Midnight's Medical Topic

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AviN4
Supporter in '21

Post   » Sat Sep 18, 2021 1:57 pm


I got the x-ray images in a higher resolution. It's not clear how much it helps, but I'll share it shortly.

Separately, a question occurred to me. As I understand it, a guinea pig has two kidneys, each with a ureter to the bladder. If only one ureter is blocked with stones, how does this become fatal? Isn't the other kidney sufficient? Or does the kidney with the blocked ureter fail in some way that causes a cascade of problems?

Also, rather than removing the stones from the ureter, what about removing the kidney instead? Is kidney removal just very difficult? Or do (elderly) guinea pigs tend to not survive such surgeries? As I understand it, kidney removal in a healthy human adult is very safe, but of course guinea pigs (especially sick, elderly ones) are not necessarily the same.

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AviN4
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Post   » Sat Sep 18, 2021 2:35 pm


OK, this is what I have. It's from a DICOM viewer of the original x-ray files. It's definitely higher resolution in the sense that I do not see individual pixel squares when I zoom in. But I think the lack of clarity is in the x-rays themselves. I asked if the x-rays go from film -> EMR or directly into the EMR, and they said the latter. So I don't think we'll get better than this without taking new x-rays. Let me know if you'd like me to zoom out or to email you the DICOM viewer link they shared with me.

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Lynx
Celebrate!!!

Post   » Sat Sep 18, 2021 9:48 pm


I believe you that this is the best you can do with what they have taken and provided you with. Agree not conclusive but the lower half does seem to me, especially at the end, to have individual stones in the ureter.

I do not have a veterinary or medical background and can't comment on the possibility of removal of a kidney. It seems likely that one kidney might function poorly and the other do more of the work. I do not recall anyone having surgery to remove a kidney in a guinea pig. This article discusses side effects in humans after removal of a kidney:
https://isuporg.org/kidney-removal-side-effects/

I think these are questions you would have to ask your vet, along with the possibility of stones in the ureter. It may be possible to evaluate the functioning of the other kidney.

I wish I had answers for you.

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AviN4
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Post   » Sat Sep 18, 2021 10:04 pm


Thanks for all the advice. Yes, I'll do some more research and then talk to a vet.

I think my perspective on kidney removal is colored by the fact that I know some people who have made altruistic kidney donations, and in these cases the risks are quite small. This page says death attributable to a living kidney donation is a mere 0.006%!

https://weillcornell.org/services/kidney-and-pancreas-transp ... ing-donation

But these are young human adults in good health. Perhaps not generalizable to an elderly sick guinea pig. I presume if nobody has brought up kidney removals to treat ureter stones then there's a good reason why.

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AviN4
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Post   » Sun Sep 19, 2021 8:53 am


I found this thread in which a vet surgically removed a guinea pig's kidney to treat a ureter stone:

https://www.guinealynx.info/forums/viewtopic.php?f=2&t=65394

It does not seem like it was an easy surgery for the guinea pig. The guinea pig died a few months later though the owner believes it was a heart condition.

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Lynx
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Post   » Sun Sep 19, 2021 10:12 am


In 20+ years, we have accumulated so much information! That topic is a very good and concise one. Happy you found more info on kidney removal in a guinea pig. And it is wonderful you know people who have donated their kidneys!

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AviN4
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Post   » Thu Sep 23, 2021 7:26 pm


