Stefano Cortellini

Plasma lactate concentrations in septic peritonitis: A retrospective study of 83 dogs (2007–2012)

Objective To determine if absolute plasma lactate concentration or lactate clearance in dogs with septic peritonitis is associated with morbidity or mortality. Design Retrospective cohort study from 2007 to 2012. Setting University teaching hospital. Animals Eighty-three dogs with septic peritonitis were included. Patients had at least 1 plasma lactate measurement during the course of the hospitalization. Results Sixty-four percent of the patients survived to discharge, 22% were euthanized, and 14% died during hospitalization. Plasma lactate concentration >2.5 mmol/L on admission (29% of the patients) was associated with mortality (P = 0.001). Median admission plasma lactate concentration (n = 81) was significantly different between nonsurvivors (2.5 mmol/L, range 0.5–8.4) and survivors (1.4 mmol/L, range 0.5–9.7; P = 0.007). Admission plasma lactate concentration >4 mmol/L yielded a sensitivity of 36% and a specificity of 92% for nonsurvival. The inability to normalize plasma lactate concentration within 6 hours of admission (n = 10/24) yielded a sensitivity of 76% and specificity of 100% for nonsurvival. Postoperative hyperlactatemia (plasma lactate concentration >2 mmol/L; n = 18/76) had a sensitivity of 46% and specificity of 88% for nonsurvival. Persistent postoperative hyperlactatemia (n = 11/18) had a sensitivity of 92% and a specificity of 100% for nonsurvival. Lactate clearance less than 21% at 6 hours (n = 20) had a sensitivity of 54% and specificity of 91% for nonsurvival. Lactate clearance less than 42% at 12 hours (n = 18) had a sensitivity of 82% and a specificity of 100% for nonsurvival. Conclusions Admission plasma lactate concentration and lactate clearance were good prognostic indicators in dogs with septic peritonitis.OBJECTIVE To determine if absolute plasma lactate concentration or lactate clearance in dogs with septic peritonitis is associated with morbidity or mortality. DESIGN Retrospective cohort study from 2007 to 2012. SETTING University teaching hospital. ANIMALS Eighty-three dogs with septic peritonitis were included. Patients had at least 1 plasma lactate measurement during the course of the hospitalization. RESULTS Sixty-four percent of the patients survived to discharge, 22% were euthanized, and 14% died during hospitalization. Plasma lactate concentration >2.5 mmol/L on admission (29% of the patients) was associated with mortality (P = 0.001). Median admission plasma lactate concentration (n = 81) was significantly different between nonsurvivors (2.5 mmol/L, range 0.5-8.4) and survivors (1.4 mmol/L, range 0.5-9.7; P = 0.007). Admission plasma lactate concentration >4 mmol/L yielded a sensitivity of 36% and a specificity of 92% for nonsurvival. The inability to normalize plasma lactate concentration within 6 hours of admission (n = 10/24) yielded a sensitivity of 76% and specificity of 100% for nonsurvival. Postoperative hyperlactatemia (plasma lactate concentration >2 mmol/L; n = 18/76) had a sensitivity of 46% and specificity of 88% for nonsurvival. Persistent postoperative hyperlactatemia (n = 11/18) had a sensitivity of 92% and a specificity of 100% for nonsurvival. Lactate clearance less than 21% at 6 hours (n = 20) had a sensitivity of 54% and specificity of 91% for nonsurvival. Lactate clearance less than 42% at 12 hours (n = 18) had a sensitivity of 82% and a specificity of 100% for nonsurvival. CONCLUSIONS Admission plasma lactate concentration and lactate clearance were good prognostic indicators in dogs with septic peritonitis.

