Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Rob Loxley — Mon, 10 Feb 2020 20:28:50 GMT

[quote userid="11493" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/28878/is-there-a-timescale-for-an-abdominal-bleed-to-be-reliably-identifiable-post-op/219348"]I think the time of analgesia wearing off could be a very useful indicator to see if we need further pain relief but it also should be enough time to decide whether a post-op bleed is likely or not[/quote]

Based on???

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Jill Butterworth — Mon, 10 Feb 2020 14:37:40 GMT

Really good question, Fransisco, and one which feeds in to my bitch spay paranoia! Like others, I too have focussed on prevention in practice, and transfixing and double ligating almost removes the risk of ligation slippage, and now I have retired I can say that I have never had a post op bitch spay bleed in 24 years, and so I would have been be extremely stressed to have had even one in in my practice. I have seen one major bleed early on in my career, by another surgeon. Unfortunately, I don't recall how many days post op it was, but the dog was walking and with frank blood dripping from the wound. It was opened up, re ligated and recovered. It certainly shocked me enough to make me always double and even triple ligate fat or difficult bitches.

Performing ovariectomies rather than ovariohysterectomies, would more than half the risk. I appreciate that may be difficult laparoscopically.

As you have the facilities and skill, why not FAST scan all your bitch spays to do an internal audit and see how many are actually oozing blood with no clinical signs? It might give surprising results, and even indicate if one of your surgeons needs to revise their technique.

Bouncy dogs shouldn't be able to make internal ligatures come off, but they can cause sub cut bleeding.

A fairly reliable but subjective guide, is that if something seems wrong, it usually is...

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Beats — Sun, 09 Feb 2020 15:40:56 GMT

specifically re bitch spays, i think i would like to see able to walk and not look sleepy before going home, i don't think i have a specific requirement beyond this, but i think if thought about i would want to keep for half an hour to an hour after surgery minimum (perhaps in an anxious patient). Generally do bitch spays in morning and would keep for between 4 hours and 8 hours before going home. I like to operate in morning, then home in afternoon, then hopefully if any issues at all identified before close in evening so doesn't end up being query to OOH provider. I would guess that most bitches that bleed it is likely when blood pressure goes up and jumps into car or gets home etc? So keeping longer in clinic to send home as you close could just mean that if a problem happens you're more likely to have an OOH problem rather than during normal working hours?

The vast majority of bitch spays I do are in small to medium dogs that are relatively young and not obese these days. I might have different thoughts if I worked in a rescue and was spaying obese large breed deep chested dogs regularly.

So I guess my thoughts are organising doing bitch spays earlier in day is potentially more of a priority than how long you keep them afterwards?

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Francisco Gomez — Sun, 09 Feb 2020 15:05:52 GMT

[quote userid="11232" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/28878/is-there-a-timescale-for-an-abdominal-bleed-to-be-reliably-identifiable-post-op/219347"]at least up and about, hopefully eaten and urinating before they go home.[/quote]

I agree. But since Alfaxan, some are up and about very very quickly. It might be unfounded but it does frighten me a little.

[quote userid="11232" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/28878/is-there-a-timescale-for-an-abdominal-bleed-to-be-reliably-identifiable-post-op/219347"]Do you do pre-op TPR? May be worth doing pre-op and pre-discharge so any major changes can be noted?[/quote]

Yes, we do.

[quote userid="11232" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/28878/is-there-a-timescale-for-an-abdominal-bleed-to-be-reliably-identifiable-post-op/219347"]How did you pick up on the last bleeds you had? What was it about the post op check that your vets noted?[/quote]

From memory, I recall an obvious bleed post-op through the wound. This has happened before from subcut tissue as well, but a quick scan has helped us identify the difference. Another one was simply the patient not waking up properly, which triggered again a scan and revision surgery.

It is in this last case where I feel waking up too quickly could be problematic: The wound is sealed, the patient is up, but then it goes downhill later on.

