Transcript
Gianluca Bini: Yeah.
Annatasha: It's 100% hot.
Ryan Bailey: so yeah i will say, i wish I was recently in Europe, France specifically, and I am shocked the number of hot dogs that are on menus everywhere.
Gianluca Bini: i
Gianluca Bini: yeah
Annatasha: Have you been to Germany or Austria?
Ryan Bailey: Like...
Annatasha: Because it's a real sausage culture.
Ryan Bailey: Sure, but, like, they said hot dog. Not, like, Xiao Chen or whatever.
Annatasha: Hmm.
Ryan Bailey: Like, hot dog would be in French.
Annatasha: Chien chaud.
Ryan Bailey: out That's much better. Yeah, they were everywhere. I had two hot dogs within the first two days and I was like, okay, they're too common. I'm going to have slow it down or I'm going to die. What's up?
Gianluca Bini: Worthy or not worthy?
Ryan Bailey: what's up
Gianluca Bini: Were they worthy or not worthy?
Ryan Bailey: I mean, the first one was i have to i still have yet to write my reviews. i've been you know i was busy eating French food and being in France and all that and learning at the World Congress of Veterinary Anesthesia.
Annatasha: Did you say flirting?
Ryan Bailey: Learning.
Annatasha: Oh, I thought you said flirting.
Gianluca Bini: I told you.
Annatasha: And i said well, that's very French of you, but also weren't you with your wife?
Ryan Bailey: yeah I was the only person I was forwarding with, in fact. She does not attend the conference, though. Uh, so the first hot dog I had stuffed in a baguette.
Ryan Bailey: It was, and it was the first one and it was awesome.
Annatasha: It's so good, right?
Gianluca Bini: co you
Annatasha: We told you to get that. Yeah. Like,
Ryan Bailey: And then we went to very historic cocktail bar called Harry's New York bar invented many of the classic cocktails we think of. They also had a hot dog.
Annatasha: Bellini was invented at Harry's in Venice.
Ryan Bailey: I did not understand this situation. were given a hot dog. I can't remember what toppings it had Maybe a mustard.
Annatasha: You went to Harry's in Paris and you got a hot dog?
Ryan Bailey: Hell yeah. also got a bova Boulevardier.
Gianluca Bini: Thank you.
Ryan Bailey: And it comes out with a cup, like a pint glass filled with relish.
Annatasha: Okay.
Ryan Bailey: Yeah, I don't know who's eating that much relish, but it was a pint glass of it. it was a one hot dog.
Annatasha: Well, this is a great segue to the fact that Gianluca is really not a big fan of pickles because, of course, relish is just chopped up pickles.
Ryan Bailey: but
Annatasha: And I just, is it pickled cucumber specifically or is it all pickled things?
Gianluca Bini: The cucumber specifically, yeah. i I like giardiniera. In Italy, giardiniera is not spicy. So we do eat giardiniera a lot as an appetizer usually.
Gianluca Bini: It's together with like cheeses a meat and and there is giardiniera in it, but it's not spicy at all.
Ryan Bailey: Oh,
Gianluca Bini: We have pickled mushrooms, we have pickled a bunch of stuff. It's just the cucumber here, it seems like at least in the US, When you ask for peacock, it's straight up cucumber, which, you know, it's not really appealing, but there is stuff.
Ryan Bailey: oh yeah
Gianluca Bini: It's it's good. So
Annatasha: i I love a pickle. I love pickled anything, like beets and turnips and carrots and beans. Like, yeah.
Gianluca Bini: going back to Paris, though.
Ryan Bailey: Yeah.
Gianluca Bini: So hear
Annatasha: You're just like totally like, you know what? That's how I feel about pickles. Moving on.
Gianluca Bini: did you know? Well, I have two questions for Ryan, right? Like i haven't seen him in a couple of weeks.
Ryan Bailey: yeah Yeah.
Gianluca Bini: So
Ryan Bailey: and
Gianluca Bini: Did you go to the Louvre?
Ryan Bailey: I did not. We walked to the area. We walked to the building.
Gianluca Bini: Fucking Ryan. Okay.
Ryan Bailey: i mean,
Gianluca Bini: okay
Annatasha: It's no big deal.
Gianluca Bini: okay
Annatasha: It's only one of the greatest art collections in the entire
Ryan Bailey: Sure, sure. im I don't doubt it. I will say i am glad we didn't go. It would have been madhouse. Paris was overall a madhouse, and there was no way we were going to be able to go on a day where it wasn't just going to be fighting crowds the entire time.
Ryan Bailey: like it was we definitely went in the high season, so that would have...
Gianluca Bini: The best way to go to a Louvre is like the day after Christmas.
Ryan Bailey: Yeah, like that would be...
Gianluca Bini: There's nobody.
Ryan Bailey: Yeah, yeah there was there were people everywhere at all the things.
Gianluca Bini: Nobody done that. Nobody.
Ryan Bailey: It was... Yeah, like we we went into Notre Dame. Actually, we went into Notre Dame literally after Macron
Ryan Bailey: reopened the towers or whatever, I guess.
Annatasha: Yes. He re-pressin the rebuild. Yeah.
Ryan Bailey: Yeah, so, like, we saw his motorcade, like, leaving as we were walking up, and, like, people were, like, going crazy. But it was...
Gianluca Bini: you saw Notre Dame 2.0.
Ryan Bailey: Yes.
Annatasha: Yeah.
Ryan Bailey: Yeah, so I saw Notre Dame 2.0.
Gianluca Bini: Nice. And then have you been to the La Dure?
Ryan Bailey: I did not go to La Durée either.
Gianluca Bini: you go You go to Paris and you don't eat fucking macarons.
Ryan Bailey: i did even I did eat macarons. I will also say macarons are not really my jam. I appreciate them as like a item, but like they are not a I'm not ever seeking out a macaron. They look absolutely gorgeous. I'm not going to lie.
Ryan Bailey: But I'm just like, yeah, I don't, I like, i read there are many other desserts I'd rather eat for sure.
Ryan Bailey: That's, that's my problem with them.
Gianluca Bini: Okay.
Ryan Bailey: That's my problem with them.
Gianluca Bini: Okay.
Ryan Bailey: But i did I did not go. We did have some really good mackerel ones while we were in Strasbourg though. And we had a bunch of different flavors and they're all really solid.
Gianluca Bini: First off, who the fuck goes to Strasburg?
Ryan Bailey: We needed a day trip from Paris and that's what worked out for the train schedules. It was really nice. It was very cute. it was a cute little town yeah.
Annatasha: It kind looks like a Grimm's fairytale town.
Gianluca Bini: Yeah. Yeah,
Ryan Bailey: yeah Yeah, and we saw the astrological clock, which is absolutely wild. It's crazy. It's like this clock that was invented a long time ago, and it like can predict the religious holidays and the rotation of the Earth and the axis of the moon and all. like it's All the things it does is like truly wild, so that was...
Gianluca Bini: yeah you should see the one in Prague. That one is really cool.
Ryan Bailey: I didn't see, I saw the church where it is when I was in Prague, but we didn't pay to see the clock.
Gianluca Bini: So wait, wait, wait. on So every time you go to a city, you basically skip everything you should actually see or do from that city and you do something else.
Ryan Bailey: I mean, I am really there to
Annatasha: Yeah, what do you us to eat hot dogs? Like what's that's the problem?
