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Dr. Sheliah Robertson on Anesthesia for Senior Dogs and Cats
505 Plays7 months ago
Welcome to another episode of the NAVAS podcast! How many times in your career, after recommending a surgical or dental procedure for a dog or cat, have you been asked whether a beloved aging pet was too old to be anesthetized? Today, we’re diving into a topic that many veterinary professionals encounter but may not always feel fully prepared for: anesthesia for senior dogs and cats. Older pets can present unique challenges when it comes to sedation and general anesthesia, and understanding how aging impacts their physiology is key to providing safe and effective care.
In this episode, we have the honor of speaking with Dr. Sheliah Robertson, a veterinary anesthesiologist who is also board-certified in animal welfare and the senior medical director at Lap of Love, a network of veterinary at-home euthanasia and hospice care providers. Dr. Robertson brings a wealth of experience and insight into the world of anesthesia for geriatric pets. We’ll be discussing everything from anesthetic risks and frailty in older animals to how aging affects vital organ function and what that means for anesthesia protocols. This conversation is guaranteed to be packed with valuable information to enhance your understanding and improve outcomes for your older patients.
Resources mentioned in this episode:
Dr. Sheliah Robertson’s work at Lap of Love
The ERAS Society (Enhanced Recovery After Surgery)
Development of ERAS protocols for veterinary medicine
A review article on improving postoperative sleep
Research on the effect of preoperative melatonin on the propofol dose required to induce anesthesia in dogs
An article on how pre-surgery rehabilitation effects surgical outcomes in aged patients
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Thank you to our sponsor, Dechra - learn more about the pharmaceutical products Dechra has to offer veterinary professionals, such as Zenalpha.
If you have questions about this episode or want to suggest topics for future episodes, reach out to the producers at education@mynavas.org.
All opinions stated by the host and their guests are theirs alone and do not represent the thoughts or opinions of any corporation, university, or other business or governmental entity.
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Transcript
Introduction to Veterinary Anesthesia Podcast
00:00:06
Speaker
Hello, everyone, and thank you for listening to the official podcast of the North American Veterinary Anesthesia Society. I'm your host, Dr. Bonnie Gatson. Our mission with this podcast is to help educate veterinary professionals to advance and improve the safe administration of anesthesia and analgesia to all animals.
Focus on Animal Pain Awareness Month
00:00:26
Speaker
We also want to acknowledge that September is Animal Pain Awareness Month, where the goal is to educate and inform the public about recognizing animal discomfort.
Challenges of Anesthesia in Geriatric Pets
00:00:37
Speaker
It's in the spirit of Animal Pain Awareness Month that we here at the Navest Podcast want to focus on a population of animals that often experiences chronic pain, but also poses a challenge to safely anesthetize, geriatric dogs and cats.
00:00:55
Speaker
And we procured an amazing guest who is going to help show us how to carefully and logically tackle these anesthetic challenges with tact and finesse. But before we get to the meat and potatoes of this episode, I want to give a big shout out to the sponsor of this podcast, Decra.
00:01:15
Speaker
They have a wonderful line of analgesic, sedative, and anesthetic medications that can help elevate your standard of care and what you can offer to your clients. For example, if you are doing a lot of sedated procedures on dogs in your practice, then you may want to consider adding zenalfa to your drug arsenal. If you don't know what I'm talking about, we have an entire NavVis podcast episode on zenalfa. So please check out that episode in our archives.
00:01:45
Speaker
I've personally used an alpha to sedate dogs and I've been pleased with the results and how quickly dogs recover from the sedation. Please visit www.decra-us s dot.com to check out their line of anesthesia related products today.
Upcoming Veterinary Anesthesia Meeting
00:02:00
Speaker
Next up, the American College of Veterinary Anesthesia and Analgesia is having their annual meeting coming up on September 25th to the 27th in Denver. It's not too late to sign up for the meeting and NavVis members get a discount. Visit acvaa.org to sign up for a fantastic meeting where you can go and get yourself some great anesthesia related CE.
Pet Owner Concerns about Anesthesia
00:02:22
Speaker
So back to today's episode.
00:02:24
Speaker
Imagine this scenario, although it probably isn't too hard for you to imagine. You are evaluating a 17-year-old cat who's not quite eating like it should, and on physical examination, you can see the resorptive teeth lesions from a mile away. But when you make the recommendation for an anesthetic dental procedure, the owner hedges and asks you, is it my cat too old for anesthesia?
00:02:51
Speaker
Well, we are hoping to answer just that question in this episode. As veterinary professionals, we are seeing more and more senior pets walk through our doors. Anesthesia of dogs and cats presenting later on in their life requires special attention. As physiological changes are occurring with age, regardless of whether or not these patients present outwardly healthy, that requires attention and diligence when functionally challenged with anesthesia.
Dr. Robertson's Career and End-of-Life Care
00:03:20
Speaker
And to guide us through these anesthetic considerations for older dogs and cats is a veterinary anesthesiologist boarded in both North America and Europe, who I would consider to be a foundational researcher who helped to revolutionize the way we recognize and treat pain in cats.
00:03:39
Speaker
Dr. Sheila Robertson. She is also board certified at Animal Welfare and is currently the senior medical director at Lap of Love, a national network of veterinary hospice and end-of-life providers. She has given countless lectures around the world about caring for geriatric patients, and I'm so happy we could snag just a moment of her time from her busy life for this discussion.
Clarifying Pet Age Terms
00:04:02
Speaker
Did you ever wonder how old does a dog or cat have to be in order to be considered a senior pet? Is there a difference between being a senior pet and a geriatric pet? What is frailty and why does that matter when older patients are put under anesthesia? And of course, is my dog or cat too old for anesthesia?
00:04:26
Speaker
We're going to answer all these questions and more with Dr. Sheila Robertson right here on the Navas Podcast.
00:04:37
Speaker
Hi, thank you so much. Welcome to the Navas podcast, Dr. Robertson. I feel like you've had a very long career that has really changed the course of like how we understand anesthesia and animals. And, you
Dr. Robertson's Background in Veterinary Medicine
00:04:52
Speaker
know, I don't think you need an introduction because I was studying the things that you were writing when I was in my residency. But I'm wondering if you can still just spend some time introducing yourself and letting us know what you're doing now.
00:05:06
Speaker
Thanks for even it for inviting me on the podcast. I listen to them all the time. They're really, really good. And I probably do need to introduce myself because there'll be a lot of people listening in that were born after I even graduated, right? So right off the bat, I have been a veterinarian now for coming up for 44 years.
