Letting the Demons Out! Some thoughts on exploratory laparotomy...

“We didn’t find anything particularly abnormal but we let the demons out!” Heard that before? Sure you have and we laugh out loud. But should we be? Are too many unnecessary negative exploratory laparotomy procedures performed? Are too many exploratory laparotomies performed prematurely?

An exploratory laparotomy is, as the name suggests (!), a laparotomy procedure that is done to explore the abdomen in a patient in whom there are clinical signs associated (at least) with the abdomen. The procedure may be done for example to:

  • Establish an unknown diagnosis
  • Confirm a suspected diagnosis and potentially establish its extent
  • Collect samples that will later provide a diagnosis
  • Perform a therapeutic intervention that can be palliative or curative including being life-saving in some cases
Potential aims/outcomes of an exploratory laparotomy procedure

Potential aims/outcomes of an exploratory laparotomy procedure

Often more than one of these outcomes is achieved during the same laparotomy procedure.

At this point you may be thinking, tell us something we don’t know. What’s your point Shailen?

Well, I wanted to discuss when an exploratory laparotomy should be performed and the concept of a negative exploratory laparotomy. Ever done one? This is not a new topic of discussion, it has been going on for a long time and no doubt will continue for a long time. But I was prompted to write this post by two recent occurrences. One was it came to my attention that a colleague of a friend performs a statistically disproportionate number of exploratory laparotomy procedures many of which are negative; now I am the first to concede that second-hand information must be treated with caution but I am convinced of this individual’s less than ideal ‘scalpel happy’ tendencies. The second occurrence was becoming aware of a young adult dog that underwent a negative exploratory laparotomy procedure and sadly suffered what was presumed to be cerebral hypoxic injury from which the dog did not recover.

Let me state clearly that I do not believe that a negative exploratory laparotomy is of no value. However the majority of what we do in veterinary medicine is essentially about a risk-benefit analysis where ‘risk’ can also include financial costs – but financial costs can also feature on the benefit side. And then practical, logistical, and equipment-/facility-related factors undoubtedly can influence what is ultimately done – it would be naïve to think otherwise. And let’s not forget the part that the individual clinician’s approach, opinion, perspective, philosophy…plays in influencing clinical decision-making.

SO what are the ‘risks’ of an exploratory laparotomy procedure?

Well:

It is true that modern anaesthetic drugs and modern general anaesthesia in veterinary medicine is very safe. It is safer in some environments, less safe in others, safer in some patients, less safe in others. But undoubtedly it is very safe. Moreover some people are able to perform exploratory laparotomy in a speedy and efficient manner minimising the time the patient spends under anaesthesia. However it is not risk-free as illustrated by the case above. Hypotension. Hypoxia. Always lurking as potential occurrences as well as random drug reactions, human errors with severe consequences etc.

Surgical risks: a negative exploratory laparotomy is not free of surgical risk either. Often an exploratory laparotomy is performed in a patient with gastrointestinal signs and there is a perspective that says that if nothing remarkable is found one should still use the opportunity to obtain (gastro)intestinal biopsy samples. Sure, I don’t disagree; but bear in mind that you will have opened the gastrointestinal tract which can have complications….you know like that slightly important septic peritonitis thing especially after 3-5 days. There are other ways too in which even a negative exploratory laparotomy can result in complications. If nothing else, you can get dehiscence or infection of the skin/subcutaneous layers.

PAIN and MORBIDITY: is it just me or do some people seem to think that performing an exploratory laparotomy is the same as a minor lump removal procedure as far as the patient is concerned? Yes, I know that nowadays we have some very effective analgesic agents but do people really think that that takes care of all the pain as well as any resulting morbidity? And that’s if modern multimodal pre-emptive dynamic liberal…analgesia is performed. Let’s not pretend it is by everyone. Now of course the amount of pain and morbidity can be moderated to an extent by good surgical skills and gentle tissue handling but the point remains very valid. Dogs especially are their own worst enemies in this regard because often their stoicism portrays that the procedure is benign enough to just do on a whim. Maybe they are not that bothered? Maybe I am over-blowing it? But we would rather not hurt patients unnecessarily right?

And then there are financial implications of a negative exploratory laparotomy procedure and the subsequent post-operative care. Now I obviously realise that these costs vary quite considerably depending on the practice in question but they are there. Note my point below on this too though.

Okay so what about the benefits?

Well there is the list above about the potential outcomes of an exploratory laparotomy procedure. It can help you to find out what is wrong with your patient and potentially to treat or cure him or her. We have to consider this in the context of emergency versus elective patients too; it can save the life of some patients, simple. And in all seriousness, there are a number – not sure of an exact number! – of anecdotal stories of dogs in particular who had a negative exploratory laparotomy procedure and their clinical signs seemed to improve or even resolve more or less straight afterwards. This is where “I let the demons out” comes from.

