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Gastrointestinal Veterinary Talk, Part 1
- 1. Earl F. Calfee, III (Trey) DVM, MS Diplomat American College of Veterinary Surgeons CSU Surgical Oncology Fellow Nashville Veterinary Specialists, PLLC
- 2. Thanks to our sponsors Pfizer IDEXX Thanks to Becky Dan Coordinator of all things detailed Resource to your clinics bdan@nashvillevetspecialists.com Marketing materials Co-marketing magnets Recycling 2 hour talk – break around 8PM
- 3. To explore or not to explore? Anatomic Review Equipment Surgical techniques Peri-operative management Questions Stop me at any point.
- 4. Vomiting Retching Abdominal distension Abdominal pain Generalized discomfort/restlessness Owner reports ingestion of something Palpation of mass effect Mass identified on rads or U/S
- 5. Often obvious Mass identified with palpation or imaging Pre-op diagnostics CBC // Serum chemistry Thoracic radiographs Abdominal ultrasound FNA with cytology - lymphoma GDV Usually clear indication for surgery Discussion of prognosis with owner Mentation is key Pre-operative prognostic indicators Plasma lactate
- 6. Septic abdomen Clear indication to explore Owner communication key Sick animals High mortality – 40-70% High costs Intensive case management Prolonged hospitalization
- 7. The “cloudy ones” Stable Inconsistent vomiting, anorexia, lethar gy Variable history Variable signalment
- 8. How do you decide on “cloudy cases” What we know Lots of differentials Foreign body, inflammatory bowel disease, non-specific gastroenteritis, liver or kidney failure, toxicity, pancreatitis, viral enteritis, GI neoplasia, intussusception, esophageal foreign body, IVDD, pyelonephritis etc., etc., etc. If you do much surgery you will wait too long on some and go in too early on others What are we trying to avoid? Operating patient that has readily identifiable non-surgical condition Pyelonephritis, Addison’s disease, IVDD, etc.
- 9. How do you decide on “cloudy cases” Multifactorial decision Signalment // History Physical exam Diagnostics
- 10. Signalment Typically young but can be older with polyphagia from concurrent disease (i.e. hyperadrenocorticism) History Owner missing something Owner witnessed chewing Already vomiting foreign material Frequent chewer – maybe operated previously Medically induced polyphagia Hyperadrenocorticism Epileptic on meds Exogenous corticosteroid admin.
- 11. History (cont.) Frequency and duration of vomiting Increased suspicion of need for surgery High frequency = upper GI obstruction Chronic intermittent vomiting combined with anorexia, possible diarrhea, weight loss = lower GI obstruction Decreased suspicion of need for surgery Chronic, intermittent – possible IBD candidate
- 12. Physical exam General exam Overall condition Concurrent disease Cats – look under tongue Stable patient? Abdominal palpation is key Palpable mass = surgery Watch out for kidney in sight hounds Make sure not feces Severe splinting in calm or depressed animals highly suspicious for peritonitis
- 13. Radiographs alone = “Let’s go to surgery” 1– 2– 3– 4-
- 16. Radiographs alone = “Let’s go to surgery” 1 - Visible foreign material 2– 3– 4-
- 17. Radiographs alone = “Let’s go to surgery” 1 - Visible foreign material 2 – GDV 3– 4-
- 20. Radiographs alone = “Let’s go to surgery” 1 - Visible foreign material 2 - GDV 3 – Pneumoperitoneum 4-
- 21. Radiographs alone = “Let’s go to surgery” 1 - Visible foreign material 2 - GDV 3 – Pneumoperitoneum 4 - Massive generalized dilation Intussusception Mesenteric torsion
- 22. Radiographs alone = maybe “Let’s go to surgery” GI distention can be confusing Concurrent gastric and small intestinal distention without volvulus Generalized pure gas distention most consistent with paralytic ileus
- 24. GI distention can be confusing Differentiation of paralytic ileus from obstruction Normal intestinal diameter Dogs - height of mid-body of L2 Cats – 12-mm
- 25. Radiographs alone = maybe “Let’s go to surgery” Evidence of obstruction Segmental mixed gas dilation pattern Mid-abdominal intestinal mass effect Comma shaped gas patterns
- 32. Contrast radiography Who uses here? I basically do not use (ultrasound) Contrast studies sent here are typically difficult to interpret Can be very time consuming Don’t over-interpret gastric retention of contrast
- 33. Ultrasound Goals depend on case specifics If mass identified pre-U/S then evaluating for: Diffuse disease Tumor originating organ Free abdominal fluid If U/S for non-specific GI signs Evidence of obstruction Non-propulsive peristalsis Fluid filled bowel loops Visible linear foreign material Free abdominal fluid User dependent and potential for misinterpretation
