Hi everyone, my name's Sophie McMorran. I'm a registered veterinary nurse and a veterinary technician specialist or VTS in small animal internal medicine. I work for a referral hospital called North West Veterinary Specialists, which is part of the Linnaeus Group, where I make up part of the internal medicine department and I'm one of 4 head nurses.

My areas of interest are endocrinology and emergency medicine. So today I'm gonna talk to you about gaining IV access and fluid therapy. So IV cannula placement is something that we all do on a daily basis as RVNs.

However, it doesn't mean that we should become complacent, because it certainly is not a benign procedure. So we need to stay up to date with our techniques and make sure that we're giving the patient everything that we can to give them the best chance, because if we do relax, then the patient can be compromised and infections and complications can occur, which can be serious. So we do place them routinely and we place them every single day.

They're recommended for all patients that are hospitalised, so if any patient is ever admitted to the hospital, it should be sick enough that it requires an IV catheter, so place one in all of those, and also any patient that's undergoing a sedation or a GA. Now the most common thing that we'll place them for is for fluid therapy, but we can also use it for blood sampling or administering important medication. And most commonly we place them peripherally, so the cephalic vein in the forelimbs is the most common site that we use, and then secondly the tephenous vein.

Now both of those are really great vessels to use, and we need to talk about how we can best access those, which vein we should choose when and what happens if we don't have access to those two vessels. So in the emergency case, every emergency ideally needs an IV cannula. So once we've done our initial assessments, we've performed a CPR, we've performed any CPR if we need to.

The next step is gain IV access in these patients so that we can stabilise them. We can give them fluid therapy rapidly if we need to, and we can give emergency drugs, it's really, really important in your emergency patients. Ideally, we want minimal restraint, so if the patient is recumbent, we can place it while it's late in lateral recumbency, and we want to try and cause as little stress as possible, especially in the patients who are critical.

Any stress can tip them into a really compromised state, so we want to minimise stress, especially in our cats. And IVF tests we can administer many different things, so crystalloids, colloids, parenteral nutrition if the patient's been anorexic for some time and can't eat via mouth, maybe it has injuries to the mouth or or that area. We can administer anaesthetics to anaesthetize the patient through the IV and we can do .

We can administer any emergency medications, so if the blood pressure does drop or if the heart rate drops, they become really bradycardic, we can give drugs to support their cardiovascular system, and then most importantly, CPR so we can give emergency drugs as and when we need to. So they are really important. It's important that we can place them quickly and successfully so that we all always have access as and when we need to.

So when we talk about fluid therapy and vascular access. We need to make sure if our patient is hypovolemic or if they have any perfusion deficits, then that fluid is going intravascularly. So we used to give subcutaneous fluid quite commonly and thankfully this is being phased out.

An IV cannula is really easy to place and it will really support that patient's vascular system. Subcutaneous fluids will not improve a patient's intravascular volume, so we need to get IV access in these patients. And it's also important that we get used to placing IV catheters in different recumvencies so they can't always just be sat in sternal recumbency.

If a patient crashes under an anaesthetic and the IV blows, we need to gain another IV access quickly. If they're in dorsal recumbency, you need to place that IV catheter in that recumbency, so you need practise. And equally in lateral recumbency, if the patient has collapsed, maybe it has a spinal injury, it's been hit by a car, we may not be able to move that patient.

So we need to practise, practise, practise, and use our stable patients to pop them into different recumbencies so that we can try and gain IV access. It will build our confidence and just help with those emergency situations for as and when we need them. And also if the usual routes are not available.

So if the patient has really poor skin or really horrible skin condition on both four limbs, we may need to go to that sofina vessel. If we're not used to placing it, then we need to be up in our practise, because practise makes perfect. Try all of the different techniques, try the different vessels so that if the time comes that we need it quickly in an emergency situation, we're confident and we can go for it.

So before we place an IV catheter, there are different factors to consider. So the patient size is a really important one and one size does not fit all. So years ago when I used the locum, I went to many different practises.

Most of them were really good with IV cannula placements. Some of them did have. Protocols in place that was kind of a one size fits all, and they will place a blue catheter in every single patient regardless of size.

That's not the best practise and we should be changing according to every single patient. If you have a patient over 25 kg, we should be going for more of a green rather than a blue. And we need to make sure that the ball is appropriate for the size of the patient, so.

Also, if we have patients like rabbits, I know so many practises that will only place a yellow catheter into a rabbit ear, even if they have a giant rabbit, you can place a blue catheter in the ear of a rabbit. You need to assess the size of the vessel and assess the size of the patient, and then make your decision accordingly. That's the most important thing for the patient and it will allow you to gain IV access and administer fluid therapy as quickly as you need it according to that patient size.

And also we need to look at the patient's temperament. So if they are really anxious or they're foot shy. Venus vessel may be more favourable.

And this will allow somebody else to restrain the head away from you, so it's safety for you as well. And they can do it studdle, so you don't need to touch the pole, you don't need to restrain the leg. You can just pop the ivy cannula into that sofina vessel while they're being distracted.

You can even feed them treats from the front if you want to, and the sovious vessel may be a much better option for any anxious patient. So take all of these considerations on board. And assess how quickly you need it.

So if you need the IVA test really quickly, then absolutely go to your most confidence in your most commonly placed site. Look at any injuries or edoema, is there any risk of contamination? So is the patient in for a salivary mucous cele and they're dripping saliva right the way down the front, contaminating all of their chest and their forelimbs?

If so, use a hind limb. Do they have ear disease and they're scratching their ears with their dewclaw, which is right next to an IV catheter. We don't want things like pseudomonas to be passing over into the IV catheter site, which can put our patient at greater risk.

So any patients with ear disease, especially if it's itchy, place it in the back leg. And then staff experience also comes into this. So this is where it's really important for, while you're practising, use those stable patients, try a different positions, gain confidence in the stable patients, because if you do have a really collapsed patient, you don't want your least experienced staff member trying to gain IV access because it could be life changing for that patient.

Only when they're confident enough. Should they be then trying IV access in all collapsed patients, so use your staff experience levels and grab the most experienced member to place it in those really poorly patients until the other staff members are up to that level. OK, so what equipment may we need?

So you can see the image of this swab cap at the top, and these are really useful. They're really cheap and it's a small cap that is impregnated with surgical spirit. So they're useful for when you're walking your patients, you can just pop one on the end of the T connector and then you're not risking contamination from the outside environment.

And the most important thing is once you've used this, and you've connected it back up to the IV catheter, that it's disposed. We don't keep these and use them for a second time. And we quite often use a clean litter tray, so we have yellow litter trays which are quite shallow and they're only used for patients GA equipment to be prepared and our IV catheter equipment can go in there as well.

So they can be cleaned and disinfected between every single patient. And in order to plate an IV catheter safely and to prevent any contamination, it starts from the very beginning. So there's no point having an excellent IV cathetic care protocol in place for once it's cared for if somebody is placing it with dirty hands because they haven't washed them, they haven't worn gloves, they haven't used an attic technique at the beginning.

And maybe they've been using, they stuck their tape to the bin or the wall ready to place it on the IV catheter. If you have one of these trays, it'll give you a plate to stick your tape and to have everything contained in a nice, clean, fresh area so that it's already there for you to place your IV catheter. So we should be wearing gloves, ideally and Whether you use a bong or a T connector is up to you and it just depends what the patient is in for.

