Acute pancreatitis in dogs

Objective: To summarize current information regarding severity assessment, diagnostic imaging, and treatment of human and canine acute pancreatitis (AP). Human‐based studies: In humans, scoring systems, advanced imaging methods, and serum markers are used to assess the severity of disease, which allows for optimization of patient management. The extent of pancreatic necrosis and the presence of infected pancreatic necrosis are the most important factors determining the development of multiple organ failure (MOF) and subsequent mortality. Considerable research efforts have focused on the development of inexpensive, easy, and reliable laboratory markers to assess disease severity as early as possible in the course of the disease. The use of prophylactic antibiotics, enteral nutrition, and surgery have been shown to be beneficial in certain patient populations. Veterinary‐based studies: The majority of what is currently known about naturally occurring canine AP has been derived from retrospective evaluations. The identification and development of inexpensive and reliable detection kits of key laboratory markers in dogs with AP could dramatically improve our ability to prognosticate and identify patient populations likely to benefit from treatment interventions. Treatment remains largely supportive and future studies evaluating the efficacy of surgery, nutritional support and other treatment modalities are warranted. Data sources: Current human and veterinary literature. Conclusions: Pancreatitis can lead to a life‐threatening severe systemic inflammatory condition, resulting in MOF and death in both humans and dogs. Given the similarities in the pathophysiology of AP in both humans and dogs, novel concepts used to assess severity and treat people with AP may be applicable to dogs.     

Retrospective Study: The association of blood lactate concentration with outcome in dogs with idiopathic immune‐mediated hemolytic anemia: 173 cases (2003–2006)

Objective – To determine the association of blood lactate with outcome and response to transfusion therapy in dogs with idiopathic immune‐mediated hemolytic anemia (IMHA). Design – Retrospective study. Setting – Urban veterinary small animal emergency hospital. Animals – One hundred and seventy‐three client‐owned dogs with IMHA. Interventions – None. Measurements and Main Results – Serial blood lactate concentration, therapeutic interventions, and outcome were recorded. Nonsurvivors were defined as those that died or were euthanized. One hundred and thirty‐three dogs (77%) survived, 35 (20%) were euthanized, and 5 (3%) died. One hundred forty‐five dogs (84%; 145/173) had a lactate concentration above the laboratory reference interval [0.46–2.31 mmol/L] on presentation. Blood lactate at presentation was higher in the nonsurvivors (median 4.8 mmol/L; 0.5–13.6) compared with survivors (median 2.9 mmol/L; 0.3–13.2) (P<0.01). All dogs presenting with hyperlactatemia that normalized (<2.0 mmol/L) within 6 hours of admission survived, whereas, 71% of dogs that had a persistent hyperlactatemia at 6 hours survived (P=0.034). Lactate was positively correlated with age, BUN, and alkaline phosphatase, and inversely correlated with PCV. Receiver operating curve analysis for lactate concentration at admission as a test for outcome had an area under the curve of 0.69 with an optimal lactate cutoff concentration of 4.4 mmol/L correctly predicting outcome 73% of the time (sensitivity 60%, specificity 77%). Conclusions – Lactate concentration at presentation was significantly higher in nonsurvivors than survivors. Lactate was significantly correlated with previously reported outcome variables but lactate concentration at admission, as a predictor for outcome was less than optimal. However, serial lactate concentration measurements may be more predictive as patients with persistent hyperlactatemia 6 hours after admission were less likely to survive. Prospective studies evaluating serial lactate concentration while controlling for other variables may provide further insight into lactate measurement as a prognostic indicator in animals with IMHA.     

Application of the Sequential Organ Failure Assessment Score to predict outcome in critically ill dogs: preliminary results

In human medicine the Sequential Organ Failure Assessment (SOFA) score is one of the most commonly organ dysfunction scoring systems used to assess critically ill patients and to predict the outcome in Intensive Care Units (ICUs). It is composed of scores from six organ systems (respiratory, cardiovascular, hepatic, coagulation, renal, and neurological) graded according to the degree of the dysfunction. The aim of the current study was to describe the applicability of the SOFA score in assessing the outcome of critically ill dogs. A total of 45 dogs admitted to the ICU was enrolled. Among these, 40 dogs completed the study: 50 % survived and left the veterinary clinic. The SOFA score was computed for each dog every 24 hours for the first 3 days of ICU stay, starting on the day of admission. A statistically significant correlation between SOFA score and death or survival was found. Most of the dogs showing an increase of the SOFA score in the first 3 days of hospitalization died, whereas the dogs with a decrease of the score survived. These results suggest that the SOFA score system could be considered a useful indicator of prognosis in ICUs hospitalized dogs.     

Analgesia and sedation in the critically ill

Objective: To summarize the challenges to recognizing pain in critically ill patients, the rationale for treatment even in the absence of signs of pain, and the therapeutic options available in the intensive care environment. Etiology: Pain is one of many stressors challenging the critically ill patient, and may in turn be multifactorial in nature. Common causes include local and systemic inflammation, injuries, diagnostic and therapeutic procedures, immobilization, and thrombosis. Diagnosis: Critically ill animals with pain may not demonstrate overt behavioral or physiologic signs of distress. Therefore, pain must be assumed to be present for animals whose condition puts them at risk. Therapy: Currently available analgesic and sedative drugs and methods of delivery are described. Several useful analgesics and sedatives may be co‐administered as fluid additives to provide continuous therapy. Prognosis: There is growing evidence that the neuroendocrine stress response to severe injury or illness may become sufficiently intense to contribute to morbidity and mortality. Many therapeutic analgesic and sedation options provide good control of pain and stress, and in some circumstances this may improve the outcome of critical illness.     

