Thank you, thank you, and thank you for all for, I guess, attending or just following this CPG this evening, it's BSAVA, so I hope sort of will have a few joining me in. Anyway, sort of what I am going to talk about today is sort of understanding what paediatric patient is. Just, just a sec.

OK, sorry. So, see, when it comes to, paediatrics in veterinary medicine, the truth is, that I've been kind of following this topic for a while now since my residency here. I've given this CPD, in a sort of a different forms and shapes, throughout the last 5.

And interestingly enough, every time I come back and try to improve presentation, I always add new stuff. There's not much going on in this field research wise, so, a lot of knowledge you will see on my papers, if you look at below slides, it's kind of a dating 200, 2006, the latest 1, 2016. But what I am very happy to kind of report it in sort of improving the knowledge in this field in last Let's say 10, perhaps 12 years, has decreased the mortality rate in this group of patients for almost 50%, which I think it's, it's, it's pretty amazing.

Now, we're not even close to what it's known in, in human paediatrics, but what at least what I'm trying to show you today, and I will review what's available out there, and I'll try to give you Lots of practical tips of how do you approach these patients on a day to day clinical life. And they are essentially really different from adults, really different. And there are tiny little tricks for you to kind of, nice to know, and will make you a little bit less stressed when these tiny little creatures present to your hospital.

So first of all, kind of, I'm gonna briefly review what I'm gonna talk about today, physical examination. I mean, there will be stuff that you know, there's stuff that I won't be able to tell anything new, but there are stuff I'm sure you don't know. And you kind of a Perhaps do it, I'm not gonna say wrong, you'd probably be like, oh my gosh, is this really how it is?

So I think I will be showing you new stuff about physical examination in, in these patients. Now, blood sampling, nothing new, couple of new tricks, interpretation of lab data, that is, I get a lot of, we get a lot of calls from referral hospitals about, you know, is this anaemia really severe? What do I do with these white blood cells?

How do I interpret liver values? There are stuff that are different. And I will, I also added tables, with reference ranges to this presentation, which you will now have.

And so you will have available for different age groups, values, you know, that you can use on a day to day clinical life. We'll talk about IV cannulation. You're thinking probably what, why, why would you want to spend time doing that, guys, because that's where we lose most of our patients.

We spend way too long, you know, placing those IV lines in those. Phallic, veins and I'm just gonna show you a couple of things that we should do different. Fluid therapy, you, we all, I'm not gonna say we because I do it differently now, but I used to do it when I was the first one, but, and then also later as an intern resident, we still do fluid therapy, and sometimes we justices for small dogs and small cats, and it's, it's, it's not like that.

So there are a couple of stuff that I'll be able to show you there and pharmacology and a paediatric patient, I'll be able to kind of I'll try to teach you what antibiotics, what drugs, how to use those drugs, and we'll help you a little bit there. So, let's start with stages of development. I think we all learned that at the vet school, but just a refresher.

And, also how I interpret and how I approach these patients when it comes to their age. So first of all, kind of a sticking strictly to the literature reports, paediatric refers to animals up to 12 weeks of age. The truth is that paediatric for me would be up to the point when all of their social lab data, physical examination findings, how they present the pro the adult levels, and this is usually about 56 months of age, so they call it adolescent period.

If you look at the literature. And for dogs, adolescent period will be 6 months in toys 12 to 15 months in giant breeds and cats and 6 months. For me, paediatrics will be up to 56 months of age.

Yes, I wouldn't really call it adolescence and, and for paediatric only up to 12 weeks of age. Now, we have neonatal periods. So neonatal period is up to 6 weeks of age.

We don't get to see that many patients from that group. We do tend to see fading puppies. We'll talk about that later.

And then we have weaning period until The puppy kittens are weaned from their, from the dam, and this would be up to 8 weeks of, of age. Now, timing of significant events, I'll take you back to the vet school, just a refresher. So the umbilical cord usually will dry and fall up about 2 to 3 days after birth.

Their eyelids will open up to 5 to 14 days after birth, the external ear canal opens 6 to 14 days. After birth, their extensive dominance develops about 5 days after birth. Capable of crawling up to 7 to 14 days after birth, urinating, defecating, and even capable of walking up to 3 weeks of age.

And now, haematology values, the approaching adult ones. So it says in the literature by 8 weeks of age, but the more research I've done in this area, yeah, social field is, it's actually about 5 to 6 months that Hematocrine and red blood cells numbers, white blood cell numbers will be similar to what we expect in adults. Then we have renal function, here's that of adults.

It says here strictly in 8 weeks, and that's what we were all taught at, at uni, 8 weeks. But it's not really true. It's about 12 weeks of age and even later, and then hepatic function years that of adult at 4 to 5 months of age.

Now, physical examination findings. Now, first of all, let's start with body temperature. Now, body temperature, here we go.

So there's large surface area to body mass, which means they will lose more heat by their surface and they have lack of insulating body fat, and they can't, you know, shiver, so their shivering mechanism are not developing DNA. So usually, to be fair guys, they won't be developed up to 8 to 12 weeks of age appropriately. So the, the temperature, you know, in the first week of life is normal on 35.6.

2nd, 3rd week of life, 37, up to 38.2, and only at a later age, it approaches the temperature of adults. So when I see the patients, the paediatric patients in our ICU and, you know, the nurses and also the vets, we try to warm them up, you know, it's 37, 37.5.

Let's ward them up to 38 °C, but it's not really true. 37, 37. You know, 0.5 °C in, in a 12 week old puppy or kitten is, is actually OK.

