2002 RECIPE BOOK: DOING THINGS THE “PETERSON & SMITH” WAY Compiled by: Courtney Bolam Tricia Salazar Sarah Begley P&S Hospital Interns 2001-2002 BASIC RECIPES ADULT HORSES GENERAL Physical exam CBC, Chemistry, +/- VBG (serial CBC’s on all colics/“sickies” every other day) Any sick, pregnant broodmare should get some progesterone supplementation Regumate 10-20 cc (22-44 mg) PO SID Hydroxyprogesterone 500-1250 mg (2-5cc) IM q1 week GI Generic (Medical) Colic NG intubation – Mineral Oil 1 gallon PRN Rectal IV Catheter Placement Consider abdominocentesis (cytology [full slide] +/- culture) Consider abdominal radiographs (sand, enteroliths, mini, weanling/yearling) Fecal float (parasites, stall-side [in sleeve] for sand) Muzzle +/- pull water bucket (based on presenting signs and presence of reflux) Analgesia (sedation +/- flunixin meglumine) Consider fluids (10 L boluses with 160 mEg KCl per “jug” and 500cc Cal MP every other “jug”, maintenance for a 450 kg horse is TID) “Water Off” any horse that has been NPO (offer water q1h until refuses, then bucket) Aggressive feeding, once passing manure (1 flake q4-6hrs with oil after 2-3 flakes) LC simple problems (resolved impactions/gas, displacements) feed ASAP Any volvulus/resection/compromised bowel, more cautious re-introduction SI involvement usually completely NPO, therefore water off, then slow reintroduction to feed Monitor cecal impactions/dysfunctions carefully for recurrence of the problem – Post-op Colics New “post-op” catheter placed K Pen 22,000 IU/kg IV QID for 5 days minimum (1 dose pre-op) Gentamicin 6.6 mg/kg IV SID +/- for 5 days at DVM discretion (1 dose pre-op) Metronidazole 15 mg/kg PO BID-TID (resections) Polymixin B 2,500,000-3,000,000 IU qs to 60cc for 450 kg horse (600 IU/kg) IV BID to TID (SI lesions, leukopenia, concerns of endotoxemia) often for 24-48 hrs Flunixin meglumine 0.55 mg/kg IV TID for minimum of 3 days (1.1 mg/kg dose pre-op) Heparin 15-20,000 units/450 kg SQ TID for minimum of 3 days (monitor mm colour/PCV) Abdominal Lavage *usually if resection* Fluids/plasma as indicated DMSO 90% 250-500cc in 5-10L IV BID (0.5-1 g/kg) for inflamed/compromised bowel *maximum of 10% solution* Consider laminitis prophylaxis Consider gastric ulcer prophylaxis Consider CRI for analgesia Butorphanol – 12 ug/kg loading dose once IV then 12 ug/kg/hr IV in saline *concerns re: decreased fecal output* Lidocaine – see AE for dose Remove suture 12-14 days post-op Stall confinement with hand walking for 2 weeks, 2 weeks turnout in round pen then free choice turnout for 1 month prior to resuming training/work Usually no grain fed while in hospital – gradual reintroduction over next 7-14 days Sand Fluids (overhydration) Mineral Oil 1 gallon PNGT BID +/- Psyllium 16 oz PNGT SID for sand Analgesia Consider surgery (PF enterotomy) Neostigmine 8-10 mg SQ q2h for up to 4 doses post enterotomy Consider feeding alfalfa post-op (leafy hay) Nephrosplenic Entrapments U/S in left paralumbar fossa to image kidney and spleen 2 vials (20 mg total) of phenylephrine in 1L fluids 15-20 min pre-op Attempt to roll in recovery stall (start with L side up) **need confirmatory U/S picture** Surgery if rolling is unsuccessful 2 tubes (7200 mg total) Strongid (pyrantel pamoate) followed by 5 days of double dose (5700 mg/day) Panacur “Power Pac” (fenbedazole) Consider prokinetics (neostigmine, erythromycin lactobionate) – risk of rupture?? Also consider in ileal impactions Impactions Oil (up to 2 gallons at a time, SID-BID) Fluids (overhydration) Flunixin meglumine (0.55 mg/kg IV TID but can have up to 1.1 mg/kg QID per DVM **skip scheduled doses**) Serial rectals to assess resolution Surgery (last resort) – PF enterotomy Small colon typically low WBC enema (enema bell or stomach tube, water +/- mineral oil) consider systemic antibiotics AE (Anterior Enteritis) NPO Must differentiate from surgical SI lesions – abdominocentesis can be helpful (WBC normal to high/high TP with AE, generally serosanguinous if surgical) K Pen 44,000 IU/kg IV QID Gentamicin 6.6 mg/kg IV SID Metronidazole 30 mg/kg per rectum TID Flunixin meglumine 0.55 mg/kg IV TID Polymixin B 3,000,000 IU for 450 kg horse IV BID to TID (often for 24-48 hrs) Ranitidine 1 – 1.5 mg/kg IV TID Erythromycin lactobionate 50 mg IV QID Reflux q4-6h Alamag 2 bottles PNGT post reflux OR K Pen 20 million IU PNGT post-reflux Fluids (consider ongoing losses) Lidocaine – loading dose 1.3 mg/kg IV bolus over 10 min (30cc 2% lidocaine for 450kg) then 0.05 mg/kg/min CRI (600 mls 2% lidocaine in 3L saline run at 450 ml/hr for 450kg [~0.04mg/kg/min]) Consider laminitis prophylaxis Consider surgical decompression and intraluminal instillation of 40 