Download Patient care report for the stabilisation of a cat with a traumatic

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Patient care report for the stabilisation of a
cat with a traumatic diaphragmatic rupture
Abstract
Diaphragmatic ruptures in cats are often seen following trauma and can cause
severe respiratory distress. This article reflects on the author’s experience of providing emergency nursing care to a 2-year-old, domestic short hair cat, with a
traumatic diaphragmatic rupture. In order to provide effective nursing care it is
essential for the veterinary nurse to understand the effects of shock in the feline
patient. Creating a protocol for the management of the dyspnoeic trauma cat
could facilitate a more efficient treatment plan, allowing for available monitoring
equipment to be fully utilised. If advanced monitoring techniques are not available, a successful patient outcome is still achievable with basic nursing skills and
a good underpinning knowledge of the emergency and critical patient.
Key words: diaphragmatic hernia, respiratory distress, shock, oxygen therapy,
fluid therapy, cat
T
his patient care report highlights the initial
veterinary nursing interventions provided to
an emergency feline patient. The patient presented to the practice with shock and dyspnoea following a suspected traumatic incident.
Signalment
Species: Feline
Breed: Domestic short hair
Age: 2 years 3 months
Sex: Neutered male
Weight: 3.18 kg
Presenting problem
The patient presented with a history of acute dyspnoea and lethargy progressing to collapse. He was reported to be inappetant and it was unknown whether
he had passed urine or faeces within the last 24 hours.
The owner reported that he had not vomited overnight and that preceding this event he was a healthy
cat. He had never been seen by a veterinarian and so
had no known previous history.
Initial patient assessment
Respiratory
Visual assessment of the patient revealed tachypnoea (respiration rate (RR) of 44 breaths per minute
Debbie Nelson Grad Dip RVN A1 Assessor, Head
Nurse, Yourvets, Stechford, Birmingham, UK
498
VETN_2015_6_8_498_503.indd 498
(bpm)) and paradoxic respiration (when breathing
movements are in reverse to normal, i.e. chest wall
moves in on inspiration and out on expiration). He
lay in sternal recumbency with abducted elbows and
neck stretched outwards (orthopnoea). Auscultation
revealed dull lung sounds and muffled heart sounds;
his airways appeared clear from obstruction.
Cardiovascular
Heart rate (HR) was bradycardic at 120 beats per
minute (btpm) with no notable arrhythmias. He had
absent peripheral pulses and pale pink mucous membranes (MMs). The capillary refill time (CRT) was delayed at 2–3 seconds. He was severely hypothermic
with a core temperature of 34.1oC. An initial systolic
blood pressure (BP) reading was attempted using the
Doppler technique (the only available method in that
practice), but was unsuccessful, as the carpal pulse
could not be determined.
Neurological
There were no signs of extracranial injuries, but he
was obtunded and quiet. The patient’s pupils were
symmetrical and pupillary responses were normal.
Veterinary investigations
An intramuscular injection of a partial μ receptor
agonist, buprenorphine (Vetergesic, Ceva Animal
Health Ltd, Buckinghamshire, UK), 20 μg/kg was given. Alternatively a full μ opioid agonist such as morphine or methadone may have been used. These act
at a number of different receptor systems and compared with partial μ receptor agonists provide more
effective analgesia (Murrell, 2011). A study by Steagall
et al (2006) found that administration of methadone
and morphine provided a longer reduced sensitivity
to pain compared with buprenorphine. The use of full
μ opioid agonists are indicated in the management
of moderate to severe pain and as methadone is the
only full μ opioid agonist with veterinary marketing
authorisation, this should be used over morphine
(Murrell, 2011).
An initial blood sample was obtained to provide
a survey of the patient’s clinical status to tailor the
treatment plan accordingly (Chapman, 2013; Tompkins, 2013). Biochemistry results revealed mildly elevated urea 14.9 mmol/litre (normal range 5.7–12.9
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mmol/litre), high alanine transaminase 740 U/litre (normal range 12–130 U/litre) and high gammaglutamyl transferase 4 U/litre (normal range 0–1 U/
litre). Complete blood count revealed increases in
haemoglobin 16.5 g/dl (normal range 9.0–15.1 g/dl)
and neutrophilia 13.66 x 109/litre (normal range 2.50–
12.50 x 109/litre); total protein and haematocrit were
both normal.
A radiograph revealed a diaphragmatic rupture.
No signs of a dilated stomach were detected (which
would indicate the need for immediate surgical intervention (Gibson et al, 2005)), so it was decided that
the patient should be stabilised for 24 hours prior to
surgical repair.
Discussion
Diaphragmatic ruptures are a common cause of respiratory distress in cats (Cariou et al, 2009) and require
rapid intervention (Rozanski and Chan, 2005; Jordan,
2011; Sharp and Rozanski, 2013; Sumner and Rozanski, 2013) such as oxygen therapy, shock interventions
and pain management. Trauma is a common cause of
diaphragmatic rupture and there are often concurrent
problems such as shock (Schmiedt et al, 2003) that need
to be addressed in order to ensure the most immediate
threats to the patient’s life are treated as priorities.
Nursing considerations and interventions
The patient displayed signs of pain on his hind quarters and his ability to mobilise, urinate and defecate
was monitored. Also consideration was given to pain
management, nutritional requirements, stress reduction and self care, which were analysed using
the Orpet and Jeffery Ability Model (2007) (Orpet
and Welsh, 2011). To discuss all of these nursing requirements is beyond the scope of this care report.
Therefore, the author has focused this discussion on
the nursing interventions required to address his immediate and life-threatening disorders.
