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S1E8 - Busted! Anesthesia Myths, Dogmas & Half-Truths
138 Plays1 month ago
Think everything you’ve heard about MDR1 mutations and anesthesia is gospel? Still worried about hyperkalemia in greyhounds or debating fluid rates like it’s 2005? In this episode, our anesthesia trio takes on some of the most persistent myths and dogmas in veterinary anesthesia. From rebreathing vs. non-rebreathing circuits to breed-based panic and outdated fluid protocols, we separate fact from fiction—with a few laughs along the way. Whether you're a vet, tech, or just anesthesia-curious, tune in to sharpen your knowledge and challenge what you thought you knew. Because in anesthesia, not everything that’s old is gold—and it’s time we start myth-busting.
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Transcript
Intro
Introduction and Market Anecdote
00:00:38
Annatasha
By the way, do you like my background today? This is my dad's evil overlord office.
00:00:45
Ryan Bailey
I was wondering if you just brought the books in to look smart today.
00:00:48
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.
00:00:52
Ryan Bailey
one Those are probably serving him really well right now because no one fucking knows what's going to happen economically.
00:01:00
Annatasha
Well, my dad does. Yeah.
00:01:02
Ryan Bailey
wasn't i bet he didn't predict the fucking market today.
00:01:05
Annatasha
No, he didn't, but he's finding the tariffs on the Antarctic pretty hilarious.
Myths and Facts in Anesthesia
00:01:10
Gianluca Bini
that's our topic for tonight. So anesthesia, urban legends, and dogmas. Okay. So, you know, how...
00:01:21
Annatasha
I feel like sitting in the evil chair overlord office is actually perfect for this stuff.
00:01:24
Ryan Bailey
Yeah.
00:01:25
Annatasha
Exactly.
00:01:28
Annatasha
Exactly. like
00:01:36
Gianluca Bini
yeah
00:01:39
Gianluca Bini
So do you check your potassium in every single gray on the units of ice?
00:01:45
Annatasha
Wow, we just went right into that. There was just whatsoever.
00:01:47
Ryan Bailey
Wow.
00:01:50
Annatasha
Well,
00:01:52
Annatasha
I can see where this is going.
00:01:54
Ryan Bailey
yeah
00:01:55
Annatasha
yeah
00:01:56
Gianluca Bini
Okay, there are some reports out there, right?
00:01:57
Annatasha
This is a fucking double-edged sword. This is a double-edged sword. So I think Bailey should answer first.
00:02:01
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.
00:02:20
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.
00:02:36
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.
00:02:41
Gianluca Bini
Right.
00:02:41
Ryan Bailey
It's a killer.
00:02:42
Gianluca Bini
It is.
00:02:43
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?
00:02:50
Ryan Bailey
Yes. So that's that's another that's another thing, too.
00:02:52
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.
00:02:59
Ryan Bailey
No, it's a different one. the That one, I think, is Mama.
00:03:04
Annatasha
Yeah, maybe that was the one where they, to feel like who else was on it?
00:03:07
Ryan Bailey
And I thought that, I don't know if that was a full...
00:03:09
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.
00:03:12
Ryan Bailey
Yes.
00:03:16
Annatasha
And I was like, oh, fuck, here we go with rumors.
00:03:17
Ryan Bailey
Yeah. So that's, that's, that alpha two stuff based on the paper from, Sidihe and Big Cat.
00:03:19
Annatasha
Reza.
00:03:27
Gianluca Bini
Yeah. iszaah
00:03:28
Annatasha
Reza.
00:03:29
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.
00:03:40
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.
00:03:53
Annatasha
The paper that I'm thinking of was, it was Kershied, Nancy Brock, Dr. Kudo, the internist and Stacey Jones.
00:04:02
Gianluca Bini
Okay.
00:04:03
Annatasha
Yeah. And that was a case report.
00:04:03
Gianluca Bini
So,
00:04:04
Annatasha
That was a case report.
00:04:05
Gianluca Bini
so
00:04:06
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.
00:04:10
Annatasha
Yeah.
00:04:11
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,
00:04:36
Gianluca Bini
Yeah, and it is, right?
00:04:36
Ryan Bailey
but fantastic
00:04:38
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?
00:04:52
Ryan Bailey
Except i would argue that once you add inhalant, that's like adding gasoline to the fire.
00:04:58
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
Anesthesia Techniques and Drug Impacts
00:05:17
Gianluca Bini
I think quoting Tasha,
00:05:17
Ryan Bailey
on both.
00:05:20
Annatasha
No, no, no. Don't drag me into this shit. I was very happy listening.
00:05:24
Gianluca Bini
quoting Tasha, see Florence sends everything to shit, right?
00:05:29
Annatasha
Isoflorn is the root of all evil and the higher you turn it, the more it goes to shit. Yeah.
00:05:35
Gianluca Bini
Anyway. Anyway, so yeah, okay, fair, fair. I'll do those papers where an anesthetized patient. So what?
00:05:43
Ryan Bailey
Okay. All right. i'll
00:05:44
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.
00:05:44
Gianluca Bini
What?
