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S1E4 - Tackling Hypertrophic Cardiomyopathy in Cats
155 Plays6 months ago
In this episode of Random Anesthesia Topic, we delve into the intricacies of hypertrophic cardiomyopathy (HCM), the most common feline heart disease. Our trio of veterinary anesthesiologists breaks down the challenges and considerations of managing anesthesia in cats with HCM. From understanding how this condition affects anesthetic management to navigating anesthesia protocols that keep our feline friends safe, we’re here to make a complex topic both enlightening and entertaining.
Whether you’re a vet professional fine-tuning your approach or a curious cat lover, tune in as we unravel the mysteries of this purr-sistently tricky heart condition.
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Transcript
00:00:01
Annatasha
Oh, there we go.
Introduction and New Year Wishes
00:00:03
Gianluca Bini
This is our new signature, like, kind of enter thing. everybody, to the Random Anesthesia but topic podcast. I guess, Happy New Year, right?
00:00:23
Annatasha
Happy 20th, everybody.
00:00:28
Gianluca Bini
Yay!
Guest Introductions
00:00:29
Annatasha
linkylinky
00:00:32
Gianluca Bini
I guess we should have popped a bottle of propofol or something, but anyway. So tonight we have Dr. Ryan Bailey from Premier Veterinary Group in Chicago, Dr. Natasha Burstell from King Animal Hospital in Ontario, and me, I'm Dr. Jeluka Bini from Oklahoma State University.
00:00:54
Annatasha
Clinky clinky.
00:00:55
Gianluca Bini
and I have my own consulting company, Safe Path Anesthesia. Tonight, I guess I'm the one that's supposed to actually choose the random topic.
Random Topics and Chicago Hot Dogs
00:01:05
Gianluca Bini
I hope, because I did pick one, but...
00:01:09
Annatasha
I mean, don't worry, I've got a lot of backups, so you're good.
00:01:13
Gianluca Bini
um I Probably this is not going to endogonize anybody, so I don't know if it's going to be as fun, but what...
00:01:21
Annatasha
Well, we can always bring up pizza on crackers again because, like,
00:01:25
Gianluca Bini
of 100% or the fucking hot dog. So here's the idea, right? So before, I was actually editing one of the, like, past episodes and I was like, holy cow. Like, my wife was looking at this Chicago hot dog kind of thing, right? And apparently, so you have two different kinds of pickles in it, right? Like you have the neon green pickle relish in it,
00:01:54
Gianluca Bini
And then you have whatever, yeah, that, that relish.
00:01:54
Ryan Bailey
That's a sweet relish.
00:01:57
Ryan Bailey
Yeah.
00:01:59
Gianluca Bini
And then you have this ginormous wedge of pickle in it, right?
00:02:02
Ryan Bailey
Yup, yup.
00:02:04
Gianluca Bini
So it's basically pickles and buns.
00:02:06
Ryan Bailey
Well, and then there's also pickled sport peppers on there.
00:02:10
Gianluca Bini
okay.
00:02:10
Ryan Bailey
So there are three kinds of pickles, each providing a different flavor.
00:02:13
Gianluca Bini
Okay, wow.
00:02:16
Annatasha
Wow, I really like the description pickles and buns because that's really taking this podcast down a whole other trajectory.
00:02:17
Gianluca Bini
But then you say that you,
00:02:28
Gianluca Bini
All right, so you have a very specific hot dog that you like, right? You say this is Vienna.
00:02:37
Ryan Bailey
Vienna beef that's like the the company actually I had I had a extern
00:02:40
Annatasha
What about the, makes it Viennese? Cause Viennese, and I've been to Vienna many times and lived there as a child. And I don't know anything about this Vienna beef situation, Bailey.
00:02:52
Ryan Bailey
They're, they're a Chicago based company. I wish I could tell you more about them. I've read about them, but like my memory is like, my brain is just completely blanking on history of the end of beef hot dogs.
00:03:02
Annatasha
Are you going to Andro pause?
00:03:07
Ryan Bailey
Most likely. Yes.
00:03:09
Gianluca Bini
hear me.
00:03:09
Annatasha
everything on parry
00:03:10
Ryan Bailey
Is that, is that why I have the receding hairline? Is that part of andro pause?
00:03:14
Annatasha
Yeah, probably. And, ah and you have a weird pet duck who is also on the podcast this evening.
00:03:18
Gianluca Bini
Right, right. What's that there?
00:03:20
Ryan Bailey
this is, this is Dr. Quack today. You can see the, you can see he's got his stethoscope. So he's ready to, you know, listen.
00:03:30
Annatasha
Oh, is he?
00:03:31
Gianluca Bini
by
00:03:31
Annatasha
I thought he was going to talk about anesthesia quackery.
00:03:35
Ryan Bailey
oh Hey, is this.
00:03:37
Annatasha
Sound effect.
00:03:43
Ryan Bailey
Is this some self-promotion there, Dr. Bartel?
00:03:45
Annatasha
I was like, okay. I was like, uh, Bini that joke wasn't funny enough for six drum rolls, but okay.
00:03:54
Gianluca Bini
yeah
00:03:54
Annatasha
Yeah, no I know. That was a good duck joke. But yeah, no, we've got hot dogs, corn sweat.
00:04:00
Ryan Bailey
but Yeah, I guess it's more of a boost.
00:04:00
Annatasha
Now we've got guests, ducks on the show. Technically, isn't that a goose, though? It's a duck? I'm a vet. Should I not know this?
00:04:08
Ryan Bailey
It is more of a goose, you're right.
00:04:10
Annatasha
I was like, hold on. I'm a vet, and I don't know the difference between a duck and a goose. Like, oh, god. Some bird association is probably going to write us a letter.
00:04:20
Ryan Bailey
God, I hope today's random topic is not about bird anesthesia.
00:04:23
Annatasha
I so hope it is.
00:04:24
Gianluca Bini
No, no, no.
00:04:26
Ryan Bailey
Please show the way the airflow moves through the bird.
00:04:31
Annatasha
During expiration. During expiration.
00:04:34
Ryan Bailey
That was for sure a board's question for me, and it was a multiple choice, and there were multiple ways the air was flowing between all the air sacs. I just was like, yes.
00:04:44
Annatasha
Be on with your life.
00:04:47
Gianluca Bini
I think I had a whole essay on avian respiratory system stuff something like that and it was
00:04:56
Annatasha
They love to get us on bird stuff because when you're anesthetizing a bird, I mean, and they're not doing well, I really start to deeply reflect on the pathway of airflow during our expiration to try and save their lives.
00:05:07
Ryan Bailey
Oh yeah.
00:05:08
Annatasha
I mean, if they're, and like, you know, if they're getting light or, you know, whatever, I can always deepen them on some maropitant or some shit.
00:05:16
Annatasha
MAC sparing.
00:05:17
Ryan Bailey
Oh my god. Ooh!
Anesthesia in Cats with HCM
00:05:20
Gianluca Bini
Now, I think that, so tonight's topic is kind of debatable, right? So how much thought, you know how we say that 50% of cats with HCM have HOCM okay? Now, you know, if you asked the average,
00:05:43
Gianluca Bini
student, or at least that's my experience when I ask my students.
00:05:47
Annatasha
Side note, why would I ask a student?
00:05:50
Gianluca Bini
Most of them have no idea what HOCM is. So how relevant do you think that is? Like you ever think about?
00:06:00
Gianluca Bini
Oh, okay, this could be one of those. Does it change your plan?
00:06:05
Annatasha
Nope.
00:06:05
Ryan Bailey
I think that's a really...
00:06:07
Gianluca Bini
That's it, the episode is done.
00:06:09
Annatasha
Yeah, ever since night, guys, happened in the air.
00:06:09
Gianluca Bini
Bye.
00:06:11
Annatasha
Nope, now moving on.
00:06:14
Ryan Bailey
That's...
00:06:14
Gianluca Bini
Thanks, Tasha, appreciate it.
00:06:17
Ryan Bailey
That's such a good question.
00:06:20
Annatasha
God brought at least gonna go down his crazy cat path right now Bini and thank God i'm not alcohol
00:06:20
Ryan Bailey
Honestly.
00:06:23
Ryan Bailey
There we go. Get ready. I'm gonna sweep this whole martini and then I'm gonna tell you all about cats.
00:06:27
Annatasha
like
00:06:31
Ryan Bailey
So listen up.
