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Navigating the Rollercoaster Ride of Pediatric Anesthesia with Dr. Ella Pittman
368 Plays1 month ago
Brace yourself for an episode that’s small in animal size but big on anesthesia challenges! In this installment of the North American Veterinary Anesthesia Society Podcast, we’re diving into the world of pediatric anesthesia——because when it comes to anesthetizing puppies, kittens, and foals, they’re not just small adults (no matter how cute they look when they're just a baby). We’ll cover the unique physiology of pediatric patients, the must-have equipment to keep them safe, and drug protocols tailored to their delicate systems. Plus, we’ll tackle common problems, so you don’t end up feeling like you’re herding foals without a halter when facing a pediatric patient in the clinic.
Joining us is Dr. Ella Pittman, a board-certified veterinary anesthesiologist at Port City Veterinary Referral Hospital—and as of this recording, New Hampshire’s only one! She’ll help us navigate the rollercoaster ride of pediatric anesthesia, from managing their unpredictable metabolism to the tricky waters of their tiny airways. So grab a coffee (or some warm fluids for your patient), and let’s get into it—because these little ones might be small, but the anesthesia challenges are anything but!
If you like what you hear, we have a couple of favors to ask of you:
Become a member of NAVAS for access to more anesthesia and analgesia educational and RACE-approved CE content. The NAVAS Virtual Spring Symposium will be held on May 3-4, 2025. Registration for the event will open soon.
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If you have questions about this episode or want to suggest topics for future episodes, reach out to the producers at education@mynavas.org.
All opinions stated by the host and their guests are theirs alone and do not represent the thoughts or opinions of any corporation, university, or other business or governmental entity.
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Transcript
Introduction and Guest Welcome
00:00:07
Speaker
Hello, Gas Passers. Welcome to a new episode of the North American Veterinary Anesthesia Society podcast of host Dr. Bonnie Gatson.
00:00:20
Speaker
Thank you everyone so much for joining us for another episode of the NavVest podcast. I have a special guest here who I'm going to ask some questions to just to give us a hint about what the topic of this month's podcast is going to be.
00:00:37
Speaker
So everyone welcome. Lily, you want to say hi? Hello, everybody. name is Lily Bell Gatson, daughter of Dr. Bonnie Gatson. Thank you for joining us today.
00:00:50
Speaker
So, Lily, I have a question for you. So, why do you think anesthetizing puppies and kittens is going to be kind of difficult and challenging? Because of the machine's uses and how you organize them and use them.
00:01:07
Speaker
I think that is a really good point. What about their size? Do you think their size is going to make things challenging? Yes. Why do you think that? Because the different sizes of and the animals, the more careful you have to be about where you place them and how big they are.
00:01:27
Speaker
I think that are two really good points for why pediatric anesthesia can be so challenging. And I'm so excited to welcome our guest today. Besides...
Pediatric Anesthesia Challenges
00:01:38
Speaker
besides Miss Lilly, our other guest is Dr. Ella Pittman, and she's going to help us explore pediatric anesthesia and understand how small animals like dogs and cats and horses, how their physiology is different when they're younger, and also how their pharmacology can be different and some strategies that you can take in your clinic to help you tackle these very challenging cases.
00:02:07
Speaker
So without further ado, let's get started on this month's episode of the Navas podcast.
00:02:18
Speaker
thank you so much for coming on the NavVest podcast. Do you mind just starting by briefly introducing yourself and talk about your past training and what you're doing right now?
00:02:29
Speaker
Hey, so I'm Ella Pittman. I'm the staff anesthesiologist at a tertiary hospital in southern New Hampshire. I went to Cornell for vet school and was pretty convinced that I was going to spend the rest of my life being an equine sports medicine vet and rotating between the big winter shows in Florida and then the the summer circuit in Vermont. And realized about two weeks into my equine internship that I actually didn't really like lameness. And so I had learned pretty early on in school that I adored anesthesia. i loved the relationship between the physiology and the pharmacology and how we as
00:03:08
Speaker
People in the anesthesia team really serve as advocates for our patients. So I headed back to Cornell for an anesthesia residency. And now I get to do something I love every day.
00:03:18
Speaker
Thank you so much for coming on. And the reason I'm having you here talking with me is because what we're going to talk about today is anesthetizing pediatric patients.
00:03:29
Speaker
I find personally interesting. that when somebody asks me to help anesthetize like a six week old puppy or kitten, there's like a part of me that has a mild amount of dread because they're not always my favorite cases to do because they can be so challenging.
00:03:47
Speaker
So why do you think anesthetizing pediatric patients can be particularly challenging, especially compared to adult animals?
Why Pediatric Anesthesia is Challenging
00:03:53
Speaker
Yeah, so peds are tough. And then you know, our human colleagues have a whole separate specialty, right, devoted to pediatrics.
00:04:00
Speaker
And part of it is size. Size is always challenging. And if you give me the choice of a 600 kilo cow or, you know, a six gram lab animal, I'm always going to take the 600 kilo cow. No question.
00:04:12
Speaker
And so, you know, it means you potentially have differences in your breathing circuits. You may have monitoring equipment. Your monitoring equipment doesn't work. Your drug volumes are going to be extremely potentially different.
00:04:25
Speaker
You may have to dilute things, which makes you more predisposed to error. And then certainly their physiology and their pharmacology can be a little bit different. That being said, i think there's very few things that are as rewarding in a way as as pediatrics and because they're just incredible. And and I had a six week old kitten over the summer who came to us from our ER completely uptunded and non-responsive, ironically with a large colon volvulus, which, you know, I was a horse vet. So for me to anesthetize a cat with a large colon volvulus was a little bit funny.
00:04:59
Speaker
And I remember the kitten was so sick. I induced it with fentanyl, a little bit of midazolam and actually put it on an epi CRI because it was so, so sick. And I had virtually no monitoring. I had an ACG. I had end title.
00:05:14
Speaker
I had no peripheral pulses, no Doppler, no pulse ox. We get into the ah OR, the colon literally ruptures in my surgeon's hands. well And I'm thinking, there's no way this cat's going to make it off the table.
00:05:27
Speaker
And three hours later, i get a video from the ICU and this cat is playing with toys. And that sort of just like miraculous defiance of all logic.
00:05:38
Speaker
I'm like, you had no perfusion for like several hours and you're fine. You know, and sure, our our patients don't necessarily have to learn to read and do long division. But I just remember thinking, man,
00:05:51
Speaker
the resilience of that cat was incredible. So that can kind of be really fun about pediatrics too, that, you know, a lot of them will bounce back in a way that our adult patients may not.
00:06:03
Speaker
I kind of like pediatrics in that life, but yes, they were very tough. Yeah. Like the ability for young animals to heal is it's crazy. And you're just like, who are you?
00:06:15
Speaker
Yeah, I had a case really not as bad as like a large colon volvulus, but I had a case not too long ago in a like four or five week old kitten that had a urinary obstruction. Like, what is that?
00:06:29
Speaker
thing I know. And it it was unfortunately not as... fun of a story that you had because the animal was just born with like a really horrible anatomic abnormality that made it just not compatible
Definitions and Implications for Anesthesia
00:06:41
Speaker
with life.
00:06:42
Speaker
But that being said, you know, we still anesthetized it and tried and man, like they're so challenging, especially when they're that sick. So why don't we start with talking a little bit about what makes them different and We'll start with definitions because I find that to be really challenging in general, especially because I do find there's a difference between not only species, but also like within breeds, especially dogs. Right.
00:07:12
Speaker
So defining neonate versus pediatric versus juvenile versus adult a little bit depends on what source you're looking at. So In general, kind of neonates are going to be patients within that first two weeks of life. And and at least in my experience, that's going to most of the time be actually your large animal cases. So, you know, that's going to be the foals with failure, plastic transfer, infected umbilicus, septic joints, same with calves, atresia ani and camelids and ruminants and things like that.
00:07:42
Speaker
Pediatrics is going to be kind of that two to 12 week mark. So they're kind of in that starting to transition of out of maybe a true neonate state developing more of their kind of more adult body systems.
