ECC All Literature

Question 1

How is anion gap calculated?

Answer 1

(Na +K) - (Cl +HCO3)

Question 2

What does an increase in anion gap signify?

Answer 2

Indicative of an increase in fixed (nonvolatile) acid and metabolic (non respiratory)acidosis (e.g. lactic or ketoacidosis)

Increased anion gap acidosis is characterized by decreased plasma bicarbonate concentration without hyperchloremia

Question 3

What might cause a normal anion gap acidosis aka a “hyperchloremic metabolic acidosis”?

Answer 3

RTA
Addisons
Severe diarrhea
Some drugs

Question 4

What is base excess or base deficit?

Answer 4

Concentration of titratable acid or alkali required to return the in vitro pH of whole blood to 7.4 at normal body temperature

Question 5

Answer 5

Objective - to investigate the accuracy of K+ supplementation in isotonic crystalloid fluids

210 bags of fluid supplemented with KCl being administered to hospitalized dogs and cats IV were sampled over a 3 month period. Measured K+ concentration was compared to the intended potassium concentration of the bag. In a second experiment, 60 stock fluid bags were supplemented to achieve a concentration of 20 molecules/L K+ mixed well. In another 12 back, K+ was added without mixing the bag well and the concentration of potassium in delivered fluid was measured at regular time points during CRI

• *the measured K+ concentration was significantly higher than the intended concentration (mean difference 9 molecules/L)
• *In 28% of samples, potassium concentration was >/= 5 mmol/L different than intended potassium concentration. With adequate mixing, potassium supplementation of fluids can be accurate with the mean difference between measured and intended potassium concentration difference of 0.7 mmol/L. When not mixed it can lead to very high delivery of potassium.

Question 6

Answer 6

Objective - to compare the effects of an isotonic crystalloid and synthetic colloid on coagulation in healthy dogs and dogs with systemic inflammation

Randomized placebo controlled blinded study. Dogs received either LPS or placebo and either crystalloid or tetra starch synthetic colloid

**Administration of either fluid to healthy dogs and dogs with systemic inflammation resulting in similar increases in PT and ACT. In comparison to saline, tetrastarch resulted in significantly decreased R in healthy dogs, as well as significantly increased aPTT and K and significantly decreased platelet count, alpha angle, MA, and vWFAg and collagen binding activity in both healthy and dogs with systemic inflammation

***healthy dogs and dogs with LPS induced systemic inflammation given tetrastarch had prolonged aPTT, hypocoagulable and hypofibrinolytic TEG variables, acquired type 1 vWF disease (decreased vWFAg and vWFCBA) compared to dogs given crystalloid fluids. These changes resolved w/in 4 hours after administration.

**Most coagulation variables were w/in RI ,which makes the hypocoagulable changes associated with tetrastarch of uncertain clinical significance

Question 7

Answer 7

Objective - to describe the incidence of and prognosis associated with hyper atresia in dogs and cats

Retrospective study of of 957 dogs and 338 cats with hypernatremia
**Within the study population, 6-8% was hypernatremic, and these patients had a higher case fatality rate
**Case fatality of dogs with hypernatremia - 21%
**Case fatality of cats with hypernatremia - 28%
Compared to 5% fatality in those dogs and cats with normal serum sodium

**The magnitude of hypernatremia was linearly associated with higher case fatality rate, and it was associated with higher case fatality than hyponatremia. Among the animals with moderate or severe hypernatremia, 50% of dogs and ~40% of cats presented with community acquired hypernatremia and 50% of dogs and 62% of cats developed hospital acquired hypernatremia. In cats, ~55% of moderate to severe hypernatremia cases were caused by urologic disease.

Question 8

Answer 8

Objective- to describe the incidence of and prognosis associated with hyponatremia in dogs and cats

Retrospective study - 25% of dogs and 50% of cats in the study population were hyponatremia

Dog case fatality - 14%
Cat case fatality 12%

Overall population case fatality - 5%
**Magnitude of hyponatremia was linearly associated with higher case fatality rate, but hyponatremia had lower case fatality than hypernatremia.

