Rabbit passed away - Questions about blood clots and dental

Question
QUESTION: Dear Dr. Krempels,

I posted this question a couple of weeks ago and I received a message that it could not be answered; at the time your account was listed as unavailable, so I'm trying to post it again in case it was a site error.

To summarize my original post, my 7.5 year old dutch bunny passed away last month over the holidays. He seemed healthy all his life until the last month. It started with a urinary tract infection (UTI). We brought him to his regular vet, got him started on antibiotics, and that same night, he somehow broke his front paw (We aren't sure how, but he wasn't hopping well because of the UTI so we think he slipped or may have gotten it stuck somewhere). When this happened, it was 4am on a Sunday so we took him to an emergency vet. They refused to splint his paw - insisting that he sees his normal vet to supposedly save us money - and prescribed a high dose of metacam before sending us home.

My bun saw his regular vet the very next morning, they splinted his paw and reduced the amount of metacam to ~1/8th of what the other vet prescribed. By this point my bun had stopped eating so we syringe-fed him Critical care (x6) times a day. Luckily he started to eat and poop again the day after we lowered his metacam dose.

Thereafter, I brought my bunny to see his regular vet for check ups at 1 week, 3 weeks, and 4 weeks after his paw was initially splinted. For the first 3 weeks, the vet said his paw was healing nice and straight... It looked really good and he got over the UTI... but my bun had lost a lot of weight and I noticed that his eyes were starting to tear. He was being fed timothy hay, some timothy pellets, and a small amount of greens. The vet swabbed a tear sample and said there were no white blood cells so it was likely due to stress. We suspected that this might have been due to his teeth, since I've never had them x-rayed. My bun was still eating, drinking, and pooping though so the vet took off the splint and replaced it with a bandage to help him move better, and we increased his pellets to try and encourage weight gain.

Towards the end of the fourth week, when he had the bandage on, there was quite a change; my bun regained some of his weight but his eyes were tearing more, he was dropping food (not pellets but greens/treats) and he seemed to be avoiding putting pressure on his bad foot. When we went in for his last check-up, the vet removed the bandage and the paw was angled awkwardly. The vet at the time thought the tendon had contracted and said to massage the area. We also booked him in for dental the very next day. I was told to stop food and water 4 hours before surgery.

It turned out 2 teeth had been moving into his cheek (wobbly, I was told) and they were removed. What was unexpected though... is that they discovered that his entire front foot was dead. At some point, somehow the circulation had been cut. Their office sent him home that afternoon with Baytril and metacam, and advised me to consider putting him down.

It was a shock. The vet had also left before the pick up time so I had to wait until the next day before I could speak with them again.

That night, trouble struck again - around 4 am again my bun was having trouble breathing. We rushed him to a different emergency clinic and they said his heart was beating irregularly. They managed to stabilize his heart with fluids (they said he was dehydrated and cold) and after conducting a blood test on the spot they thought he was starting to fight an infection, likely in the lungs. Everything else in the blood work seemed to be within normal limits though.

Based on that, the clinic thought they might be able to stabilize him long enough for an amputation. He was in an oxygen kennel to help with his breathing and it seemed like his heart had stabilized. Sadly, he passed away shortly after I left...

I realize that there was a lot going on with him. But I had a couple of questions:

1) Between his regular vet and the emergency vet (2nd one), I was told that the dead paw could have been due to a clot or the splint. The break was near the bottom of his paw; I was told it was like breaking 4 human fingers. I never saw my bun try to bite or claw at the splint or bandage. How common is it for rabbits to throw a clot? Can it be related to overgrown teeth or injuries? Are there any common signs, or treatment for clots if caught early?

2) When I was considering having his teeth checked prior to this, I was told that older rabbits may not survive being put under GA. When is typically a good time to have your bunny put under GA for a tooth examination? Are there guidelines for typical check up intervals or is it more on an as needed basis?


I have recently adopted a 3-month-old rex bunny. I'm now reading through the House Rabbit Society website for recommended vets. If you have any advice or recommendations on what else I could have done better for my last bun, it would be greatly appreciated. I'd like to learn from the incident for my new baby.