Yeah. So it's kind of like to give you an idea that lower body temperatures can be perfectly normal, especially if their conscious level is good, if their vital parameters are good. So just stick to perhaps tolerating slightly lower body temperatures.

Here it goes, cardiovascular system. This is, I'm gonna put it like this, simple. Their heart is pathetic.

Their heart muscles, so they contract their elements, they comprise about 30% of their heart mass, 30%. And in adults, it's 60% of the heart mass. So can you imagine in the cardiac output, you know, it depends on stroke value multiplied with heart rate, the stroke value, it is, is sad.

It just can't contract the heart in the same. Way, especially when you have a high demand in the case of hypovolemia, hypertension, they just can't follow it up. And so what happens in those instances, their heart rate will go up.

So the heart rate will be automatically higher to compensate for that, you know, pathetic stroke volume, I'll put it this way. So in an adult heart, when you have a patient that's hypovolemic, hypertensive, they can increase their cardiac out to about 300%. Well, to put it this way, paediatric patients can't really do that.

On top of that, they have a plasma volume and central venous pressure, which is much higher. Now, another thing that makes it a bit tricky for these poor poor creatures to cope with, you know, stressful situations, hypovolemia, hypertension, is there immature an autonomic nervous system. So that bro receptors will not be able to respond up until 12 weeks of age, but it is even later.

So, what happens is that these patients will not, you know, respond to hypovolemia hypertension, because as I said, our receptors won't cover it, so there was not to response will just not be there. So all of this, what we're typically expecting in a hypovolemic hypertensive patients, you know, you know, the typical responses, they won't be there. Now, here we go, heart murmurs, they can be normal, but bear in mind, they have to be lower grades.

1 to 2 is normal, higher grades, not that. Now, there was a recent study where they found it was published in 2015 when they were, you know, researching and detecting heart murmurs in, in, in paediatric patients. They included 195 .

Dogs, and they noted the innocent murmurs in about 28% of these patients. They're mostly systolic with a point of maximum intensity in the left cardiac base. The innocent heart murmurs, a lot of times I get asked on CPDs can be normal up to 56 months of age, so don't get too excited with the with the mild heart murmur.

Interestingly, in that study from 2015, they, they kind of found that there is a coincidence between these innocent heart murmurs and the low hematocrit in these patients. So when the hematocrits, so when their blood values switch over or, or a PCD approach the adult ones at about 56 months of age, all these innocent heart murmurs disappeared. Now, synos arrhythmia is not commonly reported in neonates.

Now then we have lower blood pressure. Again, one of those things, guys, yoz's body temperature, we have this tendency of the vats . Trying to, you know, repeating bolus, trying to use, you know, even inotropes, you know, when we have a systolic or mean blood pressure that is lower compared to adults, I'll put it like this.

If you have a puppies up to 12 weeks of age, even later, tolerating slightly lower blood pressure, 10 to 20 millimetres mercury, if the patient is conscious, the patient is responsive. If you have You know, all other vital parameters, kind of a ticking the appropriate boxes, I would be tolerating slightly lower blood pressure. I wouldn't get all excited, you know, and, and bombarding them with fluids and, and, and positive, you know jobs.

So just take time. That would be something, you know, when you're dealing with this kind of problems in these patients and see how, how they go. The respiratory system, as, as I told you, so their metabolic rate is much higher.

They have increased large surface body area to body mass, which means that there is at least 24 to 3-fold higher tissue oxygen, body demand for body weight. And then they have minimal pulmonary function reserve and they have high alveolar m ventilation. So the respiratory rates will be higher.

And another thing that Makes it a bit tricky for them as well is they have very narrow airways, narrow nasal passages, narrow underdeveloped bronchial, pathways. So, so this makes it tricky for these, animals to, you know, to, to breathe in the same way. I put it like this as an adult.

So again, tolerate slightly increased, respiratory rate in these patients. It is not. Abnormal.

I see many times nurses in our ICU would put them on oxygen support. Well, they would be sleeping and having a really high respiratory rate. So how would I go about it?

Now, guys, if you have a patients, if auscultation is fine, if you don't see any parallel and discharges, any coughing, you know, any obvious dyspnea, you can tolerate slightly increased. Respiratory rate. I think you've probably asked me, so how high can it be?

I mean, there is no rule of time. There is no set in stone rule how high it can go. I 44 up per minute would be something I tolerate.

I go even slightly higher. It depends on how the patient is and as an overall. Another thing that you tend to overinterpret, we do see, we do receive X-rays for, for a second opinion is it's interstitial pattern.

Mild interstitial pattern is normal in paediatric patients. And then another thing, the cranial So mediastinol lesions, so for example, thymus or brown fat deposits sometimes can be overinterpreted in mediastinol. And another thing in this patients, small amount of pleural effusion is OK.

Same goes for abdominal cavity. I'll talk about that later. And this is where I want to stop.

This is I hopefully, the, the slide where, where we, and I'm gonna say we because I, I used to do things when I was a first land vet and I practised in Europe and in Europe we see tonnes of power of puppies. So it was in the time when I was a first land vet was still a lot of puppy farms everywhere, so, so we get to to see. Really, a lot of paediatric patients in a very poor state and this is where things can go wrong, in when you're evaluating dehydration in these animals that present you with severe vomiting and diarrhoea.

We tend to use the same. Parameters as, as we use them in adults. So first of all, we would use skin turger and would be just sort of checking the skin tur on their heads.

And here is where things go wrong. First of all, they have lots of fat there, so their skin will be elastic. So the skin tourgo will look completely normal and be like, oh, you, you're fine, but, but they are not.

