Friday, August 8, 2014

1442. Yezin Veterinary University Final Year Students Lecture - Dog neuter and spay - Draft

DRAFT

Case studies of dog neuter and spay over past 30 years at Toa Payoh Vets
A high standard of care to sustain the practice. Over 60 vet clinics in Singapore and many have very strong financial backing to build prettier clinics attracting more clients. 

SPAY FOR NORMAL DOGS, PYOMETRA, PREGNANCY, SKIN DISEASES (HORMONAL).
NEUTER - Undescended testicles, go into abdomen for abdominal cryptorchid (beside bladder).

MONORCHID. Some vets just remove the inguinal one and leave the abdominal one - testicular neoplasia in old age and die (Rottweiler).

1. PRE-OP + INFORMED CONSENT (defence in case of litigation) + BLOOD TEST (AMA - Against Medical Advice).

Pre-op temperature check up before surgery. Check male or female. Do not trust owners as some cats have been spayed when they are males.  Owners sue.  Check pregnancy (hormonal tests?) v. pyometra - one complaint case. Be organised with an SOP (Standared Operating Procedure). 

2. ANAESTHESIA + IV DRIPS + IV CATHETER (some vets do it).
3. SURGICAL TECHNIQUE - KEEP IT SIMPLE. ASEPSIS.
4. POST-OP - antibiotics, painkillers, nursing advices, stitch removal (absorbable stitches)
5. ANAESTHETIC & SURGICAL RECORDS properly maintained as a defence in case of litigation. Some vets do not bother to write down dosages, routes used. .

6. COMPLICATIONS
6.1  Bleeding. Scrotal swelling. Anti-inflammatory. Painful & infected. Scrotal ablation.
Especially in big breeds. Double ligation. Pain-killers for more than 4 days. Usually 4 days.
6.2  Pain. Intense scrotal bruising - painful or irritation
6.3  Infection
6.4  Bloody diarrhoea after spay and died. Dog had gone to boarding kennel, contacted parvovirus. Many Singapore owners not bothered to vaccinate the dog against parvovirus annually after puppyhood vaccinations.

SOLUTIONS
FAT FEMALE BIG CROSS-BRED DOGS. Can't find ovary to hook. 10 minutes pass quickly. Sweat. 
Open big. Use fore-finger to feel for long thin uterine horn at lateral side of body.  Insert hook under the finger to hook this horn and pull out.  For new vets, use this method if can't hook.



7. INCOMPETENT SPAY
    STUMP PYOMETRA - Vaginal discharge in cat given Ovarid to suppress caterwauling..
    DOG/CAT IS STILL HAVING HEAT AFTER SPAY. Owner not happy.

8. SPEED, ACCURACY AND CORRECT SURGERY




9. EDUCATIONAL VIDEOS SPONSORED BY TOA PAYOH VETS

9.1  OTHER ANIMALS  - RABBIT SPAY VIDEO
9.2  CAT SPAY VIDEO  - 3-HAEMOSTAT METHOD
9.3  DOG SPAY VIDEO - PYOMETRA
9.4  DOG NEUTER VIDEO

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Some older male dogs feel the pain. I saw this case in 2005. Dog licking. Vet blamed. What to do?
INFORMED CONSENT FORM NOT GIVEN OR SIGNED.

http://www.asiahomes.com/singaporetpvet/0904Ads_castration_Silkie.htm

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My case operated in
Client communication important.

 http://www.kongyuensing.com/folder5/20110325Trauma_self-inflicted-scrotal-post-neuter-dogs-surgery-toapayohvets.htm

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CLIENT EDUCATION
Male dog - urine marking - lots of work for aged mother. Advised neuter.
                - barking loudly. Neuter reduces pitch.

SYNTHETIC PROGESTIN USED IN MYANMAR FOR DOGS AND CATS appear to be quite common. Pyometra increases.


