20TH ANNIVERSARY
2 February 1999
CE Refereed Peer Review
FOCAL POINT
★Critically ill companion rabbits
must be handled gently in quiet
environments using diagnostic
and therapeutic techniques
designed to provide comfort
and reduce the stress of
hospitalization.
KEY FACTS
■ A few special pieces of
equipment can make urgent
care procedures more efficient.
■ Midazolam can reduce anxiety
during stressful procedures.
■ Cystocentesis is performed with
the rabbit in dorsal recumbency;
performing cystocentesis through
the lateral abdominal wall is not
recommended.
■ Pain management is an important
aspect of rabbit critical care;
buprenorphine and fentanyl
patches are effective.
■ Maintaining caloric and fiber
intake is an important aspect of
caring for critically ill rabbits.
Vol. 21, No.
Evaluating and
Stabilizing Critically
Ill Rabbits—Part II*
University of Wisconsin University of California, Davis
Jan C. Ramer, DVM Keith G. Benson, DVM
Joanne Paul-Murphy, DVM
ABSTRACT: Performing diagnostic procedures and stabilizing critically ill rabbits require
knowledge of their general temperament as well as proper restraint, diagnostic, and support-
ive care techniques. Part I of this two-part presentation reviewed recommendations for clinical
assessment, diagnostic differentials, and initial treatment plans. Many techniques used to
manage critically ill dogs and cats can be adapted to minimize stress in critically ill rabbits.
Part II provides general guidelines for handling hospitalized rabbits and describes such diag-
nostic and therapeutic techniques as venipuncture, radiography, fluid therapy, nutritional sup-
port, analgesia, and intubation.
H
ospitalized critically ill rabbits need to be housed in a quiet, low-stress
environment. For example, barking dogs or ferret scent can cause con-
siderable stress in critically ill rabbits, thereby making evaluation of
their response to treatment difficult. If a hospitalized rabbit has a companion
rabbit at home, it is sometimes comforting for the companion to accompany the
ill rabbit during the hospital stay.
Urgent care procedures can be accomplished more efficiently when practitio-
ners utilize specific supplies and equipment. For example, digital gram scales
make weighing accurate and quick, and a skid-resistant surface helps the rabbits
feel more secure on the scale. Small-diameter feeding tubes (3.5 and 5.0 Fr) used
for nasogastric intubation are also ideal for implementing nutritional support
measures or completing pneumogastrograms. Small endotracheal tubes with and
without cuffs (2.0- and 2.5-mm outside diameter) should be used for endotra-
cheal intubation. Body temperature can be taken quickly with an infrared tym-
panic temperature scanner. A stainless-steel nasal speculum or specially made
cheek dilators (Henry Schein) can facilitate dental examinations (Figure 1). Fi-
nally, low-flow infusion pumps should be used for accurate intravenous or in-
traosseous fluid therapy.
Mild sedation is recommended during some diagnostic procedures or if rabbits be-
come panicky. Intramuscular or intravenous midazolam (1 to 2 mg/kg) is an excel-
lent sedative in rabbits.1 It is fast acting and has shorter duration of action than di-
*Part I of this two-part presentation appeared in the January 1999 issue (Vol. 21, No. 1)
of Compendium.
Compendium February 1999 20TH ANNIVERSARY Small Animal/Exotics

