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Article

Vasopressor use in 41 critically ill cats (2007–2016)


Nikki Licht, Elizabeth A. Rozanski, John E. Rush

Abstract — This study describes the use of vasopressors in critically ill cats. Records of 41 cats hospitalized in the
ICU were evaluated. Signalment, blood pressure, underlying conditions, evidence of sepsis, type of treatment
(surgical versus non-surgical), vasopressor type and duration, adverse events attributed to vasopressors, and survival
were recorded. Twenty-one cats (51%) had an underlying disease considered amenable to surgical treatment while
20 (49%) cats did not. Evidence of sepsis was present in 24 (59%) cats. Thirty-four cats developed a Doppler
blood pressure (DBP) . 80 mmHg during therapy, and 29 cats became normotensive (DBP . 90 mmHg).
Seven cats did not increase their DBP to . 80 mmHg. All cats received dopamine and/or norepinephrine and
6 cats also received other vasopressors. Sixteen cats survived (39%). Surgical intervention was associated with a
higher survival (P = 0.004). Critically ill hypotensive cats may benefit from administration of vasopressors.

Résumé — Utilisation de vasopressine chez 41 chats en état critique (2007–2016). Cette étude décrit
l’utilisation de vasopresseurs chez les chats en condition critique. Les dossiers médicaux de 41 chats hospitalisés
ont été évalués. Le signalement, pression sanguine, conditions sous-jacentes, évidence de sepsis, type de traitement
(chirurgical contre médical), type de vasopresseurs et durée, effets adverses reliés à l’utilisation des vasopresseurs
et survie ont été comptabilisés. Vingt et un chats (51 %) avaient une condition sous-jacente susceptible au
traitement chirurgical contrairement aux 20 autres chats (49 %). L’évidence de sepsis était présente dans 24 (59 %)
chats. Trente-quatre chats ont développé une pression sanguine au Doppler (DBP) . 80 mmHg durant le traitement
et 29 chats sont devenus normotensifs (DBP . 90 mmHg). Sept chats n’ont pas eu d’augmentation de leur
DBP . 80 mmHg. Tous les chats ont reçu de la dopamine et/ou de la norépinéphrine et 6 chats ont reçus d’autres
vasopresseurs. Seize chats ont survécu (39 %). Une intervention chirurgicale est associée à un plus grand taux de
survie (P = 0,004). Les chats hypotensifs en condition critique peuvent bénéficier de l’utilisation de vasopresseurs.
(Traduit par les auteurs)
Can Vet J 2018;59:1175–1180

Introduction do not exist in cats surrounding the optimal use of vasopressors.

H
However, based on expert opinion, the use of vasoactive drugs
ypotension is a common occurrence in animals admitted
such as dopamine, dobutamine, norepinephrine, phenylephrine,
to the ICU, and a subset of this population is refractory to
vasopressin, or epinephrine has been recommended to improve
fluid resuscitation (1). Hypotension in critically ill cats has been
blood pressure and subsequently restore organ perfusion (5–9).
associated with a poor prognosis, particularly when coupled with
Potential concerns surrounding the use of vasopressors in
increases in lactate (1,2). In humans, unresolved hypotension
humans include hypertension, arrhythmias, acute kidney injury
and inadequate tissue perfusion are recognized as precursors
(AKI), splanchnic and/or peripheral ischemia, and medication
to multi-organ dysfunction and death, and are important and
errors (10,11).
tangible targets for intervention (2,3). Evidence-based guidelines
The purpose of this study was to describe the use and out-
advocate the use of vasopressors in hypotensive humans who are
comes in cats treated with vasopressors in the ICU for hypoten-
adequately volume resuscitated and are therefore considered to
sion associated with critical illness.
have refractory hypotension (4), but evidence-based guidelines
Materials and methods
Cummings School of Veterinary Medicine at Tufts University, The medical record database between January 1, 2007 and
55 Willard Street, North Grafton, Massachusetts 01536, USA. May 31, 2016 was searched, using the keywords “feline,” and
Address all correspondence to Dr. Elizabeth Rozanski; e-mail: “norepinephrine,” “phenylephrine,” “epinephrine,” “dopamine,”
Elizabeth.rozanski@tufts.edu “dobutamine,” and “vasopressin.” Cats receiving vasopressors
Use of this article is limited to a single copy for personal study. for less than 1 h and cats that received vasopressors only during
Anyone interested in obtaining reprints should contact the anesthesia were excluded.
CVMA office (hbroughton@cvma-acmv.org) for additional The following data were collected from the medical record:
copies or permission to use this material elsewhere. signalment, blood pressure measurements, underlying disease

