Term
| T/F: insulin therapy is not indicated in dogs with diabetes mellitus |
|
Definition
false
insulin is required in almost every dog affected with DM |
|
|
Term
| What causes the clinical signs associated with canine DM? |
|
Definition
| progressive abnormalities in carb, protein, and fat metabolism |
|
|
Term
| How many types of DM are there and what are they? |
|
Definition
Type 1: insulin dependent
-accounts for 50% canine DM
-require insulin for control
Type 2: non-insulin dependent
-primary type in cats (80-90%)
-managed by diet, +/- oral
hypoglycemic agents, and sometimes
insulin
Type 3: insulin antagonizing hormones |
|
|
Term
| what type of diabetes is more prevalent in cats? |
|
Definition
|
|
Term
| what type of diabetes is more prevalent in dogs? |
|
Definition
|
|
Term
| What hormones are implicated in antagonizing insulin in type 3 DM? |
|
Definition
cortisol
epinephrine
glucagon
growth hormone
progesterone |
|
|
Term
| cortisol, epinephrine, glucagon, growth hormone, and progesterone all have in common that they can cause insulin ________ in a diabetic pet. |
|
Definition
|
|
Term
| Absolute defieciency of insulin; Antibodies against pancreatic B-cells; and lymphocytic infiltration of pancreatic islets are all hallmarks of what metabolic disease? |
|
Definition
|
|
Term
| what are three causes of immune destruction of B-cells in type 1 DM? |
|
Definition
-genetic predisposition
-infectious (viral?), toxic, or inflammatory damage to islets
-progressive immune-mediated destruction of B-cells (T cell regulatory dysfunction) |
|
|
Term
| What are 3 other causes of canine DM that are not related to immune-mediated destruction of B-cells? |
|
Definition
pancreatitis-> pancreatic destruction
pancreatic adenocarcinoma
Medication induced |
|
|
Term
| What medications are thought to be involved with causing DM? |
|
Definition
steroids
megesterol acetate |
|
|
Term
| What are some breeds predisposed to DM? which are predisposed to juvenile diabetes? |
|
Definition
increased risk: samoyed, australian terrier, pug, toy and min. poodles, min. schnauzers
juvenile diabetes: Keeshunds, Golden Retrievers |
|
|
Term
| At what age are dogs typically affected with DM? |
|
Definition
|
|
Term
| Is there a gender predisposition for canine DM? what is it? |
|
Definition
|
|
Term
| what is the typical signalment for canine DM? |
|
Definition
|
|
Term
| T/F: obesity predisposes dogs to DM |
|
Definition
false
however, obese dogs may not respond normally to insulin |
|
|
Term
| What clinical signs may be noted in a complicated (ie-DKA) case of canine DM? |
|
Definition
| anorexia, depression, vomiting, diarrhea, polypnea(Kussmaul breathing), altered mental state-> coma |
|
|
Term
| What key abnormalities would you see on serum chem and UA for a complicated (DKA) DM case? |
|
Definition
serum/urine ketones
metabolic acidosis |
|
|
Term
| What clinical signs support a Dx of DM? |
|
Definition
"startvation in the face of plenty"
PU/PD, polyphagia
weight loss
cataracts
if coexisting dz have signs of:
pancreatitis
UTI |
|
|
Term
| What is the cause of PU/PD in DM? |
|
Definition
| osmotic diuresis (glucose exceeds osmotic threshold)-> drink more to keep hydration in balance |
|
|
Term
| What does the typical PE look in uncomplicated DM patients? |
|
Definition
unremarkable
hepatomegaly
cataracts |
|
|
Term
| T/F: cataracts form in almost all diabetic cats and is rare in diabetic dogs |
|
Definition
False!
form in almost all dogs, rare in cats |
|
|
Term
| Why is there a species difference in cataract formation in DM patients? |
|
Definition
Aldose reductase activity differences
glucose entering the lens-> metabolized by polyol pathway-> sorbitol and fructose (highly osmotic)-> pulls water into the lens-> disrupts lens fibers-> cataract
aldose reductase is the first enzyme in the polypol pathway
-very low enzyme activity in cats |
|
|
Term
| high aldose reductase activity in diabetic patients leads to what? |
|
Definition
| cataract formation in dogs |
|
|
Term
|
Definition
Hx (PU/PD/polyphagia)
increased BG
glucosuria +/- ketonuria
CBC/Chem/UA/urine culture
some cases: BP (mild increase 50% dogs)
Trypsin-like immunoreactivity (TLI)
serum fructosamine |
|
|
Term
| T/F: you do NOT need to perform a blood glucose if glucosuria is detected to Dx DM in dogs |
|
Definition
| False: ALWAYS do a BG and a UA |
|
|
Term
| Why are UA and urine culture a "must" in newly Dx diabetics? |
|
Definition
glucosuria +/- ketonuria
pyuria
bactiuria
proteinuria (normally mild in diabetic dogs) |
|
|
Term
| T/F: negative urine sediment does not rule out an active infection |
|
Definition
|
|
Term
| T/F: the presence of ketones alone means you should trx a patient as a complicated diabetic and hospitalize the patient |
|
Definition
| False: need clinical signs of illness, vomiting, not eating, and ketones |
|
|
Term
| T/F: you should always give insulin on a regular schedule, even if the animal is not eating. |
|
Definition
|
|
Term
| Why does hepatomegaly occur in diabetic patients and what might you see on a serum chem if the liver is involved? |
|
Definition
excess glucose-> stored in liver as lipids-> hepatic lipidosis
-ALP and ALT increased (lipid accumulation, pancreatitis-> further increases ALP);
-ALP>ALT
-bilirubin may be increased w/coexisting pancreatitis |
|
|
Term
| What is EPI and how is it associated with DM? when should you be concerned about EPI? |
|
Definition
EPI= exocrine pancreatic insufficiency
it may preceed, coexist, or follow the onset of DM
Be concerned if: chronic weight loss in spite of good diabetic regulation |
|
|
Term
| How is a serum fructosamine level helpful in Dx diabetes? and how does this test work? |
|
Definition
-serum proteins (albumin) become glycosylated with sustained hyperglycemia (fructosamine)
-% glycosylation parallels duration and severity of hyperglycemia
-falsely low in hypoproteinemia
-falsely high in hyperproteinemia |
|
|
Term
| How is the use of serum fructosamine limited in Dx canine DM |
|
