Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
S1E3 - Total Intravenous Anesthesia, the Holy Grail?
163 Plays7 months ago
In this episode our trio of veterinary anesthesiologists unpacks the benefits, challenges, and species-specific considerations of Total Intravenous Anesthesia (TIVA), shedding light on its practical applications in both routine and complex procedures. From the pharmacology behind the drugs used to the real-life stories from our own cases, this episode is packed with valuable insights. Whether you're a veterinary professional curious about refining your TIVA techniques or a pet owner interested in understanding what goes into your animal’s care, this episode promises to be enlightening and engaging.
Tune in for a mix of expert knowledge, humor, and relatable anecdotes as we make learning about TIVA pawsitively enjoyable!
Recommended
Transcript
Introduction and Guest Introduction
00:00:00
Annatasha
Sound effect, Beanie?
00:00:01
Gianluca Bini
Ooh, I don't, but...
00:00:05
Gianluca Bini
No, I don't. Fuck.
00:00:10
Gianluca Bini
This is the only...
00:00:11
Annatasha
I was like, do we have intro music?
00:00:13
Ryan Bailey
It was good.
00:00:19
Annatasha
yeah
00:00:19
Gianluca Bini
Apparently, we do have an intro music, but I didn't
00:00:23
Annatasha
my
00:00:23
Gianluca Bini
but
00:00:25
Gianluca Bini
Welcome, everyone, to the random anesthesia topic podcast.
00:00:30
Annatasha
holiday podcast apparently apparently
00:00:30
Gianluca Bini
um Yes, the random holiday podcast. I don't know.
00:00:39
Gianluca Bini
Tonight we have Dr. Annatasha Bartel from King Animal Hospital in Ontario.
00:00:48
Gianluca Bini
And then we have... Dr. Ryan Bailey from Premier Veterinary Group in Chicago, The hot dog City
What is Total Intravenous Anesthesia (TIVA)?
00:01:04
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.
00:01:13
Ryan Bailey
David.
00:01:13
Annatasha
Look at his derpy little face.
00:01:14
Ryan Bailey
He also.
00:01:16
Annatasha
He's so excited to like antagonize us, which frankly is not very holiday-y in my opinion.
00:01:18
Ryan Bailey
I am.
00:01:19
Gianluca Bini
It is.
00:01:23
Ryan Bailey
I'm more of a green, even though I'm not in green.
00:01:23
Gianluca Bini
Yeah, it's not very nice of you.
00:01:27
Annatasha
No, no, but we're all balanced. We have each one of the holiday colors. Yeah.
00:01:31
Ryan Bailey
We are, yeah.
00:01:31
Gianluca Bini
It's true.
00:01:33
Ryan Bailey
I am influenced by developments.
00:01:33
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.
00:01:42
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.
00:01:52
Annatasha
i'm But yeah, they said, all I want for Christmas is ketamine. And we were like, yeah.
00:02:01
Gianluca Bini
Okay.
00:02:02
Annatasha
Is this the part where we put the disclaimer in that says nothing that we say or do, we can held liable for?
00:02:06
Ryan Bailey
Ha Ha ha ha!
00:02:10
Gianluca Bini
Well, I can see why that wouldn't make it through customs but even without the stripe.
00:02:16
Ryan Bailey
that
00:02:19
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.
00:02:25
Ryan Bailey
True.
00:02:25
Gianluca Bini
True. True story.
00:02:27
Annatasha
Yeah.
00:02:27
Ryan Bailey
And you can import drugs somehow. You have some sort of Canadian exception. You can be like, we need this. Fuck you.
00:02:32
Annatasha
That's right. That's right. We need a Ephedrine to get through cold season in the great white north.
00:02:38
Ryan Bailey
Cool. How else?
00:02:42
Annatasha
Yeah. That's what we tell customs.
Advantages of TIVA
00:02:49
Annatasha
ah
00:02:51
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.
00:03:12
Gianluca Bini
Oh, all right.
00:03:14
Annatasha
First of all, I don't read any literature, so this is going to be tough for me.
00:03:17
Ryan Bailey
Okay. I'm surprised you're a little bit.
00:03:21
Gianluca Bini
Okay.
00:03:21
Annatasha
sit
00:03:22
Ryan Bailey
It's that Canadian system.
00:03:25
Annatasha
Yeah, we don't need literature. By the way, listeners, JK, I do read literature, Jay.
00:03:27
Ryan Bailey
smith
00:03:30
Annatasha
But no, I think Bini why don't you feel this one? I'd love to hear it.
00:03:35
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.
00:03:46
Gianluca Bini
I think it's far superior, to be honest with you, compared to inhalants
00:03:53
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?
00:04:11
Gianluca Bini
always...
00:04:11
Annatasha
Bini a lot of the nausea that I get from being an anesthesiologist is probably from trace isoflurane
00:04:11
Ryan Bailey
Post-op nausea and vomiting.
00:04:18
Gianluca Bini
Yeah, no, that's fair.
00:04:18
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.
00:04:24
Gianluca Bini
Thanks.
00:04:26
Ryan Bailey
It was a nightmare.
00:04:28
Annatasha
wimps, honest to God. I have had every anesthetic drug and I wake up like a rock star.
