548. Dressing the incision wound after neuter or spay in a dog or cat

548. Dressing the incision wound after neuter or spay in a dog or cat
INSTRUCTIONS REGARDING THE DRESSING/STITCHES FOR YOUR PET
AFTER SURGERY

USE OF DRESSING
1. Before applying, clean and dry wound and the surrounding skin thoroughly.
2. Peel away the paper frame, exposing the adhesive surface.
3. Cover the wound with the dressing.
4. Smooth down the edges of the dressing.

REMOVAL OF DRESSING
1. Change the dressing 3 days after surgery or earlier if it is torn, no longer sticks or leaking with blood.
2. Lift the edge and peel fast (can be quite painful if you peel slowly).
3. Replace with a new dressing.
4. Remove the dressing 10 days after surgery.

REMOVAL OF SKIN SUTURES
1. If the vet has advised, return for stitch removal 14 days after surgery.
2. If dissolvable sutures are used, the vet will advise that there is no need to return for stitch removal.

Website and more pictures are at:
http://www.sinpets.com/F6/20110817dressing-stitch-removal-after-spay-neuter_ToaPayohVets.htm

547. How long does it take to spay a female dog at Toa Payoh Vets? 31 minutes

547. How long does it take to spay a female dog at Toa Payoh Vets? 26 minutes
KEY PERFORMANCE INDICATORS FOR SPAYING A HEALTHY
FEMALE DOG AT TOA PAYOH VETS

How long does it take to spay a female dog without complications? A case is illustrated.
The answer is around 26 minutes from skin incision to the end of stitching.
The whole process from sedation to the end of stitching is 31 minutes.

A case spayed by me as an example:

Fox Terrier, Female, 1 year, 9.3 kg
Last heat 3.5 months ago. Skin incision 1.5 - 2.0 cm long. Spay hook is used. No subcuticular or subcutaneous sutures as they do irritate the dog. No IV drip set up.

1. Time when the dog is given Domitor + Ketamine IV*. Atropine IM (A).
2. Wait 5 minutes. Isoflurane + oxygen gas in mask. Intubate.
3. Time when the skin is incised (B).
4. Time when the skin is stitched (C).

The following key performance indicators are as follows:
C - A should be less than 35 minutes
C - B should be less than 30 minutes

No. of suture packets used - one packet 2/0 absorbable
No. of stitches to close the linea alba - 3 simple interrupted
No. of stitches to close the skin - 2 horizontal mattress
Skin incision 1.5 - 2.0 cm
DOMITOR + KETAMINE IV WITHOUT NEEDING ISOFLURANE + O2 IN HEALTHY YOUNG DOGS
At 10kg bodyweight, Domitor = 0.4 ml. Ketamine = 0.5 ml. Total = 0.9 ml in one syringe. Give via IV.

If the above is given at 50% of the calculated dosage, isoflurane + O2 top up for less than 60 seconds, to effect (eyeball rolls ventrally and other signs) will be needed. Intubation is needed. Atropine IM is advised before surgery. Antisedan IM after surgery may be useful to get the dog to wake up within 2 minutes.

546. Sunday's interesting case: A 3-legged dwarf hamster with 3 warts

Tuesday Aug 16, 2011, 9.16pm typed at Toa Payoh Vets

As the owner's "hamster" vet was not free to operate on the hamster till 2 weeks later, the practice's other vet asked the owner to bring the hamster to Toa Payoh Vets. Some vets would just give oral medication but it would not work to get rid of the 3 warts.

I answered the phone and took over the case when the two ladies came. The hamster looked thin. "Very itchy, esp. the left hind thigh; it is just a stump; there is no leg."

WARTS. As the hamster disliked being handled and protested vigorously by squeaking, we could not examine her in detail. Two warts were seen. One on the front right fore leg and another one on the left thigh area. Actually there was a 3rd one seen later under anaesthesia

ANAESTHETIC RISKS. As the female, over 1-year-old hamster eats "very well," pees a lot and poops a lot, the hamster was deemed to be healthy. I warded her overnight for observation and gave oral antibiotics and anti-inflammatory. I gave a 60% chance of survival.

RECURRENCE OF WARTS. If sufficient normal skin is excised with the big wart, it is unlikely to get recurrence. But there may be a large skin wound which would expose muscles and bones, causing infections. This was communicated to the owner.

