Feline Aortic Thromboembolism: Recent advances and future prospects.

PRACTICAL RELEVANCE: Feline aortic thromboembolism (FATE) is commonly encountered in clinical medicine, especially in emergency situations. This often devastating syndrome usually develops secondarily to severe heart disease, and has short- and long-term consequences. CLINICAL FEATURES: The clinical presentation of FATE is consistent with peripheral ischemic neuropathy, usually in both pelvic limbs. Diagnosis is relatively straightforward, but can be assisted with Doppler ultrasound, point-of-care ultrasound or infrared thermal imaging. RECENT ADVANCES AND FUTURE PROSPECTS: Interpretation of survival rates in cats with FATE has been hampered by historically high admission euthanasia, but recent studies suggest a survival rate with supportive care of 30-40%. Moreover, with advances in post-FATE thromboprophylaxis, median survival times of over 1 year are being achieved. Future directions include use of thrombolytic agents and treatment of common FATE sequelae such as acute kidney injury and reperfusion injury. OUTLINE: This article, aimed at small animal veterinarians, including emergency practitioners, reviews key aspects of the clinical presentation, diagnosis and treatment options for FATE, with a view to guiding client and veterinarian decision-making. Three case studies are included to illustrate the practical application of information presented in the review. EVIDENCE BASE: There are limited prospective studies on FATE, although the recent literature reflects a resurgence in clinical research interest in the past few years. Advances in FATE treatment will benefit many cats and it is important that research efforts continue to identify appropriate treatment modalities.

Viscoelastic coagulation monitoring parameters in cats with acute arterial thromboembolism.

BACKGROUND: Hypercoagulability has been documented in cats with cardiac disease. However, hemostatic parameters, including viscoelastic coagulation monitoring (VCM) have not been reported in cats with arterial thromboembolism (ATE). HYPOTHESIS/OBJECTIVES: Compare VCM parameters in cats with acute cardiogenic ATE and in control cats. ANIMALS: Sixteen cats with ATE and 30 control cats. METHODS: Multicenter university-based prospective study. Cardiogenic ATE was diagnosed based on physical examination and by ultrasonographically-diagnosed left atrial enlargement. Viscoelastic coagulation monitor analysis, CBC, serum biochemistry profile and coagulation profile were performed at admission in cats with ATE. Analysis from healthy control cats was performed using blood collected by direct venipuncture. Our objective was comparison of VCM parameters clot time (CT), clot formation time (CFT), alpha angle (Angle), maximum clot formation (MCF), amplitude at 10 and 20 minutes (A10 and A20, respectively) and clot lysis index at 30 and 45 minutes (LI30 and LI45, respectively) between ATE and control cats. RESULTS: Cats with ATE had a decreased angle compared to control cats, with a median (range) of 43° (30-48°) compared to 47° (14-59°; P = .01). The parameters A10, A20 and MCF were decreased in ATE cats compared to control cats with a median (range) of 19 units (8-32) compared to 22 units (6-38), 24.5 units (11-40) compared to 29 units (10-47) and 29.5 units (13-44) compared to 33.5 units (14-53), respectively (P = .01, .01 and .01, respectively). The parameters CT, CFT, LI30 and LI45 were similar between groups (P = .22, .09, .62 and .34, respectively). CONCLUSIONS AND CLINICAL IMPORTANCE: Cats with cardiogenic ATE cats have VCM parameters consistent with hypocoagulability compared with healthy cats.

Breaking barriers in trauma research: A narrative review of opportunities to leverage veterinary trauma for accelerated translation to clinical solutions for pets and people.

Trauma is a common cause of morbidity and mortality in humans and companion animals. Recent efforts in procedural development, training, quality systems, data collection, and research have positively impacted patient outcomes; however, significant unmet need still exists. Coordinated efforts by collaborative, translational, multidisciplinary teams to advance trauma care and improve outcomes have the potential to benefit both human and veterinary patient populations. Strategic use of veterinary clinical trials informed by expertise along the research spectrum (i.e., benchtop discovery, applied science and engineering, large laboratory animal models, clinical veterinary studies, and human randomized trials) can lead to increased therapeutic options for animals while accelerating and enhancing translation by providing early data to reduce the cost and the risk of failed human clinical trials. Active topics of collaboration across the translational continuum include advancements in resuscitation (including austere environments), acute traumatic coagulopathy, trauma-induced coagulopathy, traumatic brain injury, systems biology, and trauma immunology. Mechanisms to improve funding and support innovative team science approaches to current problems in trauma care can accelerate needed, sustainable, and impactful progress in the field. This review article summarizes our current understanding of veterinary and human trauma, thereby identifying knowledge gaps and opportunities for collaborative, translational research to improve multispecies outcomes. This translational trauma group of MDs, PhDs, and DVMs posit that a common understanding of injury patterns and resulting cellular dysregulation in humans and companion animals has the potential to accelerate translation of research findings into clinical solutions.

