Dr. Andy Roark dusts off this Hall of Fame episode in which he discusses the essentials of anesthesia crash carts with Veterinary Anesthesia Nerd, Tasha McNerney. Together they talk about what tools should be in your anesthesia crash kit and what kind of common pitfalls they’ve seen in practice.
You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!
LINKS
Veterinary Anesthesia Nerds: https://www.facebook.com/groups/veterinaryanesthesianerds/
RECOVER Resources: https://recoverinitiative.org/category/resources-and-tools/
Upcoming Webinar (Free RACE CE): https://drandyroark.com/headcases
ABOUT OUR GUEST
Tasha McNerney is a Certified Veterinary Technician from Pennsylvania where she works as a educational consultant and relief anesthesia technician. Tasha is the founder of the Veterinary Anesthesia Nerds, while also a Certified Veterinary Pain Practitioner and board member of the International Veterinary Academy of Pain Management (IVAPM) to educate the public about animal pain awareness. In fact, Tasha was the thought leader behind the now celebrated “Animal Pain Awareness Month” within the veterinary industry. Tasha became a veterinary technician specialist in anesthesia in 2015. Tasha loves to lecture on various anesthesia and pain management topics around the globe and was previously named VMX Speaker of the Year.
EPISODE TRANSCRIPT
Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary podcast. I’m your host, Dr. Andy Roark. Guys, I am pulling one out of the vault for you, just blowing the dust off of it. This is a Hall of Fame episode with my good friend, the one and only Tasha McNerney, the original anesthesia nerd. We are doing the anesthesia crash cart crash course. It’s just a box of pearls. That’s what it is. It’s just knowledge, pearls, and I just put ’em all together in this box and here you go. From me to you. Happy holidays. It is a great episode. It is one of our most popular episodes of the last year, and you’re going to see why when you check it out, even if you heard it when it came out, it’s time to brush it up again. There’s so many mind gemstones here that you went through and you put some in your brain the first time, and I promise you there’s a lot more room. You’re ready for other ones. Now you’re ready for the next level of mind stones that go in. I don’t know what this metaphor is, but I think you’re just going to enjoy this episode. Let’s just do it.
Kelsey Beth Carpenter:
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast, Tasha McNerney. How are you?
Tasha McNerney:
I’m good. How are you?
Dr. Andy Roark:
I’m so good. It’s so good to see your face again. You’re one of my favorite people. You and me go way back. I’m like way back, way back. You were here visiting my house when the pandemic hit, and I’ll never forget you and I started the pandemic together.
Tasha McNerney:
Yes, yes. I have great memories of visiting four different stores, looking for canned goods and then finally buying all the beans at a CVS in some random South South Carolina town. Still have those beans.
Dr. Andy Roark:
I still have those beans a hundred percent. I’m like, these are my survival beans.
Tasha McNerney:
Yeah, well you save them.
Dr. Andy Roark:
My wife, she was like, “we’ll never eat these.” And I’m like, look, as long as they’re there, I’ll sleep well at night, but as soon as you throw away my emergency beans, I’m going to be like, what are we going to do if society ends? Yeah.
Tasha McNerney:
Yeah. It was a good time.
Dr. Andy Roark:
I felt, you know what? When the world went sideways, you and I took action. That’s all I’m going to say. And most people, a hundred percent did not, but we did.
Tasha McNerney:
No, people were like, is this happening? And we both looked at each other and be like, oh, we better stock up this pantry. Even though it wasn’t my pantry. I was like, I’ll help you stock up this pantry. You were with me. I had gotten a call from my husband at home saying, everything is off the shelves. It’s kind of pandemonium here. And at that same CVS, I bought two boxes of pasta and took them back in my luggage with me because I was so worried that I wouldn’t be able to find pasta when I went home. So yeah.
Dr. Andy Roark:
Oh man. That’s great to be with an anesthesia specialist because when the world goes haywire, they take action and I felt like that was instinctual for you.
