Anesthesia of Pet Birds

Thomas G. Curro, DVM, MS

It is common for veterinarians who specialize in small animals and species to be presented with pet bird patients for procedures that require general anesthesia, including complete physical examination, venipuncture, diagnostic workup, or medical and surgical treatments. The basic principles of anesthetic management that govern mammalian anesthesia also apply to birds, although specific anatomic and physiological differences must be considered. The goal of this article is to present a, clinically applicable approach to pet bird anesthesia, including preanesthetic considerations, physical restraint, induction agents, anesthetic maintenance, supportive measures, anesthetic recovery, and management of anesthetic complications. Copyright9 1998by W. B. Saunders Company. Key words: Avian, anesthesia, Psittaciforme, Passeriforme, restraint.

eterinarians who specialize in small animals and avian species are commonly presented with pet bird patients for procedures that require general anesthesia. T h e most c o m m o n pet birds belong to two major orders. Passeriformes include perching birds, such as canaries and finches. Psittaciformes include a wide variety of hooked-bill or parrot species, such as budgerigars (mistakenly called parakeets), cockatiels, conures, Amazons, cockatoos, African Greys, macaws, and others. Less frequently, doves, pigeons, quail, toucans, and poultry may be presented as pet birds. Although this article will concentrate on the Passeriforme and Psittaciforme species, the basics of avian anesthesia apply to most bird species.

stressful if p e r f o r m e d u n d e r general anesthesia, rather than with physical restraint alone. As anesthetic agents have evolved, so have avian anesthetic techniques. Before the introduction of safe inhalant anesthetics, injectable anesthetic techniques were used for immobilization. Once methoxyflurane and halothane were shown to be safe and effective inhalant agents, their use in veterinary medicine evolved to include birds. Isoflurane has replaced injectable techniques, as well as methoxyflurane and halothane, as the most commonly used and safest general anesthetic agent for birds. T h e basic principles of anesthetic m a n a g e m e n t are the same for birds and mammals. Similarities and differences, dep e n d e n t on anatomy and physiology, will become apparent as they are presented.

Preanesthetic Preparation
Before any anesthetic p r o c e d u r e in birds, a complete history should include signalment, environment, diet, immediate health problem, past health problems, and past reactions to handling and anesthesia. A complete physical examination is desirable, but this may be the reason that the bird is being anesthetized. Fasting Fasting recommendations for birds, even small passerines, have varied from no preanesthetic fasting to an overnight fast. 1-~ Because of the high metabolic rate of birds, an extended fast may be detrimental, as hepatic glycogen stores can be quickly depleted. Birds larger than 300 g are less p r o n e to hypoglycemia that could develop during a p r o l o n g e d fast. A blood glucose of <200 m g / d L is considered hypoglycemic in most bird species. Fasting is r e c o m m e n d e d to decrease the likelih o o d of regurgitation and aspiration of food. Ideally, a fast should be long e n o u g h to empty the crop of its contents. 4 It is especially important to empty the crop o f fluid contents, which are easily refluxed during general anesthesia or recovery. Frugivorous birds, such as iorikeets,

Overview of Anesthesia in Birds

Anesthesia of birds may be required to perf o r m a complete physical examination, venipuncture, diagnostic workup, and medical or surgical therapy. In fact, many procedures may be less

From the Westside Family Pet Clinic, Dane County Humane Society, Madison, WI. Address reprint requests to Thomas G. C'u*~'o,D~CWI,MS, 4326 DeVolis Pky, Madison, WI53711. Copyright 9 1998 by W. B. Saunders Company. 1055-937X/98/0701-0002508. 00/0

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Seminars in Avian and Exotic Pet Medicine, Vol 7, No I (January), 1998:pp 10-21

Anesthesia of Pet Birds

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which normally have a diet high in fluid content, are especially susceptible to regurgitation and potential aspiration. 5 I f an e m e r g e n c y situation precludes waiting for the crop to empty, a small feeding tube may be passed into the esophagus a n d / o r crop to wick fluid by capillary action or to directly aspirate fluid contents. I f passing a tube would be an unacceptable stress before anesthesia, a feeding tube m a y be passed after a bird is induced and intubated to remove fluid before diagnostic or surgical manipulation. If crop surgery is to be p e r f o r m e d , fasting should be long e n o u g h (4 to 6 hours) to e m p t y the crop. It is a generally accepted practice to fast healthy l~irds 1 to 3 hours before anesthesia. 5-s Generally, the smaller the bird, the shorter the fasting period. 4,9,1~ Small passerines, such as finches or canaries, or i m m a t u r e birds of larger species, should not n e e d m o r e than a 1 h o u r fast. Larger birds (>300 g) will tolerate an overnight fast (8 to 10 hours), but anesthesia should be p l a n n e d for early in the day. An overnight fast is reasonable, because most birds do not eat during this time. I n d e p e n d e n t of the food fast, water should be available until approximately 1 h o u r before anesthesia in most species.

