Transcript
Gianluca Bini: tonight is going to be to turn to Tasha Barthel, asking the, or bringing up the random topic, I guess. It seems like you had a rough week, so let's go with.
Annatasha: We won't discuss my week on the podcast, but it does.
Gianluca Bini: Yeah, we won't, we won't, but you know, we we'll skip over that.
Annatasha: oh
Gianluca Bini: But anyway, So what's the topic for tonight?
Annatasha: Well, because it's the February podcast of Valentine's Day, I thought we could talk about love or the lack thereof between me and most surgeons, JK.
Gianluca Bini: but Tell us all about it.
Annatasha: We're gonna talk tonight about gastroprotectants and their role in anesthesia.
Ryan Bailey: Yeah.
Ryan Bailey: Oof.
Annatasha: o yeah Is there a sound of like a heart breaking somewhere?
Ryan Bailey: Well, yeah.
Ryan Bailey: Is that like a fart sound?
Gianluca Bini: i No, I don't have that yet. I need to find it.
Annatasha: find a fart sound? Yeah.
Gianluca Bini: Oh, there probably is.
Annatasha: So gentlemen, I think probably in the past 10 years, there has been more consideration given to perioperative nausea and vomiting, um some of the gastrointestinal side effects of anesthesia, which we don't really spend that much time, I think, considering.
Annatasha: you know There's also chitchat about things like cardiac output and oxygenation.
Ryan Bailey: Thank you.
Annatasha: Those are so important. But let's talk about things like nausea, ileus, diarrhea, vomiting, emesis, reflux, regurgitation. As we've become more cognizant of it, and a lot of this research comes from the very good team in Greece. They put a lot of these papers out. They're the ones who speak at the conferences. And I hear are the re -endesthesiologists talking about protocols, and they're like,
Annatasha: do gastroprotectants really change anything? How do we know if the animals you know are actually feeling nausea or iliac? So first of all, just generally speaking, how do you guys feel about the use of, and I'm going to clarify for the listeners too, so gastroprotectants may include antacids, they may include antiemetics,
Annatasha: They may include prokinetics. There's, you know, there's pH neutralizers like sodium citrate out there. So do we think that there's a valid role, first of all, and if so, which drugs are you guys selecting and why?
Ryan Bailey: i'll I'll jump on it. and
Annatasha: open at the bit
Ryan Bailey: Just because I, so I will also say reflux is reflux regurg are like the banes. Like it feels like the bane of my existence. It's like the complication I truly hate the most. It's, it's vile. It's disgusting. I feel like I immediately start to feel emotionally bad for the patient. I also am a person who suffers from post -op nausea and vomiting. So like when I had anesthesia, I threw up for two hours.
Ryan Bailey: or threw up for 24 hours every two hours. It was really neat. Super.
Gianluca Bini: that That must have been fun.
Annatasha: You are such a ninny.
Ryan Bailey: Yeah.
Annatasha: Okay, yeah.
Ryan Bailey: I know. I know. I was 18 really at the height of my. a
Annatasha: Are we allowed to know what you were being anesthetized for?
Ryan Bailey: My wisdom some teeth. Very exciting. I know.
Annatasha: Oh, okay, no.
Ryan Bailey: Yeah.
Gianluca Bini: Was it even worth it?
Ryan Bailey: I know. I threw up on the doctor reportedly, and which I'm like,
Annatasha: Was it the dentist?
Gianluca Bini: What did you get, nitrous?
Ryan Bailey: they
Annatasha: Because I don't really like dentists.
Ryan Bailey: I think Sentinel, Magazalam, and like I'm assuming in Halent.
Annatasha: I'm okay with that.
Ryan Bailey: I'm pretty sure there was a Halent in all of them.
Gianluca Bini: this is this is why i love the difference between like you know us dentists and like european dentists they just fucking held me down on the chair they don't they don't care like you i i had it to awake i had the whole thing done awake they just blocked it no no look at block it's it was fine but like you know they don't even like
Ryan Bailey: Oh, yeah.
Ryan Bailey: Oh.
Ryan Bailey: I mean, mine were all impacted. I had to, like, drill all this bone and shit.
Annatasha: what They must have given you a local block. being
Annatasha: like but You're still biting on like a leather strap, like that seems a little ridiculous.
Gianluca Bini: they're like so fun fact when had a root canal in the past done in Italy and The first time, you know, they did the block, they got like two roots out of three. And at the third one, I was still filling. They're like, okay, this is super inflamed, probably, you know, we just send you home with enzymes for a week and then come back. It's probably just because of, you know, the acidic pH, the block is not like working as it should. I was like, all right, sure. I go back,
Gianluca Bini: And it's it didn't hurt as much, but it did hurt. And literally the guy was with his knee on my chest while it was fucking drilling down on my Okay, oh yeah, whatever.
Annatasha: The typical message here is never go to a dentist in Italy, obviously.
Ryan Bailey: Yeah.
Annatasha: I just like that story a lot. I really have a low tolerance for mouth pain, probably due to the highest concentration of the body of substance P, which is a known nociceptive neurotransmitter, but that's
Ryan Bailey: when i When I saw them do a root canal in a dog when I was a veterinary dentist, I'd never seen one, because like dentistry was not my cup of tea as a student. And I was like, my when they put the drill into the root, I was like, what?
Ryan Bailey: Is that what you do? it blew It blew my mind.
Gianluca Bini: Yep.
Ryan Bailey: It was like this thing, and it was like, zroom, zroom, and I was like, whoa.
Gianluca Bini: Yep.
Ryan Bailey: so
Annatasha: Yeah.
Ryan Bailey: I was like, wow, dentistry, they're really miles ahead of every...
Gianluca Bini: yeah
Ryan Bailey: Anyway.
Annatasha: and Yeah, the old hit him over the head and just yank it out.
Ryan Bailey: Yeah, I was like, why don't we just rip these teeth out? Who needs them?
Annatasha: But really back to your point too about like regurgitation and reflux I will tell you this, that if I could pick a cause of fatality under anesthesia in my own like patient population of patients that I've anesthetized over the last zebagillion years, I will tell you that if something, if I'm going to lose something acutely, right, in an absolute like just like horror show blaze of glory, it will be because they aspirate, right?
Ryan Bailey: Yup.
Ryan Bailey: Mm -hmm.
Ryan Bailey: Yep. Oh, yeah, for sure. That's a death sentence.
Annatasha: patients, the vast majority of patients who reflux do not regurgitate. And so the listeners know the differences is do do the gastric contents enter the esophagus or do they enter the oropharynx?
Ryan Bailey: Yep. Yep.
Annatasha: Most of it is oc cult, which means it's not noticed by the anesthetist. And of the time, even when you do regurgitate fulminantly, you don't necessarily aspirate. But let me tell you, when you do aspirate, especially if you're a cat, it's a total nightmare.
Ryan Bailey: I'm not going to move.
Annatasha: And I had this shit case once where The dog had an entrap, like hiatal hernia, and it actually caused like a ring of necrosis. And when it relaxed from induction and that released, it spewed like two liters of black fluid.
Ryan Bailey: Oh, I'm not moving.
Annatasha: And the mistake that I had is I had intubated, I had inflated the tube, I secured the tube, and I had not connected the tube to the breathing circuit. So it regurgitated, and then it aspirated through its own endotracheal tube.
Annatasha: making the aspiration both faster and more efficient and bringing death so much more quickly.
Ryan Bailey: yeah
Annatasha: So ever since then, like anytime someone indubates for something where I think like, you know, dystoches, GDVs, foreign bodies, like, I think you're going to regurgitate.
Ryan Bailey: That's.
Annatasha: I'm like, connect the circuit. And then I tell this horrible story where the dog basically aspirated through its own tube.
Ryan Bailey: Oh, yeah.
Annatasha: And it just it was it was dead in 90 seconds. And there was honestly nothing I could do. So I hate reflex and regurgitation and as well.
Ryan Bailey: Oh, I hate it.
Gianluca Bini: what the heck yeah
Ryan Bailey: It also is smelly and it's gross and you have to like flush and suction their esophagus and you got to wear gloves because I don't want that regurg on my hands. And then they're continuously like, like you do the TPLO they regurg at induction, they regurg shortly after induction. And then it's like,
Ryan Bailey: Well here we go, we're gonna be regurgiting all day and it's just like such a challenge. So anyway, I hate regurg, I hate it all. I wish there was a silver bullet. I know there's not. I'm not dumb enough to know that. They're not dumb enough to not know that.