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BE KIND TO PETS VETERINARY EDUCATIONAL VIDEOS
1. Standard Operating Procedure in Spaying A Pregnant Cat
 http://www.youtube.com/watch?v=E14zwal_yo4




 Extra care is needed in operating a heavily pregnant cat. The ovarian and uterine blood vessels are much enlarged and if not properly ligated, there will be lots of bleeding in the surgical area and a possible bleeding to death post-op. A pre-op examination to ensure that the heavily pregnant cat is fit for surgery should be part of the SOP. This was done by me (Dr Sing Kong Yuen). Blood test was not taken owing to financial considerations. The dilemma is whether the heavily pregnant cat should be spayed or should she give birth first. it is extremely difficult to find new homes for the kittens and so spaying was the decision of the owner. The other concern of the owner was whether to starve the cat for 24 hours before surgery.

The cat had eaten 6 hours ago but there is no vomiting with the xylazine + ketamine IM sedation in my experience. No vomiting was present in this case.

I advise the use of the 3-forceps method to clamp and ligate the uterine body with its engorged uterine blood vessels. The lowest 3rd forceps is clamped and then released, showing a grooved line caused by clamping. Ligate this groove and the ligature will not slip off as compared to ligation of the non-grooved smooth uterine body area. In this way, there is a guarantee of no haemorrhage. The uterine body is then incised between forceps 1 and 2, leaving a good area for the ligated stump to be released into the body.

This spay was done by Dr Daniel Sing using absorbable sutures.  Xyalzine 0.15 ml + ketamine 0.6 ml combined IM was given in this 3.6 kg cat. Isoflurane + oxygen gas top up was needed. There was no bleeding in this spay as the ligatures were properly placed and tight.  The cat was operated in the afternoon and went home in the evening.

A handing over inspection with the owner should be part of the SOP so that the owner can see that the skin stitches are properly tied. At that time, post-op instructions are given preferably by the vet to build good client relationships. Follow up 2 days later is advised by me but most vets do not bother. As at 7 days post-op, the cat is normal and the stitches should be taken out 14 days after surgery although they are absorbable monosyn.

Standard operating procedures are in place to maintain the highest standard of surgery. Handing over inspection of the surgical site with the owner is shown. The cat is OK as at 7 days post-op.

More instructional videos for vet students and pet owners are at www.toapayohvets.com/videos.htm..

This video was filmed and edited by Intern Clara Chua as part of her experiential learning at Toa Payoh Vets. Interns learn more by writing and making videos than by being an observer looking at the vet's working.

It appears to me to be well edited and has good music. My grateful thanks to Clara. I purchased the Corel software recently as the free Windows Movie Maker does not have many features.


2. Time is Running Out - An old female pyometra dog will die from septicaemia
http://www.youtube.com/watch?v=J9WJqmVPfw8

When the vet (myself) said that the dog had a very low chance of survival on the operating table and the medical costs were high in this closed-open pyometra case, the owner probably felt that it would not be justified paying for such a high risk anaesthesia.  He decided to bring the dog home to die.

But I noticed that there was this 12-year-old boy who cried his heart out. Some vets don't follow up as the owner had decided and they had no time to "solicit" for business and risk being rejected..

But this little boy loves this 14-year-old dog very much as tears streamed down his face when the father decided on no operation. He knew the outcome would be death from septicaemia (leucocytosis, neutrophilia, thromobocytopenia in the blood test).

I phoned the father (owner) the next morning. The dog was still passing bloody vaginal discharge and had become lethargic.

I reduced the surgical costs to give this high anaesthetic risky canine patient a chance to live.

Time was running out on her as she became sick again. Her serosanguinous vaginal discharge flowed out like a burst dam.

If she survived the operation, the little boy would get his companion back to health and that was what mattered to me in this case.

 "Don't wait till you have finished work this evening to bring the dog down," I advised the father. "Bring her down now while she still has a fighting chance to live. Time is running out."

Dr Daniel operated immediately in the afternoon. The dog was warded one night. The little boy was most happy to have his companion back home the next day with his mother. "Are you happy now?" I asked him as he carried his friend carefully into the car. "Yes," he beamed to me his best smile..

This is a case where a vet can make a difference if he makes time to follow up before time has run out for a little boy's best friend. Happiness in the boy's face when the dog went home the day after surgery would be hard to describe. "Are you happy now?" I asked him as he sat at the back of the car with this old dog. "Yes," he nodded vigorously while his mummy was most happy too..

Time was running out as the bacterial toxins would cause permanent kidney damage. The father's decision to operate  saved the dog's life. .

