Cat’s Tooth resorption case

pict 2Dr Yavor Stoyanov,

Veterinary clinic Bomed

Sofia, Bulgaria

A 6-year-old, neutered male domestic shorthair cat

was presented for dental cleaning due to “bed smell breath”.

No vaccinations history, irregular anthelmintic treatment.

No earlier dental care.

History of cystitis four years ago.

 

Clinical exam:

The cat was in good physical condition.

Normal temperature, auscultation, palpation.

 

Facial Exam:

Normal facial and eyes symmetry, no nose or eyes discharges.

No compression discomfort, no swollen regions, lymph nodes – normal, lips with black pigmented zones.

 

Conscious Oral exam:

The cat was cooperative.

Normal maxillomandibular joint mobility, without pain.

Normal buccal mucous membranes.  Lingual, sub lingual, caudal mouth space and  roof of the mouth was normal.

Moderate gingivitis, gingival recessions, missing all upper right premolars (106,107,108), left upper first premolar (206), first and third left mandibular premolars (307,308).

All canine teeth were with root exposure.

Many mobility teeth: 207,208,308,403, with root exposure and visual

root resorption and attachment loss.

Plaque index 2.

 

CBC, Biochemistry was in normal limits, except high globulins level.

 

Dental X-Ray was unavailable.

 

Oral exam and treatment under general anesthesia:

Missing all upper right premolars (106,107,108), left upper first premolar (206), first and third left mandibular premolars (307,308).

Moderate  gingivitis (gingival index 2).

Gingival and alveolar recessions.

No periodontal pockets. Stage 3 furcation (307, 308, 309, 208)

All canine teeth were with root exposure due to tooth extrusion.

Mobility teeth: 207(M3), 208(M2), 308(M3), 303(M3), 309(M3), 403(M3), with root exposure, visual root resorption and attachment loss.

1

Pic.1. Dental chart

Diagnosis:

 

Idiopathic Tooth Resorption

 

Treatment plan:

Multi teeth simple extraction

 

Treatment procedure:

Preoperative analgesia: Rheumocam

General anesthesia

Chlorhexidine Rinse 0.12% solution

Simple extraction with elevator and extraction forceps.

In this case because of severe attachment loss I just needed to section only one premolar.2

3

Postoperative treatment:

 

Rheumocam    24h/3 days

Stomorgil        24h/8 days

Stomodine      12h/14 days

 

Further treatment:

 

Dental and oral prophylaxis with Stomodine,

Regular examination every 3 months.

 

Discussion:

There are many theories about the etiology of Tooth resorption in domestic cats but main cause is still unknown.

Depends of the source, about 25–75% of domestic cats are affected.

There is an increasing prevalence of Tooth resorption as cats get older, with the first teeth becoming affected usually at four to six years of age.

Gender and neutering were not found to affect the prevalence of disease.

Cat owners may report halitosis, ptyalism, head shaking, dropping food

while eating, reluctance to eat hard food, excessive tongue movements,

repetitive lower jaw motions while eating, drinking or grooming,

sneezing, dysphagia, dehydration, anorexia, weight loss, and lethargy.

Clinical findings are various degrees of gingival inflammation, missing

or mobile teeth, gingival hyperplasia or recession, tooth extrusion, tooth

tissue destruction and others.

Earlier and most accurate diagnosis is made by dental X-Ray because

first changes are subgingival.

Depending on changes there are few classification based on severity

(stages 1–5) and radiographic appearance of the resorption (types 1–3).

Tooth resorption can develop with cementation and ankyloses or with

attachment loss and mobility of teeth. In case of attachment loss extraction

is easier.

 

Conclusion:

Tooth resorption is the most common progressive disease affecting the

dental tissues in domestic cats.

In every regular cat exam (with or without oral or dental abnormality)

Tooth resorption should be routinely suspected.

Choice of treatment – extraction of all affected teeth.

 

Feline chronic gingivostomatitis (FCGS): Case report

IMG_3022Stefani Sabrodin,

6th year veterinary student from Estonian University of Life Sciences

Animal data:

  • Donskoy cat
  • 6 years 10 months old
  • Spayed
  • Weight 3,66kg

Anamnesis morbi:

Owners came to visit, because of halitosis and cats’ loss of appetite. Cat has also lost some weight in previous months. Cat lives mostly inside and was not vaccinated for any diseases over 2 years.

Clinical examination:

Gingiva was very red, inflammatory and gums were bleeding when the mouth was opened. Opening a mouth was painful for the cat and ulcers on the tongue were visualised (Figure1). Cat had also a lot of calculus and she was hypersalivating. Due to the fact that cat was not vaccinated, a FeLv/FIV snap test was done, and it was negative. Also hematology and biochemistry were evaluated. In biochemistry liver and kidney values were mostly within normal limits (WNL) Only UREA was a bit low (4,5mmol/L) but it might be due to the starvation. Electrolytes were also controlled and they were WNL. In hematology only mild leukocytosis was seen.

04 02 03

 

 

 

 

 

 

 

 

 

Treatment:

After the first visit, a dental appointment was planned. The cat got one subcutaneous injection of cefovencin (Convenia) 8mg/kg and went home with oral meloxicam 0,05mg/kg for 3 days. She came to tooth removal surgery in seven days. A cat was sedated with dexmedetomidine, butorphanol, and ketamine intramuscularly. TIVA with propofol was used during surgery. Cat got 5ml/kg/h of Ringer-Lactate during the procedure and free flow oxygen was given. Buprenorphine (0,01 mg/kg) intramuscularly and meloxicam (0,3 mg/kg) subcutaneously were given for analgesia and lidocaine was used for nerve blocks. Dental radiographs were made pre-and postoperatively (Figures 2). Figure 3 shows how important are dental radiographs. 301 was broken during the extractions but it was unclear if remnant got out or not. An x-ray was made and the root was visualised. Then the root remnant was removed and a new x-ray was taken.05 08 07 06

During the procedure, clinical picture (gingivitis II-III in all dens, 204 had gingival pocket of 2mm. 404 had gingival hyperplasia and also pocket of 2mm) and full mouth radiographs were evaluated. All teeth except canines were extracted. A cat went home with oral meloxicam (0,05 mg/kg) for 5 days. A new checkup was in 7 days. Figure 5 shows that gingiva is not so inflamed anymore. Cat started eating with a good appetite already the next day after the extractions.

 

 

 

09

This picture shows how much we actually need radiographs. 301 was broken during the extractions but we were not sure if we got the remnant out or not. We made an x-ray and saw the root. Then we removed root remnant but unfortunately I have no pictures of the last x-ray, but it was clean.

 

Figure 2. (a) 409 has a tooth resorption (TR). (b) 309 is missing. (c) and (d) are made after extractions.

Figure 4. was made right after the extractions.

Background

Feline chronic gingivostomatitis (FCGS) is a common syndrome, but its’ aeitology is unclear. FCGS causes inflammation and proliferation for the gingiva and oral mucosa. Inflammation can be mild to severe and it worsens with time. Mucosal ulcers are commonly seen in cats with FCGS. Ulcers are the most commonly on gingiva, tongue, buccal mucosa, lips, palatoglossal folds, and the lateral pharyngeal walls.

Aetiology is unclear, but it might be due to bacteria (usually from plaque Pasteurella spp↑, Prevotella spp↑), viruses or immune-mediated. Feline calicivirus (FCV), feline herpesvirus (FHV-1), feline immunodeficy virus (FIV), feline leukemia virus (FeLV), feline coronavirus (FeCoV) may cause FCGS.

The most obvious clinical changes are bilateral focal or diffuse chronic gingival and oral mucosal inflammation, ulcers and hyperplasia. Cats with FCGS has halitosis, dysphagia, ptyalism, bloody saliva, anorexia, and bleeding gingiva. Caudal part of the oral cavity is also with lesions. There is no sex, age or breed predilection.

For diagnostics, laboratory examinations are mandatory. Complete blood count (CBC), biochemistry (glucose and kidney values) and serological assays (FeLV/FIV) should be done.

