Page 383 - Clinical Small Animal Internal Medicine

35 Approach to the Patient in the Critical Care Setting 351

Utilizing a goal‐directed approach, red blood cell trans- of isolation gowns should be considered if the patient is
VetBooks.ir fusion to maintain a hematocrit >30% is recommended if severely immunocompromised.
central venous oxygen saturation (S cv O 2 ) >70% is not
maintained despite supplemental oxygen and normaliza-
tion of intravascular volume and systemic blood Gastrointestinal (GI) Motility and Integrity
pressure. Many underlying conditions can result in gastric and
intestinal ileus and compromise of the GI mucosal bar-
rier. Decreased intestinal motility results in stasis of
Renal Function and Urine Output
intestinal contents and overgrowth of normal bacterial
Kidney function should be frequently evaluated in criti- flora. An altered mucosal barrier results in an increased
cally ill patients as hypotension, thrombosis, and nephro- risk for bacterial translocation and subsequent sepsis.
toxic medications can cause temporary or permanent Gastric and small intestinal stasis may result in vomiting,
injury resulting in renal insufficiency. Urine output while large intestinal derangements may lead to diar-
should be at least 1 mL/kg/h but oliguria should be eval- rhea, which can create and/or exacerbate hypovolemia.
uated in light of fluid input for an individual patient. An Medical intervention (promotility medications, physical
indwelling urinary catheter, and recording fluid in and activity) to increase GI motility and protect the mucosal
fluid out, assists in evaluating a patient’s overall fluid sta- barrier is recommended. If possible, enteral nutrition is
tus. In addition to urine output, insensible losses, losses recommended to maintain enterocyte health, decrease
from surgical drains, chest tubes or wounds should also villous atrophy, increase GI motility, and improve
be accounted for. Commonly accepted insensible loss mucosal integrity.
rates are 10–20 mL/kg/day. Fluid input includes IV fluids
(crystalloids and colloids) as well as nutritional support Drug Metabolism and Dosage
in the form of parenteral or enteral nutrition. In patients
with possible renal impairment, close monitoring of Medication doses and routes should be reviewed daily
fluid ins/outs may assist in maintaining fluid balance. for accuracy, safety (side‐effects, metabolism, and drug
Daily monitoring of serum BUN and creatinine is recom- interactions) and continued necessity. In the face of
mended to detect potential renal injury early. Especially altered renal or hepatic function, it may be prudent to
in patients with normal renal values at the time of pres- reduce the dose or increase the interval of medications
entation, even mild changes in BUN or creatinine (even to decrease the risk of toxicity and side‐effects. Highly
within the reference range) can be a harbinger of renal protein‐bound drugs should be used with caution in
injury or multiorgan failure. Early detection and aggres- hypoalbuminemic patients due to the potential for
sive treatment can have a dramatic impact on patient higher than expected plasma levels.
outcome. Analyzing urine for casts, glucose, and protein
is also used to identify renal injury and dysfunction.
Nutrition
All attempts should be made to provide appropriate
Immune Status and Antibiotic Coverage
nutritional support to critical patients in order to avoid a
Critically ill patients are often battling infections and negative energy balance contributing to organ dysfunc-
may have overextended or overwhelmed immune sys- tion, delayed healing, immunocompromise, and GI
tems. Empirical antibiotic therapy is recommended for dysfunction. Enteral nutrition is ideal and can be accom-
patients with suspected infections and antibiotic selec- plished by voluntary patient eating or feeding tubes (e.g.,
tion should be based on presumed site of infection, likely nasogastric, esophageal, gastrostomy or jejunostomy
organism involved, and hospital surveillance profiles. tubes). Total or partial parenteral nutrition is an option
When empirical antibiotics are used, initial broad‐spec- for providing nutritional support to patients with a con-
trum coverage is recommended with deescalation based traindication to enteral nutrition (severe ileus, intracta-
on results of culture and sensitivity panels. In addition to ble vomiting, malabsorptive conditions).
bacterial infections, clinicians should be aware of the
concern for rickettsial, protozoal, fungal, and parasitic Analgesia
infections that may require additional antimicrobial
therapies. In all critical patients, care should be taken to Appropriate pain management is necessary to improve
practice aseptic techniques when examining and treating patient comfort and decrease the secondary effects of
them. Clinicians and nurses should practice good hygiene pain. Common signs of pain include increased heart rate,
with frequent hand washing. Exam gloves should be agitation, and discomfort upon palpation of wounds.
worn at all times when handling any patient and the use Multiple pain scoring systems have been validated for