00:04:31
Ryan Bailey
I mean, look at me. Nothing about me says long.
00:04:35
Gianluca Bini
Okay.
00:04:36
Ryan Bailey
Everything about me says wimp.
00:04:43
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.
00:05:03
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.
TIVA in Europe vs. U.S.
00:05:15
Gianluca Bini
You know, it's...
00:05:18
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.
00:05:40
Gianluca Bini
Sometimes propofol and afoxone, they both give you myoclonus. And, afoxone is somewhat more in recovery, propofol usually more during anesthesia.
00:05:53
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
00:06:01
Annatasha
and loves thats where this is and
00:06:04
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.
00:06:16
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.
00:06:25
Annatasha
Love that.
00:06:26
Gianluca Bini
The twitchiness and the material, you're going to see that, unfortunately.
00:06:26
Annatasha
I love that part. Yeah.
00:06:33
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.
00:06:53
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,
00:07:06
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,
00:07:15
Annatasha
yeah my i'm just kidding but
00:07:20
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.
00:07:40
Annatasha
Yeah, remind me.
00:07:40
Ryan Bailey
Yeah.
00:07:41
Gianluca Bini
But you know, FDA never cleared it in the US.
00:07:43
Annatasha
I'm just kidding. I'm just kidding.
00:07:43
Gianluca Bini
you know
00:07:45
Annatasha
yes and
00:07:45
Gianluca Bini
In Europe, they use it.
00:07:46
Annatasha
you Can't get a Ephedrine can't get TCI.
00:07:51
Ryan Bailey
Oh, hey, Tony, go ahead.
00:07:52
Gianluca Bini
Well, you know.
00:07:54
Annatasha
Oh,
00:07:56
Gianluca Bini
but But yeah, it's ah it's good. I like it. What about you, Tasha?
Environmental Impact of TIVA
00:08:02
Gianluca Bini
What's your thought on Tiva?
00:08:04
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?
00:08:32
Ryan Bailey
n Clearly then.
00:08:32
Annatasha
but You're probably you the only person in Chicago who's not gonna like live or die by deep dish.
00:08:39
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.
00:08:50
Ryan Bailey
And it's like truly the greatest thing. It's like, it is abomination to what Italians consider to be pizza.
00:08:56
Annatasha
Too bad you guys can't see Gian luca's face because it looks like he's passing a kidney stone right now.
00:08:56
Ryan Bailey
It's like, oh my God.
00:09:00
Gianluca Bini
Horrified
00:09:01
Annatasha
I mean like he is.
00:09:01
Ryan Bailey
I thought say it was just like this. I was like, oh my God, he is like dying. But no,
00:09:07
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.
00:09:13
Ryan Bailey
every style all day.
00:09:18
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.
00:09:22
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.
00:09:38
Annatasha
Oh.
00:09:38
Gianluca Bini
For what?
00:09:38
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.
00:09:47
Gianluca Bini
Can you eat crackers instead of ruining pizza?
00:09:50
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?
00:10:04
Gianluca Bini
Italian beef?
00:10:05
Ryan Bailey
Yeah.
00:10:06
Gianluca Bini
I mean, we do have cows.
00:10:07
Annatasha
Hello guys, where where is this podcast going?
00:10:08
Gianluca Bini
Yeah, the rest of that would be for sure.
00:10:11
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,
00:10:40
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.
00:10:48
Annatasha
Is Chicago the heart disease capital of America?
00:10:48
Ryan Bailey
It's Oh, yeah.
00:10:50
Annatasha
like
00:10:51
Ryan Bailey
yeah
00:10:53
Annatasha
Yeah, no, I thought, I thought I would just, yeah, I was like, that's sort of how I feel.
00:10:54
Ryan Bailey
That's like like
00:10:57
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.
00:11:20
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.
00:11:44
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.
00:11:55
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?
00:12:02
Gianluca Bini
Thank you very much.
00:12:05
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.
Practical Use of TIVA in Veterinary Medicine
00:12:37
Annatasha
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,
00:12:49
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.
00:13:16
Annatasha
I think I'm making a long-term difference in the outcome of the planet switching over to Tiva? Probably not.
00:13:21
Gianluca Bini
No.
00:13:23
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.
00:13:35
Ryan Bailey
oh Well, I have done a hot dog pizza.
00:13:37
Annatasha
No, no.
00:13:38
Gianluca Bini
So, so, so, so.
00:13:39
Annatasha
You're gonna need more eggnog. eggnog.
00:13:42
Gianluca Bini
Wait, wait. So, how about hot dogs on pizza?
00:13:51
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.
00:14:00
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.
00:14:05
Ryan Bailey
so
00:14:09
Gianluca Bini
A hundred percent.
00:14:10
Annatasha
Yeah.
00:14:11
Ryan Bailey
That's what I want on a run today.
00:14:11
Gianluca Bini
Okay.
00:14:12
Ryan Bailey
i got I got a run so I can have the hot dogs.
00:14:16
Gianluca Bini
Sure.
00:14:16
Annatasha
Now there's a t-shirt. Now there's, I run for hot dogs.
00:14:19
Ryan Bailey
I'd also like everyone to know this eggnog is from last year.
00:14:20
Gianluca Bini
Run for our cooks.
