17.10. 12
Mini-Maltese, Male, 1 year, 2 kg
Right testicle undescended
I used xylazine 0.2 ml IM, then isoflurane by gas and intubated.
Two separate incision of skin areas for removal of the testicles
A: Injection of xylazine 3.45pm
B: Isoflurane + O2 gas given 3.58 pm. Intubated
E: Completion of skin stitching 4.17 pm
PDS 3/0 x 1 pack
The whole process E-A = 32 minutes.
I wasted some time trying to shift the undescended right testicle to the skin incision made for the normal testicle but it was not possible and to avoid incising the urethra accidentally, I made a separate skin incision. So, the whole process takes longer.
As Domitor was out of stock, I used xylazine IM which I used to do for many years. Now the vets tend to use domitor + ketamine IV at 0.4 ml + 0l5 ml IV for a healthy young 10 kg dog, after being convinced by me that the combinaton formula was effective and safe esp. if given at 50% and then top up with isoflurane + O2.
Friday, October 19, 2012
1148. KPI - Spaying a ferocious caterwauling cat
Today, a Nepalese couple brought in a tricolour 7-month-old caterwauling cat adopted from the SPCA. "Will she stop making noises after spaying?" the wife asked. "Yes," I said.
For caterwauling cats, the ovarian and uterine blood vessels are enlarged and special care must be made to ligate well. I threw around 10 knots on each ovarian side and around 15 knots on the uterine body. I don't do transfixing ligatures on the swollen uterine body.
As the cat was ferocious after the owner left and was put inside the cage, my assistant Min was pawed at everytime he tried to take the cat out of the cage for me to do the sedation injection. He went to get a big rag. "Don't do it," I knew this cat would escape from his crutches if he tried to grip her scruff of the neck now that the cat was big eyed and hissing.
ANAESTHESIA
"I will inject the cage through the cage," I said.
Mr Min had his idea of lassoing the cat and then pulling one leg out for me to inject the back muscle. He tried and I injected partially as the cat twisted and turned, pulling back her leg. He attempted again and I managed to inject the 80% of the remaining sedation drug. So, there was not 100% given.
Normally at xylazine 0.15 and ketamine 0.6 = 0.75 ml IM combined would give a very good anaesthesia for me to spay. In this case, the cat was twitching her legs towards the end of spay and there was no need to top up with isoflurane + O2.
Skin stitched - first skin incision = 21 minutes. I hooked out the ovary at the first attempt. A caterwauling cat takes much longer to spay as I had to ligate the ovarian side with 10 throws of the knot each and the uterine body with 15 throws. 3/0 absorbable x 1 packet used.
I would expect 10 minutes will do for normal non-caterwauling cats. Will check out my other KPI cases of cat spay.
TOTAL TIME FROM INJECTION OF SEDATION DRUG TO SKIN STITCHED =
11.43 am - 11.10 am = 33 minutes. The cat was clipped after sedation but normally I get the cat or dog clipped before sedation, thereby reducing my surgery and anaesthetic time. It takes about 2 minutes to clip.
As at Oct 25, 2012, no complaint or news from the Nepalese couple.
For caterwauling cats, the ovarian and uterine blood vessels are enlarged and special care must be made to ligate well. I threw around 10 knots on each ovarian side and around 15 knots on the uterine body. I don't do transfixing ligatures on the swollen uterine body.
As the cat was ferocious after the owner left and was put inside the cage, my assistant Min was pawed at everytime he tried to take the cat out of the cage for me to do the sedation injection. He went to get a big rag. "Don't do it," I knew this cat would escape from his crutches if he tried to grip her scruff of the neck now that the cat was big eyed and hissing.
ANAESTHESIA
"I will inject the cage through the cage," I said.
Mr Min had his idea of lassoing the cat and then pulling one leg out for me to inject the back muscle. He tried and I injected partially as the cat twisted and turned, pulling back her leg. He attempted again and I managed to inject the 80% of the remaining sedation drug. So, there was not 100% given.
