Pause, notice...and accept

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In our previous blogs we have discussed how wellbeing can be seen as a foundation on which we can build; a strong basis to help us to move towards fulfilment and achievement. 

By prioritising our physical and emotional wellbeing, as well as our happiness, we establish a springboard from which we can learn to thrive and succeed. As the first stage in this process, we have previously discussed the importance of ‘being’ and how we can overcome our ‘automatic pilot’ by simply pausing and consciously observing how we feel. This allows us to notice and acknowledge our physical and mental state in any given moment. 

Acknowledgement alone can be a great tool and can have an immediate effect on how we feel. But more significantly, it is an essential first step towards acceptance.

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Acceptance may be something that we try to avoid. Because sometimes, to accept can feel as though we have somehow given up and any hope of change has ceased to exist. But the reality is quite the opposite. Acceptance is actually the precursor for change and helps to reduce anxiety and improve self-esteem by appreciating ‘what is’ without judgement, especially of ourselves.  

Acceptance in this way can apply to many moments within our lives – both the big and the small. Seemingly small day-to-day issues such as irritation towards another road user as you navigate your journey to work or frustration as a result of running late might seem like just ‘one of those things’. You may not give it another thought.  But what could the alternative look like? Noticing, acknowledging and accepting feelings such as these is an opportunity to better understand our reaction in these moments. This helps to prevent any resulting feelings from negatively impacting our health and wellbeing. 

Acceptance can also apply to bigger issues that might be affecting us. For example, if we believe that we haven’t been looking after our body (we haven’t been paying attention to our diet, not exercising, relying on alcohol or substances for example), we may find ourselves either holding onto the judgemental feelings we have about ourselves, or repressing them altogether. However, by consciously acknowledging the issue, addressing it with kindness and allowing ourselves to accept the situation, we are far better placed to move forwards.

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And so, the big question is how do we help ourselves to be more accepting? Would it seem too simple if we said you begin by simply giving yourself permission? Whilst this might sound obvious, how often do we really take a moment to notice how we are feeling and (either silently or aloud) acknowledge that feeling along with a confirmation that it’s OK to feel that way. This conscious process is the starting point. It is fundamental to helping us to be OK in the present moment. 

And there are additional techniques which can further complement the practice. Emotional Freedom Technique (see here for more information), mindfulness training and guided meditation are good examples of other ways which can provide a basis for non-striving, non-judging acceptance. For further information on any of these and for further advise, please contact any of the VetLed team using the details below.

The great news is that improving your ability to notice, acknowledge and accept can better your sense of peace and wellbeing. The even better news is that it doesn’t end there. With acceptance comes a clarity and sense of freedom from which we can form an intention and a motivation to make change. This might mean, for example, that we become better able to accept former lifestyle habits and can now more objectively understand what we can change that might improve our health, without the burden of judgement or regret. An acceptance for ‘what is’ allows you to approach the next steps with kindness, curiosity and optimism. 

And anything done with kindness, curiosity and optimism is always good medicine for the mind, body and soul. 

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About VetLed

VetLed was founded to provide support to veterinary professionals who are faced with significant challenges every day. The VetLed team believe that creating a compassionate and professional workplace culture that puts people wellbeing and patient safety at the core of everything we do, will in turn, improve animal and people welfare. The VetLed performance approach supports veterinary professionals to maximise their own wellbeing and to fully utilise their skills to deliver optimal patient care. You can contact VetLed by emailing info@vetled.co.uk

Drowning Refresher

By Lisa Murphy DACVECC

Pathophysiology

Once the airway is below the surface of a liquid voluntary breath-holding occurs. This is then followed by involuntary laryngospasm as liquid enters the oropharynx and larynx. During both of these periods, the victim is not breathing gas and develops hypercapnia, hypoxaemia and acidosis. Once the arterial oxygen partial pressure drops sufficiently, laryngospasm stops and liquid is then actively aspirated. It is the hypoxaemia which leads to unconsciousness and apnea. 

Once aspirated, water leads to several severe side effects:

  • One of the most significant is surfactant dysfunction and washout which reduces lung compliance and leads to atelectasis.
  • Water also interferes with the normal osmotic gradient in the alveolar-capillary membrane thus directly injuring the pulmonary epithelium. Damage to these cells has several effects including the release of inflammatory mediators and increased membrane permeability worsening fluid accumulation in the lung parenchyma.

