Treatment of pyometra for valuable breeders - using uterine irrigation

Jun 12, 2014

TREATMENT OF PYOMETRA
Experiences of my associate, a senior vet aged 75 years old who did treat a few cases of pyometra in dogs.

1. Spay is the best solution. Some owners just want antibiotics. After a few cycles, the dog becomes paraplegic and it would be too late even with spay. The dog would die during surgery or not able to stand again. It is believed that the toxins from the pyometra has reached the brain or spinal cord.

2. OPEN PYOMETRA - Midline incision to view passage of the catheters into uterus via vaginal speculum. 2 cathethers via vaginal speculum to 2 uterine horns. Irrigate and flush out the pus. Use of saline and hydrogen peroxide


3. CLOSED PYOMETRA  - Treatment of uterine irrigation as for open pyometra. In one case, the owner of a Pekinese wanted the treatment. The Pekinese got pregnant with one pup at the next cycle.

4. Conclusion. Spay is the cheapest. Blood test and ultrasound needed. Polydipsia is a sign.

Two urolith cases in 2 dogs. Bladder stones in 2009. Kidney stones in 2014

TOA PAYOH VETS toapayohvets.com Date:   11 June, 2014   Focus: Small animals - dogs, cats, hamsters, guinea pigs, tortoises & rabbits toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Case 1 in 2009. Bladder stones Mum complained that the Chihuahua peed too many times a day  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS First Written: 4 March, 2009 Updated: 11 June, 2014 Summary: If your dog does not pee normally, do consult your veterinarian promptly as the bladder gets inflamed severely and the wall thickens considerably over time, due to chronic infections by bacteria. CALCIUM OXALATE UROLITHIASIS IN A CHIHUAHUA The 6-year-old male Chihuahua was in excellent body condition. Lots of good food had given him a padded body. He stayed in an apartment and seldom went down for exercise.  Around the beginning of December, he stayed with another family member - the brother. At the brother's apartment, he was shut out of the bathroom which he normally used as his toilet as the brother wanted to have a clean bathroom.  History: The brother took the dog outdoors to pee. The dog took a long time to pee. Sometimes he took 2 hours to pee. But the dog could not pee normally in Jan 20, 2009. Urinary stones blocked the flow of urine as I could not push the catheter into the bladder easily. "There is a need to analyse the urine under the microscope for urinary stones, cells and infections," I advised the owner. As the dog could pee, the owner did not want any tests as that would add to the costs of veterinary service.  "If he can't pee, I will have no choice but put him to sleep as it is too costly to treat him," he laughed. I could not persuade him to take urine tests. Clients have the freedom of choice but they must be adequately advised and such advices are best put in writing to prevent miscommunication and mistrust in a litigious society - when the dog dies and family members become very unhappy. "Do not worry, my family will not sue you," he laughed when I told him that the problem of difficulty in urination would recur and some family members might be unhappy with no tests being carried out. Unhappy people see an opportunity to sue the veterinarian to gain money for "incompetent" services and negligence and to prevent other dogs from suffering the same fate of negligence. In such cases, the vet ought to give the owner a written statement that he had had been forewarned about the prognosis. I did not do it but would record this advice in my medical records. On the 10th day after the first consultation the dog could not pee at all. "My dog did not really pee normally for the past 10 days," the slim man in his late 30s commented. Urine tests and X-rays were permitted and done. Surgery on Jan 30, 2009. Two Calcium Oxalate urinary stones removed from a dark red bladder with walls as thick as 0.8 - 1.0 cm. Normal bladder walls are around 0.2 cm. The urinary stones could not be palpated via the bladder as they were too small and the inflamed bladder was too thick. In any case, such a thick bladder wall would prevent palpation to be done properly. The dog was hospitalised till Feb 10, 2009 when he could pee normally.  What happened after the dog went home? The following record is a follow-up as I met the owner at the Surgery on March 4, 2009. At home in a high-rise apartment from March 4, 2009 1. "The dog urinated all over the kitchen floor for the first 4 days at home," the owner revealed his observations. "He drank a lot and peed a lot. I told him to pee onto the grating (drainage hole cover) in the kitchen.  "He is an intelligent dog and by the 8th day, he peed at the grating. He is now back to normal in peeing." 