Pyothorax chest drain management

RE: Pyothorax chest drain management

Martin Atkinson — Thu, 21 Sep 2017 10:24:42 GMT

For the person who obviously one starred me: did you not see the 'wicked' emoji which should have enabled even someone with a brain as small as yours to realise I was playing Devil's Advocate with the second sentence or do you just not do sarcasm?

As for the reply of where to get MILA stuff in the UK, if you have a better idea - share it, don't be an asshole.

RE: Pyothorax chest drain management

Rob Loxley — Wed, 20 Sep 2017 19:48:38 GMT

[quote user="Martin Atkinson"][quote user="Edward Jones"]Does anyone know from where the MILA small bore chest drains can be obtained, please?[/quote]... But you don't need them just stick a needle in. [/quote]

In the paper referenced "The median length of time the drain was in use was three days (one to 13 days)"

RE: Pyothorax chest drain management

Martin Atkinson — Wed, 20 Sep 2017 16:37:18 GMT

[quote user="Edward Jones"]Does anyone know from where the MILA small bore chest drains can be obtained, please?[/quote]AFAIK the MILA distributor in the UK is Direct Medical Supplies, dmsveterinary.com. But you don't need them just stick a needle in.

RE: Pyothorax chest drain management

Edward Jones — Wed, 20 Sep 2017 16:21:15 GMT

[quote user="robloxley"]

There was a paper from the RVC on using small-bore chest drains (as opposed to traditional larger drains) for managing pleural space disease http://www.milainternational.com/MILA_MEDIA/JSAP-Chest%20Tube.pdf

[/quote]

Does anyone know from where the MILA small bore chest drains can be obtained, please?

RE: Pyothorax chest drain management

Evelyn Barbour-Hill — Wed, 20 Sep 2017 15:02:10 GMT

[quote user="Anthony Todd"]Seems counter intuitive to me too so would like to see the reference although it depends what "somebody" said, as it may well be that parental admin. works as well as, apparently my local instillation did.[/quote]

It was a very respectable paper by someone with no axe to grind. No, I can't remember the reference and I can't be bothered to go hunting for it.

Counter-intuitive, maybe, but think a little harder and it makes more sense.

My point is just the fairly trivial one that fashions change and today's must-do becomes tomorrow's no-point.

RE: Pyothorax chest drain management

Anthony Todd — Wed, 20 Sep 2017 13:19:46 GMT

[quote user="Evelyn Barbour-Hill"]Yes, that's interesting, it was always the done thing to instil some antibiotic or more usually metronidazole into the chest; it was only a few years ago that somebody demonstrated that (counter-intuitively if you like) it did nothing: it had no advantage over administering antibacterial drugs by the more usual subcutaneous or intramuscular routes. So I stopped.[/quote]

Seems counter intuitive to me too so would like to see the reference although it depends what "somebody" said, as it may well be that parental admin. works as well as, apparently my local instillation did.

To be honest I can't remember for sure whether I also gave an oral course or a jab, so rather than *ull-*hitting.....

RE: Pyothorax chest drain management

Anthony Todd — Wed, 20 Sep 2017 13:13:49 GMT

[quote user="Malcolm Ness"]If a clinician's best "rememory" of their experience was reliable, then I would rely on it without the need for anything more: but it isn't, so I don't.[/quote]

Have a look at Singleton's paper on cruciate repair, I think the first one published, sounds great until I realised my referral, a disaster, had been left out..... I think the numbers were not large either....

I'd be quite happy to respect your opinion, and anyone on here even if it is only anecdotal, often anecdotes give more background to the results than a paper as well.

None of us has got any axe to grind, or reason to "adjust" results whereas a "paper" is often published with an end in view, and not many show poor results.

Going back you'll find lots of people u respect on here giving "anecdotal opinions".

I'm sure, as well, that we all remember our failures much more than our successes.

"Bad science" Ben Goldshaw will give you better, and many, examples.

RE: Pyothorax chest drain management

Evelyn Barbour-Hill — Wed, 20 Sep 2017 12:38:47 GMT

[quote user="Anthony Todd"]sometimes some 100s ccs of pus [/quote]

400ml (measured) of pus not unusual.

[quote user="Anthony Todd"]with A/Bs instilled on the way out,[/quote]

Yes, that's interesting, it was always the done thing to instil some antibiotic or more usually metronidazole into the chest; it was only a few years ago that somebody demonstrated that (counter-intuitively if you like) it did nothing: it had no advantage over administering antibacterial drugs by the more usual subcutaneous or intramuscular routes. So I stopped.

RE: Pyothorax chest drain management

Robin Grimmer — Wed, 20 Sep 2017 11:10:54 GMT

Apart from pyothorax which is curable, pretty much all other causes of pleural effusion have a fairly poor prognosis and are likely to reform.

