Sepsis is a highly fatal and costly disease; however, initially its presentation is not very dramatic often leading to delayed onset of treatment.

In 1991 the American College of Chest Physicians and the Society of Critical Care Medicine celebrated a Consensus Conference in order to establish certain concepts.

Definitions

SIRS: Systemic inflammatory response syndrome is considered clinically to be the systemic manifestation of inflammation due to either infectious or non-infectious causes.

Sepsis is defined as SIRS with (probable or documented) presence of bacterial, viral or fungal infection.

MODS: Multiple organ dysfunction syndrome as a result of SRIS or sepsis.

Systemic inflammatory response syndrome is considered present if dogs demonstrate at least 2 and cats at least 3 of the following 4 abnormalities.

SIRS criteria for dogs¹

SRIS criteria for cats¹

In 2004 the Surviving Sepsis Campaign (SSC) committee published the conclusions for sepsis, severe sepsis and septic shock management.²

The objective of this campaign is a 25% reduction in mortality rate, by establishing treatment objectives for the first hour and first six hours.

10 Tips for Successfully Treating Sepsis

Initial Resuscitation. Identify and Treat Shock Early and Aggressively³

Early goal-directed therapy in the emergency room improves survival. In a single center randomized control study, in hospital mortality was reduced from 46.5 to 30.5 percent when goal-directed therapy vs. standard therapy was utilized in the emergency room. The initial resuscitation period is defined as the first 6 hours after presentation. This goal directed approach is recommended in patients who present with lactate values greater than 4 mmol/L or are hypotensive on presentation. Goals of resuscitation are; a central venous pressure (CVP) of 8–12 mm Hg, a mean arterial pressure ≥ 65 mm Hg, urine output ≥ 0.5 ml/kg/h, and a central venous (cranial vena cava) oxygen saturation ≥ 70%.

The ability to measure blood gasses and lactate are also required. Very few people in veterinary medicine have the equipment to measure oxygen saturation. Based on the normal canine and feline oxyhemoglobin dissociation curves oxygen tension can be used, as a saturation of ≥ 70% is a PO₂ ≥ 42 mm Hg in a dog and ≥ 45 mm Hg in a cat. The following protocol is adapted from human guidelines.

Early Goal-Directed Therapy (EGDT)/First 30–60 Minutes

 Objectives: reestablishment of aerobic metabolism

 Goals (resuscitation end points)

 SBP > 100 mm Hg, MAP a 60–80 mm Hg

 Jugular refilling time < 2 sec. (then CVP 8–12 cm H₂O)

 Improvement of conscience

 Central T ≥ 36,6°C

 DT < 3°C

 10% Clearance of lactate

 Therapeutics

 Warm crystalloid bolus

 10 ml/kg within 3 min, adult dogs

 10 ml/kg within 6 min, cats and puppies

 Wait 5 min and evaluate goals

 If the goals were not achieved, give another crystalloid bolus

 2 or 3 crystalloid bolus without results

 Colloid or 7.5 % hypertonic saline bolo de colloid bolus

Keep Suspicion High

 Be proactive if SIRS signs; present look for the infectious source.

 Pneumonia.

 Pyothorax.

 Septic peritonitis.

 Pyometra.

 Prostatic infection.

 Multiple trauma.

 Nosocomial infection.

 5 times more frequent in ICU (25%).

 High probability of multiple resistant microorganism. It is important to know the microorganisms causing nosocomial infections in your clinic and their antibiotic sensibility. Monitor and register all the cases that are suspicious of having acquired a nosocomial infection. Perform serial programed cultures of different hospital areas (door holders, chlorhexidine solutions, veterinary technicians and doctors hands, etc.).

Diagnose the Infectious Agent

 Obtain samples for culture before starting antibiotic therapy.

 Samples.

 Blood (hyperthermia), abdominal fluid, tracheobronchial lavage, synovial fluid, urine.

 Bacteria?

 Urinary sediment/cytology/look for intracellular bacteria.

 Culture.

 Histopathology.

 Virus? Point-of-care (POC) tests.

 FIV/FeLV cats.

 Parvovirus/distemper.

 Images (RX thorax, AFAST).

 Name the process by identification of the origin.

 Pneumonia + fever + leukocytosis.

 UTI + fever + tachycardia.

Diagnose Sepsis

 Biomarkers.

 Early diagnosis early treatment.

 Veterinary biomarkers.

 C reactive protein does not differentiate infectious from no-infectious causes of SRIS.

 NTpCNP N-terminal peptide derived from type C natriuretic.

 Present in the vascular endothelium. Does differentiate sepsis from SRIS.

