Seminal articles 2021 Flashcards

Question 1

Q

Ionized hypocalcemia in critically ill dogs. JVIM 2009. Holowaychuck

Main takeaway points (3)

Answer

A

Incidence if ionized hypoCa = 16%
Septic dogs w/ +ve culture more likely to have iHypoCa
iHypoCa associated w/ longer ICU stay

Question 2

Q

Ionized hypocalcemia in critically ill dogs. JVIM 2009. Holowaychuck et al

Causes of iHCa in critically ill (6)

Answer

A

Parathyroid gland dysfunction
Cytokine-mediated suppression of PTH release
Vit D deficiency of lack of vit D activation
HypoMg
Ca2+ chelation
Accumulation of Ca2+ in tissue, body fluids nd cells

Question 3

Q

Effects of fluid therapy on total protein and its influence on calculated unmeasured anions in the anesthetized dog. JVECC 2008. Valverde et al

Main takeaway point

Answer

A

Degree of TP decr after 10 mL/kg of IVF did NOT affect unmeasured anions when compared to pre-fluids TP

-TP, Hgb, PCV and AG were decreased while K+ increased with IVF

Question 4

Q

Electrocardiographic assessment of hyperkalemia in dogs and cats. JVECC 2008. Tag et al

Main takeaway points (2)

Answer

A

HyperK in critically ill dogs and cats don’t correlated well w/ ECG
Strongest correlation when K>8.5 mEq/L

Question 5

Q

Electrocardiographic assessment of hyperkalemia in dogs and cats. JVECC 2008. Tag et al

How does hyperK affect cell membrane potential

Answer

A

Resting [K+] determines resting membrane potential (RMP)
K+channels are open @ rest
Increased [K+] will reduce the conc gradient across the membrane –> less -ve RMP
Although increasing K+ will make the RMP less negative, increasing K+ also inactivate the Na/K channels (=allows K+ efflux) therefore the cells actually much slower in reaching the threshold potential
Decreased K+ permeability slows K+ efflux during phase 3
Altered permeability ends when slow Ca channel closes and K+ influx returns RMP to the resting state

NET EFFECT: Depress upstroke velocity and prolongs duration of action potential

Question 6

Q

Electrocardiographic assessment of hyperkalemia in dogs and cats. JVECC 2008. Tag et al

Body protection vs hyperK (2)

Answer

A

Intracellular shift of K+ - b2 receptors
Renal excretion of K+ –> Direct effect of K+ on K channels in principall cells AND indirect effect of incr aldosterone release

Question 7

Q

Electrocardiographic assessment of hyperkalemia in dogs and cats. JVECC 2008. Tag et al

How does hyperK change ECG

Answer

A

5.5-6.5 mEq/L: Incr T wave
6.6-7 mEq/L: Decr R wave amplitude, prolonged QRS and PR interval, ST segment depression
7.1-8.5 mEq/L: Decr P wave amplitude and polonrged QT interval
8.6-10 mEq/L: No p waves (atrial standstill) and sinoventricular rhythm
>10 mEq/L: Widened QRS complex –> smooth biphasic waveform, ventricular flutter/vfib –> asystole

Question 8

Q

Arterial thromboembolism in 250 cats in

general practice. JVIM 2014. Borgeat et al

Answer

A

prevalence ATP 0.3%
61.2% euth at presentation
70.1% of remaining served >24h after pres
of these 44.1% survived for at least 7 d
for cats that survived > 7d, MST 94 days
6 cats alive one year post-presentation

Indepen predictors of 24 hr death/euth:

hypothermia
management by clinic 2

Indepen predictors of > 24hr w/in 7d death/euth:

hypothermia
failure to receive aspirin, clopidogrel or both

Question 9

Q

TRISS trial
Lower versus higher hemoglobin threshold for transfusion in
septic shock. NEJM 2014

Answer

A

In patients w/ septic shock (ICU setting), transfusion threshold of 7g/dL compared to 9g/dL had NO difference in mortality (90d) and rates of ischemic events

higher threshold had 50% fewer blood transfusion
supports surviving sepsis guidelines

Question 10

Q

LIFENOX trial

Low-molecular-weight heparin and mortality in acutely ill medical patients. NEJM 2011

Answer

A

Enoxaparin + elastic stockings compared to placebo + elastic stockings did NOT reduce rate of death from any cause among hospitalized, acutely ill patients

Question 11

Q

Acute lung injury following blood transfusion: Expanding the definition. CCM 2008 Marik

definition of TRALI

Answer

A

bilateral alveolar infiltrates
PF ratio <300mmHg
clinical exclusion of CHF
no preexisting ALI before transfusion
onset of signs occur w/in 6 hours of transfusion
no temporal relationship to alternative ALI risk factors

Question 12

Q

Acute lung injury following blood transfusion: Expanding the definition. CCM 2008 Marik

theory for TRALI (2)

Answer

A

1 antibody-mediated rx (classic TRALI)

