So welcome to today's webinar on nursing the GDV patient. My name is Sam and I'm a veterinary nurse at North Surrey, Veterinary Emergencies where I work on the emergency team. I have a further certificate in emergency and critical care, and I have a particular interest in ECC and emergency surgery.

So the reason I have chosen to cover the GDB patient today is simply because it seems to be the emergency that most people tend to panic the most about. I completely understand why it is very much a true emergency, and one that needs to be treated urgently. However, as nurses, I believe that we are fantastic at being prepared, which is why I believe, It is one of the most important things to be successfully managed GDB case, whether you've seen 50 or 1.

So looking at the learning outcomes for today, we're gonna be looking at recognising the signs, first aid for the GDV patient, preparation for surgery, and how to make things run a bit more smoothly, anaesthetic monitoring with a particular interest, and looking at ECG traces that we might commonly see during the GDV case. Post-operative care and nutrition and the importance of it in the GDB case, and then a successful discharge of the patient and then getting to go home. So a GDV just to go over the basics again and exactly what is happening to the body during that time.

So a GDV is a syndrome of gastric dilation that can lead to the body of the stomach wall twisting. This goes on to cause hypovolemic shock, pain, and eventually death if not treated quickly and effectively. So looking again what's happening to the body during the time, first of all, what we're seeing is that over distended stomach.

The pylorus then rotates from the right of the abdomen. The pylorus ends up dorsal to the gastric cardia on the left side of the abdomen, which then results in a gastric outflow obstruction. Then there's progressive distension of the stomach with air, which then leads on to you see cardiovascular effects, respiratory effects, and GI effects.

So we're really affecting every kind of system in the body with this situation and why it's why on those things it's so important just to get on top of it as quickly as possible. Although GDVs can occur at any time of the day, I just happen to they always tend to happen just as all the day staff have left the building, or when we're just happening to run on minimum team members, it just happens to be the way every time. But as one of the main causes of death in giant and large breed dogs, it is important that all nurses know how to effectively look after these cases.

So moving on to recognising the signs. The first contact I usually find that we have with a GDB patient is via a phone call. The owner will call up and with sometimes vague concerns about their dog.

One thing I will say is do not assume that all owners know what a GDD or bloat as they sometimes call it is. I often find there's a lot of owners that actually don't know what it is, so please don't assume that your owner knows what they're talking about or they're even aware of what a GDB is. I tend to find the first thing they know is that their dog is attempting to constantly wretch or vomit, as well as they're just being quite restless, not not quite right.

So there's a couple of things that I ask on the phone just to kind of edge the triage through on the phone, just to try and work out exactly what's happening. So one of the first things I always ask is how long has it been going on for? If it's a couple of hours, it's extremely unlikely to be a GDB, but if it's coming on quite suddenly, it should be in your line of thought.

So GDBs are very acute, they happen very quickly. So it's one of the things to look out for. Is the dog producing any vomit is another question you can ask.

A dog with a torsion will not be unable to actively produce vomit and they're unproductively wretched. So that's one of the things to be looking out for as well. I'll then go on after these two questions to ask what breed of the dog, what the breed of dog is.

So the most commonly affected breeds are our deep-chested large breed dogs. So we're looking at our Great Danes, ridgebacks, Dobermans, black coats, although this shouldn't rule things out. There have been reports of smaller dogs, dogs as small as shih-tzus having GDBs, so don't completely rule it out if they are a smaller breed dog, but just be aware that definitely if you're thinking Doberman large breed dog, this should definitely be in our line of thought straight away.

Has the dog recently eaten? Has the dog recently been on a walk? We don't know for definite at the moment what causes the GDV.

It's all kind of speculation, and one of the main things we do always look at is that the dog's just eaten a large meal and then gone out and exercised and things like that. So they're just further questions you can ask. I then go on to ask how does the abdomen look?

Many owners I find do not tend to instantly notice something like this, and with all triage cases over the phone, I try to always use open-ended questions rather than closed questions. I find in this case you get a much more accurate answer. So instead of saying to an owner, does the abdomen look bloated, try asking them how does the stomach look.

I find from then you actually, if you say to them, how does, is the abdomen bloated? I'll find they'll just turn around and say yes, regardless. If you ask them how does the abdomen look, you'll get a much more accurate answer.

