Exotic ICU: Nursing Care For the Avian Patient

Introduction

It is 10 p.m. in your veterinary emergency hospital and a dreaded call comes in. A panicked owner is in tears because their beloved pet is in crisis. In most cases, your team will quickly gather supplies and move swiftly to prepare for the emergent patient. This patient may strike fear in many veterinary professionals, however, because it is the dreaded avian patient presenting to a general veterinary practice (Fig 1). If the scenario above sounds too familiar, you are not alone.

Fluffed lovebird

Figure 1. A presenting bird patient can strike fear into the most competent emergency clinicians. Photo credit: Jill Murray, RVT. Click image to enlarge.

Whenever possible, a sick bird should be presented directly to an avian specialist, however reality and geography may necessitate overnight or short term care in general practice. Despite the fact that birds are one of the most popular pets in the United States (APPA 2013), many veterinary hospitals do not believe they are equipped to handle these emergencies. Fortunately, with a few tools and supplies any practice can be prepared to stabilize most avian emergencies.

There are a host of tips and tricks that can make the delicate avian patient more comfortable in an intensive care setting. Although appropriate analgesia and fluid therapy are essential for all critical care patients, this article will focus on the basic nursing care techniques that can be vital for a positive clinical response.

Begin with a basic supply list and well-trained support staff. The importance of confident and competent handlers can greatly affect your success. It is important to complete staff training before handling any avian emergencies. An emergency visit is never the appropriate time to teach restraint techniques.

Visit LafeberVet’s video series on handling parrots and passerines for detailed instructions as well as the article on handling wild birds.

 

Caging the critical bird

Intensive care caging

Once a plan is made to admit the patient, some thought should go into the cage set-up. I find that the Snyder® intensive care units (Centennial, CO) provide some noise reduction and can be used to house nervous birds that need constant monitoring (Fig 2, Fig 3). These cages can be set to room air (23% oxygen) and provide excellent climate control. Snyder cages are also large enough to place small birdcages or even large birds without cages. The one caveat is that these cages are often placed in brightly lit, busy ICUs with barking dogs and frequent traffic. Most intensive care units (ICUs) are noisy and bright. Consider placing the patient in a quiet ward with dim lighting if it is stable. Smaller birds also seem to find comfort in their cages and they appear to feel vulnerable in large, open spaces. Therefore, confining small birds to close quarters can reduce stress while preventing excessive flying or panicking.

Synder O2 cage

Figure 2. ICU cages, such as this Synyder cage shown here, provide some noise reduction and can be used to hospitalize nervous birds that require constant monitoring. Photo credit: Valerie Garuccio, LVT. Click image to enlarge.

Sun conure in ICU cage

Figure 3. In addition to allowing close monitoring and providing heat, ICU cages are also indicated for patients that require supplemental oxygen. Photo credit: Dr. Ariana Finklestein. Click image to enlarge.

If your practice is not equipped with an oxygen cage, a makeshift ICU cage can be created by running oxygen into an induction chamber (Smiths Medical; Dublin, OH) or “knock-down box”. Although not ideal, the box can be kept cracked and humidified oxygen can be piped in to provide supplemental oxygen. This substitute ICU cage can become overheated, so use a digital thermometer to measure ambient temperature. Monitor the patient closely for signs of overheating such as open-mouth breathing, wings spread apart, and/or the feathers slick or tight against the body. When administering un-humidified oxygen, such as that through an anesthetic machine, be sure to provide a method of humidification such as nebulization every 4 hours (Fig 4-Fig 7).

A makeshift ICU cage can by created by running oxygen into an induction chamber.

Figure 4. A makeshift ICU cage can by created by running oxygen into an induction chamber. Photo credit: Valerie Garuccio. Click image to enlarge.

Shown here, un-humidified oxygen is piped into the makeshift ICU cage via an anesthetic machine.

Figure 5. Un-humidified oxygen is piped into the makeshift ICU cage via an anesthetic machine. Photo credit: Valerie Garuccio Click image to enlarge.

Pipe humidified oxygen into the makeshift ICU cage to provide supplemental oxygen.

Figure 6. Pipe humidified oxygen into the makeshift ICU cage to provide supplemental oxygen. Photo credit: Valerie Garuccio. Click image to enlarge.

Close-up on an adapter used to connect tubing to an induction chamber.

Figure 7. Close-up on an adapter used to connect tubing to an induction chamber. Photo credit: Valerie Garuccio Click image to enlarge.

Supplemental heat

During critical illness, maintenance of high core body temperatures can be challenging in these tiny patients with such rapid metabolic rates. Supplemental heat has been shown to improve recovery and comfort in the hospitalized bird. For most avian patients, target incubator temperatures range from 26-32°C (80-90°F). Carefully observe the patient for signs of overheating.

The perching conundrum

Another mainstay of housing sick birds is to provide low or no perches. Minimizing perch surfaces can allow the bird to conserve energy (Galston 2012), and reduces the risk of falls and injury. I find reptile bedding, such as artificial turf, useful in these cage set-ups. This substrate is often sold in pet stores, is fairly inexpensive, and easily disinfected. Artificial turf can also be cut to size and does a nice job of providing traction without catching claws. In a pinch, surgical towels can also be used as the tight weaving will not catch on bird claws.