Neutrophil Gelatinase‐Associated Lipocalin in Dogs With Sepsis Undergoing Emergency Laparotomy: A Prospective Case–Control Study

Background Neutrophil gelatinase‐associated lipocalin (NGAL) is an early indicator of acute kidney injury (AKI) in dogs and its use has not been evaluated in dogs with sepsis. Animals Fifteen dogs with sepsis requiring laparotomy (study dogs) and 10 dogs undergoing surgery for intervertebral disc disease (control dogs). Objective To determine whether NGAL increases in dogs with sepsis undergoing emergency laparotomy and whether it is correlated with development of AKI and survival. Methods Longitudinal study conducted at a referral teaching hospital. Serum neutrophil gelatinase‐associated lipocalin (sNGAL), urinary NGAL normalized to urinary creatinine concentration (UNCR), and serum creatinine concentration were measured at 4 time points (admission, after anesthesia, and 24 and 48 hours postsurgery). Development of AKI (increase in serum creatinine concentration of 0.3 mg/dL) and in‐hospital mortality were recorded. Linear mixed‐model analysis was employed to assess differences between groups over time. Mann–Whitney U‐test was performed for comparison of continuous variables between groups and Chi square or Fishers exact tests were used to assess correlation between discrete data. Results Serum NGAL and UNCR were significantly higher in study dogs across all time points (P = .007 and P < .001, respectively) compared with controls. Urinary NGAL normalized to creatinine in the study group was not significantly different between survivors (n = 12) and nonsurvivors (n = 3). Dogs that received hydroxyethyl starch had significantly higher UNCR across all time points (P = .04) than those that did not. Discussion—Conclusion Serum neutrophil gelatinase‐associated lipocalin and UNCR are increased in dogs with sepsis requiring emergency laparotomy. Additional studies are needed to evaluate its role as a marker of AKI in this population.

Ultrasonography in the diagnosis and management of cats with ureteral obstruction

Objectives The objective was to identify clinical or ultrasonographic results associated with ureteral obstruction or outcome in cats with azotaemia. Methods This was a retrospective cross-sectional study of cats with azotaemia (serum creatinine >180 μmol/l) that had ultrasonography of the urinary tract, ultrasound images available for review and received treatment for azotaemia. Cats with pre-renal azotaemia or urethral obstruction were excluded. Associations between clinical and ultrasonographic results and the dependent variables ‘tentative diagnosis of ureteral obstruction’, ‘pyelography positive for ureteral obstruction’ and ‘death in hospital’ were tested using binary logistic regression. Results In total, 238 cats satisfied the inclusion criteria. Median age was 7 years (range 2 weeks to 20 years), duration of clinical signs was 7 days (range 1 day to 6.3 years) and serum creatinine was 417 μmol/l (range 184–2100 μmol/l). Tentative diagnosis of ureteral obstruction in 92/238 (39%) cats was significantly associated with unilateral enlarged kidney on palpation, and dilated renal pelvis and calculi within the ureter on ultrasonography. Pyelography was performed in 49/92 (53%) cats (16 bilateral) with a tentative diagnosis of ureteral obstruction, and was positive for obstruction in 46/65 (71%) instances. No significant differences in ultrasonographic signs were found between cats with obstructed and non-obstructed ureters. Receiver–operating characteristic analysis of renal pelvic diameter as a diagnostic test for ureteral obstruction found an area under the curve not significantly different from 0.5. There was good agreement between results of radiography and ultrasonography for presence of urinary calculi (kappa 0.67). Treatment was medical in 171 (72%) cats and surgical (ureteral stent or by-pass device) in 67 (28%). Death in hospital was significantly associated with serum creatinine and presence of peritoneal fluid, but not with clinical diagnosis, ultrasonographic signs or treatment method. Conclusions and relevance Ultrasonography may be used to identify azotaemic cats at greatest risk of ureteral obstruction, but when using pyelography as the reference test ultrasonography appears to be inaccurate for diagnosis of ureteral obstruction.

Abdominal trauma in dogs 1. emergency investigation

This is the first article of a two-part series on abdominal trauma in dogs. This article focuses on the initial stabilisation and investigation of these canine patients, while the second article, to be published in a subsequent issue of In Practice, will discuss management of these patients. Although divided in this fashion, investigation and management are often concurrent in the emergency patient and this will be emphasised when particularly pertinent.

