Perioperative ivft for routine ops.

Re: Perioperative ivft for routine ops.

Anthony Todd — Sun, 02 Sep 2012 12:23:14 GMT

[quote user="James Laidlaw"]Had to reply to this too[/quote]

This link gives a perspective particularly the second last paragraph....

http://www.whitecliffsvets.co.uk/Jabs.pdf

Re: Perioperative ivft for routine ops.

Rob Loxley — Sat, 01 Sep 2012 18:45:27 GMT

[quote user="Lorna McHardy"] If I do think it would benefit from intraoperative fluids I'll say so very clearly[/quote]

I'd just put it on the estimate. Likewise I'm not going to start a discussion with the owner about what suture material to use or whether or not perioperative antibiotics would be prescribed.

At least with thio gone the box for 'super-dooper-propofol-extra' has gone (or has the alfaxan box taken its place?)

Re: Perioperative ivft for routine ops.

Lorna McHardy — Sat, 01 Sep 2012 18:08:12 GMT

[quote user="robloxley"]

We don't routinely give fluids to young, healthy ops, but will add it into the estimate for an op where we consider it appropriate, we don't offer it as a 'optional extra' on the consent form. I went to a talk by John Hird (who talks a great deal of sense IMHO) who was of the opinion it was not right to put drip/no drip on the consent form since how could the owners possibly be knowledgeable to give informed consent (esp as we vets can't agree!)

[/quote]

I agree that it shouldn't be an optional extra for the owners to decide upon; and I find that a lot of colleagues actively undermine that anyway in the way in which they present it; I do that myself. *Potential and current employers who have it as an option on their consent forms please look away now* - if a young and healthy animal comes in for routine surgery I won't mention it unless the owner does, in which case I will advise that I don't really think it necessary because the risk in not doing it is very low. This exposes me to the risk of landing in the proverbial muckheap in the deeply unlikely event that something does go wrong with the GA because the patient wasn't on fluids; but such is life. If I do think it would benefit from intraoperative fluids I'll say so very clearly.

Re: Perioperative ivft for routine ops.

Rob Loxley — Sat, 01 Sep 2012 17:44:24 GMT

We have started putting iv caths (with bung) in for all GAs: pretty cheap if you buy in bulk from the right place, quick, gives iv access for drugs and fluids as needed, and frankly we couldn't think of a good clinical reason not to.

I am personally of the opinion that preGA bloods or not should be a clinical decision made by the vet having examined the animal and in discussion with the owner (and accept finances may cause an owner to decline them), not a pushy extra 'sold' to worried owners on admission who feel it will eliminate GA risks. Maybe we need to better educate our nurses and receptionists the value and limitations of such testing?

We measure BP - takes no effort since we have a oscillometric multi-parameter machine in theatre (I was under the understanding that the advantage in performance of Doppler over osc was less in anaesthetised patients than awake?). We also have a doppler, used mainly for awake patients as it is more of a faff in a busy op theatre especially when an easier option is present!

Re: Perioperative ivft for routine ops.

Michael Woodhouse — Sat, 01 Sep 2012 15:46:04 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Gareth Dowdeswell"]where the 5x figure came from[/quote]

Random guess ('cos it sounds good) and that's what they've done ever since?

[/quote]

Isn't it obvious? 10ml/kg/hr is just really easy to work out. Anaesthetists are simple people..............

Re: Perioperative ivft for routine ops.

Gareth Dowdeswell — Sat, 01 Sep 2012 15:38:57 GMT

I think if cost to owners didn't matter, IVFT for everything rather than pre GA bloods then IVFT for those who would benefit from it would be a more logical approach - would be interesting to know what charities do, if they have certain criteria above which an animal has IVFT under GA. Certainly my recommendation for pre GA bloods is much much stronger for a 14 yo dog than a 6 month old.

[quote user="Evelyn Barbour-Hill"]

[quote user="Gareth Dowdeswell"]where the 5x figure came from[/quote]

Random guess ('cos it sounds good) and that's what they've done ever since?

[/quote]

Quite possibly - think we need an anaesthetist to ask!

Re: Perioperative ivft for routine ops.

Evelyn Barbour-Hill — Sat, 01 Sep 2012 15:19:29 GMT

[quote user="Gareth Dowdeswell"]where the 5x figure came from[/quote]

Random guess ('cos it sounds good) and that's what they've done ever since?

Re: Perioperative ivft for routine ops.

