Blocked cats.....

Re: Blocked cats.....

Lorna McHardy — Sat, 01 Sep 2012 18:11:17 GMT

[quote user="James Laidlaw"]

[quote user="Mark Holmes"]I think it depends on how much you value a penis.[/quote]

Well that's put a grin on my face for the end of my Saturday at work... Quote of the month perhaps?

[/quote]

It's made me smile too, and I'm not smiling much right now. Thank you Mark

Re: Blocked cats.....

Rob Loxley — Sat, 01 Sep 2012 18:02:27 GMT

[quote user="Iain McAllister"] if so what combinations[/quote]

Usually a combination of smooth and striated muscle realaxants is suggested (acepromazine or prazosin or phenoxybenzamine and dantrolene or diazepam). Would also continue the meloxicam.

[quote user="Iain McAllister"]How long would you give things to normalise before considering surgery?[/quote]

IIRC Dibenyline can take a few days to work

Re: Blocked cats.....

James Laidlaw — Sat, 01 Sep 2012 13:57:49 GMT

[quote user="Mark Holmes"]I think it depends on how much you value a penis.[/quote]

Well that's put a grin on my face for the end of my Saturday at work... Quote of the month perhaps?

Re: Blocked cats.....

Mark Holmes — Sat, 01 Sep 2012 13:27:01 GMT

I think it depends on how much you value a penis. I have not amputated one since flushing the bladder at laparotomy and I think this is better than mutilating the urinary tract.

Re: Blocked cats.....

Iain McAllister — Sat, 01 Sep 2012 13:22:05 GMT

I'll tack thison to this thread - 8yo male neuter - of normal weight - no history of urinary tract disease until...

Monday- frequent visits to litter tray - bladder was empty - treated with metacam - symtoms settled

Wed- symptoms recurred this time had a full bladder -bloods normal GA catheterised with Jackson easily - no note of an obstruction - flushed out saline (I have inherited this case and cant talk to the vet who catheterised at the moment) Urinanalysis lots of struvite - no other details on the notes regardingthe analysis

Thu mid morning - The catheter was in for 24 hours removed -sent home on metacam - urinated that evening

Fri am - dysuria again - bladder full - re sedated and catheterised with slipperey sam- easily again - bladder radiographs -- pneumocystogram - no uroliths - no ultrasound performed- flushed fluids all day - catheter removed at end of day - sent home still on metacam and cystophan - dibenylline added in - no urination overnight -

Sat am (1st time I have seen this cat...) -re-exam bladder small orange sized - no expression possible conscious - sedated and expression performed - very slow - no stream - 90 ml obtained - urinalysis SG 1.025 blood+++ ph 6.5 sediment rbc+++ wbc+ minimal debris no crystals - culture submitted Wed result back from lab - negative

I know there is a debate about whether urethral spasm "exists" - seem to be 4 drugs commonly used - dibenylline/ dantrium / hypovase /acp - can some of these drugs be comined safely or added to the dibenylline - if so what combinations - - doesn't sound like a stricture due to the easy passing of the catheter (but I havent passed it myself so can't comment)

Was interested to see the comment about laparotomy bladder washout and cystotomy tube - or would be people go straight for perineal urethrostomy ?

How long would you give things to normalise before considering surgery?

Thanks

Re: Blocked cats.....

Mark Holmes — Fri, 26 Aug 2011 10:21:29 GMT

I was particularly referring to ctas that block repeatedly after removal of the urinary catheter. Each of the three had, when the catheter was replaced no notable physical obstruction so it would have been easy to assume spasm, each had however this thick paste which, when flushed away seemed to resolve the issue immediately.

I have consequently become much more proactive in getting baldders out and flushing them properly with complicated obstructions. A cystostomy tube is much better to manage than a indwelling urinary catheter anyway.

Re: Blocked cats.....

Anthony Todd — Thu, 25 Aug 2011 19:41:17 GMT

[quote user="Mark Holmes"]struvite paste in the baldder [/quote]

How long after the initial block?

Was the cat on an anti- struvite diet?

Where do all these observations leave the interstitial cystitisti and/or the stress believers?