Comparison of ultrasonographic findings in cats with and without azotaemia

Objectives The objective of this study was to identify the renal ultrasonographic (US) findings most strongly associated with azotaemia in cats. Methods US findings in 238 cats with (serum creatinine >180 μmol/l) and 270 cats without azotaemia were compared in a retrospective case-control study. Cats with pre-renal azotaemia or urethral obstruction were excluded. Data extracted from the medical records included age, body weight and body condition score (BCS). Quantitative and subjective US findings were extracted from archived ultrasound images and contemporaneous reports. Results In non-azotaemic cats, mean ± SD renal length was 40.1 ± 5.5 mm. Male cats had larger kidneys than female cats (mean difference 5.2 mm; P = 0.001) and, on average, the right kidney was slightly larger than the left (mean difference 1.6 mm; P = 0.01). Azotaemic cats had significantly lower mean body weight and BCS, and greater mean age and renal pelvic diameter. Renal pelvic diameter was negatively correlated with urine specific gravity (ρ –0.44, P <0.001). Compared with non-azotaemic cats, there was no difference in mean renal length of azotaemic cats because the numbers with enlarged kidneys and small kidneys were similar. Radiologists’ subjective assessments of renal size differed markedly between azotaemic and non-azotaemic cats, with azotaemic cats more likely to be recorded falsely as having abnormally small or enlarged kidneys. US findings significantly associated with azotaemia were perinephric fluid (odds ratio [OR] 26.4, 95% confidence interval [CI] 3.4–207.7), small kidneys (OR 8.4, 95% CI 4.0–17.4), hyperechoic renal cortex (OR 4.1, 95% CI 2.2–7.6), loss of corticomedullary differentiation (OR 4.1, 95% CI 1.8–9.6), renal calculi (OR 2.7, 95% CI 1.4–4.9), enlarged kidneys (OR 2.5, 95% CI 1.2–5.5) and dilated renal pelvis (OR 1.6, 95% CI 1.3–1.9). Conclusions and relevance Perinephric fluid was the US finding most strongly associated with azotaemia in this study and may merit more emphasis than it has received to date. Bias in radiologists’ subjective assessments of renal size suggests that other subjective findings will also be biased.

Abdominal trauma in dogs 2. management

Trauma represents a big challenge for emergency doctors both in human and veterinary medicine. There have been great advancements in trauma medicine in people and these often provide an inspiration for veterinary surgeons. However, the vast differences in the facilities and finances available in human and veterinary medicine make the approach to trauma in both fields quite different. This article, the second in a two-part series, describes how to manage canine trauma patients. The first part focused on the initial investigation of canine abdominal trauma (Humm and Cortellini 2017). Although this article will mention guidelines in people, these should not be automatically applied to dogs, especially when more relevant evidence for this species exists.

Use of a modified thromboelastography assay for the detection of hyperfibrinolysis in a dog infected with Angiostrongylus vasorum

A dog presenting with scleral haemorrhage and neck pain was diagnosed with Angiostrongylus vasorum on direct faecal smear. Thromboelastography (with the addition of tissue plasminogen activator) revealed evidence of hypocoagulability and hyperfibrinolysis. The administration of fresh frozen plasma and tranexamic acid was associated with the resolution of a hypocoagulable and a hyperfibrinolytic state, as well as clinical improvement.

Investigating and managing abdominal trauma in dogs

Canine abdominal trauma is fairly commonly encountered in general practice, generally as a result of road traffic accidents. Physical examination is key to both recognition of the likely trauma (if it was unwitnessed) and also to allow accurate assessment of the patient. This should initially focus on the major body systems; that is, the cardiovascular, respiratory and neurological systems. Marked derangements in any of these systems can result in rapid deterioration and death, and so stabilisation of the patient should be prioritised over other less-pressing concerns. This focused clinical examination can be repeated to allow monitoring of the progression of the patient’s condition and assessment of the dog’s response to treatment. In the abdominal trauma patient, the cardiovascular system can be affected by blood loss, leading to tachycardia, pallor and alterations in pulse quality. The respiratory and neurological systems may be affected by concurrent traumatic injuries and also need careful assessment. Once the major body systems have been assessed and stabilisation (if required) is underway, a thorough examination should be completed. It is vital to know whether the patient has suffered from blunt or penetrating abdominal trauma; that is, whether there is an opening into the abdominal …

