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Surgical Complications
 

Surgical Complications

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Overview of common complications encountered following various equine veterinary procedures

Overview of common complications encountered following various equine veterinary procedures

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    Surgical Complications Surgical Complications Presentation Transcript

    • COMPLICATION S When Things Go WrongDane Tatarniuk, DVM
    • DISCUSSION POINTS  Gastrointestinal  Orthopedic  Adhesions  Casts  Incisional Infections  Implant Infection  Incisional Dehiscence  Incisional Hernia  Rectal Tears  Ileus
    • “The one who does not operate does not have complications.”
    • ADHESIONS Prevalence of clinical adhesions:  Range – 6% to 26% after small intestinal surgery  More common in foals (up to 6 months) than weanlings and yearlings  Foals < 30 days are at greater risk than foals >30 days  Anastomosis & enterotomy sites  Prolonged post-operative ileus  Repeat laparotomy  Peritonitis  Abdominal Abscess Chronic intermittent colic or acute obstructive clinical signs Most complications from adhesions occur within the first 60 days
    • ADHESIONS Pathophysiology: Theory: Detrimental process caused by inflammation andischemia, causing a depression in fibrinolysis. Peritoneal injury creates inflammation & ischemia Inflammation:  Intestinal distension, abrasion of serosa, surgical manipulation of intestine, infection, bacterial contamination, foreign material (suture, glove powder). Ischemia:  Strangulating lesion, vascular compromise, intestinal distension, tight suture placement. Creates an imbalance between fibrin deposition and fibrinolysis
    • ADHESIONS  All comes back to the coagulation cascade…  Peritoneal injury stimulates intrinsic and extrinsic cascade  Principal modulator of adhesion formation is the fibrinolysis system, which works through the enzyme plasmin  Key regulators of fibrinolysis are tissue plasminogen activator and urokinase plasminogen activator
    • ADHESIONS Normally…  Lysis of fibrin and fibrinous adhesions occur in 48 – 72 hours after peritoneal injury  Mediated through plasmin-mediated fibrinolysis  Normal tissue restoration results However…  If excessive ischemia or inflammation occur, a depression in peritoneal fibrinolysis activity occurs  Causes fibrin accumulations to become infiltrated with fibroblasts and capillaries  End result: Permanent fibrous adhesions, formed 7 to 14 days after surgery. Adhesions can obstruct bowel lumen, incarcerate small intestine, distort or kink the mesentery or intestine.  End result is recurrent colic!
    • ADHESIONS Prevention  Gentle tissue healing  Remove damaged tissue  Meticulous hemostasis  Minimize surgical time  Frequent, copious lavage to keep bowel moist Medication  Broad spectrum antibiotics  Non-steroidal anti-inflammatories  Dimethyl sulfoxide
    • ADHESIONS Abdominal Lavage  At surgery, prior to closure  Post-operatively, passive or closed suction drains  Removes blood, fibrin & inflammatory mediators  Mechanical separation of bowel  Clinical research present that supports abdominal lavage  Serosa abrasions and peritoneal drains placed in 12 horses at surgery  6 received post-op abdominal lavage for 34 hours after surgery; 6 did not (controls)  Necropsied at 2 weeks post-op  Severe adhesions in all 6 controls, none present in the lavage group  No adverse reactions from lavage noted in treated group
    • ADHESIONS 1% Sodium Carboxymethocellulose  “Belly Jelly”  Provides a mechanical barrier between serosal and peritoneal surfaces  Helps reduce trauma by acting as a lubricant  0.4% Sodium Hyaluronate also used Bioresorbable Hyaluronate- Carboxymethylcellulose Membrane  Membranes that are applied to anastomosis sites post R&A  Act as a temporary protective barrier
    • ADHESIONS Carolina Rinse  Used in human medicine for organ transplants  Decreases reperfusion injury  Decreases migrations of neutrophils into serosa  Decreases fibroblast proliferation  Applied topically and intraluminal  Compounded, not commercial Systemic Heparin  Cofactor of Anti-thrombin III  Decreases production of thrombin  Thrombin responsible for converting fibrinogen to fibrin  Also stimulates plasminogen activator activity
    • ADHESIONS Omentectomy  Anastomotic Techniques  Controversial  Small intestinal R&A sites are  Studies showing that high risk for adhesion prophylactic omentectomy development reduces adhesion formation  Goals:  However, omentum may provide blood supply to 1) Maintain proper tissue alignment ischemic intestine 2) Promote optimal intestinal  Facilitates healing within healing the peritoneum 3) Complete mucosal coverage  Surgeon preference 4) Minimal suture exposure
    • ADHESIONS Second Laparotomy  Based on history and diagnostic findings  Primary goal is to reduce adhesions  Catch 22…  Removal of adhesions incites serosal inflammation –  Predisposes for further (recurrent) adhesion formation  If adhesion mass is too large or cannot be exteriorized to the incision –  Consider gastro-intestinal bypass surgery  Horses requiring a second look laparotomy due to adhesions have a 20% prognosis for survival
    • ADHESIONS Elective Laparoscopy  Generally performed 7 to 10 days post-operative  Time period when adhesions are fibrinous and easy to break down  Visualization of adhesions is variable  Dependent on area of scarring and position of adhesions  Position of horse, standing or recumbent  Acute colic:  Sensitivity of 82%, Specificity of 66%  Chronic colic:  Sensitivity of 63%, Specificity of 33%
    • “Every operation in surgery is an experiment in bacteriology.”
