006: Pancreatitis: When Exocrine Goes Haywire

It is that time of year. Pancreatitis season. A season that only exists in veterinary medicine. 
This week we discuss the exocrine function of the pancreas and when it gets angry. 

Show Notes:

Join Yvonne Brandenburg, RVT, VTS SAIM and Jordan Porter RVT, LVT, VTS SAIM as we talk about:

• Inflammation of the pancreas and exocrine function of the pancreas.

 Resources We Mentioned in the Show

• Texas A&M GI Lab:
  •  http://www.cvm.tamu.edu/gilab/research/pancreatitis-information

• Merck Veterinary Manual:
  • https://www.merckvetmanual.com/digestive-system/the-exocrine-pancreas/pancreatitis-in-small-animals
  • https://www.merckvetmanual.com/digestive-system/the-exocrine-pancreas/overview-of-the-exocrine-pancreas

• IMFPP Anatomy:
  •  https://www.internalmedicineforpetparents.com/endocrine.html

• CE for using Plasma in Pancreatitis patients:
  • https://vetgirlontherun.com/treating-the-pancreatitis-patient-with-plasma-vetgirl-veterinary-continuing-education-blog-scheduled/

• Transfusion Medicine:
  • https://imfpp.org/jordanstransfusionarticle 
  • https://imfpp.org/transfusionbook 
• Quality of Life Tracker
  • https://imfpp.org/QOLscale 

Thanks so much for tuning in. Join us again next week for another episode! 
 
Listening Options 

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• Subscribe on Apple Podcasts or your favorite podcast player for free! 
• If you enjoyed this episode, rate and leave us a review wherever you can! 

Contact Us! 

• Check out www.internalmedicineforvettechs.com  
• If you want to get involved, leave us a comment! 
• Visit us and give us a ‘like’ on our Facebook page!
  https://www.facebook.com/internalmedicineforvettechs 
• Email us at podcast@internalmedicineforvettechs.com  

Thanks for listening! 
– Yvonne and Jordan 

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006 Pancreatitis: When Our Veterinary Patient's Exocrine Function Goes Bad transcript powered by Sonix—the best audio to text transcription service

006 Pancreatitis: When Our Veterinary Patient's Exocrine Function Goes Bad was automatically transcribed by Sonix with the latest audio-to-text algorithms. This transcript may contain errors. Sonix is the best way to convert your audio to text in 2019.

Yvonne Brandenburg, RVT, VTS SAIM:
Welcome to the Internal Medicine For Vet Techs Podcast. If you haven't joined us before we're passionate about all things internal medicine and helping you become the best tech you can be. We'll be discussing interesting internal medicine diseases, how to work closely with pet parents, and how to become the go to tech in your practice. Now let's start the show.

Jordan Porter, RVT, LVT, VTS SAIM:
Welcome back to the Internal Medicine For Vet Techs Podcast. Thank you for listening and making a commitment to learning. Hope you guys are doing well. I am your co-host Jordan, along with Yvonne.

Yvonne Brandenburg, RVT, VTS SAIM:
Hi.

Jordan Porter, RVT, LVT, VTS SAIM:
Hi.

Yvonne Brandenburg, RVT, VTS SAIM:
How's everybody's week going?

Jordan Porter, RVT, LVT, VTS SAIM:
Mine's pretty good. Yours? Uneventful?

Yvonne Brandenburg, RVT, VTS SAIM:
Not too bad. I mean, it's Sunday morning here in California. Weather is changing.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah it's nice and cool here because it rained yesterday.

Yvonne Brandenburg, RVT, VTS SAIM:
Ah, nice. No it's cooling off. It's doing that weird hot days then cold days thing.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, Yeah, Yeah. the typical, like we can't decide if it's fall or not.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. Yeah exactly.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Well getting into the show last week our Question of the Week was how does your practice manage pain and how do you educate your clients. So if you haven't commented we would like you to on Internal Medicine For Vet Techs page and then hopefully we will kind of get on track of answering any questions and things like that too. We're prerecording, so it's kind of hard to answer questions right now.

Yvonne Brandenburg, RVT, VTS SAIM:
But, yeah, if you guys want to head over to InternalMedicineForVetTechs.com/podcast that'll work. We'll also, we just created a short link InternalMedicineForVetTechs.com/podcast is quite a mouthful. So we have imfpp.org/podcast so you can always check that out in case you don't remember we do have Internal Medicine For Pet Parents as the kind of overarching company and so a lot of our stuff is linked with them as well. And it's the same people. It's just geared towards pet owners versus technicians so it's mostly the same things.

Jordan Porter, RVT, LVT, VTS SAIM:
But just lots of ways to find us.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. Yeah there is a lot of ways to get to us.

Jordan Porter, RVT, LVT, VTS SAIM:
So this week we will be discussing pancreatitis. I know in specialty practice, well in internal medicine we see that a lot. But I know when I work in general practice we saw a lot.

Yvonne Brandenburg, RVT, VTS SAIM:
So yeah I think pancreatitis is one of those, yeah so many animals get it. It's kind of crazy. I remember in general practice we saw a ton of it too especially around the holidays and this episode should be going live right before Thanksgiving. We did this on purpose because you'll probably be seeing more of the pancreatitis in the next month. So we thought it was pretty timely to talk about the pancreatitis.

Jordan Porter, RVT, LVT, VTS SAIM:
So what is pancreatitis. So it's inflammation of the pancreas if you remember your tech schooling and learning what those words meant that -itis is inflammation of pretty much anything. Pancreatitis is the most common exocrine pancreatic disease in both dogs and cats. So not just limited to one species.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. So I have to say this because it makes me laugh every time I think exocrine and endocrine now, I believe exocrine and endocrine pancreatic functioning is how Jordan and I really met.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
So I just I'll throw this little tidbit out there. So we created the page InternalMedicineForPetParents.com/endocrine. I think that was the page, right? Endocrine?

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
And we were talking about the endocrine and the exocrine function, oh maybe it was the pancreatitis/pancreas page, anyways.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, I think it was specifically the pancreas page.

Yvonne Brandenburg, RVT, VTS SAIM:
So, we put it all up there and, it's a funny story because Ashley and I had gone back and forth, Ashley had written the post first and it was, she was in the middle of doing a bunch of stuff for conferences, and she had mixed up exocrine and endocrine. And I was like, "Ashley, I know you, I know you know this better because you lecture about this stuff all the time." And so I gave her crap about it. Well, we missed one. And it got put up on the website, and Jordan, Jordan wasn't even, she wasn't a VTS yet she was still studying for her boards. And she was like, she sent me this cute little Facebook message and she's like, "So, I don't want to be that person but I think there's a mistake. Do you mind me telling?" And I was just like, "Oh my god, I'm so sorry there's a mistake, please tell me what it is so we can fix it". And then Jordan and I kind of just hit it off after that because I was like, "Thank you. Please let me know if there's any other mistakes because we are not perfect." So also, if you guys see mistakes in anything that we put up please let us know you can do contact@internalmedicineforvettechs.com, and it'll get to us and we can fix things like exocrine and endocrine but yeah a little side note.

Jordan Porter, RVT, LVT, VTS SAIM:
That's an easy one to mix up.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, I was like, "I don't want to be that person but I swear," like well it made me feel smart I was like, "Oh my god, I got something".

Yvonne Brandenburg, RVT, VTS SAIM:
And I joked, "like Jordan pass the test, she knows the difference between exocrine and endocrine." And it's funny because I think a lot of people kind of forget what that is so I'll just go back to what is exocrine and what is endocrine. So, endocrine: -endo means inside, right? And -exo means outside, so exiting. So, endocrine is going into the body, into the bloodstream. Whereas exocrine is excreted out, so you can be excreted: excocrine. So, that is when things leave the body. So, whether that sweat, or in our case pancreatic stuff, it's leaving the body and remember, I know this is really weird and it goes way back to like tech school, but inside of your GI tract is technically the outside of your body. Because there is skin that lines the entire lining of your GI tract and that everything that's in the GI tract is outside. Which blows my mind every single time I think about it. But it is.