Does anyone actually believe that giving cats climbing frames and towers will prevent recurrence of FLUTD?

Re: Blocked cats.....

Mark Holmes — Thu, 25 Aug 2011 18:07:33 GMT

Would add one more thing, cats that repeatedly reblock, people talk alot about urethral spasm, I have fallen out with this as a diagnosis. The last three that repeatedly blocked have been given a cystotomy and the bladder flushed completely, in all cases there was a huge (quite staggering) amount of thick struvite paste in the baldder significantly more than could be appreciated on ultrasound and far more than could be removed with lavage through a urinary catheter. Almost the constistancy of primula cheese. We left a cystostomy tube in for a few days to give the urethra complete rest and there were no further problems.

Re: Blocked cats.....

Evelyn Barbour-Hill — Wed, 24 Aug 2011 01:05:16 GMT

[quote user="KathW"]osmolality[/quote]

I love that word.

Re: Blocked cats.....

KathW — Tue, 23 Aug 2011 21:12:59 GMT

It was an online course and below is my queries about this on the discussion forum. Ans from tutor at RVC

Statement - "Antibiotics shouldn't be given when a catheter is in. It doesn't prevent infection but simply means if you do get an infection it will be ressitant to whatever you have put them on. If you give them antibiotics it should be at the time of catheter removal. "

My Question "Is there never an infection there in the 1st place? I thought that was a reason for the raised ph and solutes coming out of solution? "

Answer "Not in cats. When cats have struvite crystals or stones they are almost always sterile (in contrast to dogs). These cats typically have very concentrated urine. If you take cat urine into the lab and innoculate it with bacteria the bugs die - they simply cannot cope with the osmolality.

Cats are really contrary. When they have signs of cystitis they don't have a UTI. Old cats with CKD/diabetes/hypertyroidism may get UTIs (since they have more dilute urine) but then rarely show signs of cystitis. "

My Question "If you are giving a relevant antibiotic at a theraputic level why would an infection that then developed be resistant to the antibiotic the animal is already on? "

Ans "You will either select for bacteria that are already resistant or those that can aquire (typically plasmid mediated) resistance. It is inevitable that when you breach the urinary tract defences with a catheter that some bacteria will also (with time) colonise the catheter. This is not the same as a true infection which is the colonisation, adherence and multiplication of microbes within the urinary tract. "

It does say in there - they are almost always sterile. It wa also mentioned elsewhere to send urine off for culture but the point was even if you felt you should give antibiotics then wait until the catheter was removed.

Re: Blocked cats.....

Anthony Todd — Tue, 23 Aug 2011 20:16:33 GMT

[quote user="KathW"]"These cats typically have very concentrated urine. If you take cat urine into the lab and innoculate it with bacteria the bugs die - they simply cannot cope with the osmolality. "[/quote]

So did they give any credence to the diagnosis of "bacterial cystitis" which is said to cause up to 10% of feline cystitis?

Re: Blocked cats.....

KathW — Tue, 23 Aug 2011 20:12:43 GMT

Last CPD I did with RVC this year they said never never put blocked cat on antibiotics until catheter removed (to reduce chance of resistance developing)

If you give them antibiotics it should be at the time of catheter removal.

"These cats typically have very concentrated urine. If you take cat urine into the lab and innoculate it with bacteria the bugs die - they simply cannot cope with the osmolality. "

"You will either select for bacteria that are already resistant or those that can aquire (typically plasmid mediated) resistance. It is inevitable that when you breach the urinary tract defences with a catheter that some bacteria will also (with time) colonise the catheter. This is not the same as a true infection which is the colonisation, adherence and multiplication of microbes within the urinary tract. "

Something I hadn't really appreciated.

Re: Blocked cats.....

Anthony Todd — Tue, 23 Aug 2011 18:55:36 GMT

[quote user="Robin Grimmer"] Is it not the hyperkalaemia that actually kills them ?[/quote]

I am still sceptical of hyperkalaemia causing death, in an unblocked cat

In the days well before {K++] was done pre-unblock [and usually never] I cannot recall an unblocked cat dying before during or after the unblock and it was only post 1977 when I started using post unblock fluids that anyone in my sphere realised it's significance.

