October 4, 2025 • 17 mins
Hyperkalemia in a blocked cat can feel like a five-alarm fire—until you remember what actually fixes the problem. We sit down with Drs. Stephanie Maciorowski and Elizabeth Rozanski to unpack fresh evidence showing that the simplest path is also the strongest: start IV fluids, give calcium gluconate to stabilize the myocardium, and prioritize rapid unobstruction. The headline finding is liberating for busy ERs and general practices alike—insulin with dextrose, terbutaline, or sodium bicarbonate did not outperform the foundational approach in lowering potassium or improving outcomes.
We walk through what this means at the cage-side level. Potassium often falls quickly once urine is flowing, so the early hours matter most. If a catheter won’t pass, decompressive cystocentesis can reduce pressure and buy time. We compare sedation choices, discuss monitoring strategies, and highlight which lab and ECG changes deserve your attention. The conversation also tackles a bigger theme: replacing ritual with proof. Many of us learned to stack drugs out of habit or anxiety; this study suggests we can streamline, reduce risk, and still deliver excellent survival—especially when teams move decisively to address the cause rather than chasing every downstream sign.
Along the way, we cover client education essentials—how to spot a block early, why immediate care matters, and what prevention looks like after discharge. For clinicians, we sketch out future research that could refine timing, trend analysis, and case stratification, including earlier potassium checkpoints and ionized calcium tracking. If you care about better outcomes, safer protocols, and fewer medication complications, this conversation offers practical, evidence-based steps you can use today.
If this episode helps you rethink your protocol, share it with a colleague, subscribe for more data-driven conversations, and leave a quick review so others can find the show.
JAVMA article: https://doi.org/10.2460/javma.25.04.0258
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:00):
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SPEAKER_01 (00:35):
This is Veterinary Vertex, a podcast of the AVMA
Journals.
In this episode, we chat abouthow pharmacological therapy for
hyperkelemia and feline urethralobstructions has no additional
benefit over intravenous fluidand calcium gluconate therapy
and prompt on obstruction withour guests, Stephanie Makarowski
and Elizabeth Rosansky.
SPEAKER_04 (00:59):
Welcome, listeners.
I'm Lisa Fortier,editor-in-chief for JAVMA.
I'm joined today by AssociateEditor Sarah Wright.
Today we have Stephanie andElizabeth joining us, and thank
you guys so much for taking timeout of your busy schedule to be
with us here today.
SPEAKER_02 (01:13):
Excellent.
We're happy to be here.
Thanks for having us.
SPEAKER_01 (01:16):
All right, let's dive right in.
So today we're talking about analways timely topic: blocked
cats.
So, Liz, your JAVMA articlecompares the effect of IB fluids
and calcium gluconate alone orwith insulin dextrose
tributylene or sodiumbicarbonate on hyperkelemia and
male cats presenting withurinary obstruction.
Please share with our listenersthe background on this article.
SPEAKER_03 (01:38):
Sure.
So in the emergency room, aseverybody's familiar, we see a
lot of block cats.
And the sicker block cats tendto come with very high potassium
levels.
And there's always been kind ofinternal debate over what's the
best treatment for that.
And we noticed that a lot ofpeople at some point learn to
run for the insulin anddextrose.
That's probably the most commonthing.
(01:59):
And then you hear about catsthat got insulin that then
people forget to give themdextrose and then they're having
hypoglycemic problems, or theydon't remember how much glucose
to give or how much insulin togive.
And so when we were looking atthat, that was kind of our
driving question was does itreally help to do that?
The kidneys are pretty smart.
You know, they're not the bestorgan, but they're a good organ.
(02:22):
And they're really good atfiguring out stuff.
So our thought was, gosh, if wecan get them unobstructed, I bet
they're going to take care of itpretty quickly on their own.
And if we could show that, um,that would be something that
would be really interesting tohelp people in practice and to
help people not worry about theinsulin and how much um dextrose
they're supposed to get.
(02:42):
But at the same time, we umbecause we do a lot of dogs, we
also see the dogs that bite onthe albuterol inhaler and they
drop their potassium really,really low.
And then when you look into thata little bit more in human
medicine, there's some workusing the beta-2 agonists, so
like turbutylene and albuterolfor lowering the potassium.
And I know in in JAVMA earlierthis year, another article came
(03:04):
out talking about um albuterolin cats.
Um, we have terbutalin for ourasthmatic cats.
I wonder if this would be aneasier, safer, effective choice
as well, uh, mostly because youdon't have to follow it up with
anything.
And then we wanted to addbicarbonate because that in some
of the older textbooks gets alot of press says, oh, you can
do this by changing the pH.
This will help as well.
(03:25):
And so as we're talking aboutthat, we're like, well, let's
try to set up something where wetry to take these head to head
to see if we can show if one isreally better or is really just
on blocking them and giving themfluids and calcium.
Is that going to do the trick?
So that's how we got to it.
SPEAKER_01 (03:39):
Yeah, super interesting.
