Topics in Companion An Med 39 (2020) 100403

Research Article

Acid-Base, Electrolyte and Lactate Abnormalities as Well as Gastric Necrosis

and Survival in Dogs With Gastric Dilation-Volvulus Syndrome.
A Retrospective Study in 75 Dogs
Leona Rauserova-Lexmaulovaa,*, Ivana Vanova-Uhrikovab, Kristina Rehakovab

Keywords: A B S T R A C T
disorders
gastric-dilation volvulus Gastric dilation-volvulus (GDV) syndrome in dogs is associated with complex metabolic, acid-base, and elec-
acid-Base
trolyte abnormalities. The aim of this study was to evaluate previously analyzed factors (lactate and BE) in
electrolytes
combination with other acid-base parameters (pH, pCO2, bicarbonate, base excess [BE], anion gap [AG], and
outcome
strong ion difference) and electrolyte concentrations and to evaluate their association with the incidence of
a
gastric necrosis and outcome in dogs with GDV. A retrospective study in 75 dogs with gastric dilation-volvu-
Department of Surgery and Orthopedics, Small
lus syndrome, University veterinary teaching hospital. Medical records were reviewed including signalment,
Animal Clinic, Faculty of Veterinary Medicine,
history, initial plasma lactate, acid-base parameters, and electrolyte concentrations, surgical findings and
University of Veterinary and Pharmaceutical
Sciences Brno, Brno, Czech Republic
outcome. The overall mortality was 18.7%. In dogs with gastric necrosis, higher initial plasma lactate (median
b
5.84 vs. 3.36 mmol/L) and AG (20.7 vs. 16.55 mmol/L) and lower pH (7.29 vs. 7.36), bicarbonate (18.7 vs. 22.9
Small Animal Clinical Laboratory, Faculty of
mmol/L), and BE concentration (
8.1 vs.
1.85 mmol/L) were found compared to dogs without gastric necro-
Veterinary Medicine, University of Veterinary
and Pharmaceutical Sciences Brno, Brno, Czech sis. Anorganic phosphorus was the only electrolyte investigated for which a significant difference was noted
Republic between dogs with and without gastric necrosis (1.93 vs. 1.39 mmol/L). The initial plasma lactate concentra-
tion (3.36 mmol/L vs. 9.68 mmol/L) and AG (16.8 vs. 20.95 mmol/L) were lower in survivors than nonsurvi-
vors. Survivors had higher pH (7.35 vs. 7.27), bicarbonate concentrations (22.9 vs. 17.35 mmol/L), and BE
(
1.9 vs.
9.55 mmol/L) compared to nonsurvivors. Anorganic phosphorus was ultimately the only electro-
lyte with a significant difference between survivors and nonsurvivors (1.4 vs. 1.84 mmol/L). A multivariate
logistic regression model of combination lactate, pH, bicarbonate, BE, AG, and anorganic phosphorus identi-
fied pH
7.331 and bicarbonate as factors independently associated with gastric necrosis. Similarly, pH
˃7.331, bicarbonate and anorganic phosphorus were independently associated with outcome. Higher initial
plasma lactate, AG and anorganic phosphorus levels, and lower pH, BE and bicarbonate concentrations were
found in GDV dogs with gastric necrosis. Similarly, initially higher plasma lactate, AG and anorganic
phosphorus concentrations, and lower pH, BE and bicarbonate were found in GDV dogs who required
euthanasia or who died after surgery. Of these parameters, pH and bicarbonate were strongly and
independently associated with gastric necrosis, and pH, bicarbonate and phosphorus were indepen-
dently associated with outcome.
© 2020 Elsevier Inc. All rights reserved.