    • INCISIONAL INFECTION Increases risk of incision dehiscence, abdominal herniation, eventration Retrospective reports show prevalence of infection between 7.4% and 37% Incidence after 2 or more celiotomies performed within 6 months time may be as high as 87.5% Predisposing factors:  Repeat celiotomy  Increased duration of surgery  Use of near-far-far-near pattern  Chromic gut  Leukopenia  Edema  Post-operative pain  Weight (>300kg)  1+ year vs. < 12months
    • INCISIONAL INFECTION Early indications:  Fever of unknown origin  Excessive tenderness with palpation  Warm edema formation Systemic antibiotics usually delay drainage  See drainage around 3 days post-operatively  Can be delayed up to 14 days
    • INCISIONAL INFECTION Common sense preventative measures…  Decrease surgical time  Proper aseptic preparation of the abdomen  Meticulous draping during enterotomy  Minimize trauma to incision during draping Other measures…  Decreased incidence when antibiotics are applied topically to surgical wound at time of closure (Mair et al.)  Decreased incidence when temporary drape is applied over incision during recovery (Ducharme et al.)  Can fall off easily  Decreased incidence when an abdominal bandage was used post-operatively vs. no bandage (Smith et al.)
    • INCISIONAL INFECTION Minimal research on suture type/pattern and incidence of incisions Guidelines:  Perform closure with minimally reactive suture  Braided, non-absorbable suture may cause suture sinus formation  Avoid overtly large bites – creates excessive tension & predisposes to ischemia  Optimal tissue bite for adult horses is 15mm from linea alba edge Management:  Culture & sensitivity of incision is indicated  Establish drainage  May require removal of skin or subcutaneous sutures / staples  Local & systemic antibiotics indicated if horse is febrile, or excessive edema, cellulitis present
    • INCISIONAL INFECTION Management continued…  Flushing of incision is not encouraged – can propagate infection down incision line  Belly bandage important to sustain abdominal support (risk of dehiscence)
    • INCISIONAL DEHISCENCE Rare but potentially devastating complication Prevalence after ventral midline celiotomy less than 1% Factors:  Interrupted suture patterns in linea alba less likely to dehisce  However, continuous patterns have been showing to be stronger Increased surgical time Incisional trauma during surgery Recovery  Rolling or abdominal impact during recovery  Creates a sudden increase in abdominal pressure Post-operative debility Obesity, age (older), incisional infection
    • INCISIONAL DEHISCENCE  Dehiscence usual occurs 3 – 8 days post op.  Often preceded by incisional drainage  Brown serous-anguinous  Abdominal bandages do not prevent dehiscence  But can prevent eventration of bowel  If used, incision needs to be checked frequently  Failure of body wall can progress rapidly
    • INCISIONAL DEHISCENCE Management  Apply belly bandage, if not already in place  Anesthetize horse  Examine, decontaminate, and potentially repair the incision. Minimal contamination  Early detection and minimal bowel ischemia  Remove superficial contamination with lavage Marked contamination  Lavage at surgery & place indwelling abdominal catheter for standing lavage
    • INCISIONAL DEHISCENCE Closure of abdomen necessary Surgical debridement of incision  Remove necrotic, infected tissue Closure  Full thickness vertical mattress sutures  Stainless steel wire (22 gauge)  Stents 2-3cm apart from each other  5cm apart from wound edge Incision brought into apposition Skin left open for drainage
    • INCISIONAL HERNIA Most important risk factor for incisional herniation is incisional infection  Relative risk factor of 17.8 Ventral midline hernia incidence post-op between 1% & 10% Hernias are apparent within 3-4 months post-operatively Contributing factors:  Increase intra-abdominal pressure from pain  Entrapped fat between hernia edges  Poor suture placement, suture selection, soft tissue handling 93% of sutures fail at the knot Suture loops usually fail before fascial disruption occurs
