February 28, 2002

***** Logging started: 2/28/2002 8:52:41 PM

Christine Slowiak: I would like to say thanks for coming.... My name is Chris Slowiak As for myself, I am a grandfathered technician for way too long.. I am currently the Surgery nursing supervisor at Animal Emergency and Critical Care Center. My personal interests are also emergency and high risk anesthesia.... as well as exotics anesthesia and I am one of the founding members of the "Pain Police" Team. I truly love bringing the bad cases off the table and have also practiced emergency medicine for almost 10 years

Dianne Hudson: and I am Dianne Hudson - I graduated Murray State College in 1983, I have worked for Oklahoma State University since 1984, and have spent the last 11 years in anesthesia. I enjoy equine and small animal Emergency anesthesia. The ones no one else wants to touch. I love challenge...
Christine Slowiak: Dianne is also now the president of the Veterinary Technician Anesthesia Society?? If I can say one thing, please consider joining this organization...For a meager $10... You get a great newsletter chock full of great info... Plus, it is a great great way to network and get support on concepts, new pain mgmt etc..

Christine Slowiak: Perhaps tonight since it is our first chat, we were hoping to bring about a sort of brainstorming experience in finding out what you need and what you want to learn...We would like to make this chat a regular monthly meet, and have each subsequent talk about a core subject like Pain Control, Local Analgesia, Anesthesia Machine Maintenance, etc We would also like to make sure we can address all of your concerns regarding difficult or just perplexing cases to help you best manage your next case when you might find yourself in another harrowing situation...!

Jana: deep subject.......pain control in horses.......

Christine Slowiak: Good Jana, we need to know that... Dean Knoll is our third moderator for the anesthesia boards and he along with Dianne can probably help you out mucho!
Dianne Hudson: Butorphanol is the main stay. We use a lot of Fentanyl as premeds and as cris

Jana: we use alot of butorph on our horse fracture cases during surg for pain....horses always on the ventilator so haven't seen much resp. depression

Dianne Hudson: What dose? And what inhalent?

Jana: a high dose. CSU uses.....07/Kg.....so about 3 cc per 450kg eq...with halo, seems to help while drilling....and no problems at recovery.......and I can then lessen my halo...

Dianne Hudson: Wow, I'm impressed, most places want to give a half a ml and call it good.

Jana: what about fentanyl in EQ....cost prohibitive

Dianne Hudson: Fentanyl is cheap, last time I looked $3.71/ 20ml

Jana: any comment on 3cc of torb??? pro or con..........so what is your recommendation on fentanyl of pain in EQ

Dianne Hudson: We give Xylazine 200mg & Fentanyl .5 mg to a 1000# horse for premeds and start a Fentanyl CRI after that. I use Butorphanol for some cases and have started using it as a CRI as well. If the surgeons have started a case on it I usually stay with it.

Jana: what's your CRI concentration and drip rate for fentanyl?

Dianne Hudson: 5 to 10 ug/kg/hr and if I need to I will give bolus doses as needed, I am pretty heavy handed with the stuff. The concentration we are using is 0.05 mg/ml. We us a syringe pump for the CRI's

Jana: how long post op does it last

Dianne Hudson: I expect it to last about thirty minutes after stoppped.

Jana: patches on horses...can you???

Dianne Hudson: Yes you can, but are you using patches on horses? What size?

Jana: the only patches we have are for small animal.......75ug
Robyn: we just started using fentanyl patches where I work. My question is, can you use Fentanyl inj. until the patch kicks in, or is this not rec?

Christine Slowiak: Robyn, that is completely fine.... Although there are drawbacks to injectable fentanyl. Injectable Fent is very short acting... As little as 15 minutes to as long as 45 minutes.. If you were willing and able to set up a CRI for each patient, it would be balanced but it is sometimes difficult to do that.. What type of surgeries are you patching right now? Are you using Fent patches on SA ECC cases? Or are they also for routine spay and declaw patients?