And then we have the financial considerations. It is undeniable that in some circumstances in some practices performing an exploratory laparotomy without any or with minimal pre-operative diagnostics is the most cost effective way forward. I don’t want to make light of this, it can be the motivation that has led to a number of exploratory laparotomies being performed.

One other thing we need to consider is peace of mind for the pet’s carer and more broadly the pet carer’s wishes. Sometimes the impetus for an exploratory laparotomy that may be premature or anticipated to be negative can be the pet’s carers and their wish for more definitive peace of mind.

With all of that said, based on my own personal experiences over the last 15 years and on anecdote, I think that too many exploratory laparotomy procedures are performed unnecessarily or at least prematurely. I think that there are many occasions in which some more rational clinical thinking about what is going on with the patient and additional diagnostics, or indeed the same diagnostics performed in a serial monitoring fashion (e.g. repeat abdominal radiographs) would lead one to conclude that surgery was not indicated.

Where I have worked for a significant part of my ECC career – a tertiary referral centre – negative exploratory laparotomies are very rare. “Well that’s because you have worked in a tertiary referral centre where many of the patients are insured, money is often not the major limiting factor and there are specialist diagnostic imagers” I hear you say. True. But I can also tell you that in my years spent doing first opinion Out-of-Hours work sitting here I cannot recall a time when I performed a negative exploratory laparotomy. That probably means that I have done at least one which I have chosen to forget but the point remains. And the same is true for the time I spent supervising and training and mentoring others doing first opinion Out-of-Hours work. When we talked through the case often the exploratory laparotomy they had concluded was necessary was not performed and the patient went on to recover fine. This blog is not about me of course, I am making a more general point but I wanted to share my experiences.

Okay I think that is all I really have to say on this. Basically please do what you can to avoid performing unnecessary exploratory laparotomy procedures and maybe try and share some of that philosophy with those around you…in a polite, collegiate and politically sensitive way of course!

As always I would love to hear your thoughts and opinions on this post.

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Top Tips for Coping with Night Shifts

So this is a blog post I have wanted to write for some time and thankfully the moment has arrived! I hope you find it of some interest/use. The tips and strategies that follow with respect to coping with night work are a combination of my thoughts and tips gathered from members of the Veterinary ECC Small Talk community via email – THANKS so much to those who contributed. Right, let’s get on with it…

DISCLAIMER: Before we do, I should say that I totally realise that this all sounds a bit idealistic and I am the first to admit that during my ECC career I have not always used these strategies, certainly not all of them all of the time. And moreover we are not all the same and some people find that strategies that work great for some people do not work for them, and vice versa. Obviously you need to do what works best for you…but also please take a moment and think about your routine – are you sure it can’t be improved upon?

1) Be prepared:

When approaching a run of night shifts, try to prepare by building up a sleep reserve; this can be helped for example by doing some physical activity beforehand then you could, e.g.

  • Stay up really late (at least 3am – 6am) the night before then sleep for the majority of the day before your first nightshift.
  • Or, go to bed as usual the night before, sleep in until late morning, have a big feed for lunch then go back to sleep for an afternoon nap.

2) Drink plenty of water during your shifts:

This is one that came up a lot in the feedback. It is not always easy but oh so important to stay hydrated. For example have a big water bottle that is well placed and easily accessible so having a drink does not seem really time consuming! I am willing to budge on some of the other tips in this blog but not this one! Drinking enough water is important people!

3) Plan your caffeine and go easy:

This is another one that came up a fair bit. Overall the take-home message seems to be to go easy on the caffeine. Firstly it can contribute to dehydration and if you are not consuming enough water as well, this becomes a desiccating vicious circle! Secondly if you have caffeine in the later stages of your shift  this can reduce your chances of sleeping when you do get to bed…and so you are more tired….and so you drink more caffeine etc etc.! How about a coffee when you wake up, when you get to work and maybe mid-way through the shift then stop? Make it good coffee and make some for the whole team – obviously! Seriously, if you stay hydrated, get enough rest in the day and do some exercise, you should not need to be caning the super-strength coffee/energy drinks relentlessly!

4) EAT!

We have all been there, trust me, when **** is hitting the fan and even getting water seems out of the question, so who the hell has time to eat right? Uh, wrong! ‘Eat while typing notes’ seemed to come up a fair bit. It’s important and very much helped by being prepared. Junk food is oh so easy and accessible but so not the answer! Before your run of night shifts, get your ‘proper’ healthy food organised, including meals that can easily be re-heated or eaten cold. I am no nutritionist and I am not about to start recommending what you should be eating but go easy on the sugary junk high in ‘bad’ fats!

5) If you get a break, use it!

