Post op complications

Re: Post op complications

Anthony Todd — Mon, 07 Feb 2011 09:51:04 GMT

[quote user="Malcolm Ness"]Going off at something of a tangent - is propofol + Seva definitely and demonstrably so much better than thio and halothane or is it just more expensive???[/quote]

An excellent example. And there is the learning curve with any new thing [see knotting discussion on this and other forums]

Re: Post op complications

Malcolm Ness — Mon, 07 Feb 2011 09:16:43 GMT

[quote user="Anthony Todd"]that newer materials and /or methods are inevitably better than the old [/quote]

Going off at something of a tangent - is propofol + Seva definitely and demonstrably so much better than thio and halothane or is it just more expensive???

Re: Post op complications

Anthony Todd — Sat, 05 Feb 2011 23:58:31 GMT

[quote user="Evelyn Barbour-Hill"]there are many degrees of scrubbing.[/quote]

And there are many degrees of "surgery" which are even more basic and important....

I remember watching a parotid duct transplant at the RVC, all the gowns, masks, hot and cold running nurses etc.

The eminent professor cleared the site of long facial dog hairs with his well scrubbed, well gloved hand..... and began the procedure.

Re: Post op complications

Rob Loxley — Sat, 05 Feb 2011 15:14:58 GMT

[quote user="Evelyn Barbour-Hill"]Quite so. On the other hand, you need a scrubbing brush to remove the superficial crud from your skin.[/quote]

And therefore one's scrubbing protocol might vary whether it's the first scrub-up of the day (after a morning of anal glands/ pyoderma/ farm visits) or for the 9th cat spay of the day? I tend to use a scrubbing brush for the 1st then just hibiscrub/water for the subsequent when moving from clean op to clean op.

Interestingly, watching some real surgery (ie not Holby City) in TV programmes the wearing of theatre hats is more frequent than surgical masks.

Re: Post op complications

Evelyn Barbour-Hill — Sat, 05 Feb 2011 15:12:34 GMT

[quote user="Mark Hedberg"]There was an In Practice article a few years ago that basically said washing with NO scrub brush had fewer CFU's. The idea was that scrubbing caused micro-abrasions in skin, giving bacteria more places to hide. So wash with chlorhexidine, washing in all the usual places, but scrubbing was actually slightly worse![/quote]

Yes, but "scrubbing" is not an absolute term: there are many degrees of scrubbing. Even washing hands without a brush is a mild scrubbing, using the surface of the other hand as a brush. And there is no point in "just washing" a hand that has dirt on it if said dirt is too tough to be removed by "just washing".

Re: Post op complications

Mark Hedberg — Sat, 05 Feb 2011 14:39:40 GMT

[quote user="David Beattie"]

When we're on the subject of operative sterlity etc., can I ask people's opinions on using a 'waterless' or 'brushless' scrub-up technique for surgery? My main reason for asking is trying to find a way to circumvent an inadequate scrub sink (other than convincing my boss we need a new one), but I quote from 3rd ed. Fossum:

" Most experts agree that although using the bristle end of a scrub brush under the nails may still be a good idea, the time-honored convention of vigorously scrubbing off the uppermost layers of skin with a brush is not only unnecessary, but also unwise."

[/quote]

There was an In Practice article a few years ago that basically said washing with NO scrub brush had fewer CFU's. The idea was that scrubbing caused micro-abrasions in skin, giving bacteria more places to hide. So wash with chlorhexidine, washing in all the usual places, but scrubbing was actually slightly worse!

Waterless scrub I just don't like; it makes your hands feel all sticky.

Re: Post op complications

Evelyn Barbour-Hill — Sat, 05 Feb 2011 13:38:22 GMT

[quote user="David Beattie"]" Most experts agree that although using the bristle end of a scrub brush under the nails may still be a good idea, the time-honored convention of vigorously scrubbing off the uppermost layers of skin with a brush is not only unnecessary, but also unwise."[/quote]

Quite so. On the other hand, you need a scrubbing brush to remove the superficial crud from your skin.

