Seminal articles 2021 Flashcards

Question

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

Answer 1

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

Answer 2

septic peritonitis @ presentation, intra-op hemorrhage, post-op resp distress mortality 8.8%

Answer 3

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 ```

Answer 4

Canine hemolytic anemia objective score (CHAOS): Age, temp, agglutination, alb, bil Tokyo: sex, season, PCV, PLt count, TP

Answer 5

``` SIRS-classification ASA classification Tbil ALT bun Creatinine ``` Accuracy 82% to predict outcome at discharge

Answer 6

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.

Answer 7

Anti-plt antibodies adhere to plt surface Ag --> Fc receptor mediated phagocytosis of plt by macrophages --> thrombocytopenia Originate @ level of megakaryocyte

Answer 8

1. Intoxication (metaldehyde, OP or carbamate poisoning) 2. Hypoglycemia 3. Electrolyte: hypocalcemia (<0.69 mmo/L)

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

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

Answer 14

1. Early nutrition via either route (parenteral vs enteral) had no difference in mortality 2. Caloric intake similar in both 3. EN group had more complications- hypoglycemia, vomiting

Answer 15

1. 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 2. Hypophosphatemia more common in high-intensity group CRRT in CVVHDF, replacement post-filter

Answer 16

1. GFR not sig .diff b/w outcome groups but increased in survivors 2. FCNa decreased overtime 3. 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

Answer 17

FC K = <20% FC Na <1% Both were increased @ presentation = AKI causing dysregulation of solute excretion

Answer 18

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 ```

Answer 19

BUN, Ca, MG, Phos, glucose High FC glucose indicates PCT damage

Answer 20

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

Answer 21

15% rUO w/in 1 month

Answer 22

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

Answer 23

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

Answer 24

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

Answer 25

Prazosin = a1 adrenergic receptor antagonist phenoxybenzamine = nonselective alpha-adrenergic receptor antagonist reduces urethral smooth muscle tone

Answer 26

1. 87% of pyo dogs had elevated UPC and it decr sig. post-OVH 2. Glomerulosclerosis and tubulointerstitial nephritis most common findings 3. Pyo dogs w/ UPC >1 or higher have clinically relevant renal histo changes and need follow up

Answer 27

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) ```

Answer 28

1. UO cats fatter (5.6 vs 5.1kg) 2. Mortality 8.5% 3. iCa higher in survivors (1.08 vs 0.88) 4. rUO 22% at 6mo and 24% at 2y 5. rUO had lower urine pH @ presentation (7 vs 6) 6. Indoor-outdoor cats have decr risk for rUO

Answer 29

- 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

Answer 30

``` MAP RR Cr PCV Albumin Age Medical vs surgical status ``` higher score = greater likelihood of survival

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

nonhypercapnic acute hypoxemic resp failure 1. No difference in intubation rate b/w standard O2 vs HFOT 2. 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

Answer 35

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

Answer 36

ETCO2 monitoring via a nasal catheter provides a clinically acceptable substitute to ABG -increased difference w/ O2 supplementation

Answer 37

1. Early admin of NMB (2x boluses of cisatracurium) improved 90d survival and incr time off vent w/o increasing muscle weakness 2. 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

Answer 38

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: 1. CT and surgical findings are similar in most cases of canine spontaneous pyothorax (predicted amount of pleural effusion and parenchymal abnormalities) 2. CT may be a useful diagnostic tool for guiding case management.

Answer 39

despite lung protective vent, overall mortality still > 40% - pneumonia and sepsis most common causes of ARDS - MODS = common cause of death

Answer 40

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 41

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 42

a-line and central venous catheter (ScvO2) Within 6h of presenting to the ED, want to achieve the below 1. CVP 8-12 mmHg 2. MAP 65 – 90 mmHg 3. UOP >0.5 ml/kg/hr 4. ScvO2 >70% 5. HCT >30%

Answer 43

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 44

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 45

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 46

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 47

Effects of: - Aortic compliance - Reflected pressure waves - Waveform damping

Answer 48

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 49

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 50

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 51

1. Identify patient w/ increased % of having a disease or as a screening test 2. Identify the presence of pathologic state 3. Risk stratification 4. Monitor treatment 5. Outcome/prognostic measure

Answer 52

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 53

Norepi is a1 and a2 >> 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 54

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 55

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 56

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

Answer 57

1. 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. 2. Tx of DNase or t-PA alone was ineffective

Answer 58

PIRO- predisposition, insult/infection, response and organ dysfunction A staging model for risk stratification in severe sepsis (sepsis-2)

Answer 59

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 60

1. Each component of PIRO contributes to overall risk of death 2. Increased odds of death 30-50% for each increase in one leveling individual PIRO component

Answer 61

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 62

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 63

1. Inadequate whole-body O2 delivery - Hypoperfusion -> tissue hypoxia, anaerobic metabolism 2. 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 3. 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) 4. Decreased lactate clearance - Preexisting or new hepatic dysfunction -> impaired clearance

Answer 64

1. Causative organism, MDR of causative organism, infection site, or presence of bacteremia were NOT associated w/ mortality 2. 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 65

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 66

Don't routinely use biomarkers Target BP: >65 mmHg >90mmHg if TBI 40 mmHg if hemorrhagic shock until definitive surgical hemostasis

Answer 67

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 68

Don't recommend routine monitoring Consider echo to measure CO in clinical evidence of ventricular failure and persistent shock despite adequate fluid resusc

Answer 69

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 70

Recommend frequent measurement of BP, PE (perfusion parameters) in those w/ shock IBP in refractory shock Don't recommend routine PA cath

Answer 71

Recommend starting within 6h for those in septic shock, esp if ScvO2 <70% Don't recommend targeting supranormal O2 delivery

Answer 72

FAST = focused assessment with sonography in trauma 1. Greater % of cardiovascularly or dyspneic patients had free fluid compared to stable patients (75% vs 9%) 2. Supports use of FAST scan in non traumatized unstable pets

Answer 73

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 74

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 75

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

Answer 76

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 77

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 78

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 79

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 80

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