Surgery: Setup and Supplies

Transcription

1 THE SURGERY SUITE Surgeries other than routine neuters and treatment of abscesses are performed in the surgery suite. We keep a chart with the preferences of our various surgeons, including which side they want the cat s head (right or left) along with glove size, etc. With this information, the surgery tech customize the surgical suite setup for individual surgeons. THE SURGERY TABLE Each cat remains on its own fleece blanket when transported into surgery and placed on the surgery table. The soaked gauze sponges remain on the surgery site until the surgeon is ready to begin. A clipboard with the cat s Medical Record hangs on the wall in the surgery suite for easy access. Our surgery tables are over-the-bed tables used by human hospitals for serving meals. The height adjusts to accommodate the tallest and the smallest surgeons. We cover each table with a heating pad wrapped in a thick towel, so there is a towel layer under and over the heating pad. The heating pad is only set on LOW, never higher. Our surgery lights are simple desk lamps that attach to the edge of the tables. We place the cat on her back with the chlorhexidine gauze pads covering her surgical area. To keep the cat stable and prevent tipping to one side, we bolster her with towels rolled up next to her body to keep her from tipping sideways, being careful to avoid touching the sterile field. We do not tie down the legs. In fact, we don t have leg ties on our tables at all. ADDITIONAL PAIN RELIEF: BUPRENORPHINE All cats being spayed or undergoing another involved surgery (abdominal cryptorchid, tail amputation, etc) receive buprenorphine (Buprenex ) injections for additional pain relief. The dose is determined by body weight based on the dosage chart posted in the surgery suite. We write the dose on the Medical Record and on a buprenorphine log sheet. Once the dose is recorded, we draw up the dose and administer it to the cat. Only surgical technicians are permitted to draw up and administer buprenorphine. Pain relief is most effective when administered prior to initiation of pain, thus, the buprenorphine needs to be given at least 5-10 minutes before the spay incision is made. Often, the surgical tech administers the buprenorphine while the cat is still on the prep table to allow sufficient time for absorption. ADDITIONAL ANESTHESIA: ISOFLURANE Our induction dose of injected anesthesia is typically enough for surgical prep, but too light for abdominal surgery. Most female cats require isoflurane to become completely anesthetized. If cats are adequately sedated from the initially-injected cocktail, then we do not administer isoflurane as deeper sedation increases the risks of respiratory and cardiac arrest. All cats receive oxygen, even if they don t require isoflurane. Cats receive isoflurane and oxygen through a mask that is secured to their heads with loops of rubber bands. (See the Procedures section of Our Clinic Model for more details.) We do not intubate any cats. Each isoflurane machine is attached to a GasVak system to pull exhaust gases out of the room. The exhaust exits through a duct to a chimney and to the outside. Instead of using a standard setting for the isoflurane, we monitor each cat individually and adjust the isoflurane according to each cat s plane of anesthesia. Typically, most cats receive about one percent isoflurane with an oxygen flow rate of 0.8 or 1.0 L/min on a rebreathing system. We aim for the perfect level of anesthesia: to have cats fully sedated but no deeper than absolutely necessary. We reduce the isoflurane near the end of surgery, so that cats being to exhale the isoflurane and awaken quickly when surgery is complete. Cats with upper respiratory congestion must be monitored very carefully. They may not be able to move sufficient air through the nose while under anesthesia. -1-

