Rabbit Vgel device - have you used it?

Re: Rabbit Vgel device - have you used it?

ukvet12345 — Tue, 22 Apr 2014 12:33:35 GMT

I think I may have been misquoted- I am sure that my response was to clarify that any defence could be weakened where any product or equipment had not been used in accordance with the manufacturers instructions.

Fred McKeating Technical Director VDS

Re: Rabbit Vgel device - have you used it?

Bob Russell — Thu, 06 Mar 2014 14:55:45 GMT

[quote user="Marie Kubiak"]

[quote user="Dawn Sheppard"]I spoke to Fred McKeating from the Veterinary Defense Society in the UK, he informed me that if a patient died under anaesthesia from a traumatised airway and "Lawyers4us" asked if the ETT used in the procedure was new or re-used, if the answer was a re-used tube, the VDS could not defend the vet as this was against the manufacturer's instructions.[/quote]

Having just spoken to the VDS they have advised that they would not fail to defend the vet and that I can feel free to carry on intubating my rabbit patients.

Marie

[/quote]

This is no surprise to me! PVC ET tubes are not licenced for animal use anyway so I suspect legally re-use is a minor issue.

Thankfully cascade does not extend to these items!

Aggressive marketing with veiled threats of litigation do nothing to help what is otherwise an important discussion!

Re: Rabbit Vgel device - have you used it?

Marie Kubiak — Thu, 06 Mar 2014 14:46:06 GMT

Having just spoken to the VDS they have advised that they would not fail to defend the vet and that I can feel free to carry on intubating my rabbit patients.

Marie

Re: Rabbit Vgel device - have you used it?

Rob Loxley — Thu, 06 Mar 2014 13:51:53 GMT

[quote user="Michael Woodhouse"]My simple premise is - if the product was more affordable then it would be in more practices[/quote]

[quote user="Bob Russell"]My personal view is the price of v-gels are too high[/quote]

Still, when they 1st came out you had to buy an entire set and couldn't pick and choose which sizes you needed, and I seem to remember had to sign up to some ongoing purchase agreement? I discussed this with the original sellers at BSAVA and they seemed to miss the economies of small animal practice - particularly for routine neutering procedures

Re: Rabbit Vgel device - have you used it?

Michael Woodhouse — Thu, 06 Mar 2014 13:23:41 GMT

I can buy the human ones retail via a medical distributor for £7.95 with free delivery. They are quite a fair sized item and there is money in that for the distributor.

I imagine the NHS do buy these in mass bulk and pay very little for them. I also know that Yorkshire Ambulance Service has gone back to conventional LMAs citing I-Gels as too expensive!

Re: Rabbit Vgel device - have you used it?

Mark Hedberg — Thu, 06 Mar 2014 12:52:56 GMT

[quote user="Bob Russell"]

I suspect research and development plus reduced production runs explain a large part of the difference. I suspect at £50 each sales would rocket! About £1 per use! I assume human devices are made in vast numbers!

[/quote]

Exactly. Some NHS trusts buy hundreds of thousands of units of disposables, equipment, or drugs, simply because the discount on that magnitude of purchase is huge. Without buying groups or large purchasing organizations vets just can't compete with economies of scale.

Ask 200 practices to get together and ask a company for a thousand boxes of whatever and you'll get a lower price than list price. Bargaining power.

Re: Rabbit Vgel device - have you used it?

Bob Russell — Thu, 06 Mar 2014 10:57:41 GMT

My personal view is the price of v-gels are too high. They may well find a home in practices with less experienced vets to reduce problems (probably the worst reason to use them!).

If they are that good once they are in every practice the manufacturers will do very well.

£5 is a little unrealistic I think!

Re: Rabbit Vgel device - have you used it?

Michael Woodhouse — Thu, 06 Mar 2014 10:30:09 GMT

[quote user="Dawn Sheppard"]If we work on a basis of sterility as correct practice, to give the benefits to our pets, then comparatively its actually a cost of £3.19 per rabbit v-gel v £8 per human SGAD for a properly sterilised product per patient.[/quote]

You are not allowing any time effort or electricity for the cleaning and sterilisation. You are not allowing for the time it gets pushed to the back of the autoclave and melts or sliced in the sink of washing up by some scissors.

My simple premise is - if the product was more affordable then it would be in more practices. I dare say at £5 each as a disposable item it would be in practically every practice doing any small animal work. At £100+ each then you are shrinking your market to tiny numbers of people doing a lot of 'gold standard' exotics anaesthesia. At the current price point I wouldn't even consider purchase and as a practice doing very little rabbit anaesthesia I'd probably benefit from them far more than a practice doing them regularly and tubing them.

