1. What went well with this CPR session?

2. What could we have done differently?

3. Are there any goals we can set for ourselves for future CPR sessions?

4. Are there any serious concerns you would like to bring up?

Debriefing sessions will bring your team even closer together as a functional unit. This also provides opportunities for staff members to express any stress they may have faced in a productive and constructive manner, and a chance for better understanding of the event that passed. Debriefing is intended for us to be able to think towards bettering our effectiveness in CPR, providing each individual patient the best possible chance of recovery and positive outcome. Bring your open mind, active listening, and participation to each of these debriefings. Commend each other on what was done well, regardless of the outcome. Discuss what could be done differently to perform CPR better. Every opinion is important, and should be discussed in a professional manner. Being open in communication requires trust and willingness to give and take feedback without bias and being personally affected.

## Has RECOVER Made a Difference?

In the first year since the implementation of the RECOVER guideline into our CPR training protocol, a total of 54 CPR efforts (35 dogs, 18 cats, 1 chinchilla) have been made at the author's practice (data collection for the second year is ongoing). The average age was 9 years old, with variable reasons. The average duration of CPR was 11 minutes, with the shortest effort lasting 1 minute and the longest 32 consecutive minutes (one effort lasted 47 minutes total, with intermittent ROSC). The ROSC rate was 24.1% (13 of 54), with a survival-to-discharge rate of 3.7% (2 of 54). The average duration of CPR effort achieving ROSC was 9.5 minutes (high: 27, low 1). One of the patients who were eventually discharged was suspected to have experienced hyperkalaemia related cardiac arrest from urinary obstruction, while the other was suspected to have suffered from severe metabolic acidosis and potential over-supplementation of potassium as insulin doses were reduced without a change in KCl content of IV fluids (diabetic ketoacidosis patient). Comparison with previously published statistics unfortunately does not yield a significant difference at our practice. The staff, however, feels better prepared for the ultimate emergency, and feels confident the best chances are provided for each of our patients.

## RECOVER CPR Certification – A New Standard

RECOVER has brought on some indirect changes to the veterinary field in addition to providing standardization of CPR protocols. The Academy of Veterinary Emergency and Critical Care Technicians (AVECCT) is in the process of using similar evidence grading methods used by the RECOVER initiative in creating evidence-based nursing guidelines, inspired by the initiative. Evidence-based veterinary medicine (EVBM) has gained significant momentum since RECOVER guidelines were published, and while this could be temporally a coincidence, there is no denying the initiative adds significant weight to the importance of EVBM.

The RECOVER Initiative, through accreditation by the American College of Veterinary Emergency and Critical Care, has started issuing BLS and ALS Rescuer (people who perform CPR) and Instructor (people who teach CPR) certifications to promote standardizing of veterinary CPR methods based on evidence in the veterinary field. More information on this can be found on the RECOVER Initiative website located at https://recoverinitiative.org. The RECOVER initiative has three goals of establishing
evidence-based guidelines for CPR, providing education for veterinary CPR, and conducting research to fill knowledge gaps on the topic. The non-profit endeavour is likely to have served to make the field think differently about veterinary CPR and evidence-based veterinary medicine as a whole. Advancement in the field of veterinary emergency and critical care has been accelerated due to the RECOVER initiative.
ROAD TRAFFIC ACCIDENTS – HOW CAN WE HELP?

Louise O'Dwyer MBA BSc(Hons) VTS(ECC) DipAVN(Medical&Surgical) RVN
Clinical Support Manager, Vets Now
louise.odwyer@vets-now.com

Trauma is a common cause of emergency presentations in small animal practice. Due to our patients' small size the potential for multi-system damage is high and their injuries need to be approached in a systematic manner to ensure that no life-threatening abnormalities are missed. Appropriate management in the first few hours is vital for success. Many patients benefit from a multi-modal approach in the successive days, concentrating on careful nursing, nutrition and pain relief.

Primary assessment

A major body system assessment approach should be used to rapidly identify the life-threatening problems and initiate life-saving treatment. The major body systems are:

* Cardiovascular

* Respiratory

* Neurological

Cardiovascular

Cardiovascular assessment is aimed at identification of hypoperfusion as a result of hypovolaemia. Significant blood loss can occur into body cavities and fracture sites without visible haemorrhage. This is especially true in cats. The response to hypovolaemia is initially tachycardia, vasoconstriction and increased myocardial contractility as a result of adrenergic stimulation. With continued blood loss, these compensatory measures fail to maintain tissue perfusion and signs of decompensated hypovolaemic shock ensue.

The response of dogs to blood loss is predictable and the degree of hypoperfusion can be estimated from the severity of their clinical signs (see table below). Cats are less predictable and more difficult to assess. Their higher resting heart rate also means there is less room for an increase in heart rate. We are therefore more reliant on palpation of pulse quality for assessment in these patients. Assessment of the severity of hypovolaemia is used to guide fluid therapy.

<table><thead><tr><td>Clinical signs</td><td>Mild (Compensatory</td><td>Moderate</td><td>Severe (Decompensatory)</td></tr></thead><tbody><tr><td>Heart rate</td><td>130-150</td><td>150-170</td><td>170-220</td></tr><tr><td>Mucous membrane colour</td><td>Normal to pinker than normal</td><td>Pale pink</td><td>White, grey or muddy</td></tr><tr><td>Capillary refill</td><td>Vigorous &lt;1 second</td><td>Reduced vigour, 2 seconds</td><td>&gt;2 seconds or absent</td></tr><tr><td>Pulse amplitude</td><td>Increased</td><td>Moderate decrease</td><td>Severe decrease</td></tr><tr><td>Pulse duration</td><td>Mild decrease</td><td>Moderate decrease</td><td>Severe decrease</td></tr><tr><td>Metatarsal pulse</td><td>Easily palpable</td><td>Just palpable</td><td>Absent</td></tr><tr><td>Lactate concn (mmol/L)</td><td>3-5</td><td>5-8</td><td>&gt;8</td></tr></tbody></table>
## Respiratory

Respiratory assessment is aimed at identification of dyspnoea and identification of the underlying cause. All patients presenting with dyspnoea should be provided with immediate oxygen therapy in the least stressful manner possible.

Common causes of dyspnoea following trauma include:

* Pneumothorax

* Pulmonary contusions

Less common causes include diaphragmatic hernia and chest wall trauma.

Significant haemothorax is an extremely rare cause of dyspnoea as in these patients the signs of hypovolaemia predominate.

Traumatised animals should therefore be assessed carefully for lung sounds; all areas of the thorax should be carefully auscultated. Some of these patients can be extremely challenging, especially those that have both pneumothorax and pulmonary contusion. Pleural space disease (dull lung sounds) should prompt needle thoracocentesis.

## Neurological

In the primary assessment of these patients, neurological assessment is limited to mentation, posture and assessment for limb movement and deep pain. Patients with severe cardiovascular compromise should not be assessed for neurological function until they are more stable.

**Mentation:** Patients with coma or stupor (response only to pain) are likely to have intra-cranial injury. Reduced mentation in the absence of cardiovascular abnormalities should prompt evaluation for head injury.

**Posture:** Decerebrate rigidity (extensor rigidity in all four limbs with associated abnormal mentation, opisthotonus may or may not be present) is associated with caudal midbrain or cerebellum injury. This posture has a grave prognosis for recovery.

**Decerebellate rigidity:** (extensor rigidity of forelimbs, flexion of hind limbs with opisthotonus and normal mentation) is associated with caudal cerebellar lesions. This carries a better prognosis.

**Schiff-Sherrington posture:** (extensor rigidity of forelimbs, flaccid, atonic, areflexic, analgesic pelvic limbs, normal mentation) is associated with an acute, severe, T3-L3 lesion. Prognosis has typically been thought to be poor for full recovery of motor function, however with time some of these positions can recover.

## Management of Major Body System abnormalities

### Cardiovascular

Mortality in hypovolaemic shock is related to duration of the ischaemic insult. Early replacement of circulating volume is key to successful patient management.
Stabilisation of the cardiovascular system is aimed at replacement of lost circulating volume with intravenous fluid therapy. First choice is always isotonic crystalloid fluids, e.g. lactated Ringer's solution.

The volume of fluid given is based upon the severity of hypoperfusion. A proportion of 'shock dose' is administered over a short period of time (15-20 minutes) and the patient reassessed. For example, in a patient assessed to have moderate hypovolaemia a volume of 20mL/kg is administered over 15 minutes and the patient reassessed. The patient's response to therapy will ultimately determine the approximate volume to be given. Isotonic crystalloids are effective in the majority of cases. If the patient is responding poorly to fluid resuscitation, the use of other fluid types should be considered in conjunction with evaluation for the site of on-going haemorrhage.

There is on-going debate whether to use crystalloids or colloids for resuscitation. The on-going debate is testimony to the fact that there is little difference between the two types of fluids. Colloids in theory are more efficient and have a better persistence than crystalloids.

## Respiratory

On arrival at the practice it is unlikely that the animal will have endured a car journey and therefore be stressed at the unfamiliarity of the situation. The patient should be provided with oxygen supplementation whilst a brief examination of the respiratory tract is carried out to rule out easily treatable conditions. The patient should then be left to relax (as much as is possible).

In severely dyspnoeic animals, actively taking control of the airway (which often only requires very small doses of sedative in severely dyspnoeic animals) is vastly superior to intubating them following a respiratory arrest. The decision, although a big step, may be lifesaving in conditions such as upper respiratory tract obstruction secondary to brachycephalic obstructive airway syndrome, or laryngeal paralysis. It is important to gain a capsule history with particular reference to pre-existing disease, concurrent medication, history of trauma and onset and progression of the condition.

The first part of the evaluation of the respiratory tract should be to watch and listen without a stethoscope. An enormous amount of information can be gleaned from just observation, before even touching the patient. In normal animals, the majority of inspiration is due to diaphragmatic contraction, therefore little chest wall movement is seen. As the diaphragm contracts the abdominal contents are pushed caudally and therefore the abdominal wall moves out. In cats and small dogs where the abdomen moves in with inspiration, is seen in conditions preventing adequate lung inflation with respect to thoracic wall movement and indicates severe respiratory compromise. Conditions causing this include: upper airway tract obstruction, diaphragmatic rupture or paralysis, decreased lung compliance and pleural effusion (particularly in cats).

One should also be aware of the postural manifestations of dyspnoea such as extended neck, abducted elbows, open mouth breathing, an anxious facial expression, increased abdominal movement and paradoxical abdominal movement. Straightening of the neck and open mouth breathing occur in both dogs and cats, however, some other postural manifestations of more severe dyspnoea vary between species. Dogs prefer to stand with abducted elbows, whilst cats tend to sit in sternal recumbency. Constantly changing body position in cats implies a much worse degree of
dyspnoea than it does in dogs. Lateral recumbency due to dyspnoea is a serious sign in a dog and it often means impending respiratory arrest in a cat.

The differentiation between inspiratory and expiratory dyspnoea can also aid in the localisation of the disease process. Inspiratory dyspnoea with stridor or stertor is associated with dynamic upper airway obstruction, in cats chronic pleural effusions may be associated with inspiratory dyspnoea without stertor. Expiratory dyspnoea is a feature of feline allergic airway disease. Most other causes of dyspnoea will be associated with mixed respiratory patterns. Short shallow respiration and sometimes panting may be seen in some pneumothoraces.

## Pulmonary Auscultation

Auscultation is an art that with practice can be learnt and perfected by all. It requires a methodical approach and a decent stethoscope. All lung fields should be auscultated, this is easily accomplished by dividing the thorax into a nought and crosses board, i.e. 9 smaller areas. If lungs sound dull you should be cross referencing at all stages with respect to what you would expect given the degree of dyspnoea. In normal lungs increased lung noise is expected in the cranioventral lung fields. This is due to increased turbulence in these smaller airways. The lungs should be symmetrical left to right in similar fields.

Abnormal sounds are associated with a number of different disease processes within the airways. Increased respiratory rate and effort should cause increased harshness within the lung fields, so one should cross reference findings with what would be expected given the degree of respiratory embarrassment.

The distribution of the abnormal lung sounds can provide information as to the cause of the disease. Adventitious lung sounds are associated with parenchymal disease. It is somewhat easier to classify abnormal lung sounds as either:

* Harsh - i.e. Louder and coarser than normal

* Crackles – either fine or coarse, associated with lower airway or parenchymal disease.

A cranio-ventral distribution or crackles or harshness in dogs is associated with aspiration pneumonia. Cardiogenic oedema may be associated with sounds loudest over the heart base. Neurogenic oedema is seen most commonly in puppies after cervical trauma or upper respiratory tract obstruction. This usually results in a caudo-dorsal distribution of crackles.

Pleural space disease is associated with the absence of lung sounds. The pattern of dullness provides information as to the possible cause:

* Dorsal dullness – associated with accumulation of air, pneumothorax

* Ventral dullness – fluid or soft tissue

* Gut sounds may be heard with diaphragmatic hernias.

Animals that have been hit by cars and have pneumothoraces and pulmonary contusions may complicate auscultation. The contusions cause harshness, whereas the pneumothorax dampens sounds down, resulting in overall normal sounding lung sounds.
All dyspnoeic (and hypoperfused) patients will benefit from oxygen therapy. This should be provided in a stress-free environment. Initially this is most likely to be via an anaesthetic circuit and these are often better tolerated than masks. If on-going oxygen therapy is required the use of an oxygen tent should be considered. Patients that are severely dyspnoeic should have a brief targeted examination to identify for the presence of pleural space disease. If this is not present no further stress should occur to the patient and they should be allowed to recover for a period of time in an oxygen enriched environment. Certainly, in trauma patients radiographs should not be made without careful consideration of risks/benefits. It is unlikely to change your immediate treatment plan.

If the cause of dyspnoea is thought to be pneumothorax this should be addressed as soon as possible with needle thoracocentesis. Thoracic drain placement is rarely required and anaesthesia for placement may be associated with significant morbidity. Repeat needle thoracocentesis can be performed as required as this is a low morbidity and well tolerated procedure in both dogs and cats. Should regular decompression be required placement of a chest drain using a modified Seldinger technique is recommended. The Seldinger technique involves placement of a needle into a cavity (vessel or pleural space) through which a wire is placed. A catheter can then be railroaded into the space over the wire. These kits are commercially available through Direct Medical Supplies and produced by Mila. They are reasonably priced and extremely useful. Traumatic pneumothorax is rarely a surgical condition and the vast majority will respond to conservative management. Some may require 7-14 days to resolve fully, some patience is required!

There is no specific therapy for management of pulmonary contusions. Antibiotics are NOT indicated as infection is a rare complication. No therapy has been shown to speed recovery. If a patient is severely dyspnoeic as a result of pulmonary contusions any fluid therapy can result in worsening of their signs. Careful risk benefit analysis should be performed prior to administering large volumes at rapid rates. On no account should fluid therapy be withheld in patients suffering severe hypoperfusion. In these situations, patients should be monitored carefully. Some may require artificial ventilation if there is deterioration of their respiration although the prognosis for patients requiring ventilation for pulmonary contusions is extremely poor.