Definition
| overlap b/w upper end of normal reference range and lower range of values found in diabetic dogs |
|
|
Term
| What are some goals in the regulation of uncomplicated diabetics? |
|
Definition
-improve clinical signs w/ daily insulin (avoid hypoglycemia)
-provide consistent diet and calories
-consistent daily exercise
-educate your clients!! |
|
|
Term
| What are the categories of available insulin preparations? and give examples. |
|
Definition
1. Regular or Rapid acting
2. Intermediate-acting
-NPH (neutral protamine hagadorn)
-Humulin N, Novolin
3. Long-acting
-insulin glargine*
-Insulin detemir
-ProZinc*: currently unavailable |
|
|
Term
| which category of insulin is used in dogs? cats? |
|
Definition
Dogs: intermediate acting
Cats: long acting |
|
|
Term
| What type of insulin is best used for in-hospital therapy of complicated diabetics? |
|
Definition
| rapid acting (regular) insulin |
|
|
Term
| When is the peak hypoglycemic effect and what is the duration of intermediate acting (NPH) insulin? |
|
Definition
peak: 2-10hrs
duration: 8-24hrs |
|
|
Term
| what types of insulin syringes are available? |
|
Definition
|
|
Term
| A U-40 insulin syringe is ONLY used with what type of insulin? |
|
Definition
|
|
Term
| What length of appointment should you schedule for client education when discharging a newly diabetic pet? |
|
Definition
|
|
Term
| How often should you schedule rechecks for diabetic patients (assume newly diagnosed)? |
|
Definition
-weekly for first 1-3weeks
-then monthly (for first few months)
-then every 3-6months |
|
|
Term
| T/F: a urine glucose can be used to make changes/adjustments in insulin dose |
|
Definition
|
|
Term
| What tool should you use to determine if an insulin dose adjustment is needed? and what are the adjustments based on? |
|
Definition
BG curve
base adjustments on lowest BG value (over 10-12hrs) |
|
|
Term
You should aim to maintain BG between _______mg/dL for most of the day to have optimal diabetic regulation.
a. 180-250
b. 50-80
c. 90-270
d. 230-380 |
|
Definition
|
|
Term
| what are the 5 criteria for good diabetic control? |
|
Definition
1. clinical signs have resolved!
2. pet is healthy and active
3. weight is stable
4. owner satisfied
5. BG b/w 90-270 mg/dL most of the day |
|
|
Term
| If a dog is getting >2.2 units/kg/injection of insulin what are some things you may be concerned about? |
|
Definition
-problem with storage/admin
-too much is being given (Somoygi effect)
-too little is being given (insulin resistance) |
|
|
Term
| What is the average dose of insulin for dogs to achieve good regulation? |
|
Definition
|
|
Term
| List some causes of insulin resistance |
|
Definition
-hormonal influences: spay diabetic bitches, avoid progesterone
-infection (esp UTI)
-inflammation (esp pancreatitis)
-steroids: exogenous or endogenous (Cushings) |
|
|
Term
| what type of diet can you recommend for a diabetic patient |
|
Definition
NOT semi-moist (high in simple sugars)
High in insoluble or mixed fiber |
|
|
Term
| What is the Somoygi Effect? |
|
Definition
| rebounding high BG in response to hypoglycemia; hypoglycemic episode that follows too much insulin administration |
|
|
Term
| What is the 2nd most common endocrine disorder in cats? |
|
Definition
|
|
Term
| What is the signalment of diabetic cats? |
|
Definition
older (>9), obese (>7kg), male cats
neutering may also increase risk |
|
|
Term
| T/F: obesity is correlated to DM and insulin resistance in cats |
|
Definition
|
|
Term
| What is Type II diabetes characterized by? (what is its pathophysiology) |
|
Definition
lower tissue sensitivity to insulin (insulin resistance) and hyperinsulinemia
(so insulin is there, but the
tissues dont respond)
variable loss of insulin secretory capacity |
|
|
Term
| is type 1 or 2 diabetes more prevalent in humans? |
|
Definition
|
|
Term
| T/F: later in the disease process for type 2 DM, failure of B-cells leads to low insulin levels |
|
Definition
|
|
Term
| T/F: you can get dogs to become non-diabetic again with good management and regulation |
|
Definition
|
|
Term
| what consequence of type II diabetes is associated with partial loss of B-cells due to formation of an insoluble polypeptide? |
|
Definition
| Islet Amyloidosis (due to islet amyloid polypeptide) |
|
|
Term
| How does the insoluble amyloid polypeptide affect cells? |
|
Definition
|
|
Term
| the soluble form of islet amyloid polypeptide is a regulator of what? |
|
Definition
|
|
Term
| for every molecule of insulin there are how many molecules of IAPP (islet amyloid polypeptide) |
|
Definition
|
|
Term
| What are your goals in managing a non-ketotic diabetic cat? |
|
Definition
-Maximize chances of diabetic remission
-eliminate clinical signs
-avoid symptomatic hypoglycemia
-minimize risk of complications due to chronic hyperglycemia
-make therapy "do-able" for owners |
|
|
Term
| what is a major consequence to diabetic cats if you give insulin when no longer needed? |
|
Definition
|
|
Term
| T/F: diabetes predisposes cats to hypertension, hypertensive retinopathy, and proteinuria |
|
Definition
|
|
Term
| what are some complications of chronic hyperglycemia in diabetic cats? |
|
Definition
polyphagia + weight loss
PU/PD
diabetic neuropathy
pulmonary changes (congestion, edema, histiocytosis, pneumonia, fibrosis, mineralization)
acromegaly
increased IAPP deposition
death from cardiac disease |
|
|
Term
| what are the clinical signs of diabetic neuropathy in cats? |
|
Definition
| weakness, *inability to jump, dropped hocks, plantigrade stance, hind limbs affected more commonly than front limbs, can also have sensory neuropathies |
|
|
Term
| what complication of chronic hyperglycemia in cats leads to poorly regulated DM and changes in facial bones/ head shape) |
|
Definition
| Acromegaly (increased growth homone production by pituitary) |
|
|
Term
| Why must inflammation/infections be controlled in diabetic cats? What kind of infxns may be implicated? |
|
Definition
this may resolve the diabetes!
