Important factors to consider in the emergency and critical care patient

Question 1

What are important factors to consider for gold standard management of an emergency and critical care patient?

Answer 1

• A trained team/at least a few people who know what they are doing
• Protocols for some things
• Confidence in what you are doing
• Being able to do a physical examination
• Having equipment and drugs on hand/accessible

Question 2

Reasons for increased blood glucose?

Answer 2

• Stress (esp cats and camelids)
• Underlying disease (DM)

Question 3

Why is increased blood glucose problematic in in fluid therapy?

Answer 3

• Problematic as leads to osmotic diuresis
• If you have BG above the renal threshold you are going to struggle to sort out fluid loss due to osmotic diuresis

Question 4

Reasons for decreased blood glucose?

Answer 4

• Hypotensive SIRS and sepsis patients
  
  • The disease process and inflammation is metabolically active and leads to overuse of BG
• Significant energy imbalance
• Endocrine disease – primary or secondary to underlying disease

Question 5

What should albumin levels be ideally in the sick patient?

Answer 5

• Should be above 20g/L in the acutely ill animal
  
  • Oncotic pull
  • If you don’t have enough protein in the body to heal, you will not heal

Question 6

Main causes of albumin losses?

Answer 6

GI or renal loss, liver failure (liver not producing enough), cytokine suppression of albumin production in SIRS

Question 7

How do coagulopathy/bleeding disorders generally differ between small and large animals?

Answer 7

Small animals usually see bleeding diseases whereas large animals inappropriately excessively coagulate

Question 8

Which species should be cross-matched before a blood transfusion?

Answer 8

• Cats – need to cross-match
• Dogs and horses – often can get away without cross-match with first transfusion
  
  • Can probably do multiple transfusions within the first 5 days within cross matching

Question 9

Lifespan of transfused blood cells in dogs and cats compared to horses?

Answer 9

Lifespan of transfused cells relatively long in dogs and cats; often last <5-7 days in horses

Question 10

Signs that an animal Is not coping with its anaemia?

Answer 10

• Tachycardia
• Tachpnoea

Question 11

Which is the preferred route of nutrition in a critical patient?

Answer 11

• Enteral better than parenteral
• But parenterally if you cannot do so

Question 12

What sort of food should be given to critical patients generally?

Answer 12

• Small volume, high calorie and appropriate but on increased side of protein (except in liver failure!)
• AD works really well in small animals (tasty so encourages them to eat)
• Do not feed GI diets which are not tasty if you are trying to tempt them to eat

Question 13

If you have a patient with poor perfusion due to hypotension, that is not responding to fluid challenge, what should you look for?

Answer 13

• Check for ongoing fluid loss
  
  • E.g. diarrhoea or vomiting
• Cardiac disease or dysrhythmias
• Low temp
  
  • Will become inappropriately vasodilated if hypothermic
• Low glucose
• High glucose
• Low oxygen
• Electrolyte derangements
• Brain stem pathology
  
  • That is not responding to cardiac baroreceptors
• Poor analgesia

Question 14

Level of consciousness and mentation needs REPEATED assessment and immediate investigation if declines. If it does decline is it due to what?

Answer 14

• Hypotension
• Hypoglycaemia
• Hyperammonaemia
• If none of the above can think about hypoxia, hypovolaemia, sepsis etc. (Oxygenation; Electrolytes; Fever; Hypovolaemia, Sepsis; Cardiac dysrhythmias)

Question 15

Roughly what blood pressure do you need to have enough forward flow to perfuse organs?

Answer 15

Mean above 60-65mmHg and systolic above 90mmHg

Question 16

Signs of coagulopathies in small animals?

Answer 16

• 1) Decreased ATIII (antithrombin III)
• 2) Decreased platelet count
• 3) Shortened PT, PTT, ACT
• 4) Decreased fibrinogen
• 5) Increased FDP’s

Question 17

What is the most sensitive test of renal function in an emergency patient?

Answer 17

Urinalysis

• Glycosuria in absence of hyperglycaemia
• Casts
• Infection in compromised animal

Question 18

What should be considered with immunocompromised emergency patients?

Answer 18

Need isolation and barrier nursing – FOR THEIR PROTECTION and care with invasive techniques

E.g. passing of urinary catheters etc.

Question 19

What type of antibiotic should be considered in most very sick critical patients (where necessary)?

Answer 19

• Bactericidal (low/no functioning neutrophils likely)
• Ideally C and S (but tend to have to wait 3 days)

Question 20

What are the GI risks in a critical patient?

Answer 20

• Critical illness often complicated by gastric stasis, ileus and gastric disease
• Don’t forget gut sounds in small animals – check whether present
• Bacterial translocation from compromised gut a massive concern…but also remember gastric acid there for a reason
  
  • When you get ileus it increases change of bacterial translocation
  • Gastric acid suppressants in sick animals may not be ideal as a result

Question 21

How can you minimise risks to the GI tract in critical patients?

Answer 21

• Stop animals being SICK and promote GI motility
  
  • Get them to eat
  • May involve the use of pharmacological agents
• Ideally avoid acid suppressants if you can (to avoid higher risk of bacterial translocation from the gut)
• Ideally feed enterally

Question 22

What should you consider when considering pharmacological agents in critical patients?

Answer 22

Where they are metabolised - liver, kidneys etc. - will influence your choice of drug in individual cases

Question 23

Clinical signs of pain?

Answer 23

Depression, restlessness, irritable, anorexia, tachycardia (not cats)

Question 24

What factors should you consider when choosing analgesia for critical patients?

Answer 24

• Care with NSAIDS in small animals (esp if renal compromise); not a concern in large animals (except neonates) – hardier kidneys
• Consider cardiovascular effects – alpha-2’s
• Consider sedative effects and respiratory depression (SA only) – Opioids
  
  • Tend to only see respiratory depression if large doses of opioids
• Don’t under-estimate the use of low-dose ketamine and intravenous lidocaine

Question 25

What general nursing care should be undertaken with critical patients?

Answer 25

• Check catheter sites often – any concerns, remove, culture and replace
• Ensure kind management and human contact….incl hand feeding
• Ensure appropriate temperature
• Try and get outdoors doing some normal functions as soon as possible
• Be ready for animals to seizure or for intubation if a risk
• Owner involvement in animals that have a bond (probably not horses!)
• Blankets, bedding, space, favourite toys or food/treats
• Ensure can either see or not see other animals (depending on species)

Question 26

What bandage/wound care should be undertaken?

Answer 26

• Frequent examination of the wound
• Check bandage not too loose or tight and not wet – change if latter
• Optimal wound management should be to keep them moist but not macerated
• Compression bandages used with care and good supervision