EXPOSURE OF BONE AND MUSCLES. If the wart has no stalk, it would be a bigger skin incision exposing the bone and muscles. There could be infections and gangrene. The owner was informed.

ELECTRO-INCISION WOULD BE THE BEST.

SEDATION USED
Monday Aug 15, 2011. Heavy rain. The hamster cleaned up its food bowl. Actually she stored all seeds inside the cheek pouch. However she was active and stool pellets were seen.

10.38 am Zoletil 50 x 2 drops IM, right hind muscle (left hind has wart). Usually I do it on the left. 54 g bodyweight. 1 drop would be insufficient. 2 drops would be just right. Two drops equal to 0.001 ml as the drug did not even reach the 0.01 ml mark in the 1 ml syringe. I pull in 0.08 ml of normal saline, making it total 0.01 ml and this amount was injected IM in the right thigh muscle.

Within 1 minute, the hamster was drowsy but awake.

10.44 am Electro-incision x 3 warts. Large blood vessel ruptured when left thigh wart was excised with more skin. Blood flooded lower half of the hamster. Imagine a dog with half the body with blood. It was not possible to ligate the big vein supplying this wart as in the dog. Electro-incision hopefully would cut and coagulate the vessel. But it could not as it would be a big vessel. A big wart grows big and the blood vessel also grows big too to supply more blood.
10.50 am End of surgery. Wakes up. Gave isoflurane gas to stitch up.

10.54am suture 4/0 dexon

The vet said the rabbit is normal. He died the next day.

I was busy typing the blog on pyometra in 2 old dog cases and lessons to be learnt for the owner. A young fair lady called me off the screen and asked whether she should get another rabbit. Her boyfriend's cat was being treated by Dr Vanessa.

"The vet said my rabbbit was normal," she extened her right elbow out and sideways while pulling in her left elbow and pointed her finger backwards to show the position of the rabbit. "This abnormal posture, instead of lying on the chest", she said was the reason she consulted the vet near her house in East Coast.

The rabbit died the next day. "Why did the vet say he was normal?" she asked me. The rabbit was around 5 years old and she found him lost at East Coast Park and adopted him.

"It is hard to explain why," I said. "The rabbit sounded as if he was in pain - heart pain and tried to spread out his legs to be more comfortable.

"He was also walking like a drunken person earlier," she said. The vet gave a bottle with powder. She was to add water and give it to the rabbit. After giving the medication, the rabbit died.

So this rabbit was not normal. "The cause of death would not be the medication," I said. "It would be something inside the brain or heart. A blood vessel might have ruptured. Sudden death as he was eating normally and pooping."

She agreed that it would not be possible for any vet to diagnose what's wrong without further tests like X-rays. "In any case, the rabbit could have died of stress when X-rayed," I said. So I hope she was satisfied with the explanation. As she was young, I asked her and her boyfriend to quickly apply for the new HDB flat before prices rise again.

"The HDB Duxton flat cost around $300,000 last time and everybody was complaining," the boyfriend said. Now, the flats cost at least $400,000 to more. The boyfriend's mother kept mum about marriage encouragement. It might not be the right time yet.

Lateral ear canal resection - blood test for a fat spayed poodle

The toy poodle had been scratching her ears since puppyhood. The ears at the entrance to the ear opening were as rough as leather, greyed and blackened through much scratching. She was only 4 years old. Such cases would have ulcers and some foreign bodies inside. In the horizontal canal. Very difficult to dislodge. When the owner consulted the vet, the usual ear drops and medication. After around 2 months, the same ear scratching, head shaking and pain comes back again.

Best treatment for chronic otitis externa - ear resection surgery.
Alternative conservative treatment - 2 steps. Bring down inflammation. 5-10 days later, irrigate ear.

As this dog had high triglyceride level and one liver enzyme was high, I advised wait for a few weeks. Slim the dog down to 3.5 kg (presently 4.6 kg). I don't advise surgery as anaesthesia will be risky.

543. Clinical Research - The old poodle would have lived longer if not for pyometra

I had a review of this case of pyometra today Aug 14, 2011 at 6.54 pm at the Surgery as part of my clinical research on pyometra in old female dogs seen at Toa Payoh Vets.

