Maggie

It was time to go home.  It was the last day of Maggie’s vacation and they thought they’d go for a little walk, stretch their legs, jump in the car and head home.  Maggie was happily running along a path in the woods, saw a stone wall and jumped over it, thinking there was a bank on the other side.  There wasn’t.  It was a 40 ft drop to the road below.  Her owners rushed her to R.E.A.C.H.  On presentation, Maggie was able to walk, though stiffly.  She seemed painful on all four legs, more so on the left forelimb.  Her mucous membranes were slightly muddy, she had poor pulses, an increased respiratory rate and slightly diminished lung sounds. Sharp pain was elicited on palpation of the left scapula and she had a lower canine fracture. 

She was given pain medication and started on IV fluids.  Radiographs revealed mild pneumothorax, retraction of lung lobes, mild pulmonary contusions and a minimally displaced fracture in the spine of the left scapula.  CBC was normal.  Chemistry panel showed increased CK, AST and ALT. 

A thoracocentesis removed 600 ml of air on the right thorax and 120 ml on the left side, which resulted in easier breathing.  She was started on a hydromorphone CRI, hospitalized and monitored for respiratory compromise.  During the night, her breathing became more labored, the pneumothorax had returned.  Thoracocentesis was performed again, more air was aspirated this time, and her respirations eased again.  A third time, just a few hours later, she become quite compromised, was tapped again and even more air was removed.  That was 3 thoracocenteses in less than 12 hours, each worse than the last.  The owner was called because it was evident that she had a non-resolving pneumothorax.  A chest tube was placed, which was hooked up to continuous suction.

Several attempts were made in the next day and a half to stop the suction to see if the leak had repaired itself, to no avail.  After about 40 hours, the owners were at their financial limit, with not much hope in sight for Maggie’s recovery.    Discussions with another referral/emergency hospital revealed a procedure involving an autologous blood transfusion into the thorax with the goal of achieving a blood patch and stopping the leak.  

With Maggie sedated, the air was evacuated from the thoracotomy tube to achieve negative suction.   A technician removed 170 ml (10 ml/kg) of Maggie’s blood with a butterfly catheter in 20 ml increments.  Each 20 ml was passed directly to the doctor, who inserted it directly into the thoracotomy tube.  Upon completion, Maggie was gently moved to her other side laterally to disperse the blood.  She was allowed to wake up quietly with the tube still in place but capped.  The goal was to try and not aspirate for 4 hours.  The tube was aspirated only twice in the next 12 hours, with minimal air recovered each time.  She was transferred back to her regular veterinarian, who removed the chest tube about 2 days after the autologous blood patch treatment.  Maggie recovered well and never looked back.

Reference article: Retrospective evaluation of the use of autologous blood-patch treatment for persistent pneuomthorax in dogs (2009-2012). Journal of Veterinary Emergency and Critical Care: 24(2) 2014. Nama Oppenheimer, DVM; Sigal Klainbart, DVM, DACVECC, Yael Merbl, DVM; Yaron Bruchim, DVM,  Josh Milgram, BVSc, DECVS  and Efrat kelmer, DVM, DAVCECC.