00:05:55
Gianluca Bini
No, and I can believe right? Like, you know, it's fair.
00:06:00
Ryan Bailey
Yeah.
00:06:02
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
00:06:02
Gianluca Bini
That's fair.
00:06:19
Ryan Bailey
you know, that's one to 5% of the the total invoice.
00:06:20
Gianluca Bini
no that's fair
00:06:24
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.
00:06:36
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.
00:06:43
Gianluca Bini
no of course
00:06:47
Ryan Bailey
Oh, yeah.
00:06:49
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.
00:07:00
Ryan Bailey
Yep.
00:07:02
Annatasha
So there is my answer is yes, I've checked it.
00:07:03
Ryan Bailey
Yep.
00:07:05
Annatasha
But you have to remember, I'm skewed based on my population bias.
00:07:08
Ryan Bailey
Totally agree.
00:07:08
Gianluca Bini
Yeah. Yeah.
00:07:09
Ryan Bailey
Totally agree.
00:07:10
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.
00:07:27
Ryan Bailey
Yeah.
00:07:28
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.
00:07:40
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.
00:07:51
Gianluca Bini
Yeah, yeah, that's different story.
00:07:54
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.
00:07:59
Gianluca Bini
if
00:08:06
Annatasha
you pull through the catheter, which I hate, but everyone wants to do it.
00:08:09
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.
00:08:10
Annatasha
And then, know,
00:08:18
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.
00:08:29
Gianluca Bini
come
00:08:30
Gianluca Bini
Now, second
00:08:35
Gianluca Bini
dogma. Okay,
00:08:39
Ryan Bailey
I hope it's about cats this time. It'll be cat-ma.
00:08:43
Gianluca Bini
okay. Boom, Boom, okay. Well, that that was... Yeah,
00:08:50
Annatasha
Honestly, let's just end the podcast there because not another joke is going to be better than that one.
00:08:53
Gianluca Bini
yeah, we're...
00:08:55
Annatasha
Anyway, night night, guys.
00:08:55
Gianluca Bini
Exactly. See you next time, guys.
00:08:56
Ryan Bailey
Just wait till we get to horse-ma.
00:08:58
Annatasha
That was awesome.
00:09:02
Gianluca Bini
So, okay. You have... Do you avoid certain opioids in cats due to the risk of hyperthermia post-op?
00:09:15
Ryan Bailey
No.
00:09:16
Annatasha
No, no.
00:09:16
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.
00:09:24
Gianluca Bini
yeah
00:09:25
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.
00:09:35
Ryan Bailey
Yep.
00:09:35
Annatasha
It resolves. And you can have it, I've seen it with buprenorphine.
00:09:37
Ryan Bailey
Yep.
00:09:39
Annatasha
I've seen it with Oxy.
00:09:39
Ryan Bailey
Yep. and
00:09:40
Gianluca Bini
yeah
00:09:41
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.
00:09:50
Ryan Bailey
Yeah.
00:09:50
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.
00:09:57
Ryan Bailey
yeah
00:09:58
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?
00:10:14
Annatasha
So that's my only comment. But for the most part, I don't avoid anything except surgeons.
00:10:23
Ryan Bailey
yeah
00:10:26
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?
00:10:40
Gianluca Bini
The increase in sympathetic tone.
00:10:44
Ryan Bailey
Do you ever think, of do you ever think about that as part of your opioid choice?
00:10:49
Gianluca Bini
So actually, i have been.
00:10:52
Ryan Bailey
Oh,
00:10:53
Gianluca Bini
haven't been sleeping at night. I'm thinking about it.
00:10:55
Ryan Bailey
it well might be All right, all right, all right.
00:10:57
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?
00:11:19
Gianluca Bini
So, you know, even buprenorphine has zero max sparing effect in cats.
00:11:23
Ryan Bailey
Mm-hmm.
00:11:24
Gianluca Bini
It's crazy, right? Like morphine helps
00:11:26
Annatasha
He said 11 buprenorphine has zero max pairing effect on dogs too. What a bullshit peri-anesthetic drug that is.
00:11:35
Gianluca Bini
I mean, okay, okay. In dogs, actually, it does have some sparing effect, right?
00:11:41
Annatasha
Right.
00:11:41
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.
00:11:57
Annatasha
Oh, you are singing the song of Bailey's people right now.
00:12:00
Gianluca Bini
Yeah, no, it's crazy, right? Like, I...
00:12:02
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.
00:12:18
Annatasha
Yeah. Like I said, you're singing the song of Bailey's people.
00:12:22
Gianluca Bini
Chris?
00:12:23
Annatasha
Look at him. He's like a wash and joy and comfort. been Creepy.
00:12:32
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.
00:12:50
Annatasha
I'm really glad that this podcast is all actually improving our anesthesia. Like the three of us are starting to do better.
00:12:57
Ryan Bailey
and
00:12:58
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?
00:13:06
Ryan Bailey
Oh yeah.
00:13:08
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?
00:13:21
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,
00:13:31
Annatasha
which is a 99.8% of the time about the exam
00:13:37
Ryan Bailey
hello
00:13:38
Annatasha
and not actually about anything helpful to the rest of us.