I suppose your 'fear' (reading between the lines) is if you sold them as a disposable item us evil vets would reuse them.......

[quote user="Dawn Sheppard"]here are many proven clinical studies done to show the superiority of SGADs in human anaesthesia and we suggest reading them on www.i-gel.com[/quote]

The i-gels are great, the massive advantage is a trained chimp can insert them and do a decent job of managing an airway. There are difficulties with intubation in people that do not parallel into veterinary medicine (smaller mouth opening, less manoeuvrable head, different anatomy and large numbers of obese patients).

Re: Rabbit Vgel device - have you used it?

Dawn Sheppard — Thu, 06 Mar 2014 10:19:46 GMT

Sorry my grammar was not good here! Ref 2. The human industry is much more regulated by the FDA (USA) and the MRHA (UK) with regards to cleaning and sterilising airway devices as they are deemed a high risk of cross infections. This ensures the devices are not only sterilised properly but kept in a sterile condition until used next. The veterinary market is not regulated and has had free reign as to their adoption of cleaning/sterilising.....

Re: Rabbit Vgel device - have you used it?

HMC — Thu, 06 Mar 2014 10:18:09 GMT

[quote user="Dawn Sheppard"]Neither Docsinnovent, or myself personally, have ever deemed the v-gel as 'gold standard' and never will, this is not our prerogative to do so. [/quote]

Re: Rabbit Vgel device - have you used it?

HMC — Thu, 06 Mar 2014 10:17:20 GMT

[quote user="Dawn Sheppard"]These clients are very loyal and are very rarely bad debts and these are the clients we would look at securing and would pay for the v-gel use knowing it was the best protocol for their rabbits. [/quote]

I couldn't resist, sorry, but this is the quote that I was referring to.

Re: Rabbit Vgel device - have you used it?

Dawn Sheppard — Thu, 06 Mar 2014 10:10:48 GMT

[quote user="Michael Woodhouse"]

1. Who is using PVC disposable tubes? Like the vast majority of practices we use the rubber reusable ones up to 11mm and then the silicone ones from Vet-Instrumentation up to 14mm.

2. Why is a human i-gel LMA less than £8 and contains many more times the material of these bunny ones? (http://boundtree.co.uk/i-gel-supraglottic-airway?keyword=gel&category_id=0). I suspect if they were £5 each (and even designed to be disposable) many people would add an extra cost onto the ops and use them.

3. I know a human consultant anaesthetist and he is insistent that LMAs are inferior to a properly placed ET tube.

[/quote] Ref 3. Perhaps this question can only be answered by a national or world voting poll. But in 15years of sales visiting a vast number of practices around the UK and more recently Vet Universities world-wide I would say it is pretty much an even spread on PVC v Magills red rubber across the variety of sizes I have seen a huge number completely opposite to your situation stocking the larger tubes as Magills going with the PVC in smaller sizes. All of the surgeries I have visited of one of the largest corporate groups, have only PVC tubes. I appreciate this is only my opinion and experience compared to yours. Ref 2. The human industry is much more regulated by the FDA (USA) and the MRHA (UK) with regards to cleaning and sterilising airway devices as they are deemed a high risk of cross infections. This ensures the devices are not only sterilised properly but kept in a sterile condition until used next. they are single use and properly sterilised. The veterinary market is not regulated and has had free reign as to their adoption of cleaning/sterilising. We are therefore accustomed to incorrectly re-cleaning but not sterilising a disposable human device. If we work on a basis of sterility as correct practice, to give the benefits to our pets, then comparatively its actually a cost of £3.19 per rabbit v-gel v £8 per human SGAD for a properly sterilised product per patient. This for a like for like basis Ref 3. With respect there are many more human anaesthetists who prefer human v-gels(I-gel) products for their superior performance and most hospitals do in the UK and in Europe use this type of decide as first option device. A study by the Royal Society of Anaesthesiologists stated the i-gel was the second generation of airway devices giving more benefits than the original LMA devices. There are many proven clinical studies done to show the superiority of SGADs in human anaesthesia and we suggest reading them on www.i-gel.com (and viewing the clinical trials tab) as this will clearly show this is the case. Even in the USA I-gel is now becoming more mainstream for use in emergency use and mainstream Anaesthesia day by day. The vast human market favours SGADs and this continues to grow every time and we accept the fewer will prefer to remain unchanged for their reasons. Given training and and advice this can change.