Jana: we will use it on k9 cruciate repairs.....I hate the way they just send it home with no warning to owners....
Robyn: SAECC cases -- mostly major trauma and major sx -- we rarely use for lac repairs/etc.

Christine Slowiak: I agree Jana... I think vet med has yet to see the repercussions of a child sucking on a patch and going into respiratory arrest - but unfortunately I am sure it is coming. Great.. Do you all like the patches or do you note any drawbacks?

Robyn: Other than waiting for the patch to "kick in", I think they do well. My mastiff had a fentanyl patch on post-ACL, and it helped her a lot

Christine Slowiak: Robyn - your original question regarding loading doses of fent, why not use morphine or hydromorphone? How big is your mastiff, just out of curiousity? I like morphine for loading doses except in pancreatitis cases.

Robyn: Chris, that is what we are doing now. I'm keeping her very light -- she's at 113 # she also has hip dysplasia

Dianne Hudson: I think how well they work is directly related to the person putting it on, I see too many fall off. Vet students you know...

Jana: I like rimadyl..to send home

Christine Slowiak: We use NSAID therapy as well as traditional opioid thx for peri and post op mgmt. Anyone use the new 'injectable Rimadyl'? I am curious but I haven't looked much into it. We currently use Ketoprofen
Dianne Hudson: We are using ketoprofen, carpal block and buprenorphine Jana: we use ketoprofen orally for declaws........injectable.....that would be good for the too sedate animal. We use bupre...preop.......wish they would do the carpal blocks.....do you all glue?? or stitch

Robyn: if i remember correctly, I believe we used a 75 mcg patch, and sent home etogesic and acupuncture 3 times a week until the sutures came out

Christine Slowiak: Wow! ... 75ug/hr! That's a light dose! Did she respond well to it? I love hearing people are using locals!

Robyn: i'm not sure if it was the fentanyl, or the acupuncture, or a combo of both. She was a little, i don't know, dysphoric for the first 24 hours at home
Jana: you go Robyn...love to hear about the acupunture!!!!

Christine Slowiak: Robyn, if it worked, great! I laugh because I would have given her 200ug/hr of Fent and sent her home with some Rimadyl. Conventional medicine is amazing but eastern/western med is really fascinating! Did she get an epidural? If I can suggest one procedure to you all, (perhaps you already perform this) it is lumbosacral epidurals... No, it is not voodoo, it is really quite beneficial ! See, it is an area that vets don't really have time for and is a great way for you to directly effect the recovery time and comfort of your patients as well as generating income for your practices. They have a place in every clinic from ECC, to surgery referral to day medicine
Dianne Hudson: They are wonderful and oh so simple. Duramorph and Bupivicaine
Christine Slowiak: Simple technique, simple equipment and oh so good for your state of mind!

Laura: Christine, what are they and what for?
Jana: I think you have to have a progressive practice to use epidurals.....

Christine Slowiak: Well, an epidural is an injection of a local or opioid or a combo of both into the epidural space in both canine and feline patients.... I agree Jana, but one good aggressive pain conscience tech can cause a whirlwind! Epidurals are to address pain at the level of blocking the transmission at the spinal level. Cystotomy, perineal urothrostomy, perineal hernias, thoracotomies, fracture repairs are all great examples of pain control. I know someone who uses them on all their spays which they hospitalize overnight... The use is almost endless unless of course you are trying to use it for forelimb amputations or something like that.

Jana: agressive and assertive can get you nowhere sometimes.....grrrr.

Dianne Hudson: Do clients mind the clipping?
Christine Slowiak: I don't think so ..... I have to remind people that the clipping was able to provide great pain control to their pet for almost 12-18 hours after a single injection! I think people like to hear their pet was well cared for after surgery.. In trauma (for all you ECC techs) you know when there is a HBC with obvious rear limb trauma.. Get that guy an epidural! If you can distinguish landmarks on his pelvis and he doesn't have head trauma, he is a great candidate!

