Clinical, laboratory, and hemostatic findings in cats with naturally occurring sepsis

Current and Future Practice in the Diagnosis and Management of Sepsis and Septic Shock in Small Animals

This review will explore the current knowledge, beginning with the physiologic underpinnings and delve into the evolving scientific literature, encompassing the inextricably intertwined diagnosis and management of sepsis and septic shock in human and small animal patients. Sepsis is a significant cause of morbidity and mortality in patients, mostly for failure to recognize or treat promptly and adequately. Diagnosis is based on the individual patient, clinical context, and clinical acumen. High quality supportive care in the intensive care unit setting is patient-centered with intensive nursing, focused on physiologic systems, goal-oriented, and multi-disciplinary with a team-based approach to patient care.

Serum biochemical changes in cats with naturally acquired feline cytauxzoonosis

OBJECTIVE

The geographical distribution of feline cytauxzoonosis is expanding in the US. Clinical signs of feline cytauxzoonosis, including lethargy, anorexia, and icterus, are similar to hepatic lipidosis and cholangiohepatitis. Hematologic and serum biochemical abnormality patterns may assist practitioners in prioritizing feline cytauxzoonosis as a differential diagnosis over hepatic lipidosis and cholangiohepatitis.

SAMPLE

Hematology and serum biochemical profiles of cats with naturally acquired feline cytauxzoonosis, hepatic lipidosis, or cholangiohepatitis.

PROCEDURES

Retrospective search and analysis of the Kansas State Veterinary Diagnostic Laboratory or Kansas State University Veterinary Health Center records between January 2007 and June 2018 for cats with cytauxzoonosis, hepatic lipidosis, or cholangiohepatitis.

RESULTS

Patients with acute feline cytauxzoonosis presented with frequent nonregenerative anemia (20/28 [71%]), leukopenia (23/28 [82%]), thrombocytopenia (23/23 [100%]), hyperbilirubinemia (27/28 [97%]), hypoalbuminemia (26/28 [93%]), reduced (18/28 [64%]) or low normal (10/28 [36%]) serum ALP activity, and hyponatremia (23/28 [82%]). Reduced ALP activity was unique to cats with feline cytauxzoonosis relative to hepatic lipidosis and cholangiohepatitis. No correlation between the severity of anemia and the magnitude of hyperbilirubinemia was identified in feline cytauxzoonosis patients.

CLINICAL RELEVANCE

The combination of nonregenerative anemia, leukopenia, thrombocytopenia, hyperbilirubinemia, and reduced serum ALP activity in icteric cats may increase the clinical suspicion, but is not pathognomonic, for acute feline cytauxzoonosis. Hematologic and serum biochemical abnormalities of naturally acquired feline cytauxzoonosis are like those reported with feline bacterial sepsis. Blood smear evaluation for intraerythrocytic Cytauxzoon felis piroplasms, tissue aspirates for schizont-laden macrophages, and/or molecular testing are required to diagnose feline cytauxzoonosis.

Effectiveness of a Modified Administration Protocol for the Medical Treatment of Feline Pyometra

Pyometra is a common uterine disease of dogs and cats, typical of the luteal phase. Traditionally, ovariohysterectomy was considered the elective treatment for pyometra, but in some cases, such as breeding subjects or patients with a high anesthesiologic risk, medical treatment is preferred. Aglepristone is a progesterone receptor blocker and its use proved to be effective for the medical treatment of pyometra in bitches and queens. The aim of this work is to report the effectiveness, in the feline species, of a modified aglepristone administration protocol. Five intact queens were referred to veterinary care centers for pyometra. Aglepristone (15 mg/kg) was administered at D0, D2, D5, and D8, as described by Contri and collaborators for dogs. An antibiotic treatment (marbofloxacin, 3 mg/kg) was associated, and uterine conditions were checked with regular ultrasonographic exams. The uterus returned to its normal condition 10 days after starting the treatment and no adverse effects were reported. After treatment, three queens had an uneventful pregnancy. Even if the treated group was restricted and homogeneous, the proposed modified protocol proved to be useful and promising for the medical treatment of pyometra in cats; further studies are planned to verify its effectiveness in the long-term prevention of recurrence.