Sidestream dark field imaging and biomarker evaluation reveal minimal significant changes to the microcirculation and glycocalyx in a canine hemorrhagic shock model.

OBJECTIVE: To investigate the effects of hemorrhagic shock and fresh whole blood resuscitation on the microcirculation and endothelial glycocalyx using sidestream dark field (SDF) imaging and plasma biomarkers. ANIMALS: 8 purpose-bred dogs. METHODS: Pressure-targeted hemorrhagic shock was induced in anesthetized dogs. SDF measurement of perfused boundary region and microcirculatory variables (RBC flow, total vessel density, and relative and absolute capillary blood volume), biomarker measurement (heparan sulfate, hyaluronan, VE-cadherin, and syndecan-1), mean arterial blood pressure, and cardiac output measurement were performed before anesthesia (TP0), after induction (TP1), after hemorrhagic shock (TP2), and after 50% retransfusion (TP3) and 100% retransfusion (TP4). RESULTS: At TP1, TP2, TP3, and TP4, mean arterial blood pressure was 74.25 ± 7.17 mm Hg, 49.50 ± 13.74 mm Hg, 63.50 ± 13.29 mm Hg, and 71.38 ± 8.77 mm Hg, and cardiac output was 2.57 ± 1.01 L/min, 0.8 ± 0.36 L/min, 1.81 ± 0.57 L/min, and 2.93 ± 1.22 L/min, respectively. Heparan sulfate, hyaluronan, syndecan-1, and VE-cadherin ranges were 24.80 to 77.72 ng/mL, 5.77 to 105.06 ng/mL, below detection to 1,545.69 pg/mL, and 0 to 2.52 ng/mL, respectively. Perfused boundary region, RBC flow, total vessel density, and relative and absolute capillary blood volume ranges were 1.75 to 2.68 µm, 89.6 to 584.5 µm/s, 51.7 to 1,914.3 mm/m2, 0.94 to 1.53 103 µm3, and 1.50 to 94.30 103 µm3, respectively. Heparan sulfate decreased significantly over time (P = .016). No significant differences were found for microcirculatory variables, perfused boundary regions, or other biomarkers. CLINICAL RELEVANCE: This was the first study to assess microvascular dysfunction and endothelial shedding in a canine hemorrhagic shock model using SDF microscopy (Glycocheck) and plasma biomarkers. Further studies are needed to determine clinical relevance.

Assessment of microcirculation variables and endothelial glycocalyx using sidestream dark field videomicroscopy in anesthetized dogs undergoing cardiopulmonary bypass.

Introduction: To evaluate microcirculation and endothelial glycocalyx (eGC) variables using sidestream darkfield (SDF) videomicroscopy in canine cardiopulmonary bypass (CPB). Methods: Dogs undergoing CPB for surgical correction of naturally-occurring cardiac disease were prospectively included. Variables collected included patient demographics, underlying cardiac disease, red blood cell flow (Flow), 4-25 µm vessel density (Density), absolute capillary blood volume (CBVabs), relative capillary blood volume (CBVrel) and eGC width assessed by perfused boundary region (PBR). Anesthetized healthy dogs were used as control. Microcirculation and eGC variables were compared at baseline under anesthesia (T0), on CPB prior to cross clamping (T1), after cross clamp removal following surgical correction (T2) and at surgical closure (T3). Results: Twelve dogs were enrolled, including 10 with a complete dataset. Median Flow was 233.9, 79.9, 164.3, and 136.1 µm/s at T0, T1, T2, and T3, respectively, (p = 1.00). Median Density was 173.3, 118.4, 121.0 and 155.4 mm/mm2 at T0, T1, T2, and T3, respectively, (p = 1.00). Median CBVabs decreased over time: 7.4, 6.6, 4.8 and 4.7 103µm3 at T0, T1, T2, and T3, respectively, (p < 0.01). Median CBVrel increased over time: 1.1, 1.5,1.1, and 1.3 103µm3 at T0, T1, T2, and T3, respectively, (p < 0.001). Median PBR increased over time: 1.8, 2.1, 2.4, 2.1 µm at T0, T1, T2, and T3, respectively, (p < 0.001). Compared to control dogs (n = 8), CPB dogs had lower CBVabs at T0. Conclusion: Alterations in eGC thickness and microvascular occur in dogs undergoing CPB for naturally-occurring cardiac disease.

