Dexter is a 6 year old Shih Tzu that has been a regular guest at Hollybank recently. He was primarily admitted for hospitalisation due to urinary problems. This involved intermittent signs of straining to urinate.
After further investigations on his urine, a particular type of urinary crystal was detected. This led us to arrange an ultrasound scan with our visiting diagnostic imaging specialist, Jerry Shimali. Dexter was diagnosed with a portosystemic shunt (PSS). A PSS, also known as a liver shunt, is a blood vessel that carries blood around the liver instead of through it. Normally, blood passing through the liver carries broken down food and materials which are either stored for energy, processed into safe chemicals or made into proteins and other substances. Therefore, when the blood bypasses the liver it cannot perform the role it is meant to and toxins can build up in the bloodstream or kidneys.
In Dexter’s case, the build-up of toxins in his kidneys caused crystals in his urine. The crystals can also be associated with urinary tract infection and inflammation. These factors were likely all contributing to Dexter’s difficulty to urinate. In certain cases, portosystemic shunts can be managed medically. However, as Dexter’s condition was causing him an issue he was considered to be a surgical candidate. PSS surgery is a complex and specialist procedure. Here at Hollybank veterinary centre, we are lucky to work with Catherine Sturgeon, a specialist in veterinary soft tissue surgery. Catherine came in to meet Dexter and his owner; she was able to examine him herself and discuss the surgery and post-operative care in detail. A date was planned for the surgery to go ahead, taking into account that we had a full nursing team to assist.
On the morning of Dexter’s surgery, the ‘overnight nurse’ set up the operating theatre ready for his procedure. This must include the appropriate breathing system, skin preparation materials and all the equipment needed to anaesthetise him and monitor his anaesthetic. The equipment is checked carefully to ensure it is in full working order. As Catherine is a specialist surgeon she brings her own surgical instruments. However, for complex surgeries such as this one it is important that we also prepare any extra equipment that she may need so that is is quick to hand if required.
Dexter arrived for his admit appointment. Sarah, the vet involved in Dexter’s care admitted him for his surgery and brought him into out kennel area. The nurses got him settled in his bed and carried out his pre-operative checks. Nurses carry out pre-operative checks on all patients planned to have a procedure or surgery. The checks include temperature, heart rate and respiration rate. We also check their gums to make sure they are pink and moist; this indicates if they are hydrated and have good circulation. If we are worried about anything in our checks then we will inform the vet. Dexter’s checks were all in the normal ranges. Sarah also carried out a full physical examination on Dexter. She prepared his pre-anaesthetic medications and pre-emptive pain relief injections. Nurses can then administer these medications. Dexter’s pre-medication made him sleepy and relaxed so the nurses were able to place his intravenous catheter without causing him any stress.
The nurse assigned to Dexter’s surgery repeated the checks on the equipment in theatre; this is standard procedure and acts as another check point to ensure we have everything ready. Once she was happy she brought him into the preparation area ready to be anaesthetised. Dexter was still sleepy from his pre-medication so his anaesthetic induction went smoothly. Once he was asleep the nurse attached all of the necessary monitoring equipment. Her role was then to record each manual and mechanical reading every five minutes. It is the nurse’s responsibility to inform the vet if there are any abnormalities in their readings. It is also the nurse’s job to clip and prepare the surgical area in a sterile manner.
For the PSS to be corrected surgically Catherine had to find the abnormal blood vessel and close it off. This would force the blood to flow back through the liver. However, suddenly forcing the blood back through the liver has the potential to cause problems. The liver can become overwhelmed with this sudden change in dynamics. Furthermore, the blood vessels the blood is meant to travel through can be poorly developed (through lack of use) and sometimes they may not open up quickly enough for the blood to pass through.
To avoid complication, Catherine placed an ameroid constrictor around the vessel. This specialist instrument works to slowly close off the shunt allowing the liver time to adapt to the changes. Due to the slow closure of the blood vessel Dexter needed to stay in the hospital for a minimum of five days. This was so that he could be closely monitored for the development of any complications. All of the nurses within the hospital were aware of these signs and during his stay ensured they were vigilant in looking out for them.
As Dexter required hospitalisation for a longer period of time, a jugular catheter was placed at the beginning of his surgery. This type of catheter can be kept in place for longer than placing a catheter in his leg where we would routinely place them. We used his jugular catheter for his post-operative fluids. It also meant we had constant intravenous access in case we needed to administer any emergency medications.
Whilst Dexter was waking up from his anaesthetic the nurse ensured he was kept warm in our recovery area. We wrapped him up in blankets and used the Bair Hugger; this blows hot air into a blanket which is placed around the patient. Once he was awake enough, he was returned to his kennel which had been padded with extra blankets to ensure he was comfortable and warm. A nurse then sat with him for a few hours to make sure he was recovering well; this constant supervision in the early stages meant a problem could be identified and treated as quickly as possible. Dexter recovered well over the day and was already nice and bright by the next morning!
For the first 48 hours of Dexter’s stay he was checked by a nurse every two hours. One of the most problematic complications related to PSS surgery are post-operative seizures. The nurses monitored him closely for any signs of this and a seizure protocol was put into place should they occur. At each check his heart rate, respiration rate, temperature and demeanour were recorded. Due to Dexter having urinary problems it was still important to monitor his urination so the nurse also took note of how he was toileting. Dexter required ongoing medical and nutritional treatment after his surgery. He continued his fluids until he was eating and drinking well therefore these needed ongoing care and monitoring; his jugular catheter was checked regularly and the bandage replaced daily. We ensured he got all of his medications on time and monitored his wound to check it was clean and comfortable. Lastly, we calculated the correct amount of food he should be having at each meal and encouraged him to eat with us.
All of the nursing team got to know Dexter and his cheeky ways really well. Creating bonds with our patients is very rewarding for us, especially when you see them getting better. Getting to know each pet individually also means we notice if they “are not quite right”, no matter how small the change. Dexter was in the hospital for five days following his surgery, he was very well behaved when he needed things doing with him and he loved lots of fuss and attention. Cuddles are one of the bonuses of being a nurse!
Dexter was very happy to see his mum when she came to collect him. Sarah went through post-operative care and the signs to look out for whilst he was at home. A post-operative check appointment was booked for a week later to assess his wound and progress. During that time Dexter came to stay with us for one more night; he was quiet and showing signs of an upset stomach at home, he was observed carefully overnight and by morning he was bright and allowed to go home. When he came back for his post-operative check he was doing really well at home and had been his usual happy self, playing with his sister Chloe. Dexter is on the road to recovery and we all look forward to seeing his little face again!