Tuesday, January 26, 2016

KPI. How long to do a French bulldog caesarean section? 47 minutes for 7 pups

Jan 27, 2016

A very smelly vaginal discharge. A dead pup was born 3 hours earlier at 8 am. The breeder phoned me for Caesarean section at 9 am.

The black and white French Bulldog, F, 4 years appeared normal, with normal rectal temperature at 38.4. This was her. 2nd Caesarean section.  Her swollen body looked symmetrical and I predicted 4-6 puppies.  Copious amount of dirty reddish brown vaginal discharge
She weighed kg and was stocky. "Probably all puppies are dead," the breeder said. "She's 60th day pregnant and I don't expect a dead smelly pup to be born naturally."



B: Isoflurane gas given: 10.12 am
C: Isoflurane gas stopped: 11.07 am
D: First skin incision: 10.20 am
E: Skin stitched: 11.07am

C-B = 55 min
E-D = 47 min.
7 puppies distressed. 3/7 are dead. 
Of the 3 dead pups, one was a shrivelled foetus, the other two showed yellow meconium covering the body .  
All handed to breeder to revive. He and his assistant had 4 live pups revived. the dam alive.



Details
10.23 am   incise uterine body (small incision)
10.29        4th puppy out
10.32        5th puppy
10.33        6th puppy
10.35        7th puppy to breeder.
10.36        stitch uterine body. 2 rows inverting sutures
10.49 - 10.58  stitch linea alba and muscles. lst row simple interrupted. 2nd row continuous.
10.59 - 11.07  stitch skin horizontal mattress and walk-in muscle suture

Blood test
IV dextrose during operation
IV Hartmann's + 5 ml Theracalcium to give at home. Dog vomited at the beginning of IV drip of Hartmann's.  This happened to the pre-partum Pomeranian yesterday too. She vomited yellowish brown fluid when first given the Theracalcium 1 ml but was OK subsequently and gave birth to 4 pups naturally 24 hours later.

Breeder said that the dam looks much more "solid" after the drip and would continue.

Technique
1. Skin incision around 6 cm. I did not exteriorise the whole uterus and hence skin incision smallshorter.

2. Finger inside abdomen to feel for bifurcation of uterus. This permits me to identify uterine body.
3. Incise uterine body of around 6 cm.
4. Milk out the pups.
5. Clamp umbilical cord with 2 forceps. Cut between forceps. hand pup with one forceps to breeder. 6. The shrivelled and another dead pup had dark brown colouration and were detached from the placenta.


CONCLUSION
Early foetal death of one pup. A mummified foetus. This could have become decomposed and spread the toxins to the other puppies nearby. So only 4 of the 7 puppies I took out were alive after revival by the breeder.  I advised him to use good quality commercial diet which is balanced nutritionally for pregnant dogs as he had been feeding his own chicken and fish meat mixture. Some dams would not have a balanced calcium intake.


Reference:
http://www.merckvetmanual.com/mvm/metabolic_disorders/disorders_of_calcium_metabolism/puerperal_hypocalcemia_in_small_animals.html


Sunday, January 24, 2016

2926. When there is life, there is hope - Eclampsia & Theracalcium in a pregnant Pomeranian


1.  HOOK

On Jan 24, 2016 at 8 a.m, a dog breeder phoned me as I was driving to work.
"No hope, no hope at all!" the experienced breeder told me. My 54th day pregnant Pom collapsed. Stiff. Cannot stand up. No hope. No hope. She will not survive!"



VIDEO OF POM IN SIMILAR NECK TWISTED POSITION AS IN THE IMAGE BELOW

 2. THIS IS A BKTP


 


 




Jan 24, 2016

8.30 am   He wanted a  house-call. I got him to come to the surgery. He wanted to come after his breakfast. I advised him to come immediately as it was an emergency.

9.30 am
Pomeranian could not stand up. Her legs were stretched out rigid as if she had tetanus. Slightly fast heart and breathing rate. Rectal temperature of 39.5 deg C was considered on the high side. At 54th day pregnancy, it was too early to perform an emergency Caesarean section. My first diagnosis was eclampsia (hypocalcaemia) which is rare during pregnancy in dogs as compared to after birth.