They'll actually look at the dog and they'll give you an honest opinion. So yeah, just try using more open-ended questions with them. And then from there, any dogs, I will say displaying symptoms should attend the surgery as soon as possible.

Try not to scare your clients, but advise them that it could be a life threatening situation. We don't want them to sit on it and wait. We want them to get into the surgery as soon as possible.

I always say to them as well, the only way to confirm ca is through diagnostic imaging, so X-ray. Just because it's not bloated and it doesn't look bloated, it doesn't mean there's not a torsion in there, yeah. So kind of moving on to further recognising the signs and symptoms on presentation.

On arrival to the clinic, we may see one or many of the following symptoms, excessive salivation, lip licking, lip smacking, all those kind of signs. This is usually a combination of unproductive wretching mixed with the stress and restlessness. I will point out, and I point out quite a lot through this presentation as well, that torsions are extremely painful, which is also in turn a further cause for rest restlessness.

By the point that they turn up to you, you might find, and expect to see a distended abdomen. The reason we're seeing this descended abdomen just to go over again, is it's due to the stomach being dilated due to the food or air pressure. A GDV is when the dilated summit then twists on itself, which in return results in a restricted blood supply.

In the case of a GDB, when the stomach is percussed, it will sound like a drum. I wouldn't suggest, as I said, these animals are really painful, going up and tapping their abdomen, but that's just a bit of an extra bit for you as well. Hopefully, the patient will arrive by this stage, but another thing we might see, which is a secondary to a GDV is hyperbiemic shock.

This is a result of inadequate amount of circulating blood volume. And just to follow on from that, the stomach will begin creating pressure on the posterior vena cava and portal veins, which then slows down the rate of blood return from the heart to the heart from the abdomen. So just to kind of go over back again.

Are signs of hypovolemic shock, what we're looking for. We're looking for pale and cyanose mucous membranes, tachycardia and tachyania, and the reason we're seeing the tachyanea is because the distended abdomen puts an increased pressure on the diaphragm, and it prevents it being allowed to extend properly, and that's why they're breathing quite quickly because they can't take their full deep breaths. This is something definitely we need to be bearing in mind when we get to the anaesthetic stage, but I will cover that later.

And then hypothermia, so that's a very much a sign of hypovolemic shock. This is because the peripheral circulation constricts, so the body can protect its vital organs. As with all cases of shock, we want to warn these guys slowly and not rapidly, because we want to support that mechanism.

The last thing we want to be doing is rapidly warming them up and then crashing the entire system as it's trying to protect itself. So yeah, there's some of the symptoms we might see on presentation. So first aid of the GDV patient after that, the vet's assessed it, and this confirms that he thinks it's a GDV and this is where we're gonna go from there.

As with any emergency, we want to ensure we first of all have a painting airway. If possible and if safe, I always say it's safe, remove any phlegm buildup which may include the airways. If they've got a lot of phlegm build up because they've been unproductive wretching and they're restless, try and clear the airway, but obviously these animals are quite stressed as well, so don't put your hand in in their mouth and get bitten.

Just try and safely remove anything from their airways if you can. If the patient will tolerate it, free flip oxygen by a face mask will always be beneficial as well, but assess the patient and see how, how they are and if they're gonna be coping with that or it's gonna make them more stressed. Again, I will say GDBs are extremely painful.

Make sure your vets are getting adequate analgesia on board as soon as possible, and before they're moved around for X-rays, especially. Obviously it's the vet's discretion, but just kind of always try and mention to them, do we want to get some pain relief on board for this animal sooner rather than later. I'll just quickly switch over now to radiographs and then go back to the others.

So generally it depends again discretion of the vet, but generally I find the radiographs are performed consciously with just analgesia on board. And what we want to be taking is a right lateral x-ray of the abdomen, and this is usually sufficient to confirm the presence of the torsion. You will first, obviously take the X-ray and the first thing generally you'll notice a stomach full of gas.

But to confirm a torsion, what we're looking for is the characteristic reverse C shape, which you can see outlined on the yellow on the the X-ray I've put on there. It can also look like a like a boxing glove. Some people also say a Smurf's hat, so they're just little things you can remember in your head, just so you know what you're looking for.

So reverse C-sha Smurf's hat, and that's the the what we're looking for for the confirmation of a GDB in place. Again, we're not vets, we can't diagnose, but we can be looking at these X-rays and putting our opinions across as well. So moving back onto the other first aid after we've taken our X-rays, we want to be looking into fluid therapy for these animals.

