Re:Pouch evacuation

Pete Giwojna

Dear Carol:

Yes, indeed, upside down swimming is a sure sign that there is gas or air trapped within the pouch of your male seahorse. You mentioned that the male had recently delivered a brood of babies, in which only two of the newborns were alive and healthy, whereas the others were either stillborn or died shortly after delivery. That could be significant because there may have been other unborn babies still trapped within his marsupium, and gas could be accumulating due to the decomposition of fetal fry or embryonic young or placental material that the male has been unable to cleanse from his pouch. In that case, using a small catheter or cannula to evacuate the pouch, or performing a pouch flush using a small eyedropper or a small syringe, or doing a needle aspiration might be the best option for releasing the trapped gas. I will discuss all of these possible procedures for you below so that you can see which one might work the best for you, Carol.

As you know, if your male was unable to expel any of the unborn embryonic young and placental tissue that remained in his pouch, they would begin to decompose within his body and cause more problems. This is thought to be one of the causes of pouch bloat in male seahorses. The gasses of decomposition from the decaying embryos and fetuses are believed to build up within the pouch, inflating the marsupium and resulting in positive buoyancy. The tendency to float that results will eventually make it increasingly difficult for the male to swim until he is finally bobbing helplessly at the surface like a cork. And of course the process of decay taking place within the pouch leaves the male vulnerable to secondary bacterial infections.

Pregnant males are particularly vulnerable to chronic pouch emphysema and other forms of gas bubble syndrome (GBS), and it is not uncommon for a male that is carrying a brood of young to develop problems with pouch gas and positive buoyancy. When this reaches the point where the affected male is floating at the surface are struggling against positive buoyancy, you have no choice but to release the trapped gas one way or another as soon as possible. Otherwise, the seahorse will be unable to feed and will exhaust itself struggling against the tendency to float, resulting in the build up of lactic acid in its blood and associated changes in blood chemistry (acidosis) that further aggravate its condition.

Pregnancy is naturally a high-risk period for pouch emphysema and pouch gas for a couple of reasons. First of all, breeding males are often especially susceptible to chronic pouch emphysema and GBS in general because of the placenta-like changes that occur in the lining of the pouch during pregnancy. Spongelike, its tissues expand as the capillaries and blood vessels swell and multiply. A film of tissue then forms around each embedded egg, providing it with a separate compartment (alveolus) of its own. The thickening of the wall of the marsupium and elaboration of pouch structures around the implanted eggs result in a dramatic increase in vascularization, and this increased blood supply (hence increased concentration of carbonic anhydrase) transports more dissolved gases to the pouch, increasing the risk of GBS accordingly. The increased blood supply to the marsupium during pregnancy thus makes breeding males increasingly susceptible to the formation of intravascular gas emboli (micronuclei or seed bubbles) at this time, which can result in pouch emphysema and positive buoyancy problems.

Secondly, pouch bloat can be caused by gas produced by the decay of embryonic material and the remains of placental tissue or other organic matter (possibly even stillborn young) within the brood pouch, if the male is unable to flush it out and cleanse it properly by pumping water in and out during its pouch displays (Cozzi-Schmarr, per. com.).

I know of a couple of cases in which male seahorses developed pouch emphysema and/or other forms of GBS every time they became pregnant. When they weren’t breeding, they were just fine, but when they were carrying a brood of young, they were invariably plagued with pouch gas and buoyancy problems. Providing the GBS was managed properly (typically by administering Diamox orally via gut-loaded shrimp, in cases like this), the affected male may be able to give birth normally and recover fully afterwards.

So it’s possible that this could become a recurring problem for your male whenever he becomes pregnant, Carol. If that proves to be the case, I will be happy to help you deal with the situation as it rises.

But first let’s discuss methods of flushing the pouch, which is often the most effective procedure when you suspect that the pouch gas could be related to unborn young are fetal fry within the marsupium, Carol. Pay close attention to Leslie Leddo pasta fest pouch flush instructions, in which she describes the type of catheter’s (IV catheter’s within a certain size range) that work well when evacuating air from the marsupium or performing a pouch flush.

