792106 JFM Journal of Feline Medicine and SurgeryTroìa et al

Original Article

Journal of Feline Medicine and Surgery

Multiorgan dysfunction syndrome 2019, Vol. 21(6) 559­–565

© The Author(s) 2018
Article reuse guidelines:
in feline sepsis: prevalence and sagepub.com/journals-permissions
DOI: 10.1177/1098612X18792106
https://doi.org/10.1177/1098612X18792106

prognostic implication journals.sagepub.com/home/jfm

This paper was handled and processed
by the European Editorial Office (ISFM)
for publication in JFMS

Roberta Troìa, Giulia Mascalzoni, Stefano Calipa,

Ilaria Magagnoli, Francesco Dondi and
Massimo Giunti

Abstract
Objectives The current study was designed to evaluate the prevalence and prognostic significance of multiorgan
dysfunction syndrome (MODS) in cats with sepsis.
Methods Cats hospitalised in the intensive care unit of a veterinary university hospital with a diagnosis of sepsis were
prospectively enrolled and divided according to disease severity and outcome (survivors; non-survivors). The feline
acute patient physiological and laboratory evaluation (APPLE) scores were calculated upon admission, as previously
described. Specific criteria to identify selected organ dysfunction (hepatic, renal, respiratory, cardiocirculatory,
haemostatic) were adapted from the available human and veterinary literature, and evaluated at baseline and at
the end of hospital stay. MODS was defined as the presence of at least two dysfunctional organs simultaneously.
Non-parametric statistics were used for comparisons. Univariate and multivariate regression analyses to evaluate
significant risk factors for death were carried out. Correlations between variables were assessed by the Spearman's
rank correlation coefficient. Significance was set at P <0.05.
Results A total of 43 cats with heterogeneous sources of sepsis were included. MODS was identified in 25/43 cats
upon admission and in 32/43 cats at the end of hospital stay. Regression analyses showed a significantly elevated
odds ratio for mortality for the presence of MODS, renal and cardiovascular dysfunction upon admission, as well as
for the number of dysfunctional organs. The latter was the only variable retained by the model from the multivariate
binary logistic regression analysis. Significant correlations were documented between the number of dysfunctional
organs and the APPLE scores.
Conclusions and relevance MODS is a frequent complication of feline sepsis, and is associated with worse
outcomes. In particular, renal and cardiovascular dysfunction significantly increase the odds for death. Hence,
systematic screening for organ dysfunction is advocated in cats with sepsis.

Keywords: Septic shock; acute kidney injury; organ dysfunction; prognosis; APPLE score