Introduction sequestration within the stomach and small intestine.15,19,21,22 The

Gastric dilation-volvulus syndrome (GDV) is a life-threatening
condition that usually affects large and giant breed dogs and
requires urgent surgical treatment.1-7 Mortality after surgical inter-
vention ranges between 4.3% and 23%.1-9 The pathogenesis of GDV
consists of abnormal fluid and gas accumulation in the stomach,
gastric dilation, rotation, and displacement of the stomach with risk
of gastric wall necrosis and death.1,2 An increased intra-abdominal
pressure results in hypovolemic/obstructive shock, tissue hypoper-
fusion/ischemia, and a spectrum of acid-base and electrolyte
abnormalities.10
15 Tissue ischemia and decreased oxygen delivery
lead to metabolic derangement, an increase in lactate production
and electrolyte and acid-base abnormalities.14-21 The electrolyte
and acid-base status during GDV is also affected by fluid
*Corresponding author.
E-mail address: rauserovaleona@gmail.com (L. Rauserova-Lexmaulova).
Abbreviations: AG, anion gap; AUROC, area under the receiver operating characteristic
curve; BE, base excess; GDV, gastric dilation-volvulus syndrome; ROC, receiver operat-
ing characteristic curve; SID, strong ion difference
Presented in part at the 12th EVECCS Annual Congress, Copenhagen, 2013 (JVECC 23
(S1):S25-S26 and S28
S29.
type and severity of these pathological changes can be assessed
based on measurement of lactate, pH, base excess (BE) and bicar-
bonate concentration.18-20 Many studies have reported on the asso-
ciation between gastric necrosis and mortality, and several blood
parameters have been studied as predictors of gastric necrosis and
outcome in dogs with GDV.1
3,6 Despite the confirmation of an asso-
ciation between lactate and BE with gastric necrosis and outcome in
many of these studies, only a single measurement of plasma lactate
and BE concentration and their absolute changes do not constitute
accurate prognostic indicators in all GDV patients.2,8,9,16,19,20,22-25
Therefore, the aim of this retrospective case-control study was to
evaluate previously analyzed factors (lactate and BE) in combination
with other acid-base parameters (pH, BE, bicarbonate, anion gap
[AG], strong ion difference [SID]) and electrolyte concentrations
(sodium, potassium, chlorides, total calcium, and anorganic phos-
phorus) and to establish their association with the incidence of gas-
tric necrosis and outcome in dogs with GDV. We hypothesize that
complex blood gas analysis with lactate and electrolyte concentra-
tions and AG and SID calculations can be beneficial for obtaining a
more accurate assessment risk of gastric necrosis and possible
patient death at the time of admission.

