6 tips for keeping the Subcuticular knot from popping into your incision

Hi All,
I apologize that I have not monitored this page as much as I usually do. I have had some medical issues but I am getting back into healthy mode now. Thank you for your patience.

Emerald, I will alert Dr Brock that you have another question. I believe she is back from her ski vacation this week.

Nicole, thank you for making that comment. So yes 2mm in between ligatures can be enough and, in my opinion, it is better to have 2 ligatures a bit close together than just one, most of the time. Regarding the "flashing". We 'flash' when a clamp is on the pedicle because the nature of the clamp will tend to 'spread' the tissues out, so by flashing (releasing the clamp) we allow the ligature to fully strangulate the tissues without the tissues being held 'spread out'. The flashing is needed because of the hemostat. One ligature close to another will not cause the tissues to be held spread out because the ligature circumferentially encloses the pedicle. I hope this explanation makes sense and that I understood your comment correctly. I know you are in a different time zone but hopefully you can join us for the webinar next week in case I did not adequately clarify this question.
Have an amazing day!

Thankyou Dr Sylvestre
Yes I wil continue to pursue a cat gut alternative , thanku for the monocryl tip.
As I was religating the ovarian pedicles post bitch spey bleed I only managed to get 1 ligature on he ovarian pedicles due to there not being much tissue , if I was to put 2 on this particular case there would have only been a couple of mm between the 2 ligatures , is that still better than 1, I always allow more space between ligatures due to the need for " flashing ' u talk about ?
Thanks 😊

Hi Emerald
I saw your question for Dr Brock. I know she was heading to BC today for a ski holiday. I will alert her to your question but she may not get back to you for a few days. I do not know what her computer/work availability is like while away. Just an FYI.
Thanks and have an amazing day!

Hi Nicole
Great questions, difficult case. I do believe that the spaniel had some sort of bleeding disorder, or an adverse reaction to something that might have caused the odd clotting issue. Going back in the second time certainly could have caused you to go through muscle which would lead to bruising at the incision line. I am very cautious with ligating pedicles, especially in bigger patients. I had one patient, a large mixed breed dog on which we did a hindlimb disarticulation amputation. 2 weeks post op his entire incision fell open and he was bleeding from his femoral artery. Thank goodness the owner was the veterinarian also! But it made me realize that large vessels do take a long time to clot securely closed. So I would not be using catgut on such pedicles (I used it for many years but with everything I have learnt in the past 40 years, I would not touch it anymore). PDS is a good choice but that extra strength and duration is not necessary within the abdomen so I would simply use monocryl or biosyn, or something equivalent. I do certainly embrace the Modified Miller's knot (new to me for the past few years!) as those knots do stay on securely; others, if using the surgeon's knot or slip knot (as I used to) then I would transfixed when ligating an organ/pedicle like the body of the uterus in a larger patient as these knots can slip and I would always place 2 ligatures (large patient again). I hope this helps a bit. Welcome to the program.

From Emerald:

Hi Dr Brock,
I've got an unrelated anesthesia question. We had a cat come in for urethral blockage and wanted to try a coccygeal block. We have lidocaine 2% with methylparaben in it and the container says not to use for epidurals. I used a new feature on VIN "AI mode" when searching and it said that methylparaben is not a concern in veterinary medicine when used for epidurals.
In this case 1) is it ok to use bupivicaine (we have preservative free) and at what dose? 2) Is lidocaine 2% with methylparaben still safe to use for a coccygeal epidural block?
Any other tips for this procedure are much appreciated!
Thanks,
Emerald

Hi Emerald:
It is fine to use either the lidocaine with the methylparaben or the preservative free bupivacaine for the SC epidural. But what is crucial is that in either case, the bottle from which the local anesthetic agent is drawn is newly opened as this is the only way to prevent the use of a contaminated solution.
N

From Emerald:
Hi Dr. Brock,
A follow up question about the ketamine bolus. Is the apnea related to the ketamine or the pain?
Thanks,
Emerald

Hi Emerald: The apnea is related to a predictably brief period of CNS depression that accompanies the ketamine bolus. It does not occur every time you administer a ketamine bolus but often enough that I recommend looking for it so that you can identify whether or not the patient requires some manual ventilation support. It is ok to let 30 seconds or so go by to see if spontaneous breathing will start back up but it is equally ok top give a small breath while you wait. Nancy

Hi again,

I understand that Dr. Brock has been busy so I'll keep an eye out for a response when she can.

We've been having more large mass removal surgeries, with a lot of undermining and patients have been more uncomfortable. I was wondering what your recommendation for pain management intra-op and post-op are for these large mast cell tumour or soft tissue sarcoma cases that may have the muscle fascia and a large area of tissue removed.

