What "Does Lowest Effective Dose" Mean?

Sam, cruciate ligament rupture repair

There are a few key terms that veterinarians use daily that we mistakenly presume our clients are comfortable with and understand. One term that I use daily is "lowest effective dose" or LED. I thought it would be helpful if I explained what this term means, and why we use it. I use it most commonly when I am talking about NSAID's, or non-steroidal anti-inflammatory drugs. All licensed NSAID's have a label statement on LED, and label mandate is for LED.

We use this term when we are trying to customize a drug dose for a specific patient. I use it when I am treating a pet with a drug that has either a narrow therapeutic index, and/or for a condition that either will likely need long term management, and/or a condition that I expect to change with time and therapy.

Another cruciate ligament rupture repair.
I rely heavily on NSAID's with orthopedic surgeries.

NSAID's are useful for a whole host of diseases and ailments, but because they are so tightly protein bound they have a narrow therapeutic index. This narrow therapeutic index means that your pet needs to be given the exact amount prescribed, or less. Over dosing, even by a little bit, by giving a higher dose of the medication, or by giving it more frequently than listed on the prescription can be detrimental to your pet. NSAID's as a family are the most widely reported drug to the FDA by about a 1:5-10 ratio because of their common and sometimes very serious adverse side effects.

Daisy Mae

And her broken femur

The most common side effects I see in practice are vomiting and diarrhea, but I have also seen perforated gastric ulcers that caused severe illness and required emergency surgery. I have unfortunately also seen a dog die because the owner kept giving the drug days after their dog stopped eating and began acting ill. For these drugs I have a lengthy conversation about possible side effects, things I want the owner to monitor and be aware of, and I always repeat two things;

Post-op re-check

1. Only give the NSAID if your pet is eating and drinking normally.

2. If you ever have any hint of a concern that there is a problem DO NOT GIVE THIS DRUG!

Before I prescribe a NSAID I give the pet a thorough examination, take a detailed history understanding what the client is seeing, what they are concerned about, and how the pets condition might improve with use of an NSAID. I usually always perform a baseline blood and urinalysis. If there is a problem with the pet I want to know what their kidney, liver, urine, and red and white blood cell counts are before starting the drug.

Examples of NSAID's used in veterinary medicine include; Rimadyl (generic name carprofen), Metacam (meloxicam), Deramaxx (deracoxib), Previcox (Firocoxib), Onsior (Robenacoxib). 

Because NSAID's are heavily protein bound they need to be dosed based on lean body weight, (not actually body weight). Therefore use the exact dose (your vet will tell you what your pet’s optimal body weight is. (Hint, this is the number on the scale you and your pet should be working towards). That milligram size is the maximum amount of the NSAID that you can give in the prescribed time frame.

Post-op she barely toe touches with that leg.

The key to finding LED is understanding when the drug is working and then attempting to customize to the lowest effective dose your pet needs to maintain resolution of the clinical signs that your vet prescribed the NSAID for. So for instance, if your vet prescribes an NSAID because your dog is limping in the morning due to osteoarthritis or joint pain, we would like to get the inflammation to dissipate by using a week or two of the NSAID. You should see an improvement in the form of ease of rising, ease of moving the joint, and an overall improvement in activity level and comfort. It is very important for you, as the parent, to understand and appreciate the changes that the medication makes in your pet. Without appreciating these changes it is difficult to understand how to identify their lowest effective dose. For some of my clients I ask them to keep a daily journal that describes how their pet is doing each day. The daily journal entries should also include how much of the drug was administered.

One month later she is using the leg very well.