Intestinal dehiscence and mortality in cats undergoing gastrointestinal surgery

OBJECTIVES

The aim of this study was to determine the incidence of and risk factors for both gastrointestinal (GI) incisional dehiscence and mortality in a large cohort of cats undergoing GI surgery. We hypothesized that cats with preoperative septic peritonitis (PSP), systemic inflammatory response syndrome (SIRS) or sepsis would have higher GI dehiscence and mortality rates than unaffected cats.

METHODS

A medical records search identified cats with surgically created, full-thickness incisions into their stomach, small intestines or large intestines. Preoperative data, including signalment, clinical signs, comorbidities, surgical history, current medications, presenting physical examination findings, complete blood counts and serum biochemistry values, were collected. It was determined whether or not cats had PSP, SIRS or sepsis at admission. Intraoperative data, final diagnosis and postoperative variables such as vital parameters, bloodwork and (if applicable) the development of GI dehiscence or mortality were noted. Postoperative follow-up of at least 10 days was obtained in survivors.

RESULTS

In total, 126 cats were included. One cat developed GI dehiscence following complete resection of a jejunal adenocarcinoma. Twenty-three cats (18.2%) died within 10 days of surgery. Cats with PSP (P = 0.0462) or that developed hypothermia 25-72 h postoperatively (P = 0.0055) had higher odds of mortality in multivariate analysis. Cats with PSP had 6.7-times higher odds of mortality than cats not diagnosed with PSP.

CONCLUSIONS AND RELEVANCE

In cats receiving GI surgery, the incidence of GI incisional dehiscence was <1%. Cats with PSP had a higher likelihood of mortality. SIRS was a common finding in cats with septic peritonitis, but was not associated with mortality. Postoperative mortality during the home recovery period might be significant in cats. Future studies evaluating postoperative mortality in cats should consider extending the research period beyond the date of discharge.

2022 Update of the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) Domain 1- Defining populations at risk

OBJECTIVES

To expand the number of conditions and interventions explored for their associations with thrombosis in the veterinary literature and to provide the basis for prescribing recommendations.

DESIGN

A population exposure comparison outcome format was used to represent patient, exposure, comparison, and outcome. Population Exposure Comparison Outcome questions were distributed to worksheet authors who performed comprehensive searches, summarized the evidence, and created guideline recommendations that were reviewed by domain chairs. The revised guidelines then underwent the Delphi survey process to reach consensus on the final guidelines. Diseases evaluated in this iteration included heartworm disease (dogs and cats), immune-mediated hemolytic anemia (cats), protein-losing nephropathy (cats), protein-losing enteropathy (dogs and cats), sepsis (cats), hyperadrenocorticism (cats), liver disease (dogs), congenital portosystemic shunts (dogs and cats) and the following interventions: IV catheters (dogs and cats), arterial catheters (dogs and cats), vascular access ports (dogs and cats), extracorporeal circuits (dogs and cats) and transvenous pacemakers (dogs and cats).

RESULTS

Of the diseases evaluated in this iteration, a high risk for thrombosis was defined as heartworm disease or protein-losing enteropathy. Low risk for thrombosis was defined as dogs with liver disease, cats with immune-mediated hemolytic anemia, protein-losing nephropathy, sepsis, or hyperadrenocorticism.

CONCLUSIONS

Associations with thrombosis are outlined for various conditions and interventions and provide the basis for management recommendations. Numerous knowledge gaps were identified that represent opportunities for future studies.