Diaphragmatic rupture is relatively infrequent compared to other causes of dyspnoea. There is less mortality if surgery is performed later rather than as an emergency as this allows stabilisation of other abnormalities. Indications for emergency surgery include displacement of the stomach into the thorax, intestinal volvulus or suspicion of intestinal rupture. Physical examination findings are often seen with diaphragmatic rupture include: dull lung sounds, gut sounds in the thorax, an "empty" abdomen on palpation and paradoxical abdominal movement with respiration. Suspicion of these should prompt thoracic radiographs at some point during diagnostic evaluation, although these can wait in the majority of patients.

Other injuries that may be seen rarely, although they seem to particularly affect cats, include subcutaneous emphysema and pneumomediastinum, occasionally in conjunction with a small pneumothorax. The pathogenesis of this often remains unknown although a small lung laceration or tracheal injury is often suggested. Many of these cats again will respond to conservative management.
Rib fractures are common, but rarely significant. In some patients with no other identified causes of dyspnoea these can contribute to inspiratory dyspnoea related to pain. Local anaesthesia can be used to provide analgesia at the fracture site.

## Neurological

Neurological assessment should only really be interpreted in patients that are cardiovascularly stable. Some patients also respond poorly to pain testing in the first few hours after trauma. Any abnormalities found on initial examination should be corroborated later.

Patients with suspected brain injury have inappropriate levels of mentation and often have concurrent head injury. The presence of head injuries does imply there is brain injury.

Where brain injury is suspected, cranial nerve testing should be carried out to evaluate for increased intracranial pressure. Herniation or imminent herniation is associated with deterioration in CNIII function. There is usually seen as unilateral changes in pupillary size. Unresponsive pupils that are mid-size occur with brainstorm signs that progress in to the medulla and are usually a grave sign. There may also be associated Cushing's response. This response occurs secondary to increased intracranial pressure (ICP) and results in systemic hypertension and associated secondary bradycardia. The systemic hypertension is an effort to maintain cerebral perfusion pressure (CPP = MAP- ICP).

The primary aim in patients with brain injury is to restore and maintain tissue perfusion and oxygen therapy. Oxygen should be administered and efforts to restore circulating volume initiated.

There is some data to suggest that hypertonic saline (2-4mL/kg) causes smaller increases in ICP than other fluids and may therefore be the most appropriate first choice. Steroids are NOT indicated and are associated with significant haemorrhagic gastrointestinal side effects if given at appropriate doses. Mannitol may be considered in patients that are cardiovascularly stable (0.25-1g/kg over 20 minutes) where there is evidence of increased intracranial pressure, but should not be used when there is concurrent hypovolaemia or pulmonary contusions.

Patients that are deteriorating despite appropriate medical therapy should prompt consideration of surgical intervention. This is a specialist procedure and referral should be sought sooner rather than later.
CAN BUSTER SAVE FELIX: AUTOTRANSFUSION AND XENOTRANSFUSION

Kenichiro Yagi, MS, RVT, VTS (ECC, SAIM)

Cornell University, Ithaca, NY, United States

kenyagirvt@gmail.com

Our ability to perform blood component transfusions has become a vital therapeutic option in treating many ailments affecting our patients. One of the most common uses of blood components involves replacement of red blood cells (RBC) in the case of clinical anaemia leading to tissue hypoxia. The amount of oxygen delivered (DO₂) being reduced to the point where critical oxygen exchange ratio is exceeded (signifying inadequate DO₂ to meet oxygen demand, VO₂) leads to reliance on anaerobic respiration for energy production, and is ultimately unsustainable. Supplementation of oxygen carrying capacity is warranted in these cases, and the most accessible method in providing this is through RBC transfusions. Thus, the demand for RBC products has historically been high, and the struggle for blood banks to meet demands still continues. The unavailability of RBC products is exacerbated by the presence of RBC antigens (blood types) and the potential for immunologic complications without careful consideration of compatibility risks. Alternative methods of transfusions are sought out in the effort to minimize our reliance on homologous transfusions to meet oxygen carrying capacity demands.

Xenotransfusions

A recent news report of a feline patient who was determined to require a RBC transfusion with the alternative being death has brought to the forefront of our minds how challenging obtaining feline blood matching our patient can be. A practice, for example, with an in-house bank that has two units of type B blood banked regularly, with a type B donor in the donor program ready to donate at beck-and-call would be considered very well prepared for a type B patient requiring transfusions. The practice still would be out of options for RBCs of this rare feline blood type if a patient requires multiple transfusions, or multiple patients come in and happen to be of the same type. Many practices face shortage of RBC products in general, regardless of the type. In this particular news report, the feline patient received canine blood as a part of his treatment; an example of xenotransfusion in practice.

Xenotransfusions, or transfusion of blood products between individuals from different species, have been recorded in literature dating back to 1667 involving transfusion of blood from lambs, calves, and dogs to humans for various reasons. Xenotransfusion has been employed in the 1800s with a good degree of success, though the discovery of blood types and improved knowledge on blood compatibility from the 1900s encouraged the practice of intraspecies, or homologous, transfusions. The practice of intraspecies transfusions has significantly improved the safety and effectiveness of RBC transfusions since varying degrees of haemolysis and shortened life span of RBCs were seen in xenotransfusions, with the development of high antibody titres against foreign RBCs leading to immunologic consequences. Veterinary transfusion largely is practiced in this manner, with adequate feline blood supply being challenging to sustain with the small donor pool and more complicated collection process. Being able to use, for example, canine donors of a typical donation volume of 450mL to supply our feline patients with a typical (whole blood) unit volume of 50mL would allow a
single donation to give us enough blood for nine transfusions. This seems like a great opportunity for a solution to the blood shortage. Let's discuss this further.

In order to implement xenotransfusion into our practices, we would first need to ensure the effectiveness and safety of xenotransfusions. There are several published studies specifically evaluating the effects of canine to feline transfusions, evaluating pre-transfusion predictors of immunologic complications, immunologic complication signs seen during and after transfusions, and the same on repeat xenotransfusions at varying timings.

**Efficacy:** The studies that have been conducted heavily focused on compatibility testing and immunologic complications, and less information on efficacy of the transfusion is available. Literature giving insight to the efficacy of canine to feline transfusion indicates a rapid improvement of clinical symptoms, leading to the conclusion that a positive effect of the transfusion is expected. In a case report involving a type B cat receiving blood from a Labrador Retriever resulted in an increase in PCV taken after the transfusion performed over 48 hours. The effect is relatively short lived, however, since the transfused RBCs seem to have an average lifespan of 4 days. In comparison, a typical life span of RBCs of homologous feline transfusion is 30 days. The loss of transfused RBC is attributed to delayed haemolytic transfusion reaction resulting from antibody production against RBC antigens introduced. The production of antibodies by the immune system when exposed to foreign antigens (sensitization) occurs in a delayed manner reaching significant titre levels 4-7 days post transfusion, allowing the transfused RBCs to persist for 4 days on average. The recipients have been observed to develop icterus from increased intravascular haemolysis and bilirubin load.

**Safety:** Statements regarding safety of canine to feline transfusions can be separated into three specific situations. In almost all transfusions performed in these studies, there were no acute clinical consequences to performing canine to feline transfusions as long as there was no history of previous canine blood transfusions. Subsequent transfusions performed within 4 days of the initial exposure also were performed without acute symptoms of immunologic complications. Subsequent transfusions performed more than 46 days past initial exposure resulted in anaphylaxis, which is often fatal.

Cats seem to be tolerant of the first canine blood transfusion they receive without signs of acute haemolytic or allergic reactions, indicating a lack of naturally occurring antibodies against canine RBC antigens. These observations correlate with the majority of compatibility testing methods (slide agglutination and cross match haemolysis testing) showing no signs of incompatibility. Occasional positive reactions were seen on the minor (recipient RBC mixed with donor plasma) cross match, which upon transfusion would cause some haemolysis of recipient RBC. This effect is minimized from the use of pRBC, containing very little plasma, and dilution by recipient blood volume upon transfusion. Cats in the studies rarely exhibited signs of complications, and when they did they were mild, involving tachypnoea and pyrexia during or within 24 hours of the transfusion. Delayed haemolysis occurring after 4-7 days of transfusion seems inevitable, with presence of anti-canine RBC antibodies made evident through positive slide-agglutination and cross match results when performed after this timing.
Subsequent transfusions after the initial exposure within the 4-7 day period did not result in clinical signs. Slide agglutination and cross match tests performed during this time period did not result in a positive reaction as well. This indicates a "grace period" in which antibodies are being produced to incite an anamnestic response when the next exposure occurs. Felines in the study that were given doses of canine RBC 1 and 2 days after initial exposure did not exhibit signs of immunologic complications. Test subjects having subsequent transfusions performed later than 6 days after the initial exposure showed signs of anaphylaxis with more than 66% resulting in death. Some of these cats were treated with cyclophosphamide as an immune suppressant prior to second exposure with the hypothesis of immune suppression reducing chances or severity of immunologic complications, with no positive effect seen. This serves as further evidence of the ineffectiveness of immune suppressive agents as premedication for transfusion (human studies show premedication to be ineffective).

**Summary:** Transfusion of canine blood, whether whole blood or packed RBC, can be performed without immediate consequences if it is the first transfusion of this kind. However, the benefit is short lasting, and should be reserved for patients that are in dire need of blood. The basic considerations in employing this therapeutic option should include situations where all of the following conditions are met. (1) The patient has no source of RBCs with compatible blood type (type B cat with no stocked blood, donor, or nearby hospital with stock, for example) or haemoglobin-based oxygen carrier solution. (2) The patient is imminently going to pass away or is thought to be in danger of sustaining irreversible hypoxic damage (certainly up to clinical judgment) without the ability to obtain compatible blood in a timely manner. (3) The patient is expected to benefit from a short term oxygen carrying capacity gain. In this case, the patient may have a condition where the cause of anaemia can be controlled swiftly enough to allow regenerative response to take over, or allow for time to obtain sources of compatible RBCs in the meantime. (4) The patient has never received canine blood products. (5) The owner understands the risks and consequences of performing a canine to feline transfusion. As the method is non-traditional, the owner should know our exact state of knowledge and potential consequences to give fully informed consent to the procedure.

If these conditions are met, use of transfusions of canine RBC to feline patients can be a life-saving therapeutic option in true emergency situations. If a xenotransfusion is decided on, a major and minor cross match should be performed to screen donor-recipient matches resulting in any signs of immunologic complications, and a therapeutic plan formulated with the benefit lasting 4-7 days in mind. Clear understanding of outcomes of future canine to feline xenotransfusion by the owners is important in preventing a second exposure beyond the 4-7 day mark. As responsible veterinary professionals, xenotransfusion should not become common practice in its current state. Effort invested in maintaining a good source and stock of feline RBC products should not decrease simply because "we can always turn to dog blood if we really need to".

"In its current state" is used as a qualifier in the previous passage because there is research ongoing for the human medical field involving "immunocamouflaging", or biochemical alteration of RBC antigens to prevent detection of the antigen as foreign by the immune system. The technique is still under development and its application to veterinary medicine would have an unknown timeline. Implementation of such techniques in xenotransfusions is theoretically beneficial in preventing immunologic consequences.
Autologous Transfusions

Several forms of autologous transfusions, or the act of infusing blood products derived from the patient themselves, are available in providing the patient with components necessary. These techniques can be useful in specific situations.

Autotransfusion: Autotransfusion is the act of recycling blood lost by the patient by collection and reinfusion. The term autotransfusion is specific to the form of autologous transfusion involving blood that is lost from the patient's condition or injury. In veterinary medicine, autotransfusion is most commonly performed as unwashed red cells transfused through a filter. This is accomplished through transfer of suctioned blood into an intravenous fluid bag and administered with a blood administration set. An alternative method involves the use of a 3-way stopcock attached to a syringe and extension sets. The stopcock is first opened to the extension leading to the pooled blood and syringe, and blood pulled into the syringe. The stopcock is then opened to the syringe and another extension leading to an intravenous catheter, and the blood pushed through an in-line blood filter into the patient. The syringe method can also be employed prior to surgical intervention, through percutaneous insertion of a catheter into a body cavity where haemorrhage is occurring. Autotransfusion is observed to be effective in alleviating compensatory signs from anaemia and improvement in consciousness, whereas replacement of the volume with lactated ringers did not result in the same effect.

An autologous RBC salvage system or cell-saver device is a piece of equipment with the capability of collecting blood lost into the patient, separating blood components through centrifugation, washing the RBC, and suspending them back into a suspension for administration. The salvage process can be discontinuous (batched) or continuous (uninterrupted reinfusion) depending on the device, and has the advantage of having the ability to provide higher concentration of RBC than collected blood containing fluid, as well as removing contaminants through the separation and wash process.

Autotransfusion has advantages, including the alleviation of blood bank demands in performing transfusions. Blood bank supply is often strained, with upkeep being a significant financial and staff training investment. In addition, by administering autologous blood, the concerns of immunologic complications are eliminated. Blood typing and cross-matching can also be omitted, since there should be no better match to a recipient than their own blood. Storage lesions, which include accumulation of hazardous levels of electrolytes, metabolites, and inflammatory mediators as well as RBC changes reducing their efficacy as oxygen carriers lead to blood stored longer than 14 days to be less effective in treatment of anaemia, have shorter survival time, and incite negative effects. These storage lesions can be virtually completely avoided through employment of autotransfusion, as no storage time is involved.

One of the main concerns with autologous transfusions is the theoretical potential for iatrogenic metastases of neoplastic cells that may be contained in the blood suspension. While no veterinary evidence is available, human studies indicate the lack of such consequences upon autotransfusion. This may be a combination of several factors, such as the thought of the cell salvage process and leukoreduction of the blood leading to effective removal of neoplastic cells. In addition, neoplastic cells may already be in circulation in many cases. Furthermore, allogenic transfusions are known to cause transfusion related immunomodulation resulting in down-regulation of the immune system,
associated with increased incidences of cancer recurrence. There is potential for autologous transfusions to be more beneficial for cancer patients.

Another concern with autologous transfusions lies in the case of bacterial contamination of the blood being salvaged. In the case of blood salvaged by cell-saver devices undergoing leukoreduction, 99% of the bacterial load is seen to be removed prior to transfusion, eliminating this concern. Blood collected in clean procedures not involving obvious sources of bacterial contamination such as bowel perforation or penetrating trauma is seen to contain bacteria as well, questioning the notion of all bacterial contamination being avoidable as well. While the effect of bacterial load in blood prepared for autotransfusion without cell-saver devices and leukoreduction is uncertain, the general approach to these patients involves antibiotic therapy, and there is no evidence supporting increased incidences of bacteraemia as a result of autotransfusion. The use of cell-salvage devices may also lead to cell-salvage syndrome resulting in disseminated intravascular coagulation, acute respiratory distress syndrome, acute kidney injury, or death.