00:05:28
Speaker
So I received my veterinary degree from Glasgow University back in 1980. So that's in Scotland. And then I spent some time in mixed animal practice. And then I moved to the University of Bristol and I spent a year as a house surgeon. And that would be similar to like an internship in the US, but it was focused on me becoming a surgeon.
00:05:51
Speaker
And then during that year, I did a rotation through anesthesia and suddenly a light bulb went off and I immediately knew that that was a discipline for me. And the reason being is that mostly because there were so many unanswered questions. The surgeons had an answer for every question I asked. The anesthesiologists I worked with didn't have the answers to all my questions.
00:06:17
Speaker
So I thought I would do NSEs and try and answer some of these questions. And then I stayed on and completed my PhD, which was actually looking at how horsies handle NSEs in surgery, looking at metabolic and hormonal changes.
00:06:33
Speaker
And then I spent many years in academia where I did research, trained students and interns and residents, and then obviously provided anesthesia services in teaching hospitals. But I'm really, really in interested in animal welfare. So I'm actually board certified in animal welfare, both in Europe and US, just as I am in anesthesia. And I worked at the AVMA in the animal welfare division for a couple of years.
00:07:00
Speaker
I'm a lifelong learner. There's always something to learn. So I have a certificate in acupuncture and also in shelter medicine. And I still volunteer at community cat and spay and neuteroclinics. So a bit of a varied background there.
00:07:17
Speaker
Right. So I know currently you are medical director at lap of love. So what drew you to to that position? Yeah. So my current position is ah
End-of-Life Care Challenges in Pets
00:07:27
Speaker
they call me senior medical director at lap of love, but there's only one of me. So I think senior means like I'm old.
00:07:37
Speaker
Well, that's what I think because the company was started by two of my farmer students at University of Florida, Danny McVede and Mary Gardner. So I oversee like almost 350 veterinarians now. So they're all over the United States performing end of life care in caregivers homes. And we actually do about 12,000 appointments a month now.
00:08:02
Speaker
And I know a lot of people are going, well, why would a highly trained anesthesiologist switch to focusing on end of life and euthanasia? But I found it very, very challenging and rewarding. Because if you think about it, a euthanasia appointment is the pet's last appointment with a veterinarian.
00:08:23
Speaker
And it involves sedating them and then euthanizing them, which is really an anesthetic, but it's the ultimate anesthetic, right? It's the last one that we'll ever have. And in most cases, this is done in front of the owner. So my job has been to create um really nice set of protocols and euthanasia techniques for all the different end-of-life diseases. They're in end-stage heart failure, all these different things. So to me, that has really used my anesthesia skills
Prehabilitation in Veterinary Anesthesia
00:09:00
Speaker
to help to help do that. And then, of course, we do actually see palliative and hospice patients.
00:09:07
Speaker
And I, although as an anesthesiologist, we are very qualified in acute pain management, I did educate myself and try to branch out ah by taking acupuncture courses to learn a lot more about chronic pain, which is you know a huge issue in our aging pet population. right So now I really am focused on making sure that all of these animals have a very, very peaceful transition.
00:09:36
Speaker
with their owner present.
Impact of Frailty on Anesthetic Risk
00:09:38
Speaker
And that's all about drugs. Yeah. So I think we could certainly have an amazing conversation about sedating patients for these types of end of life cases that you're talking about, but I'm going to transition us a little bit because what I really wanted to speak with you about is about older patients. We are seeing now a lot of older patients. I would say for sure that is the majority of the patients that I take care of are definitely what I would consider geriatric.
00:10:10
Speaker
But so many pet owners, despite that, they're so worried about necessizing their older pets. So we're going to focus our conversation about that today. And my first question for you is, what is your response to a pet owner if they were to say to you, my dog or my cat is too old for anesthesia?
00:10:34
Speaker
That's like a super common question. And just to confirm exactly what you said, we have access to you know massive databases from corporate practices. And if you look at the animals that are on their database, between 40, like 45 to 50% of all animals on a clinic or a hospital's database,
00:10:57
Speaker
could be classified as an aging patient. So this is a huge population that we're looking at. So the question about my dog or
Addressing Owner Concerns about Anesthesia Risks
00:11:07
Speaker
cat is too old for anesthesia is really common and valid question. And we're not alone because I'm lucky enough to interact with human anesthesiologists who um hear the same question from the children of aging patients. So I often go meet with the anesthesiologists that specialize in taking care of elderly patients when they come for anesthesia. And they say all the time, you know this elderly patient patient comes in with their child with their daughter or son and they go, well, don't we think anesthesia is too risky? And don't you think my mom or dad should just not have the surgery?
00:11:45
Speaker
And they might be talking about something like a total hip replacement, which would be life-changing because of the pain that they're in. And if they can get a new hip, it's going to make a huge difference. And so I think that I would say one of the most common reasons that we should or do need to nistai older pets is because of dental disease.
00:12:09
Speaker
And I think caregivers really underestimate the pain that comes from bad teeth and how transformational a good dental and extracting some teeth can be for that animal. I mean, for the smell from their mouth, decreasing the risk of getting an infection, just taking care of the pain in their mouth, everything. And they often don't realize until after we've done it, like how bad it it was.
00:12:36
Speaker
So I think that is my approaches, but we do need to weigh up with them and be honest about you what do we know about the risks in an elderly population, and specifically your dog, who may have you know some diseases, or he or she may just be aging. And so we want to talk to them about the pros and cons so that they can make an informed consent. Because remember, the pet's not making the decision.
00:13:04
Speaker
owners with our guidance are making that decision and looking at the risks and benefits of proceeding. Is there any data to indicate that older animals have an increased chance of having an adverse outcome from general anesthesia? If we just are thinking about age, and then obviously you know there's all the other issues like you know comorbidities and so on,
00:13:25
Speaker
But probably the largest study that was ever done is the confidential inquiry into perioperative small animal fatalities, the CEPSAF study that was led by Dave Broadbelt in the UK. So they looked at like, what, 98,000 dogs and 80,000 cats.
00:13:43
Speaker
But that was done between 2002 and 2004, so it makes it 20 years old. But what they did show was that when you just look at age, and they were able to, with very fancy statistics, look at age, regardless of health status, and cats over the age of 12 did have a higher, it was about twice the risk of an anesthetic mishap or death compared to cats one to five years of age.
00:14:13
Speaker
But we learned so much from that study that I feel that that risk may be even less because that study revealed that we have to be a lot more careful about intubating cats than we thought. We need to be much more careful about how much fluid we give them, keeping them warm, how we monitor them. So there is that data for cats and then cats, of course, age in a uniform way. Now, when it comes to the data in dogs,
00:14:43
Speaker
it's very, very difficult to interpret because there's such a wide variation in life expectancy in dogs based on their breed and their size. So the life expectancy ah of an English Mastiff is much, much shorter than a Chihuahua. And yet most of these studies look at chronological age and what happens. So ah dogs over the age of 10 or 12 have more problems.