2. Going outdoors. The owner said, "I make sure that I bring the dog down to the grass at least once a day, particularly in the morning. I want to see that he pees in a large amount all at once. If the dog is indoors, he will stand on  the kitchen grate to pee." 3. Urine marking. "Nowadays, after the surgery, the dog would pee a lot all at once when brought down. Then he would lift up his leg to mark but sometimes a small amount of urine would come out. Other times, nothing. Prior to surgery, he would pee a little bit at a time. I had to wait 2 hours to ensure that he urinates completely. Other dog owners were puzzled as to why my dog takes such a long time to pee. Now, there is no need." The owner had time as he was self-employed. I don't really know what he was doing in his profession. He is a happy-go-lucky man in his forties, in my observation and sends out good vibrations. 4. Mum's complaints in the past. "For some weeks, mum had complained that she needed to wash the toilet floor many times" the man said to me in retrospective analysis. The dog used to stay with the mum in another apartment and would use the toilet floor to pee as he had been doing so for the past 6 years. Mum would then flush the floor with water as family members had to use the toilet. But lately, mum had to do it so many times. Nobody had thought of bringing this dog for a veterinary check up. Other dog owners had also asked the man when he took over the dog to live with him in December 2008, "Why your dog takes such a long time to pee?"  "As long as two hours outdoors," the owner would wait patiently for him to pee all his urine. This behaviour is not normal but the owner did not think it was abnormal. 5. Sorrowful demeanour. "I can't remember why I brought this dog to see you," the owner said when I asked why he consulted me in the first instance.  "It must be because the dog was sorrowful." 10 days before the day of surgery on Jan 10, 2009, the owner consulted me because the dog had difficulty in urinating. The urine was cloudy. The dog seemed to be incontinent, leaking urine drops onto my consultation table. The urethra was blocked. Catherisation of the urethra lead to easier urination. The owner was not keen on X-rays and blood tests then due to the need to save money. Since the dog could urinate, he wanted the dog home. However, I did warn him that there would be the same dysuria again as the urethra was obstructed when I passed the catheter into the urinary bladder with great difficulty. 10 days later on Jan 10, he consulted me as the dog could not urinate. "The dog had never peed normally since I got him home," he said. Catherisation of the blocked urethra enabled the dog to pass golden yellow. The smell of urine ammonia was strong, as if, the toilet bowl's urine was not flushed for 24 hours. This time, the owner was agreeable to urinalysis but no blood tests (complete cell count, serum chemistry) and X-rays. Veterinary costs can add up to a large amount and I understood his financial concerns. This recession would be the worst in decades, according to all the experts.  6. Urinalysis. Calcium oxalate crystals + were the significant finding. See blood test report above. 7. X-Rays. As no big stones were palpable and the bladder wall was considerably thickened, it would be wise to X-ray the bladder to see how many urinary stones were present. The owner consented. Calcium oxalate crystals are radio-dense and 2 were easily seen on the X-ray. If no X-rays were done, the owner would feel that the bladder stones were not all removed should there be a recurrence of difficulty in peeing. Therefore, X-rays are advisable except in certain cases where the urinary stones were so large that they were palpable. This is because the owner may want to reduce veterinary costs. Every test add up to the high costs. 8. Surgery. In this case, 2 stones were seen on the X-ray. It was extremely difficult to pick up the 2nd stone as both stones were around 0.5 mm in diameter and the bladder incision had to be as small as possible. A big bladder incision would not be good for the dog. Extremely thickened bladder wall indicated that the bladder had been infected by bacteria for several years. The infection had caused the bladder to thicken and thicken its wall to fight against the bacteria. It was a losing battle and therefore the bladder became severely reddened and swollen. The mum was not aware of the need to get the dog examined when she had to wash the bathroom floor so many times a day - a change of the dog's behaviour.  In retrospect, her complaint of having to flush the toilet floor many times recently would be a clue to the urinary tract infection. Mum used to clean the floor once a day previously. Mum's complaints "Must clean the floor many times. The dog did not urinate in a big amount." Therefore frequency increased while urine volume decreased per occasion. 