Challenges of the ECC Flashcards
- Fluid Balance
Where is the fluid?
- SIRS
- Third space
Is the patient hypovolaemic?
- MBSA= 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
- (Tissue oedema)
- TP <40g/L and albumin < 20g/l; some effects seen before this if sudden fall in protein whereas many can cope with lower than this if fall has been more gradual
- Blood, plasma, (artificial colloids??)
- Blood Glucose
Increased-> osmotic diuresis, any fluids will not be retained
- Stress (esp cats and camelids)
- Underlying disease (DM)
- Problematic as leads to osmotic diuresis
Decreased
- Esp prob in hypotensive SIRS and sepsis patients
- Significant energy imbalance
- Endocrine disease – primary or secondary to underlying disease
- Electrolytes and acid-base balance
Calcium and magnesium (ideally ionised)
Sodium
Chloride
Potassium
Acid-base derangements
Often metabolic and complex
Usually acidosis, but not always
- Oxygenation and ventilation
ABP (& Arterial blood gasses)
- Hypoxaemia, hypercarbia or hyperventilation
- Needed to detect pulmonary oedema and ARDS early
Pulse oximetry to assess oxygen saturation
Oxygen supplementation
- Perfusion
- Breathing abnormalities
- AS STRESS FREE AS POSSIBLE
Cages, prongs, nasal tubes
May need mild and careful sedation
- Level of consciousness and mentation
Needs REPEATED assessment and immediate investigation if declines
- Hypotension
- Hypoglycaemia
- Hyperammonaemia
- (Oxygenation; Electrolytes; Fever; Hypovolaemia, Sepsis; Cardiac dysrhythmias)
- Hypotension
Mean above 60-65mmHg and systolic above 90mmHg
- If poor perfusion 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
Primary cardiac disease or secondary to SIRS or sepsis…..or both
- Albumin
Should be above 20g/L in the acutely ill animal
Checked daily
Many causes – GI or renal loss, liver failure, cytokine suppression of albumin production in SIRS
Associated with increased mortality in sick people
- Coagulation
Small animals usually see bleeding diseases whereas large animals inappropriately excessively coagulate
DIC (disseminated intravascular coagulation) – usually seen in sick animals
1) Decreased ATIII
2) Decreased platelet count
3) Prolonged PT, PTT, ACT
4) Decreased fibrinogen
5) Increased FDP’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 however so 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
- Renal Function
May have CRF or may be secondary to shock, hypovolaemia, hypoxia, nephrotoxic drugs
Urinalysis MOST sensitive
- Glycosuria in absence of hyperglycaemia
- Casts
- Infection in compromised animal
Urine output – can be a challenge to measure
Creatinine/ SDMA (Urea in small animals, but not large animals)
- Immune status, antibiotic dosage and selection, WBC count
WBCC and neuts and lymphs, globulin concentration, pyrexia
If immunocompromised 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- high risk of developing sepsis
Antibiotics – ideally C and S; if sick, bactericidal
- GI motility and mucosal integrity
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
Stop animals being SICK and promote GI motility
Ideally avoid acid suppressants if you can
Ideally feed enterally
- Drug dosages and metabolism
Be aware that we don’t know how sick animals handle drugs…..studies 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