00:07:56
Speaker
Juvenile is going about 12 weeks to about six to seven months, depending on what source you look at. And again, and dogs particular, depending a little bit on the breed, you're looking at adults kind of by full two years.
00:08:07
Speaker
Certainly in our small breed dogs in particular, they're going to reach kind of maturity closer to six to eight months, something like your toy breeds, whereas your sporting breed dogs and your larger breed dogs generally may be at that 18 to 24 month mark before they're fully developed.
00:08:21
Speaker
So let's discuss some of the key physiologic differences in pediatric patients that impact
Cardiovascular Differences in Pediatrics
00:08:30
Speaker
anesthesia. And let's start with the cardiovascular system.
00:08:34
Speaker
Yeah. And how is this different from an adult patient? And I think for me personally, I find the big differences is is oftentimes when I anesthetize pediatric patients, they I find the first thing that I'm dealing with that is always super frustrating is hypotension. It's almost like love to be hypotensive. And awake.
00:08:57
Speaker
And awake. Like the two states of pediatrics is like they're too deep and their blood pressure is garbage or they're like jumping off the table. Yeah. So I feel like some of that does have to do with their kind of weird physiology. It's not weird. It's just different. So let's start with the cardiovascular system.
00:09:15
Speaker
Yeah. so I think kind of one of the big key takeaways of pediatric anesthesia is that neonates are much more dependent on heart rate to maintain cardiac output than our adult patients. So they cannot increase their stroke volume to compensate for changes in cardiac output. Their heart rate has to be the predominant driver there. And Part of that is that they contain less contractile tissue per gram than adults do, and the ventricles themselves are less compliant. So in addition, they also have immature contractile proteins. So they just can't have that great pump function that you expect from an adult patient.
00:09:56
Speaker
They also potentially have issues with their calcium. So they have reduced cardiac calcium stores, again, due to like immature sarcoplasmic reticulum. And so especially with our inhalants that are direct myocardial depressants, they can have kind of an increased sensitivity to that effect.
00:10:14
Speaker
So you do have to be a little bit careful. Their baseline blood pressure though is lower than our adult patients. So typically at neonates, you actually can be okay with immune arterial pressure for about 40. And then for me, usually after that two weeks, like two to 12 week mark, I tolerate 50 to 55. By about 12 weeks, the sympathetic nervous system is fully developed.
00:10:36
Speaker
And so at that point I say, Hey, I really do want you to be above 60 at the 12 week mark. At birth, you mainly with a neonator pediatric patient have ah mature and actually dominant parasympathetic nervous system. So they are predisposed on top of everything else to having bradycardia and hypoxia induced bradycardia. And these baroreceptors, like I was saying, kind of aren't mature until 12 weeks as part of their sympathetic nervous system. So they really aren't able to respond to stressors such as hemorrhage in the same way our adult patients are. So, you know, again, big thing there is
00:11:12
Speaker
Keeping up your heart rate and maintaining that in order to maintain cardiac output. What about their respiratory system that's different that you can think of? Yeah, so first thing is intubation. goal is is anesthesia is to always maintain an airway.
00:11:26
Speaker
And, you know, certainly those of us who've had the pleasure of doing puppy and kitten resuscitation and trying to intubate those guys, it's really, really hard They've got a small oropharynx. They've got kind of a wide, flat tongue.
00:11:41
Speaker
So preparing yourself for a difficult airway, you know small sizes of endotracheal tubes, potentially having zero or one Miller blades available if that's an option, having a stylet or a bougie.
00:11:53
Speaker
and just preparing yourself for a potentially difficult airway. Their actual thoracic cage is also a little bit different. So their chest wall is relatively flexible and very compliant. and they have decreased functional residual capacity compared to older animals. So they are prone to developing hypoxemia if allowed. So pre-oxygenating these patients.
00:12:17
Speaker
Tends to be really important. Ideally, we pre oxygenate every one of our patients, but these guys, especially, they also have higher oxygen demands compared to our adult patients. They're usually about two to three times metabolic oxygen requirements. So, you know, you need to be conscientious of that and support their ventilation.
00:12:35
Speaker
At the same time, they have a slightly different muscle composition of their intercostal muscles compared to adults. In people, you don't have full development of your type one fibers until you're about two years old.
00:12:49
Speaker
And so type one fibers that are typically involved with kind of more endurance and long term activity And so these patients are prone to becoming exhausted. They also have small diameter airways, so increased work of breathing. And so they very, very easily, if you are not careful, can become fatigued. And so you need to be conscientious of that.
00:13:10
Speaker
Other piece with their respiratory system, and I guess this is a little bit more central nervous system as well, but MAC and pediatrics, It will be lower in neonates than in older patients, but generally speaking, MAC will be higher in in pediatrics than the adults.
00:13:26
Speaker
That's so interesting because i always find that if I'm using isoflurine to maintain anesthesia and I'm putting them at like one and a half you know percent isoflurine, I do feel like they like jump off the table still. Yeah.
00:13:44
Speaker
yeah So it's interesting to know that they actually do have like higher oxygen requirements. The only other thing I'm going to pipe in about maintaining ventilation in these patients, I think what you're saying about the fact that they get fatigues very easily, you do have to support their ventilation a lot of times in these pediatric patients, is that I find when when most people are ventilating animals under anesthesia,
00:14:08
Speaker
And let's say we're we're manually ventilating them because I think a lot of practices out there don't have ventilators. So if they're manually ventilating these patients, most of the time, i would say most technicians out there or veterinarians are always taught like you don't go above.
00:14:25
Speaker
20 centimeters of water on on your peep or let's say, you know, a good place to start if you're giving a breath to a patient and you're looking at your pressure gauge just to go to like 10 centimeters of water.
00:14:36
Speaker
And it's important to note that these patients have like, I call them little water bags, like their chest wall is so compliant that So like if you're going to 10, you might be actually like over ventilating these patients because their chest wall is just like super duper flexible.
00:14:56
Speaker
So for these patients, you might not need to go to 10. You could probably get away with going a little less. I don't know how you feel about that, but I think that's a really, really good point. And I will fully admit, and we're going to get into non-rebreathers a little bit later, but you know, that's where for me, I find non-rebreathers a little bit challenging compared to my circle system as I just that half liter bag on there makes me really nervous. it goes up And then I, and it's just, ah, and, and, you know, very few of us have the the lab animal, how well to, to ventilate these guys on a circle system. So yeah, I, I a hundred percent agree. You have to be very, you should be careful in every patient, but especially in these neonates, you could cause barotrauma very easily.
00:15:35
Speaker
what role do immature organ systems, kind of like the liver and the kidney, what does that play in like altering our approach to anesthetizing these patients? Sure. when i When I think of those two organs, I really think of, you know, the mainstays of drug metabolism, excretion, fluid regulation, and metabolism. Those are kind of the big jobs of those organs.
00:15:57
Speaker
And, you know, probably unsurprisingly, they don't work as well in our neonate and pediatric patients. So, You know, the nephrogenesis is really not completed until about three weeks of age. Certainly that that timeline is accelerated in our large animal patients. And, in you know, kind of what I would say, too, about our large animals, if you think about, you know, a calf, a foal, a sheep, a goat, they have to get up and move around and, you know, run away from predators. So their body systems in general are are a little bit more functional at a younger age than our, you know,
00:16:31
Speaker
kitten and puppy patients that can't even see for several weeks. So are renal function is really not developed in our small animal patients until about two, two months old. Foals and calves are going to be about four to six weeks.
00:16:43
Speaker
So the kidneys are really not as efficient at eliminating fluids. so These guys are predisposed to fluid imbalances and especially poorly tolerant of volume overload.
00:16:55
Speaker
We also know that GFR and tubular secretion is generally delayed as well. So, you know, that's going to affect our excretion of our renally excreted drugs as well as our renally excreted metabolites.
