Routine procedures and antibiotics.

Re: Routine procedures and antibiotics.

Mark Holmes — Mon, 28 Jan 2013 11:44:35 GMT

It was also discussed here http://www.vetsurgeon.org/forums/p/11878/65539.aspx#65539

Re: Routine procedures and antibiotics.

Mark Holmes — Fri, 25 Jan 2013 17:10:45 GMT

[quote user="David Mills"]

[quote user="Mark Holmes"]I have never seen anything demonstrating that Augmentin is more effective than synulox RTU or oral amoxyclav. That should read clinically effective. Augmentin is effective at spurious fee generation. Zinacef I expect is similar.

[/quote]

This is quite an ignorant statement. IV antibiosis is indicated where implants will be used, or infection would be catastrophic (e.g. spinal, thoracotomies) in clean surgeries or in clean-contaminated or dirty surgeries. In clean surgeries it should only be used perioperatively, that is, usually at induction and every 90 minutes (or time dictated by half-life of antibiotic) of op time. Intravenous is the only way of ensuring adequate tissue levels by time of incision/surgery, as the PKs and PDs are predictable. To give something orally (on an empty stomach preoperatively) or s/c or im means far more unpredictable tissue distribution, even more precipitous in animals with cardiovascular derangements. Using any other method than IV where IV is indicated is, frankly, bad practice.

As a sequel to this, possibly worse is the continuation post-operatuvely of antibiotics following a clean surgery.

[/quote] An argument full of received wisdom but lacking evidence or indeed logic. Plasma levels are plasma levels irrespective of their administration. Amoxyclav is a time dependant antibiotic (kills over hours not seconds) I doubt there is any significant clinical difference between iv or other routes. The significant issue is - is there a difference in outcome for the patient? Over a hundred cases how many would have a less than acceptable outcome receiving synulox cf Augmentin and is that difference worth the increased costs of treating all 100 with Augmentin.

Edit: I knew this had been discussed before on a number of threads, if I could support my ignorance and bad practice with a quote from this thread.

http://www.vetsurgeon.org/forums/p/3275/8091.aspx#8091

".........but ........ a few years ago we did a literature review on this and confirmed that following either IM or sub cut injection of regular synulox/nisamox etc injectable , each of the active ingredients appears to reach effective plasma levels very, very quickly. I can't remember the exact numbers but it was in the range of seconds to a few minutes. Consequently, we now use a single IM injection of potentiated amoxycillin given as the patient is draped for surgery. Several residents have questioned the practice but, having been sent away to repeat the review they have come round to our way." - Malcolm Ness

Re: Routine procedures and antibiotics.

David Mills — Fri, 25 Jan 2013 15:41:38 GMT

[/quote]

As a sequel to this, possibly worse is the continuation post-operatuvely of antibiotics following a clean surgery.

Re: Routine procedures and antibiotics.

Mark Holmes — Fri, 25 Jan 2013 15:20:10 GMT

[quote user="Elizabeth Billimore"]

[quote user="James Laidlaw"]

I guess the only clinical benefit is these can be given IV to sick patients, synulox seems to be quite painful sometimes and this is an un-necessary extra stress? Otherwise not a great deal of benefit, certainly not for routine operations or admissions?

[/quote]

I think the idea with giving IV antibiotics before an op is that you can get high enough concentrations in the tissues, at the site of the wound, in time for when you start cutting.

[/quote] I know that, what I haven't ever noticed is a change in outcome for the patient. The theory is fair enough but if it isn't reflected in a benefit, prognosis change influence of the outcome the it's not worth the money.

Re: Routine procedures and antibiotics.

Bibs — Fri, 25 Jan 2013 14:52:53 GMT

I don't give antibiotics to routine neuterings either by the way.

Re: Routine procedures and antibiotics.

Bibs — Fri, 25 Jan 2013 14:47:20 GMT

[quote user="James Laidlaw"]

[/quote]

I think the idea with giving IV antibiotics before an op is that you can get high enough concentrations in the tissues, at the site of the wound, in time for when you start cutting.

Re: Routine procedures and antibiotics.

James Laidlaw — Fri, 25 Jan 2013 14:30:03 GMT

Re: Routine procedures and antibiotics.

Mark Holmes — Fri, 25 Jan 2013 13:41:42 GMT

I have never seen anything demonstrating that Augmentin is more effective than synulox RTU or oral amoxyclav. That should read clinically effective. Augmentin is effective at spurious fee generation. Zinacef I expect is similar.

Re: Routine procedures and antibiotics.

Rajat — Fri, 25 Jan 2013 13:10:49 GMT

[quote user="James Laidlaw"]

Just bumping this thread - have seen a few cases from elsewhere that have had zinacef for various things - this is only going to be cephalosporin activity, correct? Is this vastly different in spectrum of activity from IV augmentin? Or just the same kind of thing with a different name?

[/quote]

Hi James

Cefuroxime (zinacef) is beta lactam resistant and is pretty broad spectrum. Excellent for periop use as very active against most skin bugs as well as broad sp against gram +ve and gram -ve organisms. It can be given bid-tid and the product does not spoil for 8-12 hours in the bottle when made up unlike augmentin.

