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Veterinarian Technician June 2011 (Vol 32, No 6)

Case Report: Complications After Repair of Inguinal Herniation With Jejunal Entrapment and Obstruction

by Janette Vuksinich, CVT, VTS (ECC)
    VECCS logo

    Presented at IVECCS 2010 in conjunction with Pfizer Animal Health.

    Diego—a 6-year-old, 9.1-lb (4.14-kg), neutered male Yorkshire terrier—was referred to the emergency hospital at which I work with a 3-day history of vomiting, inappetence, and not drinking. On presentation, Diego had a painful abdomen and a soft tissue thickening, which was palpated just lateral to the prepuce on the left side.

    Initial Assessment by the Referring Veterinarian

    Diego initially presented to his regular veterinarian with a 2-day history of inappetence, decreased water intake, and vomiting dark fluid. On initial examination, the patient was 5% dehydrated and had a painful abdomen. Blood work showed a high albumin level of 4.2 g/dL (normal: 2.2 to 3.9 g/dL), a high white blood cell (WBC) count of 19.56 × 10³/μL (normal: 5.50 × 10³/μL to 16.90 × 10³/μL), and a high hematocrit of 56.5% (normal: 37% to 55%). A canine pancreatic lipase immunoreactivity (CPLI) assay produced a negative result. Data have suggested that this test is highly sensitive and specific for detecting acute pancreatitis. Amylase and lipase levels have historically been used to help diagnose pancreatitis, but these enzyme levels may be falsely elevated by extrapancreatic factors, such as azotemia and glucocorticoid administration. In addition, amylase and lipase levels are frequently normal even when pancreatitis has been confirmed. The CPLI assay is not affected by renal disease or glucocorticoid administration.

    Diego was given subcutaneous fluids, injected with maropitant citrate to prevent emesis, and discharged to the owner. The next day, Diego presented to his regular veterinarian with the same signs as he had the day before. Abdominal radiographs revealed gas in the descending colon and feces in the rectum. A repeat CPLI assay produced a positive result.

    Diego was given ampicillin to treat a possible concurrent infection, maropitant citrate to prevent emesis, and famotidine (an H2-receptor antagonist) to reduce gastrointestinal (GI) acid.

    Presentation at the Emergency Hospital

    Diego was transferred to the emergency hospital for continued supportive care associated with suspected pancreatitis. Further history obtained from the owner indicated that Diego did not typically eat forbidden foods or play with or ingest toys. There had not been a recent dietary change. However, Diego’s GI tract had been sensitive in the past. Diego had been healthy since being adopted from a breeding facility 4 years earlier, at which time he was neutered. Physical examination revealed the following:

    • Temperature: 99.5°F (37.5°C) (normal: 101.5°F to 102.5°F)

    • Pulse: 140 bpm (normal [toy breed]: 110 to 140 bpm)

    • Respiratory rate: 44 breaths/min (normal: 10 to 20 breaths/min)

    • Mucous membranes: pink, muddy, and tacky (normal: pink and moist)

    • Capillary refill time: <2 seconds (normal)

    • Abdominal discomfort: 1 out of 4 (according to the Colorado State University Veterinary Medical Center canine pain scale)

    A soft tissue thickness was palpated just lateral to the prepuce on the left side; no body-wall defect was palpated. The overlying skin was mildly erythematous. Rectal examination revealed normally formed stool; however, perineal staining consistent with diarrhea was evident.

    The referring veterinarian’s radiographs revealed good serosal detail, a large amount of fecal material within the colon, and several extremely dilated intestinal loops inconsistent with the large bowel. Because obstruction of the small intestine was suspected, pneumocolonography was performed to determine whether the loops were large or small intestine (BOX 1). Pneumocolonography showed several dilated intestinal loops separate from the gas-dilated colon; therefore, abdominal ultrasonography was recommended.

    Box 1. Performing Pneumocolonography

    Supplies

    • 8-French red rubber catheter

    • Three-way stopcock

    • 60-mL syringe

    • Lubricant

    Procedure

    • Place the patient in right lateral or ventrodorsal position for radiography.

    • Lubricate and insert the red rubber catheter into the patient’s rectum.

    • Push air into the colon using the attached syringe, and use the three-way stopcock to help hold air in the colon. The amount of air depends on the size of the patient. Adding air to the colon dilates it, allowing differentiation between obstruction of the small or large intestine.

