Hospital-acquired Conditions and Complications

A veterinary technician’s approach to prevention and recognition of hospital-acquired conditions and complications, presented by Sarah Harris, CVT, VTS (ECC).

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When providing care for the critically ill patient, secondary conditions and complications are likely to occur. A lack of uniformed reporting in veterinary medicine leaves us with little organized data, but human medicine has extensive research that provides us with compelling results. Treatment for hospital-acquired infections in human hospitals requires hundreds of millions of dollars annually. Additionally, insurance companies are investing significant amounts of time and finances into educating hospital staff, with resources targeted on training registered nurses. These efforts are made with the hope of limiting the millions of people affected and, in turn, saving significant amounts of money. 

Veterinary technicians have an opportunity to strive for a similar impact in veterinary medicine by focusing on education directed at preventative medicine and by executing critical thinking while providing excellent nursing care in the ICU. Hospital-acquired conditions can incorporate a significant amount of complications that we see in our hospitalized patients, and with basic understanding, the prevalence of these conditions becomes clear. 

 

Nosocomial Infections

These are infections that were not present, or even incubating, when a patient arrived in the hospital. Most patients have the potential to develop these infections, but not all do. Certain conditions provide a selection of patients that are much more susceptible to developing nosocomial infections. Some examples of at-risk patients include pediatric and geriatric patients, those receiving immunosuppressive drugs, the neutropenic patient, and the diabetic patient. Additionally, a recent history of malnutrition, open wounds, and post-operative patients are considered at-risk. Procedural influences can affect the likelihood of the development of nosocomial infections. It has been shown that prolonged catheterization, frequent bandage changes, central venous catheters, and blood product administration can increase the patient’s risk of developing these infections. Similarly, environmental influences can also affect likelihood of the development of infection. Prolonged hospitalization, and lengthy surgery and anesthesia can increase patient risk. A significant amount of infections are believed to originate from improper handling and lack of aseptic technique when it is indicated. This warrants a unified hospital protocol for handling fluid lines, catheters and any additional sites which may form infections.

Common infection sites include urinary and respiratory tracts, surgical sites, phlebotomy or IV catheter sites, and, rarely, bloodstream infections. Veterinary technicians should be confident in quickly recognizing signs of infection which can include increased lethargy, malodorous discharge from a wound, insertion site or surgical site, edema, redness, heat, and fever. Frequently the first signs of infection may come in the form of pain or discomfort and if the patient is noted to be vocalizing, avoiding, or attempting to lick the affected area, nosocomial infection should be considered. 

Prompt recognition of infection allows for rapid and effective treatment. If an infection is recognized, submitting a sample for culture and sensitivity can aide in effective treatment i.e. selection of appropriate antibiotics. Nosocomial infections warrant additional considerations such as the presence of multidrug-resistant bacteria which are becoming more and more prevalent. Many pathogens are considered zoonotic and correct identification can help not only by efficiently treating the patient, but also by helping ensure hospital staff safety. Additional supportive care such as wound cleaning and warm or cool compressing can help make the patient more comfortable.

Intravenous catheters provide opportunity for hospital- acquired infection.

 

While predisposing risk factors make it impossible to completely prevent nosocomial infections, the entire hospital staff can make a significant impact on reducing the risk. Practicing excellent hand hygiene, wearing gloves when placing IV catheters and adhering to sterile technique for central lines, urinary and arterial catheter placement should be performed at all times. A hospital protocol should be in effect for the placement and management of higher risk tubes such as central lines, urinary, intraosseous, and arterial catheters. Some of the most influential preventative measures can include creating policies that ensure patients are provided with clean bedding, housing and the surrounding environment. 

 

Fluid Overload

Fluid therapy is an essential component to emergency, critical care, and surgical interventions. Intravenous fluids are frequently administered in efforts to obtain hemodynamic resuscitation by improving tissue perfusion and optimizing cardiac output. However, fluid administration is not always a benign treatment, and we should be aware of the potential side effects. When the body retains too much fluid, a secondary edema accumulates within the body. Fluid overload, by definition, is the condition of pathologic accumulation of extravascular body water with interstitial edema. This edema can manifest primarily within the lungs, or diffusely throughout the body. Fluid overload should always be considered a risk of fluid administration. 

