Incidence and Clinical Relevance of Hyperglycemia in Critically Ill Dogs

Assisted Enteral Feeding of Exotic Companion Animals

Malnutrition is a known concern during hospitalization for humans, dogs, and cats. The same nutrition principals to reduce the risk of malnutrition can be applied to exotic companion animal patients. However, it's important to understand that many nutritional requirements are ill defined for specific species and prudent clinical judgment is required.

Anesthetic Considerations in Dogs and Cats with Diabetes Mellitus

Understanding the effects of diabetes and hyperglycemia on hydration, acid-base status, and immune function is paramount to safely anesthetizing diabetic cats and dogs. Preoperative stabilization of glucose concentrations, hydration, and electrolyte imbalances is key to minimizing morbidity and mortality. Blood glucose monitoring perioperatively will help guide insulin and dextrose administration. Specific anesthetic considerations, and peri-anesthetic management of animals with diabetes mellitus, including anesthetic drugs and recommended insulin protocols are discussed.

Prevalence, association with systemic inflammatory response syndrome and outcome of stress hyperglycaemia in sick cats

OBJECTIVES

To determine the prevalence of stress hyperglycaemia in sick cats, and to investigate the association of stress hyperglycaemia with systemic inflammatory response syndrome and outcome.

MATERIALS AND METHODS

Medical records (2004 to 2013) from sick cats admitted to the Medicine Unit of a Veterinary Teaching Hospital were retrospectively reviewed. Cases were enrolled if a serum glucose measurement and a complete medical record were available. Cats that were healthy, hypoglycaemic, diabetic, sedated or had a previous administration of drugs (apart from vaccination and deworming) were excluded.

RESULTS

The study included 647 cats; stress hyperglycaemia (serum glucose >8.3 mmol/L) was found in 194 (30%) cats, while 453 (70%) cats were normoglycaemic. The prevalence of systemic inflammatory response syndrome was significantly higher in cats with stress hyperglycaemia (25/174, 14.4%) compared to normoglycaemic cats (26/399, 6.5%). Significantly, more cats with stress hyperglycaemia were hospitalised [97/194 (50.0%)] compared to normoglycaemic cats [171/453 (37.7%)]. However, the median duration of hospitalisation was not significantly different [4 (1 to 26) days and 4 (1 to 24) days, respectively]. The prevalence of cats with negative outcome was not significantly different between the two groups (cats with stress hyperglycaemia: 37.1%, normoglycaemic cats: 33.9%). Nonetheless, when modelling of outcome prediction included breed, age, stress hyperglycaemia and disease category as factors, cats with stress hyperglycaemia had 2.8 times the odds to have a negative outcome (95% confidence interval: 1.3 to 6.4).

CLINICAL SIGNIFICANCE

Based on the cut-off employed in this study, Stress hyperglycaemia, as defined by the cut-off is common in sick cats. Stress hyperglycaemia is associated with systemic inflammatory response syndrome development and seem to be a negative prognostic indicator.

Prognostic value of packed cell volume and blood glucose concentration in 954 client-owned chelonians

OBJECTIVE

To evaluate the prognostic value of PCV and blood glucose concentration in chelonians presented for veterinary care and to develop risk categories on the basis of the interaction of these analytes.

ANIMALS

954 client-owned chelonians (34 genera).

PROCEDURES

Medical records of 1,059 client-owned chelonians presented to 2 veterinary institutions between 2014 and 2018 were reviewed. Logistic regression models were developed to evaluate factors associated with death, including PCV and blood glucose concentrations.

RESULTS

There were 954 chelonians (34 genera) for which the data required to be included in the analysis were available. Both PCV and blood glucose concentration were significant prognostic indicators of death. Odds of death for chelonians with severe anemia (PCV, < 10%) and moderate anemia (PCV, 11% to 20%) were 6.8 times (adjusted odds ratio [aOR], 6.8; 95% CI, 3.8 to 12.3) and 1.6 times (aOR, 1.6; 95% CI, 1.01 to 2.7), respectively, the odds of death for chelonians with PCV within reference range. Odds of death for chelonians with severe hypoglycemia (< 30 mg/dL), moderate hyperglycemia (91 to 150 mg/dL), and severe hyperglycemia (> 181 mg/dL) were 5.3 times (aOR, 5.3; 95% CI; 2.4 to 11.4), 3 times (aOR, 3.0;95% CI, 1.4 to 6.3), and 4.3 times (aOR, 4.3; 95% CI, 2.4 to 7.6), respectively, the odds of death for chelonians with blood glucose concentration within reference range. Five risk categories were identified on the basis of PCV and blood glucose concentration.