00:17:09
Speaker
In terms of the liver, the cytochrome P450 system, which is one of our main kind of metabolic pathways in the liver for our drugs, is immature and and it doesn't really reach maturity until about five months old.
00:17:21
Speaker
So again, you're potentially going to have prolonged duration of some of your drugs just because they're not being as metabolized as efficiently. We also know that the liver is not quite up to snuff yet in producing plasma proteins. So things like albumin are going to be lower in our pediatric patients. And so there's going to be more free concentration of drugs floating around in the plasma because less of it's going to be bound to plasma proteins.
00:17:48
Speaker
Other big thing that we're going to get into when we talk about complications is glucose. The liver has fewer glycogen stores and is not as adept at gluconeogenesis as our adult patients. And so these patients are very, very, very predisposed to developing hypoglycemia.
00:18:05
Speaker
So based on these physiologic changes that we discussed, and I think there there are probably more, but I think this is a really good summary of like, what are the major differences? Yeah.
00:18:18
Speaker
So based off of these, what are some of the anesthetic concerns or complications that pediatric patients are more susceptible to? Yeah. so I think when we talk about kind of overall anesthetic complications, you know, I i work with my team on saying every single patient is at at risk of developing hypoventilation, hypotension, bradycardia, and hypothermia.
00:18:39
Speaker
Certainly with pediatrics, hypothermia becomes much higher on that list for me. i acknowledge it, but in private practice, actually very few of my patients now return to ICU hypothermic, which is very, Very nice.
Risk of Hypothermia in Young Animals
00:18:52
Speaker
But in neonates, basically, they have a higher body water percentage and a lower fat content. So they're less able to deal with being cold. And in addition, shivering is going to increase metabolic oxygen requirements.
00:19:06
Speaker
They have poor thermoregulatory center control, and they they just don't respond as well for those reasons. So that becomes a much bigger concern and in actively warming these patients, pre-warming these patients, doing what you can do to minimize them dropping their body temperature is huge.
00:19:23
Speaker
Hypoglycemia, kind of as we talked about, you know, with the liver immaturity and the lack of glycogen stores, that's becomes much more important in these patients. Bradycardia. So i i know we're going to kind of get to drugs, but I tend to avoid alpha twos for that reason.
00:19:39
Speaker
fos are going to be a little bit different. Foles and calves. i so I still, you know, I'm a fan of xylazine for those patients. But I don't tend to use dexmetatomidine in anything, in any small animal patients under 12 weeks because I don't want to predispose them morbidocardia. They are at risk of both hypovolemia and fluid overload. So you do have to be a little bit careful about their volume status and then certainly prolonged drug effect and and risk of drug overdoses. And I will say too, part of that, and I a little bit speak from experience with this, unfortunately,
00:20:11
Speaker
They're low volumes that most of us are not used to dealing with on an everyday. You know, how many of us in practice have kind of said, oh, three moles of propofol for a cat. Well, guess what? That three moles of propofol for a cat is going to kill something that's a neonate or pediatric if you're not careful. So, you know, those are kind of, for me, the the biggest risks of physiologic risks anyway of of pediatric anesthesia.
00:20:33
Speaker
Are there any like species specific differences that you think you could think of? I mean, you talked about, for example, with large animal patients being more comfortable with using xylozine in those patients, as opposed to like, you know, a dog or cat that's under three months of age, you know, you might avoid that with, mean, dexminetomidine because we don't use, I mean, I don't use xylozine in dogs and cats. you can But I just don't.
00:21:00
Speaker
Besides like those drug differences, at least for physiologic concerns, is there anything that is a little bit different between, you know, like maybe ah a dog or a cat versus like a more large animal species?
00:21:13
Speaker
You know, I guess part of it too, our our equine and and bovine patients tend to have lower heart rates to begin with and and have high parasympathetic tone at rest anyway. So that's one reason I don't mind using alpha twos in those species.
00:21:27
Speaker
I feel like there's something really obvious you're getting at that I am totally forgetting. that No, no, no. I wasn't. I was just curious. I think that there's nothing that's super obvious, but I think For me anyway, some of the concerns are, for example, like hypoglycemia is not something I'm like super duper worried about with something like a horse.
00:21:47
Speaker
Right, that's true. Or like a a cow or calf or something like that. Dogs and cats, I'm definitely much more worried about hypoglycemia in. And then for me anyway, you know, a lot of times I don't necessarily approach foals very differently than I do an adult horse.
00:22:08
Speaker
Right. Beyond just like obviously taking into account like their body weight, you know, but i still really, i I use a lot of the similar drugs that I do in an adult horse that I would do in a foal.
00:22:25
Speaker
I think really the big differences have to do with like equipment, at least for a foal versus like an adult horse. Right. But I do feel like i'm I'm approaching like a pediatric dog or cat very differently than I would like an adult dog or cat for me personally. I don't know how you feel about that.
00:22:45
Speaker
Yeah, well, this, you know, again, this is kind of the, I guess I would say even the advantage of, you know, horses and calves being born and having to stand within three hours and nurse and be fully functional, essentially to run away from predators. I mean, that's, that's how they evolve. So I agree that typically, certainly there, there are changes and probably, again, the true, the only true neonates, most of us are routinely anesthetizing. Well, I don't, cause I don't do large anymore, but I Yeah.
00:23:15
Speaker
are going to be the calves, the foals, and things like that. So I i would agree they they do seem significantly less fragile and and kind of more more adult. and in And I think I said this, that they typically are physiologically close to adults by four to six weeks.
00:23:31
Speaker
Yeah, I would just say for the foals anyway, i would say my only other like major or like a cow, although I i haven't really that size a lot of calves personally. But for my large animals, I think the really big difference is like how you approach the mare.
00:23:49
Speaker
i was thinking that was like... but more of the issue with large animal than it is for like dogs and cats. Yeah. And I was going to get into this a little bit later, but yeah. so you know, one of, especially coming from an equine background and I am still a hundred percent a horse girl. I have a horse.
00:24:06
Speaker
She's Sometimes challenging. She's definitely a veterinarian's horse, especially an anesthesiologist. She like drinks dorm like nobody's business. You know, safety, you have to be safe around horses and mares that are have a folder side can be particularly unpredictable.
00:24:24
Speaker
And so Half of your management of these cases, especially on the front and the back end needs to be, how do I safely handle, move around the mayor? How do I do an appropriate physical exam? How do I sedate mom?
00:24:36
Speaker
You know, what's my plan for bringing mom up to induction? And then what's my sedation plan for mom? And then what's. You know, what's my recovery plan for like, you know, making sure that they're not screaming back and forth, you know, for two hours and things like that. That is a huge part of of full anesthesia that we don't really have to worry about on the small animal side.
00:24:54
Speaker
Slash most small animals are not going to kick you in the head And even actually I would argue too, handling foals, especially once they get to a certain size can be very challenging and very dangerous without appropriate training and support.
00:25:09
Speaker
Oh yeah, 100%. So I think this is a really nice segue into talking about anesthetic management of
Evaluating Pediatric Anesthesia Patients
00:25:14
Speaker
pediatric patients. yeah So when you are evaluating a pediatric patient for anesthesia, are there any specific conditions or congenital abnormalities that you're looking out for on your initial exam?
00:25:26
Speaker
So for my small animal patients, certainly you know one of the things I'm always keeping ears on is a murmur. And there are times that you know a murmur in a pediatric patient can be normal. So our furumina valley typically closes completely within 21 days.
00:25:44
Speaker
I am still always keeping my ear out for something like a PDA, VSD, pulmonic stenosis in susceptible breeds. you know Typically, by the time certainly they reach us at a referral practice, they've that has been caught.
00:25:59
Speaker
But you know for those in GP and who might be you know looking at this first day, it's really important to potentially work those murmurs up before patients are anesthetized. um Tricuspid valve dysplasia is another one. so getting those evaluated on my large animal side, especially if I'm looking at something that's and a true neonate, I want to know its IgG levels and make sure that I don't have a partial or complete failure of passive transfer, which you know, you may know, because that's why you're going to surgery is because something, you know, you've got a septic joint an infected umbilicus related to that.
