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Dr. Lane Johnson Answers the Question: "Alfaxalone: Should I Be Using It?" - Ep. 14
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The holiday season is in full swing and you may be asking yourself if it’s time to invest in something new for your clinic. A new anesthetic agent, perhaps? If that’s the case, then Alfaxalone may be the new drug to help shake up your old anesthetic drug protocols. Although it has been around on the veterinary market for a few years now, Alfaxalone is the newest anesthetic induction agent and with it come several interesting and intriguing potential benefits. Our guide to explore this newfangled drug is Dr. Lane Johnson, a boarded veterinary anesthesiologist, Clinical Assistant Professor of Anesthesia and Pain Management at the University of Florida, reptile enthusiast and Alfaxalone researcher. Together we will discuss how Alfaxalone came to be in its current formulation, it’s unique pharmacokinetic properties and side effects, why it’s such a great drug for sedating and anesthetizing cats and bearded dragons, and why alfaxalone has gotten its recent reputation as the best induction agent for small animals with cardiac disease. Should you purchase alfaxalone to use in your clinic? How do you use alfaxalone in the most effective and safest way possible? We hope this episode will be your guide to answering these complicated questions.
This episode is an expansion on our previous episode on Induction Agents with Dr. Xander Thomson.
In addition, check out this article by previous NAVAS podcast guest, Dr. Lydia Love, Should I Be Using Alfaxalone.
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If you are feeling generous this holiday season, consider donating to the NAVAS Education fund, whose mission is to improve anesthetic and analgesic care of veterinary patients by providing continuing education to veterinary professionals and caregivers. All donations help to support continuing educational efforts for veterinary professionals.
We also ask our listeners to save the date for the NAVAS Virtual Spring Symposium on April 27th and 28th, 2024. For more information about the program, visit the NAVAS Spring Symposium website. Registration starts Feb. 1.
Thank you to our sponsor, Dechra - learn more about the pharmaceutical products Dechra has to offer veterinary professionals, such as Zenalpha.
If you have questions about this episode or want to suggest topics for future episodes, reach out to the producers at education@mynavas.org.
All opinions stated by the host and their guests are theirs alone and do not represent the thoughts or opinions of any corporation, university, or other business or governmental entity.
The NAVAS Podcast is published monthly on or near the 15th of the month.
Special thanks to Chris Webster for editing, producer Maria Bridges, and Saul Jimenez for IT support in making this podcast a reality.
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Transcript
Introduction and Holiday Message
00:00:06
Speaker
Hello to all you gas pastors out there. Welcome to another episode of the Navas Podcast, the official podcast of the North American Veterinary Anesthesia Society, sponsored by DECRA. Our mission is to help veterinary professionals and caregivers advance and improve the safe administration of anesthesia and analgesia to all animals.
00:00:29
Speaker
I am your host, Dr. Bonnie Gatson, and I can't believe we are already at the end of the year with our 12th episode. So here at the Navas Podcast, we are wishing you, your friends and your family, including your fur family,
00:00:49
Speaker
A Merry Christmas or a Happy Hanukkah or a Happy Holidays or just wishing you a wonderful end to your year and a huge thank you from us for sticking around and listening to us for an entire year.
The Gift of Knowledge and Podcast Support
00:01:04
Speaker
And if this is your first time listening, we hope this holiday season, you treat yourself to one of the best gifts that you can give yourself. Knowledge and continuing education. Not only is it the holiday season, but it's also cold season and I am definitely recovering from a bad bout of illness. So if I sound a little bit more stuffy than usual, well, the holiday season and flu season often go hand in hand.
00:01:32
Speaker
Before we get into this episode, just a few housekeeping items. If you are enjoying the content from this episode, please consider supporting the podcast by leaving us a like or a review on whatever medium you choose to use to listen to podcasts and just simply tell a friend or a coworker to listen in.
00:01:54
Speaker
If you have any questions or topic suggestions, please write to me and the producers of this podcast at education at mynavask.org. We are always appreciative of any and all listener support.
NAVAS Virtual Spring Symposium Details
00:02:09
Speaker
Next, we want to give our listeners a heads up that the NAVAS Virtual Spring Symposium will be held on April 27th and 28th of 2024. There is program content for veterinary technicians, general practitioners, and specialty veterinarians. Please visit the NAVAS website at www.mynavas.org to learn more about the program and the speaker lineup.
Introduction to Alfaxolone
00:02:34
Speaker
So this month's episode is an expansion upon our previous episode on anesthetic induction agents with Dr. Xander Thompson. So if you haven't heard that episode, we will provide a link to it in the show notes so you can go back and listen if you're interested.
00:02:53
Speaker
However, this holiday season, maybe you want a new toy at your clinic, maybe a new anesthetic agent to add to your clinic's drug repertoire. Well, our focus today is all about the newest anesthetic induction agent on the block, Alfaxolone.
00:03:10
Speaker
Now, Alfaxilone is not necessarily a new drug and it's been around for a few years now in the North American market. So many people have heard about it. Despite that, maybe you aren't sure if your practice is ready to invest in this drug or maybe you've had this drug at your practice already and you're wondering how to use this drug to its full potential.
00:03:34
Speaker
Well, if you've asked yourself any of these questions, this episode is just for you. For this episode, we are speaking with
Dr. Johnson on Alfaxolone's History and Usage
00:03:43
Speaker
Dr. Lane Johnson, a Clinical Assistant Professor of Anesthesiology at the University of Florida College of Veterinary Medicine, to discuss all the facts about Alfaxilum.
00:03:54
Speaker
We are going to talk about its history, its unique pharmacokinetic properties and side effects, why it's such a great drug for sedating and anesthetizing cats and bearded dragons, and why alphaxolone has gotten its recent reputation as the best induction agent for small animals with cardiac disease. So, should you purchase alphaxolone for your clinic?
00:04:18
Speaker
How do you use alphaxolone in the most effective and safest way possible? We hope to answer these questions right here on the Navas podcast with Dr. Lane Johnson. Good morning. How are you doing? Good morning. I'm fine. Why don't you start by introducing yourself and briefly describing your past training and your current role?
00:04:46
Speaker
So I'm Dr. Lane Johnson. I'm currently an anesthesiologist at the University of Florida's College of Veterinary Medicine. I went to vet school at Mississippi State University. I did a rotating small animal internship at Texas A&M University and then did my residency training at the University of Tennessee.
