This is likely to have been due to the repeated starvation periods before the CT and surgical procedures but equally could be explained by continued hyporexia due to pain or the adverse effects of opioid analgesia [ 16 ].
Reflecting on the literature discussed above, these 2 days of reduced food intake combined with a further 2 – 3 days of hyporexia before presentation could have provided reason to consider placing a feeding tube at the time of surgery [ 21 ]. This was not done in this case; however, on days 3 – 5 of hospitalisation the patient ' s food intake did increase and reached the desired full RER from day 3. The patient ' s weight in fact increased by 800 g throughout hospitalisation, perhaps beginning to recover from the previous period of hyporexia if initial weight loss had gone unnoticed before presentation.
Patient outcome
The patient was discharged after 5 days of hospitalisation, with recheck appointments booked for 1 week and 6 weeks post-discharge. The patient did not present for these recheck appointments but did return for splint removal a few months after discharge, at which point she was considered fully recovered.
Discussion and recommendations
This patient sustained significant injuries to the head in an RTA and received referral-level treatment of maxillofacial fractures in the course of 5 days of hospitalisation. This level of treatment was achievable due to the patient ' s demeanour and the nature of the injuries; however, complete reduction of the maxillary fracture was not possible due to the age of the injury at presentation.
The patient maintained her body temperature well throughout a long anaesthetic, with the support of some active and passive warming methods; however, it is evident that the length of the procedure was unexpected, and no prior plan was made to counteract possible significant hypothermia.
If a long procedure is anticipated, it would be beneficial to formulate a warming plan before induction so active pre-warming is achievable and additional measures could be added promptly should hypothermia occur. This can be discussed between multiple members of the veterinary team, including both the VSs and veterinary nurses( VNs) who will be involved in the patient ' s perioperative care.
In terms of the analgesia provided, consisting of a combination of locoregional analgesia for the dental extractions and multimodal systemic analgesia where local blocks were not possible, the level of pain relief was appropriate for the patient, with pain scores reflecting minimal signs of pain throughout hospitalisation.
In cases using opioids, signs of dysphoria on recovery at home or during hospitalisation should be noted and alternative analgesia used if the patient is particularly affected. While VNs cannot directly make changes to a patient ' s medication prescriptions, they can be involved in conversations with the VS regarding adverse effects that may impact on patient welfare.
Intraoperative fluids have benefits for patients under anaesthesia to balance fluid losses, but care should be taken to avoid iatrogenic fluid overload and fluids should be tapered during longer procedures.
Although this patient was able to prehend food well following surgery, the literature suggests that a better evaluation of nutritional status should have been carried out before the surgical intervention, such as a WSAVA or AAHA nutritional assessment [ 21, 22 ], and interventional measures such as oesophagostomy feeding tube placement considered at the time of fracture reduction.
It is important to consider the nutritional status of any patient undergoing significant surgical repair, especially around the head or face, including whether nutrition would be best provided in a way that is not reliant on the success of the procedure or the patient ' s ability to naturally prehend food.
The implementation of body and muscle condition scoring( BCS and MCS) could also have proven useful alongside daily recalculation of the RER to better provide adequate nutrition to the patient. BCS, MCS and nutritional assessments are techniques that can be implemented by VNs to help advocate for patient welfare in hospital and support VSs in considering holistic care for patients while they are hospitalised.
Conclusions
This patient sustained severe facial trauma following an RTA and required a high level of nursing care throughout the perioperative and hospitalisation period. The nursing interventions provided were appropriate and well coordinated, with effective airway management, multimodal analgesia, temperature support and close monitoring all contributing to a successful outcome.
The patient remained stable under anaesthesia, recovered well postoperatively and was ultimately considered fully recovered, which reflects the overall effectiveness of the care delivered. The case also demonstrates the value of VNs in supporting complex referral patients through observation, reassessment and advocacy for patient welfare.
40 Veterinary Nursing Journal