Small Animals & Avian
Outcome following inhalation anesthesia in birds
at a veterinary referral hospital: 352 cases (2004–2014)
Amanda B. Seamon bs
Erik H. Hofmeister dvm, ma
Stephen J. Divers bvetmed, dzoomed
From the Department of Small Animal Medicine and
Surgery, College of Veterinary Medicine, University of
Georgia, Athens, GA 30602. Dr. Hofmeister’s present
address is Department of Surgery, College of Veteri-
nary Medicine, Midwestern University, Glendale, AZ
85308.
Address correspondence to Dr. Hofmeister (kaastel@
gmail.com).
A nesthesia is widely used in veterinary medicine
for avian species. Birds are anesthetized for sim-
ple procedures such as nail clipping, beak trimming,
and physical examination and also for more substan-
tial, invasive surgical procedures. The patient’s out-
come after a procedure requiring anesthesia depends
on a multitude of factors, such as the patient’s disease
state, purpose of anesthesia, procedure performed
during anesthesia, the anesthetic event, and recovery
from anesthesia. Death associated with anesthesia
can be defined as death during and directly attribut-
able to anesthesia, death during anesthesia for any
ABBREVIATIONS
ASA American Society of Anesthesiologists
BCS Body condition score
ICU Intensive care unit
814 JAVMA • Vol 251 • No. 7 • October 1, 2017
OBJECTIVE
To determine the outcome in birds undergoing inhalation anesthesia and
identify patient or procedure variables associated with an increased likeli-
hood of anesthesia-related death.
DESIGN
Retrospective case series.
ANIMALS
352 birds that underwent inhalation anesthesia.
PROCEDURES
Medical records of birds that underwent inhalation anesthesia from January
1, 2004, through December 31, 2014, at a single veterinary referral hospital
were reviewed. Data collected included date of visit, age, species, sex, type
(pet, free ranging, or wild kept in captivity), body weight, body condition
score, diagnosis, procedure, American Society of Anesthesiologists status,
premedication used for anesthesia, drug for anesthetic induction, type of
maintenance anesthesia, route and type of fluid administration, volumes of
crystalloid and colloid fluids administered, intraoperative events, estimated
blood loss, duration of anesthesia, surgery duration, recovery time, recov-
ery notes, whether birds survived to hospital discharge, time of death, total
cost of hospitalization, cost of anesthesia, and nadir and peak values for
heart rate, end-tidal partial pressure of carbon dioxide, concentration of in-
haled anesthetic, and body temperature. Comparisons were made between
birds that did and did not survive to hospital discharge.
RESULTS
Of 352 birds, 303 (86%) were alive at hospital discharge, 12 (3.4%) died
during anesthesia, 15 (4.3%) died in the intensive care unit after anesthesia,
and 22 (6.3%) were euthanatized after anesthesia. Overall, none of the
variables studied were associated with survival to hospital discharge versus
not surviving to hospital discharge.
CONCLUSIONS AND CLINICAL RELEVANCE
Results confirmed previous findings that indicated birds have a high mortal-
ity rate during and after anesthesia, compared with mortality rates pub-
lished for dogs and cats. ( J Am Vet Med Assoc 2017;251:814–817)
reason, death within 24 to 48 hours after anesthesia,
and death within 7 days after anesthesia.1 It has been
shown that mortality rates within 48 hours of anes-
thesia is higher in parrots (3.95%) and other birds
(1.76%) than in cats (0.24%), dogs (0.17%), and people
(0.02% to 0.005%).2,3
The reasons for a high anesthetic-related mortality
rate in birds are unknown. Anesthesia could produce
adverse effects in birds that are different from those
in mammals and ultimately result in death. Anesthe-
sia compromises the ability of the avian lung to per-
form gas exchange.4 The amount of time that birds can
remain apneic is affected by their limited functional
residual lung volume.4 The cardiovascular system of
the bird is different from other animals in that blood
pressure and heart rate are often higher.4 Excitement
and handling of birds (ie, during capture) can increase
the blood concentrations of norepinephrine and epi-