Figure 1. Preferred towel restraint technique for Psittaciformes. the hand, a n d the head restrained between the index and middle fingers. It is not i m p o r t a n t to capture the bird in the ideal position, but rather to capture the bird quickly to avoid the stress of chasing the bird a r o u n d the cage. D i m m i n g the lights in the r o o m may facilitate capture. O n c e the bird is captured, it can be m a n i p u l a t e d to a p r e f e r r e d position. Birds breathe via m o v e m e n t of the thoracic Cage, and restriction of the thorax by the handler must be avoided.

Physical Restraint
Before the administration o f preanesthetic or anesthetic agents, the bird will n e e d physical restraint. In the case of Psittaciformes, restraint of the h e a d is i m p o r t a n t to prevent biting injury to the handler. T h e most c o m m o n restraint technique is to capture the bird with a handcovered towel, sized appropriately for the species. L e a t h e r gloves should be avoided because m a n y pet birds are hand-tame, and capturing with a gloved h a n d may cause a bird to b e c o m e hand-shy. Gloves also decrease tactile senses n e e d e d to assess the extent of the restraint. For restraint, one h a n d restrains the h e a d while the other h a n d controls the b o d y (Fig 1). Restraint of the h e a d begins by creating a ring a r o u n d the bird's neck with one hand. Gentle, but firm, pressure is used against the base of the skull and lower mandible to extend the h e a d away f r o m the body (Fig 2). This technique will work with the largest macaw, when the size of the h e a d may preclude small hands f r o m restraining the h e a d directly. Passeriformes are c o m m o n l y restrained with the bird cradled in the p a l m of

Preanesthetic Medications
Preanesthetic medications are used to provide c a r d i o p u l m o n a r y and central nervous system (CNS) stabilization, physical restraint, sedation, muscle relaxation, and analgesia, a n d / o r to decrease the doses of concurrently used anesthetic agents. O f the n u m e r o u s medications that can be used during the preanesthetic period, fluids are the most important. Crystalloid and colloid fluids aid in cardiovascular stabilization. Preoxygenation may e n h a n c e homeostasis in the respiratory-compromised patient. Steroids may be used in the event of shock or CNS injury. It is beyond the scope of this article to address all the n o n a n e s t h e t i c p r e m e d i c a t i o n s in detail, alt h o u g h fluids will be discussed in a later section. Preanesthetic medications are used infrequently in p e t birds. Although the use of anticholinergics as p r e m e d i c a n t s is rare, atropine and glycopyrrolate are effective for the t r e a t m e n t of vagally induced bradycardia. 11,12 Diazepam and

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Thomas G. Carro

Figure 2. Preferred restraint technique for Psittaciforrues, demonstrating hand positioning without towel. midazolam may produce sedation,5,7,1!-lB muscle relaxation during ketamine anesthesia, ~2,~4 and an anesthetic-sparing effect 15 in birds. Phenothiazine tranquilizers have been noted to be ineffective in birds, 11,16 although acepromazine has b e e n used in combination with ketamine. 2,5,17 Opioid agents, such as butorphanol, have demonstrated potential benefit in pet birds as sedatives and analgesics, la,19 and their use will be discussed u n d e r supportive therapy.

Induction Intramuscular/IntravenousAgents
Historically, many injectable anesthetics have b e e n used for immobilization and anesthesia in birds, including barbiturates, chloral hydrate, alpha chloralose, phenothiazines, dissociatives,

az-agonists, alphaxalone/alphadolone acetate 2~ and, more recently, propofol. 22,23Stable, uncomplicated levels of anesthesia are difficult to produce with these agents. T h e advantages of using injectable anesthetics include ease of use in the field, minimal need for technical equipment, availability, ease of administration, rapid induction, and relatively low cost. Disadvantages inelude elimination that is d e p e n d e n t on biotransformation and excretion, dose-dependent cardiopulmonary depression, potentially difficult reversal of drug effects in an emergency situation, potentially p r o l o n g e d and violent recoveries, and lack of adequate muscle relaxation with some drugs. Propofol use for induction and maintenance in chickens is associated with significant adverse cardiopulmonary effects, and cannot be r e c o m m e n d e d for use in pet birds. 23 Injectable agents may be administered intramuscularly (IM) (pectorals), intravenously (IV) (jugular, cutaneous ulnar, medial metatarsal), or intraosseously. 24 Catheterization is r e c o m m e n d e d for IV or intraosseous administration, and accurate body weight is essential for calculation of an injectable anesthetic dose. Combinations of ketamine with diazepam, midazolam, or xylazine p r o d u c e restraint to light surgical plane anesthesia, d e p e n d i n g on dosage. Ketamine alone usually produces inadequate anesthesia, and recoveries are often violent. Combining ketamine with diazepam or midazolam provides muscle relaxation and sedation, and reduces the degree of struggling on recovery, a,l~ Benzodiazepines are r e c o m m e n d e d because they produce minimal adverse cardiopulmonary effects. A tiletamine (dissociative) and zolazepam (benzodiazepine) combination (Telazol; Fort Dodge Laboratories, Fort Dodge, IA), provides effects similar to ketamine and diazepam, with a longer duration of effect. Ketamine combined with xylazine is a commonly reported injectable regimen for birds. 6,12, 17,25-29Xylazine also improves anesthetic recovery and provides sedation and analgesia when used in combination with ketamine. Unfortunately, xylazine has p o t e n t cardiopulmonary-depressive effects, which are not compensated by the effects ofketamine. Sun Conures have been n o t e d to be less tolerant of an xylazine-ketamine combination compared with other pet birds. 2vA benzodiazepine-ketamine combination is the best choice when an injectable anesthetic technique must be

