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Surgical removal of the luxated lens including the capsule (intracapsular lens extraction) in a bear

Belica_surgery118Dr Maria Savova

Veterinary Clinic NOVA

Sofia, Bulgaria

 

Violeta is a 37y.old brown bear form Belitsa Dancing bears park, Bulgaria.

She was suddenly blinded and had an urgent eye check.The ophthalmological examination revealed increased pressure (40mmHg) and displaced lens in the left eye.The cornea was mildly opaque and the lens was with senile cataract. No PLR. The retina was also degenerated resulting in marked tapetal hyper reflexivity.Belica_surgery30 Belica_surgery40

Lens subluxation (posterior) is partial detachment of the lens form the ciliary body, due to breakdown or weakness of the zonules.

We preformed surgical removal of the luxated lens including the capsule (intracapsular lens extraction).

In the “open sky” approach, the superior cornea was incised 120 – 160 degrees using a cornea knife. The lens and its capsule were removed together in one piece through the incision.Belica_surgery93 Belica_surgery100 Belica_surgery110

Hydrodissection was employed for the removal of lens. We left the eye without artificial lens (aphakic).

During the removal of the lens, prolapsed vitreous was determined and we removed it with scissors in the anterior chamber.

Following the irrigation of the anterior chamber, corneal incisions were closed by separate sutures using 8/0 polyglactine.

For the postoperative care, we applied systemic antibiotics for the first five days.Belica_surgery121 Belica_surgery126

7 days after surgery, the eye is calm; there is no secretion or swelling.

 

Now the bear is in preparation for hibernation and her eye will be examined in the spring.

OSTEOCHONDROSARCOMA- SURGERY

43715598_336141656947602_6782174039545741312_n(CASE REPORT)

DR LUCIAN FODOR HAPPY PET TIMISOARA-ROMANIA

Introduction:

Osteochondrosarcoma is an uncommon tumor that generally arises from the skulls of dogs (cranium, orbit, zygomatic arch, mandible, and maxilla) and can occasionally arise from the pelvis, ribs, and os penis. These tumors have a characteristic appearance on radiographs, CT, and MRI: generally the borders of the tumor are sharply demarcated with limited lysis of the adjacent bone, with a coarse granular density throughout. A popcorn-like appearance with stippled and heavily calcified or ossified regions has been described on survey radiographs.

Clinical signs are generally based on location and extent of the lesion; ranging from a palpable, fixed, and firm mass to pain on mouth opening for tumors involving the mandible and zygomatic arch, exophthalmos with infraorbital lesions, and neurologic abnormalities for tumors involving the cranium.

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Fig 2

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Fig 1

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Fig 3

Cara, a one year unsterilized mallinois female bitch, from the age of 7 months beggin to develop in the fronto-parietal region a globular formation(fig.1-2-3)

 

.She came to our unity with neurological manifestations, ataxia, deviation, refusal to rise from the bottom, bilateral midriasis.

Blood analyzes where in optimal parameters. After performing the CT, a giant extra and intra-cerebral form was noticed, being the imaging feature of the osteocondrosarcoma. (Fig.4-5)

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Fig 4

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Fig 5

After consulting with the owner we decided surgery.

It was performed a large, circular craniotomy with a safety margin of one cm. The formation did not adhere to dura mater, only compressing the brain. (Fig. 6-7-8-9)43828104_267060260621234_1089416852607598592_n 43727747_1873646689408833_5453387625761079296_n

T43828915_108324666763855_6959109323293196288_n 43750703_2206611569596014_4590836245717843968_nhe bone reconstruction was accomplished with Collapat, a substrate of bone based on hydroxyapatite and collagen. (Fig.10)

Concluzion:

Post operator evolution was good, 48 hours after the surgery the patient was recovered neurologically(Fig11). At six (Fig12)and 12 months post surgery,(Fig.13) Cara feels good, fully recovered.