2 SURGERY SUPPLIES Most of the surgical supplies are stored in the surgery suite. Sterile surgical packs are kept on a cart in the surgery suite. Larger, bulkier items are stored in the main prep area. We have two large sized ( H cylinder) oxygen tanks. We use one tank completely before switching to the other. By having two tanks, we always have ample oxygen on hand and can schedule delivery of a new tank on their regular delivery day. SURGERY When the surgeon is ready to begin surgery, the technician removes the soaked gauze from the prepped area. The surgical pack is spread out on an instrument stand with wheels, so it can be moved around. The surgeon uses a new blade, new gloves, new suture and a new surgical pack for every cat. Our spay pack consists of surgical drape, 5 gauze sponges, one needle holder, one spay hook, one tissue forceps, one pair of scissors, one scalpel blade handle, 2 Kelly clamps and two mosquito clamps. Cassette suture is kept on a cassette rack for when a small amount of suture is needed, so that we don t waste money by opening an entire new pack of suture. Suture on a cassette is particularly useful for tying the uterine stump in pregnant females. We try to set out the supplies in anticipation of the next surgery to expedite the surgeon s transition from cat to cat. We do not use cold sterilization for any part of the spay surgeries. The surgery tech remains within earshot of the surgeon at all times and makes regular checks on the cats and surgeon. We wrap less-frequently-used instruments separately for when a surgeon needs something in addition to our standard spay pack. We keep extra gauze sponges, towel clamps and Carmalt clamps autoclaved and on stand by. For pregnant cats, the surgeon may request euthanasia solution for the larger feti so that they do not awaken from anesthesia after being removed inside the uterus. The injection is made in the surgical suite as soon as the uterus is removed. WHY DO WE USE OVER-THE-BED (OTB) TABLES INSTEAD OF HEATED STAINLESS STEEL SURGERY TABLES? Cost was the original reason that we bought OTB tables. When comparing the cost of $99 per table to the several thousand dollar price tag on surgery tables, there was really no comparison. After using the tables for a couple of years, the surgeons began commenting that they like them better than stainless steel tables. OTB tables are narrower, so the cat is closer to the surgeon. This makes the surgeons more comfortable during long hours of surgery, because they don't have to lean over. The OTB tables have adjustable height, and with the addition of a heating pad, they are more than sufficient for feline spay/neuter. Additionally, the OTB tables are on wheels and weigh very little. We can rearrange the room when we have multiple surgeons and we can easily remove the tables for cleaning. The small size of the OTB tables allows us to have a smaller surgery suite and thus, maximize our space use efficiency. WHY DO WE USE DESK LAMPS INSTEAD OF CEILING-MOUNTED SURGICAL LAMPS? The lamps also began as an economical decision that evolved to be something that we liked better than the expensive equipment on the market. High-intensity lamps aren't needed for the relatively low technical requirements of spay/neuter. At $10 each, the price difference between our lamps and $1500 professional surgery lamps was drastic. Besides cost, one benefit of our desk lamps is that they attach to the surgery table, not to the wall. So when we rearrange the tables, the lights follow. The layout of our room is not dictated by where the surgery lamps are attached to the ceiling, because the lamps are attached to the movable tables. -2-

3 WHY DO WE USE HEATING PADS? We use heating pads set only on low to help maintain body heat during spay surgeries. Most cats begin losing heat immediately after being sedated, because the body is not moving. Muscle movement is what generates body heat, while fat keeps the heat contained. So when a cat is sedated and begins cooling off, we try to combat heat loss by adding heat externally. Pregnant cats, particularly those in later stages or with many feti, lose even more body heat once the uterus is exposed through the surgical incision. More time in surgery and more time sedated means more heat loss. Having the heating pads under the cat during surgery adds heat back to their bodies. WHY DO WE KEEP HEATING PADS ON LOW SETTING Heating pads can cause burns. Any setting other than low is potentially too hot. When an animal is sedated, it does not feel the burn and cannot move away. Furthermore, heating pad burns are not apparent until days after surgery. We strictly forbid heating pad settings to be above the low setting in order to protect the cats from unintentional burns. WHY DON'T WE TIE THE CATS TO THE SURGERY TABLE? Tying the legs stretches out the body and tightens up the cat. While it prevents the cat from moving as the surgeon manipulates the tissues, tying the cats also stretches all the ligaments inside, including those supporting the ovaries and uterus. When the ovarian and uterine ligaments are tight, the surgeon must make a larger incision to expose the uterus and ovaries. Leaving the legs untied allows slack in the abdominal ligaments, allowing easier surgical exposure through a smaller incision. A smaller incision requires less time and suture to close while reducing post-operative discomfort for the cats. WHY DO WE USE TOWELS RATHER THAN V TRAYS (THORACIC POSITIONERS) TO POSITION THE CAT? The towels are pliable, washable and accommodate the heating pad underneath. If we used the heating pad on the V tray, then the edge would stick up and interfere with the surgeon. WHY DID WE CHOOSE BUPRENORPHINE VERSUS OTHER PAIN RELIEF OPTIONS? The primary benefits of buprenorphine over other pain medications are safety and length of efficacy. Most people associate pain relievers with drowsiness, but buprenorphine has less sedative effect than both narcotic and opioid pain relievers. Cats do not have noticeably prolonged recoveries after receiving buprenorphine. Side effects of potent pain relievers, such as morphine, include depression of the heart and lung function. Although buprenorphine is 30 times more potent than morphine, respiratory depression is a rare side effect. Non-steroidal anti-inflammatory drugs (NSAIDs), such as Meloxicam, are contraindicated during anesthetic events. NSAIDs can cause harm to the gastrointestinal tract and kidneys. Butorphanol (Torbutrol or Torbugesic ) only provides 1-2 hours of pain relief. We consider this duration insufficient especially compared with 8-12 hours of additional pain relief from buprenorphine. When used alone, our anesthetic cocktail of Telazol, xylazine and ketamine provides significant pain relief. At an average cost of 50 cents per dose, we believe providing additional pain relief with buprenorphine is worth the expense and poses no additional risk to the cat. -3-

