Congress on Demand 2021: Veterinary Nursing

How to approach neurotrauma: a vet’s perspective – diagnosis and management: Neurotrauma, including traumatic brain injury (TBI) and acute spinal cord injury (SCI), is a relatively common emergency in small animal veterinary medicine that requires thorough patient assessment and a systematic approach to case management. Damage to the neuroparenchyma can be divided into primary injury directly associated with the trauma (e.g. contusion, compression, laceration and distraction) and secondary injury that occurs subsequently due to deficiencies in homeostasis and normal metabolic processes. Interventions are directed at addressing primary injury more so in SCI as well as minimizing the effects of secondary injury in both TBI and SCI. Initial investigations should be the same as any acute neurological case with a through history, physical examination and neurological examination. All patients should ideally have a minimum database performed with particular attention to electrolytes and glucose levels. Care must be taken to ensure the patient is systemically supported with a focus on airways, breathing and circulation. The level of intervention is patient dependent but can often be intense and hands-on. Prognosis for neurotrauma patients depends on the severity of injury, the site of the lesion, and the timing and efficacy of treatment, but with an appropriate response to initial management and stabilisation the outcomes of neurotrauma patients can be good.

How to approach neurotrauma: a vet nurse’s perspective – diagnosis and management: What you might expect, what to prepare for and complications in neurotrauma.

How capnography can help you identify problems with your patient: Capnography is arguably the most reliable and least error prone anaesthetic monitoring modality available, and it can contribute significantly to patient safety. Capnography relies on the measurement of inspired and expired carbon dioxide and primarily gives information about respiratory adequacy. Distinctive capnograph trace patterns can also alert the user to breathing system faults, endotracheal tube problems and acute lung pathology. Additionally, capnography is recommended to prognosticate and judge the effectiveness of chest compressions during CPR. This session discusses an approach to using and interpreting the capnograph to diagnose problems under anaesthesia.

What options you have in managing hypotension under anaesthesia if fluids don’t work: This session presents an update on recent advances and controversies in managing hypotension during general anaesthesia. Hypotension is one of the most common adverse effects of general anaesthesia. Options for managing anaesthetic-induced hypotension include: 1. reducing the inhaled anaesthetic requirement: this can be achieved directly or indirectly (e.g. by providing analgesia). 2. fluid administration: the efficacy and duration of crystalloid fluid boluses are limited but a number of tools are available to identify patients that will benefit from a fluid bolus (e.g. pulse pressure variation) 3. vasoactive agents (e.g. dexmedetomidine, dopamine, ephedrine): there are pros and cons to the different agents available. These options and practical approaches are discussed.

This case-based session explores and discusses common but still challenging cytology cases using live cytology slide examination, enabling you to see the step by step process of how we examine a slide and how the findings lead us to a diagnosis or differential diagnoses.

How does the cytologist do it? Although there are some exceptions, benign tumours consist of a uniform population of cells that resemble their normal non-neoplastic counterpart whilst malignant tumours generally show variability. In benign tumours cells are small and uniform, with small nuclei and a low nuclear:cytoplasmic (N:C) ratio. Nucleoli may be absent or nuclei may contain 1-2 small nucleoli. When in aggregates the cell arrangement is orderly and neat. Malignant tumours are recognised by identifying cellular, nuclear and cytoplasmic criteria of malignancy: Abnormal location for that cell type e.g. metastatic carcinoma cells should not be present in a lymph node; macrocytosis and karyomegaly with anisocytosis and anisokaryosis; cell clusters may be chaotic and disordered with cell or nuclear moulding; increased N:C ratio; large nucleus and sparse; bi- and multinucleation – anisokaryosis within one cell is especially significant; multiple nucleoli or a single large nucleolus; coarsely stippled to clumped nuclear chromatin; frequent/ abnormal mitoses; increased cytoplasmic basophilia and/or abnormal cytoplasmic vacuolation or granulation, or excessive secretory product. The shape and arrangement of cells will help identify the ‘family’ of cells: Epithelial cells are columnar, cuboidal, roundish or polygonal and in cohesive clusters. Mesenchymal cells are oval to spindle shaped and seen individually or in loose aggregates, sometimes with a swirling pattern, with poorly defined cell borders. Round cells are discrete. The quantity and appearance of the cytoplasm distinguishes lymphoid cells, plasma cells, histiocytic cells and mast cells.

What else does the oncologist need to know (TNM)? Staging determines the extent of disease in cancer patients, to inform treatment decisions. Recommended staging is strongly influenced by the diagnosis and likely behaviour of the tumour: a diagnosis is essential. Full staging is most appropriate for high grade tumours, and in older patients (identifying comorbidities) or before invasive/expensive treatments. Cytology is particularly useful for superficial masses and those accessible by ultrasound guidance. Carcinomas and round cell tumours tend to exfoliate well, sarcomas not. Primary tumour extent is assessed clinically and by imaging. Carcinomas, mast cell tumours, and malignant melanomas tend to metastasise by the lymphatic route, requiring assessment of locoregional lymph nodes. The closest node (moving from peripheral to central) is often likely to be the draining node, but lymphangiography can identify unexpected draining nodes in high grade tumours. Identifying and sampling these nodes leads to better staging. Imaging of retropharyngeal, axillary, medial iliac and inguinal nodes by ultrasound or CT is useful: CT allows imaging of sacral nodes e.g. in anal sac adenocarcinoma patients. FNA has a variable rate of false negatives in different tumours: in particular, FNA may be insensitive to oral melanoma metastases. For distant metastases, cytology is especially useful for assessing splenic and hepatic nodules.

