Editorial
Journal of Veterinary Emergency and Critical Care 25(1) 2015, pp 1–3 doi: 10.1111/vec.12285
The swinging pendulum between consensus and controversy in veterinary emergency and critical care Building on the successes of the RECOVER1 and the PROVETS2 initiatives, there have been calls for more consensus statements from the veterinary emergency and critical care community. The assumption with consensus statements is that the ‘agreed’ opinion among experts is a culmination of a systematic, thorough, and unbiased review of the evidence and synthesis of guidelines that can be used by clinicians in the care they provide to patients. Consensus statements can also be used to validate one’s approach to clinical problems—this is of course the case when the guidelines agree with one’s approach. However, when it does not, it is termed a ‘controversy.’ Those that are fans of Latin know that the term ‘controversy’ is derived from controversia or controversus, which means ‘turned against’ or ‘disputed.’ The Oxford Dictionary defines controversy as ‘prolonged public disagreement or heated discussion.’ With this in mind, this special issue of the Journal is devoted to Controversies in Critical Care. This issue is the culmination of almost 2 years’ worth of work from conception of the idea to publication. Submissions for this issue were solicited from the readership, and we received over 80 replies to our call. So much was the interest that proposals were solicited from those that had lodged an interest and the editorial team had to select only a few for publication in this special issue. Authors were charged with presenting a review of a controversy and asked to provide either guidance for managing conditions or to lay out the controversy and identify the gaps in knowledge that should drive further research. As it will become obvious to the reader, certain controversies benefited from a large pool of data and authors were able to explore the various facets of the issues. With certain topics, however, the lack of data only allowed authors to outline the knowledge gap about the issues, but hopefully they have laid the groundwork that will invite new research and knowledge on the topic. Starting perhaps with the most enduring controversy in critical care is the debate over crystalloid versus colloids for fluid resuscitation. Only recently Gauthier et al evaluated the effect of hydroxyethyl starch in dogs with and without systemic inflammatory response syndrome.3 However, many questions remained unresolved. In this issue, Cazzolli and Prittie4 tackle this topic by summarizing the data derived from human subjects and laboratory species and the available veterinary data in terms of using crystalloids compared with colloids C Veterinary Emergency and Critical Care Society 2015
(eg, starch-based colloids, natural colloids) for fluid resuscitation. Similar to most other analyses on the subject, they concluded that, based on the clinical data in people, no outcome advantage is identified with the use of colloids for resuscitation and, in fact, there are significant concerns over their safety.4 In effect, we have likely achieved consensus on the matter and colloids do not offer any outcome advantage over crystalloids for resuscitation. As it is difficult to dispute this conclusion, this complicates further testing of this clinical problem via prospective, randomized, placebo-controlled clinical trials. The reason being that in order to justify such trials from an ethical point of view, there must be ‘clinical equipoise.’ The ethical framework of clinical equipoise allows for randomized, placebo-controlled, blinded trials only when ‘there is genuine uncertainty within the expert medical community.’5 So, until the pendulum swings once again, it is unlikely further new research on this specific question will be carried out for some time. In regards to the safety of starch-based colloids, there is currently more lively debate. The review by Adamik et al6 in this issue of the Journal is the most comprehensive analysis to date on the controversy over the use of hydroxyethyl starches in small animals. Their analysis builds on the review recently published by Glover et al7 and offers a European perspective where hydroxyethyl starches were unavailable for clinical use for over 18 months because of safety concerns. Hydroxyethyl starches have only been recently reintroduced for clinical use in Europe with a revised label stating that it is contraindicated in patients with critical illness and sepsis and should only be used for the first 24 h of volume resuscitation.8 This is obviously of particular concern for veterinary use, since critical illness and sepsis are the major indications in small animals. Although both Glover et al7 and Adamik et al6 point out the lack of data regarding deleterious effects on kidney function or outcome related to hydroxyethyl starch in veterinary species, one cannot say this has been properly investigated. Another recent focus of interest in both human and veterinary critical care centers on the use of antimicrobial agents in critically ill septic patients. In recent years, there have been a couple of studies that have challenged some of the conventions relating to antimicrobial use in 1
