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S1E2 - The Ketamine Dilemma
196 Plays8 months ago
This month on the Random Anesthesia Topic podcast, we're excited to dive into the fascinating subject of ketamine! Join our trio of veterinary anesthesiologists as we explore ketamine’s unique role in managing chronic pain and its applications in anesthesia. From the latest research to our own clinical experiences, we’ll break down how ketamine can be a valuable tool for both pain management and anesthesia in complex cases, maybe even for cats with hypertrophic cardiomyopathy (HCM). Whether you're a seasoned vet or just curious about the science behind ketamine, this episode is packed with insights and practical tips. Tune in to learn, laugh, and leave with a fresh perspective on this versatile anesthetic agent!
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Transcript
00:00:00
vetgb89
right.
Introduction and Podcast Kickoff
00:00:01
vetgb89
What's up, everybody? We're here with Dr. Annatasha Bartel from King's Animal Hospital in Ontario. We have Dr. Ryan Bailey, anesthesiologist at Premier Veterinary Group in Chicago.
00:00:17
vetgb89
And I'm Dr. Bini from Oklahoma State University, and I have my own consulting company, Safe Pet Anesthesia. Let's get started for this second episode of the Random Anesthesia Topic Podcast.
Playful Provocation and Feedback Review
00:00:32
vetgb89
Today is going to be Dr. Annatasha Barthel hosting. Actually, she has the random topic for us. I guess this deserves this, right?
00:00:46
Annatasha
hundred percent. Okay, so a couple things before we get going tonight, gentlemen. One, I'm wearing the hat because my hair and my face are a problem this evening, but also I'm wearing it in celebration of the topic tonight because this is a party topic. And I specifically picked it because it's going to antagonize Dr. Bailey significantly, which obviously is a good time for the rest of us.
00:01:07
Annatasha
Now, I also want to have a big shout out for our first podcast, which got more than zero hits. So that's a pretty super awesome.
00:01:18
Annatasha
yeah, right. And, uh, really, really cool feedback about clearly how hilarious slash clueless the three of us are. anyway, moving on.
00:01:27
Annatasha
So tonight's random,
00:01:28
vetgb89
Let's not forget about the corn sweat.
00:01:30
Ryan Bailey
Yeah, very important.
00:01:32
Annatasha
Listen, the corn sweat is really what drove it. So we need some sort of hook tonight, too, guys.
00:01:40
Annatasha
We need some sort of sweaty vegetable hook this evening to really like bring in our dozens and dozens of listeners. So I also want to show everyone my cool mug.
Anesthesia Mug and Ketamine Myths
00:01:54
Annatasha
Yeah, I have anesthesia themed mugs for the party tonight.
00:01:59
vetgb89
That's amazing.
00:02:00
Ryan Bailey
that's a good one. I'll have to wear my ass and be able to share it someday.
00:02:01
Annatasha
Right? well
00:02:01
vetgb89
That's super nerdy.
00:02:02
Annatasha
Bini's wearing an anesthesia t-shirt. So yeah,
00:02:06
vetgb89
I am. Actually,
00:02:09
Annatasha
there you go. Safe Pet Anesthesia, our favorite telemedicine consulting service in a landslide.
00:02:09
vetgb89
safe pattern see
00:02:14
Ryan Bailey
Oh!
00:02:16
vetgb89
actually big announcement. We got selected for the VMX startup circle for 2025. So only 20 companies in the US, startup, you know, for veterinary companies get selected.
00:02:27
Ryan Bailey
well
00:02:33
vetgb89
so
00:02:35
Annatasha
Oh, Bini this is great for sure. AI won't displace you. I mean, Bailey and I will be out of a job in a year and a half, but you'll be fine.
00:02:40
Ryan Bailey
and Someone's gonna, someone's gonna drug those dogs and it's probably gonna be me. I'm just bones.
00:02:48
Annatasha
Yeah, someone needs to consult on the advanced analgesic care of Nubian goats.
00:02:53
vetgb89
So
Subcutaneous Ketamine Debate
00:02:55
Annatasha
So yeah, AI will be like, this is really not necessary. This is pretty redundant.
00:02:59
Ryan Bailey
Yeah.
00:03:00
Annatasha
I'll leave that to the real humans.
00:03:04
Annatasha
But yeah, no, you you know what, live your truth. Live your truth. Speaking of truths this evening, we're going to be discussing one of my favorite pharmacological agents, well known for its high degree of utility in chronic pain.
00:03:24
Annatasha
And you guys are like freaking out. And I'm just going to Ketamine to the table.
00:03:34
vetgb89
Oh, okay.
00:03:35
Annatasha
all over
00:03:36
vetgb89
I thought for a second I thought that you were going to say gabapentin
00:03:37
Ryan Bailey
Thank you.
00:03:41
Annatasha
No, that's a whole other podcast of us bullshitting um and and also just shitting on Gabapentin and its complete futility.
00:03:41
vetgb89
and
00:03:49
Annatasha
But yeah, tonight is ketamine. And where do I really want to ruffle some feathers is discussing a lot of the myths around ketamine. And what do we actually know?
00:04:00
Annatasha
Captain evidence-based medicine is for sure Ryan Bailey. Yeah. And you know, there's just a couple of things that are probably not great for his blood pressure, but they crack me up. So we are going to start tonight with right now there's a big clinical movement for using subcutaneous ketamine.
00:04:22
Annatasha
In chronic pain, no vomiting a allowed, Dr. Bailey. And so I'm just wondering what your guys' thoughts are on whether or not you think there's sufficient evidence to be promoting this. What kind of clinical efficaciousness have you ah ah observed?
Adjunct Use of Ketamine in Anesthesia
00:04:39
Annatasha
I mean, what are we doing here, boys?
00:04:41
Ryan Bailey
We are like jumping right in to like a hornet's nest for me. It feels like I so like yeah I'm just gonna I'm gonna jump right on the grenade.
00:04:47
Annatasha
I know.
00:04:54
Ryan Bailey
I know that from what I have gathered it is largely based on a small report put out by some people who are passionate about anesthesia and analgesia, and they reported that that very low dose of ketamine subcute seemed to resolve some painful conditions. It is in that situation, I think it is harmless.
00:05:23
vetgb89
Alright.
00:05:24
Annatasha
Do you do it?
00:05:26
Ryan Bailey
No.
00:05:28
Ryan Bailey
but But I use ketamine for painful conditions all the time. I i do really like ketamine as a drug. like I love to use it in induction plans. I love to use it in management of painful conditions as adjunct agents during anesthesia when I feel our analgesic plan is not adequate or where I think this patient is at high risk for potentially chronic chronically painful condition or where I think just continuing to hose this patient down with opioids is not going to be beneficial for this patient's long-term outcomes.
00:06:07
Ryan Bailey
And where I think, yeah, like, yes, and...
00:06:10
Annatasha
Time out, did you go to Davis, where they hose everything down with methadone, even though it's non-painful? Like 0.8 Mg per Kg for like, Phaco emulsion? What?
00:06:19
Ryan Bailey
I do use...
00:06:23
vetgb89
Sorry, I really to... i really
00:06:24
Ryan Bailey
gave
00:06:26
Annatasha
Chink like, what?
00:06:28
Ryan Bailey
I mean, I also use opioids as respiratory depressants, mac reducers, not just painful drugs like today in a patient.
00:06:38
Annatasha
Oh, are you using opioids as mac reducers in cats, Bailey?
00:06:42
Ryan Bailey
Or don't.
00:06:46
Ryan Bailey
i I put them on them and I say, let's cross our fingers and hope this is one of those few cats that gets the MAC reduction, but know that it's like, I don't know, based on the recent paper from Davis, it seems to increase sympathetic responsiveness in a variety of cats.
00:06:59
Annatasha
ahur
00:07:04
Annatasha
Oh no, here we go with Bailey and his crazy cat sympathetic tone situation. No, no, no, I'm reeling you back into the ketamine conversation because if you go in this tangent, you're never going to come off it.
00:07:10
Ryan Bailey
We have a preview of next week's topic.
00:07:16
vetgb89
That's fucking awesome.
00:07:18
Annatasha
Bini what about you?
Ketamine's Effects in Small Animals
00:07:20
Annatasha
I saw you hold up a big zero sign there and I'm just wondering what your thoughts are on the ketamine O.
00:07:25
vetgb89
Yeah, so now I can't.