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used in a cardiopulmonary-compromised patient. T h e potential for severe cardiopulmonary depression may be minimized by administering injectable agents in multiple small boluses (or as an infusion), titrated to effect, rather than as a single large bolus, especially when the IV or intraosseous route is used. 7 Current r e c o m m e n dations are that injectable anesthetics be used in pet birds only when an inhalant anesthetic, particularly isoflurane, is unavailable. Ideally, isoflurane anesthesia should be used in all situations o f debilitation, or when a prolonged duration of anesthesia is required. If injectable anesthesia is unavoidable, appropriate agents include ketamine combined with e i t h e r xylazine, diazepam, midazolam, or acepromazine (Table 1). Medetomidine (Domitor; Pfizer Animal Health, Exton, PA) with ketamine has also been reported, but is less commonly used than the other combinations at this time. Tiletamine/zolazepam is an effective injectable anesthetic combination (7.7 to 26.0 m g / k g IM). When referring to Table 1 dosages, the high-end dosage is used for smaller birds (<250 g), or when a surgical plane of anesthesia is desired in larger birds. The low-end dosage is used in larger birds (>250 g) or when only sedation is desired in smaller birds. Induction occurs in 5~to 10 minutes and complete recovery may take 2 to 4 hours or longer.

demonstrated potential analgesic and sedative effects in pet birds, can be reversed with the pure opioid antagonist, naloxone (0.3 mg/kg). Generally, reversal of opioids should only be d o n e as an emergency treatment of severely depressed birds, because reversal will also reverse analgesia. Diazepam and midazolam are antagonized with flumazenil, a pure benzodiazepine antagonist.

Inhalation Agents
Historically, ether, 3~ methoxyflurane, 3234 halothane, 9,3~ and isoflurane have been used for inhalant anesthesia in birds. Nitrous oxide has also been used in combination with other inhalants. Ideally, an inhalant should provide rapid anesthetic induction and recovery without producing p r o f o u n d cardiopulmonary depression or organ toxicity. Isoflurane is currently the p r e f e r r e d agent for general anesthesia in pet birds. This inhalant is a clinically proven safe, and effective anesthetic agent. Its potency has b e e n evaluated based on minimum anesthetic concentration (EDs0) studies in waterfowel, cranes, pigeons, and Psittaciforrues. 15,19,~6,37 Because o f isoflurane's low blood solubility and minimal metabolism (<0.2%) and the efficiency of avian respiratory gas exchange, induction, changes in anesthetic depth, and recovery are easily and quickly controlled. At sedative and light surgical planes of anesthesia with isoflurane, adverse cardiopulmonary effects are minimal, although certain species seem particularly sensitive to the respiratory-depressant effects. Isoflurane concentrations of 4 to 5 vol% are used for mask induction and must be reduced when signs of sedation and anesthesia b e c o m e apparent. Minimum anesthetic concentrations for maintenance in the intubated bird will average 1.45%. If maintained with a mask, concentrations may be 25% to 30% higher, unless the mask fits snugly. Surgical plane anesthesia will generally require isoflurane concentrations of 1.80% to 2.20% and potentially higher. Because of the dose-dependent respiratory depression of isoflurane, ventilation should be assisted or controlled, especially during p r o l o n g e d procedures.

Antagonists
Antagonism of anesthetic agents is beneficial, especially when anesthetic emergencies develop or when duration of anesthesia is prolonged. Yohimbine and tolazoline have been used to reverse the effects of xylazine. 12,26 T h e sedative and respiratory-depressant effects of xylazine can be successfully reversed with yohimbine (1 m g / k g IM). Opioids, of which butorphanol has

Table 1. Common Ketamine Combinations and

Dosages Used for Pet Bird Injectable Anesthesia
Ketamine (mg/kg) Drug Combined With Ketamine (mg/kg)

Drug Combination

Ketamine/xylazine Ketamine/diazepam Ketamine/midazolam Ketamine/acepromazine

10-50 10-50 1040 10-25

1.0-10.0 0.5-2.0 0.5-1.5 0.5-1.0

Inhalation Agent Delivery

Nonrebreathing, semiopen anesthesia circuits are r e c o m m e n d e d for inhalant delivery. The

