Wednesday, 8 April 2009

Post Spay Bleed

It is not often we get in a patient that is such an emergency the vet doesn’t have time to do anything but operate straight away, with barely time to do a proper hand scrub. In fact l only remember this happening once not long ago. Going straight in as the vet was about to do was virtually unknown and was an indication of just how bad the dog was.

I was ambling up from dog ward to do the stats in cat ward when the vet, arms full of dog pouring blood came fast down the passage. Propflo, kit, spay bleed was all he said as he turned the corner and headed to theatre suite.

Sometimes a bitch spay will bleed. It may be a suture has slipped because the owner has allowed the bitch to jump on or off furniture or allowed a slightly nutty bitch to run around despite instructions. Maybe a suture slipped as it was not tight enough. The bitch may have been in season when spayed and everything is engorged this can cause problems post op. Usually a vet won’t spay in season bitched but they may have to for some reason or she could just be coming in and was not checked properly on admit or not showing much and was missed. Bleeding may be generalised ooze as she has an undiscovered clotting defect or for some unknown reason.
Usually the first line of defence is a tight belly wrap to put pressure on and keep a close eye for strike through and pray there is none.

Operating on a post op bleeding bitch is never easy. They have to find the short stump remaining from what was removed, buried somewhere in the abdomen amongst all the abdominal contents. And while yes, the vet knows roughly where it is, real life is never that simple. They also need to check all surrounding areas for any bleeding.

I pulled up 15ml propflo, a bitch spay kit and sterile gloves then headed to theatre. The vet had an et tube ready. He barely had to wave the anaesthetic under her nose (so to speak) oh well if l had not pulled 15ml he would have wanted more. I connected the gas, unrolled a kit and while the vet scrubbed up l gave her a clean and undid the skin sutures on her abdomen. We had to use surgical prep moving her to theatre would have taken to long.

Gloves on and back the vet took a deep breath then snipped out the remaining internal sutures. Blood bubbled up in a red flood that ran over the sides of the bitch in small rivers, the vet went hunting.
I put popped 6 (large) abdominal swabs onto his kit. The small normal ones were as useful as emptying a dam with a teaspoon.

“What’s her name” l asked to put it onto my op sheet.
“Don’t know, verbal consent”
“Tsk your helpful” l mumbled he flicked a grin at me.
“You want fluids in her” l asked?
I got a grunt l translated as yes and was about to yell for a hand (so l did not have to leave the patient, theatre is a bit away from the main area) when the auxiliary appeared. She had tracked the vet following the blood trail and wanted to know what to do about the owner in the waiting room.
Well l said after you have helped me with a leg you better print a consent form and we could go from verbal to written consent.

I don’t like placing catheters when the animal is on the op table. The leg is sticking into the air and so it is high, instead of bending and looking down you are looking up. You have to consider the vet operating and can not move the dog and have to worry about sterility. Once it was in l attached a bag of No11 some bolus of voluven and placed more into the bag.
Blood transfusion would wait for now. We have a limited supply unlike human hospitals. Once the bleeding was controlled then the vet would look to give blood transfused. No point putting it in if it runs out and we have no more blood. It also depended on the owner due to cost.

People have complained about vets and costing. The NHS causes a problem in that people have no idea of cost, and then start to call vets greedy for charging a market price without realising the cost of the treatment. However go to a country that has no NHS and try and get human treatment. I am not sure that they would operate let alone do fluids, drugs and assessments until they had credit card or insurance details.

The bitch was weak stats but stable and pure white under anaesthetic. I prefer stronger stats, stable and pink but at least she was alive even if she fitted the term ‘just alive’.
Mutterings were coming from the vet and he was shifting instruments about obviously struggling.
“Want another kit you look to be getting low on ‘bits’ and should l scrub up” l asked
Another grunt, this vet was usually a happy soul who would normally make a comment with a big grin and was always good natured, all l was getting was grunts. Things were not good in the innards l perceived.
I placed another kit for the vet and called for the other nurse to take over the anaesthetic while l scrubbed up and pulled on gloves.

