The ICU patient: from reanimation to pain therapy – personal experiences

This thesis wants to be a contribution to the current knowledge in the Emergency and Critical Care medicine, by focusing on different aspects varying from the reanimation to the pain therapy of ICU patients. The thesis has been organized in different Sections, regarding the cardiovascular and respiratory systems, and haematology, respectively. The first Section, which focuses on the cardiovascular system, consists of two different clinical studies. The first describes the effect of a Limited Fluid Volume Resuscitation (LFVR) protocol in ten cats with non cardiogenic shock, unresponsive to the initial Conventional Resuscitation (CR) with isotonic crystalloids. Cats were fluid resuscitated with up to 8 mL/kg of hypertonic saline (HS: 7% NaCl) and up to 8 mL/kg of hydroxyethyl starch (HES). Each bolus was administered over 5-10 minutes and patients vital signs were reevaluated, for additional boluses, every 5-10 minutes until stabilization. Animals were considered stable once the vital parameters (heart and respiratory rates, temperature, sensorium and quality of the pulse) were within the physiological ranges. The stabilization of the vital parameters occurred in 33±12.7 minutes (15-60 minutes) in all cats. Of the ten cats, six currently enjoy good health (6-25 month follow up). The aim of the second study was to assess epidemiology and echocardiographic findings of pericardial effusion (PE) in canine patients and to determine the clinical usefulness and safety of a new pericardiocentesis technique, using a “fistula needle” for haemodialysis. On a database of 5304 dogs, PE was identified in 91 dogs (1.71%). The most common causes of PE were neoplasm in 33 cases (36.26%) and a severe degenerative mitral and tricuspid degenerative valve disease in 32 cases (35.16%). Echo-guided pericardiocentesis, using a “fistula needle” for haemodialysis, was performed in 28 cases (30.77%) with cardiac tamponade. No adverse effects were found in any of the patients during the following 48 hours of follow up. The second Section, regarding the respiratory system, consists of two different case reports. The first one was about a case of severe shock and haemothorax, due to anticoagulant rodenticides poisoning, treated with autotransfusion. The second report was about a case of acute hypoxaemic respiratory failure with haemoptysis in a dog exposed to copper sulphate powder. The third Section describes one case report of a dog with aplastic pancytopenia associated with multiple CVBDs, successfully treated with cyclosporine and aetiological treatments, and a case series of four dogs with Canine Adenovirus (CAV-1) infection, alone or together with Canine Parvovirus (CPV) The last Section was destined to the topic of pain assessment and analgesia. The first chapter of the Section describes the findings of a survey on Italian veterinarians knowledge and attitude towards pain assessment and analgesia, with the aim of assessing if any regional variation exists between the South and the North of Italy and if analgesia is an adequately considered topic in the South of Italy. The results of the survey and of the statistical analysis, showed no significant differences between the South and North groups, except for the greater use of meloxicam, methylprednisolone and local anaesthetics in the South group, whereas buprenorphine, butorphanol and ketamine were more used in the North group. The last chapter describes two clinical studies carried out on dogs undergoing hemilaminectomy for acute thoracolumbar intervertebral disc extrusion and on dogs with Degenerative Lumbosacral Stenosis (DLSS), respectively. In both study, the Short Form of the Glasgow Composite Pain Scale (GCPS-SF) was applied to evaluate pain score. Based on the results of the first study, which compared the analgesic activity of buprenorphine and tramadol, both drugs showed a good analgesic activity. However, buprenorphine showed a faster and greater analgesic effect, compared to tramadol. None of the two molecules showed any side effect. In the second study, the analgesic conservative treatment of DLSS was started with tramadol. However, after the first week of treatment, the dogs of Group A were considered to be non-responder to tramadol. For this reason, the analgesic treatment was switched to gabapentin. After that, no statistical differences have been found between the two groups. Already after the 2nd week of treatment, GCPS scores were considerably lower in both groups, suggesting that both tramadol and gabapentin could be effective in reducing lumbosacral pain in dogs with DLSS. Moreover, the improvement of muscle tone in the group treated with gabapentin after 4 weeks of follow-up could be due to the resumption of a moderate physical activity determined by a better pain control than in dogs treated with tramadol. Veterinary patients may be admitted to an Intensive Care Unit (ICU) because of different pathological conditions, that may represent a life-threatening hazard for the patient if not promptly and properly managed, as described in the cases reported in this thesis. For these reasons, the ICU doctor should have knowledge on different medical fields and should be able to take prompt decisions on the diagnostic tests and treatments to perform. “Time is money” but, in a critical patient, can also make the difference between life and death.