Augmentin is a bit more broad spectrum than Zinacef , but for the vast majority of routine cases Cefuroxime is more than enough..I would choose Augmentin over Zinacef for e.g. in a patient with Sepsis. Or documented resistance to zinacef/other cephalosporins.Can't think of other reasons why I'd use it off the top off my head. We use Zinacef routinely for periop use in clean contaminated ( or dirtier) or other surgeries where indicated.

Re: Routine procedures and antibiotics.

CatherineThomas — Fri, 25 Jan 2013 09:41:37 GMT

[quote user="James Laidlaw"]

[/quote]

Zinacef is cefuroxime. We've been using it instead of Augmentin because Augmentin was unavailable. I don't know if we've checked recently whether it's become available again or not.

Re: Routine procedures and antibiotics.

Mark Hedberg — Fri, 25 Jan 2013 08:32:21 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Bob Russell"]How much surgery time do practices offer for £35 (I presume including VAT at 20%)?[/quote]

Including 20% VAT??? None at all.

Incidentally, at the risk of starting a new branch of this branch thread: surely when working out a standard price or a quote or an estimate you don't think of a figure including VAT? VAT is something you add on to your charge, and hand over later to the Government (who then hand lots of it over to a corrupt organisation in Brussels (except when they are in Strasbourg), but that's another story.)

[/quote]

No client cares that it goes to the government, unfortunately. They only care that you are the person taking it away from them.

Re: Routine procedures and antibiotics.

James Laidlaw — Thu, 24 Jan 2013 18:59:23 GMT

Re: Routine procedures and antibiotics.

Richard Saunders — Sun, 23 Jan 2011 15:57:48 GMT

[quote user="Gillian Mostyn"]trancing is not anaesthesia.[/quote]

Thats the crucial point here I think. It is the lesser of several evils to trance a rabbit to examine/clip claws/radiograph it etc, but just because it shows no signs of distress at the time, does not mean it is not feeling pain. Making a fuss is a great way to get eaten, in the wild. And behaviour after is not a reliable indicator either, for similar reasons. Humans hypnotised to have surgery performed on them often have sedation/regional anaesthesia too, and I think its the latter which is having most beneficial effect in this case: I think we under utilise local anaesthesia as an adjunct to general anaesthesia.

Re: Routine procedures and antibiotics.

bob lehner — Thu, 20 Jan 2011 10:05:45 GMT

Thanks for that info.

Re: Routine procedures and antibiotics.

Peter Ding — Thu, 20 Jan 2011 09:07:21 GMT

[quote user="bob lehner"]

[quote user="Peter Ding"]Might i respectfully suggest that there is no evidence to suggest a locally anaesthetised and lightly sedated rabbit will suffer any more stress than a fully anaesthetised rabbit for castration [/quote]

Very interestesting - personally i've never thought of trying that .

Could you give us your dose rates/route of diazepam/vetergesic - and what vol of LA do you use and where exactly do you place it ? Also how do you prep them - clipping or just cleaning ? I find prepping rabbits for castration is a fiddle and it's v. easy to traumatise the thin scrotal skin with clippers - but if not clipped then hair often creeps into the operating site.. Thanks.

[/quote]

Diazepam 2mg/kg i.m. , Butorphenol 0.1ml/kg or Vetergesic 0.05ml/kg . Carprieve 1-2mg/kg s/c

Local approx 0.5-1 ml per side, half as a linear line s/c, half into the cord as high up as one can isolate between finger and thumb.

They key is to then leave it for a few minutes after a good rub. Then test the site of incission, then position and prep.

Relaxation of the testis which fails to retract on squeezing confirms analgesia of the cord.

Prepping them is indeed an art. We do shave and we find using those tiny narrow disposable £1 clippers can help.

Although it's not good practice ensuring the surrounding hair is quite wet is justifiable in this case.

We usually use 4 "0" vicryl for ligating and the skin suture in conjunction with a tissue adhesive (gluture)

Re: Routine procedures and antibiotics.

Rob Loxley — Wed, 19 Jan 2011 23:46:26 GMT

[quote user="James Allsop"]but what exactly does a loss leading neuter lead to?[/quote]

avoiding the OOH caesareans from clients who can ill afford them?

Re: Routine procedures and antibiotics.

Michael Woodhouse — Wed, 19 Jan 2011 22:13:20 GMT

[quote user="Kate Richardson"]I didn't necessarily mean neutering is done at a loss but how many practices actually make a significant profit on neutering compared to other surgical procedures?[/quote]

We are in a rural area and the nearest practice is 12 miles away but we still get people ringing up how much a bitch spay is, can't remember the last unsolicited phone call where they asked the cost to remove a mammary tumour! People ring around and compare, pushing the prices down.

Re: Routine procedures and antibiotics.

Kate Richardson — Wed, 19 Jan 2011 22:08:05 GMT

[quote user="James Allsop"]what exactly does a loss leading neuter lead to[/quote]

Along with the initial vaccination course consultations, hopefully a bonded client. I didn't necessarily mean neutering is done at a loss but how many practices actually make a significant profit on neutering compared to other surgical procedures? I don't know that it is a planned business model, I just see it as the way things have become.