Since the aetiology of the disease is unclear then treatment is empirical. In some cases, conservative treatment may help. Administration of antibiotics (amoxicillin/clavulanate, clindamycin, metronidazole), corticosteroids (not a good choice, because of side effects) , megestrol acetate (was used widely in the past, but now it’s not recommended due to the side effect), sodium salicylate, gold salts, lactoferrin (in mild cases, inflammation and salivation↓), interferon (poor results without extractions), professional tooth cleaning 3-4 times per year, chlorhexidine mouth rinses (usually not tolerated by cats for a long time) and teeth cleaning have been reported. The best cure is still full-mouth extractions.10

References

Holmstrom, S.E. Veterinary Dentistry: A Team Approach, 2nd edition. Elsevier 2012, 10:228- 230

Niemiec, B.A. Small Animal Dental, Oral & Maxillofacial Disease: A Colour Handbook. Manson Publishing 2012. 6:176-181

Correl C., Nind, F. Saunders Solutions in Veterinary Practice: Small Animal Dentistry. Saunders 2008. 12-15:79-97

Gorrel, C. Veterinary Dentistry for the General Practitioner 2nd Edition. Saunders, 2013

Tutt,C., Deeprose, J.& D.A. Crossley. BSAVA Manual of Canine and Feline Dentistry, 3rd edition. BSAVA. 2007.8:137-144

Alveoloplasty and correction of the symphysiolysis.

33923857_1331071137036756_1657367049904586752_nDr Vanya Stoyanova

Provet clinic , Plovdiv, Bulgaria

 

 

Aprilcho’s story takes place in the centre of Plovdiv, Bulgaria. The kitten is a victim of a car accident. Our colleague

Nina is the only one, who noticed the helpless cat , squirming on the street with painful convulsions. Nina picked him

up and brought him to the clinic. IMG-c876b25da24befa64f282c01eb7608bd-VHe was in a very bad condition – shock, prostration, severe head trauma with

neurologic symptoms, acute mouth bleeding, and convulsions. It was visible that he had maxillofacial trauma and a

mandibular symphysiolysis.

IMG-949d5241944ddd5fec26de1315bc28f8-V IMG-b0ab8099e22425bf3aa308c098ca5f89-V

First we did shock therapy so we could stabilize the patient. After we had the shock under control, we performed the oral surgery.

The upper premolars and molars had to be extracted, then alveoloplasty and correction of the symphysiolysis.

 

We’ve inserted an esophagostomy tube, so we could deliver enteral nutrition during the recovery period.

The recovery was long, due to the vestibular syndrome. He had pus expulsion from the left nostril and forehead

edema. We gave him antibiotics (Synulox) , Nootropil (piracetam) diluted with Glucose per os, and he received for

  1. 6 weeks enteral feeding with *Recovery* Liquid (Royal Canine).

The Cat is happy adopted in Germanykitty

Indolent corneal ulcer

Indolent corneal ulcer

23795882_1754305851308789_4535093565247207043_n

Dr Iuliana Ionascu

Iuliana Ionascu 

Faculty of Veterinary Medicine Bucharest

 

The fluorescein test is very important in diagnosis of corneal diseases. Is our best friend that accurately describes the size and the depth of the corneal lesions. If the fluorescein test is positive exclude primarily a foreign body (from the conjunctival fornix  or from the internal surface of the third eyelid) and then examine using the loupe, the edges of corneal lesion. If is an area of loose of the epithelium at the periphery of the lesion, looking like an “opened book (Figure 1, Figure 2 and Figure 5) your patient has indolent corneal ulcer.

fig 1

Figure 1 – Indolent corneal ulcer

fig 2

Figure 2 – Vascularized indolent

fig 3

Figure 3 – Debridement of the indolent corneal ulcer using cotton-tipped applicators

fig 4

Figure 4 – Debridement of the indolent corneal ulcer using Alger Brush®

The first step in the treatment of indolent corneal ulcer is the debridement of the denude epithelium using a cotton-tipped applicators (Figure 2), scalpel blade or Alger Brush® (Figure 3). Local anesthesia of the cornea using Benoxi® will allow you to perform debridement.

Using cotton-tipped applicators, the loose epithelium is removed using gentle lateral and circular movements. Debridement using a surgical blade is easily performed doing lateral movements, holding the blade’s sharpen edge perpendicular on the corneal surface.

The burr of the Alger Brush® device is faced towards the edges of the corneal ulcer and debridement is performed in a circular movement, following the limit between the ulcer and the healthy cornea. The small burr of the device quickly removes the epithelium so that the surgeon’s hand is laid on the periorbital area for support, to avoid accidents. Throughout debridement the corneal surface is flushed continuously using saline.

After performing the debridement of the indolent ulcer, the lesion is significantly bigger than the initial one (Figure 6), and in some cases, the anterior epithelium is completely removed.

The fluorescein test is used to reveal the size of the lesion after debridement in order to choose a therapeutic approach:

  • medical treatment – corneal healer eye drops and gels
  • therapeutic contact lens and eye drops (Figure 7)
  • VetShield® colagen contact lens and tarsorrhaphy
  • only tarsorrhaphy
fig 5

Figure 5 – Indolent corneal ulcer before debridement

fig 6

Figure 6 – Indolent corneal ulcer after debridement

fig7

Figure 7 – One day therapeutical contact lens applied after debridement of the indolent corneal ulcer

fig 8

Figure 8 – The previous case 5 days after local treatment (notice the lesion is smaller)

Indolent corneal ulcer after debridement can be healed ad integrum (Figure 8) in 5-10 days or, in some cases, we need to perform many debridements. That’s why rechecks should be performed each 5 days after debridement and fluorescein test and reexamination with the loupe is mandatory.

Alternative anesthesia protocols without use of the neuromuscular block for phacoemulsification in dogs and cats

4 (1)Authors: Stroe M.S., DVM, Ionașcu I. DVM PhD, Ion L., DVM

 

Correspondence: Stroe Marina-Stefania, DVM, Marina-Stefania.Stroe-Giurca@uliege.be

 


Abstract

Cataracts may occur at any age and in any location in the lens. Cataracts can block tapetal reflection and fundic examination partially or completely and are often classified by stage of maturation and cause.

Cataract surgery are facilitated by a central position of the eye ball within the palpebral fissure. A centrally positioned eye is normally achieved by using of neuromuscular blocking agents (NMBAs). NMBAs also decrease the ocular muscle tone and that is very useful because an increased tonus may cause ocular structures to become displaced and distorted and can also influence IOP. Use of these agents necessitates intermittent positive pressure ventilation (IPPV).

 

Objective: Offering alternatives for anesthesia to perform cataract surgery in dogs and cats without using the neuromuscular block.

The safety of anesthetic protocols consisting of midazolam, tramadol, lidocaine, propofol, fentanyl, ketamine, isoflurane without using the neuromuscular block was studied in 16 cataract surgeries in dogs and cats. The protocol’s safety was expressed by monitoring heart rate, oxygen saturation and pulse rate using pulse oximetry, respiratory rate, end-tidal carbon dioxide provided by capnography, arterial blood pressure using oscillometric method. Assessments were made for quality of induction, maintenance and recovery from anesthesia.

 

Animals: Sixteen animals, eleven dogs and five cats, all client-owned.

 

Methods: All animals were examined prior to premedication, were performed blood tests hemoleucogram and biochemistry and monitored during induction, surgery and recovery. Blood samples were analyzed for standard biochemistry panel including glucose, creatinine, ureea, hepatic transaminases and hemoleucogram. Before anesthesia, HR was measured using cardiac auscultation and MAP was measured using automated oscillometry, respectively. Protocols consisting of midazolam, tramadol, or lidocaine iv was performed. IV propofol was administered to abolish the palpebral reflex, produce jaw relaxation and facilitate ETI. Topical ocular administration of oxybuprocaine (Benoxicaine®) 0.4% drops to anesthetize cornea was performed before general anesthesia. All patients received topically sprayed laryngeal 2% lidocaine. The cough response at ETI was recorded.

