Good evening everybody and welcome to our Thursday night webinar vet members webinar. My name is Bruce Stevenson and I have the honour and pleasure of chairing tonight's webinar. I don't think we have any new members in tonight, so, I'm going to dispense with the usual housekeeping, you all know it.

And I think you all know one of my all-time favourite presenters, John Chitti. But for those of you that don't, John is an RCVS advanced practitioner in zoological medicine. He qualified from the Royal College, in 1990 and gained an RCVS certificate in zoological medicine in 2000.

He is a co-director of a small animal and exotic practise in Andover in Hampshire, with a 100% avian, exotic and small mammal case load. Both referral and first opinion. Consults, to 7 zoological collections and commercial laboratories, as well as the great bustard reintroduction project.

John has co-authored 3 texts on avian medicine, on a rabbit small animals, rabbit surgery and co-authored a textbook of tortoise medicine. He's also the author of various book chapters and papers in a range of species. John was the past president of the European Association of Avian Veterinarians from 2015 to 2017.

And he's also on the editorial board of the Journal of Exotic Vet Medicine. President of the British Small Animal Veterinary Association 2017 to 2018. And really importantly, he's a trustee and honorary secretary of VetLife.

John, once again, welcome back to the webinar vet and it's over to you. Thanks, Bruce, and thank you for the introduction stuff. Hello, everybody.

It's a very hot Thursday. So, anybody who's actually here, I, I do, I do admire you. I think now would be an appropriate time to be sinking into a gin and tonic rather than listening to bird anaesthesia.

But there we go. So basically, fundamental question is who actually enjoys Avian anaesthesia. It can be the most demanding, stressful experience in practise, and often with what may seem like a very dubious success rate.

And hopefully, I can't make it much less stressful. If I can help you manage that tonight, understand why it's stressful and hopefully that way improve the the success rate. But certainly I have a one slide, which I think will prove to you why it is stressful.

So, OK, so why don't we tend to enjoy it? Well, basically, fundamentally, birds have a very different anatomy and physiology to the mammals we're so used to. They're often pretty sick.

That's a big problem. Whenever you look at surveys and deaths, the underlying sickness really is a problem, and birds are renowned for being able to hide their signs of illness, when they find the kill, they actually are really very, very ill indeed, and that doesn't help with this. And they have a very high metabolic rate, we talk about in a moment, and as a result, they do tend to die.

So now, what has changed since we've all been bleating on about A anaesthesia for all these years? Well, actually quite a lot has, and certainly is, we've got big advances in drugs to some extent. We've, also got big advantage in monitoring.

And, we actually have a better understanding of the birds themselves, and that's a great thing with anaesthesia is that you've got to understand the animal you're actually anaesthetizing to be able to do it properly and how it's working and stuff. Therefore, how to amend it. But certainly if you're feeling, feeling bored, and you want to go back through the history of avian anaesthesia, we'll get the textbooks going back to the 80s and stuff, go through and what you find is in the original chapters, there it was all about drug dose rates and stuff.

And now it's hardly anything on drugs. It's almost all about monitoring and about keeping them alive once you're asleep. So why do we use anaesthesia if it's so dangerous and a difficult one we do it well, anaesthesia, we know the, the traditional three things it gives us remobilization.

It gives analgesia, and it gives us muscle relaxation for surgery. It will also give us oxygen and as a way of so we know we can supply these birds with oxygen. And considering how common respiratory problem is in these, these creatures, that's not a bad thing to be doing.

And bizarrely, it can reduce stress. It may not reduce your stress, but it can reduce their stress, and that's really, really important because a lot of the problems you run into, otherwise, Navy medicine is actually the stress on the patient by doing the procedures and dead in hand is not uncommon either. And fundamentally, isoflurane is much safer than adrenaline.

So if you look at what bird hearts do when they're subject to a massive flow of adrenaline, that's, that's not good. Isofluorine is much, much safer than that. And certainly if you are doing stuff handling, it's one thing to be aware of is the 4 minute rule.

As a nice studies in Amazon parrot show if you handle more than 4 minutes, you get this hyperthermia, which can reach sort of fatal levels. So again, they do get that stress that you burn. So isoflurane much better.

We've got better control now too. We, we intubate and we also, we can talk about ventilation because once we're intubated, we can control that breathing with ventilation. That's really important.

How, before we need those, we will consider things so we can see about the anatomy. So we're gonna look at the upper respiratory tracts, we got sinuses, we've got the glottis and things. So the sinuses appears really complex situation here to start get all around the skull up into the mandible as well.

And you know, really complex air flow up there too. They breathe through both their nose and their mouth, as you can see from the CT through here, see the open channels. This is a contrast CT by the way, with all the white.

And then they flow down into the, have a glottis at the back of the tongue, and then down into the trachea. And then you have a yrinx at the bottom. The syrinx will have variable types of valves depending on species, that 11 set of vowels across the base.

Some have a pair of valves, each bronchial, so bronchus where it splits into, into each lung. The lowest bridge track below that, obviously we have these fixed lungs and not like mammalian lungs. They're fixed under the rib cage.

They don't expand and instead of having alveoli, they have bronchioles. And these are some air tubes and air capillaries, and that is through those walls that the gas exchange occurs. They flow through the through the bronchioles into the air sacks, where, which, which do expand, and then they make you breathe out again back through the bronchioles out again.

So we have a double pass system, which is really cool. And these bronchioles are again fixation lungs, we can see the lungs up here. And if you have a look at a stippling here, you see all the single end on.

bronchioles. These air capilities, these bronchioles are all in facing one direction. You look at me and the orthogonal view of this, you'll see it looks like stripes going across.

They all flow in the same direction. And this is what they're doing. So this is very simplify is courtesy of Nigel Harco Brown for the BSA man of citizen birds.