00:15:10
Speaker
But 12 is really an irrelevant number when you're talking Great Dane or Mastiff compared to Chihuahua. But I would say that both the CEPSAF study and some more recent studies would say that there are some increased risks as they age. But if we know and understand what those are, then we can really try and mitigate those as much as possible.
00:15:40
Speaker
We've mentioned many times that we're talking about older animals and you kind of touched a little bit on how this might be different for dogs compared to cats, but I'm just wondering if you want to just jump out and define geriatric, like how old does a dog or a cat need to be to be considered a geriatric patient?
00:15:59
Speaker
Yeah,
Defining Senior and Geriatric Pets
00:16:00
Speaker
so that's a really good question. And there's not a universally accepted definitions. And so the terms senior and geriatric are not always well defined. So in human health care, a senior person is someone who has reached a certain age in their expected lifespan. So in humans, a senior is between 50 and 70.
00:16:25
Speaker
And in human health care, they reserve the term geriatric for describing a health status, like physical and mental, and that includes frailty and how they deal with activities of daily living. And then in veterinary medicine, a lot of different life stage categories have been proposed. ah The American Animal Hospital Association,
00:16:49
Speaker
the American Association of Feeling Practitioners, they've all got their different life stages. But I think one of the best ways to look at it in dogs, because of the variability in age related to size, I would define a senior dog when they're in the last 25% of their estimated lifespan. And we do have tables now that predict expected lifespan based on the breed or size of the dog. So you can look at that.
00:17:18
Speaker
And I think in dogs, the term geriatric is best reserved to describe health status. There's a group that work the dog aging project led by Dr.
Understanding Canine Geriatric Syndrome
00:17:30
Speaker
McKenzie. He's coined a term called the canine geriatric syndrome. And that's based on a lot of evaluations. It's physical, functional behavior, you know, metabolic changes that categorize canine aging and then the resulting manifestations of that. which includes, again, as we mentioned in humans, frailty, the quality of life, age-associated diseases. So I think senior is when they're in the last 25% of their expected lifespan. Geriatrics is more of a statement about their health status.
00:18:07
Speaker
And then in cats, there's a really, really nice study going on in the UK now that they they have an aging cat clinic at the University of Liverpool. And they call it the cat paw study. So it's cat perspective, aging and welfare study. And I like their terminology. So um'm a a mature cat is seven to 10. A senior is 11 to 14. And they have this nice term super senior.
00:18:34
Speaker
And that's i like super senior. That's cats over 15. And these are cats that are you know pretty healthy and doing well. And they reserve the term geriatric for cats with established age-related diseases. So I think geriatric refers to health status and not a chronological number in you know that the owner tells you. My dog is 14. We need to look at more things.
00:19:04
Speaker
Does that make sense? Absolutely. And I always just use senior and geriatric interchangeably, but I never thought about maybe categorizing them instead of just thinking as age as being a number, but also considering their health status when we're defining what phase of life that patient is in. And I also think owners are so connected to their pet. that sometimes they feel the term geriatric is a little, it scares them. You know, so that's why I like the term super senior if they're doing really well as a super senior cat. yeah But then, you know, if they're really struggling and they got a lot of problems, then we can talk about geriatric. I mean, I often call the older dogs, you know, he or she's a gray muzzle.
00:19:55
Speaker
now. And that's another term that's not, you know, owners identify with it not being a negative term. So I think that's important.
Frailty's Role in Anesthetic Risk
00:20:03
Speaker
So you're talking a little bit about that one study in dogs that is assessing our senior dogs based off their health status. And one of the categories they're looking at are things like frailty. So I want to touch on that a little bit more. Yeah. You know, we talked about anesthetic risk, but the ASA status has been developed as a tool for assessing risk in the peri anesthetic period. And so kind of what you touched on with the Broad Belt Study, there was some thought that potentially you would put
00:20:36
Speaker
you know a senior cat and a higher ASA grouping or something like that based off of their age. But I was reading over some articles that you were writing, which maybe suggests instead of just thinking about just like a ah number, the age, maybe subclassifying these geriatric or senior populations.
00:20:58
Speaker
based on things like level of frailty yeah or whether or not these patients do have overt or subclinical coexisting diseases. Do you mind touching on that concept a little bit more? So I usually classify them as healthy patients, but with age-related changes. because We know as we age, you know all of our organs are aging as well. so They may appear outwardly pretty healthy. You run blood work. There's not much that you see wrong.
00:21:29
Speaker
But you know that they've got age related changes in their physiology. And we can talk about that. And most of that is loss of functional reserve. You know, they just don't have so many reserves to call on in a crisis. Like if there's a sudden, you know, blood loss.
00:21:45
Speaker
we need to support them more than a young dog would probably need to support it. And then we have those animals with subclinical organ dysfunction. so we are And probably the kidney is the one that we think of most, where you know blood work can look normal when you know over 50% of renal function of the kidneys aren't even doing much.
00:22:09
Speaker
so they can function, but we're not picking up anything on blood work. But then when we challenge them with anesthesia, which would be you know fasting, they might vomit, they might not get enough fluids, they might be hypertensive, and then that subclinical you know organ dysfunction that they've been dealing with just gets tipped over the edge. And then we have the ones that you know that are the real challenge, the ones with overt conditions and multiple comorbidities and that is often the cats who are older, we truly would call them geriatric because they have like four or five different chronic diseases.
Frailty in Human vs. Veterinary Anesthesia
00:22:51
Speaker
But I think frailty, you really hit on that because frailty is something I feel for everybody here that is doing anesthesia, we need to pay more attention to it.
00:23:02
Speaker
and The term frailty is relatively new in human medicine, and Ashley was looking up PubMed. It only entered into the literature in 2001. This term frailty describes patients that have decreased functional reserve, a decline in their physiological and cognitive performance, and that makes them more vulnerable to adverse medical outcomes.
00:23:27
Speaker
And the terms that I like to use to explain it to you know your our listeners, but also owners, is that there's a loss of robustness. right you know You've got your young, healthy pet who's very robust.
00:23:44
Speaker
And so the term robustness is the ability to maintain optimal physiological function in the face of a stressor. And let's all be honest about this, anesthesia is a pretty stressful, abnormal thing to go through, then we have this term that I use with owners a lot, which is resilience. And resilience is the ability for them to bounce back, like for them to bounce back to their baseline function, um following a disturbance, an illness, an anesthetic or something. So robustness and resilience I think are good.