CVJ / VOL 59 / NOVEMBER 2018 1175


conditions, including presence or suspicion of sepsis, and bacterial (n = 18) or fungal (n = 1) cultures or supportive diag-
whether surgery was performed for the underlying condition, nostics and conclusions as noted in the medical record (n = 5).
type, and duration of vasopressor therapy, and documented Sources of sepsis included gastrointestinal (n = 6), hepatobiliary
adverse events (arrhythmias, acute kidney injury, new onset (n = 6), generalized peritonitis (n = 5), pulmonary (n = 4), pleu-
of vomiting, or bloody diarrhea) attributed to vasopressor use. ral space (n = 2), and reproductive tract (n = 1). Seventeen cats
Additionally, blood component transfusions and glucocorticoid did not have evidence of infection; in these cats, the underlying
use were recorded. Finally, survival at 24, 48, and 72 h, weaning disease included traumatic liver rupture and intraabdominal
A R T I C LE

from vasopressors, duration of hospitalization and whether mor- hemorrhage (n = 1), diabetic ketoacidosis (n = 3), cardiopulmo-
tality occurred due to euthanasia or natural death were recorded. nary disease (n = 3), renal disease (n = 2), liver disease (n = 2),
Hypotension was defined as a Doppler blood pressure anaphylaxis (n = 1), and systemic neoplasia (n = 5). Surgical
, 90 mmHg, while normotension was defined as 90 to treatment was performed in 21 cats for source control or to
150 mmHg. Doppler blood pressure determinations were made treat the underlying disease while 20 cats were considered to
using a cuff size that was 30% to 40% of the limb circumfer- have non-surgical conditions. All cats received intensive medical
ence, the same size cuff was used for repeated measurements, therapy at the discretion of the attending clinician and all cats
and usually the same limb, unless catheter location affected were resuscitated with intravenous fluids prior to the initiation
use of a specific limb. Volume status was evaluated by physical of vasopressors.
examination, vital signs, and in some cases measurement of
central venous pressure (CVP) or point-of-care ultrasound to Resuscitation
subjectively assess left ventricular size. Acute kidney injury (AKI) Five cats suspected of being volume overloaded at the time
was defined as an increase in creatinine of . 26.6 mmol/L (12). of documented hypotension did not receive additional fluid
Critical illness in a cat was defined as having clinical signs of boluses. Two cats had been transferred from another hospital
systemic disease, and inability to maintain homeostasis without and were already receiving vasopressors following an unknown
aggressive supportive measures. volume of administered crystalloids. The remaining 34 cats
Descriptive statistics were used and the Fisher’s exact test was received a combination of 1 to 4 crystalloid boluses ranging
used to compare groups, with a P-value of , 0.05 considered to from 5 mL/kg body weight (BW) to 20 mL/kg BW and contin-
be statistically significant. Correlation was evaluated using the ued to receive crystalloid fluids at rates of 45 to 120 mL/kg BW
Pearson correlation coefficient. per day. Eight cats were administered synthetic colloid boluses
(5 to 20 mL/kg BW, IV), while 9 cats received blood products
Results (fresh and stored whole blood) immediately before vasopres-
Signalment sor initiation. Four cats had CVP measurements taken which
Forty-one cats fulfilled the inclusion criteria. Breeds identified ranged from 4 to 10 mmHg. All cats, except those thought to
included 23 domestic shorthairs, 6 domestic longhairs, 3 Maine be volume overloaded, continued to receive further crystalloids,
coons, 3 Siamese cats, and 1 each of the following breeds: colloids, and blood products during vasopressor use as ongo-
Norwegian forest cat, Persian, Himalayan, Bombay, ragdoll, ing resuscitative efforts. Seven cats started vasopressor therapy
and Turkish van. There were 24 castrated males, 15 spayed during surgery after receiving multiple 5 to 10 mL/kg BW
females, and 2 intact females. The median age was 10 y (range: crystalloid and/or synthetic colloid boluses and vasopressors
1 to 19 y). were continued after surgery. The medical records stated that
the attending clinicians assessed the cats as adequately volume
Blood pressure resuscitated or volume overloaded before starting vasopressors.
Blood pressure measurements were performed using Doppler
ultrasonography in all cats. Initially all cats had a Doppler blood Vasopressor used
pressure (DBP) , 80 mmHg or a non-detectable blood pres- All vasopressors were given as continuous rate infusions.
sure before vasopressor therapy was initiated. Blood pressures Dopamine was used as the first-line vasopressor in 33 cats,
could not be measured in 14 cats. In the cats with detectable while 7 cats were treated with norepinephrine, and 1 cat was
blood pressure the median DBP was 56 mmHg (range: 40 to administered epinephrine. All cats ultimately received either
70 mmHg). Median temperature on initiation of vasopressor dopamine, norepinephrine or both. Prior to 2014, norepineph-
therapy was 36.9°C (range: 32.5°C to 40.0°C), but any hypo- rine was the first choice in 1 of the 34 cats treated compared
thermic cats were actively rewarmed before vasopressor therapy with being the first choice in 6 of 7 cats treated during or after
was intitated. Median heart rate at initiation was 160 beats/min 2014 (P , 0.001). Fourteen cats did not appear to respond to
(bpm) (range: 51 to 250 bpm). The associations between DBP the initial vasopressor by an increase in blood pressure and had
and temperature, DBP and heart rate, or heart rate and tem- another vasopressor added or had the vasopressor changed. Of
perature were not significantly correlated. the 14 cats that were given 2 vasopressors in the ICU, 13 cats
were on 2 vasopressors concurrently while 1 cat was switched
Underlying disease process, sepsis, and from one vasopressor to another. Other drugs used in 6 cats
surgical therapy in addition to either dopamine or norepinephrine included
By study design, all cats were critically ill, with a wide range of dobutamine (n = 3), epinephrine (n = 1), vasopressin (n = 1),
conditions. Twenty-four cats had evidence of sepsis based on or phenylephrine (n = 1).