CONCLUSIONS AND CLINICAL RELEVANCE

Derangements in PCV and blood glucose concentration in client-owned chelonians were associated with increased odds of death. On the basis of these results, more aggressive diagnostic testing and treatments may be indicated in chelonians with similar alterations.

Etiology and prognosis for dogs with abnormal blood glucose concentrations evaluated in an emergency room

OBJECTIVE

To determine the prevalence of glucose abnormalities in nondiabetic dogs presenting to a veterinary emergency room (ER) and their association with underlying disease processes, previous glucocorticoid administration, and overall mortality.

DESIGN

Single-center, retrospective study from January 2013 to December 2014.

SETTING

University Teaching Hospital.

ANIMALS

A total of 660 dogs presenting to an ER with a blood glucose concentration measured within 6 hours of presentation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Medical records from dogs with a blood glucose concentration measured within 6 hours of hospital admission were reviewed. Medications administered prior to blood sampling, the presence of shock, final clinical diagnosis, and survival were recorded. Hypoglycemia and hyperglycemia were defined as a blood glucose <4.4 mmol/L (80 mg/dL) and >6.7 mmol/L (120 mg/dL), respectively. Diabetic patients were removed from analysis. Hyperglycemia was found in 40.1% of dogs, whereas hypoglycemia was present in 9.0%. Hyperglycemia was most often associated with gastrointestinal disease, trauma, neoplasia, and respiratory disease. The most common diseases associated with hypoglycemia were sepsis, gastrointestinal disease, and neoplasia. Dogs in shock or with hyperlactatemia had higher blood glucose values than dogs with normal perfusion and plasma lactate concentrations (P = 0.016 and P < 0.0001, respectively). Mortality was higher in dogs with hyperglycemia (33.2%, P = 0.03) or hypoglycemia (44.6%, P = 0.0024) compared to those with normoglycemia (24.9%).

CONCLUSION

Dysglycemia in nondiabetic dogs evaluated in an ER was associated with a higher mortality rate than dogs in the same population with normoglycemia. Hyperglycemia in this population was common and may represent a stress response.

Inaccurate point-of-care blood glucose measurement in a dog with secondary erythrocytosis

BACKGROUND

Point-of-care (POC) portable blood glucose meters (PBGMs) are convenient and inexpensive tools for assessing patient blood glucose concentrations. They are often used to quickly diagnose hypoglycemia or collect serial glucose readings in diabetic patients. However, POC meters have been previously identified in human and veterinary literature to be inaccurate when utilized in patients with abnormal HCT. This problem may not be reflected in manufacturer guidelines referenced by practitioners in the POC setting.

KEY FINDINGS

A 1.5-year-old dog, previously diagnosed with multiple congenital cardiac malformations, right-to-left cardiac shunting and secondary erythrocytosis, presented to a veterinary emergency center minimally responsive and without detectable pulses. PBGM measurement identified hypoglycemia. Following stabilization of the dog, serial glucose assessments showed discordant results between PBGMs and the reference laboratory biochemistry analyzer. A pathological cause for hypoglycemia was not identified and PBGM readings were determined to be erroneously low due to the dog's abnormally high HCT.

SIGNIFICANCE

This case demonstrates the limitations of using PBGMs to assess blood glucose in a dog with secondary erythrocytosis. The report emphasizes the need for judicious use of PBGMs in critically ill patients and that these glucometers may not be reliable in patients with abnormal HCT values.

A case of canine hypoadrenocorticism needing blood transfusion for severe acute anemia due to gastrointestinal hemorrhage

A 3-year-old male Rottweiler presented with the chief complaint of recurrent vomiting, diarrhea, hypothermia, and lethargy. Hypovolemic shock was noted with abnormal electrolytes (Na/K ratio, 27.9) and anemia (hematocrit, 17.3%). Since the hematocrit was 49.2% four days earlier when the primary veterinarian examined the dog, acute anemia was diagnosed. Melena was observed on the next day. The general condition and hydration improved with treatment, and an adrenocorticotropic hormone stimulation test identified hypoadrenocorticism. However, the hematocrit decreased further to 9%, necessitating blood transfusion. The cause of severe acute anemia was thought to be gastrointestinal hemorrhage. It should be noted that hypoadrenocorticism can lead to potentially fatal anemia with gastrointestinal tract bleeding, and blood transfusion may be required.