 

 

The rhomboid flap

22264908_689114241295076_1764003733_nFlorin Cristian Delureanu

DVM, MRCVS

 

 

ABSTRACT

 

In plastic and reconstructive surgery flaps have an important place not only for the aesthetic results obtained but also because they can be used to cover an area without producing tension. The flap mechanism mainly consists of moving a piece of skin from the donor site and moving it to the recipient site (primary defect). The rhomboid flap have a big versatility because can be done anywhere on the surface of the body. Filling small and large wounds with tissue similar in texture, colour and thickness is the ideal objective of the flap. This article describes the surgical approach of two cases, one with an abscess and the other with a benign tumor located at the cutaneous level, both of which are approached by the use of the rhombic flap.

 

 

Introduction

A skin flap represent a partial detachment of a piece of skin and the adjacent subcutaneous tissue with its vascular supply intact. All skin flaps have a pivot point or base. Survival of the skin flap is made by blood circulation through its base during the procedure. From this point of view, it is important that the base of the flap be large enough to prevent necrosis.

Local flaps are based on two types of vascularization: the subdermal plexus or a vein and an artery (figure A; right side- island flap).

Classification of skin flaps is based on blood supply, transfer mode (primary motion), location, composition and configuration (most described in human medicine). Depending on the transfer method, local flaps are classified as follows: -advancement flaps: those who advance forward; -rotational flaps: describe a rotation motion (curvilinear configuration) to the primary defect.

Classification of skin flaps is based on blood supply, transfer mode (primary motion), location, composition and configuration (most described in human medicine).
Depending on the transfer method, local flaps are classified as follows:
-advancement flaps: those who advance forward;
-rotational flaps: describe a rotation motion (curvilinear configuration) to the primary defect.

 

 

The rhombic flap was invented by a human maxilofacila surgeon called Limberg Alexander Aleksandrovich in 1946. By name, the flap has rhomboid shape with two angles of 120 degrees and two angles of 60 degrees. Depending on the primary defect / lesion pattern which require coverage, the flap angles may change. It is often used in reconstructive surgery of the face in humans: eyelid, floor of nose, alar rim and chin defects with good cosmetic results. This skin flap also called Limberg flap is a transposition flap – the elevated skin will have both advancement and rotation movement when is applied over the primary defect.

 

How to design the rhombic flap

 

Whether it is a wound or a tumor, around a defect is drawn a diamond with angles of 120 degrees and 60 degrees as mentioned above. First, the short diagonal that joins the 120 degree angles (BD) must be measured and then extended in the desired direction. The extension (DE) to the outside must have the same length with the short diagonal (BD) and with the sides of the diamond. The next step is to extend another line wich is equal and parallel with the closest side of the diamond (EF). Finally the skin flap is obtained (ADEF).

Figure 1. The sketch of the rhomboid flap.The primary motion of the flap is the motion placed on it to close the primary defect; the secondary motion is the motion placed on the tissue surrounding the primary defect by the flap.

Figure 1. The sketch of the rhomboid flap.The primary motion of the flap is the motion placed on it to close the primary defect; the secondary motion is the motion placed on the tissue surrounding the primary defect by the flap.

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Figure 2. Transferring the flap to the primary defect. The direction of rotation of the flap is indicated by the purple arrow. After rotation in point A dog ear will occur (yellow elipse). During the rotation the flap describes a 120 degree movement. The higher the angle, the dog ears will be more prominent. The secondary defect will be closed following the transfer of point F to the initial position of the D point

 

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Figure 3. The final shape of the rhomboid flap. Point D reached point B, point E reached point C and point F reached point D. A is the only point which maintain the initial position.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The surgical defect created can be covered with the rhomboid flap from 4 sides (Picture 4).

Figure 4. The variants of flap usage. The best choice is to select the side with the most laxity because in this way the adjacent anatomical structures will not be disturbed. The flap has a mathematical formula in which all sides are made to be equal.

Figure 4. The variants of flap usage. The best choice is to select the side with the most laxity because in this way the adjacent anatomical structures will not be disturbed. The flap has a mathematical formula in which all sides are made to be equal.

