Thursday, August 1, 2013

1050. KPI - How long it takes to remove a big bladder stone?




3. INTRODUCTION - SAC (Speed, Accuracy, Completeness).  Speed is especially important in the old dog as the heart may fail when surgery is prolonged. This video is to share my surgical experience and process in removing a big bladder stone in a 10-year-old poodle. I have had been in small animal practice for around 30 years and therefore the surgical time taken would be shorter.  

4. Systematic Process & meticulous records
    Examination - Palpation of bladder. Risks and complications esp. in old dogs to be discussed. Economics to be discussed. Dog on antibiotics for 7 days prior to surgery by Dr Sing Kong Yuen.
    Medical advices of 4 test given to be recorded to prevent misunderstandings as the family members may not communicate with each other after visiting the vet.  These tests are:
    4.1  Urine test. Absence of urinary crystals do not mean no stones are present.
    4.2  X-ray. The owner said he was not told about X-rays in this case. I advise an air-contrast radiography by injecting 30 ml of air into the bladder prior to X-ray. (X-ray image). The female dog should be catherised for the catheterrisation.
    4.3  Blood test for health screening pre-op.
    4.4  Stone analysis is important for prevention.

5. Videos x2  by one intern. Extract relevant clips.
Case of Kerri.

X-ray of urinary stones

6. Illustrations of vet surgery to be done to reinforce the surgical techniques or pull out clips from the video and write subtitles.
Reference to X-ray (image) pre-op
Tools needed.
Sterile swabs isolates the bladder
Incision to be as small as possible
Irrigation of bladder to flush out smaller stones
Catheter into female urethra to dislodge any stone if present
First layer. 2 anchor sutures with artery forceps.
Second layer.

Post-op complications
Bleeding -
Death of old dogs in poor health. IV drips. 

Performance indicators. How long it takes for an experienced vet to remove a bladder stone from a female dog.

TEXT See below

tpvets_logo.jpg (2726 bytes)TOA PAYOH VETS

Date:   19 June, 2013  

Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits
KPI - How long it takes me to remove a bladder stone in a poodle 
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVSDate:   19 June, 2013 
Be Kind To Pets
Veterinary Education
Project 2010-0129

Friday, June 14, 2013

1460. Update: KPI - How long it takes to remove one bladder stone from a poodle?

Friday June 14, 2013

I share my surgical experience with regards to the removal of a bladder stone from an old poodle and to provide a benchmark to enhance the standard of care by younger vets at Toa Payoh Vets.

How long it takes to remove one bladder stone from a poodle?

Poodle, 10 years, 4.1 kg 38.8 C. Dog was panting but owner said this was normal behaviour of excitement. Urinated blood yesterday, incontinent and now had abdominal distension the size of a small mango, indicating a much swollen bladder with difficulty in peeing.

Had antibiotics for past 7 days. Blood in urine. Dark red cloudy urine. Dog's abdomen distended on arrival. Anti-spasomodic injection and antibiotics enabled dog to pee and on surgery, bladder was empty but swollen with 8 mm wall (normal bladder is around 3 mm)  

2 packets of sutures 3/0 absorbable Polysorb, 3/0 nylon for skin

A: Injection of Induction Drugs  2.50 pm
B:  Isoflurane gas first given:     2.55 pm
C: Isoflurane gas stopped:         3.39 pm
D: First skin incision:                3.11 pm
E: Completion of skin stitching   3.41 pm

E-D = 30 minutes for a vet with 40 years of experience. 
E-A = 51 minutes
C-B = 44 minutes of isoflurane gas + oxygen used.

1. Domitor + Ketamine 0.1 + 0.11 ml IV in 3 ml of saline
2. Dog intubated 5 minutes after Dom + Ketamine IV. She was intubated a few times but seemed not to be breathing the isoflurane. Barked twice. Eyes blinking. I did not want to waste time to mask and intubate as this is an old dog and every second counts towards her survival rate. I decided to use gas mask which was excellent anaesthesia from 3% maximum for maintenance.

