New to the veterinary ICU? What you need to know on day 1

(Shutterstock.com)It's your first day as a nurse in the intensive care unit (ICU) and you're nervous and excited-call it nervicited! Fetch dvm360 conference speaker Paula Plummer, LVT, VTS (ECC, SAIM), is here with her ICU boot camp tips on what you must know about infectious disease, patient assessment and cardiopulmonary resuscitation (CPR) so that you and your patients can thrive from day one.

Infectious disease

In cats, Plummer says the most common infectious diseases you'll see are feline leukemia virus, feline infectious peritonitis and herpesvirus. In dogs, depending on your location, you'll see leptospirosis and fungal, viral and bacterial diseases.

Handwashing is still the most important factor in eliminating disease transmission. Protect yourself and your patients by following two rules: 1. Only gloved hands touch patients. 2. Wash your hands in between every patient.

If an infectious patient needs a procedure, Plummer recommends scheduling it at the end of the day to minimize exposure to other patients. If the procedure can't wait, set aside extra time after the procedure to perform deep cleaning.

Know how your patient's disease is transmitted, because that will determine the personal protective equipment (PPE) you need-you know, clothing or equipment designed to protect the wearer's body from injury or infection. If you are unsure of how much to wear, Plummer says to err on the side of wearing more than less.

Isolate hospitalized patients with infectious disease from other patients. Try to put critical infectious patients in the least trafficked area of the ICU. Plummer suggests giving them a colored neckband that tells staff to look at the chart before touching the patient. If you are unsure of which patients go in the ICU ward and who can be hospitalized there, ask.

Label laundry from infectious patients as infectious, and wash them separately with detergent and bleach.

Visiting owners should wear the same PPE as the veterinary team to prevent disease spread. Also limit visitation time to minimize disruption to treatment and convalescence.

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Patient assessment

Remember the ABCs of triage-assess airway, breathing and circulation, in that order.

Assessment stops when you find the most life-threatening condition.

The textbook respiratory rate is 20 to 30 beats/min, but you'll find the respiratory rate of most patients in the ICU closer to 40 to 60 beats/min, says Plummer. If it's closer to 60 beats/min, then assess the patient's respiratory effort and pattern.

Know the signs of respiratory distress in a cat-an extended neck, open-mouth breathing, holding its elbows away from its chest, and holding itself off the sternum.

Check femoral pulses at the same time as ausculting the heart.

Use the dehydration score guide:

< 5% dehydration-no changes on the physical exam but the pet owner says that the patient isn't urinating or drinking as much.

10 to 12% dehydration-tachycardia, dry mucous membranes, dramatic skin turgor, and weak or bounding pulses.

Timing to a tune

In human medicine, the best song to use for chest compressions is, ironically, Staying Alive. If you're not into disco, any song that is 100 beats/min will do.

CPR

Check your protocols. Less than 6% of dogs and cats that experience cardiopulmonary arrest (CPA) survive to hospital discharge, while the survival rate in people is more than 20%. Plummer says we can improve our CPR recovery rates in veterinary medicine by improving our protocols. Use the free extensive resources from the RECOVER CPR Initiative from the Veterinary Emergency and Critical Care Society (VECCS) to learn everything you ever need to know save more patients.

Remember, the goals of CPR are to apply adequate chest compressions and provide oxygen to the vital organs.

Make sure every hospitalized patient has resuscitation orders on its chart that designates protocols, such as whether to perform CPR and do not resuscitate (DNR). CPR pages can really surprise and freak clients out, so Plummer says to brace yourself and be sensitive to what the client may be going through.

Familiarize yourself with the crash cart. Bonus points if you find out-of-date medications in there!

Recognize that time is of the essence with CPR-you have only about 30 seconds to save that patient. If the heart isn't beating, initiate chest compressions and call for help. Most hospitals have a code system that they follow. Learn it and use it.

Remember, chest compressions are difficult! Plummer's pointers: Make it easier by placing yourself perpendicular to the patient to better leverage your own body weight and improve efficacy. Get a stool if you are vertically challenged. Your landmark is the point of the elbow, since right behind the elbow is the fourth or fifth rib space. Compress the chest one-fourth to one-half and shoot for 80 to 100 compressions/min. Release compressions completely to allow complete filling of the heart. Don't worry about breaking a rib-that can be fixed later if the animal survives. Rotate out every 2.5 minutes, and if you get tired, tap out earlier.

Get inspired by inspiration. After chest compressions have been initiated, Plummer says to capture the airway with intubation and mimic breathing with manual ventilation at 10 beats/min with an estimated tidal volume of 10 ml/kg. Inspiration is longer than expiration: 1 second inspiration/breath.

Monitor your compressions with end-tidal carbon dioxide (CO2). Plummer says this is the best way to monitor your compressions.

Fetch dvm360 educator Dr. Sarah Wooten graduated from UC Davis School of Veterinary Medicine in 2002. A member of the American Society of Veterinary Journalists, Dr. Wooten divides her professional time between small animal practice in Greeley, Colorado, public speaking on associate issues, leadership and client communication, and writing. She enjoys camping with her family, skiing, scuba and participating in triathlons.