nephrine, leading to sensitizing of the myocardium
to catecholamine-induced cardiac arrhythmias.4 Be-
cause birds are generally smaller than most veterinary
patients, small volumes of intraoperative hemorrhage
can have a substantial negative effect.
The primary purpose of the present study was to
determine the outcome of birds undergoing anesthe-
sia at a single veterinary referral hospital. Our hypoth-
esis was that there would be a high anesthesia-relat-
ed mortality rate in birds, compared with previously
published anesthetic-related mortality rates for other
animals. The secondary purpose was to determine
whether patient or procedure variables were associ-
ated with an increased likelihood of anesthesia-related
death. We hypothesized that ASA status, cost of anes-
thesia, and surgery duration would correlate with an
increased likelihood of death related to anesthesia.
Materials and Methods
Case selection criteria
Medical records of birds that underwent inhala-
tion anesthesia from January 1, 2004, through Decem-
ber 31, 2014, at the University of Georgia’s Veterinary
Teaching Hospital were reviewed. Cases were identi-
fied by searching the records for patients designated
as avian and having any inhalation anesthesia charge
on their bill.
Medical records review
Data collected from the medical record included
date of visit, age, species, sex, type of bird (pet, free
ranging, or wild kept in captivity), body weight, BCS,
diagnosis, procedure, ASA status, premedication used
for anesthesia, drug for anesthetic induction, type of
maintenance anesthesia, route and type of fluid ther-
apy administration, volumes of crystalloid and colloid
fluids administered, intraoperative events, estimated
blood loss, duration of anesthesia, surgery duration, an-
esthetic recovery time, recovery notes, alive at hospital
discharge versus did not survive to hospital discharge,
time of death (hour and day), total cost of hospitaliza-
tion, cost of anesthesia, and nadir and peak values for
heart rate, end-tidal partial pressure of carbon dioxide,
concentration of inhaled anesthetic, and body temper-
ature. Body weight was measured in grams, BCS was
rated on a scale of 1 to 9 (1 = emaciated, 5 = ideal, and
9 = grossly obese), ASA status was rated on a scale of 1
to 5 (1 = clinically normal, 2 = mild systemic disease, 3
= severe systemic disease, 4 = severe systemic disease
that is a constant threat to life, and 5 = moribund and
not expected to survive without surgery), and nadir
and peak values for heart rate, end-tidal partial pres-
sure of carbon dioxide, concentration of inhaled an-
esthetic, and body temperature were obtained during
the anesthetic period.
Duration of anesthesia was defined as the time
between induction of anesthesia and extubation or
between induction of anesthesia and removal of a
facemask when endotracheal intubation was not per-
formed. Surgery duration was defined as the time be-
JAVMA • Vol 251 • No. 7 • October 1, 2017 815
Small Animals & Avian
tween the start and end of the surgical procedure.
Recovery time was the amount of time between dis-
continuing maintenance anesthesia and extubation.
Recovery notes included any remarks recorded by the
veterinarian during the patient’s anesthetic recovery.
The estimated blood loss was determined on the ba-
sis of estimations made by the surgeon and anesthesi-
ologist at the time of the procedure. The total bill was
the total amount of charges accrued for everything
pertaining to the patient’s hospital visit. The cost of
anesthesia was measured as the total accrued charges
for the anesthesia used during the procedure.
To determine the cause of death in each patient,
medical records of birds that did not survive to hospi-
tal discharge were reviewed by 2 authors: a diplomate
of the American College of Veterinary Anesthesia and
Analgesia (EHH) and a diplomate of the American Col-
lege of Zoological Medicine (SJD). Birds were separat-
ed into 4 categories as follows: survived to hospital dis-
charge, anesthesia-related death, euthanatized, or died
in the ICU after anesthetic recovery. Birds were classi-
fied as having an anesthesia-related death if they died
during anesthesia (including operative causes such as
hemorrhage), as euthanatized if they underwent eu-
thanasia at any point during or after anesthesia, or as
died in the ICU if they suddenly died after recovery
from anesthesia.
Statistical analysis
Only data from the most recent anesthetic event
for each patient were analyzed and reported here. Com-
patibility of data with a normal distribution was deter-
mined by use of the D’Agostino-Pearson omnibus test.
Most data were not normally distributed; consequently,
tests for nonparametric data were used. Comparisons
between birds that were alive at hospital discharge and
those that did not survive to hospital discharge were
made with a Mann-Whitney U test. Comparisons were
made between birds that survived to hospital discharge
and those that died during anesthesia, were euthana-
tized, or died in the ICU by use of a Kruskal-Wallis test.
Categorical data were analyzed with a χ2 test. A value of
P < 0.05 was considered significant.
Results
The outcome for 352 birds that underwent an-
esthesia was as follows: 86% (n = 303) survived to
hospital discharge, 3.4% (12) died during anesthesia,
6.3% (22) were euthanatized, and 4.3% (15) died in the
ICU. In none of the anesthesia-related deaths could
the anesthetic be ruled out as a contributing factor.
Of 352 birds, 143 were females, 112 were males, and
97 were of unknown sex. The study included more
pet birds (295) than either free-ranging birds (42) or
wild birds kept in captivity (15); 76 species were rep-
resented. None of the birds died between discontinu-
ing maintenance anesthesia and extubation.
Birds that survived to hospital discharge had
been anesthetized for various procedures, most of
which were endoscopy, mass removal, blood sample
 Small Animals & Avian