    • While keeping the syringe and catheter in place, obtain the radiograph immediately after injecting air.

    Abdominal ultrasonography was performed, and the results were consistent with obstruction of the small intestine: there were multiple loops of severely dilated small intestine (as on the referring veterinarian’s radiographs), and the stomach was severely dilated. Other portions of the small intestine appeared normal. The left inguinal mass appeared to contain an intestinal loop. There was no free peritoneal fluid. The other abdominal organs appeared normal. Abdominal ultrasonography confirmed (1) obstruction of the small intestine and (2) a left inguinal hernia due to herniation of the small intestine. Abdominal exploratory surgery was recommended.

    One dose of cefazolin (90 mg IV) was given perioperatively for gram-negative and gram-positive antibiotic coverage during surgery. Exploratory laparotomy revealed a distended, discolored jejunum bowel loop approximately 16 to 18 cm in length in the caudal abdomen. A jejunum bowel loop was found to be herniated through the inguinal ring, and the section of intestine trapped in the hernia was devitalized and ruptured. This section of small intestine (i.e., jejunum) was isolated and resected. The anastomosis site was closed using 3-0 polydioxanone suture, leak tested, and wrapped in omentum. The inguinal canal was closed using 2-0 polydioxanone suture internally and externally. The abdominal cavity was flushed with 2 L of warm, sterile 0.9% saline, and the abdominal wall was closed with 0 polydioxanone suture. The inguinal area was flushed with 500 mL of warm, sterile 0.9% saline and closed in four layers using 2-0 polydioxanone suture and skin staples (FIGURE 1) .

    Diego did well under anesthesia but experienced mild hypotension, which responded to hetastarch administration. The drug protocol for anesthesia included fentanyl for premedication, propofol for induction, and isoflurane for maintenance, along with oxygen. In addition, fentanyl was administered by constant-rate infusion (CRI) throughout the surgical procedure. At the beginning of surgery, the patient was placed on a mechanical ventilator because of apnea; toward the end of surgery, the patient was weaned from the ventilator onto standard ventilation by the anesthesia technician. Recovery from anesthesia was uneventful, and mild hypotension and hypothermia were controlled using hetastarch and external heat support.

    Postoperative Care and Monitoring

    After surgery, the following were administered:

    • Lactated Ringer solution with potassium chloride (20 mEq/L) at a rate of 6 mL/h

    • A fentanyl patch (12 μg) and 0.9% sodium chloride with fentanyl (3 μg/kg/h) at a rate of 10 mL/h to manage pain (because a fentanyl patch can take 8 to 12 hours to become effective in dogs, fentanyl supplementation by CRI for 12 to 24 hours after surgery is recommended)

    • Hetastarch at a rate of 1.7 mL/h to help maintain blood pressure

    • Ampicillin (90 mg IV tid) and enrofloxacin (41 mg IV sid) for broad-spectrum coverage of gram-positive, gram-negative, and anaerobic bacteria (based on microscopic cytology)

    • Famotidine (2 mg IV bid) as an H2-receptor blocker (to reduce gastric acid)

    • Maropitant citrate (4 mg SC sid) as an antiemetic

    The following were monitored postoperatively:

    • Temperature

    • Pulse rate

    • Respiration rate

    • Pain level

    • Electrolyte levels

    • Blood pressure

    • Signs of GI upset, especially vomiting

    Diego became febrile (103.6°F [39.8°C]) 5 hours after surgery, but his temperature returned to normal within 6 hours. Systolic blood pressure remained low at 60 to 62 mm Hg (normal: 110 to 190 mm Hg). A dopamine CRI was initiated at a rate of 5 μg/kg/min. Dopamine can be used as an α- or β-adrenergic drug depending on whether a low or high dosage is being administered. The expected effect of the drug is an increase in cardiac contractility and heart rate, with a mild increase in systemic vascular resistance. This is expected to help increase blood pressure. Lactated Ringer solution was increased to a rate of 8 mL/h, fentanyl was decreased to a rate of 8 mL/h (2 μg/kg/h), and hetastarch was increased to a rate of 4.2 mL/h (25 mL/kg/d). Systolic blood pressure increased to 72 mm Hg within 1 hour. The additional laboratory results were as follows:

    • Packed cell volume: 58% (normal: 35 to 50%)