9. Post Surgery. Today is Mar 4, 2009. Surgery was on Jan 30, 2009. The owner was now satisfied and pleased that the dog's first urination in the morning when brought outdoors was a big volume, as in the past. "There is a very small wound which seems not to heal," the owner commented. It was difficult to know what he was saying as he did not bring the dog in for consultation. Overall, he was happy so far as his best friend was living a normal pain-free life now - not having intense pain when passing urine and therefore taking a very long time to pee. Now, the dog just urinate one large volume at one go and get on with enjoying his outdoor exercise and urine-marking (with little or no urine to mark). As at Mar 4, 2009. Home-cooked food. Dog drank normally and not a lot as in the lst 4 days home. Urine-marking downstairs where other dogs had been. However little urine production or none at times. I said, "The dog may start to leave more urine inside his bladder in time to come. Then stones might form again." I asked the owner to monitor the urine intake, colour and consistency over 24 hours. The dog was banned from the bedroom because he would "pee" onto the mattress which had to be thrown away. Doors would be locked. He would pee at the kitchen drainage grate but the owner would always bring him outdoors in the morning so that he could pee all urine at one go within the first time. He continued to urine-mark with little urine as this is the natural behaviour of male dogs that have not been neutered. The dog has to pee on the spots to over-ride the smell of other dogs - to mark his territory. Conclusion X-rays are necessary before surgery in this case so as to know how many urinary stones are present in the bladder.  Calcium oxalate crystals are radio-dense and will be easily spotted on X-rays. Due to financial considerations, no X-rays were done after surgery although this is recommended. Two stones were shown to the owner as evidence. It is best to produce evidence to educate the owner. Urinalysis is also necessary. There is no guarantee that urinary stones will not be formed again. Unlike struvite (triple phosphate) urinary stones which form in the presence of alkaline urine and bacteria, calcium oxalate crystallisation is not related to the alkalinity of urine and therefore acidification of the urine in this case is not advised. If you review the blood test report, the dog's urine was acidic actually. Will the special Hills' urinary stone prescription diet to prevent calcium oxalate crystallisation work? One veterinary book doubts this will help. The owner feeds home-cooked food, so the answer in this case will not be known for some time. For other dog owners, it is advised that you get your dog examined by your vet at the first sign of difficulty in peeing as it is much more inexpensive to get early treatment than surgery and hospitalisation.   As at Aug 31, 2010. No complaint from the owner. This case may be one to "justify" neutering of the male dog to prevent urinary stasis and stone formation at an older age. This male dog needs to urine-mark his territory. He tries to retain some urine to urine-mark. Retention of urine causes crystallisation and bacterial infections of the bladder wall over the passage of time. Urinary stones form. Urine flow gets obstructed when they get stuck in the urethra. The dog can't pee normally and to some owners, it is costly to consult the veterinarian and get treatment for the dog in pain. It is hard for the dog owner to envisage the sequences of physiological events. Therefore advices to neuter this dog fall on deaf ears. I hope for the best for this dog. He would definitely be well cared for and much loved by the brother. If his health is good, he should live to a ripe old age of 15 years.   Updates will be at this webpage: bekindtopets.com/animals/20090305Calcium_Oxalate_ Urinary_Stones_Chihuahua_ToaPayohVets.htm   Case 2 in 2014. Kidney stones First written: Tuesday, June 10, 2014 Blog 1376. A 13-year-old poodle has kidney stones   The 13-year-old poodle could not stand up, leaked urine and did not eat for the past few days. She was overweight and had lost all teeth. One last upper left canine tooth remained and was as black as carbon. "What happened?" the couple asked me when I palpated the anterior abdomen and the dog reacted with painful cries. "I need an X-rays to check the abdomen," I said. "She might have urinary stones." X-rays showed kidney stones in both kidneys. This explained the anterior abdominal pain. The owners did not want to spend more money for blood and urine tests. In any case, the prognosis was poor as both kidneys were affected and would be severely inflamed and inoperable.  They took the dog home. She died the next day and was cremated.   Kidney stones (2 kidneys) Kidney stones (2 kidneys) Blog: http://2010vets.blogspot.sg/2014/06/1376-13-year-old-poodle-has-kidney.html See interesting cases in male dogs at: Urine tests for 2 dogs - shivering and leaking urine - Part 1 Tumours in 3 male dogs - Sertoli cell tumour, circum-anal tumour and oral tumour Toxaemia and anaemia in a young male Shih Tzu. What to do? Struvite stones in two Miniature Schnauzers - 2008 & 2010

