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SMALL ANIMAL INTENSIVE CARE UNIT

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					              UCD Veterinary Hospital
              Ospidéal Tréidliachta UCD




Protocol for:



      SMALL ANIMAL INTENSIVE CARE UNIT
                                                          University Veterinary Hospital   Date: 9 Sept 07
                                                          Standard Operating Procedures    Version: 1




     Revision                 Date           Author                 Reason for change




Status:                    Approved by ICU work group
Date of issue:             9 September 2007
Effective date:            9 September 2007

Relevant to:               All staff and students working in ICU




Written by:                Simone Schuller, Ian Self, Sheila Brennan, Carmel T. Mooney,
                           Robert Shiel, Florence Juvet, Thurid Freitag
Approved by:               ICU work group, Carmel T Mooney, Clinical Director
File location:             ICU




Protocol for ICU Policy & Procedures
                                                                                            Page 1 of 125
CONTENTS
                                                                                                                       PAGE
1. General topics
   1.1. Organisational structure .....................................................................................6
   1.2. Communications structure .................................................................................7
   1.3. ICU admissions criteria ......................................................................................8
   1.4. ICU admissions procedure.................................................................................9
   1.5. Financial organisation ......................................................................................10
   1.6. ICU charging ...................................................................................................11
   1.7. Price structure in ICU .......................................................................................12
   1.8. General hygiene and infection control..............................................................13
   1.9. General ICU care .............................................................................................15
   1.10. ICU patient checklist.........................................................................................16


2. Drug related topics
   2.1. ICU drug storage and administration ...............................................................18
   2.2. Use of Augmentin® ..........................................................................................19
   2.3. Preparation of heparinised saline 0.9% ...........................................................20
   2.4. Preparation of heparinised syringes.................................................................21


3. Catheter management
   3.1. Peripheral IV catheter placement.....................................................................23
   3.2. Jugular catheter placement..............................................................................25
   3.3. Blood sampling from central line ......................................................................27
   3.4. Urinary catheter placement and care (dogs)....................................................28
   3.5. Urinary catheter placement and care (cats).....................................................30
   3.6. Management of catheter associated infections................................................31


4. Blood pressure
   4.1. Arterial blood pressure measurement ..............................................................33
   4.2. Treatment of hypertension ...............................................................................35


5. Nutrition
   5.1. General feeding................................................................................................38
   5.2. Nasooesophageal tube placement ..................................................................39
   5.3. Nasooesophageal tube care ............................................................................40
   5.4. Total parenteral nutrition administration...........................................................41


6. Fluid therapy
   6.1. General rules....................................................................................................43
   6.2. Use of oxygen carrying solutions .....................................................................47
   6.3. Transfusion medicine .......................................................................................48


7. Cardiopulmonary arrest and resuscitation ............................................................52




Protocol for ICU Policy & Procedures
                                                                                                                       Page 2 of 125
CONTENTS …/continued
                                                                                                                       PAGE

8. Respiratory conditions
   8.1. Oxygen therapy ................................................................................................54
   8.2. Management of dyspnoea................................................................................55
   8.3. Placement of nasal catheter.............................................................................57
   8.4. Tracheostomy tube care ..................................................................................58
   8.5. Mechanical ventilation ......................................................................................59
   8.6. Placement of chest drains................................................................................61
   8.7. Management of chest drains............................................................................62


9. Endocrine and metabolic conditions
   9.1. Protocols for endocrine tests............................................................................64
   9.2. Treatment of hypoadrenocorticism...................................................................65
   9.3. Treatment of Nelson’s phenomenon ................................................................67
   9.4. Treatment of feline hyperthyroidism.................................................................68
   9.5. Treatment of hypercalcaemia...........................................................................70
   9.6. Treatment of diabetic ketoacidosis...................................................................71
   9.7. Treatment of hypokalaemia..............................................................................72
   9.8. Treatment of hypophosphataemia ...................................................................73
   9.9. Treatment of hypoglycaemia............................................................................74
   9.10. Treatment of insulinoma...................................................................................75
   9.11. Treatment of hepatic encephalopathy..............................................................76


10. Haematology
    10.1. Management of suspected thromboembolism in dogs ....................................78
    10.2. Management of Immune-mediated thrombocytopenia ....................................80
    10.3. Management of immune-mediated anaemia ...................................................81


11. Renal disease
    11.1. Treatment of oliguria/anuria/acute renal failure ...............................................84


12. Neurologic and neuromuscular disease
    12.1. Management of status epilepticus....................................................................87
    12.2. Management of head trauma ...........................................................................88
    12.3. Management of tetanus ...................................................................................89


13. Analgesia and anaesthesia
    13.1. Pain monitoring ................................................................................................91
    13.2. Propofol constant rate infusion.........................................................................92
    13.3. Fentanyl constant rate infusion ........................................................................93
    13.4. Use of Fentanyl patches in dogs and cats .......................................................94
    13.5. Constant rate infusion various analgesics .......................................................95
    13.6. Ketamine constant rate infusion for dogs and cats ..........................................96
    13.7. Morphine-Ketamine constant rate infusion for dogs and cats..........................97
    13.8. Morphine-Ketamine-Lidocaine constant rate infusion for dogs........................98
    13.9. Other analgesics ..............................................................................................99


14. Cardiac conditions
    14.1. Treatment of congestive heart failure............................................................ 102
    14.2. Pericardiocentesis ......................................................................................... 103



Protocol for ICU Policy & Procedures
                                                                                                                        Page 3 of 125
CONTENTS …/continued
                                                                                                                           PAGE

15. Postoperative care
    15.1. Parathyroidectomy ........................................................................................ 105


16. General wound management ................................................................................ 107


17. Management of intoxications
    17.1. Management of ethylene glycol intoxication ................................................. 109




Annexes
 1.      Dilution chart for Trigene® cleaning solution....................................................... 111
 2.      Emergency drugs stored in crash trolley ............................................................. 112
 3.      Contents of crash trolley ...................................................................................... 113
 4.      Crash trolley checklist.......................................................................................... 114
 5.      ICU treatment sheet............................................................................................. 115
 6.      Constant rate infusion calculation sheet.............................................................. 117
 7.      Transfusion chart ................................................................................................. 118
 8.      Flow chart cardiopulmonary resuscitation ........................................................... 119
 9.      List of Liquid Enteral nutrition solutions ............................................................... 120
 10.     Resting energy requirements for dogs and cats.................................................. 121
 11.     Sheet for administration of Total parenteral nutrition........................................... 122
 12.     Glasgow composite pain scale ............................................................................ 123
 13.     Modified Glasgow coma scale ............................................................................. 124




Protocol for ICU Policy & Procedures
                                                                                                                            Page 4 of 125
                           1. General topics




Protocol for ICU Policy & Procedures
                                               Page 5 of 125
1.1

Subject:                   Organisational structure
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To clarify the current organisational structure in ICU

ICU is run as an independent unit providing service to all small animal specialities in the
hospital.

At present there is one ICU clinician responsible for organising and overseeing activities in
ICU during the daytime. The ICU clinician is currently also on roster as service chief in small
animal internal medicine for 2 months per year and has some time off clinics. These
limitations require a team effort to be made in order to ensure proper care of ICU patients.

One qualified nurse is on roster for ICU during the daytime. The ICU clinician and the head
nurse oversee this nurse.

The ICU nursing staff is currently responsible for cleaning in ICU.

A group of students will be on ICU rotation as part of their small animal internal medicine
rotation during term time. During this time the students spend most of the day in ICU and are
on roster for night care as required by the ICU patient load. An intern who is backed up by
residents, senior clinicians and the ICU clinician overlooks the night care of patients.

An ICU working group includes representatives from each area of the small animal veterinary
hospital and was set up to develop and implement ICU policies and procedure protocols. The
clinical director oversees this working group.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                        Page 6 of 125
1.2

Subject:                   Communications structure
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure uninterrupted care of ICU patients and flow of information between people
involved in ICU care.

Duty of care: the ICU clinician is in charge of all patients in ICU during the day. This includes
monitoring, diagnostics and therapeutic decision-making. The ICU clinician however will keep
in close contact with the primary clinician who remains in charge of client communication. All
cases requiring analgesia will be discussed with anaesthesia clinicians.

The ICU clinician will be available between 8-10 AM and 4-5 PM for communication with
relevant staff (primary clinicians, anaesthetists, residents, interns and overnight students).

Results of diagnostic procedures have to be communicated to the ICU clinician as soon as
they become available and a written note has to be added to patient file (either radiology
report or handwritten note). ICU clinician and primary clinician are responsible for keeping
each other updated.

All observations, procedures, feedings and treatments have to be recorded on the ICU form in
order to maintain a complete patient record and assure that patient information is accessible
to all carers at all times.

Relevant “call if” criteria will be defined for each patient daily, clearly noted on the ICU form
and discussed with the overnight staff.

In case of problems during night care the student in charge will call the intern. If the intern
needs advice, a relevant resident (e.g. surgery for surgery cases, internal medicine for
medicine cases, anaesthesia for problems with analgesia) will be called. If the resident needs
advice, either a senior clinician or the ICU clinician will be called. All clinicians have to ensure
their phone numbers are available to the interns and residents, and that they remain
reachable while on roster.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                            Page 7 of 125
1.3

Subject:                   ICU admissions criteria
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure proper selection of patients requiring ICU care.

Procedures: Adherence of predefined criteria for ICU admission is required

Types of cases admitted
   • Cases requiring intensive monitoring
   • Cases requiring intensive fluid therapy with additional monitoring
   • Cases requiring enteral nutrition (initial stages or jejunostomy tubes, routine
       nasogastric feeding cases can be managed in ward)
   • Recovery from epidural anaesthesia until animal ambulatory and able to urinate
       spontaneously
   • Cases requiring central venous catheters
   • Post-operative care for at risk patients

Types of cases not admitted
   • Routine fluid therapy
   • Routine care for paralysed patients
   • Moderately to highly infectious cases
   • Routine cases for observation, except seizure watch
   • Routine recovery after uncomplicated anaesthesia or sedation


Cases may be moved to the wards under the following circumstances
   • ICU caseload high and case space needed for more critical case
   • If ICU staff feels that the patients presence in ICU is detrimental to the other ICU
      patients


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                  Page 8 of 125
1.4

Subject:                   ICU admissions procedure
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure smooth transfer of patients into ICU


ICU clinician and ICU nurse have to be informed that a patient is to be admitted into ICU. The
primary clinician is responsible for transmitting all available information about the patient to
the ICU clinician and nurse.

On admission every patient has to be recorded in the ICU book, which is located in the left
upper drawer under the syringe bins.


Nasal and perianal swabs have to be taken, if swabbing was not previously performed
(presurgically or because of a pre-existing wound on admission). The swabs must be clearly
marked with the patient details and the specification “ICU”, and can be deposited in the
container in the induction room together with the swabs from surgery.

An ICU sheet has to be filled in by the admitting clinician or the ICU clinician. Nurses and
students can fill in ICU forms, however the sheet has to be double-checked and signed by a
clinician.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                         Page 9 of 125
1.5

Subject:                   Financial organization of ICU
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


ICU functions as an individual cost centre within the UVH.

Teaching discounts can be applied to ICU charges as part of a discount on the general bill.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                      Page 10 of 125
1.6

Subject:                   ICU charging
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure ICU as a financially viable area within the hospital.


The ICU nurse and ICU clinician are responsible for charging all ICU patients according to the
ICU price list (see annex 14). ICU charges have to be updated daily and finalised at the time
of exit of the animal from ICU.

The ICU price list has to be updated regularly and new charges introduced as required.

It is the responsibility of the primary clinician to keep the owners updated on the current state
of the bill and to discuss eventual financial restraints with the ICU clinician and nurse.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                        Page 11 of 125
1.7

Subject:                   Price structure in ICU
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1

Policy: To regulate ICU tariffs and billing

Every patient entering ICU will be charged a fixed entrance fee. This charge is independent of
the animal’s status and the reasons for its admission into ICU.

According to the clinical status of the patient the patient will be classified into 1 of 3
categories.

                        Animal requiring limited monitoring and care
 Category A
                        Examples: simple fluid therapy, pain treatment (including epidural
                        catheterization)

                        Animal requiring close monitoring and intensive care
 Category B
                        Examples: in-and-outs

                        Animal requiring 24 hour uninterrupted monitoring
 Category C
                        Examples: after PSS ligation, mechanical ventilation.

The general charges include:
Crystalloid fluid therapy, oxygen therapy, monitoring of urine production, repeated blood
pressure measurements, central venous pressure measurements, pulsoxymetry,
capnography, mechanical ventilation, food, general patient care, catheter bandages,
Elizabethan collars, baths, PCV and TS.

Not included are:
Point of care and laboratory measurements, colloids including human serum albumin, plasma
and blood transfusions, drugs, sedation, general anaesthesia, central lines, urinary catheters
and collecting sets, arterial line, thoracic drain, feeding tubes, large bandages.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                         Page 12 of 125
1.8

Subject:                   General hygiene and infection control
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure maintenance of a high level of hygiene in ICU.

Routing cleaning in ICU will be performed once daily (ideally before 8 AM) by the ICU nursing
staff. Routine cleaning includes cleaning of floor and surfaces including examination tables,
sink, liquid soap dispenser, top of crash trolley and anaesthetic machine with Trigene®. The
product will be diluted according to a predefined dilution chart (see annex 1). A minimum
contact time of 5 minutes will be observed.

Additional cleaning of floor and surfaces in the afternoon is not deemed necessary at present
because of low caseload in ICU, but may need to be reconsidered at a later stage.

Other areas to be cleaned by nursing staff/technician:
   • Clippers need to be cleaned and disinfected between patients
   • Alcohol bottles will be cleaned before refill
   • Presses and Linn bins will be emptied and cleaned monthly
   • Cages and walls will be thoroughly scrubbed monthly
   • ICU computer (not in place) should have washable key cover
   • Routine cleaning of cages and tables during the day after use by students, staff and
        nurses

It is imperative that dedicated and properly labelled cleaning materials (brushes, loop mops
and buckets) are used.

The Rotawash® machine can only be used in ICU immediately after cleaning, so that no
cross contamination from other areas can occur. The purchase of additional area-coded
brushes may be considered in the future if the machine is used more regularly in ICU.


Strategies to reduce introduction of infection into ICU
Transit through ICU will be limited to a minimum. This involves limit transit of animals, people
and equipment.

      •   No postanaesthesia recovery for uncomplicated cases
      •   Limit number of students, staff, visitors (no owners!)
      •   No folders, bags, clothes or human food in ICU

ICU entrance rules
   • Verify vaccination status and infestation with ectoparasites.
   • Deny entrance for animals with moderately or highly infectious diseases.

Protective clothes (scrubs, shoes) to be considered.




Protocol for ICU Policy & Procedures
                                                                                       Page 13 of 125
1.8 continued/…
Subject:                   General hygiene and infection control


Transmission of infection
   • Hand washing before and after patient handling in high risk populations; single most
      important and immediate way of reducing hospital acquired infection.
   • High risk patients are: Immuno-suppressed animals, Neonates, Surgery patients.
   • Put up reminder signs and verbally raise issue.
   • Provide alcohol solution (Best use if attached to patient cage).
   • Wear gloves when touching any body fluids or excretions, or when handling high-risk
      patients.

Catheter associated infections
   • Limit number and duration of IV and urinary catheterisation if possible.
   • Keep urinary bag lower than patient, but off the floor.

Routine swabbing
   • ICU area (floor and key areas) once monthly.
   • Done by nurses or cleaning staff (who are to be instructed in correct procedure).
   • All animals admitted and not previously swabbed in surgery should have perineal
       and, if possible, nasal swab performed.
   • Tick box for swabbing on ICU sheet.
   • Microbiology will communicate results of routine swabbing at regular intervals or if a
       problem organism (e.g. MRSA) is identified. Microbiology results will be filed by the
       ICU clinician.

Emergency plan for MRSA or other outbreaks (already existing)

Protocols are used for
   • Sterile IV catheter placement
   • Sterile urinary catheter placement
   • Catheter maintenance
   • Management of suspected catheter associated infection
   • Rules for barrier nursing
   • Management of animals with wounds
   • Antibiotic use
   • Cleaning of instruments


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                    Page 14 of 125
1.9

Subject:                   General ICU care
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to ensure adequate patient care in ICU

An ICU treatment sheet (see annex 5) has to be kept for each animal in ICU regardless of the
amount of time spent in ICU. A daily treatment and monitoring plan will be made in the
mornings (for day-care) and at 5 PM (for night-care). Times for examinations and treatments
will be marked with marker and either ticked (was done) or crossed (was not done). The ICU
nurse and students can draw up a treatment and monitoring plan, but the ICU form has to be
double checked and signed by a clinician.

All observations, procedures, movements, feedings and treatments have to be recorded on
the ICU form in order to maintain a complete patient record and assure that patient
information is accessible to all carers at all times.

All excretions including urine, faeces, vomit and respiratory secretions have to be recorded
(quantity, quality, time).


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                    Page 15 of 125
1.10

Subject:                   ICU patient checklist
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure full and correct assessment of ICU patients

Patient ICU checklist needs to be assessed at least twice daily

    •    Organ function
             o Cardiovascular
             o Pulmonary
             o Mental
             o Visceral
             o Haematologic
             o Disease specific
    •    Hydration and electrolyte balance
             o Input/output balance
             o Changes in body weight
             o Potassium, sodium, bicarbonate, calcium, magnesium
    •    Management strategies for the primary disease
    •    Infection control
    •    Proper indwelling catheter insertion and care
    •    Aseptic procedures
    •    Patient comfort
    •    Physical – properly padded ? Clean and dry ?
    •    Emotional – properly coddled ? Adequate sleep ?
    •    Pain – analgesia ?
    •    Nutrition
    •    Medical record
    •    Owner communication


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                      Page 16 of 125
                   2. Drug related topics




Protocol for ICU Policy & Procedures
                                            Page 17 of 125
2.1

Subject:                   ICU drug storage and administration
Applicable to:             Nurses and students
Author:                    Simone Schuller
Approval:                  ICU work group
Approval Date:
Version:                   1


Policy: To ensure compliance with current drug legislation

Procedure: Adherence to following standards

No drugs other than emergency drugs and analgesics (see annex 2) will be stored in ICU.
Emergency drugs will be kept in a locked drawer in the crash trolley. Analgesics will be kept in
the ICU safe. ICU clinician and intern will have a key to both. Use of controlled drugs (see
separate list) has to be recorded according to the legal standards.

All other drugs need to be ordered from Dispensary on an individual patient basis and kept in
a basket fixed to the patient’s cage door. Drugs should not be left lying around in ICU and
must be removed when the patient leaves ICU.

A clinician must order all medications administered to patients by signing a completely filled in
dispensary slip.

The label of the dispensed medication has to be crosschecked with the written order by the
clinician.

Drug name, commercial name, dose, route, site (if appropriate), date and time have to be
recorded on the ICU sheet.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                        Page 18 of 125
2.2

Subject:                   Use of Augmentin® (amoxycillin/clavulanate)
Applicable to:             Nurses, clinicians, students
Author:                    Simone Schuller
Approval:                  ICU work group
Approval Date:
Version:                   1


Policy: To ensure correct preparation and administration of Augmentin®

Two sizes of intravenous Augmetin® are available:
   • Augmentin® 600 mg (500 mg Amoxicilline, 100 mg Clavulanate)
   • Augmentin® 1200 mg (1000 mg Amoxicilline, 200 mg Clavulanate)
   • Select vial size so that the entire dose is used within 8 hours (2 dosages)

      1. Reconstitution
         Reconstitute in either water for injection or 0.9% saline. A transient pink coloration
         may develop during reconstitution.