Infrared thermography is a novel tool to assess small intestinal surface temperature in dogs undergoing laparotomy for foreign body obstruction.

OBJECTIVE: To evaluate local temperature differences directly over and adjacent to small intestinal foreign body obstruction (FBO) using infrared thermography (IRT) in dogs. ANIMALS: 49 client-owned dogs were initially enrolled. METHODS: In a prospective, clinical observational study, IRT was utilized to compare median small intestinal (SI) surface temperature differences at the site of FBO and segments oral and aboral before and after surgical resolution from April 24, 2019, to July 19, 2020. These differences were evaluated for correlation with canine acute patient physiologic and laboratory evaluation fast (APPLEfast) scoring, lactate, foreign body material (hard vs soft), and blood pressure. RESULTS: There was not a significant surface temperature difference between SI segments at the site of FBO, oral or aboral. After resolution of obstruction, there was a significant decrease in median temperature directly over the FBO (2.4 °C; IQR, -2.55 to 10.6 °C; P = .0043). A decrease in surface temperature of the oral SI segment was appreciated with FBO due to hard material (-1.7 °C; IQR, -5.2 to 3.4 °C), whereas soft material had an increase in SI surface temperature oral to the FBO (+1.1 °C; IQR, 0.3 to 3.2 °C). This difference did not achieve significance (P = .08; Z = 1.75). No correlation was found between APPLEfast, lactate, or blood pressure and SI segment temperatures. CLINICAL RELEVANCE: IRT may be useful diagnostic modality to identify changes in small intestinal surface temperature relating to FBO. Further evaluation is warranted to determine if IRT may be a clinically useful to evaluate intestinal perfusion.

Comparison of placement characteristics using two intraosseous devices in canine and feline cadavers by novice users.

Introduction: Intraosseous (IO) catheterization enables rapid access to systemic circulation in critical patients. A battery-powered IO device (BPIO) utilized in veterinary practice is reliable in facilitating IO catheter placement. A new spring-powered IO device (SPIO) has been developed for people but has not been tested in veterinary patients. The goal of our study was to compare placement characteristics and flow rates achieved with the BPIO compared to the SPIO in animals when operated by novice users. Methods: Six veterinary students performed 72 catheterizations in the humeri and tibias of 12 dog and 6 cat cadavers. The user, cadaver, device, and site of placement were randomized. Flow rates were determined by three-minute infusions. Results: In dogs, overall success rates (50% BPIO, 46% SPIO; p = 0.775) and flow rates based on location were similar between devices. Successful placement was faster on average with the BPIO (34.4 s for BPIO and 55.0 s for SPIO, p = 0.0392). However, time to successful placement between devices was not statistically significant based on location (humerus: 34.7 s for BPIO and 43.1 s for SPIO, p = 0.3329; tibia: 33.3 s for BPIO and 132.6 s for SPIO, p = 0.1153). In cats, success rates were similar between devices (16.7% for BPIO and 16.7% for SPIO, p = 1.000), but limited successful placements prevented further analysis. Discussion: This is the first study to examine the use of the SPIO in animals, providing preliminary data for future IO studies and potential applications for training in the clinical setting.

Thromboelastographic results and hypercoagulability in dogs with surgically treated hepatocellular adenoma and carcinoma: A Veterinary Society of Surgical Oncology prospective study.

BACKGROUND: The most common haemostatic abnormality in dogs with cancer is hypercoagulability. A transient hypercoagulability has been documented in people with hepatocellular carcinoma (HCC) that resolves within weeks following hepatic tumour resection. OBJECTIVE: The objective was to compare the haemostatic status of dogs with liver tumours and healthy control dogs, by comparing coagulation and thromboelastography (TEG) measurements at three time points. METHODS: Liver tumour and healthy control dogs receiving surgery for liver lobectomy and ovariohysterectomy, respectively, were prospectively enrolled. All dogs had blood collected at three time points: pre-operative, 24 h post-operative and ~2 weeks post-operative. Haematological and haemostatic values were compared across time points in each group using repeated measures ANOVA tests. RESULTS: Ten and eight dogs were enrolled for the liver and control groups, respectively. Platelet count was significantly higher in the liver group than the control group at all time points, but within the normal range (pre-operative: 438.7 vs. 300.9 × 109 /L, p = .0078; 24 h post-operative: 416.2 vs. 283.9 × 109 /L, p = .0123; 10-14 days post-operative: 524.6 vs. 317.3 × 109 /L, p = .0072). The measure of the overall coagulant state (G-value) was significantly increased for the liver group compared to the control group at all time points (pre-operative: 15.6 vs. 8.6 d/sc, p = .0003; 24 h post-operative: 18.3 vs. 11.2 d/sc, p = .039; 10-14 days post-operative: 15.1 vs. 9.6 d/sc, p = .015). CONCLUSION: The liver group was hypercoagulable based on elevated G-values at all time points compared to the control group. This hypercoagulability was attributed to the effect of hepatic tumours alone, and not secondary to surgery and anaesthesia.