Tachycardia, I just told you, their heart muscle is pathetic. So they, they won't be able to, you know, cope with hypovolemia, hypertension, mucous membrane, that I found very interesting. I was looking in the literature.

Why does it remain moist? Most of these puppies, I mean, they have been nauseous, they have been vomiting, but even those that had just a severe diarrhoea, never ever had dry mucous membrane. They remain moist.

Now, another thing, urine concentration is unreliable. The kidneys are capable of concentrating urine only when they're 12 weeks or age even later. And their PCV, which, you know, dehydrated, you know, an adult will expected to be high.

Well, put it this way, you won't go because it's only stabled by 8 weeks of age or even later. So how do we do it right? So none of these, you know, standard things that you would kind of go to and check, it's, it's, it's not there.

So it's not, you can't be validated in the same way. So this is how we do it. So, first of all, the ventral abdomen is the best place to validate hydration status.

There's no fat there. And not only the, the fact that it's, it's, it will be, you know, prolonged if they're dehydrated, so you will see it, it will stay, you know, up, the skin, so it won't go back. Another thing, it changes the colour.

So in puppies and kittens, their tummies are always lovely, nicely pink, but in those poor dehydrated animals, it gets that greyish subtone. So, mucous membranes colour will change. They become more pale, and it's not necessary, they will be anaemic.

It's just a peripheral perfusion will become decreased and it will tend to be centralised. And that's what the pale nails will be obvious there and their CLT will be prolonged. So what I usually do in these patients is I'll turn them over, I'll check their tummy, I'll check the skin sugar and the CRT, and that will be helpful, you know, on top of obviously taking a good history, trying to evaluate how much fluid they lost, will be a good.

Way of evaluating their hydration status. Now look at this. I, I'm gonna use this photo, just kind of about to show you those tummy.

Can you see that tummy on a photo on the right hand side, you can see that lovely pink tummy. Well, when they are well hydrated, this is how it looks like unfortunately. I don't have any photo.

I could show you how the dehydrated pup tummy look like, but it definitely not that being put it this way. Now, GI tracked the abdomen. Now, I'm not gonna be able to tell you anything new here.

I think you, you're all quite on top of that, so we learned that at uni. It's gonna be a bit of a refresher. Check for cleft palate when you examine the oral cavity, check your teeth.

I personally have never seen cleft palate. I'll be very interested in the end if any of you have seen it, or sent some photos, that would be, you know, nice to see. Check for umbilical hernia always.

Some abdominal fluid can be present in normal paediatric patients. And then again, at CPDs I, I, I get asked questions, so how much? I mean, guys, it shouldn't be, you know, tendulus tach, it shouldn't be, you know, abdominal organs shouldn't be swimming in a fluid.

Yeah. That, that's probably would be too much. I put it this way.

Just to tolerate small amount, usually the medical imager will evaluate and tell you it's a minimal amount of fluid that I would tolerate. Spleen and margins of the lobes should not be palpable, and that is true. That is suggestive of an enlargement.

Skin and hair coat. So again, not telling you much new when it comes to examination of skin. I, I've seen a lot of puppies from puppy farms and they have been feted with fleas, dermatoflies, and they have litter made suckling on each other's appendices, which is, which is sometimes what, you know, dramatic.

Neurological examination, as much as our neurologists love to do, you know, neuro exams in these patients and, you know, trying to extrapolate as much out of it as possible, to be fair, up to 12 weeks of age, I don't think you can do a reliable neural exam in these patients so pastoral reactions develop fully at 6 to 8 weeks of age, . Menas response, I'm sure you know, develops up to 8 to 126 of age. Now, mus musculoskeletal system and on the other hand, can be examined pretty well in paediatric patients and to be fair, we wouldn't really do that that frequently.

It's not really the standard population we do. Orthopaedic exams in, but still they can suffer from fractures and, and, or injuries. And so musculoskeletal system can be quite reliably examined and the good locomotions, remember, I told you can be present up to 2 to 3 weeks of age.

And, so you can well assess the gait and their muscle tone. Now we come to the second big chapter, which is laboratory data, and, sort of at the end of the chapter, you will sort of see that there is some common sort of a points to, to this, and, and that will be helpful for you in a, in an emergency situation where you sort of lost completely the idea of what I told you today. I I'll kind of summarise everything in, in at the end, you'll see it will all make sense.

Now, blood sampling. What I see most frequently happening wrong is that we use the needles that are too large and that the blood is drawn with too much vacuum applied on the syringes which cause hemolysis and then makes the interpretation of the blood work quite tricky. I usually, I know you will think I'm mad, but I, I, I learned that in, in my rotations is that I usually moisten the area where I collect blood with sterile water as opposite to alcohol.

I usually I'm afraid of alcohol because it can cause them to, you know, some of the puppies can have reactions to the alcohol, . Or it can make a cold puppy even colder. It's just I I tend to avoid it, but I wouldn't sort of do what we can, but just don't soak them in alcohol as I sometimes see happening in, in our practise on occasions.

Now, red blood cell values, . Rule of thumb here is tolerate mild anaemia, mild, I'm talking here mild anaemia, and reticulocytosis up to 5 to 6 months of age. Now, I've given you tables with reference ranges, you can have an idea what you should tolerate, what you should not tolerate, but what usually happens is that they come from an environment which is hypoxic, you know, .

To an oxygen-rich environment when they're born and then a retro pointing. Which so that is, is so overriropoin after the birth, the first two weeks dramatically decreases, which results in red blood cells going really low at the 2 weeks of age. But the truth is, that we don't really take blood from 2 weeks' age, you know, neonate, so that wouldn't be such a dilemma in a practise, but that would be usually the lowest 0.2 weeks of age, not so applicable to day to day practise, .