Insulin dysregulation in horses with systemic inflammatory response syndrome

BACKGROUND

Systemic inflammation is a cause of insulin dysregulation in many species, but the insulin and glucose dynamics in adult horses diagnosed with systemic inflammatory response syndrome (SIRS) are poorly documented.

HYPOTHESIS/OBJECTIVES

In SIRS in horses, insulin and glucose dynamics will be altered and associated with survival.

ANIMALS

Adult horses diagnosed with SIRS admitted to a referral hospital.

METHODS

Prospective study enrolling horses diagnosed with SIRS in which serum insulin and glucose concentrations were measured. Horses were grouped by outcome (survival, hyperinsulinemia, and hyperglycemia) and compared with P < .05 considered significant.

RESULTS

Fifty-eight horses were included in the study and 36 (62%) survived. At admission, 21 horses (36%) were hyperinsulinemic and 44 horses (88%) were hyperglycemic, with survivors having significantly higher serum insulin and a significantly lower serum glucose concentration. Horses diagnosed with hyperinsulinemia at any time during hospitalization were 4 times more likely to survive whereas horses that were hyperglycemic at any time during hospitalization were 5 times less likely to survive. Serum glucose concentration and presence of hyperglycemia both were associated with severity of disease. Insulin/glucose ratio, reflecting insulin secretion, was significantly higher in survivors whereas glucose/insulin ratio, reflecting peripheral tissue insulin resistance, was significantly lower in nonsurvivors. Only in survivors was there a significant correlation between serum insulin and glucose concentrations.

CONCLUSIONS AND CLINICAL IMPORTANCE

Hyperinsulinemia and hyperglycemia are common features of SIRS in horses, but those presenting with relative hypoinsulinemia and corresponding hyperglycemia suggestive of endocrine pancreatic dysfunction have a worse prognosis.

Deep tissue culture and hemoculture in dogs with wounds and sepsis

ABSTRACT: Contaminated and infected wounds occur very frequently in veterinary medicine and can cause systemic inflammatory response syndrome, sepsis, and death. This study aimed to test the feasibility of collecting wound material by deep-tissue or punch biopsy for microbial culture, determine the frequency of bacteria in the wound(s) and blood cultures and the susceptibility of these microbes to antimicrobials, and evaluate clinical parameters that could be related to prognosis. Thirty dogs with wounds and signs of SIRS/sepsis were included in this study. Bacteria were isolated from all wounds and 41 bacterial isolates could be identified based on culture of the materials collected by punch biopsy; 53.66% of the isolates were gram-negative, mainly involving Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterococcus spp., and 46.34% were gram-positive bacteria such as Streptococcus spp., Enterococcus spp., and Staphylococcus spp. The survival rate was 66.67%. Based on blood culture analysis, we identified bacteremia in seven patients, predominantly of gram-negative bacteria, which negatively affected patient survival, as six dogs died. Hypoglycemia (≤60mg/dL) and severe hyperglycemia (≥180mg/dL) also negatively affected survival as 23.33% of the hypo/hyperglycemic dogs died. Factors such as blood lactate level at admission and hematocrit levels, and mean arterial pressure were not significantly correlated with death or survival of the dogs.

Concurrent hyperadrenocorticism and diabetes mellitus in dogs

Hyperadrenocorticism (HAC) and diabetes mellitus (DM) are two diseases that can occur concurrently in dogs. The objective of this study was to evaluate the coexistence of HAC and DM, and the risk factors involved that could contribute to the development of DM in dogs with HAC. A total of 235 dogs with HAC were studied and, according to their fasting glycemia, they were divided into three groups: <5.6mmol/L, between 5.6 and 10.08mmol/L and >10.08mmol/L. The following parameters were evaluated: age, gender, cause of HAC, body condition, glycemia, total cholesterol, triglycerides, urinary cortisol:creatinin ratio (UCCR) and survival time. A 13.61% concurrence of HAC and DM was observed. Dogs with a fasting glycemia >5.6mmol/L, with dislipemia, with Pituitary-Dependent Hyperadrenocorticism, UCCR >100×10^-6 and non-castrated females showed a higher risk of developing DM. The development of DM in dogs with HAC reduces the survival time.

