rowid,hash_id,code,kind,repeat,desc,narrative
62,7c8eed2e5934da8c,2.33(b)(3),Critical,0,Attending veterinarian and adequate veterinary care.,"Pertaining to IACUC approved Protocol 20100: On 4/21/23 rabbit #87 was anesthetized by investigator staff for an IACUC
approved operative procedure using injectable agents followed by an inhalant agent at 2% for maintenance anesthesia.
The animal’s heart rate began to increase during the procedure and the investigator staff increased the percentage of
inhalant agent to 3% for 30 minutes. The heart rate remained elevated and the investigator decided to administer an
additional dose of the injectable agents, kept the inhalant agent at 3%, and continued the study procedure. The rabbit’s
heart rate remained elevated, but the investigator staff did not contact the Attending Veterinarian. The inhalant agent was
discontinued when the procedure was completed, constituting over 4 hours inhalant anesthesia and over 2 hours at 3%,
but the rabbit’s oxygen level began to drop, and respiratory depression developed. At that point, investigator staff
contacted veterinary staff who immediately responded and initiated treatment. The animal’s condition continued to
deteriorate, and the rabbit was euthanized. The necropsy results were that the death was due to anesthesia error.
Per this Section, each research facility shall maintain a program of adequate veterinary care that includes the observation
of all animals to assess their health and well-being. The observation of animals may be accomplished by someone other
than the Attending Veterinarian (AV). However, a mechanism of direct and frequent communication must be in place to
convey timely and accurate information concerning any problems of animal health observed in the animals to the
Attending Veterinarian who has the authority to ensure that the animals are provided adequate veterinary care.
There was a failure of the investigator staff to contact the AV during the operative procedure when there was a problem of
animal health. The Attending Veterinarian and research facility acted promptly to address this incident and implemented
corrective measures prior to this inspection, which included additional training of the investigator staff, modifications to the
proposal for animal use, and requiring that veterinary staff administer anesthesia. There have been no additional
incidents. To remain corrected from this day 3/22/24 forward.
This inspection was conducted with facility representatives from 3/18/24 through 3/22/24. The exit briefing was held with
facility representatives on 3/22/24.
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