Case 8

Despite careful reintroduction of nutrients, Misou has developed hypophosphatemia. Frustrating, but unfortunately not uncommon. You initiate intravenous potassium phosphate supplementation at 0.01 to 0.03 mmol/kg/hr. Misou's total potassium requirements should be provided 50% by the potassium phosphate and 50% by intravenous potassium chloride, not to exceed 0.5 mEq/kg/hr. You plan to recheck the phosphorus and potassium concentrations again in six hours and adjust the supplements as needed. Misou's owners decline a blood transfusion at this time since Misou seems to be stable otherwise.

Day 4: Misou is stable this morning and her phosphorus concentration has normalized, so you discontinue the potassium phosphate. Her packed cell volume is 23%. You notice, however, that she seems more nauseated, so you decrease the frequency of her nasoesophageal tube feedings from four times a day to three times a day and start treatment for possible ileus with metoclopramide (0.02 mg/kg/hr intravenously) for its antiemetic and prokinetic effects.

Here are the results of a recheck CBC and serum chemistry profile on day 6:

CBC

Patient values

Reference range

WBC (/µl)

13,500

3,500-16,000

-Neutrophils (/µl)

10,100

2,500-8,500

-Monocytes (/µl)

900

0-600

-Lymphocytes (/µl)

1,200

1,200-8,000

-Eosinophils (/µl)

1,300

0-1,000

Hct (%)

23

29-48

Hgb (g/dl)

7.6

9.3-15.9

RBC morphology

Normal

Platelets (/µl)

210,000

200,000-500,000

Serum chemistry profile

Patient values

Reference range

BUN (mg/dl)

14

14-36

Creatinine (mg/dl)

0.9

0.6-2.4

Phosphorus (mg/dl)

3.1

2.4-8.2

ALP (IU/L)

188

6-102

ALT (IU/L)

89

10-100

GGT (IU/L)

5

1-10

Total bilirubin (mg/dl)

3.9

0.1-0.4

Glucose (mg/dl)

167

64-170

Sodium (mEq/L)

149

145-158

Potassium (mEq/L)

4.3

3.4-5.6

Triglycerides (mg/dl)

240

25-160

QUESTION 8

What is your next step for Misou given these laboratory results?

a) Her ALP activity has decreased, so continue her current treatment plan and nasoesophageal feedings.

b) Her bilirubin concentration has not really improved, which you know is atypical of primary hepatic lipidosis, so further diagnostics are indicated.

c) Her bilirubin concentration is still elevated, so add antibiotics to her treatment regimen to treat for possible bacterial cholangiohepatitis.

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