Avaliação da perfusão abdominal e biomarcadores para diagnóstico precoce de sepse e lesão hepática em cadelas com piometra
Data
2023-01-06
Autores
Título da Revista
ISSN da Revista
Título de Volume
Editor
Universidade Estadual Paulista (Unesp)
Resumo
A sepse ocasiona alta morbimortalidade, principalmente devido ao desenvolvimento da síndrome de disfunção multiorgânica (MODS), complicação decorrente principalmente de má perfusão tecidual. As técnicas utilizadas atualmente para o diagnóstico precoce destas alterações são pouco acuradas, invasivas, de alto risco ou não têm sido provadas em animais. Por estes motivos, este projeto de doutorado objetivou avaliar a perfusão abdominal e intestinal, pelas técnicas de ultrassonografia contrastada (CEUS) e Doppler, os parâmetros físicos, hematológicos e os biomarcadores inflamatórios, de função hepática e renal em cadelas saudáveis e cadelas com piometra, comparar estas variáveis entre os grupos, pacientes em sepse ou não determinada pelos critérios da síndrome da resposta inflamatória sistêmica (SIRS) ou Sequential Organ Failure Assessment (SOFA); correlacionar estas variáveis com os achados do exame histopatológico hepático; com o intuito de desenvolver critérios acurados para o diagnóstico da sepse, das alterações de perfusão intestinal e lesão hepática na espécie canina. Assim, foram utilizadas 17 cadelas com piometra de origem espontânea e 10 cadelas saudáveis, em cada uma delas foram avaliados os parâmetros de perfusão abdominal e intestinal, por meio das técnicas CEUS e Doppler espectral, os parâmetros fisiológicos e laboratoriais rotineiramente utilizados para a monitoração da sepse, função hepática e renal, assim como análise histopatológica de biopsia hepática por Trucut. Após realizar todas estas avaliações, observou-se que a piometra causa redução no volume do fluxo sanguíneo, no pico da velocidade sistólica e no índice de resistividade da aorta abdominal avaliados pelo Doppler espectral; que os pacientes em sepse identificados pelo SOFA apresentaram apenas menor pressão arterial sistólica (PAS), enquanto que os animais em sepse identificados pelo escore SIRS apresentaram menor PAS, picos de velocidade sistólica, volume de fluxo sanguíneo e índices de resistividade da aorta abdominal, assim como na avaliação CEUS maiores intensidades do pico de contraste em pixels do parênquima duodenal. As variáveis identificadas como marcadores de sepse foram: baixa temperatura, leucocitose, neutrofilia, hipoalbuminemia, hiperglobulinemia, aumento da fosfatase alcalina, da relação creatinina-proteína urinária e redução da relação PaO2/FiO2, com estas variáveis o critério diagnóstico foi alteração de no mínimo quatro parâmetros resultando em sensibilidade de 92%, especificidade 87%, valor preditivo positivo 85% e valor preditivo negativo 93%, sendo estes resultados similares aos critérios SIRS com infecção confirmada (75%, 93%, 90% e 82%; respetivamente) e superiores a escala SOFA (75%, 100%,100% e 63%; respetivamente), e a SIRS sem infecção confirmada (75%, 33%, 47%, 63%; respetivamente). Diante disso, determinou-se que a infecção e em pior grau a sepse ocasiona redução do fluxo sanguíneo abdominal, com aumento da perfusão intestinal, adicionalmente que o critério proposto permite a identificação acurada da sepse, o que possibilita uma abordagem mais assertiva da sepse na espécie canina.