UTI, dental dz, inflammation assoc. with recent surgery, skin disease, pancreatitis, IBD |
|
|
Term
| What Dx tests should be performed in a newly Dx- diabetic cat? |
|
Definition
-confirm there is NO Hx of insulin-antagonizing drugs
-CBC, Chem, UA and culture
-T4
consider:
thoracic rads; fPL; AUS; baseline fructosamine |
|
|
Term
| What must you confirm before starting insulin therapy in cats?! |
|
Definition
| Diagnosis of DM must be confirmed! |
|
|
Term
| T/F: dogs and cats differ in that cats BG is easily elevated due to stress while dogs is not. |
|
Definition
|
|
Term
| Why is it crucial to further evaluate a finding of hyperglycemia in cats? |
|
Definition
| it may just be due to stress |
|
|
Term
| What findings do you need to confirm a Dx of DM in cats? |
|
Definition
| hyperglycemia, glucosuria, AND a Hx of PU/PD, polyphagia, and weight loss |
|
|
Term
| name two suitable insulin choices for cats |
|
Definition
|
|
Term
| What is important to know regarding the materials needed to give ProZinc insulin in cats? |
|
Definition
|
|
Term
| What is the duration of insulin glargine and ProZinc? |
|
Definition
|
|
Term
| What is the recommended starting insulin dose in cats? |
|
Definition
0.25 U/Kg q 12hours
equates to ~1U/cat q 12hrs |
|
|
Term
Most cats will be regulated on what dose (U/kg q 12h) of insulin?
a. 0.2-0.8
b. 0.1-0.5
c. 2-8
d. 1-5 |
|
Definition
|
|
Term
| Which insulin is best to use in cats and why? |
|
Definition
insulin glargine:
achieves highest rate of diabetic
remission
reduced risk of hypoglycemia
consistent availability* |
|
|
Term
| how often do you want to check BG on the first day of insulin therapy in cats |
|
Definition
every 4hrs for glargine
every 2-3hrs for ProZinc |
|
|
Term
| Why should you NOT increase the insulin dose in the first week for diabetic cats? |
|
Definition
| common to see little change in BG in first few days |
|
|
Term
at 1 week after initiating insulin treatment how many hours post-injection should you assess for hypoglycemia (<150mg/dl)?
if hypoglycemia is present what are your options? |
|
Definition
6-8hrs
if hypoglycemia:
decrease insulin dose
consider dosing q24hrs |
|
|
Term
| how often should diabetic cats have an in-clinic check in the first month after trx? |
|
Definition
|
|
Term
| what are the goals of diet therapy in diabetic cats? |
|
Definition
*correcting obesity
minimizing impact of diet on postprandial BG concentration |
|
|
Term
| What kind of diet would you recommend for diabetic cats |
|
Definition
restrict CHO absorption
inhibit glucose absorption
inhibit starch digestion
high protein diet
recommend canned food for standard diabetic cats |
|
|
Term
what are some examples of oral hypoglycemic agents used in type 2 DM?
