a patient. First, a small area of fur is clipped, usu- depends on the underlying disease process. For example,
ally just caudal to the shoulder blades. The area should not stress hyperglycemia in cats associated with patient strug-
be cleaned with alcohol, as this may interfere with the gling can result in blood glucose concentrations as high as
adherence of the sensor. The sensor is then placed into the 613 mg/dl, with or without glucosuria [70]. Since stress
spring-loaded insertion device. The insertion device is hyperglycemia can last 90–120 minutes, one should wait at
placed against the patient’s skin and the sensor is dis- least three hours before retesting or instituting treatment
charged. The transmitter is then attached to the sensor, and for hyperglycemia if stress hyperglycemia is suspected.
Glycemic Control 957
(a) (b) (c)
(d) (e) (f)
Figure 73.1 Placement of Medtronic Minimed Guardian® RT continuous glucose monitoring system. (a) Equipment: monitor,
spring-loaded sensor insertion device for accurate placement, blood glucose sensor with transmitter attached. (b) Small area of
clipped fur just caudal to the scapula. (c) Using the spring-loaded device for sensor insertion. (d) Sensor in place with transmitter
attached. (e) Clear adherent dressing being placed over sensor and transmitter. (f) Dog wearing the sensor with transmitter attached.
Hyperglycemia caused by diabetes mellitus requires underlying disease condition or the development of com-
administration of the hormone insulin. Insulin promotes plications. This may involve performing a physical exami-
peripheral glucose uptake, inhibits lipolysis and release of nation, hemodynamic monitoring, and diagnostic tests.
free fatty acids, decreases glycogenolysis, and increases gly- Persistent hyperglycemia should be definitively established
cogenesis [2]. Insulin is available in several forms with dif- prior to initiating insulin therapy.
fering durations of action. Typically, regular crystalline
insulin, in which the duration of action is approximately Intravenous Insulin Constant Rate Infusion
three to eight hours when given intramuscularly (IM) or Table 73.2 is an example of an IV insulin infusion chart. The
one to four hours when given intravenously (IV), is admin- infusion is prepared by adding regular insulin (2.2 U/kg) to
istered during critical illness until the patient is eating and 250 ml of 0.9% NaCl [73, 74]. It is initially administered at a
drinking. Regular insulin is usually administered either IV rate of 10 ml/hour in a line separate from that used for fluid
as a constant rate infusion (CRI) or intermittently IM. Other therapy [73]. At least 50 ml of the insulin-containing fluid
newer, short-acting insulins, such as lispro (Humalog®, Eli should be run through the drip set and discarded prior to
Lilly) and aspart (Novolog®, Novo Nordisk) have been administering it to the patient because insulin adheres to
recently evaluated in a small number of dogs with diabetic plastic and glass; this 50 ml preflush helps saturate the inte-
ketoacidosis [71, 72]. In these studies, both aspart and lis- rior of the administration set with insulin.
pro administered as a CRI were found to be safe and effec- Generally, the placement of two separate IV catheters is
tive as compared to a CRI of regular insulin [71, 72]. recommended: one catheter for insulin and an additional
Insulin may also be used to treat persistent hyperglyce- catheter for IV fluids and blood sampling. Separate cathe-
mia that results from veterinarian-directed interventions. ters are recommended to avoid starting and stopping the
The administration of dextrose-containing fluids such as insulin infusion during blood sampling for glucose moni-
parenteral nutrition and the administration of medications toring. In addition, if IV fluids containing dextrose are
that are known to affect blood glucose, such as vasopres- being administered, blood sampling for glucose monitor-
sors or steroids, can cause hyperglycemia. ing should be done from a separate catheter to avoid falsely
When persistent hyperglycemia cannot be explained by elevated blood glucose measurements that may occur
either diabetes mellitus or veterinarian-directed interven- from contamination with dextrose-containing fluids.
tions, the patient should be reevaluated by either the vet- A multi-lumen catheter, either placed centrally or periph-
erinary technician or clinician for worsening of the erally, may also be used. The most distal lumen of the central
Table 73.2 Constant Rate Infusion of Regular Insulin. the level drops below 250 mg/dl, regular insulin is adminis-
tered IM every four to six hours or subcutaneously every
Blood glucose Rate of administration Dextrose added to eight hours if the hydration status is adequate. In patients
concentration of insulin solution maintenance with diabetic ketoacidosis, a 2.5–5% dextrose-containing
(mg/dl) (ml/hour)a intravenous fluids (%)b
infusion is initiated at this time [75]. Box 73.1 gives instruc-
> 250 10 None tions for calculating a dextrose infusion. Once the blood
glucose has reached an acceptable clinical range, it is mon-
200–250 7 2.5%
itored less frequently. The goal of insulin therapy is to
150–200 5 2.5%
cause a gradual decline in the concentration, preferably at
100–150 5 5%
a rate of about 50–75 mg/dl/hour [76]. Subcutaneous
< 100 Stop insulin infusion 5% administration of insulin is not recommended in the initial
a
Solution comprised of regular insulin at a dose of 2.2 U/kg for dogs, treatment of critically ill diabetic patients, as dehydration
or 1.1–2.2 U/kg for cats, added to 250 ml 0.9% NaCl or lactated could lead to erratic insulin absorption.
Ringer’s solution. Adjustments to rate of insulin therapy are made Regular insulin can alternatively be administered intra-
based on measurements of blood glucose.
b
These intravenous fluids are administered separately and in addition to
muscularly every four to sixhours at 0.25U/kg. This is less
the insulin infusion when needed to compensate for continuing losses, labor-intensive compared with the hourly administration of
dehydration, and to maintain intravascular volume in the patient. regular insulin. Following the first dose of insulin, blood glu-
Source: Adapted from Macintire DK. Treatment of diabetic cose is checked hourly but then the frequency of monitoring
ketoacidosis in dogs by continuous low-dose intravenous infusion of
insulin. J. Am. Vet. Med. Assoc. 1993;202:1266–1272.
can be decreased depending on the duration of insulin action.
An hourly decline of 50mg/dl is ideal. If the concentration is
catheter is typically reserved for blood sampling. A separate dropping too rapidly, the veterinarian should be notified and
peripheral catheter, in addition to the central catheter, subsequent insulin dosages may be decreased.
should be maintained for the administration of dextrose-
Initiation of Longer-Acting Insulin
containing IV fluids. This is to avoid contamination of the
blood sample being obtained for glucose monitoring with Once the patient is eating and drinking, intensive insulin
dextrose-containing IV fluids that could artifactually plans are usually replaced by longer-acting insulin therapy.
increase the measured blood glucose concentration. If the
maintenance of a separate peripheral catheter is not possible
Box 73.1 Calculation of a Percent Dextrose Solution
or the administration of greater than 5% dextrose solutions
Using 50% Dextrose
necessitates administration through the central catheter (see
section on treatment of hypoglycemia below), a large pre- C1 × V1 = C2 × V2 where C = the concentration of a solution
sample should be obtained (5–10 ml of blood) prior to check- and V = the volume
ing the blood glucose. If there is any question about the (Dextrose 0.5) × (Volume of 50% dextrose required, ml) =
(Desired strength of solution) × (Volume of infusion, ml)
measured sample (i.e. suspicion of a falsely elevated level)
even with the large presample, a direct venipuncture blood Desired Strength of Solution Volume of Dextrose needed (ml)
=
sample should be obtained for comparison. 50% Dextrose Volume of Infusion (ml)
Blood glucose concentration should be monitored every
Consider making 1 l of a 2.5% dextrose solution
one to two hours in animals on insulin CRI, and changes in
insulin rate should be made based on each measurement. 1. Convert percentage to decimals
Intravenous insulin is typically administered until the 2. 0.025 Dextrose
=
X ml
patient can be switched to a longer-acting insulin product 0.50 Dextrose 1000 ml
in patients with diabetes mellitus or when insulin adminis- 0.025 (1000 ml) = 0.50 (X ml)
tration is no longer needed to maintain glycemic control. X = 50 ml of 50% dextrose
3. Add 50 ml of 50% dextrose to 950 ml (if you do not remove
the 50 ml from the total volume, the solution will be slightly
Intramuscular Insulin Techniques
less than 2.5% dextrose)
When given IM, regular insulin can be administered hourly
or less frequently depending on the technique chosen. The Consider making 500 ml of a 5% dextrose solution
hourly technique involves the IM administration of regular 1. Convert percentage to decimals
insulin and measurement of blood glucose every hour. The 2. 0.05 Dextrose X ml
usual initial dose for the IM insulin protocol is 0.2 U/kg of =
0.50 Dextrose 500 ml
regular insulin. After one hour, the blood glucose is 0.05 (500 ml) = 0.50 (X ml)
checked, and if it exceeds 250 mg/dl, 0.1 U/kg regular insu- X = 50 ml of 50% dextrose
lin is administered IM. This protocol is repeated on an 3. Add 50 ml of 50% dextrose to 450 ml
hourly basis as long as the level exceeds 250 mg/dl. Once
Glycemic Control 959
Several intermediate-acting and long-acting insulin prod- Specific Considerations when Administering Insulin
ucts are available, including neutral protamine Hagedorn Insulin is commercially available in 40, 100, and 500 U/ml
(NPH) insulin, purified porcine insulin zinc, protamine concentrations, which are designated U-40, U-100, and
zinc insulin, and glargine insulin. U-500, respectively [82]. Depending on the concentration
Purified porcine insulin zinc (Vetsulin®, Merck Animal of the insulin being administered, there are specific
Health, Rahway, NJ) is the only FDA-approved insulin for syringes, also labeled U-40, U-100, and U-500, that should
use in both dogs and cats. Glargine insulin (Lantus, Aventis be used. For example, glargine insulin, a U-100 insulin,
Pharmaceuticals, Bridgewater, NJ) and detemir (Levemir®, should be administered only with a U-100 syringe. It is
Novo Nordisk Inc., Plainsboro, NJ) are newer insulin ana- important to always check that the label on the insulin
logues being used in the management of diabetic compan- syringe matches the concentration of the insulin being
ion animals. Twice daily subcutaneous administration of administered.
both glargine and detemir have been investigated in dia- Insulin syringes are also available in different sizes includ-
betic dogs and cats and the studies suggest that it is safe ing 1, 1/2, and 3/10 cc (1, 0.5, and 0.3 ml) with different
and effective in the management of diabetes melli- gauge needles. Lines on the insulin syringes are units. For
tus [77–81]. Detemir is a more potent insulin in dogs and example, 1 cc insulin syringes are generally marked with a
starting insulin doses are much lower than for other insu- line for every two units, that is for 2, 4, 6, and 8. The 1/2-cc
lin products. Table 73.3 lists available insulin products and syringe is marked with a line for every unit. The 3/10-cc
current initial insulin dose recommendations in dogs syringe is marked with lines for every half or one unit.
and cats. Insulin should always be stored in a refrigerator, as freez-
ing and heat inactivate insulin in the bottle. The exceptions
to this rule are glargine and detemir, which may be stored at
Table 73.3 Insulin types and initial dosing recommendations. room temperature but away from direct heat and light once
opened. Unopened glargine and detemir should be stored in
Recommended initial dose the refrigerator. Once opened, whether refrigerated or not,
glargine should be discarded after 28 days and detemir after
Insulin Concentration Dog Cat
42 days according to the manufacturer. Currently, it has also
been a common recommendation that other insulin prep-
NPH U-100a 0.25–0.5U/kg every 1 unit/cat
12 hours every 12 hours arations be discarded after one month. However, many
Porcine U-40b 0.5 U/kg every 1–2 U/cat or veterinarians allow use of an opened bottle of insulin that
Zinc 12 hours 0.25–0.5 U/kg is refrigerated for up to three months before discarding.
(Lente) every 12 hoursc However, if clinical signs recur in a previously well-controlled
PZI U-40b Not recommended 0.4 U/kg or diabetic patient, loss of activity of the insulin could be the
1 U/cat every cause, and the insulin bottle should be replaced.
12 hours
Prior to drawing insulin into the insulin syringe, the bot-
Glargine U-100a 0.5 U/kg every 0.25–0.5 U/kg tle should be gently rolled between the palms of the hands
12 hours every 12–24 h
(15–20 times) to allow for uniform resuspension of the
Detemir U-100a 0.02–0.13 U/kg 0.25 U/kg insulin within the liquid. Failure to mix the insulin prop-
every 12 hours or every 12 hours
1 U/dog/dayd if BG erly could decrease its effectiveness. It is important not to
< 360 mg/dl shake the insulin bottle, as this could create small air bub-
0.5 U/kg every bles within the vial leading to inaccurate dosing.
12 hours if BG Always administer the type of insulin as designated by
> 360 mg/dl
the treatment orders. In other words, Vetsulin® (Merck
BG, blood glucose; NPH, neutral protamine Hagedorn; Animal Health) should not be substituted for NPH, as each
PZI, protamine zinc insulin. insulin product will have a different duration of action and
a
U-100: 100 units/ml
b effect in each individual patient.
U-40: 40 units/ml
c
A recommended starting dose is 0.25 U/kg twice daily if the blood
glucose concentration (BG) is 216–342 mg/dl, and 0.5 U/kg twice Glucose Monitoring
daily if the BG is > 360 mg/dl. Alternatively, a dose of 1 U/cat twice
When insulin is administered in the treatment of hypergly-
daily for cats weighing less than 4 kg and 1.5–2.0 U/cat twice daily for
cats weighing > 4 kg can be used to initiate therapy. cemia, blood glucose is monitored closely to prevent hypo-
d
Only one study evaluating the effect of detemir in diabetic dogs glycemia. During treatment of a patient with hyperglycemia,
currently exists in the veterinary literature. These dogs were given an the patient should be observed closely for neurologic signs,
initial starting dose of 1 U/dog. Bacause of its potency, dogs may be a
such as changes in mentation and seizure activity, which
greater risk for hypoglycemia. Fracassi F, Corradini S, Hafner M et al.
Detemir insulin for treatment of diabetes mellitus in dogs. J Am Vet could indicate hypoglycemia. If neurologic signs develop,
Med Assoc 2015;247(1):73–78. blood glucose should be checked.
Treatment of Hypoglycemia midazolam (0.2 mg/kg), or levetiracetam (20–30 mg/kg)

should be administered intravenously [84]. Phenobarbital
Acute hypoglycemia requires immediate therapy because
(2–4 mg/kg IV or orally) may be used for longer-term
the longer the hypoglycemic episode lasts, the greater the
seizure control. Severe hypoglycemia and prolonged sei-
potential for irreversible brain damage. Patients that are
zure activity can result in cerebral edema. Treatment for
presented on an emergency basis or that develop clinical
cerebral edema involves oxygen administration, eleva-
signs attributable to hypoglycemia during hospitalization
tion of the head 15–30 degrees above the horizontal
are often treated with an IV bolus of 50% dextrose
plane, and administration of hypertonic agents (Chapter
(0.25–0.5 g/kg). 50% Dextrose is very hyperosmolar and
70) [85]. Hyperosmotic agents such as mannitol and
ideally it is diluted to less than 10% with sterile water if
hypertonic saline do not cross an intact blood brain bar-
given through a peripheral IV catheter. This dose of dex-
rier and thus reduce cerebral edema by osmotically draw-
trose is often repeated as indicated by serial blood glucose
ing water out of the brain. Common doses are mannitol
measurements or until clinical signs are resolved. Dextrose
0.5–1 g/kg IV or 7.0–7.5% NaCl 3–5 ml/kg IV over
and dextrose-containing fluids should never be given
15–20 minutes.
subcutaneously.
Hypoglycemia caused by insulinoma can be very chal-
Following a bolus of dextrose, the patient may be placed
lenging to treat. Dextrose administration in these patients
on a CRI of 2.5–5% dextrose in crystalloid solutions. To
can trigger tumor secretion of insulin and rebound hypo-
make 1 l of a 2.5% dextrose solution, 50 ml of 50% dextrose
glycemia. Therefore, several other medications are availa-
can be added to 950 ml of fluids (total volume of 1 l). To
ble in the treatment of insulinoma with the effect of
make 1 l of a 5% dextrose infusion, 100 ml of 50% dextrose
supporting blood glucose by increasing endogenous glu-
is added to a 900 ml of fluid (remove 100 ml of fluids from a
cose production. Dexamethasone (0.5 mg/kg IV every
1 l bag). See Box 73.1 for instructions on how to calculate a
12–24 hours) is given to increase hepatic gluconeogenesis
percentage dextrose infusion.
and glycogenolysis as well as inhibit peripheral glucose
Both 2.5% and 5% dextrose infusions may be adminis-
uptake [86]. A CRI of the hormone glucagon with concur-
tered through a peripheral venous catheter. However,
rent dextrose infusion is an additional treatment for
when higher concentrations of dextrose (> 5% solution) are
insulinoma-associated hypoglycemia [87, 88]. Glucagon
needed to maintain a normal blood glucose concentration,
should be reconstituted with the provided diluent and
higher concentrations of dextrose (> 5% solution) may be
added to 1 l of 0.9% NaCl resulting in a solution with a
administered through a central line. This is because glu-
glucagon concentration of 1 μg/ml. This medication is usu-
cose infusions greater than 5% are irritating to the vascular
ally started at a dose of 5 μg/kg/minute and the infusion
endothelium and may result in thrombophlebitis [83].
dose may be increased as needed up to 20 μg/kg/minute to
Administering higher concentrations of dextrose solutions
maintain a concentration greater than 73 mg/dl [86, 87]. A
in a larger vein will help to decrease the incidence of
syringe pump should be used to allow for accurate dosing
thrombophlebitis. Alternatively, rather than increasing the
of glucagon. This medication cannot be given orally.
concentration of the dextrose infusion, the rate (ml/hour)
Finally, the drug diazoxide, which inhibits insulin release
of dextrose administration may be increased. This will
and stimulates hepatic release of glucose via gluconeogen-
allow for increased delivery of dextrose to the patient.
esis, is also potentially useful for treatment of hypoglyce-
Finally, 5% dextrose in water may also be administered IV
mia in dogs with insulinoma. Diazoxide also causes
to supplement dextrose but should be given cautiously, as
adrenomedullary release of epinephrine, which increases
profound hyponatremia can develop if large volumes are
insulin resistance. The dose ranges from 10 to 40 mg/kg/
administered. The goal of glucose supplementation is usu-
day orally and is generally titrated as indicated by the blood
ally to maintain the blood glucose within the normal physi-
glucose concentration [86]. The most common adverse
ologic range, as hyperglycemia can have deleterious
effect seen with use of this drug is gastrointestinal upset,
consequences.
including diarrhea, vomiting, and anorexia, which may be
In addition to IV dextrose supplementation, hypoglyce-
minimized by administering this medication with
mic patients are often fed as soon as possible, which will
food [88].
help to support blood glucose concentration. However,
Blood glucose should be monitored closely, at least every
feeding may not be recommended in patients with hypo-
two hours, or more frequently, in all patients following a
tension, low body temperature, vomiting, or other condi-
hypoglycemic episode until it can be established that the
tions common in urgently and critically ill animals.
primary cause has been resolved or effectively controlled.
If seizure activity is present in a patient with low blood
Any patient that presents with symptomatic hypoglycemia
glucose and does not resolve despite attaining euglycemia,
should be hospitalized until the patient is eating and drink-
anticonvulsant therapy such as diazepam (0.25–0.5 mg/kg),
ing normally.
References 961
Conclusion blood glucose cage-side in the hospital. Continuous glu-

cose monitoring devices allow for non-invasive minute-to-
Blood glucose monitoring is an important aspect in the minute monitoring of interstitial glucose concentration,
management of acutely and critically ill companion ani- potentially allowing for quicker detection and treatment of
mals. The prompt recognition and treatment of both hyper- aberrations in blood glucose. Glycemic control in critically
glycemia and hypoglycemia are essential for the veterinary ill patients is achieved in most patients with the use of
technician and clinician. There are a number of ways to insulin and/or dextrose. It is extremely important for both
measure blood glucose concentrations in veterinary veterinary clinicians and technicians to understand the
patients; however, portable blood glucose meters and POC clinical indications for their use as well how to administer
analyzers are most commonly used to quickly measure these medications safely and effectively to our patients.
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965
74
Critical Nursing Care of the Neonate

Autumn Davidson and Janice Cain
The neonatal period, for purposes of this chapter, is the membrane oxygenation, hypothermic therapy) or even in
first two weeks of life, although some authors refer to the some cases available for other veterinary species (e.g. no
immediate (moments to hours) postpartum period as canine surfactant is available, no studies exist on bovine or
the newborn period. Neonatal mortality rates are greatest synthetic substitution). Evidence and consensus-based
during the first week of life, especially the first 48 hours; guidelines in the veterinary literature are limited. Another
reportedly the average can be as high as 18–30% [1–3]. factor that must be considered is the cost for substantial
Veterinary intervention in the prenatal, parturient, and medical intervention in the neonatal period. This choice is
postpartum periods can increase neonatal survival (and usually made by the breeder, as the neonate is not yet
hence reduce the need for admission to the critical or adopted into a family for which a strong human/animal
intensive care unit) by controlling or eliminating factors bond will exist. It is this bond that is the usual driving factor
contributing to puppy and kitten morbidity and mortality. for the decision by most owners to pursue significant inten-
Poor prepartum condition of the dam, dystocia, con- sive medical care for their pets. While veterinarians and staff
genital malformations, genetic defects, low birth weight, can be dismayed by the reality of this situation, it is impor-
postnatal injury, environmental extremes, malnutrition, tant to consider the whole picture from the breeder’s
parasitism, and infectious disease all contribute to neona- viewpoint, including emotions, time, energy, and other costs
tal morbidity and mortality. Veterinary intervention involved in raising a litter. The discussion between the
improves neonatal survival by managing pregnancy healthcare team and owner about costs and expected
(obstetrics) including ovulation timing or gestational outcomes should be approached in a nonjudgmental,
aging, labor and delivery (vaginal or surgical) to reduce informative manner.
stillbirths and fading neonates, optimizing nutrition of
the dam and neonates, controlling parasitism, and reduc-
ing infectious disease. Promoting proper genetic screen- Small-Animal Neonatal Physiology
ing for selection of breeding stock minimizes inherited
congenital defects. Recognition and appropriate medical The neonatal cardiovascular system is characterized by low
and/or surgical management of dystocia are critical to pressure, low volume, and low peripheral resistance requir-
neonatal survival. Medical management should be based ing a high heart rate, central venous pressure, cardiac output,
on objective criteria (tocodynamometry as well as Doppler and plasma volume for homeostasis. The cardiac sympa-
or ultrasound fetal heart-rate evaluation), and response to thetic nervous system and baroreceptor development are
therapy (calcium gluconate, oxytocin); surgical manage- immature. Myocardial hypoxemia results in bradycardia and
ment should be timely, whether elective or emergent anoxia results in hypotension. Chest wall compliance is stiff
(Figure 74.1). and carotid body chemoreceptors immature, predisposing
Care of the small-animal neonate in the clinical setting is to hypoventilation and hypoxemia, which can then pro-
challenging. Small-animal neonates are very small and frag- mote bacterial translocation [4]. Premature neonates (less
ile. Veterinary neonatal technology has not achieved the than around 62days of gestation counting from the luteiniz-
advances available to human neonatologists (e.g. prepartum ing hormone surge) can lack surfactant [5]. Neonates
diagnostics/intervention, ventilator therapy, extracorporeal have red blood cell macrocytosis and polychromasia, are
966 Critical Nursing Care of the Neonate
Monitor Sensor
(a) (b)
(c) (d)
(e)
Figure 74.1 (a) Tocodynamometry unit. (b) Monitoring uterine activity in a Chihuahua bitch in stage II labor. (c) Tocodynamometry
results showing normal myometrial contraction (x-axis strength of contraction in mm Hg, Y-axis time in minutes). (d, e) Fetal
heart-rate monitoring with a handheld Doppler.
hemoconcentrated at birth, then develop an anticipated pedi- repercussions later in life [6]. Intestinal motility is dependent
atric anemia. Mucous membrane color in the neonate tends upon a pressure gradient rather than myoelectrical activity;
to be red and not representative of pallor or shock. Decreased ileus, bacterial overgrowth and intussusception can result.
renal and hepatic metabolic and excretory capacity persist Neonates exhibit essential reflexes (rooting, righting, heat
until four to six months of age; both glucosuria and proteinu- seeking, suckling); electroencephalography is representative
ria are normally present. Blood pressure dictates renal blood of sleep, and neurotransmitters are immature. Neonates have
flow. Blood urea nitrogen, creatinine, and urine specific grav- a lower nociceptive threshold than adults [7]. Their body
ity are low. Sterile at birth, intestinal flora are acquired during weight to surface area makes chilling more likely. Absorption
and following birth [4]. Human neonates born by cesarean of oral drugs is altered by high gastric pH and increased
section fail to acquire typical/normal intestinal flora immedi- mucous content, decreased gastrointestinal motility, and
ately as they would have from vaginal delivery; this can have decreased bile production. Drug distribution is impacted by
Neonatal Resuscitation 967
neonatal increased body water content and decreased fat

content. Lower plasma proteins decrease drug binding. The
blood brain barrier is incomplete [4].
Cesarean Section: Emergency (Surgical