RE: Pyothorax chest drain management

Anthony Todd — Wed, 20 Sep 2017 10:04:25 GMT

[quote user="Sarah Keir"]

I understand humans form adhesions at the drop of a hat whereas dogs/cats don't (rabbits are like humans) so I understand there is not such a big concern over adhesions.

[/quote]

I have a very good friend who has been *uggered about by "specialists" for months with "chest fluid" with drainage and vague desciptions of "pleural scraping"??

Now in hospital for what he tells me is for " cancer diagnosis". Hardly relevant, except to me.

I can only say that one [some might have had another tap occasionally] has always been curative with A/Bs instilled on the way out, sometimes some 100s ccs of pus and/or fluid removed and AFAIR all OK.

All done in the consult with no clipping or anaesthesia, even local, because I was so scared or a terminal anoxic event.

But just more anecdotes which only Andrew is allowed......

RE: Pyothorax chest drain management

Kate Richardson — Tue, 19 Sep 2017 22:42:59 GMT

[quote user="Sarah Keir"]

I understand humans form adhesions at the drop of a hat whereas dogs/cats don't (rabbits are like humans) so I understand there is not such a big concern over adhesions.

[/quote]

That's interesting. When I have spoken to specialists about pyothorax cases, they have strongly advocated drain placement to minimise adhesions. One case (a dog) was drained via needle by colleague and sent home on antibiotics which I was shocked about at the time, thinking OMG this dog will die or end up with complications without a chest drain, but responded very quickly, 4 weeks abs and from memory 12-18 months later was fine. Think it had some cardiac disease diagnosed along the way though but now stretching memory beyond its capabilities

Not saying drains are a bad thing. Going back to Michael Woodhouse 's original question, the drain itself will cause some inflammation and fluid, so as David said, less than 2mls/kg and a white cell count below a certain level (which I also can't remember with out looking up) is a good indicator that it needs to come out.

RE: Pyothorax chest drain management

Michael Woodhouse — Tue, 19 Sep 2017 22:37:24 GMT

Tubes came out yesterday. Cat went home today. On Synulox/Baytril and back for a check on Friday.

Got to the point of being grumpy with us.

Happy thus far....

RE: Pyothorax chest drain management

Sarah Keir — Tue, 19 Sep 2017 16:38:12 GMT

I understand humans form adhesions at the drop of a hat whereas dogs/cats don't (rabbits are like humans) so I understand there is not such a big concern over adhesions.

RE: Pyothorax chest drain management

Clive Ansell — Tue, 19 Sep 2017 14:34:54 GMT

[quote user="Kate Richardson"]

My understanding of chest drains and flushing is not only to remove the pus but to minimise fibrin formation and adhesions within the pleural space so it would be interesting to look at both techniques ie needle drainage only and chest drain placement and look at short term survival AND long term prognosis. Do adhesions significantly compromise quality of life and reduce life expectancy? Does anyone know?

I have seen both techniques and good and bad outcomes in both

[/quote]

A very good question.

My brother had a pyothorax, and needed a chest drain for 10 days. Fibrin formation and pleural adhesions were a big concern in his case, his chest was drained and then was flushed with saline and Streptokinase used daily. There was also concern about pulmonary scarring and reduced lung function, so he was introduced to physiotherapy and breathing exercises as soon as he was able. Luckily, he didn't need the keyhole surgery to break down adhesions that was discussed initially.

A very debilitating illness, and his full recovery took 18 months.

Is Streptokinase ever used for these cases in veterinary medicine?

RE: Pyothorax chest drain management

Martin Atkinson — Tue, 19 Sep 2017 14:11:47 GMT

[quote user="Anthony Todd"] I only drained them once with a needle, and never saw the need for a semi-permanent drain. They returned to normal once the fluid/pus was removed and I don't think I ever had to drain one again, nor had one that died.[/quote]While I still tend to needle aspirate rather than place a drain at the start, it would be startlingly optimistic to say that I've never had to do it more than once, it has always been a minimum of 3 attempts (albeit maybe the third to confirm the chest is clear. Then if it is still recurring I would consider placing a drain. Sadly a high proportion do recur and some do die - you've either been very lucky or have a selective memory Anthony.

RE: Pyothorax chest drain management

Rob Loxley — Tue, 19 Sep 2017 13:49:43 GMT

RE: Pyothorax chest drain management

Kate Richardson — Mon, 18 Sep 2017 16:32:27 GMT

I have seen both techniques and good and bad outcomes in both

RE: Pyothorax chest drain management

Malcolm Ness — Mon, 18 Sep 2017 16:11:45 GMT

[quote user="Anthony Todd"]Sure, but I already know the results of the "cases study" as I already have the evidence of a number of reputable reliable vets,and my own, all who, I believe, would not, nor have any reason, spin or falsify their "anecdotes" or opinions.[/quote]

Were you ever to sit down and review the evidence of your own cases, you would very likely find - as almost all of us who have gone before have done - that your recollection of that data, which has shaped your current opinion, does not match the conclusions you will draw based on the systematic analysis of that same data.