          Augmentin® 600 mg: use 6 ml to reconstitute
          Augmentin® 1200 mg: use 12 ml to reconstitute
          Final concentration: 100 mg/ml

      2. Administration
         Inject slowly over 3-4 minutes intravenously
         Dosing interval 6-8 hours

      3. Storage
         The manufacturer advises administration within 20 minutes of reconstitution.
         However, Augmentin® is stable for a maximum of 8 hours if stored at 5ºC (fridge).
         Any residual antibiotic solution should be discharged.


OVERSIGHT/FOLLOW THROUGH:
The ICU clinician and ICU nurse are responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                         Page 19 of 125
2.3

Subject:                   Preparation of heparinized saline 0.9%
Applicable to:             Nurses
Author:                    Simone Schuller
Approval:                  ICU work group
Approval Date:
Version:                   1


Policy: To ensure correct preparation of heparinized saline 0.9%

Heparinised saline is used for priming of IV catheters before placement and flushing of IV
catheters to ensure and maintain patency.

Procedure:

             1. Add 10,000 Units of Heparin to 1,000 ml of saline 0.9%
                • 2 ml of 5,000 U/ml Heparin (Heparin® )
                • 0.4 ml of 25,000 U/ml Heparin
                • Make sure opened Heparin is dated and stored in refrigerator

             2. Label fluid bag:
                • Date of preparation
                • Quantity of heparin added (Units/1,000 ml and ml heparin)
                • Your name


OVERSIGHT/FOLLOW THROUGH:
The ICU nurse and ICU clinician are responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                         Page 20 of 125
2.4

Subject:                   Preparation of heparinized syringes
Applicable to:             Nurses
Author:                    Simone Schuller
Approval:                  ICU work group
Approval Date:
Version:                   1


Policy: To ensure correct preparation of heparinized syringes

Heparinized syringes are used for blood gas analysis and blood sampling from a central venous
catheter.

Procedure:


      1. Prepare heparinized saline 0.9%

         Add 25,000 U of heparin (Heparin®) to 20 ml of saline 0.9% by adding
         • 5 ml of 5,000 U/ml Heparin
         • 1 ml of 25,000 U/ml Heparin

      2. Heparinize syringe

         Pull 0.3 ml of this solution into a 1 ml syringe or 0.6 ml into a 2 ml syringe then expel
         solution, leaving the syringe coated with heparin.


OVERSIGHT/FOLLOW THROUGH:
The ICU clinician and ICU nurse are responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                           Page 21 of 125
               3. Catheter management




Protocol for ICU Policy & Procedures
                                        Page 22 of 125
3.1

Subject:                   Peripheral IV catheter care
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure adequate placement and maintenance of peripheral IV catheters

Standards
   • Peripheral catheters may be placed by a clinician or qualified nurse, or a student or
       trainee nurse under the supervision of either one.
   • Healthy animals undergoing short-term catheterisation for elective procedures rarely
       develop phlebitis or sepsis from sloppy technique during catheter placement. In
       contrast, sick animals with compromised immunity may not tolerate even a minor
       breach of aseptic technique. Strict adherence to aseptic technique is therefore
       crucial.

Materials
   • Appropriate sized intravenous catheter
             Cat or small-breed dog:          22 gauge
             Medium to large-breed dog:       20 gauge
             Giant-breed dog:                 18 gauge
   • Needleless connector device (CLAVE connectors, Abbott)
   • 5 ml syringe with heparinized saline solution
   • Clippers
   • Cotton balls soaked with Hibiscrub®
   • Gauze squares soaked with alcohol
   • Tape
   • Bung
   • Softban® and Vetwrap®
   • All materials have to be ready for use on a clean tray

Placement
    1. Wash hands.
    2. Clip a wide area centred on the intended venipuncture site.
    3. Scrub the area using Hibiscrub® for a minimum of 2 minutes, then wipe the site with
        alcohol-soaked gauze.
    4. Flush catheter and connector with heparinized saline, taking care not to touch the
        plastic shaft.
    5. Have an assistant occlude the vessel.
    6. Grasp firmly at the junction of the catheter and needle hub with the bevel of the
        needle facing upwards.
    7. Do not touch skin at the point of insertion and never touch the needle/catheter shaft.
    8. Advance the needle through the skin and into the vein at a 15 degree angle.
        Penetration of the vein is indicated by a flash of blood into the hub.
    9. Advance needle and catheter as a unit for 3 mm with the catheter held as parallel to
        the long axis of the vein as possible.
    10. Advance the catheter into the vein while holding the needle still.
    11. Have an assistant occlude the catheter just over the point of insertion.
    12. Remove the needle and connect to connector.
    13. Remove any blood or fluid on the catheter hub and surrounding skin with gauze.




Protocol for ICU Policy & Procedures
                                                                                      Page 23 of 125
3.1 continued/…
Subject:                   Peripheral IV catheter care


    14. Tape the catheter securely in place. The first piece of tape is passed under the
        catheter, around the limb and then over the catheter. The second piece of tape is
        placed over the wings of the catheter and then wrapped around the limb. The third
        piece of tape is placed between the bung and the wings and then around the limb.
    15. Flush the catheter with 2 ml of heparinized saline solution and place a finger proximal
        to the catheter over the vein to feel the flow.
    16. Place Vetwrap® over the catheter, securely but not too tightly.

Maintenance:
   • The catheter should be examined, flushed and re-bandaged every morning to ensure
       that it is securely in place and the dressing is clean. Replace any wet or dirty
       dressings immediately. Record on medical file.
   • A new bung has to be used each time an animal is disconnected.
   • Watch for: swelling, redness, pain or unexplained fever suggestive of phlebitis;
       oedema suggestive of improper catheter placement or dislodgement; and swelling of
       the distal limb suggestive of a bandage placed too tightly.
   • Flush before and after use with heparinized saline solution, or at least twice daily to
       ensure patency.
   • If an animal develops a pyrexia of unknown origin, the catheter should be considered
       as a possible source of infection and should be removed and the catheter tip
       submitted for culture.
   • Catheters should remain in place provided they are properly maintained, functional
       and no complications exist. The suitability of alternative sites and the length of time
       that intravenous access will be needed should be considered before routinely
       replacing a functional catheter.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician / nurse is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                       Page 24 of 125
3.2

Subject:                   Jugular catheter placement and care
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure adequate placement and maintenance of IV catheters

Central venous catheters (CVC) may be placed by a clinician or qualified nurse.

CVC can be placed into the jugular, lateral saphenous and medial saphenous veins and can
be used for infusion of colloid and crystalloid fluids, total pareneral nutrition, drug
administrations, measurement of central venous pressure and blood sampling.

Contraindications
   • Primary or secondary haemostatic defects
   • Increased intraocular or intracranial pressure

Materials
   • Clippers
   • Sterile gloves
   • Cotton balls soaked with Hibiscrub®
   • Gauze squares soaked with alcohol
   • Scalpel blade
   • 1 ml 2% Lidocaine
   • 3 ml syringe with 24-gauge needle
   • 3-0 nonabsorbable suture
   • Central venous catheter placement kit
   • Needle holder
   • 5 ml syringe with heparinized saline solution
   • T-piece
   • Sterile drape
   • Bung
   • Softban® and Vetwrap®
   • All materials have to be ready for use on a clean tray


Procedure
   1. Place patient in left lateral or dorsal recumbency. The right side is preferred for
       jugular catheter placement because it may be easier to advance the catheter into the
       cranial vena cava from this side.
   2. Clip jugular furrow from the ramus of the mandible caudally to the thoracic inlet and
       dorsally and ventrally to midline.
   3. Aseptically scrub the clipped area with Hibiscrub® and alcohol.
   4. Drape catheterisation site with sterile field drape.
   5. Have an assistant raise the vein at the level of the thoracic inlet.
   6. Infiltrate catheterisation site with 2% Lidocaine.
   7. Make skin incision.
   8. Cannulate vein with guide needle supplied with the kit.
   9. Insert flexible guide wire through the introduce catheter several inches into the vein.
   10. Feed dilator over guide wire to enlarge insertion site into vein to size of central
       catheter.
   11. Remove dilator.




Protocol for ICU Policy & Procedures
                                                                                      Page 25 of 125
3.2 continued/…
Subject:                   Jugular catheter placement and care

    12. Thread venous catheter over guide wire.
    13. Catheter is passed along the guide wire to a depth calculated to place the tip near the
        right atrium in the cranial vena cava.
    14. Aspirate all air from the catheter and then flush with heparinised saline.
    15. If catheter is not fully seated, a suture collar is placed around it and anchored to the
        skin at insertion site.
    16. Fix catheter with skin sutures.
    17. Wrap with Softban® and Vetwrap®, but let injection port of T-piece stick out.


Maintenance
   • The catheter site will be inspected daily (remove bandage) for signs of local infection
       (pain, redness, swelling of the tissue) and dislocation.
   •    The bandage will be changed daily (Gloves must be worn) and a swab with betadine
       ointment applied to the catheter site in an aseptic manner, then wrapped with
       Softban® and Coban®.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician / nurse is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                        Page 26 of 125
3.3

Subject:                   Blood sampling from central line
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To safely gain venous blood samples using a central venous line


Materials
   • Examination gloves
   • Alcohol
   • Heparinised syringe 5 ml for purge sample (how to heparinise syringe ?) containing
       0.5 - 1 ml of hepranised saline.
   • Sterile syringe 2 - 5 ml (dependent on amount needed) for sample collection
   • 2 ml or 5 ml syringe with heparinised saline 0.9%
   • 3 x 22 gauge needles

Procedure
   1. Stop fluid pump, clamp T-piece shut.
   2. Clean rubber part of the injection port with alcohol and let air-dry. Do not touch rubber
      part thereafter.
   3. Introduce needle tip into rubber in a 45-degree angle to reduce risk of “coring” of the
      rubber during insertion of needle.
   4. Collect “purge sample” (3-4 ml of blood depending on size of patient) into a syringe
      containing hepranised saline. Rotate and cap needle and set aside. This procedure
      purges the dead space of the injection port and the catheter of non whole blood.
   5. With next syringe, collect sample for analysis.
   6. Return purge sample into patient.
   7. Flush catheter with 2-3 ml of heparinised 0.9% saline solution.
   8. Open T-piece, start fluid administration.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician / nurse is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                      Page 27 of 125
3.4

Subject:                   Urinary catheter placement and care (dogs)
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Materials
   • Clippers
   • Chlorhexidine 0.05% 20 ml in syringe
   • Sterile gloves
   • Sterile Lidocaine jelly
   • Urinary catheters
   • Male: Simple urinary catheter or Foley catheter (female, male)
          o < 20 kg 6-8 French
          o > 20 kg 10-12 French
   • 3-0 non absorbable suture material, tape, needle holder (simple catheters)
   • Syringe with sterile saline 0.9% ml according to catheters size (Foley catheter)

Placement Procedure
    1. Place dog in lateral (male, female) or ventral (female) recumbency.
    2. Clip hair around prepuce/vulva at least 5 cm from catheter insertion site.
    3. Scrub prepuce/vulva with chlorhexidine 0.05%, flush with clear water.
    4. Flush vestibulum/prepuce with 4 ml 0.05% chlorhexidine solution 5 times.
    5. Wear sterile gloves.
    6. Lubricate tip of catheter with sterile Lidocaine jelly.
    7. Place catheter -
        Male dogs: Assistant extrudes penis, penis has to remain extruded until catheter in
        place.
        Female dogs: Place catheter under digital palpation of the urethral papilla or with use
        of a vaginal speculum.
    8. Advance urinary catheter into bladder, remove stylet (Foley catheter).
    9. Connect sterile collection system.
    10. Inflate balloon if Foley catheter used, then retract catheter until resistance is met.
    11. If simple urinary catheter is used (males), let prepuce fall back into normal position,
        then place two stay sutures in the tip of the prepuce and tie in with Chinese finger
        traps or place white tape around the catheter at the level of the prepuce, then suture
        the white tape to the stay sutures to secure the catheter in place.

An Elizabethan collar should be fitted to prevent self-removal of the catheter.




Protocol for ICU Policy & Procedures
                                                                                      Page 28 of 125
3.4 continued/…
Subject:                   Urinary catheter placement and care (dogs)



Maintenance
   1. To empty urinary bag: Wear Gloves. Liberally cover ‘empty’ port with alcohol, turn
       port to empty the bag, liberally cover the port again with alcohol on closure. This
       helps to avoid contamination.
   2. Clean catheter and perineal area every 12 hours or when soiled with 0.05%
       chlorhexidine solution and water.
   3. Keep urinary collection bag below level of bladder at all times to avoid reflux of urine
       and potential intraluminal contamination of the catheter.
   4. Use blue trays or sit-on incontinence sheets to keep urinary collection bag off the
       floor.
   5. Do not disconnect urinary collection bag unless absolutely necessary.
   6. If catheter patency is questionable, flush catheter with sterile saline 0.9%.
   7. Remove urinary catheter as early as possible.

The administration of routing antimicrobial drug prophylaxis is not recommended during
urinary catheterisation as this predisposes to resistant bacterial infections which are more
likely to occur with longer duration catheterisations.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician / nurse is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                      Page 29 of 125
3.5

Subject:                   Urinary catheter placement and care (cats)
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Materials
   • Clippers
   • Chlorhexidine 0.05% 5 ml in syringe
   • Sterile gloves
   • Sterile Lidocaine jelly
   • Urinary catheters
   • Tomcat or Jackson catheters
   • 3-0 non absorbable suture material, tape, needle holder

Placement Procedure
    1. Place cat in lateral (male) or ventral (female) recumbency.
    2. Clip hair around prepuce/vulva at least 3 cm from catheter insertion site.
    3. Scrub prepuce/vulva with chlorhexidine 0.05%, flush with clear water.
    4. Flush vestibulum/prepuce with 1 ml 0.05% chlorhexidine solution 5 times.
    5. Wear sterile gloves.
    6. Lubricate tip of catheter with sterile Lidocaine jelly.
    7. Place catheter -
        Male cats: Assistant extrudes penis, penis has to remain extruded until catheter in
        place.
        Female cats: Pass catheter along the vestibular floor in the midline.
    8. Advance urinary catheter into bladder.
    9. Place two stay sutures in the tip of the prepuce/vulval lips and tie in with Chinese
        finger traps or place white tape around the catheter then suture the white tape to the
        stay sutures to secure the catheter in place.
    10. Connect sterile collection system.

An Elizabethan collar should be fitted to prevent self-removal of the catheter.

Maintenance
   1. To empty urinary bag: Wear Gloves. Liberally cover ‘empty’ port with alcohol, turn
       port to empty the bag, liberally cover the port again with alcohol on closure. This
       helps to avoid contamination.
   2. Clean catheter and perineal area every 12 hours or when soiled with 0.05%
       chlorhexidine solution and water.
   3. Keep urinary collection bag below level of bladder a tall times to avoid reflux.
   4. Do not disconnect urinary collection bag unless absolutely necessary.
   5. If catheter patency is questionable, flush catheter with sterile saline 0.9%.
   6. Remove urinary catheter as early as possible.

The administration of routing antimicrobial drug prophylaxis is not recommended during
urinary catheterisation as this predisposes to resistant bacterial infections, which are more
likely to occur with longer duration catheterisations.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician / nurse is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                      Page 30 of 125
3.6

Subject:                   Management of catheter-associated infections
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to ensure adequate management of suspected catheter-associated infections

Catheter associated infection should be suspected if
   • Evidence of local swelling, erythema, pain or discharge at catheter site
   • Fever, leukocytosis or sepsis in animals with an indwelling catheter

Materials
   • Sterile scissors
   • Sterile container

Intravenous catheter-associated infection suspected
1. Disinfect skin around catheter before removal to avoid contamination. Remove catheter.
2. Use sterile scissors to cut catheter. Submit catheter tip or catheter tip and subcutaneous
    segment for culture.
3. If sepsis is suspected, perform blood cultures at the same time.
4. Initiate empiric antibiotic therapy based on results of ICU surveillance cultures. Adapt as
    required once culture results become available.

Indwelling urinary catheter-associated infection suspected
1. Obtain urine by cystocentesis or from the catheter (not the collection system) for
        - Urinalysis
        - Gram staining of active urinary sediment
        - Urinary culture
2. Clean external urethral orifice before removal to avoid contamination. Remove urinary
   catheter. Use sterile scissors to cut catheter. Submit catheter tip for culture.
3. Initiate empiric antibiotic therapy based on
        - Results of gram staining, or
        - Results of ICU surveillance cultures
4. Adapt antibiotic therapy according to culture results.


OVERSIGHT/FOLLOW THROUGH:
ICU nurse/clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                      Page 31 of 125
                            4. Blood pressure




Protocol for ICU Policy & Procedures
                                                Page 32 of 125
4.1

Subject:                   Arterial blood pressure measurement
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to ensure correct measurement of direct and indirect blood pressure

Procedure: In order to achieve consistent blood pressure measurements a standard
procedure is to be followed

General protocol for indirect techniques

      1. It is preferential that the same person performs serial measurement in one patient.
         Blood pressure measurement requires experience and patience.
      2. Measure BP in a quiet environment (remove noisy patients from ICU if possible). Let
         the animal settle and acclimatise for 5-10 minutes before attempting BP
         measurement. Do not measure directly after a stressful event.
      3. Restrain gently in a comfortable position (either ventral or lateral recumbency). The
         patient should be calm and motionless. Position animal so that the cuff is at the level
         of the right atrium.
      4. Cuff selection: the cuff should be approximately 40% of the circumference of the cuff
         site in dogs and 30-40% in cats.
      5. Cuff placement: The cuff can be placed on a limb or the tail base.
      6. Measurement: the first measurement should be discharged. At least 3, preferably 5-7
         consecutive, consistent (<20% variation in systolic values) should be recorded.
         Repeat as necessary, change cuff placement as needed to obtain consistent values.
      7. Record technique used, cuff size, site and position of patient and mean BP in patient
         file.


Doppler technique

Equipment
  Doppler
  Headset
  Ultrasound gel (don’t use KY)
  Protection for Doppler probe !!!!
  ICU equipment – arrange for regular charging

Technique
   1. Select site, place adequate cuff.
   2. Clip palmar, plantar area of the foot or ventral tail base in order to obtain a contact
       surface for the Doppler probe.
   3. Wear head set.
   4. Feel pulse, place Doppler probe on artery.
   5. Move probe gently to obtain clear Doppler sound.
   6. Inflate cuff until Doppler sound disappears. Slowly deflate cuff until Doppler sound
       reappears. The pressure at which the Doppler sound reoccurs reflects the systolic
       arterial pressure.




Protocol for ICU Policy & Procedures
                                                                                        Page 33 of 125
4.1 continued/…
Subject:                   Arterial blood pressure measurement


Oscillometric technique

Equipment
   Cardell Veterinary Monitor (In Anaesthesia)
   Appropriate cuff
   Tape (to keep cuff attached to patient)

Technique
    1. Select site
    2. Apply cuff and tape in position
    3. Ensure correct cuff size is registering on monitor (‘large cuff’ ‘Small cuff’) – (to change
       the cuff size press and hold the ‘cancel’ button).
    4. Leave the patient to settle if not recumbent as movement can upset the outcome.
    5. Press to get first reading. Discard first reading and repeat for a further 5 times.
    6. Record Cuff size used, leg cuff was on, and position animal was in.