00:07:26
Annatasha
Italian version. way
00:07:31
vetgb89
But what's
00:07:35
vetgb89
But what I always tell people is like, you know, we know that the half-life of ketamine is what like 45 minutes, something like that. At least in small animals, right? So probably an hour top, something like that. But you know, if you do it every two weeks, sub-cute, like how, it's mostly placebo. You know, if you do if you do see any result, that's placebo, 100%. There is no,
00:08:00
vetgb89
you know, they base this stuff thinking of, you know, in humans, they do micro dosing and whatever, blah, blah, blah, right. But that's like in a controlled environment, they're not doing it over two weeks sub cute You know, it's, it's, it's a totally different ballgame, you
00:08:21
vetgb89
You know, people do hope that there is a way to manage our patient's pain long-term without blasting them with NSAIDs right? Or an opioid alternative, let's say. That's why they get hooked on do gabapandin. They get hooked on do like
00:08:48
Annatasha
with me.
00:08:52
vetgb89
the reality is that the reason there isn't a way to do it, unfortunately. they only If you're looking for chronic pain management that is due to arthritis,
00:09:03
vetgb89
Thankfully now, we do have Librella and Solenzia there, that seems like they're having a huge, huge positive effect out there. Every GPS I speak with, they're really, really impressed with the results. There are some Facebook groups up there about cats dying after getting those injections. Very likely they have that they you know, the patients that normally do get those injections are really old. And that's when they get put on those and so they die.
00:09:41
vetgb89
regardless of the injection. It's not the injections that kills them. you know But you owners are trying to make that kind of association nowadays. So I don't know if you're aware of that, but there's that kind of train out there.
Receptor Distribution and Veterinary History
00:09:53
vetgb89
But going back to the Ketamine I don't think that there is any evidence whatsoever.
00:09:59
vetgb89
so
00:10:01
Annatasha
Okay. Interesting.
00:10:03
vetgb89
Great drug, otherwise. great drug for chronic pain management, intraop, like you know if you have a patient that you know has been chronically painful and you want to use it, it's a good MAC reducer, sure.
00:10:05
Annatasha
Okay. and
00:10:06
Ryan Bailey
Yes.
00:10:20
Annatasha
Here's a question. So for our three listeners out there, so one of the things that, that kind of mean does is it modulates the activity at the and NMDA receptor, which is going to be part of your pain pathway. So your afferent pain pathway, and in particular, it relates to, for example, pain chronicity, but also phantom limb pain in human beings. So that's one of the reasons why anesthesiologists will throw it on the recipe. Now, here's my question. Why are we not using it epidurally?
00:10:49
Ryan Bailey
that's a great question like i'm not
00:10:50
vetgb89
So there ah there is a paper out there that showed that, yeah.
00:10:51
Ryan Bailey
yeah
00:10:56
Annatasha
There are a few, but they are like, they're older than I am. So yeah, like there there was like this brief burst of ketamine epidurals and veterinary medicine in like the 90s, and then it kind of just abated. no one's ever really chased it anymore. And I'm just, you know, I'd like everyone's two cents on why that is.
00:11:16
Ryan Bailey
That's a great question.
00:11:17
vetgb89
Love the reference. ah you lived their reverence and There is a paper out there, at least in humans, where it shows that they have 20,000, so ketamine and epidurally, compared to morphine, it's 20,000 times less potent than morphine, which is insane.
00:11:38
Annatasha
Well, that's a big ass number, okay.
00:11:41
Ryan Bailey
but
00:11:41
vetgb89
It's crazy.
00:11:42
Annatasha
But what are we going for here, Bini we going here for acute pain management? So perioperative or perianesthetic? Or are we giving ketamine in a mixed epidural so that we both get acute onset management and as well as we're mitigating the cronicity?
00:11:57
Ryan Bailey
And we're stopped.
00:11:57
vetgb89
Good question. i think i think it also
00:11:57
Annatasha
By the way, this is me just bullshitting my way through this situation. I'm just asking a question.
00:12:04
vetgb89
a i think So here's the deal. I think it all comes down to receptor distribution, right? It seems like there isn't enough an NMDA receptor and at least in the subrac noid space.
00:12:19
vetgb89
right? So that's where that paper was going into, versus there is plenty of mu opioid receptors in that space. So if the drug can't reach
Epidurals and Hot Dog Tangents
00:12:30
vetgb89
your opioid, your receptor, either an NMDA or opioid, then, you know, it's not going to have the effect you want, right? So I think, I think their thought was purely receptor distribution.
00:12:44
vetgb89
Now, whether it's real or not, again, it's an old ass paper from the 80s. So God knows really, but you know, that's that's my thought there. I never really tried it. So I would lie to you if I told you that they tried ketamine individually. Did you guys ever try it?
00:13:02
Ryan Bailey
I've never, yeah, I've never tried it. I mean, it's a really interesting, question like I mean, I don't know why we don't do it.
00:13:05
Annatasha
No, I'm just stirring the pot.
00:13:10
Ryan Bailey
I do like, I just lazily thinking, like, if they're not doing in humans, there's gotta be a reason, you know, like, like,
00:13:22
vetgb89
Fair.
00:13:22
Ryan Bailey
they try They do a lot more than we do, especially for managing these like chronically painful conditions. yeah and like ah like so All this being said, like I use ketamine in the few like chronically painful cases. like I will put them on ketamine infusions and owners will report some degree of long-term pain management. So like this idea that the 0.2 mgs per kg of ketamine subcute is going to cause pain management, I conceptually understand why we would believe that. And I would i would like to see more evidence in this space, like more work being done on cases. I know these studies are hard to hard to do, hard to study. hard like There's a lot of barriers and
00:14:10
Ryan Bailey
I, for one, I'm just going to say I am not the person who's going to do it for a variety of reasons.
00:14:15
Annatasha
When you're too busy doing your hot dog ranking system and obsessing about cats sympathetic tone like Dr.
00:14:20
Ryan Bailey
that i mean Someone has to talk about hot dogs or, you know what, we're going to be without hot dogs and everyone's going to be sad.
00:14:24
vetgb89
but anyway Wait, wait, wait, wait.
00:14:28
Ryan Bailey
so
00:14:29
vetgb89
Wait, wait, wait.
00:14:30
Annatasha
Beanie, do you not know about Dr. Bailey and hot dogs?
00:14:33
vetgb89
Absolutely not. And that's what I was going into. Now I need to know about this.
00:14:38
Annatasha
This is weirder than the corn sweat. No, he basically is on like this lifetime mission to grade every hot dog in Chicago, which Bailey defends as being the home of the best hot dog.
00:14:45
Ryan Bailey
Happy New Year. Happy New Year.
00:14:48
Annatasha
But he will expand. like If he's in another country, he will hot dog it up there. But like he ranks the hot dogs. I'm waiting for the definitive encyclopedia of hot dog rankings to come out, authored by Dr. Bailey.
00:15:00
Annatasha
that is like his one true passion.
00:15:05
Ryan Bailey
If I, if I'd only known I could have monetized hot dogs in some way. I mean, I've read books about hot dogs. I have books I have to.
00:15:14
vetgb89
You read books and about hot dogs.
00:15:16
Ryan Bailey
was yeah Oh yeah.
00:15:16
Annatasha
First of all, I did not know there were books about hot dogs. So I'm at a loss here.
00:15:22
Ryan Bailey
There was a community. who went on a road trip in the summer during COVID and wrote a book about all the hot dogs she ate while on this road trip. It was called Raw Dog.
00:15:33
Ryan Bailey
It is a fucking hilarious book and Raw Dog.
00:15:36
vetgb89
Wait, wait. How was the book called?
00:15:39
Annatasha
Raw dog.
00:15:41
vetgb89
Wait.
00:15:42
Ryan Bailey
i learned I learned so much about dogs from that book and I already knew a lot about hot dogs.
00:15:43
Annatasha
yeah
00:15:49
Annatasha
You know, the only thing that pisses Bailey off more than subcutaneous ketamine is putting ketchup on a hot dog.
00:15:49
Ryan Bailey
just
00:15:54
Ryan Bailey
Hell yeah! That's for chi ldren!
00:15:57
vetgb89
Wait, wait.
00:15:59
Annatasha
Yeah, don't andt give ketamine and don't put ketchup on a hot dog. Bailey will just feel right over dead. Like his aorta will dissect like an overboiled hot dog.
00:16:07
Ryan Bailey
Yep. From all the hot dogs.
00:16:12
vetgb89
What do you put on it?
00:16:12
Ryan Bailey
The order's already, like, it's already on the verge because of all the hot dogs. I really upped my hot dog eating just to continue this dumb social media thing of right ranking dumb hot dogs I eat.
00:16:24
vetgb89
No, next time, next time we need to have like a hot dog contest.
00:16:30
Ryan Bailey
No.
00:16:30
vetgb89
I want a live review from you Ryan.
00:16:31
Annatasha
He won one. Bailey won a hot dog eating contest.
00:16:35
Ryan Bailey
No.
00:16:35
Annatasha
And I was more proud of him that day than I was the day he passed anesthesia boards. I was like, now there's an accomplishment.
