DEBATE ON DEX / SOLU-DELTA / CORTICO-STEROIDS

[Officially Retired]

LOL

Well, as with anything, there will always be debate I suppose.

I don't know why the second link you posted won't take (one of mine wouldn't either).

In that article you posted previously, the DVN recommends "low dose" cortico steroids for septic shock, and I've read a bunch saying not to use it.

But hey, maybe the fluids/Hypertonic saline is the way to go.

Maybe the Volvulen might prove to be a better solution.

Certainly, fluids alone aren't going to HURT the dogs ... whereas I've read steroids might cause some associated problems.

I would love to get my hands on some of those paid-for articles (that I didn't post) and see what they said.

I agree, it is confusing

Goes back the the old saying, "A man with one watch knows what time it is ... a man with many watches is never sure" ...

[FrostyPaws]

I think I may start paying for some of those articles so I can just flat out have them on hand for future reference. Either way, it is something to seriously ponder. Have people been doing it wrong for so long?

I found some studies from the 70s that advocate the use of dex in hemorrhagic shock.

70s Shock
70s Shock x2

[Officially Retired]

I think I may start paying for some of those articles so I can just flat out have them on hand for future reference. Either way, it is something to seriously ponder. Have people been doing it wrong for so long?

I found some studies from the 70s that advocate the use of dex in hemorrhagic shock.

70s Shock
70s Shock x2

Interesting, thanks.

Again, the dosages in almost every government/university reference are exactly at the high-end of the dosage range.

(If you decide to buy the paid-for articles, let us know what the finding are.)

Here are some current findings I found for Solu-Medrol:

Solu-Medrol (Pfizer) Package Label.
"Shock: In severe hemorrhagic or traumatic shock, adjunctive use of i.v. methylprednisolone may aid in achieving hemodynamic restoration. [Although there are no well-controlled (double-blind placebo) clinical trials, data from experimental animal models indicate that methylprednisolone may be useful in hemorrhagic and traumatic shock. See also Warnings regarding septic shock.] Corticoid therapy should not replace standard methods of combatting shock, but present evidence indicates that concurrent use of large doses of corticoids with other measures may improve survival rates."

And another (New Zealand Govt)
"As adjunctive therapy in life threatening conditions (e.g. shock states) the recommended dose of Methylprednisolone is 30 milligrams per kg of methylprednisolone sodium succinate, given IV over a period of at least 30 minutes. This dose may be repeated every 4 to 6 hours for up to 48 hours."

US FDA Statement on Solu-Delta
"There are reports of cardiac arrhythmias and/or cardiac arrest following the rapid administration of large IV doses of SOLU-MEDROL (greater than 0.5 gram administered over a period of less than 10 minutes). Bradycardia has been reported during or after the administration of large doses of methylprednisolone sodium succinate, and may be unrelated to the speed or duration of infusion. When high dose therapy is desired, the recommended dose of SOLU-MEDROL Sterile Powder is 30 mg/kg administered intravenously over at least 30 minutes. This dose may be repeated every 4 to 6 hours for 48 hours."

This is probably why Doc recommended it just be mixed with the bag of fluids, rather than run straight into the vein.

And I also think this almost universal adherence to the high-end of the range, for traumatic shock, is why Doc originally placed the dosages right at that high-end and left out the "ranges" ...

Jack

[Officially Retired]

Here is a great article, that actually rejects cortico-steroids, and yet extolls the use of Hypertonic Saline. It also recommends the Hetastarch you mentioned:

No steroids
"There is no data supporting the use of GC in generalized trauma (i.e. hit by car, dog fights, etc.) or heat stroke. In fact GC may increase morbidity and mortality due to the numerous adverse effects. Supportive care such as crystalloids and colloids, pain management with opioids, and body temperature are the primary recommendations along with stabilization of blood loss and fractures. Antimicrobials may also be indicated."


Advantages of Hypertonic Saline
"Hypertonic saline typically contains either a 5% or 7.2% concentration of sodium chloride. Hypertonic saline is administered relatively quickly, over 5 minutes, and results an increase in plasma osmolality. Advantages of hypertonic saline include the rapid administration of fluid, low volume, low cost, and efficacy. Studies in experimental dogs have indicated hypertonic saline, 4 mL/kg, induces a plasma volume change of 20 mL/kg. Other effects of hypertonic saline include improvements in cardiac output, arterial blood pressure, splachnic blood flow, and acid base status. Hypertonic saline does not appear to cause vasoconstriction or other changes in the mechanical properties of the circulatory system. The primary effects appear to be due to plasma volume expansion.