00:14:24
Ryan Bailey
So if I die in the middle of this podcast, that would reason.
00:14:26
Annatasha
oh
00:14:29
Ryan Bailey
And it tastes so good.
00:14:30
Gianluca Bini
Look.
00:14:33
Annatasha
poor
00:14:33
Gianluca Bini
Holy shit.
00:14:34
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.
00:14:38
Gianluca Bini
and the
00:14:42
Annatasha
I know you've got the whole gamut of cocktail glasses.
00:14:45
Ryan Bailey
I do. These were a gift to Carol in last year.
00:14:48
Annatasha
Oh, and they nog specific or will you also do like a grasshopper?
00:14:48
Gianluca Bini
all
00:14:53
Ryan Bailey
I've never made a grasshopper but a grasshopper could go in there for sure.
00:14:56
Gianluca Bini
I love glass operas.
00:14:56
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
00:15:02
Annatasha
would you put grasshopper on a painte
00:15:06
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.
00:15:16
Annatasha
I've eaten bugs. I've had worms, but you are correct.
00:15:18
Gianluca Bini
Yeah.
00:15:21
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.
00:15:31
Annatasha
So absolutely not.
00:15:33
Ryan Bailey
and
00:15:34
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,
00:15:39
Ryan Bailey
Yeah.
00:15:45
Gianluca Bini
yeah
00:15:45
Ryan Bailey
So, no, I, so I feel like I'm a bit of a late adopter.
00:15:46
Annatasha
Itching! Itching!
00:15:52
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,
00:16:19
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.
00:17:04
Ryan Bailey
with the advent of propofol and.
00:17:07
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.
00:17:15
Ryan Bailey
hope Oh, yeah. Yeah.
00:17:23
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.
00:17:33
Annatasha
And like, there's no waste anesthetic gas. And you were just like, it's not an indicated bartold.
00:17:36
Ryan Bailey
Oh, yeah.
00:17:37
Annatasha
It's totally brutal. And I was like, well, you do you.
00:17:38
Ryan Bailey
Oh, yeah. I apologize for any overly emotional debate that may have gotten into.
00:17:48
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.
00:17:59
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
00:18:51
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,
00:19:12
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?
00:19:37
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,
Benefits of TIVA in Complex Cases
00:20:16
Ryan Bailey
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,
00:20:24
Ryan Bailey
I don't know, I think it's, I'm really happy with it.
00:20:24
Gianluca Bini
Laziness.
00:20:27
Ryan Bailey
and Yeah, I think.
00:20:27
Gianluca Bini
A lot of it is laziness, I think. You know.
00:20:29
Annatasha
I think moving the needle for veterinary anesthesiologist is like, it's like shifting atlases, you know, earth on the shoulders.
00:20:34
Gianluca Bini
Yeah.
00:20:38
Ryan Bailey
it simple
00:20:39
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.
00:20:48
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?
00:21:03
Ryan Bailey
Since that is 90% of our job is battling.
00:21:05
Gianluca Bini
much better.
00:21:06
Ryan Bailey
So yeah.
00:21:07
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?
00:21:16
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 gallbladder mucocele.
00:21:34
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?
00:21:45
Annatasha
de
00:21:50
Gianluca Bini
so
00:21:50
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?
00:21:56
Gianluca Bini
lot of
00:21:59
Annatasha
And I was like, just the once.
00:22:02
Gianluca Bini
Okay.
00:22:05
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.
00:22:10
Annatasha
that They're monkey primates, right?
00:22:14
Gianluca Bini
And so, what did we do? It was like, you propo fol remi fentanyl you know, perfect, legit, amazing.
00:22:19
Ryan Bailey
Yeah. Yeah.
00:22:22
Annatasha
but The last time I did a lemur Bini was a resident.
00:22:25
Ryan Bailey
Yeah.
00:22:30
Gianluca Bini
But, I always had really good luck with TIVA I think it's it's really good.
00:22:36
Ryan Bailey
yeah
00:22:36
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.
00:22:43
Ryan Bailey
Yep.
00:22:48
Gianluca Bini
or some sort of packets of that. said And those do include in nes the in the price.
00:22:54
Ryan Bailey
Yeah.
00:22:55
Gianluca Bini
And so if you were to use propofol, you have to charge extra for the drug, right?
00:22:55
Ryan Bailey
Yeah.
00:23:00
Ryan Bailey
Yeah.
00:23:01
Ryan Bailey
Yeah.
00:23:01
Gianluca Bini
So that makes it more expensive, right?
00:23:04
Ryan Bailey
Totally. Yeah. For sure.
00:23:05
Gianluca Bini
to a degree.
00:23:07
Ryan Bailey
Yeah.
00:23:07
Gianluca Bini
Whether it's relevant or not, it doesn't matter.
00:23:09
Ryan Bailey
right Yeah.
00:23:09
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.
00:23:17
Ryan Bailey
yeah
00:23:19
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.
00:23:22
Ryan Bailey
yeah
00:23:22
Gianluca Bini
Right.
00:23:27
Ryan Bailey
yeah
00:23:28
Gianluca Bini
I mean, you do need IV access anyway, right?
