Transcript
Annatasha: Sound effect, Beanie?
Gianluca Bini: Ooh, I don't, but...
Gianluca Bini: No, I don't. Fuck.
Gianluca Bini: This is the only...
Annatasha: I was like, do we have intro music?
Ryan Bailey: It was good.
Annatasha: yeah
Gianluca Bini: Apparently, we do have an intro music, but I didn't
Annatasha: my
Gianluca Bini: but
Gianluca Bini: Welcome, everyone, to the random anesthesia topic podcast.
Annatasha: holiday podcast apparently apparently
Gianluca Bini: um Yes, the random holiday podcast. I don't know.
Gianluca Bini: Tonight we have Dr. Annatasha Bartel from King Animal Hospital in Ontario.
Gianluca Bini: And then we have... Dr. Ryan Bailey from Premier Veterinary Group in Chicago, The hot dog City
Gianluca Bini: So tonight is going to be Dr. Ryan Bailey unveiling his random topic. We have no clue what he picked. Kind of scared about it.
Ryan Bailey: David.
Annatasha: Look at his derpy little face.
Ryan Bailey: He also.
Annatasha: He's so excited to like antagonize us, which frankly is not very holiday -y in my opinion.
Ryan Bailey: I am.
Gianluca Bini: It is.
Ryan Bailey: I'm more of a green, even though I'm not in green.
Gianluca Bini: Yeah, it's not very nice of you.
Annatasha: No, no, but we're all balanced. We have each one of the holiday colors. Yeah.
Ryan Bailey: We are, yeah.
Gianluca Bini: It's true.
Ryan Bailey: I am influenced by developments.
Gianluca Bini: And we didn't, we didn't organize this. we didn't pick the colors. I like, with I had no clue what you were wearing.
Annatasha: Well, we wanted to order shirts, Bini but because of the Canada Postal Strike, we wouldn't have been able to coordinate anyway. Thanks a lot, Canada.
Annatasha: i'm But yeah, they said, all I want for Christmas is ketamine. And we were like, yeah.
Gianluca Bini: Okay.
Annatasha: Is this the part where we put the disclaimer in that says nothing that we say or do, we can held liable for?
Ryan Bailey: Ha Ha ha ha!
Gianluca Bini: Well, I can see why that wouldn't make it through customs but even without the stripe.
Ryan Bailey: that
Annatasha: No, don't be ridiculous. I can just leave a lot of here guys. I can just like, I can get a Ephedrine and you can't.
Ryan Bailey: True.
Gianluca Bini: True. True story.
Annatasha: Yeah.
Ryan Bailey: And you can import drugs somehow. You have some sort of Canadian exception. You can be like, we need this. Fuck you.
Annatasha: That's right. That's right. We need a Ephedrine to get through cold season in the great white north.
Ryan Bailey: Cool. How else?
Annatasha: Yeah. That's what we tell customs.
Annatasha: ah
Ryan Bailey: Well, I hope you all ready because I have a great topic based on some of what I saw in a AVA plus some of the recent literature that's out in VAA So I want to know what your thoughts are on total intravenous anesthesia.
Gianluca Bini: Oh, all right.
Annatasha: First of all, I don't read any literature, so this is going to be tough for me.
Ryan Bailey: Okay. I'm surprised you're a little bit.
Gianluca Bini: Okay.
Annatasha: sit
Ryan Bailey: It's that Canadian system.
Annatasha: Yeah, we don't need literature. By the way, listeners, JK, I do read literature, Jay.
Ryan Bailey: smith
Annatasha: But no, I think Bini why don't you feel this one? I'd love to hear it.
Gianluca Bini: Well, I mean, to be honest, I love it. i read I read a lot of the human literature literature on it, I think.
Gianluca Bini: I think it's far superior, to be honest with you, compared to inhalants
Gianluca Bini: they wake up better, I think. And a lot of people don't realize this, but a lot of the dysphoria and the post -operative nausea that our patients get actually comes from the inhalants right?
Gianluca Bini: always...
Annatasha: Bini a lot of the nausea that I get from being an anesthesiologist is probably from trace isoflurane
Ryan Bailey: Post -op nausea and vomiting.
Gianluca Bini: Yeah, no, that's fair.
Ryan Bailey: I have post -op nausea and vomiting myself. I threw up for 24 hours straight every two hours when I had my wisdom teeth taken out.
Gianluca Bini: Thanks.
Ryan Bailey: It was a nightmare.
Annatasha: wimps, honest to God. I have had every anesthetic drug and I wake up like a rock star.
Ryan Bailey: I mean, look at me. Nothing about me says long.
Gianluca Bini: Okay.
Ryan Bailey: Everything about me says wimp.
Gianluca Bini: Well, I think I had seven anesthetic events. four with gas three with TIVA and the ones with gasses I puked the hell out of it all night, every single time. With Tiva, like you know they bring me back to the room, and 20 minutes later, I'm walking.
Gianluca Bini: last time I had bilateral inguinal hernia repair and they I asked them, I was like, can you do that Propofol and Remi And it was like, sure, why not? And it was amazing. You know, it's...
Gianluca Bini: A lot of people don't realize that, but, you the dysphoria and the vomiting and the nausea do come from the inhalants The other side of things, though, is that it's a very different anesthesia, right? So, like, you anesthetic signs are somewhat different. The, your pub period is usually there all the time, yeah regardless of how deep your patient is.
Gianluca Bini: Sometimes propofol and afoxone, they both give you myoclonus. And, afoxone is somewhat more in recovery, propofol usually more during anesthesia.
Gianluca Bini: And so, like, people think, oh, my God, the patient is light, and they give more propofol, and then they get more myoclonus. they're going in a spiral
Annatasha: and loves thats where this is and
Gianluca Bini: they're going to do that spiral. So usually, and I do always try to get my students to kind of like try it at least once during the rotation.
Gianluca Bini: And, I always tell them the major sign you're looking for is probably jaw tone. That's probably your best anesthetic sign with TIVA you know, I always tell them the major sign you're looking for is probably Jordan. You know, that's probably your best anesthetic sign with Tyra.
Annatasha: Love that.
Gianluca Bini: The twitchiness and the material, you're going to see that, unfortunately.
Annatasha: I love that part. Yeah.
Gianluca Bini: You know, there are some reports of unstoppable myoclonus Um, I think from 2018 in Italy actually did describe that, where they had to just wake them up or paralyzed them. Um, but besides that, you know, it's pretty rare. I've never seen it.
Gianluca Bini: They do it way more often in Europe, and in Italy, actually, it's a pretty big movement on doing TIVA for our patients. Some of them use TCI,
Gianluca Bini: which has its own limitation, but it's a useful tool, and a lot of people actually probably don't even know what TCI is. TCI, for whoever is listening,
Annatasha: yeah my i'm just kidding but
Gianluca Bini: For whoever is listening, TCIS stands for Target Controlled Infusion, and basically a the pharmacokinetic model that's loaded into a computer, and the computer drives the syringe pump based on some parameters you set in the site, oversimplifying, more or less, that's what it is.
Annatasha: Yeah, remind me.
Ryan Bailey: Yeah.
Gianluca Bini: But you know, FDA never cleared it in the US.
Annatasha: I'm just kidding. I'm just kidding.
Gianluca Bini: you know
Annatasha: yes and
Gianluca Bini: In Europe, they use it.
Annatasha: you Can't get a Ephedrine can't get TCI.
Ryan Bailey: Oh, hey, Tony, go ahead.
Gianluca Bini: Well, you know.
Annatasha: Oh,
Gianluca Bini: but But yeah, it's ah it's good. I like it. What about you, Tasha? What's your thought on Tiva?
