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S1E6 - Lidocaine: Because Feeling is Overrated
177 Plays3 months ago
In this episode of Random Anesthesia Topic, our trio of veterinary anesthesiologists takes a deep dive into lidocaine — a versatile drug in anesthesia and pain management. We explore its many roles, from local anesthesia and systemic analgesia to its anti-arrhythmic and pro-kinetic effects. How does lidocaine fit into multimodal pain management? When should (or shouldn’t) you use it in dogs, cats, and horses? We tackle these questions and more, sharing clinical tips and real-world applications. Tune in for an electrifying discussion on this staple anesthetic agent!
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Transcript
Intro
Lidocaine: Introduction and Debates
00:00:41
Annatasha
Oh, hey, man.
00:00:42
Gianluca Bini
It's not Brian.
00:00:55
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?
00:00:56
Gianluca Bini
likey
00:01:01
Annatasha
Yeah, it's so funny that we're all in green.
00:01:15
Annatasha
Yeah.
00:01:15
Gianluca Bini
It's you and us, yeah. And you're the only one with the real mustache.
00:01:20
Ryan Bailey
me
00:01:23
Annatasha
Yeah, this whole mustache situation is not something that I'm enjoying. It's making
Lidocaine in Anesthesia
00:01:28
Annatasha
my upper lip sweat excessively.
00:01:30
Gianluca Bini
It's so weird.
00:01:31
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.
00:01:41
Gianluca Bini
That's awesome.
00:01:41
Ryan Bailey
Oh my god, I love it.
00:01:43
Gianluca Bini
That's awesome.
00:01:43
Ryan Bailey
This made my day. ah Very nice, very nice.
00:01:49
Annatasha
Yeah, we've been planning it for a while.
00:01:52
Ryan Bailey
yeah
00:01:54
Gianluca Bini
So technically, this was supposed to happen.
00:01:57
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.
00:02:09
Gianluca Bini
But we were planning this for the previous episode before
00:02:17
Gianluca Bini
to barels The The third butt tells.
00:02:17
Annatasha
Valentine's Day. But Dr. Bailey was late, and so we couldn't surprise Dr. Bailey. Yeah.
00:02:23
Gianluca Bini
Exactly. She was late. She forgot. so
00:02:27
Annatasha
I'm never going to hear the end of this. I just know it.
00:02:30
Ryan Bailey
you
00:02:31
Gianluca Bini
yes
00:02:33
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.
00:02:45
Ryan Bailey
I am well-marked for the mustache days.
00:02:49
Annatasha
Oh, do we have to wear it?
00:02:50
Gianluca Bini
but we
00:02:51
Annatasha
Yang.
00:02:53
Gianluca Bini
It's up to you.
00:02:53
Annatasha
I don't know.
00:02:54
Gianluca Bini
We bought a whole collection of them.
00:02:58
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.
00:03:17
Ryan Bailey
Oh my God.
00:03:20
Gianluca Bini
That's crazy. All right. So tonight's topic, it's going to be picked by Dr. Bailey, right?
00:03:27
Ryan Bailey
Mm hmm.
00:03:28
Gianluca Bini
What you got? What you got?
00:03:30
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?
00:03:43
Gianluca Bini
It's futility, I mean.
00:03:45
Ryan Bailey
What?
00:03:46
Gianluca Bini
You forgot an F there. It's futility.
00:03:52
Ryan Bailey
but but
00:03:53
Annatasha
God, Bailey, we just got burned by some of our savages Italian.
00:03:54
Gianluca Bini
I'm kidding.
00:03:57
Gianluca Bini
I'm...
00:03:58
Ryan Bailey
a a ah Oh god.
00:04:00
Annatasha
Wow.
00:04:03
Gianluca Bini
I'm kidding. I'm kidding. It has its users. It has its users.
00:04:06
Ryan Bailey
I want to know when are you reaching for it? Is it?
00:04:10
Annatasha
I'm going to numb my upper lip from this mustache. Can I please take this off now?
00:04:16
Ryan Bailey
right
00:04:18
Annatasha
wow
00:04:19
Gianluca Bini
alright All right. All right.
00:04:21
Annatasha
oh
00:04:21
Gianluca Bini
All right.
00:04:23
Annatasha
Yeah, what really I interrupted you, which is totally my jam, but anyway.
00:04:24
Gianluca Bini
Oh Jesus.
00:04:27
Ryan Bailey
no
00:04:28
Annatasha
Lyda Kane, what are we reaching for it? What's its youth utility?
00:04:32
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
Cardiac Risks and Misconceptions
00:04:44
Ryan Bailey
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?
00:05:12
Annatasha
Waste of a pump, that's our new insult for other clinicians that we don't like, by the way.
00:05:15
Ryan Bailey
a
00:05:18
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.
00:05:32
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.
00:05:37
Gianluca Bini
Right.
00:05:39
Annatasha
You're the lidocaine revolutionary. So. really know
00:05:43
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.
00:06:28
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.
00:06:40
Ryan Bailey
Mm hmm.
00:06:41
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?
00:07:21
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.
00:08:11
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
00:08:41
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.
00:09:05
Annatasha
It's extraordinarily rare that I would reach for lidocaine as my first choice for a rapid increase in depth of maintenance plane.
