Confirmed pyometra: treatment straightforward?

Re: Confirmed pyometra: treatment straightforward?

mariette asselbergs — Fri, 28 Nov 2014 17:25:18 GMT

[quote user="Gillian Mostyn"]

I agree with David. I cannot justify increasing the price that much. We only charge for the work we do, not for the risk to the dog or the possibility of complications. Those would only be charged for if they happened. Our practice has a similar bitch spay fee, with a pyo approx £350 IF it justifies it in terms of time and consumables. If a pyo turns out to require nothing more than a 'normal' spay (such as an open pyo), that is all that gets charged. I know you are only going from the price list Mariette, but maybe the owner would have preferred to take the 'risk' of immediate surgery if the cost was less... While people should be prepared to pay the correct cost of pet care, £1000 is a hell of a lot of money for what is often just a spay with a big uterus.

[/quote]

I can see your point Gilian, but unfortunately in our environment here this is the price we (have to) charge to run a hospital in an urban environment. Our bitch spays are probably uneconomically cheap if they didn't come with client bonding etc.

Having said that, in this particular case it wasn't the finances that were the limiting factor, it was that the owners had seen the dog through big mammary surgery a year ago and didn't want her go through similar again. And me and my colleagues could not convince them that it was absolutely necessary/possibly less traumatic than the mammary surgery.

Alizin would have been the solution for this case in my opinion, but unfortunately not in the opinion of the colleague who discussed the scan results and further options with the owners. I have now circulated the Alizin articles.

Mariette

Re: Confirmed pyometra: treatment straightforward?

Evelyn Barbour-Hill — Fri, 28 Nov 2014 00:34:11 GMT

Perhaps the pyometra does not qualify for the usual very low price of a routine bitch spay (done cheap for as long as I can remember, for various reasons including price comparison with neighbouring practices, the loss-leader principle, a feeling one should be charitable about it, some vague idea about "the going rate", and simple tradition).

Re: Confirmed pyometra: treatment straightforward?

Gillian Mostyn — Thu, 27 Nov 2014 23:08:00 GMT

Re: Confirmed pyometra: treatment straightforward?

David Mills — Thu, 27 Nov 2014 19:58:19 GMT

[quote user="mariette asselbergs"]

[quote user="Gillian Mostyn"]

[quote user="mariette asselbergs"]Pyometra surgery will cost £900 with a day or two hospitalisation, a drip, antibiotics, painkillers etc[/quote]

[quote user="mariette asselbergs"]But if we do a normal spay after alizin, that will be £160. [/quote]

I'm curious - why the massive price difference? I am struggling to understand that degree of difference, even with the extras you mention. I'm not querying the prices as such - we all have our own business plan- just why the big difference? (I find pyo ops to be quicker in many cases - the ovaries are a lot easier to access. Obviously if the uterus has already ruptured or ruptures during surgery, the owner is pre-warned that risks and costs will substantially increase.)

[/quote]

I do not make up the prices in the practice I work in of course.

I can sort of understand the price difference since they are never elective surgery, always sort of urgent, they do take longer and need careful handling if the uterus is full of pus, the wound is much larger, takes more time stitching up. They often need a drip and certainly if they have been polydipsic and off colour for a week.The chance of complications is much greater both in surgery and afterwards. And they need more after care. There is more cleaning up to do.

But I don't know, are there many people doing it for much cheaper. or making much lower estimates?

As for me, I just have to follow our pricing up of course.

Mariette

[/quote] The owners are idiots. Gosh I wonder how much guilt money lines the coffers of cremation companies. Re prices, I cannot see how the practice can charge 6x the cost of a spay for a spay plus drip, a day or two in hospital and some antibiotics. The difference in surgical time is negligible.

Re: Confirmed pyometra: treatment straightforward?

mariette asselbergs — Thu, 27 Nov 2014 18:37:59 GMT

[quote user="Gillian Mostyn"]

[quote user="mariette asselbergs"]Pyometra surgery will cost £900 with a day or two hospitalisation, a drip, antibiotics, painkillers etc[/quote]

[quote user="mariette asselbergs"]But if we do a normal spay after alizin, that will be £160. [/quote]

[/quote]

I do not make up the prices in the practice I work in of course.

But I don't know, are there many people doing it for much cheaper. or making much lower estimates?

As for me, I just have to follow our pricing up of course.