It is well known that some patients tolerate fluid therapy well and others are much more sensitive to the effects. Patients that have a reduced ability to compensate for the increased fluid intake, such as patients with heart disease, and kidney disease are considered the most at-risk. Additionally, it has been shown that cats are more sensitive than dogs, and that our smallest patients, including exotics, carry a high risk of fluid intolerance. 

One possible risks of fluid overload is pulmonary edema.

 

Knowing which patients are most at-risk can benefit the veterinary technician in recognizing signs of fluid overload. Clinical signs may include chemosis, serous nasal discharge, or subcutaneous edema over the hocks, submandibular space and distal limbs. The veterinary technician may auscult a new or worsening heart murmur, as well as crackles, which may represent pulmonary edema. The patient may develop an increased respiratory effort, rate, and may even become dyspneic. At-risk patients should have their weight recorded every 6-8 hours with a weight gain supporting the diagnosis of fluid overload. The veterinary technician can provide additional monitoring including calculations of INs and OUTs if a urinary catheter is in place. Central venous pressure monitoring trends may provide useful information if the patient has a central venous catheter in place, however must be interpreted carefully in light of other contributors, such as changes in right ventricular compliance and vascular tone. 

While prevention of fluid overload can be challenging, avoidance of excessive hydration is important. Additionally, hospital staff should be cautious of IV fluid administration in euvolemic patient. The veterinary technician should also be careful with neonates and exotics when flushing the patient’s IV catheter because even small syringes of saline flushes can become problematic with the smallest hospitalized patients. 

Early recognition of clinical signs is essential in successful treatment of the fluid overloaded patient. If fluid overload is suspected, fluid therapy should be immediately discontinued, and if pulmonary edema is suspected, oxygen therapy should be initiated. Pulse oximetry can be used to help determine oxygen dependency in some patients, but it is not always reliable. Thoracic radiographs should be taken to confirm a diagnosis. Treatment includes diuretic therapy as needed and supportive care. While fluid overload usually can be corrected if caught early, fluid overload is associated with an increased risk of mortality. 

 

Aspiration Pneumonia

In addition to fluid overload, aspiration pneumonia is a respiratory complication that can occur in the hospitalized patient. Aspiration pneumonia refers to the development of a bacterial pneumonia after the inhalation of irritants into the airway. These irritants can include gastric or oropharyngeal contents, food, medications or other foreign materials. Usually, there is an initial insult that causes a reduction in the patient’s airway defense mechanism which leads to a secondary infection.

There is a long list of predisposing factors: laryngeal or esophageal disorders, decreased mentation with an absent gag reflex, recumbency secondary to neurologic disease, sedation or anesthesia, feeding tubes or force feedings, gastrointestinal disease, post-ictal epileptics, head trauma, pain, anxiety, obesity and lower motor neuron diseases, including polymyositis and myasthenia gravis. Signalment does seem to influence the risk of aspiration pneumonia with middle-aged to older, male, large breed dogs being more commonly affected. More susceptible breeds include Labrador retrievers, German shepherds and golden retrievers. However, this statistic is likely impacted by the overrepresentation of these breeds in the pet-owning community due to their popularity. 

Technicians should be able to recognize clinical signs of aspiration pneumonia including: lethargy, cough, tachypnea, respiratory distress, nasal discharge, abnormal lung sounds on auscultation, and fever. If aspiration pneumonia is suspected, diagnostics may include thoracic imaging, cytology and culture, complete blood count, and evaluation of the patient’s oxygenation ability with pulse oximetry. If the accuracy of pulse oximetry is questionable, arterial blood gasses can be beneficial. 

Aspiration pneumonia is an additional respiratory complication that can occur during hospitalization.

 

If the technician identifies the patient as at-risk, preventative measures should be initiated. The recumbent patient should have its head slightly elevated with muzzle pointing downward and the patient’s gag reflex should be assessed frequently. If the gag reflex is absent, intubation should be considered. In the comatose patient, serial monitoring should include swabbing and checking the oral cavity and if nausea is identified, aggressive treatment should be started to prevent vomiting or regurgitation. When the at-risk patient requires oral medication administration, extreme caution should be taken with concern for the potential of aspiration. At-risk patients should not be force-fed.

