Take a Closer Look: "Septic Peritonitis "

Sally is a 3-year-old female spayed domestic long hair cat that was referred to the Veterinary Emergency and Specialty Center of New England with a three-day history of lethargy and one day of anorexia. The owner had noted that her abdomen appeared distended and had taken Sally to see her regular veterinarian earlier in the day. Her veterinarian took abdominal radiographs and found that Sally had a large amount of free fluid inside her abdomen (abdominal effusion). Sally was then referred for further diagnostics and 24-hour care.

At the time of presentation to VESCONE Sally was quiet but alert, moderately dehydrated and very painful in her abdomen with a fluid wave inside her abdomen that could be felt on physical exam. Abdominocentesis was performed (a needle was placed into the abdomen and a sample of the fluid was removed). The fluid was examined under the microscope and there were many bacteria and inflammatory cells seen. This finding was consistent with septic peritonitis or an infection within the abdominal cavity. The most common cause of this type of infection is a wound from the outside that penetrates the abdomen or a perforation of the stomach or intestinal tract that leaks bacteria into the abdomen.

Further diagnostics were performed to fully evaluate Sally’s overall health. A complete blood count revealed a severe elevation in her white blood cell count consistent with the infectious process occurring within her abdomen. A chemistry panel, which is used to evaluate organ function and electrolyte balances, revealed a mild elevation in one liver enzyme and a low albumin level. Albumin is a protein that his needed to maintain oncotic pressure (hold fluid within he blood vessels), carry molecules within the bloodstream and aid in the healing process. Sally was most likely losing albumin into her abdomen due to the inflammation. Sally was also found to have an elevated blood clotting time and low blood pressure.

Sally was immediately treated with intravenous fluids, analgesic medications for pain and antibiotics.With the IV fluids Sally’s blood pressure started to improve. An abdominal ultrasound was performed to help try and determine the cause of Sally’s septic peritonitis. The ultrasound showed severe inflammation of the organs within her abdomen, but no foreign object or cause of the infection could be seen. The only way to treat an infection of the abdomen like Sally had is to perform abdominal exploratory surgery, look for the source of infection (remove it if found) and flush away as much of the inflammation as possible. Taking Sally to surgery was a risk as she was a very critical patient, however, because it was the only way to treat her infection her owner elected to go ahead with surgery.

Sally’s surgery went well, the abdomen was cleaned of as much of the infection as possible and a drain was placed that went from inside the abdomen to outside her body to help continue to drain the fluid and infection. No source of infection could be identified, however, the most likely cause for Sally’s case is that she did have a small puncture wound from the outside of her body that introduced the bacteria. Sally remained in a very critical state following her surgery. She had difficulty maintaining her blood pressure due to the high volume of fluid that she continued to leak into her abdomen.

Sally remained in the hospital for one week following her surgery. She was monitored around the clock with repeated blood pressure and central venous pressure monitoring (allowing us to fully evaluate her hydration and fluid volume within her blood vessels). She was treated with two different types of intravenous fluids (crystalloid and colloid); she received three plasma transfusions (to help improve her blood clotting time and provide proteins needed for healing); she was also kept on a constant infusion of analgesic medication (to decrease pain) and a medication called dopamine (to help keep her blood pressure normal). Sally was also receiving two types of intravenous antibiotics and her abdominal drain was emptied every few hours.

During the course of her stay in the hospital Sally showed steady improvement. She began eating again the day after her surgery and despite all she had been through, she was purring and affectionate with the staff. As Sally continued to heal the amount of fluid she was leaking into her abdomen slowly decreased and there were no more bacteria visible when the fluid was examined under the microscope. A culture of the fluid from her abdomen came back from the lab and revealed two different types of bacteria (fusobacterium and bacteroides) both of which were treatable with the antibiotics Sally was receiving. Sally’s abnormal liver value returned to normal, her white blood cell count began to normalize and her blood clotting time improved. Sally’s drain was finally removed and one week following her presentation to the hospital she was discharged back to her owner.

At VESCONE, all of our departmental teams work together to bring the best care veterinary medicine has to offer. From emergency management of shock or infection to emergency surgery, we are at our best when we work together to make a difference in the life of your family – your pets.

Take a Closer Look: "Pyometra with Severe Complications"

Carrie is a 12-year-old female intact domestic shorthair that was referred to the VESCONE Emergency Department for abdominal distention that had been progressive over one week. Abdominocentesis at her RDVM showed purulent fluid and she was referred to VESCONE for possible septic peritonitis due to a ruptured pyometra. Carrie’s owner noted rare heat cycles, the last being 2-4 weeks prior to presentation. Additionally, Carrie’s owner noted weight loss, decreased appetite, vomiting and decreased energy over the previous weeks.

On presentation, Carrie was depressed, dehydrated, with a body weight of 2.6 kg. Her Body Condition Score was 1/5. Mucous membranes were pale, heart rate 230bpm, rectal temperature 104.7 deg F, blood pressure 130mm Hg. A grade 2-3 heart murmur with an occasional gallop was ausculted. She had no vulvar discharge.