1176 CVJ / VOL 59 / NOVEMBER 2018


Dopamine was used in 35 cats with a median starting cats died. All cats that were euthanized were considered mori-
dose of 10 mg/kg BW per min (range: 3 to 15 mg/kg BW per bund. Thirty-two cats (78%) survived to 24 h. Of these 32 cats,
min) and a median maximal dose of 10 mg/kg BW per min 21 (65%) had been weaned off vasopressors while 11 (35%)
(range: 5 to 15 mg/kg BW per min). Seventeen cats treated were still receiving vasopressor therapy. Eight of these 11 cats
with dopamine had their dose increased during treatment. were being administered single agent dopamine while 3 cats
Norepinephrine was used in 14 cats with a median starting had been started on dopamine and had norepinephrine added.
dose of 0.5 mg/kg BW per min (range: 0.05 to 1 mg/kg BW Twenty-six (63%) cats survived to 48 h. Nineteen (73%) of

A R T I C LE
per min) and a median maximal dose of 1.5 mg/kg BW per these cats had been weaned off vasopressors while 7 (27%)
min (range: 0.05 mg/kg BW per min to 2 mg/kg BW per min). cats continued to receive vasopressors. Twenty-four (58%) cats
Ten cats treated with norepinephrine had their dose increased survived to 72 h, and in this group, 21 (88%) cats had been
during therapy. Doses were incrementally adjusted based on weaned from vasopressor therapy, while 3 (12%) cats remained
clinician preference and adjustments were generally performed on vasopressors. For these 3 remaining cats, 1 cat was weaned
not more frequently than every 30 min. Dopamine infusion at 75 h and survived, 1 cat was weaned at 112 h and survived,
rates were increased by 2.5 to 5 mg/kg BW per min increments, and 1 cat died at 102 h. Median duration of hospitalization was
while norepinephrine doses were adjusted in increments of 6 d, with a range of 1 to 35 d.
0.1 to 0.2 mg/kg BW per min. When there were multiple
vasopressors in use, only 1 vasopressor dose was changed at Blood pressure effects
any given time. Prior to the initiation of vasopressor therapy the DBP was
, 80 mmHg or not detectable in all cats. Thirty-four cats
Side effects attributed to vasopressors (83%) had a documented DBP of at least 80 mmHg associated
Due to the critically ill nature of the cats, it was difficult to ret- with vasopressor therapy while 7 cats (17%) did not, and 28 cats
rospectively attribute side effects specifically to the use of vaso- had a documented DBP of . 90 mmHg or were discharged
pressor therapy. In cats with acute kidney injury, 7/21 (33%) from hospital.
survived compared with 9/18 (50%) cats that did not have an A single vasopressor was administered to 24 cats that achieved
increase in creatinine of . 26.6 mmol/L (P = 0.34). However, a DBP of at least 80 mmHg, and 20 of these cats received
there was no documentation in the record attributing AKI to dopamine while 4 were administered norepinephrine. Two
vasopressor use compared with multi-organ failure associated vasopressors were given to 10 cats, with 6 of these cats receiving
with critical illness, and vasopressors rates were not adjusted norepinephrine and dopamine while 1 cat each received a com-
based on the development of AKI. bination of either norepinephrine and epinephrine, dopamine
Ventricular arrhythmias were documented in the record and dobutamine, dopamine and vasopressin, or norepinephrine
of 2 cats as increasing in frequency during vasopressor use. and phenylephrine.
Both of these cats were receiving dopamine, 1 at 10 and 1 at Seven cats did not achieve a DBP of at least 80 mmHg, and
15 mg/kg BW per min. One of these cats had a prior diagnosis 3 of these were on single agent therapy while 4 cats received a
