Post surgical death

Re: Post surgical death

Michael Woodhouse — Wed, 04 Mar 2015 01:18:18 GMT

[quote user="listhestar"]SC bup takes up to 2hrs to have an affect.[/quote]

Much faster than that, but no where as quickly as butorphanol.

Re: Post surgical death

listhestar — Tue, 03 Mar 2015 15:25:04 GMT

[quote user="Starling"]about bupenorphine after methadone[/quote]

As a lecturer said on my course, very little harm can come of additional analgesia if there is any doubt as to the animal being in pain. You need to reflect and then move on. People all make mistakes. I lost a rabbit a few months back, first one in 9 years- sometimes it happens. I think being reflective is a very good thing but don't let it damage your confidence for future. My boss won't use some drugs/blames them for things that go wrong simply due to him being unsure of the effects of the drugs himself. SC bup takes up to 2hrs to have an affect. If anything unless its a nasty dog, domitor in an older dog would be more of a worry - was the blood pressure monitored through the procedure?

Lisa

Re: Post surgical death

Tim Charlesworth — Tue, 03 Mar 2015 09:32:05 GMT

Hi Robin, by far the most common presentation is an entire or recently castrated male but they have been reported in female dogs as well (and cats for that matter..)

Tim

Re: Post surgical death

Robin Grimmer — Mon, 02 Mar 2015 21:14:13 GMT

Hi Tim, have perineal ruptures been reported in anything other than entire males?

Re: Post surgical death

Tim Charlesworth — Mon, 02 Mar 2015 18:06:28 GMT

[quote user="Anthony Todd"]

[quote user="Tim Charlesworth"]Castrating older dogs does not increase the rate of prostatic neoplasia.[/quote]

Sorry Tim, is this what you meant to say; I thought castration reduced the rate, or at least, the size of the prostate??

I always believed the prostate was not palpable in castrated dogs??

I thought castration was an extreme treatment for prostatic cancer in men and mandatory in dogs??

I'm probably all wrong as usual though....

[/quote]

It's a murky area this one. There is some evidence to support an increased incidence of prostatic neoplasia in castrated dogs, this is prob due to loss of a "regulatory" role and so the effect may be more marked in dogs castrated early. Other papers have suggested that prepubertal castration may prevent prostatic neoplasia..

Given the fact that Perineal ruptures are an "old dog" disease, we don't regard any theoretical increase in risk of prostatic tumour development as a valid reason for not castrating dogs with ruptures. I freely admit that this bit is anecdotal and opinionated. The "accepted wisdom", however, is that castration prevents BPH, cysts, abscesses etc but does not protect again prostatic neoplasia. Prostatic tumours in humans are entirely androgen dependent so castration is part of the recommended therapy but this is not the case in dogs. Prostate tumours in dogs and humans are very similar (dogs often used as a research model) but there are a few important differences. Castration certainly does reduce the size of the prostate which is why my heart always sinks when we see castrated dogs with prostate lumps..

Re: Post surgical death

Anthony Todd — Mon, 02 Mar 2015 17:16:42 GMT

[quote user="Tim Charlesworth"]Castrating older dogs does not increase the rate of prostatic neoplasia.[/quote]

Sorry Tim, is this what you meant to say; I thought castration reduced the rate, or at least, the size of the prostate??

I always believed the prostate was not palpable in castrated dogs??

I thought castration was an extreme treatment for prostatic cancer in men and mandatory in dogs??

I'm probably all wrong as usual though....

Re: Post surgical death

Tim Charlesworth — Mon, 02 Mar 2015 15:46:00 GMT

Apologies for coming in late, have read the first few pages of posts but not all so apologies again if any of this repetition.

