PEDIATRICS: PUPPIES AND KITTENS 0195-5616/99 $8.00 + .

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PEDIATRIC INTENSIVE CARE

Douglass K. Macintire, DVM, MS

A veterinarian in a pediatric intensive care situation for a puppy or

kitten should be familiar with normal and abnormal vital signs/nursing
care and monitoring considerations, and probable diseases to provide
the optimal care. Following is a brief discussion of the pediatric intensive
care commonly required to treat puppies or kittens in emergency situa-
tions.

BIRTH TO 2-WEEK-OLD PUPPIES AND KITTENS

At birth to 2 weeks of age, a healthy neonate is firm, plump, and

vigorous. 6 Crying occurs in response to pain, coldness, failure to nurse,
or loss of contact with the mother. It is abnormal for a healthy neonate
to cry for longer than 20 minutes, whereas sick neonates commonly cry
incessantly. A sick neonate is limp and relaxed, with poor muscle tone.
Healthy neonates have hyperemic mucous membranes until days 4 to 7,
whereas sick neonates often have pale, gray, or cyanotic membranes.
Sick neonates lack normal bowel sounds on abdominal auscultation.
Diarrhea is present in approximately 60% of sick neonates.

General Approach to Sick Neonate

Regardless of the underlying cause, the approach to the sick neonate

is similar and should address various concerns. If a neonate is separated
from its mother, external warming must be provided. Ideally, a neonatal

From the Department of Small Animal Surgery and Medicine, College of Veterinary
MediCine, Auburn University, Auburn, Alabama

VETERINARY CLINICS OF NOR1H AMERICA: SMALL ANIMAL PRACTICE

VOLUME 29 • NUMBER 4 • JULY 1999 971

972 MACINTIRE

incubator can be used to provide an environmental temperature of 85°F

to 90°F and a humidity of 55% to 65%. A hot water blanket, rice bags,
and hot water bottles can also be used, but the neonate should be able
to crawl away from the heat source, and the source should be covered
with a towel to prevent overheating burns from direct exposure. A heat
lamp can also be used to provide warmth. A pan of water can increase
the humidity in the environment. A thermometer should be placed near
the neonate to check ambient temperature.
Hypothermia (rectal temperature of 78°F-95°F) is common in neo-
nates and is associated with depressed respiration, bradycardia, gastroin-
testinal paralysis, and coma. Until the hypothermic neonate is rewarmed,
oral feeding is not indicated, because digestion does not occur in the
face of hypothermia and ileus. Neonates must be rewarmed slowly. The
most effective method is the use of warm inspired air because it warms
the body's core as well as the external surface. This can be accomplished
through an incubator or oxygen cage. Warm fluids can also be given by
the intraosseous or intravenous route, or as a warm-water enema.
Most sick neonates are hypoglycemic due to depletion of glycogen
stores and immature hepatic function. 6 Placing a drop of blood on a
glucose reagent stick can check the blood glucose level. Glucose can be
provided orally (initially, 1-2 mL of a 5%-15% dextrose solution) to
neonates that are not dehydrated or hypothermic. If mild dehydration
is present, fluids containing 2.5% dextrose and a 0.45% sodium chloride
solution can be given subcutaneously. Hypertonic dextrose solutions
should never be given subcutaneously. Neonates exhibiting neurological
dysfunction, shock, or severe dehydration should receive glucose paren-
terally by the intravenous or intraosseous route at a dose of 0.25 mL per
25 g of 20% dextrose solution.
After dehydration and hypoglycemia are corrected, oral feeding can
be initiated if a suckling reflex and bowel sounds are present. Puppy or
kitten milk replacer can be used. The stomach capacity of the neonate is
approximately 50 mL/kg. Initially, puppies are fed 10 mL every 4 to 6
hours, and kittens are fed 5 mL every 4 to 6 hours. The amount is
gradually increased by 1 mL per feeding (puppies) or 1 mL/ d (kittens)
until the recommended guidelines are reached. If diarrhea occurs, the
formula should be diluted at a 1:2 ratio with balanced multiple electro-
lyte solution until the diarrhea resolves. Neonates can be fed with a
bottle, syringe, or feeding tube. If a feeding tube is used, care must be
taken not to place it in the trachea. Improper placement is more likely
in neonates, because the gag reflex does not develop until10 days of age.
Because of rapid total body water turnover, dehydration can occur
acutely in neonates. Hydration status is difficult to assess in neonates.
Skin turgor is not reliable due to the increased water and decreased fat
content of the skin. Mucous membranes should be moist and not tacky.
The color should be hyperemic for the first 4 to 7 days of life. Pale
mucous membranes and slow capillary refill time in the absence of
anemia indicate circulatory collapse and 12% to 15% dehydration.
Warmed intravenous fluids can be given at an initial rate of 1 mL per
 PEDIATRIC INTENSIVE CARE 973

30 g over 5 to 10 minutes. Fluid loading is continued until color and

capillary refill time (CRT) have improved. The puppy or kitten is reas-
sessed every 30 minutes until it is stable, and fluids are then adminis-
tered at a maintenance level of 60 to 90 mL/lb/d.
Vitamin K should be administered to any sick neonate less than
48 hours old or exhibiting signs of hemorrhage (0.5-2.5 mg/kg given
subcutaneously or intramuscularly). At birth, puppies have decreased
thrombin levels and are more prone to hemorrhage than adults. Weak
neonates that are unable to nurse following parturition may have atelec-
tatic lungs, aspiration of amniotic fluid, or anoxia from premature pla-
cental separation. Puppies can also develop pulmonary contusions fol-
lowing trauma from the dam. Supplemental oxygen may be beneficial
either from an oxygen cage (40%) or a nasal catheter.