1375. AUDIT. Owner's financial constraints. An 11-year-old Miniature Pinscher has calcium oxalate stones

Case TP 44133
The 11-year-old Miniature Pinscher was overweight at 12 kg and could not stand up yesterday. Two weeks of dribbling urine. He stopped eating for the past 2 days and had been dribbling urine for the last 2 weeks or more.

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Thursday, April 24, 2014

1358. An old Miniature Pinscher can't pee

"It is always best to get an X-ray done rather than just unblocking the bladder," I said to Dr Daniel as the owner of the overweight Miniature Doberman Pinscher dribbling urine wanted to save on medical costs and so the dog was warded for 2 days. So today, I got the dog X-rayed. Several big urinary stones obstructed the urethra at the os penis area and many more were in the bladder.

"The bladder is about to rupture," I advised an emergency surgery. "Around 10 stones in the os penis and more than 16 inside the bladder!"

The owner had delayed seeking veterinary treatment for many weeks. Blood tests showed kidney failure, thus explaining the persistence of daily vomiting by the dog.

The owner gave permission for the emergency surgery. The dog survived anaesthesia and surgery done by Dr Daniel. However, he passed away 3 days later.

Chances of survival after surgery are much lower if owners have been dragging their feet in getting their dog treated early by the vet.

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BLOOD TEST
Urea 44.6  (4.2-6.3), Creatinine 514 (89-177)
Haemoglobin and red cell count were below normal. Total white cell count at 26.1 (6-17) with Neutrophils at 95.5%. Haemocrit was low at 0.32 (0.37 - 0.55). However, the platelet count was normal. The dog was obese and very ill. This was a very high anaesthetic risk but the owner consented to the surgery.

X-RAYS
Urethral stones and bladder stones
To upload X-ray

URETHRAL OBSTRUCTION relieved by catherisation by Dr Daniel.
URINE TEST
pH 7, SG 1.011, Blood 4+ Crystals Nil, Bacteria Nil
No urine culture done

The dog passed away a day after surgery. The owner did not want any stone analysis.

I sent the stones c/o Hills to Minnesota Urolith Center Quantitative Urolith Analysis
Results: Calcium oxalate stones

1377. Territorial disputes of a dog

The 4-year-old Cross-bred bit the child who sat on the sofa. This was the 4th time he bit family members. Two years ago, he bit the owner and I had advised neutering him to reduce his aggression.

"This aggression could have been much reduced if you had neutered this dog 2 years ago," I said to him.  The dog was healthy and should not be put to sleep.
 
"I was advised not to neuter him," the man in his late 30s said to me as he brought the dog to me for euthanasia. Yesterday, he went to a bigger practice, but the vet rejected his request to put the dog to sleep and told him to come to me instead. SPCA apparently did not want the dog.