Contraindicative results
   Animal was moving too much
   Leg was pulled in so as blocking correct artery flow
   Wrong cuff size used



OVERSIGHT/FOLLOW THROUGH:
ICU nurse/clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                         Page 34 of 125
4.2

Subject:                   Treatment of hypertension
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1

Policy: to assure adequate management of patients with hypertension


Diagnosis of hypertension
   • Should be based on multiple BP measurements
   • Search for target-organ damage
           o Hypertensive retinopathy
           o neurologic signs
           o left ventricular hypertrophy
   • Search for underlying disease

Classification of blood pressure in dogs and cats based on risk for future target organ damage


Risk category        Systolic BP mmHg         Diastolic BP mmHg         Risk of future target
                                                                           organ damage
        I                    <150                     < 95                    Minimal
        II                  150-159                  95-99                       Mild
       III                  160-180                 100-120                   Moderate
       IV                    >180                    >120                      Severe



Decision to treat

  Risk category
         I              Do not treat
         II             Treat if target organ damage present
        III             Treat especially if target organ damage is present
        IV              Treat


Dogs: ACE inhibitors first choice
       Combine with amlodipine if ACE inhibition not sufficient


Cats: Amlodipine first choice
       Combine with ACE-inhibitor if not sufficient




Protocol for ICU Policy & Procedures
                                                                                       Page 35 of 125
4.2 continued/…
Subject:                   Treatment of hypertension


Emergency treatment of hypertension


Indications
    • Rapidly progressive target organ damage
    • Severe hypertensive retinopathy
    • Hypertensive encephalopathy
    • Severe systemic hypertension (case by case; normally >200 mmHg)


Treatment
   • Use drugs with rapid onset of action
   • Parenteral treatment
          o requires placement of an arterial line
          o Hydralazine
          o Nitroprusside
          o Esmolol
   • Oral treatment
          o Preferred because limited risk of hypotension
          o Amlodipine
          o Hydralazine



OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                        Page 36 of 125
                                       5. Nutrition




Protocol for ICU Policy & Procedures
                                                      Page 37 of 125
5.1

Subject:                   General feeding
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: The patient’s initial energy requirements will be calculated according the following
formulas or read off weight/RER table (see annex 10):


                           RER = 70 (body weight in kg)0.75
                                          or
                            RER = 30 (body weight in kg) +70


This estimation will be adapted according to the individual patients needs.

In animals which have not eaten for more than 3 days, feeding is reintroduced in a stepwise
fashion
         30% of RER on first day
         60% of RER on second day
        100% of RER from third day onwards

The amount of food to be fed and diet to be used have to be recorded on the ICU sheet.

If an animal is to be fasted, a “do not feed” sign has to be placed on the kennel door.

All meals will be measured, either by volume or weight, before feeding. The volume or weight
given will be recorded.

When food is removed from the cage, the remaining food will again be measured or weighed
and the amount eaten recorded on the patient’s treatment sheet.

One food type or flavour at a time will be offered. Commercial dog and cat food will be offered
before “human” foods.


OVERSIGHT/FOLLOW THROUGH:
ICU nurse is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                          Page 38 of 125
5.2

Subject:                   Nasooesophgeal tube placement
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure correct placement of nasooesophageal feeding tubes

Indications
    • Short term nutritional support
    • Patients with normal level of consciousness
    • Good airway control
    • Functional gastrointestinal tract

Materials
   • Local anesthaetic
   • Sterile lubricant gel
   • Feeding tube
   • Superglue
   • Elizabethan collar

Procedure
   1. Tilt the patient’s head upward toward the ceiling and place several drops of local
      anaesthetic into the nostril; allow to work for 2-3 minutes.
   2. Measure feeding tube to the levels of the 8th rib, mark the tube or record exact length
      – the tip of the tube is to sit in the distal third of the oesophagus and not in the
      stomach.
   3. Grasp the animal’s muzzle and gently and briskly insert the tube into the ventromedial
      meatus. Gently advance the tube. The patient should swallow the tube.
   4. Once the tube is passed to the premeasured length, secure tube lateral to the nostril
      and in between the eyes with a small amount of superglue.
   5. Check tube placement by gentle aspiration, which should create a vacuum, followed
      by injection of 5 ml of sterile saline 0.9%, which should not induce coughing.
   6. Tube placement can but does not have to be checked radiographically if these two
      tests are negative. Place an Elizabethan collar on the patient to prevent tube
      displacement.



OVERSIGHT/FOLLOW THROUGH:
ICU nurse/clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                     Page 39 of 125
5.3

Subject:                   Nasooesophgeal tube care
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure correct maintenance and use of nasooesophageal feeding tubes


Maintenance and use of nasooesophageal feeding tubes

      1. Check tube placement before each feeding

          Step 1: Gently aspirate catheter; a vacuum should build up as the
                  oesophagus seals around the tip of the catheter

          Step 2: Inject 5 ml of sterile saline 0.9%; no coughing should occur

          Step 3: Inject air whilst auscultating the stomach

      2. Feed slowly over 10-15 min; observe patient for discomfort during feeding

      3. Flush feeding tube with 5-10 ml of water after each feeding


For suitable liquid veterinary diets see annex 9.


OVERSIGHT/FOLLOW THROUGH:
ICU nurse is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                     Page 40 of 125
5.4

Subject:                   Total Parenteral Nutrition administration
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure correct use of Total Parenteral Nutrition (TPN)

TPN use carries a high risk of complications. The possibility of complications needs to be
addressed with the client before TPN is used.

General standards

      1.   TPN can only be administered though a dedicated central line.
      2.   NEVER disconnect the TPN line. When a patient is being moved, clamp the line and
           take the bag with you.
      3.   NEVER inject anything into the TPN line. If the line is occluded or not working
           properly, see an ICU clinician or nurse.
      4.   Remove TPN solution from the refrigerator about one hour before
           administration to allow it to warm up to room temperature.
      5.   When changing the TPN bag use a new drip set and extension set each time.
      6.    Assemble the new TPN bag, fill the line, and connect to the patient as quickly and
           aseptically as possible.
      7.   It is the responsibility of the student and/or clinician to order TPN daily or as needed.
           Refills need to be ordered weekdays before 2pm, and enough TPN for the weekend
           or holiday should be ordered before 2:00 p.m. on Friday. Except for weekends or
           holidays, TPN is ordered on a day-by-day basis.
      8.   A blood glucose and PCV/TP should be done 4-6 hours after starting TPN to check
           for hyperglycaemia. Also check serum for hyperlipidaemia.


      For TPN Feeding schedule see annex 11



OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                           Page 41 of 125
                            6. Fluid Therapy




Protocol for ICU Policy & Procedures
                                               Page 42 of 125
6.1

Subject:                   General fluid therapy - General Rules
Applicable to:             Clinicians, staff, students
Author:                    Florence Juvet
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure adequate fluid therapy in ICU patients

Aims of fluid therapy:
1) To correct hypovolaemia, restore the circulating blood volume, prevent hypovolaemic
   shock and maintain renal perfusion.
2) To correct acid-base disorders
3) To correct electrolyte imbalances. Acid-base disturbances must be corrected first.
   Acidosis leads to increased plasma potassium.
4) To replace cells. This is only necessary if cells have been lost (haemorrhage) or are
   deficient (anaemia)
5) To provide nutrients and energy. This is usually only necessary during prolonged therapy
   (>5days). Aim to provide calories, nitrogen, vitamins, trace minerals. See policy on
   parenteral nutrition.


1. CALCULATE THE NORMAL ONGOING LOSSES= maintenance fluid rate= V1

                               V1(ml/h)=Body weight X 50-60 ml/24 Hr

Normal ongoing losses result from:
          Insensible losses: respiratory tract, breathing, panting, evaporation, sweating =
          20 ml/kg/day
          Gastro-intestinal losses = normal faeces and gastric secretions = 10-20 ml/kg/day
          Urine losses = 20 ml/kg/day, this can be regulated.

2. CALCULATE THE DEFICIT VOLUME= V2

                 Percent dehydration                     Clinical signs                 Multiple
                         <5%               Not detectable
“Mild”                    5%               Subtle loss of skin elasticity                 50
“Moderate”               8%                Definite delay in return of skin to normal     80
                                           position, slight prolongation of CRT,
                                           possibly dry mucous membranes
“Severe”                  12%              Tented skin stands in place, definite          120
                                           prolongation of CRT, eyes sunken in
                                           orbits, dry mucous membranes,
                                           possibly signs of shock (tachycardia,
                                           cool extremities, rapid and weak pulses)

V2 (ml) = BW x multiple determined

                Aim to replace ½ of deficit over 6 hr and remainder over 24-48h.




Protocol for ICU Policy & Procedures
                                                                                         Page 43 of 125
6.1 continued/…
Subject:                   General fluid therapy – General Rules


3. CALCULATE THE ABNORMAL ONGOING LOSSES
   Polyuria, vomiting, diarrhoea, severe skin loss (extensive burns), respiratory tract, third
   space loss (intestinal obstruction, peritonitis, pancreatitis, effusions and haemorrhage into
   body cavities).

     V3 (ml/h) = Estimated total volume of abnormal losses/24 Hr


4. ASSESS ACID-BASE DISORDERS
   In many cases correction of hypovolaemia will alleviate this by improving renal perfusion.
   Arterial blood gas analysis is necessary to measure acid-base disturbances.
   Acidosis is a decrease in plasma pH (increase in H+ concentration). Alkalosis is an
   increase in plasma pH (decrease in H+ concentration).
   Respiratory acidosis is caused by an increase in CO2, respiratory alkalosis is caused by a
   decrease in CO2. Metabolic acidosis occurs when there is a deficit in bicarbonates or an
   increase in [H+]. Metabolic alkalosis occurs when there is an excess of bicarbonate or a
   decrease in [H+].
   Correction of acid-base disorders is treated in a separate protocol.

5.   ASSESS ELECTROLYTES IMBALANCES

Most fluids require a supplementation in potassium.

          Serum             mEq KCl to add to          Add ml KCl 15%            Maximal fluid
         Potassium            1000 ml fluid           (20mEq/10 ml) for          rate (ml/kg/h)
          (mEq/l)                                       maintenance
                                                        requirements
             <2                        80                    40                       6
           2.1-2.5                     60                    30                       8
           2.6-3.0                     40                    20                       12
           3.1-3.5                     28                    14                       18
           3.6-5.0                     20                    10                       25




                           K+ content         Add for            Add ml KCl (20mEq/10
                           (mEq/l)          maintenance           ml) for maintenance
                                            requirement              requirements
                                              (mEq/l)
     CSL                          4              16                         8
     LRS                          5              15                         8
     NaCl 0.9%                    0              20                         10




Protocol for ICU Policy & Procedures
                                                                                        Page 44 of 125
  6.1 continued/…
  Subject:                   General fluid therapy – General Rules



  6. CHOOSE FLUID TO USE: crystalloids or colloids

                                               Indications                             Contraindications/Pb
                   Isotonic solutions          1. Replacement fluid:                   • Poor plasma
                   same osmolality as the           • dehydration                          volume expansion
                   ECF (280 to 310 mmol/L)                                             • Dilution
                   NaCl 0.9%, CSL, Ringers
                                                    • exceptional loss
                   and lactated Ringer’s            • treatment of acid-base           • Avoid if: anaemia,
                   solutions , 2.5% dextrose           disorders                           hypoproteinaemia,
Crystalloids       with 0.45% saline (as                                                   hypocoagulability
                                                    • treatment of electrolytes
                   dextrose is rapidly                 disorders                       • Possible
                   metabolised this solution                                               complications:
                                               2.   maintenance
                   becomes rapidly
                                               3.   hypovolaemia and shock. Dog:       • pulmonary,
                   hypotonic)
                                                    90 ml/kg over 30-60 min., Cat:         interstitial or
                                                    40-50 ml/kg over 30-60 min.            cerebral oedema.


                   Hypotonic solutions         Pure water deficit, hypernatraemia,     They dilute electrolytes
                   Exert lower osmotic         sodium intolerance (cardiac failure)    and water may
                   pressure than body fluids                                           redistribute into cells
                   5% dextrose in water,                                               Do not use SC as they
                   NaCl 0.45%                                                          will draw electrolytes to
                                                                                       them
Crystalloids       Hypertonic solutions        Hypertonic saline (7.5%) :              They must be used IV.
                   Exert higher osmotic        Treatment of shock: use as a single     Cellular dehydration.
                   pressure than body fluids   bolus (4ml/kg) and administer           Hypertonic saline (if too
                                               slowly ( max. 1ml/kg/min)               rapid infusion):
                   Hypertonic saline (7.5%),
                   Mannitol 20%, Glucose       Mannitol 20%:                           bradycardia,
                   50%                         Oliguric renal failure: 0.25-0.5 g/kg   hypotension,
                                               IV over 5-10 min.                       bronchoconstriction,
                                                                                       shallow breathing.
                                               Acute cerebral oedema and acute
                                               glaucoma: 1-2 g/kg IV over 30 min.      Do not administer
                                               Withdraw water for first few hours      Mannitol to dehydrated
                                               post-administration. May repeat 2-4     or over-hydrated
                                               times over next 48h. Monitor            patients.
                                               hydration.
                                               Glucose 50%
                                               hypoglycaemia
                   Synthetic                   Rapid plasma volume replacement;        Nausea in cats with
                   Hetastarch (Voluven),       plasma volume expansion in the          rapid injection.
                   Gelatin solutions           treatment of hypovolaemic shock         Coagulopathy with
                   (Gelofusin)Dextrans         and patients with severe capillary      dextrans.
                                               leak syndrome or severe protein
Colloids                                       depletion.
                                               Hetastarch: Dog:10-20 ml/kg as a
                                               rapid bolus
                                               Cat: 10-15 ml/kg over 10-15 min
                   Biologic                    Each biologic colloid has specific      IV administration.
                   Albumin, Plasma, Packed     indications.                            Anaphylactic reaction,
                   red blood cells, whole       Albumin: severe burn injury, fresh     plasma overload in
                   blood                       frozen plasma: brings clotting          anaemic patients
                                               factors, whole blood: haemorrhagic      receiving whole blood
                                               shock, anaemia.                         too rapidly.




  Protocol for ICU Policy & Procedures
                                                                                                  Page 45 of 125
6.1 continued/…
Subject:                   General fluid therapy – General Rules


7. RATE OF FLUID ADMINISTRATION

     Volume to administer in ml per hour = V1 + V3 + (half V2)/6 + (half V2)/24 or 48

In the above formula V1 = maintenance fluids for 24 h.
V3 = total abnormal ongoing losses in 24 h.
V2 = total deficit calculated, of which ½ is corrected over 6 h and the other half over 24 or 48
h, as judged more appropriate.

Rq: after 6 hours (once half of the deficit calculated has been replaced), the volume to
administer becomes V1+ V3 + (half V2)/24 or 48.

To convert infusion rate to drops/minute:
Most administration sets deliver 20 drops per ml (check wrapper)

Drops / min = (drops/ml x rate (ml/h))/ 60

Particular cases:
Hypovolaemic shock: In severe shock, crystalloids fluids should be administered as a bolus of
90 ml/kg over a 30-60 min period. 2 peripheral veins are usually required in order to
administer fluids as rapidly as this. Alternatively colloids may be used (20 ml/kg over 15-30
min.). May need to replace up to twice the blood volume with crystalloids over a period of
time. (see treatment of shock)


Confounding factors of physical examination findings associated with dehydration

Parameter                       Falsely negative              Falsely positive
Skin turgor                     subcutaneous fat              Cachexia
                                Young animals                 Geriatric animals
Mucous membranes                Nausea                        After surgery (dry mouth)
(dry)
                                Vomiting                      Panting, tachypnoea
                                Drinking                      Uraemia
Position of globe                                             Cachexia

Confounding factors of physical examination findings associated with poor peripheral
perfusion

 Parameter                         Falsely negative           Falsely positive
 Mucous membranes
 Pale                                                         Vasoconstriction due to pain
                                                              or anxiety
 Dark pink or red                  Vasodilation may be        Haemodilution may be
                                   interpreted as normal      interpreted as normal volume
                                   volume
 Capillary refill time             <1 sec may be              Difficult to assess if
                                   considered adequate        peripheral vasoconstriction or
                                                              anaemia




Protocol for ICU Policy & Procedures
                                                                                           Page 46 of 125
6.2

Subject:                   Use of oxygen carrying solutions
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to ensure adequate use of Oxyglobin® solution

  Oxylobin ® is purifiedpolymerised bovine haemoglobin in modified LRS

  Product characteristics:
      • Shelf life 36 months
      • Packaging: 60 ml or 125 ml bag (foil wrapped to prevent oxidation of Hg)
      • Once foil wrap is removed Oxyglobin® should be used within 24 hours
      • Storage at room temperature
  Fluid characteristics
      • Large haemoglobin polymers carry oxygen and act as a colloid
      • Vasopressor effect (NO scavenging)
      • Plasma half life 18-43 hours
      • Licensed as a single use product

Indications
    • Severe anaemia of all causes (blood loss, haemolysis, bone-marrow disease)
    • No compatible blood donor available

Administration
Oxyglobin should not be mixed with other solutions. Other blood products, colloids and
crystalloids can be administered before and after Oxyglobin® infusion over the same catheter.
However, be aware that volume overload can occur because of colloid properties of
Oxyglobin®.

                Dose:             10-30 ml/kg (use low end of dosage range)
                Fluid rate:       Maximal rate 10 ml/kg/hour


Parameters to monitor
   • Clinical parameters: circulatory overload, blood pressure, heart rate, respiratory rate,
      respiratory noises, CRT
   • Total haemoglobin concentration (PCV does not increase)
   • Does not impair monitoring via pulsoxymetry

Adverse reactions
   • Fluid overload because of plasma expansion
   • Temporary change in colour of mucous membranes and urine
   • Interference with other laboratory parameters (colorimetric technique): Bilirubin, Liver
      enzymes, Creatinine, Glucose, urine dipstick
   • Blood gas, electrolytes and I-stat® measurements from arterial samples are
      unaffected


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                     Page 47 of 125
6.3

Subject:                   Transfusion medicine
Applicable to:             Clinicians, staff, students
Author:                    Sheila Brennan
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to ensure adequate use of blood products

Canine Blood Donation
15-20% of blood volume can be donated, which works out to be 16-18 ml/kg.
One standard blood donation is 450 +/- 45 ml, this is referred to as one unit and this is the
volume of blood that can be collected in the blood collection bag. This volume means that a
dog should not be less than 25 kg to donate a full unit of blood. To estimate if a full unit has
been collected the bag should be weighed, 1 ml of blood weighs 1.06 g - i.e. standard
collection is 477 +/- 48 g.
The minimum accepted underdraw into citrate (the usual anticoagulant) is 405 ml (429 g),
less than this can result in administration of excessive amounts of citrate to the recipient.

Canine Blood Groups
Dogs do not have alloantibodies
DEA 1.1 negative is considered to be the universal donor
DEA 1.1 negative recipients should only receive DEA 1.1 negative blood
Crossmatching is not necessary for the first transfusion

Feline Blood Donation
Some of the same principles as for canine blood collection apply to cats, however, the
maximum acceptable donation volume is 11-13 ml/kg and the standard volume donated is 60
ml (one feline unit). Cats should weigh at least 4.5 kg to donate a full feline unit. Cats can
donate once every 3-4 weeks but generally donate on a 2-3 monthly basis.
Blood is generally collected using a 19 g butterfly catheter from the jugular vein into a 60 ml
syringe into which anticoagulant has been drawn (7.5 ml of CPDA1 per 60 ml syringe,
underdraw 55 ml). If the blood is to be stored it should be transferred to a sterile storage bag.

Feline Blood Groups
Cats have alloantibodies.
All type-B cats produce very strong anti-A antibodies, this results in a potentially fatal reaction
if type A blood is transfused into a type B cat.
Type-A cats have weak anti-B alloantibodies which result in shortened survival of transfused
B blood into an A cat with mild signs of haemolytic anaemia.

Giving a Blood Transfusion
Whole blood transfusions should only be given when there is an indication for their use. If not
required the risks of transfusion reactions outweigh any benefits.
The recipient should have an intravenous catheter placed; this catheter should be checked for
patency prior to transfusion.
Prior to transfusion the donor and recipient should be blood typed and unless it is a first
transfusion cross match performed, the interpretation of cross match can be difficult if the
recipient is very anaemic or has strong autoagglutination.
The blood/blood product is given through a special blood infusion giving set that has a filter to
remove clots, platelet aggregates and some fats.
The transfusion rate is 5-10 ml/kg/hour and the initial rate is 0.25 ml/kg/h for the first 15-30
minutes during which time the animal should be monitored very carefully for signs of
transfusion reaction. The maximum rate of infusion is 22 ml/kg/h in emergency situations. A
transfusion should be complete within 4 hours.