million units of K Pen if poor response after 24 hrs of aggressive treatment Colitis Fecal samples for Salmonella PCR, C. difficile toxin test, BID Salmonella cultures x5 Allow/encourage eating Consider using less thrombogenic catheters (MILA – polyurethane) K Pen 44,000 IU/kg IV QID Gentamicin 6.6 mg/kg IV SID Metronidazole 15 mg/kg PO TID Flunixin meglumine 0.55 mg/kg IV TID Polymixin B 3,000,000 IU for 450 kg horse IV BID to TID (often for 24-48 hrs or until WBC improving) Ranitidine 6.6 mg/kg PO TID or 1 – 1.5 mg/kg IV TID Probios 30g tube PO SID - BID Charcoal 16 oz in water PNGT BID until feces “sit” on the straw Loperamide 0.1-0.2 mg/kg PO QID once WBC WNL and horse not toxic *if diarrhea still present* Fluids (consider ongoing losses) Hetastarch 10 ml/kg IV once followed by crystalloids Plasma as indicated Bicarb replacement (IV or PO [baking soda <12.5-50 g BID–QID>] as dictated by serial VBG) Biolyte (electrolytes) PRN in 2nd bucket Consider laminitis prophylaxis Right Dorsal Colitis Treat as a regular colitis EXCEPT: No NSAIDs Add sucralfate 20-40 mg/kg PO TID-QID Minimize/eliminate roughage – feed a complete pelleted ration (Purina Equine Sr.) *low residue diet* Plasma IV PRN Gastric Ulcers Poor correlation between severity of clinical signs and severity of the lesion(s) Gastroscopy for definitive diagnosis (muzzle at midnight, pull water at 5A) Bethanecol SQ/IV (0.02-0.05 mg/kg) to promote gastric emptying to improve visualization *xylazine if excitement, split total dose half and half SQ and IV* Ranitidine 6.6 mg/kg PO TID or 1-1.5 mg/kg IV TID Gastrogard minimum of 250# dose PO SID for 28 days Cytotec (misoprostol) 3-5 ug/kg PO BID - QID Sucralfate (mainly in foals) 20-40 mg/kg PO TID-QID Alamag (foals with esophageal ulceration) 60 cc PO TID (stagger with other PO meds) Consider Doxycycline 10 mg/kg PO BID Consider Metronidazole 15 mg/kg PO TID RESPIRATORY Pleuropneumonia Chest radiographs Serial Thoracic U/S (don’t forget the cranial thorax!!) CBC, Chemistry, VBG TTW for cytology and culture/sensitivity Thoracocentesis (samples for cytology, culture/sensitivity) K Pen 44,000 IU/kg IV QID Gentamicin 6.6 mg/kg IV SID Metronidazole 15 mg/kg PO TID Enrofloxacin 2.5-3 mg/kg PO BID or 5-7 mg/kg IV SID Difloxacin 25 mg/kg once PO (loading dose) then 3 mg/kg PO SID Rifampin 5-10 mg/kg (adults) PO BID Chloramphenicol 50 mg/kg PO TID Doxycycline 10 mg/kg PO BID Flunixin meglumine 0.55 mg/kg IV TID Phenylbutazone 1-2 grams PO SID (2.2-4.4 mg/kg IV or PO SID-BID) Heparin 20,000 units/450 kg horse SQ TID Aspirin 12 cc syringe capful PO SID (10-20 mg/kg) Thoracic lavage with warm Norm R or saline, then instill with antibiotic spiked fluids (10 million IU K Pen or 10 cc Enrofloxacin, plus 10 cc Gentamicin in 1L) and cork for 2-4 hrs Probios 30g tube PO SID- BID Gastric ulcer prophylaxis Allow/encourage eating and consider appetite stimulants (Quik Start ¼ tube PO QID) Arytenoid chondritis Treat respiratory distress/difficulty ASAP – minimize stress Temporary tracheostomy Endoscopy for definitive diagnosis and monitoring resolution NSAIDs to reduce inflammation (2 gram Phenylbutazone PO SID then slowly taper off) Systemic antibiotics (K Pen/Gentamicin/TMS) – until scope WNL with horse off phenylbutazone CNS CBC, SMAC (liver enzymes) Serum for EHV-1, West Nile, EEE/WEE Consider spinal tap for EPM testing + CSF cytology Consider cervical/cranial rads to rule out wobbler and trauma Flunixin meglumine 1.1 mg/kg IV SID-BID Dex SP 0.05-0.1 mg/kg IV SID-TID (more rapid onset of action) then slowly taper dose Dex 0.05-0.1 mg/kg IV SID-TID then slowly taper dose Solu-delta-cortef 500-1000mg IV SID-BID Solu-medrol **Human dose 30 mg/kg IV then 5.4 mg/kg q1h for 23 hr** DMSO 90% 250-500 mls in 5L IV BID (0.5-1 g/kg) Mannitol 20% 500-1000 mls IV BID- TID (0.25-1g IV BID-TID) Lasix 1 mg/kg IV BID - TID Consider EPM treatment (Baycox [toltrazuril], pyrimethamines/sulfas, Marquis [ponazuril]) Nursing care (rolling, decubiti management <Alamag, A & D>, gastric ulcer prophylaxis) Diazepam 25-100mg IV PRN (for seizures, not with hepatoencephalopathy – try xylazine, etc.) Phenobarbitol 5-10 mg/kg IV (for uncontrolled seizures) or 10 mg/kg PO SID-BID (for maintenance) *monitor the degree of sedation, serum levels and fine tune dose, remember to taper dose before discontinuing* MUSCULOSKELETAL Tying Up (Myositis) Monitor SGOT/AST and CPK Dantrolene 10 mg/kg PO once (loading dose) then 2 mg/kg PO SID Methocarbamol (Robaxin) 10-20 mg/kg (5 – 10 grams for 450 kg horse) IV TID (DES) Fluids +/- DMSO (for inflammation and diuresis) NSAIDs for analgesia Lasix 0.5-1 mg/kg IV BID HYPP Prevention Acetozolamide 2-4 mg/kg PO BID NaCl as fluids