Vomit or not to vomit?

RE: Vomit or not to vomit?

vetbl.locum — Mon, 15 Oct 2018 12:45:35 GMT

In an effort to finish this thread off.

I believe everyone would give fluids spiked with K+ and carry out the surgery as soon as reasonably possible.

No doubt some one with disagree with the above

RGds

RE: Vomit or not to vomit?

Anthony Dennison — Mon, 15 Oct 2018 11:25:06 GMT

[quote user="Anthony Todd"]ANother has "dismissed" my K++ reference as across species [seriously??][/quote]

I was trying to make a point about you plucking a paper out of a Google search that suited your viewpoint rather than doing some more in depth research and reading. Just because you find a paper with a similar title to your search parameters doesn't mean it is useful to your argument, or even appropriate EBVM. This is something multiple people have spoken to you about Tony, and yet still you keep doing it.

Why are you so incredulous about me saying the study was irrelevant because it was a human study? If anyone had used a human study as a reference for their case reports whilst working for a certificate or diploma I'm sure they'd have been pulled up on it too.

[quote user="Lucy Fleming"]You seem to be getting very het up about a situation where (if you re-read the posts) almost everyone including the OP is actually broadly in agreement with you...[/quote]

Everyone largely was in agreement with you Tony, then for some reason you started trying to start an argument! Then get all defensive when we disagree with you.

RE: Vomit or not to vomit?

Lucy Fleming — Sat, 13 Oct 2018 00:18:55 GMT

[quote user="Anthony Todd"]

[quote user="Lucy Fleming"]You seem to be getting very het up about a situation where (if you re-read the posts) almost everyone including the OP is actually broadly in agreement with you...[/quote]

OK. I'll have one more try:

Always difficult these cases when you don't have the funds to do all the tests

and even if you do that decision can be difficult and generally I don't advocate using an ex lap as a diagnostic tool (cue disaggreements).

Being a bit potassium obsessed, a K of 2.8 wouldn't have concerned me wrt to a GA. As said above, likely secondary to vomiting (although needs to be quite extreme usually to cause signif K drop), and in combination with inappetance.

That's my two, or three?? disagreements for starters...: tests, K++ and ex.laps. as I said]

ANother has "dismissed" my K++ reference as across species [seriously??]

[/quote]

I'm tempted to tangent this as it feels like it's straying off topic again into very familiar territory. No one on the thread suggested not ex-lapping this patient. Most have agreed with the OP that they would open it asap (but equally, that a delay of an hour or two is unlikely to have changed things much).

I tend to agree with Kate, an ex-lap wouldn't be (I would argue shouldn't be) the first diagnostic test I would jump to. Sure, sometimes it's pretty high on the list based on physical exam findings and/or history, in other cases it's not so clear cut. Not every vomiting animal has a foreign body - sometimes it's an intoxication, sometimes it's pancreatitis, sometimes it's parvovirus, sometimes it's pancreatitis due to a foreign body lodged next to the pancreas Ex-laps are valuable but if you always leap to them first, you'll have a lot of patients that had an abdominal surgery that turned out (in hindsight) to be unnecessary, and really only told you that they don't have a surgical disease. That's painful for the patient and potentially costly for the client.

If you re-read Kate's comment about the potassium you'll see that she is actually agreeing with you that it is likely secondary to the obstruction and gi changes. The only difference I can ascertain is that you wouldn't have measured it in the first place. That's fine. In this type of case, especially if we were trying to make a limited budget go as far as possible, probably neither would I. That doesn't mean the test has no value.

RE: Vomit or not to vomit?

Neil Wheadon — Fri, 12 Oct 2018 22:15:10 GMT

[quote user="Anthony Todd"]and even if you do that decision can be difficult and generally I don't advocate using an ex lap as a diagnostic tool (cue disaggreements).[/quote]

Try this great quote

"Better a negative laparotomy than a positive necropsy'

Neil

RE: Vomit or not to vomit?

Anthony Todd — Fri, 12 Oct 2018 18:57:32 GMT

[quote user="Lucy Fleming"]You seem to be getting very het up about a situation where (if you re-read the posts) almost everyone including the OP is actually broadly in agreement with you...[/quote]

OK. I'll have one more try:

Always difficult these cases when you don't have the funds to do all the tests

and even if you do that decision can be difficult and generally I don't advocate using an ex lap as a diagnostic tool (cue disaggreements).

That's my two, or three?? disagreements for starters...: tests, K++ and ex.laps. as I said]

ANother has "dismissed" my K++ reference as across species [seriously??]

RE: Vomit or not to vomit?

