Good evening everybody, and welcome to our Thursday night members webinar. My name is Bruce Stevenson, and I have the honour and privilege of chairing tonight's webinar. I don't think we have any new people on tonight, so, no need for extensive housekeeping.

You all know we'll keep the questions over to the end, into the Q&A box, and we will chat and cover as many of those as we can. So tonight's speaker is Louise and she completed an integrated degree in veterinary Conservation Medicine at the University of Liverpool in 2009. And then she completed her veterinary degree at the Royal Vic School in 2011.

After graduating, she worked in First Opinion Hospital in Southend on Sea for 4.5 years, where alongside first opinion and emergency work, she helped to set up and run an exotic animal service. Louise then moved to Manchester in 2016, where she worked as a night vet at a busy 24 hour emergency hospital before moving on to work for Vets now referral hospital in Manchester, as part of their ECC and out of hours team for a further 4 years.

Louise currently works as the veterinary lead foret on the Net, a telemedicine company with an online pharmacy that offers remote consultations for pet owners. Louise completed her two certificates, in zoological medicine and emergency and critical care back in 2017 and is an RCVS recognised advanced practitioner in emergency and critical care. Louise, welcome to the webinar, vet, and it's over to you.

Thank you very much. So thanks for taking the time to listen to this this evening. So tonight we're gonna be talking about rabbit emergencies.

So this evening's talk is split into two sections. So the first part we're gonna be talking about triaging rabbit patients and the basics of emergency care. And then for the second part of the talk, we talk about some of the common emergencies that you may well see in practise.

Do you know obviously that a lot of the medications I'm gonna discuss in this webinar are off licence and are therefore used under the cascade. So the first thing to always remember when it comes to rabbits is that they are prey species. And so this means that they do hide signs of pain and disease very, very well.

And therefore, really, any rabbit that's not eating or passing faeces as normal, or the owner just says isn't, you know, just isn't quite right. All of those rabbits really must see, be seen as soon as you possibly can. You know, they all, they all count really as an emergency.

And when it comes to triaging the rabbit emergency, it really is just a a simple three-step process. So the first thing is to take a history, and obviously if it's a rabbit that comes in very critically, you know, sort of collapse in front of you, then it may well be that you just take a capsule history initially and then go back to the owner later on to fill in any gaps. And then just before my clinical examination, and I'll go through some of the extra things we always check on rabbits in a moment.

And then the third step of your triage is to always check the blood glucose level. And I'll explain why, this is a particularly useful thing to do in bunnies, shortly. So the first thing is obviously doing the history and an awful lot of this is, is obviously exactly as you do in a dog or a cat, but I did just want to point out a few extra things that it's very important to ask rabbit owners.

So the first thing is in regards to a companion. So obviously rabbits are very, very social animals, so they're usually kept in bonded pairs. So you're going to want to know, has that rabbit got a companion?

Is, is the companion well in itself? You know, is it a new addition, so it could have brought infectious disease with it, and all those other type of questions. The other thing to ask is, is the rabbit indoors or outdoors, because obviously, you know, exposed to a different environment, so that may change your differential diagnosis list.

Do obviously make sure you ask about vaccination. So all rabbits should be vaccinated against myxomatosis and RHD. And then also make sure you do ask about the nutrient status, because we know that uterine adenocarcinoma is very, very common in female rabbits, so we need to know whether we, we need to add that onto our differential list or not.

When you're asking about eating and drinking with a rabbit, it is very important to ask about, has there been any changes to what the rabbit is choosing to eat? Because we do see in dental disease that sometimes the rabbits will just go off a particular type of food, so they may stop eating their hay, or they may stop eating their nuggets or their veg, and that can be a an early, early sign really that there's a problem happening. The next thing is to always ask about, you know, what the rabbits doing in terms of its urinating.

And do remember that that there's various different colours of rabbit urine that can be absolutely normal. So most commonly we would get this sort of yellowy, cloudy type urine, and obviously remember it's got a lot of sediment in it due to a lot of calcium being present. And then we can also get urine that's very red and orange in colour, and that can be completely normal due to the high amount of porphyrin pigments present, which come all come from the diet.

You will need to make sure you do distinguish, however, between obviously porphyrin pigments in the urine and blood in the urine. And the best way of doing this is to spin the urine down and have a little look at the sediment there for the presence of red blood cells. With faeces, we don't just want to know, you know, is it passing poo or not.

We do also want to know what the faeces are looking like. So has there been a change in the colour of the faeces? Have they changed shape or size?

Because again, this can point us towards different differentials. In terms of behavioural changes, one of the major things I'm looking for really is for signs of pain. So with rabbits, they will do things like stretching their bellies out and pushing their abdomens to the floor, and also grinding their teeth, which is otherwise known as braxism, are both sort of signs of pain in rabbits.

And then the last part of your history, obviously, you know, making sure you're asking, has it had any health problems before? Has there been a recent stressor at home that could have triggered a problem. And we do know that some bunnies can be super sensitive, so literally just a change at home, like the owner going away can be enough to trigger off a medical that faces problem.

The last thing to to just remind you of is the fact that obviously for dogs and cat histories, we're always asking about vomiting, but do remember that rabbits cannot vomit. When it comes to the clinical exam, I just wanted to point out a few extra things to make sure you do check. So the first thing is in relation to tear ducts.

So remember that rabbits can quite commonly get problems with tear ducts, and they can quite often get blocked, which is often associated with dental disease. So do have a look around the eyes for any evidence of discharge, and then you can also just apply gentle pressure in the medial campus of the eye just underneath where the tear duct lies. If you just apply gentle pressure around there, you can see if any discharge comes up into the into the eye.

The other thing to check for is for wet sleeves. So bunny rabbits do wipe their nose on their forelegs. So you will sometimes see all this sort of mucus and sticky stuff on the front legs, and that can be an indicator that they have got some nasal discharge present.

Do remember that bunnies are obligate nasal breathers, so they will do anything they can to make sure their nose is kept clear. So sometimes you don't see a lot on the nose, but you will see it on the legs. Another important thing we always do with rabbits is obviously always, always check their teeth, and, we usually use an otoscope obviously to try and get us a best, the best view of the molars that we possibly can do.