00:09:12
Ryan Bailey
That feels good.
00:09:16
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
00:10:24
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,
00:10:42
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
Veterinary Concerns and Misuse
00:10:55
Annatasha
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
00:11:35
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.
00:12:04
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.
00:12:32
Annatasha
Bailey, how do you feel about that?
00:12:33
Ryan Bailey
Yeah.
00:12:34
Annatasha
What are your thoughts on lidocaine and mustaches in general?
00:12:37
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.
00:12:58
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.
00:13:14
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.
00:13:24
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.
00:13:37
Gianluca Bini
right.
00:13:40
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,
00:13:51
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.
00:14:21
Annatasha
What are your thoughts on lidocaine and venodilation and hypotension?
00:14:22
Ryan Bailey
I think.
00:14:25
Ryan Bailey
Oh, for sure.
00:14:26
Annatasha
Because I feel like this is a very big deal, for example, in horses, right?
00:14:30
Ryan Bailey
Yeah.
00:14:31
Annatasha
Like nobody rocks a lidocaine CRI and a horse until you've basically normalized bread blood pressure, right?
00:14:33
Gianluca Bini
It is.
00:14:38
Annatasha
Like so if you have a colic on the table, know, lidocaine really one of the the contraindications quote,
00:14:38
Ryan Bailey
Yeah.
00:14:44
Annatasha
end quote, is hypotension.
00:14:46
Ryan Bailey
yeah
00:14:46
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.
00:15:02
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...
00:15:18
Gianluca Bini
Sorry, I dominated it.
00:15:20
Annatasha
That's basically how hypovolemic anesthesia goes for anybody listening. It's just like a slow descend into a minor key.
00:15:24
Ryan Bailey
Yeah.
00:15:28
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
00:15:34
Gianluca Bini
Yeah.
00:15:40
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?
00:15:50
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,
00:16:17
Ryan Bailey
Damn. So I have a healthy, like,
00:16:20
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.
00:16:32
Gianluca Bini
It sounds like they think it's a waste of a pound.
00:16:33
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,
00:16:46
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.
00:17:00
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.
00:17:13
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.
Scenarios and Complexities
00:17:23
Ryan Bailey
Oh yeah.
00:17:24
Annatasha
so like
00:17:25
Ryan Bailey
I mean, whenever they die, we always say it's the high times.
00:17:25
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.
00:17:37
Annatasha
But yeah, I stopped lidocaine in the face of refractory hypotension 100%.
00:17:40
Ryan Bailey
Oh yeah.
00:17:41
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
00:18:12
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,
00:18:38
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.
00:18:55
Annatasha
But yeah, we're just talking about it as the hypotensive agent in dogs, whereas like we're super paranoid in horses.
00:18:55
Gianluca Bini
So I...
00:19:02
Gianluca Bini
I love how Ryan was hoping that he would jump into this conversation and somehow you would be his sidekick, right?
00:19:15
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.
00:19:23
Ryan Bailey
yeah
00:19:26
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
00:19:38
Gianluca Bini
Yeah, why not
00:19:39
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.
00:19:46
Ryan Bailey
Yes.
00:19:47
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.
00:19:55
Ryan Bailey
Yes. Yes.
00:20:02
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.
00:20:13
Ryan Bailey
but So when is it that you're reaching for lidocaine as your co-induction agent?
00:20:19
Annatasha
Let's say, Bailey, that I already have a patient that I know is going to go on a lidocaine infusion, for example.
00:20:19
Ryan Bailey
look
00:20:26
Ryan Bailey
or
00:20:27
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?
00:20:47
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.
00:20:55
Ryan Bailey
Yeah.
00:20:59
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.
00:21:10
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.
00:21:14
Ryan Bailey
yeah
00:21:17
Gianluca Bini
So, so, so...
00:21:19
Annatasha
Yes, Phoebe?
00:21:21
Gianluca Bini
No, no, sorry, I didn't want to interrupt you, but...
00:21:23
Annatasha
Oh, yeah.
00:21:23
Gianluca Bini
So why did you put friends to the other things again?
00:21:24
Annatasha
that what Now, you have to pick that out your next podcast topic, okay?
00:21:33
Annatasha
Because they don't do anything. Fuck, they're such a waste of time. Like, other than anti-epileptic.
00:21:39
Gianluca Bini
It's a waste of us around.
00:21:41
Annatasha
oh
00:21:41
Gianluca Bini
It's a waste of us around.
00:21:42
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.
00:21:53
Gianluca Bini
Wow
00:21:54
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.
00:22:03
Ryan Bailey
Well, it's my mate.
00:22:09
Ryan Bailey
Yeah.
00:22:10
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.
00:22:37
Gianluca Bini
So like never.
00:22:42
Annatasha
I don't know.
00:22:43
Gianluca Bini
So you never use it.
00:22:44
Annatasha
Not infrequently, but not frequently.
00:22:45
Gianluca Bini
Basically.
00:22:47
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
00:22:47
Gianluca Bini
I'm very diplomatic.
00:22:59
Ryan Bailey
right
00:23:00
Annatasha
I mean, there is the influence of where you trained, right? Like there are certain schools where lidocaine is their absolute go-to.