    • INCISIONAL HERNIA  Clinically, hernias are usually noted cranially more than caudally  Linea alba is thickest near umbilicus & thins cranially  Many can be managed conservatively  Skin incision non-healed,  Consider sterile abdominal compression bandages  Abdominal bandaging for 1-2 months, while treating any underlying infection, helps reduce hernia size substantially
    • INCISIONAL HERNIA If hernia fails to heal, or enlarges after turn-out…surgery Hernia repair a cosmetic indication Large hernias can be repaired with synthetic mesh  Knit polypropylene mesh  Strong, elastic, inert, resists infection  Tissue grows through mesh and incorporates into herniorrhaphy  Need to make sure all infection is cleared prior to implanting mesh  May require removal of infected suture material from sinus tracts first
    • INCISIONAL HERNIA  Technique  180° degree skin incision at margin of hernia ring  Follow through with fascia and fibrous tissue  Fascia is removed using retroperitoneal dissection  Peritoneum is left intact  Can be difficult if adhesion between fascia and peritoneum intact  Or, if very thin fascia present  Inadvertent penetration of peritoneum complication  Some advocate mesh implant in subcutaneous space rather than retroperitoneal space
    • INCISIONAL HERNIA Technique continued…  Thin layer of mesh cut to size and incorporated  Closure with horizontal mattress sutures, #2 polypropylene suture  Sutures are pre-placed – make sure mesh lies flat and snug – then tighten/tie sutures  Reattach flap  Belly bandage to prevent edema/seroma formation very important
    • INCISIONAL HERNIA Novel technique  Laparoscopic mesh repair reported  Removal of retroperitoneal fat  Expose internal rectus shealth  Introduce prosthetic mesh and attach using trans-facial sutures  Examined several months later – no indication of adhesion formation to mesh
    • “Do not congratulate yourself for saving a patient from a trouble inflicted by you”
    • RECTAL TEARS  Occur from diagnostic palpation of the rectum  Usually veterinarian induced, sometime caretaker/owner  Malpractice  Copious lubrication & adequate restraint  Causes  Most occur from rupture of rectal wall as rectum contracts around arm  Not commonly from penetration with finger tips  Less common causes  Enemas  Meconium extraction in foals  Dystocia  Chronic impactions at strictures  Rectal thrombosis  Sand impactions  +/- Spontaneous tears
    • RECTAL TEARS Idiopathic tears  Tend to be transverse  One report of 5 horses revealed  4 presented with colic  1 occurred during lameness exam  Suspect literature Idiopathic tears are usually presented as colic of variable duration No reason to suspect rectal tear – referral often delayed
    • RECTAL TEARS Avoidance  Don‟t force against a peristaltic wave  Special care in Arabians, smaller horses, horses with previous tears, fractious horses Legal Recommendations  Assess severity immediately (determine grade)  Referral  Inform owner  Make no statements that imply admission of guilt or assume responsibility of payment
    • RECTAL TEARS Classification: Four Grades  Grades are important to dictate treatment plan Grade 1  Mucosa, Submucosa Grade 11  Muscular layer torn, only  Mucosa, Submucosa intact  M, SM prolapse into defect  Create area for fecal material to accumulate  More rare (3 of 85 in retrospective review)
    • RECTAL TEARS Grade III  IIIa – Involve all layers except serosa  IIIb – Involve all layers except mesorectum, retroperitoneal tissue  Grade 3b tears can pack with feces and create plane of dissection cranially and dorsally Grade IV  Involves all layers  Most serious – fecal contamination of peritoneal cavity
    • RECTAL TEARS Indicators:  Sudden release of pressure  Direct palpation of abdominal organs  Blood on rectal sleeve Within 2 hours after Grade IV tear, horse will show signs of peritonitis, endotoxic shock, low-grade colic, depression. Feces may be stained hemorrhagic Defecation accompanied by straining Most involve dorsal rectum, are 15 to 55cm from anus, and are parallel to the longitudinal axis.