Normally at xylazine 0.15 and ketamine 0.6 = 0.75 ml IM combined would give a very good anaesthesia for me to spay. In this case, the cat was twitching her legs towards the end of spay and there was no need to top up with isoflurane + O2.
Skin stitched - first skin incision = 21 minutes. I hooked out the ovary at the first attempt. A caterwauling cat takes much longer to spay as I had to ligate the ovarian side with 10 throws of the knot each and the uterine body with 15 throws. 3/0 absorbable x 1 packet used.
I would expect 10 minutes will do for normal non-caterwauling cats. Will check out my other KPI cases of cat spay.
TOTAL TIME FROM INJECTION OF SEDATION DRUG TO SKIN STITCHED =
11.43 am - 11.10 am = 33 minutes. The cat was clipped after sedation but normally I get the cat or dog clipped before sedation, thereby reducing my surgery and anaesthetic time. It takes about 2 minutes to clip.
As at Oct 25, 2012, no complaint or news from the Nepalese couple.
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.
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.
1146. The young guinea pig dies from respiratory distress
"What is the cause of death?" the woman in her 40s asked me as I phoned her to say her guinea pig had
Star tortoise passes red blood, shells ooze red blood
The case of the French-bean eating star tortoise
"I bought UV light and food as recommended by the pet shop, but my star tortoise just would not eat them," the owner said to me. "She eats only French beans and that was the only food she ate for the past 7 years."
The tortoise hospitalised the tortoise again but this time, I noted she had paler tongue and was purplish. Her shell borders ooze red blood. She passes red blood.
One week ago, the owner came as she was constipated for 2 weeks and was not eating. "Her shell is very thin," I said. "Not enough calcium. Eating French beans solely for 7 years has caused this problem. A tortoise should be eating a variety of food including shrimps and multi-vitamins and minerals."
But the tortoise just would not eat any other food. For 7 years. I asked Dr Vanessa to give her one ml of enema salts using a one-ml syringe. She pooped on the water and became more active. I gave an antibiotic injection IM. She went home but still would not eat.
So, this time, she was much weaker and her eyes closed most of the time. With so much blood leaking from her shell lines and fresh blood from her anus, the owner felt it was more humane not to let her suffer anymore. She was euthanased and cremated.
Another client with the jaw-abscessed rabbit saw the tortoise and told me how she successfully reared two tortoises now 8 years old. She showed me her i-phone images. The tortoises looked great. "I did a lot of research," she said. "I got one when she was a 50-cent coin size and then there was another one left at the pet shop. The operator asked me to take it and so I did."
"How do you train them to eat a variety of food?" I asked.
"I feed them by hand when they were young," she said. So, that was the solution to picky tortoises.
"I am more interested in how you toilet train them," I said.
"Star tortoises are not to be immersed in water as they are desert tortoises," she stated. "I put them into the water and they poop. Other times, I don't put them in the water." Normally, we don't immerse tortoises in water by use of a sloping platform for them to go up to be dry. However, medication and critical care powder was put into the water for this tortoise to drink. It was too late to cure her.
"It is excellent toilet training method," I said. "Are they still doing it now?"
"Now, the situation is haphazard since I have a domestic worker to care for them as I have a baby to care for." I requested her to write and share her knowledge as star tortoises are not common in Singapore due to a ban.
Intelligent owners nowadays know much more about the management of exotic pets than me if they have them as pets. Vets can't know everything. Now there are hermit crabs from Batam for sale and the pet shop operator has more knowledge of nutrition and husbandry than any vet in Singapore because we don't see hermit crabs in years. And today, an owner phoned me about his rat who chipped his tooth. What to do for sedation? Zoletil?
"I bought UV light and food as recommended by the pet shop, but my star tortoise just would not eat them," the owner said to me. "She eats only French beans and that was the only food she ate for the past 7 years."