In fact current thinking then was to add K++to the fluid because of the post-unblock reflex diuresis with consequent lowering of blood [K++] which was said to occur. Is this not believed to be the case now??

I just wonder if, now, the plethora of pre-unblock tests and drugs given prior to what may be a 2 minute un-block delays the reversion of the cat's biochem and exacerbates any depression of vital function for too long. I have seen blocked cats left 'til after the ops and sometimes 'til late in the day!

Don't analgesics usually have a synergistic effect with analgesia and I wonder, with respect, whether it was this and not the "relief of excruciating pain" that caused the anaesthesia to deepen?

Re: Blocked cats.....

Robin Grimmer — Tue, 23 Aug 2011 18:22:13 GMT

[quote user="bob lehner"]

[quote user="Hannah Wynne Richards"]

I think cystocentesis esp concious is a current fashion,and frankly my reaction is "ouch " .......I once lost one which was fine until I relieved the excruciating pain, when it's plane of anaesthesia suddenly deepened

Wynne

[/quote]

I've never really seen an animal express any undue pain/reaction to cystocentesis. Might it not be better to relieve the 'excruciating pain' you describe asap by cysto before embarkling on other procedures including a risky g.a. ? Is it not the hyperkalaemia that actually kills them ?

I'm surprised how liitle emphasis seems to be put on the pain these unfortunate animals must be suffering. Can you imagine anything worse than having an obstructed bladder - it's the stuff of nightmares.

[/quote]

I used to routinely cysto my blocked bladders if the bladder was really full, but I tend to avoid this now. I remember a colleague once rupturing a cat's bladder by attempting a conscious cysto on a blocked cat with a very full, firm bladder.

Re the pain - you've got to wonder how some clients can miss the agony and discomfort a blocked cat can be in. I remember one case where this poor cat came in collapsed with a rock hard bladder - urea, creatinine and potassium were dangerously high. His obstruction was actually a grass seed He did ok in the end.

Re: Blocked cats.....

Anthony Todd — Tue, 23 Aug 2011 17:31:04 GMT

[quote user="David Mills"]I simply don't buy the urethral trauma side of things[/quote] et seq

Can't agree. My recollection is that all blocked cats have an obstruction always beginning at the cranial end of the penis and, depending on the degree of block, extending cranially into the bladder, that is unless it's a repeat unblock with a resulting stricture further up.

Most cats can be unblocked with retropulsive flushing but, as you imply, not with a sideways opening whistletip catheter.

And if you use a catheter which doesn't touch the sides the pressure will be both ways, after and before the obstruction. I assume you occlude the distal urethra??

This is why I always tried to unblock under sedation and, believe me, if your catheter was hitting the urethral wall the cats let you know; under GA who knows. Certainly post catheterisation strictures are very common.

Jackson had a dramatic slide of a cat's urethra with the mucosa curling as in a finely planed piece of wood with the use a sharp catheter [not plastic, I admit] so the urethral mucosa isn't hard to damage.

Whilst straightening the male urethra makes catheter passage easier I really would be surprised if one could be passed without touching the sides.

Afraid I've seen a Jackson's through the bladder wall, mind you, conceivably, it may have had the stilette in situ when passed, no one was admitting that....

And I reckon a cat's bladder with an indwelling catheter is pretty empty all the time, certainly no more than 5cms to the far end, plus the urethra.

Try an I/V cannula, use a 22 or 24 if it makes you feel better, you won't go back to a trimmed Jackson's I'Il bet, the cat will thank you for it....

[quote user="David Mills"]but it seems highly likely to be an inflammatory disease initially. [/quote]

Wot, no crystals or uroliths?

Re: Blocked cats.....

David Mills — Tue, 23 Aug 2011 14:53:37 GMT

Each and every slippery sam we've used has ended up detaching - something we have never found with Jacksons, as it happens. I think you misunderstood the protocol - we rarely use Jacksons as indwelling unless we've run out of the Surgivet Tomcat Urethral Catheters (which are silicone and soft and round-ended: I cannot see them irritating a bladder wall). As most of these cats will be on a whacking fluid rate I doubt these bladders are ever truly empty whilst catheterised, and so the tips will be floating in urine most of the time in any case. If they were significantly irritant we wouldn't see our urine going clear, and microscopically clear of blood.