00:05:07
Speaker
So I ask all of my guests this, what drew you to specializing in anesthesia? What's so great about anesthesia? So I have to kind of tell a little bit more of my background to answer this question. So when I went to college, I majored in biomedical engineering and I
00:05:28
Speaker
Did this with the intent of maybe going to vet school, maybe going to medical school. I ultimately decided I wanted to go to that school.
00:05:37
Speaker
And I had been working in a general practice over the summer to get veterinary experience. And I really liked surgery there. I had no idea that veterinary anesthesiologists existed until I went to vet school. And of course, being an engineering major, I liked biomechanics and things like that. And so I kind of thought, maybe I want to be a surgeon. Sure. That makes sense.
00:05:59
Speaker
And then when i interacted with the anesthesiologist i was always really impressed with how much they knew how much physics they knew fluid mechanics i couldn't believe that they knew a lot of the things that i had learned in undergrad and you know in my engineering degree.
00:06:15
Speaker
And so then I kind of started thinking to myself, wow, well, this is really applicable to my degree and it's a very interesting field. And then you get to work with, you don't have to sub-specialize by species, you can work with large and small animal and exotics and everything. And so at that point, I kind of started changing my mind and then I ultimately made my mind up during my internship year that I was going to go forward with anesthesia.
00:06:41
Speaker
Yeah, it's a really interesting perspective because I don't think a lot of people who come on here say that the original thing that drew them to anesthesia was physics. That's fair. But I will agree with you in the sense that I didn't know veterinary anesthesia was even a thing until I was in vet school.
Alfaxolone's Market Entry and Formulation
00:07:05
Speaker
Yeah. So jumping into veterinary anesthesia, we're going to spend a lot of time today focusing on alphaxolone. It's our newest, it's not new per se, but it's our newest induction agent that we have available on the market.
00:07:23
Speaker
So, as I just alluded to, it has been around for a long time. So, could you start us off by telling us the story about facelone and how it came to be in its current formulation?
00:07:37
Speaker
So it's kind of well known in the anesthesia field, some of the history of alphaxolone. This drug, like you said, is not new. There was a formulation available like in the 1970s that was a combination of alphaxolone and alphatolone. And it was called, the brand name in veterinary medicine was called Safan.
00:07:57
Speaker
Safan ended up being taken off the market because the excipient in the drug, which is basically a solubizing agent, so it helps the drug stay in solution, that agent was called cremafor and it was a castor oil derivative. When they gave it to animals, it caused massive histamine release and allergic reactions.
00:08:17
Speaker
It ultimately was pulled from the market for that reason. So, what that brings us to, they reformulated alphaxolone and replaced that previous excipient with a cyclodextrin, which would not have the histamine release problems that the cremafor did.
00:08:35
Speaker
That's our modern formulation of alphaxolone, which originally had no preservative and was called alphaxan. It was released in other countries long before it was in the US. I think we finally got alphaxan in like 2015 or something like that, maybe 2014 in the US.
00:08:56
Speaker
And then in the past four or five years, they released a formulation of Alfaxin called Alfaxin multi-dose that actually does have preservative in it. And so when you breach the vial, it can be used for up to 28 days, which is obviously a lot nicer for people's pocketbooks and their inventorying and their clinics too. The preservative that's in the Alfaxin multi-dose is a combination of things like
00:09:25
Speaker
ethanol and benzethonium chloride, which that's similar preservative formulation to ketamine. So you can, there shouldn't be those concerns with some of the other preservatives like with propofol-28. Yeah, we're going to get back to alphaxium multi, hopefully at some point. So when I started using alphaxolone,
00:09:47
Speaker
We didn't have the alphaxolone multidose. We just had the non-preservative formulation. It's my understanding that it's no longer made by Gerox, but Zoetis, I believe, bought Gerox, or at least they bought alphaxolone. Yeah, I think you're right. Yeah. It's my understanding that they no longer manufacture the non-preservative alphaxolone.
00:10:10
Speaker
That's my understanding as well. And that's all we have is Alfaxilin multi-dose now. Right. Okay.
Mechanism and Administration of Alfaxolone
00:10:18
Speaker
So let's jump into a little bit about the pharmacokinetics of Alfaxilin and what happens to this drug when we put it inside of our patients.
00:10:28
Speaker
What's the classification? Like, how would you classify olfaxone as a drug? So structure-wise, it's a synthetic neurosteroid. As far as its mechanism of action, it's a GABA agonist. So similar to some of our other induction drugs, like propofol and like itomidate.
00:10:45
Speaker
So, when you give alphaxolone, it has a similar mechanism of action as propofol, at least to induce a state of unconsciousness and provide muscle relaxation. But what's its onset of action, especially compared to propofol? And how long are you going to see those effects from a single intravenous injection?
00:11:08
Speaker
at least compared to propofol. The onset of action is actually not too different from propofol so if you go and look in plums you'll see that the onset of effect after Ebola should be within around 60 seconds and usually intubation can be accomplished within one or two minutes which is not too different from propofol. Now if you give a single bolus dose of that drug it will last
00:11:35
Speaker
longer in cats than it does in dogs. So if you give a single bolus dose of alpha-axlein, you should expect that animal will probably be waking up from that bolus dose within 5 to 10 minutes, but with a cat it might take a little bit longer, more like 15, 20 minutes.
00:11:52
Speaker
And how is it eliminated from the body? And I'm asking this question because if you look classically at propofol, at least textbooks, sometimes you'll see things like propofol is better to use or more favorable to use in animals with liver disease because it has some, not all, but some extra hepatic metabolism. So what does the metabolism look like with Alfaxilin?
00:12:19
Speaker
So, alphaxolone is biotransformed in the liver, phase one and phase two, type of metabolism, psoocytic room, P450 and conjugation. And this is true for both dogs and cats. There doesn't appear to be at this time any extra hepatic metabolism of the drug, so that's different than propofol like you said, and we don't really have the
00:12:46
Speaker
clinical I guess knowledge to know how well it works in patients that have severe hepatic dysfunction. The thing with propofol is it's used a lot in humans and so we can see that humans that have
00:13:00
Speaker
or having liver transplants, for example, due to liver failure, they can get propofol and not have any adverse outcomes from that. With alphaxone, that's not approved for use in humans yet. I think that they are exploring that at this time, but we don't have a lot of data on using that in patients with severe hepatic dysfunction.
00:13:21
Speaker
And so probably still probably your best choice in that scenario because it's more of a known quantity. But if you were going to use alphaxolone, you might would do some of the things that you would do with other drugs with patients with hepatic dysfunction, like decreasing the dose, for example.