The other thing that I always look for is how much is that rabbit salivating. So rabbits that have got dental disease, they will tend to have a lot of saliva in their mouths. And, and the same can be the, the sort of reverse of it can also be very helpful.

So if you do see a rabbit that's got very tiny spurs on the molars. And, and it's not got a lot of saliva in its mouth, then I would be thinking that those spurs probably aren't causing a problem for that rabbit, and I need to be looking somewhere else for the root of the problem. The other thing that we look at on rabbits is that we always check on a rabbit that we don't do on a dog or a cat would be to listen for gut sounds.

So with gut sounds, a normal amount would be at least 1 episode of Warrigme in every 30 seconds. And then the other different thing that we always check for on bunnies is the presence of any hock sores. So, rabbits can get really bad sores on their back feet, and this can be due to just the fact that, you know, they, they're particularly house bunnies when they're running around on hard floors all the time, they can be very prone to getting abrasions there.

And these sores can end up being really painful for them. So sometimes it can be that that is more than enough to cause a gut stasis in a rabbit. And then the third part of our triage is always to check the blood glucose level.

And the way that I normally do this is I either make a little stab incision over the marginal vein just to collect a drop of blood with a needle, or otherwise, just collect some blood when I place an IV catheter. And the way that I measure the glucose is I always use the alphatra 2 monitor. And the thing to say to you is, is, I mean, I usually use the cat setting, but you certainly can use the dog setting, and you can use, there is another random number that some of the reps recommend, I think it's 7 or something like that.

So it doesn't really matter what setting you do choose to use, but whatever setting you choose, do make sure you're always keeping that consistent, particularly when you're doing serial blood measurements on the same rabbit. And the reason we do check the glucose is is that there was this really good study done by the Harcourt Browns that showed that there was actually a really good amount of information you could get by just checking the sugar level as part of your sort of triage assessment because they showed the rabbits that had hyperglycemia, so a level of over 20 were, was associated basically with conditions that had a much poorer prognosis. So rabbits that had a surgical gut stasis, or a blockage in the gut, did tend to have a really high sugar level, so it's around sort of 24 odd.

And then rabbits that had a medical gut stasis and had a much lower value, so the medical gut stasis rabbits tended to have a value of around 8.5. One of the things that I would say though is that this study did use a human glucometer.

But I have always used the AlphaTrac 2, for the last sort of 8 years or so to measure all the rabbit glucoses. And the most common number that I tend to get from medical gut stasis is 8.6.

So obviously very, very similar to what they found in the study. So to have a little bit of a a deeper dive into glucose, if the glucose level's less than 4, then that means the rabbit is hypoglycemic. And the things that cause hyperglycemia, include things like sepsis, insulinoma, pancreatitis.

But there, there always is a worry, obviously, if the rabbit is hyperglycemic, is that something very serious is going on. So you really need to get some glucose into that rabbit as soon as you can, or start feeding, obviously, if it's, if it's stable enough to do so. Between 4 and 8 is a normal lab reference range, so normally if the sugars between those levels, we're we're relatively happy, providing the rabbit itself looks OK.

With medical gut stasis, we tend to get a sugar level between 8 and 12, OK? So, and I say, most commonly around 8.5, 8.6.

So with those bunnies, and providing the rest of the clinical exam matches our findings, you know, they're the ones that we can start some pain relief for them, some fluids and pro-kinetics and supportive care for gut stasis. Between 12 and 20 in this region, we really need to watch these rabbits. So sometimes you will get rabbits with a, with a mild hypoglycemia due to things just like stress.

But also what can happen is it could be that you've caught that rabbit early and basically over time, its sugar level is going to go higher into the more critical readings. And over 20 this rabbit is severely hyperglycemic, OK, and it indicates that some serious disease process is going on. So you do need to try and get to the bottom of a diagnosis and start treating that animal ASAP.

The other thing that you may ask is, well, what about diabetes? Well, diabetes is actually really, really, really rare in rabbits. So they've only really documented it in one population of New Zealand white rabbits that were in a laboratory setting.

And in those bunnies, it was actually genetic. But otherwise, I say, it's not something we tend to recognise in rabbits. So have it right at the bottom of your differential list, but I say it's not something that we, we would be thinking of as first line.

So obviously on that last slide, there was quite a lot of information and so in summary, if the sugar level's less than 10, I'd be thinking, well, it's a medi you know hopefully medical gut stasis. Between 10 and 20, that's the range that we need to watch the rabbit. So I need to know is that glucose on its way up or is it on its way down.

And then over 20 that usually indicates something surgical is going on, so something like a liver load torsion or a, or a gut obstruction, or some other type of abdominal catastrophe, or otherwise, some other type of serious disease. So I have also seen very high glucose levels in rabbits with fractured spines. Just to say, however, always, always, always look at the rabbit in front of you.

So don't just take the glucose reading and go off of that. You need to use a glucose reading to help assist you in your assessment of that animal. So if your rabbit's in front of you and it's collapsed and its stomach feels massive and it feels like it's got an obstruction, But it's sugar levels 4 or 5, then I'm not gonna be thinking that rabbit, so it's in normal range.

It's fine. I'm gonna be thinking that that rabbit's probably heading towards death instead and it's probably heading towards the, down towards a hyperglyceemic episode. And so say always, you know, you know, look at, look at the sugar level and look at the rabbit in front of you to try and get the whole picture together.

And now thinking about some of the basics of emergency care. So the first thing we're gonna talk about is analgesia, and obviously one of the first ones we always look to use is a non-steroidal. So with the non-steroidals, the one that we most commonly use in rabbits is meloxicam.

And do remember that we do use much higher rates of meloxicam, in rabbits compared to what we would use in the dog or the cat. The other thing to mention here as well is that rabbits do seem to be a lot, a lot less susceptible to those problems that we sometimes see with non-steroidal use in dogs and cats. So they seem more they don't seem as likely to sort of develop kidney and liver issues basically due to prolonged use.

And opioids is the next thing to discuss. So with opioids, some people worry about using them because obviously in some species, it does have the, they do have the potential to reduce gastrointestinal motility. But in rabbits, this doesn't really seem to have clinical relevance, to be honest.