The tortoise hospitalised the tortoise again but this time, I noted she had paler tongue and was purplish. Her shell borders ooze red blood. She passes red blood.
One week ago, the owner came as she was constipated for 2 weeks and was not eating. "Her shell is very thin," I said. "Not enough calcium. Eating French beans solely for 7 years has caused this problem. A tortoise should be eating a variety of food including shrimps and multi-vitamins and minerals."
But the tortoise just would not eat any other food. For 7 years. I asked Dr Vanessa to give her one ml of enema salts using a one-ml syringe. She pooped on the water and became more active. I gave an antibiotic injection IM. She went home but still would not eat.
So, this time, she was much weaker and her eyes closed most of the time. With so much blood leaking from her shell lines and fresh blood from her anus, the owner felt it was more humane not to let her suffer anymore. She was euthanased and cremated.
Another client with the jaw-abscessed rabbit saw the tortoise and told me how she successfully reared two tortoises now 8 years old. She showed me her i-phone images. The tortoises looked great. "I did a lot of research," she said. "I got one when she was a 50-cent coin size and then there was another one left at the pet shop. The operator asked me to take it and so I did."
"How do you train them to eat a variety of food?" I asked.
"I feed them by hand when they were young," she said. So, that was the solution to picky tortoises.
"I am more interested in how you toilet train them," I said.
"Star tortoises are not to be immersed in water as they are desert tortoises," she stated. "I put them into the water and they poop. Other times, I don't put them in the water." Normally, we don't immerse tortoises in water by use of a sloping platform for them to go up to be dry. However, medication and critical care powder was put into the water for this tortoise to drink. It was too late to cure her.
"It is excellent toilet training method," I said. "Are they still doing it now?"
"Now, the situation is haphazard since I have a domestic worker to care for them as I have a baby to care for." I requested her to write and share her knowledge as star tortoises are not common in Singapore due to a ban.
Intelligent owners nowadays know much more about the management of exotic pets than me if they have them as pets. Vets can't know everything. Now there are hermit crabs from Batam for sale and the pet shop operator has more knowledge of nutrition and husbandry than any vet in Singapore because we don't see hermit crabs in years. And today, an owner phoned me about his rat who chipped his tooth. What to do for sedation? Zoletil?
Wednesday, October 17, 2012
1143. Triple phosphate crystals in a young Shih Tzu X - health screening
Health screening is seldom done by Singapore pet owners esp. in young dogs in Singapore. A young lady wanted me to do a complete health check on her one-year-old Shih Tzu X Jap Chin, male. The complete blood test was normal but urinary analysis showed a tendency to formation of struvite urinary bladder stones as in my email to her below:
The analysis showed a likelihood of this dog forming struvite (triple phosphate) bladder stones.
A change to a diet that will acidify the urine to pH below 7.0 and monthly urinary analysis is recommended for the next few months. Pl contact me for further discussion.
Some info on struvite urinary stones are at:
1. http://www.bekindtopets.com/
2. http://www.kongyuensing.com/
Oct 17, 2012
HEALTH SCREENING OF A YOUNG DOG
Shih Tzu X Jap Chin, Male, 1 year old
The significant findings are alkaline urine (pH 8.0), the presence of triple phosphate crystals + and bacteria 3+, high specific gravity of 1.043 (1.005-1.030).
Shih Tzu X Jap Chin, Male, 1 year old
The significant findings are alkaline urine (pH 8.0), the presence of triple phosphate crystals + and bacteria 3+, high specific gravity of 1.043 (1.005-1.030).
The analysis showed a likelihood of this dog forming struvite (triple phosphate) bladder stones.
A change to a diet that will acidify the urine to pH below 7.0 and monthly urinary analysis is recommended for the next few months. Pl contact me for further discussion.