Lucy Fleming — Fri, 12 Oct 2018 18:02:43 GMT

[quote user="Anthony Todd"]

which bit did you disagree with?

I'd like to know too.

[sorry quotes wouldn't]

1. The dismissal, of an ex. lap as a diagnostic tool. I've beaten that drum so often based on experience of mine and others; so quick, always diagnostic and conclusive even when negative. All sorts of other advantages and one of us [MJV] used to to it, sometimes between consults without problems.

2. The relevance of [K++] values in a labile abnormal bowel situation, even with a reference.....[dismissed as "from humans"....??]

3. The delay in surgery when it is blindingly obvious that:

a1) blood values will be haywire in a blocked gut or bladder and etc.

a2) once the obvious pathology is sorted the bloods will too [assuming normal animal prior]

c) the statement that you can't transfer human physiology and/or biochem, in principle, to the dog, which is nonsense.

4. the dismissal of any reference which is obviously wrong [joke, but strangely was/is still true today!!] or obviously relevant [recently] yet the contrary declared quest for EBVM?? [but only if it agrees with current dogma/"what we were taught"/certain specific possible exceptions.]

[/quote]

If you re-read Kate's post, Anthony, you'll find that actually the only one of your points which actually relates to it is point 1.

2 - she did say that in this situation she thought the K+ related to the underlying FB and would have proceeded with surgery (adding more K+ to the fluid whilst doing so)
3 - Kate's post says she would have cracked on with the surgery.
4 - no mention made of the references you posted previously.

You seem to be getting very het up about a situation where (if you re-read the posts) almost everyone including the OP is actually broadly in agreement with you...

RE: Vomit or not to vomit?

Anthony Todd — Fri, 12 Oct 2018 17:51:50 GMT

which bit did you disagree with?

I'd like to know too.

[sorry quotes wouldn't]

2. The relevance of [K++] values in a labile abnormal bowel situation, even with a reference.....[dismissed as "from humans"....??]

3. The delay in surgery when it is blindingly obvious that:

a1) blood values will be haywire in a blocked gut or bladder and etc.

a2) once the obvious pathology is sorted the bloods will too [assuming normal animal prior]

c) the statement that you can't transfer human physiology and/or biochem, in principle, to the dog, which is nonsense.

RE: Vomit or not to vomit?

Anthony Dennison — Fri, 12 Oct 2018 14:54:10 GMT

[quote user="Kate Richardson"]Anthony Todd which bit did you disagree with?[/quote]

I'd like to know too.

RE: Vomit or not to vomit?

Kate Richardson — Fri, 12 Oct 2018 10:52:51 GMT

[quote user="Kate Richardson"]

Remember that Hartmans does not have physiological amounts of K in it, its really quite inadequate and use in hypokalaemic animals can worsen the K level, so ideally use saline with K added or supplement the Hartmans.

In this case, I would have cracked on if I was certain as I could be there was a FB that was likely to cause significant problems if not removed.

Always difficult these cases when you don't have the funds to do all the tests and even if you do that decision can be difficult and generally I don't advocate using an ex lap as a diagnostic tool (cue disaggreements).

Well done to the OP and the tream, good result

[/quote]

Anthony Todd which bit did you disagree with?

RE: Vomit or not to vomit?

Arlo Guthrie — Fri, 12 Oct 2018 10:49:55 GMT

I have been through this thread deleting off-topic posts, and replies to off-topic posts. I've tried to do that without deleting anything important to the OP, but I might have, in which case sorry.

I am now trying a system whereby anyone who routinely takes clinical discussions off-topic then has to have a period of 'pre-moderation' for all their posts, just to check they are relevant to the OP's original question or point. If not, they will be asked to post it as a new or tangent discussion.

Pre-moderation is a feature on this platform that I have not ever used before, so I don't know whether it works or how well it works. We shall see!

RE: Vomit or not to vomit?

Kate Richardson — Thu, 11 Oct 2018 16:10:34 GMT

In this case, I would have cracked on if I was certain as I could be there was a FB that was likely to cause significant problems if not removed.

Well done to the OP and the tream, good result

RE: Vomit or not to vomit?

Anthony Dennison — Thu, 11 Oct 2018 15:58:55 GMT

I would probably have just put the dog on Hartmann's at surgical rates and opened up. Low K+ could have been loss from vomiting, or loss into the gut lumen due to the ileus. I would have then monitored K+ post op, which probably would rise when the dog started eating.

However, I can see the other vet's thought pattern behind their decision and have seen cases where this is done also. Unless there was a severe cardiac arrhythmia or other hypoK+ related issue, I don't think you can 100% argue for either approach.