**Pre-operative donation:** Autologous transfusions may be performed as an intentional form of blood collection prior to procedures with reasonable chances of it resulting in haemorrhaging and subsequent demand for a transfusion. Preemptively collecting blood from the patient, typically a week prior to the procedure will allow for regenerative response to have helped replace the RBC lost through collection. The collected blood is stored in preparation for the anticipated blood loss, serving as a source of autologous RBC product if need arises. Advantages similar to autotransfusion techniques exist with this form of autologous transfusion, including the elimination of need for compatibility testing and alleviation of allogenic blood demand. A differing severity of storage lesion will be seen depending on the timing of blood collection and can lead to an increase in complications related to storage lesions. The risk of bacterial contamination upon blood collection should be at a rate similar to allogenic units, dependent on quality of blood collection procedures and storage.

**Acute euvolaemic haemodilution:** The detrimental effects of storage anticipated by performing autologous transfusions through pre-operative donation can be circumvented through a technique called acute euvolaemic haemodilution. The technique involves blood collection from the patient undergoing a surgical procedure with likelihood of haemorrhaging just prior to the procedure, with replacement of lost blood volume with crystalloids to prevent hypovolaemia. While the patient will have reduced circulating RBC mass as the procedure is started, the amount of blood collected is limited to tolerable amounts to meet oxygen demands. The blood lost during the procedure will be diluted in concentration of RBC (PCV), reducing the RBC mass lost when compared to the same volume of blood with the original concentration. The collected blood can be transfused if the need for a RBC transfusion arises, with the same benefits of any autologous transfusion technique, with the additional benefit of the blood being fresh. The technique serves as a method in alleviating allogenic blood transfusion need, though is often not sufficient to eliminate needs.

The quest for providing a sufficient supply of safe RBC product is an area of ongoing improvement, as the demand for blood products is ever-present, while the negative effects of blood transfusions in current practice are increasingly understood. Ensuring supply and safety in transfusions relies on methods to reduce the need for RBC transfusions (conscientious blood sampling, assertive treatment of underlying cause, proper assessment of indication), use of alternatives to RBC transfusions, proper
risk assessment and compatibility testing, proper patient monitoring, and swift response to complications. Xenotransfusions and autologous transfusions are a couple of strategies increasing our supply of RBC products, each with their situational effectiveness and appropriate considerations.

References

Bovens C, Gruffydd-Jones T. Xenotransfusion with canine blood in the feline species: review of the literature. J Fel Med Surg 2012;15(2):62-67.

Hirst C, Adamantos S. Autologous blood transfusion following red blood cell salvage for the management of blood loss in 3 dogs with hemoperitoneum. J Vet Emerg Crit Care 2012;22(3):355-360.

Kellett-Gregory LM, Seth M, Adamantos S, Chan DL. Autologous canine red blood cell transfusion using cell salvage devices. J Vet Emerg Crit Care 2013;23(1):82-86.

Kisielewicz C, Self IA. Canine and feline blood transfusions: controversies and recent advances in administration practices. Vet Anaesth Analg 2014;41:233-242.

Prittie JE. Controversies related to red blood cell transfusion in critically ill patients. J Vet Emerg Crit Care 2010;20(2):167-176.

Safaei M, Takami HM. Blood autotransfusion outcomes compared with Ringer lactate infusion in dogs with hemorrhagic shock induced by controlled bleeding. J Res Med Sci 2011;16(10):1332-1339.
ABSTRACTS PROCEEDING TALLINN 2019

Oral presentations

INCIDENCE OF Z, I AND B LINES DETECTED WITH POINT OF CARE ULTRASOUND IN HEALTHY SHELTER DOGS

Martin Â., Gouveia D., Cardoso A., Viegas I., Busoni V., Gommeren K., Boysen S.

Introduction: Lung ultrasound has been described in dogs, although Z and I lines, which are present in healthy humans, have never been reported. Z lines are ill-defined artifacts arising from the pleural line, independent of the glide sign, not erasing A-Lines, and vanish after a few centimeters (2-5 cm), without pathologic significance. I lines have similarities with B-lines, arising from the lung surface, moving with the glide sign, but disappearing after 3-4 cm. They are short vertical artifacts of unknown clinical significance.

Objective: To describe lung ultrasound findings in a population of healthy shelter dogs using a combined pleural space and lung ultrasound protocol. We hypothesize that shelter dogs have B, Z and I lines present on lung ultrasound.

Methods: Shelter dogs prospectively underwent physical examination, three view thoracic radiographs and thoracic VPOCUS. Dogs with normal physical exam findings, unremarkable pulmonary thoracic radiographs and normal VPOCUS findings were included in the study. VPOCUS involved evaluation of the pleural space and lung, with cineloops recorded at 17 different locations.

Results: 53 dogs were enrolled. 13 dogs had 1 (n=9), 2 (n=2) or 3 (n=2) total B lines. Of the dogs with 2 B lines, one had a B line at 2 sites, and one had 2 B lines at a single site. Of the dogs with 3 total B lines, 1 had a B line at 3 sites and one had 3 at a single site. No dog had subpleural consolidation. All dogs had Z lines noted with a median of 11 (range 1-20). 43/53 dogs had a median of 3 (range 1-10) I lines noted.

Discussion: Z and I lines occur frequently in healthy dogs. They are important to identify as they can be confused for B lines. The significance of I lines is uncertain. B lines were identified in up to 25% of healthy shelter dogs, which is similar to previous reports.

Conclusion: Similar to reports in healthy humans, Z and I-lines appear to be common findings in healthy shelter dogs. The incidence of B lines in shelter dogs is similar to the incidence in other healthy dog populations.

RETROSPECTIVE EVALUATION OF THE INCIDENCE OF ACUTE KIDNEY INJURY IN DOGS
UNDERGOING SURGERY UNDER CARDIOPULMONARY BYPASS: 64 DOGS (2005-2018)

Luby J., Starybrat D., Cortellini S., Bristow P.

Introduction: Acute kidney injury (AKI) is an abrupt reduction in kidney function and has been associated with a variety of diseases in hospitalised patients. AKI is one of the recognised complications of cardiac surgery, performed with or without cardiopulmonary bypass (CPB), in people. In this population, development of AKI has a complex and multifactorial aetiology, involving processes such as exposure to exogenous and endogenous toxins, metabolic factors, ischemia-reperfusion, inflammation, oxidative injury and neurohormonal activation. Reported incidence of AKI in people after cardiac surgery varies depending on the identification criteria used and may be as high as 50%. Additionally, development of AKI has been associated with increased in-hospital mortality in this population. Currently there is no information available on incidence of AKI in dogs undergoing cardiac surgery under CPB.

Objectives: To determine the incidence of AKI in dogs undergoing surgery under CPB. To determine if any peri-operative factors influenced development of AKI and to assess if AKI affected survival to discharge.
Materials and methods: Data were retrospectively collected from records of client-owned dogs that had undergone an open heart surgery under CPB between 2005 and 2018 in a single veterinary teaching hospital.

Creatinine and urea were recorded pre-operatively and at three time points post-operatively (0-48h, 48-96h and 96-144h post-operatively). AKI grading was based on the IRIS scheme. Other variables collected included age, breed, surgery type, use of pre-operative diuretics, anaesthesia, bypass, cross-clamp and surgery time, intra-operative hypotension duration, lowest intra-operative mean arterial blood pressure and length of hospitalisation.

Results: Sixty-four dogs were included in the study. The incidence of AKI was 28.2% (18/64). Overall mortality was 22.2% (4/18) for AKI dogs and 28.3% (13/46) for non-AKI dogs, p=0.758. Longer anaesthesia and surgery duration were significantly associated with the development of AKI (p=0.01 and p=0.008 respectively).

Conclusions: AKI is a common occurrence in dogs after open heart surgery under CPB. Future studies are needed to assess the effect of other variables further and to assess whether reducing the anaesthesia and surgery time may reduce the incidence of AKI.

## SALIVARY CORTISOL CONCENTRATIONS AFTER ALFAXALONE OR PROPOFOL ADMINISTRATION IN HEALTHY CATS

Yozova I., Sano H., Owen R., Sakata H., Cockrem J.F.

Introduction: Stress response, whether exaggerated or insufficient can be detrimental in the critical care setting. Various drugs used in this setting are known to affect stress response.

Background: Alfaxalone and propofol are commonly used anaesthetics in emergency and critical care. Studies in a variety of species and with diverse designs have shown controversial results regarding the effects of both drugs on stress response. Alfaxalone and propofol effects on cortisol production have not been investigated in cats. Salivary cortisol measurements have been used as a non-invasive alternative to serum cortisol measurements.

Objective: To assess the effects of alfaxalone or propofol administration on salivary cortisol in healthy cats.

Design: Prospective, blinded, cross-over experimental study

Methods: After undergoing one week of adaptation to single metabolic cages, fifteen male castrated cats were randomized to receive intravenous continuous rate infusion of alfaxalone (4-8 mg/kg/h) propofol (6-12 mg/kg/h), producing similar levels of sedation or control (buffered balanced isotonic crystalloid, 1.2 ml/kg/h) for 30 minutes. Salivary samples were collected at T0, T30', T1h, T3h, T6h, T12h and T24h. The study was carried out in three intervention groups with a washout period of six days. Cortisol concentrations were measured using an in-house ELISA method. An area under the curve (AUC) was generated for the time points T0 through to T6h.

Statistical analyses included one way repeated measures ANOVA of log data and Tuckey's multiple comparison test using commercial software. Significance was set as p<0.05.

Results: No significant difference was found in the baseline AUC between groups (p=0.9410).

There was no significant difference in the AUC between the propofol group and the control group (p=0.1631). The AUC in the alfaxalone group was significantly higher compared to the control (p=0.0065) and propofol group (p=0.0471), respectively. T12h and T24h cortisol concentrations returned to baseline.

Discussion: In this study, alfaxalone increased short-term cortisol production compared to a control whereas propofol did not. Whether alfaxalone has a direct stimulatory effect on the hypothalamus-pituitary-adrenal axis, or acts indirectly remains unknown.

Conclusions: Alfaxalone increases salivary cortisol concentrations in healthy cats. Further studies in critically-ill cats are necessary to assess the clinical significance of these results.
# PLASMA CONCENTRATIONS OF INTESTINAL FATTY ACID BINDING PROTEIN, VASOACTIVE INTESTINAL POLYPEPTIDE, C-REACTIVE PROTEIN AND INTERLEUKIN-6 IN VOMITING DOGS WITH AND WITHOUT FOREIGN BODY INDUCED GASTROINTESTINAL OBSTRUCTION

Parratt C., Harrand R., Moody E., Boag A., Firth A.

**Introduction:** Foreign body induced gastrointestinal obstructions (FBO) can be difficult to diagnose.

**Background:** Plasma vasoactive intestinal polypeptide (VIP) concentrations increase in canine experimental bowel obstruction, and concentrations of Intestinal fatty acid binding protein (I-FABP) increase in humans with ischemic bowel obstruction.

**Objective:** To investigate plasma concentrations of VIP and I-FABP in dogs with and without FBO. C-reactive protein (CRP) and interleukin-6 (IL-6) were also measured as markers of the acute phase response.

**Methods:** Dogs were eligible for inclusion if they had vomited at least once in the preceding 24 hours, and if an FBO could not be excluded at presentation. Dogs that received corticosteroids or were less than 5.0kg or 3 months old were excluded. Dogs were categorised as FBO positive (FBO+) or negative (FBO-) based upon surgical findings, or follow up with owners or their veterinarian. The study was approved by the RCVS ethics review panel.

Sample size estimation was 101 dogs. Wilcoxon-Mann-Whitney test and receiver operator curves (ROC) were applied to investigate the diagnostic potential of each peptide. P<0.05 was considered significant.

**Results:** Overall, 112 dogs were recruited. Ten were excluded. The remaining 102 dogs were used for analysis (FBO- n=85, FBO+ n=17). There was no difference in gender, age or bodyweight between groups. FBO+ dogs had significantly greater concentrations of I-FABP than FBO- dogs (median 1.90ng/ml vs 0.61ng/ml (P=0.018). No statistically significant difference was identified in VIP, CRP or IL-6 (P>0.05). ROC area under curve (AUC) for I-FABP was 0.74 (95%CI 0.61-0.868). Using an I-FABP cut-off of 0.35ng/ml, sensitivity and specificity were 94.1% and 35.3%, and at 8.52ng/ml were 11.8% and 95.3%.

**Discussion:** I-FABP concentrations in excess of 8.52ng/ml are strongly suggestive of FBO, whilst concentrations less than 0.35ng/ml mean that an FBO is unlikely.

**Conclusion:** This is the first study to demonstrate that plasma I-FABP concentrations are increased in vomiting dogs with FBO. Specific I-FABP cut-offs were determined, which could contribute to a diagnosis in a proportion of cases. Further studies are required to fully explore its clinical utility.

# ADRENAL ACTIVITY AND THYROID AXIS IN SURVIVORS AND NON SURVIVORS IN DOGS INVOLVED IN ROAD TRAFFIC ACCIDENTS: A COHORT STUDY IN 420 DOGS

Rocchi P., Zoia A., Botto A., Bertolini G., Furlanello T., Caldin M.

**Introduction:** Response to trauma includes various endocrine, metabolic and immunological changes, that have been well documented in people but less known in veterinary patients.

**Objective:** To determine the impact of a recent trauma on the thyroid axis and adrenal activity in dogs and to assess the usefulness of urinary cortisol to creatinine ratio (UCCR), basal serum thyroid-stimulating hormone (TSH) total thyroxine (tT4) and free thyroxine (fT4) concentrations in the prediction of outcome in dogs presented for road traffic accident (RTA).

**Methods:** A retrospective cohort study was conducted from a referral and emergency Veterinary Clinic and Laboratory. Exposed group included 210 dogs involved in RTA, evaluated within 24 hours from trauma, compared with an equivalent group of dogs presented for various illnesses.

Those unexposed dogs were chosen from all dogs that presented to the clinic in the same period of time and were individually matched to a group of exposed dogs for age (± 6 months), sex and sexual status, and breed.

**Results:** UCCR resulted significantly higher in exposed than in unexposed dogs (median 101.5 vs 21.0; P < 0.0001). Serum tT4 value showed no statistical difference between exposed and
unexposed dogs, while both serum TSH and fT4 levels were significantly lower for group of exposed
dogs compared to unexposed sick dogs (median = 0.05 vs 0.08 ng/mL; P < 0.0001 for
TSH and median = 15.85 vs 17.95 pmol/L; P=0.003 for fT4). UCCR was significantly higher for
nonsurvivors compared to survivors (median = 106.7 and 47.9 respectively; P<0.04), TSH was
unremarkable, and serum tT4 and fT4 were significantly lower for nonsurvivors (median = 12.70 and
17.60 pmol/L respectively; P=0.005).

