Today I perfromed an u/s guided liver core biospy on a 10 year old Havenese with elevated liver enzymes and bile acids. PT/PTT was normal prior to biopsy and the pet is otherwise clinically normal. We used morphine and propofol for sedation and I used an 16 gauge EZ-core type biospy needle. After each sample I had the tech place pressure over the site with sterile gauze.
Today I perfromed an u/s guided liver core biospy on a 10 year old Havenese with elevated liver enzymes and bile acids. PT/PTT was normal prior to biopsy and the pet is otherwise clinically normal. We used morphine and propofol for sedation and I used an 16 gauge EZ-core type biospy needle. After each sample I had the tech place pressure over the site with sterile gauze.
At the end of the procedure there was a small triangle of fluid noted at the spleen/left kidney site, so some bleeding did occur. This was a mobile call so I was not there are the end of the day to scan the patient but they do have there own u/s machine so I instructed them to do an AFAST at the end of the day before discharging the patient but I don’t know how good they will be at this. Also had them take a PCV/TP at the time of the biopsy and asked them to repeat at the end of the day. Of course monitor mm etc.
How else can I manage these guys when doing mobile ultrasound when I am not there at the end of the day to check them? And how much bleeding is considered to be normal after a liver biopsy?
Comments
This can happen
This can happen especially in mushy livers that are hyperechoic such as bad vacuolar hepatopathy, suppurative hepatitis, lipidosis and necrotic hepatocellular carcinomas… those are th eones that tend to bleed. In a havanese unless checking for copper storage where a bigger sample is needed an 18 g should be fine. I use this rule :
18 g for cats and dogs < 15 #
16g for 15-40#
14g for > 40 #
I will skew down to smaller gauge when I see scenarios such as those listed about and skew up with coarse livers with increased portal markings or fibrosis/chirrosis and nodular hyperplasia scenarios.
Position is just as if not more important than size. Be sure to stick the transition of the echotextures between normal and abnormal and a variety of echotextures. I stick loer intercostal nearly every time because i have a direct shot at what i need and direct body wall compression on the liver without falciform fat providing a cushion. I personally believe this brings higher SE/SP on sampling than the gauge itself. (See attached image)
Re bleeds: When in right lateral recumbency, if the blood is pooling and dependent that’s a problem use a compression belly wrap and look for shock signs, crt, shocky hypocontractile heart on a quick echo, dropping pcv and total solids and consider hetastarch bolus and atropine.
If a bleed is localized between the lobes and not pooling to the dependent side of the abdomen then apply pressure and do other things like make up the bill, write up the protocol, scan the next patient and check after 3-5 minutes of pressure then check after 3 minutes of no pressure but be cool and “matter of fact” about it. If stable and no increase keep pressure and go back and check. Its important to be cool here because if the client sees it as an issue then they will stop doing bx and be afraid of them which is bad because there are many more + informative scenarios that come from bx than life threatening bleeds that derive from doing them.
Avoid dexdomitor for liver bx because it dilates the cvc and hepatic veins and you will get more oozing.
great post and subject:)
This can happen
This can happen especially in mushy livers that are hyperechoic such as bad vacuolar hepatopathy, suppurative hepatitis, lipidosis and necrotic hepatocellular carcinomas… those are th eones that tend to bleed. In a havanese unless checking for copper storage where a bigger sample is needed an 18 g should be fine. I use this rule :
18 g for cats and dogs < 15 #
16g for 15-40#
14g for > 40 #
I will skew down to smaller gauge when I see scenarios such as those listed about and skew up with coarse livers with increased portal markings or fibrosis/chirrosis and nodular hyperplasia scenarios.
Position is just as if not more important than size. Be sure to stick the transition of the echotextures between normal and abnormal and a variety of echotextures. I stick loer intercostal nearly every time because i have a direct shot at what i need and direct body wall compression on the liver without falciform fat providing a cushion. I personally believe this brings higher SE/SP on sampling than the gauge itself. (See attached image)
Re bleeds: When in right lateral recumbency, if the blood is pooling and dependent that’s a problem use a compression belly wrap and look for shock signs, crt, shocky hypocontractile heart on a quick echo, dropping pcv and total solids and consider hetastarch bolus and atropine.
If a bleed is localized between the lobes and not pooling to the dependent side of the abdomen then apply pressure and do other things like make up the bill, write up the protocol, scan the next patient and check after 3-5 minutes of pressure then check after 3 minutes of no pressure but be cool and “matter of fact” about it. If stable and no increase keep pressure and go back and check. Its important to be cool here because if the client sees it as an issue then they will stop doing bx and be afraid of them which is bad because there are many more + informative scenarios that come from bx than life threatening bleeds that derive from doing them.
Avoid dexdomitor for liver bx because it dilates the cvc and hepatic veins and you will get more oozing.
great post and subject:)
Thanks Eric
This dog’s liver
Thanks Eric
This dog’s liver looked sonographically normal on ultrasound – we proceeded because of the blood work so hopefully the 16 gauge is OK.
So do you routinely see no blood at all afterwards or sometimes a small amount? I imagine that some bleeding would be normal?
Thanks Eric
This dog’s liver
Thanks Eric
This dog’s liver looked sonographically normal on ultrasound – we proceeded because of the blood work so hopefully the 16 gauge is OK.
So do you routinely see no blood at all afterwards or sometimes a small amount? I imagine that some bleeding would be normal?
Minor to no amount is normal.
Minor to no amount is normal. Pooling is not. Latest stats I remember around 5-8% bleeding on sampling but its so variable as some pathology bleeds more than others.
Minor to no amount is normal.
Minor to no amount is normal. Pooling is not. Latest stats I remember around 5-8% bleeding on sampling but its so variable as some pathology bleeds more than others.
Got a little panicked on this
Got a little panicked on this one as it was not at my own hospital but the patient did well and is doing fine!
Got a little panicked on this
Got a little panicked on this one as it was not at my own hospital but the patient did well and is doing fine!
Keeping your cool is part of
Keeping your cool is part of the job. No good decisions are made in panick. Nothign should ever die from a core bx bleed. If they ever do its usually because they werent monitored well for complications or somethign strange like a vagal response in a cat or anethestic reaction, VWB or MCT. Those are the sneaky ones that get us in trouble. The rest is just clinical management.
Keeping your cool is part of
Keeping your cool is part of the job. No good decisions are made in panick. Nothign should ever die from a core bx bleed. If they ever do its usually because they werent monitored well for complications or somethign strange like a vagal response in a cat or anethestic reaction, VWB or MCT. Those are the sneaky ones that get us in trouble. The rest is just clinical management.