OK, good evening and welcome to tonight's webinar. My name's Sophie and I'll be chairing for tonight. So for this evening's webinar, we have the wonderful Joe Hein talking about holistic rabbit anaesthesia and looking beyond drug dosages.

So before we get started, I'd just like to say a massive thank you to JHP recruitment and Tails.com for sponsoring tonight's webinar. And if you would like to ask any questions throughout, those of you who don't know, just hover over the bottom of the screen, click the Q&A box and send your questions through to me so that I can ask Joe at the end.

Jo has worked in the veterinary industry since 2007 and has always had a special interest in rabbits. She owns and runs Lego Lane, providing a rabbits specific CPD to veterinary professionals in both the UK and internationally. She also spends a significant amount of voluntary time working with charities and parliamentary groups to highlight animal welfare and is proud to be junior vice president of the British Veterinary Nursing Association.

Co-attends many events, gives lectures and writes articles for the veterinary industry, as well as the general public and schools. She has received several awards over the years, including the Blue Cross Veterinary Nurse of the Year in 2014 and the RCBS Innovation Award winner in 2017, and the IFAW Animal Advocate Award in 2017. I'm sure you'll all agree, pretty impressive biography.

OK, Joe, over to you. Lovely, thank you very much. Thanks everybody for, for coming in.

So I'm gonna talk to you about holistic rabbit anaesthesia. First of all, just a couple of conflicts of interest, that haven't been mentioned. So Supreme Pet Food sponsor my company Lego Learn and I'm a Rabbit Welfare Association volunteer.

So what we're going to be talking about is holistic anaesthesia. So what does this mean exactly? Don't worry, I'm not gonna be telling you to turn your rabbit on its back, transit, sprinkle some turmeric and open it up just using the power of your mind.

That's not where we're going with this. What we're thinking about is holistic as in an all encompassing view. So getting away from the fact of the rabbit for the elective procedure turns up on the morning of the procedure, the pet checks, yes, it's got a heart rate, yes, it's breathing, super, let's open it up.

We actually need to know a lot more than that and it takes a while to get this information. So we want to look at our pre-op appointments and the really important thing here for elective procedures, we want to look at 6 weeks in advance to get these rabbits in and have a look at them. Now this may seem, you know, a bit of a an idealistic view, but there is a really good reason for that.

The main one being if we need to make any dietary changes, then it takes 6 weeks for that sum for the, for the . For the excuse me, the biome inside of that secu to completely change and re-adapt and get that rabbit back in a better state of health. Also we can be.

Vaccinating rabbits from 5 weeks of age, so really we want to be seeing these guys nice and early on, either from the rescue from the breeder or you know, as soon as those owners have got them, and we can start having these discussions then about the things we need to talk to talk to them about with regards to, to the holistic side. Of anaesthesia. And this is very much continued discussion, it's a perfect place for veterinary nurses to, to have.

So over these 6 weeks, all 3, or 2, you know, just moving it away from that kind of day of the procedure or a couple of days before, nurses can stay in touch, they can take a really good history, and work with the owner to change factors that may need changing. And then quite radically we can actually postpone the procedure as well for these electives. And we'll go through why we may want to do that a bit later on in the slides.

So first of all then, we want to be providing a general health check to every single rabbit that comes through the door. And not only that, we want to do it every single time we get our hands on this rabbit, regardless of whether we're a vet or a nurse, student or qualified. Now, a proper thorough health check is gonna include all 10 of these points.

And this may seem like a very long list and then it's gonna take about 3 hours to do, but once you get into the hang of it, then it's not actually too bad, and you can. You can start whizzing through these things, very quickly, you know, and a lot of the time you're doing this and you're not even realising that you're doing it. So it's important to understand, the way to start, and the way I start is with number one, as soon as that rabbit comes into the consulting room.

So pop the box on the floor, open the carrier, and see what that rabbit does. OK, while you're chatting to the owner and you're getting some history from them, keep an eye on Foxy and see what they're up to. Are they rushing out?

Are they taking their time? How are they walking? What is their.

You know, what is their kind of condition looking like? Are they limping? Is there any head tilts?

All of these can give you subtle information that you may completely miss if you just put the basket on the table and then take the rabbit out of the basket on the table and don't actually watch it move around. Also, we'll just do a visual respirate at that time as well before we actually touch the rabbits, because they are prey species, they're very stressy and as soon as we do touch them, then that respirate is gonna increase. When we do touch them, ideally if we can get down onto the floor and work with them on the floor, that's much better for them.

If not, then pop them on the table on a towel. And the next thing to check is their heart rate, because again, as much as we fiddle with them, their heart rate's gonna increase. Moving on through then, we wanna look at the eyes and the nose to make sure they're all clear, clean and bright.

No gunk or crusting or anything nasty like that. We wanna check that the eyes are, you know, bulging the right amount and equally, and we haven't got anything weird going on there. You want to move to the ears, and the thing here is always use both hands together when you're examining or palpating your patients because even if you don't know what's wrong or you don't know what's normal.

It's very rare they're gonna have a bilateral problem, so when you're palpating the jaw, when you're palpating its ear bases just to make sure there's no earbase abscesses. If you use both hands together, then you can very quickly pick up, oh actually there's a tiny grain of ice there, or a ping pong ball there, or, you know, you can feel these different changes, and you can see, oh actually it's, it's a unilateral change, therefore that's something to to flag up. We want to have a look down the ears as well, use the otoscope to have a look for any crusting, any ear mites.

And check along the spine as well, looking again for Kyla Tella around the shoulders, looking for any lecas give us, any other kind of fur mites and things that might be going on now. If they do have fur mites or ear mites, then you're gonna want to postpone your surgery because yes, we can fix them easy enough, however, it's natural for them to have a few mites, but if they're really easily visible, then this is a sign that something is going on. There's an underlying problem with this rabbit, and it's had its immune system compromised, hence why these mites have been able to proliferate and kind of take over.