The other thing to remember is that pain in rabbits causes gut stasis. And so I'd much rather give an opioid and risk risk adding to the gut stasis problem than not give an opioid, have a rabbit in pain, and then that's obviously going to lead to gut stasis anyway. The opioid that I most commonly use is buprenorphine, and it seems to be very, very well tolerated in bunnies.

And don't forget you can also use it via the oral trans mucosal route, so the same as you would do in a cat. So it can be very useful when you've got that rabbit that you're sending home from surgery. It can be really useful obviously if you're sending it home on meacca and you feel like it needs something additional, then oral buprenorphine may be a very good option.

Fentanyl and tramadol also very well tolerated in rabbits. And then the other thing to discuss is like morphine and methadone. So, certainly some people have started using methadone in rabbits, but sort of talking to the sort of reps of Comfitan and and also sort of, you know, looking through all the Research, there doesn't seem to be a lot of data available about how well methadone works, is it better than buprenorphine, you know, is it effective in rabbits?

So I cannot give you at the minute any sort of solid advice on on whether to use it or not. So at the moment, to be honest with you, I just still use buprenorphine. And if you are interested in learning a little bit more about pain and analgesia and pet rabbits, then this is certainly a very, very good, paper to have a look at.

Other analgesics you can use, obviously alpha 2 agonists do have a certain degree of analgesic properties, so we, we can use those in bunnies, but they can cause cardiovascular depression, so I'm always very careful about using them in any sick patients. Local anaesthesia can also be used, so obviously vastly underutilised in the veterinary industry, to be honest. And so certainly we, you know, we could consider adding that into our, our pain relief plan.

Do always be careful though about toxicity. So do always make sure you calculate exactly the amount you can give the rabbit, just, just to make sure you don't end up giving too much and causing a toxicity there. And then the last two analgesics to discuss will be ketamine, which we know works very nicely in rabbits, and then also paracetamol.

So with paracetamol, it has been shown to have quite poor analgesic effects and poor anti-inflammatory properties in rabbits when we compare it directly with the non-steroidal. So, to be honest with you, it's not really, you know, it's not something that I use, it's not really a first choice, to be honest in bunnies. You know, I'd much rather go to use, you know, like Metacam and buprenorphine instead, to be honest.

And next up thinking about fluid therapy. So with rabbits, do remember that they have a much higher maintenance fluid rate compared to a dog or a cat. And so it's a double the double the dog or cat rate, so it's a 4 mL per kilo per hour.

When you are doing surgery, you certainly can consider rates up to 10 mL per kg per hour. And then the best route of giving fluids would be IV, and so, the first option would definitely be to use a marginal ear vein. So do remember that you've got the aricular artery that runs down the centre of the rabbit's ear, and then you've got the marginal ear veins that go down either side of the ear.

So for each ear, you've got two veins to have a go at. We always try to avoid touching the eycular artery because if you do, cause a blood clot in that artery, then you do get in necrosis and obviously the, the owners certainly don't thank you for that. The other veins you can use will be the cephalic, and also the lateral epheus.

So the lateral sofinus is actually using usually my second choice. And so I choose that over the cephalic. And it basically because the restraint from being able to hold a rabbit for the lateral sophenus is so much better tolerated than trying to get them to stay still for a cephalic, intravenous catheter placement.

And the other thing with the lateral sinus is that it's much thicker as well, so it's, it's quite a nice chunky vein, so certainly it can be quite a good option to go for when you're trying to get a blood sample from a rabbit as well. Next up, we just need to discuss, are we going to use an infusion pump or are we gonna do bolus bonuses of fluid. I would always try to have them on an infusion pump if I can.

And usually, you know, by the time the rabbit starts to feel a bit better, it chews out its IV, you know, it chews out it's, it chews through its IV line, and then you're going to swap to bonuses anyway. But initially, I say, when they're coming in, they're very collapsed. I would always try to use the infusion pump first.

And the other routes you can give fluids by is obviously interosseous, and also subcutaneous. And the fluid that I would use most commonly would be hormons. Next I'm thinking about prokinetics, so the one that we use most commonly, if you can get hold of it, would be ranitidine.

And ranitidine's great because it stimulates gastric motility, and it also decreases gastric acid and pepsin secretion as well. And basically with bunnies, gastric ulceration is very, very common in anorexic rabbits. And so they did, they've sort of done a load of postmortems on rabbits, and they found that regardless of the cause of anorexia, a lot of them did have gastric ulcer development.

And therefore, a lot of exotic vets do recommend using miitidine in all anorexic rabbits, regardless of why it's got anorexia in the first place. And with ranitidine, it does work throughout the gastrointestinal tract, so it works on the oesophagus, stomach, small intestines, scum and colon. So it can be a very good sort of first choice really because it's gonna work on the whole thing.

The second prokinetic to talk about will be metoclopramide. Now do remember that metoclopramide is only effective in adult rabbits, so it doesn't work on very, very young rabbits. And it also only acts on the upper gastrointestinal tract.

So if you've got something like a scal action, then you may want to opt for another prokinetic instead. And then the last one we use quite commonly would be Sisapride, which is obviously available from Summit as either a liquid or a tablet. And with Sisapride, it also acts quite widely throughout the gastrointestinal tract as well.

And some certainly say that it's quite a potent prokinetic, so it's definitely another option to add in. One of the major things with prokinetics though, is always remember to stagger doses of different GI stimulants by at least 2 hours. And the reason we do that is it helps to improve their absorption and their effect.

So don't just give them all at the same time, do split them up because you're gonna get a much better response to your medications that way. Feeding bunnies. So, in general, when we're sort of trying to syringe feed a rabbit, I, my preference is always critical care or recovery plus, to be honest.

And we're usually aim into getting about 20 to 30 mLs of that food every 4 hours as a rough guide for an average sized rabbit. But certainly if you've got time, I would always calculate the exact amounts required to make sure you're meeting the nutritional requirements of that rabbit for that day. And if the bunny rabbit really will not take syringe feeds, then certainly you can consider placing a nasogastric feeding tube instead.

These are pretty easy to place and they are pretty well tolerated initially. So certainly is an option for those rabbits that are really, you know, very, very difficult to get them to eat anything. And then certainly when I was in first opinion practise, I would always suggest that anyone that brought the rabbit in for you know like a dental or a neuter or something like that, I would always ask them if they can bring a lunchbox in for the rabbit as well.