If it's in for a quick half an hour sedation for a procedure, we may just need a bone. If it's a hospitalised patient, then the T connectors are really useful because they mean you don't need, usually you get needle-free T connectors and you don't need to keep inserting a needle in which can contaminate the T connector and the IV line. You can just use the end, the tip of a syringe and they're really useful so that you can disconnect and reconnect with the other things that you may need to give such as different fluid therapy bags.

And then we just need some dressing material as well. So I don't usually enclose the foot. I think it, it upsets the patient more than it has to.

So I just put a loose bandage around the actual IV site itself and make sure it's. Tight enough to provide the protection it needs, but loose enough to not cause any complications and any swelling. And then in your collapsed patients, so if you have any, a tricky, a collapsed cat, for example, with any tricky veins, the medial to finous vein is absolutely ideal.

So this is great for if. Somebody else has tried IV access, it's really tricky, and you've used up the sofius and the cephalic veins. Then you can see here the sofius vein.

I don't have an image of the latter medial sofius, but it's just on the inside of the leg, and it runs alongside in a similar position to where this vessel does. You can see it quite obviously because it's quite superficial, and you can just plate your IV cannulate in there. It can be a little bit more tricky to tape in and secure, so it's great for your collapsed patients, but they may well pull it out or it may slip out a little easier than what the other sites may do.

Once they start to become a little bit more conscious and a little bit more alert, hopefully by that time you should be able to gain IV access in one of the more common veins. But that can be a go to vessel in any collapsed cat, because even if the peripheral, the other more common sights are really tricky to see, then this one is so superficial, you can usually see it straight away. So that is a great vessel for instant IV access.

OK, so to prepare the site, we need to wash our hands, and we should be doing this between every patient. We need a large area to be clipped and ideally clip off the wings, . Clip off any of the excess hair, so even if it's a particularly if it's a long-haired patient, you can do a 360 degrees clip so that you're not contaminating any of the sides of the tape with the fair.

You want to visualise and I find it really useful to feel the vessel prior to placement. But a tip for this is make sure you're feeling the vessel prior to cleaning it, and once you have cleaned it, you don't touch that area again. So have a really good feel, have a good look to see where about on the vessel looks best for placement, and then once you've cleaned it, don't touch that area and just maintain a sepsis because we're then contaminating that area again as soon as we touch it.

Now we want to ideally place distally if we can, so the furthest down the leg that we can, because then if it does blow or if we don't gain the IV access, we can then try again a little bit closer or a little bit further up the vessel so it just gives us an extra chance. Once the IV cannula is in, we want to advance it, ideally a 30 to 40 degree angle, and really important to make sure that the bevel is up. So the bevel needs to be placed facing you.

We don't want to be placing it with the bevel facing downwards. And it just allows us to know exactly where the IV is going. We can see the bevel, so we can see the base of the the needle itself, and we know exactly where we're placing it.

And one of the important take home messages is always, always apply a layer of tape underneath that IV. I used to work with a veterinary surgeon who always, he was quite old school, he used to always place the IV and then he'd tape over the IV cannula. The next time you get that patient out of its kennel ready for its GA, you guarantee that IV will be on the floor, because there's nothing to anchor the tape to.

It prevents it from slipping out, so place a layer underneath that IV and then it gives just some anchorage to the rest of the tape so, one underneath and then the rest over the IV itself. So when we're taking the IV it should be clean and dry. It shouldn't be contaminated with any fur, and if you do have a patient who bleeds excessively, ideally use a dry swab and just get rid of any of that excess blood.

Anything that's contaminating that tape can contaminate the site itself, and especially if this IV needs to be in for 3 days, if it's a hospitalised patient, we want it to be clean and fresh and dry. So just clean the sites before we place any of the tape. And we tend to place a comfort swab underneath the IV catheter and that's just a small gauze swab, so you can cut a normal sized one into quarters or you can buy the small ones.

We just put a little slit up the centre and then place it underneath the actual bung itself. So put one layer over, tape it in, and then underneath the bung just place that comfort swab. It just gives that extra level of comfort.

If they're feeling that the IV cannula or the bone is rubbing, they're much more likely to interfere with that cannula. So all of these little things will just help with the care and the maintenance, and the patient tolerating that IV cannula, especially if they are long stay patients. And then just secure it in as you can see in this image with just a small amount of soft ban and then a cohesive layer over the top.

So place it nice and gently, we don't need to have any tension on this. The more tension that we have, the more likely we are to see a swollen pore the next day. And then you can just place a piece of tape over it to say your initials, who's placed it, and the date, and also ideally what day it is.

So if it's the 25th of the 9th, which it says on this piece of tape, you can put day one or day two so that you know when it's been placed and what day you're on. And then once the IV cannula has been placed, we need to make sure that we're caring for it appropriately. So ideally twice a day, we should be undressing and looking at that that IV cannula site.

We need to look for any areas that may suggest phlebitis, so any swelling, any redness, any pain. Does it seem painful when you touch it? Is the patient moving their head around and licking the site?

Has the IV slipped, can you see the IV catheter itself? If so, you need to remove it and place a new one. And is there any perivascular leakage?

Is any of the fluid coming out of the site or are there any swellings above the site where it could be going subcutaneously? And we need to check the site itself, so make sure we're not just looking at it through the dressing, take that dressing off. Look at the tape, is the tape still nice and clean and dry, or have they urinated on it, have they slobbered on it?

If so, take it off and just place some fresh tape and give the area a nice clean. Now before we administer any medication or fluids through any of the access ports, we should be cleaning them ideally with alcohol. And then allow that to dry before we go administering any fluids or medication.

And we should be flushing IV cannulas with normal saline every 4 hours and just record that on the hospitalisation sheet. So in the box where we have fluid therapy going along to 24 hours on the hospitalisation sheet, we just have a small box automatically every 4 with an F next to it, which indicates flush. So you don't have to go right in a lot of things.

You just tick that you flushed it and put your initials next to him. If you do flag any complications, then write that on the notes, make sure it's written on the hospitalisation records and on the computer. So what you've found, is it red, is it swollen, but it's still patent and it looked OK, but you want to just keep a closer eye on it, so to check it again in 4 hours rather than waiting, so that you're only doing it twice a day.

And say what site as well. Is it above the line or is it beneath the line? So the more specific you can be, the least chance of complications, and the more we can closely monitor the patient's IV cannula.

And when we flush the IVs. It's useful to be aware that human patients have mentioned that they feel a cold sensation and an unpleasant smell or taste when their IV has been flushed with IV saline, which is quite interesting. And it's something that we can bear in mind for our nauseous patients in particular, if we're flushing their IV cannula with saline and they're going to get an unpleasant smell or taste, this may upset our patients.

So for those, we could try administering it a little bit more slowly. Now you can see on this image we have a sticker which says do not flush. Now these are just really useful to mention because you can buy these from MVS or any of the other wholesalers, and it just alerts people to say there may be a drug in that line.

So if you're about to administer something like paracetamol as an Ebola, don't use this line. If the patient's on potassium, for example, you can just place the sticker next to the bone, which people are likely to give give medication through, just as an extra warning to say don't flush through this line, give it through the other port via the the IV catheter. So really, really useful, definitely handy to have in, and this is also one of the swab caps that I mentioned that impregnated with surgical spirit as well.

OK, so once you've checked your IV cannula, you're happy with it. It seems clean and dry and patent, we need to redress it and it should be clean, fresh dressing twice a day. Now IV cannulas can be maintained for a maximum of 3 days in the hospital, and there have been studies to show that over 3 or 4 days can contribute towards a greater complication risk.