azepam. In addition, injec- The heart rate of healthy

tion of midazolam is less rabbits can range from 130
painful than that of diazepam to 325 beats/min (see Nor-
because water rather than pro- mal Physiologic Parameters
pylene glycol is the carrier.2 for Healthy Rabbits). A Dop-
Rabbits in respiratory dis- pler blood flow monitor can
tress must be stabilized in a be used on the central auric-
quiet oxygen cage before any ular artery, radial artery, or
procedures can be performed. plantar artery when pulses
A low flow (1 L/min) of oxy- are faint. Systolic blood pres-
gen held close to the nose is sures are measured indirectly
recommended during any man- using a 1-inch cuff above
ipulations (including physical Figure 1—Buccal retractors provide the best visualization of the where the Doppler monitor
examination) of dyspneic rab- cheek teeth in sedated rabbits. was placed on the limb.
bits. This method is generally In conscious rabbits, the
better tolerated than using a pinna can be used during
mask. pulse oximetry to monitor
the percentage of available
DIAGNOSTIC hemoglobin saturated with
PROCEDURES oxygen; whereas in de-
Restraint and Physical pressed or sedated rabbits,
Examination the probe can be placed on
Unless a rabbit requires im- the tongue or buccal mu-
mediate stabilization, physical cosa. Thoracic auscultation
examinations should begin of harsh, dry respiratory
with visual evaluation of the sounds can be caused by re-
rabbit in its carrier. As dis- ferred upper airway noise,
cussed in Part I, general atti- even in normal rabbits.
tude, respiratory rate and Lack of auscultable sounds
character, and fecal and urine Figure 2—A panicked rabbit can be wrapped in a towel for safe- over the lung fields may be
output and consistency should ty during the physical examination. caused by an area of pul-
be assessed in this manner. monary consolidation.
A thorough physical exami- Aspects of the physical ex-
nation is best performed on a Normal Physiologic Parameters amination that may be poor-
skid-free surface. While the for Healthy Rabbits ly tolerated (e.g., the oral
rabbit is on the examination examination) should be
table, the practitioner should Body temperature 101˚F–104˚F done at the end of the ex-
maintain eye contact at all Heart rate 130–325 beats/min amination to keep the rab-
times, even if the rabbit is re- Respiratory rate 30–60 breaths/min bit calm as long as possible
cumbent, because a startled Systolic blood pressure 90–120 mm Hg or done while the rabbit is
rabbit can jump from the under mild sedation.
table in seconds. Panicky rab-
bits can be wrapped in a towel (Figure 2). Radiography
Before performing procedures that might cause Radiography is an important diagnostic tool for as-
stress, practitioners should obtain the respiratory rate, sessing critically ill rabbits. Sedation can reduce stress
heart rate, and body temperature. Many rabbits toler- and thereby quicken procedure time and improve radio-
ate an infrared tympanic temperature scanner better graphic quality. Highly detailed dental radiography us-
than a rectal thermometer. When placed deep in the ing small dental film in the mouth or for oblique skull
ear canal, tympanic scanners are quite accurate or positions requires general anesthesia. Abdominal survey
within 1˚F or 2˚F of rectal temperature readings. Be- radiographs can be obtained with an unanesthetized or
cause rabbits are very heat sensitive, hyperthermia mildly sedated rabbit resting on the film cassette in ven-
(temperatures of 106˚F or higher) is a common emer- tral recumbency. As discussed in Part I, consolidated
gency presentation. material in the stomach is treated medically unless the

RESPIRATORY STRESS ■ PHYSICAL EXAMINATION ■ PHYSIOLOGIC PARAMETERS

Small Animal/Exotics 20TH ANNIVERSARY Compendium February 1999

pylorus is obstructed. It is possible.4 The jugular or lat-

normal for hair, food, and eral saphenous vein is the best
fluid to be in the stomach; choice for obtaining blood
and plain films may not dis- samples of 1 ml or more. For
tinguish these from a consol- jugular venipuncture, the
idated mass of dry material. rabbit should be restrained at
Pneumogastrography should the end of the examination
be used with caution when table, with its head and legs
plain films or physical ex- extended for good access to
aminations are inadequate the jugular vein (Figure 3).
for diagnosis. To perform Because drawing blood from
pneumogastrography on females with a large dewlap
rabbits, a small pediatric can be difficult even if the
feeding tube (3.5 to 5 Fr) dewlap is pulled tightly over
can be passed into the ven- the jugular furrow, the dew-
tral meatus of the nares (ap- lap may require clipping,
plying lidocaine gel to the which should be done cau-
tip of the tube and mucous tiously because the skin is
membranes before inserting very thin in this region.
the tube can minimize irri- A safe guideline for ob-
tation). The length of tube taining the maximum blood
needed to span the distance volume is to remove 1% of
between the nares and stom- the body weight in grams.
ach should be measured and This benchmark is particu-
marked. The tube should be larly important in dwarf
Figure 3—Proper site for jugular venipuncture in a rabbit.
gently and rapidly advanced breeds. When the volume of
ventrally and medially (keep- blood to be obtained is
ing the head in a normal flexed position to help direct small, the use of lithium heparin collection tubes in-
the tube into the esophagus rather than the trachea)3 and stead of serum clot tubes can increase the volume of
20 to 40 ml of room air slowly injected into the stom- plasma retrieved.
ach. Proper placement of the tube should be confirmed
by radiographic evidence of air in the stomach. A consol- Cystocentesis
idated mass will be outlined by air contrast. If future gas- Cystocentesis should be performed with the rabbit in
tric fluid therapy or feeding is necessary, the tube should dorsal recumbency. We do not recommend attempting
be secured to the side of the rabbit’s nose using a suture cystocentesis through the lateral body wall because the
or tissue adhesive and the tube taped between the ears. cecum may be encountered. Restraint is critical; the rab-
bit’s body should be cradled with the handler’s forearms
Venipuncture while the legs are being restrained with the handler’s
Rabbits have several accessible veins for venipunc- hands. Although some rabbits relax or become mezmer-
ture, including the marginal ear, cephalic, lateral saphe- ized when the handler places a hand over their eyes, leg
nous, and jugular veins. Restraint is important. Some restraint is still necessary. The practitioner should then
companion rabbits tolerate restraint in a towel, whereas rub alcohol in front of the pubis to allow visualization of
others are more fractious and may require mild seda- the midline without the need for clipping. We recom-
tion. Midazolam is recommended to reduce anxiety mend using a 23-gauge, 1-inch needle on a 5-ml syringe.
when several diagnostic procedures must be performed
on a frightened rabbit. THERAPEUTIC PROCEDURES
The approach to lateral saphenous and cephalic veins Fluid Therapy
is the same as that used for dogs and cats. Applying al- We recommend intravenous drug administration and
cohol to the fur without clipping it moistens the area fluid therapy for hospitalized rabbits in critical condi-
sufficiently to visualize the vein. The marginal ear vein tion. The fur over the vein should be clipped and the
is useful for obtaining small quantities of blood. Large area aseptically prepped. If time permits, a local anes-
hematomas can, however, occur. In small breeds, ve- thetic consisting of 2.5% lidocaine and 2.5% prilocaine
nous thrombosis and skin sloughing on the ear also are (EMLA Cream—Astra USA, Westborough, MA) can be