Management of Dystocia) or Elective
Most commonly, neonates are admitted to critical or inten-

sive care after unsuccessful management of dystocia result-
ing in an emergency cesarean section, less commonly
following an elective section (recommended for brachyce-
phalic and giant breeds with high incidence of dystocia,
and singleton litters), and sometimes after medically man- Figure 74.2 Bulldog clamp on umbilicus intraoperatively.
aged dystocia. Once the decision for cesarean section has
been made, time is of the essence. A well-organized team expeditiously and efficiently. Exposing only part of the
will have the operating room prepared during the time of uterus as needed to deliver fetuses while maintaining a
medical evaluation and management of dystocia; the team sterile field, is helpful, especially in a large dog with a large
can then proceed quickly. Factors to consider for positive litter. A hysterotomy incision is made on either side of the
outcome for both the dam and neonates include adequate uterine bifurcation. Fetuses are delivered quickly and
staffing and veterinary expertise, optimal anesthesia, surgi- passed to the recovery team. The umbilicus can be clamped
cal efficiency, and rehearsed neonatal resuscitation. immediately, or if preferred, the placenta can be delivered
Intraoperative intravenous (IV) balanced crystalloids are attached to the fetus and managed by the recovery team
advised. (see Neonatal Resuscitation, below) (Figure 74.2). Similarly,
There are numerous reports of anesthetic protocols for the surgeon may tear fetal membranes, or may defer to the
cesarean section; the authors prefer the following: team (Figure 74.3). Usually, all fetuses can be delivered
Preanesthetic glycopyrrolate as an anticholinergic (antici- from a single hysterotomy incision, but a second incision
pate vagal stimulation from manipulation of a gravid may become necessary for delivery of fetuses cranial in the
uterus), owing to its limited placental transfer, combined opposite horn.
with an opioid sedative (75% of usual dose/nonpregnant In most cases, all fetuses can be delivered within 15 min-
body weight) to lessen anxiety and provide analgesia for utes from the time of anesthetic induction. This promotes
the dam [8, 9]. Preoxygenation for three to five minutes is prompt recovery of the neonates; movement, breathing,
advised if the dam is not distressed by its administration; and vocalization are observed nearly immediately after
this is facilitated by preanesthetic sedation. As much surgi- delivery. After all fetuses are delivered, inhalant anesthesia
cal prepping as possible should be performed before anes- (isoflurane or sevoflurane) can be added to the regimen
thetic induction. Anesthetic induction is achieved quickly and surgery completed in a routine manner. The authors’
with IV propofol (4–7 mg/kg IV over 60–90 seconds) to per- opinion is not to perform ovariohysterectomy at the time of
mit endotracheal intubation and ventilation. Repeat cesarean section unless indicated by the condition of the
administration of propofol as mini-boluses (1.7–3 mg/kg uterus (devitalized/necrotic) because of the higher risk of
over 60 seconds) as needed to maintain a light surgical maternal mortality from postoperative hemorrhage and
plane of anesthesia. Alfaxalone (1.5–4.5 mg/kg/60 sec- potential prolongation of operative/anesthetic/recovery
onds)/maintenance (1.1–2.2 mg/kg/60 seconds) is an alter- time. A single dose of perioperative antibiotic appropriate
native induction agent. A local anesthetic block in the for fetuses/neonates (e.g. a cephalosporin) is advised.
region of the intended ventral midline incision using bupi-
vacaine 0.25% (2.5 mg/ml) or 0.5% (5 mg/ml) at 1–2 mg/kg,
lidocaine 2% (20 mg/ml) at 1–5 mg/kg, or a combination Neonatal Resuscitation
(lidocaine 2%, equal volume 0.5% bupivacaine) is advised,
reducing the amount of general anesthetic needed during Resuscitation is indicated for most neonates delivered by
surgery by providing analgesia [10]. cesarean section because of maternal (and fetal) anesthe-
The surgical technique employed during the cesarean sia. Neonatal vigor can also be negatively impacted by
section depends in part on the surgeon’s preference, litter dystocia, even with an eventual vaginal delivery, and may
size, condition of the uterus, and status of the dam and require intervention; if the dam’s actions fail to stimulate
neonates; the authors’ follows. Laparotomy is performed respiration, vocalization, and movement within one
(a) (b)
Figure 74.3 (a) Amniotic membrane over a neonate’s face. (b) Tearing the amniotic membrane intraoperatively.
minute of birth intervention is advised. Maintaining a when a 27-gauge or actual acupuncture needle is inserted
neonatal resuscitation kit is optimal (Protocol 74.1). into the nasal philtrum at the base of the nares and rotated
Neonatal resuscitation techniques are based on the same when cartilage is contacted (Figure 74.6). GV26 reportedly
principles (airway, breathing, circulation) as any cardio- increases blood pressure and the brain inspiratory
pulmonary resuscitation with one modification; ventila- centers [13].
tion takes precedence over chest compressions A detectable improvement in heart rate (normal around
(Protocol 74.1). 180–200 beats/minute) should follow successful ventila-
Neonates should be received into a warm towel, their tory support; myocardial hypoxemia is the most common
amniotic membranes should be immediately removed cause of neonatal bradycardia (< 150 beats/minute) or
from the muzzle, and the proximal airway promptly cleared asystole. The use of doxapram (sublingually or intramus-
by gentle suction with a bulb syringe or DeLee aspirator, cularly) as a respiratory stimulant is unlikely to improve
while the neonate’s head is lowered to enhance drainage hypoxemia associated with hypopnea and resultant
(Figure 74.4). Neonates should not be swung to clear air- hypoventilation and is not currently recommended [10].
ways because of the potential for concussion and resultant Atropine is also not advised in neonatal resuscitation [10].
cerebral hemorrhage [11]. Prolonged airway suction can be The mechanism of neonatal bradycardia is hypoxemia-
harmful [12]. induced myocardial depression; it is not vagally mediated,
After confirming a heartbeat (palpation, auscultation, and anticholinergic-induced tachycardia can exacerbate
Doppler), dry and stimulate the neonate to promote respi- myocardial oxygen deficits. Persistent hypopnea warrants
ration; brisk rubbing of the muzzle and thorax stimulates reevaluation of effective proximal airway clearance (no
sensory respiratory receptors. Movement of the neonate fluid present) and positive pressure ventilation (thoracic
and vocalization are positive signs, as spontaneous breath- excursions). If marked bradycardia (< 30 beats/minute) or
ing and vocalization at birth are positively associated with asystole is present, direct transthoracic cardiac compres-
survival through seven days of age. Reversal of any nar- sions (around 90–120 beats/minute) are advised as the
cotic used in the dam’s anesthetic protocol should be con- first step (two-finger lateral thoracic compressions unless
sidered (naloxone 0.0001 mg/g intramuscularly or it is a chondrodystrophic breed, then sternal); positive
subcutaneously) [10]. Ventilatory support should be initi- pressure ventilation should also continue. Cardiac com-
ated if hypopnea is evident, beginning with constant flow- pressions should be coupled with ventilation (3 : 1), due to
by O2 (40–60%) delivered by face mask. If this is ineffective neonatal myocardial oxygen requirements. Epinephrine
after one to two minutes, positive pressure ventilation 0.00001–0.0001 mg/g body weight (e.g. a 500-g neonate
(around 30–60 breaths/minute) with a snugly fitting mask, gets 0.05–0.5 ml of 1 : 10 000 [0.1 mg/ml] epinephrine solu-
or endotracheal intubation and rebreathing bag (using a tion) IV or intraosseously (IO) can be considered, as well
2-mm endotracheal tube or a 12- to 16-gauge IV catheter), as bicarbonate (guided by blood gas analysis ideally, sam-
is advised (Figure 74.5). Anecdotal success with Jen Chung pling can be challenging) at 0.001–0.003 mEq/g body
acupuncture point stimulation (GV26) has been claimed weight [10, 14]. Intracardiac injections are problematic as
Protocol 74.1 Neonatal Resuscitation Protocol

Equipment Resuscitation Protocol
● Syringes (TB) Airway, Breathing, and Circulation (ABC)
● 20–25 gauge needles, 18–24 gauge over-the-needle 1) Clear muzzle of amniotic membranes and airway of fluids
catheters, EZ-IO® catheters by suction (DeLee aspirator, bulb syringe). Do not swing.
● Drugs: Place with head below thorax to improve drainage.
⚪ Epinephrine (1 mg/ml) to be freshly diluted 1 : 9 with 2) Gentle brisk towel drying to stimulate respiration; pro-
sterile water or saline to 0.1 mg/ml solution vide flow-by oxygen as necessary.
⚪ 50% dextrose to be freshly diluted with sterile water 3) If not breathing, start positive pressure ventilation
to 2.5–5% using snug face mask and oxygen.
⚪ Ceftiofur 4) If heart rate is slow, improve airway clearance/ventila-
⚪ Lidocaine freshly diluted with dextrose 5% in water, tion/oxygenation.
0.9% sodium chloride, or lactated Ringer’s solution
Is Resuscitation Effective?
to 1%
1) Is the puppy vocalizing?
● Oxygen sources
2) Is the mucous membrane color improving?
● Suction (pediatric bulb syringes, DeLee mucus traps)
3) Is the puppy moving?
● Small face masks
4) Keep in mind that even a nonviable puppy can have
● Towels (small)
red color in the mucous membranes from the maternal
● Heat sources (Baer Hugger, warm water blanket, infrared
circulation and fetal hemoglobin.
lamp, hair dryer, warm IV fluid bags)
5) Acupressure (GV26) if hypopneic: 27-gauge or acupuncture
● Puppy box (insulated) with heat support
needle into the nasal philtrum, insert and turn.
● Multiple clean mosquito forceps and small scissors
6) External cardiac compression (lateral unless chondro-
● 3-0 monofilament suture for umbilical cord ligation
dystrophic breed, then sternal) if persistent bradycar-
● Tincture of iodine 2%
dia (< 60 beats/minute despite interventions) at 3 : 1
● Shallow stainless-steel bowls for warm water baths
compression/ventilation ratio (90 : 30).
● Pediatric/neonatal stethoscope
● Doppler Medications if ABCs Fail
● Neonatal gram scale ● Epinephrine 0.00001–0.0001 mg/g body weight IO/IV
● ± bicarbonate 0.001–0.003 mEq/g body weight IO/IV
● Atropine not advised

Ceftiofur Protocol
● Doxapram not advised
● Reconstitute vial with 20 ml sterile water to 50 mg/ml
solution. Prolonged Problematic Case
● Stable for 12 hours at room temperature (once 1) Hypothermic? Warm water bath at 95–98°F
reconstituted). 2) Hypoglycemic? Dextrose 2.5–5.0% IV, IO
● Stable for 7days if refrigerated (once reconstituted).
Reasons to Stop
● Stable for 8 weeks if frozen (once reconstituted).
1) No pulse after 10 minutes (check with Doppler or
● Freeze in 1 ml increments in labeled RTT.
pediatric stethoscope).
● Neonatal dose is 2.5 mg/kg (0.0025 mg/g) SC twice
2) Agonal breathing for more than 20 minutes.
daily for 3–5 days.
3) Severe congenital defect (client consent).
they are markedly traumatic. Venous access in the neonate distress. Replacement is not available for the canine or
is challenging; the single umbilical vein is one possibility feline neonate and premedication of the dam with corticos-
if not already thrombosed; the jugular vein another. The teroids does not induce its production [15].
proximal humerus, proximal femur, and proximomedial Hypothermia and hypoglycemia can complicate resusci-
tibia are potential intraosseous sites for effective drug tation efforts. Neonates cannot thermoregulate (shiver).
administration (Box 74.1; Figure 74.7). Chilled neonates will respond suboptimally to resuscita-
Continued hypopnea and hypoxia can indicate that the tion. Loss of body temperature occurs rapidly when a neo-
neonate is premature; prematurity is complicated by a lack nate is damp post-delivery. Keeping the neonate warm is
of surfactant and contributes to irreversible respiratory important both during resuscitation and in the immediate
(a) (b) (c)
Figure 74.4 (a) DeLee aspirator containing neonatal airway fluid. (b) DeLee in use in proximal airway of neonate. (c) Human preemie
bulb syringe.
(a) (b)
Figure 74.5 (a) Flow-by oxygen delivered by face mask. (b) Positive pressure ventilation delivered with snugly fitting face mask.
(a) (b)
Figure 74.6 (a) GV26 acupuncture site, cadaver. (b) GV26 acupuncture, neonate.
Box 74.1 Intraosseous Catheterization

Sites Complications
● Trochanteric fossa of femur ● Bilateral cortical perforation.
● Wing of ilium ● Growth plate perforation.
● Proximal humerus ● Trauma/fracture (unlikely due to immature calcification).
● Lateral tibia ● Short catheter lifespan (~ 24 hours); easily dislodged
(replace with IV catheter in 24 hours if continued IV
Technique access necessary).
● Bacterial contamination, bone necrosis, osteomyelitis.
1) Select site, clip/aseptic preparation.
● Slow infusion rate.
2) Perform lidocaine 1% block 0.001 mg/g SC ± stab
incision.
Advantages
3) Insert needle with twisting motion through 1 cortex.
4) 18–22 gauge spinal or hypodermic needle. ● Quick access.
5) Evaluate placement with 0.2–0.5 ml non-heparinized ● Rapid distribution, equal efficacy as IV route.
0.9% saline infusion. ● Appropriate for any isotonic solution given IV.
6) Apply aseptic bandage.
(a) (b)
(c)
Figure 74.7 (a) Proximal humerus intraosseous catheter in place, cadaver. (b) Proximal femur trochanteric fossa, cadaver. (c) Cephalic
catheter in septic neonate.
postpartum period. Working under a heat lamp or within a a 2.5–5.0% (25–50 mg/ml) dextrose solution. Single admin-
Bair Hugger® (3M, Maplewood, MN) warming device is istration of parenteral glucose is adequate if the neonate
helpful. During a prolonged resuscitation, placing a chilled improves and can then be fed or nurses. Because of the
neonate’s body into a warm water bath (95–99°F; 35–37°C) potential for phlebitis if administered intravenously, 50%
for a few minutes can improve response (Figure 74.8). dextrose solution should only be applied to mucous mem-
Prompt drying with thermal support should follow. After branes; however, circulation must be adequate for any
successful resuscitation, neonates should be placed in an absorption from the mucosa. Neonates repeatedly adminis-
insulated box (an insulated box with ventilation is ideal if tered dextrose should be monitored for hyperglycemia
an incubator is not available) with warmed but not exces- because of immature metabolic regulatory mechanisms. If
sively heated bedding until they can be placed with their a neonate is too weak to nurse, a mixture of a warmed, bal-
dam for nursing (Figure 74.9). anced crystalloid (half-strength saline) and 2.5% dextrose
Neonates lack glucose reserves and have minimal capac- may be administered by gavage (0.25–1 ml) until the neo-
ity for gluconeogenesis. Providing energy during prolonged nate can be fed or nurses (Protocol 74.2). Note that 5% dex-
resuscitation efforts becomes critical. Clinical hypoglyce- trose in lactated Ringer’s or Normosol® (ICU Medical, Lake
mia involves blood glucose levels less than 80 mg/dl and is Forest, IL) solution is hypertonic and contraindicated
best treated with IV or IO dextrose at a dose of 0.1–0.2 ml of unless volume expansion is desired. Subcutaneous
(a) (b)
Figure 74.8 (a) Neonate receiving chest compressions while in warm water (around 98.6°F; 37°C) bath. (b) Neonate in warm water
bath receiving flow-by oxygen.
(a) (b)
Figure 74.9 (a) Styrofoam (insulating) neonatal receiving box with warm air bag post-resuscitation. (b) Human neonatal incubator.
Protocol 74.2 Placement of a Stomach Tube in Neonates

Equipment and mark the tube. This identifies the length to reach
the distal esophagus/stomach.
● Syringes (12 cc for mild, 3 cc for tube placement
2) Lightly lubricate the distal portion of the tube without
confirmation)
occluding the openings.
● Soft red rubber or silicone feeding tube (5–10 Fr),
3) Gently introduce the tube into the oropharyngeal area,
closed end with side ports; use the largest size that can
which should stimulate a suckle or swallowing reflex.
be easily placed through the esophagus to lessen the
The tube can be gently advanced to the mark.
chance of inadvertent airway introduction
4) Test tube placement (esophageal/gastric vs. tracheal):
● Sharpie pen or adhesive tape (mark depth of tube for
a) Place the exposed end of the tube in a shallow
insertion)
bowl of water. If bubbling results, the tube is likely
● Water-soluble lubricant
in the airway. Remove and reinsert.
● Bowl
b) Infuse a small amount of 0.9% saline or water
● Dam’s/conspecific colostrum, milk, or commercial
(1–2 ml) through the tube and monitor for strug-
formula
gling/coughing. Remove and reinsert if occurs.
5) Slowly inject colostrum, milk, or formula (warmed to
Technique
approximately body temperature; 95–99°F; 35–37°C);
1) Place neonate in dorsal recumbency on a flat, padded monitoring for any distress. Volume fed should be around
surface. The cranial portion of the neonate can be half stomach capacity, which is 4–5ml/100g neonate
moderately elevated (similar to the normal nursing weight; smaller, more frequent feedings are best.
position). Measure the distance from the rostral muz- 6) Follow by stimulation to urinate, defecate if less than
zle to just beyond the last rib with the feeding tube 14 days of age.
APGAR Scoring
APGAR scoring in human neonatal resuscitation is
routinely employed at one and five minutes after birth to
measure neonatal viability in the first minutes of life
objectively. It has been described in small-animal neona-
tal resuscitation. The authors recommend the term
APVAR as small-animal neonates do not grimace
(Box 74.2). One study evaluated heart rate, respiratory
effort, reflex irritability, mobility, and mucus membrane
color five minutes after birth and found that lower scores
correlated with higher mortality two hours after
birth [17]. Another study evaluated heart rate, respira-
tory effort, reflex irritability, mobility, and mucus mem-
brane color as well as umbilical vein lactate level. The
study found that the presence of lactate was predictive
of neonatal mortality within 48 hours [18]. Dystocia or
anesthesia-associated hypoxia, followed by anaerobic
glycogenolysis and metabolic acidosis, has been found to
Figure 74.10 Subcutaneous abscess secondary to dextrose
administration. be a major contributor to intrapartum mortality in many
species; adaptive mechanisms (lower metabolic rate,
low body temperature) may contribute to neonatal
administration of glucose solutions can result in abscessa- hypoxia tolerance [19]. A later study evaluated evaluat-
tion and is not advised (Figure 74.10). Colostrum acquired ing general vitality (mucous membrane color, heart rate,
from the dam can be administered orally by gavage respiratory rate), irritability reflex and mobility evalua-
(0.25–1 ml) every 15–30 minutes until the neonate is capa- tion, rectal temperature, glucose, β-hydroxybutyrate,
ble of suckling. Colostrum supplemented neonates have a lactate, and hydration status (urine specific gravity)
lower incidence of necrotizing enterocolitis [16]. between 10 minutes and eight hours after birth, finding
or to remove the fetus and placenta as a single unit deliv-