Administration of 7% hypertonic saline solution (4-5 mL/kg) results in increases in serum osmolality by approximately 28 mOsm/L within 10 minutes. The elevation remains approximately 12 mOsm/L above control values for 4-12 hours. As expected increases in serum sodium and chloride concentrations (~13 mEq/L) occur within 10 minutes of administration. No adverse effects have been noted with these changes in osmolality and sodium concentrations. Serum potassium values decrease following administration in a similar manner to administration of isotonic fluids. Serum potassium concentrations drop by approximate 0.8 mEq/L and no adverse effects have been reported.

Hypertonic saline has been studied in experimental models of hemorrhagic shock, endotoxic shock, and shock due to gastric dilatiation with volvulus. In each case hypertonic saline produced an equal or better effect to traditional resuscitation with isotonic fluids. Resuscitation with isotonic fluids or colloids results in increased intracranial pressure and, worsens cerebral edema. Hypertonic saline does not appear to increase intracranial pressure. Additionally, hypertonic saline does not increase lung water volume during resuscitative administration as compared to isotonic fluid administration. In models of GDV in dogs, hypertonic saline (in combination with dextran-60) 5 mL/kg, resulted in a more effective and sustained resuscitation than did lactated ringers solution, 60 mL/kg. Hypertonic saline treated dogs maintained a better cardiac output for the 3 hour monitoring period and experienced less hemodiltuion. However it is important to remember that experimental models do not always predict naturally occurring conditions.

Hypertonic saline has been assessed in human clinical trials in a variety of conditions resulting in shock. Hypertonic saline (7%) was administered to patients with a variety of conditions resulting in shock which were initially non-responsive to conventional resuscitation. No adverse effects were noted and 9/11 patients which were initially non-responsive, but responded to hypertonic saline. In a controlled study, hypertonic saline in combination with dextran-70 was compared in a blind fashion to isotonic fluid therapy in trauma patients. Patients treated with hypertonic saline had significantly higher mean arterial pressures on arrival to the hospital and a subsequent higher survival rate. Postoperative hypovolemia in surgical patients treated with hypertonic saline maintained increased systemic arterial blood pressures, atrial filling pressures, and cardiac output with less volume administration as compared to isotonic fluids.

Hypertonic saline is not an appropriate choice for resuscitation of a dehydrated animal. Dehydration requires replacement of fluid and electrolyte content of which isotonic solutions are better choices. Hypernatremia is also considered a contraindication to administration of hypertonic saline. Finally, cases of fluid overload (increases in intravascular fluid volume) are also considered a contraindication to hypertonic saline."


Hetastarch
"Hetastarch is a commonly used colloid solution in veterinary medicine due to its ease of use and storage, and its relatively low cost. Hetastarch has a mean molecular weight of 70,000 (albumin is approximately 69,000 MW) with a colloid oncotic pressure of 30 mm Hg (albumin is approximately 18-20 mm Hg). Hetastarch ranges in size from 10,000 MW to 1,000,000 MW with sizes less than 50,000 MW eliminated by the kidneys, whereas large sized molecules are primarily cleared by the liver and spleen. Hetastarch is an effective volume expander with each mL capable of retaining approximately 30 mL of water. This property results in a volume expansion greater than the volume administered and may persist for up to 24 hours. Up to 50% of the administered hetastarch volume is retained in the vasculature for 48 hours. Hetastarch may increase the bleeding tendency due to a dilutional effect of clotting factors (fibrinogen and antithrombin III). A single case report in humans detailed a subclinical von Willebrand's patient that experienced increased bleeding following administration. Overall the adverse effect rate of hetastarch in humans is low, 0.085%.

Colloids are often used for shock resuscitation. Colloids provide rapid volume expansion with a low volume administration, which persists for long time periods. Hetastarch is often administered in conjunction with cystalloids to prolong the volume expansion provided by the crystalloids. A common dosing strategy for resuscitation is to administer 5 mL/kg of hypertonic saline (7.2%) followed by 5 mL/kg of hetastarch. As previously mentioned, colloids can increase intracranial pressure and cerebral edema, therefore should be used cautiously in patients with head trauma. Colloids can also be administered to hypoproteinemic animals to increase oncotic pressure and maintain proper fluid balance. A response to colloid administration is often noted within 12 hours including decreases in peripheral edema, increased urine production, and decreased lung volume. However it is important to note that hetastarch should not be used to treat cardiogenic pulmonary edema as it may worsen the condition due to increased pulmonary arterial pressures."


It remains someone confusing on the steroid issue ... but it seems universal that fluids, and hypertonic Saline, are good for after-battle shock treatment.

Time for bed now ... got a bunch of stuff to do tomorrow ... but this is getting more and more interesting.