Administer Appropriate ATB IV and Early in the Course of Disease

 Mortality significantly increases for every hour of delay before the start of antibiotic therapy. For every 1 hour after the first 6 hours a patient is diagnosed with septic shock that does not receive appropriate antimicrobial therapy, mortality increases 7.6%. Twenty-four hours of ineffective antimicrobials will reduce the chance of survival to approximately 20%.

 Understand the origin of the pathogens and their antibiotic sensibility.

 Know local and nosocomial resistances.

 High proportion of E. coli septic peritonitis resistant to a fluoroquinolone.

 Start empiric ATB until ATB gram.

 G-: amikacin (if normal renal function) or ceftriaxone (if azotemic).

 Clindamycin broad spectrum for nosocomial infections and multiple resistance.

Do Not Underestimate the 2O Hit

Hypothermia/hypotension/reduced transport of O₂.

Secondary Treatment/End Points for the First 6 Hours

 T ≥ 36,6°C in 1 h/normalization in 4 h

 10% lactate clearance in 6 h

 SBP > 100 mm Hg

 MAP > 65 mm Hg

 DU > 0,5 ml/kg/h

 CVP 8–12 mm Hg dog/8–10 mm Hg cats

 Normalize DO₂ and VO₂

 SvO₂ > 70%

 Lactate curve and y CVP (if SvO₂ not available)

Prevent Central Temperature Drop

 Cover with blankets (external passive warming) and internal warming systems

 Provide warm fluids and oxygen until MAP > 60–80 mm Hg

 Ideal crystalloid T 40°C⁴

 Warm peritoneal and pleural lavage (40–43°C)

 Warm enemas

Cardiac Function + Peripheral Resistance

 SPVC > 8 mm Hg and central T > 36.6°C in the absence of clinical improvement

 Check cardiovascular function and peripheral resistance

 Administer inotropic and/or vasopressors

 Dopamine is acceptable as initial therapy (inotropic effect)

 Norepinephrine is the first choice vasopressor agent

 0.1–0.4 mcg/kg/min to target a MAP > 65 mm Hg

O₂ Transport

 If PVC 8–12 mm Hg + SvO₂ < 70%

 Provide red blood cells until PCV 30%/Hb > 11 mg/dl

 Dobutamine 20 μg/kg/min

 Mechanical ventilation SaO₂ > 93%

Early Control of the Focus

Identify the specific anatomic site and apply control measures (e.g.; abscess drainage, tissue debridement, exploratory laparotomy) as soon as possible following initial resuscitation. The least physiologic insulting method should be employed (e.g., percutaneous rather than surgical drainage of an abscess).

Early Instrumentation

 Place as many IV access as required

 Place central venous access (monitor CVP)

 Arterial catheterization recommended if vasopressors

 Feeding tubes

 Urinary catheterization (urinary output)

 Early weaning once stable

Suspect/Prevent Nosocomial Infections

 Adequate hand hygiene

 Avoid watches or rings and nail polish

 Adequate hand lavage before, during and after patient care

 Alcohol gel

 Gloves

 Do not replace good hands hygiene/wash hands before and after wearing gloves

 Do not touch surfaces that others would touch with bare hands (instruments, door holders, gauze, alcohol, pens, etc.)

 Use a different pair when: in between a dirty to a clean procedure, between patients

 Other sources

 Venous and urinary

 Prevent bacterial translocation (provide adequate nutrition, cover wounds, surgical scrub)

 TPN total parenteral nutrition/transfusions

 Never trust a GI postop

Be Prepared for MODS

 Renal function: [Creatinine] > 0.5 mg/dl, without pre- and post-renal causes)

 Cardiovascular (shock, myocardial dysfunction)

 Respiratory failure

 Hepatic failure (total bilirubin > 0.5 mg/dl)

 CID (thrombocytopenia, PT, PTT or ACT, TEG)

 GI (vomit, ileum, constipation, diarrhea)

 Endothelial dysfunction

Actively look for the problem, constant monitoring is a key factor.

Conclusion

Transform the guides in objective applicable tools and implement motivational and reevaluation tools to monitor the impact of the implemented strategies.

References

1.  Otto C. International Veterinary Emergency and Critical Care Symposium. 2006.

2.  Hauptman. J Vet Surg. 1996.

3.  Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM, Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004;32:858–873.

4.  Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med. 2004;30:536–555.

5.  Hackett T. Biosecurity and infection control in your ICU. In: Proceedings from the 17th International Veterinary Emergency and Critical Care Symposium. September 14–18, 2011; Nashville, TN.

6.  Sharp CR. Top 10 Tips for a successful outcome in sepsis. In: Proceedings from the 17th International Veterinary Emergency and Critical Care Symposium. September 14–18, 2011; Nashville, TN.

7.  Chiang V, Hopper K, Mellema MS. In vitro evaluation of the efficacy of a veterinary dry heat fluid warmer. J Vet Emerg Crit Care. 2011;21(6):639–647.