Dental/anesthesia/von Willbrand's Test

[NeylasMom]

So Violet is scheduled for her dental on 12/17. Because of her rhabdo incident, my vet and I agreed that she should go to a dentist for special care. I ended up scheduling the consult with the dentist at the emergency/specialty hospital that treated Violet for her rhabdo because one, I was so impressed with their care and two, figured that would be the easiest in terms of the dentist communicating with the vets who treated her.

 

So we have a special anesthesia plan in place for her that avoids using Acepromazine b/c I had some concerns with her reaction to it when hospitalized. They are instead going to use Dexdomitor (not something I would typically have them use, but she received it in the ER when I told them to get her off of the Ace and responded well to it and they said the dosage they will be using will likely be less than what the ER used) followed by Propofol and then Isoflurane as the main anesthetic. The dentist said depending on how things go they may also use Butorphanol or Medazalam (sp?).

 

They also worked with me to come up with a plan to reduce the risk of her stressing before the procedure (and panting, which we think along with the stress from the car ride is in part what contributed to her rhabdo incident). So she is scheduled to go first thing in the morning and I am going to be able to stay with her in an exam room while they start the pre-anesthesia and she'll only go back when they are ready to put her under. The consult was a nice test run - I took her for a good hike that morning and gave Composure chews before we left, then when we got there we were taken right into an exam room where she settled on her own bed and worked on a Kong I had brought. She was pretty much stress free throughout.

 

Any thoughts on our plan, especially anything specific to the anesthesia? Anything I haven't thought of? Also, one specific qx. We did blood work and a U/A - everything looks great, but they also asked me to do a Von Willebrand's test. I planned to until I learned it would be nearly $200. So the dentist said instead we could do a quick test once she's under anesthesia. They cut a small slit in her gum and I guess watch for clotting? Thoughts on this? I presume it takes very little time, but I don't want to do anything unnecessary to prolong the time that she's under. She's never had symptoms of VW, but she's also never been injured outside of her rhabdo incident.

 

Dental is 2 weeks away and I am already a hot mess thinking about it. I know there's no reason to suspect she won't do fine and we're taking every precaution, but I'm terrified. Anyway, any helping in dotting my i's and crossing my t's so I can try to lessen my worry would be appreciated.

Edited December 3, 2014 by NeylasMom

[XTRAWLD]

I'm just thinking, there are different ways to care for teeth than going in for a full dental. Have you explored these options instead of just putting her under?

[NeylasMom]

I'm just thinking, there are different ways to care for teeth than going in for a full dental. Have you explored these options instead of just putting her under?

We'll do that moving forward, but she needs this one. She's only 5 and she has some bad build up and nasty breath. She is going to need a few extractions, although barring something unexpected on the x-rays, not as many as I had feared.

[Jiffer]

If they're worried at all about bleeding (and I do it prophylacticly for all procedures, anyway), give her Amicar pre- & post-surgery. It should prevent any undue bleeding.
From Dr. Couto's studies, greyhounds don't normally show positive for von Willebrand's disease, but they can bleed without cause so better safe than sorry.

Dets on Amicar:
http://www.veterinarypartner.com/Content.plx?P=A&C=301&A=3482&S=0

 

For me personally, I'm a wreck anytime they have to go under so if I were to stay with them until they go in for their procedure, I would only aggravate their nerves so I usually drop them off quickly rather than stay. It's up to you, however, but just remember, greyhounds are emotional sponges. What you're feeling, she will feel.

[NeylasMom]

If they're worried at all about bleeding (and I do it prophylacticly for all procedures, anyway), give her Amicar pre- & post-surgery. It should prevent any undue bleeding.

From Dr. Couto's studies, greyhounds don't normally show positive for von Willebrand's disease, but they can bleed without cause so better safe than sorry.

 

Dets on Amicar:

http://www.veterinarypartner.com/Content.plx?P=A&C=301&A=3482&S=0

 

For me personally, I'm a wreck anytime they have to go under so if I were to stay with them until they go in for their procedure, I would only aggravate their nerves so I usually drop them off quickly rather than stay. It's up to you, however, but just remember, greyhounds are emotional sponges. What you're feeling, she will feel.