Retrospective evaluation of ProcalAmine administration in a population of hospitalized ICU dogs: 36 cases (2010-2013)

OBJECTIVE

To describe the use of ProcalAmine as a source of parenteral nutrition in hospitalized dogs and to report complications possibly referable to its use.

DESIGN

Retrospective study.

SETTINGS

Private veterinary teaching hospital.

ANIMALS

Thirty-six dogs hospitalized in ICU receiving ProcalAmine between October 2010 and March 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The most common underlying disease process in this population of dogs was trauma (n = 8). Median duration of administration was 4 days and median resting energy requirement provided via ProcalAmine was 33%. ProcalAmine was administered via central catheters in 86% of cases and via peripheral catheters in 14% of cases. The overall mechanical complication rate was 19%. Metabolic complications possibly associated with ProcalAmine administration were documented in 12/36 dogs. Hyponatremia was most commonly identified (n = 6) followed by hyperglycemia (n = 4), hypochloremia (n = 2), azotemia (n = 2), metabolic alkalosis (n = 2), hyperchloremia (n = 1), and metabolic acidosis (n = 1).

CONCLUSION

ProcalAmine appears to be relatively safe and a viable option for parenteral nutrition in ill and injured dogs. Due to the potential for electrolyte derangements and other metabolic complications, daily monitoring of these parameters is advisable.

Clinical experience with a lipid-free, ready-made parenteral nutrition solution in dogs: 70 cases (2006-2012)

OBJECTIVE

To review the clinical use of a lipid-free, ready-made amino acid and glucose parenteral nutrition (PN) solution in dogs.

DESIGN

Retrospective study of dogs from 2006 to 2012 that received this form of PN.

SETTING

University veterinary teaching hospital.

ANIMALS

Seventy dogs presented to the hospital for treatment of various diseases in which PN was used as part of patient management. Dogs were administered PN at the discretion of the primary clinician.

INTERVENTION

A lipid-free, ready-made solution containing amino acid (59 g/L) and dextrose (100 g/L) was administered intravenously as a constant rate infusion to provide nutritional support.

MEASUREMENTS AND MAIN RESULTS

PN was provided for a median of 2.2 days (range 0.5-9.5 days) in the 70 dogs, totaling 168 days of PN. The PN provided a median of 5.5 g/100 kcal of protein (range 1-9.5 g/100 kcal) and a median of 2.2 mg/kg of bodyweight per minute (range 0.8-5.2 mg/kg/min) of glucose, which reflected a median of 57% of the resting energy requirement (range 9-100%). Metabolic complications developed in 43 of 67 dogs where these data were recorded, but the development of hyperkalemia was the only complication associated with a poor outcome (eg, death or euthanasia). Mechanical complications were seen in 28 dogs, and all but one of these occurred when PN was delivered through peripheral catheters. Septic complications were confirmed in 5 dogs.

CONCLUSIONS

This form of PN is suitable for clinical use and can provide both protein and calories to ill dogs. It was, however, associated with a high rate of complications and requires careful patient monitoring.

High concentrations of glucose reduce the oxidative metabolism of dog neutrophils in vitro

Background

Dogs are commonly affected by hyperglycemic conditions. Hyperglycemia compromises the immune response and favors bacterial infections; however, reports on the effects of glucose on neutrophil oxidative metabolism and apoptosis are conflicting in humans and rare in dogs. Considering the many complex factors that affect neutrophil oxidative metabolism in vivo, we investigated in vitro the specific effect of high concentrations of glucose on superoxide production and apoptosis rate in neutrophils from healthy dogs.

Results

The capacity of the neutrophils to reduce tetrazolium nitroblue decreased significantly in the higher concentration of glucose (15.13 ± 9.73% (8 mmol/L) versus 8.93 ± 5.71% (16 mmol/L)). However, there were no changes in tetrazolium nitroblue reduction at different glucose concentrations when the neutrophils were first activated with phorbol myristate acetate. High concentrations of glucose did not affect the viability and apoptosis rate of canine neutrophils either with or without prior camptothecin stimulation. This study provides the first evidence that high concentrations of glucose inhibit the oxidative metabolism of canine neutrophils in vitro in a manner similar to that which occurs in humans, and that the decrease in superoxide production did not increase the apoptosis rate.