Ryan Bailey: Yeah, i I do use gastrointestinal protectants in patients who, and this is actually a very timely topic because we have been out of methadone in my clinics. We've had to use hydro. We've had a lot more regurg in just one week and I'm like, goddamn hydro.
Ryan Bailey: But I do use Gastropotectans. I personally like Maropitant and Pepcid. I choose Pepcid as a veterinary anesthesiologist because it's From what I remember, it works the fastest.
Ryan Bailey: It may not have the most reduction in gastric pH, but it supposedly works faster than something like omeprazole. I'll tell you my personal cat, when she got anesthesia, she got, well, she also has like probably underlying IBD that I'm not treating, but she's relatively fine.
Ryan Bailey: She got, she just blows up, she has like,
Annatasha: Hey, shoemakers' shoes, like the shoemakers' kids never have their own shoes, right?
Ryan Bailey: She just throws up one day a month. She throws up a bunch.
Annatasha: You should edit that part out.
Ryan Bailey: We take her food away. She gets her food the next day. She's perfectly fine. She doesn't get, was I?
Annatasha: Edit the part out where Bailey doesn't treat his own cat.
Ryan Bailey: No, she's fine.
Annatasha: get rid of
Ryan Bailey: She gets her HA. She doesn't get anything that's not her food. She does great now. She, she got Famotidine and Cerenia the night before and the day of her procedure, just to decrease the chance she would have any sort of like GI upset following anesthesia. I think we are really lax in the way we treat the GI, like in a human, you have to fart to even leave the hospital. And we're like, who cares? Dog hasn't pooped in days. Send them home.
Gianluca Bini: Yeah, I mean, so, I mean, again, it is, it is, although, I mean, I'm very well aware that there is no, there is no silver bullet here, and unfortunately, well,
Annatasha: And, BIni do you think? Like, what do you... Is this one of the things that is like your radar of concern, or...?
Gianluca Bini: So I think we need to differentiate a little bit, right? if you have a patient where you're concerned, like your general patient that you're putting under anesthesia and you're worried about regurgitation aspiration, it may happen in a couple of different scenarios, right? So if it happens when the patient is regaining consciousness or it is conscious post -op,
Gianluca Bini: that is usually mostly due to the inelans. A lot of people do not realize that, but P on V is mostly due to inelans. It's not due to opioids.
Gianluca Bini: People link it to opioids. In reality, the puking that you're seeing with opioids is mostly the pre -op one that you see.
Annatasha: And also, the listeners like opioids too, like you're, you're more likely to see like nausea and vomiting, depending on whether they're hydrophilic or lipophilic.
Gianluca Bini: There there is some
Annatasha: And also, Generally speaking, if you administer an opioid, especially a full immune to a patient who's non -painful, you're more likely to see the GI side effects that we're hoping not to see.
Gianluca Bini: Right.
Annatasha: But if you have a patient who has bilateral fraction femurs and you put them on fentanyl, that patient won't barf, right?
Ryan Bailey: Right.
Annatasha: like That patient doesn't barf. And that just basically has to do like receptor expression and binding.
Gianluca Bini: Right. Right.
Annatasha: But yeah, like if you get that's why I hate when people are like, well, we're going to sedate it for x -rays.
Gianluca Bini: Right.
Annatasha: It's not really painful, but we're going to give it hydro. And I'm like, don't do that.
Ryan Bailey: right
Gianluca Bini: Why would you do that?
Annatasha: not painful, it's not indicated, it will vomit.
Ryan Bailey: Yes. Yeah.
Gianluca Bini: Yeah, no.
Annatasha: So yeah.
Ryan Bailey: yeah
Gianluca Bini: Absolutely. right And usually, as you said, you know the patient is not needing opioids, in the post -op period, you rarely see, I think, we rarely see nausea from the opioids, unless you give crap ton of it and then that's totally your fault.
Gianluca Bini: There's no way around it. right that that's you know If you do that, that's silly.
Annatasha: You just have to think about it in your job. Think about it in your job.
Gianluca Bini: No, but but you need to be aware that pain scoring your patient and guiding your pain relief based on pain score, it's probably the best way to do it.
Gianluca Bini: And that's the best way to avoid overdosing your patients with opioids. Not every patient needs crap ton of opioids post -op.
Ryan Bailey: I wonder who said that.
Gianluca Bini: some and also the
Ryan Bailey: I wonder who wrote that. two
Annatasha: Here we go.
Gianluca Bini: right
Ryan Bailey: It's you, you're the one you get.
Annatasha: Here we go.
Gianluca Bini: But anyway.
Ryan Bailey: That's paper, your paper, it's really good. It says that if you like don't pain score your dogs and you just annihilate them with methanome Q six hours, they don't eat, they're reported more as painful, they are like nauseous, they vomit.
Gianluca Bini: 100%, 100%. And that's really it's really true. So I think you need to differentiate a little bit. If you're talking about nausea, you need to target it with drugs that are targeting nausea.
Gianluca Bini: right So those are your Maropitant and those are your on dansetron which I really like too.
Annatasha: Yeah.
Gianluca Bini: Ondansetron is a really good drug, and some people They're not aware of it being potentially used in veterinary medicine. We use it all the time.
Annatasha: Yeah, I mean, too.
Gianluca Bini: When it comes down to your acid reducers, you think there are double hedges word. right like so If your patient aspirates after the higher pH stomach content,
Gianluca Bini: will get at least studies that show that they will get a worse aspiration pneumonia compared to a more acidic content. And that's because, of course, what stops bacteria growth in the stomach content is acid, right?
Gianluca Bini: So there is
Annatasha: i i I'm just going to qualify that, like what weren't the papers that looked at patients who aspirated on a neutralized stomach pH, those were like long -term ventilator patients, right?
Annatasha: so like And they had received repeated dosing. So like those those were human patients being ventilated long -term. That wasn't like one -off veterinary GAs for three hours where we treat with half a mg/ kg of famotidine.
Annatasha: So I generally like personally
Gianluca Bini: No, no, no, I agree with you. I agree with you.
Annatasha: I don't worry about the the GIPH neutralization because it's not protracted enough to at where I think where you're actually going to have an issue in terms of the aspiration.
Gianluca Bini: But that unless your patient comes in with it, like if you have a patient that is, if you have a patient that is on it long -term, then, then you're it also to.
Annatasha: Well, that's different.
Ryan Bailey: job.
Annatasha: and If you're on like.
Annatasha: And honestly, the worst offenders for those are going to be usually like muscle tumor patients, right? Because they're on H1 plus or minus H2 blockers.
Gianluca Bini: Right.
Annatasha: just listeners, you realize there's a multitude of histamine receptors.
Gianluca Bini: Correct.
Annatasha: So that means that even if you have a mast cell tumor and you only block, for example, like H1 with diphenhydramine, it can still degranulate and cause an allergic and an anaphylactic.
Gianluca Bini: stomach ulcers.
Annatasha: Yeah, it was like, you'll still get a reaction. So when you're blocking for mast cells, try to block as many of the histamine receptors as you can. But I find the mast cell ones are they usually the ones who've come in on like like the long -term GI stuff, mostly because medicine, you know,
Annatasha: they tend to give emeprazole these days, right? They're awake papers studied which ones were more efficacious.
Gianluca Bini: Now
Annatasha: And it did show that like the proton pump inhibitors are are better than the the histamine blockers. But I also remind them when I get this lecture from internists that that was not the same finding of patients under anesthesia and that the dynamics are different.
Annatasha: So we can't take awake rules and apply them to anesthetized rules, but yeah.
Ryan Bailey: There's also a time component too.
Gianluca Bini: Now, three days.
Ryan Bailey: Cause I think old members all takes a lot longer to work. And so in our, in our patients.
Annatasha: and hours right Like if you do a Meprazole, Panto is faster IV, right? But but that like the papers where we compared like anesthetized gastric pH between, you know, famotidine, ranitidine versus a Pantoprazole, it was kind of a big deal, right?
Gianluca Bini: Pando is faster IV Omeprazole takes up to three days to actually work.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: now Now, let me throw a wrench in to your, thought
Annatasha: You do that.