Accepted: 6 July 2018

Introduction to infection’.2 Progression from sepsis to MODS has been

Multiorgan dysfunction syndrome (MODS), the progres-
sive dysfunction of organ systems following an acute
threat to systemic homeostasis, is a common complica-
tion of critical illness and a leading cause of mortality
in human intensive care units (ICUs).1,2 Among the
spectrum of critical care conditions, sepsis represents
the major inciting cause for MODS. The inter-relationship
between sepsis and MODS is supported by the recent re-
definition of the sepsis syndrome as ‘the life-threatening
organ dysfunction caused by a dysregulated host response
investigated in dogs; similar to human findings, the
Department of Veterinary Medical Science, Alma Mater
Studiorum–University of Bologna, Ozzano dell’Emilia, Bologna,
Italy
Corresponding author:
Massimo Giunti DVM, PhD, Department of Veterinary Medical
Sciences, Alma Mater Studiorum–University of Bologna, Via
Tolara di Sopra 50, Ozzano dell'Emilia, Bologna 40064, Italy
Email: massimo.giunti@unibo.it
560
number of dysfunctional organs has been associated
with an increase in the mortality risk.3–5
Frequency and clinical manifestation of sepsis and
MODS are less documented in cats; however, the
reported mortality rate is elevated.6 Biomarkers of feline
sepsis, including meta-rubrocytosis, high circulating
muscle enzyme activities (aspartate transaminase; cre-
atine kinase), high band neutrophil percentage and ele-
vated serum amyloid A (SAA) concentrations, have been
investigated in this species.7–10 However, selected organ
dysfunctions have been rarely characterised in septic
cats,9–11 and studies systematically evaluating MODS in
the course of feline sepsis are lacking.
The aim of the present study was to investigate and
characterise organ dysfunctions and MODS in feline
sepsis. We hypothesised that MODS is a complication of
feline sepsis, and that its occurrence is associated with
increased mortality.
Materials and methods
Animals
Critically ill cats with sepsis presented to the Veterinary
University Hospital of Bologna and hospitalised in the
ICU between October 2015 and September 2017 were
prospectively included. The study was approved by the
local Institutional Animal Care and Use Committee.
Cats were diagnosed with sepsis if they fulfilled at the
time of presentation at least 3/4 feline systemic inflam-
matory response syndrome criteria (rectal temperature
>39.7ºC or <37.8ºC, heart rate >225 beats/min [bpm] or
<140 bpm, respiratory rate >40 breaths/min, and white
blood cell count >19,500/µl or <5000/µl or band neu-
trophil fraction >5%), as previously reported,7 and had a
documented underlying infection. Presence of infection
was confirmed by means of cytology, microbiology or
molecular diagnostic methods. Cats discharged against
medical advice or euthanased for financial reasons were
excluded.
Data collection
Attending ICU clinicians were responsible for the clini-
cal management of the patients included in the study.
For each enrolled cat, the following data were recorded:
signalment and body weight, lifestyle, vaccination his-
tory, presence of comorbidities, prior medical treat-
ments, therapies administered during ICU stay, need of
fluid resuscitation (types and volumes of intravenous
fluids), blood products, vasopressors and positive ino-
tropes, and duration of hospitalisation.
Upon admission, clinical findings, non-invasive blood
pressure measurement (Minidop ES-100VX; Hadeco),
pulse oximetry (Dash 3000 Patient Monitor; GE Medical
Systems Information Technologies) and ultrasonography
(Z5 Vet; Shenzhen Mindray Bio-Medical Electronics) for
the evaluation of body cavity fluid scores, as previously
Journal of Feline Medicine and Surgery 21(6)
reported,12 were registered. Blood was collected by
venepuncture with vacuum system according to standard
operating procedures, and analysed within 1 h of ICU
admission. The following analyses were performed:
venous blood gas, including electrolytes and lactate (ABL
800 FLEX blood gas analyser; Radiometer Medical), com-
plete blood cell count (ADVIA 2120; Siemens Healthcare
Diagnostics) and microscopic evaluation of the blood
smear, chemistry profile – including measurement of
serum creatinine, bilirubin and SAA (Beckman Coulter-
Olympus AU 480, LZ Test Eiken SAA [Eiken Chemical])
– prothrombin time (PT) and partial thromboplastin
time (PTT) (BFT II; Siemens). The feline acute patient
physiological and laboratory evaluation (APPLE) scores,
APPLEfast and APPLEfull, respectively, were calculated, as
previously described.13
Cats were classified according to their outcome as
survivors (alive to discharge) and non-survivors (died
despite medical treatment or humanely euthanased
because of moribund conditions). Cats euthanased for
other reasons were excluded.
Organ dysfunction criteria
Criteria to define organ dysfunction were adapted from
the available human and canine literature.2,3,14,15 Respiratory
dysfunction was defined in presence of SpO2 <95% in
room air, or if oxygen therapy or mechanical ventilation
were needed. Hepatic dysfunction was defined as serum
bilirubin >0.7 mg/dl in absence of haemolysis or biliary
obstruction. Acute kidney injury (AKI) was defined as
serum creatinine (sCr) >1.8 mg/dl and/or increase in
sCr of ⩾0.3 mg/dl from baseline and/or oliguria (urine
output <1 ml/kg/h over 6 h), and graded (I–V) accord-
ing to the International Renal Interest Society (IRIS) stag-
ing system, proposed by Cowgill and accepted by the
IRIS group.15 Cardiovascular dysfunction was defined as
hypotension (systolic blood pressure <90 mmHg) in
volume-replete patients requiring vasopressors therapy.
Haemostatic dysfunction was defined as PT >15 s, and/
or activated PTT (aPTT) >20 s and/or platelet count
<100,000/mm3 in the absence of platelets clumps at
blood smear evaluation. Cut-off values for specific vari-
ables (serum creatinine, PT and aPTT) were based on the
upper bound of the reference intervals of our clinical
pathology laboratory. MODS was defined as presence of
at least two dysfunctional organs simultaneously. The
number of dysfunctional organs upon admission and at
the end of hospital stay was recorded.
Statistical analysis
Statistical analysis was performed using a medical
statistic software (MedCalc 16.8.4). Data were assessed
for normality with the D'Agostino-Pearson test and
evaluated by descriptive statistics. Most data were non-
parametric; therefore, data are presented as median and
Troìa et al 561