Classification of Septic Shock Phenotypes Based on the Presence of Hypotension and Hyperlactatemia in Cats

Background: Three different phenotypes of septic shock based on changes in blood pressure and lactate are recognized in people. Dysoxic shock, representing the combination of fluid-refractory hypotension and hyperlactatemia, is characterized by greater disease severity and mortality compared to cryptic shock (hyperlactatemia alone) and vasoplegic shock (hypotension with normal blood lactate). Little is known about septic shock and specifically its phenotypes in cats. Objective: To analyze the characteristics and prognostic implications of three septic shock phenotypes in cats with sepsis. Methods: Cats with septic shock were prospectively included. Septic shock was defined by the presence of hypotension (mean blood pressure <60 mmHg) requiring vasopressor support and/or persistent hyperlactatemia (>4 mmol/L) and classified in three subgroups: dysoxic shock, vasoplegic shock and cryptic shock. Clinical and clinicopathological variables including APPLE_fast and APPLE_full scores, occurrence of multi-organ dysfunction syndrome (MODS; presence of at least two dysfunctional organs simultaneously) and outcome were compared among subgroups. Cats with sepsis showing normal blood pressure and lactate concentrations hospitalized during the study period were included as uncomplicated sepsis, and compared to cats with septic shock for selected variables. Length of hospital stay and mortality were evaluated in the whole study population. Odds ratios for mortality were calculated using logistic regression analysis. Significance was set at P < 0.05. Results: The study enrolled 48 cats with uncomplicated sepsis and 37 cats with septic shock (dysoxic shock n = 17; vasoplegic shock n = 11; cryptic shock n = 7). Cats with dysoxic shock had significantly higher APPLE_fast and APPLE_full scores compared to vasoplegic and cryptic shock. Mortality rates were not significantly different among cryptic (57%), dysoxic (65%) and vasoplegic shock (91%), while MODS occurrence was significantly lower in cats with cryptic shock (57%) compared to patients affected by dysoxic (94%) and vasoplegic (100%) shock. Cats with septic shock had higher frequency of MODS and greater mortality rate than cats with uncomplicated sepsis. Conclusion: Despite similar in-hospital mortality, cats with dysoxic and vasoplegic shock are characterized by having higher occurrence of multi- organ dysfunction compared to cats affected by cryptic shock. Results from this study suggest novel means of identifying high-risk subgroups of septic cats.

Evaluation of short-term risk factors associated with dehiscence and death following full-thickness incisions of the large intestine in cats: 84 cases (1993-2015)

OBJECTIVE

To evaluate short-term risk factors associated with dehiscence and death in cats undergoing full-thickness large intestinal incisions.

ANIMALS

84 client-owned cats that had undergone full-thickness large intestinal incisions and for which information regarding outcome through postoperative day 7 was available.

PROCEDURES

Medical records from 4 veterinary teaching hospitals were reviewed. For cats that met the inclusion criteria, signalment, history, laboratory test results, surgical and medical procedures, perioperative complications, and outcome were analyzed. A Fisher exact or Wilcoxon rank sum test was used to identify individual variables associated with dehiscence of intestinal incisions or patient nonsurvival to hospital discharge or both.

RESULTS

84 cats met the inclusion criteria. The overall dehiscence and survival to hospital discharge rates were 8.3% (7/84 cats) and 94% (79/84 cats), respectively. Factors associated with dehiscence and nonsurvival to hospital discharge included presence of band neutrophils, performance of partial colectomy with colonic resection and anastomosis, administration of blood products, postoperative cardiopulmonary arrest, and incisional inflammation or infection. Factors associated with nonsurvival to hospital discharge only included low serum globulin concentration, repair of colonic trauma or dehiscence, and postoperative colonic dehiscence. Factors associated with dehiscence only included hypoalbuminemia, renal dysfunction, administration of blood products or > 2 classes of antimicrobials, and intra-abdominal fecal contamination.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that intestinal dehiscence and mortality rates associated with large intestinal incisions in cats may be higher than previously proposed, although the risk of either outcome was still low. Factors suggestive of systemic illness were associated with colonic dehiscence or death, and focused prospective studies of risk factors are warranted.

Decreased antithrombin activity and inflammation in cats

OBJECTIVES

The objective of this study was to determine if inflammatory markers are associated with antithrombin activity in cats.