Her in-house CBC revealed severe leukocytosis (169,700/mm3; reference range 6000 – 17000/mm3), anemia (PCV 29, machine HCT 17), and thrombocytopenia (57,000/mm3; reference range 200 – 500/mm3). Her chemistry profile revealed hypoalbuminemia (1.5g/dl; reference range2.2-4.4 g/dL,) elevated BUN (32mg/dl; reference range10-30mg/dL,) hypokalemia (3.3mmol/L; reference range 3.7 – 5.8mmol/L,) and hyperglobulinemia (7.0g/dL; reference range 1.5 – 5.7g/dL). A coagulation panel yielded PT - 20 seconds (15-23), PTT-187 seconds (66-123). Cytology of the abdominal fluid revealed degenerative neutrophils with intracellular and extracellular rod bacteria. Referral radiographs demonstrated generalized poor abdominal detail and a caudoventral mass effect causing dorsal deviation of the colon and small intestine on the lateral view.

Carrie’s initial problem list included: septic peritonitis, probable ruptured pyometra, possible DIC (thrombocytopenia, coagulopathy,) dehydration, fever, heart murmur and gallop, anemia, poor body condition, hypoalbuminemia, mild elevation in BUN, mild hypokalemia and vomiting. Emergency exploratory surgery after stabilization was recommended.

Abdominal ultrasound during stabilization confirmed the diagnosis and help rule out the possibility of an intra-abdominal tumor prior to surgery. Abdominal fluid was submitted for cytology and culture. Carrie was given a dose of ampicillin 22mg/kg IV and started on 0.45% NaCl with 20meqKCl/L at 10mls/h with additional boluses. Carrie’s blood type was tested (type A) and one unit of fresh frozen plasma was administered to address her coagulopathy and hypoalbuminemia before surgery. A double lumen jugular catheter was placed, for frequent blood sampling, CVP monitoring, and possibly TPN postoperatively.

Carrie was premedicated with buprenorphine 0.05mgs IV, diazepam 1.3mgs IV, anesthesia was induced with etomidate 2.6mgs IV and then isoflurane. Hetastarch 5mls/kg bolus, a CRI of fentanyl at 10 – 20mcg/kg/h (which allowed discontinuation of isoflurane anesthesia,) and a dopamine CRI at 5-10ug/kg/min were given to address hypotension intra-operatively. One unit type A packed red blood cells was started intraoperatively.

The uterus and abdomen were distended with purulent fluid, no gross rupture was appreciated. Ovariohysterectomy was performed without complications. Post lavage, a Jackson-Pratt closed suction drain was placed to allow continuous abdominal drainage. Urine was obtained for urinalysis and culture.

Carrie was maintained on the dopamine CRI at 5ug/kg/min, a fentanyl CRI for pain management at 5ug/kg/hr, and hetastarch for colloidal support. Enrofloxacin at 5mg/kg IV SID and IV ampicillin was continued. Postoperative lab work revealed hypoglycemia (glucometer BG 30) presumably due to sepsis, and hypokalemia 2.8 suspected due to IV dieresis and third spacing. She was given an IV dextrose bolus 2mls of 50% diluted and was supplemented with 2.5% dextrose and 50meqKCl/L in her crystalloids. Her PCV after transfusion was 23. It was suspected that PCV readings may not have been an entirely accurate reflection of red cell mass as a large portion of the cellular portion of her hematocrit tubes were buffy coat. Urine output was good. Carrie’s initial CVP was 1.

In the AM, her total bilirubin was 1.6. due to transfusion hemolysis, sepsis, or hepatic disease (lipidosis). Potassium supplementation was increased to 70meq/L. Her BP was now 112mmHg, CVP 2.5. Carrie ate very well.

At 24 hours, Carrie was clinically stable. However, her BUN increased to 58 and was still dehydrated. Her weight was 1.9kg. Subjectively high urine output was good, urine SG was 1.027. Carrie’s azotemia, dehydration, and loss of body weight were due to high fluid losses - high abdominal drain output, excessive urine output, or some combination of both. High urine output may be due to an inability to concentrate her urine due to the pyometra, or sepsis causing renal failure. Fluids/crystalloids were increased, monitoring CVP and respiratory effort. Dextrose and K+ supplementation was gradually weaned. Her albumin was 1.1, total bilirubin was 0.8, BUN was 57.

Fentanyl was discontinued and she placed on buprenorphine. Three days postop, her CVP was 2.5mmHg, and body weight had increased to 2.4kg. Abdominal drain output decreased and in-house cytology showed lessening but persistent bacterial infection. Ampicillin and enrofloxacin were continued. Albumin increased, hyperbilirubinemia resolved and BUN decreased to 35.

At 5 days after surgery Carrie was receiving a very low rate of IV fluids when her gallop became more prominent and she developed a mild increased respiratory rate and effort.

Radiographs of the thorax demonstrated cardiomegaly, trace pleural effusion, and bilateral alveolar infiltrates consistent with pulmonary edema. CVP was 9. Fluids were discontinued and she was given furosemide 5mgs IV. Her respiratory effort improved. CVP decreased to 5.