collection, physical examination, radiology, crop
burn repair, nail trim and beak trim, wound manage-
ment, and crop biopsy. Of the 303 medical records of
birds that survived to hospital discharge, 61 included
ASA status data and 156 included BCSs.
Birds that had an anesthesia-related death had
been anesthetized for administration of supportive
care and antimicrobials, fluoroscopy, oviduct remov-
al, percutaneous biopsy, radiography, crop repair,
and other surgeries. Of the 12 medical records of
birds that had an anesthesia-related death, 3 included
ASA status data and 6 included BCSs.
Birds that were euthanatized had been anesthe-
tized for cloaca suture, fracture repair, coelomic mass
evaluation, blood sample collection, and euthanasia.
Of the 22 medical records of birds that were euthana-
tized, 1 included ASA status data and 6 included BCSs.
Birds that died in ICU had been anesthetized for
endoscopy, blood sample collection, wound manage-
ment, abdominal ultrasonography, surgery, and radi-
ography. Of the 15 medical records of birds that died
in ICU, 2 included ASA status data and 8 included
BCSs.
There were no significant differences among any of
the groups for any of the variables evaluated, except for
the total bill, which was lower in the euthanasia group
than in the other groups (P < 0.008; Tables 1 and 2).

Table 1—Continuous and ordinal data for patient characteristics of 352 birds that were anesthetized and classified into 1 of 4
outcomes.
Survived to hospital Anesthesia-related
Variable discharge (n = 303) Euthanatized (n = 22) ICU death (n = 15) death (n = 12)
Age (y) 9.6 ± 8.1 (8.6–10.6) 10.5 ± 10.7 (5.2–15.8) 7.4 ± 6.5 (3.7–11.2) 9.8 ± 6.0 (5.2–14.4)
Weight (kg) 0.9 ± 3.1 (0.5–1.3) 2.1 ± 3.9 (-0.2–4.3) 1.0 ± 1.7 (-0.2–2.1) 0.9 ± 0.9 (0.3–1.5)
BCS (1–9) 4.7 (3.5–5.8) 3.2 (4.1–7.3) 4.5 (3.3–5.8) 4.5 (3.5–5)
Nadir HR (beats/min) 216 ± 80 (205–228) 192 ± 50 (146–238) 244 ± 82 (168–321) 210 ± 72 (144–277)
Peak HR (beats/min) 285 ± 72 (274–295) 267 ± 55 (218–320) 265 ± 103 (179–351) 303 ± 66 (234–372)