No blood tests were performed to reduce medical cost for the breeder. Puppy prices are low nowadays owing to lack of demand for Pomeranians and alleged puppy smuggling into Singapore.

I injected Theracalcium  (France) 1 ml. slowly. The Pom vomited thrice, yellowish brown vomitus. i gave a bottle of 500 ml IV drip with amino acids and glucose till 12 noon. The dog stood up and wagged her tail. I took a video as proof

VIDEO
Since she appeared normal, I took off the IV set and asked the breeder to take the dog home. . 

3 pm
The breeder came. He said that the dog was not standing then. He phoned at 7 pm to say that I ought to have left the IV canula inside the vein so that the dog could be given another infusion. I told him that the dog had recovered and I showed him the video. He was not satisfied as the dog now was back to her original state of not being able to stand up, with the head twisted sideways rigidly.

VIDEO

7pm.    This was a relapse. The lateral right head tilt was prominently seen now. The rigid limp. But the rectal temperature was normal at 38.4 deg C. 

The calcium levels from the 1 ml of Theracalcium in the blood had not lasted for more than 6 hours. Hence the Pom collapsed again.

Dr Daniel came back from his engagment to help me out. He gave Theracalcium  1 ml slowly after setting up the IV drip of Hartmann's solution.. The dog vomited thrice, yellowish brown vomitus.
I pumped 6 ml Theracalcium inside the bottle of Hartmann's solution for slow drip at home from 8.30 pm to 2 am.

Jan 25, 2016. 
2 am
The dam recovered and ate a can of Science Diet A/D. This was good news for the breeder who expected the Pom to pass away. A bottle of 5% dextrose saline was given.

4 pm
The Pom tore off the I/V set and was back to her normal self.

9.30 pm. I visited the breeder's farm. 3 pups had been born naturally and had been kept inside a basket covered by towels. The Pom had stopped uterine contractions. "Let the 3 pups suckle her," I said. "Suckling will stimulate uterine contraction."

The Pom contracted and the 4th pup came out around one hour after the 3rd pup.

CONCLUSION
This was a rare case of eclampsia in a pregnant Pom. The 80-year-old breeder has over 50 years of breeding experience but he had not encountered such a clinical presentation. Neither will most vets as eclampsia usually occurs in the 2nd - 4th week of dogs with large litters; 

"I expected my Pom to have died, but now she gave birth to 4 beautiful puppies," the breeder remarked. He was most happy.



It was a happy ending due to the sufficient amount of calcium being given IV. This case shows the vet that "when there is life, there is hope."  The diagnosis must be correct.

Theracalcium (France)

The volume of Theracalcium must be given sufficiently and not overdosed to avoid cardiac toxicity such as arrhythmias, leading to death.

In this 5-kg Pom, the first time of 1 ml of Theracalcium IV was insufficient to last 24 hours.

The second time of 7 ml (1 ml IV direct and 6 ml in Hartmann's solution) was just right and the Pom gave birth 24 hours after the second injection.  

The manufacturer gave a guideline for IV, SC and IM injection as follows:
For dogs: 0.25 - 0.5 ml/kg.    That means 1.25 ml - 2.5 ml.
For dogs: 2-10 ml.                  I gave 7 ml during the relapse. The Pom did not die but gave birth naturally to 4 good-sized pups. I suspected the breeder had the pregnancy dates incorrect but he said that Pomeranian puppies are well developed by the 56th day. He has over 50 years of dog breeding experience. I respect his solid years of breeding experience. I am glad his prophecy was not fulfilled and we all had a very happy ending. .   

 





---------------------------------------------------------------------------------------------------------------

















POST SCRIPT.