with no supplemental KCl **No K Pen** use Ampicillin 10-15 mg/kg IV BID-TID instead No alfalfa Acute Attacks 5% Dextrose 6 ml/kg IV (in 0.9% NaCl) or to effect NaHCO3 1-2 mEq/kg IV 23% Calcium gluconate 0.2-0.4 ml/kg slow IV (dilute in fluids if possible) reduce stimulation/stress monitor respiration (for laryngeal paresis) Laminitis Phenylbutazone 4 grams IV once initially, then 2 gram PO SID Ice feet QID DMSO 90% 250-500 mls in 5-10L IV BID ACS pads Lateral P3 radiographs (repeat at 7 days) Clay stall (or other appropriate bedding – peat moss) Pentoxyfilline 8 mg/kg PO BID (longterm - deformity of rbc, improve perfusion) to TID (acute - anti-endotoxin effects) Acepromazine 50-75 mg IM SID-BID for vasodilatory effects Consider nitroglycerine patches – on 12 hrs/off 12 hrs *not as a preventative* Infected Synovial Structures (joints, tendon sheaths) Radiographs – monitor q7 days Initial fluid sample gets cytology/culture/sensitivity, subsequent samples WBC/TP only IV antibiotics for minimum of 3 weeks (for all infected synovial structures in all age horses) Monitor lameness Consider surgical debridement/lavage Regional limb perfusion pre-drill (4.0 mm) thru cortex of bone proximal to involved structure tourniquet appropriate antibiotic, qs volume to min of 35cc, injected intramedullary (extension set, “Puerto Rican infusion pump”) 20 min lag time, remove tourniquet, bandage 4 treatments (often the first time is at surgery) K Pen 44,000 IU/kg IV QID Gentamicin 6.6 mg/kg IV SID *also IA or Amikacin IA* DON’T EXCEED THE SYSTEMIC DOSE OF AMINOGYCOSIDES WHEN USING IA Ceftiofur 2-4 mg/kg IV TID or IM BID *also IA* Phenylbutazone 2.2-4.4 mg/kg IV or PO SID-BID Consider serial tap/inject with antibiotics Consider gastric ulcer prophylaxis Poultice for diffuse limb swelling U/S any “soft” spots – could be soft tissue abscess (tap, lance, lavage) Adequan 500mg IM q7d for 8 weeks (start at resolution of the infection) UROGENITAL Retained Placenta Oxytocin 2cc (20 units/ml) IM q2h until 3 hrs post-foaling (now “retained” by definition) Oxytocin 2 cc IM q15min for 4 doses Oxytocin 5cc in 1L fluids IV over 20 min Uterine infusion of 10cc gentamicin in 1 L post-foaling Uterine lavage and placental massage PRN (salt water with 10cc gentamicin instillation) Consider systemic antibiotics Consider flunixin meglumine/xylazine for analgesia Aborting Mares Phenylbutazone 2g/day PO SID or split into 1g BID Pentoxyfilline 8 mg/kg PO BID (for increased deformation of rbc and improved perfusion) Dexamethasone 20mg x 2 doses (to promote fetal lung maturation if close to foaling anyways) Anitbiotics (Pen/Gen or TMS) Regumate 20-40cc (double dose) SID PO Renal Failure CBC, VBG and Serum Chemistry *PCV/TP/VBG/electrolytes serially* Abdominocentesis (+/- ultrasound) *don’t forget adult horses can have ruptured bladders* U/A (free catch vs catherterized sample) K Pen 22,000 IU/kg IV QID Enrofloxacin 5 mg/kg IV SID IV fluids *cautious of fluid overload if anuric* (use electrolyte values to guide fluid selection) Mannitol 20% 500 ml IV TID Furosemide 0. 12mg/kg IV loading dose, followed by 0.12mg/kg/hr IV CRI (add 12 ml to 1L 0.9% NaCl for 500 kg horse) and run for 8 hours (800 ml). When CRI complete, start furosemide 1.0 mg/kg IV q 4 hr (decrease to 0.5 mg/kg if urinating well) Dopamine 1-10 ug/kg/min IV CRI if still an-oliguric w/ lasix (40 ml [8 vials of 200 mg] in 1 liter 0.9% NaCl, run at 100 ml/hr will give approx. 5/ug/kg/min for 500 kg horse) Monitor for pulmonary edema and abdominal distention OTHER Pericarditis Can be life-threatening *tamponade* U/S for diagnosis, serial monitoring Pericardiocentesis (samples for cytology, culture/sensitivity) Pericardial lavage with warm Norm R or saline, then instill with antibiotic spiked fluids Steroids 30 mg dexamethasone taper over 1 month (fluid may re-acculumate as dose is tapered) *need negative culture and no pyrexia* Long-term follow-up to monitor for restrictive pericardial disease Broad spectrum antibiotics (Pen/Gen) Hemorrhage Address primary problem Avoid NSAIDs, heparin Serial PVC/TP Naloxone 8 mg (2 x 10cc bottles) IV BID Aminocarproic Acid 10g in 1L fluids IV over 30 min BID - QID Formalin (10%) 20-50cc in 1L fluids IV over 30 min BID Yunnan Paiyao ½ -1 vial (2-4 grams) in water PO QID Acepromazine 3cc IM once Blood Tranfusion as indicated by PCV or clinical signs Eye Problems Block for thorough ophthalmic exam Stain +/-Scrape (cytology PRN) fluoroscein for discontinuous corneal epithelium rose bengal for discontinuous tear film Treat with solutions (subpalpebral lavage) or ointments Atropine *Mydriatic* Flurbiprofen *NSAID* Fortified Gentamicin (1cc (100 mg) injectable gentamicin added