#2 interaction b/w biologically active mediators in banked blood products and the lungs - phenomenon of immunomodulation 2-hit theory
(delayed TRALI)

Question 13

Q

1 antibody-mediated theory

Acute lung injury following blood transfusion: Expanding the definition. CCM 2008 Marik

Answer

A

transfusion of anti-granulocyte antibodies (donor plasma) into patients w/ leukocytes that antigens
> complement activation, pulmonary sequestration + activation of neutrophils, endothelial damage (capillary leak syndrome)
multiparous female donors

Question 14

Q

2 biologically active mediators

Acute lung injury following blood transfusion: Expanding the definition. CCM 2008 Marik

Answer

A

Released by stored WBC: histamine, eosinophilic cationic protein, eosinopihlic protein X, myeloperoxidase, PAI-1

Released by stored RBC: IL-1, IL-6, IL-8, bactericidal permeability-increasing protein, PLA2, TNF-a

Question 15

Q

2 sequence of events

Acute lung injury following blood transfusion: Expanding the definition. CCM 2008 Marik

Answer

A

1st event: Pulmonary endothelial activation + neutrophil sequestration

2nd: Mediators activate adherent neuts –> endothelial damage, capillary leak, TRALI

Question 16

Q

Acute lung injury following blood transfusion: Expanding the definition. CCM 2008 Marik

TRALI histology

Answer

A

early ARDS: interstitial and intraalveolar edema, neutrophil extravasation into interstitium + air space
increased # of neuts w/in pulmonary capillary vasculature + small pulmonary vessels

Question 17

Q

Acute lung injury following blood transfusion: Expanding the definition. CCM 2008 Marik

delayed TRALI

timing
patient population
characteristic

Answer

A

6-72 hrs after
slow development
risk factors: sepsis, trauma, burns, ICU patient,
multiple units  
resolves slowly 
uncommon to have a fever

Question 18

Q

Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care. CCM 2009

Answer

A

use in hemorrhagic shock
use in acute hemorrhage, hemodynamic instability/inadequate DO2
Restrictive strategy (7 vs 10 g/dL) is effective in hemodynamically stable anemia
Consider if Hgb<7g/dl and (1) requiring mechanical ventilation, (2) resuscitated ill trauma patients, (3) those w/ stable dz
Not used as an absolute method to improve tissue O2 consumption
assess septic patients individually
avoid transfusion in those @ risk of ALI/ARDS
RBC transfusion is an independent risk factor for MOF and SIRS
RBC transfusions independently associated w. longer ICU + hospital stay, incr complications, incr mortality

Question 19

Q

Correlation of hematocrit, platelet concentration, and plasma coagulation factors with results of thromboelastometry in canine whole blood samples. AJVR 2012 Smith

2 main points

Answer

A

Coagulation time is determined by coag factor concentration; other variables dependent on plt + fibrinogen concentration
HCT affects tracing (RBC acts as a diluent for plasma coag factors): Anemia leads to artifactual hypercoagulability and vice versa

Question 20

Q

Decontamination of the digestive tract and oropharynx in ICU patients. NEJM 2009

Answer

A

Mortality decreased by 3.5% with selective digestive decontamination (SDD) and 2.9% with selective oropharyngeal decontamination (SOD)

SDD: IV and topcai ABX to prevent 2ry g-ve colonization

SOD: application of topical antibiotics in the
oropharynx only:

Question 21

Q

Refractometric total plasma protein measurement as a cage-side indicator of hypoalbuminemia and hypoproteinemia in hospitalized dogs. JVECC 2011 Hayes

2 main points

Answer

A

Hypercholesterolemia and hyperglycemia falsely increased total plasma protein (TPP) readings
Refractometric TPP<5.8 g/dL is strongly indicative of both serum hypoalbuminemia and hypoproteinemia, with high specificity

serum totl protein (g/L) = 0.3 +0.84 (refractometric TPP [g/L]

Question 22

Q

Red cell distribution width and all-cause mortality in critically ill patients. CCM 2013

What is RDW and why does it matter

mechanism of why it predicts mortality

Answer

A

red cell distribution (RDW) expression of the variation of the size of RBC

RDW = RBC / MCV

RDW is a strong predictor for all-cause mortality in people

Question 23

Q

Red cell distribution width and all-cause mortality in critically ill patients. CCM 2013

main findings (2)

Answer

A

RDW >=13% was a strong predictor for all-cause mortality and bloodstream infection

RDW-associated mortality is independent of anemia when RDW>14.7%

Question 24

Q

Red cell distribution width and all-cause mortality in critically ill patients. CCM 2013

mechanisms (3) of why RDW predicts mortality

Answer

A

inflammation

oxidative stress –> contribute to high RDW by reducing RBC survival + release of immature RBC

atrial underfilling and activation of RAAS –> accelerate erythrocytosis and incr RDW via macrocytosis

