Consumer Guide
to Elective 
Surgery



When you, a human being, go to the hospital to have an operation, you can pretty much expect that your procedure would be done in pretty much the same way at pretty much any hospital you went to.  Sure, Bingham Memorial may be a little cheaper than EIRMC, but the level of care is about the same.  You'd get a pre-op exam, consult with the anesthetist, have some labs done if indicated, then have a catheter placed, and recieve some sedatives and other good drugs pre-op.  Then, a balanced anesthetic/pain management protocol would be administered, and have a tube placed to protect your airway. During the surgery, you'd have your vital signs monitored by trained people.  The surgeon would scrub, wear cap, mask, gown, and gloves.  The instruments that are used on you are freshly sterilized. You'd get medication for pain afterwards.  And we'd expect this level of care at both Bingham Memorial and EIRMC.  In other words, the Standard of Care is quite consistent from provider to provider.

You may be surprised to learn that this is not the case in veterinary medicine.  Things are not done the same everywhere.  The standard of care is hugely variable from clinic to clinic.  Some clinics (like ours!) do all of the above.  Others do not.   In some clinics, for example, the person in charge of monitoring your pet during surgery may also be in charge of doing laundry in another room.  The surgeon may be operating in his shirtsleeves.  Other clinics may think pain medication is for sissies.  Some veterinary clinics have been known to routinely cut some corners in anesthesia and pain control in the name of economy that would be malpractice for a human anesthesiologist to omit.  All this may or may not be a bad thing, depending on what you expect and the level of care you desire for your pet, but it is important that you be aware that the Standard of Care can vary widely between clinics, and not expect things you are not getting.

When you call up most clinics and ask for prices, they will quote you the cheapest price they can to get you to come in.  To be honest, so do we.  We do it that way because we want the chance to meet you and your pet, and to have a chance to talk the surgery over so that you can learn what the realities of anesthesia, surgery, and pain control are.  We'll give you the chance to make informed decisions about what safety and comfort precautions we use when we treat your pet.

In veterinary medicine, we do not have third-party insurance companies or the government to pay the bills, and so economics are a major factor in some of our health care decisions.  But we realize that not everybody wants things done as cheaply as possible. You personally might not want your hysterectomy done by the lowest bidder. We feel that it is important for shoppers to know what it is you are and are not getting for your money, and what risks are involved in economy surgery.

We have established a minimum standard of care for our spay and neuter patients.   We feel that this standard provides a reasonably safe anesthesia as well as fair pain management post-op.  Is this how I would want to be treated if I were having surgery?  Absolutely not.  I personally prefer safer anesthesia and better pain management.  But it is a start, and if there are bugetary restrictions this may be what you want for your pet.

Our Minimum Standard:  All of our surgical patients:
1)  All patients receice a pre-op physical examination with the owner present so questions can be answered and concerns addressed.
2)  Receive a balanced, multi-modal anesthesia and pain control program.  
3)  Are intubated to protect the airway, and gas anesthesia is used (except for feline neuters).
4)  Are monitored with a pulse oximeter to monitor heart rate and blood oxygen, 
       a capnograph to monitor expired carbon dioxide, 
       and all patients have their blood pressure monitored throughout the procedure. Click the link for a detailed explanation of 
       why Anesthetic Monitoring is so important. 
5) Our surgical nurses technicians are dedicated, meaning that they are in the OR doing nothing but assisting and monitoring, 
6) All patients are hospitalized overnight. 

We are serious about pain management.  We don't kid around.  We don't believe a single injection is enough, and we don't think that a few pills for two or three days are going to provide enough pain control.  We dispense enough medication so that all patients receive at least 6 days worth of post-operative pain medication.   Click here  for a discussion of Pets in Pain.  Click here for a somewhat more "user-friendly" video presentation on pain management by the pain management team at the Colorado State University College of Veterinary Medicine entitled Is Your Pet in Pain?".

Even though this is our minimum standard of care, it may be a bit higher standard than is found at some clinics, so consider that when you shop around.

          Is it the best that can be done? 

                    Absolutely not !


If your criteria for a successful surgery are having the right parts removed and then waking back up alive, then the cheapest way might be fine. However, if your criteria are a smooth and safe anesthesia with minimal pain afterwards, then you will want some additional safety and comfort measures for your pet. For instance, it would be medical malpractice for a human to be anesthetized without an intravenous catheter in place because venous access is so critical if there are problems. Intra-op fluid support of blood pressure is considered mandatory in all but the shortest human aesthetic procedures because low blood pressure during anesthesia is so devastating. And the folks that anesthetize humans for a living only consider administering anesthesia without pre-anesthetic blood testing under a very few circumstances because of the few patients that have hidden problems.  And who in their right mind would want to undergo surgery with only ibuprofen for pain relief when high-powered pain medications like morphine or demerol are available?

The only reason to do without these safety and comfort precautions is cost. Pre-emptive pain medication, IV fluid support, and pre-anesthetic blood testing are excellent medicine and make the surgical experience safer and more comfortable for the patient. The basic package spay surgery for small dogs, once we add the pain medication, costs around $120. With all the safety and comfort precautions, the procedure costs just over $213 for the same dog. 

