Dillinger Duckworth

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
• 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?
• Cushings?
• 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?