Tasha McNerney:
Oh, 100%. I think I always joke with the anesthesia is that we are very cool, common, collected. When everything is crashing in the ER or in the OR wherever we are, it’s very much, okay, here’s the problem, where do we go next? Alright. And we start this kind of checklist. It’s very much cool, calm and collected in anesthesia. And the joke is that we’re dead on the inside. And sometimes I would agree with that in that we’re not going to be the people freaking out like, oh my God, everything is crashing. Go get this for me. Really that actually with me that things are real bad if I get very calm and monotone. And if I say, okay, what I need you to do next is turn off that vaporizer and can you hand me the epinephrine? Okay. Things are going down. Things are going down.
Dr. Andy Roark:
Yeah. Oh man. Yeah, you are a bit dead on the inside though. That’s just inside baseball from an old friend.
Tasha McNerney:
Yeah. And you know what? Listen, I got a therapist. We’re working on it. We’re good.
Dr. Andy Roark:
I think a lot of people could stand to be more dead on the inside. I think it would probably be, we all know a people who should be a little bit less alive inside. It would help them.
Tasha McNerney:
Yeah. Just calm down.
Dr. Andy Roark:
Totally. Alright, for those who don’t know you, you are a veterinary technician, specialist in Anesthesia. You are the founder of the Veterinary Anesthesia Nerds Group. It’s a Facebook group, it’s a website, it’s a conference. This thing has grown to how many people are involved engaged with the Anesthesia nerds group now?
Tasha McNerney:
Oh, we have about 65,000 members around the world right now. Yeah.
Dr. Andy Roark:
It’s awesome. It’s super awesome. It’s super bonkers. And I could sit here and sing the praises of the anesthesia nerds. I’m all about practical education. I really like to learn stuff that I’m like, I’m actually going to use this. And that is what you guys are all about. So I really love it. I’m super glad that you’re here. I thought of you recently when I had a pet under anesthesia and I can’t remember why. It was an emergency of some sort. And I had this pet under anesthesia and it just kind of dipped there for a second. And so when you pause for a second and you’re like, is this going to be an issue? And then it kind of stabilizes and comes back out and I thought I could use a refresher on the crash cart. That’s exactly what I took away from that specific instance was it was an emergency that came in. I can’t remember what it was. It went under anesthesia to get fixed. And I thought, you know what? Let’s just freshen these skills back up. And so I wanted to get you in and just say, run through the crash cart with me real quick. Let’s do a hundred percent refresher on what’s in my crash cart, what’s it do, what do I need to know about it? And just make me feel like the dust has been blown off my crashing patient knowledge. Is that okay?
Tasha McNerney:
Oh yeah, let’s do it. So, ooh, there’s probably a lot to cover, but we’ll kind maybe put it into categories when you’re looking at your crash cart. And again, just want everybody to know that I’m talking about this in the context of an anesthetic crash cart, not necessarily your ER crash cart, which is probably going to be a little bit different, but when we look at our anesthetic crash cart or what we want to have in that top drawer of our anesthesia machine or on hand during any anesthetic event, that’s what I’m going to talk about here. That’s cool with you. All right. So first of all, any emergency, again, when I say to you, Hey, things are not looking good, can you turn off that vaporizer? And then one of the first things that I want you to do is pull out our real emergency drugs.
And when I say emergency drugs with anesthesia in mind when I’m talking about are our emergency things like atropine and epi and then our anesthetic reversals. So these are really the two big things in our crash cart. We know that we want to have atropine or anticholinergic that we will use in emergencies because it has a very fast onset, shorter duration of action than glycoparalate. But again, in an emergency, we want that fast onset. Now there’s some stuff, and I will let you guys listening at home do some research because I think this is very, very interesting. Looking at the newer research that has come out in the past couple of years asking, especially starting in human medicine, asking is there really any benefit to using atropine during a code or a CPR event? And the human medicine, human literature has actually found that there isn’t, and they actually don’t really use atropine anymore during emergencies.