PNEUMOGASTROGRAPHY ■ JUGULAR VENIPUNCTURE ■ MAXIMUM BLOOD VOLUME

Small Animal/Exotics 20TH ANNIVERSARY
generously rubbed over the
veniclysis site to decrease the
skin sensation 30 to 40 min-
utes and thereby assist in
catheter placement. A 24- or
27-gauge catheter can be
placed in most dwarf
breeds; whereas in large rab-
bits, a 22-gauge catheter
should be used.
To facilitate fluid therapy,
the largest-gauge catheter
possible in relation to the
rabbit’s size should be select-
ed. Cephalic or lateral saphe- Figure 4—Radiograph showing
nous veins are well suited for catheter in the tibia of a rabbit.
indwelling catheters. Lateral
auricular veins can tolerate small-gauge catheters, but
skin sloughing at the ear tip has been reported even with
short-term placement.4
If the ear is used, the pinna needs to be stabilized by
taping a roll of gauze along the inner surface and gently
taping the pinna around the roll. The ears can be taped
together for extra stabilization. Indwelling catheters
should be flushed frequently with saline. The use of
heparinized saline should be avoided in small breeds
because excessive heparin exposure can occur with
catheter flushing.5
Critically ill rabbits may be hypotensive or have veins
that are too small or fragile for placing an intravenous
catheter. Use of an intraosseous catheter is preferred for
these rabbits. The proximal femur and tibia are recom-
mended sites. The use of aseptic technique is essential,
although osteomyelitis is a rare sequela of intraosseous
catheterization. A 20-gauge, 1-inch spinal needle
should be inserted into the greater trochanter of the fe-
mur or into the tibial plateau and passed parallel to the
long axis of the femur or tibia, respectively.6 When the
stylet has been withdrawn, fluid should drip into the
medullary space if the needle was properly placed. The
accuracy of placement can be confirmed with radio-
graphs (Figure 4). The needle can then be secured with
a skin suture.
Although maintenance fluid requirements for criti-
cally ill rabbits are not well documented, 75 to 100
ml/kg/day should be well tolerated as a continuous in-
fusion. Crystalloids are most often indicated, but col-
loids should be considered if the rabbit is hypopro-
teinemic or when crystalloids fail to restore blood
pressure. Infusion pumps can help maintain an accu-
rate flow rate, which is especially important in small
breeds to avoid dangerous overhydration. Warm fluids
can help avoid hypothermia, which should be treated
CATHETERIZATION ■ HYPOVOLEMIA ■ PAIN CONTROL
Compendium February 1999
aggressively with one blood
volume (100 ml/kg) admin-
istered over a 20-minute pe-
riod. Whole blood transfu-
sions are recommended when
the packed cell volume is
12% or less. Blood typing
for rabbits has not been es-
tablished.
For stable rabbits, subcuta-
neous administration of ster-
ile isotonic fluids one or two
times daily at a rate of 50 to
100 ml/kg can be considered
placement of an intraosseous to provide the minimum dai-
ly fluid requirement. The
technique followed is the
same as that used in dogs and cats. Because many own-
ers are comfortable with this procedure after learning
the technique, it is a reasonable option for home care.
Oral fluids need to be provided at all times. Fresh
water should always be available. Additional fluid
choices that rabbits will accept include Gatorade® (The
Gatorade Co., Chicago, IL), any over-the-counter oral
pediatric electrolyte solution, and dilute apple or cran-
berry juice; however, these choices should always be of-
fered in addition to, not instead of, fresh water.
Analgesia
Pain management is an important aspect of rabbit
critical care. Signs of pain are subtle; as a prey species,
rabbits conceal handicaps to escape predation. Rabbits
experiencing pain may have a change in respiration, be
lethargic or anorectic, have constipation or diarrhea,
show mild bruxism, or adopt a hunched posture. Other
signs of pain may include sudden aggression, inability
to rest or sleep normally, or worried or anxious expres-
sions.7 Because of the subtlety of these signs, the severi-
ty of pain can be underevaluated and when it is recog-
nized, often underestimated. As documented in human
and domestic animal literature, effective pain manage-
ment can facilitate the healing process, which also is
true for rabbits.8
Table I lists common opioid and antiinflammatory
analgesics. In a limited number of cases, we have expe-
rienced good results when using one half of a fentanyl
patch to manage pain in a 3-kg rabbit during a 3-day
postoperative period.
Nutritional Support
Anorexia is a serious concern in rabbits when it extends
beyond 1 or 2 days. Because critically ill rabbits may be
dehydrated, electrolyte imbalances worsen the problem.
Small Animal/Exotics 20TH ANNIVERSARY Compendium February 1999