Sepsis causes high morbidity and mortality, mainly due to the development of multiorgan dysfunction syndrome (MODS), a complication mainly due to poor tissue perfusion. The techniques currently used for the early diagnosis of these alterations are inaccurate, invasive, high risk or have not been proven in animals. For these reasons, this doctoral project aimed to evaluate abdominal and intestinal perfusion by contrast-enhanced ultrasound (CEUS) and Doppler techniques, physical, hematological parameters and inflammatory biomarkers, liver and kidney function in healthy bitches and bitches with pyometra, compare these variables between groups, between patients with sepsis or not determined by the criteria of systemic inflammatory response syndrome (SIRS) or Sequential Organ Failure Assessment (SOFA); to correlate these variables with the findings of the liver histopathological examination; aiming to develop accurate criteria for the diagnosis of sepsis, alterations in intestinal perfusion and liver injury in dogs. Thus, 17 bitches with spontaneous pyometra and 10 healthy bitches were used, in each of them the parameters of abdominal and intestinal perfusion were evaluated using the CEUS and spectral Doppler techniques, the physiological and laboratory parameters routinely used for monitoring sepsis, liver and kidney function, as well as histopathological analysis of liver biopsy by Trucut. After performing all these evaluations, it was observed that pyometra causes a reduction in blood flow volume, peak systolic velocity and abdominal aorta resistivity index evaluated by spectral Doppler; that sepsis patients identified by SOFA had only lower systolic arterial pressure (SAP), while sepsis animals identified by the SIRS score had lower SAP, peak systolic velocity, blood flow volume and abdominal aorta resistivity indices, as well as higher peak contrast intensities in pixels in the CEUS evaluation of duodenal parenchyma. The variables identified as sepsis indicators were: low temperature, leukocytosis, neutrophilia, hypoalbuminemia, hyperglobulinemia, increased alkaline phosphatase, urinary creatinine-protein ratio and reduction in the PaO2/FiO2 ratio, with these variables the diagnostic criterion was a change of at least four parameters resulting in sensitivity of 92%, specificity 87%, positive predictive value 85% and negative predictive value 93%, these results being similar to the SIRS criteria with confirmed infection (75%, 93%, 90% and 82%; respectively) and above the SOFA scale (75%, 100%,100% and 63%; respectively), and the SIRS without confirmed infection (75%, 33%, 47%, 63%; respectively). In view of this, it was determined that infection and, to a worse degree, sepsis, causes a reduction in abdominal blood flow, with an increase in intestinal perfusion, in addition that the proposed criterion allows the accurate identification of sepsis, which enables a more assertive approach to sepsis in the canine species.
Sepsis causes high morbidity and mortality, mainly due to the development of multiorgan dysfunction syndrome (MODS), a complication mainly due to poor tissue perfusion. The techniques currently used for the early diagnosis of these alterations are inaccurate, invasive, high risk or have not been proven in animals. For these reasons, this doctoral project aimed to evaluate abdominal and intestinal perfusion by contrast-enhanced ultrasound (CEUS) and Doppler techniques, physical, hematological parameters and inflammatory biomarkers, liver and kidney function in healthy bitches and bitches with pyometra, compare these variables between groups, between patients with sepsis or not determined by the criteria of systemic inflammatory response syndrome (SIRS) or Sequential Organ Failure Assessment (SOFA); to correlate these variables with the findings of the liver histopathological examination; aiming to develop accurate criteria for the diagnosis of sepsis, alterations in intestinal perfusion and liver injury in dogs. Thus, 17 bitches with spontaneous pyometra and 10 healthy bitches were used, in each of them the parameters of abdominal and intestinal perfusion were evaluated using the CEUS and spectral Doppler techniques, the physiological and laboratory parameters routinely used for monitoring sepsis, liver and kidney function, as well as histopathological analysis of liver biopsy by Trucut. After performing all these evaluations, it was observed that pyometra causes a reduction in blood flow volume, peak systolic velocity and abdominal aorta resistivity index evaluated by spectral Doppler; that sepsis patients identified by SOFA had only lower systolic arterial pressure (SAP), while sepsis animals identified by the SIRS score had lower SAP, peak systolic velocity, blood flow volume and abdominal aorta resistivity indices, as well as higher peak contrast intensities in pixels in the CEUS evaluation of duodenal parenchyma. The variables identified as sepsis indicators were: low temperature, leukocytosis, neutrophilia, hypoalbuminemia, hyperglobulinemia, increased alkaline phosphatase, urinary creatinine-protein ratio and reduction in the PaO2/FiO2 ratio, with these variables the diagnostic criterion was a change of at least four parameters resulting in sensitivity of 92%, specificity 87%, positive predictive value 85% and negative predictive value 93%, these results being similar to the SIRS criteria with confirmed infection (75%, 93%, 90% and 82%; respectively) and above the SOFA scale (75%, 100%,100% and 63%; respectively), and the SIRS without confirmed infection (75%, 33%, 47%, 63%; respectively). In view of this, it was determined that infection and, to a worse degree, sepsis, causes a reduction in abdominal blood flow, with an increase in intestinal perfusion, in addition that the proposed criterion allows the accurate identification of sepsis, which enables a more assertive approach to sepsis in the canine species.
Descrição
Palavras-chave
Ultrassonografia veterinária, Falência de múltiplos órgãos, Choque séptico, Ultrassonografia Doppler, Infecção