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Special Ep2 - Broken Hearts: Anesthesia Meets Cardiology
132 Plays29 days ago
In this special episode, our trio of veterinary anesthesiologists is joined by a renowned veterinary cardiologist for an unforgettable deep dive into the world of anesthetizing patients with heart disease. From murmurs to heart failure, we unpack the art and science of safely managing cardiac patients under anesthesia. Expect clinical pearls, real-world case banter, and a healthy dose of humor as we navigate the high-stakes intersection of anesthesia and cardiology. Whether you're a seasoned vet or just curious about what happens when hearts and gas machines collide—this one's for you!
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Transcript
Intro
Introduction to Dr. Giulio Menciotti and Cardiology
00:00:39
Gianluca Bini
All right. right. Welcome, everybody, to special episode number two. Tonight, we have with us Dr. Giulio Menciotti from Virginia Tech. He's an assistant professor of cardiology.
00:00:52
Gianluca Bini
Welcome to the Podcast, Giulio. We're so grateful that you're here with us and
00:00:58
Giulio Menciotti
so much for inviting
00:00:59
Gianluca Bini
so So i met Julio probably like a year or two ago. i was locuming at Virginia Tech and he's one of the coolest cardiologists I've ever met. So I'm so grateful he's here.
00:01:13
Gianluca Bini
Even though he was late, it's totally fine. We'll forgive you, Julio.
00:01:16
Ryan Bailey
Ha ha ha.
00:01:18
Gianluca Bini
We'll forgive you.
00:01:19
Giulio Menciotti
me. I was 20 minutes late. That's not, that that's within the realm of cardiology is on time.
00:01:24
Ryan Bailey
Ha ha ha. Ha
00:01:25
Giulio Menciotti
No?
00:01:26
Gianluca Bini
that's the That's the payback.
00:01:26
Annatasha
I'm holding my judgment until we hear how he feels about Dexmedetomidine.
Humor and Key Cardiology Topics: Language, Dexmedetomidine, and Cases
00:01:31
Giulio Menciotti
i I knew this was going to be like a major topic today.
00:01:31
Ryan Bailey
ha ha.
00:01:35
Giulio Menciotti
So I'm going to blame the language barrier whenever it comes to it.
00:01:36
Annatasha
You betcha.
00:01:41
Ryan Bailey
All
00:01:42
Gianluca Bini
So Tasha,
00:01:42
Annatasha
That's okay. but You can translate from Italian, so you're fine.
00:01:46
Giulio Menciotti
Oh, man, I cannot.
00:01:48
Gianluca Bini
do you want to fire at it, Tasha? Go for it.
00:01:51
Annatasha
No, no, no. Keep going with the introduction. Like, do you want to, do or do you want to rock up hot or do you just want to like ease into with something like ketamine?
00:01:58
Giulio Menciotti
i I, I, easy to south like car mean
00:02:02
Annatasha
Or dobutamine with pomonic stenosis.
00:02:05
Gianluca Bini
Oh, he loves it.
00:02:06
Ryan Bailey
right out of the gate, Bartel.
00:02:08
Annatasha
Yeah. You know me, right? Got to get them while it's hot.
00:02:11
Gianluca Bini
well So, yeah, i I heard that you love the butamine with pulmonic stenosis cases, right?
00:02:19
Giulio Menciotti
i
00:02:19
Gianluca Bini
Yeah.
00:02:21
Giulio Menciotti
Yeah. yeah
00:02:23
Ryan Bailey
Yeah.
00:02:24
Giulio Menciotti
Well, that was an interesting thing. i have yeah I was talking with Gianluca when he came Locom at our institution and I was in a pulmonic stenologist case.
00:02:37
Giulio Menciotti
And I have to admit, i'm I'm a very nice person. I'm a very nice cardiologist. And so I i don't care too much what the anesthesiologists do.
00:02:48
Giulio Menciotti
i almost never ask what the dog is on or anything
Blood Pressure, Mitral Valve Disease, and Anesthesia Reports
00:02:51
Giulio Menciotti
until I was...
00:02:51
Annatasha
Great. We prefer that. but
00:02:55
Giulio Menciotti
Until I was literally unable to keep a flow-directed catheter, like a Berman, into the right ventricle of a dog because it kept shooting up all the way to the branch pulmonic pulmonarist artery, one of the branches, every single contraction.
00:03:13
Giulio Menciotti
it like, why why is this dog has an ejection fraction of 170%? hundred and seventy percent
00:03:19
Ryan Bailey
yeah
00:03:20
Ryan Bailey
No big deal.
00:03:22
Annatasha
You're welcome.
00:03:22
Giulio Menciotti
i i was it was I was talking with Gianluca about this story. it wasn't him on that case, to be fair. Although I feel like he would have probably done it just to piss me off.
00:03:35
Giulio Menciotti
So yeah.
00:03:35
Gianluca Bini
Oh, 100%, 100%.
00:03:36
Gianluca Bini
I was totally pissed off. so
00:03:38
Giulio Menciotti
you know
00:03:39
Gianluca Bini
But let's get into some vincere. So, you know, we we often anesthetize cases that have, you know, cardiac disease, right? And so...
00:03:50
Gianluca Bini
One of the things that you know always comes is um we always try to keep a good blood pressure, even in patients that, for example, like with pretty severe mitral valve disease.
00:04:02
Gianluca Bini
Sometimes it's really, really, really tricky because if you you can increase contractility and that may, may work fine. But, a lot of the drugs that we use to increase contractility, they also increase a little bit systemic vascular resistance. They basically constrict a little bit.
00:04:22
Gianluca Bini
what's your, what's your thought on that? Like we always, I always suggest that something like dobutamine for these cases, right? Like, because it increases contractility and, but then dobutamine sometimes invasodilates dogs. Right. And so,
00:04:37
Gianluca Bini
the effect on the numbers on the screen, it doesn't look as good, right? Like, I'm like, okay, I may i increased contractility cardiac output's better, blood pressure didn't fucking move, right?
00:04:50
Gianluca Bini
So, what's your what's your thought on that? Like, is blood pressure actually, you know, we always say that correlates with perfusion, but is it is how how real is that, right?
00:05:02
Gianluca Bini
Like, is it real?
00:05:03
Giulio Menciotti
Yeah, that that's a very, very good point. And although with mitral valve disease, I think we have ah ginormous spectrum of of patients, right?
00:05:14
Giulio Menciotti
somebody Virtually any medium, small breed dog will develop some degree of mitral valve disease in their life. And so we got to differentiate the patient that was that just received ah ah a pre-anesthetic echocardiogram because the owner was concerned or that you're working in a place in which everybody with a murmur gets a pre-anesthetic echocardiogram and gets diagnosed with a mitral valve disease at a very early stage versus a dog that is actually a dog that we would not recommend any elective procedure like and heart failure dog
00:05:41
Annatasha
Thank you.
00:05:52
Giulio Menciotti
that he's got a ton of mitral regurgitation and then ends up like being like the classic dachshund that is now a back dog, but he's already like a bad anesthetic candidate for starting with because he's got bad mitral disease.
00:06:05
Giulio Menciotti
I think they're very tricky patients. I also think they are very... sturdy patient, though, if you wish, compared to somebody with other type of cardiac diseases, meaning that contractility in small breed dogs with mitral valve disease is usually very well preserved, right?
00:06:25
Giulio Menciotti
And so you are playing with a patient that is pretty much every time his left ventricle contracts, he's shooting blood partially to his organs, but partially back into his left ation.
00:06:39
Giulio Menciotti
So I think actually ah ah a degree of vasodilation is great in terms of cardiac output. So you you got there so much so that when they are in advanced very advanced, like stage D, what we call like refractory failure, we'll put these patients on amlodipine, right?
00:06:55
Giulio Menciotti
Because they're left ventricle, is always has two outlets, the left atrium and aorta every time it
Debating Drug Warnings and Monitoring in Cardiac Anesthesia
00:07:04
Giulio Menciotti
contracts. And so if you decrease the systemic vascular resistance a little bit, it's going to be increasing forward output, even if your mean arterial blood pressure doesn't move much, right?
00:07:16
Giulio Menciotti
But that's those are those cases in which obviously that...
00:07:16
Gianluca Bini
Right.
00:07:20
Giulio Menciotti
dichotomy there of the blood pressure being an index of perfusion is probably not very true in that case because you're still perfusing more by vasodilating them a little bit, particularly with the butamine, which you're increasing contractivity
00:07:36
Gianluca Bini
right
00:07:41
Giulio Menciotti
And at that point, you are at the risk of increasing the regurgitant fraction at Tom. And so you could actually push them into left-sided failure. And then the the other odd entity, though caveat to this, is the larger dog that has got mitral valve disease. We know that large breed dogs, they ah tend to develop systolic dysfunction along with mitral disease.
00:08:07
Giulio Menciotti
So in those cases are the ones that I would actually favor if I can have a choice. And most of the times I don't have a choice. I'm not, I can have an opinion, but it may or may not be taken into account into one study consideration.
00:08:22
Giulio Menciotti
I still put it in my report, but yes, that's where probably in terms of my opinion,
00:08:25
Annatasha
Oh.
00:08:28
Annatasha
oh
00:08:29
Gianluca Bini
Okay. Okay.
00:08:30
Gianluca Bini
Okay.
00:08:30
Annatasha
why
00:08:30
Giulio Menciotti
I know.