And if you look at the newest recovery guidelines, they actually state that atropine is not necessarily beneficial, but they don’t know if it’s really going to do any harm either. So if you feel like you still want to keep that in your back pocket, you’re probably not doing any harm. But it’s a little different than we thought 10 years ago that we don’t necessarily know that it’s really doing a lot during our CPR events or our code events. But I still will get it out. And I will say that my anesthesiologist will still have us give it during an emergency. Our next is epinephrine, right? And that’s because we want that basic constriction. We want to make sure that our blood pressure stays tight. We want to make sure that we are delivering oxygen to the tissues to where it needs to go. So again, our emergency drugs, then we need to get rid of whatever anesthetic.
Again, if this is a true anesthetic emergency, we want to make sure that we have reversals in our crash cart to reverse every single drug that can be reversed. Now, most of the time with anesthesia, we are administering opioids. So that means that we need naloxone first and foremost in our crash cart. So if we have an opioid on board, we want to make sure that we reverse that opioid with naloxone. Second most common drug class that’s used are benzodiazepines, things like Midazolam or things like valium, and we have a reversal for those. A lot of clinics don’t even carry the reversal, but I would say if you’re utilizing things like medazolam or Valium in your clinic, you need to carry the reversal just in case things get crazy. And the reversal for those is a drug called flumazenil. It’s a little more expensive than naloxone.
And again, a lot of people don’t keep it regularly on their shelves. But I would say that if you have an emergency, you want to have at least one bottle of flumazenil or at least one in your, or if you have an anesthetic emergency, the next reversal agent that is very important would be antisedan or anapamazol. So this is going to reverse your dexmedetomidine or if you’re in a practice that is still using xylazine, you would want your reversal to be yohimbine, although you could use anapamazol as well working on those receptors. So you want to have antisedan for your dexmedetomidine, right? So if we came into a urgent situation, we want to make sure we have access to atropine and epi and the reversals for all of our drugs. Now, if you’re utilizing ketamine in your protocol, you don’t have a reversal agent for ketamine.
So just realize that if things get crazy and you start reversing everything, that Ketamine is still going to be on board. We don’t necessarily have a reversal for that. Now, this is just for an emergency. I will say that there are a couple other drugs that I do think of as always having in my crash cart, one maybe for some anti-arrhythmogenic effects, and then one for if we start to see maybe some irritation or something like that under anesthesia. And one of these is lidocaine and the other one is diphenhydramine. I like to keep these on board because especially with our patients that are not hemodynamically stable certain breeds, if we see a ventricular tachycardia under anesthesia, so again, this is a ventricular tachycardia, and when I say that, I mean a beat that is greater than 160 beats per minute. So if we see something like this, again, that is going to be not great for forward movement of blood and cardiac output, which delivers oxygen.
So we always want to make sure we have lidocaine available as well. Especially in these more critical patients, you might need to give like a two meg per kg lidocaine bolus if you see that your patient is in vtac. Now again, the reason I mentioned the rate is because sometimes I’ve gone into clinics where they’ll see what they describe as a slow vtac or a ventricular escape beat, or they’ll see it, but maybe the rate is still only around a hundred beats per minute or 110 beats per minute. We don’t treat those with lidocaine. That could actually make it worse. So lidocaine is for those ventricular tachycardic emergencies. And then diaphenhydramine, I usually like to have it on board because sometimes my surgeons will note, Hey, I see that this patient has had a reaction to either maybe they have severe clipper burn or they’ve had a reaction to the chlorhexer iodine that’s been used to scrub their skin and now they have hives.
