Transcript
Annatasha: Oh, hey, man.
Gianluca Bini: It's not Brian.
Ryan Bailey: Wow, oh my god but Yeah, I is anyone else on the is there anyone else on the stream right now or is it just it's just me, right?
Gianluca Bini: likey
Annatasha: Yeah, it's so funny that we're all in green.
Annatasha: Yeah.
Gianluca Bini: It's you and us, yeah. And you're the only one with the real mustache.
Ryan Bailey: me
Annatasha: Yeah, this whole mustache situation is not something that I'm enjoying. It's making my upper lip sweat excessively.
Gianluca Bini: It's so weird.
Annatasha: And I think most of my free time making sure that I'm not growing a mustache. So this is a real low point for Bartel.
Gianluca Bini: That's awesome.
Ryan Bailey: Oh my god, I love it.
Gianluca Bini: That's awesome.
Ryan Bailey: This made my day. ah Very nice, very nice.
Annatasha: Yeah, we've been planning it for a while.
Ryan Bailey: yeah
Gianluca Bini: So technically, this was supposed to happen.
Gianluca Bini: So for whoever is listening, me and Dr. Barthel are actually wearing a fake mustache to mimic Dr. Bailey's mustache. So you can watch us on YouTube or Apple Podcasts.
Gianluca Bini: But we were planning this for the previous episode before
Gianluca Bini: to barels The The third butt tells.
Annatasha: Valentine's Day. But Dr. Bailey was late, and so we couldn't surprise Dr. Bailey. Yeah.
Gianluca Bini: Exactly. She was late. She forgot. so
Annatasha: I'm never going to hear the end of this. I just know it.
Ryan Bailey: you
Gianluca Bini: yes
Annatasha: I just know it. Also, i just anyone who is watching, and I want you to think in any way that we condone mid -20th century monotical is strictly to mock Dr. Bailey.
Ryan Bailey: I am well -marked for the mustache days.
Annatasha: Oh, do we have to wear it?
Gianluca Bini: but we
Annatasha: Yang.
Gianluca Bini: It's up to you.
Annatasha: I don't know.
Gianluca Bini: We bought a whole collection of them.
Annatasha: I don't know how you put up with this. It is awful. Like my my mouth is so hot, it keeps catching things like that are flying like cat hair flying through the air. I just this is my. Yeah, I'm heading straight to the beauty salon tomorrow and I'm going to wax everything except the top. Yeah.
Ryan Bailey: Oh my God.
Gianluca Bini: That's crazy. All right. So tonight's topic, it's going to be picked by Dr. Bailey, right?
Ryan Bailey: Mm hmm.
Gianluca Bini: What you got? What you got?
Ryan Bailey: So given the discussion last month, I feel like I had I had to talk about lidocaine, its utility, like when are we using it?
Gianluca Bini: It's futility, I mean.
Ryan Bailey: What?
Gianluca Bini: You forgot an F there. It's futility.
Ryan Bailey: but but
Annatasha: God, Bailey, we just got burned by some of our savages Italian.
Gianluca Bini: I'm kidding.
Gianluca Bini: I'm...
Ryan Bailey: a a ah Oh god.
Annatasha: Wow.
Gianluca Bini: I'm kidding. I'm kidding. It has its users. It has its users.
Ryan Bailey: I want to know when are you reaching for it? Is it?
Annatasha: I'm going to numb my upper lip from this mustache. Can I please take this off now?
Ryan Bailey: right
Annatasha: wow
Gianluca Bini: alright All right. All right.
Annatasha: oh
Gianluca Bini: All right.
Annatasha: Yeah, what really I interrupted you, which is totally my jam, but anyway.
Gianluca Bini: Oh Jesus.
Ryan Bailey: no
Annatasha: Lyda Kane, what are we reaching for it? What's its youth utility?
Ryan Bailey: Yeah, like there are, you know, I feel like there are people who I have worked with who I think feel lidocaine is maybe wonder drug is a ah ah strong word, but there are people who swear by it. Everything gets, like a lot of things will get lidocaine in some people's care. And to find someone who's so vehemently against lidocaine, I just, I gotta know. I wanna know, like, what how do we all feel about it? Are we in the, it's a wonder drug? Are we in the, it's a useless waste waste of a pump, if you will?
Annatasha: Waste of a pump, that's our new insult for other clinicians that we don't like, by the way.
Ryan Bailey: a
Annatasha: This question is almost exclusively directed at Gian Luca, so I'm going to let him, like because also my provenance was what last month when he came down so hard on lidocaine that I'm now afraid to express an opinion.
Annatasha: Although it's a lot of big talk until something goes into VTAC anyway. But so yeah yeah, Beanie, like you lead this charge.
Gianluca Bini: Right.
Annatasha: You're the lidocaine revolutionary. So. really know
Gianluca Bini: No, and not I'm not. I mean, i as I said last time, I think it's, you know, I tend not to reach for it as my first choice. You know, can it be an addition? Do other drugs? Sure. But like, if I have to pick If the reason why I need an extra drug is an analgesia, that's not my first pick, right? There is a bunch of drugs that are mac -reducers that are not analgesic. a gal Like, they are probable, or fax, you know, those are mac -reducers. They're not analgesics though, right? Same way morale, but dang, right? this Because it's mac, no analgesia.
Gianluca Bini: But, you know, in reality, I feel like if I have to pick analgesics, I try to find something that I think it's a little bit better, like that's med or an opioid or calamine.
Ryan Bailey: Mm hmm.
Gianluca Bini: If I'm looking for a Canadian rhythmic, like, especially for ventricular arrhythmias, of course, like, yeah, slide again is definitely your go -to usually. You know, in some horses, like, you know, for colleagues, it's totally fine. You know, the Andandu Doxemia story I can buy and do it, it's fine. you know the You know, I was discussing this, who actually one of my VTSes today and, you know, she's she's an amazing tech and she has a VTS, she's been in this for like 20 plus years, right?
Gianluca Bini: And, you know, bouncing ideas back and forth, in reality, for some foreign bodies, maybe you don't really want to reach for live game, right? Because of the prokinetic effect and, you know, the fact that if you it depends on what kind of foreign body it is, it may or may not be beneficial for that dog, right? If it's like something metallic and it's indestined, you know? So I don't know, actually I think he has it has its But it's not usually my first pick for analgesia. If we're looking at pure mac reduction, sure, maybe, you know, with an FRK, you know, the usual family -leveling ketamine, done plenty of that. But at that point, I think there is better mac reducers too, you know.
Gianluca Bini: For me, it's a kind of that drag that's a good addition, but it's a little bit in the back burner sometimes. It's not you know my top pick. Maybe because I don't use high enough doses, right? Like, you know, there is people that like, again, as you were mentioning, you know, they end up with 200 or 100 mic per cake per minute of live again, then maybe you do see ah ah more beneficial effects, I guess. But you know
Annatasha: Yeah, I will say this about lidocaine is that I do feel I don't disagree with John Luca. I think that in terms of like, if I have a patient who's either getting light or is a little too light on the table, like we have increased abdominal tension, we you know we have bucking of a ventilator.
Annatasha: It's extraordinarily rare that I would reach for lidocaine as my first choice for a rapid increase in depth of maintenance plane.
Ryan Bailey: That feels good.
Annatasha: The other thing I have to say about lidocaine is that if I were to pick a drug that I have had problems with cardiopulmonary arrest and things, quote, dying off the needle, lidocaine is probably my personal number one. and I don't do crazy things. Like I don't whack in large boluses really quickly. Like I have had things where I've been giving lidocaine and specifically in an antiarrhythmic capacity and even at like 0 .25 mg per kg given slowly, they've arrested on me. Now, correlation is not causation. So whether the lidocaine was incidental to that or was actually the cause of the arrest, I will never know. But I've also been called frequently to a number of local anesthetic toxicity cases. I'm really going to highlight the dentists here who sometimes just hose gums down, not even knowing what toxic doses are. they mix locally anesthetics they do all sorts of wild stuff may have a CRA of one local anesthetic and then you know you're topping up with regional local anesthetic elsewhere which is technically speaking a no -no so I have
Annatasha: You know a number of cases where i've had to go into a local anesthetic toxicity arrest and those ones are more challenging to get back then like your straight forward like i left the appeal valve closed or i got really brady cardic just went into sinus arrest type situation so,
Annatasha: Lidocaine for me, I think it gets bandied around really loosely, loosey goosey lidocaine, but I have a healthy respect actually for how dangerous it is. And like I said, is it my first line in any capacity? So analgesia in max sparing, it's not, right? And then prokinesis, like the bulk of those papers are equine. And the other thing too is the bulk of the small animal papers are in vitro studies, not in vivo studies. So is there a prokinetic effect? I bet you we could, you know, get a room of nerdy anesthesiologists together and you probably end up with a reasonable divide. How potent is that prokinetic effect? I don't think we have any data on that. um And then, you know, we, I, you know, I will say clever things like, you know, it scavenges free radicals and it
Annatasha: You know, it prevents against reperfusion injury, but those are all extrapolations from human medicine. And I really can't tell you the data in that. We also have some wild opinions about there about lidocaine, quote, toxicity in cats. And I just want to clarify this point because it is one of those bones I got to pick. It is not lidocaine toxicity. It's that cats have a lower toxic threshold for lidocaine, right? Because there are plenty of times where people use lidocaine for a cat neuter or a quick lumpectomy.