00:08:30
Gianluca Bini
how you
00:08:30
Giulio Menciotti
so of the
00:08:31
Gianluca Bini
We're getting into this. We're getting into this now, right? So they the fucking cardio report, right? So every time we see that, right?
00:08:44
Gianluca Bini
And you get this cardio reports and it's like, you know, cats with HCM and they tell you you shouldn't use Dexmed. And I'm like, okay, right?
00:08:55
Annatasha
Shut up. Shut up.
00:08:57
Gianluca Bini
I'm like,
00:09:00
Annatasha
Just shut up. That's what that's what i'm like oh
00:09:04
Gianluca Bini
So like, you know, a lot of those is like, don't you don't use this, don't use that, don't use this other one. What the hell do we anesthetize them with?
00:09:13
Annatasha
Okay, I'm gonna have to interrupt here because I'm not sure I can take this much longer.
00:09:13
Gianluca Bini
you know? Yeah.
00:09:16
Annatasha
So, first of all, the longest with the three of us have ever been quiet as a group together. Bini was like our own personal world record. But, I mean, Beanie, I see the cardiologists make unhelpful little remarks, things like, be careful with fluids, which is a meaningless statement.
00:09:30
Ryan Bailey
Okay.
00:09:33
Annatasha
I think one of the the things that I take issue with is that, and it's not just a cardiology thing, but I find a lot of people have opinions about anesthesia.
00:09:42
Annatasha
when they don't perform anesthesia. And then when the shit hits the fan, everyone goes hands off and hands it over to us, right? So
00:09:47
Giulio Menciotti
This is what they ask us. Will they come to us for...
00:09:51
Annatasha
I don't wanna ask.
00:09:52
Giulio Menciotti
Come to us for......on aesthetic recommendations.
00:09:54
Annatasha
I don't ask. yeah
00:09:58
Giulio Menciotti
You know much I would love...
00:09:59
Annatasha
and I'll give you that. When you make a record, when you, when people, somebody asks, then you can have an opinion. But a lot of the times what is written in a cardiac report is an extremely restrictive and makes us liable.
00:10:08
Gianluca Bini
Yeah.
00:10:12
Annatasha
And often the statements are meaningless. Like be careful with fluids, right? Like judicious use of fluids is a meaningless statement because it doesn't tell you rate, total volume. It doesn't tell you the type of fluid. It doesn't tell you it's never based on like, what and I agree with you. It's the degree of heart disease that I take into consideration when I make distinguishing,
00:10:29
Annatasha
know, pharmacological or other treatment decisions. But yeah.
00:10:34
Annatasha
Yeah. Sometimes cardiology advice about anesthesia doesn't tickle my fancy.
00:10:35
Ryan Bailey
i else just
00:10:40
Ryan Bailey
Just in terms of, I've saved this for for years now.
00:10:40
Annatasha
Yeah.
00:10:45
Ryan Bailey
it it was ah It was a cardio report from a cardiologist who had seen a cat. The cat was diagnosed. Um... Um... Uh...
00:10:55
Ryan Bailey
Let's see.
00:10:55
Gianluca Bini
Oh, you actually did have it saved then.
00:10:56
Ryan Bailey
They're tested with the CATED dynamic outflow obstruction, but they mention in their induction it should be with an injectable such as propofol or alfaxalone, although gas induction with isoflurane and seboflurane is also appropriate.
00:11:12
Ryan Bailey
Which, I've never met this cardiologist. It was just ah ah a record I was reading, i and it was a recent one. Like, this is in 2019, so it was recent enough, but I was shocked at the quality of report that was being submitted.
00:11:25
Annatasha
In the words of Tony Soprano, get the fuck out of here.
00:11:29
Ryan Bailey
Yeah.
00:11:29
Gianluca Bini
Thank you.
00:11:31
Giulio Menciotti
No, I mean, yeah
00:11:31
Ryan Bailey
I mean, they can't be super maybe, but, like,
00:11:36
Giulio Menciotti
you know, You know much I would love not to put an anesthetic recommendation my report and just give me the numbers? You know, like, just ask for it, and I give you the numbers, and you guys work it out. Like, that's great. Not even the diagnosis or anything.
00:11:49
Giulio Menciotti
I just give you the numbers. That's awesome.
00:11:51
Ryan Bailey
I love that.
00:11:52
Giulio Menciotti
Oh, wow.
00:11:52
Ryan Bailey
that would be
00:11:53
Annatasha
We are grownups and we would know.
00:11:54
Ryan Bailey
like
00:11:55
Ryan Bailey
I want to see all the numbers. I get so aggravated when cardio is like, here's my words. Like, here's a paragraph of words. And I'm like, where's the, I want to see like the fractional shortening.
00:12:04
Giulio Menciotti
up
00:12:06
Ryan Bailey
I to see the ejection fraction. Like, give me the numbers. Like, how is the heart doing?
00:12:10
Giulio Menciotti
i
00:12:11
Giulio Menciotti
I got to bounce the ball back in your yard. And this is my favorite question. They would have like a dog with mitral disease. And I would come asking like, what is the ejection fraction? It's like, what are you talking about? It's not a disease that affects the ejection fraction. It's like 100% in this dog. It's hyper dynamic.
00:12:29
Giulio Menciotti
Dejection fraction is not your problem. The problem is that the blood is not going in the right direction. It's not how much the right direction is.
00:12:35
Ryan Bailey
We want to know it's been out.
00:12:39
Giulio Menciotti
Anyway, no, they never
Insights on Anesthetic Practices and Cardiac Output
00:12:40
Giulio Menciotti
burn out, small breed dogs. They die with an ejection fraction of like 85%, okay?
00:12:45
Annatasha
Oh my God. You know what?
00:12:45
Giulio Menciotti
No, but jokes are fine.
00:12:46
Annatasha
This is very interesting.
00:12:47
Giulio Menciotti
The problem.
00:12:47
Annatasha
I would like to hear all the things that anesthesiologists do that annoy a cardiologist.
00:12:49
Giulio Menciotti
i i
00:12:52
Annatasha
let's just you know Let's go this way because this is wildly entertaining.
00:12:53
Giulio Menciotti
the problem
00:12:53
Gianluca Bini
Yeah, yeah, yeah. Let's do it. Let's do it. Let's it.
00:12:57
Annatasha
Yeah. Tell us, what do we do that pisses you guys off?
00:12:58
Giulio Menciotti
yeah but I think the ejection fraction is like on the top of the list because the vast majority of the disease, except for like DCM, the disease that we deal with on a daily basis, they actually increase ejection fraction.
00:13:13
Giulio Menciotti
A dog with HCM has got an ejection fraction if you were to like really calculate close to 100% some of them because
00:13:19
Ryan Bailey
Oh, yeah.
00:13:20
Giulio Menciotti
The ventricle is so small that it squeezes to empty. The same for mitral disease. But it does ah ah bring up and like an interesting point is that I think out of many other specialties, are we are the ones with a lot of well-designed placebo-controlled clinical trials and stuff like that.
00:13:31
Annatasha
Thank you.
00:13:38
Giulio Menciotti
Meaning just that it's overall, i think it's a specialty that likes to work on evidence-based data. And when it comes to anesthesia, we actually have close to none.
00:13:50
Giulio Menciotti
And so were discussing just today with with my colleague how it's true that sometimes we put stuff in our report and it gets, it gets, it just reiterated just because people copy paste previous report, like for example, like the ketamine is like a good example, right?
00:14:03
Annatasha
Thank you.
00:14:10
Giulio Menciotti
And it's just because theoretically, you know, it's reported to be proarrhythmic and we know that these diseases, some of them, they are also proarrhythmic. So it's just trying to stay on the safe side. And then sometimes they get escalated. It's kind of like,
00:14:25
Giulio Menciotti
You know, when somebody says something and he starts like a lizard and it ends up being a crocodile and he gets says with like, absolutely do not use this.
00:14:31
Ryan Bailey
Yeah.
00:14:35
Giulio Menciotti
Otherwise, this patient is going to die.
00:14:37
Annatasha
Bye.
00:14:38
Gianluca Bini
Thank you.
00:14:39
Giulio Menciotti
i do believe that a lot of these things, they have a lot of theoretical basis, but not a lot of practical evidence based medicine ah ah behind it. And my come to Jesus kind of moment a few years ago, we were doing a we were doing ah ah research stuff with a human cardiologist. And it was a bunch of people from a very, very important nationwide institution. And they came to us with a double-boarded criticalist cardiologist, a pediatric criticalist and pediatric cardiologist, a cardiac surgeon, a perfusionist and everything. and
00:15:21
Giulio Menciotti
And then I was asking them like, oh, what do you put these... kids, not even kids, like infants, on when you do cardiac surgery.
00:15:30
Ryan Bailey
Thank you.
00:15:32
Giulio Menciotti
And he was like, oh, ketamine, dexmed usually is like, what? Like, they leave on like, no ketamine, no dexmed, right? And so I do have more of an open mind about that for some of these conditions than some other cardiologists, I guess.
00:15:51
Giulio Menciotti
Yeah.
00:15:53
Annatasha
For those of you listening, by the way, you can't see the three anesthesiologists all holding their hands in the air and cheering while these concessions are being made. 100%. Yeah.
00:16:04
Annatasha
They're
00:16:05
Gianluca Bini
and
00:16:06
Giulio Menciotti
i mean i do I have to say that a lot of these patients are on cardiac bypass anyway, so nobody cares about them.
00:16:06
Gianluca Bini
Yeah.
00:16:14
Annatasha
just bubbling. I feel sorry.