And they slowly then rise up and normalise by 2 to 3 months of age, as I told you. I am always a bit cautious as interpreting anaemia. I tolerate my anaemia and rely cholecytosis up to 56 months of age.

Fatal red blood cells would predominate in neonates. And they're usually larger than in adults, and they supposedly will normalise by 3 months of age. Polychromasia, how usually bodies and hind bodies and kittens.

These can be tolerated and can be perfectly normal, but again guys, don't tolerate marked changes or don't tolerate market, you know, so severe Heinz bodies, or how bodies, so be careful how you approach that. Now, white blood cells and platelets, number one, platelets will be the same as in adults from birth. So no, no, no, thrombocytopenia, we, we are taking that seriously.

Same goes for neutropenia, guys. They should not be neutropenic. That is not age related.

But yes, mild leukocytosis is tolerated again 5 to 6 months of age. Mild leukocytosis is tolerated, not a severe one. You will have a proper segmented neutrophils and lymphocytes, usually, as I said, within the adult normals references at birth, but increase above the adult reference age between 1 to 3 months of age.

So this is the strictly, if I call the literature single scan for kittens. Now, a few of you asked me, what about those lymphocytes? We're all afraid of lymphocytosis and indeed we should be afraid of lymphocytosis if it's severe, so lymphocytosis should never be ignored, you know, we have others we have.

Neplasia, but mild lymphocytosis, you know, I would rather follow it up, guys, and bear in mind all the like episoians, you know, that would be highly unlikely at this age group because it's an immune-mediated disease essentially, you know. So, so lymphocytosis, mild one, yes, you are OK to tolerate it, but keep a close eye on it, OK? Liver values, yes.

Now, liver fully developed at 4 or 5 months of age, but your bilirubin should be normal. No, we don't tolerate increased bilirubin. High levels can reported in neonates, so-called neonatal hyperbilirubinemia.

Bile acid values, they should be perfect. They should be the same as an adult, so that I wouldn't tolerate to be increased. Alkylic phosphatase because it is an enzyme, so it's not liver specific.

You will see it being increased these groups of patients usually associated with bone growth, and ALD concentration is, is decreased, but yes, we can also see it being increased. Now, you'll again probably ask me what do I consider, when do I get worried? I would get worried, where AOT.

Is increased 4 to 5 times the upper reference range and you have compatible clinical symptoms that could be indicated you have a liver disease. Bear in mind again that the liver diseases in this group of patients will be secondary and there are very limited number of liver diseases. Most group will be infectious or secondary, as I told you, could be, you know, toxic in this group of patients, but we won't see, you know, Significant liver problems in this group of patients.

Yes, we will see shunts and then we'll have balance. It's increased usually about 75 micromoles per litre, about 100 micromoles per litre. Yeah, this is shunt, yeah.

And then alkalic phosphatase, you know, you have growing bones, and again, you'll probably ask me when do I consider or worry about it yet again when it eating be increased to 5 to 6 times the upper reference range. This is where I would get worried. Proteins and albumin.

So first of all, They will be lower. They will be mildly lower as in adults, and you shouldn't worry about that. Moderate to market decreasing proteins and albumins should not be tolerated.

Why are they lower? First of all, their intestinal absorption of proteins in this decreased the liver function is not fully developed by I told you 4 to 5 months of age, and their kidneys will still have a certain amount of proteinuria. Will still be present.

Again, when do they normalise? By 6 months of age, up to 1 year of age. You all know that both puppies and ketus are born hypergammalo anaemic, so they will get the gamma globulinse via colostrum.

Glucose. I, the glucose as such should be the same levels as in adults. However, in times of need, in times of stress, in times of disease, they will not be able to compensate for the glucose consumption will be higher.

Why? Because the liver. Function is underdeveloped so glycogenolysis, glyco neogenesis is not there, guys.

So this slide, I put it here because that's what in the books that significant hypoglycemia is defined as less than 2.2. Well, for me, significant hypoglycemia is, is the same as in adults, and I will always do something about it when it's sort of a below 4, but it depends again, you know, there is no rule of thumb here.

And I'll give you one thing, a take home message today would be every paediatric patient that presents to you. On an emergency setting is hypoglycemic until proven otherwise. So that's one of the take-home messages.

So it would be the second one today is the first one is don't evaluate hydro HD status the same way as you in adults. And the second one, second one is they are hypoglycemic. I mean, they will be 9 out of 10 times, OK?

And do something about hypoglycemia way before it goes before 2.2. So kind of address it in the same way as you do it in the adults.

Kidney values. So first all GFR in kidneys and puppets will be decreased, will be lower. It will only be 20% of the adults' values of birth, normalises for several weeks of age or literature will say by 12 weeks of age.

Urea will be lower. Y increase plasma volume, decrease protein synthesis, increased metabolic state. Creatinine will be lower because the lower muscle mass and I told you also, and I've given it to you, there are specific intervals to be used in interpretation.

And when do they achieve the adult levels, usually by 12 weeks of age. Again, keep in mind that both of these values are usually on the lower end. What do I do if they are high, I address it in the same way as you would in an adult.

But bear in mind, I'll show you later what to do with your analysis. There's also breed variation in creatinine, so how creatine value in German shepherd puppies are noted in up to 8 weeks of age. Calcium and phosphate bones are growing.

They're growing, so they will be higher than in adults up until 8 weeks of age, even later, so phosphate, for example, will be elevated during rapid bone growth and it can be normal up to 8 to 12 months of age in, in, in, in, most dogs can be longer in rates to be very careful and also bear in mind calcium phosphate present in milk so in animals that are, you know, lactating or suckling animals, they will be automatically higher. Oh, here it goes, urinalysis. I love it when the vets, call me, or I'm not gonna say I don't love it, is when they say they did a water deprivation test.