Specific Disease Conditions

Poor sanitation can lead to infections of the skin, eyes, and umbili-
cus. Neonatal dermatitis results in crusting lesions on the head and neck
at 4 to 10 days of age. Treatment involves gentle cleansing with a
bactericidal shampoo and systemic antibiotics. Neonatal conjunctivitis
results when purulent exudate accumulates behind the eyelids before
they completely open. Treatment involves gentle eyelid separation,
drainage, cleansing, and topical antibiotics.
Umbilical infections can occur in the first 4 days of life and are
often due to fecally derived bacterial or Streptococcus species infection.
Treatment involves draining and flushing the abscess and providing
fluids, antibiotics, and other supportive care. Prevention can be accom-
plished by applying antiseptic solution to the newborn's umbilicus or
by administering peripartum antibiotics to dams with known genital
infections. Sanitation of the whelping quarters is also important.
Neonatal septicemia occurs when an infection becomes systemic. It
may be secondary to lack of colostrum intake or to maternal infections
such as mastitis or metritis. Causative organisms include Staphylococcus
species, Streptococcus species, Escherichia coli, and Pseudomonas species.
Neonates should be isolated from the mother and treated with antibiot-
ics, fluids, and other supportive care (the reader is referred to Appendix
1 for an outline of medical management of a septicemic puppy or kitten).
Canine herpesvirus and canine parvovirus type 1 infections cause a
rapidly fatal syndrome in which the entire litter of puppies begins
crying, develops lethargy and anorexia, and dies within 18 hours. 3' 7
Most canine herpesvirus infections are acquired during late pregnancy
and the first 3 weeks of life. The signs shown by infected puppies with
canine herpesvirus may vary from mild to severe depending on the
age, presence of maternal herpesvirus antibody, stress, and presence of
concurrent bacterial infections. If canine herpesvirus infection is acquired
in utero, fetal death, mummification, abortion, or neonatal death can
result. Most puppy losses occur between days 9 and 14 of life. Severe
974 MACINTIRE

disease in a puppy older than 4 weeks of age is unlikely. Clinically,

affected puppies present with a sudden onset of severe illness character-
ized by depression, anorexia, persistent crying, abdominal discomfort,
bloating, rapid and shallow respiration, hypothermia, and profound
weakness. Commonly, the clinical course ends in death in 18 to 24
hours. Canine herpesvirus replicates best at low core body temperatures
(92°F-98°F); thus, medical treatment involves warmth and other support-
ive care. After one litter is lost, subsequent litters may be completely nor-
mal.
Toxic milk syndrome may cause bloating, green diarrhea, crying,
and a red edematous rectum. Puppies should be removed from the
mother and supplemented with milk replacer, and the bitch should be
evaluated for underlying disease such as mastitis or metritis.
Puppies and kittens that die immediately after birth are often re-
ferred to as part of the fading puppy syndrome or fading kitten syndrome,
with a fader being a puppy or kitten apparently healthy at birth but
failing to survive beyond 2 weeks of age. Faders generally occur because
of congenital anomalies, teratogenic effects, nutritional diseases resulting
from improper diets fed to the dam or her young, abnormally low birth
weights, traumatic insults during or after the birth process (dystocia,
cannibalism, or maternal neglect), neonatal isoerythrolysis, infectious
diseases, and other miscellaneous factors.
Neonatal isoerythrolysis occurs infrequently among domestic kit-
tens but may be relatively common in certain purebred kittens. 5 Kittens
acquire maternal alloantibodies of the IgG class and (to a lesser extent)
the IgM class through colostrum ingestion. Kittens with blood type A
have weak anti-B alloantibodies, whereas kittens with blood type B
have strong anti-A alloantibodies. The alloantibodies, particularly anti-
A alloantibodies, are responsible for the major incompatibility reactions.
Signs of neonatal isoerythrolysis often develop in blood type A (or blood
type AB) kittens born to blood type B dams.
After colostrum intake, affected kittens show the first signs within
hours to days. The clinical course may vary but often includes (1) kittens
that suddenly die during the first day of life without showing any signs;
(2) kittens that stop nursing during the first 3 days of life and fail to
thrive (clinical findings include dark brown-red urine caused by severe
hemoglobinuria; affected kittens may develop icterus and severe anemia,
continue to fade, and may die during the first week of life); and (3)
kittens that continue to nurse, thrive, and show no obvious signs of
illness, except for a tail-tip necrosis between the first and second weeks
of life as part of the syndrome, and may exhibit laboratory abnormalities
such as a positive direct Coombs' test and a moderately responsive ane-
mia.

2- TO 6-WEEK-OLD PUPPIES AND KITTENS

During the period between 2 and 6 weeks of age, the most life-
threatening problems are internal and external parasites, juvenile hypo-
 PEDIATRIC INTENSIVE CARE 975