00:13:37
Speaker
So, since we're kind of on a path of comparing alphaxolone to propofol, what's the quality of anesthetic recovery with alphaxolone compared to other induction agents like propofol? So, alphaxolone, most of the time the recovery
00:13:54
Speaker
pretty smooth. However, you can have some muscle twitching myoclonic movements, nystagmus has been reported as well. And I feel like in my clinical experience that that is definitely more common with alphaxolone than propofol. You can see that with propofol as well, but it's quite rare. It's more likely to happen with alphaxolone, but that being said, the recoveries are usually smooth with alphaxolone.
00:14:21
Speaker
That has also been my clinical experience. Sometimes I feel like the recovery from Alfaxilin looks really similar to, not all the time, but sometimes can look really similar.
00:14:34
Speaker
to the recovery with ketamine, especially in cats for some reason. I feel like I see it way more commonly in cats, but I don't know what you see.
Sedation in Cats with Alfaxolone
00:14:42
Speaker
Yeah, I would agree with that. Depending upon what kind of setting you're working in, most of the time when we're recovering an animal from anesthesia, we're trying to make sure that most of those drugs are
00:14:55
Speaker
kind of off-board by that time. I will say that I'm not a big fan of Alpha excellent CRI's for that reason. I feel like the recoveries are not good with that. Yeah, so we can jump into that conversation because
00:15:13
Speaker
There is a difference between alphaxone and propofol when we talked about differences in the route of administration and also a little bit different in how animals recover. Spoiler alert, we already gave this away, but alphaxone is similar to propofol, can be given as a cause and rate infusion to maintain general anesthesia.
00:15:37
Speaker
We'll get back into that in a minute, but there are differences when it comes to the route of administration. So I'll just leave it to you to talk about what the big differences are, at least between propofol and olfaxone and how you can actually administer the drug to the patients.
00:15:53
Speaker
So everyone is pretty familiar with propofol by this point and knows that you can only give it intravenously. Whereas with alphaxolone, you can not only give it intravenously and treat it similarly to propofol in that regard, but you can also administer it intramuscularly for either premedication sedation intent or for full anesthetic induction intent.
00:16:17
Speaker
So what's the dose of Alfaxolone if you're giving it IV versus if you're giving it IM in dogs and cats? So the dose, that depends on people's personal preferences. I will say that the range for the intramuscular dosing, I feel like is a little bit wider than what we typically do for IV, but the doses are not terribly different. So for a dog or a cat, I would say for intramuscular, depending upon the size of the animal,
00:16:46
Speaker
usually talking one to four milligrams per kilogram. And then for intravenous dose, we're usually pulling up depending upon how much pre-med effect you feel like you're going to have. Like if you've given a heavier pre-med, you might draw up less. I would say two to four milligrams per kilogram for IV. And then obviously, when you are
00:17:09
Speaker
intravenously inducing an animal with alphaxone, you're giving that drug to effect similar to how you would use propofol.
00:17:17
Speaker
Yeah, that's a good point. We haven't gotten to side effects of Alfaxilone, but it's definitely recommended that you give it slowly, kind of similarly to propofol. Yeah. And then back to the intramuscular injection, because I think this is a topic where people are really interested in Alfaxilone. If you look at cats, a lot of times
00:17:40
Speaker
when we have to give intramuscular sedation to cats because they're not handleable or we just need to sedate them for a procedure or something like that. The classic drug combination to go to is like dexmedetomidine, ketamine, and betorphenol or buprenorphine or something like that. Kitty magic. Yeah, kitty magic. And so alphaxolone has got to come on the market and challenge that a little bit.
00:18:06
Speaker
And so I kind of want to talk about using alphaxolone IM to sedate cats because I think it's really where a lot of peak interest has come from, this drug. We're going to start with cats. So if you're going to use it intramuscularly in a cat, what are kind of your recommendations as far as
00:18:26
Speaker
What other drugs do you combine with it? Do you use it alone? How long can you see the effects if you're giving an IM? So just kind of like your general clinical picture of like what it looks like to use alpha-exalone intramuscularly for sedation in cats. So alpha-exalone
00:18:48
Speaker
It's a nice tool to have to give intramuscularly in calves. Combination wise, first of all, I wouldn't recommend giving out faxed loan by itself. Why is that? There's been research that shows that it's really not, the sedation isn't as reliable and you're more likely to see some of those undesired effects like the muscle twitching and stuff like that. And if you combine it with another agent, you can
00:19:14
Speaker
hopefully kind of get a synergistic effect between the two where you get more efficacious sedation and longer duration of sedation. So usually when premedicating with alphaxone, I'll combine it at the very least with an opioid. So if it's a non-painful procedure, it would do something like alphaxone-butorphenol, or if it's something where we need a full mu agonist opioid that's a painful procedure, maybe alphaxolone and methadone.
00:19:42
Speaker
And then dose-wise, it really depends on the size of the cat. So the thing about Alfaxilone and the reason it's such a big interest for cats is because cats are small and Alfaxilone is not very concentrated. It becomes kind of volume prohibitive and larger.
00:19:59
Speaker
animals. Whenever you have a cat, if you have a really big cat, I try to limit the volume of the injection. So I kind of back calculate, honestly, to make sure I'm not going to give more than 10 milligrams, which is one mill about faccellone to a cat. But that that's me personally, you can obviously give more than that. But that's just trying to limit that intramuscular volume of dose.
00:20:20
Speaker
Yeah, I find that I have, I have done all kinds of combinations about Paxilone with other agents, including Dexmedetomidine, I've used Buprenorphine. The only agent I personally don't use
00:20:36
Speaker
without axelan to sedate cats as midazolam. Yes. But I do, just because I don't really like to sedate cats with midazolam in general. However, I do know people who have done that successfully. I guess my only recommendation is that if we're going to do that, go high on the dose of midazolam.
00:20:57
Speaker
Yeah. Yeah. I think that's fair. I totally agree with you. I don't like midazolam and cats. And I think midazolam is when there's drugs, you have to be really cautious with your patient selection of who you're going to give that to. There actually, this wasn't cats, but in dogs, there was actually a study where they compared alphaxolone and an opioid with or without midazolam. And when they added midazolam in, and this was in young, healthy dogs, it made the sedation worse.
00:21:26
Speaker
Yeah, I'm not surprised by that. So, you know, a lot of people want to throw him a dazzling man there, but it's really probably not always the best idea, but I agree.
