9/19/17 1 Technician Assessment & Management of Endocrine Diseases Brittany Betancourt CVT, VTS (ECC) Veterinary Technician Supervisor Veterinary Specialty and Emergency Center BluePearl Veterinary Partners Philadelphia, PA [email protected]Garret Pachtinger, VMD, DACVECC COO, VETgirl Introduction Introduction Justine A. Lee, DVM, DACVECC, DABT CEO, VETgirl VETgirl…on the run! The tech-savvy way to get RACE-approved, online veterinary CE! A subscription-based service offering veterinary RACE-approved CE VETgirl ELITE! 50-60 podcasts/year plus 30+ hours of webinars! $199/year 40+ hours of RACE-CE Up to 5 members: $599/year Up to 10 members: $999/year > 10 members: Ping us
Veterinary Specialty and Emergency CenterBluePearl Veterinary Partners
Philadelphia, PA
9/19/17
3
A Technician’s RoleBack To Basics!Triage - Primary Assessment
Chief complaint and brief client interviewPerfusion parameters (Mentation, HR, RR, pulses, temperature, MM/CRT)Know normal parameters and what may cause them to be altered.
Performing diagnostics based on clinician’s secondary assessment.Monitoring trends to asses responsiveness to treatment (fluids, drugs, etc).
Understanding pathophysiology of diseaseBetter understanding of patient needsForesee any additional orders the doctor will want/needClient education
Pharmacology Medical mathTechnical skillsAcid Base, electrolyte and chemistry analysisMost Importantly - patient care and compassion
•failure of hormone production•disruption in hormones reaching their intended destination•when targeted tissue fails to recognize and accept the hormone
Diabetic KetoacidosisPancreas: Multifunctioning Organ
Composed of cells called Islet of LangerhansSurrounded by secreting acinar cells1. Alpha: Secrete Glucagon2. Beta: Secrete Insulin 3. Delta: Secrete Somatostatin4. F Cells: Secrete pancreatic polypeptide
Insulin is needed to transport glucose into the cells - essentially “feeding” the cellsWithout insulin, cells start to starveThe body needs a way to feed the cells!
Diabetic KetoacidosisThis is where Ketones come in….Ketones are normally found in the blood stream in small amountsOverproduction occurs due to insulin deficiency - PROTECTIVE MECHANISMThree Ketone Bodies: 1. Acetone2. Acetoacidic Acid3. Betahydroxybutyric Acid
• Read Ketones via ketometer, urine dip stick, or serum• Ketosis can’t occur without this ketone body• If patient highly suspicious but Ketometer not reading
ketones, add a drop or two of hydrogen peroxide
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Diabetic KetoacidosisHow will these patients present to the hospital?
Dependent upon comorbidites and how long the patient has been sick.Assess perfusion parameters!
Clinical Signs:Altered mentation: Flat, obtunded, weakPulses weak or poorTachycardiaTachypnicHypothermic
PerfusionParameters
Diabetic KetoacidosisWhat to also be on the look out for:
Kussmaul respirations: deep, labored breathing associated with severe metabolic acidosis (pH < 7.35, BE < -4, HCO3 < 18)Acetone smell on breathPlantigrade stance associated with diabetic peripheral neuropathy (A.K.A “Hock Drop”)
Hyperglycemia with Ketonemia and a Metabolic AcidosisGlucosuriaKetonuriaElectrolyte abnormalitiesPolycythemia (hemoconcentration due to dehydration)Leukocytosis (concurrent infection?)Increased liver enzymesAzotemia (rule out pre renal or renal)
USG via refractometer
Diabetic KetoacidosisGlucometer
Refractometer Ketometer
Initial Workup: Rule out concurrent systemic disease processesChest rads:
CHF, pneumoniaAbdominal Ultrasound:
Pancreatitis, hepatic lipidosis, kidney changesUrinalysis, Urine Culture and Sensitivity:
Cystocentesis / Urinary Catheter for sterile sampleObtain USGTest for urinary tract infection
Significant buildup of ketones and glucose in the blood cause an osmotic diuresis exacerbating dehydration and hypovolemiaFurther contributed by vomiting, diarrhea and increased urinationCrystalloid support
Shock dose : 45ml/kg in felines, 60-90ml/kg in canines of an isotonic fluid (Plasmalyte-A, NormR, 0.9% NaCl, Lactated Ringer’s Solution)
1/4-1/3 of dose, reassessColloidal support?? Controversial
Total body deficit of potassium, magnesium, sodium and phosphorus: supplementation may be needed.