[quote userid="11232" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/28878/is-there-a-timescale-for-an-abdominal-bleed-to-be-reliably-identifiable-post-op/219347"]My personal preference is a minimum of 4 hours (once the methadone has worn off) so I can be sure about post-op analgesia etc.[/quote]

This is VERY helpful and perhaps very obvious too. It is the sort of answer I was looking for. Thank you!

I think the time of analgesia wearing off could be a very useful indicator to see if we need further pain relief but it also should be enough time to decide whether a post-op bleed is likely or not.

I am guessing there would be some patients where this might be impossible to do, i.e. overly stressed individuals. But this can also be addressed by communicating properly with the owners.

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Emily Rainbow — Sun, 09 Feb 2020 14:50:03 GMT

My personal preference is a minimum of 4 hours (once the methadone has worn off) so I can be sure about post-op analgesia etc. I also want my patients at least up and about, hopefully eaten and urinating before they go home.

A major bleed E.g. cervical should be fairly obviously quite quickly, the only one I’ve see was DOA, but the owners had to carry it out of the practice that did the op as it couldn’t walk which would be a big alert to me not to discharge it!

A slower bleed eg a ovarian stump might be trickier to spot. But I’d probably trust a general demeanour, pulse rate and CRT check over afast as you’d expect some infra-abdo fluid post-op anyway. Do you do pre-op TPR? May be worth doing pre-op and pre-discharge so any major changes can be noted?

Our nurses currently call our surgical patients the day after to check all is well. I guess this might pick up a problem if they’re not back to bouncing the next morning.

How did you pick up on the last bleeds you had? What was it about the post op check that your vets noted?

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Dinu Catilina — Sun, 09 Feb 2020 14:37:48 GMT

My apologies

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Francisco Gomez — Sun, 09 Feb 2020 14:00:47 GMT

I'd like to edit my post but I'm unable to do so, therefore I am adding up here, Arlo Guthrie .

We have (as far as my memory goes), no more than 3 post-op bitch spay bleeds in the last few years, all recovered well, picked up due to our post-op checks, all done by different surgeons with different degrees of experience. We have recently introduced Alfaxan, which I'm very happy about, there are many benefits over our previous induction agent.

I'm concerned, however, that patients return to be wide awake a little too quick.

How do you determine when it is safe to send your bitch spay home? Are there any studies about this?

I'm not looking at 'how to prevent post-op bleeds'. My question is about post-op. If post-op checks weren't a thing, we wouldn't even need a kennel, but I'm not sold on asking the client to collect the pet directly from the operating table ( ). How do you decide when is the appropriate time and do you use a minimum time for observation?

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Sarah Keir — Sun, 09 Feb 2020 13:48:14 GMT

How about starting with an audit of the number of post op bleeds? Or at least the ones where a clinical problem was picked up or laparotomy required. Perhaps the question should be how to prevent them happening in the first place.

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Francisco Gomez — Sun, 09 Feb 2020 13:31:08 GMT

We probably have a post-op bleed a couple of times in the last few years, but each time it has become a cause of concern and SEA. The frequency is very small but the consequences could be serious.

Recently we have introduced alfaxan, which has definitely shortened the post-op times. I'm not keen to send a patient home 15 minutes after an op just because it seems wide awake.

Can we concentrate on the question I asked? I understand that a clear cut time doesn't exist, but what do you do? Do you send your bitch spay home while in recovery? How do you determine the time. Is it a rule of thumb?

I'm trying to be systematic without undue interference on vets freedom of practice.

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Dinu Catilina — Sun, 09 Feb 2020 13:18:16 GMT

Francisco, may I ask why? If there was a significant risk of post operative abdominal bleeds in my practice I would increase the efforts in preventing them rather than stricter post operative checks.

RE: Is there a timescale for an abdominal bleed to be reliably identifiable post-op?

Sarah Keir — Sun, 09 Feb 2020 12:01:34 GMT

If you have not found any evidence then there is none and you going on opinion. Perhaps you should set up an in practice study to answer this question?