Because presenting the rabbit with food it's familiar with in a familiar format is is only gonna try and help encourage that rabbit to get back to eating as soon as possible. And then the reason I sort of bang on a bit about feeding really is because feeding in rabbits is really important because basically they can develop ketoacidosis, which in turn leads to hepatic lipiddosis very, very, very quickly. So it can occur within 12 to 24 hours of anorexia starting.

And we know once the rabbit gets to the point of hepatic lipidosis starting, it's got a much more guarded prognosis. So when your, when your nurses come to you and tell you you've only managed to get one meal in the rabbit, is that all right? Then it's, then it's not, it's not OK.

So they need to go back and keep trying to feed that rabbit or get the nurse or the vet in the practise that's best at feeding bunnies to get on board, because, you know, say if you don't get that food in, then the rabbit's prognosis, will drop very, very quickly. And certainly I would always consider trying to get a nasogastric feeding tube in, soon if, if it is a rabbit that's, that's really hard to, to get food in orally otherwise. Next up is to talk about some diagnostics.

So, X-rays are, are really, really useful in rabbits, and they do provide us with a lot of information and they're very, very easy to take. So the, the ways we've taken them, obviously, you can sedate rabbits for these, but to be honest with you, 99% of the time, I do not sedate a rabbit for an X-ray, unless I need to get views for sort of orthopaedic surgery and things like that. And the ways that you can, sort of, restrain the rabbit for an X-ray is, is either you can do a bunny burrito, so you wrap them up in a towel and then you can sort of turn them onto their side.

Or otherwise, what I normally do is I lay the rabbit in lateral, I get a friend to help me lay them in lateral, and then I cover the face with a little towel, and then I have one hand over the sort of face, face and shoulder region, and then another hand over the rump. And if you just hold the rabbit in that position for about a minute or so. And then slowly release your back hand, then slowly release your front hand, then walk away.

It's usually more than enough time to snap a quick X-ray and then when you come back to the rabbit and touch it, it will then get up. Now, certainly I do anticipate this probably does cause a degree of stress for the rabbit to do this. I mean, most of them seem seem absolutely fine when you're doing it, but I, I presume it does cause a degree of stress.

But what I would say is the alternative obviously to sedate them, it is a high risk procedure in a sick animal, particularly when it's literally for a split second of, of taking an X-ray. So I think it's probably on a risk benefit basis. I think it's worth using that technique.

So certainly give it a go and see how you get on. And obviously we're taking the X-rays to have a little look, see if we can see any evidence of any any sort of pathology going on in there. But also do make sure you always look at the gas patterns of where the gas is sitting in the gastrointestinal tract.

And I'll go through this a bit later because it's very useful, particularly for distinguishing between medical gut stasis and a surgical gut stasis. Another thing you can do is do ultrasound. So ultrasound can be a little bit limited in bunnies, due to the fact there is a lot of gas within the gastrointestinal tract.

And also, the stomach, if it's full of food, can sometimes impair the view of the liver, but otherwise, you know, it is a useful tool still to use. And you can do a pocus or a PA scan, have a look for the presence of free fluid in the chest or the abdomen. You can also pick up things like liver though torsions, which I'll discuss shortly, and you can also look for evidence of sort of bladder and kidney disease as well.

The next thing, and the diagnostics you can do on a rabbit is bloods. And so always remember that although it's a bunny, it doesn't mean you can't do those sort of normal diagnostics you'd normally do in your dogs and cats. And certainly a lot of your lab machines will quite happily accept rabbit blood, so you can even run all these in-house.

It's not that you need to send them off to the external lab. And when we're doing our biochemistry, we're obviously looking for evidence of any underlying problems. So we can be looking for things like azotemia, or otherwise, you know, looking at things like the liver levels.

And, and do remember that ALT and LP bunnies are not liver specific, OK? But certainly they, they do go up when, when you get sort of a bad insult to the liver, such as the liver lobe torsion. Also, always have a little look at the blood in the tube.

So lipemic blood, does tend to indicate hepatic lipidosis, which, as we discussed earlier, does have a poor, it is a poor prognostic indicator basically if that is developed. The other thing you can do is obviously do your CBC or your haematology, and for that we're looking at that PCV level to see whether, you know, evidence of dehydration or anaemia. Again, with anaemia, you can certainly get, you know, anaemia of chronic disease, and anaemia due to other reasons, but you will also get anaemia due to acute blood loss.

So for things like liver load torsions, you can get a, a hemoabdomen and then you'll get an anaemia being present. And the other thing we can check for is to have a little look at those white blood cells, but they are a little bit difficult to interpret in rabbits because in rabbits, white cells can change because of the time of day, they can change because of the circadian rhythm and all sorts of different reasons. So it can sometimes be quite difficult to interpret what you're seeing there.

And then the last thing is, is that, you know, you can certainly do blood gases on rabbits, so run your epoch or your ISA or whatever machine you've got. And most of the readings you're getting on there will be very useful for bunnies, but the only thing that you, you don't need to look at is the lactate. So they have done a study looking at lactate levels in rabbits to see if they could use them as a prognostic indicator like we do in dogs with GDBs and things like that.

And but they found that it's not useful. So the lactate levels are just all over the place, so, so you don't need to look at those, those numbers. And then when it comes to anaesthesia, do remember that you don't need to starve a rabbit before an anaesthetic or sedation because they cannot be sick.

Always do pre-oxygenate the rabbit before induction if you can, because basically a lot of them will have pre-existing, respiratory disease to some degree. Do keep the bunny rabbits warm as well before anaesthesia or sedation, and particularly when you're getting that rabbit in that is really hypothermic, I would do everything I can to sort of try and get that rabbit back up to normal temperature before we go in for, before we go into theatre, because you know as soon as they're asleep, the temperature's gonna start dropping quite quickly. Do also make sure you've got everything ready that you need, so you're gonna want to minimise your time under GA intubation as much as possible.