I'm happy in every way with my conventional hand-preparation technique and don't feel like experimenting with change. I have a number of times used an alcohol-based skin gel (on clean hands) when I had to dive into a wound in a hurry, and there were no problems, for what that's worth.

Re: Post op complications

J G Wray — Sat, 05 Feb 2011 13:34:33 GMT

[quote user="Evelyn Barbour-Hill"]The only trouble is when we have professors and lecturers (who have possibly never actually used catgut) running around suggesting that this, that or the other perfectly good technique constitutes negligence.[/quote]

Hmmm, this is a bit sweeping. I am reminded of a fella called McMahon who had his moment at DC recently, involving a certain degree of post op complication who was well supported by an eminent ex academic.

JGW

PS I enjoyed the rugby last night

Re: Post op complications

Evelyn Barbour-Hill — Sat, 05 Feb 2011 13:27:54 GMT

[quote user="derrick carpenter"] The idea of using it on anything else I find a bit disturbing, but I'm sure we all find our own ways that we are comfortable with and work.[/quote]

Exactly.

Which is fine.

The only trouble is when we have professors and lecturers (who have possibly never actually used catgut) running around suggesting that this, that or the other perfectly good technique constitutes negligence.

Re: Post op complications

Anonymous — Sat, 05 Feb 2011 11:09:49 GMT

A recent Cochrane review found that:

"Alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs however this evidence comes from only one, equivalence, cluster trial which did not appear to adjust for clustering.

Four comparisons suggest that alcohol rubs are at least as, if not more, effective than aqueous scrubs though the quality of these is mixed and each study presents a different comparison, precluding meta analysis. There is no evidence to suggest that any particular alcohol rub is better than another. Evidence from 4 studies suggests that chlorhexidine gluconate based aqueous scrubs are more effective than povidone iodine based aqueous scrubs in terms of the numbers of CFUs on the hands.

There is limited evidence regarding the effects on CFUs numbers of different scrub durations. There is no evidence regarding the effect of equipment such as brushes and sponges." (http://www2.cochrane.org/reviews/en/ab004288.html)

Is anyone using these as ther preferred method of scrubbing up? Any opinions?

(Also anyone wear their wedding ring while operating? http://www.orthosupersite.com/view.aspx?rid=36001)

Cheers

Re: Post op complications

derrick carpenter — Sat, 05 Feb 2011 08:53:41 GMT

[quote user="Evelyn Barbour-Hill"]PS I have never in my life closed an abdomen with a continuous suture. That strikes me as really chancing it.[/quote]

long time lurker first time poster...

I have never in my life closed an abdomen without a continuous suture, and haven't had a breakdown in ten years of operating. Never used catgut apart from on ovarian stumps. The idea of using it on anything else I find a bit disturbing, but I'm sure we all find our own ways that we are comfortable with and work.

Re: Post op complications

Derek Copeland — Sat, 05 Feb 2011 08:52:51 GMT

[quote user="Richard Coe"]

My question to them is always, do you really know what your outcome is? Do you audit your surgical site infections with a critical eye, Because the human brain is very very poor at making REAL observations of data without actually making a measurement.

My practice (I mean the things I do, not the building/business) is to take every precaution. It is my opinion (and only that) that using gut on a reel, or not wearing gloves, or wearing a short-sleeved gown, or not wearing a hat etc. etc. etc. constitutes cutting corners and that's not how I approach surgery. I also think using blunt, reusable needles adds an extra level of difficulty to performing surgery, and to me anything I can do to make it easier - I do.

I should acknowledge that I work in a referral environment so you may immediately dismiss my view!

[/quote]

Sorry richard but have you measured the outcome of wearing a hat vs not !

I feel a whole list of references to scalp cultures coming my way

Ithink what this thread shows as some others relating particularly to surgery is the desperate need for evidencce based decisions from practice based evidence

Re: Post op complications

Anthony Todd — Sat, 05 Feb 2011 02:28:24 GMT

[quote user="Kate Richardson"]

[quote user="Malcolm Ness"]

[quote user="Anthony Todd"]the synthetics are poor knotters which everyone agrees on[/quote]

I don't.