Once insulin started, watch potassium!Insulin/Dextrose administration
Humulin R to begin with
Diabetic Ketoacidosis
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Nursing Considerations:WEAR GLOVES! Immunocompromised, increased risk of infectionPlace largest bore peripheral catheter
Catheter maintenanceBlood Pressure (Doppler vs Oscilometric vs Direct)
Don’t rely solely on this number - asses patient’s perfusion parameters as a whole
Urinary Catheter placementPre-renal vs renalCatheter maintenance
Diabetic Ketoacidosis Diabetic Ketoacidosis
VIRCHOWS TRIADIncreased risk of clot formation - patient’s need to move around
PharmacologyInsulin - watch potassium, treats KetonemiaHumulin R vs Long ActingDextrose and Insulin in the line
Medical MathConstant Rate InfusionsBolus doses and calculationsDosages for medications
Monitoring and reassessing patientFluid overloadPerfusion parametersAssess pain
NutritionTLC!
Diabetic Ketoacidosis
Goals of treatment:Restore effective circulating volumeTreat hyperglycemia/ketonemia with insulin
May take up to 3 days to resolve ketonemia even after normoglycemia
Correct electrolyte abnormalitiesPatients will be hospitalized for 3-5 days
The slower DKA is corrected, the better probability of successful long term treatment.
Diabetic KetoacidosisLong term management:
CLIENT EDUCATION AND DEDICATION (another importance of understanding pathophysiology and pharmacology)Long acting insulin (Humulin N, Glargine, PZI)BG curves until BG stabilized between 100-300 throughout the dayDiabetic Diets (Hills MD/WD, Royal Canin Glycobalance, Purina DM)Treatment of underlying disease process (if any)
Diabetic Ketoacidosis
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Addison’s = HypoadrenocorticismLook-A-Like, A.K.A “The Great Pretender”Adrenal Glands
Cortex must be atrophied 85-90% before clinical signs occur in non stressful situations
Addisonian Crisis
https://www.yourhormones.com/adrenal-glands/
Zona Glomerulosa : Secretes mineralcorticoids (aldosterone)Zona Fasiculata : Secretes Glucocorticoids (Cortisol)Zona Reticularis : Secretes Sex HormonesPheochromocytoma : mass in Adrenal Medulla
Addisonian Crisis
Aldosterone is needed to respond to hypovolemia (Renin Angiotensin Aldosterone System: RAAS)
Reabsorbs sodium to increase intravascular volume (where Na goes, water follows)
Effective OsmolePotassium excretion
No Aldosterone = Na and H2O lost excessively in states of hypovolemia, hyperkalemia
Cortisol is needed to respond to stress, GI health, stimulating an appetite, and much more!
Addisonian CrisisHow will these patients present to the hospital?
Not always straight forward, hence “The Great Pretender”History of waxing and waning GI signsUsually young female canines
Clinical Signs:Altered mentation: Flat, obtunded, weakPulses weak, poor, or absentBRADYCARDIA in face of signs of shockHypothermicGI signs (sometimes even severe)
Addisonian Crisis
Atrial StandstillHyperkalemia - resting membrane potential increasedNeeds to be treated immediately!
Na:K ratio of <27:1 - typicalLack of stress leukogramHypoglycemia (30% of cases)Polycythemia - hemoconcentration due to dehydration/hypovolemiaAzotemia - rule out pre renal vs renalAtrial StandstillHYPOVOLEMIC!ACTH stim test gold standard
SNAP Cortisol
Addisonian Crisis
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Initial Workup: Diagnosis of ExclusionFull blood panel (PCV/TS/BG/blood gas/chemistry/CBC)USG, Urinalyis/Urine Culture and SensitivityIf young, Parvo SNAP (severe GI signs)Abdominal ultrasound (pancreatitis, kidney changes, hepatic lipidosis)RadiographsSNAP Cortisol
Catheter maintenanceBlood Pressure (Doppler vs Oscilometric vs Direct)
Don’t rely solely on this number - asses patient’s perfusion parameters as a whole
Urinary Catheter placementPrerenal vs renalCatheter maintenance
Addisonian Crisis
Addisonian CrisisPharmacologyMedical Math
Constant Rate InfusionsBolus doses and calculationsDosages for medications
Monitoring and reassessing patientFluid overloadPerfusion parametersAssess pain
NutritionTLC!
Long term management:Client dedication and education
Preparing owners for a crisis or how to respond before/during/after stressful event
Life-long steroid and mineralocorticoid theoryDOCP injections every 28 days, or dependent on electrolytesAt least biannual examsPrednisone
Addisonian Crisis
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