Jordan Porter, RVT, LVT, VTS SAIM:
Right?

Yvonne Brandenburg, RVT, VTS SAIM:
Exocrine and endocrine.

Jordan Porter, RVT, LVT, VTS SAIM:
So the endocrine function of the pancreas is what produces insulin, the hormone that we should all know that decreases blood sugar or glucose in the bloodstream. And then it also produces glucagon which is a hormone that increases blood sugar in the bloodstream. So, that's within the blood that's what the pancreas is producing, so there could be a little confusing because you think that it's producing so it's excreting glucagon and insulin but it's still within the bloodstream like you said. Versus the exocrine pancreas is made up of the duct system that opens into the duodenum, that's part of the G.I. tract. So, that's the part that is outside the body. So, it secretes digestive enzymes which are essential for digestion. Just like how it breaks down proteins, triglycerides, carbohydrates, and then it's also responsible for secreting substances that are responsible for absorbing cobalamin, which we talked about already a little bit, B12. So, the exocrine function is kind of when that gets messed up, that's the pancreatitis kind of messing with excocrine function of the pancreas.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And, that's the key thing is there's that duct that goes from the pancreas out into the GI tract. And there's a lot of things that can happen with a duct. Just think of, same thing with, I know this sounds weird, but the duct in your skin. So, if it gets clogged then it causes backup and causes problems and that can also be from inflammation, junk that gets up in there, an infection. So, those are all different ways that the duct can get messed up. And the pancreas gets mad when that duct gets messed up because everything starts backing up, right? So, there's a lot of ways that duct can get clogged and we'll talk about some of those in just a few minutes.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. So, I think the way we are trying to kind of set this up is like when you go into a room with a client like what do you want to ask, like you want to know history questions, how it might present. You've got a known species that it's common in, breed, age. So, I think, I know when I think of pancreatitis or when I see a patient on the schedule that's coming in for vomiting, and diarrhea, and abdominal pain, I automatically think Schnauzer's.

Yvonne Brandenburg, RVT, VTS SAIM:
Which is funny because I automatically think Golden Retrievers.

Jordan Porter, RVT, LVT, VTS SAIM:
Oh really?

Yvonne Brandenburg, RVT, VTS SAIM:
Because they eat everything.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, I guess. Well, I think that's where you got to look at age too, so.

Yvonne Brandenburg, RVT, VTS SAIM:
But, yeah, breed specific, yeah, Schnauzers.

Jordan Porter, RVT, LVT, VTS SAIM:
So, there was a study that genetics kind of, they feel like play a role, so you have those breeds like Schnauzers and Dachshunds that are just kind of predisposed to getting pancreatitis. But of course I think, I think what people don't realize is most cases of pancreatitis are idiopathic so means we don't ever really find the cause for why their pancreas got so angry. But dietary indiscretion is believed to be the most common risk factors so there's dogs who get into the trash, after Thanksgiving they eat all that leftover grease from the turkey, or.

Yvonne Brandenburg, RVT, VTS SAIM:
When clients love their pets so much that they give them turkey and Thanksgiving dinner as well. And you're like, "Okay, well thanks for coming into my clinic now, right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah it's jobs security too.

Yvonne Brandenburg, RVT, VTS SAIM:
Another thing too is, this is, I cannot remember where I saw this at one point but it was it's one of those things where they get into the trash. It may not happen right away, it can sometimes take four to six weeks for that pancreas, that inflammation to overwhelm it and then become an issue. So, when we're getting history it's really a good idea to check to see if any time in the last two months that they get into something that they weren't supposed to. Was it the Halloween candy? Did they have chocolate for Halloween and they weren't supposed to? Because the other thing too, we talked about this a little bit, especially Schnauzers, like Schnauzers, they are predisposed to getting that high cholesterol. But our diabetic patients, because you know, that's the pancreas, right? So, high levels of sugar in the blood pisses off the pancreas, so they're more predisposed to getting pancreatitis as well. So, it's hard because it's like is the inflammation and the pancreatitis making the diabetes worse, or is the diabetes with the high sugar level making the pancreatitis worse. So, you have both that really, you have to manage both. And that's just something to kind of think about.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, I think it's just trying to like really think back about what other diseases could possibly be going on in your patient. Is it a Cushing's patient? Because they're predisposed to developing pancreatitis. Even though I don't think, at least when I was in general practice, that was not something that I would put two and two together for because I wasn't as educated as I am now.

Yvonne Brandenburg, RVT, VTS SAIM:
And we'll do an episode about Cushing's and Addison's specifically because I feel like that is one in general practice, you're like, "oh it's a Cushinoid." Like, I remember learning about it in school but I didn't understand what the heck it was until I really had just dealt with it in internal medicine on a weekly basis.

Jordan Porter, RVT, LVT, VTS SAIM:
Oh yeah. Yeah. Yeah. Oh they just have a poor haircut.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, it has something do a steroids but I don't know which way. Like you never remember which way.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Like is Cushing's low or high? Yeah, we'll talk about that. But yeah it is interesting to remember that some of these, because it's comorbidities, right? That other disease processes that these patients have that will predispose them to other disease process.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. I think you got to just think of it in the sense of like when there's other diseases going on there's other high or low levels of some sort of substance in the body that's just overwhelming the pancreas. So, I think two people underestimate trauma. So, yeah you have a patient who came in and he was bumped by a car maybe four weeks ago but it wasn't like anything major he had a couple scrapes and bruises. But then, a couple of weeks later he gets pancreatitis. But trauma, surgery. Of course major trauma. So, this dogs who really are hurt by the vehicle that they were trying to chase after. They're in hospital and you're focusing on the fracture leg or something, and then two days into the hospital they have pancreatitis.

Yvonne Brandenburg, RVT, VTS SAIM:
And kind to go along with surgery too. I think people forget this, is when you have a low blood pressure in surgery it affects the other organs right. So they become hypoxic because they're not getting blood flow. Kidneys, I mean everybody thinks kidneys, right? Low blood pressure will affect the kidneys.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
But it can also affect your pancreas. So, just you know, when you're monitoring anaesthesia just be really mindful of keeping your blood pressure where you know it should be. So, we make sure all of our organs are happy, healthy, and don't have issues. And in surgery, if you have other surgeries, so like a foreign body surgery, or a gallbladder surgery, any time you're near that duct, like the inflammation from that surgery can really mess it up and make it, make the pancreas mad. So, just kind of keep that in mind too when when you're thinking surgery and foreign bodies and all that stuff.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. The pancreas is definitely finicky.

Yvonne Brandenburg, RVT, VTS SAIM:
It doesn't like to be touched.

Jordan Porter, RVT, LVT, VTS SAIM:
And then of course you do have a foreign bodies because in actual foreign material is obstructing the G.I. tract. Therefore it's just causing inflammation to the pancreas because it can't do its normal function of trying to break down those carbs and things, so everything just becomes angry. So, trying to really see what your patient's history is: do they have a habit of eating things that they shouldn't, pinecone, corncob, they chew the stuffing out of their toys. My dogs do that all the time. I have one dog who will eat socks.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, I had one growing up, too.