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advantages of these systems are low resistance to breathing and immediate changes in the delivered anesthetic concentration when the vaporizer setting is changed. Disadvantages are that the required high oxygen flow rate wastes oxygen and anesthetic, produces excessive environmental pollution, and also causes significant patient cooling due to inspiration of cool dry gas. Various configurations of n o n r e b r e a t h i n g systems have been used. T h e Bain anesthesia circuit is commonly used because o f its low cost and weight. Small rebreathing bags (89L) are commercially available, or may be fashioned from ball o o n s Y An effective anesthetic gas scavenger should always be used with inhalant anesthetic systems to minimize h u m a n exposure to waste gas pollution: Anesthesia is induced with the head physically restrained and placed in an anesthetic mask attached to the nonrebreathing circuit. Masks may be purchased commercially, or constructed from various sized plastic tubing or syringe casings and a latex diaphragm (exam glove). Equilibrating the circuit with inhalant before patient exposure (priming) has b e e n advocated, 27 but is unnecessary because the high oxygen flow rate (>1.0 L / m i n ) quickly delivers the desired induction concentration. Priming also contributes to waste gas pollution. Once the bird is restrained in the mask, the desired concentration of anesthetic is delivered by one of two protocols. The first m e t h o d begins at low inhalant concentrations and proceeds to higher concentrations as anesthetic effects deve!op, allowing rapid reversal of anesthesia if complications arise. This protocol has b e e n suggested for debilitated birds because of less likelihood of overdosing. Unfortunately, the low-to-high protocol requires longer physical restraint and stress time, which can be especially detrimental to a debilitated bird. The benefit must be c o m p a r e d with this risk, with the goal being to avoid both overdose a n d / t h e stress associated with slowonset anesthesia. The p r e f e r r e d protocol begins with a high (4% to 5% isoflurane) concentration of inhalant, which is decreased as clinical signs of anesthesia b e c o m e apparent. The key to this m e t h o d is close monitoring of clinical signs and an appropriate and timely decrease in inhalant concentration delivered. Sedation usually occurs within seconds, and a light surgical plane of

anesthesia within minutes. This protocol has been shown to work safely on healthy, as well as debilitated, birds. Once a light surgical plane of anesthesia has b e e n induced, the mask should be removed, the bird intubated, and the endotracheal tube quickly connected to the delivery circuit. Continuous delivery of inhalant anesthetic is necessary to prevent wakening, especially during the induction phase. The vaporizer setting should then be adjusted to an appropriate concentration to maintain a stable plane o f anesthesia.

Maintenance
Intubation Endotracheal intubation provides airway access for the delivery of oxygen and anesthetic gases and an effective route for delivery of manual or mechanical ventilation. The endotracheal tube also protects the airway from aspiration of secretions and refluxed gastrointestinal contents. For an endotracheal tube to p e r f o r m these functions properly, a sealed airway is required, which cannot be achieved with either an uncuffed or an uninflated cuffed tube. Endotracheal intubation with cuffed tubes is recomm e n d e d for use in birds despite the presence of complete cartilaginous tracheal rings in all species. The cuff must be carefully inflated just e n o u g h to prevent leakage when 10 to 15 cm H 2 0 pressure is applied to the airway. The size of the bird will dictate the size of endotracheal tube used. T h e smallest available cuffed tubes have an internal diameter (ID) of 3.0 mm. Psittaciformes as small as 350 g have b e e n intubated with a 3.0 ID tube. Birds smaller than this will require the use of uncuffed tubes or large gauge IV catheters. Birds as small as 100 g may be intubated with these smaller tubes. Care should be taken when catheter-sized tubes are used, because they will not provide a sealed airway and may easily b e c o m e plugged with secretions, mucus, or blood. Also, the resistance to gas flow through small catheters is high, which may significantly impede both spontaneous and manual ventilation. Use of Murphy tubes, which have a side opening as well as an end opening, decrease the chance of mucus occlusion. Airway patency should be checked regularly during general anesthesia. Birds smaller than 100 g are

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best m a i n t a i n e d with a mask. I f a mask is used to maintain anesthesia, m o u t h gags fashioned f r o m p a p e r clip wire have b e e n used to keep the fleshy tongues of certain avian species from obstructing the glottis. Most birds are easy to intubate. T h e y lack an epiglottis and the glottis is located o n the midline at the base of the tongue (Fig 3). To visualize the glottis, the tongue is gently grasped a n d pulled forward with a forceps, or the tongue is pressed against the mandible with a cottontipped applicator. An endotracheal tube, sparingly lubricated, is then gently inserted directly into the trachea, and secured to the maxilla with tape. Endotracheal tube length should only extend caudally beyond the thoracic inlet a n d rostrally past the e n d of the b e a k no m o r e than the length of the endotracheal tube adapter. T h e latter will minimize the dead space attributable to the endotracheal tube. In the event of airway obstruction, or to p e r f o r m procedures of the h e a d or oral cavity, inhalant anesthetics may be administered into the air sacs. Percutaneous catheters for inhalant administration may be placed in the clavicular, caudal thoracic, or a b d o m i n a l air sacs, and the p r o c e d u r e for catheter p l a c e m e n t has b e e n des c r i b e d 9 ,4~ Briefly, a skin incision is m a d e over

the desired p l a c e m e n t site, the air sac m e m b r a n e is exposed, a sterile catheter is passed into the air sac, and the skin incision is closed to secure the catheter in place. Effective ventilation and delivery of gases can be administered through air sac catheters. Caudal thoracic or a b d o m i n a l air sac catheters are p r e f e r r e d because gas delivery at these sites better mimic the general flow of gases t h r o u g h the avian respiratory system. Oxygen and anesthetic gases flow f r o m the cannulated air sac and exit t h r o u g h the trachea. Unfortunately, scavenging of waste gases is not practical when this technique is used.