Bilateral lysis of aortic saddle thrombus with early tissue plasminogen activator (BLASTT): a prospective, randomized, placebo-controlled study in feline acute aortic thromboembolism.

OBJECTIVES: The aim of this study was to investigate the impact of tissue plasminogen activator (TPA) on the treatment of feline aortic thromboembolism (FATE). METHODS: Cats diagnosed with FATE involving ⩾2 limbs were enrolled in a prospective, multicenter, double-blinded, randomized, placebo-controlled study within 6 h of an event. Diagnosis was made by clinical findings and one confirmatory criterion. Cats received placebo or TPA (1 mg/kg/h with the first 10% by bolus). All cats received pain control and thromboprophylaxis. The primary outcome was a change from baseline in a published limb score at 48 h. Secondary outcomes included 48 h survival, survival to discharge and complication proportions. Statistical analyses included pattern-mixture models, logistic regression and Fisher's exact, Student's t- and Mann-Whitney-Wilcoxon tests. RESULTS: Based on a power analysis, 40 cats were enrolled; however, only 20 survived to 48 h (TPA, n = 12; placebo, n = 8 [P = 0.34]). There was a statistically significant improvement in limb scores compared with baseline for both groups (P <0.001). Limb score at 48 h was 1 point lower (better) in the TPA group (P = 0.19). Thrombolysis had no statistically significant effect on 48 h survival (P = 0.22). Lower affected limb lactate was associated with better 48 h survival (odds ratio 1.53, 95% confidence interval 1.08-2.17; P = 0.02). The survival to discharge rates were 45% (TPA) and 30% (placebo; P = 0.51). Complications in the TPA and placebo groups included acute kidney injury (22% and 19%, respectively; P = 1.00) and/or reperfusion injuries (33% and 19%, respectively; P = 0.45). CONCLUSIONS AND RELEVANCE: Survival and complication rates of acute FATE were not different with or without thrombolysis. High in-hospital mortality decreased the statistical power to detect a statistically significant difference between treatments with regard to our primary outcome.

2022 Update of the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) Domain 6: Defining rational use of thrombolytics.

OBJECTIVES: To systematically review available evidence and establish guidelines related to the use of thrombolytics for the management of small animals with suspected or confirmed thrombosis. DESIGN: PICO (Population, Intervention, Control, and Outcome) questions were formulated, and worksheets completed as part of a standardized and systematic literature evaluation. The population of interest included dogs and cats (considered separately) and arterial and venous thrombosis. The interventions assessed were the use of thrombolytics, compared to no thrombolytics, with or without anticoagulants or antiplatelet agents. Specific protocols for recombinant tissue plasminogen activator were also evaluated. Outcomes assessed included efficacy and safety. Relevant articles were categorized according to level of evidence, quality, and as to whether they supported, were neutral to, or opposed the PICO questions. Conclusions from the PICO worksheets were used to draft guidelines, which were subsequently refined via Delphi surveys undertaken by the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) working group. RESULTS: Fourteen PICO questions were developed, generating 14 guidelines. The majority of the literature addressing the PICO questions in dogs is experimental studies (level of evidence 3), thus providing insufficient evidence to determine if thrombolysis improves patient-centered outcomes. In cats, literature was more limited and often neutral to the PICO questions, precluding strong evidence-based recommendations for thrombolytic use. Rather, for both species, suggestions are made regarding considerations for when thrombolytic drugs may be considered, the combination of thrombolytics with anticoagulant or antiplatelet drugs, and the choice of thrombolytic agent. CONCLUSIONS: Substantial additional research is needed to address the role of thrombolytics for the treatment of arterial and venous thrombosis in dogs and cats. Clinical trials with patient-centered outcomes will be most valuable for addressing knowledge gaps in the field.