So if we see something like that, we want to make sure that we can administer some diaphenhydramine to them. Okay, that makes sense. Those are some emergency drugs. And so what I like to have in my anesthesia crash cart, now, these are kind of adjunct drugs that I’ll talk about really quickly, and this is more blood pressure drugs because we know that inhaling anesthesia along with a lot of the drugs that we are going to administer like ace premises, like propofol, like afaxolone, these drugs are going to cause a decrease in cardiac output and vasodilation, which is going to lower our blood pressure. We know that hypotension is going to happen, we want to be ready for it. Now, most of the time you have a normal healthy hemodynamically stable animal. Something like lowering your vaporizer setting or administering a fluid bolus. A five ml/kg is going to get you where you need to go for some animals.
But for other animals, especially if you have a longer procedure in mind, we want to make sure that we’re not just letting that blood pressure and that mean arterial pressure dip consistently below 60 because then we know that oxygen delivery to really important tissues, it’s going to be compromised. And that’s why I always like to have some blood pressure drugs ready and available. Now, I’m not saying that every clinic has to have all of these blood pressure drugs, but the three that I keep on me at all times are going to be dopamine, dobutamine, and ephedrine. And dopamine is a mixed alpha and beta, and that’s why I really like it. If you have a patient that just a cat that’s under anesthesia for, and we know that we’re going to do 12 extractions, it’s going to be a long procedure, but their blood pressure is already not doing so great and they are also a elevated kidney value patient and I want to make sure that they don’t get too hypotensive, then I’m going to start dopamine on this patient again, we’re going to have alpha effects and we’re going to have beta effects, which means the beta is going to help to increase the heart rate and the contractility and the alpha is going to give you a little bit of a squeeze on those vessels similar to another alpha active drug dexmedetomidine.
Now dobutamine, and the reason I like to have dobutamine around is because for some animals like your mitral valve disease patients like your chronic heart failure patients, these little shih tzus that come in and they have heart disease, these guys, if we’re about to do a lung procedure on them and they get hypotensive, they’re going to do better with dobutamine. And that’s because dobutamine primarily acts at disease, can’t handle the vasoconstriction that comes along with alpha activation and dopamine. So we will go with dobutamine for these guys because it’s like it’s having a party at the beta receptor. It’s like all beta all the time. And that’s why I want to have dobutamine for those specific heart cases. And then I also like to have a ephedrine, and ephedrine is one of those because it is very, very versatile. You can give ephedrine as a one-off and it’ll last for about 30 minutes.
So I find a phedrine very helpful. It’s an alpha and beta, very similar to dopamine, but unlike having to set up a concentrate infusion like you do with dopamine, you can give a one-off of ephedrine. Now you have to dilute it out. So make sure if you’re getting a vial of ephedrine, you are diluting this out. So you have maybe a one meg per mil concentration, but then you could give a dose of it. And sometimes if I say to my clinician, well, I’ve already tried the vaporizer, I’ve maybe tried giving, I don’t think the heart rate is an issue, and you’re telling me we still have 30 to 40 minutes left of this dentistry, but I need to do something about the blood pressure. If I don’t have access to dopamine or I don’t want to take the time to set up a CRIsad, I can maybe just do a one-off of ephedrine.
And that’s really effective because again, ephedrine like dopamine effective at the alpha and beta receptors, and we get about 30 minutes of activity. So that’s what I keep in my back pocket if I just need a quick something that I don’t want to set up or I don’t have access to set up a syringe pump and an infusion and et cetera. And then some other things, just like equipment that I like to keep with me at all times is an extra endotracheal tube, an extra laryngoscope. And if you are at a practice that has access to it, certainly paddles for fibrillation. Now again, remember if we are going to use paddles, this has to be a rhythm that’s a shockable rhythm. So we’re not going to shock vtac, but if you see it’s really critical things go south and crazy and your patient is in v fib, then we can shock that rhythm.