The game plan for LED is to administer the labeled dose and represents the maximum amount that can be safely given. I always ask for a re-check phone call, or update from my clients within the first week of using the NSAID. I also place them on our call back list so that we make sure that we are touching base with them at this critical time period. Most adverse reactions to NSAID’s seem to occur within the first week. This is done to assess efficacy, ensure there are no adverse effects, and to boost compliance. Once efficacy is confirmed go over a titration plan with the owner. The key is to decreasing an NSAID is to do it very slowly. Statistically about 5-10% of all patients need to stay on labeled dose, but most can go to about 25% below label dose. This saves the client money and protects our patients from the possible side effects. I remind owners to begin to look for recurrence of the clinical signs that brought the pet in the door in the beginning. How well are they still moving? Are they reluctant to use stairs? Or climb onto the couch? Or get up for all of the things that they used to  want to be a part of, for instance, when the door bell rings, when a loud car drives by, when the neighbors visit, etc. It is also important to mention that your pet will give you some indication of pain/comfort by their facial expressions and body language movements. For pets on tablets I recommend trying half the original dose on the same frequency. For dogs on liquid NSAID's decrease by 5 pound dose per week if over 20 pounds, or decrease by 1 pound per week if less than 20 pounds. When the clinical signs begin to recur it is time to increase the dose of the NSAID, this means go back to the last dose that controlled the clinical signs. This is your maintenance dose. If the dog at some point in the future has a return of clinical signs go back to the original prescribed dose for 2-3 days.

For the pet's who I do not think need the NSAID long term, like my cruciate repair surgeries, spays, neuters, and minor wound repairs or surgeries I advise my clients to use the NSAID for a short post-operative period of time (usually 2 days for a neuter, 4 for a spay, and 7 for an orthopedic surgery), and after this period I want them to try to skip a dose, or use half of the intended dose to see how their pet does. Over those next few days I want the pet to be asking for the NSAID instead of the client just assuming they need it and giving it. In my experience outside of the prescribed times listed above most pets do not need any further NSAID therapy. 

Getting better.

Our biggest concern is that a dog being titrated will exhibit clinical signs that the owner doesn't recognize and we have a painful dog. The journal is a helpful visual cue to help understand if we are using an effective dose and an effective drug. Pets should be monitored weekly until the maintenance dose is realized. After they should be monitored monthly. While your pet is on an NSAID routine examinations and blood works should be monitored. NSAID practice tips: Give NSAIDs only if eating and drinking. This means that the NSAID should only be given if the pet is feeling well. I want your pet to be pain free, but I also want your pet to be safe. The safest way to give an NSAID, a long term is to find LED and understand that your pet’s disease, ability to tolerate medication, and the treatment options will all change with time. 

The best advice; keep an open dialogue with your vet and never hesitate to ask for help in navigating the ever changing current and direction of the waters your are traveling with your pet.

I think that I am as happy as Daisy Mae is that her leg healed so well.
Daisy Mae had a serious fracture to her leg.
She required NSAID's for many weeks.

If you have any questions about NSAID's, or any other pet related question, you can find me and a whole bunch of other pet loving people at Pawbly.com. Please check us out and join our community. We are all about helping people take care of their pets, and we are free to use!

Or you can find me at the clinic, Jarrettsville Vet, or on Twitter @FreePetAdvice.

And as always, please be kind.

Many Thanks to Danny Joffe, DVM Dip ABVP who gave a talk on Metacam that was incredibly insightful and the backbone for this discussion.

The Painful Truth About Coercing Your Client. Heidi's Story.

As a veterinarian there are so many talks that you discuss so many times that you feel as if it might just be a whole lot easier to video tape the discussion, push play when the next appropriate patient presents, and pop back in the exam room to discuss the final details of the treatment plan.

Wouldn't it be so simple? You bring your pet in, I diagnose the problem, tell you how to fix it, and then we schedule it the following day.

No wasting time, no idle insignificant chit chat, no silly feelings about your pet "not wanting to go through any procedures," or ridiculous excuses about “sparing them from the hardships of recovery,” etc. etc.

It can be frustrating to feel as if I need to repeat the same thing over and over.  And yet, I’ll do it tomorrow, and the day after, and the day after,.Its my job. To tell you what disease, condition, ailment, need, etc., that your pet has and how I suggest it be treated.

How do I keep myself from feeling like a broken record? Well, I employ my clients to serve as future character witnesses, provide their own personal experiences, and pass it forward.

Here is one story I find myself repeating often. It is about bone tumors.

In large breed older dogs that present to me with swelling, lameness and intense pain at the site I will place a bet that your dog has a bone tumor. The diagnosis is usually pretty easy. OK, well, I should back track a bit and clarify.

