Page 1812 - Cote clinical veterinary advisor dogs and cats 4th

908 Sepsis and Septic Shock

• Serum biochemistry panel Acute General Treatment Nutrition/Diet
○ Azotemia may be prerenal, renal, or Antibiotic treatment: After stabilization, enteral nutrition (pp. 1106
VetBooks.ir ○ Elevated hepatocellular enzyme activi- possible. Empirically, consider broad-spectrum nutrition (p. 1148) to preserve gut function
• Give appropriate antibiotics IV as early as
and 1107) is considered superior to parenteral
postrenal.
coverage, including drugs effective against
ties from primary hepatopathy, hepatic
and integrity.
hypoperfusion, or bacterial showering from
a compromised gastrointestinal (GI) tract gram-positive aerobes (e.g., ampicillin, amoxi- Possible Complications
cillin + sulbactam, cefazolin), gram-negative
○ Hyperbilirubinemia aerobes (e.g., enrofloxacin, cefotaxime, ami- Organ dysfunction, thromboembolism, and
○ Hypoalbuminemia kacin), and anaerobes (e.g., metronidazole). intractable hypotension leading to cardiac arrest
○ Hypoglycemia (from consumption, • Single-agent, broad-spectrum antibiotic
changes in hepatic gluconeogenesis, and/ therapy can also be considered with drugs Recommended Monitoring
or insulin-like growth factor production) such as ampicillin ± sulbactam, meropenem, • Heart rate/rhythm, pulse quality, blood
• Blood lactate concentration > 2 mmol/L is or piperacillin + tazobactam. pressure, mentation, respiratory rate/effort,
an important marker of shock in dogs with • Antimicrobial treatment is adjusted per C&S and body temperature: continuously, hourly,
sepsis. results. or as indicated by case evolution
○ Hyperlactatemia often resolves quickly Hemodynamic stabilization: • Direct arterial blood pressure monitoring is rec-
after initiation of IV fluid therapy. • Treat shock: intravascular volume expansion ommended for patients receiving vasopressors
○ Hyperlactatemia despite fluid resuscitation with isotonic crystalloids (e.g., lactated Ringer’s • Continuous electrocardiogram (ECG
is a negative prognostic indicator. solution) is the mainstay of therapy; colloids [p. 1096]): all animals with arrhythmias
• Urinalysis with culture and susceptibility may be indicated for animals with hypoalbu- • Hematocrit, total protein, blood glucose,
(C&S) helps rule out urosepsis. Urine minemia. Fluid resuscitation should continue to lactate, and electrolyte concentrations: at
is obtained by cystocentesis for culture effect to normalize perfusion parameters, heart least daily
unless contraindicated (e.g., pyometra, rate, lactate, blood pressure, and mentation. • Urine output: at least q 4h
coagulopathy). • Vasopressor therapy for septic shock is • Body weight as a guide to fluid balance: at
• Coagulation testing (p. 1325) helps identify indicated if hypoperfusion persists despite least daily
coagulopathy. appropriate fluid therapy; consider dopamine • Fluid cytology from indwelling closed suction
• Point-of-care testing for infectious diseases 6-15 mcg/kg/min IV, norepinephrine drains: daily (a fresh sample of effusion
may include a vector-borne disease or parvo- 0.05-2 mcg/kg/min IV, or vasopressin should be acquired for cytology, versus
virus test in dogs, feline immunodeficiency 0.5-5.0 mU/kg/min IV. The Surviving Sepsis collection directly from the drain balloon)
virus/feline leukemia virus (FIV/FeLV) Guidelines in human medicine recommend
testing in cats norepinephrine as first-line vasopressor. PROGNOSIS & OUTCOME
• Diagnostic imaging, including chest and Vasopressors should ideally be given through
abdominal radiographs, computerized a central venous catheter (can be commenced • Mortality rates for sepsis in animals is
tomography, and/or ultrasound, is often through a peripheral catheter until a central 30%-70% and increases with increasing
necessary to elucidate the source of sepsis. line can be placed) and titrated based on number of dysfunctioning organs
direct arterial blood pressure monitoring to • Severity of underlying disease and provision
Advanced or Confirmatory Testing achieve a MAP ≥ 65 mm Hg. of early, intensive, and appropriate therapy
• Abdominocentesis (p. 1056) for abdominal • If decreased myocardial contractility is are important factors influencing mortality.