range (minimum–maximun). The Mann–Whitney U-test
was used to compare continuous variables between
groups. Univariate and multivariate logistic regressions
were used to identify variables able to predict outcome;
results are presented as odds ratio (OR) and 95% confi-
dence interval (CI). Correlations between variables were
assessed by the Spearman's rank correlation coefficient.
Significance was set at P <0.05.
Results
Forty-three cats met the criteria for inclusion in this
study. Median age was 5.2 years (range 0.2–15.7) and
median body weight was 4.0 kg (range 0.4–6.6). There
were 19/43 female cats (eight sexually intact and 11
spayed) and 24/43 males (eight sexually intact and 16
castrated). Comorbidities were recognised in the
majority of the patients (n = 28): polytrauma (n = 7),
chronic enteropathy (n = 6), diabetes mellitus (n = 4),
feline lower airway disease (n = 4), chronic kidney
disease (n = 2), hypertrophic cardiomyopathy (n = 2),
neoplasia (n = 2) and feline lower urinary tract
disease (n = 1). Upon presentation, 8/43 patients
were receiving immunosuppressive drugs (steroids, n
= 6; steroids plus melphalan, n = 2) and 17/43 were
treated with antimicrobial agents by the referring
veterinarian.
Major causes of sepsis were the following: pyothorax
(n = 13), feline panleukopenia (n = 11) and septic perito-
nitis (n = 9). Other sources of sepsis were urinary tract
infection (n = 3), bacterial cholangiohepatitis (n = 2),
endocarditis (n = 1), myocarditis (n = 1), septic arthritis
(n = 1), pyelonephritis (n = 1) and ocular abscess (n = 1).
Main clinical and clinicopathological findings in the
overall study population at presentation are shown in
Table 1.
Seventeen of 43 cats required fluid resuscitation upon
admission. Isotonic crystalloid solutions were used by
the primary clinician for fluid resuscitation in the whole
population with a median value of 20 ml/kg (range 10–
85). Tetrastarch (6% hydroxyethyl starch 130/0.4; Voluven)
or 7.5% hypertonic saline were administered in a minor-
ity of the patients at the following doses: 2 ml/kg (1–8; n
= 4) and 4 ml/kg (n = 1), respectively. Ten of 17 cats
were not responsive to fluid resuscitation and required
vasopressors. Non-responders received a significantly
higher volume of crystalloid solution compared with
responders (20.5 ml/kg [range 10–85] vs 15.0 ml/kg
[range 10–20]; P = 0.02). Vasopressor and inotropic sup-
port in cats with cardiovascular dysfunction in the
whole study period (n = 18/43) included noradrena-
line alone (n = 18/18) or in combination with dobu-
tamine (n = 14/18). During the ICU stay blood products

