Veterinary Medicine - February 2008 - (Page MV7) highly digestible diets that the nutritional companies market as their classic gastrointestinal diet. What about witholding food from a vomiting animal? Williams: How the food is introduced is probably more important than what the patient eats. I withhold food for approximately 24 hours, reintroduce it by test feeding small amounts, and gradually return to normal meal portions. Twedt: Most animals with acute self-limiting vomiting due to dietary indiscretion are better within 24 hours, so that is a good time to reintroduce a diet. If they continue to vomit, it signals something more serious, and I start to investigate other potential causes. Leib: What about uid therapy in these patients? I assume they are minimally dehydrated, based on your assessment. Jergens: I haven’t seen many cases where hydration status is an issue. We may give some subcutaneous uids in the hospital before they leave, but beyond that I don’t see signi cant dehydration. Twedt: I agree; I’ll probably give them some subcutaneous uids. Leib: Then the last thing we should address is the routine use of antiemetics. Williams: I don’t use them unless the vomiting is severe and the patient looks uncomfortable. Jergens: I agree with Dr. Williams. Furthermore, indiscriminate use of antiemetics may mask the presence of more serious diseases. Leib: That is an important point. We are assessing these animals at a speci c point in time, and they often will leave the hospital. Then we rely on the owner to monitor progress at home and decide whether they need further evaluation and treatment. If we stop the vomiting, which is the most obvious clinical sign visible to owners, then the underlying condition can worsen and we lose valuable time before the animal is returned. Let’s shift to treatment for moderate to severe clinical signs, including dehydration, diarrhea, and abdominal pain. How will therapy be di erent? Simpson: The rst step is trying to identify the cause: Does the patient have pancreatitis? Does it have renal failure? Is it an Addison’s case? Often you have to start symptomatic therapy, such as intravenous uids, if the animal is dehydrated or start colloids if it is hypoproteinemic before making a de nitive diagnosis. If the patient has been vomiting or is dehydrated and is hospitalized, we start intravenous uid therapy. Then I monitor the frequency of vomiting. Is there hematemesis? Are there severe electrolyte disturbances that require us to stop the vomiting? We monitor the frequency of vomiting so we can decide whether to use an antiemetic. When we’re dealing with a foreign body, we might not want to use metoclopramide. If the animal is dehydrated, we might not want to use a phenothiazine until we have rehydrated it. So there are contraindications for some antiemetics—although these may not apply to the newer generation medications. Leib: If we were looking at either private practice or community-based university practices, what percentage Take note • When an extensive diagnostic workup is warranted, practitioners should at least perform a classic minimum database, including: —Complete blood count —Serum chemistry panel —Urinalysis —Fecal examination. • Clinical findings from the minimum database should direct you to further diagnostics, such as radiography or ultrasonography. of patients hospitalized with acute vomiting would receive an antiemetic? Twedt: I did a survey of our intensive care unit patients that were getting intravenous uids and were vomiting. Virtually every patient was given an antiemetic. Leib: I agree that if we review the vomiting patients in our intensive care unit, close to 100% receive antiemetics. If they weren’t vomiting frequently, they might not even be in the intensive care unit. Williams: If the animal is sick enough to be hospitalized for acute vomiting, it is probably going to be given an antiemetic. Twedt: In those patients, we need to be aggressive about determining the etiology of the vomiting. An antiemetic can be e ective for the nausea and for preventing uid and electrolyte loss that occurs with vomiting. If this occurs, the patient will be more comfortable. But antiemetics should not replace a good diagnostic evaluation. Williams: In a general practice setting, mechanical obstruction 7
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