1401. Update on KPI spay Maltese

TOA PAYOH VETS toapayohvets.com Date:   28 February, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits KPI to spay a young Maltese   Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   28 February, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 1398. Domitor + Ketamine Anaesthesia for spay duration + KPI   Feb 27, 2013  I spayed a 7-month-old Maltese X., 4.3 kg. The happy couple took leave and made an appointment with me. Usually spays are done by Dr Daniel as they are routine surgeries. This dog had been vigorously licking her vulval lips such that the area above the vulva became black. "Much less licking after antibiotics last month," the lady in her late 20s said to me. I had advised spaying as there could be pyometra which leaked out vaginal discharge causing the need to lick. It could be a urinary tract infection too. The dog was on heat with uterine horns and ovaries very red and congested when I spayed her.  ANAESTHESIA Based on formula of 10 kg, young healthy dog Dom=0.4 and Ket=0.5, I gave this 4.3 kg dog IV Dom=0.2 + Ket = 0.17 totalling 0.37 ml IV one syringe with 0.13 ml Hartmann. A: Injection of D+K IV  10.22 am B: Isoflurane first given  10.43 am C: Isoflurane stopped    10.53 am D: First skin incision: 10.34 am E: Completion of skin stitching: 11.01 am. E-A = 39 minutes. This is because the dog started moving at 10.43 am (21 minutes after injecton) and the surgery was paused to give gas by mask to stabilise. This shows that duration of D + K is 21 minutes for this dog. Spay should be completed in 21 minutes but there was some delay as there was training of the new veterinary staff on gas anaesthesia.  Without traiining, spay should be completed in 30 minutes for this small breed.   E-D= 27 minutes. Dog was on heat. More time was spent ensuring no bleeding and on speed on hooking out the ovaries. Hooking left ovary took 3 trials and it was hooked out at 10.38 am. 4 minutes after incision. Right ovary was hooked out at 10.42 am, 8 minutes after skin incision. Conclusion: Usually the above formula gives at least 20 minutes of surgical anaesthesia. If spay takes longer, isoflurane top up is needed. Efficiency and timing are important in productivity of a vet surgeon. Taking too long to spay a dog is not good. Conclusion: Much time was wasted between first skin incision and injection (D-A=12 minutes) as I was teaching a new assistant since Mr Min was poached. He had worked 2 years for me and I wished him well as he ought to move on for a better future and more income. Surgery should commence around 7 minutes around injection as IV effects would occur in 5 minutes usually. Check reflexes for surgical anaesthesia like eyelid blinking. 5 minutes extra off the E-D process would mean that I would take 22 minutes and would not need isoflurane top up. The planning and proper prompt process is essential in veterinary surgery procedures and process and in less wastage of resources. More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: February 28, 2013 Toa Payoh Vets

1400. Follow up on bladder stone cat 7 days after surgery

Feb 27, 2013 - I phoned the busy gentleman owner of the cat with the bladder stones as I was reviewing the past few days' cases. All cases done by associate vets and be me are reviewed by me as much can be learned from cases done. But this takes a lot of time and time is not much when there are many other things to do.

"My cat is back to as good as normal," he said that the cat was jumping and his stools and urine were normal. He had told me the day before that the cat drank less. I explained that the cat was fed canned K/D diet and canned food has a lot of water.

"Does he eat on his own?" I asked this important question.
"He eats a bit and does not mind spoon-feeding by my maid." This was a moment of great joy to know that a surgical patient who was having kidney disease based on blood test by Vet 2 had recovered almost fully. The stitched bladder with a 8-mm cut by me to extract the 8-mm diameter stone must have healed well, otherwise this cat would be dead.

Follow ups are much appreciated and great learning lessons for any vet but we seldom have much time to do it. It creates an excellent customer service experience.

This owner loves his grandmother as he did bring her to take the cat home the day after surgery. Grandmothers are most loved as they usually spend most time with the grand children while the parents are out working and surviving in the corporate jungle. His grandmother was over 80 years old and her mind was sharp and alert.