Annatasha: oh my thoughts on Tiva. There are many. I just want the people who can't see us on podcasts tonight know that we're all enjoying some eggnog tonight, and every time one of the other anesthesiologists says something, it annoys me, I like to take a swig. So um I do also want to bring up, while I have an Italian and a Chicagoan on the line here is pizza, thin crust or deep dish?
Ryan Bailey: n Clearly then.
Annatasha: but You're probably you the only person in Chicago who's not gonna like live or die by deep dish.
Ryan Bailey: Oh, there's a movement in Chicago about this tavern style pizza where it's like super thin crust. It's like a cracker underneath. And then you get the corner piece that's like, it's almost like a tortilla chip of pizza.
Ryan Bailey: And it's like truly the greatest thing. It's like, it is abomination to what Italians consider to be pizza.
Annatasha: Too bad you guys can't see Gian luca's face because it looks like he's passing a kidney stone right now.
Ryan Bailey: It's like, oh my God.
Gianluca Bini: Horrified
Annatasha: I mean like he is.
Ryan Bailey: I thought say it was just like this. I was like, oh my God, he is like dying. But no,
Annatasha: Yeah, I think it's time for everyone to take ah ah a sip of eggnog. take a sip of your eggnog. But yeah, no, I thought, I was like, because I know Bini is still recovering from the whole don't put ketchup on your hot dog.
Ryan Bailey: every style all day.
Annatasha: And I thought, I thought Bailey, you were gonna come out swinging about deep dish, but then I forgot you're, you're a pizza freak attack.
Ryan Bailey: No. We have other style in Chicago that is like ubiquitous and it is just like little tiny squares of pizza. Like you take a big pizza and you cut it into like little tiny squares.
Annatasha: Oh.
Gianluca Bini: For what?
Ryan Bailey: and They're thin, they're crispy. It's like crispy all through. It's not like soft at all. It's like it's like a cracker underneath.
Gianluca Bini: Can you eat crackers instead of ruining pizza?
Ryan Bailey: yeah but Hey, in Chicago, we gotta do our own we gotta do it our own way. We're gonna ruin any kind of food, you know? Wait, I just realized, have you ever heard of an Italian beef?
Gianluca Bini: Italian beef?
Ryan Bailey: Yeah.
Gianluca Bini: I mean, we do have cows.
Annatasha: Hello guys, where where is this podcast going?
Gianluca Bini: Yeah, the rest of that would be for sure.
Ryan Bailey: so There's a sandwich in Chicago. It is a big hunk of beef, like a roast. It's roasted with herbs and spices, and then they slice it up real thin and cook it in this gravy, and then they take a a French bread roll, they stick the meat inside, and then if you want, if you want it dipped, they'll take the whole sandwich, meat and all, and they'll dip it into the gravy, pull it out, and then they put these hot peppers on it called giardiniera, which is like,
Ryan Bailey: But I'm I don't know if you have it there. But in Chicago, it's like oil and peppers and olive oil and carrots and cauliflower.
Annatasha: Is Chicago the heart disease capital of America?
Ryan Bailey: It's Oh, yeah.
Annatasha: like
Ryan Bailey: yeah
Annatasha: Yeah, no, I thought, I thought I would just, yeah, I was like, that's sort of how I feel.
Ryan Bailey: That's like like
Annatasha: Beanie's face reacting to your cracker pizza is sort of how I feel about inhaling anesthesia. So that's a great lead in for my Tiva talk. now I will admit that Tiva sometimes is a pain in the ass because especially if you're doing it, for example, like on an MRI and you have to run 95 lines and you know, you're pushing, you know, enough propofol through to drop a hippo.
Annatasha: from a pragmatic standpoint of you, like I get why when we asked for Tiva, like, you know, the nurse technicians are like, I remember as a resident, you know, in the middle of the night, just being like, this is just, this is just the worst. But I mean, I, I, I agree. I think that, you know, for the most part, unless you're a cat on the longterm alphaxolone, the recoveries do tend to be better.
Annatasha: I think the cost differential is probably comes out in the wash at this point. um um And the other thing too is that especially Bailey and I have definitely gone toe to toe about whether or not you use this in thoracotomies.
Annatasha: And of course, it depends like, are you do you have a ah ah punctured lung? The likelihood of a ruptured lung? Are you taking lung out? like Is there a risk of inhalant leaking into the room?
Gianluca Bini: Thank you very much.
Annatasha: But more importantly, like you have to remember inhalants deregulate hypoxic pulmonary avezo constriction. So actually being on an inhalant can in fact worsen shunting of the, you know, deoxygenated into the oxygenated circulation. you know you may contribute to overall drops in your partial pressures of bacterial oxygenation. So that's a nice consideration, especially if you do have underlying pulmonary pathology, or you know you're gonna have marked outelectasis, or you know you're going into the chest and and the lungs are gonna wanna continually collapse against loss of negative pressure. So, you know, I like Tiba, I will admit that it's a pain in the bahooki. But yeah, I mean, I think a lot of people would cite like,
Annatasha: It's better for the environment. And I think that is a marked overstatement, uh, of like how much isoflurin am I putting out into the atmosphere, contributing to the depletion of the ozone layer versus, Oh, I don't know. Major industries turning it out like, you know, in millions of gallons a day, like I'm not losing sleep over this. So.
Annatasha: I think I'm making a long -term difference in the outcome of the planet switching over to Tiva? Probably not.
Gianluca Bini: No.
Annatasha: you know, whatever gets you through the day. But yeah, I think ah ah Tiva definitely has has its place. Unlike tiny, crispy cracker pizza.
Ryan Bailey: oh Well, I have done a hot dog pizza.
Annatasha: No, no.
Gianluca Bini: So, so, so, so.
Annatasha: You're gonna need more eggnog. eggnog.
Gianluca Bini: Wait, wait. So, how about hot dogs on pizza?
Ryan Bailey: I made a Chicago style tavern pizza and then I put all the hot dog toppings on it. I bought pizza like that. Oh my God. So good. So good.
Annatasha: Remember, was it episode one where we determined that Ryan was for sure gonna die of heart disease? And I just wanna, I wanna loop back to that comment right now.
Ryan Bailey: so
Gianluca Bini: A hundred percent.
Annatasha: Yeah.
Ryan Bailey: That's what I want on a run today.
Gianluca Bini: Okay.
Ryan Bailey: i got I got a run so I can have the hot dogs.
Gianluca Bini: Sure.
Annatasha: Now there's a t -shirt. Now there's, I run for hot dogs.
Ryan Bailey: I'd also like everyone to know this eggnog is from last year.
Gianluca Bini: Run for our cooks.
Ryan Bailey: So if I die in the middle of this podcast, that would reason.
Annatasha: oh
Ryan Bailey: And it tastes so good.
Gianluca Bini: Look.
Annatasha: poor
Gianluca Bini: Holy shit.
Annatasha: Bini is going to have to take it on dansetron shortly if you don't stop. But do like your fancy eggnog glass, Bailey.
Gianluca Bini: and the
Annatasha: I know you've got the whole gamut of cocktail glasses.
Ryan Bailey: I do. These were a gift to Carol in last year.
Annatasha: Oh, and they nog specific or will you also do like a grasshopper?
Gianluca Bini: all
Ryan Bailey: I've never made a grasshopper but a grasshopper could go in there for sure.
Gianluca Bini: I love glass operas.