In the earliest stages of bone cancer it can be difficult to pin the diagnosis exactly. Because your pet knows before the x-ray does that there is a problem.

The typical presentation of a bone tumor is a progressive limb lameness that persists.

On the first trip to the vet we corroborate your suspicion; The leg hurts and the pet is limping.

The normal course of events after that first trip is to prescribe an NSAID, (a non-steroidal anti-inflammatory) and monitor for response to treatment and resolution of clinical signs, (they stop limping). These work very well on pain and inflammation associate with osteoarthritis (OA). Most older dogs, just like most older people, have some joint pain because their joints get sore after years of wear and tear.  A response to treatment is a quick, cheap, easy way to help confirm a diagnosis. If we are right, and if it is just OA, then the medications lessen the inflammation which in turn will help alleviate the pain. If we are wrong then the owner will call back in a few days/weeks and report that the lameness is worse, or no different.

Trip number two is for a re-check and x-rays. Depending on the degree of bone destruction we may or may not have visible evidence on the x-ray. (One little tip here from a weathered vet; take the x-ray of the whole foot..shoulder /hip to toes. It makes you look like a bone head when you miss the big lytic (destruction of bone) lesion in the foot because you cut the film short).

If there is a lytic lesion on the bone it is most likely a bone tumor, and the most common bone tumor is an osteosarcoma.

Osteosarcomas are incredibly painful aggressive tumors. They essentially eat away at the bone until it crumbles. They also spread fast! Those little microscopic cancer cells will hijack a ride through the bodies internal highway system (blood stream or lymphatics) and land in remote areas where they then lay down roots and begin to eat away at another part of the body.

After you and I have gotten to this point the waters get muddy and the navigational gear gets all screwy. The dance of the decisions, the debating, the doubt, the second guessing, hesitation and indecision begins.

Here’s where I want to take the conn and remove you from the bridge. What I really want to say, “OK, I got the wheel. I am steering the ship. Here's what you need to know: The estimate for surgery is $800 - $1000, average lifespan after surgery 6 months. But, trust me, your pet will be happier because they will no longer be in pain."

At which time you say, “OK, thanks doc, see you tomorrow for surgery.”

Now, I understand there is a lot to discuss. But remember I have had this discussion about 300 times before you, so in truth, I’m not looking forward to number 301.

Here are the arguments and points of discussion that pet parents have;

Number One: 
“I don’t want to put my dog through that.” OK, I’m going to put on my best “be nice” face. Your dog is in an immense amount of pain. That pain is manageable only for a short period of time. At some point we will be putting your dog down because they refuse to move, or eat, or do anything because they are in so much pain. SO, if you are telling me this I will remind you that not taking that leg off is not wanting your pet to be pain free. Be honest. I think that most people use this excuse because they don’t want to put their wallet through the procedure.

Number Two:
“He will be unhappy with three legs. I can’t do that to him.” My response; Your dog is already three legged. They are just three legged with one additional painful rotting limb stuck to them. Another important point to remember is that at some point the cancer will eat away so much of the bone that it will fracture, or crumble.

Number Three:

“The recovery will be too much on him.” Like the current excruciating minute to minute with no chance of relief in sight is better?

Now, I understand that I am not being subtle. Here’s why. I cannot stand seeing an animal in pain if there is anything that can be done about it.

So get over your phobias, and cosmetic disfigurement, and get that damned leg off!

Here is a story of a patient of mine. Her name is Heidi.

Heidi was an older mixed breed dog who presented with the above scenario.

Her dad is one of the most devoted genuine guys around. He is direct, honest, and not at all uncomfortable making you uncomfortable when it comes to his pets. I like him all the way around. We are kismet. I get him. I don’t mince words, and he doesn't tolerate it to begin with.

When Heidi first came to see me she was lame, exceptionally lame. She was in pain all the time. He knew he had to do something and he was leaning towards putting her down. When he said this I started to pull out all of the tricks of my medical bag.