Thanks, I used Amicar with Zuri's first dental since we had it done at OSU, but skipped it this last time because my regular vet just doesn't feel its warranted. I talked to the dentist about it and he felt we'd be better off doing the VW test, but we agreed that we would make sure there was a local pharmacy that had it in stock in case we needed to get it. I've heard mixed things - I know OSU/Dr. Couto feel pretty strongly about using it as part of their amp protocol and that they also use it for dentals, but the specialist said he didn't see a need and my vet researched it for me and couldn't find strong evidence to support using it. I guess my feeling is that we're talking about very small incision sites for a few extractions, not a whole limb amputation. I suppose there's really no harm in using it though. FWIW, as part of her blood work we did run 2 basic clotting profiles and they were normal.

 

And thanks, I definitely feel it's better for me to be with her, but it's a good reminder for me to remain calm until they take her away, at which point I will feel free to lose my sh*t.

[Burpdog]

I'd skip the VWD test. Very, very few greyhounds have it and as above said, if they have Amicar on hand you should be fine.

 

Wonder why they use Iso instead of sevo?

 

Also, I wonder if they have improved the VWD test. Years ago it was worthless

Edited December 3, 2014 by Burpdog

[NeylasMom]

I'd skip the VWD test. Very, very few greyhounds have it and as above said, if they have Amicar on hand you should be fine.

 

Wonder why they use Iso instead of sevo?

We talked about that too. OSU uses sevo and Dr. Radcliffe touts it. Everyone else I've spoken to doesn't feel it's better and no one around here seems to use it unless it's requested. My vet used it for Zuri's last dental anyway and it was a difference of about $300. I told the dentist I would defer to him on this issue for Violet and neither he nor the anesthesia specialist felt sevo was necessary.

 

If there were some solid evidence to support the use of Amicar before and/or sevo instead of iso I would definitely happily take it to the dentist to discuss again so please, if anyone has any good studies, send them along.

Edited December 3, 2014 by NeylasMom

[Riverhound]

I know nothing about any of he medical/scientific stuff. I do know that you have every right to lose your sh*t!!!

[DesiRayMom]

You have exactly the same protocol that Desi has had for his last 2 dentals. Domitor/Torb as a pre....then Propofol.....then iso.

He's done very well both times. I do know, however, that they don't give him a full dose of the pre or the Propofol. They cut it

back to almost 1/2 of what they would have given another breed, same weight. Good thoughts that all goes well & neither of you

get too stressed.

[tbhounds]

Here's my thoughts--skip the VW test--extremely super duper rare in ghs. Absolutely use the Amicar. Stay away from Midazolam. The difference between ISO and Sevo is not worth even mentioning--ISO is fine :-). (Fwiw--I don't see anything wrong with using a very low dose of ace)

[Batmom]

Clotting test on the gums takes maybe 3 minutes, tops.

[Guest budsmom]

As I understand it, a greyhound with the bleeding issue will test normal on a clotting test. The issue isn't that they don't clot, it is that they clot and it breaks up some time later (6-8 hrs) and then won't re-clot.

[macoduck]

I have no experience with clotting questions. However I'd lean toward using Amicar. With an amp it's the leg that bleeds. But with a dental it's the mouth that's bleeding. If there was a clotting problem I wouldn't want the airway compromised by excess blood.

[duncan41]

There is so much more to VW but I don't see where the concern originates. Amicar makes much more sense. For a dog that gets stressed to the point of being a detriment, I would be more concerned about getting her in and out in the shortest time possible. Wish I knew more about the protocol of one of the track Vets because all his dentals are in and out in less than 4 hours with absolutely no sign of drowsiness, even with multiple extractions!

[JJNg]

While it wouldn't hurt to do the von Willebrand test or check the buccal mucosal bleeding time (the test where the nick the gum and time how long it takes to clot), neither test will tell you if she's a greyhound 'bleeder'. As others have said, the greyhounds who end up needing Amicar usually have completely normal clotting panels. So unless you've had strange bleeding problems in the past, there's really no reason to spend the money.