I think it's good to justremember all the different
options.
And now we have evidence too,right?
Behind differentrecommendations.
So thank you for that.
So, Stephanie, what are theimportant take-home messages
from this Japan article?
SPEAKER_02 (03:51):
I think there's two really big take-home messages.
The first one is that we alwayskind of thought that they would
have a worse prognosis, thesecats, when they came in with
this higher potassium.
But the studies show that all ofour cats survived despite having
some really high potassiumshere.
So even if you recognize that inlab, we're still giving these
guys a shot with treatment isvery reasonable.
The other big takeaway is likewe mentioned, all these
(04:12):
treatments seem to have similaroutcomes where they all did
well.
And statistically, we didn't seeany significant difference
between the decrease inpotassium over time.
So any of these treatments couldbe helpful.
But again, the big priority isgetting them unblocked and
giving them IV fluids.
SPEAKER_04 (04:28):
Yeah, very important point.
You know, we see this in a lotof human and veterinary
medicine.
Add another drug, add anotherdrug, add another drug.
And just because you can doesn'tmean you should.
And then it just adds up, right?
And there every time you add adrug, there's another side
effect, and then you have togive another drug for a side
effect.
So I really applaud this effort.
Liz, what sparked your interestin this not the best organ?
(04:51):
I'd like to know what you thinkthat is the best organ since you
don't think so highly of thekidney.
SPEAKER_03 (04:56):
I I do like the kidney, it's it's absolutely an
important one.
But we spend, I spend a lot oftime preaching the major body
system, so the heart, brain, andlungs.
And so those are the organs thatare going to kill you.
So when I think as the heart,the brain of the lungs, I would
say they're equally important.
The kidneys you can go a littlewhile without working, but you
you honestly want good kidneys.
Um I am always impressed at howwell the kidneys sort out
(05:17):
things.
And when we have in otherdebates in emergency medicine,
do you give lactated ringers orplasma light or sodium chloride?
Um, really, all theinvestigations have shown with
normal kidneys, give somethingand they'll be okay.
Um, so I do like the kidney fromthat standpoint.
Um, it's just not a the bestorgan out there.
SPEAKER_04 (05:35):
Well, in this specific topic of comparing all
these medications head-to-head,uh, what what what what was the
impetus for for this study?
What sparked your interest inthis topic?
SPEAKER_03 (05:45):
Oh, what sparked our interest is again, uh years of
block cats that come in withhyperkalemia.
And one of our co-authors, um,uh we call him VK because we
can't pronounce his last nameeither.
Steph might do better with it.
SPEAKER_02 (05:57):
Um, do you want to give it a try?
Oh gosh, I can't.
I still got my VK.
SPEAKER_03 (06:01):
We call him VK.
Um, and he is a bit of acurmudgeon.
Um, and he is one of ourco-investigators.
He was a resident here a coupleof years ago, and he was
constantly fighting with us forwhat the right answer was and
where was the evidence.
So, really um, reallyintellectual um as well as
combative, but in a good way.
Um, and it was really his ideaas far as can we try to look at
(06:22):
these things because we arehaving a lot of um when we think
about fun things in emergencymedicine, there's so much that
we still don't really know.
It's kind of fun to have gooddebates over what do you think
you should do?
What would we do?
Um, and then a lot of the blockcats, because they're so common,
people learned something inveterinary school or in their
first year or two out, and theynever really questioned it.
(06:44):
Um, and so there's been, youknow, how do we um like flushing
the cat's bladder out?
Is that really helpful?
Is there other things that thatwe kind of do out of tradition
rather than evidence?
And so VK was great for let'slook at some evidence.
And we had had a run of reallybadly hyperkalemic cats.
Um, and we're always upset wheredifferent places people say
things like, oh, these guys arenever going to survive, like you
(07:06):
should just euthanize them.
Um, and so we were really like,I think they do pretty well.
Let's see what we can do withthat.
Um, and then we spent some timetrying to make sure they were as
matched as possible.
Um, because obviously differentpeople use different drugs or
different fluids.
So we it took a little while tomake sure we didn't miss a cat,
um, as far as doing somethingdifferent.
But yeah, that's the reallyinteresting part about where's
(07:28):
the evidence.
SPEAKER_04 (07:29):
Yeah, I'm a large animal surgeon.
We have the same thing in blockgoats.
You know, they're they'refrustrating, they can be
expensive, and then they recur.
And yeah.
SPEAKER_03 (07:38):
Uh, we're doing a project with our um large animal
folks looking at block goats aswell, um, just as kind of for
that same thing that you'retalking about, kind of that
overlap between species and howwe can work together.
SPEAKER_04 (07:49):
Yeah.
Yep.
All part of probably what we'redoing is feeding them it was a
Western diet.
I doubt all those goats out innature get blocked.
There wouldn't be any goats.
Every time, uh, Liz, that we doa study, and you know, this is
this is a fabulous study withall the different groups, um,
but we're always surprised bysomething.