00:26:35
Speaker
But that for me is an important consideration on those sides, certainly in terms of blood work, Like we talked about measuring BG and regularly kind of monitoring that's really important.
00:26:45
Speaker
ah These guys are going to have lower PCVs then than an adult patient. Their red blood cell lifespan is a little bit shorter and their EPO or erythropoietin production is lower than the adult. So that's that's going to be normal. at least for the first two to three months, they're going to have lower serum creatinines, lower BUNs, you know lower albumin, lower total protein, and plus or minus lower sodium. I don't know how clinically relevant I've ever appreciated that, but they do have a tendency to dump their sodium a little bit more than the adult patients.
00:27:16
Speaker
Yeah, the only other blood work changes that I can think of, especially in like older puppies and kittens and probably in foals too, is that their AST can sometimes be all it elevated as well. That's right.
00:27:29
Speaker
The bone isoenzyme. Yes, exactly. And then their phosphorus and their calcium can also be higher too right because they're like, they're busy making bones. Right.
00:27:39
Speaker
And I actually think that's a thing we don't talk about very much is that a lot of, especially our pediatrics, they have lax joints, lax tendons, and their their growth plates aren't fully closed. So you do need to be a little bit cognizant in how you handle them. And I will fully admit coming from equine, that was something that I had to a little bit tone back when I was dealing with small animal because I out of habit.
00:28:02
Speaker
Grabbed 18 gauge needles for everything. And you have to be a little bit cognizant of your hand skills and positioning and just the amount of force you're using on these patients because they are more fragile.
00:28:13
Speaker
Let's talk about fasting. Yeah, I think this is challenging because I I don't think there's a good like. across the board way of doing this. But for you anyway, what are the fascinating recommendations that you're giving? Because the reason this is challenging is because you're balancing like avoiding perioperative regurgitation and aspiration with like hypoglycemia.
00:28:41
Speaker
Right. So what are your recommendations? Yeah. So the we know the lower esophageal sphincter is somewhat looser in a pediatric patient until about five to six weeks. So they are more predisposed to regurgitation. However, you know, and kind of doing a little bit of of digging for this for this podcast, they're really beyond no fast and under two week patients.
00:29:03
Speaker
There's really no uniform guidelines. And i remember studying this for boards and being like, why no one agrees on anything? You know, maximum of one to two hours, typically for our patients that are under eight weeks or even really small patients under two KIGs.
00:29:17
Speaker
For me, anything eight to 16 weeks, I've kind of set them at three to four hours or if they're you know having a procedure, I'll have owners give a small half meal around 6 a.m. The reason why I sort of have transitioned away from DCing all food at 10 o'clock at night is because I was ending up having all these patients coming in, you know, morning of her surgery.
00:29:39
Speaker
And they hadn't eaten in like 10 plus hours. That made me feel really uncomfortable. And so, you know, that's why I've kind of transitioned to, okay, since I can't have you get fed at four o'clock in the morning or three o'clock in the morning, you know, let's transition you to the small meal at 6am.
00:29:55
Speaker
Typically, then they're, getting you know, hitting the table between 10 and 12. And so three to four hour fast there. And then certainly the AHA guidelines have been updated to reflect that and in healthy patients, typically four to six hours and an adult should be fine.
00:30:08
Speaker
I think in people it's like a six, four, two rule. So six hours, solid foods, four hours, non-clear liquids and two hours, clear liquids now. Yeah. And for our listeners, if you're interested in hearing more about fasting guidelines, we have a whole wonderful episode on that.
00:30:23
Speaker
So I encourage you to go check that out. But I totally agree with you about, at least for pediatric patients, that I like to make sure, especially if they're under 12 weeks, I like to make sure that they have like a little, maybe half to a quarter of whatever they normally eat and wet food at like 6 a.m.
00:30:41
Speaker
Yeah. And this is especially important if you're talking about pediatric small breed dogs like Chihuahua, Yorkie, Maltee stuff. and You definitely want to make sure they're they're eating something.
00:30:55
Speaker
Yeah, per number that's definitely, you know, and again, there's been times where i'm like, all right, well, you know what, here's here's your meatball at 8am, you'll go at noon or something like that. You said wet food tends to be preferable to dry food.
00:31:07
Speaker
Yeah, let's talk about equipment. I find equipment becomes one of the big challenges of tackling pediatric patients.
Special Equipment for Pediatrics
00:31:17
Speaker
So is there any special equipment you're recommending for use for pediatric patients?
00:31:23
Speaker
First thing I'll say is is my hat goes off to everybody in lab animal medicine who's routinely dealing with these problems and has managed to make all these things work because that to me is like really, really hard. But, you know, I think IV catheterization, you know, very simple, very straightforward, not so simple, not so straightforward and not something to take for granted in pediatric patients. That can be a very difficult process.
00:31:48
Speaker
situation And so, you know, having not only small catheters, but potentially having IO catheters available, you know, if needed can be really, really helpful.
00:31:58
Speaker
Certainly for our small animal patients having access to a non-rebreather so circuit. So typically, you know, I think most of us agree that any patient under three kilograms or so really should be on a non-rebreathing circuit where you're using higher fresh gas flows to, you know, clear CO2. And the advantage of that circuit over a circle system,
00:32:18
Speaker
is to decrease the work of breathing for these smaller patients. They scare a lot of people because I think a lot of us, myself included, you know, they're they're a little bit trickier to set up. You have to be sure that they're set up correctly. You have the correct attachments to your fresh gas inlet.
00:32:34
Speaker
They also distort your end tidal waveform because of the higher fresh gas flows that CO2 is diluted. you You know, that in itself can can be a little bit challenging. Our monitors don't always work.
00:32:45
Speaker
So certainly, you know, we can get ECG, use your temperature probe. but I find that a lot of these true smaller patients trying to get an oscillometric blood pressure is challenging, if not impossible.
00:32:56
Speaker
Certainly you can put a Doppler on Again, can't always get one. So certainly advantageous. I think there's even a recent paper at a VAA that says, hey, you know in dogs under five kilos, maybe the Doppler isn't as accurate as we thought it was.
00:33:10
Speaker
Active warming is really important to these. We talked about kind of poor thermoregulatory control. And so being able to actively warm these patients is really, really important. And again, being able to get an airway. That's probably the most important out of out of any of these. But In an ideal world, you're going to have blood pressure, ECG, temperature monitoring, capnography, kind of the the mainstays. And certainly as anesthesia enthusiasts, we always want all the things.
00:33:35
Speaker
You don't always get all the things in these guys. And certainly too, if you're anesthetizing a lot of pediatrics and you have those tools, making sure you have either pediatric adapters or ways to minimize mechanical dead space and kind of have some of those adapting pieces to take your equipment and make it suitable for those smaller patients.
00:33:55
Speaker
Yeah, I was going to say, I think that one of the bigger concerns I have for pediatric patients is being concerned about mechanical dead space, which is oftentimes for our listeners.
00:34:07
Speaker
Mechanical dead space is usually defined as parts of the endotracheal tube that's like coming out of the patient's mouth essentially. And then also if you're using a circle system, it was going to be anywhere in the circle system where there's like the Y piece, meaning like where there's like a mixture of inspiratory and extra gases like coming together.
00:34:31
Speaker
So one of the nice things about the non-rebreathing systems, not all the time, but like sometimes the mechanical dead space can be depending on the circuit, can be a little bit smaller.
00:34:43
Speaker
that's an argument. People ask me that all the time. i'm like, well, it just like depends. so and say But there are some companies, at least if you're talking about either for your, for your capnograph, there are some companies that have pediatric adapters for the capnograph, either the side stream or the mainstream.
00:35:04
Speaker
So getting ahold of those are like really important. I remember there was a practice I used to work at that just did not have any pediatric adapters for the capigraph and you're like for some of these really small things the amount at least for a side stream like the amount of gas that's being aspirated out of the stream is like the tidal volume of the patient right And so using a side stream is like not appropriate for that patient because depending on the amount of gases that are being aspirated system, it's like all the gases are being deviated out instead of going into the patient.