Box 74.2 Veterinary Small Animal APVAR
ered to the recovery technician/nurse. Removal of the fetal
(Appearance, Pulse, Vocalization, Activity, Respiration)
membranes by the surgeon is also variable. Some advocate
Scoring retaining the placental blood flow/umbilical patency to
avoid asphyxiation before respiration is initiated [21]. In
A Appearance (mucous membrane color): 2 = pink, any case, resuscitation should always take precedence over
1 = blue or pale, 0 = very blue/pale placental/umbilical care unless hemorrhage from the
P Pulse/heart rate: 2 = normal (~ 200 bpm), 1 = slow; umbilicus exists. Following successful resuscitation, the
0 = none umbilicus of neonates should be double clamped, trimmed
V Vocal/crying: 2 = immediate, 1 = minimal, 0 = none to 1 cm from the body wall, ligated and then saturated with
A Activity: 2 = moving vigorously, 1 = weakly, 0 = limp 2% tincture of iodine to reduce contamination and prevent
R Respiration: 2 = normal, 1 = intermittent, agonal, ascent of bacteria into the peritoneal cavity (omphalitis,
0 = none peritonitis); the alcohol-based tincture of iodine promotes
faster desiccation of the umbilicus (< 24 hours) than water-
Additional Notes based betadine (Figure 74.12).
● A: normal physical exam
● B: meconium significant Postnatal Support
● C: physical anomaly
● Vital neonate score 8–10 Thermal support during this period is important and can be
● Fair neonate score 6–8 accomplished with a warm air blanket, hairdryer on a low
● Poor neonate score < 6 setting, or overhead heat lamps most effectively
(Figure 74.13). Post-resuscitation nursing should be encour-
aged for immediate acquisition of colostrum. This can be
accomplished even while the dam is recovering from anes-
thesia with appropriate direct supervision from a knowl-
edgeable technician/nurse or breeder (Figure 74.14).
Removal of any residual antiseptic from the dam’s mam-
mary skin avoids contact dermatitis in the neonates
(Figure 74.15). Neonates should be stimulated by rubbing,
and placed on a nipple from which a small amount of colos-
trum has been expressed, and should be encouraged to
suckle. The neonate’s mouth can be opened gently and
placed on a nipple; the taste of colostrum can improve suck-
ling effort. Gently stoking the dorsum of a neonate against
the fur simulates the dam’s grooming and results in improved
effort to latch on and suckle. Weighing neonates with a gram
scale before and after this first nursing confirms effective
Figure 74.11 Cyanotic neonate and normal littermate. suckling. They should then be placed in the above-mentioned
Source: Courtesy of Dr. P. Olson.
warm box while the dam continues to recover. Following
anesthesia, most dams are uncoordinated and lack normal
low vitality, relative hypoglycemia, and low birth weight maternal instincts for 12–24 hours; they should always be
to be predictive of increased neonatal mortality under supervision when with their neonates.
(Figure 74.11) [20].
Neonatal Examination
Management of the Umbilicus And Placenta
Debate exists concerning the management of the umbili- Immediately post-resuscitation, a quick, thorough physical
cus and placenta in the immediate postpartum/post- examination of the neonate should be performed. This will
cesarean section period. Bitches tend to ingest the placenta determine whether the neonate is vital and normal and can
and nip the umbilical cord immediately after delivery, fol- be reunited with the dam for supervised nursing with the
lowed by removal of the fetal membranes by licking. The goal of eventual discharge to the owner’s care, or whether
surgeon’s preference may be to clamp and ligate the umbil- further critical intervention is indicated. Vital signs should
icus prior to removing the neonate from the surgical field, be obtained (Table 74.1). The head, oral cavity, nares, hair
Neonatal Examination 975
(a) (b)
Figure 74.12 (a) Application of 2% tincture of iodine (“dunk”) to ligated umbilicus. (b) Normal appearance of umbilicus after ligation
and dunking.
coat, limbs, digits, umbilicus, anus, and urogenital struc-

tures should be visually inspected. In the normal neonate,
the mucous membranes are reddish pink and moist, a suckle
reflex is present (stronger is better), the coat full and clean,
and the urethra and anus patent (Figure 74.16). The eyelids
and ear canals are closed. External genitalia should not be
ambiguous or malformed (Figure 74.17). Canine testes
descend after six weeks of age, feline testes are intrascrotal at
birth but very small. Urination can be stimulated by gently
dabbing the vulva or prepuce, and defecation (meconium or
first stool) by dabbing the anus with a fresh, moistened cot-
ton ball. The thorax should be auscultated; vesicular breath
sounds and a lack of murmur are normal; subtle flow mur-
murs, if present, should resolve within 24–48 hours.
The abdomen should be pliant and not painful, and the
Figure 74.13 Judicious use of overhead warm air for thermal
umbilicus non-patent. Muscle tone should be strong.
support and flow-by oxygen during resuscitation/umbilical care.
(a) (b)
Figure 74.14 (a) Assisted first nursing. (b) Continued nursing during the dam’s recovery.
Figure 74.15 Contact dermatitis; neonates’ dorsal nasal

planum resulting from exposure to residual preoperative
antiseptic while nursing.
Table 74.1 Normal values of body temperature, heart

and respiratory rates in the newborn. Figure 74.17 Anogenital malformation.
Vital sign Puppies Kittens
Body 95–98°F 95–98°F (35.0–37.2°C)

temperature (35.0–37.2°C)
Heart rate 200 beats/minute 200–250 beats/minute
Respiratory rate 10–18 breaths/ 10–18 breaths/minute
minute
Figure 74.18 Fading neonate; hypothermic, hypovolemic,

lethargic.
Figure 74.16 Evaluating the neonatal suckle reflex. Neonatal Diagnostics
A normal neonate will squirm and vocalize when exam- Only the minimum amount of blood to accomplish the per-
ined, will attempt to right itself if placed on its side or dor- tinent tests required in the critically sick neonate is drawn
sum, and will crawl and root to find the dam. Seeking and (Box 74.3). Typically, packed cell volume/total solids, blood
“piling up” with littermates conserves heat. Successful glucose, blood urea nitrogen and a blood smear provide a
nursing is followed by sleeping quietly; occasional twitch- minimal data base. A complete blood count, chemistry
ing is normal. Neonates awaken and seek to nurse fre- panel, urinalysis, and coagulation testing are reserved for
quently (every 10–20 minutes). Continuous crying, limp cases requiring more diagnostics. Normal neonatal labora-
muscle tone, cold extremities, and a poor suckle reflex indi- tory values are not the same as for adults; appropriate refer-
cate problems (Figure 74.18). ence ranges have been published (Tables 74.2–74.8) [37].
Early Neonatal Problems 977
microscopically to avoid false conclusions. For example,

Box 74.3 Neonatal Sampling
the gross lesions of bacterial septicemia mimic canine her-
pes and can be misleading. Ideally samples of lung, thy-
● Blood sampling must not exceed 10% of total blood
mus, umbilicus, kidney, and liver should be submitted, in
volume/day (0.075 ml/g body weight; e.g. 3.75 ml
addition to any other suspicious tissues.
from a 500-g neonate/day):
⚪ Minimum volume required for testing advised.
⚪ Use appropriately small collection tubes contain-
ing anticoagulants (EDTA or heparin for whole- Early Neonatal Problems

blood testing to avoid dilutional errors).
● Jugular vein or (larger neonates) cephalic vein sam- Neonatal mortality occurs most commonly in the first
pling optimal; 25-gsauge needle; minimize alcohol seven days of life. The most common and significant
due to cooling effect; butterfly catheter or tuberculin acquired neonatal problems are hypoxia (addressed previ-
syringe preferable. ously during resuscitation), hypothermia and hypoglyce-
● Needle stick of foot pad acceptable if unable to mia. Neonatal dogs and cats lack thermoregulatory
acquire IV sample. mechanisms until four weeks of age, so the ambient tem-
perature must be warm enough to facilitate maintenance
of a body temperature of at least 97°F (36°C), this is most
Necropsy of a neonate dying without obvious cause is critical with orphans lacking maternal companionship or
always warranted to provide proper veterinary care of the small litter sizes (Box 74.4). Hypothermia negatively
littermates, and clients should be advised (tactfully, ahead impacts immunity, nursing, heart rate, and digestion.
of time) to refrigerate (not freeze) deceased neonates and Post-resuscitation exogenous heat should be supplied
present them promptly for evaluation. Postmortem evalua- best in the form of an adjustable overhead heat lamp.
tion at commercial laboratories can be prohibitively expen- Heating pads and warm air blankets run the risk of burn-
sive; however, clinicians can more economically perform ing or overheating neonates which are incapable of mov-
the necropsy and submit pertinent tissues for histopathol- ing away from excessively hot surfaces. The heat source
ogy (with or without culture, serology, or polymerase chain should be focused on one section of the nest box, enabling
reaction, PCR). If an obvious cause for death is not seen the dam to move away if too warm (Figure 74.19). Unlike
grossly (i.e. crushed or suffocated neonate, obvious resuscitation warming, chilled older neonates must be
anatomic defect) tissues should always be evaluated rewarmed slowly (30–60 minutes) to avoid peripheral
Table 74.2 Puppy biochemical parameters from birth to approximately eight weeks of age.
Weeks 1–2 Weeks 4–5 Weeks 7–8
Biochemical parameter Days 1–3 Days 8–10 Days 28–33 Days 50–58
Albumin (g/dl) 1.76–2.75 1.71–2.5 2.17–2.97 2.38–3.22

Alkaline phosphatase (iu/l) 452–6358 195–768 153–490 153–527
Alanine transaminase (iu/l) 9.1–42.2 4.1–21.4 4.3–17.4 10.3–24.3
Bilirubin (mg/dl) 0.04–0.38 0.01–0.18 0.02–0.15 0.01–0.11
Blood urea nitrogen (mg/dl) 29.5–118 29.1–66.7 13.1–46.2 16.8–61.4
Calcium (mg/dl) 10.4–13.6 11.2–13.2 10.4–13.2 10.8–12.8
Cholesterol (mg/dl) 90–234 158–340 177–392 149–347
Creatinine (mg/dl) 0.37–1.06 0.28–0.42 0.25–0.83 0.26–0.66
Gamma-glutamyltransferase (iu/l) 163–3558 – – –
Glutamate dehydrogenase (iu/l) 1.8–17.0 0.2–17.7 1.2–9.0 1.6–7.3
Glucose (mg/dl) 76–155 101–161 121–158 122–159
Total protein (g/dl) 3.7–5.77 3.26–4.37 3.71–4.81 4.04–5.33
Triglycerides (mg/dl) 45–248 52–220 36–149 39–120
Phosphorus (mg/dl) 5.26–10.83 8.35–11.14 8.66–11.45 8.35–11.14
Source: Adapted from Center et al. [22]; Kuhl et al. [23]; Harper et al. [24].

Table 74.3 Puppy biochemical parameters up to 12 months of age.
Biochemical parameter 2–3 months 4–6 months 7–12 months
Albumin (g/dl)a 2.6–3.7 2.6–3.7 2.6–3.7

Alkaline phosphatase (iu/l) 88–532 126–438 4–252
Alanine transaminase (iu/l) 29 32 5–45
Amylase (iu/l)a 1683 1683 1683
Aspartate aminotransferase (iu/l) 7–19 3–23 2–26
Bilirubin (mg/dl) 0.01–0.13 0.01–0.13 0.3
a
Blood urea nitrogen (mg/dl) 9.8–37.3 9.8–37.3 9.8–37.3
Calcium (mg/dl) 10.4–13.6 10–13.2 10.4–12
Chloride (mEq/l)a 99–120 99–120 99–120
Cholesterol (mg/dl) 99.6–499.6 99.6–499.6 135–278
Creatine kinase (iu/l) 31–255 40–192 134
Creatinine (mg/dl) 0.39–0.49 0.27–0.88 0.21–0.89
Gamma-glutamyl transferase (iu/l) 6.2 4.3 3.2
Globulins (g/dl) 1.9–2.5 2.2–3.5 2.2–4.5
Glucose (mg/dl) 97.1–166.2 97.1–166.2 76–119
Glutamate dehydrogenase (iu/l) 1.6–9.6 1.9–8.7 1.2–8.0
Lactate dehydrogenase (iu/l) 68–290 442 9–269
Lipase (iu/l) 241 139 154
a
Magnesium (mEq/l) 1.4–5.2 1.4–5.2 1.4–5.2
Phosphorus (mg/dl) 6.4–11.3 5.6–9.6 3.5–7.8
Potassium (mEq/l) 4.5–6.3 3.9–6.1 4.2–5.6
Sodium (mEq/l) 140–156 139–159 138–158
Total protein (g/dl) 4.3–5.8 4.5–7.3 4.9–6.7
Triglycerides (mg/dl) 19.1–205.5 19.1–205.5 40–169
Trypsin-like immunoreactivity (μg/l) 5–35 – –
a
Parameters for which significant age variation was not found in puppies.
Source: Adapted from the following sources: Harper et al. [24]; Kley et al. [25]; Kraft et al. [26]; Kraft et al. [27]; Laroute et al. [28]; Vajdovich et al. [29].
Table 74.4 Kitten biochemical parameters from birth to eight weeks of age.
Week 1 Week 4 Week 8
Biochemical parameter Day 0 Day 1 Day 7 Day 28 Day 56
Albumin (g/dl) 2.5–3.0 1.9–2.7 2.0–2.5 2.4–4.9 2.4–3.0

Alkaline phosphatase (iu/l) 184–538 1348–3715 126–363 97–274 60–161
Alanine transaminase (iu/l) 7–42 29–77 11–76 14–55 12–56
Amylase (iu/l) 310–837 310–659 187–438 275–677 407–856
Aspartate aminotransferase (iu/l) 21–126 75–263 15–45 15–31 14–40
Bilirubin (mg/dl) 0.1–1.1 0.1–1.6 0.0–0.6 0.0–0.3 0.0–0.1
Blood urea nitrogen (mg/dl) 26–45 34–94 16–36 10–22 16–33
Calcium (mg/dl) 9.4–13.9 9.6–12.2 10.0–13.7 10.0–12.2 9.8–11.7
Cholesterol (mg/dl) 65–141 48–212 119–213 173–253 124–221
Creatine kinase (iu/l) 91–2300 519–2654 107–445 125–592 102–1512
Week 1 Week 4 Week 8
Biochemical parameter Day 0 Day 1 Day 7 Day 28 Day 56
Creatinine (mg/dl) 1.2–3.1 0.6–1.2 0.3–0.7 0.4–0.7 0.6–1.2

Gamma-glutamyl transferase (iu/l) 0–2 0–9 0–5 0–1 0–2
Glucose (mg/dl) 55–290 65–149 105–145 117–152 94–143
Lactate dehydrogenase (iu/l) 176–1525 302–1309 117–513 98–410 62–862
Lipase (iu/l) 12–43 21–131 8–46 4–86 6–70
Phosphorus (mg/dl) 5.9–11.2 4.9–8.9 6.7–11.0 6.7–9.0 7.6–11.7
Total protein (g/dl) 3.8–5.2 3.9–5.8 3.5–4.8 4.5–5.6 4.8–6.5
Total solids (g/dl) 3.1–4.4 3.2–5.2 3.0–4.6 4.0–6.0 4.1–6.2
Triglycerides (mg/dl) 23–132 30–644 129–963 43–721 16–170
Source: Adapted from Levy et al. [30].
Table 74.5 Kitten biochemical parameters up to 12 months of age.
Biochemical parameter < 3 Months 4–6 Months 7–12 Months
Alkaline phosphatase (iu/l) 564 37–333 21–197

Alanine transaminase (iu/l) 10–50 77 85
Amylase (iu/l) f 1800 1800 1800 ( 2200 Oriental
breeds)
Aspartate aminotransferase (iu/l) 20 30 30 ( 40 Oriental breeds)
a
Bilirubin (mg/dl) 4 4 4
Blood urea nitrogen (mg/dl)b 17–35 17–35 17–35
Calcium (mg/dl) f 9.2–12.0 9.2–12.0 9.2–12.0
Chloride (mEq/l) 97–125 102–122 104–124
Creatinine (mg/dl) 0.16–1.26 0.33–1.21 –c
Creatine kinase (iu/l) 188 160 128
f
Gamma-glutamyl transferase (iu/l) 4 4 4
Glutamate dehydrogenase (iu/l) f 7 7 7 ( 16 Oriental breeds)
b
Glucose (mg/dl) 70–150 70–150 70–150
Lactate dehydrogenase (iu/l) 68–280 442 9–269
Lipase (iu/l) 280 280 280
Magnesium (mEq/l)* 1.2–5.2 1.2–5.2 1.2–5.2
Potassium (mEq/l) 3.7–6.1 4.2–5.8 3.7–5.3
Phosphorus (mg/dl) 6.5–10.1 6–10.4 4.5–8.5
Sodium (mEq/l)* 143–160 143–160 143–160
Total protein (g/dl)d – 3.3–7.5 3.3–7.5
TLI (μg/l) 17–49e
Source: Adapted from Kraft et al. [26, 27, 31].

a
Adult values reached after 1 week of age.
b
Adult values reached after 8 weeks of age.
c
Reference ranges have not been reported for kittens over 8 months of age; 0.8–2.3 mg/dl (adult).
d
Adult levels are reached between 8 months and 8 year of age.
e
Data from Steiner [32].
f
Parameters for which significant age variation has not been found in kittens.
Table 74.6 Hematologic values for growing, healthy Beagle dogs.
Age (in weeks)

Hematologic
parameter Birthb 1b 2b 3b 4b 6b 8 12a 16a 20a 24a 28a 40a 44a 52a
RBC (× 106/μl) 4.7–5.6 (5.1) 3.6–5.9 (4.6) 3.4–4.4 (3.9) 3.5–4.3 (3.8) 3.6–4.9 (4.1) 4.3–5.1 (4.7) 4.5–5.9 (4.9) (6.34) (6.38) (6.93) (7.41) (8.45) (8.69) (8.47) (7.68)
Hemoglobin (g/dl) 14.0–17.0 (15.2) 10.4–17.5 (12.9) 9.0–11.0 (10.0) 8.6–11.6 (9.7) 8.5–10.3 (9.5) 8.5–11.3 (10.2) 10.3–12.5 (11.2) (14.3) (15.0) (16.0) (16.7) (17.7) (18.2) (18.8) (18.1)
PCV (%) 45.0–52.5 (47.5) 33.0–52.0 (40.5) 29.0–34.0 (31.8) 27.0–37.0 (31.7) 27.0–33.5 (29.9) 26.5–35.5 (32.5) 31.0–39.0 (34.8) (40.9) (43.0) (44.9) (47.6) (48.8) (50.8) (50.2) (49.3)
MCV (fl) (93.0) (89.0) (81.5) (83.0) (73.0) (69.0) (72.0) (64.6) (67.4) (64.8) (64.2) (57.8) (58.4) (59.3) (63.5)
MCH (pg) (30.0) (28.0) (25.5) (25.0) (23.0) (22.0) (22.5) (22.8) (23.5) (23.0) (22.5) (20.5) (20.9) (22.1) (23.6)
MCHC (%) (32.0) (32.0) (31.5) (31.0) (32.0) (31.5) (32.0) (35.3) (34.8) (35.6) (35.1) (36.1) (35.9) (37.3) (37.1)
nRBC/100 WBC 0–13 (2.3) 0–11 (4.0) 0–6 (2.0) 0–9 (1.6) 0–4 (1.2) 0 0–1 (0.2)
Reticulocytes (%) 4.5–9.2 (6.5) 3.8–15.2 (6.9) 4.0–8.4 (6.7) 5.0–9.0 (6.9) 4.6–6.6 (5.8) 2.6–6.2 (4.5) 1.0–6.0 (3.6)
Total WBC 6.8–18.4 (12.0) 9.0–23.0 (14.1) 8.1–15.1 (11.7) 6.7–15.1 (11.2) 8.5–16.4 (12.9) 12.6–26.7 (16.3) 12.7–17.3 (15.0) (17.1) (16.3) (14.6) (15.6) (15.5) (14.4) (13.9) (14.0)
(× 103/μl)
Segmented 4.4–15.8 (8.6) 3.8–15.2 (7.4) 3.2–10.4 (5.2) 1.4–9.4 (5.1) 3.7–12.8 (7.2) 4.2–17.6 (9.0) 6.2–11.8 (8.5) (9.8) (9.0) (8.9) (9.1) (9.1) (9.9) (8.7) (8.1)
neutrophils
Band neutrophils 0–1.5 (0.23) 0–4.8 (0.50) 0–1.2 (0.21) 0–0.5 (0.09) 0–0.3 (0.06) 0–0.3 (0.05) 0–0.3 (0.08) (0.08) (0.1) (0.02) (0.02) (0.08) (0.02) (0.02) (0.04)
Lymphocytes 0.5–4.2 (1.9) 1.3–9.4 (4.3) 1.5–7.4 (3.8) 2.1–10.1 (5.0) 1.0–8.4 (4.5) 2.8–16.6 (5.7) 3.1–6.9 (5.0) (5.7) (5.9) (4.5) (5.3) (4.8) (3.4) (4.0) (4.7)
Monocytes 0.2–2.2 (0.9) 0.3–2.5 (1.1) 0.2–1.4 (0.7) 0.1–1.4 (0.7) 0.3–1.5 (0.8) 0.5–2.7 (1.1) 0.4–1.7 (1.0) (0.9) (0.9) (0.8) (0.7) (0.7) (0.5) (0.6) (0.5)
Eosinophils 0–1.3 (0.4) 0.2–2.8 (0.8) 0.08–1.8 (0.6) 0.07–0.9 (0.3) 0–0.7 (0.25) 0.1–1.9 (0.5) 0–1.2 (0.4) (0.4) (0.4) (0.3) (0.5) (0.8) (0.6) (0.5) (0.5)
Basophils 0–0.2 (0.01) 0–0.15 (0.01)
Platelets (× 103/μl) 178–465 (302) 282–560 (352) 210–352 (290) 203–370 (272) 130–360 (287) 275–570 (371) 240–435 (324)
MCH, mean corpuscular hemoglobin; MCV, mean corpuscular volume; MCHC, mean corpuscular hemoglobin concentration; nRBC/100 WBC, number of nucleated red blood cells per 100 white blood cells; PCV,
packed cell volume; RBC, Red blood cells; total WBC, total white blood cell count. Values in parentheses are mean values.
a
Mean values from Anderson and Gee [33].
b
Normal ranges and/or mean values from Earl et al. [34].
Table 74.7 Hematologic values for growing, healthy cats.
Age (in weeks)
Hematologic parameter 0–2b 2–4b 4–6b 6–8b 8–9b 12–13b 16–17b 20a 30a 44a 52a
RBC (×106/μl) 5.29 ± 0.24 4.67 ± 0.10 5.89 ± 0.23 6.57 ± 0.26 6.95 ± 0.09 7.43 ± 0.23 8.14 ± 0.27 7.4 ± 0.7 8.0 ± 0.5 7.9 ± 0.8 7.7 ± 0.8
Hemoglobin (g/dl) 12.1 ± 0.6 8.7 ± 0.2 8.6 ± 0.3 9.1 ± 0.3 9.8 ± 0.2 10.1 ± 0.3 11.0 ± 0.4 10.7 ± 1.2 12.1 ± 1.8 13.0 ± 2.1 13.3 ± 1.8
PCV (%) 35.3 ± 1.7 26.5 ± 0.8 27.1 ± 0.8 29.8 ± 1.3 33.3 ± 0.7 33.1 ± 1.6 34.9 ± 1.1 33.4 ± 3.3 37.1 ± 3.4 37.3 ± 3.5 36.6 ± 3.6
MCV (fl) 67.4 ± 1.9 53.9 ± 1.2 45.6 ± 1.3 45.6 ± 1.0 47.8 ± 0.9 44.5 ± 1.8 43.1 ± 1.5 45 ± 5.2 46 ± 3.5 47 ± 3.4 47 ± 3.9
MCH (pg) 23.0 ± 0.6 18.8 ± 0.8 14.8 ± 0.6 13.9 ± 0.3 14.1 ± 0.2 13.7 ± 0.4 13.5 ± 0.4
MCHC (%) 34.5 ± 0.8 33.0 ± 0.5 31.9 ± 0.6 30.9 ± 0.5 29.5 ± 0.4 31.3 ± 0.9 31.6 ± 0.8 32 ± 2.0 33 ± 3.3 34 ± 3.0 36 ± 3.1
3
Total WBC (×10 /μl) 9.67 ± 0.57 15.31 ± 1.21 17.45 ± 1.37 18.07 ± 1.94 23.68 ± 1.89 23.20 ± 3.36 19.70 ± 1.12 15.9 ± 6.0 21.9 ± 6.8 18.3 ± 7.8 24.0 ± 12.5
Segmented neutrophils 5.96 ± 0.68 6.92 ± 0.77 9.57 ± 1.65 6.75 ± 1.03 11.00 ± 1.41 11.00 ± 1.77 9.74 ± 0.92
Band neutrophils 0.06 ± 0.02 0.11 ± 0.04 0.20 ± 0.06 0.22 ± 0.08 0.12 ± 0.09 0.15 ± 0.07 0.16 ± 0.07
Lymphocytes 3.73 ± 0.52 6.56 ± 0.59 6.41 ± 0.77 9.59 ± 1.57 10.17 ± 1.71 10.46 ± 2.61 8.78 ± 1.06 6.2 ± 2.1 5.3 ± 1.2 6.1 ± 2.0 5.5 ± 2.7
Monocytes 0.01 ± 0.01 0.02 ± 0.02 0 0.01 ± 0.01 0.11 ± 0.06 0 0.02 ± 0.02
Eosinophils 0.96 ± 0.43 1.40 ± 0.16 1.47 ± 0.25 1.08 ± 0.20 2.28 ± 0.31 1.55 ± 0.35 1.00 ± 0.19
Basophils 0.02 ± 0.01 0 0 0.02 ± 0.02 0 0.03 ± 0.03 0
RBC, Red blood cells; PCV, packed cell volume; MCV, mean corpuscular volume; MCH, mean corpuscular hemoglobin; MCHC, mean corpuscular hemoglobin concentration; nRBC/100 WBC,
number of nucleated red blood cells per 100 white blood cells; total WBC, total white blood cell count. Values in parentheses are mean values.
a
Normal ranges from Anderson et al. [35].
b
Normal ranges ± one standard deviation from Meyers-Wallen et al. [36].
Table 74.8 Regenerative response in puppies and kittens.
Puppies Kittens
PCV (%) Polychromasia Reticulocytesa Polychromasia Reticulocytesa
> 25 1–2+ > 80 000/μl 1–2+ > 60 000/μl