Protocol for ICU Policy & Procedures
                                                                                          Page 48 of 125
6.3 continued/…
Subject:                   Transfusion medicine

The volume of blood required depends on the PCV of the donor and recipient. A rough rule of
thumb is that 2 ml/kg of transfused whole blood raises the PCV by 1%. A more accurate
method of estimating the volume required is:

 Volume of           Recipient             85 (dog)           Recipient desired PCV-current PCV
 Donor blood        = weight           X    or         X
 to be infused (ml)   (KG)                 60 (cat)           PCV of anticoagulated donor blood

Signs of transfusion reactions include - weakness, depression, recumbency, tremors,
agitation, pyrexia, vocalisation, panting, tachycardia, bradycardia, arrhythmia, pale mucous
membranes, weak pulses, cardiopulmonary arrest, salivation, vomiting, diarrhoea, urination,
seizures, coma, angioedema and urticaria.
If signs occur the transfusion should be stopped and the signs addressed.

Blood Products:

Whole Blood
Can be stored under refrigeration at 1-6ºC.
The platelets in the blood when refrigerated for 24 hours have normal to increased function.
After 72 hours of storage the platelets haemostatic ability is lost.
Coagulation factors progressively decline under refrigeration with most factors declining in
function greatly by 2 weeks.
RBCs are useful up to 1 month following storage.
The main indication for giving whole blood is reduced blood volume where the aim is to
replace RBCs, plasma and volume.

Packed Red Blood Cells
Prepared through centrifugation of whole blood.
Contains no haemostatic properties.
The ideal blood product to replace red blood cells when there is no hypovolaemia i.e.
anaemia without hypovolaemia. Does not run the risk of volume overload as with whole blood.

Fresh Frozen Plasma
Prepared through centrifugation of blood with the cells being used for packed cell
transfusions. The separation and freezing to -18ºC must occur within 8 hours of collection.
This is the ideal product for haemostatic disorders (not useful with platelet disorders). It is
thought that the clotting factors are useful for up to 1 year when kept frozen. The protein is
useful for hypoproteinaemic animals however it is difficult to give the volume required.
After 1 year the bags should be re-named frozen plasma, which are useful for their protein
content.

Fresh Plasma
Centrifuged from whole blood and used within 8 hours of collection.
Same indications as for fresh frozen plasma.
10-30 ml/kg of plasma (fresh/fresh frozen) is the recommendation with the transfusion to be
complete within 4 hours.
22.5 ml/kg of plasma is required to raise recipients albumin by 5 g/l.

Thawed Plasma
If a unit of fresh frozen plasma is thawed but not used it should be refrigerated, if not used
within 24 hours it can still be used for up to 5 days post thaw, it will have reduced factor VIII
and vWf activities but otherwise is equivalent compared with fresh frozen plasma. Vitamin K
dependent factors will be stable i.e. II, VII, IX, X.




Protocol for ICU Policy & Procedures
                                                                                        Page 49 of 125
6.3 continued/…
Subject:                   Transfusion medicine


Cryoprecipitate
A precipitate of fresh frozen plasma which is enriched in factor VIII and vWf and is the product
of choice for treating haemophilia A and vWD.
It is a small volume prepared by thawing fresh frozen plasma to a slush at 4ºC and then
centrifuging further and removing the supernatant and leaving the factor VIII and vWf rich
precipitate.
Its use allows for repeated transfusions without the risk of volume overload.
The plasma that is not used is known as cryosupernatant and is useful as it contains protein
and vitamin K dependent factors.

Platelet Rich Plasma
Prepared through centrifugation of fresh whole blood at a lighter gravitational force than
normally used to separate RBCs and plasma, this concentrates the platelets in the plasma.
The platelet rich plasma can be stored for 3-5 days under refrigeration.
Platelet transfusion is most beneficial for thrombocytopenia caused by decreased platelet
production, it can be useful if there is increased platelet consumption and least beneficial if
there is immune mediated thrombocytopenia.
                                                                                                 9
1 unit of platelet rich plasma / 10 kg will increase the recipient’s platelet count by 35x10
platelets.
Platelet rich plasma is difficult to make and for it to be useful to a patient many units may be
required to be created from many units of whole blood - this is often not possible or practical.
10 ml/kg of fresh whole blood will increase the platelet count by 10x109/l.


Record all transfusion procedures performed on chart at annex 7.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                         Page 50 of 125
      7. Cardiopulmonary arrest and
               resuscitation




Protocol for ICU Policy & Procedures
                                       Page 51 of 125
7.

Subject:                   Cardiopulmonary arrest and resuscitation
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Follow flowchart (see annex 8)


Job tasks in CPR

     •   Team leader /Record keeping
     •   Intubate and ventilate
     •   External chest compressions
     •   IV catheter and fluid administration
     •   Attach ECG and prepare drugs


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                      Page 52 of 125
             8. Respiratory conditions




Protocol for ICU Policy & Procedures
                                         Page 53 of 125
8.1

Subject:                    Oxygen therapy
Applicable to:              Clinicians, staff, students
Author:                     Simone Schuller
Approval:                   ICU work group/Clinical director
Approval Date:
Version:                    1


Policy: To ensure adequate oxygen therapy

Indications for oxygen therapy
    • Visible dyspnoea and cyanosis
    • Congestive heart failure, pulmonary hypertension, severe pulmonary disease
    • SpO2 less than 90%
    • PaO2 <60-70 mmHg (8-9.3 kPa)
    • Post-thoracotomy

Administration
 Route                                 Flow rate              Comments
 Flow by oxygen                        2 – 5 l/min            Short term O2 administration
                                                              May be less stressful for some dyspnoeic
                                                              animals than facemask
 Facemask                              100 ml/kg/h            Short term O2 administration
                                                              May stress some dyspnoeic animals
 Buster collar/cling film              100/ml/kg/h            Leave room for leaks around collar to prevent
                                                              build-up of moisture and carbon dioxide and
                                                              puncture cling film in 2-3 places. Most
                                                              effective with mouth breathing.
 Nasal catheter                        50-100 ml/kg/min       Max flow rates
                                                                5 Fr    0.75 l/min
                                                                8 Fr    2-3 l/min
                                                              10 Fr     5-8 l/min
 Intratracheal oxygen                  10 ml/kg/min

 Oxygen cage                                                  22 degrees C, 40-50% humidity

Unhumidified oxygen causes drying of mucous membranes, impairs mucociliary clearance,
increases viscosity of mucosal secretions and increases the risk of infection. Oxygen should
therefore always be administered though a humidifying system.

Humidification: fill humidification bottle to 1/3 full with sterile water.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                             Page 54 of 125
8.2

Subject:                   Management of dyspnoea
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Approach to the dyspnoeic patient
   • Avoid stress
   • Initially examine the animal from a distance
   • Observe respiratory rate and pattern to attempt to identify site of lesion
   • Auscultate chest, trachea and larynx
   • Try to localise lesion to upper, lower respiratory tract or pleural space

If pleural effusion or pneumothorax suspected (discordant respiratory pattern, muffled heart
and ventral lung sounds) perform thoracocentesis:

      •   Keep animal in sternal position
      •   Clip and surgical preparation if tolerated by animal
      •   7-9th intercostals space on L or R
      •   Dorsal if pneumothorax
      •   Ventral if pleural effusion
      •   Submit fluid for further analysis (EDTA and sterile serum tube)


Management of upper airway obstruction* (e.g. laryngeal paralysis, excluding foreign
bodies)

      •   Oxygen supplementation
      •   Cage rest and minimise stress
      •   Sedation if necessary: acepromazine 0.01-0.03 mg/kg IM (if CV stable)
      •   Place an IV catheter if possible
      •   Dexamethasone: 0.25-0.5 mg/kg IV
      •   Monitor temperature
      •   If severe hyperthermia use cool water sprays, soaks, enemas, fan cool air, administer
          cool IV fluids
      •   Intubation/ tracheostomy and surgery if inadequate response to therapy


Management of lower airway disease

      •   Oxygen supplementation
      •   Cage rest and minimise stress
      •   Place an IV catheter if possible




Protocol for ICU Policy & Procedures
                                                                                       Page 55 of 125
8.2 continued/…
Subject:                   Management of dyspnoea



Drug                               Indications                Considerations
Dexamethasone                      Allergic airway disease    Infection
0.25-0.5 mg/kg IV or IM                                       GI side effects
Terbutaline                        Bronchoconstriction        Painful
0.015mg/kg IM                                                 Tachycardia
                                                              Hypersensitivity
Seretide evohaler                  Bronchoconstriction        Minimal side effects
(salmeterol & fluticasone)
1-2 puffs in 5-6 breaths
Antibiotics                       Pneumonia                   Will interfere with BAL C&S
Frusemide                         Pulmonary oedema            May exacerbate cough          with   primary
                                                              respiratory disease




● Monitor:
    • Respiratory rate and effort
    • Mucous membrane colour and capillary refill time
    • Lung and heart auscultation
    • Pulse oximetry / PaO2 if necessary
● Imaging and further tests may be performed once stable



OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                       Page 56 of 125
8.3

Subject:                   Placement nasal catheter
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to ensure correct placement of nasal catheters

Materials
   • Local anaesthetic
   • Sterile lubricant
   • Infant feeding tubes (5-10 French, depending on size of patient)
   • Superglue
   • Elizabethan Collar


Procedure
   1. Place 4-6 drops of local anaesthetic in ventral nasal meatus.
   2. Wait for 5 min
   3. Pre-measure feeding tube to the medial cantus to the eye and mark it.
   4. Push nose dorsally and gently advance the catheter ventromedially.
   5. Stop if there is any resistance or “crunching” sounds
   6. Glue the catheter at the lateral edge of the nostril and at the top of the head.
   7. Attach to oxygen source


Possible complications
   • Epistaxis
   • Nasal discharge
   • Sneezing
   • Gastric dilation at very high Oxygen flow rates
   • Removal by patient


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                         Page 57 of 125
8.4

Subject:                   Tracheostomy Tube Care
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to ensure correct care of tracheostomy tubes


Goals in caring for a tracheostomy patient are
   1. Clear airway secretions to maintain airway patency.
   2. Prevent infection of tracheostomy site and airway.
   3. Humidify airways.
   4. Minimize tracheal trauma.

Procedure
- Closely observe the patient for signs of occlusion.
- Humidification of airway is provided either by nebulisation or injection of sterile saline
   (0.2ml/kg) hourly.
- The inner canula of the tracheostomy tube should be removed and soaked in Hibiscrub®
   and sterile saline during nebulisation and then rinsed thoroughly in sterile saline before
   being replaced.
- Coupage of the chest wall should be performed every 4-6 hours.
- Suctioning of the tube and trachea.
           o Preoxygenate for 2 minutes before suctioning.
           o Suctioning should be intermittent, atraumatic, and as aseptic as possible.
           o Use a new suction catheter and wear examination gloves.
           o Suctioning should be stopped if the patient is excessively uncomfortable
           o Do not exceed 15 seconds of suctioning without stopping and reoxygenating.
- Deflate cuff (if inflated) for 15 minutes per hour. The cuffs are usually NOT inflated so if
   the tube becomes occluded, the patient can still breathe around the tube.
- Change the bandage daily. Check the site for signs of infection, clean around the tube
   with Hibiscrub®, apply Betadine® ointment, and rebandage.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                      Page 58 of 125
8.5

Subject:                   Mechanical ventilation
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure adequate care for patients requiring mechanical ventilation

Indications for PPV
    • Hypoxaemia unresponsive to oxygen therapy
           o Arterial PaO2 below 60 mmHg
           o SpO2 below 91%
    • Hypercapnia
           o Arterial PaCO2 above 60 mmHg
           o ETCO2 greater than 50 mmHg
    • Sustained dyspnoea, respiratory paralysis and respiratory fatigue


Getting the animal on the ventilator

      1. Intubation
         Heavy sedation or general anaesthesia for intubation with orotracheal tube, if
         tracheostomy tube in place ventilate without sedation if possible

      2. Initial ventilator settings
             Peak proximal airway pressure   10-20 cmH2O
             Tidal volume                     8-12 ml/kg
             Inspiratory time                    1 second
             Ventilatory rate                10-20 breaths/minute
             Minute ventilation              150-250 ml/kg/minute
             End-expiratory pressure         0-+2 cmH2O
             Inspired oxygen                 60-100%

      3. Maintaining the animal on the ventilator

         o    Anaesthesia (aim for a light level of anaesthesia)
         o    Adapt initial settings to meet individual patients needs
         o    Monitoring
         o    Care
              o ET Tube management
                 Move catheter ties q4h
                 Move catheter cuff q4h (flush mouth pharynx, rostral trachea with sterile
                 saline, suction, deflate cuff, reposition cuff, carefully reinflate

              o   Airway hygiene and hydration
                      o Chest coupage and tracheal suctioning (aseptic and atraumatic
                           technique) q4h
                      o Airway hydration via nebulisations q4h
              o   Fluid therapy
                      o High side of normal hydration with pneumonia
                      o Low side of normal hydration with ARDS




Protocol for ICU Policy & Procedures
                                                                                  Page 59 of 125
   8.5 continued/…
   Subject:                   Mechanical ventilation



                o    Repositioning
                        o Change position q4h (prone position best)
                        o Passive range of motion exercises q4h
                o    Mouth care
                        o Flush mouth, tongue and pharynx with                  sterile   saline   and
                             chlorhexidine mouthwash solution q4h
                        o Maintain tongue inside mouth
                o    Eye care (apply artificial tears q2h)

       o    Nutritional support
       o    Problems and troubleshooting
                         o Respiratory asynchrony
                         o Thoracic bloodflow impairment
                         o Auto-PEEP
                         o Pneumonia
                         o Hyperthermia
                         o Pneumothorax


4. Getting animal off the ventilator

   Is the animal ready for a weaning?

       o    Is PaO2:FiO2 above 300?
       o    Can oxygenation be maintained with an FiO2 below 0.4 and a PEEP below 4
            cmH2O?
       o    Is there a light level of anesthesia and strong mandibular muscle tone?
       o    Does the animal cough during tracheal suctioning?
       o    Are there any spontaneous breathing efforts?

   If answers to all question are “yes”
        o Taper sedation
        o Try spontaneous breathing
        o How is patient tolerating the discontinuance of ventilator support?

   Was it necessary to increase the FiO2 above 0.4 to maintain oxygenation?
   Did heart rate, blood pressure, breathing rate increase more than 50%?
   Did breathing effort increase or decrease appreciably?

   If answers to all questions are “no” - ventilatory support can be discontinued.



   OVERSIGHT/FOLLOW THROUGH:
   ICU clinician is responsible for assuring adherence to this policy.




   Protocol for ICU Policy & Procedures
                                                                                              Page 60 of 125
8.6

Subject:                   Placement of chest drains
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to ensure correct placement of nasal catheters

Materials
   • Sterile gloves
   • Electric clippers
   • Hibiscrub® solution
   • 2% Lidocaine
   • 3-6 ml syringe
   • Sterile surgical pack containing sterile field towels, towel clamps, scalpel blade,
       scalpel handle, needle holder, Mayo scissors, thumb forceps, haemostats
   • Sterile gauze
   • Thoracic drainage system
   • 3-0 or 2-0 non-absorbable sutures
   • Three way stopcock
   • Bandage material

Procedure
   1. Clip lateral thoracic wall between the 5th and 13th rib.
   2. Perform surgical scrub.
   3. Have an assistant pull the skin of the lateral thoracic wall cranially and ventrally.
   4. Inject 2% Lidocaine form the 10th to 7th intercostal space. Make sure the block
       includes the intercostal muscles through which the tube and trocar will pass.
   5. Drape lateral thorax with sterile field towels.
   6. Tent skin at dorsal portion of the10th intercostal space, make a small stab incision
       through the skin, making a hole just large enough for the tube to pass.
   7. Insert trocar and tube through the skin incision, tunnelling the apparatus cranially.
   8. When tip of trocar is over the seventh intercostals space, direct the trocar
       perpendicular to the thoracic wall. Grasp trocar at the level of the skin firmly and,
       using the palm of your hand, push the trocar though the intercostals space into the
       thorax.
   9. Once the trocar has entered the thorax, push the tube off of the trocar cranially and
       ventrally, and have the assistant release the skin.
   10. Immediately secure the three-way tap, have assistant empty the thorax, while you are
       securing the tube in place.
   11. Place horizontal mattress suture around the tube.
   12. Place purse-string suture around the tube, secure with a finger-trap to prevent tube
       displacement caudally.
   13. Secure tube to thorax with layer of roll gauze.
   14. A non-restrictive dressing or stockinette prevents patient interference with the chest
       tube.
   15. All connections should be glued together to prevent inadvertent disassembly by the
       patient or carer.
   16. Always ensure that three-way tap and the gate clamp are closed when not in use.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                     Page 61 of 125
8.7

Subject:                   Management of chest drains
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to assure correct management of chest drains

      •   Chest tubes and connectors will be maintained in an aseptic manner.
      •   Examination gloves have to be worn when handling the tube.
      •   Chest tube bandages will be changed as required.
      •   When draining the chest, ensure that the connection to the syringe is airtight. Use
          new sterile syringe each time.
      •   All fluids and air removed from the chest will be quantified.
      •   Analgesia: Bupivacaine can be injected directly into the chest cavity via the chest
          tube at a dose of 2 mg/kg q6h. Bupivicaine must be diluted at least 1:1 with sterile
          saline. Bicarbonate can be added at a ratio of 1:9 to decrease stinging of the solution.
          The analgesia is always given after complete chest drainage.
      •   Remove chest tube when the volume of fluid recorded is less than 2-4 ml/kg/day.


OVERSIGHT/FOLLOW THROUGH:
ICU clinician is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                         Page 62 of 125
           9. Endocrine and metabolic
                  conditions




Protocol for ICU Policy & Procedures
                                       Page 63 of 125
9.1

Subject:                   Protocols for endocrine tests
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel/Sheila Brennan/Carmel Mooney
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1




                                   ACTH Response Test (dogs)

                       Dose and route: 250 μg ACTH (Synacthen, Ciba) IM
                                  Sample times: 0 and 1 hour


• For cats use 125 μg intravenously, sampling at 0, 60 and 90 minutes




                     Low-dose Dexamethasone Suppression Test (dogs)

            Dose and route: 0.015 mg/kg dexamethasone (Dexadreson, Intervet) IV
                               Sample times: 0, 3 and 8 hours


• For cats use a combined high-dose dexamethasone/ACTH test. Inject 0.1 mg/kg
  dexamethasone intravenously, sample at 0 and 2 hours. Then inject 125 μg ACTH
  intravenously and sample 1 hour later.




