Daily Plan and Monitoring of the Critical Care Patient

I. Monitor, Record and Interpret Vital Signs

Frequency of monitoring depends on the patient's condition. Vital signs including mentation, heart rate, respiratory rate, temperature, GI motility and comments on tubes, catheters, surgery sites and fecal output should be recorded at least every 4-6 hours.

II. Arterial Blood Pressure and Urine Output

These parameters are critical to measure and document in recumbent patients. Mean arterial blood pressure should be kept above 60 mmHg. Although neonates do not produce significant amount of urine within the first 12-24 hours of life, after that minimum production should be 2-4 ml/kg/h if hydration is adequate.

III. Weigh Daily

1. Interpret daily weight change for growth which is 1-3 lbs/day (~1 kg/day) for most foals.
2. Very sick foals may lose weight within the first 24-48 hours of life.

Editor's Comment - Weight loss will then produce extreme weakness.

3. Foals which gain more than expected in a 24 hr period are having fluid retention (maybe inappropriate ADH). Slow fluids down and monitor urine output.

IV. Oral Feedings - Frequency and Amount

1. Amounts of colostrum or milk; and type of milk - goat's milk, mare's milk or milk replacer and frequency of feedings which is usually 1-2 hours.

1. Bottle feeding is recommended only if a strong suck reflex is present and always keep bottle below level of the pharynx to prevent aspiration, otherwise use a stomach tube.
2. Strictly keep the time intervals between feedings (1-2 hrs) to avoid colic, gastric distention or enteritis.

V. Parenteral Feeding

1. Deduct the amount of volume given this route from the total fluids determined for the day. Always mark new bags of TPN when started.
2. Dedicate one injection port solely to the parenteral nutrition.
3. Aseptic technique is critically important with the administration and catheter care with patients receiving parenteral nutrition.
4. Long term (polyurethane or silicone) catheters only should be used for this purpose.
5. Check liver enzymes, triglycerides daily.

VI. Intravenous Fluids

Record type, flow rate and total daily volume of fluids. Always calculate volumes with all types of fluids given to prevent overhydration or interstitial edema (crystalloids, colloids, parenteral nutrition, enteral nutrition, medications diluted in larger amounts of IV fluids). Additives should be labeled on the fluids as well as noted on records.

VII. Frequency of Chemistry and Hematology Profiles

1. Daily recheck of CBC and chemistry profiles is recommended in hospitalized neonates.
2. Check glucose and acid base every 4-6 hours if prior hypoglycemia or receiving glucose containing fluids.
3. Check lactate levels every 6-12 hours in foals with poor perfusion or hypotension.
4. Check PCV/TP every 6-12 hours in foals high risk for immune-mediated hemolytic anemia.
5. Check electrolytes and acid base balance in patients with severe acidosis, electrolyte derangements, or diarrhea every 6-12 hours.
6. Check creatinine/BUN/electrolytes more than once a day if renal compromise is suspected.
7. Check bile acids, ammonia, and bilirubin daily in foals with hepatic failure or hepatoencephalopathy.
8. Check fibrinogen every 24-48 hours in foals with suspected bacterial infection.
9. Check Clotting profile (PT, APTT, FDP, ATIII, platelets) as indicated in septic foals or in foals with high risk of coagulopathies.
10. Measure central venous pressure (CVP) and colloid oncotic pressure (COP) in critical patients once a day.

VIII. Plasma Amounts and Flow Rate

1. Always check the foal's serum IgG post transfusion and monitor serially.

IX. Oxygen Flow Rates

1. Maintain PaO2 80-100 mmHg when on supplemental O2.
2. PaO2 >58 mmHg without supplemental oxygen may be acceptable in small foals in lateral recumbency and < 36 hours of age. Arterial blood gas should be collected when recumbent foals are in sternal position.
3. Determine PaO2/FIO2 ratio and change the inspired O2 according to the results.

1. Normal is 500 (100 mmHg PaO2/0.21 inspired oxygen percentage).
2. <300 indicates acute lung injury (<60 mmHg PaO2) without O2 supplementation
3. <200 indicates Acute Respiratory Distress Syndrome (<40 mmHg PaO2) without O2 supplementation

4. Remember CO2 does not have diffusion limitation properties like O2. Normal or decreased PaCO2 with low PaO2 most likely reflects a diffusion problem (cardiopulmonary disease; increase FIO2), whereas high PaCO2 with normal or low PaO2 reflects inadequate ventilation (HIE, botulism, musculoskeletal diseases, CNS problems. Use respiratory stimulant or mechanical ventilation in these cases).

X. Frequency of Arterial Blood Gas

1. Twice daily minimum if on O2 insufflation.
2. 4-6 times daily if on a ventilator.

XI. Dose and Frequency

Dose and Frequency of antibiotics, sedatives or anticonvulsants (if seizuring), antipyretics, analgesics or other medications.

XII. Change the Level and Intensity

Change the level and intensity of care gradually. As the patient improves do not discontinue all the treatments at the same time targeted to the same organ system (fluids and diuretics or bronchodilators and nebulization).

XIII. Recheck

Recheck abdominal ultrasound for size of bladder; monitor gut motility and distension, etc.

XIV. Redo Complete Physical Examination Once Daily and Record

XV. Determine Rest Periods When Foal Can Sleep

1. After oral feedings - 1 hour of rest is desirable.
2. Turn lights down and be quiet.

XVI. Daily Convey Progress

Daily Convey Progress to owner and referring veterinarian and keep appraised of current costs.