00:23:35
Annatasha
Like IV access can be a limiting factor if you're going to run, not just like single agent Tiva, right?
00:23:36
Gianluca Bini
yeah
00:23:40
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.
00:23:54
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.
00:24:16
Gianluca Bini
All right.
00:24:18
Ryan Bailey
you know, it's not really sustainable. So you're going to need.
00:24:21
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.
00:24:29
Gianluca Bini
Yeah.
00:24:30
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.
00:24:45
Annatasha
And, like,
00:24:45
Gianluca Bini
Isn't that what we're paid for?
00:24:48
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
00:25:02
Gianluca Bini
Which you can with TCI, by the way, right?
00:25:04
Annatasha
Yeah, yeah, yeah.
00:25:05
Ryan Bailey
Oh yeah, I know.
00:25:06
Gianluca Bini
That's exactly what you can do.
00:25:06
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.
00:25:20
Ryan Bailey
Really?
00:25:21
Annatasha
Yeah, because they didn't want to give anything that might be caustic or might induce hypoxic pulmonary vaso constriction, like deregulation.
00:25:27
Ryan Bailey
yeah
00:25:28
Annatasha
So they would not use inhalants because there was smoke inhalation from a burden from a burn victim or what have you.
00:25:30
Gianluca Bini
Huh?
00:25:35
Annatasha
Tiva was the protocol of choice. Like they didn't even have vaporizers on the floor.
00:25:39
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
00:25:50
Ryan Bailey
Yeah.
00:25:52
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.
00:26:03
Annatasha
Like what's your personal record for case syringe pumps? Like mine's like 13 or 14, you know, like, yeah.
00:26:08
Ryan Bailey
Oh, I don't think it's that. No way.
00:26:11
Annatasha
Yeah. Sorry. Let me correct that. That's not all like drugs for Tiva Bailey. like
00:26:20
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.
00:26:28
Ryan Bailey
Perfect.
00:26:28
Annatasha
Yeah.
00:26:29
Gianluca Bini
Just a sprinkle of it.
00:26:29
Annatasha
Summer Peter Pasco is dying.
00:26:30
Ryan Bailey
You don't even have to think about it.
00:26:32
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
00:26:44
Annatasha
know.
00:26:45
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?
00:27:00
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?
00:27:05
Annatasha
No, I mean, I mean, I guess that depends on who you ask.
00:27:12
Gianluca Bini
Maybe.
00:27:13
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.
00:27:25
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.
00:27:36
Ryan Bailey
So what are your, what are your favorite name of species?
00:27:36
Gianluca Bini
sure
00:27:40
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?
00:27:47
Annatasha
But every time I do a lemur with a mucous seal, I 100% do propofol and Remy.
00:27:52
Ryan Bailey
I'm definitely going to do that from now on, for sure.
00:27:54
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.
00:27:58
Ryan Bailey
Oh my God. Yeah.
00:28:01
Annatasha
So.
00:28:02
Annatasha
Yeah, like King Julian, mor Maurice, like bring it on. Shout out to my favorite lemurs.
00:28:09
Ryan Bailey
I'm not.
00:28:12
Annatasha
Oh, poor Pete, you don't watch Madagascar?
00:28:12
Gianluca Bini
yeah favorite limit
00:28:14
Annatasha
You've never seen King Julian?
00:28:16
Gianluca Bini
No idea what you're talking about.
00:28:17
Annatasha
What?
00:28:18
Ryan Bailey
I'm all right.
00:28:20
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,
00:28:39
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%.
00:28:47
Ryan Bailey
yeah
00:28:51
Ryan Bailey
yeah
00:28:52
Annatasha
Those are my favorite lemurs, but let's see what other, what other species, obviously fish, clove oil.
00:28:53
Gianluca Bini
nice
00:28:59
Ryan Bailey
Yeah.
00:29:00
Annatasha
got that question wrong earlier in Jeopardy.
00:29:01
Annatasha
So it was really demoralizing.
00:29:02
Ryan Bailey
Some clothes
00:29:04
Annatasha
what else? No, I think.
00:29:07
Ryan Bailey
in here. Maybe I'm getting anesthetized.
00:29:10
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.
Favorite TIVA Protocols and Cardiac Concerns
00:29:16
Annatasha
So that's exciting. But yeah, I think that.
00:29:19
Gianluca Bini
You're such a rebel. Such a rebel.
00:29:25
Ryan Bailey
really revolutionizing veterinary anesthesia by being like, hey guys, let's do TiVo more than once a month.
00:29:31
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.
00:29:40
Ryan Bailey
Yeah, yeah, great, great case.
00:29:43
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.
00:29:57
Ryan Bailey
Yeah.
00:29:59
Gianluca Bini
yeah Unless the surgeon missed his nerve.
00:30:02
Ryan Bailey
Yes. How are you gonna?
00:30:04
Annatasha
Okay. So the surgeon shouldn't be sniffing as the technique.
00:30:04
Ryan Bailey
How are you?
00:30:05
Gianluca Bini
I'm kidding. I'm kidding.
00:30:10
Annatasha
I mean,
00:30:12
Gianluca Bini
I had to bring it up.
00:30:13
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.
00:30:16
Gianluca Bini
I had to.
00:30:26
Ryan Bailey
No way. No fucking way.