But I will also tell you that I’ve worked in plenty of places that don’t have access to paddles and they’ve done okay with that. But this is just equipment. And the reason I’ll go back to the laryngoscope in the tube really quick is on the off chance your patient during movement from induction into the theater gets extubated during the off chance that moving the patient around on the table, they get accidentally extubated. I want to make sure that I can quickly re-intubate that patient. And again, a laryngoscope is going to be the best way to do that because it’s going to give me visualization of where I’m going with the tube. If there are any problems, et cetera, I want to be ready for those problems. And that becomes especially, especially especially important if you’re dealing with brachycephalic patients, you always have an extra tube and laryngoscope ready to go.
Dr. Andy Roark:
Yeah, that totally makes sense. This is amazing. I did not have this as clearly broken down for me in vet school as you just did. This would’ve been so helpful 15, 20 years ago. This is amazing.
Hey guys, I just want to jump in here real quick and let you know about an awesome free one hour of RACE ce webinar that I’ve got coming at you real, real soon on December the 13th at 1 p.m Eastern Time. I am working with my buddy, Dr. Simon Platt, who’s a neurologist and a really interesting person. I just had him on the podcast. If you didn’t hear his episode on Spectrum of Care neurology, check it out. It’s a great episode. It’ll give you some idea of what we’re going to be talking about. But man, he is super fun and fascinating, interesting, and I cannot wait to get in and host this webinar for him.
Anyway, it’s called Head Cases, A Spectrum of Care Approach to neurology in general practice. It is made possible generously by Nationwide. There’s no fee to you. It does have RACE CE is going to be a great presentation about neurology in general practice and keeping neurology accessible to people in times when maybe people don’t have as much money as they would like or they don’t have the ability to just throw down and do the most aggressive treatment options possible. So anyway, it’s going to be fantastic. I would love to see you there. I’ll put a link to register in show notes. Let’s get back into this episode.
Alright, wonderful. Talk to me about some dosages. So are there dosage calculators that you really like because there you are and you’re doing the procedure and this is a stressful time and things start to go off the rails. What do you do to keep those things top of mind for you in a useful way where you say, okay, this is what we need. It’s not just epinephrine to effect, but although that works, but how do you track that information? How do you keep that in a very handy format? Or do you just know it, you’re just like, I know you know it, but is that the best way to approach this?
Tasha McNerney:
It’s probably not the best way to approach it because again, unless you’re really dead on the inside and you can block everything out and just go to your rolodex of drug dosages, nevermind the things beeping and people yelling again, I can do it, but I think that’s just because I don’t know, my brain functions a little bit differently, but
Dr. Andy Roark:
I’ve had people say, how much? And I show ’em with my fingers like this much, and they’re like, that’s not science.
Tasha McNerney:
Nope. Yeah, don’t do that you guys at home. But certainly I would say for anybody who’s interested, look at the vex website. They have a lot of really great things. Look at the RECOVER initiative that’s going to give you a really nice dosing chart. And I do know that if you go to RECOVER and look at the RECOVER initiative and their website, they also have posters that a lot of clinics will use that give you the dosages of based on weight. They have a quick wait chart. So a lot of ERs and emergencies will have this just hanging in their practice where they have a really nice weight chart that’s busted down between atropine, epinephrine reversal drugs, things like, again, if you’re in an ER setting and things get really crazy, you want to bust out the vasopressin, things like that. So I really would recommend recover because that’s probably the most up-to-date guidelines as far as what the research is saying, new updated dosages and having it easy and accessible.
Another thing that I do recommend that every practice does is take those dosages and make an excel spreadsheet or an emergency drug calculator, print that out based on the patient’s current weight and have that ready to go. The time to print it out and put it into the excel spreadsheet is not when everybody’s screaming and the dog’s losing a lot of blood. We want to make sure that we do that beforehand. And again, because it’s a really stressful time, it’s nice to have this printed out and checked beforehand because again, when things are really crazy and you’re really stressed out and your clinician says to you, okay, I need you to give a certain mg/kg dose, and then your brain is like, wait, how much does this patient weigh? What’s the concentration? And you’re trying to do this quick math doesn’t usually work out well. Those precious seconds that you’re taking to calculate out this drug can make a huge difference.