Jack

[bulldoghistorian]

Yeah! I mean, this whole thing is making me confuzzed. When talking with the wife last night, she says, "How do you know it's not the fluids bringing the dog around instead of the GCs?" And you know? Most of the time she's right. They're always given in conjunction. You have vets around the world advocating the usage of these drugs, but then you have vets, and a lot of science, stating that they don't increase survival rates. I just want to kick my dog at this point.

correct, that's what I understood as well

[FrostyPaws]

I meant to post a link to that article Jack, but I just forgot to do so last night. Good job on bringing that one on board also.

[Officially Retired]

One of the problems, I think, in accurately quantifying these 'studies' is the lack of controllable uniformity in what can be called "Traumatic Shock"

If we pull out the ol' microscope, and examine this term itself, we soon realize there is NO WAY to get a uniform sampling for error-free, controlled study.
There are simply too many variables, and I think this is why there have NOT been such controlled studies: there is no way TO control the damages.
It is one thing to purposely let 40% of the blood volume out of 2 groups of dogs, and get uniform, controlled studies like that, because of the ease in achieving uniformity of the challenge.
It is quite another to call all dog fights "the same," as they can involve an almost endless array of potential injuries/trauma ...

That last link that I posted has "hit by car, dog fights," etc. ... AS IF all dog fights are "the same" ... but ARE THEY?

I might have a dog that went 1.5 hours, and is "shocky," but he might have been on the ear the whole time, almost never got bit, but became "shocky" just from a combination of fatigue, coming in dry, and having a bleeder hit at the :20 mark. When correctly assessed, he really isn't "injured" at all, but has merely bled out and become too exhausted/dehydrated, to the point of shock.

On the other hand, I might have a second dog who was in a brutal, non-stop WAR with another dog, been bit in the guts, deep in the throat, become truly traumatized ... and is SWELLING BADLY in these deadly areas ...

Now then, both of these dogs were in "dog fights," per se, but yet each of them has had drastically-different injury levels

The first dog, because he's dehydrated, we would not use the Hypertonic Saline approach (as it's contra-indicated for dehydration), but we absolutely would want to give him ringers to restore lost fluids (a blood transfusion would be even better). Ideally, the first dog may well be able to be stabilized just fine without the use of steroids at all, just ringers, or a transfusion, and maybe some antibiotics.

However, the second dog, with all that FLESH TRAUMA + SWELLING in his throat/windpipe/guts, you bet your ass I'd be running a massive dose of Solu-Medrol (or even dexamethosone sodium phosphate) into that dog, so he doesn't blow-up like a bullfrog in his throat. Therefore, here again, it becomes a judgment call on the part of the owner ... and having somewhat of an understanding of WHAT THESE DRUGS DO ... and analyzing EXACTLY WHAT'S WRONG WITH THE DOG ... become the keys to making the right choices.

As with tailoring a conditioning regimen around the dog's strengths/weaknesses, so too must the medic tailor his aftercare choices around what has actually happened to his dog. To write a tiny paragraph about "trauma" and to lump all "dog fights" into one heading is shallow, at best. The truth is, it is absolutely MULTI-DIMENSIONAL what happens to any dog in a fight ... and each dog needs to be assessed individually as to what procedures should be followed, based on what has actually happened to that dog.

Jack

[FrostyPaws]

One of the problems, I think, in accurately quantifying these 'studies' is the lack of controllable uniformity in what can be called "Traumatic Shock"

If we pull out the ol' microscope, and examine this term itself, we soon realize there is NO WAY to get a uniform sampling for error-free, controlled study.
There are simply too many variables, and I think this is why there have NOT been such controlled studies: there is no way TO control the damages.
It is one thing to purposely let 40% of the blood volume out of 2 groups of dogs, and get uniform, controlled studies like that, because of the ease in achieving uniformity of the challenge.
It is quite another to call all dog fights "the same," as they can involve an almost endless array of potential injuries/trauma ...

That last link that I posted has "hit by car, dog fights," etc. ... AS IF all dog fights are "the same" ... but ARE THEY?

I might have a dog that went 1.5 hours, and is "shocky," but he might have been on the ear the whole time, almost never got bit, but became "shocky" just from a combination of fatigue, coming in dry, and having a bleeder hit at the :20 mark. When correctly assessed, he really isn't "injured" at all, but has merely bled out and become too exhausted/dehydrated, to the point of shock.

On the other hand, I might have a second dog who was in a brutal, non-stop WAR with another dog, been bit in the guts, deep in the throat, become truly traumatized ... and is SWELLING BADLY in these deadly areas ...

Now then, both of these dogs were in "dog fights," per se, but yet each of them has had drastically-different injury levels

The first dog, because he's dehydrated, we would not use the Hypertonic Saline approach (as it's contra-indicated for dehydration), but we absolutely would want to give him ringers to restore lost fluids (a blood transfusion would be even better). Ideally, the first dog may well be able to be stabilized just fine without the use of steroids at all, just ringers, or a transfusion, and maybe some antibiotics.

