Septic Patient: Approach and Medical Management
World Small Animal Veterinary Association World Congress Proceedings, 2003
Luis H. Tello, DVM, MS
Small Animal Teaching Hospital, University of Chile
Chile

Septic shock is a common complication in small animal practice and the most common cause of shock in most humans ICU. Many pathologic conditions can result in spread infection and associated Shock. The overuse of corticoids, immunosuppressive therapies, the wide spread use of IV catheters are some of the reasons that septic shock has become more familiar for Veterinary practitioners.

Effective management requires prompt recognition of early clinical signs related to systemic inflammation: mental depression, hyper or hypo body temperature, elevated heart rate, respiratory impairment in addition to a potential source of infection.

Shock has been defined as a critical imbalance of cellular energy production because failure in the delivery of oxygen and nutrients to the cell and utilization of oxygen and nutrients by the cell. More than 90% of the energy that the cell spends is about to survive from an aggressive environment. Shock may be result from any syndrome, diseases state, or injury that leads to a critical decrease in effective blood flow to the tissues, leads to derangement in cellular metabolism and ultimately cell death.

Sepsis is defined as the systemic inflammatory response to infection. Therefore systemic inflammatory response syndrome (SIRS) is a complicate syndrome that may occur as a result of trauma, burn, sepsis and is currently defined as patients that show two or more of the following criteria:

 Temperature > 39.7 or < 37.8 oC

 Respiratory rate > 30 bpm or PaCO2 < 32 mm Hg.

 Heart rate > 160 bpm (dog) or > 250 bpm (cat)

 White blood cell count > 19,000 or < 4,000 or > 10% band neutrophils

Septic shock is actually a combination of the 3 types of Shocks: hypovolemic, cardiogenic and distributive. In early stages of septic shock (hyperdynamic phase), patients may show dark red mucous membranes with a short capillary refill time (CRT<1 second), elevated heart and respiratory rate, fever, bounding pulses and signs associated to peripheral vasodilation. In more advanced stages mucous membranes may see grey and dry, Increased CRT, weak pulses. These patients need a Emergency Team approach, because the different procedures and exams that such a patient require.

Data about of septic patients should be collected to determine if they have any predisposing factor in history as immunosuppressive therapy or chemotherapy, as well metabolic diseases such as Cushing's Syndrome, Diabetes mellitus or viral infections as Parvovirus.

Blood samples should be obtained for culture, complete blood count, prothrombin time, partial thromboplastin time, clinical chemistry panel and blood gas evaluation. In the same way, urine sample must be obtained by centesis for urinalysis and culture.

The aim of treatment in septic shock is care, improve and maximize oxygen delivery to the tissues to address their demands. Two or three largest possible catheter should be placed for fluid administration and if possible, a jugular catheter for asses central venous pressure.

The adequate fluid and administration rate choice for fluid therapy remains as a very controversial issue. Initially you can start with a crystalloid fluid at 70-90 ml/kg in dogs, 45-60 ml/kg in cats, looking forward a hemodynamic stability (Blood pressure, Capillary refill time, Central Venous Pressure, Good quality and rate Femoral Pulse, Mucous Membrane Color, Peripheral temperature).

If there is not adequate response to therapy, the remainder volume can be given as a colloid such as Haemacell, Dextran or Hetastarch (10-20 ml/kg/day). Therefore, colloids should also be considered if the total protein is less than 3.5 gm/dl. In cats, the best response is achieved with colloid bolus 5-10 ml per cat. If there is a glucose level less than 60 mg/dl, a bolus of 50% dextrose should be given at a volume of 0.5-1 ml/kg, diluted with and equal volume of saline, IV.

If the microorganism source can be identified, samples should be aseptically obtained and submitted for culture and sensitivity. While wait for the culture results, antibiotic therapy should be instituted. Broad-spectrum antibiotics should be selected based on the suspected pathogen organism.

Intravenous empirical antimicrobial therapy directed to all potential infections sources should be given as early as possible. Coverage should always include Staphylococcus, Streptococcus and E. Coli.

Infectious process requiring surgical drainage or debridement should be treated promptly. Cardiopulmonary unstable function is not an acceptable reason to delay surgical treatment if sepsis is the cause of instability.

Frequent complications associated to the Septic Shock patients are sepsis and GI ulceration. Use of Famotidine, Ranitidine may help to reduce the risk of ulceration. If there is evidence of GI hemorrhage, Sucralfate is indicated by oral tube if needed.

Nutrition is the key to maximize the likelihood of healing in septic patients, and enteral nutrition is the best choice to feed both to the patient and to the enterocytes. If the patient do not eat despite adequate GI protective and antiemetic drugs, a pharyngei-esophageal tube can be placed for short-term enteral nutrition. Otherwise, total parenteral nutrition (TPN) is very expensive and does not provide nutritional support of the enterocytes.

Finally, good hospital care is very important for the patient's well being, like prevention of decubital ulcers keeping patients on soft padded surfaces covered with absorbent material to prevent scalding by urine and feces. Catheters must to be checked daily and the entrance point must be routinely disinfected.

Antibiotics and doses recommended in septic patients

Drug

Dosage

Route

Freq

Gram Spectrum

Ampicillin

20-40 mg/kg

IV

TID

G+, G-, some anaerobes

Penicillin G,

20,000-

IV, IV,

TID

G+, G-, anaerobes

aqueous

100,000 U/kg

SC

Cefazolin1

20 mg/kg

IV

TID

G+, some G-, some anaerobes

Cephalothin1

20-30 mg/kg

IV

QID

G+, some G-, some anaerobes

Cefotaxime3

20-80 mg/kg

IV, IM

TID

G+, some G-, some anaerobes

Cefoxitin2

20 mg/kg

IV

TID

some G+, some G-, some anaerobes

Trimethoprimsulfa

15 mg/kg

IV, IM

BID

some G+, G-, some anaerobes

Enrofloxacin

5-10 mg/kg 5-20 mg/kg

IV IV

SID

some G+, G-

Ciprofloxacin

5-15 mg/kg 10-20 mg/kg

PO PO

SID

some G+, G-,

Amikacin

10-15 mg/kg

IV

SID

few G+, good G-,

Gentamicin

6-9 mg/kg

IV, IM, SC

SID BID

few G+, good G-,

Tobramycin

2-4 mg/kg

IV

TID

few G+, good G-,

Clindamycin

10-12 mg/kg

IV

BID

some G+, few G-, anaerobes

Metronidazole

10 mg/kg

IV as CRI

TID

Anaerobes, protozoa

1first, 2second, 3third generation

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Luis H. Tello, DVM, MS
Teaching Veterinary Hospital
College of Veterinary Medicine, University of Chile
Chile


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