Clinical Equine Reproduction - Care of Sick Neonate Flashcards
(36 cards)
What is a red bag delivery? What consequences does it have?
Premature separation of chorion from uterine epithelium –>
First observe red velvety chorionic surface (vs. smooth amnion in normal parturition) –>
Disruption of oxygen exchange surface –>
Foal may be clinically normal or show signs of neonatal maladjustment
What is a common syndrome in foals that you oftne get is they have a red bag delivery?
What clues might the foal have that points you in this direction?
After red bag delivery - What can be seen?
- Perinatal asphyxia syndrome
- Ataxia, uncoordinated
- Head pressing
- Can it see properly? Hard to tell if it cannot see or if it just cannot move properly – but certainly not aware of its surroundings and if you left, it would circle, no interest in mare and would not be able to find udder to suckle
What are some other names for neonatal maladjustment?
•Many names
–Hypoxic Ischemic Encephalopathy (HIE)
–Perinatal Asphyxia Syndrome
–Dummy foal
–Barker
–Wanderer
What is the problem with neonatal maladjustment syndrome (perinatal asphyxia syndrome)?
- Variable clinical signs from subtle to coma
- Difficult thing about this is that its really variable – some just look a bit slow, through to coma, seizure activity and death…
What are some of the theories behind neonatal maladjustment (perinatal asphyxia syndrome) that can go on to cause neuronal injury?
With neonatal maladjustment (perinatal asphyxia syndrome), what can be higher in cells? What does this cause?
What else is activated?
What can hypoglycaemia do?
•Increased intracellular calcium and sodium
–Failure of energy dependent cell membrane ion pumps
–Cellular swelling
- Calcium accumulation activates calcium dependent phospholipases, NO synthase and proteases
- COX 2 activation increases production of inflammatory lipid mediators
- Hypoglycemia exacerbates brain injury
With neonatal maladjustment (perinatal asphyxia syndrome) what is the role of neurosteroids?
- Neurosteroids (progestagen compounds) are neuromodulatory and are integral fro the transition to extra uterine life
- NMS can be induced in normal foals by administration of allopregnanolone1
- Depression compatible with NMS but without the hypoxic-ischemic event
- Reversion to fetal consciousness with the ‘squeeze technique’
In a foal with neonatal maladjustment (perinatal asphyxia syndrome), the foal is ambulatory and shows no seizure activity yet.
How can we control cerebral oedema and inflammation?
–Mannitol and hypertonic saline (7.2%)
–NSAIDS
–Dimethyl sulphoxide (DMSO) - free radial scavenger – industrial chemical
–Glucocorticoids? Debate goes on – if inflammatory, might help, but if free radical damage might not help!
In a foal with neonatal maladjustment (perinatal asphyxia syndrome), the foal is ambulatory and shows no seizure activity yet.
How can we combat ongoing oxidative damage?
–DMSO - free radial scavenger – industrial chemical
–Magnesium - anti-oxidants and decrease damage to nerve cells
–Vit C and E
In a foal with neonatal maladjustment (perinatal asphyxia syndrome), the foal is ambulatory and shows no seizure activity yet.
What are out treatment goals overall?
Control cerebral oedema and inflammation
–Mannitol and hypertonic saline (7.2%)
–NSAIDS
–Dimethyl sulphoxide (DMSO)
–Glucocorticoids? Debate goes on – if inflammatory, might help, but if free radical damage might not help!
Combat ongoing oxidative damage
–DMSO - free radial scavenger – industrial chemical
–Magnesium - anti-oxidants and decrease damage to nerve cells
–Vit C and E
- Provide metabolic requirements
- Address any concurrent medical conditions
- Squeeze
- Nutritional support
In a foal with neonatal maladjustment (perinatal asphyxia syndrome), what is the theory behind using the ‘squeeze’ tehcnique?
If mild signs – if you squeeze them, mimic pasage of foal through maternal birth canal so get rid of some of these signs. Some success with mild cases and sometimes it will reduce clinical signs but in severely affected cases – wont do much!
Wrap rope around neck and twice around thorax – similar to making cow lie down
Mimics pressure through birth canal and usually leave on for 15-20 minutes
Good tool if you have a foal that you need to do stuff too but you just want them to lie still for a minute! They lie down and go a bit sleepy – rather than having to use drugs
With neonatal maladjustment (perinatal asphyxia syndrome), how can we combat the concurrent issue of failure of passive transfer?
–Plasma transfusion
–colostrum
With neonatal maladjustment (perinatal asphyxia syndrome), how can we combat the issue of concurrent sepsis - what can cause this sepsis?
•Concurrent sepsis (pre-partum if mare had uterine infection)
–If return of inutero placentitis that the foal may also have blood born sepsis
–Down more on wet umbilicus – increased likeliness of bacteraemia
Ina foal with neonatal maladjustment (perinatal asphyxia syndrome), how do we provide them with nutritional support?
