1463. Update on Schauzer's fits and "sudden" death case compared to dengue shock syndrome

TOA PAYOH VETS toapayohvets.com Date:   16 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits Fits in a Schnauzer  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   16 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 1439. A 10-year-old Schnauzer has fits and collapses suddenly   May 29, 2013 "Do you remember you operated on his ears?" the mother and daughter brought in a white Schnauzer that had fits and collapsed just over one hour ago. The dog had white and cyanotic tongue and was breathing fast. I put him on oxygen therapy first as he had insufficient oxygen for his red blood cells, leading to purplish tongue and mucous membranes. I reviewed the medical records and said: "Yes, he had very painful and itchy right ear and his ear canal was opened up. How's the ear?" "No more problem," the mother said. "Could the dog be suffering from a stroke?" "Hard to say at the moment, I need a blood test and examination. It is possible there is a brain abnormality e.g. tumours, infection or bleeding or a systemic infection. I advised a brain scan but that would be costly and so the owners wanted the basic treatment to be done. That included a blood and urine test.   The veins were collapsed too. Dr Daniel had to collect blood from the jugular vein. It was not a good sign. Despite intensive treatment with fluid intravenously, the dog passed away 2 hours later.  BLOOD TEST Significant findings are: 1. Total white cell count 18.3 (6-17). N 90% Absolute 16. L 9% Absolute 1.7 2. Red cell count 5 (5.5 - 8.5) 3. Haemoglobin 11 (12-18). 4. Platelets 108 (200-500). Few giant platelets present. No platelet clumps. 5. Uric acid  0.27 (<0 .13="" br=""> 6. SGOT/AST 129 (<81 br=""> 7. Urea 3.4 (4.2 - 6.3). Creatinine levels were normal.  The blood was taken from the jugular vein. The dog had around 30 minutes of oxygen therapy by mask before the blood and urine were collected. URINE TEST pH 5.0 (5-8), SG 1.020 (1.005-1.030), urobilinogen +, blood 4+, bacteria 3+, white blood cells >2250, red blood cells 315. It is important to practise evidence-based medicine. In this case, the dog could have a septicaemia. There could be a pathogenic type of bacteria picked from sniffing the grass or consuming some poisonous food or treats. The onset was "sudden" fits and recumbency. There could also be an internal bleeding and breakdown of capillaries. A post-mortem may give a definitive diagnosis as to the cause of death. As it would be costly, this was not advocated by me. A simple blood and urine test provide some clues of illness at the most economic rates as compared to brain scanning and more tests. In any case, the dog was breathing fast and had white and purplish tongue, indicating a very poor prognosis. However, other tests like brain scan needs to be advised. This Schnauzer has been well cared for as evident by his good size and body condition as so the death was a "sudden" loss to the family. No poisonous food or drink was consumed according to the mother. If no blood or urine tests were done, the owners would not know why the dog died suddenly.   The dog's ears were normal after the surgery as there was no more intense and continuous ear scratching. The case study and lateral ear canal resection surgery is at: http://www.asiahomes.com/singaporetpvet/dogs/ 0750Schnauzer_lateral_ear_resection_Singapore.htm The above case had symptoms of shock as the blood pressure was very low. A dengue haemorrhagic shock syndrome is reviewed below as this dog has similar brain, liver and low blood pressure and platelet disorders as in the case below.    Saturday, June 15, 2013 Dengue haemorrhagic shock syndrome   A 20-year-old Singaporean, Mr Ang Yong Han was the first dengue death in Singapore in 2013 (Straits Times, Home B1, Jun 1, 2013). He died one week after falling ill. Another man died.  8,305 people were infected as at May 31, 2013 for the year. Signs: fever, headache, muscle or eye pain, vomiting and diarrhoea - see a doctor Don't take aspirin or non-steroidal anti-inflammatory drugs (Nsaids, e.g. Ibuprofen or Synflex) as they make the person more ill. Pannadol is said to be safe. No drugs to cure. Must drink a lot of isotonic drinks as there is a loss of electrolytes in vomiting and diarrhoea. Patients given fluids intravenously, blood transfusion, plasma and platelet transfusion and pain killers (Pannadol). If blood pressure keeps dropping, goes into shock and die. BLOOD TEST. Virus caused liver and brain inflammation. Liver inflammation. Enyzme (AST) Aspartate transaminase levels are 10-40 units/litre of serum. 200-500 units are common in dengue patients. In Mr Ang's case, they were "way off the charts", being 1,000 and then 4,000.  Platelet counts are usually very low. Below a certain level, patient is hospitalised and given platelets. Blood test said to be useful only when the patient has fever for one week.  BRAIN SCAN Brain inflammation (confused) - brain scan done. Patient complained about stomach pain. HAEMORRHAGIC SHOCK SYNDROME Blood pressure continued falling despite being given strong medication. Due to blood vessels leaking fluid. Blood becomes concentrated and pressure falls continuously leading to death.   Updates will be on this webpage: http://www.sinpets.com/F6/20130531 fits_Schnauzer_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: June 16, 2013 Toa Payoh Vets

1462. Dengue haemorrhagic shock syndrome in Singapore

A 20-year-old Singaporean, Mr Ang Yong Han was the first dengue death in Singapore in 2013 (Straits Times, Home B1, Jun 1, 2013). He died one week after falling ill. Another man died.  8,305 people were infected as at May 31, 2013 for the year.