00:06:32
Annatasha
a
00:06:33
Ryan Bailey
But like, for everything we know about HCM in cats, we should, we, like us anesthetists aesthesiologists, should be seeing way more death under anesthesia because of their wildly uncontrolled sympathetic tone.
00:06:53
Annatasha
Oh, Jesus, the Lord Almighty.
00:06:54
Gianluca Bini
Right.
00:06:54
Ryan Bailey
and
00:06:55
Gianluca Bini
Oh,
00:06:56
Ryan Bailey
But everything says cat with HCM, they develop rapid tachycardia, likely to develop ischemic focus within the heart and essentially heart attack, death, you know, always the story of like the cats who die off the needle during their routine spays because they got Ketamine.
00:07:15
Ryan Bailey
That's why we avoid Ketamine. But like, why?
00:07:19
Annatasha
i By the way, for the listeners out there, for being here, Laura and Mara. But yeah, guys, the HCM is hypertrophic cardiomyopathy, and HOCM is hypertrophic obstructive cardiomyopathy.
00:07:28
Ryan Bailey
Oh, yes.
00:07:32
Gianluca Bini
you're saying that you have this sympathetic tone that should be really elevated in these cats. Do you think because
00:07:38
Ryan Bailey
but Just the cats have a wildly uncontrolled sympathetic tone that is like exacerbated based on some literature from Davis showing that
00:07:49
Annatasha
Oh, God. Time to drink.
00:07:52
Ryan Bailey
some of the opioids increase cat's sympathetic responsiveness under anesthesia. And and we, so we, the, like you've seen it. The cat is asleep. Surgeon does something. Heart rate spikes from a hundred to 200 down to a hundred up to 200 again. And like, it's a known HCM cat and you're just like,
00:08:17
Annatasha
the listeners, Ryan was just looking terrified, but crossing his fingers at the same time, which is real state of the art anesthesia over here.
00:08:26
Ryan Bailey
Yeah.
00:08:30
Ryan Bailey
I think it's a great use.
00:08:30
Annatasha
yeah
00:08:31
Gianluca Bini
I got this new sound effect, I really had to use it.
00:08:34
Annatasha
No, I like it. Yeah, it drowns out the sympathetic lecture.
00:08:37
Gianluca Bini
yeah
00:08:38
Annatasha
But yeah, no, continue, Ryan, continue. I want to hear where this is going.
00:08:42
Ryan Bailey
But like, why why aren't these cats?
00:08:48
Gianluca Bini
Sorry, I stopped, I stopped.
00:08:50
Ryan Bailey
You... You were like, this may not antagonize anyone and yet here we are, me on my high horse about cats and sympathetic responsiveness and how we are maybe negligent in our reaction to it because there's so little, there's one drug, there's one drug that works and it is constantly written as not to be administered to these HCM cats.
00:09:20
Annatasha
just would also like to put in this proviso that I am not admitting to any negligence and legal capacity while we're on this podcast.
00:09:27
Ryan Bailey
Yeah. Oh yeah. Yes. Like just as more as the profession writ large, like we don't, we don't have an answer for this. Like there there is no consensus answer.
00:09:39
Ryan Bailey
Cats are, cats are not dogs and they respond quite differently under anesthesia. And it's, it is.
00:09:45
Annatasha
So Ryan, what do you see then? Like if you have a cat under GA who either has known or hide like index of suspicion for hypertrophic cardiomyopathy obstructive or not, and you see like a rock and roll sympathetic response to variety of different nociceptive stimulation, what do you do?
00:09:48
Ryan Bailey
Mm-hmm.
00:10:01
Annatasha
You sweat it out?
00:10:03
Ryan Bailey
For the most part, I ride it out because I know it will calm down and I know that and minute most of the drugs in my arsenal are potentially going to be dangerous to this particular cat.
00:10:18
Annatasha
Give us an example for the listeners then, like what kind of drug would you be thinking of and elaborate on your sense of what dangerous would be?
00:10:26
Ryan Bailey
Well, most of our most of our natural reactions, given that us and small animal work so much with dogs, our natural reaction in sympathetic responsiveness is going to be to administer an opioid. It's it's not right or wrong. It blunts sympathetic responsiveness in dogs all the time.
00:10:50
Ryan Bailey
you know, if they don't have heart disease, you could use an alpha two as well. But the evidence suggests that the cats when it missed or the opioids are going to develop more, an exacerbated response to like an exacerbated sympathetic response.
00:11:08
Ryan Bailey
discusses.
00:11:09
Annatasha
Beanie?
00:11:10
Gianluca Bini
No, and that's fair, right? but so I want to go back to your comment about alpha 2, right? So why couldn't you administer an alpha 2 in cat with HCM?
00:11:17
Ryan Bailey
Yeah.
00:11:20
Annatasha
Because he went to Davis.
00:11:21
Ryan Bailey
I, no, that is, that is a cardiologist issue.
00:11:26
Gianluca Bini
Sorry, I was waiting for that.
00:11:30
Gianluca Bini
w
00:11:30
Ryan Bailey
Do we, do we want to get into this? Like seriously, because every, every, I'm trying to be tactful, but every report says, do not administer this, do not administer this, do not administer this.
00:11:32
Annatasha
Yeah, we do. I want to definitely get into this.
00:11:34
Gianluca Bini
100%, this was the sole purpose of that question.
00:11:46
Ryan Bailey
Like,
00:11:46
Gianluca Bini
Yeah, but fuck the report, right? That's bullshit.
00:11:48
Ryan Bailey
oh i Oh, I know.
00:11:49
Gianluca Bini
We didn't know that.
00:11:50
Ryan Bailey
i in Clinically, yes, fuck the report. I'm not going to just sit there and ignore it, but at the same time, by ignoring that report, there is a liability that you open yourself up to legally.
00:12:03
Gianluca Bini
Yeah. 100%. 100%.
00:12:07
Annatasha
I'm just going to go out on ah on a slight tangent, a related tangent, but this is definitely a hill I'm going to die on, is that I have virtually negligible interest in a cardiologist's opinion on how I should run anesthesia and let me tell you why.
00:12:20
Annatasha
Their job is not to make
00:12:21
Ryan Bailey
I.
00:12:22
Annatasha
and aesthetic recommendations. Their job, just like every other specialty, is to report to us on what the pathologies are and then we are to integrate that and interpret that and then make the most appropriate decisions. So first of all, I make all my cardiologists scrap that out of their section because they intentionally make me liable for things they know nothing about.
00:12:41
Annatasha
And they give these abject statements that really serve a purpose only in general practice. And as a board-certified anesthesiologist, they tie my hands. And half the time they're not appreciating the fact, and I'm going to say this again if I've not said it a thousand times, is what happens physiologically under anesthesia is not the same thing that happens in an awake patient. So if you just carte blanche right, don't use alpha-2s because it may have a heart condition because there's a focal area of thickening in the septum.
00:13:10
Annatasha
What the holy fuck? I mean, absolutely not. Am I listening to that? I will make them strike it. And if they don't strike it from the report, you should see the paragraph I write about how the cardiologist is overstepping their lane and intentionally like providing misinformation.
00:13:24
Annatasha
So that's how I feel about that.
00:13:26
Ryan Bailey
Yes.
00:13:26
Gianluca Bini
Yeah.
00:13:27
Annatasha
And you know what? The goose agrees with me.
00:13:30
Ryan Bailey
And I tell, I tell everyone I work with when they talk to me, like the cardiologist recommends and I was like, thank you. I will read what the cardiologist reported about the heart. I will look at their measurements.
00:13:41
Ryan Bailey
I will read the text about what they say that they saw, but I'm going to completely ignore their recommendations about anesthesia.
00:13:49
Annatasha
because at the end of the day, we would end up only being able to administer butorphenol and midazolam.
00:13:49
Ryan Bailey
I understand what they're for.
00:13:54
Annatasha
And you're like, this is, there's no nuance, there's no finesse, there's no profound understanding of how physiology is changed by the inhalants or by multimodal, pivotiva, whatever you wanna call that you're using that day.
00:13:54
Ryan Bailey
Yeah.
00:14:05
Ryan Bailey
Yeah.
00:14:07
Annatasha
And it's just ridiculous. Their job is not to tell us what we can and cannot use.
00:14:09
Ryan Bailey
Yes.
00:14:11
Annatasha
Their job is to report the heart disease, stabilize it as best they can and the rest, is the job of the anesthesiologist. I mean, can you imagine a human cardiologist telling a human anesthesiologist how to do their job?
