Transcript
Annatasha: By the way, do you like my background today? This is my dad's evil overlord office.
Ryan Bailey: I was wondering if you just brought the books in to look smart today.
Annatasha: No, this is my dad. So these are all like books on economics and more importantly, microeconomics and like price theory and like, oh yeah.
Ryan Bailey: one Those are probably serving him really well right now because no one fucking knows what's going to happen economically.
Annatasha: Well, my dad does. Yeah.
Ryan Bailey: wasn't i bet he didn't predict the fucking market today.
Annatasha: No, he didn't, but he's finding the tariffs on the Antarctic pretty hilarious.
Gianluca Bini: that's our topic for tonight. So anesthesia, urban legends, and dogmas. Okay. So, you know, how...
Annatasha: I feel like sitting in the evil chair overlord office is actually perfect for this stuff.
Ryan Bailey: Yeah.
Annatasha: Exactly.
Annatasha: Exactly. like
Gianluca Bini: yeah
Gianluca Bini: So do you check your potassium in every single gray on the units of ice?
Annatasha: Wow, we just went right into that. There was just whatsoever.
Ryan Bailey: Wow.
Annatasha: Well,
Annatasha: I can see where this is going.
Ryan Bailey: yeah
Annatasha: yeah
Gianluca Bini: Okay, there are some reports out there, right?
Annatasha: This is a fucking double-edged sword. This is a double-edged sword. So I think Bailey should answer first.
Ryan Bailey: Yeah, I would love to answer because I have some thoughts. I mean, i I will say i i pretty aggressively check labs in my patients because the one thing that will kill your patient faster than you can blink is potassium.
Ryan Bailey: And like... It hasn't happened to me, but I know it is a thing. I know it's not just greyhounds. There's the literature that came out from Jordan Nickel and Hofmeister that showed that was a retrospective study showing patients died of high potassium.
Ryan Bailey: So like, I think it's a ah thing that we need to just be mindful of because it is it's a killer.
Gianluca Bini: Right.
Ryan Bailey: It's a killer.
Gianluca Bini: It is.
Annatasha: What was that other paper though that also came out talking about like specifically like the sight hounds and like what they believe to be like an idiopathic hyperklemia?
Ryan Bailey: Yes. So that's that's another that's another thing, too.
Annatasha: thought there was one in press and I never actually saw if it went like final approval in press, but that could be the same paper.
Ryan Bailey: No, it's a different one. the That one, I think, is Mama.
Annatasha: Yeah, maybe that was the one where they, to feel like who else was on it?
Ryan Bailey: And I thought that, I don't know if that was a full...
Annatasha: was that There was a thing, there was no clear pathophysiology, although they deliberated whether or not it it was associated with like the alpha twos.
Ryan Bailey: Yes.
Annatasha: And I was like, oh, fuck, here we go with rumors.
Ryan Bailey: Yeah. So that's, that's, that alpha two stuff based on the paper from, Sidihe and Big Cat.
Annatasha: Reza.
Gianluca Bini: Yeah. iszaah
Annatasha: Reza.
Ryan Bailey: Um, But like, I will say, I also know someone who is collecting blood from greyhounds to look for hyperkalemia and some sort of, I don't know.
Ryan Bailey: But if if anyone who's listening to this has a greyhound who's being anesthetized, I think Minnesota is doing some work on them and like collecting blood samples. So reach out to University of Minnesota. Caitlin Tierney is the one on it.
Annatasha: The paper that I'm thinking of was, it was Kershied, Nancy Brock, Dr. Kudo, the internist and Stacey Jones.
Gianluca Bini: Okay.
Annatasha: Yeah. And that was a case report.
Gianluca Bini: So,
Annatasha: That was a case report.
Gianluca Bini: so
Ryan Bailey: So all this to say, I think there's, there's people who are trying to figure out if there's something there and more power to them.
Annatasha: Yeah.
Ryan Bailey: i don't know that I like, we'll check it, you know, religiously. Like if they've had a normal potassium prior, I will usually accept it. But if labs are over three to six months old and this is the older patient, especially if they have any evidence of like kidney disease, I'm a hundred percent checking something with electrolytes that morning because it's just such a, you're playing with fire. Like,
Gianluca Bini: Yeah, and it is, right?
Ryan Bailey: but fantastic
Gianluca Bini: But, you know, on the other side, right, you know, there is couple of papers that did show that if you have hyperkalemia, you don't necessarily have ECG changes, right?
Ryan Bailey: Except i would argue that once you add inhalant, that's like adding gasoline to the fire.
Ryan Bailey: Like the inhalant anesthetics can definitely precipitate those arrhythmias where maybe they wouldn't have been present if the patient was awake. And like, so you either say I'm going to play injectable on all these cases to avoid the arrhythmia or you throw ISO in there and potentially precipitate an arrhythmia that wasn't present without inhaling on both.
Gianluca Bini: I think quoting Tasha,
Annatasha: No, no, no. Don't drag me into this shit. I was very happy listening.
Gianluca Bini: quoting Tasha, see Florence sends everything to shit, right?
Annatasha: Isoflorn is the root of all evil and the higher you turn it, the more it goes to shit. Yeah.
Gianluca Bini: Anyway. Anyway, so yeah, okay, fair, fair. I'll do those papers where an anesthetized patient. So what?
Ryan Bailey: Okay. All right. i'll
Gianluca Bini: What?
Ryan Bailey: I'll take it. But I i do know there's some some of us who believe there is a link between inhalant, hyperkalemia, and precipitating arrhythmias.
Gianluca Bini: No, and I can believe right? Like, you know, it's fair.
Ryan Bailey: Yeah.
Ryan Bailey: I also think it's like, you know, in the grand, to my mind, in the grand scheme of things, like for, for where I work, for where most of us work, you're talking about what's probably under a hundred dollars of lab work on a patient who is probably spending
Gianluca Bini: That's fair.
Ryan Bailey: you know, that's one to 5% of the the total invoice.
Gianluca Bini: no that's fair
Ryan Bailey: So I have a hard time sitting there and having to justify this when we're talking about a much higher bill and I'm just trying to prevent the patient from crashing and burning within the first 30 seconds of anesthesia.
Annatasha: And also like 99.8% of my patients anyway, I'm going to have a repeat blood work from the day of the procedure, which includes electrolytes. And the reason is, is because my patient population is made up of crazy ASA 5Es that are circling the drain.
Gianluca Bini: no of course
Ryan Bailey: Oh, yeah.
Annatasha: And I'm basically running blood work every 20 to 30 minutes. like I don't do, you know, healthy cat neuter space stuff. So, you know, most of my patients are going to get their electrolytes and radiometer read as the baseline before I even rock up.
Ryan Bailey: Yep.
Annatasha: So there is my answer is yes, I've checked it.
Ryan Bailey: Yep.
Annatasha: But you have to remember, I'm skewed based on my population bias.
Ryan Bailey: Totally agree.
Gianluca Bini: Yeah. Yeah.
Ryan Bailey: Totally agree.
Gianluca Bini: No, of course. And like, you know, the the reference I'm making is, you know, if you have a patient that had blood work, the potassium is normal. Like I don't necessarily recheck that induction necessarily, but, you know, if the blood work has been fairly recent, like less than a month old or whatnot, which is usually what we get.
Ryan Bailey: Yeah.
Gianluca Bini: the potassium was normal before, like I'm not necessarily going to recheck that induction, even if it's a greyhound. And then, you know, if there is any CG changes, sure, I'll keep an eye on it. But like, you know.
Ryan Bailey: Yeah, i would I would generally agree with that. Like if it if it's within a fair amount of time, a month or under, I'm probably going to leave it alone. But like three to six months is where I start to get a little bit more cagey.