Question 25

Q

Primary splenic torsion in dogs: 102 cases (1992-2014). JAVMA 2016 DeGroot

Main findings-prognosis

Answer

A

91.2% survival

GSD, Great Dane, and English Bulldogs

Proposed causes: congenital absence of weakness of supporting splenic ligament or acquired laxity d/t sx, trauma, or preivous GDV

Question 26

Q

Primary splenic torsion in dogs: 102 cases (1992-2014). JAVMA 2016 DeGroot

Risk factors for death prior to hospital discharge

Answer

A

septic peritonitis @ presentation, intra-op hemorrhage, post-op resp distress

mortality 8.8%

Question 27

Q

Predicting Outcome in dogs with Primary Immune-Mediated Hemolytic Anemia: Results of a Multicenter Case Registry. JVIM 2015. Goggs

outcome

Answer

A

Survival: 74% discharged, 68% alive at 30d

CHAOS score (>=3) associated w/ death in hospital and in 30 days 
Tokyo score not associated w/ either

Question 28

Q

What is included in

CHAOS
Tokyo score

Answer

A

Canine hemolytic anemia objective score (CHAOS): Age, temp, agglutination, alb, bil

Tokyo: sex, season, PCV, PLt count, TP

Question 29

Q

Predicting Outcome in dogs with Primary Immune-Mediated Hemolytic Anemia: Results of a Multicenter Case Registry. JVIM 2015. Goggs

Parameters included in the new score

Answer

A

SIRS-classification
ASA classification
Tbil
ALT
bun
Creatinine

Accuracy 82% to predict outcome at discharge

Question 30

Q

Treatment and predictors of outcome in dogs with immune-mediated thrombocytopenia. JAVMA 2011 O’Marra

main points (3)

Answer

A

84% survival. 9% relapse
Melena + high BUN @ admission associated w/ decr probability of survival

takes 4 days for plt to improve
megakaryocyte hypoplasia was poor px indicator previously identified but not here

Results: Dog ages ranged from 5 months to 15 years (median, 8.1 years). Cocker Spaniels were overrepresented, compared with their distribution in the entire hospital population during the same period. Sixty-one of the 73 (84%) dogs survived to discharge. Seven (11 %) of those dogs were lost to follow-up. Five of the remaining 54 (9%) dogs had a relapse of the disease. The presence of melena or high BUN concentration at admission to the hospital was significantly correlated with a decreased probability of survival.

Question 31

Q

Mechanism of ITP

Answer

A

Anti-plt antibodies adhere to plt surface Ag –> Fc receptor mediated phagocytosis of plt by macrophages –> thrombocytopenia

Originate @ level of megakaryocyte

Question 32

Q

Metabolic and toxic causes of canine seizure disorders: A retrospective study of 96 cases. Vet J 2016 Brauer

Most common causes of seizures

Answer

A

Intoxication (metaldehyde, OP or carbamate poisoning)
Hypoglycemia
Electrolyte: hypocalcemia (<0.69 mmo/L)

Question 33

Q

Metabolic and toxic causes of canine seizure disorders: A retrospective study of 96 cases. Vet J 2016 Brauer

Differentials for hypoglycemia causing sz (6)

Answer

A

Insulinoma (proven or suspect)
Paraneoplastic
Iatrogenic insulin OD 
Juvenile hypoglycemia
Lactation
Hunting dog hypoglycemia

Question 34

Q

DECRA trial
Decompressive craniectomy in diffuse traumatic brain injury. NEJM 2011

3 findings

Answer

A

In those w/ diffuse TBI and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy decreased ICP and length of ICU stay

Increased more unfavorable outcome w/ sx (incr sx complications, hydrocephalus, worse GCS)
-maybe sx allowed expansion of swollen brain outside of skull -> axonal stretch

No difference b/w rate of death at 6 months

Question 35

Q

Status epilepticus and epileptic seizures in dogs. JVIM 2009 Zimmermann

main findings (3)

Answer

A

Dogs w/ reactive sz due to poisoning had a higher risk of developing status as 1st manifestation

Dogs w/ SE due to poison had better survival than dogs w/ symptomatic sz

Dogs w/ symptomatic epilepsy had lower % of survival compared to IE

Question 36

Q

Status epilepticus and epileptic seizures in dogs. JVIM 2009 Zimmermann

Spayed females had a higher risk of developing ES or SE. This is odd. Why?

Answer

A

Esotrgen has proconvulsive effect and progesterone has anticonvulsive effect

Intact females should be more at risk and this has been shown in older studies

They don’t know why

Question 37

Q

Status epilepticus and epileptic seizures in dogs. JVIM 2009 Zimmermann

Cause of neuronal death in status

Answer

A

Excitotoxicity related to glutamate and extracellular Ca2+ entering via NMDA glutamate receptor

Question 38

Q

CALORIES TRIAL
Trial of the route of early nutritional support in critically ill adults. NEJM 2014

main findings (3)

Answer

A

Early nutrition via either route (parenteral vs enteral) had no difference in mortality
Caloric intake similar in both
EN group had more complications- hypoglycemia, vomiting