And I think one of the surprisesI've heard is that the animals
(08:12):
do better regardless, or they dowell regardless of a high
potassium.
What are some what are someother surprising findings?
SPEAKER_03 (08:19):
Um, what did you want to?
I think to me, other surprisingfindings was um that it they
potassium falls fairly quickly.
Um, and I think that that'ssomething where um from a
clinical standpoint, um, whenyou if you recheck laboratory
work 24 hours later and it's notbetter, you really should be
anxious over that.
And we don't really have a lotof good data over like what does
(08:42):
creatinine or potassium do everyhalf an hour or things like
that.
So I think we need a little morelooking at that.
So I was pretty impressed withina couple of hours that the cats
were back to what we wouldconsider a cardiovascularly safe
range.
Um, the other thing that'sprobably important to note is
and we did on we gave the cats afood bowl is pretty quickly, and
we also unblocked them prettyquickly.
(09:02):
Um, and I think sometimes peopletalk about trying to make them
more stable.
Um, and I think to me it'sreally important that the thing
that's gonna make them morestable is unblocking them.
And so, you know, in ourhospital, certainly a not sick
block cat might wait 15, 20minutes to get unblocked, but
these guys are, I think, a bitpretty big all hands on deck
(09:23):
because they're gonna befixable.
Um, this is a disease we can wecan improve the outcome, they're
gonna do well with that.
Um, so that's that to me issomething I'd like us to kind of
focus on as a profession isthese guys come in, get them
some fluids, get them unblocked.
Um, so I don't think yeah, Idon't know what stuck would add
to that.
SPEAKER_02 (09:39):
Yeah, and I would say that along with the concern
for mortality going into thesecases, all these cats did really
well.
But I think the big thing wasgetting them at least some
fluids and the calciumglutinate, and then just getting
them unblocked as soon aspossible is again just the most
important thing to get theseguys on the road to recovery.
SPEAKER_04 (09:56):
I think the exact same for the goats.
We'd have these debates fromsurgeon anesthesia about we need
to stabilize them cardiovascularfor surgery.
We can anesthetize them withthat calcium.
And I was like, Well, what doyou want me to do here?
Exactly.
SPEAKER_03 (10:10):
You have something we can fix.
So we need to work on that.
SPEAKER_01 (10:13):
Yeah, I do feel like sometimes we get so caught up
with uh trying to treat theclinical signs that we forget
the underlying root cause.
And sometimes if you addressthat root cause head on, then
you can fix everything else,it'll resolve.
So, Stephanie, what are the nextsteps for research in this
topic?
SPEAKER_02 (10:27):
So I think a little bit of what Liz alluded to was
seeing exactly how quickly thispotassium drops.
We only looked at the one timepoint four hours after.
If we were able to check thatmore often, I think that would
be really interesting to look atas well.
Um, another thing to considerwould be looking at other lab
work changes.
We had looked into thecreatinine, but also maybe
looking at their ionized calciumas well would be really
(10:47):
interesting in these cases.
And maybe even looking at ECGchanges in these cases as well.
We all know kind of the theclassic ECG changes, but
actually seeing clinically howthat correlates with the
patients coming into the ERwould be really cool.
SPEAKER_01 (11:00):
Yeah, I definitely look forward to that.
Sounds really interesting.
Well, we hope to see some ofyour manuscripts then across
Stardust.
And Stephanie, do you see a rolefor AI in this area of research?
SPEAKER_02 (11:10):
That's a great question.
I feel like that's the hot topicnowadays, as so whether AI could
come in.
And I think, you know, maybe itcould come in to help go through
different treatment options.
But I think at the end of theday, we have so much knowledge
and experience that I don'tthink AI will ever really
replace that in our veterinaryexpertise.
SPEAKER_04 (11:25):
Elizabeth, you talked earlier about a uh
resident that you had that wasmaybe a bit challenging.
I think those folks arefascinating.
Oftentimes it was students fromme that would say, Do we know
that for sure?
Is there evidence for that?
And so sometimes that sparkedsome of my best studies.
So, how did your training oreven the train you being a
mentor, how did that prepare youto design this complicated
(11:47):
experiment and then write thisarticle?
SPEAKER_03 (11:49):
Oh, yeah, that's a great question.
And so to be clear, we love VK,but he is a curmudgeon.
Um, I think that what you'relooking for in you know, in any
veterinarian or veterinarytechnician is intellectual
curiosity.
And so certainly there's timesto uh like for as a from a
surgical standpoint, we alwaystell people you should never
ask, is it supposed to bleedthat much?
(12:10):
Um, like that's a bad question.
Um, but asking questions aboutthings that you learned, um, I
think one of the interestingdebates that's really hot right
now is when do you span neuterdogs?
Like, how do we answer thosequestions?
How do you answer the question?
We do a lot with GDV as well.
And when you look at the historyof um dogs with bloat or GDV, it
(12:30):
was, you know, we figured outfinally, you know, 50 years ago
and give them fluids and maybewe could take them to surgery.