Conclusions: This study offers new insights about the endocrine characteristics in emergency
dogs for RTA. UCCR is significantly higher in injured dogs than in dogs affected by other
conditions and is a prognostic factor for mortality. Serum tT4 in traumatized is similar to what
obtained in dogs affected by other diseases, while fT4 and TSH are both significantly lower in the
exposed group. Low fT4 and tT4, and increased UCCR are new prognostic factors for mortality in dogs
presented for RTA.

A NOVEL POINT OF CARE VISCOELASTIC COAGULOMETER DETECTS HYPERFIBRINOLYSIS IN
HEALTHY GREYHOUND DOGS

Jandrey K., Chang C.S, Kent M., Burges J.

Introduction & Background: Viscoelastic coagulometers can detect hypercoagulability and hyperfibrinolysis. Greyhound dogs possess unique coagulation characteristics that are uncommon in other breeds.

Objective: To measure viscoelastic coagulation in two canine blood donor populations using a novel, point-of-care coagulometer (VCM) and correlate the results to CBC data.

Methods: Healthy non-Greyhound (Group 1) and Greyhound dogs (Group 2) were enrolled after IACUC approval. Dogs with missing data, blood cell concentrations below reference intervals, or undetected VCM values were excluded. Venous whole blood was analyzed on the VCM and a unique cytometer for each group.

Statistics (significance set at p< 0.05) were completed using a commercial statistics program. To look for differences in CBC and VCM parameters, a t-test or a Wilcoxon rank-sum test were completed as appropriate.

Results: CBC data (mean[SD]): Group 1 (n=39, 12 breeds) demonstrated the Hgb concentration (17.1gm/dL[1.7]), RBC concentration (RBC, 7.7x106/microliter[5.7]), White Blood Cell concentration (WBC 7420x103/microliter[1898]), and platelet concentration (Plt, 206x103 /microliter[48]). Group 2 (n=54 Greyhound dogs) showed Hgb (18.1 gm/dL [2.5]), RBC (9.5x106 /microliter[1.4]), WBC (10022x103/microliter[2279]), and Plt 262103/microliter[99]). There is a statistical difference between all CBC values between Groups 1 and 2. VCM data (mean[SD]): Group 1 were Clot Time (CT, 288.7s[84.6]), CFT (255.9s[102.5]), AA (51.2 degrees[8.4]), Maximum Clot Firmness (MCF, 26.0 VCM units[5.7]), LI30 (86.4%[21.0] ), LI45 (84.9%[24.7]). Group 2 were CT (275.6s[51.7]), CFT (299.7s[433.6]), AA (50.3 degrees[8.1]), MCF (17.0 VCM units[4.5]), LI30 (29.4%[13.8]), LI45 (27.1%[12.8]). Statistical differences exist between groups for MCF, LI30, and LI45.

Discussion: Greyhound dogs in Group 2 have higher Hgb than all other breeds in Group 1. The other
differences in CBC data unlikely impact the overall viscoelastic assessment. Initial measurements of
fibrin formation (CT, CFT, & AA) were similar between groups. The MCF, LI30 & LI45 are profoundly
different demonstrating that Greyhounds have weaker overall clot strength and larger and consistent
fibrinolysis compared to non-Greyhound dogs. The difference in Plt may have some impact on MCF,
but the hyperfibrinolysis cannot be explained by any other measured parameter.

Conclusions: The VCM Vet clearly demonstrates hyperfibrinolysis in healthy Greyhound blood donors compared to non-Greyhound blood donor dogs.
# COMPARISON OF BASIC LIFE SUPPORT PERFORMANCE AND RETENTION PROFICIENCY BETWEEN ONLINE SELF-INSTRUCTION AND CONVENTIONAL IN-PERSON CPR REFRESHER TRAINING IN VETERINARY TECHNICIANS: A CONTROLLED RANDOMIZED STUDY

Londoño L., Stephen A., Shih A., Buckley G.J.

**Introduction:** Basic life support (BLS) with external cardiac compressions and delivered breaths are the mainstay of cardiopulmonary resuscitation (CPR) in people and animals. Frequent training of veterinarians and veterinary technicians has been advocated in the published veterinary CPR guidelines in order to improve outcomes in small animals.

**Objectives:** To assess skills and knowledge of technicians trained using two different style refresher courses in CPR-BLS.

**Methods:** This study evaluated two methods of refresher training courses of BLS amongst veterinary technicians in a veterinary teaching hospital: online self-instruction (OSI) and in-person training. Anesthesia and ICU veterinary technicians were randomized to receive OSI or in-person refresher courses every 4 months for one year. BLS performance was assessed at the end of study with an instrumented canine manikin evaluating compression depth and rate during a two minute CPR-BLS cycle. A questionnaire was given to participants to evaluate their knowledge and confidence in BLS before and after their training.

**Results:** Twenty-three veterinary technicians completed the study: 12 in the OSI group and 11 in the in-person group. There was no difference in CPR-BLS performance between the groups based on the total number of simulator alarms (compression rate and compression depth) during the 2 minute cycle (P = 0.47). There was no difference in scores between the two groups, assessing their knowledge (P = 0.92) and confidence level (P = 0.68) before and after CPR-BLS training.

**Discussion:** In this group of technicians, no difference was seen between the two groups. Before making a wider recommendation regarding provision of CPR training, it would be important to follow people over a longer period than one year to ensure retention of psychomotor skills. Additionally, this group of anesthesia and ICU technicians were already skilled in CPR compared to the general population of veterinary hospital staff, so their ability to retain skills could be improved compared to less experienced personnel. Lastly, a high fidelity simulator would allow for a wider range of BLS performance measurements.

**Conclusion:** In this population of experienced technicians there appeared to be no difference in retention or performance between the groups receiving OSI or in-person instruction.

# EVALUATION OF THE AGREEMENT BETWEEN A LUNG ULTRASOUND PROTOCOL, VET BLUE, AND THORACIC COMPUTED TOMOGRAPHY IN DOGS AND CATS

Cole L., Pivetta M., Humm K.

**Objective:** To assess agreement between a previously described lung ultrasound protocol, Vet BLUE, and thoracic computed tomography (CT).

**Methods:** Animals presenting to an emergency department were prospectively recruited between May 2017 and September 2018. The Vet BLUE protocol (whereby 4 set points on each hemithorax are assessed by ultrasound for the presence of B-lines, pleural fluid, lung consolidation or any other abnormal findings) was followed on all animals at the time of admission by a veterinarian with basic training in emergency ultrasound. Those animals that had a thoracic CT performed within 24 hours were then subsequently enrolled. A board-certified radiologist, blinded to the Vet BLUE findings, reviewed the CT images. Accuracy of the Vet BLUE protocol for detection of regional CT abnormalities was determined and a Cohen's kappa statistic was calculated to assess agreement between CT and Vet BLUE.

**Results:** 31 animals (26 dogs and 5 cats) were enrolled. CT revealed alveolar-interstitial disease in 64.5% (20/31) cases, pneumothorax in 9.68% (3/31) cases, pleural fluid in 9.68% (3/31) cases, mediastinal masses in 6.45% (2/31) cases and no abnormalities in 35.5% (11/31) cases. When using CT as gold standard, Vet BLUE had an overall accuracy of 70%. There was good agreement between
CT and Vet BLUE for detection of pleural effusion (κ= 0.783), and fair to moderate agreement for detection of pneumothorax (κ= 0.475), lack of intra-thoracic disease (κ= 0.516) and alveolar-interstitial disease (κ = 0.321). Discordance occurred with the reporting of a craniioventral soft tissue mass in one case on Vet BLUE examination that was not present on thoracic CT. Conversely, a pneumothorax was not detected on Vet BLUE in 2/3 cases and CT revealed alveolar-interstitial disease in 8 cases which did not fulfil the criteria for Vet BLUE diagnosis of alveolar-interstitial disease (≥3 B lines), however 6/8 of these cases had 1-2 B lines present.

**Conclusion:** The Vet BLUE protocol is a useful technique to detect intrathoracic disease when performed by veterinarians with basic training. Detection of 3 or more B lines is highly suggestive of significant alveolar-interstitial disease and their detection should prompt further diagnostics.

## HIGH-FLOW NASAL CANNULA OXYGEN THERAPY IN ACUTE HYPOXEMIC RESPIRATORY FAILURE IN 22 DOGS REQUIRING OXYGEN SUPPORT ESCALATION

Jagodich T., Bersenas A., Bateman S., Kerr C.

**Introduction:** Heated, humidified, high-flow nasal cannula oxygen therapy (HFNC) is an intermediate method for providing oxygen supplementation as well as promoting improved respiratory function. HFNC offers provision of continuous positive airway pressure via high gas flow rates. Successful application of HFNC to hypoxemic respiratory failure patients would provide a non-invasive level of intermediate support that has not previously been possible in veterinary patients.

**Objective:** To determine the effect of HFNC oxygen therapy on cardiopulmonary variables and outcome, in canine patients with acute hypoxemic respiratory failure.

**Methods:** This was a prospective, sequential clinical trial at a university veterinary teaching hospital. HFNC therapy was initiated in dogs with hypoxemic respiratory failure after 30 minutes on traditional oxygen supplementation failed to: increase SpO2 >96%, PaO2 >75mmHg, or improve respiratory rate/effort. Physiological variables, blood gas analysis and dyspnea/sedation/tolerance scores were collected prior to HFNC initiation (on traditional oxygen support (time 0 or T0)), and subsequently during HFNC oxygen administration at time 30, 60 minutes and 7±1 hours.

**Results:** Twenty-two client-owned dogs that failed traditional oxygen support were enrolled in the study between July 2016 and January 2018. Relative to T0, use of HFNC resulted in a decreased respiratory rate at 1 hour (P = 0.022) and 7 hours (P = 0.012), a decrease in dyspnea score at all times (P<0.01), and an increase in SpO2 at all times (P<0.01). There was no difference in arterial/venous PCO2 relative to T0, though PaCO2 was correlated with flow rate. Based on respiratory assessment, 60% of dogs responded to HFNC use by 30 minutes and 45% ultimately responded to HFNC use and survived. No clinical air-leak syndromes were observed.

**Conclusions:** HFNC use improved oxygenation and work of breathing relative to traditional oxygen therapies, without impairing ventilation. HFNC use appears to be a beneficial oxygen support modality to bridge the gap between standard oxygen supplementation and mechanical ventilation.

## ECHOCARDIOGRAPHIC VARIABLES IN ANEMIC CANINE AND FELINE PATIENTS RECEIVING BLOOD TRANSFUSIONS

Donaldson R., Seo J., Humm K., Luis Fuentes V.

**Introduction:** Blood transfusions are performed frequently in veterinary patients experiencing decompensated anaemia. Increased left atrial and ventricular dimensions have been reported in severely anaemic cats, suspected due to activation of neurohormonal compensatory responses to maintain haemodynamic stability. The clinical significance of these changes is unknown. The effect of blood transfusion on cardiac dimensions in naturally occurring anaemia has not been reported.

**Methods:** Dogs and cats with naturally occurring anemia of any cause were included. They received an echocardiogram and had packed cell volume (PCV) and total solids (TS) performed
before and within 24 hours following packed red blood cell transfusion. Signalment, body weight, disease process, transfusion duration and volume, and treatment with steroids or intravenous fluids were recorded.

Sample size calculation predicted 20 dogs and cats were required for significance. Nonparametric statistics were performed and a post hoc Bonferroni correction amongst echocardiographic variables set significance at (p <0.006).

Results: Twenty-three cats and 27 dogs were enrolled with 10 exclusions due to poor patient compliance, failure to perform post-transfusion echocardiogram, or because blood transfusion was not required. PCV significantly increased in both cats and dogs following transfusion (p = 0.001), and heart rate decreased significantly in dogs following transfusion (p <0.001). In cats, fractional shortening (FS%) significantly decreased (median 57.1, range 36.0 – 84.7, pretransfusion; and median 41.6, range 28.1 – 69.6, post-transfusion; p = 0.002) and Left Ventricular Internal Diameter in systole (LVIDs) significantly increased (median 6.5, range 2.7 -9.8, pretransfusion; and median 7.9, range 5.3 – 11.1, post-transfusion; p = 0.001).

In dogs, FS% significantly decreased (median 41.57, range 24.12 – 62.97, pre-transfusion; and median 32.94, range 12.5 – 51.47, post-transfusion; p = 0.006), and Left Ventricular Internal Diameter in diastole (LVIDd) (median 31.7, range 21.3 – 45.6, pre-transfusion; and median 34.0, range 24.7 – 51.30, post-transfusion; p = 0.006) and LVIDs (median 18.4, range 11.7 - 34.6 pretransfusion; and median 34.4, range 14.9 - 44.3, post-transfusion; p <0.001) were significantly increased, as were Bodyweight-normalised values for left ventricular dimensions.

Conclusions: Blood transfusion appears well tolerated in haemodynamically compromised patients with naturally occurring anaemia of all causes.

## UTILITY OF BLOOD CULTURES IN DOGS: A HISTORICAL COHORT STUDY (2009-2018)

Saarenkari H., Smart L., Sharp C.

Introduction: Obtaining microbiologic blood cultures when sepsis is suspected, and before administering antimicrobial therapy, is standard of care in human medicine. The objective of this historical case series was to characterise the utility of blood cultures in dogs, including yield of positive cultures, prevalence of resistant microorganisms and occurrence of antimicrobial escalation or de-escalation.

Methods: Medical records of a university hospital were searched for blood culture fee code between January 2009 and December 2018. Dogs were included if blood culture results were available. Data collected included presumed source of infection, culture and susceptibility results, and antimicrobial therapy.

Results: Forty-five dogs met inclusion criteria. Presumed sources of infection were unknown (n=12), bone and joint (10), soft tissue (10), abdomen (5), intravascular (4), central nervous system (3) and lung (1). Nine of 45 cultured positive for microorganisms: Staphylococcus pseudintermedius (n=2), and one each of Enterococcus sp, Staphylococcus aureus, Serratia marcescens, gram-positive bacilli, Pseudomonas sp and beta haemolytic Streptococcus. Both Escherichia coli and Pseudomonas aeruginosa were isolated from a single dog. Resistant bacteria were isolated in 7/9 dogs, with the most frequent reported resistance being to amoxicillin (n=4), doxycycline (n=2) and enrofloxacin (n=2). Susceptibilities were unavailable for 2/9 dogs.

Ten dogs died before culture results became available. Out of 27 culture-negative dogs, antimicrobial therapy was de-escalated in 4 and escalated in 2. Four culture-negative dogs did not receive antimicrobials and one had antimicrobials discontinued before the result was available. In most cases (11/15) when antimicrobial therapy was not de-escalated, cultures from other sites also showed no growth.