00:13:41
Gianluca Bini
right, right. i also like...
00:13:42
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.
00:13:51
Ryan Bailey
So I was like, do even use lidocaine now? Or is it like...
Genetic Mutations and Anesthesia
00:13:54
Gianluca Bini
Anyway. and
00:13:55
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.
00:13:55
Gianluca Bini
but
00:14:05
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
00:14:15
Gianluca Bini
anyway so So other other have common myth,
00:14:28
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?
00:14:41
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.
00:15:03
Gianluca Bini
But if you did, like how worried are you about that stuff?
00:15:08
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.
00:15:14
Annatasha
Thank you.
00:15:24
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.
00:15:40
Ryan Bailey
So I don't.
00:15:40
Gianluca Bini
Exactly.
00:15:41
Annatasha
it's yeah It's one of those things where it's probably not going to happen when it does. It sucks hard.
00:15:46
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...
00:15:59
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.
00:16:08
Annatasha
Are we still calling it MDR one? I thought we were supposed to be calling it like ACBC or what have you.
00:16:13
Ryan Bailey
Well, I mean...
00:16:14
Gianluca Bini
Yeah, yeah, something like that.
00:16:15
Ryan Bailey
When it was written years ago, like in 2023 when it was published, it was the same as NPR1.
00:16:20
Gianluca Bini
That was two years ago.
00:16:22
Ryan Bailey
But they do mention the ABCB1 gene.
00:16:25
Gianluca Bini
Yeah, something like
00:16:26
Annatasha
Two years can be a long time when you've recently survived a global pandemic.
00:16:32
Ryan Bailey
True story.
00:16:34
Gianluca Bini
that. Cool. And then, lastly, so
00:16:42
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,
00:16:53
Annatasha
Exactly why I don't follow Facebook veterinary anesthesia groups.
00:16:55
Ryan Bailey
Right on his face, Bush.
00:16:55
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?
00:17:16
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?
00:17:29
Gianluca Bini
They were debating maximum PIP pressure. So like positive, sorry, peak inspiratory pressures, right?
00:17:35
Ryan Bailey
Mm-hmm.
00:17:38
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.
00:17:48
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?
00:18:02
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.
00:18:33
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?
00:18:44
Ryan Bailey
So like preview for those.
00:18:46
Gianluca Bini
Is that because you blew up the bag in a barrel?
00:18:50
Ryan Bailey
yeah No, no.
00:18:54
Ryan Bailey
It is. have
00:18:56
Annatasha
out the bird.
00:19:00
Ryan Bailey
a lot of I like have a lot of thoughts on ventilation.
00:19:01
Gianluca Bini
so people that listen, people people that that
00:19:03
Ryan Bailey
i would think...
00:19:04
Annatasha
Well, you have a lot of thoughts on everything from hot dogs to cracker pizza to ventilation to sympathetic tone.
00:19:06
Ryan Bailey
I just want to and a prop
00:19:09
Annatasha
Like we're used to this. God. oh yeah
00:19:13
Gianluca Bini
OMG. So whoever is listening, you know, Ryan is showing us this beautiful book.
00:19:20
Ryan Bailey
to give a So wanted to follow up from last week's episode or our special episode whenever it's out.
00:19:21
Gianluca Bini
I mean...
00:19:26
Ryan Bailey
So if you've heard
00:19:27
Annatasha
Listen, if we're ever looking for sponsors, we should reach out to some snossage companies because...
00:19:31
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.
00:19:44
Ryan Bailey
They're made with lamb, beef, and pork. They're
Ventilation Challenges and Insights
00:19:47
Ryan Bailey
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.
00:19:56
Ryan Bailey
what I'm talking about.
00:19:57
Annatasha
Side note, have either of you two been to Iceland?
00:19:59
Ryan Bailey
I have not, but I was like, this book talks about all the hot dogs.
00:19:59
Gianluca Bini
Wait, wait,
00:20:01
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...
00:20:23
Gianluca Bini
probably
00:20:23
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.
00:20:30
Gianluca Bini
The human hearing? The human
00:20:32
Annatasha
No, horse and cow for the most part.
00:20:34
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.
00:20:41
Gianluca Bini
hearing?
00:20:41
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.
00:20:54
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.
00:21:03
Ryan Bailey
you have a hot dog, though?
00:21:05
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.
00:21:10
Ryan Bailey
in
00:21:12
Annatasha
But there is a whole urine-based food culture there. Just heads up.
00:21:16
Annatasha
Heads up. But no, I'm glad you looked up the Icelandic wieners.
00:21:20
Ryan Bailey
Yeah.
00:21:21
Annatasha
a
00:21:21
Ryan Bailey
The book just came in, so i had to read through it.
00:21:22
Annatasha
Like I said,
00:21:24
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.
00:21:33
Ryan Bailey
Fingers crossed! So anyway, peak inspiratory pressures.
00:21:40
Annatasha
Right. I forgot what you're talking about.
00:21:41
Ryan Bailey
That's another one my ventilator makes.
00:21:42
Gianluca Bini
I don't know how we went from heat-inspired dirty pressure to urine, but...