• *Among the animals with moderate or severe hyponatremia - 92% of dogs and 91% of cats presented with community **acquired hyponatremia, and 8 % of dogs and 9% of cats developed hospital acquired hyponatremia
• *In 30% of cats, moderate to severe hyponatremia was caused by urologic disease

Question 9

Answer 9

Prospective observational study performed over 4 weeks consecutively in 2 ICUs
Noisier ICUs did not display diurnal variation in noise levels. Noise level varied between ICUs despite lower occupancy levels in the louder ICU. The ICUs were loud enough to disrupt sleep in hospitalized patients

Question 10

Answer 10

Methods - chemistry and blood gas analyses performed in 10 dogs
Simplified strong ion equation was used to calculate serum pH
Published values for concentration and dissociation constant for the nonvolatile weak acids and subsequently calculated serum pH was compared with the dog’s actual pH

**The calculated serum pH did not approximate the measured pH for any dog, and the calculated pH was consistently more basic .
**Substituted values A tot and Ka did not significantly improve the accuracy. Substituting the effective strong ion difference (A tot - bicarbonate concentration) produced a strong association between calculated pH and measured pH
A tot = total protein x 0.272

Question 11

Answer 11

Objective - to evaluate the prevalence and prognostic significance of multi organ dysfunction syndrome in cats with sepsis

• *43 cats identified with sepsis, 58% developed MODS at admission and 74% developed MODS at the end of hospital stay
• *significantly elevated odds ratio for mortality for the presence of MODS, renal and cardiovascular dysfunction at admission, and for the number of dysfunctional organs

**increased numbers of organ dysfunction, particularly renal and cardiovascular dysfunction worsen the odds for death. MODS is a frequent complication of feline sepsis

Question 12

What is MODS?

Answer 12

Aka multi organ dysfunction syndrome, or progressive dysfunction of organ systems following an acute threat to systemic homeostasis

Question 13

Answer 13

Electrolytes analyzed: disorders of sodium, potassium, corrected chloride, and iCa

All four electrolytes assessed had nonlinear U shaped associations with case fatality rates — concentrations clustered around the RI had the lowest case fatality rates, while progressively abnormal concentrations were associated with proportionately increased risk of non-survival or death.

Question 14

Answer 14

Objective - to determine whether the concentration of serum canine alpha1-proteinase inhibitor has diagnostic or prognostic utility in dogs with sepsis or non infectious SIRS
19 dogs with SIRS/Sepsis, 50 healthy controls

Patients were assessed with APPLEfull or APPLEfast scores. Serum alpha1 proteinase inhibitor concentrations were measured, compared between groups, and evaluated for a correlation with the concentration of serum CRP, plasma Il6, TNFa, APPLE scores and survival to discharge

**Serum alpha1 proteinase inhibitor concentrations were LOWER in dogs with SIRS/sepsis than in healthy controls. Septic dogs had lower alpha1proteinase than SIRS dogs on days 2 and 3. Serum alpha1 proteinase did not differ between. Survivors and no survivors, but were inversely correlated with APPLEfull score and plasma IL6.

**serum alpha1 proteinase inhibitor is a negative acute phase protein in dogs. It does not help differentiate sepsis dogs from SIRS dogs, but may be a useful surrogate marker for early stratification of illness severity. It does not predict survival

Question 15

Answer 15

Retrospective case series evaluating whether appropriate empirical antibiotic therapy influenced survival in dogs with septic peritonitis

• *57% of study population survived to discharge.
• *Patients classified as being in septic shock had highest mortality - 94%
• **Empirical antimicrobial treatments were appropriate in 53% of dogs

***Appropriateness of therapy was not associated with treatment outcome overall or when compared between sepsis severity groups
Prior therapy with antimicrobials showed no association with outcome but was associated with inappropriate empirical antimicrobial selection. Recent abdominal surgery was associated with subsequent inappropriate empirical antimicrobial selection.