This dog survived the surgery and anaesthesia despite a serious heart disease. But she died two days after the surgery, of heart failure.


I first saw this poodle, female, unspayed, 9 years in 17 March 2009 for an "asthmatic" attack. he had heart murmurs and was given oral lasix. As she had bad breath, I advised dental work. No teeth was extracted as they were in good condition. Only dental scaling done under isolfurane and oxygen gas anaesthesia.

July 20, 2009, Vet 1 prescribed some medication for a "swollen face" and a review in 10 days' time.

Aug 5, 2009, I extracted the left upper PM4 tooth as it was an oro-nasal fistula which presented as a "swollen face" to Vet 1.


July 8, 2011 - Vet 2 recorded a grade 5/5 heart murmur. The blood test showed a normal total white cell count. However the monocytes were high suggestive of a chronic infection.

Total WCC normal. Monocytes 14% (1.4 x 10(9)/L). Neutrophls 60%. L 22% E.38% Basophil 1.04%, urea high but creatinine low.

July 21, 2011 - Ultrasound showed swollen left and right uterine horns. A diagnosis of open pyometra was made. The dog was operated the next day and the swollen womb was taken out. She survived the surgery but died 2 days later.


This is a typical case in which the dog would have lived longer if she had been spayed when she was one year old. In addition, she had bad teeth which seeded bacteria damaging the heart valves over her last few years of life. 11 years of life is considered a long life in Singapore's small breeds.

I have stopped advocating spays in young female dogs as many Singapore owners feel that it is cruel to deprive a female dog of her reproductive organs or have some other reasons. Reproductive disorders come in when the female dog is old, leading to much sadness and money spent.

In another case, the owner of a 13-year-old dog could not decide whether to get her operated as she was discharging pus from her vagina for the past weeks and was no longer eating. Finally, he asked me to operate but he wanted the dog home on the same day after operation to care for her. The dog surprisingly survived the surgery and anaesthesia for 7 days with him treating her at home. On Day 3 after surgery, the dog had fits and came down for IV drip. She passed away at home around Day 7. This second case showed that it was very difficult for the owner to request euthanasia and the option of surgery, as in the first case, was too late as the dog was very ill by then. So, the survival rate was very low. However, it is not always death for old dogs with pyometra. The chances of survival are very slim.

542. How to close very big wounds

Very large wounds are hard to stitch up without stitch breakdown. So, how to stitch up big wounds e.g. after breast tumour removal and loss of big pieces of skin due to traumatic injury?

1. Walking sutures to combat excessive tension are not practical in distal limbs as they may damage blood vessels, nevers and tendons. They may be used in breast tumour surgeries.

Reference:
The use of skin stretching devices and their applications to Small Animal cases is well written in the Australian Veterinary Practitioner Vol 39 (3) Sep 2009.

Large wounds can be closed by
1) skin stretching, extensive undermining, application of skin grafts, axial pattern flaps and walk-in sutures
2) induced expansion of the skin eg. neck elongation of the neck custom in some Myanmarese women. One example in veterinary use is to stitch horizontal mattress anchored to tubings to stretch the skin on both sides of the big wound in the afternoon and then operate the next day to appose the skin wound after undermining. This method is shown in the reference article mentioned below.

541. E-mail queries about a cat spay

E-MAIL TO DR SING DATED AUG 14, 2011

Hi Judy

This is t... who has 6month + female cat. (Her name is T...)
Would like to get her neutralization surgery soon.

Could you please let me know the price and when I can go there and get this done?
She never go outside before, do I need to put her in the cage when I go to there?

Thanks for your help.
Best
T...

http://www.bekindtopets.com/animals/tpvets_Dec3110.htm


E-MAIL REPLY FROM DR SING DATED AUG 15, 2011

I am Dr Sing from Toa Payoh Vets. Thank you for your e-mail to Judy.

1. My estimated fee for spaying your female cat is around $150 inclusive of anaesthetics, surgery and post-op antibiotics and pain-killer injection and tablets. The suture used is a dissolvable type and so you don't need to return for stitch removal. A dressing will be applied to the surgical wound and no e-collars are usually required. However, please confine your cat indoors preferably to a room for 7-14 days after surgery.