Oxygen therapy
It is widely agreed that oxygen therapy should be provided immediately to the dyspnoeic patient (Mackay,
2001; Rozanski and Chan, 2005; Jordan, 2011; Sharp
and Rozanski, 2013). In this incident a clinical examination took place before initiating oxygen therapy.
Although this could have prolonged the patient’s
discomfort Sumner and Rozanski (2013) advise that
a brief assessment before placement into an oxygen
cage can exclude other causes of distress such as
stress, cardiac and/or pulmonary disease. It could
have been possible to achieve both the initial clinical examination and oxygen support for this patient
if methods such as flow-by oxygen (achieving a mean
The Veterinary Nurse • Vol 6 No 8 • October 2015 VETN_2015_6_8_498_503.indd 499
fraction of inspired oxygen (FiO2) of 24–45% (Sumner and Rozanski, 2013)) had been provided. To further improve FiO2 from 24–45% to 35–55% a face
mask could have been used (Sumner and Rozanski,
2013). This is not always tolerated well and can increase stress and therefore respiratory effort (Sharp
and Rozanski, 2013). For this reason, providing flowby oxygen may have been the better approach for
this patient in order to minimise stress while oxygen
therapy was provided. However, it should be noted
that using flow-by oxygen is labour intensive as veterinary personnel need to be available to hold both
the oxygen circuit and patient (Sharp and Rozanski,
2013). In addition, using flow-by oxygen is labour intensive as veterinary personnel need to be available to
hold both the oxygen circuit and patient (Sharp and
Rozanski, 2013).
A useful way to provide oxygen therapy is with an
oxygen cage (Mackay, 2001; Mazzaferro, 2009). In the
dyspnoeic cat this can be particularly useful as it does
not require patient restraint (Mackay, 2001) and the
cage can reach reasonably high concentrations of oxygen (up to 60% FiO2 (Sumner and Rozanski, 2013))
depending on the size of the cage, patient and flow
rate (Richmond, 2010). This patient was placed into
an oxygen cage after his initial assessment; on admission his RR was 48 bpm and after 30 minutes this had
reduced to 38 bpm.
The oxygen cage (Buster® ICU cage, Kruuse,
Marslev. DK) was a basic model and could not control all aspects of the environment inside the cage.
Some complex models are able to control humidity,
temperature and oxygen levels which can be modified
from the outside of the cage. With the Buster® ICU
cage the door had to be opened at regular intervals to
gauge the temperature inside. This was to ensure the
patient did not become hyperthermic as there was no
temperature monitoring equipment in this particular
Buster® ICU cage. This results in a rapid fall in the
FiO2 (Sharp and Rozanski, 2013) which could have
been detrimental to the patient. To compensate for
this, the author suggests the use of a wall thermometer, attached to the inside of the cage. This could allow for the environmental temperature of the oxygen
cage to be monitored visually, reducing the need to
open the door unnecessarily.
Although the oxygen therapy improved the patient’s RR, it did not resolve the dyspnoea. The lowest recorded RR for this patient was 36 bpm (normal ranges 10 to 20 bpm (Jordan, 2011)) and he still
displayed some respiratory effort. This could be explained by the fact that a diaphragmatic hernia can
be classified as a pleural space disease (Pachtinger,
2013), which may only benefit from therapeutic in499
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tervention (Sumner and Rozanski, 2013) or surgical
intervention (Gibson et al, 2005).
To assess general patient improvement the registered veterinary nurse (RVN) observed for changes to
MM colour, a reduction in RR and improved demeanour. Blood gas analysis is the ‘gold standard’ method
for assessing oxygenation and ventilation. Blood gas
analysis or arterial blood gas (ABG) analysis provides
a direct assessment of gas exchange, giving an overall
view of pulmonary function (Miller, 2007). To assess
the lung’s ability to oxygenate blood the value of partial pressure of oxygen in arterial blood (PaO2) can
be measured. However, this is meaningless without
knowing the exact FiO2 (Moens and Coppens, 2007)
(see Table 1 for normal ranges). In order to assess ventilation, ABG remains the gold standard however, ventilation can be assessed by capnography, which may be
advantageous as it is not invasive and allows for continuous monitoring (Pypendop, 2009). Capnography
measures the arterial partial pressure of carbon dioxide (PCO2) although it is more accurate in intubated
patients (Pypendop, 2009). Unfortunately capnography was not available in the author’s practice. Therefore ventilation could not be accurately assessed.
As well as the lack of capnography, the author’s
practice does not currently have an ABG analyser. If
these had been available they could have been used
to determine how adequate the patient’s pulmonary
function was, facilitating the evaluation of his nursing
care needs. When deciding on ABG analysis it should
be considered that interpretation is complex. Furthermore, obtaining a sample may be distressing for
the patient and therefore detrimental to their condition. The approach that patients should not be taken
off oxygen therapy to obtain an assessment of oxygen
levels (Sumner and Rozanski, 2013) should be applied.