After intubation, auscultation of heart and lung sounds was possible by means of an oesophageal stethoscope. Pulse oximetry was used to monitor oxygen saturation of hemoglobin in arterial blood and pulse rate. The patient was connected to the inhalational anesthesia machine. The maintenance of anesthesia was achieved using isoflurane like inhalant agent and fentanyl or mixture of fentanyl, lidocaine and ketamine. Respiratory rate and end-tidal carbon dioxide was provided by capnography. Assessments were made for quality of induction, maintenance and recovery from anesthesia by evaluation of the animal’s eye position, jaw tone, heart and respiratory rates and autonomic responses to surgical stimulation.

 

Results: The purpose of this work was to perform anesthesia protocols without use of the neuromuscular block for phacoemulsification in dogs and cats and make preliminary investigation into safety for patient and to record the advantages and disadvantages. Cataract surgery are facilitated by a central position of the globe within the palpebral fissure. A centrally positioned eye is normally achieved by using neuromuscular blocking agents (NMBAs). NMBAs also decrease the ocular muscle tone and that is very useful because an increased tonus may cause ocular structures to become displaced and distorted and can also influence IOP. But if there is no possibility of using NMBAs solutions must be found.

 

Conclusion: The aim of the project was to test several variants of anesthetic protocols to compare the various effects of molecules including lidocaine, ketamine, fentanyl, tramadol, propofol, isoflurane have on the organism.

The use of anesthetic drugs without using of neuromuscular block for cataract surgery may be challenging bringing both advantages and disadvantages. The recovery period after a classic anesthesia without neuromuscular block probably is much shorter than that achieved after a curarisation and the probability for hypotension is less likely. On the other hand, without neuromuscular blocking agents we can`t obtain the central position of the eye globe and that implicate make some compromises for the surgery.

 

Keywords:  cataract, anesthesia, phacoemulsification, cat, dog,

 

Introduction

Patients with ophthalmic disease, such as cataract, vary from young, healthy animals with congenital cataract to geriatric patients, which may have significant diseases like diabetus mellitus. When planning anesthesia for cataract surgery is important to consider the general health status because there are many patients with concurrent disease and that may present significant challenges for the anesthetist [4]. It required investigations before anesthesia like blood tests and if there are changes ideally their condition should be stabilized before anesthesia. Also need to consider that animals that are blind are more likely to be stressed and fearful compared with patients that have vision, especially if the onset of blindness was acute [4].

A complete ophthalmic examination should be performed and should include examination of PLR and menace response, Schirmmer tear test, fluorescein stain test, intraocular pressure (IOP) and a fundic examination if possible. A complete physical examination is also pertinent, as cataracts may be related to extra-ocular disease.

Electroretinography and ocular ultrasonography are standard pre-operative screening tools to confirm an eye’s candidacy for cataract surgery. Although pre-operative preparation and postoperative management can be intensive, canine cataract surgery is often successful and rewarding. Risks, time commitment, and financial demands of phacoemulsification should be discussed with the pet owner.

 

 1 (2) 2 (1)

Materials and methods

Eleven dogs and five cats presenting to the ophthalmology service with ophtalmological conditions that cause blindness. All patients received the cataract diagnosis after a full ophthalmic examination. Once a cataract forms, surgery is the only treatment method to restore vision. Phacoemulsification uses ultrasonic energy to fragment and extract cataractous lens material from its capsular bag.  Exclusion criteria of the patients were concurrent diseases that could not be stabilized before anesthesia. Any pre-existing medical conditions and drugs administered were recorded.

Food and water were withheld from all patients for a minimum of 12 hours prior to surgery

Animals were gently restrained in a sitting or standing position for drug administration and data collection.

Mydriasis is obtained with topical mydriatic agents (Tropicamide) applied with 2-3 hours before intraocular surgery. Also, topical ocular administration of oxybupracaine (Benoxicaine®) 0.4% drops to anesthetized cornea was performed before general anesthesia. Topical local anesthetics are effective because of a direct action on the cornea and minimizing systemic side effects but their use is limited to diagnostic procedures and intra-operatively as they delay corneal healing, are epitheliotoxic and have a short duration of action [5].

The position of the animals during surgery was in lateral position for unilateral cataract and dorsal for bilateral cataract (Fig.1). HR was measured using cardiac auscultation and MAP was measured using automated oscillometry.5

Anesthesia was maintained with isoflurane in a oxygen delivered via a rebreathing anesthetic circuit with the oxygen flow rate set at 60 ml/kg/min and vaporizer setting of 2%. Oxygen saturation as measured by pulse oximetry, pulse rate and respiratory rate were recorded every 5 minutes after anesthetic induction until the end of anesthesia (vaporizer turned off). Pulse quality was established by manual palpation of the femoral artery and respiratory rate was recorded by observation of the capnogram and chest movement.

Measurement of rectal and esophageal temperature was performed by use of 2 thermistor probes. Rectal temperatures were measured at initial hospital intake and after the end of anesthesia. Once each patient had been induced esophageal temperature was measured by placement of an esophageal thermistor probe and was removed at the end of anesthesia.

The premedication has been achieved with lidocaine 2 mg/kg iv or tramadol 2 mg/kg iv (Fig. 2). All the patients received the propofol-midazolam combination for anesthetic induction. The dose utilized for midazolam was 0,4 mg/kg iv.

The use of ketamine was accomplished in combination with lidocaine and fentanyl for dogs and for one cat was used the ketamine-propofol combination. There is significant interest in this combination of propofol and ketamine because has several benefits in the terms of hemodynamic stability, absence of respiratory depression, post-operative analgesia and recovery [6]. The ketamine dose that was used was low at 0,6 mg/kg iv and was mixed in the same syringe with propofol 3 mg/kg.

The extubation was performed when the coughing and swallowing reflexes had returned.3

Steroidal anti-inflammatory drug (Betametazone, Diprophos®) was administered intraconjuctival at the end of the surgery.

 

Results

In total sixteen animals (eleven dogs and five cats) were enrolled in the project.

All patients were in good condition of general health just 2/11 dogs were stable diabetic patients and for they measurements have been taken to monitoring the blood glucose level before, during and after surgery.

Premedication with lidocaine 2 mg/kg was performed for 6 dogs and was made observation about cough during endotracheal intubation. IV lidocaine can decrease the incidence of cough during endotracheal intubation but does not appear to have a sparing effect on the dose of propofol required for endotracheal intubation.

Two patients receive tramadol 2 mg/kg iv in premedication, one in combination with lidocaine 2 mg/kg iv and the other just the tramadol. For the patient that receive just tramadol was not observed any changes in the propofol dose.

One dog received fentanyl in premedication and after induction was observed significant respiratory depression compared with the others. Two dogs and 6 cats did not receive anything for premedication.

The diabetic protocol for phacoemulsification consist in tramadol 2 mg/kg iv for premedication, induction with midazolam 0,4 mg/kg and propofol at effect. Maintenance of anesthesia has been achieved using isoflurane like inhalant agent and mixture of fentanyl, lidocaine and ketamine. The glucose level was measured before and every hour during anesthesia.

For all patients, cats and dogs, the induction was performed with propofol and midazolam 0,4 mg/kg and topical laryngeal lidocaine was used prior to intubation. One cat received the ketamine-propofol combination for induction.

The cough response at ETI was observed for 3 dogs, the patient that receive tramadol in premedication and the others that was not premedicated and 2 cats. In propofol anaesthetized dogs iv and topical laryngeal lidocaine attenuated the pressor response to ETI where iv lidocaine reduced the cough response.

Duration of the anesthesia from intubation to extubation was 80 min ±10 min depending of the surgical procedure, unilateral/bilateral cataract.

After induction, a rotation of the eyes towards the internal angle was observed. To achieve the phacoemulsification surgery, the eye was brought to the central position by means of the traction sutures.

 

Cardiovascular and respiratory parameters were well maintained during induction, maintenance and recovery periods for all patients. All patients receive Ringer Lactate infusion at 5 ml/kg/h. The anesthesia was maintained with isoflurane delivered via a rebreathing anesthetic circuit with the oxygen flow rate set at 60 ml/kg/min and vaporizer setting of 2%. This was completed by analgesia offered by combination of fentanyl-lidocaine-ketamine for dogs and fentanyl CRI for cats. The doses utilized for fentanyl was 4 μg/kg/h in combination with lidocaine 2 mg/kg/h and ketamine 0,6 mg/kg/h and when fentanyl was used alone, the dose was between 5-10 μg/kg/h.

