Georgina Tracey Veterinary Nursing, Fetac Level 6.
Introduction: Pyometra is an infection of the uterus in dogs and cats causing a variety of clinical and pathological signs related to genital and systemic disease. Pyometra, or uterine infection, is common in un-spayed female dogs. It is a serious condition that requires emergency surgery but surgey is not always the most affective process, but an uncomplicated surgery often leads to full recovery. The uterus is generally filled with pus and is looked upon the more adult bitches, which have not been spaded. A study was taken in Sweden, which showed that 25% of the intact female dogs will be present for canine pyometra before the age of 10 years. Pyometra is most commonly seen in intact dogs 4-8 weeks after estrus, it can also be seen 4 months post estrus as well. Although seen less commonly, in cats, they generally develop pyometra between 1-4 weeks after estrous. Pyometra generally occurs in older (7 to 8 years) intact bitches and queens; however, it may occur in younger animals that have been given estrogen (mis-mating shots) or progestins for estrus suppression. (Shawn Kennedy, 2004) Common Signs and Diagnosis: Although the disease has been recognised for decades, the true pathogenesis has still not been completely understood. It is generally recognized that progesterone and Estrogen and their receptors have a role in the development of pyometra. However, the infection is triggered by bacterial involvement; the cyclical hormonal influences of the female dog allow the uterus to go through changes that will be acceptable for fertilization of an embryo. (Shawn Kennedy, 2004) .The changes that the uterus undergoes are typical for each dog. If bacteria are introduced into the uterus at a certain time during the cycle, hormonal regulation of the uterus allows the infection to start and become fulminate. Many dogs and cats will have a closed cervix and therefore the obvious sign of a sanguineous (bloody) to mucopurulent, haemorrhagic vaginal discharge may not be present. To diagnosis
pyometra they use Radiographs (X-rays), Ultrasound of the uterus. These are some of the signs to watch out for if pyometra is present. Differential Diagnosis:
Lethargy Depression Anorexia excessive water intake excessive urination pale mucous membranes Vomiting, diarrhoea, weight loss, abdominal distension, and inflamed eyes have been reported although much less frequently Up to 16% of patients may have no clinical signs other than purulent vaginal discharge.
These symptoms would be clinical signs of pyometra. Clinical signs show that because of the infection is so over whelming due to the inflammation in the genital tract, in some cases the animal may die from its own uncontrolled inflammatory process. Once the disease has been diagnosed treatment options can be put into place. There are surgical and non-surgical procedures in which the animal can be treated. But if your pet has recently had a heat cycle and displays any of the listed clinical signs above, veterinary attention should be sought immediately.
How is Pyometra treated?
The preferred treatment is to surgically remove the uterus and ovaries. This is called an ovario-hysterectomy ("spay") and is the safest and most effective way of treating pyometra. However, these dogs are quite ill so the surgery is not as routine as the same surgery in a healthy dog. Closed cervix pyometra is a medical emergency that requires rapid intervention to prevent overwhelming sepsis and death. For most pets preoperative stabilisation and resuscitation are first and foremost. After appropriate stabilisation, ovariohysterectomy (removal of the ovaries and uterus) is the therapy of choice. Great care must be taken with the enlarged weakened uterus. It must be removed from the abdomen without allowing any pus to leak out and contaminate other tissues. Intravenous fluids are often needed before and after surgery. Antibiotics are given for 1-2 weeks. The results of this therapy are rapid
recovery with minimal risk of recurrence. Ovariohysterectomy (Spay) also negates the risk of ovarian and uterine neoplasia and future unwanted pregnancy.
Nonsurgical Treatment Options: Although surgery is considered the therapy of choice, very special case selection meeting certain criteria may allow valuable breeding bitches to be treated medically. However, in addition to the previously mentioned multiple organ problems, the dogs will generally exhibit abdominal pain, excessive vomiting/ defecation, high heart rates, salivation, dyspnea, panting and fever with the medical management. Using prostaglandins is available for valuable breeding bitches where desexing is undesirable. Prostaglandins are a group of hormones that reduce the blood level of progesterone, relax and open the cervix, and contract the uterus to expel bacteria and pus. Injections are given daily for 3-5 days. However, the success rate is much lower compared to surgical treatment. They are expensive drugs, not as safe as surgical treatment, and cause a number of side-effects.