when is their use indicated? |
|
Definition
*glipizide, metformin, darglitazone
try in:
-newly Dx diabetic cats whose owners refuse to give injections
-possibly in cats that are VERY sensitive to insulin therapy |
|
|
Term
| when is diabetic remission most likely to occur in cats? |
|
Definition
| in the first month, when BG control at 17days is good, and with weight loss |
|
|
Term
| Name two incretin hormone-based therapies currently being developed |
|
Definition
glucagon-like peptide-1 (GLP-1)
glucose-dependent insulinotropic polypeptide (GIP) |
|
|
Term
| Name 3 diabetic emergencies |
|
Definition
DKA
HHS (hyperglycemic hyperosmolar syndrome)
Insulin-induced hypoglycemia |
|
|
Term
| What are the lab findings assoc. with DKA |
|
Definition
| hyperglycemia, glucosuria, ketonuria, metabolic acidosis |
|
|
Term
| what are the lab findings assoc with Hyperglycemic Hyperosmolar Syndrome |
|
Definition
| profound hyperglycemia, hyperosmolality, pH>7.3, no significant ketonuria |
|
|
Term
| how common is HHS and what is the prognosis? |
|
Definition
Rare
poor prognosis (high mortality) |
|
|
Term
| What endogenous hormones are capable of antagonizing insulin? |
|
Definition
cortisol
epinephrine
glucagon
growth hormone
progesterone |
|
|
Term
| DKA is characterized by an increase in what ratio? |
|
Definition
|
|
Term
| the main hormone implicated in DKA and HHS is________. |
|
Definition
|
|
Term
| the main hormone implicated in DKA and HHS is________. |
|
Definition
|
|
Term
| glucagon is secreted by ______ in response to _______. |
|
Definition
pancreatic alpha cells
hypoglycemia |
|
|
Term
| what are the actions of glucagon |
|
Definition
oppose insulin
increased glycogenolysis and
gluconeogenesis
activates lipase in adipose cells (increases FFA and inhibits TG storage in liver)
promotes ketosis by shifting the liver toward FFA production (which can be converted to ketones) |
|
|
Term
| what are the clinical signs of DKA (and HHS)? |
|
Definition
| profound dehydration, shocky, hypovolemia, nausea, anorexia, vomiting |
|
|
Term
T/F: The goals of Ketoacidosis therapy include all of the following:
1. fluid therapy w/ 0.9% saline, then 5% dextrose
2. give insulin to SLOWLY reverse ketoacidosis and hyperglycemia
3. carefully monitor and manage electrolytes (K, P, Mg)
4. reverse metabolic acidosis
5. ID and trx coexisting diseases |
|
Definition
|
|
Term
| what Dx tests should be performed after stabilizing a DKA or HHS patient |
|
Definition
CBC, Chem, UA and culture
rads/AUS
T4 (cats)
ACTH stim or LDDST |
|
|
Term
| what type of insulin should be used in DKA cases |
|
Definition
rapid (regular) insulin
(low dose) |
|
|
Term
| what are some complications assoc w/ high dose insulin therapy in DKA cases? |
|
Definition
| hypoglycemia, hypokalemia, hypophosphatemia, cerebral edema |
|
|
Term
| Why are many diabetics hyponatremic on presentation? |
|
Definition
losses in urine, vomitus, diarrhea
OR
dilutional secondary to high BG (osmotic diuresis) |
|
|
Term
| What are the causes of hypokalemia in diabetic patients? |
|
Definition
-loss in vomit, diarrhea, urine
-moves into cells following insulin trx and correction of acidosis
-dilutional effect following saline
-can result in profound muscle weakness |
|
|
Term
| what are the manifestations of hypophosphatemia in diabetic patients and how is it corrected? |
|
Definition
muscle weakness and hemolytic anemia
Correct: use 50%KCl and 50%KPhos; also feeding helps |
|
|
Term
| what are some clinical signs of hypomagnesemia in diabetic patients? |
|
Definition
| depression, lethargy, muscle weakness |
|
|
Term
| How would you correct metabolic acidosis in a diabetic patient? |
|
Definition
Rarely necessary to correct.
If SEVERE give HCO3 (but only if necessary) |
|
|
Term
| What are some complications assoc with DKA therapy |
|
Definition
hypophosphatemic hemolytic anemia (insulin induced)
cerebral edema (fluid overload in HHS)
paradoxical cerebral acidosis (HCO3 induced)
hypokalemia |
|
|
Term
| how does insulin admin lead to hypophosphatemia? |
|
Definition
| following insulin admin and correction of acidosis, glucose and Phos move intracellularly, causing severe ECF phosphorous depletion |
|
|
Term
| What are the clinical signs assoc. with hypophosphatemia? |
|
Definition
| hematologic (structural and functional changes in RBC's/platelets/neutrophil; severe hemolytic anemia), neuromuscular, skeletal, hepatic |
|
|
Term
| List some complications of phosphorous therapy for diabetic patients low in phos |
|
Definition
hyperphosphatemia
hypocalcemia
soft tissue mineralization
hypotension
renal failure |
|
|
Term
| What organ and system must be functioning normally in order to maintain euglycemia? |
|
Definition
|
|
Term
| How does hypoglycemia impact insulin? |
|
Definition
|
|
Term
| how does hypoglycemia impact glucagon, epinephrine and norepinephrine |
|
Definition
|
|
Term
| how does hypoglycemia impact cortisol and growth hormone |
|
Definition
|
|
Term
| what hormone is key in affecting recovery from acute hypoglycemia? |
|
Definition
|
|
Term
| list the clinical signs associated with hypoglycemia |
|
Definition
Neuroglycopenia: lethargy, weakness, ataxia, bizarre behavior, blindness, convulsions, coma, yawning/tiredness
sympathoadrenal response: muscle tremors, nervousness, restlessness, tachycardia, hunger |
|
|
Term
| what are some DDx for hypoglycemia due to increased use? |
|
Definition
insulinoma
extra-pancreatic neoplasia
sepsis
"hunting dog hypoglycemia"/functional
hypoglycemia-exertional
severe polycythemia
late pregnancy |
|
|
Term
| what are some DDx for hypoglycemia due to decreased production/availability |
|
Definition
*hepatic failure
*hypoadrenocorticism (Addison's)
*"puppy hypoglycemia"
uremia (rare)
hypopituitarism (rare)
glycogen storage dz (rare) |
|
|
Term
| What are some other DDx for hypoglycemia (not including increased utilization or decreased production) |
|
Definition
Lab artifact!**** (Always R/O first)
Insulin overdose(iatrogenic insulinoma)
Xylitol toxicity (stimulates insulin release; then liver failure) |
|
|
Term
| What is "hunting dog hypoglycemia"/functional hypoglycemia? |
|
Definition
-seen in working dogs assoc with heavy exercise
-occurs >30min into a period of intense activity; often due to muscle weakness
-may not have been fed prior to hunting |
|
|
Term
| What are the clinical signs of functional/hunting dog hypoglycemia? |