to 15 ml bottle of ophthalmic gentamicin solution) *Antibiotic* Tobramycin *Antibiotic* Chloramphenicol *Antibiotic* all treatments q1-24 hrs depending on Miconazole *Antifungal* severity of lesion Natamycin *Antifungal* Serum Intra-ocular or systemic steroids only if indicated Consider sub-conjunctival injections Consider systemic antibiotics NSAIDs for analgesia Intracameral (anterior chamber) injection of TPA for severe fibrin deposition (R. equi) FOALS GENERAL Work up/Routine Management Complete PE at admission then TPR q4h Sterile blood collection for CBC, Chemistry, aerobic/anaerobic culture, IgG if >12h old ABG or VBG and blood glucose (monitor q6-24h) Urine specific gravity (monitor q6h) IV catheter placement Digital rectal and soapy water enema as indicated Staining of eyes at admission, then q24h if recumbent or diseased Oral exam (cleft palate, suckle) Orthopedic assessment (conformation, joint effusion, lameness) Assess for fractured ribs (handle carefully, lay with fractured side down) Ensure adequate nutrition (see below) Abdominal/thoracic radiographs as indicated Mare PE oil if <24hrs post-foaling oxytocin 2cc IM BID for 7 days post-foaling re-introduce grain slowly uterine lavage PRN domperidone (10 g PO SID) as indicated reserpine 2.5-3.75 mg (10-15 tabs) PO SID-BID to effect Neonatal Nutrition Mare’s milk, milk replacer or mixture of the two (to improve palatability) Colostrum can be F/C, others should start at 5% BW and increase by 2.5% increments q1224hrs (CKC likes a max of 25% BW initially if bucket fed) *very weak/sick preemies, start at approx 2.5% d/t concerns of delayed gastric emptying when recumbent + susceptibility to enterocolitis. If can stand/walk, start at 10%* Encourage nursing Bottle feed Bucket feed (from top or via nipple) Consider intermittent NG intubation if foal is starting to “get the hang of it” Feeding tube (see below) TPN Feeding Tube Placement Lube tube and guide wire Flex head to pass through larynx Extend head neck to pass through cardia Confirm placement of tube in stomach (radiographs, reflux, palpation) Tape “butterfly” at nostril level, suture through nostril and tape, then Chinese finger trap over tape to secure Always reflux before feeding Male injection cap to prevent sucking air Basic “Sick/ADR” Foal Protocol (Dummy Foal) K Pen 44,000 IU/kg IV QID Amikacin 20 mg/kg IV SID or Gentamicin 6.6 mg/kg IV SID Metronidazole 15 mg/kg PO BID – TID Flunixin meglumine 1.1 mg/kg IV SID Ranitidine 6.6 mg/kg PO TID or 1 – 1.5 mg/kg IV TID Lasix 1 mg/kg IV BID-TID Naloxone 4 mg (10 cc vial) IV BID x 3 doses Mannitol 20% ~0.5 g/kg (~1 ml/lb) IV BID-TID (run slowly over 20 min) Fluids (Norm R or M with 5% Dextrose) 80 ml/kg/24hr if not nursing and no losses *frequency of q2h for glucose maintenance* Plasma (IV +/- PNGT) as dictated by IgG results Sterile eye Ointment +/- antibiotics Entropion management (staples, sutures) Umbilical care (dip TID, monitor for patency or thickening) O2 Therapy (as dictated by serial ABG [want PaO2 to be at least 60], often a minimum of 24 hrs) Caffeine (for PaCO2 >50) 10 mg/kg PO once (loading dose) then 3 mg/kg PO BID *this is for foals that are not ventilating appropriately; ie: apnea, decreased chest excursions (not pneumonias)* Doxapram 0.02-0.05 mg/kg/min CRI (indications as for caffeine) Phenobarb 5 mg/kg BID starting dose to effect. Valium 1cc IV as needed may increase as needed but may consider phenobarb therapy Ensure adequate nutrition GI Enteritis Foal NPO (including meds) K Pen 44,000 IU/kg IV QID Amikacin 20 mg/kg IV SID or Gentamicin 6.6 mg/kg IV SID Metronidazole 30 mg/kg per rectum TID Flunixin meglumine 1.1 mg/kg IV SID Ranitidine 1 – 1.5 mg/kg IV TID Bethanecol 0.02-0.05 mg/kg SQ q8h (usually alternate bethanecol /metaclopramide Metaclopromide 0.1-0.3 mg/kg IM q8h so foal is getting a prokinetic q4h) Reflux q4h and adjust PRN Milk mare Fluids (consider ongoing losses) Consider nutrition - TPN (start sooner rather than later ie/ NPO for >24hrs) Consider abdominocentesis Consider U/S and radiographs of abdomen to assess degree of intestinal distention, motility and presence of gas in intestinal walls (pneumatosis intestinalis) Diarrhea (Colitis) Foal Fecal samples as in adult + Rotavirus K Pen 44,000 IU/kg IV QID Amikacin 20 mg/kg IV SID or Gentamicin 6.6 mg/kg IV SID Metronidazole 15 mg/kg PO TID Flunixin meglumine 1.1 mg/kg IV SID Ranitidine 6.6 mg/kg PO TID or 1 – 1.5 mg/kg IV TID Probios 1 gram/10 lbs PO BID Pediasorb ½ package PO BID Epic ½ package PO BID x 3 days Toxiban 8 oz bottle + 4 oz water PNGT BID. V Psyllium 4 oz/100 lbs PNGT SID-BID Immodium 0.1-0.2 mg/kg PO up to QID as long as diarrhea continues (want WBC