So thank you for that. So the air comes down here as the as the as the bird breeze in, so these air sacks were expanded this way, drawing the air basically through the air capillaries and down into, into the air sacks on expiration. The FX pushed outwards in front, basically this is very, very simplified.

The air gets pushed back through the air capillaries and back up to the trachea. So in other words, it passes through the air capilla twice. It's really efficient if you want to do things like flying and stuff, to get two guys to getting the oxygen out out of the air.

Now, how does the expansion happen? It happens through movements of the keel. They don't move their ribs particularly.

We don't have muscle on that. We don't have a diaphragm. They use the keel.

So don't obstruct that. So if you hold the bird side to side, that's great. If you hold the bird from front to back, you're gonna stop that keel moving.

You're going to restrict his breathing, and you might end up with problems. And bear in mind then too, when you're actually holding a bird on the table when you're inducing and stuff, not to stop the keel moving because that does cause fatal changes. Really difficult handling ratites, by the way, it's very easy to subst that keel, even on a big boat.

They also have a very small residual capacity if you think about our lungs because you can expand it to varying degrees, . You know, we've got quite a big residual capacity, so you're sitting there hopefully dozing off right now, using very little of your lung volume. But when you want to run to the fridge and get another beer, you've got a lot more capacity to run and do that quickly.

The birds don't have that. What they've got is what they've got. There's a little bit of reserve, but very little.

So if it's been eaten into by being overweight or by having disease, then they've got even less. But what they have is what they have. So in other words, they can't expand oxygen capacity as needed with that.

So that's difficult. So again, don't restrict to reduce it. And that involves things like positioning and stuff.

So put the bird on its back, you'll restrict the the, the, the, the, the air sacks. If you've got a lesion on one side of the air sacks and you put that on top, you're restricted. So always make sure if you've got unilateral disease, that you always put the bird down on the side with the disease.

I mentioned about high metabolic rate, and they do have a much higher metabolic rate than the mammals, especially, in the small birds. What does that mean for an anaesthesia? It means that things change fast.

So disease changes happen fast. Cure happens fast, to be honest, that's great. But, but, disease happens quickly and very importantly, the depth, the levels of anaesthesia will change very, very fast indeed as well.

So you can enter death at quite a high rate. So pre-existing illness, again, we mentioned this before, what can we do about it? Can we treat it first?

Problems happen. Can we diagnose it first? Birds aren't easy to diagnose and very often we're using anaesthesia as part of the investigation.

We need to get the X-rays properly. We might need to take blood, we might need to do endoscopy, the things we need to do to diagnose that preexisting illness. So we may try and do some stabilisation preparation first of all, but we know with birds come in as sick.

We know we haven't got much time to do that in this highly unstable situation. So we may have restricted ability to, to prepare it for anaesthesia. Many, most bird bird anaesthesia tend to be reactive rather than so we can prepare for.

So client communication is really important here. You know, the birds to them, birds have only been ill for a few hours. It's news.

It's been ill for a while. It's quite a thin burden. It's got problems going on.

That's, that's gonna be news to them too. It's probably new to we actually have to anaesthetizes doing things like that, especially when you're saying it's very ill, and I see why you're saying that too. And so you've got to prepare them about that the striking about, how long you can put off doing this for investigating against how you're going to get a risk of doing things quickly.

So you, you're always communicating and and explaining the risk of a client. So what can we actually do in terms of per patient preparation? Well, OK, again, is it possible?

Can we do stuff, balancing isoflurane versus adrenaline? Without anaesthetizing. And so how long do you actually have with that?

And they'll vary, you know, some cases you may be stabilised for a day or two. Sometimes you've probably got half an hour to an hour. You'll be very careful indeed.

And sometimes a real severe respiratory stress, you're anaesthetizing the moment you see it, putting oxygen, put a little bit of gas running through, just to get get the stress off that bird, get some oxygen into it and stabilise it that way under a little bit of anaesthesia, which seems really weird. But that does work. So we'll obviously take history and physical examination if at all possible.

We were for a bird's malnourished and we got a bit of time, we'll feed it, we'll tube feed it, we'll get some some nutrition into it. We'll get fluids, of course. Some further examination we can do without anaesthesia.

Now a controversial is about preanesthetic blood screens, again, very often using anaesthesia to take blood. So that does seem a little bit odd with that when you don't necessarily want to do that. And again, how much stress you can put that bird through before for the value of that blood screen.

And so these things can be quite nebulous in interpretation, but that's a different lecture altogether. Where possible, get some time acclimatising, so the birds come 50 miles of a car, you know, do give a little bit of time if you possibly can just to get over that, get stress over it, some warm, dark, comfortable, talk about hospitalisation in a moment. Certainly, if possible, you want a faster bird.

So certainly anything elective, you know, and that varies with the size of a bird too, maybe like an hour or two for for like a canary. It may be so like half a day for a very large parrot or for a raptor. So, you know, make sure the crops empty.

The fundamental things check our crops empty. Crops empty, you're probably fine. And we're going to use a little bit more about premedicants.

I'll talk about that in a moment too. So hospitalation needs, again, warmth is really important for these guys. The thermo neutral zones at 30, 32.

So, you know, it's quite warm. So you do need to get that temperature just to save them burning energy to stay warm. Darkness will often help with a lot of these birds because they just tend to calm them.

They're quite primitive creatures in many ways. And so some of the time we can darken down will again help, especially after journeys and stuff. Quietness too, you know, you don't want this to be surrounded by barking dogs.

You don't want them to be having like a thoroughfare and noise and disturbance because that's increase the stress and stuff. So a bit of privacy is really useful. Sometimes company we used to be in areas, having other birds around might be a help, especially the same species.

And actually sometimes too for a bird is used to having people about, just quiet people wandering about a radio on again, set to correct station, of course. You know, that can be useful too. OK, so pre-medication I mentioned.