Respiratory and Cardiovascular Effects of Alfaxolone
00:21:34
Speaker
And there's been a lot of research done with alphaxalone in combination with things like ketamine and dexmedetomidine. And those, those combinations can be used very successfully, especially if you have an animal that restraints going to be an issue, like they are very. Fractions then alphaxalone plus dexmedetomidine in an opioid, I think would be a great choice in really aggressive cats.
00:21:56
Speaker
There has been evidence, successful evidence that you can use certain drugs transmucosally to induce sedation, things like ketamine, you can squirt in their mouth at obscenely high concentrations. Our alpha-2 adrenergic agonists as well have been shown some efficacy with transmucosal menstruation. So if a cat's hissing at you, you can squirt in their mouth or something like that.
00:22:21
Speaker
I doubt that has been looked at with Alfaxilum, but I wanted to know if you knew anything about that. Right. I couldn't find anything about that and have been looking at various routes of Alfaxilum, but that is something very interesting. To your point about spraying the ketamine or the dexmedetomidine in the mouth of the cats, I have done that before. It's one of those things where
00:22:45
Speaker
It's not going to sedate them as it would an injection, but definitely something to keep in our back pockets. I don't see why something like alphaxone wouldn't do that since it is also obviously highly lipid soluble, but yeah, I was unable to find any work that said that or confirmed that. What is your clinical impression of
00:23:06
Speaker
how long it takes for cats to get sedate and with like alfaxilin combinations for sedation, intramuscular sedation. And so how long does it take them to get sedate? And then like, what is your opinion on the quality of sedation? So if you were just using an opioid and alfaxilin, it's probably going to take a little bit longer. Like I would wait at least
00:23:32
Speaker
10 or 15 minutes for the peak effect. If you are giving more, kind of a stronger combination, a cocktail of drugs like dexmedetomidine, aufaxilone, and an opioid, there have been studies that show that the sedation should be relatively quick with that. So probably five minutes, you'll see a good level of sedation.
00:23:52
Speaker
And then as far as how long it lasts, that is also dependent upon the agents that you combine with it. But probably you can get a good 20 or 30 minutes of sedation intramuscularly. But, you know, again, depending upon what you've combined it with, if you combine it with other agents, this could be extended to the longer edge of that range. But if it's just alphaxone and opioid, probably a shorter duration.
00:24:22
Speaker
This is my clinical impression about Faxelone and just moving away from cats, just to include cats and dogs. I just find that the reliability of the sedation is not always there. It could be a combination of things.
00:24:38
Speaker
I feel like it could be that you're not getting a true intramuscular injection. Maybe you're injecting intrafat or sub-q. It could be that it's such a large volume that if you have a wiggly squirmy angry cat that you just can't get it all.
00:24:58
Speaker
all the volume in that you think you've gotten in. But I also just find sometimes that even if I feel like I've gotten a decent volume in that sometimes I don't see the quality of sedation that I really am hoping to achieve. And sometimes I have to give more Alfax alone or I have to switch gears and give something else.
00:25:19
Speaker
We'll talk about it a little bit, like why we still kind of jump on alphaxolone compared to other set of agents a minute, but I didn't know if that was your clinical impression too. Yeah, I definitely agree with that clinical assessment of alphaxolone. You can't really tell what you're going to get sometimes from it. And I think, like you were saying, there are a lot of factors at play there. If the animal's already really stressed, then it's going to be harder to sedate them in general.
00:25:49
Speaker
And then, of course, absorption of the drug, which is a fair point to touch on because, you know, there have been some studies in other drugs that show that different muscle groups have better perfusion and better uptake of the drug.
00:26:02
Speaker
And that certainly could be the case, you know, depending upon where you give your injection to the animal. But I agree with you, lots of times Alfaxone is one of those drugs that you give some and then you have to go back and give a little bit more to get the effect that you want to be able to place your IV catheter or whatever it is you're trying to do, do your ultrasound.
00:26:24
Speaker
Yeah. And I also feel like sometimes I give it and like, I mean, this doesn't happen as often, but sometimes I'll give it like two minutes later, the animal is like almost anesthetized. I've done that before or I've seen that before as well. So like Alfaxilin, I still use it, but I just always have that like in the back of my brain that I might not see the level of sedation that I'm aiming for.
00:26:48
Speaker
Right. Which is not as predictable in my opinion. I totally agree with that as well. You know, when we use alphaxone as a pre-med, kind of the philosophy is you should be prepared for induction. And I agree. Anytime you use
00:27:02
Speaker
something that is an anesthetic induction drug, you know, whether it be alphaxone, propylol, if you're using those for sedation, you should be prepared for general anesthesia and have someone watching and monitoring that patient at all times because just like you said, sometimes who knows what happens. Maybe the animal is extra susceptible to the drug for whatever reason or perhaps
00:27:24
Speaker
at some point during the IM injection, it actually went into a vessel and you can get a patient that's actually induced under anesthesia. That's why it's so important to be ready for that if it does happen and have someone who's constantly monitoring that patient after you've administered this drug. Because even though you're trying to use it for sedation, it's still an induction drug and so it can anesthetize a patient. Yeah, I think that's a really good segue into talking about some of the pharmacologic effects of alpha-axolone.
00:27:53
Speaker
So do you want to talk about what are the major respiratory clinical effects of Alfaxilone? So Alfaxilone has dose-dependent respiratory depression similar to other induction agents. If you give a large dose, if you give a dose very quickly, you can certainly cause apnea during the induction period.
00:28:16
Speaker
Yeah. And I have also seen apnea during sedation, which is really important too. And so you've already alluded to the fact that if you're using alphaxolone at all, I always have somebody very closely monitoring that patient to make sure that they continue to breathe. To breathe. Yeah. That's a important part of life. Uh-huh. We have, have that tubular endoscope ready just in case.
00:28:42
Speaker
Yeah. Yeah. It's recommended to give a fax loan over 60 seconds. Is that right? Yes. Do you ever do that clinically?
00:28:56
Speaker
I don't think anyone does that clinically. It's one of those things where you have a dose in your mind, maybe like 0.5 milligrams per kilogram, and you give that relatively quickly, and then wait a few seconds, and then give another 0.5 milligrams per kilogram, and then wait 10, 15 seconds.
00:29:14
Speaker
watch for those clinical signs of unconsciousness and anesthetic induction like the lying down, their head becoming heavy, someone's having to support their head, loss of how people reflexes and relaxed jaw tone, things like that. I don't know if anyone who say draws up three milligrams per kilogram of alphaxil and then just gives that slowly over 60 seconds. I don't think I've seen anyone do that. I don't know what your experience is.