Gianluca Bini: Yeah, yeah, that's different story.
Ryan Bailey: And then I would say the the there's so many times that we get send-off blood work where we have hyperkalemia because of spurious results, because the blood sat on the clot and the potassium went up, blah, blah, blah.
Gianluca Bini: if
Annatasha: you pull through the catheter, which I hate, but everyone wants to do it.
Ryan Bailey: Yeah, so then potassium is 5.5 on the send-off lab work a week ago, and it's like, h not going forward until I see day of labs.
Annatasha: And then, know,
Ryan Bailey: Like, we have to confirm that this is a lab result. I mean, I understand it probably is, but gosh, that's like playing with fire to my mind.
Gianluca Bini: come
Gianluca Bini: Now, second
Gianluca Bini: dogma. Okay,
Ryan Bailey: I hope it's about cats this time. It'll be cat-ma.
Gianluca Bini: okay. Boom, Boom, okay. Well, that that was... Yeah,
Annatasha: Honestly, let's just end the podcast there because not another joke is going to be better than that one.
Gianluca Bini: yeah, we're...
Annatasha: Anyway, night night, guys.
Gianluca Bini: Exactly. See you next time, guys.
Ryan Bailey: Just wait till we get to horse-ma.
Annatasha: That was awesome.
Gianluca Bini: So, okay. You have... Do you avoid certain opioids in cats due to the risk of hyperthermia post-op?
Ryan Bailey: No.
Annatasha: No, no.
Ryan Bailey: No. I thought you were going somewhere and I was like, ooh, that's a really good question. And then you were like, hyperthermia. And i was like, meh.
Gianluca Bini: yeah
Annatasha: Honestly, I could feel Bailey's internal sphincters clenching from here, but, no, I don't avoid it. And I don't worry that much about opioid induced hypothermia. I mean, it's self-limiting.
Ryan Bailey: Yep.
Annatasha: It resolves. And you can have it, I've seen it with buprenorphine.
Ryan Bailey: Yep.
Annatasha: I've seen it with Oxy.
Ryan Bailey: Yep. and
Gianluca Bini: yeah
Annatasha: I've seen it with methadone. I've seen it with hydro. And, you know, ah there's only a certain number that are technically like researched or reported, but that's just because nobody can be bothered to do the study.
Ryan Bailey: Yeah.
Annatasha: um um And, you know, it tends to also have a ceiling limit on it. So it doesn't become pathologically hypothermic. So these things don't sweat it.
Ryan Bailey: yeah
Annatasha: Now, where it can be complicated, I find is where it's confounded with other things like What if the cat also had phlebitis? What if we also think it might be going septic? Then we start off to thinking outside the box where we start plucking out each issue to determine the nature of the hyperthermia versus is it true pyrexia?
Annatasha: So that's my only comment. But for the most part, I don't avoid anything except surgeons.
Ryan Bailey: yeah
Ryan Bailey: So, all right. So then that makes me want to ask, like, because your question was going somewhere that didn't go, I want to know, do you ever consider the, the, uh, the increase in sympathetic tone associated with certain opioids?
Gianluca Bini: The increase in sympathetic tone.
Ryan Bailey: Do you ever think, of do you ever think about that as part of your opioid choice?
Gianluca Bini: So actually, i have been.
Ryan Bailey: Oh,
Gianluca Bini: haven't been sleeping at night. I'm thinking about it.
Ryan Bailey: it well might be All right, all right, all right.
Gianluca Bini: bringing about the fucking sympathetic. No, so, but but I actually did give a lecture in a fat Charlotte about maintaining anesthetic stability, right? And how different drugs have max sparing effects and whatnot, right?
Gianluca Bini: So, you know, even buprenorphine has zero max sparing effect in cats.
Ryan Bailey: Mm-hmm.
Gianluca Bini: It's crazy, right? Like morphine helps
Annatasha: He said 11 buprenorphine has zero max pairing effect on dogs too. What a bullshit peri-anesthetic drug that is.
Gianluca Bini: I mean, okay, okay. In dogs, actually, it does have some sparing effect, right?
Annatasha: Right.
Gianluca Bini: in But in in and cats, it has, like, zero, right? like So 30%, I think, it's in dogs, but, you know, zero in cats. Morphine, as well, you know, 30% in dogs, zero in cats.
Annatasha: Oh, you are singing the song of Bailey's people right now.
Gianluca Bini: Yeah, no, it's crazy, right? Like, I...
Ryan Bailey: and I can hear like Bruno and Pasco just like in my ear, like talking about all the cat studies of like, we did fentanyl and half the cats who had, you know, Mac reduction, the, when we did the crossover, then they didn't have Mac reduction and this and that. and Like.
Annatasha: Yeah. Like I said, you're singing the song of Bailey's people.
Gianluca Bini: Chris?
Annatasha: Look at him. He's like a wash and joy and comfort. been Creepy.
Gianluca Bini: so Okay, fair. So yeah, I've been thinking about that, right? Like, you know, choosing the right, you know, how to improve my anesthetic stability during surgery and maybe not resourcing too much to like, you know, a Fendon LCI or something like that versus something more like Dexmed or, you know, something.
Annatasha: I'm really glad that this podcast is all actually improving our anesthesia. Like the three of us are starting to do better.
Ryan Bailey: and
Gianluca Bini: It's normal, right? Like, you know, we we share ideas and we learn, like, you can know everything, right? and that's That's the deal, right? There's no way on earth that you can know everything, right?
Ryan Bailey: Oh yeah.
Gianluca Bini: So we all started or been trained, you know, different places and we all have different inputs. And, you know, actually I think that this is something that probably collectively as a college we should be doing more often, right?
Gianluca Bini: Like just meet and chat and like, you know, come up with ideas and see how other people are doing stuff. You know, the the single meeting a year, mean, it's nearly enough. Right,
Annatasha: which is a 99.8% of the time about the exam
Ryan Bailey: hello
Annatasha: and not actually about anything helpful to the rest of us.
Gianluca Bini: right, right. i also like...
Annatasha: No, but also, I mean, you've having sleepless nights about feline sympathetic tone. How do you think we felt about the lidocaine bomb? I mean, for like two weeks we couldn't recover.
Ryan Bailey: So I was like, do even use lidocaine now? Or is it like...
Gianluca Bini: Anyway. and
Annatasha: Yeah, and like one of my VTS technicians who I've worked with for like yonks, she was like, listened to the lidocaine episode and she was like, I couldn't sleep either.
Gianluca Bini: but
Annatasha: She's like, I mean, you trained me and then like you were thrown for the loop. So I was thrown for the loop and I was like, oh yeah, the lidocaine thing, I'm still upset. like
Gianluca Bini: anyway so So other other have common myth,
Gianluca Bini: how much relevance do you give to breeds or patients that potentially have like MDR1 mutation or ABC cassette kind of mutation, whatever they're calling it now?
Gianluca Bini: Do you like, are you really like, oh, I shouldn't use Torb, I shouldn't use Ispromazine, I shouldn't use this and that? Or, you know, how how real do you think that is, right? Like how the do you actually see, first off, it's hard to find a patient a thing that actually has been tested for it.
Gianluca Bini: But if you did, like how worried are you about that stuff?
Ryan Bailey: Well, as the former blog person on the NADIS website, I can reference the MDR1 mutations, A Big Deal or Not, by Elizabeth Gaudi DeAngelis.
Annatasha: Thank you.
Ryan Bailey: And... She gets a very comprehensive overview on MDR1 mutations and how they may or may not affect anesthetic drugs. And overall, my takeaway was it's a bit of a nothing burger, but it could be a something burger, but it's mostly a nothing burger.
Ryan Bailey: So I don't.
Gianluca Bini: Exactly.