Ryan Bailey: These are a little smaller than the other martini glasses I have. These are like a three ounce so you know I don't have to like
Annatasha: would you put grasshopper on a painte
Ryan Bailey: I mean like real grasshoppers maybe if I got some. I've not eaten many bugs. I don't have an issue with it. I mean I do have an issue with eating spiders but like I'd probably eat a bug.
Annatasha: I've eaten bugs. I've had worms, but you are correct.
Gianluca Bini: Yeah.
Annatasha: I've steer cleared of the arachnids because i just I feel like that's just something that ah ah they're just trying to pull the wool over the eyes of tourists and see who's dumb enough to eat a tarantula.
Annatasha: So absolutely not.
Ryan Bailey: and
Annatasha: Yeah, no, I don't think we should continue this. The Italian, I think, is going to have a stroke soon. so So Bailey, I'd like to hear your Tiva remarks because I know you're just like,
Ryan Bailey: Yeah.
Gianluca Bini: yeah
Ryan Bailey: So, no, I, so I feel like I'm a bit of a late adopter.
Annatasha: Itching! Itching!
Ryan Bailey: We did Tiva as residents. And it was like, It was more under the realm of like, this is a technique that is possible. It is indicated in such and such cases, but essentially is not like, it is not a mainstay. um i I would quite, I i think i think it is,
Ryan Bailey: I don't know if mainstay is the right word but I think it's an appropriate technique for any case undergoing anesthesia maybe except the long term cat anesthesia case because cats are unique little creatures but like I think using injectables, propofol, alfaxalone in dogs for any kind of procedure is reasonable. And I find the anesthesia is much smoother when I add it. Like I would say I'm still inhalants. Like that is the primary way I anesthetize most of my cases. But I just wonder, I think the reason I brought this question up is I wonder if that's right. And I think the answer is it's probably not as right as we think.
Ryan Bailey: with the advent of propofol and.
Annatasha: You owe me an apology because like four or five years ago, like you ripped into me about Tiva versus inhalants, because of course you were trained at Davis and like they move in terms of medicine, like glaciers have melted more quickly, probably, you know, because of inhalant anesthesia.
Ryan Bailey: hope Oh, yeah. Yeah.
Annatasha: So, I think that, yeah, I feel like I was like, Bailey, what are you talking about? Like in human medicine, they use Tiva all the time and like, It's so nice.
Annatasha: And like, there's no waste anesthetic gas. And you were just like, it's not an indicated bartold.
Ryan Bailey: Oh, yeah.
Annatasha: It's totally brutal. And I was like, well, you do you.
Ryan Bailey: Oh, yeah. I apologize for any overly emotional debate that may have gotten into.
Ryan Bailey: like I like in clinically, I will say, I find these cases that are really challenging to manage with inhalants and injectable alone.
Ryan Bailey: And if you switch them to a Tiva technique, It's smooth sailing. Blood pressure is stable. Patient's stable. They're not moving. I can get them off pressors. We're not fluid bolusing them into oblivion. We're not having to reach for atropine. And like i like I'm sorry, I don't have enough knowledge of the inhalant pharmacokinetics to really have the best ex example like my idea is that they there's some sort of gradient issue from the lungs taking up the drug and equilibrating with the brain, and it's not going the way we predict it to. We rely so much on this like favorable equilibrium equation that I don't think is always true, and especially in those patients who maybe have some degree of inflammatory lower airway disease, they seem to just be really challenging to manage under anesthesia and you convert them to
Ryan Bailey: a TIVA or even like a PIVA with like a whisper of ISO if you don't want to like make people kind of freak out a little bit. But I've really been liking it and it is a quick, I'll give the patient one or two,
Ryan Bailey: they're rollicky anesthesia with ISO, you know, they're super tachypneic, they buck the vent as soon as I start it, I repeat an opioid dose, they have a block on board, you know, it's okay, we're reaching for injectable now. Do we do PIVA with like, you know, lidocaine, dexmed ketamine, something like that? Or do we just get rid of the inhalant, transition to propofol and see how it goes? And the results?
Ryan Bailey: in my hands have been really good and reading just some of the human stuff, it seems like it's much more common. Like it would just be like, oh yeah, I felt like using propofol today and not like using ISO and I feel just at least clinically where I'm at and where I was trained and just kind of reading the survey that came out in JAVMA or in VAA 2024, it seems like we're still there of like TIVA is a technique that we have access plus to, but it is not, is not the mainstay. And my question is, why is it, why are we doing 50 % of cases, you know, on Tiva? Like what's, what's the barrier? I mean, they, they speculate far more on like what the barriers to using Tiva, but I really think it's,
Ryan Bailey: I don't know, I think it's, I'm really happy with it.
Gianluca Bini: Laziness.
Ryan Bailey: and Yeah, I think.
Gianluca Bini: A lot of it is laziness, I think. You know.
Annatasha: I think moving the needle for veterinary anesthesiologist is like, it's like shifting atlases, you know, earth on the shoulders.
Gianluca Bini: Yeah.
Ryan Bailey: it simple
Annatasha: Like it is moving the needle in our group is agonizing because we take evidence -based medicine to the point where it becomes paralytic. So that's a hurdle.
Ryan Bailey: Well, so that's the thing is, so what are the advantages and disadvantages to TIVA? So like, what do you think, like, what is your understanding of the knowledge or the literature surrounding hemodynamic stability?
Ryan Bailey: Since that is 90 % of our job is battling.
Gianluca Bini: much better.
Ryan Bailey: So yeah.
Gianluca Bini: It's much, much better with TIVA. You We do know that you have way less chance of having hy tension with TIVA, right?
Gianluca Bini: And that's both reported in humans and in dogs. And there are some species where, I remember one night I was called in during my residency to anesthetize a ring -tailed lemur for a gall bladder mucocele.
Gianluca Bini: And the first thing, wait, the first thing I read, you know, I was like, oh, shit. I mean, I've never, I've seen them just in pictures. Like, you know, I've never actually seen one live, right?
Annatasha: de
Gianluca Bini: so
Annatasha: Well, Beanie, if isn't that the story of all of our jobs? Like, you know, today I got asked, how many times have I anesthetized a silverback gorilla?
Gianluca Bini: lot of
Annatasha: And I was like, just the once.
Gianluca Bini: Okay.
Gianluca Bini: But one of the things I was doing is that they're super sensitive to inhalants right? And so, which, I mean, yeah.
Annatasha: that They're monkey primates, right?
Gianluca Bini: And so, what did we do? It was like, you propo fol remi fentanyl you know, perfect, legit, amazing.
Ryan Bailey: Yeah. Yeah.
Annatasha: but The last time I did a lemur Bini was a resident.
Ryan Bailey: Yeah.
Gianluca Bini: But, I always had really good luck with TIVA I think it's it's really good.
Ryan Bailey: yeah
Gianluca Bini: I think part of the disadvantages are that, you especially in academia, the way we price things is that, you know, we have packets like, you know, level one, two, three, or whatever.
Ryan Bailey: Yep.
Gianluca Bini: or some sort of packets of that. said And those do include in nes the in the price.
Ryan Bailey: Yeah.
Gianluca Bini: And so if you were to use propofol, you have to charge extra for the drug, right?
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: So that makes it more expensive, right?
Ryan Bailey: Yeah.
Ryan Bailey: Totally. Yeah. For sure.
Gianluca Bini: to a degree.
Ryan Bailey: Yeah.
Gianluca Bini: Whether it's relevant or not, it doesn't matter.
Ryan Bailey: right Yeah.
Gianluca Bini: But, you know, it is much more expensive. The other side is that there is the setup, right? You need the pump, you need the lines, you need the syringes and people.