Supportive Therapy
Positioning/ThermalSupport
Positioning of the avian patient during anesthesia depends on the p r o c e d u r e being performed. Birds are usually positioned in either lateral or dorsal recumbency. W h e n positioning an anesthetized bird, it is critical that unrestricted m o v e m e n t of the thoracic cage be maintained. Because birds lack a diaphragm, ventilation is achieved by the expansion and contraction of the thoracic cage. If this m o v e m e n t is impeded, hypoventilation will be significant. A1-

Figure 3. Demonstration of the bird glottal opening before endotracheal intubation.

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Thomas G. Curro

though one r e p o r t indicated that birds in dorsal r e c u m b e n c y hypoventilate, 41 it evaluated heavybodied poultry that, because of their body configuration and thoracic musculature, could not ventilate adequately. Anesthetized, spontaneously breathing cockatoos have been studied in dorsal recumbency for up to 7 hours without development of significant hypoventilation.~9 Special padding is not n e e d e d for pet birds; in most cases, a soft towel is adequate. If more rigid, sustained positioning is needed, a c o n f o r m i n g body pad may be used. Maintenance of normal body temperature during anesthesia is extremely important in pet birds. Hypothermia reduces anesthetic requirements, increases the potential for cardiac instability, and prolongs recoveryY The n o r m a l body temperature for birds ranges from 40 to 44~ Because of their small size and high body surfaceto-volume ratio and the use of high oxygen flow rates, birds can become hypothermic very quickly during anesthesia. To minimize heat loss, all anesthetized birds should be provided with thermal support. Methods to prevent heat loss include insulating the patient with clear plastic surgical drapes or wrapping nonsurgical field regions in plastic. Plucking of feathers and surgical preparation with alcohol should be minimized. T h e use of a chlorhexidine solution and warm water is a better choice for aseptic skin preparation. Supplemental heat can be provided by increasing the ambient temperature, using a circulating warm water blanket (40.5~ administering warmed fluids, positioning a warming lamp over the bird, and placing heated water containers near the patient. Latex gloves or empty fluid bags can be filled with water, sealed, and warmed in a microwave oven. Heated water containers should never be placed directly next to the bird. They may initially be too hot and, as they cool, may actually convect heat away from the patient. Body temperature should be m o n i t o r e d with a cloacal t h e r m o m e t e r or temperature probe to evaluate the effectiveness of heat retention measures.

m e n t in resting birds is estimated to be 40 to 60 m L / k g / d a y . The estimated fluid replacement to correct dehydration is calculated as: Deficit (mL) = body weight (g) x % dehydration Debilitated birds should be assumed to be 5% to 7% dehydrated. A packed cell volume (PCV) >55% to 60% is an indication o f dehydration. A serum uric acid of > 3 0 m g / d L may indicate either dehydration or renal disease. Dehydration should be corrected with 88 to 89 of the calculated fluid deficit in the first 4 to 6 hours, with the remaining volume administered over the followi n g 2 4 hours. 42 If a bird must be anesthetized on an emergency basis before volume stabilization, the volume deficit should be incorporated into the anesthetic maintenance fluids. Healthy, anesthetized birds should receive replacement fluids at a rate of 10 m L / k g / h r for the first 2 hours, and then 5 to 8 m L / k g / h r to prevent overhydration. Fluid replacement should be considered on an individual animal basis. If h e m o r r h a g e occurs, the administered volume of a crystalloid replacement fluid should be three times the blood loss volume. If blood volume loss is >30% of the estimated normal blood volume, a blood transfusion is indicated. Oral, subcutaneous (SC), IV, or intraosseous (intramedullary) routes are appropriate for fluid administration. Alert birds without gastrointestinal disease benefit from oral fluid administration. Debilitated birds and birds with altered mentation should receive parenteral fluids. In noncritical situations, SC fluids may be administered. Preferred sites for SC fluid delivery include the propatagium (wing web), intrascapular region, and inguinal region. Care should be taken to avoid inadvertent administration of SC fluids into an air sac. Birds requiring emergency therapy should receive IV or intraosseous fluids. These two routes offer the fastest and most effective methods for large fluid volume administration. Jugular, cutaneous ulnar, and medial metatarsal veins are c o m m o n sites of IV access, d e p e n d i n g on the size of the bird. Avian veins are fragile and have little SC supportive tissue. Therefore, care must be taken to prevent vein laceration and perivaseular hemorrhage. Although butterfly catheters can be used for venipuncture, they should only be used in immobilized birds. Over-the-needle type catheters are r e c o m m e n d e d and well toler-

Fluid Administration
As with other animals, the goal of fluid administration is to provide daily fluid requirements, and to correct preexisting dehydration, electrolyte imbalances, and losses o f intravascular volu m e due to hemorrhage. Daily fluid require-