There was one option. To house him with Noah's Ark but would they accept this dog? Would this dog stop eating once he was not with this owner as it had happened before. "I am not a good owner," the man said as he spent time with the dog outside the clinic. "My dog is territorial and that was why he bit my nephew."

He would house the dog in Noah's Ark if I would be responsible for all the administrative arrangements. What if the dog bites and kill other people since he had "tasted blood" four times. I declined the heavy responsibility.

Territorial disputes happen in the canine kingdom too as between large countries. Only that the dog is the loser. He decided on euthanasia and later scattered the dog's ashes off the East Coast seas. "This is the only time I can kiss him," the wife planted a kiss on the euthanased dog. This scene reminded me of "Sleeping Beauty". Only that, the dog did not wake up when kissed by "true love",  a person who truly loved him as in the Disney movie "Maleficent" I watched recently.

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1376. A 13-year-old poodle has kidney stones

The 13-year-old poodle could not stand up, leaked urine and did not eat for the past few days. She was overweight and had lost all teeth. One last upper left canine tooth remained and was as black as carbon.

"What happened?" the couple asked me when I palpated the anterior abdomen and the dog reacted with painful cries.
"I need an X-rays to check the abdomen," I said. "She might have urinary stones."

X-rays showed kidney stones in both kidneys. This explained the anterior abdominal pain. The owners did not want to spend more money for blood and urine tests. In any case, the prognosis was poor as both kidneys were affected.  They took the dog home. She died the next day and was cremated.

  

1374. Yangon veterinary talk to vets - July 5, 2014. Pyometra & Uroliths (treatment & prevention)

Veterinary Articles for a video production for presentation to vets in Yangon on July 5, 2014:


Treatment & Prevention

1. Calcium oxalate to struvite stones
http://www.sinpets.com/dogs/20120218recurrent-urolithiasis-urinary-stones-calcium-oxalate-struvites-toa-payoh-vets_Singapore_ToaPayohVets.htm



2. How to create a compelling educational video
http://www.youtube.com/watch?v=xAlGLSCFfuI&feature=youtu.be





3. How I suture the bladder in 2 layers after stone removal - Images of a case
http://www.toapayohvets.com/surgery/20080818Shih_Tzu_Urolith_Dysuria_ToaPayohVets.htm

2007 Case. Dysuria (difficulty in peeing)
Shih Tzu, Female, 5 years. Peeing a bit here
and there many times a day for many months