Mariette

Re: Confirmed pyometra: treatment straightforward?

mariette asselbergs — Thu, 27 Nov 2014 17:51:07 GMT

Here is the sad outcome of this case:

Owners were not offered Alizin.

They did not want surgery and discharged themselves (after having been fully warned about all the risks) on ABx.

Dog brought back in collapsed 4 days later and euthanised.

Owners did want individual cremation, were obviously very fond of the dog, but we failed to offer/get through what the dog needed.

Mariette

Re: Confirmed pyometra: treatment straightforward?

Anthony Todd — Tue, 25 Nov 2014 14:35:56 GMT

[quote user="robloxley"]Reports seem to be in the order of a few percent[/quote]

Fair enough, pity they didn't even mention cause of death, but not to nit-pick.

I wonder if posters would agree with 3.2%? I'd say my guestimate would be much lower, if any, but I suppose I could be mentally eliminating some for all sorts of "justifiable" reasons.

Re: Confirmed pyometra: treatment straightforward?

Rob Loxley — Tue, 25 Nov 2014 13:45:05 GMT

[quote user="Anthony Todd"]How many massive, or any pyos, have all of you had die after surgery? [/quote]

Reports seem to be in the order of a few percent e.g. http://veterinaryrecord.bmj.com/content/173/16/396.full

Re: Confirmed pyometra: treatment straightforward?

Wren — Tue, 25 Nov 2014 10:23:45 GMT

[quote user="Anthony Dennison"]

[quote user="Wren"]

[quote user="Anthony Dennison"]

considering whether to surgerise them,

[/quote]

I have never heard this abuse of the English language before and never want to again. What is it with people trying to turn everything into a verb nowadays??

[/quote]

Apologies, it was a joke word used in my year at uni after someone nervously mispronounced 'surgeries'.

[/quote]

To be fair my reply was pretty tongue in cheek, but I forgot the smiley! You may be excused in the case of ironic usage. Just don't do it again

Re: Confirmed pyometra: treatment straightforward?

Anthony Todd — Tue, 25 Nov 2014 10:19:54 GMT

[quote user="Julian Earl"]What would you recommend?[/quote]

What?..... medical treatment with a 40% chance of recurrence...you must be joking, surely!!

How many massive, or any pyos, have all of you had die after surgery? These days with fluid therapy it must be near nil, and the recurrence rate is zero, recovery in days, sequelae nilish or less.

Back in the day when fluids were in glass bottles and pyos got a really heavy slug of anaesthetic, no added O2 and no fluids at all, [usually,] mortality was really very low provided you didn't fluff about making up your mind.

To me it's a no-brainer, bitch would be home and happier the same night...

Time and again on the forum I read of cases where the cost is factored in as part of the case management . This must confuse the owners and make the vet's decision making much more difficult.

I think it's better to say "best things to do are" [for diagnostic procedures] and "best treatment is X" and see if money is the limiting factor rather than offering a sort of restaurant menu of diagnostics and treatments then expecting the owner to choose.

Re: Confirmed pyometra: treatment straightforward?

Julian Earl — Tue, 25 Nov 2014 09:51:26 GMT

[quote user="mariette asselbergs"]

Here is one to debate for dino vets with loads of experience, younger evidence based scientifically oriented vets, and “nervousness based vet medicine” vets anxious to be struck off if they choose the wrong decision:

Seen this morning a 11 year old collie cross entire bitch. Had a large mammary tumour surgery a year ago with histology malignant carcinoma and guarded prognosis. Recommended neutering but owner did not want to subject her to another large surgery. Had a season 4 weeks ago. Was off food a week ago for a day or two, then perked up but started drinking and urinating a lot. Now off food, shivering and panting.

Came in quite perky, good body condition of 3/5, has not lost weight since last year, nice thick fur, no potbelly, T 39.6, HR 140 no murmurs, gums red, no halithosis, no vaginal discharge, abdominal palpation not easy because quite fat and solid and a large bladder.There are a number of small (1/2-1 ½ cm diameter) solid well defined lumps in various mammary glands. Sent out for a urine sample which shows high leukos, high protein and some blood, no glucose or ketones. Abdominal scan shows a large bladder with two fluid filled tubular structures on both sides, consistent with the suspicion of a closed pyometra.

Owner is not at all keen on surgery, would prefer a course of antibiotics “since it is only an infection”.

What would you recommend?

Try a course of antibiotics?What is the risk of a desastrous uterus rupture or fatal kidney damage?