00:24:25
Speaker
If you look at all the data in humans, frailty is not synonymous with aging. And in humans, chronological age is not a sensitive predictor of perioperative morbidity or mortality. But frailty is a predictor of both morbidity and mortality, whether or not they'll get a perioperative infection, and is very
Benefits of Prehabilitation for Frail Pets
00:24:48
Speaker
predictive of how long their hospital stay will be. So when a doctor is looking at an older person, they're going to evaluate them for frailty and that will put them into a different risk category if they're very frail. We now have tools in dogs and cats to assess frailty. So I think we should be doing it.
00:25:11
Speaker
You know, it's funny because I sometimes work with dentists and we oftentimes are anesthetizing older animals whereby maybe that animal hasn't had the dental care that they needed due to concerns about the animal being older and not wanting to put them under anesthesia.
00:25:29
Speaker
But we always have this conversation ah with owners about, you know, we never called it resilience, but it is resilience. So I was like, how well is your animal going to bounce back after we anesthetize your animal for pretty major dental surgery? And I feel like we always talk about amongst ourselves, like we just have this clinical intuition about the ones who we think are just not going to do that well after anesthesia and the ones that will probably bounce back really quickly. And I've never been able to put my finger on it, but maybe the answer is you get this clinical sense or this clinical intuition towards that geriatric or older population of animals that that are more frail. Yeah. No, I mean, you you you hit the nail on the head, but you see them, you know it when you see it, right? Yeah. A little skinny cat, you know, that doesn't have much muscle and all crinkly, you know, or the gray muzzle with the cloudy eyes.
00:26:24
Speaker
So, you know, but we do now have tools for you. We can actually, so you know, actually assign them a frailty index, which, you know, changes their risk status. But the thing that I think is pretty exciting is that in humans, when they go through their pre-op evaluation, because they have not frail and they call them robust patients, they have pre-fail where they have, you know,
00:26:51
Speaker
several of the, you know, they're positive for several of the things that they evaluate, but not all of them. And then they have the frail people. And if it is not an emergency procedure, they actually send them for prehabilitation to get them fitter and in better shape in order to sail through the procedure. I was just looking at a ah paper the other day which is structured pre-surgery, pre-hippilitation for aged patients undergoing elective surgery and it improves surgical outcome, length of stay, mortality, morbidity and it saved the hospital a lot of money to do this program.
00:27:34
Speaker
And the key focus is on looking at nutrition, stabilizing all their meds and what's wrong with them, but then actually putting them through a very, very simple rehab program, like gentle walking, a bit of resistance.
00:27:50
Speaker
So there's not a lot of reason we couldn't do that you know with this thing. We have an elderly Labrador that is frail and we're doing something that yeah could be a dental. So it's not necessarily an emergency.
00:28:06
Speaker
So we could make sure the nutrition is you know the way we want it. We could assign them some home you know under supervision or send them to a website or send them to rehab to get them in better shape to handle the stresses of anesthesia. And I know a lot of owners that would definitely um embrace that approach. So so I think that we can do that. One of my own personal cats was a very, very frail. I mean, he was a four out of four on the feline frailty scale. He did a dental. So I was like, okay, what can we do? So he had lost
00:28:47
Speaker
quite a lot of weight. He had chronic kidney disease. His blood pressure was a little high. So I got him on a kidney diet. I got his blood pressure controlled. I started doing more gentle exercise. I got him to actually in the seven weeks I worked on him, he gained like almost like 0.5 of a kilo.
00:29:07
Speaker
wow you know We just did little things with him to make him fitter for his dental and he ended up having several extractions and a cleaning and he was under anesthesia for a couple of hours and he did bounce back pretty well. So I think there's just these things we should be thinking about.
00:29:25
Speaker
Yeah, I love that. And for our listeners, we will provide a link to those frailty scales so you can review them in our show notes. I think the other thing that we should try and emulate is there's a society in the human arena and they're called the ERAS Society. So nothing to do with Taylor Swift's current world tour. You know, it is E-R-E-S.
00:29:51
Speaker
So this is the ERAS Society and it's the ERAS stands for Enhanced Recovery After Surgery. So this group developed multimodal perioperative care pathways to achieve an early recovery. And what they've been doing is re-examining old dogma and replacing them with evidence-based best practices.
00:30:14
Speaker
And it covers the patient's entire journey. And one of the things they focus on for all patients, including elderly patients, is nutrition and focusing on showing that there's good evidence that short fasting periods are actually beneficial. So now in humans,
00:30:34
Speaker
It doesn't matter if you're young, old, they now only fast you from solid food for six hours. And two hours before you go under anesthesia, they give you this carbohydrate drink. And they've shown that that decreases the risk of aspiration pneumonia, which we know in elderly animals is they are at higher risk. And always, you know, you think about the larger breed dogs with larpar. And then what they've shown with these just shortening the fasting period that lean muscle tissue is maintained better after surgery. They're looking at techniques, minimizing opioid use so that people want to eat and they're trying to get people out of bed and up and moving quickly. All the things that you know we can do
00:31:25
Speaker
And actually, Lewis Campoy, one of our esteemed colleagues, he is the only person I know that has published a paper mentioning the ERAS approach to anesthesia in veterinary medicine. And his was looking at using local regional techniques for early recovery, mobilization, fewer systemic drugs that make them want to sleep or regurgitate and so on. So there's a lot of data just showing that if we just stop saying we've always done it this way, oh yeah right? And look at the data that's coming out. Yeah. I mean, a lot of this is pretty intuitive, I feel like, but not really being put into practice necessarily.
00:32:13
Speaker
Yeah. Yeah, absolutely. So I think what we should transition to now is kind of like the nitty gritty of how we would approach a senior patient. We're going to start with pre anesthetic assessment. And of course, now I'm going to start doing frailty indexes as part of my approach. In any case, I read once And there was a study looking at the effectiveness at pre-anesthetic blood work and actually like altering the course of a patient's anesthesia, meaning like, do the results of the pre-anesthetic blood work make you change your approach to how you're going to nest size that patient? And I remember reading a paper which basically said that pre-anesthetic blood work like rarely altered the course of anesthesia for animals.