In humans, so that's why ideally we want to keep, we keep an eye on what they were on, whether we're on day 12 or 3, and when we get to day 3, assess is the patient likely to be going home? Does it need removing, or do we need to remove it and place a new IV catheter? And in order to maintain the IV for those 3 days, all of these, all of these things contribute towards us being able to maintain a nice patent IV with minimal complications, because if we don't take all of these steps, the chances of us maintaining that IV for 3 days is slim.

And we tend to say the placement day is day 0. And we monitor, we record the day and the date, each time we plate it and each time we change the, the dressing itself. And then other Ways that we can look out for signs of complications is regular temperature check, so the patient should have a temperature check at least once a day.

They're spike in a temperature and it's not linked to their condition, we don't know why. We need to look at, could that be linked to the IV cannula. If so, we could be starting with signs of phlebitis, and we need to visualise that IV cannula and maybe remove it and culture it, which I'll talk to you about in a moment.

So, complications that can occur, there are many, and I have found an NHS visual visual infusion phlebitis score or VIP score, which is available online. They use it in the NHS for humans and it's really useful. So it shows you what signs to look out for and when we should be acting, what we need to do, and when we need to remove the IV cannulus.

That's a really useful resource that you can use. We need to be checking if it's red, if it's painful, if it's smelly as well, if there's any discharge there. And also quite commonly we might see swollen pores.

So if you do have a swollen pore, it's important to remove all of that dressing, and ideally remove the tape as well. So cutting the tape just to allow a little bit less tension doesn't work. I've tried it and the pore still remains swollen.

So we need to remove that tape and we need to check the IV site itself. And if it's still patent and you're happy with it, place more tape but just place it nice and gently so that there's no tension there at all. And maybe put the patient down to have physio on its paw 2 or 3 times a day so somebody can just gently massage that pore to try and redisperse any of the the swelling.

And the most important thing is to make notes on the patient's records so that if it does need changing and you have notice for this in one area. If we need to change it again in the future, we don't go and place it in that same site. And as you can see by this image, this is a act that was in for spinal surgery.

You can use the ears of these patients. Look how small his legs are. So.

We're likely to be able, we're likely to have complications if we try to place an IV in those legs. Some people absolutely love placing IVs in the legs of taxis and any of the other smaller legged breeds. I personally love to place them in the ear.

I think they're well tolerated as long as you don't do a really bulky dressing. And it's nice and easy. It's great.

Usually if they're foot shy, it's, it's an ideal place to, to place it. And then it's out of the way for if they do need something like spinal surgery, it won't get in the way of any of the diagnostic imaging. So if you do think that there's a complication there, we may need to culture the the IV tip.

So if we do need to do that, which we should be doing it ideally if we have a pyrexia of unknown origin and it's not linked to the patient's condition otherwise, we don't know what's causing the spike in temperature and if it's red and swollen and especially if it's smelly. So just carefully undress and remove that catheter. With sterile scissors, you want to snip the actual tip itself into a sterile universal pot and make sure you're not touching any of the inside of that pot with the scissors or with the rest of the catheter or with your hands.

Seal the pot and just label it to say it's an IV IV cannula tip and we want to send it for culture. It will just culture any specific bacteria to let us know what's grown there. Where that complication could have come from if it is this site that has the complication.

And what treatments we can use, so it gives you a specific antibiotic that will be useful for this specific bacteria. Now this is also useful for things like pseudomonas. If you do have any patients who have ear issues and then they've spiked the temperature, this may pick up on things like pseudomonas as well.

And it's useful for us to reflect on these cases if pseudomonas is found in the IV of a patient with ear disease or skin disease. Maybe put it as a routine that it goes in a hind limb in your practise to try and reduce that complication risk. And then when we're maintaining that catheter, there's other factors to look at, so.

Do we disconnect the fluid therapy or do we leave it attached? So I think this depends on the patient. So as you can see, there's a patient here with the urinary and the faecal catheter bag.

We're walking this patient regularly and we have a fluid therapy bag attached as well. The chances of somebody becoming entangled, whether it be the patient or us, is quite high. The chances of one of those being pulled out because you can't possibly keep your eye on all of them at once, is quite high.

So in these patients, I think definitely disconnect the IV catheter. Every time you do disconnect that IV cannula or the fluid therapy, you are. Increasing the risk of introducing bacteria.

So we need to make sure we're wearing gloves, ideally place a cap of some sort over the bone. So if you have the the swab caps, they're ideal, but if not, place a bong over the end, then make sure you're not contaminating it. And then also cover the IV itself, if you have maybe a patient who has A spinal injury and they can't cock their leg, and it's a male, they will urinate standing up.

There's a high chance it's going to hit that IV cannula in the front leg. So just cover it up if that's the case, and make sure that we are we are putting a bung on the ends of those T connectors so that we can protect it and just keep it as clean as possible. And look at the weather, if we're gonna get a really soggy dressing, the chances are if it's moist and warm, it's gonna grow bacteria.

So all of these factors come into play. And we should treat all of them individually. And then when we look at fluid therapy, we need to assess the patient's dehydration.

So in order to do this, just perform a physical examination. We know that dehydrated patients or hypovolemic patients may have a tachycardia to compensate. They may have alterations in their blood pressure, so maybe they're hypotensive, so they might have a low blood pressure.

So perform your physical exam and then gauge where you think this patient is on a dehydration scale. There's also other things that we can do to assess hydration, such as your PCV and your total protein. We know that with dehydration, the PCV in total protein is likely to go up together.

Because the fluid is reduced in that protein, so it's just the serum or the plasma that's reduced, so the protein and the total protein appears higher. And lactate is also a really useful tool, especially if you have one of the small handheld monitor the devices that you can use in-house in your lab. So lactate becomes increased with a lack of perfusion.

So if you have maybe dehydration, which is stopping fluids from being perfused to certain tissues, that affects the oxygen delivery. And when that occurs, your lactate will start to creep up. With dehydration, that's why you may see an increase in elevated lactate.

So once you start to administer fluid therapy, that lactate should come down. And all of these tests are really quick and easy and cheap to perform in-house, so they can be repeated to assess the successfulness of your fluid therapy. Is it effective enough?

Is our rate high enough? Are those values coming down and responding to our fluid therapy treatment? And when we look at fluid therapy, we, if you look at shock in a textbook, it will say, 0, 60 to 90 mL per kilo.

That may be the case, but now there've been studies to say you don't just give that volume, you are much more likely to have a successful outcome for each patient if you administer each bolus at a time. So we give a 10 or 20 millo bolus depending on the patient, and then we assess all of those vital signs. So perform a TPR has the heart rate come down.

Has the patient's demeanour improved? Has the blood pressure improved? Are the are the pulses now feeling better quality?

If so, we know that our fluid therapy may be affected, effective, and then if we still need more fluids, you can give another bolus of 10 or 20 mL per kilo and just keep on giving and reassessing, giving and reassessing, because that's the most important thing to assess the effectiveness of these fluids and to prevent over infusion, particularly in those small patients. And especially in cats because we can overinfuse them very easily and very quickly. And then we need to calculate our ongoing fluid rate.

So once we feel like we've corrected the hypovolemia, what maintenance rate are we going to put them on? Are we going to just give 4 mL per kilo, or do we need a higher rate of maintenance? And then look at any ongoing losses if we are still vomiting and we're losing lots of fluids through diarrhoea, for example, then we need to factor that in as well.