And you know, so each littlewidget gives us more
information.
Um, so to me, um, we at Tufts,we end as well as a lot of the
other veterinary schools, ofcourse, have a pretty active
student summer research project.
Um, and I love seeing what theycome up with as their ideas.
(12:52):
Um, and so from uh from an ERstandpoint, there's really a
million unanswered questions.
Um and I think it just keeppicking away at each little
question is really fun.
So we love the people who comeup with what do you think we
should do?
We had one student this summerwho was looking at um do the
dogs sleep more if the lightsare off in the ICU?
(13:14):
Um, and so um, and this isperhaps one of our best
statistical findings is thatusing our light meter, it's
significantly darker when thelights are off.
Um so that's what she found asher project.
Um, but the rest of it, shefound that um dogs didn't really
care if the lights were on oroff or how loud it was.
They were happy to sleep nomatter what.
And so that was really um thosetype of questions that seem kind
(13:37):
of common sense really aren'tsometimes common sense.
And so I think as a profession,as we keep kind of picking those
off, those are great.
And we love the students andhouse officers who come in with,
hey, I'd like to question what Ithink we should be doing and try
to answer that a little bitbetter.
So those are fun questions.
SPEAKER_01 (13:55):
So now this next set of questions is going to be
really important for ourlisteners.
The first one's going to revolvearound the veterinarian's
perspective.
So, Elizabeth, what is one pieceof information the veterinarian
should know about resolution ofhyperkalemia in cats presenting
with urinary obstruction?
SPEAKER_03 (14:11):
To me, the most important thing is give fluids,
give calcium, and unblock them.
That is the and do it quickly.
I think that we um stratifiedour anesthesia sedation
protocol, but using drugs thatyou're comfortable with and
using uh conservative doses ofthem and unblocking them
quickly.
If you can't get them unblocked,luckily, um as you remember,
(14:34):
potassium kind of lowers muscletone.
So most hyperkelemate cats areactually easier to unblock than
some of the other cats.
But if you can't get themunblocked, you can also do a
decompressive cystocyntesiswhere you actually get rid of
all the urine, not just a fivemil sample, but like hook up a
uh inch and a half um 22 gaugeneedle and take off 100 or 250
(14:56):
mils.
And if you can't get themunblocked, that will help as
well.
So to me, the biggest take-homeis these cats are absolutely
fixable, but you need to actquickly.
Um, and I think we need to makesure you talk to the owners
about what to watch for andmaking sure that they're aware
that this could happen withtheir cat.
SPEAKER_01 (15:12):
My sister-in-law just adopted a male cat and
she's already asking me.
She's like, So I heard they needto drink a lot of water.
I'm like, all right, we havesome, we have some things to
discuss here.
So, Stephanie, on the other sideof this relationship, what's one
thing clients should know aboutthis topic?
SPEAKER_02 (15:27):
I think the first and most important thing is
knowing that this is a problem.
If your male cat is going in andout of the litter box a lot,
you're not seeing regularurinations or some stressful
event, like keeping an eye onthat and getting them into the
vet as soon as possible.
Like I would much rather havethe cat that the owner is
concerned they're blocked andthey're not actually blocked
than the one that's coming in,you know, peri-arrest really
(15:47):
sick.
So I think the biggest niche isclient education about this
problem.
Because then from there, youknow, discussing we can treat
this, the differentenvironmental modifications,
things we can do from there areall education points that we can
work with on the clients, butthey first need to know that
this is a problem that theyshould just be aware of to try
to help out their little kittiesat home.
SPEAKER_04 (16:06):
Very good point.
Thank you again, you guys.
Uh, such a timely and always atimely and important topic for
veterinary medicine.
Um, as you wind out, we'd liketo ask a little more of a fun
question.
So, Liz, uh, we'd like to knowwhat was the first concert you
attended?
SPEAKER_03 (16:22):
Uh, first concert was Billy Joel at the Rosemont
um outside of Chicago when I wasin high school.
That was very cool.
A good concert.
SPEAKER_04 (16:31):
Yeah, he he was still very, he is still very
good.
And Stephanie, uh, you're an ERdoc.
I'm not sure what the answer toview of this.
We Sarah and I have ahypothesis, and we're gonna do a
little study on this question.
When you complete a puzzle,Stephanie, do you begin with the
middle or the exterior?
Or do you do a pattern?
How do you approach a puzzle?
(16:52):
You have to always do the edgesfirst.
I feel like that's chaos or inthe middle.
So what's what's panning out isanybody who has like a uh
surgeon mentality does theexterior, and medicine folks
usually do the interior.
Oh, really?
So you're you're as an ER doc,you're kind of a hybrid.
SPEAKER_03 (17:11):
Yeah, absolutely.
Yeah, I I would I can imaginenot starting with the edges.
SPEAKER_02 (17:15):
Right.
I totally more surgery thanmedicine, too, anyway.
So that seems to fit.
Right.
SPEAKER_01 (17:21):
It's awesome.
