6 savvy tips for the surgical suite

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6 savvy tips for the surgical suite

From autoclavable shoes to less-mess cautery, veterinary surgeon Dr. Jennifer Wardlaw shares a few of her favorite surgical solutions.
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Apr 19, 2018

Dr. Wardlaw says that this headlamp, though designed for outdoor explorers, is perfect for surgical explorers too. Learn more below. (All images courtesy of Dr. Jennifer Wardlaw.)With 15 years of veterinary surgery under her belt, Jennifer Wardlaw, DVM, MS, DACVS-SA, of Gateway Veterinary Surgery in St. Louis, Missouri, has collected a few tips and tricks (many of which are DIY) that make surgery safer and smoother for all involved. Lucky for us, she’s generous with her genius.

Shoes that shine

“In this profession, shoes matter,” says Dr. Wardlaw. She wears Calzuro shoes in the operating room, which were designed with surgeons in mind. These deceptively simple shoes have a small heel to keep the body anatomically correct (which cuts down on fatigue), side ventilation for breathability, and massaging bumps to stimulate blood flow. But one of the main reasons Calzuro shoes are so attractive to Dr. Wardlaw is that they can be sterilized in an autoclave. Dansko clogs are high on her list as well, but they can’t go in the autoclave.

Light the way

Whenever Dr. Wardlaw posts pictures of herself on social media wearing this headlamp, everyone wants to know what it is. Answer: the Icon Headlamp from Black Diamond. This lightweight, mobile and super-bright headlamp (500 lumens for under $100) was made for climbers and spelunkers and the like, but Dr. Wardlaw thinks it’s perfect for surgical explorers too. “It gives off a really nice uniform light (so you don’t have a halo), and the strap that sits on top of my head helps keep the lamp in place,” she says. “If you’re not going to be anchored or tethered to a fiber optic light source, this AA-battery option is amazing.”

Patient prep with veterinary "Windex." Veterinary Windex?

Dr. Wardlaw has a DIY trick up her surgical sleeve—and it looks like a bottle of Windex. The self-made spray is like a liquid version of Avaguard or Sterillium hand sanitizers that she uses for final surgical patient prep in most surgeries. “Instead of a sterile scrub with povidone-iodine, chlorhexidine, etc., I use a spray that I make by combining ethyl alcohol 99% with chlorhexidine (2% or 4%), using a 3-to-1 ratio,” she says. “The idea is to keep the alcohol concentration well above 66%, while the chlorhexidine provides long-lasting residual antibiotic activity.” The concentrations are very similar to what’s in commercially available Avaguard, Dr. Wardlaw says.

To use, Dr. Wardlaw does her rough prep, and then once the patient’s ready, she sprays the area she intends to operate on and lets it dry.

Dr. Wardlaw admits that the spray does have a few issues worth noting—all of which are normal concerns when using alcohol. “You don’t want to get it on your cautery plate because you’ll ignite your patient, you don’t want to use it on a mucous membrane due to irritation, and you don’t want to use it on tiny patients because the alcohol can make them cold,” she says.

Bring the heat

“One heating option during surgery isn’t adequate,” says Dr. Wardlaw. “After the pet has been in surgery for 20 or 30 minutes, you’re less likely to bring their temperature back up as it comes down with just one thing. You need to start adding two or three heating elements proactively with small, young and thin patients and for longer surgeries.”

Dr. Wardlaw uses a wide range of cheaper and DIY options to keep patients cozy: hot water bottles, DIY hot water bottles (i.e. hot water in IV bags) and tube socks filled with lentils that can be warmed in the microwave. She also likes to use a fluid line warmer or wrap the fluid line around a hot water bottle. Whichever method you choose, heating the fluids close to the patient is key. “If you apply heat all the way at the end of the surgery table, the fluid cools down by the time it reaches the patient,” she says. “The closer the fluid warming element is to the patient, the warmer the fluid will be when it reaches it.”

To ensure that her patients are breathing warm air, Dr. Wardlaw often puts a warming element on the anesthesia circuit tube before it enters the pet’s airway.