Carrie’s urine culture was negative. Her abdominal fluid culture was positive for Proteus mirabilis species sensitive to ampicillin and enrofloxacin. A repeat CBC showed mildly regenerative anemia. Cytology of drain fluid showed no bacteria and her abdominal drain was removed. CVP monitoring continued.

At 7 days postoperatively Carrie again developed increased respiratory effort, with effusion and edema. CVP was 12. She was again given furosemide 5mgs IV, and supplemental oxygen was given for over 24 hours. Carrie had developed signs of left sided congestive heart failure, off fluids. She likely had some significant underlying cardiac disease. A contributing factor may have been the 4-6 times daily CVP measurements, requiring infusions of several milliliters of fluids to obtain each reading. Her moderate anemia, over time can cause a high output cardiac state, could have contributed to heart failure.

She was started on enalapril in addition to furosemide. Carrie’s owners returned to her veterinarian for an echocardiogram and thyroid/CBC testing.

Carrie was sent home 10 days after presentation, on oral amoxicillin, enrofloxacin, furosemide, and enalapril. On recheck with her veterinarian 17 days postop for staple removal and blood work, Carrie’s WBC had decreased to 42,600, PCV was 21.

Carrie’s echocardiogram showed chronic valvular disease, severe mitral regurgitation and moderate tricuspid regurgitation causing left and right sided congestive heart failure. She was also diagnosed with systemic hypertension and started on amlodipine. Mild to moderate azotemia persisted while she was on diuretics and was managed with intermittent subcutaneous fluids. Her owner to date reports a 3 pound wt. gain and an excellent quality of life.

At VESCONE, our nurses and surgical team are certified in emergency and critical care which enables us to provide the best that emergency surgery and intensive care monitoring has to offer. We routinely do central venous pressure, direct and indirect blood pressure monitoring, transfusions, blood gas sampling and assessment, all bedside.

Please contact us any time if you need emergency surgery or to monitor your post op patient overnight.

Inhalation Therapy for Airway Disease

The latest approach to the management of inflammatory airway disease in our small animal patients is via inhalation therapy with metered-dose inhalers (MDIs). With inhalation therapy, high drug concentrations are delivered directly to the lungs and systemic side effects are minimized. The goals of inhalation therapy for inflammatory airway disease are to prevent recurrent exacerbations of bronchoconstriction and dyspnea, as well as to provide optimal chronic anti-inflammatory therapy with minimal adverse effects.

Human MDIs are designed for actuation during a slow, deep inhalation. Our patients necessitate the addition of a spacer, as their breathing pattern cannot be controlled in the same manner. Spacers decrease the amount of medication deposited in the oropharynx, reducing systemic drug absorption. Human MDIs may be modified for use in dogs and cats with suitable face masks. They are equipped with one-way valve leaflets that allow the owner to actuate the inhaler away from the animal, and then apply the spacer. Small animal-specific spacers are now available, and are often more convenient to use. The AeroKat™ and AeroDawg™ (Trudell Medical International, London, ON, Canada) spacers are valveless. They must be positioned over the animal’s face prior to actuation. The mask should be held over the animal’s face for 10 seconds, allowing them to take several breaths in order to deliver the proper, effective dose. Spacers allow metered dose inhalers to be used in our small animal patients with inflammatory airway disease. The drugs most commonly used in veterinary medicine in MDI formulations are ß2 agonists and glucocorticoids. Each product delivers a set amount of drug per actuation.

ß2 agonists in MDIs such as albuterol may be used to treat acute exacerbations of bronchoconstriction, as they relax smooth muscle and increase airflow. ß2 agonists do not control inflammation and their use alone may exacerbate airway disease. Inhaled glucocorticoids generally take 7-10 days to reach full effect. The potential risk of adverse side effects is well balanced by their efficacy in chronic management of inflammation. Currently, Fluticasone Proprionate (Flovent) is considered the most potent formulation with the longest duration of action. It is available in 44, 110, and 220 mcg per actuation. When inhaled ß2 agonists are used in conjunction with inhaled glucocorticoids, they should be administered 5 minutes prior to the glucocorticoid. The resulting bronchodilation results in increased deposition of the glucocorticoid in the smaller airways.

Therapy of inflammatory airway disease requires control of inflammation with relief of bronchospasm. Bronchodilators and anti-inflammatory drugs can be titrated to individual patients to achieve effective therapy. Initial treatment recommendations in cats with feline asthma and dogs with chronic bronchitis include albuterol, 90 mcg (one puff) as needed (PRN) and fluticasone, 110 mcg-220 mcg (one puff) twice daily. Some patients may benefit by starting with a 5 day overlap of oral prednisone at 1 mg/kg. In patients with severe disease, long term, low dose concurrent oral prednisone (1 mg/kg every 2-3 days) may be necessary.

In summary, inhalation therapy has improved our ability to treat cats and dogs with chronic
inflammatory airway disease. It has allowed our patients to receive the benefits from these
medications without the side effects that are often intolerable. There is no one set protocol that works for all patients, however there is most often a combination of therapy available to control our most difficult cases.