51 | How to give great care to your GDV patients without the fear!

PodcastGastroenterologyEmergency + Critical Care
Written By Laura Jones

Gastric dilation-volvulus (GDV) patients are often a real challenge to nurse.

 

They’re often severely unwell on presentation, and there is a high risk of postoperative complications. But there are also lots of skills we get to use when caring for these patients!

Giving them great care starts with understanding how GDVs occur and their impact on our patients, which is precisely what we’ll be diving into in this episode of the Medical Nursing Podcast.

What IS a GDV, and how does it affect our patient?

Gastric dilation and volvulus, or GDV, is an acute, life-threatening condition in which the stomach twists on its mesenteric axis, causing gas to accumulate and become trapped in the stomach and causing it to dilate.

It doesn’t stop there, though - the distended stomach decreases venous return to the heart, resulting in distributive shock, hypovolaemia and hypotension. The distended and stretched stomach causes poor blood flow to the gastric wall and ischaemic damage. Myocardial injury, arrhythmias, sepsis and even disseminated intravascular coagulation or DIC can result. 

Which patients get GDV?

GDV is a condition affecting dogs, and there are many risk factors associated with its development, including

  • Breed,

  • Chest confirmation,

  • Increasing age

  • Family history,

  • Previous history of gastric dilation,

  • Pre-existing gastrointestinal disease or gastric foreign body

  • Previous splenectomy,

  • Wolfing a meal,

  • Eating a large volume of food once daily,

  • Anxiety or stress,

  • Eating from a raised feeder.

It is most commonly diagnosed in large breed dogs, though any deep-chested breed is at increased risk of GDV - with the disease most commonly seen in:

  • German shepherds

  • Great Danes

  • Standard poodles

  • Saint Bernards

  • Dobermans

  • Irish setters

  • Weimaraners

We can also see it in Daschunds, Shar Peis, Basset Hounds and Cocker Spaniels.

What signs do these patients present with?

GDV patients usually present with an acute history of nonproductive vomiting, gagging and retching alongside restlessness or pacing, lethargy and weakness, ptyalism (hypersalivation) and abdominal distension.

Depending on the duration and severity of the GDV, patients may be relatively alert on presentation with minimal cardiovascular signs and mild abdominal distension, or collapsed and in severe decompensated distributive shock - which is the classic GDV we all tend to think of!

So your patient has a GDV - how will you stabilise them?

Initial triage and stabilisation is our first role in nursing the GDV patient. Our priorities are cardiovascular stabilisation, decompression and analgesia.

Let’s start with fluids.

We want to place the largest bore catheters in these patients - ideally one in each cephalic vein, since this will allow rapid and significant fluid resuscitation. We want to avoid using the saphenous veins since the venous return to the heart is compromised due to the distended stomach, meaning fluid delivered caudal to the stomach won’t get to the heart effectively.

After placing the catheters, collect 2-3ml of blood for an emergency blood panel before starting fluid therapy. In these patients, we tend to run:

  • Venous blood gas

  • PCV and total solids

  • Lactate (which is used as a prognostic indicator in GDV cases)

  • Electrolytes

  • Clotting times

  • And hold serum and EDTA for biochemistry and haematology at a later stage.

After this, begin giving a balanced crystalloid solution at an appropriate rate based on your patient’s perfusion parameters. In my clinic, we tend to use bolus therapy - measuring heart rate, blood pressure, CRT, mucous membrane colour and pulse quality, and then give crystalloid boluses until these parameters normalise.

Then there’s analgesia.

Once your IV catheter is in and your fluids are underway, the next step is to get analgesia on board. It’s important not to give this IM or SC as the poor perfusion in these patients means that their pain relief won’t work as quickly if given non-IV.

Usually, a pure opioid agonist is used; it’s essential to avoid non-steroidal anti-inflammatories due to the risk of GI ulceration, especially considering that these patients already have a degree of gastric ischaemia.

And then, it’s time to think about decompression.

Once your patient is cardiovascularly stable and analgesed, we’ll confirm that a GDV is present. This is achieved with X-rays, where a lateral view shows the classic ‘double bubble’ effect - where the pylorus rotates dorsally as the stomach twists.

After your patient’s GDV is confirmed, it’s time to think about decompressing that distended stomach.

This can be performed in two ways: by percutaneous trocarisation or by placing a stomach tube.

Gastric intubation is usually easier in milder GDV cases or ones where the stomach is less distended. In obvious or severe cases, trocarisation may be needed first; this procedure must be performed by the veterinary surgeon given the entry through the abdominal cavity into the stomach wall (which registered veterinary nurses in the UK are not permitted to do).

To intubate the stomach, the tube is measured and marked at the level of the last rib before a roll of bandage is placed in the mouth as a gag, and the tube is lubricated and advanced. Slow, gentle, constant pressure is used to advance the stomach through the torsed oesophagus and into the stomach. The tube is then taped in place to the patient’s muzzle (through the mouth gag) and the outer end placed in a bucket to allow gastric drainage.