Description of the Use of Plasma Exchange in Dogs With Cutaneous and Renal Glomerular Vasculopathy

Cutaneous and renal glomerular vasculopathy (CRGV) is a rare disease affecting dogs, with a recent apparent increase in prevalence since 2012 in the UK. This disease is characterized by a vasculopathy affecting small vessels of the kidney and skin, leading to thrombotic microangiopathy. The underlying etiology remains unknown although clinicopathological and histological findings resemble features of certain forms of thrombotic microangiopathy in people, for which plasma exchange (PEX) is considered an important component of therapy. The objective of the present study is to describe the use of PEX as adjunctive treatment in dogs diagnosed with CRGV. A retrospective review of dogs diagnosed with CRGV between 2014 and 2016 treated with PEX was performed. Clinical records were reviewed and data relating to signalment, diagnostic tests and management strategies were summarized. Information and complications relating to PEX were recorded. Six dogs were diagnosed with CRGV (n = 2 ante-mortem, n = 4 post-mortem) and underwent PEX as part of their therapy. All dogs had cutaneous lesions and were azotemic with oliguria or anuria. All dogs underwent at least one PEX cycle; one dog had a single cycle PEX, three dogs two cycles PEX, and two dogs had one cycle PEX and one cycle of prolonged intermittent renal replacement treatment. Complications seen during PEX therapy included hypothermia (n = 4), tachycardia (n = 2), hypotension (n = 2), and hypocalcemia (n = 6). Two dogs survived to discharge, the remaining four dogs were euthanized. The positive outcome in two dogs treated with PEX despite the reported high mortality rate once acute kidney injury with oliguria/anuria occurs does not confirm success of this treatment. However, survival in two dogs that were initially oligoanuric highlights that further consideration and evaluation of PEX for this patient group is warranted for this specific disease. Additional studies are urgently needed to identify the underlying etiology of CRGV before more targeted therapies can be developed. Based on our findings, further evaluation of the role of PEX in this specific disease are warranted.

Magnetic resonance imaging and clinical findings in carbon monoxide intoxication in dogs

Prasentiert werden magnetresonanztomographische Befunde von drei Hunden nach Kohlenmonoxidvergiftung. Im ersten und zweiten Fall umfassten die Befunde Veranderungen im Nucleus caudatus auf beiden Seiten und im ersten Fall auch im Putamen als bilateral symmetrische, diffuse, homogene, in T2 und FLAIR hyperintense, in T1 hypointense Lasionen. Eine Kontrastmittelaufnahme zeigte sich nicht. Beim dritten Hund fanden sich sowohl multiple bilateral symmetrische in T2 und FLAIR hyperintense Lasionen als auch schlecht abgrenzbare Areale in der grauen Substanz im Frontal-, Parietal- und Okzipitallappen. Beide Colliculi caudales, Globus pallidus, Substantia nigra und der mittlere Thalamus stellten sich bilateral symmetrisch hyperintens in T2 und FLAIR dar und nach intravenoser Kontrastmittelapplikation kam es zu einer mittelgradigen Anreicherung.This paper presents magnetic resonance imaging (MRI) findings of three dogs after carbon monoxide intoxication. In the first and second cases, MRI changes were confined to both caudate nuclei and in the first case also to the putamen as bilaterally symmetric diffuse homogenous T2 and FLAIR hyperintense, T1 hypointense lesions. No contrast enhancement was seen. In the third case MRI revealed multiple areas of hyperintensity bilaterally on T2 and FLAIR as well as ill-defined areas within the frontal, parietal and occipital grey matter. The caudal colliculi, globus pallidus, substantia nigra and central area of the thalamus showed bilaterally hyperintense lesions on T2w and FLAIR with moderate enhancement after intravenous contrast administration.