Article

Critical Care of Exotic Companion Mammals

Angela M. Lennox, DMV, DABVP (Avian) Avian and Exotic Animal Clinic, Indianapolis, Indiana

Exotic companion mammals present frequently for illness and critical care. Some mammals are prey species, and tend to hide signs of illness until unable to do so. IDENTIFICATION OF THE CRITICAL PATIENT Clinic staff must be trained in over-the-phone recognition of those patients that are likely to quality as true emergencies, and direct the client to bring the patient in for immediate care (Table 1). Most ill patients benefit from transportation in a small, dark container with the provision of gentle heat. Care must be taken with less heat tolerant species (guinea pigs, chinchillas), and with patients who may be suffering from heat-related illness. Many clients have access to instant chemical warming devices or hot water bottles. Other potential sources of warmth include a potato or dried beans in a sock heated in the microwave. Clients with patients who are actively bleeding should be instructed on how to safely restraint the animal and apply direct pressure. If care is delayed, conscious patients able to swallow can benefit from administration of small amounts of sugar syrup diluted in water and administered by syringe or eyedropper. Veterinary reception staff and technicians/nurses must be trained to visually identify the critical patient and admit it directly into the hospital for immediate evaluation and care. (Table 1). EXAMINATION OF THE CRITICAL PATIENT Every exotic patient should be examined carefully from a distance before beginning restraint. Patients that are weak or in respiratory distress should be transported back into the hospital for stabilization, and full physical examination delayed. Some cursory information can be gleaned from these patients during placement into an oxygenated incubator. Quickly access overall condition based on muscle mass. This information can help plan the next diagnostic or therapeutic step (chronic vs. acute illness). In many cases, critical status becomes apparent during examination. Patients exhibiting any of these signs and symptoms should be released immediately back to the examination table or enclosure, and steps taken for emergency stabilization: increased respiratory effort and dyspnea, open-mouth breathing, especially in an obligate nasal breather (rabbits, guinea pigs and many rodents), and increasing lethargy and weakness. DECISION MAKING FOR THE CRITICAL PATIENT In many cases, the clinician is faced with a number of difficult decisions. In any single case, aggressive emergency procedures may result in the death of the patient. In contrast, failure to utilize aggressive emergency procedures may result in the death of the patient. The difficult job of determining which patients can tolerate aggressive therapy (placement of venous access, acquisition of diagnostic testing) requires considerable experience and apparently in many cases, plain good fortune. In the authors experience, patients in critical condition due to long-term, chronic disease do not tolerate aggressive therapy, and benefit from a much more conservative approach, for example, 24 hours of heat, fluids administered subcutaneously, antimicrobial therapy is clearly indicated and support feeding. Patients with more acute disease conditions, for example, trauma, may respond to a more aggressive therapeutic approach.

Oxbow Animal Health 29012 Mill Road Murdock, NE 68407 1-402-867-2400 1-800-249-0366 www.oxbowanimalhealth.com

Article

Critical Care of Exotic Companion Mammals

Angela M. Lennox, DMV, DABVP (Avian) Avian and Exotic Animal Clinic, Indianapolis, Indiana

TREATMENT OF THE CRITICAL PATIENT Airway Support Patients in respiratory distress should be placed in a warmed oxygenated chamber. The author has found administration of medications with anti-anxiety properties beneficial in many cases (see Its Great to Sedate). These drugs work synergistically to reduce anxiety with minimal respiratory depression. Airway support for mammals in respiratory distress can be challenging. Intubation of ferrets and other carnivores is performed as in a cat. Intubation of rabbits is considerably more difficult. Intubation techniques encompass a wide variety of modalities beyond traditional orotracheal intubation, or introduction of a tube via the oral cavity into the trachea. Other modalities include forced ventilation with a tight fitting mask, nasal intubation, nasotracheal intubation, and direct tracheal intubation via tracheostomy or temporary tracheostomy.1 Bronchodilators such as terbutaline at 0.01 mg/kg IM q6-8h can be effective in cases of suspected bronchoconstriction. Cardiovascular Support Vascular access in mammals can be performed via two routes: intravenous and intraosseous. IV catheterization in rabbits, ferrets and similarly sized patients is straightforward, and is most commonly performed via the cephalic vein with 24-25 g catheters. The author regular performs catheterization of larger guinea pigs and chinchillas but considers it more challenging. Intraosseous catheterization is well described in exotic companion mammals, and can be performed in patients as small as a mouse. Sites include the proximal tibia at the tibial crest, and the femur. The relatively soft bone cortex of smaller mammals allows the use of standard injection needles as intraosseous catheters, and size ranges from 22 to 27 g. Placement in much larger mammals can be facilitated with larger (22-18 g) injection or spinal needles. Correct placement can be confirmed in several ways. Injection of fluids into a correctly placed catheter does not result in accumulation of fluids into the associated soft tissues, with the exception of leakage of fluids from the entry site into the bone in a poorly seated catheter. Absolute confirmation may require evaluation of radiographs in two views. The IO catheter can be capped with a standard IV injection cap and the catheter secured by taping it to the limb. Studies in human patients indicate IO vascular access can be considered equivalent to IV access in terms of onset of action of therapeutic agents, and time to establishment of peak drug levels. Recommendations for physicians include maintenance of the catheter no more than 72 hours. Complications in humans are rare (less than 1%) and include local cellulitis and infection, fracture, and leakage of administered drugs/fluids into adjacent soft tissues.2,3 The author is unaware of a single severe complication in an mammal patient after nearly 10 years of use of this technique in clinical practice, with the exception of fracture of the tibial crest in a chinchilla, and temporary soft tissue swelling. Fluid choices, volume and rates depend on patient condition and the goal of fluid therapy. Fluids should be warmed appropriately prior to administration. Hypovolemia The patient in hypovolemic shock is usually weak and often unable to stand. Ultimate confirmation of the presence of hypovolemia is documentation of below normal blood pressure. Treatment of hypovolemic shock has been described by Lichtenberger, and relies on restoration of normal indirect systolic blood pressure.4 While difficult in very small patients, acquisition of blood pressure is relatively easy in larger mammals. Assessment of blood pressure requires a sphygmometer, pediatric cuff and an ultrasonic doppler. Placement requires practice. In most mammals, normal blood pressure is above 70 mm Hg. It should be kept in mind that a number of variables can affect blood pressure readings, and the best use may be as a trend monitor. In other words, improvement of blood pressure in a mamal that progresses from weak to standing and resisting is an indication of normovolemia, even if blood pressure readings do not exceed 70 mmHg. The author has encountered numerous cases where blood pressure readings could not be obtained, but were readily detected after initiation of fluid therapy. Fluid choices for hypovolemic shock include crytalloids (lactated Ringers and other similar solutions), and colloids (Hetastarch, Braun Medical Inc.k Irvine CA; and Oxyglobin, Biopure, Cambridge MA). A suggested flow chart for fluid resuscitation is presented in Table 2. Oxbow Animal Health 29012 Mill Road Murdock, NE 68407 1-402-867-2400 1-800-249-0366 www.oxbowanimalhealth.com