WNL) Fluids (consider ongoing losses) Bicarb replacement (IV or PO [baking soda <12.5-25 g BID – QID>]as dictated by serial VBG) +/- Lasix/Mannitol as dictated by USG and renal values Allow to nurse if desired and comfortable Consider abdominocentesis Consider U/S and radiographs of abdomen to assess degree of intestinal distention, motility and presence of gas in intestinal walls (pneumatosis intestinalis) Meconium Impactions NPO Barium enema for radiographs Systemic antibiotics/NSAIDS as per colitis foal Sedation PRN (IV or IM) Soapy water enemas q4-12h (alternate enemas so foal Acteylcysteine retention enemas q12h gets one q6h) Mineral Oil 4-6 oz/100# PNGT (try to wait until at least 12-18hr of age d/t gut closure/colostrum absorption issues) Consider surgery “Turd Herders”- long handled towel clamps to carefully extract hard fecal balls RESPIRATORY Foal Pneumonia (R. Equi) Thoracic radiographs TTW for cytology, culture and sensitivity Erythromycin stearate 25 mg/kg PO TID (pull water/wipe mouth *limit mare ingestion*) Erythromycin Lactobionate 5 mg/kg IV QID Doxycycline 10 mg/kg PO BID Azithromycin 10 mg/kg PO SID Rifampin 10 mg/kg PO BID O2 therapy as indicated Climate control (A/C) Monitor for other signs – uveitis, polysynovitis, diarrhea MUSCULOSKELETAL Lame (Joint) Foal Radiographs q7days – monitor for areas of osteomyelitis Serial tap and inject/lavage under GA (in front of stall) lavage until WBC < ~20,000 tap and inject until WBC < ~10,000 or clinical signs dictate wipe site with 1:1 water:hydrogen peroxide after procedure to help minimize “skin scurf” from repeated sterile scrubs +/- sterile bandage Initial fluid sample gets cytology/culture/sensitivity, subsequent samples WBC/TP only Direct injection of sites of osteomyelitis or physitis IV antibiotics for minimum of 3 weeks (for all infected synovial structures in all age horses) Monitor lameness and watch other joints closely Consider surgical debridement of accessible foci of osteomyelitis K Pen 44,000 IU/kg IV QID Amikacin 20 mg/kg IV SID or Gentamicin 6.6 mg/kg IV SID *also IA* DON’T EXCEED THE SYSTEMIC DOSE OF AMINOGYCOSIDES WHEN USING IA Ceftiofur 2-4 mg/kg IV TID or IM BID *also IA* Flunixin meglumine 1.1 mg/kg IV SID Gastric ulcer prophylaxis (add sucralfate 2-4 mg/kg PO TID-QID) Poultice for diffuse limb swelling U/S any “soft” spots – could be soft tissue abscess (tap, lance, lavage) Don’t forget about the foot – nerve blocks, soak booties etc. Adequan 250 mg IM q7d for 8-16 weeks (start at resolution of infection or 2 weeks post-op) Contracted foal Splints (place under sedation, 12h on/12h off) Oxytetracycline 2-3 grams IV q24h up to 3 doses (monitor renal values) Do not use or use judiciously if foal already has tendon laxity in any other limb(s) Limited turnout until relaxed UROGENITAL Ruptured Bladder/Urachus Identify (U/S, rads) Confirm (abdominocentesis <creatinine>, serum BUN/creatinine/electrolytes) Abdominal drain – 28 Fr (omentum least likely to clog tube if located caudally) Indwelling urinary catheter Fluids (address electrolyte issues) Monitor electrolytes, BUN/creatinine *address hyperkalemia with saline +/- dextrose* Systemic antibiotics/NSAIDS Surgery once stabilized (cath for 48hrs post-op) May have confounding clinical signs (enteritis, colitis, etc.) **Remember it is a MEDICAL, not surgical, emergency!!** “Red Flags” – male, newborns (~3-5 days), decreased or absent urination but may continue to urinate, abdominal distention, history of dystocia, respiratory distress Patent Urachus Can be “acquired” in a debilitated/ill foal PPG 2cc topically QID to umbilicus to assist in drying Systemic antibiotics U/S and assess umbilical structures OTHER NI Monitor renal values, total bilirubin, PCV/TP K Pen 44,000 IU/kg IV QID Amikacin 20 mg/kg IV SID or Gentamicin 6.6 mg/kg IV SID Metronidazole 15 mg/kg PO BID – TID Flunixin meglumine 1.1 mg/kg IV SID Ranitidine 6.6 mg/kg PO TID or 1 – 1.5 mg/kg IV TID Phenobarb (to promote bilirubin metabolism) ~13 mg (0.2 ml of 65 mg/ml) IV BID Solu-delta-cortef 100 mg IV initially, followed by 50 mg IV BID Blood Transfusion when PCV <12 or as indicated by clinical signs Oxyglobin 5-10 ml/kg IV PRN *max of 10 ml/kg/hr* Fluids (for diuresis in addition to meeting requirements) Lasix 1 mg/kg IV BID - TID Off mare until 48 hrs of age (supplement colostrum) OTHER HELPFUL HINTS GENERAL Sedation 1 ½ cc xylazine/1 ½ cc butorphanol IV for analgesia (colic) 1-2 cc detomidine IM for heavy duty analgesia (colic) 1 – 1 ½ cc xylazine +/- butorphanol for NG intubation, gastroscopy, radiographs 1/3 cc detomidine / 2/3 cc butorphanol for thoracocentesis, TTW 1 ½ - 2 cc xylazine / 2 ½ - 3 cc acepromazine for mares when