Ryan Bailey: Yeah, I'm there to like eat the food, drink the drinks. I have a, I have like a pretty hard limit of like one, like big historic thing per day, 0.5 to one per day.
Ryan Bailey: And I'm more than happy to just like hang at like a Parisian cafe and just like drink wine or spritzes and just like watch the Parisian life and just watch what they're doing.
Gianluca Bini: Sure.
Ryan Bailey: And just like, that's like, what?
Gianluca Bini: sure
Annatasha: What are you, 85? What are 85? but eighty five
Ryan Bailey: I mean, Venice was my favorite place to go. We went to the same Chiquetti spot every single day. it was this one guy and he was German. Apparently we found out because we went every day and we'd like talk to him and like the little bit of language we could share.
Ryan Bailey: And we ate the same Chiquetti and we drank the same spritzes and the same red wine. And it was just like the greatest. Yeah.
Gianluca Bini: Magic.
Ryan Bailey: Yeah.
Annatasha: I just booked Venice for February, actually, because I've always when I was recently getting through my near death medical scare, i just started booking on my bucket list trips because I was like, just never know.
Gianluca Bini: What if I actually die?
Annatasha: Never know when you're going to get taken out by Giordia.
Ryan Bailey: and
Annatasha: And so I booked the carnival. I've always wanted to go to the I've always wanted to go to the carnival.
Ryan Bailey: Well, I'll show you where the little Chiquetti spot we went to.
Annatasha: And I was like, well, if I survive Giordia, I'm going to have to go.
Gianluca Bini: Fair.
Ryan Bailey: oh I'll show you the Chiquetti spot we went to, Artel, and you can just post up there all the time.
Annatasha: No problem.
Gianluca Bini: All right, ventilation.
Annatasha: Ventilation.
Ryan Bailey: Anyway, ventilation. all right.
Gianluca Bini: Now that you've entered about Paris,
Ryan Bailey: Yes. Ha ha. oh see I want to, so I did have a couple, there were obviously topics we didn't get to.
Ryan Bailey: So we'll start with the kind of ventilation adjacent a little bit, but still ventilation for sure. How do you feel and what do you do and are you routinely looking at systolic pulse therapy?
Ryan Bailey: uh systolic pressure variation pathismographic variability index pulse pressure variability and then like are you routinely looking that on cases you have on the ventilator and then how do you like adjust or approach that and then how do you take into account the variance in tidal volume that you're probably working with relative to what's actually described
Gianluca Bini: Did
Annatasha: what is this? What is this? and at Like an exam essay question?
Ryan Bailey: I
Gianluca Bini: did Chachi me this?
Annatasha: I almost started taking notes. Like I was like, I'm not going to remember all this, right? Yeah. like
Ryan Bailey: i mean, I just, I think it's a, it's a big topic. Like, I think it's a important thing. Like, you know, we, we aren't ever really working at the described pressures where the human papers really wrote it up.
Ryan Bailey: So I always wonder, like, what is the merit of intervening based on That.
Gianluca Bini: Yeah. So you're saying that basically because we never reach high enough pressures, what we're seeing, if we do see s SPV or PBV whether we actually believe it or not?
Ryan Bailey: Well, that like the original human stuff was in much lower tidal volumes and much lower pressures. And on a clinical case, we we generally can't do that.
Gianluca Bini: Got
Ryan Bailey: We can't do the same lower pressure, lower tidal volume because our patients will be massively hypercapnic, blah, blah, blah.
Gianluca Bini: it. Right. so if we
Ryan Bailey: Yeah.
Gianluca Bini: But if it happens a high, so, you know,
Ryan Bailey: Yeah.
Gianluca Bini: they needed that low enough sorry but that you know low enough pressure in order to generate that PPV or s SPV.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: Now, even if you're not using the lower pressure and you're using a higher pressure,
Ryan Bailey: yeah
Gianluca Bini: that still occurs. So why wouldn't you believe that?
Ryan Bailey: Oh, yeah. My question is, like, i guess the way I interpret it that when they were noting it at the lower pressures, that's where the therapeutics were beneficial. The interventions, the fluid boluses, et cetera, were beneficial.
Gianluca Bini: gotcha
Ryan Bailey: In a clinical case, we're already above the pressures and volumes they were working with. And we know that as you increase volume and pressure, you generally do increase the likelihood of seeing systolic and pulse pressure variability, even in healthy patients who are adequately volume loaded. Like you pressurize a dog's lungs to 20 and you're going to drop the pulse trace no matter what, even though dog's totally fine.
Ryan Bailey: So like, I guess it's to say that in a clinical case, we're probably, I mean, I for one, I'm going to look at that. I'm going to look at the peak pressure I'm achieving.
Ryan Bailey: If I'm at 14 and I'm getting some pulse pressure variability, I'm probably not going to be as excitable as if I'm on the lower end 10, I'm and I'm getting pulse pressure variability, then I'm going to be a little bit more like, oh, I think this dog is volume underloaded. This cat is volume underloaded.
Ryan Bailey: Even though I know that, you know, the original evidence, we we probably are going to tend to over-treat our patients.
Annatasha: This is the longest question we've ever been asked.
Ryan Bailey: Well, you're smart, so...
Annatasha: Meany, you first.
Gianluca Bini: Yeah, no, I mean, I get what you're saying. I'm very, very cautious with fluid bonuses anyway, right?
Ryan Bailey: What's wrong?
Gianluca Bini: a And probably most of us are, right? Like, you know, we don't, we, okay. Do
Annatasha: We're the three bears. Ryan is the least, I'm the middle, and you're the most. let Let me just paint this out for the listeners.
Gianluca Bini: you?
Annatasha: like
Gianluca Bini: Okay. I forget about the daily way.
Annatasha: Okay.
Gianluca Bini: The Davis way, Ryan. I forget about that.
Ryan Bailey: Exactly.
Gianluca Bini: Yeah, right.
Ryan Bailey: Exactly.
Gianluca Bini: It's drowning in fluids.
Ryan Bailey: that
Gianluca Bini: Anyway. We're
Annatasha: Guys, we haven't been sued yet by Davis.
Gianluca Bini: totally going to get sued at some point.
Ryan Bailey: As we learn from surviving sepsis, it's some fluids, some vasopressors. It's not all of one or all the other. there' There's room for all of it.
Gianluca Bini: Agreed. Agreed. Agreed. Now,
Annatasha: I mean, I watch all those things, Bailey, right?
Gianluca Bini: no
Ryan Bailey: You know? Yeah.
Annatasha: Like I watch the PLF and I watch pulse pressure variation and, and, you know, I sort of have this bedside, you know, rule of thumb, which is if I can visualize it from across the OR, then chances are you are probably volume deplete.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah. Right.
Ryan Bailey: yes
Gianluca Bini: yeah
Annatasha: However, I think it's important to see, like, I could chase that volume and you might not be a fluid responder, in which case then I'm actually becoming more detrimental.
Ryan Bailey: but For sure.
Annatasha: So again, it's a picture of full context, right?
Ryan Bailey: What's that? Right.
Annatasha: Like it's, You know, are you hypotensive and tachycardic and you have pulse pressure variation? And I can see it from across the province.
Ryan Bailey: Okay.