In addition, hepatic TABLE I withdrawal of nutri-

lipidosis can develop Analgesic Agents Used in Rabbits
tional support.
rapidly when a rabbit Fluid and electro-
stops eating; reversing Agent Dose (mg/kg) Route Interval lyte imbalances must
this metabolic process be evaluated and cor-
can be difficult. Nutri- NSAIDs rected before initiating
tional support needs to Acetaminophen16 200–500 PO Every 6 hr nutritional support,
be provided when a Aspirin17 100 PO Every 4–6 hr which must be started
rabbit has an acute loss Ibuprofen18 10–20 PO Every 4 hr gradually. Patients in
of 10% of its body Carprofen 2–4 PO, SC Every 12–24 hr good condition can
weight or a chronic loss Flunixin 1.1 SC, IM Every 12–24 hr
receive 75% to 100%
of 20%.9 of their daily energy
meglumine18
Most commercial 19
requirement during
veterinary enteral diets Ketoprofen 1.0 IM Every 12–24 hr the first 24 to 48
are produced for carni- hours. Debilitated pa-
vores and are unsuit- Opioids tients should receive
17
able for the herbivo- Buprenorphine 0.01–0.1 SC, IV Every 6–12 hr only 40% to 70% of
rous rabbit. Human Butorphanol1 0.1–0.5 IM Every 3–4 hr their daily energy re-
diets tend to be too Oxymorphone20 0.05–0.2 SC, IM Every 8–12 hr quirement during the
high in fat content and Meperidine20 5–10 SC, IM Every 2–3 hr first 24 hours, with
low in fiber (nondi- Pentazocine20 5–10 IM, IV Every 2–4 hr the amount gradually
gestible or insoluble Morphine20 2–5 SC, IM Every 2–4 hr increased during the
fiber) to meet the di- Naloxone18,20 0.01–0.1 IM, IV Reversal next 3 to 5 days. 9,10
etary requirement of Force or tube feedings
rabbits. Rabbits, which IM = intramuscular; IV = intravenous; NSAID = nonsteroidal antiinflamma- should be divided into
(like horses) are hind- tory drug; PO = oral; SC = subcutaneous. a minimum of four
gut-fermenting herbi- daily feedings, and
vores, require high-fiber, low-fat diets. Low-fat enteral food should be warmed. The caloric need for each pa-
products for horses are commercially available and may tient should be calculated using the following formula
be better suited for other herbivores. Because 12% or for baseline metabolizable energy (ME) according to
less crude fiber has been associated with diarrhea in rab- the body weight (BW):
bits, their dietary supplement should be high in fiber.10
ME (kcal/day) =
Fiber is essential for the hind-
70 × BW.75 (kg)
gut production of short- TABLE II
chain fatty acids and stimu- Examples of Liquid Enteral Diets
The range of estimated
lation of gastrointestinal Used for Rabbit Critical Care caloric requirement is 0.5 to
motility. Lack of insoluble 3 times ME, but illness
fiber is not resolved by Diet a Manufacturer must be taken into consid-
adding soluble fibers (e.g., NutriprimeTM Ken Vet, Ashland, OH eration and is best calculat-
psyllium). Although pellets JevityTM with fiberb Ross Laboratories, Columbus, OH ed as 1.25 to 2 times ME.
can be ground and added to Ensure® with fiberb Ross Laboratories, Columbus, OH When selecting a diet, pro-
a liquid enteral product for SusticalTM with fiberb Ross Laboratories, Columbus, OH tein should be 26% of the
syringe feeding, the mixture Criticare HNTM Mead Johnson Nutritionals, total calories and fiber
is too coarse for feeding via Evansville, IN 13.6% dry matter.10 Table II
small-diameter nasogastric VitalTM Ross Laboratories, Columbus, OH lists options for enteral sup-
tubes. Osmotic diarrhea is a a port for rabbits.
potential complication of Combine various components from blenderized rabbit pel- As discussed in Part I,
lets, powdered alfalfa, blenderized green leafy vegetables and
enteral support and may be fruits, or vegetable baby foods with a liquid diet from this anorexia is often accompa-
the result of elevated fat and table to lower the kcal/ml while substantially increasing the nied by a slow gastrointesti-
carbohydrates in the diets fiber content. nal transit time and inappro-
b
commonly used for nutri- These formulations should be used with caution because they priate motility of the cecum
tional support; however, this are high-fat, low-fiber, highly digestible diets that can cause or stomach. Therefore, we
diarrhea and/or loose stools.
complication rarely merits recommend using motility-