Please don't do water deprivation test in these animals because their kidneys are unable to concentrate urine. Up to 12 weeks of age, so much we know, but I'd say even later. Please don't do water deprivation in this group of patients because it's, it's rubbish.

It won't tell you anything and you will just put in animals in great distress. Now U in puppies can vary from hypostenoric to hyperstenoric, and as I told you before, kidneys, as I said, the vessel actually respond. And hormonal response to dehydration hypovolemia is not the same as in adults.

First of all, another thing to be careful interpreting trace proteinuria can be tolerable, glucozoa, why? Because the glomerular and tubular functions are not fully developed. So this is, I, I love this.

I really do. We use it in our hospital and please share it, put it on the walls of your hospitals. These are really, really, really useful, so reference ranges for different age groups.

Bear in mind, guys, I also want to tell you here and I also say that in our hospital, that there's not been massive research done in this area, so we need to still be careful how religiously we, we sort of follow this reference ranges, OK? But you use them as a rough guidelines and bear in mind if you have struggling with interpretation of things or you're struggling with paediatric patients, I'm one email away from you or one phone call away from you, so you can always contact me about this. Now, here it goes, my favourite topic, fluid therapy.

Look at this talk. Look at this, this is what I want you to do. When it comes to giving fluids to paediatric patients, can you please turn the fluids up, just turn it up.

I see always this standard and listen, they now know that I'm a little bit allergic when I see lower fluid rates given puppies and kittens in our hospital, but I, I, I genuinely will always stop every clinician if I see that the same fluid rate is given as in adults to any patient. 6 months of age, and I'll tell you why now. First of all, their higher percentage of total body water is way higher as in adults.

They have greater surface area to body weight ratio, which is the fluid loss is higher. They have higher metabolic rates, their kidneys are pathetic. They can't concentrate the urine, and they have decreased body fat.

And have I not convinced you hopefully now enough, they need higher fluid rate. So here it goes. I managed to kind of summarise and collect everything that is reported in literature.

All that is available now, and as you can see, it's really pathetic. It's really not a lot available, but the general rule of thumb for your hospital should be the fluid rate in this patient should be 2 to 3 times higher as in adults. So your maintenance.

Right, and I know we use for maintenance 2 mLs per kilogramme per hour, and now I can hear quite a lot of my diplomat colleagues, you know, seizuring when I use this because, you know, we supposedly we should not be using 2 mL per kilogramme per hour, but, you know, I will, I use it. So for maintenance for any patient up to 6 months of age, just maintenance is 6 mL per kilogramme per hour. So 22.

3 times higher. And that's just maintenance, guys. If you have vomiting and diarrhoea and a hypovolemia on top, I mean, then you go on top of all of that.

So you're just maintenance rate is higher and must be higher, and you're not doing them any favour if you're giving them lower fluid rate. So you could just not be doing anything, OK? Same goes for Buses.

So I did give you an idea here about bonuses that are initial bola. You can see it are much higher than supposed to than what we give to, to an adult. So if those are from 30 to 40 mL per kilogramme and typically in, in, in adults, we would use much lower fluids like 10 to 20, 5 to 20, just as advised in literature.

Now canulation, . I do hope I'll be convincing you to do things differently or at least look at them differently and I'll tell you why. Canulation is one of the things that should be done in a with a speed of light.

And all of us, and I'm saying us as well, me as well, still now, we spend way too long placing those IV cannulas. Yeah. We're just trying one cephalic vessel, then we try the other leg, then we tried hind leg, and then anaesthesia comes in and they try everything.

And in the meantime, we're losing a patient. So we have, honestly, and throughout my social but from my residency onwards, actually, no, for my internship onwards, I've seen most of paediatric patients crashing while being, IV lines are placed. That's why, because we spend way too long placing them.

So first of all, I tell you how I do it right now, and I have one of my closest, France is also paediatric intensivist, or human paediatric intensivist, and I had a chance to really have a word with her, how that is done in human medicine, and I'll share that, and I think we should all be kind of taking or adopting the strength. So number one, we try cephalic vessels first. I mean, if you have someone that's very skilled or you're very Still go for that first.

But if one leg fails, can you just, you know, severely dehydrated, hypoglycemic, hypothermic puppy, don't try the other leg. Or at least if you're, if you're really good at it, if you say like, can I just try my luck in the other leg, yes, go for it. By all means, don't be wasting your time.

So what I do now next, so first of all, just I tend to use very at a small, so I usually use orange or blue cannulas and what we try again is if the cephalic vessel doesn't work, what we do is I use the jugular vein, always. Just turn them, clip it, and insert the catheter. The same scatter is used for the cephalic one, uses for the jugular guys, it's not gonna stay there forever.

You just need an axis, intravenous axis, so you can give them fluids, so you can give them those initial drugs that will keep them alive. Now, this is where we are all wimps. We are wimps, and I'm saying for myself as well, although now I've become much braver, we should use more intros as cat and I salute everyone, you know, there, out there, if you're using them, if you're brave, using them in your everyday life.

So if I don't manage to place an IV cannula, if my patient is too wobbly and I can't put it in a jugular vein, I go for the lag straight away. Now, You can use so femur, you can use humorous access. Do I always clip it now?

No. So now, interesting thing, how do they do it in humans and humans, they try sort of a, you know, so peripheral vessels first and then they go to intraos straight away. They just clean it, they Don't even give local, blocks.

