The Vet Vault 3.2.1.
Ultrasound and Livers, Before You Reach for Prokinetics, Abdominal Drain Pearls, and a Short Note on Resilience.
Heads up: I’m heading to South Africa for a very long overdue family catch-up, and then to podcast from the WVAC/SAVA Conference in Cape Town. I plan to devote my full attention to the family, so there’s a fair chance that I’m not going to writing any newsletters over the next 3 weeks. (Although writing the newsletter might be the perfect excuse to have a little break from the family!) I’ll see you back here after Easter.
3 Clinical Pearls.
1. Don’t trust your ultrasonographer…
From episode 154 in the medicine feed. With Prof Jill Maddison.
Something is making you suspicious of the liver. Maybe you ran pre-GA bloods, and those liver enzymes are flagging. Next step: scan, right?
But in this episode about interpreting liver enzymes, Prof Jill reminded us of the limitations of ultrasound in investigating liver disease with some numbers and studies:
Ultrasound is very good at assessing post-hepatic disorders. e.g. mucocoeles, cholecystitis, stones, bile duct obstructions etc.
It’s not that great, or actually, pretty rubbish, at assessing parenchymal disorders.
RVC studies have clearly demonstrated that the sensitivity of ultrasound in detecting parenchymal pathology is highly variable.
One study showed that around 40% of animals with confirmed liver disease had normal liver ultrasounds when done by board certified ultrasonographers.
On the flip side - we’ve all seen those livers that look horrible on scan, and then the biopsy results comes back as ‘benign changes’.
2. How to paralyse the intestinal tract.
From episode 152 on the ECC stream. With Dr Claire Sharp.
I find them to be some of the most frustrating cases: you’ve fixed whatever it was that upset the gut in the first place, but now your patient’s GI tract has decided to go on strike: zero peristalsis, stomach like a half-empty (half full?!) goon sack. You know your patient will feel better once that gut starts moving. So you reach for the metoclopramide, right?
But hold on a minute… in this fantastic discussion on prokinetics, Dr Claire Sharp listed some ilius-aggrevators that should be addressed BEFORE you try to beat a dead horse/ floppy gut.
Pain
Opioids (I know right - it’s a conundrum! Dr Clair discusses, in detail, how to balance these two in the episode.)
Hypothermia
Hypovolaemia
Fluid overload
Electrolyte abnormalities: hypokalaemia, hypocalcaemia OR hypercalcaemia, and potentially hypomagnesaemia.
Persistent hyperglycaemia. (Over 10mmol/l)
And then one often-overlooked thing, other than drugs, that will stimulate peristalsis really well: food.
3. Some things to know about abdominal drains.
From episode 147 on the surgery feed. With Prof Karen Tobias.
There’s a fair bit of decision-making happening for the patient with an abdominal drain. Here are a couple of pearls from our episode on septic peritonitis that might make that process a bit easier:
When you’re using cytology to monitor the health of your patient and your drain, collect fluid samples via ultrasound-guided aspiration straight from the abdomen, and NOT from the drain. Why? The fluid in the bulb and in the drain itself will be filled with very sad, toxic-looking cells, because the environment is hypoxic and hypoglycaemic.
A paper that looked at cultures of drains found that the tip and the bulb of the drain will often have bacteria on it, BUT a biofilm on the drain keeps the bacteria out of the abdomen. Pull the drain, and the problem is gone.
Normal peritoneal flow (who else didn’t know that that was a thing?) is about 8-10ml/kg/day. So don’t wait for no fluid in the bulb before you pull your drain.
“If you are not getting any fluid at all, there's something wrong with your drain.”
2 Other things.
“Mold clay into a vessel;
it is the emptiness within
that creates the usefulness of the vessel.
Thus, what we have may be something substantial,
But its usefulness lies in the unoccupied, empty space.
The substance of your body is enlivened by maintaining the part of you that is unoccupied.”
“From what I’ve seen of it, true love is hard. Real romance has death in it. It has midnight shakes and flecks of shit across a bedsheet. True love like this dies if it has to wait for fate. True love like this asks lovers to cast aside what is meant to be and work with what is.”
1 Thing to think about.
Here are some things that are resilient:
Hair bands.
The tires on your car.
Your mattress.
Trees.
Ligaments.
Vaginas.
Bungee ropes.
Your design for a solid, indestructible steel chassis for off road vehicles won’t sell, even if it’s guaranteed to outlast standard shock absorbers by decades. Leather is tough, yet we make underwear from cotton, or spandex, or other stretchy materials. (Imagine having an erection in a pair of lederhosen!) I got tired of having to replace my toothbrush every 6 weeks, so I tried using the wire brush that I use to clean the spark plugs on my old motorbike. I didn’t like it.
Tough is not the same as resilient. Resilient isn’t always tough. In fact, resilient things can be quite fragile if you use them wrong, but it’s exactly this that makes them useful.
Much love,
Hugh
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