Out of the 8 culture-positive dogs, antimicrobial therapy was changed based on susceptibility in 5 dogs. In one case, antimicrobials were not de-escalated despite indication for such, in one case a long-
acting antimicrobial was administered before results were available and in one case no information on de-escalation was available.

**Conclusion:** The submission of blood cultures was infrequent. The proportion of resistance was higher than expected and supports the use of blood cultures in cases of suspected sepsis. This study also identified a low prevalence of antimicrobial de-escalation in the face of a negative culture.

## COMPARISON OF SIX CROSSMATCH TEST METHODS FOR ESTABLISHING BLOOD TRANSFUSION INCOMPATIBILITY IN CATS.

Nectoux A., Guidetti M., Bourgeois S., Barthélemy A., Pouzot-Nevoret C., Goy-Thollot I.

**Introduction:** In feline blood transfusion, life-threatening immune-mediated hemolytic reactions can appear because of red blood cells (RBCs) agglutination due to naturally occurring alloantibodies against erythrocytes antigen. The most described erythrocyte antigens system in cats is the AB system.

**Crossmatch (XM) tests** are mandatory to prevent incompatible transfusion if typing is not available and could be recommended in addition of blood typing to detect severe non-AB incompatibility.

**Background:** Gold standard XM tests as well as reliable bedside tests are lacking in cats.

**Objective:** To compare strength of agglutination between six crossmatch test methods described in feline transfusion medicine.

**Methods:** Plasma from a type B cat, plasma from a type A cat and RBCs from a type A cat where used to perform crossmatch tests. RBCs solution was diluted to obtain a scale of agglutination reactions.

Using each dilution of RBCs, XM tests were performed using six XM methods: gel column card without antiglobulin, gel with antiglobulin, immunochromatographic strip, tube, rapid slide and microscope.

**Results:** The gel column card XM test showed strong agglutination until the dilution 1/80 and became negative at 1/110. The XM gel with antiglobulin showed strong agglutination up to the dilution 1/64 and became negative at 1/100. The immunochromatographic strip XM demonstrated strong agglutination until the dilution 1/50 and became negative at 1/64. Large agglutinates were observed until the dilution 1/64 on tube method. Large agglutinates were observed until the dilution 1/50 on rapid-slide and microscope methods and no microagglutination was seen after the dilution 1/100.

**Discussion:** Gel XM methods can detect smaller agglutination reactions but could also detect any agglutination due to an underlying disease process; they are time-consuming and require experienced operator. All currently available XM methods are able to detect strong agglutination reactions, which are the ones that lead to most severe hemolytic reactions. To date, clinical relevance due to weak agglutination reactions is unclear.

**Conclusion:** XM techniques with gel are more sensitive to detect weak agglutination reactions in cats compared to others techniques. All techniques are able to detect strong agglutination reactions and exclude risk of severe AB (and non-AB) acute reactions.
Original study posters

EFFECTS OF ROOM TEMPERATURE IN PACKED RED BLOOD CELLS UNITS

Ferreira R., Cardoso I., Durães B., Santos I., Mesa-Sanchez I., Gopegui R., Matos A.

Introduction: Very often pRBC units remain at room temperature, not only to warm up before its use, but also when the cold chain is broken due to technical refrigerator problems or unexpected longer shipping times. High temperature exposures have been related to early red blood cell (RBC) destruction and microbe contamination and proliferation. To the best of the authors' knowledge, no veterinary studies addressed haemolysis and bacterial contamination in pRBC units during long room temperature exposure periods.

Objective: This prospective study aimed to evaluate the haemolysis and bacterial contamination in pRBC units stored at room temperature (20-22C) for 5 days.

Methods: After processing, 13 pRBC units were evaluated for haemolysis (HemoCue® Hb and Plasma Low Hb determinations) and aerobic bacterial contamination (Biomerieux® aerobic culture media) at T0. Six 20 ml samples were aseptically prepared from each pRBC unit, using sterile connections to paediatric transfer blood bags specific designed for blood storage (Fresenius Kabi®). This allowed for single determinations of each sample, decreasing the repeated manipulation deleterious effect on RBCs. Haemolysis and blood cultures were evaluated after 4 hours (T1), 8 hours (T2), 12 hours (T3), 24 hours (T4), 48 hours (T5) and 120 hours (T6). Samples were kept at room temperature 20-22C.

Results: At T0 a mean haemolysis of 0.12% (SD 0.06) was calculated. The value had a linear increase, with 0.15% (SD 0.05); 0.16% (SD 0.05); 0.17% (SD 0.05); 0.19% (SD 0.05); 0.22% (SD 0.03); and 0.30% (SD 0.04) at T1, T2, T3, T4, T5 and T6, respectively. All cultures tested negative.

Discussion/Conclusion: According to the human blood banking guidelines, a maximum 0.8% haemolysis is recommended. Our determined values, that showed a gradual but slight increase in haemolysis, along with negative blood cultures, confirmed the relative low impact of the exposure to room temperature on aseptically prepared fresh units. This study helps to clarify the evolution of haemolysis in pRBC units kept at room temperature, thus avoiding unnecessary wastes when the cold chain is broken. However, the authors emphasize the need for quality control analyses to ensure the safety of its use.

EVALUATION OF THE OSCILIOMETRIC MONITOR VET20 SUN TECH® FOR BLOOD PRESSURE MEASUREMENT IN DOGS

Daza González, M.A., Belinchon S., Gómez Molins A., Arenillas Baquero M., Fragío Arnold C.

Introduction: Blood pressure (BP) can be measured invasively (invasive blood pressure, IBP) or indirectly (non-invasive blood pressure, NIBP). IBP is the gold standard, but NIBP is easier to carry out in the clinical setting.

Objective To compare performance of the oscillometric monitor Vet20 Sun Tech® with IBP measurements in anesthetized dogs, according to the American College of Veterinary Internal Medicine (ACVIM) 2007 consensus.

Methods: A prospective study was conducted comparing systolic (SBP), diastolic (DBP) and mean (MAP) blood pressure results measured with an oscillometric monitor (Vet20 SunTech® Braun, cuff over brachial artery) and an invasive method (catheter in femoral artery connected to monitor Mindray iMEC8 Vet). We included 11 dogs (6 males and 5 females), ages between 4 and 11 years, different breeds and between 4 - 20 kg of weight. All of them were normotensive and under general anesthesia to perform different surgical procedures. Agreement between IBP and NIBP measurements was explored using Bland-Altman analysis, Intraclass Correlation Coeficient (ICC), Student T-test and fulfilment of ACVIM requirements (significance set at P<0.05).

Results: T-test revealed no significant differences for SBP, DBP nor MBP measured with Vet20Suntech® (108±17, 65±16, 75±16 mmHg respectively) and IBP (115±25, 62±11, 76±15 mmHg).
The mean difference of paired measurements for SBP and DBP treated separately was <10 mm Hg, with a standard deviation < 15 mm Hg. Spearman correlation between paired measurements for DBP was 0.9, and >0.9 for SBP and MBP. 64% of all measurements for SBP and 91% for DBP and MBP treated separately lied within 10 mm Hg of the reference method (IBP). 82% of all measurements for SBP and 100% for DBP and SBP treated separately lied within 20 mm Hg of the reference method. All measurements showed excellent agreement on Bland Altman plots and a high ICC.

**Conclusions:** The Vet20 SunTech® Braun monitor meets all the criteria required by ACVIM for its validation compared with IBP measurements in anesthetized, normotensive dogs, and thus can be considered reliable for blood pressure measurement in these circumstances. Further studies in conscious and in altered BP states are needed.

## PREVALENCE AND PATTERN OF ANTIMICROBIAL RESISTANCE AMONG E. COLI AND STAPHYLOCOCCUS SPP. IN A VETERINARY UNIVERSITY HOSPITAL

Giunti M., Cocca G., Piva S., Del Magno S., Giacometti F., Serraino A.

**Introduction:** To investigate prevalence and pattern of antimicrobial resistance among rectal E. coli and oral Staphylococcus spp. isolates from dogs and cats in a Veterinary University Hospital (VUH).

**Methods:** A total of 160 swabs (80 rectal, 80 oral) for the isolation of E. coli and Staphylococcus spp. were collected between January and October 2018 from small animals in three different areas of our VUH: consultations, general ward (GW), and intensive care unit (ICU). Swabs from GW and ICU were performed both at admission and discharge from the relative area. Data concerning antimicrobial treatment were recorded. Isolated bacteria were identified by 16S rRNA sequencing and tested for antimicrobial sensitivity with disc diffusion method. Nonparametric test was used for comparison. Significance was set at < 0,05.

**Results:** E. coli and Staphylococcus spp. were isolated in 84% and 66% of total samples, respectively. Results showed that 8% of E. coli and 44% of Staphylococcus spp. isolates from consultations were multiple drug resistant (MDR). In GW and ICU, rate of MDR significantly increased from admission to discharge in E. coli (15% to 57%; P=0.009) and had a similar trend in Staphylococcus spp. (39% to 81%; P=0.07). Relative to E. coli isolates from GW, treatment with quinolones was significantly associated with resistance to enrofloxacin (P=0.02). Relative to E. coli from GW and ICU patients, there was a significant association between antimicrobial treatment and MDR (P=0.007) and between treatment with quinolones and MDR (P=0.03). Interestingly, an increase in the rate of resistance to imipenem (4 to 32%; P=0.01) was reported in E. coli isolates, despite its use in our VUH is not allowed. Relative to Staphylococcus spp. treatment with penicillins, during hospitalization in ICU, was significantly (P=0.04) associated with resistance to ampicillin.

**Conclusions:** High levels of MDR characterized E. coli and Staphylococcus spp. isolates in our VUH and tend to increase during hospitalization. Further studies are required for a wider evaluation of risk factors associated to antimicrobial resistance. Anyway, in order to tackle the spread of the latter, a rationale and prudent use of antibiotics is advocated.

## PROGNOSTIC SIGNIFICANCE OF SERUM TOTAL BILIRUBIN AND ALANINE-AMINO-TRANSFERASE IN CRITICALLY ILL DOGS: A RETROSPECTIVE STUDY

Giunti M., Mattavelli C., Tumbarello M., Agnoli C., Gentile G.

**Introduction:** Acquired cholestatic liver dysfunction and hypoxic hepatitis, distinguished by laboratory parameters, are associated with increased morbidity/mortality in intensive care unit in humans. The prognostic significance of serum total bilirubin (tBIL) and alanine-amino-transferase (ALT) in hospitalized critically ill dogs was evaluated.

**Methods:** Retrospective study on 622 dogs admitted to the intensive care unit (ICU) of a Veterinary University Hospital (January 2017-October 2018). Dogs with primary hepatic or hemolytic diseases, or
that received red blood cells transfusion or parenteral nutrition were excluded. Medical records were reviewed for: clinical diagnosis, values of tBIL and ALT at ICU admission (TO) and after 72 hours (T72), and outcome. Non-parametric statistic was used for comparison. Significance was set at <0.05.

**Results:** Median values of tBIL at TO and T72 were 0.19 mg/dL (0.01-14.47, n=515; R.I. 0.07-0.33) and 0.23 mg/dL (0.01-13.27, n=141), respectively. Median values of ALT at TO and T72 were 66 U/L (2-14564, n=491; R.I. 15-65) and 46 U/L (1-1985, n=60), respectively. The overall mortality rate at hospital discharge was 21% (132/622). Median values of tBIL at TO and T72 in nonsurvivors were significantly higher than in survivors: 0.24 (0.01-3.94, n=107) vs 0.18 (0.01-14.47, n=408), P=0.0003, and 0.35 (0.1-3.9, n=25) vs 0.22 (0.01-13.27, n=116), P=0.001, respectively. Median values of ALT at T72 in non-survivors were significantly higher than in survivors: 263 (25-1985, n=8) vs 40 (1-603, n=529), P=0.001. A significant increase of tBIL from TO to T72 was reported in non-survivors (n=23): 0.24 (0.01-3.94) vs 0.35 (0.1-3.9), P=0.02. A significant decrease of ALT from TO to T72 was reported in survivors (n=44): 64 (44-137) vs 40 (21-57), P=0.0004. According to the AUROC curve analysis, tBIL>0.34 mg/dL had a fair accuracy (AUC = 0.706) to correctly predict mortality at T72 (P=0.0002), while ALT>77 U/L had a good accuracy (AUC = 0.851) to correctly predict mortality at T72 (P<0.0001).

**Conclusions:** In this population of critically ill dogs, mild increment of tBIL during ICU stay was revealed in non-survivors, however its clinical relevance and prognostic significance need to be elucidated. Moreover, a persistent high serum activity of ALT seems to be associated to a worse outcome.

## ACUTE PHASE PROTEINS IN SURVIVOR AND NON-SURVIVOR DOGS INVOLVED IN ROAD TRAFFIC ACCIDENTS: A COHORT STUDY OF 420 DOGS

Rocchi P., Zoia A., Ceron J.J., Bertolini G., Furlanello T., Caldin M.

**Introduction:** Acute phase proteins (APPs) are proteins that change after an injury or an inflammatory condition occurs, and are often used in the diagnosis, treatment, monitoring and prognosis of different diseases in dogs. This study aimed to determine whether APPs (C-reactive protein [CRP], haptoglobin, fibrinogen, ferritin, iron, albumin and total iron binding capacity [TIBC]) could be used as early diagnostic markers in dogs involved in road traffic accidents (RTA), and their prognostic value for mortality.

**Methods:** A retrospective cohort of 420 dogs was used, of which 210 dogs were in the exposed group involved in RTAs. These dogs were evaluated within 24 h of trauma, and compared against equivalent unexposed dogs that had been presented to the clinic with various illnesses, but with no history of any trauma. Unexposed dogs were selected from all dogs presented to the institution over the same timeframe as the exposed dogs (between the 7 December, 2009, and 7 October, 2018). These dogs were individually matched to the group of exposed dogs for age (± 6 months), sex, sexual status and breed.

**Results:** The study demonstrated that haptoglobin (p < 0.0001), fibrinogen (p < 0.0001), and ferritin (p < 0.0001) are the most efficient early biomarkers in predicting dogs involved in RTA. The results showed significant differences (p = 0.0074) in CRP concentrations between the exposed and unexposed groups of dogs involved in RTA. Furthermore, the results showed that serum ferritin (p = 0.0068), albumin (p < 0.0001), and TIBC (p < 0.0001) are the most efficient early biomarkers predicting mortality of dogs within 28-days of trauma.

**Conclusions:** CRP is the most evaluated APP in dogs; however, other APPs are available and the simultaneous use of several analytes that present different kinetic patterns after trauma is as a promising diagnostic and prognostic tool, as demonstrated in the present study. Ferritin, albumin, and TIBC are correlated with mortality, with albumin and TIBC producing the best results in the ROC curves of our study.
# ABNORMALITIES ON RESPIRATORY EXAMINATION, THORACIC RADIOGRAPHS AND VETERINARY POINT OF CARE ULTRASOUND IN SHELTER DOGS

Martin Â., Gouveia D., Cardoso A., Viegas I., Gommeren K., Boysen S., Busoni V.