We don't want to just have this patient on a maintenance rate if we have further ongoing losses, so calculate those in and all of these will help us, well, will prevent us getting a dehydrated patient later on. And then just keep on monitoring that response to fluid therapy. So that's the most important thing that you can do for your patients.

Now, when we come to choosing what fluid therapy to use, crystalloids is the most common fluids that that's used globally, and it's the first line that we go to in the intensive care unit. So crystalloids are just a solution of ions which freely move through permeable membranes. So they do have ions and they do have some of them have electrolytes so that they can support the patients deficiencies that they might have, and they are quite close to the patient's plasma.

So the two most common crystalloids that we use are Hartmann solution and normal saline. So Hartman's solution, also known as lactated ringers, has a closer tenicity to plasma than normal saline does, and it also contains buffers and electrolytes. So it's really useful for those patients who may be losing electrolytes through.

Vomiting and diarrhoea or maybe they're not gaining them because they're anorexic, so this is the go to fluid therapy. Whereas normal saline is more acidic than the plasma, so it's actually quite an acidic solution. So I think the pH is around, I'm sure I read it was 5.4, which is quite acidic.

So we don't want to give this to your everyday patients. Hartman's is a great go to for everyday patients. Normal saline should be used in a more specific way.

So maybe patients with low sodium levels, like your ad. We can use normal saline and it's also also useful for those patients who we shouldn't be given any potassium containing fluids. So maybe the patient has a hyperkalemia, so a high potassium value.

Then we can give normal saline in those instances. And the chloride level is considerably higher in normal saline than in plasma. So in human patients, it has been shown to increase patient's chloride levels and they are doing studies to look at whether that can be detrimental.

So we need to assess the patient's assess the patient's status and look, are they in shock? If so, what type of shock is a cardiogenic shock because they have a cardiac issue and the heart is struggling to pump that fluid around the body and that's why perfusion is being compromised. Or is it because of hypovolemia?

In that case, we definitely need to give fluid therapy. And what's causing the hypovolemic shock? Is it a patient that's been hit by a car and we need to restore, maybe they've had a large haemorrhage, we need to restore that fluid.

So if we can look at these, sorry that the quality of this table is not great, it didn't work very well when I expanded in. But if we can grade the level of shock, so maybe it's we're sat in the severe hypovolemic grade, we can then start to reassess whether our treatment is having a benefit. So are we now reassessing and we're only classed as moderate, or then we're entering the mild hypovolemia stage, and we know that we can desperately use these tools to assess our treatment and are we doing.

And as we mentioned earlier, the shock rate of fluid therapy should be given in bolus. That's much more beneficial to the patient. We may consider colloid support if the patient is really hypovolemic and if we feel that that is necessary.

And the most important. The thing when we're administering especially fast and high volumes, is to monitor cardiovascular parameters and do it regularly. We don't just link the patients up to fluid therapy and leave them because their their needs may change, and that's our responsibility as a nurse to be assessing those parameters regularly and altering accordingly.

Now, before we end, I just wanted to pop in a slide about whether we use normal saline or a heparin solution to flush our IV catheters. So heparin, as we know, is an anticoagulant, and it's commonly used across human and veterinary, the veterinary field. Now we use it because we believe that heparin prevents the formation of clots or a thrombus in the IV catheter.

However, there have been recent studies of the literature where they've reviewed 10 different studies, and what that says is that it's not fully documented whether normal saline is more effective at maintaining patency and reducing complication risks. So, if there's no proven benefit to using heparin. Why do we use it?

So we, there's many different reasons to support the fact that we should just use normal saline, and that's because of one efficiency. So it's more efficient. We can just draw up a syringe of normal saline and use that to flush the IV.

It's cost effective. Why use an expensive drug when we don't need to and it's not proven to have any benefits? And then finally, it avoids errors.

So heparin is on the list of high alert medications. Now this is a a list which is put together in the human field and it's a list that shows you. A list of drugs which has a very narrow margin between the therapeutic range and the toxic range.

So any mistakes that are given, if too much heparin is given, it can very quickly tip over into a toxic or a dangerous range. So why use this drug if we don't need to? So the studies say there's no proven benefit, so normal saline should be the go to fluid therapy, sorry, the go to flush, flush your IV catheters and maintain patency.

OK, full of lots of different techniques. I hope you've found it useful. I hope you can utilise it in practise.

Thank you very much from me. If you do like internal medicine, please follow my Facebook or Instagram page called Veterinary Nurse Medicine Geek, and I'm here to answer any questions. Hi guys, my name's Sophie McMurra.

I'm a registered veterinary nurse and a veterinary technician specialist in small animal internal medicine. I work for a referral hospital called North West Veterinary Specialists, where I make a part of the internal medicine department and I'm also one of 4 head nurses. My areas of interest are endocrinology and emergency medicine, and today I'm gonna talk to you about nursing the blocked bladder, and I've chosen to mainly focus on blocked cats.

So blocked cats present quite commonly, whether you're in a general practise or whether you're in a referral or hospital, and they do vary in severity on how they present. So sometimes they can present comatose and it's a real emergency, but all of these cases do pose a potential life threatening risk. And although both males and females can suffer from idiopathic cystitis quite commonly, it tends to be the males that are more likely to become blocked, and that's because they have a really long narrow urethra and it's that part that tends to block.

It can be with a physical obstruction, so maybe there is a urinary stone there. But quite commonly we can also see this from urethral spasm or also edoema, and they can both be caused by stress. And typically you'll see the edoema in the bladder and also in the urethra itself.

Now stress makes up 90% of these cases, so that tends to be the main cause. So This is why it's so important that we have the owners on board for these cases, because we can do everything under our power to fix this patient, but if we're sending it home in that same environment without educating those owners or without having those owners on board understanding that it's caused by stress, then we're likely to see this patient reoccurring and re-obstructing on a regular basis. It can also be caused by metabolic issues, so struvite is the most common crystal that we see in cats, and calcium oxalate is the second most common.

Struvite is a crystal that can be dissolved with diet, whereas calcium oxalate is not. The calcium oxalate, if this is present in your, in these kitties, then we tend to check the calcium level because it's quite often coincides with a hypercalcemia. And if that's the case, it can be idiopathic and once we resolve the calcium, the hypercalcemia, then the calcium oxalate crystals can be resolved as well.

And then we can have feline idiopathic cystitis, which is we don't know the cause, they just get cystitis and it's a sterile cystitis, it's not bacterial lead. There are many other causes that can cause an obstruction, one of which is neoplasia, any anatomical abnormalities or trauma. Has the patient been involved in a road traffic accidents and have they had a previous You know, previous issue with their bladder.

It could be iatrogenic or it could be an infectious cause, so we could have a bacterial cystitis, but all of these are less common. Now clinical signs, we tend to see these patients dipping in and out of their litter tray. And quite often with the dysuria, they do vocalise quite a lot.

So they may well, Make some screaming sounds or just cry quite a lot. And that's because, as they're trying to sort out that urine, it is painful for them, so they do vocalise quite a lot. We may see lethargy, especially in those patients who have already gained some electrolyte abnormalities and some metabolic abnormalities like acidosis, then we can certainly see lethargy in those patients and nausea and vomiting.

So they call this Pandora's box and that's because The stress can cause edoema of the bladder and the urethra, but it can also cause edoema and swelling of the stomach lining itself, which can cause the vomiting. And also your metabolic acidosis can contribute to causing vomiting in these patients too, so they are likely to feel quite lousy. And then along with the vomiting and the nausea comes anorexia.