Re: Rabbit Vgel device - have you used it?

bob lehner — Thu, 06 Mar 2014 09:55:14 GMT

[quote user="Michael Woodhouse"] Why is a human i-gel LMA less than £8 [/quote]

Indeed - however good the v-gel is I can't see it taking off in a big way in your average s.a. or mixed practice where rabbit GAs are relatively uncommonly undertaken and still often done at a subsidised rate (for whatever reason).

Bring the price down and sales would go up exponentially, me thinks.

Re: Rabbit Vgel device - have you used it?

Bob Russell — Thu, 06 Mar 2014 09:52:18 GMT

[quote user="Michael Woodhouse"]

1. Who is using PVC disposable tubes? Like the vast majority of practices we use the rubber reusable ones up to 11mm and then the silicone ones from Vet-Instrumentation up to 14mm.

3. I know a human consultant anaesthetist and he is insistent that LMAs are inferior to a properly placed ET tube.

[/quote]

I suspect in cats a well placed ET tube is a perfectly good option because visualisation is better. In rabbits the v-gel is probably a safer bet for most anaesthetics because visualisation is lousy and most of us do a lot less rabbit ops than cats.

Re: Rabbit Vgel device - have you used it?

Michael Woodhouse — Thu, 06 Mar 2014 01:41:30 GMT

1. Who is using PVC disposable tubes? Like the vast majority of practices we use the rubber reusable ones up to 11mm and then the silicone ones from Vet-Instrumentation up to 14mm.

3. I know a human consultant anaesthetist and he is insistent that LMAs are inferior to a properly placed ET tube.

Re: Rabbit Vgel device - have you used it?

Ivan Crotaz — Wed, 05 Mar 2014 21:56:27 GMT

Hi all

My experience: about 10 years of first and second opinion rabbit work, especially shelter medicine/surgery - so lots of dentals... I was involved in the research work necessary to move the v-gel device on from a human anaesthesia product into rabbit anaesthesia. The following describes my clinical opinion when deciding what airway device to pick for a case:

When v-gels are useful:

1) When it is necessary to rapidly bypass nasal airways (upper respiratory disease being the most common scenario) to prevent hypoxia/hypercapnia. This can also apply to most routine anaesthesia as most rabbits hypoventilate, so being able to rapidly provide IPPV is very handy indeed.

2) Abdominal, orthopaedic and some thoracic surgeries. You can get sufficient ventilation seal in most cases for leak free IPPV. Sometimes the in-between sizes of rabbits can be a faff.

3) Extra-oral dental extractions (all situations)

4) Intraoral extractions - caudal molars 1-3 (approximately). Incisor extractions I find are quite easy with the v-gels. Some people disagree, it's a question of what you're used to.

5) Hand instrument dental rasping (I find this very easy with v-gels, you can move them around quite a bit with a spatula, without losing the seal).

When v-gels aren't useful:

1) Powered burr molar reductions/reshaping - my burr is right angled and I find that the v-gel gets in the way - a straight burr would probably be easier but I don't have one.

2) Caudal molar intraoral extractions - last 1-2 molars basically - difficult to get angled forceps in to grip the tooth.

3) Pharyngeal access procedures such as nasal flushing.

However, it is very useful to place a v-gel quickly for the initial stabilisation period after induction, so that you can then intubate a stabilised normocapnic patient, if intubation is required.

In terms of the intubation comments on the posts - I tend to teach that the ideal tube is a new single use PVC endotracheal tube (narrow wall diameter and easier to insert than silicone tubes). Single using them makes them noticeably softer and I think it is fair to say that this reduces potential trauma risk (and a hell of a lot easier to insert). Guided insertions (I tend to use otoscope guidance) are considered less traumatic than blind insertion. One point that hasn't been made is that ventilation should be considered standard for rabbit anaesthesia (nurse or machine!) as they all underventilate. A thin endotracheal tube or even a wider v-gel without ventilation means that a rabbit with a small lung volume, diaphragm compression and most likely a pre-existing lung disease has to shift a lot of air on its own - which basically they don't like to do. So in essence, I feel that single using ETTs for rabbits does bring noticeable improvements in ease of use, and reduction of trauma risk. Hope to bring peer reviewed data on morbidity comparisons between different techniques out in the next 18-24 months.

In terms of the stability comments - if you don't support and tie the v-gel in place and then you move the head, it will displace. The same is true for an ETT - it will displace or kink - especially the 2.5mm ones. I use precisely the same techniques to support v-gels, face masks and ETTs, and have minor hassles with all three. I don't feel that any one of the three airway techniques is better or worse in this respect - care and attention to detail will give good results in all cases.

