Dale, a 4-year-old, 25-kg, castrated crossbreed dog, was presented for a 4-hour history of staggering, vomiting, and excessive drinking and urinating.
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Dale, a 4-year-old, 25-kg, castrated crossbreed dog, was presented for a 4-hour history of staggering, vomiting, and excessive drinking and urinating.
Dale had been normal before this event. He is allowed to go on off-leash walks in the woods, has access to his owners’ garage, has had no other previous medical conditions, and and was current on all vaccinations (including leptospirosis) vaccines.
Dale was quiet and slightly dull but responsive. Heart and lungs were normal on auscultation, with strong synchronous pulses. Vital signs were normal. The abdomen was tense on palpation, and he was drooling. A moderate-sized soft bladder was palpated, and the patient urinated a small amount during examination. Dale was ambulatory but ataxic and had normal general conscious proprioceptive reflexes and a normal cranial nerve examination. He was approximately 8% dehydrated. Body condition score was 5/9.
Multiple toxicities and disease processes can present with acute neurologic signs.
Venous blood gas analysis (Table 1) showed metabolic acidosis with respiratory compensation and an increased anion gap (AG). A chemistry panel showed elevated blood urea nitrogen (BUN) and normal creatinine. The increased BUN was presumed to be because of dehydration. CBC showed hemoconcentration but was otherwise unremarkable. Free-catch urinalysis revealed isosthenuria and a significant number of calcium monohydrate crystals. Based on the suspicion of possible ethylene glycol (EG) toxicity from access to his owners’ garage (where antifreeze was present), a Kacey Ethylene Glycol Test Strip (Kacey Diagnostics) was performed and was positive for EG at a lethal dose of 50 mg/dL.
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Diagnostic Test | Result | Reference Range |
CBC: Red blood cells (×106/µL) | 9.2 | 5.83-8.87 |
BLOOD CHEMISTRY: Blood urea nitrogen (mg/dL) | 40 | 5-30 |
BLOOD CHEMISTRY: Creatinine (mg/dL) | 1.4 | 0.7-1.8 |
VENOUS BLOOD GAS: pH | 7.29 | 7.35-7.46 |
VENOUS BLOOD GAS: Partial pressure CO2 (mm Hg) | 22 | 40-46 |
VENOUS BLOOD GAS: Bicarbonate (HCO3–; mmol/L) | 12.8 | 22-24 |
VENOUS BLOOD GAS: Chloride (mEq/L) | 115.4 | 109-120 |
VENOUS BLOOD GAS: Sodium (mEq/L) | 160 | 140-150 |
VENOUS BLOOD GAS: Potassium (mEq/L) | 4.8 | 3.9-4.9 |
VENOUS BLOOD GAS: Base excess (mmol/L) | -10.2 | -4 - +4 |
URINALYSIS: Urine specific gravity | 1.010 | 1.018-1.050 |
URINALYSIS: Sediment | Calcium monohydrate crystals present | Negative |
ETHYLENE GLYCOL TEST: Kacey Ethylene Glycol Test Strips | Positive for 50 mg/dL | Negative |
Ethylene glycol toxicity
Patient receiving hemodialysis for EG toxicity.
Dale was hospitalized, and IV fluid therapy with a balanced electrolyte solution (PlasmaLyte A, 6 mL/kg/hr) was initiated. A bolus of 30% ethanol (1.31 mL/kg, slow IV) was administered, followed by 30% ethanol (0.42 mL/kg/hr CRI IV) as an antidote for EG toxicosis (Table 2). Dale was placed under general anesthesia, and a dialysis catheter was placed in the right jugular vein. He received an 8-hour hemodialysis treatment (Figure 1) with a urea reduction ratio goal of 95%. A high blood flow rate of 20 mL/kg/min was well-tolerated and a dialysate flow of 500 mL/min was used. The dialysate was formulated with 4 mmol/L potassium, 30 mmol/L bicarbonate, and 140 (mmol/L) sodium.
Ethanol was added to the dialysate concentration to achieve a dialysate ethanol concentration of 0.1%. Dale was also maintained on an IV ethanol infusion throughout the procedure.
Antidote | Dogs | Cats |
ETHANOL |
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4-METHYLPYRAZOLE (FOMEPIZOLE) (50 mg/mL)* |
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|
*Antizol-Vet (fomepizole, Paladin Labs) has been withdrawn from the market, but human-use fomepizole and compounded versions are available.
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Dale did well during the hemodialysis treatment and was bright, alert, and eating normally the next day. On recheck bloodwork the following morning, his renal values, BUN, and venous blood gas parameters were normal. The patient was maintained on IV fluids for an additional 24 hours and was then discharged. On recheck 2 weeks later, Dale was doing well and renal values remained normal.
Related Article: Evaluating Ataxia in Suspected Ethylene Glycol Toxicity
Related Article: Ethylene Glycol Toxicosis in Dogs & Cats
ADH = alcohol dehydrogenase, AG = anion gap, AKI = acute kidney injury, BUN = blood urea nitrogen, EG = ethylene glycol, 4-MP = 4-methyl–pyrazole
ERIN MCGOWAN, VMD, is second-year emergency and critical care resident at University of Pennsylvania. A graduate of University of Pennsylvania, she completed her small animal rotating internship at Red Bank Veterinary Hospital in Tinton Falls, New Jersey.
LORI S. WADDELL, DVM, DACVECC, is adjunct assistant professor in the intensive care unit at University of Pennsylvania Matthew J. Ryan Veterinary Hospital. Her research interests include colloid osmotic pressure and coagulation in critically ill patients. She previously worked as emergency clinician in private practice and completed a residency in emergency medicine and critical care at University of Pennsylvania. Dr. Waddell, a graduate of Cornell University, completed an internship at Angell Memorial Animal Hospital in Boston.
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