00:16:15
Giulio Menciotti
There's a machine perfusion for them, so it's a little different.
00:16:17
Ryan Bailey
Yeah.
00:16:21
Annatasha
I mean, I always say too, right? Like based on the combination of drugs we use and you know what, under anesthesia, I can't even think of a drug that I probably have not potentiated a dysrhythmia with at some point or another.
00:16:34
Giulio Menciotti
Yeah.
00:16:34
Annatasha
And I'm sure it's the polypharmacy as a component of it.
00:16:38
Annatasha
I always think that the inhalants are usually like the baseline problem for most things, especially cardiovascularly. But yeah, I think, you know, that that's, I think sometimes when we struggle a little bit with those, those little helpful, quotation mark, tips from cardiology is that, you know, if you take away a drug or a drug class as an absolute, it takes the away our ability to practice from experience and with the art of anesthesia. you know, and I understand a lot of times cardiologists make recommendations because that report might be going to a general practitioner who doesn't have an anesthesiologist, what have you. But yeah, like I said, I mean, I've given things,
00:17:14
Annatasha
dysrhythmias with pretty much every drug I can think of, including antibiotics and antacids. So, know, yeah, if you don't monitor them, you don't worry about these problems.
00:17:22
Giulio Menciotti
Absolutely.
00:17:22
Gianluca Bini
Yeah.
00:17:23
Giulio Menciotti
And I think one one of the things that came up talking with Gianluca when we were chatting together, it's very true that actually the the the monitoring makes a world of difference, right?
00:17:36
Giulio Menciotti
Like you can... And so, and I tell my residents or in general students as well, it's going to be extremely different if you anesthetize a patient and you're like inflating a Doppler cuff every 10, 15 minutes.
00:17:55
Giulio Menciotti
versus you have an invasive arterial line and you can correct stuff right away because if some of these patients, ah ah you may get in trouble and by the time you realize you got in trouble, you are like way too far gone to rescue them if you don't have appropriate monitoring, right?
00:18:11
Giulio Menciotti
So I think you're right that and lot of a lot of the reports in the field, they are overly cautious because of that, because we don't know which in which hands these patients are going to end up with.
00:18:25
Giulio Menciotti
And so better to be safe. Although, yes, sometimes we do exclude all the options. So what are you going to use?
00:18:32
Annatasha
Yeah.
00:18:33
Giulio Menciotti
We like our acepromazine. We like our butorphanol. We like our...
00:18:37
Ryan Bailey
So, do
00:18:38
Giulio Menciotti
I know that much.
00:18:38
Gianluca Bini
Thank you.
00:18:39
Giulio Menciotti
And yeah,
00:18:39
Annatasha
It is hard to kill things with utorphanol. I will tell you this.
00:18:42
Ryan Bailey
you have anything?
00:18:42
Giulio Menciotti
Yeah.
00:18:43
Annatasha
It can be done, yeah have but you have to make an effort. But yeah, I mean, one thing too, is that if you, so like I've practiced in countries too, where they only have access to like a very limited number of drugs too.
00:18:55
Annatasha
And so you basically like, if you ain't using ketamine, you ain't using anesthesia. And you're basically putting a hundred percent of your patients down without an inhalant and only injectable
00:19:00
Ryan Bailey
Yes.
00:19:05
Annatasha
And, you know, if we're calculating the percentage of those cats who do have HCM and how many of them are dying from it, it's super duper, duper, duper small.
Cardiology's Cautious Approach and Evidence Gaps
00:19:14
Annatasha
these absolute contraindications, like I said, you know, they do tie your hands and they kind of crap, you know, on
00:19:20
Giulio Menciotti
Wait, you're saying that you actually have seen cardiologists making absolute statements in the report? Because we have we have perfection, the art of being wishy-washy, I feel like.
00:19:35
Annatasha
No, no, guys, that's radiology.
00:19:35
Giulio Menciotti
but also wasn I would not do that. I would not recommend that. It's most likely this. It's most likely that. But we're kind of like second only to pathologists in that art.
00:19:46
Ryan Bailey
Yeah.
00:19:48
Annatasha
And radiologists, don't forget that.
00:19:49
Giulio Menciotti
but yeah Yeah, this is most likely this. So I would avoid that if possible, but.
00:19:55
Annatasha
Yeah.
00:19:56
Gianluca Bini
I think what... Yeah.
00:19:56
Annatasha
you I have some cardiologists who've made absolute statements, but like I said, if you're working in an environment where you only have three drugs in the toolbox, like the the whole principle of like the, you know, the cautiousness is irrelevant.
00:19:59
Ryan Bailey
yeah
00:20:10
Annatasha
And like I said, a lot of people use these drugs in the face of those advisements and, you know, mortality in our hands is still ridiculously low. So.
00:20:22
Gianluca Bini
yeah
00:20:22
Ryan Bailey
Yeah.
00:20:23
Giulio Menciotti
I agree, but also, like again, bringing back the point that I think we may have a skewed perspective of A lot of people don't know what they're doing very well, right?
00:20:36
Giulio Menciotti
And they have a deep understanding of the interplay of the systems versus the vast majority of people that are anesthetized dogs and cats, which are not more certified anesthesiologists and may
00:20:37
Gianluca Bini
Yeah.
00:20:51
Ryan Bailey
yeah
00:20:54
Giulio Menciotti
Look at numbers that are not even real, right? A heart rate that is double counted or half counted, a Doppler cuff that is not even on the patient. You know what I mean?
00:21:04
Annatasha
it just
00:21:05
Giulio Menciotti
im I'm sure that everybody's trying to do their best, but I think some of these recommendations take into account as well.
00:21:08
Annatasha
Only Ryan likes Doppler. Only Ryan likes Doppler. so
00:21:14
Ryan Bailey
Christine also likes Doppler. She texted me to say how much she loved my comment on the Doppler. So...
00:21:20
Annatasha
I just want you to know that a handful of the humans that I know that like the human medicine people. So I've got like a couple of anesthesiologists, respiratory therapists and criticalists who listen to our podcast because they find it so weird, the things that we talk about and anesthetize.
00:21:33
Annatasha
they were blown away when you said Doppler. And I don't mean that in a good way. Yeah.
00:21:37
Ryan Bailey
absolutely sure.
00:21:38
Gianluca Bini
yeah
00:21:38
Ryan Bailey
i'm at they a I also just want to mention I had like a epiphany moment too when I spent a week in the human anesthesia wards and they were doing like coronary arterial bypass grafts.
00:21:52
Ryan Bailey
And so like humans going on cardio, like who are going to go on cardiopulmonary bypass, but they're not there yet because they have to anesthetize them to place the the drains and pumps and all that. And they were all on dexamilatomia and CRIs.
Collaboration Between Cardiology and Anesthesia for Better Outcomes
00:22:05
Ryan Bailey
And my little brain was just like,
00:22:07
Ryan Bailey
what like these are like sick ass patients and they're like oh yeah like because they've got you know coronary arterial disease we want to slow their heart rates down and like increase you know diastolic time blah blah blah and i was like wow
00:22:21
Giulio Menciotti
Yeah, but again, I had that epiphany with the
00:22:22
Gianluca Bini
Yeah.
00:22:28
Giulio Menciotti
the human groups too, but i I also think that we are dealing with, these patients are instrumented head to toe.
00:22:30
Ryan Bailey
yep
00:22:32
Annatasha
Thank you.
00:22:36
Ryan Bailey
Oh yeah, and and their disease process is different than what we see.
00:22:39
Giulio Menciotti
And these exactly are different, right?
00:22:41
Ryan Bailey
Like, we didn't have coronary artery disease in dogs that I know of, or at least like if we do, it's incredibly rare.
00:22:43
Giulio Menciotti
And
00:22:47
Annatasha
yeah
00:22:49
Giulio Menciotti
Yeah, no, almost inexistent, almost inexistent, really, even with advanced diseases that should cause coronary disease. I don't know i think we should maybe try and start feeding them burgers and chips and see if that pops up, because we found a cure for problem with disease, right?
00:23:05
Annatasha
Guys, listen, as this little Canadian, if there is going to be a country where there's a subpopulation of coronary artery disease in dogs, it'll be America.
00:23:08
Gianluca Bini
Yeah. Yeah.
00:23:14
Giulio Menciotti
Probably. Probably.
00:23:16
Ryan Bailey
It's true. I was going to say, I think a lot of our patients are probably coming in eating burgers and fries and, you know, to practice.
00:23:22
Gianluca Bini
yeah
00:23:23
Giulio Menciotti
To some degree.
00:23:23
Gianluca Bini
yeah
00:23:25
Giulio Menciotti
Yeah. but But then the other yeah yeah and the other thing is the the the dose that these patients are on, right, for for these drugs as well. the you You risk that somebody that is not super experienced in attempting to treat a number, which obviously most of the time is going to be your blood pressure, not even invasive sometimes.
00:23:49
Giulio Menciotti
They keep escalating dramatically. dog like drugs that increase systemic vascular resistance in a patient that maybe is actually like having a hard time pushing blood through because it's got DCM and you don't even know about it. Right.
00:24:04
Giulio Menciotti
And then at that point, again, by the time you realize that that was not a good choice, you're, you're done. Right. And so I think a lot of recommendations actually, and I see how that can make a lot of people upset.
00:24:16
Ryan Bailey
So that that brings up a question that that I have a lot of the time when we're dealing with these these like dogs who have probably what's essentially incidental mitral insufficiency. Like the dogs who eat you know we don't know if they're going progress, but they have it.