http://dx.doi.org/10.1016/j.tcam.2020.100403
1938-9736/© 2020 Elsevier Inc. All rights reserved.
2 L. Rauserova-Lexmaulova et al. / Topics in Companion An Med 39 (2020) 100403
Materials and Methods
This retrospective case-control study was conducted on canine
patients admitted for GDV surgery between July 2010 and July 2014
in a veterinary teaching hospital setting.
Case Selection and Medical Record Review
A medical records search of dogs with a radiographic diagnosis of
GDV admitted to Small Animal Clinic, University of Veterinary and
Pharmaceutical Sciences from July 2010 to July 2014 was conducted.
The following information was collected: signalment, duration of
clinical signs, initial values of lactate, pH, pCO2, bicarbonate, BE and
electrolytes (sodium, potassium, chlorides, total calcium, and anor-
ganic phosphorus), AG, SID, surgical findings of gastric necrosis, and
survival to discharge.
Only the records of dogs with surgically treated GDV and complete
initial blood work (complete blood count, plasma biochemistry, and
blood gas analysis) collected at the time of patient admission and prior
to any treatment were included in the study. The blood samples were
required to have been processed within 15 minutes after blood
collection.a,b,c Lactate and electrolyte concentrations (sodium, potassium,
chlorides, total calcium, and phosphorus) were required to have been
measured in plasma, separated within 10 minutes of collection and
immediately analyzed using,d or stored frozen (
20°C) according to
manufacturer instructions and published conditions for processing, stor-
age, and analytic stability for routine biochemical parameters (e.g., lac-
tate, electrolytes) in canine plasma and processed the following day.26,27
Complete blood count and hemoglobin measurement were required to
have been performed immediately after blood sample collection.e
The AG and SID were calculated using the following formulas:
AG  ¼   ðNa  þ  KÞ
ðCl  þ  HCO3 Þ
SIDapp   ¼  Na
Cl
Electrolyte derangements were classified as abnormal if the concen-
trations were below or above the normal reference range of our insti-
tution laboratory: sodium ˂140 or ˃155 mmol/L, potassium ˂4 or
˃5 mmol/L, chlorides ˂104 or ˃119 mmol/L, total calcium ˂2.3 or ˃3
mmol/L, and anorganic phosphorus ˂1 or ˃2.1 mmol/L.
Metabolic alkalosis was defined as meeting, at minimum, 2 of the
following parameters: pH ˃7.44, bicarbonate ˃25 mmol/L and/or BE
˃2.1 mmol/L. Metabolic acidosis was concluded based on meeting, at
minimum, 2 of the following criteria: pH ˂7.34, bicarbonate
˂18 mmol/L and/or BE ˂
5 mmol/L. Mixed acid-base disorders were
defined based on abnormalities in previous parameters and PCO2
level (respiratory alkalosis PCO2 ˂3.52 kPa, respiratory acidosis ˃5.91
kPa), AG (metabolic acidosis AG ˃23.3 mmol/L, metabolic alkalosis
AG ˂11 mmol/L) and SIDapp (metabolic alkalosis SID ˃40 mmol/L,
metabolic acidosis SID ˂32 mmol/L) calculation.
Gastric necrosis was assessed at surgery by a specialist surgeon
based on the viability of the gastric wall (discoloration observed as dark
purple, black or green color of the gastric mucosa, decreased gastric
wall tone, and/or a lack of bleeding from the gastric wall after incision).
Statistical Analysis
All statistical analyses were performed using commercial software.f,g
The primary outcome of interest was the presence or absence of gastric
a
Monovette 1 ml, lithium-heparin syringes (Sarstedt, Germany).
b
Dispolab K3EDTA 0.5 ml (Dispolab s.r.o., Czech Republic).
c
EasyBloodGas analyser (Medica Corporation, USA).
d
DPC Konelab 20i analyzer (Thermo Fisher Scientific, Finland).
e
Celltac alfa (Nihon Kohden, Japan).
f
MedCalc Software bvba (Ostend, Belgium).
