Archives

Lewis Hamilton’s Race to Recovery

“Lewis Hamilton” a 5 month male Maine Coon cat was referred to Northwest Veterinary Specialists from his primary care practice for further investigations into regurgitating his food after eating.

Lewis came to see one of our Soft Tissue Surgery Specialists Rachel Burrow. On his examination Lewis was very well in himself, in good body condition and very active, as to be expected with his young age.

His referring veterinary practice had taken some general radiographs (x-rays) of his chest and also performed a barium swallow radiographic study where a contrast material is given orally highlighting the oesophagus.

This procedure demonstrated Lewis had a dilation in his oesophagus in front of his heart which is commonly known as a megaoesophagus.

The suspected diagnosis for Lewis was a Persistent Right Aortic Arch but this needed to be confirmed via a Computed Tomography (CT) Scan first.

Lewis was admitted to the hospital the same day and an intravenous cannula was placed and blood samples were taken to check Lewis’s liver and kidney function prior to his anaesthetic procedure.

To perform a CT scan of Lewis’s chest cavity, a full general anaesthetic was required and this was not without risks. Due to Lewis’s history of regurgitating, he had an increased risk that he may regurgitate food material from his oesophagus and aspirate some of this material into his lungs which could result in pneumonia. He was also at risk of hypoglycaemia (low blood sugar) due to his young age. Both of these complications can potentially be fatal if unnoticed.

Luckily here at Northwest Veterinary Specialists we have a team of specialist Veterinary Anaesthetists that work closely with our Registered Veterinary Nurses (RVN) to provide “gold standard” care to all of our patients.

The CT images were analysed and confirmed the suspected diagnosis of Persistent Right Aortic 4th Arch, and after a discussion between Lewis’s owner and Rachel Burrow, it was decided that Lewis would be taken to theatre the following day for open chest surgery (thoracotomy) to correct the problem.

A Persistent Right Aortic Arch is a developmental abnormality that occurs due to abnormal blood vessel development  in the foetus. This results in a blood vessel  encircling the oesophagus (and sometimes the trachea too) near the heart and compresses these structures resulting in difficulty of passage of  food through the obstruction into the stomach. In some cases breathing difficulties can be seen but this was luckily not seen in Lewis’s case.

The following morning Lewis was taken upstairs to our theatre suites and placed in a warm ward area while our team of surgical nurses and veterinary anaesthetists prepared for his procedure and general anaesthetic.

A thoracotomy (opening into the chest via surgery) is a painful procedure so a pain plan was discussed and implemented to provide sufficient pain control before, during and after the surgery ensuring Lewis remained as comfortable as possible. Lewis received a schedule 2 opioid (one of the strongest available for small animals in the UK) along with a sedative. He also received a local anaesthetic agent that was infiltrated around the surgery site before Rachel Burrow began his surgery. Lewis was placed on a mechanical ventilator to breathe for him during the operation and was carefully monitored throughout.

Rachel Burrow opened the chest wall and began the hour long procedure of dissecting away the left ligament arteriosum (the abnormal vessel) from the oesophagus. A tube was then placed into the oesophagus and slowly passed down to ensure there was sufficient dilation for food to pass through with ease.

Once the surgery was completed and Lewis’s chest was closed, a drain was placed into the chest cavity near the surgical site for drainage of any air or fluid build-up and to instil further pain relief agents to ensure a comfortable recovery for Lewis. He was then transferred into our recovery ward for further monitoring of his breathing and blood glucose along with regular assessments of his pain levels.

Lewis was exceptionally comfortable after his operation and was back to playing with one of his toys just 3 hours later! The drain in his chest was removed and he was discharged from the hospital 2 days later with guidelines for Lewis to be fed small amounts of soft food often.

Lewis returned to us 8 weeks later looking exceptionally well. He had grown in height and weight and is no longer having any problems with eating or with regurgitation. Rachel carried out a fluoroscopy examination to determine if he had any remaining problems with his oesophagus. This procedure involves feeding Lewis a barium (contrast) coated meal whilst at the same time, taking a live images similar to an X-ray using a special piece of highly technical equipment called fluoroscopy. The images were then assessed by Rachel, which highlighted the food moving through his oesophagus as expected. Lewis had this procedure performed whilst he was conscious and he was able to go home a couple of hours later and has now been completely discharged from the hospital. This is great news for Lewis and his family and a successful and interesting case for us all here at Northwest Veterinary Specialists!

