Case 11 — Second Follow-Up

Joey was seen again about 6 weeks after his last clinic visit on a Sunday on the Emergency Service. He came in dehydrated and hypothermic due to low cardiac output. This is a classic case of a dog on high-dose diuretic therapy undergoing a stressful event and/or becoming anorexic and not drinking while diuretic administration continues. Joey probably became anorexic or partially anorexic for several days prior to admission as he had lost considerable weight. He was put outside one night and not taken in again until the next morning. Owners must always be told to contact a veterinarian if a dog stops eating and especially if it stops drinking, or to stop the diuretic therapy until they can contact a veterinarian. After admission, he was treated aggressively with intravenous fluids but all it did was cause more ascites. This is a very poor prognostic sign.

Presenting Complaints

Not eating, low temperature, white gums.

Pertinent History

Joey has historical mitral regurgitation, tricuspid regurgitation, pulmonary hypertension, and right heart failure, controlled with furosemide 50 mg PO TID, enalapril 5 mg SID PO, and amlodipine 0.625 mg BID PO. He did not receive any drugs the day of admission. The previous Friday afternoon he was put outside; the next morning he was cold, shivering, had white mucous membranes, and was not eating well. A local vet recorded a temperature of ~97°F and gave an IM antibiotic. Through Saturday he had little or no appetite, vomited once, and was somewhat lethargic. He sat by his water bowl for up to an hour at a time, drinking some.

Physical Examination

  • BAR, about 7–8% dehydrated; T = 100.9°F
  • EENT: Nuclear sclerosis OU; some ear debris; some tartar on teeth
  • MS: Cachectic 1/9
  • CV: Rate 160 bpm, regular; weak femoral pulses; grade V/VI murmur right and left
  • Respiratory: Rate 40 bpm, eupneic
  • GI: Severe ascites; liver edges smooth, may be slightly enlarged
  • Rectal: No melena or blood; prostate slightly enlarged but nonpainful

Problems

  • Historical mitral regurgitation, tricuspid regurgitation, ASD, right heart failure
  • Dehydration
  • Vomiting
  • Anorexia

Clinical Diagnoses

  • Severe mitral and tricuspid regurgitation
  • Acquired ASD
  • Pulmonary hypertension
  • Gastrointestinal ulceration / hemorrhage
  • Cachexia
  • Low output and congestive heart failure

Hospital Course

9/20/98: Primary concerns were dehydration and azotemia. ICU electrolytes and CBC were basically WNL except Na = 144, Cr = 1.8, BUN = 68, Ph = 9.7. Mean BP = 85, systolic = 109, diastolic = 69. Started on IV fluids (0.9% NaCl with 20 mEq KCl at 3 mL/kg/hr). Continued furosemide at 25 mg TID PO and amlodipine 0.625 mg BID PO; discontinued enalapril as it may have been contributing to signs.

9/21/98: Joey was depressed, mostly laterally recumbent but could walk briefly. Anorexic. Abdomen quite distended. Still dehydrated. T = 98.7°F (AM) to 99.4°F (PM). Renal panel: K 6.5, Na 152, Cl 112, P 11.1, Cr 2.2, BUN 103, Ca 10.5, albumin 2.9. Abdominocentesis removed 2 liters of serosanguinous fluid (modified transudate on cytology). Thoracic radiographs: no pulmonary edema. Abdominal ultrasound: large fluid volume but no gross lesions other than hepatomegaly and distended hepatic vessels. Fluids increased to LRS at 40 mL/hr; started famotidine 4 mg IV BID.

9/22/98: Joey more depressed, mostly laterally recumbent. Dark, blood-flecked feces overnight (melena and hematochezia). Anorexic. Renal panel: Na 156, Cl 156, K 5, Cr 2.3, BUN 111, albumin 2.5. PCV 41%, TS 5.7. Abdomen filling with fluid again. Sucralfate 250 mg PO in 5 mL H2O started. LRS increased to 50 mL/hr. Due to worsening condition, owners advised. Joey was euthanized at owner’s request at 7:30 PM.

Comments

Joey’s initial stimulus for anorexia and vomiting was most likely gastrointestinal ulceration. He rapidly spiraled into severe dehydration from which, in his already compromised state, he was not able to recover. His cardiac disease was quite advanced and refractory to medication. It is quite unusual for dogs with mitral regurgitation to exhibit signs of low-output failure, yet another indication of severity. He was treated supportively for three days with aggressive fluid therapy, warmth, and gastroprotectants with no clinical response and deterioration. The owners elected euthanasia.

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