"Remember the S/D can of food given by Vet 2?" I asked the owner. "It may not be useful as the cat's urinary pH is acidic at pH=5.0. That means that the bladder stones are unlikely to be struvites as S/D is for prevention and dissolution of struvite stones. Most likely, they are calciuum oxalate stones but we have to wait for the results of the stone analysis."

This info was obtained when I collected urine before opening up the bladder for stone removal. It is important that the vet performs this procedure as it may not be possible to collect urine from an angry non-sedated cat earlier. That could be one reason Vet 2 did not do a urine analysis and just prescribed S/D of one can. It is best to practise evidence-based medicine by doing urine analysis. In this case, there were no crystals in the urine.

A 4th year vet student from the top Portugal Vet University was with me and I asked Catarina Mateu : "No crystals in the urine test means no bladder stones. Many vets will come to this conclusion. What about you?"
"Yes," she replied. "I also think this way."  She will be making a video for me. 

 



 

 

1399. Identification of patient and operation area

   

TOA PAYOH VETS toapayohvets.com Date:   28 February, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits Best practices from a plastic surgeon   Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   28 February, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 1399. Identification of patient and operation area   Monday, Feb 25, 2013 was an eventful day for me. I had a facial lump of 1x0.5x0.5 cm cut off by Prof Foo C L from the Singapore General Hospital. He thought it was just a scratch tumour as I scratched it to try to get rid of it but it persisted. Sometimes, scratching causes a reaction and the pimple or inflammatory lump disappears. But this lump persisted and increased in size. "How long has it been present?" he asked as I was on the operating table. "Months," I replied. After seeing this good-natured Syrian hamster with a malignant tumour excised at Toa Payoh Vets recently, I decided to get my skin lump on my face excised and checked for cancer. "Will local anaesthesia be painful?" I asked Dr Foo. "Only during injection," he said. He injected 3 areas but the pain was only a small ant bite. I guessed he had perfused the skin immediately on injection and the anaesthetic had numbed the area. He made a blue elliptical marker pen area and excised it. Marking the area to be excised is a good practice even for vets but not all vets do it. The SGH also has a good practice of verifying the patient's identity and operation site. I was asked my name and identity card number at various points of admission on the day of surgery, outside the operating room and inside the operating room. This practice ensures that the right patient is being operated on. I got asked which area was to be operated. This ensured that no mistakes will be made, e.g. operating on the wrong side of the face. Such mistakes have been made in human surgery with horror stories of the wrong foot amputated. For veterinary surgery, the patient can't communicate with us. The owner sometimes give incorrect information. For example, a rabbit or cat may be male but the owner says it is female. Trusting the owner who says her pet is female means just spaying the pet. The abdominal area will be shaved and the incision made. No uterus will be found after some time. The vet thinks that the pet had been spayed or worst of all, discovers it is a male. It is the responsibility of the operating vet to do a full examination including the gender of the pet to be sterilised. Owners are trusted implicitly but some of them don't really know. Pets don't talk to vets and so mistakes have been and can be made by vets in operating on the wrong site. As for my surgery, Dr Foo said general anaesthesia was unnecessary to remove my facial skin lump. "There is always a risk of death," he said. "You may be the unlucky millionth person to die under anaesthesia. Local