This case report was written by Michelle Moran RVN.

 

Noodle – Something to get off my chest!

Noodle, a 5 year old Labrador Retriever was referred to Northwest Veterinary Specialists (NWVS) from his primary vet due to a persistent cough, that did not resolve even following a course of antibiotic treatment. Although Noodle was still a typically happy Labrador who always wanted to play, the cough began to take its toll and Noodle was beginning to feel its tiring effects. Noodle came to NWS for a consultation with one of our internal medicine clinicians, Karen Crawford. On physical exam there was noticeable effort in how Noodle was breathing and when Karen listened to his lungs, there were notable abnormal sounds. Noodles cough was described as harsh sounding, deep within his lungs, which worsened with exercise.

Following consultation, it was unquestionable that Noodle required a Computerised Tomography (CT) scan. A cannula was placed for easy drug administration and blood samples were taken to check his liver and kidney function. A CT scanner works in a similar way to an X-ray machine, but coupled with a computer, it rotates around the patient to create cross sectional images of the selected part of the body, in this case, Noodle’s chest. The computer then reconstructs the images to create a 3D image, which we hoped would help diagnose why Noodle had a cough. In order to perform the scan, Noodle had to have a general anaesthetic (GA). In his case the risks were higher than any elective procedure due to his impaired breathing ability. Every pet that undergoes GA at NWS is monitored closely by one of our Registered Veterinary Nurses (RVN) from the start, right through to the recovery period and supervised by our specialist anaesthetists. During GAs our RVNs remain in direct contact with the anaesthetist overseeing the case to ensure that the best possible care is provided. The standard monitoring used during GA is capnography, pulse oximetry, blood pressure monitoring, ECG and temperature. In Noodle’s case particular focus was given to the first two monitoring aids as they show how the lungs are ventilating and getting oxygen into the blood stream, both of which were within the normal ranges.

The CT images were analysed by one of our Radiologists Annette Kerins and after close examination she discovered a large foreign body (FB) in one of the right lung lobes, with a surrounding area of pneumonia. We were positive that this was the cause of Noodles cough, so further investigation and treatment was essential. A common way of retrieving FB’s within the airway is with a bronchoscope (a camera into the lungs via the mouth) but in Noodle’s case this did not seem feasible because the FB was too deep and seemed to be wedged within the bronchus. Therefore we concluded that it could not be reached, and even if we could, we would most likely damage the bronchial wall during our attempts.

wheat-head-ct-dor-crop-words

 wheat-head-ct-crop-words

In such cases the medical and soft tissue teams join together to work out the best approach for the patient. Following much debate and due to the location of the FB, it was agreed that the most likely way of retrieving the FB was with surgery. Further discussions outlining the positives and negatives took place and both teams decided the best approach would be to perform a lung lobectomy (removal of the entire lung lobe which housed the FB).

Noodle was transported to the surgical preparation room, an area connecting to the surgical suites where patients are clipped and scrubbed before surgery. A lung lobectomy can be a rather painful surgery, so pain relief was a priority for Noodle at this stage. To begin with, Noodle received a schedule 2 opioid, the strongest class of pain relief available for our patients. Once his fur was clipped and skin scrubbed, Noodle then received two types of local anaesthetic techniques from our specialist anaesthetist, Elizabeth Leece. This reduces and potentially blocks pain sensation, not only during surgery but also during the first couple of hours following surgery.

Noodle went to surgery with soft tissue specialist Rachel Burrow. During the surgery, Rachel opened the chest cavity (thoracotomy), and Noodle was place on mechanical ventilation to breathe for him as the surrounding pressure that helps him breathe was lost. After 2 hours of intense surgery the lung lobe was removed successfully. A chest drain was placed to avoid any air or fluid accumulating in the chest which may have impaired Noodle’s ability to breathe following surgery. The chest was sutured and once surgery was complete Noodle was transported to the recovery area to wake up in a warm, quiet environment. Once Noodle was recovered, our attention turned to the lung lobe. Careful dissection reveal a large ear of wheat, measuring 5.6CM, which Noodle must have inhaled when running through a field. This would have gradually tracked deeper in the lung, pretty amazing.

fullsizerender

img_8581-crop

Whilst hospitalised overnight, hourly observations took place focusing on Noodle’s respiratory rate and effort. Noodle remained hospitalised for 5 days under the care of our Inpatient Care Team who frequently monitored his respiratory function. Following plenty of TLC and medication, Noodle was discharged, happy (as always) and cough free.