RE: Vomit or not to vomit?

Charlotte Marshall — Wed, 10 Oct 2018 18:53:58 GMT

I found I have this picture of what can happen with a pair of tights. I was called in late one night to help two younger colleagues with this who had got into the dog then been a bit outfaced as it's entire small intestine was like this and most of its colon. The dog survived multiple enterotomies but got another foreign body months later and when it had surgery the second time the surgeon reported it had adhesions galore making the second surgery very difficult.

RE: Vomit or not to vomit?

Miriam Lodewyks — Wed, 10 Oct 2018 15:12:27 GMT

An interesting topic, imo. For what it's worth I would have erred towards prompt surgical intervention, trusting the K+ to resolve once that's done and with fluid management.

However, I don't think it's unreasonable to delay by a few hours to normalise K+ first (and perhaps to deal with some other urgent cases...?).

RE: Vomit or not to vomit?

David Mills — Tue, 09 Oct 2018 22:04:51 GMT

[quote user="vetbl.locum"]….all I was asking for was an opinion as to people's thoughts on risk of low K and GA....[/quote]

Understood. Which you've had, off a few people, with differing opinions.

There is no right answer here, as in all these cases timing and work up is almost always different. To try and make a guideline or protocol out of something like this would be dangerous.

What you haven't said is whether the dog was showing any clinical signs of hypokalaemia. Which, in the end, is far more important than some blood result from a new inhoyse machine.

RE: Vomit or not to vomit?

vetbl.locum — Tue, 09 Oct 2018 21:54:40 GMT

[quote user="David Mills"] I completely disagree that these don't perforate, in fact linear fbs perforate the worst, normally from stomach, [/quote]

The major delay in this case was the owner bringing the dog in. Delay of Days

I agree linear FB are far more dangerous than stones etc.

If dog had arrived at lunchtime the ex lap would have been done by 5 pm before shift change. It was quiet at that point.

I personally would have gone into abdomen while the fluids were fixing low K ie it is a concern but not worth delaying for hours.

However, dog arrived at 1600ish along with several other cases. So while we were working them up, time was getting on. So I was out of time and energy to do op. Delay of few hours

My colleague attached greater significance to the low K than I did. Delay of several more hours

….all I was asking for was an opinion as to people's thoughts on risk of low K and GA....

RGds

PS All vets involved agreed that there was FB and we needed ex lap , it was the timing of that surgery.

RE: Vomit or not to vomit?

David Mills — Tue, 09 Oct 2018 20:57:55 GMT

Not sure re the risks of hypokalaemia for GA specifically or if there is any evidence - as a charity vet of many years, its not something I've ever routinely measured for gi issues, acute or otherwise.

Theoretically, it can cause muscle weakness (resp issues), hypotension, and cardiac excitability. However, ime, disorders of potassium are usually quite obvious clinically or discernable by other means (E.g. Blocked cat, ecg). Also, restoring some sort of normality with fluids (with working kidneys) will resolve most issues.

In your case, personally, I wouldn't have been concerned by the low potassium. The theoretical, and minimal risks, of going in and solving the problem (chronic by this point) far outweighs the risks of far greater issues further down the line - I completely disagree that these don't perforate, in fact linear fbs perforate the worst, normally from stomach, past pancreas and duct, bile duct, and everything else.

Ex laps are like ceasars - never the wrong decision, not necessarily the completely correct.

Electrolytes are always a clinical sign of something else. In the absence of signs attributable directly and definitively to them, I wouldn't subscribe to "normalising" them (if the dog continued vomiting then it would be pointless anyway in this case)

RE: Vomit or not to vomit?

vetbl.locum — Tue, 09 Oct 2018 18:39:48 GMT

The clinic is set up with 2shifts of staff so the day staff finish handover and go home. Night staff then carry on.

At this handover, the dog's xray images were viewed after brief history disclosed. Oncoming vet stated it had a FB and needed opening without any prompting by me. Vet was then asked if they were happy / confident in doing surgery. They said yes they were.

I stayed another 40mins doing consults while staff prepared for ex lap op. Vet commented that they would prefer to delay until dog had some more K spiked hartmanns. I left believing that surgery would be carried out soon and their workload was manageable.

I left as I was tired verging on fatigue and felt I had been indecisive in managing the dog which I recognise as sign of fatigue in myself. I had phoned another colleague about the dog and we both concluded ex lap was required. I did not tell oncoming vet this prior to them looking at images.

Therefore, I felt the dog had a better chance with a rested surgeon rather than the ' I started so must finish as only I can fix it' tired surgeon.