And just because it's a bunny, it doesn't mean you can't get out all your multi-parameter monitoring kit as well. So you can do catography, you can, you know, measure 02 sats, you can do blood pressures and bunnies, and you can also use sort of crocodile clips for the ECG as well. The little sticky pads that you pop on their feet, you can't use in bunnies because they don't make enough contact, so you do need to use the clips instead.

And then when it comes to knocking them out, you know, there is multiple different drug combinations that you could use, so do just make sure you're using one that you're comfortable with. With sick rabbits, I do avoid using alpha 2s just because of that risk of cardiovascular depression. And with your analgesia or with your anaesthetic, always obviously consider an analgesia as part of your pre-med and other drugs that you can use, obviously midazolam, ketamine, local anaesthesia are all sort of options to add in as well.

If you have got an IV, I would always, consider using an IV induction agent. So certainly you can use faxan in rabbits, and you can also use propofol. So when I was in practise, sort of in first opinion practise, we did obviously get hold of Profol Plus when it came out.

And we did find that there was a few bunny rabbits that my colleagues had treated that that that died basically after a profol plus induction. So since then I've not never used Propofol Plus for bunnies. I always use the standard propofol.

I mean, it may be that it's fine now, but I've always avoided that, and just use normal propofol, not the plus, from now on. And when you're obviously anaesthetizing them, do consider intubation or otherwise you can use V gels. Some exotic vets obviously are big fans of V gels and some of them are not.

Personally, I do quite like them. I find that they're, they're very useful because, you know, you can use them for IPPV if you get bunny rabbits that are, that need that support under anaesthetic or or certainly during crashes, it's really good to use a V gel. And you can also use the port for carography.

You can watch the bag moving to make sure it's in place and things like that as well. So I do think they're a pretty good thing to use if you can. And how do we know our rabbit's asleep?

Well, the, the, the biggest thing that you're looking for really is a lack of response to any tail or toe pinching. Bunnies should always maintain a sluggish pape reflex at surgical depths of anaesthesia. So if you do lose that pepe reflex completely, it may well be that that rabbit's getting a little bit too deep.

The eye may rotate ventromedly, apart from if you've used ketamine where you do tend to get more of a central eye position. And you can also use jaw tone in, in bunnies to assess anaesthetic depth but it is a little bit more difficult obviously because they're herbivores so they've got quite a small gap. And then CPR.

So with CPR, we're aiming for a breathing rate of 20 breaths per minute, and we're aiming for a compression rate of about 100 per minute. Obviously do, obviously if you can, place a V gel or intubate the rabbit, but if not, you can just place a tight fitting face mask instead to be able to offer those breaths. If you've given any drugs, do remember to reverse them.

So for example, given naloxone, if you've given an opioid. And do check the glucose because you know, hyperglycemia is a very common cause of crash in a lot of animals. Atropine as well does not work in bunnies because they've got an awful lot of atropinaes.

So if you do find your bunnies bradycardia, during a CPR then you consider using glycoprorelate instead. So now we're just gonna talk through some common emergencies in rabbits. So the first thing to talk about is medical gut stasis.

So, obviously, a lot of the bunnies that you'll see will have some degree of ileus going on, you know, regardless of what, what else is wrong with them. And what medical gut stasis is, is it's cessation of flow of ingestor through the gut tract due to gastrointestinal motility. So just due to the fact that the guts have slowed down.

It's really important to remember that gut stasis is a clinical sign and it is not a diagnosis. And so therefore, it's always really important that you do look for an underlying cause. And don't just say, oh, it's got gut stasis, that's what's wrong with it.

You know, always have a look to see if you can work out why it's happened. The clinical signs we do tend to see are signs of pain, so things like parbraxy, and also those rabbits are often a little bit dehydrated as well, because it's more of a chronic slower onset problem than than a than a surgical gut stasis, which we'll discuss in a minute. The other thing is that the stomach is usually small and it's usually quite doughy and compressible.

And the reason for that is obviously all the gut content becomes quite dehydrated, so it becomes a little bit more, say like like sort of pushing into sort of some raw dough. The other thing is the gut sounds for, for medical gut stasis are either absent completely or are reduced, in case you don't hear very many of them. And then you're also looking for either no faeces being passed or otherwise abnormal faeces being passed.

So sometimes with medical gut stasis, you end up getting very tiny faeces or faeces that are a funny shape and things like that. And how do we diagnose medical gut stasis? Well, usually, their sugar levels are say less than 10, and normally they're around 8.5, 8.6.

X-rays can be really useful when looking at medical gut stasis. So obviously, we take the X-ray to have a look to see if we can find another problem going on. But you often will see this sort of gas spread out in little pockets throughout the abdomen.

And as I say, that that is what we normally see in a normal sort of medical stasis case. And the other thing is the stomach will sometimes have a little impacted mass of material in there, surrounded by a little halo of gas as well, but the stomach is usually very small, so, a lot smaller than than the X-ray I'm gonna show you in a moment of the surgical one. Also, obviously, remember that the medical gut stasis, you know, will always have an underlying cause, if you can manage to find it.

So do, do full bloods, further diagnostics, or whatever else you need to do to look for that underlying problem. And then treatment wise, it is supportive care. So things like pain relief, fluids, pro-kinetics, feeding, also encouraging exercise is really good for gut stasis.

So making bunnies bounce around a bit can be really good at getting their guts moving. And also obviously treating any underlying cause that you find. With surgical gut stasis, what surgical gut stasis is, is the physical obstruction of the gut by either a foreign body, a stricture or or something else.

And the most commonplace we will find a surgical obstruction is in the proximal duodenum. The most common cause is a foreign body and it's most commonly caused by a compressed pellet of hair. So this picture in the corner here shows a faecal pellet that basically when you tease it apart, you can see how much hair is in that pellet.

And, and what happens basically is, is a rabbit obviously grooms, grooms themselves, they get a load of hair and the first pass through the gut, the, the rabbit's gut basically makes a very small hard pellet with loads of hair in the middle. And then what happens is the rabbit then eats the wrong poo, so it eats that hard pellet of hair, where it shouldn't have done. And on the second part through the gut tract, the stomach can't really deal with it, so it passes it straight into the duodenum where it gets stuck because it's so hard and a lot bigger than it should be.