glycemia, dehydration from diarrhea, and traumatic insult. Renal func-

tion does not mature until 8 weeks of age; thus, these puppies and
kittens remain prone to drug toxicity from decreased renal elimination
and to dehydration from decreased ability to concentrate urine. Congeni-
tal defects such as megaesophagus may become evident with the change
from liquid to solid food.
Internal parasites can result in a significant burden at 2 to 4 weeks
of age. Toxocara species can be transmitted transplacentally from the
mother and Ancylostoma species are ingested through the dam's milk.
Proper perinatal care of the mother should prevent severe parasitic
infections in puppies and kittens of this age. In cases of poor husbandry,
however, Toxocara species can cause weight loss, unthriftiness, abdominal
distention, and diarrhea, and Ancylostoma species can cause life-threat-
ening anemia. Puppies and kittens can be treated with pyrantel pamoate
(5-10 mg/kg administered orally) as early as 2 to 3 weeks of age, and
this can be repeated every 2 to 3 weeks until at least 12 weeks of age.
Severe anemia (pale mucous membranes, tachycardia, weakness,
packed cell volume < 15) and hypoproteinemia may require a whole
blood transfusion. Whole blood is diluted at a 1:10 ratio with a citrate
anticoagulant and is given through a millipore blood filter at rate of
10 mL/lb over 2 hours. Intraosseous or intravenous administration is
preferred in critically ill puppies or kittens, but blood can be given by
the intraperitoneal route as a last resort. With intraosseous administra-
tion, 95% of the red blood cells is absorbed within 5 minutes, whereas
70% is absorbed within 72 hours following intraperitoneal administra-
tion. Iron supplementation should be given following transfusion in
anemias involving blood loss.
Protozoal parasites that may cause diarrhea in young animals in-
clude Giardia species and Coccidia species. Giardiasis is treated with
metronidazole (30 mg/kg administered orally for 7 to 10 days), febantel
(30-40 mg/kg administered orally once daily for 7 days)/ or fenbenda-
zole (50 mg/kg administered orally once daily for 7 days). 1 Coccidiosis
can be effectively managed with sulfadimethoxine at 50 mg/kg on the
first day followed by a daily dose of 25 mg/kg until signs regress.
External parasites may cause severe debilitation in young animals. Most
flea and tick products should not be used in nursing animals. The
mother should be treated, but her nipples should be avoided or rinsed.
Bedding should be washed or discarded. The safest way to treat young
puppies and kittens is to spray a towel with pyrethrin insecticide and
wrap the animal's body in the towel, leaving the head out. A flea comb
can be used to remove dead and dying fleas. If the puppy or kitten is
bathed, extreme care must be taken to avoid hypothermia. In some
cases, ectoparasite infestation is so severe that a blood transfusion is
required.
Juvenile hypoglycemia can occur because of immature hepatic en-
zyme systems, lack of glycogen stores, and increased metabolic require-
ments for glucose. Signs include weakness, tremors, seizures, stupor, and
coma. Treatment involves intravenous or intraosseous administration of
976 MACINTIRE

glucose (0.5-1.0 g/kg) diluted to a 5% to 10% solution followed by other

supportive care.
Fatty liver syndrome may cause ill-thriving puppies at 4 to 16 weeks
of age and mostly involves the toy breeds. 13 Affected puppies present
with a sudden onset of severe illness characterized by depression, an-
orexia, persistent crying, diarrhea, rapid and shallow respiration, hypo-
thermia, seizures, and profound weakness. The clinical course usually
ends in death in 1 to 6 days. Treatment involves intravenous or intraos-
seous administration of glucose (0.5-1.0 g/kg) diluted to a 5% to 10%
solution followed by other supportive care.
Dehydration is always a potential problem in young puppies and
kittens that develop pediatric diarrhea. Severe consequences can be
avoided by giving subcutaneous fluids at one to two times the mainte-
nance requirement while attempting to determine the cause of the diar-
rhea. Common reasons for diarrhea include overfeeding, lactose intoler-
ance, excess solids, excess saturated fatty acids, parasites, infection,
toxemia, or improper handling of a milk replacement diet.

6- TO 12-WEEK-OLD PUPPIES AND KITTENS

Puppies and kittens 6 to 12 weeks old are more similar to adults in

terms of renal function, body temperature, and vital signs, but they still
have an increased maintenance water requirement (60-90 mL/lb/d) and
caloric requirement (220 Kcal/kg/ d). Because maternal antibody is lost
during this period, they are susceptible to infectious diseases and should
be isolated from other animals as much as possible until their vaccina-
tions are completed by 15 to 16 weeks of age.
The most life-threatening diseases in 6- to 12-week-old puppies and
kittens include infectious diseases (feline leukemia virus infection, feline
infectious peritonitis, and panleukopenia in kittens; canine distemper
and viral enteritis in puppies). General concerns regarding the manage-
ment of these sick puppies and kittens include prevention of hypoglyce-
mia, dehydration, hypoproteinemia, and anemia.
Other emergencies that are common in 6- to 12-week-old puppies
and kittens because of their inquisitive nature include foreign body
ingestion and electrical cord injury. Animals with foreign body ingestion
have a history of vomiting, and careful abdominal palpation may detect
a mass and abdominal discomfort. Classic radiographic signs include
distention of the bowel proximal to the obstruction.
Animals that bite into an electrical cord may have bums on the lips,
tongue, or oral mucous membranes. The life-threatening consequence of
electrical shock, however, is acute fulminant pulmonary edema, which
progressively worsens for the first 24 hours after the electrical insult.
The mainstays of treatment include cage rest, supplemental oxygen, and
furosemide (2 mg/kg administered intravenously every 6-12 hours).
Other treatments may include aminophylline (5-10 mg/kg administered
intramuscularly) and a single dose of corticosteroids to help stabilize
 PEDIATRIC INTENSIVE CARE 977

membranes. Other potential sequelae include cardiac arrhythmia, sei-

zures, and secondary pneumonia. Most animals recover if they survive
the initial 48 hours.
Juvenile cellulitis, sometimes referred to as puppy strangles or juvenile
pyoderma, is an idiopathic skin disease occurring in 3- to 16-week-old
puppies. No causative agent has been identified. The disease is charac-
terized by facial swelling, lymphadenopathy, deep pyoderma of the
head and face, fever, anorexia, and depression. Treatment involves topi-
cal therapy with antibacterial shampoos, systemic antibiotics (20 mg/kg
of cephalexin administered orally three times daily) and immunosup-
pressive doses of prednisolone (2.2 mg/kg administered once daily until
signs resolve followed by alternate-day therapy for 2 to 3 weeks). There
may be an immune-mediated cause for this disease, as the response to
antibiotic therapy alone is unrewarding and recrudescence can occur if
corticosteroid therapy is withdrawn too early. Without treatment, the
disease can be fatal.