00:24:35
Giulio Menciotti
Yeah.
00:24:35
Ryan Bailey
There's a murmur. Heart's not big. Everything's normal, but they have a little regurgitation. What, like, and and I'm sure you can't answer so this question entirely, but like, I always operate under the idea that like if I choose a drug that's going to increase vascular resistance, that dog's going to see more volume.
00:24:55
Ryan Bailey
but i could i you know Am I going to push this dog in front of me into congestion through... like you know like am I going to take what's a ah normal heart was never going to fail and now push it towards that direction by intensely vasoconstricting them and slowing their rate down?
00:25:14
Giulio Menciotti
I think it's definitely possible. I think we have we have seen that now and again in the clinical settings in which even like a dog with incidental My telegregitation,
Biomarkers, Mitral Valve Disease, and Coronary Abnormalities in Dogs
00:25:27
Giulio Menciotti
honestly, even without an anesthetic event, just because it was all hospitalized and overhydrated, it can can be pushed into a failure. And then when you treat them like you decrease the rate, they that they're fine.
00:25:40
Giulio Menciotti
So more so under anesthesia, of course, like if you go into that perfect storm in which you increase their vascular resistance, so it's even easier you increase their regurgitation fraction and then you even give them extra volume.
00:25:54
Giulio Menciotti
it's definitely possible. Like that said, you would, I don't know, I might limit it, I guess, experience because i when I do these consults, then I don't follow through what they did on Astizia.
00:26:06
Ryan Bailey
Right. Yeah, for sure.
00:26:07
Giulio Menciotti
But I feel like if they don't do well, then I hear about them and it's very, very rare.
00:26:11
Annatasha
Thank you.
00:26:13
Giulio Menciotti
than any of these patients. They are usually pretty stable. The one with incidental mitral regurgitation, like if they don't even have cardiomegaly, they need to be under anesthesia for like a very long time with a lot of fluids that are pushed through.
00:26:27
Ryan Bailey
Hmm.
00:26:28
Giulio Menciotti
They're, again, i'm pretty sturdy anesthetic candidate as long as they're a small breed dog and their systolic function is preserved. Yeah.
00:26:39
Gianluca Bini
yeah So I wanted to tag back on, you know, we were mentioning coronary disease, right?
00:26:46
Gianluca Bini
humans, you know, some of those changes in the ST, like actually do correlate with myocardial infarct. How much of that is true in in our patients? Like, how what do we know about that?
00:26:59
Giulio Menciotti
Oh, it is. Yeah, that's a very good that's a very good point. I think, though, the ST elevation, even in people, is evaluated with a 12-lead ECG, and it needs to be pretty specific in certain leads and things like that versus the single-lead anesthetic monitor abnormality.
00:27:12
Ryan Bailey
Thank you.
00:27:22
Giulio Menciotti
But at the same time, we do see often patients that have, for example, severe subarctic stenosis that do have those, they have some myocardial perfusion issues, and we know that long term they would develop myocardial disease because of their crazy left ventricular hypertrophy from their increased afterload chronically.
00:27:46
Giulio Menciotti
And they do develop ST elevation in certain leads.
00:27:49
Gianluca Bini
you.
00:27:51
Ryan Bailey
Hmm.
00:27:51
Giulio Menciotti
And then the other place for that in which we will look closely for it is actually acute changes. I think that's way more significant, meaning that you have been under anesthesia and you have been looking at that ECG for a while it looks the same. And then at a certain point, all of a sudden that ST segment changes.
00:28:14
Giulio Menciotti
I think that's a very dangerous point and that the should warrant consideration of some degree of perfusion or myocardial work or myocardial oxygen demand that goes a little beyond the mineral arterial brow pressure.
00:28:32
Giulio Menciotti
Because sometimes in like patients with like pulmonic stenosis that are being under anesthesia for a while, we would see those acute changes and sometimes the degenerating bad arrhythmias that are very difficult to bring
00:28:44
Gianluca Bini
Yeah.
00:28:45
Ryan Bailey
Wait, you're seeing that occur under anesthesia?
00:28:50
Giulio Menciotti
Like ST elevation? yeah absolutely.
00:28:52
Ryan Bailey
Yeah. Oh.
00:28:53
Giulio Menciotti
still watch that, you know, the some patients with pulmonic stenosis, remarkably more prevalent in English bulldog and some degree French bulldogs, they would have pulmonic stenosis and coronary artery abnormalities, for which the classic is an art way, but has been now shown that other coronary artery abnormalities that will cause that,
00:28:57
Ryan Bailey
Interesting.
00:29:20
Giulio Menciotti
And so they they have one of their coronary arteries that goes around the pulmonary artery, which will not create any problem in their life, except when you try to inflate the balloon and you stretch the pulmonary artery, you actually completely occlude coronary perfusion.
00:29:38
Ryan Bailey
oh
00:29:38
Giulio Menciotti
And so, the yeah, and so...
00:29:39
Ryan Bailey
Oh.
00:29:40
Annatasha
I'm right about when i really dial up that dobutamine to 20.
00:29:44
Giulio Menciotti
No, just die.
00:29:44
Ryan Bailey
Yeah, I was wondering if this is an institutional issue, there's more liberal use of inotropes causing more myocardial work in hearts that are already worked, you know, already on the edge of hypoxemia.
00:29:45
Giulio Menciotti
Yeah. die
00:29:58
Ryan Bailey
So I just...
00:29:59
Giulio Menciotti
I've personally, I haven't seen that, but for the, I can tell you that for these patients, when you know, or you don't know that they have a coronary artery abnormality, one of the thing that you do, for example, a, um,
00:30:02
Ryan Bailey
Yeah.
00:30:14
Giulio Menciotti
coronary tolerance test in which you inflate a balloon on the size that you want to inflate and then you look at the ECG and you see if they develop ST segment elevation and that's a the that's how much that ECG sign is reliable for myocardial perfusion so yeah
00:30:29
Ryan Bailey
Wow.
00:30:32
Annatasha
Very interesting.
00:30:33
Gianluca Bini
Yeah.
00:30:33
Gianluca Bini
Yeah. When we, ah when when I was at NC State during my residency, every time we did a PS, pulmonic stenosis, balloon valvuloplasty, in a French bulldog or, you know, English bulldog, we would always do like a CT angiogram first.
00:30:34
Ryan Bailey
That cool.
00:30:50
Ryan Bailey
Yep.
00:30:50
Giulio Menciotti
Yeah, we do we do the same.
00:30:50
Gianluca Bini
And then
00:30:52
Giulio Menciotti
And I'm going to tell you something that I kind ah kind of It will crack you up and it's going to be very interesting for this podcast. So for in our institution, we do not have a ah ah ECG
00:31:04
Annatasha
We'll see.
Anesthetic Practices in Complex Cardiac Cases
00:31:08
Giulio Menciotti
gated CT scan.
00:31:10
Giulio Menciotti
That means that the CT scan does not trigger the acquisition of images based on the phase of the cardiac cycle. Long story short, what happens is that you have a lot of more motion artifact.
00:31:22
Giulio Menciotti
with that. And so one of the solutions to that is to slow down the heart rate during the CT acquisition, right? And so when we switched to doing rather than a coronary angiogram, which requires access to the femoral artery and is like very time demanding and expensive, we wanted to put these dogs under CT, not having a CT-gated CT, needed to slow down the heart rate. So What do you think is going to be my go to for a dog with pulmonis stenosis? Well, just give them Esmolol, right?
00:31:56
Giulio Menciotti
It's great.
00:31:57
Annatasha
so
00:31:57
Giulio Menciotti
It's going to be a beta blocker. It's going to slow down the heart rate. And sure enough, the anesthesiologists start to pump up this Esmolol. And these are dogs that most of the time, they're puppies. They are otherwise doing fine because we want to get them before they have troubles from the pulmonis stenosis.
00:32:13
Giulio Menciotti
keep cranking up that Esmolol and that heart rate would not budge. And so after like 10 minutes the dog is there, remember the CGI just look at me and like, can I give him Dex mad?
00:32:27
Giulio Menciotti
and was like, sure.
00:32:28
Ryan Bailey
But...
00:32:29
Annatasha
yeah
00:32:29
Ryan Bailey
yeah
00:32:29
Giulio Menciotti
The blood of Dexmed, the heart rate goes down to like 40 or 50 and then immediately reversed and comes back up. This is great. So that's actually one of the strategies that we use now for this down group of monostenosis during CT scans.
00:32:48
Gianluca Bini
Yeah, yeah, there is Well, well...
00:32:49
Giulio Menciotti
Just for the CT scan though, just for the CT scan.
00:32:53
Annatasha
you can
00:32:53
Ryan Bailey
but
00:32:54
Annatasha
and I run my CRI for my balloon valvuloplasty on.
00:32:54
Ryan Bailey
and
00:32:57
Gianluca Bini
Me too.
00:32:58
Annatasha
Yeah. and yeah
00:32:58
Ryan Bailey
We're going to add it to Flores' work about using exonotomy and polyxenosis cases.
00:33:03
Giulio Menciotti
I know, I know.
00:33:06
Giulio Menciotti
And I'm sure that, and you know, I would have loved to see some invasive cardiac output data in my work because that's, I think, to me, the the thing that is less convenient. I really like the decreased...
00:33:25
Giulio Menciotti
arrhythmia that comes with it because I think that's very important for patients in which we are floating catheters in their heart like decreasing their arrhythmogenic substrate is super important so I'm willing to to accept that benefit I'm not sure that in that subset of patients the mean arterial blood pressure, or in general, the blood pressure is a very good representation of their organ perfusion, right?
