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Veterinarian Technician February 2005 (Vol 26, No 2)

ACECCT Case Files: Unexpected Surgical Findings in a Hound

by Shelley Harbin, BS, RVT, VTS (ECC),

    Terri, a 70-lb (32-kg), 5-year-old, female treeing Walker hound, was presented to our clinic for lethargy and anorexia. The owner explained that Terri had whelped four puppies just 3 days earlier. Our first thoughts were that her illness was related to potential whelping complications, such as metritis or retained fetus or placenta.

    Day 1

    The initial physical examination revealed that body temperature, mucous membrane color, and capillary refill time were all normal. In addition, no abnormal vaginal discharge was noted. However, a large grapefruit-sized mass was palpated in the abdomen. Abdominal radiography revealed no skeletal structures of a fetus.

    When obtaining a complete history, it was discovered that 2 years earlier Terri had suffered an abdominal injury that promoted a chronic pyogranulomatous lymphadenitis, which is an infected and inflamed lymph node in the abdominal mesentery. The patient had been treated for this injury when it was first diagnosed. It was decided that no further treatment would be initiated for this patient until an ultrasonogram of the abdomen could be obtained the next day. Terri was sent home on trimethoprim-sulfadiazine (960 mg PO q12h).

    Day 2

    Our conservative efforts were short-lived. Bright and early the next morning, the owner called to report that Terri had started vomiting. After a brief discussion, it was decided that ex­ploratory laparotomy would be performed without the diagnostic aid of an ultrasonogram because the referral clinic that could conduct the ultrasonogram was 2 hours away. An 18-gauge, 1.5-inch intravenous catheter was placed in the right cephalic vein, and lactated Ringer's solution was started at a rate of 140 ml/hr (two times maintenance). Antibiotic therapy (gentamicin at 6 mg/kg IV and ceftiofur at 3 mg/kg SC) was initiated. Dexamethasone sodium phosphate was administered at 5 mg/kg IV to treat the inflammation and help prevent endotoxemia.

    After Terri was prepared for surgery, anesthesia was induced using 8 mg/kg of IV tiletamine-zolazepam. The patient was then intubated and maintained on isoflurane at 2.5% and oxygen at 2 cm H2O. Atropine, an anticholinergic drug, was given at a dose of 0.044 mg/kg IM. IV fluids were increased to 700 ml/hr (10 ml/lb/hr) for the first hour of surgery and then reduced to 350 ml/hr (5 ml/lb/hr). This fluid rate was maintained throughout the procedure.

    Exploratory surgery revealed that 12 to 14 inches of the jejunum was impacted with wood shavings, the stomach was full of wood shavings, and a stricture had developed at an area of the lymph nodes in the mesentery. A bowel resection was performed, and approximately 10 inches of intestine was removed. A gastrotomy was performed to empty the stomach of the wood shavings. The anastomosis and gastrotomy sites were tested for leakage, the abdomen was lavaged with 2 L of warmed 0.09% normal saline solution, and the incision was closed with polydioxanone suture material.

    Immediate postsurgical care in­cluded fluid therapy, which consisted of lactated Ringer's solution and metoclopramide (2 mg/kg/day constant-rate infusion) for the regulation of peristalsis. The fluid rate was reduced back to 140 ml/hr. Dimethyl sulfoxide (DMSO) at 40 mg/kg IV in a 10% solution with normal saline was administered for inflam­mation. Butorphanol was admin­istered at 1 mg/kg IM q4h as needed to manage pain. The pa­tient's vital signs were monitored every 15 minutes for the first 2 hours of recovery and every 2 hours for the next 12 hours of recovery — and all remained within normal limits.

    Day 3

    Terri was bright and alert after the surgery. Antibiotic therapy was continued with gentamicin and ceftiofur. Fluid therapy was continued with lactated Ringer's solution at 70 ml/hr (maintenance) and metoclopramide. DMSO was discontinued. Terri was started on enteral nutrition using the basal energy requirement (BER) and the illness energy requirement (IER) formulas to calculate her nutritional needs:

    BER = (30 x Body weight [kg]) + 70 IER = (1.3 - 1.6) x RER

    By using these formulas, it was determined that Terri's daily requirement was 1,319.5 kcal/day. In order to meet this requirement, the patient would have to be fed seven cans of Hill's Prescription Diet Canine a/d. On the first day after surgery, Terri was fed one-third of the requirement (2.5 cans). The next day, she was fed two-thirds of the requirement (five cans). She was given the full feeding (seven cans) on the third day following surgery.

    Day 4

    Terri was progressing nicely. Antibiotic therapy continued with gentamicin and ceftiofur. The patient experienced no vomiting after being started on Canine a/d; therefore, fluid therapy and metoclopramide were discontinued and water was given free-choice. The patient's vital signs were all normal, as wereurination and defecation.

    Day 5

    Terri appeared to be feeling much better. Her vital signs remained within normal limits. She had no episodes of vomiting, and urination and defecation remained normal. She was eating full feed and drinking water on her own. She was released to her owners, who were instructed to continue feeding her the Canine a/d for the next 5 days. She was also to be given 1,000 mg of cephalexin PO q12h for the next 10 days, at which time a medical progress examination was scheduled.

    Conclusion

    Terri's recovery from this episode was remarkably successful, and 45 days after her surgery she was back hunting raccoon and winning field trials. Four months after the surgery, Terri was taken to Tennessee to be bred. After 72 days of gestation, she gave birth to 15 puppies!

    Case Commentary

    Making sure that Terri received proper nutrition after her surgery played a huge role in her recovery. Enteral nutrition should be initiated after gastrointestinal surgery as soon as safety permits. Nutrition is necessary for proper hyperplasia to occur, decreases the chances of bacterial infection in the intestine, and helps maintain intestinal integrity.

    This case was a great reminder that not everything is as it seems at first and that being thorough can be crucial to a patient's well-being. As veterinary technicians, our patients rely on us to explore every possibility relating to their medical needs. The suspected cause of Terri's clinical signs went from potential whelping problems to abdominal injury complications to abdominal obstruction and strictures. This case presented great diagnostic and surgical challenges. It left us with a powerful reminder that the unexpected is often a daily occurrence in our profession.

    NEXT: Diagnosing Dental Disease Film vs. Digital Radiography

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