This is saying I don't use enough and there's a reason for that, and that's when I qualified. The gas is available, mainly halothane, which most of you thought going anywhere near using, was actually lethal to it. So we tend to use injectables and they were pretty lethal as well.

They're very dreadful things. We didn't have very, very, very, very refined doses to use. So when isoflurane came along, it's brilliant.

It's fantastic. Avian anaesthesia became that much safer. So, for some of us older people, it's very hard to go back and say, oh, let's use some injectable stuff.

Let's use systemic drugs, you know, I want my gas. But actually, we can reduce isofluorine doses but that's quite good, partly because saving the planet, because I say can be linked into the ozone layer destruction. I think it's important to reduce it for that, but also because it'll lower the blood pressure quite a lot of your of your patients.

So we can actually reduce that effect, by by using premedication. It can also do stress relief too, so we use that midazolam, we can relieve a lot of stress, and that can be really important as part of that climatization period of getting a bird calm down a little bit quicker. And in some cases, just that might be enough for diagnostics like X-rays, maybe a blood draws, things like too.

Many things reversible too. And the nice thing too is you can use lots of these drugs intranasal versus intramuscularly. And intranasal is nice because it's much easier to give it that way.

And much calmerbis much calmer getting that, so that can be quite good. And in very rare case, you can get the owners to do it, but fundamentally, I'll do this in-house all the time. So when do we use these things too?

Well, OK. There are actually times that sedating only, and these are probably very noninvasive procedures, for a very anxious distressed but I might well use pre-medication. I said I probably should use it more and more and, and, and that, that's my thing I've got to come to terms with.

Some people recommending even for very anxious birds to using as part of hospitalisation regime. So basically keep sedated through or through the hospitalisation, which personally, I like to be able to observe them. I had a bird who's very distressed and flying around and flapping, I would definitely consider this.

And these are the doses been using, so midazolam 2 per kg intranasally or 1 gig intramuscularly. And if we really want to say we might add in some butter for no, 1 to 2 me per gig intranasal. The same syringe is fine.

And we'd reverse that with flumazinil at 0.1 me per gig intramuscularly, or it can go intranasal, in which case you divide it half into each nostril. Be carefullumazanil, or if you don't need to reverse the benzodiazepine, and flumazanil, I've had a few problems with before, but, you know, there's there there to use.

So Briefly about drugs, that is a brief diversion into premedication into sedation. Don't forget, although I've said about isofluorate, is there's no such thing really as a safe anaesthetic. And if you are going to use these doses, probably don't write down ones I'm giving you because these doses are really evolving fast.

And you notice that all dose rates are full and full and full to the lowest effective dose, which is really good. So just keep an eye out for it, we use the most recent dose. And if you are using sedation stuff, please remember to always keep them warm and always supply oxygen, which we'll talk about later on.

OK, now we talk about patient preparation briefly. How about preparing ourselves and this thing we really can do. So we want to have those people ready for you.

We have a vet, we have a nurse, we don't have any assistance. You don't want to have your nurse running right away, leaving the anaesthetic to get equipment, get things like that. So you want all your equipment ready and all the equipment you think you might need.

It's much simpler to put a load of stuff back again, having not used it and spent ages looking at that really rare pair of retraction you haven't seen in 2 years. Halfway through the anaesthetic, and that's, and that's Yeah, that, that's just maximising that time spent at least start. If you are having your equipment ready, so you might decide you're not going to use the ventilator this time, have it there and switched on.

Because if you do run into trouble and decide you then need it, you don't only spend time switching stuff on and booting stuff up because that takes a lot longer. So have it there, ready and switched on. In other words, just minimise the time spent when he starts.

And Again, we've been checklists and stuff and not great. I'm too old, but I do think I'm going to find more and more useful. These are really good.

They do make you think about things before you you start or as you're starting. And it's really good to go through that and make sure your equipment's there and make sure you've thought about it and got everything ready. Don't be looking for stuff partway through.

At least the checklist, at least think about it. If you remember you have forgotten something, you don't have to start yet, you can just stop for a bit longer and go and get it. And it's really good reminder for that.

So we're going to go and induce now. What are we gonna do? We use injectables, use gas, but something like, we don't often use injectable induction, but you can do.

So for some people got very big bird, for that they say a swan or something that our facts and induction can be really useful for getting onto that or, you know, so you just want to gas induce those as well. So that, that depends on your preferences and what you're dealing with too, but we will tend to gas induce. Pre-med obviously makes that a lot easier and a lot less stressful and a lot quicker, and a lot less gas used, that's good.

We will tend not to use chamber induction. I really don't like chamber reduction at all. The reason being is they always get to an excitement stage.

If you're in a chamber, they're going to better themselves. And obviously we do a bit of rap to work and stuff for can get very upset if you start damaging feathers, which I will do. But to be honest, even you know, with pet parrots and stuff, if it goes out with it it's it's carpal joints being traumatised and bleeding from recent anesthe was bashed itself against a chamber, that's not gonna look good.

So I will hold them and mask induce. Again, remember that restraint for the mask, do not obstruct the keel. So side side hold the wings, make sure a keel has clear movement the whole way through.

Now another preference thing is, do you want to start one size and move up, or do you want to start at 5% and make it very quick, but slightly more of a, if you like an IO shock because it hits there. Again, individual variants, different people do it in different ways and seem to get some success rates. Mask fairly standard.

Most time using these sorts like semi open mask with this sort of diaphragm across, you wear them rubbing on the eyes with those you're doing it, but you can do all sorts of things. So this is for young people selling which older vets would call a syringe case. They're brilliant.

And, all the ring plastic cases. But when we all kept them and you can make this wonderful mask out of them. They be plastic cupping and stuff, which you can put, make a semi open by putting a glove over the top, cut that you then put over the top of the bird works really well.