Other problems you can, other things that can cause foreign bodies include things like carpet fibre, locust beans, dry sweet corn, peanuts, and other stuff like that. Other things that can cause obstructions as well would include things like, cancer, and also any bends in the gut. So rabbits are really prone to getting adhesions in the abdomen.

So they will sometimes get really massive sort of bends in the guts due to all the guts sort of being stuck together. And you can certainly get intraabdominal abscesses fairly commonly as well. And when it comes to surgical gut stasis, it is a true emergency.

So I would take a surgical gut stasis in a rabbit as seriously as I take a GEDV in a dog. And the clinical signs that you usually see with the surgical gut stasis is usually that it's a very acute onset. OK, so the rabbit was fine and then it's very suddenly not.

They usually have this massive bloated, hard stomach in the front of the abdomen. So when you feel it, it feels like they've got a little foot in their abdomen. They're usually in a lot of pain, and sometimes they just come in absolutely collapsed, to be honest, and they usually are quite hypothermic as well.

And when you listen to the guts, they are sometimes, if you catch it early enough, they are sometimes quite hyper motile actually, because the gut is doing everything it can to sort of move all the content through. But once they get sort of further down the line and the rabbit starts to get sicker, you'll then end up hearing no gut sounds. And with the faeces, again, if you catch it early, they may be pooing normally, but say when the rabbit starts to get worse and worse, then eventually you'll get no faecal production.

But it does tend to go from normal to nothing rather than with the medical stasis, you get these sort of funny abnormal faeces passed in between. How do we diagnose a surgical gut stasis? Well, to be honest with you, I mainly diagnose surgical stasis, purely on clinical exams because I can feel this massive abdomen and everything else matches.

But, the other thing that's really useful, as I mentioned earlier, is to check that blood glucose, and usually the level is above 20. X-rays are also really helpful. And so this is an X-ray of a rabbit that had an obstruction in the proximal duodenum.

And what you can see here is that the stomach is massive, and it's got this sort of fried egg appearance in the middle of it. So you've got this sort of area of gas with sort of this bit of ingestor in the middle. And then what you may see is you may see a small section of gut, then abruptly stops basically and obviously so that point is where the obstruction is.

But the biggest thing you're looking at is, is the lack of any gas further down the gastrointestinal tract, because if there's no gas further down, it means that that rabbit is truly obstructed at the moment in time. But if you have got gas that you can see in the secum, that's a really, really good sign. So that's usually a sign that that obstruction has now moved into the secum, and basically all that gas and fluid from the upper gastrointestinal tract can now flood down, and that, that obstruction will be, you know, as soon as it gets to the secum, that obstruction will be passed out in the faeces as normal.

So how do we treat a surgical gut stasis? Well, the first thing is to, to obviously do all your, your pre-anesthetic care, so we need to give it some fluids, we need to give it some pain relief, and we need to get that temperature up to normal. You can certainly try to pass a stomach tube to release some of the gas and the stomach contents.

But to be honest with you, I don't normally do that because usually my, I'm usually sort of trying to get into theatre as quickly as I can. And I do think by the time I've faffed around trying to get a stomach tube in, I probably could have already, been in there and, and sort of relieved the obstruction, instead. The other thing to say is, is sort of percutaneous trochorization, which we often, obviously, we usually do that in dogs and dog in dogs with GDV, you know, you put the needle inside into the stomach.

We don't recommend you do that in rabbits. And the reason is that stomach ruptures very likely. And also, obviously, when you put the needle in, you will release a little bit of gas and food into the abdominal cavity.

And with rabbits, they're super, super prone to form adhesions. So you're likely to cause an adhesion in that area over time, which then could lead to long-term medical gut stasis problems for that rabbit. And then the surgery itself is super easy, I promise.

So all you need to do is do a midline incision. And then find the obstruction, which I've told you it's probably going to be in the proximal duodenum. And then basically you milk that obstruction all the way down into the secu, and then the rabbit will poo out and that's it, and that's all you need to do.

Do always try to avoid cutting the gut at any cost. So, you know, try to avoid cutting it. Don't, you know, try to avoid having to do an enter enterotomy or an enterectomy.

Basically, because the risk of stricture in that area is so high because the guts are so thin and delicate. So we always try to avoid cutting into them at all. So do always try to milk it down if at all possible.

And then comes the question about prokinetics. So I do not use prokinetics before surgery, and the reason is, is that the risk of actually rupturing the gut by stimulating contractility is actually really high in these cases. The other thing is, we know that a lot of these rabbits have very hyper motile guts, before they go into theatre.

And so actually you think, well, if I'm giving it loads more prokinetics, is it actually gonna make any difference, and it probably isn't. But you will probably need to use some prokinetics post-operatively because they do tend to develop a degree of postoperative ileus anyway. The last argument is, however, that if the owner hasn't got any money, and it's, it's either try some pro-kinetics or euthanize the rabbit, providing you can keep the rabbit comfortable, then it could be worth just trying some prokinetics and see what happens.

But you do always need to make sure you've discussed the risks of of that process with the owner. But say, you know, if it's if it's do or die situation, you can try them as long as you explain to the owner that that it's not the best idea. So I would always rather operate on these rabbits, and, and sort of move the obstruction down myself because they've got a very, very, very good prognosis if you can do that.

And just to show you a picture, so this is a picture of the rabbit that we saw in the X-rays a few slides ago. So what you can see here is you've got this massive circumferential bruise, in the, in the proximal Jude and where the obstruction was. OK.

Now, this picture is taken after I've moved that obstruction down, and that's why there's all gas and fluid all the way down the gut there. But you can see how stuck things can get in the gut, and what a degree of damage that can cause. The next thing to discuss is liver load torsions.

So with liver load torsions in bunnies, I do think they're really, really underdiagnosed, to be honest. And once you, you now know about this problem, you may start finding that you end up recognising this condition a lot more readily. So with live or torsions, any lobe can be affected.

So different papers and that you'll read will say different lobes are more commonly to be affected, but, but say it can really be any lobe at all. And with these rabbits, they do, you know, always usually have a very high blood glucose level. So it is another reason why you'd get an elevated sugar level basically in a rabbit along with those sort of say surgical gut stasis.