Over grooming is a sign that the owners can look out for a home, so quite often they'll put that leg behind the head and they'll groom between those back legs right the way up to the to the penis itself. And that's because they can start to feel pain there and they can start to feel changes in the sensation because it's becoming edematous and it's becoming irritated with that stress. So that's one of the signs that we can educate the owner to say, next time if they do start to over groom and that leg is behind the head and you, you're noticing it's becoming more common and more frequent, then that could be a sign that this patient could start, could be starting to .

To re-obstruct. And abdominal pain. So when you feel the abdomen of these patients, just as you put your fingertips on that abdomen, you can feel a really enlarged, hard, painful and tight bladder.

It doesn't take a lot of pressure at all. You can just feel it with your fingertips and that's incredibly painful for them. So we need to just treat them very gently.

And depending on how far on this, the condition has has developed and how long this patient's been left like this, they can present to us quite depressed, and even in a coma. Now we need to look at initial treatment and along with all patients who present to us, we need to do a physical examination so that we can see what's going on. So your nose to tail examination, check and see what you can find with this patient.

How's the heart rate sounding? Is the heart rate bradycardic because of a possible, because the electrolyte changes because of the hyperkalemia that we may find. Are the pulse qualities, is the pulse quality good?

Do they seem quite hypovolemic or hypotensive. We need to link up all of our other monitoring equipment like our ECG and our blood pressure to get a more thorough examination. And then we need to look at our serum electrolytes.

So what's going on there. So if you have an epoch in house that will run serum electrolytes along with your blood gas as well. So with your electrolytes, these can cause devastating changes to the body, and it has real effects on the cardiovascular system.

Quite quickly this can turn into a systemic illness, and it does require emergency treatment. So we tend to see a hyperkalemia with really high potassium value, which can be incredibly dangerous. And that's because potassium is excreted by the kidneys.

Once that obstruction is there, we can't excrete anything because our yawning can't escape. So that value just increases. But along with our potassium, we also retain our hydrogen ions, which we also usually would excrete.

And that can cause a metabolic acidosis, and that can also be quite severe. So we need to look out for those those signs and we need to correct them as soon as we can. And then also a biochemistry, so we're likely to see a severely aotemic patient, and every time you see aotemia, you need to look at the origin.

And aotemia just means an increase in your renal value, so your urea and your creatinine. Now in this it's obviously poached renal, but just to go through what that means is pre-renal just means anything before the kidney, so dehydration. If our body is dehydrated and we can't perfuse those kidneys effectively, we can't get the waste products to them in order for them to be excreted.

So that's pre-renal. If we have renal in origin, that means that there may be some renal function itself and maybe some kind of renal disease. And then post renal is anything after the, the kidneys, so your bladder and your urethra.

And that's what we have in this case. So The good thing about post renal azotemia is once you relieve that obstruction, usually that azotemia will drop quite a lot, quite quickly. And I used to work with patients with vets when I was a student nurse, and I certainly know of one or two cats that were put to sleep because of the level of azotemia in blocked cats.

However, it's important that it's not the level of the azotemia when the patient is blocked. It's how they start to progress when the blockage is relieved. As soon as that blockage is relieved, that isotemia and those electrolytes should all start to correct, and that's the most important step.

If they are coming in the right direction, then just give them enough time, enough supportive therapy, and they should come in the right direction. So we shouldn't ever think, wow, this obstructed patients too aoemic, we can't treat it because we absolutely can. So, step by step what we need to do in an emergency situation, first of all, we need to remove that obstruction, get that obstruction out and drain the bladder.

And then we need to get some fluids on board. We need to treat that hypotension and they're likely to be hypovolemic and by also giving them fluid therapy that promotes renal diuresis. With renal diuresis, we will start to excrete those.

Electrolytes that have built up, so that potassium, hyperkalemia is likely to correct and also those hydrogen ions will be excreted as well. So that will certainly help with your metabolic disturbances and your metabolic acidosis. Now I mentioned that electrolyte abnormalities can have quite severe effects on the cardiovascular system, and if we are seeing signs like bradycardia or any arrhythmias, then we need to get some cardiac protection on board as well to save the lives of these patients, and we'll talk about that treatment in a moment.

So to relieve the obstruction that totally depends on the cause. So if we have edoema or urethral spasm. It's quite a good idea to pop on a glove, lubricate your little finger, and just pop it into the rectum.

If you can feel a little bump, a little hard bump, then that may be the muscle that's in spasm. And just by gently and slowly massaging that muscle, you can relax it and that will relieve the the obstruction itself. And then quite commonly, we can have mucus plugs in the urethra.

Or even little clots in the urethra, and this can just be milked out of the penis, and as soon as that's out, that obstruction is relieved and the urine will start to flow everywhere. If we can't do either of those things, then we can pass the urinary catheter. And a good thing to use is the lacrimal tear, catheters that we use in rabbits.

They have a blunt end and you can use those. You can, if you can feel a stone, then you just pop your finger beyond the stone, pop in the lacrimal catheter, give it a flush and then release your fingers quickly so that it just blasts that stone back into the bladder so that you can relieve, relieve that obstruction from the urethra. Now every time we do pass a urinary catheter or pop anything into that urethra, we are causing an increased risk of a urinary tract infection because we're giving the bladder, sorry, we're giving the bacteria a nice easy route into that bladder.

However, sometimes we can't be avoided and we need to just get a catheter into these patients. Now we should do this ideally under GA or sedation. Sedation, if the patient is really, really flat already, and we'd need to just give them a little bit of something to sedate them, then that's absolutely fine, but it will work better with a general anaesthetic.

We can give methadone as a premedication because this is a quite a painful condition. So a pure opioid is an excellent choice to have on board. And then you can use ATP providing they are normotensive and you've checked their blood pressure.

We do not want to give ATP to a hypotensive patient. And then you can give midazolam and ketamine because this, this may be an option for a patient who has some severe cardiovascular issues. They're both cardiovascularly stable.

However, ketamine does not have that muscle relaxant. It doesn't reduce the muscle tone, so the urethral spasm is likely to still be there. So it may.

It may not help when you're trying to pass a urinary catheter because that spasm will not relax. And if we're placing, if we're doing a cystocentesis, if we can't relieve it, then it's a good idea to use a butterfly needle. And an extension with a syringe.

If you're putting a rigid needle on a syringe into that bladder, it's a rigid device. It's much more likely to be any movement as you're aspirating that urine out. It's much more likely to cause trauma to the bladder, whereas if you just pop in a butterfly needle with an extension, no matter what you're doing with your syringe, it's not moving inside the bladder.

So it's much It's a more minimally invasive technique, and you're much less likely to cause a euro abdomen. And we also want to avoid repeat cystocentesis because we don't want to cause a uro abdomen. Usually.

Once you put the needle in that hole will just seal up on its own, and you can cause, you can sometimes see a very mild your abdomen if that's the case, then that tends to not cause many issues. If it is quite a large volume, then this patient may need to be taken to theatre. So it is quite dramatic if we do end up needing surgery when we we could have quite easily fixed it.

And to test for your abdomen, we can look at our blood. So once we've relieved the obstruction, that hyperkalemia and the creatinine should be coming down. If it doesn't, it may be an indication that we have urine in the abdomen.

And if you do an ultrasound scan, you can tap that fluid, then you can test your creatinine and your electrolytes on the actual fluid itself. And if it's hyperkalemic and it has an increase in the creatinine, then it's likely to be, it means you have a uro abdomen, so that's going to be urine. OK, so some indications that we need an in growing urinary catheter is the patient who is severely compromised.