of hypertrophic cardiomyopathy and was being treated for a dia- vasopressor combination. Three cats were treated with dopamine
betic ketoacidotic crisis, but his cardiac condition worsened, he alone and 2 cats each received either dopamine and norepineph-
developed congestive heart failure, and acute kidney injury, and rine or dopamine and dobutamine.
was euthanized due to his moribund condition. The other cat A DBP of at least 80 mmHg was achieved by all 4 cats which
presented in a diabetic ketoacidotic crisis and based on point- received norepinephrine as a single agent and by 11/23 cats
of-care ultrasound in the ICU was noted to have poor cardiac (48%) on dopamine as the single agent.
contractility throughout hospitalization, developed oliguric The 34 cats that developed a DBP of at least 80 mmHg
renal failure, and was euthanized before having a formal echo- required a median time of 6 h (range: 1 to 80 h) to achieve this
cardiogram done. No other adverse events, such as evidence of target, and the 28 cats that developed a DBP of . 90 mmHg
splanchnic hypoperfusion (new onset vomiting or bloody diar- required a median of 6 h (range: 0 to 96 h) from the time of
rhea), were noted in the medical record to have been suspected initiation of vasopressor therapy. Median heart rate at the time
to be a result of vasopressor use. of documented DBP . 90 mmHg was 180 bpm (range: 51 to
Twenty-three (56%) cats received type-specific whole blood 232 bpm). At the time of discontinuation of vasopressor therapy
or component therapy as part of supportive care, with packed median body temperature was 37.8°C, range 36.4°C to 39.5°C,
red blood cells being transfused to 18 cats, whole blood to and median heart rate was 186 bpm (range: 102 to 250 bpm).
12 cats, and plasma to 4 cats. There was no survival difference Twenty-nine cats became normotensive based on a DBP
in cats receiving or not receiving each component, nor was there . 90 mmHg in 27 cats or survival to discharge without docu-
a documented effect of transfusion on blood pressure. No cat mented normotension (n = 2). Twenty-seven cats survived to
had a documented transfusion reaction; transfusion reactions be weaned off vasopressors, although 4 cats did not have docu-
may result in hypotension. mented normotension. Eleven cats overall were weaned from
vasopressors but did not survive to discharge. In this group of
Survival non-survivors, all were off vasopressors with no evidence of
Overall, 16 (39%) cats survived and were discharged from the hypotension for at least 24 h before a clinical decline associated
hospital. Fourteen (34%) cats were euthanized, and 11 (27%) with progression of their underlying illness.

CVJ / VOL 59 / NOVEMBER 2018 1177


Influence of surgery and sepsis crystalloids prior to vasopressor initiation, and further resuscita-
Surgical treatment was performed in 21 cats to control or treat tion with colloids as well as blood products was initiated before
the underlying disease, while 20 cats were considered to have and during vasopressor therapy. Although the exact indication
non-surgical conditions. Survival to discharge was 62% (13/21) for initiating vasopressors was poorly recorded in the medical
for cats treated surgically as compared to 15% (3/20) for cats record, blood pressure measurements were consistently low or
treated non-surgically (P = 0.004). Twelve of the 24 cats with undetectable despite fluid resuscitation. As in humans, it is dif-
sepsis survived (50%), while 4 of the 17 cats without evidence ficult to determine at times if an adequate fluid challenge has
A R T I C LE