We always say, and it's always advised to place two intravenous catheters via the cephalic or the jugular. We say to avoid the sous, and it's never really advised as it's ineffective due to the caudal vena cava obstruction. So yeah, try to be using cephalics, jugular, so cephalic ideally just get two IVs in place and get that fluid coming through.

We want to be looking at an isotonic crystalloid such as Hartmann's, and we want to be administering at shock rate, so 90 mL per kg per hour. Once fluid resuscitation is underway, the vet can then start with decompression. For this, we want to be preparing an orogastric stomach tube.

Lengthwise, we want to be looking at the tip of the nose to the last rib, and yeah, whichever tube is gonna be width wise the best fit to get down the oesophagus of the animal. I usually find a vet wrap getting prepared is quite helpful as well. You can just place it in the mouth and it just holds the mouth open, while the tube, while the tube's in place and it gives you a bit of an extra hand as well, so that's always a handy tip to have, .

Depending on how successful or unsuccessful placing a stomach tube is, some vets may opt to attempt decompression via tokerization, and many will simply opt to just use a wide bore needle for this or a large gauge IV catheter and just placing it into the stomach to start to release some of the gas and take some of that pressure off. Successful decompression is the aim in order to help stabilise for surgery. However, we do also need to monitor these guys very closely during this time, as rapid decompression can lead to the blood flooding back to the heart, and this in turn can cause myocardial decompression and arrhythmias.

So keep an eye. These guys, we want to decompress them, we want to stabilise them as quickly as possible, but at the same time, we need to be keeping a close eye on them at the same time. Try and stay with your vet during this time.

I know it's kind of, we want to get off and set theatre up and get everything else ready, but try and stay with the vet during this time so we've got an extra pair of eyes on these animals. Then from there I've put lab work with a question mark, gold standard, we would be doing bloods on these animals pre-surgery, and that would include a full blood profile, including blood glasses and lactate. But work with what your practise has, work with what the owner can afford and what the vet's discretion is with this.

As a minimum, we should be aiming to be taking, PCV total protein, and electrolytes. With electrolytes, we're putting a particular focus on looking for hypokalemia, and then ideally we should be taking lactate as well. Just as a side note, I know it's not, not, it's not standard in practise to have a lactate machine.

But they're a really great piece of kit that we can have in practise, especially if you're in a 24 hour night practise and you're seeing a lot of emergencies. They're quite affordable, they're just a little handheld machine that looks like a glucometer. So yeah, there's just a really, good bit of kit that you can have in-house, .

For those that might not be aware, I won't go into too much detail because lactate can be quite complex. However, to put it simply, it's an extremely sensitive indicator of hypo perfusion and acidosis. Lactate levels will normally increase before changes are even noted in the heart rate or the blood pressure.

And just for a kind of guideline, our normal lactate levels for the dog are anything under 2.5 millimoles per litre. And we know from that.

And I just put a bit of a quote at the bottom, just I think it's something to keep an eye on as well, and one for our vets more than us really is blood lactate levels greater than 9 milli per litre is indicative of severity of ischemic disease due to the GUV and carries a significantly worse prognosis. So that's just something to be aware of. It doesn't mean don't go for the surgery, but yeah, it's something to be aware of as well, and it just shows that lactate is just a really good indicator and a simple piece of kit that we can have.

So, moving on to surgical preparation, I've put a quote there, use your nurse superpower, the power of preparation. We're great as nurses as being prepared, and I think in cases, all emergency cases, and especially the GEV, this is where this really comes into play and we can really help with these cases. .

So to ensure everything runs smoothly, try to gather and have everything in your theatre ready before the animal gets in there. As much as possible. I've also outlined the most important pieces that you'll need to have ready, so crash kit, have it in theatre, having it there ready is better than having to run off and look for it if the worst does happen.

Stomach tube, or ideally this might already be in place already, so, but if not, make sure you move it from X-ray into theatre with you. A suction unit sometimes is needed. IV fluids, these guys are on a higher fluid rate.

We want to have some extra bags ready for them, just so we're not running in and out again. And again, some vets like to do an abdominal lavage at the end of surgery, so having those extra bags there and warmed is gonna help as well. Multi-parameter machine with ECG leads, work with what you've got available though.

