Friday, 10 April 2015

Magic's Surgery-Pre-op to Ready for Discharge

Continuing Magic surgery story up to discharge. Probably one more after this and then that'll be us all caught up. At the moment she is doing well from her diabetes point of view and hasn't required any insulin which is wonderful. Unfortunately, behaviourally things are not as settled which is hopefully just transient changes resulting from the neurotrauma and not permanent. In herself she is doing ok and we are managing so it is still hugely positive and the surgery was the right choice. Thank you to everyone for your lovely, kind and supportive messages.

Pre-Operatively

Magic was on a ridiculously high dose of 21units of glargine insulin (Lantus) which she was failing to respond to and she had a very high IGF-1 level of 2000. Ideally she'd have had her CT scan carried out in Glasgow with the rest of her pre-op screening. However, to limit cost and an unnecessary repeat dose of radiation, it was carried out on the Thursday at the RVC as their scanning equipment links to the Brainsight software which guides the surgeon intra-operatively during the hypophysectomy operation.
Her CT confirmed she had a 6mm tumour in her pituitary gland which is just within their threshold for surgery. I felt a little guilty and wondered if I had made the decision to go for surgery earlier would it have been smaller but I'll never know the answer to that. Unfortunately, she had a bit of a difficult post procedure reaction to the ketamine. This drug is safe and effective but it can cause hallucinations and excitement in both humans and animals so her vet let me sit quietly with her in a darkened consulting room until she eventually began settling and reorienting to her environment. He just kept popping in every half hour or so until Magic was back to normal. It was hard seeing her thrashing around in apparent distress although I knew it was just the drug but I was so glad to have to have been able to be there and to hold her through it.

I was offered a visit to the ITU which I gratefully accepted. Having an image of the ITU setting and understanding the systems and staff available routinely and in an emergency made me feel much more at ease. Clarity of reality rather than imagination, I suppose. Her critical care vet was fabulous. He was most engaged and genuinely interested in getting her optimised and home in as great a state of health as could be achieved. Our own vet from Glasgow Vet School has been wonderful and so supportive through this time too. 
 Her surgery was confirmed for the Monday and she was expected to be in ITU for a minimum of 5days and then some time in the cat ward. The plan was to optimise her over the weekend and allow her to acclimatise and settle into the hospital environment so that she was a calm and fit for surgery as possible.
 The mats in the consulting rooms looked perfectly clean and impressively hair free unlike my own carpets but obviously they had the most amazing scents
This one seemed to make her nearly faint and I think if Magic could have spoken she'd have asked me to roll it up and bring it home!
In addition to the abdominal ultrasound she'd had in Glasgow I was asked if I would give consent to her having a cardiac scan for research purposes. This is why she has a shaved tummy, legs and a bikini top! I was happy to do this and it was a lightbulb moment for me. When she became ill at first the presumed diagnosis was Hypertrophic Cardiomyopathy (HCM) and she has remained slightly cardiomegalic since. This research is looking into the link between these pituitary tumours and cardiac enlargement which certainly fitted with her clinical picture at diagnosis in June 2014. It is thought the effects of this on her heart might improve in time.
 Typical Magic, so long as she can explore the place she's happy and settled even if her dragging her IV line everywhere makes me wince.
Transphenoidal hypophysectomies are still a very novel intervention which with time I believe will become the gold standard of treatment as it has a high chance of offering a cure. It is a common enough intervention in humans with the condition but it is still relatively new in cats. Diabetes remission and treatment is a strong research interest at the RVC and this surgery is literally cutting edge. In turn it may have insights to offer human diabetes. This article from the Guardian discusses the surgery and showcases one of the early survivors.  Although I knew the positioning of the surgery to get through her mouth I actually found myself getting quite teary at the thought of this happening to my sweet Magic. 
 
Visiting her in the vet school each day and especially on the day I left was very bittersweet as you can imagine and one of the vets kindly took our picture together. She was only the 25th case to have been operated on in this manner and three cats did not survive. I had the strong sense that the way she would be managed and the expertise available was very much as a result of the learning the team have taken from each case so I offer my heartfelt gratitude to all the cats and brave owners who preceded us for the learning they left in their wake. 
 