anaesthesia will do. It takes around one hour in all." So, I was strapped on the narrow operating table to prevent me falling off. Swabs covered my eyes to shield them from the 3 bright operating lights. I could not feel the cutting as the area was numbed by the local. Dr Foo had asked whether I felt any pain before excising. This is one part which vet surgeons can't get feedback from the animal patient under local anaesthesia. "6/0 vicryl and 4/0 ethicon," he said to the nurse. The wound was closed well subcuticularly by 6/0 but he stitched up the skin with 4/0 in case of stitch breakdown. This 2-row stitching could be the secret of success in a plastic surgeon in getting a small scar. I got some antibiotic ointment which I didn't use. I asked for plaster to cover my facial wound with a few stitches so that crowds would not stare at me when I attended Cliff Richard's concert in the evening at Marina Bay Sands Grand Theatre. In any case, Cliff Richard who is 72 years old, gave such an energetic 3-hour-long performance that would put a younger singer to shame. His jokes were appreciated and the audience left much satisfied. One commented that he did not sing "Bachelor's Boy." I was waiting for him to sing "Fall In Love With You", but was disappointed. This was a song I heard at the 25th Baba & Nonya Anniversary in Malacca last year. I got a short video done. See: https://www.youtube.com/watch?v=-G48MbWTu8c Cliff Richard's "Fall In Love With you" song when he was very young is at: https://www.youtube.com/watch?v=T0EHxaVJ0ok Dr Foo sent my facial lump was sent for histology. It looked white and elliptical in the formalin bottle. There were some fine hairs of around 3 mm long on the skin of this lump as commented by Dr Foo. "Don't read too much into it," he said to me. I do not know why he commented on the presence of these fine hairs. As for the Syrian hamster operated on Valentine's day, the fair lady owner brought the 2-year-old hamster to consult me 11 days after surgery. There were large reddish skin nodules on the body, under the armpits and on the left thigh. They were around 4 mm x 4 mm raised skin rashes. Could they be due to the "anti-mite" spray the young lady was spraying to "kill the skin mites"? She had diagnosed hair loss and brought the spray from the pet shop. "Your hamster has a malignant skin tumour," I showed her the histology report which I had paid for since she did not want histology. "It is possible that these red lumps are the spread of the skin cancer which was 2.5 cm in diameter. I gave her the photo of the lump sent by the laboratory. "Should I continue the spraying of the skin?" she asked me. "No," I said. "This hair loss of the hamster could be due to other reasons and not mites." A hamster with a large skin tumour could be scratching himself a lot and hair loss would be expected due to trauma. "Let the Syrian hamster enjoy his life since he is 2 years old and their lifespan around 3 years," I told her that the rashes could be either irritation of the spray or spread of the cancer. She was to give medication for 7 days and if he nodules disappear, it would be due to irritation. "I adopted him from the SPCA," she said to me. "He is such a gentle hamster and does not bite me unlike some hamsters." "Yes, he is very good-natured," I said. "He does not bite me too." Dr Daniel who had operated on him came by and had the stitches taken out. Stitches can be taken out on the 11th day with no problem of the skin breaking down. The wound had healed. Time will tell whether the skin cancer had spread. There was a black pigmented spot on the further back before the left hip area. It was not present before. So it is hard to say whether this was cancerous. I did not advise removal as there was not much skin and there was economics to consider. Updates will be on this webpage: http://www.asiahomes.com/petshotline/20130228syrian_tumour_follow_up_toapayohvets.htm   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: February 28, 2013 Toa Payoh Vets