Pulse oximetry was used to monitor oxygen saturation of hemoglobin in arterial blood and was maintained at >95%. MAP was measured using automated oscillometry and was stabilized at 80-110 mmHg.

Respiratory rate, end-tidal carbon dioxide was provided by capnography. The respiratory rate was maintained at 10 ± 5 rpm and the level of CO2 was 45-60 mmHg. All patients breathed themselves spontaneously, just one cat need the controlled ventilation because of the elevated level of EtCO2, up to 65 mmHg and the low respiratory rate.

For all patients the recovery from anesthesia was fast and without any complication. The temperature at the end of anesthesia was 37,2 ± 5ºC.

 

Discussions

The ideal anesthetic protocol for cataract surgery should provide central position of the eye, decrease the ocular muscle tone, provide analgesia and narcosis for optimal operating conditions, be safe for the patient and comfortable for the surgeon [4] (Fig. 5).

Good communication with the surgeon before the procedure and an understanding of the surgeon’s requirements are essential when formulating an anesthesia plan. The patient position with the head lower than the heart should also be avoided and at 15 degrees head-up position during intraocular surgery has been recommended in humans.

Also, the position of the animal during surgery may influence the choice of breathing system and endotracheal tube (ETT). Related to intubation should be remembered that the mouth during tracheal intubation can increase IOP as the choroid process of the mandible moves into the orbit. Care must be taken when positioning patients for tracheal intubation, as pressure may be exerted on the globe while the maxilla is held; this is especially the case for brachycephalic breeds. An armored ETT is recommended to use[4].

The ability to influence IOP is very important part of anesthesia management. Is necessary to avoid increased IOP because in these circumstances may result in a globe rupture, risk for intraocular bleeding or retinal detachment.

The use of ketamine, a dissociative anesthetic, for ophthalmologic procedures is controversial. Ketamine used alone is likely to significantly increase IOP because it causes an increase in extraocular muscle tone [4]. The good benefits of ketamine administration consist in increased of the amount of circulating norepinephrine, increase in peripheral arteriolar resistance and muscle activity and decrease the extent of redistribution hypothermia [3]. The use of ketamine has beneficial effects on the blood pressure, cardiac output, corporal temperature and contributes to realization of a balanced anesthesia based on a multimodal analgesia. On the other hand, ketamine can increase IOP but considering that in the protocols used in this study was never used alone and the fact that the surgical procedure involves making a break through the incision of the cornea and penetrating the eye globe this pressure can be adjusted naturally without becoming hazardous for the structures of the eye.

Is mandatory to avoid coughing, sneezing, vomits when there is a risk of globe rupture because this can result in an increased central venous pressure [2]. Therefore, drugs like morphine that causes vomiting should be avoided. On the other hand, the use of alpha 2 adrenergic agonist is not prohibited; although may induce vomiting especially in cats the alpha 2 adrenergic agonist can be very useful when we are dealing with uncooperative patients and the risk of globe rupture is bigger because of the stress and manipulation. In this study, for avoiding the coughing response was used lidocaine. Both iv and topical laryngeal lidocaine attenuated the pressor response to ETI and iv lidocaine 2 mg/kg reduced the cough response to ETI in propofol anaesthetized dogs [1] [2].

Intraocular blood volume is influenced by intraocular vascular tone (vasodilatation or vasoconstriction), arterial blood pressure (ABP) and outflow of the blood from the globe [4]. Is well known that exist an inverse proportional relationship between arterial carbon dioxide tension (PaCO2) and vascular tone. Increased carbon dioxide tension causes choroidal vessel vasodilatation and an increase in IOP. Hypoxaemia can be detect using pulse oximetry and should be avoided by oxygen supplementation and ventilation. PaCO2 can be monitored by capnography or arterial blood gas analysis and controlled using IPPV. However, inappropriate use of IPPV can increase CVP by increasing intrathoracic pressure during inspiration, resulting in an increase in IOP.

Cataract phacoemulsification is not a very painful procedure except during the incision and suturing of the corneal limbus. Traditionally, most anesthetic molecules mildly decrease IOP by increasing the outflow of aqueous humor. The use of anesthetic induction agents such as propofol, alfaxalone, ketamine and etomidate may all increase IOP. All are ameliorated by co-induction agents like opioids,  midazolam or diazepam [4].

One limitation to the present study was the small number of the patients (sixteen animals – eleven dogs and five cats) used.

In conclusion, if the realization of the neuromuscular block for phacoemulsification is not possible, we can perform anesthesia for this procedure using just the standard molecules like lidocaine, propofol, midazolam, fentanyl, ketamine and tramadol. The recovery period after a classic anesthesia without neuromuscular block is much shorter than that achieved after a curarisation and the probability for hypotension is less likely. On the other hand, after induction, a basculation of the eyes towards the internal angle was observed for all studied cases. In order to achieve the phacoemulsification surgery, the eye was brought to the central position by means of the traction sutures.

The great disadvantage is the fact that without neuromuscular blocking agents we can`t obtain the central position of the eye globe and that implicate make some compromises from the surgeon.

 

Acknowledgments

6 (1)The project was provided by Di-Vet Medical – pet emergency and critical care clinic, Bucharest, Romania.

Multimodal treatment approach to canine oral malignant melanoma: a clinical case

14199647_10154460495808851_4115072769610561786_n

Dr Ana Nemec

Ana Nemec, DVM, PhD, Dipl. AVDC, Dipl. EVDC; Ana Rejec, DVM, PhD, Resident, Veterinary dentistry

 

Animal Hospital Postojna, Cesta v Staro vas 20, 6230 Postojna, Slovenia

 

Case history and clinical signs

Fig. 1

Figure 1: Amelanotic malignant melanoma affecting right rostral maxilla in a 4-year-old female German shepherd at presentation.

A 4-year-old 30-kg female spayed German shepherd was presented due to rapidly growing rostral maxillary mass. At presentation, the proliferative mass, located around right maxillary third incisor and canine tooth was ulcerated and bleeding (Fig. 1). The patient was otherwise healthy with physical exam findings, CBC and biochemistry all within normal limits. Staging options were discussed and the client elected computed tomography (CT) of the head and neck as well as chest CT together with biopsy of the lesion and an abdominal ultrasound.

 

Imaging and histopathology findings

Fig. 2

Figure 2: A CT image taken at the level of maxillary canine teeth at presentation. Note an invasive lesion occupying majority of the right nasal cavity and crossing the midline

Pre- and post-contrast CT images revealed an invasive lesion, located primarily around the maxillary canine tooth and extending from the right maxillary second  incisor tooth to the mesial root of the right maxillary second premolar tooth, occupying majority of the right nasal cavity and crossing the midline (Fig. 2). CT of the neck and chest revealed no metastatic disease to the regional lymph nodes and lungs, and abdominal ultrasound was also within normal limits.

Histopathology of the lesion revealed spindle-cell neoplasm, with differential diagnoses being fibrosarcoma or spindle-cell amelanotic melanoma, and further immunohistochemistry using Melan A and PNL-2 antibodies was performed and was suggestive of amelanotic melanoma.

A stage III (with no detectable metastasis based on the diagnostics performed) amelanotic melanoma was diagnosed.

 

Treatment and follow-up

Fig. 3

Figure 3: With the dog under general anaesthesia in dorsal recumbency an incision is planned to remove the tumor with narrow margins (“debulking surgery”).

Fig. 4

Figure 4: Once the right rostral maxilla and left incisive bone are en-block removed together with the tumor, hemostasis is achieved by ligation of major palatine arteries. Note macroscopically-visible tumor remnants in the right nasal cavity.

Fig. 5

Figure 5: Immediate post-operative photograph of the 4 years old dog with OMM.

Due to an extensive involvement of the nasal cavity, wide resection was impossible to achieve without significantly impairing the cosmetic appearance and function of the animal, and the client elected palliative-intent extended unilateral rostral maxillectomy to reduce tumor burden (Figs. 3-5), followed by a course of adjuvant hypo-fractionated radiotherapy of the surgical area (6 x 6 Gy twice weekly) 3 weeks after the surgery (Figs. 6-9).