Dr. Andy Roark:
Yeah, yeah, that’s fantastic. I’ll put a link to the RECOVER initiative drug doses in show notes, so people could check that out. I don’t think I need a link to Microsoft excel, but um
Tasha McNerney:
I usually say because people can make their own excel, again based on what they have in their clinic, because I don’t think that every clinic maybe has vasopressin ready to go for their patients.
Dr. Andy Roark:
Yeah, no, no, I love that. I think that makes a ton, a ton of sense. What are the most common pitfalls that you see? What are the things that people either putting together a crash cart or using what’s on their crash cart?
Tasha McNerney:
I think that most common pitfalls, at least from an anesthetic perspective that I see, is that there’s not a regular checking of the crash cart and whether or not the drugs are expired or whether or not we have enough volume of the drug ready to go. So for instance, I would give you, yeah, to actually do what we need to do. Yes, I may have a bottle of atropine in there, but if there’s only 0.4 mls, that might not get me where I need to go. So having somebody check that before the procedure, and I’m a huge fan of checklists, and you guys know me. I love checklists. I love anesthesia checklists. If you haven’t read the Checklist Manifesto, please do yourself a favor and read this. It’ll change the way you practice. But certainly having checklists in anesthesia and having somebody to go in before the anesthetic event even happens, check that anesthesia machine, check that cart, make sure the lidocaine is in date. Make sure that you have a bottle of glycopyrrolate ready and available. Make sure that if you’re going to use dopamine, again, you have enough volume to make up your cri because I’ll just give you an example. I was helping out anesthesia on a 62 kg
Dr. Andy Roark:
Wow.
Tasha McNerney:
Great. Dane. Yeah,
Dr. Andy Roark:
That’s 140 pound
Tasha McNerney:
Great Dane in for a CT procedure. And I went to look at the crash cart and our anesthesia machine in Ct and I looking at it, and I was like, yeah, we only have 1 ml of atropine in this bottle. So yeah, I have atropine and it’s in days, but again
Dr. Andy Roark:
That’s not going to make one side of his mouth dry.
Tasha McNerney:
Something goes crazy with this patient. Now I have to run to a whole other side of the hospital to get more atropine because that one ML is not going to be enough for that dane.
Dr. Andy Roark:
Yeah. Yeah, that totally makes sense. Awesome. Tasha McNerney, thank you so much for being here. Where can people find you online? Where can they learn more about anesthesia nerds?
Tasha McNerney:
Yeah, so the Veterinarian Season Nerds is currently a Facebook group, and that’s where we do a lot of our discussion and case-based stuff. But you can also find us on the website. And on the website we have links to the Veterinary Anesthesia Nerds podcast as well as a calendar of events. So you can see where all of us are speaking. And when I say all of us, I don’t just run anesthesia nerds by myself. I am joined by Darcy Palmer, who’s a VTS in anesthesia, and she works out in Alabama. And then I’m also joined by Steven Sital, who is a VTS in, again, not only a VTS in lab animal, but also a surgical research anesthetist and just a wealth of information there. So we have a calendar, so you can see if you wanted to come hear us talk or lecture, we have a calendar on there as well. And then we have a contact form as well. So if you have something that you wanted to ask the anesthesia nerds or you wanted to request some help for something, you can get us there.
Dr. Andy Roark:
That sounds fantastic. Awesome. Thank you so much for being here, guys. Thanks for tuning in. Take care of yourselves. Have a wonderful rest of your week.
Tasha McNerney:
Thanks for having me.
Dr. Andy Roark:
And that’s it. That’s the episode, guys. I hope you enjoyed it. I hope you got something out of it. I said, you can see now why this is the Hall of Fame episode for us, and why so, so many people loved it when it first dropped. Guys, take care of yourselves, everybody. I’ll talk to you later on.
