Comprehensive supportive care is critical in patients with immune-mediated haemolytic anaemia (IMHA), and is vital to improve the rate of good outcomes (Woolcock and Scott-Moncrieff, 2019). IMHA patients commonly require intensive attention, and can often be quite unwell (Garcia and South-Bodiford, 2012). It is therefore reasonable that these patients may require nursing within a high dependency or critical care setting, especially since Breton (2015) reported the complications of IMHA to be extensive.
Vigilant monitoring and attention to detail are required in the IMHA patient (Bays and Foltz, 2019).
Although courses of treatment will be decided by the veterinary clinician, the registered veterinary nurse (RVN) plays an important role in these patients' care. The presenting signs, the administration of the treatment options prescribed, and the potential complications that may arise, give the RVN much to consider in terms of tailoring their supportive nursing to the individual patient.
The RVN should feel comfortable clarifying any nursing instructions with the clinician, and be confident asking questions and making suggestions, in order to deliver the best supportive care (Andrews-Jones, 2012).
Andrews-Jones (2012) asserted that while advanced monitoring machines are very useful, diligent and careful nursing is of utmost importance when monitoring the critically ill patient.
Physical examination and observations
Patient monitoring in critically ill patients is essential, and RVNs are extensively involved in this aspect of patient care (Figure 1). Monitoring should be uniquely tailored to the patient, with frequency of monitoring parameters varying between patients, and between parameters (Andrews-Jones, 2012). Basic patient parameters that must be recorded frequently, regardless of the status of the patient, may include:
- Demeanour/mentation
- Rectal temperature
- Respiratory rate and effort
- Heart rate, pulse quality, mucous membrane colour and capillary refill time
- Chest auscultation
- Bodyweight/body condition score (BCS) (Andrews-Jones, 2012).
When considering the IMHA patient specifically, they may present with tachycardia, a bounding pulse quality, tachypnoea, fever, pale mucous membranes and a prolonged capillary refill time (Piek, 2011; Mitchell, 2017). In critical patients, physical assessments should be frequently repeated because of their dynamic nature. This allows detection of subtle changes which may prove significant, as well as evaluation of the patient's response to treatment (Andrews-Jones, 2012; Savino and Sierra, 2019). These changes may occur because of the underlying disease, or in response to the therapies administered. Deterioration or complications should be identified as soon as possible, allowing adjustments to be made to the patient's treatment plan. Early detection optimises the success of any interventions (Andrews-Jones, 2012).
When caring for a critical patient, the RVN should complete a physical examination in the first instance, to identify baseline parameters. This allows deviation from these parameters to be detected (Andrews-Jones, 2012). In the IMHA patient, this deviation may occur because of worsening anaemia, organ dysfunction or thromboembolism (Tzannes, 2008; Bays and Foltz, 2019). Breton (2015) asserted that monitoring of physical parameters must be undertaken and recorded at least every 8 hours, and changes should be reported to the clinician.
Breton (2015) also recommended monitoring of blood pressure and pulse oximetry, as did Bays and Foltz (2019). If the patient has a central venous line, then central venous pressure can be monitored, however central vessels should not be used in patients with concurrent thrombocytopenia, such as in Evan's syndrome. Central venous pressure monitoring may be a good option if the patient is inclined to fluctuations in blood pressure, or aggressive fluid therapy is administered (Breton, 2015).
Blood pressure should be monitored at least every 8–12 hours, in order to identify if kidney and other organ perfusion is sufficient. If a mean arterial pressure below 60 mmHg is detected, then a risk of organ failure is present because of a lack of perfusion, therefore this should be normalised (Breton, 2015).
Patient examination should also be looking for early indications of disseminated intravascular coagulation (DIC), as this can be a complication found in IMHA patients. Signs such as petechiae on the abdomen, pinna or gums, or excessive bleeding following venepuncture, should be monitored for (Breton, 2015).
Nursing considerations for blood transfusions
Blood transfusions are often required in patients with IMHA (Figure 2), and therefore intensive monitoring for possible reactions is necessary (Garcia and South Bodiford, 2012; Breton, 2015; Bays and Foltz, 2019). Monitoring of vital parameters should be undertaken on any patient receiving a blood transfusion (Gibson and Callan, 2019).