00:14:23
Ryan Bailey
I mean, like, all the all the bypass graphs, they're all on fucking DexMed. They're all on DexMed Atominade as, like, Mag reducer, blood pressure support, like slow down the heart rate to prevent a fucking heart attack under anesthesia.
00:14:32
Annatasha
One of
00:14:34
Gianluca Bini
Yeah.
00:14:36
Annatasha
the preferred protocols for pulmonic stenosis ballooning is a dexametri.
00:14:41
Gianluca Bini
Absolutely.
00:14:42
Ryan Bailey
Yeah, yeah.
00:14:42
Annatasha
So,
00:14:42
Gianluca Bini
I published 2023, I think, by Manuel, right?
00:14:47
Gianluca Bini
He did a nice study on that.
00:14:49
Ryan Bailey
That's all up.
00:14:50
Annatasha
Oh, man. Well, shout out.
00:14:51
Gianluca Bini
No.
00:14:51
Annatasha
he He won't listen to our podcast, but
00:14:52
Ryan Bailey
Yeah.
00:14:55
Gianluca Bini
So. Yeah, I mean, I use it too. And I think it's great. I use it for some PDAs as well, actually works pretty well, I think.
00:15:07
Gianluca Bini
You know, people are afraid of Dexmed. But in reality, with the pathophysiology of HCM, under anesthesia, especially if you have HOCM, Dexmed is actually a really legit choice.
00:15:19
Annatasha
Of course it is.
00:15:19
Gianluca Bini
You know, I eventually
00:15:22
Gianluca Bini
and then really put them on DaxMed CRIs. Like, it works amazing.
00:15:25
Annatasha
Yeah.
00:15:26
Gianluca Bini
Now, I do agree with you that, you know, the liability part sucks, right? Like, you know, if the cardiologist put it in the report, it opens you up.
00:15:33
Annatasha
have them strike it from the report or put your own disclaimer in your own medical record saying that the cardiologist should not be making anesthetic recommendations.
00:15:37
Ryan Bailey
Yes.
00:15:41
Annatasha
And actually that makes them liable right in return. So you can get them back. They will, they will march to the beat if you know how to push their buttons. But I mean, that'd be the same thing. Like that'd be like, if I were doing, I don't know, like anesthesia for gut biopsies, the internist is in the room telling me what to do for anesthesia.
00:15:57
Annatasha
Like here's a, here's a news flash. If you can do it better than I can, I encourage you to do so and I'll go on lunch.
00:16:01
Ryan Bailey
Well, yeah. Ugh.
00:16:06
Annatasha
Liquid lunch.
00:16:11
Annatasha
But yeah, the the job of the other specialties, is just as a nutshell, is to report all of the abnormalities and to stabilize those diseases as best they can, given whatever relevant timeframe. But it is the job of the anesthesiologist to integrate that information and design an appropriate protocol.
00:16:27
Annatasha
I do not need to take anesthesia tips from somebody who has not anesthetized a patient in 12 fucking years, right?
00:16:33
Ryan Bailey
Oh, yeah.
00:16:34
Annatasha
Like, give me a break.
00:16:34
Ryan Bailey
if the yeah the The thing that brings up, though, is like, we all know we all sit here and we're like, in humans, a lot of humans with various different types of heart disease are being put on like, dexmedetomidine mean, CRIs of some variety in humans.
00:16:53
Ryan Bailey
And yes, humans are not cats, cats are not humans, et etc, etc, all of those caveats. But like, where I
00:17:01
Annatasha
sand bread but bla bla
00:17:04
Ryan Bailey
I feel like there's just a paucity of research in like Daxamatomium-based protocols for these kinds of, these kinds of cats, you know, like.
Editorial on Anesthetic Drug Bias
00:17:14
Annatasha
Well, that's because what Bini said, everyone has this inappropriate ah ah phobia or hesitancy towards certain classes of drugs, which sometimes is cultivated straight out of the academic institutions, or taken totally over the top by other specialists.
00:17:24
Ryan Bailey
Yeah.
00:17:26
Ryan Bailey
For sure.
00:17:27
Gianluca Bini
know
00:17:30
Annatasha
You know, like I never give more than 0.1 mg/kg methadone, and it's like, yeah okay.
00:17:30
Ryan Bailey
Yes.
00:17:33
Gianluca Bini
We did that to came from?
00:17:36
Annatasha
Yeah, like go back to sewing. But but yeah, but it's totally like, should not, there was a great editorial a few years ago that I read, I think it was the British Journal of Anesthesiology, and they basically said like it's totally inappropriate to have drugs that you like or you don't like like.
00:17:53
Annatasha
All drugs have advantages. All drugs have disadvantages. All drugs have uses. And at the same time, you could probably use almost every one of our drugs in almost every clinical scenario, and you would still
00:17:58
Gianluca Bini
Yeah.
00:18:04
Annatasha
Do well as long as you have the capacity to understand a the physiology and be the pharmacology And that's honestly exactly how I feel and how I practice like yeah, I have minor preferences You know, and then I actually have evidence about things that don't work but at the same time I'm totally like you can probably appropriately use most of those drugs and when we get these carte blanche like thou shalt not use dex medetomidine and cardiac compromised, you know what that is? it's lazy
00:18:28
Ryan Bailey
Mm hmm.
00:18:33
Annatasha
It's lazy and it's stupid.
00:18:34
Ryan Bailey
Yeah.
00:18:34
Gianluca Bini
Yeah.
00:18:35
Ryan Bailey
Yeah.
00:18:37
Gianluca Bini
yeah
00:18:37
Annatasha
And you're what you're doing is you're not benefiting a patient in a way that may actually increase not only survivability to recovery, but survivability to discharge. And that's nobody's business but ours.
00:18:46
Ryan Bailey
Sure.
00:18:46
Annatasha
so
00:18:47
Gianluca Bini
Yeah.
00:18:48
Ryan Bailey
Yeah.
00:18:48
Gianluca Bini
Yeah. Yeah.
00:18:49
Ryan Bailey
Yeah.
00:18:51
Annatasha
I'm just going to, I'm going to rock up to oncology and be like, do you think that ELCHOP protocol is the most appropriate protocol? maybe you should consider this protocol. Like, you know, I just, oh, like that one time that I once gave steroids to something with lymphoma, this is what happened.
00:18:52
Ryan Bailey
Oh God.
00:19:06
Annatasha
And therefore, you know, I almost was an oncologist. Like, you know how many times I've heard people say, oh, I thought I was going to do an anesthesia residency. And I'm like, you know what? It's funny because I did one board certified.
00:19:18
Ryan Bailey
Yeah.
00:19:20
Annatasha
Like, I'm like, please don't call yourself a soldier unless you've been to war. Like it really shapes my butter.
00:19:29
Gianluca Bini
okay okay Tonight we totally triggered you. this is so
00:19:32
Annatasha
Yeah, well done. We started with something really benign like HCM or HOCM.
00:19:35
Ryan Bailey
yeah
00:19:36
Annatasha
The original question being, do I really tease out the subtle difference between obstructive and less obstructive HCM? And I stand by my original answer, which is, nope.
00:19:45
Gianluca Bini
no yeah so i do that for all of them like i don't care i mean their heart is totally fine do like sustain that thing reason after love who cares you know in reality and they hold back
00:19:46
Ryan Bailey
Yep. I mean, yeah. And like, and I mean, everything, everything says Dexmed is like and all the physio, all the, the pathophysiology and everything we know, like,
00:19:49
Annatasha
Yeah.
00:20:09
Ryan Bailey
Hypertrophic cardiomyopathy and almost every single cardiomyopathy cats get falls into the kind the larger category of diastolic dysfunction. and Taking from the human side, diastolic dysfunction is always treated with normal to slightly increase vascular tone tone and normal to slightly low heart rate because we want to promote like slow heart rates, increase diastole, increase diastolic filling, increase perfusion to the myocardium. The slight increase in afterload is going to slow that heart rate down. It's going to help out. These are thick ass hearts. They can pump
00:20:51
Ryan Bailey
Like these these hearts can pump, you know what I mean? Like their fractional shortening is like 110, or like their fractional shortening injection fraction is like 110%.
00:20:55
Gianluca Bini
No.
00:21:01
Ryan Bailey
They're like, that chamber is nothing by the time that heart's done squeezing.