00:35:42
Speaker
I don't know. So I used to prefer using mainstreams for like very small things. By very small things, I mean things that weigh like grams. Yeah. Yeah. My fear always is the mainstream. And I used to go back. I know exactly what you're going to say.
00:35:55
Speaker
In those really, really small patients, the mainstream is basically as heavy as the patient. And so you're going to say that you just have to be careful and diligent and just watch that. It just doesn't because sometimes, too, I've found that securing my endotracheal tube and some of these guys can be not so straightforward.
00:36:13
Speaker
And it goes and, you know, Next thing you know, you're like, cool, I have no airway now. I was literally about to say that, which is like the problem with the mainstream is like it's heavy. Yes.
00:36:24
Speaker
And then we had an Emma, actually. I don't know if anyone's on the podcast who's listening is familiar, but it's... something It's like a particular type of mainstream capmograph that's like a standalone system that's made by Massimo, I believe.
00:36:38
Speaker
And those are actually pretty lightweight, ah but they they still like I've had some problems. And then the other thing is for securing the endotracheal tube, my personal favorite for the pediatrics, I've tried a lot of different ways.
00:36:50
Speaker
I've done the rubber band. I've done tying with the gauze. I like to use one of two things. One is like umbilical tape is really good. okay And then two, just literally taping it to the patient's head.
00:37:04
Speaker
fair Rubber band is a great one. i have never I've never heard that or tried that, but I totally now want to. Yeah. So my problems with the rubber bands is like it depends on the type of rubber band you use.
00:37:15
Speaker
like If you use a really big rubber bands, they actually, like even when you secure it, they're still too loose. okay So you've got to use like really, really small rubber bands if you're going to do that.
00:37:26
Speaker
But again, i I like just taping them. I just put a piece of like I'll use the the like half inch tape. It's a really, really tight tape. Tape it around the endotracheal tube a few times and then just tape it to the patient's head.
00:37:38
Speaker
Just cut it at the end of the procedure. It's fine. But like, yeah. yeah That's that's personally what I like to do. And then as far as like warming is concerned, those that's so hard. It is. um I like I find bubble wrap is like my favorite, like bubble wrap. Those those little guys.
00:37:56
Speaker
so Okay, cool. Have you ever done that? No, I haven't. I admit that i I tend to be like, okay, as soon as they walk in the hospital in in a bear hugger under a blanket, you know, obviously someone's got to keep an eye on them, but like into warming they go.
00:38:11
Speaker
That's typically how I try to, and then sometimes, you know, we'll put socks on them or things like that. I do like socks. I admit I have, we have some really cute baby socks in the hospital. I, I 10 out of 10, uh, shout out to the technicians who, uh, went to, uh, Toys R Us or Bye Bye Baby and picked out some really cute ones.
00:38:28
Speaker
But yeah, I'll have to try bubble wrap. you So you just like bubble wrap the whole patient or just. The, the parts that are exposed. and I actually like, I love baby socks, but I also find they just like fall off because the patients are like smaller than the baby socks.
00:38:42
Speaker
Yeah. I mean, that's true. That's that is unfortunately true. Yeah. So what I've started doing is I've depending on the size of the patient will like cut up pieces of bubble wrap yeah and then just wrap their little limbs in bubble wrap and then sometimes vet wrap around that.
00:38:57
Speaker
sure Okay. Obviously, you want to be, you know, it depends on like where the catheter is and where your modern equipment is. You know, you want to leave a limb available for like a Doppler or something. But yeah, I mean, I i really like the bubble wrap or will bubble wrap the the head, for example. Like I've done that before where if the patient's like if they're getting an abdominal procedure.
00:39:19
Speaker
Yeah. who Bubble wrap the thorax and then almost wrap it almost around the circuit and then put the put some kind of warming device around the bubble wrap. So maybe either like some warm rice bags or like some other.
00:39:34
Speaker
weird ghetto things have I done just taking like your fluids like IV fluids and throwing in the microwave you know we've done that before but again you don't want to put that directly on the patient because that can hurt them but like if you put it on the circuit you're warming the circuit a little bit oh and then the only other thing I can think of is like you can be creative about where you put the Doppler mean I've put the Doppler directly on patients hearts before because that's like that's all all you get it's whooshing Just the smooshing of the DAPA. It's all you get. but That is true.
00:40:05
Speaker
That is very true. And one other comment about warming is I think, you know, we'd kind of mentioned like, hey, we we typically treat foals and calves very similar to adults. This is one place I actually don't that, you know, you're not going to put a bear hugger on us an adult horse.
00:40:19
Speaker
You do need to be cognizant of body temperature in these, especially these like civic septic foals and these six septic calves. You really should have warming, active warming on them um because they will surprise you.
00:40:30
Speaker
Oh, yeah. 100%. All right. Let's move on to drugs. Okay. So what are your like go to premedication and induction protocols for your pediatric dogs and cats?
Premedication Protocols for Young Patients
00:40:42
Speaker
I'm going preface this by saying, typically I am not a benzo pre-med person because i just, it they don't work except in these lovely pediatric patients, they love benzos.
00:40:53
Speaker
And so typically, you know, i'm I'm going to use some sort of an I am a dazzling with an opioid or a you know, mix of Torb. um there's another really great one in, in those guys. I really, like I said before, I tend to avoid alpha two agonists and I also,
00:41:09
Speaker
I avoid acepromazine. couple reasons. i I worry about the vasodilatory effects of acepromazine. And in a patient that potentially already can't handle a lot of physiologic changes, you know, ace is a drug that sticks around forever, can be very potent if you're not careful. and And for me, that margin of safety is just then too low when I have other options of medication. So, you know, my mainstays tend to be opioid and a benzodiazepine.
00:41:39
Speaker
Sometimes ketamine in there too, because I love ketamine. Yeah. Ketamine is a great drug. It has a wide therapeutic index. And you already mentioned like three bills of propofol is like deadly to like a, you know, a tiny little baby kitty or puppy. So yeah, ketamine all the way. Yeah. I mean, on this podcast. Yeah.
00:41:59
Speaker
I'm sure some people have already listened to this ACRAC podcast where they feature the human anesthesiologist Diver who made the drug protocol for getting the kids out of the cave in Thailand. They used IM ketamine.
00:42:10
Speaker
Like, how cool is that? Yeah, amazing. Yeah, so ketamine is a really great drug. There is a potential increased risk of mortality when used in in patients two to three weeks of age.
00:42:20
Speaker
We use ketamine in our pediatric large animal patients all the time. So, you know, again, that it's a little bit situation dependent. Do you add an anticholinergic into your protocols ever?
00:42:32
Speaker
You know, part of this, I will admit where I trained, we didn't do a lot of anticholinergic pre-med. I do a little bit more of it now as an attending. Honestly, not routinely without justification.
00:42:46
Speaker
Maybe it's worthwhile. i don't know. What do you do? It depends on whether I'm using a full agonist or not. So if I'm using like butorphanol or buprenorphine, at least for pediatrics specifically, I don't necessarily include like Lyco in that protocol. But if i feel like I need to use full agonist because they're having a particularly painful procedure, i do like to add it because as you mentioned earlier, their cardiac output is so heart rate dependent.
00:43:14
Speaker
I'd just like to... Have it on board. Like I always have it available. And one thing I will say when I'm when I'm doing these cases, especially if it's something sick, I always have diluted emergency drugs already done, already available, already drawn, ready to go. And for me, that includes glyco and atropine or glyco or atropine, whatever you have available. And so i don't hesitate to give it if needed. Or if the patient comes to me and it's already potentially a little bit bradycardic, then I'll go ahead and treat it but beforehand.
00:43:39
Speaker
What is your go-to pre-medication for like a full? Xylozine. We all love Xylozine. Yeah, Xylozine. Agreed. Everybody loves Xylozine.