1. I palpated the empty bladder with stone. In female dog, I do not catherise unless necessary.
2. I incised where the bladder was located. Spread out the SC fat, linea alba cut and pop out the empty bladder.
3. I turned the bladder backwards, exposing the dorsal part of the apex.
4. Incised 1 cm. Popped out the stone which would be slightly >1 cm across.
5. My assistant flushed bladder with saline. I squeezed out any remaining debris or crystals, known to be struvites.
6. A urinary catheter passed from inside bladder to outside the vulva to dislodge any stones if present in the urethra.
7. I suture the 8-mm thick submucosa first with a layer of inverting sutures, parallel to incision.
8. At one end, I anchored the artery forceps and proceeded to suture a similar continuous inverting suture layer to the other end from bladder serosa and mucosa. "Suturing is similar to Caesarean section uterus," I said to Dr Daniel. I used 3/0 Polysorb sutures and throw 5 knots/tie.
9. "Some vets inject saline into the bladder of the female dog after suturing to see if there is a leak," I said to Dr Daniel. "I don't do it as the closure is tight with two layers." He took a video.
10. Closure of the linea alba (simple interrupted & continuous overlay).
11. Skin - horizontal mattress x 3 with 3/0 nylon.
12. There was some profuse bleeding post -op.  "Probably the bigger artery from the caudal epigastric blood vessel," I said. After bandaging, the bleeding stopped.

The dog vomited twice, yellow gastric juice some 15 minutes after surgery, but seemed OK. "Barking non-stop before surgery," I said to the owner who visited. The dog sprang onto him as if she did not have any major op. Still barking non-stop as at 7.35 pm when I recorded this case. Incredible. The owner is advised to give the S/D diet but the dog did not like it. There are still small stones inside the left kidney and S/D may dissolve them. But the dog would not eat the S/D. "Give 10% mixed with home-cooked food and increase daily," I said. "It is important to avoid kidney stone operation!"  

An unusual old dog so active 2 hours post op. Compared to the overweight Jack Russell who is drinking lots of water and depressed, lying down 2 days after 10 small bladder stone removal surgery. He would stand up when the owner came.

I phoned the owner. He said the poodle had started to eat more and was more active. The bruised redness of the belly area had moved to the thigh. I asked him to WhatsApp the images to me. The advantage of the patient going home on the 2nd day of surgery is home nursing and lower medical costs. The disadvantage is the dog cannot be crated and running around at home movement causes wound breakdown or infection

The dog returned to Toa Payoh Vets on Saturday June 15, 2013, on the 2nd day after surgery as she was fit. The other Jack Russell, on 3 bottles of IV drip was more active and barked on Saturday, much to the joy of the owners. He was drinking and drinking a lot of water of Friday lying on his chest and looking lethargic. He would walk when taken out but preferred to lie down for the last two days..
Updates will be on this webpage:
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tpvets_logo.jpg (2726 bytes)Toa Payoh Vets
Clinical Research
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All rights reserved. Revised: June 19, 2013

Toa Payoh Vets

Video clips to be edited by interns:

497 & 504. Location of Toa Payoh Vets in 2013. Industrial Park. Lorong 8 Toa Payoh. Near a Hindu Temple off Lorong 8 and Golf driving range from Toa Payoh East.

457 & 450. Patient before surgery. June 2013. Abdominal swelling is not ascites. It is a swollen bladder as big as a mango. Edit clip to show swelling. Not eating. Passing blood in the urine. Dribbling urine.
X-ray (image), catheterisation of female urethra to empty bladder and pump in 30 ml of air into bladder for contrast radiography. (image).

460. IV sedation given by Dr Daniel Sing.

465.Surgery by Dr Sing Kong Yuen. Bladder pushed out. Incise bladder as small an incision as possible. Stone taken out. Irrigate bladder with normal saline to flush out other smaller stones. Catheter inserted from bladder into female urethra to dislodge any stones stuck inside.

3/0 absorbable sutures used.
First of 2 rows of inverting sutures to close the bladder incision in this image. The submucosa is stitched in the first row in this video.
Clip of forceps anchoring suture at two ends of the knots. (Edit clip and highlight or illustration).

483. Submucosa stitched. Knot at one end. 2nd artery forceps anchor it. (Edi clip and highlight or illustration). 2nd row of sutures being placed.

484. Bladder incison fully closed. Some vets inject saline to check for leakage. Not necessary in this case as the two rows are tight.

485. 30 minutes after surgery.

490. Post-op bleeding seen. Back area bandaged. Subcutaneous blood vessel bleeding likely.
Dog vomited twice. Bladder stone (image). Struvite from stone analysis.

492. 3 hours after surgery. Barking loudly. Goes home. Dr Sing's comments on this old dog's barking as a good sign of health.

UPDATE IN AUGUST 2013. Dog recovers at home. Refused to eat the Prescription S/D diet which is recommended to dissolve the struvite stones in the kidney. X-ray shows stones in kidneys (image of X-ray). 

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