15–25 2–3+ 2–3+
< 15 4+ 4+
a
These values represent the minimum absolute numbers of reticulocytes required for an interpretation of a
regenerative response. If the PCV is lower, the absolute number of reticulocytes should increase
proportionately.
Box 74.4 Normal Rectal Temperature of Neonates,

First Four Weeks of Life, and Associated Ambient
Temperature Range
● Neonatal normal body temperature (rectal):
⚪ Week 1: 95–99°F (35–37°C)
⚪ Weeks 2–3: 97–100°F (36–37°C)
⚪ At weaning 99–101°F (37–38°C)
● Environmental warmth required (ambient air tem-

perature in room):
⚪ Week 1: 84 – 89°F (28 – 31°C)
⚪ Weeks 2 – 3: 80°F (26°C)
⚪ Week 4: 69 – 75°F (20 – 23°C)
⚪ Week 5: 69°F (20°C)
Note: Presence of dam and littermates improves thermoregula-

tion in the litter. Overheating can be problematic for both the dam
and litter. Heating elements in or above the nest box, which
should only cover a portion of the box, will reduce the need for
ambient (room) heat. Euthermic puppies may pile up, may spread
out, and sleep/nurse/sleep. Chilled neonates will pile up, may
vocalize, and may eventually become lethargic. Overheated litter-
mates will spread out, will be restless and cry, and will have very
pink/red mucus membranes, and the dam may pant excessively or
even leave the box.
Figure 74.19 Early sign of overheating of a whelping box

vasodilation and dehydration. Tube feeding neonates using an overhead heat lamp; the bitch is panting and appears
should be delayed until the neonate is euthermic; hypo- anxious.
thermia induces ileus, and regurgitation and aspiration
can result. Appropriate, cautious thermal support should glucose assessment with a drop of blood obtained by a digi-
continue through four weeks of life. Overheating is prob- tal pad prick is indicated if hypoglycemia is suspected; IV
lematic as neonates cannot pant and have poor peripheral or IO glucose therapy should follow (Figure 74.20;
vasodilation capabilities, of concern when transported in a Protocol 74.3). Oral fluid and glucose replacement may be
small box. preferable to parenteral if the neonate has an adequate
Neonates have minimal body fat reserves and limited swallowing reflex and is not clinically compromised. In
metabolic capacity to generate glucose from precursors. one study, median glucose concentration at day 1 in pup-
Glycogen stores are depleted shortly after birth, making pies subsequently dying was 88 mg/dl (56–128 mg/dl) com-
adequate nourishment from nursing vital. Even minimal pared with 120 mg/dl (96–149 mg/dl) in puppies still alive
fasting can result in hypoglycemia. Hypoglycemia can also at day 21 [20].
result from endotoxemia, septicemia, portosystemic The neonatal caloric requirement is 0.133 calories/g/
shunts, and glycogen storage abnormalities. Rapid blood day during the first week of life, 0.155 cal/g/day for the
are superior to commercial veterinary bottles in puppies;

syringes modified with a nipple or commercial feline neo-
natal bottles are preferred in kittens. The neonate should
be in a normal feeding position (ventral recumbency with
slight elevation of the head) while suckling a bottle or
receiving gavage (Figure 74.22).
Normal neonatal weight gain is an increase of 5–10%
body weight/day. Commercially manufactured milk
replacement formulas are usually superior to homemade
versions (high lactose), but none is equivalent to the dam’s
milk, which contains high levels of lipids [38]. The use of
milk obtained from the dam or another lactating bitch
should be considered and is superior if available. Most
replacement formulas lack appropriate calcium, amino
acids, and essential fatty acids. An osmotic diarrhea (usu-
ally yellow, curdled fecal appearance) can result from over-
feeding formula; constipation can also occur necessitating
diluting the product 25–50% with water or a balanced crys-
talloid solution. Neonates should gain weight steadily from
the first day after birth (a transient mild loss from birth
weight is acceptable on day 1), with puppies gaining 1–3 g/
day/2.2 kg of anticipated adult weight and kittens 50–100 g/
week. Neonatal weights should be recorded at least daily
for the first two weeks, then every one to three days until
one month of age. The limited size of neonatal stomach
Figure 74.20 A quick blood glucose measurement can be
acquired using a glucometer and one drop of blood acquired (reportedly 4–5 ml/100 g), and propensity for regurgita-
from a pad prick. tion/aspiration if overdistension from overfeeding occurs,
necessitates multiple small feedings around the clock [16].
Most commercial milk replacers deliver approximately
Protocol 74.3 Hypoglycemia Therapy
1.0 kcal/ml; smaller more frequent volumes fed are prefer-
able (50–80% stomach capacity). One study reported supe-
1) Warm fluids to neonatal body temperature.
rior thermoregulation and weight gain in neonates
2) Acute hypoglycemia (blood glucose < 80 mg/dl):
supplemented arbitrarily with a maltodextrin enriched
a) Optimal: IV or IO bolus 2.5–5.0% (25–50 mg/ml)
milk replacer during the first 48 hours of life [39]. Kittens
dextrose solution at 0.001 ml/g neonate weight
and puppies under three weeks of age lack voluntary elimi-
(e.g. 500 g neonate gets 0.5 ml).
nation and must have the micturition and defecation
b) Alternative: balanced crystalloid (half-strength
reflexes stimulated multiple times daily using a cotton ball
saline) and 2.5% dextrose may be administered
with lubrication on the anogenital area if the dam fails to
by gavage (0.25–1 ml).
groom the neonate sufficiently. Constipation can result in
c) Suboptimal: 1 drop 50% dextrose solution
vomiting, hypoglycemia, and dehydration.
applied to mucous membranes.
Hypovolemia and dehydration are potential life-
3) Recheck blood glucose approximately hourly, and
threatening conditions in neonates, most commonly
repeat as necessary.
resulting from decreased fluid intake, vomiting, and diar-
4) Encourage nursing; consider stomach tubing with
rhea. The immature autonomic nervous system results in
colostrum/artificial milk.
an altered response to shock; tachycardia is already pre-
5) Avoid hyperglycemia/osmotic diuresis and rebound
sent and neonatal mean arterial pressure low. Skin turgor
hypoglycemia can occur.
and urine specific gravity in neonates are not indicative
of hydration status due to their increased body water
second, 0.175–0.198 calories/g/day for the third, and content/plasma volume and immature/limited glomeru-
0.220 calories/g/day for the fourth [16]. Bottle or intermit- lar filtration rate. Fluid (warmed to body temperature)
tent orogastric tube feeding is indicated for neonates who replacement via IV or IO administration is preferred
fail to gain weight or nurse effectively until weaning (Box 74.5). Intraperitoneal (IP) administration of
(Figure 74.21). Premature low flow human baby bottles fluids is an alternative but can be painful and slowly
(a)
(b) (c)
Figure 74.21 (a) Measuring the distance from the mouth to the stomach, just caudal to the last rib. (b) Marked large-diameter
orogastric tube. (c) Orogastric feeding with a smaller-diameter tube with which inadvertent placement in the airway can occur
more easily.
absorbed; the subcutaneous (SC) route is appropriate Fading Neonates

only with mild dehydration.
Neonatal bacterial septicemia can cause rapid deteriora-
tion resulting in death if not recognized and treated
Neonatal Immunodeficiency promptly. Factors that reportedly predispose a neonate to
septicemia include endometritis in the dam, prolonged
Canine and feline neonates are immunodeficient at birth. delivery/dystocia, feeding of replacement formulas (likely
Incompletely developed immune systems during the first a comorbidity), use of ampicillin, stress, low birth weight
10 days of life make neonates vulnerable to systemic (< 350 g for a medium-size breed of puppy, < 100 g for a kit-
infection (most commonly bacterial and viral). Adequate ten), and chilling (body temperature < 96° F; Figure 74.23).
ingestion of colostrum must occur promptly postpartum The organisms most frequently associated with septicemia
for neonates to acquire passive immunity, as transplacen- are Escherichia coli, streptococci, staphylococci, and Klebsiella
tal transfer is less than 5%. The intestinal absorption of spp. Umbilical contamination is the most likely route of
immunoglobulin G generally ceases by 24 hours after entry. Omphalitis leads to peritonitis, bacteremia, and pneu-
parturition. Colostrum-deprived canine neonates should monia. Abscessation can occur later at other sites (e.g. neona-
be given 10–20 ml/kg (0.01–0.02 ml/g) of serum from an tal ophthalmia; Figure 74.24). Premortem diagnosis can be
immunocompetent adult dog to achieve adequate challenging; clinical signs may not be noted owing to sudden
immunoglobulin levels. Kittens should receive 15 ml/kg death. Commonly, a decrease in weight gain, failure to suckle,
(0.015 ml/g). hematuria, persistent diarrhea, unusual vocalization, abdom-
Blood typing is important for cats. The serum can be given inal distention, and pain, and sloughing of the extremities
orally if within the first 24 hours of life, otherwise it must be indicate septicemia may be present. Prompt therapy with
given parenterally, preferably subcutaneously, divided into broad-spectrum bactericidal antibiotics, improved nutrition
reasonably small volumes with both routes [40, 41]. via supported nursing, tube or bottle feeding, maintenance of
Fading Neonates 985
(a)
(b) (c)
Figure 74.22 Bottle feeding. (a) Canine neonate. (b) Feline neonate. (c) Proper position for feeding via gavage. Source: Courtesy of
Dr. P. Dedrick.
body temperature, and appropriate fluid replacement are

Box 74.5 Intraosseous/intravenous Fluid Guidelines
indicated. The third-generation cephalosporin antibiotic
ceftiofur sodium is an appropriate choice for neonatal sep-
● Warm fluids to neonatal body temperature.
ticemia (Box 74.1). Ceftiofur minimally alters normal intesti-
● Ideal: IV or IO administration balanced crystalloid
nal flora and is usually effective against the causative
shock dose (puppy 0.02–0.04 ml/g body weight; kit-
organisms. Ceftiofur sodium should be administered at a
ten 0.02–0.03 ml/g body weight) bolus (e.g. 500 g
dose of 0.0025mg/g SC every 12hours for no longer than five
neonate receives 10–20 ml). IO requires very slow
days. Because neonates less than 48hours old have reduced
infusion rate.
thrombin levels, presumptive therapy with vitamin K1 may
● Suboptimal: IP administration balanced crystalloid
be used (0.01–1mg/neonate SC). The prognosis is guarded
(avoid hypertonic solutions).
but not hopeless.
● Less optimal: SC administration balanced crystalloid
Incompatible blood types of the parental cats can cause
(avoid hypertonic solutions).
feline neonatal mortality. This incompatibility arises when
● Maintenance fluid rate 1.2–1.8 ml/g neonate
queens with type B blood give birth to kittens who inherited
weight/day as multiple boluses or continuous
the sire’s blood type A. Type B is rare in mixed breed and
infusion.
Siamese cats but is much more common in certain
urine and is confirmed by documenting hemolytic anemia

and the blood types of the parents. If neonatal isoerythroly-
sis is suspected, the kittens are removed from the queen and
fostered on a type A queen or bottlefed for the first two days
of life. Neonatal isoerythrolysis can be avoided in catteries
by testing the blood types of breeding animals and avoiding
matings of type B queens with type A toms.
Canine herpes virus (CHV) is a commonly blamed cause
for fading puppy syndrome resulting in neonatal death.
Premortem diagnosis of CHV infection in neonates can be
challenging. Postmortem diagnostics include appropriate
histopathology, virus isolation, or PCR. Pathognomonic
changes occurring in the kidneys include multifocal pete-
chial hemorrhages, although this can be seen with bacte-
rial septicemia and associated thromboembolic disorders
as well (Figure 74.25). Intranuclear inclusion bodies can be
difficult to find. Diagnosis by virus isolation or CHV-
specific PCR is confirmatory and desirable, especially
before litter mortality reaches 100%.
Until recently, treatment of CHV infection in neonates has
been reported to be unrewarding and rare, with recovery
suspected to be associated with residual cardiac and neuro-
Figure 74.23 Low-birthweight puppy with littermates.
logic damage. Treatment with immune serum from affected
dams is reported to be ineffective in infected puppies.
Successful treatment with the antiviral agent acyclovir has
been reported [42]. Acyclovir is an antiviral agent with activ-
ity against a variety of viruses including herpes simplex.
Acyclovir is preferentially taken up by susceptible viruses
and converted into the active triphosphate form, inhibiting
viral DNA replication. It is poorly absorbed after oral admin-
istration and is primarily hepatically metabolized, and can
Figure 74.24 Neonatal ophthalmia secondary to bacteremia.
purebreds such as British Shorthair and Devon Rex cats.

Type B cats have naturally occurring anti-A antibodies.
When the kittens nurse and absorb these antibodies, the kit-
tens’ own red blood cells are hemolyzed, leading to anemia
and organ failure. The clinical course is determined by the
severity of the hemolytic reaction. In all cases, the kittens are
born healthy and nurse vigorously. Some kittens may die
suddenly in the first day, while others linger longer and fade
during the first week of life. Clinical neonatal isoerythrolysis Figure 74.25 Pinpoint hemorrhagic renal capsular foci in a
is suggested by pale mucous membranes and dark red brown confirmed canine perinatal herpes infection.
Congenital and Accuired AAnorralities 987
increase the toxicity of nephrotoxic drugs. The half-life in

humans is approximately three hours. Its use in veterinary
medicine is not well established, and it should be used with
caution and only in situations where indicated. The safety
and effectiveness in humans younger than two weeks of age
is not established. The dose was extrapolated from that for
humans (20 mg/kg orally every six hours for seven days).
Congenital and Acquired Abnormalities
Cardiovascular
Innocent (flow) murmurs are transient and are not patho-
logic. The ductus arteriosus normally closes by five days
after birth. Continuous murmurs and murmurs that per-
sist beyond two to three days of life are abnormal. The
most common congenital heart diseases are subaortic ste-
nosis and patent ductus arteriosus in dogs, and tricuspid
valve dysplasia and ventricular septal defect in cats [43]. Figure 74.26 Lateral positive contrast image illustrating
Cardiac defects can arise from environmental stress, infec- congenital megaesophagus. Non-ionic, water-soluble iodine
tion, or intoxication of the dam, but the heritability of contrast media is advised in neonates.
many has been documented. Clinical signs are often not
apparent until after weaning, although affected neonates
may not be as vigorous as normal littermates. Accurate
cardiac auscultation of subtle, persistent murmurs is best
after four to six weeks of age; echocardiography is the pre-
ferred mode of evaluation once adequate pediatric size is
attained, usually at three to four months of age.
Respiratory
Primary ciliary dyskinesia, the rare immotile cilia syndrome,
should be suspected in neonates exhibiting persistent or
recurrent mucopurulent nasal discharge, coughing, and
abnormal breath sounds without other demonstrable cause.
The presence of a cleft palate, persistent right aortic arch,
and congenital megaesophagus should be ruled out
(Figure 74.26). Abnormal mucociliary transport and neutro- Figure 74.27 Abdominal radiograph of term pregnancy
phil function result in chronic rhinitis, tracheobronchitis, illustrating mineralized fetal dentition (arrowhead).
and bronchopneumonia. Situs inversus can also be present.
The long-term prognosis, even with supportive therapy, is avoid premature delivery of surfactant deficient neonates.
poor. Neonatal dyspnea with evidence of gastrointestinal When ovulation timing is incomplete, determination of
disorders can occur secondary to congenital peritoneoperi- term pregnancy can be attempted by examination of fetal
cardial or pleuroperitoneal diaphragmatic hernias. Thoracic dental mineralization on radiographs (Figure 74.27) and
wall abnormalities, such as pectus excavatum, a sternal ultrasound presence of gastrointestinal motility [44].
intrusion into the thorax, can cause dyspnea and is variably
associated with poor growth. Surgical correction of thoracic
Gastrointestinal
wall abnormalities is sometimes possible once adequate
body size is attained. Reports of a neonatal respiratory dis- Examination of the neonatal oronasal/pharyngeal cavity
tress syndrome secondary to a deficiency of surfactant exist, should always be carefully performed. Congenital palate
and affected neonates died within five days of age. Surfactant defects occur in dogs with an incidence of up to 25%, less
deficiency secondary to prematurity is predictably problem- commonly in kittens A secondary cleft palate is a congeni-
atic. Proper timing of elective cesarean sections is vital to tal oronasal fistula resulting in incomplete closure of the
hard and soft palates (Figure 74.28). Secondary cleft palate young puppies is difficult due to patient size and anticipated
occurs alone or in combination with primary cleft palate, postoperative orofacial growth, which often requires multi-
which involves the lip and premaxilla (Figure 74.29). Cleft ple surgeries. Esophagostomy or gastrostomy tube place-
palate results from incomplete fusion of the palatine ment can facilitate feeding over time but requires significant
shelves, most critical at 25–28 days of gestation, attributed client commitment and can still result in aspiration
to genetic (recessive or incompletely dominant polygenic (Figure 74.30). Palatal prostheses are problematic in dogs. A
inheritance), teratogenic (drugs, supplements), nutritional successful method to manage nutrition in mild to moder-
(folic acid deficiency), or infectious (viral) factors. ately affected dogs until approximate adult size is attained,
Affected neonates are diagnosed by visual inspection of facilitating a single surgical correction, has been reported.
the face and oral cavity. Ineffective nursing/suckling results; Feeding the dam’s colostrum for 24 hours followed by either
these neonates fail to thrive, developing aspiration pneumo- the dam’s milk or artificial milk replacer by intermittent
nia and rhinitis. Feeding by orogastric tube is indicated (every two to six hours) orogastric tube is instituted. At four
until the neonate reaches a size permitting oral surgery, tra- to five weeks of age, transition to a dry (unsoaked) commer-
ditionally advised at 8–12 weeks of age. Palatoplasty in such cial pediatric kibble for small breeds is made. Water is made
available at this time through an overhead ballpoint tube
cap system (Figure 74.31). Surgery can be delayed until the
Figure 74.28 Secondary cleft palate.

Figure 74.30 Placement of an esophagoscopy tube in a neonate.
Figure 74.31 Effective drinking-water delivery to a puppy with

Figure 74.29 Primary cleft palate with unilateral cleft lip. a secondary cleft palate.
pet has achieved adequate size, or may never become neces- wall, occurring within the umbilical canal (omphalocele)
sary, as some degree of closure of the cleft occurs with time or lateral to the umbilical canal (gastroschisis) occurs in
(Figure 74.32) [45]. both dogs and cats (Figure 74.33). The condition is usually
A developmental anomaly resulting in extrusion of a hopeless in small pediatric veterinary patients presented to
portion of the gastrointestinal tract outside of the body the veterinarian hours after birth; however, a 30–70%
(a) (b) (c)
(d) (e) (f)
(g) (h)
Figure 74.32 Progression of spontaneous closure of a congenital secondary cleft palate: (a) neonate; (b) 2 weeks; (c) 4 weeks;
(d) 6 weeks; (e) 16 weeks; (f) 27weeks; (g) 1-week postoperatively at 16 months; (h) 4 months postoperatively.
(a) (b)
Figure 74.33 (a) Stillborn siblings. Omphalocele present in the smaller neonate. (b) Omphalocele.
survival rate is reported in humans with immediate post- dry 24 hours postpartum; erythema or drainage indicates
partum surgical intervention; the diagnosis is made pre- antibiotics should be instituted because of the potential for
partum with abdominal ultrasound, based on the peritonitis. Excessive umbilical attention by the dam can
recognition of fetal gastric wall (rugal) structures or intesti- result in exposure of the subcutaneous tissues with risk of
nal contents in an abnormal location. Earlier surgical peritonitis (Figure 74.34).
intervention before inevitable septic contamination occurs
may improve the prognosis in veterinary patients in whom
Musculoskeletal
the diagnosis is made in the immediate postpartum period.
Enteric duplication or agenesis can be confirmed ultra- Both canine and feline neonates can be born with pelvic
sonographically in pediatric patients. Duplication is rare, limb genu varum of unknown etiology; because their joints
can occur anywhere in the intestinal tract and the clinical are lax, simple bandaging in a flexed position for two to
signs may be nonspecific (abdominal distension, discom-
fort). A fluid-filled juxtaintestinal formation with variable
peristalsis and contents can be seen with ultrasound.
Enteric agenesis usually results in severe, life-threatening
clinical signs in the neonatal period with failure to defe-
cate. Ultrasonographic findings usually include marked
fluid and gas distention of bowel proximal to the defect.
Umbilical hernias can be significant if large enough to
permit bowel evisceration and strangulation. More com-
monly, omentum becomes trapped in a small umbilical
hernia in pediatric dogs and cats; closure of the hernia over
time results in a benign omental mass misinterpreted as a
hernia. Evaluation of a painful or enlarging umbilical mass
with ultrasound permits differentiation of omentum from
entrapped bowel, which has a typical enteric appearance.
Early repair is indicated if bowel entrapment is evident.
Omphalitis resulting from bacterial umbilical contamina-
tion in the postpartum period places the neonate at risk for Figure 74.34 Umbilical dehiscence resulting from excessive
bacterial septicemia. The umbilicus should be closed and maternal grooming.
three days combined with gentle physical therapy can Neurologic

