When to use intravenous fluids?

RE: When to use intravenous fluids?

mariette asselbergs — Fri, 05 Aug 2016 14:47:57 GMT

[quote user="janine redman"]

I have had to look up what stars mean - hadn't taken much notice of them before. must be a quiet day at work

[/quote]

Where did you find an explanation? I have never understood, and never tried to use them.

Mariette

RE: When to use intravenous fluids?

Rob Loxley — Fri, 05 Aug 2016 13:52:32 GMT

[quote user="Braden Collins"]They would all give a lower price on the phone, then when the client came in they would be told it was an extra $30-50 for analgesics. One would even give options of paying extra for heat mats on recovery, "superior" suture material, and multiple other up-sells.[/quote]

This might be 'bordering on exploitation'. How can the client be able to make an informed decision on this, it is purely just playing off their concerns over GA/surgery to make more money

RE: When to use intravenous fluids?

janine redman — Thu, 04 Aug 2016 18:41:10 GMT

I have had to look up what stars mean - hadn't taken much notice of them before. must be a quiet day at work

RE: When to use intravenous fluids?

janine redman — Thu, 04 Aug 2016 16:38:04 GMT

whilst I like my patients to wake up well, I dont necessarily want them to wake up fast. with buprenorphine or methadone on board a slow and steady recovery is better, especially when some cannot go home till early evening.

RE: When to use intravenous fluids?

Anthony Todd — Thu, 04 Aug 2016 15:40:18 GMT

[quote user="Braden Collins"]I'm not sure we'll ever agree on the IV fluids thing,[/quote] and the rest.

Sensible, not rude or personal so why the one star.... Arlo, we need you here....

Still need evidence of anaesthetic recovery speed though versus agent administration with or without fluids....

RE: When to use intravenous fluids?

Anthony Todd — Thu, 04 Aug 2016 15:36:21 GMT

[quote user="Neil Wheadon"]However you don't help yourself with this one as 'can you get this any more?'[/quote]

Er, my point was, with the only example I had experience of, that the rate and "style" of anaesthetic administration can have a big influence on recovery time, with or without fluids.

RE: When to use intravenous fluids?

Anthony Todd — Thu, 04 Aug 2016 15:32:53 GMT

[quote user="Dan Holden"]Some of my own data: over the last eleven years two cats have died in our practice due to anaesthesia; one had hypertrophic cardiomyopathy at post mortem (don't know if that killed it or not) and the other of acute anaphylaxis.[/quote]

Be interested, and it's EBVM, to have the total number of anaesthetics, if possible, because the last EBVM was the "Saffan" data as far as I recall.

RE: When to use intravenous fluids?

Braden Collins — Thu, 04 Aug 2016 15:07:54 GMT

I'm not sure we'll ever agree on the IV fluids thing, but I'll definitely agree with you on the one star thing - a one star needs to come with a comment. Annoys me no end when someone gets one starred without the culprit giving their point of view.

It would be around 2 years now that we have been doing IV fluids as standard, and we've experienced no issues of haemorrhage.

the discussion that lead us down the path of routine IV fluids came from the desire to have an IV catheter in place for all animals under GA. We felt this was highly desirable but it was hard to explain benefits to owners. To cover the time and cost of inserting these, we needed to increase our charges. We were already the most expensive (because we included pain relief in our prices), and people assume all vets have things in place for emergencies. We therefore found it hard to explain the increased cost difference to clients. So we decided to go all-in and hook them up to a drip. We found the animals recovered faster from the anaesthetic, and the clients responded very well to that. It was something we could truly market to the clients which they could see for themselves.

RE: When to use intravenous fluids?

Neil Wheadon — Thu, 04 Aug 2016 15:05:26 GMT

[quote user="Anthony Todd"]I remember, with straight thio, you could bounce an alsation up in 20 minutes if you gave one bolus, or 2-3 hours if you gave it progressively.[/quote]

However you don't help yourself with this one as 'can you get this any more?'

Neil

RE: When to use intravenous fluids?

Neil Wheadon — Thu, 04 Aug 2016 15:02:40 GMT

[quote user="Anthony Todd"]And, rather than 1 starring this, just explain where I'm an idiot or a troll because others may find it of interest.[/quote]

You're not an idiot Anthony, your ideas are at time old fashioned but then again I don't understand a mobile phone (ask my wife) You're akin to someone piping up in a crowded lecture theatre asking a question that half think is ridiculous, but the other half probably think ....mmm I was thinking that.

So I agree don't just red star, blow it out of the water and we'll all learn something as I have with Dan Holden here as it's re-enforced why I will IV fluid geriatric patients at the drop of a hat if given the chance because in these I do believe it makes a difference

Neil

RE: When to use intravenous fluids?

Anthony Todd — Thu, 04 Aug 2016 15:02:25 GMT

[quote user="Braden Collins"] The big one is always the recovery speed (clients can see that), and they really like it.[/quote]

That depends on the anaesthetic and it's administration, need some EBVM really...

