Lesley G. King

Prognostic Importance of Myocardial Injury in Critically Ill Dogs with Systemic Inflammation

BACKGROUND In noncardiac critical disease in humans, myocardial injury as detected by cardiac troponin I and T (cTnI and cTnT) has been linked to high intensive care unit (ICU) death independent of prognostic composite scoring. HYPOTHESIS Presence of myocardial injury predicts short-term death in critically ill dogs with systemic inflammation and provides additional prognostic information when combined with established canine prognostic composite scores. ANIMALS Forty-two dogs admitted to the ICU with evidence of systemic inflammation and no primary cardiac disease. METHODS Prospective cohort study. Blood samples were obtained at ICU admission for the measurement of cTnI and cTnT, C-reactive protein, and several cytokines. The acute patient physiologic and laboratory evaluation (APPLE) score and the survival prediction index were calculated within the first 24 hours of admission. Receiver operating characteristic (ROC) curves were used to examine the prognostic capacity of each biomarker and severity score. Multiple logistic regression analysis was performed to evaluate whether cardiac markers significantly contributed to severity scores. RESULTS Twenty-eight day case fatality rate was 26% (11/42 dogs). cTnI concentrations were (median [range]) 0.416 [0.004-141.5] ng/mL and cTnT concentrations were 13.5 [<13-3,744] ng/L. cTnI, cTnT, and the APPLE score were all significant prognosticators with areas under the ROC curves [95% CI] of 0.801 [0.649; 0.907], 0.790 [0.637; 0.900], and 0.776 [0.621; 0.889], respectively. cTnI significantly contributed to the APPLE score in providing additional prognostic specificity (P = .025). CONCLUSIONS AND CLINICAL IMPORTANCE Markers of myocardial injury predict short-term death in dogs with systemic inflammation and cTnI significantly contributes to the APPLE score.

Effect of Duration of Packed Red Blood Cell Storage on Morbidity and Mortality in Dogs After Transfusion: 3,095 cases (2001–2010)

Background Accumulating evidence suggests that transfusion of packed red blood cells (PRBCs) stored for >14 days is associated with increased rates of sepsis, multiple organ dysfunction, and mortality in human patients. Objective To determine if duration of PRBC storage has an effect on morbidity and mortality in dogs after transfusion. Animals Dogs admitted to the Matthew J Ryan Veterinary Hospital of the University of Pennsylvania. Methods A retrospective case review of dogs identified through blood bank logbooks that received PRBC transfusions (minimum, 5 mL/kg) between 2001 and 2010. Dogs were categorized according to major cause of anemia (eg, hemorrhage, hemolysis, ineffective erythropoiesis) for analysis. Results A total of 3,095 dogs received 5,412 PRBC units. Longer duration of PRBC storage was associated with development of new or progressive coagulation failure (P = .001) and thromboembolic disease (P = .005). There was no association between duration of PRBC storage and survival for all dogs overall. However, a logistic regression model indicated that for dogs with hemolysis, 90% of which had immune‐mediated hemolytic anemia, longer duration of PRBC storage was a negative risk factor for survival. For every 7 day increase in storage, there was a 0.79 lesser odds of 30 day survival (95% CI, 0.64–0.97; P = .024). Conclusions and Clinical Importance Duration of PRBC storage does not appear to be a major contributing factor to mortality in the overall canine population. However, longer duration of PRBC storage may negatively impact outcome in dogs with immune‐mediated hemolytic anemia, thus warranting further investigation with prospective studies.

Incidence of and risk factors for postoperative pneumonia in dogs anesthetized for diagnosis or treatment of intervertebral disk disease

OBJECTIVE To determine incidence of and risk factors for postoperative pneumonia in dogs anesthetized for diagnosis or treatment of intervertebral disk disease (IVDD). DESIGN Retrospective case-control study. ANIMALS 707 dogs that underwent general anesthesia for the diagnosis or treatment of IVDD between 1992 and 1996 or between 2002 and 2006. PROCEDURES Postoperative pneumonia was diagnosed if compatible clinical signs (cough or hypoxemia) and radiographic abnormalities (alveolar infiltrates) developed within 48 hours after anesthesia. To identify risk factors for postoperative pneumonia, findings for dogs that developed postoperative pneumonia between 2002 and 2006 were compared with findings for a randomly selected control group of unaffected dogs from the same population. RESULTS There were no significant differences in age, breed, body weight, sex, location of IVDD, or survival rate between the 2 time periods, but there were significant differences in the use of magnetic resonance imaging, computed tomography, and hemilaminectomy and in the percentage of dogs that developed postoperative pneumonia in the later (4.6%) versus the earlier (0.6%) years. Significant risk factors for postoperative pneumonia included preanesthetic tetraparesis, cervical lesions, undergoing magnetic resonance imaging, undergoing > 1 anesthetic procedure, longer duration of anesthesia, and postanesthetic vomiting or regurgitation. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that at this institution, the incidence of postoperative pneumonia in dogs anesthetized for diagnosis or treatment of IVDD had increased in recent years.