Jordan Porter, RVT, LVT, VTS SAIM:
So, just really trying to get that history of: "Have they ever had pancreatitis before? Do they have underlying diseases? Has there been any recent trauma? Like maybe they fell down the stairs, because I have a very clumsy dog as well.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And we actually had a foreign body where the foreign body itself was just sitting right at the outflow tract of the pancreas and the gallbladder, and it was just like everything's mad because it can't the juices can't know where they're supposed to go. Right? So, that other thing to think of with foreign bodies is it can block the duct opening, and just cause a problem.

Jordan Porter, RVT, LVT, VTS SAIM:
So, I think obtaining that history and really trying to consider the patient's record. Before you check in the patient read through briefly to see what other diseases they might be, you might be treating for already. So, I think the most common clinical signs though too when you have a pancreatitis patient is anorexia, vomiting, I mean those are the two number one things I think of when I think of a pancreatitic patient. And then lethargy, diarrhea, dehydration, and then abdominal pain. I think that abdominal pain gets overlooked sometimes.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And we've actually had a couple of animals come in through our emergency department and they're like, "oh it has back pain". Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yes! Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
And they're like, it's like, "oh yeah he's just uncomfortable, he has back pain. And you're like, "No, not the back, like his back is fine." Which is good. But it's actually pancreatitis. Because they do that you know the crunch up thing and it looks like back pain but you know that physical exam is huge to isolate where the problem is.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes. Yeah. They're still hunched, they still cry out when you pick them up like it's, yeah, I've seen a lot of those where they come in for back pain.

Yvonne Brandenburg, RVT, VTS SAIM:
So, the other thing that's interesting to remember is: cats are not small dogs. So, the dogs have the two openings: one for the bile, the common bile duct, and then one for the pancreatic outflow. So, there's two openings where those enzymes, right, because enzymes break things down. So, two openings for the enzymes to flow out into the duodenum. Whereas cats only have one opening. So, the bile and the pancreatic juices, the ducks kind of branch, or the branches come together to one call it a tree trunk. Right? And then that opens, there's like one tube that opens into the intestines. So, the problem with that is: because you've only got the one opening, if there's inflammation there, whether that's at the duodenal opening or in that duct itself. Now instead of just blocking one or the other you're blocking both. What that means for us, is we have to be really careful because these cats if they have pancreatitis they could very easily block the outflow of the gallbladder which in turn causes issues with the liver. You've got cats that are turning yellow because now our T-Bili is going up. Right? So, if you guys have heard of triaditis, that's kind of where the triaditis comes from, you've got inflammation in the three big organs that are just mad. And cats are really predisposed to it. Which is also like your DKA cats that come in, newly diagnosed diabetics that also have pancreatitis, probably are going to have some liver inflammation as well. So, it's just something to keep in mind that you may be seeing these icteric cats. But sometimes you'll see dogs with hepatitis that also have pancreatitis. So, just kind of keep that in mind. Because it's all really close. I mean, even though they connect in different spots in dogs, we're not talking a lot of space it's within an inch of each other. So, you know inflammation one can easily cause inflammation in the other. So, that's just a little anatomy thing going on there.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah exactly. So, I think when you have these patients come into the hospital and your doctor is doing differential diagnosis, things that are going to need to be ruled out: foreign body, gastritis, renal or liver diseases, kidney cats with hyper thyroid disease just because it can look similar, well they're not anorexic, but they're vomiting everywhere. So, you do want to try to rule that out. Insulinoma is a little small, tiny tumor that very hard to find on a pancreas, or any sort of pancreatic cancer. And then like Yvonne said, so gallbladder disease can definitely show up similar to pancreatitis. So, those those are some big rule outs that can be ruled out with just basic lab work. You want to do your basic chemistry, CBC, T4, U/A's. Just try to rule out all the other things that could be occurring aside from pancreatitis.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, and one thing that we kind of forgot to put in our notes, so we'll definitely put it here, is intestinal disease. I mean if you've got an inflammatory bowel disease, you've got GI lymphoma, you've got inflammation, so it could very easily cause cause obstruction as well.

Jordan Porter, RVT, LVT, VTS SAIM:
Kind of leading into the diagnostics of what we're going to do aside from baseline bloodwork, we want to talk about the things that are commonly done right off the bat. So, say your baseline blood work comes back quote unquote normal because I know a lot of people like "amylase and lipase are high", but I'll get to that. It's not reliable. You want to run a PLI. So, Idexx has that snap CPL but that just tells you a normal or abnormal. In internal medicine, I know in our specialty practice, we're looking for a specific number. So, PLI stands for pancreatic lipase immunoreactivity, we send it out to the lab. We use either Idexx, or TAMU, Texas A&M, for that number because that is something that down the line that we will occasionally recheck especially if we get this pancreatitis cases that are greater than two thousand.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
Those ones are fun.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, and having a specific number can help you monitoring going forward too. So, again, getting the baseline is huge. So, you know the snap test, positive negative, that's great because that could be a rule out but that doesn't replace getting that number to see happening.

Jordan Porter, RVT, LVT, VTS SAIM:
Especially if you get an abnormal you really want to try to shoot for that number. But nursing, technician skills kind of come into play here. The blood draws are super important, you want to try to be accurate because hemolysis of samples can really affect some of these lab results. I know, so, if you draw blood and it's extremely hemolyzed you can have elevations of some numbers that are just inaccurate. Same with letting your blood sample sit out too long. So, that can cause false hypoglycemia if you don't spin it in your serum separator to within an hour then you might have a doctor chasing after an insulinoma versus pancreatitis.

Yvonne Brandenburg, RVT, VTS SAIM:
And to go with a blood draw, you want to be as a traumatic to the cells as possible, right? So, when you're going to when you're going to draw the blood don't pull back on the plunger all the way, you want to do a slow steady draw because you want to remember the more suction, the more you're pulling those red blood cells past the needle, the more likely they are to rip. So, if you've got an animal who's kind of hemolyzing more so than than a normal pet. Just try to be as a traumatic as possible. Remember, I mean this is one of those things that way back when we were taught and we thought we'd never need to know about it, remember that when you have a lot of lipemic sample, like it's really lipemic, the lipemia, the cholesterol and all that stuff that's in there, that actually can cause hemolysis. So, you may not be able to prevent hemolysis, but do the best that you can. And if you see a sample that's really lipemic, try to spin it down as soon as possible to help prevent the lipemia, the lipids and everything, from sitting on the red blood cells causing them to lyse and rupture. That's just another kind of tech tip, is if you see that, just try to spin it down as quick as you can.

Jordan Porter, RVT, LVT, VTS SAIM:
I think what we do, I mean, some of these patients you'll see extremely like hypovolemic. So, I like butterfly catheters, I'm a huge fan of butterfly catheters.

Yvonne Brandenburg, RVT, VTS SAIM:
Love them!

Jordan Porter, RVT, LVT, VTS SAIM:
And internal medicine you'll learn that you don't do jug sticks nearly as often as you used to in general practice. So, we do a lot of back leg draws. So, those butterfly catheters instead of using a 3 cc syringe, reach for the 1 cc. You can grab three of them and just fill your sample tube that way, but that way it's a slow steady draw. You're not putting as much pressure on those cells when you're pulling back on the smaller plungers. So, I think that's a big thing. Remember it's not a race. You got to just: nice and easy slow steady draw. Sometimes it's not a race, sometimes it is. I'll give you people that.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
But and then separating the samples if you actually read what your lab requires. I know Texas really prefers that you separate the serum from the gel and put it in a plane top tube, so it can skew results. So, just kind of pay attention to what your lab wants and use your skills for drawing blood. It's a big thing.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
Your doctors will appreciate it.

Yvonne Brandenburg, RVT, VTS SAIM:
It's funny that you talk about butterflies. I love butterfly catheters. I can hit just about anything with a butterfly catheter. You put me in front of a jug and I'm like, "oh god, I got hit this." And it's funny because we work right next to our oncology department, like we're in the same room, and they use jugs for everything. And they're like, "veins are for chemo." It's really funny. And we're like,"No, no, no. Veins are for blood draws because everything has clotting disorder or liver disease." So, it's one of those things.