So if the patient comes in, it's really flat, we can't pass anything, we can't get a mucus plug out and we can't see spasm. We need to just get a urinary catheter into these guys and get that relief lifted as soon as we can. If we see severe hematuria or really strong crystal urea, then we may need to place a catheter to try and keep a patent urethra.

Post obstructive bladder so if it's been stretched too much, then it causes the bladder to just continually leak because it's overstretched, then we can place urinary catheter in these guys and then if we need to measure our urinary output, so if we have a patient with an acute kidney injury, then we may need to be measuring what's going in and exactly what's coming out. Now a closed urinary system is great. This keeps all of the urine sealed within a bag.

And it can be kept sterile. Reduce the risk of any bacteria flowing up that catheter and it prevents the patient from becoming contaminated with urine all the time. And you can also use this quite easily to measure your urinary output.

So quite often we will make sure that it is working with gravity, so it needs to be below the patient. You can pop it in the litter drey itself and they're tolerated quite well. And it makes it much easier for you to be measuring that urine and draining it regularly.

And then we need to treat the hypovolemia. So fluid therapy will treat the hypovolemia and it will promote the renal excretion of potassium and or hydrogen ions. It promotes the movement of electrolytes into the cells.

And It's questionable what we tend to go for. Do we go for sodium chloride or do we go for a Hartmann solution? So there's pros and cons of both.

We could maybe start with sodium chloride because our patient is hyperkalemic and we don't want to give it a potassium containing fluids to a hypokalemic patient, and hormone contains potassium. However, sodium chloride is very acidic. It's EH is, I'm sure it was about 5.4 when I read.

Don't quote me on that, I'm sure it is around the 5 mark, which is quite acidic, and if you have a metabolic acidosis, essentially worsening. Whereas your hormone solution contains buffers, so that will certainly help your metabolic acidosis and it will help correct that acidosis. And arguably, once we relieve the obstruction, that potassium will come down anyway, and there's such a small amount in Hartmann's solution that it's unlikely to cause any detrimental effects or change this patient's potassium at all.

So, It's up to the veterinary surgeon, there's pros and cons for both of those fluids, but the most important thing is that we get them on board and that we're giving bolus of fluids to this patient. So if you open a textbook, it will say the treatment of hypovolemic shock is anything from 10 to 60 mL per kg in a cat, and it should be given as a bolus. However, studies have shown that if we give smaller bolus more frequently and just keep reassessing after each bolus, we have a much better outcome and a much higher success rate.

Plus it's just much safer for the patients. Cats can become over-infused very quickly. We don't know how much fluid this patient's gonna need, so it's a good idea to give 10 or 20 mL per kilo bolus, reassess, has the heart rate improved?

Has the respiratory rate improved? Is the demeanour a little bit brighter? Has their pulse quality improved?

How's their blood pressure looking and their ECG? Do we need another one? If so, give another bolus, and just keep on reassessing.

These are really poorly patients, so anything can change from minute to minute and it's really important that we're keeping an eye on these patients, especially their cardiovascular system. And then once we feel that we've corrected that hypovolemia, we can then put them on more of a maintenance fluid therapy rate. Whether that's 4 to 6 mL per kg per hour depending on the patient, and depending on the clinical response.

And it's a good idea to have a monitoring machine outside of this patient's kennel for when they do go back to recovery, and you can monitor the blood pressure, you can have the heart rate, ECG continually linked up, especially if they are flat and recumbent patients, then they'll tolerate this quite easily. You can get the ECG pads, stick to the paw pads. I tend to cut them right down, cut any excess, .

Any of the excess plastic off and just have the little centre pad on the on the cat's pad, tape it on, and they tolerate them quite well until they start to become a little bit brighter. And that way you can keep a constant monitor on the ECG and the heart rate and see what's going on if there's any abnormal complexes or arrhythmias. And then assess the mentation as well as the patient starts to feel better, they're likely to become a little bit brighter and maybe start to be a bit more alert.

Now, patients with hyperkalemia above 8. You may see bradycardia, and you know that in any collapsed patient, especially a dehydrated hypovolemic patient, bradycardia is severely abnormal, and we should be, that should be ringing an alarm bell for hyperkalemia or a neurological or cardiovascular issue. So this is likely to be caused by potassium.

Because increased potassium slows the cardiac conduction and the excitability. And on your ECG you may see tall peak T waves. Now you can see here, the T wave is almost the same size as the QRS complex.

So they should be at least 2/3 the size of the QRS complex or the same size to be classed as tall and peaked. So if you just see a small spike, then it's probably unrelated, but it should be around 2/3 at least of that of that QRS complex to be caused by the, the hyperkalemia. And there's many other abnormalities that we may see on an ECG, but unless you're a pro at looking at ECGs then I won't go into too much detail there.

What I will say is that it is definitely a life threatening emergency, so we need to correct this. So if we do see abnormalities on that ECG and we see a bradycardia, well, and all, then we need to correct that and we need to give some protection to that cardiovascular system. So calcium gluconate can be given very slowly IV 1 mL per kilo, and just dilute it with water for injection.

This treats the cardiotoxic side effects of the hyperkalemia, and it just stabilises them those myocytes, so those cells of the heart. However, you do need to be aware that this does not adjust the potassium level itself, it simply just stabilises the cardiac effects and the cardiotoxic effects that the hyperkalemia causes. So get this on board first of all, that will stabilise your patient and then we need to look at correcting the hyperkalemia.

So once we unblock these patients, if that potassium isn't coming down and we're still seeing some severe side effects of that hyperkalemia, then we may need to look at other, other solutions as to how to get that potassium down. And one of the ways that we can do this, we can use a 50% dextrose solution. Well, we give neutral insulin, IV, and we know that.

Insulin sends glucose intracellularly, but that glucose is a co-transporter with potassium, so it will also do the same with the potassium. So we know that we give we give insulin to diabetic patients to bring down that glucose level, and it will do exactly the same so that potassium will come down as well. So when we give The neutral insulin, we need to keep an eye on our glucose levels because they will, it won't pick and choose which one to send it into the cells, it will send both.

And we don't want our patients to now become hypoglycemic. So you can make a 50% extra solution. So you can use 50% extras to make a 5% solution and that's 100 mLs of the 50% extra bottles that you get and you can pop that into a litre of fluids.

And then we can monitor our ETG closely and ideally don't use any potassium containing fluids if the potassium isn't correcting and it isn't coming down with that obstruction, then sodium chloride may be the fluid of choice here. And stabilisation can take between 12 and 72 hours in these patients. So metabolic acidosis can be quite severe and we need to correct it.

So fluid therapy. That usually corrects it quite, quite well. However, if it is quite severe and it's persistent, then we may occasionally need to use bicarbonate.

Now bicarb can cause some other complications like cerebral edoema and potentially fatal complications. So we need to be aware of. We need to weigh up the risks of using bicarb and see if we can correct it first of all, just with our fluid therapy Hartman solution so that we can use those buffers, have them on board and see if it corrects with the fluid therapy.

If it doesn't, then we may need to look at the bicarbonate route. And your normal blood pH is 7.35 to 7.45.

OK, so then once we've stabilised the patient, we need to investigate what's going on and then look at treatment. So urinary crystals, so the most common crystal we see in cats is strevite. And luckily these are dissolvable, so we do have diets that will dissolve these quite easily and it typically takes 2 to 4 weeks, so it's pretty quick to dissolve these, these crystals.