Scrubbing in can be confusing. As a vetnurse you get so used to NOT touching anything and suddenly you have to touch instruments and op sites.
It works in reverse for vets. If they are observing they are forever being “OYED” by the vetnurse as they are about to reach in and touch something. In fact some vets will only observe if scrubbed, it saves them being told off.

I had to hold instruments in various positions to keep them out of the way. Instrument rings on various fingers, hand tilted and fingers splayed to try and follow instructions and one hand free to pass instruments or hold others.
The vet was struggling, he had found the stump but there weren’t any slipped sutures, instead it was a sort of general ooze from different areas.
Finally everything was as ooze free as he could get it. Part of the problem was there was no set vessel bleeding. When he tried to suture the tissue that was bleeding it was very friable and tore easily.

When he decided he did not need me any more holding instruments l took back the anaesthetic, the other nurse went to check the inpatients and eventually he closed the patient up.

I gave her a clean as best l could to remove as much blood as possible but did not want to wet her down to much. After that and while she was still recovering he helped me to put a tight belly wrap on her.
Not the best of dressings as she was floppy but made easier though when you have a rugby playing vet holding the patient in the air as if she was lightweight. Was he a football player he wouldn’t have been able to hold her, ok l am biased but it is true.

Normally we do not want owners to wait but in this case we made an exception because of the circumstances and the owner was still in the waiting room, the auxiliary had made her tea. The vet went out to have a word with her and get himself a cuppa, and everyone else bar me, I only like my Dr Pepper.

Post operatively the patient was placed onto another iv catheter and a bag of blood was attached to that. She was closely monitored for any more bleeding, thankfully there was none and after a couple of days she went home, making a full recovery.

All operations even routine carry a risk, the vast majority are free of post operative problems. For my mind and most others in the veterinary profession the benefits of the standard elective operations like spay and castration outweighs post operative risk.
Un-neutered males or females are at high risk from tumours, babies and pyometras, hormonal problems, species specific virus passed during sex or fighting not to mention injuries caused with others of same sex after the mate they want or accidents with cars while looking for the dog/cat in heat.

If you do suspect anything post operatively after any operation on your pet, or if you are worried about anything, contact the vet straight away. In this case it was very obvious but it is not always and it is better to be safe than sorry.


cambstreasurer said...

We don't know how lucky we are in this country - not just the NHS, but also the law on rented accommodation mean people on very low income have no idea of the true cost of lots of things. I had to call out a plumber last Christmas and the out of hours charge was exactly the same as for the 24 hour vet. If I'd been renting the charge would have been up to the landlord.

I'm afraid that does mean many of our clients have no idea how irresponsible it is to assume they only need to budget for the cost of food for their animals.

Auntie Jane said...

You write this a week after I've had my two young girls spayed. Both are doing well, thank goodness, but it's been easier to keep one quieter than the other!

I went back to my vet 3 days post op., for a check-up. I was a little concerned as the quieter bitch's scar which had been dry was weeping just a little. He put both on anti-biotics for sakety, though he said they looked fine.

Trying to keep two active collies cool, calm and collected is no easy mater! Kate keeps grabbing a toy begging to be taken out for a game! Jazz is content (mostly), to lie beside me on the settee.

I have a large cage they could both go into, but I haven't needed it. They settle when told. But I'll be glad when I can take them out as the weather, though windy today, is so nice.

Stitches due out after Easter. The holiday makes it a couple of days late.

Vetnurse said...

Cambs l agree it is a pity people do not realise the true cost of things. I do wonder though if quite a lot of people even bother budgeting for food.

Sorry Jane :-) l saw yours had been done but all seems well, apart from a bit of a weep which is nothing to do with what l wrote about (phew!)

If it is any consolation it is very rare for post bleeds to happen. Think l have seen about 3 the past year and a bit [from the start of 08] in a busy emergency practice that covers for a lot of other practices.

Usually the animals that bounce around out of control and get a bleed are animals where the owners are not that good at control. The animal has it and not the owner. Although not always (better add that or someone will jump on me!)

Annette said...

Thank god we have people like you and the vet to see to these animals.
That poor dog, I really feel I am there when you write about these things.
As for the cost, you really should have some form of insurance for your animals, because you never know when you might need a vet.