Liposomal Bupivacaine is Not Associated with a Higher Rate of Surgical Site Infections

Ever wondered if advanced pain relief for pets could compromise their recovery from surgery? That's the burning question we tackle with Drs. Camille Andrews and Rachel Williams as they unpack the results of their study on liposomal bupivacaine, or Nocita, in dogs and cats undergoing gastrointestinal surgery. Camille and Rachel discuss how Nocita measures up to the veterinary community's expectations, squashing fears of increased surgical site infections or the emergence of antibiotic-resistant superbugs. We get the inside scoop on the motivations behind this research, from Nocita's 72-hour pain relief window to addressing off-label usage concerns to considering the financial aspect for pet owners. You won't want to miss this important episode!

JAVMA article: https://doi.org/10.2460/javma.23.08.0463

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Transcript

Speaker 1: 0:00

You're listening to Veterinary Vertex, a podcast of the AVMA journals. In this episode, we chat about the association of infection with liposomal vipivacine use in dogs and cats undergoing gastrointestinal surgery with Camille Andrews and Rachel Williams. Camille and Rachel, thank you so much for being here today. Thanks for having us. ["lyposomal Vipivacine"], camille, your study investigates the association of liposomal vipivacine in dogs and cats undergoing GI surgery with rates of surgical site or multi-drug resistant infections. Please share with our listeners the background on this study.

Speaker 2: 0:39

Yeah, so I think in considering this study and the background of it, we really analyze sort of the broad scope that a study like this might have, specifically in looking at gastrointestinal surgery and also surgical site infection rates.

Speaker 2: 0:54

Gastrointestinal surgery is extremely common in our dogs and cats and is something that is performed not only in tertiary referral hospitals like UF and U-PEN, but also in general practice and emergency practice as well.

Speaker 2: 1:09

So in developing a study like this, it was important for me to think about how it could be applicable to not only boarded surgeons but also to multiple veterinarians as well, kind of in coordination with that. Surgical site infections are something that veterinarians deal with All veterinarians kind of from top to bottom and tend to be very costly and very common, and in identifying them, prevention is something that is extremely important as well. So when Dr Williams and I were paired up as Mentor and Menti this year during my intern year, we kind of thought about what might be a good study. I was very interested in NOSIDA and sort of the applications that it had on a sort of widespread basis, and Dr Williams had previously published a study about incisional infections after gastrointestinal surgery and microorganisms that were cultured after gastrointestinal surgery from surgical site infections. So it kind of was a really good pairing in looking at the two in kind of together.

Speaker 1: 2:17

Yeah, I was just sharing with Rachel before he jumps on. I think NOSIDA is very important to look at because it's very widely used too. So just thank you for sharing your findings with Jadma and Camille. What were some of the important findings from the study?

Speaker 2: 2:31

Yeah. So I think the important findings were twofold. The first is that liposomal buhivocaine, or NOSIDA, is not associated with an increased frequency of surgical site infections in dogs and cats after gastrointestinal surgery. And I think also the other important part of that that kind of made our findings hold more weight is that the surgical site infection rates that we found with dogs and cats that received NOSIDA mirror those that are published in literature after dogs after gastrointestinal surgery. So we didn't find that. We found that A there was no big differences in the frequency between surgical site infection between the two groups, but also that the infection rates that we got in our NOSIDA group mirrored published literature as well. And then, secondly, nosida isn't associated with an increased frequency of multi-drug resistant bacteriums from surgical site infections after gastrointestinal surgery. We found that in both groups multi-drug resistant bacterium were very commonly cultured after gastrointestinal surgery.

Speaker 1: 3:38

I'm sure they'll be resharing for a lot of clinicians that use Nocita to know that and have the evidence behind it instead of just guessing. So thank you again, absolutely, and Rachel what sparked your research interest?

Speaker 3: 3:49

Yeah, so, as we know, nocita is a super hot topic right now, and the use of Nocita, or Life is Owned will be pivocaine has really taken off in the last few years, and in most settings it's used more frequently off-label than it is on-label, and so that really begs the question of the appropriateness of their use in different settings.

Speaker 3: 4:07

In addition to that, it can be pretty pricey, and in recent times it's been a little challenging to source, and so I think it's important for us to really be critically evaluating our use, the expense of it, and deciding if the relative difficulty of keeping it stocked is worth the benefit for our patients and also to make sure that we're not putting them at any increased risk for complications.

Speaker 3: 4:27

And so, in that vein, I've always heard some talk from colleagues of mine, from other surgeons, some level of concern when using Life is Owned will be pivocaine in cases that might have a higher risk of infection, so gastrointestinal surgery being one of those situations, and the reason for that is the Life is Owned nature of the product, which we love because it allows it to be present and efficacious in an incision for 72 hours, but there's a concern that maybe that increases our risk for incisional infection and wound healing complications, and so, in order to make sure that we're ensuring all the benefits of Nocita are worth it for our patients, we should also be sure that we're not putting them at any increased risk for those complications, and so that's kind of what spurred an interest in investigating this question in particular.

Speaker 1: 5:12

Yeah, I was practicing in Canada a few years ago and I obviously came from the US and practiced in the US before that. So I was familiar with Nocita and I brought up using it for a procedure that we had scheduled and they're like that's not available in Canada. We can't do that and I was like, oh, that's really a bummer, it's so great. So, yeah, definitely be frustrating when you've got restricted access, for sure.

Speaker 3: 5:33

Absolutely, and a lot of people are dealing with back orders right now and trying to seek alternative methods, like investigating use of the human product instead, and so going through all these turtles or all these hoops that you're jumping through. We definitely want to make sure that that effort is worth it 100%.