METHODS

For a retrospective population of 231 cats admitted to a referral hospital, antithrombin activity was classified as decreased (n = 77), intermediate (n = 97) or in the upper quartile (n = 57). Odds ratios (ORs) were calculated for an association between decreased or upper quartile activity and hypoalbuminemia, hyperfibrinogenemia, band neutrophilia and toxic change. Multiple logistic regression was performed to determine if an association between band neutrophilia and decreased antithrombin activity was independent of decreased hepatic synthesis, consumptive coagulopathy or protein loss.

RESULTS

Cats with decreased antithrombin activity were more likely than cats with intermediate-to-upper quartile activity to have band neutrophilia (OR 2.85, P = 0.0050), hypoalbuminemia (OR 12.1, P <0.0001) or toxic neutrophils (OR 4.47, P <0.0001). Cats with antithrombin activity in the upper quartile were less likely than those with intermediate-to-low activity to have hypoalbuminemia (OR 0.31, P = 0.0023) or toxic neutrophils (OR 0.44, P = 0.033). In a regression model that included other mechanisms for decreased antithrombin, band neutrophilia remained associated with decreased antithrombin activity (adjusted OR 2.62, P = 0.013).

CONCLUSIONS AND RELEVANCE

Contrary to previous studies suggesting antithrombin is a feline positive acute phase protein, this study demonstrates an association between decreased antithrombin activity and inflammation. Further studies are needed to determine the mechanistic basis of this association.

Leukocytes Ratios in Feline Systemic Inflammatory Response Syndrome and Sepsis: A Retrospective Analysis of 209 Cases

Simple Summary

Feline sepsis is a life-threatening syndrome in which blood diagnostic and prognostic markers are limited. We investigated the differences in neutrophil-to-lymphocyte ratio and other white-blood-cell ratios between healthy and sick cats (systemic inflammation (SIRS) and/or septic cats) and then the use of these ratios as prognostic markers. This study included 76 healthy cats (blood-donors), 54 cats with SIRS and 79 cats with sepsis. A cat with an NLR > 4.53 had a 44-fold chance to have SIRS or sepsis, although only BLR and BNLR were different between SIRS and sepsis groups. The NLR has been shown as a prognostic marker in sick cats. This is a novel investigation about leukocyte ratios in the cat, and the NLR may be used as a prognostic parameter in cats with SIRS or sepsis, and BLR and BNLR demonstrate themselves as promising tools in differentiating SIRS from sepsis.

Abstract

Sepsis is a challenging condition in which hematological prognostic and diagnostic markers in cats are limited. The aims of this study were to test if there are any differences in leukocyte ratios (NLR, BLR and BNLR) between healthy, SIRS and septic cats (sick cats), and if, within sick cats, NLR, BLR and BNLR may be prognostic markers. A retrospective medical database study included 76 healthy cats (blood-donors), 54 SIRS and 79 septic cats. SIRS group was defined if cats fulfilled SIRS criteria. Sepsis was confirmed with an infectious focus on cytology or a positive culture for bacterial infection. Leukocyte ratios were compared among the three study groups and between survivors and non-survivors in sick cats. NLR resulted significantly higher in the sick group compared to healthy cats (p < 0.0001), although NLR was not different between SIRS and sepsis. An NLR > 4.53 had a sensitivity of 76% and a specificity of 93.4% to detect SIRS/sepsis (OR 44.8 95%CI 17–107). Only BLR and BNLR were significantly different between SIRS and sepsis. NLR was associated with mortality in the sick group (p = 0.04). Although NLR resulted higher in sick cats than healthy, BLR and BNLR demonstrated as promising tools in differentiating SIRS from sepsis. NLR was associated with mortality in sick cats.

Coagulation testing: Comparison of portable (CoaguChek® XS) and automated coagulation analyzer in healthy cats

Background and Aim:

The CoaguChek^® XS (CCX) is a portable coagulation analyzer that is widely used to monitor prothrombin time (PT) in human patients taking oral anticoagulants. It can also be reliably used for screening dogs when PT is in the normal range. Efficacy of the portable CCX coagulation analyzer was evaluated for testing PT in healthy cats and the normal range was established.