Yeah, we're gathering a lot ofdata for this, Lisa.
We might have to do somethingwith it at some point.
Evidence.
Yeah, exactly.
Exactly.
Well, thank you so much,Stephanie and Liz.
We appreciate you being heretoday and also for sharing your
work with Javma.
Of course.
We're very happy to be here.
Thank you guys so much forhaving us.
And to our listeners, you canread Stephanie and Elizabeth's
article in Javma.
(17:41):
I'm Sarah Wright with LisaFortier.
Be on the lookout for nextweek's episode, and don't forget
to leave us a rating and reviewon up a podcast or whatever
platform you listen to.
From the makers of FET recommended Green East
(00:02):
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Green East Smart Essentials DryFood delivers complete balanced
nutrition with science-backedrecipes.
Green East Supplements,developed by a team of PhD
animal nutritionists, offersoptions to help support healthy
joints, digestion, and more.
(00:24):
Whether it's meal time ormobility support, Green East
helps you care for your dog fromthe inside out.
Learn more at greenies.com.
SPEAKER_01 (00:35):
This is Veterinary Vertex, a podcast of the AVMA
Journals.
In this episode, we chat abouthow pharmacological therapy for
hyperkelemia and feline urethralobstructions has no additional
benefit over intravenous fluidand calcium gluconate therapy
and prompt on obstruction withour guests, Stephanie Makarowski
and Elizabeth Rosansky.
SPEAKER_04 (00:59):
Welcome, listeners.
I'm Lisa Fortier,editor-in-chief for JAVMA.
I'm joined today by AssociateEditor Sarah Wright.
Today we have Stephanie andElizabeth joining us, and thank
you guys so much for taking timeout of your busy schedule to be
with us here today.
SPEAKER_02 (01:13):
Excellent.
We're happy to be here.
Thanks for having us.
SPEAKER_01 (01:16):
All right, let's dive right in.
So today we're talking about analways timely topic: blocked
cats.
So, Liz, your JAVMA articlecompares the effect of IB fluids
and calcium gluconate alone orwith insulin dextrose
tributylene or sodiumbicarbonate on hyperkelemia and
male cats presenting withurinary obstruction.
Please share with our listenersthe background on this article.
SPEAKER_03 (01:38):
Sure.
So in the emergency room, aseverybody's familiar, we see a
lot of block cats.
And the sicker block cats tendto come with very high potassium
levels.
And there's always been kind ofinternal debate over what's the
best treatment for that.
And we noticed that a lot ofpeople at some point learn to
run for the insulin anddextrose.
That's probably the most commonthing.
(01:59):
And then you hear about catsthat got insulin that then
people forget to give themdextrose and then they're having
hypoglycemic problems, or theydon't remember how much glucose
to give or how much insulin togive.
And so when we were looking atthat, that was kind of our
driving question was does itreally help to do that?
The kidneys are pretty smart.
You know, they're not the bestorgan, but they're a good organ.
(02:22):
And they're really good atfiguring out stuff.
So our thought was, gosh, if wecan get them unobstructed, I bet
they're going to take care of itpretty quickly on their own.
And if we could show that, um,that would be something that
would be really interesting tohelp people in practice and to
help people not worry about theinsulin and how much um dextrose
they're supposed to get.
(02:42):
But at the same time, we umbecause we do a lot of dogs, we
also see the dogs that bite onthe albuterol inhaler and they
drop their potassium really,really low.
And then when you look into thata little bit more in human
medicine, there's some workusing the beta-2 agonists, so
like turbutylene and albuterolfor lowering the potassium.
And I know in in JAVMA earlierthis year, another article came
(03:04):
out talking about um albuterolin cats.
Um, we have terbutalin for ourasthmatic cats.
I wonder if this would be aneasier, safer, effective choice
as well, uh, mostly because youdon't have to follow it up with
anything.
And then we wanted to addbicarbonate because that in some
of the older textbooks gets alot of press says, oh, you can
do this by changing the pH.
This will help as well.
(03:25):
And so as we're talking aboutthat, we're like, well, let's
try to set up something where wetry to take these head to head
to see if we can show if one isreally better or is really just
on blocking them and giving themfluids and calcium.
Is that going to do the trick?
So that's how we got to it.
SPEAKER_01 (03:39):
Yeah, super interesting.
I think it's good to justremember all the different
options.
And now we have evidence too,right?
Behind differentrecommendations.
So thank you for that.
So, Stephanie, what are theimportant take-home messages
from this Japan article?
SPEAKER_02 (03:51):
I think there's two really big take-home messages.
The first one is that we alwayskind of thought that they would
have a worse prognosis, thesecats, when they came in with
this higher potassium.
But the studies show that all ofour cats survived despite having
some really high potassiumshere.
So even if you recognize that inlab, we're still giving these
guys a shot with treatment isvery reasonable.
The other big takeaway is likewe mentioned, all these
(04:12):
treatments seem to have similaroutcomes where they all did
well.