Jordan Porter, RVT, LVT, VTS SAIM:
Please if you work in general practice and you might be referring, please save the front like veins for us to place catheters, it's super helpful.

Yvonne Brandenburg, RVT, VTS SAIM:
Just start low. Start low.

Jordan Porter, RVT, LVT, VTS SAIM:
Start as low as you can, if you're gonna place it for us. Just start, I mean you can do those pedal catheters. Don't be intimidated. So, anyway off topic. Well, not really off topic, just diverting a little.

Yvonne Brandenburg, RVT, VTS SAIM:
It's technician skills.

Jordan Porter, RVT, LVT, VTS SAIM:
All those wonderful things that like when I do have a patient come into the hospital, I'm like, "if only you would shave all the way around."

Yvonne Brandenburg, RVT, VTS SAIM:
Oh see, I'm not in all the way around shaver, but I will get the hair out of the way. Like I tuck the hair up with feathers. Because, I worked in a practice, for GP that had a lot of show dogs and, and I had a lady tell me I wasn't allowed to shave at all, and we made her sign an AMA because I was like, "No." So, I don't have it quite ingrained into me, but if you do work in a practice, either way, you want to make sure your catheter is going into a clean spot, right? So, make sure you're shaving properly where your catheter inserts. Don't drag your catheter through the hair to get into the insertion site. And then, if you do have a lot of furr or hair around the catheter, use that spray to remove it, so you're not just yanking out all their hair because then, you know, animals get mad.

Jordan Porter, RVT, LVT, VTS SAIM:
That's what we do. I just feel bad when their hair is starting to get pulled and I just, it's strictly just me feeling the patient a little bit. I'm like, "I'm so sorry". It's kind of, to get back into the pancreatitis, so, imaging I know a lot of general practices use ultrasound. So, we hold for ultrasound a lot in specialty medicine. I know there are some techs out there doing it, and great, we'll kind of not go too far into that. But on ultrasound I notice when assisting I feel like I've been doing it enough that I can I can notice. I'm like,"that pancreas looks hyperechoic, or the fat around it looks hyperechoic. And some of you might be like, "what does that mean?" It just means it's bright. So, hyperechoic, it just means it's bright. And brightness kind of leads us to believe that there's inflammation. Angry.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, I was going to that inflammation, because there's more tissue density.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, you've got fluids that are there. So, that just looks brighter on ultrasound. And the other thing too, is you can actually see sometimes the pancreas itself looks black. Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Scary.

Yvonne Brandenburg, RVT, VTS SAIM:
That's hypoechoic. But, then everything else around it is hyperechoic. Those are the ones that scare me more.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes. Yes. So, the decreased echogenicity, hypoechoic, is just suggesting that that pancreas is starting to die, it's pancreatic necrosis. That's scary. Necrotizing pancreatitis is properly one of the scariest things I can hear in internal medicine.

Yvonne Brandenburg, RVT, VTS SAIM:
That freaks me out so bad because I've lost patients to it numerous times and I'm just like, "oh god".

Jordan Porter, RVT, LVT, VTS SAIM:
You just feel for them because you're like, you know that they just feel awful, they're in a lot of pain, it's not great. So, if you are doing ultrasounds or assisting with ultrasounds in general practice and you see that nobody says anything you're like, "holy crap. This patient needs help". And then, fluid accumulation, so fluid, I mean inflammation can cause fluid, it kind of goes the same, you'll see some post ops. This is kind of off topic, but you'll see post ops where they're just not quite right and you'll do an ultrasound after surgery like after a splenectomy, and there's a little bit of fluid in there, just a little bit a scant amount of fluid, and that can be just from inflammation. So, that can be something that's frequently seen with pancreatitis patients.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And the fluid accumulation, we do sometimes get a sample of it to see what it is. Does it look inflammatory? Does it look like blood? So, that's all stuff that we can see with ultrasound, and then get an ultrasound guided aspirate of that fluid and then either do cytology in house. So, we can look at it, the doctors can look at it, or we send it out for a pathologist to look at, and that can tell us a lot as well. They may see cancer cells, and then we're like we're dealing with something completely different.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. So, I think diagnostically though, to me the PLI is pretty, like if that's high, we're treating for pancreatitis. But I know there, I've never done this, but some clinics will take like aspirants of, or biopsies of, pancreas just to truly get that definitive diagnosis of pancreatitis. I am not a huge fan just because to me you're causing more trauma to the pancreas and you're pissed off even more. Not to mention severe pancreatitis patients are poor anesthetic patients, like they're just, it's not ideal. That I feel like unless there is something specifically on the pancreas that you're really trying to get a sample of, I can't imagine just doing that to get a definitive pancreatitis.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. My doctor's definitely, they don't aspirate or a biopsy for just a pancreatitis, because they're like the PLI is up, I can see that it's mad. The only times that we'll get biopsies is usually like if they're already in there for something else, you know, maybe gallbladder mucocele, or something else, and they're like, "the pancreas looks weird". They'll biopsy it but we usually usually don't aspirate or biopsy the pancreas for the same exact reason, it just makes it mad. So, we try to leave it.

Jordan Porter, RVT, LVT, VTS SAIM:
Now you do have some of those cases that do need surgery. You have those pancreatic abscesses, like those need to come out. Those are also terrifying. I hope nobody ever sees those, so, those are scary. So, kind of leading into treatment, say you've run all the tests, on ultrasound it looks like pancreatitis, PLI is high. They have all the symptoms. Now it's kind of determining how severe is this? Is this inpatient care, or outpatient? Outpatient care is what I think, I was super used to when it came to seeing a possible pancreatitis. I feel like in general practice you kind of catch it early. So, we do sub q fluids, antiemetics, antibiotics like metro, especially if they're having diarrhea, and then appetite stimulates if needed. You really want to get the body kind of functioning normal. You want to treat symptomatic thing and get your patients eating in order to help them recover quicker.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And speaking of that, you know, when I first started in veterinary medicine, the school of thought was if you have a pancreatitis patient: you don't feed them. You try to keep smells to a minimum because we don't want to stimulate the pancreas. And so that was kind of what we did with pancreatitis patients. There's been studies out now in the last few years that say that that's actually not good. So, we try to get them eating as quickly as we can because we want to stimulate things to start passing through and get them out of the system. The other thing too is when you're starving a patient, you're starving the cells within the gastrointestinal system. And so, once those start dying off that's a problem too. So, then you then you have malnutrition set in, and everything. So, it really is a change in thought that now we feed our pancreatitis patients. So, placing a feeding tube, whether that's a nasoesophageal, or esophageal feeding tube, we have those options now.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
And appetite stimulants are huge.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. And there's so many out there now, that it's kind of, yes, it doesn't always work, but that's when the tubes come into place. But, I think to the old thought was you started your patient but then once you start feeding them again and say they are really hungry everybody wants to feed, feed, feed. You can run into refeeding syndrome which I'm sure we will get into because I do love talking about it. But, you can throw their electrolytes out of whack and actually make them sicker. So, it's one of those things where if you're starving a patient and then you do feed them and then they're like, "Oh, my god I'm so hungry", and then you're like, "Oh great. Keep eating". It's actually, it hinders their healing.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
I think that's forgotten sometimes too.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And I think it's one of those things where if you've never seen a refeeding patient, you don't know what it look,

Jordan Porter, RVT, LVT, VTS SAIM:
Definitely.

Yvonne Brandenburg, RVT, VTS SAIM:
And you don't know that you should be monitoring for it. So yeah, I think we definitely need to have an episode about refeeding syndrome because it is huge.

