Using the Information Provided by Your In-Clinic Analyzers

Transcription

1 A PUBLICATION OF HESKA S PARTNERADVANTAGE PROGRAM Fall 2010 Decision Making in Critical Care: Using the Information Provided by Your In-Clinic Analyzers Tim B. Hackett, DVM, MS, DACVECC, Colorado State University, Fort Collins, CO Emergency/Critical Care medicine has grown in no small part by the availability of reliable and rapid diagnostics.the availability of accurate, easily calibrated, and easily maintained in-clinic blood analyzers has given practitioners access to timely clinical information. We now wait only hours or even minutes for results. Clinicians are able to move quickly through their diagnostic algorithms to optimize and individualize patient care. However, with new technologies there are also new considerations. Technology for its own sake will only add to a client s bill if that information is not integrated into the care their pet receives. Diagnostic testing should be thoughtfully considered based on patient assessment, the need for baseline knowledge and with the intent that results may change the course of treatment. Nothing can replace a complete physical examination and detailed medical history. Triage skills still rely heavily on our senses to determine a patient s medical status. Patients should be prioritized and treatments rendered based on the lifethreatening nature of their clinical presentation. The dyspneic cyanotic dog should not have to wait on the results of an arterial blood gas before being placed on oxygen and the azotemic, anemic cat should not wait on a creatinine or blood lactate before venous access is secured and fluid therapy begun. Fortunately, most of us work with teams trained for multi-tasking so blood tests are run while we are making our initial assessment. Should we run baseline blood work? The answer is probably yes. The question should also be: What are you going to do with that information? The answer should be: Evaluate it in the context of our physical examination to formulate and adjust our treatment plan for this patient. Blood Gas Analysis One of the most common in-clinic emergency blood tests is the blood gas. In-clinic blood gas analyzers tell us about acidbase and electrolyte balance along with information about the patient s ventilation and oxygenation (provided we re using arterial samples). Two common challenges we are faced with when running blood gases are: continued on page 3 In This Issue FEATURE ARTICLE: Decision Making in Critical Care 1 PartnerAdvantage Profile: The Real Benefits of a Good Partnership 6 CSI Case Challenge: What s Up in the ER? 8 Special Offers 9 5 Things to Make You Smarter About Emergency Medicine 11 Inspiration in Action 12

2 Inspired by Speed. Designed for You. NEW! SEE THE NEW VITALPATH ANALYZER IN ACTION With the newest addition to Heska s Lab Systems, get vital results in just 50 seconds for 35 parameters. The VitalPath Blood Gas & Electrolyte Analyzer also greatly simplifies operations with a color LCD touch screen and flexible sampling options. Learn more about what inspired the new VitalPath analyzer. Call your Heska representative for a demo or visit inspired.heska.com. Not a member yet? Visit partner.heska.com follow Heska