It was once believed that the type of water (salt versus fresh water) was a more important determinant of outcome than the volume aspirated, however, more recent studies have found this to be untrue. This is because it’s the volume of water which affects surfactant function regardless of the type aspirated. Pool water is interesting because it typically contains agents to limit bacterial growth so secondary pneumonia is uncommon with this type of aspiration. 

The temperature of the water aspirated can also play a role in survival. Cold water is associated with higher rates of survival. This is because it reduces cellular metabolism (and thus oxygen consumption) and activates the diving reflex (leading to bradycardia, hypertension, shunting of blood to the cerebral and coronary circulations). 

Diagnosis 

The history of a drowning episode is usually known. Common tests performed in these cases include:

  • Blood gas analysis (ideally arterial) – most cases have a mixed respiratory and metabolic acidosis
  • Thoracic radiography:
    • Pulmonary oedema is likely
    • In some cases, where the volume of water aspirated wasn’t large but they suffered a choking-like episode, non-cardiogenic pulmonary oedema (NCPO) may be identified. This is suspected where the pulmonary oedema is predominantly in the caudodorsal lung field.
    • In cases which don’t go on to develop pneumonia, there is usually radiographic resolution of oedema within 7-10 days.

Treatment

The focus should be on controlling the patient’s hypoxaemia.
The risk of pneumonia is low (estimated at 12% in humans) so empirical antibiotics are not recommended. In general, it is much more likely for these cases to develop pneumonia if they undergo mechanical ventilation.
Steroids also have not been shown to increase survival and their use is not recommended. 

Similarly, there is little evidence supporting the use of diuretics in cases of NCPO. Diuretics are most useful for hydrostatic oedema which is associated with congestive heart failure. In cases of NCPO, the oedema is due to changes in pulmonary epithelium permeability (permeability oedema). Fluid can still leak into the parenchyma despite diuretic use. And since diuretics have systemic effects, they put patients at risk of dehydration and potential renal compromise. 

There are several criteria that we can use to help identify those patients who could benefit from mechanical ventilation. The main indications are as follows:

  • Arterial partial pressure of carbon dioxide > 60 mmHg
  • Arterial partial pressure of oxygen < 60 mmHg despite non-invasive oxygen supplementation 
  • Excessive respiratory effort with impending respiratory fatigue

Prognosis is not known in veterinary medicine. In general, animals showing more organ systems negatively affected and those requiring positive pressure ventilation have a worse prognosis. 

Seizure Refresher

By Lisa Murphy DACVECC

Seizures are one of the most common neurological emergencies seen by small animal vets both in general practice and in emergency clinics. What follows is a brief discussion of seizures and some of the more commonly used anticonvulsive medications for management of these cases.

Idiopathic Epilepsy:

  • Most dogs suffering from idiopathic epilepsy are between 1-5 years old with genetic predilection in the beagles, the Keeshond, the dachshund, the Irish wolfhound, Labrador and Golden Retrievers and the English springer spaniel.
  • They can have any type of seizure (generalized/tonic-clonic, focal) but generalised is more common.
  • Predisposing factors are not known in animals but in people include stress, sleep deprivation, missed medications and concurrent illness.
  • Idiopathic epilepsy is less common in cats although also usually occurs around 1-5 years old.
  • In studies evaluating dogs > 5 years old, 35% had no identifiable cause of epilepsy, while the remainder were divided into those with neoplasia (52%) and those with other aetiologies (inflammatory, vascular, congenital). All dogs in the 8-10 year old group and in the over 15-years old group, and 80% of dogs in the 11-13 years old group, had neoplasia as the underlying cause.
  • When comparing the neurological exam to MRI findings, of those who had an abnormal neurological exam 79% went on to have a lesion on MRI. A properly performed neurological exam is considered to have 74% sensitivity and 62% specificity for diagnosing secondary epilepsy. 

Metabolic and Toxic Causes:

Among the lesser studied causes of seizures in our patients are metabolic and toxin associated seizures, of which there are a number of potential culprits.

A retrospective study was performed on almost 100 dogs and found some very interesting findings. Intoxications were the most common cause with metaldehyde most likely (although this likely depends on geographic location). When evaluating metabolic causes alone, hypoglycaemia was most common. Interestingly, reactive seizures secondary to metabolic disorders or toxins had a 1.57x higher risk of a status epilepticus presentation as compared to idiopathic epilepsy.