We had gone down on the Wednesday and I'd arranged to stay till the Saturday so that I could be available for the scheduled appointments and also to give me time to rest if my knee became too painful or if it was fine then I could treat myself to a trip to Liberty's. As it was, I was so hyped with adrenaline and stress on the day of travel and the Thursday waiting on her CT results that I was surprised by how well I was coping and even managed a brief trip back into London to distract myself till the 5pm appointment. In fact I was even questioning whether I just hadn't been challenging my knee enough with exercise and thinking maybe I should get a new physio when I came home.
 Funnily I'd thought the Savoy would have had a larger entrance.
 I was really hungry and noodle and rice really hit the mark
Popping to the loo before I left lead to a rather forthright 'Too Much Information' moment
However, once after the appointment when the CT results were known and everything was confirmed and finalised for surgery the adrenaline began wearing off and on the next morning I just sort of crumpled into a sore heap. I recalled Samuel Johnson's quote that "If a man is tired of London, then he is tired of life". Well, I wasn't actually tired of London as I'd have loved to see more of it on the Friday but I simply could manage no more than the barest minimum of walking and the return train journey the next day was quite physically and emotionally taxing. Seeing this sculpture of Matthew Flinders and his faithful cat Trim while waiting for the train at Euston station made me feel it was a sort of sign that she'd be ok and I'd be back to collect my own close companion. 
On the Monday morning of her surgery I was at work and spoke with the neurosurgeon pre-operatively before spending the rest of the day on tenterhooks. The surgery lasted around three hours and then there was the time to stabilise her in ITU. The post-operative period for these cats is utterly critical particularly in the first five days as removing the pituitary gland causes a whole cascade of organ dysfunction and fluid management challenges which need closely monitored and corrected.

Her tumour and pituitary gland did not come out cleanly but required much dissection and this is possibly why she had a head tilt and was exhibiting circling behaviour to the right hand side post-operatively. Some residual effects remained when she came home, though they are now mainly resolved. Her renal values became problematic with her fluids and glucose needed close monitoring and management. On the up-side she was eating and drinking ravenously  very quickly post operatively as the rogue hormone from the tumour has a half-life of around five days after removal. She became anaemic at one point and apparently cats can haemolyse their own blood post-operatively particularly with certain anaesthetic agents so that caused a sleepless night.
 
In retrospect, I'd very much underestimated the stress of the whole venture even the sweet boy-cat seemed affected as he spent lots of time just needing to be in contact with me. He was less distressed than he had been the time she'd been hospitalised in June.
I am obsessive that both cats get equal time with me so that jealousy doesn't emerge. Magic by default had had a lot of necessary treatment and it was nice just to relax and give some concentrated time to Red as he'd been such a patient soul. 
Even de-hairing the vacuum became a joint venture 
He's actually sitting on my shoulder and upper arm here instead of on the top of the sofa as normal 
There were lots of ups and downs while Magic was in ITU and the ward post operatively but the most dangerous issues have resolved or are manageable. Eventually she was weaned off the insulin infusion and they tried to balance her new insulin regime which was significantly lower than she'd required pre-operatively.
What was hugely reassuring were the very clear telephone reports I was given twice a day by her critical care vet which I'd usually jot down so that I'd remember everything to let her own Glasgow vet know how she was doing. After ten tumultuous but ultimately healing and improving days she was deemed fit for the 400mile journey home and I joyously booked my train tickets and grabbed the wheelie carrier to go and collect my sweet cat.

I know I've taken a while to get this next part posted but I hope that I've done justice to her time in London.

11 comments:

  1. Wow, thank you for sharing all of this. Before Magic's story, I dind't know anything about insulin resistant feline diabetes. It sounds like this procedure is ultimately going to give hope to a lot of kitties and their families. Many purrs to Magic for a continued recovery.

    ReplyDelete
  2. This is all so fascinating - and I'm SO glad that the procedure has helped Magic so much! I'm sending lots of purrs for continued healing as her body keeps adjusting and readjusting.

    ReplyDelete
  3. I am very glad that Magic is doing well over all, and hope she continues with a very good recovery. It is very interesting to read of her procedure and thank you for taking the time to share it.

    ReplyDelete
  4. Thanks for sharing Magic's story with us. It's so interesting everything she...and you...went through. We're glad she's doing well and we purr that she continues to do well.

    We laughed at the bathroom sign!

    ReplyDelete
  5. We have followed Magic's story for quite a long time and she seems to have handled her hospital visits and her time in the hospital well. We hope she recovers well from her surgery and gets to feel better when she's healed and settled back at home.
    Lov Hannah and Lucy xx xx

    ReplyDelete
  6. You both went through so much. I’m glad she’s home now and thankful that you’re sharing her story.

    ReplyDelete
  7. Wonderful that Magic is home and recovering well after such a huge operation. So much progress has been made in Veterinary science!
    I love the little cat statue.

    ReplyDelete
  8. Bravo Magic for being such a wonderful candidate and handling all of the ups and downs and sideways so well. Thank you for sharing this incredible journey.

    ReplyDelete
  9. Your documentation is fascinating to me. Isn't it something how those hep lock IV's stay in with a bit of elastic ?

    ReplyDelete
  10. That bandage with the needle in it (we assume) looks scarey! We hope it all is OK soon..

    ReplyDelete
  11. I am glad Magic is recovering well! I am a bit naive when it comes to cats and didn't know all these procedures are available to help them do better. It is so interesting to read. I am going to read back in time for a bit this evening. If you are going for a checkup at the Glasgow vet school, do pop in at my work, I am in the black building opposite :-)

    ReplyDelete

It's good to talk, and we love comments so feel free to say hello!