Ryan Bailey: yeah
Annatasha: You need extra IV access, right? Like that might be a practical limitation if you're struggling with IV access, for example, like it's markedly, it's in heart failure so it's vasoconstricted or it's markedly septic and hypovolemic and all those other things.
Ryan Bailey: yeah
Gianluca Bini: Right.
Ryan Bailey: yeah
Gianluca Bini: I mean, you do need IV access anyway, right?
Annatasha: Like IV access can be a limiting factor if you're going to run, not just like single agent Tiva, right?
Gianluca Bini: yeah
Ryan Bailey: Yeah. and And that would be the other thing I'd add is like, really propofaltiva in at least in small animal patients is probably not. It's like, it's, it's not the best.
Ryan Bailey: Like it's probably going to be a multi infusion. Like you're inherently going to reach for balanced anesthesia by doing Tiva just because they become so like, unless you're willing to really max out that propofol dose and be slamming, you know, 600 mic, uh, 600 micrograms per kilo per minute into them, which is just yours is going to chew through drug and bottles and stuff.
Gianluca Bini: All right.
Ryan Bailey: you know, it's not really sustainable. So you're going to need.
Ryan Bailey: you know, an analgesic infusion potentially, a muscle relaxant potentially, like you're going to need to have multiple pieces in the the puzzle there.
Gianluca Bini: Yeah.
Annatasha: But that's what makes it fun, right? Like I didn't become a veterinary anesthesiologist. I just give them a dazzle them all the time. So like, I mean, like mixing it up. And I have heard anesthesiologists say, I don't like to use multiple drugs at once because I don't like to have to think about what they're doing.
Annatasha: And, like,
Gianluca Bini: Isn't that what we're paid for?
Annatasha: that's I was about to say like I was like if I had one of those like vaporizer guns that they do in comic books I'd be like but you're off the planet but yeah like that's the whole fun of it is like for me anyway is the challenge that you want to hit that nice like autopilot plane and not spending
Gianluca Bini: Which you can with TCI, by the way, right?
Annatasha: Yeah, yeah, yeah.
Ryan Bailey: Oh yeah, I know.
Gianluca Bini: That's exactly what you can do.
Annatasha: Just another example of the robots taking over. but yeah no i The other thing too is that like when when I did my human rotation, which we chatted about I think before the recording started, for example, like the Burn unit only used Tiva.
Ryan Bailey: Really?
Annatasha: Yeah, because they didn't want to give anything that might be caustic or might induce hypoxic pulmonary vaso constriction, like deregulation.
Ryan Bailey: yeah
Annatasha: So they would not use inhalants because there was smoke inhalation from a burden from a burn victim or what have you.
Gianluca Bini: Huh?
Annatasha: Tiva was the protocol of choice. Like they didn't even have vaporizers on the floor.
Annatasha: And I mean, it's also a nice option too for like, you know, MRI, cause then you don't have to buy a specialized, like non -magnetic equipment. And, uh, but you do need to buy a lot of plastic lines, which, no, sorry, Pacific
Ryan Bailey: Yeah.
Annatasha: yeah, no, I think, I do think it's an underutilized technique. Um, Um, and I get to like in GP that you're not going to do that because most GPs don't even have one syringe pump, nevermind.
Annatasha: Like what's your personal record for case syringe pumps? Like mine's like 13 or 14, you know, like, yeah.
Ryan Bailey: Oh, I don't think it's that. No way.
Annatasha: Yeah. Sorry. Let me correct that. That's not all like drugs for Tiva Bailey. like
Annatasha: Yes. I do this very fancy. It's called the Bartel protocol where I titrate doses of every known anesthetic agent to the very mom and give it all at the same time.
Ryan Bailey: Perfect.
Annatasha: Yeah.
Gianluca Bini: Just a sprinkle of it.
Annatasha: Summer Peter Pasco is dying.
Ryan Bailey: You don't even have to think about it.
Annatasha: No. I mean, yeah, yeah, you just put fentanyl at 40 and go for lunch. It's fine. But yeah, like I think, yeah, I, I, I enjoyed a good Tiva case my
Annatasha: know.
Ryan Bailey: I don't know. i like i I feel like should it be, should we be, you know, like, with where with where they're at in humans and the amount of Tiva they're doing, is there going to be a trickle down effect?
Ryan Bailey: And assuming this podcast goes for, you know, 10 years, in 10 years, are we going to talk about should we be using more inhalant and stop doing all this Tiva?
Annatasha: No, I mean, I mean, I guess that depends on who you ask.
Gianluca Bini: Maybe.
Annatasha: I mean, we went through a two hour AGM recently and made zero decisions as a collective community. So I don't have high hopes, Bailey, but, yeah, I do. Uh, uh, disclaimer.
Annatasha: Anyway. yeah, I think, uh, you know, we could set a new standard. We could have our own little private, We can form our own regulatory college and set new standards like I'm all for it.
Ryan Bailey: So what are your, what are your favorite name of species?
Gianluca Bini: sure
Ryan Bailey: Give me your favorite Tiva plans that you like that you're using, you know, on the regular. what What do you like? What do you use? When do you use it?
Annatasha: But every time I do a lemur with a mucous seal, I 100 % do propofol and Remy.
Ryan Bailey: I'm definitely going to do that from now on, for sure.
Annatasha: Yeah. Like I was struggling with my lemur anesthesia before, but like I hadn't thought about Remy and that makes a lot of sense.
Ryan Bailey: Oh my God. Yeah.
Annatasha: So.
Annatasha: Yeah, like King Julian, mor Maurice, like bring it on. Shout out to my favorite lemurs.
Ryan Bailey: I'm not.
Annatasha: Oh, poor Pete, you don't watch Madagascar?
Gianluca Bini: yeah favorite limit
Annatasha: You've never seen King Julian?
Gianluca Bini: No idea what you're talking about.
Annatasha: What?
Ryan Bailey: I'm all right.
Annatasha: Oh, my God, guys, oh what? Okay, so first of all, Bailey, your next movie night, I think you should select Madagascar, but also just can you go guys go YouTube King Julian for a minute because basically, he's the greatest. And if ever a cartoon character that embodied the essence of an anesthesiologist, it is him like there's one where he's like,
Annatasha: He's like, good good guy he's like, he's like, can we all like, you know, wrap up this pointless meeting so I can get back to my schedule of not being around you guys. And I'm like, Oh yeah, I'm going to put that in my next work email, like 100%.
Ryan Bailey: yeah
Ryan Bailey: yeah
Annatasha: Those are my favorite lemurs, but let's see what other, what other species, obviously fish, clove oil.
Gianluca Bini: nice
Annatasha: got that question wrong earlier in Jeopardy.
Ryan Bailey: Yeah.
Annatasha: So it was really demoralizing.
Ryan Bailey: Some clothes
Annatasha: what else? No, I think.
Ryan Bailey: in here. Maybe I'm getting anesthetized.
Annatasha: You obviously are because you've gone from being like obsessed about inhalants to all of a sudden like trying to create this Tiva revolution. So that's exciting. But yeah, I think that.
Gianluca Bini: You're such a rebel. Such a rebel.
Ryan Bailey: really revolutionizing veterinary anesthesia by being like, hey guys, let's do TiVo more than once a month.
Annatasha: Yeah. and and And the more eggnog we drink, like the more awesome Tiva's getting. No, I think my my, let's say my dog Thoracotomy.
Ryan Bailey: Yeah, yeah, great, great case.
Annatasha: I'm going to, I'm going to rock ketamine, propofol, fentanyl, and I'm probably going to do ultrasound guided, parasternal to block the line. I might do a high volume opioid based epidural for some extended post -op care. I'm trying to minimize my systemic opioids. I'm not going to use any inhalant. Go.