Secondary Intracranial Hypertension: 

While most seizures do not tend to be life-threatening, animals which have multiple seizures in a short period may be at risk for developing intracranial hypertension (ICH). Typically, intracranial pressure (ICP) is maintained within a narrow range secondary to several physiological processes. These can be disrupted as a result of seizure activity. 

If left untreated, significant intracranial hypertension may lead to the Cushings response which is often fatal. Clinically it should be suspected in a seizuring patient with systemic hypertension and bradycardia. 

Anticonvulsive Medications

Common first line anticonvulsive medications:

Thankfully, most patients presenting with seizures do not go on to develop such life-threatening complications and typically just require acute control of their seizures.

Benzodiazepines:

  • The most common medications employed to stop seizures are benzodiazepines. Diazepam and midazolam are typically given intravenously (0.5 mg/kg) or rectally (1 mg/kg) for rapid seizure control.
  • It is important to note however that they have a very short duration of action and animals may start having seizures again within 10 minutes of their administration.
  • These drugs also need to be used cautiously in patients with seizures due to hepatic encephalopathy as the drug’s metabolism will be reduced resulting in more significant sedation.
  • In some cases, a continuous infusion or repeated bolus administration must be used while waiting for the patient to respond to medications used for longer-term seizure control. Midazolam is recommended for this as it is water soluble and causes less thrombophlebitis; however, neither drug is superior to the other for seizure control.

Ketamine/Dexmedetomidine:

  • Some patients are refractory to acute control with benzodiazepines and will continue to seizure. Recent case reports in veterinary patients have shown that ketamine and dexmedetomidine may be able to offer short-term seizure control in such cases.
  • In both cases, high doses are typically needed and patients require continuous monitoring for significant side effects.
  • Patients typically remain on an infusion until they are seizure free for at least 6-12 hours. The drug then needs to be slowly weaned over the next 6-12 hours.
  •  While the dog is on these infusions, a second medication for chronic seizure control must be started.  

Common long-term anticonvulsive medications:

Phenobarbital:

  • The most commonly used drug in veterinary patients.
  • Benefits include relatively low cost and, for most animals, being well tolerated long term.
  • Major disadvantages include the need to ‘load’ the drug as therapeutic levels can take several days to be attained during which time the animal would be at continued risk of further seizures. This involves the administration of a larger dose for the first 24 hours followed by a much lower maintenance dose. At high loading doses, most dogs will be very sedated. Their carers need to be warned that they can continue to be very sedated, and potentially ataxic, for the first few days of treatment.
  • Cats tend to show fewer side effects.
  • Phenobarbital also needs to be used cautiously in animals with an underlying hepatic disease as the drug will increase hepatic enzymes over time. 

Potassium Bromide (KBr):

  • Can also be employed in dogs
  • It requires loading to attain therapeutic levels during which time the dog can be very sedated.
  • While it can offer excellent seizure control, some dogs develop significant side-effects (e.g. gastrointestinal, megaoesophagus, dysphagia) and treatment needs to be discontinued.
  • It is important to note that bromide competes with chloride ions in the renal tubule. Vets treating animals that are on chronic KBr treatment with intravenous fluids need to recognize that concurrent use of 0.9% sodium chloride will speed up renal clearance of KBr. 

Levetiracetam:

  • Has become more widely used in recent times
  • The exact mechanism of action is unknown
  • Major benefits of this drug include minimal side effects and that it attains therapeutic levels within 60 minutes of administration
  • While levetiracetam has excellent short-term effects, its use as long-term monotherapy for seizure control is controversial. It has been used in this was for idiopathic epilepsy but, after a ‘honeymoon’ period, an additional anticonvulsive medication may be needed.

Zonisamide:

  • A synthetic sulfonamide based drug
  • Takes a few days to achieve therapeutic levels
  • Tends to be well tolerated by most dogs
  • Advantages include generic drugs now available (so less cost) and the need for only twice daily dosing (so better compliance)
  • There are sparse case reports of dogs developing immune-mediated thrombocytopenia secondary to the sulpha component within the drug so this risk, while low, should be discussed with carers.
  • One caveat to its use is that concurrent use of phenobarbital increases the renal clearance of zonisamide so the dose may need to be increased. 

Pregabalin:

There is not as much data available for the use of this drug in dogs. Studies that have been performed show that it can reduce seizure frequency by fifty per cent when used in dogs on chronic phenobarbital or potassium bromide therapy.