Inpatient management Flashcards
Why is fluid balance critical in inpatient management?
Fluid overload → increases interstitial fluid, impairing oxygen & nutrient diffusion, harming renal & lung function
Fluid deficit → reduces perfusion, promotes catabolism, insulin resistance & cellular stress
How can fluid balance be monitored?
Clinical signs of hydration & perfusion
- mucous membranes
- pulse rate & quality
- blood pressure
- peripheral oedema
- chest auscultation & lung ultrasound for pulmonary oedema
What are solutions for fluid imbalances?
Adjust fluid therapy rates, use diuretics if needed
What is oncotic pressure?
Pressure exerted by proteins (mainly albumin) in blood to keep fluid inside blood vessels
Also called Colloid Osmotic Pressure (COP)
What happens when albumin is low (hypoalbuminaemia)?
Less oncotic pressure → fluid leaks out of blood vessels into tissues (causing oedema)
At same time, this can lead to low blood volume (hypovolemia), worsening perfusion
What are the clinical signs of hypoalbuminaemia?
Because fluid leaks out of blood vessels, patients may show:
- Peripheral oedema
- Pulmonary oedema on auscultation/ultrasound
- Flat caudal vena cava → Suggests low blood volume (hypovolemia)
- Low blood pressure (hypotension)
- Poor pulses
How is low oncotic pressure/hypoalbuminaemia managed?
Increase protein intake (feeding tube may be needed)
Plasma transfusion for oncotic support
Avoid synthetic colloids (risk of acute kidney injury)
What are the most common electrolyte disturbances in critical illness?
Hypokalemia (low potassium) due to reduced intake → Weakness, low head carriage, plantigrade stance
Sodium (losses or redistribution secondary to hyperglycaemia) → mentation disturbances, cerebral dehydration/swelling
Chloride (hand in hand with sodium or losses from GI → vomiting, symptoms associated with underlying disease
How are electrolyte disturbances monitored?
Electrolytes via blood/gas machine or biochem
How are electrolyte disturbances treated?
Supplementation with fluids
Where electrolytes are high - specific treatment approaches
What are the causes, respiratory responses, and clinical signs of acidosis?
Occurs when there is excess acid in body, classified into metabolic & respiratory acidosis
Metabolic – increased acid e.g. lactate, uraemia, ketones
Associated with increased RR & reduced PCO2
Respiratory – retained CO2 e.g. brainstem injury or respiratory paralysis (botulism/tetanus)
Associated with reduced RR & increased PCO2
What causes alkalosis, and how does it affect respiration?
Metabolic Alkalosis: Loss of acid (e.g., severe vomiting, pyloric foreign body). Causes reduced RR, increased PCO₂ & hypochloraemia
Respiratory Alkalosis: CO₂ loss from hyperventilation due to pain, stress, or fear
How are acid/base imbalances diagnosed?
pH measurement (blood gas machine)
PCO₂ levels (blood gas machine)
Respiratory rate (RR)
How are acid/base imbalances treated?
Hartmann’s (alkalinising) for acidosis
Saline (acidifying) for alkalosis
Treat underlying cause (e.g. pain)
Why is mentation monitoring important?
Indicates brain oxygenation, perfusion status & intracranial disease
Uses Modified Glasgow Coma Scale for standardisation
What are key cardiac abnormalities in critical patients?
Bradycardia → Check potassium levels
Arrhythmias (e.g., V-Tach) → Common in systemic disease
Poor contractility → Seen in sepsis, DCM, late-stage HCM
How are cardiac issues monitored and treated?
ECG monitoring (intermittent or continuous)
POCUS (ultrasound) to assess contractility
Lidocaine for V-Tach, Pimobendan for poor contractility
What do different blood pressure patterns indicate?
Low systolic + diastolic BP (low total BP)→ Hypovolemia
Low diastolic BP (wide gap) → inappropriate vasodilation: Distributive shock (e.g. sepsis, SIRS)
Low systolic BP (small gap) → Poor cardiac contraction
What are systolic and diastolic pressure an indirect measure for?
Systolic pressure – indirect measurement of cardiac contraction force
Diastolic pressure – indirect measure of vascular tone
How do you treat blood pressure issues?
Treatment based on underlying cause
What are some possible causes of hypothermia?
Reduced energy conservation
- e.g. anaesthesia, wet, exposure
Reduced energy production
- e.g. starvation, metabolic exhaustion, hypoxia
What are some possible causes of hyperthermia?
Increased energy conservation
- e.g. BOAS, hot day, exercise
Increased energy production
- e.g. inflammation/infection –> pyrexia
Why should hypothermia be corrected slowly?
Rapid warming can cause metabolic mismatch, harming heart & brain
How can oxygen & ventilation be monitored?
Basic:
- MM colour, resp rate & effort, pulse oximetry, lung ultrasound
Advanced:
- Blood gas analysis (PaO₂, FiO₂/PaO₂ ratio)
How are oxygenation & ventilation issues treated?
Oxygen therapy
What are causes of anaemia in critical patients?
Reduced production (chronic disease)
Destruction/haemolysis (immune-mediated or sepsis)
How can RBC/haemoglobin be monitored?