Table 1 Descriptive statistics for selected variables measured at the time of admission in cats with sepsis (n = 43)

Variable Cats with sepsis RI

Body temperature (°C) 37.2 (32–40.9) NA

Respiratory rate (rpm) 48 (20–160) NA
Heart rate (bpm) 180 (120–240) NA
SBP (mmHg) 113 (50–220) NA
APPLEfast score 31 (12–46) NA
APPLEfull score 53 (33–66) NA
Haematology
WBCs (cells × 103/mm3) 9.07 (0.05–81.48) 5–19
Platelets (cells × 103/mm3) 190 (20–1189) 50–500
Chemistry
Creatinine (μmol/l) 103.4 (29.2–433.2) 70.72–159.1
Creatinine (mg/dl) 1.17 (0.33–4.90) 0.8–1.8
Total bilirubin (μmol/l) 4.96 (0.34–140.05) 0–5.98
Total bilirubin (mg/dl) 0.29 (0.02–8.19) 0–0.35
SAA (μg/dl) 157 (1–584) 0–10
Lactate (mmol/l) 2.6 (0.8–11.6) 0.5–2
Coagulation profile
PT (s) 9.8 (6.6–18.2) 9–15
PTT (s) 16.5 (9.1–90.4) 9–20
Additional data
Number of dysfunctional organs at presentation 3 (0–4)