For birds that can be allowed to perch, an acrylic bird perch (VSP Avian Perch, Veterinary Specialty Products) that can be wrapped with bandage material is a useful investment (Fig 8). Alternatively, makeshift PVC perches of appropriate size can be placed directly on the cage floor (Fig 9).

A T-stand covered with vet wrap.

Figure 8. A T-stand covered with vet wrap to improve traction. Photo credit: Valerie Garuccio. Click image to enlarge.

PVC perch

Figure 9. PVC perch wrapped in elastic bandage material. Photo credit: Jon Perry, FeatherMe.com. Click image to enlarge.

Visual security

Most debilitated birds benefit from some form of visual security or hiding place. This can involve a towel draped over part of the incubator or even newspaper taped over part of the ICU cage door. It can be extremely challenging to balance the patient’s need for privacy and security, with the veterinary professional’s need to monitor patient status and progress. The approach to each patient must be individualized to meet that specific bird’s needs.

Medicating the critical bird

As with all exotic animal treatments, gather all supplies beforehand and restrain the patient for the minimal amount of time necessary. Medications can be made more palatable by using fruit-flavored, compounded suspensions. Injectable medications can also be given by mouth in some instances although these drugs may be bitter tasting.

Visit LafeberVet’s Oral Drug Administration in Birds, Subcutaneous Fluids in Birds, and Intramuscular Injection in Birds for additional information.

 

Feeding the critical bird

Feeding and medicating debilitated birds requires specific skills, and assisted feeding is NOT recommended unless staff members have been properly trained. Of course, even 12 hours of starvation can be detrimental to health as glycogen stores can quickly become depleted in small birds (Welsh 2009). Therefore in addition to handling and restraint, tube feeding is another technical skill that must be practiced and honed BEFORE the critically ill bird presents.

Curved gavage tubes are used to medicate and feed avian patients quickly. Although it seems stressful, the time saved restraining a bird for this technique allows more rapid care. Another time saving and stress reduction tip is to load any oral liquid medications that can be given with food into the gavage tube or the top of the syringe.

NOTE: Tube feeding should always be the last treatment provided to minimize the risk of regurgitation and subsequent aspiration. Stronger, more stable birds may tolerate syringe feedings but that may only work with birds that have been hand-reared and/or accustomed to this method and should only be attempted in birds that display head bobbing.

Is the patient capable of self-feeding? Many birds can be offered a buffet of familiar foods like seeds, pellets, fruits, and vegetables. All produce offered should be chopped to an appropriate size for easy patient handling. Are seeds a part of the “regular” diet? Dietary changes should not be instituted during a period of illness and it is best to offer a diet that closely resembles what the bird normally eats. Consider having the owner bring in a sampling of their pet’s normal diet. Hulled, organic, salt-free sunflower seeds are frequently available at local health food stores and often well accepted by the weak, anorectic, psittacine bird. Lafeber Company products such as Nutri-Berries and Avi-Cakes are frequently accepted as well.

Utilizing bandage material

Bandage material can be suited for many purposes and it is helpful to keep a supply of pre-cut “baby” bandage material on hand measuring less than 1.25 cm (0.5 in) in width for these special patients (Fig 10). Primarily used for bandaging limbs, wounds and catheters, bandage material can also be used to protect intravenous catheter tubing and hubs from the strong, curious beaks of psittacine birds. Lines and tubing can also be protected by syringe cases.

Maintain a supply of pre-cut bandage material for tiny patients.

Figure 10. Maintain a supply of pre-cut bandage material for tiny patients. Photo credit: Valerie Garuccio. Click image to enlarge.

After a bandage like a wing wrap is placed, it can be challenging to prevent the bird from picking at the wrap. “Distraction tabs”, or little tabs of tape placed on the bandage, can be used to divert the bird’s attention from the actual bandage (Fig 11). The use of distraction tabs may increase the length of time between bandage changes and will reduce the need for a stressful restraint collar.

Distraction tabs

Figure 11. Use distraction tabs (arrow) to divert the parrot’s attention from the true bandage. Click image to enlarge.

 

Monitoring the critical bird

One of the most difficult adaptations in critical nursing with the avian patient is the difficulty of assessing vital signs. Vital signs monitored in most veterinary patients include body temperature, pulse, respiratory rate, pulse quality, and mucous membranes color. Unfortunately, the frequent monitoring performed in mammalian patients would stress an avian patient. Instead careful observation of respiration, droppings, and behavior are primarily used to monitor the bird. Efficient physical examinations, including evaluation of patient pulse quality check and hydration status, are performed at the same time as treatments to minimize handling time (Fig 12). Body temperature is rarely measured due to the stress involved as well as the relatively high core body temperatures of birds measuring 41.1°C (106°F) or more (Greenacre 2004).

 Auscultation and assessment of other vital signs

Figure 12. Auscultation and assessment of other vital signs is general reserved for regular physical examinations in the avian patient. Photo credit: Dr. Isabelle Langlois. Click image to enlarge.

 

Transferring care

Since most of these patients will need further care with an avian specialist, it is imperative to communicate with the receiving veterinarian prior to transport. Discussing the case will allow the specialty veterinarian to receive the patient as smoothly as possible. If the patient is too unstable for transport, they can also offer advice to assist the general veterinarian until the patient is stable enough for transfer. Formulating relationships with your local referring veterinarian can make receiving these special patients on emergency a less stressful and more rewarding experience.

References