00:21:06
Annatasha
Yeah, that's a good point, Bail. I never thought about it, too. They actually have like more myocardium, potentially more potent contraction.
00:21:06
Gianluca Bini
Oh, yeah.
00:21:14
Ryan Bailey
Yeah.
00:21:15
Annatasha
In the face of a lower heart rate, they're still going to maintain appropriate cardiac output.
00:21:15
Ryan Bailey
the
00:21:15
Gianluca Bini
yeah
00:21:20
Ryan Bailey
Yeah, like every time I look at the Echo Report, if I see a low, like, fractional shortening EF, I'm like, ooh, this cat's heart is in trouble. Like, they should always be hyperdynamic. They should always be 80s, 90s, you know, like, fractional shortening ejection fraction because it, because that heart is so thick and that chamber size is so small, they should really be knocking it out of the park every, every beat.
00:21:46
Annatasha
I like that.
00:21:47
Ryan Bailey
Yep, yep.
00:21:47
Annatasha
I like that. Did you guys recently do that survey on whether or not you could visually assess fractional shortening?
00:21:50
Gianluca Bini
Now.
00:21:54
Ryan Bailey
I did not. I am, I am no, I am not a wizard with the probe. I have not done much ultrasound for like for heart stuff.
00:22:02
Annatasha
but You don't need to be a transesophageal probes pro to do the quiz ah ah slash by Manuel, who won't be listening.
00:22:02
Ryan Bailey
and like jana
00:22:11
Annatasha
But yeah, no, it's actually quite interesting because they do I mean, he gives you some extreme cases. And then actually, like from a baseline point of view would be a good jumping jump off point to be able to start to assess.
00:22:22
Annatasha
You know what? You know what? You know what, guys? I just had a fucking revelation after years of being told how to do anesthesia by cardiologists. I'm going to subspecialize in transesophageal echocardiology. And I'm going to start telling cardiologists how to do their job.
00:22:37
Ryan Bailey
So Actually, that was like a whole discussion during AVA this year, was cardiothoacic anesthesia and like cardiothoracic anesthesia.
00:22:48
Ryan Bailey
anesthesia is an emerging veterinary specialty, but it was also a talk from a human cardiothoracic anesthesiologist.
00:22:50
Gianluca Bini
Thank you.
00:22:51
Annatasha
Yeah.
00:22:55
Ryan Bailey
and A lot of his talk was about like how Initially, a lot of the cardiothoracic anesthesia people were learning transesophageal echo, and they were doing all the views and this and that, and then like that became its own thing of like the anesthesiologist working the like TE probe the whole time, and now it's like...
00:23:16
Annatasha
yeah in human medicine, you do a fellowship in it, and then that's basically your your shtick, right? like you
00:23:20
Ryan Bailey
Exactly, and now it's like moving back the other way, and like the anesthesiologists are doing other things now, and like
00:23:21
Annatasha
come in
00:23:28
Ryan Bailey
Yeah, it was a interesting, just interesting discussion to
00:23:32
Gianluca Bini
Do you use pitted olives for your martini?
00:23:34
Ryan Bailey
No,
00:23:38
Ryan Bailey
no I used, I like to eat the whole olive and I don't need to be, I'll be honest, I love a non-pitted olive.
00:23:42
Gianluca Bini
It's an all.
00:23:46
Ryan Bailey
These are a lovely Castlevitrano pitted.
00:23:51
Gianluca Bini
okay
00:23:53
Annatasha
what kind of martini are you having,
00:23:55
Annatasha
you having a true classic? Or it dirty? Or like what's happening over there?
00:23:59
Ryan Bailey
was a Martini from a company that started in Chicago. it's made in... I wish, man.
00:24:06
Annatasha
Are you on the board of Chicago tourism?
00:24:07
Gianluca Bini
Okay.
00:24:09
Annatasha
like
00:24:10
Gianluca Bini
He's very vague.
00:24:12
Ryan Bailey
I wish. But this is made with like a bar.
00:24:14
Annatasha
like yeah Like everything that you say, like pizza, martinis, all of those are Italian and like Beanie's just like biding his time over here on the left side of my screen and you're like Chicago, or Chicago.
00:24:21
Ryan Bailey
Yeah.
00:24:25
Ryan Bailey
This is a martini from a bar in Chicago. And they do, it's gin and vermouth, obviously, as a martini is.
00:24:32
Annatasha
Obviously.
00:24:33
Ryan Bailey
And that's got a little yuzu spritzer right over here. And then, yeah, it's pretty good. It's like a pre-made martina. Just keep in the freezer, pull it out, couple ounces.
00:24:45
Ryan Bailey
I mean, I can make my own, but, you know, this is no easy.
00:24:47
Annatasha
I like the Yuzu Spritzer. I mean, sometimes I just use one of those to freshen up at the clinic, so I smell nice and citrusy, but I guess it works in a martini too.
00:24:53
Ryan Bailey
Yeah.
00:24:56
Annatasha
It's not just for smelly vats.
00:24:58
Ryan Bailey
It's a bougie martini. It tastes really good. We won it at a silent auction.
00:25:02
Gianluca Bini
so
00:25:02
Annatasha
Interesting. Now, how would you feel if somebody said, if you, like, let's say you were a bartender, Bailey.
00:25:08
Ryan Bailey
Oh God.
00:25:09
Annatasha
And someone came up and said, Abhini, hold on to your pants here.
00:25:10
Ryan Bailey
I'd be terrible.
00:25:13
Annatasha
And like you came up to the bar and I came up to the bar and I said, I'll have a vodka martini. but just
00:25:22
Ryan Bailey
I mean, I wouldn't say anything because if that's what they want, I'm more than happy to serve them what they want.
00:25:27
Annatasha
Well, what do you think on the inside? What are you in the duck
00:25:32
Ryan Bailey
And well, and my wife loves a vodka martini 50 50 with.
00:25:41
Annatasha
you may have to edit this part of the podcast out being
00:25:43
Ryan Bailey
Yeah.
00:25:45
Ryan Bailey
see She loves a vodka martini. And I will say there's also, there used to be a bar in Chicago, I think it's closed. It's definitely closed because it used to be in our house, it was closed. they did a shaken vodka martini.
00:25:57
Ryan Bailey
And like, I have never drank a drink that tastes so cold in my entire life. And as a person who you know drinks ice, you can't see the ice in there, but there's like a ton of ice in this cup.
00:26:07
Annatasha
You may have to edit this part of the podcast out, Beanie.
00:26:11
Ryan Bailey
As people, as someone who drinks all their drinks ice cold, I was like, this drink is insane. It tastes like I'm drinking the coldest water alive. ah So yeah.
00:26:19
Gianluca Bini
So what's the deal with that's the corn sweat?
00:26:19
Annatasha
What's a corn sweat? By the way, do you have a second martini going? Like what's happening over here?
00:26:25
Ryan Bailey
Well, this is just water. This is just water and ice. And then this martini.
00:26:27
Annatasha
It's just corn sweat on ice. And that's your martini.
00:26:29
Ryan Bailey
This is done. And now I've got policy. Now I've got.
00:26:31
Annatasha
You should invent a cocktail called corn sweat.
00:26:36
Ryan Bailey
Not bad idea.
00:26:38
Annatasha
Right?
00:26:39
Ryan Bailey
More for summertime.
00:26:40
Annatasha
excuse yeah Obviously.
00:26:41
Ryan Bailey
We'll work on it.
00:26:43
Annatasha
And you could tell everybody, obviously it's from Chicago because you work for the board of tourism.
00:26:47
Ryan Bailey
Sure. I mean, if I make it from Chicago, isn't it?
00:26:48
Annatasha
Yeah.
00:26:50
Annatasha
Does the goose have little Chicago outfits?
00:26:50
Gianluca Bini
Isn't there a drink?
00:26:52
Annatasha
Like it doesn't have a bears outfit and a white socks outfit?
00:26:55
Ryan Bailey
Duck, yeah, he has a hot dog.
00:26:58
Annatasha
I think you should qualify that as he has a hot dog outfit because nobody wants to know about your goose's hot dog.
00:26:59
Ryan Bailey
The goose, I mean, I always call him the duck, the goose. He has a hot dog.
00:27:05
Ryan Bailey
Yes.
00:27:07
Gianluca Bini
When they even tell those cocktail hot dogs, those little, right?
00:27:12
Annatasha
Those are Vienna sausages, which PS, never seen one in Vienna.