 

 

 

 

 

 

 

 

 

 

Fig. 6

Figure 6: Three weeks post surgery the mucosal flaps have healed and any remaining sutures are removed to minimize irritation and inflammation before radiation therapy is initiated

Fig. 7a

Figures 7: Radiotherapy is performed 3 weeks after surgical resection of amelanotic malignant melanoma with the dog under general anesthesia. Note a lead plate positioned in the mouth to prevent irradiation (exit dose) of the healthy mandibles. A bolus is used on the maxilla to achieve optimal dose distribution in the irradiation field.

Fig. 8

Figure 8: Radiation therapy technologist adjusting the patient and equipment to correctly apply the radiation treatment plan.

Fig. 9

Figure 9: Acute side affects of radiotherapy (radiomucosititis) 2 weeks after completion of radiotherapy, which diminished with supportive antibiotic, local antiseptic and anti-inflammatory treatment.

Melanoma vaccine treatment (4-dose, biweekly protocol, then boosters in 6-month intervals) was added to the treatment protocol as an immunotherapy approach to multimodal treatment approach. At all re-checks, the patient was clinically healthy and the most recent re-check head and neck and chest CT revealed no metastases 5 years after the diagnosis (Fig. 10). Fig. 7b

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discussion

Fig. 10b

Figure 10: 5-year follow up – no clinical nor CT evidence of local tumor recurrence

Malignant melanoma (OMM) is the most common nonodontogenic oral tumour in dogs. Clinical signs may vary greatly; the tumour is not necessarily pigmented (black). Histopathological diagnostics may be complicated as a tumour may present as amelanotic variant and/or as epithelioid-cell OMM, spindle-cell OMM or mixed-cell OMM. Therefore, immunohistochemistry is often needed to determine the diagnosis. OMM is locally invasive, with 50% of tumours being associated with surrounding bone invasion. Metastases are also common: in 74% of cases, OMM metastasise in regional lymph nodes and in up to 92% of cases in the lungs.

Hence, before any treatment is attempted, a patient with an OMM needs to be properly staged. To evaluate local disease, tumor location is noted and the lesion measured. Diagnostic imaging of the local lesion should include pre- and post-contrast CT of the head, as skull radiographs and/or intraoral dental radiographs will underestimate the extent of the lesion and especially invasion of maxillary tumor into adjacent structures. Magnetic resonance imaging (MRI) can also be considered and PET/CT is becoming available in veterinary medicine as well.

Evaluation of regional lymph nodes may be challenging. Although palpation of the mandibular lymph nodes should be routinely performed, it needs to be realized, that 40% of palpably normal lymph nodes contain metastases. Fine needle aspiration of the regional lymph nodes may be helpful, but reaching the main draining center of the head – retropharyngeal lymph nodes – requires ultrasound-guided approach. Also, it has recently been described, that consensus between cytology and histopathology for staging of lymph nodes in patients with melanocytic neoplasms is poor, and negative result does not rule out metastases. Evaluation of size and contrast-enhancement pattern on post-contrast CT images can be very helpful in evaluating regional lymph nodes for metastases, and PET/CT is also very promising. Excisional biopsy of the lymph nodes is debatable, as complete staging requires removal of all lymph nodes of the head and neck. Excisional biopsy of the sentinel lymph node – technique which is well developed in human medicine – is the goal and determination of the sentinel node will hopefully become easier with advanced imaging techniques.

Staging is completed with evaluation of distant organs for possible metastatic disease, where chest CT is much more sensitive to diagnose pulmonary metastases compared to thoracic radiographs. Full body CT may be recommended, if involvement of abdominal organs is suspected, which is rare in cases of canine OMM, and abdominal ultrasound is usually performed.

Once the stage of the OMM is determined, the treatment approach(es) and prognosis can be discussed with the client. It is worth mentioning here, that scientific data on treatment outcomes for specific stage OMM, especially when several treatment approaches are combined, are scarce. Hence, proper communication with the client is extremely important to present as much as possible information and keep realistic expectations. Generally, prognosis for animals, especially if the tumour arises from dentate areas, is guarded due to early and common metastases. Dogs with small OMM (smaller than 2 cm in diameter, stage I) located rostrally and those without metastases, have the best prognosis. With radical tumour resection (tumour with associated 1 cm of healthy tissues as determined by CT) median survival time was reported to be 723 days and related to tumor stage. It has also been reported, that even incomplete tumour resection (dirty margins) increases survival time. When complete resection cannot be achieved (as was expected in the presented case), or the client declines surgical treatment, or when surgery has resulted in incomplete removal of the tumor, or when regional metastases are present, other treatment options exist, although some studies questioned the benefits of adjuvant therapies. When recommending an adjuvant treatment, most commonly suggested is radiation therapy, which can also be the sole treatment for OMM (local and regional disease). The outcome of radiation therapy depends, as with surgery, on the stage of the tumor as well as on the radiation protocol; most commonly hypo-fractionated radiation protocols are recommended and, when used as a sole treatment of OMM, can result in median survival times a bit shorter than those achieved with surgical treatment. Acute side effects, such as radiomucositis are common, expected and usually resolve with supportive treatment, while late life-threatening side effects, such as osteoradionecrosis or secondary tumors, are rare, but need to be discussed with the client in advance, especially when long-term survival of irradiated patients is expected.

OMM is considered poorly responsive to chemotherapy, but is a highly immunogenic tumor. Although the exact immune mechanisms are not completely understood and are likely individually-specific, several immunotherapy and/or gene-electrotransfer therapy approaches have been suggested for canine OMM patients. Most (clinical) research has been performed on a canine melanoma vaccine (xenogeneic plasmid DNA with a cDNA insert encoding human tyrosinase), which has been shown to be safe, but data on its’ efficacy are conflicting. Although it remains unclear, what (if any) role melanoma vaccine and other treatments played in the prevention of metastatic disease in the case described in this report, it is important to realize, that the outcome of canine OMM treatment may not neccessary be poor. In addition, new multimodal approaches are being developed to treat canine OMM and are changing this disease with historically poor outocme into a chronic disease, at least in selected cases.Fig. 10a

 

Clinical study at Animal Hospital Postojna

At Animal Hospital Postojna we recently began a study titled “Evaluation of immune system response to hypo-fractionated radiotherapy in canine non-operable oral, cutaneous or digital melanoma’ together with the Oncovet Clinical Research Centre in France. The study aims to evaluate immune system response to hypo-fractionated radiotherapy in canine non-operable oral, cutaneous, or digital melanoma and to assess the ability of this therapy to improve the response to immunotherapy in combined treatment. With the client’s agreement, we include dogs (males and females) with malignant melanoma when the tumour cannot be surgically removed, either due to its localisation preventing the recommended wide excision, or the client’s refusal to approve such a procedure. In that case, hypo-fractionated radiotherapy remains the preferred treatment. If you or anyone you know are interested in participating in the study and would like to know more about the study protocol and obligations, risks and potential constraints as well as benefits that we offer if you decide to participate, please, contact us at info@ahp.si

 

 

Brachycephalics-Anaesthesia and Intensive Care particularities

 

10455370_1662135347386201_2573188422215976094_nDr Ruxandra Costea, PhD

Bucharest, Romania

 

 

Brachycephalics are patients that are prone to the increase in the superior airways’ resistance, with the decrease of the airflow at the level of the nose or mouth, which implies higher risks and complications associated with anaesthesia.

The acute obstruction of the superior airways can manifest itself consequently to the overheating syndrome (excessive heat, excessive humidity, after physical effort, hyperthermia), post-detubation or as the worsening of a chronic obstruction.Presentation5

The overheating syndrome is represented by the the body’s incapacity to dissipate the accumulated heat and can manifest clinically through hyperthermia (> 41° C), dysfunctions of the central nervous system, the activation of the inflammatory mechanisms, hemostasis disorders and initiation of the systemic inflammatory response syndrome (SIRS). The physiopathological cascade can evolve through multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), disseminated intravascular coagulation (DIC).