**Introduction:** The health status of shelter dogs is important for infectious disease control. The use of veterinary Point of care Ultrasound (VPOCUS) for screening pleural and pulmonary disease in shelter dogs has not been described.

**Objective:** To compare abnormalities identified on clinical examination, thoracic radiographs and VPOCUS in a cohort of shelter dogs.

**Methods:** Dogs prospectively underwent physical examination, 3 thoracic radiographs and thoracic VPOCUS recording 9 points bilaterally. Radiographs were read by a board certified specialist.

Respiratory abnormalities on physical exam, pulmonary and/or pleural abnormalities on radiographs and VPOCUS abnormal findings (more than 3 B-lines, presence of subpleural consolidations) were compared.

**Results:** 66 dogs were enrolled. Abnormalities were detected on respiratory exam in 3 dogs and at VPOCUS in 1. On radiographs 2 dogs had relevant pulmonary abnormalities (1 pulmonary mass, 1 cranio-ventral alveolar pattern consistent with bronchopneumonia) and 8 had minor radiographic changes of uncertain clinical significance. Two out of the 3 dogs with abnormal clinical examination had increased respiratory rate (≥ 40 bpm) but normal radiographs and VPOCUS, one had abnormal breath sounds, a pulmonary mass on radiographs and normal VPOCUS. The dog with abnormal VPOCUS findings (10 B lines ventrocaudally on the right) had normal respiratory examination but radiographs consistent with bronchopneumonia. In the 8 dogs with minor radiographic changes, physical examination was normal and VPOCUS was either normal or showed less than 3 B lines (4 dogs). All 66 dogs had Z lines (range 1-20), 55/66 dogs had I lines (range 1-10).

**Discussion:** The dog with abnormal VPOCUS findings had a similar lesion distribution on radiographs. The pulmonary mass identified on radiographs was not identified on VPOCUS, likely because not in contact with the lung surface at sites examined at VPOCUS. I lines were identified in the majority of and Z lines in all shelter dogs regardless of health status.

**Conclusion:** Although most clinically normal dogs had no abnormal radiographic and VPOCUS findings, few discrepancies occurred between clinical, VPOCUS and radiographic examinations when abnormal images were found. This result highlights the importance of appropriately interpreting images along with clinical information.

# ACUTE PANCREATITIS AND SYSTEMIC INFLAMMATORY RESPONSE SYNDROME IN DOGS WITH AKI MANAGED BY INTERMITTENT HEMODIALYSIS

Perondi F., Gori E., Marchetti V., Pierini A., Ceccherini G., Lippi I.

**Introduction:** Acute pancreatitis (AP) is a comorbidity associated with AKI in dogs and AP most severe forms are associated with the development of a systemic inflammation (SIRS). Recently, pancreas-specific lipase (Spec cPL) levels consistent with AP in dogs with AKI undergoing intermittent hemodialysis (IHD) was reported. No association between Spec cPL and survival was found. In other recent study, AP and SIRS were associated with poor outcome in dogs managed with IHD.

**Objective:** To investigate the prevalence of AP and SIRS in dogs with AKI managed by IHD and its association with outcome.

**Methods:** Retrospective medical record review from January 2012 and December 2018. AKI dogs managed with IHD and with an ultrasound evaluation and pancreatic lipase concentration (SNAP cPL®) at presentation were included. AP diagnosis was based on compatible clinical sign, abnormal SNAP® cPL™ test and positive abdominal ultrasound for AP within 48h from the admission. SIRS was diagnosed based on published criteria. One hundred forty-one client-owned dogs were screened and 49 dogs were included in the study. Data were statistically analyzed using GraphPad Prism® for Mac.

**Results:** AP was present in 34.7% (17/49) dogs and mortality rates at 30 days were 64.7% (11/17) and 53% (17/32) for dogs with and without AP (32/49), respectively. SIRS, was present in 22/49 dogs (53%):
8/17 (47%) were AP dogs and 14/32 (43.7%) without AP. Mortality rates in dogs with and without SIRS were 68% (15/22) and 48% (13/27), respectively. No significant difference between the outcome and presence of AP or SIRS and between AP and SIRS dogs were found. Kaplan Meier curves showed that the presence of SIRS was associated with outcome (p=0.0387), while the presence of AP showed no significant difference.

**Conclusions:** AKI dogs managed by IHD showed a higher prevalence of AP and SIRS. However, although the mortality rates were high in both comorbidities groups (AP and SIRS), only the presence of SIRS was associated with the outcome in dogs treated with IHD.

## PERFORMANCE OF THE QUICK SOFA SCORE AND ITS VARIANTS IN DOGS IN EMERGENCY SETTING

Briganti A., Malloggi C., Di Franco C., Ceccherini G.

**Objective:** The aim of this study was to evaluate the validity and viability of quick SOFA (qSOFA) score, or its variants, as a simple tool for early identification of the risk of death in critically ill canine patients in the emergency department.

**Methods:** The retrospective study included dogs and cats arrived at the emergency unit between March 2017 and February 2019. For each patient the following data were collected: systolic and mean arterial pressure (SAP, MAP), respiratory rate, heart rate, rectal temperature, Glasgow coma scale (GCS), lactates, base excess, outcome (discharge, death) and diagnosis. For each parameter the best cut-off was found to discriminate between survivors and non-survivors and a score of 1 or 0 was assigned on the basis of the cut-off. Subsequently, for each patient, the classical qSOFA (FR, SAP, GCS) and its variants were evaluated with a ROC test in order to calculate specificity and sensibility.

**Results:** Of a total of 645 records, 186 dogs (137 survivors and 49 non-survivors) were enrolled.

SAP, GCS, temperature, lactates and base excess resulted significantly different between survivors and non-survivors. Quick SOFA score and the variant with the temperature instead of GCS resulted the scores best performance (sensitivity of 52% and specificity of 77%), in identifying the risk of death with a cut-off ≥2. The adjunct of lactate to qSOFA and to the variant with temperature resulted both in 65% sensitivity and 73% specificity and in 34% sensitivity and 95% specificity with a cut-off ≥2 and ≥3, respectively.

**Conclusions:** In dogs, the classical qSOFA and its variant with temperature resulted in low sensitivity and high specificity, with small capability to early identify emergency patient at risk of death. However, the adjunct of lactate, increases the sensitivity with a small reduction of specificity in identifying patients at risk of death (cut-off ≥ 2).

## SERUM TOTAL THYROXINE (TT4) EVALUATION IN CRITICALLY ILL FELINE PATIENTS

Gori E., Pierini A., Bartolomeo E., Lippi I., Ceccherini G., Pasquini A., Marchetti V.

**Introduction:** Despite numerous studies in human medicine, in the veterinary medicine the nonthyroidal illness syndrome (NTIS) has been not yet well studied. The few studies conducted on critically ill dogs show that the levels of thyroid hormones drop down during illnesses.

**Objective:** To evaluate serum total thyroxine (tT4) in hospitalized feline patients and its possible relationship with APPLEfast, SIRS and outcome.

**Methods:** Cats were included if they were hospitalized (HC) in our Veterinary Teaching Hospital. On the contrary, cats that have had previously diagnosed thyroid diseases or cats with alterations on clinical or ultrasound examination of the thyroid were excluded. The tT4 was evaluated at the time of the admission (T0) using exceeding serum samples. A control group (CG) was composed by cats with non-thyroidal chronic diseases without the necessity of hospitalization in which the tT4 was evaluated. The APPLEfast score was calculated for each cat at the admission. Cats had systemic inflammatory response syndrome (SIRS) if they showed: (1) abnormal temperature (<37.8 or=""">39.2°C), (2) tachycardia (≥225 beats/min) or bradycardia (≤140 beats/min), (3) tachypnea (≥40 breaths/min) and
(4) WBC abnormalities (WBC ≥19500 or ≤5000 or band neutrophils ≥5%). Cats were divided in survivors and non-survivors according to the 10-day outcome. Data were analyzed using statistical software.

Results: Forty-seven cats were retrospectively included. Twenty-six cats (55%) died within 10-days from the admission. The CG was composed by 37 cats. Age was lower in HC than in CG, while the two groups were similar by gender. HC showed a significantly lower tT4 compared to CG (1.3±0.7 vs. 2±0.9; p<0.0001). Non-survivors had lower mean tT4 than survivors (1.1±0.65 vs. 1.58±0.8; p=0.03). The cut-off point for tT4 for mortality was 1.65 µg/dL (sensitivity 81%, specificity 57%, OR 5.6). There was no correlation between APPLEfast score and tT4. Sixteen cats (32%) has SIRS and no association between tT4 and the presence of SIRS was found.

Conclusions: NTIS in critically ill cats may occur and the evaluation of tT4 in hospitalized cats can help the clinician with prognostic information.

## BLOOD DONATION ADVERSE REACTIONS IN FELINE DONORS

Abreu T., Ferreira R., Morais R., Oliveira A., Soares R., Matos A., Mesa-Sanchez I., Gopequi R.

Introduction: Identification of post blood donation reactions is of importance, not only by ethical reasons, but also to ensure the trust and commitment of pet owners in a blood bank program. These reactions may be acute or delayed (ugp to 5 days after the donation) and were described as swelling/hematoma or bleeding of the puncture sites, inappetence, lethargy, dermatitis/skin reactions, pale mucous membranes, abnormal behaviour, increased capillary refill time and weak pulses.

Objective: The objective of this prospective study was to evaluate the frequency of acute and delayed adverse reactions in cats after blood donation.

Methods: Adverse reactions during donation and up to 2 hours post donation were directly registered in the donor's file. A standard telephone survey was conducted to the owners of feline blood donors 5 days after the donation. For each of the possible reactions a "yes" or "no" was attributed accordingly to the answer. Comments were allowed at the end of the questionnaire.

Results: In January and February 2019, data from 345 feline donations was obtained. No acute or delayed post donation reactions were identified in 337 donors. One developed a haematoma in the catheterized forelimb, fully absorbed after one week with no need for medical assistance.

Seven showed abnormal behaviour up to 24 hours post donation. One of the donors urinated in an unusual place; four others were very upset, hissing at the companions; one was very scared till late that evening; and another donor was very sleepy for 24 hours. All the behaviours returned to normality within 3 days.

Discussion/Conclusion: Whilst post blood donation reactions in cats are possible, they are uncommon, near 2.3% according to our study. A careful pre-donation examination to ensure the donor's good health; careful punctures for catheter placement (if sedated) and for donation to minimize the chance of haematoma/swelling/bleeding; and providing a calm environment and trained staff that reduces the stress levels, will help decreasing the chances of post donation adverse reactions. This survey was highly valued by the owners, increasing their commitment with the blood bank.

## ASSESSMENT OF THE 1,2-O-DILAURYL-RAC-GLYCERO GLUTARIC ACID-(6'-METHYLRESORUFIN) ESTER (DGGR) LIPASE ASSAY FOR THE DIAGNOSTIC EFFICACY OF CONCURRENT PANCREATITIS IN DOGS WITH CONGESTIVE HEART FAILURE.

Estenbergh C., Van Israel N.

Introduction: The DGGR lipase assay has been well established as a highly reliable screening test for pancreatitis in the general canine population. The objective of this study was to assess the sensitivity and specificity of this test for the diagnosis of concurrent pancreatitis in dogs with congestive heart failure (CHF).

Methods: Medical records of dogs with CHF and with serum lipase measured using the DGGR
assay were retrospectively evaluated. Serum lipase levels above 213 U/L were considered indicative of pancreatitis according to the reference values provided by the referral lab (Synlab, Belgium). The diagnosis of pancreatitis was confirmed or ruled out by the presence or absence of clinical signs that could be attributed to pancreatitis and by abnormal findings on pancreatic imaging (ultrasonography and/or computed tomography).

**Results:** Of 58 dogs with CHF, 17 dogs showed elevated serum lipase activity (mean: 379,5 U/L (239 - 927 U/L)). In 1 of these 17 dogs the diagnosis of pancreatitis was confirmed by the presence of clinical signs (reduced appetite, vomiting) and typical findings on pancreatic imaging. This dog also had the highest lipase level detected (927 U/L). None of the remaining 16 dogs showed signs indicative of pancreatitis on clinical examination or abdominal imaging. The sensitivity of the DGGR lipase assay in diagnosing pancreatitis in these dogs was 100%, the specificity was only 71,9%. The Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of the test were respectively 5,9% and 100%.

**Discussion:** The DGGR lipase assay is highly sensitive in detecting pancreatitis in dogs with CHF but many false positives occur. This can probably be attributed to the pancreas' sensitivity to hypotension and/or hypoperfusion which is often present with CHF. A potential solution could be a higher cut-off value. A negative result rules out the presence of concurrent pancreatitis in dogs with CHF.

**Conclusion:** Elevated serum lipase activity measured by the DGGR lipase assay should be interpreted with caution in dogs with CHF failure as false positive results may occur. Diagnosis of pancreatitis in these dogs should be confirmed by the presence of clinical signs and abnormal findings on abdominal imaging.

## ASSESSMENT OF RISKS OF FELINE MISMATCHED TRANSFUSION AND NEONATAL ISOERYTHROLYSIS IN LYON (FRANCE) AREA

Nectoux A., Guidetti M., Barthélemy A., Pouzot-Nevoret C., Hoareau G., Goy-Thollot I.

**Introduction:** Significant geographical variation of AB feline blood type has been described in the world. Risks of life-threatening acute immune-mediated hemolytic reactions due to mismatched transfusion (MT) and neonatal isoerythrolysis (NI) depend on proportion of anti-A and anti-B alloantibodies and on the respective prevalence of blood types.

**Background:** The most described erythrocyte antigens system in cats is the AB system. Strong anti-A antibodies are responsible for acute hemolytic reaction whereas weak anti-B antibodies produce milder reactions such as shorten survival of red blood cells transfused.

**Objectives:** Aims of this study were to update the prevalence of feline blood types in Lyon (France) area and to determine the risk of MT and NI in kittens with unknown blood-type parents, compared with other geographical regions.

**Methods:** Blood samples were obtained from feline blood donors and cats admitted in the intensive care unit. AB blood typing was performed using an immunochromatographic strip (CHROM Method, Lab Test A+B, Alvedia). Risk of MT was estimated by adding the risk of a major transfusion reaction and the risk of a minor transfusion reaction. Risk of NI was estimated according the equation (p²)(q²) + 2pq(q²) with q the B allele frequency and p = 1-q. Results were analyzed by absolute and relative frequency and multivariate analysis.

**Results:** Cohort-study population included 320 non-pedigreed cats and 37 pedigreed cats from Lyon (France) area. Prevalence of blood types A, B and AB were 83.2%, 13.7%, and 1.7%, respectively. Considering non-pedigreed cats, prevalence of types A, B and AB were 83.8%, 14.4%, and 1.9%, respectively. Based on these percentages, the risks of MT and NI in non-pedigreed cats were 24.3% and 12.3%, respectively.