g
Microsoft Excel 2010 (Microsoft Corporation, Redmont, WA).
wall necrosis, and the secondary outcome of interest was survival to dis-
charge from hospital.
All data were assessed for the normality of data distribution by
using the Kolmogorov-Smirnov test.
The Kruskal-Wallis test was used for the comparison of nonpara-
metric data (data were presented as the median and range), and 2-
group comparisons of binary outcomes were made using Fishers
exact test. A univariate logistic regression analysis was used to assess
the association between acid-base parameters, electrolyte concentra-
tions, and the incidence of gastric necrosis and survival (data pre-
sented as the median, range, odds ratio [OR], and 95% confidence
interval [CI]). A receiver operating characteristic curve analysis (ROC)
was generated to assess the diagnostic (for gastric necrosis) and pre-
dictive (for survival) optimal cut-off values of the parameters, which
were significantly different among the groups.
The variables that were significantly associated with gastric
necrosis and mortality were added to a multivariate model for logis-
tic regression analysis. If 2 variables were highly correlated, as deter-
mined by Spearmans correlation coefficient ˃.6, then only one of the
variables was placed in the multivariate analysis to determinate its
association with gastric necrosis and mortality.
Values of P <.05 were considered significant for all statistical anal-
yses.
Results
The medical records of 326 dogs with GDV were reviewed, and of
these, 174 dogs had undergone surgery. Ninety-nine dogs were fur-
ther excluded from the study, because they had received treatment
prior to admission to our hospital or had incomplete records (e.g., an
absence of laboratory results before treatment). Seventy-five dogs
met the inclusion criteria of the study.
Characteristic of the Study Group
Forty-six dogs (61.3%) were intact males, 28 (37.3%) were intact
females, and 1 dog was a spayed female. There were 25 breeds repre-
sented. The most common breeds were Bernese Mountain dog (13
dogs), German Shepherd (8), Rhodesian Ridgeback (8), Doberman
Pinscher (6), Great Dane (4), Greater Swiss Mountain Dog (4), Central
Asian Shepherd Dog (3), Fila Brasileiro (3), Irish Setter (3), and Irish
Wolfhound (3). Basset Hound and 14 large or giant breeds were rep-
resented by 1 or 2 dogs in each breed. The median age was 6 years
(range 1-13 years) and the median body weight was 41 kg (range 23-
90 kg).
Blood was collected from the dorsal metatarsal artery in 49 of 75
(65.3%) dogs, and the jugular vein in 26 of 75 (34.7%) dogs into hepa-
rin syringes1 and K3EDTA tubes.2
Incidence of Gastric Necrosis and Mortality
Gastric necrosis was identified in 28% (21 of 75) of the dogs
(Table 1). The dogs with gastric necrosis were older (median 8 years,
range 4-12 years) than the dogs without gastric necrosis (6 years,
1-13 years, P = .018). The duration of clinical signs was longer in the
dogs with gastric necrosis (median 10 hours, range 1.5-20 hours)
than in the dogs without gastric necrosis (median 4.0 hours, range
1-24 hours, P = .0019).
The overall mortality in this case-control study of dogs with GDV
was 18.7% (14 of 75 dogs, compounds perioperative euthanasia, and
death after the surgery) and was significantly higher in the dogs with
gastric necrosis (P ˂ .0001).
Of the 14 dogs that did not survive, gastric necrosis was identified
in 92.9% (13 of 14) patients; of these, 50% (7 of 14) were euthanized
intraoperatively due to an untreatable condition and 42.9% (6 of 14)
underwent partial gastric resection, but died within 12 hours of
 L. Rauserova-Lexmaulova et al. / Topics in Companion An Med 39 (2020) 100403 3