Question 39

Q

RENAL TRIAL
Intensity of continuous renal replacement therapy in critically ill patients. NEJM 2013

main findings (2)

Answer

A

Tx with high-intensity CRRT (40ml/kg/hr vs 25 ml/kg/hr) didn’t improve mortality at 90 days with patients w/ AKI
- also no diff in complication
Hypophosphatemia more common in high-intensity group

CRRT in CVVHDF, replacement post-filter

Question 40

Q

Glomerular Filtration Rate, Urine Production, and Fractional Clearance of Electrolytes in Acute Kidney Injury in Dogs and Their Association with Survival. JVIM 2015 Brown

main findings (3)

Answer

A

GFR not sig .diff b/w outcome groups but increased in survivors
FCNa decreased overtime
Extraction ratio and fractional clearance of Na were correlated

Incr GFR, UOP and decr FCNa were markers of renal recovery
FC K decreased progressively through study

Question 41

Q

Glomerular Filtration Rate, Urine Production, and Fractional Clearance of Electrolytes in Acute Kidney Injury in Dogs and Their Association with Survival. JVIM 2015 Brown

Normal FC K and FC Na

Answer

A

FC K = <20%

FC Na <1%

Both were increased @ presentation = AKI causing dysregulation of solute excretion

Question 42

Q

The implication of FC Na reduction during AKI treatment

FCNa’s use in AKI prognostication?

Answer

A

Progressive decr reflects PCT function is restoring
(can be influenced by Na-containing fluids)

FCNa used to ddx between volume-responsive (pre-renal AKI) and intrinsic AKI

High FCna (>2-3%) = morphological tubular injury
Lower FCNa (<1%) = transient, nonoliguric AKI

Question 43

Q

Fractional clearance of what other solutes have been looked at in AKI? (5)

Answer

A

BUN, Ca, MG, Phos, glucose

High FC glucose indicates PCT damage

Question 44

Q

Evaluation of risk factors associated with recurrent obstruction in cats treated medically for urethral obstruction. JAVMA 2013 Eisenberg

Main findings (3)

Answer

A

Associated w/inc risk of rUO: older cats

Associated w/dec risk of rUO: longer duration of cath, incr water after d/c

-use 3.5Fr polypropylene cath (tom cat) to unblock then replaced w/ red rubber

Question 45

Q

Evaluation of risk factors associated with recurrent obstruction in cats treated medically for urethral obstruction. JAVMA 2013 Eisenberg

rUO rate in this study

Answer

A

15% rUO w/in 1 month

Question 46

Q

Evaluation of risk factors associated with recurrent obstruction in cats treated medically for urethral obstruction. JAVMA 2013 Eisenberg

How did longer catheterization help? (3)

Answer

A

resolution of urethral and cystic inflammation
adequate time for antispasmodic to work
resolution of postobstructive diuresis prior to discharge

Question 47

Q

Acute Azotemia as a Predictor of Mortality in Dogs and Cat. JVIM 2012 Harison

Main finding (1)

Answer

A

Level of AKI relates to mortality (30 and 90 days)
Higher sCr correlates to a worse outcome

level 0: < 1.6 and change of < 0.3
level 1: < 1.6 and change of > 0.3
level 2: > 1.6 and change of > 0.3

Dogs and cats placed in level 2 of AKI w/in 7 days more likely to die

Dogs: level 2 3.6x more likely to die <90d and 3.2x more likely to die <30d
Cats: level 2 4x more likely to die <90d and 3.1x more likely to die w/in 30d

Question 48

Q

Initial treatment factors associated with feline urethral obstruction recurrence rate: 192 cases (2004–2010). JAVMA 2013. Hetrick

overall rUO
main findings (2)

Answer

A

rUO: 11% at 24h and 24% at 30d

rUO rate lower in cats treated w/ prazosin compared to phenoxybenzamine

rUO rate lower in cats w/ 3.5Fr u-cath (compared to 5Fr), red rubber

Question 49

Q

MoA of prazosin and phenoxybenzamine

Answer

A

Prazosin = a1 adrenergic receptor antagonist

phenoxybenzamine = nonselective alpha-adrenergic receptor antagonist

reduces urethral smooth muscle tone

Question 50

Q

Evaluation of kidney injury in dogs with pyometra based on proteinuria, renal histomorphology, and urinary biomarkers.. JVIM 2011. Maddens

main findings (3)

Answer

A

87% of pyo dogs had elevated UPC and it decr sig. post-OVH
Glomerulosclerosis and tubulointerstitial nephritis most common findings
Pyo dogs w/ UPC >1 or higher have clinically relevant renal histo changes and need follow up

Question 51

Q

Evaluation of kidney injury in dogs with pyometra based on proteinuria, renal histomorphology, and urinary biomarkers. JVIM 2011. Maddens

what biomarkers were looked at and big picture results

Answer

A

high ratios of urinary biomarkers appear likely to have clinically relevant renal histologic lesions

urinary biomarkers for glomerular (urinary albumin, urinary immunoglobulin G, urinary C-reactive protein, urinary thromboxane B(2))
tubular function (urinary retinol-binding protein, urinary N-acetyl-β-d-glucosaminidase)