1.  THERACALCIUM (France) PER ML
1.  Calcium  32.6 mg (as Calcium gluconate)
2. Calcium 8.2mg      (as Calcium gulcohepatonate)

IV, IM, SC
Dogs 10-20mg/kg   2-10 ml    0.25-0.5 ml/kg.    
Therefore this dam, 5 kg = 50 - 100 mg or 1.25 ml - 2.5 ml


In this case, the dam was given 1 ml direct IV and 6 ml in the IV drip  after the relapse. This 7 ml appeared to be sufficient and not cardio-toxic.


2. BSAVA POCKETBOOK FOR VETS
Hypocalcaemia
Calcium 50-150 mg/kg calcium (as calcium boroguconate}. 0.5-1.5 ml/kg of a 10% solution IV over 20-30 min. For this 5-kg Pom, it will be 2.5 ml - 7.5 ml

According to the website of manufacturer, Theracalcium has an advantage over calcium borogluconate in being longer-lasting and having less cardio-toxicity (fast heart beat due to arrhythmia) or fast breathing rate leading to death.

Calcium gluconate increases serum levels within 5-20 min for 5-6 hours
Calcium glucoheptonate increases serum levels within 3-4 hours and up to 12 hours.
Less risk of cardiotoxicity compared to calcium borogluconate as it has lower total calcium than the usual dose administered.   Calcium equivalent in Theracalcium is 32.6g + 8.2 g = 40.8 mg of Calcium per ml



FOLLOW UP ON FEB 13, 2016
Eclampsia was in Jan 26, 2016 (see video).


The 4 pups have opened their eyes and are thriving. The breeder is most happy.








             

Saturday, January 23, 2016

Referral from clients are best. Ear disease. Skin diseases

Jan 23, 2016

Two referrals today (Saturday) are interesting.


1. "I could buy ear drops to treat the skin disease," the owner said that the vets prescribed ear drops over the years




2. "The other vets diagnosed allergies," the retiree complained. "They do test and say nothing is seen. I went to a vet who specialises in skin diseases but my dog is still not cured."

Some skin diseases are difficult to diagnose. Food allergy is one cause but the owner did not accept allergy testing.



  

Wednesday, January 20, 2016

2924. INTERN. Breeder's perception of heavy anaesthetic dose - respiratory distress of puppies

Jan 20, 2016

HOOK (Video)
Breeder:  "The puppies were overdosed with anaesthesia. That is why the puppies are not crying after delivery."

What is the answer to this question?


MEDICAL HISTORY
On the 6lst day, the Dachshund, female, 3 years was not active as on the day before. She stopped walking although she ate. The breeder decided on Caesarean section at 8 pm.

C-section. 3 large pups. 2/3 distressed as they were not crying till more than 10 minutes after delivery.  61st day (average 59-63 days)


PHYSICAL EXAMINATION
Alert, no fever. Uterine inertia
No uterine contraction




SURGERY






SURGERY





Education of the breeder is very important. This was his 6th Caesarean section in the last 3 months. He had various vets in the past 30 years performing C-sections for him and had acquired knowledge of anaesthesia and outcomes from the vets.  

Isoflurane gas
1. A very safe anaesthesia for caesarean section compared to other injectable anesthetics.  Puppies would cry on delivery provided there is no delay in getting the Caesarean done and the dam is healthy. 

Evidence: I had done over 100 caesarean section for various dog breeders in Pasir Ris. There was no complaint about puppy deaths attributed to isoflurane anaesthesia.

2. No pre-op sedation injections were given and so the puppies could not be sedated on delivery. 
3. Others

Monday, January 18, 2016

2923. An active 1.5-year-old blue-merle Shetland limps on the left fore leg

Jan 19, 2016

The mum and her young adult daughter made an appointment to see me.
"His lameness was in the back last time," the daughter said. "Now, it is on the front leg. Limping around now and then for the past 2 weeks. My brother surfed the net and thinks the cause is a sprain or genetic."

As if to confirm the owner's complaint, the 1.5-year-old Sheltie would walk around my consultation room, stood at the corner near the door and lifted up his left fore limb. When he walked, this happened too.

The mum held the dog down by putting her hand on his shoulder area while the daughter held his backside down. Not without a struggle. I muzzled the gentle dog in case he bites anyone while I manipulated the left front limb from toe to shoulder. Safety of people is important.

