There are often occasions where, under vet instruction, the veterinary nurse may have to triage the patient initially. For example, if the nurse is waiting for a veterinary surgeon to arrive at the practice or the veterinary surgeon is scrubbed for a procedure. What is found in this initial triage can be vital in providing the best care for the patient as soon as possible. A well constructed triage sheet can help provide the veterinary surgeon and veterinary nurse with much needed information on the condition of the patient.
Initial assessment
A hands off exam of the patient in its carrier should be performed first. From this the veterinary nurse can assess if the patient is collapsed or dyspnoeic, which would require immediate critical care treatment. If this is not the case, a discussion with the owner would always be the next step. Basic questions should be asked, such as age, vaccination status, pre-existing health conditions, neutering status and current medications. The issue at hand is then discussed and duration of inappetence, faecal output and behaviour changes should be asked about. After this, a physical exam should be performed including chest and abdominal auscultations. In the chest, listen for rate, quality, respiratory noise, murmurs and arrhythmias. In the abdomen, the assessor would be listening for the presence of gut sounds. The author would then do a basic check of the patient from nose to tail checking:
- Eyes – brightness, presence of discharge, presence of orbital tightening
- Nose – breathing patterns and effort, presence of discharge, nostril position
- Mouth – check mucous membranes, capillary refill time, presence of cheek flattening, incisor length and shape
- Ears – feel for temperature. If the ears feel particularly hot or cold, the author would take a rectal temperature. Check for swelling around the ear base and discharge from the ears
- Body condition – body condition score, muscle condition, fur/coat condition
- Perineal area – check for presence of faeces and quality of faeces if there is some present, cleanliness of area and whether it has been soiled by urine or faeces
- Demeanour – look at the general demeanour of the rabbit. Is it responsive? Is it tooth grinding? Is it tummy pressing? Is it interacting with its companion rabbit(s) or owner?
Further assessment and imaging
After this has been performed and noted on the patient's triage form (Figure 1), the author would take blood glucose from the rabbit. Normal blood glucose ranges for a rabbit are quoted as being between 4.2 and 8.2 mmol/l (Harcourt Brown, 2022). If the blood glucose does not exceed this, the author would report back to the owner and wait for a vet to become available to discuss potential treatment options and report all the findings of the triage to the case veterinary surgeon. If the blood glucose exceeds these parameters (Steinagel and Oglesbee, 2023), the author would discuss with the owner about performing x-rays prior to the veterinary surgeon's consultation. This can quite easily be performed consciously if you are able to position the patient laterally in a quiet, darkened room. Placing a towel or blanket over the rabbit's head and very slowly and gently lifting your hands away enables the patient to be positioned in lateral recumbency for the purpose of radiography. It is often useful to have someone outside the radiation zone who can prepare the button so that, once you are clear of the area, the image can be taken immediately. Communication is key with this to ensure safety of the team members, but is almost always a successful method of performing an initial x-ray of diagnostic quality. Sedation at this point should be avoided as the electrolyte imbalances caused by gastrointestinal stasis can make patients have a higher anaesthetic risk (Varga and Hinde, 2019). While blood glucose is a tool that is very useful, it should not be relied on to diagnose foreign bodies or need for surgery. Critically-ill rabbits will often have hyperglycemia (Mancinelli, 2016) but it is important to keep monitoring this as this can often be elevated due to pain and stress. Often, after a few hours of analgesia and fluid therapy, this will improve and resolve. Those that do not resolve, and if diagnostic imaging indicates, may become surgical. However, this is not something that should be entered into lightly as the prognosis for these patients is always guarded. The information gathered in a nurse triage equips the veterinary surgeon with a good idea of the severity of the case and sets a baseline for the patient's treatment. If the patient is admitted, the author's practice begins the Rabbit Stasis Care bundle. This is a traffic light system with red being the most serious stage of the illness, going to green where you can see symptoms beginning to resolve (Figure 2).
