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      Date:   08 June, 2010  
Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits.

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An old cat's two puncture wounds would weep all day long 
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
D
ate:  08 June, 2010
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129
 
Getting ideas from the staff is one way of improving oneself as they are in the front line of nursing and have many ideas to resolve veterinary challenges. I am constantly amazed that I encounter new situations even after 30 years of practice. As part of in-house training, I do ask my assistants how they would handle certain challenging cases.

An 11-year-old female spayed cat came in with two puncture wounds on her left flank. The wounds would not heal because they erupted a light brownish red fluid every day. Just like an active volcano.

Yet this cat was not feverish. The two wounds in the skin were around 4 mm x 4 mm. But they just would not close as they keep producing a reddish-brown liquid everyday. 

"The bite wounds are not superficial on the skin only," I said to the father and two adult daughters. "I would need the cat to be put under the anaesthetic and explore the inside of the skin for debris. Therefore the cat must be warded for treatment and observation."

I gave the old cat an antibiotic and the tolfedine painkiller injection and put her in the crate for one day of observation.

On the morning of Day 2, I noted that the wounds were still weepy. My assistant Mr Saw had sprinkled his favourite yellow antibiotic powder onto the two wounds after cleaning up yesterday. Yet, the wound wept and all his yellow powder would spill out and downwards into the lower body of the cat. This cat's subcutaneous fat had been melted away by the bacteria introduced by the attacking cat's saliva and so there was abundant patch of loose skin around the puncture wounds exposing torn muscles. The jagged muscle edges were involved in producing the brownish red fluid that prevents the wound from closing well.
 

"Just flush the inside of the skin with a 20-ml syringe," my first assistant.  Thomas replied when I asked him how this case ought to be handled.

"You know, the suction pump is perfect for this case," I said. Thomas had never seen a suction pump despite being used an assistant in over 10 years of assisting in veterinary surgery with various employer vets. The suction pump is rarely used but is useful in certain conditions like peritonitis after surgery and maybe after Caesarean sections.

"No need to use this suction pump," Thomas asserted. "Just flush normal saline using a 20-ml syringe," Thomas replied. The suction pump was a piece of fancy equipment to pragmatic Thomas. I decided to use the pump. 

TWO-STAGE SURGERIES AND TWO ANAESTHESIAS
All old cats are high anaesthetic risks. This cat was thin but she looked very young. She just did not have a large appetite normally and weighed 3.3 kg when a good weight for her would be 5 kg. There would be 2 stages of Surgery and two anaesthesias needed for two surgeries and the owner must be informed in advance as to the costs, to avoid misunderstanding.

The first stage would be to debride and flush out the dead muscle and fat cells. Then, on the next day, at the second stage, the cat would be anaesthesized to stitch up the debrided skin edges wounds. There was no other way and so the risks of the cat dying on the operating table would be doubled. Definitely, the owner should be asked to sign the surgery consent form and receive advices on the prognosis and the costs. It would be costly to treat this case. After all, it was simply just a cat's being bitten. What is so difficult about treating this case. Just an injection and some antibiotics and cream to go home. This would be what some vets would do. But the clinical outcome would be unsatisfactory for the owner.    

FIRST ANAESTHESIA.
Zoletil 100 @ 0.2 ml IV femoral vein was given. Isoflurane gas via the mask was given to supplement as over 30 minutes were needed. I needed to cut away dead skin and muscle cells from damaged layers. Thomas said: "The muscle layers inside need to be stitched up, otherwise the cat would continue to have fluid production. When stitched, there would be no problem."  It is always good to get suggestions from assistants but the vet must know what to do.

I said: "This is a very old cat. Healing of the wound will be slow. To stitch up the torn flank muscles, I would need to cut a bigger skin incision to reach deep into the muscles layer near the belly. If the big wound does not heal, the cat would be in trouble having a large skin defect. If this is a young cat, it will be OK."

I observe that the cat could walk normally and so I would not advocate stitching of the irregular torn flank muscles. In old cats and dogs, it is best not to create big skin incisions. About 1000 ml of normal saline were squirted into the big space between the skin and the left flank muscles. A big suction tube pulled out yellowish fat and dead cells. I used scissors to snip off jagged muscle edges.

After the suction was completed, I checked the cat half an hour later. The cat was on an IV drip of normal saline. She was shivering. "Take the rectal temperature," I said to my intern Teresa. She put the thermometer in the rectum and showed me 33.5 deg C. This was low and worrying. Her normal temperature should be 38.5. This old cat had not taken anaesthesia and flushing well. Thomas blew hot air onto the cat using the hair dryer and rubbed her with a towel. "Give 20 ml of glucose," I said. This was given. The cat was wrapped with a towel. 2 hours later, her temperature was 36 deg. She growled as she did not like temperature taking. By the next morning, her temperature was normal. What was the cause of this hypothermia? "Irrigation of the flank with normal saline," Thomas said. This was plausible. I would think it was more the after effects of Zoletil as well.


SECOND ANAESTHESIA
24 hours after the flushing, there was no more weeping wound. The flesh looked pink. I masked the cat and gave isoflurane gas and she did not struggle. Stitching was done using horizontal mattress sutures, walk-in-sutures onto the muscle before stitching the skin and 2 appositional sutures using 3/0 absorbable. The cat woke up fast and had no shivering. She ate and went home one day later.

CONCLUSION
Isoflurane gas would be the choice anaesthesia in old dogs and cats. However, this cat was not very happy with her puncture wounds being poked around. As I did not want to stress her, I did not give her isoflurane gas direct during the first anaesthesia. Zoletil was sufficient for flushing of the flank. The process took a long time as I wanted to be thorough. Next time, flank irrigation could be shortened to 5 minutes instead of 15 minutes after debridement for old cats as they develop hypothermia easily.

In the usual cat bite wound cases, antibiotics and cleaning of the wounds would be sufficient treatment. In this case, the muscles were torn and infected deep below the skin. That was why the two puncture wounds produced a sero-sanguinous fluid daily and would not close. My vet assistant poured antibiotic powder onto the wounds as is the usual practice. The powder would just lodge deeper into the lower abdominal subcutaneous tissue and the wound just would weep again. The only effective treatment was to flush out the dead tissues rather than pour antibiotic powder so that the wounds would heal within 14 days.

Veterinary Performance counts in private practice. If the vet gives the owner a bottle of antibiotic powder and medication expecting the wound to heal, the owner would be much disappointed as such wounds would never heal. The owner would have wasted much time in putting powder clogging up the internal loose cavities of subcutaneous tissue destroyed by the bacteria toxins. In the end, the cat still needed surgery and the owner ends up paying much more. 

This was not the simple case of cat bite wounds and the costs would be much higher as it involved two anaesthesias and surgeries. However, the clinical outcome was excellent. And that is what the owner wants - her cat's problems resolved in the fastest time.      

UPDATE AS AT JUN 8, 2010
The owner phoned as regards stitch removal. As the stitches dissolve themselves, she did not need to come to the surgery. The cat's wound healed well and so I did not see the cat for stitch removal.  

To make an appointment: e-mail judy@toapayohvets.com
tel: +65 9668-6469, 6254-3326

toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129
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Clinical Research
 

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