Page 460 - Clinical Small Animal Internal Medicine

428 Section 5 Critical Care Medicine

(ex. enrofloxacin 10–mg/kg q24h) or aminoglycosides Critical illness‐related corticosteroid deficiency
VetBooks.ir (ex. gentamicin 6–8 mg/kg q24h). (CIRCI) is a multifactorial deficiency in circulating
Once culture results are returned, the antibiotic spec-
cortisol in critically ill patients. This condition was
trum can be narrowed based on the microbial sensitivity
patients with refractory hypotension improved following
pattern. The duration of therapy required by septic first described when it was found that a subset of
patients is unknown and difficult to determine. A useful administration of physiologic doses of corticosteroids.
guide is to continue antibiotics therapy until one week Initially CIRCI was diagnosed by determining if patients
after clinical resolution of infection. responded appropriately to an adrenocorticotropic
hormone (ACTH) stimulation test. It was found, how-
ever, that even some patients with normal response to
Supportive Care ACTH stimulation benefited from corticosteroid sup-
plementation. This led to the recommendation for sup-
There are numerous additional components that are plementation of hydrocortisone in critically ill human
integral to the recovery of any critically ill animal. In patients with unresponsive hypotension regardless of
septic patients, nutrition, monitoring, and high‐quality ACTH stimulation results and in fact, ACTH stimula-
nursing care cannot be emphasized enough. Diligent tion tests are no longer considered necessary for the
monitoring is necessary for these animals as their status diagnosis of CIRCI.
can change quickly and with little notice. Heart rate, res- Corticosteroid administration should be considered
piratory rate, respiratory effort, blood pressure, hemo- only if fluids and vasopressors do not correct hypotension.
globin saturation, urine production, and blood glucose If used, the author prefers hydrocortisone 1–4 mg/kg/
should be checked at regular intervals. day divided q12h or once every 24 hours. Corticosteroids
Due to the catabolic state that occurs during sepsis,
nutritional support is a very important component of should be discontinued when the patient is no longer
vasopressor dependent.
treatment for these patients. In addition to helping pre-
vent hypoglycemia, nutrition allows for some anabolic
activity to occur and enables synthesis of components of
the immune system. In patients with severe sepsis or Prognosis
septic shock, dextrose supplementation is often neces-
sary to treat hypoglycemia. When possible, it is always The prognosis for septic shock is tremendously variable
preferable to provide these patients with enteral rather in both veterinary and human patients. Severity and
than parenteral nutrition. Early enteral nutrition reversibility of the underlying disease process as well as
(defined as consistent caloric intake within the first 24 the presence of comorbid conditions affect prognosis of
hours) has been shown to decrease length of hospitali- sepsis and septic shock. However, it must be recognized
zation in dogs with septic peritonitis. This can be that the farther along the septic spectrum (toward devel-
accomplished through voluntary alimentation by the opment of septic shock) that a patient goes, the worse
patient or through the use of feeding tubes. The use of the prognosis will be. Veterinary survival data are diffi-
feeding tubes is becoming more common in the man- cult to interpret as the practice of euthanasia complicates
agement of critically ill patients as more diets specifi- the evaluation of outcome, but survival rates of 50–60%
cally formulated to be used in small‐caliber tubes are are commonly reported. This correlates with studies
developed. While most feeding tube options require showing mortality rates of nearly 50% in humans with
heavy sedation or general anesthesia for placement, septic shock.
nasoesophagal tubes are small‐caliber tubes that can be Patients with sepsis or septic shock have significant
placed with little to no sedation and are therefore very disease and regardless of the cause, this condition is con-
useful for providing enteral nutrition to those patients sidered serious. Every effort should be made to set realis-
that are unwilling to eat voluntarily. Although patients tic owner expectations with the understanding that the
with sepsis as a rule have a negative energy balance, the prognosis is guarded to poor (especially in the case of
goal with nutritional support should be to meet the rest- septic shock). The financial and emotional cost of treat-
ing energy requirement. There is little to no evidence ing a dog with sepsis can be very high. The long‐term
that hyperalimentation improves clinical outcomes and prognosis for patients that survive sepsis and septic
it has been associated with development of complica- shock is unknown although good long‐term outcomes
tions including feeding intolerance and hyperglycemia. appear to be common.