Care of critically ill patients

Question 1

Kirby`s Rule of 20.
First 10 are?

Answer 1

1. Fluid balance
2. Oxygenation/ventilation
3. Blood pressure
4. Heart rate, rhythm
5. Glucose
6. Temperature
7. Albumin
8. Electrolytes
9. Mentation/attitude
10. RBC

Question 2

Kirby`s Rule of 20.
What are 11-20?

Answer 2

11. GI motility and mucosal integrity
12. Nutrition
13. Renal function
14. Coagulation
15. Immune system/antibiotic dosage
16. Drug dosages
17. Pain control
18. Nursing care and patient mobilization
19. Wound care and bandage change
20. Tender Loving Care

Question 3

How to assess hydration? (5)

Answer 3

• Mucous membranes
• Skin turgor
• Body weight
• Evidence of edema or effusion
• Continuing losses (vomit, blood, diarrhea)

Question 4

How to assess oxygenation/ventilation? (3)

Answer 4

• Auscultation of lungs (both hemithorax)
• Monitor respiratory rate and effort
• Use oximetry

Consider:
* Respiratory distress
* Risk for aspiration pneumonia

Question 5

How to assess Blood pressure? (3)

Answer 5

• Check pulse (femoral & metatarsal)
• Capillary refill time
• Blood pressure machine

Question 6

How to assess heart rate and rhythm? (2)

Answer 6

• Auscultation of the heart
• ECG

Question 7

How to assess glucose and how often?

Answer 7

Normal level
* 80 to 120 mg/dL or
* 3.3 mmol/L to 6.2 mmol/L
(multiply or divide by factor of 18)

• Check once a day
• Depending on underlying problem (DM (hypergly) vs parvovirosis (hypogly))

Question 8

4 categories of hypertension

Answer 8

I minimal risk: systolic <150
II mild risk: sys 150-159
III moderate risk: sys 160-179
IV severe risk: sys >180

(mainly for dogs)

Question 9

Temp. assessment in critically ill patients?

Answer 9

minimum once a day

Question 10

accelerated idioventricular arrhythmia or AIV

Answer 10

is a ventricular rhythm with a rate of between 40 and 120 beats per minute with ectopic rhythm of >3 consecutive premature beats.

common in splenic torsions and poorly controlled pain

VPCs must be differentiated from this

Question 11

Some causes of hypoglycemia. (6)

Answer 11

xylitol intoxication,
insulin overdose,
insulinoma,
neonates,
Addison’s,
sepsis

Question 12

Some causes of hyperglycemia. (5)

Answer 12

diabetes mellitus
ketoacidosis
stress
Cushings
iatrogenic

Question 13

memory trick for simplying glu percentage calc.

Answer 13

2.5% = 0.05 ml/1ml of fluid
5% = 0.1 ml/1ml of fluid

note: over 5% glu can be irritating to blood vessels

Question 14

Critical ill patients and albumin considerations. (3)

Answer 14

• Main plasma protein
• Osmotic pressure
• Effusions, edema

e.g. burns especially

consider plasma transfusions

Question 15

Critical ill patients and electrolyte considerations.

Answer 15

• Nr 1. electrolyte it Potassium
• Electrolytes to be checked at
  least once a day

hypokalemia fairly common

hyperkalemia commonly due to lower urinary tract obstruction or Addison’s

Question 16

Critical ill patients and mentation considerations. (3)

Answer 16

• Monitoring changes in your patient’s mentation
• A declining level of consciousness is a poor prognostic indicator
• Pain?

Question 17

Critical ill patients and RBC considerations. (2)

Answer 17

PCV and TS (total solids) check at least once a day

Question 18

Critical ill patients and GI motility and
mucosal integrity considerations. (6)

Answer 18

Critically ill patients are at higher risk for:
* Gastric ulcers
* Ileus
* Gastritis
* Other GI disturbances

• Is your patient eating?
• Any vomiting or diarrhea?

Question 19

Critical ill patients and Nutrition considerations.

Answer 19

Goal of nutritional support is to treat and prevent malnutrition.

Starvation leads to neg. nitrogen balance and accelerated catabolic state which in turn leads to villous atrophy, suppressed crypt cell prolif., loss of GILT, increased permeability etc.

When to start feeding the animal?
* Anorexia or decreased food intake for 3 days
* Loss of 10% of body mass not related to hydration status
* Hypoalbuminemia
* Recent trauma/surgery
* Etc., etc., etc.

Even fat animals need feeding!

Question 20

Muscle condition scoring.

Answer 20

Scale of 0-3

The higher the number the better.

Question 21

Body condition scoring for cats.

Answer 21

Question 22

Body condition scoring for dogs.

Answer 22

Question 23

Explain RER.

Answer 23

• Resting energy requirement
• Amount of calories necessary for a non-stressed animal in the postprandial state in a calm, thermoneutral environment.