    • Total protein level: 5.4 g/dL (normal: 5.0 to 7.4 g/dL)

    • Blood glucose level: 59 mg/dL (normal: 60 to 110 mg/dL)

    • Blood urea nitrogen level: 36 mg/dL (normal: 10 to 20 mg/dL)

    • Sodium level: 146 mmol/L (normal: 140 to 159 mmol/L)

    • Potassium level: 3.3 mmol/L (normal: 3.7 to 5.8 mmol/L)

    • Chloride level: 111 mmol/L (normal: 105 to 115 mmol/L)

    A 90-mL IV bolus of lactated Ringer solution was administered to support blood pressure, 5% dextrose was added to fluid therapy, and potassium supplementation was increased to 30 mEq/L. One hour later, a second 20.5-mL hetastarch bolus was administered, which brought the systolic blood pressure to 76 mm Hg. Dobutamine was added at a rate of 5 μg/kg/min CRI in conjunction with dopamine to improve blood pressure. Dobutamine is known for its β-adrenergic activity. The effect of this therapy is a significant increase in cardiac contractility with little change to heart rate and systemic vascular resistance. Thirty minutes later, the systolic pressure increased to 112 mm Hg. After initiation of dextrose supplementation, the blood glucose level remained low at 59 mg/dL. A 12-mL IV bolus of 5% dextrose was administered. Because oliguria was a concern despite volume expansion, an indwelling, 6-French, 55-cm Foley urinary catheter with a closed collection system was placed to monitor urine output.

    Through the night, Diego’s blood glucose level and blood pressure were monitored closely. Systolic blood pressure stabilized but was low (100 mm Hg). The blood glucose level fluctuated downward and then remained consistently low (i.e., 50 to 60 mg/dL). A central venous catheter was placed, and dextrose supplementation was increased to 7.5%. Thoracic radiographs were obtained to evaluate (1) the placement of the central venous catheter and (2) changes in the pulmonary parenchyma (i.e., abnormal enlargement of air spaces in the bronchioles). Vital signs normalized throughout the night. The blood urea nitrogen level had decreased to 22 mg/dL (normal: 10 to 20 mg/dL), suggesting that the previous increase was due to dehydration. No vomiting was noted through the night.

    Day 2

    Diego continued to have a depressed or quiet mentation but would respond to stimuli by lifting his head. His vital signs were normal throughout the day. Marked cutaneous bruising and erythema were noted around the incision and extending down the left proximal medial crus of the hind leg (between the femur and tarsus; the shank). The patient also had soft tissue swelling left of the medial crus of the hind leg, along with significant subcutaneous emphysema. The incision site was intact with no discharge. Diego had one vomiting episode late in the afternoon after abdominal palpation. Systolic blood pressure remained at 95 to 105 mm Hg throughout the day. Dobutamine and dopamine were continued, along with hetastarch. Mild hypokalemia persisted despite supplementation, while hypoglycemia resolved with administration of 7.5% dextrose. The WBC count remained elevated at 18.6 × 103/μL.

    During the night, dextrose supplementation was decreased to 5%; dopamine and dobutamine were decreased to 3 μg/kg/min each. The fentanyl CRI was discontinued, and a lidocaine CRI of 30 μg/kg/min was initiated to manage abdominal discomfort. Fluid therapy was changed to Normosol-R (Abbott Laboratories), according to the doctor’s preference, with 30 mEq/L of potassium chloride at a rate of 25 mL/h, and hetastarch was continued at a rate of 25 mL/kg/d. Diego’s mentation improved slightly after fentanyl was discontinued. The patient was responsive to verbal stimuli and would sit sternally for short periods. As the night progressed, dextrose supplementation was reduced to 2.5%. Regurgitation was observed, so ondansetron was started at a dose of 0.3 mg/kg IV for additional prevention of emesis. Ampicillin, enrofloxacin, famotidine, and maropitant citrate continued to be administered at the same dosages.

    Day 3

    Diego was transferred from the emergency department to the internal medicine department. On physical examination, Diego was subdued but showed appropriate responsiveness to stimuli. The abdominal incision was clean, dry, and intact but bruised along its entire length. Significant edema was present at the caudal aspect of the incision. Because of regurgitation, two-view thoracic radiographs were obtained and showed no evidence of megaesophagus or pneumonia. Systolic blood pressure was 86 mm Hg. Packed cell volume was 43%, with a total solid level of 3.4 g/dL. There was some concern about the possibility of underlying sepsis. See TABLE 1 for the blood work results.