I mean, not everyone I'm aware has a multi-parameter machine, but try at least have a pulse ox available, have an ECG, use what you have and have it there. Surgical kit with additional sterile swabs, self-retaining abdominal retractors, which I'll go on to in a second, stethoscope and not a ophageal stethoscope, which again I'll follow on to in a second, temperature control items and an elevated trough. So just kind of ideally for a GDV case, you'll need to have an anaesthetist nurse, a kit and run a nurse, and potentially a scrub nurse.

We all know it never works like this, so work with what you have, . As many people in the practises as possible, as safely as possible, get them involved in these cases. If it turns out it's just you and the vet, and that's all you have in practise at that time, work with what you have, have be prepared, have everything ready so you're not running in and out of that theatre, and as much as possible your full concentration is on the anaesthetic of that animal.

So going on to stethoscope wise, the advice is not to use an ostephageal stethoscope. And this is simply because you're potentially putting further trauma on an oesophagus which is already under a lot of stress. So try to avoid them in these cases, use your normal stethoscope.

Also, most likely if you're using a a stomach tube, it might already be in place, or you might need to put it in place during the surgery, and then if you're just putting, a an esophagescope in, it's just, yeah, it's just a bit too much, so try and just use a normal stethoscope. And then I've put an elevated trough. Although you might have a good degree of decompression prior to surgery of that stomach, I still find that these guys really struggle to take good breaths when they're in dorsal.

So due to the pressure on, and that's due to the pressure on their abdo and their diaphragms. So therefore I find if you slightly elevate the trough on the cranial end, just like with an X-ray sandbag, just put it, place it underneath the trough, that slight elevation will just then help to alleviate some of that pressure on the diaphragm and help them just breathe slightly nicer, . If you are going to be doing that, ensure you have a snug ET tube in place and then also the stomach tube, and that will just help prevent any risk of aspiration pneumonia.

Again, if you've got a cat in the graph, try and keep that running and you'll be able to kind of keep an eye on that waveform and help to see what their breaths are doing and what you can do to potentially help them just breathe a bit nicer under anaesthetic. So yeah, just kind of going over the alleviate alleviating the chest to help with the increased pressure on the diaphragm, . So surgical clip wise, we wanna go for a clip wider than we normally think would be necessary.

So I always kind of go for the mid thorax to pelvis. That way we've got that field ready for them. Obviously we don't want to be clipping them so much that they're getting even colder, but if we've got prepared that big area, we don't need to worry for everyone in the surgery.

And then try to, I try to get your multi-parameter machines on straight after inductions. GDV dogs are prone to sudden deterioration or complication. I always find that the first thing that our vet kind of wants to go off and scrub straight away as soon as that dog's on the table, if it's just you two, try and get them just the whole back and just say, I'd really like to get all the multi-parameter ECG, everything up and running as soon as possible.

As much as our eyes and monitoring skills are always our best tools, if you're the only nurse there having that multiparameter on during surgical preparation just gives you that little bit of extra bit of assistance, a little bit more, and it makes you you feel a bit more confident in the situation as well. So yeah, just try and slow your vets down and just say, let's get everything prepared, then you can go and scrub and we can go from there. So moving on to anaesthetic monitoring, another quote that I really like and one that I always stand by, no matter what surgery it is, is there's no such thing as a safe, safe anaesthetic anaesthetic, sorry, just a safe anaesthetist.

So due to the compromised state of the GDV patient, anaesthesia can be complicated with these patients. There's no denying that these can be complicated anaesthetics, but please do not panic. These patients, just to be looking out for are normally hypotensive, which is why we want to be keeping an eye on our blood pressures, hypoxic, SPOT monitoring here.

And also following on from this, they can be experiencing cardiac arrhythmias. So just to kind of go over cardiac arrhythmias first of all, the most common that we will normally see, with a GDB case is ventricular premature contractions or you might know them as VPCs. VP and you can see that on the left hand side there with the red arrow pointing.

Yeah, that, that is what we're looking for for a VPC. And then from there, this can then develop into ventricular tachycardia, which is on the video here, which I'll start in just a second. So ventricular tachycardia is classed as present when there are 4 or more VPCs in a sequence which then produce a rapid heart rate.

