ACVECC Small Animal Benchmark, May 2012

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1 ACVECC Small Animal Benchmark, May 2012 A 25 kg, 9 y MC Labrador Retriever presents with a 2-day history of cough and tachypnea. Physical exam revealed T F, HR 120 BPM, pulses strong and synchronous, respiratory rate 36/min, lung sounds harsh bilaterally with focal crackles ventrally on the right. The remainder of the exam was unremarkable. Emergency database is collected with the patient breathing room air at sea level: Ref range PCV 32 % % TP 6.0 g/dl g/dl ph PaCO mmhg mmhg PaO mmhg mmhg HCO mmol/l mmol/l BE -6.1 mmol/l -4 to 4 mmol/l Na mmol/l mmol/l K mmol/l mmol/l Cl mmol/l mmol/l Ca mmol/l mmol/l Mg mmol/l mmol/l Glu 118 mg/dl (6.5 mmol/l) mg/dl Lac 0.6 mmol/l (3.2 mmol/l) mmol/l BUN 9 mg/dl mg/dl Creat 0.6 mg/dl (53 µmol/l) mg/dl Albumin 2.6 g/dl (26 g/l) g/dl Thoracic radiographs: L lateral, R lateral and VD shown

2 L

3 1) What is the most likely diagnosis? 2) What are the most common bacterial pathogens associated with this condition?

4 3) Name four different non-surgical methods to obtain a sample from the airways/lung for culture. List the pros and cons to each method. 4) What empiric antibiotics will you use while awaiting your culture result? Defend your choice.

5 5) List five factors that may predispose to this condition. 6) What are the primary abnormalities present on the blood gas? 7) Calculate and interpret the A-a gradient (at sea level). 8) What are the causes of hypoxemia? Questions 9-17 refer to Stewart s approach to acid base. 9) What are the independent variables? 10) What are the dependent variables? 11) Considering the Strong Ion Difference, what factors affect Base Excess? (be specific)

6 12) What is the formula for corrected Chloride? 13) Calculate the contribution of chloride to base excess for this patient 14) Calculate the contribution of proteins to base excess for this patient 15) Decreases in SID suggest what type of acid base disturbance? 16) If a liter of water contains 140 meq/l of Na + and 110 meq/l of Cl -, then the SID is 30mEq; if we were to add another liter of water without adding any more electrolytes, then the solution would contain 70 meq/l Na + and 55 meq/l Cl -. The new SID is 15 meq. This represents what concept in Stewarts approach to acid base?

7 17) What factors are likely contributing to this patient s acid base disturbance? Later in the day the dog decompensates and requires mechanical ventilation. 18) What are the general indications for instituting mechanical ventilation? 19) List 5 different drugs, each with a different mechanism of action, which can be used as part of an anesthetic protocol to maintain an animal on the ventilator. For each drug, list the mechanism of action, and pros and cons to using each of the drugs. DRUG MOA PROS AND CONS

8 20) Choose initial ventilation settings for this patient and explain your choices. 21) List and explain the importance of 10 aspects of care for the ventilated patient that are NOT related to the mechanical ventilator or its settings.

9 22) What are the indications that it is time to start weaning off the ventilator and what methods/modes can you use? 23) Label the Pressure-Volume Waveform 300 Volume (ml) Pressure (cm H 2 0) a) Label the inspiratory portion of the ventilator breath b) Label expiration c) Identify the approximate Peak inspiratory pressure d) Identify the approximate inspiratory tidal volume? e) What is indicated by the smaller loop identified by the arrow? f) What is the sensitivity setting (inspiratory trigger)?

10 26) The following loops were obtained shortly after the dog was placed on the ventilator. Interpret the loops. How do you fix the problem? 27) Once you get that problem fixed, the waveforms look like the following: Interpret the loops. How do you fix the problem?

11 Volume 28) A few hours later, the following loop was obtained: Pressure Interpret the loop and discuss ways you might fix the problem. A repeat arterial blood gas was obtained: ph: 7.26 PaO2: 78 mmhg PaCO2: 60.2 mmhg HCO3: 18.6 mmhg BE: mmol/l 29) The dog s ETCO2 is 45 mmhg. What is the normal PaCO2 ETCO2 difference?

12 30) What is the clinical significance of the disparity between this patient s ETCO2 and PaCO2? 31) Label the parts of the following capnogram: ETCO 2 40 C D 0 A B time E Segment A-B: Segment B-C: Segment C-D: Point D: Segment D-E: 30) Interpret the following Capnograms: a) time b) ETCO 2 0 time

13 c) ETCO 2 0 time d) ETCO time 31) The dog develops a pneumothorax on Day 2 of ventilation. Describe the technique for placing and securing a thoracostomy tube.

14 32) Draw and label a three bottle system which can be used to provide continuous suction to the chest tube. 33) On the third day of ventilation, the dog becomes more difficult to ventilate and the PaO2:fiO2 ratio declines precipitously. Ventilator waveforms progress from A to B over a few hours.

15 What does this change in waveforms indicate? 34) What are the differentials for this change? Which is most likely and why? 35) Explain how you could alter the ventilator parameters to treat this problem.

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