Now, as at Jun 25, 2014, around 2 months after spay, the 14-year-old dog is normal.

This case encourages the vet to care for the sick pyometra dog taken home by the owners who do not want spaying. I did this by following up with the owner the next day via telephone call. Reducing the medical costs would be needed in some cases where money was a concern. I reduced the medical costs by 50% so that the little boy's companion has a chance to survive and live to a ripe old age.

3.  Judgment Day on closed pyometra - when to operate?
http://www.youtube.com/edit?o=U&video_id=ZykWoYi9imY

The old female dog had a bloated abdomen. Closed pyometra was diagnosed on history, palpation x-rays and blood tests.

The options for the owner were:
1. No operation. The dog will die from septicaemia.
2. Operation on the same day after I/V drip & medication of around 3 hours. Higher anaesthetic risk as the dog is lethargic and unfit for anaesthesia. But delay of several hours may result in the swollen uterus rupturing, spilling out the bacteria and toxins into the abdomen, killing the dog.
3. Operation on the next day after I/V drip & medication. This stabilises the dog's health as the drugs have time to take effect to kill off the bacteria inside the blood stream. However, the uterus is about to burst anytime and an emergency spay is strongly advised (Option 2) with its much higher risk of anaesthetic death on the operating table .

This is a judment call for the owner and the vet. The owner bears the responsibility for the dog's death. She selected took option 2. The dog survives the operation. She comes back on Day 11 for stitch removal. Everybody has a happy ending in this case but not all closed pyometra dogs survive.  Many die as the owner delays several days seeking veterinary treatment or the vomiting dog has had been mis-diagnosed for gastro-enteritis when the owner does not permit blood testing and X-rays. Spaying your dog young would have prevented pyometra, higher medical costs and much emotional distress when closed pyometra occurs and remain neglected resulting in the dog's untimely death.


4. How to spay a cat and prevent stump pyometra
http://www.youtube.com/watch?v=W6MUKoweHv8

This video will be shown at the Yezin University, Veterinary Science Talk to Final Year Vet Students

TALK TO FINAL YEAR STUDENTS OF VETERINARY UNIVERSITY OF VETERINARY SCIENCE, YESIN, MYANMAR ON AUG 15, 2014  - Dr Sing Kong Yuen, Toa Payoh Vets

Topic: How to be a great vet?  Belief, Passion, Drive, Perseverance & Focus. Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS


A Be Kind To Pets Veterinary Educational video will be used for presentation to Final Year students at the Yezin Vet University, Myanmar on August 14, 2014 by Dr Sing Kong Yuen of Toa Payoh Vets..

Spay surgery was performed by Dr Daniel Sing, Toa Payoh Vets.

Incise about 1.5 - 2 cm from the umbilical scar to get good access to the ovaries, especially in dogs..

In cat spays at Toa Payoh Vets, we anesthesize the cat, using xylazine + ketamine IM with isoflurane gas + O2 top up if necessary. Monosyn 3/0 absorbable suture is used. 

Stump pyometra is due to the release of an ovary or ovarian tissues into the abdomen by the vet who has had "spayed" the cat or dog. The stump of the uterine body becomes infected with pus after "spay", due to ovarian hormonal influences or synthetic progesterone (Depo-M, Contracep, Ovarid) given as birth control.

In July 2014, I had to prescribe antibiotics for a cat incompetenly spayed by a vet. The cat continues to caterwaul after spay. The owner had Ovarid before and found it to be useful in stopping this anti-social noise making by the "spayed" cat. The owner complains of a yellowish vaginal discharge after the use of Ovarid. This was a diagnosis of stump pyometra.

The owner was not keen on surgery to take out the ovarian tissue or ovary present inside the abdomen.

In Myanmar, Depo-M or Contracep IM injections are given to prevent pregnancy and there are many cases of pyometra in unspayed cats and dogs. This practice results in pyometra after a few or one injections and spaying is the solution.  

In Singapore, pyometra is common but in the older female dogs not spayed as some Singaporean dog owners believe that it is cruel to spay a dog. Dogs do not "caterwaul" unlike cats and so there is no urgency to spay them.  No Depo-M or Contracep injections or long-term Ovarid (synthetic progesterone) are given by any vet as the owners either spay or not spay their female dogs.  

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