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| TheraPeuTic uPdaTes in VeTerinary Toxicology Today's Veterinary Practice July/August 2014 26 tvpjournal.com cially when emesis induction is unproductive or con- traindicated. These toxicants typically have a narrow margin of safety or result in severe clinical signs. Table 2 outlines the indications and contraindica- tions for gastric lavage. Visit vetgirlontherun.com to view a video demonstrating how to perform gas- tric lavage. MONITORING FOR HYpERNATREMIA Hypernatremia has been anecdotally reported in poisoned patients secondary to activated charcoal (AC) administration. 4 While uncommon, second- ary hypernatremia can be severe and mimic clinical signs of worsening toxicosis. Clinical signs of atax- ia, head pressing, worsening lethargy, tremors, or obtundation may actually be due to hypernatremia rather than the toxicant. If any of these clinical signs develop, the best way to determine if a patient is hypernatremic is to imme- diately measure its serum sodium level. If the patient is receiving multiple doses of AC per day, daily sodi- um levels should always be measured. Differentiation Between Hypernatremia & poisoning Based on my experience, hypernatremia is seen more frequently in patients poisoned by certain toxi- cants—chocolate or bromethalin. Since both of these toxicants can result in clinical signs attributable to the central nervous system (eg, ataxia, agitation, tremors, seizures), it is clinically important to differ- entiate between hypernatremia and poisoning. Poisoned patients can become hypernatremic due to: • Use of salt as an emetic agent (hence, it is no longer recommended as a safe emetic agent in dogs or cats) • Dehydration due to emesis induction, which prohib- its patient's oral intake for several hours • Excessive free water loss secondary to panting (eg, secondary to stress while administering AC or excitement/agitation induced by toxin) • Other ongoing free water losses due to the toxicant (eg, vomiting, diarrhea, polyuria, polydipsia) • Administration of AC—especially when it contains a cathartic, such as sorbitol, that can result in exces- sive free water loss from the gastrointestinal (GI) tract, resulting in secondary hypernatremia. Risk factors for hypernatremia are listed in Table 3. Minimizing Risk for Hypernatremia Typically, a onetime co-administered dose of a cathar- tic, such as sorbitol, with AC is warranted in the poi- soned patient to aid in fecal expulsion of the toxicant. For patients receiving multiple doses of AC, ideally sorbitol should only be given with the first dose; addi- tional doses should not contain sorbitol. In addition: • Monitor serum sodium levels at least daily • Assess hydration status frequently • Provide appropriate fluid supplementation (IV or SC) to prevent dehydration and hypernatremia. In poisoned patients receiving IV fluids that were previously in good health, 3 main parameters should be used to assess appropriate hydration: 1. Packed cell volume (PCV)/total solids (TS): Ide- ally, patients on IV fluids should be hemodiluted down to a PCV of 35% and TS of 5 g/dL; evidence of normal PCV (45%) and TS (7 g/dL) in a patient receiving IV fluids is inappropriate as it demon- strates lack of adequate hemodilution. 2. Weight gain: Weight gain provides an easy way to assess hydration. The dehydration formula is: Percent dehydration × BWkg = Amount of mLs of IV fluid to replace. Note: the amount of mLs of IV fluid to replace is the same as anticipated weight gain (converted to kg). For example, if a 30-kg Labrador retriever is 5% dehy- drated, expected weight gain is 1.5 kg (or 1500 mL) once the patient is hydrated (hydrated weight = 31.5 kg). 3. Evidence of isosthenuria: With appropriate hemo- dilution, urine specific gravity (USG) is targeted at 1.015 to 1.018 in both cats and dogs. A USG greater than 1.025 may indicate dehydration. Risk for hypernatremia can also be minimized by use of a potent antiemetic (eg, maropitant, ondansetron, dolasetron), which helps treat any ongoing nau- sea or persistent vomiting and allows rapid return to oral water intake. For poisoned animals being managed as outpatients that have received a dose of AC, Table 3. risk Factors for development of hypernatremia in dogs & cats • dehydration • Vomiting or fasting; inability to drink • Predisposition to hyperosmolality disorders, such as chronic kidney injury, endocrine diseases (eg, diabetes mellitus, diabetes insipidus), or psychogenic polydipsia