Jordan Porter, RVT, LVT, VTS SAIM:
We'll dive down the nutrition section like how you are actually supposed to start reintroducing food to your patient.

Yvonne Brandenburg, RVT, VTS SAIM:
Oh, I know. Our nutrition peeps will love us for for talking about nutrition so.

Jordan Porter, RVT, LVT, VTS SAIM:
Maybe we should get a guest on for that one because I don't want to.

Yvonne Brandenburg, RVT, VTS SAIM:
We'll put us out in the universe: Kara Burns, if you are listening to this, we would love for you to come talk to us.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes, please. I know a little bit about nutrition but there's definitely smarter people out there.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, I was to say we can see if our VTS friends that have a nutrition VTS can come talk.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah that's exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
If you don't know who Kara Burns is, just look her up. She's kind of amazing.

Jordan Porter, RVT, LVT, VTS SAIM:
Right?

Yvonne Brandenburg, RVT, VTS SAIM:
And we all want to be like her.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah exactly. So, I mean, I know you and I are more dealing with in hospital treatment of pancreatitis so we do see the scary ones those necrotizing pancreatitis patients, or just severe pancreatitis which I take any day over necrotizing pancreatitis. So, I.V. fluids are a must because you worry about dehydration and electrolyte imbalances. I.V. meds just so they don't have to take some of those medications on an empty stomach especially when you are trying to get them to eat and pain medications are huge. We do a lot of CRIs for pancreatitis patients, which I'm pretty sure we talked about in our pain management episode.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
Fentanyl is huge for our pancreatitis patients. We love it.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And it's hard because, you know, opioids can slow down G.I. motility. So, it's a fine balance of making sure they are not painful but we're not hindering GI motility and on a side note on that. Actually, I'm going to wait, because we're going to talk about some tech skills and some stuff we can do like nursing care. So, we're going to wait, and come back to that idea in just a few minutes.

Jordan Porter, RVT, LVT, VTS SAIM:
So. Okay, so, if we're going to move forward then fresh frozen plasma has been talked about a lot when dealing with the pancreatitis patients but it's never actually been truly studied. But I know that veterinarians will sometimes use it. There's reasons behind it. So, but it's never been proven. So, in our pain protective patients they can become hypoalbuminemic. So, low albumin, low protein levels, which can be pretty scary. They can develop coagulopathies, so, they can start going into DIC or having some sort of bleeding issues. And then if you want to get into the nitty gritty they pancreatitis the inflammation releases protease and then fresh frozen plasma has antieffects to that to try to help kind of balance.

Yvonne Brandenburg, RVT, VTS SAIM:
To the protease. Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes. You say differently than I did. It's like when people say metronidazole versus metronidazole.

Yvonne Brandenburg, RVT, VTS SAIM:
Oh, potato, pahtato. Metronidazole, I hadn't heard that one.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah. Anyway so, fresh frozen plasma can definitely help in some of those situations is definitely not warranted I think in like just a normal pancreatitis patient that is responding to symptomatic medications. They need the fresh frozen plasma really to combat some of the other things going on with your pancreatitis patient.

Yvonne Brandenburg, RVT, VTS SAIM:
And I think we used to use it way more frequently and I think it's kind of fallen out of favor with my doctors. And I think part of that is there is an expense part, right, of a transfusion, plus there's the potential for transfusion reaction. So, I think we tend to not go to it first anymore. We definitely, if there's, yes if low albumin and that kind of thing we'll use it but other.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
I think we kind of tend to stay away from it.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah exactly. So then I think you throw in a couple technician skills if you are dealing with an inpatient hospital lies pancreatitis patient and again kind of touching back on to the pain management and CRIs and things like that's pretty big.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, definitely with the pancreatitis we definitely will have the pain meds on board. The other thing too, is we talked about the opioids you know it slows down GI motility, so it's a really good idea for nursing care wise that we get those patients up and moving because with movement we actually kind of help stimulate the gut. So even if a patient doesn't totally go outside just getting them up maybe walking them around the room if that's all they can do because a lot of times these guys don't want to walk.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, there's that as well. But just keeping them comfortable if it's an older pet making sure you have plenty of bedding that's soft. So, we're not getting pressure sores. Rotating them, you know, if they're not getting up on their own because we've got them on good pain meds. And then hygiene is huge. So making sure we're keeping them clean. We talked about it in the diarrhea episode we're just keeping the back end nice and clean is good.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah definitely. And then kind of going on that multimodal, I've never done it but I know I've read about it where others like those into peritoneal blocks for pancreatitis where you're, have you ever done that.

Yvonne Brandenburg, RVT, VTS SAIM:
I've never seen one and that just sounds very interesting to me. It's also super.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
I'm like wait, what? You're doing what?

Jordan Porter, RVT, LVT, VTS SAIM:
We're injecting like a foreign material into the abdomen that my thought was that it causes more inflammation. But it does, you're just blocking the pain. It's where it's interesting. I'll have to see if I can find the article and link it because I know I've read about it.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah that would be, I mean it would be cool and we could definitely, I mean it, sounds like something that we can touch on at some point too because I mean that, there's a ton of things that you could potentially use that for.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
And again, that's upping your tech skills, right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Is learning new things like that.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. I feel like you used to like post op explorers, I mean it'd be pretty cool.

Yvonne Brandenburg, RVT, VTS SAIM:
I do know for our post up explorer sometimes they'll do, they call it the lidocaine splash, where they just kind of, before they're closing up they just squirt a little, I think they do saline and lidocaine and just put it on the surfaces in the abdomen.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, yeah, I know it's a specific mixture. I got to see if I can find the article. I'm pretty sure I have it saved.

Yvonne Brandenburg, RVT, VTS SAIM:
And if not I can ask my surgeons because I'm sure they have a reference.

Jordan Porter, RVT, LVT, VTS SAIM:
Probably, probably.

Yvonne Brandenburg, RVT, VTS SAIM:
Which having a surgeon and that you can ask these questions is pretty cool because you're like, "pain management?" They're all about pain management. And that's always good.

Jordan Porter, RVT, LVT, VTS SAIM:
And then nursing skills of being able to manage a transfusion so if you are doing this fresh frozen plasma transfusions you want to monitor for transfusion reactions and just being able to know how to properly set up a fresh frozen plasma transfusion and thaw it correctly. That does take some education. So it's nice skill to use. Not necessarily for those because usually it's bad.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, yeah. But I mean transfusion administration and monitoring is huge. I'm working on some in-house continuing education for my co-workers that I'll probably revamp for us at some point. But it's understanding like cross matches and how to do that. So, transfusions it is a really good skill to have as a technician understanding how to administer it, safely, properly. So, we're not causing more harm than good. Because I think some people think that a transfusion whether it's plasma or red blood cells that it's pretty harmless.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
But it's not. There are a lot of things that you need to be looking for and so understanding that as a technician is huge. And I don't know if you have the book about...

Jordan Porter, RVT, LVT, VTS SAIM:
Transfusion medicine.

Yvonne Brandenburg, RVT, VTS SAIM:
Well yeah the Transfusion Medicine.

Jordan Porter, RVT, LVT, VTS SAIM:
And not to mention that somebody wrote an article about it recently.

Yvonne Brandenburg, RVT, VTS SAIM:
Oh, that's right! Who would that have been? Oh, wait? Is her name Jordan?

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, you know about how you would use it or why you would use transfusions.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. Where was that article published?

Jordan Porter, RVT, LVT, VTS SAIM:
That was published at NAVTA. So, if you're a member of NAVTA you should get that journal. It's in the, what month is this? It's in the October/November journal.