00:23:02
Ryan Bailey
yeah over me too
00:23:05
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.
00:23:06
Ryan Bailey
yeah
00:23:13
Ryan Bailey
Yes.
00:23:13
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,
00:23:28
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.
00:23:53
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.
00:24:02
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?
00:24:10
Annatasha
Bailey, he's hijacking your broadcast topic.
Alternative Anesthetics
00:24:18
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.
00:24:21
Gianluca Bini
Okay.
00:24:29
Annatasha
Let's do it.
00:24:32
Ryan Bailey
You're you're going to do Santa's seizure.
00:24:35
Annatasha
There you go. That's a good one, Bailey.
00:24:36
Gianluca Bini
Okay, yes, yes, I'll take it.
00:24:36
Annatasha
I like that.
00:24:36
Ryan Bailey
What's your thoughts on using lidocaine as part of your coinduction to decrease laryngeal reactivity?
00:24:43
Gianluca Bini
I'll take it, yes.
00:24:43
Ryan Bailey
Like as, yeah.
00:24:45
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.
00:24:45
Ryan Bailey
All right.
00:24:45
Gianluca Bini
And that's about it.
00:24:50
Ryan Bailey
Yes. Yes.
00:24:54
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.
00:24:57
Ryan Bailey
Yes.
00:25:03
Annatasha
We can just locally desensitize cough receptors, quick aside. But no, I like the anti-tussive component also
00:25:09
Ryan Bailey
yep
00:25:12
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.
00:25:24
Ryan Bailey
Oh, yeah, originally.
00:25:30
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?
00:25:38
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.
00:25:55
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.
00:26:01
Gianluca Bini
Where do you put the ladder window?
00:26:05
Gianluca Bini
Oh, okay.
00:26:08
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.
00:26:22
Annatasha
it's probably not that one but okay
00:26:27
Gianluca Bini
So, okay.
00:26:28
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.
00:26:39
Ryan Bailey
Like I find the
00:26:39
Gianluca Bini
Fair?
00:26:41
Annatasha
Beanie and I are not into inhalants.
00:26:41
Gianluca Bini
Fair?
00:26:43
Ryan Bailey
Yeah.
00:26:43
Annatasha
We're the Tiva podcast.
00:26:44
Gianluca Bini
Yeah.
00:26:44
Annatasha
but like Are you there?
00:26:45
Ryan Bailey
i in
00:26:46
Annatasha
but um yeah now i think i mean Think about the local spraying, though.
00:26:48
Gianluca Bini
do you,
00:26:51
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.
00:27:05
Annatasha
And I'm like, what a crock of shit that is. so ah So, you know,
00:27:11
Gianluca Bini
o so we wait wait make wait hot what
00:27:15
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?
00:27:21
Ryan Bailey
Sure.
00:27:23
Gianluca Bini
That's fair, that's fair.
00:27:23
Ryan Bailey
Sure.
00:27:23
Annatasha
I think it's more efficacious.
00:27:24
Gianluca Bini
I think the paper was from PJP or somebody.
00:27:27
Ryan Bailey
Well, I'm sure he loves that. Like he wrote so many papers about that block.
00:27:33
Ryan Bailey
It's interesting.
00:27:34
Gianluca Bini
Yeah. he
00:27:34
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?
00:27:43
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.
00:27:44
Gianluca Bini
yeah
00:27:50
Ryan Bailey
fish Absolutely.
00:27:52
Gianluca Bini
Yeah, no, I, yeah, that's, that's interesting. So, do you even use live in for your blogs? Right?
00:28:02
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.
00:28:09
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.
00:28:33
Gianluca Bini
Why I meant pivot game?
00:28:33
Ryan Bailey
So.
00:28:35
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.
00:28:42
Gianluca Bini
No, no, I meant like... No, no, I meant like, compared to rope pivot game. Sorry. Like...
00:28:48
Annatasha
Oh, it just depends on which one's more available, clinically, really.
00:28:52
Gianluca Bini
Oh, gotcha.
00:28:52
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
00:29:01
Gianluca Bini
Gotcha. So you're not looking at like their PK and all that stuff, right?
00:29:08
Annatasha
Yes, no, I definitely am.
00:29:13
Annatasha
Definitely looking at the PKA. It's nothing I love more than thinking about relative PKAs when I'm clinically doing something.
00:29:22
Ryan Bailey
Ha ha!
00:29:28
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.
00:29:54
Ryan Bailey
I'm gonna go ahead and trust you on this one, Beatty.
00:29:57
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.
00:30:13
Annatasha
Oh, suck that one boys.
00:30:13
Ryan Bailey
Wow. right.
00:30:14
Gianluca Bini
wow. Actually being so damn distinct.
00:30:16
Ryan Bailey
I feel so like a Neanderthal.
00:30:20
Gianluca Bini
nurse
00:30:22
Ryan Bailey
I'm like, well, I got lidocaine and I got bupicaine. And you know what? They do pretty good.
00:30:29
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?
00:30:50
Annatasha
Yeah, not because it's volume prohibitive and cost prohibitive.
00:30:51
Ryan Bailey
Right.
00:30:53
Annatasha
You are going to rock glidocaine. We're being very, very small animalists.
00:30:58
Ryan Bailey
Yeah, first.
