ACVC 2001 - Hospital Precautions and Procedures to Avoid Disaster in Avian Medicine

Hospital Precautions and Procedures to Avoid Disaster in Avian Medicine

Teresa L Lightfoot D.V.M., Diplomate ABVP-Avian

We have constraints inherent in the animal hospital environment that often preclude psittacine behavioral consultations. Often the bird is presented for illness and this takes precedent. Just as in dog and cat medicine, if the primary problem is NOT behavioral, then the bird needs to be handled with minimal stress during the office visit. This will be the emphasis of today's lecture.

First, some general principles that apply across species lines:

1) Exam room entrance: Open the exam room door quietly and carefully. Often, the client and bird have been waiting long enough to become relaxed (read "comatose"), and a startling entrance may cause the bird to fly off the cage or owner's shoulder and crash into the wall. This is not the best start for an exam. When you enter, if the bird is on the owner and not in a cage, ask the owner to stay seated while you talk for a while. Use this time to complete the history, observe the bird at rest, and discuss potential diagnostic and therapeutic procedures. It is usually best to sit down yourself, reducing your status from that of a potential predator, and relaxing both the bird and the client.

2) Escapees: Close all doors before catching any bird - the smaller the bird, the more important. Larger birds are slower and with experience we usually catch them more readily. Smaller birds tend to be the escapees and if full flighted, they may continue out of the exam room and cruise the waiting room, encountering a feline or canine predator or an open door. Use doors as barriers in all convenient places. Don't forget that finches and other small birds can walk out UNDER some exam room doors. This is embarrassing. Don't forget the trick of turning off the lights - most birds are subdued by low light and therefore easier to catch.

3) Restraining the bird: When the time comes to physically restrain the bird, if it is hand tamed, ask the owner to place it either on the exam table or onto the floor. Then move between the bird and the owner, and have the owner be seated. Most of these birds will readily get on your hand (or anyone else's, for that matter), to get out of the "prey" position of being at a lower altitude than others in the room. The owner is usually pleased that the bird seems to like you, and you don't have to play ring-around-the-client. If the bird is less tame, or the owner seems apprehensive, you may ask the client if they would like to be present or if they would prefer to leave the room. It is surprising how many clients take this invitation to bolt out of the exam room. When the owner is this nervous, their exit may make the procedures easier on all concerned.

4) Cage Access: Birds often come in to the hospital in their own cages and are left in these, at least temporarily. Be sure all cage doors are secure, and do NOT sit these on top of freezers counters, microwaves, etc., without checking the bird's access to adjacent electrical wires or other hazards. The radiology table is often a tempting vacant horizontal location to place these "Just for a minute". Be certain that leaded gloves, aprons, or shields, and the wires on the collimator are not within the bird's reach.

Note: Towel trained birds

As more parrot owners seek the advice of parrot behavior consultants an increasing number of pet birds are accustomed to being cuddled in a towel and held by the owner. There is a fine line between allowing the owner to attempt restraint that may be beyond their ability (or the bird's acceptance) and destroying the trust that the owner and bird have developed. There is no doubt that veterinary visits have occasionally caused serious and long-term emotional problems that can take significant time to overcome. If an owner is adamant that they are able to restrain their bird, after the necessary disclaimers, this author attempts a minor procedure such as examining a foot or wing while the owner is holding the bird. This will give both the owner and the veterinarian immediate feedback as to the feasibility of this arrangement.⁸ Once again, these owners are often well-versed in parrot behavior and one should have alternatives to the owner providing restraint that are acceptable to the owner, veterinarian and the patient.

Equipment and Handling Techniques

1) Restraint:

Sufficient restraint must be accomplished to allow a through physical examination. However, during the restraint, one must constantly monitor the bird's condition and level of stress to avoid potential disaster. The following list may seem obvious, but it should become automatic for both veterinarians and technicians.

The "Put It Down" Check List

Panting or increased respiratory rate while being examined warrant attention. It may be that these are normal compensation for a stressed or obese bird, but during restraint, it is difficult to determine the extent of the stress without reducing the effectiveness of your restraint.

a. If the bird is panting or breathing rapidly, first alter the grip on the head so the head is free to move. The bird should immediately begin to turn its head in search of something to bite. If it doesn't, PUT IT DOWN.

b. A paper towel, or a corner of the towel being used to restrain the bird, can be placed into its mouth. It should immediately begin to bite at this, demonstrating that it has sufficient oxygen reserves to do so. If it lets the material lay lamely in its mouth - PUT IT DOWN.

c. Have the bird grasp your hand or finger with both of its feet. (This should be part of the P. E. anyway, to determine symmetry and strength of grip). If the bird's grip is weak, or non-existent - PUT IT DOWN.

d. If the birds eyes close during the P. E. - PUT IT DOWN. Conversely, do not be reassured if the bird has its eyes open - many birds have held their eyes open as they drew their last breathes.

e. If in doubt - PUT IT DOWN. Return the bird to the location (cage, owner) where it is most comfortable, and observe it while talking to the owner.