So. We need to bear that in mind on how that's gonna affect our ASA grade if this rabbit's already compromised, do we want to then go on and do that procedure or do we want to, to get them back on track, and then do the elective? Looking at their body then, we want to do their weight, body condition score.

Jen will have a look at them, genitals and tail again, make sure it's clean and clear and no crusting. We will come on to poo a bit later because with rabbits, it is all about the poo. Checking those feet and nails, and I leave the jaw and.

Till last, just because that's the that's the thing that they get most upset with you having it so palpating the mandible and maxilla, and actually get the otoscope out, even if you're a nurse, you know, we are allowed to use these, break it out of its cage, and, and get in that mouth and have a good look. It's important to look at the teeth, both the inside and the outside of the arcade, but, but what's really important and often gets overlooked is looking at the soft tissue. So if there's any red spots or blood, obviously that's a, a, a big marker.

But if there's any white spots, they can be very small and they can be very far back on the tongue on the cheeks as well. This is a sign that there's, you know, these are ulcers and a sign that something's not well in that mouth, so again, would, would require some further investigation. And think about vaccination status, so have a think, what do you do in your current practise?

Are you, insisting that all your rabbits are fully vaccinated against all three diseases, before they come in for an elective procedure? If not, And it's something you really should be doing because I know of other practises within the UK who have actually spread RHD2 throughout their practise just by having, you know, an elective come in that was, that was positive and as a carrier. So going on that theory, if you haven't got them all vaccinated before they come in, then really, you won't be barrier nursing every one of these rabbits, which causes a complete nightmare as you can understand.

So again if we link that through to that 6 weeks before the operation, we can check that vaccination status. That gives us enough time to get the first vaccine, wait 2 weeks and give the second vaccine, and by that way, then they'll be covered by all 3. Bits and pieces.

And also take a really good history. So we want to understand what's going on with this rabbit, and the best rabbit expert in that room at that time is going to be that rabbit's owner. OK, so they are gonna know that rabbit inside out, in theory, and they're gonna know what they eat, what they don't eat, how much they move, what they live in.

Do they have a partner, how active are they? All these things we need to know about, and are very important and and may change our treatment plan. So it's really important that you do spend the time getting that history from them.

So think about body condition scoring then hopefully you're all doing this for cats and dogs, and this is a really good, poster, it's a two-sided poster from the PFMA to the Pet Food manufacturer Association, and it's called the Rabbit size Omoa. And it's a perfect way of body condition scoring your rabbits. So it's really important that we're not just going on weights, but we are actually looking at body condition.

And the easy way that I tell owners to do this is if you put your hands out in front of you and make a fist. Use your fingers of your other hand to rub gently across your knuckles, whilst it's in a fist shape, then that's too thin. OK, so that would be equivalent of running your fingers with a light touch over their ribs.

So a closed knuckle with your fingers over the over the knuckles is too thin. If you put your hand flat and then turn it over and use your fingertips on the underside of your knuckles, then that's too fat. OK, so that's too padded.

And again, if you have it with your palm down and run your fingers over the top of your knuckles, that's just right. So that's a nice way to, to just get the hang of body scoring for yourselves if you're not used to it, and also to teach your owners, making you feel this at home on a weekly basis. The next thing I'd like you to think about is muscle condition scoring.

Now this isn't done quite so much for cats and dogs. We don't have a rabbit muscle condition score at them as yet. We're working on one at Lego alone.

But basically we're looking at the prominent bony areas. And with regards to rabbits, this is actually really important because quite often you'll get rabbits come in and owners will say, oh they're losing weight. And we weigh them and yes they are.

However, when we look at them, they're actually losing muscle condition around the pelvis, hips, their, their back legs, around their scruff area, and these bones are really prominent. Now this is a really important factor because we wouldn't want to then get these rabbits. Given extra food to try and fatten them up to put the weight back on, that would be counterproductive because this is a sign that possibly there's some arthritis or their enclosure isn't big enough, so they're not active enough.

OK, so it's very important that we are checking our muscle conditions for on our rabbits to see, to see how well they are in themselves. And it can also be helpful if we're going to be. Knocking these rabbits down for X-rays for example.

Again, if they don't have a lot of muscle mass around their back legs and their lower spine, then this shows they're not exercising very much. And so if we're putting them under anaesthesia and stretching them out, say, to get our views that we want, this is gonna cause them, more pain, which is then gonna make your anaesthetic spike. So we need to think about our analgesia and also analgesia going home as well.

So again, something as simple as their muscle condition can change their. What, you know, what you decide to do for the treatment plan. So a healthy diet then really is the cornerstone to everything with rabbits.

And this is a very old poster, but it's one of my one of my favourite ones. And I like it because it helps explain with regards to the size of the rabbit. So for example, they need to eat 80% hay per day.

But you can say to owners, they need to eat at least a ball of hay, the same size as their body every single day. OK, when we come onto the veggies, that's the head's worth, so again, a small handful, no bigger than the rabbit's own head per day. Pellets are a vital part of the diet, and we're looking at an earful, unless you've got an English lop, and he'll say yes please, I'll have a dog bowlful, thank you very much.

So on general with the pellets for an adult rabbit, we're looking at 1 tablespoon per kilo of ideal body weight per rabbit per day. OK, so for most rabbits, that's gonna come in as 1 to 2 tablespoons per day as a general rule of thumb, giants and babies are gonna need more. And then just 5% healthy treats in there as well.

So if you're thinking about our pellets then, we, we want to avoid the muesli mix. Rabbits are naturally selective eaters, and so they will pick out all the sugary nice bits. Also, a lot of muesli mixes contain locust beds, beans, and whole seeds, and these can easily block the digestive system.

You want to go for a good quality extruded pellet, extruded rather than compressed, means that you can keep a longer chain fibre in there. It also means you can retain more of the nutrients. Now the only two extruded pellets on the market are Supreme Science Selective, and Burgess XL.