Yvonne Brandenburg, RVT, VTS SAIM:
And P.S. we will totally link to it in the show notes because it's super awesome. I was so excited when she told us she got that.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes, super excited.

Yvonne Brandenburg, RVT, VTS SAIM:
Yes.

Jordan Porter, RVT, LVT, VTS SAIM:
Anyway. So yes, we have lots of information to how to do that properly.

Yvonne Brandenburg, RVT, VTS SAIM:
I also am a giant blood nerd.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Which sounds funny. But I am. Because we'll talk about it at some point I'm sure because my passion stuff is immune mediated blood disorders. We'll get into it at some point but yes, I'm a hematology nerd. So, I'm all about it. But we'll also link to the book because that book is awesome.

Jordan Porter, RVT, LVT, VTS SAIM:
I love that book and you can get it on Amazon.

Yvonne Brandenburg, RVT, VTS SAIM:
Shout out to Ken Yagi, by the way.

Jordan Porter, RVT, LVT, VTS SAIM:
He is like the blood transfusion master, so.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, he is also one of my tech goals. I'm like I want to be like him some day.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah I went to one of his lectures and I was like I need to be you.

Yvonne Brandenburg, RVT, VTS SAIM:
Right? Let us know who your tech goals are because it's always fun to get new names.

Jordan Porter, RVT, LVT, VTS SAIM:
Right? Anyway.

Yvonne Brandenburg, RVT, VTS SAIM:
All right, we'll get back to what we were talking about.

Jordan Porter, RVT, LVT, VTS SAIM:
I know this is going to be like a common theme we're just going to have like little branches off of our episodes.

Yvonne Brandenburg, RVT, VTS SAIM:
I mean I feel like that's what we always do as technicians where we go down rabbit holes.

Jordan Porter, RVT, LVT, VTS SAIM:
I think. Yes. Yeah. You just like: shiny object. OK. So, client communication. So, say you send your patient home. What is your pet parent going to have to kind of look out for? So, I think a big thing is appetite, because that is usually one of the first things that people notice. Yes. They're going to notice their pets vomiting maybe every other day. First thing in the morning. But I guess maybe not everybody will notice but appetite is key. Are they eating a full meal, are they eating normal? Are they eating a little bit, is it slower for them to finish? These things are kind of key into knowing if they're improving or not. So, they go home. I don't really expect most of my patients to eat right away when they go home. I expect them to eat but not normal. But, I expect to see it gradually improving day to day when I check in on them.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And I like to tell my clients, not only. OK, so first of all depending on how long they've been in the clinic/hospital they're not going to be normal when they go home, right? Especially if they're in a hospital, because we're bugging them every one to two hours. They're not getting their normal sleep rhythm, right? So, I usually say they're gonna be excited to be get home. They're gonna crash out, find their spot that they love to go to and sleep. Right? Because they need to catch up on sleep. But I tell people you should see gradual improvement every single day. If you see them become stagnant or get worse, definitely let the technician know. So that's just something that's really good to make sure that we let the clients know because technicians are usually the ones doing the releases from the clinics and hospitals. So, letting them know look, they're not going to be 100% normal but we want to see them improving. And please reach out to us if you have questions or concerns.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
That's huge. Making sure they feel like they can talk to us.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, and it takes a lot off the doctor too. The doctor that you work for they're busy, they need to use a brain treating the next patient. We need to take off the communication and then we can be that middleman and be like hey you know Fluffy is not eating very well. Do you want to add on an appetite stimulant, if it wasn't sent home. Take that burden off of your doctor with having to kind of communicate those clients everyday because they are worried about that patient. It's just they have so many other things going on.

Yvonne Brandenburg, RVT, VTS SAIM:
Well and honestly most of the questions that clients have are things that we can answer and if we can't, we can go talk to our doctor and then still relay that information. But 90% of the time it's stuff that we can talk to them about.

Jordan Porter, RVT, LVT, VTS SAIM:
Especially when I'm really educated and we know exactly what the client should expect. So, I think that is big. And then I think one of the biggest questions I get is, from clients is, how am how am I going to know if they're nauseous? Lip smacking, drooling, not eating very well, or slow to eat.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. The other part of being nauseous that I tell clients is, especially with pancreatitis. You'll have a dog or a cat, right? They're super excited about the food. You put it on the ground. They go up to it. They smell it and then all of sudden they like kind of backing away from it. And you could tell that they're like, "I'm excited!" And then they smell it and they're instantly nauseous. You know what that feels like if you've ever been sick you're like "I'm so hungry". And then you smell it and you're like, "Oh no! I'm just kidding. I don't want any of that." So, you know, it's similar with dogs and cats like they get excited about the food and then they're like, "Oh no." And they either, they just back away and go away, or they vomit a little bit or whatever it is. But it's just a good thing to tell people that that could potentially be what is going on. And I like to, if you suspect that they're nauseous, go ahead and treat them for nausea. Because most of times the medications that we're giving for nausea, they don't really have side effects that we have to be worried about. So, treating for nausea great. If they're not nauseous? Well, no harm done. If they are nauseous, hopefully they feel better. So, I always tell clients ere on the side of giving an anti nausea medication than not giving it.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. What I like to tell clients too is like at least the first couple days that you're home because things are changing like give it. Gives the Cerenia, give the appetite stimulant. Just for those first two days because it says as needed on the label usually. But that way you're kind of covering grounds. And then as your pet is starting to act a little bit more normal, after resting up from being in the hospital for how many ever days, then you should see that, OK well, you know what? He is eating pretty well and let me go ahead and hold off on this today and see what happens. Som I do like them they give it at least the first day or two just to be sure.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah same here. The other thing too that because you mentioned Cerenia, or maropitant citrate. The other thing to tell clients is, there have been some studies that show that there are some pain management properties to Cerenia as far as the guts go. So, I think that also helps clients go ahead and give it. Because you know some clients don't want to give medications or they're like, "I don't know how." But if you tell them, "hey this is going to help with nausea and there are some potential pain property things that they're going on with it." I feel like they're a little bit more inclined to actually give it and just feel like, "hey, you know, it won't get rid of all of it but it can help a little bit." And so why not go ahead and use that.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah especially. And then communicating like the long term goals. I like to inform my patients or my clients who go home especially with the Schnauzer, or something, that if your dogs had pancreatitis it very well could come back or happen again not necessarily come right back but you know in a year they might be right back here with pancreatitis again.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. Because that inflammation, every time they get that inflammation there's more scar tissue. Right? And so there's more tissue damage. So they're more likely to have issues with it. So, especially if your chronic pancreatitis patients. I mean, I don't know. Sometimes we're like we have no idea what set them off but they got set off again, you know. And it's just something that talking to clients and an understanding that can help a lot.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. And then I think as long term goals for us techs though I think we do need to be aware that like, I know when I was in practice like the first couple years I was like oh pancreatitis is just vomiting you treat it. They go home they're fine but it can get worse. It can lead to bad things.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. Yes.

Jordan Porter, RVT, LVT, VTS SAIM:
And I think it was one of those diseases that when I did finally start kind of getting a little bit more education and reading about all the things that can occur from being pancreatitis, I was like: "Holy crap! These poor patients!" Especially after I had my very first bad case, I was like, "Oh my god!"

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. I mean you'll never forget your first horrible pancreatitis.

Jordan Porter, RVT, LVT, VTS SAIM:
I know. I remember my very first one it was like the typical I came in projectile vomiting and then went home and was fine, we never saw again. But it was like that classic like projectile. Which I remember it, it was a Boston. Yeah. And then I remember my worst case and it was you know. So, I think just kind of remembering for yourself that it's not always just like treat with antiemetics and send it on its way.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And something to to talk to clients about, we talked about this, you know, the quality of life versus are we fixing anything. It depends, right? So if we just have one bout of pancreatitis, sometimes that's it. There are some animals they have at once. They don't have it again. But it could be that becomes more of a chronic situation especially if owners aren't as compliant with food.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
That's that's one of the big things. Or the dog that constantly gets into the garbage. Or maybe they have little kids that throw crackers on the floor and laugh and think cheese is amazing that the dogs eats it.