resolve the condition (Figure 74.35). Puppies with notice-
Neonates sleep most of the time when not nursing. They
able flattening of the sternum at two to four weeks of age
respond to odors, touch and pain, all adaptive mechanisms
are called “swimmer puppies” by breeders. Swimmer pup-
for survival. Invasive procedures such as dewclaw removal
pies fail to develop normal ambulation at 14–21 days of life,
and tail docking should be accompanied by pain manage-
moving instead by paddling their limbs laterally and cau-
ment or avoided altogether. An open fontanelle is com-
dally. Compression and deformation of the sternum and
monly present at birth in normal puppies and should close
thorax occurs concurrently (Figure 74.36). Obese puppies
within two to five days. Congenital hydrocephalus is most
from small litters raised on slippery surfaces are predis-
commonly a breed related characteristic in brachycephalic
posed. Treatment should be instituted immediately upon
puppies, and is a result of intrauterine exposure to toxins
diagnosis, consisting of caloric restriction, physical ther-
or infectious causes in kittens. It can be associated with a
apy, and improved traction on the floor the nest box.
persistent open fontanelle, and eventually behavioral
Placement of loose hobbles helps to control limb move-
problems, blindness, and seizures. The diagnosis can be
ments and promotes normal ambulation within days
made with ultrasound through the open fontanelle
(Figure 74.36). The prognosis for swimmer puppies treated
(Figure 74.37). The prognosis is guarded; surgical
before four weeks of age is good.
(a) (b)
(c)
Figure 74.35 (a, b) Neonatal pelvic limb genu varum. (c) Correctional bandage in place.
(a) (b)
(c) (d)
Figure 74.36 (a) “Swimmer” Border Terrier puppy. (b–d) Hobbles in place in a similarly affected Labrador Retriever.
placement of a shunt and medical therapy (omeprazole, recurrent infection because of abnormal urine flow in the
furosemide, prednisone, and acetazolamide) can allow region, surgical repair is indicated usually after six to eight
partial remission. weeks of age; the diagnosis is confirmed with ultrasound.
Renal dysplasia is a heritable problem in several canine
breeds, ultrasound can identify the typical marked mor-
Urogenital Disorders
phologic abnormalities in puppies at six to eight weeks of
Dysuria, urinary incontinence, or hematuria/pyuria can age in breeds at risk. Congenital renal polycystic disease of
indicate neonatal urogenital disorders, many of which are brachycephalic cats can similarly be identified with ultra-
not apparent until three to four weeks of age. The pres- sound in 8–12-week-old kittens. Neonatal urolithiasis,
ence of a persistent patent urachus causes micturition with or without associated urinary tract infection, can
through the umbilicus and can be diagnosed within the cause outflow obstruction and signs of acute abdominal
first week of life. Eventual surgical ligation is indicated. pain. Lower urinary tract infection in neonates has the
Cystic urachal diverticula can predispose the bladder to potential for ascending and causing pyelonephritis if not
(a)
(b) (c)
Figure 74.37 (a) Hydrocephalic puppy (left) with sibling. (b, c) Intracranial ultrasound (transfontanelle) in a hydrocephalic puppy,
showing an increased amount of cerebrospinal fluid present in the ventricles. Source: Images courtesy of T.W. Baker.
detected and controlled. Ectopic ureters can cause inconti- Treatment includes gentle manual separation of the lids and
nence during the postpartum period; clinical signs are topical triple antibiotic ointment (erythromycin in kittens).
most evident after weaning when the dam is no longer Microphthalmos, enophthalmos, strabismus, distichiasis,
cleaning the puppy, but astute breeders may note that a and entropion become apparent after the eyelids separate.
puppy is leaking and may seek evaluation.
Dermatologic
Ophthalmologic
Hypotrichosis is usually regional and cosmetic
Ocular anomalies account for 15% of all congenital defects in (Figure 74.38). Sibling suckling secondary to the lack of
puppies and 9% in kittens. Eyelid agenesis occurs most com- adequate nursing/hunger can cause cutaneous hemato-
monly in kittens and is apparent at birth. The prognosis is mas; separation or rotation of nursing neonates may be
guarded for preservation of corneal integrity and correction necessary until solid food is introduced (Figure 74.39).
of the defect and blink reflex. Eyelids separate at 10–14days Most infectious, parasitic, and inherited dermatopathies
of life, before this, neonatal ophthalmia can occur causing an become apparent in older pediatric patients (e.g. demodi-
accumulation of fluid below the lids. Bacterial infection is cosis, cheyletiellosis, nutritional imbalances, ichthyosis,
most likely in puppies, viral (herpes, chlamydia) in kittens. epidermal dysplasia, acrodermatitis, dermatomyositis).
Figure 74.38 Congenital hypotrichosis (right) with normal

littermate.
Figure 74.40 Anasarca; cesarean section was necessitated by

the resultant obstructive dystocia.
Miscellaneous
Anasarca, a lethal congenital edema, can occur with or
without concurrent cardiovascular abnormalities.
Generalized subcutaneous edema, with intrathoracic and
IP fluid accumulation, are present at birth; prenatal diag-
nosis with ultrasound is possible (Figure 74.40). Anasarca
puppies commonly cause an obstructive dystocia. Therapy
is unrewarding and euthanasia likely indicated. A breed
tendency suggests it is a heritable condition (Bulldogs,
Labrador Retrievers). Congenital hereditary lymphedema
(French Bulldogs) results in edema of the extremities and
Figure 74.39 Cutaneous hematoma resulting from suckling by
sometimes head and is associated with morphologic lym-
a littermate. phatic abnormalities. Mild cases can resolve with time.
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997
75
Safe Handling and Care of Patients Exposed to Radioactive and Anti-Neoplastic Agents

Michael S. Kent and Kristen Sears
The safe handling and care of patients exposed to either are all different types of ionizing radiation used in veteri-
radioactive or chemotherapeutic agents is essential. These nary medicine for diagnostic and therapeutic purposes.
patients present a particular challenge in that they may The unit of absorbed dose for radiation is the Gray (Gy),
need extensive and intensive nursing care and may have which is defined as a joule/kg or the amount of energy
the potential to endanger the very people providing that deposited in a mass. This unit does not take into account
care if proper precautions are not taken. How to best pro- the biological damage potential, which varies with differ-
tect yourself is not always straightforward. Multiple studies ent types of radiation. For example, 10 Gy of alpha particles
have shown that improper handling of the agents and or neutrons will cause more severe damage to cells than
patients treated with these agents results in exposure of the will 10 Gy of electromagnetic radiation. To help account for
nursing staff. This can carry a serious health risk for car- this variability, the term rem or Sievert is used. These units
egivers. To decrease this risk to a minimum, procedures of absorbed dose take into account a factor assigned to dif-
and protocols should be established at each practice using ferent types of radiation based on the severity of their bio-
or caring for patients exposed to these agents. It is impor- logical effects on humans.
tant that each facility has knowledge of federal, state, and The curie (Ci) and the becquerel (Bq) are units of activity
local regulations when developing such a plan. Exposure to for a radioactive substance. A becquerel is the SI unit for
these agents can occur during chemotherapy drug or radi- radioactivity and is defined as one disintegration (dis)/sec-
opharmaceutical preparation or administration, or from ond. The curie is defined as the approximate activity of 1 g
handling an exposed or treated patient or waste from that of the isotope 226Ra (radium) and is equal to 3.7 × 1010 dis/
patient. Limiting contamination of areas where drugs are second. Generally, millicurie (mCi) doses of a radiophar-
stored and prepared, and the areas where patients are maceutical are used for imaging or therapeutic purposes.
treated and cared for is essential to maintain a safe work
environment. General radiation safety is also extremely
important when using radiation to diagnose or treat Dose Limits
patients; this includes the use of diagnostic x-ray machines.
The Nuclear Regulatory Commission (NRC) is the body
This chapter covers radiation and chemotherapy safety.
charged with regulating nuclear materials used for medical
reasons within the United States [1]. By special agreement
with contract states, licensing a facility to use radioactive
Radiation
substances may also be delegated to the state government.
The NRC has set maximum limits of radiation exposure for
Definitions and Terms
humans. These limits are different for the public, radiation
Radiation is energy that travels as waves or in the form of workers, fetuses, and other groups (Table 75.1) [2]. These
high-energy particles. Radiation is only damaging to cells if differences are based on the relative risk of each group. For
it is ionizing, meaning that it has the ability to break bonds example, fetuses are more sensitive to radiation damage
or liberate bound electrons from molecules within cells. than adults, particularly during the first three months of
X-rays, beta particles, gamma rays, electrons, and photons gestation, so they have a relatively low legal limit for
998 Safe Handling and Care of Patients Exposed to Radioactive and Anti-Neoplastic Agents
Table 75.1 Annual dose limits for whole body exposure. Table 75.2 Commonly used radiopharmaceuticals used
in veterinary medicine and their corresponding half-lives.
Personnel Dose limit
Approximate physical
Occupation dose limit (adult) 5 rems (0.05 Sv) Radionucleotide half-life
Member of the public (adult) 0.1 rem (1 mSv) 18
F-fluorodeoxyglucose (18FDG) 110 minutes
Minor (< 18 years of age; 0.5 rems (0.005 Sv)
occupational dose limit) Iodine 125 (125I) 59 days
131
Embryo/fetus (for mother who is a 0.5 rem (5 mSv) over Iodine 131 ( I) 8 days
radiation worker) term of pregnancy Samarium 153 (153Sm) 1.93 days
99m
Source: Adapted from NRC Regulations [2]. Technesium-99 M ( Tc) 6 hours
exposure. The general public is also to be protected from

with osteosarcoma or other cancers that have metastasized
increased exposure as compared with radiation workers.
to bone [8–10]. 131I is most commonly used to treat hyper-
A stochastic effect is an adverse effect that can occur at
thyroidism in cats and occasionally to treat thyroid carci-
any dose exposure, but whose risk increases as the dose
nomas in either dogs or cats [11–13]. A list of the most
increases. The risk of developing cancer after radiation
commonly used radiopharmaceuticals and their half-lives
exposure is one example of this. Compared with someone
is given in Table 75.2.
who was not exposed, exposure to even low doses of radia-
tion increases the risk of developing cancer later in life.
However, the increased risk of developing cancer with low Concept of Half-Life
level exposure when receiving, treating, and handling radi-
How long a particular radiopharmaceutical is actively
oactive patients when proper precautions are taken is dif-
emitting radiation is based on the physical half-life (t1/2) of
ficult to quantify but is probably very low.
the particular isotope. The physical half-life is defined as
the amount of time required for the radioactivity to
decrease by half and is constant for each isotope. In gen-
Radiopharmaceuticals eral, after 10 half-lives an element is considered no longer
radioactive. This is the reason that when a patient dies
Veterinary Uses
directly after receiving a radiopharmaceutical, their body
A radiopharmaceutical is a radioactive drug that is either must be stored in a shielded freezer designated for this pur-
used to diagnose or treat disease. The radiopharmaceuti- pose and is not released for 10 half-lives. In the case of 131I
cals most commonly used in veterinary medicine are this would be approximately 80 days.
18
F-fluorodeoxyglucose (18FDG), technetium-99 (99mTC) The biological half-life is defined as the amount of time
and iodine-131 (131I), although others such as samarium- for a patient to eliminate one half of the compound from
153 (153Sm) and phosphorus-32 (32P) have also been the body. Most agents are excreted in the urine and/or
used [3–7]. 18FDG is used in diagnostic positron emission feces. When a radiopharmaceutical is given to a patient,
tomography (PET) or PET/computed tomography (CT) the length of time they are actively giving off radiation is
and has a half-life of just under 110 minutes. PET, while based on both the physical half-life of the element and the
relatively uncommonly used in veterinary medicine, is biological half-life. Combining these terms gives you the
becoming more readily available either on site or in some effective half-life, which can be variable between patients
cases at a human facility. While PET is most commonly due to variation in the biological half-life between
used for staging and monitoring response to treatment or individuals.
disease progression, in oncology patients it is also being
used to help diagnose other diseases such as certain mus-
Radiation Protection
culoskeletal disorders and infectious diseases. 99mTC is
used in diagnostic radiology and has also has a relatively As with patients who are exposed to x-rays for diagnostic
short half-life. When bound to pertechnetate it is most imaging (radiographs or CT), patients receiving external
commonly used for the diagnosis of portosystemic shunts beam radiation therapy are not radioactive and do not pre-
and thyroid disorders. When bound to methylene diphos- sent a risk of exposure to caregivers. This is in contrast to
phonate, it is taken up by osteoblasts and can be used to patients who receive a radiopharmaceutical agent resulting
identify active areas of bone remodeling. It is therefore in residual radioactive material being present in their body.
commonly used to help to identify affected areas in patients This leads to risk for anyone who comes in contact with
Radiopparraceeticals 999
them, their blood or other body fluids such as urine, or largely protect you from scatter radiation and should be
with their feces. These patients also have the potential to worn. No one person should be designated to hold animals
contaminate the environment, which could also place their for radiographs and this task should be shared among
owners or caregivers at risk for exposure to radiation. trained individuals, thus limiting the exposure to any one
The most basic concept of radiation protection is to limit person. Lastly, anyone taking radiographs should have
exposure as much as possible. This concept should be received training in the proper use of equipment and the
applied to anyone potentially coming into contact with any steps that can be taken to reduce the risk of exposure.
form of radiation. The term ALARA, or as low as reasona- Anyone taking radiographs should be properly monitored
bly achievable, is a mainstay of radiation protection and using a radiation detection device (dosimeter) to ensure
should be closely adhered to. To limit exposure when work- that they are not receiving too large of a cumulative dose.
ing with radiation or with a radioactive patient, the three Radiation detection badges are usually checked monthly or
main factors to keep in mind are time, distance, and shield- quarterly and reports are to be made available to the indi-
ing. Limiting the amount of contact time with a patient vidual so they are aware of what exposure they may have
will decrease the amount of dose that the caregiver absorbs. received.
Since radiation dose falls off as the distance squared,
increasing the distance from a patient substantially
Radionucleotide Safety
decreases the dose received. For example, If you are
2 meters away from a patient who is radioactive you will Any facility using a radionucleotide will have a designated
receive one quarter of the dose you would have received if radiation safety officer and a radiation safety plan as part
you were 1 meter away. Shielding the radioactive source or of their licensing requirements. This plan will detail how
patient will also greatly reduce potential exposure. For long a patient needs to be held after exposure and safety
these reasons, patients treated with a radiopharmaceutical procedures. If a treated patient is brought into a practice
are housed separately from other patients and kept out of for care other than where it was initially treated, the facil-
commonly entered areas. This can be difficult if the patient ity should be contacted and notified. Each treating facility
is ill, particularly in the first few days after being treated. will have a plan in place for handling radioactive patients
and should be familiar with local rules and regulations.
The length of time after exposure that there is a concern
External Beam Radiation Protection
for people working with the animal or its blood depends
One potential source of exposure to radiation occurs while on the particular radionucleotide. For 18FDG with its short
taking radiographs. While it is a well-established fact that half-life, there is little risk of exposure 18 hours after injec-
you should never place any part of your body in the pri- tion. With 99mTC there is little concern of exposure after
mary beam if you are holding a patient for radiographs, 48 hours, while patients treated with I131 can present a
you may still receive exposure from scatter radiation. hazard for one month or more. It should be remembered
Whenever possible, everyone but the patient should leave that the animal’s blood, urine and feces are also radioac-
the room when a radiograph is being taken. Chemical sedative. These patients should be isolated, their cages labeled
tion and restraint devices such as sand bags can be used to as radioactive, and contact minimized until it is deter-
limit the need to have someone in the room. In some states, mined whether they still present a hazard. Minimal pre-
it is not permissible to be in the room while a radiograph is cautions to be taken include wearing gloves, gowns, plastic
being taken. Regardless of the law, every attempt should be shoe covers, and a face shield when coming into contact
made to limit exposure if someone is holding an animal with these patients. Cages should not be hosed to limit the
during this procedure. With critically ill patients, it may at risk of aerosolizing and spreading radioactive material
times be impractical to sedate or restrain the patient appro- present. The cages can also be covered with plastic lined
priately for radiographs without having one or more people absorbent material to help contain any excreta such as
holding the animal. If allowed by law in your state, precau- urine. Geiger–Müller counters can be used to measure
tions should be taken if holding an animal while a radio- electron or photon radiation directly from the surface of a
graph is being taken to minimize radiation exposure. patient or from areas that may have become contaminated.
To decrease the time of exposure, careful technique These detectors generally give readouts in counts/minute
should be used to decrease the number of repeat radio- or milliroentgen/hour (mR/hour).
graphs that are needed. Wearing lead gloves will not pre- In a patient treated with I131 a Geiger counter can be
vent exposure of your hands if they are in the primary placed over their thyroid area and over any waste or bodily
beam and the field should be properly collimated so that no fluids to check for radioactivity. To check whether the work
one has any body part within the primary beam. environment is contaminated, wipe tests should be done.
Additionally, lead gowns, gloves, and thyroid shields will Wipe tests are done by taking swabs of the cage, counters,
floors, and other areas where an irradiated patient was pre- aerosolized), absorbed through the skin, or ingested.
sent and placing the wipes in a scintillation counter. Wipe Sources of exposure to hazardous chemicals for the nurs-
tests are generally part of any radiation safety plan for a ing staff can occur during transport and handling of
facility using radionucleotides and they should be able to chemotherapy drug vials, drug preparation, administra-
run the plan. Remember that once an area is contaminated, tion, handling of animal waste from patients who have
it may take up to 10 physical half-lives for the area to be received a hazardous drug, and from working in an envi-
safe unless decontamination procedures are followed and ronment that has become contaminated from any of the
the contamination is removable. All waste from animals above [15].
should be kept separately, labeled and checked for radioac- There are multiple studies of healthcare workers that
tivity. It should be stored properly and shielded until it is show residual drug in their urine [16, 17]. In addition,
no longer radioactive before disposal. As the local legal chromosomal changes consistent with exposure to muta-
requirements vary for radioactive waste disposal the treat- gens have been found in people who regularly work with
ing facility should be consulted regarding waste disposal or chemotherapy [18, 19]. As with radiation, the additional
withholding times before any animal waste is disposed of risk of developing cancer after exposure to low levels of
in municipal trash. chemotherapy is poorly understood.
Although generally not required as part of routine
employee monitoring, if there is concern that an exposure
Limiting Exposure
might have taken place with radioactive iodine a bioassay
test can be performed to see if they have absorbed any radi- The Occupational Health and Safety Administration states
onucleotide. This procedure does require specialized that sound practices require that a hazardous safety and
equipment. It is a noninvasive test where a gamma counter drug plan be developed at institutions where hazardous
is placed near the neck area to see if a person is emitting drugs are used to minimize the risk to employees [20].
gamma rays from absorbed radionucleotide that may have Additional recommendations from the Board of Pharmacy
accumulated in the thyroid. will vary from state to state.
All chemotherapeutic drugs should be mixed in a biologi-
cal safety hood. Minimally a class II laminar flow biological
Chemotherapy safety cabinet should be used [16, 20]. A pharmacy isolator
may be preferable as it has been shown that the area directly
According to American Society of Health-System outside of laminar flow hoods can become routinely con-
Pharmacists, a drug should be considered hazardous if it is taminated [21, 22]. The use of a closed drug delivery system
genotoxic, carcinogenic, teratogenic, and/or could lead to such as the PhaSeal™ (Becton Dickinson, Franklin Lakes,
decreased fertility or cause serious organ or other toxicities NJ) system while administering chemotherapy can also
at low doses in experimental animals [14]. Drugs that are decrease the risk of exposure and avoid contamination of
classified as chemotherapeutic or antineoplastic agents fall the work environment [16, 23]. Proper training in the use of
into at least one of these categories and should be handled a closed system is important to help avoid accidents leading
with care. Drugs for which there are no data regarding to contamination [24].
these potential toxicities, such as new or investigational For larger spills or those taking place outside the hood, a
drugs, should also be handled as hazardous materials. spill kit should be used. These kits are available commer-
Chemotherapeutic drugs are most commonly used to treat cially prepackaged, or you can assemble your own
dogs and cats with cancer, although some of these same (Protocol 75.1.). See Protocol 75.1 for steps to follow to con-
agents have also been used to treat inflammatory and auto- tain a spill.
immune diseases such as granulomatous meningoen- One of the most important ways to protect yourself from
cephalitis and immune-mediated hemolytic anemia. exposure to patient or environmental chemotherapy haz-
As there is little information available as to a safe level of ards is by wearing personal protective equipment
exposure to any one particular drug or chemical, it is always (PPE) [15]. Minimum PPE to be worn for hazardous drug
safest to limit exposure to ALARA. In a sense, it is the same safety would be a gown, gloves, and goggles. Additional
concept as presented for radiological hazards earlier in this PPE, such as a respirator, may be indicated for certain
chapter. Unlike with radiation, however, there is no chemo- agents with a high aerosol potential (e.g. nitrogen mus-
therapy “dosimeter” to wear or other way to quantify expo- tard). Gloves should meet the American Society for Testing
sure that is commercially available. and Materials Standard D6798. Specially manufactured
The risk of exposure to a hazardous agent is based on chemotherapy gloves should be worn whenever mixing,
the properties of the drug itself and the amount exposed administering or handling excreta from patients who have
to. Exposure can occur by drugs being inhaled (if they are received chemotherapy. Chemotherapy gloves can be made
Cperotperapp 1001
Protocol 75.1 Containing a Spill of Chemotherapy Drug