Add metacam? What is the risk in a situation of toxic PUPD?

Alizin? What is the risk in a closed pyometra? Is there any extra risk involved for the mammary tumours?

Would the stress of surgery have a negative effect on the mammary tumours? What is this dogs life expectancy anyway with malignant carcinoma hanging above its head?

Anybody experience in using prostaglandines in these cases?

Looking forward to contributions!

Mariette

[/quote] Only used prostaglandins once in a dog as far as I can remember. Didn't solve the pyometra but it does cause profuse vomiting and diarrhoea within seconds to minutes. I would advise hospitalising the dog even just for one hour until these effects have passed. Even better, save your nurses some cleaning and take the dogs outside near drainage etc.Maybe there is a therapeutic use there, as an alternative to apomorphine for potential toxicity cases?

Re: Confirmed pyometra: treatment straightforward?

Hannah Wynne Richards — Tue, 25 Nov 2014 09:48:04 GMT

Gillian. Obvious answer. You're a traditional,ethical veterinary surgeon. You price everythingproperly on costs plus a decent level of profit. Some practices use "loss leaders" to get clients through the door, then have to make up the difference somewhere else in order to remain solvent!

Wynne

Re: Confirmed pyometra: treatment straightforward?

Anthony Dennison — Tue, 25 Nov 2014 09:43:00 GMT

[quote user="Wren"]

[quote user="Anthony Dennison"]

considering whether to surgerise them,

[/quote]

I have never heard this abuse of the English language before and never want to again. What is it with people trying to turn everything into a verb nowadays??

[/quote]

Apologies, it was a joke word used in my year at uni after someone nervously mispronounced 'surgeries'.

Re: Confirmed pyometra: treatment straightforward?

Matt Hilary — Mon, 24 Nov 2014 12:15:32 GMT

http://www.zoovet.ee/product/docs/9083017916.pdf

Fieni, F. (2006). 'Clinical evaluation of the use of aglepristone, with or without cloprostenol, to treat cystic endometrial hyperplasia-pyometra complex in bitches'. Theriogenology 66 pp 1550–1556.

Re: Confirmed pyometra: treatment straightforward?

Wren — Mon, 24 Nov 2014 10:37:10 GMT

[quote user="Anthony Dennison"]

considering whether to surgerise them,

[/quote]

I have never heard this abuse of the English language before and never want to again. What is it with people trying to turn everything into a verb nowadays??

Re: Confirmed pyometra: treatment straightforward?

John Flynn — Sun, 23 Nov 2014 20:39:37 GMT

I reckon surgery (after medical stabilisation if necessary) wins on the antibiotic-responsibility ticket.

Foolishly tried prostaglandins years back for dogs where surgery deemed to be risky - one patient reportedly experienced respiratory arrest a few hours after treatment (recovered), but I wouldn't offer that option again.

Alizin is fair enough, but a big chunk of these cases recur when managed medically in my limited experience, the owners often don't return for the safer spay afterwards and you end up in the same boat less than a year later.

My conclusion has been that medical managment is no less risky or more successful than surgery, indeed I suspect the opposite is true, and surgery is quicker and costs less (usually). I can see the logic in it being an option with a view to breeding the bitch at next season, but then there's plenty of healthy bitches out there to breed from so this doesn't really make a lot of sense to me either...

Re: Confirmed pyometra: treatment straightforward?

Gillian Mostyn — Sun, 23 Nov 2014 20:10:31 GMT

[quote user="mariette asselbergs"]Pyometra surgery will cost £900 with a day or two hospitalisation, a drip, antibiotics, painkillers etc[/quote]

[quote user="mariette asselbergs"]But if we do a normal spay after alizin, that will be £160. [/quote]

Re: Confirmed pyometra: treatment straightforward?

Charlotte Marshall — Sun, 23 Nov 2014 18:30:22 GMT

I've not tried alizin myself though there are good reports. However the last closed pyo we had was not obvious on ultrasound scan initially for some reason started on ab's over the weekend (seen OOH Thursday and rechecked Friday am) with a recommendation to spey on the Monday as we were sure it was brewing a pyo. The owner was reluctant to operate. Came in the Tuesday morning with peritonitis and a belly full of pus - which was not a fun surgery!

Because of this I would certainly be willing to try alizin though I think I would probably admit the dog for the first 24 - 48 hrs to keep an eye on it. I would not be happy sending home a known closed pyo on antibiotics etc alone (and wouldn't have been before this dog either).