Safety profile of repeated infusion of platelet-like nanoparticles in healthy dogs.

OBJECTIVE: To assess the safety and efficacy of the platelet-like nanoparticle (PLN), and to assess its safety in repeated administration. ANIMALS: 6 purpose-bred dogs. PROCEDURES: The PLN was administered IV at 3 different doses using a randomized crossover design. Each dog received a full dose of 8 X 1010 particles/10 kg, half dose, and 10 times the dose, with a 14-day washout period between doses. Biochemical, prothrombin time, partial thromboplastin time, and fibrinogen analyses were performed at baseline and 96 hours postinfusion. A CBC, kaolin-activated thromboelastography, platelet function assay closure time, and buccal mucosal bleeding time were performed at baseline and 1, 6, 24, 48, 72, and 96 hours postinfusion. RESULTS: No significant changes were observed over time in the thromboelastography parameters, closure time, and buccal mucosal bleeding time. After the administration of the half dose, hematocrit levels decreased significantly at 1, 6, 24, 48, and 96 hours, with all values within the reference range. The platelet count was decreased significantly at hours 1, 6, 24, 48, and 72 after administration of the half dose, with values less than the reference range at all hours but hour 72. No significant changes in serum biochemistry, coagulation panel, and fibrinogen were observed for all doses. No adverse events were noted during the first infusion. Three dogs experienced transient sedation and nausea after repeat infusion. CLINICAL RELEVANCE: The PLN resulted in a dilution of hematocrit and platelets, and did not significantly alter hemostasis negatively. The safety of repeated doses should be investigated further in dogs.

Prospective investigation of factors associated with success on the American College of Veterinary Emergency and Critical Care certification examination (2016-2018).

OBJECTIVE: To assess the association of candidate attributes and residency training factors with success on the American College of Veterinary Emergency and Critical Care (ACVECC) board certification examination and to develop multivariable models of first-attempt success. DESIGN: Prospective survey-based study. SETTING: Post-assessment ACVECC examination candidates. ANIMALS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Comprehensive surveys were distributed to ACVECC examination candidates in 2016 to 2018 after completion of their assessments, but prior to publication of examination results. Unique anonymous candidate identification numbers were used to match survey responses to outcome data from the office of the ACVECC Executive Secretary. After curation to retain only the first response from each candidate, there were 97 unique candidate responses available for analysis. Univariate analyses identified multiple factors associated with first-attempt success and multiple differences between academic and private practice residency programs. Multivariable logistic regression modeling suggested that 5 factors were independently associated with first-attempt success on the ACVECC examination, specifically younger age, more weeks of study prior to the examination, training at a facility with more ACVECC Diplomates, training at a facility with more ACVECC residents, and having no requirement to manage both Emergency Room (ER) and Critical Care (CC) cases simultaneously. CONCLUSIONS: Numerous resident and training center factors are associated with success in the ACVECC board certification examination. Residents and training centers might be able to use these data to enhance training, but caution must be exercised because these data are associative only.

Retrospective evaluation of the use of hydrocortisone for treatment of suspected critical illness-related corticosteroid insufficiency (CIRCI) in dogs with septic shock (2010-2017): 47 cases.

OBJECTIVE: To evaluate characteristics of septic shock patients treated with hydrocortisone (HC) due to suspicion of critical illness-related corticosteroid insufficiency (CIRCI) as compared to septic shock patients without suspicion of CIRCI. DESIGN: Retrospective study between February 2010 and October 2017. SETTING: University teaching hospital ICU. ANIMALS: Data were collected for 47 dogs with septic shock. Twenty-one dogs were treated with HC (HC-treated) due to suspicion of CIRCI. Twenty-six dogs did not receive HC (non-HC-treated). INTERVENTIONS: HC was administered either as an intermittent IV bolus or as a constant rate infusion (CRI) to those patients with suspected CIRCI. MEASUREMENTS AND MAIN RESULTS: Significantly higher baseline APPLEfull scores and predicted mortality were detected in the HC-treated patients compared to non-HC-treated patients (0.87 vs 0.44 for predicted mortality, P = 0.039). Patients in the HC-treated group were on more vasopressors and cardiotonics than those in the non-HC-treated group (2.5 vs 1.5, P <0 .001). All patients initially responded to vasopressor administration, with average time to resolution of hypotension being 90 minutes for the HC-treated group compared to 60 minutes for the non-HC-treated group (P = 0.640). However, HC-treated patients took significantly longer to have a sustained resolution (a systolic blood pressure > 90 mm Hg or a mean blood pressure > 65 mm Hg for at least 4 h) of their hypotension after starting vasopressors, as compared to their non-HC-treated counterparts (8.5 vs 4 h, P = 0.001). Three (14.3%) HC-treated patients survived to discharge compared to 9 (34.6%) non-HC-treated patients, but this was not statistically significant. CONCLUSIONS: HC-treated patients had a higher baseline risk of mortality than non-HC-treated patients. There was no significant difference in survival between the HC-treated and non-HC-treated septic shock patients. Further studies are needed to evaluate the use of HC in patients with suspected CIRCI.