00:16:41
Ryan Bailey
They were nachos for the record, but I was more proud of that than the anesthesia boards. I was like, I can't believe I won this nacho eating contest.
00:16:46
Annatasha
Oh, I'm so sorry. It was nachos. he ran I thought it was hot dogs, which is really gross.
00:16:53
Ryan Bailey
I could probably.
00:16:55
Annatasha
like Yeah, not to disparage people who are super eaters, but when you jam like 27 hot dogs there in your gullet in 20 minutes, I really, it makes me feel sick.
00:17:06
Ryan Bailey
They're doing like 60 and 10 Bartel.
00:17:09
Annatasha
Get out of here.
00:17:10
Ryan Bailey
Yeah, for sure. It's like a 10 minute contest and like the record is like 60 or 70. It's insane.
00:17:17
Annatasha
Holy, anyway, Bini is very stunned as an Italian because this is just the opposite of what he would consider to be a hot cuisine.
00:17:23
vetgb89
So
00:17:28
Annatasha
For our listeners, by the way, both Bini and Bailey are outstanding like home chefs.
00:17:28
vetgb89
definitely.
Ketamine in Cats with HCM
00:17:34
Annatasha
Both could pursue secondary careers in and like restaurant ownership and and kitchen management. But Bini is very European, and Bailey likes to eat hot dogs.
00:17:46
Annatasha
So that's where we really like
00:17:48
Ryan Bailey
Hell yeah look Maybe just some sub queue just a little bit
00:17:49
Annatasha
The stream is diverging here. But so, Gian luca if you can't see us right now, is utterly horrified by this hot dog revelation. And honestly, I feel like he needs like some intranasal ketamine to come back down to earth.
00:18:03
Annatasha
more
00:18:07
Annatasha
Yeah.
00:18:07
vetgb89
i
00:18:08
Annatasha
You know, ketamine stings. People forget that, right?
00:18:11
Ryan Bailey
right
00:18:11
Annatasha
Like, ketamine stings like the dickens when you give it.
00:18:12
vetgb89
Yeah. Think about.
00:18:13
Annatasha
And like, I am, or you, Like there's reports of patients self traumatizing because ketamine is so stingy. So it's like, not something, you know, like if we're giving ketamine sub cute and we really only have placebo results, you know, there's, there's a minor merit in arguing that you're probably doing more harm than good there.
00:18:29
Ryan Bailey
Right.
00:18:33
Ryan Bailey
Yeah, that's a reasonable argument.
00:18:34
vetgb89
Yeah, that's fair.
00:18:37
Annatasha
I thought that would make you happy, Bailey. I threw you that ah three of the bone.
00:18:39
Ryan Bailey
Thanks.
00:18:40
Annatasha
I threw you the bone.
00:18:40
Ryan Bailey
I appreciate it.
00:18:41
Annatasha
Yeah.
00:18:41
vetgb89
Yeah.
00:18:42
Annatasha
Okay. Next hard ketamine question.
00:18:44
Annatasha
Cat with HCM.
00:18:47
vetgb89
Ohhh
00:18:48
Annatasha
Well, I'm not done, it gets harder.
00:18:50
Ryan Bailey
and
00:18:50
Annatasha
Cat with HCM, constant rate infusion of ketamine under GA, a yay or nay?
00:18:59
Ryan Bailey
Cats are just like, what? And like, I am obviously a cat person. I'm sitting in our office and there is a little felt version of Lucy that is on her desk.
00:19:11
vetgb89
Aww.
00:19:14
Annatasha
Yeah, you also have a weird mustache, so that really speaks to being a cat guy.
00:19:18
Ryan Bailey
Yeah, for sure.
00:19:18
Annatasha
Yeah.
00:19:19
Ryan Bailey
a Yeah, cats are just such challenging creatures and like, they are just Like there's just, like half your drug cabinet is challenging to say the least when it comes to working with cats. And so if I have a cat under anesthesia and I think they need a ketamine infusion and I know they have HCM, I feel like you have to weigh the pros and cons and like what, like the simple, the simplest question I'm going to put back on you is why are we using ketamine in this, in this cat?
00:19:55
Annatasha
Okay, well that's a great question. So for one of the things, and I don't, I mean, this could be another podcast to be, but generally speaking, I do not put cats on lidocaine CRIs.
00:19:57
Ryan Bailey
yeah
00:20:02
Ryan Bailey
yeah I don't know.
00:20:06
Annatasha
I know it can be done, but my gonads are just not robust enough to do it, okay?
00:20:08
Ryan Bailey
Yeah.
00:20:11
Ryan Bailey
I'm much.
00:20:13
Annatasha
And I'm not a chicken.
00:20:15
Ryan Bailey
Yeah.
00:20:15
Annatasha
So so that's gone. We don't know whether or not opioids,
00:20:17
Ryan Bailey
Mm hmm.
00:20:21
Annatasha
Are they MACsparing Are they not MACsparing? Okay, fine.
00:20:23
Ryan Bailey
I can't be saying.
00:20:24
Annatasha
I mean, if I turn Platinum up high enough, it's MACsparing to the point of death, so there is that.
00:20:26
Ryan Bailey
and account
00:20:29
Annatasha
And then question or not, I mean, obviously the other option is dexmedetomidine, but let's pretend we just operate in a world where dexmedetomidine isn't available, and I'm forcing you to answer the ketamine question.
00:20:39
Ryan Bailey
Why are we putting the cat on ketamine in the first place? Is the cat challenging under anesthesia? Are we doing this as an adjunct analgesic drug in the plan before we even start the case? Is is this a case where the anesthetist keeps saying the cat's temper or heart rate and blood pressure are altering as the surgeon does surgery and then they quiet back down? um Yeah.
00:21:04
Annatasha
We could have a case where the patient is both, let's say we had poor outcome of our our regional block.
00:21:10
Ryan Bailey
Okay.
00:21:10
Annatasha
The patient's depth is getting to be problematic and cats like to do that thing where they're markedly hypotensive and fucking awake.
00:21:17
Ryan Bailey
Yeah.
00:21:17
Annatasha
and Right? And let's say it is responding intermittently with bursts of your favorite feline sympathetic tone to various forms of surgical manipulation.
00:21:22
Ryan Bailey
Yep.
00:21:27
Annatasha
And maybe we're doing an amputation where we might want to mitigate phantom limb pain issue.
00:21:30
Ryan Bailey
Totally.
00:21:32
Annatasha
Okay.
00:21:32
Ryan Bailey
Like, I don't think, like, I think nine times.
00:21:36
Annatasha
I think you should avoid answering the question.
00:21:38
Ryan Bailey
No, no, I think more nine times out of 10, I'm probably going to at least consider if not add the ketamine infusion. I think if we have an HCM cat who's getting a limb amputation, I would have a ketamine infusion as part of that cat's plan. I probably would not use a high dose of ketamine as like an induction level dose, but I feel Clinically, when I give the lower 0.5 to 1 mg per K, I don't see nearly the rate of tachycardia and sympathetic tone alterations that I see when you use those higher doses. then i you don't see those sympathetic tone changes that make me worried about this HCM cat when they're on these infusions, you know the 10, 20 micrograms per kilo.
00:22:33
Ryan Bailey
per minute. So I'm pretty comfortable doing that. especially like if we're thinking about this, I mean, right.
00:22:37
Annatasha
Would you say the spectrum or the degree of the cardiac changes associated with the HCM may affect your decision?
00:22:47
Annatasha
I mean, those doses you just quoted are basically subanesthetic. So, right. And so we don't really have good evidence about subanesthetic ketamine
00:22:52
Ryan Bailey
Which is what this is where are you i
00:22:57
Annatasha
causing an issue with cats and HCM just for the listeners to know. like There's no bulk of papers out there that looked at this.
00:23:03
Ryan Bailey
Yeah.
00:23:03
Annatasha
So as usual, this is our worthless two cents, but minus or minus two cents.
00:23:07
vetgb89
me
00:23:11
Annatasha
But yeah, like i'm just weren like I mean might err on the side of caution, for example, if the patient was dysrhythmic.
00:23:17
Ryan Bailey
Yeah.
00:23:17
Ryan Bailey
Oh, totally. Yes, for sure.
00:23:19
Annatasha
If we were close to congestive heart failure, I might pull back on that particular instance.
00:23:22
Ryan Bailey
Yeah.
00:23:24
Annatasha
But, you know, otherwise, like early ventricular septal thickening with like, you know, you've got no atrial smoke, you've got nothing like, you know, all of our cardiac output measurements are appropriate, ejection fractions, the velocity, everything is normal.
00:23:24
Ryan Bailey
I think if you saw low.
00:23:29
Ryan Bailey
Right. Yeah.
00:23:39
Annatasha
think the summary is, is yes, I would, Bailey would. What about you, Beanie?