Gianluca Bini: Now, when you have a patient that comes in, you know, it's a long term, right? You had a patient that's been on it for like two weeks or three weeks and whatnot. Do you ask for repeat blood work?
Annatasha: no, because I find that like the electrolytes imbalances, it says you have proton pump inhibitors that comes after like months of treatment. If not, like there's a cap on how long you're supposed to prescribe them up, right?
Annatasha: It's like a year. because it can leach calcium, it can leach calcium and disrupt magnesium.
Gianluca Bini: You know, what if I told you, what if I told you that most, most gastroenterologists in humans, they won't give it to you anymore for more than three weeks.
Annatasha: So like, if you've been on it for a month, I probably don't care that much, but I'm probably going to have baseline electrolytes anyway.
Ryan Bailey: Yeah.
Annatasha: bull answered
Ryan Bailey: Wow. Interesting.
Gianluca Bini: And the reason is there is newer evidence that show that actually which can lead to AKI and then CKD.
Ryan Bailey: Hmm.
Annatasha: Yeah, I know because my doctor put me on pantoprazole mostly for being an anesthesiologist. And she made it clear like my like I had to do urine and a little panel.
Ryan Bailey: Right.
Gianluca Bini: Sorry.
Annatasha: Yeah. I was like, it's funny that because I just took my panto right before this call. But it also like they've shown to like, there was a weird thing about ameprazole like contributing to idiopathic like severe hip pain.
Annatasha: Right? Cause like my mom has been on omeprazole for like 592 years.
Gianluca Bini: And order.
Annatasha: And at some point I was like, hold on, Margaret, like we need to like talk about this and like get your doctor to like revise this. I don't think you've been back for a recheck, but you're not supposed to be on omeprazole for four years.
Annatasha: And like, she's always complaining about her hips. And so I actually found this like in the, in the insert in the package, like idiopathic hip pain, idiopathic back pain.
Gianluca Bini: So.
Annatasha: whether or not that's related to disruption of calcium metabolism. I don't know. But I was like, hello, Margaret, we're like coming off this drug. Shout out to Margaret.
Gianluca Bini: Yeah, it's...
Annatasha: She'll be like, don't mention me. Shut up. so
Annatasha: Oh, hey.
Gianluca Bini: Anyway.
Annatasha: but yeah
Gianluca Bini: yeah
Gianluca Bini: that So, I don't know, like, you know, I was on it for a while because I've GERD right? And...
Annatasha: another anesthesiologist on an antacid. What a shocker.
Gianluca Bini: Nice. And now they've flipped me. I mean, they've been, for a while, they've been... They put me on famotidine rather than omeprazole because they were like, we cannot give it to you for more than three weeks because of the risk of interstitial nephritis and whatnot. And actually, it seems like most people do get the interstitial nephritis whether it evolves to AKI, it's due to other factors, maybe like genetics or whatnot. But it seems like the inflammation, it's definitely caused, but whether it evolves to damage,
Gianluca Bini: It's a maybe.
Annatasha: You know, after I just took my panto, this conversation is making me super anxious, and I might have to progress to a diaper next. Like, this is not a reassuring chat, guys.
Gianluca Bini: You started it.
Ryan Bailey: Yeah, this was your choice.
Gianluca Bini: This was your totally your choice.
Ryan Bailey: I'll remind you.
Annatasha: oh Yeah, well, yeah, my panto was gonna kill me later today from renal failure because I'm starting to sweat in weird places.
Gianluca Bini: it Nice.
Ryan Bailey: GI meds the worst.
Ryan Bailey: So maybe we shouldn't put all our patients on all these GI meds.
Gianluca Bini: Oh, yeah.
Annatasha: Well, yeah, okay, so here's one, guys.
Gianluca Bini: Probably not.
Annatasha: How do you feel about a single dose of metaclopramide pre -anesthetically? Side note, I hate it.
Ryan Bailey: Based on the papers, I think it's a good idea.
Gianluca Bini: oh
Annatasha: A good idea?
Gianluca Bini: Your finger is or it's not?
Ryan Bailey: Yeah, based on the evidence, 0 .2 megs per KIG, sub -Q, decreased nausea and vomiting in patients that they look at.
Annatasha: What paper is this, Bailey? I don't think I've read this paper because all the paper subsequently showed you had to have a metaclopramide CRI at neurotoxic doses.
Ryan Bailey: not I'm not talking about regurg. I'm talking about patients that they looked at and assessed for nausea and vomiting, and they reported the patients were illicit.
Gianluca Bini: Yeah.
Ryan Bailey: So nausea is a qualitative, or a, quanti, no, qualitative. It's a qualitative characteristic, right? It's, oh, I think this patient's nauseous. Whether animals can experience nausea or not is up for debate, whatever.
Gianluca Bini: Objective maybe.
Ryan Bailey: I'm not going to go there today, but there was a paper and I can send you the citation after this phone call.
Annatasha: I'd
Annatasha: appreciate it.
Ryan Bailey: right It was, um it was, it was like 0 .2 MIGs per KIG of medical for my sub Q and a decreased knowledge on vomiting.
Gianluca Bini: Yeah.
Ryan Bailey: So like in patients where I do think it's a risk, I think that's a really reasonable idea.
Annatasha: Yeah, but people used to give the metoclopramide not for nausea and vomiting, but specifically to promote gastric emptying, right?
Ryan Bailey: Yes.
Ryan Bailey: That's a hot wash.
Annatasha: Also, quote to quote, quote air quotes, if you can't see me, I'm air quoting, is to prevent reflux regurgitation.
Gianluca Bini: Yeah.
Annatasha: And for sure, like the motility component, you have to be on that neurotoxic CRI for it, right? Like that's pretty,
Ryan Bailey: Yeah. Oh yeah.
Ryan Bailey: A hundred percent.
Annatasha: Honestly, don't forget that metoclopramine can be unbound by the anticholinergics. So my question is, is how beneficial is it? Because almost every patient pretty much ends up getting atropenic glyco and then it's going to get bounced off anyway by the anticholinergic at the muscarinic receptor.
Annatasha: So why bother?
Gianluca Bini: Most of your patients get, most of your patients get an endocrinergic, mine's gone.
Annatasha: Especially when I can give on dansetron or serenia.
Ryan Bailey: Right.
Annatasha: Okay.
Ryan Bailey: I think.
Ryan Bailey: True.
Annatasha: Well, Bini you
Gianluca Bini: I'm I'm kidding. Okay, whatever.
Ryan Bailey: Like it's not a drug I'm using on a day rigor basis, but is something I would keep in my arsenal of tricks that you break out once in a while. Yeah.
Annatasha: Fair enough. I think that's fair. I also get concerned about like really chronic metoclopramide CR Is, because when they are awake, there is a prokinetic effect. And I don't know if you guys have ever traveled, but ilius, which is obviously can make you quite, quite nauseous, but also being prokinetic is very uncomfortable.
Ryan Bailey: yeahp
Annatasha: Like it's crampy and makes you poop your pants.
Ryan Bailey: ye
Annatasha: And you also get nauseous from that too. And sometimes what I've done is patients who've been on like a day or two of metacloperamide and they're not eating, I stop the metoclopramide And then after a few hours, they eat again.
Annatasha: And I think it's because that, and you know, it's diarrhea, it's not eating. And I'm like, well, first of all, you need to turn your fentanyl down from a billion. And second of all, take stop the metacloperamide because that prokinetic effect I think can clinically end up being quite detrimental.
Annatasha: so
Ryan Bailey: Yep.
Gianluca Bini: Yeah, no, I agree with you.
Ryan Bailey: Right here.
Annatasha: Now, let's put it this way. It's not my favorite tool in the toolbox.
Ryan Bailey: No, it's, I wouldn't say like, I'm not using that metacopromide subq as like a routine thing, but is something that I, you know, think about from time to time for, for some patients really.
Gianluca Bini: Yeah, it's a good option.
Annatasha: Cause it always used to be like every bulldog under the sun had to have metoclopra mide to like rock out on anesthesia.
Ryan Bailey: Oh yeah.
Annatasha: I know that that still goes on, and more specifically, I know it's still taught in some of the vet schools, and it kind of makes me want to, you know, take another pantoprazole until I learned that it was gonna cause renal failure, so.
Ryan Bailey: That's it.
Ryan Bailey: Yeah, I found it some like.
Annatasha: Okay. I mean, do you think that our patients suffer from nausea?
