Transcript
Gianluca Bini: All right. tonight's my topic, I guess.
Ryan Bailey: Thank
Gianluca Bini: All right. So I guess tonight's my topic. so was, you know, the other day I was, talking with some other colleagues and this kind of came up, right? Have you guys ever dealt with these new drugs that that they're using cats about, you know, SGL2 inhibitors, you know, and how to manage for some of these cats, you know, they manage glucose that way. have you ever dealt with those?
Ryan Bailey: once
Gianluca Bini: The backside cat or. From.
Ryan Bailey: one time, uh, that I know of.
Annatasha: I can't, I don't think, I know there, I've had cats in the clinic or on them, but personally, I don't think I've had to cross paths with them in terms of like, yeah, like in a diabetic cat and anesthesia yet.
Gianluca Bini: anesthesia.
Gianluca Bini: Okay.
Ryan Bailey: Yeah.
Gianluca Bini: Okay. So, and this probably falls into more broader topic of like, how do we manage diabetic patients? Right. So maybe we do things very differently. you know, the three of us are now, but so usually, know, so those cuts are not in a normal insulin regime, right? This is a, a drug that maintains their glucose quote-unquote stable, not, you know, without getting any insulin, right?
Annatasha: Mm-hmm.
Ryan Bailey: They're like not getting insulin, like at least from my, my end of one reading about it, they're like, right.
Gianluca Bini: And so...
Ryan Bailey: They started having never had insulin before. That's one of the criteria I saw, like put it on is like, they've never seen, you know, injectable insulin in their life.
Gianluca Bini: Correct, one of the requirements of being on this.
Gianluca Bini: Yeah. So that's something like, you know, when I first saw these drugs and I saw, you know, that black box warning of, you know, these cats should not be on insuline, then my question was, you know, what do we do under anesthesia, right? Like, you know, some of these patients, they may have an elevated glucose, right?
Annatasha: Yep.
Gianluca Bini: And so I reached out to one, an endocrinologist that, you know, she, she's at Louisiana state and she, she's been working with these drugs. And, and, you know, she did say that, you know, if we were really worried, you know, you could give insulin to these patients, like a regular, like a regular insulin, you could,
Annatasha: Like a short acting insulin though, right? Like Toronto insulin, right?
Ryan Bailey: On a side note, just want to ask just because have a question. Have you, do you use in the peri anesthesia period, excluding preoperative insulin that the owners may or may not give at home that you may or may not have opinions on regulating?
Ryan Bailey: Have you ever reached for long acting insulin in patient you are actively managing the anesthesia for?
Gianluca Bini: long acting specifically. Well, so
Ryan Bailey: Yeah, like I have all in managing just because you brought up, I said I just wanted jump in and throw in another question. Sorry to go a little bit.
Gianluca Bini: yeah.
Ryan Bailey: But have you reached for long acting insulin in a patient you're actively anesthetizing? I've only ever used short acting regular insulin.
Gianluca Bini: Yeah, so I think in our consulting job, think we do see more patients that, you know, some clinics may or may not have regular insulin in
Ryan Bailey: Yeah.
Gianluca Bini: for whatever reason, you know.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah. And so like, you know, we do ask to have the owner leave their own insulin if that's not, if they don't have access to regular insulin. And so, yes, the short answer is yes, we do, you know,
Gianluca Bini: I did suggest people to give in a lower doses, of course, of the long-acting, in, in, you know, without having access to the regular one.
Ryan Bailey: Yeah. Lauren, get
Gianluca Bini: ideally, sure, you should have regular insulin if you, and this is for the ophthalmologists out there. If you run a fucking ophthalmology clinic and don't have insulin,
Gianluca Bini: You definitely need to buy it. So that's all you fucking see, right? Like, I believe patients on, you know, cataracts and whatever.
Gianluca Bini: But.
Ryan Bailey: Those are your options. Get really fast or have regular insulin. Those are the two choices.
Gianluca Bini: Right, right.
Ryan Bailey: If you're under an hour, we might not check a glucose depending on how the patient's doing. So you might sneak it under the radar.
Annatasha: Yeah, I think back, like, for some reason, I'm starting to not remember what I used to do back in, quote, the start of my career, because the longer this gets, the less I can retain.
Gianluca Bini: Yeah.
Gianluca Bini: Yeah.
Annatasha: But I feel like once in a blue moon, like, people used to present with their pet and the pet's insulin, right?
Ryan Bailey: Right.
Annatasha: Like, yeah. And so if they were really, like, crazy off the charts, high, and my cutoff for high glucose is, I mean, hyperglycemia generally does not kill you for a short amount of time, whereas obviously hypoglycemia you did.
Annatasha: But remember, and maybe this was like GP anesthesia that I used to do when I was GP or whatever, but sometimes if they were really, really high, you would top them up with the remainder of their normal dose if they presented with their insulin.
Annatasha: These days, though, I just give the regular insulin, and I try to compartmentalize that the long-term management is not something that A, I'm going to fix, and B, is any of my business. I do just with the short acting insulin for the most part.
Ryan Bailey: Thank you.
Annatasha: And like I said, know, you have to be, we have to do the conversion too. So you have to be above like 30, which is probably, you know, well into 30 the Canadian units for BG, which is going to be like over 300 in American units.
Gianluca Bini: Wait, what is there Canadian units and...
Annatasha: Yeah.
Ryan Bailey: Yeah, they're scientific and I can't remember. But yeah, they do. Yes, I do it all the time. I convert all the units so I can actually understand.
Annatasha: Yeah, we were just talking about Bailey and working with some of the Canadian clinics and then he has to convert like creatinine, calcium, glucose, like.
Gianluca Bini: Wait, what can you do? It's not hugging Canadian units. That's the metric system. You know, it's like your normal, like, you know, millimoles per liter versus gram per deciliter or whatever.
Ryan Bailey: exactly.
Annatasha: right.
Gianluca Bini: It's not Canadian units. You didn't make it.
Annatasha: No, sorry, it's not. We didn't invent them. No, no, sorry. I meant as in the units that Canada uses versus that America.
Gianluca Bini: It didn't come up with it.
Annatasha: No, no, no. We've devised a tertiary system up here. It's how many moose and beaver you can... No, but it's basically Canada versus the United States.