Speaker 1: 5:51

And, with that being said, why did you choose to submit your manuscript to Javna?

Speaker 3: 5:56

Well, javna has a longstanding reputation among veterinary specialists as well as general practitioners, so a very, very wide audience, and that's something that attracted us to submit to Javna. In particular, we wanted to ensure that our manuscript, or study, was widely available to a variety of practitioners, because this product is used in a variety of clinical settings and so many people could utilize this information in their daily practice, and Javna seemed like the right journal to make that happen.

Speaker 1: 6:24

Well, thank you very much, Really happy that you shared it with us. We're happy to promote it too, for a wider audience as well. Then, rachel, what was the most surprising finding from the manuscripts?

Speaker 3: 6:34

I think the most surprising thing for me was that, of the infections that we did have, it didn't increase the amount of multi-drug resistant infections. Given that the liposomes are present for 72 hours, that's going to fall outside of the window for perioperative antimicrobials in most cases. It logically makes sense that some resistant bacteria may be able to slip through the cracks some opportunistic organisms just as a result of infiltration of this product, but thankfully we found out that that wasn't true, so we can feel comfortable using it in those settings.

Speaker 1: 7:08

Excellent, Camille. How did your advanced training prepare you to write these manuscripts?

Speaker 2: 7:14

Yeah, I think my training, although not advanced, started back in my undergraduate years. I went to a small liberal arts school and had a very unique major. I was an animal behavior major before veterinary school. For almost every single final project that we did, we had a study that we had done during the semester and submitted a scientific paper at the end of it, although it wasn't to any journal.

Speaker 2: 7:37

Receiving continuous feedback over those four years of my undergrad, I think trained me to not only be able to receive feedback in a positive sense and receive constructive criticism well, but also just fine-tuning my skills in writing scientific manuscripts. Although now my research focus is a little bit different in the clinical and surgical aspect of things, I think that those skills are very important. Additionally, during vet school I participated in the NIH BI research program over the summer, which I think was very helpful in again continuing to hone those skills, getting in contact and building my network of researchers that I can reach out to in order to help fine-tune different papers. Then being paired with Dr Williams I'm so grateful for, and my other co-authors and then providing continuous constructive criticism and edits back and forth throughout. I think every single edit that I got, every single new manuscript with some edits. I took those in and fine-tuned them until we could publish a product that we were very proud of.

Speaker 1: 8:49

Being receptive to feedback is so important, especially in scientific writing, like you said, because you're going to get reviewer feedback, feedback from your co-authors, and I think it's important to take a step back. I know it's not a personal attack, it just everyone wants us the science to be solid and good so it can really make a positive impact on the field. This next set of questions is really important for our listeners. Camille, what is one piece of information the veterinarian should know before discussing Noceta with the client?

Speaker 2: 9:16

Yeah, I think in discussing with Noceta it's important for a veterinarian to effectively communicate what it is and what the goals are to decrease pain postoperatively. While the literature is still out to whether there is a true opioid-sparing effect for dogs and it's been debated in different clinical studies I think explaining to clients that it doesn't increase the risk of surgical site infections and those more long-term postoperative complications is very important in encouraging clients to potentially give down more funds for the surgery in which Noceta could potentially be used.

Speaker 1: 9:56

And on the other side of the relationship, what's one thing the client should know about liposomal vipipigaine?

Speaker 2: 10:03

Yeah, I think that it's important for the client to know that its labeled time is 72 hours. As Dr Williams has discussed, 72 hours postoperatively is not only a very important time considering the drug but also an important time after gastrointestinal surgery, especially when the bowel has been entered, because we know that the collagenases promote sort of a breakdown of a potential sutured incision site on the bowel right around that 72 hour mark. So noticing clinical signs in an animal at the 72 hour mark is not only important because additional pain control may be needed if there was a significant analgesic effect from the nocita, but also because it could potentially mean that the gastrointestinal suture site has to hist. So I think that 72 hour mark is both important because it may be an effect where the nocita may be wearing off, but if clinical signs are noted, it also might be reminiscent of something else more serious.

Speaker 1: 11:10

Yeah, very important consideration for clients. So thank you for sharing that. Now we're going to end our episode on a bit more of a personal notes. Camille, what was the first concert that you attended?

Speaker 2: 11:20

Yeah, I remember when I was in eighth grade I attended the Maroon 5 and Train combo concert. It was amazing. I just remember singing my heart out on the Dallas lawn to all the songs.

Speaker 1: 11:33

Very nice, Rachel. What was the first concert you attended?

Speaker 3: 11:38

That sounds silly, but it was the Wiggles, which I know is probably not anyone's conventional thought when I was getting asked about their first concert, but it was huge where I was growing up and there were hundreds of people there. It was a great experience. It's probably been the best atmosphere for a concert of any that I've gone to, because people were just so excited to be there and they're great performers.

Speaker 1: 11:59

My brother used to watch that so therefore I had to watch it on TV when I was growing up, so very familiar with them. But just thank you both, Camille and Rachel. We're just really happy to have you share your work with our audience and for submitting your manuscript to JAPMA.

Speaker 3: 12:14

Absolutely. Thank you again for having us, of course.

Speaker 1: 12:18

And to our listeners. You can read Camille and Rachel's manuscript in print JAPMA or on our journals website. I'm Sarah Wright and I want to thank each of you for joining me on this episode of the Veterinary Vertex Podcast. We love sharing cutting edge veterinary research with you and we want to hear from you. Be sure to leave us a rating and review on Apple Podcasts or whatever platform you listen to.