00:30:58
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
00:31:23
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.
00:31:30
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.
00:31:40
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,
00:32:15
Gianluca Bini
you know, there is some interesting like research going on and that stuff. So another use for like logos or.
00:32:22
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?
00:32:27
Ryan Bailey
i mean
00:32:32
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?
00:32:43
Annatasha
This is news to me. This is news to me. I didn't know you were some sort of Fish fanatica fistinato.
00:32:51
Gianluca Bini
nerve, yeah.
00:32:52
Ryan Bailey
I mean, I did not.
00:32:53
Annatasha
Did you know this, Ryan?
00:32:56
Gianluca Bini
There you go. yeah, I teach the aquatic anesthesia lecture for up to higher states.
00:33:01
Ryan Bailey
Oh.
00:33:04
Gianluca Bini
So even even though I left, I still teach that.
00:33:04
Ryan Bailey
Well.
00:33:07
Gianluca Bini
Actually, I taught that two days ago.
00:33:08
Annatasha
How much fish anesthesia are you actually doing clinically, though?
Local Anesthetics: Emla Cream and Patches
00:33:13
Gianluca Bini
Now very little. you know in the past, we did a bunch before I moved.
00:33:20
Annatasha
Why and how and where?
00:33:23
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.
00:33:39
Gianluca Bini
They had like 55,000 like zebra fishes and stuff like that.
00:33:42
Ryan Bailey
They're all the rage in research for what I know, those zebrafishes.
00:33:43
Gianluca Bini
So it's like, yeah, it's crazy.
00:33:47
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.
00:33:53
Ryan Bailey
When I did have animal rotation, they were telling me all about these zebrafish.
00:33:53
Annatasha
My ignorance or your lack of?
00:33:55
Gianluca Bini
They use zebrafishes.
00:33:59
Ryan Bailey
They were like, oh, yeah, zebrafish.
00:34:00
Gianluca Bini
Yeah.
00:34:01
Ryan Bailey
They're all the data. And I was like, zebrafish, yeah.
00:34:03
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.
00:34:08
Annatasha
hi like
00:34:11
Ryan Bailey
Yeah.
00:34:11
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.
00:34:40
Annatasha
That is very cool. i will I will concede to that.
00:34:41
Ryan Bailey
Yeah.
00:34:42
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.
00:34:52
Ryan Bailey
For sure.
00:34:52
Annatasha
So.
00:34:56
Gianluca Bini
Fair, fair.
00:34:56
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.
00:35:06
Gianluca Bini
Are we down?
00:35:07
Ryan Bailey
So what do we, What does the team here feel about Emla Cream?
00:35:14
Annatasha
the eutectic mixture of local anesthetic.
00:35:17
Ryan Bailey
Oh, of course.
00:35:17
Annatasha
where
00:35:18
Ryan Bailey
Yes.
00:35:18
Annatasha
yeah
00:35:18
Gianluca Bini
hello
00:35:19
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.
00:35:28
Annatasha
What works when used? appropriately, which you basically have to put on.
00:35:34
Ryan Bailey
And how is that?
00:35:37
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?
00:35:46
Ryan Bailey
Yes. Yes.
00:35:48
Annatasha
And most people are like, they slap it on with some vet wrap for 10 minutes and out for the best.
00:35:50
Ryan Bailey
Yes.
00:35:53
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.
00:36:07
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.
00:36:19
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,
00:36:27
Ryan Bailey
right.
00:36:35
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.
00:36:47
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,
00:36:48
Ryan Bailey
yeah
00:36:59
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.
00:37:11
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.
00:37:22
Ryan Bailey
If I'm remembering the paper correctly.
00:37:24
Gianluca Bini
Yeah.
00:37:24
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.
00:37:29
Ryan Bailey
Yeah. Oh, for sure.
00:37:32
Ryan Bailey
Yeah.
00:37:34
Annatasha
Yeah, I err on this.
00:37:35
Ryan Bailey
Are you seeing, are you using a much beanie?
00:37:40
Gianluca Bini
No.
00:37:41
Ryan Bailey
That's fine.
00:37:43
Ryan Bailey
and
00:37:44
Gianluca Bini
now I mean, I think they're clinically enough.
00:37:49
Ryan Bailey
I feel like.
00:37:49
Annatasha
No. no
00:37:53
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.
00:38:05
Gianluca Bini
And by fat, you mean a fish on a feature device, or?
00:38:05
Ryan Bailey
And it just it's like.
00:38:12
Annatasha
Waste of a pump.
00:38:13
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.
00:38:27
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.
00:38:28
Gianluca Bini
Ooh, so in humans, the
00:38:33
Ryan Bailey
Oh.
00:38:38
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.
00:38:57
Gianluca Bini
I think thinking in humans,
00:38:58
Ryan Bailey
Maybe we can talk more on my just feel like there's not much more to say like Okay Yeah
00:39:03
Annatasha
Yeah.
00:39:03
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.
00:39:29
Ryan Bailey
Oh, yeah.
00:39:31
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?
00:39:44
Ryan Bailey
Yeah, for sure.
00:39:44
Gianluca Bini
There isn't really much you can do about it, right?
Toxicity Risks and Safety
00:39:48
Annatasha
I have not used them clinically.