LIQUID DIETS ■ ANOREXIA ■ FLUID AND ELECTROLYTE IMBALANCE

Compendium February 1999 20TH ANNIVERSARY Small Animal/Exotics

modifying agents (e.g., meto- Before the tube is inserted,

clopramide or cisapride) the distance from the mouth
when administering enteral to the last rib should be pre-
support. Regardless of the measured and marked on the
primary cause of anorexia, tube. The tip of the catheter
nutritional support is often should be lubricated and
necessary when rabbits are in then, with the neck flexed,
critical condition. passed through the hole in
the dowel, into the orophar-
Minimum Support ynx, and into the stomach.
Rabbits respond best when Proper placement can be con-
in a familiar environment. firmed by instilling a small
Hospitalization can be stress- amount of saline into the
ful, and home care should Figure 5—Insertion of an orogastric tube in a rabbit. catheter. However, if the rab-
be considered when feasible. bit begins to cough severely,
Minimum support may be optimal for mild to moder- the tube has most likely penetrated the trachea. Such
ately ill patients that are hospitalized or being cared for penetration can be verified by auscultating the stomach
in the home. Rabbits receiving minimum support and listening for bubbling noise while 3 to 5 ml of air is
should be fed their customary diets (i.e., same brand, being injected into the tube or by pulling the tube back
bowl, and amount). Fresh greens and timothy hay into the esophagus and thereby causing suction and re-
should be part of a rabbit’s diet and can stimulate the sultant negative pressure as the esophagus collapses
appetite of anorectic rabbits. around the tube opening. Verification of correct tube
If force feeding in the hospital or at home is required, placement is essential before food is introduced.
syringe feeding of a blenderized diet, baby food vegeta-
bles, or commercial liquid diets should be initiated. Sy- Nasogastric Tube Feeding
ringe feeding is the best way to maintain fiber in the Nasogastric tube feeding is warranted if pneumogas-
diet if a rabbit is not eating on its own. The syringe tip trograms of gastric contents are needed for radiographic
can be easily placed into evaluation, gastric bloat occurs, or multiple enteral
In-House Recipe for the diastema and the liquid feedings are required. In such situations, having access
Syringe Feeding or slurry diet introduced to a tube that can be manipulated behind the animal’s
slowly to avoid aspiration. visual field is advantageous. The primary disadvantage
®
8-oz can Ensure with fiber Table II and In-House of using nasogastric tubes for enteral feeding is their
Recipe for Syringe Feeding small diameters, which make administering fibrous ma-
(Ross Laboratories) offer syringe- and tube- terial difficult. This problem can be resolved somewhat
1 cup fruit yogurt feeding formulas. by using an open-ended tube and cutting additional
6 Tbsp alfalfa meal holes along the tube’s length, which minimizes the
Orogastric Tube Feeding chance of clogging the tip.
Mix ingredients in a blender. Orogastric tube feeding is The technique for placing nasogastric tubes is the
Total kcal = 1.4 kcal/ml with suitable only for single-epi- same as that for orogastric tubes. The accuracy of tube
13.6% fiber and 36% sode dosing during stabi- placement can be verified by lateral radiographs, fluor-
lization because if used re- oscopy of the thorax and cranial abdomen, or injection
protein. A critically ill rabbit
peatedly, it can result in of 10 ml of air while auscultating for gastric bubbles.
weighing 5 lb would need stress and considerable risk. The tube can then be secured with a drop of superglue
approximately 1 oz of this Proper restraint is necessary on the furred skin above the nose and butterfly tape
slurry every 3 hours.10 to prevent the rabbit from glued or sutured at the top of the head between the
injuring itself in attempts to ears. To avoid leakage of gastric contents, a catheter
escape the procedure; wrap- adapter can be placed over the open end. When using
ping a towel tightly around the rabbit’s body and tucking nasogastric tubes for alimentation, placement and pa-
it under the rump can be helpful during restraint. A tency can be checked before each use by injecting a
wooden or plastic dowel with a hole drilled through the small amount of saline as described in the section on
center should be placed across the diastemas. We recom- Orogastric Tube Feeding. Tube obstruction can be
mend using a round-tipped 18- to 22-Fr rubber catheter avoided by flushing the tube with water before and af-
(Figure 5) to prevent entry into the trachea. ter administering medication or nutritional support.