I had a phone consultation with a Dr. Wilson today, a vet surgeon at Center for Avian and Exotics Medicine. Some notes from the call:
  • She agreed that from the x-ray, the stones appear to be in Midnight's ureter.
  • She said if necessary, she could surgically remove the stones from the ureter, but the prognosis would be worse than stones in the bladder. She did not recommend surgery at this time, but suggested it would be a reasonable option if Midnight starts showing symptoms of kidney failure.
  • She said it's possible that all the stones could move to his bladder, in which case they could be surgically removed from his bladder, or they might pass out his urethra.
  • She suggested the option to get him another x-ray in a few weeks and see whether the stones have moved.
  • She didn't seem convinced that the weight loss was caused by the ureter stones. She said it could be arthritis or just old age. However, I still believe the stones are the most likely cause, given the timing (ureter stones showing up around the same time as the weight loss) and the association between weight loss and other cases of ureter stones on this forum.
  • When I asked if I should increase the Metacam dose, she said I could try increasing the Metacam dose of 0.25 mg once per day to 0.25 mg twice per day.
So my initial impression is that I have a few different options.
  1. Palliative care. Try to keep Midnight comfortable with Metacam, treats, etc., and bring him in to be euthanized when he starts showing any significant signs of pain or discomfort. In this case, I would not make any significant efforts to keep his weight up (e.g. Critical Care), and just let him eats what he wants. I'm leaning towards this option.
  2. Surgery. Get the ureter stones surgically removed immediately or after a longer wait-and-see approach with regard to his weight, other symptoms, tests for kidney function, etc. Given the advice I've read on this forum, as well as his apparent age, I think it's unlikely I'll pursue this path.
  3. Repeated testing. Bring Midnight in for x-rays every few weeks to see if the stones have moved to his bladder, where they can be surgically removed. Based on what I've read on this forum, stones moving from the ureter to the bladder does not seem likely, let alone all of them. Given Midnight's apparent age, the emotional toll it would likely take on me, the financial costs, and the time I'd need to take off from work, this option does not seem worthwhile to me.
If I go with option 1, it seems my main area of uncertainties are:
  1. Pain management. Should I try increasing the Metacam dosage until his weight loss slows down, or only when he shows other signs of pain? Should I try Rimadyl, either now, or at some point? For some context, he still seems to be losing around 1 oz per week, even after 10 days of Metacam, which included an increase in dosage.
  2. When to bring him in to be euthanized. On the surface, the current symptoms (gradual weight loss, increased water drinking, loss of interest in carrots) does not seem to warrant that yet. He still seems lively and happy. But maybe he's already in significant pain or discomfort and hiding it? Another consideration, albeit a smaller one, is that I don't want Moon to be alone longer than necessary. As much as I love my little guys, I don't think guinea pigs are the best companions for me, and so I don't plan to get another cagemate for Moon.

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Lynx
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Post   » Thu Sep 23, 2021 11:27 pm


Weight loss, as I mentioned, can also be a sign of pain so I would continue to weigh - and weigh daily right now. I was going to suggest increasing fluids but he is already drinking more.

I think you would also see clear signs if he was experiencing pain.
http://www.guinealynx.info/pain.html

Talishan wrote the guidelines for pain management and I think could give better advice. She stops by occasionally. I will write her tomorrow and see if she can look at your topic.

I am sorry it seems there are stones in the ureters (what I suspected).

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AviN4
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Post   » Fri Sep 24, 2021 1:12 pm


Yes, I've been weighing daily. It's easy enough since that I'm giving him Metacam each day. Incidentally he seems more docile about getting picked up too. Not sure if its old age, a symptom, or just him getting used to it.

Thanks for offering to write to Talishan about pain management. I'll do some more research as well this weekend.

I greatly appreciate your advice that it is likely ureter stones and pointing me to prior cases on it. It may have saved me and Midnight a lot of stress. I could imagine other paths of unnecessary and costly office visits, tests, surgeries, etc.

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Lynx
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Post   » Fri Sep 24, 2021 3:36 pm


I sent off a note to Talishan this morning (I think she works a late shift). Hopefully she will see it. I am interested in how she sees the options. Talishan is a very experienced person!

Talishan
You can quote me

Post   » Fri Sep 24, 2021 9:09 pm


First off -- would that every guinea pig owner be as caring, conscientous, committed and willing to learn as you, Avi. You are a wonderful, wonderful owner.