Annatasha: You know, I probably will give you fluid, right? But at the same time, I also take into consideration, what's your hematocrit doing? What are your electrolytes doing?
Gianluca Bini: Yeah.
Annatasha: What's your base excess? What's your lactate? Like, I'm looking at everything and trying to make completely arbitrary decisions.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah. Same, same. You know, I think it's, you make a good point. You know, you need to look at the full picture. You can just, you can just get that and that's it. But, you know, having some pulse pressure variation and your patient's blood pressure is normal and harsher is normal. Like who the fuck cares?
Ryan Bailey: i So maybe this is a better way to ask this question is when you are not overseeing the case and someone comes up to you and they say, hey the dog has post-pressure variation, blah, blah, blah. Do you want me to do something about it? Or like they're all fussed off about it.
Ryan Bailey: And.
Gianluca Bini: The next question is, what's the blood pressure?
Ryan Bailey: right And then you walk in the room and they're hitting, you know, a peak inspiratory pressure of like 15. fifteen And you're like, well, maybe let's back down the ventilation a little bit. Or like, maybe let's take the tidal volume down a little bit here. And like, let's see if that pulse pressure variation persists and things like that.
Ryan Bailey: feel like some people... it you know, it becomes a hot thing every once in a while, like this pulse pressure variation or systolic pressure variation. People get all excited about it and then they, you know, want to use it and do something with it.
Ryan Bailey: And then, you know, it's just part of.
Annatasha: It's great time to say, don't treat the numbers of the machine, treat the patient.
Ryan Bailey: totally. Yeah. Yeah. And.
Gianluca Bini: Yeah.
Gianluca Bini: Yeah. You can just look at the monitor and, you know that's, it's, yeah, we can't, I can't stress that enough, you know, like, you know, we always tell our students, I don't, you know, you need to look at the whole picture.
Ryan Bailey: yeah
Ryan Bailey: and
Gianluca Bini: You can just focus on these few numbers that you have in front of you. Right.
Ryan Bailey: And now with all the monitoring equipment too, like, especially as we get more and more of these like higher end human monitors make into the veterinary side, you know, they're having SPI or like PVI right on the, right on the monitor next to the pulse ox. They've got PPV right there on the monitor next to the blood pressure, like the art line trace. So you're getting all that information.
Annatasha: I think you make a good point, Ryan, about though, like, do you change your ventilation parameters based on that?
Annatasha: And I tend to agree with you. Like, I i think my level of concern changes more rapidly or more acutely when you're at a low tidal volume or a low PIP and you've got, like, marked variation versus, you know, if I –
Ryan Bailey: yeah
Annatasha: and doing something a little wild and crazy. and And, you know, like, you know, you have pressures at a 20, 25, 30. thirty
Ryan Bailey: Your peeps all dialed up.
Annatasha: Yeah, like, yes. So I think you make a good point. I think that, you know, looking at the picture of the patient, you know, are you driving a very small positive pressure?
Gianluca Bini: you
Annatasha: into the thoracic cavity and you're having a marked variation and the patient is hypotensive and the patient maybe is tachycardic and maybe it has blanched mucous membranes from, you know, peripheral vasoconstriction because you're shunting to central compartment. I don't know.
Annatasha: What's its temperature? You know, and like I said, looking at the blood work because, I mean, If I have a hematocrit of 75, probably going to give a fluid bolus.
Ryan Bailey: Yeah. Right.
Annatasha: If I have a hematocrit of 10, probably not going to give a fluid bolus.
Ryan Bailey: yeah
Annatasha: So like I said, you know, it it changes the level of like alarm or, you know, how more, you know, how aggressively am I going to intervene at this point?
Gianluca Bini: Yeah.
Annatasha: But I think that's a very good point. Like, you know, when are you seeing this variation on that spectrum of ventilation needs to be considered?
Ryan Bailey: i
Ryan Bailey: Totally. Yeah. And that's that's the thing I do oftentimes is where I see it and I know we're already working at higher pressures, I'm often going try and dial back my ventilation settings a little bit in terms of volume or pressure or both. I mean, they kind of both go in tandem, but bring those down and then see, is it still as marked as it was before or has it kind of returned to like,
Ryan Bailey: And, you know, I'll be honest, I'm good. It's for me, it's the eye test, you know, it's me looking at the trace and seeing what happens to the trace. I'm not.
Annatasha: I'm not measuring like the actual like peak variability, and like integrating a function, like, you know, great, but I'm not doing that.
Ryan Bailey: Yeah. Yeah. Yeah. Right. yeah
Annatasha: But like I said, if I can see it across the OR, then I think it's probably going to be greater than 13%. And it's probably significant. My other like really like fast bedside thing is like, if you're not doing a great, you know, job at ventilating and we do convert you to the ventilator and after, you know, two or three best, you're cutely dropped hypotensively.
Ryan Bailey: Oh my gosh, yeah.
Annatasha: That makes me go, oh, you probably need a little bit of volume there, or you need a little bit of vasoconstriction, right? Or a little bit of both.
Ryan Bailey: Yeah. Yeah.
Annatasha: So yeah, so if you acutely switch to positive pressure ventilation, and you see cardiovascular collapse as a consequence, that's a great like indication for me that one, we should probably stop mechanical ventilation while we too sort out cardiovascular stability.
Ryan Bailey: Yeah.
Annatasha: So
Gianluca Bini: Right. I mean, so, and then getting to your point, right? So
Gianluca Bini: i rarely have to ventilate to the high pressure.
Ryan Bailey: Oh, yeah.
Gianluca Bini: right? Like 15, it's rare, right? Like usually, unless there is, you know, if you have like pneumothorax or if you have chylothorax or anything that's like co occupying space in there, sure.
Gianluca Bini: But even in older patients, like you rarely hit 15, right? Like,
Ryan Bailey: Yeah, for sure.
Annatasha: Don't forget I'm doing, I do horses. So that, that comes into my conversation.
Gianluca Bini: yeah, sure, sure. Of course, of course, a large animal, different beast, literally.
Annatasha: Yeah, yeah, yeah.
Ryan Bailey: Right.
Annatasha: and
Annatasha: We are such dorks.
Ryan Bailey: Okay.
Gianluca Bini: So, okay.
Gianluca Bini: So, yeah, you you would back down your ventilation, of course, and then you go up in your respirator, right?
Ryan Bailey: right
Gianluca Bini: And so, and and now I have a question for you. So, At what point do you think that increasing the respiration becomes inefficient?
Ryan Bailey: I mean, like,
Gianluca Bini: Because over a certain number of breaths per minute, it becomes inefficient, right? Like it becomes too short.
Ryan Bailey: yeah. Oh, yeah. I mean, for me, well, I guess...
Gianluca Bini: Do you have a number?
Ryan Bailey: Generally. Yeah. And, and I think it probably varies ventilator to ventilator. So like on the Hallowells, like the, the Hallowells that everyone has, i don't know. I think it's 20 to 25. Like, I don't think you are, I mean, it, to me, it's also the closer you get to one to one IE ratio.
Ryan Bailey: So the closer you are one to one, I find in the veterinary species, you're not giving enough times to fill the lungs and you're not,
Ryan Bailey: getting good like good sampling of your alveoli and good you know accurate representation of co2 and then you're making bad decisions and you're chasing your tail it's a whole thing but i find the halo well for me it's like 20 to 25 is where it gets real cagey
Gianluca Bini: One of my mentors said but above 16 in dogs.