Following his check-up appointments, Noodle has continued to improve and is now back to full health.

This case report was written by Ana Mota an Intern at NWS.

Sparks – Acupuncture puts the spark back into Sparks

??????????? ??????????? ??????????? ???????????????????????????????

Sparks is an old boy but he still wants to enjoy life to the full.  For several years he has suffered with inflammatory bowel disease (IBD) which is a major cause of sickness and diarrhoea in dogs.

It is caused by the body’s own immune system attacking the bowel.  Sparks’ IBD responds well to drugs that suppress his immune system in a controlled way but his medication has some risk of side effects and this is managed carefully by one of our specialists in Internal Medicine, giving Sparks (and his owners) relief from the misery of chronic bowel disease.  With his bowel disease well controlled for many years, Sparks has enjoyed an active life but now suffers with limping as a result of osteoarthritis which particularly affects his hips. The pain from his arthritis can be partly controlled with non steroidal anti-inflammatory pain killers but in combination with his IBD medication these can make his IBD worse, creating something of a dilemma.

Osteoarthritis is a major cause of pain and functional limitation in both people and our pets.  There are few treatments that combine good safety with good efficacy and this can be particularly challenging in individuals, like Sparks, with complex disorders and conflicting needs in their medication.  At Northwest Surgeons our specialists in Internal Medicine work closely with specialist colleagues in Anaesthesia, Pain Management and Surgery to provide optimal pain management strategies for all of our patients in the same way that a multi-disciplinary team at a specialist human hospital would work. We commonly deal with cases like Sparks which are more complex than most and which take time to find the best solution for both owner and pet.

Amongst other treatments, Sparks was considered as a candidate for acupuncture.  This is an interesting area because although there is good scientific evidence in people for the effects of acupuncture in osteoarthritis, there is little scientific evidence on the effect in dogs.  Nevertheless, acupuncture has the advantage of a favourable safety profile when compared to some other treatments in osteoarthritis, particularly for an older character like Sparks with other medical conditions to take into account.  The evidence in people with osteoarthritis does indicate a small positive effect of acupuncture with a favourable safety profile, making this an ideal treatment to consider when more traditional osteoarthritis treatments are problematic.  Matt Gurney offers electro-acupuncture as a component of pain management strategies in suitably selected patients. Electro acupuncture involves passing a small current between two needles and is considered the gold standard in acupuncture, giving a much greater stimulation and thus a greater pain relieving effect. Usually dogs will receive an initial course of one treatment per week for four sessions and then ongoing sessions as necessary.

Sparks responded very well to his initial sessions and to his owner’s horror even started trying to chase sheep, something which he would previously have been beyond him!

Sparks now receives electro acupuncture at two week intervals, which keeps him comfortable and his owners are now very careful to make sure he is on a lead whenever he is near any livestock! On occasions where he has missed a session his owners and day care centre really notice the difference in his abilities.

References:
Kwon et al (2006) Acupuncture for peripheral joint osteoarthritis:  A systematic review and meta-analysis.  Rheumatology (2006) 45 1331-1337

Manheimer et al (2010) Acupuncture for peripheral joint osteoarthritis:  Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD001977. DOI: 10.1002/14651858.CD001977.pub2

A tale of two puppies with a heart murmur

pda-delta-2 ?????????? pda-surgery-post pda-surgery-pre fluoroscopy-pda amplatzer-deployment

Delta, an American cocker spaniel puppy, and Macey, a Labradoodle puppy, were referred to Northwest Surgeons in the same week because a heart murmur had been identified by each of their veterinary surgeons at their initial vaccinations even though they were showing no signs of heart disease and, being typical bouncy puppies, they seemed completely normal to their proud new owners. 

