WHAT’S THE BUZZ AT ACVS 2024? …AND MORE
I have a wonderful bottle brush tree just outside my office window that is awash in honeybees this morning…hence the trite title! :/
Having just returned from sunny Phoenix and the 2024 Symposium of the American College of Veterinary Surgeons, I thought it might be helpful to pass on some pearls I picked out of the information overload I always experience at conferences. (You too?) It was interesting to note that there were more topics than typical in the “soft sciences” of communication, team building, leadership, emotional intelligence, and the like. Should us surgeons take a hint?! :0 Say it isn’t so….
Ok, so here’s the scoop(s)—
INCISIONAL INFECTIONS:
There is a new/upcoming label you might see on culture & sensitivity reports, “susceptible-dose dependent, SDD”. This indicates there might be different drug doses (and thus achievable serum levels) that could work (other than that tested with their MIC). It warrants a chat with the lab.
Chloramphenochol consistently comes up “sensitive” for Staph (MSRP). Don’t believe it; clinically it is routinely resistant.
PERIOPERATIVE ANTIBIOTIC USE:
Great new term for me, “period of risk”. Antibiotics are superfluous (with greater risk than benefit) outside this period of risk…relative to surgery, when the skin is open and not yet sealed. A seal can be counted on within 24-48hrs, depending on animal health and incision “safety” (i.e. licking, skin tension, incision exposure, incision movement.) My take-aways from this concept are two-fold—1) we need to swallow hard and include all of animalkind in the “risk” equation; antibiotic resistance is an enormous risk to us all. This might mean a very sensitive, easy, superficial incisional infection at day 10 (no postop Abx dispensed) and a miffed pet owner, “Why didn’t you send home antibiotics, you quack!?” The flip-side with 2-wks of postop antibiotics for a clean procedure is we groomed a resistant MRSP and now the hospital is contaminated and the world has a new superbug. An intangible outcome…hard to factor it in…but necessary.
Speaking of incisional infections (gasp!), if we get one, get used to hearing/saying, “it depends”. Can we treat topically? Does it need antibiotics? Do I need to sample it? And get used to coaching your pet owners that one-and-done is not necessarily how it will go. Incisional infections need concierge care (use that term with a pet owner, their pet is special and unique!) Treat THE patient, not the concept of an incisional infection.
If you decide sampling is needed, “always” collect cytology (or histo if surgically debriding) with a culture sample. If there is no cytological evidence of infection or the microscope bugs differ from the culture bugs, you are covered. Good data to help make the practical decisions.
Y’all probably already know about this resource, but if not, https://www.wormsandgermsblog.com/ are wizards! Clear spoken wizards. And nice & approachable wizards! Put in the tag “antibiotics”, and you will get an excellent primer update.
PERFORMANCE MANAGEMENT, MENTORING, COACHING:
Dr. Julie Smith and team presented some helpful information on the soft science of working with people. Ugh, yes we have to, friends! She talked around the concept of “Radical Candor” as defined by Kim Scott in her book by that name (and a TED talk for a quicker ingestion). I took personal notes on one of Dr. Smith’s charts, (and maybe quoted her, but I won’t throw her under the bus)—the X-axis is “willing to piss people off” and the Y-axis is “give a damn”. Put those two axes together, and you make four quadrants. Introspection can then introduce yourself to yourself; and awareness can help you understand the messages come toward you from others. Adjust, adapt, empathize, learn, shields up…you choose. Good bit of info.
ROOT CAUSE ANALYSIS:
Great concept, not new, but often too scary to implement. Check out the “fishbone diagram” and use categories like: patient, procedure, people, team communication, training, leadership, equipment/environmental factors. Use it routinely after large or small adverse events; step away from only pointing to one person’s error and dig deep to find systems that protect against any errors. (I would add that large and small beneficial events warrant just as much scrutiny.) Turpin Mott pointed out to all of us that 99% of our day is successful and 1% might be unsuccessful; let’s use some science to find systems that promote more successes. Start with: get good sleep, drink lots of water and eat your veggies!!
Ok, now for some real science, right?!