Rather than repeatedly massaging the pouch to release the trapped gas, which can be harsh on the delicate membranes of the pouch when it needs to be done again and again, I would recommend first inserting a fine catheter or cannula into the aperture of the pouch or actually performing a pouch flush this time in order to cleanse the pouch of trapped gas. Flushing the pouch can be done with nothing more than clean, well-mixed, aged saltwater (NOT freshwater) when necessary, or it can be flushed using an antibiotic solution, or it can be flushed with a solution of the Diamox. I will run through some instructions for performing such pouch flushes below; hopefully, one of the procedures will prove to be practical for you while you are attempting to obtain the Diamox.

In short, Carol, I would avoid doing another pouch massage at this time. That procedure can be too rough on the delicate tissues of the male marsupium if it has to be performed repeatedly.

A pouch flush or an eye dropper evacuation may be a better option. It is easier on the pouch in several respects, since you can use a little suction to help remove the trapped gas, rather than compressing or massaging the sides of the pouch to force the bubbles out. But unless the aperture of the seahorse’s pouch is relaxed or dilated, as it is shortly after a male gives birth or performs vigorous displays of pumping during courtship, it can sometimes be difficult to insert the tip of the eyedropper past the sphincter muscle at the mouth of the pouch.

During the breeding season, a septum or wall of tissue forms in the middle of the marsupium of mature males that divides their pouches into left and right halves, so if you are inserting an eyedropper our small pipette into the pouch to help release the trapped gas, try to angle it to the right of the pouch once and to the left of the pouch once when you evacuate the bubbles so that you removed them from both sides of the seahorse’s pouch.

And instead of merely releasing the trapped gas next time, Carol, I would recommend performing a pouch flush using Neil Garrick-Maidment’s technique, as discussed below. If you don’t have a pouch kit, you could use your eyedropper as the pipette when performing the pouch flush (depending on the size of the male). Just cut off the bulb from the end of the eyedropper so that you can use a handheld spray bottle to direct a stream of water down the barrel of the eyedropper in order to flush both sides of the pouch thoroughly with clean saltwater that is the same temperature as your seahorse tank. For best results, you should repeat the pouch flushes once a day for three consecutive days.

Flushing the pouch can be a little tricky if you have never performed the procedure before, so first I will run through several different methods of flushing out the pouch so you can get a better feel for what’s involved, and then recommend the procedure that I think might be most effective in your case. For starters, here are Neil Garrick-Maidment’s instructions for performing his extremely successful pouch flushing procedure, which can be done without any sort of medication when necessary:

[open quote]
Hi Pete,

Hope you don’t mind me interjecting on the point about gas bubble in the
pouch but it is important to emphasise a few things.

When I devised and developed this treatment quite a number of years ago, I
was shocked to hear some of the ways people were clearing the bubbles within
the pouch, from cocktail sticks to straws, which caused irreparable damage
to the pouch and the Seahorse. It is vital that great care is taken when
doing this process and the purchase of a fine blunt ended pipette from the
chemist is the best way.

When handling the Seahorse make sure you have a
firm grip with the pouch facing outwards under the water, its best to have
the tail curled around the little finger to add stability. Then insert the
pipette almost vertically, through the pouch opening so the pipette goes
down into the pouch (almost parallel with the body) and not in towards the
body which will cause major internal and secondary problems.

Once the pipette is safely in the pouch then a fine nozzled hand spray (it must be
fine to fit into the end of the pipette) must be used to flush down through
the pipette, you will notice bubbles of gas being vented from the pouch as
you flush the pouch, initially with water from the tank, this stops shock to
the animal and at the same time clears the pouch. This same method (do not
remove the pipette in between stages) should then be used to add medication

When withdrawing the pipette use a slight twisting motion and remove in
exactly the same direction as it has gone in. The Seahorse will seem a
little shell shocked after this but the immediate release from floating etc will
will provide instant relief.

I have had 100% success with this process but
you must be in mind of the Seahorse and its discomfort at all times.
Just before starting make sure you have all your equipment and medication in
place, there is nothing worse than getting part way through and realising
you have forgotten something.

Hope this helps

Best wishes
Neil Garrick-Maidment [close quote]

Next, here are detailed instructions from Leslie Leddo and myself explaining how to perform a pouch flush:

"Pouch Flush Techniques and Tips"
By Leslie Leddo

You will need:

·A small syringe. I like to use a 1-cc syringe.