Question 52

Q

Urethral obstruction in cats: predisposing factors, clinical, clinicopathological characteristics and prognosis. JFMS 2011. Segev

Main findings (6)

Answer

A

UO cats fatter (5.6 vs 5.1kg)
Mortality 8.5%
iCa higher in survivors (1.08 vs 0.88)
rUO 22% at 6mo and 24% at 2y
rUO had lower urine pH @ presentation (7 vs 6)
Indoor-outdoor cats have decr risk for rUO

Question 53

Q

Associations among albuminuria, C-reactive
protein concentrations, survival predictor index scores, and survival in 78 critically ill dog. JVIM 2011 Segev

main finding

Answer

A

U-Alb and SPI2 significantly associated with 7-day survival
U-ALB, UACR, and SPI2 score were significantly associated with 30-day survival

CPR not associated

Consistent with previous studies, CRP concentration also was not associated with short- or longer-term survival
CRP is a sensitive acute phase reactant, often increasing within 4 hours of tissue injury

Question 54

Q

SPI2 parameters (7)

Answer

A

MAP
RR
Cr
PCV
Albumin
Age
Medical vs surgical status

higher score = greater likelihood of survival

Question 55

Q

The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial. CCM 2011 Foronda

main finding

Answer

A

A daily evaluation to check readiness for weaning combined with a spontaneous breathing test reduced the mechanical ventilation duration for children on mechanical ventilation for >24 hrs, without increasing the extubation failure rate or the need for noninvasive ventilation.

extubation failure= need to reintbuate w/in 48-72h after ETT removed; associated w/ poor px and incr mortality rate
most common cause for vent: pneumonia, wheezing, bronchiolitis, septic shock, coma

Question 56

Q

The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial. CCM 2011 Foronda

What is the SBT?
Criteria to try SBT? (10)

Answer

A

SBT used to monitor signs of respiratory muscle fatigue while the patient is still intubated.

Criteria to try SBT:

FiO2 =< 50%
PEEP =<8
PIP =<25
No new infiltrates on CXR
Has resp drive
No continuous sedation
No NMB in the past 24h
Corrected electrolytes (Ca,, Mg, Phos, K)
Hemodynamic stability (Nitroprusside, dopamine or dobutamine <10mcg/kg/min)
Hgb =>8g/dL

Question 57

Q

The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial. CCM 2011 Foronda

How to do SBT

Answer

A

SBT w/ PEEP of 5, pressure support at 10 and same FiO2 used for past 2h

Monitor for intolerance

incr RR or HR >20% above baseline
incr WOB (use of accessory muscle or paradoxical respiration)
incrc LOC
BP <5th percentile
SaO2 <90% or PaCO2 >50 mmHg

Question 58

Q

FLORALI trial

High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. NEJM 2015

main findings (2)

Answer

A

nonhypercapnic acute hypoxemic resp failure

No difference in intubation rate b/w standard O2 vs HFOT
HF reduced mortality in the ICU and at 90 days and had more vent free days
- Less patient with PF<200 were intubated in HF group

Question 59

Q

Quantification and characterization of pleural fluid in healthy dogs with thoracostomy tubes. AJVR 2016

main findings (2)

Answer

A

Presence of a TT induced a minimal volume of pleural effusion in healthy dogs (0.48 mL/kg) - much lower than “2mL/kg/d”
Pyothorax developed after 4-6 days –> should remove by day 4

Question 60

Q

Partial pressure of end-tidal CO2 sampled via an intranasal catheter as a substitute for partial pressure of arterial CO2 in dogs. JVECC 2007 Pang

main finding

Answer

A

ETCO2 monitoring via a nasal catheter provides a clinically acceptable substitute to ABG

-increased difference w/ O2 supplementation

Question 61

Q

ACURASYS
Neuromuscular blockers in early acute respiratory distress syndrome. NEJM 2010

main finding (2)

Answer

A

Early admin of NMB (2x boluses of cisatracurium) improved 90d survival and incr time off vent w/o increasing muscle weakness
Survival benefit most pronounced in those w / PF ratios <120 mmHg

Improve patient-ventilator synchrony, allows for accurate adjustment of tidal volume + pressure levels –> limits risk of both asynchrony-related alveolar collapse and regional alveolar pressure (overdistension)
May also decr lung or systemic inflammation

Petal 2019: ARDS (PF <150) with high PEEP (8) -> cisatracurium = no survival benefit

Question 62

Q

Computed tomographic findings in canine pyothorax and correlation with findings at exploratory thoracotomy. JSAP 2011

main finding

Answer

A

Results: Twelve dogs were included. Eight were managed surgically, three were managed medically and one died before management. Pleural fluid was present in all dogs on CT (n=12) and at surgery (n=8). Pleural gas was identified in five dogs on CT. Pleural thickening was detected in eight dogs on CT (seven visceral, one parietal and six mediastinal) and eight dogs at surgery (seven visceral, eight parietal and six mediastinal), six of which were identified by CT. Abnormal pulmonary parenchyma was detected in 10 dogs on CT and 5 dogs at surgery, all of which were identified by CT. Mediastinal involvement was detected in 10 dogs on CT and 6 dogs at surgery, 5 of which were identified by CT.