So usually, I remember I was giving him lidocaine. Now I don't do that. I just go for it straight away.

And so you can use 80 to 22 gauge needles, cats, young dogs, 8 to 25 gauche hypodermic needles in 8s of any species. So essentially, try to clean the area. If you have enough time, try and clip it.

And just insert a needle in the bone, usually goes really well. And lidocaine, to be fair, it needs to have some amount of time to work. I don't use it anymore, as I said, I used to do it.

And one thing, this, cannulas, so intraosis one, should not stay in place for longer. You use it so that you can give initial bolie, initial fluids, and then you switch to the peripheral vessels, that's stuff. All points so you can visualise so the cephalic, you know, veins get better, you know, that the profusion is better, so you can, you know, place a cat where it can stay longer.

Usually in canals, they stay, so it literature says rarely stay in place for more than 24 hours. I haven't managed to, haven't managed it to stay in place for more than a few hours. So as I said, I use it just to give initial fluid like glu glucose and sometimes pain medication just for initial stabilisation of these patients.

Intraperitoneal, I don't use it for anything else but to help warming them up. So if I have a very, hypo hypothermic kitten or a puppy, usually this will be patients up to 12 weeks of age. I would give them warm fluids intraperitoneally.

It works magic and you should never use fluids that are maximum 2 degrees Celsiium hard and core body temp. Now, the literature says you can use cholostrum whole blood, intraperitoneal. I've never given it and apparently it gets not absorbed up to 2 to 72 hours.

I'm not like really sure why would I give blood that's not absorbed for 2 to 3 hours, because if you are giving blood, you should, you know, you should have it available, should be absorbed straight away. So just kind of according what I found in, in the literature, in case you're gonna go and research this topic yourself. Subcutaneous fluids.

I don't give this now, but I did give them when I was the first one that I would usually give them to very mildly dehydrated animals, usually in the puppies that had one bout of diarrhoea or vomiting and have not eaten for a day. I would use subcutaneous fluids, always use warm fluids, try not to use dextrose because it's an . It will sort of additionally sort of drag the fluid in a subcutaneous place.

If I do use sort of a dextrous supplementation is desired, I would use 0.45% sodium chloride with 2.% dextrose, and I have a lot of these social formulations available.

I can send them to you later if you want to. But as I said, I typically don't do that and you don't use subcutaneous fluids that much, but I did use them as a first. Like that, and I would advise you to, you know, you can go ahead, use it for this mildly dehydrated patients.

I always believe that if you have a puppy or kitten presented to you, you know, in this sort of a, but if you have a client who perhaps can't afford, can't afford IV fluids or stay in a hospital for a day, I mean, give them fluids, subcutaneous. It's, it's better than nothing, put it this way, but don't use subcutaneous fluids in emergency setting. Oral fluids.

I love this. So these are the fluids that you can give to suckling animals. This is fantastic for feeding puppies.

So what are fading puppies? The fading puppies is what all of us tend to see quite a lot, as I said, in Europe, we would see more powerful viroses puppies, but in Britain, I do tend to see fading puppies quite a lot. So feeding puppies are puppies that are born in a sort of a, in a same with the same same status in the same way as the other litter mates, but in the following few weeks, they start to fade and by meaning fades, they usually their suffering mechanism becomes, you know, not that well, .

So their suckling mechanism deteriorates so they can't suckle anymore. They will be pushed away from their mother by the other litter mates. They will usually therefore not be able to access the milk, will not gain weight, will not grow, and these puppies are usually more susceptible for infectious diseases.

So these are the puppies that what you will see, and this is what happened 3 weeks ago in our hospital. So we had a feeding puppy presented, and I know my first one that's automatic tendency was, oh, let me now just place an IV line. Let me give him a lots of fluids, bolae, and like just put him on fluids.

But the truth is that, the first thing what you should do is, as I said, evaluate their hydration status and just have a catch up or ask the owner whether the puppy is circling or not. That would be the first thing to do. Not every puppy that presents to you that is a feeding puppy needs immediately fluids.

They need food because they haven't had an access to food. So the first thing that you try is just to see, just use the bottle, use some of the artificial milk and see if they suckle at all. So this particular puppy didn't do that.

So what you can use then is 5 to 8 French feeding tube. And yes, this is the scary part, and I'm always scared, to be honest with you. So you pass it, in the mouth of my oesophagus to the stomach, and you probably ask me, do they swallow the tube?

No, they don't really, you don't sort of feel the swallow, and that, that's why it's scary because you're, what am I in the lungs. So usually, to be fair, guys, it's if you do access trachea, if you access the Lungs, they will cough. They, there will be more of a discomfort shown by a puppy, but it happens very rarely.

It's quite automatically. You can push that to the stomach and apply some suctions to the syringe, and usually you will be in the stomach and then you can give them food in this manner. And this specific puppy, and a lot of these puppies, you can keep them, you know, well, alive until the point they get stronger, so you can offer them, you know, solid food.

The stomach capacity of the unit is approximately 50 mL per kilogramme. That is a rough guideline, but typically you can use the same guidelines as you would use for supplementing artificial milk, just sort of a, or milk and powder, just sort of that you will have to place the French, feeding tube every time for every feeding. Now, what are the current recommendations of types of fluids use?

I would use the same types of fluids as, as, as for adults, I'd use heartless solution, I use lactated ringle solution. Lactate is also a perfect filling neonates and type of hyperglycemia. And again, warm these fluids up.

