HISTORY
The cat was first seen as an emergency, having fallen off a 7th floor balcony sometime during the night. On admittance she had a temperature of 34.8°C, very pale mucous membranes, could not walk and was dyspnoeic. She was immediately treated for shock, hypothermia, pain, and dyspnoea. The following day she was given a short general anaesthetic and radiographed. The thoracic radiograph showed pneumothorax with pulmonary haemorrhage and haemothorax, no diaphragmatic line being visible. She had also suffered a fractured L ischium which was badly displaced. It was considered that this needed repair but the thoracic injuries were too severe for the cat to have a lengthy anaesthetic - she was very dyspnoeic under anaesthetic. She had also suffered fractures of all metatarsals on both hind legs, the left being badly displaced. The bladder was intact but the cat was not urinating and so the bladder was expressed manually until 5 days later when bladder function returned and she was able to urinate voluntarily. The thorax was radiographed 3 days later and showed an intact diaphragm and improvement in the lungs. See radiographs at end of case. By day 5 she was very bright, eating well, temperature normal and although still on 0.03mg buprenorphine (Temgesic, Rickett & Coleman) s/c twice daily and 10 mg carprofen orally once daily she was not considered a critical patient. On day 10 she didnt want to eat, had not passed faeces for 3 days, was a little depressed but had normal temperature and no vomitting. She was given i/v fluids and a packed red cell volume showed 20% (L/L), and was started on a course of 30mg ampicillin (Amfipen) s/c daily. Over the next 2 days she ate a tiny amount, had no vomitting, temperature normal, PCV remained at 20% (L/L). Palpation of the abdomen did not reveal any abnormalities. The following day she was very depressed and collapsed, despite daily fluid infusions, with very pale mucous membranes. Her weight at this time was 2.5kg, so she had lost 0.2kg since being admitted, and her temperature that morning was 36.2°C.

This is the point at which this intensive care case starts, as the author was not involved with the cat before this time.

AIMS OF INTENSIVE CARE IN THIS CASE

• To identify reason for collapse 2.
• Treat the above.
• Support body systems to preserve life until animal able to make a recovery and maintain own body systems without external support.

Diagnosis
A conscious radiography in right lateral recumbency was taken of the abdomen. This showed a smudgy appearance to the intestines. This indicated possible ascites and abdocentesis was performed. This involved placing a 23g intravenous catheter aseptically into the abdomen just to the left of the umbilicus. Slightly viscous yellowish fluid was allowed to drip out and a smear was taken of the fluid and stained for microscopic analysis. Before placing the catheter it is important to make 2 fenestrations near the tip with a sterile scalpel blade. This decreases the chance of the catheter becoming blocked by omentum etc. It is also important not to aspirate with a syringe but just allow fluid to drip out, as aspiration encourages tissue to block the passage of fluid through the hole. (Professor Mike Willard, Head of Small Animal Medicine, Texas University). This technique allows small amounts of fluid present in the abdomen to be sampled. The stained sample showed both diplococci and streptococci to be present in large quantities. Therefore peritonitis was diagnosed and a decision made that an exploratory laparotomy had to be performed, in spite of the cat's very poor state of health at this time. The owners were contacted and advised that the prognosis for this cat was extremely poor.

Treatment
The cat had already been put on an infusion of 200mls colloids (Haemaccel, Hoechst Roussel) earlier in the morning, as the PCV had dropped to 18% (L/L) and blood urea was 6 mmol/l. Premedication was given with 0.5mg morphine, after which the cat vomited. Induction was achieved with 1mg diazemuls i/v followed by 10mg propofol i/v. No nitrous oxide was used, due to the anaemia and previous thoracic injuries. Depth of maintenance of anaesthesia was kept as light as possible to preserve blood pressure, which recorded at 79/81 systolic. During anaesthesia the ECG showed multiple single premature ventricular contractions and some other unidentified arrythmias with sinustachycardia at 250bpm. 300mls of purulent fluid was suctioned from the abdomen. A tear in the stomach near the pyloris was sutured, a tear in the liver which was healing, and previous haemorrhage from the right ovary were both noted. The abdomen was flushed with 3L of warm 0.9% saline before closure. Every effort was made to preserve temperature during the surgery.