                                       TRH Response Test (dogs)

                     Dose and route: 200 μg TRH (Protirelin, Cambridge) IV
                           Sample times: 0, 30 minutes and 4 hours




Protocol for ICU Policy & Procedures
                                                                                  Page 64 of 125
9.2

Subject:                   Treatment of hypoadrenocorticism
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel/Sheila Brennan/Carmel Mooney
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1

•     Take urine and blood for routine haematology, biochemistry and basal cortisol
•     Place intravenous catheter
•     Administer 0.9% saline to correct dehydration and decrease serum K
Fluid rates
                 20 - 40 ml/kg in first 1 - 2 hours
          ↑ to 40 – 80 ml/kg if severely hypovolaemic
•     Inject 250 μg ACTH (Synacthen, Ciba) intramuscularly
•     Take blood for cortisol, Na and K one hour later
•     Infuse hydrocortisone sodium succinate (Solucortef, Pharmacia & Upjohn)
Dose rate: 0.625 mg/kg/hour

•     Alternatively use 0.5 – 2.0 mg/kg dexamethasone (Dexadreson, Intervet)
      intravenously, repeating every 2 - 6 hours
•     Adjust fluid rate to 2 X MR (up to 4 X)
•     Check hydration and K every 1 - 6 hours, adjusting fluid rate as required
•     Check urea and creatinine every 12 - 24 hours
•     Switch to 5% dextrose or 2.5% dextrose (add 50 ml 50% dextrose per L fluids) if blood
      glucose low
•     When tolerated begin oral therapy

          Fludrocortisone acetate (Florinef, Squibb): 15 μg/kg SID
               Prednisolone: 0.5 mg/kg once or divided twice daily

•     Discharge once stable, using fludrocortisone acetate daily and prednisolone (0.2 – 0.5
      mg/kg/day) for times of stress

Adequate fluid therapy is the most important facet of therapy and with mineralo/glucocorticoid
supplementation, other therapies are rarely required




Protocol for ICU Policy & Procedures
                                                                                      Page 65 of 125
9.2 continued/…
Subject:                   Treatment of hypoadrenocorticism


Alternatives for unresponsive hyperkalaemia or life-threatening cardiac arrhythmias

•   Add 5 - 10 ml/kg of 10% glucose (or 1 – 2 ml/kg 50% solution) in fluids and deliver over
    30 - 60 minutes
•   Administer regular insulin (Insuvet Neutral, Schering Plough or Actrapid, Novo Nordisk) at
    a rate of 0.25 - 0.5 iu/kg intravenously. For each unit of insulin administered give 20 ml of
    10% glucose (or 4 ml 50% glucose) to prevent hypoglycaemia. Half should be
    administered as a bolus, with the remainder infused over 6 – 8 hours
•   Administer 1 - 2 mmol/kg sodium bicarbonate intravenously over 5 - 15 minutes
•   Administer 0.5 - 1.0 ml/kg 10% calcium gluconate intravenously over 10 – 20 minutes.
    Continuous ECG recommended. Circulating K unaltered.



Hyperkalaemia - consider
•   Diffuse cell death
•   Increased intake
         • Potassium rich infusions
•   Decreased renal elimination
         • Hypoadrenocorticism
         • Acute renal failure
         • Terminal chronic renal failure
         • Urethral obstruction
         • Lower urinary tract rupture
•   Translocation
         • Metabolic acidosis
•   Pseudohyperkalaemia
         • Thrombocytosis/extreme leucocytosis
         • Stored blood or haemolysis (Akitas)




Protocol for ICU Policy & Procedures
                                                                                        Page 66 of 125
9.3

Subject:                   Treatment of Nelson’s phenomenon
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel/Sheila Brennan/Carmel Mooney
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1



Nelson’s phenomenon
•     Development of neurological signs from a rapidly growing pituitary tumour
•     Develops after starting treatment with mitotane or trilostane
•     Assess response to 0.1 mg/kg dexamethasone intravenously/day until signs disappear,
      then decrease dose
•     Alternatively use prednisolone at 2 mg/kg/day




Protocol for ICU Policy & Procedures
                                                                                 Page 67 of 125
9.4

Subject:                   Treatment of hypoparathyroidism
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel/Sheila Brennan/Carmel Mooney
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1



                 Acute                                  Subacute
Dose             10-15 mg/kg elemental calcium          60-90 mg/kg/day elemental calcium
Route            Slow intravenous injection             Intravenous infusion
Directions       Equivalent to 1.0-1.5 ml/kg            25 ml of 10% calcium gluconate in 250
                 10% calcium gluconate                  ml saline at 2.5 ml/kg/hour
Alternatives     0.2-0.5 ml/kg 10% calcium              Subcutaneous injection of acute dose
                 chloride                               diluted 1:1 in normal saline every 6 to 8
                                                        hours
Precautions      Stop if bradycardia develops           Commence oral therapy concurrently


                                              Chronic
Dose             50-75 mg/kg/day            Dihydrotachysterol
                 elemental calcium
Route            Oral                       Oral
Directions       Equivalent to 125-187      0.03 mg/kg/day
                 mg/kg/day calcium          decreasing to 0.01 mg/kg/day or eod
                 carbonate
Alternatives     400-600 mg/kg/day          10-30 ng/kg/day calcitriol or alfacalcidol decreasing
                 calcium lactate            to 5-10 ng/kg/day
Precautions      Measure serum calcium concentration regularly

(Dihydrotachysterol; AT 10, Intrapharm Laboratories. Calcitriol; Rocaltrol, Roche. Alfacalcidol;
One-alpha, Leo)




Protocol for ICU Policy & Procedures
                                                                                          Page 68 of 125
9.4 continued/…
Subject:                   Treatment of hypoparathyroidism



      Hypocalcaemia - consider
      •     Laboratory error - retest
      •     Sample collection with EDTA
      •     Hypoalbuminaemia
      •     Hypoparathyroidism
      •     Hyperadrenocorticism
      •     Renal failure (chronic and acute)
      •     Nutritional secondary hyperparathyroidism
      •     Eclampsia
      •     Acute pancreatitis
      •     Drug induced (including anticonvulsants)
      •     Hypomagnaseamia
      •     Systemic inflammatory response
      •     Tumour lysis syndrome
      •     Hypercalcitonism (medullary carcinoma)
      •     Ethylene glycol toxicity
      •     Rhabdomyolysis


Patients at risk for hypocalcaemia
    • Cats and dogs post thyroidectomy
    • Cats and dogs post parathyroidectomy (the higher presurgical calcium concentration
       and the more chronic the condition, the higher the risk of post surgical hypocalcaemia
       due to atrophy of the remaining parathyroid glands)
    • Animals on bisphosphonate treatment




    Clinical signs associated with acute onset hypocalcaemia
        • Panting
        • Nervousness
        • Muscle trembling, twitching
        • Leg cramping, pain
        • Ataxia, stiff gait
        • Facial rubbing
        • Focal or generalised seizures
        • Biting of the feet




Protocol for ICU Policy & Procedures
                                                                                     Page 69 of 125
9.5

Subject:                   Treatment of hypercalcaemia
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel/Sheila Brennan/Carmel Mooney
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


To confirm hypercalcaemia preferably measure ionised calcium.


• Fluid diuresis (0.9% saline) at twice maintenance rates (5 ml/kg/hour)
       o hypokalaemia and pulmonary oedema are potential risks
• Frusemide (Lasix, Aventis) intravenous bolus at 5 mg/kg
      o followed by infusion of 5 mg/kg/hour
• Glucocorticoids
      o dexamathasone (Dexadreson, Intervet) intravenously at 0.1 – 0.2 mg/kg BID
• Sodium bicarbonate as a slow intravenous bolus
      o 1 mmol/kg repeated every 10-15 minutes for a maximum of four treatments
      o magnitude of calcium reduction mild
• Calcitonin (Calsynar, Rhone-Poulenc Rorer)
       o 4 – 6 iu/kg BID – TID subcutaneously
       o short-term effect, multiple treatments required
• Plicamycin
       o 25 μg/kg slowly intravenously over 4 – 6 hours once/twice weekly
       o associated with numerous adverse reactions (thrombocytopenia, hepatic necrosis,
         renal failure)
• Bisphosphonates
      o pamidronate disodium (Aredia®, Novartis) at 1.3 mg/kg intravenously over 2 hours
         in 150 ml 0.9% saline (dose applies to cats and dogs). Ensure minimum of pre and
         post diruresis of 4 hours
      o clodronate at 25 mg/kg in 500 ml of saline over 4 hours



Hyercalcaemia - consider
            •    Hyperalbuminaemia
            •    Young age
            •    Malignancy
            •    Hyperparathyroidism
            •    Hypervitaminosis D
            •    Hypoadrenocorticism
            •    Osteolytic bone disease
            •    Renal failure
            •    Disuse osteoporosis
            •    Severe hypothermia
            •    Factitious (lipaemia)




Protocol for ICU Policy & Procedures
                                                                                 Page 70 of 125
9.6

Subject:                   Treatment of diabetic ketoacidosis
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel/Sheila Brennan/Carmel Mooney
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1

• Institute fluid therapy (normal saline) to correct dehydration

                                         Fluid requirements

                               % dehydration x kg body weight x 1000
                                                 +
                                        60 - 65 ml/kg/day
                                                 +
                                         any other losses


• Administer as slowly as possible – fastest recommended is one half over first 2 - 4 hours,
      then the rest over 20 - 22 hours
• Administer 0.2 iu/kg regular insulin (Insuvet Neutral, Schering-Plough; Actrapid, Novo
      Nordisk) intramuscularly
• Measure blood glucose concentrations hourly
• Inject 0.1 iu/kg insulin intramuscularly hourly until blood glucose 10 - 15 mmol/l, usually
      takes 4 to 8 hours
• Switch fluids to 5% dextrose or dextrose saline to maintain glucose as above
• Start subcutaneous insulin injections (0.25 0 0.5 iu/kg) every 6 hours, adjusting dose (0.5
      to 1.0 iu) based on response
• Once animal stable and eating, start lente insulin at the same dose rate as subcutaneous
      regular insulin
• Hypokalaemia likely within first 2 - 12 hours
• Hypophosphataemia can occur within 12 - 24 hours




Protocol for ICU Policy & Procedures
                                                                                     Page 71 of 125
9.7

Subject:                   Treatment of hypokalaemia
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel/Sheila Brennan/Carmel Mooney
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1

• Injectable 15% (1.5 g in 10 ml) solution containing 2 mmol K/ml (Strong KCl Solution,
  Antigen Pharmaceuticals)
• <2.0            - 80 mmol per litre of fluids infused at maintenance rates
• 2.0 - 2.5        - 60 mmol
• 2.5 - 3.0        - 40 mmol (Use this rate if circulating K concentration unknown)
• 3.0 - 3.5        - 30 mmol
• >3.5 - 20 mmol
• Do not exceed 0.5 mmol/kg/hour



Hypokalaemia - consider
      •     Decreased intake
      •     Gastrointestinal loss (vomiting &
            diarrhoea)
      •     Potassium deplete infusions
      •     Chronic renal failure
      •     Renal tubular acidosis
      •     Metabolic alkalosis
      •     Diuretic administration
      •     Diabetic ketoacidosis
      •     Hyperadrenocorticism
      •     Conn’s syndrome
            (hyperaldosteronism)
      •     Factitious (improper sample handling/
            hyperlipidaemia)




Protocol for ICU Policy & Procedures
                                                                                      Page 72 of 125
9.8

Subject:                   Treatment of hypophosphataemia
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel/Sheila Brennan/Carmel Mooney
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


• 0.01 - 0.03 mmol/kg/hour intravenously for 6 hours

• Increase to 0.06 mmol/kg/hour if necessary

• Hypocalcaemia is a possibility



Hypophosphataemia - consider
•     Diabetic ketoacidosis
•     Hyperparathyroidism
•     Hypovitaminosis D
•     Respiratory alkalosis due to hyperventilation
•     Malabsorption
•     Fanconi syndrome
•     Hypothermia




Protocol for ICU Policy & Procedures
                                                                             Page 73 of 125
9.9

Subject:                   Treatment of hypoglycaemia
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Hypoglycaemia is present if serum glucose is less than 3 mmol/l


Treatment

Give 1 vial of Hypostop® if animal awake and able to swallow, feed small meal afterwards if
animal stable. This is the preferred route in animals with insulinoma given that rapid IV
injections of glucose can trigger massive insulin release.
         or
Give 0.5-1 ml/kg of 50% dextrose IV
Dilute 50% dextrose to a 25% solution (1:1) to avoid phlebitis
Bolus can be repeated several times until hypoglycaemia resolved

Follow with fluids containing 2.5-5% glucose

To make 5% glucose solution add 50 ml of glucose 50% to 1,000 ml of crystalloid fluids

Monitor glycaemia after glucose administration and hourly thereafter until glycaemia stable
and every 4-6 hours thereafter.

If hypoglycaemia persists despite appropriate intravenous glucose administration give
glucagon as a constant rate infusion.
Initial dose 5ng/kg/min (can be increased in 5 ng/kg/min increments up to 20 ng/kg/min)


Hypoglycaemia - consider
•     Insulin overdose
•     Insulinoma
•     Starvation/exertional (toy/hunting breeds)
•     Hypoadrencorticism
•     Hepatic failure
•     Diffuse neoplasia
•     Septicaemia
•     Pituitary dwarfism
•     Ethylene glycol toxicity
•     Glycogen storage disease
•     Factitious (polycythaemia/inappropriate
      anticoagulant)




Protocol for ICU Policy & Procedures
                                                                                    Page 74 of 125
9.10

Subject:                   Treatment of insulinoma
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel/Sheila Brennan/Carmel Mooney
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


• If considering insulinoma, measure insulin when blood glucose low (<3.5 mmol/l)
• Serial starved blood glucose samples may be required (can take 24 - 36 hours).
  Alternatively, Fructosamine may indicate chronic hypoglycaemia.

Treatment
• Rub glucose (Hypostop, Bio-diagnostics) onto gums
• Administer a bolus 1.0 ml/kg of 50% (2.0 ml/kg 25%) dextrose intravenously slowly over 10
  minutes
• Maintain on 5.0% dextrose drip
• Frequent feeding
• Diazoxide (Eudemine, Evans) at 10 (not to exceed 60) mg/kg divided twice daily (+
  hydrochlorthiazide at 2 - 4 mg/kg/day)
• Prednisolone at 0.5 mg/kg/day, increasing to 4 – 6 mg/kg/day for response
• Octreotide (Sandostatin, Sandoz) 10 - 20 μg/kg subcutaneously BID
• Surgical debulking
• Streptozotocin
  • pretreatment intravenous fluid diuresis (18.3 ml/kg/hr of 0.9% saline) for 3 hours
  • mix streptozotocin in enough saline to administer 18.3 ml/kg over 2 hours
  • streptozotocin dose of 500 mg/m2
  • post-treatment diuresis for a further 2 hours
  • post-treatment anti-emetic (butorphenol at 0.4 mg/kg im)
  • CBC, renal panel and glucose prior to each treatment
  • CBC at 7-10 days post-treatment for myelosuppression
  • 5 – 7 cycles may be required at 3 weekly intervals but only if hypoglycaemia is not
     resolved




Protocol for ICU Policy & Procedures
                                                                                    Page 75 of 125
9.11

Subject:                   Treatment of hepatic encephalopathy
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1

Policy: to assure adequate treatment of animals with acute and chronic hepatic
encephalopathy

Diagnose                                                      Precipitating factors for HE
Signalment, history, clinical signs
                                                                  •   Anorexia (catabolism)
Check:                                                            •   Dehydration
   • Plasma Ammonia                                               •   Protein rich meal
   • Blood gas                                                    •   Melaena
   • Electrolytes                                                 •   Metabolic alkalosis
   • Glucose                                                      •   Hypokalaemia
   • Rectal exam (melaena ?)                                      •   Formation of ascites

Acute HE
    •    Nothing by mouth
    •    Fluids given intravenously, avoid lactate containing fluids
             o Use: 0.45% saline in 2.5% dextrose with added potassium at a maintenance
                 or 1.5 x maintenance rate
    •    Administer enemas every 6 hours until stable
            o Warm water cleansing enema followed by
            o Retention enema with lactulose (3 parts lactulose in 7 parts water at 20
                ml/kg) instil into colon with a Foley catheter; leave in place for 15 - 20 min
    •    Give Ranitidine (2 mg/kg BID) or Omeprazole (1 - 2 mg/kg SID) and sucralfate 1 g/kg
         TID if evidence of gastrointestinal ulceration
    •    Treat hypoglycaemia aggressively if present (see separate protocol)
    •    Do not use Benzodiazepines for sedation (increased activity of neuronal with
         GABA/diazepin system)

Chronic HE
    •    Protein restricted diet
    •    Lactulose
    •    Dogs     2.5 - 15 ml PO TID (aim for 2 - 3 soft stools per day, reduce if diarrhoea
    •    Cats:    2.5 - 5 ml PO TID
    •    Antibiotics (any of these)
             o Ampicillin ( 20 mg/kg PO TID)
             o Neomycin sulphate (20 mg/kg PO TID)
             o Metronidazole (7.5 mg/kg PO TID)




Protocol for ICU Policy & Procedures
                                                                                          Page 76 of 125
                          10. Haematology




Protocol for ICU Policy & Procedures
                                            Page 77 of 125
    10.1

    Subject:                   Management of suspected thromboembolism in dogs
    Applicable to:             Clinicians, residents, interns, staff, students
    Author:                    Simone Schuller
    Approval:                  ICU work group/Clinical director
    Approval Date:
    Version:                   1


                                             Clinical suspicion



                                           D-Dimer concentration




                  Negative                                                     Positive




               PTE ruled out                              Ask:
                                                             1.    Is D-Dimer concentration > 500 ng/ml ?
                                                             2.    Is there a known disease predilection ?
                                                             3.    Is there significant pulmonary hypertension ?
                                                             4.    Do thoracic radiographs exclude other
                                                                   potential causes of pulmonary hypertension or
                                                                   respiratory disease ?




  Low clinical probability            Intermediate clinical probability             High clinical probability

Affirmative response to 1 in 4          Affirmative response to 2 in 4           Affirmative response to 3-4 in 4
             Or                                       Or                                       Or
   Affirmative response to            Affirmative response to question 1             D-Dimer > 2000 ng/ml
 question 1 and D-Dimer >                and D-Dimer > 1000 ng/ml
     1000 ng/ml, move to
  intermediated probablity
    Known Risk Factors for Thromboembolism in Humans and Dogs




    Protocol for ICU Policy & Procedures
                                                                                                Page 78 of 125
10.1 continued/…
Subject:                    Management of suspected thromboembolism in dogs



 Humans                                       Dogs


 Age (>40 y)                                  Protein-losing disease (nephropathy or
                                              gastrointestinal)

 History of venous thromboembolism            Cancer

 Anesthesia (>30 min)                         Sepsis

 Prolonged immobilization                     Pancreatitis

 Congestive heart failure                     Immune-mediated diseases

 Cerebrovascular accident                     Endogenous, exogenous corticosteroids

 Cancer                                       Vascular diseases (i.e., heartworm)

 Fractures (pelvis, femur or tibia)

 Obesity

 Pregnancy

 Postpartum

 Estrogen therapy

 Steroid therapy

 Inflammatory bowel disease

 Sepsis

 Genetic or acquired thrombophilia

 Genetic or acquired coagulation factor
 deficiency




From: Nelson, OL, JAAHA, 2005




Protocol for ICU Policy & Procedures
                                                                                       Page 79 of 125
10.2

Subject:                   Management of Immune Mediated Thrombocytopenia
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1

•      Handle gently with minimal restraint.
•      Ensure kennel is well padded
•      ALL BLOOD SAMPLES SHOULD BE TAKE FROM A PERIPHERAL VEIN
•      If the animal is anaemic, oxygen therapy and cage rest may be necessary
•      Place an intravenous catheter
           - Perform a manual PCV and TP with blood obtained at catheter placement
•      Obtain blood samples
           - EDTA x 2, lithium heparin, sodium citrate, serum
           - General panel, +/- Coomb’s test, coagulation profile, d-dimer, ANA
•      Commence intravenous fluid therapy

Drug                      Dose                   Considerations
*Glucocorticoids
Dexamethasone             0.2 mg/kg IV           GI side effects possible, give dexamethasone
                                                 instead of prednisolone if oral therapy not
                                                 suitable
Prednisolone              1 mg/kg p.o. q12h      GI side effects, Iatrogenic
                                                 hyperadrenocorticism, Do not suddenly
                                                 discontinue therapy
Additional therapy
*Vincristine              0.02 mg/kg IV          Minimal side effects at this dose
                          (repeated once
                          weekly if required)
*Azathioprine             2 mg/kg p.o. q24h.     Do not split or crush tablets
                          Decrease dose to       NOT useful for initial control
                          q48 after 2 weeks.     GI upset, liver toxicity, myelosuppression
**Cyclophosphamide        50 mg/m2 p.o. or IV    Effect not proven
                          on the first 4 days    Tablets should not be split
                          of each week           Haemorrhagic cystitis
                                                 ensure adequate hydration & urination
                                                 +/- frusemide
                                                 Myelosuppression, GI upset
**Human                   0.5-1.0 g/kg IV over   Expensive
immunoglobulin            6-12 hours             Reserve for non-responsive cases
**Blood transfusion                              Only necessary if severe anaemia with
                                                 associated clinical signs
Other treatments include danazol, chlorambucil
Benefit of these drugs largely unproven
*Routinely concurrently used. ** Reserved for severe, non-responsive cases.
•      PCV should be monitored daily. A full haematology should be performed every 1-2 days
       to assess platelet numbers and for evidence of IMHA.
•      Further diagnostic tests (diagnostic imaging, infectious disease investigations, etc.) may
       be performed once the animal is stable.