**Discussion:** Regarding previously published data on prevalence of AB blood type, the five countries where risks of MT and NI are the most elevated are Australia, England, Turkey, Greece and Ireland. France appears to be the sixth country at risk.
**Conclusions:** Prevalence of type B cats is high in France and associated with high risks of MT and NI. These results confirm the importance of performing blood typing prior to any blood transfusion or mating.

# ECHOCARDIOGRAPHIC DIAGNOSIS OF CANINE CARDIAC EFFUSION: CHANGING INCIDENCE IN UNDERLYING CAUSE?

Vidal P.A., Burnotte P., Gommeren K., Merveille A.C.

**Introduction:** Neoplasia and idiopathic pericarditis are the most common causes of pericardial effusion. Echocardiography is the preferred clinical diagnostic test for pericardial effusion and tamponade. Determining the underlying cause is pivotal for treatment and prognosis. The reported incidence of cardiac neoplasia in dogs with pericardial effusion varies between 30% to 62%. Our aim was to evaluate diagnosed underlying etiologies at our institution.

**Methods:** All dogs echocardiographically diagnosed with pericardial effusion by a single cardiologist from 2008 until January 2019 were included. The presence of cardiac tamponade and echocardiographical diagnosis of underlying etiology were recorded. The incidence of underlying etiologies was compared between cohorts presented prior to and after 2014.

**Results:** 82 cases of pericardial effusion (70 with cardiac tamponade) were included. Underlying etiology in cardiac effusion and cardiac tamponade were neoplasia (53 vs 49), idiopathic (17 vs 16), and 'other' (12 vs 5). 'Other' causes were 6 dogs with right-side congestive heart disease (1 tamponade), 4 atrial ruptures (2 tamponades), 1 coagulopathy and 1 peritoneal-pericardial hernia (both tamponades). Before 2014, 15 cardiac tamponades were recorded, 60% (9/15) with neoplasia and 40% (6/15) idiopathic. After 2014, in 55 cardiac tamponade cases, 72% (40/55) displayed neoplasia, 19% (10/55) were idiopathic, 9% (5/55) due to other causes (listed above).

**Discussion:** Echocardiography is accepted as clinical reference diagnosis when performed by a cardiologist for the diagnosis of pericardial effusion and underlying etiology. Right sided congestive heart failure appears to be a rare cause of cardiac tamponade. The incidence of neoplasia in dogs with pericardial effusion or tamponade was 64,5% (53/82) or 70% (49/70). The incidence of cardiac tamponade due to neoplasia before 2014 (60%; 9/15) was lower than after 2014 (72%; 40/55). This difference could be due to the increased ability of the observer to detect neoplasia, or be a coincidence. Technical improvements however seem unlikely, as the same machine was used throughout the study.

**Conclusion:** Cardiac tamponades of neoplastic origin appear more common than described. Atrial ruptures do not always present with tamponade, while right sided congestive heart disease may induce tamponade. Findings of this study must be confirmed in multicenter studies before drawing conclusions.
## Case report posters

# BALLOON-EXPANDABLE AORTIC STENT-GRAFT FOR TREATMENT OF AORTIC ANEURYSM AND RUPTURE

Klainbart S., Segev G., Peery D., Shipov A.

**Complete history:** A 4 years old, female spayed mixed breed, 25 kg. dog was presented with a history of acute onset of weakness and respiratory distress.

**Complete diagnostic investigation:** On presentation the dog was lateral and unresponsive, hypothermic, tachycardic, and tachypneic. T-FAST revealed pleural effusion in the right hemithorax. Thoracic radiographs showed widening of the cranial mediastinum with fluid opacity, and moderate amount of pleural effusion on the right side. Thoracentesis revealed non coagulable blood. Hematology revealed normal PCV and total plasma protein (42%/5.8gr/dl, respectively) that dropped to 20%/5gr/dl, and normal platelet count and coagulation profile. The dog was treated with IV fluids, transexemic-acid and FFP. CT examination revealed mild focal widening of the descending thoracic aortic lumen. A small out-pouching of the lumen was noted at the level of the eleventh thoracic vertebra, representing an aortic aneurysm and bleb. Irregular mineralization of the right ventrolateral aortic wall was demonstrated just cranially to the lesion. The descending thoracic aorta was surrounded by a non-enhancing tissue consistent with a peri-aortic hematoma.

**Therapy and outcome:** Due to the visible defect in the aortic wall, it was assessed that the likelihood of recurrent bleeding was high, a decision was made to attempt treatment with a stent graft. Following general anesthesia, a marker catheter was inserted to the esophagus. A 10Fr sheath was inserted to the right femoral artery and an angiography catheter was advanced over a wire. As the normal aortic diameter was 10mm and lesion length was 15mm, a 50mm X 12mm balloon expandable stent graft was chosen. Following angiography, the stent-graft was placed over the wire and deployed under fluoroscopic guidance. The dog recovered uneventfully, with no evidence of recurrent bleeding and was discharged two days following the procedure with antibiotics, anthelmintic, and anticoagulant treatment. At 10-day follow-up, the dog was doing well and stent position was radiographically confirmed.

**Discussion:** Aortic aneurisms are uncommon and challenging pathology in the veterinary practice with little available treatment options. Stent-graft placement is a minimally invasive option in which a covered stent is placed over the lesion and prevents its rupture.

# WATERHOUSE-FRIDERICHSEN SYNDROME IN A CAT WITH KLEBSIELLA SPP. INFECTION

Cole L, Tinson E.

**Signalement:** 12 year male neutered Domestic Short Hair, weighing 4.5kg.

**History:** The cat was referred to a veterinary hospital for further management of pneumothorax and pulmonary contusions 48 hours post blunt trauma.

**Main clinical examination findings:** On admission the cat was alert, ambulatory and responsive but dyspnoeic with reduced lung sounds bilaterally. The heart rate was 220 beats per minute and the systolic blood pressure was 90mmHg.

**Diagnostic investigation and outcome:** Needle thoracocentesis was performed and oxygen therapy and multimodal analgesia was initiated. Due to worsening hypercapnia the patient was anaesthetised and mechanical ventilation (MV) was initiated. Computed tomography revealed multiple rib fractures and pulmonary contusions. Venous carbon dioxide improved on MV. Epidural catheter and an oesophagostomy tube was placed prior to ventilator weaning. Despite cessation of all intravenous anaesthetic drugs and spontaneous ventilation the cat remained comatosed. The cat developed harsh lung sounds 12 hours post cessation of MV. Thoracic radiographs and endotracheal wash was consistent with Klebsiella pneumoniae pneumonia. Intravenous antibiotics was initiated. Five days after discontinuing anaesthetic drugs the cat showed response to auditory stimuli. On day 6 post termination of MV the cat became acutely hypotensive and bradycardic with atrial premature
complexes. Blood work revealed metabolic acidosis, azotaemia and hyperkalaemia. Despite therapy the cat experienced a sudden cardiac arrest and the owner declined resuscitation. A necropsy was performed. Microscopic findings revealed necrotizing adrenalitis with diffuse severe cortical haemorrhage and intralesional bacteria. The adrenal lesions were consistent with Waterhouse-Friderichsen syndrome. The brain was macroscopically and microscopically unremarkable. Culture of the epidural catheter grew Klebsiella pneumoniae.

**Discussion:** Acute haemorrhagic necrosis of the adrenal gland and clinical adrenal insufficiency, termed Waterhouse-Friderichsen syndrome is a rarely reported condition in people. The condition is primarily considered a complication of meningococcal septicemia, but has been associated with other bacterial pathogens including K. pneumonia. To the authors' knowledge, this is the first report in veterinary medicine of Waterhouse-Friderichsen syndrome secondary to bacterial infection. This condition led to a rapid clinical deterioration and cardiac arrest in this patient. Awareness of this condition may allow for earlier recognition and appropriate treatment of this syndrome ante-mortem.

## PLASMAPHERESIS IN A DOG WITH NAPROXEN INTOXICATION

Fisher H., Dörfelt R.

**Signalement:** 2 year old, female Jack Russell Terrier

**History:** The patient was presented for suspected ingestion of 310 mg/kg of naproxen, which is 12 times the reported nephrotoxic dose, 1–3 hours before presentation. Clinical examination revealed no abnormalities.

**Diagnostic Investigations:** Complete bloodwork comprised of automated complete blood count with differentiation, blood gas analysis, coagulation profile, serum biochemistry and blood group were obtained at the time of presentation. The dog had a mild lymphocytosis (3.95 x 10⁹/l), hyperglycemia (6.8 mmol/l) and hypoproteinemia (55.4 g/l). Albumin (42.2 g/l), creatinine (90 µmol/l) and urea (5.8 mmol/l) were within reference range.

**Therapy:** After inducing emesis, the dog was treated with IV fluids, esomeprazol, misoprostol, antiemetics, plasmapheresis and repeated activated charcoal application.

Plasmapheresis was performed applying the VETSmart® machine and the PEX 100 tubing and filter system. Heparin was used for systemic anticoagulation. During 2 hours treatment time, 1.8 times plasma volume was removed. Plasma was replaced with ½ fresh frozen plasma and ½ HES 6% (130 KDa/0.42) solution. Blood samples to analyze naproxen concentration were obtained before, during and after plasmapheresis, frozen at -80 °C and sent for batch analysis via high-pressure liquid chromatography.

Naproxen plasma concentration was 110 µg/ml at presentation, 52 µg/ml after 1 hour and 47 µg/ml after 2 hours of plasmapheresis. Twenty hours after plasmapheresis, naproxen plasma concentration had increased to 97 µg/ml. At day 6, naproxen concentration was 5 µg/l. The dog was discharged with omeprazole and misoprostol the day after plasmapheresis. Creatinine values did not increase, but mild, self-limiting, gastrointestinal signs occurred during the next 5 days.

**Discussion:** Plasmapheresis has been described as potential treatment option in several NSAID intoxications, though none described naproxen. Plasma concentrations of naproxen were reduced by 50% during the course of plasmapheresis. As plasmapheresis was started early in the disease process, increase in naproxen serum concentrations on the day after plasmapheresis could have been caused by additional naproxen resorption or redistribution.
# SUCCESSFUL MANAGEMENT OF SPONTANEOUS HAEMOPERITONEUM DUE TO PELIOSIS HEPATIS IN A CAT USING SURGICAL INTERVENTION, AUTOLOGOUS, XENO- AND ALLOGENIC BLOOD TRANSFUSION

Potter J., Hope A., Kirby B., O'Brien P., Bennett A.

**Signalment, History, Clinical Examination:** A male-castrated domestic short hair cat, 5 years old, weighing 4.5 kg presented for acute collapse with no history of trauma. Clinical examination detected pale mucous membranes, prolonged capillary refill time, open-mouth breathing (respiratory rate of 80 breaths per minute), unremarkable thoracic auscultation apart from significant bradycardia (heart rate of 120 beats per minute), weak but synchronous femoral pulses and severe hypothermia (rectal temperature 35.1°C).

**Investigations:** Serum biochemistry identified azotaemia (creatinine 220 mmol/L; RI 27 – 180, urea 11 mmol/L; RI 3.6 – 10.7 mmol/L), increased serum ALT (232 U/L; RI 20-100 U/L), severe hyperglycaemia (21.6 mmol/L; RI 3.9 – 8.3 mmol/L) and hypoproteinaemia (52 g/L; RI 54 – 82 g/L). Venous blood gas analysis revealed a moderate metabolic acidosis, respiratory alkalosis and increased lactate concentration (pH 7.309, PvCO2 3.81 kPa, BE(ecf) -12.2, lactate 6.43 mmol/L). Complete blood count detected a non-regenerative anaemia (Hct 19%; RI 24 – 45%) and moderate thrombocytopaenia (manual count 75 x 109/L; RI 180-550 x 109/L). Thoracic ultrasonography was unremarkable. Abdominal ultrasonography revealed a peritoneal effusion and hyperechoic liver. Haemoperitoneum was determined via abdominocentesis (packed cell volume 26%). Hypovolemic haemorrhagic shock was diagnosed. Exploratory laparotomy identified lacerations in the liver as sources of haemorrhage.

## Therapy:

The left liver lobe was resected and the hilus of the caudate lobe ligated. During surgery, peritoneal blood was autotransfused to the patient and a non-crossmatched type-appropriate whole blood transfusion from a donor cat was administered. After surgery three additional blood transfusions were administered (canine packed red blood cells, non-crossmatched type appropriate cat whole blood, and crossmatched type-appropriate cat whole blood), alongside intensive supportive care. Histopathology identified peliosis hepatis as the cause of the spontaneous haemoperitoneum. The patient survived to discharge and two month followup demonstrated no clinical concerns.

## Discussion:

This is the first report of successful peliosis hepatis treatment in a cat, and the first case report where autologous, xeno- and allogenic transfusions were administered to the same cat. Based on this case, the authors recommend consideration of peliosis hepatis as a differential diagnosis for spontaneous haemoperitoneum and suggest that survival is possible with aggressive management.

# SPONTANEOUS PNEUMOTHORAX SECONDARY TO PULMONARY THROMBOEMBOLISM IN A DOG WITH PANCREATITIS

Llambrich S., Molina C., Mallol C., Novellas R., Martin L., Torrente C., Bosch L.

## Complete history and signalment

A 12-year-old male mixed breed dog was presented for acute depression, lameness and seizures. On admission the patient was depressed, showed abdominal pain and neurological abnormalities suggestive of right prosencephalon lesion. Initial diagnostic test included CBC, biochemistry, PT and aPTT, thoracic radiographs, abdominal ultrasound, cPL snap test, pancreatic and prostatic FNA, MRI and CSF analysis. Changes on pancreatic and prostatic parenchyma were present on AUS; FNA was compatible with pancreatitis and benign prostatic hyperplasia respectively; cPL snap test was positive; on MRI an intracranial hemorrhage was present. Over the following days a mild tachypnea that progressed to marked dyspnea was noted and a hydropneumothorax was diagnosed on thoracic radiographs. CT scan confirmed multiple wedge shaped peripheral parenchymal lesions compatible with pulmonary thromboembolisms (PTE), lung hemorrhages and right cranial vena cava, brachiocephalic and subclavian vein thrombosis.

## Complete diagnostic investigation
Diagnostic test looking for an underlying hypercoagulable condition included T4-TSH, UP/C ratio, 4dx snap test, leishmanial serology and ACTH stimulation test. All results were within normal limits. Since thromboelastography was not available PT, aPTT, fibrinogen and platelet count were performed several times. Results were within normal limits. Echocardiographic examination revealed mitral valve disease B1 along with pulmonary hypertension.

## Therapy

Supportive treatment along with a continuous drainage chest system (Pleurevac) was placed.