00:21:46
Ryan Bailey
Yep. You know, we're all over place.
00:21:48
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...
00:22:04
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.
00:22:11
Gianluca Bini
No, no, don't spoil it............................
00:22:13
Ryan Bailey
know, but
00:22:13
Annatasha
Now, don't spoil your topic.
00:22:15
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.
00:22:32
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.
00:22:47
Ryan Bailey
was like, I like put the ECG on.
00:22:48
Annatasha
Nice. Very unusual. Okay.
00:22:49
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,
00:22:56
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.
00:23:06
Ryan Bailey
So anyway, i that dog would like would not saturate.
00:23:07
Gianluca Bini
Right.
00:23:10
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
00:23:20
Gianluca Bini
Yeah.
00:23:38
Gianluca Bini
So you don't know that.
00:23:38
Annatasha
know what? I do not want Bailey to ever ventilate me, but I would say, too,
00:23:44
Ryan Bailey
That's why I anesthesia ventilation, not fucking critical care who's like, the lungs. Oh
00:23:49
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,
00:23:56
Ryan Bailey
my god, it's like, it's like we're going to six centimeters of water.
00:23:59
Gianluca Bini
Thank you.
00:24:00
Ryan Bailey
Everyone, bang, down the hatches.
00:24:04
Annatasha
Now, I think if you have, especially if you have restrictive intrapulmonary disease, so the actual pulmonary interstitium is highly diseased.
00:24:11
Ryan Bailey
Oh yeah, yeah, yeah.
00:24:12
Annatasha
Don't drive pressures above 20. it will be dead in three minutes.
00:24:16
Ryan Bailey
Oh, yeah.
00:24:17
Annatasha
So also think the difference between 15 and 20 or 22, those are arbitrary.
00:24:17
Ryan Bailey
Ooh.
00:24:22
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.
00:24:34
Ryan Bailey
I like it.
00:24:34
Annatasha
Holy shit. Understand how it works. And then there is no weight based.
00:24:39
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.
00:25:11
Ryan Bailey
Are you going to ask about re-expansion pulmonary edema?
00:25:14
Gianluca Bini
Yeah, I mean, so, of course, but, you know, in reality,
00:25:17
Ryan Bailey
part Of course!
00:25:18
Annatasha
no
00:25:19
Ryan Bailey
Of course, yes.
00:25:20
Annatasha
ah we would you we Were you getting a vibe about that? Because I was just like, didn't get that vibe.
00:25:24
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.
00:25:33
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.
00:25:51
Gianluca Bini
Yeah, okay. you know, did you do you see any potential like re-expansion injury, any pulmonary edema afterwards? Yeah.
00:26:03
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
00:26:32
Annatasha
That's a super weird choice for that entire situation.
00:26:35
Annatasha
But anyway, if whatever.
00:26:37
Ryan Bailey
with no pressure gauge.
00:26:41
Ryan Bailey
I was like, well,
00:26:44
Annatasha
Were you doing anesthesia like in in a field with no electricity?
00:26:47
Ryan Bailey
who built this was i was walking in.
00:26:48
Annatasha
Like what's happening here?
00:26:49
Gianluca Bini
No, no.
00:26:50
Ryan Bailey
walking
00:26:50
Gianluca Bini
No, Artash.
00:26:51
Ryan Bailey
i was walking in
00:26:51
Gianluca Bini
He was a He was a Davis. Yes.
00:26:55
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.
00:27:12
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.
00:27:12
Gianluca Bini
feel
00:27:24
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.
00:27:31
Gianluca Bini
Thank you.
00:27:31
Annatasha
I'm going to handbag with a gaugeless Jackson Reese.
00:27:35
Ryan Bailey
Fucking handbagging. Like, if you're really like, I'm going to handbag this case, like, you should rethink your career.
00:27:46
Ryan Bailey
I have never, never had success. Like...
00:27:52
Annatasha
I will switch to a couple manual assisted breaths because I like to feel compliance.
00:27:55
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.
00:28:07
Ryan Bailey
and saw I saw an actual airway obstruction a CSF tap.
00:28:10
Annatasha
yeah Stop calling it handbagging, by the way. That's disgusting.
00:28:14
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.
00:28:27
Ryan Bailey
Whenever you can stop, maybe give it a break. Don't can't breathe. Everything was fine.
00:28:36
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
00:28:41
Gianluca Bini
We probably... Yeah. Somebody hand me a Jackson Reese.
00:28:47
Ryan Bailey
Yeah.
00:28:48
Annatasha
like are you doing trauma anesthesia in a war zone like i don't understand don't understand
00:28:52
Ryan Bailey
I hate the, like, the bane is the bane of my existence.
00:28:57
Gianluca Bini
The banner will exist.
00:28:57
Annatasha
We know.
00:28:58
Gianluca Bini
So...
00:28:59
Annatasha
We know, Bailey.
00:28:59
Ryan Bailey
I know. I can... I have, like, a...
00:29:01
Annatasha
Is it ketchup on a hot dog or like same thing?
00:29:05
Ryan Bailey
Same thing.