There was arm wrestling, and some somewhat questionable, unethical promises. I also pulled out the “past experience” card. He was so stubbornly stuck on not being able to put her through surgery that I had to double down and confided to him that “if Heidi was my dog I would take her leg off.”

Now I’m going to be really honest. I hate when vets do this. It is coercion in my opinion. We should never ever use this as a way to persuade. While I’m being so honest I will also admit that I do say this. For my friends I feel OK saying it.

Before I convince you to take a bad terminal leg off, do your due diligence. A pet that is a candidate for amputation should have a full bloodwork and urinalysis done. They should also have a full 3 view set of chest x-rays. If everything is clear and normal I recommend amputation. If there is evidence of metastasis to the chest than the prognosis is poor and the floor is opened up again for discussion and debate.

I have some distinct advantages to being so sure footed here. I have years and years of cases to use as my precedence. I have never had one owner tell me that they regretted amputating a leg after they did it. Every single pet a week later was a thousand times happier than they were the day before their surgery. Taking pain away from a pet is giving them back their life.

When I told Heidi's dad that I wanted to write about her story he sent me the following;

Krista,

Please find attached several pics of Heidi.  She's such a house girl that oftentimes when she's outside...and this was long before her surgery...she looks sad and bent-out-of-shape.  

Here's an impromptu paragraph on Heidi:

Heidi was found wandering in the street on a summer afternoon near Lake Redman, PA.  As I already had two dogs, I coaxed her into my truck and drove straight to the York County SPCA.  After checking on her over the course of a week, I was told that since she hadn't been adopted within a two week period, she was likely to be euthanized at any time.  I couldn't allow that and immediately drove up there to adopt her.  I then had three dogs for a short time until one of my "kids" died after 15 years of blessing me with her company.  

I must confess that Heidi, almost from Day 1, endeared herself to me.  I've had many, many canine kids through my 61 years, but Heidi, for whatever intangible reason, became my favorite of all time.  Then, after she developed a "limp", which after several weeks I finally realized wasn't the result of her stepping into a gopher hole somewhere on my two acres, I brought her to my long-term veterinarian, Jarrettsville Veterinary Center.  Initially, I was devastated when I was told that her diagnosis was Sarcinoma (you'll have to help me with this, Krista).  I also struggled with mixed feelings about whether Heidi would have any kind of fulfilling life when I learned that she would have to have her leg amputated up through the shoulder area.  After several days of tormented feelings, I decided to go ahead with the amputation, hoping that her cancer could be excised.  I might add, that financially that was a hardship at the time, but I felt as if I had no other choice that I could live with. 

Within 24 hours of her amputation, Heidi was remarkable.  I brought her home, using a towel sling to carry her into the house.  What did she do immediately after I released pressure on her towel sling? She took off on her own accord across the house to go to her water bowl and then down the hall to her bed.  We were moved beyond words by her strength and resilience. 

Within several weeks, she began to exhibit a deep, horrible cough.  We thought the worst, as we read online about how cancer when it spreads to the chest is often accompanied by such a cough.  Initially we put her on cough medication to suppress the cough.  When that wasn't real effective, we were able to obtain an antibiotic medication and her cough went away.  That was more than six months ago.  Her operation was almost ten months ago.  

Heidi had been my "special" child now for those ten months.  She's doing well.  She's not the same alpha dog that she was back before her illness.  These days she's a sweet, trusting, loving survivor.  I am so happy that's she's in my life!

Update, 12/1/13.

Heidi passed away at the clinic with her dad and I on 11/24/13. She was unable to hold herself up anymore. Before her surgery her hips were weak and arthritic and the additional stress and strain her body had to carry with the loss of her front leg made the hip stress more pronounced. Her dad bought a special harness for her with a handle to help her get up and provide an extra point of stability. The harness was also the way that her dad could help carry some of her weight and keep her from slipping or falling.

This was the email I received from Heidi's dad on November 21. 

Heidi has really taken a turn for the worse.  Her back legs sway and are wobbly...she's unable to cintrol her bladder...acts as if she is in a daze...takes one or two steps and stops...pants a lot more..and in the last few days has had little appetite.  We're thinking that her quality of life sucks and that it's time. Are you going to be there at all this weekend?