foals being restrained, taken to sx, euthanized Routine Surgeries (Primarily arthroscopies) Pre/Post Operative radiographs +/- intra-operative radiographs Pre-op CBC/muzzle (~6-8 hr pre-op) Temporary Catheter K Pen 2 x 10 million IU doses (pre and post-op) Tetanus toxoid / anti-toxin (foals < 4 months) Phenylbutazone 2 grams PO SID/ flunixin meglumine (foals) Bandage changes PRN for 2 weeks post-op Adequan 500mg IM q7d for 8 weeks (start 2 weeks post-op) for arthroscopies and fx Remove arthroscopy sutures 10-14 days post-op Reduced grain while stall confined Stall confinement only for 2 weeks, followed by 6 weeks hand walking before turnout in a round pen or small paddock for 2 months prior to resuming training/work Stifle arthroscopy (FP pouch) – use laproscopy cannula in supra patellar pouch to allow flushing of debris from joint Nasal Edema (Post Anaesthesia) 20 mg (2cc) phenylephrine qs to 20 cc or Afrin intranasally in the recovery stall GI (COLICS) VML - 3 layer closure “Clear” the linea first with mayos and use electrocautery for hemostasis Surgeon and assistant to start from either end Linea - 3 Vicryl soaked in Biosol – SC pattern SQ - 2-0 PDS – SC pattern Skin – 1 Braunamid – continuous horizontal mattress (extra “pull” tabs) Suture Line is then sprayed with “Aluspray” **Linea – 2 PDS <250#, 2 Vicryl 250-750#, 3 Vicryl or 2 Vicryl doubled >750#** PF Enterotomy Grasp edges with Allis tissue forceps (ensure mucosa everted) TA-90 across incision Trim edges Rinse with saline with biosol, then with heparin Other enterotomies (SI for foreign body) - longitudinal incision, closed transversely Omentectomy Isolate omentum Split into reasonable size segments (3-4), clamp Transfix and ligate with 1 PDS (“flash” the hemostat) Transect with mayos in “crush” Inspect stump for bleeding and release Abdominal Lavage (in surgery) Final step prior to closure Warm, sterile saline Suction until clear Leave 1L with 2cc heparin +/- extra litre in abdomen *unless hemorrhage* 2cc heparin IV Decompression of Gas Distention 12 g thru mattress suture (2-0 PDS) 16 g for stomach 18 g (tunneled) Resections LC TA-90 across mesentery (2 proximal <stay in>, 1 distal <removed>) then hand ligate all large blood vessels Handsewn (2 layer, inverting) Copious abdominal lavage in surgery Abdominal drain (described below) generally handsewn (end to end, end to side jejunocecostomy) GIA-90 for ileocecal anastomosis (ileal bypass) SI Abdominal Drain (for peritonitis, post LC resections, ruptured bladder) Stab incision lateral to VML Chinese finger trap suture Condom as one-way (Heimlich) valve 10L Norm R lavage at immediately-2 hrs post-op, 6-8 hrs post-op, (12 hrs post-op) then q12h (gravity flow) Can be done standing, under sedation, with U/S guidance (caudal third of abdomen to minimize omental interference and visceral trauma) Ileal Impactions 60 cc DSS in 1L saline instilled intraluminally and subsequent mixing with intestinal contents Must ensure that resolved impaction passes thru ileocecal valve easily, otherwise consider ileocecal anastomosis (bypass) Cecal Trocarization Use when surgery is not an option or to stabilize prior to surgery Must be able to auscult a “ping” in right flank Clip and prep (QUICKLY) +/- Carbocaine bleb (if time permits) Stab (skin) incision with 15 blade Cecal trocar into peritonem/cecum Inject 5cc gentamicin as withdraw Rectal Tear After-care (Beavis) Ring and liner placed in surgery Concerns re: impaction at site of ring Laxative diet (alfalfa!!) *complete pellets* Mineral Oil enemas (bell enema) q6h to assist fecal passage Mineral Oil PNGT PRN Eventually developed abscess at tear site – flushed with dilute Nolvasan BID rectally via NGT RESPIRATORY Laryngoplasty/Throat Surgery (laser) Mineral oil early AM pre-op Phenylbutazone 10cc (2 grams) IV once pre-op then 2 grams PO SID Gentamicin 30cc IV SID (to start pre-op) K Pen 2 x 10 million IU IV (pre and post-op, may continue on TID-QID) Recover with “sticky” Ioban drape over sx site (staples for closure) Doxycycline 10 mg/kg PO BID (to go home for 5 days) Stall confinement with hand or mechanical walking for 8 weeks then resume training/work (want to minimize movement of the larynx while scar tissue forms to mimic the suture) Other particulars Contact Nd:YAG for cordectomies (standing, under neuroleptanalgesia) Hooked blade (intranasally) under GA for epiglotic entrapment Sodium Thiopentol for anaesthesia induction to inhibit gag reflex “Bikini” vs “Boxer” trim for staphlectomy Post-op tracheotomy for aretynoidectomies Nasal septum resection Skull films (DV/lateral) Consider alar fold resection Post-op packing of nasal cavity/suture nostrils shut (pull ~48 hr