00:29:05
Gianluca Bini
so
00:29:06
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.
00:29:19
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
00:29:28
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
Equipment and Circuit Considerations
00:29:37
Annatasha
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.
00:29:40
Gianluca Bini
About the fucking Jacksonville.
00:29:46
Annatasha
and then, you know, I don't know. I just, but I would read your vitriolic blog on anti-non-rebreathing circuits.
00:29:56
Ryan Bailey
I hate them.
00:29:56
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?
00:29:56
Annatasha
Yes.
00:30:08
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?
00:30:21
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.
00:30:21
Gianluca Bini
What you see?
00:30:28
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.
00:30:45
Annatasha
so
00:30:45
Gianluca Bini
No, no, I get it. But like, you know, our listeners may not understand the machine, right?
00:30:48
Ryan Bailey
yeah listeners may not have as many feelings about a Bane and a re-breather as we do but
00:30:50
Gianluca Bini
So and that's why we're listening.
00:30:51
Annatasha
But do they understand rage?
00:31:00
Ryan Bailey
and like so i I think that is a holdover from like anesthesia from a long time ago.
00:31:01
Gianluca Bini
Look.
00:31:07
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.
00:31:20
Ryan Bailey
i
00:31:20
Annatasha
also...
00:31:20
Ryan Bailey
i know.
00:31:24
Annatasha
Why do you know what the weight of the former disc was? Like unidirectional valves or something like.
00:31:28
Ryan Bailey
Well, because we had... i mean
00:31:32
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.
00:31:40
Annatasha
Of course, that's why I was driving the bag in the barrel.
00:31:43
Gianluca Bini
Thank you.
00:31:44
Annatasha
Yeah.
00:31:44
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.
00:32:04
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,
00:32:13
Gianluca Bini
Nice. Nice.
00:32:14
Ryan Bailey
and like And if I'm wrong, I will 100% switch to this dog the ventilator.
00:32:21
Gianluca Bini
Nice.
00:32:24
Annatasha
is it just me or is Bailey extra funny tonight
00:32:27
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.
00:32:33
Gianluca Bini
and
00:32:37
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.
00:32:48
Gianluca Bini
Yeah.
00:32:49
Ryan Bailey
And then it takes out the whole question of whether the patient can breathe on the circuit or not.
00:32:53
Gianluca Bini
Exactly.
00:32:54
Gianluca Bini
Exactly.
00:32:55
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.
00:33:06
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.
00:33:13
Annatasha
But remember, a lot of GPs won't have a ventilator.
00:33:16
Ryan Bailey
Yes. Oh, for sure.
00:33:17
Annatasha
and They will go back and forth.
00:33:17
Ryan Bailey
For sure.
00:33:19
Annatasha
And so I always make sure they understand what the indication is or like what's the level of tolerance.
00:33:21
Ryan Bailey
good
00:33:23
Annatasha
For example, like if you're going to rebreathe like two points of CO2, I really don't give two points of shit.
00:33:25
Gianluca Bini
Yes.
00:33:27
Ryan Bailey
Yep.
00:33:28
Annatasha
But, you know, if it's if it's really like
00:33:28
Ryan Bailey
Big Mac live.
00:33:32
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.
00:33:36
Ryan Bailey
Yep.
00:33:42
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,
00:33:52
Ryan Bailey
Yep. Mm-hmm.
00:33:56
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.
00:34:14
Ryan Bailey
That is your like, that's a classic cartel.
00:34:17
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
00:34:24
Gianluca Bini
Thank you.
00:34:24
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
00:34:38
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.
00:34:56
Gianluca Bini
Oh, yeah. Absolutely. Thank you.
00:35:00
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.
00:35:13
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.
00:35:22
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.
00:35:23
Ryan Bailey
exactly can't be touching this vaporizer all the time.
00:35:33
Annatasha
that They don't hate me.
00:35:37
Gianluca Bini
um That's why I hate you. That's why fucking hate you.
00:35:44
Annatasha
They fear me and there's a difference.
00:35:48
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,
00:36:07
Gianluca Bini
Stonehenge era anesthesia machine.
00:36:10
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.
00:36:28
Gianluca Bini
Aw, that's cute.
00:36:31
Annatasha
She was counting the world brownies.
00:36:32
Ryan Bailey
Loves it.
00:36:33
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.
00:36:45
Gianluca Bini
So how about
00:36:50
Gianluca Bini
blacksmith in diabetic patients?
00:36:53
Ryan Bailey
Hmm.
00:36:55
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.
00:37:11
Annatasha
Oh, I like that qualification.
00:37:12
Ryan Bailey
Same horse.
00:37:14
Annatasha
i also think this is a really complicated question. and
00:37:18
Ryan Bailey
Okay.
00:37:18
Annatasha
I might crush some candy as well. Bailey takes care. i' Just kidding. But
00:37:24
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.
00:37:37
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?
00:37:52
Annatasha
So that's really the important parameter.
00:37:52
Gianluca Bini
Right.
00:37:55
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.
00:38:17
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.
00:38:26
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?
00:38:48
Annatasha
What?