The risk factors for the triggering of the overheating syndrome are represented by any anterior episodes, obesity, breed (brachycephalics, Golden Retriever, Labrador), elevated ambiental temperatures and humidity,  poor acclimatization, low resistance to physical effort.29425659_10211461064425220_967441903115042816_o

Hyperthermia can generate cerebral hypoperfusion, neuronal necrosis, vascular lesions, cerebral edema, haemorrhages, multifocal vascular thromboses. The clinical signs can be spontaneous haemorrhages (petechiae, hematemesis, hematochezia).DIC can appear anytime during the first 24 hours after the incident (close monitoring). Hyperthermia can trigger oxidative stress mechanisms, which can act at gastrointestinal level through intestinal ischemia, cytoskeleton relaxation, increase in intestinal permeability and finally, bacterial translocation. Temperature control is essential for the limitation of clinical manifestations (tachypnea, tachycardia, vasodilation, massive haemorrhagic diarrhea and hematemesis coagulopathies, miocardial hypoperfusion, lactic acidosis, electrolitic disturbances, cardiac arrhythmias, stupor, convulsions, exitus). The patient will have to be cooled simultaneously with the administration of  fluids for the control of tissular perfusion and hydroelectrolytic disorders. Crystalloid isotonic fluids will be administered, supplementing, if needed, with colloid boluses, depending on the hydration state, cardiovascular potential and the electrolytic status of the patient. The therapy will continue without interruptions until the patient is stable. In severe cases, it is necessary to start the antimicrobial therapy for restricting the endotoxemia and preventing sepsis ( broad-spectrum antibiotics). The therapy will be completed with gastrointestinal protectors, H2 antagonists (famotidine) and proton pump inhibitors (pantoprazole). Continuous monitoring throughout the therapy is mandatory, because the patients need re-evaluation and consequent adaptation of the therapy.

The key points in the therapeutical management of the overheating syndrome are:

  • Oxygen supplementation
  • Sedation, general anaesthesia
  • Temperature control
  • Control of the tissular perfusion and of the acid-base and hydroelectrolytic disorders
  • Correction of homeostasis disorders
  • Maintenance of the renal function
  • Blood glucose monitoring
  • Antimicrobial therapyPurpose:  Presentation4 

    Oxygen supplementation is necessary when the patient first shows up ( starting with the triage phase) in the case of acute respiratory distress syndrome (ARDS), noncardiogenic pulmonary edema or laryngeal edema. Brachycephalics in thermal shock exhibit compensatory hyperventilation or can’t oxygenate themselves enough, consequently to respiratory insufficiency, with high respiratory effort, hyperthermia, muscular exhaustion and, finally, respiratory arrest! The immediate control of hypoxemia initially requires oxygenation through noninvasive methods, followed, if needed, by additional invasive procedures (general anaesthesia with endotracheal intubation, nasal oxygenation catheter, tracheal catheter, tracheotomy/ tracheostomy). High air flow devices can be used for oxygenation (>15l /min.)- oxygen tent/cage, AMBU-bag or low flow devices(<6l/min.)-mask, nasal oxygenation tube, endotracheal probe, tracheal catheter.29388957_10211461064265216_3957696742744391680_n 29425012_10211461064385219_3239167496015577088_n

    Assisted ventilation is recommended either in case of hypercapnia (PaC O2 >60 mmHg) or severe hypoxemia (PaC O2 <80 mmHg or SpO2 <90%) with persistent cyanosis despite having oxygenation levels reaching 100%.Possible complications regarding mechanic ventilation are correlated to the accidental disconnection of the patient, device failures, barotrauma, atelectasis or oxygen toxicity.

    Brachycephalics are NOT the best candidates for „a simple sedation”, requiring, in most cases, general anaesthesia protocols. Given the fact that all anaesthetics affect the respiratory function through central depression or through muscle relaxation, a continuous monitoring is necessary, from premedication to the patient waking up from anaesthesia.Presentation1

    Preanaesthetic evaluation will be cautiosly approached, in order to reduce the perioperative mortality, by tracing and evaluating the risks and by adjusting the perioperative protocols. The patients will be premedicated in order to reduce stress, anxiety, agitation, this also leading to a decrease of the doses that are necessary for maintenance. For critical patients, premedication can be excluded, but analgesia must be maintained! A minimal contention is recommended, without a muzzle! For brachycephalics, preoperative preoxygenation is mandatory. For induction, the lowest propofol doses will be slowly administered intravenously. (1.0 mg/kg slowly injected intravenously for the first 15 seconds, then another 1.5-2 mg/kg until reaching the desired effect). The administration of propofol in rapid bolus causes apnea, bradycardia, hypotension and respiratory depression. Propofol reduces the cerebral metabolism, the cerebral blood flow and the intracranial pressure, also alleviating the effects of the hypoxic lesions, and inhibiting lipid peroxidation, having an antioxidative action.

    The endotracheal intubation of the brachycephalics must be done with care. It is hard to anticipate the dimension of the trachea by the size of the patients, because they often  have hypoplastic tracheas. Anaesthesia is maintained gaseously, ensuring the efficient ventilation of the patient.  For avoiding regurgitation, the patients will be positioned slighly forward, with the anterior extremity lifted at . Inhalation anaesthesia protocols can be carried out, if needed, at the same time with the administration of opioids (bolus or CRI) or with locoregional anaesthesia techniques (blockages, infiltrations, epidural etc.).29496194_10211461064545223_8396511414134505472_n

    Secondary effects can appear at high doses of opioids (dysphoria, bradycardia, respiratory depression). For ensuring the polymodal analgesia, opioids, NSAIDs and local anaesthetics can be administred.

    Managing the hemostasis disturbances implies the stabilization of the coagulation system, the administration of fresh frozen plasma or anticoagulants, for preventing thromboses.

     

    Maintaining the renal function is possible in the case of patients suffering from thermal shock through maintaining the perfusion and oxygenation of the kidney. Hypovolemia and dehydration will determine the arterial tension and the cardiac output to lower, leading to the decrease of the renal perfusion ( renal ischemia). Lowering the oxygenation at renal level will favor the triggering of acute renal insufficiency. Consequent rhabdomyolysis and myoglobulinemia will damage the kidney even more. If the urine output is low (<1ml/kg/h) even after fluidotherapy, furosemide and/or mannitol can be administered. Mannitol (osmotic diuretic) will reduce the water content of the neuronal cells, will increase the reanl perfusion and diuresis. Furosemide can be administered at 15 minutes after the administration of mannitol. An option for hyperhydration, uremia or different electrolytic imbalances is represented by hemodialysis.

     

    Monitoring the glycemia is very important for critical patients, because the ones that are hypoglycemic have a hard time compensating!

     

    A particular situation is represented by the acute obstruction of the superior airways after detubation. The muscles of the superior airways, which are relaxed post anaesthesia, can favor the appearance of acute obstructions at brachycephalic breeds, together with the inflammation of the larynx and the pharynx, especially after the specific correctional surgical procedures. That is the reason why it is recommended to postpone these patients’ extubation for as long as possible after anaesthesia and to supplement their oxygenation through noninvasive methods (nasal oxygenation probes, prongs, oxygen cage), until they have completely recovered from it. Since the risk of complications is high, it is good to be prepared for a possible reintubation or even for invasive oxygenation methods (trecheotomy, trecheostomy).