00:23:44
Ryan Bailey
But wait, one thing though, the only thing I just want to point out is like, if you're saying this is a cat under anesthesia, who is sympathetically responding to the surgical stimulus, and you are saying, I am going to withhold ketamine, because I am worried that the sympathetic tone derived from ketamine is going to negatively impact this patient's cardiac like already compromised cardiac system I'm just going to let a completely fucking unregulated sympathetic tone to just keep going ham on this cat like what logical sense does that make it like
00:23:45
Annatasha
Oh, he's not done.
00:23:47
vetgb89
What?
00:24:22
Ryan Bailey
hurts my brain when I think about it for more than two seconds. It's like, okay, I'm not gonna give this drug because it affects sympathetic tone. Meanwhile, sympathetic tone is just like, whoa and you're just like, what is going on here? Anyway, sorry, that's just my two sons.
00:24:39
Annatasha
No, and you made it emphatically. which we appreciate the passion.
00:24:43
Annatasha
Like, yeah, like, you know, live your truth, Bailey. Like you've got the passion for what, you know, you love common sense and evidence-based medicine and cats and mustaches.
00:24:52
Ryan Bailey
and hot dogs.
00:24:52
vetgb89
and i go
00:24:54
Ryan Bailey
Anyway, to Beanie, would you put this cat on?
00:24:54
vetgb89
Wait, wait, wait. Are cats the bane of your existence?
00:25:02
Annatasha
Hmm. Trick question. That's harder than the ketamine question.
00:25:07
Ryan Bailey
But I love cats so much.
00:25:10
Annatasha
So much.
00:25:10
Ryan Bailey
Bartel and I send each other cat memes all day long.
00:25:13
Annatasha
hot and anesthesia meme We send Sometimes we send food memes.
00:25:16
Ryan Bailey
yeah
00:25:20
Annatasha
Once in a blue moon, if I catch like like a like ah ah stinging hot dog one, I'll send that his way. But for the most part, it's 99.9% cats.
00:25:28
vetgb89
Before I answer that question, what do we put on your hot dogs?
00:25:33
Ryan Bailey
me
00:25:34
vetgb89
Yeah. Because if you don't put ketchup, what do you put on it?
00:25:37
Annatasha
Bini is panicking, the the Italian inside him is panicking because he didn't know about the ketchup roll.
00:25:37
Ryan Bailey
yes
00:25:42
Ryan Bailey
So in in Chicago, the classic hot dog is Vienna beef hot dog in a poppy seed bun with relish, onion, pickle, sport pepper, tomato slices, mustard, and then celery salt sprinkled on top. Now, there's a variation that I find quite good where we take off the tomatoes. We don't always add the celery salt, so it's just onion, relish, pickle, and mustard.
00:26:10
Ryan Bailey
called the depression dog, usually served with french fries kind of rolled up into the hot dog.
00:26:12
Annatasha
a
00:26:16
Ryan Bailey
Those are like my two.
00:26:18
Annatasha
Well, Bini thanks for uncorking that bottle.
00:26:18
Ryan Bailey
those
00:26:19
vetgb89
Can you, can you, so wait, wait, can you even taste the hot dogs after you put all the stuff in it?
00:26:21
Annatasha
Also, we know more about hot dogs than we do about ketamine.
00:26:31
Ryan Bailey
Oh yeah. Cause the the Chicago hot dog has like a spice to it. It's kind of like, it's not like hot, but it's a little spicy and there's a lot of paprika and garlic in there. Oh man. You can definitely taste it. When you have like a shitty ass ballpark or like East coast hot dog tastes like dognet like, yeah, you can't taste it because you have all the vegetable matter, but It's because they they were developed in the Great Depression because then you got a salad with your meal and so you could get a hot dog for like a nickel.
00:26:59
Ryan Bailey
Man, could you imagine hot dogs for a nickel?
00:27:00
vetgb89
Wow.
00:27:01
Ryan Bailey
I would be dead.
00:27:03
Annatasha
Yeah, Bailey, you should never get ketamine, because I don't think your coronary arteries are going to take it.
00:27:10
Annatasha
Good lord.
00:27:11
Ryan Bailey
But that's like, that's another great point is humans have but so much more coronary arterial disease than our veterinary patients and we get ketamine and people aren't afraid of it. I mean, I don't think they're.
00:27:22
Annatasha
Well, it has a massive safety index, right? Like your, your, your lethal doses of ketamine are like off the chart and to have like any sort of form of like chronic detriment associated with like abusive levels of ketamine literally takes years now.
00:27:35
Ryan Bailey
Yeah.
00:27:36
Annatasha
When it does happen, your lower urinary tract necrosis and sloughs out of your body, which does not sound like a good time. I'm not condoning that. But ketamine really does have a very high index of safety from a point of view of clinical use. And I feel like people think that ketamine is like this like monster hammer of a drug that you only bring in for like pets who are really fractious or like you really needed to like drop them hard and I'm like you know just like a little whiff of ketamine really goes a long way you know like a spoonful of sugar with a little bit of ketamine like induction improves your first like 30 to 40 minutes of anesthetic plane improve you know like there's no rock and roll going on you can
00:28:18
Annatasha
Yeah, like I just, people are so weird about ketamine and I'm like, ugh.
00:28:23
vetgb89
yeah Yeah, sorry, I so yeah, shock, sorry.
00:28:24
Ryan Bailey
Well, anyway, Bini you got to answer the question. Are you going to put this cat on?
00:28:27
Annatasha
All right, he hasn't recovered from the hot dogs.
00:28:33
Ryan Bailey
what
00:28:33
Annatasha
Have you been playing catch up on your hot dog?
00:28:35
Annatasha
Cause this is.
00:28:36
vetgb89
I what they usually do is catch a tomato together on my hot dog.
00:28:40
Ryan Bailey
Hell yeah.
00:28:46
vetgb89
And In reality, I don't do it as often as I would like to anymore because the only hot dogs we get are when we are in a rush we're at Costco, and you know the $1.50 hot dog at the end seems like a lifesaver after you spend like three hours in fucking Costco.
00:29:10
Ryan Bailey
so
00:29:10
Annatasha
thousand dollars
00:29:11
vetgb89
Debating with your wife whether you should buy
00:29:12
Annatasha
yeah
00:29:16
vetgb89
or not, the ginormous garden penguin for Christmas, the one with the scarf and the like, you know.
00:29:24
Annatasha
I seriously hope that you guys got the penguin.
00:29:27
vetgb89
Well, I'm debating between the penguin, which is basically almost as tall as me, and then there is this ginormous teddy bear, which is twice as tall as me, which is enormous.
00:29:37
Ryan Bailey
Oh my gosh.
00:29:42
vetgb89
Also, we had this huge debate between the 7.5 feet, the feet, of 12 15 feet Christmas tree.
00:29:52
Ryan Bailey
well Oh my God.
00:29:54
Annatasha
Listen, Beanie, I mean, if you're gonna do it, like go hard or go home. And no wonder you need a $1.50 hot dog at the end of this.
00:29:59
vetgb89
The 15 feet Christmas tree is like $1,600.
00:29:59
Ryan Bailey
Yeah.
00:30:01
Annatasha
Like this is a shocking
00:30:02
Ryan Bailey
Yeah.
00:30:05
Ryan Bailey
Hell yeah.
00:30:09
vetgb89
I can do that.
00:30:11
Ryan Bailey
Yeah.
00:30:13
vetgb89
Yeah, a thousand.
00:30:13
Ryan Bailey
You have to kill you.
00:30:15
vetgb89
A thousand fucking hot dogs. Straight up.
00:30:19
Annatasha
Just straight up 1,000 hot dogs. Yeah, you'd all be dead.
00:30:23
vetgb89
A shift to Bailey.
00:30:26
Annatasha
god he would love it
00:30:27
Ryan Bailey
he yeah
00:30:28
Annatasha
but okay so Bini would you what
Ketamine for Cats with Cardiac Issues
00:30:29
Annatasha
are your thoughts here hcm academy of mean
00:30:30
vetgb89
Yeah, I would so if was responding to surgery 100%, right? If I didn't have Dexmed I didn't have Fentanyl I didn't have buprenorphine or anything like that, then yes, ketamine will be fine.
00:30:44
vetgb89
I don't think the low dose ketamine, like in a CRI or, you know, even just small boluses actually do cause the tachycardia that everybody's afraid of with HCM cats.
00:30:52
Ryan Bailey
Hell yeah.
00:30:56
vetgb89
At least I've never seen it. The other part of the story is that, you know, we do know that cats with heart murmur don't necessarily have heart disease.
00:31:11
vetgb89
Cats without heart murmur may or may not have heart disease. And probably 99% of the cats in the world go under with Kitty magic, right? DKT
00:31:22
vetgb89
Where, for whoever's listening, K stands for ketamine.