The important thing to look at when you're picking pellets of these two, well of any of them, but these are the top two that you can get is the crude fibre, and that's legally what needs to be on the bag is the crude fibre. OK, any other terms are just kind of marketing terms. So.

For example, Science Selective has 25% crude fibre, and Burgess XL adult has 19% crude fibre, and the minimum, recommended crude fibre is 18%. So just bear that in mind when you are. Keep your packets.

You also want to make sure that you're feeding a lifestyle diet. So again, both of those brands do a junior, an adult, and a mature food. So you want to be feeding to the right life stage as well, the same as we do with our cats and dogs.

With regards to the fresh food, Technically, there's a lot of safe veg that you can feed these guys. The Rabbit Waker Association, the RWAF have a, have an amazing website full of loads of really good information, and they have a safe list on there as well of all the veg that is safe for you to feed. However, bear in mind that anything that gives us gas can give these guys gas too, so Brussels sprouts and cabbage and kale and all these sorts of things, can be gassy on what is already quite a gassy tummy for these guys, so just, just bear them in mind.

And fruit, as much as rabbits love it, and love their bananas, I'm yet to see any manage to climb a tree and pick a banana. Therefore, if we just don't give it to them, they're not gonna miss it. OK, it's very sugary, very high in starches, it's not good for the teeth and it's not good for that digestive system either.

So the best thing really is to avoid fruit, avoid root veg for the same reason. And they'll get just as excited over other different types of, of, healthy treats. So just avoid those if you can.

What is fabulous to feed daily are fresh herbs. Now, the top 4, the basil, parsley, mint and coriander are all perfectly safe to feed every single day. And you're just looking at a combined amount of one small handful, no bigger than the rabbit's own head per day.

The reason for this strict balance is because hay is the most important thing and that's what's gonna keep their teeth and their digestive system working really well. So if we change that balance at all, if we give too much veg or too much pellets. It means they reduce their consumption of hay, and then that upsets the the digestion and the teeth as well.

So being really strict is the best way. They can also have deal and thyme and rosemary. These are quite strong flavours and maybe only once or twice a week.

Let's see what the rabbits fancy. So the importance of poop, I said we'd get there and here we are. It's really important to know what good normal poo looks like.

OK? So the first picture we've got up here are the normal faecal pellets, and these should be a nice uniform size and shape and colour. I don't mind what the colour is.

There are some people that on the, you know, just looking out for the, the holy grail of the golden poo, but it doesn't really matter. That literally relates to what hay you're feeding as to what colour they're gonna be coming out. It's important that they're all kind of the same sort of size, a decent size, and you can crush them between your fingers, but they shouldn't stick.

And they shouldn't be rock hard, so that's, that's the normal ones, and they do about 200 of these a day, per rabbit, so we should have plenty of these to have a look at. They also do their seegatrophs, otherwise known as under snacks or bum toffees or, you know, night toffees, all these different, names that owners come up with. Personally, I think you'll never look at a blackberry the same way again after looking at seekgatros.

However, these are special poos that come through. They have a very pungent slimy coating, and that means that they can go back through the digestive system again and that coating means they survive going through the stomach, that stomach acid and get through to that sum. And that's because rabbits have a very high fibre low nutrient diet, so to really extract the best out of it, they, they kind of bubble up and they take it through again.

These are completely normal, however, we don't want to be seeing these because if the diet is balanced and the rabbit is healthy, they should eat these straight from their anus, so they, we shouldn't be seeing these lurking around the cage. And we shouldn't be seeing squishes of them or stuck on back feet or stuck around genitals and things like that. When we've got that, that's an indication that the diet's not quite right and or there's some physiological problems going on as well.

OK, so they're starting to get a bit of arthritis if the housing isn't big enough for them to move around in. Then that's gonna show you've got a problem. Moving on, we've got the string of pearls and not something I'd like to wear, but this is, this is a sign that the gut is starting to slow down and starting to have some problems.

Now it's completely normal for a rabbit gut to have fur in it, and quite a lot of fur in it at all times, that that's fine. It moves on through. However, when we start to see this, if they're moulting or if they're not drinking as well, or if they're not eating well, this is a sign, this is that the gut is kind of waving a red flag saying, hang on a minute, I, I'm starting to have a few problems.

And basically that it's slowing down, it's dehydrating inside of that gut, and that's why you've got a poo, then a rope, then a poo, then a rope. OK, so we need to start increasing the grooming, make sure they're drinking, and look for any potential underlying problems going on. And then of course we come to the Stacey's poos, so the bottom left of that last photo.

Shows how these poos can just get smaller and smaller and smaller and they they are rock hard, you cannot squish these at all. It literally feels like Lego if you're standing on these, and they're angular, and they're all different sizes, and they'll just get smaller until they stop. And this is, this is a real problem.

This is the gut is in complete ileus and shut down, and very dehydrated. So it's important to know what all of these look like. It's also important to realise that that rabbit poo is the best way to understand how hydrated your patient's gut is.

So I strongly recommend that every time the rabbit comes into practise. Practise, you ask the owners to bring a sample of poo from that day's litter box or from overnight, because then you've got a good idea of where you are right at the start. And if we think about these abnormal poos, if we think about these smears of seotrophs or these strings of pearls or, or, the stasis poos, OK, this is, this is the equivalent of bringing, a dog in for its routine neuter that's got diarrhoea.

Now, would you do that? Would you actually go ahead and castrate that dog when it's got diarrhoea? Or would you decide to actually take some remedial action and get that animal slightly better?