- 34. Additional diagnostics CBC/Serum chemistry WBC count Normal vs mild to moderate leukocytosis vs leukemoid reaction Major organ function Thrombocytopenia Hypoalbuminemia SNAP PLI Serum lactate levels Tissue hypoxia Normal values <2.5 mmol/L
- 35. Additional diagnostics Abdominocentesis Paired serum and effusion samples of glucose and/or lactate Lactate > 2.5 mmol/L Blood to fluid glucose difference - >20 mg/dL Cytology on cytospin Bacteria and neutrophil status
- 38. Anesthesia Machine // Drugs // Fluids // Monitor Patient table Instrument table Patient prep solution Sterile patient and table draping Instrument pack with suture
Editor's Notes
- JAVMA April 2010Association between outcome and changes in plasma lactate concentration during presurgical treatment in dogs with gastric dilatation-volvulus: 64 cases (2002-2008).Zacher LA, Berg J, Shaw SP, Kudej RK.36 of 40 (90%) dogs with an initial lactate concentration <or= 9.0 mmol/L survived, compared with only 13 of 24 (54%) dogs with a high initial lactate (HIL) concentration (> 9.0 mmol/L). Within HIL dogs, there was no difference in mean +/- SD initial lactate concentration between survivors and nonsurvivors (10.6 +/- 2.3 mmol/L vs 11.2 +/- 2.3 mmol/L, respectively); however, there were significant differences in post-treatment lactate concentration, absolute change in lactate concentration, and percentage change in lactate concentration following resuscitative treatment. By use of optimal cutoff values within HIL dogs, survival rates for dogs with final lactate concentration > 6.4 mmol/L (23%), absolute change in lactate concentration <or= 4 mmol/L (10%), or percentage change in lactate concentration <or= 42.5% (15%) were significantly lower than survival rates for dogs with a final lactate concentration <or= 6.4 mmol/L (91%), absolute change in lactate concentration > 4 mmol/L (86%), or percentage change in lactate concentration > 42.5% (100%).
- Jed SlingerlandJed's radiographs and clinical signs are consistent with a gastrointestinal foreign body. At this point, his radiographs indicate that the object (suspected to be a rock) is down the GI tract from his stomach and is not obstructing his gastrointestinal tract. It is unclear if the rock is in the colon (will pass in Jed's feces in the next 12-24 hours) or is still in the small intestinal tract (may continue to pass or may become obstructive). It will be extremely important to continue monitoring Jed for the next 24-48 hours or until he passes the object as if the object obstructs his intestinal tract, it will be a surgical emergency.Please withhold food from Jed until tomorrow morning. Please encourage him to drink small amounts of water frequently. If Jed vomits once after drinking water, withhold water for 2-4 hours and offer it again. If he continues to vomit, please have him re-evaluated by a veterinarian. If Jed is improved to normal tomorrow morning, you can offer him breakfast (a small amount). If he has no vomiting associated with eating and continues to do well, he should be rechecked by his regular veterinarian tomorrow for repeat radiographs to ensure that the object is continuing to move through the GI tract. If Jed is not normal tomorrow, please withhold food in case he requires anesthesia and surgery tomorrow.
- Jed SlingerlandJed's radiographs and clinical signs are consistent with a gastrointestinal foreign body. At this point, his radiographs indicate that the object (suspected to be a rock) is down the GI tract from his stomach and is not obstructing his gastrointestinal tract. It is unclear if the rock is in the colon (will pass in Jed's feces in the next 12-24 hours) or is still in the small intestinal tract (may continue to pass or may become obstructive). It will be extremely important to continue monitoring Jed for the next 24-48 hours or until he passes the object as if the object obstructs his intestinal tract, it will be a surgical emergency.Please withhold food from Jed until tomorrow morning. Please encourage him to drink small amounts of water frequently. If Jed vomits once after drinking water, withhold water for 2-4 hours and offer it again. If he continues to vomit, please have him re-evaluated by a veterinarian. If Jed is improved to normal tomorrow morning, you can offer him breakfast (a small amount). If he has no vomiting associated with eating and continues to do well, he should be rechecked by his regular veterinarian tomorrow for repeat radiographs to ensure that the object is continuing to move through the GI tract. If Jed is not normal tomorrow, please withhold food in case he requires anesthesia and surgery tomorrow.