4 WHY DON'T WE GIVE BUPRENORPHINE TO EVERY CAT? All cats being spayed or undergoing another involved surgery receive buprenorphine. For extra-abdominal procedures, we believe our anesthetic cocktail of Telazol, xylazine and ketamine already provides significant pain relief. WHY DO WE USE A MASK AND NOT AN ENDOTRACHEAL TUBE FOR ANESTHESIA? Endotracheal intubation requires more expertise to install and results in more time under anesthesia. Using tubes requires that someone individually monitor the cats at recovery so they do not wake up, chew the tube in half and inhale the lower end of the tube. Endotracheal tubes can be irritating to the trachea, especially when experiencing spasm of the larynx. Irritation can lead to coughing and sore throat after anesthesia. The benefits of intubation are the preservation of a patent airway and the direct administration of oxygen during prolonged procedures. Masking cats is simpler, faster, cheaper and very safe. We have used isoflurane / oxygen via mask since 1998 and have been very happy with its performance. The GasVak system maintains fresh gas flow through the mask to eliminate exhaust gases and provide sufficient oxygen to the cat. Most of our cats are in surgery for less than ten minutes, not a prolonged period. One of the benefits of Telazol is the preservation of many reflexes, such as the laryngeal reflex. This reflex complicates endotracheal intubation, because touching the larynx causes spasm. Forced placement against the spasm can irritate the larynx. Topical anesthesia can relieve the spasm, but we do not believe the effort to intubate is necessary. We believe the 70,000 surgeries performed under our protocol is proof of safety and efficacy. WHY DO WE PERFORM SURGERY ON CATS WITH UPPER RESPIRATORY INFECTIONS? Many cats that come to us have only one opportunity for spay/neuter. If the cat gets trapped and brought to our clinic, we do everything possible during this opportunity to help the cat. Most caretakers have no facility to hold cats for treatment prior to surgery. Many lack the time, money or skill to medicate a feral-behaving cat, if indicated for upper respiratory infection (URI). Since 1997, we have altered many cats with URIs and developed ways to maintain safety. WHAT RISKS ARE ASSOCIATED WITH SURGERY ON URI CATS? A cat with severe nasal congestion relies on breathing through its mouth. When sedated, the cat cannot consciously open its mouth. When we put the cat s face into an anesthetic mask, we force the mouth shut. If the cat cannot breathe through its nose, it can become hypoxic and suffocate. HOW DO WE AVOID COMPLICATIONS WHEN ANESTHESIZING URI CATS? For cats with severe URI and nasal congestion, we may increase the dose of injectable anesthetic to avoid the need for gas anesthetic. Another option is to use a small mouth gag to hold open the cat s mouth along with using the mask and isoflurane. We fashion a mouth gag by cutting a small segment of a 1 cc syringe and placing the open ends over an upper and lower canine tooth to hold open the jaws. WHAT HAPPENS TO REMOVED TISSUE AFTER THE CLINIC? Occasionally, the tissue is used by local universities for teaching purposes. If not used for education, the tissue is bagged, frozen and picked up by a service that handles biological waste. -4-

5 COST-SAVING PRACTICES See a full list of our Cost Saving Practices in the Resources section of Our Clinic Model. Using Over-the-bed (OTB) Surgery Tables Compare the price of $99 per over-the-bed table to the two thousand dollar or more prices of stainless steel surgery tables. The savings are huge. Now our surgeons prefer OTB tables, because they are narrower which positions the cat closer to the surgeon. This increases comfort during many hours of surgery, because the surgeons do not need to lean over to do surgery. The OTB tables have adjustable height, and with the addition of a heating pad, they are more than sufficient for feline spay/neuter. Additionally, the OTB tables are on wheels and weigh very little. We can rearrange the room when we have multiple surgeons, and we can easily remove the tables for cleaning. The small size of the OTB tables allows us to have a smaller surgery suite and thus, maximize our space to its greatest efficiency. Reusing syringes saves thousands of dollars each year For buprenorphine, we reuse one single syringe all day, with a new needle for each cat. We save money in two ways, primarily in the cost of medication. By not discarding the 0.07 ml of anesthetic that remains in the syringe tip and needle hub after injection, we save thousands of dollars. Although 0.07 ml does not sound like much, when multiplied over thousands of spays each year, we save hundreds of ml or thousands of dollars in medication that would otherwise be discarded. Heating Pads, no Heated Tables The $20 for a heating pad does not compare to the several thousand-dollar cost of a heated surgery table. For 5-15 minute spays, heating pads set on LOW are more than sufficient. Surgery Lamps Desk lamps that attach to the surgical tables provide plenty of lighting for spay surgeries. Even the most complex of spays does not require intense lighting. Surgical lights start at $1500 each. We have used $20 desk lamps for ten years with happy surgeons. -5-