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When Liver Meets Lungs – Diaphragmatic Hernia in a Cat

Up a TreeOne evening whilst playing outside, a little 6 month old kitten (let’s call her Tilly) climbed up a tree. A rather inexperienced hunter, when she saw a little birdie on the end of the branch she reached out to get it and, crash! The branch was too thin to support her weight and she fell to the ground. Now what they say is often true, cats do tend to land on their feet, but not always and poor Tilly landed on her side. She got up though and ran into the house, so her owner assumed she was OK. A few hours later her owner noticed that she was quieter than normal and not interested in her dinner. She was also breathing faster than normal but otherwise seemed OK, purring and affectionate, so her owner went to bed and planned to take her to the vet if she was still not right in the morning. As you could probably guess, at 8:00 the next morning I got a phone call from Tilly’s owner, as she had not gotten any better overnight - she was still very quiet and breathing even faster than before. We told her to come straight down and we would take a look right away. A few minutes later Tilly arrived, looking quite sorry for herself, but still happy enough to give me a little purr. I did a full physical exam and found her to be in good health except for her breathing, which sounded quieter than normal through the stethoscope. Her respiratory or breathing rate was very high and she seemed to be struggling to get enough air in. She also seemed depressed, certainly not what I would expect of such a lively young kitten. Once we were certain that everything else seemed to be OK, we gave her some pain medicine and then a little bit of sedation so she would sit still while we took some x-rays of her chest. What we found was no surprise given her history, but still always comes as a bit of a shock when we see it – Tilly had a diaphragmatic hernia. What is a diaphragmatic hernia? The diaphragm is a large, thin muscle that separates the chest cavity (with the heart and lungs) from the abdomen (with the stomach, liver and intestines among other things). It is normally an air-tight barrier which allows the chest cavity to achieve negative pressure, in other words there is pressure on the lungs to expand out rather than collapse in. When the diaphragm moves down with each breath, the lungs move with it causing them to expand even further when you breathe in. And when it moves back up again, it helps the lungs to contract so the air is forced out when you exhale. Without a diaphragm or with a damaged one you can still breathe, just not very well, and this is what poor Tilly was experiencing. A hernia is the protrusion of an organ through a hole in the body cavity which normally contains it. In the case of a diaphragmatic hernia, a hole develops in the diaphragm which allows the organs of the abdomen to enter the chest cavity. As you can imagine, this is neither good for chest, as the invading organ takes up precious lung space, nor for the organ itself as sometimes its blood supply can get cut off in the process. Some diaphragmatic hernias are emergencies and need to be corrected immediately, while some can go on for weeks without anybody even noticing, it depends on the size of the hole and which organs get displaced. Some animals are even born with them. In Tilly’s case, the sudden pressure on her belly from hitting the ground caused her diaphragm to tear and some of her liver to move up through the hole. It was a serious condition but not a life-threatening emergency, and it has been shown that there is a higher success rate in some cases if surgery is done after 24-48 hours, so she was scheduled for surgery to repair the hernia the following day and kept in hospital under close observation until then. [caption id="attachment_1805" align="aligncenter" width="640" caption="This is an image of Tilly’s chest – the dotted line shows where the diaphragm usually sits and the solid line shows Tilly’s diaphragm, with the liver sitting inside the bulge. A relatively easy but dramatic diagnosis!"]This is an image of Tilly’s chest – the dotted line shows where the diaphragm usually sits and the solid line shows Tilly’s diaphragm, with the liver sitting inside the bulge.  A relatively easy but dramatic diagnosis![/caption] So what happened? We took Tilly to surgery the following day and once we could see inside, the extent of the injury became apparent. There was a 5 cm tear in the diaphragm muscle, and about half of her liver was now sitting right next to her lungs! We were able to carefully pull the liver back into the abdomen and sew up the hole, making sure that all the organs looked happy and healthy before finishing the surgery. Our nurse did a fantastic job keeping Tilly stable under the anaesthetic, and even had to breathe for her for a few minutes while we sewed up the hole. Just before we woke her up, we inserted a needle into the chest to drain out all the extra air so that her chest cavity could regain its negative pressure. Her breathing was immediately improved, and stayed that way throughout her recovery. The next day she was eating and even trying to play with the notes on her cage, so she was able to go home. It has now been nearly a week and Tilly is still doing really well. Her owner says she is even trying to climb things, despite being told that she must stay very quiet to allow her injuries some time to heal. If only you could explain to her how she got into this trouble in the first place! All the best to brave Tilly and her brave owners, I expect she will make a full recovery and be back to her usual kitten acrobatics in no time. If you are worried about any problems with your cat, talk to your vet or try our Interactive Cat Symptom Guide to help decide what to do next.