ENDOCRINOLOGY UPDATES:
Cinacalcet is a relatively new medical therapy for primary hyperparathyroidism. How it applies to what’s important to this surgeon (!) is that it might be a conduit to a more stable pre-intra-postop patient. It is easy to start-stop, no weaning. Short-term use has few, self-limiting side effects. As a calcimimetic with T1/2= 8hrs, it binds Ca++sensing receptors, tricking them into thinking there is enough Ca++ around, and thus decreasing PTH production. Perhaps we can now support our patients through the diagnostics, and then prepare them for a “simple” surgical resection with fewer postoperative hypocalcemic concerns. Really good ultrasound diagnostics are helpful in planning surgical treatment. Not only is it nice to have a clearly abnormal gland (1 of 4), but absent that, U/S hunting for enlarged ectopic glands cranial, caudal and dorsal can save the day!
Insulinomas remain sneaky. No real change in preop or chronic management—frequent carbohydrate meals and low-dose pred (0.25-1mg/kg q12hr). Data does support that prognosis is poorer for the emergent cases that come in bottomed-out and in need of glucose CRI. Surgically, they remain tough to find, but nowadays, perhaps intraop ultrasound and intraop glucose monitoring can help find a few more. The buzzword of the conference was Near Intra Red Fluorescence using Indocyanine Green (0k, six words…) When I come rolling in with a NIRF camera someday, you will know I have “arrived” on so many levels! Postop monitoring is perhaps made easier now with Libre3plus. These cases can benefit just like the diabetes cases with this new-fangled option.
CONSERVATIVE ORTHOPEDICS:
My ears were burned by an heretical statement, “NSAIDs are analgesic but NOT anti- inflammatory to the joint.” Hmmm. Dogma is being peeled away. It seems all of the osteoarthritis science driven by enormous demand (or Big Pharma market analysis) is beginning to adjust our learned “basics”. Take-way is we should not expect or portray NSAIDs as an OA disease treatment, per se. Good for pain, but not treating inflammatory disease.
While parsing data around BedinvetmAb (Librela), one interesting thing jumped out. The treatment effect size for NSAIDs was 0.3 and the treatment effect size for mild-moderate activity and weight loss was 0.3. Hmmm. I know, preaching to the choir. On the negative side of BedinvetmAb, data is trickling in about a phenomenon/disease recognized on the human side with Nerve Growth Factor Antibodies (NGF-Ab)—Rapidly Progressive OsteoArthritis/Arthropathy. This is a destructive arthropathy seen (thus far) in a small percent of canine cases but is recognized as a big deal in humans. Company reps say “report, report, report” any adverse events; they want to know.
PROGNOSTIC FACTORS WAS ANOTHER BUZZWORD(S):
Brachycephalic Obstructive Airway Syndrome—bad if ER presentation, >3yrs, female, laryngeal collapse. Pertinent here is, cut these early and prophylactically! I can help with that. 😉
Mast Cell Tumors—bad if Shar Pei, large, rapid growth, ulcerated, perineal/inguinal/preputial/scrotal/muzzle/periorbital/oral , GI or degranulation signs, recurrent.
Anal Gland AdenoCA—bad if >2.5cm, elevated Ca++, lymph node involvement
Soft tissue Sarcoma—bad margins common if small dog, large tumor, less experienced surgery personnel
Melanoma—bad if rapid growth, large, amelanotic, necrotic, high Mitotic Index, lymph node involvement
Caesarian section—NOT bad with multiple litters (no difference in morbidity for subsequent procedures)
Malpractice/legal stuff—Doing something (even if wrong) IS defensible; doing nothing (not recording, not communicating, not using contracts, i.e. avoiding) is BAD prognostic factor!! Exception, fudging records; big zippo on that one! Make a dated addendum instead.
No informed consent is bad. Informed consent is “what a reasonable person needs to know…common and major”. Make it written, verbal and document both happened.
And finally, a revisit on the topic of Checklists. Back in 2012 I wrote a brief book report on The Checklist Manifesto. Great read. Insightful author. Checklists in a hospital setting are site specific as well as event specific. If a checklist is exhaustive, by definition people will get tired of it. If too brief, people think ridiculous. So, find your Goldilocks checklist template for the high risk, high performance events and practice, practice, practice until it is the common lingo, the ”thing to do”! Eliminating one “oops” from your week, year, career can save ego and heartache for so many.
Thanks for reading. If I can help you and your patients with surgery or surgical knowledge at any point, drop me a line.
Razz
Lara Rasmussen, DVM, MS
Diplomate, American College of Veterinary Surgeons
Direct Veterinary Surgery, PC
www.directvetsurg.com
directvetsurg@gmail.com
651 829-1111