The dog yelped in pain when I flexed and extend the left elbow and shoulder.
"This is acute pain," I said.
"Should we X-ray the joints?" the mum thinks this could be genetic in cause.
"This is a young dog. Did he jump up and down inside the apartment and run down the flight of stairs?" I noted the owner lived on the 22nd floor.

"No," the daughter said. "We take the lift. However he does jump from the car floor to the road, play roughly with other dogs downstairs and runs down the ramp."

"Young dogs, like young men and women think they are invincible and take risks to their lives," I said. "Some suffer injuries or deaths because of this type of life-style."

No x-rays for the time being. The dog was given painkillers and to avoid jumping on or off the car, run down and up the ramp and play rough with the other dogs for one month. If not, the joint pain will worsen.

This is the third of 3 recent cases where the mum and young daughter brings the pet to the vet. The other. The other case was the chronic coughing cat and the tattoeed hand girl with her mum bringing the Schnauzer with strangulated uterus.

2922. An eosinophilic cat has a "lungworm"?








Has the chronic coughing cat a lungworm?

This is a strange case. The much beloved old Himalayan cat has chronic coughing for the past 6 months. Yet the heart and lung sounds were normal when examined by Vet 1 earlier and myself on Jan 18, 2016. I could hear rapid breathing which could be due to this cat being unhappy at the vet.
The cat had good appetite but now had a sore throat owing to daily coughing nowadays. 

MEDICAL HISTORY.
Oct 2015. Went to Vet 1.  Occasional cough. Cough medicine did not banish the coughing.
Dec 2015. Went to Vet 1.  Coughing more often. Vet 1 wrapped cat around towel to examine the cat in a room away from the owner. Vet 1 prescribed antibiotics and steroids but the owner did not give them to the cat as there was no definitive diagnosis. Vet 1 did advise X-rays.Vet 1 noted that the heart and lungs sounds were normal.

On Jan 18, 2016, a mother and young adult daughter brought the cat to consult me. I confirmed the heart and lung sounds were normal. There was a rapid breathing rate which I attributed to the cat being unhappy with examination by any vet as he tried to claw me now and then. He did not like his head area touched. I palpated his enlarged left submandibular lymph node when the owners were distracting him, but he would not permit opening of his mouth. Was there a tumour in his painful throat?

"X-rays of the throat and lungs are needed to check for tumours or other abnormalities," I advised as simply giving antibiotics would not be useful in chronic coughing. "A blood test is needed to check for blood-borne infection and diseases of the liver and kidneys." 

The owners agreed and the results are as follows:


X-RAYS

The cat was stressed when isoflurane gas was given via the carrier and bag. As an alternative, he was given a lowest dosage of IM injection - xylazine 0.3 + ketamine 0.2 ml IM to enable a thorough physical examination of the mouth, throat and abdomen.

Reversin 0.15 Im woke up the cat in less than 15 minutes.


 
 

 

BLOOD TEST
Leucocytois with neutrophilia and thrombocytopenia suggest a septicaemia on Jan 18, 2016.
Eosinophilia suggests allergy, parasitic or tumour condition. 
No liver or kidney disorders.

COMMENTS
Close up of the X-ray appeared to show a donut-shaped object looking like a lung worm swallowed inside the left lower lung. This would account for the eosinophilia. Tumours would also cause eosinophilia. Eosinophilic granuloma is a possibility although the lesions manifest in the mouth and skin usually.

The X-ray shows a full stomach, suggesting that the cat has a good appetite. The throat was very painful due to daily coughing. Antibiotics and anti-inflammatory medication was given. Review in 10 days. May need deworming (Panacur, ivomectin or Revolution).

PHYSICAL EXAMINATION UNDER SEDATION
Tonsils are enlarged. The owner said they had been enlarged for some time. No tartar or calculus in all snow white teeth as if they were brushed daily. 


 

CONCLUSION

Follow up by tel on Jan 19, 2016. 
"The cat eats and is more active," the young lady said. "Less coughing."
"If the lung lesion is not a tumour or lungworm, we will see complete recovery in a month," I said. 