Debate on Pre-Anesthetic Blood Work
00:32:56
Speaker
It turns out, which is unshocking, that I think it's more nuanced than that because there are other studies that I've read since then that have focused more on an older population of animals. And they have shown that pre-anesthetic blood work was able to detect some kind of underlying disease that like wasn't known. And I feel like in one of the studies, it was a very high percentage. It was almost 30% of the animals. But don't quote me on that. like That was... No, I know you're right. Because I know exactly. the paper That was one from South Africa. Yeah, it was from South Africa. Yeah, did the South African paper. Yeah. So the first one that you're talking about was from the UK. And they did preoperative blood screening work on dogs and cats. And they were, you know, mature, older animals. And, you know, based on the veterinarian's physical exam, only 1% of the blood work was unexpected.
00:33:47
Speaker
Yeah. And then the results of the blood work, I think had them occasionally they would delay the case to maybe give some pre-op fluids or something, or they would change the protocol in like, I think it was like 4% of cats and maybe 9% of dogs. So it was pretty minimal, like what it made them do. But the South African paper They actually diagnosed new diseases that no one had any idea about the document for a procedure. They ran the blood work and they were like, well, they canceled the case because now they had actually diagnosed a disease like it could have been cancer, addisons or something. Right. So I think, obviously, the key, and it's the same for doesn't matter what age your patient is, is getting a very, very good history, and also an excellent thorough physical exam, and then choosing what pre-op workout you might want to do, whether it be blood work or an echo or thoracic radiograph, because we're always going to be thinking about, you know, if we run everything,
00:34:56
Speaker
then the owner has no money left for the procedure, right? So we're checking budgets. So I think you need to be goal. So what do I really need to know about this animal? You know, I heard a murmur, is it relevant or not? Maybe yes, we could run, you know, cardiac biomarkers or let's do an echo if we can, you know, in a litigation society, which we are, you know, I think baseline CBC in chemistry,
00:35:22
Speaker
and always a UA are kind of for me in the older population. And that is to have we missed something, but also to give us a baseline in case something changes afterwards. And you can see where were we and what has happened.
00:35:42
Speaker
So that's kind of how I look at it. And when I see, I think the history, I can't emphasize that enough now that I've moved into working with older populations and people that are going to Dr. Google and then finding things that they think will help their older pet. So I think it's really important to ask the right questions. So you can say to an owner,
00:36:08
Speaker
you know Because you may be their veterinarian and you know what drugs they're on. But getting from the owner, what drugs is your dog or cat? um Are you giving? And they'll give you a list if there are prescription meds. But what I found out is that owners don't consider aspirin a drug, right? Because they often take the mini you know the the small dose themselves every day because it's good for your heart. So sometimes you have to say to them, and do you give aspirin?
00:36:38
Speaker
to your dog. And they're like, yes. And I like, well, that's a choice. And we didn't know that, right? The other thing is they're giving so many over the counter products now. Right. And they assume that because they're natural, you know, or herbal, or whatever, or CBD products, that must be harmless. And the ASA, the Association, you know, the American Society of Anesthesiologists have a really good link to supplements and anesthesia. And you know if you just look on that website, there's things that people are giving to pets like ginseng, garlic, ginkgo, and all of those increase the risk of bleeding during a procedure. So I always say, you know are you giving any herbal medications? you know Things like St. John's Wart. I mean, a lot of people give that to their pets thinking it helps for anxiety. And
00:37:32
Speaker
If we don't know that, we might have an animal with a prolonged, you know just not waking up from anesthesia, but we didn't know we don't know there's some John's war on board. right so i think asking about over over-the-counter, obviously nowadays, cannabinoids. Any herbal is really important to ask them about that. Not to say, like, please just tell me everything your dog's on, you know, you're not judging them, because they're just doing this themselves without us knowing.
00:38:02
Speaker
But there are two other screening tests that I think you mentioned. My opinions on them have changed over time as well. But for senior pets, and you know I have been starting to recommend more thoracic radiographs for senior pets. And it's only because I have had a few cases now whereby we were planning to do an elective procedure. And we did set elective procedure, but then the patient just like didn't bounce back after anesthesia.
00:38:29
Speaker
or they just kind of just never like got well. And it turns out that patient had maybe subclinical cardiac disease or maybe had you know metastatic cancer that we just didn't know about before the case. And so I've been starting to recommend more and more thoracic radiographs for that. No, I'm not saying thoracic radiographs are an amazing screening tool to pick up those diseases, especially when they're subclinical. But I also feel like it helps a little bit as a for peace of mind, at least for owners and for yourself beforehand. By yourself, I mean the anesthetist, but I didn't know how you felt about that because I do know you always have to take into consideration cost as well.
00:39:14
Speaker
There's nothing that you just said that I would disagree with, unless cause is a huge, huge issue. But oftentimes you're taking a radiograph of something, another part of the body anyway. And so to get a good thoracic radiograph, I think is a good idea. And we may find some surprises that just can't be picked up on physical exam and out from blood work. So no, I agree with what you said.
00:39:42
Speaker
And the other test that I've been recommending as well, especially with senior cats is blood pressure. Yes. For sure. yeah So I've also been recommending that as part of a prancetic screening for senior cats. And I have started doing it for dogs as well, but I do find it's more rewarding for cats. Yeah.
00:40:04
Speaker
And it's interesting because I feel like a lot of times I will be the first person, you know the animal will come to see me and you know I do a physical exam. I do a blood pressure myself before I anesthetize them and I'm oftentimes picking up hypertension. The question then becomes, you know do we pause the procedure and get this animal's blood pressure under control before we start or do we just you know do the procedure and then you know start afterwards controlling the blood pressure? and I don't know the answers to that question. It's a really good question and and i and I think it's a real conundrum because sometimes
00:40:43
Speaker
A lot of people will, you know, when you take a ah cat's blood pressure, I always do it with the doctor, headphones on, try and calm them down, take several readings. Because a lot of people say, well, of course the blood pressure is always up because they're in the clinic and they're stressed.
00:40:59
Speaker
you can look at you know how the cat looks. You look at its blood pressure, look at its heart rate, and come to a conclusion. But there's a lot of cats that are going to be you know early stage chronic kidney disease. Their blood pressure is creeping up.
00:41:14
Speaker
If you look really carefully, they've maybe you've been losing a little bit of weight since the the last appointment, and it all starts to add up. And then if it's not an emergency procedure, I think you can say, well, you know why don't we maybe look into this a little bit more? you know Because we're not in a rush and put to rest that there's not another new issue.
00:41:39
Speaker
The other thing that makes it really hard in cats is that so many of us are now doing the comfort kits that the owners get. So they give them the gabapentin or now pre-gabalin at home. right And now we just have a new paper from Dr. Jessica Quimby showing that gabapentin decreases blood pressure in cats.
00:42:01
Speaker
And she has a little concern that that could be an issue in cats with chronic kidney disease and you may get a false reading. So there's so many things to think about, but again, it's your intuition, experience.