Re: Confirmed pyometra: treatment straightforward?

Anthony Dennison — Sun, 23 Nov 2014 11:21:54 GMT

[quote user="Elizabeth Billimore"]My experience of trying alizin wasn't great. 24 hours after being seen and given alizin and antibiotics I had a much sicker dog and the only option seemed to be IVFT and surgery. [/quote]

They someones do get worse for the first 24-48 hours and then pick up. We have hospitalised animals in these cases, considering whether to surgerise them, then they start improving.

Re: Confirmed pyometra: treatment straightforward?

Richard Carter — Sat, 22 Nov 2014 17:35:20 GMT

If it is a choice of pts or avoiding pyo surgery at all costs and you not thrilled about alizin, then a good combination antibiotic regime (amox/clav with metronidazole) for 10 - 14 d and spay at the end without all the drips etc but make sure the owner is aware this would not be your first choice as you could end up with endotoxic shock, renal and hepatic damage etc.

Once the ovaries are out, many of the more benign mammary lumps will remain relatively dormant and hopefully the dog will find another way to leave this planet before the tumours decide to progress to a more malignant form so I wouldn't waste time on the table removing mammary tumours that are firm, small and relatively inactive.

Re: Confirmed pyometra: treatment straightforward?

Bibs — Sat, 22 Nov 2014 12:08:32 GMT

My experience of trying alizin wasn't great. 24 hours after being seen and given alizin and antibiotics I had a much sicker dog and the only option seemed to be IVFT and surgery.

There might be some use for it but personally I wouldnt rely on it as a treatment option as there is a risk they could deteriorate in the mean time. Might be worth trying if they are not unwell and surgery is out of the question but would need close monitoring. That's my view anyway.

Re: Confirmed pyometra: treatment straightforward?

tess — Fri, 21 Nov 2014 23:25:05 GMT

Playing devil's advocate here, but what if she doesn't respond to the Alizin?

Re: Confirmed pyometra: treatment straightforward?

mariette asselbergs — Fri, 21 Nov 2014 22:52:13 GMT

Thank you all very much for your input and I am sure it will give a nice overview of options.

Let me now put in some financial context in this case (in my practice).

The cost of alizin treatment is considerable: 3 injections each of them with a re-examination charge, altogether for this 29 kg dog will come to around £200. Combined with antibiotics, probably up to £250. Pyometra surgery will cost £900 with a day or two hospitalisation, a drip, antibiotics, painkillers etc. If we want chest x rays there is £150 or another abdominal scan for liver/spleen screening £100 to pay. If we want bloods that's another £80.

But if we do a normal spay after alizin, that will be £160.

Do I now still press for surgery? (I know Wynne, I don't need to anticipatye financial worries of the owner, but I would like to have both my financial picture and the best treatment (or acceptable treatment) right in my head when talking to the owner.

PS When she had mammary tumour surgery in January 2014 there was no lymphnode involvement as far as palpable lymphnodes, and up to now, no lymphnode involvement palpable, no weight loss, and only well defined, solid marble like growths. A different but related debate maybe: how often do we see dogs actually dying from mammary tumours? (I can only remember the odd one, one horrible mastitis carcinomatosa, but otherwise, usually operable tumours and dogs dying from something else before the mammary tumours became unmanageable).

Mariette

Re: Confirmed pyometra: treatment straightforward?

Nicola Cole — Fri, 21 Nov 2014 21:19:02 GMT

Personally for a closed pyo I would advise surgery as I think is the most straightforward option (as am under the impression that would want to spay anyway before next season if medically treated). In this particular scenario I would advise radiographing chest first and discuss medical options. But if chest clear, if this was my dog and otherwise 'healthy' , I would operate.

Re: Confirmed pyometra: treatment straightforward?

Rob Loxley — Fri, 21 Nov 2014 13:47:17 GMT

Given the mammary carcinoma history I'd be interested to scan the liver/spleen and radiograph the chest. Also how was the tumor graded, any LN involvement etc.

However there's still the pyo to deal with and I'd offer Alizin as an option. There is lots written up regarding its use and outcomes e.g. http://www.ncbi.nlm.nih.gov/pubmed/14633233 & http://www.ncbi.nlm.nih.gov/pubmed/25234791

I agree that we need to make clear the seriousness of the situation, but I'd also be interested where the client's objection is rooted ?risks of surgery/ cost etc.