HISTORY
The cat arrived as an emergency; one of two cats that had been witnessed by the finder appearing to be thrown out of a 4th floor window. One cat died instantly and Sulek was brought in by the finder. On arrival the cat was in extreme pain with obvious severe injuries to both hind legs, suspected thoracic injuries due to the severe dyspnoea, very pale mucous membranes which were tinged with blue, cold extremities and collapsed veins - all indicative of shock. Intensive care started immediately and continued for 9 days before the cat was considered to be fit enough to survive the lengthy general anaesthetic required for the necessary major surgery needed to repair the injuries sustained during the fall. These included RH multiple comminution of the talus and compound collapse of the joint space with luxation of the the tibia, LH segmental fracture of the tibia and nondisplaced fracture of the talus, haemothorax and pulmonary haemorrhage with right lung collapse. See radiographs at end of case.

For a detailed account of the intensive care carried out on this cat please see the example day sheet by clicking here.

The general aims of intensive care in this case were as follows:

• Preservation of life and relief from suffering - emergency treatment on admittance 2.
• Maintenance of life - support of body systems not immediately life threatening but which were temporarily unable to function adequately, until such time that those systems were able to function without external support, to allow skeletal repair to be undertaken.  

INTENSIVE CARE TECHNIQUES USED

Oxygen therapy
Oxygen therapy was necessary on admittance and on several occasions during treatment, to support the respiratory system. A pulse oximeter reading taken from the ear (which was white) recording below 90% indicated hypoxaemia, and also observation of dyspnoea which occurred after handling the cat and general anaesthesia all resulted in oxygen therapy being adminstered. This was achieved by using cling film over the front of the cage and passing an oxygen line into the cage. It is necessary to humidify oxygen when using it for any length of time. This is done by passing the oxygen through water before it reaches the patient. If this is not done the animal's upper respiratory tract dries and they can easily become dehydrated. A humidifier was used in this case. See figure 1 above (Note the humidifier attached to cage below.).

Fluid therapy
Hypovolaemic shock can be fatal and fluid therapy was instituted immediately. The cat was showing signs of shock on admittance. See clinical history. Hartmanns crystalloid Ivex no.11 was infused by i/v route at a rate of 50mls/kg for the first hour and then slowed to 10mls/kg/hr. Hartmanns was the correct crystalloid to choose, but as only approximately 25% remains in the circulation after 30 mins it might have slightly better to start the infusion with a plasma replacement (colloid), such as Haemaccel, which has a half life of 2 to 5 hours before being excreted by the kidney. This would have been followed with Hartmanns. Haemodilution is greater when using crystalloids alone, but as long as the PCV does not fall below 20%(L/L) it is not a problem. The cat responded well to the fluid therapy and was sitting up 3 hours after commencing treatment. Haemaccel was used later in the day when the cat had an anaesthetic to allow dressings to be applied to the fractured legs, as the mucous membrane colour was very pale under general anaesthesia. Fluid therapy was continued for the next 2 days until the cat was eating, and able to maintain it's own cardiovascular system.

Analgesia
This is a vital part of intensive care as animals that are in pain are more likely to die than those with good pain management, and appropriate analgesia should always be given on humane grounds. Potent analgesia was given immediately, ie a combination of 15mg carprofen (Rimadyl, Pfizer) s/c and 1mg morphine (Evans) s/c. It is now generally accepted that in thoracic injuries the respiratory depression caused by pain is greater than the respiratory depression caused by morphine, therefore these were suitable analgesics to use. Unfortunately even this combination did not totally aleviate the cat's pain. There are other forms of analgesia, two of which were used in this case. Firstly, after the cat was admitted it was placed in a baker's bread delivery tray lined with vetbeds. This was an improvisation necessary due to lack of suitable equipment. See figure 2 above right. This enabled the cat to be moved from kennels to the treatment area without having to pick it up (which was causing great pain from both the chest injuries and unstable fractures of the hindlegs, despite analgesia). Secondly, support dressings on both fractured legs relieved pain, but this was only possible to do after the shock treatment was complete and a short general anaesthetic was considered safe.

Other medication
As the cat had an open fracture and other injuries, antibiotic cover was provided daily with 50mg of cephalexin (Ceporex, Schering-Plough) s/c. On Day 4 the cat's breathing became very wheezy and after assessment by the clinician, was given 70mg etamiphyline camsylate (Millophyline, Arnolds) s/c and 5mg frusemide (Lasix, Hoechst Roussel) i/v. On Day 6 the analgesics were changed to 0.05mg buprenorphine (Temgesic, Rickett & Coleman) s/c twice daily and 15mg carprofen once daily.