Rajat — Sat, 01 Sep 2012 15:03:46 GMT

[quote user="Michael Woodhouse"]

[quote user="Gareth Dowdeswell"] always offer pre GA bloods with varying degrees of recommendation[/quote]

It's a tangent but this is another area that borders on profiteering rather than what is in the best interests of the animal. I agree the expensive biochemistry machine needs to be paid for somehow but if you look at the NICE guidelines for the NHS they don't recommend routine bloods in healthy individuals. Look how litigious human medicine has become, IF there was evidence there that they increased safety I will look again.

Personally I'd rather drip everything than bleed everything (needlessly).

[not saying I never do bloods before a GA but this discussion is healthy young animals as far as I am aware]

[/quote]

Completely agree- preop bloods is a waste of time in young healthy (ASA i-ii animals ) , I'd drip them everytime than take a blood sample..It has not been shown to be of any value..

Re: Perioperative ivft for routine ops.

Michael Woodhouse — Sat, 01 Sep 2012 14:59:36 GMT

[quote user="Gareth Dowdeswell"] always offer pre GA bloods with varying degrees of recommendation[/quote]

Personally I'd rather drip everything than bleed everything (needlessly).

[not saying I never do bloods before a GA but this discussion is healthy young animals as far as I am aware]

Re: Perioperative ivft for routine ops.

Gareth Dowdeswell — Sat, 01 Sep 2012 14:58:55 GMT

[quote user="James Laidlaw"]

[quote user="Evelyn Barbour-Hill"]

[quote user="Gareth Dowdeswell"]5x maintenance was the rate being used at the RVC when I was training 4 years ago. Guess there is a risk of volume overload but these animals should be monitored much more closely than an animal on IVFT would normally be checked so any signs should be picked up pretty quickly.[/quote]

Now I'm more confused than ever. Wouldn't you need a pretty good reason to deliberately give far too much so that there is a risk of volume overload?

[/quote]

Agreed, also, WHAT do you monitor... People always say monitor closely and the like, but are there specific ranges, or just wait until fluid is pouring out of an/all orifice(s)???

[/quote]

I was just passing on what was been taught recently at the RVC, Don't remember it ever being mentioned where the 5x figure came from, that was just what the anaesthesia service did. I've never seen an animal have overload problems with 5x maintenance under GA, (or on any other occasion) but I still wouldn't be happy leaving an animal on 5x maintenance in a kennel without very regular checks.

Presumably you might notice changes in respiratory rate, pattern and maybe heart rate (which should all be serially monitored under GA) before the fluid pouring out the nose stage?

Re: Perioperative ivft for routine ops.

Rajat — Sat, 01 Sep 2012 14:53:15 GMT

The standard rate of surgical fluid administration is 10ml/kg/hour = 5x maintenance

The reason to administer fluids (sorry to state the obvious) other than maintaining perfusion is that under anaesthesia we have a 'relative' hypovolemia, due to the vasodilatory effects of many of the anaesthetic drugs that we use. So we need to 'fill the tank' that has become a bit empty due to these drugs.

The early signs of volume overload are chemosis and oedema over the achilles tendon - I ask my trainee nurses to feel this before/after or feel it on a few normals as it is one of the first places to see it.

Fluid from the nose/orifices is a late sign of fluid overload... though I did have on lab where there was a tiny nasal drip without chemosis but with achilles region oedema. Guess they don't all read the textbooks. He was being treated for HGE and hypovolemic shock, and it occured 24 hours post admission.

Respiratory rates would also be a useful thing to monitor, but worth remembering the pulmonary lymphatics and veins are pretty good at removing fluid and oedema develops in the systemic venous circulation at much lower pressures than in the pulmonary -hence the achilles tendon site and chemosis being earlier signs.

Re: Perioperative ivft for routine ops.

James Laidlaw — Sat, 01 Sep 2012 12:28:48 GMT

[quote user="Evelyn Barbour-Hill"]

Now I'm more confused than ever. Wouldn't you need a pretty good reason to deliberately give far too much so that there is a risk of volume overload?

[/quote]

Agreed, also, WHAT do you monitor... People always say monitor closely and the like, but are there specific ranges, or just wait until fluid is pouring out of an/all orifice(s)???

Re: Perioperative ivft for routine ops.

Evelyn Barbour-Hill — Sat, 01 Sep 2012 12:26:24 GMT

Now I'm more confused than ever. Wouldn't you need a pretty good reason to deliberately give far too much so that there is a risk of volume overload?

Re: Perioperative ivft for routine ops.