00:33:56
Annatasha
Kind of, yeah.
00:33:56
Giulio Menciotti
But these are patients that they have already a fixed obstruction, And if you wish, you can think of the cardiovascular system just stretched out as one big loop.
00:34:10
Giulio Menciotti
And by increasing the systemic vascular resistance, you're actually adding another barrier that your ventricle needs to push through to circulate blood through. And so I accept that your numbers may look good, but I think we are all familiar also with the experimental and clinical data about the dramatic decrease in cardiac output in healthy dogs that receive alpha 2 agonists.
00:34:39
Giulio Menciotti
And so in dogs that already have a fixed obstruction, a little hesitant to that. Now, from that to say that they don't do well anesthesia under anesthesia, obviously they do because the papers tell us that they do, I'm feeling not so...
00:34:53
Annatasha
Well, they do like the show on the road with the ballooning, but if you're going to fart around for nine hours, then yeah.
Critiquing Standards in Anesthesia Education and Practice
00:35:02
Giulio Menciotti
i
00:35:02
Gianluca Bini
Yeah, if you move your ass.
00:35:03
Giulio Menciotti
Well, you know, I'm sure you're familiar with the concept that things sometimes look easy on paper, but in real life, you may not.
00:35:13
Annatasha
No.
00:35:13
Giulio Menciotti
la Like if I haven't seen you guys fucking around for like two hours, like trying to put an arterial line, just put the thing in the wall, in the pipe, right?
00:35:15
Annatasha
No.
00:35:24
Giulio Menciotti
Easy to me, Give me the banana bubble ask this.
00:35:25
Annatasha
Maybe you're anesthesiologist.
00:35:26
Ryan Bailey
but That's like, you know, coolest dog you've ever seen because you want to get them when they're puppies and they're still healthy.
00:35:33
Giulio Menciotti
there,
00:35:33
Annatasha
to to you a little bit though, because I know we talk a lot about the fall and cardiac output. And I think what is incredibly important to remember from the point of view of the anesthesiologist, and I always have to tip people off about that, is that the cardiac output, like the drop in cardiac output, and the reason that the patients tend to do well is because anesthesia is basically like brainwave activity aside, but from a physiological point, cardiovascularly, pulmonary, gastrointestinally, what have you, it's mimicking sleep.
00:36:03
Annatasha
And, you know, there is a big difference between awake cardiac output and sleep cardiac output for all species, right? And so we're so focused on maintaining cardiac output, but it's maintaining cardiac output in the context of being conscious and and or, you know, active.
00:36:18
Annatasha
And that's not what's happening in our patients, which is why sometimes I see students, you know like they're starting to panic because the dog's heart rate might drop into the thirties. But I'm thinking to myself, like, this is a young, healthy dog.
00:36:29
Annatasha
If they were also sleeping just normally at home in a restful state, that's probably what their that heart rate and their cardiac output is like. So I always find this concern about cardiac output is a little bit disproportional because like I said, this is a, this is a biomimetic state of sleep, essentially from a physiological standpoint, they don't have that same cardiac output requirement when they are anesthetized.
00:36:54
Giulio Menciotti
i I'm not sure that my cardiac output when I'm sleeping falls by like 30%, like 230% of what it was like with Dexmed or and like that dramatically.
00:37:08
Giulio Menciotti
But at the same time, i also understand that we are providing fluid support. So we we are and we have other means to to provide that organ perfusion.
00:37:16
Annatasha
yeah We spend a lot of time fussing about what's normal, but it's normal based on consciousness, right? And we're working a skill of consciousness.
00:37:23
Giulio Menciotti
i I agree. I don't know what my mean arterial brow pressure, since it's a parameter that you focus a lot on, is when I'm sleeping. I hope it doesn't go down to the thirty s or the forty s but
00:37:38
Annatasha
No, but I also think too, like in terms of dexmedetomidine, particularly for patients who are anesthetized, because it's very uncommon for you to only be anesthetized with dexmedetomidine.
00:37:39
Ryan Bailey
Mm-hmm.
00:37:47
Annatasha
is that because we have multiple drugs on the table, like what you see with an awake patient, and if you were just to give dexmedetomidine and like you see that spike in systemic vascular resistance, we don't see that in the anesthetized patient, right?
00:38:00
Annatasha
Like if I bullous you dexmedetomidine, you don't get hypertensive unless I really like screwed the pooch.
00:38:06
Ryan Bailey
Mm-hmm.
00:38:06
Annatasha
So, you know, most of the time it's, it's a, it's a foil for normal attention, if anything.
00:38:12
Giulio Menciotti
Yeah, Yeah, i'm um'm I'm a little worried, though, that you do not see that because all the other systems are still like in place to actually keep the systemic vascular resistance at bay by decreasing, indeed, cardiac output, right?
00:38:12
Annatasha
Um,
00:38:30
Giulio Menciotti
If you were maintain your
00:38:31
Annatasha
you wanted fon is is ah is one of our anesthetic parameters, right? So that's probably also why you don't see such like a dramatic explosion. But I do think...
00:38:40
Ryan Bailey
That's actually, that's an interesting question.
00:38:40
Annatasha
Unless Ryan's going to go on his cat tangent, everybody, buckle up.
00:38:45
Gianluca Bini
Thank
00:38:47
Ryan Bailey
What to ask the cardiologists about is is the thing that we don't, I don't know, that we kind of gloss over sometimes is like, so if we if we we worry more about like the drug effect on
Patient Variability and Advancements in Cardiology and Anesthesia
00:39:00
Ryan Bailey
and cardiac output, heart rate, et cetera, et cetera, but there's a whole system that we in certain patients, right?
00:39:09
Ryan Bailey
whatever, I'm not gonna get into it, but insert patients.
00:39:11
Annatasha
was like, cats.
00:39:12
Ryan Bailey
We can't can control it all. And like their sympathetic tone is can be super dysregulated. So you can have a cat one minute, heart rate 100, you know, you've got a ah ah map in the 40s, 50s, you get set up to do, you know, dopamine, whatever you're doing, and you're getting it set up. The surgeon does something like pulls an organ or something.
00:39:35
Ryan Bailey
And all of a sudden heart rate's well over 200. MAP is now over 100. Like, is that better? Is this system better with this completely dysregulated sympathetic tone?
00:39:47
Ryan Bailey
So your anisex chart looks like this with heart rate and blood pressure going up and down versus giving a drug that is going to modulate cardiac output to some extent.
00:39:59
Ryan Bailey
Like to me, in my brain, and this could be wrong, i worry much more about this dysregulated sympathetic tone
00:40:03
Annatasha
oh
00:40:09
Ryan Bailey
I mean, we don't see, like that being said, I don't see patients like drop dad but like, why is that less of a concern for us? and And you may not, that's like, this is not a question.
00:40:20
Giulio Menciotti
Yeah, I know, like, and we see so few cats under anesthesia as a primary service because interventions in cats are,
00:40:21
Ryan Bailey
It's a rhetorical question. It happens all the time.
00:40:31
Ryan Bailey
true.
00:40:33
Giulio Menciotti
So rare, but at the same time, i don't know. I think that the answer that is when those adaptive systems become maladaptive.
00:40:43
Giulio Menciotti
And I don't have an answer for that. And I don't know that anybody does because your anesthetic chart looking more flat,
00:40:48
Ryan Bailey
Yeah. Yeah.
00:40:52
Giulio Menciotti
may mean that your organ perfusion now is going like this. And you can see, right? Versus your anesthetic chart that takes into account pressure and heart rate mostly is going like this because actually their organ perfusion needs to be maintained like this. Does it make sense?
00:41:07
Giulio Menciotti
Like those systems of changing those parameters are in place.
00:41:11
Annatasha
True, but you have to remember systemic blood pressure, there's sub auto regulation in most of the functional organ beds themselves, right? So even in the face of wild fluctuations, you maintain perfusion regardless, like kidney, brain, heart, lung, they all do that, right?
00:41:26
Giulio Menciotti
Yeah. And that's why I'm saying, like, i don't know that the answer that we know, that we can know the answer because it's where is that slight barrier where adaptive systems become maladaptive, right?
00:41:39
Giulio Menciotti
Where that vascular resistance increase that happens in healthy patients all the time, right? To maintain, then becomes maladaptive at a certain point because,
00:41:51
Giulio Menciotti
there's so much of it that you actually decrease perfusion to the organ or when that is associated with also a decrease in systolic function for which now you have heart that has got like an obstacle to pump against and does not have the reserve that is your other side of that equation to to pump against it.
00:42:15
Giulio Menciotti
So i'm I'm not sure that we are ever going to have the answer to that. I do, again, I'm probably a little bit more open-minded than many cardiologists in which I don't like hard statements, particularly in the face of lack of evidence-based medicine.
00:42:27
Ryan Bailey
Okay.
00:42:38
Giulio Menciotti
I'm not sure that for the Dexmed pulmonic stenosis thing that everybody wants to talk about, we do still have ah that solid evidence base.
00:42:50
Giulio Menciotti
Again, I think.
00:42:52
Annatasha
I guess what what I'm really trying to drive at is when we look at some of these cardiovascular parameters, I'm not sure we know when the numbers become relevant, right?
00:43:02
Giulio Menciotti
Yeah, ye I agree.