Transfusion of blood products must be administered carefully, and with strict asepsis, in order to reduce the risk of adverse effects. Complications that may arise include transfusion reactions, anaphylaxis, circulatory overload, thromboembolism, sepsis, and infectious disease. Administration and monitoring must be carried out effectively as early identification of transfusion reactions allow prompt treatment. Signs of transfusion reaction the RVN should be aware of may include pyrexia, tachypnoea, tachycardia, vocalisation, arrhythmias, hypotension, muscle tremors, cardiac arrest, and/or a significant drop in packed cell volume (PCV). Signs of anaphylaxis are facial swelling, pruritus, urticaria, pyrexia, vomiting and dyspnoea. Prior to administration of any blood products, a baseline temperature, pulse rate and respiratory rate (TPR), and physical assessment should be recorded. Monitoring during the first 15 minutes of administration is the most critical as the most severe reactions typically occur during this time. The RVN must be especially diligent and parameters should be recorded every 5 minutes initially, alongside constant visual monitoring, and infusion at a lower initial rate. Any significant deviation from the baseline observations must be reported immediately to the veterinary clinician in charge (Garcia and South-Bodiford, 2012). The transfusion should be paused while seeking clinician advice.
Oxygen supplementation and respiratory distress
As pulmonary thromboembolism (PTE) may occur in IMHA patients, and can be disastrous for the patient, close attention to vital signs is paramount. In particular the RVN should monitor the respiratory rate and pattern, allowing early recognition and intervention, which can alter the outcome for the patient (Garcia and South-Bodiford, 2012; Bays and Foltz, 2019). If the patient develops sudden respiratory distress, then a PTE is suspected (Breton, 2015).
Oxygen therapy is not necessarily beneficial to the IMHA patient as the lack of oxygen carrying capacity is the greatest source of hypoxaemia. Oxygen supplementation also provides little benefit in cases with PTE (Garcia and South-Bodiford, 2012). However, if oxygen therapy is used it must be delivered in the least stressful method possible (Breton, 2015).
Fluid therapy and urine output
Administration of fluid therapy is generally undertaken and monitored by the RVN (Garcia and South-Bodiford, 2012; Hughston, 2016). Fluid therapy is an important aspect of treatment for the IMHA patient, with crystalloids often used to stabilise the patient (Breton, 2015) Signs of dehydration should be identified in order to be addressed promptly (Bays and Foltz, 2019). It is important to maintain tissue perfusion, even if the haematocrit is lowered further (Breton, 2015).
Fluid therapy is usually indicated to improve perfusion, and decrease blood sludging, therefore reducing the risk of thromboembolism. It is also beneficial if intravascular haemolysis is present, as free haemoglobin may damage kidney function leading to renal insufficiency (Garcia and South-Bodiford, 2012; Bays and Foltz, 2019). Renal failure can be a complication in IMHA patients, therefore renal perfusion should be maintained through fluid therapy. Fluid therapy also helps the patient cope with high circulating bilirubin levels (Breton, 2015).
Urine output should also be monitored and recorded regularly (Tzannes, 2008; Breton, 2015). This provides an indication of renal function in the critically ill patient (Savino and Sierra, 2019). This is particularly important in the IMHA patient because of the risk of acute kidney injury as a result of hypoperfusion and hypotension. Quantification of urine output, aids monitoring of fluid therapy and assessment in patients with renal disease. The amount of urine produced should match the volume administered (Breton, 2015). The RVN should report any sudden drop in urinary output, as this may indicate acute renal injury. Urine should also be monitored for abnormalities in colour or odour (Savino and Sierra, 2019). In the IMHA patient, hyperbilirubinaemia may cause urine to be pigmented yellow. Haemolysis of RBCs, either as a result of IMHA itself or transfusion reaction, may also cause haemoglobinuria (Tzannes, 2008).
Monitoring of bodyweight is an easy and effective way the RVN can monitor fluid therapy, and any increase of over 10% from baseline should be investigated for evidence of fluid overload, such as tachypnoea, crackles on thoracic auscultation or clear nasal discharge. Swelling of the conjunctiva, known as chemosis, can occur as a late sign of fluid overload. Fluid overload can lead to pulmonary oedema, peripheral oedema, and ascites. In the event the RVN detects signs of fluid overload, the clinician should be informed immediately (Hughston, 2016). BCS may be used alongside bodyweight. In addition, in the author's experience, clinicians might request measuring abdominal width up to three or four times daily in order to assess for ascites. This is undertaken at the level of the umbilicus in order to ensure consistency between nurses.
Infection control
Critical patients must be checked frequently for cleanliness, with any tubes, catheters and bandages kept clean and dry and inspected regularly. Removal or replacement should be undertaken in the event of a problem (Gottlieb, 2019).
As the IMHA patient is immunosuppressed, vulnerability to infection must be carefully considered in regards to catheter hygiene (Tzannes, 2008). Aseptic techniques must be adhered to stringently, because of an increased risk of infection and sepsis (Garcia and South-Bodiford, 2012; Bays and Foltz, 2019).