00:27:17
Ryan Bailey
Yeah, I'm sure. I've not. I mean, I've had cocktail weenies, little smokies from a hillshark.
00:27:21
Gianluca Bini
Yeah, those little, you love those?
00:27:22
Ryan Bailey
I love those things.
00:27:24
Annatasha
If you serve those to a person from Vienna, they would probably flick you in the middle of your forehead. Like there's zero chance.
00:27:28
Ryan Bailey
i' I'm sure. I'm sure.
00:27:30
Annatasha
Yeah.
00:27:31
Gianluca Bini
Holy shit.
00:27:32
Annatasha
And the people keep branding stuff as being like Vienna, this and Vienna, that.
00:27:35
Annatasha
And I'm like, have you been to Vienna? Like, no.
00:27:40
Gianluca Bini
Apparently, I didn't know this, but I heard or read that there is a ah ah counter at the Vienna airport for people that flew in and thought that they were in Australia.
00:27:53
Annatasha
That's not true. However, I will tell you this that when we lived in Austria, when I was a young child, my parents would get mail that had been like had gone through Australia and had been redirected.
00:27:54
Gianluca Bini
Okay.
00:28:07
Annatasha
Yeah.
00:28:08
Ryan Bailey
ah
00:28:09
Annatasha
Yeah. And sometimes too, like I have throughout my whole life, I'd be like, Oh, my dad's from Austria. And people will be like, Oh, and they'll start being like, throw the shrimp on the bay and like start talking about kangaroos. So in Vienna, you can actually buy a shirt that says no kangaroos in Austria.
00:28:24
Annatasha
because that is like, that is also a common myth, but there's no airport booth, but there should be, and you should get a free kangaroo shirt, I think. yeah, no, it's, I never figured out why people have never heard of Austria due to its, you know, significant 20th century contributions, but I'm talking about Freud, everybody relax.
00:28:43
Annatasha
But yeah, no, it's,
00:28:44
Gianluca Bini
I wasn't working about the monster balls, but that's about it.
00:28:48
Annatasha
Well, that's because you're European and sophisticated, Bini, but yeah. But anyway, should be a what?
00:28:53
Gianluca Bini
I'm going to ship you a Mozart ball daily next time.
00:28:56
Ryan Bailey
The what?
00:28:57
Gianluca Bini
A Mozart ball?
00:28:59
Annatasha
Oh, a Mozart ball, yes. Yeah, well, they serve all those Vienna sausages, not.
00:29:00
Gianluca Bini
Mozart.
00:29:01
Ryan Bailey
Oh, so fancy, jeez.
00:29:02
Gianluca Bini
Never heard of Mozart.
00:29:08
Annatasha
So should we talk about anesthesia?
00:29:08
Gianluca Bini
just to
00:29:10
Annatasha
I have a question I want to ask you guys.
00:29:10
Ryan Bailey
Yes. Yeah, hit me.
00:29:12
Gianluca Bini
Go for it.
00:29:16
Annatasha
How do you feel about gabapentin for acute pain?
00:29:22
Gianluca Bini
Okay, we went over this three times.
00:29:23
Ryan Bailey
Hey.
00:29:25
Annatasha
I just, I mean, we've gone over Dexmed a few times too, but but um yeah, no gabapentin and acute pain, discuss.
00:29:27
Gianluca Bini
Yeah.
00:29:34
Annatasha
Chickpeas are neither chicks nor peas, discuss.
00:29:39
Ryan Bailey
I mean, like, I don't think the research is out there, right? Like, clinically, it doesn't work. But like, i I will say, I have been approached about setting up a study to really kind of tease that out.
00:29:47
Gianluca Bini
yeah
00:29:59
Ryan Bailey
And I gave some guidance as to like, how I would try to set that up to the best of my ability.
00:30:06
Annatasha
and which was.
00:30:07
Ryan Bailey
with some other people. Well, we were discussing like caseload and like, you know, in a private practice, I was like, I think you have to use TPLOs just because you have access to so many.
Gabapentin in Acute Pain Management
00:30:17
Ryan Bailey
And you would set up a control group where one gets standard protocol of like NSAIDs and the other instead of NSAIDs gets gabapentin.
00:30:18
Gianluca Bini
Right.
00:30:28
Ryan Bailey
I mean, I think there's a lot of confounding factors though. And I You know, point that out because you're going to have to standardize the anesthesia protocols if you can standardize nerve block epidural. Do you choose only systemic drugs? I mean, I don't think that's appropriate.
00:30:44
Ryan Bailey
like I would i I want to see the research I wanted to get out there I just I don't think we have it yet but I think to me it's it's a no like it's I strongly suggest we come up with an alternative option for those cases I know why people I everyone I know why we want it I know we want it because
00:30:45
Gianluca Bini
and
00:31:03
Ryan Bailey
It's safe. And we we label it as a safe, no renal disease, no GI ulceration. We need to take a fucking chill pill.
00:31:14
Ryan Bailey
fat I'm sorry. like We have to take a chill pill on GI ulceration.
00:31:16
Annatasha
but
00:31:21
Ryan Bailey
Come on. I say, to me, it's a no. It's a it's a no from me, dog. and
00:31:28
Annatasha
Bini?
00:31:30
Gianluca Bini
Yeah, I think it's a no for everybody, really. It's a good for sedation but that's about it.
00:31:33
Annatasha
Here's a question. I'm going to give you a scenario. So let's say you have like a young, healthy dog who acutely like has a CCL rupture. Okay. So, uh, and then comes in and, you know, Okay, fine.
00:31:40
Ryan Bailey
Mm-hmm. But, but timeout, that dog doesn't have an acute CCL rupture. We all know that.
00:31:49
Annatasha
So finally has its complete tear after limping around on its partial tear.
00:31:52
Ryan Bailey
So it has chronic pain.
00:31:54
Annatasha
Yeah, so it has some degree of chronic pain. Now, someone...
00:31:57
Ryan Bailey
So Gaba pentin the appropriate choice.
00:32:00
Annatasha
I'm going to punch you in the goose in a minute. Let me finish the fucking story. Don't you don't she back him up with his bullshit Bini. will beat you.
00:32:09
Ryan Bailey
That's Dr. Bailey.
00:32:12
Annatasha
That's about the level of stethoscope you deserve. So let's say you have a dog who comes in with like mild to moderate
00:32:21
Annatasha
You know who's going to get a gastric ulcer shortly? It's going to be fucking me. But anyway, so, what, uh, if you have a like healthy dog who comes in with some mild to moderate knee pain and then we put it through the TPLO procedure, whatever, whatever they do, TTA is extra capular.
00:32:36
Annatasha
I don't give two flying, you know, what's, and then the dog wakes up for maybe like a three out of 10 pain at like nine, 10 out of 10 pain. Are you going to chart gabapentin for that?
00:32:47
Ryan Bailey
No.
00:32:48
Annatasha
Bini?
00:32:50
Gianluca Bini
No.
00:32:50
Annatasha
Me either. And how often does Gabapentin get charted by the surgeons?
00:32:55
Gianluca Bini
all the time. The reason why is the same as why the cardiologists shouldn't put an anesthesia blurb in the report.
00:32:56
Annatasha
100%.
00:32:57
Ryan Bailey
Because ever yeah, why are why are we so scared?
00:33:09
Gianluca Bini
That's because that's not their job.
00:33:11
Ryan Bailey
Maybe we need to prescribe an NSAID at every instance we can. You know, Gabapentin is really not so useful for acute pain and, you know, trying to educate the whole hospital.
00:33:23
Annatasha
So useful, Bailey, or useful at all?
00:33:26
Ryan Bailey
I mean, I think so, like, having done some time with the human chronic pain side, like the human beings who experience chronic pain, I think gabapentin is hit or miss.
00:33:40
Ryan Bailey
Humans, some people swear to God that they started gabapentin and their lives were different.
00:33:45
Annatasha
Yep.
00:33:46
Ryan Bailey
They say it absolutely changed my life for the better. I am a different person because of gabapentin. And some humans are like, I absolutely hated gabapentin.