Ryan Bailey: Yeah.
Gianluca Bini: yeah Unless the surgeon missed his nerve.
Ryan Bailey: Yes. How are you gonna?
Annatasha: Okay. So the surgeon shouldn't be sniffing as the technique.
Ryan Bailey: How are you?
Gianluca Bini: I'm kidding. I'm kidding.
Annatasha: I mean,
Gianluca Bini: I had to bring it up.
Annatasha: get it I just, I just, I just, nobody out there, if you're listening, if you, if you take one message home other than cracker pizza sounds disgusting.
Gianluca Bini: I had to.
Ryan Bailey: No way. No fucking way.
Annatasha: Do not do sniff tests in any capacity for inhalants. Don't sniff to see there's a leak of your tube. Don't sniff to sniff your machine. Stop sniffing.
Ryan Bailey: i
Annatasha: Because by the time you can actually smell the inhalant, your exposure is like 25 times the recommended daily dose.
Ryan Bailey: people do
Gianluca Bini: yeah
Annatasha: Please stop it.
Ryan Bailey: Yeah.
Annatasha: Please stop.
Ryan Bailey: Yeah.
Annatasha: And if you guys look at those old papers, like in in even in the 70s and 80s where they were looking at like long -term alkenes and human anesthesiologists and how many of them were like curdling up from like hepatic cirrhosis and long -term halothane exposure, you would really think twice about your little sniffing techniques.
Gianluca Bini: Yeah.
Gianluca Bini: Yeah.
Annatasha: So yeah, ixnay on the sniffing, ixnay on the cracker pizza.
Gianluca Bini: Yes.
Gianluca Bini: My protocol is usually, I usually do probofol, dexmed and remi fentanyl or fentanyl in dogs, for example. you And that's usually for any procedure, really. Except for maybe you know if you have like a patient with increased intracranial pressure. Not because the dexmed we know the dexmed does decrease intracranial pressure.
Ryan Bailey: Yeah.
Gianluca Bini: There is a paper in 2006 about it.
Ryan Bailey: Yeah.
Ryan Bailey: yeah
Gianluca Bini: I prefer Remi Fentanyl because of how high you can go and how much sparing effects it has.
Ryan Bailey: Yeah.
Gianluca Bini: And then when you turn it off, it's gone. You know, you don't have to worry about, you know, accumulation and dysphoria post -op or any any that. But, you if you don't have any fentanyl, fentanyl works just fine.
Gianluca Bini: oh But yeah.
Annatasha: I mean, yeah, I think we should probably speak to like Tiva and also like, you know, your contents context sensitive, like halftime things too. So my decisions on my protocols are like, whether I'm going to use Piva versus Tiva may also depend on duration of procedure and like, what's going on pathophysiologically with that patient, right?
Annatasha: Cause I'm like, I'm not super keen about like 15 hours of fentanyl. because waking that patient up is going to suck.
Ryan Bailey: yeah
Ryan Bailey: Oh, yeah.
Annatasha: but yeah, for the most part, luckily in vet med, like we don't separate conjoined twins and we don't do major organ transplants.
Gianluca Bini: yeah
Annatasha: So we're not usually, in there on like, you know, a 29 hour straight procedure. So I don't, once in a blue moon, I'll be like, Ooh, this really geriatric super morbidly obese patient.
Annatasha: Maybe we should start titrating the propofol down after four or five hours, but yeah. for the most part, yeah, I think, Now, Bini I have a question for you because I know that there's a certain population who's going to listen to the podcast is going to hear that you're, this is slightly off topic, but that you're using like Remy and Dexmed together and like your thoughts on cardiac output. Cause like I, I don't have a handful of anesthesiologists that I know personally who absolutely will not give fentanyl with Dexmed because they think it hammers cardiac output to the
Annatasha: I, uh, it's just a discussion.
Gianluca Bini: Okay, sure.
Annatasha: You can't see his face, everyone, but it's extremely judgmental.
Gianluca Bini: that
Annatasha: And I'm not saying, like, you know me, like, I would just be like, is the heart beating? Are you oxygenating? Move on with your day. Like, I don't care. But, uh, yeah. what What are your thoughts on that?
Gianluca Bini: Well, sure. To be honest, I think that if you're not giving a bolus to a Remi fentanyl you're not seeing a huge drop in cardiac output
Gianluca Bini: but You know, I usually start it and I don't really give any bonus, right? This is the drug that I usually do not bolus
Gianluca Bini: And if you do, it's scary, right? The heart rate to drop dramatically, capital D dramatically.
Annatasha: And they stop breathing.
Ryan Bailey: Yeah, quite exciting.
Gianluca Bini: Yeah, well, I mean, usually they're on a vent anyway If we are doing TIVA but...
Annatasha: Yeah, I was like, side note about Remi Fentanyl, if you're going to turn it up to the point where you don't need to inhale it, you need to have a ventilator to our listeners. I know you guys know that, but just, you know.
Gianluca Bini: Yeah, just FYI, you do need a ventilator.
Gianluca Bini: And, you know, the dexmed too, like, if you're not bolusing it, you know, seeing a huge drop in the recovery there, you know,
Gianluca Bini: I never had issues with it. Blood pressure is always good. That's the only way that we have to measure perfusion at the moment. like It's a surrogate. We're not really measuring perfusion. But I can't really measure cardiac output on a daily basis. So the the truth is that I can't measure that. So I don't know, really. But if blood pressure is good,
Gianluca Bini: I'm okay. I'm not overthinking it too much.
Annatasha: Okay.
Annatasha: Yeah. And if they're not deep enough, you can always give them miracle drug gabapentin, like I can lock them out.
Gianluca Bini: um
Ryan Bailey: fuck
Gianluca Bini: Sure, why not?
Annatasha: Yeah.
Annatasha: Yeah. Just, just like Christmas sprinkles. Yeah. Just give them gabapentin. It'll be fine. I have a funny story about gabapentin actually, that, so my surgeon was working in, while we were still finishing up my hospital, my surgeon was working in the pharmacy, right?
Annatasha: And he he was sat under the letter G and he actually ended up, he's like, I can't work here anymore. He's like, people go in to get gabapentin so much that he's like, I lose my thought like every three minutes.
Ryan Bailey: but sir
Annatasha: And I was like, look guys, we're overusing the drug if the surgeon has to move where they're sitting. Like, I mean, but anyway, I think, okay.
Gianluca Bini: Oh, gee, yeah.
Annatasha: No, I was just, you know, thinking about your thoughts are. Cause like I said, I mean, one of the, Oh yeah.
Gianluca Bini: I mean, the sparing effect you get is huge from that, right?
Ryan Bailey: Oh, yeah.
Gianluca Bini: Like, it's huge.
Ryan Bailey: In fact, you could probably just turn off the inhaler.
Annatasha: Listen guys, if you turn any of the injectable drugs up enough, me it's 100 % sparing because when your heart doesn't beat anymore, you don't need any inhalant.
Ryan Bailey: It turns into Tiva itself, right?
Ryan Bailey: oh yeah So I feel this conversation really focused on dogs and cats, where Tiva is actually a mainstay technique in equine species, for sure.
Annatasha: Yeah, I can turn this drug up enough and it will be super max sparing.
Gianluca Bini: Will that be me?
Annatasha: Yes.
Gianluca Bini: I understand.
Annatasha: Well, standing, right. I mean, fair.
Ryan Bailey: But even, even recumbent, you might do triple drip.
Gianluca Bini: Triple drip.
Ryan Bailey: You can do like ketamine zyosine, repeated infusion, and get like a castration done.