Gareth Dowdeswell — Sat, 01 Sep 2012 11:11:17 GMT

I'm in the never camp - always offer pre GA bloods with varying degrees of recommendation and obviously if there was something on those might be putting onto fluids but wouldn't do it without an indication.

5x maintenance was the rate being used at the RVC when I was training 4 years ago. Guess there is a risk of volume overload but these animals should be monitored much more closely than an animal on IVFT would normally be checked so any signs should be picked up pretty quickly.

[quote user="Anthony Todd"]

Has anyone mentioned the extra GA time taken to set up the drip, monitor the BP, etc. and the possible effect on post-op complications etc. or is there no extra time?

Geez, you'll have a cat cast. taking an hour soon....

[/quote]

Would it not make sense to drip the animal prior to knocking it out, unless you couldn't for reasons of temperament? Monitoring nurse should presumably have time to set up BP monitoring once things are underway so don't think either should actually add to GA time.

Re: Perioperative ivft for routine ops.

plantagenet — Sat, 01 Sep 2012 10:39:14 GMT

[quote user="Anthony Todd"]

Has anyone mentioned the extra GA time taken to set up the drip, monitor the BP, etc. and the possible effect on post-op complications etc. or is there no extra time?

Geez, you'll have a cat cast. taking an hour soon....

[/quote]

You will also have routine spay price inflation which will cause more people not having animals neutered and the resultant welfare and health implications.

When I am neutering feral cats, I cut a few corners - I don't gown up for example - I don't have any more post-op problems in these than my clients cats. (yes I would know, because although the farmers aren't paying, they damn well tell you if something goes wrong or a cat goes missing)

We need to be careful to do what is necessary and not hide behind 'gold standard' as an excuse for doing things that are not, in truth, adding any extra benefit either to the individual or the wide population of animals.

Re: Perioperative ivft for routine ops.

Rajat — Sat, 01 Sep 2012 09:33:15 GMT

Hi Anthony

Sure thing, having 4 dopplers and 3 diff types of oscillometrics means have had a chance to compare and contrast em

The old time classic and my favourite is the Parks Doppler - available from Burtons, costs 900 squid - it is very sturdy, rechargeable from the mains, the sensor is tiny and very sensitive, the machine is a joy to use, made of solid metal, not flimsy, reliable...can't go wrong with this one!

http://www.burtons.uk.com/products.asp?recnumber=139

Eickenmeyer do their version of a Parks and it is the same beast but the sphyg and the cuffs annoy me, instead of a trigger to release pressure there is a button which means one has less fine control..but the sensor and machine are the same as a Parks and is around £750

http://www.eickemeyer.co.uk/cms/upload/aktuelles/news/Jubilumsangebot-UK_09-2011-lr.pdf

Huntleigh do a doppler too, which I have in the branch surgery where I work, and it is also a great little machine, small + good sensor, and a little handheld probe that can be used to check for pulses for e.g. over the corneas in resuscitation - obviously that's a rarity! But a nice little package. Takes batteries though.

Thames medical Cat Doppler- the oldest doppler we have, I'm not a fan - machine picks up fair bit of interference and the sensor footprint is quite large meaning its awkward for cats (despite its name!) - but it works - and prob the cheapest if I remember right around £600

Raj

Re: Perioperative ivft for routine ops.

Anthony Todd — Fri, 31 Aug 2012 23:00:33 GMT

[quote user="Rajat"]Anthony, a doppler is by far my favourite[/quote]

Can you give me the brand and model please and any other observations pm if you like but I'm sure others are interested too.[quote user="Rajat"]Anthony, a doppler is by far my favourite[/quote]

Re: Perioperative ivft for routine ops.

Evelyn Barbour-Hill — Fri, 31 Aug 2012 22:39:17 GMT

[quote user="Rajat"]and so far cannot find a good reason why bag sharing is so bad (other than you saying so).[/quote]

'Cos it's skanky.

www.youtube.com/watch

Re: Perioperative ivft for routine ops.

Rajat — Fri, 31 Aug 2012 22:24:18 GMT

[quote user="Evelyn Barbour-Hill"]Reducing contaminants is not sterilisation.[/quote]

I was referring to 'all' contaminants of a previously clean sterile surface, including bacteria fungi viruses.. - you get me. So you don't believe it sterilizes the bung, then why do it?

