Plus-Hex CLINICAL be undertaken by the VN caring for the patient . This will allow trends to be identified and appropriate adjustments made to the treatment as required , under the direction of the VS [ 6 ] .
VNs should be aware of the reasoning involved in the choice of fluid for each patient and feel confident in discussing the VS ' s treatment request and in raising concerns if they believe an error has been made . Adopting an open , ‘ no-blame ’ approach allows all parties involved to progress and learn from each other . In one hospital , for example , it is standard practice for all fluid bags to have an identifying label bearing the patient ' s details , which is countersigned by another VN or VS , to minimise human error when setting up and administering fluid therapy .
The patient in this case was normotensive on presentation , with moderate pulses , but had pale MMs and hypothermia , consistent with hypovolaemia . It was decided to commence IVFT at 6 ml / kg / hr . The VS was responsible for choosing the rate of IVFT for the patient , but VNs should also appreciate what is an appropriate rate for the patient . This patient was not provided with a fluid bolus at this time , due to underestimation of the need for a fluid assessment and fluid plan . The VN did discuss this choice with the VS . The treatment choice was not changed , due to the caseload of the clinic and staffing limitations , but it is unlikely that this decision affected the patient ' s outcome in this case . It can be common practice for VSs to prescribe a fluid rate that is a multiple of the maintenance rate ( MR ); however , published MRs can vary and they do not accurately assess the individual patient ' s fluid replacement requirement . Each patient should have an individual fluid plan , to minimise the risk of errors and unintentional harm to the patient . Fluid calculations can be found in Table 2 [ 17 ] .
Moderate hyperkalaemia ( 6 – 8 mmol / l ) can be treated with other medical therapies alongside IVFT , including dextrose / glucose [ 18 ] . Dextrose administration causes K + in the plasma to translocate intracellularly by stimulating the release of endogenous insulin [ 19 ] . This process can be accelerated by IV administration of insulin at a dose of 1 IU / cat [ 12 ] . This should be followed by a bolus of dextrose 50 % at 1 ml / kg , diluted to a 10 – 20 % solution for administration to prevent phlebitis , and then a constantrate infusion ( CRI ) of dextrose to prevent concurrent hypoglycaemia [ 12 ] . The VN is vital in this process , as they will be directly responsible for monitoring the patient ' s blood glucose ( BG ) in response to this treatment . The VN ' s role would include taking blood samples to determine BG either after a bolus is administered or at regular intervals if the patient is on a CRI , to ensure the rate is appropriate for its requirements . In the author ' s current clinic , it is protocol for the VS to provide a plan for monitoring BG in such patients , facilitated by a BG range outside which the VS should be alerted to amend the current treatment plan . A patient ' s mentation will notably change when they become hypoglycaemic : they will become duller , less responsive and , in extreme cases , show seizure-like activity . If any of these signs are observed , the venous BG should be checked and the VS alerted .
Patients on a dextrose CRI should have their BG checked every 4 hours to reduce the risk of any hypoglycaemic or hyperglycaemic events [ 20 ] . Central venous blood analysis would provide more accurate results , so placement of a central line would be advantageous . However , in cases where a central line is not placed , for patient comfort , venous sampling with insulin needles would be preferential to multiple peripheral punctures , such as ear or pad pricks . Use of a local anaesthetic cream or spray would also increase the patient ' s comfort . If the patient ' s mentation were to deteriorate , this could indicate a hypoglycaemic episode that would require the VS to be swiftly alerted , to enable intervention and a bolus of glucose to be given . In this case , the transferring history notes indicated that the PCP had administered an IV bolus of insulin with multiple glucose boluses , but no CRI had been started . Although the patient ' s BG was noted , there were no notes from the VS or VN on how the measurements were established .
In cases of severe hyperkalaemia (> 10 mmol / l ), it is advisable to administer calcium gluconate 10 % [ 19 ] at a dose of 0.5 – 1.5 ml / kg ( 50 – 150 mg / kg ) over 20 – 30 min . In emergencies this time can be reduced to 2 – 3 min [ 16 ] . Although calcium gluconate does not directly treat hyperkalaemia , it will protect the myocardium from the cardiotoxicity of the high K + levels , as well as treating the associated ionised hypocalcaemia [ 20 ] . If this medication is administered , an ECG must also be done to determine whether bradycardia worsens or the QT interval shortens [ 19 ] . If these changes were to occur , the treatment should be stopped and the patient evaluated , and the treatment plan would need to be revised by the VS . This patient was hypocalcaemic but was not exhibiting clinical signs associated with hypocalcaemia . Had treatment continued , calcium gluconate administration would have been advisable due to the cardiotoxicity of the prolonged hyperkalaemia and the resultant arrhythmia that occurred .
The decision not to give a bolus of calcium gluconate was made on a financial basis , as the client had expressed financial constraints . The patient was in a critical condition and , once the VS had explained the grave prognosis and associated costs of the treatment
Table 2 . Fluid calculations for patients .
Replacement fluid required ( ml / hr ) = dehydration (%) + maintenance rate ( ml / hr ) + ongoing losses ( ml / hr ) Maintenance rate for cats = 80 × body weight ( kg ) 0 . 75 ( ml / 24 hr ) or 2 – 3 ml / kg / hr
Volume 39 ( 3 ) • June 2024
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