Jana: hummm we have a jackass that we need to do a kidney dye study on.......that would help....

Dianne Hudson: Is anyone using epidural catheters?

Laura: Do you also use Iso or something after the epidural?
Jana: n

Christine Slowiak: You can,... Depending on what you use the epidural for.... Sometimes you don't need it!

Robyn: where can one get training in placing an epidural catheter?

Dianne Hudson: It is a catheter designed for use in the epidural space. They are very similar to epidurals you are just leaving a catheter in. They come is kits, I just got a sample from Mila. They carry a wide variety of items talk to your rep and see if you can get a sample
Christine Slowiak: Robyn, I think a university can help you out to start.. or an experienced ECC vet with training in placing them. Also - cadavers are great to work with. They are good to get used to introducing the needle and also feeding and placing the catheter. The most complicated and sticky part is the taping and suturing I think

Jana: we use mila for our long term cath....

Christine Slowiak: Dianne, can you give examples of sizes based on patient size and how to choose the catheter best?
Dianne Hudson: To be honest we do not use the in small animal ICU, there is concern over too many people being involved. The ones we used were 22 ga I believe and I would have to look at the sample I got. I would tend to use them on lager cases, labs, goldens.etc.
Christine Slowiak: Now, I know some people are saying.. "There is no way we can do this!" Well, I don't know.

Jana: I think that the routine practioners won't use it.....IMHO

Christine Slowiak: I understand, like Jana said that aggressiveness can get you in trouble... But with anything, the key to a successful persuasion is all in the presentation and education. Maybe you can't get the catheters ordered but you might be able to work on the epidurals.. I think our role as techs is most importantly the nursing care we can give both on the surgery table and the comfort and critical care afterwards
Dianne Hudson: Keeping everything very clean is an absolute must,

Jana: one trick I learned was to have your painful side down when doing it for best effect

Dianne Hudson: Yes, and they take time to start working
Christine Slowiak: BTW - If anyone needs info on any of the mentioned techniques or ideas.. Please post to the Anesthesia board and I'm sure we'll be able to get you what you need! Jana: small animal has the luxury of blocks and epi.....wish Large animal did...kind of hard to get them up when they don't know where their legs are...
Dianne Hudson: Chris what drugs and doses are you using for your epidurals on thoracotomies
Christine Slowiak: Epidurals our clinic uses morphine at 0.1mg/kg and bupivacaine at 1mg/kg... For thoracotomies you can cut the dose with saline 50/50 to drug quantity. I have to admit that for thoracotomies, I prefer an intercostal nerve block to an epidural if I am not placing an epidural catheter

Laura: Money is always a consideration/ How do costs compare in these techniques?

Christine Slowiak: Say comparing fent patches to butorphanol? Or epidurals to others?

Laura: Epidurals to others

Dianne Hudson: do you see respiratory depression?
Christine Slowiak: Epidurals are another method to manage pain...You can use them with all of your preexisting protocols... Say for example you are doing a cruciate. You give your systemic opioid like morphine or butorphanol. You can also give your local block at the site with a splash of bupivacaine or lidocaine. You can also give your epidural and you can apply a fent patch and give an NSAID. This should work cohesively.... Now - don't get me wrong... You don't have all day to dilly around with one pet but you can get fast with everything so that you are able to get a patient clipped prepped and analagesied in 20 minutes. Cost is a factor for a lot of practices.. Local blocks are cheapest probably... It only costs you a syringe and perhaps 5cc of local (depending on the agent). Epidurals need to be performed with a spinal needle and sterile gloves
Dianne Hudson: multiple modality... opioids, blocks, nsaids most opioid are cheap as well as regional blocks
Christine Slowiak: Your opioid can be as cheap as morphine or as expensive as an Alpha2 or maybe even ketamine (yes, the epidural space is a virtual party waiting to happen!) You should try to not think of wanting to swap this out for that...You can't have that pain relief party without the participants (drugs). The more safe partiers the better, right?