|
Definition
| seizure, weakness, or collapse in the field |
|
|
Term
| what is a DDx for hunting dog hypoglycemia? |
|
Definition
| exercise-induced collapse |
|
|
Term
| How do you Dx and Trx hunting dog/functional hypoglycemia? |
|
Definition
Dx: BG during or shortly after episode
Trx: feed dog before & during exercise, steroids promote gluconeogenesis |
|
|
Term
| what breeds are at particular risk for puppy hypoglycemia |
|
Definition
|
|
Term
| what is the proposed cause of puppy hypoglycemia? |
|
Definition
| limited glycogen stores and immature enzymes of gluconeogenesis? |
|
|
Term
| what are the clinical signs of puppy hypoglycemia |
|
Definition
weak, ataxic, collapsed or seizures
+/- coexisting illness (vomiting, diarrhea, shipping, stress) |
|
|
Term
| how do you trx puppy hypoglycemia |
|
Definition
IV glucose
correct underlying dz
provide adequate calories at more
frequent intervals |
|
|
Term
| Name 3 types of pancreatic neoplasia |
|
Definition
Pancreatic adenocarcinoma
"Insulinoma" B-cell tumors
Gastrinoma G-cell tumors |
|
|
Term
| Insulinomas are tumors affecting what cell type? |
|
Definition
|
|
Term
| Insulinoma's are common in which species? |
|
Definition
ferrets
also occur in dogs (rare in cats) |
|
|
Term
| What age and breeds of dogs are more at risk for insulinomas? |
|
Definition
~10yo dogs
Large breeds: irish setter, goldens, boxers, german shepherd dogs, standard poodles, fox terriers, mix breeds |
|
|
Term
| what are the clinical signs assoc with insulinomas |
|
Definition
*Relate to hypoglycemia
(biological product of the tumor is insulin)
convulsions or collapse, neuro signs (if slow BG decline) |
|
|
Term
| what things may exacerbate the signs assoc with insulinoma |
|
Definition
|
|
Term
| 1/3 of patients are treated for what prior to insulinoma Dx? |
|
Definition
|
|
Term
| How do you Dx insulinoma? (and what is seen on the Dx tests) |
|
Definition
Diagnosis of exclusion!
Hx, PE findings,results of Dx tests
CBC/Chem/UA(normal,EXCEPT hypoglycemic)
BG <70mg/dl
ID hypoglycemia cause ;eliminate R/O's
*assay serum insulin on any hypoglycemic sample when other causes are not found
AUS (may detect small pancreatic ndules or mets in the liver) |
|
|
Term
|
Definition
|
|
Term
| describe the pre-op management for insulinoma surgery |
|
Definition
multiple small meals high in protein and complex carbs prior to Sx
IV glucose to controlsymptomatic hypoglycemia
fast 8-12hrs prior to Sx (and keep on IV dextrose overnight) |
|
|
Term
| What is done during Sx for insulinoma? |
|
Definition
esplore and carefully evaluate the pancreas for nodules (small, 1-2.5cm)
also, evaluate liver and regional lymph nodes for mets |
|
|
Term
| What are some complications that may be encountered post-op for insulinomas? |
|
Definition
persistent hypoglycemia
traumatic pancreatitis
paradoxical DM
acquired epilepsy
generalized polyneuropathy |
|
|
Term
| what is the prognosis for medically trx dogs with insulinoma? |
|
Definition
mean survival ~1yr
younger dogs have shorter survival (high serum insulin and distant mets)
combos of Sx and medical management may allow improved survival times (>3yrs) |
|
|
Term
| What is the approximate age range were dogs and cats are said to be geriatric? |
|
Definition
| 7-10 yo (w/ giant breeds on the low end) |
|
|
Term
| What tests comprise a senior profile? |
|
Definition
CBC, Chem, UA
BP
total T4 +/- thyroid panel (cats)
Bicavitary rads |
|
|
Term
| What are some common geriatric diseases? |
|
Definition
| Periodontal dz, ocular changes, dermatologic changes, Neuro dz (cognitive dysfunction, old dog vestibular dz), urinary incontinence, feline constipation, etc |
|
|
Term
| What are the clinical signs of periodontal dz in geriatric animals? |
|
Definition
| dropping food, drooling?, pawing at face?, decreased appetite?, decreased interest in dry food? |
|
|
Term
| What are 2 ocular changes associated with old age in animals? |
|
Definition
Lenticular nuclear sclerosis
Iris atrophy |
|
|
Term
| What is another ocular change that looks very similar to lenticular nuclear sclerosis? |
|
Definition
|
|
Term
| contrast the appearance of cataracts and lenticular nuclear sclerosis |
|
Definition
cataracts: "ground glass", cant see tapetal reflection or fundus, interferes with vision
lenticular nuclear sclerosis: homogenous/smooth and "pearly", does NOT interfere with vision, can still see tapetal reflxn and fundus |
|
|
Term
| What is the most common cause of incomplete PLRs? |
|
Definition
|
|
Term
| What are some dermatologic conditions that you might see in geriatric patients? |
|
Definition
decreased skin elasticity
tumors- benign and malignant
coat changes (signal other issues) |
|
|
Term
| What is cognitive dysfunction and what causes it in geriatric pets? |
|
Definition
-synonymous with senility in humans
-impairments in momory, learning,
perception & awareness
B-amyloid peptide deposition in neurons
Slowly progressive |
|
|
Term
| is cognitive dysfuntion more common in geriatric females or males |
|
Definition
|
|
Term
| Describe the 5 historical findings associated with cognitive dysfunction. |
|
Definition
DISHA
Disorientation: getting lost in familiar environments, confused
Interactions:w/humans or other animals can be altered, doesnt recognize you, turns away from petting, tail doesnt wag like it used to
Sleep-wake cycle alterations, barks at night for no reason
Housetraining- and other learned behaviors deteriorate
Activity-sometimes decreased, sometimes increased, restless behavior |
|
|
Term
| How do you Dx cognitive dysfunction? |
|
Definition
|
|
Term
| What are some R/O for cognitive dysfunction? |
|
Definition
| intracranial disease (ie neoplasia); hepatic or uremic encephalopathy; endocrine (ie hyperthyroidism); anxiety disorder/behavior |
|
|
Term
| How do you trx cognitive dysfunction in geriatric patients? |
|
Definition
*Selegiline
Propentofylline
Supplements
Senilife
*Diet
*Environmental enrichment, training, play
*predictable daily routine |
|
|
Term
| What is the mechanism of Selegiline (used for cognitive dysfunction)? |
|
Definition
MAO-B inhibitor
improves dopamine transmission; enhances catecholamines in the brain; maybe decreasesfree radicals |
|
|
Term
| When is the use of Selegiline contraindicated? |
|
Definition
*with PPA (phenylpropanolamine, SSRIs, and TCAs (including Mirtazapine!)