Values for each analyte are presented as median (range). RI = reference interval; NA = not applicable; rpm = respirations per min; bpm =
beats per min; SBP = systolic blood pressure; APPLE = acute patient physiological and laboratory evaluation; WBCs = white blood cells;
SAA = serum amyloid A; PT = prothrombin time; PTT = partial thromboplastin time
562
Table 2 Univariate and multivariate binary logistic regression of variables that were associated with outcome (survivors/
non-survivors) in 43 cats with sepsis
Variable
Univariate logistic regression
Presence of renal dysfunction at presentation
Presence of cardiovascular dysfunction at presentation
Requirement of fluid resuscitation at presentation
Number of dysfunctional organs at presentation
Number of dysfunctional organs at the end of ICU stay
Multivariate binary logistic regression
Number of dysfunctional organs at presentation
P value indicates difference between survivors and non-survivors in the overall population of septic cats; bold indicates significance (P <0.05).
RC = regression coefficient; SEM = standard error of the mean; OR = odds ratio; CI = confidence interval; ICU = intensive care unit
Figure 1 Scatter diagram showing the relationship between
the number of dysfunctional organs (ODs) and the feline
acute patient physiological and laboratory evaluation (APPLE)
score, APPLEfast, in cats with sepsis (n = 43). The Spearman’s
rank correlation coefficient was 0.66 (P <0.0001)
were administered in 12/43 cats, with 10/12 receiving
fresh frozen plasma, 3/12 packed red blood cells and
2/12 fresh whole blood. Twenty-six of 43 cats were sur-
vivors, whereas 17/43 were non-survivors (9/17 cats
were humanely euthanased because of moribund con-
ditions and 8/17 died despite medical treatment).
The following variables evaluated at presentation
were significantly different between survivors and
non-survivors: body temperature (38.4°C [range 33.2–
40.9°C] vs 35.6°C [range 32–40.5°C]; P = 0.04); APPLEfast
score (26 [range 18–40] vs 34 [range 12–46]; P = 0.02),
leukocyte count (12.185 cells × 103/mm3 [range 0.25–
81.48 cells × 103/mm3] vs 4.01 cells × 103/mm3 [range
0.05–60.91 cells × 103/mm3]; P = 0.03); total amount of
intravenous fluids administered during hospitalisation
(47 ml/kg/day [range 5–93 ml/kg/day] vs 87 ml/kg/
day [range 30–148 ml/kg/day]; P = 0.001). None of the
Journal of Feline Medicine and Surgery 21(6)
RC SEM OR (95% CI) P value
1.552 0.695 4.72 (1.208–18.468) 0.025
1.68 0.787 5.37 (1.147–25.105) 0.033
1.81 0.688 6.111 (1.584–23.567) 0.009
0.874 0.313 2.397 (1.296–4.434) 0.005
0.525 0.255 1.69 (1.025–2.788) 0.040
0.962 0.33 2.618 (1.368–5.007) 0.004
latter variables were retained from the univariate
regression analysis.
Organ dysfunction: prevalence and associations
with outcome
At presentation, 25/43 cats had evidence of MODS and
frequencies of dysfunctional organs were distributed as
follows: haemostatic dysfunction (n = 24), respiratory
dysfunction (n = 23), hepatic dysfunction (n = 15), renal
dysfunction (n = 14) and cardiovascular dysfunction
(n = 10). During ICU stay, 37/43 cats developed MODS
with the following frequencies: 32 had haemostatic dys-
function, 26 had hepatic dysfunction, 26 had respiratory
dysfunction, 18 had cardiovascular dysfunction and 18
had renal dysfunction. Upon admission, the majority of
the cats with renal dysfunction (n = 11/14) had an
increased sCr and were classified as IRIS stage 2 (n = 6)
and stage 3 (n = 5), respectively, whereas only 3/14 cats
had an IRIS stage of 1 and a sCr within the normal range.
Results of the univariate logistic regression showed a
significantly elevated OR for mortality for the presence of
MODS, renal and cardiovascular dysfunction, as well as
for requirement of fluid resuscitation and for the number
of dysfunctional organs recorded upon admission and at
the end of ICU stay. When the multivariate binary logistic
regression analysis was performed, the number of dys-
functional organs recorded upon admission was the only
variable retained by the model (Table 2).
The Spearman’s rank correlation coefficient between
the number of dysfunctional organs and the APPLEfast
score at presentation was 0.66 (P <0.0001; Figure 1). The
Spearman’s rank correlation coefficient between the
number of dysfunctional organs and the APPLEfull score
at presentation was 0.56 (P = 0.011).
Discussion
The present study investigated the prevalence and the
prognostic significance of MODS in a population of cats
Troìa et al
with sepsis. A focused organ-by-organ assessment was