Jana: y

Dianne Hudson: I never thought of the epidural space a party spot... :)
Christine Slowiak: So, you also have to see the benefits of doing parts and pieces of pain control. For every modality of regional pain control you use, you can definitely see a reduction (in most patients) of the need for inhalant anesthetics
Dianne Hudson: If you are giving post op fluids, morphine and ketamine cris are great and very cost effective.
Christine Slowiak: Maybe not for the 85# lab, all keyed up and going nutz just prior to induction.. He just needs acepromazine, let's face it! But you should look at your geriatrics or mellow feline friends who will only show you they are hurting by changes in heart rate or blood pressure...You can keep all your monitoring modalities in better line and decrease your gas anesthetic which will benefit your patient in many ways, right?

Jana: and the questions about resp??? effects?

Christine Slowiak: Respiratory effects of epidurals... ? On injection, you will notice that once you pop through the ligamentum flavum (that big big piece of connective tissue) they will react if they are not on a deep anesthetic plane. I see this a lot because I try to get my epidural on board prior to clipping for the procedure for the best possible contact time prior to the pain beginning. You can also notice a cessation in all respiration. You should watch carefully as you inject your agents Using Ketamine (or something that causes increased cranial pressures) will give you a patient much more prone to respiratory depression as injecting into that epidural space does change the flow and pressure in that spinal canal. Dianne, anything to add here?
Dianne Hudson: If you are using regular morphine and not Duramorph you need to be aware that your patient can react to the preservative. Duramorph is preservative free and will not case a reaction. Usually what I have seen was an animal that want to chew at it's tail or just screams in pain
Christine Slowiak: Dianne, I have also.. I have noted this especially with poor technique or later finding out the injection went paravertebral (off the side of the vertebrae)

Jana: as with any change in protocol it's scary to try something new and see things like, apnea.....

Christine Slowiak: Agreed Jana... I can say that in the time of 4 years I have been doing regular epidurals of more than 5 per week, I have seen perhaps 4 bad reactions...This is not a difficult technique though so don't be afraid. The rule of thumb is, if you can't find the landmarks for injection, just don't do it.
Dianne Hudson: Practice on cadavors if you can. If I can teach veterinary students, anyone can learn...lol

Jana: dianne...good Idea!!!

Christine Slowiak: Heck, I have seen more bad stuff with Sevo and you are probably all using it, right?? ;)

Jana: haha......would love sevo.....but we don't do enough masking...would love it in my foals

Dianne Hudson: I love it in horses,it's ok in small animal.

Jana: but expensive a 200 dollar btl. of sevo;...Dianne??

Dianne Hudson: Yes,it is very expensive. I worry about the issue of exposure

Jana: exposure??? you mean waste gases??

Dianne Hudson: Yes Exposure of staff during mask inductions I have a doctor that loves the stuff, but I have student learning to intubate not a good combination

Jana: I think it would be great in induction tanks..for exotics and old cats....

Dianne Hudson: Yes, it does work well, I guess what I am seeing is patients that in the past would have been induced with propofol are now being induced with Sevo
Christine Slowiak: Sevo is a whole topic unto itself isn't it?
Dianne Hudson: Good night everyone and thank you for coming!
Christine Slowiak: Thanks so much everyone!!!

Margaret: You guys did a great job.
Laura: Thanks everyone, I think I like my job more every day when I hear what others are doing out there!

Christine Slowiak: Glad you came Laura.. If we can help you out at all please come see us on the boards.. We love case studies!

Laura: Will be there with some "remedial" questions
Rosemary: Very interesting. Unfortunately had to keep going away. Good night everyone

***** Logging stopped: 2/28/2002 10:37:00 PM

Participants: Debbie, Jana, Laura, Margaret, Phyllis, Robyn, Rosemary