00:29:42
Speaker
Not really. I think the classic way that if you're only using alpha-oxalone to induce with alpha-oxalone, I usually drop a two make per kick dose. And I usually start with my aim of giving like half the volume. And I give it slow, but I wouldn't say I give it over 60 seconds. But generally speaking, I'm doing like a slow push until I'm starting to see the animal relax.
00:30:06
Speaker
And then I just intubate. And if they become APNIC, I just always pre-actionate my patients. So if I do have difficulty intubating, I don't run into hypoxemia, hopefully. And I just intubate and manually ventilate them if I need to. But one thing I have seen a lot of people doing with alphaxolone is combining alphaxolone with co-induction agents.
00:30:34
Speaker
And I think that comes from the popularity of doing it with propofol.
00:30:41
Speaker
When I was in my residency, which was a while ago, people were super jazzed about combining propofol with midazolam to try to reduce the volume and therefore the total dose of propofol you're giving in an animal. The goal of doing that was thinking that while your respiratory signs or your respiratory and cardiovascular adverse offense with propofol are dose-related, so if we can reduce the volume and therefore the dose,
00:31:09
Speaker
we can reduce these side effects. And so I have seen people combining alphaxol with midazolam to potentially offset maybe some of the respiratory effects of alphaxolone. And I don't know if you've come across anything in your research about alphaxolone or anything like that, that favors combining alphaxolone with midazolam in particular, but now even with ketamine.
00:31:37
Speaker
It's very interesting because I feel like pretty much all of the co-induction studies that are out there with midazolam and propofol or midazolam, alphaxolone, don't really show any benefit but people still want to do it.
00:31:57
Speaker
Even similar with ketamine, which I am not aware of if ketamine has been investigated for co-induction with alphaxolone for the clinical effects. I'm not aware if that work's been done, but I know in propofol that that was shown to not really change the amount of propofol that you need necessarily. But you could argue there are other reasons to give ketamine, even if you're using the same amount and that you get a sympathomimetic effect and increase your heart rate and hopefully have some compensation for
00:32:27
Speaker
the vasodilation that occurs with these drugs. But yeah, to say that you're giving a co-induction agent to decrease the dose hasn't really held up in the things that I've read.
00:32:38
Speaker
Yeah, people still really like doing it in clinical practice. And I think that it's because it was really popular like a few years ago, and it was being recommended by the anesthesia community, I feel like. And also people, generally speaking out there, only have access to something like propofol. And when they have to anesthetize something that's like less than stable, and you only have midazolam, like I think that's why people are kind of still doing that.
00:33:07
Speaker
Yeah. Yeah. I think, I think that's fair. Midazolam for all of its faults, it's minimal. Cardiorespiratory depression makes people want to use it a lot. Yeah, I agree. So moving back to alphaxolone, let's jump to the cardiovascular effects because I do have a lot of questions about this. So let's just start with if you're giving like an intravenous dose of alphaxolone, what are the cardiovascular effects that you would expect in your patient?
00:33:36
Speaker
There are some things here which we keep comparing it to propofol. There are some things here that are similar to propofol and then some that are a little bit different. Similar to other induction agents, you will see some decrease in afterload, so a drop in your systemic vascular resistance or vasodilation basically. But unlike propofol, with alphaxolone, the heart rates maintained a little bit better. So with propofol, you'll have that vasodilation and usually the heart rate does not
00:34:06
Speaker
have any compensatory increase for that. Whereas with alphaxolone, you could see a little bit more compensation with the heart rate, which could make your blood pressure stay a little bit more stable. However, that really depends on the dose and how quickly you administer it. These are all dose-dependent effects, but you should expect some degree of drop in blood pressure invasive dilation from administration of alphaxolone.
00:34:32
Speaker
I feel like alphaxolone gets labeled as the more cardiovascular safe induction agent. And I will admit that if I have a cardiac case, for example, if I have a dog with mitral valve disease,
00:34:50
Speaker
I'll sometimes use alphaxolone over propofol, but I feel like depending on the degree and severity of cardiac disease, you could probably just get away with using propofol in a lot of these animals. Oh, certainly. But why do you think alphaxolone got labeled as the more cardiovascular friendly drug or induction agent? I mean, it's got to be the
00:35:16
Speaker
what I was saying about the heart rate and maintaining the blood pressure a little bit better. The interesting thing is that there was a study that compared when you actually administered both of those drugs as CRIs, the hemodynamic effects were no different from each other. So I think it really depends on how you're using the drug and how you're giving it. You can see very similar
00:35:39
Speaker
effects to propofol clinically speaking. But I think it's just because that heart rate's maintained a little bit better and can maintain your blood pressure a little bit better that it's gotten that label. Because especially for dogs with mitral valve disease, that would be a benefit to keep their heart rate a little bit higher. Yeah, I will say like I grew up
00:36:02
Speaker
my residency in a time where we had an option between atomidate and alpha-axolome. And for our listeners, atomidate is another reduction agent that has been available for a long time. That is the classic cardiovascularly safe induction agent, although I think there are some challenges to that idea now. But in any case, it was classically presented as the cardiovascularly safe induction agent.
00:36:28
Speaker
And I would induce a lot of my dogs with severe cardiac disease, I would use out-etopinate, and the induction quality is awful with-etopinate.
Comparison with Etomidate and Drug Mixing Issues
00:36:39
Speaker
And so over the years, I don't use-etopinate anymore, period. Even when I have dogs I'm working with severe mitral valve disease or severe cardiac disease,
00:36:54
Speaker
I'm almost always using olfaxilum because of that tachycardia that we talked about. I mean, sometimes it will cause tachycardia or at least it keeps the heart rate a little bit elevated compared to propofol in my clinical experience. But also the quality of induction is just so much better.
00:37:11
Speaker
And there's something to be said for these dogs. Like if you have a really crummy induction, it increases your sympathetic tone and not necessarily beneficial for patients. But what are you typically using for induction and for cardiac patients? Are you still using atomidate to use alphaxolome? Like what are you doing? Yeah, I don't use atomidate very much anymore either, to be honest. And I feel like in my clinical experience, you know, the textbooks and
00:37:41
Speaker
All the literature tells you that it maintains the stroke volume and the vascular tone pretty well, but I find that it drops the heart rate a lot. Yes, obviously that's going to affect your cardiac output, you know, and it's something that you don't want.
00:37:58
Speaker
and patients that have valvular disease. You don't want bradycardia in those guys. That allows more time for the regurgitant flow to happen, which is not what we want and could precipitate, you know, faster heart failure basically or volume overload at least.