prospectively performed in the enrolled cats, both at the
time of presentation and at the end of the ICU stay.
Organ dysfunction occurred frequently in septic cats and
was related to higher APPLE scores and worse outcomes.
Specifically, presence of MODS, renal and cardiovascular
dysfunction at presentation significantly increased the
risk of death. The overall number of dysfunctional organs
was the strongest predictor of mortality in the current
population. These results are novel in feline critical care
medicine, resemble the data reported in humans and
dogs with sepsis, and further corroborate the link
between this syndrome and the development of organ
dysfunction.3–5,16–19
Moreover, the number of dysfunctional organs in this
population was positively correlated with the feline
APPLE scores. The latter are outcome predictors vali-
dated in critical feline patients,13 but only the APPLEfast
score was significantly higher in non-survivors com-
pared with survivors, even though it was not prognostic
according to the univariate logistic regression. Although
the latter result was not completely expected, the feline
APPLE scores lack an extensive validation in sepsis;
thus, their potential prognostic significance in this clini-
cal setting needs to be confirmed.
Renal dysfunction was defined as the presence of AKI
according to the recent IRIS guidelines established in
veterinary patients.15 AKI is a common complication of
human sepsis, being related to inflammatory mediators,
tubular injury and renal microcirculatory alteration.16,17,20
There is a paucity of studies concerning sepsis-related
AKI in veterinary medicine,21 and standardised criteria
for the early identification of this syndrome have been
only occasionally used in cats.22 The prevalence of AKI
was elevated in this population of septic cats at the time
of presentation. In this regard, two of the azotaemic cats
had primary renal involvement due to urosepsis (one cat
with pyelonephritis, one cat with septic uroabdomen).
Additionally, CKD was suspected in other two cases
owing to history and imaging findings. These results
could have influenced the real frequency of sepsis-
related AKI in our population. However, the presence of
AKI at presentation was a strong predictor of mortality
in our study. This result could support the use of the
application of the IRIS staging system to aid early identi-
fication of renal dysfunction in septic cats.
Cardiovascular dysfunction was defined as hypoten-
sion in volume-replete patients requiring vasopressor
support. Despite hypotension and relative bradycardia
being described in cats with sepsis, epidemiological data
for feline sepsis-induced cardiovascular dysfunction are
lacking.6,7 Cardiovascular dysfunction occurred fre-
quently in this population, with septic peritonitis and
feline panleukopenia being the main diseases associated
563
with it (data not shown). According to the univariate
logistic regression analysis, the presence of cardiovascu-
lar dysfunction upon admission was associated with
elevated odds for mortality. This result parallels the data
available from human and small animal studies, as per-
sistent hypotension despite fluid-resuscitation is consid-
ered the most serious manifestation of sepsis, with a
reported mortality rate as high as 80–90% in both spe-
cies.2–5,19,23,24 As such, the presence of cardiovascular dys-
function might reflect greater disease severity and be
associated with worse outcomes. The negative impact of
hypotension on systemic organ perfusion and oxygen
supply has to be considered as a further mechanism
leading to worsening clinical pictures and, eventually,
death.25
Hepatic, respiratory and haemostatic dysfunction
occurred with a variable frequency in the current study
population, but no association with outcome was noted.
Icterus and hyperbilirubinaemia have been described as
markers of sepsis in cats,7,9 and seem to have a potential
prognostic role.10 Prevalence of hepatic dysfunction was
elevated in the study reported herein, and raised during
hospitalisation. Whether hyperbilirubinaemia reflected
true hepatocyte dysfunction or sepsis-induced cholesta-
sis remains unknown.
Despite the recent definition of criteria to identify
acute respiratory distress syndrome in small animals,11,26
respiratory dysfunction is commonly identified as the
need for oxygen therapy, mechanical ventilation or
hypoxaemia.3,14 However, such criteria are subjective
(eg, opinions may differ over the need for supplemental
oxygen therapy), and, owing to technical reasons, arte-