00:43:50
Speaker
What about induction agents? I mean, we talked about ketamine as a pre-med. What's kind of like your go-to induction agent for like a puppy or kitten? And I guess also a full, you can go there too.
00:44:01
Speaker
Yeah. So for our small and old patients, honestly, it's take your pick and what do you have available? but Some people are really into alfaxalone. i am not a huge alfaxalone fan. i find the recovery is rough. I also don't like to log controls when in when the state in which I practice, I don't have to log propofol.
00:44:16
Speaker
So typically, you know, I will use propofol. You could use Atomidate with those patients as well. It really... Really depends. Some people might reach for alfaxalone to try to keep that heart rate up a little bit higher.
00:44:28
Speaker
i don't know neonates whether I've appreciated that maintenance of heart rate comparatively. Certainly, you know, I think all of us have had that story where you give give alfaxalone to an adult and you're getting called because something's in sinus tack.
00:44:40
Speaker
And you're like, well, that was that was not really what I had in mind. and So for those guys, it's it's what you have and what you like. Let's talk about NSAID use in pediatric patients. a lot of NSAIDs, if you look at the labels, especially like Milleuxacam or Carprofen or something like that, they have like warnings against using them in pediatric patients. Do you mind just like talking a little bit more about just NSAID use and pediatric patients?
00:45:04
Speaker
Yeah, so going through kind of our main, our main NSAIDs. So carprofen is labeled for puppies greater than six weeks of age. Meloxicam is actually labeled for puppies and kittens greater than six months of age.
00:45:17
Speaker
Robenococciv or Onsior is greater than four months of age. And interestingly enough, banamine and phenylbutazone are routinely given to pigs about two days age, calves, you know, a week old. Certainly I've i've given banamine plenty to neonatal foals. So You know, the big things I think if you're going to use an onsteroidal, you really got to be sure that your patients are adequately hydrated, have, you know, whether that's their nursing or kind of having transitioned to solid foods or you're supporting their nutrition and kind of making sure that you're protecting those kidneys.
00:45:54
Speaker
Some of those things I honestly have a discussion with my surgeon about because the end of the day, if if there's a problem and it's off-label use, it's on them. it's it's It's less on us. I probably am a little bit more cautious in my small animal patients than I am in my large animal patients.
00:46:09
Speaker
and don't know. What are your thoughts? No, I agree with you. I just follow labels. Yeah. And I think it can be really challenging for pediatric patients to provide adequate pain management just because, you know, you do get tied a little bit in NSAID use. And we know NSAIDs are probably our most efficacious oral analgesics that we have.
00:46:29
Speaker
So I do find managing postoperative pain for puppies and kittens, like really young that are below kind of the age range for carprofen can be like real challenging.
00:46:41
Speaker
you know So, yeah, I find that providing post-operative pain management for puppies and kittens, I mean, i'm talking like one or two months of age, is really hard because our oral NSAIDs we know are our most efficacious, least oral analgesics that we have for dogs and cats.
00:47:00
Speaker
So pain management for that population can be very, very challenging. Yeah. Yeah. And, you know, certainly a lot of us, you know, utilize local regional techniques, you know, in those patients, very few of us, I think, have either ultrasound probes that that are small enough or or really able to image well enough to do rum block or, you know, a sapheno sciatic block. it They're just tough.
00:47:25
Speaker
You know, certainly there are reports of of epidurals and in human use, but, you know, that becomes challenging as well. Yeah. Do you do anything to change your approach to fluid therapy in younger patients? We talked about the fact that they have, you know, higher metabolic requirements.
00:47:42
Speaker
They have higher like of their total body weight. ah A larger percentage of that is water compared to fat. So do you do anything different for fluid therapy or do you just kind of do the same thing you would do for an adult for a pediatric patient?
00:47:57
Speaker
I tend to run my pediatrics at slightly lower rates because I am worried about volume overloading them. Yes, they have a greater greater body water, but i I worry more about overloading them on the back end and them having either respiratory complications or or cardiac overload. And so I tend to run them, depending on the case, at about three mils per kg per hour.
00:48:18
Speaker
Maybe if it's an open abdomen, i'm i'm going to push them a little bit higher. Or maybe if blood work is showing me that they have a really high lactate or the PCB is higher than I expected or clinically they seem very volume behind. But typically I tend to be a much more conservative um fluid use in those patients. Yeah.
00:48:36
Speaker
Let's talk about managing hypoglycemia in these patients. I get a lot of questions in my day-to-day practice about like, should I be checking blood glucose on this patient? And like, what age is my cutoff and things like that?
00:48:51
Speaker
And my general rule of thumb is like, even if you're mildly worried about it, just check it because I mean, it's like such an easy test to do. But I don't know if you have like, how often are you checking blood sugars? Is there like a cutoff age upon which you like stop checking blood sugars?
Managing Blood Sugar During Anesthesia
00:49:08
Speaker
Like, are you adding dextrose into your fluids all the time? Like, what is your approach to this? Yeah, so I don't uniformly add dextrose unless clinically indicated. and And part of that is i only have the giant bottles of dextrose now and I have to crack them once every 24 hours. And I just that feels really wasteful in patients that it's not indicated.
00:49:32
Speaker
So typically what I have them do is is actually very similar to the diabetics that they come in they get a spot BG immediately on admit. And ideally we try to get those patients done first thing in the morning and depending on where their, their blood glucose is. If they're very well within normal limits, I may wait an hour and check out an induction.
00:49:49
Speaker
If they're a little bit low well, then I may say, okay, you know let's go ahead and get ready to run this one on dextrose or maybe we'll do a little bit caro syrup or something. And then recheck probably within 30 minutes. um So it's a little bit patient dependent. And then certainly um i have at least one spot check on recovery. And and if they're taking, you know, having a prolonged recovery, so greater than 30 to 45 minutes, then I'm doing, you know, a few more frequent checks to say, hey, is hypoglycemia the reason why we're having a prolonged recovery?
00:50:19
Speaker
And then in hospital, once they start eating, I kind of go, okay, you know what? I, you should you should, you should be good. I do something very similar to you. So hooray. i love being validated.
00:50:30
Speaker
Me too. Because it's always a little bit intimidating when you're like telling somebody else who like you really respect, hey, this is what I do. Please don't think I'm an idiot. ah so No, I do exactly what you do. I do a spot check. And a lot of times I'm doing a spot check pretty much on any animal that's less than a year old. so I think it's just like a good rule of thumb.
00:50:50
Speaker
It's hard because those very small like Yorkies, Maltese, et cetera, you know, their body systems in theory are supposed to mature a lot more quickly than like a Dane or a Rottweiler, like a pit bull or something.
00:51:03
Speaker
But I do find they still get hypoglycemic. Oh, yeah. Yeah. Even adults, like sometimes those really small ones, just fasting them gets them hypoglycemic. So I think like if you want like a a cutoff age, I think a year is fine. But again, you could take it patient to patient. You know, if you're talking about like a pit bull or something, probably by six months, they're good.
00:51:24
Speaker
But you never know. Well, and and those patients that you rattled off, the Yorkies and the small breed dogs, they're the ones that are also potentially going to surprise you with a portosystemic shunt. So, yeah you know, they like to to do that and be like, hey.
00:51:36
Speaker
So, you know, I think I agree. It's it's those patients warrant, even though they're, you know, they should be adults, they warrant a little bit more judicious monitoring. I agree.
00:51:47
Speaker
I think a year old is like a good cutoff. But again, patient to patient, I think is good. If they're normal on a admit, a lot of times I just do one more when they wake up from anesthesia. But if I'm having to add dextrose to their fluids or something like that, like i'm going to be monitoring a lot more ah like every 30 minutes to every hour for sure. So I just do it patient to patient.
00:52:09
Speaker
Yeah. It's very hard to make like across the board recommendations, but you know, with those things, cause it's so case dependent. I want to talk about managing hypotension in these patients
Addressing Hypotension in Pediatrics
00:52:21
Speaker
besides hypothermia. It's like probably yeah the next most common complication.