·A catheter of some sort. It needs to be something that is plastic, very narrow, cannulated, blunt tipped, semi pliable, but not so soft that it bends from just a bit of pressure, on one end and fits snugly on to the tip of a syringe at the opposite end. Some suggestions would include an a plastic intravenous catheter, with the center introducer needle used to puncture the skin and vein order to introduce the catheter removed, a plastic pipette, or the syringe tips that come inside some of the aquarium test kits. If you have access to an IV catheter any size, between an 18 and 25g will work well.

·A bowl. I like to use something with a wide rim so I have space to move freely and have enough room should I need another pair of hands…i.e., an assistant. The syringe and pipette/catheter are both used to flush the pouch as well as to aspirate the previous days flush from the pouch.

How to prepare the Syringe and Catheter:

Draw about 1cc of the medicated flush solution into the syringe by pulling back on the plunger.

Invert the syringe so the tip is pointed up. With the syringe inverted, gently tap it until all the air bubbles come to the surface just below the syringe tip; with the syringe still inverted depress the plunger until all the air is removed from the syringe and a small amount of the solution is emerging from the syringe tip.

Attach the catheter or pipette to the tip of the syringe, depress the plunger of the syringe to fill (prime) the catheter or pipette with the solution.

Okay, now you are ready to flush the pouch. Proceed as follows:

Gently place the horse in the bowl filled with his own tank water. Very gently and slowly introduce the tip of the catheter through the pouch opening, into the pouch. When you enter the pouch you may meet some resistance. If you encounter resistance when inserting the catheter, I have found that it helps to try different angles, rather than pushing forcefully. I have never dissected a seahorse, but from all the evacuations and flushes I have done it feels to me as if the opening to the pouch is more than a simple opening. It feels like a short tunnel, with folds or pockets of tissue along the walls of the tunnel. I have had to flush/evacuate several different horses. They all seem to be built a bit differently.

I have had success entering the pouch opening straight and then angling the catheter down a bit as well as entering at an angle from the start.

Once you have the catheter tip inside the pouch, depress the plunger of the syringe, flushing the pouch until you see some of the solution coming back out of the pouch. Continue to flush the pouch with about .2 to .3 cc.

Once the pouch has been flushed, you want to leave a small amount of flush inside the pouch. Pulling back on the plunger aspirate the some of the fluid until some of the solution has been removed from the pouch, leaving enough so that the pouch remains softly full, but is not at all taught or tight. Place your horse back in his tank

The next day, prior to the new flush, aspirate the previous days flush from the pouch. Using the syringe with the catheter/pipette attached to the tip, insert it as described above. Pull back on the plunger of the syringe withdrawing the flush from the day before.

Now you are ready to administer the newly mixed flush by repeating the steps described above.

Antibiotic Pouch Washes

If you can obtain a suitable small glass eyedropper with a rubber squeeze bulb, the tip of which you can insert into the pouch orifice, you can use the eyedropper to flush the pouch instead. Otherwise, you’ll have to obtain a small pipette or use a small syringe and catheter for the flushes, as previously described in Leslie Leddo’s pouch flushing tips. You will be flushing the male’s pouch once a day for three consecutive days, using a medicated pouch flush solution.

The first thing you’ll need to do is prepare the pouch flush solution. I recommend using a combination of nifurpirinol and neomycin sulfate for the pouch flushes, since that combo works together synergistically to forms a wide spectrum antibiotic with potent antifungal as well as antibacterial properties (Basleer, 2000). Nifurpirinol and neomycin sulfate are the active ingredients in two different commercial products designed for aquarium use, and both of them should both be readily available at your local fish store. Prepare a 50:50 solution by taking approximately 1/10 teaspoon of nifurpirinol and 1/10 teaspoon of neomycin powder (from a capsule) and mixing them together with about 40 cc (or 2-1/2 tablespoons) of tank water from your seahorse setup. (Nifurpirinol comes in tablet form, so you’ll have to crush a tablet into as fine a powder as possible, using a blender if necessary, and then use 1/10 teaspoon of this nifurpirinol powder for the mixture.) Mix the nifurpirinol powder and neomycin sulfate powder with the tank water very well until the medication is thoroughly dissolved. Avoid any undissolved residue that remains. (You will have to make up a new batch of this solution each day for 3 days.)