For a full record of the intensive care that followed see attached inpatient sheets.

Post-operative care
As soon as the anaesthetic was turned off the cat, which was still on oxygen therapy, was dried with a towel. Then a hair drier was used to dry all the fur to stop any further heat loss by evaporation. The cat remained on the heated operating table while this was done. Then it was wrapped in bubble wrap and vet beds and put in an oxygen cage with 2 L oxygen run through a humidifier containing warm water. The oxygen cage was left on the heated operating table and the cat checked every 10 minutes for 2 hours.

INTENSIVE CARE TECHNIQUES USED
Oxygen therapy
This was very important for several reasons. Firstly the cat was anaemic and therefore had a lower oxygen carrying capacity. Secondly the cat was extremely ill and the sepsis requires higher metabolic requirements for the healing process to take place. Also the respiratory system is depressed under general anaesthesia and oxygen therapy is helpful until the animal is fully round. The oxygen was humidified to stop the upper respiratory tract drying. It was also run through warm water in order to heat it a little - oxygen coming from a remote bunker is very cold.

Temperature
This was one of the most critical parameters in this intensive care case. The cat, although adult, weighed only 2.5kg. So there was no fat at all to help insulate this animal, and these very thin cats are very difficult to maintain good temperature. Hourly checks were made on temperature for the first two days and a lot of effort put in to keep Sabrina's temperature up in the normal range. This involved covered hot water bottles, heated drips, bubblewrap, plenty of bedding, running the drip lines through bowls of warmed water and ensuring she kept free from urine contamination. Hypothermia in extremely ill animals post-operatively can make the difference between recovery and death. She also had a large area of the abdomen clipped and was still draining some saline from her wound, so bedding had to changed regularly. See picture above right, taken 6 hours post operatively and the cat is critically ill.

Temperature management was very successful during this case. One hour after the end of anaesthesia the temperature was 37.8°C which was 1°C higher than the pre-operative temperature.

Fluids
Supporting the cardiovascular system is very important in every intensive care patient. In this case it was a good choice to use a colloid as initial pre-operative fluids. In Sabrina's case she was both anaemic due to previous blood loss, and probably hypoprotanaemic due to her peritonitis. Hartmanns was the crystalloid of choice to use after colloids. As she wasn't eating or drinking and was losing fluid into the abdomen she needed daily fluid therapy. In an anaemic patient it is difficult to assess the fluid balance by measuring the PCV, and daily weighing, which is another method of fluid assessment, is also of no use when an animal is producing ascites as the weight will remain the same whilst the animal is becoming dehydrated.

Nutrition
Nutrition was very important in this case and probably could be considered to be one of the critical factors in the intensive care. The practice does not have any means of measuring potassium levels but it was suspected that the cat was hypokalaemic. Hypokalaemia can occur from anorexia, alkalosis, hypovolaemia, prolonged excessive fluid therapy and gastric losses all of which had occurred with Sabrina, bearing in mind her history over the previous 10 days. Hypokalaemia can cause the cardiac arrythmias she suffered from and it also causes muscle weakness. She became so weak post-operatively that she could not lift her head or chew food despite wanting to eat. If left untreated the animal will not usually make a recovery. The practice does not have an intravenous form of potassium, and it would be unwise to administer potassium in this form without any way of measuring the serum levels. Potassium can be absorbed by the body from food within 12 to 24 hours, so the following morning intensive hand feeding began with Hill's a/d which she was able to lick whilst in lateral recumbency. She was fed every hour during the day and evening in an effort to provide some potassium intake and also because, in order to recover from sepsis the energy requirements of the animal are approximately 1.5 times the normal intake requirements. Hill's a/d was chosen as it is specially formulated for critical patients, providing more than twice the nutritional value of normal catfood. It is also supplied as a paste which suitable for syringe and hand feeding. Intensive hand feeding continued until the cat was able to feed itself. See picture left, taken on day 4 when the cat had started to eat by itself.