 

 

 

 

 

 

 

 

 

Case 1

                  

History

 

Daisy, a six years old female cat of the Maine Coon breed presented with a sebaceous cyst, 2 cm diameter, round shape, locatad on the dorsal lombo-sacral area. The owner says that the cat have a decreased appetite. The pacient was rescued and adopted and was vaccinated just when was young. The cat lives with another 3 cats in the same house, all with the same vaccination status.

General Examination

At clinical examination, apart from the wound, dehydration 6%  and a small buccal ulcer behind the last molar on the right mandible were detected. The patient was initially treated with clindamycin and meloxicam for 7 days but no improvement observed. The cyst was infected, with bad smell, partially covered with agglutinated hair and inside soft tissue necrosis was present.

Figure 5. The initial appearance of the wound, 24 hours prior to surgery.

Figure 5. The initial appearance of the wound, 24 hours prior
to surgery.

After inspection, dead space was noticed under the skin around the wound. One day before the surgery we noticed fever (40,1°C) and dehydration 8%. CBC, serum biochemistry and FeLV/FIV test were performed. Neutropenia (0.15 x 109/L, normal range: 1.48 – 10.29) and hyperglobulinemia (57g/L, normal range: 28-51) and decreased ALKP (<10 U/L, normal range: 14-111). IDEXX Snap FeLV/FIV was negative. The cat was hospitalized 24 hours for fluid therapy and i.v. antibiotic (Cefuroxime-Zinacef). After stabilizing the patient the intervention was performed.

 

 

 

Descripting the surgical steps

 

The area was clipped and clorhexidine was used for local antisepsis. Sterile marker was used to draw the rhombic shape around the primary defect.

Figure 6. Appearance of the wound after cleaning. Necrotic tissue and pus was present in the middle of the wound;

Figure 6. Appearance of the wound after cleaning. Necrotic tissue and pus was present in the middle of the wound;

 

 

 

 

 

 

 

 

 

 

Due to the presence of dead spaces   under the skin, the round shape of the primary defect was converted to a rhomboid and the rhombic lines were positioned about 1 cm from the wound margin. In this way the tissue that was not healthy was removed. Identifying the area with the highest laxity is the next step. This was done by pinching the skin around the primary defect. After choosing the appropriate area, the flap that must be transferred was drawn.

The first side of the flap (the extended line outward of the defect) and the second side of the flap (line that is the same length as the first, to the adjacent side of the defect and makes an angle of 60 degrees at the flap apex) were cut and the flap was elevated after undermining

Figure 8. The rhomboid flap is designed. The blue arrow describe the direction in which the flap will be rotated.

Figure 8. The rhomboid flap is designed. The blue arrow describe the direction in which the flap will be rotated.

Figure 9. The primary lesion was excised and the underlying tissues are undermined.

Figure 9. The primary lesion was excised and the underlying tissues are undermined.

Figure 7. The picture illustrates the extension to outside of the short diagonal of the diamond

Figure 7. The picture illustrates the extension to outside of the
short diagonal of the diamond

 

 

 

 

 

 

 

 

 

Skin cuts were made perpendicular with No.10 scalpel blade and and the flap was mobilized with help of Metzenbaum scissors. The surrounding tissues are widely undermined to avoid any tension and the flap is rotated into the recipient site. After rotation, the flap is locked in place by fixing its corners by subcutaneous sutures. The donor site is closed as the flap moves over into the new location. Finally the skin was closed with 4/0 PDX in simple interrupted suture pattern.

Figure 10. Elevation of the flap. Stay suture are used to decrease the risk of flap tip necrosis. This inconvenience usually occurs due to faulty handling during the transfer procedure (usually crushing between fingers).

Figure 10. Elevation of the flap. Stay suture are used to decrease the risk of flap tip necrosis. This inconvenience usually occurs due to faulty handling during the transfer procedure (usually crushing between fingers).

Figure 11. The flap is rotated in the desired place and the first stich is applied on the maximum point of tension. The second and the third stich are placed on the other two corners of the flap (yellow dots).