post-op) Monitor PCV/TP PRN Post-op temporary tracheotomy Post-op antibiotics Sinus flap Pack in surgery Pull packing ~24hr later Monitor PCV/TP PRN Flush SID with saline Thoracocentesis U/S to confirm location of fluid Clip hair, sterile prep of area Carbocaine block Stab incision thru skin 28 or 32 Fr thoracic drain Condom as one-way valve Chinese finger-trap suture CNS Myelogram Pre-op temporary catheter, 500 mg flunixin meglumine and 20 mg dexamethasone IV once Anaesthetize and place on sx table in R lateral recumbency Neutral plain films (to set positioning and technique) AO/LS tap (18g spinal needle, sterile extension set)– drain 60-80 cc CSF under sterile technique over ~5 min AO tap – inject 60-80 cc omnipaque (iohexol) under sterile technique over ~5 min Elevate front of table for ~5 min to encourage caudal flow of iohexol (may need longer) 3V (with contrast) neutral +/- extended (increase kVp by 5) flexed (increase kVp by 5) Recover in lateral with head elevated (encourage CSF flow caudally to help minimize risk of seizures) Post-op 2 grams Phenylbutazone PO SID Examine films for >70% reduction in the width of the dorsal dye column decrease of 20% or greater in the total dural diameter (dorsal and ventral dye columns included) when comparing intravertebral and intervertebral measurements Post mortem Euthanize with head uphill Starting techniques for the yellow “sub” x-ray machine o Cranial 80/0.14 o Middle 80/0.18 (increase kVp by 5 for flexed) o Caudal 80/0.20-0.22 (increase kVp by 5 for flexed) “Wobbler” Films Assess films subjectively looking for obvious stenosis, malalignment, physeal flaring, etc Measure sagittal ratios for C4-7 Narrowest part of the canal (within the vertebral body) – may be cranial or caudal Widest part of the vertebral body (cranial aspect) Want >0.5 when divide Also measure the shortest oblique distance between the caudal aspect of C3 and the cranial aspect of C4 (repeat for C4/5, C5/6, C6/7) Supposed to be a better predictor of disease *should always be >> than intravertebral sagittal ratios No numbers yet MUSCULOSKELETAL Medial Condylar Fracture Cast ASAP (pre-op) Radiographs (need to “pick-off” the fracture line) Full limb cast post-op Tether initially with cast and then when cast removed Assist to stand if “bad” leg down (+/- roll PRN) Clay stall (or other appropriate bedding – peat moss) Cast Application Stockinette – 2 layers, with felt over pressure points in between layers Yellow cast foam – 1 layer Fibreglass casting tape Build up heel if desired with plaster rolls Elasticon at top to prevent debris falling into cast Must cure for 20 min (GA) Block +/- ACS pad on contralateral limb to even out length and for support Hoof Abscess Pare out hoof – attempt to establish ventral drainage Consider foot radiographs (5 views) Soak boot with Betadine “tea” QID Animalintex or icthammol poultice ALD Measure the angle from the distal radial physis (grossly or radiographically) with a goniometer Must consider if horse is bench-kneed “Straight” horse will measure ~4 degrees valgus, however if bench-kneed “straight” may be 6-8 degree valgus Examine at rest and at walk (want MCIII to be perpendicular to ground when placed) Transphyseal bridge preferred to periosteal elevation/transection 6.5 mm cancellous bone screws (25-35 mm long) 18 g wire UROGENITAL Penile Prolapse/Hematoma Vaseline and massage to return penis to prepuce Probang and surcingle to retain penis and promote resolution of edema Probang assembled from PVC pipe fitted with cotton taped onto one end (Q-tip) to fit snugly into prepuce Surcingle assembled primarily from 2” white tape – around barrel, through hind legs, around tail RV Tears/Perineal Lacerations Wait for initial healing to occur Muzzle for minimum of 24 hrs Mineral Oil 1-2 gallons PNGT upon arrival (~24 hr pre-op) Sedation/neuroleptanalgesia for restraint in stocks Epidural (¾ cc xylazine + ¾ carbocaine qs to 10cc) Clip hair (~2” wide) over hamstrings Scrub of rectum/vulva/perineum with Ivory soap then betadine Stay sutures to retract labia and improve visualization Tight seal of repair with no palpable suture (from rectal side in particular) Close dead space with SC running suture Long tails on Braunamid (vaginal side) Leave anal sphincter discontinuous (do not attempt to repair – risk of stricture) Caslicks to protect repair Continue with SID-BID mineral oil PRN post-op Post-op antibiotics REMOVE sutures at 14 days Dystocia Assess vitals (P, R, mm) IV catheter Preliminary bloodwork (PCV/TP/VBG) Stabilize mare Sedation/neuroleptanalgesia for restraint in stocks Epidural (¾ cc xylazine + ¾ carbocaine qs to 10cc) Vaginal exam (bare arm, lots of lube) Limited manipulation/mutation in stocks**especially if foal is the priority (watch the clock!)