Let's put that in perspective.  The difference between the bare minimum and the best is $93.  That is less than a tank of gas for my pickup.  You could easily spend more on dinner and a movie.  You can't drive to Grand Targhee and ski for $93.

What are the options?   Listed below are some options you may wish to consider. We recommend them all because they are good medicine and make the experience safer and more confortable for the patient.  If you do not feel that for economic reasons you can choose all the options, we recommend that you choose them in the order they are listed.

Pre-emptive Pain Medication  

All surgery patients experience pain, 100% of them. Although some people don't believe pets feel pain, or that they don't feel it for very long, at Sunnyside Veterinary Clinic we believe that surgery hurts, and the pain needs to be medicated for several days post-op. We recommend that your first upgrade be Pre-emptive Pain Medication. If powerful pain medication is given before the painful stimulus, the whole pain response is dampend and the pain never gets as severe as it would have.  The medications we give at the dosages we use are known to last from 8 to 12 hours, which makes for a much more pleasant post-operative experience. These medications are much better than the pills often used for post-op pain relief. They are comparable to morphine or demerol, which are the highly potent pain drugs you would get if you had major surgery. The cost for this ranges from $18 to $22, depending on the size of your pet, and we recommend that they be given because of the increased pain control and stress relief they provide.  Click here to go to a page on the science behind pre-emptive pain management.  Click here for a somewhat more "user-friendly" video presentation on pain management by the pain management team at the Colorado State University College of Veterinary Medicine entitled Is Your Pet in Pain?".



IV Fluid Support 

In the old days before veterinarians measured blood pressure during surgery, they didn't know that many of their patients were getting into blood pressure problems during procedures.  Now that we are monitoring blood pressure, we find in this practice that about 30% to 40% of our surgical patients experience low blood pressure at some point during their anesthesia.  Practices that do not monitor blood pressure do not even know that their patients are experiencing low blood pressure. Now, this is not because we are doing something wrong.  It is just part of the anesthesia game.  It happens to humans under anesthesia too.  This is why whenever a human is anesthetized, there is always am IV line in and there are always fluids running.

The consequences of low blood pressure, or hypotension, can be severe.  Patients that develop hypotension are at a greatly increased risk of anesthetic-related problems.  It has been recently reported at the 2005 annual meeting of the American Society of Anesthesiologists (a human anesthesiology group) that "Low intraoperative blood pressure is associated with a significantly greater number of negative outcomes after surgery, according to preliminary results of an ongoing investigation. Researchers at the University of Michigan Medical School, Ann Arbor, said the study showed that patients whose systolic blood pressure drops below 90 mm Hg are more likely to die than are their counterparts whose systolic blood pressure remains above this level."   They found that patients with hypotension had from two to six times the risk of death.  You can read the full text here.  In our animal patients, especially cats, hypotension has been associated with kidney damage.  Low blood pressure during surgery also predisposes the patient to have adverse reactions to pain medications given post-op.  At the very least, hypotension causes the patient to feel bad for the next few days post-op, presumably due to decreased bloodflow to the brain.

To help prevent dangerous episodes of low blood pressure, we recommend that your second upgrade be IV fluid support. Giving IV fluids helps maintain healthy blood pressure, replaces fluids lost during surgery, helps prevent kidney damage, makes the post-op pain medication safer, and provides emergency venous access for resuscitation in case of problems during anesthesia.  This upgrade costs about $33, and we recommend it because of the increased safety and comfort it provides.


Pre-Anesthetic Blood Testing 
 
This is often done before humans are given anesthesia. The reason is that not everybody is as healthy as they look  A blood sample is drawn, and it is analyzed to determine whether or not there are any problems with the liver, the kidneys, blood sugar, dehydration, etc.   We find that not every one of our veterinary patients are as healthy as they look either. Somewhere on the order of 1% to 2% of the healthy-looking patients end up having some significant problems when they are tested. While this is not a huge percentage, and even though a perfect test does not guarantee that no problems will occur, pre-anesthetic blood testing has saved more than one life in this practice.  While many young, healthy humans are anesthetized without having pre-op labs done, it remains a great idea for our veterinary patients who cannot talk and tell us about any problems they may be having.  While studies have shown that pre-anesthetic testing is of limited value in young healthy humans, those same studies have shown that an accurate health history is vital to ensuring a safe anesthesia.  Since we are not able to talk to and interview our veterinary patients, pre-anesthetic testing becomes a much more important tool.  It costs about $42, and is well worth the added safety it affords.


When we meet for your pet's pre-surgical exam, we can discuss any concerns or questions you may have. You will be asked to decide whether to accept or decline our recommendations for pre-emptive pain medication, IV fluid support, and pre-anesthetic blood testing. We recommend the first class package, with all the safety and comfort options. If budget is a problem, we recommend that you choose first the Pre-emptive pain medication, since 100% of surgical patients experience pain, then IV Fluid support, since 40% or so of anesthetized patients experience blood pressure problems, and thirdly pre-anesthetic blood testing.


I hope you've enjoyed your trip through The Consumer Guide to Elective Surgery.  I'm sure you found it to be somewhat of an information overload.  During your pre-surgery consultation, there will be plenty of time to discuss any questions you may have.  Surgical FAQ's is another helpful page about spay and neuter surgeries.  Declawing Cats is a helpful page on declawing.