The bunny rabbits are usually anaemic as well, and the reason for that is that when the liver lobe causes, it does start to bleed, so you end up with a hemo abdomen. And that's why you can sometimes also appreciate a bit of a fluid thrill to the abdomen as well. And you can sometimes also palpate that affected lobe in the abdomen as as sort of this painful hard mass.

Do, however, be very careful when you're feeling around the liver in these rabbits, because obviously it's very, very friable, that that liver lobe so you don't want to cause any further bleeding. They will also quite commonly get an increase, increase in liver enzymes. So often we see the ALP and the ALT sort of be quite high.

And you can also ultrasound the liver, and you'll be able to see this sort of enlarged heterogeneous lobe when they when they of the tors lobe basically in there. Lobectomy is usually the treatment choice for these rabbits, so it it is sort of just going in there and removing that lobe, and obviously some of them will also need a blood transfusion and things like that as well. Without surgery, so, so basically, if the rat, if the owner cannot afford surgery, really, you can tell them that two things are the possible outcome.

So the first thing that can happen is the rabbit just dies, and they ended up, they end up dying usually, you know, a day or so later, potentially, and it's usually that they die because of endotoxic shock or paralytic ileus or that they bleed to death. The other thing that can happen is you can actually sometimes get recovery of the rabbit, sort of after this liver lobe is caused. And what happens basically is the liver lobe can then degenerate and start to atrophy.

And so, so sometimes I say, they can recover without surgery, so it's not that they definitely will die. And the reason we know that some rabbits can recover is that they have done a lot of postmortem studies, and basically they did find a lot of, tours liver in some rabbits, so they found sort of these old sort of, old sort of lobes that were all sort of shrivelled up. So we know that some rabbits can get, can get over it without, without treatment.

And just so you know, it is really obvious when you're in there which lobes are twisted and which ones are are not. So unfortunately this was from a rabbit that didn't make it, hence why I could cut out a big chunk of the normal liver, but you can see it looks very, very different. The next thing to talk about is just to talk about seizures.

So your differential diagnosis of seizures and bunnies, it's gonna be very, very similar to what it is in other species. And our differentials do include, obviously things like intracranial problems, extracranial problems, and toxicity. So the same sort of three categories that we would use on our dogs or cats.

The other thing that rabbits can get as well though is e caniculi, so you do need to add that to your differential diagnosis list. Always check the glucose level when you get a rabbit that comes in seizuring, because obviously hyperglycemia can be a very common cause of, of seizuring. So you need to know whether that sugar's low and you need to supplement it.

And then in terms of diagnosing problems with seizures, it's exactly the same as you do in your dogs and cats. So you start off with doing a full blood test, and then, the other thing you may want to consider is doing Eiculitittis. And then obviously, if, if money allows and you can't find anything else, then obviously MRI is an option, the same as it would be in a dog or a cat.

And then treatment wise, if the rabbits, seizuring at the moment in time, we would use, diazepam. And then for longer term control, if you've got a rabbit with epilepsy, you can certainly consider using phenobarbital. And head tilts, are obviously a very common emergency presentation that we see in practise as well.

And there are multiple possible causes of why the rabbit's got a head tilt, but the most common causes we usually see are eciculi or ear problems, so, bacterial problems in the in the inner ear. Obviously there are other differential diagnoses such as neoplasia and metabolic disease as well. With caniculi, they do now think it's actually a fungus, which I thought was quite interesting.

And, clinical signs wise, obviously you get the head, you can get tortoollis and ataxia, and you can also get eiculi causing uveitis, but they only get that if they've contracted echiiculi while they were in the womb. The other stuff you can get is posterior paralysis. They go off their back legs, and they can also get urine incontinence and renal disease.

So say the two systems really the ecuicular effects is the renal system and the neurological system. And to diagnose Eiculi, we're most often doing serology, and we're looking at the IGM and the IgG levels. Do remember though that 55% of rabbits in the UK are sero positive anyway, so you do often need to do paired readings.

And IGM goes up basically in the acute phase infection, and IgG just tells you about, you know, whether the rabbit's been exposed to it long term. The other ways you can diagnose it is obviously on postmortem and also via PCRs. And the treatment for ekiculi is to give febendazole, and then obviously all your supportive care, so including sort of, you know, pro-kinetics, padding environments, keeping the eyes lubricated and things like that.

And do also remember that ekiculi is zoonotic, so it's important you tell owners that. And I just wanted to show this video because it does show really like how severely affected some rabbits can be with the caniculi. So you see this rabbit is really, really struggling to even keep up, right?

And it is always important, you know, if rabbits do have a very, very severe head tilt and are showing sort of very severe neurological signs, that we do consider euthanasia early on. Because, you know, these rabbits are prey species, and this must be absolutely terrifying for them because they can't get away from any, you know, suspected predators and things like that. So do always consider euthanasia and talk about that early in rabbits that are severely affected.

And another problem we see quite commonly would be dyspnea. And so do remember that rabbits are obligate nasal breathers, OK, so they only will attempt to open mouth breathe if they're really, really, really dysneic. So if you've got a rabbit that's opening its mouth, it really needs to come in and go straight into oxygen, to be honest.

And obviously your emergency care, the first thing, as I say, is to get them in oxygen, and it may well be that you leave them in oxygen for a good 1015 minutes until they've settled down. The, the next stuff is obviously reducing the stress, consider some analgesia. If you do think the problem with them is cardiac, then obviously you can consider giving some diuretics, so free someide injection.

And then other parts of your care may include things like antibiotics if you believe it's infectious, and also obviously nebulization. And don't forget that you can nebulize with a whole range of different stuff. So it's not just water, you can nebulize with things like F10 and Batrol and things like that.

And the differential diagnosis of this new bunnies, includes sort of a very similar list to what you'd see in dogs and cats. Don't forget that rabbits also get thymoma. So these end up growing to, to a humongous size in the cranial thorax and can really obviously affect, you know, the amount of lung space that's available for those rabbits to breathe.

And when we're doing our emergency diagnostics on bunnies, the same what we would do with dogs and cats with with dyspnea, is to, first of all, grab your ultrasound machine. So, you know, doing a blue or a or a Tart can be super useful in these animals. And we're obviously looking for the presence of pleural effusion, like you can see in this picture, all the evidence of things like bee lines, which obviously indicates wet lungs.