    • RECTAL TEARS Stop straining  Sedation  Epidural  Prior to examination of tear  Eliminates straining and rectal contractions  Buscopan  Lidocaine enema Inspect tear using tube speculum or endoscope  Rectal folds can obscure visualization of tear Alternatively, palpate digitally with gloved hand
    • RECTAL TEARS Non-surgical management  Reduce activity of rectum  Gentle removal of feces from rectum  Treatment of septic shock, peritonitis  Administration of epidural  Packing of rectum Grade 1, 2 tears – antibiotics, laxatives, packing of rectum Rectal packing  Prevent conversion of grade 3 to 4  Protect tear from fecal contamination during healing period
    • RECTAL TEARS Material  3 inch stockinet filled with moistened rolled cotton  Soaked in povidone-iodine  Outside lubricated with surgical gel Apply packing 10cm proximal to tear Close anus with towel clamps or purse-string Grade 1: Generally heal in 7 – 10 days
    • RECTAL TEARS Grade 2 – Can over-sew diverticulum via laparotomy Grade 3, 4 – Require some form of surgical management Standing repair per anus  Expandable speculum  Difficult to maneuver, blind approach  Can be combined with diverting procedure if concern of integrity of repair  Best in fresh, clean tears close to anus  Can incise anal sphincter to improve access  Simple & inexpensive
    • RECTAL TEARS  Technique  Epidural, evacuate rectum, clean tear with moist 4x4s, gentle gravity lavage  Suture: 5 Dacron, 6 to 8cm, half cutting or trocar point needle, needle halfway on suture thread  Simple interrupted or cruciate  Continuous = stricture, dehiscence  May cause lumen reduction, edges turn into lumen  Suture ends kept long to facilitate removal  Rectal performed at 24, 48 hours  Suture that feels slack from loosening, decreased edema is removed & replaced  Sutures removed in 12 to 14 days  Learning curve
    • RECTAL TEARS Deschamps needle  Similar to indirect hand sutured technique  Needle attached to extended long arm with handle  Both left, right configurations  One hand works the instrument, the other hand is placed rectally and guides the tissue onto the needle
    • RECTAL TEARS Temporary Indwelling Rectal Liner  Horse anesthetized, dorsal recumbancy  Prolapse ring with rectal sleeve attached  Pass well-lubricated ring through anus  Surgeon guides ring proximal to tear  Circumferential suture (#3 catgut) placed around small colon, followed by equidistant retention sutures & Lembert apposition of serosa  Pelvic flexure enterotomy  Circumferential suture cuts through rectal wall in 9 – 12 days  Allows passage of ring/liner in feces  Four retention sutures keep ring in normal alignment, so that small colon does not twist or obstruct lumen  Failures caused by tearing of sleeve, retraction of sleeve, formation of recto- peritoneal fistula
    • RECTAL TEARS Diverting “Loop” Colostomy  Gravity prevents passage of feces into distal small colon  Can be performed standing – incision into flank  Made 1 meter from rectum, in small colon  Fold small colon and suture together using absorbable material, lembert  Sero-muscular layer of colon sutured to abdominal muscles, fascia  Stoma made along the anti-mesenteric side of colon (size of colon lumen)  Sutured to skin, simple interrupted, 2-0 nylon or prolene
    • RECTAL TEARS Colostomy Reversal  Lateral recumbancy  Resect the stoma  Perform colonic anastomosis  Incision infection very high  Often place penrose drains, left in place, for ~3 days Complications of Correcting a Complication  Dehiscence  Abscessation  Peri-stomal herniation  Prolapse  Spontaneous closure  Rupture of colostomy  Anastomotic impaction / dehiscence
    • RECTAL TEARS  Complications of Surgical  Overall Prognosis: Management:  Conservative 82%  Peritonitis  Surgical 55%  Rectal stricture  Pelvic Abscesses  Future techniques: Laparoscopic repair
    • “Nothing spoils good results as much as follow up.”
