Plus-Hex CLINICAL
Learning outcomes
• Ability to identify key nursing care factors relevant to feline cardiac patients .
• A basic understanding of the different phenotypes and stages of cardiomyopathy .
• An understanding of which factors have negative prognostic indicators for patients .
• A basic understanding of the possible progression of the disease .
• Ability to provide owners with the necessary information and skills to provide the best possible care at home .
Case background
The patient presented as an emergency to the out-ofhours service with a history of tachypnoea , lethargy and anorexia . He had been in his owners ' possession since he was a kitten . He spent most of his time indoors but had access to an enclosed garden . He was normally fed a mixture of wet and dry complete food . He was fully vaccinated and treated monthly for fleas and worms .
Patient signalment
Species : Cat Breed : Domestic shorthair Age : 12 years Sex : Male , neutered Weight : 6.55 kg
Patient status on presentation
On physical examination , the patient was quiet , alert and responsive . He had a heart rate of 230 bpm with a grade 4 / 6 left apical systolic murmur with a gallop rhythm . Femoral pulses were weak but synchronous . Respiratory rate was 80 breaths / min with mildly increased respiratory effort and episodes of openmouth breathing when handled . Mucous membranes ( MMs ) were pink and capillary refill time ( CRT ) was < 2 s . A temperature was not taken at this stage , to minimise patient stress . He weighed 6.55 kg and had a body condition score of 6 / 9 .
Differential diagnosis
Based on the clinical findings of a gallop rhythm , tachypnoea and a heart murmur , the differential diagnosis was thought to be CHF related to cardiomyopathy , most likely HCM .
Other , less likely differential diagnoses included pleural effusion related to neoplasia , pyothorax or parenchymal lung disease with concurrent heart disease .
Initial diagnostics and results
Planned diagnostic tests included a T-FAST ( thoracicfocused assessment with sonography for trauma , triage and tracking ); thoracocentesis , if required ; and once the patient was stable enough for further investigation , BP measurement , echocardiography , thoracic radiography and blood sampling for haematology , biochemistry and measurement of electrolytes .
An initial bolus of 2 mg / kg furosemide was administered intramuscularly before any investigations . The patient was placed in an oxygen kennel and his respiratory rate and effort were monitored every 30 min .
After an hour , the patient ' s respiratory rate reduced to 56 breaths / min with mild respiratory effort . No further episodes of open-mouth breathing were noted and the patient appeared more settled .
T-FAST
The patient was positioned in sternal recumbency . Flowby oxygen was provided at 2 l / min . A brief scan revealed a moderate amount of pleural effusion , mainly on the right side , and an enlarged left atrium .
A T-FAST scan allows rapid assessment during patient stabilisation and can be used to identify possible causes of respiratory distress , including pleural effusion , pericardial effusion and pneumothorax . The confirmation of the presence of pleural effusion meant that thoracocentesis was needed to stabilise the patient .
Thoracocentesis
The patient was quiet but anxious . An intravenous ( IV ) cannula was placed in the left cephalic vein and 0.2 mg / kg butorphanol was administered IV to enable thoracocentesis to be safely performed . Butorphanol has a minimal cardiovascular effect and generally provides an adequate level of sedation , as well as being an anxiolytic .
A total of 123 ml of modified transudate was removed from the right side of the chest cavity . Only a minimal amount of effusion was seen on the left side . Diuresis will help to clear pulmonary oedema and prevent the buildup of pleural effusion but it is an inefficient treatment for clearing pleural effusion in severely affected patients . In these cases thoracocentesis is essential .
The patient was returned to the oxygen kennel to minimise stress and allow him time to settle prior to further investigation .
Volume 38 ( 4 ) • August 2023
43