Materials and Methods:

Blood samples of 82 cats were collected from the jugular vein and PT was measured using both the CCX and an automated coagulation analyzer (ACA). Spearman’s correlation was used to measure the strength and direction of association between the two analyzers, while limits of agreement were assessed utilizing Bland-Altman analysis.

Results:

Range of PT using the CCX was 10.1-14.1 s. Correlation between the two analyzers was moderate but significant (r=0.3465, p=0.0014). Mean difference between CCX-PT and ACA-PT was 1.624 s and standard deviation was 0.890 with 95.1% of the samples falling within the limits of agreement.

Conclusion:

The CCX is a portable, easy to use coagulation analyzer that requires a small volume of blood and gives results within 1 min. Results showed moderate correlation and good agreement with a standard automated laboratory analyzer. The CCX can be used for screening coagulation testing when PT is in the normal range for cats. However, testing accuracy of the CCX in abnormal PT cats should be further investigated before diagnostic coagulopathy applications.

Troxerutin attenuates inflammatory response in lipopolysaccharide-induced sepsis in mice

Troxerutin (Tx), known as vitamin P₄ is a derivative of natural bioflavonoid rutin. Tx possesses different biological activities such as antioxidant, anticancer, and anti-inflammatory. The current study was conducted to determine potential therapeutic effect of Tx in lipopolysaccharides (LPS)-induced sepsis in mice. In LPS-induced sepsis, the mice were treated intraperitoneally (ip) with Tx twice daily. Therapeutic effect was assessed by measuring serum level of cytokines, alanine aminotransferase (ALT) and lactate dehydrogenase (LDH). Level of nitric oxide (NO), superoxide dismutase (SOD), catalase (CAT), Myeloperoxidase (MPO) and Malondialdehyde (MDA) was measured. Expression of CD40 receptor on leucocytes was measured using flowcytometry. Splenocyte proliferation was evaluated using MTT assay. The effect of Tx on survival rate during administration of lethal dose of LPS was investigated. The results showed that Tx inhibited LPS induced NO production. Inflammatory pathways were suppressed by reduction of inflammatory cytokines production. Further, elevated CD40 expression of leucocytes and proliferation of splenocytes markedly reduced in Tx treated group. Antioxidant defense system was enhanced by increased activity of SOD and CAT and decreased level of MDA. MPO, ALT and LDH activity. Additionally, treatment with Tx significantly increased the mean survival time of mice compared with the LPS treated group. Histologically, Tx treatment decreased inflammatory cells infiltration and histopathologicl changes in the liver. Our findings showed that reduced inflammatory parameters, improved antioxidant activity, reduced histological lesions and increased survival rate. These findings suggest that Tx is an effective anti-inflammatory agent for the treatment of LPS-induced sepsis.

Deep Vegetal Foreign Bodies in Cats: A Retrospective Study of 10 Cases

The aim of this study was to describe the anatomic locations and treatments available for deeply located vegetal foreign bodies in cats. Ten cases of migrating vegetal foreign bodies (vFBs) requiring surgical removal are reported. The diagnoses of vFBs in the thoracic cavity (4/10), retroperitoneal space (2/10), and paratracheal region (1/10) were obtained by ultrasound examination; however, in the perineum or penile urethra (2/10) and peritoneum (1/10), the vFBs were found during surgery. Intraoperative ultrasound guidance helped remove vFBs from the retroperitoneal space and paratracheal tissues. Clinical signs resolved in 8 out of 10 cases, 1 out of 10 cases had recurrent draining fistula, and 1 out of 10 was euthanized for ethical reasons. The intrathoracic was the most common location in the present study, followed by retroperitoneal space and urethra/perineum. Ultrasound guidance was essential for the diagnosis and/or treatment of vFBs located in the thoracic, retroperitoneal, and cervical regions.