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ated by debilitated, conscious birds, if mobility is restricted. Catheters should be sutured or glued with cyanoacrylate tissue glue to the underlying skin. Restrictive collars (Elizabethan, tube) may be used to prevent dislodgment of the catheter. W h e n venous access is unavailable because of the size of the bird or hydration status, fluids may be administered via an intraosseous catheter. The distal ulna and the proximal tibiotarsus provide access sites for intraosseous catheterization. Procedures for catheter placement have b e e n described. 43 Aseptic preparation of the site is essential. Spinal needles (22 or 20 G) approximately one-third the length of the bone are r e c o m m e n d e d in larger birds, whereas hypodermic needles (27 to 25 G) have b e e n used in smaller birds. 43 Catheters are sutured or taped in place. If ulnar access is used, the wing should be immobilized for the duration of catheter placement. Intraosseous catheters should not be placed in pneumatic bones (humerus or femur). During anesthesia, balanced electrolyte solutions may be given by SC boluses, IV boluses, or continuous infusion. Lactated Ringer's solution (LRS) is the most commonly used crystalloid. As a replacement fluid, LRS is useful for rehydration, intravascular volume support, and fluid maintenance. Dextrose solutions may be used for the prevention or treatment of hypoglycemia. Parenteral administration of dextrose solutions should be conservative because they may induce compartmental shifts in water and electrolytes, leading to hypovolemia. 42 Dextrose solutions >2.5% concentration are contraindicated for SC use. Half-strength dextrose with halfstrength LRS is useful during p r o l o n g e d anesthesia. T h e r e are few reports describing the use of synthetic colloids (Dextran, starch, oxypolygelatin) in birds. 44 These solutions are useful when osmotic support is n e e d e d for intravascular volu m e expansion, Synthetic colloids should be considered during hypovolemic, hypotensive, or hypoproteinemic crises when blood products are unavailable. If a hemorrhagic event produces a > 3 0 % total body blood volume loss, crystalloid therapy needs to be supplemented with a synthetic or natural colloid product. Blood transfusions are indicated in birds with a total plasma protein of <2.5 g/dL, a PCV of <15% to 25%, or an acute blood loss > 3 0 % of the total blood volume. Total blood volume

(mL) may be estimated as 10% of the body weight (g). D o n o r blood should be from a bird of close parental relation or of a similar phylogenetic lineage. Because the availability of similar lineage blood donors may be limited, chicken or pigeon s blood may be transfused successfully to Psittaciformes. Single transfusions do not usually p r o d u c e immunologic complications. Major a n d / o r minor crossmatching should be d o n e for multiple transfusions. No commercial crossmatching test kits are available for birds. Diseasefree donors, screened for appropriate hematogenously spread avian diseases, are essential. All fluids should be warmed before administration to minimize their contribution to anestheticinduced hypothermia. Crystalloid and synthetic colloid solutions may be easily warmed to a temperature of 38 ~ to 39~ in a microwave oven without affecting their composition. Natural blood products should be warmed in a warm water bath.

Monitoring
Sensitivity to anesthesia differs between individuals and species. Therefore, monitoring the effects and d e p t h of anesthesia is essential, because birds are p r o n e to develop anesthetic complications relatively acutely. Ideally, anesthetic depth should be just adequate to p e r f o r m the necessary procedure, and respiratory, cardiovascular, and CNS status should be continuously monitored. Respiration is usually rapid and irregular with a shallow tidal volume during initial stages of induction, but becomes slow, regular, and deep as a medium surgical plane is achieved. Respiratory rate and tidal volume continue to decrease as anesthetic depth increases. Visual monitoring of the bird and the r e b r e a t h i n g bag will allow assessment of respiratory rate and provide crude evaluation of tidal volume. Clear, plastic surgical drapes should be used to assist visual monitoring. Electronic respiratory devices, which produce an auditory tidal flow signal, are effective for assessment of respiratory rate. Unfortunately, some do not function well with the small tidal volumes of pet birds or with high oxygen flow rates used in birds. H e a r t rate and rhythm should be monitored. Direct auscultation with a stethoscope is useful, but may be difficult in small birds u n d e r surgical drapes. An electrocardiograph (ECG) provides