Annatasha: and the cats are not just dying all over the place. So it's just people need to be cognizant of the fact that certain species have different thresholds for toxicity. And there are people who will run lidocaine CRI's in a cat and God bless them and their large gonads, but I just, you know, I'm not one of them. I don't think lidocaine is the end all be all and it's rarely my primary drug. It's more so my adjunct therapy.
Annatasha: Bailey, how do you feel about that?
Ryan Bailey: Yeah.
Annatasha: What are your thoughts on lidocaine and mustaches in general?
Ryan Bailey: i mean I actually love them. Lidocaine, you know it's it's a tool in the arsenal and to your point many moons ago, like there's no reason to have a favorite drug or to prefer one drug over another. Lidocaine's a tool in the toolbox.
Ryan Bailey: like to me, advantages are it's a non controlled substance. So in some clinics, it's easier to grab off the shelf without going through a bunch of hoops to get a controlled drug to then worry about waste and you know, exactly.
Annatasha: Addiction, theft. It's also cheap, right? Well, at least it is in Canada. It's very cheap and cheerful. So if you do have a cost limitation, I think that's a reasonable consideration.
Ryan Bailey: And it's, it's a drug you should be really familiar with and really comfortable because if your patient goes into a ventricular arrhythmia, you sure shit better know how to use lidocaine. And if you're like, this is my first time using it ever, it's like, that's not the situation you want to be using lidocaine for the first time.
Gianluca Bini: right.
Ryan Bailey: I mean, it's absolutely the situation you should be using lidocaine, but like having a passing familiarity is really important. Theoretically, I love the, you know,
Ryan Bailey: Literature from people much smarter than me. They're like it's you know, it's maybe anti -inflammatory And maybe it helps with like inflamed GI tracts and helps with like some kinesis following like all the inflammation We create during surgery like love it for those reasons May or may not be a mac reducer while also reducing cardiac output in the same way isoflurane reduces cardiac output so like like the magnitude is equals the mac reduction is irrelevant like Yeah, it's a fair point.
Ryan Bailey: I think.
Annatasha: What are your thoughts on lidocaine and venodilation and hypotension?
Ryan Bailey: Oh, for sure.
Annatasha: Because I feel like this is a very big deal, for example, in horses, right?
Ryan Bailey: Yeah.
Annatasha: Like nobody rocks a lidocaine CRI and a horse until you've basically normalized bread blood pressure, right?
Gianluca Bini: It is.
Annatasha: Like so if you have a colic on the table, know, lidocaine really one of the the contraindications quote,
Ryan Bailey: Yeah.
Annatasha: end quote, is hypotension.
Ryan Bailey: yeah
Annatasha: We don't really fuss about it though in small animal nearly as much as we do in horses. ah mean, I always, you know, if I coming in and something's like really like poop in the bed and they're pooping the bed from hypotension, that's mostly basal dilatory.
Annatasha: I don't care as much about, for example, like hypovolemic, but I mean, I care, but just not in this capacity. to be clear, hypovolemia, who cares? But, know, I don't usually think like...
Gianluca Bini: Sorry, I dominated it.
Annatasha: That's basically how hypovolemic anesthesia goes for anybody listening. It's just like a slow descend into a minor key.
Ryan Bailey: Yeah.
Annatasha: But, no, I, you know, lidocaine is something I would stop as a consideration. so yeah, why do we focus on it so much in horses other than obviously horses have a higher
Gianluca Bini: Yeah.
Annatasha: morbidity mortality associated with general anesthesia or is we don't have the evidence in small or we just don't think about it. Are we just lazy?
Ryan Bailey: I want to jump in real quick. I will never forget. We brought a journal club to my residency and it was about lidocaine and mac reduction and this and that. And the way the faculty jumped all over and were like the amount of mac reduction you get in the magnitude of cardiac output depression from lidocaine is equivalent to the isoflorine you're replacing. So by adding a lidocaine CRI, you do nothing beneficial for the patient. And I was like,
Ryan Bailey: Damn. So I have a healthy, like,
Annatasha: I sat through the same group of faculty and journal club and they said exactly the same thing about Alpha 2 agonists. So I'm wondering if they just temptate everything because they're really end inhalants, but yeah.
Gianluca Bini: It sounds like they think it's a waste of a pound.
Ryan Bailey: well it, I mean, for sure, for sure. Like, and yet I still use it, but I will say there are, I can like, there are too many patients account where I'm like,
Ryan Bailey: Oh, I am really struggling with hypotension here. Let's just stop the lidocaine and then like boom, boom, boom, everything's all better. So like when it works, it's nice, but not every patient can tolerate it.
Ryan Bailey: And I think being willing to stop it when it's, you know, those theoretical anti -inflammatory free radical scavenging, blah, blah, blah. Like maybe it's not the right thing for that, that patient in front of you.
Annatasha: Well, how much does free radical oxidative cellular damage contribute to mortality in veterinary patients? Side note, neither of you can answer that because none of us know.
Ryan Bailey: Oh yeah.
Annatasha: so like
Ryan Bailey: I mean, whenever they die, we always say it's the high times.
Annatasha: just you say because it makes the system smart, but I really don't know for for where this shenanigans started and really what clinical relevance it is.
Annatasha: But yeah, I stopped lidocaine in the face of refractory hypotension 100%.
Ryan Bailey: Oh yeah.
Annatasha: The other problem I have with it is it makes tissues poofy. It basically generates like tissue edema. So if you ever actually pay attention to like, you know how we put Lidocaine topical on cat's larynx is even though lidocaine is toxic and that one spray dose for sure exceeds the toxic threshold and yet somehow none of those cats die Look at their retinoids a few minutes later and notice how a dermatus they've actually become and I think that's and this is before like everyone's traumatized it by trying to intubate a cat this is strictly because of the lidocaine so
Annatasha: there is tissue edema associated with it and it's probably because of the venodilation and also there is hypotension. and And like I said, you can acutely cause something to arrest because if you sodium channel block heart cells, like they just don't beat. So yeah, I don't know. Lidocaine is, I mean, I will say this out there for the local regional and neuroxial enthusiasts obviously it's, you know,
Annatasha: The local anesthetics are irreplaceable from the point of view of you know regional limbs and what have you. But so yeah, systemically as a CRI, it is a different kettle of fish. I don't think it carries the same oomph that it does for neural anesthesia.
Annatasha: But yeah, we're just talking about it as the hypotensive agent in dogs, whereas like we're super paranoid in horses.
Gianluca Bini: So I...
Gianluca Bini: I love how Ryan was hoping that he would jump into this conversation and somehow you would be his sidekick, right?
Gianluca Bini: And then actually it was a lot happening that the day would turn and we're both shitting on lido caine that he loves so much.
Ryan Bailey: yeah
Ryan Bailey: I wouldn't say I love lidocaine. Like, so I've gone places and like lidocaine is part of their co -induction sequence, like a regular co -induction, which is like
Gianluca Bini: Yeah, why not
Annatasha: on it. And like, if I, and I'm not, I don't, if you want to break up my next topic, we can bring up why Tasha hates benzodiazepines, but yeah.
Ryan Bailey: Yes.
Annatasha: like But bur but yeah, I mean, you know. I mean, i I love a good dose of ketamine. and I'm not personally, but as my co -induction agent, but sometimes it's not the one I reach for and I do reach for lidocaine instead.
Ryan Bailey: Yes. Yes.
Annatasha: And it is published just so the listeners know it's not one of these like malarkey type situations that we all just collectively believe in, in but nobody actually cares to substantiate. So yeah.
Ryan Bailey: but So when is it that you're reaching for lidocaine as your co -induction agent?