Protocol for ICU Policy & Procedures
                                                                                          Page 80 of 125
10.3

Subject:                   Management of Immune Mediated Anaemia
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1



•      If severely or acutely anaemic, provide oxygen therapy, cage rest and avoid stress
•      Place an intravenous catheter
         - Perform a manual PCV and TP with blood obtained at catheter placement
•      Obtain blood samples
         - EDTA x 2, lithium heparin, sodium citrate, serum
         - General panel, Coomb’s test
         - +/- coagulation profile, d-dimer, ANA
•      Perform a slide agglutination test

         Slide agglutination test
         Place one drop of 0.9% saline and 1 drop of EDTA blood on a microscope slide, mix
         gently by tilting the slide
         If positive, visible granularity appears
         Granularity should persist when 1-2 drops of saline are added and slide is rocked
         gently

● Commence intravenous fluid therapy




                                                                         Continued over page/...




Protocol for ICU Policy & Procedures
                                                                                        Page 81 of 125
10.3 continued/…
Subject:                   Management of Immune Mediated Anaemia




Drug                      Dose                   Considerations
*Glucocorticoids
Dexamethasone             0.2 mg/kg IV           GI side effects possible, give dexamethasone
                                                 instead of prednisolone if oral therapy not
                                                 suitable
Prednisolone              1 mg/kg p.o. q12h      GI side effects, Iatrogenic
                                                 hyperadrenocorticism, Do not suddenly
                                                 discontinue therapy
Other immunosuppressive drugs
*Azathioprine     2 mg/kg p.o. q24h.             Do not split or crush tablets
                  Decrease dose to               NOT useful for initial control
                  q48 after 2 weeks.             GI upset, liver toxicity, myelosuppression
**Cyclophosphamide        200 mg/m2 p.o. or      Effect not proven and may negatively effect
                          IV ONCE, or,           survival
                          50 mg/m2 p.o. or IV    Tablets should not be split
                          on the first 4 days    Haemorrhagic cystitis
                          of each week           ensure adequate hydration & urination
                                                 +/- frusemide
                                                 Myelosuppression, GI upset
Additional therapy
**Human                   0.5-1.0 g/kg IV overExpensive
immunoglobulin            6-12 hours          Reserve for non-responsive cases
*Aspirin                0.5 mg/kg/day         Side effects uncommon at this dose
(ultralow dose)                               Higher doses may inhibit prostacyclin, tablet
                                              size may be unsuitable for small patients
**Blood transfusion                           Only given if clinically necessary
**Haemoglobin           30ml/kg IV at rate    Mucous membrane and plasma discoloration
glutamer-200            of 0.5-3.0 ml/kg/h    will occur
(bovine)                (dogs)                Monitor urine output
Other treatments include danazol, cyclosporine, heparin
Benefit of these drugs largely unproven
*Routinely concurrently used. ** Reserved for severe, non-responsive cases.

•     PCV should be monitored daily. A full haematology should be performed every 1-2 days
      to assess regenerative response and platelet numbers.
•     Further diagnostic tests (diagnostic imaging, infectious disease investigations, etc.) may
      be performed once the animal is stable.




Protocol for ICU Policy & Procedures
                                                                                        Page 82 of 125
                        11. Renal disease




Protocol for ICU Policy & Procedures
                                            Page 83 of 125
11.1

Subject:                   Treatment of oliguria/anuria/acute renal failure
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Thurid Freitag/Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Definition: Anuria is the lack of urine production. Oliguria is defined as a UOP of < 1
ml/kg/hr in a well-hydrated animal.


            Obstructive          Urolithiasis, severe glomerulonephritis
Causes                           Acute renal failure, shock, severe dehydration, necrotising
            Nonobstructive
                                 glomerulonephritis, rupture of the bladder, ureters or urethra


Assessment
Clinical: HR, Pulse quality, RR, MM colour & CRT, hydration, BW, MAP, Temperature, check
for abdominal effusions (abdominocentesis, cytology, TP, SG & culture if effusion present).
Monitor hourly after initial assessment; or as indicated by clinician in charge.
Minimum database: Acid-base balance, electrolytes, Urea, Creatinine, PCV, TP, albumin, UA
including SG & sediment


Treatment
1. Place urinary catheter & connect a sterile closed collection system to measure
   output
    •    If urinary obstruction expected, refer to “treatment of urinary tract obstruction /
                  FLUTD”
2. Place IV catheter
3. Start fluid therapy to establish renal perfusion & to correct dehydration
    •    Fluid choice
             o 0.9% NaCl (to avoid/treat hyperkalaemia)
             o CSL once dehydration & electrolyte disturbances corrected
             o 0.45% NaCl + 2.5% dextrose if hypernatraemia
    •    Fluid therapy = Maintenance + Fluid deficits + Ongoing losses + Volume expansion
         ‘push’
           o Maintenance = 2.5 ml/kg/hr
           o Correct fluid deficit over 6 hours
                         ml of fluid (total) =% dehydration x BW x 1000
           o Ongoing losses
                         Estimate hourly losses (ml) from vomiting, diarrhoea, panting
           o Volume expansion push (ml/d) = 3-5% BW (kg) x 1000




Protocol for ICU Policy & Procedures
                                                                                               Page 84 of 125
11.1 continued/...
Subject:                         Treatment of oliguria/anuria/acute renal failure



4. Correct electrolyte disturbances
     •     Hyperkalaemia
            o Ultrasound to confirm absence of bladder rupture - if not present, refer to
                “treatment of hyperkalaemia”. If present, treat hyperkalaemia & bladder rupture
                concurrently
     •     Hypernatraemia
            o Use 0.45% NaCl + 2.5% Dextrose
5. Correct severe acid-base disturbances
     •     See elsewhere
6. Induce Polyuria
     •     If the animal is well hydrated & MAP is > 60 mmHg, systolic BP > 90 mmHg (or CVP
           > 5 mmHg), induce polyuria as indicated below. If MAP <60 mmHg or systolic BP <90
           mmHg, improve BP (see elsewhere). If dehydrated, correct dehydration & reassess
           UOP.
              o Mannitol: 0.5 g/kg as a bolus IV over 15 - 20 min
              o Assess UOP after 1hour & if no response, give 2nd bolus. If response seen,
                  may continue CRI of Mannitol at 1 mg/kg/min. Do not exceed 2 g/kg/day in
                  total. Do not give Mannitol if overhydration is suspected, as this may
                  cause pulmonary oedema.
              o Furosemide: Do not use if suspected aminoglycoside poisoning, otherwise:
                  2 - 12 mg/kg IV bolus. Start with 2 mg/kg IV & if no response after 0.5 - 1 hour,
                  double or triple dose. If response, give 2 - 4 mg/kg QID IV. Alternatively, give
                  CRI at 0.66 mg/kg/hr. Can be given concurrently with Mannitol (different line)
                  and Dopamine.
              o Dopamine 1: CRI at 0.2 - 5 μg/kg/min. Use syringe-pump. Use dopamine diluted
                  in D-5-W, 0.9% NaCl or CSL. Give Dopamine in conjunction with furosemide.
                  Expect tachycardia & ventricular arrhythmia at higher doses. Discontinue
                  dopamine if arrhythmias are seen & continue at lower dose once arrhythmias
                  have resolved.
7.    Once well hydrated, avoid overhydration & pulmonary oedema: “In = Out”
     •     Measure outgoing fluids (“Out”) and calculate fluid rate (“In”) every 4 hours
           accordingly:
             o “Out” per 4 hrs = (UOP/4hrs + 3 ml/kg 2 + estimate in ongoing losses/4 hrs (ml)
             o Fluid rate (ml/hr) = (“Out” per 4 hrs)/4
     •     Also monitor BW – may pick up fluid loss into cavities.
8. Additional Measures
     •     Treat vomiting, potential uraemic gastrointestinal ulcers, stomatitis and pain
           appropriately as indicated elsewhere.


                          TREATMENT IS SUCCESSFUL IF UOP >1-4 ML/HR.




1
  Poor response in cat. Diuresis in cat mainly due to increases in MAP at doses >10μg/kg/min. Care: Tachycardia & ventricular
arrhythmia possible.
2
  Estimated metabolic and respiratory water loss per 4 hours
Protocol for ICU Policy & Procedures
                                                                                                                    Page 85 of 125
       12. Neurologic and
           Neuromuscular Disease




Protocol for ICU Policy & Procedures
                                       Page 86 of 125
12.1


Subject:                   Management of Status epilepticus
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Robert Shiel
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


● Place IV catheter
            o Obtain blood sample (EDTA, lithium heparin, serum) and measure
                      Electrolytes
                      Glucose
                      Blood gases
                      PCV
                      Total proteins
                      Ammonia
            o Submit for full CBC, biochemistry, serum bile acids and                         serum
                phenobarbitone concentration if animal on treatment
            o If abnormality detected follow relevant protocol

•   Administer Diazepam (Diazemuls®) at 0.5 - 1 mg/kg IV
•   (maximum dose 20 mg)
•   maximum of 3 doses every 5 - 10 minutes
•   Repeat only if effective but seizures recur
•   Administer rectally at 0.5 - 2.0 mg/kg if unable to obtain IV access

● If seizures not controlled administer phenobarbitone
         o 4 - 5 mg/kg IV every 30 minutes for four doses (if not receiving oral
            phenobarbitone)
         o Each 4.5 mg/kg dose increases serum concentration by 7.5 μg/ml
         o Thus, 4 doses will achieve mid therapeutic range
         o If receiving oral phenobarbitone, do not exceed total daily dose of 24 mg/kg
         o If seizures continue, continuous rate infusion (CRI) may be commenced

       Drug                              CRI rate              Formulation      CRI rate
                                         (mg/kg/h)             (mg/ml)          (ml/kg/h)
       Phenobarbitone*                   1                     60               0.016
       Propofol                          6 - 30                10               0.6 – 3
       Diazepam                          0.1 - 2               5                0.02 - 0.4
    * Phenobarbitone is the first choice for CRI in uncontrolled status epilepticus

● Monitor:
       - Rectal temperature (cool if > 39.2 °C)
       - Level of consciousness
       - Record number of seizures, duration and time of occurrence Intubation may be
           necessary if ventilation is inadequate
       - If signs of cerebral oedema
                  o Mannitol 1 g/kg IV over 15 minutes
                  o Methylprednisolone sodium succinate 30 mg/kg IV or
                  o Dexamethasone sodium phosphate 1 mg/kg IV

● Oral therapy (phenobarbitone +/- KBr) should be commenced once stable




Protocol for ICU Policy & Procedures
                                                                                             Page 87 of 125
   12.2

   Subject:                   Management of head trauma
   Applicable to:             Clinicians, residents, interns, staff, students
   Author:                    Robert Shiel
   Approval:                  ICU work group/Clinical director
   Approval Date:
   Version:                   1

        •     Assess for severe injury e.g. internal haemorrhage, shock, diaphragmatic rupture and
              treat as appropriate. Spinal trauma may also be present.
        •     Position patient
        •     30o angle with head elevated
        •     Do not flex neck
        •     Do not take jugular blood samples
        •     Place intravenous catheter
        •     Obtain arterial (preferably) blood sample
        •     Depending on severity, the following monitoring may be necessary:
              - Modified Glasgow Coma Scale
                       o 1. Level of consciousness
                       o 2. Brainstem reflexes
                       o 3. Motor activity / posture
              - Blood Pressure, heart rate and rhythm, PCO2, PO2, pulse oximetry, rectal
                  temperature, electrolytes, blood glucose concentration

     Treatment               Indication                  Dose                           Consideration

Hypertonic saline       Elevated ICP.         4-5 ml/kg over 3-5           Monitor electrolytes.
                                              minutes.                     Monitor hydration status.
                                              Repeat if necessary but      May need to follow with colloids.
                                              monitor for adverse
                                              effects.                     Effects only last up to 1 hour.

Mannitol                Elevated ICP          0.25-1 g/kg over 15 mins     Monitor hydration.
                                              Repeat if necessary          Monitor electrolytes.
                                              But monitor for adverse      Monitor blood pressure.
                                              effects.                     Effect lasts 2-5 hours.
                                                                           Concurrent frusemide (0.7 mg/kg) may be
                                                                           synergistic.
Fluid therapy           Prevent cerebral      Colloids / crystalloids at   Hypovolaemia will cause reduced cerebral
                        hypoperfusion.        dose to maintain             perfusion and contribute to brain injury.
                        Treatment of shock    normovolaemia.                Monitor hydration, blood pressure and
                                                                           electrolytes.
Oxygen                  Prevent hypoxia       Maintain                     Supplement oxygen. Intubation and IPPV
                                              SPO2 > 95% &                 may be necessary.
                                              PO2 > 80 mmHg
Ventilation             Prevent hypercarbia   Maintain                     Avoid hyperventilation as may lead to
                                              PCO2 30-40 mmHg              vasoconstriction and hypoxia
Glucocorticoids         Not indicated                       -              No proven benefit but many adverse
                                                                           effects
Phenobarbitone          Seizures              2 mg/kg IV q6-8 hours        Monitor blood pressure and respiratory
                                                                           function




   Protocol for ICU Policy & Procedures
                                                                                                 Page 88 of 125
12.3

Subject:                   Management of Tetanus
Applicable to:             Clinicians, residents, interns, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To assure appropriate treatment of animals with tetanus

Tetanus is caused by a neurotoxin (tetanospasmin) formed during the vegetative growth of
Clostridium tenani. Binding of tetanospasmin to the presynaptic membrane of inhibitory neurons
results in inhibition of release of inhibitory glycin and GABA leading to overexcitability, muscle
spasms and autonomic dysfunction. Tetanus can occur in a localised or generalised form. Early
treatment is crucial.

1. Identify entrance point: skin wound (may have healed up), genital infections (pyometra,
   ovariohysterectomy, miscarriage). Perform wound debridement as soon as animal stable
   enough for a general anaesthesia.

2. Tetanus antitoxin (equine or human) IV administration is superior to IM or SC
   administration but can lead to anaphylaxis. This is a single dose treatment. Do not repeat.
   a) Administer diphenhydramine prophylactically:
   b) Prepare Adrenaline       0.1 ml/kg (diluted 1:10,000) for IV injection
   c) Administer Tetanus antitoxin (100 – 1,000 U/kg – maximal total dose 20,000 U) over 10
       - 20 min. Remain vigilant. If anaphylaxis develops stop infusion immediately and
       administer adrenaline.

3. Metronidazole: Cats and dogs:15 mg/kg IV BID

4. Keep animal in a quiet and dark room. Plug ears. Treat hyperexcitablility and muscle
   spasms as required.
   a) Hyperexcitability:      Azepromazine            0.02 mg/kg q8h
   b) Convulsions:            Phenobarbitone          1 - 4 mg/kg q6-12h
   c) Muscle spasms:          Diazepam                0.1 - 0.2 mg/kg IM q2-4h

5. Assure proper nursing care: nutritional support, tender loving care, soft bedding, regular
   turning, bladder emptying, management of constipation

6. Monitor for: muscle spasms, hypoventilation, hyperthermia, hyper- or hypotension, cardiac
   arrhythmias (brady- or tachyarrhythmias), oesophageal dysfunction (including hiatal
   hernia), urinary retention and constipation, aspiration pneumonia

                           Source: Green, Infectious diseases in dogs and cats, p. 402




Protocol for ICU Policy & Procedures
                                                                                         Page 89 of 125
                       13. Analgesia and
                          Anaesthesia




Protocol for ICU Policy & Procedures
                                           Page 90 of 125
13.1

Subject:                   Pain monitoring
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To continuously ensure adequate pain-relief

1. All ICU patients will be assessed hourly for pain.

2. Assessment of pain will include the following parameters:
      a.       Heart rate
      b.       Respiratory rate
      c.       Temperature
      d.       Blood pressure when ordered
      e.       Vocalization
      f.       Inability to rest or sleep
      g.       Unwillingness to move
      h.       Agitation
      i.       Aggression
      j.       Abnormal posture
      k.       Depression
      l.       Trembling
      m.       Inappetence
      n.       Whether or not a potentially painful procedure has occurred

All of these parameters will be weighed equally. Pain medications should not be withheld in
case of doubt.

For guidance and reporting, see Pain Scale, annex 12


OVERSIGHT/FOLLOW THROUGH:
ICU clinician/nurse is responsible for assuring adherence to this policy.




Protocol for ICU Policy & Procedures
                                                                                   Page 91 of 125
13.2

Subject:                   Propofol constant rate infusion
Applicable to:             Clinicians, staff, students
Author:                    Ian Self, Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To assure adequate use of Propofol® as a constant rate infusion

Indications:

    o    Mechanical ventilation
    o    Status epilepticus that does not respond to bolus injection of diazepam or
         phenobarbitone


Dosage

• Routine maintenance
• Dogs
          o Boluses of ¼ to ⅓ of the original induction dose (range = 4 - 6 mg/kg) as
              needed
          o CRI at 0.2 - 0.4 mg/kg/minute
          o If too light, give 0.5 - 1.0 mg/kg IV then increase CRI rate by 25%
          o If too deep, stop Propofol until suitable anesthetic level is reached, then
              reinitiate CRI at 25% lower rate
• Cats
          o Boluses of ¼ to ⅓ of the original induction dose as needed
          o CRI at 0.05 mg/kg/minute
          o If too light, give 0.5 mg/kg IV then increase CRI rate by 25%
          o If too deep, stop Propofol until suitable anesthetic level is reached, then
              reinitiate CRI at 25% lower rate
          o Feline patients do not clear Propofol well
          o Subsequent boluses or ongoing CRI doses should be adjusted downward
              over time
          o Recovery will be more prolonged than with dogs




Protocol for ICU Policy & Procedures
                                                                               Page 92 of 125
13.3

Subject:                   Fentanyl constant rate infusion
Applicable to:             Clinicians, staff, students
Author:                    Ian Self
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To assure adequate use of Fentanyl® as a constant rate infusion


Dosage

FENTANYL – 0.02 to 0.06 μg/kg/minute (0.0012 - 0.0036 mg/kg/hr).

Fentanyl’s duration of effect is only about 30 minutes. Undesirable effects will not linger as
long as when morphine is used.

If no previous mu-agonist has been given, administer 0.003 mg/kg of Fentanyl IM or IV to
rapidly achieve initial therapeutic blood levels.

Given the volume of Fentanyl this is, a similar volume of the diluent should be removed before
any other drugs are added.




Protocol for ICU Policy & Procedures
                                                                                      Page 93 of 125
13.4

Subject:                   Use of fentanyl patches in dogs and cats
Applicable to:             Clinicians, staff, students
Author:                    Valentina Andreoni and Ella West
Approval:                  Lynne Hughes
Approval Date:
Version:                   1


Skin preparation
•    Clip the area (e.g. lateral thorax, dorsal neck region). Avoid infected, inflamed or
     scarred skin.
•    Do not shave skin with razor blade
•    Do not use any detergent or alcohol to prep the area. Water may be used, but the skin
     must be dried.