Ryan Bailey: 19.43 is 350 in conventional versus
Annatasha: It's what?
Gianluca Bini: Sure. Okay.
Annatasha: Yeah.
Gianluca Bini: Okay.
Ryan Bailey: And
Annatasha: Yeah.
Annatasha: Yeah. So it's got to be reasonably high for me to intervene in terms of hyperglycemia, because also too, I'm like, you know, there's that component of the stress effect. There's also the component of, I always get confounded by blood glucose and dexamethatomidine.
Annatasha: And so, yeah, I, I, I try not to fart around with the long-term stuff and nobody ever comes in with their own insulin anymore. I've noticed, and I'm not sure when that change took place or why, but anyway, yeah,
Ryan Bailey: Yep.
Annatasha: You know, like said, I'm more concerned about hypoglycemia than I am about hyper per se. Okay.
Gianluca Bini: we do tell people to have their own bring in their own so and I think it's a good thing to do like you know sometimes you have patients that are really off the charts like I had you know an ophthalmology patient that was like in the 650 and you know had
Annatasha: Okay.
Gianluca Bini: To be honest, the conversation I had with that person was kind of surprising because was like, you know, what's your, and the owners didn't leave insulin did insulin, they didn't have it.
Gianluca Bini: And so was like, what was your plan? And I was like, well, write it off. I was like, 650, it's not something that you should, you know, I wouldn't understand this thing.
Gianluca Bini: that's 650.
Ryan Bailey: It's
Gianluca Bini: And, and, and the argument was,
Annatasha: Anesthesiologists are so not fun.
Gianluca Bini: no, no, fine. We're trying not to fucking kill their patients. Right. Like that's the goal here. Right. Like, so,
Ryan Bailey: not going to die. The diabetes is not going to die in our hands. They could have their 600 glucose while we're anesthetizing it, and it's going to pretty copacetic for us, and that's going to go home.
Gianluca Bini: And I did.
Ryan Bailey: develop DNA, you either die at home or come to the hospital, $10,000 later, can't get it out, drop dead, you know, like,
Gianluca Bini: Yeah, right, right. that's the deal.
Ryan Bailey: You know, that's what also say. have worked with some people who, like, hyperkalemic crisis, they're only giving dextrose.
Annatasha: Oh God, that's so like 20 years ago.
Ryan Bailey: Like...
Annatasha: Like everyone does that.
Gianluca Bini: Yeah.
Ryan Bailey: I know, I'm like...
Annatasha: And then there's never enough endogenous insulin secreted for it to actually anything.
Ryan Bailey: I... I know. And then I, you know, I give insulin because like, that's the way the thing works and like get the patient out of the hyperkalemic crisis, keep it alive during whatever thing is going on.
Ryan Bailey: And then they're like, you bottled out the blood glucose. We had to put on dextrose for hours afterwards. It's like, yeah, well, I saved his life. So, uh, yeah.
Gianluca Bini: Yeah, the fucking dog is alive. Yeah, right. But, you know, the other thing is, yeah.
Ryan Bailey: Yeah.
Gianluca Bini: What's your cutoff for, like, when do you start treating these things, right? Like, when do you start treating glucose? Right? Above what number?
Gianluca Bini: Do you have a cutoff? It's like...
Ryan Bailey: I mean, yeah.
Annatasha: It's usually around 30. Mm-hmm.
Ryan Bailey: I mean, in America, in American units, do 350 is where I start to get a little cagey, and it probably depends on what the patient... If I have information on what the patient's curves have looked like, take that into account. But 350, 350,
Ryan Bailey: I start to get a little bit cagey 450 I'm almost always going to treat. I can't think of many situations where I wouldn't treat 450. And
Annatasha: Yeah, I'm similar. That's probably where I'm jumping into.
Ryan Bailey: then I'll give you the conversion to Canada units for our international 24.98 apparently.
Gianluca Bini: That's fine.
Annatasha: Yeah, somewhere between 25 and 35 Canadian and 350 and 450 American is probably my threshold for jumping in and also looking at what else is going on in terms of the patient too, so.
Gianluca Bini: Yeah.
Ryan Bailey: where we at in the procedure? What procedure is happening? What's the patient's like? Yeah, like all those, all those things.
Ryan Bailey: And then for me, it's regular insulin quarter unit IV.
Gianluca Bini: Okay, so you go quarter, you run it quarter. Yeah, I do similar.
Ryan Bailey: Like 0.2 to a quarter one unit, because that's all I can administer to the small patient. Yeah.
Gianluca Bini: Yeah, that's fair. And I usually start, I treat around 300, 350, that's when start,
Gianluca Bini: Yeah, because you're not the one dealing with the decay afterwards.
Ryan Bailey: Yeah, and I also have gotten a fair amount of pushback about like, why are we treating this diabetes? And I'm like, ain't my problem.
Ryan Bailey: Why are we changing blood glucose? Because I'm trying to avoid the DKA that's going to come if we don't keep this glucose under control right now in this stressful perianesthesia period. I don't want them to have sequelae following this that may or may not be followed up with in a timely fashion.
Ryan Bailey: We know how they're very short.
Gianluca Bini: Yeah, that's...
Annatasha: I guess the overall question is like, how concerned are you about anesthetizing diabetics? Because I feel like that's an area where people seem to be very upregulated. And, you know, unless you're basically in DKA, I really don't find it that big of a deal personally.
Ryan Bailey: If your curve's all over the place, I do get a little cagey. If your curve's coming in and you're over 500 regularly, I'm a little bit like, okay, so you're not well regulated there's a chance you either like where on the curve of your next DKA event are you? Are you like about to hit it? Or you like, we're slowly ramping up to DKA territory and you're just going to be handed to me to give you the DKA.
Ryan Bailey: So like if I have access to a curve where I can review that, I definitely look at it kind of closely to see what their last curves look like.
Annatasha: Thank you.
Ryan Bailey: Or you know if they've been at the vet and their curves look like absolute and their sugars are like 80 80 80 and i'm like okay cool this will be like annoying to anesthetize i'll probably to give it sugar but i don't get that worried about that one but the ones who are run really high do i get a little more cagey because i think they're probably on the in the in the works to get the dka
Gianluca Bini: Yeah.
Gianluca Bini: Yeah. And so like, then the point is, right. Do you think that,
Gianluca Bini: do you see, do you think because people don't see sequela, do you think they tend to care less?