I remember, with straight thio, you could bounce an alsation up in 20 minutes if you gave one bolus, or 2-3 hours if you gave it progressively.

RE: When to use intravenous fluids?

Anthony Todd — Thu, 04 Aug 2016 14:56:45 GMT

[quote user="Braden Collins"]I don't think minimising haemorrhage is a reason not to give fluids.[/quote]

No, of course not, but, when the use of fluids is struggling to be justified, it may well turn out that if fluids [er, once we can decide on dose rate[!!]] become routine suddenly and coincidentally there is a rise in peri-operative haemorrhage, remembering that haemorrhage is diagnosed visually....

Can anyone tell me the normal resting BP in a normal cat. It may be that, under GA, BP, assumed to be low, is actually just the resting BP, which seems likely in a cat with no muscle activity and on 100% oxygen??

And, rather than 1 starring this, just explain where I'm an idiot or a troll because others may find it of interest.

All you guys are screaming for EBVM but only if it agrees with the accepted view or opinion, just look at some of the threads, "gloving" is the latest...

RE: When to use intravenous fluids?

Braden Collins — Thu, 04 Aug 2016 14:54:59 GMT

[quote user="robloxley"]

[quote user="Dan Holden"]I certainly don't regard it as "bordering on exploitation"[/quote]

I think it is the way some practices pile on the pressure for the clients to go for gold-standard (or even best practice) extras but there is an extra charge to pay - be it for giving fluids or using a pulse oximeter.
If you feel something should be getting fluids or preop bloods or a pulse ox or whatever then do it, and build it into your fee. To present the owners with the option with a guilt-trip over 'safety', to make more money, is where owners might be exploited.

[/quote]

We believe it is important, so we make it standard and avoid any pressure on clients.

Until recently, most of the opposition clinics in the area didn't include take-home pain relief for desexing in their quoted prices. They would all give a lower price on the phone, then when the client came in they would be told it was an extra $30-50 for analgesics. One would even give options of paying extra for heat mats on recovery, "superior" suture material, and multiple other up-sells.

Of course we needed to market the fact that we give IV fluids routinely. It costs more, so we need to educate the clients as to the benefits. The big one is always the recovery speed (clients can see that), and they really like it.

RE: When to use intravenous fluids?

Neil Wheadon — Thu, 04 Aug 2016 14:43:19 GMT

[quote user="Dan Holden"]There is compelling evidence within the literature that injectable and volatile anaesthetic agents cause dose-dependent cardiovascular depression, primarily through vasodilation but in some circumstances also via direct myocardial effects or effects on heart rate. Because the vasodilation causes a relative hypovolaemia, fluid boluses and/or infusion can improve hypotension produced by inhalant anaesthetics.[/quote]

The physiology of this is not in doubt, the question here is 'should we as vets be routinely addressing the issue?'

Evidence based medicine is all the rage, so what's the evidence?

Undoubtedly the effects described in these papers happen but what are the consequences to an animal not receiving IV fluids for routine procedures?

Anecdotally (there seems to be a resistance to this) thousands of animals are routinely anaesthetised and spayed using similar protocols across the UK with propofol and maintained on isofluorane. There are few huge variables. Anecdotally the vast vast majority are bouncing about 2 days later, if death occurs or debilitation in cases we would notice this. How many deaths are attributed to hypotension as a causative factor?

If some members of the profession wish to use this as a routine then either side should understand the reasoning.

What we mustn't get involved in is practices doing this saying that their method is the gold standard inferring that everyone else is doing the job badly, because an IV line doesn't mean that everything else is top notch.

One final off the wall thought. It's terribly wasteful isn't it? An IV line/bag of fluids in the bin, when hospitals in Syria and third world countries are crying out for this, get the clients to donate to UNICEF instead or send those drip lines abroad, are we going just too far?

Neil

RE: When to use intravenous fluids?

Rob Loxley — Thu, 04 Aug 2016 14:42:23 GMT

[quote user="Dan Holden"]I certainly don't regard it as "bordering on exploitation"[/quote]

RE: When to use intravenous fluids?

Braden Collins — Thu, 04 Aug 2016 14:36:51 GMT

[quote user="Anthony Todd"]

[quote user="Braden Collins"]Presumably veterinarians in both these scenario have the same concerns about hypotension etc. [/quote]

I wonder if the "concern" about hypotension is because we now know about it, and via a multicoloured screen!! [must be important]

We therefore make efforts to correct the problem which isn't a problem in a 5 minute procedure.

How low is a cat's BP when it is fast asleep?

Is there any advantage in boosting an animal's BP and thereby increasing the tendency and volume of haemorrhage?

[/quote]

I don't use IV fluids just for the hypotension. I also find it improves recovery from the anaesthetics, so there are multiple benefits.

If giving fluids leads to increased risk of haemorrhage, I would be assessing my surgical technique. If something is bleeding at a normal blood pressure, it needs to be dealt with. I don't think minimising haemorrhage is a reason not to give fluids.

RE: When to use intravenous fluids?