Gianluca Bini: Yep. Yep.
Ryan Bailey: I mean, those are quick procedures, but like it's Tiva for all intents and the purposes, right?
Gianluca Bini: Yep.
Ryan Bailey: Like, and.
Gianluca Bini: Yep.
Annatasha: No, no. I mean, I always run horses at a minimum Piva, like I'm not an inhaling or bust kind of gal for anything.
Ryan Bailey: Exactly.
Annatasha: Cause that's a shit recovery, but yeah.
Ryan Bailey: and
Gianluca Bini: yeah
Ryan Bailey: it It's just an interesting comparison. Cause like, I think we think about this in like our very fancy, like we're doing propofol remi for dogs and kind of like taking it from the human side and like these really kind of TCI type things, but like we were teaching students daily.
Ryan Bailey: Tiva techniques in equine species every single day. And Tiva is still, at least in America, at least in American institutions, it's still kind of reserved for like, okay, it's got, it's a craniotomy.
Ryan Bailey: It's an open wall case. Otherwise, like it's a resident who wants to try it to see what it's like, but like.
Annatasha: Like, yeah, it's not LSD, guys.
Ryan Bailey: Yeah. think yeah Oh no.
Annatasha: like it's It's not like something you just experiment with college and then just leave behind like when you grow up. but But you're right. No, Bailey, that was your real mic drop moment. I think you've been saving that.
Ryan Bailey: There's a note, there's a whole note on my computer I've got ready for this.
Ryan Bailey: So I was, I came prepared.
Annatasha: But yeah, no what you're right. We've been utilizing and teaching Tiva on large animal side. since the dawn of large animal medicine. but like we we treat it like this, you know, it's like the dishes that you only take out during the holiday, right?
Annatasha: like ah ah Holiday theme, holiday theme. But yeah like, ah you only take out your Tiva for like you said, like very like specific things. But your question is valid in the sense like, why?
Ryan Bailey: Yeah.
Annatasha: Why do we do that?
Ryan Bailey: Right. In humans, it's not in humans. It's a daily, a daily occurrence. It's on the whim of the anesthetist or, or sorry, anesthesiologist or, or the anesthetist, I guess. And like, it's, they like the recovery.
Ryan Bailey: This person has P O N V like.
Annatasha: I think I need to practice more whim anesthesia. know my my my technicians will love that, like I'll just be like, just let a whim, I'm gonna do this today, yeah.
Ryan Bailey: Oh. X, Y, Z in a long time, like Bini I'm sure does it all the time with his students. Like the student comes to with the exact same plan five days in a row and you're like, all right, let's change one thing today.
Ryan Bailey: Maybe we won't use Midazolam as the co -induction agent, or maybe, like different movie you know, like,
Annatasha: We'll use diazepam, dun!
Gianluca Bini: dum, dum, dum. Nice.
Ryan Bailey: it like It does get a little rote, like if I'm being honest, and it helps to expand people's knowledge and help you know just deepen their skill level because not every case is going to be straightforward and respond the way you think it is.
Gianluca Bini: Damn.
Ryan Bailey: and so like Yeah, sometimes we have to do things essentially on a whim because we need to, you know, as long as it's in in you and I and all of us know this, there are very, very few absolute contraindications in anesthesia for our veterinary patients.
Ryan Bailey: And so as long as it's safe, you know, for that patient,
Gianluca Bini: Yeah. Yeah. No, absolutely. but I agree with you. and like I know. Sometimes and you know people get comfortable, and that's what they do, and that is it, right?
Gianluca Bini: Sometimes it's easier to not think too much.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: You know what I mean? To not put too much effort.
Ryan Bailey: Yeah.
Annatasha: Well, those people become surgeons, but
Gianluca Bini: Nice.
Ryan Bailey: who
Gianluca Bini: I mean, the other thing that...
Annatasha: Do not put that in the promo clip. You always put some me saying something dicky in the promo clip, but yeah.
Ryan Bailey: like have south
Gianluca Bini: I that attracts viewers,
Gianluca Bini: like...
Annatasha: Yeah, but I know I think you know, I mean on the other flip side of the coin though I do think there is something to be said for you know Remembering that most vets and to a certain extent veterinary technicians maybe get 10 business days of anesthesia training and then they go out They're limited in their ability in terms of the drugs that they're available to them in practice and I do think there's a lot to be said for if you do something over and over you actually become safer because that
Ryan Bailey: Oh, oh yes.
Annatasha: Yeah. so I have no problem.
Ryan Bailey: so
Annatasha: And like, you know, you could, you, so when I was a resident, the surgeon used to say that I only anesthetize things with a Bartini, which was my classic cocktail was a Bartini, which was like fentanyl from a fall ketamine, right?
Annatasha: And he's like, he's like, I don't know why we even need you Tash.
Ryan Bailey: Great, huh?
Annatasha: He's like, let's just Bartini everything. And I'm like, look, you could probably anesthetize 99 .99999 % of every patient with this cocktail and you would get away with it. Like, and that's also true.
Ryan Bailey: Yeah.
Gianluca Bini: or with any cocktail.
Annatasha: Yeah. Like, and that's true.
Ryan Bailey: Yeah.
Annatasha: Like you could switch it to midazolam. You could switch it to methadone. You could could um like the safety margin on our drugs and our protocols is super high, but I know I'm not sure everyone has the capacity to quote, you know, experiment and think.
Ryan Bailey: and
Ryan Bailey: yeah
Annatasha: but But we do. And so I'm just going to like, I'm going to come in like on Friday when I'm next on clinics and I'm just going to be like, today is a day of nothing but wins, right?
Ryan Bailey: Oh, yeah. Well, for instance,
Annatasha: I'm going to win it. And I'm just, you know what? I'm going to be like, you know what? Today guys, we're going to do going to do a natural curium CRI, like buckle up.
Ryan Bailey: I mean, for we've been doing like, I've been doing some of our CTs on propofol TIVA just because they're quick, they're fast, recovery is better that way, you have less chance for an iso -dysphoric recovery.
Gianluca Bini: Why
Ryan Bailey: And it's a technique to get people exposed to. So when you're doing bronchoscopy, they're exposed to it already before it's like it's a bronch. The case is not doing well. And now they're doing Tiva and they're uncomfortable. These are straightforward CTs. And some of the texts have really picked up on that and they've started to use it and they're like, Oh, I want to do this like CT Rhino. And I was like, okay, well, let's try it out. Or like, Hey, I want to do an endoscopy. And I was like, all right, well, let's see how it goes.
Annatasha: I mean, it's a lot better option than just constantly like, because people are, I was like, well, we're going to sedate it with this and then we'll top up all facts along. And I'm like, why don't you just sedate it properly?
Ryan Bailey: Yeah.
Annatasha: Or just put it on an infusion pump.
Ryan Bailey: Yeah.
Annatasha: Like, why do you keep running in there every 15 minutes to top something? I'm just fucking crazy.
Ryan Bailey: and That's what the robots are for. That is why we made robots.
Annatasha: God damn it. I'm going to put in a cost request tomorrow for an anesthesia robot.
Annatasha: I'm sure my CEO will love that. But, yeah, I would rather than be on the propofol Sierra and then people be running in and out doing these bullish top ups where the patient goes transiently apneic and then the we went blue and I need to intubate and it's like, Oh my God.
Ryan Bailey: yeah
Annatasha: Oh my God. Oh my God. Oh my God. just, just, yeah, be better, be better.
Ryan Bailey: so All right, the elephant in the room.
Annatasha: Yes.
Ryan Bailey: What do you do for cats?