Signs: fever, headache, muscle or eye pain, vomiting and diarrhoea - see a doctor
Don't take aspirin or non-steroidal anti-inflammatory drugs (Nsaids, e.g. Ibuprofen or Synflex) as they make the person more ill. Pannadol is said to be safe.

No drugs to cure. Must drink a lot of isotonic drinks as there is a loss of electrolytes in vomiting and diarrhoea. Patients given fluids intravenously, blood transfusion, plasma and platelet transfusion and pain killers (pannadol). If blood pressure keeps dropping, goes into shock and die.

BLOOD TEST. Virus caused liver and brain inflammation.

Liver inflammation.
Enyzme (AST) Aspartate transaminase levels are 10-40 units/litre of serum. 200-500 units are common in dengue patients. In Mr Ang's case, they were "way off the charts", being 1,000 and then 4,000. 

Platelet counts are usually very low. Below a certain level, patient is hospitalised and given platelets. Blood test said to be useful only when the patient has fever for one week. 

BRAIN SCAN
Brain inflammation (confused) - brain scan done. Patient complained about stomach pain.

Blood pressure continued falling despite being given strong medication. Due to blood vessels leaking fluid. Blood becomes concentrated and pressure falls.

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The PURPLE dengue alert banner is a recent introduction in coloured banners by town councils. It is deployed in areas with HIGH Aedes mosquito populations. 

 

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.

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

Poodle, 10 years, 4.1 kg 38.2 C. Dog was panting but owner said this was normal behaviour of excitement. Urinated blood yesterday, incontinent and now had abdominal distension.

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.





ANAESTHESIA
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.

SURGERY
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 femal 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.

POST OP
The dog vomited twice, yellow gastric juice 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.

1459. Update: Overweight Jack Russell 13 hours after bladder stone surgery

Friday July 14, 2013  9.34 am Toa Payoh Vets


I reviewed the Jack Russell, operated by Dr Daniel yesterday afternoon, 13 hours ago and to ensure he has his medication including pain-killers. He drinks and is OK. The 10 small calcium oxalate stones were so small (2-3 mm across)  and were flushed out via the urinary catheter from the penile end. My assistant took some images as he is being trained in digital photography and video graphy to enhance his skills when he seeks another employer later.

It is always good to see an old dog recovering well from surgery as no vet can expect a 100% success in old dog surgeries. Many have health problems as they have no regular medical check ups over the years. Old dogs are like house furniture. The owner does not bother with yearly check ups. After all, human beings don't go for annual health screenings.

Initially I wanted an air contrast X-ray. Dr Daniel, Dr Daniel did not do it as the radiographer wanted to charge an additional $100. 50-100 ml of air would be pumped into the bladder via the catheter.  I got the X-ray image cropped as there were small stones in a row seen. According to Dr Daniel's interpretation, the stones were in a row because the bladder had no urine and so had collapsed. Sounds logical to me. "The stones are too big to be sucked out," he said. "In female dogs, the urethra is straight and not bent and an endoscope may be able to suck them out without surgery."

In any case, opening up the bladder would be most economical in dogs and 10 stones were irrigated out. The images will be shown later.  

10 small calcium oxalate stones removed from the bladder on Jun 13, 2013

 