only licensed for use in dogs |
|
|
Term
| What diet is recommended for the trx of cognitive dysfunctin? |
|
Definition
Hill's b/d Aging and Alertness
Purina One SmartBlend Vibrant Maturity 7+ |
|
|
Term
| What clinical signs are associated with old dog vestibular disease? |
|
Definition
acute onset, non-progressive
head tilt, ataxia/collapse/falling/circling in one direction, nystagmus (rotary or horizontal), vomiting, decreased appetite |
|
|
Term
| What are the only two types of nystagmus that you see in dogs with old dog vestibular disease? |
|
Definition
| ONLY rotary or horizontal |
|
|
Term
| What are some clinical signs that do NOT fit with old dog vestibular disease? |
|
Definition
-vertical nystagmus (brain disease)
-abnormal strength, reflexes, or proprioception (brain dz)
-abnomal mentation
-other CN deficits (peripheral or central)
-Horner's syndrome |
|
|
Term
| T/F: vertical nystagmus, abnormal mentation, head tilt, vomiting, and Horner's syndrome are all clinical signs associated with old dog vestibular disease |
|
Definition
False:
head tilt, vomiting/decreased appetite, ataxia/collapse/falling/circling/rotary or horizontal nystagmus = old dog vestibular disease
(NOT assoc: vertical nystagmus, abnormal strength/reflexes/ proprioception, abnormal mentation, other CN deficits, Horner's syndrome) |
|
|
Term
| How do you trx old dog vestibular disease |
|
Definition
self-limiting
control nausea (meclizine, maropitant)
supportive care
client education |
|
|
Term
| what is urinary incontinence |
|
Definition
| loss of voluntary control of micturition; often occurs when relaxed/sleeping |
|
|
Term
| what are 2 geriatric causes of urinary incontinence |
|
Definition
-Urethral sphincter mechanism incontinence ("hormone responsive incontinence")
-Neurologic- lumbosacral myelopathy |
|
|
Term
| what is the signalment for urethral sphincter mechanism incontinence? |
|
Definition
| spayed female geriatric dogs |
|
|
Term
| what are some general (DAMNIT) causes of neurologic urinary incontinence in geriatric patients? |
|
Definition
| IVDD, tumor, vascular, degenerative |
|
|
Term
| What are the trx options for urethral sphincter mechanism incontinence? |
|
Definition
*Phenylpropanolamine (PPA) - BID-TID
-Proin, Propaline, Cystoalmine
*Diethylstilbesterol (DES) -once weekly
-Hormone replacement
Collagen (injected into urethra)
Hydraulic occluders
Diapers |
|
|
Term
| What is the mechanasm of phenylpropanolamine? |
|
Definition
| Alpha agonist that increases urethral tone |
|
|
Term
| A geriatric cat that presents with a history of small firm dry feces, frequent trips to the litter box, non-productive straining, defecation outside the litterbox, hematochezia, and small amounts of diarrhea. what is your most likely Dx? |
|
Definition
|
|
Term
| *What are the potential causes for feline constipation? which is most common? |
|
Definition
*Idiopathic (most common)
*DDx
- ingestion of foreign material/FB
- reluctance to defecate due to
litterbox aversion or pain
- Dehydration (ie- CKD cats)
- Neurologic dysfunction
- obstructive dz (intra- or extra-
luminal tumors |
|
|
Term
| Describe the *treatment* options for feline constipation |
|
Definition
*Enemas: warm H2O & lube; DSS
*Go-lytely: polyethylene glycol
electrolyte solution
-last option trx, really old cats;
-give slowly via NE tube
*manual evacuation
*surgery (sub-total colectomy)
*Laxatives: lactulose, miralax
*Prokinetics: cisapride
*increase waterintake
*Diet |
|
|
Term
| What are the trx options for geriatric patients with declining appetites? |
|
Definition
Appetite stimulants
Feeding and diet changes
Feeding tubes |
|
|
Term
| What are the available appetite stimulants for geriatric patients? |
|
Definition
*Mirtazapine
*Cyproheptadine
*Diazepam (Valium)
*Maropitant (Cerenia)
*Steroids? |
|
|
Term
| *Describe the mechanism, side effects, and contraindications associated with Mirtazapine (used for declining appetite)? |
|
Definition
Tricyclic antidepressant w/ antiserotonin activity
side effects: anti-emetic, may cause sedation or agitation
contraindicated: in animals taking Selegiline for cognitive dysfunction |
|
|
Term
| *Describe the mechanism and side effects associated with Cyproheptadine(used for declining appetite)? |
|
Definition
Mechanism: serotonin antagonist, antihistamine
side effects: may cause sedation or agitation |
|
|
Term
| What appetite stimulant has been implicated in having a risk of hepatotoxicity in cats when it is given orally? |
|
Definition
|
|
Term
| *When/how long should an NE tube be used? |
|
Definition
| Short term feeding (7-10days) |
|
|
Term
| *What can be given through an NE tube? |
|
Definition
Liquid diet (Clinicare, Vivonex)
some liquid meds |
|
|
Term
| Why would you place a feeding tube? and what are the 3 feeding tube options? |
|
Definition
provides a non-stressful way to administer nutrition, water, meds
Nasoesophageal (NE)
Esophageal
Gastric |
|
|
Term
| T/F: an NE tube is a more permanent feeding tube option, is less irritating, you can give blended canned food and medications. However, you should beware in patients w/ low albumin or on steroids |
|
Definition
False
these are the *properties for an esophagostomy tube* |
|
|
Term
All of the following are properties of a gastrotomy tube EXCEPT...