1398. Domitor + Ketamine Anaesthesia for spay duration + KPI

Feb 27, 2013  I spayed a Maltese X., 4.3 kg

ANAESTHESIA
Based on formula of 10 kg, young healthy dog Dom=0.4 and Ket=0.5, I gave this 4.3 kg dog IV Dom=0.2 + Ket = 0.17 totalling 0.37 ml IV one syringe with 0.13 ml Hartmann.

A: Injection of D+K IV  10.22 am
B: Isoflurane first given  10.43 am
C: Isoflurane stopped    10.53 am
D: First skin incision: 10.34 am
E: Completion of skin stitching: 11.01 am.

E-A = 39 minutes. This is because the dog started moving at 10.43 am (21 minutes after injecton)and the surgery was paused to give gas by mask to stabilise. This shows that duration of D + K is 21 minutes for this dog. Spay should be completed in 21 minutes but there was some delay as there was training of the new veterinary staff on gas anaesthesia.  Without traiining, spay should be completed in 30 minutes for this small breed.   

E-D= 27 minutes. Dog was on heat. More time was spent ensuring no bleeding and on speed on hooking out the ovaries.
Hooking left ovary took 3 trials and it was hooked out at 10.38 am. 4 minutes after incision. Right ovary was hooked out at 10.42 am, 8 minutes after skin incision. 

Conclusion: Usually the above formula gives at least 20 minutes of surgical anaesthesia. If spay takes longer, isoflurane top up is needed. Efficiency and timing are important in productivity of a vet surgeon. Taking too long to spay a dog is not good.

1397. Follow up on the dog with a cancerous leg

 

TOA PAYOH VETS toapayohvets.com Date:   27 February, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits The old dog had a cancerous leg   Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   27 February, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 1397. Follow up on the dog with a cancerous leg EMAIL FROM DR SING DATED FEB 27, 2013 It is very difficult to diagnose based on emails as what you write may not be what I think as regards "dead space." The "success of surgery" is not a guarantee in any surgery as there are many risks and complications involved especially in an older patient with poor health. Old age and poor health delay in wound healing in people as well as in animals. Pl understand that some old aged patient undergoing surgeries have post-operation complications like bleeding and infections especially when the dog was not in good health (e.g old age, cancer, delay in seeking treatment, spreading of cancerous cells). I will advise you bringing the dog to me or your vet for examination and treatment of the post-operation complications in your older dog which nearly did not survive the general anaesthesia during the amputation of the cancerous leg. Best wishes. EMAIL TO DR SING DATED FEB 26, 2013 On Tue, Feb 26, 2013 at 2:31 PM, S@hotmail.com> wrote:   Hi, By the way, I read that with that dead space the dog's wound will heal much slower. Does this mean that the surgery was not successful? What can be done to increase the healing process?   Thanks.   EMAIL TO DR SING DATED FEB 25, 2013 From: s@hotmail.com Sent: Monday, February 25, 2013 10:23 PM To: Kong Yuen Sing Subject: Re: X-rays and blood test report for xxx (Appt 15 Feb 2013, 9.30am)   Hi,   There seems to be a dead space as liquid keeps flowing out of the wound. I have cleaned the dog's wound and squeezed out the liquid in his leg. Other then that his wounds seems fine. Thanks.   EMAIL FROM DR SING DATED FEB 25, 2013   From: Kong Yuen Sing Sent: Monday, February 25, 2013 6:10 AM To: S Cc: Kong Yuen Sing ; daniel sing   Subject: Re: X-rays and blood test report for bobby (Appt 15 Feb 2013, 9.30am) How is the dog now? Is his wound healing well?  BACKGROUND OF CASE An old dog with a non-healing ulcerated skin wound on the left hind leg. Vet 1 diagnosed skin cancer. Vet 2 did an X-ray and skin biopsy and advised leg amputation but did not do it. The biopsy showed squamous cell carcinoma. The X-ray showed bone involvement around the hock area. The owner consulted me. EMAIL TO DR SING DATED FEB 14, 2013 On Thu, Feb 14, 2013 at 6:42 PM, S@hotmail.com> wrote: Hi,   I am S... I made an appointment for 15 Feb 2013 at 9.30am for my dog to undergo surgery to amputate his leg due to cancer. I have attached the relevant information to this email for your reference.   Thanks.   The dog was operated at Toa Payoh Vets and I followed up on Feb 25, 2013, around 10 days after the amputation of the left hind leg above the knee joint by Dr Daniel of Toa Payoh Vets. It was a very high anaesthetic risk case as the dog was not in good health. 5965. Squamous cell carcinoma spreads to bones. Leg amputation is done Video: Squamous cell carcinoma (skin cancer)   Updates will be on this webpage: www.bekindtopets.com/animals/20130227leg_bone_squamous _cell_sarcoma_toapayohvets.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: February 27, 2013 Toa Payoh Vets

 

1396. Feb 26, 2013

Cat owner with bladder stones didn't phone me yesterday. Today Tue Feb 26, he phoned to report progress.