[quote user="Evelyn Barbour-Hill"]Ok, you deny the microbes are there. But if they are there, they can migrate up the walls of the tubing, where the flow will be extremely slow; possibly helped up by local turbulence , or stagnation, at connecting points where the diameter suddenly changes.[/quote]

Ok picture this- the cap for the male luer for a drip line is removed. A sterile needle is attached. It is inserted into a sterile (new) bung. Fluids are given. The line is taped to the patient's leg. The needle is removed, grasping behind the male luer of the the giving set- not a millimetre but more like 2-3 cm. The needle is capped (shh dont tell the human medics) and then twisted and removed while grasping the needle cap. A new, sterile needle is attached, with its cap still on and the drip when needed is transferred to the next patient.No fingers have come within a mm let alone a cm of the male luer nor the end of the sterile needle.

I don't deny bacteria if introduced may persist in tubing, I am curious as to their migration, genuinely so, and I am intrigued by your strong assertions of the same and intimate knowledge of their movements in fluid...(lol just kidding about the last bit).. I did google this I found some references to total parenteral nutrition line colonisation, which is very different for obvious reasons to plain IV fluids..I found one reference in an ICU setting where they changed IV burettes q 72hrs vs q 48 hours and found some difference in significant bacterial contamination (0.6% vs 0.3%) but none resulted in bacteremia [http://www.jstor.org/discover/10.2307/30145100?uid=3738032&uid=2&uid=4&sid=21101014675603]

..additionally 2 references were too old (70s and 80s) to even have abstracts, so I have no clue what they found..there was nothing else that I could find on this topic to support what you said sorry, but obviously I didn't look at every page of google scholar

[quote user="Evelyn Barbour-Hill"]Sure, we've all taken chances with contamination when circumstances dictate – remember the quite recent discussion about open heart massage? – but that's not germane to the particular point under discussion[/quote]

Yup, I do, and interesting isn't it, the risks we take to save a life, and the smaller risks we 'may' take to save health like share bags,

[quote user="Evelyn Barbour-Hill"]I might well use the bag that I know does not fulfil the criteria for sterility because it's already been used [/quote]

Good to know! [quote user="Evelyn Barbour-Hill"]And hang on a minute; the charity doesn't have four or five quid extra to spare? Should it (in the Western world) be doing this surgery at all? [/quote]

Some charities pay x amount and no more per op. And we are in private practice, but also seeing a charitiy's routine ops, in my proposed imaginary situation :)

[quote user="Evelyn Barbour-Hill"]Regarding charity: if you're going to be charitable, be charitable; don't do things badly to try and claw back some of your charity.[/quote]

Quite. I think we do things pretty well, even though I say so myself, and anyone who works at my place of work knows exactly how much stuff we do for free including orthopaedic surgeries, major abdo stuff, scans and so on on strays and RSPCA animals...we are VERY charitable. But if one can be more charitable for the same amount of 'charity' (read money) and safely, then why not remains the question. You maintain it cannot be done, I say it can. I don't, however give these patients fluids routinely nor do I share bags but happily would in this setting, and so far cannot find a good reason why bag sharing is so bad (other than you saying so).

am knackered after a hectic week like you say its is Friday and my bottle of wine is calling as is my bed..;) Also sorry for the hijack of the thread Mark R.

Best

Raj

Re: Perioperative ivft for routine ops.

Rajat — Fri, 31 Aug 2012 21:52:53 GMT

Anthony, a doppler is by far my favourite, but getting into direct BPs soon hopefully! Bit obsessive about monitoring BP...but to be fair it is considered the 4th vital sign in ppl for a good reason.. ;)

Yup, dog with a bone is me, ...grrrr stay away from my bone grrr.. lol

Re: Perioperative ivft for routine ops.

Anthony Todd — Fri, 31 Aug 2012 21:42:33 GMT

Has anyone mentioned the extra GA time taken to set up the drip, monitor the BP, etc. and the possible effect on post-op complications etc. or is there no extra time?

Geez, you'll have a cat cast. taking an hour soon....

Re: Perioperative ivft for routine ops.

Anthony Todd — Fri, 31 Aug 2012 21:40:01 GMT

Bloody 'ell Rajat you're worse than me, talk about a dog at a bone but it's very interesting.

By the way what is your favourite BP instrument?? 'cos sounds as if you've done loads.

Re: Perioperative ivft for routine ops.

Evelyn Barbour-Hill — Fri, 31 Aug 2012 21:30:38 GMT

You can tell it's Friday night, can't you?

[quote user="Rajat"]then why do it unless it greatly reduces if not removes contaminants?[/quote]

Reducing contaminants is not sterilisation.

[quote user="Rajat"]

Let's not presume everyone handles the drip sets the same way, with the same degree of carefulness.