Anticoagulant therapy was initiated with enoxaparin (0,8mg/kg/sc/6h) and clopidogrel (2mg/kg/po/24h). Patient's condition improved and continuous drainage was removed after 72 hours and discharged sixteen days after admission.

## Discussion

Acute and chronic pancreatitis have been related to thrombosis. Proposed mechanisms include systemic inflammatory response syndrome with procoagulant activity and perivascular inflammation of the splenic vein adjacent to the peripancreatic tissues among others. PTE and pneumothorax have been well described in veterinary medicine although there is little report on association between them. In this case, PTE caused an acute pneumothorax and this might have been related to a hypercoagulable state secondary to pancreatitis. Although PTE is a rare cause of pneumothorax, it should be considered as a differential diagnosis in patients with pancreatitis and other underlying hypercoagulable disease who develop acute respiratory distress.

# LETHAL ACUTE HEMORRHAGE FROM AN AORTIC-ESOPHAGEAL FISTULA FOLLOWING ENDOSCOPY-ASSISTED ESOPHAGEAL FOREIGN BODY REMOVAL IN A DOG.

Rimer D., Lerman O., Klainbart S., Nivy R.

Complete history: A 12-year-old, mixed breed male dog presented with a 6-day history of gagging, hematemesis and anorexia. Physical examination upon arrival was unremarkable.

Complete diagnostic investigation and therapy: Blood work revealed leukocytosis without anemia and normal platelet count. Thoracic radiographs demonstrated the presence of an esophageal foreign-body (EFB) with osseous opacity at the level of the heart base. Subsequently esophagoscopy was performed under general anesthesia. A triangular-shaped, osseous EFB was visualized and successfully removed by a grasping forceps and basket. Following its removal, a deep, non-bleeding, presumably non-perforated, esophageal ulcer was noted.

**Outcome:** While recovering from anesthesia, the dog's condition acutely deteriorated, becoming laterally recumbent and non-responsive, tachycardic, with weak femoral pulses, white-pale mucous membranes, hypothermic and without spontaneous respiration. Blood tests revealed severe anemia. A presumptive diagnosis of hypovolemic shock was considered, likely secondary to acute, post-procedural bleeding. The dog was intubated and maintained on mechanical ventilation until return of spontaneous respiration. Medical management included rapid blood transfusion (15 ml/kg, canine pRBC), crystalloid fluid-therapy and tranexamic acid. Esophagoscopy was repeated and corroborated the clinical suspicion of severe esophageal hemorrhage with copious amounts of blood and blood clots in the esophagus and stomach. Despite initial stabilization, several hours post-procedurally, the dog suffered cardiac arrest and CPR was unsuccessful. Post-mortem examination revealed two, bilateral symmetrical, partially perforating ulcers in the esophagus, corresponding to the location of the entrapped EFB. Examination of the thoracic aorta revealed a rough area of endothelial thickening with a central transmural defect directly aligned with the right esophageal ulcer, corresponding with aortic-esophageal fistula (AEF). The stomach, small intestine and colon contained fresh blood and black stool, respectively. There were no hemorrhagic effusions within the abdominal or thoracic cavities.

**Discussion:** This case report describes a rare, fatal, immediate, post-procedural complication following EFB removal. An AEF should be considered in any patient with severe post-procedural bleeding, since timely surgical intervention is mandatory to prevent fatal exsanguination. Furthermore, a history of sentinel bleeding in a dog with esophageal foreign body, including
hematemesis or melena, as described herein, should raise the clinical suspicion of an AEF, and dictate case management accordingly.

## USE OF A CENTRAL VENOUS CATHETER AS A PERCUTANEOUSLY PLACED INTRATRACHEAL CATHETER FOR TEMPORARY OXYGEN SUPPLEMENTATION IN A TOY BREED DOG WITH A TRACHEAL COLLAPSE GRADE III

Barbarino A., Francey T., Schweighauser A., Adamik K.

**Signalement and history:** A 9-year-old intact male Yorkshire Terrier, weighting 2.9 kg, suffered from severe respiratory distress due to tracheal collapse grade III and acute decompensation due to additional pneumonia. Supplemental oxygen (oxygen-cage with 50% fraction of inspired oxygen) did not improve blood oxygen saturation (SpO2 70%). An emergency intervention to temporarily bypass the upper airway obstruction in order to provide supplemental oxygen was essential. A naso-tracheal oxygen tube was not considered due to the small size of the dog. Endotracheal intubation was dismissed to avoid anesthesia and subsequent risk of requiring mechanical ventilation afterwards.

**Description of the technique:** Placement of a percutaneous intratracheal oxygen catheter under light sedation was performed. Intravenous butorphanol (0.3 mg/kg) for sedation and lidocaine (0.5 ml) for local analgesia were administered. The dog was in sternal recumbency, with the neck extended. Oxygen was provided via face mask. The trachea was palpated and a 0.5 cm transverse incision through the skin was performed, at 1 cm distal to the larynx. Through the incision, a 20 Ga needle was introduced between the 2nd and 3rd tracheal ring. A guide-wire was advanced 10 cm into the tracheal lumen. The needle was removed and the tissue dilator was carefully forwarded over the wire into the distal trachea. The dilator was removed again and a central venous catheter (7 Fr., 16 cm) was carefully forwarded over the wire 8 cm into the distal trachea. The wire was removed, and an oxygen source was immediately connected to the catheter. The catheter was sutured to the skin, and a light bandage was applied. This technique allowed a stabilization by direct delivery of oxygen into the catheter while bypassing the collapse. Pulse oximetry revealed a SpO2 higher than 96% after the procedure, and until the patient underwent tracheal stent placement on the following day.

**Discussion:** Placement of a central venous catheter into the trachea under local anesthesia and sedation only, is a minimally invasive technique to bypass a tracheal collapse when endotracheal intubation is not possible, and to directly deliver oxygen until a definitive therapeutic procedure can be performed.

## ALFA-2 AGONIST HYPERKALAEMIA AND HYPERGLYCAEMIA IN A CAT

Briganti A., Aida F.G, Degani M., Nardi S., Figà Talamanca G.

**Signalment:** A ten years old castrated male cat arrived in the intensive care unite after sedation with dexmedetomidine and methadone for diagnostic procedures.

**History and main clinical examination findings:** the cat had a history of polydipsia and slow recovery after an oncologic surgery done 10 days before. Pre-anaesthetic evaluation and blood exams were normal. At the end of anaesthesia the cat was hospitalized in order to receive fluid therapy and stay in observation. One hour after the extubation the cat was still very lethargic even though atipamezol was administrated at the end of the procedure.

**Diagnostic Investigations:** heart rate and blood pressure were within the physiological ranges, only temperature was still low (36°C). After 30 minutes the cat was still very depressed and a venous blood gas analysis was performed to evaluate PCO2 and glucose. The results showed a light respiratory acidosis with 7.29 of pH and 56 mmHg of PCO2, a severe hyperkalaemia (7.9 mEq/L) and hyperglycaemia (279 mg/dL), whereas all the other parameters resulted within the normal ranges.

**Therapy:** ECG was immediately performed and a widening of the QRS complex was revealed, with normal P waves. A bolus of furosemide 1 mg/kg was administered and blood and urine
samples were taken for haematobiochemical exams. Bladder catheterization was done to evaluate
urine production. A blood gas exams, repeated after 30 minutes, showed the reduction of the
hyperkalaemia to 6.6 mEq/L, the ECG was normal, the temperature was 37.6 °C and the cat was
responsive. After 3 hours the plasma level of potassium was normalized. The results of the
heamatobiochemical exams did not show any alteration with the exception of hyperglycaemia, which
resulted normal on the day after.

Discussion: the causes of hyperkalaemia are renal disease, cell death from reperfusion injury, Addison disease, dehydration, diabetes and potassium supplement. All these causes were excluded for this cat. Hyperkalaemia associated to hyperglycaemia is a fatal event reported in big felines after the use of alfa-2-agonists. The mechanism is still unclear and seems related to the inhibition of the release of insulin by the alfa-2-agonist. The cat recovered uneventfully with a symptomatic therapy.

USE OF TRANEXAMIC ACID IN CATS WITH CAVITARY HEMORRHAGE DUE TO HIGH-RISE SYNDROME

Girol A.M, Moreno-Torres M., Herrería-Bustillo V.

Objective: To describe the use of tranexamic acid (TXA) in a population of cats with high-rise syndrome and associated cavitary bleeding.

Design: Retrospective case series.

Methods: Search of the hospital's database from 2018 to 2019 for cats with high-rise syndrome that received TXA.

Complete history and signalment: 5 domestic short hair cats presented to the hospital with a history of high-rise syndrome after falling various heights (2nd-6th floor). Mean age in months and standard deviation (SD) were 7,6 and 3 respectively. There were 2 entire females and 3 entire males. Abnormal physical examination findings included weak pulses (4/5), altered mentation (3/5), tachypnea (3/5), epistaxis (2/5), mandibular instability (2/5), bradycardia (2/5), oral bleeding (2/5), carpal/tarsal instability (2/5), tachycardia (1/5) and subcutaneous emphysema (1/5).

Clinicopathological abnormalities included hyperglycemia (mean 212 mg/dL, SD 54,5), hyperlactatemia (mean 3,5 mmol/dL, SD 1,4) acidemia (mean pH 7,27, SD 0,08), alveolar patterns compatible with pulmonary contusions (5/5), pneumothorax (2/5), rib fractures (1/5), pelvic fractures (1/5), free thoracic fluid compatible with hemothorax (2/5) and free abdominal fluid compatible with hemoabdomen (5/5). The median abdominal fluid score (AFS) was 1 (interquartile range 0,5).

Therapy: All patients received TXA 10 mg/kg IV every 8 hours. Additional treatments administered were oxygen therapy via oxygen cage, maropitant, methadone, buprenorphine, meloxicam and crystalloid fluid therapy. None of the patients required a blood transfusion or a surgical procedure to control bleeding. All cats were discharged from hospital within four days.

Discussion: TXA is an antifibrinolytic drug that acts by blocking the lysine-binding site of the plasminogen molecules inhibiting its conversion into plasmin. The use of TXA has been previously described in dogs (traumatic and non-traumatic hemoabdomen, post-interventional bleeding in greyhounds and acute traumatic coagulopathy) but to the authors' knowledge it has not been described in cats. The main adverse effect in canines is vomiting. The cats in our study received preemptive therapy with maropitant to avoid this complication. TXA appears to be safe in felines at the doses used in this study with preemptive antiemetics.

HETEROLOGOUS CANINE PLATELET GEL APPLICATION TO A CHRONIC WOUND

Membiela F., Mesa-Sanchez I., Correia S., Ferreira R., Ruiz De Gopegui R., Matos A.

SIGNALMENT AND HISTORY:

A 6-year-old male intact greyhound presented to our emergency service for evaluation of a 3-month history of non-healing wounds after a snake bite. The patient had been treated by his primary veterinarian with several antibiotics, meloxicam, surgical debridement of the wounds, honey dressings and laser therapy, with incomplete response.
**CLINICAL EXAMINATION:**

Physical examination revealed 3 skin ulcers of 5, 4 and 2 cm in diameter on the flexor surface of the elbow, the caudal aspect of the forearm and the sternum, respectively. The ulcers presented as craters with full-thickness skin loss and affectation of subcutaneous tissue and muscle. No other relevant findings were detected on physical examination.

**DIAGNOSTIC INVESTIGATION:**

Complete blood count showed non-regenerative anemia (PCV 33%, 37-55), leukocytosis (23,125/µL; 5,000-18,000) and thrombocytopenia (142,100/µL; 175-500). Serum biochemistry and urianalysis values were within reference range. Swab cultures of the wounds were negative.

**THERAPY:**

Platelet gel (PG) was made by mixing a platelet lysate (obtained by freezing a heterologous platelet-rich plasma solution at -80°C) with 10% calcium gluconate. Platelet lysate units were thawed at room temperature at the time of application. The edges of the ulcers were infiltrated with plasma lysate, while PG was applied to wound beds. The ulcers were covered with hydrocellular foam dressings. Application of both platelet lysate and gel was performed weekly for 4 weeks. After a week of treatment the ulcers were reduced by 50%, and wound healing was complete after 33 days.

**DISCUSSION:**

PG is a hemocomponent obtained by activation of concentrated platelets with calcium and biologic or pharmacologic substances. In the activation process, platelet granules release numerous growth factors which can stimulate angiogenesis, collagen synthesis and tissue repair. Previous studies in dogs have shown that application of autologous PG to chronic decubital ulcers results in a more rapid healing. Although the use of autologous PG could eliminate potential concerns for disease transmission or immunogenic reactions, in this case we used heterologous PG with no obvious adverse reactions. In summary, PG appears to be an efficacious, simple, and cost-effective treatment for non-healing chronic skin ulcers in dogs.

## ACUTE KIDNEY INJURY IN FOUR DOGS AFTER MALEIC ACID INTOXICATION

Richter P., Dörfelt R., Ostermeier S.

**Signalment:** Four healthy adult mixbreed dogs, weighing 30.0–40.5 kg, age 1–8 years.

**History:** The four dogs were presented on the same day after ingestion of 17 g of a maleic acid containing descaling agent accidentally mixed with food.

**Diagnostic investigation:** All four dogs underwent clinical and laboratory investigation and abdominal ultrasound. Creatinine values were increased (282–1502 µmol/l) on day 4. Glucosuria and decreased urine specific gravity was detected in urine analysis. The abdominal ultrasound showed enlarged, hyperechoic kidneys.

**Therapy:** All four dogs were treated as out-patients hospitalized at day 4. Treatment consisted of intravenous Lactated Ringer's, furosemide, metamizole, omeprazole, sucralfate, ranitidin and maropitant. After 2 days creatinine values decreased in two dogs. Two dogs did not respond to treatment. Creatinine increased to 1467 and 1723 µmol/l at day 6 and day 7, respectively. One of these dogs was referred for hemodialysis at day 6, the other at day 8 in a worse clinical condition. Intermittent hemodialysis was performed with a Fresenius 4008 machine, pediatric tubing and a FX 60 dialyzer at day 7, 8, 9, 11 and 15 for the first and at day 8 and 9 for the second dog. Heparin was used for systemic anticoagulation. Conventionally treated dogs were discharged at day 16 with creatinine values in the reference range. The dog referred at day 6 was discharged at day 22 with a creatinine of 179 µmol/l. The dog referred at day 8 was euthanized at day 9 due to sepsis and worsening of the clinical situation on owner's request. At 2, 4 and 6 month after maleic acid ingestion creatinine of all surviving dogs was within the reference range.

**Discussion:** Maleic acid lead to acute kidney injury (AKI) in all four exposed dogs. Two dogs could be managed conservatively. In two dogs, dialysis was mandatory to control uremia. The AKI due to maleic acid intoxication is of good prognosis if uremia can be controlled either conventionally or by dialysis.
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