1458. Skin disease & urinary stone cases

TOA PAYOH VETS toapayohvets.com Date:   14 June, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits Skin disease & urinary stone cases Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   14 June, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Thursday, June 13, 2013 1458. Two skin disease & two urinary stone cases TWO SKIN DISEASE CASES   June 13, 2013  7.35 pm review I may or may not work in the evenings as Dr Daniel would be present. However, on June 13, 2013,. Dr Daniel had gone to a "Dirty Dancing" concert at Marina Bay Sands and so I handled the cases after 6 pm. Surprisingly two dogs had intense ear and skin itchiness were brought in by two couples in their 30s. I used the UVL to show and tell. One dog was an aggressive Jack Russell. The other was a Shih Tzu. Both ringworm-infested hair shafts fluoresce apple-green while the normal hair showed plain lighting. This was quite impressive to the owner. I asked intern Ms Toh to video the UVL procedure but I know it is difficult to capture the real images owing to our lack of experience in videography.  "Lots of hard rubbing of the skin and ear irrigation and medication is needed," I emphasized to the two couples. "Review in 3 weeks." Case 1. The ferocious Jack Russell that all vets avoid The first couple had seen a few vets and skin scrapings were negative. "The main problem is the painful itchy left ear," I said. "There is a red circular skin patch in front of the left ear of 4 cm across. It would be ringworm . Also, the left inguinal area is extremely red while the right is normal white. Therefore, I can say that this is not a case of contact dermatitis although some vets will say it is ventral contact dermatitis. In such cases, both the left and right inguinal areas are inflamed. Your dog only has the left side blood red, now obvious after clipping the whole body bald." The couple had brought the dog in the morning. I gave him immediately a Dom + Ket 0.1 ml + 0.11 ml IM and the dog was sedated for dental scaling and hair clipping without biting my assistant and me.  The owner came in the evening after work to take the dog home and I had a lengthy discussion with them as generalised skin diseases are not so easily treated by owners despite seeing several vets. "If you see 10 vets, you will have 10 different opinions as to the cause of the skin disease. "From my observation, the dog uses his left hind paws to scratch vigorously the left inguinal area because the left ear is extremely painful. Most owners will wonder what the left inguinal area's itchiness has to do with the left ear being infected? There is a nerve connection and you will see the dog's hind leg moving whenever the same sided ear is itchy. Only in this dog, the leg scratches the inguinal area. Normally it scratches the flank and belly area." The Jack Russell shook his head sideways and this was a clue that he has ear problems. As to which ear he scratches more, the couple did not know. "I saw both ears being scratched," the husband said. I would say it is the left ear as the inflamed skin was present mainly on the left ear base and the left inguinal area. Only the dog knows and he cannot talk! Case 2. The timid Shih Tzu is a tiger at home. As for the Shih Tzu, he bites the owners but was docile at the consultation table. He did not bite me or my assistant. I advised: "Feed the anti-fungal and antibiotic medication tablets inside cheese balls when he is hungry. Irrigate his ears with ear drops downstairs away from his home base as he may be more docile. "Do you sell muzzles?" the wife asked me. "This Shih Tzu is hard to muzzle as he has a flat face," I said. "Use the net from the oranges for sale to cover his face but I doubt it will work."  I muzzled the dog with my muzzle but it was too long. "More for a Jack Russell with long nose," the wife laughed. Still the owner must work hard on the ear to resolve the problem. Going downstairs to clean the ears may be successful as the dog appears timid in the clinic but ferocious at home.  In the Jack Russell, it is unusual as the left inguinal and scrotal area were very red. Neck skin and paws also were red. One paw showed fluorescence at the pad junction but the dog wanted to bite me when I tried to lift the paw up to shine the UV light. The wife was convinced. In the Shih Tzu, the neck showed a large circular patch of 5 x 4 cm which fluroesce green in certain parts, confirming ringworm. The wife was quite impressed with this show and tell. The chin was inflamed too. Ear surface were rough but not much pain when I pressed both ears. In this case, the main area of itchiness was inflamed by ringworm and the belly, flank and inguinal area were OK.      THREE URINARY STONE CASES. Case 1. Urine crystals 3+ but no stones in the X-rays. This morning, I got a 2-year-old female cross X-rayed as her urine test showed triple phosphate 3+ crystals. X-rays did not show any stones.  S/D diet for 2 months advised by Dr Daniel. Case 2. 10 little stones Yesterday's X-ray of the male, overweight older Jack Russell, emptied bladder and catherised showed at least 6 bladder stones of 3 mm across. Dr Daniel operated today and removed 10 stones. Urine test showed Calcium oxalate. The dog is resting as I typed this report and is given IV drip. "His bladder bleeds and tears whenever I stitch the tissues," Dr Daniel says. "His bladder wall is thin as he is not badly infected for some time. There is little inflammation and so there is a difficulty in stitching with 3/0 monosyn."   As for me, I used 3/0 absorbable braided with smaller needle but the monosyn comes with a bigger needle. Each vet has his or her own preferences. Case 3. Update on blood in the urine   6189 - 6192. Female dog urethral catherisation and 30 ml of air into bladder provides excellent contrast X-rays. Against Medical Advices Female Poodle with one big bladder stone and small kidney stones. The owner phoned for appointment tomorrow Friday for surgery. I will be operating. This case was infected as the total WCC was high at 25 but now the dog is OK and active. Case is at: Against Medical Advices. So, my operation can proceed tomorrow, Jun 14, 2013.   Update will be on this webpage: www.sinpets.com/F5/20130613 skin_diseases_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: June 14, 2013 Toa Payoh Vets