Conclusion:

CT and surgical findings are similar in most cases of canine spontaneous pyothorax (predicted amount of pleural effusion and parenchymal abnormalities)
CT may be a useful diagnostic tool for guiding case management.

Question 63

Q

The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation. ICM 2011

main finding

Answer

A

despite lung protective vent, overall mortality still > 40%

pneumonia and sepsis most common causes of ARDS
MODS = common cause of death

Question 64

Q

Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007 Annane

Answer

A

There is no evidence for a difference in efficacy and safety between epinephrine alone and norepinephrine plus dobutamine for the management of septic shock.

Similar adverse events

Answer 65

A

In Aus + NZ

No difference in mortality between critically ill patients presenting to ED receiving EGDT vs usual care for treatment of septic shock.

Answer 66

A

a-line and central venous catheter (ScvO2)

Within 6h of presenting to the ED, want to achieve the below

CVP 8-12 mmHg
MAP 65 – 90 mmHg
UOP >0.5 ml/kg/hr
ScvO2 >70%
HCT >30%

Answer 67

A

Using a cut off value of 10.1 pmol/L, NT-proCNP low sensitivity (65%) to ddx septic dogs from NSIRS or healthy control
specificity was ok (89%)

NT-proCNP esp. poor at detecting peritoneal sepsis (suspect d/t compartmentalization -> more inflammatory markers in peritoneal fluid but not in blood)

NT-proCNP was not associated w/ survival

Answer 68

A

amino-terminal (NT) portion of pro C-type natriuretic peptide (CNP)

Expressed by vascular endothelium & macrophages in response to inflammation (TNF, IL-1B, TGF-b). Microbial products (LPS) also directly stimulate its production

Antimicrobial function

Large molecule w/ long half-life and doesn’t cross-react w/ other natriuretic peptides

Answer 69

A

Endotoxin activity, tumor necrosis factor, interleukin-6, nitric oxide, IL 10, procalcitonin mRNA, markers of coagulation, von Willebrand factor antigen concentration, C-reactive protein

Answer 70

A

Results: Bland-Altman analysis did not indicate good agreement between measurements obtained by use of the PulseCO and LiDCO methods, despite no significant change in cardiac index (CI) over time as measured with the LiDCO method. The percentage error for the overall difference in CI values between the PulseCO and LiDCO measurements was 122%, which indicated that the PulseCO method was not an acceptable means of CO measurement when compared with the LiDCO method for this patient population.

Conclusions and clinical relevance: Agreement between the PulseCO and LiDCO methods for measurement of CO was not acceptable at 4- and 8-hour intervals after calibration in conscious dogs with naturally occurring SIRS

PulseCO overestimated CI at higher values
Less bias normal and lower values

Answer 71

A

Effects of:

Aortic compliance
Reflected pressure waves
Waveform damping

Answer 72

A

Glucose difference of => 38 mg/dL between plasma and peritoneal effusion (fluid or supernatant) had improved Sn (88%), Sp (100%), PPV compared to WB-PF of 20 mg/dL.

WB-PF 20 mg/dL diff in this study had 41% Sn and 100% Sp

Answer 73

A

Bonczynski study used WB and PF

WB analyzed by blood chemistry analyzer
not subject to the inaccuracies generated by water exclusion or excess in whole blood or peritoneal fluid samples.

Koenig study compared WB or plasma VS PF-PF supernatant on handheld glucometers
-HCT affects BG on glucometers by altering the degree of plasma displacement by cells at the test strip. (high HCT decr BG while low HCT falsely incr BG)

Answer 74

A

A characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention

Answer 75

A

Identify patient w/ increased % of having a disease or as a screening test
Identify the presence of pathologic state
Risk stratification
Monitor treatment
Outcome/prognostic measure

Answer 76

A

septic patients with a positive passive leg raising test at baseline suggesting the presence of preload dependency,

In patients w/ preload dependency, norepi increased cardiac preload (recruit cardiac reserve) and CI and reduced the degree of preload dependency

Answer 77

A

Norepi is a1 and a2&raquo_space; b1 agonist

alpha vasoconstriction effects on both ARTERIAL and VENOUS side
Venous: Recruit blood from venous unstressed volume (splanchnic)–> incr cardiac preload
Norepi effects on preload affect preload dependency (i.e. reserve) of ventricles = improves their ability to “response” to an increased preload –> incr CO

Answer 78

A

SDD eradicates g-ve in both GIT and resp tract

Topical nonabsorbable ABX in oropharynx and GIT (tobra, amphotericin B, colistin)
Systemic ABX prophylaxis (cefotaxime = 3rd getn cephalosporin)
Used for first 4 days of ICU stay

SOD eradicates resp tract colonization
-Only applies some mouth past

Answer 79

A

incidence densities of intensive care unit-acquired gram-negative bacteremia was 4.5 during patient days with both intestinal and respiratory tract gram-negative bacteria carriage

Respiratory tract decolonization was associated with a 33% and intestinal tract decolonization was associated with a 45% reduction in the occurrence of intensive care unit-acquired gram-negative bacteremia.