Ryan Bailey: interesting yeah
Gianluca Bini: I couldn't find a reference for it anywhere. but a lot of this stuff, there is no reference, right? Like this is stuff that's been passed down, you know?
Ryan Bailey: Yeah.
Gianluca Bini: And so I don't know.
Ryan Bailey: I always think it's like 30 because at 30, you're about one-to-one IE ratio because 30 breaths per minute, you have to spend one time inhaling, one time exhaling.
Gianluca Bini: Right.
Ryan Bailey: So the closer you get there.
Gianluca Bini: Right. But 15, it's one to two.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: So 16, it's kind of there.
Ryan Bailey: Maybe that's why. yeah Maybe that was the rationale.
Gianluca Bini: It's kind of there.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah. I don't know. I mean, do you do you know about any of this, Tasha? Do you have a number in your...
Annatasha: I don't have a number. no
Ryan Bailey: I mean, I'm always on the low rate, right? I'm always dialing it back. You know, if the, we started 20 to 25, I'm always, which is such a funny thing. I've got another point about that, but it's such a funny thing.
Ryan Bailey: You know, if we started 20, 25 and the patient's not, you know, getting capture or whatever, I usually tend to back them down rate wise pretty quick and try and up their volume.
Ryan Bailey: I don't overventilate or I go really aggressive and I dial up their volume really aggressively and try and get it. drop their co2 in a matter of minutes and then get them converted but one thing i was we i have heard taught and i've said it myself is like when you're dealing with an exotic species and you have never ventilated them before and you want to start them on the ventilator what is a good approach to that i know
Annatasha: Like anyone knows the answer to that.
Ryan Bailey: I know. And one thing that kind of always gets talked about is like, well, take their resting respiratory rate when they're hanging out on your physical exam and use that as your starting parameter.
Ryan Bailey: You're never going to start.
Annatasha: sleep parameters, right? Like there's sleep parameters.
Ryan Bailey: and I mean, yeah, that's a good point. and You would never get one to sleep because they're not to
Annatasha: If, if they sleep, like, I mean, if it's, like, if it's a shark, I don't know.
Ryan Bailey: Yeah. Let's not talk about fish. but like, like weakness. but like you would never ventilate a dog at like 32 breaths per minute. That would bonkers.
Ryan Bailey: The ventilator would probably just like jump off the
Annatasha: And I think you would kill a reptile doing that. Like, I just, i like, yeah, I i mean, i don't have a great answer for this.
Ryan Bailey: but
Annatasha: All I can do is conjecture based on, like, my loosey-goosey physiology for the exotic groupings or the geni. But, yeah, I mean, I think it's better to start more conservatively and then respond accordingly. But, I mean, have no idea. I mean, fuck, I'm
Ryan Bailey: and Anyway, that was... yeah
Annatasha: Half of them, like some of them don't have diaphragms and some of them have half a diaphragm. And I'm like, I don't know. You know, and they oxygenate at expiration and inspiration or they have hypoxic drives.
Gianluca Bini: so
Annatasha: And it's just like, I don't really think that there's probably more than a handful of people in the world who really know what they're doing in this.
Ryan Bailey: That's true. That's very true.
Gianluca Bini: That's true.
Annatasha: Yeah. Like maybe not to talk it, but like but other than that, it's pretty much guesswork.
Gianluca Bini: So...
Annatasha: Like I once had to ventilate a budgie. And, you know, that was wild.
Gianluca Bini: Oh, my God.
Ryan Bailey: Couldn't you just like that?
Annatasha: yeah little like My tiny little bellies, my tiny little circle circuit.
Ryan Bailey: I
Annatasha: It was quite cute, actually. i felt like I Barbie anesthesia.
Gianluca Bini: So...
Annatasha: But, yeah, I mean, that was a that was like beep, beep, beep, beep. Like it was fast respirate. But.
Ryan Bailey: bet.
Gianluca Bini: Okay, so I have another question for you. This is probably a little bit more advanced, but so then,
Annatasha: really than making up exotics?
Ryan Bailey: Do you think we can handle on it?
Gianluca Bini: I don't know. But so, you know, let's say you have a patient with pulmonary hypertension, right?
Annatasha: Yes.
Gianluca Bini: What are your, okay, don't get too excited, guys. The fuck?
Annatasha: Pulmonary hypertension is not my favorite thing to anesthetize.
Gianluca Bini: It's nobody's favorite thing to anesthetize.
Annatasha: Oh, good. I thought it was just the cheese stands alone, but I'm glad everyone else hates it too. So that's
Gianluca Bini: no Nobody likes it. And those are usually the patients that do die.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: Right? so what are your goals? What do you do?
Ryan Bailey: Drop their CO2.
Gianluca Bini: Okay.
Ryan Bailey: Actionate them.
Gianluca Bini: But how do you do that? Like, do you... Okay.
Ryan Bailey: Carefully. Excellent
Annatasha: This is like having a conversation with my dad.
Ryan Bailey: question. Thank you so much.
Annatasha: Like it's super annoying.
Gianluca Bini: Okay. So, but how do you do it? Like, do you, do you have a specific ventilation modality that you prefer? do you target like, you know, high respirate, low volume? What do you, what what what do you do, Ryan?
Gianluca Bini: Yeah.
Ryan Bailey: I
Annatasha: Yeah, Ryan, what do you do?
Ryan Bailey: yeah yeah right
Gianluca Bini: What do you do?
Annatasha: Yeah, let's go hot dog guy.
Ryan Bailey: but feel that, and some people back me up on some other people I've discussed pulmonary hypertension with, because when you look up veterinary pulmonary hypertension, it's like yeah big old goose egg for the amount of literature we have on management of anesthetized patients with pulmonary hypertension.
Annatasha: I think I have like maybe three overviews in my cache.
Ryan Bailey: Yeah, yeah it's it's just not a topic we write about a lot. And I think it's in part because a lot of our patients have pH and they do fine and I don't know why. And then you have that one that like you anesthetize and immediately become cyanotic and dies.
Ryan Bailey: And you're just like, uh...
Annatasha: Maybe we should ask cardiology how to do the anesthesia.
Ryan Bailey: It happened to me, and I had to use a... I had to get a bucket of water and stick the hose in there to create peat because I didn't have a peat valve where I was working at the time, and I saved that dog's life. Thanks, Dr. Brosnan, for teaching me how to make a peat valve with a bucket and water.
Ryan Bailey: Because that's what it is.
Ryan Bailey: Yeah, it was kind of crazy. So...
Ryan Bailey: so
Annatasha: I mean, my i mean mike my goal with marked pulmonary, like you said, I think most of them, like mild or undetected or whatever, are probably going to rock it quite well. But I try to be very simple when I do these cases and not make my life harder by trying to be cool or fancy or rebellious.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Annatasha: And, you know, in my head, the golden rule is don't let the PVR increase anymore and don't let the SVR drop anymore.
Ryan Bailey: Yep.
Annatasha: And then my differentials for those are the usual things that kill you under anesthesia anyway, right? Like hypercapnia, acidemia, hypoxemia, right?
Ryan Bailey: Yep.
Annatasha: So, you know, I'm trying to use pretty straightforward enough.
Gianluca Bini: do you know Do you send your patients on with sildenafil?