00:31:22
Ryan Bailey
Yeah.
00:31:26
vetgb89
so Almost every single cat in the world gets ketamine at some point in their life, whether we know or we do not know if they have a murmur or not, or if they have HCM or not. So like I think ketamine is actually rather safe. We have this huge scare about it for the you know potential to Tach y cardia that you can get.
00:31:46
vetgb89
But as long as you don't go crazy with it, I think you're fine. I personally maybe wouldn't induce with it, like, ketamine midazolam kind of induction, you know, I would use that I could do propo fol ketamine, where, you know, the ketamine is just a co-inductor, I can use it at one or two Mg per Kgs Fine. Now, I wouldn't slap five Mg per Kg in one shot in a cat, maybe, if I knew that it had HCM. But you know, why not? Low dose, pain management, sure, whatever. For the record, what doses do you do normally for your ketamine CRI's?
00:32:28
Annatasha
Gosh, anywhere from five to 20 usually, although once in a blue moon, I'll kick it up to 40.
00:32:36
vetgb89
wow
00:32:36
Ryan Bailey
Yeah, I'm in the 10 to 20. I don't really get out of bed before 10 and then go to 20 something. I mean, like, I'm sure you know Bini but isn't it but somewhere up in Canada where they go like 120, right?
00:32:54
Annatasha
Uh, it's OVC, which is just, you know, a stone's throw from where I live.
00:32:55
vetgb89
that
00:32:59
Ryan Bailey
Yes.
00:32:59
Annatasha
Not really, but OVC is in Ontario and they start most of their ketamine infusions between 20 and 40 moderate.
00:33:06
Ryan Bailey
yeah
00:33:07
vetgb89
I think you're talking about lidocaine they go up to 200.
00:33:10
Ryan Bailey
oh man and thought there was some
00:33:13
Annatasha
Okay. And they do, they go up to 200, they go, they start one 20 is their sort of moderate intermediary, but they will go up to 200 and they've published it, but.
00:33:24
Ryan Bailey
I thought there were some people that went up to like, I think it's a hundred a hundred and 120 where you're starting to get like actual anesthetic effects of ketamine. And I think that's, that's at least what I remember learning in residency.
00:33:35
Ryan Bailey
And I thought there's some group somewhere who does that not infrequently, but I could not.
00:33:42
Annatasha
Well, let's not blame Canada, first of all.
00:33:44
Ryan Bailey
<unk>
00:33:44
Annatasha
And we only have like three vet schools, so I doubt it's us.
00:33:44
Ryan Bailey
i happen to think
00:33:49
Annatasha
Yeah, and one's in French, so we'll never know.
Neuroprotection and Septic Use of Ketamine
00:33:52
Annatasha
but and But yeah, okay, and then gentlemen, in the interest of time, let's move on to everyone's next favorite topic, which is ketamine and seizures and ketamine being neuroprotective.
00:34:05
Annatasha
Bini, I'm gonna lead with you.
00:34:05
vetgb89
Nice.
00:34:07
Annatasha
What are your thoughts?
00:34:07
vetgb89
So I think if you have imaging and we knew it doesn't have an occupying space lesion, then yes, I could do that.
00:34:08
Annatasha
If you have a patient with well-controlled seizures, will you put ketamine into your anesthetic protocol?
00:34:26
vetgb89
If I believe the retina,
00:34:28
Annatasha
And just explain to the listeners why you make that differentiation about having something that's causing compression within the brain or within the skull, I should say.
00:34:35
vetgb89
well Yeah, so like if your patient has a either a hemorrhage or you know a mass or something that increases the volume within the skull, of course, you're going to have a potential increase intracranial pressure. One of the goals under anesthesia for managing patients with potential increase intracranial pressure is to decrease cerebral blood flow, we do know that we do not really know what ketamine does with cerebral blood flow. There are studies that show that we don't know. That's the legit answer there. There are studies that show that it does increase cerebral blood flow and intracranial pressure. There are studies that show that it decreases cerebral blood flow and intracranial pressure. So we don't really know. When I don't know, I try not to use it.
00:35:26
vetgb89
And so that's that's my my reasoning. If it's just a case of idiopathic epilepsy, whatever. Actually, there are studies that show that high doses of ketamine are anti-epileptic, so you know why not?
00:35:43
Annatasha
Yeah, that's the perfect medical attitude. Fuck it.
00:35:48
Ryan Bailey
Oh, yeah.
00:35:48
Annatasha
Fuck it. Let's see what happens. By the way, just kidding, that's not how we treat patients. Bini, I'm getting the feeling that you agree with ah ah Bailey, sorry, but God, there's so many bees.
00:35:59
Annatasha
Bailey, you agree? I'm a bee too.
00:36:01
Ryan Bailey
Yeah, we really should have thought, one of us should have changed our name at least so we're not all just bees. We really should have like thought about that one or just like, you know, recruited.
00:36:10
Annatasha
No, I love it. I love Bini Bailey Bartel. i so I talk about us all the time like that. It has nice literation.
00:36:17
Ryan Bailey
i yeah like I would definitely use it, especially where we know there's no space occupying lesion. Epileptic patient who's getting a TPLO, yeah, induced with ketamine, don't really care. like I'm not going to think twice about it, honestly.
00:36:31
Ryan Bailey
um um Now, if we have the patient who needs an emergent brain um MRI was a potential vehicular trauma case and like Someone's like, we're gonna do rapid sequence induction, which like, whatever, taking from the taking terminology from the human literature, rapid sequence induction would be like, generally in humans seems to be propofol and ketamine is the preferred rapid sequence agents. I'm probably gonna push back on that and question whether the ketamine's going to be super, like, is it the best drug in that situation?
00:37:09
Ryan Bailey
I'll be honest, I don't know enough about the kind of neuroprotective stuff coming from the human brain trauma literature. So like, I don't feel
00:37:18
Annatasha
Well, it's funny that you brought that up because that was parlaying into my next question.
00:37:22
Ryan Bailey
and wow
00:37:24
Annatasha
Yeah, I was about to say that actually in rat models where they have traumatic like induced traumatic brain injury, ketamine has been shown to have like potent anti-inflammatory effects.
00:37:37
Annatasha
In fact, it's meant to be anti-endotoxemic, right?
00:37:41
Ryan Bailey
Right.
00:37:42
Annatasha
So in TBI, actually, there's quite
00:37:43
Ryan Bailey
Yes.
00:37:46
Annatasha
a robust amount of literature that ketamine, even at higher doses, can be highly beneficial. Now, I'm going to counter that with, I don't know if you guys have ever seen a TBI who's on ketamine, but your ability to perform reasonable neurological assessment can be impeded because that patient who A, has swelling on the brain, and B, who just gave a dissociative anesthetic to.
00:38:12
Annatasha
They look absolutely mental. So so like I don't know how neurology mitigates that. But at the same time, like like they really like are whoop-de-doo, all over the kennel and what have you.
00:38:19
Ryan Bailey
Yeah.
00:38:25
Annatasha
So whether or not that's concerning, I mean, I could see it might be concerning if you had other fractures or other traumas. like And then like just thrashing around and being like nutso on the ketamine might not be necessarily the most helpful thing.
00:38:36
Annatasha
But um yeah, no, I think there there's pretty decent evidence about potent anti-inflammatory, potent anti-cytokine basically, anti lipopolysaccharide, which is really like the mitigator of endotoxemia.
00:38:38
vetgb89
Okay. Okay. Okay. Okay.
00:38:50
Annatasha
These are all things that we can attribute to ketamine in these models. So yeah,
00:38:57
Ryan Bailey
and i asked aen hi um
00:39:02
Ryan Bailey
So then with the antistatic kind of anti endotoxemic, should we be using it in our potentially septic cases? Should we be using it more often? You know, again, I think all three of us are probably going to generally agree, like I'm not going to be using ketamine to like, you know, five makes per keg of ketamine midazolam to like induce a patient. But, you know, should it be considered early on in these potentially septic cases?
00:39:33
Annatasha
Well, I'm going to tease this out a little bit because there's a there's that subtle difference between sepsis and endotoxemia, right?
00:39:42
Ryan Bailey
Right.
00:39:42
Annatasha
And we don't actually get true endotoxemia in dogs and cats the way, for example, we see in horses, right?
00:39:42
Ryan Bailey
Yeah.
00:39:49
Ryan Bailey
Right.
00:39:50
Annatasha
So will I run my horse patients on ketamine?
00:39:53
Ryan Bailey
Yeah.
00:39:54
Annatasha
if I suspect colic sepsis endotoxemia, because all of that stuff can really cascade quickly down the drain when you're under GA.
