Technicians will be asked at some point in their career to monitor critical patients, where a high level of care, concentration, and critical thinking skills are required. Technicians must be comfortable with monitoring these patients and alerting the clinician when patient parameters change.
An example is a patient on the critical care ventilator. Most general practices and some specialty facilities do not have such equipment, but the process of caring for a ventilator patient can be translated to any critical patient. Everything a technician has learned in school is applied. Multiple monitoring devices should be used to keep an eye on the patient’s vitals, hydration and ventilation status, and organ function. Documentation is very critical. Every change in a patient’s condition should be documented, and vitals should be taken on the patient frequently.
Many technicians ask, “What do we need to do first?” The answer is to assess the patient’s airway.
Ventilator patients should be intubated for as long as possible. Since they are sedated, they are on multiple medications to help decrease their respiratory drive and allow the machine to breathe for them, making them at risk for regurgitation and aspiration.
One of the major complications of a mechanically ventilated patient is hospital-acquired pneumonia due to bacteria being introduced by the endotracheal tube. A sterile or aseptic technique should be used to place the endotracheal tube to ensure there are minimal bacteria entering the airway.
A pulse oximeter should be placed on the patient to make sure they are appropriately perfusing their organs. Capnography should also be used to make sure the patient is ventilating appropriately and getting a normal end-tidal carbon dioxide (ETCO2) reading of 35-45 mmHg. Suctioning and humidifying of the endotracheal tube should be performed every four hours, or as needed, to prevent mucous secretions from clogging the endotracheal tube.
Placing venous access
Hopefully, the patient already had venous access. If not, a peripheral catheter most likely will not be enough. Triple or quadruple lumen central lines should be placed, which will help with the multiple medications these patients are on, as well as possibly be used for intravenous nutrition and blood sampling. These can be placed in the jugular veins, saphenous veins, medial veins, or ombobracheal veins.
Ombobracheal veins are very hard to see, so I would suggest going for the other veins first. If placing a central line in a jugular vein, a radiograph must be performed to make sure the catheter is placed in the cranial vena cava right above the right atrium.
Monitoring blood pressure
Blood pressure on critical patients is a very important diagnostic tool to let a veterinary team know how the patient’s perfusion is doing. An invasive blood pressure monitoring is going to be the most acuate way to measure blood pressure. Attempting an arterial catheter on a patient that has a blood pressure lower than 60 mm/Hg can be very difficult, so the next best way to do so is with a doppler.
Doppler blood pressure measures systolic blood pressure. Normal systolic blood pressure in veterinary patients should be around 90-120 mm/Hg. Oscillometric blood pressure can be used, but it should be taken into consideration it may not be as accurate in small or awake animals.
A multiparameter unit should be placed on the patient to assess heart rhythm, ETCO2,blood pressure, oxygenation, and temperature. The electrocardiogram clips should be placed on “sticky” pads to ensure the metal clips do not cause skin damage.
The patient should also be placed on a properly cushioned area. When it comes to critical patients, it is easier on everyone if the patient is placed on an elevated table. This way, you can get around the patient on all four sides. These patients are prone to pressure sores, especially when they start losing muscle mass due to inactivity.
Once the patient is hooked up to all monitoring devices, there are multiple areas to consider. The patient’s airway, mouth, eyes, ears, and urinary and gastrointestinal systems must be cared for. The technician must also preform physical therapy.
1) Airway. If the patient has an endotracheal tube, it must be properly cared for to make sure the patient does not contract hospital-acquired pneumonia. The endotracheal tube must be replaced every 24 hours with a sterile technique. In a recumbent patient, you must inflate the cuff
to ensure the lungs inflate appropriately. One complication of the cuff being inflated, or overinflated, could cause tissue necrosis of the trachea. It is suggested to deflate the cuff and reposition the endotracheal tube every four hours to prevent tissue necrosis.
These patients also need humidification of their airway. This can decrease mucous viscosity and decrease tracheal inflammation. To do this, technicians can instill a small amount of sterile water into the endotracheal tube and then suction the endotracheal tube after. Suctioning of endotracheal tube is necessary to prevent mucous buildup and occlusion of the airway. This should be performed every four hours or on an as-needed basis.
Patients that are recumbent and have endotracheal tubes or tracheal tubes in are at an increased risk of ulcers in their oral cavity. To prevent this, the whole mouth must be kept moist. The technician must suction out all mucous and debris. Use a different suction catheter than the one used for the tracheal tube. This will prevent bacteria from being introduced into the lungs.
A glycerin solution can then be used to prevent drying out the tongue. The tongue can also be covered with a glycerin-soaked gauze. Do not wrap the tongue as this can cause ranulas to form. The pulse oximeter probe should also be taken off the tongue and moved to a different area to prevent necrosis. This procedure should be done every four hours.
2) Eye care. Critical patients that are recumbent are at an increased risk of eye ulcers because they cannot blink. Artificial tears should be placed on the eyes every two hours. Goggles can also be used to seal off the eye from the environment. Most clinics do not have goggles, so trying to keep the eyes closed with tape could also be used. Technicians should check for ulcers in the eyes at least once a day.
3) Urinary tract care. A urinary catheter should be placed in these critical patients. Technicians should use a long-term urinary catheter, such as a foley, and place with a sterile technique. A collection bag should be placed on the catheter to ensure the amount of urine the kidneys are producing is measured.
Urinary catheters should be cleaned every eight hours to prevent infection. This includes flushing the prepuce with a dilute chlorhexidine solution and wiping the lines associated with the urinary catheter.
The urinary bag should be emptied every four hours to assess kidney function. A technician should calculate how much fluid is going in and out of the patient to assess kidney function and hydration status. Patients are at a higher risk of acquiring urinary catheter infections, so keeping the catheter clean will help keep the infections at bay.
4) Nutrition. Critical patients need nutrition. This can be delivered via central line by parenteral nutrition, or via nasogastric or nasoesophageal tube by liquid diets. Do not place non-sterile nutrition through the central line to avoid infections in the blood stream and further complications. Most likely, these patients will have diarrhea.
Technicians must keep the patient clean and dry. Keep a close eye on the color of the fecal material. Black or bloody stool can indicate a more serious complication and will need more attention.
5) Physical therapy. This is very important in critically ill patients as they are prone to losing muscle mass quickly; they can also acquire pressure sores and ulcers. Passive range of motion and rotating of the hips should be done every four hours. Patients can get out of the hospital quicker the sooner physical therapy is started.
Critical patients can be very time-consuming, and technicians will have to think and troubleshoot their way through many organ systems of these patients. There are multiple drug calculations and every part of nursing care technicians have ever learned about. When a critical patient walks out the door, it can be a very rewarding experience for the whole team.
Tami Lind, BS, RVT, VTS (ECC), is the current ICU and ER supervisor at Purdue University Veterinary Teaching Hospital. Lind has been at the university for 10 years. She went to veterinary technology school at Purdue and graduated in 2010 with her bachelor’s degree in veterinary technology and has never left. She started as a veterinary technician in the ICU and has been the supervisor at Purdue since 2012.
- Battaglia, Andrea M., and Andrea M. Steele. Small Animal Emergency and Critical Care for Veterinary Technicians. 2016. 3rd ed. Elsevier, 2016. https://evolve.elsevier.com/cs/product/9780323227902?role=student&CT=CA
- Silverstein, Deborah C., and Kate Hopper. Small Animal Critical Care Medicine. 2009. St. Louis, MO. Saunders/Elsevier. https://www.researchgate.net/publication/297702984_Small_Animal_Critical_Care_Medicine