00:39:53
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?
00:40:07
Gianluca Bini
yeah
00:40:18
Ryan Bailey
Right.
00:40:19
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?
00:40:28
Gianluca Bini
Yeah.
00:40:35
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.
00:40:51
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.
00:41:05
Annatasha
You this?
00:41:07
Ryan Bailey
No, I looked at it. I wrote about it in a presentation I did.
00:41:08
Annatasha
Oh.
00:41:11
Annatasha
Gotcha.
00:41:12
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.
00:41:24
Annatasha
Well, that's because you're putting it on mucosal skin, not skin with proper epidermis, right? So it like perivascular, perivaginally, right?
00:41:34
Ryan Bailey
Yeah.
00:41:34
Annatasha
That's a different kind of skin than it is like, like over your naps.
00:41:35
Ryan Bailey
Yeah. Oh, for sure. True.
00:41:38
Annatasha
But I'm wondering what the, like the utility, for example, of a lidocaine patch might be.
00:41:38
Ryan Bailey
Yeah.
00:41:42
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.
00:42:00
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.
00:42:08
Gianluca Bini
we give we give morphine to every single horse that's painful and it's especially if they are having colic surgery.
00:42:09
Annatasha
I get that all the time. just
00:42:18
Gianluca Bini
right And the pain pain definitely does cause way more colic than the morphine does.
00:42:18
Annatasha
Yeah, 100%. No.
00:42:26
Ryan Bailey
Oh, yeah.
00:42:26
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.
00:42:39
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.
00:42:39
Gianluca Bini
like
00:42:48
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.
00:43:01
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.
00:43:37
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?
00:44:01
Gianluca Bini
You know what I mean? But once that wears off, then I can see it, right?
00:44:03
Annatasha
No, no, no, I-
00:44:05
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?
00:44:09
Ryan Bailey
Yeah.
00:44:18
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
00:44:37
Annatasha
Yes, but probably, I mean, I'm always worried that anything that you put on an animal, they may groom it or eat
00:44:45
Ryan Bailey
thank
00:44:47
Annatasha
um I mean, I don't worry as much about horses like they're
00:44:49
Gianluca Bini
right.
00:44:51
Gianluca Bini
No.
00:44:51
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.
00:45:08
Ryan Bailey
Thank you.
00:45:08
Gianluca Bini
yeah
00:45:14
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.
00:45:30
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?
00:45:37
Ryan Bailey
Yeah.
00:45:48
Gianluca Bini
Would you use it as a co-inductor? Press this section or.
00:45:50
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.
00:46:03
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?
00:46:13
Ryan Bailey
Because the the pH of the fetal blood is so low that the...
00:46:15
Gianluca Bini
Hi.
00:46:19
Annatasha
Yeah, the PKA gets shifted because of the pH of the environment.
00:46:21
Ryan Bailey
Yeah.
00:46:23
Annatasha
You have to explain it to the listeners there, Bailey.
00:46:26
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.
00:46:53
Gianluca Bini
Gotcha. Yeah. And and so, I mean, somebody has the argument.
00:46:58
Annatasha
and this but Is this the one time where you randomly reach for lidocaine?
00:46:59
Gianluca Bini
yeah
00:47:05
Annatasha
Do you use d is it for
00:47:06
Gianluca Bini
What? No, no, are you crazy?
00:47:09
Gianluca Bini
No.
00:47:09
Annatasha
i was like
00:47:10
Ryan Bailey
you crazy
00:47:13
Annatasha
i was like I haven't had a glass of wine, but I feel like I might need it after this conversation, yeah.
00:47:17
Gianluca Bini
No, no. No, I mean, I don't use it as this anyway, but you know, you know, especially in those.
00:47:23
Ryan Bailey
Yeah. That lidocaine bottle in Beanie's in Beanie's Clinic still has a bunch of dust on it. It's never.
00:47:30
Gianluca Bini
They expire.
00:47:32
Ryan Bailey
Yeah, it was it
00:47:32
Gianluca Bini
They just fucking
Mixing Anesthetics: Challenges
00:47:33
Ryan Bailey
was the the first bottle.
00:47:33
Gianluca Bini
expire.
00:47:35
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.
00:47:44
Ryan Bailey
telling
00:47:50
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.
00:48:04
Ryan Bailey
So one other thing to just talk about for the for the listeners out there, mixing local anesthetics.
00:48:10
Annatasha
<unk>
00:48:11
Gianluca Bini
oh
00:48:11
Ryan Bailey
I feel like we just
00:48:14
Annatasha
the
00:48:14
Ryan Bailey
I know, I know, we're all gonna be like, it's terrible, don't do it, but like, why?
00:48:20
Annatasha
Uh... Why?
00:48:23
Ryan Bailey
I mean, I know why.
00:48:23
Annatasha
All right.
00:48:24
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?
00:48:47
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.
00:49:01
Gianluca Bini
So like, it's totally the opposite to what you want, really.
00:49:04
Annatasha
And toxicity is mostly synergistic, which means you're more likely to have an ish if you mix them.
00:49:04
Gianluca Bini
Right? And so, exactly.
00:49:10
Annatasha
Now, Bailey, I have a question for you. I'm going to tease this out a little bit.