Side-effects include restlessness, panting, vomiting, defecation, salivation, and abdominal pain. This occurs within about 15 minutes of an injection and last for a few hours.
They give no clinical improvement for about 48 hours and severely ill dogs can't wait that long.
Because they contract the uterus, it is possible for the uterus to rupture and spill infection into the abdominal cavity. This is most likely to happen when the cervix is closed, and can be fatal.
The success rate for treating open-cervix pyometra is around 80-90%. The success rate for treating closed-cervix pyometra is only about 25%. The disease will recur within 2 years in 75% of cases The chance of subsequent successful breeding even after successful treatment is only 40-80%.
A new drug called Alizin has also been tried but appears to have many of the same limitations as Prostaglandin. (Hospital, 2006) It generally takes 5 days to see an effect is seen to
treat pyometra with low doses of Prostaglandin. (Shawn Kennedy, 2004) But Dogs are susceptible
to developing pyometra again after medical treatment. Potential Complications & Surgical Risks: As any surgery has risks, pre-operative checks are vital but these would be some of the surgical risks that would prove implication during and after surgery.
Anaesthetic death Bladder infection Peritonitis, which is infection of the abdomen Abdominal abscess formation Disseminated intravascular coagulation, which is a clotting disorder from the infection and causes death in many patients.
Sepsis poisoning of the body by toxins from bacteria
Pre-Operative Care: As Surgical care does not begin and end in the surgery suite. Exemplary surgical care addresses the patients pre-, intra-, and post-operative needs, the nursing care are vital to the rehabilitation of the treatment of the animal. To make sure the surgery will be a success the nurses will inform the owners about pre surgical procedures. 1. Care and attention when you have left our nursing team will settle your pet into their new environment which includes warm fluffy bedding (I would use special material that wicks away moisture so your pet stays warm and dry).
2. Blood Tests a blood test may be performed to check vital organ functions, we will discuss this either before surgery day or during admission with you (in some cases this blood test may be performed prior to admission). 3. Pre-anesthetic checkup our veterinarian will perform a physical examination (to check things such as teeth, ears, nails, lumps etc.) and a TPR check (Temperature, Pulse, Respiratory) prior to commencing surgery. 4. Pre-medication will be given to minimise stress and settle them down prior to the anesthetic. 5. Intravenous Catheter a catheter may be placed into a vein to provide access to your pets circulatory system. This enables us to easily administer intravenous fluids, anesthetic and pain relief. 6. Pain Relief To ensure your pet is as comfortable as possible we have a detailed pain relief protocol to ensure your pet receives the appropriate level of pain relief. 7. Instruments, gowns and surgical area - Prior to surgery all instruments are sterilised prior to use and our theatre provides a sterile environment for your pets surgery. On the day of surgery we need your pet in the hospital between 7:30 AM and 9 AM. Take away all food and water when you go to bed the evening before surgery, and do not give your dog anything to eat or drink the morning of surgery. Pre-aesthetic preparation is important in every surgery we perform, no matter how routine, because surgery is not an area to cut corners. All spays receive a physical exam prior to surgery. Only if they pass this exam will we draw a small amount of blood for an in-hospital pre-aesthetic test. When everything is to our satisfaction sedative is administered. This will calm the pet down and make the administration of the actual aesthetic, along with post-operative recovery, much smoother. Once a pet is anesthetized, prepared for surgery, and had its monitoring equipment hooked up and reading accurately, the surgery can begin. Every major surgery begins with proper patient preparation. This will help prevent infection, which could be a serious complication in this surgery because during a spay there is an opening into the abdomen. This is the final look of the skin in a pet that is ready for surgery. In the very centre of the screen is the umbilicus (belly button), an important landmark for the surgery. This x-ray shows an enlarged uterus in the abdomen. The uterus (U) is the area just to the left of the bladder (B). You can see it as several areas that are circular or elongate. A normal uterus does not usually show up on an x-ray.