Monitoring pulse, respiration and temperature
Sometimes compromises have to be made depending on the patient's particular problems. This cat was of nervous temperament and severely dyspnoeic for the first 3 days. Cats often die if they are severely dyspnoeic and are subjected to any further stress. Monitoring was strictly limited to observation for the first few hours, due to dyspnoea. Oxygen therapy, analgesia and fluids were the priority and then the cat was placed in an oxygen cage, not to be handled unless apnoea occurred. A towel was placed over the cage and visual observation took place every 10 mins. Quite frequently over the next two days monitoring was abandoned due to dyspnoea. Pulse or heart rate was difficult to record, due to the dressings on the hindlegs and the haemothorax made listening to the heart difficult. Measuring capillary refill was difficult due to stress. Having one person looking after the cat helped in this case as it was so nervous, because animals become accustomed to one person after a couple of days and become less stressed. This became evident when someone else was asked to weigh him and he panicked, resulting in a severe attack of dyspnoea. Having one person assigned to an animal also allows subtle changes to be noticed because they get to know the animal's habits and character. Temperature is extremely important in critical patients. Every effort should be made to keep the temperature up in the normal range (assuming it is not high due to infection) as this can make the difference between recovery and death. In this case temperature was not the main concern except after each general anaesthetic when the temperature fell to 35°C - 36°C. Wrapped hot water bottles, vetbeds and bubble wrap were used on these occasions and the temperature was up again after 2 to 3 hours. Generally he probably kept reasonable temperature due to being fat and having the hindlimbs bandaged. His blood pressure was measured on the second day using an indirect doppler. The systolic recorded at 120 which was reasonable, as dopplers tend to record a little low on cats, and indicated that the shock had been managed adequately. Blood samples measuring the packed red cell volume and blood urea were taken on the first day to act as base samples for monitoring over the next few days. This could give an indication of the state of bleeding within the thorax and the blood urea was taken as a bladder could not be palpated initially. It was decided not to drain the haemothorax, as continued bleeding would have resulted in anaemia. Previous cases have shown that the blood is usually reabsorbed. The PCV fell from 38% (L/L) on admittance to 25% the following day. This was mostly due to haemodilution by the crystalloid infusions. The following day the PCV fell to 23%, which was just below the bottom of the normal range, but acceptable. The following day the PCV was recorded at 25% (L/L).

Radiography
This was an important adjunct to the intensive care nursing. Radiography was used to evaluate the extent of the injuries. See radiographs 1 to 9. This revealed the injuries described in the clinical history. The results from the radiographs showed that the cat had suffered right lung collapse, which was relevant information for subsequent intensive care. This meant that the cat should not be placed in left lateral recumbency, because the weight of the upper lung and heart always compromises the lower lung - so the good lung should never be placed under a dysfunctional one. This appeared to have quite a marked effect when the cat moved itself into left lateral recumbency, and dyspnoea increased within 2 to 3 minutes.

Nutrition
Nutrition is extremely important during intensive care. Water balance in the body can be maintained with i/v fluids but nutritional needs must be either met orally, with feeding tubes or parentally with specially prepared i/v solutions. These are very expensive and not available at this practice. In this case, although recumbent and inappetant, the cat would eat if coaxed and handfed. This is time consuming but a suitable amount of food can be given if fed often. The first 2 days proved to be difficult, but thereafter with a lot of effort he ate enough to maintain his bodyweight. Lack of nutrition will lead to a lowered immune system and the energy requirements of the body to repair tissues is greatly increased in this severity of trauma (1.5 to 1.7 times the maintenance energy requirement). Hills a/d diet was used in this case as it has a much higher nutritional value than normal catfood and is the diet formulated for post-operative care. The fact that this cat was overweight is of no consequence with regard to intensive care - if an animal moves into a catabolic state, healing of tissues will be much slower.

Bedding and hygiene
Ample bedding was used to cover all the area of the kennel, firstly because it is more comfortable than lying on newspaper only, and secondly to keep the cat warm. Vet beds were also used to cover the cat and, if needed, hot water bottles were placed under the vetbeds. These are not ideal, as close monitoring is necessary to ensure no burns occur. See figure 3 right. Ideally the cat should have had a urinary catheter placed and attached to an empty drip bag, both to stop soiling and to measure urine output. This was one area where the care could have been improved. However, the cat was being monitored closely and as soon as urine or faeces were produced the bedding was changed so the dressings did not get wet and the cat did not get soiled with faeces. Monitoring urine output will indicate whether the fluid therapy is adequate - for this cat urine output should be 5 to 10mls per hour.

As the cat progresses to moving around it is a good idea to allow the animal to choose the most comfortable position for itself, even if it looks very painful to us, rather than trying to reposition it to what we would assume to be a comfortable position. See figure 4 left.

It is also helpful to provide anything that might help with patient comfort. In this case a box was used to raise the food bowl up to a height where the cat could reach it from the position it found most comfortable to be in. See figure 5 below.

Morale
Often described as TLC, this is an extremely important part of nursing any critical patient. Cats, particularly, if depressed give up the will to live and need the comfort of being stroked, groomed and talked to. Morale visits should not be confined to treatment times, as when combined with painful treatments, will be of little benefit. Stroking etc. is also an important way to get inappetant cats to start eating.

Progress
The cat responded well to the initial shock therapy but severe dyspnoea was a problem for 2 days, necessating oxygen therapy. Thereafter, although still dyspnoeic there was some improvement and oxygen therapy was no longer needed. On Day 4 the breathing became audibly wheezy, was treated, and seemed to resolve by Day 6. The cat's thorax was radio-graphed on the first, second and third day and each day unfortunately showed more haemorrhage. By Day 4, the breathing became audibly noisy. After treatment the breathing improved and by Day 8 appeared normal. Radiography on the first day showed that the bladder was intact and the cat was able to urinate. The cat was comfortable with the dressings and generally very bright. On Day 9 it was declared fit for orthopaedic surgery and has been booked for repair of the left hind and assessment of the right, after radiography of the thorax showed confirmation of a diaphragmatic line and clearing of the lungs. The radiographs/photos of the radiographs are arranged in chronological order.

GENERAL COMMENTS ON INTENSIVE CARE
It is indisputable that intensive care increases the chances of survival in critical patients. However, good intensive care is only possible if the facilities, expertise, drugs and staff solely dedicated to intensive care are available. The advantage of this type of monitoring is that trends can be spotted and treated before they become critical. In this particular case the intensive care can be considered successful, as the intensive care aims had been achieved.

References
Trauma Management in the Dog and Cat, Houlton & Taylor. Wright 1987
Diploma Notes