Annatasha: Let's say, Bailey, that I already have a patient that I know is going to go on a lidocaine infusion, for example.
Ryan Bailey: look
Ryan Bailey: or
Annatasha: like and this Fuck you. And then this will be, this will be, for example, and hey you This would be for a patient, for example, who's arrhythmogenic and is is not responding to or is not sustaining sinus rhythm in the face of intermittent bolusing, right?
Annatasha: So like, let's say a splenectomy, right? Who's like highly arrhythmogenic. I mean, I actually don't often see them being that arrhythmogenic until post, but for the sake of this argument and making me look right, I'm going to pretend that that happens.
Ryan Bailey: Yeah.
Annatasha: um I might use my co -inductionation in that case because they're already arrhythmogenic, so maybe I'll be a little bit more gun shy about ketamine. I hate benzodiazepines.
Annatasha: And I'm going to put the infusion, so I'm cheating and using it also as my loading dose, right? So that would be one indication if I felt like my favorite one.
Ryan Bailey: yeah
Gianluca Bini: So, so, so...
Annatasha: Yes, Phoebe?
Gianluca Bini: No, no, sorry, I didn't want to interrupt you, but...
Annatasha: Oh, yeah.
Gianluca Bini: So why did you put friends to the other things again?
Annatasha: that what Now, you have to pick that out your next podcast topic, okay?
Annatasha: Because they don't do anything. Fuck, they're such a waste of time. Like, other than anti -epileptic.
Gianluca Bini: It's a waste of us around.
Annatasha: oh
Gianluca Bini: It's a waste of us around.
Annatasha: There's a waste of a pump, right? Like, barely max sparing for more than two hot seconds, non -analgesic, and usually makes dopey sedation and dopey recoveries. Like, thanks but no thanks.
Gianluca Bini: Wow
Annatasha: Yeah, and unpredictable in most instances, unless you're a neonate, a severe geriatric, or literally half dead on the table. So it's just, oh, yes, thank you, okay.
Ryan Bailey: Well, it's my mate.
Ryan Bailey: Yeah.
Annatasha: Okay, this is a fun game. Anyway, back to lidocaine, but the other thing too is like, let's say I didn't want to use ketamine as my co -induction agent because like I said before, you're already a rhythmogenic or whether I think you're in really like closer to end stage heart disease where I worry about overworking the heart when it's already going to be strained under anesthesia. I'll pick lidocaine in that instance, but It's not my first line co -induction agent, but it is is for sure an option that I will you know use.
Gianluca Bini: So like never.
Annatasha: I don't know.
Gianluca Bini: So you never use it.
Annatasha: Not infrequently, but not frequently.
Gianluca Bini: Basically.
Ryan Bailey: I've worked places where it's like that's like their their go -to like it's like 50 -50 whether you get benzo or light again is your co -induction and it's just like
Gianluca Bini: I'm very diplomatic.
Ryan Bailey: right
Annatasha: I mean, there is the influence of where you trained, right? Like there are certain schools where lidocaine is their absolute go -to.
Ryan Bailey: yeah over me too
Annatasha: And I happen to work clinically with two anesthesiologists who trained in one of those schools and they will like, it's like a hose of lidocaine on most of their cases.
Ryan Bailey: yeah
Ryan Bailey: Yes.
Annatasha: And I make fun of them all the time because I'm like, guys, be creative. Like mix it up a little, like use dexametatomy once in a while or do something. But like, like we, you know, when I'm on clinics and the two, of and I'm covering for them and they're off, like I have to like,
Annatasha: I'll have to like control the RVTs from putting everything on 200 mics per gig per minute of lidocaine. Because I do take, that is above toxic threshold. And even though it's published, if anything were to happen to that patient, and I sat before a regulatory body, which is made up of non -anesthesiologists, and they actually figure out it's above toxic threshold, I will not be able to weasel my way out of that liability. So that's the other thing.
Annatasha: but I try not to practice fear -based medicine because of liability, but I feel like that is a real hot red flashing light.
Gianluca Bini: Yeah, it is. So, but, you know, so you go back to your benzos, right? For a second, you I mean, who cares about live again, right?
Annatasha: Bailey, he's hijacking your broadcast topic.
Ryan Bailey: Hey, I've got, I've got lots more questions about lidocaine. I have a whole prepared, so like, all right, how about let's talk about some instances where I love, I love a little lidocaine brain dogs with a brain tumor.
Gianluca Bini: Okay.
Annatasha: Let's do it.
Ryan Bailey: You're you're going to do Santa's seizure.
Annatasha: There you go. That's a good one, Bailey.
Gianluca Bini: Okay, yes, yes, I'll take it.
Annatasha: I like that.
Ryan Bailey: What's your thoughts on using lidocaine as part of your coinduction to decrease laryngeal reactivity?
Gianluca Bini: I'll take it, yes.
Ryan Bailey: Like as, yeah.
Annatasha: Yeah, or have been you know if you have a patient who's really like coughing significantly, I will actually use lidocaine sometimes in bronchoscopes.
Ryan Bailey: All right.
Gianluca Bini: And that's about it.
Ryan Bailey: Yes. Yes.
Annatasha: In human medicine, they spray the lidocaine down the bronchoscopes. I've actually taught a lot of internists about that so that I don't have to increase systemic plane of anesthesia.
Ryan Bailey: Yes.
Annatasha: We can just locally desensitize cough receptors, quick aside. But no, I like the anti -tussive component also
Ryan Bailey: yep
Annatasha: Okay, so I know a lot of people talk about things like ketamine raising intracranial pressure, but there's that paper that shows that across the board, just the process of intubating raises intracranial pressure, and it's fairly equivocal based regardless of what and co induction or co -induction agent you use.
Ryan Bailey: Oh, yeah, originally.
Annatasha: So I don't overly sweat it. But yeah, I think that think that's a good one. Where else do you like spread the lidocaine love?
Ryan Bailey: So so like, again, with those anti tussles, I like to use it for retroflexing, like in dogs, like when they have to retroflex into the nasopharynx. Again, it's just that I can annihilate them with ISO and they're still going to cough and gag.
Ryan Bailey: And then like a little bit of lidocaine in those situations, they tend to, it just gets them through. Like it it like in their veins.
Gianluca Bini: Where do you put the ladder window?
Gianluca Bini: Oh, okay.
Ryan Bailey: Like just a little, little IV lidocaine. And it's like, so it's either like stupidly, it's either the lidocaine has an effect on that, like the anti tussle effect like Bartel is talking about, or they just get just so deep, so quick, and then it could just increase antiseg depth enough.
Annatasha: it's probably not that one but okay
Gianluca Bini: So, okay.
Ryan Bailey: Like, i I don't know, I personally find inhalant is not the end all be all of anesthesia. And sometimes you need injectable anesthesia to get a patient to stop reacting to specific stimuli.
Ryan Bailey: Like I find the
Gianluca Bini: Fair?
Annatasha: Beanie and I are not into inhalants.
Gianluca Bini: Fair?
Ryan Bailey: Yeah.
Annatasha: We're the Tiva podcast.
Gianluca Bini: Yeah.
Annatasha: but like Are you there?
Ryan Bailey: i in
Annatasha: but um yeah now i think i mean Think about the local spraying, though.
Gianluca Bini: do you,
Annatasha: See whether or not you guys have a soap. Instead of like flushing water, you can actually flush a dish of topical local anesthetic. Because I also find, as a side note, when we do things like, um um I'm going to do an intraoral nerve block because you guys are going to do like nasal biopsies or whatever.
Annatasha: And I'm like, what a crock of shit that is. so ah So, you know,
Gianluca Bini: o so we wait wait make wait hot what
Annatasha: but and the maxillary does not affect the medial part of the septum, so if they are taking caudal medial biopsies, that block is a total waste of time, right?
Ryan Bailey: Sure.
Gianluca Bini: That's fair, that's fair.
Ryan Bailey: Sure.
Annatasha: I think it's more efficacious.
Gianluca Bini: I think the paper was from PJP or somebody.
Ryan Bailey: Well, I'm sure he loves that. Like he wrote so many papers about that block.
Ryan Bailey: It's interesting.
Annatasha: but I think it's probably more efficacious to actually have them like almost atomize it locally on the area that's affected, right?
Gianluca Bini: Yeah. he
Annatasha: Bearing in mind, though, that that tissue may get edematous, but honestly, they're ripping out hunks anyway, so you're probably destined for edema.
Gianluca Bini: yeah
Ryan Bailey: fish Absolutely.