Re: Routine procedures and antibiotics.

James Allsop — Wed, 19 Jan 2011 21:48:09 GMT

[quote user="Kate Richardson"]But neutering is a veterinary loss leader[/quote]

forgive my inexperience of buisness matters, but what exactly does a loss leading neuter lead to? I can see the repeat business of lower cost vaccines etc but surely you can only neuter a pet once?

I know a few practices that offer low cost neuters but I just cant understand the economics, i am genuinely intrigued to understand why this business model is successful. I can see the ethics for not aiming to make much profit on such a procedure as on the whole we are trying to prevent unwanted offspring. I have been having this discussion with my colleagues but nodoby has been able to offer a satisfactory arguement for loss leading neuter surgery as a business model.

Re: Routine procedures and antibiotics.

Gillian Mostyn — Wed, 19 Jan 2011 19:36:30 GMT

I have re-read my post and it does sound a bit patronising - sorry! I didn't mean it that way, I just meant that new graduates have the knowledge but little practical expertise or confidence. They usually gain that from working alongside the other vets - and getting the reassurance from them that all is well. Without that, they may not have the courage to try.

Re: Routine procedures and antibiotics.

Julian Earl — Wed, 19 Jan 2011 18:51:00 GMT

[quote user="Gillian Mostyn"]

[quote user="bob lehner"]I am still surprised when speaking to young graduates how little formal tuition some of them get on these species, which is not great when one considers that rabbits are now the third most popular pet and are seen daily in most s.a. practices.[/quote]

I know - very frustrating! But I do think that the theory is now there in most unis but, like everything else, the actual learning comes from your experience in practice. As the more senior members of the profession still aren't doing much beyond rasping molars and dispensing oral baytril, without the guidance they inevitably need new graduates can easily forget anything they ever knew.

[/quote]

They won't forget at this practice. As a, errm, non-junior member, I find new graduates are very useful for giving guidance and teaching me about the modern ways of anaesthetising rabbits and the like! Probably helps them remember as well.

Re: Routine procedures and antibiotics.

bob lehner — Wed, 19 Jan 2011 16:34:12 GMT

Very interestesting - personally i've never thought of trying that .

Re: Routine procedures and antibiotics.

Mark Holmes — Wed, 19 Jan 2011 11:04:20 GMT

[quote user="Peter Ding"]

Might i respectfully suggest that there is no evidence to suggest a locally anaesthetised and lightly sedated rabbit will suffer any more stress than a fully anaesthetised rabbit for castration no matter what position it is in. The rabbits are sitting on their bottoms at approximately 45degrees. Yes, some appear 'tranced' but most do not!

In fact quite the opposite, some continue to eat whilst the procedure is carried out, most are responsive and move their heads watching you, all continue to behave pretty normally immediately post procedure. More importantly even that significant percentage with subclinical pneumonia recover just as well and to date, none have died and none have developed clinical pneumonia a few days later. it is IMHO well worth considering as an option in a well-handled male rabbit.

In fact might i suggest cortisol levels are highly likely to rise post g.a. and surgery in all species. Your logic is flawed. Inappropriate extrapolation.Tranced" rabbits in the experiment you refer to were fully conscious with no analgesia or sedation. That experiment concluded it should not be used as a sole form of restraint for anything even slightly painfull and one should remember it was stressful in itself.

Even if they were all "tranced" why could that not be safely used as an adjunct to conventional sedation and local anaesthesia, providing you test the efficacy with the pateint being tested in a normal position? I find that It is fairly easy to assess if concious rabbits are sensate in the perineal region.

We anaesthetise and tube (most) rabbits for ovaro-hysterectomy and get good results with stable anaesthesia, but one can certainly tell which ones have significant pneumonia by their breathing pattern and responses to GA and surgery. They are significant anaesthetic risk patients. However there is no safer alternatives to that approach in females. In males there is, don't be blind to it!

One can blame pre-existent pneumonia for many problems associated with neutering in females, but perhaps one should blame the decision to use a GA if one gets problems in the male.

[/quote]

Whilst its not my routine meathod for castrating rabbits I have done a good number like this and well handled sedated rabbits do very well and behave perfectly normally ( for a sedated rabbit) afterwards.

Re: Routine procedures and antibiotics.

Peter Ding — Wed, 19 Jan 2011 10:49:00 GMT

One can blame pre-existent pneumonia for many problems associated with neutering in females, but perhaps one should blame the decision to use a GA if one gets problems in the male.

Re: Routine procedures and antibiotics.

Vikki Halliday LLB — Tue, 18 Jan 2011 22:53:46 GMT

[quote user="Evelyn Barbour-Hill"]when working out a standard price or a quote or an estimate [/quote]

Oh no! Estimates always Evelyn, NEVER quotes!

[quote user="Evelyn Barbour-Hill"]VAT is something you add on to your charge, and hand over later to the Government (who then hand lots of it over to a corrupt organisation in Brussels (except when they are in Strasbourg), but that's another story.)[/quote]