2. You must bring the cat to Toa Payoh Vets in a carrier cage as some cats do run away as they feel frightened in a new environment of dogs and other animals. Once I had to find a box and tape up the cover for a young lady who brought in a cat to spay inside a towel. The cat was spayed. But she was nervous when the owner came to pick her up to go home. Once a cat jumps out of the plastic bag, she would be lost forever.

3. Bring the cat in at 9.30 am and she should be able to go home at 12.00 noon. No food and water after 10 pm the day before.

4. It is best that your female cat has 3 vaccinations completed before surgery.

540. Sunday Aug 14, 2011 - interesting case

Usually the vet gives an injection and ear drops and antibiotics. But no cure. The owner is unhappy as the dog keeps on scratching and the ears become smelly and red.

CASE STUDY

Ears very painful, esp. painful for the last 4 weeks. The dog just scratched her ears to death.
The Maltese just could not stop scratching her two ears. So the busy lady consulted me. The ear canals were swollen and red and so I would not be able to scope the ear canals to see what's wrong.

In this case, I suspect some foreign bodies stuck deep inside the horizontal canal.

ADVICE 1
My treatment in such cases would be 2 steps.

1. Anti-inflammatory and antibiotics to control the itchiness and infections. The owner is asked to return 5 days later for ear irrigation.

2. Ear irrigation 5 days later (Sunday today). The dog was wary of her ears being touched. So, I advised sedation. The owner wanted to know whether no sedation would be possible. How badly infected were thears? Could she just apply the ear ointment? Could she see me irrigating the ears so that she would learn how to do it?

ADVICE 2
Option: Vertical ear canal resection for long-standing ear infections (over several months and years) but most Singapore owners are not keen on this option. However, this option must be told as it is another option to monthly cleaning of the ears.

EAR IRRIGATION
1. Sedation is best. The poor dog would be avoiding and turning her head if forced to be restrained to be irrigated in the ears. In the past, I had tried to do ear irrigation without sedation (to save the owner some money) but it was very painful and stressful to the dog.

COACHING LESSON FOR MY ASSISTANT

540. Dad's favourite Chinese Crested 3 kg only

"She weighs only 3 kg. This is Dad's favourite dog," the young lady said to me solemnly and worriedly as I had advised anaesthesia to pluck the big thick turf of ear hairs, clip the nails short, clip paw hairs, de-matt a few areas and do dental scaling. The dog just would not permit her to do it and now had red skin in the paws, legs, ears. She also had lots of dry scales or dandruff.

"Will you be the one doing the surgery?" she asked. "Yes," I said. The key to success in anaesthesia is to give the minimal dosage. And the vet must be vigilant and has experienced assistants who know anaesthesia very well. In this case, I ensure that I was in charge of anaesthesia as well.

I gave 50% of the calculated dosage of domitor and ketamine IV. I asked my assistant Min to get an electronic calculator and coached him on how the dosage is calculated. I wrote down on the paper the calculations to teach him the basics.

At 10 kg, a young healthy dog will be OK with domitor 0.4 ml and ketamine 0.5 ml combined IV in one syringe as an IV general anaethesia.

But this is a thin Chinese crested, stressed out by skin itchiness over the years and not in top health as dandruff keeps peeling off her skin. I did not take a blood test this time as I deemed it not necessary from general physical examination and history. However, the anaesthesia must be lowest but effective. So, I gave 50% based on 3kg.

All went well. I gave the dog a sniff of isoflurane gas as she was getting up. A sniff of less than 60 seconds. I observed the eye white being prominent. This indicated Stage 4 as the eyeball had rolled down and into danger territory. So, the gas was switched off. Everything went well. The dosage was sufficient for around 30 minutes which included all grooming and dental scaling.

Just to be on the safe side, I gave the antidote - Antisedan. In less than 1 minute, the Chinese Crested stood up and looked as fine. Pooped green stools. Went home in the afternoon after ear irrigation and a bath as the father and daughter came to pick her up and the Miniature Schnauzer (9 years old with similar requirements but had 7 loose teeth extracted). Also 50% dosage based on weight. And antisedan.

"No steroids," the young lady said. In this case, I have prescribed Atopica for 2 months plus the young lady's own special oil application to the skin as she had done successfully for the other Chinese Crested (hairless). Otherwise the Chinese crested keeps scratching herself day in and day out.