Question 16

Answer 16

Objective - to investigate the diagnostic and prognostic value over time of plasma iron compared with the inflammatory markers albumin, CRP, and fibrinogen in dogs with SIRS

Prospective observational study

• *On admission, dogs with SIRS had significantly lower plasma iron than dogs with focal inflammation and had lower albumin and higher CRP.
• *Plasma iron, albumin, and CRP effectively discriminated the SIRS/sepsis group from those presenting with focal inflammation
• *Admission values for these variables did not discriminate survivors from non survivors within the SIRS/sepsis group.
• *Magnitude of increase in iron concentration and the decrease in CRP concentration from admission to discharge was higher in survivors than in non survivors within the sIRS/Sepsis group. Iron and CRP levels in the SIRS/sepsis survivors were similar to the focal inflammation group

Question 17

Answer 17

Objective - to determine if selected serum biomarkers are superior to APPLE complete score in predicting 30 day mortality in a non homogenous disease population of critically ill dogs

Prospective cohort study comparing serum biomarkers adiponectin, leptin, CRP, and S100A12 concentrations between surviving and non surviving critically ill dogs

***Leptin was the only biomarker that was significantly correlated with the APPLE complete score. Only the APPLE complete score and illness duration of <1 day were significantly associated with outcome. None of the biomarkers in the study provided benefit in predicting outcome over the APPLE complete score. Serum leptin was correlated with disease severity as determined by APPLE scoring. Longer illness duration prior to admission was associated with a higher risk of death. APPLE scores were highest in dogs with infectious disease, immune mediated disease, and bite wounds.

Question 18

What is S100A12?

Answer 18

A calgranulin which is a chemoattractant
It is expressed by macrophages and functions to regulate phagocyte chemotaxis, migration, activation and sustained recruitment of leukocytes, oxidant scavenging, and plays a role in cytokine synthesis

Question 19

Answer 19

Objective - to determine if cell free DNA was identifiable in canine plasma, to evaluate 3 techniques for measurement of plasma cell free DNA in dogs presented to an ER, and to compare the plasma cell free DNA concentrations of healthy dogs to those with sepsis, trauma, and neoplasia

Both assays had good linearity, acceptable repeatability and reproducibility.
***Plasma cell free DNA concentrations were significantly increased in dogs with sepsis and moderate to severe trauma with both assays in comparison to controls.
Dogs with neoplasia had significantly increased cfDNA concentrations with the quant-iTassay only.

**When measurements were performed on purified DNA, only dogs with moderate to severe trauma had significantly increased cfDNA concentrations.

**Extraction of cfDNA from plasma provided no advantage over direct measurement and likely resulted in reduction in cfDNA concentrations.

Question 20

Answer 20

Objective - to evaluate the use of gastric and bladder to nome try for assessing tissue hypoperfusion in dogs during sevoflurane induced hypotension, and to compare these measurements with delivery of oxygen, arterial oxygen content, and plasma lactate concentration

Patients were anesthetized and a tonometric catheter was introduced into the stomach to measure gastric tonometry. Samples of saline from the balloon of a filet catheter placed in the bladder were collected q 10 min and used to measure bladder tonometry by gas analysis.

Tonometry measurements, plasma lactate, and oxygen delivery and consumption wree compared at three time points - baseline, hypotension and during treatment

**Tonometric measurements (CO2 levels) in stomach and bladder increased significantly during the hypotensive period. Correlations were found between these values and the delivery of oxygen. Gastric tonometry values had stronger correlations compared with bladder tonometry values. These measurements can be used to detect hypoperfusion.

Question 21

Answer 21

Objective - to determine if absolute plasma lactate concentration or lactate clearance in dogs with septic peritonitis is associated with morbidity or mortality

• *Plasma lactate concentration >2.5 mmol/L on admission (29% of patients) was associated with mortality. Median admission plasma lactate concentration was significantly different between non survivors and survivors.
• **64% of dogs survived to discharge. Hyperlactatemia and failure to clear lactate within 6-12 hours was predictive of nonsurvival.