Figure 11. The flap is rotated in the desired place and the first stich is applied on the maximum point of tension. The second and the third stich are placed on the other two corners of the flap (yellow dots).

Figure 12. Immediate postoperative appearance of the flap. Simple interrupted sutures are used for skin closure

Figure 12. Immediate postoperative appearance of the flap. Simple interrupted sutures are used for skin closure

 

 

 

 

 

 

 

 

 

 

 

 

A common unaesthetic appearance after transposed flap was the “dog ears” at the pivot point. In this situation, dog ear was corrected by excising one triangle along one side of its base.

Figure 13. The aspect of the flap at 48 hours after surgery

Figure 13. The aspect of the flap at 48 hours after surgery

Figure14. The aspect of the flap in the eighth day after surgery. The direction of the hair grow is change because of the rotation.

Figure14. The aspect of the flap in the eighth day after
surgery. The direction of the hair grow is change because of the rotation.

 Figure 15. Seventeen days post surgery. The stiches were removed after ten days. No complicatios were encountered. Is very difficult to distinguish the change of the hair growth direction


Figure 15. Seventeen days post surgery. The stiches were removed after ten days. No complicatios were encountered. Is very difficult to distinguish the change of the hair growth direction

 

 

 

 

 

 

 

 

 

 

 

 

Case 2

 

History

 

Coco, a mix breed male dog, three years old was brought to the clinic because a lump was identified on the skin. Owner reports that the mass was seen some days ago and does not believe it has increased significantly. Also says it makes itching and that the dog often scratch there and bleeds. This was the owner’s only concern.

 

General examination

 

No abnormalities were detected after clinical examination except the lump. With a cauliflower aspect, the lump had a small base of implantation and 1,2/1,4 cm in diameter. After palpation of the skin around, no pain or local temperature were identified. FNA and blood tests were recommended before surgery and histopathological examination after. The owner declined for financial reasons the FNA and blood test but accepted the histopathological examination. In this situation, a two centimeter safety margin clearance was decided.

 

Surgical approach

 

            Surgical steps along with flap drawing were described above except for asepsis. In this case  iodine povidone was used.

Figure 16. The mass is identified on the left scapular area after clipping; local asepsis was made.

Figure 16. The mass is identified on the left scapular area after clipping; local asepsis was made.

Figure 17. The diamond is designed around the mass; The mid-third skin of the cranial chest was chosen for transfer

Figure 17. The diamond is designed around the mass; The mid-third skin of the cranial chest was chosen for transfer

Figure 18. Sectioning on contour lines.Control of bleeding is done by hemostat forceps

Figure 18. Sectioning on contour lines.Control of bleeding is done by hemostat forceps

 

 

 

 

 

 

 

 

 

Figure 19. The final aspect of the flap; the skin is closed with 3/0 PGA in simple interrupted pattern.

Figure 19. The final aspect of the flap; the skin is closed with 3/0 PGA in simple interrupted pattern.

 

 

 

 

 

 

 

 

Histopathological result

               Description: Cutaneous/ subcutaneous mass composed of  chistic masses well delimited by a cheratinized multilayered epithelium with epithelial cells with squamous differentiation oxifiles, mixed with abundant, granular and amorphous keratin; multifocal with the tendency of confluence, inflammatory infiltration with neutrophils, macrophages and epithelial cells is observed. Malignant neoplastic cells are not present in the examined sections.

 

               Interpretation: Benign follicular tumor – pilomatrixoma with associated granulomatous inflammatory process.

 

Figure 20. Wiev of the flap 4 days after surgery; small necrosis was noticed on the tip of the flap (green arrow).

Figure 20. Wiev of the flap 4 days after surgery; small necrosis was noticed on the tip of the flap (green arrow).

Figure 21. The aspect of the flap 23 days after surgery; the hair was cut to facilitate flap view. Small crusts are present on the tip of the flap and on the pivot point (blue arrows).Notice the cosmetic scar lines (yellow arrows).