Instead of ABG analysis the use of a pulse oximeter
could have been considered, as this is non-invasive
method of measuring the patient’s oxygen saturation
Table 1. Normal values of blood gas analysis
Parameter
Normal value
Decrease
Increase
PaCO2
35–45 mmHg
Respiratory
component:
alkalosis
Respiratory
component:
acidosis
PaCO2
If oxygen levels
in inspired gas
(FiO2) = 21%:
80–100 mmHg
(10.7–13.3kPa
Hypoxaemia: <60
mmHg (8kPa)
Due to increase
FiO2 or increased
atmospheric
pressure
SaO2
95–100%
Hypoxaemia:
<90%
Moen and Coppens (2007)
500
VETN_2015_6_8_498_503.indd 500
(Pachtinger, 2013). However, pulse oximetery only
provides a ratio of the percentage of haemoglobin saturated with oxygen (SpO2) using infared light (Moens
and Coppens, 2007). The PaO2 measured in ABG displays the oxygen molecules dissolved in plasma, i.e.
not bound to haemoglobin. Therefore, to determine
how much oxygen is in the blood, combined measurements of PaO2, oxygen saturated arterial blood
(SaO2) and haemoglobin content (CaO2) need to be
assessed (Martin, 1999). Oxygen therapy was discontinued when the patient was considered stable (reduced RR, improved respiratory effort and improved
pallor) and only auscultation and visual checks continued. A pulse oximeter could have been used for
continued monitoring, giving a measurement of the
patient’s oxygenation. However, as patients with diaphragmatic ruptures are most likely to have issues
with ventilation, measuring the PCO2 or partial pressure of carbon dioxide in the blood (PaCO2) may have
been more beneficial (Barton, 2009).
Fluid therapy
The impairment to cellular oxygen delivery due to
the failure of global tissue perfusion is described as
hypoperfusion and is commonly referred to as shock
(Boag and Hughes, 2005; Jordan, 2012). One of the
most common forms of shock in the emergency patient is hypovolaemia (Boag and Hughes, 2005) and
is characterised in most species by hypotension (decompensated hypovolaemia), tachycardia, pale MMs
with a prolonged CRT, mild to absent peripheral pulses and altered mentation (Boag and Hughes, 2005;
Goggs et al, 2008; Mazzaferro and Powell, 2013).
In comparison to dogs, cats have unique physiological responses to shock and display clinical effects associated with bradycardia, hypotension, and hypothermia, known as the ‘shock triad’ (Kirby, 2004). These
findings are supported by Brady et al (2000) who found
that in cats with distributive shock, over half presented with these three clinical abnormalities. The shock
triad were present in this patient so bolus compound
sodium lactate (Aquapharm 11 Hartmann’s solution,
Animalcare Ltd, York, Uk) 40 ml/kg (127.2 mls), over
30 minutes, was prescribed. This was to be continued
until a minimum BP of 80 mmHg was recorded. During this time the RVN monitored for improvements
in pulse strength, HR and mentation and systolic BP
monitoring was repeated using the Doppler technique.
The veterinary surgeon requested that the fluids were
to be continued at 40 ml/kg, to achieve a minimum
systolic BP of 80 mmHg, with the view to reassessing
fluid administration rates in order to ensure a normal
BP was reached. Waddel and Brown (2009) advise
that in cats a normal systolic BP is between 120–170
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mmHg, with hypotension being defined as less than
80 mmHg. This supports the veterinary surgeon’s goal
of providing shock rate fluids to achieve a minimum
systolic BP of 80 mmHg.
Venous access had to be achieved to provide fluid
therapy, which is often the responsibility of the RVN
(Goddard, 2010). The fur at the patient’s right cephalic vein was clipped, and oxygen supplementation
provided via flow-by during this time. There were no
visual signs of the vein and it could not be palpated,
so, the area at the right lateral saphenous vein was
clipped instead. With successful visualisation of the
saphenous vein, lignocaine 25 mg/g and prilocaine 25
mg/g cream (Emla, AstraZeneca UK Limited, Bedforshire, UK) was applied and left for 15 minutes. A 22 g
intravenous (IV) catheter was inserted by the RVN,
using an aseptic technique and secured and dressed
accordingly. The RVN calculated that 21.2 mls of Aquapharm 11 could be given every 6 minutes, in an attempt to provide the prescribed dose of 40 mls/kg/30
minutes. Although this only allowed the administration of 21.2 mls of fluid every 6 minutes and not the
prescribed dose of 40 ml/kg over 30 minutes. Using
an infusion pump or syringe driver may have been a
more appropriate way to administer the recommended bolus of fluids (Aldridge, 2009).
Although the choice and rate of the fluids prescribed is the responsibility of the veterinary surgeon
the RVN must understand the reasons for selected
rates of infusion and the physiological effects of administration (Sheridan, 2009) to avoid associated
complications such as over infusion or inadequate
fluid resuscitation. It is generally the RVN’s role to
administer fluid therapy, and close observation of
the patient while doing so is important. It should be
appreciated that cats are at risk of volume overload;
careful administration along with thoracic auscultation should be performed to monitor for signs of
pulmonary and pleural fluid accumulation (Kirby,
2004), which would indicate signs of over infusion.
Should these become apparent fluid therapy should
be stopped, oxygen therapy initiated and the veterinary surgeon informed immediately, so that the
patient can be assessed and administration of drugs
(i.e. diuretics) can be initiated if indicated (Davis et
al, 2013).
After the first 127.2 mls of Aquapharm 11 was administered, a systolic BP of 60 mmHg was recorded.
After a further 18 minutes of fluid administration a
systolic BP of 80 mmHg was achieved. At this stage
the patient’s other vital signs had also shown improvement. The RVN noted that peripheral pulses
were stronger, the HR had increased to 168 btpm and
MMs were pinker with a CRT of <2 seconds. The paThe Veterinary Nurse • Vol 6 No 8 • October 2015 VETN_2015_6_8_498_503.indd 501
tient’s temperature had also increased from 34.1oC to
37.9oC and he appeared more alert and responsive.
The method in which this patient was reperfused is
supported by many (Kirby, 2004; Boag and Hughes,
2005; Goggs et al, 2008; Mensack, 2008; Pachtinger,
2013), but it could be argued that perfusion in this patient could have been monitored more accurately by
measuring serum lactate concentrations (Karagiannis et al, 2006) or systemic oxygen parameters (Boag
and Hughes, 2005). It is important to highlight that
(as with this patient) these monitoring tools are not
always available, regardless, the RVN’s role of monitoring critical patients is crucial. They can detect
physiological changes in the patient and facilitate the
development of the care plan to avoid patient deterioration (Polton and Branscombe, 2008).