    • ILEUS Def: A disruption of the normal propulsive motility of the GI tract Risk factors:  Prolonged surgical/anesthetic time  Small intestinal lesions (particularly strangulating)  Elevated PCV Indicators  Post operative colic  Elevated heart rate  Anorexia  Depression Prevalence: Occurs in 10 to 20% of colic surgeries
    • ILEUS Recognition: Pass nasogastric tube and reflux horse After nasogastric intubation, ultrasound/rectal can be performed  Indicator of severity Ultrasound: Small intestinal distension with/without sedimentation  Minimal to absent motility
    • ILEUS  Gastric decompression, every 2-4 hours, is important part of management  Also helps provide a benchmark to evaluate response to therapy  Nasogastric tube may be left indwelling or re- placed each time  Left indwelling can delay gastric outflow, perpetuating/prolonging problem  Re-placement each time may cause more irritation and distress to horse  Pharyngeal trauma  Esophageal rupture
    • ILEUS Fluid therapy: Adjust IV fluid rate to compensate for gastric reflux loss  Maintenance fluid rate (2 mL/kg/h) + Quantity of gastric reflux (L/h) = total hourly crystalloid fluid requirement Anticipate hypocalcaemia & hypokalemia  Calcium – smooth muscle in gastro-intestinal tract / vessels require extracellular Ca for motility Consider parenteral nutrition in horses with long-standing ileus
    • ILEUS Pro-kinetic therapy  Used in refractory cases  Lidocaine most commonly used  Others:  Erythromycin  Metoclopramid e  Neostigmine
    • ILEUS Lidocaine  Affects contractility in the proximal duodenum only  Well tolerated  In-vivo, has been shown to decrease jejunal distension and peritoneal fluid accumulation  Improved time for fecal passage and shorter hospitalization stays  In normal horses, have not been able to demonstrate pro-motility effects  Current theory is that lidocaine acts as a pain modulator, thereby allowing motility  Toxicity: Tremors, muscle fasciculations, somnolence, collapse  Stop therapy until signs resolve  Effective for about 36 hours post-initiation
    • ILEUS Erythromycin  Stimulates motilin receptors  Affects contractility in the pyloric antrum and middle jejunum  Where motilin receptors are most concentrated  Macrolide antibiotic  Very effective in improving gastric emptying time  Complication : can create colitis / diarrhea
    • ILEUS Metoclopramide  Affects contractility in pyloric antrum, proximal duodenum, and middle jejunum  Administered intermittently or continuously  Dopamine antagonist - Increases myo-mechanical activity  Toxicity – when metoclopramide crosses the BBB into CNS  Excitement  Restlessness
    • ILEUS Failure to respond to therapy results from secondary damage due to distension  Distension causes injury to the muscle structure and myenteric neurological control as a result of ischemia On histology  Hemorrhage, edema, neutrophillic infiltrate Have not been able to demonstrate improved survival rates with pro-kinetic use… Comes down to patience and crossed fingers
    • “The less it’s indicated; the more complications.”
    • CAST COMPLICATIONS Hard to avoid, if you place enough casts Change the cast if:  Diminishing comfort  Focal heat  Odor  Discharge Develop from overly tight application  Dermal pressure necrosis Overly loose application  Swelling decreases  Muscle atrophy  Compression of cast padding
    • CAST COMPLICATIONS Too short a half limb cast  Severe tendon injury – limb is partially flexed  Linear pressure on unprotected tendons Proximal dorsal cannon bone sore  Can apply a heel wedge to offset pressure applied by cast  Still recommended to change cast within 7 – 14 days Absolutely need to keep cast on…  Consider trans-fixation pins  Will limit motion within cast – possible decrease rub sores  Complications include:  Thermal injury & ring sequestra  Pin breakage
    • CAST COMPLICATIONS Broken cast  Ideally should be replaced  However, can „patch‟ cast if the hinge at the break is minor  Most casts break over point of a joint  Apply 90% of cast material in longitudinal direction over compression side  ie. dorsal fetlock  Applying more cast material circumferentially usually re-fails
    • CAST COMPLICATIONS Cast Removal  Oscillating saw – inadvertent damage to flexor tendons on palmer aspect  Cutting over infection or implant  Seed infection - contamination of deep tissues Foals  Post-coaptation laxity of tendons  Pro vs. Con  Decide whether stabilization more important than potential laxity  Helps to gradually decrease coaptation with progressively lighter bandages, application of splints  Heel extension glue on shoes
    • “The source of most complications is in the operating room.”