The association of coagulation indicators with in-hospital mortality and 1-year mortality of patients with sepsis at ICU admissions: A retrospective cohort study

BACKGROUND

Coagulation activation is the host's response to pathogens during sepsis and is considered to be one of the reasons for tissue damage and multiple organ failure. This study is designed to evaluate whether the alterations of coagulation indicators are related to in-hospital mortality and 1-year mortality of patients with sepsis.

METHOD

Data of all 2258 patients were extracted from the database Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC III). The relationship between the in-hospital mortality of patients with sepsis and coagulation indicators was analyzed with a receiver operating characteristic (ROC) curve analysis and logistic regression model. Effects of coagulation indicators on patients' 1-year mortality were determined by using a Cox hazard regression model, and clinical experience or quintiles were used to classify the activated partial thromboplastin time (APTT) to determine the cutoff values to explore segmentation effects.

RESULT

International normalized ratio (INR) was positively associated with hospital mortality of patients with sepsis after adjusting confounders with an odds ratio (OR) of 1.86 [95% confidence interval (CI), 1.37-2.52], and a hazard ratio (HR) of 1.465[95%CI(1.24-1.74)] for 1-year mortality, respectively. 1-year mortality of patients with sepsis demonstrated a U-shaped relationship with APTT, ranging from 25 to 37, indicating the lowest risk. The adjusted HR (95% CI) values for 1-year mortality of septic patients with risk values <25 and >37 were 1.493 (1.02, 2.19) and 1.379 (1.06, 1.79), respectively.

CONCLUSION

Increased INR in critically ill septic patients is related to greater in-hospital mortality and 1-year mortality. A U-shaped relationship was found between APTT and 1-year mortality of patients with sepsis.

Review of oncological emergencies in small animal patients

Oncological emergencies can occur at any time during the course of a malignancy and need to be recognized promptly to maximize successful outcomes. Emergencies are characterized as chemotherapy-induced, paraneoplastic syndromes, or directly related to the neoplasm. Prompt identification with treatment of these emergencies can prolong survival and improve quality of life, even in the setting of terminal illness. This review aims to educate the reader on the pathophysiology, clinical presentation and treatment of some of these emergencies, and to review the current veterinary literature to help educate veterinarians in primary and tertiary facilities to know how to diagnose and treat these serious conditions.

Multiorgan dysfunction syndrome in feline sepsis: prevalence and prognostic implication

OBJECTIVES

The current study was designed to evaluate the prevalence and prognostic significance of multiorgan dysfunction syndrome (MODS) in cats with sepsis.

METHODS

Cats hospitalised in the intensive care unit of a veterinary university hospital with a diagnosis of sepsis were prospectively enrolled and divided according to disease severity and outcome (survivors; non-survivors). The feline acute patient physiological and laboratory evaluation (APPLE) scores were calculated upon admission, as previously described. Specific criteria to identify selected organ dysfunction (hepatic, renal, respiratory, cardiocirculatory, haemostatic) were adapted from the available human and veterinary literature, and evaluated at baseline and at the end of hospital stay. MODS was defined as the presence of at least two dysfunctional organs simultaneously. Non-parametric statistics were used for comparisons. Univariate and multivariate regression analyses to evaluate significant risk factors for death were carried out. Correlations between variables were assessed by the Spearman's rank correlation coefficient. Significance was set at P <0.05.

RESULTS

A total of 43 cats with heterogeneous sources of sepsis were included. MODS was identified in 25/43 cats upon admission and in 32/43 cats at the end of hospital stay. Regression analyses showed a significantly elevated odds ratio for mortality for the presence of MODS, renal and cardiovascular dysfunction upon admission, as well as for the number of dysfunctional organs. The latter was the only variable retained by the model from the multivariate binary logistic regression analysis. Significant correlations were documented between the number of dysfunctional organs and the APPLE scores.

CONCLUSIONS AND RELEVANCE

MODS is a frequent complication of feline sepsis, and is associated with worse outcomes. In particular, renal and cardiovascular dysfunction significantly increase the odds for death. Hence, systematic screening for organ dysfunction is advocated in cats with sepsis.