Annatasha: it's yeah It's one of those things where it's probably not going to happen when it does. It sucks hard.
Ryan Bailey: Yep, for sure. And like the. I can't remember. like the There's a university, I think it's Washington maybe, or maybe it's Oregon who like is the leader in a lot of the...
Ryan Bailey: It's Washington State who does a lot of the... Who does some of the research on like the MDR-1 and which drugs are impacted and dogs and this and that.
Annatasha: Are we still calling it MDR one? I thought we were supposed to be calling it like ACBC or what have you.
Ryan Bailey: Well, I mean...
Gianluca Bini: Yeah, yeah, something like that.
Ryan Bailey: When it was written years ago, like in 2023 when it was published, it was the same as NPR1.
Gianluca Bini: That was two years ago.
Ryan Bailey: But they do mention the ABCB1 gene.
Gianluca Bini: Yeah, something like
Annatasha: Two years can be a long time when you've recently survived a global pandemic.
Ryan Bailey: True story.
Gianluca Bini: that. Cool. And then, lastly, so
Gianluca Bini: You know, this is something that came up on Facebook, you know probably one week or two ago. And in one of the Facebook groups, you know, somebody was debating,
Annatasha: Exactly why I don't follow Facebook veterinary anesthesia groups.
Ryan Bailey: Right on his face, Bush.
Gianluca Bini: No, but it's interesting. It's interesting, right? like So sometimes there's really good questions, right? Sometimes it's, you know, a lot of people don't have access to, unfortunately, one of us, right? So, like, I get it that it's kind of hard to, you know, to get, you know, accurate, quote-unquote, information out there sometimes, right?
Gianluca Bini: And we don't really do a good job at right? Sometimes, you know, in anesthesia, we have a huge lack of, you know, support for people. There's very few groups that actually do something, right?
Gianluca Bini: They were debating maximum PIP pressure. So like positive, sorry, peak inspiratory pressures, right?
Ryan Bailey: Mm-hmm.
Gianluca Bini: that That you're giving to your patient when you breathe, right? So there is this common thing about like, hey, don't go above 20 centimeters of water.
Gianluca Bini: What do you think about that? Do you think it's like, it's real? Do you think it's, you know Do you do anything different? Because this there was a huge debate on 15 versus 20 versus 25 versus 18. Does it even matter?
Annatasha: This is what I think. So I think that when you take a like turnpike curve on or off a highway and they give you a speed limit, they cut that speed limit down probably by like 50% below the actual number that your car is going to like two wheel it and you may or may not tip over. And I think that's also true of the 10, 20 centimeters of water, because let me tell you, particularly in dogs, I will drive above that pressure if I need to, to keep you alive.
Ryan Bailey: Totally agree. i actually, i was like kind trying to come with the topic and like ventilation was like immediately where my brain went to when I was thinking about like, what's my topic going to be?
Ryan Bailey: So like preview for those.
Gianluca Bini: Is that because you blew up the bag in a barrel?
Ryan Bailey: yeah No, no.
Ryan Bailey: It is. have
Annatasha: out the bird.
Ryan Bailey: a lot of I like have a lot of thoughts on ventilation.
Gianluca Bini: so people that listen, people people that that
Ryan Bailey: i would think...
Annatasha: Well, you have a lot of thoughts on everything from hot dogs to cracker pizza to ventilation to sympathetic tone.
Ryan Bailey: I just want to and a prop
Annatasha: Like we're used to this. God. oh yeah
Gianluca Bini: OMG. So whoever is listening, you know, Ryan is showing us this beautiful book.
Ryan Bailey: to give a So wanted to follow up from last week's episode or our special episode whenever it's out.
Gianluca Bini: I mean...
Ryan Bailey: So if you've heard
Annatasha: Listen, if we're ever looking for sponsors, we should reach out to some snossage companies because...
Ryan Bailey: Oh my god, i would be so excited. Anyway, the hot dog that Dr. Pockel was referencing is called ah ah Pilsa, and they're found all over Iceland.
Ryan Bailey: They're made with lamb, beef, and pork. They're boiled. They're served on a steamed bun with ketchup, Icelandic mustard, a mayo-based remoulade, raw chopped onions, and fried onion bits. And that sounds fucking good as hell.
Ryan Bailey: what I'm talking about.
Annatasha: Side note, have either of you two been to Iceland?
Ryan Bailey: I have not, but I was like, this book talks about all the hot dogs.
Gianluca Bini: Wait, wait,
Annatasha: Okay, I've been like four times. Take Icelandic food just a little bit with caution because there's a lot of stuff there that's been marinated in various forms of urine. and I just, I don't know what the hell Icelandic mustard involves, but immediately my red flag was like, betcha there's urine, betcha there's urine. So yeah, I mean...
Gianluca Bini: probably
Annatasha: Yeah, you ferment all sorts of stuff is like put in fermented urine. It's like a holdover from Viking times where they were basically starving to death.
Gianluca Bini: The human hearing? The human
Annatasha: No, horse and cow for the most part.
Ryan Bailey: i didn't read ah ah I didn't read anything about urine when I did review this, but you know maybe I need to look a little closer. But it sounds lovely.
Gianluca Bini: hearing?
Annatasha: It might not be the hot dog itself, but it could be because when they stipulated Icelandic mustard and I'm thinking to myself, what does that mean? And then my first thought was maybe it has urine in it. So or like, you know, like breast of puffin.
Annatasha: So, yeah, I just I'm sure I mean, there's I don't want to insult Icelandic people. It's a super cool country. I've been there four times. Love it.
Ryan Bailey: you have a hot dog, though?
Annatasha: I don't think did. I think I stayed close to like a lot of the seafood-y type things that were urine-free.
Ryan Bailey: in
Annatasha: But there is a whole urine-based food culture there. Just heads up.
Annatasha: Heads up. But no, I'm glad you looked up the Icelandic wieners.
Ryan Bailey: Yeah.
Annatasha: a
Ryan Bailey: The book just came in, so i had to read through it.
Annatasha: Like I said,
Annatasha: Thank you to all our followers have been building with the success of podcasters. Cause we're getting up to the level now where sauce, sauce sponsorship of our veterinary anesthesia podcast is a potential.
Ryan Bailey: Fingers crossed! So anyway, peak inspiratory pressures.
Annatasha: Right. I forgot what you're talking about.
Ryan Bailey: That's another one my ventilator makes.
Gianluca Bini: I don't know how we went from heat-inspired dirty pressure to urine, but...
Ryan Bailey: Yep. You know, we're all over place.
Ryan Bailey: I like to get such a high peak inspiratory pressure that it actually evacuates the bladder. and just get so much pressure across that diaphragm, it's translating straight into the bladder. But no, actually, that's it I've had a couple really good topical cases because we...
Ryan Bailey: So, general rule of thumb, I fall... Man, I really want to like bring on my topic, but I want to spoil it and worst all it.
Gianluca Bini: No, no, don't spoil it............................
Ryan Bailey: know, but
Annatasha: Now, don't spoil your topic.
Ryan Bailey: I know, but I like have so many feelings about ventilation and like it's just going to spill over. But like yeah, I'm definitely in the 10 to 20 peak inspiratory pressure range on the average case. like Average dog and cat who I'm ventilating, 10 to 20 for sure. That's what I'm sticking to.
Ryan Bailey: Now, the other day... we had a case, probably a page with like a pulmonary thromboembolism, had clots everywhere. First time I'm almost a hundred percent sure I saw myocardial infarct on the ECG and like ST elevation.
Ryan Bailey: was like, I like put the ECG on.
Annatasha: Nice. Very unusual. Okay.
Ryan Bailey: I was like, this dog has ST elevation. I was like, so jazz. I like took pictures of it. I sent it to a bunch of people and like,
Gianluca Bini: So this was actually my my lead on my other question, right? So like, whatever, we're going to get to ST elevation or depression.