And then get reinventive so very strange shaped birds like this Maribou. Here we're using a basically a 2 litre lemonade bottle, which works beautifully. There are some really, really weird stuff you actually buy.

And this is a long beak bird mask. And if you notice very short mask, that's what we're doing is with pelican in areas are here. So actually it's got close on here.

It's got a closed area here. It's a very short mask and you see just pumping the gas over the top there. Those are quite quite cool.

So once it's induced, you, you'd want to intubate, the glosses says on the back of a tongue when you got like a raptor, it's actually quite simple to see. You can see how muscular it is, and that can have some difficulties, but, you know, fundamentally, it's very relatively raptor is relatively easy to intubate. Chickens are actually one of the most difficult because although they have a very small tongue, it's very easy to visualise.

The, the gloss seems to be very mobile, it can go very deep down long way down the neck. And so it can be really, really hard. To, to intubate without actually fixing the glottis in position with your fingers from outside of the neck.

So that, I find one most frustrating. Parrots are also quite tricky compared to that's mainly because they've got this very, very thick, fleshy tongue. The gloss still in the same place or whatever so it's really hard to visualise that tongue in a way.

And one of the tip I've got for you is that, a pair of curved on flat scissors is actually when when closed to blade to close is the most perfect tongue depressor. The, the, shapes exactly right, the curvature is exactly right. And so just use that just to push your tongue down and you can visualise the glot is much easier.

So, what do you see to make? We use these all the time. These are step tubes, also called cold tubes.

They're great. They come from a range of different suppliers now, absolutely fantastic. And the nice thing is always relatively short tubes going down the trachea, and this step closes against the glotters.

The avian trachea has complete cartilage rings, so you do not want to use cuff tubes. They don't take that very kindly at all. You know range of tubes again, so you get into like a 1 millimetre tube with the style that down it for very small birds.

We can get clever and use like urinary catheters and your cats work very well for ties. So, you know, all that sort of thing can be adapted. So you can do that too.

Now can you have some problems with intubation, in very small spaces, there is a high risk of blockage, . And that's with mucus and stuff and discharges because it's such a tiny, tiny hole. So in some cases you don't actually tube those because it's almost too dangerous.

. One advantage of this is actually you can, ventilate, and what ventilators do is not actually so much blow with discharge out of the way, but actually it'll tell you if it blocks much sooner than you're gonna find it any other way because the ventilator will start working. Position also important that if you, it's very easy to kinker tube, especially in very small birds, especially and also when you use rigid plastic things you made yourself. So just be, be aware of that and watch out again and again, but how device we can actually pick up the the blockage early.

One thing has cropped over time, time is stricture. That seems especially prone in the cause, and those thoughts is linked to red rubber tubes, is it linked to cleaning agents left behind in there. But actually what seems to be that length of the tube.

And if you look in the because we use a long tube, and this is one reason I do like this step is not a long tube going down there. . 2/3 way down, there is a natural thinning of the trachea, and that's also where we tend to spend these tubes are rubbing on that little space there and seeming to cause formation of an irritant stricture about a few days after the anaesthetic.

Those are remarkably hard to treat. So just be careful, use a very short tube in those. OK, in terms of circuits and things, again, this is, this is why this talks called practical a bird anaesthesia because I'm not, I'm not an anaesthetist.

I don't talk about posh stuff very much at all. There'll be a couple of complicated sites, but I'll tell you bird be given to me by somebody else. So what you know, what do we do stuff?

Well, basically, mask and tube is fine for very, very quick, simple procedures, but always have rest to get available. Otherwise, they do use things to resistance dead space, those things to, to basically and fundamentally, if you're using most birds under 10 kg, so T piece is fine. If you're using, your bird over 10 kg so swans, that type of stuff, then use a bigger circuit.

Simple as that. So here's another thing too, it's one reason why birds are actually quite cool and avian anaesthesia has big advantage of mammalian. There are times we actually want to work on the head.

Now something like this is fairly simple. You intubate, carry on from the normal, just turn the bird upside down. And watch a bit more carefully is upside down.

And . We can operate on that bit. This is more complicated when you do like big surgery because you can see here the the bigs that here, but the tube is actually beginning to get in the way as we begin to work on it.

That's not instrumental in this case, but it's being awkward. But actually we got same way you actually got something like say Aspergillus, where you got a fungal blockage of a trachea, then we have to work on the trachea have to work in the head and gets right in the way there. So what we can do is we do airs that cannulation.

This is really cool. This is actually a cold tube. This is saying where we've got, it's really nicely with holes.

Like collar here, and it's a just a proper tubing by you can actually make these yourself by cutting up the the, the cat and the qui tubes we don't tell you small colleagues. And what you do is you basically make a hole in the side of a bird. And this is where we're going for endoscopy.

So it's behind the last rib in front of the leg, under under the spine. And so we go straight into either the abdominal or into the cordal thoracic air sac. And we just basically make a hole in the skin.

We use a pair of hemostats to push through the muscles, and then we push that through there, and that goes into the air sac. And what we'll do then do is we can connect in the . The the the the the circuit.

Now we'll normally reduce the air flow to a third of what we normally calculate to go in this way. So we have a low flow passive breathing. Obviously, you can't ventilate by this route.

We have a low flow passive breathing and this works really well. This is great when you've got some sort of blockage up here, and we want to bypass it. And at the end of it, you can actually leave that in place.

Most birds tend to leave them alone, even parrots, so that's quite handy as well. This enables us to do things like in this case, we're operating on an aspergilloma here. Now the one disadvantage is, of course, you've got a passive breathing, which is pushing us flowing up through here.

So the poor old surgeon does get a bit of a face full of the whole way through in terms of operator safety, this is not great. You do have to take a lot of breaks and stuff. It actually being able to do the job effectively.

It's sometimes the only way you can do it. So just be careful if you do do that. You have protective gear to wear, please wear protective gear.