Antimicrobial therapy and aerobic bacteriologic culture patterns in canine intensive care unit patients: 74 dogs (January–June 2006)

OBJECTIVE Describe antimicrobial therapy and aerobic bacteriologic culture patterns in canine intensive care unit (ICU) patients in a university hospital. DESIGN Retrospective descriptive. SETTING A tertiary university referral hospital. ANIMALS Seventy-four canine ICU patients. INTERVENTIONS From January to June 2006 patient antimicrobial use, minimum inhibitory concentration (MIC) results, and clinical data were recorded. Appropriate antimicrobial use was analyzed relative to the time of culture submission and MIC results. MEASUREMENTS AND MAIN RESULTS Mean+/-SD age was 7.2+/-4.2 years. Median (range) length of ICU and hospital stays were 3 days (1-25 d) and 4 days (1-27 d), respectively. A total of 106 cultures were submitted; 47 of 106 (44%) cultures were positive for 70 isolates, including Escherichia coli (16/70 [23%]), Staphylococcus intermedius (7/70 [10%]), and Acinetobacter baumannii (5/70 [7%]). A multidrug resistant pattern occurred in 19 of 70 (27%) isolates, and was significantly more likely after 48 hours of hospitalization (P<0.001). Antimicrobials were administered before culture submission in 42 of 74 dogs (57%) and included enrofloxacin (23/42 [55%]), ampicillin (20/42 [48%]), and amoxicillin/clavulanic acid (8/42 [19%]). Antimicrobial choices were appropriate 19% of the time. While pending culture results, antimicrobials were administered to 67 of 72 (94%) dogs remaining alive, and were appropriate 75% of the time. The most common antimicrobials administered while awaiting culture results were ampicillin (52/67 [78%]), enrofloxacin (49/67 [73%]), and amikacin (9/67 [13%]). Post-MIC antimicrobials were appropriate 89% of the time. Of 45 dogs remaining alive, 17 (37%) continued to receive antimicrobials despite negative cultures. CONCLUSIONS Antimicrobial use was extensive in this patient population, but when available, MIC results were used to guide antimicrobial therapy. Many patients with negative cultures continued to receive antimicrobial therapy. Multidrug resistant bacteria were more likely in cultures taken after 48 hours of hospitalization.

Accuracy of a continuous glucose monitoring system in dogs and cats with diabetic ketoacidosis.

OBJECTIVE (1) To determine the ability of a continuous interstitial glucose monitoring system (CGMS) to accurately estimate blood glucose (BG) in dogs and cats with diabetic ketoacidosis. (2) To determine the effect of perfusion, hydration, body condition score, severity of ketosis, and frequency of calibration on the accuracy of the CGMS. DESIGN Prospective study. SETTING University Teaching Hospital. ANIMALS Thirteen dogs and 11 cats diagnosed with diabetic ketoacidosis were enrolled in the study within 24 hours of presentation. INTERVENTIONS Once BG dropped below 22.2 mmol/L (400 mg/dL), a sterile flexible glucose sensor was placed aseptically in the interstitial space and attached to the continuous glucose monitoring device for estimation of the interstitial glucose every 5 minutes. MEASUREMENTS AND MAIN RESULTS BG measurements were taken with a portable BG meter every 2-4 hours at the discretion of the primary clinician and compared with CGMS glucose measurements. The CGMS estimates of BG and BG measured on the glucometer were strongly associated regardless of calibration frequency (calibration every 8 h: r=0.86, P<0.001; calibration every 12 h: r=0.85, P<0.001). Evaluation of this data using both the Clarke and Consensus error grids showed that 96.7% and 99% of the CGMS readings, respectively, were deemed clinically acceptable (Zones A and B errors). Interpatient variability in the accuracy of the CGMS glucose measurements was found but was not associated with body condition, perfusion, or degree of ketosis. A weak association between hydration status of the patient as assessed with the visual analog scale and absolute percent error (Spearmans rank correlation, rho=-0.079, 95% CI=-0.15 to -0.01, P=0.03) was found, with the device being more accurate in the more hydrated patients. CONCLUSIONS The CGMS provides clinically accurate estimates of BG in patients with diabetic ketoacidosis.

Postoperative pulmonary complications in dogs undergoing laparotomy: frequency, characterization and disease‐related risk factors

Objective: To determine the frequency of postoperative pulmonary complications (PPCs) in dogs following laparotomy, characterize the nature of PPCs, and identify disease-related risk factors for PPCs in dogs. Design: Retrospective clinical study. Setting: University-affiliated small animal teaching hospital. Animals: One hundred and sixty-two dogs without preoperative pulmonary pathology that underwent laparotomy surgery. Interventions: None. Measurements and main results: Cases were evaluated for factors including patient signalment, preexisting disease, primary and ancillary surgical procedure(s), development of postoperative pulmonary disease, characteristics of perioperative hospitalization and therapy, and survival. Twenty-two percent of dogs in the study developed PPCs. PPCs included respiratory arrest (n=4), acute respiratory distress syndrome (ARDS) (n=3), pneumonia (n=8), hypoventilation (n=13), and transient hypoxemia (n=8). Dogs that developed PPCs had a significantly longer duration of oxygen therapy, longer duration of stay in intensive care unit (ICU), and decreased survival. Dogs with perioperative vomiting or regurgitation were more likely to develop PPCs. Animals that underwent exploratory laparotomy for biliary or septic peritonitis were also more likely to develop PPCs. Conclusions: PPCs occur in dogs following laparotomy and contribute significantly to the morbidity and mortality of these surgical patients. In this patient population, animals with vomiting, regurgitation, or peritonitis may be at a higher risk of developing PPCs. Animals with the identified risk factors should be monitored carefully postoperatively for development of pulmonary complications.