Ryan Bailey: So anyway, i that dog would like would not saturate.
Gianluca Bini: Right.
Ryan Bailey: like Nothing was going. And I was like, we are going whip these lungs into shape and I was like crack up that ventilator we're gonna get the alveolar recruitment maneuvers you whip that like ventilation up to like 35 centimeters of water pressure get the peep valve we're gonna get the ventilator out we're gonna like hammer these lungs and we're gonna inflate the shit out of us and we're gonna get any alveoli that want to play in to participate because we have to saturate this dog because 80 for this long is not acceptable
Gianluca Bini: Yeah.
Gianluca Bini: So you don't know that.
Annatasha: know what? I do not want Bailey to ever ventilate me, but I would say, too,
Ryan Bailey: That's why I anesthesia ventilation, not fucking critical care who's like, the lungs. Oh
Annatasha: let's go to six centimeters of water, but set the RR at 2000 and then wonder why our PACO2 is 114. Yeah, no,
Ryan Bailey: my god, it's like, it's like we're going to six centimeters of water.
Gianluca Bini: Thank you.
Ryan Bailey: Everyone, bang, down the hatches.
Annatasha: Now, I think if you have, especially if you have restrictive intrapulmonary disease, so the actual pulmonary interstitium is highly diseased.
Ryan Bailey: Oh yeah, yeah, yeah.
Annatasha: Don't drive pressures above 20. it will be dead in three minutes.
Ryan Bailey: Oh, yeah.
Annatasha: So also think the difference between 15 and 20 or 22, those are arbitrary.
Ryan Bailey: Ooh.
Annatasha: i think that is a waste of an argument. That's really not where we need to be focusing our attention. But these abject numbers, like, you know, you you put a patient, you know, for example, like the cutoff for Bain is 10 kilos or five kilos or seven kilos.
Ryan Bailey: I like it.
Annatasha: Holy shit. Understand how it works. And then there is no weight based.
Annatasha: I know you hate the band, but there is no weight cutoff. And it's the same thing with the ventilator, like understand exactly what the different types of intrathoracic pressures are. Like what's difference between intrapulmonary and transpulmonary and all Also, like what's going on in terms of lung pathology and ventilation and oxygenation and what will be your repercussions if you do something either super aggressive or way too passive? know, like there's i hate these absolute rules about things because it just means we've stopped thinking about what's going on in terms of physiology.
Ryan Bailey: Are you going to ask about re-expansion pulmonary edema?
Gianluca Bini: Yeah, I mean, so, of course, but, you know, in reality,
Ryan Bailey: part Of course!
Annatasha: no
Ryan Bailey: Of course, yes.
Annatasha: ah we would you we Were you getting a vibe about that? Because I was just like, didn't get that vibe.
Gianluca Bini: I was thinking about that. why so when you When you go so high, right do you had you had peep, right? For sure. You do that.
Ryan Bailey: and And yeah, like if I, I would say like in the case where I have to reach for these high, high peak inspiratory pressures, like to me, I'm adding PEAT because it, it probably means this patient is hypoxemic. And one of the ways we're dealing with that is with PEAT.
Gianluca Bini: Yeah, okay. you know, did you do you see any potential like re-expansion injury, any pulmonary edema afterwards? Yeah.
Ryan Bailey: knock wood have not seen re-expansion pulmonary edema will relay a story in my residency i was called in for a diaphragmatic hernia repair and i walked in and it was a bulldog being manually ventilated with like a modified non-rebreathing circuit i think it was technically like a mapleson f if anyone wants to get fancy maybe a mapleson b i know i know i know fucking maplesons right
Annatasha: That's a super weird choice for that entire situation.
Annatasha: But anyway, if whatever.
Ryan Bailey: with no pressure gauge.
Ryan Bailey: I was like, well,
Annatasha: Were you doing anesthesia like in in a field with no electricity?
Ryan Bailey: who built this was i was walking in.
Annatasha: Like what's happening here?
Gianluca Bini: No, no.
Ryan Bailey: walking
Gianluca Bini: No, Artash.
Ryan Bailey: i was walking in
Gianluca Bini: He was a He was a Davis. Yes.
Ryan Bailey: I know i was I was walking in to go assess my patient before I started anesthesia and it was a bulldog who was a respiratory distress and it was intubated and on positive pressure ventilation, but they didn't get out like the whole vent because it was going to surgery. So they were just manually ventilating with this modified Naplesen system.
Ryan Bailey: And like, I was like, well, if any case is going to get re-expansion pulmonary edema, it's definitely this one where we have no clue what the peak inspiratory pressure was.
Gianluca Bini: feel
Annatasha: Like why in this particular situation would you pull a Jackson Reese? Like you'd be like, oh, this is going badly. Oh, it has a hernia. Oh, I'm worried about this.
Gianluca Bini: Thank you.
Annatasha: I'm going to handbag with a gaugeless Jackson Reese.
Ryan Bailey: Fucking handbagging. Like, if you're really like, I'm going to handbag this case, like, you should rethink your career.
Ryan Bailey: I have never, never had success. Like...
Annatasha: I will switch to a couple manual assisted breaths because I like to feel compliance.
Ryan Bailey: that Yeah, the manual assisted breath. Not like I'm going to i'm going to ventilate a case. Ooh, I have another good compliance. I've had got a lot of good stories in the last couple weeks.
Ryan Bailey: and saw I saw an actual airway obstruction a CSF tap.
Annatasha: yeah Stop calling it handbagging, by the way. That's disgusting.
Ryan Bailey: ah ah A live patient in a dog. I've never actually seen the airway obstruct. and I was like, hey, guys, I think the airway is obstructing. But I was like, let me back. Oh, it's tight as hell. Oh, his chest ain't moving.
Ryan Bailey: Whenever you can stop, maybe give it a break. Don't can't breathe. Everything was fine.
Annatasha: yeah the next time i have a respiratory crisis under anesthesia i'm definitely going to think you know what someone passed down jackson reese so i can just mean
Gianluca Bini: We probably... Yeah. Somebody hand me a Jackson Reese.
Ryan Bailey: Yeah.
Annatasha: like are you doing trauma anesthesia in a war zone like i don't understand don't understand
Ryan Bailey: I hate the, like, the bane is the bane of my existence.
Gianluca Bini: The banner will exist.
Annatasha: We know.
Gianluca Bini: So...
Annatasha: We know, Bailey.
Ryan Bailey: I know. I can... I have, like, a...
Annatasha: Is it ketchup on a hot dog or like same thing?
Ryan Bailey: Same thing.
Gianluca Bini: so
Ryan Bailey: I have, like, a half-written blog on how much I hate non-rebreathers, and I just, like, i have so many feelings. It's, like, halfway written, and I've put out so much vitriol on, like, why non-rebreathers are, like, terrible pieces of shit.
Ryan Bailey: And, like... ah just i'm like is this does anyone want to read this does anyone or i want to read my like diatribe on not
Annatasha: 100%, Bailey. I would read it and laugh and also then think about this whole Jackson-Rees situation and just maintain the state. This is, again, I'm going to be up tonight just in a state of bewilderment, think trying to think my way through the physics, what was happening in this situation, and to come to no real resolution.
Gianluca Bini: About the fucking Jacksonville.
Annatasha: and then, you know, I don't know. I just, but I would read your vitriolic blog on anti-non-rebreathing circuits.
Ryan Bailey: I hate them.
Gianluca Bini: So how about the whole story of like, you can't put a patient less than five gigs or seven gigs or 10 gigs, right?
Annatasha: Yes.
Gianluca Bini: Because this is another dogma that's being perpetrated, you know, for ages now in veterinary anesthesia, right? You can put something's more than five gigs on a rebreather, right?