Ryan Bailey: Yes.
Ryan Bailey: Well, there's
Gianluca Bini: Ignore?
Ryan Bailey: And I think it's twofold, right? There's the long-term sequelae of the poorly managed diabetes that they may experience probably in the 48 to 72 hours post-anesthetic procedure versus the five to six hours post-anesthesia where their blood sugar may drop precipitously from the one dose of insulin you may give during it. Maybe it's just one, maybe it's two if they're really poorly regulated.
Ryan Bailey: And they see that they think, oh, now we have another intervention we have to make for this patient when we could have done no interventions and the patient could have gone home and been just fine. And, oh, their decay developed because, you know, they were already in the process of getting a decay because their diabetes is poorly regulated. It has nothing to do with the anesthetic period.
Ryan Bailey: You know, there's a lot of blame shifting that can happen in that situation, I think.
Gianluca Bini: Yeah. I think that that's kind of shitty though, right?
Gianluca Bini: If you think it's all fake, it's one
Ryan Bailey: Yeah.
Annatasha: I swear to God, if I have 10,000 diabetic anesthesias booked next week, am retiring.
Gianluca Bini: of those big pharma kind of things, right? It's all made up, just to sell the insulin.
Annatasha: I mean, insulin was discovered here in Canada by Frederick Banting and, I can't remember Bess's first name, but Banting and Bess discovered it here and, you know, course, changed the lives of millions of people to follow. So shout out to Canada on that one. But anyway, no, I just, I find, I don't think that, for example, I'm either ignorant or complacent about the long-term effects being that I also have a diabetic cat. But I just might, I guess my question is like, how, how often are we seeing anesthesia causing real diabetic dysregulation or disruption? mean, I remember sort of the thought process being during training that anesthesia could just throw the whole thing off, you know, and it would just be like end of times or every time you anesthetize the diabetic. And I just really, I haven't observed that clinically
Annatasha: in 15 years that every time I anesthetize a diabetic patient, like they spend weeks being dysregulated. It's just a nightmare. And so I don't know. And of course I work with internists and criticalists and we don't really have this loop back around for these catastrophic post anesthetic diabetic patients.
Annatasha: I have a pretty hard and fast rule that unless you're dying in front of me, I don't anesthetize you if you're in DKA, right?
Ryan Bailey: Right.
Annatasha: Like I'm what is it that we possibly need to do to this pet unless you're bleeding to death in front of me that we need to go to anesthesia.
Ryan Bailey: I mean,
Annatasha: But, you know, most DKA's are cats who are, you know, they have cat problems like renal insufficiency. And like, so there's not a lot of anesthetic indication for them. So I don't tend to have to have that ridiculous conversation about anesthetizing things who have, you know, blood pH of 7.1.
Gianluca Bini: Yeah. Yeah.
Annatasha: So anyway, yeah, I just, it's not that it's not interesting.
Annatasha: I mean, I, you know, like I said, I seem to be collecting animals with problems around here and my most favorite cat, don't tell the other cats. is the diabetic. But yeah, and that cat, honestly, you miss a single dose of insulin and it's like full-blown DKA pancreatitis for like, and we only come out of ICU once the bill hits $7,000.
Annatasha: And then that's like the routine. But yeah, I don't know. I mean, guess here's a good question for diabetes that I have interest in is, do you guys tend to stay away from the alpha-2 agonists just because it does confound our ability to interpret what actual...
Annatasha: patient glucose is. So, you know, cause for the most part dexmedetominin raises blood glucose, but not necessarily intracellular and it does antagonize insulin, but antagonizes endogenous insulin, not exogenous insulin.
Gianluca Bini: on and
Annatasha: But at the same time, it tends to normalize really quickly and really they don't tend to have big problems other than a normal like osmotic diuresis. So do you guys use dexmededotinomidine when you have a diabetic or you try to avoid it or what do you
Ryan Bailey: I'll let John Luca go first.
Annatasha: Nothing. Cool.
Gianluca Bini: So, so I understand both sides of the argument.
Annatasha: Awesome. Awesome.
Gianluca Bini: I tend not to unless necessary, right? So if the patient is, I can sedate the patient with other means and, you know, Dexmed thankfully, it's a really good sedative and it's a really effective one and, know,
Gianluca Bini: Sometimes, don't want say it's the only option, but it's a really good option. And so really needed, use it. If I can avoid it and use a calfaxone AM together with the opioid or a spromazine AM with the opioid, I usually try to avoid it.
Gianluca Bini: What do you do, Ryan?
Ryan Bailey: Yeah, I mean, I fall in the same camp. Like, my thought is we have a large enough arsenal of drugs. Like, if there's one can avoid that may or may not be associated with some degree of complications, we should probably do what we can to avoid it. And we should open up the arsenal of drugs that we have and try and find alternative options to avoid confounding or complicating what could be complicated situation to begin with. So yeah, like I think, you know, would reach for alfaxone, acepromazine, ketamine, you know, if we're looking for the sedative effects.
Ryan Bailey: You know, if it's as an adjunct under anesthesia, I mean, yeah, that's going to be challenge. I think there's other things to consider too, is like these diabetics are already losing a lot of fluids potentially through their urine diet the dexmat is going increase urine production so you're gonna you know have to compensate for that increased urine production as well so it's just another thing to like add to the milieu of things we have to think about and consider so yeah i try to try to avoid it if i can is is my thought prop but if i have you know 10 out of 10 aggressive dog and i don't think ace promazine is going to be enough of a sedative and I want to handle this patient safely in a timely fashion and get things, you know, rolling and not be monkeying around with sedation for the better part of two hours, which I don't think is beneficial for you, the patient or the clinic.
Ryan Bailey: I think Dexmed is probably going to be the better option for the reliable degree of sedation that you get, knowing that you might have some, you know, There's potential for glucose issues that may or may not become manifest.
Ryan Bailey: That's my thought.
Gianluca Bini: Yeah,
Ryan Bailey: How about you, Martel? Since you asked the
Gianluca Bini: what did you do, Lesha?
Annatasha: Same. I try not to make my life more difficult than it inherently already is.
Annatasha: And so, you know, if I don't, if I don't, quote, need dexmedetomidine, right? Like, you know, if it was like violently fractious, I might be like, okay, this is happening.