Minimum Contents Needed for a Spill Kit 4) Gently place absorbent pads on spill.
5) Place absorbent pads in plastic bags marked as
● PPE (mask, gloves, gown, goggles)
“hazardous waste.”
● Absorbent materials (pads, towels)
6) Rinse spill with equal amount of neutralizing agent
● Plastic bags
(such as Peridox™, Contec, Spartanburg, SC) by
● Incident report form
pour-over method (do not spray).
● Cautionary signage
7) Use more absorbent pads to pick up the rinse, and
thoroughly dry the area, moving from the outside of
Procedure the spill inward.
8) All contaminated materials, including PPE, should then
1) Put on gloves, mask, and goggles.
be put in a second plastic bag and disposed of in
2) If there is a large spill, restrict access to the spill area
proper containers.
and place cautionary signage, if applicable.
9) Fill out an incident report form, if applicable.
3) Wait for any aerosols to settle.
from different materials but are always powder free. Double patient should be considered a potential exposure hazard.
gloves should be worn; the first glove goes underneath the PPE should be worn when handling waste and it should be
gown, then the second pair extends over the cuff of the disposed of as chemotherapy waste. Patients that remain in
gown at the wrist, so no skin is exposed. These gloves must the hospital after receiving chemotherapy should have
undergo testing by the manufacturer to ensure that they their cages clearly marked with cautionary signage, and
are not permeable to chemotherapy agents and will be the staff should be trained in safe handling of waste prod-
clearly labeled as such. Examination gloves in general are ucts. Kennels that have housed chemotherapy patients
not sufficient to protect from exposure. should not be washed with a high-pressure hose to avoid
Gowns should be single use, close in the back, and be aerosolization of the waste. Soiled bedding should be
rated for their impermeability to hazardous drugs. They stored separately from other laundry and prewashed, and
should have closed cuffs to facilitate gloving. Surgical then washed for a second time with regular laundry. The
scrubs, lab coats, isolation gowns, and other permeable or laundry bag should either be disposed of as chemotherapy
absorbent materials do not provide enough protection and waste or washed with the bedding if it is reusable.
may increase exposure by absorbing and holding contami- Checking for environmental contamination with haz-
nation against the skin. ardous drugs is not easy, as commercial wipe tests are not
The disposal of contaminated materials and waste from readily available. This means that to minimize exposure
chemotherapy preparation, administration and from several basic steps should be taken. Work areas where haz-
patients exposed to chemotherapy is regulated by federal ardous drugs are prepared or used should be clearly labeled
(Environment Protection Agency), state, and local regula- with appropriate signage and should be separate from
tion, and an institutional plan should be developed to make other drug preparation areas. No eating, drinking, smok-
sure any facility using these hazardous drugs is in compli- ing, applying of cosmetics, or other activities of this type
ance. In general, all needles and other sharps should be should be done in an area where hazardous drugs are used
disposed of in a separate appropriately labeled chemother- or where patients treated with these drugs are housed.
apy designated sharps container. Needles should not be Personnel that are pregnant, believe they might be preg-
removed, recapped or broken off from syringes that come nant, are actively trying to conceive, or are breastfeeding
in contact with hazardous chemicals and blood or bodily should avoid any chemotherapy agents and the area in
fluids from patients exposed to chemotherapy agents. which they are administered. As this may require reassign-
Syringes should never be reused. ment of duties or changes in job descriptions, labor laws
Most of the data we have on drug excretion have been should be followed, but minimally the employee should be
extrapolated from studies on human patients, but it is safe made aware of potential risks to their fetus if they are
to assume that the routes of excretion are the same. It has exposed to chemotherapeutic agents. Proper handling of
been recommended that bedding contaminated with blood, all hazardous drugs for preparation, transport, and admin-
urine, feces, or other bodily fluids from patients treated istration should be carried out as outlined elsewhere in this
with chemotherapy are treated as potentially hazardous for chapter. The work areas and patient handling areas should
at least 48 hours after treatment. Any waste from a treated be regularly cleaned.
Chemotherapy Elimination
doxorubicin, vinblastine, and vincristine. After oral cyclo-
How long the drug is present in a patient after it is dosed phosphamide dosing, there was no detectable drug in the
depends on many factors including properties of the drug urine after one day. With vincristine and vinblastine, low
itself, its metabolism, and individual patient and species levels of drug were detectable for up to seven days post-
characteristics. For most cytotoxic drugs, full pharmacoki- treatment. Doxorubicin still had low but detectable levels of
netic information is not available in veterinary patients. One drug at three weeks after administration [26]. In a separate
study showed that vincristine, vinblastine, cyclophospha- study, these same investigators found that most serum sam-
mide, and doxorubicin could all be detected in dog urine ples contained little to no detectable drug by seven days after
after infusion [25]. Another study looked at residual drug in treatment [27]. These results indicate that care should be
dog urine after dogs were treated with several commonly taken when handling chemotherapy patients for up to
used chemotherapy drugs including cyclophosphamide, several weeks after treatment.
References
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Governing Legislation. http://www.nrc.gov/about-nrc/ Assoc. 229: 542–548.
governing-laws.html (accessed 22 August 2022). 12 Adams, W.H., Walker, M.A., Daniel, G.B. et al. (1995).
2 United States Nuclear Regulatory Commission. NRC Treatment of differentiated thyroid carcinoma in 7 dogs
Regulations Title 10 Code of Federal Regulations. Part 20: utilizing 131I. Vet. Radiol. Ultrasound 36: 417–424.
Standard for Protection against Radiation. 2022. https:// 13 Chun, R., Garrett, L.D., Sargeant, J. et al. (2002).
www.nrc.gov/reading-rm/doc-collections/cfr/part020/ Predictors of response to radioiodine therapy in
full-text.html (accessed 22 August 2022). hyperthyroid cats. Vet. Radiol. Ultrasound 43: 587–591.
3 Moe, L., Boysen, M., Aas, M. et al. (1996). Maxillectomy 14 (1990). ASHP technical assistance bulletin on handling
and targeted radionuclide therapy with 153Sm-EDTMP in cytotoxic and hazardous drugs. Am. J. Hosp. Pharm. 47:
a recurrent canine osteosarcoma. J. Small Anim. Pract. 1033–1049.
37: 241–246. 15 National Institute for Occupational Safety and Health.
4 Lattimer, J.C., Corwin, L.A. Jr., Stapleton, J. et al. (1990). (2016) NIOSH List of Antineoplastic and Other
Clinical and clinicopathologic response of canine bone Hazardous Drugs in Healthcare Settings. DHHS (NIOSH)
tumor patients to treatment with samarium-153-EDTMP Publication No. 2016–161. Washington, DC: Department
[see comments]. J. Nucl. Med. 31: 1316–1325. of Health and Human Services.
5 Shapiro, W. and Turrel, J. (1988). Management of pleural 16 Wick, C., Slawson, M.H., Jorgenson, J.A. et al. (2003).
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dog. J. Am. Vet. Med. Assoc. 192: 530–532. personnel exposure to antineoplastic agents. Am.
6 Smith, M. and Turrel, J.M. (1989). Radiophosphorus J. Health Syst. Pharm. 60: 2314–2320.
(32P) treatment of bone marrow disorders in dogs: 11 17 Sessink, P.J., de Roos, J.H., Pierik, F.H. et al. (1993).
cases (1970–1987). J. Am. Vet. Med. Assoc. 194: 98–102. Occupational exposure of animal caretakers to
7 LeBlanc, A.K. and Morandi, F. (2014). Off-site PET cyclophosphamide. J. Occup. Med. 35: 47–52.
imaging programs: challenges and opportunities. Vet. 18 Connor, T.H. (2006). Hazardous anticancer drugs in
Radiol. Ultrasound 55: 109–112. health care: environmental exposure assessment. Ann.
8 Berg, J., Lamb, C.R., and O’Callaghan, M.W. (1990). Bone N.Y. Acad. Sci. 1076: 615–623.
scintigraphy in the initial evaluation of dogs with primary 19 Sessink, P.J., Cerna, M., Rossner, P. et al. (1994). Urinary
bone tumors. J. Am. Vet. Med. Assoc. 196: 917–920. cyclophosphamide excretion and chromosomal
9 Forrest, L.J. and Thrall, D.E. (1994). Bone scintigraphy for aberrations in peripheral blood lymphocytes after
metastasis detection in canine osteosarcoma. Vet. Radiol. occupational exposure to antineoplastic agents. Mutat.
Ultrasound 35: 124–130. Res. 309: 193–199.
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scanning with 99mTc-HDP for the initial evaluation of and Health Administration. Controlling Occupational
osseous metastasis in canine osteosarcoma. Vet. Comp. Exposure to Hazardous Drugs. OSHA Technical Manual,
Oncol. 1: 152–158. VI: Chapter 2. https://www.osha.gov/hazardous-drugs/
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Surface contamination with antineoplastic agents in six anti-cancer chemotherapy by liquid chromatography-
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ifosfamide in an i.v. admixture area. Am. J. Health Syst. anticancer chemotherapy. J. Vet. Intern. Med. 24: 384–390.
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(2010). Reduction of workplace contamination with chemotherapy. J. Vet. Intern. Med. 24: 379–383.
1005
76
Handling the Suspected Cruelty Case

Alison Liu
Veterinary professionals, especially those working in emer- One veterinarian may be responsible for providing both
gency medicine, may become involved with the evaluation the initial evaluation and continuing medical care. That
and treatment of animals that are part of criminal animal veterinarian may also have been the individual who made
cruelty cases. Animal cruelty cases are medicolegal cases, the good faith report of suspected animal cruelty to law
which means that they have both medical and legal aspects. enforcement. In many instances, all three roles, which are
Veterinary forensic medicine is veterinary medicine prac- elaborated below, are carried out by the same veterinarian.
ticed within a legal context. Alternatively, responsibilities may be handled by multiple
While the term “animal cruelty” is used commonly in veterinarians each serving more specialized roles.
the veterinary community and in society, animal cruelty is
a legal determination. All 50 of the United States have ani-
Recognizing and Reporting
mal cruelty laws, but how they are defined and what con-
duct they prohibit may differ. While veterinary professionals Veterinarians frequently play an essential role in animal
are not expected to be legal experts, they should have a cruelty cases by recognizing suspected cruelty and report-
general understanding of their local animal-related laws, ing to law enforcement. While animal cruelty cases may be
including but not limited to veterinary reporting of sus- thought of as originating in animal shelters and welfare
pected animal cruelty. organizations, any veterinarian may be presented with an
Response to animal cruelty cases varies by community. animal that has been the victim of non-accidental injury
In many cities and counties, local humane societies or ani- and/or neglect. Veterinarians working in emergency medi-
mal welfare organizations have deputized humane officers cine and general practice are not uncommonly presented
that respond to and investigate animal cruelty complaints. with animals with suspicious injuries. Reporting suspected
In other communities, law enforcement agencies (e.g. police animal cruelty can be a difficult and uncomfortable task,
departments, sheriffs’ offices, animal control) enforce especially if the veterinarian has a long-standing relation-
animal cruelty laws. Veterinary professionals should be ship with the client. The veterinarian does not have the
familiar with which agency responds to animal cruelty burden of investigating and determining whether a crime
complaints in their community so that when they are pre- has been committed or who is guilty of a crime (it may not
sented with a suspicious case, they know to whom to be the owner); those are the responsibilities of law enforce-
make their good faith report. The National Link Coalition ment, prosecutors, and the courts.
maintains a database with respective reporting agencies by Veterinarians should be familiar with their state’s laws
state and community [1]. regarding reporting suspected animal cruelty. As of October
2021, 36 states had laws regarding veterinarians reporting
suspected animal cruelty; 19 states had mandatory report-
Veterinary Roles ing laws, and most states provide civil immunity to veteri-
narians who report in good faith [2]. The referenced AVMA
Veterinary professionals can have several roles in sus- website [2] contains updated information.
pected animal cruelty cases, which can vary based on how The reporting of suspected animal cruelty aligns with
the case is initiated (i.e. veterinary or law enforcement). the veterinarian’s broader role of protecting public health.
1006 Handling the Suspected Cruelty Case
“The Link” is the well-established connection between prosecutors. They may also be asked to provide expert wit-
animal cruelty and other forms of family and interpersonal ness reports or testimony in a hearing or at trial. In some
violence. In a survey of battered women entering shelters, jurisdictions, local law enforcement may establish relation-
71% of pet-owning women reported that their intimate ships with designated veterinarians, who serve as forensic
partners injured, killed, or threatened a family pet, and 57% veterinarians in all animal cruelty related investigations.
reported that actual harm or killing had occurred [3]. However, the involvement of a designated forensic veteri-
Another similar survey revealed that of battered women narian does not preclude any other veterinary profession-
reporting violence toward their pets, 88% of the reported als involved in the care of the animal from being called to
cases occurred in the presence of women and 76% occurred testify on behalf of either the prosecution or defense.
in the presence of children [4]. Concern for safety of their
pets can be a reason that survivors delay or do not leave their
Medical Care
abusive situation. Reporting animal cruelty may provide
an individual or family an opportunity to leave an unsafe After the animal is assessed, a treatment plan should be
situation. developed to address the presenting medical concerns.
Owner consent must be obtained for any treatments and
Recognizing Non-accidental Injury procedures. When animals are seized by law enforcement
Non-accidental injury is physical trauma purposely and the owner has not provided consent, medical care should
inflicted by a person on an animal. One of the most chal- not extend beyond what is considered “medically necessary.”
lenging aspects is acknowledging it as a differential. While Spays and neuters are common examples of “elective” proce-
there is no single, consistent indicator, there may be vari- dures that should not be performed except in instances where
ous aspects of either the reported history or clinical presen- they are considered a medical necessity. When an animal’s
tation of the patient that increase the veterinarian’s index medical needs exceed the capabilities of the hospital or
of suspicion (Box 76.1). shelter, the animal should ideally be transferred to another
veterinary facility that is able to provide appropriate care.
Forensic Evaluation
Forensic veterinary medicine is veterinary medicine prac- Documentation of the Suspected
ticed within a legal context. An animal that is part of an
Cruelty Victim
alleged animal cruelty case is not only a patient; it can also
be evidence in that criminal case. The findings from the
History
examination and medical treatment of the patient may be
used in a court of law. Documentation of the medical find- As with any animal that presents to a hospital for evalua-
ings should be accurate, objective, and thorough. tion of a medical concern, it is important to obtain a thor-
In most cases, the veterinarians providing medical care ough history. Client service representatives, veterinary
will also fulfill the forensic evaluation role by communicat- assistants, and veterinary technicians typically have initial
ing the animal’s medical status to law enforcement and contact with owners and serve as essential communicators.
Box 76.1 Features That May Increase a Veterinary Health Care Worker’s Index of Suspicion for Non-Accidental Injury
History Clinical Findings
● History is inconsistent with the injuries ● Repetitive injuries (the animal has presented previ-
● History is discrepant (e.g. changes from person to ously with injuries or has injuries in various stages of
person, owner changes their story) healing)
● No history is provided ● Injuries cannot be explained by an accident
● Another animal in the household has a history of ● Fractures feature prominently
injuries or death ● Multiple fractures
● Absence of an accidental scenario ● Fractures involving multiple areas of the body
● Animal is kept primarily or only indoors ● Transverse fractures
● Known or suspected violence in the home ● Fractures in later stages of healing
● Behavior of the owner arouses suspicion ● Multiple fractures at different stages of healing
Source: Adapted from references [5–10].
ocuuentation oo the Suspected Cruelty ictiu 1007
A comprehensive set of questions should be asked of the Photography

client and attention to details they provide may increase
Every animal should be documented by a taking a standard
the index of suspicion for reporting suspected cruelty
series of whole-body photographs during initial examina-
(Box 76.1). The history should be thoroughly documented
tion. In a survey where prosecutors were asked what type
in the patient’s medical record.
of animal evidence influenced their decision to prosecute a
When law enforcement brings animals for evaluation,
case, approximately two thirds cited photographs as a sig-
veterinary staff should inquire whether scene photos and/
nificant factor [14].
or video as well as any reports were created and if so,
Photographs should be taken as close to the time of initial
request them for review. Photographs and video of where
examination as possible because the animal’s appearance
the animal was found can provide the veterinarian better
will change with time and after receiving treatment.
context when evaluating the animal’s medical findings as
Photographs taken after treatment may affect a veterinari-
they relate to their living environment. Scene documen-
an’s ability to draw conclusions about a particular injury. For
tation can also help the veterinarian assess the suitability
example, gunshot wounds will appear remarkably different
of living conditions, a frequent question that arises in
after they are clipped, cleaned, and surgically addressed.
neglect cases.
Certain characteristics that help determine which wound
was an entrance and which was an exit wound will be lost. A
Physical Examination wound that is left to heal by second intention may appear
different several days later. While photographs should be
A thorough physical examination should be performed
taken prior to non-urgent medical intervention, photogra-
at presentation. While full physical examination would
phy should not delay any life-saving medical care.
ideally occur prior to treatment that could alter the
A photograph of the animal’s identification (e.g. an iden-
patient’s presenting state, thorough examination should
tifying case board or label) should be taken at the com-
never preclude medical stabilization. As with any other
mencement of the photo series and should include the
emergency patient being triaged, pain medication should
date, case number, and animal identification number or
be provided as clinically indicated.
name. Photographic views should include all sides of the
The initial physical examination should include assign-
animal’s entire body (Figure 76.1). Photographs of denti-
ing a body condition score, which is especially crucial in
tion will document the appearance of the teeth, which can
underweight animals. The Purina Body Condition Scale
be used to estimate the age of the animal. Areas of interest,
is a widely used tool that had been scientifically vali-
such as a wound or other lesion, should also be photo-
dated [11–13]. When evaluating an underweight animal,
graphed. When photographing areas of interest, overview,
the veterinarian does not want to under or overestimate
mid-range, and close views should be taken to help orient
how much weight the animal has lost; hence, the value of
the viewer (Figure 76.2). A scale placed in the visual field,
the objective scoring system. Final assessment of the ani-
adjacent to the area of interest, of at least one photograph
mal’s ideal body condition after weight gain may provide
can help provide relative size information. The American
further guidance in assessing whether the estimate of their
Board of Forensic Odontology number 2 photo scale is an
initial body condition was accurate.
inexpensive scale that is widely accessible online. If a scale
A pain assessment should also be performed. A stand-
is not available, an object that has a standardized size such
ardized pain scale, such as the Glasgow Composite Measure
as a coin can be placed in the visual field.
Pain Scale or the Colorado State University’s Acute Canine
Because photographs are potential evidence in a crimi-
(or Feline) Pain Scale can be used. At a minimum, docu-
nal case, they should not be deleted or altered. Deleting a
mentation of abnormal behavior interpreted as pain during
photograph in a series will cause a gap in the digital photo
examination should be noted in the medical record.
numbering system. Photographs should be saved in a
Reevaluation after analgesics have been administered can
secured location, such as a secured drive or cloud-based
serve as additional documentation of an animal’s pain or
storage system. If photographs that are used in a written
discomfort during initial intake.
report are altered (e.g., cropped, enlarged, edited), ensure
Scanning the animal for an identifying microchip may
that the original unaltered photograph has been saved.
be helpful in cases involving stray or abandoned animals.
This information can provide law enforcement a poten-
tial lead in a case where the ownership status is
Videography
unknown. In some cases, claims made by an apparent
“good Samaritan” of recently finding an animal may be Video can be another tool in documenting an animal’s pre-
dispelled after it is determined that the microchip is senting condition. Video can be especially impactful in
registered to them. cases in which the animal has a neurologic condition or
(a) (b)
(c) (d)
(e) (f)
(g) (h)
Figure 76.1 Photographic series of a dog at initial intake. (a) Photo label with date, case, and animal identifying information. (b) Left
lateral. (c) Right lateral. (d) Cranial. (e) Ventral. (f) Dorsal. (g) Caudal. (h) Oral (right side of the mouth).
ocuuentation oo the Suspected Cruelty ictiu 1009
and urinalysis. Dogs should be tested for heartworm dis-

ease and cats should be tested for feline leukemia and
feline immunodeficiency viruses. The biochemistry panel
should include creatine phosphokinase (also known as cre-
atine kinase, CK) and aspartate aminotransferase (AST),
which are often excluded from basic biochemistry panels;
both can be beneficial in assessing muscle injury.
Animals with significant laboratory work abnormalities
should have their bloodwork rechecked at appropriate
intervals. The normalization of certain values shortly after
initial presentation may help the veterinarian form conclu-
(a)
sions about injuries. For example, a high alanine ami-
notransferase (ALT) level at initial presentation that
normalizes shortly after presentation without treatment
may indicate acute hepatic injury.
A fecal ova and parasite test should also be performed.
Ruling in or out intestinal parasites is especially important
in underweight animals. Intestinal parasites are often
reported by owners as the reason their pet is underweight.
In large, multi-animal cases (e.g. hoarding or other neglect
case involving multiple animals) a high prevalence of
intestinal parasites may serve as further evidence of the
lack of appropriate care and poor environmental condi-
tions of the population.
(b)
Diagnostic Imaging
Radiographs should be taken as part of the initial mini-
mum database. Orthogonal thoracic and abdominal radio-
graphs should be considered the minimum survey views.
Additional views should be taken based on physical exami-
nation findings. A dog with a strangulating wound to one
of its limbs should have radiographs taken of the affected
limb and of the contralateral limb for comparison. Animals
that have blunt force trauma injuries or are alleged to have
experienced trauma should have full body radiographs,
including skull, thorax, abdomen, pelvis, and limbs. It is
(c) not uncommon to diagnose additional injuries not identi-
fied on physical examination (Figure 76.3). This is a com-
Figure 76.2 Photographic series of an area of interest (sharp mon diagnostic tool used to identify injuries at different
force injury). (a) Overview. (b) Mid-range and (c) close, both with
stages of healing. Healing or healed rib fractures are exam-
standardized measurement device in frame.
ples of older injuries that are typically not palpated during
physical examination.
lameness. Video may also better visually communicate an Because animals that are part of alleged cruelty investi-
animal’s pain and discomfort than words and photo- gations frequently present to veterinarians with a limited
graphs alone. or ambiguous medical history, performing survey radio-
graphs allows for the most comprehensive evaluation of
that animal. Not only can radiographs help identify addi-
Laboratory Tests
tional injuries not seen on physical examination, they can
Every animal should have survey laboratory tests per- also diagnose unrelated medical conditions that the veteri-
formed at initial intake regardless of their physical exami- narian may need to address.
nation findings. An ideal minimum database includes a Ultrasound can be contributory as part of the initial eval-
complete blood count, comprehensive serum biochemistry, uation. Thoracic and abdominal point of care ultrasound
Injuries
Animal cruelty cases are often classified into two categories:

physical abuse and neglect. Physical abuse may also be
referred to as intentional abuse or non-accidental injury.
Neglect cases involve failing to provide proper care or acts of
omission. Below is an overview of some of the types of inju-
ries that may be seen in animal cruelty cases. Additional
resources are provided for reference at the end of this chapter.
Physical Abuse
Blunt Force Trauma
Blunt force trauma is the most common type of physical
trauma that veterinarians encounter. Blunt force trauma is
trauma caused by impact of a blunt object against a body,
impact of the animal against a blunt surface, or a combina-
tion of both. Blunt force injuries include abrasions, contu-
sions, lacerations, and fractures. Abrasions are superficial
injuries that result in loss of the top layer of skin from fric-
tion with a blunt object. Contusions are bruises caused
when a blunt impact ruptures blood vessels, resulting in
Figure 76.3 Ventral-dorsal thoracic radiograph of four-month- blood leaking into surrounding tissue. Lacerations are
old dog that was presented for reportedly being malnourished. tears in soft tissue and typically have irregular, jagged mar-
In addition to being underweight, the dog was found to have gins. Bony fractures can occur with significant blunt force
many fractures at different stages of healing, including 22 rib
injury. Skin injuries may not always be easily detected on
fractures (shown with arrows).
physical examination, especially those that are small and
superficial. Careful examination of the skin by parting the
should be considered in cases of known or suspected hair coat can help detect subtle injuries. In areas where
trauma to the abdominal and thoracic cavities (Chapters 27 skin injury is identified or suspected, clipping the hair coat
and 39). Animals that show evidence of liver injury on will provide better visualization (Figure 76.4). It is not
bloodwork may benefit from a complete abdominal ultra-
sound. For underweight animals, ultrasound may help to
rule out certain disease processes that account for weight
loss. As with the diagnostic workup of any non-criminal
case, ultrasound may be indicated for animals with a vari-
ety of other medical conditions (e.g. pyometra, intestinal
disease).
Computed tomography (CT) can be a valuable tool for
evaluating animals with traumatic injuries. CT provides
superior detail compared with radiography and can reveal
injuries that were not apparent radiographically. In a pro-
spective study of dogs that presented to a hospital with a
history of motor vehicle accident injuries, CT was deter-
mined to be more sensitive for detecting thoracic trauma
than radiography [15]. Magnetic resonance imaging may
be indicated for certain neurologic conditions. When con-
sidering advanced imaging, the animal’s overall health sta-
tus must be considered. Critically ill animals may be
medically unstable for sedation, and advanced diagnostics
such as these should not be done in patients in which it is Figure 76.4 The skin contusions on the dorsal aspect of this
medically contraindicated. dog’s head are best appreciated after fur is clipped.
nnuries 1011
uncommon for animals to have no recognizable soft tissue wounds that are longer than they are deep (e.g. surgical
injury on physical examination. The absence of injury does incision). Sharp force injuries typically cause a significant
not rule out blunt force trauma. amount of hemorrhage and a minimal amount of bruising
Thorough evaluation of the animal’s injuries may allow in contrast to blunt force injuries. The edges of the wound
the veterinarian to conclude whether the injuries are more are straight and well defined; however, these physical fea-
consistent with an accidental scenario or non-accidental tures may be more challenging to appreciate the older the
injury. In a retrospective study of dogs and cats that sus- wound is. The measurements of sharp force wounds do not
tained non-accidental blunt force trauma compared to always equate to the size of the instrument used to cause
those that were injured from a motor vehicle accident, them. For example, a stab wound may be deeper than the
there was a difference in the pattern of injuries. Box 76.2 length of the blade if the knife is pressed firmly into the
summarizes the injuries that were found to be signifi- animal, depressing the skin and underlying soft tissues.
cantly associated with the respective groups. Note that Gunshot injuries are caused by penetration of a projec-
head injuries (scleral hemorrhage, dental fractures, skull tile from a firearm. Gunshot wounds may be difficult to
fractures) were found to be associated with non-accidental distinguish from other injuries, especially if the wounds
injury, whereas a more caudal pattern of skeletal injuries are older. Radiographs can confirm the presence of a
(pelvic/sacral fractures, sacroiliac luxations) was found projectile and assess the extent of the injuries; however,
to be more commonly associated with motor vehicle projectiles that pass through and exit the body (referred
accidents. to as through-and-through injuries) will not be detected
radiographically.
Penetrating Trauma While low velocity firearms like air-powered pellet guns
Penetrating trauma is trauma that involves injury from and BB guns have less speed than high velocity firearms
penetration of an object into the body and includes sharp such as handguns and rifles, low velocity firearms can
force trauma and gunshot wounds. Some bite wound inju- cause devastating injuries. Law enforcement should be
ries can also be classified as penetrating trauma. notified in cases where a projectile is recovered so that if
Sharp force trauma is injury resulting from a sharp indicated, they can take possession of it for evidentiary
object, such as a knife, scissors, glass, or other sharp object. purposes. Projectiles should not be handled with metal for-
Stab wounds are sharp force wounds that are deeper than ceps to prevent damaging them. While the veterinarian’s
they are wide, whereas incisional wounds are sharp force basic assessment of the projectile (e.g., being consistent
with a certain type of weapon such as a pellet) can be con-
tributory to the initial investigation, further analysis should
Box 76.2 Injuries Found to be Significantly be reserved for law enforcement ballistic experts.
Associated with Non-Accidental Blunt Force Trauma The veterinarian should attempt to determine the
Compared with Motor Vehicle Trauma entrance and exit wound, if present. Entrance wounds are
Non-accidental usually smaller than exit wounds. They often have a
rounder shape in contrast to exit wounds that typically
● Scleral hemorrhage have a more irregular shape. Entrance wounds typically
● Teeth fractures have an inward beveled appearance and there may be hair
● Skull fractures that has been pushed into the wound from the projectile
● Rib fractures entering the tissue (Figure 76.5).
● Vertebral fractures Bite wounds can be classified as penetrating injury if the
● Damage to claws tooth penetrates through the tissue. Bite wounds frequently
● Older fractures also involve some degree of blunt trauma in the form of
crushing injury from the animal’s jaws.
Motor vehicle accident
● Pneumothorax Burns
● Pulmonary contusions Burns can either be intentional or accidental. While there
● Sacroiliac luxations may be characteristics that are more supportive of one ver-
● Pelvic/sacral fractures sus the other, the veterinarian may not be able to form a
● Abrasions definitive conclusion about the nature of the burns. Burns
● Degloving injuries that are suspected to be accidental may constitute making
a good faith report if it appears there has been a significant
Source: Intarapanich et al. (2016) [6]
delay in seeking treatment.
emaciation. It generally takes one to two months for an