Nadir Petco2 (mm Hg) 28 ± 10 (26–30) 38 ± 5 (25–51) 37 ± 5 (25–48) 18 ± 9 (-4–40)
Peak Petco2 (mm Hg) 46 ± 11 (44–48) 50 ± 9 (26–73) 51 ± 5 (40–62) 36 ± 12 (6–65)
Inhaled anesthetic nadir 1.7 ± 1.1 (1.6–1.9) 2.1 ± 0.5 (1.6–2.6) 1 ± 0.6 (0.2–1.8) 2.2 ± 0.9 (1.0–3.3)
Inhaled anesthetic peak 3.4 ± 1.3 (3.2–3.6) 3.3 ± 1.4 (1.5–5.1) 3.7 ± 1.2 (2.2–5.2) 4.3 ± 1.5 (1.9–6.6)
Body temperature nadir (°C) 37.0 ± 2.3 (36.6–37.4) 37.1 ± 0.6 (35.5–38.7) 37.2 ± 2.5 (33.1–41.2) 37.4 ± 0.4 (36.4–38.3)
Body temperature peak (°C) 39.2 ± 1.4 (38.9–39.4) 38.7 ± 2.7 (31.9–45.5) 38.7 ± 2.7 (31.9–45.5) 39.1 ± 1.5 (35.5–42.8)
Body temperature nadir (°F) 98.7 ± 4.2 (97.9–99.4) 98.8 ± 1.1 (95.9–101.6) 98.9 ± 4.6 (91.6–106.2) 99.2 ± 0.7 (97.5–100.9)
Body temperature peak (°F) 102.5 ± 2.6 (102–102.9) 101.6 ± 3 (94–109) 101.7 ± 4.9 (89.5–113.9) 102.4 ± 2.7 (95.8–109)
Estimated blood loss (mL) 0.3 ± 1.2 (0.2–0.4) 0.1 ± 0.2 (-0.1–0.2) 0.1 ± 0.4 (-0.1–0.4) 0
Duration of anesthesia (min) 64 ± 57 (56–73) 32 ± 10 (6–58) 52 ± 34 (15–88) NA
Surgery duration (min) 46 ± 36 (39–53) 27 ± 5 (-18–71) 31 ± 13 (10–52) NA
Recovery time (min) 11 ± 22 (7–15) 3 ± 0 (3) 17 ± 19 (-155–188) NA
Total bill (USD) 693 ± 664 (664–771) 321 ± 362 (156–486) 601 ± 376 (374–828) 533 ± 390 (173–894)
Cost of anesthesia (USD) 93 ± 99 (81–105) 67 ± 50 (43–90) 90 ± 64 (47–133) 94 ± 76 (24–164)

Data are presented as mean ± SD (95% confidence interval) except for BCS that is presented as median (interquartile range).
HR = Heart rate. NA = Not applicable. Petco2 = End-tidal partial pressure of carbon dioxide. USD = US dollars.

Table 2—Categorical data for patient characteristics of 352 birds that were anesthetized and
classified into 1 of 4 outcomes.
Survived to hospital Anesthesia-related Euthanatized ICU death
Variable discharge (n = 303) death (n = 12) (n = 22) (n = 15)
Sex
Male 92 6 7 7
Female 125 6 6 6
Unknown 86 0 9 2
Type
Wild bird in captivity 12 1 2 0
Free-ranging bird 34 2 5 0
Pet bird 257 9 15 15
ASA Status
1 3 0 0 0
2 52 0 1 2
3 41 0 1 2
4 16 1 0 0
5 1 0 0 0

Data are presented as number of birds.

See Table 1 for remainder of key.

