Diagnosis/classification

Question 1

What are the elements of the SOFA score and qSOFA score?

Answer 1

SOFA (0-4, score of > or = 2 –> at least 10% mortality in humans):
1. PaO2
2. Platelets
3. Serum bilirubin
4. Hypotension
5. GCS
6. Serum creat (mg/dL)

qSOFA (> or =2 increases likelihood of poor outcome)
1. Altered mentation
2. SBP < or = 100mmHg
3. RR > or = 22mmHg

Question 2

What are the elements of the APPLE scores in dogs? (acute patient physiologic and laboratory evaluation)

Answer 2

APPLE full: (max score 80)
1. Creat
2. WBC
3. Albumin
4. SpO2
5. Tbil
6. Mentation score
7. RR
8. Age
9. Fluid score
10. Lactate

APPLE fast: (max score 50)
1. Glucose
2. Albumin
3. Lactate
4. PLT
5. Mentation score

Question 3

What are the elements of the APPLE scores in cats

Answer 3

APPLE full: (max score 80)
1. Mentation score
2. Temperature
3. MAP
4. Lactate
5. PCV
6. BUN
7. Chloride
8. Body cavity fluid score

APPLE fast: (max score 50)
1. Mentation score
2. Temperature
3. MAP
4. Lactate
5. PCV

Question 4

What are the criteria for SIRS diagnosis in dogs and cats?

Answer 4

Depends on reference

Dogs 2/4 changes required
Cats 3/4 changes required

1. Temperature
   - Dogs: <38.1or > 39.2
   - Cats: <37.8 or > 40
2. HR
   - Dogs: > 120bpm
   - Cats: <140 or > 225bpm
3. RR
   - Dogs: > 20brpm
   - Cats: > 40 rpm
4. WBC (x 10^9/L); %bands
   - Dogs: < 6 or > 16; > 3%
   - Cats: < 5 or > 19

Question 5

What was the outcome of the 2015 study looking at usefulness of point-of-care glucometer to identify septic peritonitis in dogs?

Answer 5

• The glucose concentration difference between whole blood and peritoneal effusion using POC glucometer cannot be used to reliably identify septic peritonitis (lots of false negatives using cutoff of 20mg/dL, Sp 100% but Se 40%)
• Difference between plasma and peritoneal fluid as well as plasma and peritoneal fluid supernatant had acceptable sensitivity (80-88%) when using > 20mg/dL cutoff but Sp decreased to ~80% ; specificity improved when using > 38mg/dL cutoff (with same Se)

Question 6

Define sepsis and septic shock

Answer 6

1. Sepsis-3 definitions:
   - Sepsis: life threatening organ dysfunction caused by a dysregulated host response to infection (organ dysfunction defined as change in SOFA score ≥ 2)

• Septic shock: subset of sepsis with circulatory and cellular dysfunction associated with higher risk of mortality (identified by requirement of vasopressors to keep MAP ≥ 65 and persistence of lactate > 2 mmol/L despite adequate volume resuscitation)

2. Veterinary definitions:
   - Sepsis: Systemic inflammatory response to infection (= fulfilment of SIRS criteria + confirmed infection)

• Severe sepsis: Sepsis with organ dysfunction and/or hypoperfusion
• Septic shock: Sepsis with persistent arterial hypotension that is not responsive to fluid therapy (= vasopressor dependent)

Question 7

For what is the use of qSOFA score recommended in humans? Is it useful in veterinary patients?

Answer 7

For humans recommended as screening tool for hospitalized patients (to identify sepsis)

Not correlated with presence of sepsis or mortality in overall veterinary patients (cut-offs not appropriate) but correlates with higher mortality in subset of patients with sepsis

Question 8

Define MODS

Answer 8

Multiple organ dysfunction syndrome = presence of two or more dysfunctional organs in an acutely ill patient such that homeostasis cannot be maintained without intervention

Question 9

What screening tools can be used to identify patients with sepsis

Answer 9

• SIRS criteria
• National Early Warning Score (NEWS) in humans - based on mentation, HR, SBP, T, SpO2, RR
• SOFA score and qSOFA score - not very useful as screening tool in veterinary medicine and controversial in humans (not recommended over SIRS or NEWS)
• Could use APPLEscore but not very practical as screening tool

Question 10

How can CIRCI be identified

Answer 10

• No good test to identify it - treatment should be based on prolonged vasopressor requirement and not on tests
• Can measure cortisol difference after an ACTH stim (in septic dogs, delta cortisol < 3 ug/dL (83 nmol/L) following standard or low dose ACTH stimulation indicates a higher likelihood of being hypotensive / needing vasopressors and mortality)

Question 11

List some biomarkers of sepsis / SIRS

Answer 11

• HMGB-1 (peaks ~72h after initiation of inflammation)
• TNF-alpha but peaks within 2h and quickly becomes undetectable
• IL-6 - could be associated with mortality
• Keratinocyte chemoattractant-like (KC-like)
• CCL2 (chemokine) - also predictor of death
• Cell-free DNA
• CRP (peaks ~36h after initiation of inflammation) - in dogs
• SAA
• Procalcitonin - could be associated with mortality
• These biomarkers are not specific for sepsis and usually not correlated with mortality