**Admission plasma lactate concentration > 4 mmol/L yielded a sensitivity of 36% and specificity of 92% for non survival

**Inability to normalize plasma lactate concentration within 6 hours of admission yielded a sensitivity of 76% and specificity of 100% for nonsurvival

Postoperative hyperlactatemia >2 had a sensitivity of 46% and specificity of 88% for nonsurvival

Persistent postoperative hyperlactatemia had a sensitivity of 92% and specificity of 100% for nonsurvival

Lactate clearance less than 21% at 6 hrs had a sensitivity of 54% and specificity of 91% for nonsurvival
Lactate clearance less Than 42% at 12 hours had a sensitivity of 82% and specificity of 100% for nonsurvival

Question 22

Answer 22

Retrospective case study comparing clinical signs, lab test results and imaging findings between dogs with suspected anaphylaxis and dogs with sepsis

All dogs in the anaphylaxis group fulfilled criteria for SIRS

Both sepsis and anaphylaxis group had GI signs, lethargy, mentation change, and bleeding abnormalities

• *Dogs with suspected anaphylaxis had a higher eosinophil count and ALT and lower pH than dog with sepsis
• *Dogs w/ sepsis had a significantly higher band neutrophil count, serum glob concentration, and ALP and lower glucose

**Dogs in both groups had intracavitary free fluid and ultrasonographic findings of thickened intestines, gas or fluid filled intestines or thickened gall bladder wall

Question 23

What occurs during anaphylaxis?

Answer 23

Characterized by initial immunologic sensitization to an antigen and production of IgE that binds to receptor on basophils and mast cells. Subsequent exposure to an antigen results in cross linking of the antigen between 2 iGE molecules, followed by a massive systemic response mediated by the release of vasoactive substances including histamine, heparin, proteases and proteoglycans

Clinical signs are species specific and dependent on the organ containing the highest concentration of mast cells

Cats - pulmonary pathological effects predominate — respiratory distress characterized by airway edema, bronchospasm, low O2 sat
Dogs - high concentrations of mast cells in liver - anaphylaxis results in profound splanchnic vasodilation, resulting in severe decrease in cardiac output, decreased perfusion and secondary portal hypertension. Do not commonly present with respiratory distress

Question 24

Answer 24

Objective - to assess signalment and concurrent disease processes in dogs with aortic thrombotic disease

Retrospective case control study

Incidence of aortic thrombotic disease in the study population of 0.03%
Odds of ATD did not differ significantly by sex, age, or body weight
Shetland sheepdogs had a significantly higher odds of ATD compared to MBD
PLN (22% in ATD population) was the most commonly recorded concurrent disease in dogs with ATD
Other diseases associated with ATD included: PLN, neoplasia, systemic hypertension, hyperadrenocorticism, and hypothyroidism

Question 25

Answer 25

Objective - to characterize clinical and lab findings in cats with naturally occurring sepsis, emphasizing hemostasis related findings, and evaluate these variables for associations with patient outcomes Prospective observational clinical study evaluating 31 cats with sepsis and 33 healthy controls Most common cause was pythorax (32%) Novel laboratory changes: metarubricytes, hypertriglyceridemia and high CK levels Hemostasis changes were common, but DIC (18%) was not common in the sepsis population Survival rate was 63% - no risk values were found to be statistically significant

Question 26

Answer 26

Retrospective cohort study with the objective of evaluating the lipidemia status and serum concentrations of cholesterol and triglycerides of dogs when initially examined for hospitalization in the ICU of a VTH and determine whether these variables were predictive of survival to discharge Factors associated with increased odds of sick dogs not surviving to discharge were: hypocholesterolemia (OR 1.9), hypertriglyceridemia (OR 3.2), and concurrent hypocholesterolemia and hypertriglyceridemia (OR 55.7)**** at the time of initial evaluation

Question 27

Which inflammatory cytokines may suppress hepatic production of HDL apolipoproteins and cholesterol?

Answer 27

TNFa, IL1B, IL6

Question 28

Which cytokines/ inflammatory markers may increased hepatic triglyceride synthesis while down regulating endothelial lipoprotein lipase activity?