“A lot of people are also loving the thermal blankets that come in emergency kits too,” says Dr. Wardlaw, “but it’s important to put it on the patient while it’s still warm. It can’t rewarm a patient. It needs body heat to start with.”

Dr. Wardlaw says she likes Bair Hugger forced air patient warming systems too. “I’ve had some clinics use them and put a pillowcase on the end or a bouffant cap,” she says. “Bair Huggers are common in the operating room but not in recovery cages because they’re so expensive. However, generic options, like BedJet, are now available, so the idea isn’t as cost-prohibitive.”

Wet paper towels enhance conduction without making a mess.Less-mess cautery

Cautery can get a little messy when the patient’s fur meets ultrasonic gel. Because Dr. Wardlaw uses cautery on almost every patient, she’s found a way to make the process less annoying. “Traditionally, we put ultrasonic gel on the ground plate to enhance conduction. To get the same benefits without the mess, I soak paper towels, washcloths or towels in water and place them between the pet and the ground plate,” she explains. “If the pet has a really thick coat, I’ll pour water between the patient and the ground plate to give it that contact. As long as you’re not in surgery for eight hours and your plate dries out, this method gives you plenty of contact without any hot spots or sticky, matted fur.”

However, Dr. Wardlaw notes that if ultrasonic gel is your thing, it’s easiest to remove if you comb it out with alcohol later, as the alcohol will dissolve the gel.

Creating a sterile, water-impermeable foot wrap with small pieces of drape.Wrap right

Dr. Wardlaw’s DIY solutions extend to contamination control as well. “There was a really nice study in Veterinary Surgery that looked at infection issues with veterinary professionals wrapping the foot when the patient is undergoing surgery on the leg or the knee since we can’t shave and sterilize the foot,” she says. “The study showed that you need to have a sterile, water-impermeable layer to best prevent infection, but many veterinary professionals skip this step and simply wrap the foot in Vetrap or tape.”

This, Dr. Wardlaw explains, is a problem: “You can take 20 layers of Vetrap, place it over the top of a cup of water and tip it upside down, and that water will eventually seep through the wrap. So when the patient is bleeding or you’re using lavage, and you’re touching the foot to manipulate the leg, you’ve got free-flowing bacteria in and out of that foot wrap,” she says.

To remedy this, Dr. Wardlaw cuts a little spool of water-impermeable drape that she calls “foot wrap” and puts it in all of her orthopedic packs. It looks like a short spool of wrapping paper that she wraps around the foot after capturing it with vet wrap. “I know some veterinary professionals who autoclave aluminum foil and wrap it around the foot,” she adds. “You just need to make sure that whatever you choose to use covers all of the Vetrap.”

Stay tuned ...

One more item on Dr. Wardlaw’s bag of surgical tips and tricks: a surgical checklist. “If you don’t have one, you need one,” she says. Check back to dvm360.com next month for a free downloadable surgical checklist.

wow

wow this is absolutely amazing to read. Doctor Jennifer Wadlaw you have an amazing talent! It is amazing that some people don't know how much it goes into taking care of these little fur babies!

Great job keep it up!

-Eger
window tint tomball

Warming measures

Hot water bottles and bean bags are not safe forms of warming measures. There is no way to ensure they are not too hot and will not burn your patient. Multiple different measures of heat support are definitely the way to go and I love that you mention warming the anesthetic circuit, but the method used is not as safe as an anesthetic unit that has the capability to warm the gas (which is cost prohibitive for most). Must haves for surgical patients: A safe under-patient heating unit like the hot dog warming system, an in line IV fluid warmer, Bair hugger warming system, and socks to wrap the feet in. Bubble wrap is also a great insulator to prevent heat loss initially, and it's important to put the patient on heat support at the time of pre-medication as they can lose 5-7° of body heat between pre-medication and induction. ANY heat source can malfunction and cause burns, but sticking to equipment that is designed and quality tested to warm patients is the safest bet.