Placement of the patch
•    Wear non-sterile gloves; the adherent layer contains fentanyl which can be absorbed by
     the operator’s skin.
•    Open the foil packet and remove protective covers from the patch
•    Do not cut the patch and do not fold it; to adjust the patch size leave a portion of the
     backing cover in place.
•    Place the patch with the adhesive layer towards the skin
•    Hold in place firmly with your hand for two minutes
•    Write on the patch: dose, date and time
•    Cover with a non adherent bandage such as Soffban and Vetwrap, allowing the patch to
     move with the skin
•    Label the bandage
•    Consider a Buster collar to prevent the patient reaching the patch

Patch management
•    Supplement analgesia until the patch is effective (use pure mu opioid agonists only e.g.
     morphine or pethidine)
•    Check the patch and assess analgesia every day
•    Do not place heated beds or lamps near the patient
•    Used patches should be cut and flushed down the toilet or sluice

                                              Dog                            Cat
 Dose                                         2 - 4 µg/kg/h                  4 µg/kg/h
 Onset                                        12 - 24 hrs                    6 - 12 hrs
 Duration                                     72 hrs                         72 - 100 hrs
 Persistence of plasma concentration after    3 - 6 hrs                      12 - 24 hrs
 patch removal
 Application of a new patch                   At 60 hrs.                     At the same time as removal
                                              Remove the old one at 72 hrs   of the old patch

Potential side effects:
•   Skin irritation                                 •     Sedation
•   Hyperthermia                                    •     Respiratory depression
•   Bradycardia                                     •     Euphoria

Contraindications:
•   Infected, inflamed or scarred skin.            •      Bradycardia
•   Resp. depression not caused by pain            •      Hepatic and renal disease
•   Raised intracranial pressure                   •      Pyrex




Protocol for ICU Policy & Procedures
                                                                                       Page 94 of 125
13.5

Subject:                   Constant rate infusion various analgesics
Applicable to:             Clinicians, staff, students
Author:                    Ian Self
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1

KETAMINE (100 mg/ml)

Dosage: 2 to 20 μg/kg/minute (0.12 - 1.2 mg/kg/hr).

An initial 0.25 - 0.50 mg/kg IV bolus is given to rapidly achieve initial therapeutic blood levels
of the drug (while the CRI is intended to maintain, or very slowly increase, blood levels).
Failure to administer this "loading" dose will result in an excessive delay in the drug reaching
therapeutic levels.
 2 to 20 μg/kg/min = 0.002 to 0.020 mg/kg/min.

MORPHINE (10 mg/ml)

Dosage: 2 to 6 μg/kg/minute (0.12 - 0.36 mg/kg/hr).

If no previous mu-agonist has been given, administer 0.5 mg/kg of Morphine IM (or very
slowly IV) to rapidly achieve initial therapeutic blood levels.
Morphine is light sensitive. Make sure the syringe or IV bag is covered to protect the
morphine from light when using long-term morphine CRIs.
2 to 6 μg/kg/min = 0.002 to 0.006 mg/kg/min.

LIDOCAINE (20 mg/ml)

Dosage: 10 to 50 μg/kg/minute (0.6 to 3.0 mg/kg/hr).

An initial 1 mg/kg IV bolus is given to rapidly achieve initial therapeutic blood levels. Given the
volume of 2% Lidocaine this is, a similar volume of the diluent should be removed BEFORE
any other drugs are added.
Lidocaine is light sensitive too. Make sure the syringe or IV bag is covered to protect the
Lidocaine from light when using long-term Lidocaine CRIs.
10 to 50 μg/kg/min = 0.010 to 0.050 mg/kg/min.


GENERAL INFORMATION
•      All three drugs are used routinely in dogs and in any combination.
•      Cats - the routine use of morphine CRIs in cats is not common. But it can be an
       effective option if the feline patient is monitored closely for dysphoric trends. Always
       start at the low end of the opioid CRI dose range.
•      Cats - until more data is obtained, Lidocaine’s use in cats cannot be recommended, due
       to potential toxicity issues. If it is used in cats, do not exceed 10 μg/kg/minute, and
       monitor carefully for seizure activity and cardiac abnormalities (bradycardia).
•      10 μg/kg/min = 0.010 mg/kg/min. Ketamine/morphine/saline solutions have been shown
       to be stable for at least 4 days.




Protocol for ICU Policy & Procedures
                                                                                          Page 95 of 125
13.6

Subject:                   Ketamine CRI for dogs and cats
Applicable to:             Clinicians, staff, students
Author:                    Ian Self
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


This simple recipe is based on routine supportive fluid rates of 10 to 20 ml/kg/hr.

This is the recommended starting recipe for those new to CRI analgesics.
The following recipe can be used in dogs and cats.

KETAMINE: Add 60 mg ketamine (0.6 ml) to 1,000 ml fluids
Deliver at normal anesthesia supportive fluid rate of 10 ml/kg/hr = 10 μg/kg/min or 0.6
mg/kg/hr.

GENERAL INFORMATION
•      Rate can be doubled to 20 ml/kg/hr to deliver 20 μg/kg/min.
•      If higher fluid rates are needed, add a second fluid line to meet the patient’s need.
•      Remember the loading dose requirement detailed above.
•      This recipe assumes that the ketamine concentration is 100 mg/ml.




Protocol for ICU Policy & Procedures
                                                                                          Page 96 of 125
13.7

Subject:                   Morphine-Ketamine CRI for dogs and cats
Applicable to:             Clinicians, staff, students
Author:                    Ian Self
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1



This simple recipe is based on a 1 ml of the final dilution/kg/hr fluid rate.
The following recipe can be used in dogs and cats.


KETAMINE: 60 mg/500 ml = 0.6 ml/500 ml diluent = 1.2 ml/1,000 ml diluent
•   Deliver at 1ml/kg/hr fluid rate = 2 μg/kg/min or 0.12 mg/kg/hr
•   This recipe assumes that the ketamine concentration is 100 mg/ml.


MORPHINE: 60 mg/500 ml = 6 ml/500ml = 12 ml/1,000 ml
•  Deliver at 1ml/kg/hr fluid rate = 2 μg/kg/min or 0.12 mg/kg/hr
•  This recipe assumes that the morphine concentration is 10 mg/ml.



GENERAL INFORMATION
•   It’s easy then to just enter the patient's wt (in kg) in the infusion pump for the proper
    initial fluid rate.
•   Dogs – fluid rates can be increased up to 3 ml/kg/hr without exceeding the dosage
    guidelines for either of the drugs.
•   Cats – fluid rates can be increased up to 3 ml/kg/hr but may cause unwanted dysphoria
    in awake feline patients. Monitor closely and reduce rate if dysphoria occurs.

•      To substitute fentanyl for morphine at a dose equipotent to the morphine dose above
       add:



FENTANYL (0.05 mg/ml): 0.6 mg/500 ml = 12 ml/500 ml diluent = 24 ml/1,000 ml diluent.
•   Deliver at 1ml/kg/hr fluid rate = 0.02 μg/kg/min or 0.0012 mg/kg/hr
•   Given the volume of fentanyl this is, a similar volume of the diluent should be removed
    before any other drugs are added.
•   For dogs, the fluid rate can be increased up to 3 ml/kg/hr as noted above.
•   Remember the loading dose requirements detailed above.




Protocol for ICU Policy & Procedures
                                                                                     Page 97 of 125
13.8

Subject:                   Morphine-Ketamine-Lidocaine CRI for dogs
Applicable to:             Clinicians, staff, students
Author:                    Ian Self
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1

This simple recipe is based on a 1 ml of the final dilution/kg/hr fluid rate.
The following three drugs can be used in any combination for dogs.


KETAMINE: 60 mg/500 ml = 0.6 ml/500 ml diluent = 1.2 ml/1,000 ml diluent
•   Deliver at 1ml/kg/hr fluid rate = 2 μg/kg/min or 0.12 mg/kg/hr
•   This recipe assumes that the ketamine concentration is 100 mg/ml.


MORPHINE: 60 mg/500 ml = 6 ml/500ml diluent = 12 ml/1,000 ml diluent
•  Deliver at 1ml/kg/hr fluid rate = 2 μg/kg/min or 0.12 mg/kg/hr
•  This recipe assumes that the morphine concentration is 10 mg/ml.


LIDOCAINE: 500 mg/500 ml = 25 ml/500 ml diluent = 50 ml/1,000 ml diluent
•   Deliver at 1ml/kg/hr fluid rate = 17 μg/kg/min or 1.0 mg/kg/hr
•   This recipe assumes that the Lidocaine concentration is 20 mg/ml.


GENERAL INFORMATION
•   Just enter the patient's weight (in kg) in the infusion pump for the proper initial fluid rate.
•   Don’t forget to remove a volume equal to the Lidocaine volume from the diluent bag
    before adding any of the drugs planned for the CRI.
•   Remember the loading dose requirements detailed above.
•   Dogs – fluid rates can be increased up to 3 ml/kg/hr without exceeding the dosage
    guidelines for any of the drugs (irrespective of the drug combinations).
•   Cats - until more data is obtained, Lidocaine’s use in cats cannot be recommended, due
    to potential toxicity issues. If it is used in cats, do not exceed 10 μg/kg/minute, and
    monitor carefully for seizure activity and cardiac depression (bradycardia, hypotension).


LIDOCAINE (20 mg/ml): 300 mg/500 ml diluent = 15 ml/500 ml diluent = 30 ml/1,000 ml
diluent
•     Deliver at 1ml/kg/hr fluid rate = 10 μg/kg/min or 0.6 mg/kg/hr
•     To substitute fentanyl for morphine at a dose equipotent to the morphine dose above,
      add:


FENTANYL (0.05 mg/ml): 0.6 mg/500 ml = 12 ml/500 ml diluent = 24 ml/1,000 ml diluent.
•   Deliver at 1ml/kg/hr fluid rate = 0.02 μg/kg/min or 0.0012 mg/kg/hr
•   Given the volume of fentanyl this is, a similar volume of the diluent should be removed
    before any other drugs are added.
•   For dogs, the fluid rate can be increased up to 3 ml/kg/hr as noted above.




Protocol for ICU Policy & Procedures
                                                                                          Page 98 of 125
13.9

Subject:                   Other analgesics
Applicable to:             Clinicians, staff, students
Author:                    Ian Self
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1

Opioids

Adverse effects
• Respiratory depression (fentanyl, alfentanyl).
• Bradycardia (morphine) tachycardia (fentanyl).
• Vomiting (morphine) and diarrhoea (sometimes).
• Constipation with chronic use.
• Tolerance.

Morphine
• Cheap and effective.
• Dose – 0.1 - 0.5 mg/kg dogs, 0.1 - 0.2 mg/kg cats
• IV, IM, SC, articular, epidural, spinal.
• Lasts 4 to 6 hours. 24 hours epidural. 20 min onset.
• Bradycardia, vomit, histamine release IV.

Pethidine
•    Less effective than morphine for severe pain.
•    Dose 3 – 5 mg/kg IM.
•    NOT IV – histamine release.
•    Lasts 1 - 2 hours, same onset. Maintains heart rate.

Fentanyl
•    Ultra-potent, short duration, IV or skin patches – skin patch dose 2-4 μg/kg/hr.; IV dose
     up to 10 μg/kg (respiratory depression)
•    Lasts 30 min (patches 3 days in dogs, 4 - 5 in cats), onset 2 min after IV
     injection.Severe respiratory depression/bradycardia.

Buprenorphine
•   Partial agonist – mild pain only but better in cats.
•   Lasts 6-8 hours, takes 45 minutes to start working.
•   to 0.02 mg/kg intravenous or intramuscular two to four times per day
•   Hypnorm reversal?

Butorphanol
•    Mixed agonist-antagonist for mild pain.
•    Various routes of administration.
•    Dose 0.1 - 0.2 mg/kg.
•    ONLY ANALGESIC FOR 10 - 30 MINUTES!!
•    Sedation good for up to 6 hours. Good cough suppressant.




Protocol for ICU Policy & Procedures
                                                                                      Page 99 of 125
13.9 continued/...
Subject:                   Other analgesics


NSAIDs – Non-steroidal Anti-inflammatory Drugs

Adverse effects
• G.I.T. ulceration.
• Renal failure.
• Clotting problems – affect platelet aggregation.
• Cats VERY sensitive to harmful effects.
• Under GA – maintain BP (fluids) and only use carprofen/meloxicam.
• DO NOT give with steroids.

Carprofen
• IV, SC or PO. No cat long-term licences but can be used in dogs.
• Lasts 24 hours. Quite safe. COX 2 inhibitor.

Meloxicam
•   SC or PO. Same problems in cats but? Safer??
•   Dose initially = 0.2 mg/kg SC/IV in dogs.
•   Also used in small furries.
•   Similar clinically to carprofen.


Other Analgesic Agents

Ketamine
•   Good for burns and ‘phantom-limb pain’.
•   See CRI doses.
•   Repeat dosing or infusion.
•   Prevent ‘wind-up’ via NMDA receptors.

Medetomidine
•   Good visceral analgesia.
•   Epidural.


Local Anaesthetic Drugs

Lidocaine
•    Lasts 2 hours, starts working immediately but square on-off profile. Sometimes used
     with adrenaline.
•    Toxic dose in dogs = 10 mg/kg, cats 4mg/kg.
•    Also used at lower dose 2 mg/kg to treat cardiac arrhythmias – particularly ventricular
     fibrillation.

Bupivicaine
•    Lasts 6 hours but 30 minutes to start working.
•    DO NOT USE IV – max dose in dogs 2mg/kg.




Protocol for ICU Policy & Procedures
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                14. Cardiac conditions




Protocol for ICU Policy & Procedures
                                         Page 101 of 125
    14.1

    Subject:                   Treatment of congestive heart failure patients
    Applicable to:             Clinicians, staff, students
    Author:                    Robert Shiel
    Approval:                  ICU work group/Clinical director
    Approval Date:
    Version:                   1

    Treatment of fulminant congestive heart failure

    ● Do not stress animal. Handle with minimal restraint
    ● Provide Oxygen by face mask, intranasal tube or kennel
    ● Frusemide (Dimazon)
        o 4 - 8 mg/kg (dog); 2 - 4mg (cat)
        o Onset of action 5 minutes, peak effect 30 minutes
        o IV if possible (without excessive stress), otherwise IM
        o Repeat if inadequate response up to every 30-60 minutes
        o Treatment, if effective, should lead to a reduction in respiratory rate
    ● Glyceryl trinitrate (Percutol)
        o Apply 1/8 (small cat) to 2 (large dog) inches to inner pinna or thigh
        o Label the record and cage door with notice of drug used and site of application
        o Apply buster collar if necessary to prevent licking
    ● Place an IV catheter if it can be placed without undue stress
    ● Monitor:
       • Respiratory and heart rates
       • Mucous membrane colour and capillary refill time
       • Heart and lung sounds
       • Hydration status
       • Heart and lung auscultation
       • ECG (if arrhythmia present)
       • Do not exacerbate stress by excessive monitoring
    ● Once stable, further diagnostic tests (imaging, clinical pathology) can be performed
    ● Maintenance therapy will be dependent on the underlying disease process
    Drug                  Dose               Indications                         Contraindications /
                                                                                 Considerations
    Frusemide             2 mg/kg p.o.       Congestive heart failure            Dose may be increased if
    (Lasix) (c,d)         q12h (d)                                               necessary
                          1mg/kg p.o. q12h                                       Monitor potassium and hydration
                          (c)                                                    status
    Spironolactone        2-4 mg/kg p.o.     Congestive heart failure            Added if frusemide alone
    (Aldactone) (d)       q24h               Ascites                             unsuccessful
    Benazepril            0.25-5 mg/kg       Cardiac disease                     Monitor renal parameters in
    (Fortekor) (d)        p.o. q12h          Hypertension                        azotaemic animals
    Pimobendan            0.1-0.3 mg/kg      Congestive heart failure            Do NOT use if HCM present
    (Vetmedin) (d)        p.o. q12h          DCM                                 Give tablet at least 1h after feeding
    Diltiazem             1.5-2.5 mg/kg      HCM                                 May decompensate after
    (Hypercard) (c)       q8h                                                    introduction
    Atenolol              6.25-12.5 mg/cat   HCM                                 May decompensate after
    (Atecor) (c)          q24h               Preferred to propanolol in feline   introduction
                                             asthma
    Propranolol           2.5-5 mg/cat q8h   HCM                                 May decompensate after
    (Inderal) (c)                                                                introduction.
                                                                                  Do not use in asthmatics
    Aspirin (c)           75 mg/cat q72h     Prevention of thromboembolic        Minimal side effects at this dose
                                             disease

•       Commonly used drugs for the treatment of heart failure in the UVH.
•       Antiarrhythmic medications have not been included.
•       Treatments (other than frusemide and glycerol trinitrate) will take from several hours to
        several days to exert their effect.


    Protocol for ICU Policy & Procedures
                                                                                                 Page 102 of 125
14.2

Subject:                   Pericardiocentesis
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to assure adequate management of animals with pericardial effusions

Presence of pericardial fluid facilitates viusalisation of intrapericardial tumours. Therefore
echocardiographic assessment before drainage is preferable. However, if no
ultrasonographist is available and the animal is showing signs of cardiac tamponade,
pericardiocentesis has to be performed immediately.

Materials
   • Pericardiocentesis needle
   • Cotton balls soaked with Hibiscrub®
   • Cotton balls soaked with alcohol
   • 2% Lidocaine
   • Clippers
   • One-way valve
   • Extension set
   • Kidney dish
   • EDTA and Serum tubes for sample collection
   • Crash trolley in case of cardiac arrest

Procedure
   1. Mild sedation may be performed if blood pressure is stable. IV fluids should be
       administered should hypotension develop after sedation.
   2. (Acepromacine 0.025 mg/kg IM; Buprenorphine 0.005 mg/kg IM).
   3. Place patient in dorsal recumbency, slightly oblique to the left.
   4. ECG leads are attached.
   5. Clip right lateral chest wall.
   6. Find adequate drainage site (either 5th intercostals space at costochondral junction or
       echographically guided).
   7. Inject Lidocaine so as to block skin, subcutaneous tissue and pleura.
   8. Make small skin incision.
   9. Advance catheter through skin incision, along the cranial border of the 5th rib through
       the pleural space into the pericardium.
   10. ECG is monitored for extrasystoles in case the heart is pricked with the catheter.
   11. Once the pericardial space in entered, fluid enters the catheter lumen.
   12. Collect fluid for cytology and culture and fill one serum tube to monitor for clotting.
   13. If blood does not clot (meaning that it does not come from a blood vessel or the
       cardiac chambers), drain as much fluid as possible.
   14. After drainage remove catheter, place suture on skin incision if necessary.




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               15. Postoperative care




Protocol for ICU Policy & Procedures
                                        Page 104 of 125
15.1

Subject:                   Parathyroidectomy
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: to ensure           adequate    postoperative     management       of   animals   after
parathyroidectomy

Normal parayhyroid glands atrophy if their function has been suppressed for prolonged
periods due to autonomous secretion of PTH of abnormal parathyroid tissue (parathyroid
adenoma, hyperplasia, carcinoma). Surgical removal or ablation of this source for PTH results
in a rapid decline in circulating PTH and a corresponding decline in serum calcium
concentrations.

Clinically significant postoperative hypocalcaemia develops in about 30% of animals typically
1 - 7 days post-surgery or ablation. The more chronic and the higher hypercalcaemia the
more likely hypocalcaemia is to occur post-surgery.


Post operative management

-   Keep animals quiet as tetany is more likely to occur during activity
-   Monitor animal closely for signs suggestive of hypocalcaemia (see box)
-   Monitor ionised calcium once or twice daily for 3 - 7 days
-   Start treatment with Vit D (0.05 μg/kg; One Alpha®) and oral Calcium carbonate if
             o ionised calcium is below 0.8 mmol/l
             o clinical signs consistent with hypocalcaemia develop

-   Goal: avoid clinical signs of hypocalcaemia while keeping calcium low enough to
    stimulate recovery of function in atrophied parathyroid glands




            Clinical signs associated with acute
            onset hypocalcaemia
                • Panting
                • Nervousness
                • Muscle trembling, twitching
                • Leg cramping, pain
                • Ataxia, stiff gait
                • Facial rubbing
                • Focal or generalised seizures
                • Biting of the feet




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                     16. General wound
                        management




Protocol for ICU Policy & Procedures
                                         Page 106 of 125
16.