00:43:02
Annatasha
That's really what I'm getting at. And so your cardiac output falls under anesthesia by 30%, we don't know the answer to how is that clinically relevant to the majority of the patients who leave the table.
00:43:06
Ryan Bailey
It's a nice.
00:43:13
Annatasha
I mean, I see People, like for sure, like anytime you lecture at a conference or or do some seminars, people are super upregulated about acute kidney insufficiency, right? I've seen that once.
00:43:23
Giulio Menciotti
yeah
00:43:26
Annatasha
And that post-arrest in a patient. You know what I mean? Like that's not something...
00:43:31
Giulio Menciotti
yeah You have seen like AKI post anesthesia once?
00:43:36
Annatasha
Well, I'm very, very good at my job, Giulio.
00:43:39
Giulio Menciotti
Wow, you asked me, like really?
00:43:39
Annatasha
But yeah. Yeah.
00:43:42
Giulio Menciotti
Wow, yeah, I mean, and again, it's not we see it all the time, but like, yeah, now and again, like the very,
00:43:43
Gianluca Bini
Thank you.
00:43:50
Annatasha
The patient had a rungid kidney from a polytrauma anyway. So, i mean, it was a Euro abdomen drama. But anyway, you know these are the type of things like,
00:43:57
Ryan Bailey
Thank you.
00:44:00
Annatasha
And while while we were talking to you, I did Google what your cardiac output falls when you sleep and PubMed told me it was 26%. So um um yeah, so but the thing is, is that what does that really mean, right? Like if you say cardiac output falls 40%, okay, sure.
00:44:14
Annatasha
But my question is, so what? do we actually have outcome numbers, long-term mortality, post-anesthetic, like what kind and we don't, right?
00:44:19
Giulio Menciotti
Yeah.
00:44:23
Annatasha
and i'm and i'm And I'm agreeing with you in the sense that you know we have to be a little bit cautious about being so conservative to the point where we're binding ourselves in terms of practice particularly when we we lack in vivo and we lack a lot of these studies to be done in patients who are already anesthetized right so yeah i get yeah like that's always my thing like people shout numbers at me and i'm like and where do we go then with relevance like how is this relevant to me in terms of my patient outcomes
00:44:42
Gianluca Bini
yeah
00:44:51
Giulio Menciotti
Well, you know, so some some questions are better not answered.
00:44:56
Gianluca Bini
Thank you.
00:44:56
Giulio Menciotti
We may now want to find out what is the critical cardiac output for most dogs, but no, I agree.
00:44:57
Annatasha
yeah
00:45:03
Giulio Menciotti
Like, yeah, nobody has ever shown that
00:45:06
Annatasha
Yeah.
00:45:07
Giulio Menciotti
in a double blinded controlled clinical trial that furosemide does better for heart failure than non-furosemide, if you wish. You know what I mean? no, I'm being provocative now.
00:45:17
Giulio Menciotti
Like I totally get your point and I will bring it back to particularly when you said about the AKI thing to the level of care,
00:45:19
Ryan Bailey
and
00:45:31
Giulio Menciotti
that that these patients are
Role of Anesthesiologists and Specialties Collaboration in Veterinary Medicine
00:45:32
Giulio Menciotti
monitoring, that these patients receive, because although it's true, if I think about it, that i I've never seen in any of my patients that instance occurring, I can think of a lot of patients that get referred to us for AKI as a hospital level, and they have recently theory received an anesthetic event, right?
00:45:53
Giulio Menciotti
in in In practice in general.
00:45:53
Gianluca Bini
Yeah. Yeah.
00:45:56
Giulio Menciotti
And so I think...
00:45:56
Annatasha
Oh yeah.
00:45:58
Giulio Menciotti
the the that monitoring and the awareness of all these systems that come into play, it's awesome. But the conversation that we are having tonight are something that escapes a lot, like the vast majority of our patients, right?
00:46:18
Giulio Menciotti
We are at a...
00:46:19
Annatasha
Listen, nothing scares the anesthesia world more than the anesthesia that a lot of cases actually is happening. know, we're, yeah, like 90% of our anesthetic cases are done in a GP level.
00:46:29
Ryan Bailey
written
00:46:32
Annatasha
And we have to remember that like, and this is nobody's fault, but you know, you go through vet school and you get 10 business days of anesthesia training, you know, and, or not or less, you know, and you have people with no in vivo practice, you know, going into these
00:46:38
Giulio Menciotti
Yeah.
00:46:40
Gianluca Bini
Yeah. Yeah.
00:46:47
Annatasha
you know, debilitated senior patients are having protracted, you know, cohort procedures. And yeah, it doesn't surprise me that they do those do come off the table with AKI. So you're totally right.
00:46:57
Gianluca Bini
Yeah.
00:46:57
Annatasha
it just It's your sampling bias. But I think for the in-house cases, like our PSs and like our pacemaker placements and things like that, like when you have
00:46:59
Ryan Bailey
And there's a there's a dosing issue, too.
00:47:07
Gianluca Bini
yeah
00:47:07
Ryan Bailey
there's There's also a dosing issue as well. It's like, you know, you and i and Gianluca are going to dose a lot differently than the RDVM down the street who's, you know, had their 10 business days of anesthesia and they're looking at the bottle and they're looking at the label dose.
00:47:25
Ryan Bailey
And for just singling out dexmedetomidine, there's a massive discrepancy what does.
00:47:27
Gianluca Bini
Yeah.
00:47:32
Gianluca Bini
Oh, it's huge.
00:47:33
Giulio Menciotti
Yeah.
00:47:34
Ryan Bailey
I'm going to give versus what the bottle of Dex Metatomany tells me to give.
00:47:38
Annatasha
Or even just like reference plums.
00:47:38
Gianluca Bini
Yeah.
00:47:39
Ryan Bailey
And like,
00:47:40
Annatasha
And I always tell people, I'm like, plums is three to four years out of date based on literature.
00:47:41
Giulio Menciotti
Absolutely.
00:47:42
Ryan Bailey
yeah.
00:47:46
Annatasha
And people forget that, right?
00:47:46
Ryan Bailey
Mm-hmm.
00:47:46
Gianluca Bini
Oh, yeah. Okay.
00:47:47
Annatasha
Like it's not a real time reference in the sense that, for example, like literature might be, or like referencing like people in the field, like plums is static and it gets outdated quickly, especially on certain topics.
00:48:00
Annatasha
And so you might look up a dose. And the other problem is, is some of these dose ranges are big, right? Like ketamine, you know, one to hundred.
00:48:08
Ryan Bailey
Probably.
00:48:08
Annatasha
Where
00:48:23
Giulio Menciotti
in which you've got to get a dog down and get it intubated and ah ah before you even start any instrumentation in because like staffing is an issue. And so I do agree.
00:48:35
Giulio Menciotti
And again, it comes back to the classic cardiac report recommendations that are sometimes overly, I agree, conservative because I take into account these realities.
00:48:41
Annatasha
Thank you.
00:48:47
Giulio Menciotti
you know
00:48:47
Gianluca Bini
Yeah.
00:48:48
Giulio Menciotti
And Jean-Luc has been at our institution, you know, that my I interfere close to none with anesthesia. And sometimes if I'm bored and I'm just waiting for my rice then to do something, I would just be kind of like, oh, what did you guys induce this dog with?
00:49:06
Giulio Menciotti
But just because I'm curious, not because I have an opinion about it. But when I write ah ah cardiology report, I do take into account the fact that
00:49:10
Ryan Bailey
Yes, yes, yes.
00:49:17
Giulio Menciotti
I don't know in which hands necessarily the dog is going to end up in which type of monitoring and so rather err on the side of caution.
00:49:23
Annatasha
Sure.
00:49:23
Gianluca Bini
Yeah.
00:49:31
Gianluca Bini
Yeah, monitoring is key, right? Like I always tell i always tell my students, like, you know, and in most pets your protocol doesn't really matter. What really matters is that, again, you you know what the drugs do and you know what to monitor and what to do if shit happens, right?
00:49:49
Gianluca Bini
Like that's key, right? Like, and unfortunately, again, and and i I'm a fold of this, like, every like you know, or everybody in academia is a fold of this, right?
00:49:54
Ryan Bailey
Yeah.
00:50:00
Gianluca Bini
that we sometimes
00:50:06
Gianluca Bini
you know try to streamline the course and streamline the rotation for the students. and And unfortunately, 10 business days of anesthesia is not enough. Like 10 business days of cardio is not enough either. Right. And so i think the that that's kind of insanity, right? like they we are pushed to, you know, shorten these rotations more and more. and and And these guys graduate without enough energy.
00:50:37
Gianluca Bini
experience and then and then maybe just to squeeze in an externship to jo down the street you know what i mean where they basically knock you know anesthetize them by hitting him in the head with a bat you know and so yeah and that's and that's what they believe that's normal right
00:50:45
Ryan Bailey
Oh.
00:50:50
Ryan Bailey
Oh.
00:50:55
Annatasha
I can't
Cultural Differences and Light-hearted Exchanges
00:50:56
Annatasha
read.
00:50:57
Giulio Menciotti
but we know We see a lot of the bias of also like, well, in the real world, this is what we do. Well, so it's like in that in university, that's what you're doing in the real world.
00:50:57
Gianluca Bini
i literally had a student
00:51:08
Gianluca Bini
Yeah, but that's bullshit, right? like So, but that's bullshit,
00:51:11
Giulio Menciotti
Yeah.
00:51:12
Gianluca Bini
I know a lot of people that will say, hey, you know, we don't show them this.
