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“Dillinger” Duckworth

“Dillinger” Duckworth. 11yo MN Siberian Husky MR# 12957. Dillinger 11yo MN Siberian Husky. Presenting complaint: PU/PD and urinary incontinence

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“Dillinger” Duckworth

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  1. “Dillinger” Duckworth 11yo MN Siberian Husky MR# 12957

  2. Dillinger 11yo MN Siberian Husky • Presenting complaint: PU/PD and urinary incontinence • History: 1-year history of slight incontinence. Over the past few months, the owner observed increased thirst and increased frequency of drinking. Consequently, he has been urinating more and appears to be more incontinent. Otherwise, there are no other clinical signs.

  3. History • Medical history – 12/03: Hpercalcemia = 12.5; USpG = 1.007 • No previous surgery besides neuter • Travel history – Texas and California • Medications – Rimadyl PRN; Cephalexin for hot spots

  4. Physical Exam • P.E.: BAR, vitals WNL, reluctant to allow palpation of the caudal abdomen, normal rectal exam.

  5. Problem List • PU/PD • Incontinence? • Hypercalcemia • Intact PTH – 134.5 (20-130) • Ionized Calcium – 2.16 (1.24-1.43) • Calcium – 12.8 (8.9-11.4)

  6. Primary HyperPTH • Working diagnosis of primary hyperparathyroidism • Additional diagnostics: • Cervical ultrasound • Thoracic radiographs • Abdominal ultrasound SEE RADIOLOGY/US REPORT

  7. Adrenal Mass? • FNAC • Neuroendocrine/Adrenal tumor • High-dose Dexamethasone suppression test • Cortisol, 0hr – 5.2 (0.0-10.0) • Cortisol, 4hr – 0.4 • Cortisol, 8hr – <0.3 (0.0-1.4) • Suspect Pheochromocytoma

  8. Plan • BP = 105 systolic • Parathyroidectomy 1st • PU/PD • ↑ Ca2+ • +/- Adrenalectomy (Pheo.)? • Incidental finding? (approx 30%) • PU/PD (25%)

  9. Other possible diagnostics? • Diagnostic Imaging • CT/MRI • Rosenstien (MSU) Vet Rad/US 2000 • P-[18F] fluorobenzylguanidine (PET) • Berry et. al. (NCSU) Vet Rad/US 2002

  10. Other possible diagnostics? • Hormonal testing • Plasma catecholamines • Clonidine supression test • Urinary catecholamies/metabolites • Metanephrine, Normetanephrine, VMA • Pentolamine test

  11. Plan • Initiate Phenoxybenzamine • Alpha-adrenergic blocking agent • Minimize hypertensive reactions and cardiac arrhythmias • +/- beta blocker • If hypertension present despite phenoxybenzamine • If arrhythmias or tachycardia present

  12. Surgery (10/27/04) • CBC, Chem, UA • Saline diuresis • Parathryoidectomy • Intra-operative PVCs • Blood pressure • Systolic 70-90 • Mean 50-70 • Responded to Lidocaine

  13. Surgery (10/27/04) • Recovered well post-op • Fluids • ECG, BP • Calcium checks • Analgesia • Hypocalcemia (expected) - stabilized • Discharged 10/30/04 • Parathryoid adenoma

  14. Follow-up 11/14/04 • Normocalcemic • No improvement in the PU/PD • Plan  Adrenalectomy

  15. Surgery (11/17/04) • Anesthetic considerations • Alpha-blocking agent • +/- Lidocaine before induction • Avoid Ketamine – sympathetic stim. • Isoflourane • +/- non-depolarizing NM blocking agent • Fentanyl CRI intra-op • Direct BP • Central line

  16. Surgery (11/17/04) • Intra-op • Large adrenal mass engulfing the left kidney • Nephrectomy and Adrenalectomy • No arrhythmias • BP (60-120 systolic) • HR ↑ 200 in one reading

  17. Surgery (11/17/04) • Intra-op • Blood loss  hypotension • ↑ fluids • Hetastarch • Whole blood transfusion

  18. Surgery (11/17/04) • Immediately post-op • Sudden arrest in prep-room as central line being placed • CPR  no response

  19. Surgery (11/17/04) • Possible causes? • Blood loss • Rapid hypotension post-pheo. removal • Cardiac arrhythmia • Hemorrhage • Thromboembolic episode

  20. Histopathology • Adrenal carcinoma? • Cushing’s? • Thromboembolic episode?

  21. Histopathology • Requested special stains • Churukian-Schenk silver stain • Pheochromocytoma

  22. Discussion • What could have been done differently? • Lidocaine pre-med? • LMWH? • Direct BP? • Beta blocker?

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