SUPPORT MEASURES ■ ENTERAL FEEDING ■ TUBE OBSTRUCTION

Small Animal/Exotics 20TH ANNIVERSARY Compendium February 1999

Nasogastric tubes are generally tolerated by rabbits.
Elizabethan collars can be stressful for rabbits and
should be used only if well tolerated. For rabbits that
do not accept a nasogastric tube or Elizabethan collar,
other options such as feeding via percutaneous tube or
force feeding with a syringe should be considered.
Percutaneous Gastrostomy Tube Feeding
Feeding by percutaneous gastrostomy tube may be
necessary for some rabbits. Percutaneous placement of
gastrostomy tubes adapted to use in rabbits follows a
technique similar to that used for other companion ani-
mals.11 Because rabbits have a small oral cavity, however,
a bronchoscope rather than a small endoscope is neces-
sary. Caution must be exercised when passing the bron-
nary catheter (flared end cut off after placement) can be
advanced into the trachea as a guide. The laryngoscope
blade should then be removed and the ET advanced over
the guide and into the trachea.14
Several other methods of endotracheal intubation de-
scribed in the literature involve insertion of a rigid
bronchoscope through the ET for better visualization
of the vocal folds15 and use of a special stethoscope fit-
ted with an ET for better auscultation of breathing
sounds at intubation.16 Positive-pressure ventilation and
chest excursions should never be used to test placement
of the ET because air entering the stomach often mim-
ics true chest excursion.
ENDIU
Cardiopulmonary MP

M’
20th

CO

S

choscope over the base of the tongue (between the rab- Resuscitation 1 9 7
9 - 1
9 9 9