00:49:13
Ryan Bailey
Oh, alright and know So both are great points.
00:49:13
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?
00:49:24
Annatasha
Or do you mean I gave an epidural with bupivacaine and then I put it on a lidocaine CRI?
00:49:32
Gianluca Bini
oh
00:49:33
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.
00:49:43
Annatasha
Let's call out the ophthalmologists because that's who's doing it.
00:49:47
Ryan Bailey
Oh, let's talk about using local.
00:49:48
Gianluca Bini
for that listening.
00:49:49
Annatasha
a
00:49:54
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?
00:50:17
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
00:50:24
Annatasha
Well, Bailey, if it has chronic pain, why don't you just give it half a mink per cake of sub-cucetamine?
00:50:29
Gianluca Bini
Every two weeks. Every two weeks!
00:50:31
Ryan Bailey
but Yeah, exactly.
00:50:39
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.
00:50:53
Annatasha
as opposed to ketamine.
00:50:54
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.
00:51:11
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?
00:51:14
Ryan Bailey
Very true. Sure.
00:51:19
Annatasha
um um And then you want to put them on a light again.
00:51:21
Ryan Bailey
I just have to do it on my own, but yep yep, all that stuff sounds great Bartel, very good.
00:51:25
Annatasha
basic and um um And then you also will put them on the lidocaine infusion.
00:51:28
Ryan Bailey
I never, never said I wasn't.
00:51:35
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,
00:51:39
Ryan Bailey
Yeah. Yeah. Sir. Okay.
00:51:50
Gianluca Bini
I thought you laughed there.
00:51:52
Annatasha
Yeah, it was the best. There's nothing more I care about than NSAIDs in the giraffe for tens of hours.
00:51:56
Ryan Bailey
wave
00:51:57
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.
00:52:12
Annatasha
However, I've done it.
00:52:17
Annatasha
because I'm wondering like, what is your systemic uptake of the bupivacaine?
00:52:18
Gianluca Bini
Yeah.
00:52:21
Annatasha
And I'm also using it for different purposes.
00:52:21
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.
00:52:53
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.
00:52:59
Annatasha
Okay.
00:53:08
Ryan Bailey
Oh, yeah, for sure.
00:53:08
Gianluca Bini
And then the cost style is the fastest, right?
00:53:10
Annatasha
First his leg, blah, blah, blah.
00:53:12
Ryan Bailey
Yeah, I remember.
00:53:16
Gianluca Bini
Okay.
00:53:17
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.
00:53:32
Ryan Bailey
Like, that's
00:53:33
Gianluca Bini
No, no, at that point it doesn't.
00:53:34
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.
00:53:41
Ryan Bailey
Yeah.
00:53:44
Ryan Bailey
Right.
00:53:46
Annatasha
And what is systemically, is that going to cause me a huge problem?
00:53:46
Ryan Bailey
For sure.
00:53:51
Annatasha
No. However, if I've been doing a big series of blocks, right?
00:53:52
Ryan Bailey
Right.
00:53:54
Ryan Bailey
Sure.
00:53:56
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.
00:53:56
Ryan Bailey
Yeah.
00:54:01
Ryan Bailey
Yeah.
00:54:04
Annatasha
but then also have a patient who happens to go into, I don't know.
00:54:04
Ryan Bailey
Yeah.
00:54:08
Ryan Bailey
Yeah. yeah
00:54:10
Annatasha
I cannot put them on a bupivacaine CRI. I mean, to be fair, it will the V-TAC forever.
00:54:14
Ryan Bailey
Yeah.
00:54:17
Ryan Bailey
Yeah.
00:54:18
Annatasha
But I can't do a bupivacaine CRI.
00:54:20
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?
00:54:32
Annatasha
Honestly, my worry is pretty minimal, even though, you know,
00:54:34
Ryan Bailey
yeah
00:54:37
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.
00:54:39
Ryan Bailey
Yeah.
00:54:45
Ryan Bailey
Yeah.
00:54:46
Annatasha
So, I don't know.
00:54:49
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.
00:55:04
Ryan Bailey
Like I think it's intercostals number one. And then I think it's a brachial plexus number two.
00:55:09
Annatasha
Anything close to either major arteries or plural, right?
00:55:09
Ryan Bailey
Yes.
00:55:13
Annatasha
Like, like, sorry, no, a mesothelial uptake, right?
00:55:13
Ryan Bailey
Yes. Yes.
00:55:15
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?
00:55:29
Ryan Bailey
yeah
00:55:35
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.
00:55:41
Ryan Bailey
Yeah.
00:55:47
Annatasha
That being said i don't really do many intercostals these days right i'm probably doing.
00:55:50
Ryan Bailey
Yeah.
00:55:52
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.
00:56:05
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.
00:56:10
Ryan Bailey
Yeah.
00:56:11
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
00:56:19
Ryan Bailey
Oh,
00:56:22
Annatasha
uptake just from adjacent to the artery, right?
00:56:23
Ryan Bailey
yeah.
00:56:24
Annatasha
So it's
00:56:25
Ryan Bailey
Yeah.
Recovery and Side Effects
00:56:26
Annatasha
legit.
00:56:26
Annatasha
But yeah, like I said, mixing locals in this capacity.