I saw them on the 24th, and it was time to say goodbye.

A week later her dad sent me this.

Happy Thanksgiving!  Now that a week has passed, I was finally able to log on to read the "Heidi" blog.  Thank you so much for being so candid and forthright.  I had wanted Heidi's struggle to end on a positive bend.  I'm grateful to you for being that enabler.  

I also want to say to all those who might know of many conflicting emotions that the "journey" with Heidi encompassed...I would do it again in a heartbeat!  Heidi taught me about compassion, perseverance, strength, and how to love more deeply.  

Thank you, Krista.

Heidi's "Dad":)

For related stories;

three stories of three heroic three legged dogs.

Cesar Milan's story on three legged dogs.

Related Posts;

Donner. My three legged cat's story.

A new Immunotherapy for canine osteosarcoma yields promising findings so that perhaps amputation is no longer indicated?

If you have any pet related questions you can find me, and a whole bunch of amazing people at

Pawbly.

Or you can find me on Twitter @FreePetAdvice.

Emergency Kit. The Veterinarians At Home Kit.

I was asked by a follower on Twitter for "my best pet advice," so I had to think about this open ended question for a moment and decided that one of my best pieces of advice was that every pet owner should have an at home emergency kit.

Here is what I think it should have in it;

1. A list of emergency phone numbers. 

I give out business cards so that my clients have one for their regular vet and also a card for our emergency clinic. (It has their number in very big NUMBERS so even in the emergency you see it). I also want the directions to be on the card. When you get stressed you forget to listen or pay attention to anything.

Pet Poison Hotline. Their number is 1-800-213-6680, a fee applies for their services.

2. A big blanket. 

It can act as a straitjacket, a warming blanket, and absorb fluids if needed.

3. Thick absorbent bandages and Tape. 

Some people actually use women's maxi pads. They are cheap, and highly absorbent, and pre-packaged. Vets love Vetwrap. You can find it pet supply stores, or stores that sell horse products. It sticks to itself but not your pet, or their fur.

4. 3% Hydrogen Peroxide. 

If you are concerned that your pet ingested something toxic or dangerous you need to have this on hand. Call your vet or the Pet Poison Helpline BEFORE inducing vomiting. Their number is 1-800-213-6680, OR call your vet, OR local pet emergency clinic. DO NOT WAIT. Seconds count, and hours can kill. (For more information on when to use this please see my blog, To Puke Or Not To Puke, That Is The Question..)

5. Benadryl (generic is called diphenhydramine). 

You need this anti-histamine for bug bites, (or if you are my dog Charlie, eating frogs) or any other allergic reaction. If your pet gets red skin, or hives, or is even having a worse allergic reaction it is your go to drug to try to slow or stop the progression of the reaction. If your pet is having trouble breathing, get in the car and go immediately to the closest ER.

6. Eye wash. 

Over the counter generic eye wash, sterile saline, is fine. Cheap stuff. Use it to flood the eye if the eye looks inflamed, has any abnormal discharge, or is being held shut (squinting). If the eye doesn't appear to be improving after an hour, or if it is painful, or you see yellow or thick discharge you need to go to the vet ASAP.

7. Thermometer and Lube. 

Please use a digital thermometer. The old mercury ones are too dangerous and fragile. What would happen if your pet sat down while you are trying to take their temperature? The normal temperature of a dog or cat is about 100.5  to 102.5 degrees F, or 38.5 to 39.2 degrees Celsius. If your pet is below 98 or above 104 degrees F go to the vet immediately. DO NOT WAIT! It is very likely the temperature is on its way to worsening, and seconds count!

8. Nail trimmers and Quik-Stop.

It is important to have the right trimmers for your pet. Ask your vet to show you what they use, and how to use them. Kwik-Stop is the product we use to stop the bleeding if we accidentally cut the nail too short. Here is my primer on How To Trim Nails.
I swear I have had this same bottle since 1995. It is still full, it takes forever to go through a bottle, and you get better at trimming nails with practice.