[/quote][/quote]

Looked through the catgut thread again and, yes, "poor knotters" is too strong. Concensus from that thread seems to be that Vicryl etc. might slip the first throw and catgut breaks, but still enough cat-gut supporters to make me still believe that "catgut is negligent" is bollards.

All the disparate and conflicting views still make me think skill and sympathy might be the only common factor in suturing success.

Re: Post op complications

Evelyn Barbour-Hill — Fri, 04 Feb 2011 20:14:52 GMT

[quote user="Richard Coe"]My question to them is always, do you really know what your outcome is? Do you audit your surgical site infections with a critical eye, remembering that ANY inflammation around the surgical incision/sutures is abnormal?[/quote]

Yes.

But I think you mean externally detectable inflammation is abnormal. (Interesting philosphical point really. A cut in the tissues with sutures stuck in them is abnormal anyway, isn't it?) Inflammation in itself is a normal part of the healing process.

[quote user="Richard Coe"]Can you tell me how many ovarian pedicle re-haemorrhages you had in your practice in the last five years?[/quote]

Yes. None.

[quote user="Richard Coe"]I also think using blunt, reusable needles adds an extra level of difficulty to performing surgery, and to me anything I can do to make it easier - I do.[/quote]

Oh yes, I do agree.

PS I have never in my life closed an abdomen with a continuous suture. That strikes me as really chancing it.

Re: Post op complications

Richard Coe — Fri, 04 Feb 2011 18:00:47 GMT

[quote user="Richard Carter"]Slightly red incision line 5 days later - wouldn't think this at all abnormal given the dog is probably lying on the floor giving the wound the occasional lick.[/quote]

Hi Richard - It may not be "abnormal" or perhaps "atypical" but a surgical incision can and should heal without redness (putting licking on one side). I'm not saying that a small amount of redness requires intervention or antibiotic treatment but it is mild surgical site inflammation and if you're auditing your outcomes and especially if you're comparing groups (i.e. with or without antibiotic) then this is a real outcome to track.

Re: Post op complications

Simon Neuhoff — Fri, 04 Feb 2011 11:19:39 GMT

[quote user="Anthony Todd"]

[quote user="Richard Coe"]Because the human brain is very very poor at making REAL observations of data without actually making a measurement.[/quote]

I couldn't agree more!

While the 10% complication rate sounds high to one who believes his post-op complications were lower than that, I've not got a shred of evidence to support my "firm belief". [a Firm Belief is much stronger than any statistic or trial, of course.....]

What gets me though is another "firm belief" that newer materials and /or methods are inevitably better than the old [which are trusted, solely, by the aforementioned "firm belief"].

[/quote]

Anthony we had a fairly robust debate about the difference between real world observations/field experience and proper clinical trials on the Cascade thread. Do you not feel that you are contradicting yourself here - and previously on this thread?

Re: Post op complications

Richard Carter — Fri, 04 Feb 2011 10:24:48 GMT

Have had a staffy walk into the surgery with its intestines dragging on the ground post spay - just happened to be walking past at the time fortunately for her. Cat gut midline.....so why take the risk? This I would rate as a post op complication. Have recently had a post op disaster where a fat labrador developed a fatal inflammatory peritonitis and pancreatitis 5 days post op. No sign of infection or bacteria on pm. First time in 20 odd years seen one of these post spay so definitely a post op complication. Slightly red incision line 5 days later - wouldn't think this at all abnormal given the dog is probably lying on the floor giving the wound the occasional lick.