Hypothermia
In order to avoid peripheral vasodilation, caused by
warming the patient while hypovolaemic, hypothermia was the last abnormality to be addressed. Severe
hypothermia causes the hypothalamus to become
less responsive and if the core temperature drops
below 31°C, thermoregulation is unattainable (Kirby,
2004). To avoid the risk of diminished thermoregulation, patient warming was initiated using the Buster®
ICU cage. This acted like a heated incubator by increasing the air temperature around the patient. It
was decided against the use of blankets so that the
patient could be observed easily. This approach was
also adopted by Tompkins (2013) who opted out of the
use of a forced air warming blanket so that patient observations could be continued without restrictions.
This method did help increase the patient’s rectal
temperature to 36°C. The patient was removed from
the Buster® ICU cage when the environment inside
was deemed to be too hot for the patient to reside
in comfortably. This was judged by observing the
patient’s behaviour for signs of discomfort, e.g. restlessness, panting (Boag and Nichols, 2011) and by
how warm the inside of the cage felt to the RVN. As
previously stated, using a thermometer or thermostat
mounted on the inside of the cage would have been a
more reliable way to assess the temperature and could
have reduced the risk of removing the patient from
an oxygen enriched environment too early.When the
patient was removed from the Buster® ICU cage, passive surface re-warming (with the use of bubble wrap
and blankets) continued until a core temperature of
37.9°C was achieved. The use of heat pads was avoided
to eliminate the risk of skin burns and to prevent peripheral vasodilation. As sensory nerve fibres in the
skin are particularly sensitive to changes in local temperature (Sjaastad et al, 2003), peripheral vasodilation
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Key Points
ll
Diaphragmatic ruptures are a common cause of respiratory distress in cats and
require rapid intervention.
ll
In comparison to dogs, cats have uniquely different physiological responses to
shock and display a triad of clinical effects identified as bradycardia, hypotension and hypothermia.
ll
When advanced monitoring techniques are not available, a successful patient
outcome is still achievable with basic monitoring skills and good underpinning
knowledge.
could cause a reduced response to neuronal feedback,
thus decreasing the body’s ability to maintain core internal temperature (Kirby, 2004).
Armstrong et al (2005) and Byers (2014) suggest
that for moderate to severe hypothermic patients
the use of active surface re-warming, such as forced
air warming blankets, should be considered. These
minimise heat loss by raising the temperature of the
microenvironment of the skin, reducing the temperature gradient between the body and the environment
(Armstrong et al, 2005). The author’s practice does
not currently have a forced air warming blanket, but
this could have been useful instead of passive surface
re-warming. With the use of bubble wrap and blankets it took approximately 4 hours for the patient to
reach an optimal core body temperature, which may
have been reduced with a forced air warming blanket.
Additional recommendations
In addition to the recommendations made in the
previous section the author would suggest that a protocol for the management of dyspnoeic trauma patients is created. Although it is important to consider
the individual needs of a patient, the availability of a
guiding protocol could facilitate the development of
a more efficient treatment plan. A study by Hancill
(2013) found that introducing a ‘care bundle’ (a set of
evidence-based interventions performed simultane-
ously) improved some individual quality indicators,
i.e. patient checks, and although compliance in their
use was low, the potential for these ‘care bundles’ to
improve patient care was recognised. Once guiding
protocols are established, they can be adopted by the
RVNs to ensure that basic therapy, such as immediate
oxygen supplementation or the use of available monitoring systems, is not overlooked.
Patient outcome
The care administered to this patient did have a positive outcome. The patient stabilised overnight and
had surgery to repair the diaphragmatic rupture the
following day. The patient made a full recovery and
was discharged after a total of 3 days’ hospitalisation.
Conclusion
Initial assessment of the dyspnoeic patient identifies
relevant clinical issues and facilitates the creation of
appropriate nursing interventions. In turn, this allows for the RVN to evaluate the care given and highlight any problems that have progressed or improved.
Even when advanced monitoring techniques are not
available, a successful patient outcome is still achievable with basic monitoring skills and a good underpinning knowledge of the pathophysiology of disease
processes in the emergency and critical patient. VN
Acknowledgements
This article was produced as part of the author’s studies at the Royal Veterinary College, Graduate Diploma
in Professional and Clinical Veterinary Nursing. The
author would like to thank the Course leader Perdi
Welsh BSc (Hons)DipAVN (Surg) Cert Ed RVN, module contributors Karen Humm MA VetMB CertVA DipACVECC FHEA MRCVS and Belinda Andrew-Jones
VTS (ECC) DipAVN (Surg) PG Dip Vet Ed RVN FHEA.
With thanks also to Louise O’Dwyer MBA BSc(Hons)
VTS(Anaesthesia & ECC) DipAVN(Medical & Surgical) RVN and Yourvets.
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In: Hotston Moore A, Rudd
S, eds. BSAVA Manual of Advanced Veterinary Nursing,
2nd ed. British Small Animal Veterinary Association,
Gloucestershire: 9–53
Tompkins E (2013) Intensive
nursing care provided to
a patient with permethrin
toxicosis. The Veterinary
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Sharp CR, Rozanski EA (2013)
Physical Examination of the
Respiratory System. Companion Animal Medicine
28(3): 79–85
Waddell LS, Brown AJ (2009)
Hemodynamic Monitoring.