In terms of mortality - we have some evidence coming through now of laryngeal and tracheal trauma as a cause of death in rabbit cases. Not much as few people PM a rabbit death! I suspect it is a causative factor and I have seen both laryngeal spasm and laryngeal oedema postop in intubated cases (all 3 survived due to early identification by my nurses). We have a published 1:137 death rate in healthy rabbits which is only slightly ahead of horses (Brodbelt anaesthesia study), so at this stage, I think it's fair to say that there is a long way to go. My suggestion - v-gel is a useful device that allows a good rabbit clinician to establish a wide airway rapidly and ventilate a patient with decent airway monitoring. It's not suitable for every patient, just like everything else we use - hopefully the list above gives people an idea of what they might use it for.

Re: Rabbit Vgel device - have you used it?

Dawn Sheppard — Wed, 05 Mar 2014 18:55:57 GMT

[quote user="Mark Holmes"]Dawn the issue is that when you suggest change to Vets many of them react like you are asking them to sacrifice their first born child. I have no doubt that shoving something hard down a trachea causes trauma and I have seen cats with the after effects of tracheal rupture - thankfully not caused by me. It's these cases which make me question the dogma that tubing everything is gold standard.

[/quote] Thank you Mark ... I was beginning to think I was fighting the world single handed!

Re: Rabbit Vgel device - have you used it?

Dawn Sheppard — Wed, 05 Mar 2014 18:38:27 GMT

I agree this forum is not the place to get personal and it was not my intention to 'put anyone's backs up' - the comments and sales pitch can be proven with published papers and Key opinion leader research available publicly on the internet should you wish to look. The v-gel is sold on an educational basis trying to bring the experience and expertise of the human airway management field into the veterinary market, where the ETT is used as per manufacturer instructions and the supra glottic airway devices have improved on speed, trauma and safety for both patients and staff. Docsinnovent are not diatribing the ETT but saying within the profession it is generally used incorrectly and as such has been proven to cause trauma (albeit to varying degrees dependant on the user). Neither Docsinnovent, or myself personally, have ever deemed the v-gel as 'gold standard' and never will, this is not our prerogative to do so. There will always be a place for the ETT in airway management, whether it is the veterinary or human field, as there will be some situations where the v-gel can not be used (collapsed tracheas, gastroscopy, placement of pharyngeal feeding tubes etc). So when we do use it we are asking vets look at the techniques used to improve their patients well-being by using it as per manufacturer instructions and not just because we have 'always done it that way.' When we look at anaesthesia techniques we have a lot of options available to us in improved drugs: different combinations of drugs: different modes of administering them... But when it comes to airway management we only have had 3 options - no airway management: the mask or the ETT. Docsinnovent have provided the profession with another option; another tool in your tool box so to speak. We ask you to now look at your patient. Look at the procedure and make a choice of the best airway management device for that situation. (Hannah - if it was me, I honestly do not recall an email conversation on ethylene oxide, I will look back at the archives)

Re: Rabbit Vgel device - have you used it?

HMC — Wed, 05 Mar 2014 17:22:21 GMT

[quote user="Bob Russell"]Sadly this seems to be putting peoples backs up rather than being constructive.[/quote]

I couldn't have put it better.

It is a shame that a potentially useful product goes hand-in-hand with annoying and condescending advice. I really disagree with Dawn, both in the content on this forum and by personal email in the past. You'd think from the diatribe that ET tubes were the devil and that all dogs/cats intubated suffer horrendously. You'd also think that a new product is the gold standard (an accolade given by the company it seems). And we had a very interesting debate about the benefits of sterilisation by ethylene oxide via email.

Despite my rage (well, irritation), I don't have a problem with the product. Just the sales pitch.

Re: Rabbit Vgel device - have you used it?

Dawn Sheppard — Wed, 05 Mar 2014 11:48:16 GMT

[quote user="Nicola Lawlor"]

Why does a used but well cleaned and maintained ETT carry a greater risk of causing problems when used compared with a brand new ETT, other than perhaps the theoretical issue of passing infection? Assumption made that these are both inserted with care as is the norm in practice.

