Management of Difficult Airway in a Cat with Tonsillitis

Background: Tracheal intubation is performed in an anesthetized patient in order to optimize oxygenation and to allow the administration of volatile anesthetics. Some patients have characteristics that make intubation a challenge. Therefore, an adequate pre-anesthetic evaluation enables the anesthesiologist to define the best management. There are reports of the impossibility of performing conventional intubation attributed to the lack of pre-anesthetic consultation in Medicine, which motivates and justifies the discussion of these aspects in Veterinary Medicine. Therefore, this study aims to report a case of difficult airway management in a feline with tonsillitis. Case: A 3-year-old male NDB cat weighing 3.5 kg was admitted to the Veterinary Hospital, Federal University of Pampa (UNIPAMPA) - Uruguaiana, for consultation. After physical examination, total tooth extraction and tonsillectomy was recommended. On the day of the procedure, a physical evaluation of the patient was performed, and he was classified as ASA II. Zolazepam and tiletamine [Zoletil®️ - 5 mg/kg, i.m] associated with morphine [Dimorf®️ - 0.3 mg/kg, i.m] was given as premedication. Given the difficulty of intubation in a previous procedure reported by the tutor, a thoughtful conduct was planned for the intubation of the patient, considering the possibility of tracheostomy. The patient was pre-oxygenated, and subsequently, propofol [Propovan®️ - 4 mg/kg, i.v] was administered to promote anesthetic induction. The first attempt at intubation was done by laryngoscopy, but despite the use of a 6 cm blade, it was too large in relation to the hyperplastic tissue; then swabs and a flashlight were subsequently used. With the help of two people, the experienced anesthesiologist was able to position the endotracheal tube correctly approximately 25 min after the first attempt, requiring supplemental doses of propofol [Propovan®️ to the effect, i.v] and oxygenation between the attempts. Anesthetic maintenance was achieved with isoflurane [Isoforine®️ vaporized in 100% oxygen] in a system without gas rebreathing. Locoregional block of the maxillary nerve and inferior branch of the mandibular nerve was performed with lidocaine 2% [0.1 mL/kg]. During the transoperative, the vital parameters remained stable and there was no need for analgesic rescue. After the end of the procedure and extubation, the patient received oxygen therapy via facemask until he regained consciousness and had no complications.Discussion: The mortality of dogs and cats related to anesthetic procedures is substantially higher when compared to humans. Studies have shown that most anesthetic-related complications in humans are predictable. The lack of adequate pre-anesthetic evaluation or anesthetic consultation are factors that can cause losses in the transoperative period. Therefore, sharing information that can mitigate these situations is critical. The scarcity of reports on pre-anesthetic evaluation in veterinary medicine allows the identification of a gap on the role of the anesthesiologist in this important stage of anesthesia, and how it is performed in the hospital routine or in veterinary clinics. The success in managing the difficult airway in the case reported here can be attributed to the procedures adopted in all stages of the procedure, especially the planning based on information obtained during the pre-anesthetic period. It is worth mentioning that the owner was a veterinarian and we believe this also contributed to the outcome, since he informed the anesthesiologist about the difficulties encountered during the previous procedure. This case motivated the implementation of a pre-anesthetic consultation service in the hospital in question. In addition to the physical examination, a complete anamnesis carried out with the owner may reveal relevant details for determining the most appropriate and safe anesthetic conduct for the patient.Keywords: preanesthetic evaluation, endotracheal intubation, veterinary anesthesia.Título: Manejo da via aérea difícil em um gato com tonsiliteDescritores: avaliação pré-anestésica, intubação endotraqueal, anestesiologia veterinária.

Clinical Approach for Treating Dilated Cardiomyopathy in a Hog-nosed Skunk (Conepatus chinga)