Jordan Porter, RVT, LVT, VTS SAIM:
And cats, cats get chronic pancreatitis all the time.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. This is very true, actually. So, in cats as well. Although I feel like they don't eat as many crackers from kids. I feel like cats are just their own special things.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes cats just have their own underlying disease. They're like we're going to act fine until we're not.

Yvonne Brandenburg, RVT, VTS SAIM:
Or in the like the diabetic patients, right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yes!

Yvonne Brandenburg, RVT, VTS SAIM:
Like just there they're going to have, you can almost guarantee they're going to have pancreatitis again.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
So talking to a client about quality of life is huge. We have a quality of a life tracker that you guys can download and give to your clients. It's based on quality of life tracker that was created, and I can't think of her name right now, but it's based off of something that a doctor especially for cancer patients. But it relates to any kind of chronic disease, right? We have a tracker you can download it. We'll put the link in the notes so that you can have it.

Jordan Porter, RVT, LVT, VTS SAIM:
You can get that on our Web site pretty easily at the bottom of the page. The internalmedicineforvettechs.com page.

Yvonne Brandenburg, RVT, VTS SAIM:
And so just having them, especially because then you could quantitate like what are the different things? And you can say, you know, how many good days do we have? How many bad days? Do we see a trend? So that's something to for clients that can really help them as far as like figuring out long term what's going to happen with my pet. How are they doing? And they may not need it. But sometimes it gives them something concrete.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
To tell you about, right? And give you a number.

Jordan Porter, RVT, LVT, VTS SAIM:
Versus calling you. I get a lot of phone calls where they're like, "Well, I think it's time". And I'm like you know your best.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
Like I knew your pet for four days. So, I think that is a helpful tool and then, I mean, I think just follow up is key just kind of keep in touch with your clients find out what symptoms they're exhibiting at home helps them do the tracker if they need it. And then rechecking that PLI, we do that pretty frequently especially with those high numbers like because we like the number so much we like to recheck it in 10 days especially if they're doing well even.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
Some clients won't follow up.

Yvonne Brandenburg, RVT, VTS SAIM:
We also do recheck ultrasounds as well sometime. Where we just do a quick peek at the pancreas, does it look less inflamed? What's going on? So, just rechecking something, something concrete. Right? So the ultrasound image to look at the pancreas or the PLI that gives you a specific number. And just remember too with you with the PLI, depending on where they're at in the disease process, you know, we may catch it on the way up like especially if it's an acute pancreatitis, like you're catching it on the way up. It may go up higher and then it will start to come down or it could be the other way.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So it depends on where you catch it when the numbers are going to do. But that's another reason to kind of keep track of that. You can, and you know, you can check especially your chronic pancreatitis patients if they're feeling a little bit off maybe you check the PLI and see where they're at. Are they about to have a bad episode and then we treat and kind of get things to settle down or is it something else that's going on with them.

Jordan Porter, RVT, LVT, VTS SAIM:
I think the communication is key. You know you take the notes of what you've been talking about with your client, then they come in for the recheck, and the doctor can read your notes and then visually see the pancreas looks happier on ultrasound and PLI is a little bit better. And they see what symptoms have been exhibiting for the last 10 days. It's helpful. And I think it's appreciated by doctors too, especially if we can get those good communications written in the record.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah definitely.

Jordan Porter, RVT, LVT, VTS SAIM:
And then I know medications that most pets go home with are like symptomatic medications. You have your anti medics appetite stimulants plus or minus antibiotics. We've sent not many home with sub q fluids like the ones that we send home teaching them so keep fluids are the ones who declined in hospital care, which is fine, it happens. Yeah, we try to manage it the best we can. But I know in the cases of patients not responding, it's usually when it's referred to us. But we've sent some severe cases that don't respond home on like prednisone and/or cyclosporine, just to try to get that body to calm down.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah and there is some thought that some of these patients may actually be an auto immune disease. And so using the steroids and the cyclosporine can potentially suppress the immune system from attacking the pancreas. Which is kind of an interesting thought process and I think there's more studies that are going into that. So I think in the next few years your probably going to hear a little bit more of that.

Jordan Porter, RVT, LVT, VTS SAIM:
Definitely.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, sometimes using the anti inflammatory plus the immune suppression can get these kids especially your chronic ones they're starting to see that there may be some auto immune component to it. But again, that's probably something that you guys aren't going to be dealing with in a general practice but if you're working at an internal medicine practice, or specialty practice, that might be something that you're noticing or that you're talking about.

Jordan Porter, RVT, LVT, VTS SAIM:
I imagine that'll be like a feline study since it's always like, "Why did this cat get pancreatitis?" They don't eat all the garbage.

Yvonne Brandenburg, RVT, VTS SAIM:
Mine does. I don't know what you're talking about.

Jordan Porter, RVT, LVT, VTS SAIM:
So I think cautions to look out for. I have this really long snippet that we'll put in our show notes that I obtained from a Web site that we'll link. But pancreatitis can lead to other complications. So generalized inflammation can lead to DIC, pulmonary failure, myocarditis, and even multiorgan failure. So it can get bad, and I'll put the reason in our show notes as to exactly what's happening that kind of allows that to occur.

Yvonne Brandenburg, RVT, VTS SAIM:
And I think that's probably in reference to like SIRS. So, systemic inflammatory response syndrome which, again, you have a major inflammation and things just get mad. Right? Like the cascades are all activated and things just go crazy. So, that's sometimes why these kids just tank, right? And then we have to support them and get through it.

Jordan Porter, RVT, LVT, VTS SAIM:
And I'm a firm believer that some patients just choose to be done. So, it's like, you know sometimes you can see that look in their eye and sometimes I even tell my doctor, I'm like, "I just think that they're just kind of over it. They don't want to do this anymore.".

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
We get a lot of those like 15 year old patients and I'm like, I wouldn't want to do it anymore.

Yvonne Brandenburg, RVT, VTS SAIM:
You're like, "ehhh". And I mean that's where patient/client visits can help too. Right? They know. I mean, I remember when my dog was in the hospital for something, I just looked at her face and I was like, "Nope. She's done." I could tell. I was like, no. Given everything that's going on I see that look on her face. And again, you know your pet best, clients know their pet best. And we may, because we do this, right? We want to save everything.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes, it's hard.

Yvonne Brandenburg, RVT, VTS SAIM:
We need to take ourselves out of that, right? And just be like what is best for our clients, what is best for our patients, and also what's best for us. It's not always in our best interest to do the, "I'm going to be the savior thing", right? Sometimes the best thing that we can do is know that it's time to stop.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly. Now I will admit that like my favorite cases are those ones that are really, really bad and we do pull back from the brink and I'm like it's just so rewarding.

Yvonne Brandenburg, RVT, VTS SAIM:
Those are amazing.

Jordan Porter, RVT, LVT, VTS SAIM:
We do have those clients. Yeah, I have those patients that I look at an occasional bad you look miserable and like nothing I'm doing is helping. So, I just like those ones are the ones that, you know, the reasons why we get brutality.

Yvonne Brandenburg, RVT, VTS SAIM:
I believe that is called ethical fatigue. Yes.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
We'll talk about that some other time.