00:38:13
Speaker
So for that reason, and the stormy inductions with atomodate, I agree. I tend to use more alphaxol now. I can't even remember the last time I used to atomodate, to be honest. I remember the last time I used to atomodate.
00:38:30
Speaker
And the day I was like, I'm not using this drug anymore, which I don't like to do that, generally speaking, but I was inducing a dog with atominate and midazolam for a PDA procedure. I think it was a PDA, some kind of advanced cardiac disease patients. And we induced the dog and the dog's heart rate dropped into the 30s.
00:38:52
Speaker
Yep. And we had to do like some minor CPR and the dog was wanting to atropine, but at that point I was like, why am I using this truck? Right. What is the point now? Yeah. Like the induction was awful and now I'm finding a heart, like this low heart rate. So I think at that point I was like, I'm just going to use Alfaxilone. Yeah. Yeah. So that kind of goes to the point back to where we're talking about sedation with Alfaxilone. And so especially with cats,
00:39:22
Speaker
I feel like for me, and I'm just wondering where you stand on this, but we use so much, you know, kitty magic to sedate cats, which is like the ketamine, dexametomidine combinations. And there's so many cats with subclinical heart disease that if, like I've just stopped using those combinations, meaning like ketamine, dexametomidine combinations in older cats and started favoring alphaxolome, but I don't know what has been your experience. What are you doing?
00:39:52
Speaker
How do you approach sedating those older cats? Yeah, I agree with you I don't for a domestic cat I I will try my best to avoid giving it intramuscular ketamine for a pre-med Because like you said lots of them have subclinical cardiac disease, which in a cat is most likely to be hypertrophic cardiomyopathy and if you give Ketamine you will get that sympathetic effect which is gonna
00:40:22
Speaker
have increased inotropy, increased heart rate, and that's the exact thing you don't want with HCM cats. And that's why I have never experienced this myself, but there are all of those horror stories about patients that have been premedicated with Kitty Magic and are found dead from their premedication just because of the catamune, most likely. Because we know that, you know, the opioids not going to be an issue and that
00:40:49
Speaker
Alpha-2 agonists for cats with HCM, those are actually beneficial by increasing the afterload and dropping the heart rate. By ketamine, yeah, I tried. Just because of that, I try not. It's a risk versus benefit thing. We have other drugs now, like you said, like Alfaxilone, that can take the place of ketamine that are not going to cause those issues.
00:41:13
Speaker
So, I remember reading somewhere that, at least for the multi-dose vials that have the preservative in it, that occasionally the preservative that's in aufaxilone can precipitate with certain types of adjunctive agents. And so, do you see that clinically? Do you give your aufaxilone, your multi-dose aufaxilone, separate from your other drugs? Do you mix them all together? What do you do?
00:41:38
Speaker
Yeah, so the label says that you should not mix them, that you should give alphaxolone separately from other drugs. And I've certainly heard reports of some degree of precipitation when you mix it with various things, like especially, I feel like midazolam.
00:41:55
Speaker
as a classic example of something that kind of precipitates with alphaxolone. That being said, most of the time when we are giving alphaxolone, we're most of the time starting out unless it's a really bad case that needs extra extra pre-medication. We're usually just doing an opioid in alphaxolone and we mix those together. I don't know what's your personal experiences with that but
00:42:20
Speaker
I think it's that I usually give off oxalones separate and it's only because I don't want to be surprised if something precipitates when I'm mixing it and then I have to go through the whole... Right. It's like purely laziness. I just don't want to have to go back and if it does precipitate... Re-draw the drugs and do... Yeah.
00:42:39
Speaker
Yes. I oftentimes will tell staff to give it separately and it's also on the label. I understand if you have experience already mixing your drugs and
00:42:52
Speaker
they don't precipitate, that's excellent. I would say like for a really good example also is like buprenorphine. So there's so many different like concentrations and formulations of buprenorphine that I work in a lot of different practices. So I never know like which type of buprenorphine I'm dealing with. So that's a great symbol of a drug I just, I always give, if I'm going to give buprenorphine and alpha-axolone, I'm just getting intramuscularly, I'm just giving them separately.
00:43:17
Speaker
Yeah, yeah, that makes sense. That's definitely, you know, it's one of those things where you kind of, again, risk versus benefit. If you think you're only going to get one shot with a cat, for example, then it might be worth mixing them and then see if you see any precipitation. And then obviously, if you do, you have kind of got to regroup from there. But otherwise, yeah, I think it's best case scenario to follow the label as closely as you can, for sure.
00:43:47
Speaker
Since we're basically spending a lot of time comparing our facts on the propofol, propofol is not considered a controlled drug, at least federally, I know in different states.
00:44:00
Speaker
Some states will be treated controlled. Correct. What about Alfaxilin? Is that a controlled drug? Yes. Alfaxilin is considered Schedule IV substance. It's a lower grade than ketamine, which ketamine is three. It's more in the, I think, butorphenols, Schedule IV as well. It's pretty low down there, but it is considered a controlled substance. Like you were saying, comparing it to propofol, propofol is not federally
00:44:28
Speaker
controlled, but lots of states treat it that way. What about the costs of Alfaxilone versus Probofall? Because I do think Alfaxilone has its place, as we've discussed, sedation. It has a really nice place, at least in our sedation repertoire for cats.
00:44:46
Speaker
in the pre-aesthetic period. But I do get a lot of pushback from some people who are interested in using Alfaxilone that it's just really expensive. So in your experience, if we're going to be comparing a cost per mil or something like that of Alfaxilone versus Propofol, do you think that it's similar? Do you think Alfaxilone truly is more expensive? What's your experience, at least from where you work currently?
00:45:15
Speaker
Yeah, first of all, yeah, disclaimer that where people source their drugs from apparently factors heavily into this. So I actually did speak with our pharmacist about this and asked her what we pay for these drugs. And she told me that as far as propofol, which remember there are two formulations of propofol still available, there's
00:45:38
Speaker
propofol non-preservative like original propofol. And then there's propofol 28. Whereas with Alfaxilin, they've eliminated the preservative free and it's only Alfaxin multidose. So propofol by itself, like no preservative propofol, propoflo is the brand name, is pretty cheap. So we can get that for about $10 per vial. Whereas with propofol 28 and Alfaxin multidose,
00:46:06
Speaker
Those are more expensive, you know, about three times as much as that. But it can be a range, so depending upon supply chain things and other stuff that I don't understand, the dose range for those drugs can be anywhere from $30 to $75 per vial for those. Whereas propofol, regular propofol is quite cheap, so it's probably why a lot of clinics still stick with just the original.