Table 1 Association Between Lactate, pH, Bicarbonate, BE, AG, and Phosphorus
Evidence of Gastric Necrosis and Survival in 75 Dogs Treated Surgically for Gastric Dila- Concentration and Gastric Necrosis
tion-Volvulus Syndrome at a Veterinary Teaching Hospital
A multivariate logistic regression analysis model was used for the
Gastric Necrosis combination of plasma lactate concentration, pH, bicarbonate, BE,
Present Absent AG, and anorganic phosphorus concentration and showed that pH
Survivors (n = 61) 8 (13.1%) 53 (86.9%)
7.331 (OR 6.081; 95% CI 1.536-24.081, P = .010) and bicarbonate (OR
Nonsurvivors (n = 14) 13 (92.9%) 1 (7.1%) 0.780; CI .638-.954, P = .016) were independently associated with the
incidence of gastric necrosis.

surgery. The only dog without gastric necrosis died due to coagulop-
athy and uncontrolled bleeding 6 hours after surgery.
Relationship Between Blood Parameters and the Incidence of Gastric
Necrosis
Plasma Lactate Concentrations
The initial plasma lactate concentration was significantly associ-
ated with gastric necrosis (median 5.84 mmol/L, range 2.1-
15.97 mmol/L vs. without necrosis 3.36 mmol/L, 0.83-12.91 mmol/L,
P = .0001), as shown in Table 2.
Acid Base Assessment (pH, PCO2, Bicarbonate, BE, AG, and SID)
Primary respiratory acidosis was found in 9.5% (2 of 21) of the
dogs with gastric necrosis and in 7.4% (4 of 54) of the dogs with-
out gastric necrosis, and metabolic or mixed acid-base disorders
were identified in 81% (17 of 21) of the dogs with gastric necrosis
and in 55.6% (30 of 54) of the dogs without gastric necrosis
(Table 3).
Blood pH was significantly associated with the incidence of gastric
necrosis (median 7.29, range 7.05-7.37 vs. 7.36, 7.25-7.45, P ˂ .0001).
Similar statistically significant associations were found for bicarbon-
ate, base excess, and anion gap (Tables 2 and 4).
Relationship Between Blood Parameters and Outcome
The nonsurvivors were significantly older (median 8.15 years,
range 4.4-12 years vs. 6 years, 1-13 years, P = .011), and the duration
of clinical signs in these patients was significantly longer (median
11 hours, range 3-20 hours) than in the survivors (median 4 hours,
range 1-24 hours, P ˂ .0001).
Plasma Lactate Concentrations
Initial plasma lactate concentration was significantly associated
with mortality (nonsurvivors median 9.68 mmol/L, range 5.84-
13.49 mmol/L vs. survivors, median 3.36 mmol/L, range 2.42-
5.64 mmol/L, P ˂ .0001), as shown in Table 5.
Acid Base Assessment (pH, PCO2, Bicarbonate, BE, AG, and SID)
Primary respiratory acidosis was found in 8.2% (5 of 61) of the sur-
vivors and in 7.1% (1 of 14) of the nonsurvivors, and metabolic or
mixed acid-base disorders were identified in 57.4% (35 of 61) of the
survivors and 85.7% (12 of 14) of the nonsurvivors (Table 3).
The nonsurvivors had significantly lower blood pH values (median
7.27, range 7.1-7.36) than the survivors (median 7.35, range 7.05-
7.45, P ˂ .0001).
Similar statistically significant associations were found for bicar-
bonate, BE and AG (Table 4).