Article

Critical Care of Exotic Companion Mammals

Angela M. Lennox, DMV, DABVP (Avian) Avian and Exotic Animal Clinic, Indianapolis, Indiana

Dehydration Dehydration deficits are calculated after correction of hypovolemia, if present. Determination of percent dehydration is determined using criteria as used in traditional mammals. Information can also be gleaned from PCV and measurement of blood proteins. Volume of fluids for correction of dehydration is calculated using the formula: Volume (ml) = hydration deficit x body weight (kg) x 1000 ml. Add hydration deficits to daily maintenance needs (3-4 ml/kg/h) and administer over 24 hours.4 It is also useful to add projected ongoing losses (polyuria and vomiting) to the total as well. Ongoing needs are adjusted during treatment, and re-evaluated after 24 hours. Control of Hemorrhage In most cases, effective clotting mechanisms and efficient compensatory mechanisms prevent fatal hemorrhage. However, animals on sub-optimal diets or with other underlying illness may be more at risk. Other common sources of bleeding include traumatic wounds (including self-trauma), superficial neoplasms and bleeding from the gastrointestinal or reproductive tract. Restoration of Normothermia Measurement of body temperature can be problematic in small patients, but is enhanced with the use of small flexible temperature probes. Methods of active rewarming include forced air (incubator, Bair Hugger) and administration of warmed intravenous fluids. Table 1. Selected signs and symptoms commonly associated with the critical avian patient

Sign/Symptom
Active bleeding Respiratory distress Seizure Depression Weakness

Comments

Often exhibited as non-interest in surroundings Especially laterally recumbency

Oxbow Animal Health 29012 Mill Road Murdock, NE 68407 1-402-867-2400 1-800-249-0366 www.oxbowanimalhealth.com

Article

Critical Care of Exotic Companion Mammals

Angela M. Lennox, DMV, DABVP (Avian) Avian and Exotic Animal Clinic, Indianapolis, Indiana

Table 2. Flow chart for fluid resuscitation of the patient with hypovolemia and shock, and subsequent calculation of fluids needs.4

Step

Comments

Determine starting blood pressure, Use starting number as a baseline and monitor trends during treatment. Due to and measure periodically throughout numerous factors, actual numbers may vary significantly from those reported treatment in the literature. Note that in severely hypovolemic patient, BP may not initially be detected. Administer Crystalloids Administer Colloids (Hetastarch, Oxyglobin) If patient condition and BP measurements are not improving: If no improvement: If Oxyglobin unavailable: If no improvement: Once normovolemia is established, calculate hydration deficits Add daily maintenance needs Add to total estimated ongoing losses in excess of normal Administer total over 24 hours and then re-evaluate 10 ml/kg IV or IO 1-2 boluses 3-5 ml/kg IV or IO over 10 minutes 1-2 boluses Administer third dose of cystalloids and colloids. Administer Oxyglobin at 5 ml/kg IV or IO 1-2 boluses Administer hypertonic saline 7.5% a 5 ml/kg bolus slowly over 10 minutes, followed by crystalloids Continue fluid administration via infusion pump and monitor for response to therapy V (ml) = hydration deficit x body weight (kg) x 1000 ml. 3-4 ml/kg/h Losses can stem from polyuria or regurgitation; ideally, these should be measured and added to the calculation.

References: Lennox A. Intubation of Exotic Companion Mammals. J Exotic Pet Med, in print, 2008. Buck ML. Intraosseous administration of drugs in infants and children. Pediatr Pharm 12(12), 2006. Medicine Journal (serial online) 2008. Available at http://www.medscape.com/viewarticle/552022 Accessed 4/08. Tein Tay E, Hafeez W. Intraosseous access. EMedicine Journal, 2008. Available at http://www.emedicine.com/proc/TOPIC80431.HTM. Accessed 4/08. Lichtenberger M. (2007) Shock and cardiopulmonary-cerebral resuscitation in small mammals and birds. Vet Clin Exot Anim 10:275-291. Reprinted in part from the Proceedings of the Kentucky Veterinary Medical Association Annual Conference, 2008.

Oxbow Animal Health 29012 Mill Road Murdock, NE 68407 1-402-867-2400 1-800-249-0366 www.oxbowanimalhealth.com

9-7-2011