Editorial
animals.9,10 These studies dealt with a crucial aspect of emergency medicine that involves empirical treatment with antimicrobials.9,10 Without the benefit of bacterial culture results, clinicians must choose antimicrobial agents solely on assumptions. Great emphasis has always been placed on the appropriateness of these empirical choices. Challenging this presumption, Dickinson et al11 evaluated the impact of appropriate empirical antimicrobial therapy on outcome of dogs with septic peritonitis. There were two very important findings of this study—one that, although in only 52% of cases were the appropriate antimicrobials selected, this did not appear to impact outcome. Secondly, that antimicrobial therapy in the preceding 30 days from diagnosis was associated with inappropriate selection of antimicrobial therapy.11 It is clear that further work is required to clarify what clinicians should do when treating presumed infections empirically and this is one of the focal points in the review by Keir and Dickinson, also in this issue.12 Complementing the analysis by Keir and Dickinson,12 which focused on the implications of antimicrobial choice for small animals, Dunkel and Johns focused on different aspects of antimicrobial use in horses.13 Based on the available evidence in horses, recommendations are made that clarify rational use of antimicrobials and also question unnecessary prolonged use of antimicrobials.13 Guidance for appropriate duration of antimicrobial use via biomarkers was also suggested by Keir and Dickinson although research in this area is warranted.12 The use of biomarkers is an interesting developing area but, as Radcliffe et al14 point out, many biomarkers require a great deal of refinement and development before they can be used reliably in the clinical setting.14 An additional area that has garnered some controversy in horses involves the use of nonsteroidal antiinflammatory drugs (NSAIDs) and this is explored by Cook et al.15 Despite a long history of using NSAIDs in critically ill horses, there are controversial aspects that merited a closer review. The aspects of emergency and critical care that are perhaps most controversial typically involve therapeutic strategies. In this issue, the controversies regarding the therapeutic use of fresh frozen plasma,16 the treatment of pyothorax,17 urethral obstruction,18 and septic shock19 are explored. In some cases, the paucity of information prevented authors from being able to synthesize firm guidelines and instead they have summarized what we know and what we must explore. With some controversies, part of the challenge involves simply clarifying a sometimes very confusing topic. Critical illness-related corticosteroid insufficiency is a clinical entity that has undergone a number of name changes and revisions. For these reasons, the review by Burkitt-Creedon20 on the subject is particularly welcomed. 2
Finally, as outlined in the editorial by Hall and Sharp,21 we must strive to build on established work and always push towards the next step. In the study by Ateca et al,22 there were two important findings relating to outcome in dogs with severe bite wounds: that the time from presentation to anesthesia had an impact on morbidity, and that duration of anesthesia has an impact on mortality.22 So the review by Peterson et al23 is very timely, as they explored the controversy relating to this very issue— timing of surgical intervention in severe trauma.23 It is also befitting that, with that publication, the stage has been set for the first set of evidence-based guidelines stemming from the Veterinary Committee on Trauma (VetCOT) that will be featured in an upcoming issue. In closing, the title of this editorial makes reference to a ‘swinging pendulum.’ This metaphor normally refers to the alternating evolution of expert opinions on many controversial issues. Although this can be frustrating for clinicians, constant reevaluation of the evidence and reframing our approaches is something that we must embrace in order to deliver the best standard of care to our patients. So perhaps the choice of the ‘swinging pendulum’ metaphor was entirely appropriate, as it is the force generated by the pendulum of a clock that turns the gears and advances the time. Therefore, it is hoped that this issue devoted to controversies in critical care also generates momentum in our field, and that new solutions to a number of important issues will be pursued.
Daniel L. Chan, DVM, DACVECC, DECVECC, DACVN, FHEA, MRCVS Editor-in-Chief The Royal Veterinary College, University of London, UK The author declares no conflict of interest.
