BLOCKED CATS: DISPELLING THE MYTHS

Dez Hughes, BVSc, MRCVS, Dip. ACVECC Senior Lecturer, Emergency and Critical Care, Royal Veterinary College, London Blocked cats are arguably the most common condition seen in practice that is life threatening yet potentially curable. Success rates for unblocking and survival can and should approach 100%. This depends upon prompt and accurate assessment of each case, careful stabilisation and optimal treatment. Nevertheless, the majority can survive and moreover, go on to a full and happy life.

Unfortunately the optimal management of the cat with urethral obstruction is marred by certain problems and popular misconceptions. The most important things to consider to optimise success rates are: An immediate and accurate assessment of the major body system abnormalities of the cat Measurement of electrolyte and ideally acid base status Electrocardiographic monitoring Optimise initial stabilisation prior to unblocking: o Aggressive fluid therapy is sometimes necessary and can be administered safely despite the obstruction o Use isotonic crystalloids NOT 0.18% saline (the Devils fluid!) o Calcium gluconate is a wonder drug and should be used in preference to insulin/ dextrose or bicarbonate for hyperkalaemia Do not perform cystocentesis Optimise technique for urethral catheterisation to increase success rates and avoid urethral trauma dont use Walpoles Dont use baseline azotaemia as a prognostic indicator (my record for a blocked cat is over 3000!!!)

Initial assessment A streamlined, efficient major body system examination is performed to rapidly identify any imminently life-threatening problems. The cardiovascular, respiratory and central nervous systems should be evaluated first, followed by abdominal palpation and body temperature. Stabilization measures should be initiated for any major problems prior to the remainder of the full physical evaluation. For the cardiovascular system, evaluation of the mucous membrane colour, capillary refill time (CRT) and vigour, pulse profile (height and width), heart rate, and cardiac auscultation should be performed. The astute clinician may be alerted to the possibility of hyperkalaemia following this initial cardiovascular assessment. A common finding is that the heart rate is inappropriately slow for the degree of hypoperfusion present. For example, a cat with very pale mucous membranes, absent capillary refill time, weak femoral pulses but a heart rate of only 100 140 has an inappropriate bradycardia. This finding should prompt an immediate electrocardiogram. Indeed an ECG is the quickest and easiest means of making the diagnosis of hyperkalaemia provided that one is familiar with the typical changes seen.

ECG The cardinal signs of hyperkalaemia are relative bradycardia, peaked T waves, absent P waves and in severe cases, wide bizarre QRS complexes. The most severe ECG change seen is the so-called sine wave conformation (left). It is important to realise that individual animals vary in their ECG response to hyperkalaemia. For example, some blocked cats will be virtually normal with a potassium concentration of 7 mmol/L whereas others may be near death. Treatment should always be based upon the perfusion status of the animal and the electrocardiogram not the plasma potassium concentration. ECG showing bradycardia, absence of P waves and spiked T waves

ECG from blocked cat with severe hyperkalaemia and sine wave configuration.

Diagnostic evaluation and stabilisation The emergency minimum data base should comprise at least PCV, TS, blood glucose and BUN and ideally full haematology and biochemistry and a venous blood gas.

In hypovolaemic patients, volume resuscitation should be performed with isotonic crystalloid solutions in the first instance with infusion rates appropriate to the degree of hypoperfusion. Rates of up to 40-60 ml/ kg/hr in the cat may be required providing that there are no contraindications for rapid fluid therapy (and urethral obstruction is not one of them!). It makes sense to use fluids without potassium in hyperkalaemic patients. If 0.9% NaCl is used rather than a crystalloid with a higher pH, the cats pH will be slower to return to normal but this does not appear to be clinically significant. DO NOT USE 0.18% SALINE!!!! This fluid is seriously hypotonic (1/5 of normal osmolality). Because of its high water content, it rapidly diffuses into cells and is therefore a lousy intravascular volume expander. More importantly it can cause a very rapid fall in plasma sodium concentration. Water then diffuses into the brain which causes cerebral oedema, seizures and death. This is not a possible problem; it is a real and definite danger. In hyperkalaemic blocked cats the response to 1-5 ml of intravenous 10% calcium gluconate can be truly amazing and this treatment along with 50 - 200 ml of NaCl over 1 hour is usually sufficient to stabilise the majority of hypovolaemic, hyperkalaemic blocked cats. In severe cases adjunctive therapy with insulin and glucose or bicarbonate can be considered. It cannot be overemphasized that cats must be stabilised prior to urethral catheterisation. In my experience, there is virtually never a need to perform cystocentesis. Furthermore, I have seen cases of subsequent uroabdomen requiring exploratory laparotomy where the only bladder lesion found was the cystocentesis hole. I expect that in cases where urinary flow is maintained after unblocking that cystocentesis will not result in a serious problem, but in cases where they are still dysuric and the bladder consequently fills, then the risk of uroabdomen following cystocentesis is higher.

