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Dharma was referred to Dr Margiocco because her family veterinarian had detected an abnormal heart rhythm (cardiac arrhythmia) approximately two weeks earlier while investigating Dharma’s history of exercise intolerance and an episode of acute weakness (“flopping down”) while walking. Dharma was not receiving any medication at that time.
An ECG was done and revealed a heart block (second degree AV block) causing an abnormally low heart rate which was likely responsible for her episodes of weakness. The red arrows show where the blocks occur.
The next step was to give atropine, a medication used to increase the heart rate. As her heart rate did not respond as expected (it should have increased significantly), structural damage to the heart’s conduction system was suspected. An ultrasound (echocardiogram) was normal indicating the absence of other significant heart diseases.
A 24 hour Holter monitor (continuous ECG reading) recording was able to detect that Dharma’s heart rate frequently dropped down to approximately 40 beats per minute during the day, which is a quite low heart rate for a dog.
Advanced second degree AV block carries a high risk for the patient. An artificial permanent pacemaker is the treatment of choice for this condition.
Dharma's pacemaker lead placement under fluoroscopy
Dharma was hospitalized the day prior to the pacemaker implantation surgery. On the day of the procedure, we placed two adhesive electrodes on her chest to be able to pace her heart once she was anesthetized (in case her heart rate dropped dramatically during the procedure).
Dharma’s surgery went very well and the anesthesiologist was happy with how quickly she recovered from anesthesia in the intensive care unit.
She was discharged to the care of her owners the day after the procedure.
Her ECG at discharge showed that the pacemaker was indeed taking over when her heart block (red arrow) would have caused a drop in the heart rate. The pacemaker (blue arrows) takes over and ensures that her heart rate is maintained in a normal range to allow her to go about her Lhasa Apso dog activities.
Dharma's ECG at discharge
Sutures were removed 9 days later, and a brief recheck two weeks after the surgery showed that Dharma was healing without complications. We can barely see the small neck incision.
Dharma at recheck
Dharma was scheduled to come back at the beginning of this year. At that time the pacemaker will be “interrogated” with a special computer via a radiofrequency “wand” placed on the patient’s skin. Modern pacemakers collect and store data that is used to optimize the settings of the device with the intention of optimizing the patient’s quality of life and of maximizing the battery duration.
We all know the adage that you can’t teach an old dog a new trick. However, advances in treatment for canine knee injuries in recent years have shown that rethinking – and reshaping – how the knee works actually results in better outcomes than the older approach of trying to restore the same movements in the knee that existed prior to the injury.
Knee injuries are pretty common amongst sportspeople, and we often hear about athletes tearing their ACL – the Anterior Cruciate Ligament. Similar injuries happen in dogs, but because they walk on all fours, the injured ligament is described as the Cranial Cruciate Ligament – CCL. Following a CCL tear the knee is swollen, painful, and somewhat unstable. It is one of the most common orthopedic conditions we see in dogs at Canada West.
Patient with a cruciate injury before surgery
There is one fundamental difference in cruciate injuries between dogs and people; in humans this is normally a traumatic injury (a bad fall while skiing, or a hard tackle in football), while in dogs it is actually a chronic degeneration of the ligament. We don’t really know why this occurs, and is probably due to a combination of factors including some genetic aspects. It does tend to be seen more commonly in certain breeds – Labradors, Rottweilers, and Boxers for example.
Because cruciate rupture in dogs occurs due to a gradual weakening of the ligament, we can’t repair it surgically, or expect it to heal. The degeneration would continue and the ligament would basically fail again. Therefore, a lot of treatments for this condition in the past focused on trying to replace the ligament with another structure – either a tissue graft taken from within the leg, or an artificial material such as surgical nylon placed around the joint. While patients do improve after these kinds of treatments, they take a long time to begin using the leg to any degree, they do not return to using the leg normally, and arthritis progresses within the joint over time.
More recently, a different approach has been taken to treating canine cruciate ruptures, with good results. Instead of trying to replace or mimic the function of the cruciate ligament, we can alter the way the muscles act around the knee so that they do not need a cruciate ligament anymore.
A variety of techniques have been described to do this, though the most commonly performed are the Tibial Plateau Leveling Osteotomy (TPLO) and the more recently developed Tibial Tuberosity Advancement (TTA)
In both cases a portion of the tibia bone is cut and shifted just a few millimeters, which slightly changes the direction that the quadriceps (the strongest muscles of the thigh) are pulling on the knee. The abnormal movement that occurs in a knee with a ruptured cruciate ligament is no longer present, and the joint is now stable for the dog to walk and run. There is no difference in outcome between the two procedures, and the decision about which is best for a certain patient usually depends on the specific shape of the knee.
