Thursday, October 18, 2012

1147. KPI. The Golden Retriever has a painful golf-ball cheek

Sunday's interesting case

Oct 14, 2012

I was worried that I would not be able to operate on this golf-ball-sized cheek. The Golden Retriever was thin and had a low total white cell count of 3.3 (6-17) when Dr Daniel took a blood test as part of health check up and vaccination in June 4, 2012.

Why such a low TWCC? I took a blood test on Oct 15 before surgery. It was still low at 5.2.
The platelets were low at 110 in June but was normal in Oct 15 at 251. So, what was going on in this skinny dog, said to be a selective eater? At his age, he should weigh more than 27 kg. He was 24 kg in June and so would have gained weight.

The good-natured dog whined when I palpated the firm lump. He did not bite me. Could this be an abscess? A needle aspiration showed some blood-tinged fluid but nothing else. The lump was more solid. A tumour? A salivary gland cyst (submandibular and sublingual) but the location was inside the cheek tissues. Fortunately as it is a messy operation to remove the salivary gland cyst known as mucocoele. Too many nerves and blood vessels in this neck area.

Give some medication and wait and see? Well, this would not cure the dog. Could the pain be some chronic pain that made the dog not wanting to eat? The following is my management of this high-risk case

24-HOUR BEFORE OP
IV dextrose saline  2 bags + duphalytes + baytril

ANAESTHESIA
27kg
I used xyalzine 1.3 ml + ketamine 0.3 ml IV - at 50% of the calculated dose.
It was not effective but isoflurane gas mask knocked him down and allowed intubation

To benchmark for my other vets, the record showed:
Time of use of isoflurane gas + O2 = 85 minutes
First stitch to last stitch of skin       =  57 minutes
The dog was not healthy and so the shorter the anaesthesia, the better the survival outcome
SURGICAL APPROACH
How to remove this large golf ball and still have skin to close up the left cheek?
Marker pen drawing of surgical lines
In the end I electro-incised a vertical line, excise the mass of cystic fluid and tissues from the dermis of the skin, sent the lumps to lab for histopathology

Ligated bleeders
Nylon 2/0 x 2 packets, PDS 2/0 X 1 packet to close up the wound and ligate

HISTOPATHOLOGY
Inflamed granulation tissue. No sign of malignancy.

I informed the owner. He asked what would be the cause?
"Possibly an infected abscess. Something sharp pierced the cheek and lodged inside."
"It could be chicken wing," he sighed.

This report is to set some benchmarks by me for my associate vets in veterinary surgery.
Obviously, I have over 40 years of surgery experience and I don't expect the younger vets to achieve the 57-minute surgery till they have more surgeries under their belt.
But there must be some bench-marks and this case is one of them.

All surgeries and anaesthesia records are nowadays written with the above-mentioned timing to upgrade the standard of veterinary surgery. Taking time to operate a pet is frowned upon by me and proper planning must be done to shorten anaesthetic and surgical time if Toa Payoh Vets is to be the top 5 veterinary surgery in Singapore.

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