I simply don't buy the urethral trauma side of things - in many of our cases the blockage isn't distal and you can't generate enough retropulsive pressure with an i/v catheter anyway - and I suspect the stretching of the urethra with saline under pressure is potentially more damaging than passing a Jackson with its end cut (cut cleanly with a scalpel). The key to avoiding trauma is technique - extruding the penis as far as possible and keeping it extended whilst passing the catheter. And use a catheter that isn't flush to the urethral wall for unblocking - not only will it produce a higher pressure jet but it won't cause drag.

Re antibiotics we obviously don't know exactly what causes urethral obstructions but it seems highly likely to be an inflammatory disease initially. One simply cannot justify using antibiotics - especially broad spectrum culprits such as cephalexin or amoxiclav (assume most people use these?) - for initial treatment on the current evidence base. Any mild bacterial colonisation of the catheter would likely be expressed and dealt with by the urine flow/environment in any case. And just because it happens in humans has no bearing in animals without evidence.

Re: Blocked cats.....

Anthony Todd — Tue, 23 Aug 2011 13:24:58 GMT

[quote user="Martin Atkinson"]a Jackson catheter with the tip cut off is the most traumatic[/quote]

I totally agree!!

Any plastic cannula/catheter is very very sharp and irregular and will, I guarantee, traumatise the urethra and, if too long penetrate the bladder wall as the full Jacksons certainly does and the sharp cut one would go through like a cheese tester.

Those short irrigating cannulae are the worst of all, they won't even slide into an anal gland duct but grip the wall.

Remember the "prejudged length" is when the bladder is empty and, thinking about it, the emptying bladder contracts onto this sharp or even smooth catheter which is stitched and therefore fixed at the other end so unless you get the length slightly less than to the contracted wall it'll penetrate, or it might!!

I've always believed that bacteria found in fresh urine samples were commensals and not pathogens except in samples from an indwelling catheter where secondary infection is the norm!!

I'm still to be convinced that a true primary bacterial cystitis has ever been proven, and Koch's [sorry] postulates has ever been satisfied, or am I very much mistaken.

We get a number of reports after a "gritty" unblock diagnosing "bacterial cystitis or "interstitial cystitis" and "no crystals found" and they then recur and this time crystals are looked for and found in the fresh urine......

Re: Blocked cats.....

Martin Atkinson — Tue, 23 Aug 2011 10:46:22 GMT

[quote user="David Mills"]

Re catheters, Jacksons are suitable for indwelling, although Tomcat urethral catheters are better, and softer. NEVER use Slippery Sams - the central portion disconnects and can be taken either into the bladder or the cat can merely push it out. The stuff about catheter tips irritating the bladder wall is nonsense.

[/quote]

I've not copied all the post because I cannot argue with the reaarch on infection and your treatment protocol is fine. However I don't understand why you would have a problem with Slippery Sams I never have and the catheter is far more likely to disconnect from the hub on a Jackson, to the extent I would super-glue it to stop it coming loose. As for the catheter tips not irritiating the bladder - how can it fail not to unless you use catheters that are exactly the correct length to exit the urethra into the bladder with a few mm to spare? I would suggest that a Jackson catheter with the tip cut off is the most traumatic of all unless you are cutting it to exactly the length suggested above but you've still got to pass the now sharp tip through the urethra. Whether this irritation is significant is a different matter but when you can actually see the catheter tip protruding into the bladder wall it cant fail but to irritate.