00:38:53
Annatasha
but
00:38:54
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?
00:39:09
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.
00:39:19
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.
00:39:30
Ryan Bailey
Yeah.
00:39:32
Annatasha
And for the safety of both my staff and her, I'm going to give it to her.
00:39:32
Ryan Bailey
Yeah.
00:39:36
Annatasha
And anyway, half the time she's freaking insulin resistant from pancreatitis. Anyways, what difference does it make?
00:39:42
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?
00:39:50
Annatasha
Exactly.
00:39:51
Ryan Bailey
yeah
00:39:51
Gianluca Bini
i Especially if you have cat with HCM, right? Or you want to give the Dex map.
00:39:59
Ryan Bailey
but
00:40:01
Annatasha
To manage that feline sympathetic tone associated with ATSI.
00:40:04
Ryan Bailey
eight Exactly.
00:40:06
Gianluca Bini
Exactly.
00:40:07
Ryan Bailey
That's a perfect example. Dexman manages Sympathetic Tone great, for the record. like It stabilizes that nice and smooth.
00:40:13
Gianluca Bini
Again? Yes.
00:40:16
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.
00:40:33
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.
00:40:38
Ryan Bailey
Yeah. Mm-hmm.
00:40:39
Gianluca Bini
Yeah, that's part of our right? That's what Absolutely.
Fluid Management and Surgical Preparation
00:40:44
Gianluca Bini
you know that's part of our job that's that's what we do
00:40:46
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.
00:41:02
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,
00:41:16
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.
00:41:26
Annatasha
um um And so, yeah, well, but to be fair, we all could use the qualification most of the time.
00:41:27
Gianluca Bini
Most of
00:41:30
Ryan Bailey
Except the ones that don't.
00:41:35
Annatasha
I mean, I've crashed patients twice in my career on famotidine.
00:41:36
Gianluca Bini
them.
00:41:39
Annatasha
So heads up on that one.
00:41:42
Ryan Bailey
Oh, yeah.
00:41:43
Gianluca Bini
Nice.
00:41:43
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.
00:42:08
Annatasha
And that's just the way the cookie crumbles. So
00:42:11
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,
00:42:22
Gianluca Bini
you know, some practices do 10 ml per kip per hour of fluids during surgery.
00:42:30
Annatasha
Oh, fuck. I hate talking about you so much.
00:42:32
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?
00:42:43
Ryan Bailey
Oh.
00:42:47
Gianluca Bini
And so, and I was like, okay.
00:42:48
Ryan Bailey
So he's outsourcing his work here, Bartel, is what we're learning.
00:42:52
Gianluca Bini
What?
00:42:53
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.
00:43:02
Gianluca Bini
you know Those are questions that people ask. right
00:43:05
Ryan Bailey
I'm only kidding.
00:43:06
Gianluca Bini
you know it's it's I'm trying to give people the answers to the questions that they normally ask.
00:43:13
Ryan Bailey
Yeah. Oh, for sure.
00:43:15
Gianluca Bini
right And then we'll talk about ventilation next time, Ryan.
00:43:16
Ryan Bailey
Yeah.
00:43:18
Gianluca Bini
don't worry.
00:43:18
Ryan Bailey
Yeah, we'll talk about, like, my insane ventilation theories.
00:43:22
Gianluca Bini
We'll get there.
00:43:23
Annatasha
He could be cocktail night again if we do that.
00:43:23
Gianluca Bini
We'll get
00:43:25
Ryan Bailey
Yeah.
00:43:29
Gianluca Bini
there.
00:43:30
Annatasha
So what's the question? Sorry, I totally interjected with my hand.
00:43:31
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.
00:43:43
Gianluca Bini
yeah
00:43:43
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
00:43:50
Gianluca Bini
It doesn't matter.
00:43:51
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.
00:43:58
Ryan Bailey
I feel like we were so, I mean,
00:44:03
Ryan Bailey
This may just show my complete lack of understanding of anesthesia as a student.
00:44:07
Annatasha
Probably.
00:44:07
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.
00:44:25
Ryan Bailey
And it was just like everything.
00:44:25
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.
00:44:29
Ryan Bailey
Oh, I never saw it That sounds crazy.
00:44:33
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.
00:44:45
Gianluca Bini
know you were that old.
00:44:47
Annatasha
Well, that's because I Botox.
00:44:52
Gianluca Bini
a Okay, whatever.
00:44:55
Annatasha
how smooth this forehead is everybody does it move
00:44:55
Gianluca Bini
All right.
00:45:03
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.
00:45:15
Gianluca Bini
but right
00:45:16
Ryan Bailey
yeah
00:45:17
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.
00:45:26
Gianluca Bini
Yeah.
00:45:27
Ryan Bailey
I'm And like, oh, everything gets its own.
00:45:28
Gianluca Bini
do you really fucking do?
00:45:32
Ryan Bailey
I'm like, long long long um MRI, three mils per kilo per hour, no open in body cavity.
00:45:33
Annatasha
Thank
00:45:37
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.
00:45:48
Ryan Bailey
And I'm thinking about it as like the total amount of fluid based on a very good lecture from Dr.