Background: Dilated cardiomyopathy (DCM) is a multifactorial disease characterized by systolic dysfunction of myocardium, affecting domestic animals like dogs, cats, and ferrets. It was sporadically described in non-domestic species, generally as a necropsy observation. The hog-nosed skunk (Conepatus chinga) is a small mammal, carnivore, belonging to the Mephitidae family, found in southern South America, and considered as concerned in a conservation status of the species. The goal of this issue is report the first clinical approach of dilated cardiomyopathy in a young hog-nosed skunk, elucidating the challenging aspects of the diagnostic, therapy, and clinical outcome.  Case: A newborn hog-nosed skunk (Conepatus chinga) was found in a farm of southern Brazil in poor nutritional and behavioral conditions. Thirty days of nutritional supplementation based on cow's milk, fruits and insects were necessary to recover its body weight score and activity level. However, 2 months after adoption, the skunk showed acute dyspnea and abnormal breath sound, decreased appetite, and loss of weight. Firstly, these signs were associated with a possible pulmonary infection or other respiratory disease. However, the general cardiomegaly and pulmonary edema pattern observed on the thoracic radiography, changed the clinical approach, conducting the presumptive diagnosis to congestive heart failure (pulmonary edema) caused by an unknown cardiac disease as a dilated cardiomyopathy (CDM). An adequate physical, echocardiographic, electrocardiographic, and hematological evaluation was possible only after chemical restraint by sevofluorane. Systolic heart murmur and pulmonary cracking sounds were detected on thoracic auscultation. These findings associated to the echocardiography features of four chamber dilatation, systolic (fractional shortening-FS = 9% and ejection fraction-EF= 22%) and diastolic (mitral E/A ratio = 4.93) dysfunctions, and bilateral ventriculoatrial regurgitation (mitral and tricuspid) were highly correlated with DCM. Considering the etiologies of CDM described in domestic species and the poor nutritional condition previously observed in the case, nutritional and idiopathic etiologies of DCM were considered for this case. Therapy was based on furosemide at hospital (4 mg/kg subcutaneous, single doses) and home (2 mg/kg orally, BID), enalapril maleate (0.5 mg/kg orally, every 48 h), taurine supplementation (100 mg orally, SID), and pimobendan (0.5 mg/kg orally, BID). Clinical improvement was already observed on the second day of treatment, and monitored for 5 months, when the skunk was completely revaluated. The second echocardiographic exam showed improvement in systolic (FS = 20% and EF = 43%) and diastolic functions (mitral E/A ratio = 2.05), tricuspid regurgitation was not observed, and decrease the left atrial and ventricular dimensions were seen. Due to good clinical outcome, furosemide was gradually reduced until complete withdrawal without any clinical complications or worsening. After 30 months of therapy of pimobendan, taurine, and enalapril maleate, the skunk has good quality captive life without congestive heart failure recurrence.    Discussion: The lack of information about DCM in hog-nosed skunk turns the clinical diagnosis and therapy challenging. However, the radiographic and echocardiographic features seamed to lead the same domestic animal patterns. The therapy based on decrease the cardiac overload, increase the myocardial inotropic function (pimobendan and taurine) resulted on excellent clinical and echocardiographic outcome. Although the etiologies of DCM in this species are not stablished, the diagnostic and therapeutic approaches applied resulted on excellent clinical results, and therefore may provide useful information about this cardiac condition in skunk species. Keywords: cardiovascular, disease, Mephitidae, therapy, wild animals.

Management of Difficult Airway in a Cat with Tonsillitis

Background: Tracheal intubation is performed in an anesthetized patient in order to optimize oxygenation and to allow the administration of volatile anesthetics. Some patients have characteristics that make intubation a challenge. Therefore, an adequate pre-anesthetic evaluation enables the anesthesiologist to define the best management. There are reports of the impossibility of performing conventional intubation attributed to the lack of pre-anesthetic consultation in Medicine, which motivates and justifies the discussion of these aspects in Veterinary Medicine. Therefore, this study aims to report a case of difficult airway management in a feline with tonsillitis. Case: A 3-year-old male NDB cat weighing 3.5 kg was admitted to the Veterinary Hospital, Federal University of Pampa (UNIPAMPA) - Uruguaiana, for consultation. After physical examination, total tooth extraction and tonsillectomy was recommended. On the day of the procedure, a physical evaluation of the patient was performed, and he was classified as ASA II. Zolazepam and tiletamine [Zoletil®️ - 5 mg/kg, i.m] associated with morphine [Dimorf®️ - 0.3 mg/kg, i.m] was given as premedication. Given the difficulty of intubation in a previous procedure reported by the tutor, a thoughtful conduct was planned for the intubation of the patient, considering the possibility of tracheostomy. The patient was pre-oxygenated, and subsequently, propofol [Propovan®️ - 4 mg/kg, i.v] was administered to promote anesthetic induction. The first attempt at intubation was done by laryngoscopy, but despite the use of a 6 cm blade, it was too large in relation to the hyperplastic tissue; then swabs and a flashlight were subsequently used. With the help of two people, the experienced anesthesiologist was able to position the endotracheal tube correctly approximately 25 min after the first attempt, requiring supplemental doses of propofol [Propovan®️ to the effect, i.v] and oxygenation between the attempts. Anesthetic maintenance was achieved with isoflurane [Isoforine®️ vaporized in 100% oxygen] in a system without gas rebreathing. Locoregional block of the maxillary nerve and inferior branch of the mandibular nerve was performed with lidocaine 2% [0.1 mL/kg]. During the transoperative, the vital parameters remained stable and there was no need for analgesic rescue. After the end of the procedure and extubation, the patient received oxygen therapy via facemask until he regained consciousness and had no complications.Discussion: The mortality of dogs and cats related to anesthetic procedures is substantially higher when compared to humans. Studies have shown that most anesthetic-related complications in humans are predictable. The lack of adequate pre-anesthetic evaluation or anesthetic consultation are factors that can cause losses in the transoperative period. Therefore, sharing information that can mitigate these situations is critical. The scarcity of reports on pre-anesthetic evaluation in veterinary medicine allows the identification of a gap on the role of the anesthesiologist in this important stage of anesthesia, and how it is performed in the hospital routine or in veterinary clinics. The success in managing the difficult airway in the case reported here can be attributed to the procedures adopted in all stages of the procedure, especially the planning based on information obtained during the pre-anesthetic period. It is worth mentioning that the owner was a veterinarian and we believe this also contributed to the outcome, since he informed the anesthesiologist about the difficulties encountered during the previous procedure. This case motivated the implementation of a pre-anesthetic consultation service in the hospital in question. In addition to the physical examination, a complete anamnesis carried out with the owner may reveal relevant details for determining the most appropriate and safe anesthetic conduct for the patient.Keywords: preanesthetic evaluation, endotracheal intubation, veterinary anesthesia.Título: Manejo da via aérea difícil em um gato com tonsiliteDescritores: avaliação pré-anestésica, intubação endotraqueal, anestesiologia veterinária.