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Fluffy Can Give Blood Too! Blood Transfusions in Cats

DaisyFor the past month our local radio station has been bombarding us with adverts asking us to give blood due to increased need over the holidays. My husband and I ignored them at first but then eventually gave in. On the way home after giving blood, we started talking about cats donating blood and I realised it had been ages since I’d seen a feline transfusion. They are relatively uncommon, especially in general practice, but it’s an interesting subject so I thought I might look into it a bit further. Hopefully your cat will never need one, but if they do (or if you’re just curious about the whole process!), here’s a little bit about what goes on behind the scenes. Why would a cat need a blood transfusion? The main reason why cats get blood transfusions is because they are severely anaemic, which means they don’t have enough red blood cells in their blood. Red blood cells are responsible for carrying the body’s oxygen, so not having enough of them leads to serious problems. Anaemia can occur for three main reasons – not enough red blood cells are produced (problems with the bone marrow or chronic diseases such as cancer), too many are lost (major bleeding after an injury or surgery), or too many are destroyed (autoimmune disease or poisoning). Mild anaemia is not a problem and the cat’s body will usually recover on its own, but severe red blood cell loss either needs to be treated or else it can end in euthanasia. Sometimes medication is enough to fix the anaemia, but occasionally the lost blood cells need to be replaced. The way we measure red blood cells is called PCV (packed cell volume), also sometimes referred to as HCT (haematocrit), and transfusions are only really indicated when that number gets below 12-14% along with clinical signs. If a cat has a disease that can be treated such as infection, autoimmune disease or severe bleeding, then a transfusion may be performed but if their condition cannot be fixed, such as most cancers or end-stage chronic kidney disease, then it probably won’t. Do cats have different blood types? Alice and MavisYes. Just like people, cats have different blood types and giving the wrong one can have disastrous consequences. Feline blood types are called A, B, or AB, similarly named to those in people but entirely different chemically, and the difference between them is the type of chemical called an antigen that the cells have on their surfaces. The cat’s body knows to leave cells with its own antigens alone but to kill off cells that have the other type of antigen, so giving the wrong type of blood will not only result in severe inflammatory disease in the cat but also the immediate destruction of the new cells that have just been given. Therefore, it is essential that all cats be blood typed prior to donating or receiving blood (unlike dogs, who are not as picky for their first transfusion). Most cats worldwide are type A, fewer are type B, and very few are type AB. Interestingly, certain breeds are more likely to have certain blood types, with most Siamese having type A and most Devon Rex having type B. Most standard domestic shorthair cats are type A. There are other variations in feline blood, such as Mik positive or negative, which can cause reactions but these are less well studied and it is not yet possible to test for them. If any sort of mismatch is suspected, then a drop of the donor’s blood is mixed with a drop of the recipient’s blood on a card and the cells are monitored for a reaction. Where does the blood for transfusions come from? Although there are some feline blood banks in the US, most feline blood transfusions in the UK come directly from donor cats at the time it is needed. Donor cats, who are often staff pets but if your cat is big and healthy there’s no reason why they couldn’t donate, should be at least 4 kg but preferably over 5 kg in weight and must not have donated blood in the past 2 months. They should also be fully vaccinated, screened for infectious diseases and not on any medications. Potential donors are given a full physical exam and blood test to ensure they are healthy enough to give blood, and a blood type is done. Once they have passed all of these tests, they are usually sedated and approximately 50-60 ml of blood is collected from the jugular vein in the neck over about 10-15 minutes, followed by the administration of IV fluids to help replace some of the lost blood volume. The blood can then be stored in the refrigerator for up to 24 hours because it is mixed with an anti-coagulant to keep it from clotting. How is a blood transfusion given? The blood from the donor cat is then attached to an IV fluid line and filter and given very slowly into the patient’s vein. The recipient cat needs to be watched very carefully for any sign of reaction such as fever, changes in heart rate or changes in blood pressure. The whole process usually takes several hours and the cat is checked regularly throughout. The prognosis for any cat given a blood transfusion depends much more on the underlying condition than the transfusion itself, but it can significantly improve survival for cats with certain kinds of conditions. Feline blood transfusions are most commonly done in large referral centres, but as there is no special equipment needed they can be done in general practice as well. Because of the time and cost associated with screening both donor and recipient cats, as well as the collection and transfusion process itself, blood transfusions are very expensive and therefore not often chosen by the owner even if they are on offer. But as veterinary medicine progresses and we become more comfortable with the process, it will hopefully become a more practical option in the future. If you are worried about any problems with your cat, speak to your vet or try our Interactive Cat Symptom Guide to help decide what to do next.