Plasma Electrolyte Concentrations

Plasma Electrolyte Concentrations Electrolyte abnormalities were noted in 90.1% (55 of 61) of the
Electrolyte abnormalities were noted in 100% (21 of 21) of the survivors and in 100% (14 of 14) of the nonsurvivors (Table 5).
dogs with gastric necrosis and in 90.7% (49 of 54) of the dogs without The only significant finding was that of a higher anorganic phos-
gastric necrosis (Table 6). Of the electrolytes recorded, only anorganic phorus concentration in the nonsurvivors (median 1.84 mmol/L,
phosphorus concentration was identified to be associated with gas- range 0.68-3.8 mmol/L) vs. the survivors (median 1.4 mmol/L, range
tric necrosis (median 1.93 mmol/L, range 0.43-6.75 mmol/L vs. .43-4.12 mmol/L, P = .0053, Tables 5 and 6).
1.39 mmol/L, 0.51-4.12 mmol/L, P = .039, Tables 2 and 6).
ROC Analysis for the Prediction of Survival
ROC Analysis for the Prediction of Gastric Necrosis Based on ROC analysis, the optimal cut-off points to predict
By using ROC analysis, the following cut-off concentrations were patient survival were lactate
5.62 mmol/L (75.4% sensitivity, 85.7%
estimated: lactate ˃4.65 mmol/L (76.2% sensitivity, 66.7% specificity, specificity, AUROC curve .86), pH ˃7.331 (70.5% sensitivity, 92.9%
area under the receiver operating characteristic curve [AUROC] .75), specificity, AUROC .86), BE ˃
7.8 mmol/L (93.3% sensitivity and 71.4%
pH
7.331 (81% sensitivity, 74.1% specificity, AUROC .83), bicarbonate specificity, AUROC .90), bicarbonate ˃20.5 mmol/L (72.1% sensitivity,

20.2 mmol/L (76.2% sensitivity, 75.9% specificity, AUROC .79), BE 92.9% specificity, AUROC .85), AG ˂19.9 mmol/L (77% sensitivity,


6.4 mmol/L (71.4% sensitivity, 87% specificity, AUROC .83), AG 71.4% specificity, AUROC .72), and phosphorus
1.5 mmol/L (63.9%
˃20.4 mmol/L (57.1% sensitivity, 79.6% specificity, AUROC .68) and sensitivity, 85.7% specificity, AUROC .75).
anorganic phosphorus concentration ˃1.82 mmol/L (47.62% sensitiv-
ity, 83.33% specificity, AUROC .65). Association Between Lactate, pH, BE, Bicarbonate, AG, and Phosphorus
Concentration and Outcome
A multivariate logistic regression analysis model was used to ana-
Table 2 lyze combinations of plasma lactate concentration, pH, bicarbonate,
Univariate Logistic Regression Analysis of Initial Plasma Lactate, pH, Bicarbonate, BE, BE, AG, and anorganic phosphorus concentration, with the results
AG, and Phosphorus Concentrations and Gastric Necrosis in 75 Dogs Treated Surgically identifying that the variables of pH ˃7.331 (OR 14.259; CI 1.321-
for Gastric Dilation-Volvulus Syndrome at a Veterinary Teaching Hospital
153.890, P = .029), bicarbonate (OR 1.443, CI 1.070-1.946, P = .016),
Variable Odds Ratio 95% Confidence Interval P Value and phosphorus (OR .261; CI .087-.780, P = .016) were independently
associated with the incidence of mortality.
Lactate 1.35 1.138-1.591 .0001
pH 5.67 £ 10
11 2.6745 £ 10
16 to 0.0000 ˂.0001
Base excess .707 0.595-.839 ˂.0001 Discussion
Bicarbonate .718 0.599-.859 ˂.0001
AG 1.123 0.564-.785 .0288 This study of 75 dogs presenting with GDV had a similar survival
Phosphorus 2.199 1.01-4.8 .0039
rate (81.3%) to hospital discharge rates reported in previous studies,
4 L. Rauserova-Lexmaulova et al. / Topics in Companion An Med 39 (2020) 100403