Mucous membranes
Resp rate
Heart rate
Haematology/PCV
Blood smear
Saline agglutination test
How can anaemia be treated?
Oxygen therapy
Transfusion if needed
- pRBCs or whole blood
How does disruption of the endothelial glycocalyx contribute to coagulation disorders?
Endothelial glycocalyx is protective layer of blood vessel endothelium
Disruption (due to disease, trauma, or colloid administration) exposes endothelium, triggering coagulation cascade
In severe cases, this can lead to Disseminated Intravascular Coagulation (DIC), causing widespread clotting & bleeding
How can coagulation disorders be monitored?
Mucous membranes - Petechiae
Bleeding from IV canula sites
Increased RR/RE (e.g. pulmonary thromboembolism (PTE))
Primary coagulation tests (platelet counts & BMBT)
Secondary haemostasis tests (coagulation factors (PT, APTT))
Fibrinolysis tests (D-dimers & FDPs)
Global coagulation test (thromboelastography (TEG))
How can coagulation disorders be treated?
Fresh frozen plasma transfusion for coagulation factors
Platelet transfusion
Other supportive care
- e.g. oxygen therapy for PTE
What are common kidney issues in critical patients?
Acute kidney injury (low urine output)
Reduced renal function
Hyperkalemia (life-threatening, must be treated ASAP)
How can renal function be monitored?
Fluid balance & urine output
- acute increase/decrease in urine output
Urinalysis (USG, cytology)
Biochemistry (urea, creatinine, phosphate, potassium)
How can issues of renal function be treated?
Hyperkalaemia treatment is priority
Managing fluid balance through ins/outs
Avoid fluid overload
Diuretics (e.g. furosemide) to encourage urine output if overload is developing
What are the risks of GI dysfunction in critical patients?
Ileus (gut stasis) → Can cause bacterial translocation & sepsis
Malnutrition → Increases catabolism & weakens recovery
How can GI motility & nutrition be monitored?
Signs of vomiting/diarrhoea
BCS
Weight
MCS
How can GI motility & nutrition issues be treated?
Food (GI diet, tube feed if indicated)
Reduce other medications if possible (e.g. opiates)
Anti-emetics/anti-nausea meds (e.g. maropitant, ondansetron)
Prokinetic agents if obstruction ruled out (e.g. metoclopramide)
What are possible causes of hypoglycaemia in critical care?
Increased usage/storage
- increased metabolic rate, septicaemia!, insulinoma, xylitol
Increased loss
- renal losses
Lack of intake
- nutritional or malabsorption
What are possible causes of hyperglycaemia in critical care?
Reduced usage
- diabetes mellitus!/DKA, insulin resistance
Increased mobilisation
- Stress, TBI!
How can glucose be monitored?
Blood glucose checks
Signs of weakness, reduced mentation, wobbly (look drunk)
How can hypoglycaemia be treated?
Food & glucose supplementation
Treat underlying cause
How can hyperglycaemia be treated?
Treat underlying cause
How can critical illness weaken immune function?
Increased risk of secondary infections, even in non-infectious diseases
Wounds source of infection
How can immune function be monitored?
GI signs indicating GI disruption
WBC counts (esp. left shift neutrophilia)
Hypoglycaemia
Temperature
Surgical sites/canula sites
Urinalysis (e.g. UTI)
Wound checks & dressing changes
- wound dressing is barrier to infection
How can decreased immune function be treated?
Find source & control it
Sample - culture & sensitivity
Antibiotics if needed
Clean & debride traumatic wounds
Appropriate dressing to stage of healing
Why does critical illness affect drug dosage?
Critical illness affects organ function (liver & kidney) & as a result, metabolic pathways & speed of metabolism/clearance
How can drug dosage & metabolism be monitored?
Liver function tests (urea, bile acids)
Liver damage tests (ALT, ALP, GGT, GLDH)
Renal function (urea, creatinine, phosphate, potassium)
Be aware of individual drug side effects & signs to look for
How can drug dosage in critical patients be managed?
Tempering of drug dosages based on effect, regular monitoring of their need, e.g.:
- Pain scores for analgesic drugs
- BP for vasopressors
- Signs of nausea for anti-emetics
Aim for lowest effective dose
Why is it important to control pain in critical patients?
Important welfare consideration
Uncontrolled pain can result in worse outcomes & delayed wound healing
How can pain be monitored?
Pain scores (e.g. Glasgow composite measure pain scale)
Repeat exams regularly
How can pain be treated?
Opiates
- Full Mu (e.g. methadone, morphine, fentanyl)
NSAIDS
- take care if concerns re BP & renal blood supply/function
Local anaesthetics
- local blocks or systemic administration (e.g. lidocaine CRI)
NMDA receptor antagonists
- Ketamine CRI or amantadine
Others
- e.g. a2 agonists, gabapentin
Why are nurses essential to caring for critical patient?
They are hands on with patient
Will notice changes before you
Can perform many procedures (often better than you)
How do you maximise nursing as a vet?
Listen to them
Involve them in decision making & case discussions, ask for their opinion, empower them
If things go wrong – debrief with them, learn from mistakes made (esp. your own) & be humble
Remember you are team
Why is TLC important?
Human interaction improves patient recovery