Success of treatment can vary, but early recognition of aspiration is undoubtedly beneficial. When aspiration events result in aspiration pneumonia, antimicrobial therapy is indicated. Infections are more likely to be antibiotic resistant in patients that have already been receiving antibiotics, or have been hospitalized for more than 48 hours. Airway sampling such as endotracheal or transtracheal wash should be considered for these patients. Nebulization and coupage can be added to the patient’s treatment plan and oxygen support initiated as needed. If the aspiration pneumonia patient quickly deteriorates, recumbency care should be initiated as needed. When changing patient positioning, sternal recumbency should be included as part of the rotation.

 

Gastrointestinal Complications 

Any patient with prolonged periods of hypoperfusion is at risk for injury to the gastrointestinal tract. Additionally, there are many iatrogenic influences in veterinary medicine that can cause gastrointestinal complications, from altered motility to direct mucosal injury. Some of these influences include: antimicrobial and opioid administration, dietary changes, and poorly controlled stress and anxiety in the hospitalized patient. 

Technicians should be looking for changes in a patient's condition, such as increased heart rate or respiratory rate.

 

Some of the clinical signs of gastrointestinal complications include: vomiting, regurgitation, diarrhea, constipation and urine retention, inappetence or decreased appetite and abdominal discomfort. While some gastrointestinal complications cannot be avoided, there are some preventative measures that technicians can take to minimize the severity and frequency of these complications. Preventative measures can include the administration of anxiolytics and should be considered in patients who exhibit signs of stress or anxiety in hospital. The veterinary technician can calculate the patient’s nutritional requirements and avoid over-feeding the eagerly eating patient. Additionally, technicians need to be aware of food allergies and should attempt to feed the patient’s own food when possible. When preventative measures fail: interventions can include medications and probiotics. 

 

Additional Conditions and Complications

There are many other conditions that can fall under the hospital-acquired category. Some of these conditions include acute kidney injury, anemia, and multiple organ dysfunction syndrome (MODS). Thromboembolic events also can be considered hospital-acquired and probably occur more frequently than we are aware. Many diseases and medications in veterinary medicine can make patients at-risk for events such as pulmonary thromboembolisms. 

Iatrogenic complications can occur in veterinary medicine but tend to be less common. Some of these complications include pneumothorax secondary to thoracocentesis or misplaced nasoenteric feeding tube, urethral tear with urinary catheter placement, abdominal aorta laceration secondary to cystocentesis or abdominocentesis, tracheal injuries secondary to intubation or pop-off valve misuse, or soft tissue, orthopedic and dental injuries. While many of these are procedural complications that cannot be completely avoided, efforts towards staff education and development can minimize the frequency.

 

Conclusion

The veterinary technician should be confident that their job responsibilities go well beyond the TPR. The skilled and advanced technician will excel at picking up on subtle changes in their hospitalized patient and can play an essential role in both preventing and treating many of the hospital-acquired conditions and complications that we see frequently in veterinary medicine. 

 

References

Cavanagh, A. A., (2016, August). Hospital-acquired catheter-related bloodstream infections. Veterinary Team Brief, 29-35.

Cavanagh, A. A., Sullivan, L. A., & Hansen, B. D. (2016). Retrospective evaluation of fluid overload and relationship to outcome in critically ill dogs. Journal of Veterinary Emergency and Critical Care, 26(4), 578-586. doi:10.1111/vec.12477.

Lynch, A. H., (2016). Hospital acquired disease: Their fault or ours? In IVECCS 2016: International Veterinary Emergency & Critical Care Symposium: September 7-11 2016, Gaylord Texan Resort & Convention Center, Grapevine, TX (pp. 305-308). San Antonio, TX: Veterinary Emergency & Critical Care Society.

Sharpe, C. R. (2016). Respiratory complications in the ICU. In IVECCS 2016: International Veterinary Emergency & Critical Care Symposium: September 7-11 2016,

Gaylord Texan Resort & Convention Center, Grapevine, TX (pp. 535-540). San Antonio, TX: Veterinary Emergency & Critical Care Society.

Swann, J. W., Maunder, C. L., Roberts, E., Mclauchlan, G., & Adamantos, S. (2015). Prevalence and risk factors for development of hemorrhagic gastro-intestinal disease in veterinary intensive care units in the United Kingdom. Journal of Veterinary Emergency and Critical Care, 26(3), 419-427. doi:10.1111/vec.12434.

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