Kirby's Rule of 20 Flashcards
What is Kirby’s rule of 20?
The parameters to evaluate in the critical patient
Order depends on clinical situation
What are the 20 parameters?
Fluid balance
Oncotic pull
Blood glucose
Electrolyte and acid-base balance
Oxygenation/ventilation
Consciousness and mentation
Hypotension
Heartrate, rhythm, contractility
Albumin
Coagulation
RBC/Hb concentration
Renal Function
Immune status, antibiotic doses, WBC count
GI motility and Mucosal integrity
Drug doses and metabolism
Nutrition
Analgesia
Nursing care and patient mobilisation
Wound care and bandage changes
Tender loving care
- Fluid Balance
Where is the fluid?
○ SIRS - has it been redistributed?
○ Third space - pleural or peritoneal space?
Is the patient hypovolaemic?
○ Major Body System Assessment
○ Lactate
○ Urine output
Is the patient dehydrated?
○ Weight loss
○ Skin tent
Tacky MM
Oncotic Pull
- Any signs of inability to keep products in the intravascular space?
○ Peripheral oedema and/or issue oedema
○ If TP <40g/L and albumin < 20g/l will be difficult to keep products in intravascular space
Some effects seen before this if sudden fall in protein whereas many can cope with lower than this if fall has been more gradual - Think about giving blood, plasma, (artificial colloids??)
Blood Glucose
- Increased
○ Stress (esp. cats and camelids)
○ Underlying disease (Diabetes Mellitus)
○ Problematic - leads to osmotic diuresis - Decreased
○ Esp. prob in hypotensive SIRS and sepsis patients
○ Significant of energy imbalance
○ Endocrine disease – primary or secondary to underlying disease
Electrolyte and Acid-base Balance
Should be able to measure:
○ Calcium and magnesium (ideally ionised)
○ Sodium
○ Chloride
○ Potassium
○ Acid-base derangements
Often metabolic and complex in ECC patients
Usually acidosis, but not always
Oxygenation and Ventilation
Arteriole Blood Gasses
○ Look for Hypoxaemia, hypercarbia or hyperventilation
○ Needed to detect pulmonary oedema and ARDS early
Pulse oximetry
○ Look at % of oxygen saturation
Oxygen supplementation
○ If patient has poor perfusion
OR
○ Breathing abnormalities
○ AS STRESS FREE AS POSSIBLE
Cages, prongs, nasal tubes
May need mild and careful sedation
Consciousness and Mentation
Needs REPEATED assessment and immediate investigation if declines
○ Hypotension
○ Hypoglycaemia
○ Hyperammonaemia (secondary to liver disease/failure)
(Oxygenation; Electrolytes; Fever; Hypovolaemia, Sepsis; Cardiac dysrhythmias)
Hypotension
Measure indirectly with blood pressure cuffs
Ideally want mean above 60-65mmHg and systolic above 90mmHg
○ Irrelevant of species
If poor perfusion occurs that does not respond to fluid challenges:
○ Check for ongoing fluid loss
○ Cardiac disease or dysrhythmias
○ Low temp
○ Low glucose
○ Low oxygen
○ Electrolyte derangements
○ Brain stem pathology
Poor analgesia
Heart rate, rhythm, contractility
Check for murmurs and dysrhythmias with ECG
Can have primary cardiac disease or secondary to SIRS or sepsis
OR both
Albumin
Should be above 20g/L in the acutely ill animal
Many causes
○ GI or renal loss
○ Liver failure
○ Cytokine suppression of albumin production in SIRS
Associated with increased mortality in sick people
Coagulation
Big species difference
Small animals
○ Usually see bleeding diseases
Large animals
○ Inappropriately excessively coagulate
Disseminated Intravascular Coagulation – usually seen in sick animals
Measures we can take:
a. Decreased Antithrombin III
b. Decreased platelet count
c. Prolonged Prothrombin, Pro-thromboplastin, Activated Clotting Times
d. Decreased fibrinogen
e. Increased Fibrin Degradation Product’s
RBC/Hb concentration
- Need to have enough to deliver oxygen
- Tolerance varies on rate of RBC loss or reduced production
- <20% acutely and <15% chronically rules of thumb
- Transfusions are not innocuous but should be used prudently
○ Cats – cross-match
○ Dogs and horses – often can get away without cross-match with first transfusion
○ Lifespan of transfused cells relatively long in dogs and cats
○ Often last <5-7 days in horses - short term fix in horses
Renal Function
- May have Chronic Renal Failure then get sick
○ Go from compensating to decompensating - May have compromised renal function secondary to:
○ Shock, hypovolaemia, hypoxia, nephrotoxic drugs - Urinalysis is MOST sensitive for assessing renal function
○ Glycosuria in absence of hyperglycaemia
○ Casts
○ Infection in compromised animal - Urine output – can be a challenge to measure
- Creatinine (Urea in small animals, but not large animals - protein dependent)
2/3 of kidney impacted before see significant change
Immune status, antibiotic dosage and WBCC
- In sepsis WBCC can increase or decrease
- Also think about neutrophils and lymphocytes, globulin concentration, pyrexia
- If immunocompromised (low WBCC)
○ Need isolation and barrier nursing
○ FOR THEIR PROTECTION and care with invasive techniques - Consider metaphylaxis for seriously sick animals that may not be due to sepsis
○ E.g. RTA - Antibiotics – ideally C and S; if sick, bactericidal
GI Motility and Mucosal Integrity
- Critical illness is 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 - We want to stop animals being SICK and promote GI motility
○ Ideally avoid acid suppressants if you can
Ideally feed enterally where appropriate
Drug Doses and Metabolism
Be aware that we don’t know how sick animals handle drugs
○ Studies are done in healthy animals
Young animals do not handle drugs the same as adults
Lots of extrapolations of dosages from other species that may be wrong
Use of antimicrobial dosages set 50 years ago that may be inappropriate/ineffective
Consider where metabolised as may influence choices
Liver, kidneys
Nutriton
- ABSOLOUTELY ESSENTIAL AND OFTEN FORGOTTEN
- Enteral always better than parenteral
- Feeding always better than via tube
- Needs implementing immediately and constantly assessing
○ No-one gets better if their tissues are catabolising - Feed appropriate foods
Small volume, high calorie and appropriate but on increased side of protein (except in liver failure!)
Analgesia
- Depression, restlessness, irritable, anorexia, tachycardia (not cats)
○ Need to think about why? - if in doubt assume pain - Try to use multi-modal approaches
- Care with NSAIDS in small animals
○ Not a concern in large animals (except neonates) they have hardier kidneys - Consider cardiovascular effects
○ Alpha-2’s are very depressive - Consider sedative effects and respiratory depression (SA only)
○ Opioids
Don’t under-estimate the use of low-dose ketamine and intravenous lidocaine
Nursing Care and Patient Mobilisation
- ABSOLUTELY ESSENTIAL!
- 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
Nursing Care and Patient Mobilisation
- ABSOLUTELY ESSENTIAL!
- 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
Wound care and Bandage Changes
- Frequent examination of the wound
- Check bandage not too loose or tight and not wet
- Optimal wound management should be to keep them moist but not macerated
- Compression bandages used with care and good supervision
Don’t make patient uncomfortable