Ryan Bailey: I think that I think they do. I'm I told you I'm not going to get into it. I think they do, but I.
Annatasha: No, you have to get into it. That's the point of the podcast.
Ryan Bailey: You know, I don't know enough about nausea to be like, well, based on the brain and the nausea. Yeah, they look they're like smack in their lips. They look like they're going to get the patients like I can tell when my cat's going to throw up because she starts doing this.
Annatasha: And they start making that noise like the whole.
Ryan Bailey: No, no, before that, before that, she'll be sitting in my lap and she'll be like licking her lips constantly, which is what I do when I'm about to throw up.
Annatasha: like oh my on
Ryan Bailey: I'm like, oh yeah, I can tell I'm gonna vomit shortly.
Gianluca Bini: I mean, I can tell you that.
Annatasha: Yeah. Yeah. I think they do. And I think the histopathological staining studies have shown like there's a really similar pathway, like the pain, the itch and the nausea pathways are really, really like physiologically similar and closely related.
Ryan Bailey: Sure.
Gianluca Bini: Yeah.
Annatasha: And like when they've done the histopathological staining in dogs, they've actually shown that they have like the same pathway, the same receptor. So there is some good data or evidence that's looked at this, especially because they use dogs all the time for human studies.
Ryan Bailey: Who wants?
Annatasha: So, you know, and I think clinically, you know, you see the patient have like prodromal signs and then they vomit. So, I think that's consistent with nausea. And I have a high degree of concern because personally, I don't know about you gentlemen, but if I had a choice between like a high degree of pain and a high degree of nausea, I would take the pain.
Ryan Bailey: so Who wants that one?
Annatasha: I find I'm so intolerant towards nausea.
Ryan Bailey: westland
Annatasha: like I hate it. would I just hate it. And I just like, you know, if I get a migraine, like the pounding is one thing, but once I become nauseous, I'm basically incapacitated.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah, no, I agree.
Ryan Bailey: f
Gianluca Bini: I mean, I think, again, I mean, I think the metoclopramide is definitely a good option.
Ryan Bailey: Yeah.
Gianluca Bini: I usually reach out for, like, Maropitant and then On dansetron before I do metaclopramide and I usually but give them together.
Ryan Bailey: yeah
Gianluca Bini: I also, um I can tell you that, you know,
Gianluca Bini: To be honest with you, all these patients that are, they already know that potentials are gonna be nauseous and whatnot, like, you know, brachycephalics, and I just threw them on TIVA. Like, why would that make it worse with fucking gases?
Annatasha: no
Ryan Bailey: Back to TIVA Hell Yeah.
Annatasha: I mean, now, do you guys think, like, let's talk, yeah, well, let's talk a little bit about Ativa and nausea because I want to, I want to address an urban myth about lidocaine and nausea. Thoughts, comments?
Gianluca Bini: So I never seen it with the Lidocaine to be honest with you, although during my residency, people did believe that that was a thing. I've never seen it to be honest with you. Maybe I use it to not high enough doses to see that. Like, you know, if you go at the Ontario veterinary college, they 200 micrograms per kg per minute of Lidocaine for the first hour and then decrease it and whatnot.
Gianluca Bini: which is fine i mean i get it there the reasoning is try to get the sparing effect try to get the you know analgesic side of things great um um maybe at those doses yes you you may end up seeing the nausea right like i and i have no clue i didn't try it i never i wasn't ballsy enough
Annatasha: That was my, my understanding of wherever I read this a hundred years ago, this is the problem. It's like the longer this career goes on, the less I can remember my own references.
Ryan Bailey: Thank you.
Annatasha: But there was, I remember so like sitting for boards and it was like, you know, lidocaine nausea, like the existing evidence that we have, it's like up at a hundred mics per kg per minute. And that's not an awake CRI dose, right?
Ryan Bailey: Yeah.
Gianluca Bini: right
Ryan Bailey: No.
Annatasha: That's an anesthetic dose. So when we have something like sitting in ICU and it's on 20 mics per kg of fentanyl,
Gianluca Bini: no
Annatasha: But then it's also won like seven, like sorry, 20 mcg per kg of lidocaine. And then it's also in there at like five to seven on fentanyl. And they're like, it's nauseous. I'm going to stop the lidocaine. And I'm like, what makes you think that it's the lidocaine, right?
Ryan Bailey: Right.
Annatasha: Like I don't know where this like urban legend came from.
Gianluca Bini: Right. Now.
Annatasha: I've never found a reference. I think it's a, like, I think it's a very widely accepted thing that quote, lidocaine causes nausea. And I've had this battle many times with the criticalists, but I'm like,
Annatasha: I think it's probably like the really high doses of opioids were cranking through them.
Ryan Bailey: other comment I would add to this discussion is in multiple species, it's been shown to be a prokinetic agent, humans, equids.
Annatasha: and
Gianluca Bini: Right.
Ryan Bailey: Yeah.
Annatasha: Horses specifically are the ones where they showed in vitro, not just in vivo, that it caused gastrointestinal -like little difficult for dogs, right?
Gianluca Bini: Right.
Ryan Bailey: And so like there's a few studies in dogs. There's really not that many. There's one or two that I can think of that I've seen where they looked at it. And and the evidence was was not. Yeah, and so like I'm hard pressed to believe that it's like definitely not a prokinetic, just with the lack of lack of papers that are out there.
Ryan Bailey: like And it just fascinates me to think that in these species, it's a prokinetic agent, but not in dogs. like Is it a dose? is it you know like Is there something special about their GI tract that's like different than like a human or a horse?
Gianluca Bini: Yeah.
Ryan Bailey: like It's a little odd to me.
Annatasha: Well, I would understand if it was a different class of animals. Like if you said, no iguanas, it's not prokinetic, but it is in pigs.
Ryan Bailey: Yeah.
Annatasha: I'd be like, why that? Because mammals reptiles, like cuddly.
Ryan Bailey: Right.
Annatasha: not
Ryan Bailey: Well, also you've got two monogasterics. Humans are monogastic, dogs are monogasterics.
Annatasha: So I struggled that you couldn't extrapolate per se from another like domestic mammal, like
Ryan Bailey: it's
Ryan Bailey: Yeah. So I, I'd like, I do wonder also if it, if we did the right study with the right materials and methods, we would find that's a pro kinetic. I mean, I, I will, I want it to be, I'm like always holding out hope that someone's going to do the paper and they'd be like, in lidocaine's a pro kinetic in dogs. I'll be like, yeah.
Annatasha: I would love that too, because if I have to read another paper on a local block or on a plasma concentration dose of buprenorphine, I'm going to rip my hair. and Like somebody published something different, like shout out to anyone listening, like come up with something else other than local blocks and like pharmacokinetic studies like OMG.
Annatasha: but that's, that's another aside, but yeah, I don't know. Like I think the lidocaine from my understanding, but like I said, I can no longer remember these references. This shit just pops in my head and I'm like, is that something Gleed said?
Annatasha: Like, you know, like I don't know anymore. anymore. Um, was it the fourth edition of lemon shows?
Gianluca Bini: sir
Annatasha: Was the fifth edition of Lumb & Jones?
Gianluca Bini: So, but my question for you is why the hell do you use light again?
Annatasha: I don't know anymore, but I do remember being like lidocaine, like the nausea that is, high dose, high dose.
Annatasha: i do what what
Gianluca Bini: I think the lidocaine is the gabapandin of injectable analgesics, right?
Annatasha: i
Annatasha: Bailey's going to have him in Eastern.
Ryan Bailey: Come on, that's pretty, that's pretty overblown.
Gianluca Bini: is iss going It's having a seizure.
Ryan Bailey: Lidocaine is a very useful drug.
Gianluca Bini: Is it?
Ryan Bailey: Yes.
Annatasha: Oh, I'm not sure I missed what to miss.
Gianluca Bini: Do you think that he has legit analgesia?
Annatasha: I'm going to just sit back over here.
Ryan Bailey: I think it provides some degree of analgesia. It's a known mac reducer.
Gianluca Bini: Okay.
Ryan Bailey: It's an anti -arrhythmic drug.
Gianluca Bini: Gotcha.
Annatasha: It's a free radical scavenger.
Ryan Bailey: It's a free radical scavenger.
Gianluca Bini: besides the undearithmic properties.
Ryan Bailey: Was it?