bit’s sharp molar teeth). In addition, rabbits must be at a Cardiopulmonary arrest is ANNIVERSARY
surgical plane of anesthesia before tube insertion. Appli- the sudden cessation of
cation of lidocaine gel on the tip of the bronchoscope
and the feeding tube facilitates insertion. The presence
spontaneous, effective venti-
lation and circulation. Re- A LookBack
of hair and digesta in the stomach should be anticipat- spiratory arrest generally oc-
Twenty years ago, domesticated
ed, even if a rabbit has been anorectic for several days. curs first, followed by cardiac
arrest several minutes later if rabbits were not as popular
Pharyngostomy Tube Feeding the respiratory arrest is not companion animals as were
Pharyngostomy tube feeding is apparently well toler- resolved. The goal of car- dogs and cats, and
ated by rabbits, although abscesses can develop along diopulmonary resuscitation veterinarians therefore did not
the subcutaneous tract of the catheter. Placement and (CPR) of rabbits is similar to have to address the issues raised
maintenance of pharyngostomy tubes have been de- that for other mammals— today. Because of our growing
scribed in the literature.12 We recommend practicing provide ventilation and cir-
awareness, however, today we
pharyngostomy tube placement on cadavers before at- culatory support until spon-
tempting the procedure on critically ill rabbits. taneous functions have been can utilize increased knowledge
restored. The chief difference of the gastrointestinal (GI)
Intubation between CPR for rabbits and system in general and therefore
The use of an uncuffed 1.0- to 2.5-mm endotracheal that for other companion an- of the nutritional needs of
tube (ET) is recommended for intubation of rabbits imals involves the rabbit’s rabbits. For example, we now
weighing 3 kg or less.13 Blind intubation of small rabbits small size and rapid metabol- know that high fiber is
can be either oral or nasal but should only be attempted ic rate and the difficulty of
necessary for proper GI motility
if the rabbit is breathing and not in respiratory arrest. establishing a patent airway.
Anesthesia can be induced by slow injection of intra- Because their rapid heart and and realize that the presence of
venous propofol (2 to 4 mg/kg) or mask inhalation of respiratory rates correlate trichobezoars is not a signal for
isoflurane. The rabbit should be placed in sternal recum- with more circulations per surgery but is a result of
bency with its head extended so the trachea is perpendic- minute, rabbits succumb to decreased GI motility. In fact,
ular to the table surface. To avoid laryngospasm, 1 ml of cardiopulmonary arrest more these rabbits generally do very
lidocaine should be applied topically to the larynx. quickly than do larger mam- well with medical manage-
While advancing the ET to the proximal larynx, practi- mals. The difficulty of estab-
ment, an option not recognized
tioners should listen at the end of the adapter for inspira- lishing a patent airway is
tion sounds. When the sound is at the loudest, the tube compounded by the in- 20 years ago.
can be slowly advanced into the trachea. In large rabbits creased urgency of time. If
(weighing 3 kg or more), the glottis can usually be visu- endotracheal intubation has
alized through a laryngoscope with a No. 1 Miller blade; not been accomplished with-
however, the oral cavity is often too small to maintain vi- in 60 seconds, the airway
sualization when the ET has been inserted into the should be assessed via tra-
oropharynx. A 5- or 8-Fr, 56-cm long polypropylene uri- cheostomy. Endotracheal in-