The murmurs were similar, with a characteristic continuous, so-called “machinery” sound.    The “machinery” murmur is very suggestive of a heart defect present from birth called a patent ductus arteriosus (pronounced duck-tuss  art-ear-i-oh-suss), but which is usually abbreviated to “PDA”.  Such a diagnosis is obviously a shock to the owner of a bright young puppy, but happily a PDA is one of the conditions that can be completely cured by surgery to close off the abnormal blood vessel.  The earlier it is diagnosed and treated, the better the long term outcome for the patient.  This is one of the reasons why a health check by your veterinary surgeon at the time of vaccination is so important to detect these things so that specialist investigation and treatment can be offered promptly if needed.

In the womb, babies (whatever their species) have a special blood vessel (the ductus arteriosus) which bypasses the lungs because the lungs are not needed in the womb.  However, soon after birth the ductus arteriosus should close off, redirecting blood appropriately through the heart and lungs.  A PDA is what happens when this blood vessel fails to close properly after birth.  The result of a PDA is that blood flows in an abnormal way around the heart and lungs and it is the abnormal flow of blood that causes the abnormal heart sound or murmur. As a result of the blood flowing in an abnormal way, the heart becomes overloaded and without treatment most affected dogs will die of heart failure before 12 months of age.

There are two techniques available to close the PDA:

·       The so-called “open” surgical technique involves opening the chest, carefully dissecting around the ductus then tying it off with non-absorbable suture material.  This is a very delicate procedure as tearing the fragile ductus arteriosus can be fatal.  We are fortunate at Northwest Surgeons to have a very experienced specialist soft tissue surgeon who has performed this operation many times.  As the chest is opened, the anaesthetist has to take over breathing during the procedure using a ventilator.

·       The non-surgical technique requires catheterisation of the heart and a specialised real-time x-ray called fluoroscopy.  This is similar to that used in the investigation of humans with coronary artery disease.  A small incision is made over one of the arteries in the groin and catheters are guided from here through the arteries in the body, into the chest and across the PDA.  Following some initial tests using the fluoroscopy, a special device (called an Amplatzer after its inventor) is passed along the catheter in the arteries and into the PDA.  The Amplatzer is a mesh of wire that folds up to fit in the catheter.  It has memory so as it is pushed out of the catheter it resumes its original shape.  In this case it forms a dumb-bell shape that blocks the PDA, redirecting blood flow in the appropriate direction.  Further fluoroscopy studies are performed after the Amplatzer is placed to confirm successful blockage of the abnormal blood vessel.  This approach has the advantage that there is no need to open the chest, but irregular heartbeats are often seen and again an experienced and well qualified specialist anaesthetist is vital.

Both procedures have similar success rates.  Open surgery usually requires a shorter anaesthetic time than the catheter technique, but recovery from the catheter procedure is faster because there is no need for major surgery to open the chest.  Often the choice depends on the size of the ductus arteriosus and the size of the arteries in the groin.  Only a small handful of specialist referral centres in the UK have the expertise to offer both procedures and the presence of specialists in so many disciplines at Northwest Surgeons allows us treat these patients using the best option for each pet.

Further investigations including echocardiography (heart scan) confirmed the presence of large PDAs in both puppies.  As these puppies were young, it was likely that these would cause premature heart failure and death if not treated properly.  In Delta’s case, the vessels were too small to allow the catheters to pass and she had open surgery.  She recovered well and was discharged three days after surgery.  Macey was much larger and we were able to use the catheter technique to close the PDA.  She was discharged the day following the procedure.

Both dogs returned after one month for re-evaluation.  No murmurs could be detected and an echocardiography examination confirmed closure of the ductus arteriosus in each dog.  In addition, the heart size was smaller as it was remodelling back towards normal from its original overloaded state.  Both dogs are still typical puppies full of beans and the good news for them and their owners is that they should now have a normal life expectancy in full health.

Both cases were referred to Simon Swift, European specialist in veterinary cardiology.  Macey’s procedure was performed by Simon.  Thanks to Catherine Sturgeon, European & RCVS specialist in soft tissue surgery, for treating Delta and to Matt Gurney, European specialist in anaesthesia and analgesia, for anaesthetising both patients.