Annatasha: Yeah.
Gianluca Bini: If you know, you know, you have an angle that tells you, hey, you know, there is pH severe, moderate to severe, what would you do? Do you suggest a few days of sildenafil beforehand?
Annatasha: Yeah, usually if I can get it on board beforehand.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Annatasha: I will actually. Do I send them home per se, like assuming that they live?
Annatasha: like really think I can't really think of an instance where i specifically have done that.
Gianluca Bini: Okay. Oh.
Ryan Bailey: I guess, so to the to your ventilation question, i think this is a case where the little bit fancier modes are really going to help you. So I feel like this is a patient where if they come in, they have pH, we get them anesthetized, either c o two is really high or they're hypoxemic at induction, but they still have a respiratory drive.
Annatasha: Thank you.
Ryan Bailey: This is one where I would probably try like a PSV to start. because you're gonna you're gonna follow the patience pattern. and so you're gonna synchronize a little bit more nicely that would That would be what I would personally try in these guys to – like if if, for instance, I was had the nice ventilator I do now and I had PSV on it and I was anesthetizing this dog that became cyanotic immediately after induction even though I used like a fairly reasonable induction plan and I couldn't get him out of cyanosis without super aggressive ventilation strategies.
Ryan Bailey: I feel like this is one where I would love to have some PSV and been able to kind of dial in the pressure settings to kind of help as the dog breathes, like we're helping him a little bit more with every breath.
Gianluca Bini: Oh yeah.
Ryan Bailey: So I think that's, that's probably what I would try initial. Yeah.
Annatasha: Yeah, I mean, i mean i don't disagree.
Ryan Bailey: Yeah.
Annatasha: And I also think too, like I tend to be more conservative with it because, you know, peeps going to make it worse to the right side of the heart and high tidal volumes and high plateau pressures, like all of that's going to hammer the right side of the heart.
Ryan Bailey: yeah
Gianluca Bini: oh yeah
Annatasha: And that's really what kills you, right? Is if you go into suicidal right ventricle mode. So again, this is one of those things where I'm like, I start conservatively and see how the patient responds and I try to keep my parameters within normal limits and, you know, rub my lucky rabbit's foot and hope for the best.
Gianluca Bini: So,
Ryan Bailey: How about you, Beanie? What are you doing? Do you have a favorite strategy for these?
Gianluca Bini: yeah, no, I think, I think it's, you know, a combination of what you guys mentioned. I think, you know, they, definitely being aggressive for the beginning, it's probably not great.
Gianluca Bini: at some point you need to sometimes, right? Like depends on the patient. you know, I wish we had some of the you know tools that they have in humans, right?
Gianluca Bini: Like to vasodilate a little bit, like nitric oxide.
Ryan Bailey: and was going to ask you to about the inhaled basal dilators. Yeah.
Gianluca Bini: Yeah, the nitric oxide stuff, that would be nice, but like, you know, we could do that.
Annatasha: Well, we have beta blockers, right? Like I do my intratracheal sylbutanol puffing.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: Yeah.
Annatasha: I'll do that. But yeah, I don't obviously have nitric oxide.
Gianluca Bini: Yeah, that would be nice.
Annatasha: Make them a little septic. It'll kick up the nitric oxide levels.
Annatasha: Woo! Do not listen to me, anybody.
Gianluca Bini: No,
Annatasha: Again, disclaimer, do not take my advice. Yeah.
Gianluca Bini: no, I agree.
Ryan Bailey: Yeah.
Gianluca Bini: agree with you. Like, I mean, it would be nice. It's just that the the cost, it's cost prohibitive.
Ryan Bailey: Yeah. Ooh.
Gianluca Bini: You know, that's, yeah. Do you have a specific inalien that you like with those, you know, with the whole idea about, you know, epoxy pulmonary vasoconstriction and hollyalens how inalien, how inalien is like affected, right?
Gianluca Bini: Like, versus like, so,
Ryan Bailey: How
Annatasha: I try to keep these guys off the inhalants, actually.
Ryan Bailey: about no inhalants? Yeah.
Gianluca Bini: Yeah.
Annatasha: Right? Because you either have to have like such a low percentage of one of them to avoid hypoxic pulmonary vasoconstriction, but then you're also going to get dose-dependent hypotension. So I'm mean doing exactly what you don't want to do. So I run those on Teva.
Annatasha: Oh, there's brownie.
Gianluca Bini: Yeah.
Annatasha: Yeah.
Gianluca Bini: Do you do Proboful or a fax event?
Annatasha: Does it matter?
Ryan Bailey: but
Gianluca Bini: doesn Well, I mean, there was a recent post on the Navas Facebook page
Gianluca Bini: that made some pretty, don't know, like audacious stuff.
Annatasha: Made a lot of people clench, although just as a casual reminder, it was just an infographic and data can be interpreted subjectively even at the best of times. And it, it did not in any way give a people any sort of preferred option. I mean, you know what I mean? But, yeah, no, propofol or alfaxilone, I mean, it a cat or a dog?
Annatasha: how long are we going to be under? Those are probably more my considerations than necessarily what I think, is going to happen either, you know, with HPV or with cardiovascular, what have you, that's probably more of what I'm considering.
Gianluca Bini: right No,
Annatasha: Like, how long are we going to be down and what's my recovery going to be like? and that kind of stuff, the more practical components.
Ryan Bailey: Yeah. And the size of the patient, right? Like if you're with a big dog, you're probably just going use Probofol because...
Annatasha: Yep.
Ryan Bailey: it's easier to get a lot more of it than it is to get a lot more alfaxilin.
Gianluca Bini: hard.
Ryan Bailey: Like you buy a 100 mil vial of propofol and that can last you all day in the case versus 10 vials of alfaxilin.
Gianluca Bini: yeah
Annatasha: Oh, you can get those like 500 mils or like liter bottles of propofol that they use in human medicine, right? They just spike them like a bag and they run them when they do like burn Teva and then, cause they always run burn victims on Teva, right?
Gianluca Bini: Love that. Yeah.
Annatasha: And they, and they do actually use propofol in those cases, which is like maybe a good point, right? Like why are the, we should ask Mika, the human anesthesiologist at our next talk, like why is, you know, propofol,
Annatasha: Teva, I mean, I understand obviously the lungs have been burned and what have you, but, you know, like why aren't you doing fentanyl ketamine or why aren't you doing key to fall or that kind of stuff?
Ryan Bailey: I'm
Annatasha: so I think that might be a cool question for her, like, you know, smoke inhalation and burn victims.
Gianluca Bini: yeah
Annatasha: And, but yeah, you can actually just get like a huge, it looks like a high bottle of hypertonic saline, except it's purple fall and you spike it.
Gianluca Bini: no
Annatasha: Yeah.
Ryan Bailey: not seeing one that big.
Gianluca Bini: Nice.
Annatasha: Yeah.
Ryan Bailey: Like one day. Okay.
Annatasha: day
Gianluca Bini: One day.
Ryan Bailey: One of my favorite ventilation topics.
Gianluca Bini: Okay.
Ryan Bailey: Handbag.
Annatasha: Wait, what our are ours or you're about to broach yours?
Ryan Bailey: I'm about to broach one of my least favorite topics in the entire ventilation world.
Annatasha: wow
Ryan Bailey: and it's it's about handbagging.