3 FEATURE ARTICLE continued from page 1 1) Failing to get arterial samples in hypoxemic patients. 2) Failing to address abnormal findings (e.g., ignoring a rising PCO 2, keeping a patient on an alkalinizing fluid despite a high ph, not addressing increasingly abnormal electrolyte values). Acid/Base Measurement Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis ph pco 2 HCO 3 - DIFFERENTIAL Normal or decreasing* Normal or increasing* Normal or increasing* Normal or decreasing* Diabetes, Addison s, Renal failure, increased acid production Vomiting from upper GI obstruction, administration of alkaline solutions Obstruction, Pneumonia, Mediastinal Disease Anemia, CHF, Exuberant mechanical ventilation Blood ph, PCO 2, HCO 3 and serum base excess (SBE) are evaluated to assess a patient s acid-base status. The ph of the blood is normally maintained between 7.35 and 7.45 for normal enzymatic functions. Blood ph below 7.35 is referred to as acidemia, while a ph above 7.45 is alkalemia. If an acid-base disturbance is present, the PCO 2, HCO 3 and base excess are evaluated to determine if the problem is primarily respiratory, metabolic or mixed. PCO 2 values below normal are caused by hyperventilation causing a respiratory alkalosis. Retaining CO 2 by hypoventilation causes a respiratory acidosis. Again, an acidosis or alkalosis simply indicates an abnormality exists while the body s many buffering systems may continue to maintain a normal ph. Metabolic acidosis results from a loss of normal buffers. This is seen in the blood gases as a low HCO 3 and negative base excess. Metabolic acidosis is one of the most common findings in the critically ill and implies poor tissue perfusion. Elevated HCO 3 and a positive base excess signal a metabolic alkalosis. Acid-base disorders can be defined as primarily respiratory, metabolic or a mixed disorder. They can then be further categorized as uncompensated, partially compensated or fully compensated. In an uncompensated metabolic acidosis, the ph is low (acidemia), the HCO 3 and base excess are low and there is indication of increased ventilation to blow off excess CO 2. With compensation, the PCO 2 drops as the respiratory system hyperventilates to compensate. With metabolic alkalosis, the HCO 3 and base excess rise. Respiratory compensation will result in an increased CO 2 as more volatile acid is retained through hypoventilation. Respiratory compensation of metabolic acid-base problems occurs very quickly while it may take days for the kidneys to adjust HCO 3 levels in response to a primary respiratory disturbance. Gas Exchange The partial pressure of oxygen while the patient is breathing room air (FIO 2 = 21%) is the most important blood gas variable to assess in patients with respiratory disease. PO 2 levels below normal indicate hypoxemia. Serial arterial blood gas analysis is a great way to monitor changes in pulmonary pathology, changes that may not be obvious on radiographs. Gas exchange is quantitated using the Alveolar-arterial (A-a) gradient which is provided by some blood gas analyzers or can be calculated. Serial measurements of the A-a gradient will give a more objective assessment of change (either better or worse) in pulmonary function. Lactate, Electrolytes and Glucose Blood lactate is an indicator of tissue perfusion. Prior to blood lactate, clinicians had to rely on measures like serum creatinine to indicate inadequate tissue oxygenation. Lactate measurements are superior to measurement of cardiac output with regards to predicting outcome in critically ill humans, and elevated lactate concentrations are linked to increased mortality rates. Measurement of lactate concentration is a minimally invasive technique that can be easily accomplished continued on next page 3

4 FEATURE ARTICLE continued from page 3 using venous blood specimens and inexpensive patient side monitors. Hyperlactatemia indicates poor tissue perfusion and should be quickly followed by an assessment of cardiopulmonary function and fluid balance. Serial lactate readings in the context of the patient s response to therapy are more valuable than a single measurement. Limitations: Lactate should be interpreted along with other clinical findings. A normal lactate in a hypotensive shock patient may not mean normal perfusion. There is a delay between the onset of anaerobic metabolism and elevated blood lactate. Only when the body s lactate clearance is overwhelmed will the measured lactate begin to rise. Conversely an elevated lactate does not always indicate impaired perfusion. An example is a hyperlactatemia that occurs with intracranial neurologic disease. We have seen meningioma patients anesthetized for MRI with normal perfusion parameters and a consistently elevated blood lactate despite aggressive fluid resuscitation. Summary In conclusion, it is important to look at all of your laboratory results and try to explain them. Sodium, potassium, calcium, bicarbonate and glucose are often ignored in patients for whom blood gas tests are being performed. We can all recognize the hyperkalemia and hyponatremia seen with classic Addison s disease. In that context, the electrolyte evaluation is diagnostic. The in-clinic analyzer s value isn t in making an etiologic diagnosis but instead, providing accurate and current information to make adjustments in treatment. This enables us to finely tune the type and composition of fluids used in the hospitalized patient. We need to look at abnormalities in the context of fluid balance and appropriate replacement therapy. Fluid choices can be refined if the clinician knows the patient s Na +, Cl -, and K + status. Days of crystalloid fluid replacement often result in hypernatremia and hypokalemia. By looking at these trends, patients can be switched to lower sodium, potassium-supplemented fluids for ongoing maintenance. There are many hematologic, biochemical and electrolyte disturbances that can be identified using in-clinic analyzers. A complete review is beyond the scope of this article although the importance of following up on abnormal results cannot be overstated. For more on decision making in critical care, see 5 Things to Make You Smarter on page 11. 4