Conclusions

A high concentration of glucose reduces the oxidative metabolism of canine neutrophils in vitro. It is likely that glucose at high concentrations rapidly affects membrane receptors responsible for the activation of NADPH oxidase in neutrophils; therefore, the nonspecific immune response can be compromised in dogs with acute and chronic hyperglycemic conditions.

Effect of hematocrit on accuracy of two point-of-care glucometers for use in dogs

OBJECTIVE

To determine the effect of Hct on blood glucose readings of dogs obtained by use of 2 point-of-care (POC) blood glucometers and a laboratory analyzer.

ANIMALS

184 dogs, including 139 Greyhounds.

PROCEDURES

Venous blood samples collected from 184 dogs with a range of Hcts (measured in EDTA-anticoagulated blood) were immediately analyzed with a handheld glucometer specifically developed for veterinary use and a glucometer developed for use in humans. The remainder of each blood sample was placed in fluoride oxalate tubes, and plasma glucose concentration was measured with a laboratory analyzer. Agreement between results for the POC glucometers and laboratory analyzer and effect of Hct on glucometer accuracy was assessed via regression analysis.

RESULTS

Significant differences were detected between results of the glucometers and the reference laboratory analyzer. The Hct affected the correlation between results for the glucometers and the laboratory analyzer. Deviations of the glucometers from the reference interval varied with Hct. The glucometer for veterinary use more closely correlated with the glucose concentration when Hct was within or above its reference interval. The glucometer for use in humans more closely approximated laboratory reference glucose concentrations in anemic dogs.

CONCLUSIONS AND CLINICAL RELEVANCE

Hct had a relevant impact on the correlation between whole blood and plasma glucose concentrations in dogs. Significant variations between results obtained with the 2 glucometers could be critical when interpreting blood glucose measurements or selecting a POC glucometer for an intensive care setting and precise glycemic control in critically ill dogs.

Transient hyperglycaemia in a prediabetic dog treated with prednisone and cyclosporin A

A dog with immune-mediated haemolytic anaemia developed transient hyperglycaemia and glucosuria requiring insulin therapy in association with prednisone and cyclosporin A therapy. Following short-term therapy with insulin and cyclosporin A, the dog remained on prednisone therapy but required no further insulin therapy for 12 weeks, at which time the dog became permanently diabetic. We hypothesise that prednisone and cyclosporin A contributed to insulin resistance in a prediabetic dog with suboptimal endogenous insulin concentration and that the degree of insulin resistance decreased when cyclosporin A therapy was discontinued.

The prevalence and significance of hyperglycemia in hospitalized cats

OBJECTIVE

To report the prevalence of hyperglycemia in cats admitted to a veterinary hospital and to determine if hyperglycemic cats had increased morbidity and mortality when compared with normoglycemic cats. DESIGN - Retrospective clinical study.

SETTING

Community-based referral hospital.

ANIMALS

Nondiabetic cats admitted to the hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The medical records of nondiabetic cats admitted to the hospital over a 1-year period were reviewed. There were 182 cats that met the criteria for inclusion in the study. Information obtained included signalment, length of hospitalization, initial and highest blood glucose measurement, diagnosis, treatment, and final disposition. Sixty-three percent of cats (116/182) were hyperglycemic at the time of presentation. Total incidence of hyperglycemia at any point during hospitalization was 64% (118/182). No association was found between hyperglycemia either initially or at any point during the hospitalization and mortality. However, a significant association was documented between the presence of hyperglycemia and increased length of hospitalization (LOH) (P=0.04). The duration of LOH was also significantly associated with the degree of hyperglycemia (P=0.01). A number of different disease processes were represented in the study population. However, the number of cats in each disease category was small and no association could be found between any of them and blood glucose affecting mortality and morbidity.

CONCLUSION

The prevalence of hyperglycemia in feline patients admitted to a primary referral hospital was 64%. Cats with hyperglycemia had a longer LOH when compared with normoglycemic cats; however, presence of hyperglycemia did not impact mortality in this population of cats.