So let's see what we're doing through a normal route. What are we gonna do for maintenance, but again, I said we can use masks and stuff, we can do that. We can connect them up.

We can choose ordinary passive breathing. That's fine. In many cases, that's OK.

But actually what we're finding is we get much better results if we do do IPPV. Now that can be manual, and you can certainly back it like, like you would, normally, and what we do is basically calculate it to being the rate being, roughly what we would normally. So we'd probably do about 20 to 30 breaths a minute.

Be careful when you do that because again these fixed lungs, you can overinflate, you can damage lungs. So if you're doing that, watch the keel very carefully and you'd be amazed how little pressure you've got to put on this on the bag to actually move the keel up and down, but you can do it very carefully. Alternatively, go for a mechanical ventilator, and this is what we use all the time.

Two types of mechanical ventilator, one's a volumetric. There was it pushed out a fixed volume of gas every single push. The other one is a pressure vent limited ventilator.

The volumetrics are actually tend to be much better, and they also, and they're also more expensive. In birds, they, when, when the bird is, if you like, Closed body cavity, that's fine. You know, volumetrics are actually are better.

But if you're using, if you're doing abdominal surgery, so you open up the air sacks, suddenly your system is no longer closed. So the nice thing about pressure limited ventilator is that actually it stops pressure limiting. So ventilation will stop as you open the air sacks, and it becomes a continuous flow, and that's really useful.

So that's why we, we tend to use pressure limited ventilators to say also cheaper and smaller, which is great on bird tables. So while we're asleep, very important aspects again, temperature is really important. One of the big reasons why, birds die under aesthetic is because they get cold, and they've got high body temperature.

They've got, a high surface area to volume ratio. And one of the thing where they keep warm a fluff of feathers, things like that, all those are taken away from them when they're under anaesthetic. So we want to keep them warm.

Nice simple things work too. So you can actually use things like hot hands and very small birds like this. There's nothing wrong with that at all.

You can slate to if you want to depend on how warm you want to get how quickly. Heat pads again work great. Be aware of getting things wet, but then again should be careful about getting birds wet anyway.

Radian heats also are really nice. So can these infrared lamps work really, really well indeed. Well, we tend to use more the bear hugger type things now.

We will be hot air air blowers, and they work really well as well. Be careful of the eyes. So again, they can get dry eyes, so again use lube and stuff.

And if you are mask inducing, it's quite easy to traumatise the eyes because the edge of the, the diaphragm of the the the mask can rub over them. So just be careful and look after them and and keep them lubricated. When you're operating, be careful of blood loss, all those can withstand quite a high volume of blood loss we get in trouble, 50-60% of blood volume, which is amazing.

But if you're dealing with a 20 grand budget, that doesn't isn't doesn't equate to very much blood. So again, your anesthes will thank you a lot if you don't lose too much. As mentioned before, don't forget the position.

Yes, you've got to get a right position to do the job tailor how you're anaesthetizing to . To, to that, to that position. So, you know, if you're lying going on back, you might need to increase that ventilation pressure a little bit more.

So just, just be aware of that. And if you can get away with putting a bird on, on, on the side, please do so. So it's a hot air blower in process.

We're actually not chopping wear's leg off. We're actually taking a, we've pinned it we we're chopping a pin off that, but these, these, these hackers are fantastic and we use them all the time, and they work really, really well and a lot safer than the heat pads. So while we sleep to again mentioned the emphasis now is much more monitoring about looking as vital capacities, making sure they're OK.

And can appreciate things like respiratory rate, you can appreciate the lung perfusion, hot blood oxygenation, heart rate regularity, pulse rate regularity, peripheral blood flow, body temperature, that type of thing. All those are really important. Now again, this is one of the problems you can have for ventilation is that if you put a mechanical ventilator on, suddenly you can't monitor breathing because the ventilators doing it, the bird can be long gone, and the vents still pumping away quite happily.

So you have got to tailor your, your monitoring to other things and just be a little bit careful about that too. And here we are, here we're using a canograph to just assess the effect of a perfusion of, of the bird. Now, what I haven't mentioned there is things like reflexes, and this is the slide that explains to you why Avi anaesthetists live on the edge.

This is an anaesthetized Amazon parrot. What we can see is we got this pupil here, it's central. It's fixed and it's dilated.

And this bird is in perfect surgical anaesthesia. It's basically just one click away from death, and that's where you want them. And that's why avianists are really stressed up, because that's how close they're flirting with overdosage.

The trouble with birds is if you've got reflex, if you got a withdrawal reflex, if you got a corneal reflex, they're very, very light indeed. They're probably about to walk off or fly off the table. And that's the problem.

They basically have the reflex they gone until the very end there. So, so just be aware of just just how they look at look where stars and it really is difficult. So don't use those reflexes as part of your guide to to to how they're doing.

And above all, I said, you do need an anaesthetist. You've got to have somebody looking after all these, looking at what's going on there, not one of getting stuff too. So practise joke is how many people I need to operate operate with.

And the reason I do genuinely need at least two people because I do want to to go and get stuff, fetch up and do stuff and assist me while the need this just stays there and stays on the bird and stays on the bird and stays on the bird. That's really important. Now, I may show a graph.

Now again, back to saying this is a technical bit. This is being given to me by Keith Simpson electronics. Thank goodness because it's way beyond me.

Monitoring carbon dioxide is a really good thing to do. For all these reasons, it's constant. It's expired level respects cardiovascular respiratory efficiencies.

And every time you look at those, you just remember that statement, that's what it's doing. It's early warning of hypoxia. I'll show you pulse ox in a minute, but I love this much more because everything in a bird that can go wrong, I want an early warning on.

So telling you not just how but is breathing, it tells you how well it's breathing, which is what's so good. And it gives you those those expired carbon dioxide concentrations. And this is a reflection of what's happening in the pulmonary artery.