1457. Emptied bladder shows 9 calcium oxalate stones (X-ray)

Kidney ok
Blood in urine two times

1456. Two You tube videos - canine i/v placement & cherry eye tucked in

I/V catheter placement in a dog
http://www.youtube.com/watch?v=wt_K1beUZEI


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TOA PAYOH VETS toapayohvets.com Date:   13 June, 2013   Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits

Cherry Eye in 2 Dogs in 2002 and 2010 Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Case 1 written: 20 Sep 2002 Case 2 written: 01 Sep 2010 Updated: 13 Jun 2013 toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Case 1: Cherry Eye in a Cocker Spaniel puppy in 2002 Case 2: Cherry Eye in a English Bulldog in 2010 8 years had passed since I documented the cherry eye in the Cocker Spaniel case above. In 2010, there are over 200 pet shops and more than 10 approved puppy breeders in Singapore. I got a referral of a cherry eye recently. The man said: "The seller told me to wait till the other eye develops a cherry eye before going to the vet for the surgery." I operated on this puppy and excised the gland. There was no complaint from him since 3 months ago. He did not want any recurrence or popping out of the cherry eye if I did the "tucked in surgery" which costs much more and which is not guaranteed. Many Singapore pet owners are cost-conscious and therefore do not follow up or wish to pay for repeat surgery which may occur in the "tucked in surgery".  Some get very upset at having to repeat the surgery.  Therefore, the vet has to be understanding and practical. Any surgery over $200 seem to meet a resistance level from pet owners in Singapore. In such cases, the vet has to snip off the cherry eye although it is said that the dog may develop dry eye if the cherry eye has been cut off. Using the cheaper method of excision, the veterinary treatment of the excision of the cherry eye in the dog is discussed below:   CHERRY EYE EXCISION SURGERY IN THIS BRITISH BULLDOG PUPPY 1. Gas mask isoflurane - no problem 2. Local anaesthestic subconjuctiva below the cherry eye 3. Clamp for a few seconds 4. Remove clamp unless there is space below the clamp to perform step 5. 5. Ligate central vertical area where blood supply to the cherry eye is located 6. Excise gland with scalpel 7. No bleeding post-operation using this procedure   ALTERNATIVE TO ABOVE-MENTIONED SURGICAL EXCISION APPROACH As above, but no ligation. Profuse bleeding post-operation is temporary. I find that this approach is satisfactory.  Excise as little of the cherry eye as possible as it is said to produce 30-40% of the tears. NO EXCISION APPROACH - CHERRY EYE TUCKED IN METHOD The re-positioning of the cherry eye and suturing it is usually advised but this approach is costly and does not guarantee that the cherry eye will not prolapse. Extra veterinary costs for additional surgery is not be acceptable by many Singapore pet owner. The vet cannot guarantee a successful treatment outcome in this approach and so the owner is reluctant to pay more for this surgery. The culture for most Singaporean pet owners and travellers is to go for the cheapest although there are more sophisticated ones in 2013 wanting to know more about the quality than quantity of service.   Jun 13, 2013. Cherry eye tucked in surgery videos from You tube 1.  Cherry eye tucked in surgery video seen on You Tube Electro-excision, continuous sutures,  local anaesthestic, two sutures knots away from the cornea. 7 days later to remove knots. http://www.youtube.com/watch?v=Xsaq8ks2Jg4 Well filmed video. The suture used is likely to be 2/0. 2. http://www.youtube.com/watch?v=SvXybSHaZ9w A video by Neartown Animal Clinic - a vet used absorbable 5/0 and use scissors instead of electro-excision to cut and undermine the conjunctival surface away from the cherry eye. She cuts out the conjunctiva covering the cherry eye. Then she used a continuous suture to close the wound after tucking in the cherry eye. This piece of conjunctiva cut off is shown in the video. Her procedure is described in 4th edition of the Small Animal textbook edited by T W Fossum. She used a corneal shield availabe from Ellman, Item H781. Sutures are placed away from the cornea on the outside skin of the eye area. 3. http://www.youtube.com/watch?v=EAu2QpxpdBA Cherry eye surgery at Shinki Vet Hospital 4.  http://www.youtube.com/watch?v=uBmCpekwpcc Suture anchoring tack method. Sharing of knowledge from the video producers benefit many pet owners and vet surgeons as each party provides new ideas and tools about veterinary surgery. Updates will be on this webpage. URL is: http://www.sinpets.com/dogs/cherryeye.htm   Advertisement Asia USA Realty (Singapore) asiahomes.com Pte Ltd   VARIOUS UNITS ARE FOR RENT AT VARIOUS TIMES: Tel: +65 9668 6468, Email: judy@asiahomes.com Asia USA Realty More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129

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