I think a lot of us now, I mean, most of us, to be fair, work on you. Know that you will get an emergency coming in, you know, and you can sort of, establish a few hours before you get patient presented that it will be a paediatric patients. It gives you a few hours chance to warm the fluids up and offer them warm fluids because, as I said, there will be hypoglycemic, hypothermic, and just helping them, warming them up will help how they respond to fluid therapy.

Glycemic control, they are hypoglycemic. I'm not discussing this any further. I told you before that.

And what I usually do is because the clinical signs of hypoglycemia are not seen. They're just flat. They're flat as a pancake on your table, you know that.

And I usually ask my nurse to use some glucogel. If you don't have a glucogel, use whatever glucose you have at hand and just give it a little bit in the mouth while you guys are getting. Busy with canneation, just give them the glucose.

Remember, if you do give them dextroseboli, you always have to follow that up with the CRI because they can have a rebound hypoglycemia, OK? So, warm fluids, give them glucose, just a little bit of glucagil in the mouth while you're getting busy with canniation. Control the body temperature.

I have trained my nurses, trained my staff that when we see puppies or kittens or paediatric patients presented and they're very, in a very poor state, so we do automatically warm them up, so we use warming lamps, we use blankets, and as I said, in addition, giving them glucogel. Why? Because the symptoms of hypothermia.

Gluten, you won't be able to establish is due to dehydration, is it due because you're hypoglycemic, is it due because dehydrated. They are all three of these. And the symptoms are usually cardiovascular alteration.

They can be bradycardia, hypertensive, decreased cardiac, they can have arrhythmias. They will have prolonged recovery time and poor response to drugs. They will have increased infection rate, decreased wound healing.

And the most important things you guys will see if you do all three, give them big bolie, give them glucose, warm them up. They will get back on their feet and be cute as hell in a few, in a half an hour if you're doing the things correctly. Heat sources obviously must be safe and then you have to monitor them closely.

Incubators, they say it's good. Now incubator has its pluses, has its minuses. It keeps the temperature stable, but sometimes they can get overheated.

You need to open and close it, several times, at least the ones we have, and you, they, they don't always lag the hands-on approach. So I usually tend to use warming pillows or just blankets to keep them warm. Pharmacokinetic alterations from a that is sort of the last slides of today.

And I swear to God if you're gonna bombard me now, and I know you will have the tendency to do that, to ask me about each drug that you tend to use, can I use it in paediatric patients? I mean, I won't be able to tell you about every drug that you use in practise if it's, you know, acceptable for, for younger. Animals usually here we talk about animals up to the 8 weeks of age.

I, I won't be able to tell for, for, for all of the drugs, but I will be more than willing to help you you know, reply to these questions if you email me about specific drugs that you tend to use. Now, first of all, the pharmacokinetic alteration units paediatric patients. So first of All, we know that from the vets called primary pharmacokinetic parameters, which is absorption, distribution, metabolism, elimination.

I mean, we talked about their bodies, we talked about their perfusion, for cardiovascular system, lack of insulating fat, their poor intestinal absorption, kidney function is underdeveloped, which means that drugs will be affected by that. Now, they first of all, have limited organ reserve. They have decreased ability to respond to physiologic challenge.

Remember, we've spoken about their hearts. We've spoken about their underdeveloped sy you know, sympathetic system. Therefore, decreased doses of certain drugs are required.

And now, from week to week, the drug handling and the drugs you can use on them can change because their organs will be developed from week to week, more and more developed. Now, the difference in the use of drugs will depend on the condition that you treat and the rape index of the drug. And you will probably ask me now, so what do I do if I don't know if I can use a specific drug?

First of all, I don't believe that you're using such an exotic drugs that you won't have an information sheet available at your hand where you You can look it up, or BSA formulary or plums that will tell you whether you can use this drug for a specific age group. And if it's not available there, just drop me an email. I'll help you best I can because that's also my, my, my interest area.

So we'll research it for you with, with, with delight, to put it this way. So why is the pharmacokinetics different? Hyperalbuminemia.

So albumin is a boat for most of the drugs, so like barbiturates, ketamine, NSA, so the free drug will be higher because the albumins are lower. Increased permeability of the neonatal blood brain barrier. We have increased percentage of body water content which will affect the specifically increase the extracellular water content will affect the certain drugs like NSAs, for example, metabolism.

Centralised circulation, which means the specific drugs will reach the central of the system faster, so we have an increased circulation in the, in the larger vessels. We have lower body fat percentage which will affect how the drugs are metabolised, how the drugs are, you know, dispersed. We have lower hepatic metabolism, kind of imagine anaesthetizing or using the drugs in the patient that's got a liver failure.

That's it. So certain drugs. Same goes for the next point where you have lower GFR for the 1st 2 weeks of life and slower tubular suppression, a kind of a, when you use the drugs that have are metabolised by liver or metabolised via kidneys, you know, keep in mind that you kind of treat them in the same way as you would, or, or give them drugs in the same way as you would give them for patients with liver or, or, or kidney failures.

So be careful. And then have a high metabolic rate and oxygen consumption. Now, here you go.

A lot of vets will ask me this question and let's just cover that. What antibiotics can I use? So first of all, every antibiotic in this group of patients, let's kind of make that clear, carries some risk.

But no antibiotic is absolutely contraindicated. If the only antibiotic that shows activity is one that you must avoid, be prepared to use it in life-threatening situations. So here we go.

Par of the puppy, neutropenic animals, septic puppies. Can I use fluoroquinolones? Yes, you can, and yes, you should because you're saving lives.

If it's a sort of a situation of life. For that matter life and that you should use flurokine alone, guys. And so for example, I'll give you a rough idea.