of sepsis survived (24%; P = 0.11). Surgical intervention in cats been administered before starting vasopressors (14), but there
with sepsis resulted in 11 cats surviving (61%) compared to is growing evidence that a positive fluid balance is linked to an
survival of 1 of the 6 cats (17%) with sepsis that did not have increase in mortality (15,16).
surgery due to a lack of surgical options for source control (e.g., All the cats in this study were assessed by the clinician as
cholangiohepatitis) (P = 0.15). being adequately volume resuscitated, but considerable chal-
lenges exist in accurate determination of volume status. Physical
Glucocorticoids and cortisol determination examination parameters, response to fluid boluses, and CVP
Glucocorticoids were given to 13 cats. Five of these cats had were all used to determine volume status and perfusion. Central
been diagnosed with either lymphoma or a mast cell tumor, venous pressure has recently been recognized as a less useful tool
while 3 cats were receiving chronic glucocorticoid therapy in determining volume status (17). Echocardiography may have
for suspected inflammatory bowel disease. Three cats received some role in determining volume status, but was not used in this
glucocorticoids for support of suspected/confirmed sepsis and study for this purpose. Point-of-care ultrasound examination
possible critical illness associated corticosteroid insufficiency; was performed to assess left ventricular volume as a surrogate
1 cat received glucocorticoids for the treatment of anaphylaxis, indicator of adequacy of preload. As a retrospective study, it is
and 1 cat was given steroids to decrease airway inflammation impossible to determine if some cats may have responded to
secondary to upper airway obstruction as a result of suspected further fluid resuscitation rather than vasopressor therapy.
laryngeal paralysis. Five (38%) of the 13 cats that received glu- Vasopressor choice in this retrospective study was based on
cocorticoids survived, while 11 (39%) of the 28 cats that did clinician preferences, with a recent shift from dopamine to
not receive glucocorticoids survived (P = 1.0). norepinephrine presumably paralleling guidelines in humans
Cortisol levels were determined for 4 cats, including 3 with (4). Dopamine was historically favored as a vasopressor, but
septic conditions. Baseline cortisol values ranged from 129.7 to due to apparent improved outcome in septic shock in humans,
460.8 nmol/L. ACTH stimulation tests were performed on norepinephrine is now preferred over dopamine in this subset
2 cats, 1 with sepsis and 1 with liver disease. One septic cat had of human vasopressor-dependent patients (18). Whether this
an ACTH stimulation test result consistent with diminished recommendation is applicable to critically ill cats with a more
adrenal reserves (13) (delta cortisol 52.4 nmol/L), received heterogeneous spectrum of disease is unknown. In this study
hydrocortisone therapy and survived to be discharged. 80% of cats were started on dopamine compared with 17.5%
on norepinephrine, but no conclusions could be drawn as to
Influence of vasopressor their relative effectiveness due to the small number of cats and
Twenty-three cats received only dopamine as a vasopressor, the variability of the clinical picture.
and 8 (47%) survived. Four cats received only norepinephrine Dobutamine provides primarily inotropic support and only
and 2 survived. Fourteen cats received 2 vasopressors and 6 (42%) has indirect vasopressor actions. Dobutamine was given to 3 cats
survived. There was no statistical benefit of dopamine compared with refractory hypotension, 2 of which had underlying cardiac
with norepinephrine or the use of multiple vasopressors. The disease with reduced contractility documented with an echo-
median time to normalization of blood pressure (6 h) was similar cardiogram. In cats, use of dobutamine has been infrequently
whether cats received either dopamine or norepinephrine. reported, with documented increases in myocardial performance
in healthy cats (19,20), but limited data applicable to our ICU
Discussion patient population exist. Potential side effects of dobutamine
The results of this retrospective study describe the use of vaso- include seizures at doses . 5 mg/kg BW per min (21), which
pressors in a population of critically ill cats with hypotension. was not noted in our patient population.
Cats being treated with vasopressors generally had an increase in Epinephrine was used in 1 cat as a CRI following a severe
their blood pressure, with 29 of 41 cats achieving normotension. anaphylactic event. In veterinary medicine, epinephrine is
Persistent hypotension in cats has previously been associated largely reserved for anaphylaxis due to concerns over beta-
with a poor outcome (1,2). In septic human patients, the sur- agonist effects and increased myocardial oxygen consumption
viving sepsis guidelines (4) recommend providing vasopressors as well as splanchnic ischemia due to excessive vasoconstriction
if the mean blood pressure is , 65 mmHg despite adequate (5,22). Vasopressin is a non-adrenergic vasopressor that acts
fluid resuscitation. In critically ill animals, most clinicians directly to increase vasoconstriction and potentiate the effects
also recommend use of vasopressors when administration of of adrenergic agonists (5). Prolonged hypotension in humans
an adequate fluid replacement volume has failed to improve and dogs results in a depletion in vasopressin stores (23) and it
blood pressure (8). All of the cats that were perceived to be has been suggested that vasopressin therapy may be helpful in
fluid tolerant in this study received fluid therapy consisting of cases of prolonged refractory hypotension (24) or hypotension