00:33:58
Ryan Bailey
It was like I was in a fog. I didn't really understand what was going on. It did nothing for my pain, blah, blah. And to my mind, that is probably the experience our pets have when they are on Gabapentin. There are probably some dogs who you put them on Gabapentin and their world is different. They are more comfortable, they feel better, and there are probably some dogs who go on it and it doesn't work. And how do we predict that? That's a great question. like That is where we need to do better chronic
00:34:29
Ryan Bailey
you know, pain management, like questionnaires or like, we need a Glasgow scale for chronic pain. That's like validated across, you know, the, the board or whatever, but like,
00:34:40
Gianluca Bini
which is going to extremely hard to get. like Even research-wise, it's really hard to design those
00:34:48
Gianluca Bini
And especially with the caseloads we have, you
00:34:48
Ryan Bailey
And yeah.
00:34:50
Gianluca Bini
you know
00:34:52
Gianluca Bini
the biggest hospital, what they roll like probably like 3,000 to 5,000 anesthesia cases a year, maybe.
00:34:52
Ryan Bailey
Yeah.
00:35:00
Ryan Bailey
Yeah.
00:35:01
Gianluca Bini
It's it's tiny compared to what they can do in humans.
00:35:05
Ryan Bailey
So i I don't think you have a pen to the magic bullet and I don't think we need, I think we do over prescribe it for sure. I think that comes from a fear of side effects of the other analgesic drugs. I don't think that's appropriate.
00:35:18
Ryan Bailey
But I do think, I don't like, to our point earlier, I like and I don't like certain drugs. That's not that's not a good way to view these things. I think there's a place for gabapentin for some subsets of patients.
00:35:32
Ryan Bailey
It's just what are those and how do we find those? That's a great question. and And I think it's just an individual thing. And like, I wish we could talk to dogs, you know, or cats, mostly cats, but.
00:35:42
Annatasha
Mostly cats.
00:35:42
Gianluca Bini
That'd be nice.
00:35:45
Annatasha
I was like, I'm sure whatever a dog has to say is not usually as interesting as what a cat would.
00:35:45
Gianluca Bini
That'd be nice.
00:35:50
Gianluca Bini
But going back to our original question before we diverted on like, winners and, you know, nothing got abandoned, you know, how, so like, what's your normal protocol goal for a cat with HCM that is not
00:35:56
Annatasha
uminni
00:36:06
Gianluca Bini
you know in heart failure or or that you know in a mild to moderate hcm cut and that's how you kill it but if you have to wonder if
00:36:14
Annatasha
40 Migs per Keg Academy? I'm kidding. Side note, I'm just kidding.
00:36:25
Ryan Bailey
Artel's just trying to get her day over with, you know? If she gives them that much, all the cases go lickety-split, you know what I mean?
00:36:30
Annatasha
Yeah, I can go home and drink tea.
00:36:33
Gianluca Bini
If you want to keep the cat alive, I should have specified, sorry.
00:36:35
Annatasha
All right, yeah, yeah, yeah.
00:36:36
Gianluca Bini
If you wanted to keep it alive.
00:36:39
Annatasha
Yeah, be clear about your strategic plan.
00:36:39
Gianluca Bini
what both what
00:36:41
Ryan Bailey
Yeah, yeah.
00:36:41
Annatasha
like
00:36:45
Annatasha
If I want to keep the cat alive, and what kind of procedure are we doing, painful or non-painful?
00:36:49
Gianluca Bini
Let's say you're doing a fracture in a cat. Would work?
00:36:56
Annatasha
Well, I don't know. I've daily laughed and I don't know why I'm laughing in return, but okay.
00:37:02
Annatasha
I feel a
00:37:02
Ryan Bailey
This is the last time you get a fracture in a cat.
00:37:06
Gianluca Bini
If you have a better one, do it. like you know i don't know like
00:37:09
Annatasha
How can he feel about any fall, right? So maybe you're fixing one fraction of mold.
00:37:11
Ryan Bailey
but Let's tune up today. INS has a cat maybe with HCM based on the echo. you know And it was pretty equivocal.
00:37:18
Gianluca Bini
For what?
00:37:21
Annatasha
what What did you use?
00:37:21
Ryan Bailey
So. So for me, Cal is already on methadone.
00:37:24
Annatasha
Yeah, chuckles.
00:37:25
Ryan Bailey
I repeated the methadone dose. Induction with alfaxalone and diazepam.
00:37:32
Annatasha
Did it upregulate the cat's sympathetic tone?
00:37:32
Ryan Bailey
okay
00:37:35
Ryan Bailey
it Not so much, actually. It was a little surprising. I did i did have a discussion with anesthetist that you know this cat may or may not have HCM based on the report from 2021, the current years.
00:37:50
Ryan Bailey
The current year in this case was anesthetizes 2024.
00:37:54
Gianluca Bini
Any years later. So, question really, why did you pick alfaxa lone?
00:38:01
Ryan Bailey
I personally really like, oh my God.
00:38:02
Annatasha
Ugh!
00:38:05
Ryan Bailey
I think.
00:38:05
Annatasha
Jesus! Do better!
00:38:07
Ryan Bailey
I think the induction quality of alfaxalone in cats is just so reliable and it's so rapid, they get deep quickly and it has a really nice intubation condition.
00:38:19
Ryan Bailey
I think better than other...
00:38:21
Annatasha
i Bini, it's because he's using Chicago alfaxalone.
00:38:25
Ryan Bailey
Yeah, exactly. Oh my God.
00:38:25
Annatasha
Yeah, no, ah because my alphaxolone is not this awesome.
00:38:26
Gianluca Bini
Wait, wait, wait, wait.
00:38:26
Ryan Bailey
This
00:38:30
Gianluca Bini
But we did say that your goal for HCM, right, they're, you know, you need to lower your heart rate and all that.
00:38:35
Annatasha
I know it's coming.
00:38:36
Ryan Bailey
and what I know, I know where you're going. I know, I know where you're going. And yes.
00:38:40
Gianluca Bini
And so, with alfaxalone and we do know, for whoever is listening that doesn't know, is that at times, it may increase heart rate, right?
00:38:49
Ryan Bailey
Yes.
00:38:50
Gianluca Bini
So why why would you do that?
00:38:50
Ryan Bailey
Yep.
00:38:53
Annatasha
Yeah, Bailey, why would you?
00:38:54
Ryan Bailey
Uh, cause I like to live on the edge. I'm trying to go home and drink tea. tea. Um, uh, for me, it's because like,
00:39:05
Ryan Bailey
It gives me such a nice quality induction, and it's really rapid. This cat, we were able to get away with three milligrams of alphaxolone, and that was it.
00:39:16
Gianluca Bini
I mean, even the other way with two may go probable too.
00:39:19
Annatasha
I can get away with less than that.
00:39:21
Ryan Bailey
We weren't late for the record, and the cat did have a little sympathetic response in this.
00:39:21
Annatasha
So up my protocol, if anyone cares, did you block the cat?
00:39:29
Ryan Bailey
I did not.
00:39:31
Gianluca Bini
Is the cat still alive?
00:39:33
Ryan Bailey
It sure is. highest HR we got was 130, but I did have a whole discussion about how, and I don't...
00:39:34
Annatasha
All right.
00:39:40
Ryan Bailey
Again, cats are just strange creatures. He was sitting with a heart rate of 100 to 110 at like after induction and in prep. We got into the ah OR OR and it had a whole discussion about cats and their sympathetic responsiveness and we need to be mindful and watch it and kind of see you know what they do because not every cat does it. Not every cat goes you know skyrocketing. And the cat was normal intensive the entire time. and The echo report was quite a while ago and the cat's never been rechecked.
00:40:09
Ryan Bailey
He does have a heart murmur, did have a heart murmur, does, I guess. I guess he did during my auscultation, but I don't know if it's still there. like We all know cats can throw murmurs.
00:40:21
Ryan Bailey
I think it's not crazy.
00:40:21
Gianluca Bini
let's sure For whoever is listening, you know, you may have cats with heart murmur that have HCM. You may have cats with heart murmur and no heart disease. You can have cats with no murmur and heart disease.
00:40:34
Ryan Bailey
Yeah.
00:40:34
Gianluca Bini
So like cats are random creatures, which is funny.
00:40:35
Ryan Bailey
Yeah. Oh my God, I know.
00:40:38
Annatasha
Well, if I were going to anesthetize the same case, I would have done, my premed have been methadone, dexamet, and I would have induced propofolminazolam.
00:40:39
Ryan Bailey
and Yeah.
00:40:45
Ryan Bailey
Yep.
00:40:46
Annatasha
And then I would have blocked whatever I could block, and I would have lived my best life and gone home for tea.