I would hope you would get that animal slightly better, and we need to realise that this, needs to work the same way for our rabbits as well, OK, because as soon as we load that gut with the stress of being in the practise, the stress and the problems, That's that we're gonna do to its metabolism by slowing it down with the drugs we're giving it, the stress we're doing, all these different bits and pieces. If we're doing that on an already compromised gut, then we're gonna have more problems during our anaesthesia, and we're gonna have more problems during our recovery. OK, so sometimes this can just be the case of, you know, certainly for that ingested further, it can just be the case of, OK, well, we'll give them a good fluids for a day, an extra or two days, and we'll give it at home and give them extra grooming or something and get this through and then we'll, you know.

Then we'll go ahead and do it. Alternatively, with the diet, with the smushy, rose, we may need to change that diet, and that then goes back to that six week period of, OK, well, let's do a diet review, see if we need to make some changes and give time for that to kick in because we need to make all the changes gradually, and then also, get them, get them back in and get them rechecked to make sure everything's going OK. Also we need to understand the urine, so this could be a very scary picture for some people, certainly some owners are gonna be very concerned about this.

And have a think about what you can see in front of you here, 1 to 5, which of those urine samples would concern you as either an owner or as a veterinary professional if this was brought in or a photo was brought into you. But in actual fact, all 5 of those are completely normal. So it just depends on what their diet is.

So number 3, for example, is very, very dark, calcium oxalate tends to make the, the weed very dark. So a lot of dark leafy greens, beetroot crops or dandelion, for example, if they have that, it tends to turn the urine that very dark colour. And again, they're very light #5, almost luminous, but nothing really to worry about.

Those 2 in the top photo, completely normal urine from two completely different rabbits, OK. What we do need to worry about is swirls within the urine. So you can see here the main urine is about probably about 4, and we've got a swirl of a 3-ish going through there.

That's, that to me, is a clear indication of hematura. OK? We don't end up that top picture if it was all complete blood, then they would be in a, in a terrible state and they'd be quite more abundant and we have a big problem.

But when you do get blood in urine or excess calcium of a of a real sludge issue, it's swirls of white or swirls of red within the normal colour. So again, it sure you know what's normal for that rabbit so you don't freak yourselves out. If they come in for a procedure and all of a sudden you think they're peeing blood after they've had their their er.

In closure, the current RWF standard, minimum standard guidelines are 10 ft by 6 ft at all times as a minimum space. OK, now this needs to include their their living area and their exercise area. And this is actually really important.

You think, oh my goodness, 60 square foot, where on earth is any owner ever gonna fit that in. But we look at the studies of what happens with rabbits, . You know, a female rabbit will naturally forage and mooch across the area the same size in an Olympic swimming pool every single day.

So all of a sudden the 60 square foot doesn't seem too big. And why am I talking about enclosure when we're supposed to be talking about anaesthesia? OK, so I alluded to it earlier.

These guys need to hop a lot, and it's actually a natural gut stimulant by them constantly foraging and mooching around through the day. That's how they would normally work. Again, they've got this, this high fibre, low nutrient diet naturally, so they're constantly grazing all these different things, and this hopping is churning that gut around and keeping the peristassis, keeping everything going, OK?

Now if they're in a tiny little hutch or they don't have access to a run, then these guys aren't flipping around, so their guts are slower, their guts are not working as well as they should be. And we need to know that again for the reasons I've previously said, some of these drugs that we're using are gonna have a depressive function on their digestive tract. OK, so if they're already compromised by their living space, we need to think about that and ideally rectify that before we take this kind of surgery.

And also the height of it, it should be 3 ft high to allow them to fully periscope up. OK. Now if they can't do that.

As I said earlier, we've got to think about our handling of these rabbits because they haven't had a chance to stretch, and we could cause them damage as well as definitely causing them pain by how we're handling them when they're asleep with the GA because we're putting them in the positions we need on their backs when they're asleep, so we can shave them up and stretch them around, and this is gonna cause. Cause us to need to use more analgesia, potentially more anaesthetic gas for maintaining gas, and also gonna give them a worse recovery. So the enclosure is actually really important.

Stress reduction at home, these guys, they really should be living in bonded neutered pairs. Now, if this is the case, if they're coming into you, they need to stay in their pens, OK? They're prey animals, they need to have that body.

We think about what we're doing when we bring them into practise. We're bringing them into somewhere that smells of death and stress because no matter how much lavender cleaner we use, it still smells of death and stress to these parts because of all the pheromones and. If they've got their buddy with them, they can chill out more, you know, because when we take them away from their body.

And put them in this tiny, you know, in this, in this kennel and it's all scary, and we're trying to get them to eat and we're wondering why they're not. Well, they don't feel safe enough to put their head down to eat because they don't have their body looking out for them, checking the coast is clear. They're very mere catty about these sorts of things, OK, so keep these guys together.

We don't want to trance them at all. You know, we wanna do proper handling, for these guys, minimal handling. You can use a, a towel to do the bunny burrito if you, if you need to, but often just being calm and quiet with them is perfectly fine.

And there's some, products that are really good to start these guys on, kind of 3 or 4 days before they're coming into the practise. So the Pro C probiotic by Betar is fabulous. It's nutraceutical, it's got extra vitamin C because when rabbits are stressed, they really burn through their vitamin C.

So on top of that is is very helpful. It just goes in the water or in a separate water bowl, and they can have a, a bowl of that a day, and it just helps with, pre and probiotics and that vitamin C to just kind of help keep them on an even keel. It's very good in times of stress and if they're moulting.

As well. And the pet remedy spray, again, this is perfect for use at home, in practise, in the travelling car, whatever, because it's a natural, smell. It's can smell a bit of sock or herbie.

You can get plug-ins and all sorts. And it's, it's I found such really good results with this, and you can use it, get these rabbits used and then get them chilled out before they're coming in and use it within the practise, and then go home with it as well. OK?

So thinking about RASA grading then after everything we've just spoken about, so we've spoken about the diet and how that's gonna, how that can impact us, and we've spoke about the enclosure. So if we sum that back up to our ASA grade, where do you think you're seeing your rabbits? OK.