And statistically, we didn't seeany significant difference
between the decrease inpotassium over time.
So any of these treatments couldbe helpful.
But again, the big priority isgetting them unblocked and
giving them IV fluids.
SPEAKER_04 (04:28):
Yeah, very important point.
You know, we see this in a lotof human and veterinary
medicine.
Add another drug, add anotherdrug, add another drug.
And just because you can doesn'tmean you should.
And then it just adds up, right?
And there every time you add adrug, there's another side
effect, and then you have togive another drug for a side
effect.
So I really applaud this effort.
Liz, what sparked your interestin this not the best organ?
(04:51):
I'd like to know what you thinkthat is the best organ since you
don't think so highly of thekidney.
SPEAKER_03 (04:56):
I I do like the kidney, it's it's absolutely an
important one.
But we spend, I spend a lot oftime preaching the major body
system, so the heart, brain, andlungs.
And so those are the organs thatare going to kill you.
So when I think as the heart,the brain of the lungs, I would
say they're equally important.
The kidneys you can go a littlewhile without working, but you
you honestly want good kidneys.
Um I am always impressed at howwell the kidneys sort out
(05:17):
things.
And when we have in otherdebates in emergency medicine,
do you give lactated ringers orplasma light or sodium chloride?
Um, really, all theinvestigations have shown with
normal kidneys, give somethingand they'll be okay.
Um, so I do like the kidney fromthat standpoint.
Um, it's just not a the bestorgan out there.
SPEAKER_04 (05:35):
Well, in this specific topic of comparing all
these medications head-to-head,uh, what what what what was the
impetus for for this study?
What sparked your interest inthis topic?
SPEAKER_03 (05:45):
Oh, what sparked our interest is again, uh years of
block cats that come in withhyperkalemia.
And one of our co-authors, um,uh we call him VK because we
can't pronounce his last nameeither.
Steph might do better with it.
SPEAKER_02 (05:57):
Um, do you want to give it a try?
Oh gosh, I can't.
I still got my VK.
SPEAKER_03 (06:01):
We call him VK.
Um, and he is a bit of acurmudgeon.
Um, and he is one of ourco-investigators.
He was a resident here a coupleof years ago, and he was
constantly fighting with us forwhat the right answer was and
where was the evidence.
So, really um, reallyintellectual um as well as
combative, but in a good way.
Um, and it was really his ideaas far as can we try to look at
(06:22):
these things because we arehaving a lot of um when we think
about fun things in emergencymedicine, there's so much that
we still don't really know.
It's kind of fun to have gooddebates over what do you think
you should do?
What would we do?
Um, and then a lot of the blockcats, because they're so common,
people learned something inveterinary school or in their
first year or two out, and theynever really questioned it.
(06:44):
Um, and so there's been, youknow, how do we um like flushing
the cat's bladder out?
Is that really helpful?
Is there other things that thatwe kind of do out of tradition
rather than evidence?
And so VK was great for let'slook at some evidence.
And we had had a run of reallybadly hyperkalemic cats.
Um, and we're always upset wheredifferent places people say
things like, oh, these guys arenever going to survive, like you
(07:06):
should just euthanize them.
Um, and so we were really like,I think they do pretty well.
Let's see what we can do withthat.
Um, and then we spent some timetrying to make sure they were as
matched as possible.
Um, because obviously differentpeople use different drugs or
different fluids.
So we it took a little while tomake sure we didn't miss a cat,
um, as far as doing somethingdifferent.
But yeah, that's the reallyinteresting part about where's
(07:28):
the evidence.
SPEAKER_04 (07:29):
Yeah, I'm a large animal surgeon.
We have the same thing in blockgoats.
You know, they're they'refrustrating, they can be
expensive, and then they recur.
And yeah.
SPEAKER_03 (07:38):
Uh, we're doing a project with our um large animal
folks looking at block goats aswell, um, just as kind of for
that same thing that you'retalking about, kind of that
overlap between species and howwe can work together.
SPEAKER_04 (07:49):
Yeah.
Yep.
All part of probably what we'redoing is feeding them it was a
Western diet.
I doubt all those goats out innature get blocked.
There wouldn't be any goats.
Every time, uh, Liz, that we doa study, and you know, this is
this is a fabulous study withall the different groups, um,
but we're always surprised bysomething.
And I think one of the surprisesI've heard is that the animals
(08:12):
do better regardless, or they dowell regardless of a high
potassium.
What are some what are someother surprising findings?
SPEAKER_03 (08:19):
Um, what did you want to?
I think to me, other surprisingfindings was um that it they
potassium falls fairly quickly.
Um, and I think that that'ssomething where um from a
clinical standpoint, um, whenyou if you recheck laboratory
work 24 hours later and it's notbetter, you really should be
anxious over that.
And we don't really have a lotof good data over like what does
(08:42):
creatinine or potassium do everyhalf an hour or things like
that.
So I think we need a little morelooking at that.