    • IMPLANT INFECTIONS The most significant complication in orthopedic surgery Contributes to the cost, cosmetic and functional outcome of a case  Increases cost 5 to 10 fold  Infection can lead to instability of internal fixation  Possible outcomes include mechanical failure or delayed/non-union healing The first step in treating implant infections is recognizing that sepsis is present The earlier the realization = the better the intervention
    • IMPLANT INFECTIONS Indications:  Fever, otherwise non-explainable  Decrease in comfort  Failure of swelling to decrease post-operatively  Return or development of swelling post-operatively  Drainage  Failure of incision to heal  Blood-work  Plasma fibrinogen best indicator  Leukocytosis not conclusive; can be normal with infection present
    • IMPLANT INFECTIONS  Radiographs  Best indicator of mid to late stage infection  Osteolysis  Specifically radiolucency at implant – cortex interface  Increased soft tissue swelling or dissection of soft tissue planes  Periosteal proliferation  Not associated with fracture healing  Lysis extending into medullary cavity = end stage  Ultrasound  Exudate adjacent to implants
    • IMPLANT INFECTIONS Goal of therapy  Local delivery of high doses of antibiotics to infected tissue / implants  Allows high concentration of antibiotic exposure to pathogens  Avoidance of systemic side-effects  More cost effective using regional techniques  Systemic antibiotics alone just doesn‟t cut it
    • IMPLANT INFECTIONS  Follow basic principles of treating infection…  Drainage:  Ultrasound area to visualize exudate  Excise tissue intact skin or ventral aspect of incision in a gravitational dependent area  Culture:  Sensitivity will help provide consistent results  Prepare superficial tissues; culture depths of draining tract  Alternatively, ultrasound guided needle aspirate of exudate
    • IMPLANT INFECTIONS Polymethylmethacrylate Beads  Delivers high concentrations of antibiotics  Biocompatible with tissue  Diffusion of antibiotics from cement well studied  Readily available in a sterile, easy to use form  Disadvantage – non absorbable  Disadvantage – can‟t incorporate with heat labile antibiotics  Ratio: 1 - 2 grams antibiotic per 10 grams PMMA  Gentamicin, amikacin, tobramycin, enrofloxacin, cephalos porins
    • IMPLANT INFECTIONS Plaster of Paris Beads  Similar principle as PMMA  Main difference is that POP is slowly degraded & absorbed by the body  Set up time is slow, therefore best to make POP beads and then sterilize them  Can be mixed with a cancellous bone graft
    • IMPLANT INFECTIONS Regional Limb Perfusion  Peripheral vessel & isolated limb via tourniquet  Concerns:  State of tissues close to implant (disrupted vasculature?)  May induce vascular damage  Enrofloxacin has been shown to induce vasculitis Placement  Tourniquet above and below region the best  Minimum is exposed vessel distal to proximal tourniquet
    • IMPLANT INFECTIONS Sedation  Preventing movement is ideal for adequate tissue penetration of antibiotic  Concurrent analgesia can be considered  Carbocaine (vs. saline) as volume dilute  Local nerve block Catheter  Smaller the better  Repeated injections require care to preserve vessel integrity  25 to 27 gauge butterfly catheter Volume  1/3rd of antibiotic systemic dose  Diluted to 30 to 60ml
    • IMPLANT INFECTIONS Technique  Slow injection – needle bore small  Leave tourniquet in place for 30 to 45 minutes  Cover injection site with compression bandage  Consider treating injection site with DMSO, Surpass Other indications for regional limb perfusion  Wound therapy  Joint therapy  Pre-operative antimicrobial dosing
    • Complications are a price all veterinarians eventually pay.Experience and increasing skill will decrease many of them butcertainly not all.The most important thing is for the veterinarian to react correctlyto a complication. Acknowledge the mistake (or bad luck)quickly, and take whatever steps you can to correct the problem.Because so many equine cases have the potential forcomplications, recognizing and responding properly to thesecomplications are imperative for successful outcomes. - D.W. Richardson (in: Vet Clinics North America 2008) QUESTIONS?