00:45:51
Gianluca Bini
Ooh, okay, okay. Yeah, that's a good way.
00:45:54
Ryan Bailey
Lydia Love. want to shout that one out on...
00:45:55
Gianluca Bini
Yeah.
00:45:57
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.
00:45:59
Ryan Bailey
Dream Symposium.
00:46:01
Gianluca Bini
She was amazing.
00:46:04
Ryan Bailey
Yes.
00:46:07
Gianluca Bini
Absolutely.
00:46:07
Annatasha
Obviously, if your rate is billion mils per hour, then rate will then become a factor that you need to take into consideration.
00:46:08
Ryan Bailey
Yeah.
00:46:15
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?
00:46:24
Ryan Bailey
Exactly. Yep.
00:46:26
Gianluca Bini
Okay.
00:46:26
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.
00:46:28
Ryan Bailey
Yes.
00:46:37
Ryan Bailey
hip
00:46:42
Ryan Bailey
You do get... That is like your passion, and I'm just like, put them on the fluids, who cares?
00:46:49
Annatasha
when i was I presented the 10-year literature review of fluid therapy last year at AVA.
00:46:49
Ryan Bailey
But...
00:46:55
Annatasha
And I started the conversation with is, before anyone gets excited, I don't have any answers for you.
00:46:56
Ryan Bailey
Wow.
00:47:01
Ryan Bailey
No. That is the consensus.
00:47:02
Annatasha
And I just went through, like, tell you how many papers on fluid therapy
00:47:04
Ryan Bailey
No one fucking knows.
00:47:08
Gianluca Bini
Nobody knows.
00:47:08
Annatasha
yeah
00:47:09
Gianluca Bini
Nobody knows. I think it's an answer.
00:47:10
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.
00:47:22
Ryan Bailey
Totally.
00:47:22
Gianluca Bini
Yes, it is.
00:47:23
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.
00:47:36
Ryan Bailey
Give an intra-op, I think, was the...
00:47:38
Gianluca Bini
I mean, it makes sense, right?
00:47:40
Ryan Bailey
Yeah.
00:47:40
Gianluca Bini
There's patients that normally don't eat slash puke, right?
00:47:43
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.
00:47:44
Gianluca Bini
Yeah,
00:47:50
Ryan Bailey
I'm pretty sure it was DAVMA within the last couple of months.
00:47:51
Gianluca Bini
you're not sure.
00:47:52
Annatasha
Well, I love it when people publish incredibly obvious things, but no shit. Like the better you optimize
00:47:57
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,
00:48:02
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.
00:48:14
Ryan Bailey
Yeah, exactly.
00:48:14
Annatasha
But yeah, I, I mean, it it totally makes sense.
00:48:16
Ryan Bailey
That's exactly what happened. so much
00:48:18
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.
00:48:29
Gianluca Bini
no shit no
00:48:30
Annatasha
Yeah.
00:48:31
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.
00:48:38
Gianluca Bini
have
00:48:38
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.
00:48:52
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.
00:49:01
Annatasha
Fail.
00:49:02
Gianluca Bini
Look at you not referencing your stuff, Ryan.
00:49:04
Ryan Bailey
I know, I know.
00:49:06
Annatasha
Happens with age.
00:49:06
Ryan Bailey
Yeah, like I know. My brain. Sometimes just can't remember the
00:49:09
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.
00:49:20
Ryan Bailey
That's true.
00:49:20
Annatasha
I listened to that podcast on memory.
00:49:21
Ryan Bailey
Totally.
00:49:22
Annatasha
So... But yeah, no, I think like fluids is quackery for the most part.
00:49:28
Ryan Bailey
Totally.
00:49:28
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.
00:49:43
Ryan Bailey
Yeah, exactly. Like I end up just doing it.
00:49:45
Annatasha
Awesome.
00:49:46
Ryan Bailey
And like,
00:49:48
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.
00:49:59
Annatasha
Right.
00:50:01
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.
00:50:12
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.
00:50:26
Ryan Bailey
Like this is not a static.
00:50:26
Annatasha
Also, the hour cutoff is entirely arbitrary. Like why, why in minutes or why is it not seven?
00:50:30
Gianluca Bini
you
00:50:30
Ryan Bailey
Right.
00:50:32
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.
00:50:33
Ryan Bailey
Yeah, sure.
00:50:44
Annatasha
That's the most meaningless sentence in the history of medicine.
00:50:48
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.
00:50:56
Gianluca Bini
All right, all right. So very, very, very last question, and then you let everybody go.
00:50:58
Annatasha
That sentence just sends me into a rage.
00:51:05
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.
00:51:12
Ryan Bailey
Love it. I love it.
00:51:16
Ryan Bailey
I get so excited.
00:51:17
Gianluca Bini
per cup of water to a moment.
00:51:20
Ryan Bailey
i am like, like I,
00:51:21
Gianluca Bini
It's usually on the echo report.
00:51:24
Annatasha
I can't answer this question because I have to go to the happy place in my head.
00:51:27
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.
00:51:37
Annatasha
aneurysm is already forming just from the question.