1178 CVJ / VOL 59 / NOVEMBER 2018


in association with a severely acidemic patient. Vasopressin has References
not been explored as a single agent in cats. However, studies in   1. Shea EK, Dombrowski SC, Silverstein DC. Survival analysis of hypo-
humans have not indicated a clear benefit (25) and the current tensive cats admitted to an intensive care unit with or without hyper-
cost of vasopressin limits its use. lactatemia: 39 cases (2005–2011). J Am Vet Med Assoc 2017;250:
887–893.
The use of multiple vasopressors, most commonly dopamine   2. Silverstein DC, Wininger FA, Shofer FS, King LG. Relationship
and norepinephrine, was described in this study, as was chang- between Doppler blood pressure and survival or response to treat-
ing from 1 vasopressor to another. Practical considerations in ment in critically ill cats: 83 cases (2003–2004). J Am Vet Med Assoc
2008;232:893–897.

A R T I C LE
switching vasopressors include inadvertent bolus associated   3. Asfar P, Hauser B, Radermacher P, Matejovic M. Catecholamines and
with flushing the IV catheter and increased potential for drug vasopressin during critical illness. Crit Care Clin 2006;22:131–149,
calculation errors. From a clinical perspective, in human medi- vii–viii.
  4. Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign:
cine, current recommendations for sepsis include starting with International guidelines for management of sepsis and septic shock:
norepinephrine, and adding either epinephrine or vasopressin 2016. Intensive Care Med 2017;43:304–377.
if norepinephrine is ineffective or with vasopressin to allow the   5. Silverstein DC, Santoro Beer KA. Controversies regarding choice of
vasopressor therapy for management of septic shock in animals. J Vet
down titration of the infusion rate of norepinephrine. Direct Emerg Crit Care 2015;25:48–54.
switches from 1 vasopressor to another are rare unless there is   6. Scroggin RD, Jr, Quandt J. The use of vasopressin for treating vasodila-
evidence of significant side effects, such as ectopy. tory shock and cardiopulmonary arrest. J Vet Emerg Crit Care 2009;
19:145–157.
Cats that were treated surgically did significantly better than   7. Wohl JSD, Clark TP. Pressor therapy in critically ill patients. J Vet
cats that did not have a surgical intervention. Cats treated sur- Emerg Crit Care 2000;10:21–34.
gically were more likely to have sepsis. A recent human study   8. Haskins SC. Catecholamines. In: Silverstein D, ed. Small Animal
Critical Care Medicine. 2nd ed. St. Louis, Missouri: Elsevier, 2015:
clearly documented a survival benefit in patients with sepsis 829–835.
who underwent source control compared to patients who did   9. Butler AL. Goal-directed therapy in small animal critical illness. Vet
not have source control, supporting the theory that control of Clin North Am Small Anim Pract 2011;41:817–838.
10. Rowcliff K, de Waal K, Mohamed AL, Chaudhari T. Noradrenaline
the source of sepsis is useful (26). in preterm infants with cardiovascular compromise. Eur J Pediatr
Limitations of this study include those of most retrospective 2016;175:1967–1973.
studies, namely a varied approach to vasopressor use by indi- 11. Koczmara CK, St-Arnaud C, Martinez HQ, et al. Vasopressor steward-
ship: A case report and lesson shared. Dynamics 2014;25:26–29.
vidual clinicians, and lack of a standardized approach to fluid 12. Harison E, Langston C, Palma D, Lamb K. Acute azotemia as a predic-
resuscitation prior to beginning vasopressors. Volume status tor of mortality in dogs and cats. J Vet Intern Med 2012;26:1093–1098.
in cats is particularly difficult to assess, and cats are prone to 13 Durkan S, De Laforcade A, Rozanski E, Rush JE. Suspected rela-
tive adrenal insufficiency in a critically ill cat. J Vet Emerg Crit Care
fluid overload from occult cardiomyopathy (27). Additionally, 2007;17:197–201.