Annatasha: And I'm okay to explain that to people in a harsh and condescending way. So I think, yeah, I think it's not an absolute contraindication, which most things usually aren't. But, you know, for the process of, you know, simplicity and even sometimes a little bit of diplomacy, which generally is not my jam, I will totally reach for it as needed or as not needed. By the way, I got a new pencil case. Check it out.
Annatasha: Says my name.
Gianluca Bini: Well,
Annatasha: That's right.
Gianluca Bini: who even owns or buys a Penzo case in 2026?
Annatasha: Well, Beanie, not only do I own one, but I had it personalized.
Gianluca Bini: You know why they have time to personalize it? Because they sell one.
Ryan Bailey: Yeah. So,
Annatasha: I thought you said you, I thought, I thought this was like, why do you have time to buy a personalized pencil case? And I was like, cause I'm busy giving Dexmed to all the diabetics. So
Annatasha: yeah.
Gianluca Bini: Holy shit, Petra.
Annatasha: Yeah.
Annatasha: I mean, like I still do crosswords on paper sometimes. So I need a pencil and a pencil sharpener and an eraser. Yes. My eraser's cat shaped.
Ryan Bailey: I have a question, though, because think there's an issue that we're just kind of dancing around that the real crux of this all is like, so in humans, we know that having blood sugars outside of the normal range is associated with a whole host of
Annatasha: Yes.
Ryan Bailey: increased hospitalization, complications following the procedure, during the procedure, etc., etc. And I don't think we have the same level of evidence for pets as of yet, I'm going to say.
Ryan Bailey: just follow our human compatriots, although their insulin regulation is so tight. Like they make us look cavalier. You know, I think they're talking within a hundred points or something, not within like 400 points or whatever we will allow before we intervene.
Annatasha: Yeah, that's an interesting point, Bailey. Maybe we are more cavalier or maybe they're just more regulated from a liability point of view because I do have a close family member who is a type 2 diabetic.
Ryan Bailey: Yeah.
Annatasha: Besides the point, but when we do go in, like the readings generally are a little bit high and like the anesthesiologist came out. This was like a routine endoscopy type thing and, and no specific issue.
Ryan Bailey: Yeah. Yeah.
Annatasha: And the anesthesiologist came out and literally was like, your blood glucose is inappropriate. And before we even do this procedure, we want to hospitalize you for four to five days to bring it into regulation.
Annatasha: And familial member was like, absolutely not because I love being crazy. But at the same time, too, like I was like, well, what is the blood glucose? And I was like, it's not even that high. Like, I mean, it was like, I think, 18 or 19 in Canadian units. So like, like below the 300 crush. And I was like, why is he being like, whoa, like why? What? We don't need to go to ICU for that. Like, apparently the answer was yes.
Annatasha: And I was like, great. I was like, take this member of my family and keep them in ICU for five days so I can have a break. But but at the same time too, I was like, wow, that like, I like the anesthesiologist actually like marched out of the endoscopy room to like make this like, you know, bold statement.
Annatasha: And in my head was like, okay, like maybe I'm a little too relaxed on this situation.
Ryan Bailey: You should see what we do with these dogs and cats.
Annatasha: know I was like, eight year blood glucose is going to be 700. And I'd still be like, we're pulling this tooth. Like, yeah.
Ryan Bailey: yeah I it's a constant wonder to my mind like yeah do we have a good level of evidence to support what we do
Gianluca Bini: And probably not. And again, it's really hard to make these studies. What the fuck are you doing?
Ryan Bailey: absolutely absolutely
Annatasha: I'm just pointing out the insanity of vet med on the whole, which is totally like, do we have any evidence? No. Are we still doing a bunch of stuff that we think is right? Yes. Is it?
Gianluca Bini: Yes.
Annatasha: Who knows? don't know. Yeah.
Ryan Bailey: And like, I will say it's probably taken so close to what the human, like, it's like extrapolation from what the humans do to like apply it to our patients because like we know we keep our, our glucose is way less regulated than they do in human beings, even in like the day to day regulation of sugars. Like humans keep a much tighter level because of,
Ryan Bailey: the wearable insulin pumps and the, like all the information they can get. So like their, their glucoses are probably, if they hit 300, you know, American units, they're probably freaking out, but you know, we're just like 300, you're fine.
Ryan Bailey: Maybe, maybe we'll see you in a few months for another curve or whatever they do. I don't know. I'm not an internist. yeah.
Annatasha: All right. Have we sufficiently covered diet? Is there another, I guess, okay, I think we've like killed diabetes, but I guess, is there another chronic disease that you guys find tends to be like a little bit either contentious or if people find very stressful that sometimes you have to coach?
Ryan Bailey: Thank you.
Gianluca Bini: How about trilostein in Cushing disease?
Annatasha: Like, what?
Annatasha: So a cushionoid dog.
Gianluca Bini: Do you anesthesia, or do you continue trilostein in patients with Cushing?
Gianluca Bini: Because there is a blog post of
Gianluca Bini: one of our colleagues that does say that in order to simulate the increasing cortisol level that we normally have with procedures, you should be discontinuing trial and stay in the morning of the procedure.
Gianluca Bini: Now, there is zero guidelines out there for this, but what do you do? you even care? And the answer is probably not.
Ryan Bailey: Don't even think about it. I got enough on my plate to worry about that like whether the dog gets its trial of stain for its... So like, I'll also say Cushing's disease is like whatever.
Ryan Bailey: Big ol' nothing burger.
Annatasha: Really? You don't get a little bit worried about like them being hypercoagulable and throwing clots. Cause I think I've had a couple cases where they have either been doing that or done that. And I know the pathophysiology clots and hypercoagulability and Cushing's is not clear, but that's probably the one place where Cush and my dogs, I'm almost like, and they usually ventilate like poo and they have that creepy, creepy skin.
Annatasha: But the other thing too, is these days for some, I don't even can't remember the last time I anesthetized the dog. who is overtly clinical for Cushing's disease. If anything, I'm the one who tends to pick up their endocrinopathy on the pre-anesthetic blood work because I'm just like, oh, hey, friend, you are 100% subclinically Cushinoid.
Ryan Bailey: Oh, your platelets are 1 million? bet you have Cushing's.