5 Inspired. HemaTrue Hematology Analyzer DRI-CHEM 4000 Chemistry Analyzer DRI-CHEM 7000 Chemistry Analyzer VitalPath Blood Gas & Electrolyte Analyzer To meet the needs of your busy practice, Heska has put inspiration into action. Heska s lab systems offer more than just accuracy and reliability. Whether it s blood gas and electrolytes plus a full CBC in under 1 minute, or sample volumes as small as 20 microliters for sick patients, Heska has brought inspired ideas to life for your in-clinic lab. NOW THROUGH 12/31/10: Take Advantage of the Section 179 Tax Incentive GO HESKA I inspired.heska.com follow Heska

6 The Real Benefits of a Good Partnership Wauconda Animal Hospital Wauconda, Illinois M Staff: 2 doctors, 1 practice manager, 4 technicians, 3 receptionists M Enrolled: April 12, 2010 M Current Products: Solo Step CH Heartworm Tests HemaTrue Hematology Analyzer DRI-CHEM 4000 Chemistry Analyzer Vet/IV Infusion Pump UltraNasal FVRCP Vaccine M Special Offers: Spring and fall promotions on Solo Step Heartworm Tests = $5000 in PartnerAdvantage Points (PA Points) Triple Points offer on hematology and chemistry analyzers Chemistry trade-in incentives M Redemptions: purchased with PA Points Vet/IV Infusion Pump HemaTrue Hematology Analyzer PARTNER Profiles M Total Points Earned Since Enrollment: 11,570 Take a look at your keychain, in your wallet, or in your inbox. There s probably at least one sign of a rewards program. In fact, the average household belongs to at least four rewards or loyalty programs. Often when we think of a rewards program, we think of the free $4 latte at a coffee shop. Rarely, if ever, does a program offer rewards that total in the thousands of dollars. For one clinic, the PartnerAdvantage Program has provided over 10,000 reasons why being a part of this rewards program pays. With a progressive team of highly talented professionals, Dr. Carolyn Nemmers spends her day doing what many clinic owners do multitasking. Everyone in the industry will agree that veterinarians and their staff are not compensated nearly enough for the intensive work they do, so when a rewards program comes around that can offer a clinic well over $10,000 in returns in less than one year, Dr. Nemmers and her staff took notice. Practice manager, Shannon Witt, enrolled in Heska s program during a heartworm test booking period where clinics purchasing Solo Step Heartworm Tests could earn $1000 worth of PartnerAdvantage points (PA Points) for every 14-box order. Now, with a total balance of over $2000 in points to use for any product or service Heska offers, Shannon knew just what to do. With plenty of points left over for future purchases, she redeemed some points for Heska s popular Vet/IV Infusion Pump....You don t have to be a big city practice generating lots of revenue to reap the benefits of the PartnerAdvantage Program. Shannon Witt, Practice Manager As their PA points balance continued growing with every purchase, Dr. Nemmers and her staff knew the time had come to reevaluate their need for analyzers. Until recently, the clinic was sending to a local lab for all hematology and chemistry tests. Dr. Nemmers took advantage of Heska s Triple Points special offer (any points balances worth 3x their value if redeemed toward HESKA hematology and chemistry analyzers). In addition to cost savings for running in-house blood analysis and time savings for staff and clients, this meant that a balance of 2900 points was worth $8, toward a HemaTrue Veterinary Hematology Analyzer! To take care of their chemistry needs, Dr. Nemmers traded in an old VetTest analyzer. This trade-in provided an additional $ off of a DRI-CHEM 4000 Veterinary Chemistry Analyzer. Today, Wauconda Animal Hospital can use their PA Points to generate pure profit by redeeming points for products like ALLERCEPT Testing and Immunotherapy, or Pre-surgical panels. Wauconda s staff have taken advantage of an important opportunity to meet their clinic s needs and maximize returns through the PartnerAdvantage program. Shannon says it best. We just focus on good medicine, client education, great pet care and smart business. You don t have to be a big city practice generating lots of revenue to reap the benefits of Heska s PartnerAdvantage Program. 6