Annatasha: Do you remember a couple podcasts ago when I said, you have to understand the machine and its components, otherwise you don't actually understand anesthesia.
Gianluca Bini: What you see?
Annatasha: is the perfect example. You can put whatever you want on a fracking non-rebreathing as long as you have a flow meter and sufficient oxygen to do so. It has nothing to do with the circuit. And I'm just like, if you understand the machine, then you could answer that question without any input from the three of us.
Annatasha: so
Gianluca Bini: No, no, I get it. But like, you know, our listeners may not understand the machine, right?
Ryan Bailey: yeah listeners may not have as many feelings about a Bane and a re-breather as we do but
Gianluca Bini: So and that's why we're listening.
Annatasha: But do they understand rage?
Ryan Bailey: and like so i I think that is a holdover from like anesthesia from a long time ago.
Gianluca Bini: Look.
Ryan Bailey: Because back in the day, the one-way unidirectional valves were made, they were metal discs. They were almost like the weight of a silver dollar. like For anyone who you know remembers a silver dollar.
Ryan Bailey: i
Annatasha: also...
Ryan Bailey: i know.
Annatasha: Why do you know what the weight of the former disc was? Like unidirectional valves or something like.
Ryan Bailey: Well, because we had... i mean
Ryan Bailey: and Once again, in my residency, we had some older machines that had the... They still had the metal discs in them. And like, yeah.
Annatasha: Of course, that's why I was driving the bag in the barrel.
Gianluca Bini: Thank you.
Annatasha: Yeah.
Ryan Bailey: but That's why... Those smaller patients probably cannot move those more weighted discs, but now they're like such lightweight plastic. Like I will say i have, push the limit every day when I get a small patient, I'm like, can I fucking get this thing on the goddamn rebreather? Cause I'm going to fucking try for sure. A hundred percent.
Ryan Bailey: And like the text will be like, but Dr. Bailey, it's a small little dog. And I was like, and I don't give a shit. Get me the circle. And then,
Gianluca Bini: Nice. Nice.
Ryan Bailey: and like And if I'm wrong, I will 100% switch to this dog the ventilator.
Gianluca Bini: Nice.
Annatasha: is it just me or is Bailey extra funny tonight
Ryan Bailey: my god. it's It's because you got me on some topics that I really am like deeply passionate about, and I like care way more than anyone ever should.
Gianluca Bini: and
Ryan Bailey: But yeah, i like, I'll put it on. And then if they rebreathe, I'll be like, all right, well, I guess we have to think about the vein while I get the ventilator going. Because it's like, we have ventilation. We could just put this patient on the ventilator.
Gianluca Bini: Yeah.
Ryan Bailey: And then it takes out the whole question of whether the patient can breathe on the circuit or not.
Gianluca Bini: Exactly.
Gianluca Bini: Exactly.
Ryan Bailey: And like, My equipment, and I've got like not really good equipment for the anesthesia machine, i can go down to like one kilo. i think I took a dog that was half a kilo on a circle and it was just fine.
Gianluca Bini: Yeah. I mean, if you're ventilating them and the ventilator can handle such a small tidal volume, you know, it doesn't document it.
Annatasha: But remember, a lot of GPs won't have a ventilator.
Ryan Bailey: Yes. Oh, for sure.
Annatasha: and They will go back and forth.
Ryan Bailey: For sure.
Annatasha: And so I always make sure they understand what the indication is or like what's the level of tolerance.
Ryan Bailey: good
Annatasha: For example, like if you're going to rebreathe like two points of CO2, I really don't give two points of shit.
Gianluca Bini: Yes.
Ryan Bailey: Yep.
Annatasha: But, you know, if it's if it's really like
Ryan Bailey: Big Mac live.
Annatasha: causing depth challenge and making you hypercapnic and then sure. So i do think I don't have this passion of pain that you do.
Ryan Bailey: Yep.
Annatasha: But I do like people to understand that if you really are struggling with a patient and resistance to breathing because of the additional components of the circle, I also think you're right, Bailey, it is a hangover probably from days where people were doing like,
Ryan Bailey: Yep. Mm-hmm.
Annatasha: the to and fro, you know, like you got to basically like breathe back and forth over the bubbling boil vaporizer, like, you know, but I still, I still think non-rebreathing does also have a place to don't forget an ambu bag is a Mapleson C and we all use it.
Ryan Bailey: That is your like, that's a classic cartel.
Annatasha: And also too, they use non-rebreathing all the time. So for example, if you had a tension pneumothorax and you were doing like
Gianluca Bini: Thank you.
Annatasha: flow by non-rebreathing and as opposed to like bub-ap or c-pap because those will kill somebody who has a per perforated lung so put that in your little hot dog pipe and smoke
Ryan Bailey: i I also, i just don't, I personally think that non-rebreathers are far more challenging from like the anesthetist perspective. There's so, the vaporizer changes are so rapid that like, it is just so easy to be over under with just little hair movements on vaporizer.
Gianluca Bini: Oh, yeah. Absolutely. Thank you.
Ryan Bailey: And I find Like if I'm running a patient on a non-rebreather, i am often playing vaporizer jockey and I'm just like constantly touching that thing when I've got a lot of other things that I really would be better doing.
Ryan Bailey: Like, I mean, there's a phone. It's not going to text itself. You know, i have emails to read. There's social media that I could be reviewing.
Annatasha: crushing candies. like so i Sometimes I just gently adjust the surgery table without telling the surgeons to just make them think that they're going insane.
Ryan Bailey: exactly can't be touching this vaporizer all the time.
Annatasha: that They don't hate me.
Gianluca Bini: um That's why I hate you. That's why fucking hate you.
Annatasha: They fear me and there's a difference.
Gianluca Bini: But so, okay. Fair, fair. Okay. So, yeah. So we can put patients that are smaller, long story short, on a rebreather as long as either we have a ventilator or, you know, you have a not,
Gianluca Bini: Stonehenge era anesthesia machine.
Ryan Bailey: And you have to have capnography though, I guess that that's also another, i mean, and for us, that's a given because we all work in specialty, but like, yeah, you probably also really need capnography. If you're going to try to take small patients and put them on a rebrand.
Gianluca Bini: Aw, that's cute.
Annatasha: She was counting the world brownies.
Ryan Bailey: Loves it.
Gianluca Bini: Oh, a little brownie. So, okay, fair. So I think we're we're uncovering a lot of like this little kind of dogmas, right? Along the line.
Gianluca Bini: So how about
Gianluca Bini: blacksmith in diabetic patients?
Ryan Bailey: Hmm.
Gianluca Bini: Boom. Do you use it? You don't use it? What would you do? Because, you know, i mean, to be fair, i think it depends on which kind of diabetes the patient has.
Annatasha: Oh, I like that qualification.
Ryan Bailey: Same horse.
Annatasha: i also think this is a really complicated question. and
Ryan Bailey: Okay.
Annatasha: I might crush some candy as well. Bailey takes care. i' Just kidding. But
Annatasha: listen, this is my general attitude. I like alpha two agonists. I think they play a very important role in ah ah the majority of the cases with which I am involved.
Annatasha: um um I love wheat thins, but oh um'm here's the thing. If you have a true diabetes mellitus animal, you have to remember there's a difference between blood sugar and intracellular sugar, right?
Annatasha: So that's really the important parameter.
Gianluca Bini: Right.
Annatasha: And the thing is, is that dexmenetomany for the most part affects diabetes. blood sugar level, but not necessarily the intracellular. However, if I can do something to avoid having to manage a complicated interpretation or in any way contribute to deregulation of that diabetic patient, then I'm going to err on the side of caution and that capacity.