rial PaO2 assessment through blood gas analysis was
only rarely performed herein. The prevalence of respira-
tory dysfunction was elevated in our study, but mainly
documented in cats diagnosed with pyothorax (n =
10/23) and not necessarily associated with lung disease.
Additionally, the presence of respiratory dysfunction
was not related to outcome in this study population. The
favourable survival rate documented in the majority of
the cats with pyothorax might partially explain the latter
result. Moreover, it is possible that the degree of respira-
tory dysfunction was only moderate in this population
of septic cats.
Abnormalities in the haemostatic profile were com-
mon in our population, representing the most frequently
reported organ system dysfunction at the time of inclu-
sion and during ICU stay. No association between hae-
mostatic dysfunction and outcome was identified.
Potential limitations in the criteria used for the assess-
ment of haemostatic dysfunction in the present study
must be considered, not allowing specific characterisa-
tion of either the severity or the nature of the dysfunc-
tion itself (presence of a hyper- or hypocoagulable state).
564
Blood product administration was reserved to cats con-
sidered at risk of bleeding (n = 10/12) or with signs of
active bleeding (n = 2/12), and could have potentially
affected their outcome.
Additional clinical variables were different between
survivors and non-survivors in the present study. Of
note, non-survivors received a significantly greater
amount of intravenous fluids, and requirement for fluid
resuscitation carried an elevated OR for death. Whether
intravenous fluid therapy reflected higher illness sever-
ity or concurred to worsen prognosis and sepsis-related
complications cannot be clarified from our data.
However, this result parallels similar findings in human
and canine ICU patients,27,28 and need to be addressed
by further studies.
There are some limitations to consider when inter-
preting our results. The small size of the population and
the different sources of sepsis might have influenced the
results of the study. In addition, organ dysfunction was
not graded according to severity, but only deemed as
present or absent on the basis of criteria adapted from
canine medicine. This latter approach, despite being
questionable, was inevitable owing to the lack of estab-
lished standards in cats. The intrinsic limitations of such
criteria might have biased some of our findings espe-
cially in respect to prognosis, as already discussed;
moreover, neurological and gastrointestinal dysfunc-
tions were not assessed for the current study. Finally,
organ dysfunction was deemed present regardless of the
location of the primary septic focus, potentially increas-
ing its prevalence in some cases.
Conclusions
The results of the present study document a high prev-
alence of organ dysfunction in cats with sepsis. The
presence of MODS is associated with higher APPLE
scores and worse outcomes, with renal and cardiocir-
culatory dysfunction markedly increasing the odds of
death. Screening for dysfunctional organs has to be
advocated early in the management of feline sepsis, in
order to identify the most critically ill patients and
maximise supportive care. Further larger studies
aimed at characterising MODS in feline sepsis and to
investigate its prognostic significance are warranted.
Acknowledgements The authors would like to acknowl-
edge Dr Valentina Stocchetti for the technical help in case
recruitment and sample collection.
Conflict of interest The authors declared no potential
conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Funding The authors received no financial support for the
research, authorship, and/or publication of this article.
Journal of Feline Medicine and Surgery 21(6)
ORCID iD Massimo Giunti https://orcid.org/0000-0002-
7957-9320
References
1 Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European
intensive care units: results of the SOAP study. Crit Care
Med 2006; 34: 344–353.
2 Singer M, Deutschman CS, Seymour CW, et al. The Third
International Consensus Definition for Sepsis and Septic
Shock (Sepsis-3). JAMA 2016; 315: 801–810.
3 Kenney EM, Rozanski EA, Rush JE, et al. Association
between outcome and organ system dysfunction in dogs
with sepsis: 114 cases (2003–2007). J Am Vet Med Assoc
2010; 236: 83–87.
4 Gravelyn T and Guillaumin J. Clinical features and
outcome of septic shock in dogs: 37 cases (2008–2015).
Abstracts from the International Veterinary Emergency
and Critical Care Symposium, the European Veterinary