CANINE PARVOVIRUS TYPE 2 ENTERITIS

Without immediate treatment, canine parvovirus type 2 enteritis is

often a rapidly fatal disease in puppies aged 6 weeks to 6 months,
ending in severe dehydration, endotoxic or septic shock, and multiple
organ failure. 8' 11 With aggressive therapy and supportive care, however,
a survival rate of 85% to 95% can be achieved in most breeds of
dogs, with the exception being the Rottweiler. A summary of various
therapeutic products and a management protocol for canine parvovirus
type 2 enteritis are provided in the Table 1 and Appendix 2, respec-
tively.8, 10

Initial Assessment

When a puppy is first presented to the veterinary facility with a

history suggestive of canine parvovirus type 2 enteritis, a fecal parvovi-
rus antigen test should be performed to confirm the diagnosis if
possible. 9' 11 If the fecal antigen test is positive, the puppy should be
isolated from other hospitalized animals, and all contaminated surfaces
should be cleaned with household bleach solution diluted at a 1:30 ratio.
Strict cleanliness should be observed to avoid spreading the disease to
other animals. If the fecal antigen test is negative, other causes of
acute vomiting/ diarrhea such as a foreign body, pancreatitis, intestinal
parasitism, toxicosis, or dietary indiscretion should be ruled out. Because
of the possibility of false-negative results on the fecal antigen test,
animals with a compatible history should receive appropriate supportive
care and be retested 48 hours later.
The severity of the disease should be assessed through evaluation of
physical examination findings and blood drawn for an initial minimum
978 MACINTIRE

Table 1. SUMMARY OF PRODUCTS FOR MANAGEMENT OF CANINE PAROVIRAL

ENTERITIS

Drug Dosage and Route

Antiemetic agents 0.5 mg/kg tid IM
Chlorpromazine 1.0 mg/kg tid rectally via plastic catheter
(calculated dose diluted in 1 mL of normal
saline solution)
0.05 mg/kg tid IV
Metoclopramide 0.2-0.4 mg/kg tid SC
1-2 mg/kg administered every 24 hours as a
slow IV infusion for severe vomiting
Prochlorperazine 0.1 mg/kg tid-qid IM
Antimicrobial agents
Ampicillin 10-20 mg/kg tid-qid IV, IM, SC
Cefazolin 22 mg/kg tid IV, 1M
Ceftiofur 2.2-4.4 mg/kg bid SC
Gentamicin 2 mg/kg tid IM, SC
Adjunctive therapies
Antiendotoxin According to manufacturer's directions
Recombinant granulocyte colony 5 f.Lg/kg sid SC
stimulating factor
Specific hyperimmune plasma 1.1-2.2 mL/kg IV or SC
Gastric protectants
Cimetidine 5-10 mg/kg bid-tid IM, IV
Ranitidine 2-4 mg/kg bid-tid SC, IV

SC = subcutaneous administration; IV = intravenous administration; IM = intramuscular admin-

istration; sid = once daily, bid = twice daily; tid = three times daily; qid = four times daily.

database. Rapid screening tests that aid in the puppy's assessment and
fluid choice include the packed cell volume, total plasma solids, serum
electrolytes, and reagent sticks for blood glucose and blood urea nitrogen
levels. A complete blood cell count or blood smear also aids in the
assessment, because leukopenia is generally associated with more severe
disease and a more guarded prognosis. The percentage of dehydration
should be estimated through physical examination findings.

Initial Fluid Therapy

Fluid replacement for losses incurred through vomiting/ diarrhea is

the cornerstone of treatment for puppies with canine parvovirus type 2
enteritis and should be continued until oral intake is resumed. The
initial fluid of choice is a balanced multiple electrolyte solution (lactated
Ringer's solution or Normosol-R [CEVA Laboratories, Overland Park,
KS]). The route and rate of initial fluid therapy vary. If canine parvovirus
type 2 infection has resulted in hypovolemic shock, a rapid intravenous
fluid bolus of up to 90 mL/kg/h may be necessary to restore perfusion.
Puppies in shock have pale or muddy mucous membranes and a
slow CRT. Fluid therapy should be administered at a fairly rapid rate
until mucous membrane color becomes pinker and CRT is restored to
 PEDIATRIC INTENSIVE CARE 979

1.0 to 1.5 seconds. If circulatory collapse prevents venous access, fluid

solutions can be administered initially via a 20-gauge 1.5-inch spinal
needle placed aseptically in the intraosseous space in the shaft of the
femur or humerus. Once circulation has been improved by means of
intraosseous fluids, an intravenous catheter can be placed for continued
fluid therapy. It is important to note that puppies with severe dehydra-
tion or circulatory collapse because of peripheral vasoconstriction do not
absorb subcutaneous fluids. In addition, hypertonic solutions should be
avoided in dehydrated patients.
Puppies that are dehydrated but not in shock should be rehydrated
over 4 hours. The amount of fluid given is estimated by the following
formula:
% dehydration X body weight (kg) = number of liters required to
replace deficit
Maintenance requirements (2-3 mL/kg/h) as well as continuing
losses from vomiting/ diarrhea must also be taken into consideration
during initial fluid therapy.