a. lasts months to years
b. placed endoscopically or
percutaneously w/ ELD
c. used for short term feeding
d. beware in patients with low
albumin or on steroids |
|
Definition
| c. short term feeding (property of an NE tube) |
|
|
Term
All of the following should be considered in patients w/ endocrine dz EXCEPT
a. these patients have increased anesthetic risk
b. you should prepare for potential complications
c. it is important to stabilize patients and run pre-op blood work
d. minimizing stress is important
e. all of the above |
|
Definition
|
|
Term
| Why is it important to schedule surgery in the morning for diabetic patients? |
|
Definition
| animals are fasted and normally these patients need to be on a regular feeding and insulin schedule |
|
|
Term
| T/F: stress should be avoided in diabetic patients due to the consequences of increased sympathetic tone and increased BG |
|
Definition
|
|
Term
| At what BG level should you administer insulin in diabetic patients about to undergo anesthesia? |
|
Definition
| BG> 150-200 (give 1/2 insulin dose) |
|
|
Term
How often should you monitor BG in anesthetized diabetic patients?
What should you do if it is low? |
|
Definition
every 30-45min
give 1-5% dextrose IV |
|
|
Term
| In a diabetic patient that has just had surgery, when is it ok to go back to you rnormal feeding/insulin schedule? |
|
Definition
|
|
Term
| What premed and induction drugs should be avoided in diabetic patients? why? |
|
Definition
Premeds:
alpha-2 agonists (xylazine,dexmed)
-increase BG
Induction:
Barbiturates (glucose effect)
-Rabbits & some birds will be re-
sedated after waking up to due
glocose levels as a result of these
drugs
Ketamine (sympathetic stim-> incr. BG |
|
|
Term
Which of the following principles is important regarding diabetic animals?
a. Sx first in the morning
b. avoid stress
c. check BG pre-, intra-, and post-op
d. give insulin and/or 2.5-5% dextrose as necessary
e. avoid alpha-2 agonists and
ketamine; caution in some species
with barbiturates
f. all of the above |
|
Definition
|
|
Term
The following multisystemic effects are associated with which endocrine disorder?
*difficult ventilation/oxygenation
-pendulous abdomen
-muscle weakness (protein catabolism)
-pulmonary thromboembolism (PTE)
-pulmonary interstitial and bronchial
mineralization
*fragile veins and skin
-bruise with venipuncture
*Hypertension
*Thromboembolism |
|
Definition
| Hyperadrenocorticism (Cushing's) |
|
|
Term
| Due to the difficult ventilation/oxygenation that occurs in dogs with Hyperadrenocorticism it is important to do what before sx? |
|
Definition
| IPPV (intermittent positive pressure ventilation) and preoxygenation before induction |
|
|
Term
| What are the causes of thrombembolism in patients with hyperadrenocorticism? |
|
Definition
hypercoagulability
increased PCV and vascular stasis
increased clotting factors/fibrinogen
decreased antithrombin
fragile vessels
prolonged recumbency |
|
|
Term
| Hypertension in patients with hyperadrenocorticism is associated with what 2 factors? |
|
Definition
increased sensitivity to pressors
increased renin & renin-angiotensin
system |
|
|
Term
| T/F: hypertension in hyperadrenocorticism makes patients less prone to hypotensive effects of general anesthesia. |
|
Definition
| False. hypertension is there all the time in these patients therefore they are unable to compensate well and are more prone hypotension |
|
|
Term
| What is one drug that a dog with Cushing's may be on that you should consider when developing your anesthetic protocol due to the risk of serotonin syndrome? why would a Cushing's pet be on this drug? |
|
Definition
Anipryl (selegiline)
-irreversible inhibition of MAO-B
*trx Cushing due to pituitary origin
-risk of drug interaction
-leads to more serotonin in the body
so avoid giving drugs that block
serotonin uptake |
|
|
Term
| What anesthetic drugs are contraindicated in patient's w/Cushings that are on Anipryl/selegiline? |
|
Definition
-opioids (meperidine)-> serotonin syndrome (due to blocked serotonin uptake)
-ketamine-> sympathetic stimulation
-sympathomimetic drugs |
|
|
Term
| What are some other drugs that can be used as premeds, induction meds, and inhalants in Cushinoid dogs? |
|
Definition
Premeds: butorphanol, full-mu agonists, midazolam
Induction: etomidate, propofol, midazolam, diazepam
Inhalent: iso, sevo |
|
|
Term
| what clinical signs characterize serotonin syndrome? (serotonin syndrome may occur when a patient is on selegiline and is given meperidine) |
|
Definition
| confusion, fever, shivering, diaphoresis, ataxia, hyperreflexia, myoclonus, diarrhea |
|
|
Term
Which of the following is NOT an important principle to consider when anesthetizing Cushinoid dogs?