- Titan Mawae – Gastric rupture
- Titan Mawae- Gastric rupture
- Logan Lippl – 4 year old, male, castrate, golden retriever with less than 12 hour duration of abnormal behavior (mostly described as restless) Physical Temp – normal Heart rate – moderate tachycardia with strong femoral pulses, mm – pk and moist Bright, alert and responsiveAdministered oxymorphone and became restful with normalization of heart rate.
- Brownie Guerrero "Brownie" is a 1 y M/N chihuahua 24 hour period of vomiting, inappetance and lethargy. He began vomiting red tinged fluid yesterday then vomited clear fluid every 5 minutes for an hour. Patient continued to vomit intermittently over the course of the day and night, becoming increasingly lethargic. He has vomited a total of 10+ times in 24 hours. He has had no interest in food or water but did take some pedialyte which he then vomited. P is current on vaccines and flea/tick prevention but is not on heartworm prevention. Owner reports patient does chew objects but has not noted any missing toys. Brownie has not received any inappropriate foods that his owner is aware of. His owner feels that he is painful on the right side of his abdomen. He is an only dog and is mostly indoors. -Gastrotomy at antrum to remove gastric FB and cut/release linear FB traveling down intestines -3x5cm chewed plastic object with felt and string -closed with 4-0 PDS sc (2 layer appositional closure) -Enterotomy - mid-jejunum over obstructing FB -2x3cm firm, chewed plastic with string attached -closed with 4-0 PDS si, leak tested -Monitored affected intestines for additional 5 minutes with no improvement in color of mesenteric surface -Performed resection and anastamosis of distal duodenum to proximal jejunum (12" total) -ligated vessels with 4-0 PDS (ligaclips on resected portion) -anastomosis with 4-0 PDS si, leak tested
- Brownie Guerrero"Brownie" is a 1 y M/N chihuahuapresentsing for a 24 hour period of vomiting, inappetance and lethargy. He began vomiting red tinged fluid yesterday then vomited clear fluid every 5 minutes for an hour. Patient continued to vomit intermittently over the course of the day and night, becoming increasingly lethargic. He has vomited a total of 10+ times in 24 hours. He has had no interest in food or water but did take some pedialyte which he then vomited. P is current on vaccines and flea/tick prevention but is not on heartworm prevention. Owner reports patient does chew objects but has not noted any missing toys. Brownie has not received any inappropriate foods that his owner is aware of. His owner feels that he is painful on the right side of his abdomen. He is an only dog and is mostly indoors. -Gastrotomy at antrum to remove gastric FB and cut/release linear FB traveling down intestines -3x5cm chewed plastic object with felt and string -closed with 4-0 PDS sc (2 layer appositional closure) -Enterotomy - mid-jejunum over obstructing FB -2x3cm firm, chewed plastic with string attached -closed with 4-0 PDS si, leak tested -Monitored affected intestines for additional 5 minutes with no improvement in color of mesenteric surface -Performed resection and anastamosis of distal duodenum to proximal jejunum (12" total) -ligated vessels with 4-0 PDS (ligaclips on resected portion) -anastomosis with 4-0 PDS si, leak tested
- Charlie Pinkley2 year old MC ScottieHistory: (Dr. Hamm)o Patient started vomiting overnight, was taken to RDVM. Patient did not vomit at RDVM clinic but has had multiple episodes of vomiting since returning home. Emesis in exam room is brown liquid and has a coffee ground appearance.Charlie is a scavenger--eats sticks, used to eat rocks, eats mortar, etc. Owner is giving pumpkin to try to stop copraphagicbehaviour. No CSD--owner is concerned patient may constipated.o Current Rx/Tx: Cerenia and panacuro Owner gave Sucralfate and Metronidazole Physical exam: (performed by Dr. Hamm) o Temperature: 101.3 Fº; Pulse: 132 BPM; Respiration: 28 BPMo Weight: 10.3kg o Mentation: Depressed o EENT: PLR/Menace intact OU; eyes seem sunken back; Patient has two ulcers on tongue at rostral tip--possbily from canines o Mucous Membranes: Bright pink, tacky CRT=2sec o Heart/Lungs: Tachycardic--HR during exam was 160 and very bounding. Pulses were weak, but match o Lungs: NSF o Musculoskeletal: Ambulatory, in good flesh o Urogenital: No abnormal findings o Abdomen: Doughy, groans/grunts on palpation but does not splint up; no palpable masses o Integument: Skin turgor mildly decreased o Lymph Nodes: No abnormal findings Diagnostics: o Xray - VD/Lateral Abdominal Rads: Fundus appears increased in density and in dorsal aspect on vd view has material suspicious of foreign material present. Duodenum and jejunum appear displaced laterally and