    Day 4

    Diego was alert, responsive, ambulatory, and much more mentally bright than he had been the previous day. He was adequately hydrated, and his vital signs were within normal ranges. The abdominal incision was intact and clean; however, some serosanguineous material was oozing from the caudal aspect of the incision. There was also some edema at the caudal end of the incision. Significant bruising and hyperemia of the entire ventral abdomen, left inguinal region, and left hindlimb were also noted. Regurgitation had decreased overnight with only one episode noted in the previous 12 hours. Systolic blood pressure remained stable at >100 mm Hg. The blood glucose level was >90 mg/dL. The packed cell volume was 34%, and the total solid level was 4.0 g/dL. Diego started drinking small amounts of water but had no interest in food. The WBC count decreased to 42.0 μL (normal: 4.0 to 15.5 μL). Because excessive bruising was a concern, prothrombin time (PT) and partial thromboplastin time (PTT) were checked; both were within normal limits. PT is used to test the extrinsic and common coagulation pathways and is very sensitive to vitamin K deficiency or antagonism. PT is less sensitive than PTT to the effects of heparin. PTT is used to test the intrinsic and common coagulation pathways.

    A dermatologic consultation was requested because of significant bruising and hyperemia along the ventral abdomen and extending cranially to the xyphoid. No dermatologic conditions were found. The ventral hyperemia and bruising were considered to be most consistent with disseminated intravascular coagulation (DIC), which may have been present after surgery (BOX 2). Other differentials included vasculitis and adverse drug reaction. Because urine output was adequate, the urinary catheter was removed. All other medications and fluid additives were maintained except for ampicillin, which was discontinued because of potential for a drug reaction. Clindamycin was added at a dose of 54 mg IV bid to provide gram-positive and anaerobic bacterial coverage. Throughout the day, Diego maintained a systolic blood pressure of 172 mm Hg, which was on the high end of the normal range; therefore, dobutamine was decreased to a rate of 1.5 μg/kg/min. Throughout the day, the dose of dobutamine was gradually decreased and finally discontinued as the blood pressure stabilized.

    Box 2. Disseminated Intravascular Coagulation

    Disseminated intravascular coagulation (DIC) is intravascular activation of hemostasis resulting in microcirculatory thrombosis. Exaggerated consumption of platelets and coagulation factors results in defective hemostasis and a tendency to bleed. DIC is always caused by an underlying disease, which should be identified quickly. In patients with DIC, PT and, more often, PTT may be prolonged, but both may be normal if compensatory clotting factor production is adequate.

    Day 5

    Diego was alert, responsive, ambulatory, and adequately hydrated. His abdomen was nonpainful on palpation, and the abdominal incision was clean and dry. Some soft swelling was present at the proximal and distal ends of the abdominal incision. Bruising was significantly decreased compared with the previous day. Diego did well overnight, with no vomiting or regurgitation, but his appetite remained decreased. His systolic blood pressure remained stable at 166 mm Hg despite discontinuation of all blood pressure medications. The blood glucose level was maintained despite decreasing dextrose supplementation to 2.5%. The WBC count had decreased to 31.3 × 103/µL, and the platelet count was 41 × 103/µL with clumping. To estimate a platelet count when a slide has a moderate to large number of clumps, it helps to differentiate a true platelet count from an artifactually low count; this was done using a manual differential count on a blood smear. Platelet clumping is a common in vitro phenomenon that prevents accurate automated or manual platelet counting. The platelet estimate is the best indicator of whether the platelet count is adequate, which it was. The platelet estimate is a subjective estimation of platelet numbers when viewing a stained blood film. This estimate accounts for the size and numbers of platelets even when an accurate manual or automated count cannot be obtained because of platelet clumping. The estimate is obtained by counting the average number of platelets seen per 100× oil-immersion field in the monolayer of a well-spread smear. A manual platelet count is performed using (1) a hemocytometer and a microscope or (2) an automated analyzer. Manual counts are often less accurate than automated counts because platelets can be hard to distinguish from debris.

    Dextrose supplementation was discontinued, and the blood glucose level was closely monitored. The other existing fluids, additives, and medications remained unchanged, but mirtazapine was added at a dose of 1.88 mg PO daily to stimulate appetite.

