Bitch Spay Complications Flashcards
Complications of a bitch spay in season and obese:
Just before you close the abdomen, you check for haemorrhage within the peritoneum, and can see a large amount pooling in the dorsal abdomen. You conclude that one or more of your ligatures has failed, and requires replacing. The nurse has not yet replaced the intravenous catheter.
What are you going to do, and in what order?
- Get your boss in for extra help and tell your anaesthetist its bleeding
- Get some else scrubbed in with you
- Make you incision bigger
- Wounds heal side to side not back and forward
- Duodenal and colic manourer and/or retractors
- Get the nurse to replace the IV and get the dog on fluids
- Place artery forceps on the bleeders
- Retie ligatures
- Count swabs out and in
Do you stop the haemorrhage, or give fluid therapy first?
- Stop bleeding first and give bolus of fluids
- Check the anaesthesia status of the dog
How much and what type of fluids are you going to give to a bleeding spay?
- Hartmanns
- Amount of fluids depending on amount of blood lost
- 90ml/kg/hr shock rate for a lot of loss
- 2-3 x maintenance for low loss.
How are you going to be able to find and tie off the bleeding stump – bearing in mind that previously the fat and other organs were in the way –you now have an abdomen full of blood and a retracted stump to complicate matters?
- Duodenal and colic manoevrs
- Get extra hands
- Retractors
- Make incision larger.
how can you stop any replacement ligatures from sliding off?
Stop the ligatures slipping with a millers of modified millers know
Transfixing ligatures
Don’t use forceps to tie off the cervix if it is really friable and it takes the sutures better.
In an acute bleeding, how do we stop the bleeding?
- Improve your access - open up your incision
- Visualise the area:
- Right ovarian stump –usually problem one as it lies more cranially – retract the duodenum out of the way towards the midline to expose
- If this is not bleeding, go to the left side – retract the colon towards the midline to expose left ovarian stump.
- If this is not bleeding, then check the cervical stump.
- Visualisation – if you are still struggling, you can get the intestines out of the abdomen, resting on a drape, but remember to keep them moist and return to the abdomen as soon as you can.
- Get someone scrubbed in to retract structures
- Remove the pooled blood using suction or swabs. Count all your swabs in and out of the abdomen. Leaving a swab inside this bitch is another complication you do not want!
- Once you have improved access and visualisation, the bleeding stumps are easy to identify.
- If the animal has lost a lot of blood, you can place the haemostat, then sort out iv catheter and fluids, then come back to ligate the vessels. If the dog is stable, then continue to ligate the vessels.
- Ligate the vessels - repeat steps of applying haemostats, ligating, checking for bleeding and slowly releasing. The main problem in these cases is usually failure to visualise the area properly (or occasionally not tying knots correctly…)
In an acute bleed, how do you approach re-establishing IV access?
- You should always do this as soon as you lose an IV line so you are not in this situation
- An IV catheter gives you control over the situation – lack of a catheter gives you another out of control variable
How do you monitor a bleeding spay post op?
- Monitor blood pressure
- Frequent TPR
- Watch for longer then normal/ intensive care for 15 minutes monitoring every 5 mintues. And then after 15 minutes check every 15 minutes for the next hour
- Keep her on fluids until she is resolved
- Repeat methodone after 4hrs if she had it in in the premedication
- NSAIDS
- If she has had medetomidine reverse
When would you send a bleeding bitch spay home?
- When we are happy she is ok
- Depends on the dogs condition
- If she is struggling to recover we can delay going home until she is stable
What do you tell the owner post spay of a dog who bled, and was in season during the spay?
- Tell them she was in season
- Tell them to monitor the bitch carefully
- What to look out for in terms of bleeding
- Explain the risk of pseudopregnancy
- If any issues bring her back immediately.
If the surgery went without complication, but you noticed problems post-operatively (bitch taking a long time to recover from anaesthesia, pale mucous membranes, rapid pulse rate, tachycardic), how would you confirm whether these clinical signs are related to haemorrhage, or pain / a delayed recovery from anaesthesia?
- Pain scoring assessment – Glasgow pain score
- Records of when she last had analgesia
- What did she have in her premed?
- Multimodal analgesia
- Scan the abdomen for bleeders- the abdomen will be full of blood.
- Wont see changed in PCV so acutely.
- Check the wound for discharge
- Heat and swelling of the surgical site.
If the surgery went without complication, but you noticed problems post-operatively (bitch taking a long time to recover from anaesthesia, pale mucous membranes, rapid pulse rate, tachycardic).. What would the pulse feel like?
- Depend on hypovolaemia
- Moderate hypovolaemia = weak and thready
- Mild hypovolaemia= bounding
- Severe hypovolaemia= non existant
- Pulse would be rapid, weak and thready with haemorrhage but bounding with pain – but this is not a precise assessment!
How could you confirm peritoneal haemorrhage?
- Ultrasound
- You can sometimes ballot fluid within the abdomen, or see it leaking from the abdominal incision.
- You can quickly and easily confirm the presence of free fluid within the peritoneal cavity (normal would be less than 5-10ml) by abdominal ultrasound. There may be gas within the abdomen obscuring your image, so you need to look for fluid pooling ventrally (its easiest to do this with the dog in the standing position)
- Paracentesis can confirm that this is haemorrhage, or can be used in cases where there is too much gas in the abdomen to visualise structures.
How valuable would a PCV and total protein be if you have no reference values prior to surgery?
- PCV / total protein can be used, but if you don’t have pre-op bloods, you will only detect this once haemorrhage is significant (rather than seeing a relatively small drop from the animal’s normal levels). Splenic contraction can keep PCV artificially raised initially, so total protein may drop first. PCV / TP is a good way of assessing the amount of blood lost.
- No valuable
- Should have done pre op bloods to get a reference
- Even with such an acute bleed you wouldn’t see a change
- Might see subtle changes
- TS decrease
- PCV decrease
- TS changes first.
How would you approach a bitch spay which was overweight and in season?
- Fluid therapy and stabilisation pre-op becomes more important, so case assessment and pre-op stabilisation is important to get this dog through induction
- Pre, intra and post op fluids is gold standard.
- (we wouldn’t have spayed a bitch in season TBH)