00:52:24
Speaker
What is your like, I mean, let's just say it's a pretty normal, healthy, puppy that's getting like a spay or something. What are your like step to step ways that you approach it? I think the interesting thing you said at the beginning of the podcast is that you're a little bit more tolerant of like menorrhage pressures and like the 50s or so for, you know, these young patients.
00:52:45
Speaker
But I'm just curious what your approach hypotension is. Yeah. so you know, main thing is we always try to do multimodal anesthetic protocols, right, to be able to to decrease our inhalant as much as possible. And so, you know, if you have the opportunity to either incorporate local regional techniques or CRIs to help mitigate some of that, I think that kind of preventing the problem on the on the front end will be really, really beneficial. Or if you can Get your surgeons to utilize good at home, you know, kind of pre-hospital medications. You know, that can certainly also help as well.
00:53:19
Speaker
For me, it a little bit depends on the procedure. So certainly on an open abdomen, I'm i'm willing to try one, maybe two five mil per gig fluid boluses and seeing if, you know, this is volume related or vasodilation from inhalant that I can correct with volume.
00:53:34
Speaker
Certainly using anticholinergics to bump heart rate. And then from there, if I'm reaching for a presser, tend to be um on team norepi. I like getting some some beta agonism as well as having that alpha vasoconstriction, certainly in really sick things or something i really that's really young and I really need that beta. I'll actually...
00:53:53
Speaker
jump to epi. Again, i I worked with a really fantastic criticalist who taught me to be a little bit less afraid of of epinephrine. I tend to not put these guys on any sort of phenylephrine just because i I don't really want any sort of reflux bradycardia.
00:54:07
Speaker
Certainly you could use dopamine as well. i don't know if you have strong thoughts, but it didn't seem seem to me in kind of going through the literature that there was a strong consensus in PEDS anyway, about what's what's that kind of gold standard vasopressor.
00:54:19
Speaker
or you could use the vitamin, I guess, as well. Yeah, for me, my practice in this has evolved over time because, okay, so first of all, I'm like an old school. I don't even think I'm that old school, but i'm a little old school in the sense that if we're talking about adults, my like go to like, if I'm going to be starting to add on medications to particularly to treat hypotension.
00:54:47
Speaker
I'm old school in the sense that I'm like a dopamine girl because I've used it forever. a lot of the newer residents that are coming out are reaching for norepi. And there is like tons of evidence to support that. so I'm not like anti-norepi. I just use a lot of dopamine. But that being said, moving to pediatric patients, what I'm talking about, my practice has evolved or changed.
00:55:07
Speaker
I think you said this at the top of the hour which is like these puppies and kittens, the way their cardiovascular system is designed or it's different is that they're so sensitive to the effects of isoflurine.
00:55:20
Speaker
i think the isoflurine is like the problem. And so what I've started to do personally is i i always start with like heart rate, you know, like We're going to bump up the heart rate. That's going to be the first and foremost thing, depending on the breed of dog or cat. I mean, I'm talking like I like to be like 130, 150, like or higher, you know, depending if it's a kitten, like 180, you know, like you're going high on these these little guys.
00:55:46
Speaker
And if I'm doing that and that's not really doing anything, I might try a fluid bolus. I agree with you about that. But I'm not like going to be putting a lot of weight into my fluid boluses, especially if I don't have a lot of indications that they're dehydrated or hypovolemic on my exam.
00:56:01
Speaker
So what I've started doing is if I've tried bottom-up the heart rate, It's not good. I actually just don't use ISO. Like I've just started running them on propofol CRIs personally. Okay. And it is challenging because again, they can be very small.
00:56:16
Speaker
So you've got to be careful with your volume for sure. But if I'm talking about like, you know, four month old puppies that you're doing like a fracture repair on and they're just like not doing well, like their means are like 40 or whatever.
00:56:30
Speaker
i just stopped using ISO and I'm trying other things. And I've been very happy with that. personally. Okay. I don't know if you've ever done that. I mean, you know what? I have an MRI for ah various logistical reasons when your vaporizer or whatever decides to blow, inhale it in the room.
00:56:48
Speaker
You have to switch everybody to Tiva. But yeah, Yeah, I'm going to try that. I think a lot of the four month old fracture pairs, those at least are typically old enough. I can usually get a block on board too. um And certainly in those cases, I do lean fairly heavily on like a ketamine CRI, lidocaine CRI, but I'm game to try switching them to Teva.
00:57:08
Speaker
I like that plan. The other thing, i this is like a brand new thing I just started doing. And i had some idea, like this is not my original idea. so i don't want to take it, but like for granted, but I've been starting to add midazolam CRIs.
00:57:25
Speaker
I do love, I do love like benzo top ups. That was never something I did in a residency. neither. yeah i i never did that. i just started doing that now, especially for puppies and kittens. Like they love benzodiazepines.
00:57:38
Speaker
And at least in our adult patients, we know that there are studies that show that even in adults, you know some these and you have to go a little high, like 0.6 mix per kg per hour But at those like higher doses of CRIs, it will cause like a 30% MAC reduction.
00:57:56
Speaker
yeah And so if you could just get your iso lower, even if you could just add either midazolam top offs, you know, if you don't have a syringe pump, just giving them some more boluses of benzos or something to try to like lower your isofluorane. I just like think that's that's just like key to these guys. Like try to lower your iso as much as you can.
00:58:17
Speaker
I think, you know, we always worry in in your young, healthy patients that like benzos, you know, without an hour to kind of metabolize them, they're going to wake up like Froot Loops.
00:58:27
Speaker
That doesn't seem to happen in the true meat meats. Because i I agree with you. I've definitely done the thing where, you know, 20 minutes in I've got 20 minutes to go, pop them with a you know a little bit of more of a benzo, they don't wake up cuckoo for Cocoa Puffs.
00:58:41
Speaker
So yes, I agree. I think benzo CRIs, I i would say if you can, ideally midazolam is going to be your friend more than diazepam in a CRI. But if you have nothing else, then certainly you can you can use diazepam.
00:58:55
Speaker
Yeah. And just as a general rule of thumb, you know, if you're using benzodiazepines in your practice, you should have flumazenil. Yes. So just like make sure that you have that because again, as you mentioned at the top of the hour these animals do have issues with metabolizing.
00:59:13
Speaker
These drugs are very heavily metabolized in the liver like benzodiazepines. So if you're, you know, if you're, you gave a lot of bedazolam to a puppy and it's like not waking up, after you check your blood sugar, you know you can give some flumazanil to these friends to help them out.
00:59:29
Speaker
Maybe one day we'll get remy mazalem. That's my new that's my new like hope of where I see things go in like 10 to 15 years is maybe we'll get remy mazalem. Remy mazalem? Like something that just like gets metabolized outside of the liver?
00:59:41
Speaker
Yeah. So my horse has been... And unknown lameness and her hind end and because she's owned by an anesthesiologist blocking hers has been impossible. She tries to kill vet. And so I go, no, no, no. So I took her for a bone scan and, you know, fast forward and she's just done a lot of walk rehab. So I listened to human anesthesia podcasts.
01:00:00
Speaker
And so there was this whole one on remy Mazelan and it's similar remy fentanyl in that it's, you know, broken down by plasma esterases and it's shorter acting. I think it's half-life is like 10 minutes, still 16 to nine second onset. So a little bit slower acting than propofol.
01:00:16
Speaker
But in some of those patients where you need a shorter acting benzo, that's independent of hepatic metabolism. It's really cool. So anyway, yeah that is something that may be coming down the pipeline for us in, you know, 10 to 15 That's like the, you literally just like the first person who's ever said that to me. is So that's so exciting.
01:00:35
Speaker
So yeah, no, it was cool. It was a, think a university of Kentucky anesthesia department podcast. So shout out to shout out to whatever third year resident talked about Remy Mazelan. That's so cool. Okay. So let's just end our conversation on a case study.
01:00:51
Speaker
think that was fun. I love case. but All right. So we're going to, I'm going to give you like a hypothetical situation And then you'll just tell me a little bit about like how you would approach this friend. Okay.