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Thomas G. Curro

monitoring of the heart rate, rhythm, and electrical conduction activity. The avian ECG has b e e n described, 45 and normal ECG values have b e e n established for African Grey and Amazon Parrots. 46 The mammalian hexagonal ECG lead system is applied to birds. Normally, the avian RS complex deflects downward in lead II. Attachm e n t of most ECG leads involves an alligator clip that is potentially traumatic to the thin skin of birds. To prevent injury, alligator clips can be attached to stainless steel wire suture that is l o o p e d through the skin, or leads with stick-on attachments may be used. Likewise, small (27 to 25 G) hypodermic needles may be placed cutaneously, to which clips may be attached. Another useful technique involves cutting small pieces of gauze to pad the skin u n d e r the clips. Moistening the gauze pads with alcohol provides adequate ECG lead contact. Leads are commonly attached to the propatagium and to loose skin in the stifle region. Although an ECG will reflect myocardial electrical activity, it does not indicate adequate cardiac output and tissue perfusion. H e a r t rate, rhythm, and tissue perfusion can be m o n i t o r e d with a Doppler flow p r o b e device, which is discussed in detail in Bailey's article. In larger birds, an inflatable cuff and sphygmoman o m e t e r may be used in combination with the Doppler to monitor systolic blood pressure. Pulse oximeters are becoming a popular monitoring tool in veterinary medicine. These devices provide an indirect measure of h e m o g l o b i n saturation with oxygen. Pulse oximeters are useful evaluators of changes in pulse rate and percentage of oxygen saturation. Reflectance p r o b e s have been successfully used orally and cloacally. CNS monitoring involves the evaluation of muscle tone and variOus reflexes. Anesthetic depth follows a relatively predictable progression in pet birds. During the initial stages o f anesthesia, birds will be lethargic and have drooping eyelids, a lowered head, and ruffled feathers, but will be easily arousable. As the bird progresses to a light surgical plane, palpebral, corneal, cere, and pedal reflexes remain present and potentially brisk, 'but there is no voluntary m o v e m e n t at this stage. At a m e d i u m surgical plane, corneal and pedal reflexes are slow to intermittent with loss of the palpebral reflex. During deep surgical anesthesia, respirations are slow and shallow, and reflexes are no longer present. 1~

In larger birds, ventilation, oxygenation, and acid-base status may be assessed with the measurem e n t of arterial blood gases. However, arterial blood samples are technically difficult to obtain in most pet birds, and evaluation requires the immediate availability of a blood gas analyzer.

Ventilation
Ventilation in birds results from active muscular movement of the thoracic cage during inspiration and expiration. Any restriction of thoracic movement (excessive restraint, heavy surgical drapes) will exacerbate anesthetic-induced hypoventilation. Ventilation should be manually assisted or mechanically controlled in all anesthetized birds because hypoventilation can result in cardiac depression and arrest. Emergency parameters for ventilation are discussed u n d e r Complications. Inhalant anesthetics p r o d u c e dose-dependent depression of ventilation, and certain avian species are more susceptible to this effect. In a study comparing three species of parrots, cockatoos and Blue-fronted Amazons ventilated normally, but African Grey Parrots hypoventilated at minim u m anesthetic concentrations of isoflurane. 19 Additional reports support the finding that African Grey Parrots do hypoventilate during isoflurane anesthesia. 4s,49Xylazine is a p r o f o u n d respiratory depressant and ventilation should be monitored closely during injectable regimens that include this sedative.

Analgesics
Analgesics, particularly opioids, are gaining popularity as a therapeutic adjunct in pet birds. Their use is largely based on clinical impressions. The published dose for butorphanol (3 to 4 m g / k g ) resulted from a clinical trial involving budgerigars.~S Controlled research on the analgesic effects of b u t o r p h a n o l in cockatoos and African Grey Parrots has demonstrated potential analgesic properties.19,36 Butorphanol does cause a decrease in both heart rate and minute ventilation, but neither effect results in significant physiologic alterations. Nonsteroidal anti-inflammatory agents have also been used clinically in birds. Flunixin meglumine (1 to 10 m g / k g IM) and ace@salicylic acid (aspirin) (one 5 grain tablet/250 mL drinking

Anesthesia of Pet Birds

19

water) have been r e c o m m e n d e d , although neither has been critically evaluated in birds.

pathophysiological changes will greatly increase the patient's anesthetic risk status.

Recovery
Recovery should include delivery of 100% oxygen after the inhalant has been discontinued. After swabbing the oral cavity of any accumulated secretions, detaching the endotracheal tube from the beak, and deflating the cuff, the tube is removed when the bird is light enough to object to its presence. Regardless of the anesthetic protocol used, most birds will experience e m e r g e n c e delirium, which usually occurs at the time o f or shortly after extubation. Vigorous wing flapping and disorientation are c o m m o n and usually m o r e p r o n o u n c e d during recovery from injectable anesthetics. A potential complication of anesthetic recovery is self-inflicted trauma, and restraint is essential to prevent postanesthedc injury. Birds should be lightly wrapped in a towel and manually restrained by available personnel until able to stand. Recovery from isoflurane anesthesia occurs within 5 to 15 minutes after anesthetic delivery is discontinued. If recovery personnel are not available, or if a p r o l o n g e d recovery is anticipated, birds can be wrapped in a towel or paper and placed in a small, empty, p a d d e d enclosure. Restraint should be minimal so that once a bird recovers sufficiently, it can easily free itself from the restraint. As with induction, restraint must not interfere with the normal breathing movement. T h e recovery area should be warm (25 to 30~ quiet, and dimly lighted or dark to minimize external stimulation during recovery. Food and water should be offered as soon as the bird is alert and able to perch.