Subject:                   General wound management
Applicable to:             Clinicians, staff, students
Author:                    Pre-existing protocol
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Wounds will be checked for gross inflammation, discharge and missing sutures. Any
abnormalities noted will be recorded and reported to the clinician in charge.

Dressings will be checked regularly in order to assure that they are clean, dry and in place.

Bandages likely to become wet during walks will be covered with plastic bags before the
patient is taken outside.

Soiled dressings or dressings with strike through will be replaced immediately unless
particular orders have been given by the primary clinician not to do so.
All consumables used have to be recorded on consumable sheet.


Open wounds
•     Daily wound management of open wounds is performed under strict asepsis.
•     Sterile irrigation solution, sterile bowl, syringes and gloves are required.
•     All irrigation solutions must be warmed before application




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                         17. Management of
                            intoxications




Protocol for ICU Policy & Procedures
                                             Page 108 of 125
17.1

Subject:                   Management ethylene glycol intoxiaction
Applicable to:             Clinicians, staff, students
Author:                    Simone Schuller
Approval:                  ICU work group/Clinical director
Approval Date:
Version:                   1


Policy: To ensure adequate management of patients with suspected or confirmed
ethylene glycol intoxication


Apply this protocol if there is: Evidence of toxin ingestion or evidence of renal failure with
either of the following: presence of severe hypocalcaemia, ion gap metabolic acidosis and
calcium oxalate crystalluria


Recent ingestion:

    1. Induce emesis
    2. Administer charcoal and cathartics

Ingestion 8 - 12 hours previously

    1. Administer ethanol or fomepizole (4-methyl-pyrazole):

         Ethanol (dogs and cats)
            •     IV CRI of 20% solution in saline at a dose of 5 - 5.5 ml/kg q6h for 5 - 6
                  treatments. Titrate dose to obtain mild CNS depression but not semicoma.

         Fomepizole (dogs only, not effective in cats)
            •   Slow IV bolus injection, 20 mg/kg initially, followed by 15 mg/kg at 12 hours
                and 24 hours and then 5 mg/kg at 36 hours.

    2. Treat aggressively for acute renal failure (see separate protocol)

    3. Periotoneal dialysis should be considered if animal oliguric, because toxin may be
       removed from the organism by this route, thus potentially avoiding renal damage.




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                                       Annexes




Protocol for ICU Policy & Procedures
                                                 Page 110 of 125
Annex 1: Dilution chart for Trigene® cleaning solution




Protocol for ICU Policy & Procedures
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Drug drawer
Drug                  Commercial name             Indication                          Quantity/Comments
Adrenaline            Adrenaline® 1 mg/ml         Asystole                            1 box 10 vials
Atropine sulphate     Atropine® 600μg/ml          Asystole, bradycardia               1 box 10 vials
Diazepam              Diazemuls® 5 mg/ml          Convulsions, provides sedation      1 box 10 vials; required
                                                  and muscle relaxation               to be kept locked away
Doxapram              Doxapram® 20 mg/ml          Respiratory depression              1 bottle 10 ml
Lidocaine             Lidocaine® 100 mg/ml        Ventricular premature complexes     1 box
hydrochloride 1%
Naloxone              Naloxone® 0.4 mg/ml         Opoid reversal                      1 box 3 vials; not
                                                                                      licenced; hold off
Propofol              Rapinovet® 10 mg/ml         Convulsions, GA for intubations     1 vial 20 ml
Furosemide            Dimazon® 50 mg/ml           Pulmonary oedema, volume            10 ml
                                                  overload, anuria, oliguria
Methylprednisolone    Solu-Medrol® 500 mg, 1000   Head and spinal cord trauma         1 each
sodium succinate      mg 500 mg or1000mg/8 ml
Dexamethasone         Colvasone® 2 mg/ml          Cerebral oedema                     1 vial
sodium phosphate
Dobutamine            Dobutamine® 12.5 mg/ml      Myocardial failure                  Licensed form not yet
                                                                                      available
Dopamine              Dopamine® 40 mg/ml          Hypotension, anuria, oliguria       1 vial
50% Glucose           50 g/100 ml                 Hypoglycaemia, hyperkalaemia        50 ml
10% Ca Gluconate      Ca Gluconate 100 mg/ml      Hypocalcaemia, hyperkalaemia        1 box 10 vials,
                                                                                      licensing problems
                                                                                      hold off
Magnesium sulphate                                Hypomagnesaemia,                    Needs to be ordered
                                                  polymorphous ventricular
                                                  tachycardia
Mannitol 20%          20 g/100 ml                 Cerebral oedema, anuria, oliguria   500 ml
KCl 15% v/w           20 mEq/10 ml                Hypokalaemia                        5x 10 ml
8.4% w/v Sodium       8.4 g/100 ml                Give 10 min into CPR, earlier if    100 ml
bicarbonate                                       preexisting acidosis,
                                                  hyperkalaemia
Water for injection                                                                   100 ml
   Annex 3: Contents of Crash trolley in ICU

Location      Object                                   Description                   Quantity
Top of        Electrical defibrillator (plugged in)
trolley
              HAES                                     Voluven® 130/0.7, 500 ml      1 bag
              Lactated Ringer’s solution               500 ml, 1000 ml               1 each
              NaCl 0.9%                                100 ml, 500 ml                1 each
              Giving sets crystalloids + blood                                       2 each
              Extension sets                                                         2
              IV catheters                             12/14, 18, 20, 22, 24 gauge   3 each
              Intraosseus catheter                     Gauge ?                       1
              Wraps                                    Co-plus® 7.5 cm, 10 cm        2 each
              Soft wraps                               Softban®plus 7.5 cm, 10 cm    2 each
              Tape                                                                   2
              Sterile swabs                                                          10
              Scalpel blade                                                          3
              Bungs                                                                  5
              Syringes                                 1, 2, 5, 10, 20 ml            5 each
              Needles                                  18, 20, 21, 23 gauge          5 each
              Thoracocentesis/Pericardiocentesis set
              Needles                                  20 gauge                      5
              Butterfly catheters                      Sizes long needles            5
              Pericardiocentesis needle                                              2
              Chest drains
              Syringe                                  60 ml                         2
              3 way stopcock                                                         3
              IV extension set                                                       2
              1 way drain valve
              Suture material (non absorbable)
              Gate clamps
              ECG dots                                                               2 packets
              Endotracheal tubes                       3 - 12 mm                     1 tube each
              Laryngoscope with spare batteries
              KY Jelly                                                               1x
              Knitband                                 5 cm                          2
              Ambo bag                                 Small, big                    1 each
              Face masks                               Various sizes                 1each
              Tracheostomy tubes (sterile)             3 mm, 5 mm, 7 mm, 10mm        1 each
              Surgical instruments needed for                                        1 pack
              tracheostomy
              Urinary catheters                        6, 8,10 French                2 each size
                                                       Simple urinary catheters +
                                                       Foley catheters
              Intranasal catheters                     Various sizes                 2 each
              Infant feeding tubes                     6, 8, 10, 12 French           2 each
              Superglue                                                              1 tube

   Protocol for ICU Policy & Procedures
                                                                                          Page 113 of 125
Annex 4: Crash trolley checklist

Date                  Supplies replaced   Person responsible




Protocol for ICU Policy & Procedures
                                                               Page 114 of 125
Annex 5: ICU treatment sheet


(See next page)




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                                       Page 115 of 125
Protocol for ICU Policy & Procedures
                                       Page 116 of 125
Annex 6: CRI calculation sheet (link: www.vin.com )

                                       SYRINGE BASED CRI INFUSIONS
                                         Kilogram based calculations
Patient Wt.                    kg
               Drug dose rate                      CRI duration          Total drug          Total volume

Ketamine                 1.2   mg/kg/hr                3   hrs.              0   mg          0.00   ml

Morphine             0.36 mg/kg/hr                   1 hrs.              0 mg                0.00   ml
               Choose either morphine or fentanyl - do not include both drugs

Fentanyl             0.0036    mg/kg/hr                3   hrs.              0   mg          0.00   ml

Lidocaine                  3   mg/kg/hr                3   hrs.              0   mg          0.00   ml
                                                                   Total syringe volume      0.00   ml

                                            Drug CRI Dose Range
KETAMINE - 0.12 to 1.2 mg/kg/hr (2 to 20 μg/kg/minute).
MORPHINE - 0.12 to 0.36 mg/kg/hr (2 to 6 μg/kg/minute).
               Choose either morphine or fentanyl - do not include both drugs
FENTANYL – 0.0012 to 0.0048 mg/kg/hr (0.02 to 0.08 μg/kg/minute).
            Dogs - max. rate of 0.008 mg/kg/hr (0.10 μg/kg/min) for general analgesia. Max of 0.042
            mg/kg/hr (0.70 μg/kg/min) for general anesthesia strategies in debilitated animals intolerant
            of inhalants.
LIDOCAINE - 0.6 to 3.0 mg/kg/hr (10 to 50 μg/kg/minute).
               Cats should be limited to a max. dose of 1.5 mg/kg/hr (25 mcg/kg/min)

                                               Loading Doses
KETAMINE - 0.25 to 0.50 mg/kg IV bolus
               At 0.25 mg/kg this patients needs a loading dose of:                          0.00   ml
MORPHINE - 0.5 mg/kg IM (or very slowly IV)
               At 0.5 mg/kg this patients needs a loading dose of:                           0.00   ml
               Choose either morphine or fentanyl - do not include both drugs
FENTANYL - 0.002 to 0.003 mg/kg IM or IV
               At 0.002 mg/kg this patient needs a loading dose of:                          0.00   ml
LIDOCAINE - 0.5 to 1 mg/kg IV
                                       At 0.5 mg/kg this patients needs a loading dose of:   0.00   ml
                                       At 1.0 mg/kg this patients needs a loading dose of:   0.00   ml
               CATS - Limit cats to 0.5 mg/kg loading dose
               DOGS - 1.0 mg/kg is the normal loading dose

                                            Drug Concentrations
KETAMINE - 100 mg/ml
MORPHINE - 15 mg/ml
FENTANYL – 0.05 mg/ml
LIDOCAINE - 20 mg/ml




Protocol for ICU Policy & Procedures
                                                                                               Page 117 of 125
Annex 7: Transfusion chart




Blood component:______________________________

Donor:_______________________________________

Blood type:__________ PCV:______TP:____________

Cross match:          yes                      no

Patient data at baseline:


Temp                 HR                   RR                  PCV            TP


Transfusion
Maximum volume:             20 ml/kg over 4 hours
Maximum rate:               First 30 min:             0.25 ml/kg
                            Cardiac patients:         4 ml/kg/h

Time in            0:00      0:10      0:20    0:30    1:00   2:00   3:00   4:00   Call clinician if:

T                                                                                    >         <

P                                                                                    >         <

R                                                                                    >         <


Heart and                                                                          Worsening of heart
lung sounds                                                                        or lung sounds

Other                                                                              Any of these
reactions                                                                          observed

Rate (ml/h)



Patient post transfusion : PCV:______TP:____________

Transfusion reactions: restlessness, vomiting, diarrhoea, urticaria, increased rectal
temperature, dyspnoea, hypotension, collapse

IF ANY SIGNS OCCUR STOP TRANSFUSION AND CALL CLINICIAN




Protocol for ICU Policy & Procedures
                                                                                     Page 118 of 125
                                        Cardiopulmonary Arrest
             Annex 8:

                     Begin basic life support
                     Airway
                         - Assess for potential airway obstruction
                         - Assess for breathing
                         - Perform intubation
                     Breathing
                         - Ventilate with 100% oxygen
                         - Provide 10-24 breaths/min
                     Circulation
                         - Assess for heart beat and pulses, if absent begin external chest
                             compressions
                         - Provide 100-120 compressions/minute
                          Check if compressions are effective (peripheral pulse, Doppler)

                                            yes                     no

    Begin advanced life support                                             - Change compression technique
               ECG determine arrest rhythm                                      - Faster or slower
               Obtain access for drug therapy                                   - Release longer in between
                                                                                   compressions
                                                                                - Change compressor
                                                                            - Use augmenting techniques
                                                                                - Intermittent abdominal compression
                                                                                - Caudal abdomen tourniquet
                                                                                - Simultaneous ventilation and
                                                                                   compression
                                                                            - Open chest direct heart compression

VF/VT                                                      Asystole/Bradycardia/PEA

-    Defibrillate
     -       external 2-5 J/kg
     -       Internal 0.5 –1 J/kg                          Drug therapy
     -       Up to 3 consecutive shocks                        -    Atropine 0.04 mg/kg IV
                                                                    Lower dose if palpable pulse or suspected vagal arrest
-    Resume chest compressions
-    Drug therapy                                              -    Adrenaline 0.1 mg/kg IV
     -       Adrenaline 0.1 mg/kg IV                                May repeat at 3-5 min intervals
                      or                                                        or
     -       Vasopressin 0.8 U/kg IV                                Vasopressin 0.8 U/kg IV
                                                                    Given one time only
     -       Lidocaine 2 mg/kg IV
                      or                                   Consider transthoracic pacing
     -       Amiodarone 5-10 mg/kg IV

-    Repeat defibrillation (double energy)

                        During CPR
         -     Consider sodium bicarbonate (1-2 mEq IV in prolonged CPR (>10 min)
         -     Consider calcium gluconate (50 mg/kg IV) in severe hyperkalaemia or ionised hypocalcaemia
         -     Consider magnesium sulfate (30 mg/kg IV) in severe hypomagnesaemia
         -     Monitor ongoing resuscitation efforts
         -     Search for underlying conditions

             Protocol for ICU Policy & Procedures
                                                                                                                   Page 119 of 125
Annex 9: List of Liquid Enteral nutrition solutions




        Macronutrient Composition of Selected Veterinary Liquid Enteral Formulations

                                        NUTRIENTS (% OF TOTAL kcal)
                               CALORIC
                  PROTEIN      DENSITY                            FORMULA
 PRODUCT          TYPE         (kcal/ml) PROTEIN FAT CARBOHYDRATE CHARACTERISTICS
 Prescription      Liver       1.3      34        55   4                 Isotonic, lactose
 diet Canine &     Chicken                                               free, fiber 1.3% DM,
 Feline a/d        Corn                                                  adequate taurine,
 (Hill's)          flour                                                 fatty acid ratio
                   Casein                                                (n6:n3 = 2.2:1)
 Eukanuba          Chicken     2.1      29        66   5                 Isotonic, lactose
 Maximum-          Chicken                                               free, fiber 1.6% DM,
 Calorie           by-                                                   adequate taurine,
 Canine &          product                                               fatty acid ratio
 Feline (Iams)     meal                                                  (n6:n3 = 8.3:11)
 CliniCare         80%         1.0      20        55   25                Isotonic (230
 Canine            casein                                                mOsm/kg), lactose
 (Abbott)          20%                                                   free, fiber free, fatty
                   whey                                                  acid ratio (n6:n3 =
                                                                         6.4:1)
 Clinicare         60%         1.0      30        45   25                Isotonic (235
 Feline            casein                                                mOsm/kg), lactose
 (Abbott)          40%                                                   free, fiber free,
                   whey                                                  adequate taurine,
                                                                         fatty acid ratio
                                                                         (n6:n3 = 6.4:1)
 Clinicare RF      80%         1.0      22        57   21                Isotonic (165
 Specialized       casein                                                mOsm/kg), lactose
 Feline            20%                                                   free, fiber free,
 (Abbott)          whey                                                  adequate taurine,
                                                                         fatty acid ratio
                                                                         (n6:n3 = 6.4:1)


           Modified from Marks SL: The principles and practical application of enteral
                  nutrition, Vet Clin North Am Small Anim Pract 28:677, 1998.




Protocol for ICU Policy & Procedures
                                                                                         Page 120 of 125
Annex 10 : Resting energy requirements for dogs and cats

Weight (kg)           RER (kcal/day)   Weight (kg)   RER (kcal/day)
0.5                   42               27            829
1                     70               28            852
1.5                   95               29            875
2                     118              30            897
2.5                   139              31            920
3                     160              32            942
3.5                   179              33            964
4                     198              34            986
4.5                   216              35            1007
5                     220              36            1029
5.5                   235              37            1050
6                     268              38            1071
6.5                   265              39            1092
7                     301              40            1113
8                     333              41            1134
9                     364              42            1155
10                    394              43            1175
11                    423              44            1196
12                    451              45            1216
13                    479              46            1236
14                    507              47            1257
15                    534              48            1277
16                    560              49            1296
17                    586              50            1316
18                    612
19                    637
20                    662
21                    687
22                    711
23                    735
24                    759
25                    783
26                    806




Protocol for ICU Policy & Procedures
                                                                      Page 121 of 125
Annex 11: Total parenteral nutrition (Kabiven®) administration sheet



Date: _____________________

Body weight: _______________


Reason for TPN:____________                        TPN solution: KABIVEN® peri




Calculate RER (kcal/day)
                                                 Per 1440 ml
           RER (kcal/d) = 70 (kg BW)0.75         Energy:     1000 kcal
           RER (kcal/d) = 30 (kg BW)+70          Amino acids    34 g
                                                 Glucose        97 g
                                                 Fat            51 g


Total daily requirements (ml/day)



             RER _______ kcal/day x 1440 ml/1000 kcal = __________ ml/day


Administration

           Rate:                              Dedicated jugular catheter
                                              Do not disconnect
           Day 1 ______ ml/h ( 25%)           Handle fluid lines and catheter aseptically
                                              Monitor
           Day 2 ______ ml/h ( 50%)              • Lipidaemia (macroscopic)
                                                 • Electrolytes
                                                 • Glucose
           Day 3______ ml/h (100%)
                                                 • Urea/creatinine




Protocol for ICU Policy & Procedures
                                                                               Page 122 of 125
Annex 12: Glasgow composite pain scale




Protocol for ICU Policy & Procedures
                                         Page 123 of 125
Annex 13: Assessment of head trauma patients


                           MODIFIED GLASGOW COMA SCALE
Date:_____________________


Time:____________________


Examiner:_________________

Select a score (1-6) for each of the 3 areas                                             Score
Motor Activity
Normal gait, normal spinal reflexes                                                      6
Hemiparesis, tetraparesis or decerebrate activity                                        5
Recumbent, intermittent extensor rigidity                                                4
Recumbent, constant extensor rigidity                                                    3
Recumbent, constant extensor rigidity with opisthotonus                                  2
Recumbent, hypotonia of muscles, depressed or absent spinal reflexes                     1

Brain Stem Reflexes
Normal pupillary light reflexes and oculocephalic reflexes                               6
Slow pupillary light reflexes and normal to reduced oculocephalic reflexes               5
Bilateral unresponsive miosis with normal- reduced oculocephalic reflexes                4
Pinpoint pupils with reduced to absent oculocephalic reflexes                            3
Unilateral, unresponsive mydriasis with reduced-absent oculocephalic reflexes            2
Bilateral, unresponsive mydriasis with reduced- absent oculocephalic reflexes            1

Level of consciousness
Occasional periods of alertness and responsive to environment                            6
Depression or delirium, capable of responding but response may be inappropriate          5

Semicomatose, responsive to visual stimuli                                               4
Semicomatose, responsive to auditory stimuli                                             3
Semicomatose, responsive only to repeated noxious stimuli                                2
Comatose, unresponsive to repeated noxious stimuli                                       1


Total score
Prognosis
       3 – 8 Grave
      9 – 14 Guarded
    15 – 18 Good


Protocol for ICU Policy & Procedures
                                                                                  Page 124 of 125
 From Platt et al., The Prognostic Value of the Modified Glasgow Coma Scale in Head
 Trauma in Dogs, JVIM; 2001; 15:581-584




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