Gianluca Bini: Yeah, whatever. Whatever. So, me.
Ryan Bailey: I'm not like, I'm not like, okay guys, I'm gonna put the dog on a lidocaine CRI and I'm gonna fucking cure his pain. I'm like, I'm gonna add a lidocaine CRI onto this dog where we're resecting a giant intestinal mass because it's probably full of free radicals and all sorts of nonsense I don't want on the bloodstream.
Gianluca Bini: Right. So, to me.
Annatasha: Bailey, maybe Bini doesn't like lidocaine because he went to an Italian dentist.
Gianluca Bini: Awesome.
Gianluca Bini: Probably. But also, to me, to be honest with you, if I need to like, unless it's like for anti -arithmetic purposes, a light against your eye, it's a waste of a pump.
Ryan Bailey: Wow.
Annatasha: very strong opinion.
Ryan Bailey: Well, I don't, I mean, I'm not in a world where I have to pick and choose.
Annatasha: I'm so interested.
Gianluca Bini: Like,
Ryan Bailey: You know what I'm saying? Like I can have a pump. If I need a pump, it's getting a pump. Like I can find a pump.
Annatasha: Wait, Bini why, what, why? Why?
Gianluca Bini: because you have so many other things. You know, you have Daxmed, right?
Annatasha: Okay.
Gianluca Bini: I'd rather do Dexmed before I do Lidocaine
Annatasha: Even for somatic pain?
Gianluca Bini: I I mean, yeah at that point, I mean, I think the Ketamine, Ketamine Fentanyl work better for it than Lidocaine does.
Annatasha: Okay.
Gianluca Bini: Like we know that this MAC sparing effect of Lidocaine it's so, compared to the others, I'm not saying on its own, right? You know, it has this 30 % MAC sparing effect, right? But like in reality,
Gianluca Bini: the others perform so much better, right? Why do I need to have an extra layer of complication and actually your potential error, right? Unless I can use it only in some species because you know in cats, you can't, right?
Ryan Bailey: All right.
Gianluca Bini: So like you need to make sure that if you're dealing,
Annatasha: Well, you can't, but you have to have really robust gonads, and you have to really watch those doses, right?
Ryan Bailey: Yeah.
Gianluca Bini: fair.
Ryan Bailey: Yeah, for
Gianluca Bini: Like, it's...
Annatasha: I like to make it really complicated so I seem smart.
Ryan Bailey: Oh yeah.
Annatasha: I'm just kidding.
Ryan Bailey: 90 % of my job is like, 90 % of my job is like in the alveoluses and then everyone's eyes immediately just like glaze over and I'm like, good.
Annatasha: I'm just kidding. That was an anesthesia joke.
Ryan Bailey: We can move, we can now move on. Thank you. Thank you. I bow and then step out of the room.
Annatasha: Yeah, you just say it doesn't sound great in the room, and you're like, well, I don't think that's true because of the Meyer -Over ton theory, and then you just waltz out.
Gianluca Bini: andt know i mean
Ryan Bailey: know
Annatasha: Right? And then everyone just looks stunned, and you're like, see you later, I'm going for coffee.
Ryan Bailey: Yeah.
Gianluca Bini: Like, I don't know, I think we're forcing Lidocaine into this great thing, where in reality, I think it has way more users post -op than intra-op, to be honest with you, because, you know, there are some limitations to other drugs we use, like you can't go as high on your friend in post -op.
Ryan Bailey: Interesting.
Gianluca Bini: because they will get nauseous, right? You can't go as high on your dex meth because they will be sedated, right? You can't go as high on your ketamine zero because of course they're gonna be stunned, right? A little bit. And so like, then adding on the lidocaine at that point, it has way more sense, but in tra-op to me, it's like, when I came to,
Gianluca Bini: Oklahoma State, you know, I you know i had one technician that she really loves horses and she's amazing, I love her. and But, you know, she would do Lido caine pretty often for most horses, right? And I was like, how about we switch it to Dexmed?
Annatasha: Yeah.
Gianluca Bini: Tried it the first two times, fell in love with it, right? And now she won't do any horse without Dexmed. which I agree with and I love it, right? But in reality,
Annatasha: But here's a question. Bini So this is all very interesting. I feel like everyone from OVC is probably like going to stop listening to our podcast because if you, like, do you not worry, for example, like, let's say you have the patient on fentanyl and ketamine right?
Gianluca Bini: Having a seizure, yeah, yeah, yeah.
Ryan Bailey: I'll get on the next update.
Annatasha: And you got to Jack that fentanyl up to like 2030. I don't know how high you're comfortable going, but do you not worry at all about You know, I try to practice opioid sparing anesthesia.
Gianluca Bini: Yeah, no, no, I agree with you. I don't go much high than that. Like I usually, my max is at 12.
Annatasha: Okay.
Gianluca Bini: Right, like i know and I don't go as high unless, unless, unless I'm dealing with Remi fentanyl now.
Annatasha: Okay. but
Annatasha: okay
Gianluca Bini: And then, then we can go, the sky's the limit, right?
Annatasha: like If you have a ventilator, just, just. five
Gianluca Bini: The sky's the limit with Remi fentanil, right?
Annatasha: Yeah, like, wow. We're not even drinking tonight, and that was wild.
Gianluca Bini: But, oh,
Ryan Bailey: yeah
Annatasha: no Don't do that at home.
Ryan Bailey: no
Annatasha: Unless you know what you're doing.
Gianluca Bini: Don't try this at home.
Ryan Bailey: Or in your practice, at home or in your practice.
Annatasha: Do not do this. Like, do not rock up tomorrow on all your catnators and discharge. You're gonna put them on 50 of Remy Fentanyl. Like, don't do that.
Annatasha: But yeah, no, I'm i'm very interested.
Gianluca Bini: You totally can.
Annatasha: I'm gonna lie awake all night.
Gianluca Bini: You totally can and it's fine.
Annatasha: Shut up. I know you can. but
Gianluca Bini: That's the purpose of that drug. The purpose of that drug is to let you have such a ginormous sparing effect. that, and then when you turn it off, it disappears.
Gianluca Bini: So like, fuck it. Like in humans, they actually are using it together with like, you know, this new drug, remimazolam, for TIVA, and they just do remimazolam and remifentanil that is it.
Annatasha: really like
Gianluca Bini: There is no propofol involved.
Annatasha: lamb I feel like i'm gonna if I have a kid, I'm going to call it that.
Gianluca Bini: But be be on the lookout for our new paper because we just submitted it.
Ryan Bailey: Oh.
Annatasha: Thank you for writing a paper on something that doesn't involve buprenorphine plasma concentrations.
Gianluca Bini: bump on Anyway,
Gianluca Bini: but anyway, so we did this MAC study and actually the reaction is ginormous. Like if you even just re mifentanil it alone, a 0 .6 mcg per kg per minute,
Gianluca Bini: There was like an 81 % MAC reduction of isoflurane in dogs.
Ryan Bailey: in dogs, what about cats?
Gianluca Bini: and We didn't do cats, sorry, we did just.
Annatasha: I can feel the Davis opioid reluctance about opioids being MAC sparing during bubbling up in Bailey right now. Everybody like it's bubbling.
Gianluca Bini: And when you had the Remi mazolam in it, you had a 98 % MAC sparing effect.
Ryan Bailey: Well, yeah.
Gianluca Bini: So it was basically at zero on most dogs.
Annatasha: I was about to say, why bother? like
Ryan Bailey: Okay. Okay. So then, so just like we're totally derailing GI protectives but like, okay.
Gianluca Bini: A hundred percent.
Ryan Bailey: So let me just ask what, like, what is the advantage of Remy fentanil Remy mazolam versus propofol? Like, I mean, like propofol is that slow.
Gianluca Bini: Because once you turn them off, gone.
Ryan Bailey: Like, what are we talking about?
Annatasha: also analgesics, like side note.
Ryan Bailey: Sure. Okay.
Gianluca Bini: Yeah.
Ryan Bailey: Like,
Gianluca Bini: Right.
Ryan Bailey: But you can get that with other things as well, just to his point about Lidocaine. You can get what Lidocaine provides with other things. Like, you could, with what with Remy mazolam and Remy fentanil you can do all that with propofol.