Treatment of Severe Adverse Cutaneous Drug Reactions With Human Intravenous Immunoglobulin in Two Dogs

Severe adverse cutaneous reactions were documented in two dogs with acute skin lesions and systemic signs after exposure to several oral and injectable drugs. Because of the high morbidity and mortality rates of many severe cutaneous drug reactions and a poor response to supportive care, wound management, and conventional immunosuppressive therapy, human intravenous immunoglobulin (IVIG) was infused on 2 consecutive days (1 g/kg per day) after informed consent was received. Human IVIG, with supportive care, resulted in rapid resolution of dermatological and systemic signs in both dogs; this treatment may be considered in other cases of severe cutaneous drug reactions.

Relationship between Doppler blood pressure and survival or response to treatment in critically ill cats: 83 cases (2003–2004)

OBJECTIVE To evaluate the relationship between Doppler blood pressure (DBP) and survival or response to treatment in critically ill cats. DESIGN Retrospective case series. ANIMALS 83 cats. PROCEDURES Medical records from cats admitted to the intensive care unit with at least 2 recorded DBP measurements were included in the study. Hypotension was defined as 1 or more DBP measurements d 90 mm Hg. Change in blood pressure, survival to hospital discharge, heart rate, rectal temperature, PCV, plasma pH, serum ionized calcium concentration, disease process, body weight, age, duration of hospitalization, and catecholamine treatment were also evaluated. RESULTS 39 cats were included in the hypotensive group, and 44 were consistently normotensive. Overall survival rate was 53% (44/83), with a significantly higher mortality rate in the hypotensive group (64% vs 32%). Among other variables, only low rectal temperature and low PCV were significantly associated with hypotension. Hypotensive cats with an increase in blood pressure of >or=20 mm Hg during hospitalization were more likely to survive to discharge (mortality rate, 69% vs 17%). CONCLUSIONS AND CLINICAL RELEVANCE Hypotensive cats had increased mortality rate with lower rectal temperatures and lower PCV, compared with normotensive critically ill cats. The implications of these findings with regard to treatment remain to be elucidated, but addressing these abnormalities may be appropriate.

Case-control study to evaluate risk factors for the development of sepsis (neutropenia and fever) in dogs receiving chemotherapy

OBJECTIVE-To identify risk factors for development of sepsis in dogs treated with chemotherapeutics and to evaluate the impact of sepsis on outcome. DESIGN-Case-control study. ANIMALS-Client-owned dogs with various cancers undergoing standard chemotherapeutic treatment at the University of Pennsylvania veterinary hospital. PROCEDURES-39 dogs with sepsis (cases) were identified through a search of the medical record database. Controls (n = 77) were randomly selected from dogs admitted during the same time period. Variables analyzed included patient demographics, tumor type, stage, remission status, treatment phase, chemotherapeutics used, and outcome. RESULTS-Dogs that weighed less and dogs with lymphoma were significantly more likely to become septic, compared with larger dogs or dogs with solid tumors. Septic dogs were also significantly more likely to have received doxorubicin (odds ratio [OR], 12.5; 95% confidence interval [CI], 2.4 to 66.0) or vincristine (OR, 9.0; 95% CI, 1.6 to 52.0) than controls. Of the 39 cases, 28 (71.8%) were in the induction phase of their protocol, and 19 of 39 (48.7%) became septic after receiving the chemotherapeutic drug for the first time. Median survival time of the cases (253 days) was not significantly different from that of the controls (371 days). CONCLUSIONS AND CLINICAL RELEVANCE-Dogs that weighed less were at increased risk for chemotherapy-induced sepsis. Tumor type and chemotherapeutic drug used were also important risk factors. These results may lead to the implementation of prophylactic measures, especially when doxorubicin or vincristine is used in the induction phase in small dogs with lymphoma.

Postoperative Management of the Emergency Surgery Small Animal Patient

Hypovolemia, hypothermia, and hypotension are common postoperative findings that predispose the critically ill patient to secondary complications. This patient population is especially vulnerable to sepsis, hypoxia, and immune dysfunction. Careful monitoring is essential for early recognition of potentially life-threatening physiologic derangements. Early and aggressive intervention may help minimize systemic insult before it progresses to acute respiratory distress syndrome, acute renal failure, disseminated intravascular coagulation, or multiple organ failure.