Figure 21. The aspect of the flap 23 days after surgery; the hair was cut to facilitate flap view. Small crusts are present on the tip of the flap and on the pivot point (blue arrows).Notice the cosmetic scar lines (yellow arrows).

 

 

 

 

 

 

 

 

 

 

Common complication of the flap

 

  • Hematoma;
  • Bleeding;
  • Flap necrosis;
  • Secondary infection.

 

Short indications for proper surgical procedure

 

  • The sides of the rhomboid must have the same length;
  • The sides of the flap must must have the same length;
  • Depending on the shape of the primary lesion, the diamond angles may vary in degrees;
  • Any defect in rhombic shape shows 4 variants in which it can be covered.
  • The lowest laxity region should be chosen and as far as possible so as not to alter anatomical plans.

 

 

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

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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).

     

INGHINO-SCROTAL HERNIA/INTESTINAL OCCLUSION, ACUTE ABDOMEN

timisoara

Dr Fodor Lucian

Lazar Laura¹,    Fodor Lucian²,

¹ʼ²ʼDVM, Veterinary clinic, Happy  Pet Timisoara, Romania

 

Key words:   inguinal hernia, intestinal occlusion, acute abdomen, enterectomy

 

 

Introduction:

An inguinal hernia is a condition in which the abdominal contents protrude through the inguinal canal or inguinal ring, an opening which occurs in the muscle wall in the groin area.

In dogs, inguinal hernias may be acquired (not present at birth but developing later in life) or congenital (present at birth). Factors which predispose a dog to develop an inguinal hernia include trauma, obesity, and pregnancy.

Most inguinal hernias are uncomplicated and cause no symptoms other than a swelling in the groin area. However, if contents from the abdominal cavity (such as the bladder, a loop of intestines or the uterus) pass through the opening and become entrapped there, the situation can become life-threatening.(2)1 2 3 4 5 6

 

 

 

 

 

 

 

 

 

Inguinal hernia may evolve to scrotal hernia when herniated viscera pass down the inguinal canal.The internal, or deep, inguinal ring remains patent in intact male animals.(1)

Inguinal hernias can usually be diagnosed by finding the swelling caused by the hernia on a physical examination. However, sometimes contrast radiographs (X-rays) or an abdominal ultrasound are needed to determine which abdominal contents, if any, are entrapped.(2)

 

Case  report:

 

A six year old intact male jack russel terrier,fully vaccinated and dewormed  suffering an episod of  letarghia, voma  and apatia for two days.He followed an symptomathic treatment with painkillers and antispastics from his current veterinarian.

The owner became worried because his symptoms got worse, so he was admitted in our clinic as an emergency after the program hours.

 

Clinical evaluation

his symtomps included:

-severe peritoneal response

-apatia, lethargya

-medium dehydration

-the left testicle was increased in volume

An abdominal ultrasound was performed, was noticed a decreased intestinal motility, with gas presence.

Diagnosis:

inghino-scrotal hernia/intestinal occlusion

 

Treatment

The pacient was initially rehydrated, after stabilization of vital functions was put under general anesthesia and intubated.Surgical intervention was performed, starting initially with the opening of the affected testicle who was enlarged, coloured modified  and continuing with medial celiotomy(Fig.1).The terminal part of the small intestine was herniated inside of the spermatic cord (Fig.2).The affected part was aproximatly 10 cm long, with modified tissue and with the rupture of the intestine wall. (Fig 2,3,4) .Following this an enterectomy was performed (fig. 5) with termino-terminal enteroanastomosis.( Fig. 6,).The pacient was also castrated.

 

     After surgery

The patient condition improved very fast within hours he drank water and ate food.He was also very responsive and playful from the first day.He followed five days of treatment with Metronidazol (20 mg/kg/2×1/day).

 

Conclusion:

The inghino-scrotal hernia is a medical emergency and the intervention must be in the shortest time due to life threatening.