Answer 28

LPS, TNFa, IL1B, and IL6

Question 29

Answer 29

Objective - Prospective clinical evaluation to evaluate the usefulness of a veterinary POC glucometer for identification of septic peritonitis in dogs with peritoneal effusion 39 dogs with peritoneal effusion POC glucometer was used to measure plasma and peritoneal fluid glucose, and whole blood, and peritoneal fluid supernatant 17 dogs had confirmed septic peritonitis, 22 had non septic peritoneal effusion with a cutoff of >20 mg/DL, the glucose concentration difference for whole blood vs peritoneal fluid was an insensitive indicator of septic peritonitis (sensitivity 41%, specificity 100%) **The glucose concentration differences for plasma - peritoneal fluid glucose and plasma -peritoneal fluid supernatant glucose had higher sensitivity (88% and 82%) but lower specificity (80% and 78%). With a glucose concentration difference cutoff of >/= 38 mg/dL, specificity, PPV, and accuracy of P-PF and P- PFS improved. P-PF was the most useful of the tests

Question 30

Answer 30

Objective - to determine whether critically ill hypotensive dogs without hyperlactatemia have the same prognosis as critically ill hypotensive dogs with hyperlactatemia 28% of study population in this retrospective case series survived Hypotensive dogs WITHOUT hyperlactatemia had a significantly higher BP and were 3.23 times as likely to survive, compared with hypotensive dogs with hyperlactatemia. Age, weight, severity of c/s and duration of hospitalization did not differ significantly between dogs with and without hyperlactatemia

Question 31

What is the difference between type A and type B lactic acidosis? Which is more common?

Answer 31

Type A - due to hypotension and hypoperfusion - MOST COMMON Type B - decreased clearance with clinically normal blood oxygen concentration and SBP (may be due to hepatic disease, sepsis, neoplasia, DM, renal failure) can result from mitochondrial defects or conditions that results in inadequate oxygen use

Question 32

Answer 32

Retrospective case series of critically ill hypotensive cats 15% (6/39) cats survived to discharge 31% of study population had normal lactate, while 69% had high lactate Hypotensive vats with normal lactate had higher BP and higher survival rate than hypotensive cats with hyperlactatemia 5 day Kaplan Meier survival rates were 57% for normolactatemic cats and 17 % for hyperlactatemia cats Age, body weight, duration of hospitalization, PCV and illness severity did not differ significantly between hypotensive cats with and without hyperlactatemia

Question 33

Answer 33

Objective - prospective observational study to determine the association of blood lactate concentration with physically assessed perfusion variables, SAP, and outcome in cats Cats with white mucous membranes, abnormal peripheral pulse quality, and hypothermia had significantly higher lactate concentration than did cats without these findings * *Median lactate concentration for hypotensive cats was 3.3, and was higher than cats that were normotensive (SAP :>90 mmHg) at 2.35 mmol/L * * Cats with severe shock had higher lactate concentration (4.3) compared to cats in other shock categories Median initial lactate concentration at admission did not differ between cats that did and did not survive to discharge from the hospital. Change in lacerate during hospitalization was not associated with outcome. Blood lactate can be elevated in cats with normal physical perfusion variables

Question 34

Answer 34

Background - lidocaine has analgesic and inflammatory modulator properties and is commonly used as a local anesthetic Objective - to determine whether intraoperative administration of lidocaine to dogs with septic peritonitis was associated with short term survival after surgery. The proportion of dogs that survived for 48 hours after surgery was significantly greater for the lidocaine group (83%) over the opioid group (60%) Intraoperative lidocaine infusion increased the odds of short term survival. No significant differences seen between two treatment groups for variables assessed pre and post operatively

Question 35

Answer 35

Objective - retrospective case series to determine the rate of and factors associated with survival to hospital discharge in dogs with uroabdomen Urinary tract rupture occurred most commonly in the urinary bladder (56%) then the urethra (26%), kidney (5%), ureter (2%), both UB and kidney (2%), and undetermined sites (9%) Most common cause of rupture was traumatic (47%), then obstructive (21%), and iatrogenic (16%), or were unknown (16%) Surgery was performed in 86% of patients, and was surgically corrected in 92% of patients Complications included death and regurgitation 79% survived to discharge, and creatinine at admission was not associated with survival to discharge

Question 36

How is uroabdomen diagnosed?