7 Welcome to Working Smarter, Together... Heska. Participation is easy: 1. Register at partner.heska.com and monitor rewards account online. 2. Earn PartnerAdvantage Points for purchasing qualifying HESKA products. 3. Redeem Points to purchase any product or service Heska offers. Call GO HESKA or visit partner.heska.com to get started. 7

8 TM CSI: CASE CHALLENGE In partnership with Clinician s Brief and Educational Concepts, CSI Case Challenges are now featured at two online advanced learning centers Essential Learning in Clinical Pathology and Essential Learning in Allergy Diagnosis & Treatment. Every issue of the PracticePartner newsletter will include a current CSI Case Challenge that can also be taken at one of these online learning centers for free C.E. EARN FREE C.E. IN 3 SIMPLE STEPS: 1. Read these overviews and the associated case challenge questions. 2. Visit or to answer the Case Challenge Questions. 3. Earn RACE Credit for every 6 questions answered. What s up in the ER? CASE OVERVIEW: ESSENTIAL LEARNING IN CLINICAL PATHOLOGY A 3-year-old spayed female terrier mix named Chewie is presented to your ER with a history of inappetence and vomiting for the past 2 weeks. The owners aren t aware of any toxin ingestion or dietary indiscretion. They report that she is depressed. On initial exam she is found to be ambulatory and responsive but subdued in her reactions. Her temperature is Tacky mucous membranes and sluggish skin turgor indicate dehydration and she is tachycardic with a heart rate of 160 beats per minute. Her femoral pulses are slightly weak and the mucous membranes have a gray appearance with a capillary refill time of 3 seconds. Respiration is slow at 15 breaths per minute. She tenses and shows splinting with abdominal palpation. Chewie is hospitalized and per doctor s orders, blood is drawn for a CBC, chemistry panel and venous blood gas. A shock drip of LRS is started. Blood results reveal she has abnormal venous blood gas values: Most notably, she has a severe hypochloremic, metabolic alkalosis with a ph of 7.6 and a chloride of 90 meq/l ( ), She also has a high HCO 3 = 56 mmol/l (25-35), and a high PCO 2 = 65.5 mmhg (35-46) indicating hypoventilation that can cause hypoxia. Since Chewie s ph is elevated, we know the primary problem is the metabolic alkalosis. CASE CHALLENGE QUESTION What are some treatment considerations and appropriate actions for this patient now that you have the lab results? A. Wait for x-rays before modifying the treatment plan or administering any further treatment. B. Put Chewie in an oxygen cage and take care of your other patients. C. Change the LRS drip to a nonbuffered fluid such as 0.9% Sodium Chloride. D. Take the dog to surgery ASAP. Correct answer on page 11. 8

9 Heska Special Offers Purchase Heska s 1-step heartworm tests and receive your choice of the following with qualifying purchases:» 1,000 PartnerAdvantage Program Points (1 point = $1.00)» FREE Vet/IV 2.2 Infusion Pump ($1, value) with qualified purchases of Solo Step Heartworm Tests. While quantities last. Take Advantage of Section 179 Tax Incentive Lease or pay cash by 12/31/10 and you can deduct the full purchase price of your new HESKA analyzers!* Buy 6 boxes E.R.D.-HealthScreen Urine Tests for the Price of 4! Save $196. Get the most sensitive in-clinic measurement for detecting kidney damage and early disease. Please specify canine, feline or combination of your choice. Offer expires 10/31/10. *Consult with your tax advisor for more information on this opportunity. Call GO HESKA ( ), option 1 To take advantage of these promotions, mention promo code PPHB1010SO. 9