Gianluca Bini: Yeah, no, I, yeah, that's, that's interesting. So, do you even use live in for your blogs? Right?
Gianluca Bini: Like, you know, I think was totally, I mean, at least myself, I totally switched to ro piva caine I never really actually even like touch anything.
Annatasha: Not often. I don't use it often except if we're doing something, pardon my français, a little bit fast and dirty and I've been caught a little bit more off guard and I want instant efficaciousness, right? That's that's probably the only time I'll reach for lidocaine as a block, right? rest of the time I'm either using like a medium duration one like my pivocaine and then the rest of the time be pivocaine.
Gianluca Bini: Why I meant pivot game?
Ryan Bailey: So.
Annatasha: because it lasts a wee bit longer than lidocaine. So for example, like, you know, the walking up a dural, you might want to use like a medium length local as opposed to.
Gianluca Bini: No, no, I meant like... No, no, I meant like, compared to rope pivot game. Sorry. Like...
Annatasha: Oh, it just depends on which one's more available, clinically, really.
Gianluca Bini: Oh, gotcha.
Annatasha: The difference between mipivacaine and ropivacaine for me clinically is fairly indistinct. So it just really depends on what I have on the shelf in that hospital. If at all, right, a lot of places don't
Gianluca Bini: Gotcha. So you're not looking at like their PK and all that stuff, right?
Annatasha: Yes, no, I definitely am.
Annatasha: Definitely looking at the PKA. It's nothing I love more than thinking about relative PKAs when I'm clinically doing something.
Ryan Bailey: Ha ha!
Gianluca Bini: and But, so yeah, and so for whoever is listening, I think like, you know, material gain supposedly actually performs better than raw pivot gain in an acidic environment, right? Slightly better, right? Because the PGA should be a little bit lower, right? Compared to, you know, raw pivot gain and view pivot gain. So material gain, it's actually performs a little bit better in that case.
Ryan Bailey: I'm gonna go ahead and trust you on this one, Beatty.
Annatasha: I mean, the other thing too is it's less, chondrotoxic than rapivacaine and bupivacaine. So if you were doing something that involved a joint, that would probably be the other option. Personally, my favorite local anesthetic is articaine.
Annatasha: Oh, suck that one boys.
Ryan Bailey: Wow. right.
Gianluca Bini: wow. Actually being so damn distinct.
Ryan Bailey: I feel so like a Neanderthal.
Gianluca Bini: nurse
Ryan Bailey: I'm like, well, I got lidocaine and I got bupicaine. And you know what? They do pretty good.
Annatasha: But think about cows for a second, right? Like, are you gonna do right, like a disparate root table or an inverted L block and an emergency C section where you have to put in like 4 billion mills of local anesthetic to block the damn cow so that they can actually have their cesarean with mypivacaine or bupivacaine?
Annatasha: Yeah, not because it's volume prohibitive and cost prohibitive.
Ryan Bailey: Right.
Annatasha: You are going to rock glidocaine. We're being very, very small animalists.
Ryan Bailey: Yeah, first.
Annatasha: and i don't want to ignore our one cow person out there who's listening but yeah i would there's there's a nice indication for farm animals where it is large volume is necessary you need really fast onset because the patience for it and those kinds of like you've got to go fast and also the cost lidocaine is probably my preferred agent in those instances ooh
Gianluca Bini: Here, they still use me piva caine by the way. They use my pivot gain in large animal all the time. So I don't think they carry it.
Annatasha: Well, you are the one standing in the house where, as I'm just up here in 25 centimeters of snow. So that's good to know.
Gianluca Bini: But the other cool use of lighter gain you know, for example, ah some some people nowadays they've been using it, for example, like inflation, you know, so there is a protocol where you actually pair with probable for immersion, which has been described, and I heard that it works pretty good. You know, people are trying to move away a little bit from an attitude to try different things or,
Gianluca Bini: you know, there is some interesting like research going on and that stuff. So another use for like logos or.
Annatasha: Why do you know that? Like, are you reading the fish anesthesia journals that were not like, why are you abreast of what's happening with fish?
Ryan Bailey: i mean
Gianluca Bini: But I mean, besides the fact that I really like aquatic eggs, I have all the aquatic books, like, you know, I read the stuff all the time, it's pretty cool. But I also teach the aquatic and, what?
Annatasha: This is news to me. This is news to me. I didn't know you were some sort of Fish fanatica fistinato.
Gianluca Bini: nerve, yeah.
Ryan Bailey: I mean, I did not.
Annatasha: Did you know this, Ryan?
Gianluca Bini: There you go. yeah, I teach the aquatic anesthesia lecture for up to higher states.
Ryan Bailey: Oh.
Gianluca Bini: So even even though I left, I still teach that.
Ryan Bailey: Well.
Gianluca Bini: Actually, I taught that two days ago.
Annatasha: How much fish anesthesia are you actually doing clinically, though?
Gianluca Bini: Now very little. you know in the past, we did a bunch before I moved.
Annatasha: Why and how and where?
Gianluca Bini: Well, some of the stuff was was research. So like, you know, they had like a huge colony of fishes, like Ohio State and stuff like that. Not not specifically Ohio State, but it was like the children's hospital that they had like a huge research facility.
Gianluca Bini: They had like 55 ,000 like zebra fishes and stuff like that.
Ryan Bailey: They're all the rage in research for what I know, those zebrafishes.
Gianluca Bini: So it's like, yeah, it's crazy.
Annatasha: Why do you know that? And why don't I know either of these things? I can't decide which part is more concerning.
Ryan Bailey: When I did have animal rotation, they were telling me all about these zebrafish.
Annatasha: My ignorance or your lack of?
Gianluca Bini: They use zebrafishes.
Ryan Bailey: They were like, oh, yeah, zebrafish.
Gianluca Bini: Yeah.
Ryan Bailey: They're all the data. And I was like, zebrafish, yeah.
Gianluca Bini: The cool thing of zebrafish, actually, if I'm talking for whoever is listening, is that, so especially when they're young, they're like transparent.
Annatasha: hi like
Ryan Bailey: Yeah.
Gianluca Bini: And so basically you can tag their CNS with fluorescent genes. So there's some genes that can express fluorescent in their CNS. And so like they can look at like how the CNS actually develops visually. You don't need imaging. You know you just like look at it. So there is some bunch of studies with how ketamine affects CNS development and stuff like that. and like you can see a visual, so it's pretty cool.
Annatasha: That is very cool. i will I will concede to that.
Ryan Bailey: Yeah.
Annatasha: Although if I were to have a child make me laugh and then it needed anesthesia and I was like, what's the research? And someone was like, oh, don't worry. We just had zebrafish. I would clench my butt pretty tight.
Ryan Bailey: For sure.
Annatasha: So.
Gianluca Bini: Fair, fair.
Ryan Bailey: So other things I feel like we should talk about, since we are, you know, experts, if you will, in local anti -sex.
Gianluca Bini: Are we down?
Ryan Bailey: So what do we, What does the team here feel about Emla Cream?
Annatasha: the eutectic mixture of local anesthetic.
Ryan Bailey: Oh, of course.
Annatasha: where
Ryan Bailey: Yes.
Annatasha: yeah
Gianluca Bini: hello
Ryan Bailey: I know I'm reaching a little bit on that one, but you know, it just felt like a reasonable thing to bring up. Like it was five years ago, it was all the rage. Like everything was getting.
Annatasha: What works when used? appropriately, which you basically have to put on.
Ryan Bailey: And how is that?
Annatasha: I mean, it's heat activated, right? Because you have to get to the eutectic point of the two local anesthetics, which means It does have to be warmed, so, and it needs time to work, right?
Ryan Bailey: Yes. Yes.
Annatasha: And most people are like, they slap it on with some vet wrap for 10 minutes and out for the best.
Ryan Bailey: Yes.
Annatasha: And I'm like, you probably need about 40 minutes, min, and you probably want to do something like a saran wrap, occlusive dressing, and then allow it to come to body temperature so that it actually activates, but then it also has to percolate through the skin.
Annatasha: And of course, if this were a zebra fresh, know, there's going to be variability uptake versus like a bulldog versus a Yorkie versus a cat versus a cow who has leather for skin.
Annatasha: So, Emma Cream, if you have the luxury of time, but look which so many of us do clinically, I think it would be a very kind thing to, you know,
Ryan Bailey: right.
Annatasha: numb the area of catheter placement because I do think catheter placement is somewhere between uncomfortable to mildly painful. Like if you put a catheter in me, I will hold my breath and go to my happy place.