BLOCKED CAT PROTOCOL

(for cats without other serious major body system abnormalities or concurrent disease)

Dez Hughes BVSc, MRCVS, Dip. ACVECC

ASSESSMENT 1. ABCs and major body system evaluation 2. Intravenous catheter 3. Emergency database (PCV/TS/Azostick/BG/electrolytes and ideally full biochemistry) 4. Electrocardiogram TREATMENT ALWAYS STABILISE CARDIOVASCULAR STATUS BEFORE UNBLOCKING Fluid therapy (up to 40-60ml/kg/hr) Treat hyperkalaemia 1. calcium gluconate: 0.5- 1.5 ml/kg @ 1 ml/min IV 2. +/- insulin: 0.25 0.5 iu/kg IV + 2g/iu of insulin administered and add 2.5% glucose to IV fluids 3. occasionally +/- sodium bicarbonate: 1-4 ml/kg

RELIEVE OBSTRUCTION 1. Palpate penis and urethra to pelvic brim and attempt to manually break up any obstruction 2. If necessary sedate with benzodiazepine (0.3 0.6 ml/cat) and ketamine (0.1 0.2 ml/cat) or opiate/benzodiazepine if hypoperfusion and hyperkalaemia was present or if otherwise unstable 3. Have assistant restrain in dorsal recumbency with hip flexion and extrude penis 4. If penis cyanotic, palpate for intrapenile obstruction 5. Pass lubricated urinary catheter into tip of penis for 2-4 mm 6. Allow penis to return into prepuce then pull prepuce caudally and dorsally to straighten urethra 7. Twist and gently advance catheter 8. Attach 20 ml syringe with isotonic flush to catheter ideally via short, small bore extension tubing 9. Administer short, sharp flushes whilst twisting and advancing catheter 10. Fully drain bladder 11. Flush bladder repeatedly until urine as clear as possible 12. Palpate bladder while flushing to evacuate as much sediment as possible 13. Inject 0.5 ml lignocaine while withdrawing catheter ( not always done) 14. Pass 3.5 5F flexible urinary catheter/feeding tube 15. Secure with tape butterfly & mattress suture either side of prepuce and secure catheter to tail (tape to catheter then tape to tail) 16. Attach to IV tubing and empty IV fluid bag ( if stored correctly capped < 7 days) or proprietary bag i.e Mila .

FURTHER TREATMENT AND MONITORING 1. Fluid therapy: initially 5-10 ml/kg as if euvolaemic & no contraindications then modify on the basis of urine output, PCV/TS, electrolytes and hydration status 2. Allow for elimination of any IV fluid bolus then modify IV fluid rate to exceed urine output by maintenance ( exceed by 2ml.kg.hr) and replacement requirements (for a 5kg cat, 5% dehydration = 10 ml/kg/hr) 3. MBS parameters q 2-6 hrs 4. Assess urine output q 2-4 hrs 5. PCV/TS/electrolytes q 2-6 hrs initial for sick cats 6. Consider need for analgesia and anti-inflammatory drugs 7. Consider phenoxybenzamine 8. no antibiotics, corticosteroids or bethanechol 9. Leave urinary catheter in >24 hrs until urine is clear 10. Consider cystocentesis, urine analysis (dipstick and sediment) +/- culture after catheter removal