[/quote]

Exactly so.

[quote user="Rajat"] But I will google it because I am curious how bacteria 'migrate' up a drip tubing while the drip is running and how they get there without nothing 'septic' being touched.[/quote]

Ok, you deny the microbes are there. But if they are there, they can migrate up the walls of the tubing, where the flow will be extremely slow; possibly helped up by local turbulence , or stagnation, at connecting points where the diameter suddenly changes.

[quote user="Rajat"]Curious, how do you know the bacteria 'definitely' swirl around - are you watching with a microscope or have you read about it somewhere?[/quote]

I read it. "Swirl around" was my own phrase for local turbulence, brief reverse flow, and similar phenomena which obviously occur – you can sometimes see it happening if you carefully watch your drips going into the catheter – and would lead to the back-contamination on the hub side which has been demonstrated.

Basically: bacteria get everywhere unless you take huge precautions against them and I don't believe trusting to fluid flow is enough; nor trusting to a supposed millimetre gap and using fingers which have been in brief contact with alcohol.

Sure, we've all taken chances with contamination when circumstances dictate – remember the quite recent discussion about open heart massage? – but that's not germane to the particular point under discussion. So:

[quote user="Rajat"]How about the bitch that has bled during an OVH> and it is hypotensive and needs fluids. No way the charity is paying for fluids- they dont have the money. Would you use a bag you 'believe' to be sterile but has been used on another patient with or without changing the giving set?[/quote]

I might well use the bag that I know does not fulfil the criteria for sterility because it's already been used . (After getting the owner to sign an off-licence consent form, of course. oops, wrong thread again )......... but er, I don't think that's relevant. 'Cos this discussion started with routine fluid administration to every op. And hang on a minute; the charity doesn't have four or five quid extra to spare? Should it (in the Western world) be doing this surgery at all?

[quote user="Rajat"](your boss is a money grabbing bas***,[/quote] The charity is a money-grabbing bas****? Or are we in private practice again? Anyway, that kind of boss will a) see that he ain't gonna get any money if the dog dies, and b) if he's that money-grabbing he'll invest a tenner's worth of fluid and stuff and charge the client an extra sixty quid for "special emergency measures".

[quote user="Rajat"]I see shades of gray in this setting, and in doing charity work we have to be flexible, use the resources the best we can, Evelyn seems like you see B+W.[/quote]

Perhaps you misunderstand me, perhaps not. (I'm misunderstood! )

Regarding charity: if you're going to be charitable, be charitable; don't do things badly to try and claw back some of your charity.

Regarding asepsis: there is only black and white. There are no degrees of sterility.

[quote user="Rajat"]Re: flow rates- I did not make that statement, and I don't believe this overloads patients not at risk of fluid overload already, far from it in fact. Most (IME all) healthy dogs and cats can tolerate far greater fluid challenges than 10ml/kg/hour, if they have no underlying disease causing volume overload or a propensity to poorly handle volume.[/quote]

I know you didn't make that statement. But no-one yet has answered the question.

Re: Perioperative ivft for routine ops.

Rajat — Fri, 31 Aug 2012 20:37:12 GMT

[quote user="Evelyn Barbour-Hill"]Yes. I don't kid myself this renders it sterile.[/quote]

then why do it unless it greatly reduces if not removes contaminants?

[quote user="Evelyn Barbour-Hill"]All fingers are bacteria-laden unless freshly scrubbed for three minutes with surgical scrub, in which case they will be just mildly bacteria-carrying. And no, probably no one will sit rubbing the connector (don't stake your life on it though). They will very probably touch it or brush it though, maybe without realising and remember the immediate outside of the connector is most definitely contaminated. The more you faff around with these things, the more contamination is likely. Would you be happy about a surgical instrument being sterile if your nurse's fingers had been messing about with a contaminated instrument " a whole millimetre away, sir"[/quote]

Sorry, this is just supposition (other than the outside of the connector being contaminated I agree) and some more drama (dirty instruments one mm away, staking my life on it etc) Let's not presume everyone handles the drip sets the same way, with the same degree of carefulness.

[quote user="Evelyn Barbour-Hill"]Tough. I have better things to do with my life than memorise the references to every significant text I read . As you told me a while ago on another matter, you can "google it".[/quote]

Lol yes, I remember and I will. And I knew you'd say that Evelyn which is only fair. The reason I asked though is because you sounded so darn sure about it ("definitely...occur frequently") and you have said this before if I am not mistaken on these forums. But I will google it because I am curious how bacteria 'migrate' up a drip tubing while the drip is running and how they get there without nothing 'septic' being touched. I don't deny your statement is true, just curious that's all.