Re: Blocked cats.....

rhona kerr — Tue, 23 Aug 2011 07:58:07 GMT

Sorry, haven't read them all, but in my experience doing OOH as well as GP work, I use the i/v cannulae to unblock, I have used indwelling catheter, but if easy to unblock (once started) I often send them home as soon as bloods improved with fluid flushing. These cats are often/usually triggered by stress and so the compeltely non-stressful indwelling catheter/hopsital situation is obviously ideal! After close owner monitoring and once daily visits for a few days I will try and reduce the frequency of visits, again to reduce stress. I usually advise wet food diet, my understanding is that crystals ARE NOT necessarily involved, but it is sheer concentration/pH/irritation that triggers it. I have had many less returns since putting on all wet food and lo stress. I advise re water availability/fountains, etc also. Have used the dantrium/hypovase treatment, I think useful after indwelling catheter to help reduce the spasms, meloxicam is definitely my drug of choice for these, and I like Cystaid/ease too. I use acupuncture in practice and some cats can respond very strongly to acupuncture for this too, worth considering if difficulty with drugs/client keen/reach[quote user="Anthony Todd"]

[quote user="bob lehner"] pain these unfortunate animals must be suffering.[/quote]

Yeah, Thomas's post about the block clearing after analgesia tends to support the good idea of analgesia straight away.

I'd add it to my protocol if I did another I reckon [although someone will quote something knocking it wont they??]

[/quote]ing end stage.

May be the reason acupuncture can help too - poss underlying pain reducing ability/willingness to urinate?

Re: Blocked cats.....

David Mills — Mon, 22 Aug 2011 20:49:17 GMT

We've been culturing catheter tips in our hospital for the last 6 months from those cats on antibiotics from admission and those not given any. N=101, 7 tips show growth after 72hrs, 3 not on abx 4 on. Urine collected at admission via cysto showed bacteria present in only small numbers in 10 cats, 7 of which showed no growth on culture.

In our opinion, antibiotics are not indicated for urolithiasis. Most of the bacteria are thought to be biofilm-like collections on catheter tips rather than active infections. Our protocol for any blocked cat is bloods (if hyperkal, given ca2+ immediately), sedate, cysto (straight away), unblock (Jackson catheter with tip cut off), catheterise, fluids (NaCl esp if going to be using ca2+), and wait until urine runs clear if possible. All done at surgical levels of sterility. Meds are nsaids and hyopvase only, metahdone for 24hr after admission +/- followed by buprenorphine.

We regard bloods as absolutely essential for both degree of azotaemia and k+.

Sedation wise we go for ket+midazolam, occasionally medetomodine at low dose - it doens't half relax the urethra.

Hope this helps.

Re: Blocked cats.....

Anthony Todd — Sat, 20 Aug 2011 11:24:19 GMT

[quote user="mariette asselbergs"]sprinkle salt over their food [/quote]

Good idea, but they add MgCl2 sometimes to make it flow but now I see they use an "anti-caking agent" in some so it maybe OK.

We used to use analytical NaCl at the height of the struvite epidemic.

Re: Blocked cats.....

Martin Atkinson — Sat, 20 Aug 2011 10:55:24 GMT

[quote user="mariette asselbergs"]

Mind you have you ever got a cat to do anything it didn't want to do??

I always advice clients with cystitis or blocked cats to sprinkle salt over their food to increase drinking. Same for rams and billy goats.

[/quote]

Re: Blocked cats.....

mariette asselbergs — Fri, 19 Aug 2011 21:11:13 GMT

Mind you have you ever got a cat to do anything it didn't want to do??

I always advice clients with cystitis or blocked cats to sprinkle salt over their food to increase drinking. Same for rams and billy goats.

Re: Blocked cats.....

Martin Atkinson — Fri, 19 Aug 2011 18:16:12 GMT

[quote user="Thomas Johnson"]

What I have found a couple of times though is that I've admitted an unwell male cat with an over-full painful bladder, given it an acepromazine and buprenorphine pre-med, gone back 20-30 minutes later to GA and unblock it, and found that it has passed urine in the kennel.

[/quote]

I have found that this is the scenario in a good 25% of cases.

Re: Blocked cats.....

Anthony Todd — Fri, 19 Aug 2011 15:55:11 GMT

[quote user="bob lehner"] pain these unfortunate animals must be suffering.[/quote]

Yeah, Thomas's post about the block clearing after analgesia tends to support the good idea of analgesia straight away.

I'd add it to my protocol if I did another I reckon [although someone will quote something knocking it wont they??]