Annatasha: Your ALP is up, right?
Gianluca Bini: Mm-hmm.
Ryan Bailey: That's a good guess.
Annatasha: Right?
Ryan Bailey: The only patients I see with platelets as high as a million is Cushing's patients, from what I remember.
Annatasha: I do get a lot of people coming to me being like, is it okay to give the NSAID because the ALP is up? And I'm like, I just want to be clear that this is not a hepatic issue, that dollars to donuts, this is a subclinical endocrinopathy.
Annatasha: And I was like, based on the rest of the blood work, it's either likely hypothyroidism or Cushenoid disease, which I'm often extrapolating because of the breed of the patient and its age.
Ryan Bailey: I mean,
Annatasha: But yeah, you know, the one weird chronic disease, and I know I'm sure some people are thinking like, oh, hope they talk about chronic kidney disease.
Annatasha: But actually the one thing where I do find that people maybe are a little bit under-informed is really poorly regulated hyperthyroid patient.
Annatasha: I think people are appropriately like worried about dysregulated hyperthyroid patients. And if not, you should be because those ones really do love to crash and burn. But I find like, well, he's hypothyroid, you know, and like he's either not a medication, he's not well regulated, but you know, no big deal.
Ryan Bailey: you
Annatasha: And in my head, I'm like, it's not great for anesthesia. You know, these patients with down-regulated adrenergic receptors who don't really respond to some pathomimetics appropriately do not thrill my soul.
Annatasha: Yeah, like they don't throw myself and I feel like that's one place where people are very cavalier. And I'm just like, you know, this drug's thyroid hormone is pretty much in the toilet and it's like dragging itself around and I'm like,
Ryan Bailey: Okay, okay. Yeah, a dog in a myxodema coma? Yeah, yeah, we shouldn't be anesthetizing that one for sure. The number of myxodema coma dogs I've seen is big bad zero.
Ryan Bailey: Somehow I've fortunately avoided all the myxodema coma dogs. But going back to...
Annatasha: I've had patients come out who've developed myxodema comas and nobody knew what was going on. That happened to me once in Singapore and once at Cornell.
Ryan Bailey: Interesting.
Annatasha: So, I mean, obviously, like percentage-wise, it's still pretty small based on cases per career.
Ryan Bailey: Yeah.
Annatasha: But I do – I mean, do you guys care if your patient is an untreated hypothyroid? Because I do tend to care, actually. Like on the spectrum of not giving a shit, which mine is pretty broad, but this is one of those places where I'm like – you know, we are probably going to struggle a bit with you regulating the dopamine or the norepinephrine or the whatever sympathomimetic you're using.
Ryan Bailey: Yeah, I care so little about hypothyroidism that don't look at the routinely because I don't find it of diagnostic value or clinical significance or predictive of anything that's going to occur in the few hours that I'm going to be dealing with the patient.
Annatasha: Thank you.
Ryan Bailey: And like, there's enough information for me to process in regards to a case. And the chance that thyroid is going to mean something relevant to the dog I'm anesthetizing is next to zero.
Ryan Bailey: Plus I've also done a physical, like, you know, in my previous job, I've done a physical on those patients. So I know, you know, what their mentation is. I mean, dog who's truly hypothyroid, you should catch, you know, because like, they're not super with it, you know what I mean?
Annatasha: What if they're not in a coma, but they're clearly quite clinical for thyroid disease? I'm not saying that this is the thing that sends me off the end of the bridge.
Ryan Bailey: Sure.
Annatasha: As we all know, that's listening to cardiologists tell me about how to do anesthesia, or anybody for that matter. But I don't know. I just feel like it gets a little bit downplayed.
Annatasha: And I've definitely had patients on the table where I'm like, here we go blood pressure, because they're just poor responders.
Ryan Bailey: we really thinking of hypothyroidism? Like, I guess that's what I'm, that's like, are we just blaming the thyroid because it's something we can glom onto when there's like a million other things that could have caused the poor blood pressure?
Annatasha: Well, I understand that it's multifactorial, but I do tend to find that the clinically unregulated or poorly regulated ones, they're more of a challenge to find, quote, the sweet spot with this empathomimetic than I think either a physiologically, quote, normal patient is or well-regulated hypothyroid patient is.
Ryan Bailey: Right.
Ryan Bailey: I mean, I ultimately
Annatasha: And maybe, maybe it's just a confirmation bias. Maybe it's just something I tell myself to feel vindicated in this like weird soundbite that I like to check out there. But, you know, it, there is a physiological process associated with autonomic nervous system, secondary to hypothyroidism.
Annatasha: And I feel people are cavalier.
Ryan Bailey: Oh yeah, we know hypothyroidism is not going respond well to like, you our sympathomimetic drugs.
Annatasha: Yeah.
Ryan Bailey: Like it's a known thing. So like maybe, like maybe you've anesthetized them and I have just, you know, not would, been fortunate enough not to do that in my career. you know, will definitely say believe hypothyroidism is a hoax.
Ryan Bailey: Propagated by big thyroid.
Annatasha: It's like Tasha doesn't believe in diabetes. Ryan Bailey doesn't believe in thyroid disease.
Ryan Bailey: Yeah.
Annatasha: Oh, we're all revealing our weird little truths.
Ryan Bailey: Exactly, exactly. You know, I think it's overdiagnosed and it's, you know, most of these patients are probably you thyroid sick and they're, you know, they get their thyroid.
Annatasha: Don't you look at your FT4 equilibrium dialysis? You know, I'm less concerned, and this is a general statement about the absolute values on blood work as I am, for example, about whether or not you have a blood work value that's actually affecting a clinical change.
Annatasha: Because if you have a clinical change, it means you have decompensated, whereas if you do not, you're still in the compensation zone.
Ryan Bailey: Right.
Annatasha: So for the thyroid disease, like, mean, we don't see like FT4 equilibrium dialysis as much on like that routine blood work.
Ryan Bailey: Right.
Annatasha: And of course, if you want to send out for it to prove that you are right, you're waiting for three days and then someone's having a tantrum that you paused anesthesia.
Ryan Bailey: Exactly.
Annatasha: But know. I just found, and like I said, maybe it's an inherent confirmation bias that I'm causing amongst my cells, but they're crustier to regulate on the table. I find they ventilate more poorly.