However, the second dog, with all that FLESH TRAUMA + SWELLING in his throat/windpipe/guts, you bet your ass I'd be running a massive dose of Solu-Medrol (or even dexamethosone sodium phosphate) into that dog, so he doesn't blow-up like a bullfrog in his throat. Therefore, here again, it becomes a judgment call on the part of the owner ... and having somewhat of an understanding of WHAT THESE DRUGS DO ... and analyzing EXACTLY WHAT'S WRONG WITH THE DOG ... become the keys to making the right choices.

As with tailoring a conditioning regimen around the dog's strengths/weaknesses, so too must the medic tailor his aftercare choices around what has actually happened to his dog. To write a tiny paragraph about "trauma" and to lump all "dog fights" into one heading is shallow, at best. The truth is, it is absolutely MULTI-DIMENSIONAL what happens to any dog in a fight ... and each dog needs to be assessed individually as to what procedures should be followed, based on what has actually happened to that dog.

Jack

I don't think all fights are exactly the same, no. I do think a great majority of them are the same in regards to actual damage and exhaustion instead of any type of shock. When I sit here and think about everything I've seen in relation to these dogs, I think I've seen no more than 10 dogs that I believe were actually in shock and not just at a point of exhaustion. Do I think there are times to use some of those drugs? Yes I do, but I don't believe it's after every long, hard show a dog may have as I've seen too many dogs handle those shows with just fluids, and some of those dogs were hanging around death's door.

I don't think many people are able to make a distinction between sheer exhaustion and shock, and that included me at one point in time. I think for 98% of the shows out there, dex or any anti-inflammatory isn't a MUST have drug. It's not a bad idea to have them on hand if the dog is actually IN shock, and at this point, I think people should learn what shock actually is and what the signs/symptoms of such a process are. If not, they could be causing more overall harm than good to their dogs.

[Officially Retired]

I don't think all fights are exactly the same, no. I do think a great majority of them are the same in regards to actual damage and exhaustion instead of any type of shock. When I sit here and think about everything I've seen in relation to these dogs, I think I've seen no more than 10 dogs that I believe were actually in shock and not just at a point of exhaustion.

Hmmm, I can think of several dogs I have seen with unresponsive pupils dilated, etc. Some that would hardly blink when their eyes were touched, etc.

Do I think there are times to use some of those drugs? Yes I do, but I don't believe it's after every long, hard show a dog may have as I've seen too many dogs handle those shows with just fluids, and some of those dogs were hanging around death's door.

Clearly, fluids and antibiotics are numero uno.

I agree that not every dog that goes the long haul is in shock, sure.

Yet, I believe every one of them could still benefit from the anti-inflammatory properties of something like dex. Not at the shock doses, but general doses given to reduce swelling, pain, and discomfort.

Again, all based on individual assessment.

I don't think many people are able to make a distinction between sheer exhaustion and shock, and that included me at one point in time.

I am sure this is true.

I think for 98% of the shows out there, dex or any anti-inflammatory isn't a MUST have drug.

I would have to disagree.

Some, yes.
98%, no.

I hear what you're saying (most dogs quit before they're in shock), so the winner will be able to survive just fine on fluids/antibiotics, I get that.

But to say the winner doen't really need anti-inflammatory? I can't agree with that.

Anti-inflammatories may not be critical for their survival, but they absolutely WILL reduce swelling and not make them have to go through painful, swollen hell.

Again, you may not always have to give the shock dose, but SOME anti-inflammatory will make their recovery easier, I absolutely know this to be true.

It's not a bad idea to have them on hand if the dog is actually IN shock, and at this point, I think people should learn what shock actually is and what the signs/symptoms of such a process are. If not, they could be causing more overall harm than good to their dogs.

I agree with this: I think the SHOCK DOSE of these drugs should be used judiciously. But I think the use of the swelling dose should be given after every single match, because that dog has HOLES and SWELLING ... and will be swollen/stiff as hell without them.

We do agree that the SHOCK doses of these drugs should hardly ever be given ...

Thanks,

Jack

[FrostyPaws]

I know anti-inflammatories will decrease the swelling. I'm not saying it won't do that. I simply don't think it's needed near as much as people give it.

I can't remember the last time I gave dex, or another type drug, after a show. Again, I think it's simply a reaction to pull it out and give it most of the time. Are there times where it's used? Certainly, but most of the times I've seen it used, I didn't think it warranted. Some swelling isn't necessarily a bad thing. While swelling is unsightly, and at times painful, it also serves another purpose in which to keep a possible infection within a certain area of the body. That's one of the reasons I like to use Rimadyl, or something of the like, afterwards. It doesn't so much effect any type of swelling, but it does wonders for pain and discomfort.