Percutaneous gastric decompression is performed by inserting a large catheter through the clipped and aseptically prepared abdominal wall and into the stomach. Once the stylet is removed the gas should release under pressure from the catheter hub.

What else do we need to think about?

Other factors to consider when stabilising GDV cases include:

  • ECG monitoring: up to 40% of dogs with GDV have ventricular arrhythmias, so continuous ECG monitoring is recommended if you have access to it

  • Oxygen supplementation: patients with poor perfusion haven’t just got a disorder of fluid balance - they’re also not delivering oxygen to their tissues effectively, meaning they may benefit from oxygen supplementation

  • Plasma products: complications like disseminated intravascular coagulation (DIC), where patients consume their platelets and clotting factors and haemorrhage as a result, are recognised in GDV cases. Patients with prolonged clotting times may require plasma products to counteract this.

  • Dextrose: septic shock can also be seen in GDV cases, particularly if the gastric wall is ruptured. Hypoglycaemia is a common complication in septic patients, so if your patient is hypoglycaemic, dextrose supplementation may be required.

Once your patient has been initially stabilised and decompressed, they’re off to theatre for emergency surgery.

Here we’ll:

  • Reposition the torsed stomach

  • Evaluate the abdominal organs as blood flow to them is restored

  • Look for necrotic tissue that needs removing (sometimes a splenectomy or partial gastrectomy is required)

  • Perform a gastropexy, where the stomach wall is attached to the abdominal wall, preventing repeat torsion in the future. Gastropexy should always be performed, since the rate of GDV recurrence is high (55-75%).

And how do we care for these patients postoperatively?

Let’s talk medical treatment.

Much of our postoperative treatment is continuing medications from preoperative stabilisation:

  • Fluid therapy will continue based on the patient’s hydration and perfusion status, using a balanced crystalloid solution, and rates adjusted according to ongoing fluid assessment

  • Analgesia will continue using an appropriate opioid, and avoiding NSAIDs due to decreased gastric perfusion. Additional multimodal analgesic agents such as lidocaine and paracetamol can also be used where needed depending on the veterinary surgeon’s preference and individual patient

  • Gatroprotectants such as sucralfate and omeprazole may be used depending on the individual patient and their degree of gastric necrosis and ulceration

  • Perioperative antibiotics typically continue postoperatively due to the risk of bacterial translocation and sepsis in GDV patients

  • Antiemetics in nauseous or vomiting patients

  • Prokinetics in patients with postoperative ileus.

What about monitoring?

It’s no secret that there is a LOT to keep an eye on in these patients - they’re at risk of significant postoperative complications, such as ongoing distributive shock and hypotension, sepsis, and bleeding disorders.

There’s also reperfusion injury to contend with. When we restore blood (and therefore oxygen) flow to the ischaemic gastric wall and other abdominal organs, we can see a sudden release of toxic metabolites into the bloodstream. These target other cells, damaging them and causing cellular dysfunction and inflammation - risking acute kidney injury, hepatic failure and cardiac arrhythmias.

All of this means that one of our primary nursing considerations is monitoring, including:

  • TPR, MM, CRT,

  • Weight,

  • Blood pressure

  • ECG

  • Pain

  • Nausea and vomiting,

  • Fluid balance

  • Urine output

  • PCV and total solids

  • Venous blood gas

  • Coagulation times

  • Lactate

  • Renal parameters

  • Blood glucose

The frequency of these checks should be tailored to the individual patient and their stability.

And then there’s nutrition.

Getting good enteral nutrition into our medical patients early is vital - and our GDV patients are no exception. They should be offered food as soon as they are awake enough and cardiovascularly stable enough to be fed.

Ideally, an enteral feeding tube should be placed during surgery; if not, then a naso-oesophageal tube can be placed in recovery and is usually well tolerated. An energy-dense diet allows smaller feed volumes to be administered; meals should be small and frequent to prevent distending the stomach, fed at an appropriate percentage of the patient’s RER, depending on their gastric motility and duration of any anorexia present.

What else do we need to consider?

Alongside monitoring, fluid balance, pain, nausea, medications and nutrition, we need to add many other factors to our nursing plan, including general nursing care, managing IV catheters and other indwelling lines and devices, minimising stress in the hospital, and much more.

So there you have it! That’s my top take-home messages on confidently caring for patients with GDV. Yes, they’re often really intensive emergencies requiring prompt stabilisation and LOTS of ongoing care - but with the challenges this brings comes lots of opportunities for us to use our skills.

I’d love to know more about the cases you’ve been seeing and the skills you’ve been using when caring for these patients - how do you manage your GDV cases? Drop me a DM, and let’s chat! 

Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!

Thanks for learning with me this week, and I’ll see you next time!

References and Further Reading

Laura Jones
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