I thought this Sunday,
July 3, 2011 would be an uneventful Sunday with the usual
veterinary conditions seen throughout the years. I still
consult on Sunday mornings although I would rather go to
the parks and smell the roses.
I would work half a day and take the afternoon off since
Dr Vanessa Lin would be on duty. Then I would watch the
movie "Jane Eyre" at 7 pm at the Shaw Lido cinema.
Suddenly a young worried-looking young man in his early
30s and a lady came with a very thin Maltese passing pus
from her vagina for the past 5 months. They had consulted
my associate yesterday, Dr Jason Teo had given an
anti-fever and antibiotic injection yesterday as the dog
had high fever. However, she had no fever now.
"What do you advise?" the sister asked me. "Do you
recommend euthanasia?" This was a very old female dog.
Very thin and weak and would be a very high anaesthetic
risk.
"It is up to the owner as to whether he wants to euthanase
this dog or not," I replied. "I don't advise euthanasia or
surgery. It is up to the owner as surgery has a high risk
of death on the operating table for this very old dog. In
human years, she would be over 100 years old!"
The young man was hesitant. "Please think it over," I
said. "You may not see this dog alive once she enters the
operating table."
To euthanase or not? As long as there is life, there is
hope. It does not mean that a very old dog that is in very
poor health will definitely die on the operating table. It
is just that the probability of dying is over 90% in this
case.
"In pyometra cases, there is no choice but to operate.
Much depends on economics," I advised. "Pyometra surgery
and anaesthesia will cost around $1,000 as it takes a
longer time as compared to a normal spay which is much
cheaper."
The young man could not decide. I said: "Please wait in
the reception room and think about the surgery." Why did
he wait for over 3 months of the dog passing pus in the
vagina to seek treatment, I did not ask him. Most likely,
he anticipated that the dog would die on the operating
table and therefore procrastinated till the dog was very
thin and unable to eat.
I don't relish operating on high risk dogs as I do get
emotionally affected whenever a dog dies on the operating
table. For whatever reason. Some 40 years ago, I would
have advised euthanasia as that was the prevalent thinking
of my baby-boomer generation. Not much hope of survival.
So why spend money on doing surgery? Save the owner some
money. The vet who advises euthanasia for very sick dogs
becomes despised and deemed uncaring and incompetent.
This type of advice does not resonate well with the
younger generation. So, nowadays, I let the owner make the
final decision of euthanasia or surgery in serious
pyometra cases of old dogs. This case would be my second
case of a very old dog past 15 years of age, suffering
from pyometra. There are only a handful of such cases seen
by me in my 40 years of practice and the other case was
deemed a success.
Yet one swallow does not make a summer. I did not want to
operate. Yet euthanasia would be unacceptable for me too.
This would be a very high risk surgery. Why risk my
reputation?
The young man finally said: "OK, do the surgery." He did
not want any blood test to be done.
Below is the account of the surgery, anaesthesia and
follow-up.
ANAESTHESIA
Isoflurane gas at 5% given by mask. No sedation. IV drip.
Intubated and give gas at 1-3%.
The dog was given just sufficient gas but this was
insufficient to bring her deeper into surgical
anaesthesia. The dog kept moving and I would stop the
surgery while she inhaled more gas. This method prolonged
the surgery which started from 10.50 am and completed at
11.35 am on this Sunday. In normal pyometra dog
anaesthesia, the dog would be fully anaesthesized and the
surgery could be completed in less than 30 minutes.
But this was a very old dog and life and death depended on
the anaesthetic skills of the vet. My assistant Min wanted
to increase the isoflurane percentage to 5% to get a
deeper anaesthesia. "Don't do it," I told him off. "She is
a very old dog and normally 2% is sufficient in normal
dogs. Just wait a while at 3% maximum. Old dogs die when
given 5% for some time as she is in a very unstable
anaesthetic stage."
After removal of the womb and ovaries, the dog's
anaesthesia was excellent.
SURGERY
"The blood is bright red," I said to my assistant. "It is
a good sign as toxic blood is usually dark blue due to
lack of oxygenation." An unusual bright red in this case
as compared to the cyanotic blue of another case in a
Golden Retriever I operated in 2008.
Dark bluish blood from the
omental blood vessels were
seen during surgery of a
Golden Retriever with
pyometra. The dog survived
the anaesthesia and surgery
but died post-operation.
See: Pyometra
in 2 Golden Retrievers. 5
Management Tips For Vets
There are three
significant aspects of this surgical case.
1. Cysts and swelling in parts of the uterine bodies,
indicating a partial rupture of the uterus and spilling of
the toxic pus into the abdomen.