Annatasha: Sound effect.
Ryan Bailey: ah
Annatasha: Did you notice how we all gently skirt? I mean, I would rather talk about lemurs than cat, Tiva, but.
Ryan Bailey: I know. I know. But what like every like A, I think it's A, have you done it?
Gianluca Bini: So.
Ryan Bailey: Have you had success? What do you use? How much do you worry about red blood cell oxidative damage with propofol?
Gianluca Bini: Oh, that's bullshit.
Ryan Bailey: No, but I wanted to bring it up because it's reported out there. It is dogma. like People believe it. I know.
Gianluca Bini: Polly Taylor made really good studies on it. And, you know, yeah, and we we do know that you need so much fucking Propo fol multiple days in a row, multiple infusions
Ryan Bailey: Yeah.
Ryan Bailey: ye Yeah.
Gianluca Bini: Nobody fucking does that, right?
Ryan Bailey: He said it's multiple day, multiple infusion crap.
Gianluca Bini: So like, right.
Ryan Bailey: That's, I'm like, it's multiple days and multiple infusions. It's not one infusion for a couple hours. Like know we know that.
Gianluca Bini: Right. Now. Alfaxalone TIVA in cats, good luck, because it works. But then the recovery, it's super long, smooth, but super long, right?
Ryan Bailey: Oh yeah. Oh yeah. but
Gianluca Bini: And so that's that a problem. Probable, you know, if you do one or two hours, it's fine.
Ryan Bailey: Yeah.
Gianluca Bini: Above that, the recoveries can be slower, right?
Ryan Bailey: Yeah.
Gianluca Bini: so
Ryan Bailey: Yeah.
Annatasha: I would say the vast majority of my cat Tiva protocols are going to have dexametalminine, right?
Ryan Bailey: yeah
Annatasha: That's actually usually the crux of my, like dexmedetomidine maybe an opioid. so yeah, ketamine, I have no issue with propofol, I have no issue with alphax, depending on what we're doing, but dexmed is probably the one that I really like in cats because I mean,
Annatasha: It just buys you such a smooth plane, some cardiovascular stability.
Gianluca Bini: Yeah.
Annatasha: It's synergistic for analgesia. It has a visceral component to it. Like they don't wake up like, you know, when they wake up from fentanyl and they're just like, and you're just like, Oh my God. Oh my God.
Annatasha: Oh my God. Um, then you end up bolusing Dexmed, but if you have the Dexmed on board, they tend to wake up, a much smoother recovery.
Ryan Bailey: al
Annatasha: So that's, that's what I spend around my Dexmed, but Dexmed for me is usually the core of the cat Tiva.
Gianluca Bini: Yeah. I think
Ryan Bailey: And then, You have a limit? like an equine species, we think of Tiva.
Annatasha: Are we still talking about Tiva?
Ryan Bailey: yeah
Annatasha: I was like, oh, I got a lot of limits, Bailey.
Annatasha: My limit for surgeons is you could fit in a shot glass.
Ryan Bailey: well
Ryan Bailey: so well but a Yeah, yeah, yeah, yeah, yeah, yeah.
Annatasha: on
Annatasha: But I was like, we're still talking about Tiva, right?
Annatasha: OK. Do I have a limit for my dexametatomidine dose in a can?
Ryan Bailey: so for no no no no No, for duration. For instance, for equine procedures, we tend to think of Tiva greater than one and a half hours is going to have a significant chance to really decrease recovery quality and lead to some potential complications in recovery.
Ryan Bailey: And for cats, we think of hepatic metabolism as limiting, or at least I have always thought like we limit cat Tiva to like an hour to maybe two hours because the drug is going to accumulate because their hepatic metabolism is different and the kinetics become much less predictable.
Ryan Bailey: And it like to Bini's point, it really prolongs recovery time. So do you, you know,
Annatasha: We'll just put them on Remy fentanyl. just but It's instead of a Bartini, it's a Barbini.
Gianluca Bini: wow
Ryan Bailey: Oh my god.
Gianluca Bini: she She's... Love it, love it, love it.
Annatasha: wapwa
Gianluca Bini: If it if it wasn't expensive, I would run remifentanil on every single patient. Yeah, that would...
Ryan Bailey: It seems like that way in human medicine seems like it's just running forever.
Gianluca Bini: It is?
Gianluca Bini: Yeah, it's legit.
Ryan Bailey: and Yeah.
Annatasha: Yeah. So yeah, do I have these hard cutoff limits?
Gianluca Bini: The
Annatasha: Not necessarily because, uh, what's the evidence?
Gianluca Bini: No.
Annatasha: what's the.
Ryan Bailey: Right.
Ryan Bailey: I mean, there is evidence that infusions do, especially from, from Alfax, I can think of a paper off the top of my head from Davis, that Alfax's own infusions do decrease or like increase recovery time, at least in cats.
Annatasha: Yeah.
Gianluca Bini: Of course.
Gianluca Bini: Oh, I have to witness it.
Annatasha: yeah
Ryan Bailey: You know, wrote that up for sure.
Annatasha: Yeah, no, we do need some sort of sound for when Bailey cites Davis.
Gianluca Bini: Yeah.
Annatasha: like i you know I know it's like maybe like the sound of a super antique car horn or something so that we can signal when 1945 anesthesia quotes are coming.
Gianluca Bini: I'm working on that this.
Annatasha: But yeah, no, I think, yeah, I think, yeah, there is some evidence, but I'm like, who's to say in a cat that the difference between two hours of propofol and two and a half hours? like
Ryan Bailey: Right, totally, yeah.
Annatasha: And my surgeons, to their credit, underline this moment, wicked fast.
Gianluca Bini: Yeah.
Ryan Bailey: Yeah, and so you and I are coming from private practice where we tend to be, things tend to be a little bit faster than where Bini's coming from, where it's gonna be you know more academic. So there's more learning for everyone involved.
Gianluca Bini: Yeah.
Ryan Bailey: So things tend to be slower overall. So there's definitely limitations that Bini experiences that we don't and vice versa, for sure.
Annatasha: Yeah, no, he's, he, he, we actually practice different anesthesia in the, in the sense that we practice short duration procedure.
Gianluca Bini: Yeah.
Ryan Bailey: Yeah.
Ryan Bailey: e
Annatasha: being, he probably has more protracted anesthetic because it's a training facility.
Annatasha: So I think that's, that's a really great point that, you know, our techniques might not be mutually applicable because it is different type of anesthesia.
Ryan Bailey: Oh, yeah.
Ryan Bailey: Absolutely.
Gianluca Bini: Yeah.
Annatasha: Right. Right. Like my surgeon is going to get in there and whip out like a spleen in like 15 minutes.
Ryan Bailey: Absolutely.
Gianluca Bini: Yeah.
Ryan Bailey: Yeah. Oh,
Ryan Bailey: First game.
Annatasha: Right? So I don't even, why would I even put isoflooring on?
Ryan Bailey: Yeah.
Gianluca Bini: Yeah.
Ryan Bailey: Ugh.
Annatasha: Right? Why would I bother?
Ryan Bailey: If Sometimes it's like their hands away from the vaporizer.
Annatasha: yeah
Gianluca Bini: the out
Ryan Bailey: Thank you.
Annatasha: I mean, the vaporizers, I mean the ones that are made of metal, you could hook up to like a small electrical shock.
Annatasha: good old tech -free vaporizers that you could just, you know, like just like, don't touch that. I mean, we have, expiratory gas analysis too, right?
Ryan Bailey: Yeah.
Annatasha: And like, like at some point I dial it, let my inhalant down to the point where I'm like, just turn it off.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Annatasha: Right? Like I'm like, just turn it off.