00:42:16
Speaker
And it's not just one thing, it's like putting the composite picture together about this cat and whether or not this is this one high blood pressure or you'll probably do several. And often I'll say, well, let's just let them chill out, you know, let them sit in their cage, get used to us, then let's do it again, you know, in their cage. And if it's still higher, like, oh, okay, maybe we need to take this seriously. But that's a tough one.
00:42:42
Speaker
Yeah, I don't know. And I also think the conundrum too is that we don't have super great guidelines on how to alter antiseg management of patients with hypertension. correct like We have some like intuition, but that's also a challenge and and a question I get asked a lot. I never know how to answer it because I just don't think we we know enough.
00:43:03
Speaker
yeah no i think because i mean If they're already hypertensive, mean if that's how they're functioning and we need to take it to surgery, are we trying to correct it back to the generic normal of the population? Because this dog or cat is obviously an outlier, right? so It's a question, so you need to look at things like, are they perfusing well? Are they making urine? and they you know Like all the other things that would tell you that cardiac output, perfusion, all these things are are good, even though this blood pressure's they you know on the bell curve, somewhere outside of the normal population. So that's, again, experience and skill set that you're talking about.
00:43:48
Speaker
Well, let's get into physiology. yep Why don't we start talking about how the body changes with aging, obviously in the context of general anesthesia. And the first thing I'm going to ask you about are drugs. So do we know if the pharmacokinetics of commonly used anesthetic agents is altered in older populations?
00:44:13
Speaker
So in humans, they have tons of data, right? They can look up dozens of drugs, including antibiotics and everything you're going to use periodically and find out how the pharmacokinetics and pharmacodynamics, so how the body handles it and what the drug does to the body based on age-related changes.
00:44:34
Speaker
The only paper that I found is and is is an old paper, but it's a good one that is along those lines. And it was looking at the pharmacokinetics of propofol in dogs. So these were 30 kilogram dogs, so pretty decent sized dogs between the age of eight and a half and 10 and a half.
00:44:56
Speaker
So, you know, definitely in that older population. And what they found was that the induction dose of propofol was lower and they had a cohort of younger dogs um of the same size but in the four to five year age range.
00:45:14
Speaker
And the amount of propofol the older dogs needed in order to be able to easily intubate them was actually significantly less than the younger dogs. And then they were doing blood work in pharmacokinetics and the older dogs had lower clearance of the propofol, but that's one of the very few studies. um Other than like Jessica Quimby again, with gabapentin, she's showing that the plasma levels of gabapentin and the sedation that you get is correlated pretty closely with their creatinine levels, because that's a really excreted drug.
00:45:55
Speaker
I try to inform people a lot, but at least about gabapentin, that especially the animals with renal insufficiency, there was that really nice paper that said you should reduce, I think it's by half. Yeah. yeah She, I mean, she really, you could see the correlation between creatinine levels and the dose of gabapentin. And I think the cats with iris stage two and three,
00:46:17
Speaker
They were more sedate on 10 mg per kilo than healthy young cats without kidney disease that were getting 20 mg per kilo. So it's pretty significant the effect of gabapentin on cats with and without chronic kidney disease.
00:46:34
Speaker
Just because something is old doesn't mean it's not good, as you mentioned before, and this whole conversation is about. But that paper you talked about with propofol is not shocking to me, at least like from my clinical intuition. But it's a shame that we don't know more about other drugs.
00:46:52
Speaker
There's a few other drugs that I remember working with some of the people that trained me in anesthesia way back in the day in the UK, and they were looking at things like pethidine or myperidine, and how that differed in young dogs compared to older dogs. So that's all kind of buried in the literature.
00:47:13
Speaker
I actually resurrected it for the chapter on Aniseas of Ageing in the new Lemon Jones book. But there isn't a lot of research, I mean, looking at how different these young animals are compared to the aging population. And then we know that the older dogs and cats, a lot of them have sarcopenia, so they've lost muscle mass.
00:47:37
Speaker
And all of us that learn physiology and pharmacology and everything, we know that after we give an anesthetic, obviously, you know, talk about an induction agent goes IV goes to the brain, they go to sleep, but then it reverses out of the brain. And one of the places it goes is the muscle and it kind of sits there. That's kind of like a depot or a spot, whatever, and then slowly gets released and then either really excreted or metabolized.
00:48:06
Speaker
So these older pets have less muscle mass. So, you know, we've got to think about that. If we're talking about, let's say, like an opioid, for example, like a pre-medication agent, are you considering when you're dosing these drugs out? Do you ever do like a dose reduction if your patient has sarcopenia? I actually don't. The way that I approach these animals is that I try and use drugs that can be titrated to effect as best I can. I like to use anything that's reversible right because you can reverse an opioid if if you've got so too much but you don't want to you know, leave them painful. So I think that's a really hard prediction. So I use drugs that are titratable to effect. So for induction, pubofol, olfax, olfaxolone, something that's reversible. So all the, you know, dexmedetomidine, medetomidine, you know, Medazolam is reversible, likes all these reversible drugs, and then choose something with the highest therapeutic index that we have. So the opioids are high therapeutic index,
00:49:22
Speaker
olfaxone, higher than propofol, short-acting drug, you know, because there's not a magic ball that we can look at and predict. So we do it, you know, using our skill set.
00:49:36
Speaker
Oh, it sure it certainly makes sense since I think that's a pretty good rule of thumb for approaching kind of the analgesic plan, at least a drug plan for those patients. I just also want to touch base because you touched on this a little bit earlier, but I want to just briefly talk about how aging affects the normal function of so our body functions.
00:49:58
Speaker
And what can we expect as a result of some of these physiologic changes? And I think we should focus probably on the cardiovascular respiratory systems and probably also renal function. So let's start with like the cardiovascular system. So what are changes that we should expect? So with age, what we're going to see is decrease in cardiac compliance, is you know what everybody reports in all the physiology papers.
00:50:22
Speaker
And then I think what's very relevant to anesthesia is a decreased sympathetic response. So if an older animal suddenly, you know, there's a bit of a whoopsie and we're having a lot of blood loss,
00:50:38
Speaker
So a younger animal would sympathetically you know be able to respond better. I mean, anesthesia blunts a lot of that anyway, but an an older animal doesn't have have that sympathetic response that a younger animal has, and they don't have the functional reserve to call on. So that's why we need to be very vigilant and then jump in to be their surrogate to to help them.
00:51:05
Speaker
And then most older animals like people have a slower circulation time and when that becomes relevant is at induction. So I always try and get people when they're inducing most of the time but with the older animals thinking about, okay, you've got your needle inserted into the injection port.
