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Hypoxic-Ischemic Encephalopathy(HIE)

By: Dr. Mary Rose Paradis

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In order to diagnose the specific cause of your foal's mental dysfunction, your veterinarian will need to do some basic blood work. This includes a complete blood count, a blood glucose, a chemistry profile and an immunoglobulin level. The complete blood count is usually normal in the foal with HIE whereas in the septic foal there may be a very low or high white blood cell count. A low blood glucose can be found in any foal that has not eaten. This could occur in both a septic foal and a foal with HIE. If the mental disturbance is secondary a low blood glucose then correction of it with intravenous glucose will correct the problem.

A chemistry profile will report on the status of the foal's kidney, liver and muscle functions and his electrolyte levels. In white muscle disease the muscle enzymes will be very high.

Other tests that may be performed at a hospital facility may include a cerebral spinal fluid (CSF) analysis and a CT or MRI study. The CSF analysis would generally be normal in the foal with HIE but would contain an elevated white cell count and protein in the foal with septic meningitis. The CT or MRI may be helpful in the diagnosis of developmental abnormalities such as hydrocephalus.

The goals of veterinary care for foals with HIE are centered on three different needs of the foal – the neurologic needs, the immunologic needs and the supportive needs.

  • Neurologic needs. The treatment of the neurologic problem in the affected foals is focused on decreasing the seizure activity and decreasing the swelling in the brain. Seizure control is usually met through the use of anticonvulsants such as Valium and phenobarbital. Swelling of the brain (cerebral edema) if mild will correct itself with supportive fluids over a short period of time (1 to 2 days). Severe edema may need more aggressive therapy with drugs that decrease inflammation and fluid in the brain. These drugs include a substance called DMSO or a drug called mannitol. The use of these drugs is to try to draw fluid away from the brain at the same time that you are increasing the blood flow. It is important to maintain adequate blood flow to the brain or more hypoxic ischemic damage may occur.

  • Immunologic needs. Many of the foals with HIE do not stand and nurse at birth. In severe cases, the neurologic signs are present at birth. It is very important to remember that this foal needs to receive a good quality and quantity of colostrum. If this does not happen then the foal should be treated as if he has the potential to become septic. He should receive a plasma transfusion if he is over 12 hours of age and has not received colostrum. Your veterinarian will often give protective antibiotics.

  • Supportive needs. This is the biggest category of needs. Foals with HIE are unable to do anything for themselves and can be rather self-destructive in the process of their disease. It is important to provide the best supportive care in order to decrease the possible complications that can occur in a recumbent foal.

    Because these foals are not mentally aware of their surroundings and have the potential to have seizures, they should have a personal 24-hour attendant. Human restraint is the best method of preventing the foal from self-inflicted trauma. Even when they are not seizing, these foals often struggle and throw themselves around. The attendant may need to hold the foal in his lap in order to prevent the foal from hurting himself. Wrapping the foal's legs and making a head protector or helmet out of a piece of foam may further protect the foal.

    Foals with HIE will often cause trauma to their eyes during their seizure episodes. Careful examination of the eyes on a twice-daily routine is important. Your veterinarian may stain the eyes with a fluorescent dye to look for corneal ulcers or abrasions. Antibacterial ophthalmic ointments are often used as both a preventative and a treatment of corneal ulcers. Treatment should be applied every 4 to 6 hours.

    These foals do not have a suckle reflex, so all of their nutrition and fluids must be provided for them by nasogastric tube or intravenously. It is best to feed the foal by utilizing the intestinal tract if it is working. So in an HIE foal with no intestinal complications it is best to feed them with the nasogastric tube. This is a small diameter plastic tube that is inserted through the foal's nose and passed down his throat and esophagus into the stomach. Because the foal needs to be fed every 1 to 2 hours, the tube is generally secured in place with tape or a suture through his nostril. A foal that is about 100 pounds should be receiving a total of 9 to 12 liters of mare's milk or foal formula per day. This works out to approximately 375 to 500 mls of fluid per hour.

    If the foal is recumbent then he should be kept warm and dry. Urine scalding can create skin irritation. Frequent cleaning of the foal and application of baby powder will reduce the problem. Keeping the foal on a soft cushion is important in prevention of pressure sores. Even in deeply bedded stalls, the seizing foal will work his way down to the dirt floor. Pressure sores develop over the bony prominences such as the elbow, the hock, the shoulder, the stifle and the hip. It is important to palpate the skin over these areas daily. In the beginning the skin may feel slightly thicker. It then begins to take on the appearance of leather with a sharp demarcation between the normal and the affected skin. Soon the leathery skin will peel away leaving an open wound. Pressure sores can develop quickly if the foal is on a hard surface.

    Once pressure sores develop then they need to be cleaned and bandaged. The bandage will provide some protection and cushioning to decrease the severity of the sore. It is easy to bandage the lower limbs but difficult to keep a bandage or cushion on the stifle, hip or shoulder. This can best be accomplished by placing sutures around the wound and lacing umbilical tape through the suture to hold a pad of sterile gauze over the wound.

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