Re: Post op complications

Mark Holmes — Fri, 04 Feb 2011 10:03:17 GMT

My issue with gut is that it might have sufficient tensile strength at sufficient thickness but I don't think it takes shock loading very well and as a climber I am well aware there is a huge difference between tensile strength of a material and its ability to handle shock loads. Equally the load on a wound might not be equally distributed along the wound. Some sutures taking more than others. For exampple fat wide chested dogs, cranial sutures often take more than caudal ones. The shock loading on something like that may easily be sufficient to cause a suture to snap. Once one goes the tension on the others increases and next thing a dogs spleen is on the floor. (I've seen it happen)

Re: Post op complications

Anthony Todd — Fri, 04 Feb 2011 09:42:28 GMT

[quote user="Richard Coe"]Because the human brain is very very poor at making REAL observations of data without actually making a measurement.[/quote]

I couldn't agree more!

What gets me though is another "firm belief" that newer materials and /or methods are inevitably better than the old [which are trusted, solely, by the aforementioned "firm belief"].

Re: Post op complications

Richard Coe — Fri, 04 Feb 2011 08:45:47 GMT

I haven't read every post in this thread so apologies if I'm duplicating someone else's opinion inadvertently....

There is an interesting conflict here between 1. a huge, vast mass of anecdotal experience that using products like catgut or other suture on a reel results in a level of complications which clearly does not equate to some huge problem and 2. a sense that these products are inferior in principle to single packets of synthetic suture with swaged on needles. I've talked to a lot of practitioners at CPD events about this because I think it's really interesting. I think it parallels a similar debate about the degree of aseptic precautions that should be taken where there is a conflict between 1. a similar huge, vast mass of anecdotal experience that operating without a hat, mask, long-sleeved gown, cloth drapes covering the whole patient that aren't so thin as to be translucent etc, also doesn't result in an post-op infection rate that is grossly unacceptable vs. 2. the principles of surgery dictate that taking more precautions as listed should result in lower contamination of the field and hence less risk of infection or "wound inflammation"

My sense is that there isn't a disagreement that this conflict exists. I don't think people think gut is exactly equivalent to a synthetic product or that operating without aseptic precautions is the same as taking all precautions. What they argue, with some justification, is that the OUTCOME for the patient is not detectably different so why go to the extra expense?

My question to them is always, do you really know what your outcome is? Do you audit your surgical site infections with a critical eye, remembering that ANY inflammation around the surgical incision/sutures is abnormal? Can you tell me how many ovarian pedicle re-haemorrhages you had in your practice in the last five years? Because the human brain is very very poor at making REAL observations of data without actually making a measurement. Our opinion/sense of what is going on is capable of being wildly wrong because of totally unconscious bias. I also ask them if they routinely give antibiotics for clean surgery and if so, ask them to consider the overall impact of the use of antibiotics on the world as a whole and whether the cost of the antibiotic might be better spent on improving an element of the aseptic precautions.

I should acknowledge that I work in a referral environment so you may immediately dismiss my view!

Re: Post op complications

Anthony Todd — Fri, 04 Feb 2011 02:50:23 GMT

[quote user="Jane Dunnett"]Just my opinion.[/quote]

Not solely an opinion, but based on an observation which would be hard to dispute so must be considered. To be fair though, the intra abdominal "inflammatory reaction" may well be the necrotising uterine stump and not the suture itself. See M. Ness's remarks re synthetic knots and infection....

I can't reconcile all these negative opinions and observations with the history of many many abdo ops. done solely with gut which seemed to be totally fine.

Re: Post op complications

Heather Toft — Fri, 04 Feb 2011 02:12:34 GMT

I tend to use catgut for ligating only, and vicryl (visorb off the roll if I don't want a whole packet's worth) for closing linea alba/muscle/subcut etc. I probably wouldn't close a spey with catgut.

However, I am also a big fat hypocrite, having just finished a sheep caesar where I've sutured every layer except the skin with continuous catgut. I'm sure she'll do fine.

Re: Post op complications

jd2008 — Fri, 04 Feb 2011 01:56:45 GMT

Quite a few years ago now I remember spending a Sunday afternoon resuturing a JRT whose linea alba had opened (it was while working for you Tony!)

The dog in question had recently had surgery at a vet school performed by an eminent professor.

The wound had broken down whilst the skin sutures were still in place IIRC so less than 2 weeks postop.