01:01:02
Speaker
Yeah. so let's say we have a let's make it, let's make it really young. Let's say like three month old. Okay. Let's say you're doing like a three month old, otherwise healthy Yorkie. Let's say i was going to say spay, but I think that's not appropriate because we made it really little.
01:01:19
Speaker
yeah.
01:01:22
Speaker
I don't know, let's say it's getting anesthetized for, oh, let's do a fracture repair. Say it broke its little radius. I don't know, the owner was like dropped it or something short accident and it broke its radius.
01:01:34
Speaker
And so it needs to be anesthetized for a fracture repair for some reason. I personally would co-op this, but like, let's say you've decided to go surgery for this. ah Okay.
01:01:45
Speaker
So how would you approach this case? Yeah. So in theory, you know, this is going to be a case that has come into your ER and has hospitalized overnight. You know, in my dream world, this gets gabapentin and trazodone plus or minus melatonin, you know, night before morning of to just help the entire team out.
01:02:04
Speaker
In this case, I'm also going to presume that this kiddo has a catheter already in. So, you know, certainly you could tweak these drugs and tweak these doses if you need to give IM because you don't have a catheter in or, you know,
01:02:15
Speaker
As we've all had, you bring the patient in from from ICU and your catheter is out and you are very sad. So for me, 12 weeks or three months is kind of my cut off of of using alpha twos. And actually, one of the things I found most interesting when I spent a week at Wild Medical during my residency was that they use Dexmed in every pediatric and neonate because in people, you don't have the marked reflex bradycardia in response to alpha twos that our veterinary patients do.
Case Study: Yorkie Fracture Repair
01:02:44
Speaker
So, you know, would whack this dog with with an alpha-2? No. You know, so maybe a half to one microgram per kilo IV. Certainly if we're already bradycardic from being on a fentanyl CRI overnight, then then maybe, you know, like we talked about, I would pretreat with an anticholinergic. Typically in those cases, I do like to do glycopyrrolate at 0.01 mg per kg IM.
01:03:05
Speaker
And then with the dexmedetomine, I would probably in that case put in some opioids. So kind of up to you and what you have at your practice, whether that's going to be hydromorphone, whether that's going to be morphine, whether that's going to be a little bit of methadone, or you could also maintain, you know, a little bit of a top up of your fentanyl and then maintain a fentanyl CRI through surgery.
01:03:23
Speaker
In terms of blood work for me with these guys, you know, if I have ah a PCB, a total solid BG, and then some sort of BUN, I'm really lucky in my practice, I have what we call a pre surge, which is like liver and kidney values as its own panel. And it's so that's really, really nice.
01:03:41
Speaker
I don't find that I need a full CBC chem on these guys, you know, getting, getting set up, you know, this one's probably going to be on a non rebreather. I'm going to want small endotracheal tubes, probably like three to five.
01:03:53
Speaker
Um, and you know, then again, I might consider putting fluids either on a pump or on a PD and, um, a 60 drip set with a beer trawl or even a syringe pump. I know syringes and things like that are, are kind of a little bit on back order right now. and And everyone's kind of having some logistical challenges there. But again, I'm i'm i'm very cautious about inadvertently volume overloading those from from, you know, 1000 mil bag that no one's paying attention to. And it just runs the whole thing into the dog over an hour. So
01:04:24
Speaker
For induction, I tend to be a big fan of ketofol for fracture pairs. So usually for me, that means two and two. And I would probably reach for a ketamine CRI um on this case. I, you know, the 10 to 20 micrograms per kilo per minute.
01:04:38
Speaker
Depending on how big our Yorkie friend is, I would at least try to run block it, see if I could at least see something. Certainly, You know, if if you don't have an ultrasound, that's probably not going to be an option. um Maintenance can be isoflurane, seboflurane, or, you know, again, Teva, if if um that tends to be your jam.
01:04:57
Speaker
Fluids for me, three to five mils per kilo per hour. um and then other rescue options. If I don't block, I'd consider adding in a lidocaine CRI. um You could do a fentanyl CRI. You could do methadone, boluses, and things like that.
01:05:11
Speaker
Yeah, and I'm a dazzling CRI. But remember that doesn't provide analgesia. So you got to do something else for your analgesia. This is just to keep your Mac down. Well, I think that's an excellent plan. i mean, the only critique I think I would use is something you mentioned, which is like the volumes are going to be so small, especially for like ketamine and dexminatomidine.
01:05:34
Speaker
That would be my only concern, especially if this Yorkie is like a kilo or something. True. and And that's, I've spent a lot of time and I can only speak to my hospital, like dilutions has been a big project of mine. And so at this point, I work with a team where I am comfortable enough to say, hey, and this is what we're going to do. and And I feel very comfortable in my nurses doing those dilutions appropriately, and they always cross check it.
01:05:58
Speaker
So that's, that's really important to make sure that in those cases, someone is always cross checking those dilutions. Absolutely. You know, I find that in these really tiny patients, I'm oftentimes reaching for fentanyl only because the concentration is like, you know, is is appropriate so that you can actually give like 0.1 mils as opposed to like 0.01 mils.
01:06:26
Speaker
And the only other thing I like to do um is that if you're seeing a lot of pediatrics or very small patients, just use like the un hundred insulin syringes.
01:06:36
Speaker
we That was not something we ever did when I was a resident. And i we do it in in the practice I work at now. And it's, I have a love-hate relationship with them. I will fully admit the needles always bend exactly when the dog is clean. I give it one mic per kilo of Dexmed. And I'm like, well, this is now useless.
01:06:54
Speaker
I totally agree with you. the I wish that somebody would make those like U100 syringes with like a more sturdy needle. Right. Yeah. We could just give like low volumes of drugs to like dogs. Anyway, if you're out there and you're a person who wants to try to make that, there's a call for you to like step up and do that.
01:07:15
Speaker
Yes, please make all of us who are trying to quickly inject drugs, especially again, coming at a large animal and just like, this is stupid. yeah ah Well, something that was not stupid was chatting with you today. So I appreciate you coming on the podcast and talking all about puppies and kittens.
01:07:34
Speaker
We love a good puppy and kitten here. And I'm sure you do too. Yeah, I like snuggling them. I don't know that I i actually truly enjoy anesthetizing them. But you know, again, they they can be very, very rewarding and very satisfactory when it goes well.
01:07:49
Speaker
Well, thank you again.
01:07:57
Speaker
Thank you for joining us today. If you enjoyed this episode, we invite you to explore the North American Veterinary Anesthesia Society and consider being a member.
01:08:09
Speaker
Membership with NAVAS provides incredible benefits, including access to anesthesia and pain management CE events, informative blog posts, fireside chats with board-certified anesthesiologists and specialty technicians, and much more.
01:08:24
Speaker
NAVAS members also enjoy VIN rounds, hour-long presentations on specific topics in veterinary anesthesia that offer valuable tips to use right away in practice. If you're interested, visit www.mynavas.org to elevate your anesthesia journey today.
01:08:41
Speaker
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01:08:56
Speaker
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01:09:08
Speaker
We always love to hear from all of you. a very special thanks to our sponsor, DECRA, for making this podcast possible. To learn more about their veterinary anesthesia products, visit www.decra-us.com.
01:09:24
Speaker
And of course, a big thank you to our guest today. First, Dr. Ella Pittman for her insightful discussion on pediatric veterinary anesthesia. And of course, a very special thank you to my two daughters for helping to provide some insight into pediatric anesthesia themselves.
01:09:43
Speaker
This episode was produced by Maria Bridges, edited by Chris Webster of Chris Webster Productions, with technical support from Saul Jimenez. Finally, thank you for all of our gas passers out there for spending time with us on the Navas podcast.
01:10:01
Speaker
Veterinary anesthesia is a lifelong journey of learning and growth, and we hope you'll join us next month as we continue exploring it together. Thanks for listening, and stay tuned for next month for another episode of the Navas podcast with my mom, Dr. Bonnie Gatson.
01:10:18
Speaker
Thank you.