Although regarded as a routine operation, neutering is probably the most invasive procedure undertaken in the majority of pets in the UK. Anaesthesia should be tailored to each patient to ensure not only anaesthesia adequate depth for the operation, but also to ensure preservation of normal physiology as well as excellent analgesia. This session explores the possible approaches that could be applied in practice. It examines the importance of a thorough clinical examination, benefits of tailored premedication, and outlines best practice in anaesthetic induction, maintenance and recovery. Finally, examples are given of how the approach could be modified when dealing with commonly encountered breed specific and clinical problems.

Nursing of cardiac patients generally falls into two categories, chronic and acute. Chronic nursing may be pre-congestive heart failure (CHF) and post CHF. This means patients may have heart disease without having presented with CHF. Patients also require chronic nursing after an acute onset of CHF. Acute nursing includes presentation, typically to an emergency center, for rapid control of CHF. This session reviews the American College of Veterinary Internal Medicine consensus statement regarding the stages of heart disease, then link nursing schema to each stage of heart disease. Many diagnostics and therapies overlap into different stages. For instance, echocardiography is indicated at all stages of heart disease to monitor progression of cardiac enlargement. Certain therapies have specific indications for their introductions. This overview provides a 10,000 foot perspective of cardiac nursing.

Nutritional therapy, like medical and surgical treatments, is recommended to manage many diseases. It is vital that these recommendations are based on a solid evidence base. In this session, the evidence behind nutritional recommendations to manage kidney disease, including protein restriction, phosphorus restriction and fish oil supplementation, are discussed. This includes ways to assess the evidence behind the recommendations and how to use these nutritional recommendations to improve patient outcome.

Managing expectations – client education: Owners often need help to understand the difference between acute and chronic pain; that often we cannot cure the problem; and that the main priority is to reduce the patient’s suffering (which may include side effects and restricted access to resources). Suffering is assessed by changes in individual behaviour and chronic pain is a chronic stressor. We cannot teach our patients not to feel stressed by the sensation of pain and owners must understand that the treatment of chronic pain necessarily involves more veterinary input because of this. A dynamic approach will usually begin with pharmacological analgesia, but may be followed with more physical treatments to help reduce the amount of medicine required and to maintain the animal’s strength and mobility. The clinician should stay open to discussing any approach and be prepared to explore other avenues if the owner requests them. Medicines often a carry a negative association for many clients and the clinician should be clear in explaining expected outcomes; possible side effects; monitoring; and frequency of review. Getting the owners involved in weight control; physiotherapy exercises; comfort; improved core territory; and replacement of lost resources will help with compliance by giving them a sense of control over their pet’s pain.

Monitoring pain therapies: Chronic pain can seem like trial and error sometimes. Having a firm understanding of the pet’s pain and a baseline pain score is essential for judging the efficacy of any future therapies. The identification of pain behaviours is recommended. When asked what they want for their pet, most owners will reply that pain reduction and maintenance of quality of life is their goal. I do ask this directly to owners so we can establish common ground and start to manage expectations. However, when asked to rate quality of life as a direct question in the Canine Brief Pain Inventory owner response can vary according on the message they wish to convey to you. We will discuss this point in the session. Questioning across health domains associated with quality of life can give us vital information and this is the basis of the Vetmetrica scoring system. I adapt the pain/HRQL scoring system I use according to the owner – which can help with the spectrum of pain presentations – another point for discussion. Writing down treatment goals and pain behaviours helps owners recall the consultation and draws focus to each aspect of management. Highlighting the importance of each intervention is valuable to the owners understanding.

Post-operative complications commonly seen in veterinary practice range from wound healing difficulties to multiple organ failure and death. Regardless of their severity, whenever post-operative complications arise, they are never welcome; let’s face it, the last thing you want to hear when reaching for your coat, after mopping the floor, hungry and tired after a long day, is that the bitch spay from this morning is not doing well and needs to return to theatre as a bleed is suspected. To reduce the rate of post-op complications, clinical audits are used to support quality improvement in clinical settings. Clinical audits enable patient care to be improved by assessing and evaluating current processes in a systematic way. By selecting the correct type of audit, getting the whole practice team on board, and ensuring a blame-free culture is embraced improvement strategies can be identified and implemented. The surgical safety checklist (SSC) is an example of a tool that has been proven to reduce the rates of post-operative complications. By involving the whole practice team in tackling post-operative complications though adoption of audits and checklists the benefits quickly become obvious and real improvements in patient care can be seen.