"My cat is drinking less, otherwise he is ok. No puking. I run out of K/D diet. Shall I feed him the S/D can (given by Vet 2?).
"As his bladder  stone is still being analysed, no point feeding the S/D unless he has struvite stones," I advised. He will buy more K/D for the time being. K/D is given because of renal impairment accordin to the Vet 2's blood test..

1395. Update: A cat has bladder stones and "renal failure".

1394. Follow up. Sunday. Cat with bladder stone

Sunday Feb 24, 2013
6.23 pm Yishun public library to type this report
Communications post-op is most important. The cat owner phoned me twice and left his name and phone number. My receptionist reminded me to phone him after my consultations. I was kept busy with the owners of a cat from an American couple regarding removal of the claws, a rat with nasal swelling on the right and a large skin lump on its back and a rabbit from Woodlands for "spay" from a Malay family who had stated incorrectly the gender. Two big terrapins came yesterday for Dr Jason Teo - one would not eat and the other one had puffy eyes and I had them cleaned and given eye drops and bask in the bright morning sunshine. I had to supervise a new vet technician as Mr Min would be moving on to better future after having worked two years with me, increasing his value to the new employer as an experienced vet technician.

Back to the cat with the bladder stones was operated on Thursday, 3 days ago. The owner phoned me yesterday and today to provide me feedback and that was important.

"My cat did not vomit after eating food. He drank a lot, around 375 ml of water and peed a lot," he said. "He laid on his urine and so his surgical wound is very red."

"It is good news that he pees a lot," I said. "This shows that his bladder is normal." I tried not to joke that this showed that his bladder was not leaking after my surgery.

"What should I do to the red area of his wound?" the owner asked.

"It is very difficult for me to know what you are describing," I said. "Was the cat licking the wound since you did mention about taking off the e-collar?"

"No, he is still wearing the e-collar."

Since the owner was working, I suggested that he changed the plaster covering the wound and replace with a new square one. "It could be the blood clot from the skin after stitching," I said. Will wait and see.

It seems that the cat with the renal impairment based on blood tests taken by Vet 2 on Wednesday (4 days ago) is doing well.  He did not vomit his food. I asked the owner to give 2 cans 6 times/day instead of feeding him one can of the K/D diet yesterday. He has a good maid and with home care, this cat should thrive.

Before I forget, the Thursday surgery in brief is as follows:

ANAESTHESIA
5 kg bodyweight. I gave xylazine 0.2 and ketamine 0.8 ml IM in one syringe. Isoflurane gas top up was necessary for a short while. Rectal temperature was 36.8 C after sedation as the cat was angry and we could not want to antagonise him more.

SURGERY to remove bladder stones seen on X-rays taken by Vet 2.
1. Catherise the bladder
2. Withdraw urine for urine analysis
3. Inflate bladder with 40 ml normal saline so that it is palpable.
4. Incise skin and linea alba.
5. Press out the distended bladder.
6. Incise at apex of 8 mm as I know the stone was around this diameter.
7. I insert an artery forceps to grab and take out the stone without making too big a bladder incision.
8. My assistant Min pumps in more normal saline as I closed the wound for a while.
9. 3 small pieces of stones of around 3 mm x 2mm flowed out with the bloody mucus and blood.
10. More irrigation of the bladder.
11. I stitched the mucosa 3/0 absorbable - inverting layer
12. I stitched the serosa similarly - another inverting laye.
13. To check leakage, I asked Min to pump in more saline via the catheter to inflate the bladder. No leakage.
14. I put the bladder back into the abdomen and closed up the linea alba (2/0 absorbable) and skin (2/0 nylon).
14. I put the bladder back.
15. Post-op baytril and tolfedine
16. Cat goes home in the evening as the cat was quite ferocious and nursing at home would be better as the cat would be hand-fed food (K/D) and medication.

Friday - Day 1 after surgery. I phoned the cat owner.
"Vomiting one hour after food and medication," the owner reported as he had given medication on the evening of the surgery. I advised not giving the tolfedine tablets, just the Baytril tablet from Vet 2 and give honey water by hand.