cranially within the abdomen and are moderately distended with gas and possible foreign material. Rest of small intestine has moderate gas distension, relatively uniform. Entire colon is full of stool. Microchip visible on both views. Advised owner concern is foreign body vs. ileus secondary to dehydration. o Abdominal Ultrasound - Assessment: GI obstruction with fluid filled bowels and stomach, severe GI stasis, mild free fluid in abdomen. Highly suspect GI obstruction with early perforation.o Findings: The gall bladder is moderately distended and appears normal. The liver appears normal. The spleen is unremarkable. The stomach if fluid filled and many of the bowel loops are fluid filled with severe GI stasis. There is very mild free fluid around spleen and bladder. The stomach and intestinal wall look normal except in mid right lateral abdomen bowel walls look less distinct and somewhat corrugated. There are no masses or enlarge lymph node seen. The bladder is moderately distended. o Bloodwork - consistent with dehydration, mild thrombocytopenia, mild increase in AlkPhosTreatments: Abdominal exploratory with gastrointestinal resection and anastomosisMedications dispensed: Tramadol & ClavamoxSummary/Comments: Based on the history, physical exam, and diagnostics (radiographs & ultrasound), Charlie was taken to surgery for an abdominal exploratory. A complete obstruction with evidence of necrosis was noted in the proximal jejunum due to a stuffed toy. No sign of leakage was noted. A resection and anastomosis of ~8" of jejunum was performed. An additional area of bruising was noted in the proximal duodenum, that improved during the surgery and was not resected. The remainder of the exploratory was within normal limits. Surgery was performed without complications and the anesthetic recovery was uneventful. The owners are planning to bring Charlie back to either your clinic or our surgical service for suture removal in approximately 2 weeks. The prognosis following surgery with resection and anastomosis is good - although leakage and dehiscence is a possibility. Surgery reportAbdominal exploration -diaphram - wnl -liver & GB - wnl, non-distended GB -Kidneys - wnl -spleen -wnl -bladder - wnl -Stomach - moderately distended with fluid - passed orogastric tube - green fluid -duodenum - 3" section of descending with moderate to severe bruising -suspect previous site of obstruction -bruising improved and was only mild paintbrush at closure -jejunum - proximal jejunum - 8" section of severely bruised to necrotic with 3" tubular FG -Resection & Anastomosis of this 8" section -closed with 3-0 PDS si, leak tested, omental patch -ileum/cecum/colon - wnl -flushed abdomen with sterile saline and suctioned dry
- Charlie PinkleyThank you for the referral of Charlie Pinkley to Nashville Veterinary Specialists (NVS) for evaluation of suspected gastrointestinal foreign body. Below please find a summary of Charlie's consultation.History: (Dr. Hamm)o Patient started vomiting overnight, was taken to RDVM. Patient did not vomit at RDVM clinic but has had multiple episodes of vomiting since returning home. Emesis in exam room is brown liquid and has a coffee ground appearance.o Had Cerenia and started on panacur because has hx of ingesting rabbit feces. Charlie is a scavenger--eats sticks, used to eat rocks, eats mortar, etc. Patient eats E/N and owner is gradually mixing in Solid Gold. Owner gave a dose of Metronidazole and Sucralfate tonight--he vomited Metronidazole but seemed to feel better after the Sucralfate. Owner is giving pumpkin to try to stop copraphagicbehaviour. No CSD--owner is concerned patient may constipated.o Patient cannot have "Pepcid" per owner.o Current Rx/Tx: Cerenia and panacuro Owner gave Sucralfate and Metronidazole Physical exam: (performed by Dr. Hamm) o Temperature: 101.3 Fº; Pulse: 132 BPM; Respiration: 28 BPMo Weight: 10.3kg o Mentation: Depressed o EENT: PLR/Menace intact OU; eyes seem sunken back; Patient has two ulcers on tongue at rostral tip--possbily from canines o Mucous Membranes: Bright pink, tacky CRT=2sec o Heart/Lungs: Tachycardic--HR during exam was 160 and very bounding. Pulses were weak, but match o Lungs: NSF o Musculoskeletal: Ambulatory, in good flesh o Urogenital: No abnormal findings o Abdomen: Doughy, groans/grunts on palpation but does not splint up; no palpable masses o Integument: Skin turgor mildly decreased o Lymph Nodes: No abnormal findings Diagnostics: o Xray - VD/Lateral Abdominal Rads: Fundus appears increased in density and in dorsal aspect on vd view has material suspicious of foreign material present. Duodenum and jejunum appear displaced laterally and cranially within the abdomen and are moderately distended with gas and possible