Whenever you make a cut in any bone it has to be held in place while it heals over about 6 weeks. Special plates are used with TTA and TPLO to fix the bone securely, though it is still very important to keep the patient as quiet and rested as possible during that 6 week period to achieve correct healing.
TTA: plate/fork
Despite being a big surgery, dogs that have a TPLO or TTA performed are usually walking very comfortably on the operated leg 24 or 48 hours after surgery, which is much sooner than we usually see with the older techniques.
They also go on to use the leg more normally long-term, and can in most cases return to the same level of exercise ability they enjoyed before the injury. Additionally there is significantly less arthritis that forms in the knee as they get older.
TTA patient 24 hours after surgery
These surgeries have revolutionized our ability to treat CCL rupture in dogs, and make us much more successful in getting them back to normal athletic activity. Our surgeons have been performing TPLO and TTA for several years now, and it is not unusual for four or five to be operated in our hospital in one day. They are very involved procedures however, requiring a lot of specialized equipment and carry a risk of serious complications if not performed by experienced surgeons.
We are very pleased to be able to offer both TPLO and TTA, and love the new lease on life it gives to some of our most active patients.
Pyothorax literally means an accumulation of pus in the chest around lungs. The fluid causes the lungs to partially collapse.
These types of infections occur more often in cats. We believe that their thin chest walls can easily be penetrated with a sharp claw; the hole closes over and we now have a moist, dark environment low in oxygen which allows a certain type of bacteria to thrive.
In dogs, this is most commonly seen in sporting and hunting dogs, or at the very least, very active dogs that go deep into the bushes where they can sustain piercing chest wounds. It can also occur from from inhaling debris into a lung, or more rarely, from pneumonia. Any of these can result in a lung abcess that can rupture and lead to the accumulation of pus in the chest cavity.
Fluid in the chest shown below the aqua line
Winston was taken to see his family veterinarian because he hadn’t been feeling well for a few days and his breathing seemed more shallow. Radiographs done by his family veterinarian showed that Winston had an abnormal accumulation of fluid in the chest cavity and they noted he had a high fever. He was referred to our hospital for further care of a suspected pyothorax.
An ultrasound was done to further determine whether Winston could sufficiently be treated with chest tubes (tubes that are placed in the chest cavity and allow drainage and flushing of the chest cavity), or whether it would be more likely that he would require surgery.
The ultrasound was very abnormal and it was decided that Winston’s best chance would be to undergo surgery but we were concerned that he was very sick and feverish at this point. We elected to drain his chest cavity to start, treat him with intravenous fluids, antibiotics and undertake his surgery the next day. Dr Mareschal, one of our radiologists, drained more than 2 liters of pus by using the ultrasound to guide the needle in the pockets of fluid. Samples of the pus were sent to a veterinary bacteriologist for accurate identification of the types of bacteria involved and the antibiotics they would be most sensitive to.
Winston being monitored in the ICU after his surgery
Surgery was done and Dr Weh spent the better part of 2 hours removing debris from poor Winston’s chest wall. It did appear that his pyothorax had been caused by a penetrating chest injury which had since healed up but caused quite a reaction in his chest.
Winston recovered well and seemed comfortable enough except that his breathing rate concerned us. It remained more rapid and with more effort than we would have liked. About 24 hours after the surgery, we became very worried that he could not sustain working this hard to breathe. Even when he was given more oxygen and his pain medications were adjusted, he seemed to continue to have too much difficulties breathing.
On the ventilator
In order to give his body a chance to rest from his exhausting breathing efforts , we talked with his family about putting him on a ventilator for 24 hours.
Dr Lang chose settings for him on our specialized mechanical ventilator that would allow his breathing to be taken over. The nursing care is intensive and these patients always having someone by their side – their own nurse or one of the ICU doctors.
Winston did very well once we started breathing for him and the only concern we had is that he required a lot of anesthetic drugs to be able to keep him asleep for that time!
Our boy was ventilated for 24 hours. His lungs seemed happier and his breathing was more normal. We had hoped that this was enough and Dr Enberg was able to wean him from the mechanical ventilator the next day.
Winston feeling better without his chest tubes
His breathing seemed more much normal and he no longer needed extra oxygen. He continued to improve. The chest tubes were then removed, his antibiotics were being given orally (since he was eating readily as seen here). He was sent home a few days later with several weeks worth of antibiotics. We expect he will make a full recovery and will be able to return to his usual activities but given that he had open chest surgery, this will take a few months.
Home sweet home...