00:40:03
Ryan Bailey
yeah
00:40:04
Annatasha
Yes, I will probably be highly inclined to do so. But how often do I see true endotoxemia in a dog or a cat? i't can i answer I don't think I can answer that question.
00:40:13
Ryan Bailey
What's in it? Like the anti-cytokine, like those kinds of...
00:40:17
Annatasha
Yeah, and cytokines mitigate different parts of the inflammatory pathway.
00:40:20
Ryan Bailey
Yeah.
00:40:20
Annatasha
So that it might be, I mean, most subject patients I put on ketamine anyway, because I want to have iso at zero, if I can possibly manage it.
00:40:28
Ryan Bailey
Right. Yeah. Yeah, for sure.
00:40:32
Annatasha
Yeah, so I think there's probably merit in that.
00:40:33
vetgb89
Okay. Okay. Okay. Okay.
00:40:34
Annatasha
I mean, a lot of the drugs are doing a lot of things that we probably don't know about. And in the most part, we're lucky because it's either benign or
00:40:45
Annatasha
the negative, the adverse outcome is irrelevant or we're lucky enough to benefit in some way, right? so
00:40:52
vetgb89
Right. I mean, in reality, a bunch of these, you know, neuroproductive effects are also seen in lidocaine and vitro, right? Never been proven in vivo from what I'm aware of. But, you know, that was the reasoning why a lot of people will run horse colleagues with lidocaine CRI's. Now, that said, I do tend to run horses and also colleagues with calamine CRI's. I usually start at 30 mpg per minute and I leave it there.
00:41:31
Annatasha
I love about an anesthesiologist when we say things like, I sort of start at 30. And for our listeners, when you hear an anesthesiologist say that in that particular tone, it means I have no evidence for this decision other than that's what I'm comfortable doing, but I have no idea actually.
00:41:46
Annatasha
Just yeah just translating for everybody.
00:41:48
vetgb89
that
00:41:48
Annatasha
Yeah.
00:41:48
vetgb89
that's probably, probably accurate.
00:41:50
Annatasha
yeah yeah
00:41:52
vetgb89
But anyway, um um but yeah, so, you know, in places like at N C State they've been doing this for years, right? So we would run every single horse, including colics in, on Dexmed, Ketamine, and Lidocaine CRIs
00:42:11
vetgb89
That's because we want to keep their ISO around zero.
00:42:17
vetgb89
without killing us all. but know But anyway, so yeah, um but so now circling back to your question, right?
00:42:18
Annatasha
Yeah.
Balanced Anesthesia Methods
00:42:36
vetgb89
If you want to keep your ISO at zero, why don't you fucking do TIVA?
00:42:41
Annatasha
I mean, I'm i'm basically, yeah, Tiva is fine. I'm all for Tiva. And I don't know what Bailey is doing right now.
00:42:45
vetgb89
I
00:42:47
Annatasha
He's having some sort of Tiva meltdown, but and I have gotten into it before about Tiva and thoracotomies. But yeah, I mean, I'm all for Tiva, but you know,
00:42:58
Annatasha
I'm not actually gunning for necessarily, it depends on, again, it's your spectrum of how sick your patient is.
00:42:59
vetgb89
had a third gamut.
00:43:03
Annatasha
If you have like a colic who kind of walks in with like the symptoms and the sweating, and maybe it has like nephrosponic entrapment, sure, I'm going to probably, you know, be a little bit more or less safe fair my isoflurane. So, you know, I might use it only to mitigate the issue of unconsciousness, whereas everything else I'll use for muscle relaxation and analgesia, abated autonomic tone. I don't really think we get amnesia, but luckily horses aren't smart enough, actually, I think to remember, so it's fine.
00:43:38
Annatasha
But yeah, I think in the case of can you do TIVA? sure. If they're very sick, I won't have them on inhalant at all. And sometimes the animal tells you that, right?
00:43:46
Annatasha
Like you start on inhalant and you're like, oh, no, this is a bad idea. And then the surgeon goes, how are things going? And you're like, well, the ISO has been off since you cut.
00:43:53
vetgb89
I had a surgeon that specifically did not, you mentioned the thoracotomies right?
00:43:55
Annatasha
So you tell me.
00:43:57
Ryan Bailey
ah
00:44:00
vetgb89
I had a surgeon that specifically didn't want thor acotomies on Tiva because they wanted to be able to smell whether there was a leak in the lungs.
00:44:08
Ryan Bailey
Oh my god.
00:44:12
Ryan Bailey
What?
00:44:14
Annatasha
You know what? You don't have to be that smart to be a surgeon and you can put that in the podcast.
00:44:20
Annatasha
That is the most irresponsibly stupid thing that I've heard.
00:44:20
Ryan Bailey
That is such a wild
00:44:26
Annatasha
probably since three o'clock today. There was a lot of stupidity earlier in my day, but yeah, like, no, everybody who's listening, we do not intentionally wait until we can smell inhalation agents and we're 25 times over the recommended daily exposure limits, not to mention just chewing through the ozone layer with waste and aesthetic gas.
00:44:44
Annatasha
Like we do not intentionally ever try to smell the inhalant in any circumstance.
Advocacy for Evidence-Based Practices
00:44:48
Annatasha
So a surgeon who says that should probably not cross my path in the OR.
00:44:51
Ryan Bailey
Uh,
00:44:55
Ryan Bailey
what it's like your sense of smell like you, like that's going to be the thing that like, Oh, there's a leak cause I can sniff it.
00:45:06
Ryan Bailey
I got a real good schnozel or whatever. Like, like the bubble test has been around for a long time. Like what are we?
00:45:15
vetgb89
yeah right
00:45:17
Ryan Bailey
Yeah.
00:45:18
Annatasha
Yeah, that's kind of like, oh, I wonder if there's a carbon monoxide leak. Maybe I'll just close all the windows and see if I can sniff that one out. Like, absolutely not.
00:45:28
Annatasha
Unacceptable.
00:45:29
Ryan Bailey
Yeah.
00:45:30
Annatasha
Unacceptable standard of medical practice.
00:45:30
Ryan Bailey
Yeah.
00:45:33
Ryan Bailey
Yes. Yes.
00:45:34
vetgb89
and
00:45:34
Ryan Bailey
Like, when I listen for a leak in the cup, A, first of all, the ISO is not on because...
00:45:36
vetgb89
Yeah,
00:45:42
Ryan Bailey
any number of reasons. And two, it's like, I use my ear.
00:45:44
vetgb89
right?
00:45:46
Ryan Bailey
Like, I'm not like...
00:45:51
Annatasha
No. Yeah. No, I'm so antagonized by that comment, Beanie. Oh my God. Like I started to sweat in weird places when you said that.
00:45:59
vetgb89
You can imagine my surprise when I had to hear that. I was like, okay.
00:46:03
Annatasha
Also, I would appreciate if surgeons stay out of the anesthetic protocol mix because it's basically like having your mechanic giving you gynecological advice.
00:46:03
Ryan Bailey
What if you were like, oh!
00:46:11
Annatasha
Like it's not appropriate.
00:46:15
Ryan Bailey
like Desfloraine? Like, how good is he at detecting Sivo or Des?
00:46:21
Annatasha
I don't know, maybe he's crossbred with some kind of like bloodhound and has like a high degree of sensitivity for this, but I'm like, no, this is not acceptable.
00:46:21
vetgb89
That could be a stylist.
00:46:28
Ryan Bailey
No way.
00:46:30
Annatasha
We did not sniff out the problem for God's sakes.
00:46:35
Annatasha
Not bomber dogs, people.
00:46:40
Annatasha
Wild, wild. Yeah, there's just some stuff that goes on.
00:46:43
vetgb89
people are wild.
00:46:45
Annatasha
I'm sure it goes on in all anesthesia, but in veterinary anesthesia, it is extra mental, 100%. like
00:46:50
Ryan Bailey
Oh yeah.
00:46:52
Annatasha
Yeah, I'm sad to say, bless the hearts of all of us who do this job, but honestly, there are just days where I'm just like head shake, just head shake and glass of wine.
00:47:02
Ryan Bailey
Yeah, just praying for the day the A.I.
00:47:04
vetgb89
yeah
00:47:05
Ryan Bailey
overlords come to take my job.
00:47:08
Annatasha
Bailey, you have the hot dog as a backup.
00:47:12
Ryan Bailey
That's true. I could open a hot dog stand. I could probably do it. I've got the mustache for it.
00:47:16
vetgb89
Okay.
00:47:16
Ryan Bailey
All right.
00:47:16
Annatasha
You can teach a TED Talk on hot dogs, yeah.
00:47:17
Ryan Bailey
yeah feel all those cool paper Oh, my God.
00:47:20
Annatasha
You could teach a Ted Talk on hot dogs. I don't know who'd listen, Norm from Cheers, but that's about like, yeah.