foreign material. Rest of small intestine has moderate gas distension, relatively uniform. Entire colon is full of stool. Microchip visible on both views. Advised owner concern is foreign body vs. ileus secondary to dehydration. o Abdominal Ultrasound - Assessment: GI obstruction with fluid filled bowels and stomach, severe GI stasis, mild free fluid in abdomen. Highly suspect GI obstruction with early perforation.o Findings: The gall bladder is moderately distended and appears normal. The liver appears normal. The spleen is unremarkable. The stomach if fluid filled and many of the bowel loops are fluid filled with severe GI stasis. There is very mild free fluid around spleen and bladder. The stomach and intestinal wall look normal except in mid right lateral abdomen bowel walls look less distinct and somewhat corrugated. There are no masses or enlarge lymph node seen. The bladder is moderately distended. o Bloodwork - consistent with dehydration, mild thrombocytopenia, mild increase in AlkPhosTreatments: Abdominal exploratory with gastrointestinal resection and anastomosisMedications dispensed: Tramadol & ClavamoxSummary/Comments: Based on the history, physical exam, and diagnostics (radiographs & ultrasound), Charlie was taken to surgery for an abdominal exploratory. A complete obstruction with evidence of necrosis was noted in the proximal jejunum due to a stuffed toy. No sign of leakage was noted. A resection and anastomosis of ~8" of jejunum was performed. An additional area of bruising was noted in the proximal duodenum, that improved during the surgery and was not resected. The remainder of the exploratory was within normal limits. Surgery was performed without complications and the anesthetic recovery was uneventful. The owners are planning to bring Charlie back to either your clinic or our surgical service for suture removal in approximately 2 weeks. The prognosis following surgery with resection and anastomosis is good - although leakage and dehiscence is a possibility. Surgery ReportAbdominal exploration -diaphram - wnl -liver & GB - wnl, non-distended GB -Kidneys - wnl -spleen -wnl -bladder - wnl -Stomach - moderately distended with fluid - passed orogastric tube - green fluid -duodenum - 3" section of descending with moderate to severe bruising -suspect previous site of obstruction -bruising improved and was only mild paintbrush at closure -jejunum - proximal jejunum - 8" section of severely bruised to necrotic with 3" tubular FG -Resection & Anastomosis of this 8" section -closed with 3-0 PDS si, leak tested, omental patch -ileum/cecum/colon - wnl -flushed abdomen with sterile saline and suctioned dry
- Amber Flowers – linear cloth and plastic foreign body. 7 year old lab mix. Approximately 36 hour history of vomiting with recent increase in frequency (approximately 10 x in 12 hours). Epileptic on seizure meds for approximately 4 years. PolyphagicGastrotomy and three enterotomies
- Amber Flowers – linear cloth and plastic foreign body. 7 year old lab mix. Approximately 36 hour history of vomiting with recent increase in frequency (approximately 10 x in 12 hours). Epileptic on seizure meds for approximately 4 years. PolyphagicGastrotomy and three enterotomies
- Measurements of blood-lactate levels help in assessing critically ill patientJan 1, 2005By: Beatrix Nanai, DVM, Ronald Lyman, DVM, Dipl. ACVIMDVM NEWSMAGAZINE Under aerobic conditions, the intermediate product of glycogenolysis, pyruvic acid, follows an aerobic glycolysis pathway and eventually participates in the Citric-acid cycle or "Krebs cycle" that provides substrates (16 H+) for the oxidative phosphorylation. This oxidative phosphorylation provides a large amount of energy for the cells. Under anaerobic conditions, pyruvic acid follows a different route, the anaerobic glycolysis pathway, and the end-product of this complex cascade of reactions results in accumulation of lactate.In a recent veterinary publication (Mirinda N. et al. Prognostic Value of Blood Lactate, Blood Glucose, and Hematocrit in Canine Babesiosis, J Vet Intern Med 2004; 18:471-476) reference was made to human studies which found that measurement and follow up of serial blood lactate levels were the best prognostic indicator for survival of critically ill patients. The ability to resolve or reduce hyperlactatemia within the first 24 hours after presentation also had strong association with survival. The authors suggested that if blood lactate level cannot be sufficiently decreased after one hour of aggressive therapy, then alternative treatment should be considered. In humans, blood-lactate level elevation precedes the clinical deterioration of the patient, making the blood-lactate concentration an early prognostic indicator.