    During the afternoon, Diego developed mild tachypnea. The results of thoracic auscultation were unremarkable; however, the presence of mild pulmonary edema on thoracic radiographs suggested overhydration. There was no evidence of pneumonia on the thoracic radiographs. Oxygen saturation remained normal at 99%. The rate of Normosol-R was decreased to 10 mL/h, and furosemide was administered at a dose of 5 mg IV. Within 2 hours, the patient’s respiratory rate decreased, and the patient seemed much more comfortable. The plan was to continue monitoring the blood glucose level, blood pressure, and vital signs overnight and to potentially discharge Diego the next day.

    Day 6

    Overnight, tachypnea returned, resulting in orthopnea (extension of the head and neck to facilitate breathing). The patient collapsed and went into respiratory arrest at 3:00 am despite having a pulse oximetry result of 99% 30 minutes earlier. An endotracheal tube was placed, and a large amount of foamy, blood-tinged fluid filled the tube. Furosemide (4 mg/kg IV), atropine (0.5 mL IV), and epinephrine (0.5 mL IV) were administered. The patient began breathing on his own soon after intubation, so he was extubated and placed in an oxygen cage.

    After the respiratory arrest, the systolic blood pressure was 86 mm Hg. Fluid therapy was decreased to a rate of 2 mL/h. The potassium level was 2.4 mEq/L, so potassium supplementation was increased to 0.3 mEq/kg/h. Dobutamine was initiated at a rate of 3 μg/kg/min, and a single dose (1/8-inch strip) of nitroglycerin was applied inside the pinna. (Nitroglycerin—a vasodilator—relaxes vascular smooth muscle, primarily on the venous side, and is often used to treat congestive heart failure.) Systolic blood pressure remained stable at >90 mm Hg. Diego remained somewhat tachypneic in the early morning hours.

    On the morning of day 6, echocardiography was performed by a board-certified cardiologist after a pulse oximetry result of 85% was obtained. The echocardiogram revealed (1) a large pulmonary thromboembolism in the pulmonary artery and (2) normal cardiac function. A repeat right lateral thoracic radiograph revealed a diffuse alveolar and interstitial pattern. Systolic blood pressure was 103 mm Hg. Diego was started on treatment for pulmonary thromboembolism, including heparin (1500 IU SC tid). (Heparin is used as an anticoagulant for treating DIC and thromboembolic disease.) Terbutaline was initiated at a dose of 0.625 mg PO bid for rapid bronchodilation. Sildenafil (10 mg PO tid) was used for vasodilation to treat pulmonary hypertension. Clopidogrel bisulfate (18.75 mg PO sid) was used to inhibit platelet aggregation to prevent thromboembolic disease. All other administered medications and treatments were continued. Through the course of the morning, the patient remained tachypneic but not dyspneic and was administered oxygen. The owners were given a guarded prognosis for recovery. Only 25% of patients with pulmonary thromboembolism are discharged from the hospital.1–3

    Conclusion

    After visiting with Diego for most of the day, the owners requested that he be euthanized because of their concern for his quality of life and guarded prognosis.

    Diego’s case was difficult from the beginning. It is suspected that the strangulated bowel caused bacterial translocation that led to sepsis. Although no blood cultures were analyzed, sepsis was highly suspected because of the patient’s laboratory results, clinical appearance, temperature fluctuations, low blood glucose level, and low systolic blood pressure. Sepsis compounded the patient’s other problems, eventually leading to DIC, which was evidenced by severe bruising along the whole ventral aspect of the abdomen and the hindlimbs. It is thought that Diego had DIC after surgery and subsequently developed pulmonary thromboembolism, as evidenced by the echocardiogram and clinical signs.

    Downloadable PDF

    1. Bateman SW. Hypercoagulable states. In: Silverstein DC, Hopper K, eds. Small Animal and Critical Care Medicine. St Louis: WB Saunders; 2009:505-506.

    2. Johnson LR. Thromboembolism. In: Silverstein DC, Hopper K, eds. Small Animal and Critical Care Medicine. St Louis: WB Saunders; 2009:86-95.

    3. Adamantos S. Pulmonary edema. In: Silverstein DC, Hopper K, eds. Small Animal and Critical Care Medicine. St Louis: WB Saunders; 2009:114-117.

    References »

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