I also have very definite opinions on nail trimmers. Don't buy the cheap guillotine kind. Buy spring loaded heavy duty nail trimmers if your dog is over 30 pounds. ALWAYS have quik-stop standing by JIC.

9. If your pet has any medical issues you may need other drugs in this kit. 

I keep an NSAID, (old dog pains), and ear wash for floppy eared Beagle-pup. Along with previously prescribed drugs, ointments, etc. Always ask your vet before using old medications. many expire, and often clients inadvertently use the wrong drug on the wrong species or at the incorrect dose. I also keep heartworm, flea and tick preventatives close by in a locked container.

Please remember to not use prescription medications, (or ANY medications) without your Veterinarian's "OK" first. Many clients over use and abuse the prescription ear medications and over time make the ears much harder to treat.

Always use the medications given to you completely and exactly as directed on the label. I also have unfortunately seen many owners give their pets "human drugs" that are toxic to pets. I have actually lost pets due to owners giving medications that are toxic, and/or giving doses of drugs that are way over what a pet can tolerate. If you are in doubt, "Don't give it!"

10. I also keep my pets medical records with the medical kit. 

So if you need to run to the emergency Vet you have your pets records.

11. A Leash, Harness, Collar, and/or Pet Carrier.

If you need to get your pet somewhere fast it really helps to have these things at your finger tips.

12. Something to use as a Muzzle.

Also, some dogs do not do well with shock collars, or invisible fences. Please seek advice before purchasing products that might be potentially harmful and/or not work for your pet.

In the event your pet is hurt, or scared be prepared with a soft cloth muzzle. You can make one yourself with a long scarf, leash, a necktie, or pantyhose (if you use this don't pull it too tight this stuff is hard to get off and can act like a tourniquet) or length of gauze. I promise you your pet will bite if they are in pain and you are trying to do anything to them. When you are in pain you are not the same individual. Ask any woman who delivered a baby what came out of their mouth in the delivery room. A dog, or cat, or anything reacts without thinking if you touch them, and they are in pain. So just put one on and then don't get upset if they resent the muzzle. Improvise your own muzzle by making a noose by tying a loose knot in the middle of the length of the strip, leaving a large loop. Approach the dog quietly from behind and slip the noose over their nose. Do not block the nose, they need to breathe through this. If your dog is really struggling to breathe then do not tie the noose so tight. It should only be tight enough to not allow their mouth to bite you. Put the noose about mid-way on their muzzle/nose. Pull the know tight with the know on the chin, then pull the ends behind the ears and fasten a bow.

 The following picture is from "The Dog Lover's Companion," Fog City Press, a great resource for all dog owners.

Here is a picture of Savannah, my dog, modeling, (unhappily) an improvised muzzle.

And here is Joe, my husband, being a goof, because I asked him to show me how put it on ( a little quiz to see if he was paying attention), after I had put it on Savannah.

Here are some of my pets. I promise you that I have used my emergency kit on every one of them. (Did I ever tell you about the time my whole staff came over to our house to go fishing and my dog Charlie bit into the 3 pronged barbed fishing hook? That was emergency sedation, first-aid, and surgery. I'll tell you that story later.)


Ms. Pig just saying "hello"

Miss Pig, Ambrose, and Savannah on a perfect summer day. That's Ms. Pigs house. It is insulated and cozy year around.

Here is Squeak Box, DC, and Donner. We only go out on supervised outings. They are indoor kitties. But they love to go for walks with us and think of themselves as vicious predatory jungle lions.

Ambrose looking for attention.

Lilly, my moms dog. She's another story. In this photo she has Cushings disease. It was not treated at this point. Now she's an Addisonian. I'll explain her saga someday.

Disney's Dilemma

A few years ago a very nice woman came into the clinic with her not very nice dog Disney. Disney was all black, about 40 pounds, and had a long fluffy full coat. She was always overweight even though she always tried to hide it all under a big full jet black coat. I tried many, many, times to convince Mrs. Nicks that Disney was overweight and needed a strict diet, (i.e. no more table scraps), but I knew that she lived with her elderly mother, who she cared for, and between the loneliness of caring for a mom with dementia, and the mom with dementia not ever remembering not to feed Disney table scraps, it was pretty much a lost cause.