Annatasha: So um yeah, I think, ah ah like I said, if you have the luxury of time and you understand what eutectic means um um and you actually use it appropriately,
Ryan Bailey: yeah
Annatasha: and it actually works, which I find it rarely does, then I think that would be lovely for all of our patients in anesthesia never, never land.
Ryan Bailey: and I think there was a paper, they use very heavy, what I would describe as fairly heavy sedation, but I think they showed it might work as little as 30 minutes in dogs.
Ryan Bailey: If I'm remembering the paper correctly.
Gianluca Bini: Yeah.
Annatasha: It's like I said, I usually give it a good, like if I'm really gonna do it, I commit to it. I like to give it a support even before I go for the poke.
Ryan Bailey: Yeah. Oh, for sure.
Ryan Bailey: Yeah.
Annatasha: Yeah, I err on this.
Ryan Bailey: Are you seeing, are you using a much beanie?
Gianluca Bini: No.
Ryan Bailey: That's fine.
Gianluca Bini: now I mean, I think they're clinically enough.
Ryan Bailey: and
Ryan Bailey: I feel like.
Annatasha: No. no
Ryan Bailey: Like I've I've workplaces were like, oh, we'll use all the time. And then, you know, it's like a fad like it comes. It's like, oh, yeah, we're going to use this. And then people use it and then like they forget about it.
Gianluca Bini: And by fat, you mean a fish on a feature device, or?
Ryan Bailey: And it just it's like.
Annatasha: Waste of a pump.
Ryan Bailey: All right, all right. I mean, and I know the answer to this one, but may I ask you anyway? Because I feel like it's probably out there and there's people who listen to this who probably want to know. Lidocaine patches for animal patients.
Annatasha: I mean, just so you know, I wasn't done with Emily, I will say I found it very efficacious for my own personal mosquito bites.
Gianluca Bini: Ooh, so in humans, the
Ryan Bailey: Oh.
Annatasha: Which I think clinically has been my greatest use to date because I really dislike itching and I really dislike being bitten by arthropods. So I will emblem myself if I'm, you know, surviving um mosquito attack just so, just so everybody knows. But yes, lidocaine patches. Sorry. Done. I'm done with emblem now.
Gianluca Bini: I think thinking in humans,
Ryan Bailey: Maybe we can talk more on my just feel like there's not much more to say like Okay Yeah
Annatasha: Yeah.
Gianluca Bini: i think but so emla you know i I would use it if we had it, we don't have it. so like The Lidocaine patches, in humans they work great. I think there are some issues with absorption with skin and yeah animals. and so like I can't say I've ever used one in an animal, really, in humans all the time.
Ryan Bailey: Oh, yeah.
Gianluca Bini: Like I think, like even both me and my wife have some back pain and they were legit good. But, you know, the if the insertion isn't great, I mean, what do you do?
Ryan Bailey: Yeah, for sure.
Gianluca Bini: There isn't really much you can do about it, right?
Annatasha: I have not used them clinically.
Annatasha: And I guess my questions about lidocaine patches, I'm not fearful of them. i just I'm not sure it ever occurs to me, but it's a reasonable consideration. think We don't have, I mean, there are some papers out there that have looked at it, but again, how are you supposed to know what uptake is going to, or efficaciousness is going to end up being for like a morbidly obese, unneutered bulldog?
Gianluca Bini: yeah
Ryan Bailey: Right.
Annatasha: versus like a petite Yorkie with that thin paper see -through skin. Like I don't have any idea what plasma effective concentration, you know, what are the pharmacokinetics and pharmacodynamics associated with these patches?
Gianluca Bini: Yeah.
Annatasha: And, you know, looking at five healthy beagles in the lab doesn't tell me much about anything in dogs clinically. But I wonder whether or not we're the place that we could really be using it to a greater advantage would be Oh, okay, yeah.
Ryan Bailey: So, I do, I think I wrote a presentation a while ago and they actually looked at patches versus Emla cream for, I think it was like a, I wanna see.
Annatasha: You this?
Ryan Bailey: No, I looked at it. I wrote about it in a presentation I did.
Annatasha: Oh.
Annatasha: Gotcha.
Ryan Bailey: And I think they, if I remember right, they were doing like a vaginal surgery on these horses. So they were either applying molycrine or putting the patches on, and they found that molycrine was far more efficacious than the patches.
Annatasha: Well, that's because you're putting it on mucosal skin, not skin with proper epidermis, right? So it like perivascular, perivaginally, right?
Ryan Bailey: Yeah.
Annatasha: That's a different kind of skin than it is like, like over your naps.
Ryan Bailey: Yeah. Oh, for sure. True.
Annatasha: But I'm wondering what the, like the utility, for example, of a lidocaine patch might be.
Ryan Bailey: Yeah.
Annatasha: because we still struggle a lot with pain management in large animals. And I still, to this very day, have to argue with equine surgeons about whether or not butorphanol is sufficiently analgesic for major surgery. P .S., it's not.
Annatasha: But, you know, they get so upregulated about opioids and colic, even though, in my opinion, pain is more likely to cause a severe colic.
Gianluca Bini: we give we give morphine to every single horse that's painful and it's especially if they are having colic surgery.
Annatasha: I get that all the time. just
Gianluca Bini: right And the pain pain definitely does cause way more colic than the morphine does.
Annatasha: Yeah, 100%. No.
Ryan Bailey: Oh, yeah.
Gianluca Bini: And again, it comes back to what we were saying the other time. right like You would see Because the horse does need that analgesia, you're not seeing as much of that sort of effect from the opioid.
Annatasha: Yeah, but I also struggle to this day with surgeons who will say things like, you know, they're like digging around and legs and joints and things like that.
Gianluca Bini: like
Annatasha: And right. The horse is, you know, reacting like, you know, like you can see like blood pressure and eyes and ah ah going up and down. And I'm like, could you just, you know, like stop plucking that nerve and maybe, know, put some local on it so that I don't have to keep loading the horse systemically.
Annatasha: So it's recovery. Isn't going to be a hot mess. And they'll be like, no, no, no, I want it to do that. Right? Like I want to be reactive. All right. I want it to be reactive and painful. And you're like, Oh my God, how can we still be having this conversation in 2025? But I'm wondering like, what if lidocaine patches are a nice way to deal with, you know, post surgical wound analgesic management and, um, and, um, you know, that way we can spare the systemic drugs and some of the adverse effects and potential concerns associated with it. I don't know.
Gianluca Bini: Yeah, that could be, yeah, it could be an option, I guess. I mean, I'll do at that point, a lot of the times you just do a logo block, right? And so, I don't know if the latter has been patched with. I mean, if the logo block works fine, you know, most of the, you even need detection of GZ probably, right?
Gianluca Bini: You know what I mean? But once that wears off, then I can see it, right?
Annatasha: No, no, no, I -
Gianluca Bini: Like, you know, unfortunately, all those don't last forever, right? Even if you use something like a liposomal bupivacaine, you know, in reality, it's not infinite, right?
Ryan Bailey: Yeah.
Gianluca Bini: At some point, wears off. So I guess the live game patch would be Probably a good addition. I mean, do you still have those concerns that you would have with like a feminine patch? Like, you know, if you send it home and the kids eat it or another animal eats it, you know what I mean? like
Annatasha: Yes, but probably, I mean, I'm always worried that anything that you put on an animal, they may groom it or eat
Ryan Bailey: thank
Gianluca Bini: right.
Annatasha: um I mean, I don't worry as much about horses like they're
Gianluca Bini: No.
Annatasha: They're not indiscriminatory eaters way like a cow is, right? Like cows will just swallow a bucket of nails and not even care. But, you know, dogs and cats for sure. And yeah, of course, I always have a concern that anything exogenous externally placed and you know has potential complications associated with it if kids or even adults with issues come into contact.
Ryan Bailey: Thank you.
Gianluca Bini: yeah
Annatasha: You know, I don't want to do harm to either that pet, another pet or any other person in that family. So, yeah, but am I as worried as fentanyl? Anecdotally, probably not. Is that correct? I don't know.
Gianluca Bini: All right. So I want to ask another question to Ryan, right? So now you brought up the topic of lidocaine, right? So how do you deal with lidocaine, IV, and pregnant patients?
Ryan Bailey: Yeah.
Gianluca Bini: Would you use it as a co -inductor? Press this section or.
Ryan Bailey: Straight up, do not. I feel there's... I cannot think of a situation in which I would use would reach for it.