Maintenance Fluid Therapy

Once perfusion has been restored, the fluid rate can be decreased to
4 to 6 mL/kg/h in most puppies. Hydration should be monitored by
evaluating mucous membrane color, CRT, pulse quality, packed cell
volume and total plasma solids, urine output (which should approxi-
mate 1-2 mL/kg/h), and urine specific gravity (which should range
from 1.015-1.020). Fluid therapy should be adjusted to replace continu-
ing losses through vomiting/ diarrhea. As fluid losses subside, the fluid
rate is gradually tapered.
Many puppies, especially the toy breeds or septic puppies, are
more prone to hypoglycemia with canine parvovirus type 2 enteritis.
Following rehydration, a 2.5% to 5.0% dextrose solution can be added
to lactated Ringer's solution or Normosol-R (100 mL of 50% dextrose
added to 1 L of lactated Ringer's solution or Normosol-R makes a 5%
solution).
Puppies with anorexia and vomiting/ diarrhea are also prone to
hypokalemia, which can result in muscle weakness, ileus, polyuria,
cardiac arrhythmia, and general malaise. Serum potassium should be
monitored daily in these puppies. If low, potassium chloride should be
added to the fluids: up to 40 mEq of potassium chloride is added to 500
mL of lactated Ringer's solution or Normosol-R. If serum potassium is
within its normal range, 14 to 20 mEq of potassium chloride should be
added to each liter of lactated Ringer's solution or Normosol-R.
If the puppy is anemic because of parasitism or gastrointestinal
blood loss, a transfusion of whole blood (preferably from a recovered
animal with a high serum canine parvovirus type 2 antibody titer) is
indicated. A dose of 10 to 20 mL/kg can safely be administered to
980 MACINTIRE

most puppies over a 4-hour period. If the puppy is not anemic but is
hypoproteinemic, a plasma transfusion (10-20 mL/kg intravenously)
should be administered through an in-line filter over 2 to 4 hours. In
addition to providing oncotic components, both whole blood and plasma
contain antibodies and serum protease inhibitors that may be beneficial
in neutralizing circulating virus and controlling the systemic inflamma-
tory response associated with the disease. Plasma and blood products
are available through commercial blood banks.
Puppies with decreasing total protein and edema should receive a
synthetic colloid such as hetastarch or dextran 70. To avoid potential
volume overload, the dosage of 20 mL/kg/ d should not be exceeded,
but colloid infusions can be repeated after 24 hours if needed. Colloid
solutions can be given rapidly to puppies in shock or as a continuous
infusion over 24 hours to more stable puppies. General guidelines are
to supply one third of fluid needs as a colloid and two thirds as lactated
Ringer's solution or Normosol-R.

Systemic Antibiotics

Hemorrhagic diarrhea and mucosal sloughing are commonly seen

in dogs with canine parvovirus type 2 enteritis and are indicators of
breakdown of the gastrointestinal mucosal barrier which may contribute
to bacterial translocation, endotoxemia, and sepsis. Severe neutropenia
often coincides with the severe enteritis and contributes to the risk
of sepsis. For these reasons, intravenous, broad-spectrum, bacteriocidal
antibiotics are indicated in severely affected puppies. A combination of
an aminoglycoside (2.2 mg/kg of gentamicin administered every 8 hours
or 10 mg/kg of amikacin administered every 8 hours) with a beta-lactam
antibiotic (22 mg/kg of ampicillin administered every 8 hours or 22
mg/kg of cefazolin administered every 8 hours) provides excellent ther-
apy against the gram-negative and anaerobic bacteria that originate from
the gastrointestinal tract.
Aminoglycosides can cause acute renal failure and should only be
administered after rehydration has been accomplished. Once-daily dos-
ing of aminoglycosides may minimize renal damage while maximizing
bacterial kill because of high peak and low trough antibiotic concentra-
tions, but the high dose should never be given to dehydrated puppies.
Urine sediment should be monitored for the appearance of proteinuria
or renal tubular casts, which would warrant discontinuation of amino-
glycoside therapy.
Enrofloxacin (5 mg/kg administered every 12 hours) is an alterna-
tive choice to the aminoglycosides. It has an excellent gram-negative
spectrum but is not approved for intravenous use and may cause carti-
lage abnormalities in young growing puppies. The author has not en-
countered any problems with enrofloxacin when it is diluted at a 1:1
ratio with sterile saline solution and administered slowly intravenously
on a relatively short-term basis (usually 3-5 days) in puppies with
 PEDIATRIC INTENSIVE CARE 981

canine parvovirus type 2 enteritis. Rapid administration may cause

vomiting.
Mildly affected puppies with an adequate neutrophil count gener-
ally do not require combination antibiotic therapy. Appropriate antibiotic
choices might include ampicillin, cephalosporins, or a trimethoprim-
sulfonamide combination.