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“Please don’t tell me I have to brush my cat’s teeth, because I’d rather keep my fingers…”

Lucien's teethMy last article talked about a few of the dental problems most commonly seen in cats, and how easily they can be missed by both owners and vets. Remember, a cat with dental disease will probably act just like a healthy cat, but that doesn’t mean they’re not in pain! I’ll continue now by mentioning some of the preventative measures and treatments that can help keep your cat’s mouth healthy and pain-free. What can I do to help prevent dental disease in cats? Of the diseases mentioned previously, periodontal disease (gum disease) is by far the most common but fortunately the easiest to help prevent. Although genetics plays some role in whether or not a particular cat is going to have bad teeth, there are several things you can do to help keep the pain and inflammation to a minimum: Brush the teeth - OK, this is admittedly not going to work for everybody. Or even most people. Or really even more than just a few people. But it’s worth giving it a try because if you are lucky enough to have one of the most chilled out cats on the planet, tooth brushing is the gold standard in preventative dental health care. By removing the bacteria before they are able to cause disease, the whole disease process is stopped in its tracks. Just use common sense and don’t get bit – if your cat doesn’t even like to be picked up or stroked, he probably won’t take too kindly to you shoving a toothbrush in his mouth. Dental rinses or gels - These products work by killing off some of the bacteria in the mouth before they have a chance to cause disease. For cats (who let’s face it, probably won’t let you get anywhere near their mouths), one of the most sensible options is an antiseptic liquid (often containing chlorhexidine) that you put in their drinking water which can have the added benefit of freshening your cat’s breath. In most cases, if it sounds too good to be true, it probably is so although products like this can have some beneficial effect, they are not likely to solve all of your problems. Special dental food - Some vets still say that plain old dry kibble helps keep your cat’s teeth clean. And many food manufacturers make similar claims to that effect. Although there is likely to be some truth to this, it is probably not as effective as we like to think. Most dry food is small and easy to swallow whole, so only a small percentage of it actually gets chewed. And I’ve seen plenty of cats who have seen nothing but dry food their whole lives with horrible teeth. If you want to help prevent dental disease with your choice of food, do your research and choose one that has been scientifically proven to decrease plaque formation. These foods tend to be more expensive, larger in size so they have to be chewed thoroughly before swallowing, and made in a special way such that they achieve maximum contact with the tooth surface. Ask your vet for their preferred dental health diet, which is often only available by prescription. Regular dental cleanings at the vet - Unfortunately, even if you could train your cat to open her mouth and sit still on command, this would probably still require general anaesthesia. Vets use the same kinds of dental instruments on cats that dentists use on people (ultrasonic scalers, polishers, and drills) and the procedure itself varies from mild discomfort (with a simple scale and polish) to severe pain (with a surgical tooth extraction) and the use of local anaesthetics is not as reliable in cats because they can’t tell us what they feel. Also, dental cleanings require a lot of water and it is essential that an endotracheal tube (soft rubber tube inserted into the trachea or windpipe after they are asleep to aid breathing) is placed to prevent water from being breathed into the lungs. Although a general anaesthetic may sound like a risk that is greater than the benefit of clean teeth, most people both overestimate the risk and underestimate the benefit. When you consider that severe periodontal disease can have potentially fatal consequences, a dental cleaning can actually help save your cat’s life. Many people are (understandably) also concerned with the cost of having their cat’s teeth cleaned. I can assure you that if vets had figured out an easier, faster or less expensive way of cleaning animals’ teeth, we would all be doing it. And by having routine dental cleanings throughout an animal’s life, you can help prevent major vets’ bills down the road from complicated surgical tooth extractions or related systemic illness. As they say, an ounce of prevention is worth a pound of cure! How can I tell if my cat has dental disease? Signs of severe dental disease or pain in cats include bad breath, wobbly teeth, excessive salivation or drooling, teeth chattering or strange gnawing motions. Other symptoms can include lethargy, decreased appetite, depression or hiding/not wanting to be touched, although these can be seen with almost any illness! Another important yet subtle sign is whether or not your cat actually chews their food before swallowing it. Even some cats with no teeth at all will happily eat dry food by swallowing it whole, so instead of just assuming that everything is ok, try to notice how much crunching they do with each bite. If you’re particularly observant, you may even notice your cat chewing more on one side of the mouth (the healthier side) to avoid touching a painful tooth. You may not ever notice them in pain, but more often than not owners remark after the painful teeth are removed that their cat is acting like a kitten again. This is further proof that they show such subtle signs of pain that they are often missed by owners and even vets, and although it is nice to be able to help them feel better, how much nicer would it be to prevent these problems from occurring in the first place! If you have noticed any of the symptoms listed above or are otherwise worried about your cat’s teeth, please speak to your vet. Because until your cat learns how to phone us herself, she’s relying on you to make sure that she doesn’t have to suffer with painful dental disease in silence.
