An 8-year-old intact female Doberman Pinscher is rushed i...

This is Dr. Okafor. An 8-year-old Doberman Pinscher presenting with acute non-productive retching, abdominal distention, and collapse, with radiographs confirming GDV, is a critical emergency. Time is of the essence, and a systematic approach to both stabilization and surgery is paramount for a positive outcome.

Critical Steps for Initial Medical Stabilization

Upon arrival, my immediate focus is on stabilizing the patient's cardiovascular status and decompressing the stomach.

Vascular Access and Shock Fluid Therapy: This is the absolute priority. I need at least two large-bore (18-gauge or larger) cephalic catheters placed immediately. Aggressive shock fluid therapy with crystalloids (e.g., LRS, 0.9% NaCl) at a rate of 60-90 mL/kg/hr (titrated to effect) should commence. In cases of severe hypotension, I may consider a bolus of a synthetic colloid (e.g., VetStarch) at 5 mL/kg over 15-20 minutes, followed by a CRI.

Gastric Decompression: While fluids are running, concurrent gastric decompression is crucial to reduce pressure on the caudal vena cava, improve venous return, and alleviate respiratory compromise.

Orogastric Intubation: My preference, if possible. Measure the tube from the nose to the last rib, lubricate generously, and pass it gently. If resistance is met, do not* force it, as esophageal perforation is a severe complication.
* Trocarization: If an orogastric tube cannot be passed, or as an initial rapid decompression step, perform trocarization on the right side of the abdomen, caudal to the last rib, over the most tympanic area. This is a temporary measure but can be life-saving.

Pain Management: These patients are in significant pain. I'll administer an opioid such as methadone (0.2-0.5 mg/kg IV/IM q4-6h) or hydromorphone (0.05-0.1 mg/kg IV q4-6h) for analgesia and sedation, which also helps facilitate gastric tube passage.

Antibiotics: Prophylactic broad-spectrum antibiotics are indicated due to the risk of bacterial translocation and potential gastric wall necrosis. I'll administer cefazolin (22 mg/kg IV at induction, repeated q90 min intra-op) or ampicillin/sulbactam (30 mg/kg IV).

ECG Monitoring: GDV patients are prone to ventricular arrhythmias, often post-operatively but can be present pre-operatively. Continuous ECG monitoring is essential. While many arrhythmias resolve with gastric decompression and fluid resuscitation, sustained ventricular tachycardia may require anti-arrhythmic therapy (e.g., lidocaine, if on formulary, otherwise managed by ECC).

Blood Work: Baseline PCV/TS, lactate, electrolytes, and blood gas analysis provide critical information for guiding fluid therapy and assessing prognosis. A rising lactate despite resuscitation is a poor prognostic indicator.

Surgical Considerations During Gastropexy

Once the patient is reasonably stable (e.g., improving blood pressure, decreasing lactate, successful decompression), we proceed to surgery without undue delay.

Approach and Derotation: A full ventral midline celiotomy from xiphoid to pubis is required. The stomach is typically rotated clockwise (viewed from the surgeon's perspective, looking cranially), with the pylorus migrating ventrally and to the left, and the fundus dorsally and to the right. To derotate, I typically grasp the pylorus (which will be visible under the spleen or on the left side) and pull it ventrally and to the right, while simultaneously depressing the fundus.

Assessment of Gastric Wall Viability: After derotation, a thorough assessment of the stomach wall is critical. Look for areas of necrosis (dark blue, black, thin, non-peristaltic tissue, often in the fundus or greater curvature). If more than 50% of the stomach is necrotic, the prognosis is grave, and I'll have a frank discussion with the owner about euthanasia. Smaller, localized areas of necrosis require partial gastrectomy, ensuring removal of all non-viable tissue.

Splenic Assessment: The spleen is often displaced or congested. Assess its viability. If there's evidence of splenic torsion, thrombosis, or severe congestion that won't resolve, a splenectomy is indicated.

Gastropexy Technique: The goal is to permanently adhere the stomach to the right body wall to prevent future volvulus. My preferred technique is an incisional gastropexy. This involves incising the seromuscular layer of the pyloric antrum (right side of the stomach) and incising the transversus abdominis muscle and peritoneum on the right body wall. The two incisions are then sutured together using an absorbable monofilament suture (e.g., 2-0 or 3-0 PDS) in a simple continuous pattern. This creates a strong, broad adhesion.

Abdominal Exploration: After the gastropexy, a systematic exploration of the rest of the abdomen is performed to rule out any concurrent pathology or complications.

Post-Operative Care Discussion: I'll brief the ECC team on expected post-op complications, particularly the high risk of ventricular arrhythmias, and pain management strategies. We'll continue fentanyl CRI (2-5 mcg/kg/hr IV) and ketamine CRI (2-10 mcg/kg/min) intra-operatively and into the immediate post-operative period for robust analgesia.

The Doberman's breed predisposition and acute presentation underscore the urgency. Prompt and decisive action in both stabilization and surgery is the best course for this patient.