Gianluca Bini: and they're both reversible even if if you even if they were to accumulate in a bit like remi fentanyl doesn't really accumulate remi mazolam it's kind of a weird drug it is it is although well i mean i don't want to spoil this paper that much but anyway regardless basically
Ryan Bailey: Right.
Annatasha: So Remy mazolam is also broken down by plasma esterases then, so it's okay.
Ryan Bailey: Uh -oh.
Annatasha: It's okay, no one listens to the podcast anyway, it's fine.
Gianluca Bini: It does, they don't, it's true, it's true. We actually had shit tons of views. That's unbelievable. Like the total views, it's for the last episodes, they're like blown up.
Annatasha: Oh my God, you guys, we're We're bringing, we're bringing sarcastic anesthesia to the masses.
Gianluca Bini: So, it's, it's...
Ryan Bailey: limited to the people we work with and now now the whole world gets to enjoy ours.
Annatasha: Well, I also forced my family to listen to it.
Ryan Bailey: as you
Annatasha: Like let's not forget them, like all four of them.
Gianluca Bini: they put know
Annatasha: And they're like, we have no idea what you're talking about, but it sounds funny.
Gianluca Bini: Somebody out there has a phone with Spotify on loop on our podcast forever.
Annatasha: I mean, I got, I got email by an Iranian vet who was like, I want to check out your podcast, but I can't necessarily use all these platforms to stream in Iran. And I was like, guys, we're doing this.
Gianluca Bini: Oh, wow.
Annatasha: This is happening.
Ryan Bailey: Oh yeah.
Gianluca Bini: We can figure out a platform for that, like, I don't know if, like, I mean, maybe even YouTube, but I think they have access to YouTube probably.
Annatasha: Well, they need, they probably need a VPN to go around it, depending on what countries have what limitations, like, you know, there's
Ryan Bailey: Yeah.
Gianluca Bini: Gotcha.
Annatasha: They can't watch it on certain things in China or what have you.
Gianluca Bini: Yeah.
Annatasha: But yeah, VPNs will get you around that in most cases. This has nothing to do with gastro protectants, by the way.
Ryan Bailey: So what are your regimens?
Gianluca Bini: None of it.
Annatasha: What's my, like, standard?
Gianluca Bini: What do you mean?
Ryan Bailey: What do you know, what's your like breaking some phalic regimen? What's your like, okay, this patient had regurg, this was a TPLO, regurg under anesthesia last time. Do we make any modifications to his plan for the future?
Annatasha: Okay, well, I think this is...
Ryan Bailey: You know, he's doing the other side of a few months later, like this is like a patient who's been intractably vomiting overnight and is getting surgery for a GI foreign body.
Annatasha: Yeah, I think a good lead -in to this
Ryan Bailey: And oh, by the way, we know he has a stomach that's literally filled with fluid.
Annatasha: Okay.
Ryan Bailey: I know a G2.
Annatasha: So very interesting. I'm going to say to you that, so first of all, like I always consider what part of the patient population you're in and what the likelihood is that you're going to reflect slash regurg, right? So just for the listeners, a little bit of background that reflux and regurg is anywhere from like a quarter to like two thirds of patients there.
Annatasha: You have some degree of gastric contents entering and exiting the esophagus. And it's because the anesthetic drugs, lower, lower esophageal sphincter tone right so usually that sphincter is nice and tight unless you have GERD or you're an anesthesiologist um um and in which case it's like constant all the time but what happens I mean propofol is probably one of the worst offenders for relaxation of that sphincter so usually I find if you're gonna have like a catastrophic regurgitation event it's that induction of the anesthesia um but yeah, I think it's important to understand that when it's entering and exiting, like, why do you care? Like, why do I care if get like acidic gastric contents enter the esophagus? I mean, for me clinically, what I always teach, what my consideration is, is the vast majority of patients are not going to have
Annatasha: serious like morbidity or immortality. Although when, like I said, aspiration happens, it does tend to be a little bit more cataclysmic. But what I think it does is I think it contributes to further reflux, and I think it contributes to low -grade esophagitis. And because our criteria to discharge is the patient is supposed to be eating, if you're nauseous because you're jacked out on opioids, and or you're painful, and or you've had isoflurine, you basically have a lot of stuff that's causing GI disruption, you're not going to eat.
Annatasha: And nine times out of 10 people are gonna say you're painful and they're gonna turn the drugs up more and make the situation worse. So what I'm trying to do in these cases is I'm trying to get ahead of the curve from esophagitis and I'm trying to mitigate the issue so that I can really look to improving discharge time. So I always say like what I do on the table affects what's gonna happen tomorrow in a week, right? Like it's not just tube in, tube out and have a nice day. So for me, one of the things that what I used to do when I was a resident and they do this in human women If you're going in for an emergency cesarean and you not fasted, right?
Annatasha: Because like maybe you, you know, I had an aunt whose water broke right after brunch. Like she basically ate her way into labor, which I was like props.
Ryan Bailey: No.
Annatasha: But you're not fasted and they do want to do the cesarean, they make you drink sodium citrate, right? Which is a neutralizer. And so if we had known on fasted patients when I was at Cornell, then we would try to have the patient take the sodium citrate.
Annatasha: now It's messy, it's sticky, it's purple, it smells like grape, and if the dog's a weenus, like trying to get, like and it's a huge volume, right? So you're running, like you're trying to put 40 mils into a Great Dane before a G .D .V., like it's really challenging.
Annatasha: But I also know people used to intentionally induce vomiting in patients to empty the stomach, right? They'd be like, no, give the hydro, make it barf, which puts you again behind that esophagitis curve.
Gianluca Bini: Right.
Annatasha: and i think precipitates further nausea right so and not a nausea fan so you know generally speaking I think if it's unless it's a very brief case I'm gonna give both an antacid and and and sort of like sometimes I pick one because I ran out of the other one and sometimes the volume is so enormous that it's cost prohibitive to do Pantoprazole like they'll be like hey Bartel is 17 mils of Pantoprazole and it's gonna cost $100 and I'm like bucket, give famotidine, right?
Annatasha: So, smaller volume or cost effects.
Ryan Bailey: Right.
Annatasha: I try to have an antacid on board. And then I try to have some kind of anti, no, also listeners, there is a difference between an anti -nauseant and an anti -emetic.
Ryan Bailey: Mm hmm.
Annatasha: And it's a subtle difference, but it's important to understand that, for example, like on dansetron and moropotent, do you have that subtle difference? One is an anti -nauseant, one's technically an anti -emetic. So for the patients who are really like fulminantly clinical and nauseous, I'll do both, because I find one doesn't control.
Ryan Bailey: Mm hmm.
Gianluca Bini: Yeah, same.
Annatasha: But so most of the time you're getting a gastroprotectant, you're getting the antacid, you're getting an anti -nauseant for me. then I'm trying to minimize the drugs that I'm giving that may contribute to that post -op problem.
Ryan Bailey: Yeah.
Annatasha: but The population also, so the listeners know like you know, the longer the anesthetic, the more likely.
Gianluca Bini: Yeah.
Annatasha: Inappropriate fasting times, depending on what species you are. like If you fast for too long, you increase stomach acid production, so like a 12 -hour fast in a dog is highly problematic. um um If I know you're going to be flipped a billion times, and that is a shout -out to the TPLO, where it's like, First we take x -rays, and then we flip you for clip and prep, and then we flip you for block, and then we flip you back for surgery, and then the surgeon takes it into dorsal, and then we go back and we flip you for x -ray, and I'm like, flip it a few more times.
Annatasha: It's like a roller coaster.
Ryan Bailey: Yeah.
Annatasha: I'm like, keep flipping it. I'm like, $50 a flip, guys. That dog's going to regurgitate, right? And it's like big dogs, over 40 kilos, over four years of age.
Gianluca Bini: and percent
Annatasha: So if I have like a walking regurgitation poster child, which in my head is a fat Labrador having a TPLO, then I'm going to be more aggressive about it.
Gianluca Bini: Yeah.
Annatasha: That was a lot of me talking.
Gianluca Bini: No, that's fair.
Annatasha: Bini.
Gianluca Bini: It's a lot of, yeah, no, no, but it's a lot of good information, right? Like, so do you do that for every single patient and it's just specifically the ones that you're more worried about?
Annatasha: ah ah You know, honestly, like, if we're gonna do something like, like, if we're just gonna do like a brief CT under sedation, I'm not gonna, I'm not gonna throw the the kettle of gesture protections at them.