measurement of blood pressure in cats is challenging at times, 14. Bednarczyk JM, Fridfinnson JA, Kumar A, et al. Incorporating dynamic
particularly in hypotensive and/or vasoconstricted cats (28–30). assessment of fluid responsiveness into goal-directed therapy: A system-
atic review and meta-analysis. Crit Care Med 2017;45:1538–1545.
The specific rationale behind vasopressor decisions was not 15. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resus-
always clear, which might have impacted outcome. There was citation in septic shock: A positive fluid balance and elevated central
no apparent benefit to norepinephrine over dopamine, but due venous pressure are associated with increased mortality. Crit Care Med
2011;39:259–265.
to the small sample size, the possibility of a type 2 error exists. 16. Marik PE. Iatrogenic salt water drowning and the hazards of a high
It is possible other cats hospitalized during the study period central venous pressure. Ann Intensive Care 2014;4:21.
had hypotension, but did not receive vasopressors and survived, 17. Marik P, Cavallazzi R. Does the central venous pressure predict fluid
responsiveness? An updated meta-analysis and a plea for some common
and it is certainly possible that some cats in this study may have sense. Crit Care Med 2013;41:1774–1781.
responded to more aggressive fluid therapy alone. 18. Belletti A, Benedetto U, Biondi-Zoccai G, et al. The effect of vasoactive
From a practical standpoint, based upon the results of this drugs on mortality in patients with severe sepsis and septic shock. A net-
work meta-analysis of randomized trials. J Crit Care 2017;37:91–98.
study, vasopressors appear to have a role in support of blood 19. Pascoe PJ, Ilkiw JE, Pypendop BH. Effects of increasing infusion rates
pressure in critically ill cats. Recommendations for clinical of dopamine, dobutamine, epinephrine, and phenylephrine in healthy
management of cats with hypotension include an aggressive anesthetized cats. Am J Vet Res 2006;67:1491–1499.
20. Hori Y, Uechi M, Indou A, et al. Changes in the myocardial perfor-
search for an underlying cause and aggressive fluid resuscita- mance index during dobutamine administration in anesthetized cats.
tion with crystalloids (10 to 20 mL/kg BW boluses repeated Am J Vet Res 2007;68:385–388.
as needed). Electrolyte and acid-base disturbances should be 21. Fox PR. Feline myocardial diseases. Proceedings of the 18th Annual
Waltham/OSU Symposium: Cardiology. Vernon, California, USA,
corrected. If hypotension persists, either dopamine starting at 1994:117.
5 mg/kg BW per min or norepinephrine starting at 0.1 mg/kg 22. Levy B, Bollaert PE, Charpentier C, et al. Comparison of norepineph-
BW per min is acceptable and should be initiated and titrated rine and dobutamine to epinephrine for hemodynamics, lactate metabo-
lism, and gastric tonometric variables in septic shock: A prospective,
to effect. Vasopressors may be slowly decreased after a DBP of randomized study. Intensive Care Med 1997;23:282–287.
90 mmHg is maintained for at least 1 h, but the cat should be 23. Landry DW, Levin HR, Gallant EM, et al. Vasopressin deficiency
closely monitored for relapse. contributes to the vasodilation of septic shock. Circulation 1997;95:
1122–1125.
In conclusion, this study describes the use of vasopres- 24. Silverstein DC, Waddell LS, Drobatz KJ, King LG. Vasopressin therapy
sors in cats with various underlying causes of critical illness. in dogs with dopamine-resistant hypotension and vasodilatory shock.
Vasopressors appear appropriate for use in critically ill cats and J Vet Emerg Crit Care 2007;17:399–408.
25. Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine
hypotensive cats recovering from surgery in particular may infusion in patients with septic shock (VASST). N Engl J Med 2008;
benefit from the use of vasopressors. CVJ 358:877–887.