Annatasha: But if my diabetic patient needs dexmedetomidine, like there's a strong and appropriate indication otherwise, then that's fine. I'm going to do it.
Ryan Bailey: Yeah, i would I would echo similar sentiments. i I would say I have not routinely used it in diabetic patients. I can't think of a diabetic patient in which I have used it. like i think you know i also think there's merit in using it in cases that it's warranted. So For whatever reason, we've got a diabetic dog who wants to tear your face off and is intractable, right?
Annatasha: What?
Annatasha: but
Ryan Bailey: You know, should we be should we be dicking around with like, you know, ACE and opioid sedation that may not get the level of sedation to make that patient handleable?
Ryan Bailey: Probably not like when we can hit it with Dexmed, get a handleable in a safe, quick fashion. You know, i I think that's like a good.
Annatasha: Well, listen, my own spicy little brown cat brownie who has diabetes mellitus, you know, sometimes you just need the dex med to sedate that one because she's a real serial killer when she's in the clinic.
Ryan Bailey: Yeah.
Annatasha: And for the safety of both my staff and her, I'm going to give it to her.
Ryan Bailey: Yeah.
Annatasha: And anyway, half the time she's freaking insulin resistant from pancreatitis. Anyways, what difference does it make?
Gianluca Bini: Right, that's what i'm saying. Like, you know, if you have a cat, right? You know, some of them are ends are in resistance. So then at that point, doesn't even matter, and right?
Annatasha: Exactly.
Ryan Bailey: yeah
Gianluca Bini: i Especially if you have cat with HCM, right? Or you want to give the Dex map.
Ryan Bailey: but
Annatasha: To manage that feline sympathetic tone associated with ATSI.
Ryan Bailey: eight Exactly.
Gianluca Bini: Exactly.
Ryan Bailey: That's a perfect example. Dexman manages Sympathetic Tone great, for the record. like It stabilizes that nice and smooth.
Gianluca Bini: Again? Yes.
Annatasha: i I agree. I agree. But like I said, they're like i said be you're never there are very few things where you're going to find where I have absolute objections to thinking through complicated situations and maybe coming up with things that are a little more creative than the bog standard person might be used to for their you know day-to-day anesthesia.
Annatasha: And that's fine, but that's really what we're meant to do. And that's not necessarily what everybody is meant to do. So I'm cool it.
Ryan Bailey: Yeah. Mm-hmm.
Gianluca Bini: Yeah, that's part of our right? That's what Absolutely. you know that's part of our job that's that's what we do
Annatasha: Yeah. Our job is to take things that nobody else wants to anesthetize and do it successfully, safely, and wake those patients up and send them home. Like that's the whole point of what we do. And there's about a bajillion different ways to do it um and to do it well.
Annatasha: know, and there's a lot of things that I do and I don't do. And I probably, we would never have consensus agreement on so many different things. And and I think that's really where the experience and the art come in. And that's why it's nice to talk to other anesthesiologists. Cause like,
Annatasha: when you guys did the fireside chat Manuel and he was saying, you know, like I have friends who do ketamine and HCM cats all the time and but far and away those cats do absolutely fine.
Annatasha: um um And so, yeah, well, but to be fair, we all could use the qualification most of the time.
Gianluca Bini: Most of
Ryan Bailey: Except the ones that don't.
Annatasha: I mean, I've crashed patients twice in my career on famotidine.
Gianluca Bini: them.
Annatasha: So heads up on that one.
Ryan Bailey: Oh, yeah.
Gianluca Bini: Nice.
Annatasha: Yeah. So like at at the end of the day, if you do anything enough, the statistics of the situation will always catch up with you. Even if your best practice, you know, textbook, like all that kind of stuff, because you're always, there's something idiosyncratic that will be on your knowledge and your control. And, you know, it will burn you, you know, every once in a while, just to give you a little dose of humility and put you back in the box.
Annatasha: And that's just the way the cookie crumbles. So
Gianluca Bini: Yeah. No, that's, I mean, absolutely, right? So, and then i think this is going to be the last question for for tonight. So,
Gianluca Bini: you know, some practices do 10 ml per kip per hour of fluids during surgery.
Annatasha: Oh, fuck. I hate talking about you so much.
Gianluca Bini: Some practices do some, right? So here's what I've been doing, right? In preparation for this session, I've been looking at Facebook posts and like, you know, listserv stuff, right?
Ryan Bailey: Oh.
Gianluca Bini: And so, and I was like, okay.
Ryan Bailey: So he's outsourcing his work here, Bartel, is what we're learning.
Gianluca Bini: What?
Ryan Bailey: I said, so you're outsourcing your work is what Bartel and I are learning. where We're using all our brains to come up with these insane topics we talk about. Oh, no. I'm only kidding.
Gianluca Bini: you know Those are questions that people ask. right
Ryan Bailey: I'm only kidding.
Gianluca Bini: you know it's it's I'm trying to give people the answers to the questions that they normally ask.
Ryan Bailey: Yeah. Oh, for sure.
Gianluca Bini: right And then we'll talk about ventilation next time, Ryan.
Ryan Bailey: Yeah.
Gianluca Bini: don't worry.
Ryan Bailey: Yeah, we'll talk about, like, my insane ventilation theories.
Gianluca Bini: We'll get there.
Annatasha: He could be cocktail night again if we do that.
Gianluca Bini: We'll get
Ryan Bailey: Yeah.
Gianluca Bini: there.
Annatasha: So what's the question? Sorry, I totally interjected with my hand.
Gianluca Bini: The question was, right like do you think there is any value in having a different fluid rate? right like So 5 ml packet per hour versus 10 versus 3.
Gianluca Bini: yeah
Ryan Bailey: I'm all over the place. My fluid rates are like, how am I feeling today? how wet is it out there? How dry is
Gianluca Bini: It doesn't matter.
Annatasha: Just in case anyone can't see, I'm holding my head in my hands right now because I'm just remiss about this topic.
Ryan Bailey: I feel like we were so, I mean,
Ryan Bailey: This may just show my complete lack of understanding of anesthesia as a student.
Annatasha: Probably.
Ryan Bailey: probably I mean, I feel like I was ah ah was probably a pretty strong anesthesia student. I kind of knew I wanted to do it. I'm sure my faculty will probably beg to differ. But I feel like back in the day when I was a student, everything it was like 10 mils per kilo, fucking hose down.
Ryan Bailey: And it was just like everything.
Annatasha: and ken 10 was the low end. 20 was the high end. So if you, well, I'm much, much older than the two of you.
Ryan Bailey: Oh, I never saw it That sounds crazy.
Annatasha: So, i mean, like for sure, like, you know, 20 would be the high if you were hypovolemic or actively bleeding and da, da, da, This is what happened in the early 2000s, everybody. Okay.
Gianluca Bini: know you were that old.
Annatasha: Well, that's because I Botox.
Gianluca Bini: a Okay, whatever.
Annatasha: how smooth this forehead is everybody does it move
Gianluca Bini: All right.
Ryan Bailey: Soon enough, people are going to be like, Dr. Bailey, you use 10 mils per kilo per hour of fluids. I'll be like, yeah. And my hairline tells the story.
Ryan Bailey: yeah
Gianluca Bini: but right
Ryan Bailey: Everything is 10. TPLO, 10 mils per kilo. CT, 10 mils per kilo. i I really think a lot about fluid rates and i go back and forth.
Gianluca Bini: Yeah.
Ryan Bailey: I'm And like, oh, everything gets its own.
Gianluca Bini: do you really fucking do?
Ryan Bailey: I'm like, long long long um MRI, three mils per kilo per hour, no open in body cavity.
Annatasha: Thank
Ryan Bailey: We're going to be under anesthesia for like two plus hours, like you have three. Or like, i don't know. Sometimes they do like a CT and I'll do like 10 mils per kilo per hour because it's a quick CT.
