1402. Update. Cat with 4 calcium oxalate bladder stones

TOA PAYOH VETS toapayohvets.com Date:   01 March, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits A cat has bladder stones   Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   01 March, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Saturday, February 23, 2013 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 potatoes 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 so that the feline patient is delivered alive to the owner? A surgeon must deliver. A cat alive at the end of surgery. No excuses. Sunday, February 24, 2013 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 layer. 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. Wednesday, February 27, 2013 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 struvites stones. Most likely, they are calcium 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.  Friday, March 1, 2013I phoned the owner to inform him that stone analysis revealed calcium, oxalate and magnesium in the bladder stone. I advised canned C/D food for at life. But it is relatively expensive compared to the usual canned foods.  He said: "My cat is ok now. Only that he is inactive when he wears the e-collar. When do I come for stitch removal?" "Your cat has never worn e-collars before. Once the skin stitches are removed on this Sunday, your cat will be free of the burden of this collar." URETHRAL OBSTRUCTION IN AN OLDER MALE CAT The above-mentioned case of the cat with the bladder stones had a different history. The owner had complained that the cat was not eating for 5 days, not blood or difficulty in urination. On March 1, 2013 I discharged an 8-year-old male neutered cat with urethral obstruction after one day of hospitalisation. He was a good-natured cat. The owner had told me that the cat could not pass urine for 2 days. The cat certainly could pee and did have blood 4+ on urinary analysis done by me prior to surgery to remove the stone which was calcium oxalate in an acidic urinary pH environment with bacteria present. As for this second cat, the history of difficulty in urination for 2 days was dubious. "The high urea and creatinine values, more than 6X the higher range of normal and the vomiting  indicated that the cat was having urination problems more than 2 days," I said to her. "There is kidney damage and the cat may get kidney failure now." "He had peed blood for over a month. A 10-cent coin of red urine. I was too busy to bring him to the vet. When he could not pee at all for 2 days, I knew I had no choice but to send him to you for treatment."  Under sedation, the urinary catheter was passed into the bladder with great difficulty as the sand blocked the passage at the bend of the urethra. So the bladder started filling to half the size of the mango and the cat could not pee at all. I had to pump in normal saline via the catheter to dislodge the sand back into the bladder. Then I irrigate the bladder with more saline and suck out the blood and sand. The urinary catheter was stitched on the prepuce and be kept for 3 days. As no X-rays were done to lower the veterinary costs and as no stones were palpable in the bladder, I told the owner that there might be bladder stones if the condition recurred. X-rays would have to be done. The heartlanders have a limit as to veterinary expenditure in these times of rising costs and economic recession.  "No more dry cat food or cat treats," I said to the working lady in her 50s. "Just this can of K/D and then C/D." "What if he eats the food from the other cats?" she asked. "Then you may get a recurrence of the bladder blockage problem." "I know what I will do," she had a solution. "I will feed him in another room. When he is full, he will not eat the other cat's food."  P.S I spoke to Hills' supplier. He told me that feline S/D was no longer produced since 9 months ago. The feline C/D is found to be effective to prevent S/D as well and so it is the only product for kidney health for cats. He was surprised that Vet 2 still had cans of feline S/D. Updates will be on this webpage; http://www.bekindtopets.com/stories/20130301cat_bladder_stones_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: March 01, 2013 Toa Payoh Vets

1406. Spaying a ferocious young cat

Today Friday Mar 1, 2013, morning, the young couple brought in a cat, born around Jan 2011, for spaying. In the presence of the owners, she was quiet. So I put her in her own carrier to be spayed in the afternoon. 

I thought the carrier door would open sideways as in all carriers. However, it was not working and one has to click open the two sides and front corners to open up the top half of the carrier. The sounds of clicking open the hinges were extremely loud, like a gun firing in a small room on the table top.. The cat was too angry and my assistant tried to hold her. She stretched out her claws. He took one step backwards.   leaped off and in the process some anal sac oil splattered in at least 6 spots on the top of my shirt. The smell was rancid oil. The cat landed on the floor and hid in a corner. What to do?

In short, I got a lasso to restrain her, put her inside a wired crate. Later I had to pack in newspapers and phone books. The cat snarled everytime the papers were put in. "She is cramped at one side," my assistant called me. I inserted the fine needle and the cat leapt up while inside the crate. My 27G needle bent and flew to the floor as I pressed the plunger. In short, the cat did not get the 100% of the sedation IM.

