Page 1910 - Cote clinical veterinary advisor dogs and cats 4th

Systemic Inflammatory Response Syndrome 955.e5

DIAGNOSIS • Biochemical changes depend on the source evidence to treat nondiabetic patients
and extent of the inflammatory response. with insulin to control increased blood
VetBooks.ir The diagnosis of SIRS is based on the following ments are necessary to monitor progression • Antibiotics are indicated when infection is Diseases and Disorders
Diagnostic Overview
• Serial renal and hepatic biochemistry assess-
glucose levels in the context of SIRS, but
use dextrose-containing fluids judiciously.
toward MODS, regardless of the underlying
criteria:
disease.
• Urinalysis diagnosed or strongly suspected (p. 907).
○ Empirical broad-spectrum antibiotic
Canine Values ○ Urine sediment findings may indicate therapy to cover gram-positive, gram-
Parameter (≥2 Criteria) evidence of infection. Inactive sediment negative, aerobic, and anaerobic organisms
Temperature <100.6°F (38.1°C), does not exclude the need for diligent should be administered while cultures are
>102.6°F (39.2°C) workup to rule out sepsis. pending.
○ Granular casts may be seen and indicate ○ First-line antibiotic choices include
Heart rate >120 beats/min acute renal tubular injury. ampicillin, enrofloxacin, cephalosporins,
Respiratory rate >20 breaths/min • Bacteriologic culture and susceptibility and metronidazole, often in combination.
WBC (× 10 /mcL); <6000, >16,000; >3% (C&S) testing are indicated for animals with ○ Do not withhold antibiotic therapy while
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% bands SIRS. Sites for culture specimen collection C&S results are pending. Ongoing therapy
include should be adjusted as needed based on
○ Urine, even if infection is not readily these results once available.
evident on urinalysis ○ Culture samples should be collected as
Feline Values ○ Blood cultures should be considered if early as possible but not at the expense
Parameter (≥3 Criteria)*
an otherwise unidentifiable septic focus of delayed treatment.
Temperature <100°F (37.8°C), is suspected, particularly in patients with ○ When hospital-acquired infection
>104°F (40°C) a new or higher-grade heart murmur and is suspected, empirical therapy for
Heart rate <140, >225 beats/min suspicion of endocarditis. antimicrobial-resistant bacteria should be
○ Any third-space fluid accumulation (e.g., chosen, such as imipenem or amikacin,
Respiratory rate >40 breaths/min ascites, joint fluid, pericardial effusion) as based on a hospital antibiogram (see
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WBC (× 10 /mcL) <5000, >19,000 ○ Fine-needle aspirates of abdominal organs Drug Interactions).
(e.g., liver) • Other indications for antibiotic therapy
*Note differences specific to cats: ≥ 3 criteria, bradycardia included, include diseases with risk of bacterial translo-
wider temperature and white blood cell (WBC) ranges, and no Advanced or Confirmatory Testing
requirement for band neutrophils. cation across a compromised gastrointestinal
Diagnosis of SIRS depends on recognizing the (GI) mucosa (e.g., parvoviral enteritis).
constellation of signs and underlying diseases • In cases of clinically significant coagulopathy,
Differential Diagnosis associated with this syndrome. Currently, no treat with fresh-frozen plasma and/or fresh
Sepsis, defined as SIRS due to infection, is an test exists to definitively differentiate a patient whole blood (p. 269).
important differential. It is essential to treat suffering from infectious vs. noninfectious • Blood transfusions may be needed (p. 1169)
a septic or potentially septic patient with causes of SIRS. for hemorrhage or severe anemia.
antibiotics as soon as possible. • Supplemental oxygen (p. 1146) should be
TREATMENT provided when respiratory distress and/or
Initial Database hypoxemia is present (cyanosis, SpO 2 < 95%,
Main goal is to determine the source of the Treatment Overview PaO 2 < 80 mm Hg).
systemic inflammatory response: Three essential treatment principles exist for
• Point-of-care blood tests are ideal when management of SIRS: Nutrition/Diet
available. • Hemodynamic support After GI signs are controlled, consider an early
• Blood lactate concentration is helpful for • Identify, track, and support organ dysfunc- enteral nutrition plan. Parenteral nutrition
assessment of tissue perfusion. Serial lactate tion. Prompt antibiotic administration must must be considered when enteral feedings are
measurements can help guide fluid therapy be instituted in patients with sepsis or with contraindicated or not tolerated (p. 1148).
and resuscitation endpoints. high suspicion for sepsis.
• CBC • Treat underlying disease as soon as a diagnosis Behavior/Exercise
○ Leukocytosis or leukopenia ± a left shift is made. • Restrict activity according to patient stability
as indicated by the presence of band and needs associated with primary disease.
neutrophils (see table above) Acute General Treatment Recumbent patients should undergo passive
○ Thrombocytopenia (associated with a • IV fluids are the mainstay for treating range-of-motion exercise to promote periph-
consumptive coagulopathy) and hemo- hypovolemia and electrolyte abnormalities. eral circulation, prevent decubital ulceration,
concentration are also common findings. Individual patient needs are the most crucial and minimize dependent edema.
• Serum biochemistry panel guide for tailoring fluid therapy. • Encourage sternal recumbency to avoid aspi-
○ Electrolyte derangements reflective of ○ In general, isotonic crystalloids may be ration pneumonia and pulmonary atelectasis.
hypovolemia or third-space fluid loss. given IV in incremental bolus doses: Promote short periods of standing, walking,
○ Hypoalbuminemia: impaired hepatic syn- 10-15 mL/kg for cats, 20-30 mL/kg for and active range-of-motion exercise when
thesis, increased endothelial permeability dogs, with reassessment after the bolus possible during recovery.
○ Hyperglycemia or hypoglycemia: altered and a repeated bolus if endpoints that
carbohydrate metabolism, high levels of indicate improved perfusion are not met. Drug Interactions
circulating catecholamines • Supplement dextrose and electrolytes as • Patients with SIRS may receive multiple
○ Hyperbilirubinemia: cholestasis, hemolysis needed. medications, and drug interactions are
○ Elevated blood urea nitrogen (BUN) and ○ Large fluctuations in blood glucose have possible. Refer to therapeutic pharmacologic
creatinine concentrations: prerenal and/ been associated with a negative prognosis. guidelines for drug-drug compatibility and
or renal azotemia Target blood glucose should be ≤ 180 mg/ drug-fluid compatibility.
○ Elevated liver enzymes: perfusion altera- dL (≤10 mmol/L) and ≥ 70-80 mg/dL • Hypoalbuminemia may alter pharmacokinet-
tions (≥3.9-4.4 mmol/L). There is not strong ics of highly protein-bound drugs.

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