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Gastric Torsion in Dogs

Also known as Bloat, Twisted Stomach, Gastric Dilatation-Volvulus or GDV, this condition is one of the most serious emergencies in small animal practice, and it can make all the difference to the outcome if it is recognised immediately. There are two parts to this condition, the bloat and the torsion. Bloat is when the dog’s stomach fills up with gas, fluid, froth or a mixture of all of these, to a far greater size than normal. Torsion (volvulus) is when the whole stomach twists inside the abdomen so that it is closed off at both its entrance and its exit, just like a sausage which is twisted closed at both ends. They may both occur together, or one may lead to the other. If bloat occurs first, the enlarged stomach is at greater risk of torsion. If torsion occurs first, bloating will definitely result. No food can leave the stomach, so it ferments, and no gas can be belched up. [caption id="attachment_1592" align="alignleft" width="214" caption="Annie, a Gordon Setter, suffered with bloat but survived thanks to her owner spotting the signs"]Annie, a Gordon Setter, suffered with bloat but survived thanks to her owner spotting the signs[/caption] The effect of the swollen stomach is that it presses on all of the other vital organs close to it. The breathing will become difficult and if the large blood vessels within the abdomen get squeezed so much that they cannot allow blood flow, then other organs will begin to shut down. The stomach wall and the spleen can become necrotic or dead due to loss of blood flow, and this releases toxins into the bloodstream. It is very painful, and if not corrected, the dog will die. The reasons for this condition occurring are not fully understood, but there are some well known and definite risk factors. The condition happens mainly in larger breeds, particularly those with a deep-chested shape like Great Danes, German Shepherds, Setters, Wolfhounds and Boxers, but these are not the only breeds affected. It also happens more (but not exclusively) in dogs over 7 years of age, and it is more common in males than in females. The risks increase if the stomach is very full, either with food or with water, so a dog which is fed once daily and eats very quickly, or gets access to the food store and gorges itself, would be at higher risk. Exercising after eating or after a big drink also increases the risk. Symptoms The onset of a gastric torsion is usually very rapid. The dog can appear quite normal one minute but once symptoms start they very quickly get worse. The most common symptoms are some or all of:
  • Restlessness, anxiety
  • Discomfort, followed by worsening pain
  • Arched back, reluctance to lie down
  • Drooling saliva or froth
  • Attempts to vomit (retching) with little being brought up
  • Swollen abdomen, often feels hard and if tapped feels like a balloon
  • Rapid breathing
  • Pale coloured gums and tongue
  • Collapse
  • Shock, possible death
It is vital to get veterinary attention as soon as possible if you suspect bloat or torsion. Always phone your surgery or your emergency service first as it will save valuable time if you go to the right place where the staff are prepared for your arrival. Occasionally, there can be a slower onset. This may mean that the stomach has bloated without twisting, but there is still a high risk of torsion occurring so advice should be sought from your surgery. Diagnosis & Treatment Diagnosing the condition can be very straightforward if a dog is showing all of the classic symptoms. X-rays may be needed to confirm it. Blood tests will probably be taken to find out how serious the changes in the blood are, because changes in the circulating levels of salts in the blood can be life-threatening. These will be treated with intravenous fluids given quickly and at high volumes. A stomach tube may be passed, but this will not be successful if the stomach has twisted because the tube will not be able to get through the obstructed entrance. The vet may decide to decompress the stomach (let some gas out) by inserting a needle into the dog’s side. The order in which these procedures may be carried out will depend on just how ill the dog is. A surgical operation will be needed to untwist the stomach, to check for damage to the organs and to try to prevent it from happening again. Some will need immediate surgery and others will need to be stabilised first to improve their chances of survival. Some dogs have to have part of the stomach or the spleen removed if the damage has been severe. The surgery is very high risk especially if the dog is already in shock because of the effects on the circulation and breathing. When successful surgery is carried out, with the stomach and spleen returned to their normal position or repaired if damaged, it is common to perform a procedure to try to stop the condition occurring again, known as a gastropexy. There are different ways of doing this, but the aim is to anchor the stomach to the abdominal wall so that it is unable to twist. It could still bloat, but hopefully the consequences would not be so serious. The survival rate following this condition varies a lot, but sadly, many dogs die each year from gastric torsion. The survival rate is better in younger dogs and if immediate treatment is given. Prevention
