The Power of Collaborative Care

Case Study: Hattie Edwards
6 yr. old, F/S, Spaniel X

Primary Care Veterinarian: 
Dr. Lewis at Banfield - The Pet Hospital at Chesapeake Square

Initial presentation: Hattie presented to her primary care veterinarian for a routine dental prophylaxis. Lab work revealed elevated hepatic enzymes. Based on a history of PU/PD and polyphagia, Cushing's disease was suspected. An ACTH stimulation test was recommended, and Mrs. Edwards agreed to proceed. The results of the ACTH stimulation test were normal. Other significant abnormalities detected on the comprehensive lab work included thrombocytosis (515), increased ALP (1726), and increased ALT (191). At this point, Dr. Lewis recommended an abdominal U/S. Mrs. Edwards contacted The COVE and set up an appointment for Hattie to see Dr. Nobles, DVM, DAVCECC, for further evaluation of Hattie's elevated hepatic enzymes.

P hoto credit: 
Happy Tails Resort, Norfolk, VA. 
Photo #27 

Condition upon arrival at The COVE: Hattie was BAR and vitals were WNLs. On physical examination, the following abnormalities were noted: Grade 2/6 holosystolic heart murmur, missing OS (previous enucleation), cranial abdominal organomegaly, 5-7cm lateral thoracic SQ mass.  

Diagnostics: Abdominal U/S revealed a hypoechoic, diffusely nodular liver parenchyma, a distended gall bladder with hyperechoic debris radiating from the outer wall to the center, normal extrahepatic biliary parameters, hyperechoic foci along the capsule of the spleen, some loss of renal corticomedullary distinction and small cortical cysts in the right kidney. All else was found to be unremarkable (WNLs). A cardiac consult with Dr. Small, DVM, DACVIM (Cardiology), revealed well-compensated mitral and tricuspid insufficiencies due to early endocardiosis. PT and PTT were WNLs. An FNA of the liver was obtained at the time of the U/S evaluation and submitted for cytological evaluation. Results revealed mixed suppurative and lymphoplasmacytic inflammation with a histiocytic component, mild to moderate vacuolar change and extramedullary hematopoiesis.

Assessment: Upon completion of Dr. Nobles' evaluation, the following assessments were made: Suspicion of chronic active hepatopathy; emerging gall bladder mucocele; early, compensated valvular heart disease. Based on the liver enzyme elevations, U/S  and cytological findings, Dr. Nobles recommended laparoscopic liver biopsies and cholecystectomy due to concern for future mucocele development. A consult with Dr. Stallings, DVM, DACVS, for an evaluation and discussion of surgical options was subsequently arranged for Hattie and Mrs. Edwards.

Surgical assessment and recommendations: Based on the lab work, U/S, and cytological findings, Dr. Stallings recommended laparoscopic abdominal exploration, cholecystectomy, multiple hepatic biopsies with histopathology, C&S and quantitative copper analysis. Mrs. Edwards elected to proceed.

Preoperative evaluation: A coagulation profile, blood type, cross-match, CBC, biochemical profile, U/A, T4, BP, and 2 view thoracic radiographs were done. Aside from Hattie's historical CBC and biochemical abnormalities, the results were WNLs. Hattie was also hyposthenuric (USG - 1.018).

Surgery: A 5-port laparoscopic array was established in standard fashion for the procedure. The liver was cobble-stone appearing and extremely irregular on the surface with a diffusely mottled appearance. Additionally, there were multiple small (2-4 mm diam.), irregular, raised lesions noted on the diaphragm. The gallbladder appeared distended and was determined to be softer proximally and firmer distally. The spleen, stomach, pancreas, and intestines appeared grossly normal. Multiple representative hepatic biopsies were obtained and submitted for histopathology, C&S and quantitative copper analysis. The diaphragmatic lesions were biopsied and submitted as well. A cholecystectomy was then done. The gall bladder was removed from the abdomen in a specimen bag and submitted for histopathology. A sample of bile was submitted for C&S. After irrigation, the instrumentation was removed, and the abdomen was desufflated. The portal sites were closed.

Post-operative course: After surgery, Hattie was transferred back to Dr. Nobles and the ER for recovery monitoring and individualized pain management. Hattie was eating and drinking within 12 hours of surgery. She did regurgitate once, the morning after surgery. Post-operative lab work revealed an increase in hepatic enzyme elevations, most likely secondary to the multiple biopsies and surgical manipulation. Hattie was felt to be doing well enough to be discharged the day after surgery. She was sent home with Denamarin, metaclopromide, Tylenol #3, and gabapentin. Hattie was scheduled for a re-check two weeks post operatively for incisional evaluation and lab work. 

Results: Histopathology: Gall bladder - cystic mucinous hyperplasia; Liver - marked diffuse nonzonal vacuolar degeneration, nodular hyperplasia, multifocal parenchymal collapse, mild ductal reaction and suspected bridging fibrosis; Diaphragm - mild mesothelial hyperplasia, chronic hemorrhage, mild lymphohistiocytic inflammation. Bile C&S - no growth; Hepatic parenchymal C&S - no growth. 

Follow-up: Hattie continued to do well at home. In a phone communication four days post discharge, Mrs. Edwards reported that Hattie seemed to be "back to normal." Hattie experienced a mild delay in her incisional healing due to owner non-compliance, which resolved following client re-education and another week of healing (verified at re-check 10/15/18). Lab work revealed continued hepatic enzyme elevations consistent with the diagnosis of chronic active hepatopathy. Regular follow-up re-checks and lab work with Dr. Lewis was recommended. During a recent phone re-check (11/28/18), Mrs. Edwards reported that Hattie was doing very well clinically and seemed to be back to her normal self. Mrs. Edwards has chosen not to follow recommendations with regard to follow-up lab work, etc. 