00:47:23
Ryan Bailey
Yeah.
00:47:27
Annatasha
Like your your level of hot dog knowledge is moderately terrifying.
00:47:34
Ryan Bailey
So and do you have any other questions
Ketamine's Reputation in Veterinary Medicine
00:47:36
Ryan Bailey
about Academy or can I ask some?
00:47:36
Annatasha
You know what, Bailey? How about it? Let's rock this.
00:47:41
Ryan Bailey
All right. So we are we are probably all of the, I don't know, like the probably transitional generation of veterinary professionals where the people before us, ketamine was like a mainstay.
00:48:01
Ryan Bailey
Like ketamine was, that was it. That was what you had. And there was no, yeah.
00:48:07
Annatasha
Cheap, cheerful, effective, available, probably wasn't controlled in those days.
00:48:14
Ryan Bailey
yeah
00:48:15
Annatasha
Yeah. It's just, okay, it's hosin' it down, Ketamine.
00:48:15
Ryan Bailey
Yeah.
00:48:18
Annatasha
Yeah, I hear ya.
00:48:19
Ryan Bailey
And
00:48:21
Ryan Bailey
Like, I will say as a student, I don't, like as a student who was really interested in anesthesia as a student, I cannot say if I use ketamine and like, you know, whatever.
00:48:33
vetgb89
Where did you go to that group?
00:48:35
Ryan Bailey
Yeah, I don't, I just don't know if I did, I'm just trying to think. I mean, that was like so long ago now. I'm just like, what do you have to do to use ketamine?
00:48:44
Ryan Bailey
And now you have, University of Illinois.
00:48:48
vetgb89
Oh nice, with the corn sweat.
00:48:49
Ryan Bailey
with Clark Price and Jordan Bastian.
00:48:52
Annatasha
Yeah.
00:48:53
Ryan Bailey
Yeah, exactly, exactly.
00:48:57
Annatasha
That's the name of their football team.
00:48:57
Ryan Bailey
If a football team's in a transition because of the names, they even have some rules.
00:49:06
Ryan Bailey
And I feel the new generations really don't like the way traditional ketamine inductions look because they're so used to propofol now and olfax alone that you see these like patients who are like, relax, head down, tongue, know, like no pale people reflux, like they are anesthetized. And ketamine, they just don't look that way and you get people who are not comfortable with this drug and they're pushing ketamine and then the dog starts to have the psychomimetic effects
00:49:40
Ryan Bailey
and then they're pushing ketamine and the dog has more psychomimetic effects and like he's still too light I need more drugs and you're like no you don't you just need to get the tube in at this point because the dog is like loaded up on ketamine I promise you so like I don't like I don't know if I have a question there more of a statement I
00:49:59
Annatasha
i was wondering if we were getting to the point soon but yeah
00:50:04
Ryan Bailey
feel like I think we've done a disservice just generally with like the advent of purple falling off. Excellent. That ketamine has really are just knowledge and use of it has fallen out of favor.
00:50:15
Ryan Bailey
And that I think is a disservice and what can we do to, you know, bring back the.
00:50:20
Annatasha
No, I'm not sure my opinion on the situation isn't necessarily driven per se from an induction point of view. But I can tell you that I do feel like ketamine has almost been vilified, right?
00:50:28
Ryan Bailey
still put thats like
00:50:33
Ryan Bailey
Yeah. Yeah.
00:50:34
Annatasha
I don't know if it's because it's old fashioned. I don't know if it's because it's so weird though, because in vet med and vet anesthesia, people get upregulated about very specific side effects associated with drugs.
00:50:44
Annatasha
And meanwhile, every drug has side effects. So where we'll drown something. in an opioid, even though you can have hypoventilation, bradycardia, hyperthermia, hypothermia, panting, amesis. Don't give a shit. You know, just push, push, push fentanyl until the patient is like, we're coming and regurgitating. But like a little bit of ketamine, it's totally like We don't need that. The patient's not that fractious. Or like, I don't want to cause tachycardia. And you're just like, first of all, if you're using ketamine at normal clinical doses and using it appropriately, oftentimes in conjunction with other balanced anesthetic protocols, I never see these tachycardic hypertensive explosions from ketamine.
00:51:27
Annatasha
so I'm like, you know, like let's, I'll take it down a notch because we are okay with these side effects on this drug, right? But we're not okay with the known side effects that are less actually clinically relevant on this drug.
00:51:40
Annatasha
And like I said, you know, like you'll have people sedate with like 0.2 Torb and like two of Dexmed IM and then you want to put it into a CT for half an hour. And the patient's like re writing a book and you're like, okay, well, let's just top it up with some ketamine.
00:51:54
Annatasha
And they'll be like, I'd rather push all facts.
00:51:57
Ryan Bailey
Oh my gosh.
00:51:57
Annatasha
And your speech makes no sense whatsoever.
00:51:58
Ryan Bailey
Yes.
00:52:01
Ryan Bailey
Yes, it's like we are anesthetizing horses every day with like ketamine xylazine. Little put two ketamine, one xylazine. Little push here, little push there.
00:52:12
Ryan Bailey
Horse stays asleep, nice and beautiful. Wakes up super pretty. Everyone's happy. We move on with our lives. And it's like, oh, you want to, maybe we'll use some ketamine in this wound repair that's not going super well.
00:52:24
Ryan Bailey
And like, we'll top it up with little a little ketamine and then once he starts getting rigid, we'll add a little dexmed for some muscle.
00:52:28
Annatasha
and it's And it's driven by other clinicians too, right? Like other clinicians tell me, I don't think the ketamine is necessary.
00:52:35
Ryan Bailey
yeah
00:52:35
Annatasha
And i mean what is that statement based on?
00:52:36
Ryan Bailey
yeah
00:52:39
Annatasha
I don't think ketamine is necessary because it is really efficacious as a sedative and it's going to buy you like 30 to 40 minutes of the patient being still. And in conjunction with the Torb and dex med, you're gonna get good relaxation.
00:52:51
Annatasha
And then it's just gonna wake up really nicely and go home. Or you'd rather just keep bolusing propofol until the patient goes blue and I have to intubate it. Like, it doesn't make any fucking sense to me.
00:52:59
Ryan Bailey
yes.
00:53:02
Annatasha
And it is super frustrating. And other people are like, I don't think that's necessary. And I'm like, I sedate a zillion things a day for the last zillion years. And you're coming in this one time and giving me smack talk about ketamine.
00:53:14
Annatasha
Where did this come from?
00:53:16
Ryan Bailey
Yes, I'm telling you, I think it's a generational shift where ketamine was day bread and butter every day, all the time. And then it became out of favor because of the way the induction quality looked.
00:53:28
Ryan Bailey
And now it's like ketamine is reserved for like the wildest of the wild animals.
00:53:32
Annatasha
Like, are you going to do a zebu or anroco dile?
00:53:34
vetgb89
a while.
00:53:36
Annatasha
Like, then you are allowed to use ketamine, but the rest of the time, like for the cat, he'll take your face off.
00:53:41
Ryan Bailey
Oh yeah.
00:53:41
Annatasha
Oh, let's just try to try to olfax one and see how that goes.
00:53:47
Annatasha
What?
00:53:49
vetgb89
Yeah, I think so I always push my students to do try at least ones in the rotation, Academy Midazolam, and usually
00:53:57
Ryan Bailey
but see at least one right why not all like I mean like but for a variety of reasons, but it's just funny because it's like we try, I get them to try it once, you know, I'm, I'm the same way.
00:54:08
Ryan Bailey
I'm not, I'm no different than you. be I'm not like denigrating you. I'm just saying like, we're all like, let's try it. Let's just, uh, just try it. It'll be okay. Like I'll be right here.
00:54:17
Annatasha
yeah
00:54:18
Ryan Bailey
I'm not like, I'm not like, okay, kill this dog in front of me and then I'm going to blame you for it.
00:54:24
vetgb89
so But I could follow up on that statement.
00:54:28
Annatasha
The side notes, just a side note to all our listeners, Dr.
00:54:28
vetgb89
So I usually try to do this.
00:54:31
Annatasha
Bailey is not in an academic position where he's in charge of training students.
00:54:39
Annatasha
My word.
00:54:41
vetgb89
So I always try to like to try to get them to try once.
00:54:42
Ryan Bailey
Bye.
00:54:46
vetgb89
And I usually do it in the very first week of the rotation. And the answer I get afterwards, when I asked them, what do you think? It it was the same. They didn't see any difference between propofol ketamine or propofol midazolam and ketamine midazolam. If you use an adequate dose of midazolam, I don't think that you see these major differences. I don't know if people
00:55:17
vetgb89
got into the habit of using ketamine alone as a sole agent and hoping that they wouldn't be rig i d.