This is the time to discuss with the owner the reasons for the bird's increased oxygen demand, the time it should take for a normal bird to stop open mouth breathing (panting), (1-3 minutes) and the possible etiologies of underlying conditions if the bird continues to have respiratory problems for a longer period.

You may discuss further diagnostics, therapeutics, etc. Be aware that this is not an ideal time to continue directly into Isoflurane anesthesia and radiographs.

Generally, bloodwork can be drawn within a short period of time, since it is quicker and easier to draw blood in most birds than it is to perform a thorough physical examination. However, if the bird was severely stressed, and was presented for a wellness examination, it should be allowed to go home that day whether or not venipuncture is performed, where it will recover more readily.

(Eating and sleeping in the comfort of its own environment - a lesson to be extrapolated into human medicine - but that is another story...).

If the bird was presented for a medical problem it should be kept in the hospital, and placed in oxygen until it appears compensated. Subsequent venipuncture and/or supportive care if needed should then be initiated, evaluating the bird constantly during these procedures. For very obese birds, venipuncture can take a little longer. It is nice to have these blood values, since concurrent hepatic infection with bacteria (reflected in the CBC) due to the frequent occurrence of hepatic lipidosis with documentation of elevations in bile acids and hepatic enzymes that may encourage the owner to consider the underlying obesity more seriously. However, obtaining bloodwork is not worth causing the death of the bird.

2) Scales

a. Perch - various types of perch scales can be purchased or designed for under $100.00. The digital scales that read in grams, usually up to 2 kg., can have perches either hot-glued to the base (which provides better stability), or have various size perches that can be placed on the scale as needed for the particular patient size.

b. Basket (balance scale) - This scale is used for weighing small, fast, often full-flighted birds. They can get their toes or beak back to the edge of the pot before you get the lid back on the scale. Before you close the lid tightly, peak through the chicken-cooker holes to make sure you're not about to do an unrequested high beak or nail trim. (This is also true for hamsters, gerbils, rats and mice).

c. Shoreline^R - the "Cat" scale is ideal for larger baby birds, and adult, calm, non-perch-happy species (such as Umbrella cockatoos). It weighs in either pounds or kilograms, from 10 grams to 40 pounds. They cost about $ 250.00 each, but hold up extremely well. These also work well for iguanas, and cats.

3) Perches

a. Toilet bowl plunger - fits perfectly across a Shoreline^R cage, can be adjusted to any height or depth in the cage, cost about $ 3.00, and can be disposed of if soiled or chewed through. These also have an additional use..

b. PVC pipe - Vet Wrap for grip stability and cleanliness.

c. Wooden - careful with disease transmission - can not easily sterilize wood.

d. Concrete - For most birds between about 200 - 600 grams, these work very well. They can be too abrasive for heavy birds if the nutritional status is poor (and therefore epithelial and ligamentous integrity are not good), and /or the birds have no alternate perches to use. Concrete perches have greatly reduced the need for frequent toe nail trims, and removal of hyperkeratosis on the beaks of otherwise normal psittacines.

4) Incubators

a. Synder^R- Expensive, but work well, containing temp. and humidity gauges, nebulizer ports, self-contained seed and water cups, and an alternate center swivel door for access.

b. Aquabrood^R - the manufacturer will make these with nebulizer ports - good for pre-warmed, humidified environment. Obviously not portable due to warm water used as source of heat. Temperature reading of water runs about ten degrees F higher than the temperature in incubator chamber.

c. Corners Limited^R - less expensive, less fancy, but a more airtight metal incubator, with a good seal for nebulization. Designed with a Plexiglas removable front, and we still use our 10 year old one for nebulization.

d. Aquaria - with multiple exotics being seen in practice, the possession of several 5, 10 and 20 gallon aquaria with secure lids, (or lots of full packs six-packs of soda braced on the corners), used with newspaper protected heating pads under the cage, and/or lights over the cage, can serve as temporary incubators.

e. Regular Dog and Cat cages - good for most birds that are not critical - can use various perches inside, being sure to have seed and water both on the floor, and at the level the bird can easily reach from the height of the perch you have supplied.

5) Injections

IM. Aspirate first, since there is a higher incidence of both hitting a vessel and of hemorrhage than there is in mammals. Seldom are subcutaneous injections administered. Subcutaneous injections are reserved mainly for fluids and vaccinations.