Annatasha: I think their recoveries are a little bit slower because their thermoregulatory capacity dampened. Like I said, I mean, I don't lie awake at night thinking about thyroids, but generally...
Gianluca Bini: Aren't you?
Gianluca Bini: think you did.
Ryan Bailey: It's probably a thyroid that keeps you up at night, though, you know what I mean?
Annatasha: Honestly, the number of times, too, that I ask my doctor if I'm hypothyroid because I just want any excuse for being chubby other than I just eat and drink too much. But I'm always like, you sure it's not my thyroid? And she's like, stop.
Ryan Bailey: can't have anesthesia, Doc. It's my thyroid.
Annatasha: Not everybody has Ryan Bailey's hot dog metabolism. Like, we can't just all eat pure cholesterol and weigh 110 pounds soaking wet.
Ryan Bailey: That's true.
Annatasha: Hmm.
Ryan Bailey: Exactly. It'll probably give me diabetes one day and then I'll be a problem to anesthetize. But, you know, until then, I'm going fucking keep
Annatasha: Don't worry. Beanie and I will come and we'll anesthetize you and be completely cavalier about it.
Gianluca Bini: It's okay.
Ryan Bailey: eating. Blood sugar, 1400? Who fucking cares?
Gianluca Bini: It's fine, Ryan. Just get on the 500 bucks a month Zapp bound prescription thing and you're good.
Ryan Bailey: Totally. Yeah, exactly.
Gianluca Bini: Yeah.
Ryan Bailey: Exactly.
Gianluca Bini: That's how you improve all your blood values, right? You're just like, boom, 500 bucks a month. Blood works amazing.
Annatasha: Well, you know, live in, you know, like that's another thing, right? Like the medications for that, you know, the GLP inhibitors and what have you that people use.
Annatasha: I'm wondering when that will cross the threshold into VetMed and then we'll have a podcast, boys. Then we'll have podcast.
Gianluca Bini: Thank you.
Ryan Bailey: I got to cancel so many cases today. That's the only thing I know about those GLP-1 inhibitors is that if you're on them and you didn't skip it, your case, you can fucking go fuck.
Ryan Bailey: They're anesthetizing you, not for any reason.
Annatasha: Yeah, that is actually true. And they're like very upregulated about what's going on in your gallbladder. That's the other thing too, right?
Ryan Bailey: I was just saying.
Annatasha: It's just gallbladders really are sending them over the edge right now because that seems to be one of the things that's happening in the longterm is people are having issues associated with their gallbladders, which is interesting.
Ryan Bailey: you don't need that. Just snip it out.
Gianluca Bini: Yeah, good bloodless are overrated.
Annatasha: A gallbladder is overrated, but if you do have yours removed, going onto a low-fat diet will inherently also help you lose weight loss. So...
Ryan Bailey: Yeah. I want to go back to something John Lucas said about Cushing's disease.
Ryan Bailey: And that the clots. Well, we all, well, I didn't jump in on the clot formation because, you know
Annatasha: I did. And, and, and you know, the other group of people, and I've actually seen them physically throw clots and die in front of my own eyes are the, uh, the protein losing enteropathies. Those, those suckers love an in-hospital clot and just to keel over.
Gianluca Bini: yeah
Ryan Bailey: Oh, yeah.
Annatasha: And I'm always like, and the internist always looks at me and I was like, I have not even touched this patient. So before you get excited about blaming anesthesia, I didn't even look at it yet.
Ryan Bailey: are my...
Annatasha: Yeah.
Ryan Bailey: After pulmonary hypertension cases, PLE dogs and PLN cases are my least... I mean, I know I can get them through the anesthetic event. I know it's just going to be a very painful experience and I may as well just like induce them with the norepi going because their pressures are going to be dog, dog shit.
Ryan Bailey: But the clot stuff is like, we are so cavalier about the,
Annatasha: Thank you.
Ryan Bailey: institutional specific, I'm going to, I'll put that caveat out there, but we are so cavalier about clots in our patients. And then to compare it to the way humans are about clots, like you go to, you get anesthetized, they put those little boots on you that do the leg squeezing so you don't form like DVTs in your legs just because you're lying there for like an hour.
Gianluca Bini: Yeah. Yeah.
Ryan Bailey: Like,
Annatasha: They also heparinize you to the point where I'm surprised you just don't bleed to death, right? Like, the degree of heparinization, it's like semi-terrifying.
Ryan Bailey: And I know the evidence doesn't suggest our patients form clots at the same rate that we as human beings form clots during the anesthesia period, but it is, it's alarming to see the absolute difference in management.
Gianluca Bini: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: Also, like they have a lot of meds that can help them fight the clots.
Gianluca Bini: And we don't have any of those, right? Like so ADP and all that stuff, like we don't.
Ryan Bailey: But we have meds and we're like patients who are pro-coagul are often not on meds at all because like there's no, there's not a good, there's not a good consensus on it.
Gianluca Bini: Yeah.
Ryan Bailey: People aren't running like tags routinely on patients. I'm not saying we need to like, I'm not here to be like, let's fix clotting in veterinary medicine. But like, you know, we gotta stop the clot.
Ryan Bailey: You know I'm saying?
Gianluca Bini: Yeah.
Annatasha: Yeah, no, I mean, people definitely like... What was I going to say when I was watching? I watched when I had to do my human anesthesia rotations back in residency. Obviously, I watched a lot of cases, like observed a lot of cases. And basically, like everybody and their Aunt Edna was heparinized to the point where I'm like, holy crossballs. But more importantly, what I did do one day is happened to be on rotation when all the residents were doing their mock exams for like, I think it was like the level two.
Annatasha: examination for, you know, moving forward to third or fourth year. And honest to God, like, first of all, that was a transitively terrifying experience. But I was just like, I was like, oh my God, I don't can sit through this because I hadn't quite done my oral exams yet. But, you know, a good portion, if not close to 50%, or maybe just a titch more in that examination was asking those anesthesia residents about how to heparinize patients appropriately or whatever drug you choose to use, how to interpret the blood parameters during the various procedures such that you could adjust the degree of anticoagulability or coagulability as the case may be, and then how to rectify it because, of course, a lot of anesthesiologists just directly, like they have...