00:30:28
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.
00:30:39
Ryan Bailey
i
00:30:40
Annatasha
Because by the time you can actually smell the inhalant, your exposure is like 25 times the recommended daily dose.
00:30:40
Ryan Bailey
people do
00:30:46
Gianluca Bini
yeah
00:30:46
Annatasha
Please stop it.
00:30:47
Ryan Bailey
Yeah.
00:30:48
Annatasha
Please stop.
00:30:48
Ryan Bailey
Yeah.
00:30:48
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.
00:30:52
Gianluca Bini
Yeah.
00:31:02
Gianluca Bini
Yeah.
00:31:05
Annatasha
So yeah, ixnay on the sniffing, ixnay on the cracker pizza.
00:31:10
Gianluca Bini
Yes.
00:31:13
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.
00:31:39
Ryan Bailey
Yeah.
00:31:40
Gianluca Bini
There is a paper in 2006 about it.
00:31:40
Ryan Bailey
Yeah.
00:31:46
Ryan Bailey
yeah
00:31:50
Gianluca Bini
I prefer Remi Fentanyl because of how high you can go and how much sparing effects it has.
00:31:55
Ryan Bailey
Yeah.
00:32:00
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.
00:32:14
Gianluca Bini
oh But yeah.
00:32:15
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?
00:32:34
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.
00:32:38
Ryan Bailey
yeah
00:32:40
Ryan Bailey
Oh, yeah.
00:32:42
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.
00:32:42
Gianluca Bini
yeah
00:32:47
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.
00:32:58
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
00:33:30
Annatasha
I, uh, it's just a discussion.
00:33:34
Gianluca Bini
Okay, sure.
00:33:35
Annatasha
You can't see his face, everyone, but it's extremely judgmental.
00:33:36
Gianluca Bini
that
00:33:38
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?
00:33:49
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
00:33:59
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
00:34:07
Gianluca Bini
And if you do, it's scary, right? The heart rate to drop dramatically, capital D dramatically.
00:34:14
Annatasha
And they stop breathing.
00:34:16
Ryan Bailey
Yeah, quite exciting.
00:34:17
Gianluca Bini
Yeah, well, I mean, usually they're on a vent anyway If we are doing TIVA but...
00:34:20
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.
00:34:29
Gianluca Bini
Yeah, just FYI, you do need a ventilator.
00:34:33
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,
00:34:45
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,
00:35:09
Gianluca Bini
I'm okay. I'm not overthinking it too much.
00:35:11
Annatasha
Okay.
00:35:13
Annatasha
Yeah. And if they're not deep enough, you can always give them miracle drug gabapentin, like I can lock them out.
00:35:13
Gianluca Bini
um
00:35:18
Ryan Bailey
fuck
00:35:18
Gianluca Bini
Sure, why not?
00:35:19
Annatasha
Yeah.
00:35:20
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?
00:35:33
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.
00:35:43
Ryan Bailey
but sir
00:35:45
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.
00:35:51
Gianluca Bini
Oh, gee, yeah.
00:35:54
Annatasha
No, I was just, you know, thinking about your thoughts are. Cause like I said, I mean, one of the, Oh yeah.
00:35:58
Gianluca Bini
I mean, the sparing effect you get is huge from that, right?
00:36:01
Ryan Bailey
Oh, yeah.
00:36:02
Gianluca Bini
Like, it's huge.
00:36:04
Ryan Bailey
In fact, you could probably just turn off the inhaler.
00:36:06
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.
00:36:10
Ryan Bailey
It turns into Tiva itself, right?
00:36:17
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.
00:36:20
Annatasha
Yeah, I can turn this drug up enough and it will be super max sparing.
00:36:27
Gianluca Bini
Will that be me?
00:36:31
Annatasha
Yes.
00:36:36
Gianluca Bini
I understand.
00:36:37
Annatasha
Well, standing, right. I mean, fair.
00:36:39
Ryan Bailey
But even, even recumbent, you might do triple drip.
00:36:41
Gianluca Bini
Triple drip.
00:36:43
Ryan Bailey
You can do like ketamine zyosine, repeated infusion, and get like a castration done.
00:36:45
Gianluca Bini
Yep. Yep.
00:36:48
Ryan Bailey
I mean, those are quick procedures, but like it's Tiva for all intents and the purposes, right?
00:36:51
Gianluca Bini
Yep.
00:36:53
Ryan Bailey
Like, and.
00:36:53
Gianluca Bini
Yep.
00:36:54
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.
00:36:59
Ryan Bailey
Exactly.
00:37:00
Annatasha
Cause that's a shit recovery, but yeah.
00:37:03
Ryan Bailey
and
00:37:04
Gianluca Bini
yeah
00:37:04
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.
00:37:23
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.
00:37:37
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.
00:37:46
Annatasha
Like, yeah, it's not LSD, guys.
00:37:46
Ryan Bailey
Yeah. think yeah Oh no.
00:37:48
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.
00:37:59
Ryan Bailey
There's a note, there's a whole note on my computer I've got ready for this.
00:38:03
Ryan Bailey
So I was, I came prepared.
00:38:06
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?
00:38:20
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?
00:38:29
Ryan Bailey
Yeah.