Ryan Bailey: And I'm thinking about it as like the total amount of fluid based on a very good lecture from Dr.
Gianluca Bini: Ooh, okay, okay. Yeah, that's a good way.
Ryan Bailey: Lydia Love. want to shout that one out on...
Gianluca Bini: Yeah.
Annatasha: I agree. I'm going to shout out Lydia Love for that too, because it's really more about the total volume we're delivering over time in most instances, as opposed to the difference between the rate between five and 10.
Ryan Bailey: Dream Symposium.
Gianluca Bini: She was amazing.
Ryan Bailey: Yes.
Gianluca Bini: Absolutely.
Annatasha: Obviously, if your rate is billion mils per hour, then rate will then become a factor that you need to take into consideration.
Ryan Bailey: Yeah.
Annatasha: But it's really like, you know, if you set them at three mils per kg per hour and the neuter takes seven minutes, like congrats, you gave them 0.4 mils. Like why bother with food at all?
Ryan Bailey: Exactly. Yep.
Gianluca Bini: Okay.
Annatasha: So it's the total volume and over time and it's the type of volume as well because you know after 30 minutes like well so that shenanigan is long gone from the vascular space so yeah this is why fluids just fill me with consternation like.
Ryan Bailey: Yes.
Ryan Bailey: hip
Ryan Bailey: You do get... That is like your passion, and I'm just like, put them on the fluids, who cares?
Annatasha: when i was I presented the 10-year literature review of fluid therapy last year at AVA.
Ryan Bailey: But...
Annatasha: And I started the conversation with is, before anyone gets excited, I don't have any answers for you.
Ryan Bailey: Wow.
Ryan Bailey: No. That is the consensus.
Annatasha: And I just went through, like, tell you how many papers on fluid therapy
Ryan Bailey: No one fucking knows.
Gianluca Bini: Nobody knows.
Annatasha: yeah
Gianluca Bini: Nobody knows. I think it's an answer.
Annatasha: Nobody knows. Nobody has the right answer. It's so it's these is one of those things that this is like, like this is serious, like quackery is my opinion. Fluid therapy is fucking quackery.
Ryan Bailey: Totally.
Gianluca Bini: Yes, it is.
Ryan Bailey: did you Did any of you guys see the... Any of you all, sorry. See the Javma fluid therapy prior to surgery for GI i foreign body reduced the amount of fluids.
Ryan Bailey: Give an intra-op, I think, was the...
Gianluca Bini: I mean, it makes sense, right?
Ryan Bailey: Yeah.
Gianluca Bini: There's patients that normally don't eat slash puke, right?
Ryan Bailey: Yeah. And they were, they were saying that there was like much less interventions if the patients were like, well, like essentially rehydrated prior to anesthesia.
Gianluca Bini: Yeah,
Ryan Bailey: I'm pretty sure it was DAVMA within the last couple of months.
Gianluca Bini: you're not sure.
Annatasha: Well, I love it when people publish incredibly obvious things, but no shit. Like the better you optimize
Ryan Bailey: Yeah. But in clinical practice, that's not done. They're like, Oh, dog's got a foreign body. Get him in the OR as fast as we possibly can. It's like,
Annatasha: Yeah, but that's why anesthesia is supposed to be the stopgap. Cause I'll be like, this patient's not optimized. You have not solved fluid resuscitation and electrolyte balance appropriately. And I'm like, have a nice day. Although secretly I actually just take it and fix it myself because it's faster and better.
Ryan Bailey: Yeah, exactly.
Annatasha: But yeah, I, I mean, it it totally makes sense.
Ryan Bailey: That's exactly what happened. so much
Annatasha: Like you basically, this paper is a, is a, is a clinical example of if you optimize the patient before anesthesia, it does better under anesthesia. So you just published an, ah an obvious statement.
Gianluca Bini: no shit no
Annatasha: Yeah.
Ryan Bailey: But now you have something, but now we, the like, you know, people who believe in it have something we can be like, here, here's the evidence.
Gianluca Bini: have
Ryan Bailey: Here's evidence. You can read it. You can read this paper by someone who's not me who wrote this and they said this and it was clear and byh blah, blah, blah, blah. Like there was the paper from the UK that's like, you can sit on a GDV for a couple hours and they do just fine.
Ryan Bailey: As long as you stabilize them and optimize them prior to anesthesia. Pretty that was a UK paper if I remember correct. Don't remember the author, so sorry.
Annatasha: Fail.
Gianluca Bini: Look at you not referencing your stuff, Ryan.
Ryan Bailey: I know, I know.
Annatasha: Happens with age.
Ryan Bailey: Yeah, like I know. My brain. Sometimes just can't remember the
Annatasha: It happens with age. The longer you live, the more your head starts to fill with stuff, which means that you start to forget more because you have a larger capacity of things to remember.
Ryan Bailey: That's true.
Annatasha: I listened to that podcast on memory.
Ryan Bailey: Totally.
Annatasha: So... But yeah, no, I think like fluids is quackery for the most part.
Ryan Bailey: Totally.
Annatasha: And I agree, like, obviously, like the more you stabilize the patient, the less work we're going to do under anesthesia. But in most instances, I don't win that battle. And I'm not interested in spending three hours of my life waiting for someone else to clue into it. So I usually just fix it myself.
Ryan Bailey: Yeah, exactly. Like I end up just doing it.
Annatasha: Awesome.
Ryan Bailey: And like,
Ryan Bailey: you know, sometimes you have those patients who are coming in and they do need emergent surgery and they are somewhat dehydrated. You do what you can. And then, you know, in that first hour, maybe I am running them on the old school 10 mils per kilo, but it's a one hour limit.
Annatasha: Right.
Ryan Bailey: And I set the pump and I set it all up. So it's all like, you know, me proof. And so like at one hour, the fluid pump beeps, it clicks over to the maintenance rate. We go down to five mils per kilo per hour hour.
Ryan Bailey: I reevaluate. I think, you know, I talked to a surgeon, Hey surgeon, are the guts all dry? And he's like, yeah, they're so dry. And I'm like, all right, well, we're going to keep going to, you know, 10 mils per kilo per hour or like, yeah, i I constantly adjust my fluid rates.
Ryan Bailey: Like this is not a static.
Annatasha: Also, the hour cutoff is entirely arbitrary. Like why, why in minutes or why is it not seven?
Gianluca Bini: you
Ryan Bailey: Right.
Annatasha: Like there's so much this, like, you know how you have like this meltdown over like the bane, the the sentence that tips me over the fucking edge is careful with fluids.
Ryan Bailey: Yeah, sure.
Annatasha: That's the most meaningless sentence in the history of medicine.
Annatasha: I have no idea what that sentence means. And I hate when people say it or write it in a report. And I was like that, like, i will stroke out over be judicious with fluids.
Gianluca Bini: All right, all right. So very, very, very last question, and then you let everybody go.
Annatasha: That sentence just sends me into a rage.
Gianluca Bini: What do you think of the dogma? It has heart disease. we We can't give fluids, or we need to lower the fluid rate to 3 a.m.
Ryan Bailey: Love it. I love it.
Ryan Bailey: I get so excited.
Gianluca Bini: per cup of water to a moment.
Ryan Bailey: i am like, like I,
Gianluca Bini: It's usually on the echo report.
Annatasha: I can't answer this question because I have to go to the happy place in my head.
Ryan Bailey: I it so excited when I have the dog, you know, and Bartel is probably gonna have a fucking stroke here. So Bartel, make sure you're seated Get ready.
Annatasha: aneurysm is already forming just from the question.
Ryan Bailey: We have dogs under anesthesia, blood pressure's dropped, we're hypotensive, and I'm like, give a fluid bolus. And the technician looks at me like, but Dr. Bailey, this dog has burblest.