- Brief summary of pair serum and abdominal fluid lactate and glucose values interpretationA progressive increase in peritoneal fluid lactate concentration occurs in dogs with segmental bowel strangulation and likely results from anaerobic metabolism from both bacterial infection and tissue anoxia.16 A peritoneal fluid lactate concentration>2.5 mmol/L is 91% sensitive and 100% specific for diagnosis of septic peritonitis from peritoneal effusions obtained by abdominocentesis.9 A concentration difference of>20 mg/dL between blood and peritoneal fluid glucose concentrations is 100% sensitive and 100% specific for a diagnosis of septic peritonitis in dogs, and a concentration difference between blood and peritoneal fluid lactate of<−2.0 mmol/L is 63% sensitive and 100% specific.8,9Comparison of peritoneal fluid and peripheral blood pH, bicarbonate, glucose, and lactate concentration as a diagnostic tool for septic peritonitis in dogs and cats.Bonczynski JJ, Ludwig LL, Barton LJ, Loar A, Peterson ME.SourceDepartment of Surgery , The E. and M. Bobst Hospital, The Animal Medical Center, New York, NY 10021, USA.AbstractOBJECTIVE:To establish a reliable diagnostic tool for septic peritonitis in dogs and cats using pH, bicarbonate, lactate, and glucose concentrations in peritoneal fluid and venous blood.STUDY DESIGN:Prospective clinical study.ANIMALS:Eighteen dogs and 12 cats with peritoneal effusion.METHODS:pH, bicarbonate, electrolyte, lactate, and glucose concentrations were measured on 1- to 2-mL samples of venous blood and peritoneal fluid collected at admission. The concentration difference between blood and peritoneal fluid for pH, bicarbonate, glucose, and lactate concentrations were calculated by subtracting the peritoneal fluid concentration from the blood concentration. Peritoneal fluid was submitted for cytologic examination and bacterial culture. Peritonitis was classified as septic or nonseptic based on cytology and bacterial culture results.RESULTS:In dogs, with septic effusion, peritoneal fluid glucose concentration was always lower than the blood glucose concentration. A blood-to-fluid glucose (BFG) difference > 20 mg/dL was 100% sensitive and 100% specific for the diagnosis of septic peritoneal effusion in dogs. In 7 dogs in which it was evaluated, a blood-to-fluid lactate (BFL) difference < -2.0 mmol/L was also 100% sensitive and specific for a diagnosis of septic peritoneal effusion. In cats, the BFG difference was 86% sensitive and 100% specific for a diagnosis of septic peritonitis. In dogs and cats, the BFG difference was more accurate for a diagnosis of septic peritonitis than peritoneal fluid glucose concentration alone.CONCLUSIONS:A concentration difference > 20 mg/dL between blood and peritoneal fluid glucose concentration provides a rapid and reliable means to differentiate a septic peritoneal effusion from a nonseptic peritoneal effusion in dogs and cats.CLINICAL RELEVANCE:The difference between blood and peritoneal fluid glucose concentrations should be used as a more reliable diagnostic indicator of septic peritoneal effusion than peritoneal fluid glucose concentration alone.
- Patient table - HeatedInstrument table - Large Patient prep solution – ChlorhexidineSterile patient and table drape – Pre-made and disposable except for table cover and gownsAnesthesia machine – isofluraneAnesthesia monitor – ECG // Pulse oximetry // ETCO2 // Blood pressure (doppler, osillometric // direct) // Instrument pack (thumb forceps, needle driver, scalpel blade handle, towel clamps, carmalts, poole suction tip, 4x4 with radiographic markers, lap sponges, saline bowl, light handles, mayo scissors, metzenbaum scissors and suture scissors)