Pain meds and palliative care are a continuum, just like in humans. Metacam and Rimadyl are NSAIDs, like ibuprofen is to us. (Rimadyl is carprofen; Metacam is meloxicam, which I think is a COX-inhibitor, but I could be remembering wrong on that.) We have used infants' Tylenol successfully at a dose of 1 mg/kg, up to 5 mg/kg.

Next up the chain is Tramadol. This is a mild opiate. If or when Midnight begins to need significant pain management, that's where I'd start. It will need to be compounded by a compounding pharmacy and sent to you; the vet should be familiar with this.

Up from there is buprenorphine, a "real" opiate. Small doses; highly effective, but can really zonk them out and can have an emotionally disturbing effect in some pigs. Not that different from humans, really -- we're all mammals, after all.

Ureter stones, and bladder stones, will in my experience not cause severe pain until or unless they 1) get really, really big or 2) (and much more dangerous) begin to exit the bladder and travel down the urethra. If Midnight starts having discomfort (squealing, crying, hunching his back) while peeing or defecating (or both), and/or if you see blood in the cage (bloody pee), keep a VERY SHARP eye out. The stone(s) can obstruct the urethra, either partially or completely blocking his urethra, making him unable to pee at all. That is an absolute emergency, and he would need either emergency surgery to remove the stone or euthanasia. It is horribly painful and again, an absolute emergency.

All that said, hopefully that won't happen. I read your whole thread. Midnight is pretty old. I'm hopeful he has a while left with you and Moon, with pain management and good supportive care. Good pain management will help him eat more, and slow (but probably not reverse) his weight loss. If the stone(s) just stay in his bladder, they will make him achy/feel mildly cruddy but not unmanageable and not life-threatening.

As far as euthanasia goes -- this may sound weird but you will know. You will know when to continue to treat him, and when to help him over. The rule at our house is if they are still active, bright, responsive, eating and engaged in their surroundings -- even with some pain and 'bad days' -- we keep going. You will know when it's time. He will let you know.

In the meantime -- watch out for any blood in the cage, and ask about Tramadol. Tramadol can be combined with Metacam and/or Tylenol iirc; double-check that with the vet.

Very, very best wishes and blessings to Midnight, Moon and you. You're doing a magnificent job. Keep going.

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Lynx
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Post   » Fri Sep 24, 2021 9:45 pm


So glad you were able to stop by, Talishan. You have a way of explaining things that is thorough and knowledgeable (have had many guinea pigs).

Somewhere I may have mentioned possibly offering moistened balls of critical care to help supplement diet. If Midnight is fond of critical care and still actively eating, a little now and again may help him maintain weight until you start seeing clear signs of pain or blood.

Talishan
You can quote me

Post   » Fri Sep 24, 2021 10:21 pm


Ditto Lynx on the Critical Care 'meatballs'.

You can also try 'pellet stew'. Soften a small number of pellets in warm water, then mix with carrot baby food, squash baby food, or canned pumpkin. Put this on a small plate in a little mound or ridge. My husband drizzles carrot baby food over it for icing. 😊 Some of ours have loved this, and it has really helped them.

bpatters
And got the T-shirt

Post   » Fri Sep 24, 2021 10:43 pm


Lynx, can we put Talishan's response somewhere easily findable?

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Lynx
Celebrate!!!

Post   » Sat Sep 25, 2021 8:55 am


Perhaps a link to her post on the pain page?

I will give it some thought.

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AviN4
Supporter in '21

Post   » Sun Sep 26, 2021 8:48 pm


Talishan, Thanks so much for all the helpful advice and kind words!

