This example can be used as a reference for veterinary staff managing NSAID toxicities who may not have access to sophisticated machine TPE equipment or expertise but are attempting to manage a severe level of toxicity. However, this example demonstrates a comparable reduction in carprofen (57%) to a previously reported use of machine TPE that documented a 51% reduction. It is not possible to attribute the success of this recovery solely to the use of manual TPE due to the use of additional interventions. In this case study, the veterinary staff successfully performed manual TPE alongside routine decontamination techniques with minimal complications. Other potential complications can include vomiting, hypocalcemia, systemic clotting, infection, and technical problems. The patient experienced hematochezia (bloody stools) and hypovolemia as a complication of manual TPE but was treated appropriately and made a full recovery. Manual TPE involves removing a safe percentage of whole blood, centrifuging the sample to remove the drug-containing plasma, and returning the remaining cellular components to the patient along with replacement volume of crystalloids. A downside of manual TPE is that it is time and labor consuming. Manual TPE is a potential alternative option when machine TPE is not accessible because it is technically simpler and uses commonly found equipment. However, its use is limited by access to laboratory equipment and expertise only found at select hospitals and specialty locations. Machine TPE is already proven as an effective adjunct for NSAID toxicity treatment. The combination of these therapies resulted in a 57% reduction in carprofen levels. The decision to begin manual TPE was based on the severity of the toxicity. Treatment escalated to include activated charcoal, lipid emulsion, and supportive care. Upon presentation to the veterinarian, the patient received 2 doses of apomorphine in an unsuccessful attempt to force emesis. When consumed at high doses, carprofen may cause significant neurologic, gastrointestinal, renal, and hepatic toxicities. Carprofen is a non-steroidal anti-inflammatory drug (NSAID) that is a selective inhibitor of cyclooxegenase-2 (COX-2) which is responsible for prostaglandin synthesis involved in inflammation. When consumed at the proper dosage, carprofen is a safe, effective treatment for canine osteoarthritis and general pain control. This case study presented in the Journal of Veterinary Emergency and Critical Care 1 demonstrates a successful treatment of carprofen toxicity combining recommended agents and the less proven strategy of manual therapeutic plasma exchange (TPE). She consumed 4463 mg (223mg/kg), which is approximately 50 times the recommended dosing at 4.4mg/kg. After receiving an appropriate 37.5 mg dose of carprofen for suspected osteoarthritis the night before, a 12-year-old female Pembroke Welsh corgi ingested the contents of the entire bottle.
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