I am not going to get into the legalities etc. of this but in theory everyone is entitled to some sort of break during a night shift. If you are able to take one, use it. Some people like to have a power nap (I love them!), others like to take a walk, or have some distraction (e.g. TV). Working non-stop without a break can actually make you less and less efficient – it is a bit of a false economy sometimes to just keep ‘powering through’ and taking a short break can bring you back firing on all cylinders again.

6) When it comes to going home time, if you feel too tired to drive, please don’t!

We have all heard stories of people who have driven home falling asleep at the wheel, sometimes nearly having an accident with potentially disastrous consequences. In fact some of you may have had or know people who have had accidents. I know this sounds like a sermon but driving when you are too tired to do so safely is not big and it is not clever! Can you get a taxi? Can someone come to collect you? Can someone drop you home? Indeed, is there somewhere you can sleep at work?

7) Have some ‘breakfast’ before bed:

Opinions and preferences vary here in terms of what people like to eat. For some it is normal breakfast food, for others it is more the sorts of food you might usually eat in the evening. BUT the bottom line is again, try and stay on the healthy side, don’t eat foods and especially large amounts which will interfere with you falling asleep. No curry and beer in the morning! And many people like something that is quick and easy and does not delay sleep for too long.

8) When you do get to bed, take steps to ensure that you can sleep well, fall into refreshing deep sleep:

As far as possible, keep interruptions to a minimum from family – including the furry kind! Get uber curtains that keep as much light out as possible; or use some other means of covering the windows, e.g. black out blinds; or get an eye patch. Unless absolutely necessary, get rid of all devices such as mobile phones or tablets from your room; they can be such an intrusion on sleep! And if needs be, get some ear plugs for noise cancellation.

9) Go easy/stay off the alcohol:

Yes it can relax you after a crazy shift – tick. Yes it can help you to get to sleep – tick. But it can also stop you from getting quality sleep and therefore exacerbate tiredness. Have one drink before bed if you must, but stop there!

10) Exercise:

This is something else that came up a lot in the feedback, the importance of trying to fit in some exercise. Some people like to do this at the end of a shift to help unwind and help with sleeping; others like to do it when they wake up to invigorate before going to work. It does not have to be for very long and it does not have to be super-hardcore. Just do some physical activity in-between shifts!

11) Try to keep the days free for sleeping:

I know this one can be a real challenge especially for parents where kids need taking care of (!) but as far as possible don’t make ‘unnecessary’ commitments for the days when you are working nights. Can those things wait until your nights shifts are over before the next stint?

And look seriously if you really find night work too much, too exhausting, too debilitating…think seriously about whether it is for you. Depression is more common than we care to admit and this sort of work can be a factor in either causing or at least exacerbating that. If you are worried or struggling, get some help; there are plenty of places not least your doctor.

Okay, well that’s it from me. If any of you have any other tips or coping strategies or don’t agree with some of what I have said, I would love to hear from you so get in touch!

PS. I decided not to talk about transitioning to day shifts again – the so-called ‘turnaround’ – as the blog is already quite long. There are different ways of turning around and do feel free to share comments about that too.

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Ever seen dialysis disequilibrium syndrome in tomcat urethral obstruction?

Ostroski CJ, Cooper ES. Development of dialysis disequilibrium-like clinical signs during postobstructive management of feline urethral obstruction. J Vet Emerg Crit Care 2014. 24(4):444-449.

Tomcat urethral obstruction is one of my favourite topics to discuss and teach about (sad, I know!) and yet again they do not fail me! Like many of you I’m sure, I have managed a large number of tomcats with urethral obstruction in my time and I don’t recall this progression ever happening. I have been aware of dialysis disequilibrium syndrome, especially having worked in a hospital where dialysis is available, and I found this case report very interesting. As always of course it is very difficult to know the true incidence of this development in blocked tomcats as it may go unrecognised by the people managing the case if neurological signs are attributed to another aetiology, or indeed it may be suspected but go unreported. I guess I can say that from my own personal experience and that of colleagues, it is a rare development in tomcats with urethral obstruction but definitely something to bear in mind.

Have you ever come across this before? If so, I would love to hear about it!

Case report highlights

Some of the bits from the report that I thought it worth including here are as follows. If anyone actually wants a PDF of the case report then feel free to email me – I think it is okay for me to send a copy to individuals for educational purposes without breaking any laws!

“Dialysis disequilibrium syndrome (DDS) is characterized by neurologic symptoms of varying severity resulting from overly rapid decreases in peripheral osmolality during a dialysis procedure…With rapid decreases in blood osmolality, cerebral edema develops due to the resulting gradient between cerebral tissues and blood, causing an acute increase in intracranial pressure. This syndrome has been recognized in both human and veterinary patients undergoing hemodialysis…Cats with urethral obstruction are often severely azotemic on presentation and therefore have the potential for similar rapid decreases in urea concentrations in the postobstructive period. The purpose of this report is to describe an instance of suspected postobstructive DDS-like clinical signs in a male cat.”