Most people I ask this say they think that their normal healthy elective, procedure, Nta is an ASA one. Unfortunately, you're never gonna see an ASA one. OK, rabbits always have something else going on, which just makes them extra hard work.

OK, so at the very least, your rabbits are coming in as ASA twos, and they're the ones that you're thinking are really happy, healthy, good to go. Now if we add on a messy bottom, or if we add on a small enclosure that's slowed that gut down, we've then pushed that rabbit to an ASA 3. OK, so just again relate that back to your cats and dogs.

If you had a cat come in that was an ASA grade 3, would you happily knock that down for its neuter? Or would you take remedial action and decide, actually, I'm gonna, whether that be fluids for a couple of hours or, you know, pain relief or sort out whatever this underlying issue is, or postpone it for 3 weeks. I would hope that most of you would not happily knock down an ASA grade 3, just for an elective, you would try and get them in a better position, OK?

So on the day, we really do need to keep calm. Obviously we all work in the oasis of tranquilly in practise, it's lovely and calm and quiet. And of course we don't, we live in the real world, it's very busy and barky and, all these things are going on.

So, but we do need to try and make the best of a bad deal and get things as calm and quiet as we can. So switching radios off, asking people to be quiet, and really get prepped for, for when these rabbits are gonna be around, OK? Think about where we're gonna put them then, obviously we can't put them in 60 square foot of enclosures in in veterinary surgery.

So we put them in cat kennels, right? They're a small animal, they're put in a small cage. Sadly, that's not what we want to do.

Again, let's think about what we're doing to these guys. We're bringing a prey species into an area usually with predators, into a strange metal box, and we are stressing them out and they can't move, they can't hide. Can't do anything.

OK, so that is going to change. It's gonna have metabolic changes. So then their blood cortisol is gonna increase, their, their blood pressure potentially is gonna go up or down, depending on whether they go kind of shocky or whether they, they just stay stressy.

And their gut function's gonna slow down. So here's the holy grail of rabbit enclosure. On the top left there we've got John Chitty's, practise, Anton Bets, and they have a lovely rabbit ward, which you'd expect for for an exotic specialist, which has these great areas where they can put the runs down and they can really chill out and have good enrichment.

OK, and on the bottom left. These are dog walking kennels. So again, we need to be using our, the big cages.

We don't need the height of it, but what we need is is the floor space. And if we can't do that, then let's have some, some puppy panels or some puppy pens. Gosh, that's lots of these, to try and give ourselves that we can put these animals in these exercise areas when they're in recovery to again get them hopping and moving around.

And at the very least, what we can do is we can enrich their enclosure, excuse me. So if we look at the top right picture there from the royal dick, we can give the rabbit a hide, so we can get very excited, go and find our cardboard box and pop a hide in for them. We do want to make sure it's a hide not a lookout, so always turn that box to the side so that they can actually get away from us.

It means it's a bit more difficult for us to see, but we want to turn that around so that they can hide. And also, we want to put the food and water inside of the hide because if they're finding it scary outside, they're not gonna come out to try and get to their food either. OK?

So that's the least we can do even if we have to use a small cat kennel. So thinking about stress reduction in practise, ideally we don't want these guys near predators. So if you, if you do have a rabbit ward, fabulous, well done, very few of us do.

If you have an isolation ward that you sometimes use for rabbits, right, that's, you know, that's. That's a good step forward. If you're in a mixed kennels, then, there's a few things you can do and you know, you certainly don't want to be housing directly opposite big barky dogs or hissy cats and things.

Now one thing I've recommended and some practises are implementing is having a Rabbit only ox day. Now obviously you're always gonna have emergencies coming in, but there's absolutely no reason why we can't think about it and go, actually, do you know what, every 2nd Thursday, depending how often you see them, or every Thursday, it's gonna be our rabbit ops day. That way you don't need to worry about having predators in the mixed kennels.

You can have all your drugs out, you're always thinking rabbit, you can have all your warming aids, everything. It can be a quiet, quieter area, OK, and there's no reason why we can't do this. It just takes a bit of planning in the same way that we know not to have more than 2 dentals on or these other things.

We can just start block booking our rabbits in for these elective procedures, and that can really help with us to keep their stress low. We want minimal handling with these guys, as I've mentioned, and a large kennel. Now when the owners bring these rabbits in, I want them to be very well prepped and also look like they're moving in for 3 weeks.

OK, so they're bringing their food. If they're used to sleeping on blankies and they don't chew them and eat them, then bring a blankie in, literally a whole plethora of things. Otherwise you've got to keep so much in stock to try and keep these guys happy, so the food, the bowls, the water bottles, whatever.

Even hide boxes if they've got something that that's small enough and suitable. OK, so get the owners to bring all these things in. Keep them together, OK, as I said, it's really, really important these guys stay together, and that also means in the same kennel, right up until the one that's going through the procedure goes and has like their procedure.

They look exactly the same. To check their microchips. If they are microchipped, if not, try and get the microchipped.

And if not, then at the very least clip a bit of fur on the, on the ear of the rabbit that you want to be doing. Ideally, you're gonna be placing an IV catheter anyway, so you can just get that hair clipped up and the emerald put on in preparation. Unlike cats who only like 3/4 of their kennel covered, rabbits actually like the entire thing covered because they run down their bulk hole, they're in their warren, and, and, you know, they've gone through the eyes.

So every single one, regardless of how stressed they are, make sure you've got that towel cover up again, spray it with pet remedy because that's just gonna help everybody in that room calm down. I just have a think about injections for a minute. So I'd imagine that a lot of you are using IM injections as as part of your, your combinations, your injection for anaesthesia, combinations.

And let's think about what we're doing, OK, so we have to get the rabbit out of his cage. Put it on a table, which is quite stressful. Pin the rabbit down and hold a leg out, usually unless unless you're going in the lumbers, which, as soon as you pop that injection in, and I say pop, I mean, as soon as you stab it, basically, into the muscle, the rabbit kicks because it hurts.