Intravenous catheters must be inspected regularly (Figure 3) (Garcia and South-Bodiford, 2012), and Andrews-Jones (2012) and Bays and Foltz (2019) recommended at least once daily. In the author's view, all intravenous sites should be inspected four times daily, especially in more critical patients with higher risk for complications. This allows detection of any problems, ensures treatment including medications and fluid therapy are being administered effectively, and avoids patient discomfort.
Close attention must be paid to patency, signs of phlebitis, infection or thrombosis. The catheter should be changed immediately on detection of any of these findings. Any wounds, incisions or insertion points of any medical devices must also be closely monitored. If patient monitoring detects an unexplained fever, this must be immediately addressed as this may be a sign of infection (Bays and Foltz, 2019).
Care must be taken not to expose the IMHA patient to infectious disease. This includes via equipment and materials, as well as other hospitalised patients (Tzannes, 2008). Immunosuppressive therapy may also leave the patient susceptible to urinary tract infections (UTIs) (Swann et al, 2019). The RVN should therefore monitor for any signs of a developing UTI and report to the clinician.
If infections are detected, the clinician may wish to alter the patient's immunosuppressive drug treatment plan, depending on its nature and severity (Swann et al, 2019). Therefore, any signs of infection must be promptly reported by the RVN to the clinician. Swann et al (2019) recommended close monitoring for any signs of the onset of sepsis in the IMHA patient, such as change in demeanour, vital parameters or new gastrointestinal symptoms.
Bays and Foltz (2019) advised wearing gloves when handling the IMHA patient in order to protect them from infection.
Nutrition
In critically ill patients, nutritional support is important for recovery (Latimer-Jones, 2020). IMHA patients commonly have a depressed appetite, therefore adequate nutritional provision must be considered, particularly with prolonged hospitalisation. If the patient is not vomiting, then this is ideally through enteral means. A feeding tube may be considered by the clinician (Tzannes, 2008). Latimer-Jones (2020) described oral feeding as ideal, but because of poor appetite commonly found in critically ill patients, nutrition should be delivered via enteral tubes (naso-oesophageal or oesophageal) before a significant period has passed. Frequent bodyweight checks in hospitalised patients, as advised by Andrew-Jones (2012), along with BCS, will allow the RVN to monitor the effects of adequate nutrition.
Clean water should be available at all times, and small amounts of fresh food should be offered regularly. The RVN should take into account the patient's normal diet when tempting them to eat (Gottlieb, 2019).
Administration of medications and monitoring for side effects
The RVN is also often responsible for administering medications prescribed by the clinician. It is also important for the RVN to be aware of drug side effects, in order to monitor for complications (Tzannes, 2008; Bays and Foltz, 2019).
Side effect of corticosteroids include increased thirst and urination (Tzannes, 2008; Swann and Skelly, 2016; Swann et al, 2019). Therefore, despite fluid therapy usually being indicated and administered (Garcia and South-Bodiford, 2012), water should always be available (Tzannes, 2008).
Azathioprine can lead to bone marrow suppression, hepatic toxicity, adverse gastrointestinal effects, or pancreatitis (Tzannes, 2008; Swann et al, 2019). Mycophenolate mofetil can also be associated with gastrointestinal effects (Tzannes, 2008; Swann et al, 2019), therefore it is recommended to monitor for gastrointestinal signs (Swann et al, 2019).
Cyclosporine may also cause gastrointestinal complications including anorexia, nausea, vomiting and diarrhoea. Administering with food may reduce the chances of such effects, however this carries a risk of drug absorption alteration (Swann et al, 2019).
Leflunomide may lead to lethargy, as well as gastrointestinal effects including vomiting, diarrhoea and/or inappetence (Swann et al, 2019).
The RVN should also be aware of the importance of care when handling these medications. Gloves should be worn and tablets should not be split or crushed, as this presents health and safety risks for the handler, because of the cytotoxic and/or teratogenic effects of some of these medications. In addition, nurses should wear gloves when handling urine or faeces from patients receiving these medications (Tzannes, 2008). Mycophenolate mofetil has teratogenic effects (Electronic Medicines Compendium, 2021), therefore particular care should be taken if the nurse is pregnant, or could be pregnant, as they should not handle this medication.
Monitoring of gastrointestinal signs
As detailed, many of the medications used for IMHA patients have the potential for gastrointestinal side effects (Tzannes, 2008; Swann et al, 2019). Hyperbilirubinaemia may also cause the IMHA patient to feel nauseous. Gastrointestinal problems, such as ulceration or bleeding, may also occur secondary to DIC, or thrombocytopenia, or ischaemic injury (Breton, 2015). Therefore, the RVN should monitor for any gastrointestinal symptoms. The clinician may prescribe IMHA patients anti-emetics, such as maropitant, metoclopramide or ondansetron, because of inappetence, nausea and/or vomiting (Mitchell, 2017).