While poisonings are typically seen either at the family veterinarian or local emergency clinics, if the pets deteriorate, they are often referred to us for intensive care, monitoring and follow up tests in our laboratory.
I was struck in the past few weeks by how many toxicities we have seen recently. One of of them was an extremely sad story as it had a fatal outcome.
One was a lovely toy poodle which ingested poison in a North Vancouver park (Princess Park) this week-end. The other dogs in the household were also sick but, given the patient’s small size, the amount of poison he consumed, he did not survive. His presentation was extremely unusual case as the antifreeze (ethylene glycol) was laced with something else which made the detection more difficult. We were told by the family that poison is at times put out in the parks of North Vancouver for dogs and wildlife (bears, coyotes or raccoons). While we can not think who would be so misguided as to do this, we wish to warn the pet owners in that area.
We recently saw a cat who had been exposed to minoxidil (Rogaine). It is known to cause irreversible heart failure in cats. Whether there is some left on hands after applying it, or even if they like to nuzzle (or lick) the treated area or the bottle itself, they become exposed.
As more compounds are available for topical treatments (to lessen side effects to humans), we must remember that the reason these work is that they can be absorbed from the skin. As most cats and dogs are much smaller than humans, being exposed to or ingesting such products can cause them to absorb enough to get very ill.
A small dog was exposed to the perimenopausal hormonal cream the owner was using; the cream was sometimes put at the bend of the elbow where the dog liked to sleep. That dog had serious side effects from high estrogen levels.
In another ingestion of medicated creams, a terrier ate some cream used to treat psoriasis. The medication increased the dog’s calcium levels so much that it can cause rapid kidney failure and for calcium to deposit in some organs. It was treated with specific medication to prevent further stores of calcium in the bones from being accessed and supportive care to help the kidneys flush out the calcium.
A cat was exposed to moth balls which made his blood cells more fragile and affected his kidneys.
We also saw a young lab whose family had witnessed him ingest something in an off-leash park in Richmond. They rushed over to see what he was eating and found some odd looking kibble (with blue-green marks) buried under the grassy area. The dog almost died and needed several transfusions to save his life. The kibbles were suspected to contain rat poison.
We can not protect our furry friends from all catastrophes but this is a reminder to keep all medications away from pets (whether prescribed or over the counter) and we recommend that you do not use human medications in animals without consulting your family veterinarian.
Should you want more information, we recommend you visit the Animal Poison Control Centre website.
We recently worked on a Serval Cat!
Serval cats are medium size cats from Africa. The cheetah is thought to descend from them. Like so many other animals in the wild, their numbers have dwindled. Their population has been in decline largerly due to human population encroaching on their habitats or being hunted for their beautiful pelts. Servals can also be preyed upon by other large cats.Their introduction as pets in North America is recent but the ancient Egyptians worshipped the serval as gods, and kept them as pets.
Servals are known to develop an intense emotional bond with their original owners and this lovely girl was no different. We could not have approached her easily on our own (servals have unusual long legs and proportionally small heads but she showed us her teeth were definitely full size!) without stressing her and possibly causing her harm, but she was completely trusting of her owner and calm in her presence.
I called in Dr Craig Mosley, our anesthesiologist, who has worked with with large cats in the past (as well as lions and tigers and bears, oh my!). He devised a sedation plan that would have her stay in her owner’s arm while we gave her an injection to minimize her stress and that we would work quickly once she was sedated to anesthetize her, that Dr Francis would do the surgery to fix the fractures in her hind legs and have her stay in the hospital only until she was awake enough to know that she has safely recovered from the long anesthesia which would be required.
Full physical exam once asleep...
I am happy to report that she has been recovering well at home for the past few weeks
It made me think back to the various unusual animals we have treated over the years. We usually restrict our practice to small animals, predominantly cats and dogs with the very occasional ferret or rodent but, given the expertise of the various specialists we have treated a wolverine, help participate in the care of several aquatic mammals, treated a bear with neck pain to name a few.
There are fairly strict regulations in place for owning exotic pets (http://www.env.gov.bc.ca/fw/wildlifeactreview/cas) and while it is likely due to the danger that these animals can pause to humans as well as to reduce illegal importation, it should also be because their habitat and diet are so difficult to emulate to ensure the best environment for these different breeds and species. While many exotics pets are not banned, it is at times very difficult to find accurate information as to the type and quality of the diets these animals require, the quantity of food to feed them (wild animals are lean!) and the type of exercise that may most benefit them in their new home.
Some private practice veterinarians who have extensive experience with exotics and zoo medicine veterinarians are good resources for family veterinarians who help care for these special pets.
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