First of all wrt perineal rupture (it's not a hernia..)- you can get sig bleeding during the procedure. The obturator vessels are within striking distance as is the gluteal artery if the internal obturator muscle is tenotomised when raising the flap (this is the "standard repair" that most surgeons will use as much lower recurrence rate then cobbling together atrophied/weak muscles). The gluteal artery can bleed like stink as can the obturator and sig H+ from either of these vessels could be fatal if left unattended. H+ would be seen at the time of surgery however and it's not subtle (I've done it in a big dog, nurse thought dog was having a wee when she heard fluid on the floor..). Any smaller vessels may go unnoticed if the dog was hypovolaemic during GA but these would be unlikely to cause fatal exsanguination. Dogs are routinely castrated to decrease benign prostatic hypertrophy which is though to contribute to weakening of the pelvic diaphragm by release of various substances (eg relaxin) and also mass effect contributing to faecal tenesmus etc. Castrating older dogs does not increase the rate of prostatic neoplasia.

Re the case in the OP, if the dog was pale/white then it was clearly shocked, this could be cardiogenic, hypovolaemic, distributive etc etc and as has been siad, without PM, I'm araid you won't know. I wonder if when the dog appeared sleepy prior to buprenorphine injection - it was actually already weak or "shocked". I'd begin by asking the surgeon if there was sig blood loss (remember that bl vol is only approx 85ml/kg lean weight so if 4 kg then total bl vol -340ml, a 20% "critical" blood loss would only be 68mls ie 7 swabs worth.. Was the dog on IVFT? Was the BP measured etc etc

Lots of possibilities I'm afraid but I wouldn't blame the buprenorphine..

Re: Post surgical death

Julie Innes — Mon, 02 Mar 2015 14:18:16 GMT

That was one of the things we thought of, Rob, but as we weren't really expecting the dog to survive, histo wasn't done at the time! I did keep a section, so it may be one to send just for my own interest

Re: Post surgical death

Rob Davis — Mon, 02 Mar 2015 14:16:22 GMT

Was histo done? Thinking possibly mast cell degranulation?

Re: Post surgical death

Julie Innes — Mon, 02 Mar 2015 13:05:37 GMT

Finding this thread really interesting, in view of a case we had last week. Little Lhasa with a huge mass at her back end, not associated with the bowel, removed, seemed to shell out fairly easily, bled a bit, but no large vessels. Took ages to come round, came round, then became sleepy again, although colour ok, no sign haemorrhage from wound etc. Subsequently started passing bloody faeces, became very non-responsive. I wondered if she had actually had some sort of cerebro-vascular incident, as she was so almost comatose. I took her home, gave her fluids, gave owners a very grave prognosis, but she came to life around midnight (typically!) and was well enough to go home the next day, albeit still having bloody D+. We had no idea what had caused the bloody diarrhoea, as we were nowhere near the bowel, but we wondered if it could be to do with pressure on the bowel after the surgery, or something released from the mass, or inflammation of nerves, or some kind of drug reaction. She had nevere had a GA before, was premedicated with vetergesic/ acp, induced propfol and maintained iso. She had loxicom pre-op too. Sounds a lot like this case, in that both ops were in the same (perineal) area. Ideas??

Re: Post surgical death

J G Wray — Sun, 01 Mar 2015 17:35:49 GMT

[quote user="Michael Woodhouse"] but how many practices really have a person specifically tasked with HR? [/quote]

We have this role clearly defined here.

[quote user="Michael Woodhouse"]Every practice I have worked in has picked up the task by various partners. Most vet practices are not big enough for it to be a real role.[/quote]

If you employ just one other person......

Re: Post surgical death

Michael Woodhouse — Sat, 28 Feb 2015 23:09:19 GMT

[quote user="Hannah Wynne Richards"]

But if not all the sites are occupied, then the methadone will still give additional analgesia - try it and see.

[/quote]

I agree and have done this a number of times with good effect +/- ketamine at a low dose (0.2ml/10kg)

[quote user="J G Wray"]particularly the person charged with HR responsibilities about all this stuff?[/quote]

JGW - A lot of what you have said on this thread is very helpful, but how many practices really have a person specifically tasked with HR? Every practice I have worked in has picked up the task by various partners. Most vet practices are not big enough for it to be a real role.