Saturday - Day 2 after surgery.
Vomiting once. Drinks a lot. Pees a lot. "There could be gastric ulcers due to the high BUN kidney disorders," I said. "That would account for vomiting. Feed less amounts"

Sunday - Day 3 after surgery.
Feedback in above paragraphs.  Will need to summarise all later,

Discovered and borrowed two thick books published in 2012 and 2013 from Yishun library.
1. Web Marketing All-in-one for Dummies. 8 books in one.
2. Social Media Marketing All-in-one for Dummies. 9 books in one.
Thick as a bible. No wonder most doctors and vets give them a miss.

1303. Bladder stone in a 7-year-old cat

Wednesday Feb 20, 2013
"Can you operate today?" the owner of this 7-year-old with a disc-shaped bladder stone of 8 mm x 8 mm and 3 smaller stones was referred to me by his vet friend working in Biopolis.  I had asked him how he came to know about Toa Payoh Vets as presently, one salesman told me the 52nd vet clinic is about to open in Singapore.  

"I can operate today, but you may have a dead cat at the end of surgery," I showed him the high total white cell count and neutrophils of the cat's blood test taken earlier in the day. "These data showed that the cat has a generalised blood infection of bacteria and is not in a good health state to be under anaesthesia and surgery. He may die on the operating table."

"But Vet 2 told me that my cat is suffering from a serious kidney failure. She said I should operate soon and any delay will result in death." Vet 2's blood test result show BUN as "---", creatinine and phosphorus as exceedingly high. This indicated an acute renal failure.

"It is best to stabilise this cat first," I had read the medical reports and viewed the X-ray. "Was there any antibiotic injection given to the cat? Any fluid therapy? Any urine test? Any fever?"

"I don't think so," the gentleman is typical of the increasingly educated and well informed pet owners in Singapore putting vets on their toes as he would have done his internet research on his pet's urolithiasis with one click of the mouse. "Otherwise my bill will have this item charged. Vet 2 did say that the cat was slightly dehydrated"

The cat was now furious and the owner could not handle him. I did not want to provoke this frightened cat further as the cat would go crazy and very aggressive. I asked the owner to hold and talk to him while I gave the Baytril antibiotic injection SC. I assessed that this cat would not need the fluid therapy as he was drinking and peeing. Only that he was not eating for a few days and the owner had brought him to consult his regular vet (Vet 1). Vet 1 had asked him to return again if the cat had not recovered but Vet 1 closed on Wednesday and so he remembered Vet 2's colleague whom he had seen before. Vet 2 told him that she was not sufficiently experienced to operate and her colleague's surgical bookings were full house. So he had to find another vet and that was where his vet friend referred him to me. I don't know this vet friend and so it was a surprise.      

The operation would be done the next day. Weighing the cat, taking the rectal temperature and giving SC drip would be out of question as the cat was quite fed up with Vet 2's blood taking and X-raying. Cats are notoriously difficult to take blood and Vet 2 had managed well. I presumed she X-rayed first, otherwise it would be very difficult to restrain this little tiger.

Thursday Feb 21, 2013
The main worry was the possibility of death under anaesthesia as this cat was just not fit for surgery based on Vet 2's blood test of a severe kidney disorder. I would say it would be acute nephritis but this cat had no history of vomiting. Would this cat die on the operating table? This was one of those hot potatos vets prefer not to handle as death may result in bad-mouthing of the vet's incompetence. Who to pass the buck to? I decided to operate myself under such negative conditions of impending death of a cat. Ideally, the cat should wait 3 or more days before surgery. But the owner was much worried and the kidney disorder may worsen to severe vomiting and death owing to delays. The kidney enzymes were exceedingly high. To wait would be risky as a cat in deteriorating health would die anyway. 

So, I was holding the hot potato one way or another. To operate or to wait more than one day. 
What safe anaesthesia to give? This is hard to say.