00:51:18
Gianluca Bini
We don't carry this because they won't see it in private practice. Now that's stupid, right? Because by not showing them what's actually appropriate, we'll never advance.
00:51:33
Gianluca Bini
We'll never advance. Fucking vet med is stuck to 25 years ago because of this, right? We we' are 25 years behind humans because we don't show the students what they could do to do better, right? And it's simple things. It's little things sometimes, right?
00:51:50
Gianluca Bini
We're like, oh, we don't...
00:51:50
Giulio Menciotti
Yeah, sometimes it's other things. I think sometimes it's like cost plays obviously a a role. Like, I don't know, i think 50, 70% when I ask a stupid question because I'm bored, how are patients that get induced with Atomidate?
00:52:04
Giulio Menciotti
And then i'm I'm told, I guess, that that's kind of expensive and a lot of private practice will not use that or things like that.
00:52:05
Annatasha
Thank you.
00:52:13
Giulio Menciotti
I do have to give a shout out to our, i guess, at least in our area, our referral population is actually extremely, extremely good in both consulting with us and like, and I understand the patient, but obviously that the reality out there, there's there's bad realities, although I have to say.
00:52:33
Giulio Menciotti
I think you're getting better it probably by that approach of showing showing our our students how to do things better. But yeah.
00:52:44
Giulio Menciotti
yeah
00:52:45
Gianluca Bini
Yeah. Yeah. And again, it's tough.
00:52:47
Ryan Bailey
I've got a couple questions for you.
00:52:51
Annatasha
Is it about ketchup and hot dogs?
00:52:54
Ryan Bailey
Well, first of all, we'll start with easy one.
00:52:54
Annatasha
I did not actually think of
00:52:56
Ryan Bailey
This may not be so easy for you, but what is, if you were, like, what is your favorite hot dog?
00:53:04
Annatasha
that.
00:53:05
Giulio Menciotti
Yeah, dog, what are you talking about?
00:53:07
Annatasha
not actually
00:53:07
Giulio Menciotti
Is there different types of dog dogs?
00:53:08
Ryan Bailey
love hot dogs.
00:53:08
Annatasha
yeah
00:53:09
Gianluca Bini
Okay.
00:53:10
Ryan Bailey
i
00:53:10
Gianluca Bini
okay
00:53:11
Giulio Menciotti
i so don'
00:53:13
Ryan Bailey
I love hot dogs. I'm from Chicago. We have a fucking classic hot dog here. I know in Italy, there's a hot dog with french fries pizza that's apparently for children. i had it when was there.
00:53:24
Ryan Bailey
I enjoyed it.
00:53:25
Giulio Menciotti
Absolutely. Like this is one of the most shocking things that i always tell people that the probably the third, second or third most common pizza in Italy is pizza with hot dogs.
00:53:26
Ryan Bailey
All of us did on here.
00:53:36
Giulio Menciotti
You know, we wouldn't put pineapple on it, but actually pizza with hot dogs, we call it like the end style, again, like the city.
00:53:42
Annatasha
Don't drag Vienna into this.
00:53:42
Giulio Menciotti
But
00:53:43
Annatasha
i
00:53:45
Giulio Menciotti
but
00:53:45
Annatasha
I'm half Viennese, and we don't want to hear anything about the Austrians being blamed for your weird hot dog pizza, so.
00:53:49
Ryan Bailey
Oh, yeah. Oh,
00:53:51
Giulio Menciotti
yeah but but But wait, you you're telling me that there's different types of hot dogs? What are you talking about?
00:53:56
Ryan Bailey
oh yeah oh yeah
00:53:57
Gianluca Bini
oh my god
00:53:59
Giulio Menciotti
it about the hot dog itself or the toppings or the bread or Yeah.
00:53:59
Annatasha
This is going to be more controversial than Dexmen and P.S., but...
00:54:04
Ryan Bailey
There's all of it. There's different brands. Like in Chicago, we have a specific like style, but then ah then ah then we top our hot dogs with a bunch of stuff. So it's got tomato and onion and pickle and patent and sport peppers and relish and mustard and celery salts.
00:54:19
Giulio Menciotti
Yes.
00:54:19
Ryan Bailey
Oh, that's so good.
00:54:19
Gianluca Bini
beautiful
00:54:20
Giulio Menciotti
The answer is yes. Yeah. food that Put it off. Yeah.
00:54:22
Ryan Bailey
All right.
00:54:22
Annatasha
Coronary artery disease happening right here.
00:54:24
Giulio Menciotti
but But then if you can do that and then chop it off and just put it inside a deep dish pizza, I think that would be great.
00:54:35
Giulio Menciotti
That's Chicago's at the best, right?
00:54:38
Ryan Bailey
if If anyone's going to coronary arterial disease, it's me.
00:54:42
Giulio Menciotti
There you go. There you go.
00:54:42
Gianluca Bini
So, so
00:54:43
Ryan Bailey
Well...
00:54:44
Giulio Menciotti
I did like, I was in Chicago, I did like the deep dish pizza.
00:54:49
Ryan Bailey
and
00:54:49
Ryan Bailey
other The other question I had is, more seriously, how would you like us, the anesthesia team, to approach the cardiac workup for these patients?
00:55:01
Ryan Bailey
Because I think, I feel like that's the other point of contention is there's, there's anesthesiologists out there who want to see an echo in every single patient they diagnose a murmur in.
00:55:11
Annatasha
I'll grow a set already. gone
00:55:13
Ryan Bailey
It's not me. It's not me.
00:55:16
Giulio Menciotti
Yeah, we we have good data about that for mitral valve disease, and I'm a little biased because our group has been working mostly on mitral valve disease. And so when we take into account the general population of dogs, things may be different. And then lately that diet related DCM threw things and a little bit off, obviously. But if we take those few instances out of the equation, i think we have very good evidence from thousands of dogs that
00:55:53
Giulio Menciotti
If you take a population approach, understanding that we are talking about the average and 90 something percent of dogs, a small breed dog, small to medium breed dog that has a murmur that is less than a three out of six, it's extremely unlikely to have significant heart disease, meaning heart disease with cardiomegaly.
00:56:14
Giulio Menciotti
Okay. So we know that we have like very, very good chances if we echo with the dog and we know already that if we act with a dog, he's gonna have some micro-regurgitation, normal cardiac chambers, okay?
00:56:30
Giulio Menciotti
And sometimes we just do that.
00:56:30
Annatasha
Thank you.
00:56:33
Giulio Menciotti
we When people ask for a consult and he's like, listen, I can tell you already by looking at the dog and I listen to the dog, this is what we're going to find.
00:56:35
Ryan Bailey
Yeah.
00:56:43
Giulio Menciotti
do you really want to spend $500, $800 of this owner on this? It's fair if they do because they want to be thorough. Because if you were a person, that's what they would do, honestly.
00:56:52
Ryan Bailey
Yeah.
00:56:53
Giulio Menciotti
Like they would do it all if money is not an issue.
00:56:53
Ryan Bailey
yeah
00:56:55
Giulio Menciotti
But at the same time, I think we have very good confidence for these patients
Conclusion and Farewell to Dr. Menciotti
00:57:00
Giulio Menciotti
that we know what they have. Very good confidence that we know what they have. and We know the degree of severity of the disease that they have.
00:57:09
Giulio Menciotti
Unfortunately, when it comes to other patients that large dogs or cats, oftentimes it's ah ah really a coin toss. Whether they have a murmur or not,
00:57:21
Giulio Menciotti
to the point that we we got into this discussion a few years ago with our neurology team. I was like, well, should we echo every Doberman picture that needs an anesthesia for like MRI?
00:57:35
Giulio Menciotti
And I'm not sure that that would be a recommendation, but remember that there is a reason why is called occult DCM until they are in a failure.
00:57:47
Giulio Menciotti
Because a dog, like a Doberman could walk around with a fractional shortening of like 7% and be totally fine running in his backyard for real and not have a murmur.
00:57:58
Giulio Menciotti
The same for the cat with HCM. We know very well that there is about a third of cats with HCM that do not have a murmur and a third of normal cats that have a murmur.
00:58:11
Giulio Menciotti
And so hearing or not hearing murmur in the cat is a coin toss. Right. I think we are and little behind in the use of biomarkers in some of these disease. I think there is definitely a very good role of biomarkers in cats with HCM in a setting in which you do not ever readily access.
00:58:37
Giulio Menciotti
echococargra I think if you use it consciously with the conservative cutoffs, also in dogs, know that BNP that is above in dogs is associate associated with failure or things like that.
00:58:57
Giulio Menciotti
It's not super sensitive. While in cats, I think we have good studies that show that it's a relatively sensitive and specific biomarker for heart disease.
00:59:09
Giulio Menciotti
So I'm not sure whether you would have to recommend a workup, a pre-anesthetic workup, a cardiac workup in every cat and in every large dog. I think it would be insane from the cost.
00:59:25
Giulio Menciotti
but you would have to invoke that kind of population-wide approach for which we do our best. We work on likelihood of disease. We work on statistics and even every time we use any drug or intervention, to be fair, I tell our owners, you know, this is what works on average on the dogs. Every patient is a single individual, which comes back to the monitoring, I guess, standpoint and recognition of you being in trouble early rather than later makes a lot of difference cardiovascular standpoint.
01:00:04
Gianluca Bini
Yeah. No, that makes a lot of sense. To follow up on Ryan's question, so did you, no, it's about, did you try tavern style pizza?
01:00:12
Ryan Bailey
I'm on hot dogs, assume.
