Wednesday, July 6, 2011

492. Sixteen-year-old Maltese X with pyometra - euthanasia or not?

Sunday Jul 3, 2011

I thought this Sunday would be an uneventful Sunday with the usual veterinary conditions seen throughout the years.

I would work half a day and take the afternoon off. Then I would watch the movie "Jane Eyre" at 7 pm at the Shaw Lido cinema. Suddenly a young worried-looking young man in his early 30s and a lady came with a very thin Maltese passing pus from her vagina for the past 5 months. They had consulted my associate yesterday, Dr Jason Teo had given an anti-fever and antibiotic injection yesterday as the dog had high fever. However, she had no fever now.

"What do you advise?" the sister asked me. "Do you recommend euthanasia?" This was a very old female dog. Very thin and weak and would be a very high anaesthetic risk.

"It is up to the owner as to whether he wants to euthanase this dog or not," I replied. "I don't advise euthanasia or surgery. It is up to the owner as surgery has a high risk of death on the operating table for this very old dog. In human years, she would be over 100 years old!"

The young man was hesitant. "Please think it over," I said. "You may not see this dog alive once she enters the operating table."

To euthanase or not? As long as there is life, there is hope. It does not mean that a very old dog that is in very poor health will definitely die on the operating table. It is just that the probability of dying is over 90% in this case.

"In pyometra cases, there is no choice but to operate. Much depends on economics," I advised. "Pyometra surgery and anaesthesia will cost around $1,000 as it takes a longer time as compared to a normal spay which is much cheaper."

The young man could not decide. I said: "Please wait in the reception room and think about the surgery." Why did he wait for over 3 months of the dog passing pus in the vagina to seek treatment, I did not ask him. Most likely, he anticipated that the dog would die on the operating table and therefore procrastinated till the dog was very thin and unable to eat.

I don't relish operating on high risk dogs as I do get emotionally affected whenever a dog dies on the operating table. For whatever reason. Some 40 years ago, I would have advised euthanasia as that was the prevalent thinking of my baby-boomer generation. Not much hope of survival. So why spend money on doing surgery? Save the owner some money. The vet who advises euthanasia for very sick dogs becomes despised and deemed uncaring and incompetent.

This type of advice does not resonate well with the younger generation. So, nowadays, I let the owner make the final decision of euthanasia or surgery in serious pyometra cases of old dogs. This case would be my second case of a very old dog past 15 years of age, suffering from pyometra. There are only a handful of such such cases seen by me in my 40 years of practice and the other case was deemed a success.

Yet one swallow does not make a summer. I did not want to operate. Yet euthanasia would be unacceptable for me too. This would be a very high risk surgery. Why risk my reputation?

The young man finally said: "OK, do the surgery." He did not want any blood test to be done.

Below is the account of the surgery, anaesthesia and follow-up.

ANAESTHESIA
Isoflurane gas at 5% given by mask. No sedation. IV drip.
Intubated and give gas at 1-3%.

The dog was given just sufficient gas but this was insufficient to bring her deeper into surgical anaesthesia. The dog kept moving and I would stop the surgery while she inhaled more gas. This method prolonged the surgery which started from 10.50 am and completed at 11.35 am on this Sunday. In normal pyometra dog anaesthesia, the dog would be fully anaesthesized and the surgery could be completed in less than 30 minutes.

But this was a very old dog and life and death depended on the anaesthetic skills of the vet. My assistant Min wanted to increase the isoflurane percentage to 5% to get a deeper anaesthesia. "Don't do it," I told him off. "She is a very old dog and normally 2% is sufficient in normal dogs. Just wait a while at 3% maximum. Old dogs die when given 5% for some time as she is in a very unstable anaesthetic stage."

After removal of the womb and ovaries, the dog's anaesthesia was excellent.

SURGERY
"The blood is bright red," I said to my assistant. "It is a good sign as toxic blood is usually dark blue due to lack of oxygenation." An unusual bright red in this case as compared to the cyanotic blue of another case in a Golden Retriever I operated in 2008 (see hyperlink).

There are three significant aspects of this surgical case.
1. Cysts and swelling in parts of the uterine bodies, indicating a partial rupture of the uterus and spilling of the toxic pus into the abdomen.

2. This is shown in a very thick peritoneum of 3 mm thickness. Normally, the peritoneum is thinner than 1 mm. So, there was peritonitis.

3. A grossly swollen vagina and cervix was seen. I did not get a photo taken as I was in a rush to complete the surgery which was taking too long due to an unstable anaesthesia. This is extremely rare. Was there a tumour inside the vagina? Was there an abnormal hymen? I don't know. I put in 3 ligatures to prevent the pus from the vagina from leaking into the abdomen as I removed the uterine horns and ovaries.

BLEEDING. Lots of bleeding from the omental blood vessels which were fragile. Probably a result of cystic ovaries producing abnormal amounts of hormone. I checked carefully that there was no major blood vessel from the uterine body haemorrhaging as I had 3 ligatures around the uterine body. I swabbed off the blood.

SUTURE
After 3 ligatures of the uterine body, I closed the muscles with a continuous suture 2/0 absorbable. Normally, I don't bother with continuous sutures but just use simple interrupted sutures and I find that fine. After the continouous sutures, I stitched another 3 interrupted sutures. The skin incision was stitched horizontal mattress sutures as these hold well and are not easily licked off unlike interrupted sutures, in my experience.


POST-OP
The young man insisted on taking the dog home to nurse by himself. He was not experience in post-operation nursing. If owners are insistent, I would ask them to sign a discharge form saying that they want the dog discharged against medical advice. However, he agreed to let her rest overnight at Toa Payoh Vets and get the necessary drip.

POST-OP NURSING CARE DAY 1-3

1. Vomiting.

"The dog vomits when I feed her very small amounts of the A/D canned food and water," the owner phoned me on Day 1 and 2. I advised feeding separately at 6 times per day but he said the dog would vomit after a while. "What's the cause?" he asked. "My dog does not vomit before the surgery."

"It is hard to tell you the cause," I said. "You did not want blood test. It could be stomach ulceration due to kidney disorders and uraemia. Or liver disorders. It could be gastritis or any other reason."

2. Fits on Day 3.
On Day 3, the owner phoned me saying that the dog had a few seconds of fits. "What's the cause?" he asked. "It could be due to low blood sugar or kidney disorders. Come for an IV drip and review."

After dextrose saline and amino acid drips, the owner took the dog home with another bottle of drip which he would administer himself.

3. Day 3 - Day 6 (today). No more vomiting. The owner was told to feed the canned food and the multi-vitamin paste but not to give water. I had given a Baytril antibiotic and anti-inflam pred injection with the drip on Day 3 when he came for the fits.

CONCLUSION
The dog started to eat by herself from Day 3 to 6. That was good news. I advised giving water in small amounts at different times. So far, so good. This is one of my most unusual cases. As for the vulval swelling of 30x, I told the owner that the swelling had reduced by 80% on Day 3 when he came in for the review of fits.

The road back to good health is long. This is one of the rare cases where the owner does not opt for euthanasia as most will do so.






More pictures are at
http://www.sinpets.com/201006265pyometra-16years-MalteseX-swollen-vagina-toapayohvets-Singapore-ToaPayohVets.htm

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