00:51:40
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.
00:51:52
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.
00:52:04
Annatasha
Is every day at work for you like an episode of the Muppet show? like
00:52:07
Gianluca Bini
It sounds a lot like it, yes.
00:52:08
Ryan Bailey
I mean,
00:52:10
Ryan Bailey
Guys, I'm more like...
00:52:12
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.
00:52:23
Ryan Bailey
Yep.
00:52:23
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.
00:52:27
Ryan Bailey
Yep.
00:52:31
Ryan Bailey
yeah
00:52:31
Annatasha
So I don't sweat it and I have no hard objection to it, but,
00:52:36
Gianluca Bini
Right. Right.
00:52:38
Annatasha
This statement, heart disease is almost as meaningless as be careful with fluid therapy. What does heart disease mean?
00:52:46
Ryan Bailey
Yeah.
00:52:47
Gianluca Bini
right
00:52:47
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.
00:52:58
Annatasha
Like, I don't know what, and that question just makes me so mad.
00:53:01
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.
00:53:14
Ryan Bailey
But they have like real fucking heart disease because they smoke and they drink and their hearts are all jacked up.
00:53:14
Gianluca Bini
Thank you.
00:53:19
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.
00:53:30
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,
00:53:41
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.
00:53:45
Gianluca Bini
What is it?
00:53:47
Annatasha
Let me tell you.
00:53:47
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.
00:54:04
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.
00:54:20
Ryan Bailey
And like yeah, you want to make sure your patient is adequately volume loaded.
00:54:23
Gianluca Bini
You
00:54:24
Ryan Bailey
A more full ventricle does beat stronger. We don't need to overfill it, but we want the Goldilocks.
00:54:27
Gianluca Bini
could.
00:54:30
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
00:54:40
Gianluca Bini
you could.
00:54:41
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.
00:54:41
Annatasha
Anesthesiologist in human medicine does all the TEE, right? Like.
00:54:46
Gianluca Bini
Yep.
00:54:53
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.
00:55:01
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?
00:55:12
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?
00:55:23
Annatasha
so Guys, it's not a dry pump.
00:55:25
Annatasha
It's not a dry, it's not pneumatic.
00:55:25
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
00:55:27
Annatasha
It's not, it's not, you need to have volume.
00:55:40
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.
00:55:44
Gianluca Bini
is the There is a street side right, Van Vigel, you mean? Yeah.
00:55:48
Ryan Bailey
Not that one That's part of
00:55:49
Annatasha
It's just every ventricle is when the right ventricle just stops fucking contracting, whether there's volume or not.
00:55:54
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.
00:56:05
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
00:56:20
Annatasha
It's the Bezold-Jahres reflex. Yeah,
00:56:22
Ryan Bailey
I thought it was bezel Jarish god damn it I should have said bezel Jarish god damn it
00:56:24
Gianluca Bini
Of course it was the Bezo Gerag.
00:56:29
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.
00:56:33
Ryan Bailey
Yes. That is exactly what it's doing. It's like, fuck.
00:56:38
Gianluca Bini
Fuck.
00:56:40
Ryan Bailey
Yeah, so this cardiologist was like, when the patient is standing, you should administer Lasix. And I was like, hell yeah.
00:56:47
Gianluca Bini
Okay.
00:56:49
Ryan Bailey
What?
00:56:49
Gianluca Bini
Specifically when it's standing.
00:56:51
Ryan Bailey
Yes.
00:56:52
Gianluca Bini
If it doesn't stand, you don't.
00:56:54
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.
00:57:16
Ryan Bailey
I just.
00:57:16
Annatasha
And that's exactly why I'll be doing all my own transesophageal echocardiology.
00:57:20
Ryan Bailey
just
00:57:20
Annatasha
The rest of my...
00:57:21
Ryan Bailey
I just see the numbers you you calculated, please, to to decide how this patient's heart is. Thank you.
00:57:27
Gianluca Bini
this
00:57:28
Annatasha
Unbelievable. Unbelievable. That's so irritating me.
00:57:32
Gianluca Bini
right And on that note, now I think on that note, we can have this night here.
00:57:42
Annatasha
You should end it before it ends in violence. like
00:57:42
Gianluca Bini
you very much.
00:57:45
Ryan Bailey
Yeah.
00:57:45
Gianluca Bini
Yeah, I see the rage in Ryan's face and I was like, holy shit.
00:57:49
Ryan Bailey
I'm trying to go get my pitchfork and go down to the nearest cardiologist.
00:57:52
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.
00:57:52
Gianluca Bini
It's
00:57:59
Gianluca Bini
I was like, he's either going to kill somebody or rob an odd dog stand. oh
00:58:08
Ryan Bailey
Ooh, don't throw me with a good time.
00:58:11
Annatasha
Thanks everyone.
00:58:13
Gianluca Bini
So thank you everyone for listening.
00:58:14
Annatasha
love
00:58:16
Gianluca Bini
Remember, you can watch us on Apple Podcasts YouTube. We'll see you next time.
00:58:22
Annatasha
thanks everyone
00:58:22
Gianluca Bini
Thanks, everybody.