00:38:32
Annatasha
Why do we do that?
00:38:33
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.
00:38:45
Ryan Bailey
This person has P O N V like.
00:38:48
Annatasha
I think I need to practice more whim anesthesia.
Teaching TIVA to Students
00:38:51
Annatasha
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.
00:38:55
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.
00:39:12
Ryan Bailey
Maybe we won't use Midazolam as the co-induction agent, or maybe, like different movie you know, like,
00:39:16
Annatasha
We'll use diazepam, dun!
00:39:20
Gianluca Bini
dum, dum, dum. Nice.
00:39:23
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.
00:39:33
Gianluca Bini
Damn.
00:39:37
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.
00:39:54
Ryan Bailey
And so as long as it's safe, you know, for that patient,
00:39:58
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?
00:40:08
Gianluca Bini
Sometimes it's easier to not think too much.
00:40:09
Ryan Bailey
Yeah.
00:40:12
Ryan Bailey
Yeah.
00:40:12
Gianluca Bini
You know what I mean? To not put too much effort.
00:40:13
Ryan Bailey
Yeah.
00:40:14
Annatasha
Well, those people become surgeons, but
00:40:23
Gianluca Bini
Nice.
00:40:24
Ryan Bailey
who
00:40:27
Gianluca Bini
I mean, the other thing that...
00:40:27
Annatasha
Do not put that in the promo clip. You always put some me saying something dicky in the promo clip, but yeah.
00:40:33
Ryan Bailey
like have south
00:40:35
Gianluca Bini
I that attracts viewers,
00:40:36
Gianluca Bini
like...
00:40:38
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
00:40:58
Ryan Bailey
Oh, oh yes.
00:41:04
Annatasha
Yeah. so I have no problem.
00:41:04
Ryan Bailey
so
00:41:05
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?
00:41:18
Annatasha
And he's like, he's like, I don't know why we even need you Tash.
00:41:18
Ryan Bailey
Great, huh?
00:41:20
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.
00:41:29
Ryan Bailey
Yeah.
00:41:30
Gianluca Bini
or with any cocktail.
00:41:31
Annatasha
Yeah. Like, and that's true.
00:41:32
Ryan Bailey
Yeah.
00:41:32
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.
00:41:35
Ryan Bailey
and
00:41:46
Ryan Bailey
yeah
00:41:46
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?
00:41:55
Ryan Bailey
Oh, yeah. Well, for instance,
00:41:57
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.
00:42:06
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.
00:42:07
Gianluca Bini
Why
00:42:22
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.
00:42:48
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?
00:42:54
Ryan Bailey
Yeah.
00:42:56
Annatasha
Or just put it on an infusion pump.
00:42:56
Ryan Bailey
Yeah.
00:42:58
Annatasha
Like, why do you keep running in there every 15 minutes to top something? I'm just fucking crazy.
00:43:03
Ryan Bailey
and That's what the robots are for. That is why we made robots.
00:43:09
Annatasha
God damn it. I'm going to put in a cost request tomorrow for an anesthesia robot.
00:43:13
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.
00:43:23
Ryan Bailey
yeah
00:43:25
Annatasha
Oh my God. Oh my God. Oh my God. just, just, yeah, be better, be better.
00:43:31
Ryan Bailey
so All right, the elephant in the room.
00:43:33
Annatasha
Yes.
00:43:34
Ryan Bailey
What do you do for cats?
00:43:39
Annatasha
Sound effect.
00:43:41
Ryan Bailey
ah
00:43:42
Annatasha
Did you notice how we all gently skirt? I mean, I would rather talk about lemurs than cat, Tiva, but.
00:43:46
Ryan Bailey
I know. I know. But what like every like A, I think it's A, have you done it?
00:43:50
Gianluca Bini
So.
00:43:54
Ryan Bailey
Have you had success? What do you use?
Challenges of TIVA in Cats
00:43:57
Ryan Bailey
How much do you worry about red blood cell oxidative damage with propofol?
00:43:57
Gianluca Bini
Oh, that's bullshit.
00:44:03
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.
00:44:10
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
00:44:14
Ryan Bailey
Yeah.
00:44:20
Ryan Bailey
ye Yeah.
00:44:23
Gianluca Bini
Nobody fucking does that, right?
00:44:24
Ryan Bailey
He said it's multiple day, multiple infusion crap.
00:44:25
Gianluca Bini
So like, right.
00:44:28
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.
00:44:34
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?
00:44:42
Ryan Bailey
Oh yeah. Oh yeah. but
00:44:50
Gianluca Bini
And so that's that a problem. Probable, you know, if you do one or two hours, it's fine.
00:44:56
Ryan Bailey
Yeah.
00:44:57
Gianluca Bini
Above that, the recoveries can be slower, right?
00:44:59
Ryan Bailey
Yeah.
00:45:01
Gianluca Bini
so
00:45:01
Ryan Bailey
Yeah.
00:45:03
Annatasha
I would say the vast majority of my cat Tiva protocols are going to have dexametalminine, right?
00:45:07
Ryan Bailey
yeah
00:45:08
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,
00:45:26
Annatasha
It just buys you such a smooth plane, some cardiovascular stability.
00:45:28
Gianluca Bini
Yeah.