10 FOR ALL OF THE RIGHT REASONS... 1 The ONLY 1-step heartworm tests available 2 FREE confirmatory testing on all positive canine results 3 Up to 24 months shelf-life 4 Delayed billing until March 2011 Now is the best time to choose Solo Step Qualifying purchases of Solo Step tests earn you 1000 PartnerAdvantage Points that can be redeemed toward any HESKA product or service (1 point = $1.00).* *As an alternative to points, you may also choose a Vet/IV Infusion Pump. follow Heska

11 Five Things to Make You Smarter About Emergency Medicine Focus on the Big Picture AND the Details: When presented with an urgently ill patient, nothing can replace a complete physical examination and detailed medical history. This is a time when paying attention to the small stuff can really pay off. Veterinarians have multiple mechanisms for gathering information about their patients and no single piece of information holds all of the clues. The best path to initial treatment and accurate diagnosis always starts with good listening and thorough patient assessment. Focusing on one piece of the puzzle can work in some situations but it often leads to missed information and missed opportunities. Baseline and Beyond: Wellness testing is a generally accepted standard of practice these days. Regardless of your protocol, establishing at least a one time hematologic and chemistry snap shot of your healthy patient is a good thing and should be encouraged. In the ER, different considerations come into play. Diagnostic testing should be thoughtfully considered based on patient assessment and history, the need for baseline knowledge, and with the intent that results may change the course of treatment. Choose Your Tests Wisely: With the expanding menu of tests that has become available to veterinary practitioners, it is important to think before testing. Ordering a multitude of procedures and tests to aid in your diagnostic and treatment efforts is necessary in some cases and may be prudent given the established standard of care. However, there are times when careful attention to history, physical examination and results of the minimum data base can be enough to put the clinical puzzle together. The next time you are ready to add on a test, assuming that it is affordable for the client, ask yourself if the results might alter the prognosis or the course of therapy. If the answer is yes, go for it. Put it All Together: Look at all of your test results and try to explain them in relation to the patient presentation and physical examination. If all blood and urine values and other results such as radiology, ECG, etc. are compatible with what the patient s condition is telling you, then move forward with treatment and additional testing, if necessary. If a particular finding doesn t quite fit the picture, step back, listen to your intuition and explore a little further. This reassessment may result in repeating a test, or using other tools to confirm your suspicions. Measure Treatment Success: Veterinary practices, including emergency facilities, always have to be conscious of the client s financial resources. No one wants to run unnecessary tests, but dollars are well spent on serial measurement of abnormal parameters. Important decisions such as changing the electrolyte composition of maintenance IV fluids can only be made when the patient s values are known and sequentially measured. In the long run, customizing your patient s care based on sequential testing will hopefully result in more timely decision making, better response to treatment and shorter hospital stays. CSI Case Challenge Answer: C. The decision to change the fluids to 0.9% Sodium Chloride is a good one. Because metabolic acidosis is much more common than alkalosis with dehydrated patients, the choice of alkalinizing fluids would normally be preferred but in this patient that is not the case. For more information on this case challenge and why C is the correct answer, visit 11

12 INSPIR ATION IN ACTION Winning Ideas Up to $25,000 Voting begins December 1, 2010 Heska asked the veterinary community... How would you use $25,000 to support your profession and inspire the veterinary industry? The competition has begun and the winning ideas will get the chance to bring their inspired ideas to life. Learn more at and follow the progress of the contest on Facebook. follow Heska 2010 Heska Corporation. All Rights Reserved. Clinician s Brief is a registered trademark of Educational Concepts, LLC. DRI-CHEM is a registered trademark of FUJIFILM Corporation. Facebook is a registered trademark of Facebook, Inc. Twitter is a trademark of Twitter, Inc. HESKA, ALLERCEPT, E.R.D.- HealthScreen, Feline UltraNasal, HemaTrue, and Solo Step are registered trademarks and CBC-Diff, PracticePartner, PartnerAdvantage, Smarter, Together, Vet/IV and VitalPath are trademarks and CSI: Clinic Scene Investigation and/or logo are trademarks of Heska Corporation in the U.S. and other countries. Order# Q310