Anaesthetic Protocol: Before giving the dog anaesthetic it will require a blood test that will evaluate liver and kidney functions. Most dogs that are not suited for anaesthesia will not have normal values from these blood tests. Don't feed the dog within 12 hours of the cleaning. If the dog has food in his stomach, this increases the likelihood of nausea during and after surgery. If the dog vomits during the cleaning, he can inhale it and choke. When all the pre-operative checks are done the administration of a general anaesthesia is need, which includes a combination of both ketamine (5-10 mg/kg i.v.) and xylazine (0.5-1.0 mg/kg i.m.) While the pet is under anaesthesia, monitoring is vitally important. The dog's temperature should be monitored throughout the procedure to watch for a rare condition in which a dog allergic to anaesthesia has soaring temperatures in response. ECG evaluations allow veterinarians to monitor the dog's heart during the procedure and a respiratory monitor can alert them of apnea. Blood pressure and oxygen content should also be monitored. Intra- Operative Care: The surgical care role of the vet nurse is particularly important in the operating theatre. Within veterinary practice it is normal for anaesthetics to be carried out by a vet nurse, under the direction of the vet who is operating and who retains overall responsibility for the care of the patient. Therefore, the nurse needs to have a sound knowledge of anaesthetic procedures, the monitoring of the condition of the patient while under anaesthetic and how to recognise and respond in an emergency. Intubation - Anesthesia is induced and maintained with gas by placing a tube into the pet's windpipe.
Theatre - the pet is placed on a heated surgical table in our sterile operating theatre Monitoring care - Respiratory monitors are used and show when a breath has been taken, stethoscopes allow us to hear the pet's heartbeat and pulse oximeters give a read out of heart rate, pulse strength and blood oxygen levels. Nursing team a dedicated, trained nurse assists our veterinarian during your pets procedure. Within 10 minutes after use, instruments should be rinsed under running water, to remove debris. If you cant rinse them immediately, keep instruments from drying out by placing a wet towel on top of them. When you wash the instruments, take care to use a neutral pH cleanser. Fluid Therapy - In most cases intravenous fluids are administered during surgery to assist in recovery. Procedure The surgeon will make a small incision and remove part of the pets reproductive system. Once this has been done, they will carefully suture the area.
Postoperative Care: The need for nursing supervision continues after surgery, initially to ensure that the patient is coming round safely from the anaesthetic and then to provide the post-operative care and pain relief that the vet has prescribed. This may include the application of dressings, the maintenance of catheters and intravenous drips, and ensuring the patient is kept warm and comfortable until ready to go home. Care and Recovery the pet will be moved to a main treatment area where a nurse will carefully monitor your pets recovery. It is very important the pet stays warm during the initial stages of recovery so we will use items such as heating pads and keep them comfortable. (Shawn Kennedy, 2004) Most dogs go home late in the afternoon on the day we perform the surgery. They might be groggy from the pain injection
which is advantageous because they will remain calm and allow the healing process to start immediately. By the following morning the grogginess will have worn off. The Nurse will advise the owners on post-operative care. When the owner first gets home do not be in a big rush to feed. After 1 hour at home offer a small amount of food and water. If the appetite is good, offer more several hours later. Do not over do the feeding the first night because anaesthesia can make them nauseous. The care is generally the same as it would be for a routine Ovariohysterectomy; however, the dog and cat will be on antibiotics as prescribed by the veterinarian for at least 10 days. The animal should not be allowed have normal play, stairs, or any off leash activities since recent surgery has occurred and abdominal herniation is possible if not careful.
Bibliography
Precautions for Dog Dental Cleaning with Anesthetics. (n.d.). Retrieved January 20, 2012, from Vet information: http://www.vetinfo.com/dog-dental-cleaning-anesthetics.html Hospital, I. V. (2006, December 12). Ingleburnvet. Retrieved January 21, 2012, from Ingleburn Veterinary Hospital : http://www.ingleburnvet.com.au/pyometra.htm Shawn Kennedy, D. (2004, August 13). Pyometra Cats & Dogs-American College of Veterinary Surgeons. Retrieved January 20, 2012, from American College of Veterinary Surgeons: http://www.acvs.org/AnimalOwners/HealthConditions/SmallAnimalTopics/PyometrainDogs Cats/ Cornick-Seahorn, J. Formulating an aesthetic plan for your patients. Veterinary Forum 2000; 46-53