Animals should be weighed daily to assess whether the feeding regime employed is adequate. Obviously, if the cat is losing weight then the food intake is insufficient. In this case Sabrina lost 0.3kg post-operatively because 300mls of ascites weighs approximately 0.3kg, which makes weighing inaccurate in animals that are losing fluid into a body cavity. After this she kept her weight and by Day 5 she had put on 0.1kg. This meant that nutrition was managed successfully.

Pulse and respiration
Pulse and respiration were monitored regularly. The heart rate on Day 2 seemed quite slow but an ECG confirmed that the arrythmias had ceased and a normal ECG trace was recorded. Respiration remained quite constant throughout.

Bedding and hygeine
This was important for comfort, warmth and keeping the cat dry. Being a female it was decided not to catheterise her, so bedding had to be changed regularly for the first 4 days to avoid urine contamination of the wound and also for temperature maintenance.

Positioning
As the cat was too weak to move for 3 days it was important to turn her every 2 hours to prevent hypostatic pneumonia from developing. At night an effort was made to try and prop her up on her sternum.

Antibiotics
Administration of these were obviously a vital part of Sabrina's intensive care. During and after surgery the cat was given 50mg metronidazole (Torgyl solution, Merial) intravenously in Hartmanns infusion. This was followed up with ampicillin50 mg (Amfipen, Intervet) tablets twice daily and spiramycin 46.9mg/metronidazole 25mg (Stomorgyl 2, Merial) tablets twice daily. These tablets proved very difficult to give and eventually had to be crushed and mixed with a small amount of a/d each time. Constant injections over the previous 10 days had left the cat's neck very bruised and giving injections became difficult.

Analgesia
This was an important part of intensive care as the pelvis was very painful, together with abdominal surgery. Good pain management is necessary for humanitarian reasons, to encourage eating and decrease depression. An animal in pain will have less chance of recovery. The analgesia consisted of 0.5mg morphine (Evans) s/c and 10mg carprofen (Rimadyl, Pfizer) s/c. After 3 days 0.02mg buprenorphine (Temgesic, Rickett & Coleman) was substituted for morphine.

Morale
Stroking, grooming and talking to the animal is a very important part of intensive care. This cat had already been through 10 days of treatment and cage confinement before the peritonitis occurred. Cats can become depressed and give up the will to live so care and attention is greatly needed. See picture right.

Progress
This cat was extremely ill and nobody expected it to survive the first night post-operatively. For the first day it was unable to lift it's head and could not stand until the fourth day when it managed to walk to it's food bowl and litter tray. See picture right. On the fifth day it was very bright and happy and no longer needed intensive care.

The following day it went home and seems to have made a full recovery from the peritonitis. It is walking reasonably well on the fractured pelvis and metatarsals and is passing faeces successfully.

GENERAL COMMENTS ON INTENSIVE CARE
Good intensive care requires a 100% committment on the part of the nurse, and good observation skills are necessary to spot subtle changes in the animal's condition. This case also illustrates that the unexpected can always happen and small changes in condition should always arouse suspicion. It is amazing that this cat could have eaten for 8 days, without vomiting, and was actually recovering from her thoracic injuries whilst she had a hole in her stomach. Fortunately she survived and the intensive care in this case could be considered successful, as the initial aims were achieved.

References
Trauma Management in the Dog and Cat, Houlton, Taylor 1989
Critical Care Nursing, Steve Haskins BSAVA Congress 1999
The Acute Abdomen, M Willard BSAVA Congress 1999