Chronic coughing of 6 months' duration and old age suggests a high probability of a pulmonary tumour.  A review is needed in 2-4 weeks' time by telephone.

   




Sunday, January 17, 2016

2921. A much loved 13-year-old Sheltie has a right head tilt - vestibular disease

Jan 16, 2016

The 13-year-old Sheltie has a right head tilt, became off-balance. What is the cause and solution?
Some old dogs suffer from chronic ear infections. The infections rupture the ear drum and affect the middle ear where the organs of balance are located. Many old dogs suffer from vestibular disease.


In this Sheltie, the first vet did not resolve the loss of appetite and balance to the owner's satisfaction. The owner consulted me on Jan 2, 2016.  I anaesthesized the dog and irrigated the right ear and did a dental scaling. There was fresh blood deep inside the right ear.

Around a week later, the lady owner phoned me saying that she cleaned the pus discharging from the right ear every day.  I checked the dog's right ear on Saturday Jan 16, 2016. There were thick plugs of brownish yellow purulent exudate. These were flushed out. X-rays of the ear showed some masses at the horizontal canal area.

   

Saturday, January 16, 2016

2920. Saving an old Silkie Terrier's eyeball

Jan 17, 2016

After one month of intense eye pain and rubbing, the first vet advised enucleation (removal of the eyeball) to resolve the problem. This was a deep corneal ulcer. The owner asked me for a second opinion. He was an old client but had gone to the other vet.

It was already one month and the tarsorrhaphy works very well with injuries sustained within 24 hours. He was agreeable to the surgery. Outcome was excellent. The dog did not need enucleation and has his eyeball and eyesight back. Images are shown below but not in order. There is a video at:
https://www.youtube.com/watch?v=aUEC5WmmJ-s












  

2919. Top 10 most common bird blogs

1.  10000birds.com
2. blog.aba.org
3. leesbird.com
4. birdingblogs.com

5. birdchick.com/blog.htm
6. nemesisbird.com

7. billofthebirds.blogspot.com
8. birdingisfun.com

9. urbanhawks.blogs.com
10. besgroup.org    Bird Ecology Study Group

2918. X-ray interpretation website - ear x-rays

http://www.acvr.org/node/335 used to provide case interpretations of x-rays  in 2015 but now no more.



Cat

Friday, January 15, 2016

2917. Fat deposit behind the rabbit eye's cornea? Images





Jan 16, 2016

Fatty deposit behind the cornea of a rabbit's eye?






Thursday, January 14, 2016

2916. Farm Visit with intern - Caesarean section of 3-day-old Maltese pups healthy










Jan 14, 2016

I find time to visit the breeder after Caesarean section to do a follow up. For home breeders, I phone them to enquire about the dam and puppies. Much can be learned by going to the grass root level instead of being in the ivory tower all the time.

In this visit, Breeder William Goh wanted subcutaneous sutures as the ends of the sutures will not prick the suckling puppies. I did use subcuticular sutures and two horizontal mattress sutures on the Dachshund and he had no complaint. He was not happy with the simple interrupted sutures done by Dr Daniel and said it was old school and outdated as the ends pricked the puppies trying to suckle.

He has a point. I use only horizontal mattress sutures in over 100 caesarean sections in dogs and had no complaint. He did not complain about my sutures being stiff and high risk to his puppies because I use Polysorb which is a braided absorbable while Dr Daniel used Monosyn which is monofilament absorbable closer to the "nylon" in composition. What he wanted was subcuticular sutures for all his Caesarean sections. This is not necessary and I seldom use this subcuticular sutures as they may break down. I used horizontal mattress sutures with the ends on one side of the incision, unlike monofilament simple interrupted sutures with ends on both sides..    

Horizontal mattress sutures may not look good but they are not crossing the incision line and may be stronger in holding the ends of the skin together. This is my experience in over 100 C-sections.

I hope the intern Su-en going to 3rd year of Melbourne University Vet School in 2016 learnt more on this farm visit than from textbooks and lectures.