Sincerely,

Kira

ANSWER: Dear Kira,

I am very sorry about the sad passing of your friend.  It does sound as if he had a lot going on, so it's going to be hard to pinpoint exactly what was the cause of death.

You wrote:

1) Between his regular vet and the emergency vet (2nd one), I was told that the dead paw could have been due to a clot or the splint. The break was near the bottom of his paw; I was told it was like breaking 4 human fingers. I never saw my bun try to bite or claw at the splint or bandage. How common is it for rabbits to throw a clot? Can it be related to overgrown teeth or injuries? Are there any common signs, or treatment for clots if caught early?

I have no idea how common it is for a bunny to form a clot that could cut off circulation to the entire paw.  It does seem more likely that the splint could have done the damage, but I have no way to know that for sure.  Blood-thinning drugs such as aspirin could prevent clotting, but metacam also has some anti-clotting qualities.  Given that he was on pretty large doses of metacam, I'd lean towards the splint being too tight.  But again...I'm guessing this without seeing anything.


2) When I was considering having his teeth checked prior to this, I was told that older rabbits may not survive being put under GA. When is typically a good time to have your bunny put under GA for a tooth examination? Are there guidelines for typical check up intervals or is it more on an as needed basis?

At 7.5 years, your bunny wasn't really "older".  If a bun is in generally good health, there's no reason GA should be an undue risk.  We have anesthetized plenty of middle-ages and even elderly bunnies without problems.  It's all a matter of underlying health and any idiosyncracies a bunny might have that can't be detected until it's too late.  :(


I think a good lesson to learn from this is:  avoid emergency clinics if you can, unless you KNOW there's a rabbit-savvy vet on the staff.  I don't know what dose of metacam they prescribed, but the maximum recommended for anyone these days is 1mg/kg once every 24 hours (12, if absolutely necessary).  If they gave more than that, there could be GI problems resulting, as well as insult to the kidneys and possibly the liver.

There are just so many things going on with your bunny that it's hard to say.

I hope you have a long, happy friendship with your new bunny.

Sincerely,

Dana



---------- FOLLOW-UP ----------

QUESTION: Hi Dr. Krempels,

Thank you for the reply and the advice concerning the emergency clinics. My bunny did look more lively and started to eat by himself again after we reduced the metacam dose. I don't remember the dosage they gave him - just that it was 8x higher than what his regular vet gave him and that even she thought it was way too much. At the time, we were sure that he broke his paw so we wanted to get him looked at asap. The difficulty is that many of the clinics in my area are closed late at night and on Sundays... which is when the break happened :(

To follow up, my bunny was on metacam only for the first 10 days with the splint. He was taken off of it completely for the remaining 3 weeks before the dental. If he were on metacam, would this have helped? From what I understand, the vet did not continue giving it to him because of the concern that long term use would upset his digestive system. Also, for the future, is there any way of telling if a splint is too tight?

He also did not have blood work done before the dental because of his weight loss. So you're right, there may have been underlying conditions that were undetected. In general, is it recommended to get blood work done before surgery?

Thank you,

Kira

Answer
Hi, Kira

It's hard to say whether being on metacam would have helped with his dental surgery.  As long as he was on SOME kind of pain meds, that should be sufficient.  We've found that tramadol really helps with bone and dental pain.  Did he get anything like that?  Another opioid?

With metacam, the concern is less about GI tract (though with a massive dose, even a Cox-2 inhibitor like metacam can cause problems) and more about kidneys.  All NSAIDS (non-steroidal anti-inflammatory drugs) reduce blood flow to the kidneys (and other areas), and this can cause problems in the long term, and especially in animals (including humans) with existing renal problems.

While his weight loss might have been due to his dental pain, there's also the possibility that he had renal disease, one sign of which is wasting, even if a bunny eats well.  It's not possible to know that now.  Blood chemistry would have revealed this, but now it's just an untestable idea.

Having blood work done before surgery is never a bad idea, unless it causes major stress to the bunny.  It's not always necessary, and it won't *always* prevent unforseen, idiosyncratic reactions to anesthesia or other weird problems.  But at least you know going in that what a bunny's general health is, and that a good blood panel means he's a reasonable candidate for surgery.  No surgery is 100% risk free, but you do the best you can.

I hope this helps.

Dana