00:45:29
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.
00:45:39
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.
00:45:40
Ryan Bailey
al
00:45:46
Annatasha
So that's, that's what I spend around my Dexmed, but Dexmed for me is usually the core of the cat Tiva.
00:45:53
Gianluca Bini
Yeah. I think
00:45:54
Ryan Bailey
And then, You have a limit? like an equine species, we think of Tiva.
00:45:58
Annatasha
Are we still talking about Tiva?
00:46:00
Ryan Bailey
yeah
00:46:01
Annatasha
I was like, oh, I got a lot of limits, Bailey.
00:46:06
Annatasha
My limit for surgeons is you could fit in a shot glass.
00:46:06
Ryan Bailey
well
00:46:09
Ryan Bailey
so well but a Yeah, yeah, yeah, yeah, yeah, yeah.
00:46:09
Annatasha
on
00:46:14
Annatasha
But I was like, we're still talking about Tiva, right?
00:46:18
Annatasha
OK. Do I have a limit for my dexametatomidine dose in a can?
00:46:22
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.
00:46:38
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.
00:46:55
Ryan Bailey
And it like to Bini's point, it really prolongs recovery time. So do you, you know,
00:47:00
Annatasha
We'll just put them on Remy fentanyl. just but It's instead of a Bartini, it's a Barbini.
00:47:04
Gianluca Bini
wow
00:47:09
Ryan Bailey
Oh my god.
00:47:09
Gianluca Bini
she She's... Love it, love it, love it.
00:47:14
Annatasha
wapwa
00:47:16
Gianluca Bini
If it if it wasn't expensive, I would run remifentanil on every single patient. Yeah, that would...
00:47:22
Ryan Bailey
It seems like that way in human medicine seems like it's just running forever.
00:47:25
Gianluca Bini
It is?
00:47:26
Gianluca Bini
Yeah, it's legit.
00:47:27
Ryan Bailey
and Yeah.
00:47:30
Annatasha
Yeah. So yeah, do I have these hard cutoff limits?
00:47:30
Gianluca Bini
The
00:47:32
Annatasha
Not necessarily because, uh, what's the evidence?
00:47:33
Gianluca Bini
No.
00:47:37
Ryan Bailey
Right.
00:47:38
Annatasha
what's the.
00:47:38
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.
00:47:48
Annatasha
Yeah.
00:47:48
Gianluca Bini
Of course.
00:47:54
Gianluca Bini
Oh, I have to witness it.
00:47:55
Annatasha
yeah
00:47:56
Ryan Bailey
You know, wrote that up for sure.
00:47:59
Annatasha
Yeah, no, we do need some sort of sound for when Bailey cites Davis.
00:47:59
Gianluca Bini
Yeah.
00:48:03
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.
00:48:05
Gianluca Bini
I'm working on that this.
00:48:15
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
00:48:24
Ryan Bailey
Right, totally, yeah.
00:48:26
Annatasha
And my surgeons, to their credit, underline this moment, wicked fast.
00:48:27
Gianluca Bini
Yeah.
00:48:32
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.
00:48:42
Gianluca Bini
Yeah.
00:48:43
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.
00:48:52
Annatasha
Yeah, no, he's, he, he, we actually practice different anesthesia in the, in the sense that
00:48:52
Gianluca Bini
Yeah.
Procedure Speed and Anesthesia Choices
00:48:56
Annatasha
we practice short duration procedure.
00:48:56
Ryan Bailey
Yeah.
00:48:59
Ryan Bailey
e
00:49:00
Annatasha
being, he probably has more protracted anesthetic because it's a training facility.
00:49:03
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.
00:49:04
Ryan Bailey
Oh, yeah.
00:49:11
Ryan Bailey
Absolutely.
00:49:11
Gianluca Bini
Yeah.
00:49:12
Annatasha
Right. Right. Like my surgeon is going to get in there and whip out like a spleen in like 15 minutes.
00:49:12
Ryan Bailey
Absolutely.
00:49:12
Gianluca Bini
Yeah.
00:49:16
Ryan Bailey
Yeah. Oh,
00:49:17
Ryan Bailey
First game.
00:49:18
Annatasha
Right? So I don't even, why would I even put isoflooring on?
00:49:19
Ryan Bailey
Yeah.
00:49:19
Gianluca Bini
Yeah.
00:49:22
Ryan Bailey
Ugh.
00:49:23
Annatasha
Right? Why would I bother?
00:49:24
Ryan Bailey
If Sometimes it's like their hands away from the vaporizer.
00:49:27
Annatasha
yeah
00:49:27
Gianluca Bini
the out
00:49:34
Ryan Bailey
Thank you.
00:49:35
Annatasha
I mean, the vaporizers, I mean the ones that are made of metal, you could hook up to like a small electrical shock.
00:49:45
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?
00:49:49
Ryan Bailey
Yeah.
00:49:53
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.
00:49:54
Ryan Bailey
Yeah.
00:49:58
Ryan Bailey
Yeah.
00:49:58
Annatasha
Right? Like I'm like, just turn it off.
00:49:58
Ryan Bailey
yeah yeah
00:49:59
Gianluca Bini
Yeah.