Anthony Todd — Thu, 04 Aug 2016 12:10:09 GMT

[quote user="Braden Collins"]Presumably veterinarians in both these scenario have the same concerns about hypotension etc. [/quote]

I wonder if the "concern" about hypotension is because we now know about it, and via a multicoloured screen!! [must be important]

We therefore make efforts to correct the problem which isn't a problem in a 5 minute procedure.

How low is a cat's BP when it is fast asleep?

Is there any advantage in boosting an animal's BP and thereby increasing the tendency and volume of haemorrhage?

RE: When to use intravenous fluids?

Anthony Todd — Thu, 04 Aug 2016 12:01:21 GMT

[quote user="Braden Collins"]We do a lot of routine work for a local charity at a very heavy discount. They all still have IV fluids, and we just sucked up the extra cost for these cases. Part of our marketing on this topic is "every animal has IV fluids", so we don't make exceptions for charities.[/quote]

Didn't imagine it would come down to a marketing decision; bit like gloving then?.....

I'm rather disappointed at this, although not surprised as wading through the quoted abstracts seems to show little agreement, even on infusion rates.

Nor it seems is there any demonstrated actual benefit particularly in very short procedures.

There is still no decent evidence that "fluid overload" is a problem in cats either, and no evidence that I can see, so far, that, even though fluids will increase blood pressure, it has any relevance, per se, in complications or outcomes in cats.

One thing that is the elephant in the operation is the time under GA....

My observation is that, with tubing, cannula, or often cannulae!!, extended prep time let alone actual surgery time, the time under GA; even though skin to skin time may still be reasonably short, is the real factor in determining post op or intra op complications?

Nothing yet on the newer intramuscular anaesthetics either.

RE: When to use intravenous fluids?

Martin Atkinson — Thu, 04 Aug 2016 11:07:43 GMT

[quote user="rhmrcvs"]I think VDS advise that they have numerous reports of problems with intubation in cats ( cuffed tubes) , they call it crackle puss in the newsletters.[/quote]I think the problem is not necessarily the cuff but the tip of the tube. If you look on X-ray in the majority of cats if you tie a 3.5mm ET tube with the tape distal to where the cuff enters the tube the tip will be exactly at the thoracic inlet where the trachea bends so the end of the tube could really dig in if there is any movement.

RE: When to use intravenous fluids?

Braden Collins — Thu, 04 Aug 2016 10:51:58 GMT

[quote user="J G Wray"]

Here's a clinical/ethical conundrum

If you were taking part in a charity sponsored neutering campaign, in the UK for instance, would you put patients on iv fluids?

If you were taking part in a charity sponsored neutering campaign, in a First World country, like Spain, would you put patients on iv fluids?

Presumably veterinarians in both these scenario have the same concerns about hypotension etc.

[/quote]

We do a lot of routine work for a local charity at a very heavy discount. They all still have IV fluids, and we just sucked up the extra cost for these cases. Part of our marketing on this topic is "every animal has IV fluids", so we don't make exceptions for charities.

RE: When to use intravenous fluids?

rhmrcvs — Thu, 04 Aug 2016 10:25:54 GMT

Not misleading , merely the discussion.

I think VDS advise that they have numerous reports of problems with intubation in cats ( cuffed tubes) , they call it crackle puss in the newsletters.

RE: When to use intravenous fluids?

Martin Atkinson — Thu, 04 Aug 2016 09:54:19 GMT

[quote user="Dan Holden"]about 3 million anaesthetics happen in the NHS each year - 56% have some sort or supraglottic airway management with around 38% properly intubated; the rest get a mask.[/quote]It is misleading to compare human anaesthesia with our patients. Despite being told to starve their pets many ignore this advice/don't have the sense to tell everyone else in the household or don't think to pick up the other pet's food and/or let the cat out so don't know if its eaten or not. Consequently, the risk of vomiting is much higher. We used to use xylazine as a premed in cats and I would estimate that 50% of allegedly starved cats vomited food. I can't think of a single complication to intubating a dog and only one cat that had a damaged trachea in 40 years and that was because an untrained nurse was continually turning the cat over without disconnecting the tube during a dental procedure.

RE: When to use intravenous fluids?

J G Wray — Thu, 04 Aug 2016 09:00:38 GMT

Here's a clinical/ethical conundrum

If you were taking part in a charity sponsored neutering campaign, in the UK for instance, would you put patients on iv fluids?

If you were taking part in a charity sponsored neutering campaign, in a First World country, like Spain, would you put patients on iv fluids?

Presumably veterinarians in both these scenario have the same concerns about hypotension etc.

RE: When to use intravenous fluids?

rhmrcvs — Thu, 04 Aug 2016 08:56:35 GMT

It aint what you do , its the way that you do it.......... ( Fun Boy Three / Bananrama , 1982)

RE: When to use intravenous fluids?

janine redman — Thu, 04 Aug 2016 08:18:18 GMT

Many thanks Dan , doesn't make easy reading but that was exactly what I was looking for . I never know whether we are over complicating things

janine