Re: Post surgical death

Anne Seawright — Sat, 28 Feb 2015 17:10:16 GMT

[quote user="Anthony Dennison"]

[quote user="Hannah Wynne Richards"]I often premed with buprenorphine, and then add methadone if I think more pain relief is necessary.[/quote]

Doesn't burpenorphine have a stronger affinity for the opioid receptors, so if methadone (a full agonist) is given after buprenorphine (a partial agonist), it is less effective due to the competition for binding sites from buprenorphine?

[/quote] According to CPD with Jo Murrell last Tuesday this seems to not be the issue they once thought and she recommends giving rescue pain relief with methadone if needed even after buprenorphine. The paper she quoted showing methadone still effective as a rescue analgesic after buprenorphine was 'Comparison of premedication with buprenorphine or methadone with meloxicam for postoperative analgesia in dogs undergoing orthopaedic surgery. Hunt et al. (Sorry don't have what journal it is published in or other info.)

Re: Post surgical death

Hannah Wynne Richards — Sat, 28 Feb 2015 14:04:40 GMT

But if not all the sites are occupied, then the methadone will still give additional analgesia - try it and see.

Wynne

Re: Post surgical death

Anthony Dennison — Sat, 28 Feb 2015 13:20:49 GMT

[quote user="Hannah Wynne Richards"]I often premed with buprenorphine, and then add methadone if I think more pain relief is necessary.[/quote]

Re: Post surgical death

Hannah Wynne Richards — Sat, 28 Feb 2015 11:25:35 GMT

My misunderstanding, but picking on the smallest child in the playground/newest graduate in the practice is (unfortunately) human nature. As for buprenorphine after methadone, I often premed with buprenorphine, and then add methadone if I think more pain relief is necessary.

Wynne

Re: Post surgical death

Starling — Sat, 28 Feb 2015 10:42:23 GMT

Sorry, they aren't bullies, anybody has blamed me, but a collegue who doesn't like opiods made a comment about bupenorphine after methadone and I'm sure it was without the aim of making me feel bad. But I'm 100% sure that there wasn't any mistake in what I did.

Re: Post surgical death

Hannah Wynne Richards — Sat, 28 Feb 2015 09:07:22 GMT

Starling Your involvement in this case is marginal. Look at it mathematically. A bookmaker would put the odds of you being at fault as 100/1 - and the odds of whoever did the surgery as 1/100 on.

The fact that you're upset means that with experience you'll become one of the best veterinary surgeons around.

As for your "colleagues", they sound like a pack of bullies, who know it's easy to kick someone who's already down. Don't let them.

Wynne

Re: Post surgical death

J G Wray — Sat, 28 Feb 2015 08:25:46 GMT

[quote user="Starling"]This is helping me a lot, thank you all[/quote]

Why aren't you talking to your colleagues at work, particularly the person charged with HR responsibilities about all this stuff? Having a sounding board like this forum is all very well, but ethereal. Should something profoundly accountable land on your plate, no one on this forum can actually provide you with substantive support - you are after all just a name here, an unknown and in the real world that counts for nothing.

Internet discussion forums have a v bad Press at the moment where the vulnerable are drawn in to an appealing sympathetic world.

Your difficulties are for you to sort out and that starts with you deciding you are going to control this, not the other way round. There are lots of methods available and long term seeking solace here is not going to serve you substantially, it's a quick jag.

You may have discovered a personal vulnerability you have been hitherto unaware of. If, for all your logical ability, aptitude and training you are having an emotional response about this patient you can be sure it's going to happen again if you don't deal with it in a suitable way.

Take a plaster from this forum, but for the long term - "physician heal thyself.."

Re: Post surgical death

Sarah McGurk — Sat, 28 Feb 2015 07:24:06 GMT

It strikes me Starling, that if you have reached two years as a qualified vet, and you haven't before experienced any animal which has died unexpectedly after a procedure, you are doing exceptionally well. I know I lost a pyo on the table when I was about one year qualified, and I believe it was entirely through inexperience. I felt awful but I learned from it and moved on.

There are a lot of things that can go wrong in veterinary practice, and as Malcolm has demonstrated, even after years of experience, disasters still happen now and then. Keep your head up. It doesn't sound to me as if you are in any way to blame. You gave the dog an analgesic, which demonstrates that you had its best interests at heart. If anyone suggested that you were at fault, it sounds like they were trying to offload their own guilt.