And the nice thing is there's a fixed gradient between this and it works in birds like works in mammals. And the nice thing is the figures are exactly the same. Yeah, that's great.

So you're looking at about 4% expired carbon dioxide, and that's just great there too. And you do get a typical catnogram like you do in mammals, and it means exactly the same stuff, and that's what's so good. So this is a typical catgram.

Again, when sampling to your side stream, you want to take very low volume off there because again, you're using lower flows. So a very small creatures. If you've got too high a suction off here, you'll be taking off too much inspired.

What happens should be dilute down and get lower figures for your ETCO2. This is a typical one you're looking about right the figures here, and this is what it looks. In action.

I'm hoping the same won't come through because we were talking of the topic, which is very careless, but we can see just going through that. Now it's actually an induction one. What you can see is you get little breast happening occasionally, and what that's showing is the bird is is basically still partly breathing for itself as the when it gets caught by the ventilator.

Some reason now disappeared and here we go back into what we should do. So we just play that again, again, you can see. Nothing happened.

Damn. I knew I shouldn't put videos in here. OK, fine.

But basically, this is what we're kind of looking through there. We've got a little bit of residual there where it's fighting it, the smaller ones as you as you're backing through. So That's kind of the thing.

Another good thing to do with this all time is we we look at peripheral blood flow, and this is really useful. So we start 8 MHz Doppler. This is what we use for measuring blood pressure in cats and stuff.

Those things exotic like we use them long before the cat people did, and it's not to be taken away from us. But basically it's worth fighting for because he's really useful there too. He has got a periphery, so he has got a foot or it has to go on a wing.

And what you're looking for is you get the pulse rate, which is great. Your pulse rhythm, which is really useful. And you get the strength of the pulse, which is phenomenally useful.

Because when things go into shock, when the first things gonna start happening, or start to die basically under anaesthesia, is you get a shutdown of peripheral blood flow. So if that noise the Doppler is making starts getting quieter, either it's slipped off the artery or it's getting, it's getting, getting weaker and getting problems occurring with the anaesthesia. And that's really useful.

And we fixed it to the inside the elbow. So we got a nice brachial artery there. We put over the top that's really easy place to get.

And then we use this sort of two lollipop system, with tongue depressor, not lollipops same difference. And basically just down below here, we've got a bit of tape holding these together to make a little fork, and that's holding in place. That holds it really, really well.

And so we use that and that, that, that gives a lot of information goes straight. You can do ECG monitoring, I don't do very often for just this reason. They see all the leads everywhere.

That just get right in the way. But it is something you can do, and there's a really good reason for doing it sometimes. It's where attach and basically on the pro pottaium, which is the tendon in the top of the wings, and again onto the toes.

I'm using a traumatic clips, which I'm better tolerated and don't cause so much damage. You're quite delicate there. Now The reason why it's quite useful in some ways is not because dysrhythmias are really common.

We detect them and certainly if you have got a bone with heart disease, you know, certainly good reason to do it. But because of this. And this is the basically the heart beats per minute of a normal anaesthetized grey parrot.

That's 444. And so when I see somebody with the stethoscope writing down numbers, you can't count that. There's absolutely no way a human being can count 888 dumps per minute.

So it it does mean that you always got a huge factor of error when you're working those things out. So that's how you saying which monitors the heart rate is really useful. ECG can certainly do that for you.

And 444 is is quite a frightening figure if you look at it in sort of real time here. You know, it's kind of flying along there. 4 dropped to 413 there, but you're gonna need some sort of device to actually help you calculate that and actually see that happening.

You can't do that by ear. And I said that's an anaesthetized bird as well, when they're consciously even even better. Now, there are ways of reducing wires, and this is .

This is a system we've been experimenting with for a year or two now, kind of do occasionally, but this is an esophageal ECG and you can feed that down into the crop and basically you can feed it through beyond the crop if you're careful. But above all, you get it just next to the heart there, you can pick up a trace. Now what you can see from the trace there is that it's much, much smaller.

That's because we like with a muffling effect. Now, that's OK in terms of monitoring regularity and kind of looking at basic. You see, the basic wave shapes the same, that's fine.

What it does is actually the ECG machine finds it difficult to pick it up. So it's still actually record that as being a zero heart rate, which is frustrating. We haven't got a number we can look at and see how it's changing.

We have to look at wavefall the whole time. So, Just, if you like. Judgement out on the on the esophageal ECG I think it's got a lot of potential to it.

And hopefully, in future, I can actually tell you a little bit more about that. . In future to because we've done a bit more work with it.

But if you do want your heart rate, you got to say like an ECG just to check it up on that. So I did promise you I'd mentioned pulse ox. Now this, as you can see this, this bird, you've been seeing all these things that actually looks remarkably familiar in every single one.

That's it's the same bird. Now, you've been seeing some of the numbers come up there, we're looking quite good numbers. We got 4% expired carbon dioxide.

It's got heart rate of 400. It's in its regular and it is looking pretty healthy. Well, this was the pulse ox put on its toe and it's down to SPO2 of 75.

And, that's effectively dead. So, Essentially, the pulse ox doesn't work very well on the toes and extremities and stuff. And hopefully we panicky you got that.

You can cloacal probes you can use, which are a bit better. But again, this is saying what I very, very rarely use and very rarely like, partly because I find it unreliable from terms of these numbers and partly also because it's good pulse ox and whenever it goes off, you just switch off and again it reckon it's it's gone bonkers. And when in fact, actually using your cameragraph and stuff, you tend to believe what it's saying.

So I very use, I use my Kanograph instead. Much prefer. So, above all that, if you can use one thing, your sensitive, reliable, reactive anaesthetic monitoring device.

You want one of these people sat on that bird. And this is one where, you know, where we are, we aren't using devices here. What we've got is we've got some of the stethoscope on one bit with their finger on the pulse of the leg, so comparing heart rate and pulse rate.