Annatasha: You know, because I don't think first of all, we're giving it in a fashion such that it's timely to be efficacious for them.
Gianluca Bini: right
Annatasha: But yeah, like, I would say, oh,
Gianluca Bini: I think if you wanna do something really efficacious, you should suction, right?
Annatasha: okay.
Gianluca Bini: So you induce, you indubate, you cuff the tube, suction.
Ryan Bailey: Yeah.
Gianluca Bini: The suction, the esophagus, right? Mouth and the esophagus.
Ryan Bailey: All of ours.
Gianluca Bini: And before...
Gianluca Bini: I don't know.
Annatasha: Well, there's lavage and then there's what are you lavaging with there sodium bicarbonate people.
Gianluca Bini: Right, right, right, right.
Ryan Bailey: I mean, I just, yeah.
Gianluca Bini: i'm
Gianluca Bini: Yeah, that worries me a little bit.
Ryan Bailey: Okay.
Gianluca Bini: Meaning like you need to make sure that then you suction the full amount that you put in there.
Ryan Bailey: Right. Right.
Gianluca Bini: Because aspirating bicarb sucks way more than aspirating acid.
Ryan Bailey: Oh yeah.
Ryan Bailey: I'm a, I'm a tap water person for the record.
Ryan Bailey: I am not a buy car person.
Gianluca Bini: Fair, fair.
Annatasha: out of my car person.
Gianluca Bini: Then at that point I'm fine with it.
Annatasha: I think putting something in that's that basic is just as caustic as putting in something.
Ryan Bailey: math The math is the math. Water is a neutral pH. Enough water, you will eventually neutralize the stomach acid. They're not regurgitating gallons of material.
Ryan Bailey: you know like There's stuff that just can't fit gallons.
Gianluca Bini: Yeah, yeah.
Ryan Bailey: you know
Annatasha: No. And I, like I said, I think you putting in something that has like a pH of 13 is just as damaging as pH h two.
Gianluca Bini: Right,
Annatasha: Like that's, it was a crazy time for me.
Ryan Bailey: yes Yeah.
Gianluca Bini: Absolutely, absolutely.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: But I usually try to suction after indubation and before X.
Annatasha: Every case.
Gianluca Bini: No, but the ones where I'm worried about it, right?
Annatasha: okay
Gianluca Bini: Rather than like relying on a pharmacologic occasion, they would do know that it doesn't fix regurgitation, right?
Ryan Bailey: Oh. Mm -hmm.
Gianluca Bini: Like there is no fix for it.
Annatasha: There is no drug that treats or prevents regurgitation.
Ryan Bailey: Mm.
Annatasha: What you we're doing is mitigating the symptoms associated.
Gianluca Bini: Right. There was some evidence behind cisapride at some point, maybe, right?
Annatasha: Have you taken us to cisapride
Ryan Bailey: Yep.
Annatasha: Because be near a toilet when that happens, gentlemen.
Gianluca Bini: Gross.
Gianluca Bini: Right, so, so, you know, I, I do agree with the nausea meds. I try to stick with T IVA if I can but
Annatasha: because you I'm gonna lie awake all night thinking about lidocaine and fucking pantoprazole. Thanks a lot.
Ryan Bailey: I think we'll find out plenty about lidocaine next month.
Annatasha: Oh.
Gianluca Bini: and and
Ryan Bailey: After this conversation, I like i got to know.
Annatasha: Oh, we're coming with the big guns. Oh God, I'm I'm gonna have to study.
Gianluca Bini: anyway
Annatasha: I'm gonna have to crack my Lumb & Jones sixth edition, which currently is still sitting in its wrapper on my desk.
Ryan Bailey: That's a great version. It's a real upgrade.
Gianluca Bini: Anyway... I heard really good things about it.
Ryan Bailey: Big temple.
Gianluca Bini: I don't have it yet.
Ryan Bailey: Big upgrade, big upgrade.
Gianluca Bini: oh But yeah, no, I believe you. it's
Annatasha: We're like Goldilocks and the Three Bears, except with Lumb & Jones.
Ryan Bailey: Okay.
Annatasha: It's like, one has it and it's readt it one has it and it hasn't read it, and one doesn't even fucking have it.
Ryan Bailey: so So then what about Cerenia?
Gianluca Bini: It's...
Ryan Bailey: Like, what about the the new school, if you will? Because Bini's really like the new school of the three of us.
Gianluca Bini: Okay.
Annatasha: Excuse you.
Ryan Bailey: Like just with when he when he finished, like you and I are on the tail end of what I think is one school of anesthesia and Bini is definitively in the early phases of the new, the slightly newer school of anesthesia.
Annatasha: you
Gianluca Bini: well
Ryan Bailey: And so all those, I just, I want to know about like all the people out there who are like Serenia for anything getting an
Gianluca Bini: I don't know if I should take it as a compliment or if it's...
Ryan Bailey: um
Annatasha: let's not forget how max varying serenia is so you can
Gianluca Bini: Absolutely not.
Ryan Bailey: i I'm not even going to go there, but like, you know, you know what I'm talking about. There are, there are people who do that and there are people who I respect to do that. And I understand why they do it. I don't agree with it.
Annatasha: I don't even cookbook anesthesia.
Ryan Bailey: Where are you guys at?
Annatasha: So there's that like, I don't have a separate goal for every single patient.
Gianluca Bini: Why?
Annatasha: Like my GDV is can change from one day to an ex. Like it's almost like I always do this.
Ryan Bailey: Right.
Ryan Bailey: Yeah.
Annatasha: And and you do that.
Gianluca Bini: Right.
Annatasha: But
Gianluca Bini: But why would you need to give, like, so here's my deal, right? Like, why do you need to give a drug to try to fix a problem you're creating, right?
Ryan Bailey: Oh, and then. And then when are we giving it?
Gianluca Bini: So if you are, if you know, if you know that you're going to create that problem, just try to avoid creating the problem in the first place, right?
Ryan Bailey: Yeah.
Annatasha: which is 100 % what you're supposed to do, right?
Gianluca Bini: Why do you factor you need to give hydromorphone?
Annatasha: Like you're supposed to avoid making the patient nauseous, but what if it comes in nauseous?
Ryan Bailey: Right.
Gianluca Bini: Right.
Gianluca Bini: but But that's something that we're dealing with afterwards. right like I don't give them Cerenia from the get -go if I believe it's it's ah you know if it's not a brachycephalic, if it's not a patient that has a mast cell tumor, if it's not a patient that has any hystory of GERD or something, I'm not going to give that Cerenia randomly. right I'm not giving random drugs to everybody. It's not like candies. right like This is becoming like the gabapentin of you know vomiting and nausea here.
Annatasha: Famotidine was already that drug.
Gianluca Bini: like
Ryan Bailey: But for some people, some people, Cerenia is like, everything gets Cerenia.
Annatasha: Famotidine's thunder. Famotidine used to be given to every hospitalized patient 100 % of the time until the internist lost their marbles. so
Ryan Bailey: Oh, we're gonna give it opiate. Should we give it Cerenia? Like, I don't agree with that. I don't like, and then they're like, oh, well, we're gonna give it hydro. So should we give it Cerenia?
Annatasha: You have to give it like a minimum, like an hour, right? like
Ryan Bailey: Yeah, that's why I asked every time.
Annatasha: get
Ryan Bailey: I was like, do you have an hour to give the Cerenia before you give your hydromorphone? Because if you don't, you're giving a drug for no purpose like you're, you're giving a drug to treat something that you don't know may or may not happen.
Annatasha: Yeah.
Ryan Bailey: And so.
Annatasha: and And I think like, you I mean, guess you could argue if you gave it at before pre -med or around peri induction, that it would be more related to recovery. Cause don't forget Bini too. We got people out there who don't even have an infusion pump.
Annatasha: So TIVA is not an option.
Ryan Bailey: Yeah, true.
Annatasha: Right.
Gianluca Bini: You can drip propofol.
Annatasha: Okay.
Ryan Bailey: They, you can and that's how they, they have it for humans where they have the bottles with the little hang things.
Annatasha: Fancy pants. You know what I mean?
Gianluca Bini: We have it, we have it.
Annatasha: funnels yeah
Ryan Bailey: Yeah.
Gianluca Bini: You just hang the bottle, just spike it.
Ryan Bailey: yeah Oh yeah.