I believe our anesthetic protocol is similar to our routine procedures: 5mcg/kg dexmedetomidine + 0.05mg/kg hydromorphone with a top up of hydromorphone at the same dose 30 minutes later. We give meloxicam intra-op closer to finishing the surgery if blood pressure has been good and top up hydromorphone ending with buprenorphine every 3-4 hours post-op (usually another hydro dose and a buprenorphine dose prior to discharge). Dispensed with 4 additional days of metacam and gabapentin 5mg/kg BID for ~5 days.

My biggest question is your thoughts on tramadol PO vs buprenorphine TM (I feel like they are the rootbeer of the pharmaceuticals - vets love one and hate the other but I'm not getting a clear consensus of which is better, maybe this is because I'm listening to anecdotes). Since these were both large dogs either option is cost prohibitive.

I think we should be increasing gabapentin to 10-20mg/kg TID, I want to discuss adding in CRI's intra-op. We did reach for subcutaneous ketamine in both situations to alleviate pain with a good response.

Thank you for dealing with all my questions!

Emerald

Hi Dr Brock,

I've got an unrelated anesthesia question. We had a cat come in for urethral blockage and wanted to try a coccygeal block. We have lidocaine 2% with methylparaben in it and the container says not to use for epidurals. I used a new feature on VIN "AI mode" when searching and it said that methylparaben is not a concern in veterinary medicine when used for epidurals.

In this case 1) is it ok to use bupivicaine (we have preservative free) and at what dose? 2) Is lidocaine 2% with methylparaben still safe to use for a coccygeal epidural block?

Any other tips for this procedure are much appreciated!

Thanks,

Emerald

Hi Dr Sylvestre
can i ask about the modified millers, so to practice these i used them for a dog castration this morning did one obviously seemed a bit qak handed but i am developing a technique crossing the suture material over clamp, to slide into the crush ( more tricky doing a modified millers but getting there) the one thing i noticed was on a couple of ligatures the 2 strands of suture material going round the vessel ( or pedicle ) where not exactly next to each other, there was a couple of mm gap between them when i pulled it tight ( sorry i know difficult to understand without a photo hopefully you know what i mean) is this ok?? im sure in one of your videos this happend but wanted to check,
the ligature was tight , was very happy with them but just wanted to check thats ok if it happens when im doing an ovarian pedicle.
its actually very difficult changing what your doing, when what you were doing previously ( ie surgeons knot on cat gut ) never failed me, but i obviously know moving forward i need to get away from that , but change is making me anxious hence all the wuestions, so i greatly appreciate all your help and support thankyou!

Hi Dr Brock
Thank-you so much

Hi Dr. Brock,

A follow up question about the ketamine bolus. Is the apnea related to the ketamine or the pain?

Thanks,

Emerald

Hi Nicole:
0.5 mg/kg as an IV bolus will buy you about 5 to 10 minutes of intense analgesia.
Isoflurane is not analgesic at all. If you perceive that your patient is responding to a painful stimulus then the ketamine addresses the pain within 30 seconds.
Be on the lookout for apnea. You may need to deliver a few small breaths until spontaneous breathing returns, usually within a minute

Hi Nicole:
0.5 mg/kg as an IV bolus will buy you about 5 to 10 minutes of intense analgesia.
Isoflurane is not analgesic at all. If you perceive that your patient is responding to a painful stimulus then the ketamine addresses the pain within 30 seconds.
Be on the lookout

Hi Dr Sylvestre
Can I ask for some tips for going back into a bleeding bitch spay.
Obviously happens pretty rarely , iv done 2 in 20 years first v obvious 2 day post spay cervix easily sorted . Last one recently not so straight forward presented 9 d post spey , abdomen full of blood pcv and and platelets fine , dog well. Opened up lots of blood , vet had used cat gut for all ligatures . Very small clots on both ovarian pedicures slightly bigger cervix . Smallish 17kg spaniel. 30y qualified vet did procedure . Microclots throughout omentum etc. No ligature on cervix found ( wondered if blood in abdomen caused cat gut to dissolve more rapidly) an should have had transfixing apparently. No obvious active bleeding , I retied both ovaries and cervix. All looked good then post op bleeding from muscle 24 h later actually think poss clotting disorder?, going back thru linea alba wasn't easy as 2nd op so think it then bled from muscle. 3 weeks later tranexamic acid and a variety of clotting disorder bloods still waiting for , bleeding has resolved. After this I felt worried maybe I hadn't retied well? thou never any further blood seen in the in abdomen. Made me think I probably do one every 10 years and could do with some tips ( doing ur mentorship programme as qualified 20 y now mentoring new grads and they do things quite different to how we were taught and thought I should get upto date. Trying to get away from catgut and do pds with modified miller's but when I do I worry as its new eek ! In UK we still use a lot of cat gut .

Hi Nicole
Thank you for. your comment. I will alert Dr Brock that you have a question for her.

Hi Dr Brock
I saw in one of the neutering videos you sometimes use iv ketamine for analgesia rather than increasing the isoflurane. Can you please tell me the dose. I had it written down and tried it for an ear mass and it worked perfectly but I can't find the dose now
Thanks nicole