Page 1544 - Cote clinical veterinary advisor dogs and cats 4th

780 Peritonitis, Septic

pyometra; wounds if penetrating abdominal • Abdominal ultrasound: identify free abdomi- • Exploratory laparotomy is warranted
trauma) nal fluid, mucocele, pyometra, GI foreign promptly after adequate stabilization.
VetBooks.ir Etiology and Pathophysiology • Coagulation profile (p. 1325): disseminated ○ Biopsy/removal of affected tissues and
body, neoplasia, granuloma/abscess
○ Repair of the lesion
intravascular coagulation complication of
intraoperative cultures
• Bacteria gain access to the abdominal cavity
most frequently by GI tract perforation,
although leakage or translocation from other septic peritonitis (p. 269) ○ Lavage
○ Closed-suction drainage (warranted in
internal sources (genitourinary tract, liver) Advanced or Confirmatory Testing almost all cases)
and external sources (penetrating trauma) • Abdominocentesis (p. 1056) and diagnostic ○ Open abdominal drainage if extensive
are possible. peritoneal lavage (DPL) are safe and reliable contamination is present
• Infection in the abdominal cavity causes for evaluating a patient suspected of having
inflammation, cellular infiltration (primarily septic peritonitis; however, with the emer- Possible Complications
macrophages and neutrophils), and fibrin gence of rapid abdominal ultrasonography • Disseminated intravascular coagulopathy
production. (FAST [p. 1102]), DPL is rarely performed. (p. 269)
• The peritoneum responds with increased ○ For patients with physical exam consistent • Multiple organ dysfunction syndrome
vascular permeability, and systemic with abdominal sepsis but without ascites, (p. 665)
manifestations of inflammation (e.g., fever, recheck of FAST scan after IV fluid • Dehiscence of prior repair (usually occurs
vasodilation, hyperdynamic shock) develop. resuscitation may reveal fluid that has 3-5 days after initial surgery)
• Electrolytes, plasma proteins, and erythrocytes extravasated during resuscitation. • Hypoalbuminemia
extravasate and are lost through third spacing • Diagnosis of septic peritonitis is based on
into the abdominal cavity. These losses may the finding of degenerate neutrophils with Recommended Monitoring
cause hypovolemia, hemoconcentration, and intracellular bacteria or fungal organisms in • Hydration and vascular volume status
metabolic derangements. the abdominal fluid (p. 1343). • Serum total protein, albumin, electrolyte,
○ An effusion glucose level of at least and glucose levels
DIAGNOSIS 20 mg/dL (1.1 mmol/L) less than that • Vital parameters, body weight, and blood
of peripheral blood is very specific and pressure
Diagnostic Overview moderately sensitive for septic effusion. • Renal function/urine output
The diagnosis of septic peritonitis, regardless of the ○ In dogs, abdominal fluid lactate • Pain management
underlying cause, is based on demonstration— > 2 mmol/L greater than the blood lactate
typically by cytologic evaluation of fluid level predicts abdominal sepsis. PROGNOSIS & OUTCOME
obtained by abdominocentesis—of intraperi- ○ Fluid should be submitted for bacterial
toneal toxic, degenerative neutrophils contain- culture and susceptibility. Prognosis variable, and worsens with organ
ing intracellular organisms. A diagnostic and failure. The reported mortality rate for dogs and
treatment algorithm is presented on p. 1439. TREATMENT cats with all-cause septic peritonitis is 27%-70%.
Differential Diagnosis Treatment Overview PEARLS & CONSIDERATIONS
• For abdominal pain or distention (i.e., acute Stabilize patient; identify and control source of
abdomen): acute pancreatitis, gastric dilation/ infection if possible (i.e., surgical correction) Comments
volvulus, intestinal or mesenteric torsion, • Gastric perforations may result in a large
pyometra, splenic, hepatic, renal, or GI Acute General Treatment volume of free intraabdominal air without
neoplasia, biliary tract obstruction, ureteral • Initial treatment directed toward stabilization fluid or fluid with low numbers of bacteria.
obstruction (pp. 21 and 1192) of the metabolic consequences of peritonitis. • Linear foreign bodies are particularly prone
• For suppurative abdominal effusion: feline • IV crystalloid fluids (up to 60-90 mL/kg), to causing GI perforation.
infectious peritonitis, acute necrotizing fresh-frozen plasma (10-15 mL/kg), packed • Severely dehydrated animals may not develop
pancreatitis, ischemia or thrombosis of GI red blood cells, or whole blood may be neces- significant volumes of abdominal effusion
tract, sterile bile peritonitis sary to maintain cardiac output (see p. 907). until after fluid resuscitation.
○ Maintain hematocrit above a target of • Consider nasogastric tube placement at the
Initial Database 21%. time of surgery to facilitate early enteral
• CBC, serum chemistry panel, urinalysis with • IV antibiotic therapy should be started as nutrition (p. 1107).
culture soon as sepsis is suspected. Broad-spectrum
○ Common findings on CBC include options: Technician Tips
neutrophilia or neutropenia with a left ○ Ampicillin or ampicillin/sulbactam + • Monitor closed-suction drain fluid for
shift, thrombocytopenia, and/or anemia. enrofloxacin 10 mg/kg IV q 24h in dogs, changes in character or volume.
Neutrophilic toxic changes are often 5 mg/kg IV q 24h in cats • A return of sepsis (e.g., from intestinal
noted. ■ Enrofloxacin should be diluted 1 : 9 in dehiscence) may be recognized by unex-
○ Metabolic derangements common saline and given over at least 10 minutes; plained tachycardia, hypotension, increased
(e.g., acidosis, electrolyte disorders, IV use is off-label in dogs and cats drain volume/ascites, or decline in patient
hyperglycemia/hypoglycemia) ○ Ampicillin 30 mg/kg IV q 6h or awareness.
○ Urine sample should be obtained by ampicillin/sulbactam 30 mg/kg IV q 8h
catheterization if possible; cystocentesis plus gentamicin 6 mg/kg IV q 24h or SUGGESTED READING
may inadvertently retrieve septic fluid or amikacin 15 mg/kg IV q 24h Bentley AM, et al: Comparison of dogs with septic
puncture a pyometra. ■ Aminoglycoside therapy only after the peritonitis: 1988-1993 versus 1999-2003. J Vet
• Abdominal radiographs may document GI animal is hydrated and producing urine. Emerg Crit Care 17(4):391-398, 2017.
foreign body obstruction, intraabdominal ○ Cefoxitin 30 mg/kg IV q 6-8h AUTHORS: Mary Aslanian, DVM, DACVECC; Danna M.
neoplasia, or free intraabdominal air or fluid. • Upgrade antibiotic selection for hospital- Torre, DVM, DACVECC
○ Free air highly suggestive/specific for septic acquired infections pending culture results. EDITOR: Benjamin M. Brainard, VMD, DACVAA,
peritonitis unless air is result of prior ○ De-escalate antibiotics based on culture DACVECC
abdominal surgery in the preceding weeks and sensitivity.

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