I appreciate your explanation of the different kinds of pain medications. A few questions on this:
  1. It's good to know infant's Tylenol is an option. Is it safe to combine this with NSAIDs? I think it's safe in humans, so I'd guess so?
  2. To get the 1mg/kg Tylenol dosing, I presume that requires significant dilution? I see the normal dose for infants is 160mg.
  3. Does it make sense to give opiates long-term to a terminally ill guinea pig? Or is that more like to cope with short-term severe pain? Or to ride out a tough weekend until the vet's office opens (for surgery or euthanasia)?
  4. Are there cases where the pain appears to be only minor to moderate, but opiates are still the right tool? Perhaps because the NSAIDs just aren't working in the particular case?
  5. Is it difficult to get prescriptions for opiates for guinea pigs? I imagine they're likely a controlled substance, abusable by humans.
With regard to symptoms of stones reaching his urethra, yes, I'll be sure to keep an eye out. I'm not totally sure what I'd do in that case: on one hand, if there are still stones in his ureter, then I'd opt for euthanasia. On the other hand, if one stone has reached his urethra, then it's possible rest of the stones have moved to his bladder? And in that case an x-ray may be warranted. I suppose I should think it over and come up with a plan in advance.

Also, Lynx and Talishan, thanks for the helpful advice on diet supplements. I've been experimenting with a few of these strategies and will see if any of them seem to work. I'm also trying rolled oats. And I was also surprised to find that Midnight seems to like Oxbow "Garden Select" pellets. (Based on anecdotes on this forum, most guinea pigs seem to like the "Essentials" better.) We'll see if he continues eating it or if he gets bored. And I was finally able to place an order of 5lb of KMS pellets today. Hopefully between these calorie dense food options, he'll eat enough of something.

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Lynx
Celebrate!!!

Post   » Sun Sep 26, 2021 9:41 pm


The analgesics page has some guidance regarding mixing the various types of drugs. Some combinations are safe, others not so much.
http://www.guinealynx.info/analgesics.html

Talishan
You can quote me

Post   » Sun Sep 26, 2021 11:41 pm


Ok. With apologies to Lynx, I'm going to break this out into multiple posts. (I'm on a phone and if it loses a great long post I will get extremely agitated. Just ask my husband. 😉)

1. Yes. Tylenol is an NSAID and NSAIDs can be mixed, although with some care. Imagine you took some Advil for sore muscles, and also some aspirin for a headache. Don't take tons of it, but you'd be ok.

2. The infants' Tylenol I have is 160 mg/5 ml. This is, thus, 32 mg/ml. (I hope you're pretty good with math. If you're not now, you're gonna be. 😁 All kidding aside, don't hesitate to post here and ask any calculations you make to be double-checked. Someone will confirm or correct.)

Let's assume Midnight is 1 kg. You will need 1/32, or .03 ml of the stuff in the bottle, or an eyelash more. Get a 1cc oral syringe (no needle) from the vet, or sometimes human pharmacies will sell you one, or just give you a few, if you explain you are caring for a small pet. It'll be a tiny tiny amount, but draw-able. First try just offering it to Midnight. Most of our pigs have loved the mild grape flavor they use, and have taken it straight from the syringe readily.

Talishan
You can quote me

Post   » Sun Sep 26, 2021 11:52 pm


3. Yes. To all three. A mild narcotic like Tramadol can be used long term. The stronger ones can too, but they are more for the acute, emergent needs you mention.

4. Yes. Again, especially a mildish one like Tramadol.

In my experience (and I am not a vet, RN or medical professional of any kind), NSAIDs seem to work on a threshold basis, while narcotics/opiates work more linearly. That is, for an NSAID to do any good the dose has to get above a certain level, then it works. The narcotics seem to work more on a sliding scale; give a little more or less, get a little more or less result. They are more tweak-able.

Talishan
You can quote me

Post   » Mon Sep 27, 2021 12:03 am


You will need an accurate weight for Midnight, for all of this.

5. This will depend on how willing and comfortable your vet(s) are in working with these meds. Some vets won't like using even mild narcotics, but good, cavy-knowledgeable vets know how important pain management is.

The drug classifications are the same (afaik) for human and veterinary meds (they're the same molecules), but the distribution and regulatory chains are separate. Your vet should NOT have to go through all the hoop-jumping and scrutiny to give Midnight Tramadol or buprenorphine that a human doctor would to give you Vicodin.

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