So do grab that and do that as your first line before you try and stress that rabbit by trying to take an X-ray. And the other stuff you can do as well is you take your full bloods as well, and as part of your sort of emergency diagnostic plan once the rabbit's a little bit more stable. And then further diagnostics to try and obviously distinguish, you know, try and work out the actual cause of the problem, we're thinking about things like doing CT, bronchoscopy, you know, cytology, culture, echo, and things like that.

And then the last thing I wanted to talk to you about was just about fly strike. So with fly strike, and remember it's not normal for, for maggots to, to grow on your body. So there's usually some reason why that rabbit has developed that problem.

So certainly things like poor nutrition, and dental disease, they can't groom away those flies and fly eggs, and being overweight, not being able to move around as normal. And also anything that's going to cause urinary and GI disease. So, you know, the rabbit basically having a lot of faeces caked on the back end or or being covered in in sort of urine and causing sort of urine scaling.

And the treatment for fly strike would include giving them fluids, so don't forget that they do lose a lot of fluid through these massive wounds that they end up getting. You also should make sure they've obviously got good good pain relief on board, and then you need to obviously clip and clean and remove all those maggots. And it may sometimes be that you need to do that under a sedation if the rabbit's too uncomfortable.

Do consider giving systemic ivermectin just to make sure that all the maggots are killed off. You can also use things like sin spray, consider whether systemic antibiotics are indicated, and also, things like Flamazine also can be very useful. And then to prevent fly strike happening, remember to, you know, make sure you do have a look at what could have caused fly strike in the first place and think about correcting or treating those contributing factors.

And also obviously consider the use of rear guard as well to try and prevent, to try to prevent fly striking these rabbits. And do remember, if you're bathing the rabbit quite a lot, you're gonna have to frequently reapply that rear guard as well, just to make sure they're protected. And that's what I have to say this evening.

I do hope you found that useful and I'm happy to take any questions. Louise, thank you very much. That certainly was incredibly interesting and also very, very helpful.

So thank you for your time and thank you for sharing your knowledge with us. Oh thank you. A couple of questions that we've had to come through.

The first one when you were talking about pain control, was tramadol. Does tramadol have a consistent effect in bunnies, a predictable effect, or is it more like we're seeing research showing us in other species where it's a little bit hit and miss? Yeah, so I sort of I have used it in rabbits and I do seem to think it does have an a a reasonable effect.

And certainly I think it's, I think it is difficult to know if it's actually a very good pain control. For rabbits, the same as we sort of question it in dogs and cats and things like that as well. So, although I have used it, my preference actually would be to use, a meloxicam and also an opioid, so use like a buprenorphine, orally instead, to be honest.

You can be, you can, you know, they have got, dose ranges available for it, so, so it's a potentially an option if if you, if you need something else to use. Yeah, I was, I was interested to see that you can use the trans mucosal bu. I didn't know that in bunnies.

I knew we used it a lot in cats, but I didn't know in, in bunnies. Yeah, yeah, and I say it's brilliant, you know, I've had those rabbits that have gone home, you know, post-surgery, and you just feel like they need something extra, rather than just meloxicam. So it's definitely something to consider using, you know, I think I feel like it works very well in them.

Yeah, it's certainly worth knowing. Karida asked, would blood lactate measurement in rabbits be helpful when diagnosing a liver lobe torsion? So there is a paper that, that sort of suggested that basically the levels were all over the place when they, they measured them, in, in rabbits, for, for the lactate.

So they, they measured the lactate in loads of different rabbits, basically, and they, they just all all random. So it may well be that it is a bit high. I mean, to be honest, those rabbits that I have that, that are a bit sicker, I do notice their lactate levels tend to be higher than than ones that are very you know, much healthier.

But you can't overly interpret the level, because basically, sometimes you'll get a rabbit in that's otherwise quite well and you're checking routine bloods. And if it really loads, then you can sometimes get a lapate of sort of 15. And, and so you can't overly interpret it.

But it would be quite interesting to see actually in those liver load torsions whether it is always very high. But, but yeah, so it's not something that I've particularly recognise and I say I, I've sort of, always been told just just ignore it because it's not relevant. So yeah.

Interesting. There you go, Karia, there's a, a research project for you to do. That would be fascinating.

Last question that we have for you now is, for many years, we had, this, this, I don't know what the polite word is, myth that alhaxan was so much safer than propofol in bunnies and critical and sick old cats and that. And recently, we've seen some research coming through that shows in fact that that's not true. I, what do you prefer in bunnies, faxan or propofol?

You see, I've always used propofol, so I have used alfaxan a little bit more over the last few years, but my preference always, if I get an obstructed rabbit, you know. Proximal dude and obstruction and rabbit, I always grab that propofol. I'm familiar with it, and I, I feel like it's safe.

I say the only thing that I've ever worried about is the Profile Plus, because I say, when I was in first opinion practise, I had a few good few colleagues that, had bunnies die after they were induced with Profile Plus. And, you know, I mean, I can't say it was definitely the profile plus, but you always worry that it is. So I've always avoided it.

So I, I tend to use propofol, if I'm honest, . But yeah, I don't, I don't know, I haven't actually looked into the recent studies and I'm not sure whether they have got exact figures for bunnies, if they've managed to show any, you know, if they've actually analysed it compared in comparison to propofol to see, see what's safer. Yeah, yeah.

I guess it goes back to that age old adage of the best anaesthetic is the one that you're familiar with. Yeah, yeah, 100%. And obviously, yeah, for the last 5 years or so, I've worked in emergency as well, and when you're in emergency and critical care, it's really not the time to start experimenting with protocols because your bunnies are always very, very sick at that point.

So CSA a creature of habit, really, I must say. Yeah, I think that's that's always a good thing, especially when it's a good habit. Yeah, fantastic.

Louise, we have come to the end of this evening. Once again, a huge big thank you to you for all your time and for sharing your knowledge with us. We really do appreciate it.

Oh, thank you very much and have a good evening, everyone. And to everybody who attended tonight, thank you very much for your time to Kyle, my controller in the background for making everything happen seamlessly. Thank you very much.

And from myself, Bruce Stevenson, it's good night.