So I was pretty impressed withina couple of hours that the cats
were back to what we wouldconsider a cardiovascularly safe
range.
Um, the other thing that'sprobably important to note is
and we did on we gave the cats afood bowl is pretty quickly, and
we also unblocked them prettyquickly.
(09:02):
Um, and I think sometimes peopletalk about trying to make them
more stable.
Um, and I think to me it'sreally important that the thing
that's gonna make them morestable is unblocking them.
And so, you know, in ourhospital, certainly a not sick
block cat might wait 15, 20minutes to get unblocked, but
these guys are, I think, a bitpretty big all hands on deck
(09:23):
because they're gonna befixable.
Um, this is a disease we can wecan improve the outcome, they're
gonna do well with that.
Um, so that's that to me issomething I'd like us to kind of
focus on as a profession isthese guys come in, get them
some fluids, get them unblocked.
Um, so I don't think yeah, Idon't know what stuck would add
to that.
SPEAKER_02 (09:39):
Yeah, and I would say that along with the concern
for mortality going into thesecases, all these cats did really
well.
But I think the big thing wasgetting them at least some
fluids and the calciumglutinate, and then just getting
them unblocked as soon aspossible is again just the most
important thing to get theseguys on the road to recovery.
SPEAKER_04 (09:56):
I think the exact same for the goats.
We'd have these debates fromsurgeon anesthesia about we need
to stabilize them cardiovascularfor surgery.
We can anesthetize them withthat calcium.
And I was like, Well, what doyou want me to do here?
Exactly.
SPEAKER_03 (10:10):
You have something we can fix.
So we need to work on that.
SPEAKER_01 (10:13):
Yeah, I do feel like sometimes we get so caught up
with uh trying to treat theclinical signs that we forget
the underlying root cause.
And sometimes if you addressthat root cause head on, then
you can fix everything else,it'll resolve.
So, Stephanie, what are the nextsteps for research in this
topic?
SPEAKER_02 (10:27):
So I think a little bit of what Liz alluded to was
seeing exactly how quickly thispotassium drops.
We only looked at the one timepoint four hours after.
If we were able to check thatmore often, I think that would
be really interesting to look atas well.
Um, another thing to considerwould be looking at other lab
work changes.
We had looked into thecreatinine, but also maybe
looking at their ionized calciumas well would be really
(10:47):
interesting in these cases.
And maybe even looking at ECGchanges in these cases as well.
We all know kind of the theclassic ECG changes, but
actually seeing clinically howthat correlates with the
patients coming into the ERwould be really cool.
SPEAKER_01 (11:00):
Yeah, I definitely look forward to that.
Sounds really interesting.
Well, we hope to see some ofyour manuscripts then across
Stardust.
And Stephanie, do you see a rolefor AI in this area of research?
SPEAKER_02 (11:10):
That's a great question.
I feel like that's the hot topicnowadays, as so whether AI could
come in.
And I think, you know, maybe itcould come in to help go through
different treatment options.
But I think at the end of theday, we have so much knowledge
and experience that I don'tthink AI will ever really
replace that in our veterinaryexpertise.
SPEAKER_04 (11:25):
Elizabeth, you talked earlier about a uh
resident that you had that wasmaybe a bit challenging.
I think those folks arefascinating.
Oftentimes it was students fromme that would say, Do we know
that for sure?
Is there evidence for that?
And so sometimes that sparkedsome of my best studies.
So, how did your training oreven the train you being a
mentor, how did that prepare youto design this complicated
(11:47):
experiment and then write thisarticle?
SPEAKER_03 (11:49):
Oh, yeah, that's a great question.
And so to be clear, we love VK,but he is a curmudgeon.
Um, I think that what you'relooking for in you know, in any
veterinarian or veterinarytechnician is intellectual
curiosity.
And so certainly there's timesto uh like for as a from a
surgical standpoint, we alwaystell people you should never
ask, is it supposed to bleedthat much?
(12:10):
Um, like that's a bad question.
Um, but asking questions aboutthings that you learned, um, I
think one of the interestingdebates that's really hot right
now is when do you span neuterdogs?
Like, how do we answer thosequestions?
How do you answer the question?
We do a lot with GDV as well.
And when you look at the historyof um dogs with bloat or GDV, it
(12:30):
was, you know, we figured outfinally, you know, 50 years ago
and give them fluids and maybewe could take them to surgery.
And you know, so each littlewidget gives us more
information.
Um, so to me, um, we at Tufts,we end as well as a lot of the
other veterinary schools, ofcourse, have a pretty active
student summer research project.
Um, and I love seeing what theycome up with as their ideas.
(12:52):
Um, and so from uh from an ERstandpoint, there's really a
million unanswered questions.
Um and I think it just keeppicking away at each little
question is really fun.
So we love the people who comeup with what do you think we
should do?
We had one student this summerwho was looking at um do the
dogs sleep more if the lightsare off in the ICU?
(13:14):
Um, and so um, and this isperhaps one of our best
statistical findings is thatusing our light meter, it's
significantly darker when thelights are off.