Anti emetics

Vomiting often decreases when oral intake of food and water is

discontinued, but in some puppies, the problem persists and must be
treated to reduce fluid losses and increase patient comfort. The antiemet-
ics most commonly used in puppies with canine parvovirus type 2
enteritis are metoclopramide and chlorpromazine. Metoclopramide is a
gastric promotility drug that reduces vomiting by stimulating gastric
emptying and inhibiting the chemoreceptor trigger zone. Metoclopram-
ide can be added to the intravenous fluids or administered in a separate
drip at a dosage of 1 to 2 mg/kg administered every 24 hours and given
as a constant rate infusion.
If metoclopramide is ineffective in controlling vomiting, chlorprom-
azine can be used. This drug is a phenothiazine derivative and acts on
the emetic center, chemoreceptor trigger zone, and peripheral receptors
to reduce the vomiting reflex. The recommended dosage is 0.1 mg/kg
administered intravenously every 4 to 6 hours or 0.2 to 0.5 mg/kg
administered intramuscularly every 6 to 8 hours as needed. Phenothi-
azine derivatives can cause hypotension and systemic vasodilation via
their alpha-adrenergic blocking effect and should only be given after the
puppy is well hydrated.
In puppies with intractable vomiting, metoclopramide and chlor-
promazine may be used together but only with caution, because the
potential for side effects increases. Puppies should be monitored for
restlessness, hyperactivity, bizarre behavior, or extreme drowsiness, and
if any of these signs occur, antiemetic therapy should be discontinued.
Intractable vomiting may respond to treatment with the new serotonin
antagonist odansetron (Zofran) administered intravenously at a rate of
0.1 to 0.15 mg/kg every 6 to 12 hours. Although the drug is highly
effective and safe, it is also expensive.
Anticholinergic drugs should not be administered to dogs with
canine parvovirus type 2 enteritis as they increase the potential for
gastric atony, ileus, and intussusception of an irritated bowel segment.
Dogs with intractable vomiting should always be evaluated for foreign
body obstruction or intussusception. Other causes of continued vomiting
include reflux esophagitis and acute pancreatitis. Reflux esophagitis may
be manifested by signs of drooling, nausea, and exaggerated swallowing
motions. Treatment involves administration of a systemic antacid (0.5
mg/kg of famotidine given intravenously or 2 mg/kg of ranitidine given
intravenously every 12 hours) and an oral suspension of sucralfate (1 g
982 MACINTIRE

dissolved in 10 mL of warm water every 8 hours). Ideally, the antacid

should be administered 1 to 2 hours after the sucralfate.

Immunotherapy

Bacterial endotoxemia is believed to be an important factor in the

terminal acute shock that occurs in severe cases of canine parvovirus
type 2 enteritis. A polyvalent antiserum of equine origin directed against
lipopolysaccharide endotoxin is available for use in small animals
(SEPTI-SERUM; Immvac, Columbia, M0). 4 It is recommended that the
product be administered over 30 to 60 minutes at a rate of 4.4 mL/kg
and diluted at a 1:1 ratio with intravenous crystalloid fluids.
Antiendotoxin should be most effective if it is administered before
antibiotic therapy, because circulating plasma lipopolysaccaride concen-
trations can increase dramatically following antibiotic kill off of gram-
negative bacteria. Puppies receiving the antiserum of equine origin must
be observed closely during administration for signs of anaphylaxis. If a
second administration of the antiserum is deemed necessary, it should
be given within 5 to 7 days following the initial treatment. After that
time, a severe immunological reaction is more likely to occur.
Anecdotal reports describe the use of convalescent serum (1.1-2.2
mL/kg administered intravenously or subcutaneously) collected from
canine parvovirus type 2-recovered dogs in an effort to provide passive
immunity to exposed or infected dogs. Research is needed to determine
the efficacy and safety of this practice .

. Aggressive Adjunctive Treatments

Corticosteroids and flunixin meglumine (Banamine) have shown

beneficial effects in animal models of septic and endotoxic shock if
administered early in the shock state. Potential beneficial effects of
corticosteroids include improved tissue perfusion, decreased leukocyte
margination, enhanced membrane stabilization, and reduced absorption
of endotoxins. Flunixin meglumine is a potent nonsteroidal anti-in-
flammatory analgesic agent that has antidiarrheal and antipyretic effects
and may reduce the severity of the intestinal inflammation associated
with canine parvovirus type 2 enteritis.
Both corticosteroids and flunixin meglumine can cause severe gas-
trointestinal ulceration as an unwanted side effect. Because of this possi-
bility, this author rarely uses these agents and reserves their use for
puppies exhibiting early signs of sepsis or endotoxemia, specifically,
fever, tachycardia, injected or muddy mucous membranes, and evidence
of gastrointestinal mucosal barrier breakdown. These agents should not
be administered until after the initial fluid bolus has been given. Dexa-
methasone sodium phosphate (2-4 mg/kg administered intravenously)
or flunixine meglumine (1 mg/kg administered intravenously) can be
 PEDIATRIC INTENSIVE CARE 983

administered at the clinician's discretion in select cases. Repeated doses

are not recommended as they increase the likelihood of deleterious
side effects.
Recently, recombinant granulocyte colony stimulating factor has
been used in puppies with severe leukopenia secondary to canine par-
vovirus type 2 enteritis.U The recommended dosage is 5 to 10 J.Lg/kg
per day administered subcutaneously. Puppies that respond generally
show an increase in white blood cell count within 24 hours. Unfortu-
nately, preliminary findings do not show an increased rate of survival
with the use of this product, and it is expensive.

Eradication of Intestinal Parasites

The presence of intestinal parasites has been identified as a factor

that can exacerbate canine parvovirus type 2 enteritis by enhancing
intestinal cell turnover and subsequent viral replication. Fecal samples
should be evaluated to identify Coccidia species, Giardia species, hook-
worms, roundworms, or whipworms. Appropriate oral therapy can be
initiated as soon as vomiting ceases, or ivermectin (250 J.Lg/kg adminis-
tered subcutaneously) can be given to non-Collie mix dogs.