Intraoperative
Intraoperative h e m o r r h a g e must be immediately controlled. Estimated blood volume of birds, in milliliters, is 10% of the body weight in grams. The average volume of a drop of blood is 0.05 mL. Because the blood volume o f a 30-g bird is 3 mL, the loss of 20 drops (or 1 mL, which is barely a spot on a gauze sponge) will result in a 30% blood loss in this bird. Although this is a dramatic example, it does demonstrate the critical importance of intraoperative hemostasis in birds. Delicate surgical technique and the application of electrocautery will aid in minimizing blood loss. Hypoventilation (decreased tidal volume or rate) or apnea for longer than 20 seconds requires application of ventilatory support and assessment of airway patency and anesthetic depth. Decreasing the anesthetic depth is usually indicated, and should precede application of assisted or controlled positive-pressure ventilation. Assisted ventilation is delivered with a peak inspiratory pressure o f 10 to 15 cm H20, 2 to 3 times per minute, in addition to the bird's rate. Controlled ventilation should deliver 10 to 12 b r e a t h s / m i n u t e with a peak inspiratory pressure of 8 to 12 cm H2O pressure. If an endotracheal tube is not placed, and the tracheal airway is unobstructed, effective ventilation may be delivered by moving the sternum ventrally and dorsally, which produces inflation and deflation of the air sacs, respectively. This action should produce adequate m o v e m e n t of gas through the lungs because of the avxan unidirectional gas flow pattern. Cessation o f breathing in birds may be rapidly followed by cardiac arrest. Therefore, immediate recognition and intervention is required. It is best to prevent cardiac arrest by maintaining normovolemia, adequate oxygenation and ventilation, appropriate anesthetic depth, minimal use of cardiodepressive drugs, and adequate monitoring. If cardiac arrest occurs, circulation may be assisted by manipulating the sternum as described for ventilatory assistance, which uses the thoracic-pump mechanism o f cardiopulmonary resuscitation. Direct cardiac massage is difficult in birds because of the structure of t h e thoracic cage. 1V or intracardiac epinephrine

Complications
Preoperative
Like all other species, birds should be stabilized before general anesthesia, whenever possible. Contraindicafions for general anesthesia include shock, respiratory distress, ascites, dehydration, anemia (PCV < 1 5 % to 17%), hypoproteinemia (total protein <2.5 to 3.0 g / d L ) , hypoglycemia (<200 m g / d L ) , metabolic acidosis, and: a fluid-filled crop. Unless corrected, these

20

Thomas G. Curro

may be used in an attempt to stimulate the return o f cardiac function. 1~ Unfortunately, cardiac resuscitation is frequently and frustratingly unsuccessful in birds and prevention is of critical importance.

19.

References
1. Mandelker L: Introduction to avian anesthesia. CompanionAnim Pract 2:31-32, 1988 2. Stunkard JA, Miller JC: An outline guide to general anesthesia in exotic species. Vet Med/Small Anim Clin 69:1181-1186, 1974 3. Harrison GJ: Pre-anesthetic fasting recommended. J Assoc Avian Vet 5:126, 1991 4. Thorstad CL: Anesthesia and monitoring of the avian surgical patient. Vet Pract Staff 5:1,8-11, 1993 5. Wheler C: Avian anesthetics, analgesics, and tranquilizers. Senfin Avian Exotic Pet Med 2:7-12, 1993 6. Bennett RA: Basic anesthesia and surgery in avian patients, in the Proceedings of the North American Veterinary Conference, Orlando, FL, January 16-21, 1993, pp 701-703 7. Hartsfield SM, McGrath CJ: Anesthetic techniques in poultry. Vet Clin North Am Food Anim Pract 2:711-730, 1986 8. McCluggage DM: Presurgical evaluation and intraoperative support techniques, in the Proceedings of the Association of Avian Veterinarians. Seattle, WA, Association of Avian Veterinarians, 1989, pp 441-444 9. Amand WB: Avian anesthesia. Curr Vet Ther 4:395-398, 1974 10. Hartsfield SM: A review of avian anesthesia. The Southwestern Vet 35:117-126, 1982 11. Heard DJ: Overview of avian anesthesia. Assoc Avian Vet Today 2:92-95, 1988 12. Taylor M: Avian anesthesia--A clinical update, in the Proceedings of the First International Conference in Zoological and Avian Medicine. Oahu, HI, Association of Avian Veterinarians and American Association of Zoo Veterinarians, 1987, pp 519-524 13. Valverde A, Honeyman VL, Dyson DH, et al: Determination of a sedative dose and infuence of midazolam on cardiopulmonary function in Canada geese. Am J Vet Res 51:1071-1074, 1990 14. McDonald SE: Common anesthetic dosages for use in psittacine birds.J Assoc Avian Vet 3:186-187, 1989 15. Smith J, Mason DE, Muir WW: The influence of midazolam on the minimum concentration of isoflurane in racing pigeons. Proceedings of the Veterinary Midwest Anesthesia Conference, Champaign-Urbana, IL, June 5, 1993, p 11 (abstr) 16. Muir WW, Hubbell J: Anesthetic procedures and techniques in birds, fish, reptiles, amphibians, rodents, and exotic cats, in Muir WW, HubbellJ (eds): Handbook of Veterinary Anesthesia. St. Louis, MO, Mosby, 1989, pp 234-244 17. Mandelker L: Avian anesthesia, part 2: Injectable agents. Companion Anim Pract 2 (10) :21-23, 1988 18. Bauck L: Analgesics in avian medicine, in 1990. Proceed-

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