01:00:15
Giulio Menciotti
bla da
01:00:19
Ryan Bailey
yeah What?
01:00:22
Giulio Menciotti
night What are you talking about?
01:00:22
Ryan Bailey
What?
01:00:24
Giulio Menciotti
What? Tavern style pizza? What is that?
01:00:26
Gianluca Bini
Oh my God. Oh my God. oh my God.
01:00:28
Annatasha
Half of our podcast is talking about food.
01:00:29
Giulio Menciotti
What are you? Yeah.
01:00:31
Ryan Bailey
let you I'll let you explain this, Beanie, since you you had it while you were
01:00:34
Gianluca Bini
So, you know, like the the very, like, know, teen crust?
01:00:40
Giulio Menciotti
yeah
01:00:40
Gianluca Bini
even more thin. It's literally like a Kregger, but it's basically a pizza that's so thin and it's so crispy that it looks like a Kregger, but it looks like like it has all the pizza topping and all that shit, right?
01:00:53
Gianluca Bini
And so Chicago is divided in people that like dip dish and people that like tavern-style pizza. So next time you go to Chicago, you need to hook up for Ryan's
01:01:07
Gianluca Bini
And he's going to take you to a try Chicago-style hot dogs, and B, you know, the tarot shop.
01:01:07
Ryan Bailey
True.
01:01:07
Ryan Bailey
Mm-hmm. Yes.
01:01:16
Giulio Menciotti
i'm ah I'm I'm relatively open-minded when it comes to food, to the point that sometimes I upset my Italian
01:01:25
Ryan Bailey
and we cut it into squares like this, like little, like a whole pizza cut into like squares, like a sewer grid almost.
01:01:32
Giulio Menciotti
That's totally fine. That's OK. Yeah, that's all right. It's all right. I'm willing to try it. It all comes down to the toppings, right?
01:01:43
Gianluca Bini
Yeah, that's fair. That's fair. What's your favorite pizza topping? What's your favorite pizza?
01:01:46
Giulio Menciotti
Oh, I have like a wild varieties. I like what is called Capriccio in Italy, which has got like a lot of toppings. like capers to pepperoni to mushroom and artichokes, mostly with a tomato sauce.
01:01:59
Gianluca Bini
Yeah, that's pretty good.
01:02:00
Ryan Bailey
Oh. foka
01:02:01
Giulio Menciotti
But even like a classic pepperoni pizza is probably my go-to most the times. I actually have a pizza, though, that I'm growing right now.
01:02:06
Annatasha
can you
01:02:10
Giulio Menciotti
Yeah, I'm baking.
01:02:10
Ryan Bailey
and hello
01:02:11
Gianluca Bini
Oh, wow.
01:02:12
Giulio Menciotti
Yeah.
01:02:12
Gianluca Bini
You're ready to cook pizza.
01:02:13
Giulio Menciotti
be waiting for tomorrow, yeah?
01:02:15
Ryan Bailey
yeah
01:02:15
Gianluca Bini
Yeah. What's your favorite toppings, Ryan? What's your favorite pizza?
01:02:19
Ryan Bailey
I mean, tavern style, I'm going sausage and giardiniera, like, every single time. Like, spicy like spicy sausage and giardiniera.
01:02:26
Annatasha
Thank you.
01:02:28
Ryan Bailey
And then if I'm doing, like, more of, like, an Italian, like...
01:02:35
Gianluca Bini
Napoleon style.
01:02:36
Ryan Bailey
Yeah, Neapolitan style. Man, I don't know. What do I do? i mean... Sauce is always pretty solid. I mean, I've tried my hand at doing like a margarita style with like sliced tomatoes. I just, they come out too watery when I cook it in my like pizza oven at home. So I gotta, I gotta work on that. But I like the simple, just like basil, cheese, olive oil.
01:03:01
Ryan Bailey
I'm pretty happy with that. Like there can't be enough basil in food for me, honestly.
01:03:06
Gianluca Bini
What about you, Tasha? What's your favorite pizza?
01:03:10
Annatasha
I don't know have a favorite pizza, but my favorite topping is artichoke.
01:03:13
Ryan Bailey
Oh. Oh.
01:03:14
Gianluca Bini
Oh, wow.
01:03:14
Annatasha
I really feel it brings out the flavor and gives it like a a nice little like kick.
01:03:15
Gianluca Bini
Okay.
01:03:18
Annatasha
It balances like the acid with the fat of the cheese.
01:03:22
Giulio Menciotti
Absolutely.
01:03:22
Annatasha
Yeah.
01:03:22
Gianluca Bini
Yeah, yeah. My favorite is probably like quattro formaggi, which is basically, what's yeah, four cheeses, right?
01:03:28
Giulio Menciotti
Poor Jesus.
01:03:31
Gianluca Bini
and But the four cheeses here is not the same as the four cheeses in Italy, because like here they don't use gorgonzola cheese, because a lot of Americans don't like gorgonzola cheese.
01:03:40
Giulio Menciotti
Correct.
01:03:40
Ryan Bailey
oh
01:03:44
Gianluca Bini
Yeah. But yeah, no, I love it. When we do it at home, it's legit. When I go out, I'm never heated because like I know that's fake and there's no...
01:03:54
Giulio Menciotti
Oh, you want something that I always wow people with that a lot of pizzerias, well, not lot pizzerias have, you should try is mascarpone cheese with Parma ham with like prosciutto.
01:04:06
Gianluca Bini
Oh, yeah.
01:04:07
Annatasha
That sounds...
01:04:08
Ryan Bailey
Damn.
01:04:08
Giulio Menciotti
A base mascarpone cheese that melts and then prosciutto.
01:04:08
Ryan Bailey
Do
01:04:08
Gianluca Bini
Oh, yeah.
01:04:11
Giulio Menciotti
And the mascarpone has got like the little sweetness to it.
01:04:14
Ryan Bailey
you put the mascarpone on before it goes in oven?
01:04:16
Giulio Menciotti
Oh, after.
01:04:17
Ryan Bailey
After? Okay. And then same with the parma.
01:04:20
Giulio Menciotti
Yep, same.
01:04:21
Ryan Bailey
Ooh, you know what else I love? i love mortadella on at the end. Just like...
01:04:27
Giulio Menciotti
That's another go-to for me, yeah. Yeah, mo la fresh mortalella on top of it, yeah.
01:04:29
Gianluca Bini
Yeah.
01:04:31
Ryan Bailey
hate cooked mortadella. I don't know why.
01:04:35
Gianluca Bini
Yeah, cooked more.
01:04:36
Giulio Menciotti
It's meant to be cooked,
01:04:36
Gianluca Bini
Yeah, it's gross.
01:04:38
Ryan Bailey
Okay, good.
01:04:38
Annatasha
You know what i hate is when they put barbecue sauce instead of tomato sauce on the pizza.
01:04:38
Ryan Bailey
It makes me feel better. It makes me feel better.
01:04:45
Annatasha
that I find that really disgusting.
01:04:47
Gianluca Bini
mean
01:04:48
Giulio Menciotti
yeah.
01:04:48
Gianluca Bini
yeah
01:04:49
Giulio Menciotti
Oh my God, that's like giving that smart to it.
01:04:50
Annatasha
Yeah, it's a barbecue pizza and they put...
01:04:51
Giulio Menciotti
No, sorry, I was...
01:04:54
Annatasha
No, yeah. instead There's no, like, there's a marinara, like, there's nothing. It's just barbecue sauce, cheese, and then they barbecue meat on it, and I'm like, hell no. Yeah.
01:05:02
Gianluca Bini
What the fuck? It's gross. Gross.
01:05:07
Annatasha
Mm-hmm.
01:05:08
Giulio Menciotti
Whatever works for people. You're
01:05:10
Ryan Bailey
You
01:05:10
Gianluca Bini
All right, guys.
01:05:12
Annatasha
Yeah,
01:05:13
Gianluca Bini
I mean, we're coming up on the hour. Well, thank you so much, Giulio, for being here. Thank you for being a good sport with all of our, like, you know, anti-cardio. Thank you.
01:05:24
Giulio Menciotti
not anti-cardia.
01:05:24
Gianluca Bini
of
01:05:27
Giulio Menciotti
You're just anti-organ perfusion. That's great. Anyway, sorry.
01:05:30
Annatasha
yeah
01:05:32
Gianluca Bini
Nice, nice.
01:05:33
Annatasha
no, actually, know what it is, is we're anti other people telling us what to do. It's really, it's really.
01:05:37
Ryan Bailey
It's true.
01:05:37
Giulio Menciotti
I think that's fair.
01:05:38
Ryan Bailey
It is true. We are control freaks to the max.
01:05:38
Giulio Menciotti
Yeah.
01:05:40
Annatasha
Mm-hmm.
01:05:41
Giulio Menciotti
Yeah.
01:05:41
Gianluca Bini
There you go. There you go.
01:05:41
Annatasha
Yeah.
01:05:43
Annatasha
And I certainly don't want two-bit opinions on anesthesia from like fucking ER interns.
01:05:52
Annatasha
Fuck.
01:05:53
Gianluca Bini
a ah a ah Well, thank you. Thank you so much, everybody. You can listen to this on, you know, a lot of platforms, but you can also watch it on Apple Podcasts and YouTube. Thank you, everybody. Have a good night.
01:06:10
Annatasha
Thank you.
01:06:10
Giulio Menciotti
Have a good night. Bye. Thank you much.
01:06:11
Ryan Bailey
Bye.