[quote user="Evelyn Barbour-Hill"]

[quote user="Rajat"]A needle used into a properly swabbed bung followed by removal of the needle and replacing with a clean one while using clean disinfected(alcohol rubbed ) hands should not lead to bacterial contamination of the bung. [/quote]

But it will. Why do you think multidose injectables incorporate an antibacterial such as phenol or benzyl alcohol.

[/quote]

Because the holes get bigger people are lazy and dont clean the bung properly and bacteria invade and multiply. The more times they are used over a longer period, the more the risk, that's why, IMHO.

[quote user="Evelyn Barbour-Hill"]

[quote user="Rajat"]No one is going to rub the end of the male giving set with bacterial laden fingers, lets not be dramatic now![/quote]

Bacteria migrate wherever they can. Up the walls of the tubing, flow will be much slower than that in the centre of the lumen. And we are talking here about "standard surgical rate" of only 10ml/kg/hour (incidentally, why is that not excessive if it "overloads" a substantial proportion of patients?) And they most definitely swirl around in the fluid when the disconnection is made.

Curious, how do you know the bacteria 'definitely' swirl around - are you watching with a microscope or have you read about it somewhere?

[quote user="Rajat"]I will agree with it being cheapskate and I don't do it, but done properly to share a bag between 2-3 patients in a charity type situation,[/quote]

Ah. On to "charity" now. Well, that would reduce a small cost to a half or one third of a small cost. And as mentioned before in another thread, I don't understand this business about bad practice being necessary for charity.

[/quote]

Re: flow rates- I did not make that statement, and I don't believe this overloads patients not at risk of fluid overload already, far from it in fact. Most (IME all) healthy dogs and cats can tolerate far greater fluid challenges than 10ml/kg/hour, if they have no underlying disease causing volume overload or a propensity to poorly handle volume.

I mean an actual charity not a broad 'charity' case. We do bitch spays for peanuts for charities for e.g. If a bag can be shared between 3 bitch spays and they benefit from it with minimal risk (which we disagree about, evidently ) and we can maintain organ perfusion better than otherwise, then I believe it not to be a bad thing to do. Cheapskate yes, bad no.

General question to the room (and Evelyn) - How about the bitch that has bled during an OVH> and it is hypotensive and needs fluids. No way the charity is paying for fluids- they dont have the money. Would you use a bag you 'believe' to be sterile but has been used on another patient with or without changing the giving set? Or would you let it take its chances thinking no way am I giving that bitch fluids they may be contaminated? Or do you pay for it out of your own pocket (your boss is a money grabbing bas***, and will not be lenient here, and expect payment...note mine is the opposite of that!) ?

I see shades of gray in this setting, and in doing charity work we have to be flexible, use the resources the best we can, Evelyn seems like you see B+W. I will search for the references to YOUR strong assertions and report back if I find anything ..

Best

Raj

Re: Perioperative ivft for routine ops.

Evelyn Barbour-Hill — Fri, 31 Aug 2012 20:01:06 GMT

[quote user="Rajat"]I disagree with blanket statements such as these..and anyways before giving any injection one needs to swab the injection port. Do you do this routinely, out of curiosity?[/quote]

Yes. I don't kid myself this renders it sterile.

But it will. Why do you think multidose injectables incorporate an antibacterial such as phenol or benzyl alcohol.

[quote user="Rajat"]No one is going to rub the end of the male giving set with bacterial laden fingers, lets not be dramatic now![/quote]

All fingers are bacteria-laden unless freshly scrubbed for three minutes with surgical scrub, in which case they will be just mildly bacteria-carrying. And no, probably no one will sit rubbing the connector (don't stake your life on it though). They will very probably touch it or brush it though, maybe without realising and remember the immediate outside of the connector is most definitely contaminated. The more you faff around with these things, the more contamination is likely. Would you be happy about a surgical instrument being sterile if your nurse's fingers had been messing about with a contaminated instrument " a whole millimetre away, sir"

[quote user="Rajat"]Made me smile, I'd like to see the reference for bacteria migrating while the drip is going..no chapter and verse needed, just a wee link will do![/quote]

Tough. I have better things to do with my life than memorise the references to every significant text I read . As you told me a while ago on another matter, you can "google it".

[quote user="Rajat"]I will agree with it being cheapskate and I don't do it, but done properly to share a bag between 2-3 patients in a charity type situation,[/quote]