Emergency and Critical Care Annual Congress, and the
ACVECC VetCOT Veterinary Trauma and Critical Care
Conference; 2016 September 7–11; Grapevine, TX, USA.
Grapevine, TX: IVECCS XXII, 2016, pp S5.
5 Conti-Patara A, de Araujo Caldeira J, de Mattos-Junior
E, et al. Changes in tissue perfusion parameters in dogs
with severe sepsis/septic shock in response to goal-
directed hemodynamic optimization at admission to ICU
and the relation to outcome. J Vet Emerg Crit Care 2012; 22:
409–418.
6 Babyak JM and Sharp CR. Epidemiology of systemic
inflammatory response syndrome and sepsis in cats hos-
pitalized in a veterinary teaching hospital. J Am Vet Med
Assoc 2016; 249: 65–71.
7 Brady CA, Otto CM, Van Winkle TJ, et al. Severe sepsis in
cats: 29 cases (1986–1998). J Am Vet Med Assoc 2000; 217:
531–535.
8 DeClue AE, Delgado C, Chang CH, et al. Clinical and
immunologic assessment of sepsis and the systemic
inflammatory response syndrome in cats. J Am Vet Med
Assoc 2011; 238: 890–897.
9 Klainbart S, Agi L, Bdolah-Abram T, et al. Clinical, labora-
tory, and hemostatic findings in cats with naturally occur-
ring sepsis. J Am Vet Med Assoc 2017; 251: 1025–1034.
10 Troìa R, Gruarin M, Foglia A, et al. Serum amyloid A in
the diagnosis of feline sepsis. J Vet Diagn Invest 2017; 29:
856–859.
11 Balakrishnan A, Drobatz KJ and Silverstein DC. Retro-
spective evaluation of the prevalence, risk factors, man-
agement, outcome, and necropsy findings of acute lung
injury and acute respiratory distress syndrome in dogs
and cats: 29 cases (2011–2013). J Vet Emerg Crit Care 2017;
27: 662–673.
12 Lisciandro GR. Abdominal and thoracic focused assess-
ment with sonography for trauma, triage, and monitoring
in small animals. J Vet Emerg Crit Care 2011; 21: 104–122.
13 Hayes G, Mathews K, Doig G, et al. The feline acute patient
physiologic and laboratory evaluation (feline APPLE)
score: a severity of illness stratification system for hospi-
talized cats. J Vet Intern Med 2011; 25: 26–38.
Troìa et al
14 Ripanti D, Dino G, Piovano G, et al. Application of the
sequential organ failure assessment score to predict out-
come in critically ill dogs: preliminary results. Schweiz
Arch Tierheilkd 2012; 154: 325–330.
15 Cowgill LD. Staging patients with acute kidney injury:
a new paradigm. Proceedings of the 2010 ACVIM Forum;
2010 Jun 9–12; Anaheim, CA, USA. Red Hook, NY: American
College of Veterinary Internal Medicine, 2010, p 673.
16 Balk RA. Severe sepsis and septic shock: definitions,
epidemiology, and clinical manifestations. Crit Care Clin
2000; 16: 179–192.
17 Balk RA. Pathogenesis and management of multiple
organ dysfunction or failure in severe sepsis and septic
shock. Crit Care Clin 2000; 16: 337–352.
18 Johnson V, Alison G, Chan DL, et al. Multiple organ dys-
function syndrome in humans and dogs. J Vet Emerg Crit
Care 2004; 14: 158–166.
19 Osteburn K, Mann FA, Kuroki K, et al. Multiple organ dys-
function syndrome in humans and animals. J Vet Intern
Med 2014; 28: 1141–1151.
20 Bellomo R, Kellum JA, Ronco C, et al. Acute kidney injury
in sepsis. Intensive Care Med 2017; 43: 816–828.
21 Keir I and Kellum JA. Acute kidney injury in severe
sepsis: pathophysioogy, diagnosis, and treatment recom-
mendations. J Vet Emerg Crit Care 2015; 25: 200–209.
565
22 Harison E, Langston C, Palma D, et al. Acute azotemia as
a predictor of mortality in dogs and cats. J Vet Intern Med
2012; 6: 1093–1098.
23 Bulmer BJ. Cardiovascular dysfunction in sepsis and criti-
cal illness. Vet Clin North Am Small Anim Pract 2011; 41:
717–726.
24 Kakihana Y, Ito T, Kanahara M, et al. Sepsis-induced myo-
cardial dysfunction: pathophysiology and management.
J Intensive Care 2016; 4: 22.
25 Donati A, Carsetti A and Damiani E. The role of cardiac
dysfunction in multiorgan dysfunction. Curr Opin Anes-
thesiol 2016; 29: 172–177.
26 Wilkins PA, Otto CM, Baumgardner JE, et al. Acute lung
injury and acute respiratory distress syndromes in veteri-
nary medicine: consensus definition: the Dorothy Russell
Havemeyer Working Group on ALI and ARDS in veteri-
nary medicine. J Vet Emerg Crit Care 2007; 17: 333–339.
27 Silversides JA, Major E, Ferguson AJ, et al. Conservative
fluid management or deresuscitation for patients with sep-
sis or acute respiratory distress syndrome following the
resuscitation phase or critical illness: a systematic review
and meta-analysis. Intensive Care Med 2017; 43: 155–170.
28 Cavanagh AA, Sullivan LA and Hensen BD. Retrospective
evaluation of fluid overload and relationship to outcome
in critically ill dogs. J Vet Emerg Crit Care 2016; 26: 578–586.