00:46:32
Speaker
But if you're talking about propofol-28 versus alphaxolone multidose, it seems like it's going to be kind of similar on a per milliliter basis because we only buy the small vials of both of those. You could almost argue that it's going to be kind of a wash because your dose on a mig-per-kig basis of alphaxolone is lower than propofol.
00:46:57
Speaker
you could really get into the weeds with that and kind of look and see how much, if you wanted to do a trial, you know, get a few vials of the drug and kind of compare and see how many males of each you're using and kind of compare them because it could turn out, depending upon how much you're paying for each drug, that they will be very similarly priced between propofol-28 and alphaxin multidose, or you could even come out a little bit ahead with the alphaxin multidose.
Alfaxolone in Cardiac and Exotic Cases
00:47:27
Speaker
However, acknowledging that original propofol is gonna be much cheaper, about a third, at least a third of the price, if not more of both of those drugs. Yeah, I think you can meet the price of like, or OG propofol. Yeah, OG propofol. And ketamine. Well, yes, and ketamine also, very cheap, very cheap. Yeah, those drugs have been around for a while, so they have lost their patents, so I feel like they are a bit cheaper.
00:47:54
Speaker
I wanted to ask about cases whereby you would absolutely consider using alphaxolone and then maybe any cases where you would absolutely avoid it using alphaxolone. So a case where I was high confidence probably be using alphaxolone. And are you talking pre-med or are you talking induction or both? Both. Both. Like a case where you'd be like, yes, I'm going to use alphaxolone from this animal.
00:48:23
Speaker
Yeah, so definitely the first one that pops into my head is a cat with a heart murmur who I have no idea what kind of cardiac disease it has. That's no cardio workup because, you know, playing the odds, a cat with a murmur probably has hypertrophic cardiomyopathy, but I have seen cats with valvular disease before.
00:48:45
Speaker
So, trying to be as safe as we possibly can, I wouldn't want to pre-medicate that patient with dexametatomidine in case it is one of those weird cats that does have valvular disease. And I wouldn't want to pre-medicate it with ketamine in case it has HCM. So, I would go with aufaxilone and probably an opioid for pre-medication and induction in that case. So, that's kind of like the classic case or
00:49:11
Speaker
or patients that are older and have documented cardiac disease. That's kind of the cases where I tend to reach for alphaxolone over propofol or ketamine, for example. And then for the ones that I would not use it for, something requiring Tiva or total intravenous anesthesia, I would not use alphaxolone.
00:49:34
Speaker
Because those recoveries, I don't like them at all. And then, well, this is outside of the realm of dogs and cats, but large animal horses, I would not use alphaxone. I have actually tried it before and I was not very happy with the results. And there are studies that show the recoveries not great with alphaxone.
00:49:54
Speaker
So speaking of other species, you can use alphaxolone in, you know, one of the reasons I wanted to speak with you is because you have done or at least assisted with certain studies looking at alphaxolone in exotic species. And so are there other species where, like beyond dogs and cats, and I guess beyond horses, whereby alphaxolone would be beneficial to include as part of the sedation or reduction protocol?
00:50:21
Speaker
Yeah, so since you can give Alfaxilone intramuscularly, it's very popular for some other species, exotics, reptiles in particular. I like using Alfaxilone and reptiles like you alluded to. I did a study and wrote the grant, did all the stuff for bearded dragons and intramuscular Alfaxilone.
00:50:43
Speaker
And if I have to sedate a bearded dragon, I would use alphaxlone for sure. And of course, there have been lots of studies using alphaxlone in various species of snakes and kilonians or turtles and tortoises as well very successfully. Intramuscularly and intravenously can be used
00:51:01
Speaker
And then also small mammals. There have been several studies in rabbits, for example, using intramuscular alphaxlone for pre-medication. And, you know, some people are still kind of scared of it, but all of the studies have shown that it usually works very well, and they didn't have any problems with the animals in their studies as far as apnea or things like that. However, that is still always a risk. Going back to that, and you should always
00:51:29
Speaker
treat your anesthetic induction agents with respect that they deserve. I haven't had an S-size rabbit in a while. I think the last rabbit I did was like a year ago, but I really like using like a big burkeg of alphaxolone, intramuscularly with like a half a big burkeg of midazolam and
00:51:48
Speaker
I've done that now for at least, I want to say I've done that for at least somewhere between eight to 10 rabbits. I really liked the sedation and I did not see apnea with that combination, but I also would say that the rabbits that I was using that with were pretty healthy. Yeah. That's a lower dose than what they use.
00:52:06
Speaker
So that's the other thing is with exotics, they tend to use much higher doses, which makes sense with allometric scaling, I suppose, you know, the smaller the creature, the higher per pound or per kilogram body weight, the dose that an animal requires is that's what that means. So like for the bearded dragons, for example, we were giving 10 milligrams per kilogram IM, which is much more than I would ever give to a dog or a cat.
00:52:30
Speaker
There are some studies in rabbits where they do like six migs per keg or eight migs per keg and things like that too. So I would be very shocked, you know, if you're giving one or two migs per keg and then a rabbit got apnic, I would be, I'd be very surprised by that. Do you like to use off-axleter rabbits? Like, is that kind of something that you've done before? I have done it before. I have not done it at UF because whenever we're working with rabbits, we're kind of working in combination with our
00:52:57
Speaker
zoom and department and they are not big fans of alphax on for that reason of apnea and being worried that.
00:53:05
Speaker
that animal would not be able to be intubated. And I think that they have had some bad experiences in the past with that. So I try to respect that and do things that are a little bit more comfortable for them. So most of the time when I'm premedicating a rabbit, it's going to be probably an opioid and maybe a little bit of ketamine if they need that. And then inducing intravenously with
00:53:31
Speaker
whatever combination, you know, cadmium adazolam or something like that, where you can try, most try to avoid apnea. I have given intramuscular alphaxone to a rabbit when I was locuming. I've done that before and I was really happy with it. But like, similar to you, I used kind of that lower dose, two migs per gig or less. I can't remember the exact dose, but it wasn't anything too high.
00:53:55
Speaker
And I was very happy with it and we were able to place an Ivy catheter and finish our induction intravenously that way. If you give like 10 bigs per gig of alphaxolone to a bearded dragon, like how long are they staying like asleep for? Unconscious for.