     

FELINE LYMPHOPLASMACYTIC GINGIVITIS STOMATITIS COMPLEX

index

Dr Adriana Moise

CASE PRESENTATION

  1. MOISE ADRIANA

TAZY-VET, BUCHAREST

 

SIGNALMENT AND HISTORY

  • FEMALE CAT , 2 YEARS OLD WAS PRESENTED FOR A CLINICAL EXAMINATION WITH HYPERSALIVATION , HALITOSIS, LACK OF APPETITE FOR PROCESSED DRY FOOD

CLINICAL FINDINGS

-THE CAT HAD NORMOTHERMIA AND A NORMAL BODY WEIGHT

-AT PHYSICAL EXAMINATION SHE PRESENTED ULCERATIVE LESIONS IN ORAL CAVITY, LOCALISED ON GINGIVAL MUCOSA, INFLAMATION ON PALATOGLOSSAL FOLDS AND PHARYNGEAL WALLS

-EDEMA WAS PRESENTED AND LOCAL LYMPHNODES WERE REACTIVE TOO

der2

photo 1

der3

photo 2

LESIONS WERE PRESENTED BILATERAL ( photo 1,2)

DIFFERENTIAL DIAGNOSTIC

-FELINE LYMPHOPLASMACYTIC GINGIVITIS-STOMATITIS COMPLEX

-FELINE CALICIVIRUS INFECTION

-FELINE HERPESVIRUS INFECTION

-FeLV-FIV

-FELINE EOSINOFILIC SINDROME

-NEOPLASIA

FURTHER INVESTIGATIONS

-FELINE CALICIVIRUS Ac –NEGATIVE

-FELINE IMMUNODEFICIENCY – FIV Ac-ELISA –NEGATIVE

-FELINE LEUCHEMIA –FELV Ag-ELISA – NEGATIVE

-THE CORONAVIRUS Ac TITRE – INCREASE

-CITOLOGY FROM IMPRESSION SMEAR – INCREASE NUMBER OF BACTERIA AND NUMEROUS ACTIVE INFLAMATORY CELLS

BLOOD TEST (BIOCHEMISTRY)  WAS NORMAL

-HEMATOLOGY REVEALS LYMPHOCYTOSIS

-CYTOLOGY AND HYSTOPATOLOGIC EXAM CONFIRMED THE DIAGNOSTIC – FELINE LYMPHOPLASMACYTIC GINGIVITIS STOMATITIS COMPLEX

 

DIAGNOSTIC

FELINE LYMPHOPLASMACYTIC GINGIVITIS STOMATITIS COMPLEX

TREATMENT

UNTIL WE GOT THE RESULTS THE OWNER BEGINS TO TREAT THE CAT WITH

-STOMODINE GEL TWISE A DAY, 14 DAYS

-CEFA CURE 20MG/KG/DAY, 10 DAYS

-SYNBIOTIC D-C 1CPS/DAY, 10 DAYS

-K9 IMMUNE SUPPORT CAT

 

-AFTER 10 DAYS OF TREATMENT THE INFLAMATION BEGAN TO REDUCE BUT THE ULCERS DO NOT HAVE THE TENDANCE OF HEALING

AFTER WE GOT THE DIAGNOSTIC THE CAT GETS THE FURTHER TREATMENT

-PREDNISON 2MG/KG/DAY, 5 DAYS; THEN 1MG/KG/DAY , 5 DAYS FOLLOWEDBY EVERY OTHER DAY

-STOMODINE GEL TWICE A DAY LOCAL

-HONNEY WITH PROPOLIS LOCAL

WHEN SHE CAME FOR THE EVALUATION AFTER 5 DAYS OF TREATMENT WE SAW THAT THE LESIONS HAD A TENDANCE TO REDUCE, BUT AFTER ANOTHER 5 DAYS THE LESIONS WERE EXACTLY THE SAME AS THE BEGINNING

-WE DECIDED TO INTRODUCE CYCLOSPORINE IN THE TREATMENT

-CYCLOSPORIN 7MG/KG/DAY

derder1

-THE CAT IS PERMANENTLY MONITORIZED ; HLG IS MADE EVERY 2 WEEKS

-AFTER 2 WEEKS OF TREATMENT THE LOCAL INFLAMATION BEGINS TO REDUCE

-AFTER 1 MONTH OF TREATMENT THE LESIONS FROM ONE SIDE WERE HEALD

-THE CAT IS STILL UNDER TREATMENT

-THERE IS NO SIGN OF SECOND EFFECTS OF CYCLOSPORINE

 

How to start up an exotic animal department in your private clinic

ama

Dr Ama Groza Mrcvs

If you have already realised that providing high quality veterinary medicine services to exotic pets can increase your turnover and enhance clientele then let me congratulate you! This article will give you an easy step-by-step guide to follow in order to make the best of your new venture.

Have you wondered why so few vets are seeing exotics? Some frequent explanations include:

  • Most vets get little training in caring for exotic pets and as a consequence they get stressed when having to see an exotic pet. Many clinicians will refuse to see them unless it’s a first aid situation and the ones that do, probably won’t generate sufficient income to cover their time.
  • If surgical intervention is required, the price for the time spent with an exotic animal, a rabbit for example, is almost half that compared with the same time spent caring for a dog or a cat.

It is no surprise that exotic animal medicine is not high on the preference list of any sensible practice owner. But this is because you’ve been doing it all wrong!

These steps will guide you in starting up a successful exotic animal department in your clinic.

 

  1. Don’t cut corners, practice good quality medicine

The slogan “Gold standard practice” is unfortunately overused these days. Many practices advertise gold standard protocols, however these apply to dog and cat patients only. When it comes to seeing an exotic pet, basic investigations like a simple blood sample or a faecal test are often not even offered to owners and this is where the clinic is losing money and clients.

Through having your staff trained and consequently confident in carrying out specific procedures on exotic pets this will not be the case.

Protocols for different alignments should be in place for exotic animals as well as for small mammals to secure the best care for all pets. Having protocols in place will facilitate a fast treatment set-up at the best standard, easily followed even by inexperienced vets when there’s no support around.

There are a wealth of specialised procedures to be carried out on exotics and trained veterinarians and/or nurses will be able to offer all this to customers, generating more income for the practice.

Encouraging best care practice will stimulate your staff to keep up to date with their training; practice high standard procedures and good outcomes will not stay unnoticed for long. As a consequence more owners will register with your practice. Your staff will be delighted to be at the top of their job taking pride in what they do.

 

  1. Train your staff

Having your staff trained into caring for exotic animals their procedures can be fast, successful and stress free. Because major differences exist between exotic and small mammals, one must have specialised training in order to be able to look after exotics.

Knowledge and confidence is what you need in your team. Offering a generous list of fairly priced specialised procedures will generate more work for the practice and can only be an asset comparing with your competitors (I will return to this later in this article).

Naturally, trained staff will exude confidence and gain owners trust. Consequently, owners will be more likely to agree to more high risk or specialised procedures which they might otherwise hesitate upon; again, thus increasing your revenue.

Practices with trained staff to care for exotics are scarce, so letting your customers know what your team can do and what their level of training is, will not only serve to retain existing clients but will also attract new customers to the practice, and these new customers will often have more than one pet. And who doesn’t like a growing client base?!

 

  1. Charge a fair price for your services

Establishing a fair price is the key factor in setting up your business for failure or success.

Firstly, it is important to understand that there is no relation between the purchase price of a pet and the costs for its medical treatment.

Some people will adopt stray dogs and request for expensive laparoscopic rather than traditional neutering. No surgeon would hesitate to give them an accurate estimate. However when contemplating performing a tortoise spay, most surgeons will doubt the owners’ willingness to accept the surgery as a first option because of the costs involved. However, this is only our assumption!

pic 1

I always try and explain before an estimate that the medicines and consumables we use are the same price for all pets. My practice overheads are the same regardless of whether I work with dogs or parrots so why should my work time be priced up differently?

Set your pricing to charge fairly for your time, your assistants’ time, the materials used and not least for your skill.

Pricing all  materials used (like catheters, swabs, gloves etc.) separately will show owners how much the consumables cost, otherwise owners have no idea how much an urinary catheter is and not giving them a detailed bill can lead to confusion. Pricing of the consultation fee should cover time spent with the client and overhead costs such as rent, electricity, water etc. Pricing for the individual procedures carried out (like “placing an IV catheter” or” blood collection”) must cover your salary costs and the cost of ongoing training. The message here is that all costs should be factored in rather than just absorbed.

To your advantage is the fact that few veterinary surgeries offer good quality medicine for unusual pets. If you are clearly the best at it, you have little competition. There is nothing inherently wrong with being expensive but you should not forget that this approach requires continuous training and investment in equipment.

My experience has shown that owners shopping around for price rarely become good, loyal clients. They will always be difficult to convince to agree to investigations and will be likely to complain more if things don’t work out immediately (this is natural, because they can’t afford to spend more money for further tests if needed). The question is not whether you need these clients, but whether you can afford them. Charitable care organisations might be more appropriate for financially challenged clients.

pic 22

This is a baby Russian tortoise (Agrionemys horsfieldii ), has a lifespan of 75 years

Customers shopping for quality and excellence in veterinary care will be yours for life and will pay fairly for your services because they understand and appreciate your approach. Make this group your target clientele and your efforts will pay off.