Answer 80

A

In the US

Protocol-based resuscitation of suspected septic shock patients presenting to ED did not improve outcome.

Answer 81

A

Use of intrapleural tPA-DNase combo therapy improved fluid drainage in patients w/ pleural infection (empyema) and reduced frequency of surgical referral and duration of hospital stay.
Tx of DNase or t-PA alone was ineffective

Answer 82

A

PIRO- predisposition, insult/infection, response and organ dysfunction

A staging model for risk stratification in severe sepsis (sepsis-2)

Answer 83

A

P 0-4

Age
Dz: chronic liver dz, congestive cardiomyopathy

I 0-4
-Presence of community-acquired UTI or other sources of infection (bacterial, fungal)

R0-1
0=no tachycardia or tachypnea, 1= yes

O 0-4
-Any presence of organ failure and # of organs involved

Answer 84

A

Each component of PIRO contributes to overall risk of death
Increased odds of death 30-50% for each increase in one leveling individual PIRO component

Answer 85

A

Low-dose vasopressin didn’t change mortality compared to norepi among septic shock patients who were already on norepi (5 mcg/kg/min)

(looked at the addition of vasopressin to standard vasopressors vs standard vasopressors alone)

Answer 86

A

Glycolytic flux from glucose -> pyruvate generates H+ but that H+ is consumed when pyruvate -> lactate

ATP hydrolysis is the main contributor to incr H+ and this acid is consumed by the Krebs cycle normally
Therefore acid builds up during tissue hypoxia when Krebs cycle is reduced

Answer 87

A

Inadequate whole-body O2 delivery
- Hypoperfusion -> tissue hypoxia, anaerobic metabolism
Impaired tissue oxygen extraction and microcirculatory failure
- ER ratio drops to =<50%
- Inflammatory mediator induce heterogenous of tissue perfusion -> generate lactate
- Mitochondrial dysfunction -> anaerobic metabolism
Increased glycolytic flux and Na/K ATPase activity via b2 stimulation
- Glycolytic flux = PDH capacity exceeded so pyruvate -> lactate via LDH
- Incr ATPase activity associated w/ glycolytic flux
- Catecholamine (norepi, epi)
- Reduced by b2 antagonists (e.g. esmolol)
Decreased lactate clearance
- Preexisting or new hepatic dysfunction -> impaired clearance

Answer 88

A

Causative organism, MDR of causative organism, infection site, or presence of bacteremia were NOT associated w/ mortality
Early appropriate ABX therapy consistently associated w/ better survival in community-acquired and hospital-acquired, and ICU-acquired sepsis

-aerobic g-ve more common than g+ve

Answer 89

A

Life-threatening, generalized maldistribution of blood flow resulting in failure to deliver and/or utilize adequate amounts of oxygen, leading to tissue dysoxia.

Hypotension not required to define shock

In absence of hypotension, use other markers of hypoperfusion (Decr ScvO2 or SvO2, elevated lactate, incr base deficit, perfusion-related low pH)

Answer 90

A

Don’t routinely use biomarkers

Target BP:
>65 mmHg
>90mmHg if TBI
40 mmHg if hemorrhagic shock until definitive surgical hemostasis

Answer 91

A

Don’t use it alone

Low CVP, RAP, and PAOP, ventricular volume -> consider fluid resuscitation

Consider fluid challenge to predict responsiveness - either give crystalloids or do passive leg raise

Don’t recommend use of dynamic measurements (PPV, aortic flow changes, systolic pressure variation, respiratory systolic variation, vena cava collapsibility)

Answer 92

A

Don’t recommend routine monitoring

Consider echo to measure CO in clinical evidence of ventricular failure and persistent shock despite adequate fluid resusc

Answer 93

A

Macroscopic level: tonometry, sublingual capnometry, laser doppler flowmetery (mucosal perfusion), indocyanine green clearance, lidocaine metabolism

microscopic level: orthogonal polarization spectral (OPS) imaging, intravital microscopy, and near-infrared spectroscopy (NIRS)

Consider serial lactate measurements
Don’t recommend routine gastric tonometry, sublingual capnography, OPS, or others to assess regional microcirculation

Answer 94

A

Recommend frequent measurement of BP, PE (perfusion parameters) in those w/ shock

IBP in refractory shock

Don’t recommend routine PA cath

Answer 95

A

Recommend starting within 6h for those in septic shock, esp if ScvO2 <70%

Don’t recommend targeting supranormal O2 delivery

Answer 96

A

FAST = focused assessment with sonography in trauma

Greater % of cardiovascularly or dyspneic patients had free fluid compared to stable patients (75% vs 9%)
Supports use of FAST scan in non traumatized unstable pets

Answer 97

A

In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C

Takeaway- targeted hypothermia @ 36C is fine.