The first stage (red) (Figure 2) focuses on stabilising the patient, providing analgesia, rehydrating the patient and regaining normothermia. The author's practice finds it to be counter intuitive to provide all medications at once as sometimes they are not needed and it can limit where you can escalate to as it is difficult to know what has been effective. It is important to consider that taking regular rectal temperatures is contraindicated in rabbits as it can damage their rectums (Varga, 2013). Doing a baseline temperature can be useful and then checking the temperature of their ears by hand can be a good way of assessing that they are normothermic. In the author's opinion, the two most important goals with stasis patients is to rehydrate them and to provide analgesia. Rehydrating the patient encourages gut motility and, in some cases, will even allow a small gastrointestinal blockage to pass. It is the author's preference to do this by giving hourly boluses of fluids. Unless a rabbit patient is completely immobile, using drip lines and maintaining patency of the cannula is next to impossible. Also, encouraging these patients to move around will both encourage gut motility and help the patient maintain their body temperature. This is not possible when a drip line is connected to the catheter. Patient interference is high in rabbits, whether that is by chewing, head shaking or just pulling the line. Boluses allow the patient to ambulate normally without the restriction of a line and make the cannula less likely to be interfered with by the patient. As a lot of these patients will be hypothermic, it is important to prewarm the fluids given intravenously. In the author's practice a human baby bottle warmer is used to warm up the fluids prior to administration. In terms of analgesia, creating a multimodal analgesia plan gives the patient the best chance of eating by themselves without assisted feeding. Maropitant is anecdotally thought to have good visceral analgesic action in rabbits. Use of buprenorphine or any opioids can be controversial in rabbits with gastrointestinal stasis as they are known to impact gut motility (Di Girolamo and Scarabelli, 2020). However, it is the author's preference to always provide stronger pain relief. Often this does not need to be continued and only used in the short term and the pros of using outweigh the cons. At this point, the clinic would be reluctant to use pro-kinetic drugs or provide assisted feeding until blockage has been completely ruled out.
The second stage (amber) (Figure 2) looks at whether the initial treatment has been effective and whether further medications need to be added. If the patient is beginning to stabilise, this would be when to look at doing further diagnostics and looking into the cause of the ileus. The author's practice refers to the Newcastle University Rabbit Grimace Scale (Keating et al, 2012) as indicators of pain as well as other signs such as tummy pressing, shifting weight and tooth grinding. At this point you can begin to play detective and really observe how the rabbit is behaving. If the rabbit has started eating, is it favouring one side when it eats or dropping crumbs? If it has been admitted with its companion(s), how are they interacting with each other? Are they grooming and sitting together or are they ignoring each other or chasing each other? You would be surprised how many rabbit bonds are not as good as owners perceive them to be. If the rabbit is starting to move around more, what is its gait like? Does it look stiff or have a strange gait? Has a stressful event occurred recently such as building work, fireworks or a house move? The author used to have a rabbit who came in once a month with stasis after the gardener had been mowing the lawn. The noise and stress of this used to send the rabbit into stasis. All of this information acquired can help inform the veterinary surgeon of where to go next with the patient. All of these things require time observing the rabbit rather than touching the rabbit. They will try their best to hide symptoms so you have to look very closely and carefully.
Stage three (Figure 1) is the green stage and looks at transitioning the animal to oral medications and thinking towards discharge. Fluids are lowered to maintenance fluids and supplemental feeding can be considered at this point, although the author would always try to encourage the patient to eat unassisted first. Often if you place food in front of the rabbit's mouth long enough, they will get irritated and try to bite it or move it away. When they do this they often taste the food and realise that it is actually quite nice or begin to ‘angry eat’. Either way, it gets them eating on their own, which is always the goal. It is also the author's personal preference to do feeds less frequently – a larger amount, over fewer feeds. Care should always be taken when feeding and allow the patient to take breaks between mouthfuls to prevent aspiration (Oxbow, 2020). However, the author personally prefer larger feeds less frequently for a couple of reasons. Firstly, as it allows them to have a gap in between feeds making them more likely to want to eat when offered fresh food. Secondly, because it can also be quite a stressful process, particularly for a rabbit that is not used to handling, and may be counterintuitive, as stress could be a major factor to their stasis. You will also notice on stage three, that there is an estimate section for the cost of treatment. In the author's experience it can be useful to explain to the client the treatment plan and give them an upfront idea of the cost if we do all three stages. We make it clear that this is flexible and liable to change depending on the response to the treatment, but we find it useful to give the client the worst case scenario cost and treatment wise. Rabbit owners are amongst the most informed and devoted clients we see. However, this can mean that they require a lot of information, guidance and support through this process. Seeing that there is a plan in place and that we have a set treatment plan for their pet's stay, can often help put the client's mind at rest to an extent.
Conclusions
This plan has been formulated, tested and approved by both veterinary surgeons and veterinary nurses in the author's practice. It makes the veterinary surgeon's job easier as they can simply say to begin the stasis protocol that has drugs, doses and a treatment plan ready to go. It also helps to prompt the veterinary nurse at points of when to communicate findings to the veterinary surgeon and guide them through the process of caring for these patients, which is particularly helpful for less confident nurses. The author's practice frequently sees gut stasis rabbits and frequently these patients are well enough to discharge after a one day stay. Hopefully this plan may help take some of the fear away of managing a gut stasis rabbit patient!
KEY POINTS
- Gut stasis in rabbits requires a collaborative approach with the veterinary team in order to create a successful treatment plan.
- Putting in place care plans and bundles can help those who are less confident treating rabbit patients, as it provides a step-by-step guide for how to manage them.
- Nurses can be the eyes and ears for the veterinary surgeon. By observing the patient, they may be able to pick up on clues as to why the rabbit has gone into stasis and this information can assist the veterinary surgeon's diagnosis.