The preop blood was taken as the dog was very subdued ! ( we wanted to run a blood in our machine as training for staff anyway ) The client was not charged. We found a potentially serious abnormality which we acted upon to correct so I believe covered ourselves.

I recognise handovers between vets has potential problems as we don't get lots of practice at them nor know the importance stuff to convey.

The above is in no way to criticise the oncoming vet hence I left out all these details but felt compelled to reply to AT (un)helpful remarks

So does anyone have any evidence / comments on low K risk factors in GA ?

RE: Vomit or not to vomit?

Gillian Mostyn — Tue, 09 Oct 2018 17:48:32 GMT

I'd much rather the 'fresh' vet operated on my dog, rather than the one who'd already been working for 15 hours. Much more likely to have the energy, and most importantly patience, needed to do a good job. Speaking personally, I certainly wouldn't be at my best after a 15 hour shift!

As far as the delay to surgery - I probably would have cracked on with the surgery, while being aware of the K issue. I guess i would have seen the risk of complications being worse from delaying. However, I don't think the surgeon was wrong to delay surgery in order to correct the electrolytes, as long as they could justify doing so and kept a close eye to ensure there was no indication of any deterioration.

RE: Vomit or not to vomit?

Robin Grimmer — Tue, 09 Oct 2018 17:45:22 GMT

It's the norm in ooh clinics, hospitals to have a handover for the next staff coming on shift. Much like in human hospitals.

RE: Vomit or not to vomit?

Anthony Todd — Tue, 09 Oct 2018 15:10:38 GMT

I also don't like being brow-beaten by clients over money, especially when they've left it for 3 days and it's now a Sunday.

I have never ever ever made "money" a consideration in a clinical decision and i doubt if anyone would find a dinovet that did.

Sadly it is now often an essential diagnostic test and the profession is not enhanced by this development.

RE: Vomit or not to vomit?

Robin Grimmer — Tue, 09 Oct 2018 14:20:56 GMT

There are pros and cons of diving straight in and waiting a bit. Personally, I like to have all the information first. I also don't like being brow-beaten by clients over money, especially when they've left it for 3 days and it's now a Sunday. Also, the majority of your costs are going to be the surgery, anaesthetic and hospitalisation etc.

This case may seem cut and dried, but I would never rely 100% on the history in these cases. I recall a case of a vomiting cat, that had reputedly swallowed some sort of small rubber object. Money was a bit of an issue, and the vet concerned thought they could feel something per abdo so went straight in and found - nothing. So then x-rayed and found a needle in the oesophagus.

RE: Vomit or not to vomit?

Neil Wheadon — Tue, 09 Oct 2018 12:12:55 GMT

[quote user="Sarah Wheadon"]I imagine that having turned up an abnormality on a pre-op blood test, your colleague felt that it was their responsibility to time the surgery when they felt the patient was best stabilised to undergo it successfully. Hope the dog is now doing well. [/quote]

Interesting disciplinary case in Australia recently. A vet was reprimanded for not acting on the results or informing the client.

In effect all points of view are correct in my opinion

If you crack on and just do it, as I would then that's OK

If you look for something, find something that in your opinion (and others) needs correcting or requires consent, then you need to take that into account.

It's an interesting debate I feel because as I have seen the more you look the more you find. This then leads to more indecision and discussion and each case needs to be taken on it's merits

In this case, no money, almost definite diagnosis so are you better to simply crack on and do it without opening yourself up to more costs and potential litigation?

Neil

RE: Vomit or not to vomit?

Jill Butterworth — Tue, 09 Oct 2018 10:37:36 GMT

[quote user="Robin Grimmer"] No danger of perforation with this type of FB [/quote]

Sorry to contradict, but I've seen long strips of material cut through the bowel at multiple sites as peristalsis tries to move the stuff on, but it's snagged somewhere. Partial obstructions give very confusing signs. On balance, I've seen more stuff ups from procrastination and delaying surgery, commonly from handover to another surgeon and would now always prefer the lower risk option of early (and possibly unneeded) exploratory surgery as it's the quickest way for a definitive diagnosis and resolution.

So yes, I'm with you on surgery ASAP, but I'm not a much of a medic... I think we would be surprised how often this scenario happens in the NHS with so many handovers and opinions...

RE: Vomit or not to vomit?

Anthony Todd — Mon, 08 Oct 2018 22:43:44 GMT

BITD, I think most dinovets would diagnose on initial, obvious, simple, palpation and operate that day, or night, and let the [K+] value sort itself out once the tights had been removed,

Probably not even run bloods with such obvious pathology.

Edited for timeline accuracy