Middle-aged and older dogs are seldom given much attention by many owners all over the world, unlike puppies. Such dogs don't live long lives if their sickness is not treated.  After many months of painful urination, the owner consulted me. I palpated a large bladder stone and advised surgery after 10 days of antibiotics. The owner forgot about the surgery and the difficulty in urination problem recurred. Surgery was inevitable to resolve the problem. But was it too late and would the old dog survive the anaesthesia and not die on the operating table or after surgery? The owner understood the risk. The dog was alive after the surgery. The pictures of the surgery are shown below.
I prefer to incise the ventral wall of the bladder and find no problem of "the heavy weight of the internal organs pressing down on the bladder" and therefore adversely affecting the healing.	Thick and reddish bladder wall of nearly 5 mm in thickness indicates that the bladder infection has gone on for many years. Some dogs die as bacterial infection spreads to the kidneys and into the blood.	The submucosa of the bladder is stitched with an inverting suture pattern.
2nd layer of inverting suture is now placed. Forceps on the left anchors the knot of the first layer. No omental fat layer is sutured onto the suture line although some vets do it. CASE 4 POOR VETERINARY WORK - Some vets, not only in Singapore but elsewhere consider urine analysis unnecessary as in this case   2010 Case. Dysuria (difficulty in peeing)  at the end stage of urination Feb 26, 2010.  At 13 years of age, he just had dental scaling at another vet practice. The vet had performed 2 blood tests 3 weeks apart and this indicated excellent health. Then the owner consulted another practice (Vet 1) as the dog took a long time to pee at the end part of urination. Vet 1 advised surgery. The owner phoned me for advice after Vet 1 had been consulted. I had not seen the case and I asked "Was the dog's urine analysed?  Struvite urinary stones, if small, may be dissolved by the acidification of urine."  The young lady owner said, "No." Later, she told me that Vet 1 considered urinalysis unnecessary.     I saw the case and got the owner's permission to do a urine analysis. The urine pH was 6.5 and there were no crystals in the urine on urinalysis. So, these tests indicated that the urinary stones might not be struvites and therefore acidification of the urine would not be effective. Surgical removal, as advised by Vet 1 was my recommendation. But will the dog that growled at me,  die on the operating table as he was so old?    ---------------------------------------------- THERE ARE OWNERS WHO DO NOT WANT SURGERY TO REMOVE BLADDER STONES  Case 1: 2010 - The Shih Tzu keeps passing blood in the urine every day X-rays and blood tests would be best but sometimes it is not possible due to economic reasons. The vet has to be compassionate when the owner request least-cost surgery. However the diagnosis must be spot-on and the surgery must be planned to ensure survival of a dog during anaesthesia.   "Your Shih Tzu needs an operation to remove the big bladder stone I felt," I advised the young man whose female dog passes blood in the urine for the past 2 months. I could feel the creptitus (gas-like feeling) in the bladder. But the owner did not want an X-ray nor surgery. He wanted drugs. One month later, his dog had not stopped passing red blood. He requested surgery, but no blood tests or X-rays. I was OK with this request. "It is an open-and-shut case," I thought when I saw one stone coming out. "This was the big stone I had palpated. Stitch up the bladder and go home. Another big stone was stuck partially in the urethra as my catheter could not pass through. What to do? The stone was stuck fast. Finally the forceps managed to grip one end and pull it out  Smaller stones spilled out like small bombs when the bladder was flushed. Catheter was earlier passed out via the vagina No more urinary stones after irrigation of the bladder   Day 3 after surgery. There has been difficulty in passing urine but the dog eats and has no fever. Antibiotics and pain-killers are given. I phone the owner that the dog can't go back today Sep 6, 2010 as the dog has dysuria. REFERENCES http://www.cvm.umn.edu/depts/minnesotaurolithcenter/   RECOMMENDATIONS ON TYPES OF STONES http://www.cvm.umn.edu/depts/minnesotaurolithcenter/recommendations/home.html	Dog warded 3 days for observation. Goes home. No complaint about difficulty in urination for the next 18 months.	The gentleman owner was not interested in follow up health checks and urine testing. Urinary stone (right) is from the bladder of this Shih Tzu. The two stones (left) are from another dog.

A drooling Chinchilla - anaesthesia

June 9, 2014
Case study on the effects of an injectable anaesthesia on a chinchilla

TP 43843
Chinchilla, Female, 1 year 10 months, 350 g.

"She has wet mouth since March," the owner said. "I thought she was suckling the kid she just gave birth to. But it is now Jun 5 and the mouth is still wet!"

"Your rabbit is drooling," I said. "Usually the cause is sharp molar teeth or mis-aligned front teeth."
It is hard to check the molars as the chinchilla would run back into the cage after grabbing the food pellet given by the owner to entice her to come out.

XYLAZINE & KETAMINE SEDATION
Formula for rabbit applied to chinchilla
Xylazine 20 + Ketamine 100 at 0.25ml/kg + 0.35 ml/kg IM

At 350 g, X=0.08 ml + K=0.12 ml IM
At 50% dosage, I gave X=0.04 + K=0.06 ml IM in one syringe.

FOLLOW UP WITH OWNER on MONDAY JUNE 9, 2014

End of January- Gave birth. One kid, still alive.
Beginning of March - mouth wet. Owner thought she was producing milk and milk had overflowed onto the mouth area. The Chinchilla stopped gnawing the apple stick after giving birth.