Table 3
Evidence of Acid-Base Disorders, Gastric Necrosis and Survival in 75 Dogs Treated Surgically for Gastric Dilation-Volvulus Syndrome at a Veterinary Teaching Hospital

Abnormality Gastric Necrosis (n = 21) Without Necrosis (n = 54) Nonsurvivors (n = 14) Survivors (n = 61)

Respiratory acidosis 2 4 1 5
Metabolic alkalosis 0 6 0 6
Metabolic acidosis 8 10 7 11
Mixed disorders 9 14 5 18

Table 4
pH, Bicarbonate, BE, and AG values (Median, Range) and the Incidence of Gastric Necrosis, and Survival in 75 Dogs Treated Surgically for Gastric Dilation-Volvulus Syndrome at a
Veterinary Teaching Hospital

With Gastric Necrosis Without Gastric Necrosis P Value Nonsurvivors Survivors P Value

pH 7.29 (7.05-7.37) 7.36 (7.25-7.45) <.0001 7.27 (7.1-7.36) 7.35 (7.05-7.45) <.0001
Bicarbonate (mmol/L) 18.7 (11.7-26) 22.9 (14.1-29.7) <.0001 17.35 (11.7-22.1) 22.9 (14.1-29.7) <.0001
BE (mmol/L)
8.1 (
14 to 0.1)
1.85 (
14.4 to 5.4) <.0001
9.55 (
14 to
3.7)
1.9 (
14.4 to 5.4) <.0001
Anion gap (mmol/L) 20.7 (16.95-24.25) 16.55 (14.30-19.60) =.029 20.95 (14.30-19.67) 16.8 (17.90-21.80) = 0.049

Table 5 gastric necrosis and predictor of outcome in GDV patients.2,8,9,16,23-

25,28-32
Univariate Logistic Regression Analysis of Initial Plasma Lactate, pH, Bicarbonate, BE, Although the present study confirmed this finding, nonethe-
AG, and Phosphorus Concentrations and Survival in 75 Dogs Treated Surgically for Gas-
less some of the survivors of our GDV study group presented with
tric Dilation-Volvulus Syndrome at a Veterinary Teaching Hospital
significantly elevated plasma lactate without signs of gastric wall
Variable Odds Ratio 95% Confidence Interval P Value necrosis. These patients demonstrate that lactate may not be predic-
Lactate 1.511 1.249-1.895 ˂.0001 tive of gastric wall necrosis or outcome in all cases. In contrast, only
pH 8.77 £ 107 1577.306 to 4.88 £ 1012 ˂.0001 moderately increased lactate with low BE has previously been
BE .658 .517-.799 ˂.0001 reported in GDV dogs.20,33-36 Therefore, in this study, we chose to
Bicarbonate .660 .514-.814 ˂.0001
focus on a complex evaluation that included acid-base analysis and
AG .8896 .606-.819 .0490
Phosphorus 3.306 1.402-8.953 .0053
electrolyte concentrations, in an attempt to improve gastric necrosis
and outcome prediction.20,24,32,37-39
As previously reported, the incidence of acid-base abnormalities is
in which patient outcome was negatively influenced by gastric relatively common in dogs with GDV, although the type and severity
necrosis.1,2,4,5,8,9,23,25,28 Similarly, the increased duration of clinical vary.9,22,25,35,36 In this study, we observed metabolic acidosis, meta-
signs prior to presentation to the hospital was significantly associated bolic alkalosis, mixed metabolic alkalosis/respiratory acidosis, and
with both gastric necrosis and decreased survival.3,13,14,23 This study mixed metabolic acidosis/alkalosis. The finding of a higher prevalence
found an association between increased age and a higher risk of gas- of low pH, BE, bicarbonate, and higher AG in dogs with gastric necro-
tric necrosis and mortality and confirmed preliminary information sis and in nonsurvivors in combination with the absence of metabolic
published by Glickman et al in 1996.28 alkalosis in nonsurvivors is partially consistent with reports in previous
The main findings of this study are as follows: (1) Gastric studies, in which decreased concentrations of BE and bicarbonate corre-
necrosis was associated with significant changes in the dogs’ ini- sponded with a more serious derangement of the acid-base status in
tial plasma lactate concentration, pH, bicarbonate, BE, AG, and the body and worse prognosis.6,9,20,31,33-36,37-43 Bicarbonate concentra-
anorganic phosphorus concentrations. (2)The initial changes in tion was not evaluated in previous studies. In this study, the
the dogs’ plasma lactate, pH, bicarbonate, BE, AG, and anorganic influence of PCO2 on bicarbonate concentration in the blood was
phosphorus concentrations were also significantly associated with not evaluated. In contrast to bicarbonate, BE concentration should
outcome. (3) Multivariate logistic regression analysis of combina- be less affected by PCO2; therefore, BE is considered to be the
tions of plasma lactate, pH, bicarbonate, BE, AG, and anorganic purest marker of the metabolic component of a dog’s acid-base
phosphorus concentrations showed that pH and bicarbonate were status.18,19,24,35,43,44
the only factors found to be independently associated with the Because of the production of hydrogen ions and lactate during
incidence of gastric necrosis and pH, bicarbonate, and phosphorus anaerobic glycolysis (which is common when a patient is in shock),
for mortality. significant amounts of various unmeasured anions can be generated,
Of the various laboratory parameters that are commonly recorded all of which play important role in the genesis of acid-base abnormal-
in a veterinary care setting, lactate has been used as an indicator of ities.15-20,45 However, the sequestration of fluid rich in potassium,