And then second commonly we see calcium oxalates. Now these don't dissolve. And if we do see calcium oxalate in these patients, then hypercalcemia may coincide with it.

So always run bloods and always check your calcium level, your ionised calcium. Quite often that is an idiopathic hypercalcemia, and we can start to correct that in order to bring that level down. Now, we can look at crystals on a urinalysis, but it doesn't necessarily mean that that's what the stone is.

So what we tend to do is we can correct the obstruction, get the patient stabilised, and once they do go home, they can go home on one of the the diets to dissolve the strevi crystals. If it tends to be struvite, then win-win. We see them back after about 4 weeks, and we expect to see those stones about 50% the size.

So if they've halved, then we know our treatment is working, success, carry on as we are doing. If they haven't reduced by 50%, then we may not have stre right there and we may need to look at other other treatment. And if that's the case, that's when we may need to start looking at a surgical route to remove those crystals.

If we're lucky enough to have a crystal come out of the catheter when we, sorry, a stone, when, when we unblock the patient, great, we can send that off the hills for analysis and we know exactly what's going on with that in that bladder with the stones and we know what to do for treatment. And once we have unblocked these patients, it can take a few days for that swelling to be reduced. So that catheter should ideally stay in for a little while, and the myelo catheters are really nice and soft, so they're the best ones to stay in.

If the patient comes back in and it's re-blocked, which quite commonly they can come back in and it's likely that they'll come back in within 2 weeks of re-obstructing. Then we need to look at the home environment. So there are things that we can do.

So we can do a cystoomy, we can remove the stones. We can do a perineal urethrostomy, which is where they remove the penis and they do an opening further down the urethra so that we've got rid of that thin section which typically causes the obstruction and it just prevents the patient from obstructing again. However, It will stop it from obstructing, but it won't stop the cystitis and it won't stop the cat feeling poorly and having A really stressful environment.

So the stressful environment is really the important thing that we need to focus on for these cats, because unless we rectify that, the patient will still obstruct and arguably it is a bit of a welfare issue if they are constantly suffering with cystitis, suffering with an edematous, stomach and bladder and all of the other side effects that come along with stress. However, we've just done surgery to stop it from obstructing, we're not necessarily treating this issue. So the stress is one of the most important things and the most important take home messages for, for the owner.

Now we need to look at pain relief. So, Pain scores are invaluable in these patients. So you can use the Colorado pain score, which is really great for cats, and we tend to recommend doing them as and when, depends on what drug you're using.

If your drug lasts 4 hours, do your pain score every 4 hours. Note down what you've, what score you've been given. And who's performed it, so that next time someone can come along and say, ah, this cat looked painful.

Last time it had a pain score of 4 and it was given buprenorphine, that seemed to have a good effect. So always go back if you can and just note down how the patient has reacted to that analgesic drug that you've chosen. Non-steroidals can be given as long as they're stabilised patients and they're not hypotensive and there's no azotemia still present, then you can give non-steroidals because it, they do have a good analgesic property and it will help with that inflammation.

And they may even reduce the severity of the clinical signs, however, it tend to work much better alongside another analgesic rather than on their own. And opioids are a great choice to give, so you could start them off on a pure opioid, so maybe methadone, and then as they start to get better, you can switch them to buprenorphine. And another good option for these patients is sublingual buprenorphine.

If you still feel that they are a little bit uncomfortable once they go home, you can give sublingual buprenorphine, and it's a great option for your fractious cats if they are hitting at you quite a lot and you're unable to get near them, then you can spray that sublingual buprenorphine into their mouth, and that will just provide some level of analgesia and it works just as effectively, so it's a really great drug to use. And stress management. So again, this is one of the most important things that we need to be saying to this owner.

So we need to try and pinpoint what's causing that stress. So is it when maybe the husband, the wife, the cat lives with the wife and the husband worked away and it's when he comes home. Is it because you've moved house?

Is it because we're in a multi-cat household and it doesn't get on with the other cats? There's multiple things that can be causing stress in cats, and just because other cats don't seem stressed doesn't mean that this one won't be, because every single cat is different and obviously the stress is coming from somewhere. And also we need to reduce, ideally, we can reduce the urine specific gravity.

So cats like concentrated urine. They can quite commonly have urine specific gravity of 1060, and that's absolutely fine. So if we can bring down that specific gravity and just dilute that urine, it will give us a greater chance of preventing the formation of stones and crystals and preventing a further blockage.

The water stations are ideal, wet food as well. Anything that we can do to try and get more water into these patients to bring down that urine specific gravity is great. If they like to drink from a tap, let them drink from a tap.

If they like running water, buy them one of the water stations. Anything you can do will all contribute to the successful management of this condition. Feeding stations, if they don't like to be fed near other cats or, you know, look at all of these different aspects, litter trays, so.

Certain cats get on with others. If there's a group of cats that really they lay together all day, they love each other, they're absolutely fine, and then there's another cat who doesn't do that with those cats, then they, those two groups definitely need separate litter trays. So We can also look at the the cat litter that you're using if they're not fond of the litter, so many different things that cats are quite particular about.

So try to ask as many questions as you can to this owner so that you can try and pinpoint what they may need to change and what could Possibly be causing stress in the, in the cat cos they are complicated creatures and it may not be quite so obvious to us or to the owner, so we need to really delve deeply into the cat's normal life. And then we can use anti-anxiety products. So fairyway or fairy friends is really good.

Fairy friends tends to be the pheromone from a lactating mammary gland. So It's quite motherly. They tend to like that quite a lot.

We have things like zilke, we have calm food from Royal Cannon, which has zilke products in. And then the most important thing is owner education. So if they know what to look out for, if they can set up a little sanctuary in the.

In one of the quiet rooms where they know the cat likes to go with its own litter tray, have it dark, have it covered, have a hidy hole in there, have its food in there if it wants it, especially if they know to expect a stressful situation. So if it is when one of the The members of the household comes home from work. Then we know if that sanctuary is set up, the cats have somewhere to go to escape and it's much much less likely to reoccur quite commonly because they can reoccur and reoccur and reoccur.

It's not just gonna happen once if we don't rectify the stress. And then there are dietary management options that we can use. So, Pills have some options.

Royal Cannon have options. There's many many different urinary diets out there now. The aim is to reduce the urinary pH.

And it should ideally be wet food if we can, because that will help lower that ordinary specific gravity. Now we know in some countries, maybe if the wet food goes off quite quickly because you have a warmer climate, you may need to use a dryer diet and maybe the cat won't eat a wet diet. In those cases we need to do everything that we can in order to try and increase the the moisture in that food.

And the, you know, the wholesalers, the people who've made these diets have have factored that in. So the dry diets will also still be beneficial, but the, the dry, the wet diet is much better if we can get the cat to eat this and if it is appropriate to your surroundings and your climate as well. So ideally we want that your specific gravity being below 1035 and that will just prevent the reformation of crystals and it will give a nicer environment for that for that bladder.

And they also help to decrease urinary concentration of magnesium and phosphorus as well. And as I mentioned earlier, struvite stones can be dissolved, however, it may take between 2 and 4 weeks. So, we tend to send them home with the ordinary diet, see them back in 4 weeks' time.

If those stones have maybe. In size when we do an ultrasound or an X-ray, whichever modality you choose, then we know it's working. Absolutely great.