Um so that's what she found asher project.
Um, but the rest of it, shefound that um dogs didn't really
care if the lights were on oroff or how loud it was.
They were happy to sleep nomatter what.
And so that was really um thosetype of questions that seem kind
(13:37):
of common sense really aren'tsometimes common sense.
And so I think as a profession,as we keep kind of picking those
off, those are great.
And we love the students andhouse officers who come in with,
hey, I'd like to question what Ithink we should be doing and try
to answer that a little bitbetter.
So those are fun questions.
SPEAKER_01 (13:55):
So now this next set of questions is going to be
really important for ourlisteners.
The first one's going to revolvearound the veterinarian's
perspective.
So, Elizabeth, what is one pieceof information the veterinarian
should know about resolution ofhyperkalemia in cats presenting
with urinary obstruction?
SPEAKER_03 (14:11):
To me, the most important thing is give fluids,
give calcium, and unblock them.
That is the and do it quickly.
I think that we um stratifiedour anesthesia sedation
protocol, but using drugs thatyou're comfortable with and
using uh conservative doses ofthem and unblocking them
quickly.
If you can't get them unblocked,luckily, um as you remember,
(14:34):
potassium kind of lowers muscletone.
So most hyperkelemate cats areactually easier to unblock than
some of the other cats.
But if you can't get themunblocked, you can also do a
decompressive cystocyntesiswhere you actually get rid of
all the urine, not just a fivemil sample, but like hook up a
uh inch and a half um 22 gaugeneedle and take off 100 or 250
(14:56):
mils.
And if you can't get themunblocked, that will help as
well.
So to me, the biggest take-homeis these cats are absolutely
fixable, but you need to actquickly.
Um, and I think we need to makesure you talk to the owners
about what to watch for andmaking sure that they're aware
that this could happen withtheir cat.
SPEAKER_01 (15:12):
My sister-in-law just adopted a male cat and
she's already asking me.
She's like, So I heard they needto drink a lot of water.
I'm like, all right, we havesome, we have some things to
discuss here.
So, Stephanie, on the other sideof this relationship, what's one
thing clients should know aboutthis topic?
SPEAKER_02 (15:27):
I think the first and most important thing is
knowing that this is a problem.
If your male cat is going in andout of the litter box a lot,
you're not seeing regularurinations or some stressful
event, like keeping an eye onthat and getting them into the
vet as soon as possible.
Like I would much rather havethe cat that the owner is
concerned they're blocked andthey're not actually blocked
than the one that's coming in,you know, peri-arrest really
(15:47):
sick.
So I think the biggest niche isclient education about this
problem.
Because then from there, youknow, discussing we can treat
this, the differentenvironmental modifications,
things we can do from there areall education points that we can
work with on the clients, butthey first need to know that
this is a problem that theyshould just be aware of to try
to help out their little kittiesat home.
SPEAKER_04 (16:06):
Very good point.
Thank you again, you guys.
Uh, such a timely and always atimely and important topic for
veterinary medicine.
Um, as you wind out, we'd liketo ask a little more of a fun
question.
So, Liz, uh, we'd like to knowwhat was the first concert you
attended?
SPEAKER_03 (16:22):
Uh, first concert was Billy Joel at the Rosemont
um outside of Chicago when I wasin high school.
That was very cool.
A good concert.
SPEAKER_04 (16:31):
Yeah, he he was still very, he is still very
good.
And Stephanie, uh, you're an ERdoc.
I'm not sure what the answer toview of this.
We Sarah and I have ahypothesis, and we're gonna do a
little study on this question.
When you complete a puzzle,Stephanie, do you begin with the
middle or the exterior?
Or do you do a pattern?
How do you approach a puzzle?
(16:52):
You have to always do the edgesfirst.
I feel like that's chaos or inthe middle.
So what's what's panning out isanybody who has like a uh
surgeon mentality does theexterior, and medicine folks
usually do the interior.
Oh, really?
So you're you're as an ER doc,you're kind of a hybrid.
SPEAKER_03 (17:11):
Yeah, absolutely.
Yeah, I I would I can imaginenot starting with the edges.
SPEAKER_02 (17:15):
Right.
I totally more surgery thanmedicine, too, anyway.
So that seems to fit.
Right.
SPEAKER_01 (17:21):
It's awesome.
Yeah, we're gathering a lot ofdata for this, Lisa.
We might have to do somethingwith it at some point.
Evidence.
Yeah, exactly.
Exactly.
Well, thank you so much,Stephanie and Liz.
We appreciate you being heretoday and also for sharing your
work with Javma.
Of course.
We're very happy to be here.
Thank you guys so much forhaving us.
And to our listeners, you canread Stephanie and Elizabeth's
article in Javma.
(17:41):
I'm Sarah Wright with LisaFortier.
Be on the lookout for nextweek's episode, and don't forget
to leave us a rating and reviewon up a podcast or whatever
platform you listen to.
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