Double Checking? PF with antibiotic?

Dear Tim:

Pouch flushes are still necessary in order to resolve problems with chronic pouch emphysema, a form of Gas Bubble Syndrome (GBS) in which gas repeatedly builds up within the male’s brood pouch until the seahorse is having problems with positive buoyancy, unable to swim normally or to remain at the bottom of the tank. If untreated the gas will continue to build up until the unfortunate seahorse is eventually left floating helplessly at the top of the tank like a cork.

The proper way to resolve such problems is to first carefully insert a small cannula or tiny pipette into the aperture of the pouch in order to release as much of the trapped gas as possible by applying gentle pressure to the sides of the pouch near the bottom, and then working your way upwards very gently, while the pipette or cannula keeps the mouth of the pouch open. Next you must thoroughly flush out the pouch in order to prevent the problem with pouch gas from recurring.

Some experts prefer to use clean saltwater only for performing the pouch flushes, while others use a solution that include broad-spectrum antibiotics for the pouch flushes, and stubborn cases of chronic pouch emphysema often require the pouch to be flushed using a solution made from a carbonic anhydrase inhibitor such as acetazolamide (brand name Diamox).

I will discuss the different methods for performing pouch flushes that are currently commonly used in more detail below, Tim, beginning with Neil Garrick-Maidment’s technique. But first I would like to explain that if you don’t have a suitable small cannula or pipette to use when performing the pouch flush, then a small eyedropper can be used as the pipette when performing the pouch flush. 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
etc.

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
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
biofilter.

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, 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:

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.

Best wishes with all your fishes, Tim! Here’s hoping that you never have a need to perform a pouch flush on any of your ponies.

Respectfully,
Pete Giwojna, Ocean Rider Tech Support