Carry on. If not, then we may not be dealing with struvite stones. We may have calcium oxalate or maybe we have a stone which has different layers to it.

And those are the cases where we may need to look at other options such as surgery to actually remove those stones and unfortunately we can't dissolve them. And then we can look at different medication to treat urethral spasm, so hyperhase. So the urinary tract is made up of smooth and skeletal muscle.

So hypervise relaxes the smooth muscle and bantrium relaxes the skeletal muscle. So this is a great drug to use. And then if we do have a urinary catheter in as nurses, we need to be looking after this on a daily basis.

So we need to do daily catheter care at least twice a day. So how we do that, we make sure that we are wearing gloves at all times. We need to keep this as attic as possible, and you can see here there's a cat with a urinary catheter in and we're using gravity to pull that cat that urine out.

So it's on the floor on a clean incontinence sheet and there is actually a a a clean disinfected litter tray underneath that tray as well, just to keep it off the floor, sorry, underneath the inco sheet. We need to wear gloves, we need to clean the catheter. So ideally we want to avoid chlorhexidine because it can be quite abrasive to some of the the mucous membranes into some areas.

So Covaine iodine is a great solution to use for ordinary catheters. We want to look at preventing the patient from becoming tangled, so some people like to take the urinary catheter to the tail. Some prefer to take it to the leg.

Others just like to leave it dangling. It depends on the patient and it depends on what you prefer as well. But if the patient is bothered by it, we need to look at ways that we can prevent that tension on the prep use.

And we can also, if we don't want it, if the patient's in a top kennel, we can hang the urinary catheter bag on the front of the kennel just with a little cup, or you can place it in a clean litter tray on the floor and just allow gravity to help help that flow out. And then we need to look at our urinary output. So we should be calculating this regularly.

We need to be monitoring and emptying that urinary catheter bag, ideally every 4 hours or more frequently if we need to. And the normal urine output for a cat is 1 to 2 mL per kg per hour or 25 to 50 mL per kg per day, whichever calculation you prefer to use. So calculate that urinary output.

And look at, is it within the normal range? Is it too low? Do we need to increase fluids for this patient?

Is it really concentrated if we do a USG? This cat urine looked incredibly concentrated, so that looks like it would be quite a highSG and that might indicate that we need to increase our fluid therapy because As we've mentioned earlier, we want to get that urine specific gravity down to below 10:35. So concentrated urine is not our friend in these guys.

So it's really useful to look at the urine volume as a production, sorry, the urine production, look at the volume, is there enough? Is there too much? And then we can assess with urine specific gravity as a really easy, quick and cheap tool.

And when we're looking at the urine, look at the appearance. Is it really dark? Is it brown?

Does it look like this patient is really, it is concentrating its urine and it's really dehydrated? Or is it almost clear like water? Are we giving too much fluid to this patient or are our kidneys not functioning as well as they should be?

Do we need to keep a very close eye on this patient's renal function? Does it have a strong smell? Does it smell fishy?

Could it be a a urinary tract infection? And again monitor the, the volume to see if it's too high or too low. And then note the appearance.

So is it clear or is it cloudy? Is the blood and mucus there? Does it look like there's any sand or grit in the urine that's coming out that could be small urine stones.

So all of these things are really important and they should all be Observed and noted on the clinical record so that we can see if we can find out what's going on, going on in this patient, and it helps us tailor our treatment therapy. So we can look at our fluid therapy rates and we can get a great idea as to how beneficial our fluid therapy rate is for this patient basing that on its urine. And then the nursing care when they're in the kennel, pain scores, I can't stress how important these are.

So do pain scores regularly and note down every single time what pain score you get. There's no point giving an analgesic after doing a pain school but not writing it down, because when you finish your shift and the next person comes along, they have no idea why you gave it, what signs were occurring. Is it, does it seem to be improving at all, or is it actually getting worse?

We need to look at what pain, what analgesics were beneficial, and if there were some that weren't, pain scores are really important and recording what we've found and what we've given. Is equally as important. We do need to bust the collar on these patients.

However, we also need to give them some time with it off. So some of these patients, they're in for stress, we want to minimise the stress as much as possible. Go in, give them some TLC, give them a fuss, get that collar off, try and encourage them to eat some of their wet food.

Anything that you can do as much TLC as possible will definitely be beneficial to these patients, and the Buster collar does seem to be a winner when you need these these patients to eat, remove that collar, give them some TLC and quite often they will start to eat on their own. And also daily grooming, so these patients are used to being able to groom themselves. They now have a buster collar and a urinary catheter attached to their penis.

So if we can groom for them, they're likely to have some discomfort in that area because they have swelling, they're already stressed and now there's a catheter stitch to it. So if we can groom that area, keep it as clean as possible, make them feel as good as we possibly can in our environment, then that will all contribute to a happy recovery. If and when we can, when we're not linked up to a million different wires and once our monitoring equipment is off and our fluids are off, give this patient a hidy hole.

If you can have a little hide in the corner, even if it's a cardboard box and you've cut out a hole, give them somewhere to hide, cover the front of the kennel. Get a radio, put some really low classical music on. If there's a window in your cattery, allow them, face them towards the window, put them in a kennel so that they can see out.

All of these different things really help, and it's a good idea to always have a fairyway plugged in in your cattery because it will just help with those pheromones and distract them from the smell and the sounds of all the other cats that may be in there. Anything that we can do will benefit this patient and will certainly it's likely to help preventing a re-obstruction. And then signs that we need to remove the indwelling urinary catheter is once we feel the patient is recovered.

So if we've given it long enough that that swelling and edoema should come down, we've resolved the metabolic problems and they're no longer hyperkalemic and the acidosis is corrected. If it becomes non patent, so if it does become blocked it maybe a mucus plug or a blood clot or something or a kink, then we need to remove it. If we're performing our daily catheter care and we come across contamination at the entry site.

Or if the cat starts to show any signs of sepsis, so an increase in their heart rate, a pyrexia. Of unknown origin, so it doesn't seem to be linked to anything that the patients presented for. It may be signs that the patient is going into sepsis.

So we need to look at removing that catheter and culture in the tip. So to culture the tip, you can pop it into to remove the catheter, do not touch any of the actual catheter itself, use sterile scissors and gloves and just pop, snip the, the tip off into a sterile universal pot and send that off for culture. So if it does culture any bacteria, you can also look at sensitivity to see what, what antibiotics this the bacteria is sensitive to so that we can treat it successfully.

And then problems that we may see post ordinary catheterization is persistent detrusor ehey. So this is just where the bladder becomes too overly stretched that it struggles to function correctly afterwards. So some of the nerves can be damaged, and these patients can quite often just drip and leak urine.

We can have inflammation, quite severe inflammation to the urethra, because we've popped a rigid catheter up there if it if that's what we've used at the start, and it's important not to ever leave those rigid catheters in place. It should be a nice soft silicone catheter. But it depends how easily this patient was to catheterize.

You can traumatise that urethra quite a lot. And functional urinary obstruction. So if, if the patient goes into spasm again, so those muscles can spasm quite easily in the urethra.

And then if we, we can also see a bacterial urinary tract infection in these patients, and there is quite a high chance, I think about 60% chance of a bacterial UTI in patients who require a urinary catheter, unfortunately. OK, so that's all from me. That was a lot of information to take on board, so I hope you've enjoyed it.

If you do like internal medicine, you can follow my Facebook and Instagram page called Veterinary Nurse Medicine Geek. I hope you've enjoyed it and I'm gonna stick around to answer any questions you might have.