And if ever you've had an IM injection, you'll know that it does really hurt, and sometimes it can hurt for 2 or 3 days afterwards. So we're giving something to calm them down in a very stressful way that actually winds them up. And why are we doing it?

Well, because we always have, and because, well, you know, if we give it subcut, it's gonna take an extra 5 minutes. And that's literally all we're looking at is an extra 5 minutes to go from an iron injection to a subcut injection, or even better, look at PIA or tea, so you're using total intravenous anaesthesia. OK, so one thing you can try is to ditch those iron injections.

There's no point winding our guys up with extra stress and extra pain to then give them something to, to say right now if they sleep above eyes. So when does induction start then? Well.

Some people say it's when you give the pre-med, some people say it's when they walk into the room. And for me, I think it would start at the TPR. There's, there's no right or wrong reasons, but I think for me that it would start at the TPR, and ideally I would be doing that TPR in the very first, as soon as they're admitted in that consult room.

So I've got a baseline for these guys. We only need to withhold food for up to 30 minutes before they're pre-med. It's very important these guys always eat and we don't want to starve them, at all, so 30 minutes is adequate to, to get them sorted.

Obviously this does mean there's gonna be some food remnants in their mouths, no matter what. We fed them, there always seems to be something green and slimy lurking in the back of those teeth. So we want to flush that mouth out.

And by doing that, what I mean is we want to have, 2 mLs of fluid that we flush into the mouth, but we allow them to swallow it naturally so we're not forcing any expiration the moment or anything on these kinds. Analgesia is a real hot potato and really important, so we wanna get this on board at the pre-med starter stage and we're looking at multimodal analgesia there. Pre-oxygenation is really, really important, but they only need 3 to 5 breaths to be fully saturated for for 2 to 3 minutes.

OK, now this is really important because we don't want to sit them in an oxygen tent for 10 minutes. We don't want to clamp a mask on them for, for 10 minutes either, OK, so literally 3 to 5 breaths is enough to get these guys, well saturated so that you can carry on and do whatever your next steps are going to be. I've mentioned the IV access.

I would hope you're putting IVs in for all of your patients, either for your pre-meds and anaesthesia, fluids, and certainly in case of emergencies as well. So get that IV access in that marginal ear vein, not the cular artery, so that you've got quite good in going. So a quick example drug protocol then, I'm not gonna go through it too much, you know, but usually something like meatomidine, ketamine and buorphenol, or buprenorphine can can work really well and you're gonna re reverse that off with atipiazole, although you're actually, you're gonna antagonise that off rather than reversing it.

So looking at the airway management options, basically you've got 3 main options. You've got the mask, the ET tube, and the superglottic airway devices, which are the V gels. Now, there are no gold standards for this.

What is important is you check that airway is clear visually. You flush that mouth, you'd let them swallow any debris. Ensure they're fully asleep.

There's a horrible video did the rounds a couple of years ago, of a nurse that was very proud of her intubation technique. And she said, Oh, look, you can see when you get the tube in the right place because they cough. And this rabbit's literally leaping off the table, and she's, she's poking into its trachea.

So we do want these guys fully asleep at before we are attempting to place any ET tube or B gel. We do want to use lidocaine before intubation, because they're actually more sensitive to this, to laryngospasm than cats. It's just not very well recognised or documented.

So make sure we are using that lidocaine. And ideally use your otoscope to visualise where you want it to go rather than just dropping it onto the back of the tongue. If you're in bees, just be aware of the same with cats, just be aware of the strength of that because sometimes that can cause them to, they can be very high, and if we're using local in other places, we don't wanna, we don't want OD them in the local, OK, and pre-oxygenate them.

The thing, oh sorry, the thing to remember about ET tubes is every time you place an ET tube, it does damage to the airway. So every time you place it, even if you place it perfectly, you're going to scrape off a long row of cilia down that trachea. Now that's, that's the mucus highway that will get rid of all the mucus and the bugs and all the rubbish and stop that going down into the lungs.

So every time we place that tube or remove that tube, that's cutting grooves in, and there's other problems with ET tubes with regards to not, you know, there should be single use. We're not using single use. So the chemicals you're getting in chemical.

Burns, stretches, necrosis, all these sorts of things, and tears, tracheal tears, and until we actually go looking for it, there, there is documents and papers on this, this research, but it's something we're not really looking for, and it's something we were taught, but I was certainly taught at college to say to owners, oh, your dog may have a soft cough for a couple of weeks. Well, that's actually because we've torn that cilia off of that off of his throat, off of his trachea, and so. That can cause more problems than good.

So there's, there's times to use all of these devices. The gels are super quick and easy to place, but they can rotate if you've got the wrong size, if you're one is too small, and masks obviously have a huge PPE risk to, health and safety risk to the humans that are using them, but all are completely viable. You just got to realise that that not one of them is actually gold standard.

Now positioning again, my other favourite image that's in every single one of my my presentations, it feels. And what I want you to look at here is the very, very tiny lung fields on the right hand side and you can see they wrap right over that diaphragm, wrapped right over the top of the liver towards that stomach. So they've got a very tiny lung fields, and then they've got a whopping great big heart stuck in the middle of that as well.

Three course of their body is wobbly bits, OK? And so whenever we put this rabbit in any other way than up, those wobbly bits are pushing on that diaphragm, and that's the important thing I want you to remember here, is that we have to help these guys breathe at all times. These these are short distance runners, these are not long sprinters.

They've got very short, small lung fields. So it's very important that we, we help these guys out when we're handling them. And that's when they're asleep as well, OK?

So when you're carrying through from prep to theatre, don't, you just cause you've scrub the tummy if it, if that's where you're going in, they just swab on it, turn them back into ternal, and then take them through, OK, cause you're just causing more problems than than they need. With regards to the positioning, you want to elevate that chest. We don't want it too far up because that's pushing certainly if you're doing a spade because it's gonna push all those abdominal contents down onto that bladder, and onto that, that, reproductive area.