emaciated animal to reach ideal body condition and for a
veterinarian to form their final conclusions.
Animals that show evidence of malnourishment should
initially be fed a refeeding diet to minimize the risk of
refeeding syndrome, a potentially fatal complication that
can occur when reintroducing food to an animal that has
experienced prolonged malnutrition. The shift from fat to
carbohydrate metabolism can result in dangerous electro-
lyte abnormalities. A refeeding protocol should consist of a
restricted caloric diet during the first days. After these first
days, if the animal does not show signs of refeeding syn-
(a)
drome, the caloric intake can be gradually increased until
feeding for resting energy requirements is reached
(Chapter 42).
The animal should be weighed and their body condition
monitored regularly. Most underweight animals can be
weighed every one to two weeks. After an animal reaches
an ideal body condition, the weight gained can be com-
pared as a percent of initial intake weight. Most animals
that were emaciated at initial presentation should be
expected to gain approximately one third or more of their
presenting body weight.
Animals should only be dewormed if parasites are
detected in their fecal examination. The presence of intes-
(b)
tinal parasites in an otherwise asymptomatic animal is
Figure 76.5 Gunshot wounds in a Dalmatian dog. (a) Entrance typically an incidental finding and not a significant con-
wound; note the round shape, smaller size, and hair being pulled tributing factor to weight loss. Animals that are immuno-
into the entry wound. (b) Exit wound; note the more irregular suppressed and/or exposed to poor environmental
shape and larger size of the exit wound.
conditions are most susceptible to infections, including
parasitism.
Taking a biopsy of the suspected burn may be contribu- Hair Coat Matting
tory as it can provide confirmation that the wound is a Hair coat matting resulting from inadequate grooming
burn as well as establish an estimated age of the injury. over a long period of time can lead to meaningful medical
Histopathology cannot definitively differentiate between issues including dermatitis, wounds, myiasis (infestation
chemical and thermal burns. by fly larvae), impaired mobility, and pain. Dogs with
severe hair matting may need to be anesthetized to be ade-
quately groomed. Mats should be examined and photo-
Neglect
graphed. The weight of the removed hair mats should be
Chronic Inadequate Feeding obtained and compared to the intake weight of the animal.
Chronic or prolonged inadequate feeding is inadequate Because matting can prevent full examination of the skin,
feeding over a long period of time (generally at least several dogs should be examined before and after grooming.
weeks) and is frequently referred to as starvation. Because Hair matting along the limbs can cause strangulation
“starvation” often evokes thoughts of complete withhold- wounds from ischemic necrosis (Figure 76.6). This can
ing of food, it is the author’s opinion that chronic or pro- result in soft tissue infection, necrosis, osteomyelitis, and
longed inadequate feeding are usually preferable terms. It injury to ligaments and tendons. In more severe cases,
is not uncommon for non-medically trained individuals to complete separation of the paw from the limb can occur.
assume that an emaciated animal has been withheld food. While many strangulation wounds can heal with regular
Only after ruling out medical conditions that would wound management over several weeks, some injuries are
account for weight loss and monitoring the animal’s weight so severe that the limb must be amputated. A biopsy of the
for a period of time after initial presentation will a veteri- wound can be contributory by confirming the diagnosis
narian be able to determine the cause of the presenting and establishing an estimated age of the wound.
nnuries 1013
healing seen on radiography of fractures. When consider-

ing reporting a suspected medical neglect case, a review of
previous medical records may be beneficial in demonstrat-
ing previous attempts to seek medical care. However, it is
important to note that this information may not be availa-
ble at the time the veterinarian initially sees the animal and
may only be discoverable when law enforcement performs
their investigation.
Exposure to Environmental Extremes

Heat stroke is the most serious form of heat-induced
injury and can become rapidly fatal. Thermal tissue
injury can occur when the body is no longer able to dis-
sipate heat adequately to maintain temperature below a
safe point.
While animals that are housed both outdoors as well as
indoors can become victims of heat-related injury, animals
that are confined are less able to exert control over their
environment and are at greater risk for experiencing heat
stroke. For example, consider how being restricted by a
short tether in direct sunlight on an outdoor balcony with-
Figure 76.6 Left thoracic limb paw, dorsal surface. This
out water when the ambient temperature is 90°F increases
extensive wound is a strangulation injury caused by severe hair
matting that resulted in severe tissue infection, necrosis, and a dog’s risk for heat injury in contrast to that same dog
sloughing. being loose inside a backyard with multiple areas of shade
and access to water.
Embedded Collar Animals confined inside vehicles not being operated
Embedded collar wounds are injuries to the neck caused can become victims of heat-induced injury very quickly.
when a collar, chain, leash, or other neck lead becomes Even when the ambient temperature outside is relatively
embedded in the skin, resulting in injury to the skin and mild, the temperature inside the vehicle can rapidly rise,
possibly underlying tissues. This injury is most commonly creating dangerous conditions. A study by McLaren, et al.
seen in young, growing animals. Collars should be cut found that in ambient temperatures of 72–96°F, the
away, measured, and that measurement compared to the temperature inside a car increased on average 40°F in a
circumference of the animal’s neck. In the event the collar one-hour period with 80% of the temperature rise occurring
has been removed and does not accompany the animal to during the first 30 minutes. In this same study, cracking
the veterinarian, conclusions about the cause of these the windows 1.5 inches (3.8 cm) did not make a signifi-
wounds can often still be made based on these wounds’ cant difference [16].
characteristic appearance of being fully or partially cir- Animals exposed to frigid temperatures should be evalu-
cumferential and located in the cervical region; collar ated for signs of hypothermia. Signs of hypothermia, espe-
embedment wounds frequently have granulation tissue. cially if mild, such as shivering and heat seeking behavior,
Whenever possible, a skin biopsy should be considered and frequently resolve quickly once the animal is removed
may help establish an estimated age of the wound. A wedge from the environment. Animals that have experienced
biopsy perpendicular to the wound should be taken and extreme cold are at risk of developing frostbite, which is
should include haired skin through scar tissue to most often seen along the extremities.
healthy tissue. With any suspected case of exposure to extreme tem-
peratures, it is important to take the animal’s temperature
Medical Neglect as soon as possible while keeping in mind that their tem-
Medical neglect can include virtually any injury or illness perature frequently changes drastically during transpor-
where it is alleged that treatment was not sought or not tation from the environment to the hospital. Because of
sought in a reasonable timeframe. These cases are often this, animals may have a normal body temperature at
also referred to as “failure to treat.” Establishing an esti- time of initial examination. It is not uncommon for ani-
mated timeframe is a crucial component of medical neglect mals exposed to environmental extremes to show no
cases. This may be done by reviewing previous medical appreciable abnormalities on physical examination or
records, taking biopsies of wounds, or assessing degree of diagnostics.
Special Considerations for Deceased The body should ideally be sent to a veterinary diagnostic
Animals laboratory for a pathologist to perform the necropsy. If the
necropsy is performed by a veterinarian in-house, tissue
Veterinary hospitals may be presented with deceased ani- samples should be collected and submitted for histopathol-
mals that veterinary staff become suspicious about after ogy. While some diagnoses can be made based on gross dis-
hearing the owner or caregiver’s reported history. section (e.g. traumatic injuries), histopathology is often
Examination of a deceased animal should not be per- necessary for a definitive diagnosis. Histopathology is also
formed until legal consent is obtained. In contrast to live contributory in ruling out other conditions and providing
animals that may have been seized by law enforcement, an estimated duration of injuries or illness.
examination of deceased animals is not medically neces-
sary. Because a necropsy results in the collection of evi-
dence, either consent from the owner or a search warrant Summary
obtained by law enforcement is necessary prior to being
performed. Veterinary professionals working in emergency medicine
Like the examination of live animals, the external exami- may encounter animals that they believe may have been vic-
nation of deceased animals should include photographs of tims of animal cruelty. Careful evaluation of the patient’s
all sides of the entire body. Photographs should also be reported history and assessment of their injuries may
taken of any external packaging around the body as that increase a veterinarian’s index of suspicion and support
packaging is being opened (e.g. bags, boxes, carriers). making a good faith report to law enforcement. Animal cru-
Radiographs can aid in diagnosing conditions and can elty can be classified as either physical abuse or neglect.
provide direction on areas of the body where post-mortem Because animals in criminal animal cruelty cases can be evi-
examination should be better focused. A complete nec- dence, their condition should be thoroughly documented,
ropsy should then be performed and photographs taken. while simultaneously providing necessary medical care.
References
1 National Link Coalition. How do I report suspected abuse? 7 Munro, R. and Munro, H.M.C. (2008). Animal Abuse and
http://nationallinkcoalition.org/how-do-i-report- Unlawful Killing: Forensic Veterinary Pathology.
suspected-abuse (accessed 29 September 2022). Edinburgh, UK: Elsevier Saunders.
2 American Veterinary Medical Association (2021) 8 Munro, H.M.C. and Thrusfield, M.V. (2001). “Battered
Summary Report: Reporting requirements for animal pets”: non-accidental physical injuries found in dogs and
abuse (by state). Washington, DC: AVMA. https://www. cats. J. Small Anim. Pract. 42 (6): 279–290.
avma.org/sites/default/files/2021-10/Reporting- 9 Munro, H.M.C. and Thrusfield, M.V. (2001). “Battered
requirements_for-animal-abuse.pdf (accessed 29 pets”: features that raise suspicion of non-accidental
September 2022). injury. J. Small Anim. Pract. 42 (5): 218–226.
3 Ascione, F.R. (1998). Battered women’s reports of their 10 Tong, L. (2014). Fracture characteristics to distinguish
partners’ and their children’s cruelty to animals. J. Emot. between accidental injury and non-accidental injury in
Abuse 1: 119–133. dogs. Vet. J. 199 (3): 392–398.
4 Quinlisk, J.A. (1999). Animal abuse and family violence. 11 Mawby, D., Bartges, J.W., Moyers, T. et al. (2001).
In: Child Abuse, Domestic Violence, and Animal Abuse: Comparison of body fat estimates by dual-energy x-ray
Linking the circles of compassion for prevention and absorptiometry and deuterium oxide dilution in client
intervention (ed. P. Arkow and F.R. Asione), 168–175. West owned dogs. Compendium 23 (9A): 70.
Lafayette, IN: Purdue University Press. 12 Laflamme, D.P. (1997). Development and validation of a
5 Arkow, P., Boyden, P., and Patterson-Kane, E. (2011). body condition score system for dogs. Canine Pract.
Practical Guidance for the Effective Response by 22: 10–15.
Veterinarians to Suspected Animal Cruelty, Abuse and 13 Kealy, R.D., Lawler, D.F., Ballam, J.M. et al. (2002). Effects
Neglect. Schaumburg, IL: American Veterinary Medical of diet restriction on life span and age-related changes in
Association. dogs. J. Am. Vet. Med. Assoc. 220 (9): 1315–1320.
6 Intarapanich, N.P., McCobb, E.C., Reisman, R.W. et al. 14 Lockwood, R., Touroo, R., Olin, J., and Dolan, E. (2019).
(2016). Characterization and comparison of injuries caused The influence of evidence on animal cruelty prosecution
by accidental and non-accidental blunt force trauma in and case outcomes: results of a survey. J. Forensic Sci. 64
dogs and cats. J. Forensic Sci. 61 (4): 993–999. (6): 1687–1692.
Recouuended Reading 1015
15 Dancer, S.C., Le Roux, C., Fosgate, G.T., and Kirberger, 16 McLaren, C., Null, J., and Quinn, J. (2005). Heat stress
R.M. (2019). Radiography is less sensitive relative to CT from enclosed vehicles: moderate ambient temperatures
for detecting thoracic radiographic changes in dogs cause significant temperature rise in enclosed vehicles.
affected by blunt trauma secondary to a motor vehicle Pediatrics 116 (1): e109–e112.
accident. Vet. Radiol. Ultrasound 60 (6): 648–658.
Recommended Reading
Animal Folks MN (2020). Reporting Animal Cruelty: The role animalfolksmn.org/downloads.html (accessed 29
of the veterinarian establishing protocols to identify and September 2022).
report animal cruelty in Minnesota. St. Paul, MN: Animal Merck, M. (ed.) (2013). Veterinary Forensics, 2e. Wiley:
Folks/Animal Law Resources MN. https://www. Ames, IA.
1017
Section Eleven
Wellness for the Veterinary Health Care Team
1019
77
Self-Compassion: The Cornerstone of Wellbeing

Deborah A. Stone
Introduction including human and animal health. Compassion fatigue,

in the health arena, is the result of individuals caring for
Veterinary professionals consistently work in emotionally and giving to their patients to the point where there is often
charged and physically demanding environments. little or no energy to care for themselves.
Continuously serving clients, patients, and other practice Literature consistently advises caregivers to be mindful of
stakeholders is a familiar expectation within every work prioritizing self-care over patient care, so the best outcomes
shift. Veterinary professionals are known to give of them- are realized. This often resembles the oxygen and mask anal-
selves regularly to an exhaustive level to patients, clients, ogy, where the flight attendant announces, in the case of an
and the practice team, thus often realizing that there is not emergency, first place the mask on yourself before placing
much left for themselves. Too often, they may feel stuck in on a child or someone in need. According to one of the lead-
an endless cycle of going to work, giving their all, going ing compassion fatigue researchers, Charles R. Figley [1],
home, and doing it all over again the next day. “There is a cost to caring. Professionals who listen to clients’
Practice team members regularly experience the joys of stories of fear, pain, and suffering may feel similar fear, pain,
positive outcomes as well as the stresses associated with and suffering because they care. Sometimes we feel we are
negative outcomes and a constantly changing profession. losing our sense of self to the clients we serve.” This likely
The wellbeing of veterinary professionals is a growing con- resonates with many veterinary professionals as they listen
cern within the veterinary industry, and as a result, there to and empathize with the clients who bring in their pets for
are increased endeavors to raise awareness and develop end-of-life care and share the fear, pain, and suffering of los-
actionable resources. ing their best friend or family member.
This chapter introduces the powerful yet challenging Figley, together with co-researcher, Robert G. Roop, spe-
construct of self-compassion. It explores why the construct cifically addresses compassion fatigue in the veterinary
is so challenging and provides resources to help us to profession. As noted in their book, Compassion Fatigue in
understand the importance of giving ourselves a break the Animal-Care Community [2], “For years, compassion
when things do not go as we had hoped or planned. fatigue was an unspoken occupational hazard of humane
In addition, the constructs of compassion fatigue and work. It caused diminished productivity, high attrition
burnout are discussed. These terms may already be rates among shelter workers, and, worst of all, despair.”
familiar from a significant number of available resources. This text advises the importance of self-care and of devel-
The nuances between compassion fatigue, burnout, and oping specific plans that can mitigate the symptoms of
self-compassion are also discussed. compassion fatigue (Box 77.1).
Compassion Fatigue How to Address Compassion Fatigue
An often-mentioned construct in the wellbeing space is The veterinary profession continues to learn about compassion
compassion fatigue. This term is associated with fatigue and the impact it has on practice team members.
individuals working across all caregiving professions, There are many resources, including assessments, available
1020 Self-Compassion: The Cornerstone of Wellbeing
syndrome has been documented in a wide range of

Box 77.1 Common Personal Symptoms
health care professions, and job stress is recognized
of Compassion Fatigue
as the principal cause of burnout.
● Bottled-up emotions
● Sadness and empathy Stressors associated with burnout are often linked to the
● Inability to get pleasure from activities that previ- workplace in areas such as level of exhaustion and the
ously were enjoyable many nuances associated with practice culture. Examples
● Isolation of these stressors may be seen when practice team mem-
● Difficulty concentrating bers are scheduled to work long intervals of overtime,
● Feeling mentally and physically tired the practice leadership is perceived by team members
● Chronic physical ailments as not being approachable to ask questions, or may be
● Voicing excessive complaints about your job, your consistently overwhelmed by a constantly overscheduled
manager(s) and/co-workers patient caseload.
● Lack of self-care, including poor hygiene and a drop- To reduce the symptoms of compassion fatigue and
off in your appearance burnout (Box 77.3), experts advise the necessity of self-
● Recurring nightmares of flashbacks care. Examples of self-care in regard to compassion fatigue
● Substance abuse or other compulsive behaviors such might include taking care of yourself physically and men-
as over-eating or gambling tally and connecting with others to discuss successes and
Source: American Veterinary Medical Association. Work and com- challenges. Through self-care and reflection, you may
passion fatigue. remember what brings you joy in your life Asking yourself:
are you experiencing that joy and if not, why not? And if so,
how can you do more of that joy?
Box 77.2 Personal Approaches to Combat Examples of self-care in regard to burnout (Box 77.4) are
Compassion Fatigue very similar to those in compassion fatigue. They may also
include moments of reflection to determine whether your
Focus on building your resilience
current work environment is still working for you. How much
●
Take time to be alone with yourself

of the increased cases and stress is associated with a tempo-
●
Engage in meditation and/or mindfulness-based stress

rary change event or is this truly the culture? Do you have a
●
reduction
voice that is heard by the practice leadership? The reflective
Engage with co-workers
self-care may help to determine whether you stay or go.
●
Connect with other colleagues

The examples for both compassion fatigue and burnout
●
Practice expressive writing

both indicate reflection, which may present uncomfortable
●
● Practice your spiritual beliefs

● Complete basic hygiene tasks
Wash up before you leave work
Box 77.3 Common Symptoms of Burnout
●
Source: American Veterinary Medical Association. Work and com-

passion fatigue. ● Excessive stress
● Fatigue
● Insomnia
to help veterinary professionals reduce the impact of ● Sadness, anger, or irritability
compassion fatigue (Box 77.2) so they may continue ● Alcohol or substance misuse
doing more of what they love to do, both personally and ● Vulnerability to illnesses
professionally. Source: Mayo Clinic. Job burnout: How to spot it and take action.
Burnout
Box 77.4 Handling Burnout
Another often referred to construct that presents a signifi- ● Evaluate your options
cant number of resources in the veterinary space is burn- ● Seek support
out. According to Hayes et al. [3]: ● Try a relaxing activity
● Get some exercise
Burnout has been defined as a psychological state ● Get some sleep
typified by emotional exhaustion, depersonalization, ● Mindfulness
or cynicism towards patients and colleagues, and a
Source: Mayo Clinic. Job burnout: How to spot it and take action.
reduced sense of personal accomplishment. Burnout
ntrooduing Self-Compassion 1021
processes. Making significant life changes is very rarely

Box 77.5 The Nine Dimensions of Wellbeing
easy. Doing the work and reflecting on where you are now
and where you would like to go will provide increased 1) Occupational – Being engaged in work that gives
chances for positive change and making goals a reality. you personal satisfaction, and aligns with your val-
ues, goals, and lifestyle
2) Intellectual – Learning new things; Participating in
Self-Care and Wellbeing activities that foster critical thinking and expand
your worldviews
As we saw with the compassion fatigue and burnout dis- 3) Spiritual – Having a sense of inner harmony
cussions, self-care is critical to reduce many potentially and balance
debilitating symptoms. Self-care intersects these two con- 4) Social – Surrounding yourself with a network of
structs, is included in our roadmaps to wellbeing, and support built on mutual trust, respect, and
comes in many different forms. compassion
This chapter refers to wellbeing and constructs related to 5) Emotional – Being able to identify and manage your
wellbeing. According to the American Association of full range of emotions, and seeking help when
Veterinary Medical Colleges (AAVMC) [4], “Health is a state necessary
of being, often represented by numbers in a medical history. In 6) Physical – Taking care of your body e.g. getting
contrast, wellbeing is a state of living that speaks to our overall enough sleep, eating a well-balanced diet, exercis-
quality of life”. The AAVMC reference to health being “repre- ing regularly, etc.
sented by numbers” refers to the medical diagnostic results 7) Financial – Being aware of your personal finances
included in our personal medical history. The definition of and adhering to a budget that enables you to meet
wellbeing used by the National Wellness Institute, “Well(being) your financial goals
is an active process through which people become aware of, 8) Creative – Participating in diverse cultural and artis-
and make choices toward, a more successful existence”. tic experiences
According to the American Veterinary Medical 9) Environmental – Taking an active role in preserving,
Association (AVMA) [5]: protecting, and improving the environment
Source: American Veterinary Medical Association. The nine dimen-
“Your mental and physical wellbeing depends largely sions of wellbeing.
on your ability to care for yourself in addition to your
patients. You do not have to do it alone, but you have to
do it. You’re the one who has to prioritize your own care Introducing Self-Compassion
as well as that of your patients and clients. Why? It is
simple: If you are not taking care of yourself, you’ll be The introduction of the construct self-compassion allows
less able to care for others. Your own wellbeing affects for yet another dimension of self-care. What happens when
your ability to care for your patients and your loved ones.” things do not go as planned, whether in our personal or
professional lives? What do we tell ourselves? Are we as
Self-care may be a personal challenge for many veterinary kind to ourselves as we are to our colleagues and friends?
professionals to weave into their life routines due to many There is a significant amount of research, literature, and
variables, which may include, “I don’t have time” or “I don’t empirical data associated with the self-compassion con-
know where to start.” Concerning where to start, the AVMA struct. In the context of this chapter, insight and steps to
lists nine dimensions of wellbeing [5] that allows opportuni- help veterinary professionals understand and practice self-
ties to reflect and target areas that may need your attention. compassion are provided.
When reflecting on these nine dimensions (Box 77.5), you In spite of all the things veterinary professionals do every
are trying to identify gaps in your wellbeing. If you identify a day in practice, such as providing patient care, communi-
gap or a deficit, consider referring to the resources provided cating with clients, and working with team members, we
at the end of this chapter. Assessing the nine dimensions of also often hold onto events we believe did not go as well
wellbeing may be a first step toward identifying where to as planned. We may ruminate about how “I could have
start to develop self-care plans and help establish goals, done something differently,” or “Why didn’t I?” or “If I
improve wellbeing, and do more of what we love to do. only,” and castigate ourselves for things that may have been
We have discussed terms and concepts that may already out of their control.
be familiar to many veterinary professionals. Even if this What happens if a mistake was actually made? Do we
serves as a refresher, the reminder for the common denom- continue to ruminate about the “woulda, coulda, shoulda”?
inator, self-care, may prove helpful to keep on all our radars Do we get stuck and incessantly beat ourselves up? We
and assess our progress. may hold onto those events to the detriment of our own
wellbeing, which leads us to the important self-care con- time, fail, or notice something you don’t like about
struct, self-compassion. yourself. Instead of just ignoring your pain with a
Self-compassion dives into how truly giving ourselves a ‘stiff upper lip’ mentality, you stop to tell yourself
break and treating ourselves as we would our own best ‘This is really difficult right now,’ how can I comfort
friend, if in need of support, is OK. Caring for and demon- and care for myself in this moment?
strating empathy toward others is nothing most veterinary
professionals need to learn. Caring for ourselves and giving Neff’s body of work with self-compassion encompasses
ourselves a break with as much compassion is. Exploring propositions that are relevant to the veterinary profession, as
the components of self-compassion will provide additional can be seen with this consideration, “Instead of mercilessly
insight into how we may strengthen our heart, mind, soul judging and criticizing yourself for various inadequacies or
and, body to, as mentioned previously, do more of what we shortcomings, self-compassion means you are kind and
love to do. understanding when confronted with personal failings – after
The self-compassion construct is supported by more all, who ever said you were supposed to be perfect?” [6].
than 4000 studies and significant empirical data are avail-
able. Much of the research associated with self-compassion
included in this chapter comes from the studies conducted by Self-Compassion: Three Core Elements
one of the leading self-compassion researchers, Dr. Kristin
Neff. In addition to the discussion, available resources are According to Neff’s self-compassion model, there are three
listed for additional information. core elements: self-kindness, common humanity, and
mindfulness.
Self-Compassion: What is It?