Answer 36

Must meet 2 of the following criteria: The peritoneal effusion creatinine is >4 x that of the upper reference interval for serum creatinine The effusion to serum creatinine ratio is >2 The effusion to serum potassium is > 1.4

Question 37

Answer 37

Objective - to describe the epidemiology of the SIRS and sepsis in cats hospitalized at a VTH Non infectious SIRS (33%) was more common than sepsis (7%) or infections The prevalence of sepsis at hospital admission was 6.2 cases per 100 admissions Mortality rate was 33.3% for septic cats The most common septic foci were the peritoneal space and urogenital system, and gram negative organisms were the most common cause

Question 38

Answer 38

Objective - to determine the percentage of dogs surviving to hospital discharge and identify factors associated with death prior to hospital discharge among dogs undergoing surgery due to primary splenic torsion. 91% of dogs survived to discharge GSD, Great Dane, and English bulldog accounted for 50% of cases Risk factors associated with death included concurrent sepsis at presentation (OR 32.4), intraoperative hemorrhage (OR 22.6) and postoperative respiratory distress (OR 35.7). No histopathologic evidence of neoplasia was found

Question 39

What are two different manifestations of primary splenic torsion?

Answer 39

Acute - results in severe abdominal pain, weakness, cardiovascular collapse that can occur rapidly Chronic - vomiting, lethargy, weakness, abdominal pain, hematuria, and diarrhea - signs can be vague or intermittent

Question 40

What are potential proposed etiologies for primary splenic torsion?

Answer 40

Poorly understood Congenital absence or weakness of supporting ligaments of the spleen Laxity of the ligaments supporting spleen due to previous GDV

Question 41

Answer 41

Retrospective case series describing transfusion practices for treatment of dogs undergoing splenectomy for splenic masses 44% of dogs undergoing splenectomy for masses received transfusions - pRBCs more frequently used Dogs that received transfusions had higher mean illness severity score, HR,RR, and blood lactate, and PT with lower HCT, PLT and TS and albumin and base deficit. Hemoabdomen and hemangiosarcoma were more common in the transfusion group. 92% of dogs survived to discharge. Dogs that received transfusions had higher odds of death or euthanasia while hospitalized and lower odds of surviving 30 or 180 days after discharge.

Question 42

Answer 42

36% of dogs that presented for trauma received transfusions and pRBCs were the most commonly administered product (93%) Reasons for transfusion - peri operative hemodynamic support and treatment of shock or worsening anemia. Dogs that had transfusions had higher mean HR, lactate and animal trauma triage scores with lower mean PCV, TS and rectal temperature at admission. 87% of dogs survived to discharge, and dogs that did not have transfusions were more likely to survive.

Question 43

Answer 43

Transthoracic or transesophageal ultrasonography revealed grass awns in the pleural space of 25% of dogs Surgical removal of grass awns was successful on the first attempt in 21/23 (~50%)dogs, including those that had intraoperative ultrasonography performed The other half of the dogs a foreign body couldn’t be found and the majority developed fistulas and they later went to sx. 4 (~10 %) - grass awns were never found and they were managed medically

Question 44

Answer 44

Prospective study with the objective of evaluating peripheral blood and abdominal fluid variables as predictors of intestinal surgical site failure in dogs with septic peritonitis following celiotomy and closed suction abdominal drain placement 3/26 dogs (12%) developed postoperative septic peritonitis while the remainder recovered normally On day 3 postoperatively, the abdominal fluid WBC count was significantly LOWER and the blood to fluid WBC and neutrophil ratios were significantly HIGHER for dogs with postoperative septic peritonitis Overall - no significant indicators of postoperative septic peritonitis were identified

Question 45

Answer 45

Higher APPLE fast score, creatinine, lactate, anion gap, and ALT were associated with increased mortality in dogs with SIRS Higher TP, albumin, antithrombin activity, and base excess were associated with decreased mortality in dogs with SIRS

Question 46

Answer 46

In dogs diagnosed with shock, lactate on admission did not predict survival Survivors had shorter plasma lactate time > 2 and higher lactate clearance at various time points

Question 47

Answer 47

Multicenter retrospective observational study to describe the clinical characteristics of recurrent septic peritonitis in dogs Original cause septic peritonitis was most commonly previous sx for GI FB removal, then GI neoplasia, then Gastric or duodenal ulceration, biliary leakage, and single instances of various other causes There was no difference detected between survivors and non survivors in dogs with recurrent peritonitis. Overall survival was 44%, (mortality was 56%) but no prognostic indicators identified.