00:56:27
Ryan Bailey
Yeah.
00:56:31
Annatasha
I haven't yet encountered a problem, which is not a great justification.
00:56:37
Ryan Bailey
Right.
00:56:39
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.
00:56:52
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.
00:57:11
Annatasha
I mean, our patients are awake, so there's that, right? So for sure, I can crank those.
00:57:15
Ryan Bailey
i
00:57:15
Annatasha
I mean, I'll put fentanyl at 20, which I would never do an awake patient because A would not move.
00:57:21
Ryan Bailey
He would no longer be an awake patient.
00:57:22
Annatasha
yeah wouldnt be but um So we can get away with doses that are not appropriate for sentient
00:57:25
Ryan Bailey
Oh,
00:57:28
Ryan Bailey
oh I agree.
00:57:29
Annatasha
patient.
00:57:29
Ryan Bailey
Yeah.
00:57:30
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.
00:57:48
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.
00:57:59
Annatasha
They will stop the lidocaine and turn the fentanyl up to control the patient's pain, but to abate the nausea.
00:58:03
Ryan Bailey
Oh my god.
00:58:06
Gianluca Bini
Yeah.
00:58:07
Annatasha
And that has got to be the dumbest thing I have in my life.
00:58:09
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.
00:58:28
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.
00:58:30
Ryan Bailey
f
00:58:34
Gianluca Bini
Yeah.
00:58:39
Annatasha
And I'm like, but we're okay to crank fentanyl up to five, you know, or so seven.
00:58:40
Gianluca Bini
yeah
00:58:42
Ryan Bailey
Yeah. Oh, yes. Yeah. Yeah.
00:58:47
Annatasha
And I wonder why the patient is regurgitating, recumbent, and hyporexic.
00:58:47
Ryan Bailey
yeah
00:58:53
Annatasha
And I'm like, hmm, think, think, think, think, think.
00:58:53
Ryan Bailey
Yeah.
00:58:55
Annatasha
I wonder which drug it is.
00:58:57
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.
00:59:04
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.
00:59:07
Ryan Bailey
Oh, for sure.
00:59:15
Annatasha
If you are dysphoric, you are not going to eat. So, um, So, um, yeah, I don't know.
00:59:18
Ryan Bailey
Yeah.
00:59:21
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
00:59:41
Gianluca Bini
no, I agree with you. I agree with yeah, I hate when, when they do that.
00:59:44
Annatasha
because
00:59:46
Ryan Bailey
anecdotal question about lidocaine and then I will leave it alone. So I did
00:59:52
Annatasha
You had a lot of questions about Lidocaine more than I was anticipating, actually.
00:59:55
Gianluca Bini
Yeah.
00:59:56
Annatasha
How far can this conversation go?
00:59:56
Gianluca Bini
It's crazy.
00:59:56
Ryan Bailey
the research. So have you seen seizures at induction following lidocaine?
00:59:59
Annatasha
Here we are.
01:00:08
Annatasha
Oh.
01:00:10
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.
01:00:33
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.
01:00:46
Gianluca Bini
Right.
01:00:48
Ryan Bailey
And then I was recently doing a locum thing, and they had said they were recording instances of lidocaine causing seizures.
01:01:00
Ryan Bailey
and that they had seen a rash of it.
01:01:04
Annatasha
A rash of it.
01:01:05
Ryan Bailey
Well, I'm sure they use the word rash.
01:01:06
Gianluca Bini
wow
01:01:07
Ryan Bailey
That's my, you know, whatever.
01:01:08
Annatasha
Now that's a bile because I'm for sure.
01:01:09
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.
01:01:18
Gianluca Bini
Interesting.
01:01:19
Ryan Bailey
i hope I've only seen it one time and that dog ate a bunch of coffee grounds.
01:01:24
Gianluca Bini
Yeah, interesting.
01:01:25
Annatasha
Beanie?
01:01:25
Gianluca Bini
Now, I can say i can't say I've seen that.
01:01:25
Ryan Bailey
Anyway, just wanted to ask.
01:01:30
Gianluca Bini
But, you know, I that's fair.
01:01:31
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.
01:01:33
Ryan Bailey
yeah
01:01:41
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?
01:01:59
Gianluca Bini
talk.
01:02:00
Annatasha
I think there's a potential for an allergic reaction.
01:02:00
Ryan Bailey
Yep. Yep.
01:02:02
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.
01:02:02
Ryan Bailey
Good thing.
01:02:07
Ryan Bailey
Yeah.
01:02:11
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,
01:02:30
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,
01:02:32
Ryan Bailey
but like
01:02:46
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.
01:02:48
Ryan Bailey
Yeah.
01:02:54
Gianluca Bini
Wow.
01:02:58
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.
01:03:21
Ryan Bailey
Yeah.
01:03:22
Annatasha
But i' yeah, I've had dexametatomidine causes seizure.
01:03:25
Ryan Bailey
Oh, yeah.
01:03:25
Ryan Bailey
Oh, at the end of the day.
01:03:25
Annatasha
i've I've had anaphylaxis from formodidine.
01:03:29
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.
01:03:46
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?
01:03:52
Ryan Bailey
Oh, yeah.