00:54:15
Speaker
So usually, like the ones in our study, they were all recovered by two hours, which for reptiles, pretty good. And as you know, you've worked with a lot of reptiles that anesthetic recovery and sedation recovery for reptiles, they just do everything slower, right?
00:54:35
Speaker
But the nice thing about Alfax alone is that all of the animals that we worked with, they all recovered within a two hour period, some much shorter than that. But I would say one to two hours, two hours being like the longer end of the spectrum. And when I say recovery, I mean that they are able to.
00:54:53
Speaker
They've regained their writing reflex, which means they can flip themselves over and they can hold their heads up basically. Do you think that, I don't know if your study assessed this, but would intramuscular alphaxolone be enough to do like a minor surgical procedure?
00:55:10
Speaker
On a reptile, maybe you would have to give an opioid on top of that or something like that, but what's your clinical impression of that? You might be able to. Yeah, you would definitely have to combine it with an opioid because we didn't mention this before, but Alfoxone does not have any analgesic properties. If you're doing anything painful, you definitely need to add in a good analgesic agent.
00:55:33
Speaker
So if you combined that with, yeah, hydromorphone or morphine or whatever you like in your reptiles, you probably could accomplish something that would be relatively quick. Like say you were doing a like a tiny little minor mass removal that's going to take you less than 20 minutes or so.
00:55:54
Speaker
then I say you could do something like that probably. But it really depends because like with our study, we combine some other things with the study that we still are working on publishing those parts of the results. Like we did echocardiograms. So you can definitely use that drug to accomplish non-painful diagnostic procedures like radiographs, echoes, things like that. We also did tracheal washes and cloacal swabs as well.
00:56:23
Speaker
So all of those things were able to be accomplished. But if you were going to do something more surgical, you would definitely have to have at least an opioid on board. If you were going to do a longer procedure, I would just continue on, like pre-med them that way. You might be able to either place an IV catheter and finish induction that way, or you potentially could intubate them and kind of finish the induction with inhaled anesthetic as well.
00:56:49
Speaker
So, I kind of want to wrap up our conversation by just asking you, in your opinion, if a practice was weighing the cost and the benefit of whether or not to carry all fax loan, what would you recommend as far as what are the benefits versus the cons, I suppose?
Summary and Closing Remarks
00:57:13
Speaker
you know, I guess which types of practices or under which circumstances would it be beneficial to carry all facts alone at your clinic? So I think it definitely would be beneficial to practices who are doing a lot of cardiac procedures like specialty hospitals that do some of those more advanced interventional things, PDAs, stuff like that.
00:57:35
Speaker
Also, if you are in a practice where you see a lot of cats, especially if you're a feline practice, I think it would definitely be worth it to have alphaxlone. Then places that see a lot of small mammals and exotics, I think that would be a good choice as well.
00:57:54
Speaker
and especially reptiles. I think Alfaxone is a good choice for a lot of those guys too. Yeah, I usually recommend to some clients if they're unsure about it, maybe ordering a very small amount and trying the drug and maybe limiting
00:58:12
Speaker
what type of patients you're using it for. So like if you are a practice that's doing dentistry, for example, and you have like old decrepit white dogs. Yes, that all have heart disease. Yes. Yeah. And you're anesthetizing them for dentals. You know, it might be nice to use Alfaxilum, but probably before you decide to use it on that like old decrepit thing, try using it on a small breed.
00:58:37
Speaker
healthy dog and seeing what it looks like so you can get familiar with it before you're using it for a little bit of like a decrepit dog. But I feel like you can get away with like special ordering it sometimes if you're not a practice that falls into like one of those things that you've just recommended. Yeah. Oh, for sure. That's true. Oh, yeah. If you were going to summarize Alfaxilone, like in one sentence, what would you say? Like what would be like your sentence? Yeah, I guess I would just say that Alfaxilone is
00:59:06
Speaker
similar to propofol but has an intramuscular option and more heart rate stability or stimulation. I tell people it's clear controlled propofol. That's true. The control part, that's good. But the stuff you added on in the ends is actually really important.
00:59:33
Speaker
I mean, you hit the nail on the head though. I mean, it's definitely when you're using this drug, it shouldn't feel like too alien. You can use it in very similar ways to propofol. So if you're used to using propofol, it shouldn't be too scary to use this drug. The only caveat being if you're using it for sedation, which I think that is a great strength of this drug is the fact that you can give it intramuscularly
01:00:00
Speaker
but you have to treat it with the respect it deserves. Well, that is a really nice way to end everything. Thank you so much for coming on the podcast and chatting with me all about all the facts about Alfaxillan. Of course. Have a great one.
01:00:26
Speaker
If you like what you heard today, I encourage you to check out NAVAS and consider becoming a member. As a member of the North American Veterinary Anesthesia Society, you get tons of benefits, including access to CE events, focusing on anesthesia and pain management, blog posts, fireside chats with boarded anesthesiologists, as well as specialty technicians, and just so much more. Visit www.mynavas.org to advance your anesthesia journey today.
01:00:57
Speaker
Also, if you are feeling generous this holiday season, consider a donation to the NavAss Educational Fund. This NavAss Educational Fund strives to improve anesthetic and analgesic care of veterinary patients by providing continuing education to veterinary professionals and caregivers. Learn more at www.mynavass.org slash donations.
01:01:24
Speaker
As a reminder, the Navas Virtual Spring Symposium will be taking place on April 27th and 28th of 2024. More information, including the speaker lineup and topics that will be presented are available now on the Navas website. To learn more about the Navas Virtual Spring Symposium, visit www.mynavas.org slash 2024 dash spring dash symposium.
01:01:54
Speaker
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01:02:09
Speaker
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01:02:27
Speaker
Also, a huge thank you to our sponsor, Decra, without whom this podcast would not be possible. Visit their website, www.decra-us.com to learn more about their line of veterinary anesthesia products. This podcast was produced by Maria Bridges, edited by Chris Webster of Chris Webster Productions, and technical support was provided by Saul Hymanes.
01:02:55
Speaker
I want to thank our guest, Dr. Lane Johnson, for this insightful discussion on Alfaxilim. And lastly, a huge thank you to all the GAS pastors out there who choose to spend their time with me today on the NavVis podcast. Becoming a skilled anesthetist is a lifelong journey of learning and self-discovery, so I hope you consider listening in the future.
01:03:16
Speaker
I'm your host, Dr. Bonnie Gatson, and thank you for listening. We here at the Naves Podcast are wishing you a very happy holiday season, and we hope you continue tuning in next year.