This case is ambulatory but suck relfex if poor. Can tolerate enteral nutrition.
•Options
–Colostrum – little bit old for colostrum (as about 18h by now) but yes, if mare has it – milk mare and give it to the foal!
–Wont be able to nurse for 3 or 4 days likely…
–Can try bucket or bottle but will be hard for it to
–Total IV nutrition but £££
–Using its gut – as long as doesn’t have ileus, colic or reflex – so placed enteral feeding tube
•How much
–A normal foal might eat 20% of the BW per day – so if 50kg foal, that’s about 10L – usually drink about 6x per hour which is not something we can mimix
–Hand strip mare if she has enough
–Milk replacer
–In sick neonate – they might not be able to tolerate 20% so might aim for 10% - roughly 400ml/every 2h
- Mare’s milk
- Hand strip in to a clean bowl
- Milk replacer (3/4 strength)
- Healthy foal will consume 20-25% body weight per day (10L/day)
–Nursing up to 6 times per hour
•Compromised neonate aim for 10% body weight (5L in 24 hours)
–400mls every 2 hours
–Start at 200mls/2hr and increase over first 24 hours
Why is increased fibrinogen significant in a neonatal foal?
Increased fibrinogen – acute phase protein, takes a while to get going to high levels – so if you see that this is high in a neonate, then this foal has probably had an in-utero infections in order to get this response to be high at this age
What is SIRS?
- 2 or more of
- Increased or decreased body temperature
- Tachycardia
- Tachypnea
- Leukocytosis, leukopenia or >10% band neutrophils
How do we define severe sepsis?
- SIRS plus organ dysfunction or hypo perfusion
- Lactate>4mmol/l
How do we define septic shock?
•Severe sepsis refractory to volume resuscitation
What is the pathophysiology of sepsis?
Pathogen associated molecular patterns (PAMPS) e.g. LPS lipotechoic acid, flagellin or damaged associated molecular patterns (DAMPS) e.g. extracellualr DNA and RNA, heat shock proteins –>
Pattern recognition receptors eg TLR-4 on macrophages
–>
Pro-inflammatory cytokines TNFalpha, Il-1B, IL-2, IFN-gamma
–>
Acute phase protein production, endothelial cell damage
With sepsis, you get microvascular thrombosis and neutrophil chemotaxis - what does this lead to?
Microvascular thrombosis and neutrophil chemotaxis –>
Increased capillary permeability –>
Hypotension –>
Multi-organ dysfunction
Key things – active of coagulation cascade, change in membrane permeability, hypotension and if we don’t restore perfusion to tissues – will get MODS and once we get to this stage, death is usually the outcome!
In a foal with neonatal sepsis, what are out initial stabilisation and diagnostics?
- Gloves and aprons etc
- Warm dry clean bed
- Aseptically placed jugular catheter (in this case over the wire MILA 2 lumen)
–Wrapped – as foals are good at rubbing things out!
•Resuscitation fluids
–Incremental fluid bolus concept
–20ml/kg (1L for a 50kg foal)
–Up to 4 boluses (initially 1L hyperimmunised plasma and 1L Hartmann’s)
–Multiple ways to volume resuscitate – warm fluids, haartmans, 20mk/kg is rough dose for resus – bag if fluids, squeeze it in, reevaluate after its had 1 or 2 L
•Intranasal oxygen
–Whilst waiting for arterial blood gas results
- Urinary catheter
- Arterial blood gas analysis
In a foal with neonatal sepsis - what are the estiamted costs of treatment?
What is their prognosis like?
- Estimated cost of treatment £1000 per day initially (minimum of 72 hours intensive care)
- Prognosis is difficult to predict (even without financial constraints)
- Reported short term survival ranges from 50-70%1
–Outcome has improved significantly over recent years
- Owner elected to pursue treatment
- They are really expensive! Need to keep costs in mind and let owners know this! Will require MIMIMUM of 3 day intensive care
In foals with neonatal sepsis, what antibiotics should we give?
- Always take a blood culture of these foals but often have to wait for these results so give:
- Broad spectrum antibiotics (awaiting blood culture)
–Penicillin G 22,000-44,000IU/kg IV q 6hrs
–Plus gentamicin (8-12mg/kg IV q24hrs) – be aware that dose is different in foals (they have larger volume of distribution due to increased body water)
•Product License is for 6.6mg/kg IV
»This is probably an inadequate dose
•Up to 15mg/kg maybe required but requires gentamicin kinetics to be run
–Or ceftiofur 2-10mg/kg IM or IV q6-12hr
How does a foals volume of distribution differ to that of an adults?
Be aware that dosages are different in foals (they have larger volume of distribution due to increased body water)