Clinical features and outcome of septic shock in dogs: 37 Cases (2008-2015).

OBJECTIVES: To describe patient characteristics of dogs with septic shock, investigate markers of disease severity, and assess treatment impact on outcome. DESIGN: Retrospective study. SETTING: Single center, university veterinary teaching intensive care unit. ANIMALS: Thirty-seven dogs with septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mean number of organ dysfunction was 3.24 ± 1.0, and included cardiovascular (100%), respiratory (73%), hematologic (68%), renal (49%), and hepatic (32%) dysfunction. The gastrointestinal tract was the most common source of sepsis. Mean blood pressure prior to resuscitation was 50 ± 8 mm Hg. All dogs were given IV fluids before vasopressor therapy with a mean rate of 12.1 ± 11.0 mL/kg/h. All dogs were given antimicrobials, administered within a mean of 4.3 ± 5.7 hours after diagnosis. Dopamine or norepinephrine was administered IV, respectively in 51.3% and 37.8% of dogs, with a mean duration of hypotension of 2.6 ± 3.0 hours. Mortality rate was 81.1%. Survivors were more likely to have a feeding tube (P = 0.007) and to have gastrointestinal sepsis (P = 0.012), and less likely to have respiratory dysfunction (P < 0.001). APPLEFull scores (P = 0.014) and time to antimicrobial therapy (P = 0.047) were identified as predictors of mortality. Treatment bundles consisting of 7 interventions that may improve outcomes in people with septic shock were evaluated. Survivors received 4.1 ± 1.3 interventions, whereas nonsurvivors received 2.4 ± 1.4 (P = 0.003). CONCLUSIONS: Septic shock in dogs confers a guarded prognosis. Early antimicrobial therapy and the utilization of treatment bundles may increase survivability in dogs with septic shock. More research is warranted to investigate the impact of specific interventions on survival.

Resuscitation Patterns and Massive Transfusion for the Critical Bleeding Dog-A Multicentric Retrospective Study of 69 Cases (2007-2013).

Objective: To describe resuscitation patterns of critically bleeding dogs, including those receiving massive transfusion (MT). Design: Retrospective study from three universities (2007-2013). Animals: Critically bleeding dogs, defined as dogs who received ≥ 25 ml/kg of blood products for treatment of hemorrhagic shock caused by blood loss. Measurements and Main Results: Sixty-nine dogs were included. Sources of critical bleeding were trauma (26.1%), intra/perioperative surgical period (26.1%), miscellaneous (24.6%), and spontaneous hemoabdomen (23.1%). Median (range) age was 7 years (0.5-18). Median body weight was 20 kg (2.6-57). Median pre-transfusion hematocrit, total protein, systolic blood pressure, and lactate were 25% (10-63), 4.1 g/dl (2-7.1), 80 mm Hg (20-181), and 6.4 mmol/L (1.1-18.2), respectively. Median blood product volume administered was 44 ml/kg (25-137.4). Median plasma to red blood cell ratio was 0.8 (0-4), and median non-blood product resuscitation fluid to blood product ratio was 0.5 (0-3.6). MT was given to 47.8% of dogs. Survival rate was 40.6%. The estimated odds of survival were higher by a factor of 1.8 (95% CI: 1.174, 3.094) for a dog with 1 g/dl higher total protein above reference interval and were lower by a factor of 0.6 (95% CI: 0.340, 0.915) per 100% prolongation of partial thromboplastin time above the reference interval. No predictors of MT were identified. Conclusions: Critical bleeding in dogs was associated with a wide range of resuscitation patterns and carries a guarded to poor prognosis.

Vitamin C in Health and Disease: A Companion Animal Focus.