Friday Jun 5, 2014. Injection of X + K given at 50% calculated dose IM
Lower molar spurs laterally (image and video), on both mandibles clipped. Maxillary molars worn out, no spurs. Went home recumbent with shallow chest movements. She took 2-3 hours to wake up and was very tired till Sunday Jun 7, 2014.

Saturday Jun 6, 2014. 6 pm. Ate "pellets softened with water."
Started to eat hard pellets on Sunday.

Drooling much less. "A lot better," said the owner today Monday Jun 9, 2014.

Apple stick gnawing is now not favoured by this Chinchilla. So molar spurs may return.

1372. Optional tour - volcano & hot springs

It is up to the tour manager to market the volcano tour as the agency did not help him. In the agency brochure, there is only one sentence: "Suggested optional: Volcano boat tour".   No more information. So, some think that there are poisonous hydrogen sulphide acid and gas spurting out from the volcano, risking their health. I did not hear the manager giving a briefing and he might have done so.

The volcano is dormant. There is also the visit to the "Hot Spring" and a swim towards it.

I decided to go to this tour at the last minute and asked the manager to arrange it. Outside the booking booth, the advert said: "15 Euros".  There was some pricing exclamation from some members of the tour group.
"How much did you pay?" I asked Jamie.
"55 Euros," she said. "Are you going to pay the manager?"
It was a savings of 40 Euros apparently. As the tour manager was with us on the tour taking care of us, I should not begrudge him his commissions as he does not get much from his agency, esp. if he is a freelancer.

1371. Anaesthetic challenge. Leg amputation in a dwarf hamster

A dragging fractured hind limb is usually not tolerated by an active dwarf hamster. In this 1-year-9-month-old hamster, the right limb was fractured at the distal tibia. The fractured area became red and swollen over the last 5 days as the hamster felt the pain and the burden.




Amputation was the choice as infection and gangrene would set in. However, anaesthesia is a challenge in this case as the margin of safety is low in such small creatures. A bit more anaesthesia would kill. I gave 2 drops of Zoletil 50 IM and operated fast, within 10 minutes to remove the leg. Details are in the illustration and video.

As at 7 days after surgery, the hamster is OK and active.
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1370. Caesarean section of a Corgi using xyazine + ketamine + gas

May 26, 2014.

Corgi, F, 3 years was said to be 63 days pregnant, being mated on Mar 24, 2014 and had no obvious uterine contractions today May 26, 2014. The attending vet took 2 X-rays which showed 5 or 6 pups as one pup "could be deep inside the rib cage area".

Her ultrasound showed 2 or 3 pups with strong heart beats. But she had no manpower to perform the elective Caesarean section. Uterine inertia has happened and the overdue pups may die if the home breeder waits longer. Little milk seen when I expressed the nipples. Dog had abnormal sized nipples as if she had given birth before. "Six puppies likely," I said as the swollen belly was symmetrically enlarged.

ANAESTHESIA
1. Isoflurane + O2 gas only. I had performed over 200 C-sections using this method. The disadvantage is that some dams struggled a lot on inhaling the gas and it takes a much longer time. Some vets think that the dam will die of heart attack. I would take off the mask when such dams struggle and re-mask. All this takes a lot of time.

2. Xylazine + Ketamine at 1 ml + 0.5 ml IV induction for a 20-kg dog as a guideline and depending on the dog's health. 0.1-0.2 ml + 0.05-0.1 ml for a 2-3 kg Chihuahua. Just sufficient to intubate.

No struggling of the dam. I decided on this method in this Corgi.
For this Corgi, 14.1 kg, 38 deg C, normal heart and lungs, I gave Xylazine 0.3 ml + Ketamine 0.15 ml IV at 50% of the calculated dose. It was insufficient to intubate the dog. The dog vomited food after 5 minutes.

She was masked, intubated and given the isoflurane + O2 gas. Maintenance of gas was at 2% initially to 1% to 0% at the stitching of the linea alba and skin. The dog opened her eyes wide just after my last skin stitch of the skin as if from a deep sleep.