In: Silverstein DC, Hopper
K, eds. Small Animal Critical Care Medicine. Saunders
Elsevier, Missouri: C203
Sheridan L (2009) Fluid therapy – the basics. Veterinary
Nursing Journal 24(1): 33–6
Pypendop BH (2009) Capnography. In: Silverstein DC,
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Sjaastad OV, Hove K, Sand O
Volume 1 Number 1
October 2010
The
Veterinary Nurse
CPD
Monthly international peer-reviewed journal
EDITORIAL
Do we need a new peer-reviewed veterinary nursing
journal?
EDUCATION AND TRAINING
Evaluating the need for continuing professional
development (CPD)
CLINICAL
Small animal post-operative orthopaedic
rehabilitation
Pain assessment and pain scoring models:
a review
Ear mites: tackling a persistent problem
Plant toxicosis in birds: educating owners
The Veterinary Nurse offers a programme of continuing
professional development (CPD) approved by Harper Adams
University College, to provide veterinary nurses access to
CPD.
PRODUCT FOCUS
Manuka honey: an effective wound healing
Clinical
environment
PRACTICAL
Clinical
How to obtain vascular access: the importance
Soft tissue massage techniques
of good placement
and aseptic technique
Animal physiotherapists are highly skilled in the
use of manual therapy techniques, electrotherapy,
hydrotherapy, exercise prescription, the use of gait
aids and various forms of bracing and splinting.
Veterinary nurses who have received appropriate
training in animal rehabilitation are able to administer several treatment techniques including icing, heat
treatment, soft tissue massage, joint ROM exercises,
gentle strengthening exercises, as well as assisting
with hydrotherapy and the animal’s home exercise
programmes.
Following orthopaedic surgery, soft tissue massage
techniques are aimed at reducing muscle tension and
associated pain, to allow normal movement of a joint
or limb. They can also be used to induce relaxation in
an animal in preparation for other stronger treatments.
RESEARCH
The effect of adding butorphanol tartrate to an
acepromazine maleate premedicant on anaesthetic
Figure 6. Three point standing balance exercise.
induction and recovery in dogs
Each issue of the journal will contain an article selected for
CPD – 10 multiple choice questions on that article will be
available for completion online.
Cryotherapy/ice treatment
Ice treatment in the early post-operative period has
been shown to reduce pain (Lessard et al, 1997; Raynor
et al, 2005), swelling and inflammation (Shumway,
2007), improve weight bearing and reduce use of pain
medication (Lessard et al, 1997). Ice treatment can
commence on the day of surgery once the patient’s
body temperature has returned to normal. The cold
reduces blood flow to the area, reducing swelling and
release of inflammatory mediators.
Various flexible commercial ice packs are available; to avoid ice burns they should be wrapped in
a layer of wet material, such as a towel, before being
placed over the affected area. Using repeated, rather
than continuous, ice applications of 10 minutes, helps
sustain reduced muscle temperature without compromising the skin and allows the superficial skin
temperature to return to normal while deeper muscle
temperature remains low.
Ice treatment can be used in this repeated way for
the first 48 hours, then reduced to 10 minute treatments, three times per day for the first post-operative
week, or longer if required.
All animals should be supervised while they are receiving ice treatment and their skin checked regularly
at 5 minute intervals for excessive redness or irritation, to ensure they do not sustain an ice burn.
MANAGEMENT
Creating a nurse rota
PROFESSIONAL
tures, but also allows gentle loading that assists muscle strengthening. When used as part of a structured
physiotherapy programme, underwater treadmill
It is extremely
therapy can accelerate return to function
followingimportant to educate the owner in all
aspects of their pet’s condition, giving them clear and
orthopaedic surgery (Monk et al, 2006).
imporpost-operative
notes, including the impor
Hydrotherapy can commence once concise
the wound
has
post-opertance of rest and confinement to prevent post-oper
healed, typically at 2 weeks post surgery.
ative complications due to over activity.
Hydrotherapy contraindications Home exercises should be clearly demonstrated
and documented.
The owner should practice them
A thorough assessment should be performed
by the
underofthe
supervision of the treating therapist to
referring veterinarian to ensure suitability
hydrocheck to
that
they are able to do them correctly. At each
therapy for each patient. Contraindications
hydroall exercises should be reviewed and updated.
therapy following orthopaedic surgeryvisit
include:
Education of the owner/home
exercise programme
z Open wounds or unhealed surgical incisions
z Vomiting/diarrhoea
There are many different mobility aids ranging
z Elevated body temperature/infection
from doggie wheelchairs to harnesses, protective
z Respiratory compromise
aniboots,
z Severe systemic conditions: cardiac,
liver,ramps
kidneyand slings. When assessing an ani
mal for aids it is important to determine the exex
disease
act needs of the animal, its home environment, its
z Uncontrolled epilepsy
levels, and the owner’s expectations and
z External fixation of fractures (due toactivity
open wounds)
ability to use the aids correctly. Once purchased
z Severe skin irritations
correct fit and use of the aid should be assessed
z Ear infection (if ears could become the
immersed).
and reviewed regularly.
Additional equipment
Veterinary nursing in the UK: moving towards
statutory regulation
Figure 7. Baited stretches encouraging cervical and thoracic
Figure 2. Passive hip flexion.
flexion.
COMMENT
Gentle strengthening
Human wrongs, animal rights
Certification of completed CPD will be available to download
from The Veterinary Nurse website, which can then be
retained in your personal development folder.
Hydrotherapy programmes are best devised by an animal physiotherapist or veterinary nurse with special
training in hydrotherapy for animals.