Some info on struvite urinary stones are at:
1. http://www.bekindtopets.com/
2. http://www.kongyuensing.com/
Friday, October 12, 2012
The 73-year-old flower seller and her 7-year-old Jack Russell
"My friend's dog vomited and died when sent to the vet," the 73-year-old flower seller from Geylang market limped badly yesterday (Oct 11,2012) and came by taxi at 8.30 pm. She was worried that her dog might die.
"Why are you still selling flowers?" I asked."Don't your children support you?"
"Why are you still selling flowers?" I asked."Don't your children support you?"
1141. Blood in the stools or no?
"To be frank with you, I consulted another" vet yesterday," the lady gave me a container with mucoid stools and some tissues of blood. "atA very nice place. The vet was nice and checked the stools under the microscope. He said no blood in the stools and no parasites. But my dog still has blood in the stools."
The other vet also prescribed some liquid medication and gave assurances that there was no blood.
"To me, this pinkish tissue looks like blood. But the lady said she fed the dog beetroot.
"Could it be the colour of beetroot?" she asked.
Fortunately, I had studied in Scotland and am familiar with the purplish blue beetroot which is eaten by Westerners.
"There will be very little blood," I said. "So, I will send this sample to the laboratory that specialises in blood and faecal tests as they will have the more sophisticated machines to detect it."
LAB RESULTS
STOOL FEME AND OB
Stool Analysis
Appearance Soft brownish stools
Microscopic examination (wet mount) leucocyters, erythrocytes+ detected
Occult blood Positive
The owner phoned at 10 am for the results. I told her. She asked me to fax a copy of the report to the other vet.
The other vet also prescribed some liquid medication and gave assurances that there was no blood.
"To me, this pinkish tissue looks like blood. But the lady said she fed the dog beetroot.
"Could it be the colour of beetroot?" she asked.
Fortunately, I had studied in Scotland and am familiar with the purplish blue beetroot which is eaten by Westerners.
"There will be very little blood," I said. "So, I will send this sample to the laboratory that specialises in blood and faecal tests as they will have the more sophisticated machines to detect it."
LAB RESULTS
STOOL FEME AND OB
Stool Analysis
Appearance Soft brownish stools
Microscopic examination (wet mount) leucocyters, erythrocytes+ detected
Occult blood Positive
The owner phoned at 10 am for the results. I told her. She asked me to fax a copy of the report to the other vet.
1140. Management of practice: 2 growling big mongrels
Yesterday, I noticed that 2 mongrels (male and female) were kept in the room. As I opened the door, they growled. We don't have space to house big dogs esp. the male Great Dane Cross. In any case, the owner wanted the dogs back on the same day. We also had a Husky in for treatment of constipation for the next few days and one big dog is sufficient.
"Why are the dogs not sterilised?" I asked Dr A.
"I didn't know Min is off today."
"Don't accept big fierce dogs if you can't handle them. Phone the owner and ask her to take rthem back! The vet in charge has to take responsibility for the sedation, not Mr Min. I have two vets and must we wait for Min to do it tomorrow?"
I advised the two vets how to get the male dog sedated without being bitten.
Dr B went to the room to get the male dog out. Gently talking to them and as the dogs have leashes, he could just talk his way in and take the male dog out. I asked the clients with the Beagle to go out of the clinic first.
"Muzzling is not possible," Dr B tried outside the clinic but the male cream dog would not accept it. "Why don't you try?"
I am no superman. Drs A and B managed to inject the sedatives IM behind the waiting room and so I did not see how they did it. I did advise blocking the chest and head with the door closed on this part of the body while Dr A injected the back muscles.
"What happens if Dr B gets bitten?" Dr A asked me during the post-op discussion.
"In the first place, Dr B should understand dog pyschology and body language and he would not be bitten in the first place. Most dogs give warning e.g. growling and if the vet ignores it, he deserves to be bitten.
It was 9.30 pm when the male dog was picked up by the owner. As the clinic manager, I have to ensure that the work processes are efficiently and effectively done. Otherwise, the practice loses money for every case handled. This accountancy is not obvious to the employee vets who still gets the salary anyway.