Vitamin C is synthesized in the liver in most species, including dogs and cats, and is widely distributed through body tissues. Vitamin C has an important physiologic role in numerous metabolic functions including tissue growth and maintenance, amelioration of oxidative stress, and immune regulation. It is also a co-factor in the production of important substances such as catecholamines and vasopressin. Decreased vitamin C levels have been documented in a wide variety of diseases, and in critically ill human patients may be associated with increased severity of disease and decreased survival. Intravenous supplementation with vitamin C has been proposed as a potential life-saving treatment in conditions such as septic shock, and results of small some human trials are promising. Data in companion in animals is very limited, but the possible benefits and , seemingly low risk of adverse effects , and the low cost of this treatment make vitamin C therapy a promising area of future investigation in critically ill dogs and cats.

Effect of packed red blood cell transfusion on thromboelastographic tracings in dogs with naturally occurring anemia.

OBJECTIVE: To assess the effect of packed RBC (pRBC) transfusion on thromboelastographic (TEG) tracings in dogs with naturally occurring anemia. ANIMALS: 22 clinically anemic dogs that received a pRBC transfusion. PROCEDURES: For each dog, a blood sample was collected before and within 3 hours after completion of the pRBC transfusion for a CBC, nonactivated TEG analysis, and measurement of blood viscosity. Wilcoxon signed rank tests were used to compare CBC, viscosity, and TEG variables between pretransfusion and posttransfusion blood samples. Multivariable linear regression was used to assess the effects of pretransfusion-posttransfusion changes in Hct, WBC count, and platelet count on changes in TEG variables. RESULTS: Median posttransfusion Hct (21%; range, 13% to 34%) was significantly greater than the median pretransfusion Hct (12.5%; range, 7% to 29%). Packed RBC transfusion was associated with a median increase in Hct of 6.2% (range, 1.2% to 13%). Maximum amplitude significantly decreased from 74.9 to 73.8 mm and clot strength significantly decreased from 14,906 to 14,119 dynes/s after pRBC transfusion. Blood viscosity significantly increased, whereas platelet and WBC counts significantly decreased after transfusion. Multivariable linear regression revealed that pretransfusion-posttransfusion changes in Hct, WBC count, and platelet count were not associated with changes in TEG variables. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that pRBC transfusion had only small effects on the TEG tracings of hemodynamically stable dogs. Therefore, large changes in TEG tracings following pRBC transfusion are unlikely to be the result of the transfusion and should be investigated further.

Outcome and treatments of dogs with aortic thrombosis: 100 cases (1997-2014).

BACKGROUND: Aortic thrombosis (ATh) is an uncommon condition in dogs, with limited understanding of risks factors, outcomes, and treatments. OBJECTIVES/HYPOTHESIS: To describe potential risk factors, outcome, and treatments in dogs with ATh. ANIMALS: Client-owned dogs with a diagnosis of ATh based on ultrasonographic or gross necropsy examination. METHOD: Multicentric retrospective study from 2 academic institutions. RESULTS: One hundred dogs were identified. Anti-thrombin diagnosis, 35/100 dogs were nonambulatory. The dogs were classified as acute (n = 27), chronic (n = 72), or unknown (n = 1). Fifty-four dogs had at least one comorbidity thought to predispose to ATh, and 23 others had multiple comorbidities. The remaining 23 dogs with no obvious comorbidities were classified as cryptogenic. Concurrent illnesses potentially related to the development of ATh included protein-losing nephropathy (PLN) (n = 32), neoplasia (n = 22), exogenous corticosteroid administration (n = 16), endocrine disease (n = 13), and infection (n = 9). Dogs with PLN had lower antithrombin activity than those without PLN (64% and 82%, respectively) (P = .04). Sixty-five dogs were hospitalized with 41 subsequently discharged. Sixteen were treated as outpatient and 19 euthanized at admission. In-hospital treatments varied, but included thrombolytics (n = 12), alone or in combination with thrombectomy (n = 9). Fifty-seven dogs survived to discharge. Sixteen were alive at 180 days. Using regression analysis, ambulation status at the time of presentation was significantly correlated with survival-to-discharge (P < .001). CONCLUSIONS/CLINICAL IMPORTANCE: Dogs with ATh have a poor prognosis, with nonambulatory dogs at the time of presentation having worse outcome. Although the presence of comorbid conditions associated with hypercoagulability is common, an underlying cause for ATh was not always identified.

Clinical use of cryopoor plasma continuous rate infusion in critically ill, hypoalbuminemic dogs.