So although it's impossible to record it in that position, and it's impossible to get the exact numbers and stuff, you can at least get that relationship with that too and there's very close monitoring and very sensitive reactive to sensing and knowing that the patterns by monitoring continuously, not by going back to every few minutes. So my nestis is the most precious thing to me when I'm operating. Now, we mentioned about injectable mentioned about sedation stuff, but actually there are other times when you can do injectables.

If you're working in the field, well, you can do that. The other thing too is really good. You get these ISO and air machines.

And John Lewis, who did a lot of zoo anaesthesia was a great exponent of this and absolutely fantastic with it. And you can just pump air through I Iotech using this device and actually provide that in the same way as the field. So that's really useful.

Alternatively, you can use injectable regimes, which you can find in books and and stuff. For special species like ratite, you really are gonna have to use, injectable regimes, and they don't, ostriches don't take kindly to being masked down. .

So those who tend to be used alpha 2 and ketamine normally in some various relationship and again, those rates available. And that was beginning to be a bit of a move with some of the parrots and stuff again to total injectable regimes. And again, just illustrating, I think we, we, the increase in knowledge of the birds and knowledge of how to monitor them, is it now it's much safer to be able to do those total injectable regimes within those.

And I think what your space in very, very in early infancy, but then maybe tell those could be quite an effective way forward. Now, one other important thing mentioned about anaesthesia is about analgesia. Now, of course, isofluorine anaesthetic doesn't really provide that.

Now, if you are pre-meding, you may find that it helps a lot with the analgesia side. That's important. But analgesia is important.

Now, this is one difficulty, but. Is that we're presuming birds feel pain. They do appear to feel pain, but actually very little is known about how they do and what mechanisms they they use it.

We do a lot is based on presumption from other species. And assessing pain in birds is really difficult because they don't show many signs. And That is a is a big issue with them.

Certainly you can in terms of what you can use, you can use NSAID. I always advise people are using NSAID to do it at the end of the anaesthesia because they do get pretty hypertensive with the gases, and that can be an effective renal flow. So use your NAs at the end when the blood pressure's coming up and always ensure they're well hydrated and you're giving fluid therapy as well.

Opiates are much more interesting with them, and that is that there seem to be very big differences in where the new and the Kappa receptors are on the bird brain compared to the mammalian. And there seem to be very different effects from full versus partial antagonist or agonist, sorry, with the opiates. Our result being is that generally most people prefer using a partial agonist rather than a full agonist, which is the opposite to mammals.

There are those rates and there's many contradictory studies. I think one of the things here too I think this is one of those areas where I think you'll be aware, when we talk about bird anaesthesia, it's not like dog anaesthesia. And we know it's big breed differences.

We only talk about one species, we're talking about bird anaesthesia, we could be talking about thousands of species. And just because one of them needs this dose of buprenorphine doesn't mean that's what they all need. And even more studies done shows the bigger and bigger differences between different species and species groups, especially in terms of opiates, which opiate they respond to best and which data is.

So whenever you use opiates, do go to the, not just for formularies, but also to the current literature. So it does mean doing you so you know, you'll be a proper Google Scholar searches and and . Oh, the other ones, I forgot my name pub bed searches, looking for, what the latest papers are the latest that those studies are to use the best drug for those and how long they last.ga massive difference between species and how long we appear to last.

Now part of that too is also hampered by the fact is drug studies in pain relief studies in parrots is hindered by how clever they are. It doesn't take a parrot very long to learn that scientists approaching them with something nasty and sharp is probably about to make them hurt a bit. So they actually do preemptive pain signs and things like that and preemptive reactions, and that does blow the whole experiment out of the water.

So pain studies in parrots are really hard to do well. One big difference I would say, say with with opiates is some of these are very, very sedative. And that it's very difficult in a clinical setting of determined difference between sedation and the apparent effect of pain relief.

And so sometimes you just think, oh great, I'll give it. I give i is great. I think it's very sleepy looking bird and it seems whatever else there.

It may be just sedated. It may not be experiencing analgesia. And that's dangerous because we might think, yeah, aren't we been great, and the bird is just saying ouch, ouch, ou ouch, ouch, and that's not good.

So be careful about that. What can we do instead? Right.

If you're using a multimodalism injectable regime, using ketamine, don't forget you've got good pain relief from the from dissociations that that can be useful for you. One thing we we're using more and more is local anaesthesia. And if you think about it, local anaesthesia is the only true painkiller, because actually blocks the impulse through the nerves.

Every other thing we do is like anti-inflammatory or is modifying the, the, the response to that. So local anaesthesia is really useful and really does a lot better to different ways you use it, you splashes, you can use regional blocks. You can use infiltrations, incisional blocks, that kind of stuff, use them all if possible.

And one thing to be aware of is be aware of the toxic doses. So again, check your form before you go ahead, which are the class that you're using, and make sure you just simply don't exceed that maximum dose. That's fine.

Afterwards, again, don't you think about how to modify the bird's response pain stuff is, don't forget the, the, the, the effect of the environment. So if a bird is stimulated, Happy and enriched, he's actually gonna feel a lot less pain, just like we would if we were stimulated happy and enriched. So again, putting in a stark hospital cage with nothing to interact with is probably going to make you think, oh my goodness me, I'm worried and frightened and scared and gosh, doesn't this hurt?

Whereas if you give me saying do like a like an enrichment feeder or saying on those lines, actually, you're very often going to find the bird is showing fewer signs of pain and appears less distressed at the end of that. So environment can have quite a big effect too. So you mentioned anaesthesia, again, infiltration, incision splash and things that too.

And actually, we found we we start doing a lot more of that, we are beginning to reduce the isofluorine doses by using those. And again, good thing too, less systemic effects, less gas in the air. And again, assessing these two.