"Why are the dogs not sterilised?" I asked Dr A.
"I didn't know Min is off today."
"Don't accept big fierce dogs if you can't handle them. Phone the owner and ask her to take rthem back! The vet in charge has to take responsibility for the sedation, not Mr Min. I have two vets and must we wait for Min to do it tomorrow?"
I advised the two vets how to get the male dog sedated without being bitten.
Dr B went to the room to get the male dog out. Gently talking to them and as the dogs have leashes, he could just talk his way in and take the male dog out. I asked the clients with the Beagle to go out of the clinic first.
"Muzzling is not possible," Dr B tried outside the clinic but the male cream dog would not accept it. "Why don't you try?"
I am no superman. Drs A and B managed to inject the sedatives IM behind the waiting room and so I did not see how they did it. I did advise blocking the chest and head with the door closed on this part of the body while Dr A injected the back muscles.
"What happens if Dr B gets bitten?" Dr A asked me during the post-op discussion.
"In the first place, Dr B should understand dog pyschology and body language and he would not be bitten in the first place. Most dogs give warning e.g. growling and if the vet ignores it, he deserves to be bitten.
It was 9.30 pm when the male dog was picked up by the owner. As the clinic manager, I have to ensure that the work processes are efficiently and effectively done. Otherwise, the practice loses money for every case handled. This accountancy is not obvious to the employee vets who still gets the salary anyway.
History of anaesthesia in dogs and cats
I just spoke to a senior vet to enquire whether he has domitor as my vets have run out of it. He does not use it. Some interesting history from this experienced small animal vet now in his 70s. He started practice some 50 years ago when Singapore had only 3 vet practices and the government Animal Infirmary. Now there are around 50.
1. Xylazine knock down. Nembutal IV to effect. "Despite the vet books claiming that Nembutal will cause drowsy puppies, I did not have any. Intubate and give halothane gas + O2 or just O2 will do." He did a few thousand dog Caesareans. Minimal dosage. Nembutal no longer available easily.
2. Now he uses xylazine + ketamine. It is better, easier to handle and cheaper. Does not need to have many nurses to assist in spay.
E.g. Shih Tzu which is bigge than a cat, xylazine 2% at 0.6 to 0.7 ml and ketamine at 0.4 to 0.5 ml IM or IV. The vet needs to experience the dosage. .
E.g. adult cat in Singapore xylazine at 0.4 to 0.5 ml & ketamine at 0.4-0.5 ml IM.
3. His younger vet uses propofol
4. He does not use zoletil, diazepam or domitor for sedation.
This is good management as too many sedatives increase stock costs as they expire. Younger employee vets seldom know about the high overheads in a vet practice as they order various kinds of sedatives based on their likes and dislikes. When they open their practice, they may then understand.
1. Xylazine knock down. Nembutal IV to effect. "Despite the vet books claiming that Nembutal will cause drowsy puppies, I did not have any. Intubate and give halothane gas + O2 or just O2 will do." He did a few thousand dog Caesareans. Minimal dosage. Nembutal no longer available easily.
2. Now he uses xylazine + ketamine. It is better, easier to handle and cheaper. Does not need to have many nurses to assist in spay.
E.g. Shih Tzu which is bigge than a cat, xylazine 2% at 0.6 to 0.7 ml and ketamine at 0.4 to 0.5 ml IM or IV. The vet needs to experience the dosage. .
E.g. adult cat in Singapore xylazine at 0.4 to 0.5 ml & ketamine at 0.4-0.5 ml IM.
3. His younger vet uses propofol
4. He does not use zoletil, diazepam or domitor for sedation.
This is good management as too many sedatives increase stock costs as they expire. Younger employee vets seldom know about the high overheads in a vet practice as they order various kinds of sedatives based on their likes and dislikes. When they open their practice, they may then understand.
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