OBJECTIVE: To investigate the impact of cryopoor plasma (CPP) continuous rate infusion (CRI) on albumin concentration and colloid osmotic pressure (COP) in critically ill dogs with hypoalbuminemia. DESIGN: Retrospective study between 2013 and 2015 with a 90-day follow-up on survivors. SETTING: University teaching hospital. ANIMALS: Ten hypoalbuminemic dogs receiving a CPP CRI for albumin replacement or oncotic support. All patients with documented hypoalbuminemia or low COP receiving CPP administration for albumin or oncotic support during the study period were included. INTERVENTIONS: CRI of CPP. MEASUREMENTS AND MAIN RESULTS: Mean age was 7.4 ± 4.5 years. Mean survival prediction index score was 0.66 ± 0.13. Seven dogs were septic, with 2 of 7 in septic shock and 5 of 7 having septic peritonitis. The mean pre- and postinfusion albumin was 15 ± 4 g/L and 21 ± 2 g/L, respectively. The median pre- and postinfusion COP was 8.6 mm Hg (4.9-9.7 mm Hg) and 10.2 mm Hg (8.1-13.3 mm Hg), respectively. The median duration of CRI was 16 hours (11-121 h). The mean CPP rate was 1.8 ± 0.6 mL/kg/h, the mean crystalloid rate administered concurrently was 0.8 ± 0.9 mL/kg/h, and the mean hydroxyethyl starch rate administered concurrently was 1.2 ± 0.9 mL/kg/h. The difference in pre- and postinfusion albumin was significantly correlated with CPP rate (P = 0.0004), whereas the difference in pre- and postinfusion COP was correlated with hydroxyethyl starch rate (P = 0.0128). Mean duration of hospitalization was 8.6 ± 3.9 days. Mann-Whitney U and Fisher's exact tests were used to compare survivors and nonsurvivors. Survivors were significantly younger than nonsurvivors (3.5 vs 11.5 y, P = 0.033). No side effects were reported. Survival to discharge was 40% with identical 90-day survival. Of the nonsurvivors, 50% died naturally. CONCLUSIONS: There was an association between the rate of CPP and the change in albumin after CPP CRI in critically ill dogs, suggesting that CPP may be a viable option for treatment of hypoalbuminemia.

Acute kidney injury management using intermittent low efficiency haemodiafiltration in a critical care unit: 39 dogs (2012-2015).

BACKGROUND: Veterinary studies describing acute kidney injury (AKI) management using renal replacement therapy (RRT) are limited and have primarily focused on intermittent haemodialysis in North American populations. European data are lacking, although differences in populations, pathogen and toxin exposure and RRT modalities may exist between Europe and North America. The present study reviewed RRT-managed cases from the intensive care unit (ICU) of VetAgro Sup, Lyon, France, for the period 2012-2015. The aims were to describe a 4-h RRT protocol of intermittent low efficiency haemodiafiltration, population characteristics and outcomes in canine AKI cases requiring RRT and to identify prognostic variables. We defined DeltaCreat/h as the difference between the serum creatinine level after RRT treatment N and that before treatment N + 1 divided by the time between treatments (in hours). RESULTS: Thirty-nine dogs were included, and 67% were males. The median (range) age, weight, hospitalization length and number of RRT treatments were 4.4 (0.25-15) years, 26.6 (6.7-69) kg, 8 (1-23) days and 3 (1-8) treatments, respectively. The main AKI causes were leptospirosis (74.4%) and nephrotoxins (15.4%). Age (4.0 vs 5.4 years; P = 0.04), admission urine output (0.5 mL/kg/h vs 0 mL/kg/h; P = 0.02) and hospitalization length (10 vs 4 days; P < 0.001) differed between survivors and non-survivors. Hospitalization length [odds ratio (OR) = 0.4], number of treatments (OR = 5.1), serum potassium level on day 2 (OR = 1.9), DeltaCreat/h between the first and second treatments (OR = 1.2), and UOP during hospitalization (OR = 0.2) were correlated with outcome. The main causes of death were euthanasia (44%) and haemorrhagic diatheses (33%). The overall survival rate was 54%, with 55% of survivors discharged with a median creatinine < 240 µmol/L. CONCLUSIONS: This is the first description in the veterinary literature of a 4-h protocol of intermittent low efficiency haemodiafiltration to provide RRT in a veterinary critical care unit. While this protocol appears promising, the clinical application of this protocol requires further investigation. Among parameters associated with survival, UOP and DeltaCreat/h between the first and second RRT treatments may be prognostic indicators. The applicability of these parameters to other populations is unknown, and further international, multicentre prospective studies are warranted to confirm these preliminary observations.