Ryan Bailey: I think there are other drugs that I would prioritize above lidocaine in a pregnant bitch, ah ah especially because of, was it ion trapping or whatever?
Ryan Bailey: Because the the pH of the fetal blood is so low that the...
Gianluca Bini: Hi.
Annatasha: Yeah, the PKA gets shifted because of the pH of the environment.
Ryan Bailey: Yeah.
Annatasha: You have to explain it to the listeners there, Bailey.
Ryan Bailey: Yeah, was I was getting there. I was saying the blood of the neonates is so low, the pH is so low that the lidocaine ends up accumulating in the the like neonates or like the pre -born puppies essentially. And so they have higher systemic concentrations relative to the to the pregnant bitch or whatever. So yeah, I would not, that would not be a drug I add to my, not not one I'm using personally.
Gianluca Bini: Gotcha. Yeah. And and so, I mean, somebody has the argument.
Annatasha: and this but Is this the one time where you randomly reach for lidocaine?
Gianluca Bini: yeah
Annatasha: Do you use d is it for
Gianluca Bini: What? No, no, are you crazy?
Annatasha: i was like
Gianluca Bini: No.
Ryan Bailey: you crazy
Annatasha: i was like I haven't had a glass of wine, but I feel like I might need it after this conversation, yeah.
Gianluca Bini: No, no. No, I mean, I don't use it as this anyway, but you know, you know, especially in those.
Ryan Bailey: Yeah. That lidocaine bottle in Beanie's in Beanie's Clinic still has a bunch of dust on it. It's never.
Gianluca Bini: They expire.
Ryan Bailey: Yeah, it was it was the the first bottle.
Gianluca Bini: They just fucking expire.
Annatasha: funny anecdote tangent. When I first moved to Singapore, they literally like their bottle of ketamine. I think it expired before they even opened it, right? And then after the first month of me being there, they're like, we have never gone through this much ketamine in the history of a hospital.
Ryan Bailey: telling
Annatasha: And I was like, what? But it was like, I like blew the dust off and then I just opened the ketamine party to, you know, Southeast Asia. But, yeah, I can see Beanie being like, oh, I had a cancer.
Ryan Bailey: So one other thing to just talk about for the for the listeners out there, mixing local anesthetics.
Annatasha: <unk>
Gianluca Bini: oh
Ryan Bailey: I feel like we just
Annatasha: the
Ryan Bailey: I know, I know, we're all gonna be like, it's terrible, don't do it, but like, why?
Annatasha: Uh... Why?
Ryan Bailey: I mean, I know why.
Annatasha: All right.
Gianluca Bini: Because you messed up with the whole pharmacological profile of the drug, right? There's studies where people were trying to do this but by pairing the other thing and doing it again, for example. right Hoping that that would Normally, live again has a faster onset of action, and BP again has a longer duration of action, right?
Gianluca Bini: And so people were trying to achieve the duration of action on the BP again, and the fast onset of live again, right? By mixing them. And in reality, the study showed that the duration is shorter and the onset is longer.
Gianluca Bini: So like, it's totally the opposite to what you want, really.
Annatasha: And toxicity is mostly synergistic, which means you're more likely to have an ish if you mix them.
Gianluca Bini: Right? And so, exactly.
Annatasha: Now, Bailey, I have a question for you. I'm going to tease this out a little bit.
Ryan Bailey: Oh, alright and know So both are great points.
Annatasha: When you say mix local anesthetics, do you mean, as described by John Luca, which is you basically take a little lido and a little bupivy and shake it up and you inject it?
Annatasha: Or do you mean I gave an epidural with bupivacaine and then I put it on a lidocaine CRI?
Gianluca Bini: oh
Ryan Bailey: Uh, what I was specifically referring to is some practices where people do mix two drugs in the same syringe and administer them as part of their local.
Annatasha: Let's call out the ophthalmologists because that's who's doing it.
Ryan Bailey: Oh, let's talk about using local.
Gianluca Bini: for that listening.
Annatasha: a
Ryan Bailey: So that's a great, that's actually a really good question because a lot of those, patients who are going to get both IV lidocaine and local regional are patients that I think a lot of us are going to say this patient is at risk or probably is already experiencing some degree of chronic pain, right?
Ryan Bailey: Like to my mind, that that's where I'm going to be, like that's where lidocaine is often used in my practice is patients
Annatasha: Well, Bailey, if it has chronic pain, why don't you just give it half a mink per cake of sub -cucetamine?
Gianluca Bini: Every two weeks. Every two weeks!
Ryan Bailey: but Yeah, exactly.
Ryan Bailey: ah ah Like those, those hind limb amputations, right? Like that patient, you know, chronic pain, phantom limb, whatever you want to like talk about. Like I would easily put that patient on a lidocaine infusion.
Annatasha: as opposed to ketamine.
Ryan Bailey: right Ketamine is the first one. Sometimes I do both. It just depends on my mood a little bit. If I feel like like making a combo syringe and putting it together, or just like, I mean, ketamine ketamine's always there because there's evidence for it. Lidocaine's hit or miss for me, but.
Annatasha: So would you block the leg legs? So let's say you're doing a hyaline amputation and you're doing something like a perisacral sciatic and a psoas compartment, right?
Ryan Bailey: Very true. Sure.
Annatasha: um um And then you want to put them on a light again.
Ryan Bailey: I just have to do it on my own, but yep yep, all that stuff sounds great Bartel, very good.
Annatasha: basic and um um And then you also will put them on the lidocaine infusion.
Ryan Bailey: I never, never said I wasn't.
Annatasha: Is that kind of a the thought process? Because so that that's my question is, is when we talk about mixing, technically speaking, like if this were a board exam, which I'd rather swallow glass than sit there again, and that that this question came up like,
Ryan Bailey: Yeah. Yeah. Sir. Okay.
Gianluca Bini: I thought you laughed there.
Annatasha: Yeah, it was the best. There's nothing more I care about than NSAIDs in the giraffe for tens of hours.
Ryan Bailey: wave
Annatasha: But yeah, i if this were a board exam question and they said, would you give a bupivocaine based epidural and then put them on a lidocaine infusion, technically speaking, in the purest sense of the word, my answer to that would be no, because you're not meant to mix local anesthetics.
Annatasha: However, I've done it.
Annatasha: because I'm wondering like, what is your systemic uptake of the bupivacaine?
Gianluca Bini: Yeah.
Annatasha: And I'm also using it for different purposes.
Ryan Bailey: well so that's Right. So that's a known quantity though, to some extent. Like we know at least extrapolating from human resources, human literature, we know that the highest risk of local anesthetic toxicity when administering it for local anesthetic is doing bilateral intercostal nerve blocks. That's the one where you see the highest plasma concentrations, if I remember correctly from the human literature.
Gianluca Bini: There is a study actually, now that you mentioned this, there is a study looking at absorption of IM pre -meds and how different masses group actually absorbs differently.
Annatasha: Okay.
Ryan Bailey: Oh, yeah, for sure.
Gianluca Bini: And then the cost style is the fastest, right?
Annatasha: First his leg, blah, blah, blah.
Ryan Bailey: Yeah, I remember.
Gianluca Bini: Okay.
Ryan Bailey: So are you so are you worried about? So I guess my question is, are you worried about systemic toxicity? Or are you worried about I mean, they're not going to alter the pKa though, because you're not going to get them at the same side of action.
Ryan Bailey: Like, that's
Gianluca Bini: No, no, at that point it doesn't.
Annatasha: Yes, I'm wondering if the local has gone neural axially, or in other words, am I doing a spinal or an epidural? Because I'm, you know, it's such a small whisper of a volume to begin with.
Ryan Bailey: Yeah.
Ryan Bailey: Right.
Annatasha: And what is systemically, is that going to cause me a huge problem?
Ryan Bailey: For sure.
Annatasha: No. However, if I've been doing a big series of blocks, right?
Ryan Bailey: Right.
Ryan Bailey: Sure.
Annatasha: Let's say I've been doing, I don't know, bilateral tap, where I actually go for the 0 .4 mils per gig, which works out to the two mils per gig of bupivacaine.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Annatasha: but then also have a patient who happens to go into, I don't know.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah. yeah
Annatasha: I cannot put them on a bupivacaine CRI. I mean, to be fair, it will the V -TAC forever.
Ryan Bailey: Yeah.
Annatasha: But I can't do a bupivacaine CRI.
Ryan Bailey: Yeah.