a. problems w/ventilation/oxygenation;
so preoxygenate and IPPV
b. difficult IV catheter placement due
to bruising
c. PTE; hypertension
d. perform surgery in morning and
avoid stress
e. if on selegiline, careful w/
meperidine |
|
Definition
| d. sx in morning and avoiding stress are important principles for DM |
|
|
Term
| what is Addison's syndrome? |
|
Definition
hypoadrenocorticism
- decreased glucocorticoids
- +/- decreased mineralocorticoids |
|
|
Term
Glucocorticoids do all of the following EXCEPT:
a. gluconeogenesis, glycogenesis,
erythrocytosis
b. enhance fat and protein metabolism
c. maintain normal BP
d. enhance the effects of stress |
|
Definition
| D. glucocorticoids counteract the effects of stress |
|
|
Term
Mineralocorticoids do all of the following EXCEPT:
a. reabsorption of Na+
b. reapsorption of K+
c. plasma volume regulation
d. secretion of H+ |
|
Definition
| b. mineralocorticoids are responsible for secretion of K+ (not resorption of K+) |
|
|
Term
| What are some consequences/ lab findings assoc w/ Addison's syndrome (hypoadrenocorticism)? |
|
Definition
hyperkalemia (causes arrhythmias)
hyponatremia
metabolic acidosis
hypoperfusion
CV collapse
-peripheral vasoconstriction,
decreased venous return, decreased
CO, decreased contractility,
bradycardia
hypoglycemia |
|
|
Term
| T/F: an addison's patient does not need to be stabilized prior to induction as it is more important to get them to Sx |
|
Definition
False!!
Always stabilize the patient before induction |
|
|
Term
| what do you need to accomplish in order to stabilize an Addison's patient prior to induction? |
|
Definition
increase intravascular volume-> fluids!
increase BP
improve renal perfusion
decrease potassium |
|
|
Term
| Glucocorticoid supplements may be indicated prior to induction to prevent circulatory collapse and adrenal crisis, what are the supplement options? |
|
Definition
hydrocortisone
dexamethasone
prednisolone
sodium succinate (IV) |
|
|
Term
| When you hear the word "Addison's" you should always think ______ when considering your pre-anesthetic work up? |
|
Definition
|
|
Term
| What does an Addisonian crisis look like (clinical signs)? |
|
Definition
| severe hypotension, tachycardia or bradycardia, hypoglycemia |
|
|
Term
| how would you trx an Addisonian crisis? |
|
Definition
aggressive fluid therapy
dopamine and/or dobutamine
trx hyperkalemia
corticosteroids |
|
|
Term
| Are there any anesthetic drug considerations for Addisonian patients? |
|
Definition
no
management of an Addisonian crisis is more important than the anesthetic regimen |
|
|
Term
All of the following are important principles to consider prior to anesthesia in an Addisonian (Hypoadrenocorticism) patient EXCEPT:
a. may be volume depleted
b. risk of CV collapse
c. possible hyperkalemia
d. avoid stress at induction/recovery
e. avoid meperidine if on Selegiline
f. pre-treat w/ corticosteroids
g. treat hypertension aggressively |
|
Definition
| e. meperidine should be avoided if Cushinoid (Hyperadrenocorticism) patients are on selegiline; there are NO contraindicated drugs for Addisonian patients... |
|
|
Term
| T/F: mixing drugs is OK as there are hardly ever any bad drug interactions |
|
Definition
False: drug interactions are often unknown
- some are good, some are bad
-Bad: ketamine and diazepam; NSAIDs
and steroids |
|
|
Term
| List 6 drug administration mishaps |
|
Definition
1. labeling- unlabeled syringes= BAD!
2. wrong bottle
3. wrong route
4. calculation errors
(kg vs lb; concentration)
5. Incorrect filling of inhalant
vaporizer
6. Multiple vaporizers on at same time |
|
|
Term
| What would happen is thiopental was not given correctly... (ie wrong route) |
|
Definition
| tissue sloughing and necrosis if extravascular |
|
|
Term
Which is worse? why?
-iso in a sevo vaporizer?
-sevo in an iso vaporizer? |
|
Definition
iso in a sevo vaporizer
-issue comes from different MAC
values...could give too much iso (if
its in a sevo vaporizer) |
|
|
Term
| What are/is the risks and benefits associated with NO use? |
|
Definition
Risks:
hypoxia
diffusion into closed gas cavities
benefits:
has some analgesic effect (increases HR and BP)
can add NO and turn down inhalents (MACs are additive) |
|
|
Term
| T/F: MACs are additive so you could turn down your inhalant and supplement with some NO |
|
Definition
|
|
Term
| Why is Nitrous oxide assoc w/ a risk of hypoxia? |
|
Definition
| NO displaces O2 from lungs (and other closed gas cavities); doesn't like to stay in the blood |
|
|
Term
| T/F: If your anesthesia machine tips over in transport it is OK to just stand it up and put it away or continue using it. |
|
Definition
False!
inhalant will leak into areas it shouldnt and the vaporizer could have been damaged leading to incorrect inhalant amounts being given |
|
|
Term
| why is leaving the pop-off valve closed a potentially lethal mistake? |
|
Definition
| too much pressure in patients lungs-> lungs could rupture |
|
|
Term
| is leaving the pop off valve closed a more critical mistake with rebreathing or non-rebreathing systems? |
|
Definition
|
|
Term
| T/F: 2 things that will kill your patient include leaving the pop off valve closed and forgetting to turn the O2 back on after giving a breath |
|
Definition
|
|
Term
| Most drugs result in what if their dose is repeated? |
|
Definition
|
|
Term
| Repeating Propofol doses in cats can have a number of adverse effects, what are they? |
|
Definition
| lethargy, malaise, oxidative damage* (heinz body formation) |
|
|
Term
| T/F: you should always inflate the cuff of your patients ET tube |
|
Definition
False
Only inflate if there is a leak |
|
|
Term
| what is the concern of using laser therapy with/near an ET tube? |
|
Definition
All three elements of the "fire triangle"
-fuel + accelerant + ignition source
(plastic tube + oxygen + laser) |
|
|