Clinical Approach for Treating Dilated Cardiomyopathy in a Hog-nosed Skunk (Conepatus chinga)

Background: Dilated cardiomyopathy (DCM) is a multifactorial disease characterized by systolic dysfunction of myocardium, affecting domestic animals like dogs, cats, and ferrets. It was sporadically described in non-domestic species, generally as a necropsy observation. The hog-nosed skunk (Conepatus chinga) is a small mammal, carnivore, belonging to the Mephitidae family, found in southern South America, and considered as concerned in a conservation status of the species. The goal of this issue is report the first clinical approach of dilated cardiomyopathy in a young hog-nosed skunk, elucidating the challenging aspects of the diagnostic, therapy, and clinical outcome.  Case: A newborn hog-nosed skunk (Conepatus chinga) was found in a farm of southern Brazil in poor nutritional and behavioral conditions. Thirty days of nutritional supplementation based on cow's milk, fruits and insects were necessary to recover its body weight score and activity level. However, 2 months after adoption, the skunk showed acute dyspnea and abnormal breath sound, decreased appetite, and loss of weight. Firstly, these signs were associated with a possible pulmonary infection or other respiratory disease. However, the general cardiomegaly and pulmonary edema pattern observed on the thoracic radiography, changed the clinical approach, conducting the presumptive diagnosis to congestive heart failure (pulmonary edema) caused by an unknown cardiac disease as a dilated cardiomyopathy (CDM). An adequate physical, echocardiographic, electrocardiographic, and hematological evaluation was possible only after chemical restraint by sevofluorane. Systolic heart murmur and pulmonary cracking sounds were detected on thoracic auscultation. These findings associated to the echocardiography features of four chamber dilatation, systolic (fractional shortening-FS = 9% and ejection fraction-EF= 22%) and diastolic (mitral E/A ratio = 4.93) dysfunctions, and bilateral ventriculoatrial regurgitation (mitral and tricuspid) were highly correlated with DCM. Considering the etiologies of CDM described in domestic species and the poor nutritional condition previously observed in the case, nutritional and idiopathic etiologies of DCM were considered for this case. Therapy was based on furosemide at hospital (4 mg/kg subcutaneous, single doses) and home (2 mg/kg orally, BID), enalapril maleate (0.5 mg/kg orally, every 48 h), taurine supplementation (100 mg orally, SID), and pimobendan (0.5 mg/kg orally, BID). Clinical improvement was already observed on the second day of treatment, and monitored for 5 months, when the skunk was completely revaluated. The second echocardiographic exam showed improvement in systolic (FS = 20% and EF = 43%) and diastolic functions (mitral E/A ratio = 2.05), tricuspid regurgitation was not observed, and decrease the left atrial and ventricular dimensions were seen. Due to good clinical outcome, furosemide was gradually reduced until complete withdrawal without any clinical complications or worsening. After 30 months of therapy of pimobendan, taurine, and enalapril maleate, the skunk has good quality captive life without congestive heart failure recurrence.    Discussion: The lack of information about DCM in hog-nosed skunk turns the clinical diagnosis and therapy challenging. However, the radiographic and echocardiographic features seamed to lead the same domestic animal patterns. The therapy based on decrease the cardiac overload, increase the myocardial inotropic function (pimobendan and taurine) resulted on excellent clinical and echocardiographic outcome. Although the etiologies of DCM in this species are not stablished, the diagnostic and therapeutic approaches applied resulted on excellent clinical results, and therefore may provide useful information about this cardiac condition in skunk species. Keywords: cardiovascular, disease, Mephitidae, therapy, wild animals.

ISSN 1996-0808 ©2009 Academic Journals Review

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