Swimming is a great form of hydrotherapy and can
be used to increase joint ROM, muscular endurance,
to unload
theaaffected limb or to activate incorrect
encourage limb use and general fitness
providing
medium for exercise when land-basedmusculature,
exercise is tooto ensure each exercise is performed
correctly.
painful. Animals need to be introduced
to swimming
A slow
pace
slowly and closely monitored for signs of
distress
or walking programme can commence
following
removal, initially consisting of a
poor limb use. Always start with small
sessionsbandage
and
5 minute walk for toileting two to four times a day,
increase as the patient improves.
degradually
increasing over the next 6 to 8 weeks de
Underwater treadmill therapy (Figure
5) provides
the animal’s condition, and lameness.
buoyancy to reduce weight bearing onpending
healingon
struc-
Clinical
The Veterinary Nurse • Vol 6 No 8 • October 2015 Passive movements of the peripheral (limb) joints
can be used to reduce pain, regain normal movement
and prevent joint contracture. Passive movements are
performed by the therapist, with the animal in a comfortable and well supported position with their muscles at rest. Movements should only be performed
within pain free range and tolerance of the animal
(Figure 2, 3 and 4).
The aim of these exercises is to take each affected
joint repetitively through its available range of motion.
These movements should not be forced or painful.
Suggested starting dosage: 10–20 repetitions (depending on pain) of affected joints, three times per day.
When to refer on
If at any time during the rehabilitation programme a
patient stops improving, is not achieving the expected outcomes or clinically deteriorates, they should be
referred back to their veterinarian for reassessment.
Conclusions
The addition of rehabilitation programmes to the
management of the post-operative orthopaedic patient can accelerate return to function and greatly
improve quality of life. All patients should be assessed prior to commencement of treatment, have
a tailor made programme and be continually monitored for their response to treatment, with their
programme adjusted accordingly. Animal health
professionals interested in providing this service should complete continuing education in the
small animal rehabilitation field to ensure safe and
effective practice.
VN
Contraindications to treatment
Conflict of interest: none
Controlled exercise including weight bearing or inWhen
creased mechanical load has been shown
to attending
increase for rehabilitation, animals should be
for lameness, swelling, and avail
avail- Acknowledgements:
muscle strength and stimulate bone regularly
and soft reassessed
tissue
joint
range. Owners should be questioned about Dogs in Motion and Animal Physiotherapy Solutions
healing (Thomopoulos et al, 2008).able
Early
controlhow they
feel the animal is progressing both physi
physi- for the use of the photographs included in this article.
led weight bearing following orthopaedic
surgery
can assist in the prevention of disuse muscle atrophy, increase healing and aid the animal’s return to
full function (Oldmeadow et al, 2006). Controlled
weight bearing exercise, such as three
point
Edlich
FR,standTowler MA, Goitz RJ
dola A, Vaz MD (1997) The
after tibial plateau leveling
Affects Knee Joint Mechanics
Braund KG ed. International
efficacy of cryotherapy foldefi
et al 7(1987)
fol
osteotomy in dogs with defiDuring a Single-Legged Drop
Veterinary Information Serving (Figure 6) or baited exercises (Figures
and 8)Bioengineering
lowing arthroscopic knee
principles of hydrotherapy. J
ciency of the cranial cruciate
Landing. Am J Sports Med
ice, New York
along with a slow pace on lead walkingBurn
programme,
Care Rehab 8(6):
surgery. J Orthop Sports Phys
(6): 580–4
ligament. Am J Vet Res 67(3):
35(8): 1269–75
Thomopoulos S, Zampiakis E,
Ther 26(1):
529–36
(1): 14–22
can be used to encourage weight bearing
on TL
the, afafChristensen M,
Raynor MC, Pietroban R, Guller
Das R, Silva MJ, Gelberman
Jakobsen
U, Higgins LD (2005) CryoRH (2008) The effect of musChristensen SS, Olsen M, Moffet H, Richards CL, Malouin Oldmeadow LB, Edwards ER,
fected limbs.
Kimmel LA, Kipen E, Roberttherapy ofter ACL reconstruccle loading on flexor tendonBandholm T (2009) ReliabilRobert
F, Bravo G, Paradis G (1994).
When prescribing exercises it is important
for joint
the range of moson VJ, Bailey MJ (2006) No
tion. J Knee Surg 18(2):123–9
to-bone healing in a canine
ity of knee
Early and intensive physi
physiand circumference
measrest for the wounded: early Shumway R (2007) Rehabilitamodel. J Orthop Res 26(12):
tioneach
therapist to observe the animal performing
exerotherapy accelerates recovery
ambulation after hip surgery
1611–7
urements after total knee
postarthroscopic meniscec
meniscection in the first 48 hours after
cise, correcting any compensatory strategies
they use
References
Small animal post-operative
orthopaedic rehabilitation
Figure 8. Baited stretches encouraging cervical and thoracic
side flexion.
6
There are many different massage techniques available, from gentle superficial techniques to very deep
tissue techniques. In orthopaedic post-operative cases, gentle massage of major muscle groups in affected
limbs is recommended, ensuring the animal is not
caused pain. Massaging towards the heart can help
removal of swelling and waste products from an immobilized area. For safety, deeper techniques should
be reserved for use by an animal physiotherapist or
qualified animal remedial masseur. No massage
should be performed near the surgical site for at least
the first 48 hours. After this time, gentle techniques
can be performed closer to the surgical site, avoiding
the actual wound. Once the wound is well healed,
usually at 2 weeks post surgery, scar massage to the
incision site can be performed if the scar is adhered
to the underlying tissues.
Abstract
October 2010 • Vol 1 No 1 • The Veterinary Nurse
While exercising in water is beneficial, exercises
performed on land cannot be simply repeated in
the water. Movements are generally slower; animals
may have different awareness of their body and limbs
and may also be initially fearful of the environment.