At the next time, more newspapers filled the crate and another helper pushed the cat towards the side, facing me. Ths time I could inject. Lots of time spent in just this case. Cats and dogs do get ferocious once the owner is away.

A: Sedation IM   2.19 pm
B: Isoflurane first given. No need.
C. Isoflurane stopped. No need.
D: First skin incision: 2.33 pm
E: Completion of skin stitching: 3.01 pm

E-A  = 42 min
E-D = 28 min.

The cat was in the middle of heat. So much time was spent to ensure that the big ovarian blood vessels were properly ligated. The ovaries were incised at least 5 mm from the uterus after ligation just in case some remnants of ovarian tissues were left in the body. There have been complaints of cats and dogs still having heat after spay and one reason is that some ovarian tissues were left behind during the spaying.

The best way is to incise the skin near to the umbilicus to expose the whole ovary plus suspensory ligaments. usually made an incision of 1 cm long starting 0.5 cm from the umbilical scar in cats. This incision is insufficiently long to access the bifurcation of the uterine bodies after hooking out the left ovary. Therefore I had to make the incision longer by extending another 1 cm caudally to expose the bifurcation of the uterine body..

For this cat on heat, the skin incision came to 2 cm long. For cats not on heat, I could open 0.8 cm long in the spay. Longer incision takes longer time. 28 minutes to spay this cat when a cat not on heat would take 10 minutes.

Surgical anaesthesia was sufficient at this dosage for 2.1 kg cat as there was no reaction .

 

Update: Feline S/D discontinued

UPDATE

The supplier told me today that Feline S/D had been discontinued by Hills since 9 months ago. I told him I saw a can being given by Vet 2 recently to the cat with bladder stones I operated on.

He said that feline C/D does dissolve struvites as well and is recommended for cats with calcium oxalate too, targeting the urine pH = 6.2-6.4.

Follow up: Stone analysis results for cat with bladder stone

Report received today.

Calcium, oxalate, magnesium positive.
Preventive diet will be C/D for life
Target urinary pH to be 6.2 to 6.4

1403. SOP - Urethral obstruction in a male cat

Written: Feb 28, 2013  10.49 am reviewing this case to compare to the cat with bladder stones operated.

Feb 28, 2013

Urethral obstruction in cats may be quite common. A lady phoned me near midnight about her cat's difficulty in urination 2 days ago but she did not want to go to the emergency clinic I referred her to. So, I presumed this 13-year-old male neutered black and white cat to be the owner who came on Feb 28, 2013 as he cat could not pass urine and had blood in the urine passed.

"No, I did not phone you," the lady in her late 40s said to me as I palpated a bladder the 50% the size of a Thai mango.

"How long had he been having this problem?" I asked.
"Two days."
"Did he vomit?" I wanted to ascertain the kidney involvement as owners seldom volunteer this info.
"He vomited 3 times yesterday."
"He must be eating dry cat food since young," I predicted.
"Yes," she said. I feed dry IAMS and ikan bilis since he was young."
"He seldom drinks water," I said.
"You are correct."

This was a gentle old cat. He did not like me massaging his penile area to loosen the urethral plug and hissed.

Standard Operating Procedure (SOP). Emergency treatment usually

1. Sedate the cat. Collect blood and urine if possible. Blood collected. No urine
2. I Injected SC baytril and tolfedine. I used xylazine 0.1 and ketamine 0.4 ml IM. Sufficient.
3. Collect urine via catheter. This was not possible as the urethra was severely blocked at the bend of the penile area.
4. Put saline into syringe and flush into catheter to unblock. This was successful. Do not force catheter inwards as this tramatise the urethra as I had seen a vet doing it. Sedate first.
5. Urine flows out. Collect for urine analysis.
6. Irrigate bladder with saline and suck out any sand and blood
7. Stitch 3 areas catheter with absorbable to anchor catheter for 2 days. Blood still flows out on Day 2 (today).
8. Hospitalised overnight and goes home next day.

BLOOD TEST RESULTS
Urea 59 (7-11)
Creatinine 1003  (7-160)
Platelets 93  (300-800). Cat's mucous membranes were pale. Nose looked pale as compared to normal cat.

