Peri-operative antibiotics

RE: Peri-operative antibiotics

Alet Engelbrecht — Mon, 02 May 2016 18:22:31 GMT

Found this on another forum I belong to wrt using gloves:

http://www.veterinarypracticenews.com/why-gloves-can-be-your-no-1-weapon-against-ssis/

RE: Peri-operative antibiotics

Julian Earl — Tue, 26 Apr 2016 18:07:13 GMT

Hear hear. If you have any doubt then it's better to assume the condition is painful.

Wynne

I absolutely agree Hannah. I've suggested for years now, sincwe 1995 in fact after a knee operation on me, that some do tend to use antibiotics when analgesics are better. Those swollen/inflamed post-op wounds given antibiotics eg after a mammary strip can respond dramatically better to NSAIDs. My argument has been that not everything we see ill has infection but most will have pain. Wounds obviously arelikely to be painful. Severely dehydrated people complain of the hangover-headache from hell. Wecould presume that those animals with the really sunkren eyes/tented skin recoil/ and body-weight loss suffer pain as a result. Okay we give them fluids and have to consider renal effectsin hypovolaemic animals but those animsals dull and depressed, no fever, might simply have chronic pain.

I had an aggressive middle-agedWestie that stopped being aggressive within days of receiving carprofen. All I then had to do was diagnose the cause of the shown! Neck pain I think it was? A memorable case, with dramatic benefit from pain-relief.

RE: Peri-operative antibiotics

Julian Earl — Tue, 26 Apr 2016 17:55:51 GMT

The theme of this thread is unsurprisingly, core to the RCVS welfare certificate and yes, it isconsidered best to assume that they feel physical pain in a broadly similar way to us because the nervous system of animals functions the same way. The difficulty is understanding mental perception of pain., and best to assume the worst so treat accordingly. I have had Tramadol and suffered no halluvcinations but was extremely drowsy for 12-18 hours.

Re. hallucinations at a Pain-seminar in Harrogate some years ago we were told how effective ketamine is i.e. extremely for chronic pain and that the inventor/creator used to lecture all over the USA promoting the use. Then he received ketamine himself when hospitalised and suffered such dreadful hallucinations he never promoted it again. Anecdotal but that is what we were told.

I've used ketamine at 1ml/100kg intramuscularly for dogs with severe arthritis that are responding sub-optimally to NSAIDs for chronic pain following pain-management lectures.There is science by Duncan Lascelles IIRC; that it works but know of no clinical trials !

RE: Peri-operative antibiotics

Rob Loxley — Tue, 26 Apr 2016 17:47:13 GMT

[quote user="Braden Collins"]I certainly tell any dog owner about the side effects I had with tramadol before I dispense it for their pets[/quote]

n=1?

RE: Peri-operative antibiotics

Elliot Kneba — Tue, 26 Apr 2016 15:20:21 GMT

I have heard similar things about hallucinations with Tramadol, as well as in humans who take enrofloxacin. I have not experienced much dysphoria in hospitalised patients on tramadol, but who knows.

RE: Peri-operative antibiotics

Anthony Dennison — Tue, 26 Apr 2016 14:55:33 GMT

[quote user="Braden Collins"]I found the side effects of the tramadol were worse than the pain, as I was having very strange dreams which seemed very real.[/quote]

I had the same problem when I was on it for my shoulder a couple of years back. Very vivid dreams, and would move around and shout in my sleep too.

RE: Peri-operative antibiotics

Braden Collins — Tue, 26 Apr 2016 14:43:48 GMT

A few months ago I had a head on crash with a car while riding my bike. I managed to break some ribs, smash some teeth, cuts and bruises everywhere. I refused analgesia in the ambulance just because I was worried that if I got a taste of opiods I might like it and help myself to it, though I eventually had some codeine and paracetamol in hosptial, then tramadol when I got home. I found the side effects of the tramadol were worse than the pain, as I was having very strange dreams which seemed very real. The other pain relief was needed though as I couldn't move much without it.

I think we do need to assume pain is present in our patients every bit as much as it is in us, but we need to realise that the medication can have side effects and we therefore need to always balance the risks and benefits. I certainly tell any dog owner about the side effects I had with tramadol before I dispense it for their pets, but if the owner thinks they need it I will still dispense it.

RE: Peri-operative antibiotics

Hannah Wynne Richards — Tue, 26 Apr 2016 14:39:47 GMT

Hear hear. If you have any doubt then it's better to assume the condition is painful.