Annatasha: I've already blocked their abdomen because I was expecting, like, I wanted to protract, for example, surgical recovery analgesia. And now I'm kind of stuck. So do I do it? Yeah. Do I worry about it?
Annatasha: Honestly, my worry is pretty minimal, even though, you know,
Ryan Bailey: yeah
Annatasha: There's potential. And like I said, I have a healthy respect for the local anesthetics and their ability to really stop your heart in a one beat situation.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Annatasha: So, I don't know.
Ryan Bailey: I mean, I would be worried if I was doing an open chest case and we did bilateral intercostal nerve blocks and then the patient went to VTAC. That would be a scary situation because that's the one where we know they have the highest concentrations.
Ryan Bailey: Like I think it's intercostals number one. And then I think it's a brachial plexus number two.
Annatasha: Anything close to either major arteries or plural, right?
Ryan Bailey: Yes.
Annatasha: Like, like, sorry, no, a mesothelial uptake, right?
Ryan Bailey: Yes. Yes.
Annatasha: Which basically is plural or peritoneum. We know that, for example, like when you do like an an an infusion or an infiltration through a chest tube, or you quote, do the splash box that they used to do, you know, a closure of for space, you know, mesothelial cell uptake of local anesthetics is significantly more rapid than skin cells, right?
Ryan Bailey: yeah
Annatasha: and so they're short acting and you can actually get like, People have seen local anesthetic adverse events neurological cardiac associated with some of those blocks because of it.
Ryan Bailey: Yeah.
Annatasha: That being said i don't really do many intercostals these days right i'm probably doing.
Ryan Bailey: Yeah.
Annatasha: a peristernal ultrasound guided now for sternotomies, which is really fast and easy and really lowers the the volume. And it's because you're at that deep bed of the musculature, I'm not right up against the plural mesothelium.
Annatasha: So I don't worry as much. The brachial plexus, 100 % because you've got that whacking, big frack and blood muscle right in there.
Ryan Bailey: Yeah.
Annatasha: And like, even when I mixed dexmedetomonene with my bupivacaine for that block, which side note is my most hated block, can sometimes see like the drop in heart rate because of the dexmedetomonene
Ryan Bailey: Oh,
Annatasha: uptake just from adjacent to the artery, right?
Ryan Bailey: yeah.
Annatasha: So it's legit.
Ryan Bailey: Yeah.
Annatasha: But yeah, like I said, mixing locals in this capacity.
Ryan Bailey: Yeah.
Annatasha: I haven't yet encountered a problem, which is not a great justification.
Ryan Bailey: Right.
Annatasha: But am I worried about it? No. Not a lot, not a lot. I don't stress about it too much. But like I said, if this were a board exam, I would sing you a different song for sure.
Ryan Bailey: Man, speaking of side effects, I didn't even get to like, how often do you really see the GI nausea, vomiting, side effects that everyone worries so much about with lidocaine and like all those other things that people are very highly stressed about that we're like, all right, we're gonna put them on 100 and we're gonna move on.
Annatasha: I mean, our patients are awake, so there's that, right? So for sure, I can crank those.
Ryan Bailey: i
Annatasha: I mean, I'll put fentanyl at 20, which I would never do an awake patient because A would not move.
Ryan Bailey: He would no longer be an awake patient.
Annatasha: yeah wouldnt be but um So we can get away with doses that are not appropriate for sentient
Ryan Bailey: Oh,
Ryan Bailey: oh I agree.
Annatasha: patient.
Ryan Bailey: Yeah.
Annatasha: There's that. Now the whole thing about nausea, it is dose dependent. And I pisses me off so badly. Like this is one of those things like this one might be one of the hills I die on when you have a patient who's on like 20 mics per cake per minute of lidocaine, which is probably sub analgesic.
Annatasha: and then And I'm calling out critical care here because this bullshit comes from them. They will stop. And if you can't see us right now, the other the guys are nodding because they know it's true.
Annatasha: They will stop the lidocaine and turn the fentanyl up to control the patient's pain, but to abate the nausea.
Ryan Bailey: Oh my god.
Gianluca Bini: Yeah.
Annatasha: And that has got to be the dumbest thing I have in my life.
Ryan Bailey: a Like that drives me bonkers. I'm like okay guys we're talking about this patient who's like fucking intestines are paralyzed and they're not eating and they're nauseous and they're vomiting and we're like and here we go we are.
Annatasha: and And it's always the first thing they want to stop is always the lidocaine when I'm like, it is such a bunch of shit because you only see the nausea close up to around the hundred mics per keg per minute.
Ryan Bailey: f
Gianluca Bini: Yeah.
Annatasha: And I'm like, but we're okay to crank fentanyl up to five, you know, or so seven.
Gianluca Bini: yeah
Ryan Bailey: Yeah. Oh, yes. Yeah. Yeah.
Annatasha: And I wonder why the patient is regurgitating, recumbent, and hyporexic.
Ryan Bailey: yeah
Annatasha: And I'm like, hmm, think, think, think, think, think.
Ryan Bailey: Yeah.
Annatasha: I wonder which drug it is.
Ryan Bailey: and It's like, turn it off. Let's add some like light, like let's add light. It came. Let's add kind of mean, you know.
Annatasha: Meanwhile, ketamine can also cause you to be dysphoric, which if in people and often explain, tell you that dysphoria is one of the worst medical experiences you can have, like being dysphoric for sure.
Ryan Bailey: Oh, for sure.
Annatasha: If you are dysphoric, you are not going to eat. So, um, So, um, yeah, I don't know.
Ryan Bailey: Yeah.
Annatasha: I just, this, this whole anti lidocaine pro nausea garbage yeah critical care guys you need to stop with it you need to stop with the lidocaine bullshit okay that's that's my two cents
Gianluca Bini: no, I agree with you. I agree with yeah, I hate when, when they do that.
Annatasha: because
Ryan Bailey: anecdotal question about lidocaine and then I will leave it alone. So I did
Annatasha: You had a lot of questions about Lidocaine more than I was anticipating, actually.
Gianluca Bini: Yeah.
Annatasha: How far can this conversation go?
Gianluca Bini: It's crazy.
Ryan Bailey: the research. So have you seen seizures at induction following lidocaine?
Annatasha: Here we are.
Annatasha: Oh.
Ryan Bailey: So i can I can share one anecdotal story. I do not think the lidocaine is the culprit, but it just so happened that we pushed the lidocaine, the dog dropped to the ground and immediately started convulsing in front of us. That dog had also, by the way, ingested a metric ton of coffee grounds that we were not aware of.
Ryan Bailey: We were going in for a foreign body surgery, and oh, in the intestines, it is literally jam -packed with coffee grounds. So i think I think we know the culprit there, but of a fascinating sort of events.
Gianluca Bini: Right.
Ryan Bailey: And then I was recently doing a locum thing, and they had said they were recording instances of lidocaine causing seizures.
Ryan Bailey: and that they had seen a rash of it.
Annatasha: A rash of it.
Ryan Bailey: Well, I'm sure they use the word rash.
Gianluca Bini: wow
Ryan Bailey: That's my, you know, whatever.
Annatasha: Now that's a bile because I'm for sure.
Ryan Bailey: But they had seen like a fair number of seizures following lidocaine because they were using as like, it was one of their main co -induction agents. And I was like, that's interesting.
Gianluca Bini: Interesting.
Ryan Bailey: i hope I've only seen it one time and that dog ate a bunch of coffee grounds.
Gianluca Bini: Yeah, interesting.
Annatasha: Beanie?
Gianluca Bini: Now, I can say i can't say I've seen that.
Ryan Bailey: Anyway, just wanted to ask.
Gianluca Bini: But, you know, I that's fair.
Annatasha: I wouldn't dismiss it though, right? like I mean, I haven't seen it either, but I wouldn't dismiss it because neurotoxicity obviously is one of the critical terms of local anesthesia toxicity.
Ryan Bailey: yeah
Annatasha: On the other hand, my my my opinion on anything that we put into a body that is foreign, exogenous, illogenous, however many adjectives you want to use for it, doesn't belong in the body, I think has potential to generate a reaction, an adverse reaction, right?
Gianluca Bini: talk.
Annatasha: I think there's a potential for an allergic reaction.
Ryan Bailey: Yep. Yep.
Annatasha: I think there's a potential for, especially in the sedative class of drugs, anything that you're doing that is going to change normal brainwave activity.
Ryan Bailey: Good thing.
Ryan Bailey: Yeah.