On opening the dog I was surprised, to say the least, to find that a continuous gut suture had been used in the linea alba. The gut had disintegrated resulting in the wound breakdown. A few strands remained which fell apart in my hands when I removed them.

I duly noted my findings in my clinical notes and faxed them to the vet school.

A week or so later I received what can only be described as a rather snotty letter from the professor in question stating that continuous gut was an entirely appropriate choice (I hadn't questioned it in my notes) and how surprised he was at the wound breakdown

Regardless, I have never used gut in a midline and never will (was told at Glasgow VS in early nineties that it amounted to negligence)

I don't use it in the abdomen/thorax either. I don't think promoting an inflammatory reaction (which gut requires to break down) insde a body cavity is a great idea.

Just my opinion.

Re: Post op complications

Evelyn Barbour-Hill — Fri, 04 Feb 2011 01:16:35 GMT

[quote user="Anthony Todd"]

[quote user="Evelyn Barbour-Hill"]And, by the way, I was an early adopter of Vicryl.[/quote]

For bitch spays? If so, why?

[/quote]

I just like it better. Let me try and think of the original reasons, which I have forgotten.......

I like swaged-on needles. I just like them.

You can use a size or two finer in Vicryl than in catgut.

I thought sometimes I was getting "stitch abscesses" over the catgut knots.

But if I found that one day I had to close a bitch spay with catgut I wouldn't lose a minute's sleep over it.

Where did this "catgut is negligence" rubbish come from?

PS if your catgut breaks while ligaturing, either you haven't used the right gauge or you have pulled with insufficient sensitivity. And yes, I broke a piece only the other day.

Re: Post op complications

Anthony Todd — Thu, 03 Feb 2011 23:13:59 GMT

[quote user="Malcolm Ness"]

[quote user="Clive Ansell"]discharge from the surgical wound, a swab was taken for bacteriology. All showed no bacterial growth.[/quote]

Negative culture from a swab like this does not come close to excluding infection as a cause. I would question the swab/lab technique here as swabbing multiple patients whose skin is wet with serum/exudate or whatever and getting consistently negative results is very surprising.

Chromic gut loses about 1/3 strength after a week while the vicryl-like sutures lose about 1/5 strength over the same time. The synthetics start out massively stronger (size for size) so, as long as you select a big enough (= strong enough) size of chromic gut there is no good reason why it shouldn't be used for abdominal wound closure. However, in bigger patients even 7 metric gut will sometimes have you sailing quite close to the wind. Gut is absorbed (remarkably slowly) by an inflammatory mediated process but as this all happens in deep tissue and is not terribly severe, it is of little, if any clinical significance in most instances. The vicrl-like sutures are absorbed a little more quickly by a hydrolysis-like process which elicits vitually no inflammatory response. But (big but!!) the vicryl-like sutures appear to potentiate infection to a much greater degree than gut and a low level of contamination/asepsis breach that might go nowhere with gut sutures will usually localise around the vicryl-type suture material and induce the so-called "vicryl reaction". These are almost certainly suture related infections and not adverse reactions. In my experience (dealing with second opinion and out of hours surgical cases) almost all wound breakdowns can be laid squarely at the feet of the surgeon - sutures untying themselves is much the most common scenario (and that means technical error, no question) followed by badly placed sutures pulling through tissue - typically a fat laparotomy in which the linea alba incision has strayed into the adjacent muscle with a closure that has involved the inadvertent suturing of muscle or linea alba onto fat.

We use polysorb routinely to close abdomens because of its strenght-size ratio which allows us to place adequately strong sutures in the linea alba while using the same material which is sufficiently small to allow us to close the skin with a sub-cuticular pattern. We ligate with gut.

[/quote]

Sorry, was trying to quote the bit about knots and infection not make it a favourite but I can't find a way to unbutton it.

However, on re-reading the whole post it seems to agree with what I was advancing but much more elegantly.

Of course, no doubt, joining viscera, stitching cornea etc. then swaged needles are the obvious and superior choice but we started on post-op spays and castrates.