816 JAVMA • Vol 251 • No. 7 • October 1, 2017


Discussion
The results from this study provided no evidence
to suggest that any of the variables studied were associ-
ated with the likelihood of death caused by anesthesia
in birds. It would not be helpful to use these variables
in determining an individual bird’s risk for anesthesia-
related death. It is possible that other variables that
were not examined in our study could provide insight
into anesthesia-related death. The variables used in
this study were chosen on the basis of frequency of
use in the study institution and relevance for clinical
decision making. It is unsurprising that birds that were
euthanatized had a significantly lower bill, as it is like-
ly that these patients were euthanatized before they
could accrue numerous charges.
The initial primary hypothesis was supported by
the 3.4% incidence of death in birds associated with an-
esthesia. This rate, as predicted, was higher than that
found previously in dogs, cats, and people.2,3 Birds may
have a higher anesthesia-related mortality rate because
of their physiology, the nature of the procedures they
undergo, the difficulty in assessing patient status before
anesthesia (eg, via analysis of blood samples), or the
difficulty of monitoring in birds.4 Birds have evolved
highly efficient cardiorespiratory systems to manage
the increased metabolic demands resulting from the
ability to fly. A part of this system is the unique struc-
ture of the airway, with the glottis positioned at the base
of the tongue and a long and wide trachea that extends
from the oral cavity to the syrinx. The trachea has con-
siderable dead space, compared with that of mammals,
and has extensive bronchi division.5 Dead space refers
to the volume of air inhaled that does not take part
in gas exchange. Because the efficiency of the avian
cardiorespiratory system is dependent on an uninter-
rupted flow of air through the lungs, these anatomic
differences between birds and mammals can be the
source of some difficulty when it comes to anesthetiz-
ing birds.4 For bird species, even small periods of ap-
nea are serious because of the small functional reserve
capacity of the avian respiratory system.5 Birds must be
physically restrained to induce anesthesia; however,
this restraint can be stressful for birds and may cause
injuries or trauma to the bird if handled incorrectly
prior to administration of anesthesia.5
Monitoring birds under anesthesia and during
postoperative care are also vital parts of the anesthetic
process. Blood loss, blood pressure, and internal body
temperature must be carefully monitored in small
animals and can be difficult to accomplish. Arterial
catheterization to monitor blood pressure and blood
gas measurements can be difficult to perform and
may require practice.5 Postoperative care may require
extensive measures such as assisted feeding, manual
body temperature maintenance, or the assistance of an
oxygen mask to ensure the bird recovers to normalcy.5
There was no significant difference in BCS be-
tween birds that died and those that survived. This
was unexpected because birds of an unhealthy weight
JAVMA • Vol 251 • No. 7 • October 1, 2017 817
Small Animals & Avian
are usually considered to be more at risk when under-
going surgery. The ASA status was rarely available for
the cases included in the study. Many of the birds were
anesthetized for short diagnostic procedures by the ex-
otics service, where a complete anesthetic assessment
was not always performed and a full record of anesthe-
sia was not always maintained. Most institutions are
unlikely to perform a full assessment of anesthesia and
complete monitoring of birds undergoing anesthesia
for routine diagnostic procedures. It is possible that
ASA status may be related to anesthesia-related death,
as it has been shown to be in dogs and cats.3 However,
several of the anesthesia-related deaths were in appar-
ently healthy birds anesthetized for diagnostic proce-
dures, suggesting that even healthy birds may be at a
relatively high risk for anesthesia-related death.
Limitations in this study could have included
misinterpretation of the cause of death as a result of
minimal information provided in the medical record.
In some cases, the pathology report was the only in-
dication in the record that a patient had died. In most
cases, ASA status and BCS range were not recorded for
the birds being studied. This could have led to skewed
inferences on the basis of minimal data in these 2 cat-
egories. Also, birds that died in the ICU may have had
deaths related to anesthesia; however, it was not pos-
sible to determine this on the basis of the information
in their medical record. It is possible no difference was
found because of the small total number of deaths re-
lated to anesthesia. A larger sample size may be useful,
but may be difficult to obtain from a single institution.
In conclusion, the anesthesia-related mortal-
ity rate in birds of this study was higher than has
been reported for other animals. Clients should be
informed about the higher risk when birds are anes-
thetized. None of the variables investigated were as-
sociated with an increased risk of anesthesia-related
death. Therefore, it was difficult to predict which
birds were likely to have an anesthesia-related death.
Acknowledgments
Presented at the University of Georgia’s Center for Under-
graduate Research Opportunities Symposium, Athens, Georgia
April 2014 and March 2015.
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