00:50:00
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
00:50:05
Ryan Bailey
Yeah, absolutely.
00:50:06
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.
00:50:21
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.
00:50:25
Ryan Bailey
Oh yeah.
00:50:29
Annatasha
So.
00:50:30
Ryan Bailey
Yeah.
00:50:31
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?
00:50:39
Ryan Bailey
Yeah.
00:50:42
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?
00:50:55
Ryan Bailey
yeah
00:50:59
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.
00:51:10
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.
00:51:21
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.
00:51:27
Ryan Bailey
air you
00:51:31
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.
00:51:39
Annatasha
No, isoflurane is the root of all evil.
00:51:40
Ryan Bailey
It is
00:51:41
Annatasha
The more you dial it up, the more everything goes to shit.
00:51:43
Ryan Bailey
oh Yeah.
00:51:44
Annatasha
So why would I do that?
00:51:46
Ryan Bailey
Yeah. And that's where propofol just comes in and goes from heaven.
00:51:47
Gianluca Bini
yeah
00:51:52
Ryan Bailey
And you're just like, here we go. Grab the bottle.
00:51:54
Annatasha
like Like catch up on a hot dog.
00:51:55
Gianluca Bini
so It's so heavenly.
00:52:00
Ryan Bailey
Ah, Ah, no. No.
00:52:05
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.
00:52:26
Ryan Bailey
I'm not standing in nature, everybody.
00:52:31
Annatasha
Yeah, I was like, oh, I threw myself off.
00:52:32
Gianluca Bini
to
00:52:32
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.
00:52:37
Ryan Bailey
Yep.
00:52:38
Annatasha
It can be a great a pain in the ass.
00:52:40
Ryan Bailey
Oh, my God.
00:52:40
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?
00:52:51
Gianluca Bini
Okay.
00:52:55
Annatasha
Right? Like I'm like, why are you not controlling depth with injectable when it's more predictable, more reliable and faster?
00:52:59
Ryan Bailey
Yep. Yep.
00:53:02
Annatasha
Like why are, like, don't, I think, I'm serious, don't touch the
00:53:03
Gianluca Bini
yeah
00:53:05
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
00:53:25
Annatasha
Hmm,
Managing Vaporizers vs. Injectables
00:53:26
Gianluca Bini
Yeah. That's right.
00:53:27
Annatasha
I love that vaporizer jockey.
00:53:30
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.
00:53:38
Gianluca Bini
The Bain of your existence.
00:53:41
Ryan Bailey
I, I despise them. I wish I.
00:53:45
Annatasha
I don't have a strong emotion about this, like what?
00:53:45
Ryan Bailey
that Yeah.
00:53:47
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.
00:53:50
Gianluca Bini
Yeah. keep got on sport
00:53:57
Ryan Bailey
I could be a Bain and Tiva.
00:54:00
Gianluca Bini
Boom. Awesome.
00:54:07
Gianluca Bini
All right guys, so we're coming back from the hour.
00:54:07
Annatasha
Well, we drank all the eggnog, so.
00:54:09
Gianluca Bini
This is the degenerating we're about.
00:54:12
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.
00:54:14
Gianluca Bini
The haggardant is gone.
Conclusion and Lighthearted Farewell
00:54:22
Annatasha
What, the bane or the eggnog?
00:54:28
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.
00:54:29
Gianluca Bini
mean Just with eggnog.
00:54:37
Ryan Bailey
in a painting.
00:54:39
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.
00:54:45
Ryan Bailey
Exactly.
00:54:49
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.
00:54:50
Annatasha
What a way to go, Bailey.
00:54:57
Gianluca Bini
Jesus Christ. How didn't you die?
00:55:00
Ryan Bailey
this will be yeah This will be my last podcast, everyone, because I'm just going to
00:55:04
Annatasha
tomorrow you're going to cuel over from eggna
00:55:05
Gianluca Bini
I need to find somebody else. You're gonna die.
00:55:06
Annatasha
bulley No, supposed to be one of those things that, like, you can age eggnog, right Bailey?
00:55:13
Ryan Bailey
Yeah, and that is what you're supposed to be able to do.
00:55:16
Gianluca Bini
I doubt it that that's real.
00:55:17
Ryan Bailey
We'll find out.
00:55:21
Ryan Bailey
I'm working on this year's already for next, no, not for next year.
00:55:24
Gianluca Bini
The Costco one goes bad in two weeks, so...
00:55:29
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.
00:55:37
Ryan Bailey
Yeah.
00:55:38
Annatasha
like Well, Americans don't have Boxing Day, but on December 26th, for those in the Commonwealth, eggnog breakfast is the best. so
00:55:48
Gianluca Bini
Awesome. All right. Well, thank you everybody for listening. I guess next time it's my turn, right?
00:55:57
Ryan Bailey
It is.
00:55:57
Gianluca Bini
For a topic?
00:55:57
Annatasha
Yeah, and it will be the new year.
00:55:58
Gianluca Bini
It is.
00:56:00
Ryan Bailey
Woo.
00:56:00
Annatasha
i'm
00:56:01
Gianluca Bini
It's true.
00:56:03
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.
00:56:17
Gianluca Bini
Happy holidays everyone.
00:56:19
Ryan Bailey
and Happy holidays.