ENDOTRACHEAL PROCEDURES ■ RESUSCITATION ■ TRACHEOSTOMY

Compendium February 1999 20TH ANNIVERSARY
tubation can be extremely difficult when a rabbit is not
breathing.
Although a tracheostomy tube can be placed with the
rabbit under local anesthesia, often rabbits in cardiopul-
monary arrest have lost consciousness and anesthesia is
unnecessary. Alcohol can be poured over the ventral
neck region to part the hair and aid in visualization of
the trachea. An incision should then be made over the
trachea immediately caudal to the larynx, the trachea
pulled toward the incision, and retracting sutures placed
in the third and fourth rings. Next, an incision should
be made between the cartilaginous rings and the retract-
ing sutures gently pulled apart. We advise taking ex-
treme caution and exerting minimal force while guiding
the sterile 2.0-mm tracheostomy tube into the distal tra-
chea. After tube placement, oxygen should be provided
and positive-pressure ventilation initiated.
SUMMARY
Because they can become stressed so quickly, critical-
ly ill rabbits can be challenging patients. The basic
principles guiding emergency and critical care for rab-
bits are the same as those used for other mammals;
however, the presenting signs and diagnostic approach-
es differ considerably. Practitioners need to assess a crit-
ically ill rabbit while it remains in its cage We recom-
mend evaluating the general attitude, respiratory rate
and character, and fecal and urine consistency before
removing a companion rabbit from its cage. In addi-
tion, once rabbits has been removed from a familiar en-
vironment, such as their cage, they can hide clinical
signs that would be more apparent in other companion
animals. Thus, practitioners must look for subtle indi-
cations of pain or discomfort.
When hospitalization is necessary, rabbits must be
housed in a quiet, low-stress environment separate from
the sounds and scents of other animals. Because rabbits
can become panicky or agitated, practitioners should
make special efforts to provide a calming atmosphere.
References
1. Carpenter JW, Mashima TY, Rupiper DJ: Exotic Animal
Formulary. Manhattan, KS, Greystone Publications, 1996.
2. Plumb DC: Veterinary Drug Handbook. Ames, IA, Iowa State
University Press, 1995.
3. Bennet RA: Nasogastric intubation for enteral alimentation.
Proc Fifth Intl Vet Emerg Crit Care Symp:723, 1996.
4. Mader DR: Basic approach to veterinary care, in Hillyer EV,
Quesenberry KE (eds): Ferrets, Rabbits and Rodents: Clinical
Medicine and Surgery. Philadelphia, WB Saunders Co, 1997,
pp 160–168.
5. Stevens LC, Haire WD, Tarantolo S, et al: Normal saline
verses heparin flush for maintaining central venous catheter
patency during apheresis collection of peripheral blood stem
cells. Transfusion Sci 18(2):187–193, 1997.
Small Animal/Exotics
6. Anderson NL: Intraosseous fluid therapy in small exotic ani-
mals, in Kirk’s Current Veterinary Therapy. XII. Philadelphia,
WB Saunders Co, 1995, pp 1331–1335.
7. Eisele PH: Signs of pain in small mammals. Proc TNAVC:795–
796, 1997.
8. Eisele PH: Analgesia in small mammals. Proc TNAVC:796–
799, 1997.
9. Donoghue S, Langenberg J: Clinical nutrition of exotic pets.
Aust Vet J 71(10):337–341, 1994.
10. Donoghue S: Nutrition and pet rabbits, in Rosenthal KL (ed):
Practical Exotic Animal Medicine (The Compendium Collec-
tion). Trenton, NJ, Veterinary Learning Systems, 1997, p
107.
11. Smith DA, Olson PO, Mathews KA: Nutritional support for
rabbits using a percutaneously placed gastrostomy tube: A
preliminary study. JAAHA 33(1):48–54, 1997.
12. Rogers G, Taylor C, Austin JC, et al: A pharyngostomy
technique for chronic oral dosing of rabbits. Lab Anim Sci
38(5):619–620, 1988.
13. Paul-Murphy J: Little critters: Emergency medicine for small
rodents. Proc Fifth Intl Vet Emerg Crit Care Symp:714–718,
1996.
14. Eisele PH: Anesthesia for the rabbit. Proc TNAVC:792–794,
1997.
15. Conlon KC, Corbally MT, Bading JR, Brennan MF: Atrau-
matic endotracheal intubation in small rabbits. Lab Anim
Sci 40(2):221–222, 1990.
16. Patil VU, Fairbrother C, Dunham BM: Endotracheal intu-
bation in the rabbit: A quick, reliable method. Lab Anim Feb:
28–29, 1997.
17. Wixson SK: Anesthesia and analgesia, in Manning PJ, Ring-
ler DH, Newcomer CE (eds): The Biology of the Laboratory
Rabbit, ed 2. New York, Academic Press, 1994.
18. Flecknell PA: Post-operative analgesia in rabbits and rodents.
Lab Anim 20(2):34–37, 1991.
19. Smith DA, Burgmann PM: Formulary, in Hillyer EV, Que-
senberry KE (eds): Ferrets, Rabbits and Rodents: Clinical
Medicine and Surgery. Philadelphia, WB Saunders Co, 1997,
pp 392–403.
20. Perrin A, Milano G, Thyss A, et al: Biochemical and phar-
macological consequences of the interaction between metho-
trexate and ketoprofen in the rabbit. Brit J Cancer 62:736–
741, 1990.
21. Mason DE: Anesthesia, analgesia, and sedation for small
mammals, in Hillyer EV, Quesenberry KE (eds): Ferrets, Rab-
bits and Rodents: Clinical Medicine and Surgery. Philadelphia,
WB Saunders Co, 1997, pp 378–391.
About the Authors
When this article was accepted for publication, Dr. Ramer
was affiliated with the Department of Surgical Sciences,
School of Veterinary Medicine, University of Wisconsin,
Madison, Wisconsin; she is presently affiliated with the In-
dianapolis Zoo, Indianapolis, Indiana. Dr. Paul-Murphy is
affiliated with the Department of Surgical Sciences,
School of Veterinary Medicine, University of Wisconsin,
Madison, Wisconsin, and is a Diplomate of the American
College of Zoological Medicine. Dr. Benson is a resident
in Zoological Medicine at the School of Veterinary Medi-
cine, University of California, Davis, California.