effusion and SIRS. Neutrophilic inflamma- present by echocardiography, dobutamine
tion with intracellular bacteria is diagnostic of 5-15 mcg/kg/min (dogs) or 1-5 mcg/kg/min PEARLS & CONSIDERATIONS
septic effusion. Ascitic fluid glucose 20 mg/ (cats) may be required; may cause seizures
dL (1.1 mmol/L) or more below the blood in awake cats. Comments
glucose level can support a diagnosis of Source control: Delayed recognition of sepsis (and specifically
abdominal sepsis. • As soon as possible after hemodynamic sta- delayed administration of antibiotics) can result
• Thoracocentesis (p. 1164) and cytologic bilization; may include drainage of abscesses in increased morbidity and mortality.
evaluation; bacterial culture to identify or thorax, surgical thoracotomy, celiotomy,
pyothorax in animals with pleural effusion arthrotomy, or an exploratory procedure Prevention
• Consider transtracheal wash or bronchoalveo- Support of organ function: • Treat infections aggressively before they
lar lavage (pp. 1073 and 1074) for cytologic • Supplemental oxygen (p. 1146) if hypoxemia; progress to sepsis.
analysis and culture if radiographic evidence mechanical ventilation (p. 1185) if PaO 2 • Take precautions to prevent nosocomial
of pneumonia < 60 mm Hg despite oxygen supplementation infection (e.g., good hand hygiene, use of
• Echocardiography (p. 1094) if source of • GI dysfunction: injectable antacids (e.g., aseptic technique for procedures, removing
sepsis is difficult to identify, especially with a famotidine, pantoprazole), antiemetics (e.g., indwelling devices as soon as possible).
new-onset heart murmur. Valvular vegetative maropitant, dolasetron/ondansetron, meto-
lesions suggest endocarditis. Echocardiogra- clopramide), and/or oral gastroprotectants Technician Tips
phy also is used for the diagnosis of secondary (e.g., sucralfate) Close patient monitoring, ideally with
myocardial dysfunction. • Oligoanuric acute kidney injury (p. 23) may continuous monitoring devices, is essential;
• Blood cultures are indicated in any critically require pharmacologic therapy (e.g., furose- any deterioration in patient status should be
ill animal whose source of sepsis remains mide, fenoldopam, or mannitol to encourage communicated to the veterinarian immediately.
elusive despite routine testing. urine output) or renal replacement therapy.
• Hemorrhage associated with DIC or the SUGGESTED READING
TREATMENT need for surgery in a patient with prolonged Lewis DH, et al: The immunopathology of sepsis:
clotting times is an indication for fresh-frozen pattern recognition, systemic inflammation, the
Treatment Overview plasma transfusion (p. 1169). It is not recom- compensatory anti-inflammatory response, and
Treatment involves early IV antibiotics, identify- mended to give plasma for prolonged clotting regulatory T cells. J Vet Intern Med 26(3):457-
ing and treating shock, early aggressive source times in the absence of clinical bleeding. 482, 2012.
control, and supportive care (particularly for Conversely, a hypercoagulable state, especially AUTHOR: Claire R. Sharp, BVMS, MS, DACVECC
organ dysfunctions). A step-by-step approach with evidence of thromboembolism, may be EDITOR: Benjamin M. Brainard, VMD, DACVAA,
to treatment is shown on p. 1448. an indication for anticoagulation. DACVECC
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