Blood sampling
The RVN will also be involved in blood sampling from these patients. Blood sampling for biochemistry and complete blood count (CBC) are recommended for patients receiving various immunosuppressive medications to monitor for adverse effects, such as bone marrow suppression and hepatotoxicity (Swann et al, 2019). This testing, alongside electrolyte monitoring, is also useful to ascertain if the patient is responding well to treatment (Bays and Foltz, 2019).
IMHA patients commonly require regular blood sampling, therefore Breton (2015) recommended the placement of a central venous line, provided concurrent thrombocytopenia is not present, unless the clinician feels the patient's platelet levels are adequate. However, while central venous lines facilitate sampling of blood, they are associated with increased risk of thrombus. They may also provide an infection route in patients already considered immunocompromised (Bays and Foltz, 2019). Alternatively, it may be preferable to use the lateral saphenous vein (Breton, 2015).
Tender loving care, general comfort, and reducing stress
Andrews-Jones (2012) asserted the importance of getting to know your patients as an RVN. In the author's experience this allows detection of subtle changes in demeanour and behaviour allowing for quicker identification of deterioration or improvement. It is also useful in the nervous patient to build a relationship.
The RVN should always be searching for ways to improve patient comfort, and should act as an advocate for their patient. Of all the tasks undertaken by the RVN, basic tender loving care (TLC) is possibly the most important (Gottlieb, 2019).
Reducing stress is important in all intensive care patients, not only for overall comfort, but it may also affect morbidity and mortality (Gottlieb, 2019). Providing a calm environment, with reduced stress also encourages them to eat (Latimer-Jones 2020).
Patients with IMHA should be exposed to minimal stress (Tzannes, 2008), therefore the RVN must be considerate of this when handling the patient for physical examination or any other nursing interventions. Stress may also impact clinical parameters such as heart and respiratory rate, giving artificial results.
Savino and Sierra (2019) suggested completing physical examinations and interventions in stages if the patient is dyspnoeic, in order to reduce handling and therefore stress.
Other methods to reduce stress, anxiety and sleep deprivation in the critical patient may include:
- Silencing monitoring equipment
- Reducing traffic in the ward
- Moving noisy patients
- Placing cotton in the ears of noise sensitive patients
- Gentle, calm interactions
- Soothing voices, stroking, and social interaction (Figure 4)
- Turning down bright lights
- Keeping the ward at a comfortable temperature (Gottlieb, 2019).
Patients with severe IMHA may be recumbent, therefore consideration must be given to appropriate bedding (Tzannes, 2008). Collapsed patients must also be kept clean and dry, and turning should be undertaken to avoid lung lobe atelectasis if the patient is unable to turn themselves (Breton, 2015). This should be undertaken every 2–4 hours, or the patient should be kept in sternal recumbency (Davis, 2001). Turning is also important for avoiding pressure sore development and to encourage mobility (Gottlieb, 2019). In the author's experience, even if ambulatory, dogs with IMHA tend to tire quickly. Therefore, having access to toileting facilities that are just a short walk from their kennel is beneficial. Ambulatory critical patients should be walked frequently, particularly if receiving fluid therapy (Gottlieb, 2019).
Conclusions
Canine patients with IMHA have a guarded prognosis, and require diligent nursing care in order to increase the likelihood of a positive outcome. Their needs are comprehensive and individual to each patient, making them incredibly rewarding cases to nurse for the RVN. There are many considerations to bear in mind, either as a result of the clinical presentation of the disease itself, treatment options prescribed by the clinician, or complications that may arise. A wide range of aspects of these patients' care are likely to be undertaken by the RVN, with frequent communication with the clinician influencing their treatment plan.
KEY POINTS
- Canine patients with immune-mediated haemolytic anaemia (IMHA) require comprehensive nursing care from the registered veterinary nurse (RVN), which is vital to improve their outcome.
- Patient monitoring should include establishing baseline parameters, followed by close regular monitoring, with any deviations reported to the clinician.
- The RVN must monitor for complications such as thrombus formation, renal failure or disseminated intravascular coagulation.
- The administration of treatment options, such as intravenous fluid therapy, blood transfusions and immunosuppressive medications, requires close monitoring for adverse effects such as fluid overload or transfusion reactions, as well as stringent infection control.
- Supportive nursing, patient comfort and tender loving care (TLC) form an important part of nursing the canine IMHA patient.