One of the things it seems like if you're talking about, we don't know what these drugs do is, do we do that? When do we think we use, can we avoid it? A bird doesn't look like it's showing pain.

Always ask yourself this question. Would the lesion be painful to a human? Now if you male like me, fine, great.

It's probably everything's painful. Is the lesion damaging tissues where if you're just done surgery, you've damaged some tissues, you are gonna need some kind of analgesia. And these are the signs of pain in birth.

So basically, it's almost anything you care to think of. So if a bird is doing anything that's different to its normal behaviour, or normal behaviour for that bird type of bird, you can probably bet your bottom dollar is experiencing some kind of pain. So in that case, you do need to start considering analgesia with that too, given all the issues I've highlighted already.

OK, fluid therapy again, always useful. Consider the losses. Consider how much you need to give support to support blood pressure, to support the renal flow, that type of stuff too.

Which one are you gonna give? Well, ideally you're gonna be measuring blood electrolytes and stuff. You can base it on that.

But if you're not, well, again, straight saline, can't go wrong with that too often. I think we like these sort of problems it's having, you may want to, to consider different types of fluid from that based on what it should have just like we would in dogs and cats and stuff. And we can give fluids intravenously, we can give in osseously, which I tend to use more in intravenous.

These to place a bone catheter that is an intravenous and maintain it. You give it subcutaneously, which is again in the initial stabilisation and really nice, easy, quick, well absorbed group. For giving a large bolus of fluids that way.

And certainly, after surgery, once the bird is fully around and standing, you can chew feed, you can give oral fluids. You can mix that with some critical care formulas formula and get some critical nutrition immediately after, after surgery, and that can be very useful. Now, it makes sense so easy, doesn't it?

We stuff there, everything's great. Well, we do get problems. One advantage of isoflurane, one of the big reasons why isoflurane took over and made life life much better for us all, was that good old halothane was respiratory and cardiac depressive.

That meant when it stopped breathing, generally the heart to stop too, and that's that's a difficult place to get it back from. Isofluorine is more respiratory depressant, but it's much less cardiac depressant. So that means when it stops breathing, generally the heart is still working.

And that's great, that gives a chance to get the bird back again. So you see soon that breathing stops, you're jumping on it, you've generally got a bit more chance. In terms of how to deal with those really protocol is exactly as in mammals.

This is got good old ABC. So, you know, anyway, if you haven't got a tube in place, get a tube in place quickly. If you haven't gotten the ventilation, get ventilation quickly.

Even if you're just using a bag, if you're doing manual IPPB do that and get the, the, the, get the, the air moving through those air sacks as quick as you can. Circulation is more difficult because you've got this keel, which is bony sort of surround around the chest. It's very, very hard to do cardiac massage like near enough impossible.

You can pump the keel and you might get a little bit of effect from there. You probably will do that if you're getting in that stage, it's really difficult to do. And here's the important thing, you only go to your drugs after you've done these three stages.

So this is when we do use things like Doxopran where you use adrenalines, that kind of stuff, very, very similar to what we're doing in, in, in mammals. Again, importantly you have your crash box to hand, you have your stuff ready to go, and you're doing this very fast. Then hopefully once things got going again, you then you reach for your fluids and, and do that.

So just like in mammals, really, just get that mantra, the ABC mantra going in your head. Hopefully we won't need that. Hope the birds can recover nice and then eventually, and really important you supervise them to a standing a lot of problems will happen in that immediate post anaesthetic period.

So make sure you actually watch them until they're fully standing, fully moving around, fully OK. During this time, keep them warm. They won't start to the regulate properly until they're really up and about properly.

So again, just watch sure where we're get warm and we'll wrap them, partly for warmth, but also because you often get post-operative excitement. They stop some flapping around. Now it may affect the wounds and stuff what we've done to it, but also because again, they're likely damage themselves and do things.

So can wrap them up, and that's really helpful. And extubation will only do want to really, basically move the head around a lot, actually was throwing the tube out the mouth themselves. They go a little bit earlier and so like a Mccaw because there's a much higher chance for McCaw biting through the side of a tube.

So again, extubate as soon as it is it's safe to do so. So in summary, You can in these size birds, even, even very small ones, can be quite tricky, but you can do it. Just go into it knowing you're mostly more gonna be high risk than you expect in small animal practise.

And again, go into knowing you're going to communicate that risk for clients, so they know what's going to happen, what we're doing too. And the big deal of all this, if you're going to get one bit of gear, if you're doing a lot of birds, get a ventilator. The ventilator really, really does keep things alive and it saves more birds and probably anything else we've done recently.

So yeah, that's that's big be get a ventilator. Thank you very much. John, that was absolutely fascinating as always.

Yeah, you, you make it sound so easy. It's really scary. Oh, it's scary.

I didn't say it wasn't scary. No, that's true. You didn't say it wasn't scary.

But yeah, certainly big advances from when we qualified, you know, where, it was, I hoped in a prayer mat and, and nothing more. So it's, it's fantastic to see what guys like yourself and and your colleagues are really developing for birds. So, thank you for your time tonight in sharing this with us.

No worries. We haven't had any questions coming through tonight, John, and, I, I've been sitting in a wrapped up in everything you've been saying. So I too have not come up with any questions for you.

So, I think we're gonna let you off the hook on this one. OK. Well, don't forget anyway if you want to ask questions, I think some people feel very shy about doing it.

. You know, just drop me an email saying that I'm very happy to try and answer them. Fantastic. Once again, thank you for your time to all of the attendees tonight.

Thank you very much for your time as well. I hope you have enjoyed it as much as I have. John is definitely one of my favourite speakers and you've just experienced why.

So, I look forward to seeing you on another webinar soon to Amy, my controller in the background, thank you for making everything happen. And from myself, Bruce Stevenson, it's good night.