Nutritional Support

Puppies with severe canine parvovirus type 2 enteritis may have an

extended course of hospitalization and may require nutritional support
to prevent catabolism and immune dysfunction associated with negative
nitrogen balance. Partial parenteral nutrition (PPN) does not supply the
puppy's entire nutrient needs but may provide short-term support for
puppies that are expected to recover soon. The advantage of PPN solu-
tions is that they can be delivered through a peripheral vein rather than
through a large central vein. PPN solutions are usually given at a
maintenance dosage (60 mL/kg/d), and additional fluid needs are met
with lactated Ringer's solution or Normosol-R as described earlier.
Procalamine (McGaw, Inc., Irvine, CA) is a commercial product
that contains 3% amino acids, 3% glycerol, and electrolytes. 10 A "home-
made" PPN solution can be made by adding 300 mL of 8.5% amino acid
solution to 700 mL of lactated Ringer's solution with 5% dextrose. The
addition of lipid emulsions is controversial. Although lipids are rich in
caloric content, they have been associated with immunosuppression
through impairment of reticuloendothelial function and reduction of
white blood cell phagocytosis. A common complication of PPN solutions
is catheter phlebitis, because the solutions are hypertonic. Catheters
must be placed aseptically, and the site must be monitored carefully for
redness, swelling, or pain. Solutions containing dextrose should be ta-
pered off gradually to prevent rebound hypoglycemia.
Most veterinarians offer water after vomiting has been absent for
984 MACINTIRE

12 to 24 hours. Early enteral nutrition is important to promote intestinal

regeneration. A liquid nutritional supplementation can be offered ini-
tially, or gruel can be made with an easily digestible high-carbohydrate
low-fat diet. The addition of glutamine powder (0.5 g/kg divided and
administered every 12 hours) to drinking water may promote gastroin-
testinal healing in puppies recovering from canine parvovirus type 2
enteritis. Various veterinary recovery diets are available for posthospital
care. The puppy may have temporary intestinal malabsorption and
protein-losing enteropathy until intestinal villi are repaired. Initial feed-
ing should consist of small amounts of an easily digestible low-fat diet
fed frequently. The normal diet is gradually reintroduced after appetite
and stools are returned to normal. Following recovery, immunity to
canine parvovirus type 2 enteritis lasts at least 2 years and may even be
lifelong.

CONCLUSIONS

Pediatric intensive care for a puppy or kitten includes having

knowledge about normal and abnormal vital signs, nursing care and
monitoring considerations, and probable diseases. Without immediate
treatment, most pediatric diseases, and specifically canine parvovirus
type 2 enteritis, may be rapidly fatal to puppies or kittens aged 6 weeks
to 6 months.

References

1. Barr SC, Bowman DD, Heller RL: Efficacy of fenbendazole against giardiasis in dogs.
Am J Vet Res 55:988, 1994
2. Barr SC, Bowman DD, Frongillo MF, et al: Efficacy of a drug combination of praziquan-
tel, pyrantel pamoate, and febantel against giardiasis in dogs. Am J Vet Res 59:1134,
1998
3. Carmichael LE, Greene CE: Canine herpesvirus infection. In Greene CE (ed): Infectious
Diseases of the Dog and Cat, ed 2. Philadelphia, WB Saunders, 1998, p 28
4. Dimmitt R: Clinical experience with cross-protective antiendotoxin antiserum in dogs
with parvoviral enteritis. Canine Pract 16:23, 1991
5. Giger U, Casal ML, Niggemeier A: The fading kitten syndrome and neonatal isoer-
ythrolysis. Proceedings of the American College of Veterinary Internal Medicine
15:208, 1997
6. Hoskins JD: Examination of the young dog and cat: Birth to four months. Proceedings
of the American College of Veterinary Internal Medicine 8:631, 1990
7. Hoskins JD: Canine viral enteritis. In Greene CE (ed): Infectious Diseases of the Dog
and Cat, ed 2. Philadelphia, WB Saunders, 1998, p 40
8. Hoskins JD: Update on canine parvoviral enteritis. Vet Med (Praha) 92:694, 1997
9. Hoskins JD, Mirza T, Taylor HW: Evaluation of a fecal antigen ELISA test for the
diagnosis of canine parvovirus. Journal of the American College of Veterinary Internal
Medicine 10:159, 1996
10. Kirby R: Cases, protocols, techniques, and procedures. In Proceedings of the Central
States Veterinary Conference, Kansas City, MO, 1997, p 104
11. Macintire DK, Smith-Carr S: Canine parvovirus. Part II. Clinical signs, diagnosis, and
treatment. Compend Contin Educ Pract Vet 19:291, 1997
 PEDIATRIC INTENSIVE CARE 985

12. Rewerts JM, Harrington DP, McCaw D, et a!: Effect of rhG-CSF administration on the
clinical outcome of neutropenic parvovirus-infected puppies. Journal of the American
College of Veterinary Internal Medicine 10:178, 1996
13. van der Linde-Sipman JS, van den lngh TSGAM, van Toor AJ: Fatty liver syndrome
in puppies. J Am Anim Hosp Assoc 26:9, 1990

Address reprint requests to

Douglass K. Macintire, DVM, MS
Department of Small Animal Surgery and Medicine
College of Veterinary Medicine
Auburn University
Auburn, AL 36849

APPENDIX 1
Medical Management of a Septicemic
Puppy or Kitten
I. External warming procedure
A. Use circulating hot water blanket, rice bags, or hot water bottles
B. Take at least20 to 30 minutes for gradual warming of the animal
C. Tum the animal every hour
D. Record rectal temperature every hour
II. Parenteral fluid therapy
A. Use balanced multiple electrolyte solution supplemented with
5% dextrose solution
B. Supplement the fluids with potassium chloride solution if plasma
potassium concentration is less than 2.5 mEq/L
C. Administer warm fluids slowly by intravenous or intraosseous
route
III. Glucose replacement therapy
A. Administer 5% dextrose solution intravenously or intraosseously
to effect
B. Administer 1 to 2 mL/kg of a 10% to 20% dextrose solution to
the animal that is profoundly depressed or having seizures
C. Maintain plasma glucose concentration at 80 to 200 mg/ dL for
normoglycemia
IV. Antimicrobial therapy
A. Collect bacterial culture samples (whole blood, urine, exudate,
and feces) before initiation of antimicrobial therapy
1. For blood culture, collect 1 mL of whole blood aseptically and
inoculate blood directly into enriched tryptic or trypticase soy
broth, dilute the whole blood 1:5 to 1:10 in enriched broth,
and examine broth for bacterial growth 6 to 18 hours later
2. For urine culture, collect urine by cystocentesis, and culture
it by standard methods
3. For exudate and fecal cultures, collect and culture by stan-
dard methods
986 MACINTIRE