If a clinician's best "rememory" of their experience was reliable, then I would rely on it without the need for anything more: but it isn't, so I don't.

RE: Pyothorax chest drain management

Evelyn Barbour-Hill — Mon, 18 Sep 2017 15:39:25 GMT

[quote user="Thomas Johnson"]If that were the case we'd still be bleeding our patients and firing horses legs.[/quote]

Firing, perhaps, but not bleeding. Doctors and veterinary surgeons didn't stop bleeding because of published papers, they stopped because they gradually realised it was wrong.

RE: Pyothorax chest drain management

Thomas Johnson — Mon, 18 Sep 2017 15:20:34 GMT

[quote user="Anthony Todd"]

I'd rather rely on our opinions rather than a paper ,of possibly dubious provenance, ignoring specific circumstances, or just plain wrong.

[/quote]

If that were the case we'd still be bleeding our patients and firing horses legs.

RE: Pyothorax chest drain management

Anthony Todd — Mon, 18 Sep 2017 12:55:17 GMT

[quote user="Thomas Johnson"]I don't understand your problem with David's suggestion? He's suggesting that a case-series could be published, a perfectly valid way of looking at historical data. If you can show that all of the cats that presented to you with a pyothorax were treated in a certain way, and they all made a good recovery, that would be a useful paper.[/quote]

Sure, but I already know the results of the "cases study" as I already have the evidence of a number of reputable reliable vets,and my own, all who, I believe, would not, nor have any reason, spin or falsify their "anecdotes" or opinions.

eg, in this case [as previously in blocked cats] if a uni published their results of "our" needle draining of cat chests, all nice and scientific etc, nice tables with ages etc, etc.

I'll bet the results would not be good probably due, but not mentioned, to delay since onset and technical variation between operators [viz, the allusion to damage during the procedure previously mentioned]

I'd rather rely on our opinions rather than a paper ,of possibly dubious provenance, ignoring specific circumstances, or just plain wrong.

I'd say there are more dodgy "papers" than there are dodgy opinions from respected, practising, professionals, obviously depending on the specifics of that opinion and the subject.

[don't start me on vaccine immunity durations]

RE: Pyothorax chest drain management

Thomas Johnson — Mon, 18 Sep 2017 12:43:11 GMT

[quote user="Anthony Todd"]

[quote user="David Mills"]In this situ I always say that if you saw so many that did well with just centesis then send me all your pyothorax records and I'll happy turn them into a quite revolutionary paper. Until then. It's, at best, anecdote. I won't be rude on this occasion. [/quote]

What on earth, by any standard or logic, is a "prepared" paper giving the collected anecdotes of, now, a couple of vets, better than a list of cats with mainly irrelevant details, in relation to the same condition, and similar treatments as far as results are concerned?

[/quote]

I don't understand your problem with David's suggestion? He's suggesting that a case-series could be published, a perfectly valid way of looking at historical data. If you can show that all of the cats that presented to you with a pyothorax were treated in a certain way, and they all made a good recovery, that would be a useful paper.

RE: Pyothorax chest drain management

Evelyn Barbour-Hill — Mon, 18 Sep 2017 12:17:17 GMT

[quote user="Anthony Todd"]Respond with a one star; it's now the scientific way on here.[/quote]

Looks as if you got it......

RE: Pyothorax chest drain management

Anthony Todd — Mon, 18 Sep 2017 11:29:21 GMT

And, as we know, some "revolutionary papers" turn out to be even worse than a three vets' describing their collective experiences.

Cruciate repair with a piece of skin anyone?? [and missing out the failure]

Remember the "paper" on "Thyroxin toxicity in a dog"....

Medical science has many discredited "papers".

[Draining a CBA with a 12G needle; probably would work nearly as well; slashing a hole in the chest; not so sensible....]

Respond with a one star; it's now the scientific way on here.

RE: Pyothorax chest drain management

Evelyn Barbour-Hill — Mon, 18 Sep 2017 01:07:41 GMT

[quote user="Robin Grimmer"]

Thinking about it logically - a pyothorax is just a form of abscess. So it requires drainage. If you just drained it with a needle you would expect it to refill, hence the need for a drain.

[/quote]

Ye-es.... but the fact is that many (nearly all, in my hands) recover fine with needle drainage, commonly (not always) just once. I'm not disputing the use of drains, I'm saying that at the hands of somebody good at it needle drainage is very effective.

I'm not convinced of the need for flushing though. Again, not criticising those who do it.