So if we turn that video on there, you can see that we're getting constant VPCs going through, and an extremely high heart rate. I don't believe this one that's actually recording on a GDV patient, but it's exactly the same that we could be expecting. So we're seeing that really, really high tachycardia, and the heart's under a lot of pressure, so it's something that we want to get on top of and be aware that is happening.

Surgical correction of the torsion often eliminates cardiac arrhythmias. However, in other cases, poor profusion and hypoxia have affected the myocardium, and these arrhythmias will persist regardless, and it can happen for up to 24 hours after the incident as well. So after the surgery or the GDV has taken place, .

A lot of people I find get extremely stressed about GDV about ECG sorry, especially if you're not used to using the ECG machine. And in that case they'll just choose not to use it. Please use the ECG, get used to using your ECGs even if you're not confident with traces.

Try not to stress over recognising a different trace. It's not our job to diagnose exactly what's going on with a GD with an ECG trace. Just be able to recognise what a normal ECG trace is.

Recognise a normal QRS complex. If you can recognise that from there you can alert your vet when you're seeing something that isn't normal. So don't worry about knowing, oh, there's a VPC there, I think this animal's in ventric tachycardia.

As long as you can say this animal's not got a normal QRS complex, this ECG trace isn't normal, you can alert your vet from there and then you're you're helping the animal instantly because from there they can work out what's going on and what needs to take place from here, . Generally, the intervention needed is a lidocaine CRI. So again, when you're setting up, it could be something that you can start to get ready, is get ready some lidocaine, and take your formulary as well into surgery with you, or perhaps just write down a quick quick calculation just so again that lidocaine CRI can be started if necessary.

As I said, other key areas of monitoring for these patients include blood pressure. We're assessing for hypertension as well as SPO2, as these patients are generally hypoxic. Yeah, so a lot of the main complications you're gonna be seeing is before that twist is actually, been corrected.

So again, Keep an eye on these patients, be their eyes and their ears, know exactly what's going on with your anaesthetic. Try not to stress, treat it as you would other anaesthetic. Just be aware of the complications that might take place and be ready to alert your vet to something that isn't quite right with them.

So surgical correction, I won't obviously go into too much depth. It's, it's not what we're doing, but just so you're aware of exactly what is happening. So the GDB surgery takes place to correct the abnormal positioning of the stomach.

I've put the spleen in black brackets here, as at times the spleen can get caught in the twist of the stomach. And if this happens, depending on the condition of the spleen, once the vet gets in there, a splenectomy you might actually need to take place as well. So that's something to be aware of.

During the the correction of the stomach is carefully rotated anti-clockwise to the normal position and from here it can then be fully deflated. At this point, you may need to carefully pla the stomach tube to safely remove the stomach contents, have a kick bucket ready under your table to collect all that. Although some vets may opt to have a stomach tube in place from an induction, but yeah, just be aware that you might need to place that stomach tube through the mouth, just so that after the twist, we can get a full emptying of the stomach at that point.

And that's the point where you start, most likely start to see these guys breathing a bit easier. After successful deflation, a gastrolexy is then normally performed with suturing to the right ventrolateral abdominal wall. It's important to point out a gastroopexy significantly reduces the possibility of a of a volubus occurring again in the future.

It doesn't rule it out, it's not impossible, but it significantly reduces. Also be aware that gas distension is still possible in these patients that have undergoneexy. The stomach can still bloat.

It's just more unlikely that it then won't then continue to twist as well. So just be aware, a gastroopexy does not completely rule out it happening again, it just significantly reduces the, the chances of it happening again. So moving on, sorry, to postoperative care.

Recovery is just as important as surgical correction, and again, this is really a point where we as nurses really have a role in this, the recovery of these patients, and our nursing skills really come into play with these cases, and it's why I love these cases so much, because we really have a chance to really show our skills here. So these guys need to be treated as high dependency for up to 48 hours post-surgery. So it's a long time.

We're correcting that surgery. It doesn't instantly mean that they're OK. They remain high dependency for 48 hours, no matter how quickly they recover.

I've seen some dogs, especially our flat coats and our retrievers, within an hour they're up and they think there's nothing wrong with them anymore. They are still high dependency of animals, and we need to keep a close eye on them. And This does mean ideally they need to be staying in hospital for that long afterwards as well.

However, again, that's discretion, but we can obviously say that all patients need to be assessed as individuals, and we need to monitor their stress levels in a hospital environment. Are they more stressed in the hospital than they would be at home? Is that in turn again, giving them further complications?