00:55:23
Annatasha
As like as an academy stun. Yeah, that is old school and I'm not on board for that.
00:55:28
vetgb89
It is. It is. But you know, I don't know if that's what scares people out. I don't know if I don't know. I think it's a trend, really. But
00:55:36
Ryan Bailey
Yeah. yeah
00:55:39
Annatasha
I think we need to stop vilifying ketamine.
00:55:41
Ryan Bailey
Oh yeah. Yeah. That was, that was my point is like, that's a drug that.
00:55:44
Annatasha
Yeah. Like I always rock up like when I when I first went to Singapore, right? They didn't even have ketamine in anesthesia. And within the first month, we went through one of like the 100 mil bottles. And they everybody was like, and now everybody's always like, you know, because I'm like, it, it has high clinical utility in a wide safety margin, and it's highly beneficial.
00:55:53
Ryan Bailey
Yeah.
00:56:02
Annatasha
So this weird reservation for ketamine for only like the wackiest patients or the the meanest animals, you know, and it's like, why would you not rather do that than have to constantly top up a hypnotic agent where you could crash and burn them big time from that.
00:56:18
Annatasha
I recently had this ah ER ER case that came in and I was literally, it was one of those cases where I'm just like strolling through the room, like looking for snacks.
00:56:18
vetgb89
Yeah.
00:56:19
Ryan Bailey
Right.
00:56:25
Annatasha
And like this patient is on the table and it's, and it's you know, paradoxically breathing and it's blue. And I was like, oh, timeout, like what's going on? And they're like, well, we're not really sure. Anyway, a patient had a tension pneumothorax from a lung purr from a foreign body, right?
00:56:38
Annatasha
And I was like, time to, they were like, we're not sure we should intubate. And I was like, okay, well, just to be clear, when the patient looks like this and it's blue, like it's time to intubate, like you need to support it. Otherwise it's going to arrest. Fair enough. But they handed me a syringe of propofol.
00:56:52
Annatasha
right to try and just take the edge off to induce it. And I just kept passing the propofol right along. I was like, can you give me some ketamine? I was like, I'm not pushing propofol. This patient will die.
00:57:03
Annatasha
right And I was like, that is not the appropriate choice in that kind of level of respiratory distress that you're going to push a drug that induces apnea. I mean, the patient's already cyanotic.
00:57:13
Ryan Bailey
Right.
00:57:13
Annatasha
But it's like, we treat propofol and alphaxolone They're these almost like benign agents that you can just endlessly top up forever and there'll never be a consequence or a penalty.
00:57:26
Annatasha
And I'm like, let me be clear. I will kill this dog if I push propofol. Let me be clear, I will not kill it if I push ketamine and imidaz.
00:57:30
Ryan Bailey
Oh, yeah.
00:57:34
Annatasha
And ketamine is a broncho dilator, so I'd know.
00:57:35
vetgb89
Yeah.
00:57:38
vetgb89
Yeah. A lot of people forget. I always tell my students in the lectures, like, you know, it it is one of the agents of choice in the battlefield, you know, because they don't have access to oxygen.
00:57:47
Ryan Bailey
Yeah.
00:57:50
vetgb89
So they need to keep those patients breathing. They don't have a mean to intubate them and breathe for them. So that's what they that's what they use. If you get injured in the battlefield, they do use ketamine and some other agent.
00:58:02
vetgb89
But, you know,
00:58:04
Annatasha
Oh, our next podcast, I really want to talk about battlefield anesthesia. It's like profoundly interesting the way that they choose to practice it, but yeah.
00:58:08
Ryan Bailey
Yeah, okay.
00:58:16
Annatasha
Yeah, battlefield anesthesia is a wild.
00:58:20
Annatasha
Anyway, so summary of this evening's random anesthesia topic is that we all really very much appreciate ketamine, often use it in first line therapy,
Episode Wrap-up and Future Teasers
00:58:33
Annatasha
A lot of the urban legends around the contraindications are easily mitigated through appropriate dosing balanced anesthesia, and Bailey's probably going to have a coronary from hot dogs.
00:58:45
Annatasha
so
00:58:49
Ryan Bailey
That's perfect music.
00:58:50
Annatasha
That's hot dog music, Bini. like That's what you play at the game when people are jamming hot dogs down their gullet.
00:58:52
Ryan Bailey
It is.
00:58:56
Ryan Bailey
I am jamming hot dogs.
00:58:59
Annatasha
They're so weird. They're Anyway, yeah, like that that's our random anesthesia topic. Bailey managed to get through it without dissecting his aorta or stroking out.
00:59:10
Ryan Bailey
Nice.
00:59:10
Annatasha
But yeah, we're not, we love ketamine, bless its heart.
00:59:14
Annatasha
I don't think any of us are overly excited about the sub-cute ketamine, placebo, shenanigans. I don't understand why anesthesia has these bursts of weird trends and popularities.
00:59:25
Annatasha
Like we're some sort of Instagram phenomenon. like You know, it was gabapentin and maropitant and now all of a sudden we're on this subcute ketamine like a trend kick and it's like...
00:59:36
Ryan Bailey
It has to do with side effects. It's like, well, this seems like it has to do with side effects, so we should do it.
00:59:43
Annatasha
Oh yeah, I mean, I laugh because one of my surgeons was using the workstation and the pharmacy below the cupboard that had gabapentin and he had to move his workstation because so many times a day people went into gabapentin, he could not get any work done.
00:59:45
Ryan Bailey
it's so
00:59:49
vetgb89
Okay.
00:59:56
vetgb89
Okay.
00:59:57
Annatasha
He was like, I can't focus. He's like, someone's in the gabapentin cupboard like every 14 seconds. And I was like, mm-hmm. Totally inappropriate, total inappropriate use of gabapentin. But yeah, I was like, yeah, don't sit under the gabapentin. Don't sit under the gabapentin, everybody.
01:00:16
Ryan Bailey
and
01:00:16
Annatasha
you'll never
01:00:16
Ryan Bailey
oh
01:00:17
Ryan Bailey
And budding anesthesia residents or, you know, the people who are smarter than me, let's, let's do a study on this 0.2 Mg per Kgs sub-cute of, of, uh, ketamine and see if it's like the home run, the hot dog, if you will.
01:00:26
vetgb89
That's nice.
01:00:33
Annatasha
Is ketamine, this is it, is subcutaneous ketamine the hot dog of the drug world?
01:00:39
Ryan Bailey
Ah.
01:00:42
Annatasha
You know what guys, why don't we write the paper and I'll be on a call, that'll be the title. VAA will jump at publishing that.
01:00:48
Ryan Bailey
I mean humans always have those like great names to their papers like the what was it like the high low study or like the the lung protect method where like lung protect stands for like a whole ventilation thing.
01:01:05
Annatasha
Yeah, and our studies are always like, this dose of buprenorphine in four healthy cats when isoflurine was at 1.4% under the case of lateralized spatoin, it's like the entire abstract is in the middle.
01:01:16
Ryan Bailey
Of course, yeah.
01:01:18
Annatasha
And you're like, I've already given up the will to live and I haven't even read like results. So yeah, I mean, we could definitely publish this subcutaneous ketamine, the hot dog of pain management.
01:01:27
vetgb89
A hundred percent.
01:01:31
Annatasha
and would never It would be my proudest moment.
01:01:33
Ryan Bailey
me too, me too.
01:01:36
Annatasha
Yeah, it would be ate all the nachos.
01:01:36
vetgb89
Anyway.
01:01:41
vetgb89
I think we're coming up on the hour here. Thank you, everybody, for listening. Next time, I think Dr. Bailey is going to pick the random topic.
01:01:49
Ryan Bailey
I'm ready. I am ready.
01:01:51
vetgb89
I also want to know what's your favorite hot dog brand?
01:01:59
Ryan Bailey
I think.
01:01:59
vetgb89
like If you were to make one.
01:02:00
Annatasha
Wait, was that question for Ryan or for me?
01:02:03
vetgb89
No, for Ryan.
01:02:04
Ryan Bailey
Well, you can answer after me, but my opinion is the Vienna beef natural casing hot dog is the greatest hot dog.
01:02:04
Annatasha
Clearly.
01:02:06
vetgb89
Exactly.
01:02:14
vetgb89
Okay. Can you find it in grocery stores?
01:02:15
Ryan Bailey
That's pretty neat. In Chicago, you have to go to the Vienna Beef Factory to buy them or you can order them online and pay like a lot of money.
01:02:22
vetgb89
Oh, wow. never I never have ordered hot dogs online.
01:02:28
Ryan Bailey
i had dogs or
01:02:29
Annatasha
Well, Bini that's because you're a normal person. So although you are discussing the merits of a 27-foot Christmas teddy bear. So you know what? The summary is I'm the only normal one on this podcast, which is a real shocker.