URINE
pH 6.5  SG 1.012 (not reliable as saline was used to unblock obstruction)
Blood 4+, Bacteria 3+, no crystals
(No crystals does not mean no bladder stone. Palpation of bladder on Day 2 - no hard stones). No urethral obstruction as catheter is in place.

X-RAYS not done to reduce cost for this first occurrence. Will do if recur.

ADVICE
Change slowly to canned food. Urine analysis 1 month later. K/D for 10 days. Seldom gets followed up as most owners don't comply.    

1403. Update Key Performance Indicators for spay & SOP

TOA PAYOH VETS toapayohvets.com 01 March, 2013 Focus: Small animals - dogs, cats, hamsters, turtles, guinea pigs & rabbits
Toa Payoh Vets Clinical Research Standard Operating Procedures (SOP) & Key Performance Indicators (KPI) For other cases, goto: Dogs
One of the effective management systems is to ensure consistency of process and to execute Key Performance Indicators. To maintain the highest standards of veterinary practice and productivity as well as sharing knowledge, the Standard Operating Procedures (SOP) and Key Performance Indicators (KPI) are being implemented in Toa Payoh Vets from 2011. Good written records are a strong defence in the cases of litigation and complaints
Standard Operating Procedures (SOP)
5491 -5495. The internet connections open the doors...
5417. SOP: Eye corneal ulcer & tarsorrhaphy		5412. SOP: Veterinary Surgery Report format	5413. SOP: Urinary Tract Infections and struvite stones	SOP: A new puppy with blood in the stools
Key Performance Indicators (KPI) for an experienced vet E-D = Time from first skin incision to skin stitched up
5991. Feb 2013. KPI spay Maltese on heat. E-D=27 min. Isoflurane gas top up needed.
5448. KPI for spaying a dog with false pregnancy. E-D=19 min	5448. KPI for spaying a dog with pyometra. E-D=26 min	5615. KPI: Spaying a fat dog. E-D=28 min	KPI: Dog spay - Chihuahua. E-D=23 min	KPI: Dog spay - Fox Terrier E-D=26 min and Shih Tzu E-D=18 min
5545. KPI for spaying a Miniature Schnauzer with closed pyometra. E-D=41 min.				KPI: Neuter E-A=18 min and tarsorrhapy
Veterinary Management: Processes, Protocols, Procedures & Best Practices
5990. Best practices from a plastic surgeon
5286. A vision for Toa Payoh Vets to be a top 3 veterinary surgery in Singapore	5385. Procedure: Female dog urethral catherisation	5111. Pet grooming business success in Singapore	5288. Reversing the decline in horse racing - Part 2	5212. Veterinary clinic inspection
5142. A neat and good spay suture pattern is important	4980. Dressing casually at Toa Payoh Vets	4981. Character and competence of interns and young employees
Toa Payoh Vets Clinical Research Standard Operating Procedures (SOP) & Key Performance Indicators (KPI) For other cases, goto: Dogs This webpage is: www.bekindtopets.com/animals/20081201PG9standard-operating-procedures-vets_ToaPayohVets.htm
Copyright © Asiahomes All rights reserved. Revised: March 01, 2013 Toa Payoh Vets

1402. Digital images of 83g hamster now 77g after surgery

Make use of digital photography to show tumours excised, hamster recovering etc as the owner will be educated and happier to know what had happened. This hamster of 83 g was not knocked down by 3 drops of Zoelietil 50 IM today. I thought it was too little. After 5 minutes, he became drowsy. Clipped and excised the large left inguinal tumours and left ear wart. Weighed him. He was 77 g and pooped a lot. Owner was pleased.

1401. Abdominal cryptorchid in a dog

"Is the vet competent?" the owner asked me. The young male dog had been sent in for neutering. Two undescended testicles. So, just get on with the operation. Many times, there is no problem locating the two undescended testicles under the skin.

However veterinary surgery throws the vet a surprise. In this dog, one testicle was located. The only was nowhere under the skin!

Be meticulous. Make a thorough examination before any surgery. If the undescended testicle cannot be felt under the skin while the dog is standing, don't expect to find it when he is on his back! There will be a lot of doubts from the owner when the vet can't find this testicle as it is inside the abdomen.
Have an examination procedure. Verify gender. Verify presence of both undescended testicles under the skin. If not, let the dog owner know immediately and open up the abdomen. The abdominal testicle usually is located next to the bladder at the side.
Be humble if you don't know and ask your senior vet what to do.