If they're stressed in hospital, are they gonna eat? In turn, that can cause further complications. So we, ideally, these guys are going to be in hospital for 48 hours post surgery, but treat every patient and every dog as an individual.

And if you are concerned that the stress levels that they're experiencing in hospital is affecting their wellbeing and their recovery, talk to your vets about it. Obviously, broach your opinions. This is a team effort here with these patients, and I really think we can make a difference here and we can put our opinions across of how we feel these patients are being treated in hospital.

So frequent monitoring is essential to ensure a safe recovery of these patients. We wanna be looking at our vital signs that we're always monitoring anyway. So mucous membranes, pulse rate and quality, respiration, again, rate and quality.

And then also our temperature should be monitored monitored as standard. And further things that we should be, and hopefully our monitoring as well, is blood pressure frequently, as well as urine output to ensure a good profusion and that the animal's perfusing well. Just to go over, a normal urine output is a minimum production of 2 mL per kg per hour.

However, we will most likely see a higher rate of fluid, higher rate of this urine. Sorry, however, you'll most likely see a higher rate urinary output and this is due to the higher rate of fluid you use throughout stabilisation and surgery. Also, again, another one just kind of going over that analgesic side of it and the pain that they these animals are experiencing pre, during and post-surgery.

We should be frequently pain scoring postoperativeoperatively, and this is using a standard recognised pain scoring chart. The reason I say use a pain scoring chart, as we should be with most cases, is if we're using, one person is using a standard pain scoring chart, we can ensure continuity and adequate analgesia during staff changeovers. If this animal is going to be staying in hospital for 48 hours, we're gonna have a lot, a lot of staff handover during that time.

By using a standard pain scoring sheet, we can all make sure we're on the same level and that we're using the same kind of guide to ensure what this animal's pain score is and that they're that they're receiving adequate pain relief. Just as a side note, intravenous paracetamol works extremely well with these guys, and it's an extremely effective analgesia in the post-surgical GDV alongside the use of opioids as well. As well, if your, if your animal has been put onto a lidocaine infusion for arrhythmias, just be aware that this will also have the additional benefit of being an analgesia as well.

So again, we wanna be looking at multi-modal analgesia for these guys. By you and then as much as obviously again, it's our vets that are prescribing the pain relief for these animals, but be their eyes, be their ears, and just let them, you know, your vets know if you think this animal's not coping well with their pain levels. Arrhythmias, as we said, are extremely common postoperatively in these guys, and even if they, they didn't develop during surgery, they can still continue to develop up to 24 hours post-surgery, 24 to 48.

Again, we're looking out for our ventricular premature contractions, BPCs, and ventricular tachycardia. It's also recommended that a PCV in total protein is monitored postoperatively. Gold standard, we're looking at including biochemistry and electrolytes to monitor organ function and need for supplementation there.

Again, wound management, keep an eye on our wounds. Does the, patient need intervention in the form of buster collar? Pet medical shirts are really good in these cases as well, rather than buster collar.

So yeah, make sure they're not interfering with their wounds as well. Post-operative nutrition, again, not all nurses I know get excited about nutrition in animals, but again, nutrition is vitally important in the success of these cases and it's again it's another place where us nurses really can get on board with these cases. Early nutritional support is beneficial in reducing the risk of systemic inflammatory response syndrome, or SARS as we might know it, and DRC.

So it's really important that early nutritional support is given to these animals, just to get everything healing, we all know the importance of nutrition and healing. Get these animals eating, get them, get them their body healing. And Again, following on, I'll keep going on about it, but again, it's extremely important that we are our patients advocates for pain.

Inadequate analgesia can lead to a pain-induced anorexia. So get on top of pain, get on top of everything else for these animals. We need to make sure that they're they're they're comfortable and that they want to continue as normal for them.

Some vets do opt to place a gastric feeding tube at the time of surgery, and this just guarantees nutritional supplementation, but again, it's down to your discretion of the vets, so it depends on what they want to do for that animal. As a generally, generally speaking rule, we, we generally introduce water from 2 hours post-surgery, and what we want to be doing is little and often. We don't want to be putting down a big bowl and letting them gulp down a lot of water, because again, that stomach can still bloat.