CVJ / VOL 59 / NOVEMBER 2018 1179


26. Martinez ML, Ferrer R, Torrents E, et al. Impact of source con- 29. da Cunha AF, Saile K, Beaufrère H, Wolfson W, Seaton D, Acierno MJ.
trol in patients with severe sepsis and septic shock. Crit Care Med Measuring level of agreement between values obtained by directly mea-
2017;45:11–19. sured blood pressure and ultrasonic Doppler flow detector in cats. J Vet
27. Luis Fuentes V, Wilkie LJ. Asymptomatic hypertrophic cardiomyopathy: Emerg Crit Care (San Antonio) 2014;24:272–278.
Diagnosis and therapy. Vet Clin North Am Small Anim Pract 2017; 30. Brown S, Atkins C, Bagley R, et al. ACVIM consensus statement:
47:1041–1054. Guidelines for the identification, evaluation, and management of
28. Caulkett NA, Cantwell SL, Houston DM. A comparison of indirect systemic hypertension in dogs and cats. J Vet Intern Med 2007;21:
blood pressure monitoring techniques in the anesthetized cat. Vet Surg 542–558.
1998;27:370–377.
A R T I C LE

Answers to Quiz Corner


Les réponses du test éclair
1. A) Taurine and arachidonic acid are not found in plant sources D) La chirurgie dans cette région n’est pas habituellement
and are required by cats. Cats cannot convert the vitamin A possible. Les uretères se terminent à cet endroit et il n’est
precursors found in plants to vitamin A; therefore, vitamin A habituellement pas possible d’enlever la tumeur au complet.
from meat sources is required by the cat. La cystectomie avec la pose d’un sac externe de récupération
A) La taurine et l’acide arachidonique ne sont pas rencontrés de l’urine est le traitement de choix chez les humains, mais
dans les plantes et les chats en ont besoin. Les chats ne n’est pas pratique chez les animaux. La radiothérapie possède
peuvent pas convertir les précurseurs de la vitamine A des effets limités à ce jour. La chimiothérapie à l’aide de
trouvés dans les plantes en vitamine A. La vitamine A composés de platine possède une réponse limitée sur le
provenant des viandes est dont nécessaire pour les chats traitement au proxicam seul; la néphrotoxicité représente
un effet secondaire limitant.
2. B) A swelling under the tongue could be associated with a ranula
or, potentially, a neoplastic process. While neoplasia may 4. A) The correct answer is to treat all contact animals. Chorioptic
lead to laryngeal paralysis, the neoplasia is typically found mange is common in draft breeds, is not associated with poor
in the ventral cervical region or the cranial mediastinum, not nutrition or hygiene, and is not a reportable condition. It is
under the tongue. The other 4 answers are common present- transmitted via direct and indirect contact and pruritus may
ing complaints in dogs afflicted with laryngeal paralysis. not be present; thus, all contact animals should be treated.
B) L’enflure sublinguale est associée à une ranula ou, A) La bonne réponse est de traiter tous les animaux qui ont
potentiellement, à une néoplasie. Bien que la néoplasie des contacts. La gale chorioptique est commune chez les
puisse conduire à une paralysie laryngée, la néoplasie est races de chevaux de trait et n’est pas associée à la mauvaise
rencontrée de façon caractéristique dans la région cervicale nutrition ou à la mauvaise hygiène et n’est pas une maladie
ventrale ou dans le médiastin cranial et non sous la langue. à déclaration obligatoire. Elle est transmise par contact
Les quatre autres réponses sont des troubles fréquents des direct ou indirect et le prurit peut être absent; ainsi, tous les
chiens atteints de paralysie laryngée. animaux qui ont des contacts doivent être traités.

3. D) Surgery in this region is usually not possible. The ureters 5. A) Mycoplasma polyarthritis is common in feedlots and rare on
are located there, and it is usually not possible to resect the dairy farms. Otitis interna is common in dairy calves but not
entire tumor. Cystectomy with the creation of an external beef. Mycoplasma spp. are not implicated in the etiology of
bag for urine collection is the preferred treatment for humans puerperal metritis. Mycoplasma pneumonia is common in all
but is not a practical therapy for pets. Radiation therapy has bovine settings.
limited benefits to date. Chemotherapy with platinum com- A) La polyarthrite à Mycoplasma est commune dans les parcs
pounds has limited response over that of piroxicam alone; d’engraissement mais rare dans les fermes laitières. L’otite
nephrotoxicity is a limiting side effect. interne est commune chez les veaux de races laitières mais
non chez ceux de races de boucherie. Mycoplasma sp. n’est
pas impliqué dans l’étiologie de la métrite puerpérale. La
pneumonie à Mycoplasma est commune chez tous les bovins.

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