options , the client was able to give an informed decision for euthanasia . The administration of calcium gluconate could have aided the patient , but was not an essential medication to preserve life .
Although a VS can give an animal medication without express consent from the owner , they cannot recover the associated costs of the treatment without informed consent . This could have had negative repercussions for the staff involved , as the clinic ' s policy for financially restricted cases is to provide first aid and / or analgesia to relieve a patient ' s suffering , as dictated by the RCVS Code of Professional Conduct for Veterinary Surgeons . Therefore , it could be argued that the administration of calcium gluconate would not have been a first aid measure in this case , and the financial impact on the clinic could have led to disciplinary measures being taken by the clinic ' s management against the staff involved . The decision whether to proceed with treatment would have been based on the VS ' s clinical judgement . In cases of UO where calcium gluconate treatment is deemed clinically appropriate by the VS , monitoring the changes in blood electrolytes in response to the treatment is an essential part of the VN ' s care of the patient .
Post-obstructive diuresis
Monitoring urine output ( UOP ) is crucial when nursing patients post UO , to ensure the removal of toxins that have built up in the patient ' s blood during the obstruction . UOP should be measured to determine whether post-obstructive diuresis ( POD ) is present , as it can cause dehydration and depletion of electrolytes , including K + , in some cases leading to supplementation being required [ 21 ] . The volume of urine collected in the first hour post-catheterisation is regarded as urine from the obstructed bladder and so should not be included in the initial UOP that is calculated to provide a baseline for future measurements . Measurements should then be made at a minimum of every 4 hours , although this schedule can be adapted on a case-by-case basis [ 22 ] .
POD is a complication associated with UO , whereby urine output exceeds 2 ml / kg / hr ; in severe cases it has been reported to be > 5 ml / kg / hr [ 23 ] . The pathophysiology of POD is not fully understood but is thought to be due to the accumulation of diuretic solutes during UO [ 22 ] . There is evidence to suggest that there is a decreased response of the collecting ducts to antidiuretic hormone , resulting in diuresis [ 24 ] . Studies of populations of cats post UO have reported a prevalence of POD ranging from 46 % to 87.7 % [ 22 , 23 , 25 ] , indicating that it is common , and UOP should be closely monitored in these cases to prevent dehydration , hypovolaemia and further organ damage [ 21 ] . POD has been shown to be significantly worse after the first 4 hours in patients that are acidaemic , but this was irrelevant if the acidaemia was present on admission [ 22 ] . This could potentially have been a contributing factor in the patient ' s poor prognosis .
Fluid rates calculated based on UOP and ongoing losses may exceed the patient ' s requirements , exacerbating POD and increasing the risk of fluid overload [ 14 , 23 ] . Therefore , monitoring of the RR , respiratory effort and auscultation should be conducted to assess for fluid accumulation in the chest . In this case , the time of urine production was noted when the collection system was unclamped , with the aim of allowing the bladder to empty within 1 hour and then enable the UOP to be measured every 2 hours . This allowed the VN time to provide the patient with suitable kennelling , with a multiparameter monitor attached , facilitating visual observations of the patient while the VN continued to triage new cases and provide care to in-patients .
Ideally , this patient would have received 1:1 care , but this was not feasible due to staff limitations and caseload . All staff involved provided the best care they could in the situation . On reflection , the patient ' s welfare was a priority , and the decision for euthanasia was made quickly once the patient decompensated . Increased staff levels could have allowed for more intensive care of the patient ; the clinic normally had support from a second VN and VS for part of the shift . Unfilled gaps in the shift meant that the VN and VS were under pressure to maintain high clinical standards with a heavy caseload . Staffing responsibilities lay outside their remit and , as providers of OOH care , they were obligated to provide emergency care to all animals presented to them .
Conclusions
On admission , the patient was in a critical condition . The cardiotoxicity caused by hyperkalaemia in this case could be appreciated on the ECG output provided by the multiparameter monitor connected to the patient .
The patient ' s bradycardia evolved into severe ventricular tachycardia (> 300 bpm ), which contributed to the poor outcome , as it was an influencing factor in the owner ' s decision to choose euthanasia .
In a busy clinic without the use of a multiparameter monitor as a visual aid , the patient ' s deterioration might not have been observed as rapidly , which could have unnecessarily prolonged its suffering .
Future recommendations
The need for critical care is often underestimated in cases of UO . If VNs are overstretched in their duties , the deterioration of these patients can be easily missed . VNs should be actively encouraged to develop their skills in caring for critical cases such as these , as they are the primary caregiver and advocate for their patients . Acquiring these skills will improve VNs ' confidence and job satisfaction .
46 Veterinary Nursing Journal