So classical part of a puppy scenario is they will reach Nadir of neutrophils, strava, you will have that 2 to 4 days Nadir. What they will be neutrope and this is where quite a lot of them will die. This is the time where you can use fluoroquinolones, and you should use them, or you have a septic puppy, let's say you have a puppy from the puppy farm puppy that's got, you know, severe bacterial enteritis.

Of course, you want to use this drug. And now, I, however, how, how would I do it? And I've spoken with a lot of specialists about it.

They would do exactly the same. So this is how we do it. So essentially, when you are using fluoroumulants, this is not the kind of a drug that you will send a paediatric patient home with.

Put it this way. If you have a patient that is Neutropenic or need the hospitalisation, use those lu accumulants for a limited period of days. So just for the time being, where they're out of the works and then stop these drugs.

Don't use these drugs for a really prolonged periods of time. And to be fair, I personally, and I would love to discuss this further, you know, this is sort of a Downside of webinar that we can't discuss this further for longer is, I, I don't think they ever are in a state where you would need these drugs for a really long time. And if they are, again, write me, ask me, I would more than willing to help you guide your treatment in this kind of patients where you feel like you need to use fluoroqui lens for longer than only a few days.

Now the best antibiotics, the most safest are penicillins or cephalospirins, and avoid oral and IM dosing seriously on neonates. I mean, I am, won't get resolved oral, I'd be a bit afraid of their microflora, or the GI flora. So this is it and With this, I am kind of wrapping up finishing my, my CPD my presentation for today, and I just hoped I did manage to teach you something and guys, honestly, if you still feel like you, you, you I want to know more.

I'll be honest with you, it's, it's not so much published out there. So you have to use common sense, but do treat them differently. Do treat them differently.

So you should understand that they are unique and you should understand that diagnosis, monitoring, treatment is, is different and especially, you know, as I said, drug dosages, laboratory data, diagnostic image. Is that different significantly, but yet again, this is not such massively researched field in our profession that we would, as a specialist, be able to give you clear guidelines, but we will always, always be able to help you if you need help. So this is the last slide.

So this is my puppy. She is mental, completely mental dog, and Healthy so far so good. Touch wood, and, as I said, please, if you have questions, suggestions, I'd be more than willing to answer them if you want to, you know, email me, this, just ask the organisers to send you my email address and I'll be really, really willing to, you know, discuss these cases with you.

Thank you very much. Alenka, that was absolutely fascinating. Thank you so much.

I think your insight into paediatrics has stimulated lots of thought process and, and, and many, many questions. So, I hope you have got some, some time for us to keep going on. Of course.

Jill wants to know when you were talking about foetal haemoglobin and that, is it a similar situation in human medicine? Oh gosh, that's that's a good, put it this way, I'll be quite honest, I don't know. And I would be very curious, why would my myendee like to know that?

Is this like some is this a human GP? What, I, I'm just curious and my, my honest answer would be, I don't know. I never studied it, never compared it, and that would be interesting.

Why would kind of that be I'm not gonna say relevant because it's, it is relevant for anyone who asks that, but just kind of a curiosity why this question. Come on, Jill, pop it in the questions here. Why the relevant question.

We'll come back to it. Christianao wants to know, with intraperitoneal blood administration, how do the erythrocytes get into the vessels? See, that is a fantastic question.

I have never done it. I have found I have never done it, put it this way. I have found it in the literature.

Want to kind of show you that this is something that you can do. And I'll look into that. And if, if the specific, you know, the, the person who asked me that wants to know that, I will be more than willing to email that.

It's a fantastic question, put it this way, and, and never ask myself this question, but I will research it and I'll send him an email if that's OK. Perfect. So Jill has popped in that she was asking that question about the haemoglobin because she finds paediatric patients' urine, that they pass is very high in bilirubin.

It's very interesting. Are we talking here about what sort of, is this any sort of a more breed-related, age-related? I'm very curious, where did she find it?

In what context? I'm, I'm very curious and in what specific context was that tested? I'm very curious about that.

Maybe, maybe this is a an email exchange that you and Jill can have afterwards. Susan has made a fabulous comment. Susan, I agree with you on this one.

She says this has been very useful. Lots of things that are good to know. I wish I had known them 30 years ago.

Thank you. We have a question about nutritional requirements. So once you've got your puppies, through the initial emergency and you've stabilised them and warmed them and hydrated them and given them glucose, what, what do you do about the calorific requirements going forward?

So the calorie requirements nowadays, first of all, they, they Calorie requirements should be calculated based on age, and now, nowadays, formulas are available, so age appropriate formulas are available in nutrition books, and I usually follow those formulas. I will send the colleague these formulas if she wants them because I know for the practise, this is very useful, and I'll be honest with you, don't know them from the top of my head, but I have nice formulas available for different age groups, and I can send that through if she wants them to. Excellent.

Alenka, there's a a question comes through of, would you mind sharing your email address with everybody? Just right now, spell it out, or, or is it possible if I email it to you and then you email it because it's it's what we do folks if you can, if you are interested in contacting Eleka, send an email through to to Dawn. She's popped the email address in the chat box of office at the webinar vet.com and she will be able to forward alenka's email address to you or vice versa.

She can put the two of you in touch. Better, better way to do it there. So that's send it into office at the webinar vet.com.

Right, yeah, Alenka, I'm sure everybody would be happy to stay on all night and keep talking to you. This really has been fascinating and so, so useful. Anthony always likes to say if we were in an auditorium now, you would have got thunderous round of applause.

So, from my side, from everybody attending, thank you so much for this, and all those who have not attended tonight because they're at BSAA. Yeah, they will be lucky enough that this is being recorded and it can go on the website. So thank you so much for your time.