Ryan Bailey: yeah yeah
Gianluca Bini: Yeah.
Annatasha: This is just stupid. Right? But what I'm doing is I'm weaning the comfort level of the Anesta test as opposed to my own, because
Ryan Bailey: Yeah, absolutely.
Annatasha: They get very, like I definitely see that look of, p like I've got a slightly newer team at this job, like, younger texts, less anesthesia experience than like my, some of my previous jobs are like, I had like VTS really senior technicians and we worked together for a really long time, like really heavy caseload.
Annatasha: And so, yeah, they would be like, we don't need, we don't need inhalant. And I'd be like, God, no. but these guys are still like, it's still a transition period for my training.
Ryan Bailey: Oh yeah.
Annatasha: So.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah. I mean, what a lot of people don't realize realize is that we don't really know how inhalants work either We have no fucking clue. A hundred years later, we have no fucking glue how England's actually work, you know?
Ryan Bailey: Yeah.
Annatasha: And also that statement, like I hear myself saying it sometimes too, where you're like, what alveolar concentration is proportional to brain concentration. And that's where the side of action is for inhalants. But I think that statement is such a gross oversimplification, like to Bailey's point earlier, where he's like, he's like, if you've got lower airway disease, you know, what's your cardiac output?
Ryan Bailey: yeah
Annatasha: Like, like, you know, there's so many micro factors, you know, you can insert Bartel's favorite expression, like fancy guessing, like we don't know what the hell is going on.
Annatasha: And you can have like a good expired, you know, percentage of your inhalant bearing in mind that of course doses are averages, which is another thing that I have to say all the time too.
Annatasha: But you know, it may be that that patient is your three standard deviation outlier. And your life would be a lot easier if you went to injectable.
Ryan Bailey: air you
Ryan Bailey: Are you willing to turn the vaporizer to the three standard deviation? Are you willing to make that that like, no way, no fucking way.
Annatasha: No, isoflurane is the root of all evil.
Ryan Bailey: It is
Annatasha: The more you dial it up, the more everything goes to shit.
Ryan Bailey: oh Yeah.
Annatasha: So why would I do that?
Ryan Bailey: Yeah. And that's where propofol just comes in and goes from heaven.
Gianluca Bini: yeah
Ryan Bailey: And you're just like, here we go. Grab the bottle.
Annatasha: like Like catch up on a hot dog.
Gianluca Bini: so It's so heavenly.
Ryan Bailey: Ah, Ah, no. No.
Annatasha: Yeah, no, our regulatory college rule has to have something like in our, our mandate about certain food rules. Like why, why just, why don't you just make pizza crackers and stop spoiling pizza? Gotta be the fucking quote of the night for sure. But yeah, I think, yeah, like, I forgot what you were saying, because I got distracted by propofol and ketchup.
Ryan Bailey: I'm not standing in nature, everybody.
Annatasha: Yeah, I was like, oh, I threw myself off.
Gianluca Bini: to
Annatasha: I threw myself off my own game with, with ketchup. But, I think there's too much that we don't know about inhalants.
Ryan Bailey: Yep.
Annatasha: It can be a great a pain in the ass.
Ryan Bailey: Oh, my God.
Annatasha: The more you delve them in. and And the thing is too, is like this, the other thing that drives me crazy is like people are like, well, I felt like his plane wasn't deep enough. So I went from one to 1 .2. And I'm like, well, in 40 years when that kicks in, but still makes no clinical difference, could you let me know?
Gianluca Bini: Okay.
Annatasha: Right? Like I'm like, why are you not controlling depth with injectable when it's more predictable, more reliable and faster?
Ryan Bailey: Yep. Yep.
Annatasha: Like why are, like, don't, I think, I'm serious, don't touch the
Gianluca Bini: yeah
Ryan Bailey: I go to never touch the vaporizer during a case if I can if I can get it to like just to dial it in with all like with blocks or Co infusions or whatever where I can just like sit and monitor and actually watch the patient and not like my job is not to be a vaporizer jockey like
Annatasha: Hmm, I love that vaporizer jockey.
Gianluca Bini: Yeah. That's right.
Ryan Bailey: That's why I hate, maybe, maybe this is a spoiler for my next topic, but why hate Bain circuits? Cause it's just, it's just like, one but but yeah, no, truly.
Gianluca Bini: The Bain of your existence.
Ryan Bailey: I, I despise them. I wish I.
Annatasha: I don't have a strong emotion about this, like what?
Ryan Bailey: that Yeah.
Annatasha: what Okay, well, this is another topic. This is another topic. But I'm like, normally we all get upregulated about the same shit, but I'm like, you guys are like really like laying in the veins and I'm like.
Gianluca Bini: Yeah. keep got on sport
Ryan Bailey: I could be a Bain and Tiva.
Gianluca Bini: Boom. Awesome.
Gianluca Bini: All right guys, so we're coming back from the hour.
Annatasha: Well, we drank all the eggnog, so.
Gianluca Bini: This is the degenerating we're about.
Ryan Bailey: I feel like my topic was great and really provoked some thought, but I think the thing is we love it and we realize we need to use it more.
Gianluca Bini: The haggardant is gone.
Annatasha: What, the bane or the eggnog?
Annatasha: Yeah, no, no, I think we should have a cocktail theme for every podcast with the disclaimer that if you follow our advice and anything bad happens, that's on you.
Gianluca Bini: mean Just with eggnog.
Ryan Bailey: in a painting.
Annatasha: Oh, can you, oh, Bailey would be happy because his life's goal is to obstruct his coronary arteries. So that, you know, like we'll put him on eggnog Tiva and he'll just, yeah.
Ryan Bailey: Exactly.
Ryan Bailey: We'll find out after this one year old eggnog sitting in the back of my fridge for menting or whatever it's doing.
Annatasha: What a way to go, Bailey.
Gianluca Bini: Jesus Christ. How didn't you die?
Ryan Bailey: this will be yeah This will be my last podcast, everyone, because I'm just going to
Annatasha: tomorrow you're going to cuel over from eggna
Gianluca Bini: I need to find somebody else. You're gonna die.
Annatasha: bulley No, supposed to be one of those things that, like, you can age eggnog, right Bailey?
Ryan Bailey: Yeah, and that is what you're supposed to be able to do.
Gianluca Bini: I doubt it that that's real.
Ryan Bailey: We'll find out.
Ryan Bailey: I'm working on this year's already for next, no, not for next year.
Gianluca Bini: The Costco one goes bad in two weeks, so...
Annatasha: The best thing about eggnog is that my dad, like he boozes it up for sure. like I don't know how many bottles go in that bowl, but my favorite thing is like just eggnog breakfast.
Ryan Bailey: Yeah.
Annatasha: like Well, Americans don't have Boxing Day, but on December 26th, for those in the Commonwealth, eggnog breakfast is the best. so
Gianluca Bini: Awesome. All right. Well, thank you everybody for listening. I guess next time it's my turn, right?
Ryan Bailey: It is.
Gianluca Bini: For a topic?
Annatasha: Yeah, and it will be the new year.
Gianluca Bini: It is.
Ryan Bailey: Woo.
Annatasha: i'm
Gianluca Bini: It's true.
Annatasha: Yeah. And so wishing you guys was super, like whatever holiday that you choose to partake in, even though I know both of you celebrate Christmas. So Merry Christmas. And to everyone listening, whether you celebrate Christmas or Hanukkah or Kwanzaa or what have you, have a happy holiday.
Gianluca Bini: Happy holidays everyone.
Ryan Bailey: and Happy holidays.