Wynne

RE: Peri-operative antibiotics

Elliot Kneba — Tue, 26 Apr 2016 14:32:26 GMT

[quote user="Martin Atkinson"]There is a huge leap of faith here that animals regard pain in the same way as we do - indeed there is also a huge difference in how humans regard pain. [/quote]

Perhaps, but I would rather err on the side of giving plentiful analgesia, constantly evaluating my patient's response, and adjusting as necessary rather than letting them go under analgesed. Pain has no benefit, and we know that it delays healing, so I cannot get on board with that argument.

RE: Peri-operative antibiotics

Julian Earl — Mon, 25 Apr 2016 17:28:03 GMT

My understanding from surgical CPD that intravenous potentiated amoxicillin is adequate for allsurgery, if that is available any more? That's from the Improve International year-long surgical module course . But I agree that minimal tissue trauma/ speed of procedure and flushing are more important. Personal experience is tha procedures lasting over 60-90 minutes have much greater risk of infection post-operatively. Keep the tissues moist and non-traumatised where possible. Any contamination? Flush and flush again.

HTH?t

RE: Peri-operative antibiotics

John Flynn — Sat, 23 Apr 2016 22:50:04 GMT

In my limited experience, the majority of surgical site infections have been with bugs that I suspected came from the patient's skin. Is this just me or have others had similar experience?

That would lead me to conclude that adequate skin preparation and draping of the patient is possibly a priority over air quality and my own attire?

I have seen picture in textbooks of heavily protected humans in a room operating on a dog with a large section of its chlorhexidine/alcohol-"cleaned", shaved skin merrily sitting uncovered around the surgical incision - I reckoned a cheap cut-thru sticky drape at the surgical site would probably be of more use than the shoe covers...

That said I always wear gloves when operating and wear a mask for anything significant - I'd be very surprised if the mask is not beneficial when I'm staring into a joint and talking at the same time, but then i perhaps spit too much when I talk. I tend to put a hat on as well, but reckon the mask more helpful. I don a long-sleeved gown for anything when I'll be sticking my hands into or where I anticipate will take more than 30mins or so.

RE: Peri-operative antibiotics

Evelyn Barbour-Hill — Sat, 23 Apr 2016 21:47:52 GMT

[quote user="Anthony Todd"]Semantics; I think most would know what I meant.[/quote]

[quote user="Anthony Todd"]I suppose the next time someone gets a swollen, red, painful wound they'll say "Don't worry, that's normal, inflammation and pain are an essential part of healing. I was wearing gloves so it can't be my fault " .....[/quote]

No, Anthony, I don't think so.

RE: Peri-operative antibiotics

Anthony Todd — Sat, 23 Apr 2016 16:56:48 GMT

[quote user="Evelyn Barbour-Hill"]Inflammation is an essential part of healing (A level biology) even of a single cut made with the finest of scalpels.[/quote]

Semantics; I think most would know what I meant.

I suppose the next time someone gets a swollen, red, painful wound they'll say "Don't worry, that's normal, inflammation and pain are an essential part of healing. I was wearing gloves so it can't be my fault " .....

RE: Peri-operative antibiotics

Evelyn Barbour-Hill — Sat, 23 Apr 2016 16:10:06 GMT

[quote user="Anthony Todd"]Where does "inflamed" come in? [/quote]

After any tissue is damaged it will be repaired. Blood flow increases locally, white cells come wriggling out of capillaries, all sorts of cytokines get swilled around,and so on and so on. Inflammation is an essential part of healing (A level biology) even of a single cut made with the finest of scalpels.

Pain is one of the five pillars of inflammation (dolor, calor, rubor, tumor, laesio functio) (first year pathology).

It is of course the surgeon's duty to attempt to minimise damage and minimise inflammation, and one of the ways in which this is done is by aiming for asepsis; hence the need for sterile gloves.

RE: Peri-operative antibiotics

Anthony Todd — Sat, 23 Apr 2016 15:12:51 GMT

[quote user="Elliot Kneba"]cutting and tearing tissue will always be painful regardless or your experience. Having multiple tissue layers excised, stretched, inflamed, and then sutured back into a different position is an unavoidable source of pain regardless of your technique.[/quote]

Trouble with this argument is the "good" surgeons do cut but don't tear and try to minimise stretch and suturing back at all [if you split the right way.]

Cutting, after the cut, is virtually painless.

Where does "inflamed" come in? If it does it shouldn't.