B. Empirical treatment with antimicrobial agent(s) begins immedi-

ately after collection of appropriate bacterial culture samples
C. Adjust the dosage and dosing interval of antimicrobial agent(s)
· selected
D. Administer antimicrobial agent(s) by the intravenous or intraos-
seous route
V. Provide oxygen and nutritional therapy
A. Administer oxygen by mask or intranasal catheter to counteract
tissue hypoxemia
B. Encourage food intake once animal is normothermic and ade-
quately hydrated
VI. Monitor effectiveness of medical management
A. Observe for improvement in animal's general demeanor
B. Regularly assess the cardiopulmonary status (it is extremely easy
to overhydrate the ill puppy and kitten; thus, attentive monitor-
ing of breathing pattern is helpful for early recognition of overhy-
dration)
C. Weigh the animal three to four times a day to record weight gain
D. Observe for moistness of mucous membranes in assessing for
adequate hydration

APPENDIX 2
Suggested Protocol for Optimal Care of
Puppies with Canine Parvoviral
Enteritis
Initial Treatment Plan
1. Aseptically place an intravenous or intraosseous indwelling
catheter.
2. Obtain a minimum database, including packed cell volume,
total plasma solids, blood urea nitrogen, glucose, sodium, and
potassium, or even better, obtain a complete blood cell count
and serum chemistry profile.
3. Provide adequate fluids for reperfusion of vital organs using
lactated Ringer's solution or Normosol-R at a volume and rate
adequate to restore perfusion to the vital organ at a supranormal
level. If perfusion is poor, rapidly infuse a bolus of hetastarch
or dextran 70 at a rate of 20 mL/kg for initial resuscitation and
provide supplemental oxygen by nasal cannula. Do not use
hypertonic saline solution in this resuscitative process, as the
puppy is usually severely dehydrated.
4. Rehydrate with lactated Ringer's solution or Normosol-R at a
rate of 3 to 10 mL/kg/h initially until hydration is restored
over 4 hours. The maintenance rate is 2 to 3 mL/kg/h. Using
hetastarch or dextran 70, less fluid is lost into the gastrointestinal
 PEDIATRIC INTENSIVE CARE 987

tract, and the total volume of fluid required for rehydration is

approximately 50% of what is used when lactated Ringer's
solution or Normosol-R is used alone.
5. Administer intravenous antibiotics such as first-generation ceph-
alosporins. If the puppy appears to be septic, consider cephalo-
sporins, an aminoglycoside, and metronidazole once perfusion
has improved.
6. Palpate the puppy's abdomen at least every 4 hours to detect
intussusception.
7. Give nothing orally until vomiting is controlled.
8. Flush indwelling catheter with heparinized saline every 6 hours.
9. Warm or cool the puppy as deemed necessary once perfusion
has been restored.
10. Listen for bowel sounds. If decreased or no bowel sounds are
detected, put the puppy on metoclopramide via the intrave-
nous drip.
11. Control significant vomiting with metoclopramide or chlor-
promazine. If vomiting is persistent, place a nasogastric tube
and suction the gastric contents every 1 to 2 hours initially. Back
off the frequency of suctioning as directed by withdrawal of
gastric fluid. Use the nasogastric tube to give microenteral nutri-
tion.
12. Consider nutritional support early in the course of hospitaliza-
tion. Once the vomiting has been controlled, begin the puppy
on oral electrolyte solution supplemented with glucose. This
can be done by giving 2 to 10 mL of an oral electrolyte solution
by dosing syringe, or the oral electrolyte solution can be placed
in a fluid bag and dripped continuously into the nasogastric
tube at a rate of 2 to 10 mL/h. Once the puppy tolerates the
oral electrolyte solution for at least 4 to 6 hours, begin liquid
nutritional supplementation (such as Clinicare, Abbott Labora-
tories, Chicago, IL).
Monitoring Plan
1. Packed cell volume, total plasma solids, blood urea nitrogen,
glucose, sodium, and potassium every 4 to 6 hours. Supplement
and adjust fluid rate as deemed necessary.
2. Check perfusion parameters (mucous membrane color, pulse rate
and intensity, capillary refill time, blood pressure, central venous
pressure) every 2 to 4 hours, and resuscitate with fluids ±
hetastarch or dextran 70 as necessary.
3. Estimate quantity of vomiting, diarrhea, and urine output, and
record observations every 2 hours.
4. Monitor rectal temperature every 4 to 6 hours.
Maintenance Plan
1. Anticipate the problems of poor perfusion, severe dehydration,
hypokalemia, hypoglycemia, hypoproteinemia, aspiration pneu-
988 MACINTIRE

monia, sepsis/septic shock, intussusception, hyperthermia or hy-

pothermia, and massive fluid replacement requirements.
2. Maintain the albumin concentration above 2 mg/ dL, which likely
·needs to be done with fresh-frozen plasma on hospital days 2
to 4.
3. Administer hetastarch or dextran 70 at a rate of 20 mL/kg over
4 hours, decreasing lactated Ringer's solution or Normosol-R
during this time interval, on hospital days 2 and 3.