6) Venipuncture

a. Jugular - right larger than left - may elect to use smaller (left) one on larger birds. The jugular vein provides the easiest access, least discomfort and fastest draw in most situations. (See "Common Mistakes" for more information).

b. Basilic (ulnar or wing) vein - common to have hematoma formation, both due to location, and to increased flapping of the wing during and after venipuncture. One trick is to infuse saline into the area subcutaneously post venipuncture, and the back-pressure will often stop hemorrhage, though the bird may flap the wing more for a few minutes due to discomfort. Another method is to introduce the needle under the tendon and into the back (dorsal) side of the vein. The underlying musculature will them help prevent hematoma formation. We generally use this vein anesthetized birds, or in emergencies.

c. Median metatarsal - Good for seabirds (especially pelicans). Can also use in psittacines. Some bird tend to bleed post-venipuncture, but there is little subcutaneous space for a hematoma, so a pressure wrap will stop the bleeding.

7) Fluids

a. Subcutaneous - Subcutaneous fluid with hyaluronidase (Wydase^R) either lyophilized or stabilized - the 150 units/ml - add 1.0 ml to each bag of fluid for subcutaneous use. Can order through Burns, Butler, other companies. Has been used for years in dog and cat medicine - fell by the wayside with the advent of I.V. catheters, but is tremendously useful in birds. Maintenance fluid dosage is approximately 3.0 ml/100 grams B - TID.

b. Intraosseous - Do NOT give large boluses of fluids, which may cause pain, hypervolemia, cardiac overload, and death during or immediately after administration in the severely compromised patient. Many texts advocate the use of bolus IV or IO fluids in critical cases. In this author's experience, this procedure, (most likely due to the combination of increased oxygen demand due to handling, increased epinephrine release from pain/discomfort of placing the IO or IV catheter, and the sudden change in blood volume), often lead to the bird's demise. One's own clinical experience should dictate the cases where bolus IV or IO fluids may be attempted prior to stabilization of the patient. The use of subcutaneous fluid with the addition of Wydase (hyaluronidase) in experienced hands may be less stressful, and the fluid is absorbed within 20 minutes. See copy of Seminars in Avian and Exotic Pet Medicine, April 1997, Therapeutic Avian Techniques (p. 55).

c. Intravenous - (see same reference as above). Various clinicians are comfortable with medial metatarsal, jugular, or basilic (ulnar) I.V. catheters.

8) Crop feeding:

Do not initiate crop feeding unless the bird is sufficiently stable to stand and ambulate, due to the danger of aspiration. Generally, in adult birds, 3 ml/100 grams, QID of a hand feeding formula (HBD and Exact are two favorites) will maintain weight, when accompanied by subcutaneous fluids in an anorexic bird. After the technique has been mastered, it is often easier for one person to do this alone, especially on smaller birds (up through about 400 grams, or Amazon size) using your thumb to not only feel the crop feeder pass through the esophagus (separate from the trachea, which is cranial to your thumb), but also using the thumb to occlude the esophagus, preventing back-flow of any material from the crop into the pharynx. Hand-feeding baby birds can usually receive up to 10% of their body weight at each feeding - the number of feedings depending on age. (So a healthy four week old cockatiel, which may weigh 100 grams, would be getting up to 10 ml/feeding, three to four times/day).

9) Radiography

Correctly positioned radiographs are imperative when doing a well-bird exam. If the sternum and vertebrae are not perfectly superimposed on the ventro-dorsal view, if the wings are not extended symmetrically, and the legs pulled down evenly and to the maximum extent, you will have difficulty evaluating lungs, air sacs, and liver size. On the lateral view, the tendency is to over rotate the bird by taping both wings down to the table. This prevents the sternum from being parallel with the cassette, and will make the proventriculus appear large, the kidneys appear larger, and make interpretation difficult However, when you suspect heavy metal toxicity, and you have a very sick, regurgitating bird, you may not want to anesthetize this patient. We see an average of at least one heavy metal toxicity (usually zinc from galvanized material) per week, and in over half the cases, the owners are totally unaware of any potential source of heavy metal access. If the owner's history states that the bird roams free in the house, even if they say its only while supervised, be suspicious of heavy metal. My youngest son, when he was two years old, stuck a "supervised" Lego up his nose, and I didn't know it. A quick ventro-dorsal view, obtained while holding the bird's head and feet with gloved hands will confirm the presence of metal, and give you an indication to start chelation therapy. Blood lead & zinc levels are certainly the means to confirm these. However, time constraints (next day results are the soonest most of us can get), financial constraints, and blood volume concerns (cockatiels that are often the victims of this syndrome have sometimes had a CBC and serum chemistries run that day, and were anemic initially from the heavy metal) may prevent further blood drawing. This is a good example of avoiding disasters, by adhering to the "Tentatively diagnosed cured patient is always preferable" principle.