This was a 5-year old castrated male domestic short hair cat weighing 5.26 kg.
On presentation this patient was towards the severe end of the spectrum of presentation being moribund and with clinically significant hyperkalaemia; interestingly also a mild hypoglycaemia (not unheard of in these cases but I would say definitely unusual) that actually persisted and had to be corrected by supplementation.
Nothing about the management was especially noteworthy I would say (cystocentesis was performed before catheterisation was attempted which is very much not what I do/teach but let’s leave that aside on this occasion!).

Following catheterisation the cat developed a marked post-obstructive diuresis.

Approximately 5 hours after catheterisation he had a generalised seizure and then developed respiratory arrest:

“Repeat assessment of electrolyte concentrations and blood-gas values revealed resolution of acidemia, mild hypocalcemia, and marked reduction in azotemia…Given that neither hypoglycemia nor hypocalcemia appeared to be the cause of the seizure activity, the concern was raised that an acute change in BUN, and thereby osmolality was responsible (in a process similar to DDS). Because of this concern, the patient was administered a bolus of 7% hypertonic saline (2 mL/kg, IV) over 5 minutes. By the end of the infusion he started to breathe spontaneously and his PLRs had improved. The patient was still mentally obtunded but was able to be extubated 15 minutes later….Approximately 90 minutes after this initial episode, the cat's neurologic condition again deteriorated. He displayed opisthotonus and his PLRs were diminished. Because of the continued concern for osmotic injury, the patient was given an additional IV bolus of hypertonic saline (2 mL/kg), after which the cat's mentation again improved. At this point, a continuous rate IV infusion of 3% sodium chloride was initiated in an effort to maintain blood osmolality and to prevent further clinical signs….The following morning, the patient's mentation remained depressed but he was slightly more responsive; there were no further seizures….His mental status steadily improved throughout the course of the day and his urine output (and IV fluid rate) gradually decreased.

Throughout the remainder of hospitalization the patient's neurologic status continued to improve and appeared to be completely mentally appropriate within 40 hours of the onset of seizure activity.”

He was eventually discharged and was reportedly doing fine at follow up after 2 days and 3 months.

“As a clinical syndrome, DDS has been reported in human and veterinary patients undergoing hemodialysis for treatment of renal disease.

The pathogenesis of DDS is still unclear, but there are 2 major theories to explain the development of cerebral edema. Both theories are predicated on the presence of a hyperosmolar state and the development of a gradient between cerebral tissues and the blood followed by rapid reduction of peripheral osmolality. The result is an intracellular shift of extracellular water leading to neuronal swelling, increased intracranial pressure, and the clinical signs associated with cerebral edema (eg, dull mentation, seizures).” I am not going to include any more detail about the theories here!

“The diagnosis of DDS is one of exclusion, and is primarily based on a predisposing clinical situation and development of characteristic neurologic signs…DDS has been documented in both experimental models and clinical reports of veterinary species undergoing dialysis…Based on clinical signs and available laboratory data, we suspect that the patient described in this report suffered from clinical signs similar to DDS. This syndrome is typically seen in patients that undergo a rapid decrease in serum urea in a short period and is a diagnosis of exclusion. In this case, the patient had BUN of 89.3 mmol/L [250 mg/dL] at first measurement that rapidly decreased to 19.9 mmol/L [56 mg/dL] over a 7 hour time span. This likely occurred secondary to a marked post-obstructive diuresis, producing 92.5 mL/h of urine in the 4 hours just prior to the onset of neurologic signs. Although the decline of BUN is not as rapid as that seen with DDS in hemodialysis patients, this patient still experienced a change in osmolality of 67 mOsm/kg (or ∼ 9 mOsm/kg/h) during that period, much faster than the target rate of 1–2 mOsm/kg/h...Furthermore, administration of hypertonic saline repeatedly resulted in significant improvement in the patient's neurologic status, supporting the notion that the signs were a result of changes in serum osmolality.”

“Based on the clinical signs, laboratory values, and response to treatment, we suspect that this patient experienced an episode (characterized by altered mentation, seizure, and brief cessation of breathing) consistent with the clinical syndrome associated with DDS. The patient's neurologic signs corresponded with rapid decreases in BUN (secondary to marked postobstructive diuresis) and responded to treatment with a hyperosmolar solution. To the authors’ knowledge, this has not been reported as a potential complication to treatment of feline urethral obstruction in veterinary medicine. Practitioners should be aware of this potential complication as a cause of prolonged neurologic recovery or seizures in the postobstructive period of severely azotemic patients, and frequent monitoring of electrolytes, BUN, and neurologic status may be indicated. If rapid decreases in osmolarity and BUN are detected during early case management, or if otherwise unexplained neurologic signs develop, administration of hyperosmolar solutions may be of benefit.”