Table 6
Incidence of Electrolyte Abnormalities in Dogs With and Without Gastric Necrosis, Survivors and Nonsurvivors in 75 Dogs Treated Surgically for Gastric Dilation-Volvulus Syndrome
at a Veterinary Teaching Hospital

Abnormality Gastric Necrosis (n = 21) Without Gastric Necrosis (n = 54) Nonsurvivors (n = 14) Survivors (n = 61)

Hyponatremia (˂ 140 mmol/L) 2 3 2 3

Hypernatremia (˃ 155 mmol/L)
Hypokalemia (˂ 4 mmol/L)
Hypochloremia (˂ 104 mmol/L)
Hyperchloremia (˃ 119 mmol/L)
Hypocalcemia (˂ 2.3 mmol/L)
Hypercalcemia (˃ 3 mmol/L)
Hypophosphatemia (˂1 mmol/L)
Hyperphosphatemia (˃2.1 mmol/L)
1 14 1 3
14 42 9 47
0 5 0 5
0 3 0 3
3 6 1 8
2 6 1 7
5 11 1 15
5 3 2 7
 L. Rauserova-Lexmaulova et al. / Topics in Companion An Med 39 (2020) 100403
chloride, and sodium, in combination with impaired renal function
during the episode of shock (which is frequently present in GDV),
results in the impairment of water, electrolyte, and acid-base balance
in the body.
The concentration of plasma electrolytes has significant influence
on a dog’s acid-base balance; therefore, the combination of an acid-
base analysis with that of lactate and electrolyte concentrations can
more accurately reflect the degree of homeostatic disturbance in
GDV patients.9,24,25,28,35,40,42-44 In contrast to previous studies, this
study also detected a high prevalence of electrolyte abnormalities,
although their incidence was not significantly different between dogs
with and without gastric necrosis, or between survivors and nonsur-
vivors.13,22 Hypokalemia was a relatively common electrolyte abnor-
mality in both the surviving and nonsurviving GDV patients, with
previous GDV studies reporting similar findings.14,22 This decrease in
the plasma potassium concentration was probably caused by third
space fluid sequestration and the intracellular shifting of potassium
secondary to alkalosis, high catecholamine level and renin angioten-
sin aldosterone axis activation.39,42,46 In contrast to the nonsurvivors
and dogs with gastric necrosis, hypochloremia was found only in the
survivors and dogs without gastric necrosis, with this result able to
reflect metabolic alkalosis.18,35 Furthermore, hyperchloremia, which
was also observed in the survivors, could be explained by either the
retention of chlorides or the excessive loss of sodium in relation to
chlorides.18,34,35,40 Interestingly, a significant difference between the
dogs with and without gastric necrosis, and between the survivors
and nonsurvivors, was identified only based on phosphorus concen-
trations in this study. The higher phosphorus concentrations
observed in these patients was likely due to reduced renal blood
flow, which originated from hypovolemia and hypotension during
GDV presentation, and decreased phosphorus clearance by
urination.6,11,45,47 Another reason could be the leakage of phosphorus
from dead cells, with a consequent increase in the plasma concentra-
tion of this electrolyte.15,45,48-51 The ROC curve analysis was used to
define the cut-off levels for lactate, pH, bicarbonate, BE, AG, and anor-
ganic phosphorus concentrations and was found to deliver a good
predictive effectiveness especially for lactate, pH, bicarbonate, and BE
for both gastric necrosis and outcome. The good positive predictive
effectiveness of lactate, pH, bicarbonate, and BE supported the inter-
pretation that increased lactate concentration and acid-base disor-
ders play more important roles as prognostic indicators than
electrolyte abnormalities.15-19,42
The multivariate logistic regression analysis model used to ana-
lyze combinations of plasma lactate, pH, bicarbonate, BE, AG, and
anorganic phosphorus concentrations demonstrated that the pH and
bicarbonate were significant, independent predictors for gastric
necrosis and that pH, bicarbonate, and phosphorus were detected as
independent predictors for patient outcome. This result differs from
some prior veterinary and human medicine studies, in which a supe-
rior lactate value is used as a prognostic indicator.9,19,24,47,52-55
However, to the authors knowledge, no studies have evaluated
lactate, pH, bicarbonate, BE, and anorganic phosphorus concentra-
tions together in GDV patients as markers of the severity of illness for
the determination of dogs with gastric necrosis and increased risk of
mortality.
This study has a number of limitations. The first is that samples
from both arterial and venous sources were used for the comparison
of lactate, acid-base values and electrolyte status, and agreement
between arterial and venous samples does not always
exist.36,46,49,56,57 Second, the influence of PCO2 on the blood bicarbon-
ate concentration was not evaluated, which could have led to an inac-
curate interpretation of the blood gas analysis results.18,24,33-35,39,44,45
The third limitation is the risk of possible concurrent diseases
(e.g., cardiac, liver, and renal), which could not be excluded in our
patients and could thus be associated with the increased risk of mor-
tality observed in the older patients. The fourth limitation was the
5
relatively small number of patients, which would promote the possi-
bility for our statistical analysis of the electrolyte abnormalities to
yield biased results. The last limitation was our definition of the non-
survivor dogs, which included patients (7 of 14) that were euthanized
during surgery. It is unknown whether some of these euthanized
dogs could have survived if continued treatment had been elected, as
was reported in the study by Green et al.23 The retrospective nature
of the study reduced our ability to assess the dogs’ outcomes until
discharge from the hospital, and as a result, the long-term outcomes
of this study population remain unknown.
A larger prospective study evaluating lactate in combination with
acid-base parameters, electrolyte concentrations and gastric necrosis,
and the short- and long-term outcomes of GDV patients would be
beneficial.
Conclusion
The results of the present study demonstrate a good association
between initial plasma lactate, pH, bicarbonate, BE, AG, and phospho-
rus concentrations and the incidence of gastric necrosis and outcome,
of which pH, bicarbonate (and phosphorus only in outcome) seem to
have the strongest influence. Therefore, the complex assessment of
all of these parameters may provide more accurate information
regarding patient condition in comparison to single-value assess-
ments of these same variables. Such an approach would allow for a
more selective discrimination of patients who are increased risk of
gastric necrosis and mortality, and who usually require more aggres-
sive treatment and monitoring.
Author Contribution
LR is the author of the study objective, contributed the materials,
developed the methods, collected the samples, data and wrote the
manuscript. IU and KR processed the blood samples in the laboratory
and provided statistical analysis.
Acknowledgment
The authors would like to thank colleagues for their help and sup-
port and RNDr. Jiri Jarkovsky for his help with statistical analysis.
None of the authors of this article has a financial or personal relation-
ship with other people or organizations that could inappropriately
influence or bias the content of the paper.
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