 

 

 

Biblioghaphy

 

  1. Jubb, Kennedy and Palmer’s, Pathology of domestic animals, E Book, vol. II, pg.80

Full thickness mesh graft in a cat with degloving wound – case presentation

22264908_689114241295076_1764003733_n

Delureanu FlorinCristian

Dr Delureanu FlorinCristian

Veterinary Center Otopeni

Bucharest, Romania

 

 

Introduction

An ample loss of skin with underlying tissue and exposure of deep components (eg. tendons, ligaments, bones) define a degloving injury. This kind of wounds are most frequent seen on the distal limbs, medial tarsus/ metatarsus. The main cause of deglowing wounds is car accident, special when the animal is dragged or pushed by a moving car. In all of the cases bacteria and debris are present in the wound.

Free grafts are described as a piece of skin detached from an area of the body and placed over the wound. There are two tipes of free grafts when we talk about graft thickness: full thickness (epidermis and entire dermis); partial/split thickness (epidermis and a variable portion of dermis). Skin grafts are using when exist a defect that cannot be closed by skin flaps or direct apposition. Two factors influence skin graft survival: revascularization and absorbtion of the tissue fluid.

Case report

A 4 years old female shorthair cat, weighting 3,25kg was presented to our clinic. Before that, the owner was at another clinic for consult and he was disappointed because they recommended euthanasia or amputation of the limb. Besides, the first vet treated the cat with Amoxi+Clavulanic Acid and Nekro Veyxym. The owner said that she went missing for about 10 days.

Clinical examination

IMG_6649

Picture 1. Dorsal aspect of the metatarsal wound Deep tissue is affected; low to moderate discharge is present.

IMG_6644

Picture 2. Ventral aspect of the wound; Note the big swelling and the holes at the base of the fingers (red arrows)

IMG_6645

Picture 3. Deep wound with circular aspect, approximate 1,5cm diameter located near saphenous vein

After a thorough clinical exam we found that all was normal excepting the degloving injury. The back right leg was affected. There was a massive inflammation with infection and a lot of debris on the dorsal surface of metatarsal area and ventral, above metatarsal pad. On the dorsal surface of metatarsal area (Picture 1). Besides, also in the ventral area, another wond proximal to the metatarsal pad and 3 deep holes was identified at the base of second, third and fourth finger (Picture 2). It could be distinguished the chronic aspect. A third lesion was registrated on the same leg, in the medial aspect of the thigh. This wound was deep with a circular shape (Picture 3). We estimated that the lesion occurred about two weeks ago. We register pain and high local temperature after palpation. The cat was stable, normothermic, with normal color on mucous membrane, CRT 3seconds and normal superficial lymph nodes.

 

 

 

 

 

 

 

Radiograph of the affected back limb

pirpi

Picture 4a

pirpi1

Picture 4b

Two x-ray views was made to eliminate bone changes or foreign bodies (Picture 4a, Picture 4b).

Picture 4a, 4b- Specialist describe: Suspected slight thickening of phalanges cortical 1 fingers 3-4 and gently bending them. Soft tissue swelling of the tibio-tarso-metatarsian region.

 

 

 

 

 

 

 

Approach 

DSC08924

Picture 5a

DSC08931

Picture 5b

After evaluation, the initial recommendation include a good wound management under anesthesia. Before surgical debridment (Picture 5a, 5b), culture was done.

Picture 5a and Picture 5b – Dorsal and ventral aspect of the lesions after surgical debridment

 

Next, wound lavage was initiated with one bag of 500 ml of worm saline (the most easy way to deliver fluids on the wound is to connect the saline bag with a administration set to the syringe and needle with a 3-way stop cock a large amount of liquid is needed to be effective).

DSC08936

Picture 6. Wound closure by simple interrupted suture.

Finally, this first stage ends with a wet to dry bandage. A primary wound closure was performed for the lesion placed on the medial aspect of the thigh (Picture 6), after intensive cleaning, removal of foreign bodies and dead skin .

Empirically the cat receive Cefquinome until the result arrive and for pain management we administered Tramadol 3mg/kg and Meloxicam 0,1-0,2mg/kg. The cat recover well after anesthesia.