  • Be aware of the signs to look out for
  • Feed larger dogs two or three smaller meals a day
  • Do not allow your dog to exercise after eating or after a big drink
  • Try to discourage rapid eating by separating competitive dogs at feeding time
  • Try a specially shaped feeding bowl designed to slow eating down
  • The effects of type of food and feeding from a raised bowl are under constant review and more research will show whether these are significant or not
[caption id="attachment_1596" align="alignright" width="183" caption="Martha with her young friend Tilly"]Martha with her young friend Tilly[/caption] I suspect that most vets never forget the first case of gastric torsion that they see. Mine was in a Great Dane, which I worked on all night with the help of two nurses. That one was fortunate and survived. It was a great moment for all of us when it left the surgery mid-morning the next day. The nurses jokingly told me that there was another one on the way in but I didn’t believe them, at least, not until I saw it walk in, arriving just as the first one left. Since then I have treated many dogs with gastric torsion and it is always memorable and always a challenge. My own boxer Martha died of this condition last year despite very prompt attention and all preventative measures being in place. Sadly, her age was against her and our only consolation is that her suffering was very short-lived. If you are concerned about your dog's health, talk to your vet or use our interactive Dog Symptom Guide to help decide what to do next.
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Neutering dogs – Bitch spay operation: a step by step guide

Deciding whether to spay Spaying or neutering a female dog is not a small operation, so owners should think carefully about all the pros and cons before deciding. The main advantages of spaying are preventing pregnancy, preventing infection of the uterus (pyometra), preventing ovarian or uterine cancer and reducing the likelihood of mammary (breast) cancer, all of which can be life-threatening. It also prevents the inconvenience of having a bitch in season with unwanted attention from male dogs. The main disadvantages are major surgery with associated risks, an anaesthetic with associated risks and the increased likelihood of urinary incontinence in later life. Fortunately, the risks involved in anaesthesia and surgery are very small indeed compared with the risks of the other conditions which are prevented by spaying. Urinary incontinence in later life is a nuisance but not very common, and can usually be controlled by drugs. There is no medical reason to let a bitch have one litter before spay, in fact some of the benefits like protection against mammary tumours, are lost if the operation is delayed. Unless an owner is committed to having a litter, with all the work and expense that can be involved, and the bitch is also suitable in temperament and free of any hereditary problems, then breeding should not be considered. Tilly GrinSome people expect that their bitch will get fat after spay, but in fact this is entirely preventable with a healthy diet and proper exercise. My own opinion is that most bitches should be spayed because of the health benefits. My boxer bitch Tilly was recently spayed. Deciding when to spay It is not a good idea to spay when a bitch is in season or about to come into season, because the blood vessels supplying the uterus and ovaries are all larger and this will increase the risks of surgery. The other time we try to avoid is the 8 weeks after a season, when a bitch may suffer from a hormonal imbalance called a false pregnancy. If this happens, she may be acting as if she is nursing pups and the operation at this time would cause such sudden changes in hormone levels that it would be unfair to her. Also if she was producing milk, the enlargement of the milk glands would make it more difficult for the spay wound to heal. For all of these reasons, the time chosen to spay is usually either before the first season occurs, or 3-4 months after a season. A physical examination by the vet will determine whether a 5-6 month old bitch puppy is mature enough to spay before her first season. Before the operation As well as timing the operation carefully to reduce any risks, it is also important that the bitch is not overweight. Because this increases the difficulty of the operation, it may well be advised that an overweight bitch should lose weight before the operation. Another important way of spotting avoidable risks is by taking a blood test before the anaesthetic. This could be done on the day of the operation or a few days earlier. This is used to check the liver and kidney function (both vital when dealing with anaesthetic drugs) and to rule out any unsuspected illnesses. Before going to the surgery Before any anaesthetic the