00:40:47
Gianluca Bini
Yeah.
00:40:49
Ryan Bailey
Yep. And this cat did great, like this cat was one of the most stable and not super responsive cats. And I i don't know why they're like that.
00:41:01
Ryan Bailey
It's like when I was a resident and they were discussing cats and some of the research they did on cats and how like they did you know no lot are nitrous oxide and fentanyl as like macroducers and like, well in one population, it reduced it and then we crossed them over and then the patients who got reduction didn't get reduction in the next time.
00:41:19
Ryan Bailey
And it's like,
00:41:19
Annatasha
What ever happened to nitrous oxide? like
00:41:23
Ryan Bailey
It's a big greenhouse gas emitter
00:41:25
Annatasha
But I use it when I was a student and I still use it when I was a resident.
00:41:26
Gianluca Bini
No, I get that you need to use it, but do you use it now?
00:41:32
Gianluca Bini
But now, you don't.
00:41:33
Annatasha
I don't have the, we don't have the piping for it.
00:41:36
Gianluca Bini
Thank God.
00:41:36
Ryan Bailey
Yeah.
00:41:37
Gianluca Bini
Okay, good.
00:41:38
Ryan Bailey
It's also controlled, isn't it?
00:41:42
Annatasha
i' Not here in Canadian, but no, it was,
00:41:44
Ryan Bailey
Hello.
00:41:47
Annatasha
extremely effective.
Historical Use of Nitrous Oxide
00:41:49
Ryan Bailey
Yeah.
00:41:49
Annatasha
It's analgesic and it would provide cardiovascular stability. And and yeah, no, it was great.
00:41:53
Ryan Bailey
Yep.
00:41:56
Annatasha
It was great.
00:41:57
Ryan Bailey
You just need to make sure you don't just.
00:41:57
Annatasha
if the patient If the patient can handle a reduced inspired fraction of oxygen, then, you know, nitrous was, you know, it's kind of like, you know, oh God, I'm becoming one of those old anesthesiologists, like the ones who still talk about how great thiopental was, you know, like you always like, why do we get rid of thiopental?
00:42:01
Ryan Bailey
Yep.
00:42:13
Ryan Bailey
Bartel, tell us about Halotane!
00:42:18
Annatasha
That's why I wore this sweater. and It's a shout out to Halotane. No, I still...
00:42:21
Ryan Bailey
Bartel, tell how you used to the smoke cigarettes in the OR, but you had to keep your hands low so you didn't spark the Halotane.
00:42:26
Annatasha
Guys, stop. I used to hold ether down just in front of the horse's face and just like basket muzzle it to like the ground. Like, yeah. Yeah, and yeah. No, I'm kidding. Bini, relax.
00:42:38
Ryan Bailey
That's why they had the chains on all the chairs of Davis so they wouldn't spark the agents.
00:42:42
Annatasha
Really? Are you sure it wasn't because so when the bag and barrel exploded, it didn't kill you in the room?
00:42:52
Ryan Bailey
yeah
00:42:53
Annatasha
Yeah.
00:42:53
Gianluca Bini
i I've never, so I love the bag in a barrel thing. It was one of the most entertaining pieces of my,
00:43:04
Annatasha
You mean, I mean, sure, I could also build an anesthesia machine and ventilator out of shit in my dad's garage, but I could also just buy something really nice from, you know, Data Ohmeda or like GE and like get on with my day.
00:43:12
Gianluca Bini
which is what they did.
00:43:17
Annatasha
Like, yeah. I'm not one of those people who like, what's wrong?
00:43:21
Gianluca Bini
cheese
00:43:23
Annatasha
Oh, Bailey, when he wants to peep, he runs his piping through a fucking bucket of water, like.
00:43:27
Ryan Bailey
I did that one time because I was at a clinic who didn't have a pee valve and the dog was de-saturating in front of me with pulmonary hypertension. And I was like, I have to do something. And I did learn that if you stick the exhaust hose through a water bucket, it will cause it will create positive end-expertory pressure.
00:43:45
Annatasha
See Bini, you thought I was kidding.
00:43:45
Gianluca Bini
that if you actually measure the centimeters of water, that's actually the pressure you get, right?
00:43:46
Annatasha
You thought I was kidding, but he's actually done it.
00:43:56
Ryan Bailey
Yeah.
00:43:57
Gianluca Bini
That's how it works.
00:43:57
Ryan Bailey
Yeah.
00:43:58
Gianluca Bini
like Literally, that's how it works.
00:43:59
Ryan Bailey
Uh, yeah. Yeah.
00:44:03
Annatasha
Yeah. I mean, honestly, I don't want to break anybody's hearts, but you literally could build like an anesthesia circuit at home and a ventilator at home for sure.
00:44:04
Gianluca Bini
Oh,
00:44:08
Ryan Bailey
Oh, sure.
00:44:10
Annatasha
I mean,
00:44:10
Ryan Bailey
Sure.
Oxygen Blenders in Medicine
00:44:11
Annatasha
we dress them up in $80,000 outfits with computer chips, but at the end of the day,
00:44:11
Gianluca Bini
sure.
00:44:14
Ryan Bailey
but
00:44:15
Ryan Bailey
I don't know why. Well, so Bartel, this cat, you're anesthetizing. How much Daxmat are you giving? Are you putting him on a Dexmed CRI?
00:44:24
Annatasha
I am now just to fucking mix it up.
00:44:28
Ryan Bailey
How much?
00:44:29
Annatasha
I guess, here's my question, which is irritating, but but relevant is, was my pre-med IM or IV?
00:44:31
Ryan Bailey
Yep. Yep.
00:44:36
Annatasha
Now in my world, almost everything is Ivy because I hate IM injections.
00:44:39
Ryan Bailey
Give me both. Give me both.
00:44:41
Annatasha
Yeah. So I would say for, and is the cat fractious or not? But I'm probably going to give that cat, um I'm going to assume I have a catheter and I'm going to assume the cat is just like a fairly like anxious, but normal cat.
00:44:53
Annatasha
So like the use, two to three mg per kg IV.
00:44:54
Gianluca Bini
Chuck.
00:44:55
Ryan Bailey
Yeah.
00:44:56
Gianluca Bini
Chuck.
00:44:58
Ryan Bailey
Okay. And then are you putting them on an infusion during the case?
00:45:00
Annatasha
my muthroom
00:45:04
Annatasha
Sure. Why not?
00:45:04
Ryan Bailey
So let's say you're doing an abdominal procedure, which block are you choosing?
00:45:04
Annatasha
Let's. look like
00:45:08
Annatasha
tap, and visceral pain.
00:45:09
Ryan Bailey
Okay. So we know that the tap doesn't cover any internal organs. So the cat's still going to deal with some degree of sympathetic responsiveness when the surgeon goes pulling around in there and yeah, exactly.
00:45:21
Ryan Bailey
So.
00:45:21
Annatasha
So I'm going to do the Dexmed CRI, just to make you happy.
00:45:24
Ryan Bailey
Would you have done that from the start?
00:45:26
Annatasha
Probably.
00:45:27
Ryan Bailey
Oh, okay.
00:45:27
Annatasha
I love a Dexmed CRI. It's like some of the best quality anesthesia that money can buy.
00:45:29
Ryan Bailey
Yeah.
00:45:33
Gianluca Bini
It's true.
00:45:33
Ryan Bailey
Yeah. It blocks that sympathetic tone, which is what we all want.
00:45:38
Annatasha
You more than anyone, Bailey.
00:45:41
Ryan Bailey
I mean.
00:45:42
Gianluca Bini
now Now the most important question.
00:45:43
Annatasha
I mean, if my choice was like, let's say, am I going to do Dexman and and a TAP versus an epidural?
00:45:50
Ryan Bailey
Sure. Yeah.
00:45:51
Annatasha
first Personally, I would do the TAP and the CRI because I think the conferred risk to the patient, I mean, there are people, you know, we treat, we're very lucky.
00:45:51
Ryan Bailey
That's a great, that's a great question.
00:45:56
Ryan Bailey
yeah
00:46:01
Annatasha
no big whoop-de-do about epidurals, even though an epidural is a really great way to cause a pretty bad problem. so But yeah, I think I would rather do the CRI and the TAP block, probably because I will have less technique failure in that capacity.
00:46:12
Gianluca Bini
agree Agreed,
00:46:13
Ryan Bailey
Yeah. Yeah.