 

 

 

Culture result

One day before performing surgery, we recived the culture result. Streptococcus canis (++++) was identified and was sensible to many antibiotics. Amoxicilin+Clavulanic Acid (Synulox) was initiate for general therapy and chloramphenicol ointment (Opticlor-Pasteur) for local therapy.

Next, a full thickness mesh graft was used on the dorsal aspect of the limb due to the length and depth of the wound and the other wound was left for healing by second intention, both being protected by bandages. In the next 10 day the limb wounds was treated in the same manner. Removal of bacteria, granulation tissue formation and the beginning of epithelization were supported by next bandages as follows: ·

Day 1 – wet-to-dry bandage was used after surgical debridment. (this kind of bandages adhere to the wound and remove the little layer of dead tissue when we take off). Soaked in warm saline 1-2 minutes before removing, they were changed after 24hours one to the other. Cotton gauze was the primary contact-layer of the bandage.

  • Day 2 and day 3
    24.06.2017

    Picture 7a Fresh Sorbalgon is applied on both wounds. This dressing can absorb 20-30 times its weight in fluid, stimulate fibroblast and macrophage activity.

    DSC08981

    Picture 7b Calcium alginate dressing must be changed when the fibres transforms in gel.

– moisture retentive dressing (MDR) – calcium alginate (Sorbalgon-Hartmann) was the primary contact-layer. It is good to use when it exist high exudate like in our patient (Picture 7a, 7b).

 

 

 

  • Day 4,6 and day 9
IMG_6726

Picture 8. Hydrocolloid is indicated because he stimulate granulation and epitelisation and have a good autolytic debridment

– moisture retentive dressing (MDR) – hydrocolloid (Hydrocoll-Hartmann) was the primary contact-layer because the discharge decreased (Picture 8).

 

 

 

 

 

Describing surgical procedure:

IMG_6747

Picture 9. The wound is refreshed by removing the new epithelium formed around the whole wound

Preoperative surgical site preparation: The cat was placed in left lateral recumbency, with the wound exposed. The limb was clipped entirely and povidone iodine and alcohol was used for aseptic surgery. Sterile warm saline 0.9% was use for wound lavage. Meanwhile a colleague prepare the donor site in the same manner- lower cranio-lateral thorax (right side). Almost 1mm of epithelium that has started to grow from the wound edges over the granulation tissue was removed using a thumb forceps and a no. 10 scalpel blade (Picture 9). A perpendicular incision was made right at the edge of haired skin with epithelium. The wound was incised all around and after that the epithelium was removed by advancing the scalpel blade under the epithelium around

the wound. Then, undermining was performed around the wound edges. A fragment of sterile surgical drape was used over the wound to get the exact shape. The drape “pattern” was placed to the donor area.

 

 

To maintain the wound moist, i placed over it a cotton gauze moistened in warm sterile saline 0.9% while the graft is transferred.

IMG_6755

Picture 10. The donor site-removing the skin; black arrow show the direction of the hair groth.

IMG_6769

Picture 11a. Skin from dorsal thorax is advanced

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Picture 11b. Simple interrupted suture is used for skin closure.

The direction of hair groth was marked with a black arrow above the donor site so that the direction of the hair groth on the graft will be the same as the hair groth direction on the skin surrounding the wound. After that, the margins of the drape “pattern” was traced on the skin. The skin of the donor bed was incised with No.10 scalpel balde and removed using thumb forceps and Metzenbaum scissors (Picture 10). The defect left after removing the graft was primary closed by undermining and advancing the skin edges with walking sutures using 3-0 monofilament absorbable suture material and finally the skin was sutured in a simple interrupted suture manner using 2-0 monofilament absorbable suture (Picture 11a, 11b).

 

 

 

 

 

 

 

 

 

 

Preparing the graft

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Picture 12. Final aspect of the skin graft after removal

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Picture 13. The skin is stretched on the receiving bed so the incisions made in it expand.