patient should be starved for a number of hours, according to the instructions of the surgery. This prevents any problems with vomiting which could be dangerous. It is also a good idea to allow the dog enough exercise to empty the bladder and bowels. Apart from that, it is best to stick as closely as possible to the normal routines of the day so that the dog does not feel anxious. Being admitted for surgery On arrival at the surgery, you can expect to be seen by a vet or a veterinary nurse who will check that you understand the nature of the operation and will answer any questions you may have. They will ask you to read and to sign a consent form for the procedure and ask you to supply contact phone numbers. This is very important in case anything needs to be discussed with the owner before or during the operation. Before the anaesthetic Your bitch will be weighed to help calculate the dosages of drugs and given a physical examination including checking her heart. If a pre-anaesthetic blood test has not already been done, it will be done now and the results checked before proceeding. If any abnormalities are found, these will be discussed with the owner before deciding whether the operation goes ahead or not. One possible outcome is that extra precautions such as intravenous fluids may be given. A pre-med, which is usually a combination of several drugs, will be given by injection. This begins to make the dog feel a bit sleepy and ensures that pain relief will be as effective as possible. The anaesthetic There are several ways in which this can be given, but the most common is by an injection into the vein of the front leg. The effects of the most commonly used drugs are very fast, but don’t last for very long, so a tube is placed into the windpipe to allow anaesthetic gas and oxygen to be given. The anaesthetic gas allows the right level of anaesthesia to be maintained safely for as long as necessary. Various pieces of equipment will then be connected up to monitor the anaesthetic. This is a skilled job which would usually be carried out by a qualified veterinary nurse. Apart from the operating table, the instruments and the anaesthetic machine, a lot of specialised equipment will be on “stand by” in case it is needed. The area where the surgical incision is to be made will be prepared by clipping and thorough cleaning to make it as close to sterile as possible. The site is usually in the middle of the tummy, but some vets prefer to use an incision through the side of the tummy. The operation While the bitch is being prepared for surgery as mentioned above, the surgeon will be “scrubbing up” and putting on sterile clothing (gown, gloves, hat & mask) just as in all television surgical drama programmes. The surgical instruments will have been sterilised in advance and are opened and laid out at the start of the operation. The operation involves removal of the ovaries and uterus (ovario-hysterectomy). The surgeon carefully opens the abdomen by cutting through the various layers. The first ovary is located and its blood vessels are tied off before it can be cut free at one end, then this is repeated with the second ovary. It is a delicate and fiddly job, needing great care and attention. The main body of the womb or uterus is then tied off as well before the whole thing can be cut free and removed. After checking for any bleeding, the layers of the tummy can then be sewn closed again. A dressing might be applied to the wound. Further drugs may be given now as needed. When the operation is finished, the gas anaesthetic is reduced and the bitch begins to wake up. She will be constantly monitored and the tube removed from her windpipe when she reaches the right level of wakefulness. Recovery Like humans, dogs are often a bit woozy as they come round, so she will be placed in a cage with soft warm bedding and kept under observation. Usually they will wake up uneventfully and then sleep it off for the rest of the day. After-care The bitch will not be allowed home until she is able to walk and is comfortable. Full instructions should be given by the surgery concerning after-care. The most important things would be to check the appearance of the wound, to prevent the bitch from licking it (with a plastic bucket-collar if necessary) and to limit her exercise by keeping her on the lead. Any concerns of any kind should be raised with the surgery. Any medication supplied should be given according to the instructions. Pain relief can be given by tablets or liquid on the food. Antibiotics are not always needed, but may be supplied if there is a need for them. Usually there will be stitches in the skin which need to be removed after about 10 days, but sometimes these are concealed under the surface and will dissolve by themselves.

tilly's wound with text

After a couple of weeks, if all goes according to plan, the bitch can be allowed to gradually increase her exercise levels. This is the stage that Tilly has now reached and she is thoroughly enjoying a good run again now that she is feeling back to normal.
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