Annatasha: fellowships essentially in critical care. So a lot of that ICU work is being done directly by essentially an anesthesiologist for recovery. And like a huge part of that exam was about essentially coagulation cascade and like management and like how to interpret, like how often do you do your ACT if the patient's on like bypass?
Ryan Bailey: Yeah.
Annatasha: And I was just like, should I know this? Like I was like, mean, I know it, but I don't know it to this extent. Or it was just like the perception of emphasis on that sort of threw me for a little bit of loop because I was like, clearly we are in very different pages.
Annatasha: from the point of view of human to vet. And sometimes it's because it's species relevant. And sometimes it's because we haven't caught up, right? Like that's usually, that's what keeps me awake at night is when we're not doing something that ideally we should be.
Annatasha: And I guess my question is, is it's rare that I have a patient where I think they're truly hypercoagulable.
Ryan Bailey: That's right. Yep.
Gianluca Bini: Thank you.
Annatasha: I don't find that the Cushenoid dogs tend to be clot prone per se. But I do hear a lot of murmurs from the criticalists, for example, if a patient does acutely die like postoperatively in ICU and there's really no clear cut answer as to why that happened.
Annatasha: Like it kind of just like four days afterwards, it kind of just went boop. and like fell over, they'll blame a clot, right? They'll be like, oh, it's probably a clot. And I feel like that's like the new thing to say so that we have something to say, but I'm like, we're not PMing these patients. So we don't have an actual answer of what instance or in, in,
Annatasha: instance that it's occurring and whether or not it's significant. So once again, it's like, but at the same time too, like I said, when I was sitting through that mock exam with the human residents, I was like, you guys are super into ACT. And I was just like, wow, for me, ACT is it's like BNBT. It's one of those tests that we do. And it's so subjectively performed that my ability to interpret it with any degree of confidence is limited. So yeah.
Gianluca Bini: Yeah, we definitely pay way less attention to that. And I think part of it is also that testing isn't as readily available, nor think that, you know, people really understand a lot of how that works either.
Ryan Bailey: Yeah.
Gianluca Bini: You know, the degree of, like, when I tell people, you know, about tags or VCMs, right, like the cartridge-based system, you know,
Gianluca Bini: they have no fucking clue what I'm talking about. You know what mean? Like, and, and, and part of it is that, you know, none of this stuff gets taught to them, right? Like even, I think that even in critical care, like, you know, they, I doubt that the criticalists have some of this in their lectures, you know, in their, you know, in their preclinical lectures for the students, right? Like maybe they touch on it, maybe barely, but like,
Ryan Bailey: Yeah.
Gianluca Bini: I don't think that it's something that gets taught to a decent degree. And so, and then...
Annatasha: mean, the Europeans have really done like the bulk of the work too on veterinary,
Gianluca Bini: Oh yeah, of course.
Annatasha: of course.
Gianluca Bini: I mean, a lot of the stuff comes up, let's be honest, right?
Annatasha: Of course. Yeah, your is better.
Gianluca Bini: Like, I think for some things, especially anesthesia-wise or critical care-wise, they're, you know, priority way ahead, you know.
Ryan Bailey: I mean,
Gianluca Bini: Yeah.
Annatasha: Yeah, I mean, but they like the point being that they basically have bedside rotom for looking at coagulation profiles. And that's pretty routine. Like if you practice in Switzerland, like rotom is just right there and you do it all the time. And I feel like we really don't. And therefore, my question is, is like, you know, it's hard to worry or not worry based on the fact that we really have no idea what's going on.
Ryan Bailey: But it's funny that we say it's hard to worry, but then we're quick to blame the clot. If it's our first differential for why the fucking dog dropped dead before our very eyes, should it not be larger thing keeping...
Ryan Bailey: I don't know. That's just...
Gianluca Bini: Yeah, I mean, it is, but the reality is that it's easy to blame a clot, right? Sometimes you don't even see it in post-mortem, right? And sometimes it's like, or you see it, but you can't say, you know, that's why it died.
Ryan Bailey: Right.
Gianluca Bini: There is clot in there because the fucking blood flow stopped.
Ryan Bailey: Right. Just like it's easy to blame anesthesia, you know.
Gianluca Bini: God knows. Yeah, that's how it is, but the reality is that
Ryan Bailey: guess the thing we worry about.
Annatasha: If only the listeners could see my face right now. I'm so aggravated about that.
Annatasha: Hmm.
Gianluca Bini: To be honest with you, though, honest with you, though, I think the moment I made the shift from in-person to consulting, I think that the level blaming anesthesia is way lower, right?
Ryan Bailey: Yeah.
Gianluca Bini: These people that reach out for this, it's people that actually... I want to say that they care. mean, I think they all, everybody cares, but people, they actually appreciate what you're doing, right?
Gianluca Bini: Convert to like, you know, a multi-specialty place where anesthesia is sort of imposed to them and ended on, you know, may or may not be appreciative of, right?
Gianluca Bini: So I think that we're biased in the kind of clinics we deal with because those are clinics that do want you there.
Ryan Bailey: Yeah.
Gianluca Bini: and, But, you know, it's been kind of refreshing, right? Like it's been... Right, Ryan? don't know if that's the same...
Ryan Bailey: Yeah.
Gianluca Bini: I don't know if that's the same feeling you got, but it's been kind of like...
Ryan Bailey: Yeah. Change of pace for sure.
Gianluca Bini: Right? It's been kind of refreshing to be like, oh, there is somebody that actually care.
Gianluca Bini: You know? it's interesting.
Ryan Bailey: You're no longer streaming into the void.
Gianluca Bini: Yeah, and it's funny because then... These other people are the ones that have the luxury of having somebody in person, which it is a luxury.
Ryan Bailey: Yeah.
Gianluca Bini: And then when you're remote, they appreciate you more than when you're in person, which is kind of funny, right?
Annatasha: you know what, it reflected well on all the things that go through our head in a normal day, right? Because it's not like any of us do these anesthesia cases where it's like, today, I'm only going to do diabetics.
Ryan Bailey: Yeah.
Annatasha: And tomorrow, I'm only going to cushion. It's like, we jump from case to case to case. And sometimes we have these things happening at the same time.
Gianluca Bini: Yeah.
Annatasha: So It's actually a good reflection of what's really happening in our heads, which is totally like, pretty sure that dog is hypothyroid. That cat's not well-regulated on diabetes. This one is on the cusp of renal failure.