TRANSPLACENTAL EFECTS ON THE PUPS
According to a senior vet who practises the Xylazine + Ketamine IV sedation for many years, there is no transplacental transmission to make the pups sleepy. Even for pentobarbitone which he used many years ago, a minimal amount was used. He said pups would take some time to cry loudly but he had pups who cried immediately. His tip was to wait for the dam to have uterine contractions before Caesarean section. This would decrease lots of bleeding even the surgery was done before contractions. As the Corgi had no contractions at 63rd day, possibly uterine inertia, I had seen much more bleeding during the C-section when I extracted the placentas.    

SURGERY

Skin incised around 3 cm from umbilicus. Length of incision around 8 cm long. Vet textbooks advised much longer incision to exteriorise the whole uterus, probably needing 15 cm in this Corgi as the pups were large and long, the longest being around 15 cm.
I located the bifurcation of the two horns, incised at right angles to the bifurcation, around 8 cm long and manipulated the 6 pups into this opening. I could exteriorise the uterus after removal of the pups to ensure no more trapped pups. One pup was deep under the rib cage and it took some time to extract him out. 

Six puppies were delivered. They appeared "dead". I held each with both hands, stood with my legs apart and swung it 5-6 times in an arc vigorously, to expel any water in the lungs. My assistant would massage the top part of the neck with the head downwards and stimulate the hard palate and cleaned the mucus off the nostrils. It took over 5 minutes to get faint cries and some movement. At an average of 10 minutes, the C-section took a long time. It was around one hour before loud cries from two pups were heard. The surgery started around 7.30 pm and ended around 9 pm.

Two pups wee not crying and their noses were cyanotic in colour, after completion of stitching of the dam. But they had tongue movements.

"No hope for this biggest pup," I said as >45 minutes had passed with the pup still gasping. "Some pups do recover with prolonged neck massage." I swung this pup 5 times and dislodged some lung mucus.  Then I put the pup into my mouth and blew into his lungs. I could hear the lungs opening up. The husband continued massaging this pup after he had successfully revived the other pup. (see video). Incredibly, this large pup cried (see video). The owners brought the pups home.

MEDICATION
Oxytocin 2 ml SC, Baytril 1.5 ml SC and Tolfedine 1.5 ml SC. On reaching home, the dam had milk for the pups and so there was no need for bottle feeding. 4 males and 2 females.  Sire and dam were brown/white. Mating was once, on Mar 24, 2014 by bringing the dam to the sire who belonged to the friend.

CONCLUSION
The home-breeders were happy as 6 pups and the dam were alive. It is not a guarantee that such the vet will get successful outcomes. Know how to swing the pups and massage them. Blow air into their lungs may be needed although some vets may not like to do this. In this case, the largest pup had air blown to inflate his lungs and he did survive.  The C-section took me, with experience, 1.5 hours as each of the 6 pups needed swinging and revival. Assuming each pup takes 5 minutes of my time with the assistant, 30 minutes had been spent on this. Fortunately, the dam did not die and was well anaesthesized at 1% - 1.5% maintenance.

For vets with no experience in C-sections or capable assistants, it is best to avoid doing this surgery as owners are just not happy to receive dead dams or pups, blaming the vets. Read up on how to revive distressed pups.  The anaesthesia and surgery was $900 but the stresses on delivery of "dead" pups were tremendous.      

X-RAYS BY THE FIRST VET.  Two weeks earlier (could see only 5 pups on ventral dorsal view) and yesterday (on lateral view, 2 skeletons).  Ultrasound (2 pups with strong heart beats, one with weak beats).

FOLLOW UP ON MAY 27, 2014, 10 AM.  
The dam had milk on reaching home at around 10 pm. The pups are suckling and active. A whelping box prevents pups from wandering. Vaccination advised 6-8 weeks. 3 vaccinations. Weaning to puppy food at 4th week.