So it's gonna make it harder for the surgeon. You just need the chest slightly lifted to just release that pressure off of the diaphragm. We want to monitor, monitor these guys really, really closely.

Ideally have one person purely monitoring the anaesthetic and the other person doing the breathing or using a ventilator or something like that. Make sure you know your vitals, however, you know, we're not super nurses. We don't have to remember these off the top of our heads.

Let's have specific rabbit anaesthesia forms. Because that means all of our little crosses aren't just stuck at one end because the graph doesn't go high enough. And we can actually print these vitals as a reference range on the very top.

Underneath that, we can put our first TPR to match it, and then we can match that again through to where we're going, through the anaesthesia and how these guys are getting up. It goes beyond just the beepy things. We want to look at behaviour and pain scoring and the EDDU, you know, what's going in, what's coming out.

Now capnography is the one thing that will always make all of your anaesthesia safer. It's the only thing that will do that. So if you're gonna buy one bit of kit, then a cat graph is the most important thing.

And the things you need to think about are the the trace line. It just needs to be a. Nice even line, a nice even roller coaster, and the end number as well, because these guys will knock them down and they'll be in the 50 to 60 entitled CO2 and problems start occurring around 60, entitled CO2 and MHG.

So we need to be very careful. We want to supplement IPPV for these guys. So, say 1 in 3 breaths, just to make sure that we are keeping them breathing quite nicely.

Fluid therapy, again, we've said about the poos can give us a really good idea of what's going on. If you can just take a quick PCV as well, certainly you can get the blood off the end of the catheter sign for that. It's usually quick, easy and cheap.

And it's a bit old school, but we are looking at deficits and looking at the, you know, what that dehydration is going to mean. And again, this changes your ASA grade, so it is important stuff. Lots of options, but think about what you're doing with this fluid.

If you're gonna do a spa, don't do an IP fluid because then as soon as you open it up, you've lost all your fluid. And the same way if you've got a broken leg, let's not fill that up with fluid. It sounds really obvious, but but that's what you wanna do.

So IV is preferred. Now what I will do though is ditch that drip giving set, OK, because they get in the way and rabbits just chew them. So if you've got a nice light catheter in with a light bandage, just give them a slow bolus, as and when they need it, OK?

And you're looking at kind of old fashioned surgical rates, but what you're looking at is 25 mL per kg per hour for the 1st 2 hours. And then that's just gonna come into their 100 mL per kg per day for their, for their normal fluid, needs. Really important we keep these guys at the right temperature, and that means not too hot as well as not too cold, OK?

So we need to think about, certainly at the moment, have these rabbits been living outside? If so, they've been experiencing about 4 degrees. And if we're bringing them into our lovely cosy 21, 22, 23, 27 kennel degrees kennel area, .

You know, they're gonna be sweating and trying to take this fur coat off before they've even got to theatre, which is gonna be causing metabolic changes in these rabbits. So again it goes back to your history and why it's important to know, what their current environment is. We've got to be careful with how we warm them as well, because if We're using direct heat, we're actually causing vasodilation on the skin.

So that means we're taking all that blood from those internal organs that we're trying to support and bringing it to one patch on the bottom or wherever we've led that heat mat. So we wanna do, you know, nice environmental warming like bear huggers or or warm ts or something like that. Their body's gonna keep them warm as well, so post op, by keeping them together that's gonna help keep that temperature up without having to worry about, adding in lots of extra warming aids.

It's really important to know what normal behaviour is, these are great posters from the rabbithouse.com, I recommend you go and have a look. Good for you, good for, for the owners as well.

So you've got to be able to identify and speak rabbit and see what they're trying to tell you, because our pain score that we've got really is quite difficult to understand, and it's kind of one whisker moves this way and one whisker moves another way, and that tells us how much pain we're in. I recommend you take a photo as long as you've got consent, and take a photo of your patient at the pre-op check and then at the morning of the admit as well, because then you can see what that rabbit looks like, OK, when they're happy and well and healthy, and then you can say, oh, actually their eyes are a bit closed, their ears are in a different position, the whiskers are dropped a little bit. OK, so by understanding your patient and the behaviour for them, combining that with the behaviour that you know, you know, hunching, tooth grinding, all these sorts of things, you can identify that pain and really make sure you record that on your notes, both on the the computer notes as well as your handwritten notes, and anticipate this pain, OK, so we shouldn't be saying, well, should we give pain relief?

We need to be thinking, why wouldn't we give pain relief? OK. And there's a really good study, done on a, a paediatric oncology ward actually, where they gave half the boys, Game Boys, I'm showing my age, and half the, the children didn't.

And it showed that actually, the children with the Game Boys reported less pain. Now this isn't saying pain is completely psychosomatic than than what you're talking about. What it means is it's just.

Giving them that stimulation, that something else to to think about and something else to get on with. And that's another reason why we need to keep them with their body and keep their cage entertaining so they can move around. They have got a loo roll stuffed with hay that they can throw around.

If they've got something to do, they're not gonna sit there and be sheep-like about it and say, oh, I hurt, therefore I'm going to try and die. Multimodal analgesia is fabulous. There's lots of things we can use.

If you are using an NSAID, make sure that's not contraindicated with any shock, or dehydration. And if you are using Meloxicam, just note that we are looking at 0.3 to 0.6 twice a day, OK?

These, these guys just metabolise it really, really quickly. So you want to be sending them home with 3 days' worth of pain relief to have twice a day because it's only kind of lasting 12 hours on them. Local analgesia I mentioned earlier, use lidocaine and literally splash that stuff everywhere.

Draw up half their total dose, dilute it with about 5 mLs of sterile water. That way you know you can do ring blocks, splash blocks, you can do skin, subcuts in there, set. And you can put it into the, into the scrotum if you're doing, castrates, you can put it into the uterine stumps.