Annatasha: Oh, I totally thought you were going to say it spirometry.
Ryan Bailey: No.
Gianluca Bini: Thank
Ryan Bailey: I love swarming. think it's great. I'm just not... I don't do it every day now, so I'm not as good at it. So I can't...
Annatasha: assisted ventilation using the reservoir or re-breathing back.
Ryan Bailey: Yes.
Annatasha: or an Ambu bag,
Ryan Bailey: Yeah. I hate it. I think it is dog shit. And I think it is and incredibly, when we have machines that do the job literally infinitesimally better than us, I think it is detrimental to be used regularly.
Annatasha: So you're saying like, you're saying like bagging the patient, not just once or twice.
Ryan Bailey: ye Nope.
Annatasha: You mean like bagging the patient in lieu of putting it on a ventilator.
Ryan Bailey: Yep.
Gianluca Bini: okay
Annatasha: Why would you do that? Do I look like I want to get some sort of weird wrist cramp? Like, no.
Ryan Bailey: I mean, I i know people who have, you know, said you need to know how to do this and be and do this and this is the way we're going to do this.
Ryan Bailey: Yeah. And i think you end up, it's, it never, in my hands, I can never get CO2 where I want it. I can never get a good waveform.
Ryan Bailey: It's all like, and I, trust me, I try a lot of different ways. You tend to just overventilate them so rapidly. Their CO2 just like falls, like just stone to the earth.
Gianluca Bini: Thank you.
Annatasha: Well, it begs the question, actually, like if you are going to hand ventilate or what have you, I mean, Carrie Craig at Davis, actually, I remember i was listening to her round once with the students and she actually said like, how much do you need to ventilate?
Ryan Bailey: Yeah.
Annatasha: How do you make that decision? Right. And like one of the students to think like, you know, is there a set number of times per minute or are you being driven by SpO2? Are you being driven by ETCO2?
Annatasha: But yeah, I mean, I can understand because there might not be places where you have access to a ventilator. So that could be
Ryan Bailey: I understand that situation.
Annatasha: Yeah. And like, or if you were to do, for example, like field anesthesia in a traumatic war zone where they everything is portable in hand, I get that.
Ryan Bailey: Yes. first
Ryan Bailey: i yeah
Annatasha: But if I have access to a ventilator, why, you know, the only, you know, here's a scenario where I would do that, where I want to feel the compliance of the chest myself.
Ryan Bailey: Okay, sure. We're talking like continuous, like 10 minutes, 20 minutes, hour.
Gianluca Bini: Thank you.
Ryan Bailey: Yeah.
Annatasha: If you have like a tension pneumothorax or you think you have a tension pneumothorax, I usually give them like a breath because I will probably have bagged them at the start for like your endotracheal tube leak check thing.
Annatasha: And I can tell you off that one or two bags that I give them whether or not they have the actual tension pneumothorax.
Ryan Bailey: yeah
Annatasha: So that's probably the only time or like if if I want to really have primary control over ventilation because you're in a crisis and you can't,
Ryan Bailey: Right.
Annatasha: up and down with the ventilator. So you end up going back and forth.
Ryan Bailey: Yeah.
Annatasha: and you know So maybe I only breathe once a minute. Maybe I want to breathe twice a minute. It gives me more flexibility in that way. But like for routine, big youre like I don't understand why anyone would do that.
Ryan Bailey: Right.
Ryan Bailey: Okay.
Gianluca Bini: No, that makes that makes sense.
Annatasha: Beanie?
Gianluca Bini: oh I don't think anybody, if you have a ventilator, you
Annatasha: The cat's done.
Gianluca Bini: have a ventilator, use the ventilator, right? But I mean, there is clinics out there that do not have a ventilator.
Ryan Bailey: Yeah.
Gianluca Bini: And sometimes, you know, they have cases where they do need to handbag. And at that point, that's what you do. But if you do have a ventilator, you know probably you should ventilate with it.
Ryan Bailey: i
Ryan Bailey: feel like I come from the, like, you have that patient. The the ones i experience it with a lot, other than where, like, it's a teaching thing. Like, oh, if you've got a ventilator, like, you've always got a ventilator with you. And they, like, hold their hands up. It's like, yeah, I get it. But, like, it sucks. And it's, like, the worst one. Like, it's worse than a Hallowell, which is saying a lot.
Ryan Bailey: But, like... But, like, you've got those patients, you try to get them on the ventilator, and they won't synchronize. And you're like, I'm going to do it by hand. And, like, some of those guys, you can kind of, like, create a system where you're ventilating them by hand, and you can, like, get their – and, like, I don't know if it's the way you drive the breath because – The Hallowell only drives the breath one way versus like the newer machines. You could have variable ways that the flow goes in. So you can try different ventilation strategies. You know, you can like slam the bag real fast. You can like slow push and hold. Yeah, I don't know. I hate handbagging. It's my nightmare and it's never fun for me.
Annatasha: Maybe your hands are just all like clawed up from all the hot dogs and that's what
Ryan Bailey: it it's Yeah, it's probably something with all the sodium that is in the hot dogs. I'm just like, yeah, it's hard because I'm always like just punching at the back like this.
Gianluca Bini: Maybe you're just stuck with it, Ryan.
Ryan Bailey: I mean, I can't. That's also what I wanted to see. Are you getting like great waveform traces and like the CO2 stays exactly where you want to when you breathe for that? Yeah, exactly.
Gianluca Bini: no Okay.
Ryan Bailey: Yeah. I mean, i also once had to handbag a cow. That was a nightmare.
Annatasha: Oh, no. I've actually had to do that, too, in a cow specifically. And it's basically like, you've got two minutes before I'm, like, fatigued and we're, like, we're done here.
Ryan Bailey: yeah
Annatasha: Like, that's crazy.
Ryan Bailey: It's like a whole body. You're like...
Annatasha: No. Like, you cling on to it like you're climbing, like, a coconut, like a palm tree.
Ryan Bailey: The
Annatasha: Like, you're just, you know, and it's just no.
Ryan Bailey: Okay.
Gianluca Bini: You guys are nuts.
Annatasha: Okay.
Ryan Bailey: Okay. Where... So, hypercapnia. Everyone loves it. Everyone loves the permissive hypercapnia stuff. Where... So in and the average healthy patient where you've chosen to ventilate them, where are you starting for permissive hypercapnia?
Ryan Bailey: How high? And what patients are you actually going to be like targeting that permissive hypercapnia? Okay.
Gianluca Bini: 55 is my limit 60 if it's you know occasionally depends on the patient
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: oh I don't use permissive epichapnea just as a mean of, you know, yeah, sure, it benefits with your sympathetic tone and it increases potentially little bit your vasoconstriction and it gives, well, not really, like whatever.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: It increases your blood pressure a little bit.
Ryan Bailey: yeah yeah
Gianluca Bini: But also it doesn't decrease your preload. Right? Like, you know, that's the other deal. Like, I don't want to be ventilating something and then i take away the sympathetic tone simulation, but also I'm reducing the preload a little bit, right?
Gianluca Bini: Because every time you breathe with positive pressure, unfortunately you do squeeze the vena cave a little bit, right?
Ryan Bailey: Yeah.
Gianluca Bini: And so like, I think it's more like, it's not just, you know, permissive cappnea so that I get that sympathetic stone simulation, but also like, I don't really want to be, i don't want to be shooting myself on the foot.