Annatasha: You know, and it's totally like, you know, this is, this is, these are the conversations we're having with ourselves or with the other clinicians, you know, in any given minute of the day.
Annatasha: So we never have time really to sit around.
Ryan Bailey: Yeah.
Annatasha: Like I don't sit around and wax the philosophical with the other anesthesiologists for hours at a time about like the nuances of, I don't know what, like some dermatological case, right? Like I'm just like, don't have time for this. Like we have 30 cases to get through, you know, and I'm totally like, this is what probably what's going to happen if we were really unlucky today. So let's just make sure we're prepared and like we move forward. So.
Ryan Bailey: which anticoagulants should we stop on this patient who's on them and which should we keep going because, and what's worse, the clot forming or the patient bleeding to death on the table, you know, like those are.
Gianluca Bini: I get that question a lot, actually, right?
Ryan Bailey: There's
Gianluca Bini: Recently, I've been getting that question at least in last
Ryan Bailey: a great paper, shout out Ben Brainerd, curative, great paper, level of evidence.
Annatasha: Ben Brainer is, if to be fair, my go-to person for when it comes to coagulation, so...
Ryan Bailey: That paper is great, but it's like to the point we made earlier about the level of evidence. It's not fucking there. Everything is just like, well, from the human side, this is what we got. Here's the veterinary studies. They don't exist, fools.
Ryan Bailey: It's a very well thought out, like very good discussion.
Ryan Bailey: And use it, you know, all the time when I actually see a patient come in on an anticoagulant.
Gianluca Bini: Yeah.
Annatasha: Next time we should delve into the whole antihypertensives. That's a good one because I recently did have discord with myself and the other anesthesiologists because...
Gianluca Bini: I'm done. There is way more evidence on those, but I'm not going to spoil it.
Ryan Bailey: Oh.
Ryan Bailey: Luke and I had Discord as well.
Annatasha: Yeah.
Gianluca Bini: Really?
Annatasha: Yeah.
Ryan Bailey: We disagreed. mean, we didn't have big strike, but...
Gianluca Bini: On.
Annatasha: Is it because you said the Doppler is the most important monitoring instrument?
Ryan Bailey: That was exactly what I said.
Annatasha: Yeah.
Gianluca Bini: Thank
Ryan Bailey: I said, I will refuse to anesthetize this well-controlled diabetic if we can not get a Doppler into this room. It's a whole thing's
Annatasha: To be honest, Bailey, I can actually hear you saying that kind of dumb shit. But anyway...
Ryan Bailey: Never, never. I was always, how can I get to yes? What can we do for this patient that can get me to be a yes on your case?
Annatasha: I agree. I think the job of the anesthesia team is to take the cases that other people struggle to anesthetize and get it done if it's in the patient's based interest, either diagnostically or therapeutically.
Ryan Bailey: Yes.
Annatasha: Like my job is to say yes, and it's my job to manage this. And that's really...
Ryan Bailey: Maybe maybe I can't say yesterday, maybe I can say yes tomorrow or maybe I can say yes in an hour or maybe I can say yes in half an hour or whatever, know, like.
Gianluca Bini: Yeah.
Annatasha: I think this is a shocking, people might not expect this from me, but I can't even remember the last time I said no to a case or canceled it from the point of view of like, I don't think this patient is optimized or stabilized enough because what I do is like Beanie said, there's DVM after my name too.
Gianluca Bini: Yeah.
Annatasha: And if you can do it, I can do it. So I generally stabilize my own patients and move on with it. Right. So I can't remember the last time I exonated a case from a medical point of view.
Ryan Bailey: Yeah. Yeah.
Annatasha: And I was like, I could probably get through like this amount, but let's all settle down about these overbooked MPLs. But anyway...
Gianluca Bini: Yeah, with the appropriate warning, right? So you need to, think we need to be clear on what the risks are and so that people can convey it appropriately to the owners. But, you know, yeah, we don't, you know, we don't say, yes, you can or cannot do this.
Gianluca Bini: It's just, you know, you need to be aware that this is the risk. If you're accepting the risk, then we're good. Yeah.
Ryan Bailey: I think the big one me is...
Annatasha: Yeah. And people always say yes. I find people always say yes to accepting the risk. And then if something does adverse happen associated with the, like the pre explained risks, they're still mad as hell.
Ryan Bailey: Yeah.
Annatasha: Right. Like.
Gianluca Bini: And that's where you got the told you so.
Ryan Bailey: Yeah.
Gianluca Bini: At that point, I told you, you still wanted to do
Annatasha: Yes. Clients and clinicians love that. I mean, don't get me wrong. I am miss. I told you so, but yeah.
Gianluca Bini: Not happening there.
Annatasha: Yeah.
Gianluca Bini: I did tell you, you still did it. It's okay.
Ryan Bailey: I think the one, the one I do get cagey on is the elected patient who got full breakfast in the morning. It's like full breakfast.
Annatasha: That got a what? Sorry.
Gianluca Bini: Fair. Fair.
Ryan Bailey: That's one where I'm like, yeah.
Ryan Bailey: How long are we waiting?
Annatasha: That's another area where humans are a lot more restrictive.
Ryan Bailey: Yeah.
Annatasha: Like, you know, they won't even let you have, like before colonoscopy where you've basically, like put yourself into a clinical state of actual dehydration because there is no possible way you can keep up with that kind of fluid loss.
Annatasha: You can't even have water like two hours before they anesthetize you.
Ryan Bailey: Yeah.
Annatasha: And they anesthetize you for like seven minutes on propofol.
Ryan Bailey: Yeah.
Annatasha: And I'm like, can I please have a sip of water? And they're like, oh no, you know, like their level of caring about regurgitation is like off the chart too, so.
Annatasha: Just in case anyone wanted to know whether or not I get my routine colonoscopies, I do.
Gianluca Bini: Well, they got started.
Gianluca Bini: Well done. That's lovely.
Ryan Bailey: We're getting there, gentlemen.
Gianluca Bini: sure that all of our listeners love to learn that. But, well, thank you so much.
Annatasha: Listen, if you're going to talk the talk, you better walk the walk.
Gianluca Bini: Okay, we're degenerating here. All right. Let's see you next time, guys.
Annatasha: Bye, guys.