RE: Peri-operative antibiotics

Alex Gough — Sat, 23 Apr 2016 11:19:02 GMT

[quote user="David Mills"]See above. You're using 'scientifically proven' a) illogically and b) culturally because you think scientific gives it some degree of surety.[/quote]

Scientifically proven has a specific meaning and Hannah is using this correctly. There is no illogic there, nor is science cultural. Things either are, or they are not. To prove whether things are or are not, we use science. Science isn't perfect, but it's the best we have. As scientists, we do or should understand the limits of science, and the extent to which science has proven or disproven a thing. By Hannah saying that something is scientifically proven, she means that controlled trials with statistical analysis make a thing likely, or unlikely. When multiple trials, systematic reviews and meta-analyses all say the same thing, then that thing becomes proven beyond reasonable doubt.

[quote user="David Mills"]All or most have come from some 'scientific' theory,[/quote]

We aren't talking scientific theory though are we? We are talking a theory that has been tested, which is very different.

More below on your reply to me, but I'll take it off on a tangent if I can work out how to do that!

BTW, David, I'm sure I've said this before, but you are a very intelligent guy who makes really thought provoking arguments. (good article in the ethics section of In Practice BTW). So why weaken your position with words like petulantly?

Alex

RE: Peri-operative antibiotics

David Mills — Sat, 23 Apr 2016 09:40:43 GMT

[quote user="alex gough"]Of course every single possible way homeopathy is used has not been tested, but is that relevant?[/quote]

For a scientist, of course it is. Inference or induction is fundamentally illogical. In demonising homeopathy you are relying heavily on inference/induction from a limited data set to the general case. You are relying on the "weight of evidence being overwhelming" - which is a subjective, non-scientific assessment. This is not justified. All the campaign can say is that as far as we know, homeopathy doesn't work and we believe is unlikely to work in most cases. That would be a probabilistic, scieintific statement (with its own issues, admittedly, but better). But that wouldn't be as dramatic, culturally impactful, or public relations savvy. You may be right, homeopathy may be a load of tosh, but the epistemological leap, wallpapered with emotive words such as 'scientific' and 'rational' is, sadly, reminiscent of the Brexit debate. A shame, because the campaign is probably right, just over-excited and over-PR'd in its presentation.

RE: Peri-operative antibiotics

janine redman — Sat, 23 Apr 2016 09:38:08 GMT

As someone who felt nauseous, giddy and really unwell on paracetamol and codeine, I think I would also prefer moderate pain. And some of the dogs on buprenorphine at higher doses are more unsettled and unhappy until it has worn off. However the use of ACP at low doses for sedation seems to be frowned on by some of my younger colleagues

RE: Peri-operative antibiotics

David Mills — Sat, 23 Apr 2016 09:31:32 GMT

[quote user="Hannah Wynne Richards"] I presume that what you're really claiming is they haven't been proven to make things worse.[/quote]

No. I'm saying they haven't been shown to not work. There is an epistemological leap, which I don't think has been justified well, from testing some and then saying "homeopathy doesn't work". It was a response to the pithy "lack of evidence is not evidence of lack of effect" or somesuch. The way we do science, if you're Popperian (and even if you're not, I guess - because science is Popperian essentially when it comes to trials) is that nothing is ever provable, only falsifiable. So we can estimate the truth, but to say that evidence speaks for itself, or something must be true is a fallacy. We could only say something was true in all cases if we were to be able to study all those cases.

[quote user="Hannah Wynne Richards"] scientifically proven treatments[/quote]

See above. You're using 'scientifically proven' a) illogically and b) culturally because you think scientific gives it some degree of surety. Maybe it does. But not as much as you think. Read What is this thing called Science? if you want it further expounding, great book for a rainy day in darkest Wales.

[quote user="Hannah Wynne Richards"]none of whom can give informed consent[/quote]

The history of 'scientific' veterinary medicine is littered - perhaps more so than in human medicine - with therapies that have subsequently shown to be utter shite, harmful or both. All or most have come from some 'scientific' theory, from the Herriot days to present, and were administered with the best of intents. Most of the stuff we do now has little evidence, far far below what would be required for authorisation in human medicine. It is our lot and forever will be that animals cannot consent. The question homeopaths pose make us uncomfortable - evidence of what? - but to petulantly demand they are banned in response is taking us into thoughtcrime leftist territory. Who'd have thought that of you? Funny old world.