Ryan Bailey: I'm like, give a fluid bolus. I'm like, are you sure? Do we really, we only want to give five? And I'm like, give it, no.
Annatasha: Is every day at work for you like an episode of the Muppet show? like
Gianluca Bini: It sounds a lot like it, yes.
Ryan Bailey: I mean,
Ryan Bailey: Guys, I'm more like...
Annatasha: No, listen, I'm a believer. If you need volume, whatever you want to qualify that as of course, Lord, it's a call it. If it's, you know, you need platelets, if you need plasma, whatever, if you need it, you need it.
Ryan Bailey: Yep.
Annatasha: If your heart, if your heart is diseased, I can work around that to a certain point. But at the end of the day, if I do cause a little bit of congestion, I can usually back you back out of that anyway.
Ryan Bailey: Yep.
Ryan Bailey: yeah
Annatasha: So I don't sweat it and I have no hard objection to it, but,
Gianluca Bini: Right. Right.
Annatasha: This statement, heart disease is almost as meaningless as be careful with fluid therapy. What does heart disease mean?
Ryan Bailey: Yeah.
Gianluca Bini: right
Annatasha: Electrical? Is it pericardial? yeah Is it myocardial? Is it mild? Is it moderate? Is it severe? Is it compensated? Like, is it multifactorial? Fuck off.
Annatasha: Like, I don't know what, and that question just makes me so mad.
Ryan Bailey: and And there's no, all the evidence suggests that you should not be running these patients dry, especially like coming from the human literature where they have like fucking real heart disease. We have like play pretend heart disease, like, oh, the heart's kind of bad or whatever.
Ryan Bailey: But they have like real fucking heart disease because they smoke and they drink and their hearts are all jacked up.
Gianluca Bini: Thank you.
Ryan Bailey: And like they live a lot longer, so their hearts are in all kinds of different failure that we can even possibly comprehend. And like all the evidence says, do not run these patients dry.
Ryan Bailey: There is no benefit to doing that. Don't do it. Like we should not be doing that. We should not be falling into the trap of doing that. It's stupid. And it's like, i mean, I don't like,
Annatasha: you he Make sure you splice this segment and then share it to all the cardiologists because I'll fucking live for that moment.
Gianluca Bini: What is it?
Annatasha: Let me tell you.
Ryan Bailey: mean I mean, if I was to go into boards and I was like, well, the cardiology report says, be careful with fluids. I'll be running this patient dry, Dr. Pippadop. And he would be like, he would just like, he would just walk out of the room, slam his pencil on the table. my God.
Ryan Bailey: Slam his pencil on the table. And, uh, i would I would fail right there on the spot. you would have like I would have to say, would maximize end-diastolic volume to like ensure that the patient is well volume loaded prior to anesthesia and not run them dry, blah, blah, blah.
Ryan Bailey: And like yeah, you want to make sure your patient is adequately volume loaded.
Gianluca Bini: You
Ryan Bailey: A more full ventricle does beat stronger. We don't need to overfill it, but we want the Goldilocks.
Gianluca Bini: could.
Ryan Bailey: like Should we be doing preoperative echo? like Should we learn pre-op echo? Should we learn AFAS and like TFAS and all that? Probably, but we've got enough
Gianluca Bini: you could.
Ryan Bailey: on our that that's That was like a whole conversation at ABA in London was that like human, like the big thing for cardiothoracic human anesthesiologists was like learning TEE.
Annatasha: Anesthesiologist in human medicine does all the TEE, right? Like.
Gianluca Bini: Yep.
Ryan Bailey: And now there's like a big movement of like cardio trying to take back TEE and perform the TEE under like anesthesia now instead of having the anesthesiologist.
Annatasha: Well, you know what? I'm not going to advocate for that because if they're going to give me anesthesia recommendations and I'm going to TEE my own fracking patients. like that cardio How do you like that?
Gianluca Bini: i Jokes aside, though. like you know and And that's what I tell my students all the time. If the heart doesn't have enough blood, it's not going to pump. What does it mean?
Annatasha: so Guys, it's not a dry pump.
Annatasha: It's not a dry, it's not pneumatic.
Ryan Bailey: I think there's a there's a specific reflex I think not Herring Brewer I don't think it's Bezel Jerish what's the like empty heart causes arrhythmias and like the
Annatasha: It's not, it's not, you need to have volume.
Ryan Bailey: You know what I'm Like the empty ventricle, the squeezing of the empty ventricle causes like, it's one of the cardiac reflexes.
Gianluca Bini: is the There is a street side right, Van Vigel, you mean? Yeah.
Ryan Bailey: Not that one That's part of
Annatasha: It's just every ventricle is when the right ventricle just stops fucking contracting, whether there's volume or not.
Ryan Bailey: the an empty heart beating, like an empty heart contracting causes, there's, it's a cardiac reflex. I don't remember what it is, but it is, it's a cardiac reflex.
Ryan Bailey: fuck that I was thinking about ah fucking cardio thing and now I just oh I remember I saw the best cardio thing they said that you should be careful with fluids and that when the patient is standing you should administer a dose of Lasix
Annatasha: It's the Bezold-Jahres reflex. Yeah,
Ryan Bailey: I thought it was bezel Jarish god damn it I should have said bezel Jarish god damn it
Gianluca Bini: Of course it was the Bezo Gerag.
Annatasha: an empty ventricle causes a reflex bradycardia because the heart's like, well, if I don't need to pump, I might as well die.
Ryan Bailey: Yes. That is exactly what it's doing. It's like, fuck.
Gianluca Bini: Fuck.
Ryan Bailey: Yeah, so this cardiologist was like, when the patient is standing, you should administer Lasix. And I was like, hell yeah.
Gianluca Bini: Okay.
Ryan Bailey: What?
Gianluca Bini: Specifically when it's standing.
Ryan Bailey: Yes.
Gianluca Bini: If it doesn't stand, you don't.
Ryan Bailey: I, you know, I didn't call them for the recommendations because i was like, this is a waste of my time and I'm not going to do that. In fact, the other day I called someone for an echo report. i was like, can I have the echo report? And they said, oh, well, we're not done finalizing it, but I can read you the anesthesia things. And I like, damn, you're cut them off mid-sentence. was like, no, no, no, no. no I'll decide how to anesthetize this patient. Thank you so much.
Ryan Bailey: I just.
Annatasha: And that's exactly why I'll be doing all my own transesophageal echocardiology.
Ryan Bailey: just
Annatasha: The rest of my...
Ryan Bailey: I just see the numbers you you calculated, please, to to decide how this patient's heart is. Thank you.
Gianluca Bini: this
Annatasha: Unbelievable. Unbelievable. That's so irritating me.
Gianluca Bini: right And on that note, now I think on that note, we can have this night here.
Gianluca Bini: you very much.
Annatasha: You should end it before it ends in violence. like
Gianluca Bini: Yeah, I see the rage in Ryan's face and I was like, holy shit.
Ryan Bailey: Yeah.
Ryan Bailey: I'm trying to go get my pitchfork and go down to the nearest cardiologist.
Annatasha: If you get your pitchfork, I'll get my lighted torch and we'll go like on our way over to like ACVIM bracket cardio bracket.
Gianluca Bini: It's
Gianluca Bini: I was like, he's either going to kill somebody or rob an odd dog stand. oh
Ryan Bailey: Ooh, don't throw me with a good time.
Annatasha: Thanks everyone.
Gianluca Bini: So thank you everyone for listening.
Annatasha: love
Gianluca Bini: Remember, you can watch us on Apple Podcasts YouTube. We'll see you next time.
Annatasha: thanks everyone
Gianluca Bini: Thanks, everybody.