Ryan Bailey: Right. Yeah.
Gianluca Bini: So, and the other side of thing is also, you know, sometimes less is more.
Ryan Bailey: Yeah.
Gianluca Bini: Right. So,
Annatasha: I don't disagree. I mean, assuming like otherwise healthy, like I don't really get that worked up till around 55, 60, especially after induction where I'm trying to build CO2.
Ryan Bailey: Yeah.
Annatasha: So you take a breath.
Gianluca Bini: No.
Ryan Bailey: Right. Yeah.
Annatasha: i Do I treat vasodilation with permissive hypercapnia?
Ryan Bailey: Right.
Annatasha: No.
Ryan Bailey: Yeah.
Gianluca Bini: know
Annatasha: But I really don't start getting my knickers in a twist until I think you're going to start to drive pH down and affect myocardial contraction, which is somewhere in the 60s. Like I don't have an absolute cutoff per se, but if I have a blood gas to hand and I'm like, oh, you're 7.2 and, you know, then I'm going to be like, all right, like we should probably do something.
Ryan Bailey: Yeah.
Annatasha: But yeah, it's, it's, but yeah it's hard it's not hard and fast but like once you start sitting in the 60s on paco2 you know i'm probably gonna faff abound with a couple of things
Gianluca Bini: Yeah.
Ryan Bailey: All right, so speaking of increasing CO2, what is your kind of average strategy to wean your patients off the vent?
Gianluca Bini: Turn it off.
Gianluca Bini: Wait till it breathes.
Annatasha: Yeah, i mean if you if you've been down a long time and you're on like you're still metabolizing your way through high doses of respiratory depressants, so let's say you've been on fentanyl 20 for like eight hours,
Ryan Bailey: Wow. Wow, all right.
Ryan Bailey: Right. right
Gianluca Bini: Who the fuck keeps it at 20 for eight hours?
Annatasha: i
Annatasha: Okay, well, maybe that's a bad example. But anyway, but yeah, like I'm just saying like it depends on what drugs you're on and where we are with weaning that too. But, you know, sometimes I just turn it off and sometimes I slowly turn down like respirate per se and let them start to breathe. And once they were starting to breathe on their own appropriately, like I just turn it off because I don't like it when they breathe against the ventilator.
Ryan Bailey: Mm-hmm.
Annatasha: But yeah, I am... And sometimes you have those patients where you're just like, I mean, I had a patient just actually yesterday, Sunday, like healthy dog, foreign body, had it on Siva fluorine.
Annatasha: And that dog just didn't didn't read the medical textbook. It did take a hot minute to wake up. And I was like, what are you doing?
Ryan Bailey: and
Annatasha: like And I never had it on the ventilator for the whole procedure. And even though it was on Sivo, it just kind of kept sleeping on through. And I was like, chippy chop, like Tasha wants to go home. It's a Sunday.
Ryan Bailey: you Come on.
Annatasha: Yep, chippy chop. But yeah, sometimes like I just turn it off and sometimes I'll wean, rest down and see whether or not they can start to breathe on their own. Otherwise, you do that thing where like you turn it off and they're like apneic and they're not actually breathing off the inhaling.
Gianluca Bini: Thank you. here
Ryan Bailey: right. Yeah.
Annatasha: And then you flip it back on, you know, and'll be and then you do that like on and off for a while. And so if the patient's be responding like that, then I tend to set a lower rate. and keep them so because i you know i'm doing other stuff like you know i'm disconnecting them and i want to move them and we're cleaning the incisional say and pulling the art line and all that kind of stuff so
Ryan Bailey: Yeah.
Ryan Bailey: Right.
Gianluca Bini: So here is my thought, right? So otherwise, I'll be patient, right? You have a pulse ox that tells you whether your patient hemoglobin is saturated or not, right?
Annatasha: yep
Ryan Bailey: Right. Yeah.
Gianluca Bini: We do know that the respiratory drive, the main drive CO2, right?
Ryan Bailey: Yes.
Gianluca Bini: There are other things as well, you know, when you become severely epoxic, blah, blah, blah, that, you know, affects it too.
Ryan Bailey: All right.
Gianluca Bini: But the main thing is CO2.
Ryan Bailey: Yeah.
Gianluca Bini: So, and if you breathe for them, they will the CO2 will never accumulate enough to start triggering their brainstem, right?
Ryan Bailey: Right.
Gianluca Bini: And so and that's so so that's what I do.
Ryan Bailey: For sure.
Gianluca Bini: i could just turn it off, wait for that CO2 to build up. I look at the pulse ox. If the pulse ox is fine, I don't give a breath.
Annatasha: Thank you.
Gianluca Bini: If I do need to give a breath, I will. But like, it doesn't matter.
Ryan Bailey: So I guess.
Gianluca Bini: and And most people are like, yeah, give a breath a minute. And then you look at the clock. A minute is a terribly long time. Like, you know, nobody actually does wait a minute.
Ryan Bailey: Oh, I know. I know.
Gianluca Bini: you know?
Ryan Bailey: It's great. And for people to wait a minute with the patient apneic, have like slap their hands at least five times.
Gianluca Bini: Oh, yeah. And...
Ryan Bailey: They'll be like, oh, I'm like, no, leave alone.
Gianluca Bini: Now, the only exception I have is patients with potential endocrinial disease. And those I do go in CMV. I use CMV in those patients.
Gianluca Bini: And actually, you know, the practices they use are services when, and they do brain patients at times. I'm like, you need to have a machine with CMV because that's, to me, one of the best ways to wear win them off, right?
Ryan Bailey: Yeah.
Gianluca Bini: Everything else, it doesn't matter. And the only reason why it matters in these intracranial patients is because, you know, if you have too high of a rise in CO2, that's going to base with a later brain capillaries and increase intracranial pressure and kill them.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: And I've seen most of the the patients that I've seen dying with intracranial disease are always in recovery.
Ryan Bailey: yeah
Ryan Bailey: Oh, for sure.
Gianluca Bini: Always. 100%.
Ryan Bailey: Yeah, so that's, I guess, what I was... That's part of what I was getting at It's interesting that you're both in the cold turkey strategy versus the, like... I tend to go for the no more inhalant, continue ventilation, drive out all the CO2, drive out all the inhalant as fast as I possibly can, and then try and cold turkey them there.
Gianluca Bini: oh
Ryan Bailey: I don't have a good way to describe it other than I call it the fast way. And that's what I use for most of my patients. As long as I'm not doing, you know, if they're not being transported from one place to another, like we're just done with the case, I usually just crack off the inhalant, let the ventilator keep firing, get that ISO down as low as I can possibly go.
Gianluca Bini: Thank you.
Ryan Bailey: Usually 0.3 is the magic number. And then I'll, you know, turn the ventilator off and see if the patient has decided to breathe breathe or if they've hopefully like bucked the vent one time during that cycle i've usually turned it off by then which i guess is like is that good or bad i don't know bucking the vent they do it all the time you know when you at least get them started you have to fight them a little bit so it's not the end of the world but like yeah there is that one drawback to that and then
Annatasha: Thank you.
Ryan Bailey: The other question I had is when are you weaning your patients?
Gianluca Bini: They're done.