If you can’t find both nifurpirinol and neomycin, then you can use either one alone, or substitute kanamycin capsules alone, to make your medicated pouch solution. In that case, just use 1/10 teaspoon of the antibiotic powder and mix it thoroughly with about 20 cc (or 1-1/2 tablespoons) of tank water. Again, make a new batch of pouch-flush solution each day.

And here are instructions from Keith Gentry explaining how to do a pouch-flush directly with Diamox:

Pouch Flush

In cases of recurring pouch emphysema, diamox can be administered as a solution injected into the pouch via an narrow gauge irrigating cannula or plastic 26 or 28 gauge IV catheter sleeve attached to a 0.5 or 1ml syringe (larger syringes should not be used).

Using a blender, mix ½ of a 250mg Diamox tablet with a cup of seawater at the same specific gravity as the tank. Fill the syringe with about .5ml of this solution, avoiding the residue at the bottom of the cup. The seahorse should be held as per the procedure for pouch evacuations.

Insert the catheter sleeve slowly and gently a small way into the pouch opening and inject this solution SLOWLY into the seahorse’s pouch, leaving the solution in the pouch. Make sure you are familiar with the location of the pouch opening.

Never use a metal needle for this procedure.

The procedure may have to be repeated twice to be effective. In stubborn cases, it is recommended to concurrently administer broad spectrum antibiotics. Diamox and antibiotics have been used simultaneously and successfully without appararent side effects.

I believe the dosage of antibiotic is one 250mg tablet of neosulfex per 10 gallons. It’s important you treat the horse in a quarantine tank. Diamox and neosulfex can kill your

For neomycin and sulfa you can use up to 4 times the marine dosage listed on the instruction or are up to 8 times the recommended freshwater dosage. [End quote]

One of these techniques should work well for you, Carol, depending on what medications and equipment you have on hand or have access to for performing the pouch flushes. But the procedure that I have found is often the most effective is to perform a pouch flush with Diamox in three steps, as explained below, if and when you can obtain the medication:

The proper way to perform a pouch flush with Diamox is to first use the catheter or cannula from the syringe to evacuate the air from the pouch, and then once the trapped gas has been released from the pouch, you gently inject about 1 mL of the Diamox solution and leave it in the pouch. Don’t aspirate the Diamox solution, suck it back out of the pouch or flush it out of the pouch afterwards. Just leave it in the pouch so it can be absorbed into the bloodstream through the heavily vascularized lining of the marsupium.

But first you must release the trapped gas from the pouch, which is very easy using a catheter/cannula of appropriate size. Simply place the catheter into the pouch without the syringe and then just apply firm pressure to the pouch and all the air will come out of the catheter. Then place the syringe on the catheter and fill the pouch with Diamox solution.

Prepare the Diamox solution according to Keith Gentry’s instructions above. Sometimes you need to repeat this procedure two or three times in stubborn cases, but it usually produces the desired result

in addition, you may also want to consider purchasing a Pouch Kit from (see "Accessories" on the home page of this site), which would make the pouch flushes a bit easier. Here are the instructions for using the Ocean Rider Pouch Kit, Carol:

Pouch Kit Instructions

Click here: – Seahorse, Sea Life, Marine Life, Aquafarm Sales, Feeds and Accessories – Pouch Wash

The antibiotic pouch kit should be like a fire extinguisher in the kitchen and used only in an emergency and NEVER as a prophylactic. Please perform this procedure in a separate vessel so that the antibiotic wash does not flow into the holding tank. You may wish to trim the plastic tip of the syringe attachment to accommodate the orpheus of your seahorse. You can express the air in the pouch by gently inserting this tip into the opening.

PLEASE KEEP REFRIGERATED shake well before using

What you need to do:

First: Find someone to help you!

Second: Keep the head and gill area of the seahorse submerged at all times! You may cut the end of the tip to fit your needs.

Third: The Procedure should be preformed in a separate hospital tank where the antibiotic flush will not harm your biological filter:

*Have one person hold the seahorse upside down with the head in the water and his tail and abdomen out of the water. He may wrap his tail firmly around your finger. Insert the tip of the pipette into the opening in the pouch being careful not to insert it too far. (You may cut the end of the tip to fit your needs.)

*Gently massage out any air bubbles into the pipette.