Animals less than 2kg:
* RER=70*(body weight^0,75)

Animals over 2kg:
* RER= 30*(body weight)+70
* Bodyweight in kg

• Usually started with 1/4 -1/3 of RER, increased daily, if tolerated well.

In stressful conditions, caloric needs are actually higher but our goal is to meet the minimum.

Question 24

Critical ill patients and feeding options. (4)

Answer 24

• Syringe feeding
• Tube feeding
• Parenteral feeding
• Microenteral feeding (used seldomly, orally, in working dogs in severe/stressful environments who work long hours)

Question 25

Describe Feeding tubes

Answer 25

* Measured in unit: French (Fr) * 1 French = 0,33mm Usually start with 1/4- 1/3 of daily RER * Nasoesophageal (-gastric) tube * Oesophagostomy tube (Pharyngostomy tube) * Gastrostomy tube * Jejunostomy tube

Question 26

Describe Nasoesophageal (-gastric) tube

Answer 26

* 3,5-8 Fr * Easy to place; requires local anaesthetic only * Generally well tolerated * Short term (up to 14 days) * Liquid diet only * Contraindications: facial trauma, coagulopathy, respiratory disease * Always verify correct placement with x-ray! * Complications: sneezing, aspiration pneumonia, vomiting, tube migration, esophageal irritation, inflammation and scarring, tube clogging, epistaxis.

Question 27

How to place a naso-esophageal tube?

Answer 27

Question 28

Describe Oesophagostomy tubes.

Answer 28

* 12—22 Fr (cat vs large breed dog) * Animals tolerate well * Can be used for long period (weeks, months) * Wider selection of diets (larger lumen) * Works In patients with facial/oral diseases * Requires general anesthesia to place * Verify the correct placement by x-ray! Animals can even eat independently while tube is placed (at that point you can consider removing the tube if they have recovered). Esophageal placement may be favored to avoid irritating the gastroesophageal sphincter. * Complications: cellulitis or infection of placement site, displacement during vomiting or regurgitation, clogging of the tube. * More severe complications: pneumothorax, pneumomediastinum, damage to vascular structures or nerves in cervical region (rare).

Question 29

Describe Refeeding syndrome

Answer 29

medical complications that result from fluid and electrolyte shifts as a result of aggressive nutritional rehabilitation. * More common In tube-fed cats (reported also in dogs), not super common in general but does happen. * Hypokalemia * Hypophosphatemia * Hyperglycemia * +/- hypomagnesemia Clinical signs: vomiting, lethargy, muscle weakness, pale mucous membranes, bleeding, arrhythmias, impaired mental status, seizures, cardiac arrest. Daily monitoring: clinical signs, monitoring K, Phos, Glu First step is to decrease feeding. Supplement minerals/electrolytes as required.

Question 30

Critical ill patients and renal function.

Answer 30

* Monitor Urine production * ideally place Urinary catheters * Record urine production as well * Normal cats produce 18-28 ml/kg/day of urine (5-60 ml/kg/day in kittens) * Polyuria has a urine volume of more than 40 ml/kg/day * Normal dogs produce 20-100 ml/kg/day of urine

Question 31

Critical ill patients and coagulation.

Answer 31

* Watch for Petechiae and ecchymosis * make notes of More bleeding after venipuncture DIC - disseminated intravascular coagulation * characterized by systemic activation of blood coagulation * which results in generation and deposition of fibrin * leading to microvascular thrombi in various organs and contributing to multiple organ dysfunction syndrome (MODS) * Consumption of clotting factors and platelets in DIC can result in life-threatening hemorrhage. Prognosis is very poor.

Question 32

MODS

Answer 32

multiple organ dysfunction syndrome is altered organ function in an acutely ill patient requiring immediate medical intervention. associated with the failure of one or more organ systems.

Question 33

Critical ill patients and Immune system/antibiotic dosage. (4)

Answer 33

* Decreased immune function * Wear gloves * Try to minimize the risk of infections, asepsis! * When needed, administer antibiotics

Question 34

Critical ill patients and drug dosages. (3)

Answer 34

Appropriate documentation * Treatment sheets/plans * Drug interaction * What and when is given Appropriate dosages Weighing the animal regularly and adjusting dosages.

Question 35

Critical ill patients and pain control.

Answer 35

* Monitor and assess animal posture/behavior * Multimodal analgesia Consider if infiltration or regional analgesia might be required.

Question 36

Critical ill patients and Nursing care and patient mobilization (4)

Answer 36

Turning patients (soft bedding too) Passive range of motion; physical therapy or joint massage Keeping the patient free of urine scald and bed sores Bathing, cleaning, clipping

Question 37

Critical ill patients and Wound care and bandage change (3)

Answer 37

* Clean bandages * Changing interval * Appropriate local treatment

Question 38

Critical ill patients and Tender Loving Care

Answer 38

Kindness and love * Talk to them * Take your time * Playtime * Walking * Owner visits * Recognize that mental health of your patient plays a direct role in their recovery. Happiness helps with healing!