[/quote] Hi Nicola A new PVC ETT, although the wrong shaped and has a hard beveled end is relatively flexible. On spectrometry examination after their re-use, they are hardened and this inflexibility along with the hard tip and the curvature impounds the trauma caused. There are 3 main reasons for the hardening that we know of: 1. The bacteria that is present in the mouth feed on the plasticizer in the PVC 2. UV light reacts with materials and hardens them 3. The cold sterilant chemicals hardened them We also have the issues of internally cleaning the very small diameter tubes and we also don't rinse them long enough. This is evident as the tubes turn yellow - this is the build up of the chemicals over a long period some of these chemicals are caustic to the membranes and can cause other forms of trauma The manufactures do not make these tubes from re-usable materials as in the human field they are used as single use products

Re: Rabbit Vgel device - have you used it?

Nicola Lawlor — Wed, 05 Mar 2014 11:30:01 GMT

Re: Rabbit Vgel device - have you used it?

Mark Holmes — Wed, 05 Mar 2014 10:58:14 GMT

Dawn the issue is that when you suggest change to Vets many of them react like you are asking them to sacrifice their first born child. I have no doubt that shoving something hard down a trachea causes trauma and I have seen cats with the after effects of tracheal rupture - thankfully not caused by me. It's these cases which make me question the dogma that tubing everything is gold standard.

Re: Rabbit Vgel device - have you used it?

Bob Russell — Wed, 05 Mar 2014 09:29:31 GMT

Sadly this seems to be putting peoples backs up rather than being constructive.

ETT's live in a cupboard. I do use sterile water based lubricant, we have a whole range of cut down tubes, patients are moved with great care if intubated. Capnograph is standard, ventilation used as required (not by machine though!).

None of my patients have been reported as coughing in years!

I admit that after careful cleaning and cold sterilisation they do get used more than once but are checked carefully each time and discarded regularly.

All surgery comes with downsides and complications but these are uncommon IME.

I believe you have a great product (perhaps especially good if in the hands of less experienced vets?) and I am sure many will move across in time. It will be interesting to see what the v-gel using dentists have to say!

Re: Rabbit Vgel device - have you used it?

Dawn Sheppard — Wed, 05 Mar 2014 07:49:41 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Dawn Sheppard"] Most of the published papers (including the ones mentioned) are about the trauma we cause due to the incorrect use of ETTs,[/quote]

"the trauma we cause due to the incorrect use...........?" I use endotracheal tubes correctly.

[quote user="Dawn Sheppard"]Sorry , i did not understand your question regards the ethics of devices designed to be re-used.[/quote]

Well, you seemed to be labouring your point that re-using single-use tubes was indefensible while ignoring the fact that most of us use re-usable tubes.

[quote user="Dawn Sheppard"] However I have asked a coupe of vets I know who have successfully used v-gels in rabbit dentistry to comment on this forum or contact you direct.[/quote]

Now that would be good. On the forum would be best. A demonstration would be best of all.

[/quote]

My point on the single-use ETT has always been directed towards PVC single use devices (which is used profusely world-wide in our profession) and my 'we' referred to the veterinary profession in general, not directed to any one person. As an airway management company, we have only found a handful of people around the World who use ETT's tubes correctly. I am sure there are more, I hope there are more, but the habitual re-use of pvc ETT's is very wide spread but that does not make it correct.

If a vet used a new ETT each time, if they are kept in a dark drawer away from UV light, if they are lubricated with sterile water-based lubricant prior to insertion, if they are measured and cut down to correct size of the patient, if the patient and tube were limited on their movement, if a manometer were used to monitor cuff pressure if used and if, in particular rabbits are monitored with capnography and ventilate when required, then the ETT is being used the best of its ability. That doesn't mean the patient will have no trauma and of course there is still the matter of airway resistance.

I, as you say, have laboured my point enough and I will hopefully bow out to the dentistry vets I have contacted as this seems to be turning into a two way fight :) I will agree to differ

Re: Rabbit Vgel device - have you used it?

Evelyn Barbour-Hill — Tue, 04 Mar 2014 23:45:15 GMT

[quote user="Dawn Sheppard"] Most of the published papers (including the ones mentioned) are about the trauma we cause due to the incorrect use of ETTs,[/quote]

"the trauma we cause due to the incorrect use...........?" I use endotracheal tubes correctly.

[quote user="Dawn Sheppard"]Sorry , i did not understand your question regards the ethics of devices designed to be re-used.[/quote]

Well, you seemed to be labouring your point that re-using single-use tubes was indefensible while ignoring the fact that most of us use re-usable tubes.

[quote user="Dawn Sheppard"] However I have asked a coupe of vets I know who have successfully used v-gels in rabbit dentistry to comment on this forum or contact you direct.[/quote]

Now that would be good. On the forum would be best. A demonstration would be best of all.