** May elect to manipulate/mutate under GA in recovery stall **time is still IMPT** Otherwise terminal C-section (if foal is the only priority) C-section via VML under GA (if delivery of a live or dead fetus is otherwise impossible or where mare and foal are both the priority) fetotomy (if foal is dead and/or mare is the only priority) C-section Hemostasis of uterus (clear placenta) with running stitch or isolate vessels and transfix Copious lavage of abdomen Ovariectomy (usually unilateral GCT) Palpation/ultrasound pre-op to confirm diagnosis and side/size of affected ovary Oblique paramedian ventral incision over affected ovary Consider VML for exceptionally large ovaries “Corkscrew” to assist with traction of ovary TA-90 to “ligate” mesovarium Endometrial Cysts Sedation/neuroleptanalgesia for restraint in stocks Contact ablation with Nd:YAG laser Post-foaling Broodmares (immediate) Consider clamping vulva when placing in dorsal recumbency for sx to prevent/minimize uterine/bladder prolapse RADIOLOGY CHEAT SHEET GENERAL Labels always lateral to the limb, except dorsal when shooting a lateral view Soft tissue should just be visible without a hot light (DES) STANDARD ORTHOPEDIC SERIES Front Fetlock Straight lateral Flexed lateral AP DMPLO DLPMO Carpus Straight lateral Flexed lateral AP DMPLO DLPMO Skyline (distal row) Elbow Flexed Lateral (pull limb forward to ensure joint is isolated) AP (abduct limb to assist in placing plate to image olecranon) Can use the bucky for lateral, otherwise need to use GRID Shoulder Flexed lateral (pull limb forward to isolate joint over trachea) Position bucky first Hind Fetlock Straight lateral +/- Flexed lateral AP DMPLO DLPMO “Up/down” obliques – for plantar pieces, sesamoid fractures Skyline (sesamoids) – for apical fractures Hock Straight lateral AP DMPLO PLDMO Skyline (calcaneus) Stifle Straight lateral (condyles should overlap) Flexed lateral PA PLDMO (pick off the medial condyle) MC or MT II-IV *splint/cannon bone fractures (condylar, stress)* Straight lateral AP Obliques Attempting to pick off the fracture line and/or highlight the affected area Hip (foal) GA GRID Foot Prep the foot – hoof knife, clean, pack with play-do Lateral (paperclip at coronary band) – use block AP (foot) – use block, shoot parallel to the ground Coffin bone – use tunnel, collimate, 60 degree angle Skyline (navicular) – use tunnel, collimate, 45-60 degree angle AP (navicular) – use “notched” block to hold toe and gridded plate, collimate C-spine 3V (standard 450 kg horse) C1-3 (include occipital protuberances) C2-? (need to have C2 to “name” other vertebrae) C?-7 (C6 generally is shorter and has a flatter ventral border, may be transposed with C7; technique should allow visualization of C7 and the dorsal spinous process of T1) Occasionally need DV view Skull Lateral AP Obliques Alter technique depending on “target” “light” for ethmoid turbinates “hot” for teeth STANDARD SOFT TISSUE VIEWS Thorax 3V (standard 450 kg horse) Inspiratory exposures Need to be able to see mediastinum caudal border of heart entire diaphragm Abdomen Need “hot” technique Can use sand in viscera to assess if technique is appropriate Corresponding diagram to illustrate where films were centered Foals can be standing or recumbent (standing preferred) one shot to assess feeding tube placement or to identify free fluid,/intestinal distention FORMULA CALCULATIONS 1) NaHCO3 Replacement [(BW in kgs) (base deficit) (0.4)]/(0.6) = amount of NaHCO3 required (mls) Eg: 50 kg foal w/ BE (ecf) = –5.2 [(50) (5.2) (0.4)]/(0.6)= 173 mls deficit 2) Neonatal Feeding (by % body weight in POUNDS) (BW in pounds)(% of BW to be fed)= total pounds milk needed in 24 hours. To figure out number of ounces per feeding: (pounds of milk)(16 ounces/pound) = total ounces in 24 hr (total ounces in 24 hours)/12 feedings = oz needed q 2 hours Eg: 50 lb foal that needs 2.5% BW feeding q 2 hours (50 pounds)(0.025)=1.25 total pounds of milk needed (1.25 pounds)(16 oz/pound)=20 ounces total needed in 24 hr (20 ounces)/12 =1.7 (round to 2) ounces every two hours 3) Neonatal Feeding (by % body weight in KILOGRAMS) (BW in kgs)(%BW to be fed)=liters needed in 24 hours (liters needed) x 1000 = milliliters needed (milliliters needed)/(30)= ounces needed in 24 hours(*since there are 30 mls per ounce). Divide total by 12 for amount needed q 2 hours 3) DILUTIONS (volume) (concentration)= (volume) (concentration) Eg: You want a 20 mls of a 3.3 % Natacyn sol’n and have a 5% solution 5%= 50 mg/ml (50 mg/ml)(“x” mls) = (33mg/ml)(20 ml) 50 x = 660 mg x = 13.2 ml of 5% needed. Bring up to a total of 20 ml