Ryan Bailey: Like where are those specific patients? So intracranial pressure patients, I totally agree. I'm going to wean them. because like that's where the disaster happens is you let their co2 spike up and their brain herniates because i also like to i don't know if it's like weaning per se but i do like to do a little double check in any of the like cervical lesion patients just to make sure that they're able to maintain a semi-normal co2 before we go to wake them up not like
Gianluca Bini: that
Ryan Bailey: it's It's not like we wean them so much as like I make sure that when they do breathe that it's like a normal breath on the waveform and that the CO2 fits with like a normal size breath for that patient.
Ryan Bailey: And then the patients where I've used paralytics, I like to obviously make sure the patients are breathing. Yeah.
Gianluca Bini: Yeah.
Ryan Bailey: where they're, you know, again, they're not being weaned per se. i don't know where we, i think the true, the only real weaning cases are those ICP cases, like you said.
Annatasha: Thank you.
Ryan Bailey: but those are the only ones I could think of where I'm going to like specifically target a different way to get them out off the ventilator. Yeah.
Gianluca Bini: And I tend to reverse some of those patients too. Like, you know, the intracranial patients, I try to like, I'm more proactive in reversing opioids, reverse like, you know, or at least trying to minimize the respiratory side effects from them, right?
Ryan Bailey: Yeah.
Gianluca Bini: I have this feeling that TNL and the doses we give
Ryan Bailey: Yes.
Gianluca Bini: unless you overdose them, they're not super respiratory depressant or compared to the rest of the drugs we have. Right?
Ryan Bailey: OK.
Gianluca Bini: Like I think that opioids do a way worse job at it. I think of course, probably for a vaccine, they do a way worse job at it.
Ryan Bailey: Yeah.
Ryan Bailey: yeah
Gianluca Bini: don't know. I don't think they're the worst drugs that we have out there for respiratory depression. I think they're... That's why they called Turkey probably from me and Tasha. You know, that's that's where that comes from.
Gianluca Bini: Like, I don't think that the Nielans, that's the huge role there. Yeah.
Ryan Bailey: Yeah. Makes sense.
Gianluca Bini: Yeah.
Ryan Bailey: I just kind of wanted to know. How about you, Bartell? When are you weaning your patients?
Annatasha: when I remember.
Gianluca Bini: Thank you.
Annatasha: I mean, i mean, I don't run a lot of primary cases. Right. So, and, and if I do have like multiple cases down, like I can't always be there at the moment where I think like, you know, closure is complete or whatever, you know, and it's a lot of texting back and forth or walkie talkies and, and, but you know, when am I weaning?
Ryan Bailey: Sure. Sure.
Annatasha: probably when I start turning down my CRIs, I start to wean everything collectively. So I step down everything to try and expedite recovery.
Ryan Bailey: Hmm. just
Annatasha: yeah, I, I'm pretty impatient actually about recovery because, uh, you know, i got to get the horses up. I got to get these subject patients like stabilizing. And also I got to turn over to the other case.
Annatasha: So like I got a 20 minute cutoff for anesthesia recovery before I'm starting to get like
Ryan Bailey: Right.
Annatasha: sing in my ethyl merman broadway voice and reverse drugs so yeah i i don't have a particular cutoff but i as soon as i start stepping everything else down i'm going to step the ventilation down with it too obviously unless they have some sort of other type of physiological compromise but
Ryan Bailey: Yeah. Right.
Annatasha: you yeah you also have that thing too where it's like there's so much like kerfuffle afterwards like you know
Ryan Bailey: How about
Annatasha: We need post-op rods.
Ryan Bailey: Oh, yeah.
Annatasha: Can you put an NG tube in? And does anyone want to do you, Kevin?
Ryan Bailey: Right.
Annatasha: You know, so and you're just like, how much longer is this?
Ryan Bailey: Yeah.
Annatasha: It's going to go on. That's also a factor sometimes so because sometimes I'm like wrapping it up and then they're like, oh, actually, you know what?
Ryan Bailey: Yeah.
Annatasha: Let's go back to CT. And you're like, go right? So anyway, that also happens very frequently.
Ryan Bailey: so in regards to those icp cases what is your ventilation strategy and approach are you like right off the bat by the book
Gianluca Bini: 28 to 35. twenty eight thirty five and direct
Annatasha: I tend to stay at the like the lower end of the end-tidal CO2 range. I know that there's really not a lot of evidence about prophylactic hypocapnia in terms of preventing herniation.
Gianluca Bini: Thank
Annatasha: It really is more of a reaction to... a herni herniation event per se. But my theory is, is that it's easier for me to jump you from 30 down to 20 than it is for me to jump you from 55 to 20.
Ryan Bailey: right
Annatasha: So I err on the side of the low end of of the end tidal CO2 for mechanical ventilation so that if I do have to intervene, I can do it more quickly and and without making wildly aberrant changes in pH, which I also don't think helps.
Ryan Bailey: Yeah.
Ryan Bailey: Right.
Annatasha: the cerebrum. So yeah, so my my strategy is I do tend to ventilate them from the get go.
Ryan Bailey: OK.
Ryan Bailey: Mm-hmm.
Annatasha: And I do tend to want to drive their PaCO2 to that lower end, because like I said, I could sit you at 20 the whole time. but It's actually not that great for your brain, because you know, around 18, you start to hit cerebral ischemia.
Ryan Bailey: Right, right.
Annatasha: So the goal is, is to optimize cerebral perfusion. And if they have an adverse reaction, then to intervene. But like I said,
Ryan Bailey: Yeah.
Annatasha: i and I drive at the lower end so that my intervention is is easier to achieve.
Gianluca Bini: yeah I usually do 28 to 35, something like that. the Depends where you read for cerebral experience. Some places say even 24. So
Ryan Bailey: yeah So are you Right off the bat, patient's down, get them on the vent, immediately drop their CO2.
Gianluca Bini: yeah. Yeah.
Gianluca Bini: Preset the vent, hook them up, flip the switch, be good.
Ryan Bailey: Are you getting a blood gas on these patients then? Routinely?
Gianluca Bini: You should.
Annatasha: Yes.
Ryan Bailey: yeah
Gianluca Bini: the answer is no, though, like practically no.
Ryan Bailey: just Bartell mentioned and just wanted to ask about it because it is, you know, there are obviously patients out there where the gradient is greater than five. And so that, you know, I just wondered what you're.
Gianluca Bini: of
Gianluca Bini: Although there is evidence where if you start ventilation from the get-go, you can minimize that gap.
Ryan Bailey: That's true.
Annatasha: Yeah. And I mean, all my MRIs have an art line anyway, because I don't have very useful oscillometric in the MRI. So if I have the art line and I think that you're going to be physiologically aberrant, I do take my blood gas sample as my baseline and see what's see what's up.
Gianluca Bini: yeah
Ryan Bailey: Yes. Yes.
Ryan Bailey: Yes.
Annatasha: like you know Especially if they do have like high intracranial pressure and then they're in that
Ryan Bailey: yeah
Annatasha: Like Cushing's triad, actually the first change is the change in breathing, and most people don't pick up on that clinically. And so might I anticipate that you're likely going to have weird PaO2 and PaCO2, and I want to know what's up before I start doing crazy ventilation things.
Ryan Bailey: yeah
Gianluca Bini: Yeah. Yeah.
Ryan Bailey: makes sense.
Gianluca Bini: Yeah, makes sense.