Annatasha: for example, this is why if you're going to see seizures, usually see them at recovery, right? Because you're going like, you know, down here from almost flat brain activity line and you're bouncing back up and you're reorganizing like the electrical, syncytium of the brain. know, anything that's playing with that, right? In other words,
Annatasha: As we continue to play God and and the edge death and bring to the edge of death and bring you back, I think if you are going to interrupt the novel electrical firing of either an awake or an asleep brain, because anesthesia is not really sleep,
Ryan Bailey: but like
Annatasha: I think has teasuring potential because on at this point, maybe with the exception of lidocaine, I've had patients seizure on butorphan all, know, and these are patients sometimes will have an uncontrolled seizure background.
Ryan Bailey: Yeah.
Gianluca Bini: Wow.
Annatasha: Those are usually the ones who are going to have a, like be a hot mess when you go to sedate them or where you're trying to recover them. I find are the ones who are like known epileptics, but they only seizure once a month, so they're untreated. Those guys usually give me a bit of a pain. the one time I'll use my benzodiazepine conduction agent, but I think anything that plays with your brain activity has, has you know, can be a leptogenic essentially.
Ryan Bailey: Yeah.
Annatasha: But i' yeah, I've had dexametatomidine causes seizure.
Ryan Bailey: Oh, yeah.
Annatasha: i've I've had anaphylaxis from formodidine.
Ryan Bailey: Oh, at the end of the day.
Annatasha: I've gone into V -TAC on slow cephasilin, not personally, but slow cephasilin. So every single drug I've seen, you know i I believe because it's a foreign material in the body and because there's only so much we know slash fancy guessing potentiate an adverse event.
Annatasha: So even though it might not be a published outcome of lidocaine, is it possible? Totally. Is it possible in a non toxic context?
Ryan Bailey: Oh, yeah.
Gianluca Bini: so yeah
Annatasha: Totally. um I questioned the rash of seizureing of things associated with lidocaine.
Ryan Bailey: and right Yeah.
Annatasha: They might want to consider sending their, throwing that bottle out, sending it for analysis, reporting it to the manufacturing and rocking up with something different.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Annatasha: But yeah, I haven't seen it, but You know, saying that it'll probably happen tomorrow, so.
Ryan Bailey: and yeah The dogs don't get in the coffee grounds.
Annatasha: Well, that's the other thing.
Annatasha: Like, was it's so hard to really know what's going on when we've done like three or four, five, 10, 14 different things, right? And you're just like, which one caused the seizure?
Ryan Bailey: Yeah.
Gianluca Bini: Yeah.
Ryan Bailey: Right. Exactly. Yeah.
Annatasha: But if you act like read plums sometimes, it will tell you that dexametatomy lowers the seizure threshold.
Gianluca Bini: Yeah.
Ryan Bailey: Sure.
Annatasha: And I'm like, where did that shenanigans come from?
Ryan Bailey: Right.
Ryan Bailey: What?
Gianluca Bini: I mean, yeah.
Ryan Bailey: saving
Gianluca Bini: I mean, I don't know how much credit to give to them, but sure.
Annatasha: No, I had a GP call me up once because this dog who was like a known epileptic, but was well -managed and I pre -med it because it was bonkers. I pre -med it with Dex metatome and the GP called me up and attempted to read me out about Dex metatome and seizure and thresholds. And I was like, oh, sir, boy, did you pick the wrong person for the wrong fight on the wrong day, right? Like I was like, you don't want to do this. You don't want to do this.
Gianluca Bini: Oh, hello.
Annatasha: But anyway, yeah so that's my two cents. I think lidocaine causes teetering. No, but I think it's possible.
Ryan Bailey: Oh no, I don't think it causes, seat not not to say that, but I just wondered if you happen to come across it in all your travels.
Annatasha: Not yet, Bailey, but the day is not over.
Ryan Bailey: I know.
Annatasha: And honestly, there's still, even though I do little less clinics than I used to, there's still not a day that swings by in my life as a veterinarian in the greater culture of veterinary medicine where I did not learn something or are surprised by something.
Annatasha: Could be anesthetic, could be non -anesthetic, but yeah, every day to me is like, i oh, this is a first.
Ryan Bailey: Right?
Annatasha: so, you know, it could happen.
Gianluca Bini: All right, guys, I think we're coming up on the hour. We're done answering questions about light again, and it's utility slash utility.
Annatasha: I hope every podcast and every topic, basically, we never land on any meaningful conclusions.
Gianluca Bini: If you...
Annatasha: We just basically wish she and...
Gianluca Bini: There isn't... I think the light...
Annatasha: Yeah, totally wish.
Gianluca Bini: So to give a summary, right? So no lidogaine in pregnant patients, for sure. It may or may not. It doesn't, so it doesn't, we don't see any na nausea in unless you go really high on the dose. If you need to pick within fentanyl and lidogaine in a post -op patient on which one to turn off or decrease, if you're seeing nausea, pick the fentanyl.
Gianluca Bini: And then, don't try to mix up login aesthetics, I guess. Although, like if you did a block and did the Lilacine Zero, that's probably okay -ish.
Gianluca Bini: And then, what else? Yeah, MLite Cream, it takes fucking forever, otherwise it's cool.
Annatasha: Great for mosquito bites. Great for mosquito bites.
Gianluca Bini: Mosquito Bites, great. Lilacine Patches, we should probably use them more, but we don't.
Ryan Bailey: Probably not great.
Gianluca Bini: But,
Annatasha: And I will never mustache because they're sweaty and disgusting and they trap weird stuff.
Annatasha: And that was the worst four minutes of my whole life.
Ryan Bailey: Let me tell you, facial hair in the winter is great. Really keeps you nice and warm.
Annatasha: Mm.
Gianluca Bini: So now I have this last question for you, Raya. Now, you know is there any like weird -ass special food or crap that happens in Chicago during St.
Ryan Bailey: yeah
Gianluca Bini: Patrick's Day? or
Ryan Bailey: I mean, we die the river green.
Gianluca Bini: you You do what?
Ryan Bailey: the
Annatasha: The poor Italian doesn't know this.
Ryan Bailey: Every year, they they have this dye that they the the plumbers use to look for like leaks in your pipes, but it's like an orange dye, and then what's added to water turns it like bright, like neon green, and they go up and down the Chicago River just dumping all the dye into the river, and the whole river turns green.
Ryan Bailey: If you look look up pictures, it looks like it's got a filter, or like it's some Instagram thing. No, that river is like, great like Kelly green color it is you know we don't have so much I mean they claim it's like a non -toxic I think and I mean they claim it's okay but like man they're like they've got like and and they're just hosing all this stuff around yeah
Gianluca Bini: Is it, is it okay for the, is it okay for like, you know, the environment?
Gianluca Bini: a
Annatasha: you ah say say where we yeah the wrote
Annatasha: Should use it in the superfish to see whether or not it's good for the environment.
Gianluca Bini: sir
Ryan Bailey: I mean, the Chicago River is not something you want to swim in or spend any great amount of time in because they used to like dump all sorts of shit in. But like they're trying to clean it up and get it better.
Ryan Bailey: But you know, we still like to deny it.
Annatasha: i think that's right like I think a good rule of thumb circa Paris Olympics is don't swim in poopy dead body urban rivers.
Gianluca Bini: But they still...
Ryan Bailey: yeah yes Yeah.
Annatasha: Chicago is no a no exception.
Ryan Bailey: Yeah. Yeah. Yeah. Yeah.
Annatasha: Although one of my favorite quotes from the movie, The Fugitive, which I think is one of A, the best movies and B, one of the best Chicago movies, Bailey.
Ryan Bailey: Sure.
Annatasha: is when they're at the St. Patrick's Day parade and they're chasing Harrison Ford down and Tommy Lee Jones is like, well, if they can, you know, dye it green for three, for this day, why can't they dye it blue for the other 364 days?
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Annatasha: I'm always like, because the rest of the time it's like that gross muddy river
Gianluca Bini: Awesome.
Ryan Bailey: Yeah.
Annatasha: um But I'll snigger at that part when they're like, just dye blue the rest of the year. but
Ryan Bailey: yeah
Annatasha: Our younger listeners probably won't understand that that cultural reference to the maybe the fugitive, but mm -hmm.
Gianluca Bini: All right, guys. guess, thank you so much for listening. We'll see you in the next episode. If you are listening and you want to watch, you can watch us on Apple Podcast with the Just Fund Out. I didn't really know that you could watch us on the Apple Podcast.
Gianluca Bini: But you can definitely watch us on YouTube as well. yeah, hope you guys have a good night.
Annatasha: And a good St. Patrick's Day.