01:03:52
Gianluca Bini
so yeah
01:03:54
Annatasha
Totally. um I questioned the rash of seizureing of things associated with lidocaine.
01:03:58
Ryan Bailey
and right Yeah.
01:04:00
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.
01:04:04
Ryan Bailey
Yeah.
01:04:07
Ryan Bailey
Yeah.
01:04:07
Annatasha
But yeah, I haven't seen it, but You know, saying that it'll probably happen tomorrow, so.
01:04:14
Ryan Bailey
and yeah The dogs don't get in the coffee grounds.
01:04:19
Annatasha
Well, that's the other thing.
01:04:21
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?
01:04:28
Ryan Bailey
Yeah.
01:04:30
Gianluca Bini
Yeah.
01:04:30
Ryan Bailey
Right. Exactly. Yeah.
01:04:32
Annatasha
But if you act like read plums sometimes, it will tell you that dexametatomy lowers the seizure threshold.
01:04:32
Gianluca Bini
Yeah.
01:04:38
Ryan Bailey
Sure.
01:04:38
Annatasha
And I'm like, where did that shenanigans come from?
01:04:39
Ryan Bailey
Right.
01:04:41
Ryan Bailey
What?
01:04:41
Gianluca Bini
I mean, yeah.
01:04:41
Ryan Bailey
saving
01:04:43
Gianluca Bini
I mean, I don't know how much credit to give to them, but sure.
01:04:49
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.
01:05:16
Gianluca Bini
Oh, hello.
01:05:16
Annatasha
But anyway, yeah so that's my two cents. I think lidocaine causes teetering. No, but I think it's possible.
01:05:22
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.
01:05:30
Annatasha
Not yet, Bailey, but the day is not over.
01:05:33
Ryan Bailey
I know.
01:05:35
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.
01:05:48
Annatasha
Could be anesthetic, could be non-anesthetic, but yeah, every day to me is like, i oh, this is a first.
Wrapping Up and St. Patrick's Day
01:05:54
Ryan Bailey
Right?
01:05:54
Annatasha
so, you know, it could happen.
01:05:57
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.
01:06:12
Annatasha
I hope every podcast and every topic, basically, we never land on any meaningful conclusions.
01:06:12
Gianluca Bini
If you...
01:06:19
Annatasha
We just basically wish she and...
01:06:20
Gianluca Bini
There isn't... I think the light...
01:06:25
Annatasha
Yeah, totally wish.
01:06:25
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.
01:06:54
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.
01:07:06
Gianluca Bini
And then, what else? Yeah, MLite Cream, it takes fucking forever, otherwise it's cool.
01:07:10
Annatasha
Great for mosquito bites. Great for mosquito bites.
01:07:13
Gianluca Bini
Mosquito Bites, great. Lilacine Patches, we should probably use them more, but we don't.
01:07:19
Ryan Bailey
Probably not great.
01:07:21
Gianluca Bini
But,
01:07:21
Annatasha
And I will never mustache because they're sweaty and disgusting and they trap weird stuff.
01:07:26
Annatasha
And that was the worst four minutes of my whole life.
01:07:29
Ryan Bailey
Let me tell you, facial hair in the winter is great. Really keeps you nice and warm.
01:07:34
Annatasha
Mm.
01:07:34
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.
01:07:38
Ryan Bailey
yeah
01:07:50
Gianluca Bini
Patrick's Day? or
01:07:52
Ryan Bailey
I mean, we die the river green.
01:07:56
Gianluca Bini
you You do what?
01:07:58
Ryan Bailey
the
01:08:00
Annatasha
The poor Italian doesn't know this.
01:08:02
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.
01:08:26
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
01:08:36
Gianluca Bini
Is it, is it okay for the, is it okay for like, you know, the environment?
01:08:49
Gianluca Bini
a
01:08:52
Annatasha
you ah say say where we yeah the wrote
01:08:58
Annatasha
Should use it in the superfish to see whether or not it's good for the environment.
01:08:58
Gianluca Bini
sir
01:09:01
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.
01:09:12
Ryan Bailey
But you know, we still like to deny it.
01:09:13
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.
01:09:13
Gianluca Bini
But they still...
01:09:18
Ryan Bailey
yeah yes Yeah.
01:09:22
Annatasha
Chicago is no a no exception.
01:09:22
Ryan Bailey
Yeah. Yeah. Yeah. Yeah.
01:09:25
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.
01:09:32
Ryan Bailey
Sure.
01:09:33
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?
01:09:36
Ryan Bailey
Yeah.
01:09:45
Ryan Bailey
Yeah.
01:09:49
Annatasha
I'm always like, because the rest of the time it's like that gross muddy river
01:09:50
Gianluca Bini
Awesome.
01:09:50
Ryan Bailey
Yeah.
01:09:53
Annatasha
um But I'll snigger at that part when they're like, just dye blue the rest of the year. but
01:09:57
Ryan Bailey
yeah
01:09:58
Annatasha
Our younger listeners probably won't understand that that cultural reference to the maybe the fugitive, but mm-hmm.
01:10:07
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.
01:10:25
Gianluca Bini
But you can definitely watch us on YouTube as well. yeah, hope you guys have a good night.
01:10:33
Annatasha
And a good St. Patrick's Day.