In the human medical world, post-operative rehabilitation is imperative to the
successful outcome of the orthopaedic surgery patient. Rehabilitation of the canine patient is now also becoming recognized as an important facet of veterinary
medicine. Rehabilitation may be provided by a variety of animal health professionals including animal physiotherapists, veterinarians and veterinary nurses. While
having a qualified animal physiotherapist on site to oversee the rehabilitation of all
patients is desirable, it is not always possible and treatment is often administered
by veterinary nurses. This article outlines the aims of rehabilitation following orthopaedic surgery, when to commence therapy, appropriate selection, administration and monitoring of treatment techniques, contraindications and when to refer
on to a qualified animal physiotherapist or back to the referring veterinarian.
Key words: physiotherapy, rehabilitation, hydrotherapy, exercise
I
n the human medical world, post-operative rehabilitation is imperative to the successful outcome
of the orthopaedic surgery patient. Rehabilitation
of the canine patient is now also becoming recognized
as an important facet of veterinary medicine. Rehabilitation may be provided either in the veterinary clinic
or in purpose-built rehabilitation centres by a variety
of animal health professionals including animal physiotherapists, veterinarians and veterinary nurses. Many
countries have qualified animal physiotherapists, who
are able to provide appropriately designed treatment
programmes, transerring their expertise and knowledge to rehabilitation of small animals. While having a
qualified animal physiotherapist on site to oversee the
rehabilitation of all patients is desirable, it is not always possible and treatment is often administered by
veterinary nurses.
Nurses administering rehabilitation programmes
for animals should have completed animal rehabilitation courses and work under the guidance of a veterinarian. When devising rehabilitation programmes
Thermotherapy/heat treatment
Once acute swelling and inflammation has subsided,
usually at 48 hours post surgery, heat can be used to
reduce pain and muscle guarding as well as improve
circulation to the affected area to assist with healing.
Heat wheat packs are ideal as they are light weight
and conform well to the body. Ensure that they are
only ever applied warm. Do not secure a heat pack to
an animal or leave an animal sitting on a heat pack as
this can lead to thermal burns. Application of heat for
10 minutes three times per day prior to passive ROM
exercises is recommended.
After the first 48 hours, or when acute swelling
has ceased, alternating cold and heat therapy can be
used to assist in the removal of swelling. Placing an
ice pack on the area reduces blood flow and swelling,
then heating the area increases blood flow, helping to
‘pump’ out swelling from the affected area. Use heat
and ice alternatively for 10 minutes each, over a 60
minute period, three times per day.
Figure 4. Whole limb flexion (hip, stifle and
tarsal flexion).
Lindsey Connell MAnSt (Animal Physiotherapy)
is Director of Animal Physiotherapy Solutions,
Veterinary Specialist Services, Shop 14
‘Hometown’, Corner of Lexington and Logan Roads,
Underwood, Q 4119, Australia. Michelle Monk
MAnSt (Animal Physiotherapy) is Director of Dogs
in Motion Canine Rehabilitation, Doveton, Australia.
Correspondence to: Lindsey Connell
Hydrotherapy
Water is an excellent medium to assist in the rehabilitation of the post-operative orthopaedic patient. For
the animal patient, exercising in water allows unloading of painful joints, as well as earlier weight bearing on otherwise very weak or painful limbs (Steiss,
2003). Hydrostatic pressure is the pressure of water
on the body surfaces. This pressure increases with
depth of immersion (Edlich et al, 1987) and can be
useful to assist in the reduction of oedema in limbs
following surgery. Friction between water molecules
causes the water to be viscous. The viscosity of the
water adds resistance that can be used to accelerate strengthening when the animal swims or walks
against the water.
2
Figure 5 Underwater treadmill.
5
accelerates recovery. ANZ J
tomy: results of a randomized
surgery. Clin Tech Small Anim Young A (1993) Current issues in
Surg 76(7): 607–11
controlled study. Arch PhysiPract 22(4): 166–70
arthrogenous inhibition. Ann
cal Med Rehab 75(4):415–26
Palmieri-Smith RM, Kreinbrink Steiss JE (2003) Canine RehabiliRheum Dis 52(11): 829–34
pmid/journal/Physiother%20
J, Ashton-Miller JA, Wojtys
Monk M, Preston C, McGowan
tation. Clinical Neurology in
Res%20Int (accessed May 20
EM (2007) Quadriceps InhiInhi
C (2006) Effects of early in
inSmall Animals - Localization,
2010)
bition Induced by an ExperiExperi
tensive postoperative physi
physiDiagnosis and Treatment.
mental Knee Joint Effusion
on limb function
arthroplasty: does tester experience matter? Physiother
October 2010 • Vol 1 No 1 • TheRes
Veterinary
Nurse
Int: http://lib.bioinfo.pl/
Figure 3. Passive hip extension.
4
The Veterinary Nurse • Vol 1 No 1 • October 2010
VETN_2015_6_8_498_503.indd 503
cally and behaviourally. If they have any concerns
or if the animal’s progress has plateaued, a further
veterinary review should be sought.
NEWS ANALYSIS • LETTERS • BOOK REVIEWS • JOBS
Passive ROM exercises
Clinical
www.theveterinarynurse.com
Clinical
Key Points
z Post-operative orthopaedic rehabilitation accelerates recovery.
z Early controlled rehabilitation is essential.
z Early commencement helps to reduce pain, swelling and inflammation.
z Rehabilitation helps to prevent muscle atrophy and increase muscle strength.
z Post-operative orthopaedic rehabilitation increases range of motion.