00:51:25
Speaker
and you're injecting it. But think about it's flowing up the vein, it's going to the heart, it's going around the heart, it's going out, you know, and eventually gets to the brain. But just don't rush to give a second bolus because the first bolus might not have got there yet.
00:51:44
Speaker
right? Because things are moving a little bit slower. And everybody knows that when they've got a big dose of dexametatone on board, things move slowly. But if you start saying, okay, they're not going to go to sleep and boom, I give it then you've got wham wham to, you know, more drug than you needed arriving all at once. And then they kind of like go wham on the table.
00:52:07
Speaker
So I think you want to be, no matter who's breathing down your neck, telling you to hurry up, go slow and to affect that induction. And often when we go slow and give it time to get there, we end up actually using less of the induction agent anyway. So that's beneficial.
00:52:24
Speaker
I'm so glad you said that because that is like one of my soapbox things. Good. but Well, we can stand on the soapbox together. Yeah. Just take your time with these patients. Yep. Take your time. And I often like, I call it the anesthesia sandwich, uh, co-induction techniques.
00:52:41
Speaker
So I give them a very, very small amount of either propofol or olfaxilone. Then I give them a chaser of midazolam. And sometimes we're done. And people are saying, you're kidding me. Like they only got half a meg per kilo of propofol. And I'm like, uh-huh. And we're ready to intubate because yeah they're an older patient. And we're done.
00:53:03
Speaker
And you're not dealing with the hypotension from your propofol or faccellon as well. Yep. And then if you're not ready to intubate, then you go and you say, well, we're just going to give a little bit more of our induction agent until we get there. And it's nice and smooth and it works really well. You were talking a little early about renal function and how that's altered in aging. So what should we expect as anesthetists as far as changes that will happen with our patient under anesthesia as they relate to renal function?
00:53:32
Speaker
Yeah. So I think that the the biggest issue to think about is like you can have, I've run pre-op blood work and it looks fine, but that patient might only have 25% of like actually functional renal tissue because they have decreased renal mass, decreased perfusion. Now add on to that, the fact that a lot of our older dogs and cats have osteoarthritis and they may be on a non-steroidal or they're on a non-steroidal for another reason.
00:54:02
Speaker
So for me, one of the things i I'm really focused on with the older patients is ah making sure that I am able to monitor blood pressure well. And if the blood pressure is low, that we aggressively and quickly fix that.
00:54:22
Speaker
because people need to remember if they've already got a nonsteroidal on board, what the kidneys would normally do, if you're under anesthesia and the kidneys are like saying, hello, I don't feel like I'm getting enough perfusion. So very smart. What they do is they send out vasodilatory prostaglandins that then brings blood flow and glomerification rate back. They're like, it's a self-preserving loop. Now, if they're on nonsteroidals,
00:54:51
Speaker
They can't do that right because they're prostaglandin inhibitors. so We need to be very, very cognizant of aggressively treating hypotension, watching if there's more bleeding than there should be. and Some of the older dogs and cats and the ones we know have chronic kidney disease I'll get them into the hospital early, place an IV catheter and actually let them sit there getting fluids maybe for two or three hours ahead of the time that they're ready to go into the OR. And that's actually in the AAFP guidelines and in the um AHA anesthesia guidelines that some of those patients could benefit from just sitting there, you know, for several hours just getting fluids.
00:55:37
Speaker
Yeah. And that is something I think I've personally changed in my practice as well recently as I try to, and I don't just do this for my, my older populations. I actually do it for all of my patients, as long as they don't have substantial cardiac disease. I'm going to jump to a totally different topic and I want to talk a little bit about cognitive dysfunction because I find for me recommending, you know, drug protocols for this population can be kind of challenging.
00:56:07
Speaker
I think cognitive dysfunction for dogs and cats, it's very stressful. It's stressful for pet owners, but it's also really stressful for the veterinary team when you know you have to do some kind of anti-psych procedure on these patients. And these patients can be super challenging to handle, especially when they're stressed from the hospital environment. So I've personally have been asked about set of protocols to administer either at home by the owner,
00:56:35
Speaker
And, you know, even for patients that maybe are experiencing sundowning in the evenings, or sometimes amass about protocols for these patients, like even before they get to the hospital, to make them less stressed and to make handling these patients a little easier. I'm just curious, what are you recommending to help sedate these patients with cognitive dysfunction. And I guess also beyond just like medications, I'm curious if there's like other tools you can recommend that help that will help these patients.
00:57:06
Speaker
so There's so many things that we do as anesthesia technicians or anesthesiologists, anyone in the team working with these animals in that periodic period. There's so much that we can do that's not rocket science, right? It's not some crazy new drug that we can give.
00:57:24
Speaker
So with cognitive dysfunction, which is pretty common in dogs older dogs and cats, you know it's the the cat or the dog that's pacing at night and you know that awful vocalizing and and so on. So the one thing, and it's the same in in people, the one thing that really is upsetting for those animals is any change in their daily routine, right? They don't like changes in routine. They don't like strange places and they don't like strangers, right? These are all things that what's going on. You know, I walked into this room and I don't recognize this room. What am I doing here? And you can kind of see it on their face. yeah um And it can be really distressing for them. And what I've seen is some of them come into hospital
00:58:10
Speaker
and they literally shut down or give up. you know they just like they're They're kind of glazed over. And so what I do is I suggest that you schedule the oldest patient on your surgery list or procedure list should be first thing in the morning so that you can try and get them dealt with as an outpatient and get them home because that's where they do best. But I always, always tell the owner to bring their, um great well, you can do this for any patient. I think it's important for these ones to bring their own bedding with them, not all clean and washed and, you know, like the bedding that smells like them and what smells like home. So I have them bring their bedding in with them to bring their favorite toy.
00:58:59
Speaker
and also bring something that the owner has worn recently and not washed,
Melatonin for Pet Anxiety
00:59:04
Speaker
like a t-shirt or something that they've been wearing that smells like the owner, and you put that in with the dog or the cat. That all goes in their little cage or kennel, and that should be left with them. The other thing I try and do is assign one person in the team to be with that pet in the hope that they might build a bond. So they're not seeing six different people. One person who comes to take the temperature, one person comes to do the pre-meds, one person comes to, you know, so it's maybe one person that kind of like guides that pet through the whole procedure, kind of holding their hand like it would give us a person. So I think there's some little things like that. And then, because we haven't talked about it before, we have to remember that these older pets
00:59:55
Speaker
and it's part to do with their brain and it's part to do with their change in muscle mass, they don't thermoregulate very well. So they get cold very easily. So we need to make sure we focus on keeping them warm from the minute they arrive. So microclimate in their cage or kennel, wearing a jacket, keeping the prep area and recovery rooms warm, that type of stuff.