 

The good thing is that the majority of greyhounds that need Amicar do fine even if it's not started until post-op, at the very first sign of excess bruising or bleeding. So as long as you have some on hand or know of a source where you can get it quickly, you might consider only using it if there's a sign she needs it. The vast majority of retired racers are spayed and neutered without Amicar, and it's also not routine to use it for all dental extractions.

 

I've only had one case where I prescribed Amicar after a dental with extractions, and that was for a greyhound who was still bleeding some from a couple of the sites 4-5 hours after the procedure (most extraction sites clot and stop actively bleeding before the dog wakes up from anesthesia although there may still be a small amount of bloody drool for a couple days). I had the owner get the Amicar from the pharmacy on her way to pick up the dog and start it that evening.

 

Regarding isoflurane vs sevoflurane, when I was in school, I was taught that there really isn't much of a difference in safety profile. Sevo just has a faster response time, so you can adjust depth of anesthesia more quickly, and they go down and wake up faster. But as long as the patient is monitored closely, sevo isn't any safer. I still use iso at my clinic because that's what we have the equipment for, and the cost difference.

[NeylasMom]

Thanks all and especially the medical peeps on here. Your input is invaluable. I think in light of the comments we'll stick to our plan. I just need to confirm that they have identified a place for me to get Amicar if she needs it. I'm on the fence about the gum test. Seems like there's no real harm in doing it as a precaution since it only takes a few minutes? Or could it be problematic for some reason?

 

Oh, tbhounds, why no Midazolam? We're avoiding Ace because she reacted poorly to it when she was hospitalized. If we should avoid this one too, I will bring it up but at some point they're probably going to get annoyed with me.

[tbhounds]

Midazolam is used frequently by many clinicans--but, I'll always argue against it's use. It's in the Valium family and one perk is it doesn't have to be given IV. I just don't like it because I don't like how dogs behave after receiving their dose. Panting, pacing, vocalizing and general agitation--not what you want to see a gh respond like--esp your girl.

Why does the Dr feel you should rule out VW? If your girl is having pre-operative bloodwork the morning of the procedure all they have to do is see how long it takes for her blood to clot once placed into the serum tube-easy peasy (quite frankly any tech worth their snot should always check that with every patient -one exception is if they don't use a serum tube but use a lithium heparin tube).

[NeylasMom]

Okay, good to know, thanks. I'll ask them to use the morphine drug if they need something else and try to avoid the Midazolam.

 

Re: VW, it came up when I brought up Amicar, but he said they have seen a few cases of it. I get the feeling it's a better safe than sorry sort of thing. We already did the blood work though, wtih my regular vet. No blood work morning of.

[tbhounds]

Morphine drug??? Nope! Are you referring to Butorphanol? I would have to read back but, I thought you mentioned they would give Dexdomitor/Torb (Butorphanol) as a premed and induce with Propofol and maintain on Isoflurane?

[NeylasMom]

Morphine drug??? Nope! Are you referring to Butorphanol? I would have to read back but, I thought you mentioned they would give Dexdomitor/Torb (Butorphanol) as a premed and induce with Propofol and maintain on Isoflurane?

Sorry, yes I was talking about the Butorphanol, I meant to say opioid. I was just trying to avoid typing out Butorphanol.

Edited December 6, 2014 by NeylasMom

[NeylasMom]

So Violet's dental is on Wednesday. I've been trying not to think about it, but its getting harder. I'm going to be a mess by Wednesday morning.

 

So I need to call the office tomorrow to make sure they've either acquired Amicar or located a source nearby. I'm also going to request that they use Torb instead of Midazilam if they need a second pre-sedative. I'm still on the fence about the gum bleeding test thingy.

 

Any additional thoughts on that or anything else I should ask them when I call?

 

More importantly, any suggestions for suppressing the nausea I feel every time I think about this?

[Riverhound]

More importantly, any suggestions for suppressing the nausea I feel every time I think about this?

Xanax. Everyone should have a few around the house for times like this.