 

pic 2

This is a replica cake of a Russian tortoise (Agrionemys horsfieldii ), it survived for 1 day”

  1. Facilities

Working with exotic pets requires that some adjustments to the hospital facilities and dispensary are made. Exotic pets are escape artists, easily stressed and some of them are poikilothermic, will need special hospitalisation facilities like a vivarium or even an incubator. With a modest budget you’ll be able to adjust your clinic to their needs (to keep costs down you can consider buying vivariums, loupes or surgical instruments second hand).

Most medication used is similar to that for small mammals, however, be aware that dosage is not, so be careful and make sure to consult your exotic medicine library.

pic 3

My favourite books which I have always at hand

ARAV.ORG, AAV.ORG  , AEMV.ORG are prestigious, reliable sources of information, so do invest in membership to this organisations. This will give you access to updated care sheets, up to date research data, specific event information and most important, a lot of colleagues to get in touch with in case you need advice on your cases.

 

  1. Advertise

There’s not much gain, except of course personal gain, in being very good at your job if nobody knows about it. In order to keep the business going one should make sure existing and prospective clients know about the range of services the clinic is offering.

You could periodically inform clients about any new equipment purchased and about what training your staff has undertaken. This will not only act as a “refresher” on what your service offering is but will also spread by word of mouth. You may be surprised to find how much impact the users of specialised forums have when a new exotic pet owner is looking for a knowledgeable vet. Make sure your name appears there, next to a good review of course.

Always remember to keep your colleagues informed about your services. Referral cases are a good source of income and a great way of practicing your specialist skills. Organizing open days and continual professional development courses will keep you on the radar of colleagues and clients alike, they should know that you exist and are doing well.

An unusual pet can easily become a news subject and this can get you free advertising. Don’t be shy, let the world know about your successful cases, consider local newspapers, TV and radio as well as social media.

  1. Stay at the top

Don’t ever stop learning.

Exotic animal medicine is developing fast, trends are changing and new protocols are being elaborated at an incredible speed. Refresh your library (very important: change your Carpenter’s Exotic Formulary with any new edition) periodically.

Re-evaluate your protocols every year, attend refresher courses, learn new surgical procedures, and stay updated. When you are the best you can be, you have no competition other than yourself.

Enjoy your success!

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Next event of Dr Ama Groza, soon in Bucharest, Romania!

 

Encephalitozoon cuniculi – associated Phacoclastic Uveitis with Second Glaucoma in Rabbit

12607134_1258198090860834_1767228054_n

Dr Vesela Elenkova

Dr Vesela Elenkova – master scintific in veterinary ophthalmology and surgery, veterinary clinic “Eskovet”– Bulgaria, Sofia

Case presentation :

A nine month female rabbit presented for a right eye lesion of two weeks duration. There was cataract on the same eye from birth. The referring veterinarian had prescribed a course of topical and systemic antibiotics but it continued to deteriorate. The eye was become very painful. The lesion appeared as a whitish-yellow mass into the hyperemic iris, slightly protruding into the anterior chamber. There was a mature cataract formation and the pupil was mydriatic with no response to light. The intraocular pressure (IOP) of the affected eye was 40. On the other was 11and it was not clamped. Fluorescein staining was negative for corneal lesions on both eyes. On the ultrasound examination there was no changes into the posterior segment of the affected eye.

12540490_1258197917527518_1937293050_n

The right eye of the rabbit with E.culiculi-assosiated lens-induced uveitis. Note the mature cataract, the large mass into the hyperemic iris and the midriatic pupil not responding to light. IOP is 40.

There was only seen the hyperechogenic lens and the lesion in the iris. The rabbit was in pain when touched and didn’t want to eat well.

12583861_1258201577527152_195897903_n

Ultrasound image of the eye. Note the hyperehogenic lens and the 7mm lesion behind the iris. The posterior chamber is not affected.

The patient history and appearance of the lesion were compatible with Encephalitozoon cuniculi-induced phacoclastic uveitis, and a tentative diagnosis was made. Other diagnostic defferentials included granuloma caused by Pasteurella or other bacterial infections, but they were unlikely considering cataract formation. Diagnostic included complete blood count, biochemical profile and serology testing.
The complete blood count and serum biochemical profile were within normal limits. The serum IgG-antibodies were not so high, but the IgM-antibodies indicate active infection in most cases. They bought are not indicative for utero infection.

We opted medical management. 12570932_1258201610860482_1705138233_nExcept of the antibiotic therapy (with enrofloxacin PO and ciprofloxacin eye drops), the treatment was continued with fenbendazole at 20 mg/kg PO q24h for 28 days. 12607270_1258201650860478_1726829549_nPrednisolone acetate ophthalmic drops were prescribed to treat the uveitis and dorzolamide hydrochloride and timolol maleate drops for the eye pressure.

12499408_1258197950860848_625277437_o

The left eye of the rabbit appeared unaffected

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After one week recheck. The iris is not so hyperemic and IOP is 6.

After 1-week recheck, the lesion had not changed, hyperemia was decreased, the IOP had become low – 6. There was no pain in the eye and the rabbit was doing well. The pupil still does not respond to light. After 2 weeks more, there was no change. The rabbit was in very good condition, but the vision in the right eye was compromised. Surgery might be necessary in the future depending on progression of the lesion, discomfort, and long term effects on the eye.

Discussion

Encephalitozoon cuniculi (E. cuniculi) is a protozoal parasite. The parasite primarily affects rabbits, but cases have been reported in sheep, goats, dogs, cats, monkeys, guinea pigs, foxes, pigs and humans. It is a recognized zoonosis, but the zoonotic risk seems to be minimal to healthy individuals observing basic hygiene and to date there have been no reported cases of direct transmission from a rabbit to a human. However, those individuals who are immunosuppressed should implement strict hygiene and if possible avoid animals suspected or confirmed of being infected with E. cuniculi. Spores are shed in infected animals’ urine and transmission is usually by ingestion of contaminated food or water, or less commonly by inhalation of spores. Transmission from mother to young (transplacental) also occurs so that offspring are born infected. Most of the time, these organisms do not cause any obvious clinical disease. When E. cuniculi reach nerve tissue, rabbits can experience neurologic impairment, characterized by partial or complete paralysis, loss of coordination, seizures and head tilting.
E.cuniculi-assosiated phacoclastic uveitis is recognized in rabbits. There is no sex predisposition and the condition is often seen in younger rabbits. The mechanism by which the protozoan causes cataract is unclear in detail, but its lifecycle gives clues as to aetiopathogenesis of cataract. Passage of parasite between adult and young happen in utero with the parasite circulating in the fetus and sometimes ending up residing in the developing lens. The parasite migrates through the anterior lens capsule causing liberation of lens protein into the iris and anterior chamber and subsequent development of lens-induced uveitis, however, the posterior chamber usually remains unaffected. Normally this uveitis presents as a white-yellow mass in or near the pupil, sometimes with neovascularisation rendering it red or pink.
Serum ELISA antibody titers are helpful in making a diagnosis, however, serology only indicates past exposure and is not diagnostic of or necessarily correlated with clinical disease and infection. Immunofluorescence assay and polymerase chain reaction (PCR) testing of tissue, urine and feces samples, as well as cerebrospinal fluid and removed lens material. These test looks for antigens, unlike serology, which test for antibodies. Simultaneous testing of IgG and IgM-specific antibodies can give an indication of infection status because IgM antibodies indicate active infection. If transmission is transplacental, bought IgG and IgM antibodies may be low.
In this cases treatment options include antiprotozoal medication, topical corticosteroids for the uveitis, surgery to remove the affected lens and granuloma if it is possible. The other option is enucleation, but it is not common if the eye is functional, because it is unlikely to eradicate the infection. In other cases the eye may atrophy without surgery (phthisis bulbi).

Conclusion

E.cuniculi-assosiated phacoclastic uveitis should be always suspected for rabbits presenting with ocular lesions and uveitis and oral antiprotozoal medications are always recommended, as affected rabbits may develop infection in the brain and encephalitis, that can lead to death.