The dermal side of the graft was placed on a polystyrene board with a thickness of 10cm covered with a sterile drape and after that we fixed and stretched with 21G needles. The subcutaneous tissue was removed from the graft. Next, made parallel incisions was made in the graft, 0.5-0.7cm long and apart (Picture 12). At the end, the graft was placed on the granulation bed and sutured with 4-0 monofilament nonabsorbable suture in a simple interrupted suture manner. Additional tacking suture was placed to ensure the expansion of the mesh incision and allow the fluid drainage (Picture 13).

 

 

Choosing the right bandage after grafting and aftercare

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Picture 14. Grassolind is ointment free of medication, broad mesh, air permeable and exudate; impregnated with neutral ointment. Ointment contain petroleum jelly, fatty acid esters, carbonate and bicarbonate diglycerol, synthetic wax.

It is important to use a nonadherent primary dressing. My initial choise was Grassolind (Hartmann), is sufficiently porous to allow easy passage of exudate from the wound surface, preventing maceration of surrounding tissue (Picture 14). The ventral metatarsal wound maintain hydrocolloid dressing (Hydrocoll-Hartmann) as primary layer. After that, a thin layer of chloramphenicol oinment (Opticlor-Pasteur) was used all around both wounds and over the graft.

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Picture 15. Note that the “half clamshell” is extended with approximately 1cm toward fingers (red arrow) so the leg does not touch the ground

Over the first dressings was applied 5cmx5cm compress (Medicomp-Hartmann) and a roll gauze was the second layer. After a few laps of gauze stirrups was placed to secure the bandage in place. Extemporaneous half “clamshell” splint (Picture 15) was made from plastic material wich was curved in such a way that the limb was fixed in semi flexion. The splint is a little bit longer than the extremity of the pelvic limb (“toe-dancing” position), thus provide a maximum relief pressure. In the proximal area, under the splint, I put cotton to prevent pressure injuries on the caudal aspect of the thigh. Applied from proximal to distal and with moderate tension, elastic warp was the final protective layer of the bandage and it was secured at the proximal end with tape.

 

 

 

 

Changing bandages

The bandage was changed in day 1, 3, 5, 7 and 10 post op. In day 10 the suture material was removed from the graft and from the donor site. From day 17 to day 29 hydrogel (Hydrosorb-Hartmann) was used as primary bandage layer and the bandage was changed from 4 to 4 days. In day 29 no discharge was present in the bandage; the wound was completely healed and 0,2-0,4 mm of hair was present in the center of the graft.

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Picture 16. Delayed healing on day 45 – epitelization stopped at this level.

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Picture 17b. Honey improve wound nutrition, promotes the granulation tissue and epithelization, reduce inflammation and edema. Also it has a wide antibacterial effect.

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Picture 17a. DTL laser type is alaser light emitting diode in the red field (wavelength 650 nm) and infrared (wavelength 808 nm) of the light spectrum with next clinical effect: anesthetic effect; decreases edema and inflammation; activates microcirculation; stimulates wound healing; improves tissue trophicity; reflexogenic effect.

A delayed healing occurred at the wound in the ventral region (Picture 16). From day 29 to day 59 epithelization has advanced very hard and granulation tissue has captured an appearance of ulcer (in this time the wound was asepseptic prepared and hydrocolloid and hydrogel was used as primary layer bandage and without the splint). In day 59 the wound was refreshed on the surface with a scalpel blade and laser therapy (Picture 17a) and medical Manuka honey (Picture 17b) was used daily for 14 days. After that, a complete healing was reached.

 

 

 

 

 

 

 

Illustrating wounds evolution after surgery

 

Day 1

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Day 11

 

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Day 28

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Day 35

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Day 49

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Day 11 after honey and laser therapy

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 Day 16 after honey and laser therapy

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Comparing day 1 and after 3 Months

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FELINE LYMPHOPLASMACYTIC GINGIVITIS STOMATITIS COMPLEX

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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

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photo 1

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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

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-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

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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!

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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.

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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.

 

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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.

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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!