Re: Post surgical death

David Mills — Fri, 27 Feb 2015 18:49:19 GMT

Clinically, some thoughts, but without a PM this is guess work. It is possible - though very unlikely - that the buprenorphine killed the dog. Animals like people can have idiosyncratic drug reactions (or even to preservatives etc) and the problem with the final common pathway of death is that it is difficult to know premortem (and indeed a lot of the time post mortem) what was responsible. Similarly, malignant arrhythmias may come to the fore 24-48h post-GA if there was any myocardial hypoxia/ischaemia during the GA or inflammatory reaction from the surgery. The usual culprits of thromboembolism, haemorrhage or other may apply. Blood in the colon/faeces may or may not be significant. We had one recently that had formed a colonic mesenteric embolism and the colon was black and sloughing - the toxaemia from colonic issues can be rapid, severe and deadly within a few hours. Given the surgery, bowel entrapment then released could easily have led to SIDs, release of potassium, and all sorts of events.

JGW is right in that being objective about the whole case is important both from a clinical and personal perspective. This is difficult given your involvement was transitory - it is far easier if you did the surgery and saw the case through from pre-op to end, as clinical notes can be selective or deficient in many cases. However, the process of becoming objective allows a rational assessment of what happened, and hopefully, what might be done better (if anything) in future. From a personal perspective, it allows a cognitive dissonance between things you can control, things you can't, and how you can affect (or not) these things.

Anecdote alert. Although a young buck in comparison to Atko's ageing and withering body, I have lost patients unexpectedly in the past. It is difficult to accept. However, without a concrete reason, sometimes one has to accept that shit happens. This is difficult because we often think of human operations and the furore that would attend an unexpected death. We as a profession (even at universities and referral centres) are neither equipped nor knowledgeable enough to cater and detect every abnormality - indeed pre-operative testing for any contraindication is a very poor use of resources and has been shown to be inferior to clinical exam in human medicine. We've had a couple of stable open pyos die post-operatively recently. Do we know why? No. Old dogs, no operative problems, normal recoveries, run of the mill pyos. Could we have done anything to prevent e.g. PTEs, myocardial infarcts? No. It is upsetting, both for vets and owners. But to shrug and say that's life (or death) is not to say you don't care but to realise that our powers are limited, finite, and human. Problems may arise with owners who expect human medical standards, but this is not a criticism of vets, but unrealistic expectations (may be unavoidable). Re practice politics, rest assured that you wil be a better vet for worrying about this than those senior who seem to want to pass blame and deny responsibility- I bet those concerned are male surgeons.

Re: Post surgical death

Hannah Wynne Richards — Fri, 27 Feb 2015 18:11:53 GMT

During the mid Wales hydatid scheme (in the 80s) we used droncit (much pleasanter)

Re: Post surgical death

Anthony Todd — Fri, 27 Feb 2015 16:49:50 GMT

[quote user="Gillian Mostyn"]simple case of colitis that dropped dead[/quote]

This scenario was highlighted in NZ during the hydatid elimination program, when arecoline was blamed for killing dogs after dosing, until a dog dropped dead on the dosing strip before it had been dosed.

Re: Post surgical death

Anthony Todd — Fri, 27 Feb 2015 16:36:40 GMT

[quote user="Robin Grimmer"]would have thought even a dinovet would have known that! [/quote]

Touche...

I'll have to be more specific.

For those of you that don't know everything the lethal execution is 100 mEq, given as a bolus, I assume. [and Hartmans 5mEq/L, as you all know]

Re: Post surgical death

Robin Grimmer — Fri, 27 Feb 2015 16:19:58 GMT

[quote user="Martin Atkinson"]

[quote user="Anthony Todd"]

It may be helpful to those still practising to know what rate you now recommend and what rate was dangerous and what the drip was ie just Hartmans or what.

I didn't know potassium could be dangerous I/V.....

[/quote]Well they use it as part of the lethal cocktail in euthasia and execution for that reason!

[/quote]

would have thought even a dinovet would have known that!