Literally put it everywhere. And you know you can use all that 5 mL because it's only half their total dose that they need. And that's really synergistic with some of the other drugs, and can really help give, prolong that anaesthesia, that analgesia.

For the recovery then, we need to be really sneaky beaky about it and we want to be hands off, because we want to keep the stress to a minimum, but we've got to keep a really close eye on them. So pop them in a wire cat carrier, you've got it all nice and warm and cosy ready for them to go in and keep them with you, OK, if you don't have a kennel nurse, then keep them in theatre or in prep or wherever you need to keep them so that you are watching these guys like a hawk until they're properly lifting their head up. And when they're lifting their head up and they're starting to wobble around, leave them in that cat carrier but put them back into their kennel with their body, OK, because instantly they will feel better because they're safe, they're not gonna get drowned or jumped on or anything like that.

They're safe inside their basket, but they can see their body, they can relax, you can put some food in there, they can have a nibble if they want to, and you can see what poos they're doing, you can see what poos the other one's doing, but it just really helps that recovery. Tempt them to eat when they are, as soon as they are walking around, obviously take them out of the basket and let them both interact as normal together. Tempt them to eat.

If you keep touching them on the lips with a bit of food, they'll kind of get the hump with it. And then they'll snap at it and I go, oh, yes, I forgot I like that. I like eating that, and then, you know, you can keep feeding it in, and keep checking what those poos are doing.

They should continue to get better and back to the poos that they had when they were coming in. Going home actually starts at 6 weeks before they come in, because how often do we tell owners that they need to keep the rabbit in overnight? Certainly at this time of year as well, OK, now if we're discharging at 6 or 7 p.m.

In the evening. And we haven't told them this, where are they gonna put the rabbit. So give them time to be compliant, show them how to use their drugs, show them how to syringe feed if they need to.

We are syringe feeding a completely inactive rabbit, we're looking at 10 to 15 mLs per kilo, 4 times a day. OK, we don't want to do it too often because it stresses them. We want to give them enough to go into their tummy.

We want to make sure that they're pooing before they're going home, they should be eating and pooing before they go home, otherwise they need to stay and have more treatment. And make sure you're giving a good emergency fact sheet out with them so that they've got your number, your emergency number, if they've got to travel somewhere else for this, you know, and what constitutes an emergency as well. So we're really setting these guys up to succeed.

So to pull that all together then, I hope that's that's explained what holistic anaesthesia is. It's thinking about how all these different things come together to, to directly affect the anaesthesia that, that you're gonna give or the anaesthetic you're gonna give to this patient. So we do need to know what their diet is and we need to rectify it, what's.

Enclosure, are they with a bonded friend? OK, we need to keep stress to a minimum. We need to make sure we've got our proper training and protocol ready in practise, and we're doing a full assessment of these guys, and we need to keep calm as well and not panic too much and, and try and take the day off because we've got a bad an anaesthesia coming in.

Thank you very much. I'm happy to take a question if you've got time. Thank you very much, Joe, absolutely brilliant webinar, really, really great.

I'll just wait and see if we have any questions come through and for those of you who don't know how to ask the questions, just hover over the bottom of the screen and click the Q&A box, and then that'll pop through to me so I can ask Joe. While waiting, I'd just like to send a massive thanks again to JHP recruitment and tails.com for sponsoring tonight's webinar.

And yeah, thank you very much for that. And I'll just wait and see if we have any questions. So Joe, you mentioned about the study they've done in children with the Game Boys, a rabbit was on its own and didn't have a companion in the kennel, would you, what kind of things would you recommend to try and entertain them?

So you can ask the owners to bring in if they've got any toys, sometimes they'll have a, a soft toy or something that that they that they live with and don't chew. You can literally use a cardboard box or a plain paper bag and stuff some hay in there with a couple of pellets in. You can peg up their fresh food on the kennel.

On the cage bars, they have to stretch up and get that or even just shove a great big pile of hay in there so that they have to just mooch around. It's, it's giving them the space, and the opportunity to, to kind of have something to interact with rather than just a cage with a bit of newspaper, maybe a bit of vet bed, and that's it. They just sit there and think about how poorly they feel.

OK, just give them something, something to think about. Yeah. Excellent.

OK, we do have one question. What experience do you have of adhesions in rabbits with ex-lap sorry, with rabbit X laps example space, do you use Verapamil? OK, really good question actually.

So rabbits are the adhesion makers of the world, so much so they're used as models for human medicine, . The wrapper mill, in my experience, bear in mind I'm a nurse, not a vet, but in my experience, doesn't make that much difference, and you have to have a course of it beforehand, and then carry on afterwards. What does make a difference is your surgical technique.

So you want to have a. Glove technique, you wanna have a wet swab technique and you, you wanna touch as little as possible. Literally, you are just reflecting that bladder, finding those, the uterine horns and touch the bits that you're taking out, that's fine, but literally try and touch as little as possible.

The other thing is when you're about to stitch up, when you're finished and everything's removed, get, a good amount of warm, fluids. And fill that abdominal cavity back up, literally slosh that in there so that's all right up there before you close up your muscle layer. Because when you cut into the abdomen, you're gonna lose a lot of fluid naturally you're gonna see that come out and wrap it and the more you can put back in, it means that all those, those wobbly bits are sliding over each other very nicely.

Avoid powdered gloves as well, and that's, that usually it is enough to reduce those dhesions down. Excellent, thank you very much. That seems to be all for the questions so far other than a couple of comments just to say what a helpful talk it was and just to say thank you very much.

So on that note, I'd just like to thank all of our listeners for logging in tonight and listening to Joe's webinar and thank you very much, Joe, for your time. It's been an absolutely brilliant webinar, so thank you very much. My pleasure.

Thank you. Enjoy the rest of your evening.