In a nutshell: Hattie's case illustrates a remarkable collaborative effort between the primary care veterinarian and multiple specialists to head off what was undoubtedly an impending health crisis with a state-of-the-art operative intervention. This is a clear example of the type of teamwork that leads to outstanding patient and client care and the most favorable clinical outcome possible under the circumstances.

TECH TIP:  Alternative Pain Management Options for the Veterinary Practice 
Brandyn M. Sinclair, Surgery LVT and Lilybeth Santiago, Surgery LVT
Recently, more studies have disproved the efficacy of Tramadol(4). Although Gabapentin has proven to be an outstanding drug choice for neuropathic pain, as well as for its anxiolytic properties, adjunctive options are available that can increase its efficacy.  At The COVE, personalized pain management protocols are an essential part of our commitment to excellent patient care. We are continually enhancing our strategies to provide the most effective pain control methods for all of our patients.  
  • Maropitant (Cerenia): Newer studies have shown that Maropitant provides analgesia to both the viscera and bladder (due to the NK-1 receptor). MAC sparing properties have also been demonstrated in these studies. Recently, this has proven helpful in our laparoscopic surgeries and cystotomies at the normal oral dosing of 1mg/kg IV SID, followed by 2mg/kg PO post operatively.(1)
  • Acetaminophen-Codeine 300mg-30mg (Tylenol 3): The recommended dose is 10-15mg/kg PO TID (dosing for acetaminophen) for post-operative pain (canine only). A mild to moderate sedative effect is noted, but pain management seems adequate.(2)
  • Amantadine HCl: This has NMDA-antagonist properties (similar to ketamine) and can be useful as an adjunctive therapy for chronic pain, neuropathic pain, or to prevent wind up. When used at a dose of 2-5mg PO SID (this can be increased to BID due to its short half-life), in conjunction with other pain management, great analgesic effects are achieved with chronically or acutely painful cases (i.e., multiple pelvic fractures, neuropathies, etc.).(3)

  1. Alvillar BM, Boscan P, Mama KR, Ferreira TH, Congdon J, Twedt DC. Effect of epidural and intravenous use of the neurokinin-1 (NK-1) receptor antagonist maropitant on the sevoflurane minimum alveolar concentration (MAC) in dogs. Vet Anaesth Analg. 2012; 39(2): 201-205.
  2. "Canine Quick Dosage Sheet" International Veterinary Academy of Pain Management . IVAPM 2017. https://ivapm.org/wp-content/uploads/2017/03/IVAPM-Dosage-Chart-2017.pdf
  3. Lascelles, BDX, Gaynor, JS, Smith, ES et al. Amantadine in a Multimodal Analgesic Regimen for Alleviation of Refractory Osteoarthritis Pain in Dogs. J Vet Intern Med. 2008; 22: 53-59.
  4. MAF study finds tramadol ineffective against osteoarthritis in dogs" Veterinary Practice News. Veterinary Practice News 2018. https://www.veterinarypracticenews.com/maf-study-debunks-osteoarthritis-drug/
Best Uses For Tie-Over Bandages
Courtney Judson and Melissa Heath, Surgical Team Members
Here at The COVE, our surgery service offers many bandaging options for wound management and post-operative care. One of the bandage techniques is a "tie-over" bandage. There are many advantages of utilizing this method. Tie-over bandages are effective in highly mobile areas, draining wounds, and areas that would otherwise be difficult to cover. We use tie-over bandages in most of our wound management cases to protect the bodies' vital tissues as the granulation bed begins to form prior to delayed wound closure. Tie-over bandages also help stretch the surrounding skin before wound closure, which causes tissue regeneration and increased vascularity, assisting with speedier wound healing. The following supplies are needed to apply this style of bandage:
  • Sterile laparotomy sponges 
  • Kruuse Manuka G sterile wound dressing OR Kruuse Manuka AD honey impregnated dressing
  • Sterile saline
  • Sterile gauze squares
  • Needle drivers, operating scissors, and thumb forceps
  • Size 0 non-absorbable suture
Today's Technician: Principles of Wound Care & Bandaging Techniques. (2018, May 22). Retrieved from https://todaysveterinarypractice.com/todays-technician-principles-of-wound-care-bandaging-techniques/
May 28-31, 2019: The COVE Seaside CE Event in Virginia Beach

Enjoy the salty air, let down your hair and join us for a complimentary continuing education event for doctors, technicians, and managers featuring topics in cardiology, surgery, critical care, and dentistry. Attend one or attend them all - a unique opportunity to earn up to 9 CE credits.  Look for registration information in a few months.
We've got a new website!

In case you missed it, check out our new  website , filled with lots of valuable information for pet owners and referring veterinarians. 
The COVE offers Minimally Invasive Surgery (MIS)

In cases where surgery is required, we always look for options that will cause the least amount of pain and provide the quickest recovery option for our patients. In a minimally invasive procedure, small incisions are made and used as passageways for a laparoscope or endoscope, which are tiny fiber optic video cameras. Working from the images provided from the scope, special instruments are then passed through other openings and operated by remote control to perform the necessary procedure.

Benefits to your patients:

  • Smaller incisions
  • Quicker recovery time
  • Less pain
  • Less scarring
  • Lower risk of infection
  • Reduced blood loss
We offer MIS for:
  • Laparoscopy: Abdominal and pelvic surgery
  • Thoracoscopy: 
    Lung/chest surgery
  • Arthroscopy: Joint surgery
Would you like to learn more?  Please call us anytime!

24/7 Emergency and Critical Care | Surgery | Cardiology | Dentistry
6550 Hampton Roads Pkwy, #113 | Suffolk, VA 23435
P: 757.935.9111 | F: 757.935.9110 | thecovevets.com
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