Page 432 - Clinical Small Animal Internal Medicine

400 Section 5 Critical Care Medicine

Oral Care hours. Other indwelling catheters such as chest tubes
VetBooks.ir Care of the oral cavity is of the utmost importance in should be cared for as appropriate.

these patients. Oral ulceration is a common problem
and with poor oral care may occur in 90% or more of
patients. Oral ulceration is a primary source of bacterial Complications of Mechanical Ventilation
proliferation and has been reported as a major cause of
VAP in human PPV patients. Prevention of oral ulcera- Hemodynamic Compromise
tion with careful positioning of mouth gags, keeping Positive pressure ventilation can lead to reductions in
the tongue and mucous membranes moist, and fre- cardiac output in some patients. The associated increase
quent repositioning of the tongue and ET tube are in intrathoracic pressure can reduce systemic venous
essential. The mouth and oropharynx should be care- return which in the steady state is equal to cardiac
fully rinsed and suctioned every four hours. A chlo- output. Although animals with higher mean airway
rhexidine rinse of the mouth should be performed pressures are at greater risk for developing impaired car-
every eight hours. diovascular performance, those with significant pulmo-
nary disease tend to have such poorly compliant lungs
that very little of the increased airway pressure is trans-
Eye Care
ferred to the cardiovascular system. Hemodynamic com-
Ventilator patients are under anesthesia and require eye promise secondary to PPV is more of a problem for
care to prevent the development of corneal drying and animals with concurrent hypovolemia or other causes of
ulceration. Artificial tear ointment should be applied at reduced cardiac filling pressures. Continuous heart rate
least every two hours. If an ulcer is suspected, fluorescein and blood pressure monitoring is advised for all ventila-
staining should be performed and the patient should be tor patients. Fluid and drug therapy should be given as
started on an antibiotic ophthalmic ointment. Temporary appropriate if hypovolemia or volume‐unresponsive
tarsorrhaphy may be necessary in some cases. hypotension develops.

Recumbent Patient Care Ventilator‐Associated Pneumonia
Prolonged recumbency can lead to muscle atrophy, In human medicine, VAP occurs in 10–48% of patients
pressure sores, peripheral edema, and nerve damage. and leads to an increase in mortality. Endotracheal intu-
Patients should be repositioned at least every four bation compromises the normal upper airway defenses
hours and should have passive range of motion exer- and bacteria from the oral cavity have greater access to
cises performed. Ventilator patients should be kept on the lower airways. This problem can be compounded by
sufficient padding that is changed immediately if soiled. intermittent aspiration of oral secretions or gastroesoph-
Frequent changes in body position also help prevent ageal contents.
the pooling of secretions in one region of the airways Ventilator‐associated pneumonia is typically diag-
and atelectasis of the dependent lung lobes. Turning nosed when new radiographic evidence of pulmonary
may be associated with desaturation in animals with infiltrates is detected 48 hours or longer after beginning
substantial pulmonary pathology; some patients will IPPV. Decreases in oxygenation, a change in the charac-
not tolerate lateral recumbency in which case they may ter of airway secretions, new rhonchi or crackles, changes
require sternal recumbency with only their hips turned in white blood cell count, and new fevers are also com-
regularly. Oxygenation should be monitored carefully mon clinical signs associated with VAP. Prevention of
after changes in position. Sternal positioning is generally VAP includes maintaining careful oral hygiene stand-
associated with the best lung function and may be ben- ards, including chlorhexidine rinses and the use of sterile
eficial in hypoxemic patients. technique when handling the circuit or endotracheal or
tracheostomy tube. Minimizing circuit disconnections is
Catheter Care advised. It is now recommended in some guidelines that
ventilator circuits only be replaced every five days (ear-
All indwelling catheters should receive diligent catheter lier if gross contamination is evident). Many VAP infec-
care as ventilator patients are at high risk for secondary tions have been found to come from the hands of
infections and catheters provide possible entry sites for caregivers, so wearing gloves and frequent hand washing
microorganisms. Urinary catheters require appropriate are strongly recommended for all those dealing with ven-
cleaning and care every eight hours. Intravascular cath- tilator patients. Wearing gloves should be considered
eters should be unwrapped and cleaned every 24–48 mandatory when dealing with the oral cavity.