00:46:18
Ryan Bailey
Mm-hmm.
00:46:20
Annatasha
And I feel more confident than I am diffusely reaching the viscera in a reliable way than I might do with the epidural.
00:46:26
Gianluca Bini
Yeah.
00:46:27
Ryan Bailey
Okay. Do you.
00:46:28
Gianluca Bini
Now the main question is post-op, do you give a gabapentin? Yeah.
00:46:37
Ryan Bailey
I mean.
00:46:38
Annatasha
yeah I give the gabapentin to myself so I can get out of this conversation. But yeah, no, I am. now Now, there are certain cases where I think that certain types of visceral pain may contribute to some degree of like neuropathic pain. And the one that I do think that they do respond to well clinically, and i my my hypothesis is related to the fact that it is because there has been sustained neuropathic nociceptive amplification is blocked cats who've had a really large, you know, when their bladder is so big that by the time like it actually is released and then they pee blood for three days anyway, because it's just been so distended.
00:47:15
Ryan Bailey
i am
00:47:20
Annatasha
And I do think that contributes to some degree of like neuropathic pain. so I think they respond well to gabapentin, or I could just be being thrown under the bus by essentially like the fact that you're sedating them.
00:47:34
Annatasha
And of course, the more you sedate, post-up or post-procedural blocked cats, the less likely they are to re-block.
00:47:42
Ryan Bailey
Oh, yeah.
00:47:42
Annatasha
So I haven't really teased that one out, but I do.
00:47:43
Ryan Bailey
Yeah.
00:47:45
Annatasha
Well, on board, Gabbo, there what?
00:47:45
Ryan Bailey
Plus they're also super. Oh, they're, I mean, if they're, if they're a black cat, they probably are an anxious cat to begin with. Like part of, part of blocking is like anxiety, essentially anxiety.
00:47:54
Annatasha
Yeah, yeah.
00:47:58
Annatasha
You know what cats are like? Like another cat walks by the window and they're like, I'm gonna die. So yeah, no, I think
00:48:02
Ryan Bailey
Yeah. Like, oh, yes, we're over. I now have to stop peeing.
00:48:06
Annatasha
But yeah, the cats who are still sort of having that like bloody pee a few days out, not necessarily like they're not just uric or shrink uric or what have you, but they're still, you know, they're not eating quite as well. And they're maybe just, you know, doing cat things like hiding or,
00:48:21
Annatasha
They're like less interactive with the one person in the world that they like. Those ones I think Gabapentin may have an important indication, whether I'm right that that's because of neuropathic or whether it's because the sedation is conferring some anxiolytic capacity. I don't know, but either way, I'm helping them out somehow clinically, I think.
00:48:43
Ryan Bailey
I've got a question about sympathetic arcs in cats. m So when ACVS and ACVAA combined together, there was a human anesthesiologist, and he was talking about like enhanced recovery after anesthesia pathways, like the ERAS pathways or whatever, and he was discussing a patient
00:49:24
Gianluca Bini
They do that.
00:49:32
Gianluca Bini
Yes, they do that in humans. you have an increased heart rate, and and don't even think about whether it's pain or not, they don't care, they just give a beta blocker, that's it.
Pain Management: Human vs Veterinary
00:49:48
Gianluca Bini
Dan, dan!
00:49:49
Annatasha
No, but the human medicine does not care as much about pain as we do. Like where we become so pathologically phobic that we're missing an iota of pain. And we've probably gone to the point where we're over medicating a lot of patients for pain.
00:50:01
Annatasha
And also in the, in the human.
00:50:02
Gianluca Bini
Yeah.
00:50:03
Annatasha
there
00:50:08
Annatasha
um
00:50:11
Annatasha
also don't forget in humans, like they're super reluctant to give analgesia because they're so upregulated about the liability associated opioid addiction. All right.
00:50:21
Gianluca Bini
yeah
00:50:21
Annatasha
Like you, you honestly, like you could literally fall from a building and have bones sticking out all over the place. And they'll be like two mics for cake of fentanyl, take care. And you're like, wait, what? Or you should take a, take a Tylenol, take Tylenol.
00:50:32
Gianluca Bini
Yeah, yeah.
00:50:32
Ryan Bailey
Oh.
00:50:36
Annatasha
Yeah. And you're like, uh, I don't think so. why
00:50:40
Gianluca Bini
I
00:50:40
Annatasha
associated here.
00:50:40
Gianluca Bini
that's for sure. But the NSAIDs, a lot of people like undervalue the value of how good an NSAID is.
00:51:16
Annatasha
I know, but that's a big argument, man, because like I've heard internists actually say, I think that NSAIDs should be banned clinically full stop. And I'm like, you know what?
00:51:27
Annatasha
right Should we ban NSAIDs?
00:51:28
Gianluca Bini
I think we should keep this for another podcast. we're going hour
00:51:33
Annatasha
I mean, I'm always a big fan of like anytime someone tells me something's not painful or like the degree of pain or whatever. And I'm like, well, no problem. I was like, well, let's just try it on you and you let me know how it goes. You know, like when people say things like, ovary hysterectomy is not as painful as I don't, I don't understand that whole thing of that meant like spays aren't painful.
00:51:44
Ryan Bailey
Yeah.
00:51:52
Annatasha
know, but like we will in the end, like analogies the shit out of a splenectomy, which is an amputation of the organ.
00:51:53
Gianluca Bini
Yes. yes
00:51:57
Ryan Bailey
Oh, yeah.
00:51:59
Annatasha
But for a hysterectomy, we're like, I'm gonna give it Bu torphanol. And you're just like, what? Like, if I were a human who had a hysterectomy, you gave me like a pat on the back for analgesia, knock your teeth out.
00:52:05
Gianluca Bini
No, they're crazy.
00:52:10
Annatasha
So I think that's wild. But
00:52:13
Gianluca Bini
Yeah.
00:52:16
Annatasha
Oh yeah, people who want to ban NSAIDs, I just think, you know, Robyn, let's tell you what, you've been over it.
00:52:16
Gianluca Bini
No, I agree with you. I agree with you.
00:52:23
Annatasha
I'll poke you in the perinein with a 24 gauge needle and if you don't react, I won't i won't give this dog anything.
00:52:32
Annatasha
Simple enough, right?
00:52:33
Gianluca Bini
and
00:52:34
Annatasha
If you don't react, I won't give this dog and a lick of pain medication because obviously it's gonna rock its socks, but like, I'm totally like, that's the most ridiculous thing I've ever heard. And I'm not an over like pain medicator, but like I'm totally like, understand your physiology please.
00:52:45
Gianluca Bini
That should work.
00:52:52
Gianluca Bini
You got triggered so much during this episode, Tasha.
00:52:55
Annatasha
Probably because I just drank three glasses of champagne.
00:52:56
Gianluca Bini
I may need to send you a bit of block now.
00:53:03
Annatasha
Yeah, you came in on like low key Bini with your HCM, HOCM, which honestly I was like, whoa, this is gonna be a weird podcast because I have nothing left to say for the next 59 minutes.
00:53:03
Gianluca Bini
hu
00:53:14
Annatasha
But here we are.
00:53:25
Annatasha
Next recording is mine and I'm gonna do something wild.
00:53:27
Gianluca Bini
i it Okay.
00:53:29
Annatasha
Like buckle up for marine mammals, gentlemen.
00:53:32
Ryan Bailey
Boy.
00:53:43
Annatasha
Oh, you can phone a cousin and be like, Yeah, Jimmy. But yeah, no, I yeah, we gotta ah I'm gonna my next topic is going to be like wildly irritating.
00:53:55
Ryan Bailey
A doozy.
00:53:56
Annatasha
Yeah.
00:53:56
Ryan Bailey
Oh my God.
00:53:56
Gianluca Bini
Wild, wild.
00:54:01
Gianluca Bini
All right.
00:54:01
Annatasha
Camelot cells, something like that.
00:54:06
Gianluca Bini
Well, thank you, everybody, for listening. I guess next time is the third.
00:54:09
Annatasha
Happy New Year.
00:54:11
Gianluca Bini
Happy new year. Next time is the third. Happy new year. Yay. She kept it for the end. Unbelievable.
00:54:23
Annatasha
Yeah, is that is it velvet, Bailey?
00:54:23
Gianluca Bini
Awesome.
00:54:28
Gianluca Bini
That's so cute.
00:54:30
Annatasha
I