2. This is shown in a very thick peritoneum of 3 mm
thickness. Normally, the peritoneum is thinner than 1 mm.
So, there was peritonitis.
3. A grossly swollen vagina and cervix was seen. I did not
get a photo taken as I was in a rush to complete the
surgery which was taking too long due to an unstable
anaesthesia. This is extremely rare. Was there a tumour
inside the vagina? Was there an abnormal hymen? I don't
know. I put in 3 ligatures to prevent the pus from the
vagina from leaking into the abdomen as I removed the
uterine horns and ovaries.
BLEEDING. Lots of bleeding from the omental blood vessels
which were fragile. Probably a result of cystic ovaries
producing abnormal amounts of hormone. I checked carefully
that there was no major blood vessel from the uterine body
haemorrhaging as I had 3 ligatures around the uterine
body. I swabbed off the blood.
24-HOURS AFTER SURGERY.
Surprisingly, this old and
very thin dog has a pink
mucous membrane tongue and
gum colour of a normal dog,
before and after operation.
Why? I don't know as the
owner did not want a blood
test. I suspect it could be
associated with
hyper-oestrogenism (vulva
enlarged at least 30X) and
cystic ovaries.
SUTURE
After 3 ligatures of the uterine body, I closed the
muscles with a continuous suture 2/0 absorbable. Normally,
I don't bother with continuous sutures but just use simple
interrupted sutures and I find that fine. After the
continuous sutures, I stitched another 3 interrupted
sutures. The skin incision was stitched horizontal
mattress sutures as these hold well and are not easily
licked off unlike interrupted sutures, in my experience.
POST-OP
The young man insisted on taking the dog home to nurse by
himself. He was not experience in post-operation nursing.
If owners are insistent, I would ask them to sign a
discharge form saying that they want the dog discharged
against medical advice. However, he agreed to let her rest
overnight at Toa Payoh Vets and get the necessary drip.
POST-OP NURSING CARE DAY 1-6
1. Vomiting.
"The dog vomits when I feed her very small amounts of the
A/D canned food and water," the owner phoned me on Day 1
and 2. I advised feeding separately at 6 times per day but
he said the dog would vomit after a while. "What's the
cause?" he asked. "My dog does not vomit before the
surgery."
"It is hard to tell you the cause," I said. "You did not
want blood test. It could be stomach ulceration due to
kidney disorders and uraemia. Or liver disorders. It could
be gastritis or any other reason."
2. Fits on Day 3.
On Day 3, the owner phoned me saying that the dog had a
few seconds of fits. "What's the cause?" he asked. "It
could be due to low blood sugar or kidney disorders. Come
for an IV drip and review."
After dextrose saline and amino acid drips, the owner took
the dog home with another bottle of drip which he would
administer himself.
3. Day 3 - Day 6 (today). No more vomiting. The
owner was told to feed the canned food and the
multi-vitamin paste but not to give water. I had given a
Baytril antibiotic and anti-inflammatory pred injection
with the drip on Day 3 when he came for the fits.
CONCLUSION
The dog started to eat by herself from Day 3 to 6. That
was good news. I advised giving water in small amounts at
different times. So far, so good. This is one of my most
unusual cases. As for the vulval swelling of 30x, I told
the owner that the swelling had reduced by 80% on Day 3
when he came in for the review of fits.
The road back to good health is long. This is one of the
rare cases where the owner does not opt for euthanasia as
most will do so. The vet must give only the minimal
anaesthesia such that there is movement of the omental fat
and intestines but any deeper surgical anaesthetic stage
would likely to cause heart failure. This means 1-3%
isoflurane gas maintenance. The new veterinary assistant
may switch to 5% to achieve deep surgical anaesthesia.
Stop him from doing it as in this case.
Just stop the surgery for a while and then continue. It
takes a much longer time. However, what the owner wants is
a dog alive and nothing matters to the owner if the vet
produces a dead dog at the end of surgery.
P.S RECTAL TEMPERATURE.
This dog had been treated with antibiotics and tolfedine
injection to bring down the fever some 12 hours ago by my
associate vet Dr Jason Teo. In fact, the rectal
temperature was 37.6 deg C which indicated a lower than
normal temperature and perhaps a deterioration of the
health of the dog. Hence I had to operate immediately.
The owner did his own rectal temperature checks at home
from Day 1 onwards. From Day 1-Day 3, the temperature did
not drop below 37.8 deg C. This showed that the dog has
good "fighting spirit" to survive - from a layman's point
of view. The dog still can't stand up at Day 5. As
the dog starts eating, this may be good news. When there
is life, there is hope?
TOA
PAYOH VETS