RE: Peri-operative antibiotics

Martin Atkinson — Fri, 22 Apr 2016 15:40:22 GMT

[quote user="Elliot Kneba"]

Having multiple tissue layers excised, stretched, inflamed, and then sutured back into a different position is an unavoidable source of pain regardless of your technique.

We as a community have been terrible at identifying animal pain for years.

[/quote]There is a huge leap of faith here that animals regard pain in the same way as we do - indeed there is also a huge difference in how humans regard pain.

I have had several potentially painful injuries and surgical procedures over the years: fractured bones, and a ruptured ACL mainly - things we regard in animals as potentially more painful than soft tissue surgery. I can honestly say that I would rather put up with moderate pain and intermittent acute pain than the side effects from opioids and have told surgeons not to give me any - I will manage it myself with paracetomol/NSAIDs.

Maybe I'm a nutter with a high pain threshold but it shows that we can't make an assumption that all individuals feel the same way about pain relief. How do you know that our patients would not rather put up with a bit of pain than feel nauseous and sedated and stressed about not being in a position to defend themselves?

RE: Peri-operative antibiotics

Hannah Wynne Richards — Fri, 22 Apr 2016 12:36:55 GMT

David You say there's a huge swathe of homeopathic remedies that haven't been proven to be non-efficaceous.

I presume that what you're really claiming is they haven't been proven to make things worse. Hardly surprising, since there's literally nothing in the pills.

If adults chose to doctor themselves with nothing pills, as opposed to scientifically proven treatments, that is their legal right. It is a very different matter when these witch-doctor "remedies" are used on animals, children, or those suffering from dementia - none of whom can give informed consent. This should definitely be forbdden.

Wynne

RE: Peri-operative antibiotics

Elliot Kneba — Fri, 22 Apr 2016 11:51:34 GMT

[quote user="Anthony Todd"]I'm very suspicious of any vet's C/S technique that needs an Elizabethan collar, for example[/quote]

Healing can still causing pruritis even with excellent technique. I agree that most animals do not need them, and that most cats go back to jumping around like maniacs on day two, but I wouldn't necessarily chalk up an animal needing a E-Collar to bad technique.

RE: Peri-operative antibiotics

Elliot Kneba — Fri, 22 Apr 2016 11:47:52 GMT

[quote user="Clive Ansell"] including multi modal analgesia for cat speys, methadone for routine neuters, even the possibility of epidural and local blocks for bitch speys. Nowhere at all was the quality or skill of the surgeon mentioned - one good to avoid pain must surely be to avoid causing it in the first place with careful, gentle well planned surgery. [/quote]

All of these options are designed to avoid causing pain in the first place by preventing it. Of course tissue handling is very important, but cutting and tearing tissue will always be painful regardless or your experience. Having multiple tissue layers excised, stretched, inflamed, and then sutured back into a different position is an unavoidable source of pain regardless of your technique.

We as a community have been terrible at identifying animal pain for years. We are getting better now, but there is no reason not to err on the side of caution. Lidocaine and methadone are cheap, certainly cheaper than buprenorphine, and easy to implement. We should always remember our Halsted's principles, but that doesn't mean we cannot use excellent analgesia as well.

RE: Peri-operative antibiotics

Alex Gough — Thu, 21 Apr 2016 14:26:53 GMT

I would argue with your use of the word "some". There is a LOT of rigorous scientific data testing a LOT of homeopathic remedies, with the conclusions coming back over and over again that there is no effect beyond placebo. Of course every single possible way homeopathy is used has not been tested, but is that relevant? Going back to the original thread, if there was a study showing that the use of surgical gloves didn't decrease the incidence of peri-operative infections, would you say, ah, but they didn't test pink gloves? It is indeed very hard to prove a negative, or indeed anything conclusively in science. What we do is go with the weight of evidence, and when the weight of that evidence is overwhelming, it is hard to argue against it from a scientific point of view.

RE: Peri-operative antibiotics

David Mills — Thu, 21 Apr 2016 13:06:37 GMT

[quote user="alex gough"]scientific literature proving homeopathy doesn't work. [/quote]

Leaving aside the difficulty (or naivety) in proving anything scientific, there is some evidence that some homeopathic treatments appear to have no effect. There is a huge swathe of homeopathic remedies that haven't been shown to be non-efficacious. So the statement applies.

(This is one of the problems I have with the Campaign - there is an authoritarianism and a naive concept of the evidence 'speaking for itself' which is not supported epistemologically. But that's a whole other thread)