So what we want to do is introduce it slowly, little and often for these guys. And then food can slowly be introduced at 8 to 12 hours post-op, again, little and often meals. When deciding on a food, highly digestible and energy dense diet is what is what we're looking for.

So yeah, something that breaks down easy, a lot of energy. Maybe looking at things like recovery, AD and things like that, something that's just gonna break down nice and easily for them, but it's gonna have a lot of calories and it's gonna have a lot of energy to help that body heal. The body's been under a lot of stress, it needs the nutrients to help it heal.

Again, just reiterating the importance of little and often approach just to prevent overstretching of the stomach wall, from there meals can slowly build be built back up to normal. Also, one other thing to point out as well is obviously these patients need to go out to the toilet. We don't want them urinating on themselves because that's when we can get obviously wound infections and such like that.

So we want to be taking them out for short walks. We don't want them to be doing too much, especially with our bigger dogs, we know how prone they prone they are to just pull us once they're outside. If possible, go out with two nurses or one nurse, one vet, just go out and just keep those guys nice and calm, short, go to the toilet, back in again.

We won't want anything too strenuous, we don't want them bouncing around. We want them to rest as much as possible. So then moving on to patient discharge.

When it's time for the dog to go home, I, I think for most cases this is probably true as well, but I would recommend booking a longer discharge than normal, but also for this to happen before the dog is reintroduced to the owner. So book him a discharge, keep the, the dog up in kennels, whoever's discharging, whether it's the vet or the nurse. And keep the dog up in kennels away from the owner.

Have a sit down with them, talk to them, go over everything, make sure they're compliant, and then reintroduce the dog back to them. I often find, I'm sure as we're all aware that if the dog's there during the discharge, the owner's concentration isn't there as much. They're excited to see the animal again.

The dog's getting excited cos it's in, it's being reunited with its owner, and the concentration just isn't there as much as it should be, . Also reiterate everything by having a printed sheet out as well that way once they get home they've had a chance to just take everything in, they can go over that sheet again and just make sure they're compliant with everything. Client compliance is key with these cases again, so just make sure that yeah, you think that they're they're listening and everything's going well for them.

So as well as the normal wound management discussions, it's important to discuss the restricted exercise as well as the continuation of the small meals. So don't obviously undo all the hard work that's been done in hospital by then failing to mention that actually we don't want these guys going out on long walks straight away. We don't want them to be having massive meals.

This needs to continue at home and it really needs to be a whole family on board with this to get the successful management of these animals. Again, I will always say just go over again or your vet to go over whoever's whoever's doing that discharge, that a gastropexy reduces the possibility of the poluus occurring again in the future, but gas dissension is still possible and it is not unknown for an animal that's had a aexi to then potentially go on to have a GDV again. So we need to make sure that they're still aware of what the signs are.

This potentially could happen again in the future. Just because they had a pet secret in place doesn't mean it completely rules them out in the future. Make sure the owner is aware of this, don't scare them again, but just make sure they're aware and that way they know what to look out for and if they show any concern at all, they can ring the practise straight back up again.

And I usually find by saying things like that and making sure that they're aware, they tend to be more compliant with the exercise restriction and the feeding restrictions. Yeah, so kind compliance is crucial with these animals. So again, veterinary nurse, I prefer the name, the term badass lifesaver.

I find so many members of our veterinary team worry about the possible GDB case, vets and nurses included. I completely understand why we don't see them as frequently as we see everything else. Some people have never seen them in their whole career.

Some people have been qualified a year and they've seen many of them. It's just the luck of the draw of who sees it and who doesn't. They're highly critical, highly dependent cases, .

I understand why people worry, but they're also incredibly rewarding when they're successful. And it is one of the cases where we as nurses play a huge role in the successful treatment of these cases and we can really get involved, we can really show our skills here and we can really play an important role, and that's why I really think that it's important that nurses. Understand what is actually happening in during the GDB, why they can, where they can help and what they can do, and it really aids the successful management of these cases.

It's a team effort with these cases, it's a team effort in the GDV and we can really show our skills here. I hope this webinar's been helpful and it's put you a little bit more ease at the possibility of these cases. And I think one of the most important things I always say is remember your nursing power, and that's the power of preparation.

Be prepared. That's the most successful thing that we can do for these cases is be prepared and make sure that we've got everything running smoothly and also be a pain advocate for your patient. Pain control is the best thing we can do for these animals.