The first two years of knowing Ms. Nicks and Disney we had the routine examinations, vaccinations, repetitive pleading of trying to get some weight off Disney, etc. etc. then one day Ms. Nicks called me to tell me that Disney was going outside trying to pee but only a few drops were coming out. And she kept going to the door, and Ms. Nicks kept taking her out, but all Disney could produce were a few drops of urine. I told her to bring Disney in right away. I was expecting to find that Disney had cystitis, (inflammation of the urinary bladder). So all I needed was a few drops of urine, and all Disney needed was an anti-inflammatory and an antibiotic and we were on the mend.

When Disney arrived I gave her an examination. I cannot ever express to the new vets out there how absolutely imperative it is to always give a full complete comprehensive examination.  Instead of finding an empty flaccid small sensitive bladder low in the pelvis, I found a very large full distended painful bladder that took up almost the entire caudal (back half of the) abdomen.  I took a gasp and swallowed the horrified look in my heart. We next went to x-ray. I was hoping to not find anything obstructing her ability to urinate, like a tumor, stones lodged in the neck of the bladder, etc. I was afraid to try to manually express her bladder by pushing too hard on it. You see at this point the bladder has been so distended for so long that often it is a thin weak balloon, and any amount of pressure can cause it to rupture. If the bladder ruptures it will spill the urine into the abdomen and the urine acts like caustic acid to the sensitive peritoneum (the lining of the inside of your abdominal wall). My next plan was to try to sedate Disney to place a urinary catheter. My first priority was to relieve her bladder distension and then try to figure out why this was happening to her. We placed an i.v. catheter collected our blood work and then gave some i.v. sedation. Within minutes there was a flood of dark pungent urine everywhere. I took a deep sigh of relief for Disney. We sutured the catheter in place and started her on the aggressive i.v. fluids I knew she needed to start correcting all of her kidney and electrolyte abnormalities. The next few days Disney seemed to feel more and more like herself. Which in Disneys terms meant she was less and less of a cooperative patient. When she was feeling well enough to not be able to be handled at all I called her mom and sent her home.

During her time in the hospital we ruled out everything except a neurogenic cause to her problem. This meant that the root of her inability to empty her bladder was because she either couldn’t squeeze the muscle of her bladder wall down tight enough to empty, or she couldn’t open the valves that keep the bladder shut. So I started her on all of the medications I could to try to tell her nerves and muscles to work the way they were supposed to. This plan worked for a few months.

Over the next year there were many interrupted evenings of meeting Disney at the clinic to try to repeat the procedures we had tried so successfully the first time. Each time it became harder and harder to get her relief. Until finally one evening I told Ms. Nicks that I would have to open up her abdomen and try to empty her bladder from the inside. I remember crying with her in the surgery room. I knew that Ms. Nicks knew that I was having as much of a difficult time making the decision as I was. I knew that my only hope of getting Disney off of the surgery table alive was with a urinary catheter being placed from inside the balloon instead of my usually threading it through the urogenital opening.  I looked into Ms. Nicks eyes, both of us sobbing, and she said to me, “I know you want to know why she can’t urinate, and I know you want to try to help her again, but I can’t put her through any more”. It was a hard painful decision for all of us. Ms. Nicks had lost her mom a few months ago, and she was losing her last companion. I knew that putting Disney under general anesthesia and exploring her abdomen and bladder might fill in some of the answers I had not been able to get before. But I also knew that we were at the end of her or her mom’s ability to treat her. I lowered my head and told her mom that I was so sorry. I then said goodbye to Disney and injected the pink syrup into her i.v. catheter. I turned off her monitors and I cried over her as she died.

I have talked to Ms. Nicks many times since that day. She still comes to our Christmas parties, and she still drops in to say hello every so often. I have even called her to see if she would be interested in helping us by fostering a dog. But she always tells me that she still isn’t ready for another dog yet. And I understand, and tell her that we miss Disney too. Even though I am pretty sure Disney never liked me back.

If you would like tolearn more about neurogenic anuria and cystitis please see the link below;
http://tinyurl.com/3fwekct