01:00:18
Speaker
The one thing that's pretty interesting from the human arena, and I use it a lot, is melatonin. So melatonin, some people probably know about the CHIL protocol, but in in humans, and and I was surprised when I talked to some of the University of Florida anesthesiologists that deal with elderly patients and and and young children, anyone.
01:00:42
Speaker
that they use melatonin as an anti-anxiety medication before and after surgery. And then the other thing is there's some really interesting work going on and anyone listening that's had an anesthetic probably knows that after an anesthetic, your sleep pattern is is disturbed, right? Your circadian rhythm is knocked out of whack. And so they're now, they've actually, that I read a paper just recently that they're using melatonin to reset circadian rhythms after propofol and it sees in people.
01:01:17
Speaker
So when I was at Michigan State, and that's a while ago now, with my older pet population, I always recommended that the evening of surgery, or the evening after surgery, that we gave those pets melatonin, either in the hospital or to go home and do it for several days. And I had one owner who had a 14-year-old Labrador that had had multiple procedures done, and she said that it really did make a difference. I have no hard evidence-based data, but I think based on the human literature and my personal experience, I would do that. And then, of course, I just need to mention that we've got to give them melatonin that does not contain xylitol, right? So make sure you check the label.
01:02:07
Speaker
So, what dose do you use yeah so there's there's one study in in the veterinary literature where they were using it as a pre-med and they were looking at the sort of happy dogs and then they called them, I think they called them the sketchy dogs, so the ones that were a little bit nervous. It was a European study and they were looking to see if melatonin was actually was able to take the sketch off like sketching this off like they used to look at you like I'm a little scared and so they were giving five milligrams per kilo so what they found was yes that's a massive dose right like that's a lot yeah that's a lot so they did show though that the dogs that were anxious are sketchy or No, skeptical. That's the word they use. Oh, that's probably a better term. in case You want skeptical dogs. It's a little nervous. They had the most most benefit from that dose of melatonin and it decreased the induction dose of propofol.
01:03:08
Speaker
but that's a massive dose. I tend to use doses that are more similar to the one that is written into the Jill protocol. So the little dogs will get three milligrams, the bigger dogs, five, 10, but I, you know, play around with that. So if I have a lab, an old Labrador that's come in and on his way out the door, I'll make sure that it may be probably gets 10 milligrams of melatonin that night.
01:03:37
Speaker
xylitol free melatonin. And I don't know, but there's certainly a lot of research in humans. And there's that one paper that did show that it did help take the anxiety away from the skeptical dogs.
01:03:53
Speaker
Do you find that gabapentin or triazodone is helpful for this particular population of of dogs? Yeah. So I think, you know, when we do our, you know, the pre-vet and revisit drugs, a lot of cats are getting gabapentin or the new bond cat. So pre-gabalin. which I think, you know, works well as an anti-anxiety agent and dogs can get gabapentin as well. Trasadone can certainly help. So I think, you know, thinking about these drugs to help smooth out the anxiety about being in the clinic is important because if they become very, very anxious and anxiety drives pain and makes pain worse. And then if they're painful, they get more anxious and it's just a vicious cycle. yeah so i think you know and There is a lot to be said for some animals, and you know so I know we're all busy and we're short-staffed, but some um there's a new paper showing that it was actually for brachycephalics, but they showed that if you allowed the owners in to the recovery area to sit with their pet,
01:05:02
Speaker
the recoveries in Bregus of Alex was much, much smoother than when the owner was not present. Now, that I know is going to be like, some people are going to say, no way is that going to happen. but like That's very controversial. Yes, but they did the study and they showed that it was possible. But that's why I like the owners to bring the pet's own bedding and then leave something that they that smells of them with the dog or cat. Molly,
01:05:30
Speaker
Sheila, we've spoken a lot about geriatric patients and I have learned a ton today. And I'm just so grateful that you came onto our podcast and chatted with us about how we can handle our senior animals with love and compassion when we anesthetize them. So thank you so much.
01:05:48
Speaker
yeah Well, thanks for having me on. and they They have a special place in our hearts, right you know the grey muzzles and you know these old pets. and um They really need a lot of care and it's tender, loving care, like it like every patient, but they are a little more fragile. andan Like I say, I always tell my students, you know anesthesia is not rocket science. A lot of it is just practical, simple things. You keep them warm. You tell the owner to bring some bedding from home, a toy from home. You know, you just position them carefully because you know, they've got creaky joints, you know, just all those little things that all add up and it can be hugely successful. Yeah. Well, thank you again. Okay. Thank you.
01:06:42
Speaker
If you like what you heard today, I encourage you to check out the North American Veterinary Anesthesia Society and consider becoming a member. As a member of NAVAS, you get tons of benefits, including access to CE events, focusing on anesthesia and pain management, blog posts, fireside chats with boarded anesthesiologists, as well as specialty technicians, and just so much more. VIN rounds are another benefit for NAVAS members.
01:07:06
Speaker
Vin rounds are hour-long presentations on specific topics in veterinary anesthesia that provide tips and tricks that you can use at your next day of work. If this sounds interesting to you, visit www.mynavas.org to advance your anesthesia journey today. If you've been enjoying the content of this podcast, I would sincerely appreciate it if you could give us a like or subscribe to our podcast, write a review, or simply spread the word about this podcast to your friends and coworkers.
01:07:35
Speaker
We appreciate any and all listener support. If you have any questions about this week's episode or the NavAss podcast in general, or if you want to suggest topics you would like for us to discuss in future episodes, please reach out to us at education at mynavass.org. We would love to hear from all of you.
01:07:55
Speaker
Also a huge thank you to our sponsor Decra, without whom this podcast would not be possible. Visit their website www.decra-us s dot.com to learn more about their line of veterinary anesthesia products. I wanted to thank our guest, Dr. Sheila Robertson, for this insightful discussion on caring for older dogs and cats undergoing anesthesia. This podcast was produced by Maria Bridges, edited by Chris Webster of Chris Webster Productions, and technical support was provided by Sal Hemenes. And lastly, a huge thank you to all the gas pastors out there who choose to spend their time with me today on the North American Veterinary Anesthesia Society podcast.
01:08:36
Speaker
Becoming a skilled anesthetist is a lifelong journey of learning and self-discovery, so I hope you consider listening in the future. I'm your host, Dr. Moni Gatson, and thank you for listening. See you next month with another episode of the NavAss Podcast.