Lessard LA, Scudds RA, Amenotherapy
for animals it is important
to follow evidence-based
guidelines to ensure that treatments
administered
are2010
The Veterinary Nurse
• Vol 1 No 1 • October
safe and effective, avoiding complications caused by
inappropriate exercise regimens or treatments. This
article outlines the aims of rehabilitation following
orthopaedic surgery, when to commence therapy, appropriate selection, administration and monitoring
of treatment techniques performed by the veterinary
nurse. It looks at contraindications to treatment and
when to refer on to a qualified animal physiotherapist
or back to the referring veterinarian.
7
Clinical
Aims of treatment
protective muscle guarding. For a successful return to
full function
and muscle
strength, joint ROM needs
The aims of rehabilitation
following
orthopaedic
to be restored.
surgery are to accelerate recovery
and return to funcWhen assessing joint ROM it is important to recogtion by reducing pain, swelling and inflammation,
nize factors limiting movement and only work within
improving joint range of the
motion
and
mus-gradually regaining
animal’s(ROM)
pain free
motion,
joint range
as pain
and swelling
decreases.
cle strength, while protecting
painful
and/or
healing
structures. This is accomplished through a combiImproving muscle strength
nation of carefully selected
and administered treatOnce initial pain, swelling, inflammation and musment techniques, in conjunction
with
structured
cle inhibition
are aaddressed,
muscle strengthening
can commence.
Specificfor
strengthening
exercises
and individualized home exercise
programme
the
to grow muscle. In the absence of pain,
animal, to be completed are
by needed
the owner
or carer. An
reflex muscle inhibition will continue without speintegral part of this rehabilitation
programme is the
cific exercise to the affected muscles (Young, 1993).
education of the owner with
regards
to the
Patients
receiving
anorthopaeearly intensive physiotherapy
programme
following
orthopaedic surgery achieve
dic condition and surgery,
the exercise
restrictions
not only more rapid strengthening, but larger overfor the animal after surgery
and exact instructions
all increases in muscle strength (Moffet et al, 1994). Figure 1. Goniometry measuring hip range of motion.
for home care and therapy,
to reduce
incidence
Exercises
should the
initially
be very gentle and controlof post-operative complications
and totothose
accelerate
In conjunction with the objective measures, the
led, progressing
that overload the muscle, altreatowner should be questioned on response to treat
lowing increased adaptation and strength.
recovery.
Assessment and monitoring
Reducing pain, swelling
and inflammation
A thorough
initial assessment of the patient is re-
Pain, swelling and inflammation
common
clinical
quired inare
order
to devise
a patient-specific rehabilitation
programme.
observing or palpatsigns following orthopaedic
surgery
and areBefore
known
ing the patient, the veterinary nurse should obtain
to cause arthrogenic muscle inhibition (Palmierias much background information as possible. This
Smith et al, 2007), where muscles
become
reflexively
may involve
obtaining
veterinary surgery and treatment reports,
imaging results,
expected prognosis,
inhibited or difficult to ‘switch
on’. If muscles
are not
and current
management.
contracting well, atrophy occurs
andmedical
decreased
mus- An understanding of the animal’s home environment and level
cle strength. Physiotherapy modalities, such as ice,
of exercise, both current and prior to injury, will
compression and gentle help
movement,
aretreatment
now comto guide the
programme and home
exercise
advice.
monly used in the orthopaedic
post-operative
animal
Once
these(Shumway,
subjective data
have been obtained, obpatient to help reduce these
signs
2007)
jective assessment can commence. Objective measand assist the animal’s recovery.
ures that can be repeated to determine effectiveness
of treatment are vital. The animal’s posture, willingImproving joint ROM ness to weight bear, lameness and muscle atrophy
should be observed before handling the patient.
Following orthopaedic surgery
joint ROM is often
Lameness assessment is a useful tool; however it is
reduced because of pain,very
swelling,
joint stiffness or
subjective with many different lameness assessment tools identified in the literature. More objective
October 2010 measures
• Vol 1 No of
1 •the
Theanimal’s
Veterinary
Nurse can be made by
lameness
videoing their gait pattern at the start, and end of the
rehabilitation programme as well as at several points
throughout the programme.
Measures of limb circumference and joint ROM using goniometry can also be used as objective markers
to monitor outcomes (Figure 1). These measures have
been proven to be most reliable when repeated with
the one observer (Jakobsen et al, 2009).
The Veterinary Nurse • Vol 1 No 1 • October 2010
proment at home, completion of the home exercise pro
gramme and any other concerns or queries they may
idehave. Each time the animal returns for treatment, ide
ally twice a week, a reassessment should be performed
to determine response to the programme. The outcome
treatof this assessment will help guide progression of treat
ment and ensure the programme stays specific for each
individual patient.
When to start treatment
Treatment should be started on the day of surgery.
Early commencement of treatment following orthopaedic surgery reduces pain, swelling, inflammation,
lameness, use of non steroidal anti-inflammatory
medication (Shumway, 2007), and reflex muscle inhibition, which leads to accelerated muscle strengthening (Moffet et al, 1994). Icing, gentle passive motion
and massage away from the wound, along with early
controlled weight bearing can all start in the early
post-operative period. Hydrotherapy can start once
the wound has fully healed — typically at 10–14 days
post operatively.
503
Treatment techniques
There are a multitude of treatment techniques that
can be administered by the veterinary nurse following orthopaedic surgery. Selection of these techniques must be individualized and based on the assessment findings. Additional factors to consider that
may require modification of the treatment technique
include, the animal’s age, the presence of concurrent
pathologies, aggression or fear and response to pain.
3
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