Jun 29, 2019
by Dr. Michael Trapani
Last month, we left sweet kitty Puck teetering on the verge of death due to a (presumed) severe infection and S.I.R.S. (Systemic Inflammatory Response to Stress) causing capillary leak syndrome, as we pondered how best to keep him alive. He had been started on MA-JOR antibiotic therapy, but his real problem was the worsening of his vascular integrity. Puck’s SIRS was causing the lining cells of his capillaries to un-couple and his low serum albumen level was allowing fluid to seep out of his blood vessels. Puck’s vascular system was leaking like a sieve. What to do? The IV fluid Puck had been given wouldn’t stay in-side his blood vessels!
Fortunately, there are other kinds of fluids. So far, Puck had only been treated with crystal-loid IV fluids. These products are life-saving but are essentially just variants of salt water. Crystalloids, even in healthy patients, quickly diffuse out of blood vessels and disappear into the tissues, particularly in a patient like Puck, with low albumen levels. The alternative to crystalloids are colloid fluids. Colloids include things like plasma and contain proteins or other osmotically active substances that stay inside the blood vessel and make other fluids stay there too. Hetastarch is a colloid made of high molecular weight dextran (starch), which stays inside the blood vessels and helps resolve capillary leak syndrome. Puck is alive today because of hetastarch.
The spectacular thing about high molecular weight dextran is its ability to clog the gaps be-tween capillary endothelial cells while serving the same function as serum albumen in keep-ing fluid inside blood vessels where it belongs. When we give 90 ml of hetastarch to Puck, we increase his blood volume by MORE than 90 ml because the hetastarch actually pulls fluid from his soggy tissues back into his blood vessels.
By the evening of his first day, Puck’s condition is stable. He even feels like licking a little gravy from his cat foot. The next morning, we re-evaluate Puck to find he has a low-grade fever (he’s now in good enough shape to actually show a fever) and it’s clear that he has fluid in his abdomen.
The emergency hospital believed that Puck had abnormal abdominal fluid but was unable to locate a fluid pocket large enough to obtain a sample. Because of his improved circulatory status, Puck has manifested an identifiable volume of fluid in his abdomen. We aspirate his tummy, obtain a sample of thick yellow fluid, and two minutes later the microscopic exami-nation of this fluid confirms that Puck has peritonitis (his abdominal cavity is full of pus). In this case, with lots and lots of bacteria.
We now know that Puck needs to go to surgery to have his abdomen explored, but it’s dicey. Sure, he has a belly full of pus, but why? The most likely possibility is that Puck has a perforated stomach or intestine, but other possibilities are even worse. His chance of sur-vival, even with surgery, is unpredictable, but his chances are bad. There’s just no way to be certain in advance what a patient like Puck will do.
Puck’s owner is dedicated and makes the decision to go ahead with exploratory surgery despite the risks.
WARNING! GRAPHIC DISEASE DESCRIPTION IN NEXT PARAGRAPH!
And here we go! Puck is stable under anesthesia. When we enter his abdomen, we are greeted by 400 ml (that’s 13 ounces) of disgusting, stinky pus, complete with lovely yellow "sulphur granules" indicating a longer term infection. His omentum (a lacy organ that polic-es the abdominal cavity and seals leaks), is four times its normal thickness and is an ugly shade of gray-green. Puck’s intestines have roughened surfaces, as if they have been sand-ed. This is a very unhappy abdomen.
Wash wash, scrub scrub. Using warm saline and strong antibiotic solution, we flush and aspirate Puck’s abdomen until it is clean, and every bit of visible purulent material is gone. During inspection, we find no holes anywhere in his bowel and nothing to suggest a pene-trating wound to his abdomen. His body cavity has become contaminated from somewhere, but we simply can’t see where. Chances are, we’ll never know.
Puck’s anesthetic recovery is rough, but powerful pain relievers, big-time antibiotics, and hetastarch get him through. By morning, he’s hungry, and licking up gravy from his favor-ite Friskies. By that evening, he’s eating solid food. Thirty-six hours later, he’s home.
Puck will be on antibiotic for at least a month.He started gaining weight and his white cell count returned to normal within ten days. The mystery of how he developed peritonitis is likely to remain - unless, that is, his infection returns. We simply cannot search an abdomen like his thoroughly enough to be truly certain of success, no matter how much effort we expend. Maybe in a year I’ll convince myself that he’s fully healed, and I can stop worry-ing about him.
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