Kindness
According to Dr. Kristin Neff [6], “Having compassion for The motivational core of self-compassion is kindness.
oneself is really no different than having compassion for According to Neff [7]:
others.” Neff provides an example [6]:
It’s a warm, friendly, and supportive attitude toward
Think about what the experience of compassion ourselves as we wade through the mud of life. Too
feels like. First, to have compassion for others you often when we struggle, we are more likely to beat
must notice that they are suffering. If you ignore ourselves up than put a supportive arm around our
that homeless person on the street, you cannot feel own shoulder. Even people who are unfailingly kind
compassion for how difficult his or her experience to others often treat themselves like crap. Self-
is. Second, compassion involves feeling moved by kindness reverses this tendency so that we are genu-
others’ suffering so that your heart responds to their inely good to ourselves.
pain (the word compassion literally means to “suffer
with”). When this occurs, you feel warmth, caring, Veterinary professionals may have learned about the
and the desire to help the suffering person in some impostor syndrome construct that addresses perfection-
way. Having compassion also means that you offer ism. In relation, according to Neff, “We can’t be perfect.
understanding and kindness to others when they Our lives will inevitably involve struggle.” “Self-kindness
fail or make mistakes, rather than judging them provides the resources to cope with hardship and makes it
harshly. Finally, when you feel compassion for more bearable. It’s a rewarding and fulfilling emotion, the
another (rather than mere pity), it means that you sweetness that counters the bitterness of life.”
realize that suffering, failure, and imperfection is
part of the shared human experience.
Common Humanity
Veterinary professionals have the compassion for others According to Neff’s research, “Also central to self-
down perfectly. Now, to address the compassion for ourselves. compassion is recognition of our own humanity. In fact,
Neff’s research continues by acknowledging how the this is what differentiates self-compassion from self-pity.”
compassion we express for others may lead us to look Neff’s studies revealed that, “Compassion is predicted on
inward and show that same compassion for ourselves [6]: the idea that all conscious beings are intrinsically worthy
of humane treatment”. This includes you. It is to be hoped
Self-compassion involves acting the same way that this resonates with all veterinary professionals who
toward yourself when you are having a difficult read this chapter.
Self-Compassion: What it is ot 1023
Mindfulness and lasting happiness often involves a certain

amount of displeasure (such as quitting smoking,
According to Neff, “The foundation of self-compassion is
losing weight, exercising). People are often very
the ability to turn mindfully toward our discomfort and
hard on themselves when they notice something
acknowledge it”. Neff continues, “Mindfulness allows us to
they want to change because they think they can
see clearly when we’ve made a mistake or failed.” Turning
shame themselves into action – the self-flagellation
toward zones of discomfort and acknowledging it is often
approach. However, this approach often backfires if
difficult, but Neff’s research reveals that, “Mindfulness is
you cannot face difficult truths about yourself
essential to self-compassion so we can know when we’re
because you are so afraid of hating yourself if you
suffering and respond with kindness.”
do. Thus, weaknesses may remain unacknowledged
in an unconscious attempt to avoid self-censure. In
contrast, the care intrinsic to compassion provides a
Self-Compassion: What it is Not powerful motivating force for growth and change,
while also providing the safety needed to see the self
Self-Compassion Is Not Self-Pity clearly without fear of self-condemnation.
According to Neff’s research [6]:

Self-Compassion Is Not Self-Esteem
When individuals feel self-pity, they become Neff’s research contrasts the two constructs [6]:
immersed in their own problems and forget that oth-
ers have similar problems. They ignore their intercon- Although self-compassion may seem similar to self-
nections with others, and instead feel that they are the esteem, they are different in many ways. Self-esteem
only ones in the world who are suffering. Self-pity refers to our sense of self-worth, perceived value, or
tends to emphasize egocentric feelings of separation how much we like ourselves. While there is little doubt
from others and exaggerate the extent of personal suf- that low self-esteem is problematic and often leads to
fering. Self-compassion, on the other hand, allows one depression and lack of motivation, trying to have
to see the related experiences of self and other without higher self-esteem can also be problematic. In contrast
these feelings of isolation and disconnection. to self-esteem, self-compassion is not based on self-
evaluations. People feel compassion for themselves
In addition, the self-pity card may play a role in “I am the because all human beings deserve compassion and
victim,” thus justifying negative behavior and justification understanding, not because they possess some particu-
for stoking self-pity. lar set of traits (pretty, smart, talented, and so on). This
means that with self-compassion, you do not have to
feel better than others to feel good about yourself.
Self-Compassion Is Not Self-Indulgence
According to Neff’s research [6]:
Self-Compassion Assessments
Self-compassion is also very different from self- According to Neff and Germer [8], “The path to self-
indulgence. Many people say they are reluctant to be compassion often begins with an objective assessment of how
self-compassionate because they’re afraid they would self-compassionate or not we are”. Researchers of self-
let themselves get away with anything. ‘I’m stressed compassion frequently use the self-compassion scale to meas-
out today so to be kind to myself I’ll just watch TV all ure the link between self-compassion and wellbeing. Neff and
day and eat a quart of ice cream.’ This, however, is self- Germer have adapted a shorter version (Protocol 77.1) of the
indulgence rather than self-compassion. Remember scale. This gives an idea of the reflective questions that are
that being compassionate to oneself means that you included in the assessments. Details of the electronic version
want to be happy and healthy in the long term. of this assessment, as well as the full version, are available in
the resources section at the end this chapter.
Neff’s research reveals more about the impact of As a reminder, “The path to self-compassion often begins
indulgence [6]: with an objective assessment of how self-compassionate or
not we are” [8]. Scores are intended to give insight into the
In many cases, just giving oneself pleasure may level of self-compassionate you may or not have toward
harm wellbeing (such as taking drugs, over-eating, yourself. It reflects a snapshot in time and may act as a
being a couch potato), while giving yourself health starting point to learn more about yourself.
Protocol 77.1 Self-Compassion Scale Short Form

How I Typically Act Towards Myself in Difficult Times
Please read each statement carefully before answering. Indicate how often you behave in the stated manner, using the
following scale:
Almost never-1, Occasioanally-2, About half of the time-3,
Fairly often-4, Almost always-5
1) When I fail at something important to me I become consumed by feelings of inadequacy.
2) I try to be understanding and patient towards those aspects of my personality I don’t like.
3) When something painful happens I try to take a balanced view of the situation.
4) When I’m feeling down, I tend to feel like most other people are probably happier than I am.
5) I try to see my failings as part of the human condition.
6) When I’m going through a very hard time, I give myself the caring and tenderness I need.
7) When something upsets me I try to keep my emotions in balance.
8) When I fail at something that’s important to me, I tend to feel alone in my failure.
9) When I’m feeling down I tend to obsess and fixate on everything that’s wrong.
10) When I feel inadequate in some way, I try to remind myself that feelings of inadequacy are shared by most people.
11) I’m disapproving and judgmental about my own flaws and inadequacies.
12) I’m intolerant and impatient towards those aspects of my personality I don’t like.
Scoring Key
Self-Kindness Items: 2, 6
Self-Judgment Items (Reverse Scored): 11, 12
Common Humanity Items: 5, 10
Isolation Items (Reverse Scored): 4, 8
Mindfulness Items: 3, 7
Over-identification Items (Reverse Scored): 1, 9
To reverse score items (1=5, 2=4, 3=3, 4=2, 5=1).
To Compute a Total Self-Compassion Score

● First reverse score the negative subscale items: self-judgment, isolation, and over-identification
● Then take the mean of each subscale
● Next compute a total mean (the average of the six subscale mean)
Norms and Score Significance

There are no clinical norms or scores which indicate that an individual is high or low in self-compassion. Rather, scores
are mainly used in a comparative manner to examine outcomes for people scoring higher or lower in
self-compassion.
You can consider these scores (as an ad hoc rubric):
LOW: 1.0–2.49
MODERATE: 2.5–3.5
HIGH: 3.51–5.0
(When trying to determine whether self-compassion levels are high or low relevant to a particular sample, some
researchers use a median split.)
Source: Neff K. [9] Dr. Kristin Neff has granted permission to share this assessment.
References 1025
There are more exercises and information on how to grow

Protocol 77.2 How Would You Treat a Friend?
your self-compassion in the resources section at the end
Please take out a sheet of paper and answer the follow- of this chapter.
ing questions:
1) First, think about times when a close friend feels
really bad about themselves or is really struggling Conclusion
in some way. How would you respond to your friend
in this situation (especially when you are at your Veterinary professionals do many tremendously good
best)? Please write down what you typically do, what things for those they serve in every work day. They pro-
you say, and note the tone in which you typically talk vide medical care to patients, communicate with clients
to your friends. to help them understand what is best for their pet, and
2) Now think about times when you feel bad about engage with their practice team on many levels. They
yourself or are struggling. How do you typically demonstrate empathy and kindness to practice stakehold-
respond to yourself in these situations? Please write ers even when they may be on fumes from exhaustion or
down what you typically do, what you say, and note constant stress.
the tone in which you talk to yourself. Learning about wellbeing and self-compassion is about
3) Did you notice a difference? If so, ask yourself why. being mindful that veterinary professionals are also worthy
What factors or fears come into play that lead you to of compassion and kindness, especially from ourselves.
treat yourself and others so differently? Since much of this chapter highlights the work of self-
4) Please write down how you think things might compassion expert, Dr. Kristin Neff, I end this chapter with
change if you responded to yourself in the same way a few words from her most recent book, Fierce [7]:
you typically respond to a close friend when you are
I’ve been practicing self-compassion daily for almost
suffering.
twenty-five years now. Although I’m definitely
Why not try treating yourself like a good friend and see stronger, calmer, and happier because of it, my inner
what happens? bulldog barks less often than it used to, I still strug-
gle. I’m as imperfect as ever, and this is how it should
be. Being human is not about getting it right, it is
Growing self-compassion starts with assessing, reflect- about opening up your heart-whether you get it
ing, listening, and learning more about how we can care wrong or right. I’ve learned to do this over time, just
as much, if not more, about ourselves as we do others. by moving through all my mistakes and difficult
Taking time out to check in regularly with ourselves and experiences.
engaging in reflective exercises is helpful toward not only
our self-compassion but also our wellbeing. Neff [6] pro- I trust this may resonate with all my veterinary col-
vides an example of a reflective exercise (Protocol 77.2). leagues and friends.
References
1 Figley, C.R. (1995). Compassion Fatigue: Coping with 5 American Veterinary Medical Association (AVMA).
Secondary Traumatic Stress Disorder in those Who Treat the Self-care for veterinarians. Accessed online: https://www.
Traumatized. New York: Routledge, Taylor & avma.org/resources-tools/wellbeing/self-care-veterinarians
Francis Group. 6 Kristin Neff, Ph.D. Self-compassion. Accessed online:
2 Figley, C.R. and Roop, R.G. (2006). Compassion Fatigue in https://self-compassion.org
the Animal-Care Community. Washington: Humane 7 Kristin Neff, Ph.D. Fierce Self-Compassion: How Women
Society Press. Can Harness Kindness to Speak up, Claim their Power, and
3 Hayes, G.M. et al. (2019). Investigation of Burnout Thrive. New York: Harper Collins, 2021.
Syndrome and Job-Related Risk Factors in Veterinary 8 Neff, K. and Germer, C. (2018). The Mindful Self-
Technicians in Specialty Teaching Hospitals: A Multicenter Compassion Workbook. New York: The Guilford Press.
Cross-Sectional Study. New York: Wiley. 9 Raes, F., Pommier, E., Neff, K.D., and Van Gucht, D. (2011).
4 American Association of Veterinary Medical Colleges Construction and factorial validation of a short form of the
(AAVMC). Wellbeing. Accessed online: https://www. self-compassion scale. Clin. Psychol. Psychother. 18:
aavmc.org/programs/wellbeing 250–255.
Resources
Wellbeing
American Veterinary Medical Association. The nine rising-professional/your-wellbeing/wellbeing-self-

dimensions of wellbeing: holistic health for the veterinarian. assessment (accessed 23 August 2022).
https://www.avma.org/blog/nine-dimensions-wellbeing- Peterson M. Wellbeing. American Association of Veterinary
holistic-health-veterinarian (accessed 23 August 2022). Medical Colleges. https://www.aavmc.org/programs/
American Veterinary Medical Association. Wellbeing. https:// wellbeing (accessed 23 August 2022).
www.avma.org/resources-tools/wellbeing (accessed 23 Texas Veterinary Medical Association. Wellness kit. https://
August 2022). www.tvma.org/Practice/Wellness/Wellness-Kit (accessed
American Veterinary Medical Association. Wellbeing 23 August 2022).
assessment for veterinaraians. https://myvetlife.avma.org/
Compassion Fatigue
American Veterinary Medical Association. Work and resources-tools/wellbeing/work-and-compassion-fatigue
compassion fatigue. https://www.avma.org/ (accessed 23 August 2022).
Burnout
Psychology Today. Burnout. https://www.psychologytoday. Mayo Clinic. Job burnout: How to spot it and take action.
com/us/basics/burnout (accessed 23 August 2022). https://www.mayoclinic.org/healthy-lifestyle/adult-health/
in-depth/burnout/art-20046642 (accessed 23 August 2022).
Self-Compassion
American Veterinary Medical Association. Self-care for Dr. Kristin Neff. Self-compassion instrument for researchers.
veterinarians. https://www.avma.org/resources-tools/ https://self-compassion.org/self-compassion-scales-for-
wellbeing/self-care-veterinarians (accessed 23 August 2022). researchers (accessed 23 August 2022).
Dr. Kristin Neff. Self-compassion. https://self-compassion.org
(accessed 23 August 2022).
1027
Index
a patient problems 175–177, compensation 765

A‐a gradient 344, 345 176f, 177f compensatory acid–base
ABCDEs, in triage 5–9, 10p technical problems 175 disorder 1 766
Abdominal curtain sign, in point‐of‐ thresholds of concern 177–178 compensatory acid–base
care ultrasound 352, troubleshooting 178, 178p disorder 2 766
355f, 357 Absorption atelectasis 324. See also hydrogen ion concentration 763
Abdominal effusion 518, 783 Atelectasis interpretation of acid‐base
Abdominal fluid sampling 503–507 Acariasis (mange) 846t measurements 763
Abdominal imaging 500–503 Accelerated idioventricular pH 768
abdominal radiographs 501–502 rhythm 147, 147b, 148f. See sampling and storage of blood
computed tomography 503 also Electrocardiogram for 763, 764p
ultrasound 502 interpretation simple vs. mixed
veterinary point of care Acceleromyography (AMG) 693, disturbances 766
ultrasound 500 694, 694p, 695f Acid citrate dextrose (ACD), for
Abdominal pain 499. See also Acetaminophen blood collection 907
Analgesia (paracetamol) 643–644, 643t, Acidemia 758, 763
Abdominal paracentesis 503 954, 954t Acids, as antiseptics 837, 838t
Abdominal point‐of‐care Acetone 713, 775, 790 Action potential 127
ultrasound 513–520 Acetylcholine (ACh) 691, 692 Activated charcoal 607–608
left paralumbar 518 Acetylcholinesterase (AChE) administration procedure 525f,
patient positioning and machine inhibitors 691–693, 696 530, 530p, 531, 532, 532f
settings 513–514 Acetylcysteine, see N‐acetylcysteine indications 532
pitfalls 520 Acid–base abnormalities 766 Activated clotting time
right paralumbar site 518 Acid‐base balance 763 (ACT) 734, 735p
subxiphoid site 514–516, measures of metabolic Activated partial thromboplastin
514–516f contribution 764–765 time (aPTT) 728,
umbilical site 516–517 metabolic component of 767–769 734–735, 741–742
urinary bladder 517–518, 517f respiratory component Active closed‐suction
Abdominal ultrasound, see of 763, 766–767 drains 541–542, 542f
Ultrasound Acid‐base evaluation Acute abdomen 500
Abdominocentesis 503, 503–504p, algorithm for 765f Acute allergy 891
503f, 783 arterial acid‐base values for normal Acute hemorrhage 520
Aβ fibers 619 individuals 765t Acute hypersensitivity
Abnormal arterial pressure arterial versus venous blood gas reactions 892, 894
waveforms 175–178 values 764t Acute intravascular hemolysis 893
1028 Index
Acute kidney injury (AKI) 431–432, Airway humidification 384–385. Alveolar‐to‐arterial difference, see
467, 481–482 See also Humidification A‐a gradient
Acute lymphoid leukemia 732f Airway obstruction 418 Alveolar‐to‐arterial gradient, see A‐a
Acute metabolic compensation, in during mechanical ventilation, see gradient
acid–base balance 765 Ventilator waveforms Amantadine 643, 643t
Acute respiratory distress syndrome treatment, see Endotracheal Ambulatory continuous
(ARDS) 429 intubation; Oxygen electrocardiogram 132
Adaptive pain (inflammatory) 618t supplementation; Temporary Amide local anesthetics 651
Adaptive pain (nociceptive) 618t tracheostomy Amikacin sulfate 611
Adenosine triphosphate (ATP) 551 Airway pressure, in mechanical Amino acids 556–557, 568, 591
Adjunctive analgesics 641–644, ventilation 401 aromatic 556
642b, 643t Airway resistance, during branched chain 556
ADR, see Adverse drug reaction mechanical ventilation 410, Aminoglycoside antibiotics 19
Advanced supportive 411, 417, 421, 421f Aminophylline 604t, 607
therapies 37–38 Airway suctioning 406 Amiodarone 269, 288t, 661
Adverse drug reactions (ADRs) Albumin 773–775, 893–896 Amorphous phosphate, in urine
defined 626 deficit estimation 894 sediment 793
potential 627 therapy 882 Ampicillin 604t, 611
Adverse effects of therapy Alcohol‐based hand rubs, for Amplitude ratio, to determine the
antivenom therapy 898 minimizing hospital‐acquired damping coefficient
Digitalis glycosides (digoxin) 900 infections 811–812 164, 164f
of epidurals 661 Alcohols 482, 483b, 838, 838t Anaerobic blood sampling 759
of fresh frozen plasma 883 as antiseptics and disinfectants Analgesia 19–20, 105, 277, 612,
human intravenous 837, 838t 631, 679
immunoglobulin ethanol 775b adjunctive 641–644, 642b, 643t
(hIVIG) 896 isopropyl 263, 264, 269, 283, definition 618t
nonsteroidal anti‐inflammatory 775b, 838 in gastric dilation and volvulus
drugs (NS

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Advanced Monitoring and

Procedures for Small Animal

Jamie M. Burkitt Creedon

Limit of Liability/Disclaimer of Warranty

Library of Congress Cataloging-in-Publication Data applied for

Cover Design: Wiley

Set in 9.5/12.5pt STIXTwoText by Straive, Pondicherry, India

Section One Fundamental Elements of Emergency and Critical Care Practice 1

2 The Small Animal Emergency Room 13

3 Intensive Care Unit Design 23

4 Developing and Using Checklists in Practice 47

6 Point-of-Care Ultrasound for Emergency and Critical Care 75

Section Two Cardiovascular Procedures and Monitoring 81

7 Catheterization of the Venous Compartment 83

8 Arterial Puncture and Catheterization 103

9 Ultrasound-Guided Vascular Access 117

10 Principles of Electrocardiography 127

11 Electrocardiogram Interpretation 135

12 Fluid-Filled Hemodynamic Monitoring Systems 153

13 Direct Systemic Arterial Blood Pressure Monitoring 169

14 Noninvasive Arterial Blood Pressure Monitoring 181

15 Central Venous Pressure Monitoring 191

16 Cardiac Output Monitoring 207

17 Point-of-Care Cardiac Ultrasound 225

19 Monitoring Tissue Perfusion: Clinicopathologic Aids and Advanced Techniques 251

20 Cardiopulmonary Resuscitation 261

21 Open-Chest Cardiopulmonary Resuscitation 271

23 Temporary Cardiac Pacing 291

Section Three Respiratory Procedures and Monitoring 309

24 Oxygen Therapy 311

25 Pulse Oximetry and Co-Oximetry 327

26 Blood Gas Analysis 339

27 Point-of-Care Lung and Pleural Space Ultrasound 347

28 Tracheal Intubation 365

29 Temporary Tracheostomy 377

31 Mechanical Ventilation 399

32 Ventilator Waveform Analysis 409

33 Alternative Methods of Augmented Ventilation 427

34 Pleural Space Drainage 431

Section Four Urinary and Gastrointestinal Procedures 449

35 Urethral Catheterization 451

36 Peritoneal Dialysis 467

37 Technical Management of Hemodialysis 481

38 Peritoneal Evaluation 499

39 Point-of-Care Abdominal Ultrasound 513

40 Specialized Gastrointestinal Techniques 523

41 Postoperative Peritoneal Drainage Techniques 539

Section Five Nutrition 545

42 Nutritional Requirements in Critical Illness 547

43 Enteral Diets for Critically Ill Patients 555

44 Assisted Enteral Feeding 567

45 Parenteral Nutrition 585

Section Six Analgesia and Anesthesia 599

46 Drug Administration 601

47 Pain Recognition and Management 617

48 Systemic Analgesia 631

49 Local Anesthesia 651

50 Monitoring the Anesthetized Patient 665

51 Nursing Care of the Long-Term Anesthetized Patient 681

52 Neuromuscular Blockade 691

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