gastric dilatation volvulus (GDV)

The procedure and nursing considerations

GDV patients are critical and fast reactions on arrival can greatly impact on the outcomes of the case. First treatment should be to decompress the stomach, usually by passing an orogastric tube. I would recommend using a roll of conforming bandage such as VetWrap to place inside the mouth to keep the patient from biting down on it, but any gag can be used. Measure your orogastric tube from the mouth to the last rib, lubricate the tube, then pass it through the mouth and into the stomach. Gentle pressure can be needed to pass the tube through the torsion but be mindful that it shouldn't be forced.

If this is unsuccessful, then trocharisation of the stomach can be performed instead, using a large bore cannula. Make sure to clip and clean the area before this is placed.

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If there are enough members of staff around, whilst the decompression is happening, get a colleague to place large bore (18G is ideal) cannula in both front legs and begin fluid therapy. Often these patients present in shock, so fluid resuscitation is often warranted. There is some mixed opinion about the best fluid approach to take in these cases so you should discuss this with your vet, but my normal approach is to bolus 20ml/kg of lactated Ringers solution over 10-15 minutes and repeat this up until a total of 80-90ml/kg of fluids has been given (i.e. repeat this bolus 4-5 times). This allows for rechecks to be done after each interval rather than overcorrecting and overloading.

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Analgesia should also be at the forefront of your mind at this stage too as it can help reduce stress and oxygen consumption, improving the patient's overall status. I would recommend giving any analgesia IV rather than IM or SQ, since peripheral circulation is often compromised in shocky patients and any meds given this route may not be as effective. 

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Once the patient has been decompressed and IV fluids and analgesia are on board, the patient will hopefully be in a more stable condition to prepare for surgery. Ensure that they are warmed and preoxygenated prior to induction of anaesthesia - GDV patients are often cold due to poor peripheral circulation and shock so active warming is best started early too.

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As these patients are usually critical, it could be worth discussing placing a central line at this stage as well if you have the equipment and capabilities. This is especially useful as the patient will likely be having frequent blood samples and fluids over the next few days, and sometimes the high bolus rates used to stabilise can cause phlebitis in the cannula placed in the forelegs.

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Have the patient on their back for clipping - sometimes they need sandbags to keep them steady. The surgery will need clear visualisation of the stomach and other abdominal organs, so usually a large incision is required. Clip fur up to the 10th/11th rib and down to the very base of the pubis. The edges will need to be clipped far back too, to reduce risk of any fur entering the abdomen. Clip fur using size 40 blade clippers and clean the surgical site with your scrub of choice. Sometimes it is useful to have a dedicated vacuum to remove fur from the surgical site prior to scrubbing. 

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At this stage it is recommended to place a urinary catheter and drain the bladder so that it isn't full whilst the surgeon is in the abdomen. For male dogs this procedure is straightforward enough, but this can prove more difficult in bitches. I will leave the urinary catheter in place throughout surgery and, for male dogs, secure it to the left thigh to keep it out of the way. (Often the incision will run along the right-hand side of the penis).

If time allows and the patient is stable, I recommend performing a local line block along the incision area at this stage using a 1-2mg/kg dose of bupivicaine. Any bupivicaine left in the syringe can be kept for a splash block at the point of closing the surgical site.

Move the patient to the surgical table and postion on their back. If you have use of a vacuum mat, then these can be great to keep patients warm, supported, and stable throughout the surgery. Patients can lose a lot of heat during these procedures due to the large clipped patch and the opened abdomen, so I would always recommend using active warming devices such as Bair Huggers to keep them warm, especially if they were cold on presentation. If the patient is already using a forced-air warming device, pause it oncein theatre and wait until the patient is fully draped before turning it back on. Then give another scrub and prep the area using a final cleaning stage e.g. ChloraPrep. I also like to place several incontinence sheets around the patient and the floor to help keep the theatre as clean and dry as possible - especially when it comes to lavaging the abdomen.

The surgeon can then perform the procedure. Visualisation is really helpful in these surgeries, so I often will have a large abdominal wall retractor, such as Balfour retractors, to hand.

All abdominal surgeries have a risk of bleeding due to numerous vessels being present. Ensure that your patient is on IV fluids throughout the surgery (surgical maintenance rate is 5ml/kg/hr in canines) to help with blood pressure and have bolus rates prepared and written down in case of a bleed.

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Ideally the patient will have recieved sufficient analgesia with their premedication as well as an adjuvant analgesia prior to surgery. However, abdominal surgery can prove more painful for some patients than others. Watch out for changes in heart rate, respiration rate, or blood pressure at this point. Paracetamol can be given if it hasn't been given already (at a dose of 10-20mg/kg slow IV) or, if very severe pain response is seen, ketamine CRIs or fentanyl CRIs can be started. For ketamine, give a loading dose of 0.5mg/kg IM or slow IV, followed by CRI of 10-30ug/kg/min. For fentanyl, give a loading dose of 5μg/kg slow IV, followed by CRI of 2.5ug-10ug/kg/hr. Be mindful for signs of apnoea if giving ketamine or fentanyl. Fentanyl can also cause bradycardia in some patients.

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It is common for GDV patients to develop cardiac arrythmias such as ventricular premature complexes (VPCs) post-operatively but also during surgery - especially when the spleen is handled. The normal recommendation is to begin a lidocaine CRI during surgery as this can help reduce the arrythmias as well as provide a small amount of analgesia as well as reduce arrythmia complications post-op. For lidocaine, give a loading dose of 1-2mg/kg slow IV (10-15 mins) followed by CRI of 20-100ug/kg/min.

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If the surgeon has needed to enter the gastrointestinal tract, then fresh gloves and instruments are required once this area has been closed to maintain abdominal sterility.

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It is recommended to fully lavage the abdomen after any gastrointestinal surgery is performed as this can reduce bacterial load and help warm the patient. If any parts of the gastrointestinal tract have been opened, then it is recommended to flush through with up to 200ml/kg of sterile saline. Ensure any flush is warmed before using it (I like to have a bucket of warm water that the irrigating fluids can sit in to stay warm during surgery). 

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Before finishing surgery it is worth discussing placing a feeding tube with your vet. There is some variation in recommendations of how soon after surgery to begin feeding for GDV patients, but having a feeding tube in place will make getting adequate nutrition post-op much easier. 

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Remember to lubricate the eyes during surgery and on recovery to reduce risks of corneal ulcers forming and keep the patient wrapped up warm. 

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In recovery, continue the lidoaine CRI as well as slowly wean off any other analgesic CRIs that the patient was on, and monitor the patient's pain scores and ECG for any changes. Continue to nurse the patient as a critical one checking for any abdominal distension, bleeds, blood measurements, and breathing rate and effort.