Page 13 - Winter 16

regular, with a rate of 100/min. Further Vetergesic and Arnica was given. 9 hours post- op she remained bright, CRT 1-2 seconds, rectal temperature 37.2C, heart rate of 120, passed urine outside when taken, but she had started panting. At this time I began treatment
count had reduced to 15.84 x 109, and her HCT was 0.407 L/L (0.37-0.55). At this stage I stopped the Marbocyl, reduced the prednisolone to 3 tablets every morning, and reduced the Zantac to 500mg bid. Probiotics (Synbiotic capsules – Protexin) were begun, as she had now started to eat regularly.
By October 8th she was markedly brighter and had started playing again with the other dogs. Blood tests showed platelets now to be 707 X 109 (175-500), though the in-house machine measures total platelet mass rather than numbers, so I suspect this reflected the size of the platelets in circulation rather than
presence of acute D.I.C. (disseminated intravascular coagulation).
D.I.C. is characterised by systemic microthromboses, which can lead to life threatening haemorrhage. It occurs secondary to many conditions, including neoplastic and inflammatory disorders, plus bacterial and fungal infections. It is characterised by a consumption of platelets and clotting factors in circulation due to an increase in thrombin production, a reduction in physiological anti- coagulation pathways together with impaired fibrinolysis and an activation of inflammatory pathways. The effect can vary from very mild to no signs, up to life threatening due to haemorrhage and organ malfunction as a result of the microthromboses. More detailed information on the causations, pathogenesis, clinical manifestations and treatment can be found in a variety of standard texts, so will not be repeated here.
http://coursewareobjects.elsevier.com/
with Crotallus horridus 30c (given twice daily, alongside the Arnica 6c which was continued). Blood tests taken about 12 hours post-op showed HCT of 0.526 L/L (0.37-0.55); WBC of
13.16 x109, and PLT of 71 x 109 (175-500). Through the day she refused all offers of food and water. Further Vetergesic was given, together with Zantac (ranitidine) i/v, plus on- going antibiotic support. She was still panting later that afternoon, but remained reasonably bright, temperature 37.9C, heart rate 148, CRT 1 second. The decision was made to allow her to go home, and she was discharged with Tramadol and Marbocyl, plus Crotallus horridus 30c.
I examined her the following day and she was reported to have been panting and restless all night, and not eaten though she had been drinking. On examination her abdomen was only mildly uncomfortable, her membranes were a healthy pink colour, CRT 1 second, and temperature 37.1C, but she looked very dull and lethargic compared to the previous day. She had passed a diarrhoeic stool and, although she had not been sick, she exhibited ptyalism and had been eating grass. Haematology showed her platelets had started to fall again, now being 41 x109, with WBC increased to 35.73 x 109 (Neutrophils 29.14 x 109), but normal HCT (0.47). I gave her an injection of Dexadreson at this time, as I was concerned at a potential immune-mediated thrombocytopaenia creating more serious problems.
The next day (1/10/2015) she was brighter, and had started to eat a little. Steroid therapy was continued at 15mg prednisolone bid, together with the on-going Zantac, antibiosis, and Crotallus horridus, together with a vitamin B12 injection.
2 days later she was considerably brighter with increasing appetite and energy levels. Blood tests showed her platelets to be back to 237 x 109, although her RBC count was just below normal at 5.12 x 109 (5.5-8.5), The WBC
necessarily an increase in numbers. The RBC count had reverted to normal (5.72 x 109) with the WBC at 21.36 x 109 (5.5-16.9), again this largely due to neutrophilia (14.09 x 109), although monocytes were 2.6 x 109 (0.3 – 2.0 x 109). The prednisolone was slowly tailed off, initially to 3 every 2 days, then to 2 every 2 days, and then stopped. A blood test taken on October 27th, 1 week after all medications ceased, showed all haematological parameters to be back to normal. Crumble was said to be brighter than she had been for months. A further sample sent to Idexx Laborotories on 13th November confirmed that all parameters had remained within normal limits (bar a very slight lymphocytosis at 5.2 x 109, normal being below 4.9). I have not seen her since this time.
Discussion
After her initial admission for a straightforward ovario-hysterectomy as a surgical treatment for a presumed pyometra, it soon became clear that there was a lot more going on in this case. I first saw her when called into the operating theatre, when the nature of the abdominal fluid became clear, and the more complicated nature of her case becoming apparent. Initially my concern that this was a ruptured pyometra, but once surgery had progressed and the abdominal contents could be properly examined, there was no visible evidence of peritonitis as would have been expected. Also the free abdominal fluid, although dark and bloody in nature, was not notably cloudy or purulent looking, as would have been anticipated with a case of ruptured pyometra. On examination of the uterus, no leakage was evident. However, it was also not a particularly enlarged uterus compared to a number I have seen, and this, together with the absence of a leucocytosis and normal hepatic biochemistry, did not suggest to me that this was likely to be a simple toxaemia problem. I suspected the
Detailed discussion of the conventional therapy will also not be given. Suffice to say that the pyometra, being frequently associated with bacterial sepsis, toxaemia, and release of circulating inflammatory mediators, is a potential initiating cause of this syndrome.
Correction of the underlying cause (in this case surgical ovario-hysterectomy), aggressive fluid therapy to restore circulation and use of antibiosis to control bacterial infection, all play an important role. In this case, I decided also to introduce steroid therapy, as the platelet count had begun to reduce to dangerously low levels again 2 days post-surgery, despite the other on-going support treatments and the absence of any obvious physiological reason for excessive usage. Immune-mediated factors can also be a predisposing factor in D.I.C., and I felt, I needed to arrest any immune-mediated thrombocytopaenia involvement in her case. The actual dose of steroid used arguably was below the 1-2mg/kg bodyweight bid to achieve this, being nearer the recommended anti- inflammatory dose, but I was reluctant to introduce the drug to such a level so soon post major surgery with a high WBC count suggesting potential body reaction to infection. Increase to the recommended dose levels to influence immune-mediated pathology was not necessary, as there was a good clinical response in a short time.
Homeopathy
Arnica Montana
What more is there that we can say about this beautiful little flower with such immense hidden powers? It is of such invaluable service in general practice in acute injury situations and during and after surgery. We all know of its healing powers in trauma, soft tissue injuries, and bruising. What is, perhaps, less well remembered is its worth in septic states.
Concordant Materia medica (Vermeulen
continued on p12
11