Jordan Porter, RVT, LVT, VTS SAIM:
And then once again a kind of one of the cautions is before you bring up the fresh frozen plasma to your doctor, it is used but there is no literature to support it. So, I don't want people to be like, "where's the study?" But I do have a link as to, I think it was Vet Girl On the Run who did that. I'll have that link, she did a CE on it.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah and if anybody finds a random study by the way that please share it with us, we would love, we love links to studies. Because, again, we work in internal medicine. So, studies are amazing. Or if you know your doctor has something that they refer to please, please forward it.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
It's awesome. The more information we get the more you get the more we share.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
The smarter we all get.

Jordan Porter, RVT, LVT, VTS SAIM:
The whole reason why we're doing this is to just get more education.

Jordan Porter, RVT, LVT, VTS SAIM:
So our tip of the week: it's the tip of the week.

Do not assume that a pancreatitis patient is not painful. I think it's pretty, you know, we have those pain charts for a reason. See if you can assess your patient's pain. Have your doctor helping the abdomen. I think that is one thing that gets overlooked unfortunately sometimes in increased patients that they'll come into the specialty practice like, they're so painful.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And I know that we do a lot of ultrasounds for our patients and that's something when you're restraining for an ultrasound. You know, if you're pet's painful it may need some pain medications to get through that ultrasound especially if they've got like pancreatitis or some other thing that you're pushing on their abdomen.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
If they're responding they're painful.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
So you know, it may not be behavior.

Jordan Porter, RVT, LVT, VTS SAIM:
Peritonitis.

Yvonne Brandenburg, RVT, VTS SAIM:
It could be painful. So just, again, keep that in mind.

Jordan Porter, RVT, LVT, VTS SAIM:
Advocate for your patients. For sure. And then watch for disease progression. So, like I said I'll have that link about like what all can happen. But yeah you can lead to those coagulopathies and multi-organ failure. So, definitely watch out for the progression and just kind of keep an eye on the patient if things are not moving in the direction that you or your doctor feel like it should, speak up.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, progression of disease, and that's where as technicians we use our skills, right? Because we are kind of the front line for our doctors, because I don't know about you but my doctor sometimes goes into our CCU maybe two-three times a day to look at patients, unless one of the techs in CCU comes and says, "Hey I'm noticing, X Y Z, whatever it is. Can you take a look at them?" But we are the ones that are going to have our eyes and ears on our patients, our hands on patients most of the time.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Our CCU techs, at least once an hour, in a cage looking at things. So, making sure that if you, you got Spidey senses, right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yes!

Yvonne Brandenburg, RVT, VTS SAIM:
So, use your Spidey senses and just and just talk to your doctor because if you're like, "something's wrong, something's off, have your doctor come check them out and see, you know is there something that they're noticing. They're like, "oh yeah, we're noticing petechia, or we're noticing increased effort for respiration", or whatever it is. And then you can have that conversation and, again, using your tech skills.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
Using your tech Spidey senses.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, I think it just makes us more valuable. It makes us more valuable to our doctors if we have the education behind us and we can explain what we think we're seeing, why we think it's occurring, and you know we just have those senses where we're monitoring our patients so closely that we can bring it to the doctor. It makes their job easier so therefore they value us more.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And honestly if you're still a baby tech, you know, there is nothing wrong with you asking a question. So even if it's just the senior tech that's in your clinic and be like, "hey I don't understand this or I'm noticing this", and maybe they can talk you through it.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
And so that you learn, "oh yeah, that's normal or no that's not normal". And then maybe they go, "oh no, we need to talk to the doctor". Or "no that's, we're expecting to see that". Right? And then again, this is a soapbox for me, is documenting stuff, right? So, making sure in your notes that you're putting what you're seeing so that we can watch for progression, right? If you're all of a sudden your heart rate or your respiration rate went from 22, now it's 28, or four hours later it's 32 and then it's 44. Now all of a sudden we're at 60. You know, we can talk to the doctor and be like hey our respiration rate's increasing what's going on. Is it painful? Is it fluid overload or whatever? So again, you're watching for progression and talking to your doctor, talking to the team, and being proactive.

Jordan Porter, RVT, LVT, VTS SAIM:
I love it when the techs ask me questions like especially in the ICU and they're like, "why are we giving this medication?" I love it. So you know, don't be afraid to ask.

Yvonne Brandenburg, RVT, VTS SAIM:
And what we think is normal, you know, because we have our VTS, so we're like "Oh yeah, everybody knows that". That doesn't mean that the newest person in your clinic knows. So again, don't be afraid to ask questions otherwise,

Jordan Porter, RVT, LVT, VTS SAIM:
I love it.

Yvonne Brandenburg, RVT, VTS SAIM:
Otherwise you're never going to know, right? So, if you have a question either ask someone, look it up, you know, we have plenty of books in my clinic so sometimes I just go grab a book off the shelf and I'm like, "What is it that I'm thinking of."

Jordan Porter, RVT, LVT, VTS SAIM:
So, I love it. I think the best example I have for like just like a difference in opinions is we have people who will be like, "the hematocrit is 30, what do we do?" And I'm like, "30? That's not bad, that's great. What are you talking about? So, I think it really just depends.

Yvonne Brandenburg, RVT, VTS SAIM:
And now for the question of the week.

Yvonne Brandenburg, RVT, VTS SAIM:
So, our question for this week is going to be what it was the most rewarding case of pancreatitis you've seen. So, something that you're like, "Whoo-Hoo! We got him out of the hospital!" Or is there one specific case that you learned the most from? We'd love to hear what your experiences are with pancreatitis and if you have tips or tricks that you guys used with these, that would be cool too. So, definitely check out the episode. This is episode number 6 on pancreatitis. So, if you go to InternalMedicineForVetTechs.com/podcastshownotes and you will see episode number 6 in the show notes. So, go to the show notes page. All of our handouts will be there, all the resources, the links that we have. We've got plenty of them for you. And make sure to take a look at those. Let us know if you've got anything else. And if you have articles, send us articles.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes!

Yvonne Brandenburg, RVT, VTS SAIM:
You can always put it in the comments there and we can get some communication going on that.

Jordan Porter, RVT, LVT, VTS SAIM:
We have ways for you to contact us. You can e-mail the show and we'll definitely try to get back to you. If you have questions concerns or if you just want to submit something that you want us to share. We can definitely do that for you.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. If there is a specific topic you want us to cover: send it to us. We would love to know what you guys want to hear about. Otherwise we're just gonna talk about stuff that we want to talk about, which is cool. You know, whatever. Is there anything else that you want to talk about this week Jordan or you think we got the pancreatitis kind of covered for the moment.

Jordan Porter, RVT, LVT, VTS SAIM:
I think so. I feel like we did good. So lots of information.

Yvonne Brandenburg, RVT, VTS SAIM:
All right guys well it was awesome talking to you guys again hopefully you got to work on time cause I know I listened to podcast episodes in the car, keeps my commute from being horrible. And we will definitely talk to you guys next week. So, next week we'll be talking about endoscopic foreign bodies so you know we'll get into that and a little bit of us endoscopy. We're going to start with foreign bodies because it's a little bit easier than talking about the typical endoscopy that we do.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah and then you know we will see you guys next week.

Jordan Porter, RVT, LVT, VTS SAIM:
Have a good week, bye!

Yvonne Brandenburg, RVT, VTS SAIM:
Bye!

Thank you for listening to today's episode of the Internal Medicine For Vet Tech's Podcast. If you like what you heard, we'd love for you to share with someone you think might enjoy the podcast and make sure to subscribe so you never miss an episode. Want to give us a boost? Please leave a review on iTunes or your favorite pod catcher and we'll be sure to say thank you. Find out everything about us at internalmedicineforvettechs.com. Talk to you next week, bye.

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Question of the Week

What was the most rewarding case of pancreatitis you have seen, or the one you learned the most from?