Incidence and clinical relevance of hyperglycemia in critically ill dogs

BACKGROUND: Hyperglycemia associated with critical illness in nondiabetic human patients is a common occurrence in the intensive care unit (ICU), with a reported incidence as high as 71%. HYPOTHESIS: Hyperglycemia in critically ill dogs increases the risk of morbidity and mortality. ANIMALS: Two hundred forty-five dogs hospitalized in the ICU over a 2-month period were evaluated. METHODS: Prospective observational study was conducted over a 2-month period. All dogs in the ICU had their highest daily blood glucose concentration recorded. All dogs with diabetes were excluded from the study. Hyperglycemia was defined as a blood glucose concentration >120 mg/dL. Dogs with hyperglycemia were monitored for persistence and resolution of hyperglycemia. RESULTS: During the study period, 245 dogs were evaluated, of which 38 (16%) were hyperglycemic. Twenty-six percent (10/ 38) developed hyperglycemia during hospitalization, whereas 74% (28/38) were hyperglycemic at presentation. Length of hospitalization (LOH) was shorter in dogs that presented with hyperglycemia compared with those that developed hyperglycemia during hospitalization (P = .001). Seventy-one percent (27/38) of dogs were discharged from the hospital, whereas the remaining 29% (11/38) died or were euthanatized. Nonsurvivors had significantly higher median glucose concentration (median, 176 mg/dL; range 122-310 mg/dL) than did survivors (median, 139 mg/dL; 121-191 mg/dL; P = .021). CONCLUSIONS AND CLINICAL IMPORTANCE: The incidence of hyperglycemia in this population of dogs was 16%. Dogs that developed hyperglycemia had longer LOH and nonsurvivors had more pronounced hyperglycemia than did survivors.     

Relationship between hydration estimate and body weight change after fluid therapy in critically ill dogs and cats

Objective: To characterize the relationship between clinical estimates of hydration in dogs and cats admitted to an intensive care unit (ICU) and changes in their body weight following 24–48 hours of fluid therapy. Design: Outcome study. Setting: ICU at a veterinary teaching hospital (VTH). Animals: A total of 151 dogs and 42 cats with various medical disorders that had not had surgery within 48 hours of admission into the ICU were consecutively admitted into the study. Animals with any condition predisposing to excess fluid loss or retention were excluded: heart disease, sepsis, trauma, pancreatitis, pleural or pericardial effusion, ascites, and pathologic oliguria. Animals that acquired any of the following during the observation period were excluded: gastrointestinal fluid loss, edema or diseases predisposing to edema, oliguria, diuretic therapy, and body fluid drainage or hemorrhage. Fluid therapy was ordered based on estimate of hydration at admission. Other treatments were not modified or withheld. Interventions: Physiologic data were collected at the time of admission and 24–48 hours later. Measurements and main results: Hydration was estimated on admission to the ICU using clinical judgement with no supporting laboratory data. Each admitting clinician used this estimate to plan fluid therapy. Fluid therapy was defined as the administration of any enteral or parenteral fluids as well as any decision to withhold fluids. Paired measurements taken on admission and at 24–48 hours included packed cell volume (PCV), total plasma solids (TS), and body weight. Amount and type of fluids or blood products administered were noted. Neither clinician estimates of dehydration nor baseline PCV or TS predicted clinically significant changes in body weight following fluid therapy, and there was no relationship between weight change and changes in PCV or TS. Conclusions: A clinical diagnosis of dehydration in our ICU does not predict weight gain following fluid therapy. Neither baseline PCV/TS nor changes in these measurements following 24–48 hours of fluid therapy predicted changes in body weight.     

The role of albumin replacement in the critically ill veterinary patient

Objective: To review the human and veterinary literature on the physiological role and effects of therapeutic albumin supplementation. Data sources: Data from human and veterinary literature was reviewed. Human data synthesis: Hypoalbuminemia often occurs in a variety of critical illnesses, and contributes to the development of life‐threatening complications, including pulmonary edema, delayed wound healing, feeding intolerance, hypercoaguability, and multiple organ dysfunction. Serum albumin concentration has been used as a prognostic indicator in cases of chronic hypoalbuminemia. The use of albumin replacement therapy in humans is sometimes controversial, but may be associated with improved morbidity and decreased mortality. Veterinary data synthesis: Unlike human literature, there is a paucity of controlled clinical studies in the literature regarding albumin supplementation in veterinary patients. Rather, the majority of published studies were performed in experimental animals or via retrospective analyses. One recent study evaluated the use of plasma to improve albumin concentration in dogs with hypoalbuminemia. Other older studies investigated wound healing in dogs with experimentally induced hypoalbuminemia. As in human medicine, serum albumin concentration may be helpful as a prognostic indicator in critically ill dogs. Conclusion: Albumin is one of the most important proteins in the body because of its role in maintenance of colloid oncotic pressure, substrate transport, buffering capacity, as a mediator of coagulation and wound healing, and free‐radical scavenging. Albumin replacement in veterinary medicine is difficult, but until prospective clinical trials determine the efficacy of albumin replacement are conducted, a suggested clinical guideline would be to maintain albumin concentration at or above 2.0 g/dl utilizing fresh frozen plasma.