*Remove the pipette and express the air bubbles from the pipette.

*Rinse the tip of the pipette with alcohol and let dry.

*Withdraw approximately 2 ml’s of pouch wash into the pipette. The quantity will actually vary according to the size of the males pouch. The extra large males can easily use 2 mls of pouch wash and the smaller males less than one.

*Reinsert the tip into the pouch and gently force the liquid into the pouch and then gently suck it out. Do this twice and then release the male into his tank.

*He may seem slightly stunned or shocked. Don’t panic! Simply turn off the lights and allow the male to rest. If you have any red shrimp he may enjoy them at this time.

*You may have to repeat this procedure again the following day.

*Return him to his normal diet of frozen mysis shrimp enriched with Vibrance the day after the procedure.

In a pinch, Carol, you can also perform a pouch flush using a small syringe (minus the needle, of course) in place of the a pipette or small catheter, as described below:

<open quote>
Thanks for the great reply. It was really helpful. It was air in the pouch. I could see it in there when I looked closely. I think it may have gotten in there when I had him out of the water briefly to transfer him a few days ago.

I think I got all of the air out today but it was tricky. He’s too small for the bobby pin or even a small blunt syringe needle tip to fit into the opening of the pouch so I tried a slightly different approach. I took a small, fine but blunt tipped syringe and squirted salt water at the opening of the pouch while pressing the needle tip against but not into the opening. This fully inflated the pouch. I then held him upright, gently squeezed the pouch, and massaged the pouch opening with the needle tip. This made him vacate the pouch. I repeated that 3 times. The seahorse did not make it easy though. He was a feisty little stallion and fought me every step of the way. He even bit me twice which I didn’t think was possible for a seahorse.

He is still a little subdued but he is swimming right side up again.
<Close quote>

If you suspect that your male may be pregnant again (stallions often remate within a day or two of delivering their last brood), Carol, that you may want to consider performing a needle aspiration to remove the trapped gas. When a gravid male develops problems with pouch gas and positive buoyancy during the course of his pregnancy, I usually recommend performing a needle aspiration to release the trapped gas in a noninvasive manner that make allow the male to carry his brood full term and deliver them normally in due course, as described below:

Needle Aspirations

A needle aspiration is a very straightforward technique that simply involves inserting a hypodermic needle through the side of the pouch, tapping into the pocket(s) of trapped gas or fluid, withdrawing the plunger on the syringe and removing the fluid or gas. If you have never done a needle aspiration before, I know it sounds a bit gruesome, but it is a surprisingly painless procedure for the seahorse and is often easier and less stressful for both the aquarist and the patient than performing pouch flushes or repeatedly massaging the pouch. Not only is a needle aspiration less traumatic, as a rule, but it is also often more effective in removing the trapped gas and relieving the problem. A needle aspiration is easier to perform if you have a helper, since an extra pair of hands is very helpful when you’re ready to withdraw the plunger on the syringe and extract the gas from the encapsulated bubble.

The procedure is accomplished while the seahorse is held under water, just as you would if burping or flushing the pouch, and you grasp the seahorse in the same manner as well.

Prepare the needle and syringe ahead of time by sterilizing the hypodermic. When you are ready, wet your hands first and hold the seahorse upright in the water with your non-dominant hand, allowing his tail to wrap your little finger or ring finger so he has a good grip and feels secure.

While the seahorse is thus restrained, use your dominant hand to insert the needle into the side of the pouch (not the front) so you can tap into the pocket(s) of trapped gas.

Remember, you are not performing a subcutaneous or intramuscular injection, so there is no need to use a shallow angle when penetrating the wall of the pouch. Depress the plunger all the way and then insert the hypodermic laterally, from the side of the pouch rather than the front, at a perpendicular angle to the wall of the pouch. Use a big firm, gentle pressure to penetrate the wall of the pouch.

If you missed the pocket of trapped gas on your first attempt, the hypodermic may also withdraw placental fluid from the marsupium and/or yolk from ova implanted within the lining of the pouch, depending on how far advanced the pregnancy is, but that’s not a problem. Very few, if any, of the fetal fry or embryonic young are affected during a needle aspiration, compared to the alternative which is performing a pouch flush and thoroughly cleaning out his pouch.