Annatasha: like but
Ryan Bailey: You just got those.
Annatasha: If you, if you do a lot of burn work, right?
Ryan Bailey: I was like, I want the a hundred mill bottles of propofol now for TiVo.
Gianluca Bini: yeah
Annatasha: Burn work is always Tiva because they'll never ever put them on and inhale it because they're concerned about smoke inhalation and ARDS and SIRS. So just hang the 500 mil bottle and spike it directly.
Annatasha: You can hang a 50 mil and do that too.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah.
Annatasha: It's just, you lose a lot to the line, that's all.
Gianluca Bini: Yeah.
Annatasha: But I mean, yeah.
Ryan Bailey: Yeah.
Annatasha: I mean, I think that's a nice idea to put out there too and um get the cogs turning, but you know that 95 % of anesthesia is isoflurane for, you know, for what we do.
Ryan Bailey: Well,
Annatasha: Not for us.
Gianluca Bini: Yeah, but in reality, that's, you know, yeah, I mean, I don't want to go too deep into that, you know, we did or a whole episode on T IVA probably we should revise it at some point, but
Annatasha: right
Ryan Bailey: already, already we need to revise our TUF.
Annatasha: Already we need team up here too.
Gianluca Bini: Not revisor, but like.
Annatasha: And apparently it's, it's not allowed again. So yeah. Yeah. Fuck. I feel like, I feel like shit, but, no, I, no, we're not even old school.
Ryan Bailey: Yeah, but so but like we're not we're not old school and here we have Bini talking about like Remy fentanil on the Remy mazolam or like what are those?
Annatasha: We're like middle school now.
Ryan Bailey: Yeah, it's true That's true
Annatasha: Well, so we have to have like a, like a young whipper snapper like Bini in here to like push us back into the light.
Annatasha: That's yeah.
Gianluca Bini: such an enlightening role into this no I mean I mean I'm not saying I'm not saying that you
Annatasha: Yeah.
Ryan Bailey: No, no one's using lidocaine anymore, guys. it's It's fucking, it's too old.
Annatasha: Halothane of injectables, like i like okay.
Ryan Bailey: Yeah. You're still using lidocaine?
Annatasha: That was like, it was like Like, ugh.
Gianluca Bini: I'm not saying that you shouldn't use it.
Ryan Bailey: For me, it's bad.
Gianluca Bini: I'm saying that to me, it's overrated, right? Like we had this idea, we had this idea of wanting to use, I mean, multimodal it's a great thing.
Gianluca Bini: Like I'm all for multimodal anesthesia, multimodal analgesia and all of that, right? But in reality, especially nowadays where we do more and more blocks, do you really need to have that stupid drug in it?
Gianluca Bini: Like it's such it's such a low MAC pairing effect is not even worth it.
Ryan Bailey: Plus it reduces cardiac output.
Gianluca Bini: Right?
Annatasha: And it's a venodilator, which means if you're trying to it, it's never gonna come out.
Gianluca Bini: Yeah, it causes vasodilation.
Ryan Bailey: Yeah, yeah.
Annatasha: Look, look, none of these terms are part of it.
Gianluca Bini: It causes vasodilation. I mean, and and if and if somebody was to fuck up the dose, it is toxic, right?
Ryan Bailey: True, true.
Annatasha: Bini, honestly, I don't know what OVC is gonna do if they hear this podcast.
Gianluca Bini: right and And so they are probably gonna sue me.
Annatasha: Like, they honestly, like, they put, I would say they put almost 100 % of patients on a lidocaine CRI. And they run it between 100 and 200 mike per keg per minute, which makes me a little uncomfortable because it exceeds the actual toxic threshold.
Gianluca Bini: And that's fair. And that's fair.
Annatasha: And I feel like if anything went potty, the regulatory body ain't going to look favorably on that. But you know they have their research that shows the animals tolerate it.
Annatasha: so But yeah, like it's it's like the crux of that school of thought.
Gianluca Bini: No, and that's fair.
Gianluca Bini: No, that's fair, but the fact that they tolerate it doesn't mean that it's, you know, you any advantage is to you, right? Like at the doses we use, because I don't want to put my patients on a 100 or 200 micro per kilo per minute of Lidocaine, right?
Annatasha: oh yeah
Gianluca Bini: So at those doses, it may be a different story, but at the doses we use, which is usually around 50 or 30 micro mcg per kilo per minute, I don't mean that the advantage I see besides the anti -arrhythmic effect, it's worth it, right?
Ryan Bailey: Hmm.
Annatasha: Bailey and I are going to have more debrief about this.
Gianluca Bini: And so then,
Ryan Bailey: Yeah.
Annatasha: I think you're rocking our confidence.
Annatasha: And I was like, I feel shook.
Gianluca Bini: Oh, whatever, guys.
Annatasha: I am shook about this Lido caine. Yeah.
Gianluca Bini: I don't know.
Annatasha: I mean, this is why we do this, right?
Gianluca Bini: Yeah, it's...
Annatasha: Like, you know, learning ideas, new tech.
Ryan Bailey: Yeah.
Annatasha: I mean, I'm sure I could spend the rest of my career doing exactly the same anesthetic protocol for everything and I'd get away with it.
Gianluca Bini: Yeah.
Annatasha: But do I want to be that person? Not really.
Gianluca Bini: Yeah. I mean, if we didn't have any ideas, we would still be stuck at the bag a barrel, right?
Annatasha: no he we we We still be putting that little mask where you with the cloth on it and then you just spray the ether on it and then they just take a breath through it, right?
Ryan Bailey: Yeah.
Ryan Bailey: Oh, it's still used by Hammer.
Gianluca Bini: That's the thing you do to horses, right?
Annatasha: like Or you just go to Italy and they hold you down with a knee.
Ryan Bailey: Yeah.
Gianluca Bini: yeah that That was an experience, I have to tell you down that. was
Ryan Bailey: You don't say, you don't say.
Annatasha: I was like, I'm not even going to get into the PTSD of poor quality anesthesia because that's not the topic tonight, but yeah.
Ryan Bailey: Yeah.
Annatasha: summary, I'll give the summary and the summary is is that we I think there's a high degree of concern for reflux regurgitation, the adverse events associated with perianesthetic drugs. So your nausea, your amesis, your diarrhea, let's not forget. Conversely, your ileus, your inappetence. One, because of the welfare associated you know for the patient itself, because it's miserable to be nauseous.
Annatasha: and to the discharge, because you know that the faster you can discharge patients, the less likely they are to have hospital -associated morbidity. so the decisions we make around our protocols affect how those patients go home and when they go home.
Annatasha: There's no clear cut treatment or preventative for regurgitation specifically.
Gianluca Bini: Yeah.
Annatasha: The best we can try to do is limit what we do as anesthetists and anesthesiologists to incur it and then just you know think about the drugs and exactly what they're targeting and and try to make you know informed decisions as opposed to like standardizing just promoted it in Serenia for everything across the board all the time.
Annatasha: Did I miss anything? Oh, Beatty hates light again.
Gianluca Bini: No, I think that...
Ryan Bailey: Yeah, he hates it.
Gianluca Bini: No.
Annatasha: hates light again, and I'm taking myself off Pantope Resolve because I don't want to have to have a kidney transplant. Good times.
Ryan Bailey: yeah
Gianluca Bini: Awesome. Awesome. that I think that that summarizes for the evening.
Annatasha: Yeah, and and don't go to it an Italian dentist because
Gianluca Bini: Well, thank you.
Gianluca Bini: Yeah, done. Done.
Annatasha: No, the anesthesiologist carries a big club and speaks softly.
Gianluca Bini: talk
Annatasha: Like, no thanks.
Gianluca Bini: Yeah, no. Anyway, thank you, everybody, for listening. Just for yeah whoever wants to watch this rather than listen, it you can watch us on YouTube you didn't know. Now you know. Thank you, everybody. And I guess we'll see you in the next episode.
Annatasha: which will be St. Patrick's Day themed and all about Ryan and Lyda Kane.
Ryan Bailey: Oh yeah, hell yeah!
Annatasha: Yeah.
Gianluca Bini: Yeah.
Annatasha: Green beer gentlemen, green beer.
Gianluca Bini: Oh, yeah.
Gianluca Bini: Alright, see ya guys.
Ryan Bailey: Wow.
Annatasha: Peace.