References 1. Fletcher DJ, Boller M, Brainard BM, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: clinical guidelines. J Vet Emerg Crit Care 2012; 22(S1):S102–S131. 2. Goggs R, Brainard B, de Laforcade AM, et al. Partnership on rotational viscoelastic test standardization (PROVETS): evidence-based guidelines on rotational viscoelastic assays in veterinary medicine. J Vet Emerg Crit Care 2014; 24(1):1–22. 3. Gauthier V, Holowaychuk MK, Kerr CL, et al. Effect of synthetic colloid administration on hemodynamic and laboratory variables in healthy dogs and dogs with systemic inflammation. J Vet Emerg Crit Care 2014; 24(3):251–258. 4. Cazzolli D, Prittie J. The crystalloid-colloid debate: consequences of resuscitation fluid selection in veterinary critical care. J Vet Emerg Crit Care 2015; 25(1):6–19. 5. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med 1987; 317(3):141–145. 6. Adamik KN, Yozova ID, Regenscheit N. Controversies in the use of hydroxyethyl starch solution in small animal emergency and critical care. J Vet Emerg Crit Care 2015; 25(1):20–47. C Veterinary Emergency and Critical Care Society 2015, doi: 10.1111/vec.12285
Editorial 7. Glover PA, Rudloff E, Kirby R. Hydroxyethyl starch: a review of pharmacokinetics, pharmacodynamics, current products, and potential clinical risks, benefits, and use. J Vet Emerg Crit Care 2014; 24(6):642–661. 8. Volulyte package insert. 2014. Fresenius Kabi. Runcore, Cheshire, UK. 9. Proulx A, Hume DZ, Drobatz KJ, et al. In vitro bacterial isolate susceptibility to empirically selected antimicrobials in 111 dogs with bacterial pneumonia. J Vet Emerg Crit Care 2014; 24(2):194–200. 10. Abelson AL, Buckley GJ, Rozanski EA. Positive impact of an emergency department protocol on time to antimicrobial administration in dogs with septic peritonitis. J Vet Emerg Crit Care 2013; 23(5):551– 556. 11. Dickinson AE, Summers JF, Wignall J, et al. Impact of appropriate empirical antimicrobial therapy on outcome of dogs with septic peritonitis. J Vet Emerg Crit Care 2015; 25(1):152–159. 12. Keir I, Dickinson AE. The role of antimicrobials in the treatment of sepsis and critical illness-related bacterial infections: examination of the evidence. J Vet Emerg Crit Care 2015; 25(1):55–62. 13. Dunkel B, Johns IC. Antimicrobial use in critically ill horses. J Vet Emerg Crit Care 2015; 25(1):89–100. 14. Radcliffe RM, Buchnan BR, Cook VL, et al. The clinical value of whole blood point-of-care biomarkers in large animal emergency and critical care medicine. J Vet Emerg Crit Care 2015; 25(1):138– 151.
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15. Cook VL. Blikslager AT. The use of nonsteroidal anti-inflammatory drugs in critically ill horses. J Vet Emerg Crit Care 2015; 25(1): 76–88. 16. Santoro-Beer KA, Silverstein DC. Controversies in the use of fresh frozen plasma in critically ill small animal patients. J Vet Emerg Crit Care 2015; 25(1):101–106. 17. Stillion JR, Letendre J. A clinical review of the pathophysiology, diagnosis, and treatment of pyothorax in dogs and cats. J Vet Emerg Crit Care 2015; 25(1):113–129. 18. Cooper ES. Controversies in the management of feline urethral obstruction. J Vet Emerg Crit Care 2015; 25(1):130–137. 19. Silverstein DC, Santoro-Beer KA. Controversies regarding choice of vasopressor therapy for management of septic shock in animals. J Vet Emerg Crit Care 2015; 25(1):48–54. 20. Burkitt Creedon JM. Controversies surrounding critical illnessrelated corticosteroid insufficiency in animals. J Vet Emerg Crit Care 2015; 25(1):107–112. 21. Hall K, Sharp C. The veterinary trauma initiative: why bother (editorial). J Vet Emerg Crit Care 2014; 24(6):639–641. 22. Ateca LB, Drobatz KJ, King LG. Organ dysfunction and mortality risk factors in severe canine bite wound trauma. J Vet Emerg Crit Care 2014; 24(6):705–714. 23. Peterson NW, Buote NJ, Barr JW. The impact of surgical timing and intervention on outcome in traumatized dogs and cats. J Vet Emerg Crit Care 2015; 25(1):63–75.
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