Don’t worry that performing a needle aspiration will injure your male or cause any irreparable damage to the stallion or the young he may be carrying. I can assure you that needle aspirations will not ruin your male for breeding or cause him any permanent harm, Cheryl. For instance, releasing the air or gas from a tiny dwarf seahorse male is much more difficult than it is for the larger seahorses, and sometimes requires extraordinary measures to accomplish. Here is an account of one such case in which Kirk Strawn — the leading expert on Hippocampus zosterae in the wild — had to evacuate the air from a pregnant dwarf seahorse several times during the course of its pregnancy:

<Open quote>
Herald and Rakowicz (1951) found bubbles to occur in the large seahorses, Hippocampus hudsonius punctatus, as the result of gas given off by decaying young remaining in the pouch after delivery. They recommended removing the bubble by inserting a needle into the opening of the pouch after delivery. This is a more difficult operation on the little dwarfs. It is more easily accomplished either during courtship or following the delivery of young — at which times the opening to the pouch is dilated. Inserting a needle through the entrance of the pouch does not ruin a male for future breeding. A male kept away from females from February until June had bubbles removed on three occasions by puncturing the side of the pouch with a needle and squeezing out the bubble. (Males go through the motions of courtship and may pick up bubbles even if no females are present.) On June seventh he was placed with a ripe, freshly caught female. On the seventeenth I cut a slit in the side of the pouch and removed a bubble and two partly formed babies. By the twentieth [3 days later] the slit was healed over, and he had another air bubble. On the 23rd I partially removed this bubble by forcing a needle through the entrance of the pouch. On the 25th [2 days later] yolk came out when the needle was inserted. On July 5th he gave birth to a large brood after which a bubble was squeezed out of the dilated opening of the pouch without the aid of a needle. The next day he sucked in another bubble while courting. Although removing bubbles does not permanently damage the fish, it is much easier to put a fence, such as a cylinder of plastic screen, around the air stone and its rising stream of bubbles.
<Close quote>

Note that in this episode, Strawn had to perform needle aspirations on his pregnant male multiple times in addition to eventually performing surgery and cutting open the side of the pouch on one occasion, Cheryl. Yet even after all of these traumatic events, some of which resulted in yolk or embryonic young being released along with the air, the male still went on to deliver a large brood normally at the appointed time afterwards. So you needn’t be concerned that your efforts to evacuate the gas from your stallion’s pouch will cause him injury or damage, or necessarily doom any fertile eggs are developing young he may still be carrying.

You must release the gas that is bloating his pouch and causing positive buoyancy to provide a stallion with pouch bloat with some relief, and I would suggest performing a needle aspiration this time and/or treating your male with Diamox (the tablet form of acetazolamide) as soon as possible, Cheryl. Of these two treatment options, a needle aspiration is probably your best bet because it will provide your stallion with immediate relief from the positive buoyancy (Diamox may take several days to work and it is a prescription drug that is often difficult for hobbyists to obtain). As I said, removing any gas that is build up via a needle aspiration will have a negative impact on very few of the developing young as compared to attempting to manually evacuate the gas by burping the pouch or performing a pouch massage or pouch flush.

In short, it is the changes the marsupium undergoes during pregnancy that leave the gravid male so susceptible to pouch emphysema, and a needle aspiration is the best way to remove the gas that is built up within the pouch in such cases. But it’s best to avoid flushing the pouch with the antibiotic solution when you perform the needle aspiration(s) if you suspect that the male may be pregnant and carrying embryonic young or fetal fry.

As to what may have caused this problem, I suspect it could be complications due to pregnancy, as we discussed earlier in this post. A taller aquarium would also help to minimize problems with GBS in the future since the increased hydrostatic pressure at depth is protective against various forms of GBS. When males are basking in the stream of bubbles from an air hose, they can sometimes get gas trapped within their pouch if they are performing their pouch displays and pumping well in the bubble stream, but that is unlikely with the larger air bubbles produced by an air hose without in airstone…

Best of luck resolving the problem with recurring pouch emphysema! I would consider performing one or more pouch flushes or performing a needle aspiration while you are waiting to obtain Diamox, rather than repeatedly massaging your male’s pouch. But, one way or another, you will need to release the trapped gas from your male’s marsupium so that he can swim and feed normally in the interim.

Pete Giwojna

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