Answer 98

A

UDCO is non-invasive

Small bolus of isotonic saline is injected into the venous circulation -> creates transient hemodilution -> change in the ultrasound velocity detected by arterial flow sensor -> calculates CO

Answer 99

A

when comp to LiDCO UDCO viable method for measuring CO in normo and hypovol

Answer 100

A

Noninvasive, disposable, small plastic devices that are fitted on the end of ET tube

Contains a one-way valve w/ a set opening pressure (cracking pressure)

It generates a momentary airway resistance and increases negative intrathoracic pressure during spontaneous breathing –> improve venous return

Low racking pressure (-7cmH2O) in SBT and high cracking pressure for CPCR (-12cmH2O)

Answer 101

A

During SBT, rate + depth of respiration promotes venous return and enhances CO via “abdomino-thoracic or respiratory pump”
During inspiration, CW expands and diaphragm descends -> pleural pressure becomes more -ve and causes intravascular + intracardiac pressures to fall
As RAP falls, the pressure gradient for venous return to the RV increases

With ITD, the transient inspiratory resistance creates an even greater -ve intrathoracic pressure and greater transthoracic gradient from the extra- to intrathoracic great veins –> increased venous return into RA every time patient takes a breath

ITD in hemorr improved cardio parameters but had neg effects on RC and ResR

Answer 102

A

gastric tonometry estimates mucosal perfusion by measuring the amount of CO2 produced by gastric mucosa

a catheter is inserted into the gastric cavity to estimate visceral blood perfusion (GBF)

gastric-arterial CO2 gap (N=8-10) reflects mucosal blood supply, considered marker of gastric perfusion
(splanchnic hypoperfusion occurs early in circulatory shock -> intramucosal hypercapnia and acidosis.)

Answer 103

A

ITD during acute hemorrhagic hypovolemic shock improved CI and DO2, increased SAP and MAP

ITD decreased respiratory compliance and respiratory resistance

-doesn’t work in normotensive, euvolemic pets

Answer 104

A

Acute kidney injury (AKI) has been documented to occur in 12% of dogs with abdominal sepsis

14% of affected dogs surviving to hospital discharge
only mild histo changes in kidney
dopamine not helpful in tx or prevention
AKI in septic people correlated with IL-6 concentrations
inc inflammatory mediators
ROS
Serum concentrations of endogenous ROS scavengers including superoxide dismutase have been shown to be reduced in the same model of endotoxemia.
widespread tubular epithelial dysfunc –> dec GFR
link through activation of tubuloglom feedback
tubular dysfun –> lack of NaCl reabs from prox tubule
detected as increase in Na and Cl to MD in distal tubule
causes vasoconstr of aff art and decreased GFR
Epithelial dysfunction is also seen with the disruption of tight junctions between renal tubular epithelial cells resulting in back leakage of tubular fluid across the epithelium.
Cellular injury may also result in loss of cellular adhesion to the basement membrane and shedding of the epithelial cells in to tubular lumen resulting in the appearance of tubular epithelial cell casts in the urine
debris may block renal tubules
sublethal injury –> loss of transport fucntion but cells then undergo repair, regen and prolif
production of creatinine is decreased during sepsis that further limits the use of creatinine as an early indicator of AKI
urine concentrations of interleukin-18 (IL-18) are higher in septic patients with AKI compared to nonseptic AKI patients
urinary NGAL able to ID patients with AKI 12 hours before changes in creat or serum NGAL
there was a significant association with incidence of RIFLE-I and RIFLE-F AKI and the use of chloride-rich fluids. One explanation for the observed increase in AKI may be due to higher concentration of sodium and chloride being delivered to the renal tubules, activating the macula densa and inducing renal afferent arteriole vasoconstriction.
current evidence supports use of NE as first line vasopressor given potential detrimental effects of dopamine
Dopamine has historically been seen as having renoprotective properties in critical illness. When administered to healthy individuals at low doses (1-3

g/kg/min) it causes renal vasodilation, increased GFR and diuresis - seen in healthy people but not in AKI

in patients with AKI, dopamine significantly increased

renal vascular resistance and reduced renal blood flow

Additional negative effects of dopamine, even at low doses, include tachyarrythmias andmyocardial hypoxia, reduced splanchnic blood flow, and suppressed T-cell function
Fenoldopam mesylate is a pure dopamine type-1 receptor agonist that acts to cause renal vasodilation but without the - and -adrenergic activation seen with dopamine; may also have antiinflam effects
NACysteine for ROS scavenging? - animal studies show attenuated ischemic and nephrotoxic AKI
evidence in humans doesn’t support the use
human studies showed no diff in outcomes w IHD vs. CRRT

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